Nursing Plan of Care Concept MapStudent Name: __David Ngo_________ Unique Patient Identifier:__501042111____Date of Care: 04/26/2011_

***Complete Pathophysiology, Therapeutic regimen, Functional Changes & Labs in Nurse2

Intervention Rationale Evaluation1. Maintain neutral positioning of hip. 1. _Prevents stress at the site of fixation_ 1. _Client engages in therapeutic positioning.

2. Instruct and assist in position changes 2. Encourages client's active participation_ 2. Assist in position changes; shows increased

And transfers.___________________ While preventing stress on hip fixation._ Independence in transfers.______

3. Instruct in and supervise isometric,_ 3. Strengthen muscles needed for walking. 3. Exercises every 2 hours while awake._

Quadriceps-setting, and gluteal-setting __________________________________ __________________________________

Exercises._______________________ _________________________________ ________________________________

4. Place pillow between legs when turning._ 4. Supports leg; prevents adduction.__ 4. Uses pillow between legs when turning.__

5. Encourage use of trapeze._________

________________________________

5. Strengthens shoulder and arm muscles_

Necessary for use of ambulatory aids._

5. Uses trapeze_______________________

___________________________________

6. _Offer encouragement and support __ 6. Reconditioning exercises can be ____ 6 . Actively participates in exercise regimen_

Exercise regimen.______________________ Uncomfortable and fatiguing; encourage-_

Ment helps patient comply with the program

__________________________________

Credits: MBancroft, JAdams, AMaradiaga ` 12/13/2010

Nursing Dx (NANDA): Impaired physical mobility r/t fractured hip

As evidenced by (AEB): Defining Characteristics (Signs/Sx/Data) that support NDX

1. Acute Pain; discomfort_2/10____

2. Joint Stiffness__________________

3. Lack of environmental supports____

___________________________________

Goals with time frames:

_________________________________

1. Achieves pain-free_0/10__

2. Functional - Joint movement Freely_

3. Without help from another person

__and equipment device._____

Reverse

or Improve

Interventions: What you will do: Assessments, Actions (do), Teaching, Meds if applicable. As many in each category as needed.

Rationales (Why?). Cite References

Smeltzer and Hinkle, 2010, p. 2102

Evaluation of Interventions (Give supporting data)

Evaluation of Goals: Did you reach the goal? Give Evidence

_Yes. Client is in less pain, because pain level is at 1/10. After regular exercise, client mobility has improve by walking__

_a short distance without any help.__

________________________________

________________________________

Nursing Plan of Care Concept MapStudent Name: __David Ngo_________ Unique Patient Identifier:__501042111____Date of Care: 04/26/2011_

Credits: MBancroft, JAdams, AMaradiaga ` 12/13/2010