Mind map
GS, 84: Right Hip Fracture
Mind map: right hip fracture nursing care plan
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GS, 84: Right Hip Fracture
Post-op day 2
- Risk for Infection
- Major bruising near incision site
- Staples dry & intact, but no dressing on top of incision
- Nurse will cleanse wound as per orders following aseptic technique
- Nurse will assess site q shift, monitor for abnormalities
- Nurse will cleanse wound as per orders following aseptic technique
- Staples dry & intact, but no dressing on top of incision
- WBC Count: 10.7, neutrophils 8.2
- Temp 36.7
- E.Coli culture: >100 x E6 CFU/L
- Nurse will continue to evaluate recent blood work
- Antibiotics: Ceftriaxone
- Nurse will continue to monitor for elevation in temperature
- Pt ate less than 50% of breakfast & lunch, stated food was bad
- Nurse will educate about importance of increasing protein, calories and fluids to support wound healing
- Major bruising near incision site
- Risk for Infection
Poor circulation
- Ineffective Tissue Perfusion
- Lower extremities cool to touch, feet had cyanosis
- Nurse will slightly elevate client's lower extremities to increase venous return to the heart
- 2+ Pitting edema present bilaterally in low legs, ankles & feet
- Dorsalis pedis & posterior tibial pulses could not be palpated
- Nurse will encourage participation in tolerated ROM active and/or passive ROM exercises
- Dorsalis pedis & posterior tibial pulses could not be palpated
- Lower extremities cool to touch, feet had cyanosis
- Hypertension
- Ineffective Tissue Perfusion
Increased pain
- Impaired Comfort
- Cannot assess pain via pain scale
- Facial grimacing, moaning & grabbing pained site
- Nurse will attempt a verbal pain assessment, also observing for body cues r/t pain q hr
- Facial grimacing, moaning & grabbing pained site
- Acute pain in right leg upon rest & activity, knee tender on light palpation
- Tenderness in edematous site in lower extremities
- Nurse will administer scheduled pain meds and.or PRN's as per doc's orders
- Routine medications: Tylenol, ASA EC, Celecoxib, Tramadol
- Nurse will administer scheduled pain meds and.or PRN's as per doc's orders
- Tenderness in edematous site in lower extremities
- Pt asked why she should continue taking Tylenol when she didn't feel pain
- Nurse will discuss misbeliefs with use of medications for pain control.
- Cannot assess pain via pain scale
- Osteoarthritis
- Impaired Comfort
Physical impairment
- Impaired Physical Mobility
- Can move upper extremities, but lower extremities stiff, especially right side
- Nurse will encourage pt independence in performing ADL's as tolerated
- Pain in from surgery and in lower extremities
- Increased falls risk (pt had a fall, and now has surgery and mobility is impaired)
- Nurse will continue to monitor pt and environment, ensuring pt safety (ie bed in lowest position, alarm is on when pt is in bed)
- Can move upper extremities, but lower extremities stiff, especially right side
- Impaired Physical Mobility
Surgical procedure: ORIF