Please answer: alteration in health(diagnosis), pathophysiology related to client's problem, health promotion and disease prevention, risk factors, expected findings, laboratory tests, diagnostic procedures, safety considerations, nursing care, therapeutic procedures, medications, client education, interprofessional care and complications using the below case study.
Mr. Shirley Grace a 68 year old Female, single and lives alone, and presents with chief complaints of pain to left hip, radiating to left leg rating pain level "11" on the numeric scale 0 – 10. Client is currently admitted with a medical diagnosis of Left Hip Fx. On this admission, client reports medical h/o HTN, CAD, Obesity, DM, Chronic pain > 3 months to left Hip, Hyperlipidemia (HLD), smoke one pack cigarette a day, client denies elicit drugs and alcohol. Client Denies Claudication and paresthesia symptoms at the affected site.
Current medications: Oxygen 2 liter via N/C, continuous
Metoprolol Tartrate 25 mg 1 tab oral two time
Heparin injectable 5,000 unit subcutaneous every 12 hours
Insulin Garglene injectable (Lantus) 20 unit Subcutaneous at bedtime
Pantoprazole 40 milligrams 1 tablet oral every day
Simvastatin 10 my 1 tab oral daily at bedtime
Meds PRN
Acetaminophen 325 mg 2 tabs oral every 6 hours as PRN (needed )(1 – 3)
Hydromorphone injectable 1 mg IVP every 6 hours PRN (as needed) (7 – 10)
Oxycodone 5 mg/Acetaminophen 325 mg 2 tabs oral every 4 hours PRN (as needed) 4 – 6.
Physical assessment findings: Ms. SG appears anxious, moderately dyspneic at rest. Color WNL for ethnicity
Vital signs (V/S) B/P 130/80, HR. 110, R. 22. oxygen oxymetry: 92% in 2 L via N/C
ABG: PC02 45, PAO2 92%, PH 7.38
Weight: 170 Lbs, height: 5.4
Labs: On admission Peak Flow Rate (PFR) 60% which indicates mild dyspnea. Lungs clear on auscultation
CBC: Hemoglobin 14 and Hematocrit 45 (H/H) 16/49, WBC: 5,000.
Review of system information (ROS):
Neurological: Alert and oriented to time, place, and person. Good historian
Respiratory: Mild Dyspnea
Breath sounds: inspiratoty = expiratory, and on auscultation
Adventitious sounds: None findings bilaterally
Cardiovascular: Heart rate 110 strong and regular
Jugular venous distention: Negative on assessment
Peripheral edema 2 +
Elimination Pattern
Gastro intestinal (GI): Abdominal soft. nondistended
Bowel sounds present in all four quadrants
Bowel habits: Consistent. Last BM: 9/16/2022: Stools characteristics: Firm
Genitourinary (GU): As per patient states, no abnormality upon urination. Void frequently, color: Clear yellow urine
Mobility: Mobile with unsteady gait
Integumentary (skin): Dry, warm, and intact
Skin color: WNL for etvhnicity
Diet: 2 grams sodium as ordered
Oral fluids: No restrictions
