Question

write a care plan for the following scenario

Care Plan Scenario Steve Gralen, a 32-year-old male, was admitted to your unit after a motorcycle accident. He has a diagnosis of fractured right femur, fractured right wrist and lacerated abdomen. He has a cast on his right arm and leg and the lacerations of the abdomen have beern surgically repaired. He has returned from surgery with a foley catheter that is draining clear, yellow urine. He is alert and oriented x 3 and is complaining of pain at the incision site, He rates his pain as an 8 on a scale of 1-10. His abdominal dressing is intact with a small amount of serous drainage. His lungs are clear in all lobes. He has an IV of LR infusing at 100 c/hr. His IV site is in the left arm and is clean, dry and intact. Right toes and fingers are warm to touch. Bowel sounds are absent at this time. Abdomen is soft and flat. MM are dry. PPPPE. No complaints of nausea. Steve refuses to turn. cough and d breath. He states that it hurts when he moves. Physician Orders: IV LR to infuse at 100 cc/hr Clear liquid diet for supper than advance as tolerated PT consult for ambulation Demerol 50-75 mg IM Q4h prm pain Lovenox 30 mg SQ BID Ascorbic Acid 500 mg po TID Ferrus Sulfate 325 mg po BID Ancef 1 gram IVPB Q8hr Out of bed in AM D/C Foley catheter Dressing changes with Montgomery straps in AM and then QS and prn Lab Results Hgb - 10 gdL Hot-36 % glucose - 120 mg/dL WBC-12,000uL

Answer 1

Care Plan

Nursing Diagnosis	expected Outcome	Nursing Intervention	Rationale	Evaluation
Acute pain related to fracture secondary to road traffic accident as evidenced by pain of 8 verbalized by the patient	STG:patient verbalized of pain of 4 at the end of 8 hours shift LTG:patient verbalized of pain of 2 after 2 days and is able to move the limbs without grimacing	Assess the pain of the patient every second hourly Assess the vital signs for tachycardia Provide comfortable position Encourage to use diversion all therapies like music ,movies Provide a calm and quiet environment encourage the patient to do deep breathing and meditation Encourage the patient to verbalize interventions of his choice Administer analgesics Educate the patient to verbalize any discomfort,increase Or decrease in pain   Educate the relatives to touch and comfort the patie	To get a baseline data Vital signs like tachycardia shows that the patient may have pain To provide relaxation and diversion It will help the patient to concentrate on relaxation techniques and keep distraction away To help him cope better Touch therapy helps the human body to heal	STG patient verbalized pain of 4/10 at the end of 8 hours LTG:patient verbalized pain of 2/10 after 2 days patient is able to move the limbs in ROM without grimacing