Health problem & data Acute Pain Health problem & data Risk for fall
Left hip Fx with surgical repair.
Pulse 60 regular Pulse 60 regular Respiration 12
Respiration 12 regular Medical/surgical problem and
What you plan to asses/ data you need to collect regular
Pain 9/10 in left hip Pain 9/10 in left hip
Pulse Ox 94% on room air Temperature
Pulse Ox 94% on room air
B/P 124/82 Pulse
B/P 124/82
T 98.1 oral Pain
T 98.1 oral
LOC- alert H/R
LOC- alert
Orientation-oriented to person only Pulse Ox
Orientation-oriented to person only
Distal pulses-femoral +1, popliteal +1, ABG
Distal pulses-femoral +1, popliteal
posterior tibial+1, dorsal pedis+1. All Capillary refill
+1, posterior tibial+1, dorsal
pulses equal bilaterally. Skin integrity
pedis+1. All pulses equal
Capillary refill 2 secs in both lower Edema
bilaterally.
extremities. Inspect Incision site
Capillary refill 2 secs in both lower
No edema present Check for bleeding
extremities.
Positive sensation in all extremities. Cyanosis
No edema present
ROM, 100% active upper extremities, ROM
Fall risk assessment: 21, high risk
lower extremities: left 0%active, 25% Sensation
Strength of upper extremities: +3
passive. Right 75% active and 75% Distal pulses
bilaterally. Lower extremity: right
passive. Color of extremities
+3, left +1.
Bowel sounds audible in 4 quadrants, Bowel and bladder functions
Fatigue
normoactive. H&H
Orthostatic hypotension.
BM: last BM, 4 days ago. Normal Fatigue
pattern q2days. Activity tolerance
Oxycodone 5mg q3hrs per order. Orthostatic hypotension.
HEALTH PROBLEM:__ Left hip fracture with surgical repair______________________________________________________
Behavioral Outcome (must be measurable and in a time frame):
The patient will verbally express relief from pain, as evident by a pain level between 0-3/10, respiration maintained within 12-20 breaths /min, oriented to
place and agreeing to turning/repositioning every 2 hours with assistance by the end of the day.
_____________________________________________________________________________________________
Nursing Interventions (action to meet outcome) Rationale Patient Response
1. Take vital signs every 4 hours. Especially: 1. To monitor for infection, respiratory depression 1. Vital signs within normal limits compared to
temp., respiration and Neurovascular and blood circulation. her baseline. (resp. 12, temp, 98.1).capillary
assessment. refill +2 in all extremities.
2.change dressing per order and inspect incision 2. Inspect for bleeding, other drainages, 2. No sigh of infection, bleeding, redness or
site erythema, edema and infection. drainage observed.
3. Implement non-pharmacological pain 3. to relieve pain non- pharmacologically 3. patient verbalizes comfort and pain relief
management: distraction, relaxation techniques,
therapeutic touch and music.
4. Administer Oxycodone per order 4. for pain relief 4. patient verbalizes pain relief as evident by
pain level of 3/10
5. Encourage ambulation with walker per order 5. To increase mobility as tolerated, help prevent 5. Pt. ambulated with unsteady gait using
constipation walker for a distance of 15 feet without full
weight bearing on left leg.
6. Encourage turning/repositioning every 2hours 6. To reduce the risk of pressure ulcer 6.Patient accepted to be turned every 2 hours
per order. development
7.Reorient pt. to place and time 7.To increase her awareness of the environment 7. pt. oriented to place but not time
and prevent confusion
8.Help with ADLs and encourage fluid intake 8. To increase pt. comfort and relaxation 8. patient relaxed, BM large and brown
Summarize overall progress toward outcome. Was the outcome met, partially met or unmet (explain)? Outcome was met.
Patient verbalizes pain level 3/10, respiration 12, pt. oriented to place but not time and agrees to turning/repositioning with
assistance every 2 hours at the end of the day.
