Hi! Please help me fill the rest

Hi! Please help me fill the rest out of my nursing diagnoses in relation to what I already have (as I need minimum 6 interventions and rationale). Most of it is filled out but some isn’t (will have ‘???’ ). Maybe the goal and evaluation as well, if needed. I attached the case study in reference for the nursing diagnoses. Thank you so much. Please feel free to ask me any questions if needed 🙂 ———————————————————————————————– Case Study 1: Mr William Wright is a 95yr old male, He has been admitted to the rehab ward post a fall at home. He has a Right fractured NOF (neck of femur), it was repaired 12 days ago under General anaesthetic. His past medical history includes Congestive Heart Failure, Asthma, Bowel Cancer, Chronic Bronchitis, Type 2 Diabetes on insulin and is obese. Post his surgery he has lost 10kg within 2 weeks, Has an IDC insitu and his bowels have not been open for four days. He complains of constant thirst despite Polyuria. His skin is dry and lips are dry and cracked. He is reluctant to mobilise due to previous fall. He will only ambulate to the bathroom and back to his bed, refusing to walk any further due to increase anxiety. His skin assessment reveals the following: Stage II Surgical wound on Right Hip 10cmX2cm without eschar. There is minimal serous exudate. The surrounding tissue is pink with poor capillary return. Fresh category I skin tear on his Left forearm measuring 6cmX3cms Stage II pressure ulcer to his sacrum measuring 2cmX2cm with minimal exudate or odour. Nursing Care Plan Nursing Diagnosis (NANDA diagnosis): Deficient Knowledge related to lack of exposure/recall or information misinterpretation/unfamiliarity with information resources as evidenced by inaccurate follow-through of instructions, and development of preventable complications. Goals/Expected Outcome The patient will verbalize understanding of the condition, prognosis, and potential complications. The patient will correctly perform necessary procedures and explain reasons for actions. Interventions/Actions Rationale Discuss the importance of clinical and therapy follow-up appointments. Fracture healing may take as long as a year for completion, and patient cooperation with the medical regimen facilitates the proper union of bone. Physical therapy (PT) or occupational therapy (OT) may be indicated for exercises to maintain and strengthen muscles and improve function. Additional modalities such as low-intensity ultrasound may be used to stimulate healing of lower-forearm or lower-leg fractures. Review pathology, prognosis, and future expectations. Provides knowledge base from which patient can make informed choices. Internal fixation devices can ultimately compromise the bone’s strength, and intramedullary nails and rods or plates may be removed at a future date. Discuss individual drug regimens as appropriate. Proper use of pain medication and antiplatelet agents can reduce the risk of complications. Long-term use of alendronate (Fosamax) may reduce the risk of stress fractures. Note: Fosamax should be taken on an empty stomach with plain water because the absorption of the drug may be altered by food and some medications (antacids, calcium supplements). Teach patient and significant other to identify signs and symptoms requiring medical evaluation. These symptoms include severe pain, fever, chills, foul odours, changes in sensation, swelling, burning, numbness, tingling, skin discoloration, paralysis, white or cool toes or fingertips, warm spots, soft areas, cracks in the cast). Prompt intervention may reduce the severity of complications such as infection or impaired circulation. Note: Some skin darkening (vascular congestion) may normally occur when walking on the casted extremity or using a casted arm; however, this should resolve with rest and elevation. Inform the patient that muscles may appear flabby and atrophied (less muscle mass). Recommend supporting the joint above and below the affected part and using mobility aids (elastic bandages, splints, braces, crutches, walkers, or canes). Muscle strength will be reduced, and new or different aches and pains may occur for a while secondary to loss of support. 6. ??? ??? Evaluation of results: The patient verbalized understanding of the condition, prognosis, and potential complications. The patient correctly performed necessary procedures and explain reasons for actions. Nursing Care Plan Nursing Diagnosis (NANDA diagnosis): Risk for falls related to weakness/loss of skeletal integrity (fractures)/movement of bone fragments. Goals/Expected Outcome Patient will achieve correct body alignment. Patient will demonstrate techniques to support movement. Patient will remain free from falls or injury while ambulating. Interventions/Actions Rationale 1. Maintain bed rest or limb rest as indicated. Provide support to joints above and below the fracture site, especially when moving and turning. Provides stability, reducing the possibility of disturbing alignment and muscle spasms, which enhances healing. 2. Support fracture site with pillows or folded blankets. Maintain a neutral position of the affected part with sandbags, splints, trochanter roll, and footboard. Prevents unnecessary movement and disruption of alignment. Proper placement of pillows also can prevent pressure deformities in the drying cast. 3. Maintain position or integrity of traction. Traction permits pulling on the fractured bone’s long axis and overcoming muscle tension or shortening to facilitate alignment and union. Skeletal traction (pins, wires, tongs) permits greater weight for traction pull than can be applied to skin tissues. 4. ??? ??? 5. ??? ??? 6. ??? ??? Evaluation of results: The patient achieved correct body alignment. The patient demonstrated techniques to support movement. The patient remained free from falls or injury while ambulating. Nursing Care Plan Nursing Diagnosis (NANDA diagnosis): Objective: His bowels have not been open for 4 days. Risk for constipation related to immobility. Goals/Expected Outcome Patient will have a solid bowel movement at least every 3 days. Patient will report no straining or discomfort with defecation. Patient will implement 2 measures to prevent constipation. Interventions/Actions Rationale 1. Administer stool softeners or laxatives. The most common side effect of opioid medications is constipation. When prescribed these medications a stool softener should be used prophylactically in conjunction. For severe constipation, enemas may be required. 2. Educate on the risk and prevention of constipation Educate the patient that constipation is increased due to their immobility and use of opioids (if taking). Stool softeners should be taken before constipation occurs to prevent impaction or serious complications such as bowel obstruction. 3. Increase fluids. Fluids keep stools soft and easier to pass. Patients should drink plenty of water (if not contraindicated) as well as juices such as prune juice. Hot beverages like tea also stimulate bowel movements. 4. Increase mobility as tolerated. Immobility from fractures can also slow down peristalsis. While the patient must first follow activity instructions, once the patient may safely ambulate or exercise, this should be encouraged. 5. ??? ??? 6. ??? ??? Evaluation of results: The patient had a solid bowel movement at least every 3 days. The patient reported no staining or discomfort with defecation. The patient implemented 2 measures to prevent constipation. Nursing Care Plan Nursing Diagnosis (NANDA diagnosis): Impaired physical mobility related to Loss of integrity of bone structure/Pain/Prescribed activity restrictions/Reluctance to initiate movement as evidenced by reports of pain/unwillingness to move/limited ROM/decreased muscle strength. Goals/Expected Outcome The patient will verbalize relief of pain. The patient will display a relaxed manner. The patient will demonstrate the ability to participate in activities with minimal complaints of discomfort. The patient will demonstrate the use of relaxation skills and diversional activities as indicated for individual situation. Interventions/Actions Rationale 1. Encourage independence. Patient should be encouraged to care as much for themselves as possible. Even patients confined to a bed can assist with turning themselves and should be encouraged to perform ADLs such as feeding or washing their face if possible. 2. Premeditate before movement. The nurse should anticipate pain and premeditate before potentially painful activities such as PT sessions or complete bed baths. This will help relax the patient and improve their ability to perform exercises. 3. Collaborate with PT/OT. Hip fractures, spinal fractures, or other serious fractures may require PT or OT to assist with safe movement. These specialists can teach patients how to use canes, crutches, and other devices as well as instruct them on exercises to strengthen muscles. 4. Encourage the use of assistive devices and equipment. Any equipment that will support safe movements such as bedside commodes, grab bars, walkers, or scooters should be utilized. 5.??? ??? 6.??? ??? Evaluation of results: The patient verbalized relief of pain. The patient displayed a relaxed manner. The patient demonstrated the ability to participate in activities with minimal complaints of discomfort. The patient demonstrated the use of relaxation skills and diversional activities as indicated for individual situation.

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