Give pain medications prior to physical activity as pain impairs mobility and the patient is more likely to succeed in reaching her physical activity goals if her pain is under good control. Impaired physical mobility R/T recent surgery 2° right intertrochanteric hip fracture AEB pt. only being able to ambulate 40 ft with walker & assist x 1. Acute pain R/T recent surgery 2° to intertrochanteric right hip fracture AEB pt. rating pain as a 10/10. Ensure pt. changes position at least Q 2hr to prevent muscle atrophy & pressure sores from immobility & extended periods of friction as these can discourage physical activity. Assess pain Q 2 hrs & following pain medication administration as per protocol, in order to "stay on top of the pain" & treat it before it gets out of hand. The pt. will rate her pain no higher than a 4/10 on the pain scale by the end of my shift on 12-5-11 at 12:00 pm. CONCEPT MAP, 12-5-11
Pt. will ambulate 60 ft with walker & assist x 1 by the end of my shift on 12-5-11 at 12:00 pm. PT consult for instruction on use of assistive devices (walker, crutches, etc.) Encourage pt. to perform AROM exercises Q 2hrs as tolerated as this will prevent muscle atrophy as well ass condition the pt. & work pt. up to full ambulation. Evaluate effectiveness of ALL pain control measures used (not just meds), as research shows the most common reason for unrelieved pain is failure to routinely assess pain & pain relief. Establish a baseline assessment of pain and have pt. choose goal pain level, as baseline assessment gives a reference point & alerts staff about changes in pain status. Administer prn pain medication as needed per MD orders.
Pt. education re: non-pharmacologic approach to pain relief. Claudia Forrisi