I need help with my care plan!

[divastar50401]

I have a care plan due and I'm pretty confident that I'm doing it correctly but I just need a little reassurance, and some help!

The client has a broken right hip and is unable to bear any weight. She is A and OX2, drowsy. She thinks it's 1977.

She uses SRX2 and is a fall risk. She is pivot transfer AX2. Her DP in right foot is 2+, left foot is 3+, they are warm dry and sensation to light touch.

ecchymosis to right hip and edema 2+ right foot.

lungs are clear throughout, no cough.

bowel sounds are hypoactiveX4 and firm, distended. brown soft BM, v-300ml clear yellow.

IV in left anticubital space with D5 1/2NS running at 100/hr. no signs of infiltration.

VS--T97.5 P100 R16 BP138/88

I feel like my nursing DX would be Acute Pain R/t movement of bone, edema and/or injury to tissue. I'm not sure which one to exactly pick.

The interventions I've chosen are:

1. Evaluate/document reports of pain on faces pain scale, note any non-verbal pain cues.

2. Perform active/passive ROM

3. Apply cold ice pack PRN

4. Monitor vital signs

My rationale for choosing these are:

1. To monitor effectiveness of interventions

2. To maintain strength and mobility of unaffected muscles.

3. Reduce edema, decrease pain.

4.

Obviously I am having some issues coming up with the rationale for why I am doing what I am doing. Can anyone help me out?

[duskyjewel]

Warning, I am a CNA and have not yet started my nursing program, so take my comment for what it's worth. It seems to me that the rationale behind monitoring vital signs is to evaluate the stability of the patient's condition and to receive indication that it might be deteriorating (or improving) based on the reading. How often would you be checking? Also, elevated blood pressure and heart rate can indicate pain, so that's another rationale for checking vitals if you think your patient can't communicate effectively.