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Help with nursing care plan

I need to do a nursing care plan for a case study I was given with 4 nursing diagnosis and for each diagnosis, 4 interventions including the rationale and expected outcomes for each. I have spent the past three days beating my head on a brick wall and don't feel as though I'm any further ahead than when I started this assignment.

This is what (little) I have for information:

Patient is a 75 year old widow admitted to an orthopeadic unit following a total right hip replacement after a fall at home. She is 1 day post op with the following orders:
*Maintain IV fluids of 5%D .45% NACL at 100 mls/hour until lab values return to normal and tolerating fluids po
* Change dressing today and apply dressing strip
* Up walking today with physiotherapy
* Dilaudid 2.5 mg IV via PCA pump
* Use incentive spirometer every 1 hour

When considering the ABC's it would seem that the ineffective breathing would be a priority (assumably ineffective breathing... this is very much a guessing game because the information given is so limited and it's difficult to do an assessment on a hypothetical patient with limited data).

I'm thinking of the following nursing diagnosis:
*Risk for ineffective breathing related to muscoloskeletal impairment and general anesthesia
* Acute pain related to surgical incision
* Risk for infection related to surgical incision
* Risk for impaired mobility related to ____ (either muscoloskeletal trauma or surgery... not sure which to use)

Shouldn't the patient's IV be of a concern somewhere in here? What is a nursing diagnosis for that?
Should I not be considering constipation because of the limited mobility status

I'm stressed over this... does anyone have any ideas or can point me in the right direction to get this done? This assignment has me stressed enough to want to throw the books away and move on to something different for my life's goal :(

OMG, I hated nursing diagnoses, but I hope I can help you.

Quote:

Originally Posted by lifetimegoal

Shouldn't the patient's IV be of a concern somewhere in here? What is a nursing diagnosis for that?

Try maintain adequate tissue perfusion.

I'm going to pick your post apart. Not to discourage you, but to help you think critically

Quote:

Originally Posted by lifetimegoal

*Maintain IV fluids of 5%D .45% NACL at 100 mls/hour until lab values

In the real clinical setting this would be ordered as Maintain IV fluids of D5LR and Normal Saline... etc.

Quote:

Originally Posted by lifetimegoal

*Risk for ineffective breathing related to muscoloskeletal impairment and general anesthesia

Remember that Dilaudid can also decrease respiratory drive.

Quote:

Originally Posted by lifetimegoal

* Acute pain related to surgical incision

Very good, but would it be the incision that is causing the most pain? Or the hip replacement itself?

Quote:

Originally Posted by lifetimegoal

* Risk for infection related to surgical incision

Good one. What would your interventions be? Consider tissue perfusion. Would adequate tissue perfusion decrease the risk of infection?

Quote:

Originally Posted by lifetimegoal

* Risk for impaired mobility related to ____ (either muscoloskeletal trauma or surgery... not sure which to use)

I would use musculoskeletal trauma. BUT, what are your interventions going to be?

Quote:

Originally Posted by lifetimegoal

Shouldn't the patient's IV be of a concern somewhere in here? What is a nursing diagnosis for that?

Remember tissue perfusion. You have D5LR and NS running at 100ml/h... both of them, that means 50ml/h per bag. Is that adequate? Should it be higher?

Quote:

Originally Posted by J_9

I'm going to pick your post apart. Not to discourage you, but to help you think critically I appreciate it

Very good, but would it be the incision that is causing the most pain? Or the hip replacement itself?
I don't know this because of the limited information we were given in the scenario - I wondered that myself... would I change my diagnosis to reflect that the pain can be from either or?

Good one. What would your interventions be? Consider tissue perfusion. Would adequate tissue perfusion decrease the risk of infection?
Consideration needs to be given to chain of infection... her body's first line of defense (skin) is already "broken" so then it's our role to protect any microorganisms from entering into the incision that would cause the infection, yes? And to do that you would use your universal precautions, surgical asepsis as two means of controlling it

I would use musculoskeletal trauma. BUT, what are your interventions going to be?
1) She needs to mobilize with the assistance of physiotherpay (that's a given according to the orders that were given), 2) she would need adequate pain control to even feel like beginning to move (which I used as one dignosis) -would frequent repositioning (q2h) be something to consider, what about assessing for risk of thrombophlebitis or risk for constipation due to immobility (or would those be considered nursing diagnosis)?

Remember tissue perfusion. You have D5LR and NS running at 100ml/h...both of them, that means 50ml/h per bag. Is that adequate? Should it be higher?

You would obviously have to monitor intake and output of her IV fluids as well as what ever it is she is taking in po, you would have to assess her IV line frequently to be sure it isn't infected or leaking... am I thinking along the right lines?

The IV should NEVER be leaking. You should notice that from the time of insertion.

Thank you soooo much for your help... I appreciate it more than you will ever know. I think I have enough information to allow me to complete this assignment. I appreciate you pointing out things to make me think outside the box

You are very welcome. I have been where you are. If you need any help, please don't hesitate to ask.

Quote:

Originally Posted by J_9

You are very welcome. I have been where you are. If you need any help, please don't hesitate to ask.

I'm doing a refresher right now... decided to try out the "other" real world for awhile and am kicking myself for it now. The last unit I worked on in an acute care setting was on the orthopeadic floor but I'm flooding my brain with a boat load of information in such a short time that I just couldn't wrap my mind around it all much less put down in writing what we did on a daily basis anyway (and then have to rationalize it all).