Morrisville State College

Division of Nursing
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Student Name: Date:

Assessments Nursing Diagnosis Goal/Plan Interventions Evaluation

Red
1. Assess pts level of
comfort frequently using
pain scale from 0 – 10
maintain pain control
with analgesics or to
promote comfort every 6
hours. Pain med given.
PRN med: Oxycodone
5mg given
1. Acute pain R/T 1. Patient will verbalize a 1. Teach patient other 1. Maintaining pt w/in
fractured left femoral decrease in pain score (< methods of pain control acceptable pain levels
neck and muscle spasm 5) by the end of the shift besides the use of the makes pt feel comfortable
AEB patient verbalized on 3/22/18. medication such as icing to move around &
pain as a 7 out of 10. and repositioning every promotes circulation for
two hours. the healing process. Goal
was met. Pt verbalized
pain score of 4 by end of
shift.

2. Assess pts ability to
perform ADL’s & pay
close attention to reports
of weakness, fatigue, &
difficulty accomplishing
tasks.
2. Impaired physical 2. Patient will be able to 2. Use a gait walk belt 2. Gait belt improves the
mobility R/T bed rest and walk at minimum 50 feet when ambulating patient caregivers grasp and
fractured left femoral by the end of shift on to prevent further injury. reduces the probability of
neck AEB her unsteady 3/22/18 injury. Goal was met. Pt
gait. was able to walk to the
bathroom and back to
bed. (approx. 50 feet)

3. Assess pt for signs of
decreased tissue perfusion
such as decreased BP,
restlessness, confusion,
cool extremities,
diminished or absent
peripheral pulses, slow
capillary refill, or edema.
3. Risk for ineffective 3. Patient will continue to
tissue perfusion R/T not exhibit any signs of
unstable bones and decreased tissue profusion
swelling. by the end of shift on
3/22/18
3. Pt will wiggle her toes 3. Evaluation provides a
on her left leg. Distal baseline for future
pulses are present & comparison. Goal met.
bilaterally strong; both
legs are warm.
 Morrisville State College
Division of Nursing
Linear Concept Map

4. Assess pts surgical site
dressing for bleeding,
purulent drainage, &
infection: s/s - swelling,
tenderness, and redness
5. Assess pt fall risk by
using Morse falls risk
assessment tool - scored
20 (high risk for falls).
4. Risk for infection R/T 4. Patient will remain
Pts surgical site on left free of infection (WBC >
leg. 10.5) by the end of shift
on 3/22/18
5. Risk for falls R/T 5. Patient will maintain
history of frequent falls. free of falls by the end of
shift on 3/22/18
4. Prophylactic antibiotic 4. Pt had moderate
therapy. amount of serosanguinous
drainage with WBC of 5.1.
Cephalexin 500mg given. Pt goal was met.
5. Patient was given call 5. Pt remained free of falls
bell and educated not to during shift and
get out of bed unassisted verbalized understanding
by caregiver. the use of the call bell
system.

Daily Meds:
Vitamin C 500mg
ASA EC 81mg
Cephalexin 500mg
Vitamin D 5000u
Celexa 40mg
Fe 325 mg
Lasix 40mg

Prn Meds:
Oxycodone 5mg
Colace 100mg