Question

You are assigned to Mrs. Z. a 72-year-old woman who fell at home and was admitted to your unit for a fracture of the right hip. She was alert and oriented on admission. After the initial workup, she was taken to surgery for an open reduction with internal fixation (ORIF) of her right hip. This is her first postop day. Her right hip dressing has a small amount of dried dark red drainage.

Handoff Report for Mrs. Z:

Patient has an IV of D5/0.45% NS at 75 mL/hr, oxygen at 2L/min/nasal cannula, and is on a clear fluid diet. The neurovascular checks to the right leg are q4h for the first 24 hours. The right leg is warm, pedal pulse present, capillary refill around 2 seconds. IV PCA with morphine sulfate delivering 1 mg/hr continuous infusion. The following medications are ordered: FeSO4 325 mg po tid with meals (start when on regular diet), docusate sodium 100 mg po daily. The urinary catheter is draining clear urine. Current vital signs are P 80, R 18, BP 110/84. She is very restless and confused this morning.

Subjective Data

• Fell at home when she tried to get up to go to the bathroom
• Her husband took her to the hospital
• She has a past medical history of hypertension which is well controlled by enalapril (Vasotec) for the past 6 years
• She had the flu a week ago
• Complains of pain in right hip

Objective Data

• Blood pressure 110/84
• Diaphoretic and pale skin
• Pedal pulses present
• Capillary refill 2 seconds
• Restless
• Oriented x2

Diagnostic Studies

• x-ray of right hip revealed fracture
• ABGs: PaO2 80 mmHg, PaCO2 35 mmHg, pH 7.42

Nursing Care Kardex

Name: Mrs. Z

Age: 72

Diagnosis: Fracture of right hip

• VS q4h
• Ambulate with assistance prn
• O2 @ 2L/min/NP
• neurovascular checks q4r for the first 24 hours
• I&O
• IV of D5/0.45% NS at 75 mL/hr
• IV PCA with morphine sulfate 1mg/hr continuous infusion
• Catheter care: bid
• Diet: clear fluid diet
• Routine meds:  FeSO4 325 mg po tid with meals (start when on regular diet); docusate sodium 100 mg po daily.

It is now 0730. As you enter her room you noticed that Mrs. Z is very restless and confused this morning. You are planning your care activities for Mrs. Z

Follow Up Nursing Action Plan

During the follow-up assessment for the first postop day, you note the following:

• Pedal pulse present: weak in the right foot, stronger on left foot
• Hemoglobin 10.5g/dL and hematocrit 32%
• Bowel sounds hypoactive in all quadrants
• Anxious and restless
• Crackles in the lower bases of the lung

On the second postop day Mrs. Z is still very confused and is trying to get out of bed. She has bilateral scattered crackles in the lungs, labored breathing, shortness of breath on exertion,R32, P 108, pulse oximetry 92% and a productive cough, whitish sputum. Skin cool, pallor noted.

Answer the following questions:

1. What else would you do in this situation with Mrs. Z?
2. What other options or alternatives would you explore and why for Mrs. Z?
3. What referrals might you make for Mrs. Z at this time?
4. Who else on the interprofessional team would you involve in Mrs. Z’s care?

Answer 1

1

• Assess the patient
• Maintain oxygenation
• Inform physicians
• ABG analysis
• Hemodynamic monitoring
• Drug as per doctor's order
• Fowler's position to minimize breathing difficulty
• Maintain fluid balance
• Nebulization as per doctor's order
• Documentation

2. Respiratory team

Cardiac team

3.

Dietitian

Physiotherapist

Speech therapist