NR 325 Care Plan 2 Diagnosis
Student Name
Chamberlain University
NR-325 Adult Health II
Prof. Name
Date
Clinical iSBAR
Introduce Yourself
Your Name: GG
Your Title: RN
Reason for Being Here: To provide a comprehensive clinical handoff report and ensure continuity of patient care using the iSBAR communication framework.
S – Situation
Patient: AE
Age: 87
Gender: Female
Height/Weight: Not documented
Allergies: No known drug allergies (NKDA)
Code Status: Full Code
Attending Physician: Dr. Limperis
Patient Chief Complaint: Right hip fracture due to a mechanical fall at home, accompanied by nasal bone fracture.
B – Background
The patient has a complex medical history that contributes to her current health status. She sustained injuries following a fall, which resulted in a right hip fracture and a nasal bone fracture. She has a documented history of multiple chronic conditions, including hypertension, hyperlipidemia, and anemia, with a current medication regimen that includes aspirin, cephalexin, Lipitor, and ferrous sulfate.
Past Medical History: Not fully detailed in the chart but significant for cardiovascular disease and anemia.
Social History: Unknown marital status, no documentation of tobacco, alcohol, or illicit drug use.
Current Medications: Aspirin, Cephalexin, Lipitor, Ferrous Sulfate.
A – Assessment
| Vital Signs | BP | HR | RR | Temp (°F) | SpO₂ | Pain (0–10) |
|---|---|---|---|---|---|---|
| Reading 1 | 111/56 | 119 | 20 | 97.2 | 97% | 6 |
| Reading 2 | 151/80 | 105 | 18 | 96.9 | 96% | 7 |
Falls Risk: Yes (high risk)
IV Site: Saline lock in place; no fluids currently infusing
Accu-Chek: Yes (daily monitoring)
Isolation Precautions: None required
Respiratory: Clear and equal bilateral breath sounds; patient encouraged to use incentive spirometer post-operatively
Cardiovascular: Blood pressure fluctuations noted; requires close monitoring
Neurological: Weakness in the right lower extremity secondary to fracture; alert and oriented ×3
GI/GU: Constipation likely secondary to opioid use; urinary incontinence present
Integumentary: Skin dry and pink; no open wounds observed except surgical incision site
Psychological: No documented family support; appears cooperative but fatigued
R – Request/Recommendation
Handoff report should be provided to the incoming nurse with emphasis on:
- Pain control
- Monitoring for post-surgical complications
- Bowel management plan to address opioid-induced constipation
- Blood pressure and heart rate monitoring due to instability
Reason for Admission
The patient was admitted following a fall at home resulting in a right hip fracture and nasal bone fracture. She is currently recovering post-operatively and undergoing physical rehabilitation to regain mobility.
Medical Orders Summary
| Order | Rationale |
|---|---|
| Cardiac diet | Reduces cardiovascular strain and manages hypertension risk |
| Ambulate with assistance | Minimizes fall risk while promoting recovery |
| Monitor bowel movements | Addresses constipation risk from Norco use |
| Vital signs every 4 hours | Detects blood pressure and heart rate fluctuations |
| Daily blood glucose checks | Monitors elevated glucose levels in diabetic patient |
| CBC/BMP daily | Tracks electrolytes, kidney function, and infection markers |
| Physical therapy | Restores strength and mobility following hip fracture |
Recent Lab Results
| Date | Lab Test | Result | Normal Range | Comment |
|---|---|---|---|---|
| 7/3 | Sodium (Na) | 138 | 135–145 | Normal |
| 7/3 | Potassium (K⁺) | 3.6 | 3.5–5.0 | Normal |
| 7/3 | Chloride (Cl) | 110 (H) | 97–107 | Elevated, likely dehydration |
| 7/3 | CO₂ | 22 (L) | 23–29 | Low due to dehydration |
| 7/3 | Glucose | 139 (H) | 70–99 | Hyperglycemia, diabetic history |
| 7/5 | WBC | 12.7 (H) | 4.5–11.0 ×10³/µL | Possible infection |
| 7/5 | Hemoglobin | 10.2 (L) | 12.0–15.5 | Anemia present |
Medications
(Example entry shown; all medications reformatted in similar table style for clarity)
| Generic / Brand Name | Class | Dose Ordered | Indication | Route / Frequency | Adverse Effects | Nursing Considerations |
|---|---|---|---|---|---|---|
| Cephalexin / Keflex | Anti-infective | 500 mg | Post-surgical infection prevention | Oral q6h | GI upset, rash, seizures | Monitor for allergic reaction, assess wound site |
Nursing Care Plans
1. Acute Pain
Related to: Hip fracture
As evidenced by: Patient reports pain, guards affected area
Goals: Patient will verbalize reduced pain within 24 hours
Interventions:
- Maintain immobilization of the right hip
- Elevate and support the injured extremity
- Provide pain medication as prescribed and monitor effectiveness
- Encourage relaxation techniques
2. Impaired Skin Integrity
Related to: Physical immobilization
As evidenced by: Skin redness at pressure points
Goals: Maintain intact skin throughout hospitalization
Interventions:
- Reposition every 2 hours
- Inspect skin for breakdown daily
- Use pressure-relieving devices
3. Impaired Physical Mobility
Related to: Pain and weakness
As evidenced by: Limited range of motion and decreased muscle strength
Goals: Patient will demonstrate improved mobility with assistance by discharge
Interventions:
- Encourage active and passive range of motion
- Assist with physical therapy sessions
- Support safe ambulation with assistive devices
NR 325 Care Plan 2 Diagnosis
References
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). ANA.
Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2023). Fundamentals of nursing (11th ed.). Elsevier Health Sciences.
NR 325 Care Plan 2 Diagnosis
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2020). Brunner & Suddarth’s textbook of medical-surgical nursing (15th ed.). Wolters Kluwer.