Thai male patient age 66 years old
BW: 43kgs Height 156cm. BMI=17.67
Admission Date: 18/03/2022
Dx. S720 Fracture of neck of femur Lt.

CC: Left hip pain for 5 hrs PTA
PHI: 5 hrs PTA the patient fell down, left hip hit the floor then the patient felt pain, so he decided to come to hospital.
PH: Underlying disease: DM, HT, DLP, old Cerebrovascular accident(cva), right side muscle weakness

• Refuse of drug and food allergy history.
• He has surgery history about internal fixation left leg 30 years ago after accident

19/2/2022
Potassium 3.4 mmol/L (Low)
21/2/2022
Potassium 3.0 mmol/L (Low)
22/3/2022
Potassium 3.4 mmol/L (Low)

Extremities : Fracture neck of femur LT.

18/03/2022
Bring Cefazolin 2g to OR
retain foley catheter
morphine 2 mg IV infusion prn for pain every 4 hours
Tylenol (500)1tab po prn for relieve pain every 4 hours
NPO from 5am
Review preoperative laboratory (CBC,FPG,BUN,Cr,PT,PTT,INR,LFT,CXT,EKG)
E.kcl 30ml oral stat

Evaluation Criteria:

1. Pain score=0 or decrease
2. Normal vital signs: T=36.5-37,5 C BP=90/60-120/80mmHg, HR=60-100 bpm, RR=12-20 bpm
3. Patient can sleep well
4. Patient’s face brightened, refreshed, and showed no pain.

Evaluation:

• pain score=0
• Normal vital signs: T=36.5 C BP=130/65mmHg, HR=54bpm, RR=18 bpm, SpO2=98%
• Patient can sleep well
• Patient’s face brightened, refreshed, and showed no pain.

19/03/2022
E.kcl 30ml po stat
Test potassium level
Epidural OPIOID:morphine 3mg at 14:00
0.9%Nacl 1000ml IV infusion 100ml/hr
Cefazolin 1g every 6 hours
Omeprazole 40mg OD
Celeboex (200)1*1po pc
On venaflow 16:00,off venaflow 21:00

20/03/2022
Epidural morphine 4 mg in normal saline 6ml
retain foley catheter 8:27
On Nacl 0.9% 1000ml IV drip 60ml/hr 9:05
Morphine 3 mg IV prn for pain every 4 hours
onsia 4mg iv prn for nausea and vomiting every 6 hours
Dicloxa(500)1x4 po pc
omeprazole 1x1po pc
caltrate plus 1tab po OD

CXR AP UPRIGHT PIRT

• Mild cardiomegaly with atherosclerosis change of the aorta
• Mild increase pulmonary vascularity and reticular opacity in LUL

BOTH HIPS (AP) AND LEFT HIP (LATERAL CROSS-TABLE)

• Bones : No displaced fracture. No bone destruction. Normal mineralization
• Jonits : No dislocation. S/P bipolar hemiarthroplasty of left hip
• Soft tissues : No radiopaque foreign. Soft tissue swelling with drainage catheter at left hip

Fracture of left femoral neck with mild displacement. Normal both hip joints

Subject:-
Objective data: The patient received bipolar hemiarthroplasty operation on 19th,March,2022

Subjective data: Pain score=6/10
Objective data:

• The patient has surgical wound at left hip
• The patient receive Morphine 3 mg IV prn for pain every 4 hours(20/03/2022)

For prevent wound infection:
1.Client will remain free of infection, as evidenced by normal vital signs and absence of signs and symptoms of infection.
2.Client will maintain or restore defenses.
3.Patient will verbalizea meticulous hand washing technique.
4.Alleviate or reduce the problems related with the infection.

For prevent DVT:
1.Maintain position of function and skin integrity as evidenced by absence of contractures, footdrop, decubitus, and so forth.
2.Maintain or increase strength and function of affected and/or compensatory body part.
3.The patient will absence :Swelling of the calf, thigh, or the entire leg;Redness, warm and hard flesh, low-grade fever, and chills;Asymmetrical enlargement of one leg relative to the other;Increased leg spasms and cramping;Abdominal pain

For prevent hip dislocatio
1.The patient will demonstrate correctly how to use the trochanter roll to help hip alignment.
2.The patient will demonstrate how to properly change positions to relieve pressure with a little pain possible.

Wound infection:
-Monitor patient's vital sign every 4 hours,especially the body temperature
-observe the wound characteristics,such as redness,swelling,discharge and so om
-Maintain strict asepsis for dressing changes, wound care, intravenous therapy.
-Wash hands or perform hand hygiene before having contact with the patient. Also, impart these duties to the patient and their significant others and know the instances when to perform hand hygiene or “5 moments for hand hygiene”
Moment 1 - before touching a patient.
Moment 2 - before a procedure.
Moment 3 - after a procedure or body fluid exposure risk.
Moment 4 - after touching a patient.
Moment 5 - after touching a patient's surroundings
-Educate clients and SO (significant other) about appropriate cleaning, disinfecting.

DVT:
-Monitor vital signs every 4 hours
-Suggest the patient keep bedrest to prevent clot dislodgment
-Encourage the patient elevate affected or both legs
-Turn patient every 2 hours without crossing legs
-Provide range-of-motion exercises to the unaffected.
-Assess patient for complications of PE, such as shortness of breath, chest pain, apprehension, cough,
hemoptysis, tachypnea, crackles, tachycardia, diaphoresis, and fever

Hip dislocation:
-Remind the patient must be cautioned not to sit too low or cross the legs.
-Suggest the patient’s leg should be positioned in ABDUCTION.This is to prevent dislocation of the prosthesis. It is very crucial that the femoral head component of the acetabular cap is maintained in the correct position.
-Put two or three pillows between the legs of the patient will keep the hip in abduction.
-Tell the patient the hip of the patient should NOT be flexed more than 45 to 60 degrees.
-To prevent acute hip flexion, elevate the head of bed not more than 45 degree
-Remind patient not to sleep on the operated side until this position is cleared with the surgeon.
-1-4 days after operation, assist the patient in early ambulation to promote blood flow of oxygen throughout the body while maintaining normal breathing functions
-Teach the patient recognize dislocation of the prosthesis which includes:Shortening of the leg;Inability to move the leg;Malalignment of the leg;Abnormal rotation;Increased discomfort

• Assess V/S and pain score every 4 hrs
• Administer medication follow doctor order (Morphine 3 mg IV prn for pain every 4 hours) and observe side effects of medication such as constipation, nausea and vomiting, dry mouth, dizziness
• Teach the patient to perform non- pharmacological pain relief methods such as deep breathing exercise, reading a book, etc.
• Adjust comfortable position to reduce pain
• Promote bedrest by organize nursing activities to stay at the same time / do not disturb the patient while resting / sleeping
• Assess pain score again after provide nursing care

1. The patient will be free from wound infection
2. The patient will ne free from deep venous thrombosis
3. The patient will be free feom hip dislocation

Subjective data:
Objective data:

• The patient recieve Eliquis FC 5 mg 0.5 tab 2time morning and evening *7days(19/03/2022)

• Assess knowledge and understanding about self care at home
• Explain to the patient the importance of doing the right behavior at home and giving them opportunities to ask questions.
• Preparing the patient before discharge followed D-METHOD.
• D Diagnosis : Fracture neck of femur LT
• M Medication : Tylenol = Observe signs and symptoms of medicine such as nausea, loss of appetite, itching, rash and etc.
  Caltrate plus = Observe signs and symptoms of medicine such as nausea, loss of appetite, weight loss and etc.
  Celebrex = Observe signs and symptoms of medicine such as nausea, diarrhea, bloating and etc.
• E Environment and Economic : Don't sitting leg crossed, Avoid bend of hips more than 90 degrees and the floor should not be too slippery to prevent slipping.
• T Treatment : Encouraging the patient to do exercise every day such as bed mobility training, standing with walker 4-5 steps, wheelchair training and education relative about how to transfer patient
• H Health : Advice on physical exercise for recovery after surgery and avoid wound contact with water
• O Outpatient referral : Should see a doctor immediately when there are abnormal symptoms as follows: Severe hip pain and not able to walk or put on weight, fever, red, swollen wounds or having discharge, etc.
  Patient comes to check by appointment every time.(29/03/2022)
• D Diet : Eat 5 foods group and eat foods high protein to help recovery wound.
• Eat high calcium such as Spinach, broccoli, almonds, milk etc. to help bone healing.

Evaluation Criteria:

1. Laborabory result normal range

• Hb 12-16 g/dl
• Hct= 38-47%
• PT= 10.4-13.3 sec
• PTT= 21.4-29.6 sec
• INR= 0.8-1.1

2. There was no gastrointestinal bleeding, hematemesis , no black stool
3. There is no bleeding on skin or petechiae

Subjective data:
Objective data: The patient recieved HCTZ(hydrochorothiazide) to treat Hypertension
19/2/2022
Potassium 3.4 mmol/L
21/2/2022
Potassium 3.0 mmol/L
22/3/2022
Potassium 3.4 mmol/L

-Client will display heart rate, blood pressure, and laboratory results within the normal limit and absence of paresthesia, muscle weakness, and cognitive impairment.
-The patient will leep normal serum potassium concentration ranges from 3.5 to 5.0 mEq/L.

Operation: Bipolar Hemiarthroplasty Left hip(19/03/2022)
Diagnosis
Pre-operation diagnosis: Fracture neck femur Lt
Post-operation diagnosis: Fracture neck femur Lt
Operation diagnosis: Hip hemiarthroplasty

1.Monitor heart rate and rhythm. Be aware that cardiac arrest can occur.
2.Monitor respiratory rate and depth. Encourage deep breathing and coughing exercise. Elevate the head of the bed.
3.Assess the level of consciousness and neuromuscular function, including sensation, strength, and movement.
4.Monitor urine output.
5.Encourage intake of carbohydrates and fats and low potassium food such as pineapple, plums, strawberries, carrots, cauliflower, corn, and whole grains.
6.Monitor laboratory results, such as serum potassium as indicated.
7.Administer medications, as indicated：SYR KCL 20mE q/15ml 60ml 30ml STAT 1day (21/03/2022)
SYR KCL 20mE q/15ml 60ml 15ml STAT 1day (22/03/2022)

• Patient has knowledge about taking care himself
• Patient is able to take care himself at home
• Developing the patient's self-care potential

Cooperate in conducting and taking care of himself properly.

• Observe and assess sign & symptoms of bleeding such as petechiae on skin or blood in stool, to be prevented from the beginning if bleeding.
• Assess vital sign every 4 hour for observing abnormal sign.
• Monitor and evaluate blood test results to follow the result of PP, PPT, INR and platelet that related with blood clotting
• Monitor Hct and platelet counts periodically to assess bleeding tendencies.
• After injection has to press the injection area for 5-10min stop bleeding
• Administer Omeprazole 40mg OD (19/03/2022) for prevent bleeding in stomach
• Observe side effects of medication such as headache, N/V, diarrhea and constipation
  

Wound infection:
-The Patient don't have sign and symptoms of wound infection, there is no redness, no fever
-The patient metain stable vital.
BP:128/76mm Hg, RR:18times/min, BT:37.3℃，PR:79bpm
-The patient was not infected

DVT:
-The patient metain good skin elastic.
-The patient had no thigh or calf swelling, no skin fever, symmetrical legs, no symptoms of pulmonary embolism, and no leg spasm

Hip dislocation:
-The patient know how to turn the position

• Explain the bed settings to the patient including how bed remote controls works.
• Avoid wet floors
• Ensure the availability of a call bell when in the toilet.
• Provide adequate lighting
• Provide proper shoes or slippers
• Bed at the lowest level
• Valuables should be within reach
  

Bipolar Hemiarthroplasty Left hip(19/03/2022)

• The patient doesn't has any injuries on his body
• The patient doesn't fall from from bed, doesn't slip and falls

Supportive data :
Objective data : The patient received bipolar hemiarthroplasty operation on 19th,March,2022

-HumuLIN 100 unit/ml 10ml inject STAT 1DAY 22/03/2022-23/03/2022
-Norvasc 5mg tab 1tab 1time at breakfast 7days 22/03/2022-29/03/2022
-Norvasc 5mg tab 1tab STST1 day 22/03/2022-23/03/2022
-Kcl syr 20mEq/15ml 60ml 15ml STAT1day 22/03/2022-23/03/2022
-Kcl syr 20mEq/15ml 60ml 30ml STAT1day 21/03/2022-22/03/2022
-SUSO MOM 240ml /bot 30ml Once daily at bedtime 7days 21/03/2022-28/03/2022
-TAEC Eliquis FC 5mg tab 0.5tab BID PC breakfast and dinner7day 21/03/2011-28/03/2022
-Dicloxacilin 500mg cap 1 Cap QID ac Breakfast lunch dinner bedtime7days 20/03/2022-27/03/2022
-Caltrate 600 +D400 tab Once day PC Breakfast7days 20/03/2022-27/03/2022
-Omeprazole 20mg cap 1 cap once daily ac breakfast 7days 20/03/2022-27/03/2022
-Celebrex 200mg cap 1 cap once daily pc breakfast 7days 19/03/2022-26/03/2022
-Tylenol 500mg tab 1tab QID pc breakfast lunch dinner bedtime 7days 19/03/2022-26/03/2022
-Tylenol 500mg tab 1tab every 4 hours prn *7days 18/03/2022-25/03/2022

Tylenol 1pc
Caltrate plus 11po pc
Celebrex 1*1po pc

-ASA
-Gemigliptin
-Glipizde
-Pioglitazone
-Amlodipine
-HCTZ(hydrochorothiazide)
-Simvastatin
-Doxazosin
-Finasteride
-Omeprazole
-Simethicone