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Clinical Reasoning

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INTRODUCTION Gemma is a 75 yr old female patient. She had her first Total Hip Replacement (THR) surgery due to arthritis. Although Gemma’s pathway appears to be quite normal according to the transition record, she has some issues need to be addressed. She is old, had a major surgery of trauma score 5 orthopedic, history of Asthma and hypertension, and high BMI. She needs to be monitored for complications since she is not only a surgical patient but also an orthopedic patient. The shift started at 1600 on post operation day one. The care plan for Gemma for the PM shift will employ clinical reasoning cycle: including nursing problems in order of priority, interventions with rationales and evidences, evaluations on Gemma’s performance. This…show more content…
The impact of fear of falling was greater one year post hip fracture suggesting, efforts to address fear should be ongoing long after the hip fracture occurs. (Resnick et al, 2007) PART B: 3 Highest Priorities Nursing Diagnosis for Gemma DISCUSSION: Considering Gemma is not only a surgical patient but also an orthopedic patient, the initial information a nurse needs to know should include respiratory, cardiovascular, neurological, urinary and wound assessments in order of priorities. Due to the complications and potential alterations in each function, the 3 highest priorities nursing diagnosis for Gemma would be 1) Breathing problems 2) Impaired balance of fluid volume and 3) Risks of Kidneys or Urinary system Infection 1. Breathing problems: To prevent potential complication of hypoxemia, a nurse needs to make sure airway clearance, breathing pattern, gas exchange and risk for aspiration. On RMO’s (Resident Medical Officer) examination after the surgery, Gemma’s temperature was 38.4/ RR 26/ O2Sats 95% and Oxygen maintained via Hudson at 6 liters a minute. BP was OK and both heart sounds were present. But there was a decreased air entry at the base of lungs and the right was greater than the left. CXR is organized and needs to discuss outcomes with surgeon. Continue with IV antibiotics and O2 Hudson
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