Please evaluate my nursing care plan thanks I am new lpn student

[pugmama1970]

Assessment

Nursing Diagnosis

Nursing Plan

Goals

Implementation

Evaluation

- Subjective Data: Mrs. Brown is a 75 year old patient c/o Rt femur pain S/P orthopedic surgery for Rt femur repair with pin placement due to a Rt femur fracture related to osteoporosis

Patient states "pain is 8/10- 4 hours after surgery upon admission to the recovery unit

Objective Data:

BP 144/82 Pulse 98, RR 18

Appears to be grimacing restless and has an elevated pulse rate

- Acute Pain post operatively

- Activity Intolerance due to Rt femur fracture and surgical repair

• Use pain rating scale to identify current pain level
  
• Report that pain management regimen relieves pain to satisfactory level with acceptable and manageable side effects
  
• Describe alternative methods that can be used to help control pain such as ice application
  
• Encourage and facilitate early ambulation and other ADLs when possible
  
• Assess for developing Lower Extremity DVT by checking lower legs twice per day
  
• Check skin integrity for decubitius ulcers daily due to prolonged laying
  

• To control pain at a level of 4/10 or below within 24 hours post op
  
• To assist patient with gaining mobility with assistance and to get into wheelchair daily within 24 hours post op
  
• Within 24 hours post op vitals and signs will be WNL
  

• Ask the client to describe past experiences with pain and effectiveness of methods used to manage pain
  
• Change positioning every hour to avoid pain place abduction pillow between legs alternating with laying in a dorsal recumbent and semi fowlers position
  
• Observe or monitor signs and symptoms associated with pain
  

• Self report of pain is 4/10 giving prescribed pain medications 24 hours post op
  
• client began to to ambulate with assistance within 24 hours post-operatively by getting into wheelchair with assistance and using a walker for 5 minutes
  
• 24 hours postoperatively Client appears to have normal vital signs such as BP, heart rate, temperature, color and moisture of skin, restlessness, and ability to focus.