COMPREHENSIVE NURSING CARE PLAN
ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSI EXPLANATION
S
SUBJECTIVE Impaired The natural process of After 5 days of INDEPENDENT: INDEPENDENT After 5 days of nursing
DATA: NONE physical healing a fracture starts nursing 1. Assess degree of immobility 1. Patient may be restricted by self- intervention, the patient will;
mobility when the injured bone intervention, the produced by injury/treatment and view/self-perception out of proportion
OBJECTIVE related to and surrounding tissues patient will be note patient’s perception of with actual physical limitations, requiring - Regained/maintained
DATA: bleed, forming a fracture able to; immobility information/interventions to promote mobility at the highest
application
-Inability to Hematoma. The blood progress toward wellness. possible level.
of traction or
move coagulates to form a -Regain/maintain - Maintained position of
purposefully cast as blood clot situated mobility at the function.
2. Instruct patient in/assist with 2.Increases blood flow to muscles and
within the evidenced by between the broken highest possible - Increased strength/function
Increases blood flow to muscles bone to improve muscle tone, maintain
physical assessment fragments. Within a few level. active/passive ROM exercises of joint mobility; prevent of affected and compensatory
environment, days blood vessels grow -Maintain position affected and unaffected contractures/atrophy and calcium body parts.
imposed into the jelly-like matrix of function. extremities. resorption from disuse - Demonstrated techniques
restrictions of the blood clot. The -Increase that enable resumption of
-Reluctance to new blood vessels bring strength/function 3. Encourage use of isometric 3. Isometrics contract muscles without activities.
attempt phagocytes to the area, of affected and exercises starting with the bending joints or moving limbs and help
movement; which gradually remove compensatory unaffected limb maintain muscle strength and mass. Note:
limited ROM the non- viable material. body parts. These exercises are contraindicated while
-Decreased The blood vessels also -Demonstrate acute bleeding/edema is present.
muscle bring fibroblasts in the techniques that
strength/control walls of the vessels and enable 4.Provide footboard, wrist splints, 4. Useful in maintaining functional
these multiply and resumption of trochanter/hand rolls as position of extremities, hands/feet, and
produce collagen fibers. appropriate preventing complications (e.g.,
activities.
In this way the blood clot contractures/footdrop).
is replaced by a matrix of
collagen. Collagen’s 5. Place in supine position 5. Reduces risk of flexion contracture of
rubbery consistency periodically if possible, when hip.
allows bone fragments to traction is used to stabilize lower
move only a small limb fractures
amount unless severe or
persistent force is 6. Instruct in/encourage use of 6. Facilitates movement during
applied. trapeze and “post position” for hygiene/skin care and linen changes;
lower limb fractures. reduces discomfort of remaining flat in
At this stage, some of the bed. “Post position” involves placing the
fibroblasts begin to lay uninjured foot flat on the bed with the
down bone matrix knee bent while grasping the trapeze and
(calcium hydroxyapatite) lifting the body off the bed.
in the form of insoluble
crystals. This 7. Assist with/encourage self-care 7. Improves muscle strength and
mineralization of the activities (e.g., bathing, shaving). circulation, enhances patient control in
collagen matrix stiffens situation, and promotes self-directed
it and transforms it into wellness.
bone. In fact, bone is a
mineralized collagen 8. Provide/assist with mobility by 8. Early mobility reduces complications
matrix; if the mineral is means of wheelchair, walker, of bed rest (e.g., phlebitis) and promotes
dissolved out of bone, it crutches, canes as soon as healing and normalization of organ
becomes rubbery. possible. Instruct in safe use of function. Learning the correct way
Healing bone callus is on mobility aids. to use aids is important to maintain
average sufficiently optimal mobility and patient safety.
mineralized to show up
on X-ray within 6 weeks 9. Monitor blood pressure (BP) 9. Postural hypotension is a common
in adults and less in with resumption of activity. Note problem following prolonged bed rest and
children. This initial reports of dizziness. may require specific interventions (e.g.,
“woven” bone does not tilt table with gradual
have the strong
mechanical properties of 10. Reposition periodically and 10. elevation to upright position).
mature bone. By a encourage coughing/deep- Prevents/reduces incidence of skin and
process of remodeling, breathing exercises. respiratory complications (e.g., decubitus,
the woven bone is atelectasis, pneumonia).
replaced by mature
“lamellar” bone. The 11. Auscultate bowel sounds. 11. Bed rest, use of analgesics, and
whole process can take Monitor elimination habits and changes in dietary habits can slow
up to 18 months, but in provide for regular bowel routine. peristalsis and produce constipation.
adults the strength of the Place on bedside commode, if Nursing measures that facilitate
healing bone is usually feasible, or use fracture pan. elimination may
80% of normal by 3 Provide privacy. prevent/limit complications. Fracture pan
months after the injury. limits flexion of hips and lessens pressure
Several factors can on lumbar region/lower extremity cast.
help or hinder the bone
healing process. For 12. Encourage increased fluid 12. Keeps the body well hydrated,
example, any form of intake to 2000–3000 mL/day decreasing risk of urinary infection, stone
nicotine hinders the (within cardiac tolerance), formation, and constipation
including acid/ash juices.
process of bone
healing, and adequate 13. Provide diet high in proteins, 13. In the presence of musculoskeletal
nutrition (including carbohydrates, vitamins, and injuries, nutrients required for healing are
calcium intake) will minerals, limiting protein content rapidly depleted, often resulting in a
help the bone healing until after first bowel movement. weight loss of as much as 20/30 lb during
process. Weight- skeletal traction. This can have a
bearing stress on bone, profound effect on muscle mass, tone, and
after the bone has strength. Note: Protein foods increase
healed sufficiently to contents in small bowel, resulting in gas
bear the weight, also formation and constipation. Therefore,
builds bone strength. gastrointestinal (GI) function should be
fully restored
The bone shards can
before protein foods are increased.
also embed in the
muscle causing great 14. Adding bulk to stool helps prevent
pain. Although there 14. Increase the amount of constipation. Gas-forming foods may
are theoretical roughage/fiber in the diet. Limit cause abdominal distension, especially in
concerns about gas-forming foods. presence of decreased intestinal motility.
NSAIDs slowing the
rate of healing, there is 15. Consult with 15. Useful in creating individualized
not enough evidence to physical/occupational therapist activity/exercise program. Patient may
warrant withholding and/or rehabilitation specialist. require long-term assistance with
the use of this type movement, strengthening, and weight-
bearing activities, as well as use of
analgesic in simple
adjuncts, e.g., walkers, crutches, canes;
fractures elevated toilet seats; pickup
sticks/reachers; special eating utensils.
