Nursing Care Plan


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Medical Diagnoses: Acute pain related to hip trauma, constipation, risk for falls and sleep deprivation.


1.      Acute pain related to right hip trauma.

 

:  Patient taking pain PO meds q4 hours.

 

:  Pain has been high as 7 on pain scale.

 

:  Patient grimaces and groans when movement of hip occurs.

2.  Constipation related to pain meds and immobility.

 

:  Pain medications leading to a lack of bowel movement.

 

:  Decreased mobility and oral intake aid in difficulty of bowel movements.

3.  Risk for falls related to right hip trauma.

 

:  Altered mobility due to use of walker or caregiver.

 

:  Unable to have normal gait.

4.  Impaired physical mobility related to acute pain.

 

:  Unable to sit in chair.

 

:  Pain upon movement in bed.

 

:  Unable to ambulate without assistance. 

  59 Caucasian Male  Active and Healthy

BP 126/78     Temp 97.6 F

HR 67  RR 16   Clear Lung Sounds

EKG Normal Sinus Rhythm

Height 5’10”   Weight 173lbs  BMI 25

No significant lab values.      

 

Chief Complaint:  Acute pain right hip due to bicycle accident.  Unable to have BM due to immobility and pain medication.                     

6.  Sleep deprivation related to acute pain and unfamiliar surroundings.

 

:  Patient is a side sleeper and unable to sleep due to hip pain.

 

:  Patient states misses home and being with friends and family.

5.  Risk for skin integrity related to being bed ridden and lack of mobility.

 

:  Patient currently free of skin breakdown.

 

:  Patient is repositioned minimally every 2 hours.

 

:  Nutritional needs met to maintain skin integrity.

7.  Impaired Walking related to right hip trauma.

 

:  Unable to walk without assistance.

 

:  Unsteady due to being on pain medication.

 

:  Unable to bear weight on right hip.

8.  Readiness for enhanced knowledge as related to post op care and recovery.

 

:  Patient has had 3 previous hip surgeries/replacements.

 

:  Patient willing to do anything to speed healing and mobility.


NANDA Diagnostic Statement: Acute pain related to ® hip trauma AEB impaired physical mobility and patient reports.

 

Behavioral Outcome / Goal: Patient to have pain of level 3 or less on pain scale until scheduled surgery.


Nursing Interventions:

 

1. Assess pain severity on scale of 1-10.

 

2.  Offer pain medicine q4 per physician order.

 

3.  Reposition patient every 2 hours beginning 8 AM.

 

4.  Direct and educate patient on muscle relaxation techniques to help manage pain.

 

5.  Reduce environmental factors, such as noise, in patient room.

 

 

Rationale:

 

1.  Assessment provides baseline.                  

 

2.  Medication will help maintain patient comfort.

 

3.  Repositioning helps in prevention of pressure ulcers and aids in comfort.

 

4.  Relaxation techniques help with self -control when pain develops.

 

5.  Pleasurable sensory stimuli reduce pain perception.

Client Response:

 

1.  Patient states pain is 3 on pain scale.

 

2.  Patient is maintaining a level of 3 on the pain scale.

 

3.  Client remains free of pressure ulcers and is able to reposition with assistance.

 

4.  Patient listened and was able to demonstrate understanding of breathing exercises. 

 

5.  Patient requested door be kept closed to reduce noise and lighting to be at a minimum.

Summarize impressions of client progress toward outcomes / problem resolution:  Patient stable and maintaining comfort prior to surgery.  BP 126/78 and temp 97.6 F.  Still has pain in right hip, maintains level 3 on pain scale but may reach 4 or 5 as meds begin to wear off but responds quickly within 30 min of taking meds.  Patient is NPO until surgery but has received pre-op dose of normal Saline.  Patient is relaxed and is optimistic regarding surgery and maintains a very positive attitude and has excellent family support.  This is patients 3rd hip surgery so he understands risks and knows what recovery entails. 


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