Assessment Nursing Diagnosis Planning Intervention Rationale Expected Outcomes

Subjective data: Acute pain related to total Short term: Independent: Independent: Short term:
hip arthroplasty 1. Assess patients for 1. Pain is expected after a
Objective data: After 2-3 hours of nursing pain using a standard surgical procedure because of After 2-3 hours of nursing
(Replacement)
V/S pain intensity scale. the surgical trauma and tissue intervention;
intervention;
Temp. response. Muscle spasms
RR ● The patient will be occur after total hip ● The patient shall have
HR replacements. Immobility described his/her
able to describe
O2 sat causes discomfort at pressure
Bp his/her discomfort. points. discomfort.
● COLDSPA
● Facial Grimace
● Restlessness ● The patient will be ● The patient is able to
● Lethargic Independent: Independent: express confidence to
able to express his/her
● Patient up with 2. Ask patients to 2. Pain characteristics may
assistance confidence in efforts describe discomfort. help to determine the cause of control the pain
● Inadequate knowledge discomfort. Pain may be due .
to control the pain.
in medication as to complications (hematoma,
prescribed infection, dislocation). Pain is ● The patient’s pain
● The patient’s pain will an individual experience-it shall be reduced and
means different things to
be reduced and the different people. the pain intensity will
pain intensity scores decrease.
will decrease.
Long term:
Long term:
 After 3 days of nursing
intervention, the patient  After 3 days of nursing

will be able to use intervention, the patient

physical, psychological, Dependent: Dependent: uses physical,
3. Acknowledge 3. The nurse can reduce the
and pharmacologic psychological, and
existence of pain; stress experienced by the
measures to reduce pain inform patient of patient by communicating pharmacologic measures
available analgesic concern and availability of
and discomfort. to reduce pain and
agents or muscle assistance to help the patient
relaxants. deal with the pain. discomfort.

a. Use pain-modifying a. Patients will require

techniques. parenteral opioids during the
Administer analgesic first 24-48 hours and then will
agents as prescribed. progress to oral analgesic
agents.
b. Change position
within prescribed b. The use of pillows to
limits. provide adequate support and
relief of pressure on bony
prominences assists in
minimizing pain.
c. Modify the
environment. c. Interactions with others,
distractions, and sensory
overload or deprivation may
d. Notify the primary affect pain experience.
provider about
persistent pain. d. Surgical intervention may
be necessary if pain is due to
hematoma or excessive
edema.

Dependent: Dependent:
4. Evaluate and record 4. Effectiveness of action is
discomfort and based on experience, data
effectiveness of pain- provide a baseline about pain
modifying techniques. experiences, pain
management, and pain relief.
Subjective Data: Impaired physical mobility Short term: Independent: Independent: Short term:
related to positioning, 1. Maintain proper 1. Prevents dislocation of hip
Objective Data: weight bearing, and activity After 4 hours of nursing positioning of the hip joint prosthesis. After 4 hours of nursing
V/S restrictions after total hip intervention; (abduction, neutral rotation, Independent: intervention;
Temp. arthroplasty. limited flexion)
RR ● The patient will not independent: 2. Prevents pressure ulcer on ● The patient shall have
HR have heel pressure. heel. no heel pressure.
O2 sat 2. Keep pressure off the heel.
Bp
● The patient will be Independent: Independent: ● The patient shall
● Weakness
● Facial Grimace when able to participate in 3. Instruct and assist in 3. Encourages patient's active participate in
position changes and participation while preventing
moving progressive transfers. dislocation. progressive
● Report Discomfort
and pain upon ambulation program. ambulation program.
movement.
● Guarding Behavior on
● The patient will be ● The patient shall
the operated
Extremity. able to exercise hourly exercise hourly while
● Patient is need
while awake. awake.
assistance
● Lack of motivation
After 4 days of nursing Independent: Independent: Long term:
intervention; 4. Instruct and supervise 4. Strengthens muscles
isometric quadriceps and needed for walking. After 4 days of nursing
● The patient will be gluteal setting intervention;
able to assist in ● The patient shall be
Collaborative: Collaborative:
position changes. 5. In consultation with a 5. Amount of weight bearing assisted in position
physical therapist, instruct depends on the patient's changes.
and supervise progressive condition and prosthesis;
● The patient will be safe ambulation within ambulatory aids are used to ● The patient shall
able to actively limitations of weight-bearing assist the patient with non actively participate in
prescription. weight-bearing and partial
participate in the Weight-bearing ambulation. the exercise regimen.
exercise regimen. ● The patient shall
Independent: Independent:
6. Offer encouragement and 6. Reconditioning exercises maintain a prescribed
support exercise regimen. can be uncomfortable and
 ● The patient will be fatiguing; encouragement position.
helps patients comply with
able to maintain a ● The patient shall show
exercise programs.
prescribed position. increased
Independent: Independent:
independence in
● The patient will be 7. Instruct and supervise safe 7. Prevents injury from unsafe transfers.
use of ambulatory aids. use and prevents falls.
able to show increased ● The patient shall use
independence in ambulatory aids
transfers. correctly and safely.

● The patient will be

able to use ambulatory
aids correctly and
safely.

Subjective Data: COLLABORATIVE Short term: Hemorrhage Short term:

PROBLEMS: Independent: Independent:
Objective Data: After 8 hours of nursing 1. Monitor vital signs, 1. Changes in pulse, blood After 8 hours of nursing
V/S Risk for bleeding related to intervention; observing for shock. pressure, and respirations may intervention;
Temp. indicate development of
surgery. ● The patient’s vital
RR ● The patient’s vital shock. Blood loss and stress
HR of surgery may contribute to signs shall be
O2 sat signs will be able to development of shock. stabilized within
Bp stabilize within normal limits.
● Active Bleeding Independent: Independent:
● Decreased Blood test normal limits. 2. Note character and amount 2. Within 48 hours, bloody ● The patient’s drainage
results: of drainage. drainage collected in portable amount shall be
Hematocrit suction devices, if in use, decreased.
● The patient’s drainage should decrease to 25-30 mL
Hemoglobin
per 8 hours. Excessive ● The patient shall have
amount will be able to
drainage (>250 mL in the first no bright-red bloody
decrease. 8 hours after surgery) and drainage.
bright-red drainage may
• The patient’s
indicate active bleeding.
● The patient will have hematology values
Collaborative Collaborative shall be within normal
 no bright-red bloody 3. Notify the primary provider 3. Corrective measures need limits.
if a patient develops shock or to be instituted.
drainage.
excessive bleeding, and
prepare for administration of
● The patient’s fluids, blood component
therapy, and medications.
hematology values
Independent: Independent:
will be within normal
4. Monitor hemoglobin and 4.Anemia due to blood loss
limits. hematocrit values. may develop. Blood
replacement or iron
supplementation may be
needed.

Subjective Data: Collaborative Problems. After 8 hours of nursing Neurovascular Dysfunction After 8 hrs of nursing
Risk for Independent:
Peripheral intervention the client will: Independent: intervention;
Objective Data: 1. Assess affected extremity 1. The skin becomes pale and
V/S Neurovascular Dysfunction ● Maintain function as for color and temperature. feels cool with decreased  The patient skin color
Temp. related to surgery. tissue perfusion. Venous shall be normal.
RR evidenced by congestion may produce
HR sensation, movement cyanosis.  The patient extremity
O2 sat shall be arm .
Bp within normal limits Independent: Independent:
 The patient capillary
● COLDSPA for the individual 2. Assess toes for capillary 2. After compression of the
refill response. nail, rapid return of pink color refill shall be normal.
● Diminished or absent situation. indicates good capillary
perfusion.  The patient
pulses, delayed
edema ,swelling and ;
capillary refill time, ● Demonstrate adequate Independent: Independent: tissue not palpably tense
tissue perfusion as 3. Assess extremity for edema 3. The trauma of surgery will shall be Moderate
pallor, blanching,
and swelling. Report patient cause edema. Excessive
cyanosis, and evidenced by palpable complaints of leg tightness. swelling and hematoma  The patient Pain shall be
formation can compromise controllable
coldness of skin. pulses, brisk capillary
circulation and function.
● excessive bleeding or refill, skin warm/ dry ,  The patient shall have No
Independent: Independent: pain with passive
hematoma and normal color. dorsiflexion.
4.Elevate lower extremity. 4. Minimizes dependent
formation. Keep elevated extremity edema. Hip is never flexed
lower than hip when in a more than 90 degrees to  The patient sensation
● More than 200- chair. prevent dislocation. shall be Normal..
500ml wound Independent:  The patient motor
drainage in the first Independent: 5. Surgical pain can be abilities shall be normal.
5. Assess for deep, throbbing, controlled; pain due to
24 hrs. unrelenting pain. neurovascular compromise is  The patient Pulses shall
● Lab. results not relieved by treatment. be strong and equal.

hct  The patient shall have No

paresthesia and No
● Positioning
paresis or paralysis.
● swelling
Independent: Independent:
● Clothing 6. Assess for pain on passive 6. With nerve ischemia, there
● Confusion flexion of foot. will be pain
on passive stretch.
Additionally, pain or
tenderness may indicate deep
vein thrombosis.

Independent: Independent
7. Assess for change in 7. Diminished pain and
sensations and numbness. sensory function may indicate
nerve damage. Sensation in
web between great and
second toe peroneal nerve;
sensation on sole of foot-
tibial nerve.

Independent: Independent:
8. Assess ability to move feet 8. Dorsiflexion of the ankle
and toes. and extension of toes indicate
function of the peroneal
nerve. Plantar flexion of ankle
and flexion of toes indicate
function of tibial nerve.
 Independent: Independent:
9. Assess pedal pulses in both 9. Indicator of extremity
feet. circulation.

Collaborative: Collaborative:
10. Notify Neurosurgeon if 10. Function of extremity
altered neurovascular status is needs to be preserved.
noted.

Subjective Data: Collaborative problem: After 8 hours of nursing Dependent: Dependent: After 8 hours of nursing
Objective Data: Dislocation of Prosthesis intervention; 1. Position patient as 1. Hip component positioning intervention;
V/S related to Surgery. prescribed. (femoral component in
Temp.  the Patient Prosthesis will acetabular component) needs • the patient Prosthesis shall
RR not be dislocated. to be maintained. not be dislocated.
HR  The Patient will Adheres
O2 sat to recommendations to Dependent: Dependent:  The patient shall Adheres
Bp prevent dislocation. 2. Use abductor splints or 2. Keeps hip in abduction and to recommendations to
pillows to maintain position in a neutral rotation to prevent prevent dislocation.
● Shortening of and to support extremity. dislocation.
the leg.
● Inability to move the Dependent: Dependent:
leg. 3. Support leg and place 3.Prevent dislocation.
● Malalignment of the pillows between legs when
leg. patient is turning and side
● Abnormal rotation. lying; turn to the unaffected
side.

Independent: Independent:
4. Avoid acute flexion of the 4. Findings may indicate
hip (head of bed less than or dislocation of prosthesis.
equal 90 degrees).

Dependent: Dependent:
5. Avoid crossing legs. 5. Joint dislocations
compromise neurovascular
status and future function of
extremity.

Independent: Independent:
 6. Assess for dislocation of 6. Joint dislocations
prosthesis (extremity compromise neurovascular
shortens, internally or status and future function
externally rotated, severe hip
pain, patient unable to move
extremity).

Collaborative:
7. Notify the surgeon of
possible dislocation.

Subjective data: Collaborative problems: Short term: Deep Vein Thrombosis After 8 hours of nursing
Pain Ineffective tissue perfusion intervention the client shall
● Pleuritic chest pain After 8 hours of nursing Dependent: Dependent: be:
related to surgery.
intervention the client will: 1. Use anti embolism stocking 1. Aids in venous blood
Objective data: and sequential compression return and prevent stasis.
V/S ● Maintain optimal devices as prescribed.  Wearing anti embolism
Temp. stocking; uses
RR peripheral tissue Dependent: Dependent:
HR 2. Remove stocking for 20 2. Skin care is necessary to compression devices.
perfusion in the
O2 sat minutes twice a day and avoid breakdown. Extended
affected extremity, as provide skin care.  No skin breakdown
Bp removal of stocking defeats
● Tenderness the purpose of stocking.  Pulses equal and strong
evidenced by strong
● Pitting edema  Skin temperature normal.
● Warm or cool skin palpable pulses, Independent: Independent:
● Skin Discoloration 3. Assess popliteal, dorsalis 3. Pulses indicate arterial  No calf pain or
reduction in and or pedis, and posterior tibial perfusion of extremity.
absence of pain, pulses. tenderness.
● PE examination:
● Dyspnea warm, and dry Independent:  Changes position with
Independent:
● Tachycardia
extremities,and 4. Assess skin temperature of 4. Local inflammation will assistance and
● Confusion
legs. increase local skin
inadequate capillary supervision
temperature.
refill.  Participates in exercise
Independent: Independent:
5. Assess for unilateral calf 5. Pain or tenderness may regimen
● Not experience pain or tenderness every 8 indicate deep vein  Normal Body
hours. thrombosis.
 pulmonary embolism, Independent: Independent: temperature.
6. Avoid pressure on popliteal 6. Compression of blood
as evidenced by  Well hydrated.
blood vessels from equipment vessels diminishes blood
normal breathing, (e.g., adductor splint straps, flow.  No chest pain; lungs clear
sequential compression
Normal heart rate, and to auscultation; no
stockings) or pillows.
absence of dyspnea evidence of pulmonary
Dependent: Dependent:
and chest pain. 7. Change position and 7. Activity promotes emboli
increase activity as circulation and diminishes
prescribed. venous stasis.

Dependent: Dependent:
8. Supervise ankle exercises 8. Muscle exercise promotes
hourly. circulation.

Independent: Independent:
9. Monitor body temperature. 9. Body temperature increases
with inflammation.

Independent: Independent:
10. Encourage fluids. 10. Dehydration increases
blood viscosity.

Subjective Data: Risk for Infection related to Short term: Infection

Pain a site for organism invasion Independent: Independent: After 8 hours of nursing
After 8 hours of nursing 1. Monitor vital signs. 1. Temperature, pulse, and intervention, shall have:
secondary to surgery.
Objective Data: intervention, the client will: respirations increase in
V/S response to infection.  Vital signs normal
Temp.: Increase temperature ● Identify the risk factors (Magnitude of response may
RR be minimal in older adults.)  Tolerates antibiotics
that are present.
HR  Well-approximated
O2 sat ● Have full understanding Independent: Independent:
Bp 2. Use aseptic technique for 2. Avoids introducing incision without drainage
about infection control.
● Purulent drainage w/ dressing changes and organisms. or excessive
foul odor ● Have full knowledge in emptying of portable
● Wound Redness drainage. inflammatory response.
identifying the risk factors
● Swelling  Minimal discomfort; no
of the infection. Independent: Independent:
 ● Age ● Be free from any signs 3. Assess wound appearance 3. Red, swollen, draining hematoma.
● Obese, poorly and character of drainage. incision is indicative of
and symptoms related to  Tolerates antibiotics.
nurished. infection.
● Use of corticosteroids infection.
● Hematomas Independent: Independent:
● Free be from discomfort. 4. Assess complaints of pain. 4. Pain may be due to wound
Health history : ● Tolerate antibiotics. hematoma, a possible locus of
● Diabetes infection-that needs to be
● Rheumatoid Arthritis ● Wound will have no surgically evacuated.
● Concurrent infections drainage and excessive
● MRSA Dependent: Dependent:
inflammation. 5. Administer prophylactic 5. Infected prosthesis is
● Have normal Vital signs. antibiotics if prescribed, and avoided.
observe for side effects.

Subjective data: Risk for ineffective health After 3 days of Nursing Independent: Independent: After 3 days of Nursing
maintenance related to total Intervention ; 1. Assess home environment 1. Physical barriers Intervention ;
hip replacement. for discharge planning. (especially stairs, bathrooms) Long term:
Objective data : Long term: may limit a patient's ability to
Temp. ambulate and care for self at  The client Home shall be
RR  The client will Cares of home. accessible at time of
HR self at Home. discharge.
O2 sat  The client will Independent: Independent:
Bp demonstrates ability to 2. Encourage patients to 2. Patients may have special  The client shall
● Abnormal range of lab provide necessary express concerns about care at problems that need to be Demonstrates ability to
values. assistance within the home; explore together identified and resolved. provide necessary
therapeutic prescription. possible solutions to the assistance within d
● Inability to perform  The client will Appears problem. therapeutic prescription
health maintenance relaxed and develop
behaviors due to strategies to deal with Collaborative: Collaborative:
physical impairment identified problems. 3. Assess availability of 3. Because of limitation of  The client Appearance
● Demonstrated lack of  The client will complies physical assistance for mobility and shall be relaxed and
home care program. healthcare activities. limited hip range of motion, develops strategies to
adherence
 The client will keep patients may require some deal with identified
● Lack of motivation assistance in routine health problems.
follow-up check ups.
● Life crisis care.
 The client Personal
Independent: Independent: assistance shall be
4. Teach home health care 4. Understanding of the available.
regimen to caregivers. rehabilitative regimen is
necessary for compliance.  The client shall Complies
with home care
Independent: Independent: programs.
5. Instruct patient on post 5. Lack of knowledge and
hospital care: poor preparation for care at  The client shall Keeps
home contribute to patient follow-up health care
a. Activity limitations (hip anxiety, insecurity, and non appointments.
precautions, weight-bearing adherence to therapeutic
limits) regimen.
b. Exercise instructions

c. Safe use of ambulatory aids

d. Wound care

e. Measures to promote
healing

f. Medications, if any

g. Potential problems

h. Continuing health care

supervision and management.