Nursing Plan of Care Concept Map - Immobility - Hip Fracture

Nursing Plan of Care Concept Map Stud Studen entt Name Name:: __Davi __David d Ngo__ Ngo____ _____ _____ __ of Care: 04/26/2011_  04/26/2011_ 

Uniq Un ique ue Pat Patie ient nt Ide Ident ntif ifie ier: r:__5 __501 0104 0421 2111 11__ ____ __Dat Date e

***Complete Pathophysiology, Pathophysiology, Therapeutic regimen, Functional Changes & Labs in Nurse2 Nursing Dx (NANDA): Impaired physical mobility r/t Goals with time frames: fractured hip As evidenced by (AEB ): Defining

Characteristics (Signs/Sx/Data) that support NDX

 _________________________________  1. Achieves pain-free_0/10__ 

1. Acute Pain; discomfort_2/10____ 

Reverse or Improve

2. Joint Stiffness__________________  Stiffness__________________ 

2. Functional - Joint Joint movement movement Freely_  3. Without help help from another person

3. Lack of environmental supports____   ________________________  ___________________________________  ___________ 

 __and equipment device._____  (Why?). Cite Rationales References

Interventions: What you will do:

Smeltzer andofHinkle, p. : Did you Evaluation Goals2010, 2102 the goal? Give Evidence reach

Assessments, Actions (do), Teaching, Meds if applicable.  As many in each

 _Yes. Client is is in less pain, because pain level is at 1/10. After regular exercise, client mobility has improve by walking__ 

category as needed.

Evaluation of Interventions (Give

supporting data)

 _a short distance without any help.__ 

1. Maintain neutral positioning of hip. hip.

 ________________________________  Evaluation 1. _Prevents _Prevents stress stress at the site of  1. _Client engages in therapeutic  ________________________________ 

2. Instruct and assist in in position

fixation_  2. Encourages client's active

positioning. 2. Assist in in position changes; shows

changes And transf transfers ers.___ .______ _______ ________ _______ _____ __

participation_  While While preven preventin ting g stress stress on hip

increased Independence in transfers.______ 

3. Instruct in and supervise

fixation. _   _  3. Strengthen muscles muscles needed for

3. Exercises every every 2 hours while

Intervention

isometric,_  Quadriceps-setting, and gluteal-

Rationale

walking. ___ _ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

awake._  ____ ______ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ___  _  _ 

setting Exer Exerci cise ses. s.__ ____ _____ _____ _____ _____ ____ _____ _____ ____ __ 4. Place pillow pillow between legs when

____ _______ _____ ____ _____ _____ _____ _____ ____ _____ _____ _____ _____ __ 4. Supports leg; leg; prevents

_____ _______ _____ _____ _____ _____ ____ _____ _____ _____ _____ ____ ___  _  4. Uses pillow pillow between legs when

turning._  5. Encourage use of 

adduction.__  5. Strengthens shoulder shoulder and arm

turning.__  5. Uses trapeze _-

trapeze._________ 

muscles _ 

 ______________________ 

________________________________ 

Necessary for use of ambulatory

Credits: MBancroft, JAdams, AMaradiaga `

__________________________________ 

12/13/2010

Nursing Plan of Care Concept Map Student Name: __David Ngo_________ of Care: 04/26/2011_  6. _Offer encouragement and support  __  Exercise regimen.______________________ 

Unique Patient Identifier:__501042111____Date

aids. _ 6. Reconditioning exercises can be  ____  Uncomfortable and fatiguing;

_  6 . Actively participates in exercise regimen_  __________________________________ 

encourage-_  Ment helps patient comply with the program

Credits: MBancroft, JAdams, AMaradiaga `

12/13/2010