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.