Health problem & data

Acute Pain Left hip Fx with surgical repair.

Health problem & data

Risk for fall

Pulse 60 regular Respiration 12 regular Pain 9/10 in left hip Pulse Ox 94% on room air B/P 124/82 T 98.1 oral LOC- alert Orientation-oriented to person only Distal pulses-femoral +1, popliteal +1, posterior tibial+1, dorsal pedis+1. All pulses equal bilaterally. Capillary refill 2 secs in both lower extremities. No edema present Positive sensation in all extremities. ROM, 100% active upper extremities, lower extremities: left 0%active, 25% passive. Right 75% active and 75% passive. Bowel sounds audible in 4 quadrants, normoactive. BM: last BM, 4 days ago. Normal pattern q2days. Oxycodone 5mg q3hrs per order.

Medical/surgical problem and What you plan to asses/ data you need to collect

Temperature Pulse Pain H/R Pulse Ox ABG Capillary refill Skin integrity Edema Inspect Incision site Check for bleeding Cyanosis ROM Sensation Distal pulses Color of extremities Bowel and bladder functions H&H Fatigue Activity tolerance Orthostatic hypotension.

Pulse 60 regular Respiration 12 regular Pain 9/10 in left hip Pulse Ox 94% on room air B/P 124/82 T 98.1 oral LOC- alert Orientation-oriented to person only Distal pulses-femoral +1, popliteal +1, posterior tibial+1, dorsal pedis+1. All pulses equal bilaterally. Capillary refill 2 secs in both lower extremities. No edema present Fall risk assessment: 21, high risk Strength of upper extremities: +3 bilaterally. Lower extremity: right +3, left +1. Fatigue 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)

1. Take vital signs every 4 hours. Especially: temp., respiration and Neurovascular assessment. 2.change dressing per order and inspect incision site 3. Implement non-pharmacological pain management: distraction, relaxation techniques, therapeutic touch and music. 4. Administer Oxycodone per order

Rationale
1. To monitor for infection, respiratory depression and blood circulation.

Patient Response
1. Vital signs within normal limits compared to her baseline. (resp. 12, temp, 98.1).capillary refill +2 in all extremities. 2. No sigh of infection, bleeding, redness or drainage observed. 3. patient verbalizes comfort and pain relief

2. Inspect for bleeding, other drainages, erythema, edema and infection. 3. to relieve pain non- pharmacologically

4. for pain relief

4. patient verbalizes pain relief as evident by pain level of 3/10 5. Pt. ambulated with unsteady gait using walker for a distance of 15 feet without full weight bearing on left leg. 6.Patient accepted to be turned every 2 hours

5. Encourage ambulation with walker per order

5. To increase mobility as tolerated, help prevent constipation

6. Encourage turning/repositioning every 2hours per order. 7.Reorient pt. to place and time

6. To reduce the risk of pressure ulcer development 7.To increase her awareness of the environment and prevent confusion 8. To increase pt. comfort and relaxation

7. pt. oriented to place but not time

8.Help with ADLs and encourage fluid intake

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.