Question
What is the Care plan for this case below?
A patient admitted to orthopedic ward with right upper limb fracture( Humur, fourth phalanx) and left posterior 7 rib fracture too after beating by their fighting with their neighbor.
A patient admitted to orthopedic ward with right upper limb fracture( Humur, fourth phalanx) and left posterior 7 rib fracture too after beating by their fighting with their neighbor.
Answers
GPT-4o mini
Creating a care plan for a patient admitted to an orthopedic ward with a right upper limb fracture (humerus and fourth phalanx) and a left posterior rib fracture involves several components, including assessments, nursing diagnoses, goals, interventions, and evaluations. Here's a structured care plan:
### Patient Profile
- **Patient Demographics**: (assumed) Adult male/female
- **Admitting Diagnosis**: Right upper limb fracture (humerus and fourth phalanx) and left posterior rib fracture due to trauma from a physical altercation.
### Assessments
- **Physical Assessment**:
- Vital signs (to assess stability and rule out shock)
- Neurovascular assessment of the affected upper limb (capillary refill, sensation, movement)
- Assessment of pain level (using a pain scale)
- Respiratory assessment (due to rib fractures)
- **Psychosocial Assessment**:
- Assessment of the patient's emotional state (anxiety, coping mechanisms for trauma)
- Assessment of social support (family, friends)
### Nursing Diagnoses
1. **Acute Pain** related to fractures as evidenced by patient report of pain and altered mobility.
2. **Impaired Physical Mobility** related to fractures as evidenced by limited range of motion and inability to perform activities of daily living (ADLs).
3. **Risk for Impaired Skin Integrity** related to immobilization and the presence of injuries.
4. **Ineffective Breathing Pattern** related to rib fractures as evidenced by pain during deep breaths or shortness of breath.
### Goals/Outcomes
1. The patient will report a decrease in pain to a manageable level (3/10 or less) within 48 hours.
2. The patient will demonstrate improved mobility and be able to perform some ADLs independently within 7 days.
3. The patient will maintain intact skin integrity throughout hospitalization.
4. The patient will demonstrate effective breathing patterns and report no respiratory distress.
### Nursing Interventions
1. **For Acute Pain**:
- Administer pain medication as prescribed; assess pain level every 4 hours or as needed.
- Use non-pharmacological methods (e.g., ice, rest, elevation of the affected limb) to manage pain.
- Provide education on pain management strategies.
2. **For Impaired Physical Mobility**:
- Assist the patient with positioning and support for the affected limb.
- Encourage gradual mobilization and participate in physical therapy sessions as prescribed.
- Instruct the patient in range-of-motion exercises for the unaffected limbs.
3. **For Risk for Impaired Skin Integrity**:
- Inspect the skin around the cast/splint for signs of irritation or breakdown.
- Educate the patient on the importance of keeping the cast dry and clean.
- Reposition the patient frequently to prevent skin breakdown.
4. **For Ineffective Breathing Pattern**:
- Encourage deep breathing exercises and the use of incentive spirometry.
- Monitor respiratory rate and rhythm.
- Educate the patient about splinting the rib area for comfort while coughing or breathing deeply.
### Evaluation
- Reassess pain levels and document changes in the patient's reports; adjust pain management as needed.
- Evaluate the patient’s mobility and independence in performing ADLs; make referrals to physical therapy if necessary.
- Monitor the skin condition regularly for any signs of breakdown or irritation.
- Assess respiratory status regularly; encourage adherence to breathing exercises and evaluate their effectiveness.
### Additional Considerations
- Assess for any signs of complications, such as compartment syndrome or deep vein thrombosis (DVT), and intervene as necessary.
- Provide psychosocial support, including counseling or referral to mental health services if needed.
- Educate the patient about proper follow-up care, including fracture management, signs of complications, and lifestyle modifications after discharge.
This comprehensive care plan should be customized based on the individual patient's needs, response to treatment, and evolving condition throughout their hospitalization. Regular reassessment and adjustments to the plan are essential for optimal patient outcomes.
### Patient Profile
- **Patient Demographics**: (assumed) Adult male/female
- **Admitting Diagnosis**: Right upper limb fracture (humerus and fourth phalanx) and left posterior rib fracture due to trauma from a physical altercation.
### Assessments
- **Physical Assessment**:
- Vital signs (to assess stability and rule out shock)
- Neurovascular assessment of the affected upper limb (capillary refill, sensation, movement)
- Assessment of pain level (using a pain scale)
- Respiratory assessment (due to rib fractures)
- **Psychosocial Assessment**:
- Assessment of the patient's emotional state (anxiety, coping mechanisms for trauma)
- Assessment of social support (family, friends)
### Nursing Diagnoses
1. **Acute Pain** related to fractures as evidenced by patient report of pain and altered mobility.
2. **Impaired Physical Mobility** related to fractures as evidenced by limited range of motion and inability to perform activities of daily living (ADLs).
3. **Risk for Impaired Skin Integrity** related to immobilization and the presence of injuries.
4. **Ineffective Breathing Pattern** related to rib fractures as evidenced by pain during deep breaths or shortness of breath.
### Goals/Outcomes
1. The patient will report a decrease in pain to a manageable level (3/10 or less) within 48 hours.
2. The patient will demonstrate improved mobility and be able to perform some ADLs independently within 7 days.
3. The patient will maintain intact skin integrity throughout hospitalization.
4. The patient will demonstrate effective breathing patterns and report no respiratory distress.
### Nursing Interventions
1. **For Acute Pain**:
- Administer pain medication as prescribed; assess pain level every 4 hours or as needed.
- Use non-pharmacological methods (e.g., ice, rest, elevation of the affected limb) to manage pain.
- Provide education on pain management strategies.
2. **For Impaired Physical Mobility**:
- Assist the patient with positioning and support for the affected limb.
- Encourage gradual mobilization and participate in physical therapy sessions as prescribed.
- Instruct the patient in range-of-motion exercises for the unaffected limbs.
3. **For Risk for Impaired Skin Integrity**:
- Inspect the skin around the cast/splint for signs of irritation or breakdown.
- Educate the patient on the importance of keeping the cast dry and clean.
- Reposition the patient frequently to prevent skin breakdown.
4. **For Ineffective Breathing Pattern**:
- Encourage deep breathing exercises and the use of incentive spirometry.
- Monitor respiratory rate and rhythm.
- Educate the patient about splinting the rib area for comfort while coughing or breathing deeply.
### Evaluation
- Reassess pain levels and document changes in the patient's reports; adjust pain management as needed.
- Evaluate the patient’s mobility and independence in performing ADLs; make referrals to physical therapy if necessary.
- Monitor the skin condition regularly for any signs of breakdown or irritation.
- Assess respiratory status regularly; encourage adherence to breathing exercises and evaluate their effectiveness.
### Additional Considerations
- Assess for any signs of complications, such as compartment syndrome or deep vein thrombosis (DVT), and intervene as necessary.
- Provide psychosocial support, including counseling or referral to mental health services if needed.
- Educate the patient about proper follow-up care, including fracture management, signs of complications, and lifestyle modifications after discharge.
This comprehensive care plan should be customized based on the individual patient's needs, response to treatment, and evolving condition throughout their hospitalization. Regular reassessment and adjustments to the plan are essential for optimal patient outcomes.