Nursing Process( Page7)
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7 Part B: The Nursing process Nursing Diagnosis •
•
Goal
Acute pain • related to fractured left hip as evidenced by complains of throbbing pain 9/10 on pain scale and unable to weight bear on left leg.
In effective peripheral tissue perfusion related to fractured left hip as evidenced by weak and faint left pedal pulse and pale in color on her left lower extremity.
•
At the end of the shift the patients complain of pain will decrease from 9/10 to 4/10 in pain scale.
After implementing the nursing interventions, the patients pedal pulses are palpable and the left lower extremity is pinkish in color and warm to touch.
Nursing Intervention • • • •
• • • •
Assess COLDSPA Administer pain medication PRN Monitor Vital signs Elevate her left leg to decrease pressure and facilitate circulation.
Assess pedal pulses Assess Capillary Refill on left lower extremity. Elevate feet to prevent edema and facilitate circulation. Inspect the skin of the left foot for color, temperature edema and skin changes.
Evaluation •
Patients feeling of pain decrease from 9/10 to 5/10 in pain scale after 7 hrs.
•
Patients pedal pulses are strong palpable and bilaterally equal. Cap refill on patients feet are less than 5sec and warm to touch. After 2 days.
7
•
Goal
Acute pain • related to fractured left hip as evidenced by complains of throbbing pain 9/10 on pain scale and unable to weight bear on left leg.
In effective peripheral tissue perfusion related to fractured left hip as evidenced by weak and faint left pedal pulse and pale in color on her left lower extremity.
•
At the end of the shift the patients complain of pain will decrease from 9/10 to 4/10 in pain scale.
After implementing the nursing interventions, the patients pedal pulses are palpable and the left lower extremity is pinkish in color and warm to touch.
Nursing Intervention • • • •
• • • •
Assess COLDSPA Administer pain medication PRN Monitor Vital signs Elevate her left leg to decrease pressure and facilitate circulation.
Assess pedal pulses Assess Capillary Refill on left lower extremity. Elevate feet to prevent edema and facilitate circulation. Inspect the skin of the left foot for color, temperature edema and skin changes.
Evaluation •
Patients feeling of pain decrease from 9/10 to 5/10 in pain scale after 7 hrs.
•
Patients pedal pulses are strong palpable and bilaterally equal. Cap refill on patients feet are less than 5sec and warm to touch. After 2 days.
7
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