Nursing Care Plan for Fracture

Nursing Diagnosis Pain, acute related to Muscle spasms Movement of bone fragments, edema, and injury to the soft tissue Cues Reports of pain Distraction; selffocusing/narr owed focus; facial mask of pain Goals Verbalize relief of pain Display relaxed manner; able to participate in activities, sleep/rest appropriately. Intervention Independent 1. Maintain immobilization of affected part by means of bed rest, cast, splint, traction. 2. Elevate and support injured extremity. 3. Avoid use of plastic sheets/pillows under limbs in cast. 4. Elevate bed covers; keep linens off toes. 5. Evaluate/document reports of pain/discomfort, noting location and characteristics, including intensity (010 scale), relieving and aggravating factors. Note nonverbal pain cues (changes in vital signs and emotions/behavior). 6. Listen to reports of family member/SO regarding patients pain. 7. Encourage patient to discuss problems related to injury. 8. Provide alternative comfort measures, e.g., massage, back rub, position changes. 9. Provide emotional support and encourage use of stress management techniques, e.g., progressive relaxation, deep-breathing exercises, visualization/guided imagery; provide Therapeutic Touch. 10. Identify diversional activities appropriate for patient age, physical abilities, and personal preferences.

Traction/immobil Guarding, ity device protective behavior; Stress, Anxiety alteration in muscle tone; autonomic responses

Dependent 1. Apply cold/ice pack first 24 72 hr and as necessary. 2. Administer medications as indicated: narcotic and nonnarcotic analgesics, e.g., morphine, meperidine (Demerol), hydrocodone (Vicodin); injectable and oral nonsteroidal antiinflammatory drugs (NSAIDs), e.g., ketorolac (Toradol), ibuprofen (Motrin); and/or muscle relaxants, e.g., cyclobenzaprine (Flexeril), carisoprodol (Soma), diazepam (Valium). Administer analgesics around the clock for 35 days. 3. Explain procedures before beginning them. Medicate before care activities. Let patient know it is important to request medication before pain becomes severe. Independent 1. Assess degree of immobility produced by injury/treatment and note patients perception of immobility. 2. Reposition periodically and encourage coughing/deep breathing exercises. 3. Encourage increased fluid intake to 20003000 mL/day (within cardiac tolerance), including acid/ash juices. 4. Encourage participation in diversional/recreational activities. 5. Maintain stimulating

Mobility, impaired physical May be related to Neuromuscular skeletal impairment; pain/discomfort; restrictive therapies (limb immobilization) Psychological immobility

Inability to move purposefully within the physical environment, imposed restrictions Reluctance to attempt movement;

Regain/maintain mobility at the highest possible level. Maintain position of function. Increase strength/functio n of affected and

limited ROM

compensatory body parts.

Decreased muscle Demonstrate strength/cont techniques that rol enable resumption of activities.

environment, e.g., radio, TV, newspapers, personal possessions/pictures, clock, calendar, visits from family/friends. Instruct patient in/assist with active/passive ROM exercises of affected and unaffected extremities. 6. Encourage use of isometric exercises starting with the unaffected limb. 7. Provide footboard, wrist splints, trochanter/hand rolls as appropriate. 8. Place in supine position periodically if possible, when traction is used to stabilize lower limb fractures. 9. Instruct in/encourage use of trapeze and post position for lower limb fractures. 10. Assist with/encourage selfcare activities (e.g., bathing, shaving). 11. Provide/assist with mobility by means of wheelchair, walker, crutches, canes as soon as possible. Instruct in safe use of mobility aids. 12. Monitor blood pressure (BP) with resumption of activity. Note reports of dizziness. Collaborative 13. Consult with physical/occupational therapist and/or rehabilitation specialist. Independent 1. Examine the skin for open wounds, foreign bodies, rashes, bleeding, discoloration, duskiness, blanching.

Impaired skin/tissue integrity r/t : Puncture injury; compound

Reports of itching, pain, numbness, pressure in

Verbalize relief of discomfort. Demonstrate

fracture; surgical affected/surr repair; insertion ounding area of traction pins, wires, screws Disruption of skin surface; Altered invasion of sensation, body circulation; structures; accumulation of destruction excretions/secre of skin tions layers/tissue s Physical immobilization

behaviors/techni ques to prevent skin breakdown/facili tate healing as indicated.

Achieve timely wound/lesion healing if present.

2. Massage skin and bony prominences. Keep the bed linens dry and free of wrinkles. Place water pads/other padding under elbows/heels as indicated. 3. Reposition frequently. Encourage use of trapeze if possible. 4. Assess position of splint ring of traction device.

Cast Care: Wet (NIC) 1. Plaster cast application and skin care: Cleanse skin with soap and water. Rub gently with alcohol and/or dust with small amount of a zinc or stearate powder; 2. Cut a length of stockinette to cover the area and extend several inches beyond the cast; 3. Use palm of hand to apply, hold, or move cast and support on pillows after application; Independent 1. Trim excess plaster from edges of cast as soon as casting is completed; 2. Promote cast drying by removing bed linen, exposing to circulating air; 3. Observe for potential pressure areas, especially at the edges of and under the splint/cast; 4. Pad (petal) the edges of the cast with waterproof tape; 5. Cleanse excess plaster from skin while still wet, if possible;

6. Protect cast and skin in perineal area. Provide frequent perineal care; 7. Instruct patient/SO to avoid inserting objects inside casts; 8. Massage the skin around the cast edges; 9. Turn frequently to include the uninvolved side, back, and prone positions (as tolerated) with patients feet over the end of the mattress. Traction/Immobilization Care (NIC) Skin traction application and skin care: 1. Cleanse the skin with warm, soapy water; 2. Apply tincture of benzoin; 3. Apply commercial skin traction tapes (or make some with strips of moleskin/adhesive tape) lengthwise on opposite sides of the affected limb; 4. Extend the tapes beyond the length of the limb; 5. Place protective padding under the leg and over bony prominences; 6. Wrap the limb circumference, including tapes and padding, with elastic bandages, being careful to wrap snugly but not too tightly; 7. Palpate taped tissues daily and document any tenderness or pain; 8. Remove skin traction every 24 hr, per protocol; inspect and give skin care.

Skeletal traction/fixation application and skin care: y Bend wire ends or cover ends of wires/pins with rubber or cork protectors or needle caps; y Pad slings/frame with sheepskin, foam. Pressure Management (NIC) Collaborative Provide foam mattress, sheepskins, flotation pads, or air mattress as indicated. Monovalve, bivalve, or cut a window in the cast, per protocol. Peripheral Neurovascular, dysfunction, risk for Risk factors may include Reduction/interr uption of blood flow Direct vascular injury, tissue trauma, excessive edema, thrombus formation Hypovolemia Independent Maintain tissue perfusion as evidenced by palpable pulses, skin warm/dry, normal sensation, usual sensorium, stable vital signs, and adequate urinary output for individual situation. 1. Remove jewelry from affected limb. 2. Evaluate presence/quality of peripheral pulse distal to injury via palpation/Doppler. Compare with uninjured limb. 3. Assess capillary return, skin color, and warmth distal to the fracture. 4. Assess entire length of injured extremity for swelling/edema formation. Measure injured extremity and compare with uninjured extremity. Note appearance/spread of hematoma. 5. Note reports of pain extreme for type of injury or increasing pain on passive movement of extremity, development of paresthesia,

muscle tension/tenderness with erythema, and change in pulse quality distal to injury. Do not elevate extremity. Report symptoms to physician at once. 6. Encourage patient to routinely exercise digits/joints distal to injury. Ambulate as soon as possible. Collaborative Apply ice bags around fracture site for short periods of time on an intermittent basis for 2472 hr. Infection, risk for Risk factors may include Inadequate primary defenses: broken skin, traumatized tissues; environmental exposure Invasive procedures, skeletal traction Independent Achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile. 1. Inspect the skin for preexisting irritation or breaks in continuity. 2. Assess pin sites/skin areas, noting reports of increased pain/burning sensation or presence of edema, erythema, foul odor, or drainage. 3. Provide sterile pin/wound care according to protocol, and exercise meticulous handwashing. 4. Observe wounds for formation of bullae, crepitation, bronze discoloration of skin, frothy/fruity-smelling drainage. 5. Assess muscle tone, reflexes, and ability to speak. 6. Monitor vital signs. Note presence of chills, fever, malaise, changes in mentation. 7. Investigate abrupt onset of

pain/limitation of movement with localized edema/erythema in injured extremity. Collaborative Monitor laboratory/diagnostic studies, e.g.: Complete blood count (CBC); ESR; Cultures and sensitivity of wound/serum/bone; Radioisotope scans. Administer medications as indicated, e.g.: IV/topical antibiotics; Tetanus toxoid. Gas Exchange, risk for impaired Risk factors may include: Altered blood flow; blood/fat emboli Alveolar/capillar y membrane changes: interstitial, pulmonary edema, congestion Independent Maintain adequate respiratory function, as evidenced by absence of dyspnea/cyanos is; respiratory rate and arterial blood gases (ABGs) within patients normal range. 1. Monitor respiratory rate and effort. Note stridor, use of accessory muscles, retractions, development of central cyanosis. 2. Auscultate breath sounds, noting development of unequal, hyperresonant sounds; also note presence of crackles/ rhonchi/wheezes and inspiratory crowing or croupy sounds. 3. Instruct and assist with deep-breathing and coughing. Reposition frequently. 4. Note increasing restlessness, confusion, lethargy, stupor. Collaborative Assist with incentive spirometry. Administer supplemental oxygen if indicated. Monitor laboratory studies e.g ABG

Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, selfcare, and discharge needs May be related to Lack of exposure/recall Information misinterpretation /unfamiliarity with information resources

Knowledge: Treatment Regimen (NOC) Verbalize understanding of condition, prognosis, and potential complications. Correctly perform necessary procedures and explain reasons for actions.

Teaching: Disease Process (NIC) Independent 1. Review pathology, prognosis, and future expectations. 2. Discuss dietary needs. 3. Discuss individual drug regimen as appropriate. 4. Reinforce methods of mobility and ambulation as instructed by physical therapist when indicated. 5. List activities patient can perform independently and those that require assistance. 6. Identify available community services, e.g., rehabilitation teams, home nursing/homemaker services. 7. Encourage patient to continue active exercises for the joints above and below the fracture. 8. Discuss importance of clinical and therapy followup appointments. 9. Review proper pin/wound care. 10. Recommend cleaning external fixator regularly. Teaching Disease Process: 1. Identifysigns/symptoms requiring medical evaluation, e.g., severe pain, fever/chills, foul odors; changes in sensation, swelling, burning, numbness, tingling, skin discoloration, paralysis, white/cool toes or fingertips; warm spots, soft areas,

cracks in cast. 2. Demonstrate use of plastic bags to cover plaster cast during wet weather or while bathing. 3. Clean soiled cast with a slightly dampened cloth and some scouring powder. 4. Emphasize importance of not adjusting clamps/nuts of external fixator. 5. Demonstrate use of plastic bags to cover plaster cast during wet weather or while bathing. Clean soiled cast with a slightly dampened cloth and some scouring powder. 6. Emphasize importance of not adjusting clamps/nuts of external fixator.