Problem
A 76-year-old white male named John Doe (JD) with a past medical history of HTN, HLD, GERD, moderate dementia, and chronic back pain status post-CT 3 through 6 (laminectomy). The wife is the primary caregiver.
JD presented to the emergency department on Aug. 01, with a chief complaint of a mechanical fall at home with right thigh and shoulder pain. JD fell while putting on his clothes today, has no LOC, and has been at his baseline health for the past few weeks. Over the past few months, JD has been deteriorating with weakness, weight loss, dysphagia, and also dementia, which was diagnosed last December. He has extensive without for these symptoms with PCP, GI, and ENT, but no cause was found, and he was sent to PT for his deconditioning. No prior cardiac or lung diseases. Outpatient prescriptions for atorvastatin, lisinopril, quetiapine 25 qhs started last February, donepezil, memantine, gabapentin 100 twice daily, and Celebrex, which appear to be JD's chronic daily medications.
In the emergency department, blood pressure was initially 153/90, heart rate 67, respirations 18, saturating 97% on room air. Labs showed WBC of 14.95, otherwise unremarkable CBC. BMP with normal electrolytes and creatinine of 1.28, slightly up from JD's baseline of 1.1. LFTs unremarkable. Hip and pelvis x-rays showed diffuse osteopenia but evidence of the right femoral neck fracture. The case was discussed with orthopedics, who planned for OR in the morning. ECG showed sinus rhythm at 66. In the emergency department, JD was given a single dose of oxycodone.
JD's admitting diagnoses are a fracture of the neck of right femur, chronic pain, history of laminectomy, HTN, HLP, and dementia.
Labs:
WBC: 19.62 (Aug 02) → 13.67 (Aug 03)
RBC: 4.54 (Aug 02) → 4.15 (Aug 03)
Hgb: 14.6 (Aug 02) → 13.3 (Aug 03)
Hct: 43.1 (Aug 02) → 39.7 (Aug 03)
Plt: 220 (Aug 02) → 207 (Aug 03)
Na: 140.0 (Aug 02) → 137.0 (Aug 03)
K: 4.9 (Aug 02) → 4.6 (Aug 03)
CO2: 24.7 (Aug 02) → 22.9 (Aug 03)
BUN: 23 (Aug 02) → 18 (Aug 03)
Crt: 1.28 (Aug 02) → 1.23 (Aug 03)
Glucose: 142 (Aug 02) → 127 (Aug 03)
A. What CONCEPT will you focus on based on patient JD's primary problem or nursing priority?
B. INTERRELATED CONCEPTS: What secondary or collaborative information relates to the primary problem?
C. INTERPRETING: What clinical data from the chart is RELEVANT that needs to be trended (interpreting) because it is clinically significant?
D. RESPONDING: What nursing priority(s) will guide your plan of care?
E. What nursing interventions will you initiate based on this priority(s)?
F. What are the desired outcomes?
G. REFLECTION: What is the worst possible/most likely complication(s) to anticipate today with patient JD?
H. REFLECTION IN ACTION: What nursing assessments will you need to initiate to identify this complication if it develops?