Nursing Care Plan

On
Fracture

Submitted By:
Purnima Sahay
M.Sc.(N) 1st yr.
IDENTIFICATION DATA
Name : Mr. Surya
Age : 30yrs
Sex : Male
Diagnosis : Fracture
Religion : Hindu
Marital status : Unmarried
Literacy : 10th pass
Occupation : Worker
Address : Panipat

I. PRESENT MEDICAL/ SURGICAL HISTORY:

Patient was admitted with complaints of:
- Acute pain
- Numbness or weakness of leg
- Loss of function
- Swelling, tenderness, localized edema
- bleeding
II. PAST MEDICAL / SURGICAL HISTORY:
Surgical history : Not significant
Blood transfusion : No

III. PERSONAL HISTORY:

Mr. Surya is a vegetarian and no habit of substance abuse like
Any drug addiction, smoking or alcohol etc. He performs exercises
occasionally. The sleep pattern is disturbed.
He has normal bowel and bladder habits.
Dietary habits : Vegetarian
Personal habits : Patient is not having any specific
habit of smoking or drinking.
Presence of any specific : No H/O DM, HTN, Allergy or any
heart disease
FAMILY HISTORY:
No of family members :4
Any disease in family : Not significant
Illness in family
 Health status of family member : Healthy
Interpersonal relationship : Satisfactory
Specific interests and hobbies : Watching TV
III. PERSONAL HISTORY:
Habit : Habit of smoking non drinking
Bowel : Regular
Bladder movements : Regular
Hygiene : Maintained
Addiction : No
IV. SOCIOECONOMIC STATUS:
A. Housing condition:
House : Own / pucca
Ventilation : Adequate
Sanitary condition : Closed
Water facilities : MCD supply
Electricity facilities : Yes
Method of waste : Proper
disposal
B. Financial support :
 Total no. of earning members :3
Total income : 15000/month
Socio-economic : Middle class

V. PHYSICAL EXAMINATION :
General appearance:
Nourishment : Well nourished
Body built : Healthy
Body posture : Normal
Activity : Tired
Body movements : No limp
HEAD TO TOE ASSESSMENT:
1. Neurological system :
 Level of consciousness :
 GCS: Patient is oriented, opens eyes spontaneously, and follows verbal orders. He is having GCS
as E4 V5 M6
 Eyes : Opens spontaneously
 Verbal Response :normal
 Motor Response : normal
 Eyes: The shape and movement of eyes are normal.
 No crust or discharge formation
  Colour of sclera is light pale and conjunctiva is red
 Eyelids are present and normal movement of eyeballs.
 Neck :
 No flexion and extension of neck
 Distension of jugular vein
 Swelling of lymph nodes and normal thyroid gland
 Reflexes :
 Superficial reflexes normal
 Deep tendon reflexes normal
2. Sensory system :
 Eyes
 visual acuity : normal
 Ears :
 Patients hearing ability is normal and there is no discharge from ears. Cerumen
is present.
 Nose :
 External nares are dry and there is no abnormal discharge.
 Mouth and Pharynx:
 Lips the lips are dry and pallor.
 Teeth : teeth are yellowish and unhygienic
 Gums : normal
 Tongue : pale, dry.
 Odour : halitosis
3. Respiratory system :
 Chest : chest symmetry is normal and equal
 Trachea : normal
  Breathing pattern: regular.
 Breath sounds: 18/min
4. Cardiovascular system :
 Cardiac pattern: heart rate is 76/ min and rhythm is regular.
 Pericardial movements :
 No distension of neck viens
 S1 and S2 are normal, no murmur is present.
 Capillary Refill: 3 seconds.
5. Gastrointestinal system :
 Abdominal girth : 45 cm
 Observation : abdomen is sound , no distension , no lesion
 Palpation : abdomen is soft to touch and non tender
 Auscultation : bowel movements regular
 Percussion : hollow sound heard
 Feeding pattern : oral
 Diet : high protein diet
 Bowel per day : 1 time
6. Renal system :
 Urine output : 80ml/hr
 Colour : yellowish
 Voiding pattern: normal.
7. Integumentary system :
 Skin colour, texture, turgidity and temperature : color brownish, texture is dry, skin
turgidity is maintained .
 Vascularity : normal
  Lesions : no lesions present
 Infections : no skin infection
8. Musculoskeletal system :
 Activity level : less active
 Extremities : able to move extremities
 Joints : able to flex and extend the joints

NURSING DIAGNOSIS
1) Acute pain and swelling related to fracture
2) Risk for hemorrhage and shock related to open fracture
3) Risk for infection related to the open wound
4) Knowledge deficit related to the care of fracture and home care

Sr. Nursing Nursing Planning Implementation Evaluation

no. assessment diagnosis
1. Assess the Acute pain To assess the level of The level of pain is assessed as the patient has Pain is reduced
level of and pain severe pain in leg
pain as told swelling To reduce the pain as Patient is immobilized because the movement
by the related to much as possible increases the pain
patient fracture To immobilize the Patient has provided comfortable position, to
 (severe injured part take rest
pain in leg) To provide comfortable Pain killer are provided to the patient as
position to the patient prescribed by the doctor
To provide prescribed
analgesics to reduce the
pain.

2. Assess the Risk for To assess the need of Need for the oxygen is assessed Risk for
risk of hemorrhage oxygen for the patient Blood pressure is checked as (100/70) slightly hemorrhage is
more and shock To check the blood low than normal reduced
hemorrhage related to pressure of patient Ice packs are applied on the patient to reduce
and shock open To observe for any bleeding and for easy vasoconstriction
related to fracture bleeding Intravenous fluids are administered to the
open To provide ice packs and patient, to improve the fluid level
fracture sponging application for Intake and output chart also maintained
vasoconstriction Patient is provided comfort as much as
To administer I/V fluids possible
To maintain intake and
output chart

3. Assess the Risk for To assess the condition Condition of the patient is assessed Risk of
condition infection of the wound Wound of the patient is regularly cleaned and infection is
of the related to To clean and irrigate the irrigate so as to prevent infection reduced
wound as the open wound Proper aseptic techniques are used during
infection wound To maintain good dressing of the wound
may occur personal hygiene Special care is provided to the patient when
To use proper aseptic plaster is applied
technique when doing Wound is closed as dressing is done
 dressing There is no bleeding from the dressing
to provide special care to
the patient in plaster
cases
to prevent to be open

4. Assess the Knowledge To assess the level of Level of knowledge is assessed Patient is
level of deficit knowledge Patient is adviced to take care of the plaster provided
knowledge related to To provide complete Patient and family members has provided enough
and the care of knowledge about the knowledge about the treatment end the knowledge
understandi fracture treatment and home care rehabilitation care at home about the care
ng about and home To provide rehabilitation Rehabilitation training is provided to the of patient with
the care training to the patient patient and family members fracture.
treatment To introduce to Both are introduced to the physiotherapists
and physiotherapists and Patient is adviced not to do exercise until the
rehabilitati promote for exercise to condition is improved.
on care the patient