Nursing Care Plan - Posterior Hip Dislocation Left

NURSING CARE PLAN ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

- Assess for history of the injury, presence of factors that may cause pathologic fractures (osteoporosis, osteomyelitis, neoplastic diseases, etc.). - Assess presence of signs of fracture (edema, pain, loss of motion, crepitus, extremity disproportion or abnormal positioning). - Assess presence of signs and symptoms of soft tissues involvement (swelling, hemorrhage, impaired sensation in the extremity). - Assess extremity for presence of open fracture and severe external hemorrhage. - Assess vital signs, fluid balance and urine output. - Assess diagnostic tests and procedures for abnormal values. - Assess routine preoperative history

- Acute pain and immobility , related to diagnosis of fracture.

- Increase comfort, decrease pain. - Prevent avoidable injury. - Prevent complications of immobility. - Provide optimal bone and wound healing. - Then surgical intervention prescribed, prevent postoperative complications. - Decreased anxiety with increased knowledge.

- Provide emergency care if requires (hemostasis, respiratory care, prevention of shock).

- To rule out worsening of underlying condition or development of complications.

- Reports increased comfort, decreased pain. - No evidence of respiratory, vascular or skin complications of immobility. - Maintains stable vital signs, fluid and metabolic balance, nutritional state. - Has sufficient fracture healing rate. - Laboratory tests results shows no abnormalities. - No postoperative complications, or treatment complications. - Learned of crutch-walking, taking care of himself then possible. - Demonstration of understanding of fracture healing process, diagnostic and treatment procedures, trauma prevention, and need for follow-up.

- Provide fracture fixation to prevent following injury of tissues. - Observe signs of fat embolism (especially during first 48 hours after the fracture).

- Monitor client’s vital signs. - Monitor fluids input and output continuously, insert IV catheter, urinary catheter.

- Individual with external locus of control may take little or no responsibility for pain management. - Observations may or may not be congruent with verbal reports indicating need for further evaluation. - Vital signs usually altered in acute pain.