John 50 yr/old male admitted 2 days ago due to a right hip fracture from a MVA
par Tyson McKnight
1. Pathophysiology of Primary Dx: Disruption of the bony structure of Pelvis
2. Risk factors: elderly, *obese, substance abuse, *osteoporosis, *pneumonia
3. Clinical Manifestations: *infection; *pain/tenderness in hip, groin, or lower back; *bruising/swelling; *numbness/tingling; *hypovolemic shock
4. Nursing Dx #2: Impaired Physical Mobility
4.1. Outcome: Patient will reposition every 2 hours
4.1.1. Nursing Interventions: passive ROM, OT/PT, turning/repositioning, assistive devices
5. Diagnostics: X-ray, ultrasound, MRI, CT scan
6. Nursing assessment of Primary Dx: assess for redness, swelling, warmth, and tenderness; control patient pain; vitals (fever, blood pressure), check for sensation of feeling; check for CMS
7. Secondary Dx: Type II Diabetes Mellitus
7.1. Pathophysiology: Genetic and environmental--> Insulin resistance--> decreased glucose uptake--> hyperglycemia
7.2. Nursing assessment: Monitor blood sugar, infection, check lower extremities, perform neurological function test
7.3. Risk factors: *risk for infection, Native American decent, *risk for impaired skin integrity, *risk for unstable blood glucose level
7.4. Clinical Manifestations: *Polydipsia, *polyuria, *obesity, recurrent blurred vision, fatigue, paresthesia, *skin infection
7.5. Diagnostics: OGTT (pregnant women), A1C, fasting glucose, random glucose
8. Nursing Dx #1: Impaired Comfort
8.1. Outcome: patient will maintain 4/10 on pain scale at end of hospital stay
8.1.1. Nursing Interventions: pillow wedge, pain scale, heat/ice therapy, pain medication
9. Nursing Dx #3: Anxiety
9.1. Outcome: Patient will have therapy dog visit one time daily
9.1.1. Nursing interventions: aroma therapy, education, relaxation/meditation, religious views (chaplaincy)