Student Name __Tiffany Ching_________ Date _____April 10, 2017______
N256 Mini Care Plan
Expected
(complete before assessment)
Nursing Diagnoses
(NANDA)
1. Risk for infection related to surgical incision
(right hip hemiarthroplasty)
2. Impaired physical mobility AEB pain and
discomfort on movement (right hip).
3. Risk for peripheral neurovascular dysfunction r/t
right hip hemiarthroplasty.
Focus of physical 1. Right hip incision site
assessment 2. Peripheral pulses
3. ROM
4. Lower extremities
Need more 1. Knowledge of signs and symptoms of infection.
information from 2. Physical therapy and occupation therapy.
patient/family/ 3. Ability to ambulate (use of assistive device)
doctor about:
4. Caregiver/home health aide/nurse
Top three priorities 1. Monitor for signs and symptoms of infection.
(goals) for patient 2. Patient will be able to perform deep breathing
care and incentive spirometry exercises 10x/hr while
awake.
3. Patient will be able to ambulate in the hallway
prior to discharge with no SOB and tolerable pain.
Nursing Interventions 1. Monitor right hip incision site for infection.
2. Encourage pt. to ambulate x3/day with help.
3. Instruct patient to call for help when OOB.
4. Assess for pain during hourly rounding.
5. Instruct patient to perform deep breathing
exercises and use IS 10x QHR while awake.
Teaching 1. Observation of signs and symptoms of DVT,
needed/provided pulmonary embolism.
2. Educate patient to take ambulate as tolerable or
at least 3x/day.
3. Report any signs of infection (redness, swelling,
fever, drainage from incision)
4. Create an environment that is calm and quiet.
Discharge planning 1. Ensure that patient is able to take ambulate with
assistive device at home.
2. Have a demonstration of proper deep breathing
and incentive spirometry exercises.
3. Improve mobility (no signs of SOB, tachypnea,
pain).
4. Evaluate patients support system if any (at
home).
Found
(complete after assessment)
1. Risk for infection related to surgical incision (right hip hemiarthroplasty)
2. Impaired physical mobility AEB pain and discomfort on movement (right
hip).
3. Risk for peripheral neurovascular dysfunction r/t right hip hemiarthroplasty.
4. Acute pain related to alteration in skin integrity (surgical incision site)
1. Right hip incision site
2. Peripheral pulses
3. ROM
4. Lower extremities
1. Knowledge of signs and symptoms of infection.
2. Physical therapy and occupation therapy.
3. Ability to ambulate (use of assistive device)
4. Caregiver/home health aide/nurse
1. Monitor for signs and symptoms of infection.
2. Patient will be able to perform deep breathing and incentive spirometry
exercises 10x/hr while awake.
3. Patient will be able to ambulate in the hallway prior to discharge with no
SOB and tolerable pain.
1. Monitor right hip incision site for infection.
2. Encourage pt. to ambulate x3/day with help.
3. Instruct patient to call for help when OOB.
4. Assess for pain during hourly rounding.
5. Instruct patient to perform deep breathing
exercises and use IS 10x QHR while awake.
1. Observation of signs and symptoms of DVT, pulmonary embolism.
2. Educate patient to take ambulate as tolerable or at least 3x/day.
3. Report any signs of infection (redness, swelling, fever, drainage from
incision)
4. Create an environment that is calm and quiet.
1. Ensure that patient is able to take ambulate with assistive device at home.
2. Have a demonstration of proper deep breathing and incentive spirometry
exercises.
3. Improve mobility (no signs of SOB, tachypnea, pain).
4. Evaluate patients support system if any (at home).