NURSING CARE PLAN
ASSESSMENT
- Assess for history of the
injury, presence of factors
that may cause pathologic
fractures (osteoporosis,
osteomyelitis, neoplastic
diseases, etc.).
- Assess presence of signs
of fracture (edema, pain,
loss of motion, crepitus,
extremity disproportion or
abnormal positioning).
- Assess presence of signs
and symptoms of soft
tissues involvement
(swelling, hemorrhage,
impaired sensation in the
extremity).
- Assess extremity for
presence of open fracture
and severe external
hemorrhage.
- Assess vital signs, fluid
balance and urine output.
- Assess diagnostic tests
and procedures for
abnormal values.
- Assess routine
preoperative history
NURSING PLANNING
DIAGNOSIS
- Acute pain and - Increase comfort,
immobility , related to decrease pain.
diagnosis of fracture. - Prevent avoidable injury.
- Prevent complications of
immobility.
- Provide optimal bone
and wound healing.
- Then surgical
intervention prescribed,
prevent postoperative
complications.
- Decreased anxiety with
increased knowledge.
INTERVENTIONS
- Provide emergency care
if requires (hemostasis,
respiratory care,
prevention of shock).
- Provide fracture fixation
to prevent following
injury of tissues.
- Observe signs of fat
embolism (especially
during first 48 hours after
the fracture).
- Monitor client’s vital
signs.
- Monitor fluids input and
output continuously, insert
IV catheter, urinary
catheter.
RATIONALE
- To rule out worsening of
underlying condition or
development of
complications.
- Individual with external
locus of control may take
little or no responsibility
for pain management.
- Observations may or
may not be congruent with
verbal reports indicating
need for further
evaluation.
- Vital signs usually
altered in acute pain.
EVALUATION
- Reports increased comfort,
decreased pain.
- No evidence of respiratory,
vascular or skin
complications of immobility.
- Maintains stable vital
signs, fluid and metabolic
balance, nutritional state.
- Has sufficient fracture
healing rate.
- Laboratory tests results
shows no abnormalities.
- No postoperative
complications, or treatment
complications.
- Learned of crutch-walking,
taking care of himself then
possible.
- Demonstration of
understanding of fracture
healing process, diagnostic
and treatment procedures,
trauma prevention, and need
for follow-up.