Care Plan for Hip Fracture Patient: Bessie Crandell Age: Current Date: April 3, 2010 Dates Care Given: Sex: Admission Diagnosis/History: Fractured right hip with total hip replacement Nursing Diagnosis: Alteration in Comfort, Immobility, Difficulty with Elimination (Urine), Difficulty with Elimination (Stool), Alteration in Skin Integrity ASSESSMENT Objective Data Foley catheter with cloudy urine Redness of Sacrum Wound Drainage Edema No BM since ? Subjective Data Pain score 8/10 Confusion Potential Complications: Wound infection, Sepsis, Pressure Ulcer, Falls Expected Outcome Full Ambulation Wean off Foley No pressure ulcers Heal wound Pain within stated tolerance GOALS Outcome Criteria Walk with contact guard only to 100 feet Voiding without difficulty on regular schedule Normal skin on sacrum Surgical wound clean and dry Pain reports pain of less than 3/10 with therapy TD: Target Date DA: Date Achieved NURSING INTERVENTIONS Interventions With MD order, remove foley Stage 1 protocol to sacrum Increase narcotics Disimpact patient Begin routine laxative Evaluation: Rationale Avoid complications of foley Avoid progression of redness Improve pain management Restore normal bowel function Maintain bowel function TD DA Signature: _____________________________________ Date: __________________