Student Name

Melanie Goo
Mini Care Plan
Expected
(complete before assessment)

Found
(complete after assessment)

1. Acute pain r/t surgery

1. Acute pain r/t total joint arthroplasty

2. Impaired mobility r/t surgery

2. Impaired mobility r/t total joint arthroplasty

3. Risk for falls r/t impaired mobility

3. Risk for falls r/t impaired mobility & pain medications

Focus of physical
assessment

R hip surgical site & affected extremity

R hip surgical site & affected extremity

Need more
information
from
patient/family/
doctor about:

Info from patient about pain and limitations

Info from doctor about limitations and dressing
care

Info from patient about pain and limitations

Info from doctor about limitations and dressing care

1. Safety

1. Patient safety/Risk for falls

2. Pain control

2. Acceptable comfort level

3. Increase mobility

3. Increase mobility

Nursing
Diagnoses
(NANDA)

Top three
priorities (goals)
for patient care

Nursing
Interventions

1. Provide a safe environment

2. Assessment: pain, incision site, dressing,
affected extremity
3. Administer pain medications reg sch &/or
PRN, especially before PT/OT
4. Reposition for comfort, maintain proper
alignment of operated extremity
5. Encourage independent ROM to prevent
complications of immobility

Teaching
needed/provided

Use of assistive devices

Surgical site/dressing care
ROM exercises
Proper techniques for mobility after hip surgery

Discharge
planning

PT/OT
Follow-up appts
Assistive device for home

1. Pt safety/Risk for falls

- Educate pt regarding side effects of pain medications
(hypotension, dizziness, drowsiness, nausea)
- Bed locked, low position, side rails up, pt using no skid
footwear, call light within reach, up w/ assist, assistive device,
family member at bedside
- Assess pt needs during rounding
- Referral to PT/OT
2: Acceptable comfort level
- Assess pain (level, type, location, quality), assess incision site
- Administer scheduled pain meds and any PRN meds that pt
requests; educate to request pain meds before pain gets to severe
-Use alternative comfort measures (repositioning, proper
alignment, relaxation, breathing, quiet environment)
- Reassess pain after interventions
- Educate/monitor side effects of meds
3: Increase mobility
- Referral to PT/OT, use of assistive devices
- Pre-medicate before PT/OT
- Encourage pt to perform independent ROM exercises, get out
of bed POD1
- Educate about consequences of decreased mobility (resp
problems, constipation, muscle atrophy)
- Assist with providing an acceptable comfort level

Use of assistive devices

Surgical site/dressing care
ROM exercises
Proper techniques for mobility after hip surgery
Info about pain meds schedule & side effects
PT/OT in & out of shower, ROM, dressing
Follow-up appt Maui & Oahu
Assistive device for home walker &/or crutches