HIP DISLOCATION
Name
Date
Background information:
Age: A.G Gender: MALE Ethnicity: AFRICAN AMERICAN Religion: BAPTIST
Occupation: RETIRED
Code Status: FULL CODE Allergies: BENAZEPRIL HCL and AMLODIPINE BESYLATE
Presenting symptoms (include history of present illness)
DISLOCATION OF HIP JOINT PROSTHESIS (Right Hip)
Past Medical History
HYPERTENSION
AVASCULAR NECROSIS OF BOTH HIPS
Past Surgical History
HIP SURGERY- BILATERAL HIP REPLACEMENT OF BOTH HIPS
-123825-390525Physiologic
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Neurologic:
Cardiovascular
Respiratory
Gastrointestinal
Urinary
Musculoskeletal
Integumentary
Reproductive
00Physiologic
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Neurologic:
Cardiovascular
Respiratory
Gastrointestinal
Urinary
Musculoskeletal
Integumentary
Reproductive
Primary diagnosis: physical therapy;
Secondary Diagnosis: Total hip replacements; implants
Pathophysiology
Prescribed medications at home:
Generic & trade name
& classification of medication Dose/route Frequency Purpose
GEeneric name:
Phenylbutazone
Trade name:
Cotylbutazone
1-2 months depending on the severity of injury 2 tablet 2 times daily Relieving pain
Medications ordered this hospitalization:
Generic & trade name
& classification of medication Dose/route Frequency Reason administered
to this client Effects of medication
on this client
.) Ondansetron Hcl. Zofran injection 4mg
.) Acetaminophen. Tylenol
.) Valsartan. Diovan
.) Al Hydrox/ Mg Hydrox/ Simethicone. Maalox
.) Mupirocin Bactroban Nasal 2%. Ointment
.) Magnesium Hydroxide. Milk of Magnesia
.) Hydromorphone Hcl. Dilaudid
.) Hydrochlorothiazide. Hydrodiuril 4mg IV
650mg PO
160mg PO
15ml PO
1 gm NS 2000 ONE
30ml PO
0.5mg IV
12.5mg PO Q8HR PRN
Q6HR PRN
QDAY SCH
Q6HR PRN
DAILY PRN
Q3HR PRN
QDAY SCH For Nausea and Vomiting
Temperature greater than 105
For upset stomach/indigestion
For constipation
For Pain Dizziness
Activity
Pain relief
Diarrhea
Insomnia
Irritation
Diagnostic studies:
Test & definition Initial admission test results &
date performed Significance of results
to client’s condition Most recent test results (if test repeated) & date performed Significance of repeated test results to client’s condition
Physical therapy
Surgery
10/09/2012
12/09/2012
Pain relieving
Treatment Test not repeated
Test not repeated Not applicable
Not applicable
Based on your assessment data and the chart above, identify as many problems as possible, for example: Pain, Anxiety, Infection. (List Below)
1. Confusion
2. Panicking
3. Asthenia
4. Depression
5. Bone pain
6. Joint pain
7. Headache
8. Severe skin reactions
9. Dyspepsia
10. Bone loss
Based on the problems you have listed, identify the top three problems, and prioritize them.
Severe skin reactions
Depression
Bone pain
Using the problem with the highest priority, identify an appropriate nursing diagnosis based on NANDA and develop a Care Plan for your client.
Prioritize 3 nursing diagnoses for your client and write a plan or care.
#1. Nursing Diagnosis
Related to: Severe skin reactions
As evidenced by: Diagnosis process of the Hip dislocation
Subjective data: Primary diagnosis
Objective data: Secondary diagnosis
Goal: Permanent and long lasting remedy to the three prioritized effects
Expected Client Outcome
(in behavioral terms, time referenced, measurable) “Client will. . . “ Prioritized Interventions: Rationale(s) for Interventions Evaluation of Client Outcomes:
(state date achieved)
Then client will be relieved from pain, recover and be discharged after a rigorous treatment for a period of two months. The diagnosis will be done at a very slow rate to ensure that the patient is fully treated. Giving a combination of physical therapy and recommended drugs to the patient Perpetually mitigating the conditions On 07/10/2012, the patient fully recovers.
All the problems solved
#2. Nursing Diagnosis
Related to: Depression
As evidenced by: Nurse
Subjective data: Primary diagnosis
Objective data: Secondary diagnosis
Goal: To permanently relieve the patient from depression
Expected Client Outcome
(in behavioral terms, time referenced, measurable) “Client will. . . “ Prioritized Interventions: Rationale(s) for Interventions Evaluation of Client Outcomes:
(state date achieved)
The patient is to be mentally stable and regain full consciousness after a two week therapy (French, Linda M. and Dietz, F., 2004). Counseling therapy to be carried out. The patient will be seriously counseled on the best steps to take in order to lead a more comfortable life.
The patient fully recovers on 1/10/2012
#3. Nursing Diagnosis
Related to: Bone pain
As evidenced by: The nurse
Subjective data: Primary therapy
Objective data: Secondary therapy
Goal: To solve the problem of bone loss
Expected Client Outcome
(in behavioral terms, time referenced, measurable) “Client will. . . “ Prioritized Interventions: Rationale(s) for Interventions Evaluation of Client Outcomes:
(state date achieved)
The patient is expected to recover within one month Use of pain relieving drugs: Acetaminophen Hydrocodone and
Acetaminophen Tramadol Floyd, R.T., 2009). Permanently relieving bone pains from the patient The patient fully recovers on 6/10/2012.
References
Floyd, R.T. (2009). Manual of structural kinesiology. New York, NY: McGraw-Hil
French, Linda M. and Dietz, F. (2004) Screening for Developmental Dysplasia of the Hip. American Academy of Family Physicians.
