Ashley Christensen- Clinical Week 2

Admit Date Medical Diagnosis Nursing Assessment This is a 54 year-old female passenger involved in a related to rear-ending a stopped vehicle going approximately 50 mph; patient denies losing consciousness but states that she was thrown from the motorcycle. Patient presented in the ER on April 6 with obvious deformity to right femur with an open fracture and soft tissue injury. Patient was admitted to the OR for external fixation of femur-tibial fracture, an open reduction internal fixation of her left lateral malleolus fracture, irrigation and debridement of skin soft tissue and bone, followed by management of trauma. On April 9th, patient had CT of abdomen and pelvis, which showed evidence of a mild T12 and L1 compression fracture. At this time, the patient is awake, alert and oriented complaining of moderate lower bilateral leg pain reported 6/10 worsened upon movement. PERL. Mucous membranes moist and pink in color. Speech is clear and coherent with no significant facial asymmetry noted. Neck is supple, midline trachea. Patients lungs are clear to auscultation anterior and posterior to bases in regular rate 1 closure of the wound. She was admitted to STU for

Concept Map Care Plan

April 6, 2013

T12-L1 superior end plate compression fracture, right open femur fracture, right tibia

motor vehicle accident with her husband as the driver

54 years old No known allergies Diet Regular Diet Code Status Medical History Full Code Pt has a history of mild hypertension, chronic headaches, depression, and Hyperlipidemia with no known family history. Psychosocial, Functional, Spiritual, Growth & Development 54-year-old Caucasian adopted female; Married with used one Sources Medications Vital Signs son for rationales Catholic; Generatively vs. Stagnation Lovenox, 99.9 Oral Ackley, B.J., Fluconazole, 92 Pulse Zosyn, Senokot, Percocet, 110/66 BP 18 R 97 % Room Air G.B. (2011). Allergies

Age

fracture

Diagnosis

Nursing

Acute pain RT traumatized tissue AEB report of 6/10 pain Plan / Expected Outcome

Nursing Diagnoses

Constipation RT immobility AEB report of hard stool Plan / Expected Outcome

Nursing Diagnoses

Risk of infection RT traumatized tissue Plan / Expected Outcome

Nursing Diagnoses

Patient will report relief from 6/10 pain by end of clinical day Nursing Interventions Assess pain using reliable self-report

Patient will state relief from discomfort of constipation by the end of clinical day Nursing Interventions Administer stool softeners as

Patient will remain free from symptoms of infection until the end of clinical day Nursing Interventions Observe and report signs of

dimension pain ratings are valid and reliable measures of pain intensity.
Administer opioid and non-opioid

pain tool such as 0-10. Single-

ordered. Prophylactic laxatives

decrease constipation risks.

infection. Change in mental status,

analgesics for treatment of pain.

Nonpharmacological methods such

analgesics as ordered. First line

L/day unless contraindicated. When

Encourage fluid intake of 1.5 to 2

hypotension are indicators of sepsis.

Use appropriate hand hygiene.

fever, shaking, chills, and

dehydrated body absorbs additional water from stools resulting in hard stool.

precautions are required to prevent infection.

Meticulous infection prevention

be used to supplement not replace pharmacological interventions.

Eliminate additional stressors.

as relaxation and imagery. Should

Provide privacy for defecation.

lack of privacy can hinder the defecation urge.

Use sterile technique wherever there

agents can invade when a treatment damages the skin.

is loss of skin integrity. Infectious

Stressors may increase the patients

1``

Use opioids cautiously. Opioids

pain level or frustration level.

Evaluation

cause constipation.

Use evidence-based practice in care of peripheral catheters: Use aseptic Evaluation technique for insertion and care, Goal Met. Patient remained free label insertion sites with date and from signs of infection until end of time. Reduces catheter related

Goal partially met. Pt reported 2/10 Anticipate need for pain relief. pain by end of clinical day.

Prevent the pain from getting out of

Evaluation Encourage turning and changing Goal not met. Pt unrelieved of positions in bed. Bed rest and discomfort from constipation by end

decreased mobility lead to