Medical History

Pt has a history of mild hypertension, chronic headaches, depression, and Hyperlipidemia with no

Medications

Lovenox, Fluconazole,

Zosyn, Senokot, Percocet, Ducolax Laxative,

Morphine, Milk

Vital Signs

99.9 Oral92 Pulse

110/66 BP18 R

97 % Room Air O2

Concept Map Care PlanAshley Christensen- Clinical Week 2

Admit DateApril 6, 2013

Age54 years old

Diet

Regular Diet

Medical DiagnosisT12-L1 superior end plate

compression fracture, right open femur fracture, right

tibia fracture

AllergiesNo known allergies

Code Status

Full Code

Psychosocial, Functional, Spiritual, Growth & Development

54-year-old Caucasian adopted female; Married with one

Nursing Assessment

This is a 54 –year-old female passenger involved in a motor vehicle accident with her husband as the driver

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 closure of the wound. She was admitted to STU for 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. Patient’s lungs are clear to auscultation anterior and posterior to bases in regular

rate and pattern. Apical pulse of 92 per minute with normal S1 and S2 heart sounds and no murmur or

gallop noted. Patient’s abdomen is soft, nontender with normal bowel sounds x 4 quadrants. Patient’s skin is

dry, warm and within normal limits for patient’s ethnicity with <3 second capillary refill to all

extremities. Patient has a central PICC Line in her right basilic vein that is dry intact with no drainage noted and no current infusions. Patient’s radial pulse +2 normal,

bilateral pedis pulse +2 normal. Pt has localized dependent edema in right lower leg, non-pitting. Pt has

Sources used for

rationales

Ackley, B.J., G.B. (2011).

Nursing Diagnosis

Handbook. (9 ed).

1

1``

Plan / Expected Outcome Patient will remain free from

symptoms of infection until the end of clinical day

2

Nursing Diagnoses Acute pain RT traumatized tissue

AEB report of 6/10 pain

Plan / Expected Outcome Patient will report relief from 6/10

pain by end of clinical day

Nursing Interventions

Assess pain using reliable self-report pain tool such as 0-10.

Single-dimension pain ratings are valid and reliable measures of pain

intensity.

Administer opioid and non-opioid analgesics as ordered. First line analgesics for treatment of pain.

Nonpharmacological methods such as relaxation and imagery. Should be used to supplement not replace

pharmacological interventions.

Eliminate additional stressors. Stressors may increase the

patient’s pain level or frustration level.

Anticipate need for pain relief. Prevent the pain from getting out

of control.

Evaluation Goal partially met. Pt reported 2/10 pain by end of clinical day.

Nursing Diagnoses Constipation RT immobility AEB

report of hard stool

Plan / Expected Outcome Patient will state relief from

discomfort of constipation by the end of clinical day

Nursing Interventions

Administer stool softeners as ordered. Prophylactic laxatives

decrease constipation risks.

Encourage fluid intake of 1.5 to 2 L/day unless contraindicated. When

dehydrated body absorbs additional water from stools

resulting in hard stool.

Provide privacy for defecation. A lack of privacy can hinder the

defecation urge.

Use opioids cautiously. Opioids cause constipation.

Encourage turning and changing positions in bed. Bed rest and

decreased mobility lead to constipation

Evaluation Goal not met. Pt unrelieved of

discomfort from constipation by

Nursing Diagnoses Risk of infection RT traumatized

tissue

Nursing Interventions

Observe and report signs of infection. Change in mental status,

fever, shaking, chills, and hypotension are indicators of

sepsis.

Use appropriate hand hygiene. Meticulous infection prevention

precautions are required to prevent infection.

Use sterile technique wherever there is loss of skin integrity.

Infectious agents can invade when a treatment damages the skin.

Use evidence-based practice in care of peripheral catheters: Use

aseptic technique for insertion and care, label insertion sites with date and time. Reduces catheter related

bloodstream infections.

Evaluation Goal Met. Patient remained free

from signs of infection until end of 3