KEY PROBLEM: Skin KEY PROBLEM: Activity KEY PROBLEM Risk for DVT #2

Breakdown #3 Altercation #6 Nursing Diagnosis & Related to:

Nursing Diagnosis & Related Nursing Diagnosis & Related Supporting data:
to: Risk for skin to:Risk for falls -Since my pt is bed ridden with only help
breakdown Supporting data: from PT to ambulate, she is at risk for
Supporting data: - Right total hip blood clots and is on coumadin.
-Immobilized replacement -Pt is using SCDs
-pressure points from the -Medications( pain meds) -Foot pumps are in place when pt. is in
bed can breakdown skin -Altered gait-slowed bed
-Pt. favors one side -Needs to use a walker to -she doesn’t get up and exercise/ no
- pt has difficulty moving ambulate muscle movement decreases venous
on her own return
-pt is overweight which
can increase pressure on Reason for Health Care (medical dx
boney prominences. Total R Hip replacement (Dx: DJD)
Key Assessments: Pain, mobility, risk for KEY PROBLEM: Infection
infection, risk for blood clots. #5
Nursing Diagnosis & Related
to: Risk for infection
KEY PROBLEM Potential difficulty
KEY PROBLEM Pain #1 breathing #4 Supporting data:
Nursing Diagnosis & Related to: Acute Pain Nursing Diagnosis & Related to: -Had positive culture for
Supporting data: Supporting data: Impaired gas exchange strep.
-Pain was 6/10 early in the day. Her -Immobilized -pt is on antibiotics
incision sight was where the pain stemmed -Pt. has had ARDS exacerbation before -post surgical
from and was radiating down her thigh -pt. has been diagnosed with chronic -staying at hospital she is at
above her knee bronchitis prior to surgery. risk for nosocomial
-Pain meds were administered at 1030 - pt was on anesthesia and sleeps a lot/ she infection and other
cannot use spirometer or deep breathing opportunistic infections.
when pain was 6/10.
while sleeping. -potential longer stay.
-Pain with movement/ constant dull ache