Student Name _Kristin Miura_________

Date

week 4

N256 Mini Care Plan

Nursing
Diagnoses
(NANDA)

Expected
(complete before assessment)

Found
(complete after assessment)

1. __Activity intolerance r/t pain ______

1. _Acute Pain r/t surgery (allograft) (Gulanick, p.

2._Risk for ineffective tissue perfusion

660)

3. Risk for falls r/t age, use of crutches, hx of

2._Ineffective breathing pattern r/t sedation

falls

(hydromorphone and methadone) (Gulanick, p. 242)

3. _Risk for DVT r/t immobility & refusal of
sequential compression device (Gulanick, p. 248)

Focus of physical
assessment

1. Pain management
2. Circulation, movement, sensation to left lower
extremity
3. Ensure good color, capillary refill, absence of
pain and numbness, strong palpable pulses,
warm.
4. Assess readiness to ambulate: absence of
dizziness, proper footwear, good gait and
balance, pain is controlled prior, stable Vital
signs.

Pain
*Check the site for signs of infection
*Assess vital signs alterations r/t pain
*Facial expressions (grimace)
*Numerical number
Respiratory
*Pt. respiratory rate was 15, unlabored, symmetrical,
breath sounds clear in both lungs, SpO2 was 91%.
*Assess lung sounds
*Symmetry of respirations
*Tissue perfusion (cyanosis, fatigue)
Risk for DVT
*Assess legs for warmth, redness, swelling
*Assess for s/s of stroke (alterations in mental status,
paralysis to one side of the body) and pulmonary
embolism (difficulty breathing, impending doom, chest
pain)
*Decreased circulation to LLE (surgical site) & tissue
perfusion (stasis of blood)
*Assess cardiac output (VS especially BP and pulse)

Need more
information
from
patient/family/
doctor about:

Subjective: Determine the patients

perception of causes of activity
intolerance

Pain
*Location, intensity, type/characteristics, relief, goal
(level pt. is able to do ADL)

Activity tolerance: Observe and

document response to activity (Dyspnea,
excessive weakness, fatigue, lighteadedness, chest discomfort)

CMS symptoms from patient

Patient: ability to ambulate (good balance, absence
of dizziness)

Respiratory
*Asthma triggers
*Shortness of breath, dyspnea, fatigue, difficulty
breathing
*Oxygen via nasal cannula parameters/protocol

Patient: history of fall causes

Doctor: possibly administering probiotics related
to 2 antibiotics (current) and history of
osteomyelitis which is treated with antibiotics.
Doctor: possibly administering iron to promote
RBC production (healing) r/t low hgb & hct with
high RDW
Family: mental status intact, questions or concerns
related to treatment regimen or patient progress
Top three
priorities (goals)
for patient care

Risk for DVT

*Willingness to ambulate
*Reasons for refusal of sequential compression device
*Should this patient be on prophylaxis anticoagulants
(possibly 81mg of Aspirin)
*Change patient from sequential compression device to
compression stockings.

1. _Pt. will have adequate pain management in

1. _Pain: Pt. pain will be controlled to a number (goal)

order to ambulate once this shift after

that allows him to function and perform ADL

medication has been given to control the pain.

2._Respiratory: Pt. oxygenation status will remain

2.__Assess neurovascular status, and apply

within normal limits throughout this shift.

interventions (elevate extremity, ice) to prevent

3. _DVT: Pt. will be encouraged to increase range of

complications of surgery

motion and have education on DVT prevention.

3. Pt. will not fall during shift and will be

assessed prior to any ambulation and after
Nursing
Interventions

1. __Manage pain and encourage early

1. _Pain: Assess pain, and administer scheduled pain

ambulation post-op_____

medication (Controlling pain can also improve

2.__Assess and compare neurovascular status of

oxygenation). Recheck Pain within an hour of Pain

extremities & Notify physician stat if signs of

medications.

altered circulation are noted ___

2. Respiratory: Raise the head of bed (promote

3. __Elevate the extremity and apply ice packs

expansion of the lungs)

after the ORIF, apply sequential compression

3. Respiratory: Tell patient to take deep breaths and

devices,

cough, reassess SpO2 (Increased to 94%)

4. _Assess the pt. current history related to

4. _DVT: Encourage ambulation, ROM, and

medications and how he tolerated previous

Sequential Compression Device

ambulation so far. This helps me to understand

5. _DVT: Assess CMS to affected extremity (LLE

what I need to watch out for, such as if he is

ORIF) to ensure adequate perfusion

experiencing dizziness d/t rx, or if he had a

difficult time ambulating so far.
5. Encourage pt. to wear glasses if necessary,
assess the environment for anything that could

be a potential problem.
Teaching
needed/provided

Discharge
planning

Pain: Encourage the patient to continue to

ambulate at home and to manage pain
effectively. Proper pain management can
prevent immobility, respiratory infections,
promote healing, if pain is hindering mobility.
Perfusion: Teach patient about poor CMS. Signs
and symptoms to report.
Perfusion: Promoting good hygiene, nutrition,
exercise as tolerated & prescribed to prevent
complications of surgery
Pain: Teach patient about managing pain, and
to prevent it from escalating because its better
to manage it well before it hits the upper end
numbers (8, 9, 10).
Falls: Teach patient about sitting up for a
minute before ambulating, and to let staff know
if he is experiencing side effects of medication
(severe sedation, dizziness)

Pain
*Communicate pain with staff so that interventions can
be made to bring pain level to a level where ADL can be
performed
*Adequate pain management is easier to manage than
pain that gets out of control

Ensure the patient is comfortable and using

proper technique for crutches (assistive device)
Ensure patient is able to take care of self (ADL)
Ensure patient has proper education on
medication regimen

Pain
Teach patient about sedation with medications (Not to
drive or operate machinery that requires concentration).
Pt. will have a clear understanding of management of
pain before discharge.

Respiratory
*Notify staff if having difficulty breathing
DVT:
*Do range of motion exercises in bed
* Wear Sequential Compression Devices to pump the
blood while in bed
*Notify staff if numbness, tingling, decreased sensation,
edema presents in LLE (CMS compromise to surgical
extremity)

Respiratory
Patients respiratory status will be stable and pt. will be
educated on the side effects of his medication (sedation
which can alter respiratory status)
DVT
Pt. will be able to ambulate and function (OT, PT) to
promote mobility and prevent DVT.
Pt. will also be educated to stay hydrated to prevent the
blood from becoming viscous.

Gulanick, PhD, APRN, FAAN, M., & Myers, RN, MSN, J. L. (2011). Nursing care plans: Diagnoses, interventions,
and outcomes Missouri: Elsevier Mosby.