1 Mark is due to go to theatre for stabilisation of his mid-shaft fractured femur.

Write a pre-operative (day of surgery) nursing care plan for Mark while he is
being nursed in the orthopaedic ward. It is expected that you will have three
nursing diagnoses with four nursing interventions for each. Each nursing
intervention should include a rationale and have up-to-date supporting
literature and research. One of your nursing diagnoses must have a focus on
Marks mental health.

Nursing Diagnosis 1: Acute pain related to tissue injury caused by closed mid-
shaft transverse femoral fracture as the patient indicated pain score of 7 on a 0 to 10
(Numeric Pain Scale [NPS]) pain scale.

Goal: The patient reports a reduction of his pain severity from 7 to 1 or 2 on a 0 to 10

pain scale with 30 minutes of interventions.

Interventions Rationale

1. Half hourly assessment of pain
by using OLDCART (Onset,
Location, Duration,
Characteristics, Aggravating
and Relieving factors,
Treatment) pain scale as well as
the Numeric Rating Scale (NRS)
which measures the intensity or
the severity of the pain.
The studies showed that if NRS is applied
in combination with a descriptive pain
scale such as OLDCART, a nurse will be
facilitated with choosing the most
appropriate pain management intervention
for the client ((Lord, 2016, p. 40; Jacques,
2017, para.5). Adding to this, the NRS,
which is based on the abstract thinking of
the patient, helps the nurse to assign the
correct score to the client, which indeed,
assists him / her (the nurse) to choose the
most suitable pro re nata (p.r.n.) analgesia
(Tandon et al., 2016, p. 229).
2: Advise the patient to keep his right
limb slightly elevated with the help of
pillows and instruct him to maintain the
affected limb at the neutral/ stable
position.
Limb elevation promote the venous return
to the heart and minimising the venous
congestion which in turn helps in reducing
oedema and pain in the affected limb
(Tota et al., 2013, p. 510). However,
maintaining the neutral position of the
limb helps in preventing the discomfort
caused by the extension of the tissue
injury (Murray, Tremblay, Corriveau,
Hamel & Cabana, 2015, pp. 555-556).

3: Check the medication chart for
prescribed medication and administer
the most accurate analgesia as
prescribed by Marks physician and as
per his pain score.
Checking the medication chart, helps the
nurse to eliminate the chance to do
medication error and promote the clients
safety ( 2012, Lippincott).

4: Identify the willingness / It is evidenced that the effectiveness of

preferences and ability of Mr Jones to
participate in non-pharmacological
relaxation strategies which includes
deep breathing exercises, quiet and
non- disruptive environment with dim
light.
pain management strategies could be
increased by involving the client in the
planning process (Lim, Yobas & Chen,
2014, p. 890).
The breathing exercises help in reducing
the unnecessary muscle tension which
reduces the pain intensity. However, the
relaxed environment promotes the client to
stay focused on the above interventions
(pp. 892- 894).

Evaluation: Mr Jones reported a reduction of his pain score to 2/10 on NPS with half
an hour of interventions.

Nursing Diagnosis 2: Ineffective tissue perfusion on the distal part of the fractured
limb related to the impaired arterial supply and venous drainage that could be
caused by tight tractions, excessive blood loss or thrombus formation.
Goal: The patient maintains the peripheral tissue profusion as evidenced by his
stable vital signs including the normal neurovascular response within 20 minutes of
nursing interventions.
 Interventions: Rationale:

1: Assess and monitor vital signs which Excessive blood loss during injury
includes investigating the generalised reduces circulatory blood volume which
signs of cyanosis represented by cold, increases the chances to get in
clammy and pale skin. adequate tissue perfusion by reducing
the cardiac output (McMullen & Patrick,
2013, para 3).
2: Perform peripheral neurological Impaired circulation to the nerve or
response for both sensory and motor direct trauma to the nerve may cause
stimuli, on the affected limb by providing the loss of sensory/ motor perception on
pin prick on the toe and examining the affected limb which is evidenced by
dorsiflex response. numbness, tingling sensation and
difficulty to dorsiflex the toe if indicated
(Fallon & Varshavski, 2017, p. 6).
3: Investigate and access lower The evidences show that long term
extremities for erythema, discoloration, immobilisation or disruption of vascular
swelling and pain. system in the fractured limb may cause
tissue ischaemia or swelling on the
distal aspect of limb (Ikonomidis et al.,
2014, pp. 105-106 ).
4: Use anti embolism stockings as These compression stockings
indicated so as to provide an optimum encourage venous drainage of the
amount of pressure. affected limb which reduces the risk of
thrombus formation (Macintyre, Stewart
& Rae, 2014, pp. 20-22).
5: Maintain electrolyte and fluid balance It aids in maintaining circulatory volume
by administering IV fluids as prescribed. which helps in delivering adequate
oxygen supply to the tissues (McMullen
& Patrick, 2013, para 3).

Evaluation: Mark demonstrates an adequate peripheral tissue perfusion as

evidenced by the presence of sensation and stable pulse and absence of any signs
of discoloration on his lower extremities within 20 minutes of interventions.

Nursing Diagnosis 3: Anxiety related to knowledge deficit about the surgical

procedure and postsurgical health outcome as evidenced by the clients facial
tension.
Goal: 45 minutes after nursing interventions, Mr Jones will verbalise awareness
about the surgical procedure and will identify the expected post-surgical health
outcome, which will help him to reduce his fear to a manageable level.

Interventions: Rationale:
 1: Identify patients level of anxiety and
provide the most accurate preoperative
knowledge based on the initial assessment
findings.
Different coping strategies are influenced by
different level of anxieties. Preoperative
knowledge helps the client to understand their
situation which in turn helps in alleviating their
fear (Goodman, 2015, pp. 305-306).

Anesth Pain Med. 2016 Feb; 6(1): e32101.

Published online 2016 Jan 17. doi: 10.5812/aapm.32101

PMCID: PMC4834447

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Objective Pain Score Vs. Numeric Rating Scale For the Evaluation of Acute Pain: A Comparative
Study. Journal Of Anaesthesia And Pain Medicine, 6(1), 228- 235. doi: 10.5812/aapm.32101.

Manish Tandon,1,* Anshuman Singh,1 Vandana Saluja,1 Mandeep Dhankhar,1 Chandra Kant
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