NCM 116a: MODULE 4 UNIT QUIZ

CARE OF PATIENTS WITH PROBLEMS ON PERCEPTION AND COORDINATION

Name: GUADIZ, Yessamin T.

Group/Section: BSN 3 F 1

ANSWER SHEET

II. Case Analysis: Nursing Care Plan (40 points)

Problem Identification:
Nursing Diagnosis/es
1. Acute pain related to femoral fracture
2. Ineffective airway clearance related to
retained secretions secondary to immobility
3. Impaired physical mobility related to
skeletal traction
4. Risk for infection related to surgical
wounds in skeletal traction
Prioritization/Justification
This is the top priority because the patient rates
her pain as 8/10 which falls under the category
of intense pain. She rated it as such even after
50 mgs of Ketorolac IVP was administered.
Lastly, even after surgery, pain brought by
skeletal traction can be persistent due to the
consistent pulling force. Pain is the sixth vital
sign and needs immediate intervention.
This is the second priority because crackles are
present on the right lower lobe of the lungs,
which signify retained secretions that may be a
result of immobility. The case mentioned that
the patient has productive cough, but is not
experiencing any other respiratory compromise
that needs immediate attention. Moreover,
interventions such as coughing exercises are
already being done.
It is only the third day post procedure, and
immobility is expected. This makes the patient
dependent in performing most ADL’s.
However, as healing of the fracture progresses,
the patient may start practicing being mobile
again. Hence, this is prioritized as the 3rd actual
problem.
The pin sites are clean, dry, and are being
checked daily. On the wound site, signs of
infection are not yet present. However, the
patient is experiencing fever which may be a
sign of infection. The fever itself is not
confirmatory that the patient acquired an

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5. Risk for ineffective coping related to
difficulty adapting with immobility
infection, but she is at risk for it.
It was mentioned that the patient was irritable
due to her inability to move and frustrated for
not being able to get up from bed. The patient is
showing emotional distress due to her
condition. This is listed as the second risk
diagnosis because it is only three days post op,
and the patient may still be adapting, and
having difficulty accepting her situation. If this
persists, the patient becomes more and more at
risk of ineffective coping.

1. Priority Nursing Problem: Acute pain related to femoral fracture

Expected Outcome Patient will be free from pain
Goal of Care
STO: 1. Verbalize minimized feeling of pain with a pain rating of less than
5/10
After 8 hours of nursing
interventions, the
patient will be able to:
2. Verbalize different methods and techniques of pain relief

LTO 1. Utilize relaxation techniques and diversional activities in providing

pain relief
After 72 hours of
nursing interventions,
the patient will be able
to: 2. Participate in ADL’s and desired activities with minimal
complaints of discomfort

Care Plan
INTERVENTIONS RATIONALE
Dx:
1. Monitor and record vital signs 1. Alterations from normal vital signs may be
a sign of nonverbal pain cues i.e. increased
PR, RR, BP
2. Monitor level of pain by utilizing numeric
pain intensity rating scale with
corresponding PQRST characteristics 2. Influences the selection of appropriate and
effective interventions based on the
severity of pain. May indicate resolution or
development of complications

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 Tx:
Independent:
1. Provide alternative comfort measure such 1. Improves comfort, general circulation;
as massage, backrubs, DBE, and reduces risk of development of pressure
acupressure ulcers, muscle fatigue, and pain

2. Encourage diversional activities and 2. Distracts attention on the pain and reduces
relaxation techniques such as focused overall tension
breathing, visualization and guided
imagery

Dependent:
1. Administer pain relief medications as 1. Relieves pain, decreases inflammation,
ordered by the physician and promotes muscle relaxation

2. Turn the patient every two hours as ordered 2. Prevents pressure ulcers that may cause
by the physician further pain

Collaborative:
1. Perform active and passive ROM exercises 1. Maintains strength and mobility of
on the unaffected leg with the supervision unaffected muscles and facilitates
of a physical therapist resolution of inflammation in injured
tissues.

2. Schedule the patient to a session with a 2. Pain may be aggravated by psycho

psychiatric nurse or a psychiatrist to assess emotional distress
possible psycho emotional distress

Ed:
1. Educate patient on different diversional 1. Prevents boredom, reduces muscle tension,
activities according to preference and may enhance coping abilities

2. Educate the patient regarding activity 2. Immediately exerting too much energy,
restrictions, and allow patient to perform may further cause pain and discomfort.
ADL’s within her capacity Being independent with ADL’s should be

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 practiced gradually.

References:

RNpedia. (n.d.). Fractures nursing care plan and management. Retrieved from
https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/fractures-nursing-
management/

Vera, M. (2019). 11 Fracture nursing care plans. Retrieved from

https://nurseslabs.com/8-fracture-nursing-care-plans/2/

Wayne, G. (2020). Acute pain nursing care plan. Retrieved from

https://nurseslabs.com/acute-pain/

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means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited. 4