Care Plan Assistance-- Need feedback please

[Peachez82, BSN, RN]

Oh boy I am excited about being back in school and terrified as well. I have been a LPN since 2009 and only briefly were we introduced to Careplans. Well here we go and today on the first day I get present with a scenario if I even want to call it that. Here is the info I was presented with.

I have an Elderly patient 86 y/o fell at home. Patient is confused to place and time scheduled for surgery tomorrow.

With the info I have one nursing diagnosis I want to use is:

Impaired Mobility related to muscular skeletal impairment AEB fractured hip.

Desired outcomes

*Regain/maintain mobility at the highest possible level.

*Patient demonstrates the use of adaptive devices to increase mobility

Interventions:

1. Provide and assist patient with mobility means of wheelchair, walker as soon as possible and instruct safe use of mobility aids.

2. Assist with self care activities.

3. Execute passive or active assistive ROM to all extremities.

Rationales:

1. Early mobility reduces complication of bed rest (phlebitis) and promotes healing. Learning the correct way to use aids is important to maintain optimal mobility and patient safety.

2. Improves muscle strength and circulation, enhances patient control in situation, and promotes self-directed wellness.

3. Exercise enhances increased venous return, prevents stiffness, and maintains muscle strength and stamina.

Can someone tell me how this looks.

Tanks in advance Crystal

[NICUismylife, ADN, BSN, RN]

Are you allowed to use "risk for" diagnoses yet? I know when I was first semester, we couldn't but later on, we could. There are several "risk for" that I think would be higher priority, but if you're not allowed to use them yet, then that dx is probably ok.

Your goal needs to be measurable, so that will need to be modified.

How does assisting with ADLs improve mobility? It is something that needs to be done, but it doesn't fit this dx.

You cannot do ROM exercises on a fractured hip. That needs to be modified.

I'd add some education in there for sure.

What about meds?

Do you have a care planning book? I'd strongly suggest an All-in-one care planning book. They are around $15 on Amazon and well worth it. The interventions and rationales are super helpful when you're first learning to care plan.

[Peachez82, BSN, RN]

First and foremost thank you for the response. I have looked over the syllabus and emailed the instructor we are allowed to use risk for nursing diagnosis. The one I was working on last night was [COLOR=#424242]Risk for Peripheral Neurovascular Dysfunction. [/COLOR]

[COLOR=#424242]The other diagnosis I was thinking is related to Acute pain and I am currently trying to get further clarification on the scenario patient's mental status which is vague. It would help if I knew if the confusion led to the fall that caused the hip fracture or did the client become confused d/t unfamiliar surroundings. [/COLOR]

[COLOR=#424242]Thank you for your feedback as I pressed send and was looking at my original post I was looking at the range or motion exercise as an intervention and was thinking that probably isn't possible during this hospital stay so I scratched that intervention. I guess with the assisting with ADL's I was thinking along the lines of getting the client used to doing as much for themselves as possible which you are right does not directly affect Mobility. I also realize I didn't add the time I would like to see my goals achieved.[/COLOR]

[COLOR=#424242]I am currently awaiting my Mosby's Guide to Nursing Diagnosis according to Amazon should arrive sometime today. I also accidently ordered Ackley's Nursing Diagnosis handbook on my kindle which I heard is the extended version of the book I'm currently waiting on.[/COLOR]

[COLOR=#424242]Can you recommend a careplan book:

This is the one I have my eye on but it older and has a new edition coming out but it isn't out yet and I need one ASAP. [/COLOR][h=1]Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e 8th Edition[/h]

by Meg Gulanick PhD APRN FAAN (Author), Judith L. Myers RN MSN (Author)

Again Thank you for your feedback it is appreciated.

Crystal