Desired Outcomes

Interventions

Pain
1. Patient will have pain management with
decrease to tolerable pain level by the end of
my shift.
2. Patient outcome was met.

1. Pain assessment (Pain, Quality, Radiation,

Severity, Timing) (Intermittent pain to Right
Surgical site 5/10 with touch; Constant
tolerable pain to Right groin 3/10 that
increases with movement OOB; Intermittent
pain to lower back stabbing 4/10)
2. Monitor vitas and LOC (Apical pulse 88-92;
BP 122/64 and 122/68. Patient A&O x3)
3. Assess for DVT to surgical extremity (Negative
Homans sign, no swelling, redness, or
tenderness, pain present with touch &
getting OOB)
4. Note when last pain med was given and next
available dose (1 Percocet last given 0321 &
next dose can be given at 0721- Q4H PRN
orders)
5. Offer and administer pain meds in timely
manner (2 Percocet given)
6. Educate on side effects of Percocet
(Headache, drowsiness, confusion,
palpitations, and constipation)
7. Reevaluate med effectiveness within 1 hr of
administration (Pain decreased to 2/10 to
lower back; pain to Right surgical site and
right groin comfortable at rest)
8. Offer non pharmacologic pain management
(Offered ice pack, reposition, and rest)
9. Note imaging findings (Patient had pelvis xray done for Right Hip osteoarthritis and
s/p Right Total Hip Replacement

Bleeding
1. Patient will not experience hemorrhage or
hematoma formation by end of my shift.
2. Patient outcome was met.

1. Assess surgical site (staples intact, would

well approximated, dressing with scant
amount of bloody drainage, no s/sx of
infection- no redness, swelling, or
tenderness, pain and drainage present)
2. Monitor vitals (Apical pulse 88-92; BP 122/64
and 122/68)
3. Monitor labs-CBC (RBC 2.81L, Hgb 8.6L, Hct
25.4 L, & platelet 132 L
4. Note orders for blood transfusion (Patient was
given 2 PRBC on previous shift)
5. Monitor HV (Patient had HV dcd on
previous shift)
6. Note EBL during surgery (I know now, but at
the time forgot to note)
7. Assess patient for dizziness upon movement
or getting OOB) Patient denied any dizziness
upon movement or getting OOB)

Nausea
1. Patient will verbalize decreased nausea by the
end of my shift.
2. Patient outcome was met.

1. Assess nausea and cause (Patient

complained of nausea after Percocet given)
2. Note PRN antiemetic order (PRN order for
Zofran IV push)
3. Administer antiemetic timely (Zofran
administered on my shift)
4. Educate on possible side effects (Headache,
dry mouth, and diarrhea)
5. Evaluate effectiveness of antiemetic (Patients
nausea slowly resolved by end of my shift
with med and rest)
6. Offer rest (Patient was given undisturbed
time to rest)
7. Offer repositioning (Patient was comfortable
in bed)
8. Offer ice chips (Patient had ice chips at the
bedside)

Fever
1. Monitor vitals & recheck abnormalities in 30
min to 1 hr (Apical pulse 88-92; BP 122/64
1. Patient will be absent of fever by the end of my
shift.
and 122/68; Temp 37.7C and 37.5C)
2. Patient outcome was not met.
2. Assess for symptoms of fever (Patient denied
feeling of fever & chills. No rigors.)
3. Note orders for fever and administer as
needed (PRN Tylenol for temp >38.6C/
101.5F. Patients temp was under so no
meds needed at the time)
4. Educate on side effects of Tylenol (abd pain,
cramping & GI bleed)
5. Monitor labs (WBC 7.0 normal)
6. Assess surgical site for infection (Pain and
drainage present, no redness, swelling,
warmth, or tenderness)

Impaired Physical Mobility

1. Patient will perform physical activity within
limits of activity restriction by end of my shift.
2. Patient outcome partially met.

1. Assess ROM (Patient with limited movement

to Right Lower extremity)
2. Note orders for activity (Patient is up with
assist with front wheel walker and partial
weight bearing to right lower extremity)
3. Assess patients ability with assistive device
(Patient uses front wheel walker properly)
4. Assess and administer pain meds before
therapy to allow for participation with pain
management (Patient did not have therapy
during my shift because of being
discharged that day, but had on previous
shifts)
5. Assess mobility (Patient is up with minimal 1
person assist)
6. Reinforce therapy teaching (Patient
verbalized understanding of teachings 1)
butt squeezes 2) ankle & foot pumps and 3)
straightening right leg to work thigh
muscles)
7. Encourage participation with PT/OT. (Patient
was schedule for discharge on date of care,
so no therapy was scheduled, but patient
had previous PT/OT sessions)
8. CMS check to Right lower extremity (cap refill
<3 sec, pedal pulses palpable, skin color
normal for ethnicity, skin temp warm, able
to wiggle toes, dorsiflex and plantar flex, no
numbness or tingling)
9. Administered ordered meds (Patient received
scheduled hydroxychloroquine &
cholecalciferol)
10. Note PRN orders muscle spasms (PRN order
for Flexeril PO QHS)
11. Educate on possible medication side effects
(hydroxychloroquine: headache, dizziness,
blurred vision, N/V; cholecalciferol:
hypotension, dry mouth, fatigue, & metallic
taste; Flexural: dizziness, tachycardia, &
postural hypotension)

Knowledge Deficit
1. Patient verbalizes understanding of preventive
measures by end of my shift.
2. Patient outcome met.

1. Assess, reinforce and evaluate teaching of

total hip precautions (Patient verbalized
understanding of teaching 1) No turning
toes inward 2) No crossing legs & 3) No
bending at the waist >90 degrees; place
abductor wedge for hip abduction &
prevent hip dislocation when laying in bed
and turning on the side; extend surgical leg
out before sitting down, scoot t the edge of
bed before standing; use an elevated toilet
seat & chair; caution when getting in and
out of the car; no driving until cleared by
MD; activity restrictions: no running,
jumping, twisting until clear by MD; use of
assistive devices and weight bearing status
as ordered by MD)
2. Educate and evaluate teaching of s/sx of
infection to right hip surgical site to monitor for
(Patient verbalized understanding of
teaching of s/sx of infection to monitor for:
redness, swelling, pain, tenderness,
drainage, staples coming out, and
separation of wound edges)
3. Ask patient for any concerns (Patient had no
other concerns at the time)

Ineffective Airway Clearance

1. Patient will maintain clear open airways as
evidence by normal breath sounds, and normal
rate and depth of respirations throughout my
shift.
2. Patient outcome was met.

Ineffective Airway Clearance

1. Assess airway for patency (No S/sx of
obstruction, cough or secretions)
2. Auscultate breath sounds (Lung sounds clear
bilaterally to all lobes and unlabored)
3. Monitor vitals and LOC (RR 16-18; O2 sat 97
-100 RA, patient A&Ox3)
4. Assess skin turgor (no tenting) and mucous
membranes (moist)
5. Use of incentive spirometer (Patient
encouraged to use IS and able to)
6. Administer bronchodilators (Advair Diskus
administered)
7. PRN bronchodilator orders (Ventolin HFA)
8. Administer scheduled Pepcid (Patient has hx
GERD and scheduled Pepcid BID)
9. Educate on possible medication side effects
(Advair: chest pain, dry mouth, & pounding
heartbeat; Ventolin: palpitations,
tachycardia, & hypertension; Pepcid:
headache, dizziness, & abd cramps)

Self Care Deficit

1. Assess ability to perform ADLs (Patient

independent with feeding and brushing
teeth, but needed minimal assist with
toileting, bathing, dressing, and
transferring)
2. Assess pain (Patient had pain to lower back,
right groin and right surgical site when
getting OOB or touch)
3. Assess cause of deficit (Patient had Right Hip
Total Replacement and was POD 3 on date
cared for)
4. Allow for adequate time for patient to complete
tasks (Patient was given time needed to
complete task)
5. Instruct patient when putting bottoms/pants on
to put leg through affected leg first Patient
verbalized understanding of teaching to
proper way to put pants on for hip surgery
and to prevent dislocation of the hip)
6. When transferring patient to wheelchair, put
wheelchair on patients stronger side (At time
of discharge patient was assisted with
transfer to wheelchair placed on left side
since surgery was on the right hip)
7. Encourage independence (Patient tried to be
independent as much as possible)
8. Allow for rest between activities Patient was
allowed rest during activities to conserve
energy)

Discharge Plan/Patient Teaching

Patient was being discharged POD 3 on my shift to Rehab of the Pacific around 12p.
Support system was husband and daughter. Daughter goes to school on the mainland, but was
staying with parents for a while. Patient needed minimal assistance with ADLs such as
transferring, ambulating, dressing, toileting and bathing. As far as feeding and brushing teeth,
patient was independent. Patient would be needing front wheel walker for assistance
ambulating and dressing changes to right hip surgical incision. Patient seemed to learn by
verbal instructions and visual demonstration. I did not observe any barriers to learning for my
patient. Topics needed to be addressed were signs and symptoms of infection to look for at
surgical site, monitor bleeding at surgical site, dressing changes, total hip precautions, proper
repositioning techniques to prevent shearing of skin, discharge meds and pain medications
instructions and its possible side effects, notifying MD of complications such as hip dislocation
or infection, activity restrictions and weight bearing orders of MD, PT and OT teaching, and any
follow up appointment with MD.