Marilyn Hughes Nursing Care Plan PDF

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Marilyn Hughes Nursing Care Plan...

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Pace University Lienhard School of Nursing Nursing Care Plan Name: Riley Leonard Pt's Initials: M.H. Age: 45 Gender: Female Diagnosis: Compartment syndrome Left mid-shaft tibia-fibula fracture Date: 04/09/20 Assessment Pathophysiolog Goals Nursing Diagnosis Nursing Interventions Rationale Evaluation y

Chief Complaint: Severe pain in left leg due to a mid-shaft tibia-fibula fracture after slipping on ice

Doctor ordered vital signs to be taken every 30 minutes

To restore circulation to limb to prevent necrosis or nerve damage

Lower leg to heart level Subjective: Patient states that her pain is a 9/10 The patient states they cannot move toes and that they feel numb

The pt report s that she

Loosen the dressing on the patient’s leg (because they complained it was too tight) Assess the patients dressing Check the pedal pulses Check for neurovascula r function Ask patient if they can move their toes Ask patient if they can feel

Pain management to promote healing of fracture

Educate patient about a fasciotomy and the healing process

Acute pain related to left tibia-fibula fracture as evidenced by self-report of a pain intensity of 9 using the numeric rating scale

Assessing patients’ vital signs every 30 minutes (BP, respiratory rate, pulse, temperature, SpO2 %)

Patient states she is a 9/10 on a pain rating scale. Morphine did not help the first time. So consult with the doctor about Assess for signs associated with pain main medication.

Short- term goal: control and management of patient pain Evaluation: Administer the ordered pain medication

Assess the patient’s response to pain

Short- term goal: monitor patients vital signs Evaluation: make sure blood pressure does not drop, and respiratory rate is not high

Assess the patient’s expectation for pain relief

Ineffective tissue perfusion related to increased Goal to relieve fascia pressure as pressure by evidenced by loosening dressing absent pulse and and keeping leg at alerted sensation heart level Impaired skin integrity related to altered sensation evidenced by patient reporting Examine skin for: pain and discoloration and numbness blanching

Patient is on morphine which lowers blood pressure and the pain level can make respiratory rate increase

Long- term goal: provide patient education Evaluation: she will need to be educated about she will need to be wound care and the steps to take to educated about ensure healing and wound care and the steps to take to restore function to ensure healing and her limb restore function to her limb Long- term goal:

their toes

canno t move or toes and that they feel numb The pt

Assess the patient’s IV site Insert a new IV for the morphine Ask patient about allergies Determine patient’s pain Administer 46 mg if morphine via IV push Provide patient education

Assess the patient sensation to touch Risk for Peripheral Neurovascular Dysfunction evidenced by pain, paresthesia, pallor and pulseless

Risk for impaired gas exchange related to altered blood flow

Assess capillary return, skin color, or temperature of the skin Assess the peripheral pulse via Doppler

Monitor respiratory rate and effort Auscultate breath sounds, noting development of unequal sounds (crackles or wheezes) Not increasing restlessness, confusion, lethargic

Patient will be on crutches and is a fall risk

assess patients’ home and help/support system Evaluation: to ensure the patient gets discharged to a safe place b/c she is a fall risk

report s that she canno t move or toes and that they feel

numb The pt report s that she canno t move or toes and

that they feel numb Objective:

The left pedal pulse was absent, and the skin is cold and clammy. Initial assessment Vital signs:

Temp (oral): 99 F

SpO2: 98% Respiratory rate: 21breaths per minute

Blood Pressure: 155/92 mm Hg

Heart rate: 99

HPI Healthy. Does not take any medications and has no known allergies

EP 1/2019; Nursing Care Plan single sheet...