Fractures, commonly known as broken bones, are a frequent injury resulting from various causes, ranging from traumatic events like motor vehicle accidents to age-related conditions such as osteoporosis, and overuse injuries like stress fractures in athletes. Understanding fractures and their management is crucial in healthcare, especially for nurses who play a pivotal role in patient care and recovery.
Fractures are classified into several types, including:
- Open (compound) fracture: The broken bone pierces through the skin, increasing the risk of infection.
- Closed fracture: The bone is broken, but the skin remains intact.
- Greenstick fracture: More common in children, where the bone bends and cracks but doesn’t break completely.
- Comminuted fracture: The bone is broken into multiple fragments.
The Nursing Process in Fracture Care
Nurses are integral to the care of patients with fractures across diverse healthcare settings, including emergency rooms, urgent care facilities, and inpatient hospital units, particularly following surgical interventions. The spectrum of fractures nurses manage is broad, from minor breaks like a fractured toe requiring simple splinting to severe injuries such as hip, neck, or femur fractures necessitating surgery, extensive hospitalization, and prolonged rehabilitation. Nursing care is essential for effective pain management, addressing mobility limitations, preventing potential complications, and ensuring comprehensive discharge planning to support recovery.
Fracture Nursing Care Plans: Prioritizing Patient Needs
Developing effective nursing care plans is paramount once a nurse identifies the pertinent nursing diagnoses for a patient with a fracture. These care plans serve as a roadmap, prioritizing assessments and interventions to achieve both immediate and long-term patient care objectives. Below are examples of nursing care plans tailored for patients with fractures, focusing on common nursing diagnoses.
Acute Pain Nursing Care Plan
Fracture-related pain is an acute response to the injury, stemming from damage to surrounding tissues, muscles, and nerve endings.
Nursing Diagnosis: Acute Pain related to bone fracture.
Related Factors:
- Bone displacement and instability.
- Soft tissue injury and inflammation at the fracture site.
- Muscle spasms surrounding the fractured bone.
- Edema and hematoma formation.
- Nerve compression or injury due to fracture fragments or swelling.
As Evidenced By:
- Patient’s verbal report of pain, describing intensity, location, and character.
- Observed guarding behavior, such as protecting the injured area and reluctance to move.
- Facial expressions of pain, including grimacing, furrowed brow, or crying.
- Physiological responses like diaphoresis (sweating), restlessness, and changes in vital signs.
- Distraction behaviors, such as moaning, irritability, or seeking comfort.
- Changes in vital signs: tachypnea (increased respiratory rate), tachycardia (increased heart rate), and elevated blood pressure.
Expected Outcomes:
- The patient will report a pain level of 2 out of 10 or less using a pain scale by discharge.
- The patient will demonstrate relaxed body language and utilize effective pain management techniques.
- The patient will verbalize understanding of pain management strategies and medication regimen.
- The patient will achieve a stable heart rate and blood pressure within their normal range, indicating pain control.
Assessments:
1. Comprehensive Pain Assessment: Employ age-appropriate pain assessment tools such as numeric rating scales (0-10), Wong-Baker FACES Pain Rating Scale, or FLACC scale for nonverbal patients or children. Assess pain characteristics (onset, location, duration, quality, aggravating/relieving factors) to understand the patient’s pain experience comprehensively. Regular reassessment is crucial to monitor pain fluctuations and treatment effectiveness.
2. Vital Signs Monitoring: Monitor vital signs (blood pressure, heart rate, respiratory rate) at regular intervals, especially before and after pain interventions. Elevated vital signs can indicate pain intensity and physiological stress. Improvement in vital signs following pain management indicates effective intervention.
3. Evaluate Pain Relief Effectiveness: Within one hour after administering pain medication or implementing non-pharmacological interventions, reassess the patient’s pain level using the same pain scale. This evaluation helps determine the efficacy of the intervention and guides adjustments to the pain management plan.
Interventions:
1. Administer Analgesic Medications: Provide prescribed analgesics promptly, considering the fracture severity and patient’s pain level. This may include opioids for severe acute pain, often administered orally or intravenously. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can be used concurrently with opioids to reduce inflammation and provide synergistic pain relief. Adhere to the prescribed dosage, frequency, and route of administration, and monitor for potential side effects.
2. Implement Non-pharmacological Pain Relief Measures: Integrate non-pharmacological strategies to complement medication and empower patients in pain management. Apply ice packs to the fracture site to reduce swelling and numb pain (typically 15-20 minutes at a time). Heat therapy can alleviate muscle spasms and stiffness (use cautiously to avoid burns). Gentle massage around the affected area (avoiding direct pressure on the fracture site) can promote relaxation. Employ distraction techniques such as music, reading, or conversation to divert attention from pain. Guide the patient in controlled breathing exercises to promote relaxation and reduce pain perception.
3. Provide Support and Immobilization: Ensure proper support and immobilization of the fractured extremity. Elevate the injured limb above heart level to minimize swelling. Utilize prescribed splints, casts, traction, or braces to stabilize the fracture and reduce movement that exacerbates pain. Educate the patient on maintaining proper alignment and adhering to weight-bearing restrictions to promote bone healing and minimize pain.
4. Patient Education on Pain Management at Discharge: Provide comprehensive discharge instructions on pain management. Educate the patient about prescribed pain medications, including dosage, frequency, potential side effects (drowsiness, dizziness, nausea, constipation), and precautions (avoid driving or operating machinery while taking narcotics). Emphasize the importance of not exceeding prescribed doses and contacting their healthcare provider if pain is not adequately controlled. Reinforce non-pharmacological pain management techniques for home use.
Impaired Physical Mobility Nursing Care Plan
Fractures inherently limit mobility due to pain, instability, and treatment modalities, increasing the risk of falls and hindering the ability to perform daily activities.
Nursing Diagnosis: Impaired Physical Mobility related to fracture.
Related Factors:
- Disruption of bone integrity and structural support.
- Fracture pain and discomfort limiting movement.
- Prescribed activity restrictions such as immobilization or non-weight bearing.
- Fear of movement or re-injury leading to reluctance to move.
- Muscle weakness and deconditioning from disuse.
- Swelling, stiffness, and joint immobility associated with the fracture and healing process.
As Evidenced By:
- Patient reports of pain or discomfort upon movement or attempted mobility.
- Observed reluctance to initiate movement or participate in activities.
- Limited range of motion (ROM) in the affected limb or body part.
- Decreased muscle strength and endurance in affected and compensatory muscle groups.
- Difficulty performing age-appropriate motor skills or activities of daily living (ADLs).
- Postural instability or impaired balance during movement.
Expected Outcomes:
- Patient will demonstrate increased mobility and participate in ADLs within prescribed limitations.
- Patient will utilize assistive devices safely and effectively to enhance mobility.
- Patient will verbalize understanding of safe mobility techniques and precautions.
- Patient will maintain or improve muscle strength and prevent contractures through prescribed exercises.
- Patient will remain free from falls or further injury related to impaired mobility.
Assessments:
1. Assess Degree of Mobility Limitation: Evaluate the patient’s current functional mobility status. Determine the extent of physical limitations based on fracture location, severity, pain, swelling, and prescribed treatment (e.g., cast, traction). Assess the patient’s ability to perform ADLs such as bathing, dressing, toileting, and feeding. Identify specific movements or activities that are most challenging or restricted. This assessment forms the basis for individualized interventions.
2. Psychological and Emotional Factors: Assess the patient’s pain levels, anxiety, and emotional state as these significantly impact motivation and willingness to move. Depression and anxiety can hinder participation in mobility activities. Address psychological barriers to promote active participation in rehabilitation.
3. Evaluate Support System and Home Environment: Determine the availability of support systems (family, caregivers) at home and assess the home environment for mobility barriers (stairs, narrow doorways, lack of assistive devices). This assessment is crucial for discharge planning and determining the need for home healthcare, rehabilitation facilities, or assistive equipment.
Interventions:
1. Promote Independence and Self-Care: Encourage the patient to participate actively in self-care activities within their mobility limitations. Even bedridden patients can assist with turning, repositioning, and performing upper body ADLs like washing their face or eating. Foster a sense of control and independence to enhance motivation and prevent learned helplessness.
2. Pre-medicate for Pain Before Activity: Anticipate pain associated with mobility activities and administer prescribed analgesics prior to physical therapy sessions, ambulation, or ADL performance. Preemptive pain management can reduce discomfort, improve patient participation, and facilitate more effective movement and exercise.
3. Collaborate with Physical and Occupational Therapy (PT/OT): Consult with PT and OT for specialized mobility interventions. For fractures such as hip fractures or spinal fractures, PT/OT are essential for developing individualized exercise programs, teaching safe transfer techniques, gait training with assistive devices (canes, crutches, walkers), and instructing on muscle strengthening and ROM exercises.
4. Utilize Assistive Devices and Adaptive Equipment: Provide and instruct on the use of assistive devices to promote safe mobility and independence. This may include walkers, crutches, canes, bedside commodes, grab bars, long-handled reachers, and dressing aids. Ensure proper fitting, safe usage techniques, and regular equipment maintenance.
Risk for Constipation Nursing Care Plan
Opioid analgesics, commonly used for fracture pain, significantly increase the risk of constipation by slowing gastrointestinal motility. Immobility further exacerbates this risk.
Nursing Diagnosis: Risk for Constipation related to fracture management.
Related Factors:
- Decreased physical activity and immobility associated with fracture and treatment.
- Opioid analgesic use, which slows bowel motility.
- Changes in dietary patterns, such as reduced fiber intake.
- Inadequate fluid intake due to pain, immobility, or decreased oral intake.
- Pain medications can also directly affect bowel function.
Note: Risk nursing diagnoses are potential problems; therefore, there are no “as evidenced by” statements. Interventions are preventative.
Expected Outcomes:
- Patient will maintain regular bowel movements (every 1-3 days) without straining.
- Patient will verbalize understanding of constipation prevention strategies.
- Patient will implement at least two measures to prevent or manage constipation.
- Patient will report reduced or absent symptoms of constipation such as abdominal distention or discomfort.
Assessments:
1. Auscultate Bowel Sounds: Assess bowel sounds in all four quadrants of the abdomen to determine bowel activity. Note the presence, frequency, and character of bowel sounds (active, hypoactive, hyperactive, absent). Hypoactive or absent bowel sounds may indicate decreased peristalsis and increased risk of constipation.
2. Assess Bowel History and Patterns: Inquire about the patient’s usual bowel patterns, frequency, consistency, and any history of constipation. Establish a baseline for comparison and identify deviations from their normal pattern. Determine factors that may contribute to constipation, such as diet, fluid intake, and medication use.
Interventions:
1. Administer Stool Softeners and Laxatives Prophylactically: Anticipate constipation related to opioid use and immobility. Administer stool softeners (e.g., docusate sodium) routinely to prevent constipation. Laxatives (e.g., senna, bisacodyl, polyethylene glycol) may be needed if stool softeners are insufficient or for pre-existing constipation. Follow physician orders and monitor bowel movements to adjust medication as needed.
2. Educate on Constipation Risk and Prevention: Educate the patient about the increased risk of constipation due to immobility and opioid pain medications. Explain preventative measures, including increasing fluid intake (water, juice, warm liquids), increasing dietary fiber (fruits, vegetables, whole grains), and the importance of ambulation as tolerated. Discuss the appropriate use of stool softeners and laxatives as prescribed.
3. Encourage Increased Fluid Intake: Promote adequate hydration by encouraging the patient to drink plenty of fluids throughout the day, unless contraindicated by other medical conditions. Water is essential for maintaining stool consistency. Prune juice and warm liquids can also stimulate bowel movements.
4. Promote Mobility and Exercise as Tolerated: Encourage the patient to increase their activity level as permitted by their fracture and treatment plan. Even limited mobility, such as bed exercises or short walks (if weight-bearing is allowed), can stimulate peristalsis and bowel function. Consult with PT/OT for appropriate exercises and mobility guidelines.
References
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