The RN is developing a plan of care for an 86-year-old patient who was admitted after falling at home. The patient is confused to place and time and has a right hip fracture that will be repaired tomorrow. The patient has an intravenous infusion of normal saline infusing at 100mL per hour, and is NPO after midnight. The patient’s vital signs are stable. The RN has included these nursing diagnostic labels in the plan of care: Initial Discussion Post:
Nursing Diagnosis Labels and Plan of Care for an 86-Year-Old Patient with Confusion and a Right Hip Fracture
In order to effectively address the needs of the 86-year-old patient who has been admitted after a fall at home and is experiencing confusion and a right hip fracture, the registered nurse (RN) has developed a plan of care. The plan of care includes nursing diagnostic labels, which are essential for identifying the patient’s health problems and guiding the interventions and outcomes of nursing care. This discussion post will analyze the nursing diagnostic labels included in the plan of care and discuss the rationale behind them.
The first nursing diagnostic label included in the plan of care is “Confusion related to cognitive impairment as evidenced by disorientation to place and time.” This diagnosis identifies the patient’s confusion as the main health problem. The underlying cause of the confusion is cognitive impairment, which is evident from the patient’s disorientation to place and time. This diagnosis is crucial as it helps direct nursing interventions and enables the RN to monitor and evaluate the patient’s progress in addressing this issue.
The second nursing diagnostic label included is “Risk for falls related to confusion and impaired mobility.” This diagnosis recognizes the increased risk of falls associated with the patient’s confusion and impaired mobility resulting from the right hip fracture. The hip fracture may result in difficulties with balance and stability, making the patient vulnerable to falls. This diagnosis is important as it prompts the RN to implement measures to prevent falls, such as close patient supervision, frequent reorientation, and the use of assistive devices like walkers or handrails.
The third nursing diagnostic label included is “Acute pain related to right hip fracture as evidence by reports of pain and observation of guarding behavior.” This diagnosis acknowledges the presence of acute pain as a result of the right hip fracture. The patient’s self-report of pain and the observation of guarding behavior provide evidence for this diagnosis. In addressing this issue, the RN can administer appropriate pain medications, provide comfort measures, and assess the effectiveness of pain management interventions.
The fourth nursing diagnostic label included is “Deficient knowledge related to hospitalization, surgery, and post-operative care as evidenced by questions and requests for information.” This diagnosis highlights the patient’s lack of knowledge regarding the hospitalization process, surgery, and post-operative care. The patient’s questions and requests for information indicate this deficiency. By recognizing this diagnosis, the RN can prioritize patient education, ensuring that the patient understands the upcoming surgical procedure, the post-operative recovery process, and any necessary self-care measures.
The fifth nursing diagnostic label included is “Risk for impaired skin integrity related to immobility and altered mental status.” This diagnosis acknowledges the heightened risk of skin breakdown as a result of immobility and the patient’s altered mental status. Due to the hip fracture and confusion, the patient may have difficulty repositioning themselves or may not be aware of discomfort or pressure on the skin. To address this issue, the RN can implement preventive measures, such as frequent turning and skin assessments, as well as providing appropriate support surfaces.
In conclusion, the RN has developed a comprehensive plan of care for the 86-year-old patient with confusion and a right hip fracture. The nursing diagnostic labels included in the plan serve as essential guides for addressing the patient’s health problems and implementing appropriate nursing interventions. By recognizing the patient’s confusion, risk for falls, acute pain, deficient knowledge, and risk for impaired skin integrity, the RN can ensure comprehensive care, promote patient safety, and facilitate a positive recovery outcome.