Upon physical exam, she is afebrile with unremarkable findings with exception to
ID: 242789 • Letter: U
Question
Upon physical exam, she is afebrile with unremarkable findings with exception to the musculoskeletal system. She weighs 132 pounds and is 5 feet 5 inches. At her last exam 8 months ago, she was 5 feet 6 inches. Upon palpation, guarding and tenderness are present in the cervical, thoracic and lumbar spine with limited range of motion. No spasticity, rigidity or flaccidity is present. She has active range of motion in all joints, with no edema, redness or heat present in joint areas. She exhibits notable guarding and rigidity performing range of motion of lower and upper back areas. There is also noticeable guarding with some limitation of movement at the cervical spine area. She is able to endure the exam with noticeable painful expressions on her face when asked to do range of motion with back, guarding and tenderness noted at cervical spine area. There is no presence of dowager's hump. She has no evidence of herniation or disc displacement upon inspection. No scoliosis or lordosis is present. Her preliminary urinalysis and CBC are unremarkable.
During the night shift Joan becomes confused, repeatedly attempts to get out of bed, and hollers for the nurse repeatedly. The daughter who is still with the client is concerned and questions what is happening.
What has occurred to cause this change? Explain your answer.
The next morning following shift report the client is found lying on the floor between the bed and the bathroom. The client is awake and able to state her name. There is shortening and external rotation of the left leg. The client states she had to go to the bathroom and nobody came when she called.
5a. What assessments will the nurse perform? (10pts)
5b. What interventions will she need to take and why? (10pts)
What orders does the nurse anticipate from the health care provider?
hart View
Provider Post-operative Orders
VS every 4 hours
Clear liquid diet – advance as tolerated
Consult physical therapy
Up as tolerated with assistance
Abductor pillow while in bed
Cold therapy machine to left hip while in bed
Compression stockings
0.9% NS @ 100 ml/hr x 8 hrs then decrease to 40ml/hr
SCDs while in bed
Hemovac drain, may pull on post op day 2 if no drainage, notify me if still draining
Continue all home meds
Cefazolin 1 gram IV every 6 hours for 3 days
PTT, PT/INR, CBC, and Metabolic panel daily
The client returns to the medical surgical unit from the PACU. Assessment reveals intact neurovascular status and pain 8/10 on numerical scale. Client and her daughter are concerned about what will happen next. Identify 2 priority nursing diagnosis for this client. What interventions (list as many as you can) will be implemented?
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hart View
Provider Post-operative Orders
VS every 4 hours
Clear liquid diet – advance as tolerated
Consult physical therapy
Up as tolerated with assistance
Abductor pillow while in bed
Cold therapy machine to left hip while in bed
Compression stockings
0.9% NS @ 100 ml/hr x 8 hrs then decrease to 40ml/hr
SCDs while in bed
Hemovac drain, may pull on post op day 2 if no drainage, notify me if still draining
Continue all home meds
Cefazolin 1 gram IV every 6 hours for 3 days
PTT, PT/INR, CBC, and Metabolic panel daily
Explanation / Answer
Joan must have disoriented at that particular night,and also developed anxiety ,so she must have hollers for the nurse repeatedly.
5a.the nurse must perform complete mental status examination,inorder to assess the presence and extent of a person's mental impairement.
5b. the interventions which to be taken are,regular vital signs monitoring,
provide comfort measures,
intake and output measuring,
assessing orientation of the client,
and providing psychological support.
the orders to anticipate from health care provider are,
VS every 4hours
clear liquid diet
physical therapy
continue all home meds
Nursing diagnosis;
1.Disturbed thought process as manifested by experiences in a disruption in mental activities as reality orientation,problem solving judgement.
nursing interventions;
*assess the mental status of the client
*reorient the client to the environment,time and persons.
*reassure the client regarding the prognosis of the condition
*maintain confidentiality with the client to gain confidence of the client.
2.Acute confusion as manifested by disturbances in attention,cognition,psychomotor activity and sleep/wake cycle.
nursing interventions;
*assess mood and affect,cognition and attention.
*Assess temperature,fluid electrolyte imbalances
*closely monitor lab reports.
*evaluate extent of disorientation,ability to follow directions and appropriateness ofresponse.
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