Nursing Diagnosis Patient Discharged

I need help on a care plan. My patient is 34 male had open hip reduction. Only thing is he had it done last Thursday, and I will be taking care of him tomorrow. I had the opportunity to meet him on Sunday and the doctor said he would probably be discharged Tuesday morning.

His only complaint was pain on the actual site and movements. He does have a cast on it and his wife has been taught to assist him with movements and how to transfer to and from wheelchair. I have to come up with 8 diagnosis.

I have to work 3 of them out with a goal for each of those 3. His fluid balance is all in line, his abnormal labs are low rbc, hct, hgb. I'm guessing just because of blood loss, plus he had a small blood transfusion, his vital signs are all within normal range as well.

He is at risk for falls, acute pain, impaired mobility, risk for injury. But my teacher doesn't like us to use at risk unless we have to, or at risk for infection is an exception, but since this surgery was 5 days ago, that priority has probably dropped a bit.

Most likely I am going to have a new patient in which I will have to do an entirely new care plan. It be acute pain, impaired skin integrity, impaired movement, followed by?

I need to come up with 8, but even more important I need the top 3 to be in absolute order since I am woking those ones out.... I know Airway breathing circulation comes first, but I do not know that any of that even applies here, the guy seems healthy.

4 Answers

Specializes in med/surg, telemetry, IV therapy, mgmt.

When you have to come up with some kind of skeleton care plan on a patient you haven't seen yet, all you can work with is the data you have been given. That data, if I understand what you have posted is:

  • open hip reduction
  • pain on the actual site
  • pain with movement
  • a cast
  • wife has been taught to assist him with movements and how to transfer to and from wheelchair
  • abnormal labs are low rbc,hct,hgb

If you have been reading any of the information that I post on care planning and the nursing process then the place to begin is with this data. You should be looking up everything you can find on what is done by a physician during an open hip reduction and what the normal medical treatment and aftercare are. Since the patient has a cast he will need to be given or taught post-discharge instructions on the care and management of the cast. Obviously, mobility is going to be a problem when he goes home. So, are the performance of his activities of daily living. How are his ADLs going to be affected and need assistance at home? You will need to assess and teach on these points. If the patient is anemic due to some blood loss as a result of the surgery what are some nursing actions or teaching you can give him to follow when he gets home? How is the man performing his toileting with a cast on his leg? How is he getting pants on? Have you thought about suggesting adding foods to his diet that would be high in iron and folate? What classification of a nursing diagnosis would that come under?

The way I see this the patient has issues of pain, mobility, nutrition, self-care deficits and healing of the actual surgical trauma to deal with. That covers 5+ nursing diagnoses right there, none of them "Risk fors". When you actually work with the patient you'll be able to streamline the actual care plan.

  1. Impaired Skin Integrity
  2. Impaired Mobility
  3. Acute Pain
  4. Toileting Self-care Deficit
  5. Dressing Self-care Deficit
  6. Fatigue (this would be a symptom of the anemia)
  7. Ineffective Health Maintenance (R/T dietary changes needed to boost his blood system as a result of the blood loss anemia)
  8. Risk for Injury (potential for fat or blood embolism, potential for thrombophlebitis)

There's your 8 in priority order and only one is an anticipatory diagnosis. You have to think in a very practical and logical way when you are planning care. Picture your own self with the same cast on your leg and imagine the kinds of situations you might have to deal with as you go through your daily life. There's a big part of your care plan right there. I'll let you come up with a goal for each of the first 3 from your care plan book.

Specializes in ICU.

Do you think he will need additional teaching before he goes home? Knowledge defecit?

Thanks for the reply. in his charts, it said he and his wife were educated. But I think it definately needs to me retaught and emphasized until they understand. Knowledge Deficit is possible I suppose.

I'm looking in Handbook of Nursing Diagnoses

Are any of these helpful?

  1. Risk for Impaired Skin Integrity related to pressure of cast on skin surface
  2. Risk for Injury related to hazards of crutch-walking and impaired mobility secondary to cast.
  3. Risk for Impaired Home maintenance related to the restrictions imposed by cast on performing activities of daily living and role responsibilities
  4. Self-Care Deficit related to limitation of movement secondary to cast
  5. Deficient Diversional Activity related to boredom and inability to perform usual recreational activities
  6. Risk for Ineffective Therapeutic Regimen Management related to insufficient knowledge of cast care, signs and symptoms of complications, use of assistive devices, and hazards
  7. Collaborative Problems listed are
  8. Pressure (edema, mechanical)
  9. Compartmental syndrome
  10. Ulcer formation
  11. Infection
+ Join the Discussion