Reason for
Admission
Associated
Diagnosis
Key Assessments
Allergies
Left hip fracture
Positive CAM
assessment,
Neurovascular
assessment, mobility,
pain, infection,
compartment
syndrome,
Sulfa, Garlic
Rank 1:
Concept:
Pain
Nursing Diagnosis:
Acute pain due to left hip bipolar surgery
Supportive Data:
Patient had left hip surgery
Patient on pain medications such as Acetaminophen
Patient states she is in pain
Patient expresses pain (I.e., verbally, facial expressions) when being repositioned
Rank 2:
Concept:
Elimination
Nursing Diagnosis:
Urinary Retention
Supportive Data:
Patient stated she could not urinate
Patient stated she was having pain in suprapubic area
Bladder scan showed 700mL of fluid in bladder
Abdomen distended on palpation
Rank 3:
Concept:
Infection
Nursing Diagnosis:
Risk for infection related to left bipolar hip surgery
Supporting Data:
Low Leukocytes
Low Platelets
Low Neutrophils
Low Monocytes
Urine retention
Surgical wound exposed to air
Rank 4:
Concept:
Skin Integrity
Nursing diagnosis:
Risk for impaired skin integrity due to immobility
Supportive Data:
Patient needs to be assisted to move
Wound drainage on periwound skin
Changing of adherent dressings
Using rough washcloths to wash patients skin
Rank 5:
Concept:
Confusion
Nursing Diagnosis
Acute confusion
Supportive Data:
Patient unaware of date, time and place
Patient states she is waiting for an ambulance
Patient has positive CAM result
Patient asks where she is