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Introduction
Situation and Background: ! 39 year old Caucasian male came in to ER with nausea, vomiting and Leukocytosis affecting patients previous right hip surgery. Social History:
! He is divorced and has family issues about which nursing home to put his father in. Loves RC racing cars and magazines. He currently works for a trailer company.
Past Medical/Surgical History: ! Chronic right hip pain, total hip arthroplasty (10-27-11), infection removed by extended trochanteric osteotomy
Nursing Assessment
Assessment: ! Patient has infection in previous right hip surgery ! Is not weight bearing on right leg ! Patient denies any pain. ! Patient is suffering from depression due to personal family matters. ! Patient is also a type 1 diabetic and does not properly monitor glucose levels ! Patient has stated suicidal comments ! Patient is taking prescribed antibiotics History of present illness: ! Diabetes Mellitus Type 1, Chills, Infection Medical diagnosis (es): ! Nausea, Vomiting, Leukocytosis
Nursing Diagnosis #1
! Impaired physical mobility
Nursing diagnosis
Related to [etiology]
! Inability to move purposefully within physical environment, reluctant to attempt movement, use of walker, hip surgery 10-27-11, nonweight bearing on right leg
Goal: The patient will ambulate from the bed 10 feet to the chair by the end of the shift using the walker.
Intervention: The nurse will encourage and facilitate early ambulation when possible.
Rationale: Patient may be reluctant to move and a positive approach allows the learner to feel good about the activity.
Outcome: At first patient reluctant to ambulate to chair so implemented other interventions to maintain patient active. 45minutes before the end of the shift patient finally decided to ambulate the 10 feet to the chair.
Rationale: Assistance device helps to enhance mobility especially if a patient is nonweight bearing
Rationale: Early mobility promotes confidence and reduce the chance that debilitation will occur.
Intervention: The nurse will instruct the patient regarding the need to make the home environment safe
Goal: The patient will not sustain a fall by the end of the shift.
Intervention: The nurse will place items used by the patient in easy reach, such as call light, urinal, walker, and telephone.
Intervention: The nurse will educate patient about potential risk factors for falls.
Outcome: Patient did not sustain a fall. However, future teaching is required because patient applied light pressure on right leg which is non-weight bearing.
Rationale: Stretching to get items form bedside table that are out of reach can disrupt the patients balance and contribute to falls.
Rationale: Teaching patient will help inform patient to prevent easy to fix hazards that could lead to falls.
Nursing Diagnosis #2
Nursing diagnosis
Related to [etiology]
Intervention: The nurse will monitor blood glucose levels AC and HS.
Intervention: The nurse will teach about importance of maintaining proper diet.
Outcome: Patients glucose level was 65 mg/dL. Glucose levels lowered then normal which is within 70-100mg/dL. Potential reason is that patient is stressed about family issues and refuses to eat enough food to maintain glucose levels.
Rationale: Hyperglycemia results when inadequate insulin is present to use glucose. Excess glucose in the bloodstream creates an osmotic effect that results in increase thirst, increased hunger and restlessness.
Rationale: Monitoring glucose levels before breakfast and bed time can help provide data to see how much patient fluctuates in glucose levels.
Rationale: Following a specific diet provided by a dietician will help maintain adequate glucose levels.
Rationale: In teaching the patient about maintaining a proper diet will help maintain safe glucose levels when patient goes home.
Goal: Patient will verbalize correct information about type 1 diabetes and treatment by the end of shift.
Intervention: The nurse will pace the instruction and keep sessions short.
Rationale: A calm quiet environment assists the patient with concentrating more completely and decreases stress. Rationale: understanding the different types of insulin and injection sites will help decrease potential of hyperand hypo- glycemia and insulimia. Rotating sites decreases the chance of skin breakdown.
Outcome: Patient was not first interested, but by the end of the shift patient was able to verbalize learned material correctly.
Rationale: Learning requires energy, so shorter, well-paced sessions reduce stress and fatigue on the patient.
Barriers
Barrier: Patient is uncooperative Barrier: Patient is depressed Goal Interference: patient is not interested in learning fall precaution Barrier: Patient does not eat recommende d calories Goal Interference: Being able to maintain glucose level of 70 100mg/dL
Barrier: Patient not interested in learning
Linkages
Prolonged bed rest
Ambulating