1.

Risk for ineffective breathing

pattern
- Morphine PCA
- Increased age
- post-operative (Total Hip)
- general anesthesia
- RR 20, HR 74, O2 96%
- incentive spirometer
- anxiety r/t rejected from
desired rehabilitation facility

3. Risk for ineffective tissue

perfusion (CMS)
- Edema BLE: right +3, left
+2
- cap refill < 3 sec BLE
- skin warm to touch BLE
- peripheral pulses equal, bil
- skin color normal for race
- no c/o paresthesias
- full ROM left ankle and toes
- full ROM right ankles and toes
- SCDs intermittently BLE
- negative Homans sign
- no tenderness/redness/pain to
calves
- no palpable cords

6. Impaired tissue integrity

- R femur fx with ORIF: fixator pins +
sutures
- reddened, intact, blanchable, circular
(stage I) pressure ulcer, 2 mm in
diameter
- no albumin/prealbumin levels drawn
- decreased PO intake
- dislikes hospital food
- decreased mobility
- wedge for positioning; change
positions q2h

Chief Diagnosis: R femur fracture

with ORIF
Priority Assessments: Risk for
ineffective breathing pattern, acute
pain, risk for altered CMS, risk for
infection, risk for bleeding, impaired
tissue integrity

4. Risk for infection

- R femur fx with ORIF
- temp 98.7 tymp
- orthopedic fixator pins
- hx HTN, DM II
- sutures
- Glucose 139
- indwelling urinary catheter
- Basophils
0.8
- WBC 13.2
- Eosinophils 3.9
- Lymphocytes 77.3
- Monocytes 11.5
- no coughing
- urine clear, yellow
- PO prednisone 10 days
- flu shot at discharge
- no weight loss
- wound care
teaching
- IV cefazolin 10 days

2. Acute pain
- R femur fx with ORIF
- decreased mobility
- edema to lower
extremities
- morphine PCA
- PRN Tylenol
- PRN oxycodone
- with morphine PCA: 2/10
at rest; 4/10 with activity
- without morphine PCA:
2/10 at rest; 8/10 with
activity

5. Risk for bleeding

- hx aspirin 81 mg QD 3
years
- R femur fx with ORIF
- RBC 3.12
- H&H 10.2 & 29.9
- Platelets 189
- PT 13.7
- INR 1
- PTT 33
- no occult blood, no
hematuria
- no hematoma, no
increased edema, no
increased inflammation
to any body part, nor
surgical site
- GCS 15; no rebound
tenderness to abd; abd
soft, non-distended

Desired Outcomes
Risk for
ineffective
breathing pattern
1. The patient will
maintain an
effective breathing
pattern, as
evidenced by
relaxed breathing
at normal rate and
depth and absence
of dyspnea.

Acute pain
1. Patient reports
satisfactory pain
control at a level
less than 3 to 4 on a
0 to 10 scale.

Risk for
ineffective tissue
perfusion (CMS)

Interventions
Risk for ineffective breathing pattern
1. Assess respiratory rate, rhythm, and depth.
2. Assess for use of accessory muscles.
3. Monitor pulse oximetry arterial blood gases as appropriate.
Note changes.
4. Instruct patient not to allow others to push PCA button.
5. Monitor breathing patterns: bradypnea, tachypnea,
hyperventilation, kussmauls respirations, cheyne-stokes
respiration, apneusis, biots respirations, ataxic patterns.
6. Position the patient with proper body alignment for optimal
breathing pattern.
7. Maintain oxygen saturation at or above prescribed order:
92%.
8. Encourage sustained deep breaths by using incentive
spirometer.
Acute pain
1. Anticipate the need for pain relief
2. Respond immediately to complaint of pain
3. Eliminate additional stressors or sources of discomfort
whenever possible
4. Assess pain characteristics: quality, severity, location, onset,
duration, precipitating or relieving factors.
5. Observe or monitor s&s associated with pain, such as BP,
heart rate, temperature, color and moisture of skin,
restlessness, and ability to focus
6. Assess for probable cause of pain
7. Assess patients knowledge of or preference for the array of
pain relief strategies available
8. Give analgesics as ordered, evaluating effectiveness and
observing for any signs and symptoms of untoward effects
Risk for ineffective tissue perfusion

1. Assess and compare neurovascular status of all extremities

after surgical reduction of fracture
1. Patient maintains 2. Assess the affected extremity q1-2h for signs of neurovascular
optimal tissue
compromise and damage: skin temperature, capillary refill of
perfusion, as
nail beds, skin color, peripheral pulses, paresthesias, ROM,
evidenced by warm
pain.
extremities, good
3. Assess for symptoms of fat embolism
color, good
4. Elevate extremity, and apply ice packs after ORIF
capillary refill,
5. Apply sequential compression devices as ordered
absence of pain and 6. Instruct the patient in symptoms of fat embolism: a sense of

numbness, and
bilaterally strong,
palpable pulses.
Risk for infection
1. Patient remains
free of infection, as
evidenced by
normal vital signs
and absence of
purulent drainage
from wounds,
incisions, and
tubes.

Risk for bleeding

1. Patient will
remain free from
unusual bleeding.

Impaired tissue
integrity
1. Patients tissue
will return to
normal structure
and function.

impending doom, chest pain, s&s of shock, including

tachypnea, tachycardia, hypoxia, confusion, or disorientation.
The patient may manifest a rash over the chest from below
the nipple line up to the neck and/or conjunctiva.
Risk for infection
1. Assess for presence, existence of, and history of risk factors
such as open wounds and abrasions; indwelling catheters,
orthopedic fixator pins, and sutures
2. Monitor WBC count
3. Monitor for signs of infection: redness, swelling; increased
pain; purulent drainage from incisions, and catheters;
elevated temperature; appearance of urine.
4. Assess nutritional status
5. Assess for use of medications (prednisone) that may cause
immunosuppression
6. Assess immunization status
7. Maintain and teach asepsis for dressing changes and wound
care, catheter care and handling, and peripheral IV and
central venous access management.
8. Administer antibiotic drugs as ordered
Risk for bleeding
1. Monitor for bleeding. Check color of urine, occult blood in
stool, and/or changes in vital signs.
2. Monitor PT, PTT, INR for normal/therapeutic values.
3. Monitor H&H.
4. Monitor vital signs, especially pulse and blood pressure.
5. Monitor for safe administration and monitoring of medication
(aspirin).
6. Monitor all potential bleeding sites: IV site, indwelling
catheter, brain (ICP), abdomen, surgical site, etc.
7. Monitor respiratory status.
Impaired tissue integrity
1. Determine the etiology of tissue damage.
2. Assess condition of tissue.
3. Assess characteristics of the wound, including color, size,
drainage, and odor.
4. Assess the patients level of discomfort.
5. Provide skin care as needed
6. Turn patient at least q2h.
7. Administer aseptic wound care
8. Encourage diet that meets nutritional needs

Evaluation:
The patient was on a morphine PCA, and was at risk for ineffective breathing patterns. The
patient has maintained an effective breathing pattern, as evidenced by relaxed breathing at
normal rate and depth and absence of dyspnea, during my shift. The patients respirations
were 20 and normal at rest, with no use of accessory muscles or extra effort. The patients
O2 saturations were recorded at 96% at rest, and incentive spirometer use was taught and
encouraged. The goal was met during my shift.
The patient was post-operative for a R ORIF, and the patient was in acute pain. On POD 1
the patient reported satisfactory pain control at a level of 2 at rest on a 0 to 10 scale, and a
level of 4 during activity with the PT team on a 0 to 10 scale. The patient used the morphine
PCA pump before, during and after physical therapy. No further medications were
requested on the first day. On POD 2, the patient requested to discontinue the PCA pump,
and PO oxycodone was offered and administered before physical therapy with a pain level
of 2 at rest and a level of 8 during activity. The goal was met during the first day, and the
goals was partially met on the second day, as the patient no longer had access to the
immediate pain relief of the PCA pump.
The patient was at risk for neurovascular compromise / impaired tissue perfusion. The
goal was met during my shift, as the patient maintained optimal tissue perfusion, as
evidenced by warm extremities, good color, good capillary refill, absence of pain and
numbness, and bilaterally strong, palpable pulses. There was no evidence of redness to the
calves or other extremities and the patient was negative for the Homans sign.
The patient was at risk for infection a/w R ORIF, and during my shift the goal was met. The
patient remained free of infection as evidenced by normal vital signs and absence of
purulent drainage from wounds, incisions, and tubes. I also discontinued the patients
indwelling urinary catheter on POD 2, as ordered. This also decreased the patients risk for
infection. The patient received PO steroids to reduce swelling, which is an
immunosuppressor that increases the patients risk for inability to combat pathogens and
cause infection; however, as stated above the patients VS maintained within normal limits
and the patient had no complaints of HA, dizziness, or other signs of infection. The patients
WBCs were high and the H&H was slightly low, which is consistent with blood loss and
inflammation r/t surgery.
The patient was at risk for bleeding associated with R ORIF. The patients urine was clear
and yellow, the patient did not have a BM during my shift, and the patients wounds (R
femur and coccyx pressure ulcer) were not actively bleeding. The patients PT, PTT and INR
were within normal limits as the patient only started taking PO aspirin on POD 2. The
patients H&H was slightly low and consistent with post-operative surgery a/w blood loss.
The patient had no active bleeding in general, GCS was 15, the patient had no c/o
abdominal pain, and the patient had no rebound tenderness nor hematomas anywhere on
the body. The patients respiratory status was steady throughout both days of care. The
goal was met during my shift.

The patient had impaired tissue integrity, with an intact, stage I pressure ulcer on the
coccyx and R ORIF with sutures, fixator pins, and sutures with a dressing. The goal that the
patients tissue will return to normal structure and function was partially met during my
shift, and will be completely met when both wounds are completely healed (3-14 days for
the pressure ulcer and at least 6 months for the right hip incision). The pressure ulcer
occurred from decreased mobility associated with post-operative pain/anticipation of pain
and obesity. The incision to the right hip is associated with an open-reduction internal
fixation. The pressure ulcer was intact, slightly reddened, circular in shape, with a diameter
of 2 mm. The wound was 5 inches in length, well approximated, sutures intact, decreasing
edema and no redness. The patient was taught how to care for the wound and how long
healing would occur before the patient is able to resume water sports, as the patient
enjoys this activity. The patient was also encouraged to eat adequate amounts of protein to
promote wound healing, and the patient asked her family and friends to bring desirable
foods because the hospital food was not to the patients liking.
Discharge Planning:
The patient anticipated going to a specific rehabilitation facility on the island; however,
during physical therapy on POD 2 the patient was unable to perform the ordered activities
(standing, walking to chair) and the patient was informed that her progress deemed her
incompatible with the rehabs physical therapy regimen. The patient was quite anxious
about this, and was referred to the case manager. After about 2-3 hours, the case manager
spoke with the patient about other options and the patient became satisfied with the case
managers response. The case manager determined that the patient was able to stay at the
SNF associated with the hospital. The patient was to be discharged to that SNF for 1-2
months, depending on the patients specific healing time.
The patient has a husband, who visits daily. Both the patient and her husband are retired,
and have close friends who also visit often. These people brought desired foods for the
patient after she expressed her dissatisfaction of the food selection in the hospital. The
friends and family will continue to offer support when she transfers to the SNF for rehab
and to home.
The patient requires assistance with ADLs, especially turning, ambulating, and toileting.
Assistance will be provided at the SNF until further healing occurs and the patient will be
expected to do these tasks independently again.
The occupational therapy team taught the patient how to use devices to assist with ADLs.
The patient already has some of these devices (back scratcher) r/t hx of bil knee
replacements. Further teaching will occur during rehabilitation at the SNF.
The patient does not have a walker at home, but the SNF will have a walker for assistance
in ambulation during rehabilitation. It is expected that the patient will not need a walker
after healing, as she did not require a walker before the injury (R femur fx).
The patient is cooperative and is receptive to teaching. The patient is also a retired nurse,
who remembers many aspects of nursing when taught to her. The patient used the call light
during my shift when assistance was needed (to urinate, etc.). Teaching was provided

regarding s&s of bleeding, infection, fat embolism, pulmonary embolism, DVT/VTE and
impaired tissue perfusion (neurovascular compromise). The patient was also instructed to
notify the MD regarding increasing pain, swelling, or edema not relieved by medications.