Name: Naomi Masuda

Date: 3/28/2016

Nursing Care Plans

Desired Outcome
Impaired Physical Mobility
The patient will demonstrate use of
walker appropriately to increase
mobility at the discharge.

Pain
The patient will perform activities
with acceptable level of pain at the
end of the shift.

Altered Nutrition: Less Than

Body Requirements
The patient will consume at least
50% of meal at the end of shift.

Skin Integrity
The patient will maintain free from
infection at the end of shift.

Interventions
1. Teach hip precautions.
2. Monitor and record the patients
ability to tolerate activity and use all
four extremities: note pulse rate,
blood pressure, dyspnea, and skin
color before and after activity.
3. PT/OT as ordered.
4. Before activity, observe for and treat
pain.
5. Use a gait belt when ambulating the
patient.
6. Teach the patient to call for assistance
when getting out of bed.
1. Assess pain using a self-report 0 to 10
numerical pain rating scale
2. Teach and encourage to take prn
analgesics
3. Administer prn analgesics as ordered
4. Obtain routine analgesics order
5. Teach nonpharmacological
interventions, such as deep breathing,
repositioning, watching TV
6. Provide massage to alleviate pain as
needed
1. Daily weight
2. Assess new lab values (albumin,
protein, glucose, chemistries, H&H)
3. Encourage oral intake
4. Provide Booster Pudding as ordered
5. Ask family to bring the patients
favorite food
6. Incontinence care and mouth care ac
meals
1. Assess site of kin impairment for color
change, redness, swelling, warmth
pain, or other signs of infection.
2. Keep the surgical incision site open to
the air, clean and dry
3. Provide adequate perineal care to
prevent exposure to urine and stools
from erode the skin.

Decreased Tissue
Perfusion/Oxygenation
The patient will maintain adequate
tissue perfusion as evidenced by
warm and dry skin and absence of
respiratory distress at the end of
shift.
Activity Intolerance
The patient will demonstrate
increased activity tolerance at the
discharge.

Elimination
The patient will maintain intact
perineal skin at the end of shift.

Knowledge Deficit
The patient will understand and
demonstrate hip precautions at the
discharge.

4. Teach and encourage increased PO

intake for wound healing.
5. Avoid position the patient on site of
skin impairment.
6. Teach the patient about the signs and
symptoms of infection.
1. Monitor VS, capillary refill, skin color,
mucous membranes.
2. Administer ferrous sulfate as ordered.
3. Raise the head of the bed as
tolerated.
4. Administer oxygen as needed.
5. Teach the patient on dietary
adjustment.
6. Provide bed rest.
1. Assess the patients ability to perform
ADLs.
2. Monitor H&H, RBC, and reticulocyte
counts.
3. Cluster care and provide adequate
rest.
4. PT/OT as ordered.
5. Monitor pain level and administer
analgesics as needed.
6. Allow the patient extra time to carry
out activities.
1. Cleanse the perineal skin regularly
using a cleanser capable of removing
irritants.
2. Assess perineal skin for skin irritation.
3. Obtain order of moisture barrier
containing zinc oxide for irritation as
needed.
4. Provide privacy and support when
changing incontinent devices.
5. Avoid brisk scrubbing and use of a
washcloth when cleansing the skin of
an aging patient.
6. Assess baseline of bowel and bladder
function and the causes of the
incontinence.
1. Assess the patients ability and
readiness to learn.
2. Use easy to understand language
when giving information to the
patient.
3. Use visual aids such as pictures and
videos.

4. Repeat and reinforce information.

5. Evaluate the patients learning
through return demonstrations and
verbalizations.
6. Teach the hip precaution to the
caregivers.

Evaluation:
The outcome of impaired physical mobility was met. The patient was able to
demonstrate the proper use of her walker with PT. She was taught hip precautions
and the staff and student nurse monitored her mobilitys and the tolerance
constantly. Continuous reminders and supervision are needed d/t her impaired
cognition status.
The desired outcome for pain was partially met. The nurses were
administering prn pain medications when the patient started experiencing pain, so
there was a time lag. This was causing the patient to become restless. I believe that
routine acetaminophen is beneficial for the patients pain management more than
prn analgesics since she has some cognitive impairment and status of post ORIF,
however, the primary nurse disagreed with my plan.
When the patient started complaining pain, the primary nurse administered
acetaminophen prn, then Percocet prn. The back massage was effective to alleviate
her pain before the analgesics reached the therapeutic level. However, due to the
tight staff-patient ratio, a 30 min back massage is not realistic for the floor staff.
The altered nutrition outcome was met. The patients nephew agreed to bring
her favorite food at the next his visit. The patient received incontinence and mouth
care before meals, and proper positioning for feeding. She consumed 50% of her
lunch at the end of my shift. She verbalized her understanding of the importance of
proper nutritional intake for wound healing and anemia.
The patients skin was free from infection and the outcome was met. Perineal
care was provided adequately and the patient was of the importance of PO intake
for wound healing. Frequent reminders are needed due to her impaired cognitive
status d/t dementia.

The patient maintained warm and dry skin with no respiratory distress. The
outcome was met. Her VS, cap refill, skin color, mucous membranes were monitored
at the beginning of the shift and prn. The purpose of ferrous sulfate and dietary
adjustment, such as eating red meat, sea foods, beans, tofu, and dark greens, were
instructed and the patient verbalized understanding it. Continuous reminders and
supervision are necessary after discharge from hospital.
The outcome of activity intolerance was met, and still in progress. The patient
was able to tolerate ambulation exercise and OT with therapists. ADLs were assisted
and she was encouraged to perform it herself as tolerated. Adequate rest period
was provided to restore her energy. To improve activity tolerance, the routine
Tylenol for her pain management should be beneficial, however, the primary nurse
disagreed with it.
The patient maintained intact perineal skin and the outcome was met. The
patients baseline elimination patterns were not identified by the chart, staff and the
patient. The patient was able to tell if she wet her incontinent briefs, however, she
was not able to verbalize the need for urination. The perineal care was provided
adequately and the skin was assessed at each time of the care.
The outcome of knowledge deficit was met, and still in progress. The patient
verbalized understanding and was able to demonstrate appropriately hip
precautions with step-by-step instruction during ambulation and position changes.
Continuous reminders and supervisions are needed d/t her impaired cognitive
status.

Discharge Plan/Patient Teaching:

1. Placement/type of dwelling: Short term SNF for rehab, then care home
2. Support system: Never married, nephew is POA. According to the patient, she
is not close to her family.
3. Assistance needed with ADLs: Assistance needed for bathing, dressing,
mobility, transfer, toileting. Verbal reminders for oral care and grooming,
Encouragement needed for feeding.
4. Equipment needs: Walker
5. Patient teaching: Hip precautions, fall precautions, and diet modifications
need to be addressed. The patient prefers visual aids and demonstration to
learn. However, her dementia and pain interfere with her learning. Frequent
reminders and supervisions are needed.

References
Gulanick, M. & Myers, J. L., (2014). Nursing Care Plans: Diagnoses, interventions, and
outcomes (8th). Philadelphia: Elsevier
Ignagtavicius, D. D. & Workman, L. M., (2013). Medical-Surgical Nursing (7th ed.). St.
Louis: Elsevier.
Iron deficiency anemia. (n.d.). Retrieved March 24, 2016, from
http://www.mayoclinic.org/diseases-conditions/iron-deficiencyanemia/basics/prevention/CON-20019327
Pagana, K. D. & Pagana, T. J., (2014). Mosbys manual of diagnostic and laboratory
tests (11th). St. Louis: Elsevier
Port, C. M., (2011). Essentials of pathophysiology (3rd ed. ). Philadelphia: Lippincott
Williams & Wilkins.

Total Hip Replacement Precautions. (n.d.). Retrieved March 24, 2016, from
http://www.upmc.com/patients-visitors/education/rehab/Pages/total-hip-replacementprecautions.aspx