NURSING CARE PLAN (N.C.P.) Name: Paula Nicole Anne R.

Marin Assessment Subjective: Medyo giniginaw ako kaya ako nakakumot. Pero wala naman akong lagnat as verbalized by the patient Nursing Diagnosis Risk for peripheral neurovascular dysfunction related to interruption of blood flow as manifested by pallor and delayed capillary refill of 4 seconds, chills Etiology Planning Fracture Within 8 hours of nursing interventions, the patient will exhibit no signs and symptoms of neurovascular compromise Interventions Monitor v/s Year/Section: BSN 4-4 Rationale Systemic perfusion will be impaired if circulating blood volume is inadequate Increasing circumference of injured extremity may suggest general tissue swelling/edema but may reflect hemorrhage. Note: A 1-in increase in an adult thigh can equal approximately 1 unit of sequestered blood. Facilitates monitoring of circulatory status of extremity Evaluation

Compression of various end capillary bed (decreased capillary refill)

Objective: (+) pallor (+) delayed capillary refill of 4 seconds (+) chills

Assess entire length of injured extremity for swelling/edema formation. Measure injured extremity and compare with uninjured extremity. Note appearance/sprea d of hematoma. Provide immobilization to joints above and below the fractured site, leaving enough room to assess pulses Palpate peripheral pulses and identify changes in equity or character of pulses distal to injury Monitor extremity involved for rapid capillary refill, skin color, warmth, and sensation

Increased capillary hydrostatic pressure

Increased intracompartmental pressure (pain upon movement)

Decreased or absent pulses may indicate vascular injury that requires immediate intervention Circulatory impairment may result in delayed refill greater than 5 seconds. Arterial compromise may occur when skin is

Compression of arterioles :

Compressed arterial flow (pallor and chills)

Monitor for changes in neurovascular integrity every 12 hours as warranted.

Evaluate complaints of pain that are abnormal for the type of injury sustained, pain with passive muscle stretching, or decreases in muscle movement distal to injury.

Assess skin around tibial pin for redness or pressure points, or for complaints of burning

cool-cold and white, and venous compromise may occur with cyanosis. Sudden ischemic signs may be caused with joint dislocation resulting from injury to adjacent arterial structures Paresthesias, numbness, tingling, or diffused pain may occur when nerves have been damaged or when circulation is impaired, and may require intervention Hemorrhage and/or edema within the muscle fascia can impair blood flow and cause compartmental syndrome that will require emergency intervention to restore circulation. Compartmental syndrome can result in permanent dysfunction and deformity within 2448 hours and irreversible damage may occur after 6 hours without intervention Pressure can result to ischemia and tissue breakdown. Burning pain may indicate pressure areas.

Position injured site in proper alignment Avoid flexion of fractured extremity

Instruct patient in signs/ symptoms to notify nurse/ physician: increased pain, decreased sensation or movement, or changes in temperature or color of injured part Instruct patient/family in correct positioning techniques, and methods to use to obtain relief from pressure

Circulation may be compromised if correct alignment is not maintained May result in decreased venous circulation and increase potential for neurovascular compromise Provides knowledge and allows for patient involvement in care. Provides method for prompt detection of potential complications to facilitate prompt intervention. Provides knowledge and helps to avoid venous pooling and potential pressure ulcerations

NURSING CARE PLAN (N.C.P.) Name: Paula Nicole Anne R. Marin Assessment Subjective: Ang hirap kasi limitado lang yung galaw ko. Mahirap gumalaw. Nursing Diagnosis Impaired physical mobility related to fracture as manifested by reluctance to move at will because of external fixator Etiology Fracture Planning Within 6 hours of nursing interventions, the patient will maintain optimal mobility and function of injured areas. Interventions Evaluate degree of immobility that has resulted from injury and patients perception of his limitations Rationale After trauma, patients perception of limitations may be out of proportion with their physical levels of activities and may require further information to dispel false concepts Decreases potential for further injury and impairment in alignment while stabilizing the injured area Prevents formation of pressure areas and improves circulation Prevents muscle atrophy, increases blood flow, improves joint mobility, and helps prevent reabsorption of calcium resulting from disuse Traction apparatus may be cumbersome and heavy and may require increased personnel to Year/Section: BSN 4-4 Evaluation

Limited range of motion

Pain

Objective: (+) exfix at right leg (+) open fracture, complete nondisplaced inferior pole patella @ L leg (+) open fracture, complete segmental displaced tibia @ R leg (+) reluctance to move at will

Reluctance to move injured part

Loss of function

Maintain bedrest and move injured limbs gently, supporting areas above and below the fracture Reposition patient every 2 hours and prn Assist patient with range of motion exercises of all extremities as warranted

Ensure that adequate numbers of personnel are present for repositioning

Evaluate integrity of traction apparatus and set-up

Observe for redness, tenderness, pain, or swelling to the calf

avoid injury to the patient or the nurses Traction provides for a pulling force on the long axis of a fractured bone to facilitate proper alignment and healing May indicate thrombophebitis

NURSING CARE PLAN (N.C.P.) Name: Paula Nicole Anne R. Marin Assessment Subjective: Isang lingo na akong hindi dumudumi. Nursing Diagnosis Constipation related to decreased activity as manifested by inability to pass stool for a week Etiology maintenance of tone in the intestinal and abdominal muscles requires regular exercise Planning Within 16 hours of nursing interventions, the patient will have normal bowel function with no complications to fluid status Interventions Assess bowel habits of patients; normal routines, frequency of stools, use of cathartics Administer laxatives or stool softeners as ordered. Tap water enemas should be avoided Rationale Provides baseline from which to plan interventions Year/Section: BSN 4-4 Evaluation

Objective: No stool output

Decreased activity

intestinal muscles become slackened, intestinal motility slows down Slow intestinal motility

constipation

Instruct patients in massaging abdomen along transverse and descending colon each day Instruct patient/family in appropriate use of laxatives, stool softeners, and enemas

Caution must be used in selection of pharmacologic agent so as not to further ass to fluid volume overload. Water in the enemas can be absorbed and increased overload Massage may assist to stimulate peristalsis

Overuse of purgative may increase fluid and electrolyte loss, create laxative dependence, and damage intestinal mucosa