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 the nuances of fractures and their subsequent care is crucial for healthcare professionals, especially nurses. This guide provides a comprehensive overview of nursing diagnoses related to fractures, designed to enhance your understanding and improve patient care in diverse healthcare settings.
Fractures are categorized into several types, each requiring specific management approaches:
- Open (Compound) Fracture: Characterized by the bone breaking through the skin, increasing the risk of infection.
- Closed Fracture: The bone is broken, but the skin remains intact.
- Greenstick Fracture: Incomplete fracture common in children, where the bone bends but doesn’t fully break.
- Comminuted Fracture: The bone is fractured into multiple fragments.
The Nursing Process in Fracture Management
Nurses are integral in the care of patients with fractures across various healthcare environments, including emergency rooms, urgent care centers, and inpatient units following surgical interventions. The spectrum of fractures nurses encounter ranges from minor fractures, such as a broken toe requiring only splinting, to severe fractures like hip, neck, or femur fractures necessitating surgery, extended hospital stays, and prolonged rehabilitation. Nursing care is multifaceted, focusing on pain management, addressing mobility limitations, preventing complications, and ensuring thorough discharge planning.
To effectively manage patient care, nurses utilize nursing diagnoses to guide their interventions. Nursing care plans are then developed based on these diagnoses, prioritizing assessments and interventions to achieve both immediate and long-term patient goals. Let’s delve into specific nursing care plan examples for common fracture-related issues.
Common Nursing Diagnoses and Care Plans for Fractures
Acute Pain
Fractures invariably lead to acute pain due to the injury to surrounding tissues, muscles, and nerves. Effective pain management is a primary nursing concern.
Nursing Diagnosis: Acute Pain
Related Factors:
- Bone displacement
- Tissue injury
- Muscle spasms
- Edema
Evidenced By:
- Patient verbal reports of pain
- Protective guarding of the injured area
- Facial expressions of pain (grimacing, crying)
- Diaphoresis
- Restlessness and agitation
- Distraction behaviors
- Changes in vital signs (tachypnea, tachycardia, increased blood pressure)
Desired Outcomes:
- Patient will report a pain level of 2 out of 10 or less by discharge.
- Patient will exhibit comfort through relaxed posture and stable vital signs.
- Patient will effectively use non-pharmacological pain relief techniques.
Nursing Assessments:
1. Pain Assessment: Employ appropriate pain assessment tools based on the patient’s age and cognitive status, such as numeric pain scales, Wong-Baker FACES Pain Rating Scale, or FLACC scale for children. Document the pain’s severity, location, characteristics (sharp, dull, throbbing), and frequency.
2. Vital Signs Monitoring: Recognize that elevated blood pressure and heart rate are physiological responses to pain. Monitor vital signs regularly to assess pain levels and the effectiveness of interventions. Improvement in vital signs should be observed as pain management strategies are implemented.
3. Reassessment of Pain Relief: After administering pain medication or implementing non-pharmacologic interventions, reassess the patient’s pain level within one hour to evaluate the effectiveness of the chosen strategies. Adjustments to the pain management plan should be made based on this reassessment.
Nursing Interventions:
1. Administer Analgesics: For acute fracture pain, analgesics are crucial. This often includes narcotic pain relief, administered orally or intravenously, especially in the initial phase. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen are frequently used in conjunction with narcotics to address inflammation. Administer medications as prescribed and monitor for effectiveness and side effects.
2. Implement Non-pharmacologic Comfort Measures: Emphasize a multimodal approach to pain management. Encourage and implement alternative comfort measures such as:
- Ice packs: To reduce swelling and numb pain.
- Heat application: To relieve muscle spasms and stiffness (avoid in acute phase of injury).
- Massage: Gentle massage around the injury site (avoid direct pressure on the fracture) to promote relaxation.
- Distraction techniques: Engage the patient in activities that divert their attention from pain, such as reading, watching movies, or conversation.
- Controlled breathing exercises: Teach and encourage deep, slow breathing to promote relaxation and reduce pain perception.
3. Provide Support and Immobilization: Ensure the fractured extremity is properly supported and elevated to minimize swelling. Utilize splints, casts, or traction devices as prescribed to immobilize the fracture site. Adhere strictly to weight-bearing restrictions to facilitate bone healing.
4. Patient Education on Pain Management at Discharge: Provide comprehensive discharge instructions regarding pain medications. Educate patients:
- Not to exceed prescribed medication frequency.
- To contact their healthcare provider if pain is not adequately controlled by the prescribed dosage.
- About precautions associated with narcotic pain medications, such as avoiding driving or operating heavy machinery due to drowsiness and dizziness.
- Potential side effects like nausea, dizziness, and constipation, and strategies to manage them.
Impaired Physical Mobility
Fractures inherently impair physical mobility, affecting ambulation, the ability to perform Activities of Daily Living (ADLs), and increasing the risk of falls and further injuries.
Nursing Diagnosis: Impaired Physical Mobility
Related Factors:
- Disruption of bone structure integrity
- Pain and discomfort
- Prescribed activity limitations (casts, traction)
- Fear of movement or re-injury
- Deconditioning from immobility
Evidenced By:
- Patient reports of pain with movement
- Reluctance or unwillingness to move
- Limited range of motion (ROM)
- Decreased muscle strength and endurance
Desired Outcomes:
- Patient will progressively increase ambulation distance and participation in ADLs within their limitations.
- Patient will demonstrate safe techniques for movement and mobility.
- Patient will remain free from falls and further injury during ambulation and movement.
Nursing Assessments:
1. Assess Degree of Mobility Limitation: Evaluate the extent of the patient’s physical limitations. This depends on the fracture location, severity, pain level, and swelling. Determine what ADLs the patient can perform independently and what assistance they require.
2. Identify Barriers to Mobility: Assess for factors hindering mobility, including:
- Pain: Severity and adequacy of pain management.
- Psychological Factors: Presence of depression, anxiety, or fear, which can inhibit movement.
- Physical Factors: Stiffness, muscle weakness, presence of assistive devices.
- Recognize that prolonged immobility can worsen pain and lead to complications like contractures and muscle atrophy.
3. Evaluate Support System: Assess the patient’s support system at home. Determine if they have caregivers capable of assisting with mobility needs post-discharge. If adequate support is lacking, explore the need for short-term rehabilitation facilities or home healthcare services.
Nursing Interventions:
1. Promote Independence: Encourage the patient to participate in self-care to the best of their ability. Even bedridden patients can be encouraged to assist with repositioning and perform ADLs like feeding or washing as independently as possible.
2. Pre-medicate for Movement: Anticipate pain associated with activities such as physical therapy sessions or hygiene care. Administer pain medication prior to these activities to enhance patient comfort and participation.
3. Collaborate with Physical and Occupational Therapy (PT/OT): For significant fractures like hip or spinal fractures, or any fracture causing substantial mobility impairment, PT and OT are essential. These specialists can:
- Teach patients how to safely use assistive devices such as canes, crutches, walkers, and wheelchairs.
- Develop individualized exercise programs to strengthen muscles, improve balance, and increase mobility.
- Instruct on techniques for safe transfers and ambulation.
4. Facilitate Use of Assistive Devices and Equipment: Ensure the patient has access to and utilizes appropriate assistive devices and equipment to promote safe mobility, such as:
- Bedside commodes to reduce the need to walk to the bathroom.
- Grab bars in bathrooms to enhance safety.
- Walkers or scooters to aid ambulation.
- Encourage the consistent use of prescribed assistive devices to prevent falls and promote safe movement.
Risk for Constipation
Opioid analgesics, frequently used for fracture pain management, can significantly increase the risk of constipation by slowing gastric emptying and intestinal peristalsis. Preventing constipation is vital to patient comfort and to avoid complications.
Nursing Diagnosis: Risk for Constipation
Related Factors:
- Decreased physical activity and immobility
- Opioid medication use
- Changes in dietary patterns
- Reduced fluid intake
Note: As a risk diagnosis, there are no “evidenced by” signs and symptoms, as the problem is being prevented. Nursing interventions are proactive and aimed at preventing the onset of constipation.
Desired Outcomes:
- Patient will achieve a bowel movement at least every three days.
- Patient will report no straining or discomfort during defecation.
- Patient will implement at least two strategies to prevent constipation.
Nursing Assessments:
1. Auscultate Bowel Sounds: Assess the presence, frequency, and character of bowel sounds in all four quadrants of the abdomen to establish baseline bowel activity.
2. Assess Normal Bowel Patterns: Inquire about the patient’s usual bowel habits, including frequency, consistency, and any regular aids to bowel movements. Recognize that normal bowel patterns vary, and bowel movements every 2-3 days can be normal for some individuals, provided there is no discomfort.
Nursing Interventions:
1. Administer Stool Softeners and Laxatives Prophylactically: Recognize constipation as a common side effect of opioid analgesics. When opioids are prescribed, a stool softener should be initiated concurrently to prevent constipation. For patients who develop constipation, laxatives or even enemas may be necessary, as prescribed.
2. Educate on Risk and Prevention of Constipation: Educate the patient about:
- The increased risk of constipation due to immobility and opioid use.
- The importance of proactive measures to prevent constipation.
- The need to take stool softeners as prescribed, before constipation becomes established, to avoid impaction or more serious complications like bowel obstruction.
3. Encourage Increased Fluid Intake: Promote adequate hydration to maintain stool softness and ease passage. Encourage the patient to drink plenty of water (unless contraindicated by other health conditions) and fluids like prune juice, which has natural laxative effects. Warm beverages, such as tea, can also stimulate bowel motility.
4. Promote Mobility as Tolerated: Recognize that immobility from fractures contributes to slowed peristalsis. As soon as medically safe and activity restrictions allow, encourage the patient to ambulate or engage in gentle exercises to stimulate bowel function.
By addressing these key nursing diagnoses and implementing tailored care plans, nurses can significantly enhance the recovery and well-being of patients with fractures. Effective nursing care focuses not only on the physical healing of the fracture but also on managing pain, restoring mobility, and preventing common complications, leading to improved patient outcomes and quality of life.
References
Osteoporosis Nursing Diagnosis & Care Plan
Nursing Diagnosis: Your Guide to Formulation & Types
Nursing Care Plans: Your Ultimate Guide
Acute Pain Nursing Diagnosis & Care Plan
Edema Nursing Diagnosis & Care Plan
Tachycardia Nursing Diagnosis & Care Plan
Hypertension Nursing Diagnosis & Care Plan
Impaired Physical Mobility Nursing Diagnosis & Care Plan
Risk for Falls Nursing Diagnosis & Care Plan
Major Depression Nursing Diagnosis & Care Plan
Anxiety Nursing Diagnosis & Care Plan
Hip Fracture Nursing Diagnosis & Care Plan
Nursing Interventions: Comprehensive Guide
Nausea Nursing Diagnosis & Care Plan
Small Bowel Obstruction Nursing Diagnosis & Care Plan
