Question

Sue is an 82-year-old woman, who is being admitted to the...

Sue is an 82-year-old woman, who is being admitted to the medical-surgical unit for severe leg pain. The client reports that her lower left leg has been increasingly painful for several weeks and today she fell and injured her left hip. The client is 64 inches tall and weighs 220 lbs; body mass index (BMI) of 37.8. There is shortening of the left leg with external rotation and a large amount of swelling at the proximal thigh and hip. Sue is oriented to people only and states "my leg hurts badly."

Blood Pressure; 100/65 mmHg

Heart rate; 108 bpm

Respirations; 22 breaths/min

Temperature; 97.5 F

Oxygen; 90% RA


Past Medical History:

Hypertension, diabetes, obesity, and osteoporosis.

Sue is usually alert to herself and lives with her son. She is a retired school teacher, widowed and has two sons.



Question

Based on the above senario what could be the Potential condition, nursing Priority action to take and Parameter to Monitor ?

Answer 1

Sue likely has a hip fracture, necessitating stabilization, pain management, and preparation for surgery. Nursing priorities are monitoring vital signs, particularly blood pressure and heart rate, and preventing complications. Parameters like oxygen saturation and level of consciousness should also be monitored closely.

Step-by-step explanation:

Sue, an 82-year-old woman with a history of hypertension, diabetes, obesity, and osteoporosis, presents with severe leg pain, a fall with injury to her left hip, and symptoms including leg shortening and external rotation, swelling, and pain. Her vital signs show low blood pressure, tachycardia, tachypnea, low-grade fever, and decreased oxygen saturation. The clinical presentation suggests a potential hip fracture, which is a common injury in elderly people with osteoporosis and can be life threatening due to complications from immobility.

Nursing Priority Action

The nursing priority action for Sue would be to stabilize her cardiovascular status, manage pain, and prevent complications. This includes administering oxygen to maintain oxygen saturation, pain management, immobilizing the affected limb, monitoring vital signs closely, particularly blood pressure and heart rate, and preparing for likely surgical intervention.

Parameters to Monitor

Parameters to monitor include Sue's pain level, vital signs including blood pressure and heart rate, respiratory rate, oxygen saturation, temperature, level of consciousness, and any signs of complications, such as venous thromboembolism, pneumonia, or pressure sores.