NR 341 Week 8 COPD Hip Fracture Care Plan Example

Complex Care Plan: Pain Against Breathing in a 79-Year-Old Man With Severe COPD, Two Days After Hip Fracture Repair

Student Name

College of Nursing, Chamberlain University

NR 341: Complex Adult Health

Instructor Name

Month Day, Year

Complex Care Plan: Pain Against Breathing in a 79-Year-Old Man With Severe COPD, Two Days After Hip Fracture Repair

Mr. L., and the Tension in His Care

Mr. L. is 79, a retired machinist with severe chronic obstructive pulmonary disease who uses 2 liters of oxygen at home and has a baseline arterial carbon dioxide of 52 mmHg recorded at his last clinic visit. He fell at home and had a hemiarthroplasty for a left hip fracture two days ago. Details are composite. Today at 0800: pain 7 of 10 on moving, 3 at rest; breathing 22; saturation 90% on 2 L; heart rate 96; temperature 37.4 C. He has taken only a few steps with physical therapy and has been awake much of the night. His wife says he was "not himself" yesterday evening.

The tension that runs through this plan is simple to state. He needs enough pain relief to breathe deeply, cough and walk, because shallow breathing and lying still after a hip fracture lead to pneumonia, clots and delirium. But the opioids that relieve his pain can slow his breathing, and in a man whose carbon dioxide is already high, that can tip him into respiratory failure. Every intervention below is judged against both sides of that tension.

Ranking, Justified Once

Five nursing problems are identified. They are ranked by how quickly each could harm him and by how much each affects the others. Pain on movement is first, because it drives the breathing, mobility and delirium problems below it; treating it well improves three others. Risk of respiratory failure is second, because it is the most dangerous single outcome and the one most directly worsened by the treatment for the first. Risk of delirium is third, since his wife's comment suggests it may already be starting. Constipation is fourth, because opioids and immobility make it likely and it worsens pain and delirium. Pressure injury is fifth, and it is the problem held at maintenance.

Problem 1: Acute Pain on Movement

Assessment: pain 7 on moving, 3 at rest; takes a few steps only; breathes shallowly when turning.

Goal: pain at or below 4 during physical therapy at 1000 and 1500 today, measured on the 0 to 10 scale, with at least 20 meters walked by the evening.

Interventions and rationale: ask the anesthesia team whether a fascia iliaca block can be placed or repeated, because a Cochrane review of 49 trials found that peripheral nerve blocks for hip fracture reduced pain on movement, reduced acute confusion and probably reduced chest infections (Guay & Kopp, 2020), all of which are problems on this plan. Give scheduled acetaminophen every 6 hours rather than as needed. Give the smallest effective opioid dose 30 to 45 minutes before therapy rather than on a fixed schedule, so the opioid is concentrated where it does the most good.

What it takes: the opioid timed before therapy costs the most on the breathing side, so Problem 2 checks are set around it.

Problem 2: Risk of Hypercapnic Respiratory Failure

Assessment: breathing 22, saturation 90% on 2 L; baseline carbon dioxide 52.

Goal: breathing rate 12 to 24 and saturation 88 to 92%, awake and rousable, throughout the shift.

Interventions and rationale: keep oxygen titrated to a saturation of 88 to 92%, the range the British Thoracic Society sets for people who retain carbon dioxide (O'Driscoll et al., 2017); higher targets can raise his carbon dioxide further. Check sedation level and breathing rate 30 and 60 minutes after each opioid dose. Sit him upright in a chair for meals. Encourage incentive spirometry 10 times an hour while awake.

What it takes: tighter checks take time from other patients; the checks are timed to the doses so they are not spread evenly across the day.

Problem 3: Risk of Delirium

Assessment: "not himself" last evening per his wife; awake most of the night.

Goal: negative screen on the confusion assessment at 0800, 1600 and 0000.

Interventions: glasses and hearing aids on during the day; clock and calendar visible; lights on and blinds open by day, dark and quiet at night; his wife encouraged to visit in the afternoon; no sleeping medicines. Pain control from Problem 1 also serves this goal.

Problem 4: Constipation

Assessment: no bowel movement since admission three days ago.

Goal: a bowel movement by tomorrow morning.

Interventions: scheduled stool softener and stimulant laxative as ordered, fluids to at least 1.5 liters a day unless restricted, and walking as in Problem 1.

Why it is on this plan at all: constipation is easy to dismiss beside breathing and pain, but in this man it feeds both. Straining and a full bowel raise his pain and can splint his diaphragm, and constipation is a known contributor to delirium in older adults. It ranks fourth because it can wait a day without harm, not because it does not matter.

One Problem Held at Maintenance

Pressure injury risk is real in an immobile 79-year-old, but his skin is intact today and the unit's routine measures are enough: a pressure-redistributing mattress, turning every 2 hours while in bed, heel protectors, and a skin check each shift. Nothing extra is added. Holding this problem at maintenance is a decision, not an oversight: the time that a more active skin plan would take is better spent on the walking in Problem 1, which will do more for his skin than any extra turning.

Evaluation as Conditions

The plan is working if, by this evening, he walks 20 meters with pain at 4 or below, his breathing stays between 12 and 24, his saturation between 88 and 92%, and his confusion screens are negative. It is failing if his pain stays above 6 during therapy, in which case the anesthesia team is asked again about a block, or if he becomes hard to wake or his breathing falls below 10, in which case opioids are held, the provider is called and an arterial gas is requested. It is failing in the other direction if he is comfortable but will not move, which would mean the opioid dose is too high for what it achieves.

Transition, Tested Against the Tension

He is expected to move to a rehabilitation unit in three to four days. The handover will name the tension first: his pain regimen, the time of his last opioid and what it did to his breathing, his oxygen target of 88 to 92%, and the sign that would mean he has had too much. A transition plan that lists only his medications would hand on the treatment and leave out the balance it depends on.

References

Guay, J., & Kopp, S. (2020). Peripheral nerve blocks for hip fractures in adults. Cochrane Database of Systematic Reviews, (11), Article CD001159. https://doi.org/10.1002/14651858.CD001159.pub3

O'Driscoll, B. R., Howard, L. S., Earis, J., & Mak, V. (2017). BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax, 72(Suppl. 1), ii1-ii90. https://doi.org/10.1136/thoraxjnl-2016-209729