Assignment task:
Mrs. Ryan is a 75-year-old female who was admitted to the hospital 72 hours earlier because of a right hip fracture sustained while walking her dog. She is currently 36 hours status post (S/P) total right-hip replacement. She has a history of hypertension, no known drug allergies (NKDA), and full code status.
Mrs. Ryan's vital signs are T 36.6° C (97.9° F), P 84 and regular, R 20 and unlabored, and BP 164/90, with a pulse oximetry reading of 99% on room air (RA). She rates her pain as 8 of 10, located primarily at the surgical site when she moves in bed or tries to get up to go to the chair or bathroom. She states, "The pain is sharp and shooting from my hip to midcalf when I move too fast." She grimaces when changing position and is reluctant to move. The right hip incision is well approximated, with slight redness at the edges, no swelling, and minimal serosanguineous drainage on the dressing. Mrs. Ryan complains of weakness and fatigue while bathing or ambulating. Her Braden score is 20, and her Morse Falls Risk score is 80. Her hemoglobin and hematocrit are 10.5 and 36.9, respectively.
Treatment orders are as follows:
Vital signs q 4 hr., including neurovascular checks
Adult regular diet
Intravenous (IV) access saline lock
Bathroom privileges (BRP) and ambulation with assistance
Dry, sterile dressing to the incision site, change q 8 hr
Intake and output (I&O)
Encourage coughing and deep breathing (C&DB)
Incentive spirometry q 1 hr while awake
Knee-high anti-embolism stockings
Sequential compression devices (SCDs) while awake and in bed
Complete blood count (CBC) every morning
Medication orders are as follows:
Morphine sulfate: 4 mg intravenous piggyback q 4 hr PRN for severe pain
Lovenox: 60 mg subcutaneously q 12 hr for deep vein thrombus prophylaxis
Metoprolol: 50 mg PO bid for hypertension
List focused assessments with rationales that should be completed on Mrs. Ryan during her second postoperative day. Want Professional Help?
Write a short-term and long-term goal for this nursing diagnosis: Impaired Physical Mobility related to postoperative limitations as evidenced by a pain rating of 8 out of 10, grimacing with movement, and reluctance to move.
Identify at least four actions with rationales that should be taken to provide for Mrs. Ryan's safety and prevent her from falling.
Identify a minimum of five nursing interventions necessary to prevent postoperative complications of immobility.