Question

The new nurse received a new patient, fresh from surgery, to her unit. Mr George is a 68-year-old man who underwent a surgical repair of a right sided fractured femur. As you receive report from the postanesthesia recovery unit, you learn that his medical history includes hypertension, 35 year history of smoking (1 pack per day), and COPD. His surgical repair was successful but complicated by excessive bleeding, and he is receiving IV fluids to compensate. His current VS include: BP 91/54, HR 115, RR 20, temperature 100.8 degrees F, SpO2 sat 99% on 2L O2 per nasal cannula. The patient rates his right leg pain at an 8/10 on the pain rating scale. Mr George does have morphine and Norco ordered prn for pain. He is widowed, and his three children are scattered throughout the United States. He lives alone, receives Meals on Wheels, and pays a cleaning service to keep his home clean. Mr George was told that he would need to go to acute rehab for about 1-2 weeks following surgery, and Mr George is refusing to go.

1. A. Come up with 2 nursing diagnoses for this patient – write out “r/t” and “AEB” statements for each, the best you can.

2. Determine which nursing diagnosis is your top priority for this patient.

2. For your top rated nursing diagnosis, come up with 1 patient outcome. Make sure this is written utilizing the SMART acronym
3. For your identified patient outcome, write out 3 nursing interventions that you would implement to help the patient achieve their goal.

Answer 1

1) As the patient has a post operative status and underwent repair of right sided fractured femur hence rates pain in the scale of 8/10.

Along with this the patient has an history of copd along with an excessive fluid loss hence may have hypovolemia.

Along with that the patient is unable to perform activities of daily living.

The patients priority nursing diagnosis may include

1) deficit fluid volume related to post operative complications as evidenced by bp-91/54.

2) acute pain related to post operative status as evidenced by pain scale of 8/10.

1)Deficit fluid volume rated to post operative complications as evidenced by bp-91/54.

By 1 week the fluid Volume of the patient is within normal level.

Intervention-

Monitor for the level of fluid loss.

Monitor the cause of fluid loss.

Monitor the necessary fluid management requirements of the patient.

Assess the skin turgor for signs of dehydration.

Monitor strict intake and output chart of the patient.

Administration of albumin in case of severe protein loss.

Monitor central venous pressure, pulmonary artery diastolic pressure.

Administration of fluids plays a very important part.

Ensure adequate hydration.