NEED A PERFECT PAPER? PLACE YOUR FIRST ORDER AND SAVE 15% USING COUPON:

Assign Create a care using the template below with information provided for the patient  Dx: Left hip fracture Summary :  is an 85-year-old white female

Assign Create a care using the template below with information provided for the patient 

Dx: Left hip fracture

Summary :

 is an 85-year-old white female

Click here to Order a Custom answer to this Question from our writers. It’s fast and plagiarism-free.

Assign Create a care using the template below with information provided for the patient 

Dx: Left hip fracture

Summary :

 is an 85-year-old white female with a history of osteoporosis. She lives at home by herself where she fell and broke her left hip yesterday evening, after having complaints of dizziness, weakness, and fatigue. She is scheduled to have surgery in 2 days.

Medications:

· Enoxaparin sodium 40 mg SQ daily

· Docusate sodium 100 mg PO daily

· Morphine sulfate 4 mg IV q4h prn for pain

· Metoprolol 25 mg PO BID

· Furosemide 20mg PO daily

Orders:

· Vital signs every 4 hours

· Activity: Bed rest

· Anti-embolism stockings on both legs (knee-length)

report

S: Mrs. Jacobson is an 85-year-old white female who was admitted last evening after falling and fracturing her hip. X-rays have been taken and show left intertrochanteric hip fracture. Mrs. Jacobson is scheduled for surgery in 2 days.

B: Mrs. Jacobson has a 10-year history of osteoporosis and was newly diagnosed with congestive heart failure last year. Her daughter reports that recently Mrs. Jacobson has been having dizzy spells, fatigue, and weakness. Mrs. Jacobson lives alone and is usually able to perform all her ADLs independently. She does have a cane at home but often times refuses to use it because she “doesn’t think she needs it”. Mrs. Jacobson is usually pretty active, but has been much more sedentary lately due to increasing weakness and fatigue due to medication non-compliance with her heart failure medications.

R: You will need to reposition Mrs. Jacobson as she needs to be turned every 2 hours. You should perform a focused musculoskeletal assessment, reinforce safety, and provide patient education on fall risk. Assess her pain level and medicate for pain if needed. Course Number and Name

Course: NURS 101L

NURSING CARE PLAN TEMPLATE

NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L

Student

Date

Instructor

Course

Patient Initial

Unit/ Room#

DOB

09/20/1935

Code Status

Full code

Height/Weight

152cm/47.6kg

Allergies

No known

Temp (C/F Site)

Pulse (Site)

Respiration

Pulse Ox (O2 Sat)

Blood Pressure

Pain Scale 1-10

99F/ oral

90bpm/ radial

15bpm

97

134/80

2/10

History of Present Illness including Admission Diagnosis &

Chief Complaint (normal & abnormal) supported with Evidence Based Citations

Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations

Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),

include dates and rationales supported with Evidence Based Citations

Past Medical & Surgical History,

Pathophysiology of medical diagnoses

(include dates, if not found state so)

Supported with Evidence Based Citations

Erikson’s Developmental Stage with Rationale

And supported by Evidence Based Citations

Socioeconomic/Cultural/Spiritual Orientation

& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations

Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each

(“At Risk for…” nursing dx)

Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale

supported with Evidence Based Citations

Signs and

Symptoms

As evidenced by

Related to

Contributing

Factors

Diagnostic

Label

Priority Nursing Diagnosis

(at least 2)

Written in three part statement

Planning

(outcome/goal)

Measureable goal during your shift

(at least 1 per Nursing diagnosis)

Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching

(at least 4 per goal)

Rationale Each must be

supported with Evidence Based Citations

Evaluation

Goal Met, Partially Met,

or Not Met

& Explanation

MEDICATION LIST

Medications (with APA citations

Class/Purpose

Route

Frequency

Dose (& range)

If out of range, why?

Mechanism of action

Onset of action

Common side effects

Nursing considerations

specific to this patient

Enoxaparin sodium

Anticoagulants

subcutaneous

daily

40

Docusate sodium

Laxatives, Stool Softener

oral

daily

100

Morphin

Opiate, narcotic

IV

PRN every 4 hrs

4

Revision Date: Month, Year (i.e. February, 2010) Page 1
Page 1 of 3

Place your order now for a similar assignment and have exceptional work written by one of our experts, guaranteeing you an A result.

Need an Essay Written?

This sample is available to anyone. If you want a unique paper order it from one of our professional writers.

Get help with your academic paper right away

Quality & Timely Delivery

Free Editing & Plagiarism Check

Security, Privacy & Confidentiality