Case Scenario: Y.Y. Total Hip Replacement
YY is going to be discharged in a few days. She will need physical therapy, and, because she will have limited ability to ambulate, she will not be able to return to her own home without someone to care for her. She has only one child who is 60 years old and lives in a city that is many miles away.
You have given YY excellent physical care that has prevented complications related to her surgery such as problems with elimination, respiratory problems, and risk for infection. Her physical needs that seemed overwhelming on admission appear less important now as you listen to Yolanda Yost state her feelings. What can you do to help her? All of what she says is true. She will need help with her care, at least temporarily. She probably will not be able to go home or live independently until she is able to care for herself.
YY states that she will not be able to care for herself, and nothing can be done about her situation. She frequently cries when you attempt to speak to her about her problems. When you try to involve her in care, she says, “Why should I care for myself? I can’t go home anyway.”
Nursing Assessment
YY is an 80-year-old woman who has fallen and fractured her hip. She has had a total hip replacement and a rapid recovery for someone her age. Her vital signs are stable, and she has minimal pain. Her pain is relieved with oral analgesic medications.
You have made a referral to the social work department and anticipate that YY will have to be discharged to a long-term care facility for rehabilitation. In the meantime, you wonder what you can do to help YY to cope with her situation.
As you review her history and her symptoms, you see a pattern emerging. Yolanda Yost believes that no matter what she does, her actions will not affect the outcome. She believes that she has no control over her situation.
A. ASSESS
1. Identify the significant symptoms by underlining them in the assessment.
2. List those symptoms (those you have underlined) that indicate the client has a health problem.
3. Group the symptoms that are similar.
B. DIAGNOSE
1. Select possible nursing diagnoses for this client.
Do this by looking at the list of nursing diagnoses in NANDA 2021-2023.pdf Download NANDA 2021-2023.pdf
Possible nursing diagnoses:
2. Validate the possible nursing diagnoses.
Compare the signs and symptoms (defining characteristics) that you have identified from your client assessment with the defining characteristics for the nursing diagnosis that you have selected. Also read the definition and determine if this diagnosis fits this client.
Validated nursing diagnoses include:
Write a nursing diagnostic statement for one of the nursing diagnoses by combining the nursing diagnosis label with the “related to” (r/t) factors.
The label is the title of the nursing diagnosis as defined by NANDA.
An r/t statement describes factors that may be contributing to or causing the problem that resulted in the nursing diagnosis.
NANDA label:
Definition:
Defining Characteristics:
Related Factors (r/t):
WHAT is the complete nursing diagnostic statement?
