Question

Simulated Patient’s Name in EHR: Simuwell Jackson

Brief History: Mr. Jackson was admitted two days ago, brought to the Emergency Department (ED) by ambulance after being struck by a vehicle while riding his motorcycle. He has suffered a fractured right tibia and fibula, and was taken to the OR on admission for an open reduction and internal fixation of the leg. Pins have been placed surgically through the bone above and below the fracture site to immobilize the bone as per radiological studies in EHR. Mr. Jackson has multiple lacerations to his right upper leg and is complaining of pain.

What are possible nursing interventions you anticipate providing for this patient?

Answer 1

Ans) Possible nursing diagnosis for this patient:

- Risk for Trauma: Falls related to history of previous fall.
- Acute Pain related to fracture
- Impaired Physical Mobility related to fracture.
- Impaired Skin Integrity related to multiple lacerations.
- Deficient Knowledge related to the treatment regimen
- Self-Care Deficit related to immobility.

Possible Nursing intervention:

- Assessment of the patient's conditions- Vital signs, level of tolerance.

- Maintain bed rest or limb rest as indicated. Provide support of joints above and below fracture site, especially when moving and turning- Provides stability, reducing the possibility of disturbing alignment and muscle spasms, which enhances healing.

- Secure a bed board under the mattress or place patient on the orthopedic bed- A soft or sagging mattress may deform a wet (green) plaster cast, crack a dry cast, or interfere with the pull of traction

- Maintain position or integrity of traction. Traction permits pull on the long axis of the fractured bone and overcome muscle tension or shortening to facilitate alignment and union- Skeletal traction (pins, wires, tongs) permits the use of greater weight for traction pull than can be applied to skin tissues.

- Assess and record the patient’s level of pain utilizing pain intensity rating scale including Wong Baker FACES pain rating scale, visual analog scale, and FLACC (face, legs, activity, crying, consolability) scale. Note relieving and aggravating factors, and nonverbal pain cues such as changes in vital signs, emotions, and behavior. Influences the effectiveness of interventions. Many factors, including the level of anxiety, may affect the perception of pain.

- Encourage patient to discuss problems related to the injury. Helps alleviate anxiety. The patient may feel the need to relive the accident experience.

- Maintain immobilization of affected part by means of bed rest, cast, splint, traction. Relieves pain and prevents bone displacement and extension of tissue injury.

- Elevate and support injured extremity. Promotes venous return, decreases edema, and may reduce pain.

- Avoid use of plastic sheets and pillows under limbs in cast- Can increase discomfort by enhancing heat production in the drying cast.

- Elevate bed covers; keep linens off toes- Maintains body warmth without discomfort due to the pressure of bedclothes on affected parts.

- Explain procedures before beginning them- Allows patient to prepare mentally for activity and to participate in controlling the level of discomfort.

- Medicate before care activities- Let the patient know it is important to request medication before pain becomes severe. Promotes muscle relaxation and enhances participation.