- Acute Pain related to trauma/ Injury as evidenced by expression of pain and limited mobility
- Impaired transfer ability related to musculoskeletal impairment as evidenced by difficulty in transferring between bed and chair, toilet, standing.
- Risk for Infection related to surgical interventions and difficulty managing wound care as evidenced by signs and symptoms
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: -Expressions of pain, such as crying -Unpleasant feeling (such as a prick, burn, or ache) Objective Data: -Expression of pain -Expressive behavior -Guarding behavior -Positioning to ease pain -Limited mobility | Acute Pain related to trauma/ Injury as evidenced by expression of pain and limited mobility | The patient will express pain relief from the administration of pain medication The patient will implement nonpharmacologic pain relief measures | 1. Administer the appropriately prescribed analgesic. Analgesic drugs like NSAIDS, opioids, and local anesthetics pharmacologically reduce acute pain quickly and effectively. Painkillers available over the counter, such as acetaminophen, aspirin, or ibuprofen Prescription pain relievers, such as corticosteroids or specific COX-2 inhibitors Opioid drugs, which may be administered for severe pain after an operation or injury Specific neuropathic pain or functional pain syndromes may be treated with antidepressant or seizure medicines. 2. Follow the pain ladder. The pain ladder is crucial for assessing the patient’s pain level and prescribing the appropriate drugs. The pain ladder comprises a three-step transition from non-opioids through mild opioids to potent opioids to provide adequate pain relief. It consists of three steps: Mild pain uses non-opioid analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen. Moderate pain utilizes weak opioids (such as hydrocodone, codeine, and tramadol) with or without non-opioid pain relievers. Severe and persistent pain uses potent opioids with or without non-opioid painkillers. Potent opioids are morphine, methadone, fentanyl, oxycodone, buprenorphine, tapentadol, hydromorphone, and oxymorphone. 3. Assess the appropriateness of a patient controlled analgesia (PCA) pump. Assess if the patient is a PCA candidate. PCA is the IV infusion of opioids through a pump controlled by the patient. If the patient meets the criteria, this can be a more effective method of pain management. PCA enables patients to self-administer analgesia and gives the patient some degree of control over the dosage they receive. It is important to assess if the patient is both physically able and willing to hit the PCA button but also mentally competent to understand that doing so will relieve their discomfort. 4. Evaluate pain after interventions. Reassess pain level after 30 minutes of interventions. It is essential to reassess pain following interventions to determine if those actions were practical and if the patient’s pain control goals have been met. 5. Educate the patient about pain management. Teach regarding effective timing of medication doses prior to activities that exacerbate pain and to avoid periods of intense pain. Patients can help effectively manage their pain with additional knowledge of when to request pain medication to maximize its effectiveness and prevent severe pain episodes. 6. Encourage feedback from the patient. Instruct the patient to assess the interventions’ effectiveness and report the effectiveness of different interventions to the care team. Feedback can assist the care team in modifying and improving pain control strategies. 7. Respond immediately to reports of pain. If the patient is experiencing an altered passage of time due to pain, fear of delayed pain relief can exacerbate the pain experience. Prompt responses to reports of pain reduce anxiety and promote trust. 8. Promote periods of rest for the patient. Fatigue can contribute to pain. A quiet, darkened room with minimal noise and interruptions can promote rest and reduce pain. 9. Remove the stimuli. Divert away the patient’s attention from the painful stimuli using effective distractors that can reduce the pain the patient perceives. Provide appropriate and engaging distractions for the patient to redirect their attention. Diversional therapy involves using the mind to redirect the attention to something else. The patient can put the pain on hold and concentrate instead on things like playing games, counting, practicing breathing exercises, and many other things. 10. Monitor for side effects of medications. Monitoring for side effects is also essential to maintain the patient’s comfort and safety. Drugs have varying effects based on each person’s metabolism, and efficacy should be evaluated case by case. Sedation, mental fogginess, nausea, vomiting, constipation, physical dependence, tolerance, and respiratory depression are typical adverse effects of opioid treatment. Watch out for physical dependence that may put the patient at risk for overdosage and poor pain management. 11. Follow RICE for minor injuries. For minor injuries that do not require medical attention, follow RICE: Rest the affected area. Ice the affected area with a towel-wrapped cold pack for 10 to 20 minutes to reduce swelling. Compress by wrapping the affected area with an elastic bandage to provide support. It should be applied tightly enough to prevent numbness. Elevate the affected area above the heart to encourage venous return. | Patient reported relief of pain. Patient rated the pain scale lower than the initial rate at a level that is acceptable to them or 0/10. Patient manifested vital signs within normal limits. Patient verbalized regaining appetite and sleep. |
| Subjective Data: Verbalizes fear of contracting Infection Objective Data: -Difficulty transferring between bed and chair -Difficulty standing -Difficulty transferring to the toilet -Difficulty transferring into a vehicle | Impaired transfer ability related to musculoskeletal impairment as evidenced by difficulty in transferring between bed and chair, toilet, standing. | The patient will demonstrate effective transfer ability with minimal supervision The patient will transfer safely using assistive devices | 1. Provide medications as ordered. Analgesics are often indicated to help reduce pain so the patient is more inclined to attempt to transfer. 2. Encourage ADLs within limitations. Depending on the patient’s individual activity orders, bed rest and traction may be required and limit mobility. Provide trapeze bars and items such as wash basins and toiletries so the patient can still participate and maintain independence. 3. Collaborate with PT or OT for rehabilitation. Rehabilitation therapy is critical for patients recovering from hip fractures. The nurse can prepare the patient for their therapy sessions by premedicating and completing tasks before and after PT/OT visits. 4. Provide transfer aids and assist patients in moving. Initially, patients with hip fractures may need assistive devices such as bedside commodes and walkers. Support safe transferring by using gait belts, non slip shoes, and remaining within arm’s reach. | The patient demonstrated effective transfer ability with minimal supervision The patient transferred safely using assistive devices |
| Subjective Data: Verbalizes fear of contracting Infection Objective Data: -Difficulty managing wound care -Other chronic nonhealing wounds and pressure ulcers -Inadequate knowledge to avoid exposure to pathogens | Risk for Infection related to surgical interventions and difficulty managing wound care as evidenced by signs and symptoms | The patient will remain free of symptoms of infection and demonstrate strategies to effectively prevent infection | 1. Provide wound care. The surgical site must be kept clean and dry at all times. Educate the patient and family members on how to provide appropriate wound care at discharge. 2. Teach the patient about hand hygiene. Infection prevention includes strict hand hygiene. Always wash hands when visibly soiled and use alcohol-based hand rubs before touching the patient. 3. Administer antibiotics as ordered. Antibiotic therapy is often provided for patients following surgery to prevent infection and promote wound healing. 4. Remove invasive lines as soon as possible. IV lines, urinary catheters, PICC lines, and more increase the risk of catheter-related bloodstream infections. Discontinue invasive lines as soon as they are no longer needed. | The patient remained free of symptoms of infection and demonstrate strategies to effectively prevent infection |