Multidimensional 1
Congotown
Jeanine_Porter_75-Year-Old_with_a_Total_Hip_ReplacementSTUDENT1.rtf4
Case Study
Copyright © 2017 by Mosby, an imprint of Elsevier Inc.
Copyright © 2017 by Mosby, an imprint of Elsevier Inc.
Ackley: Nursing Diagnosis Handbook, 11th Edition
Lecture Notes
Problem-Based Learning/Critical Thinking
Case Study - Jeanine Porter_75-Year-Old with a Total Hip Replacement
Case Scenario
Jeanine Porter is a 75-year-old woman who was admitted to the hospital after she fell at home and sustained an intracapsular fracture of the left hip at the femoral neck. She is widowed and lives with her daughter and son-in-law and their three children, ages 15, 12, and 4. She has a 50 pack-a-year smoking history and denies alcohol use. She has severe osteoarthritis of her knees and coronary artery disease (CAD). She underwent coronary artery bypass grafting (CABG) 9 months ago. Since her surgery, she has engaged in minimal exercises at home. Mrs. Porter underwent a total hip replacement. Her postoperative period was unremarkable, and she was transferred to the rehabilitation facility on her third postoperative day. She did well with her therapy and was discharged home after 10 days.
Nursing Assessment
At a home health visit 2 weeks after discharge, Mrs. Porter was in the living room, seated in a rocking chair. Her walker was across the room. The room smelled of smoke, and a significant amount of dust was evident on all of the furniture, as well as open bags of chips and several open soft drink cans. The floor was littered with toy trains and cars, and the sofa was full of unfolded, clean laundry. In the kitchen, the countertops and sink were loaded with dirty dishes, pots, and pans. Mrs. Porter said, “My daughter is really doing her best. I guess I am just too much for her…what with the children and all.” Mrs. Porter’s daughter replied, “I can handle it, I just don’t get any help from anyone, including my mother.”
ASSESS
- Identify the significant symptoms by underlining them in the above assessment.
- List the symptoms (those you have underlined) that indicate the client has a health problem.
- Group the symptoms that are similar.
DIAGNOSE
Do this by looking at the list of nursing diagnoses in, the nursing diagnosis book under course materials or nurselabs.com.
Possible nursing diagnoses:
Validate the possible nursing diagnoses.
Compare the signs and symptoms (defining characteristics) that you have identified from your client assessment with the defining characteristics for the nursing diagnosis that you have selected. Also read the definition and determine if this diagnosis fits this client.
Validated nursing diagnoses include:
- Write/select a nursing diagnostic statement for one of the nursing diagnoses by combining the nursing diagnosis label with the related to (r/t) factors. Resource: https://nurseslabs.com/nursing-diagnosis/" https://nurseslabs.com/nursing-diagnosis/
Example for formatting:
The complete nursing diagnostic statement is:
PLAN
- Develop 2 SMART Goals. (Specific, Measurable, Appropriate, Realistic, and Timely).
The client will:
Goal 1:
Goal 2:
IMPLEMENTATION/INTERVENTIONS
Goal 1: intervention 1 : intervention 2:
Goal 2 : intervention 1 : intervention 2:
EVALUATE
After putting into effect the nursing interventions, the results of the care should be evaluated by determining if the outcomes were met. If the outcomes are acceptable, the care plan is resolved. If the outcomes are not acceptable, further assessment should be done to answer the following questions:
Was the correct nursing diagnosis chosen?
Were the outcomes appropriate?
Were the interventions appropriate in this situation?
What other interventions might have been helpful?
Changes in the nursing diagnosis, outcomes, and interventions should be made as needed. This is continued use of critical thinking to ensure appropriate nursing care.
Goal 1 Evaluation:
Goal 2 Evaluation:
