1.

Assessment

General Information.

Patient Initials: L.P

Gender: Female

Age: 55

Allergies

Food: Shellfish, Seafood, Gluten

Medications: Levofloxacin, Anafranil, ASA-aspirin(Stomach ulcer).

IYM Status: 1PA

Diet: High Protein, High Calorie, Minced Diet, Ensure +235ml Daily Calorie Counts

Health History & Current Medical Diagnosis.

 COPD
 HTN
 IBS **
 Depression
 Deaf-Left ear (Cochlear implant)
 Celiac **
 Right Hip Replacement
 Small bowel obstruction
 Aspiration Pneumonia
 Malnutrition

Key Assessment Findings.

Subjective Data

• “I have alway been skinny but I have lost a lot of weight in the past few years”
• “There’s no point anyway...it won’t change anything.”

Objective Data.

• Severe muscle weakness (lower extremities only)

• Limited mobility (most likely a result of muscle weakness)
• Impaired hearing
• Vital Signs constantly stable
• Severe pain (only during transfers)
• Mood changes
• Knowledge deficit regarding necessary nutrients
• Eats only about ¼ of meals

Lab Values.

• Low RBC count **

• Low potassium leels
 • Low sodium levels

2. Diagnosing

Admitting Diagnosis.

Left Hip Fracture

Current Diagnosis.

Hip Dynamic Screw

Priority Nursing Diagnosis.

 Imbalanced nutrition related to decreased oral intake as evidenced by physical appearance.

 Hopelessness related to long-term stress, as evidenced by negative statements of current
situation.

3. Planning & Implementating

Planning (for diagnosis #1).

Imbalanced nutrition related to decreased oral intake as evidenced by physical appearance.

Implementation (for diagnosis #1).

Planning (for diagnosis #2.

Hopelessness related to long-term stress, as evidenced by negative statements of current situation.

Implementation (for diagnosis #2).

4. Evaluation.

• Nursing Actions.

Occasionally ask L.P about feelings.

Patient Response and Finding.

She states that she is feeling energetic and is willing to attend group activity.

• Nursing Actions.

Weigh L.P

Patient Response and Finding.

L.P gains over 2 pounds in a month

 • Nursing Actions.

Observe L.P’s daily oral intake.

Patient Response and Finding.

She consumes up to ½ of meals and finishes high protein and high caloric food items.

• Nursing Actions.

Observe L.P’s physical appearance.

Patient Response and Finding.

Patient appears to have more subcutaneous fat