Nursing care plan

BEST NOTES

1. FRACTURE
NURSING DIAGNOSIS: risk for [additional] Trauma
Risk factors may include
Loss of skeletal integrity (fractures)/movement of bone fragments
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an
actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
 Independent: Maintain bed rest/limb rest as indicated.
Provide support of joints above and below fracture site,
especially when moving/turning.
Rat: Provides stability, reducing possibility of disturbing
alignment/muscle spasms, which enhances healing.
 Support fracture site with pillows/folded blankets.
Maintain neutral position of affected part with sandbags,
splints, trochanter roll, footboard.
Rat: Prevents unnecessary movement and disruption of
alignment.
 Use the palms of hands, not the fingertips, when touching
the wet cast.
Rat: Fingertips can dent the cast before it is dry.
 Evaluate splinted extremity for edema resolution.
Rat: As edema subsides, readjustment of
splint or application of plaster/fiberglass cast may be
required for continued alignment of fracture.
 Maintain position/integrity of traction (e.g., Buck,
Dunlop, Pearson, Russell).

2. Rat: Traction permits pull on the long axis of the fractured
bone and overcomes muscle tension/shortening to
facilitate alignment and union.

NURSING DIAGNOSIS: acute Pain
May be related to
Muscle spasms
Movement of bone fragments, edema, and injury to the soft tissue
Traction/immobility device
Stress, anxiety
Possibly evidenced by
Reports of pain
Distraction, self-focusing/narrowed focus, facial mask of pain
Guarding, protective behavior; alteration in muscle tone; autonomic
responses
DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
Pain Level (NOC)
Verbalize relief of pain.
Display relaxed manner, able to participate in activities, sleep/rest
appropriately.

NURSING DIAGNOSIS: ineffective Airway Clearance May be related to
Bronchospasm Increased production of secretions, retained

3. secretions, thick, viscous secretions Decreased energy/fatigue
Possibly evidenced by Statement of difficulty breathing Changes in
depth/rate of respirations, use of accessory muscles Abnormal
breath sounds; e.g., wheezes, rhonchi, crackles Cough (persistent),
with/without sputum production.
RESPIRATORY: CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
AND ASTHMA
121
DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
RESPIRATORY STATUS: Airway Patency (NOC) Maintain patent airway
with breath sounds clear/clearing. Demonstrate behaviors to
improve airway clearance; e.g., cough effectively and expectorate
secretions.
ESPIRATORY: CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
AND ASTHMA
123
NURSING DIAGNOSIS: impaired Gas Exchange May be related to
Altered oxygen supply (obstruction of airways by secretions,
bronchospasm, air trapping) Alveoli destruction Possibly evidenced
by Dyspnea Confusion, restlessness Inability to move secretions
Abnormal ABG values (hypoxia and hypercapnia) Changes in vital
signs Reduced tolerance for activity
DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
RESPIRATORY STATUS: Gas Exchange (NOC) Demonstrate improved
ventilation and adequate oxygenation of tissues by ABGs within
client’s normal range and be free of symptoms of respiratory
distress. Participate in treatment regimen within level of
ability/situation.