Patient medical information
K.A, a 17years old high school gymnast, fall and fracture his left femur several weeks ago. He has been on bed rest in skeletal traction since then, because of painful muscle spasms ,He often refuses to be turn or to move voluntarily.
1) Create a nursing care plan for KA with the above medical conditions.
2) Nursing Diagnosis?
Goals/Expected Outcomes?
Nursing Orders?
3) Define terms of assessment of the musculoskeletal system.
Nursing care plan for patient K. A
The nursing care plan is targeted at managing the muscle spasm and pain experienced by the patient.
Nursing diagnosis for this patient is that of Acute Pain. This may be related to muscle spasms, movement of bone fragments, edema and injury to the soft tissue, traction/immobility device, stress and anxiety. The possible evidence that helped to make this musculoskeletal assessment is that which relates to the reports of pain, distraction, self-focusing/narrowed focus, facial mask of pain, Guarding, protective behavior, alteration of the muscle tone and autonomic responses.
There is a desired outcome for the nursing care plan; This relates to verbalizing the relief of pain, display relaxed manner, able to participate in activities, acceptance of turning around and movement voluntarily, state of relaxation and sleeping properly.
Nursing diagnosis, goals and expected outcomes for patient K.A
- The increased risk of bone inflammation related to open fracture; in cases like this, the best nursing plan and intervention is to provide fixation of the fracture so as to help prevent the injury to the tissues hence reduce the risk of inflammation.
- Increased risk of fat embolism related to fracture of the long bones; when there are signs like this on the patient, such signs would have to observe continuously during the first 48 hours of patient fracture and admission.
- Increased risk of severe fluid, electrolyte, and metabolic imbalances related to injury or inflammation. The required nursing plan and intervention for this patient is to ensure that the fluid input and output is being monitored continuously while the insertion of IV catheter and urinary catheter are being done very carefully.
- Pain and immobility , related to diagnosis of fracture. As regards to this diagnosis which seems to be the most important regarding to the patient, the patient vital signs and responses need to be monitored to understand the response to the pain management. The required IV therapies, analgesics, antibiotic and other medications need to be administered appropriately to ensure that the patient is managed well as indicated.
- Increased risk of respiratory, cardiovascular, bowel, and skin complications related to a long period of immobility. The nursing plan and intervention for this nursing diagnosis is just to ensure that the required laboratory test is done and test evaluated appropriately to check any case of abnormalities.
- Anxiety related to the symptoms of disease and fear of the unknown. This is usually due to several factors. One important factor is that which relates to the fear of the intended surgical procedures. In cases of this, the patient and the family need to be prepared emotionally and physically for the intended surgical procedures.
Goals/expected outcome
There are several goals/expected outcome that need to be achieved while managing patient K.A. Such goals include the following listed below;
- Prevent all forms of avoidable injury common to such kind of patients.
- Prevent complications of immobility which could lead to some other problems.
- Provide optimal bone and wound healing to help reduce the patient hospital stay.
- Then surgical intervention prescribed, prevent postoperative complications.
- Decreased anxiety with increased knowledge and adequate emotional preparation.
In order to achieve the goals and expected outcomes for this patient, certain important steps are essential. These include;
- Care for the traction by checking the weights (if hanging properly and freely), check the skin (to avoid any form of irritation), site of the skeletal traction for the prevention of any form of infection. This can be done by ensuring aseptic technique for all procedures.
- Respiratory exercises are needed to prevent any form of lung infection in cases of associated risks.
- Checking for signs of thrombophlebitis often and report immediately when noticed.
- Risk of pressure sores should be avoided using appropriate skin care method.
Definition of terms of musculoskeletal assessment
- Atrophy : This described the state of muscle wasting with subsequent reduction in the size of the muscle.
- Hypertrophy: Simply describes the state of increased in muscle mass
- Contracture: Simply described the state of shortening in the length of muscle
- Fasciculation: means there is an involuntary muscle movement
References
Matt Vera (2013). 8 Fracture Nursing Care Plans. Nursing Care Plans. Nurses Labs.
Retrieved 4 December, 2013 from http://nurseslabs.com/8-fracture-nursing-care-plans/
International Biopharm Association (2005). Nursing Care Plan to the Client with Fractures of the Extremities and Extremities Surgery. Nursing assessment. Nursing care plan of fractures.
Retrieved 4 December, 2013 from http://nursingcareplanfractures.blogspot.com/
Peter, D. (2003). Skeletal pin traction: guidelines on postoperative care and support. Supplement. Fact File. Wound Care. 27 May 2003. Vol 99 No 21.
