Nurses’ Notes: 0700 Tony Rivera, an 84-year-old that was admitted for left hip fracture. Surgical repair is scheduled for tomorrow. Past medical history includes 1-2 alcoholic beverages in the e
Nurses’ Notes: 0700 Tony Rivera, an 84-year-old that was admitted for left hip fracture. Surgical repair is scheduled for tomorrow. Past medical history includes 1-2 alcoholic beverages in the evening. No history of falls. Lives alone but has 2 adult children that live close. Client states pain is very uncomfortable; reported a pain level of 7 out of 10. Femoral and pedal pulses are 2+ bilaterally.
Vital Signs: 0700 BP 170/86, P 88, RR 24, T 99.1?F, SpO2 94% on room air
Medications: Oxycodone / acetaminophen 5 mg / 325 mg 1 – 2 tablets PO PRN 6 hours
Morphine sulfate 2 – 4 mg IV PRN 2 hours
1. Recognize Cues (Assessment)
a. What additional factors should the nurse include in the plan of care for this client? e.g., age, religious, nursing knowledge, literacy, or cultural preferences
b. What are the relevant factors contributing to the client’s condition?
2. Analyze cues (Analysis)
a. Identify potential client problems.
b. What potential complications is the client at risk for if the pain is not controlled?
3. Prioritize Hypothesis (Analysis)
a. What is the client’s primary problem? Provide rationale for your decision
b. What fndings require immediate follow-up?
4. Generate solutions (Planning)
a. What safety considerations should be included when planning care for this client? Fall risk (e.g., medication, age, mobility).
b. Identify two potential client outcomes.
c. What potential provider orders should the nurse anticipate?
5. Take actions (Implementation)
a. What actions should the nurse perform to address the client’s primary problem?
b. What education should the nurse provide for this client?
c. Self-care, health promotion, disease management (e.g., medication, diet, activity, ADLs).
d. What should the client be monitored for based on the nursing actions performed?
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