Nursing Care Plan


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Medical Diagnoses:Acute Pain related to surgical incision, sleep deprivation, impaired physical mobility and Constipation


1.  Acute Pain related to surgical incision.

 

Patient 7 on pain scale

 

Patient grimaces upon movement

 

Patient unable to achieve comfort

 

Surgical incision on right hip

4.  Impaired Physical Mobility related to acute pain.

 

Unable to ambulate without assistance

 

Pain upon movement

 

Fatigue

6.  Risk for Impaired Skin Integrity related to surgical incision.

 

Assist in repositioning every 2 hours

 

Maintain nutrition levels

 

Assess minimum every 2 hours

2.  Sleep Deprivation related to acute pain and hospitalization

 

Patient unable to sleep in supine position.

 

Patient states wants to be at home in his own bed.

 

Patient states too much noise in hospital.

54 M  AA  163lbs   6’0”  Smoker

Sickle Cell Trait

BP 123/83  Temp 97.7  HR 69   RR 18

 

 

Chief Complaint:  Pain in right hip

 

Admit Diagnosis:  Failed Total Hip Replacement

 

Patient had hip replacement 2004 and has been in pain for past 4 weeks. 

7.  Risk for Falls related to hip surgery.

 

Altered mobility due to use of walker

 

Pain medications

 

Unable to recognize own limitations

3.  Constipation related to surgery and immobility.

 

Bed rest increases difficulty of bowel movement.

 

Pain medication causes constipation

 

Stool softener given to relieve constipation

5.  Deficient Knowledge related to pain management.

 

Patient reluctant to take prescribed pain medication.

 

States afraid of addiction does not want to be a cry baby.

8.  Risk for Injury related to altered mobility.

 

Using Walker

 

Refrains from asking for assistance

 

Lack of family support


NANDA Diagnostic Statement: Acute Pain related to revision of right hip replacement AEB patient reports 7 out of 10 on pain scale and impaired physical mobility.

 

Behavioral Outcome / Goal: Patient will have pain level of 4 or less on pain scale by end of shift and follow medication regimen ordered by physician.


Nursing Interventions:

 

1.  Assess pain severity on scale of 1-10 every hour by asking patient.

 

2.  Monitor Vital Signs.

 

3.  Offer and encourage pain medication every 4 hours per physician order.

 

4.  Educate patient on importance of pain management to promote rest & healing.

 

5.  Educate and have patient demonstrate relaxation techniques to help pain management.

 

6.  Reposition every 2 hours beginning 8 AM.

Rationale:

 

1.  Initial assessment provides baseline and comparison. 

 

2.  Usually altered in acute pain.

 

3.  Medication will help in providing comfort.

 

4.  Lack of sleep/rest impedes healing process.

 

5.  Will help to relieve tension to reduce stress and pain level.

 

6.  Repositioning aids in prevention of pressure ulcers and aids in comfort.

Client Response:

 

1.  Patient states 7 on pain scale.

 

2.  Vital signs 97.7 temp.  BP 123/83 

HR 69  RR 18

 

3.  After PCA pump patient states pain 5 on pain scale.

 

4.  Patient agrees to take pain medicine as ordered.

 

5.  Patient listened about relaxation and performed some deep breath exercises & watched TV for distraction.

 

6.  No pressure ulcers & repositioned with patient assistance.

Summarize impressions of client progress toward outcomes / problem resolution:  Patient is stable and pain level lowered from 7 to 5 on pain scale.  Patient was using PCA pump as ordered and agreed to take PO meds at bedtime in order to assist sleep.  Patient ate breakfast and lunch and was compliant with PT as ordered.  No family support so patient was advised on importance of following all MD orders upon discharge.


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