Fractures, commonly known as broken bones, are a frequent injury encountered across various healthcare settings. These injuries can result from a multitude of causes, ranging from traumatic events like motor vehicle accidents to age-related conditions such as osteoporosis, and even repetitive stress, as seen in athletes with stress fractures. Understanding the nuances of fracture diagnosis and developing effective care plans are paramount for healthcare professionals to ensure optimal patient recovery.
Fractures are classified into different types, each requiring specific management approaches. Common types include:
- Open (Compound) Fracture: A fracture where the broken bone pierces the skin, creating an open wound and a higher risk of infection.
- Closed Fracture: A fracture where the bone is broken, but the skin remains intact.
- Greenstick Fracture: An incomplete fracture, more commonly seen in children, where the bone bends and cracks but doesn’t break completely.
- Comminuted Fracture: A severe fracture characterized by the bone breaking into multiple fragments or pieces.
The Nursing Process in Fracture Care
Nurses play a pivotal role in the care of patients with fractures, from the initial assessment in emergency departments and urgent care centers to post-surgical inpatient care and rehabilitation. Fracture management can range from simple interventions for minor fractures, such as splinting a broken toe, to complex care for major fractures like hip, neck, or femur fractures, often necessitating surgery, extended hospitalization, and prolonged recovery periods. Key nursing responsibilities include effective pain management, addressing activity limitations, preventing potential complications, and comprehensive discharge planning to facilitate a smooth transition to home care.
Developing robust nursing care plans is essential once nursing diagnoses are established for a patient with a fracture. These plans serve as a roadmap, prioritizing assessments and interventions to achieve both short-term and long-term patient care goals. The following sections provide detailed nursing care plan examples for common issues associated with fractures.
Managing Acute Pain in Fracture Patients
Acute pain is a significant concern for patients with fractures, stemming from the injury itself and the subsequent damage to surrounding tissues, muscles, and nerves.
Nursing Diagnosis: Acute Pain
Related Factors:
- Bone displacement following the fracture
- Tissue trauma and damage at the fracture site
- Muscle spasms surrounding the injury
- Edema and swelling contributing to pain
Evidence of Pain:
- Patient’s verbal report of pain intensity and discomfort
- Observable guarding behavior of the injured area
- Facial expressions of grimacing or crying indicative of pain
- Diaphoresis (excessive sweating) as a physiological response to pain
- Restlessness and agitation due to pain
- Distracted behavior and difficulty concentrating because of pain
- Physiological changes like tachypnea (rapid breathing), tachycardia (increased heart rate), and elevated blood pressure
Expected Patient Outcomes:
- Patient will report a pain level of 2 out of 10 or less by the time of hospital discharge, indicating effective pain management.
- Patient will exhibit signs of comfort, such as resting with eyes closed and maintaining vital signs within normal limits.
- Patient will effectively utilize nonpharmacologic pain relief measures in conjunction with prescribed medications.
Nursing Assessments:
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Comprehensive Pain Assessment: Utilize age-appropriate and cognitively suitable pain scales (e.g., numeric pain rating scale, Wong-Baker FACES Pain Rating Scale, FLACC Behavioral Scale for nonverbal patients) to accurately assess pain severity. Thoroughly evaluate pain location, characteristics (sharp, dull, throbbing), and frequency to understand the patient’s pain experience.
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Vital Signs Monitoring: Regularly monitor vital signs, noting that elevated blood pressure and heart rate are typical physiological responses to acute pain. Improvements in these vital signs after pain management interventions indicate effective pain control.
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Pain Relief Evaluation: Following the administration of pain medications or implementation of non-pharmacologic interventions, conduct a timely follow-up assessment within one hour to determine the effectiveness of the pain relief strategies employed.
Nursing Interventions:
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Administer Prescribed Analgesics: For acute fractures, narcotic analgesics are often necessary for effective pain relief. These may be administered via oral or intravenous routes, depending on pain severity and patient status. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen are frequently used in conjunction with narcotics to target inflammation and provide multimodal pain management.
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Implement Non-pharmacologic Comfort Measures: Emphasize to patients that pain management should not solely rely on medications. Integrate alternative comfort measures such as applying ice packs to reduce swelling and pain, using heat therapy to soothe muscle spasms, gentle massage to promote relaxation, distraction techniques to divert attention from pain, and teaching controlled breathing exercises to enhance relaxation and pain coping.
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Provide Support and Immobilization to the Injured Area: Ensure the fractured extremity is properly elevated to minimize swelling and edema formation. Utilize splints, casts, or traction devices as prescribed to immobilize the fracture site, promoting bone alignment and healing. Strictly adhere to weight-bearing restrictions to prevent further injury and facilitate bone union.
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Discharge Medication Education: Thoroughly instruct patients on their prescribed pain medications at discharge. Emphasize the importance of adhering to prescribed dosages and frequencies and caution against exceeding recommended doses. Advise patients to contact their healthcare provider if prescribed pain medication is inadequate for pain control. Educate patients about potential side effects of narcotic pain medications, including drowsiness, dizziness, nausea, and constipation, as well as precautions such as avoiding driving or operating heavy machinery while taking these medications.
Addressing Impaired Physical Mobility Following Fracture
Fractures inherently limit physical mobility, impacting a patient’s ability to ambulate, perform activities of daily living (ADLs), and increasing the risk of falls and secondary injuries.
Nursing Diagnosis: Impaired Physical Mobility
Related Factors:
- Loss of bone structure integrity due to the fracture
- Pain limiting movement and willingness to participate in activity
- Prescribed activity restrictions to promote fracture healing
- Patient reluctance to initiate movement due to fear of pain or further injury
- Deconditioning resulting from prolonged immobility
Evidence of Impaired Mobility:
- Patient reports of pain limiting movement capabilities
- Unwillingness to move or participate in mobility activities
- Observed limitations in range of motion (ROM) in affected limbs
- Decreased muscle strength and endurance
Expected Patient Outcomes:
- Patient will progressively increase ambulation distance and active participation in ADLs as tolerated within their physical limitations.
- Patient will demonstrate safe and effective techniques to support movement and mobility while protecting the fracture site.
- Patient will remain free from falls or further injury during ambulation and mobility activities throughout their recovery.
Nursing Assessments:
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Assess the Extent of Physical Limitations: Evaluate the degree of physical immobility, recognizing that it varies based on fracture location, severity, pain levels, and swelling. Tailor nursing interventions based on a comprehensive assessment of what the patient can and cannot physically do.
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Identify Barriers to Mobility: Assess for pain and other psychological factors, such as depression and anxiety, that may hinder patient motivation and willingness to move. Recognize that delayed mobility can exacerbate pain, lead to muscle contractures, and result in muscle weakness and atrophy.
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Evaluate Support Systems: Assess the patient’s available support system at home, as mobility limitations at discharge may necessitate additional assistance. Determine if the patient has capable caregivers or if they may require short-term placement in a rehabilitation facility or in-home care services to support their recovery.
Nursing Interventions:
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Promote Patient Independence: Encourage patients to be as independent as possible within their mobility restrictions. Even patients confined to bed can participate in self-care activities. Encourage active participation in ADLs, such as feeding, washing, and grooming, to maintain function and promote self-esteem.
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Pre-Medicate for Pain Before Activity: Anticipate pain associated with mobility activities and proactively premedicate patients with analgesics before potentially painful activities like physical therapy (PT) sessions or complete bed baths. Pre-medication can help relax the patient, reduce pain perception, and improve their ability to engage in therapeutic exercises and activities.
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Collaborate with Physical and Occupational Therapy (PT/OT): For complex fractures, such as hip fractures, spinal fractures, or femur fractures, collaborate closely with PT and OT specialists. These professionals can provide expert guidance on safe movement techniques, teach patients how to use assistive devices like canes, crutches, and walkers, and develop individualized exercise programs to strengthen muscles, improve balance, and enhance functional mobility.
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Utilize Assistive Devices and Equipment: Provide and encourage the use of assistive devices and equipment to promote safe mobility and independence. Ensure access to and proper use of bedside commodes, grab bars in bathrooms, walkers, wheelchairs, or scooters, as appropriate, to support patient mobility and reduce the risk of falls.
Preventing Constipation in Fracture Patients
Opioid analgesics, commonly used for fracture pain management, can cause constipation by slowing gastric emptying and intestinal peristalsis. Proactive prevention and management of constipation are crucial to avoid patient discomfort and potential complications.
Nursing Diagnosis: Risk for Constipation
Related Factors:
- Reduced physical activity and immobility associated with fracture recovery
- Opioid medication use for pain management
- Changes in dietary patterns and reduced fiber intake
- Insufficient fluid intake
Expected Patient Outcomes:
- Patient will achieve a bowel movement of soft consistency at least every three days, indicating regular bowel function.
- Patient will report the absence of straining or discomfort during defecation.
- Patient will implement at least two preventative measures to minimize the risk of constipation.
Nursing Assessments:
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Auscultate Bowel Sounds: Regularly assess bowel sounds to determine their presence, location (quadrants), and characteristics (normal, hypoactive, hyperactive). Decreased or absent bowel sounds may indicate reduced bowel motility and increased risk of constipation.
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Assess Bowel Movement Patterns: Inquire about the patient’s normal bowel movement patterns before the fracture. Recognize that bowel movement frequency varies among individuals, and bowel movements every 2-3 days can be normal as long as the patient experiences no discomfort or straining.
Nursing Interventions:
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Administer Stool Softeners and Laxatives as Prescribed: Recognize that constipation is a common side effect of opioid medications. Administer stool softeners prophylactically concurrently with opioid analgesics to prevent constipation. For existing constipation, laxatives or even enemas may be required to promote bowel evacuation.
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Educate on Constipation Risk and Prevention: Educate patients about the increased risk of constipation due to immobility and opioid use (if applicable). Emphasize the importance of taking stool softeners proactively to prevent impaction and serious complications like bowel obstruction.
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Promote Increased Fluid Intake: Encourage patients to increase their fluid intake, as adequate hydration helps soften stools and facilitates easier passage. Recommend drinking plenty of water (unless contraindicated by other medical conditions) and incorporating fluids like prune juice or warm beverages like tea, which can stimulate bowel movements.
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Encourage Increased Mobility as Tolerated: Recognize that immobility associated with fractures can contribute to slowed peristalsis and constipation. As soon as medically safe and activity restrictions allow, encourage patients to ambulate or engage in gentle exercises to promote bowel motility and prevent constipation.
References
- NurseTogether – Nursing Diagnosis
- NurseTogether – Nursing Care Plans
- NurseTogether – Acute Pain Nursing Diagnosis Care Plan
- NurseTogether – Edema Nursing Diagnosis Care Plan
- NurseTogether – Tachycardia Nursing Diagnosis Care Plan
- NurseTogether – Hypertension Nursing Diagnosis Care Plan
- NurseTogether – Nausea Nursing Diagnosis Care Plan
- NurseTogether – Osteoporosis Nursing Diagnosis Care Plan
- NurseTogether – Risk for Falls Nursing Diagnosis Care Plan
- NurseTogether – Impaired Physical Mobility Nursing Diagnosis Care Plan
- NurseTogether – Major Depression Nursing Diagnosis Care Plan
- NurseTogether – Anxiety Nursing Diagnosis Care Plan
- NurseTogether – Hip Fracture Nursing Diagnosis Care Plan
- NurseTogether – Nursing Interventions
- NurseTogether – Small Bowel Obstruction Nursing Diagnosis Care Plan
