Care Plan for (insert condition)

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
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Objective Data
Foley catheter with cloudy urine
Redness of Sacrum
Wound Drainage
Edema
No BM since ?
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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:
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Date:
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