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?
Featured Replies
Join the conversation
You can post now and register later.
If you have an account, sign in now to post with your account.
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?