Nursing Care Plan Activity PDF

Preview

Summary

in class activity...

Description

Assessment

Nursing Diagnosis(es)

Desired Outcomes

Nursing Interventions

Evaluation

(Include subjective & objective data, diagnostic data, health history, etc.)  85 year old female  Lives with son  Uses walker  Limited mobility  Spends days in recliner

(Entire statement – NDx, r/t, AEB)

(Specific and Measurable)

(Specific and individualized; include rationale)

(Evaluate desired outcomes)

Acute pain related to tissue trauma secondary to right hip fracture AEB c/o right side pain, red spot on right hip, unwilling to change position.

1. Patient will rate pain as 3 on a scale of 0-10 by the end of the shift.

 Assess pain every 4 hours  Assess for factors that increase pain and eliminate those factors  Administer pain medication every 4 hrs as per physician order

Outcome partially met (Patient rated pain as 4 in a scale of 0-10 twice per shift)

      

found on the floor c/o right side pain Red spot on right hip medical Diagnosis: broken hip & dehydration c/o pain (pain score not mentioned) taking pain med sparingly Unwilling to change position in bed

Impaired physical mobility related to decreased muscle strength (OR tissue trauma right hip) secondary to right hip fracture AEB ROM limitations in right hip, medical diagnosis of right hip fracture, c/o of right hip pain, unwilling to change position in bed.

2. Patient will experience a satisfactory pain relief as evidenced by increased participation in pain management strategies throughout the hospital stay.

    

weight loss: 21 lbs “I am not that hungry” Decreased intake of food c/o dentures hurting Serum albumin: 3.2

Imbalanced nutrition: less than body requirement related to decreased desire to eat (OR decreased oral intake, mouth discomfort) AEB decreased intake of food, serum albumin: 3.2, weight loss: 21 lbs, stated “I am not that hungry”, c/o dentures hurting and slipping.

Other nursing diagnoses are: “Fluid volume deficit” (dehydration) “Impaired skin integrity” if the fracture is an open fracture) “Risk for infection” (if open fracture) “Risk for impaired skin integrity” (if closed fracture and pt is not changing position/bedridden)...