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Nursing Care Plan for Clavicle Fracture

The nursing care plan is for a 39-year-old male patient with a closed fracture of the left clavicle following surgery. The nursing diagnosis is risk for impaired comfort related to the operative site. Interventions include assessing factors contributing to discomfort, assisting in alleviating discomfort through limiting use and providing a sling, and teaching non-pharmacological pain management techniques. Analgesics will also be administered as ordered. The goals are for the client to engage in behaviors to increase comfort, sense comfort after interventions, and receive health teaching about post-surgery discomfort management.

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Joanne Careah
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65 views2 pages

Nursing Care Plan for Clavicle Fracture

The nursing care plan is for a 39-year-old male patient with a closed fracture of the left clavicle following surgery. The nursing diagnosis is risk for impaired comfort related to the operative site. Interventions include assessing factors contributing to discomfort, assisting in alleviating discomfort through limiting use and providing a sling, and teaching non-pharmacological pain management techniques. Analgesics will also be administered as ordered. The goals are for the client to engage in behaviors to increase comfort, sense comfort after interventions, and receive health teaching about post-surgery discomfort management.

Uploaded by

Joanne Careah
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City NURSING CARE PLAN Name of Patient: ___R.D.

JR.__ Age: 39 years old Nursing Diagnosis Ward/Bed Number: Rationale Perceived lack of ease, relief and transcendence in physical, psycho spiritual, environmental and social dimensions OR___ Outcome Criteria Nursing Interventions 1. Assess the etiology or precipitating factors contributing to discomfort such as tenderness of the operative site. 2. Assist client in alleviating discomfort such as providing sling and limitation of use. 3. promote wellness through teaching the client about nonpharmacological managements of discomfort such as imagery, music therapy, aroma therapy, back massage, tepid-sponge bath. 4. administer analgesics and pain medications as ordered. Rationale 1. assessing the etiology of discomfort is essential in creating and planning unique client care for the patient 2. assisting client in alleviation of discomfort and limitation of limb function would limit the usage of the limb, promoting extra time for the bone and tissue repair to happen. 3. nonpharmacologic measures of pain management eases the patient from discomfort while promoting drug independence 4. administering pain medications provides pharmacological effects not gained through nonpharmacologic measures. Goals Unmet 1. client was unable able to engage in behaviors or lifestyle changes to increase level of ease after the intervention 2. client was unable to sense of comfort after the intervention. 3. clieant was not yet given the health teaching about management of discomfort post surgery. Evaluation Attending Physician: Dr.J. and Dr. A Impression / Diagnosis:Closed fracture oblique, displaced middle 3rd left clavicle secondary to VA

Clustered Cues

Date and Time: 9/18/12 1:00 pm

Risk for impaired comfort related to operative site

Following surgery, usually the patients operative site follows a series and physical changes to restore normal bone and tissue functions, promote healing and restoration of full function. In the process it is uncomfortable for the patient to utilize the organ.

1. Client will be able to engage in behaviors or lifestyle changes to increase level of ease after the intervention 2. client will verbalized sense of comfort after the intervention. 3. promote wellness by providing health teaching about management of discomfort post surgery.

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