Surgical Patient Patient: S.N.94 year old female sustained a fall…

Question Surgical Patient Patient: S.N.94 year old female sustained a fall… Surgical Patient Patient: S.N.  94 year old female sustained a fall at home. S/P ORIF L hip. Medical hx: CAD, HTN, mild dementia, cataracts, arthritis. Surgical hx: Cholecystectomy many years ago. She is 2 days post operative, presents A/O x 3 with periods of confusion/sundowning. Foley catheter removed 8am today.Left hip appears reddened, very warm to the touch, 23 staples in place. Last Bowel movement 3 days ago. Spo2 is 97%. WBC is WNL. Patient screams “Leave me alone! Get out of here!” when she needs to be repositioned or washed. Orders:Diet-2gm sodiumNKDA(Ultram)Tramadol Hydrochloride 50mg oral Q 6H(MiraLax)Polyethylene Glycol 17 grams dissolved in 4-8oz beverage HS time one dose(Tylenol) Acetaminophen650 mg PO Q 6H PRN temp > 101.0Norvasc)Amlodipine Besylate 5mg oral once a day(Keflex)Cephalexin 500 oral Q12H for 7 daysLeft IVLOC 24g  flush with 3-5ml Sodium Chloride q shift.Treatment: Cleanse surgical area with Normal Saline, apply Betadine solution, cover with dry protective dressing twice a day. Assess and document. Bathe with chlorhexidine dailyVitals: T 101.4 P90 R 20 BP 156/90Pick ONE NANDA DX: Impaired mobility, Self-care deficit, chronic confusion or Risk for Fall(must be a dx that you have not done before, each week will be a new dx for you).At the bottom of the care plan page type your SBAR. You are calling the MD/APN because of the pts increased confusion/uncooperative. Use the correct format as shown.S:B:A:R: Health Science Science Nursing Share QuestionEmailCopy link Comments (0)