NURSING CARE PLAN IN PATIENT ASSESMENT WITH CLOUSED FRACTURE

PROXIMA 1/3 FEMUR IN WARD EMERGENCY I, SRINAGARIND HOSPITAL

KHON KAEN

279 731 Advanced Nursing Practice in Selected Areas of Interest 1 (Adult 1)

Presented to:

Assoc Prof. Dr. Earmporn Thongkrajai

TIARA A5850600298

Master of Nursing Science Program

Faculty of Nursing, Khon Kaen University

First Semester, Academic Year 2015

NURSING CARE PLAN IN PATIENT ASSESMENT WITH CLOUSED FRACTURE

PROXIMA 1/3 FEMUR IN WARD EMERGENCY I, SRINAGARIND HOSPITAL

KHON KAEN

A. Health history

Assesment at january, 21-01-2016

1. Client profile

Mr. J is 79 years old admited on january 14 th 2016,. patients come to the hospital

delivered by his family . The patient fall down in the floor when he want to keep

the blanket in cupbroad. After the accident the patient was taken to Udon Tani in

his province but the dr did not given treatment only splinting bandages and some

medication . The Patients had been hospitalized in Udon thani Public Hospital

more than 7 days. Then, from the request of the patient's family and the advice of

the doctor the patient had been referred to srinagarind hospital on january 14th

April 2016 at 19.00. In emergency room the patient got the some medication such

us morfine, paracetamol 500 mg, fosfomin inj 2 mg, propranolol 10 mg. And

IVFD 20 drop/minutes.

The patient's wife said that the patient was in an unhealthy condition of patients

had a history of surgery at the hip in 2 years ago. after that the patient is difficult

to walk and move and have problems with his memory, sometimes patients forget

time and place. and he has problem with bladder habit like incontinentia urine.

At the time of assessment, namely on january 22th 2016 patients said pain in the

right foot. The patient feel Pain when he move, the pain makes the patient very

uncomfortable. And the patient uses a traction 5 kg. The patient could not eat and

unclear when he speaking. Vital signs blood presure is 141/78, pulse is 97

 times/minute, respiration rate 24 times/minute, tenperature is 37.8 C., O2

saturation is 92 %. Treatment/Medication

1. Past illnesses/hospitalizations

He has of surgery on his hip 2 years ago, and he has DM and HT since he was 45

years old and he has CVT 2 years ago.

2. Allergies

No history of allergy to drugs, foods or other medication.

3. Developmental history

He has two brother and he is the second. He grew up with the family who very
love him.
The care giver said that the patient has history of smoking more than 20 years and
he stoped at the age of 76 years old , the care giver explained that the patient stop
smoking when he have a CVA, and the care giver said that the patient drink
alchohol up to present with the amount of 200 cc/day.

B. Funcional health pattern (GORDON)

1. Health perception / health management pattern

He feel unconfortable, he could not do activities as usual. If he got sick he went to

the doctor or health care services. Pain is very severe and expect that he will get

sick for a long time after hospitalized.

His wife is his care tak. He drink alcohol and uses a tobacco sometime. He does

not exercise regularly. The care giver said that the patient can not eat and very

weak.

2. Nutrition/ metabolic

Height : 175 cm

Weigh : 55 kg

Body massa index: 15.2

 Usual eating pattern :Before he gots sickness he eat three time/day, the patient

does not problem to eat, he doesn have allergy of foods. But during sick , he used

NGT, 250 x 4 feed, he do not want to eat. Does not wear any dentures . Nails hard

and smoot, he doesn have constipation, diarrhea.

3. Elimination pattern

Bowel habits : before sick he dont have problem with bowel pattern, after

sick and hospitalized he has problem with bowel at least 2-3 time a days (soft and

brown), no mucus, no blood, or tarry stool, no rectal bleeding. But since in the

hospital he has bowel habits once in every 2 days.

Blader habit : before sick he dont have problem with blader habit, usually

2 3 time a days, no dysuria, no hematuria, now on ureternal catheter , no blood ,

the color is yellow dark turbidity + 2. Urine output 1000-2000 / day. But after

sick he has problem with blader habit, he feel pain when urinating, 2-3 time a day.

800-1200cc a day, and since in hospital he used on dwelling urethral chateter.

4. Activity exercise pattern

Before sick : he wake up at 06.00, does he chores around the house, joging, farm

and breakfast with his wife. He has no regular exercise regimen, just take a rilax

time with his wife and his dog.

After sick : Patient looks weakness, the patient use a Russels traction 5 kg, the

patient cant sit. Self care ability is 4.

Self care ability : 0 = independent, 1 = assistive device, 2=assistance from others,

3 = assistance from person and equipment, 4= dipenden/unable.

The care giver said that she help patient in all of the activities.

5. Sleep/rest pattern
 He goes to bed at 10 pm and weak up at 5 am, but usualy he sleep uncertain. He

agitated and sometimes he awakened during sleep. He has problem with his sleep

patternt because discomfort and severe pain in his hip and in his femur. Sometime

sleep only 2-3 hour in at night. And he tried to sleep again but could not. He has

dark sircle under his eyes. The patient looked tense

6. Sensory /perceptual pattern

Vision : he has not any problem with his eyes, he can see clearly, no

discharge, redness or trauma and not used eyes glasses.

Hearing : he has not problem in his ears. He does not wear any hearing aids.

Touch : he felt more comfortable and feel better if some one touch his both of

leg and give the soft massage in the area. the patient can feel when being touched

his skin and his fingers.

Pain : admit pain in his right femur and his hip. He can not walk, just laying down

in the bed.

7. Patient Cognitive pattern

Speech sometime unclear, he can speaks english very well.

Examines ideas unclear , The patient has amnesia at the time, drowsy at times,

occassionally to place and times.

8. Role / relationship patient

He was married with Thai people 5 years ago , previously met in the UK and

communication with fb , then he met and married at the age of 64 years old, and

his wife has two daughters. The patient has gotten caring from his wife. His wife

is taking care of him 24 hours. The care giver (patients wife) said that their house

is far from the hospital so only she who can stay in hospital to accompany the

patient.
 9. Value belief pattern

Used to be Cristian, but occassasionally attanded church. Becoming a budhhist

when meried to this Thai wife usually go to temples with the family .

10. Coping / stress tolerance pattern

Not well tolerate to pain or discomfort. He will complaint immediatly as he as a

very strait forward person.

C. General physical assesment

1. General physical profile

Height : 174, weight 55 kg , he loss his weight 5 kg/ 3 months.

Blood pressure is 141/78mmHg, pulse 97 times/minutes, Respiration rate is 24

times/minute, temperature is 37.5 C and O2 92%.

The patient look weak, not well patient not cooperative when the nurse did

assesment to the patient. From the document explained that the patiet has CVA

and hypertention. Sometime his face shown like holding pain, grimace and

hold the pain fracture in his femur. Feel severe pain in his right femur.

2. Assesment of skin, hair and nails

Skin : pale and fragile with some of spot. Temperature warm on upper and

lower extremities.no skin turgor . patient skin was dry and fragile with some

petichiae, skin irritation and bleeding are abviously around both arms. This maybe

due to previous restrainsting of patient.

Hair : Hair of patient is clean and dry.

Nails : fingers nails short, thick and clear. No clubbing fingers. Capilary nail

refill test less than 3 seconds.

3. Assesment of head and neck

- Head symetrically round, trachea midline and no scars.

4. Assesment of eye and ear

- Eyes : equal size and shape bilaterally, patients does not use eyes glasses to

see. No diagnosed blindness, No swelling, redness or thickening.

- Ear : color of the skin ear consisten with color of skin face. No lumps or

lession. The patient does not use heariy device. Do not has problem in her ear.

5. Assesment of nose and sinusess

- Nasal septum : midline without bleeding or perforation, no inflamation on

skin lesions. Frontal and maxillary sinuses

- Non tander bilateral.

6. Assesment of mouth and pharynx

- Do not find any problems in mouth and pharynx.

- Lips moist, some time dry, no lesion or ulcerations. Hard palate smooth

without lessions and masses.

- Tongue midline when protruded, no fasciculation, no masses or lession

7. Assesment of heart

- Blood presure : 141/78 mmHg

- The ECG resulth is sinus tacichardia

8. Assesment of peripheral vascular system

- Arms : equal in size and symetry, there is a red rash, warm and dry to touch

bilaterally, there is petichiae in arms area

- Capillary refill time < 3 second

- Legs : the right foot is fracture, installed a traction 5 kg.

9. Assesment of thorax and lungs

- No lesion present, no nasal faring, tenderness or masses

- The patient dont have problem with his breath

10. Assesment of breast

- Breast is symetrical in size. No lesions, tenderness on palpation bilateral.

11. assesment of abdomen

- abdomen : no lession , no ascites

- abdomen sounds or bowel sound is listened every 8-10 second

12. assesment of genitourinary

- patient uses catheterization

- the patient said that dificult to urinating, sometime he feel pain when

urinating.

13. assesment of musculoskeletal

0 No detection of muscular contraction

1 A barely detectable flicker or trace of contraction with observation

or palpation.

2 Active movement of body part with elimination of gravity.

3 Active movement against gravity only and not against resistance

4 Active movement against gravity & some resistance

5 Active movement against full resistance without evident fatigue

(Normal muscle strength)
 14. assesment of neurological

patient does not have neurogical history before

15. assesment of extremity

- patient has fracture on his right foot. The color of skin is pale, The patient

said that can feel the foot when the nurse touch his foot

- The patient has history periprosthetic on his hip. The patient said that they feel

pain when move,

- Upperr extremity can full ROM, but the lower extremity cant

D. supported assesment

1. laboratory summary

a. laboratory report

Test name Resulth Unit Reference value

FREE T3 2.35 Pg/ml 2.30-6.90

FREE T2 1.28 Ng/dl 0.78-2.11

TSH 1.420 mIU/L 0.200-4.200

b.

Test name Resulth Unit Reference value

CK-MB 13 U/L 0-25

TNT(TROPONIN-T) 0.028 ng/ml 0.000-0.100

 Test name Resulth Unit Reference value
Urynalisis
Color Pale yellow
Turbidity Clear ng/ml
Sp.Gr 1.004 N
pH 7.5 N
PRO Neg -
GLU Neg -
KET Neg -
UBG Normal

c.

Test name Resulth Unit Reference value

BUN 8.9 mg/dl 5.8-19.1
CREATINE 0.6 mg/dl 0.5-1.5
SODIUM 135 mg/dl 130-147
PATASSIUM 3.9 mg/dl 3.4-4.7
BICARBONATE 26.5 mg/dl 20.6-28.3
CLORIDE 97 mg/dl 96-107
CALCIUM 87 mg/dl 8.4-10.2
PHOSPORUS 2.9 mg/dl 2.5-4.6
MAGNESIUM 2.0 mg/dl 1.6-2.6

2. medication

- D 5-W = 100ml

- Paracetamol = 500 mg

- Fosfomin inj = 2 Gm

- Propranolol = 10 mg
 DATA ANALYZE

NO DATA PROBLEM ETIOLOGY

1. SD Impaired physical Fracture femure
- the care giver said that the patient cant mobility
walk
- the patient said that he feel pain when
he move
- the care giver said that the patient bed
rest total
DO
- closed fracture 1/3 fremur
- patient look bedrest total
- patient weakness
- uses traction 5 kg
2 SD Acute pain related fracture
- the patient said that she feel pain
when move
- the patient said that the pain in his
right leg
OD :
- the patient look not relax
- the patient look restless
- the patient look not comfort

3. DS Risk for ineffective unstable bones

- tissue perfusion
OD :
- blood pressure is 141/78
- pulse is 97 times/minute
- physical examination found the
closed fracture femur
- feet smaller (atrophy)
4. DS Family knowladge Few of information
- The care giver said that the patient deficiency
doesn know knowladge about the
fracture
- The care giver said the patient doesn
know how to take care the patient
OD
- the care (wife) confuse when the nurse
ask about the patient
5 SD : Sleep pattern disorder hospitalization
- the care giver said that the Patient
can,t sleep well
- the care giver said that the patient
restless
- the care giver said that the patient
rages
OD :
 - patient look restless
- patient look tired
- patient cann sleep

6 SD: the patient said that he feel itchy Impaired skin integrity damage to the skin

OD :
- there is petichiae in both
arms
- bleeding
7 SD : Impaired Urinary bladder neck
- he said that he feel pain when Elimination obstruction
urinating
- he said that his blader habit not
regular

OD :
- the patient used catheter
- he look pain when urinating
- he has had difficulty starting urination
 Nursing intervention

No. Nursing diagnoses Purpose and results criteria Nursing

intervention
1 Acute Pain related to NOC NIC
surgical wound infection Pain control 1. Teach patient
With results criteria: hoe to do pain
SD: SD: management
The patient said that Patient said the pain less non-
he feels pain if try to (Scale 1-3) and/ no pain pharmacology,
move (right side). such as listening
Patient said that has Patient said that he can does the music,
pain on the left lower pain management sleeping, and
extremity with: talking with
P: surgical OD: others
wound, Patient looks relax 2. Identify cause of
fracture. Patient looks smile pain
Q: Stabbing 3. Identify when
R: on right foot the pain
S: 6 (Moderate 4. Solve the causes
Pain) that increase the
T: when pain
moving and 5. Collaboration to
wound care give analgesic

OD:
Blood pressure is
141/78, pulse is 97
times/minute
Temperature is 37,8
C.
The patient looks not
relax
The patient looks
grimacing in pain
2 Integrity of skin disorder NOC NIC
related to the open fracture Tissue skin and mucous 1. Wound care
membrane integrity effectively
SD: With results criteria: 2. Monitor of the
Patient said that wound and skin
the wound on his SD: 3. Monitor patient
left foot Patient said that the wound nutrition status
The documentation has already healing 4. Monitor sign of
explained that the infection on
patient has fracture OD: wound
and occur vascular The wound on patient left
injury in his tibia foot is not infection and in
(left side) process to be healing

OD:
Patient has surgical
wound on his left
foot.
The nurse said that
the patient skin in
wound area looks
red and the
surgical wound has
infection
The patients
wound looks
bandaged.
Wound
Assessment
T = Tissue
non viable
I = Infection
and/or
inflammation,
M = Moisture
imbalance
E = non-
advancing or
undermined

3. Immobility related to NOC NIC

vascular injury, destruction Joint movement mobility level 1. Discuss to give
of bone tissue Self care ADLs tools ambulatory
With results criteria: to the patient
SD: 2. Teach patient
The patient said that SD: how to
 he is only bed rest. The patient said that he can ambulatory
The patient said that do activity and move by him technique
he feels pain if try to self 3. Identify patient
lift his foot right ability to do
side). OD: mobilization
Mobility level is less than 4. Collaborationto
OD: 10 score do physical
The patient looks bed therapy
rest. 5. Identifyand
The patient looks not monitor of
relax cause of his mobility level
pain.
5 Patient and family Knowledge: disease 1. Teach patient
knowledge deficiency Knowledge: health behavior and family about
related to few of With results criteria: patients disease
information 2. Teachpatient
DS and family how
SD: The care giver said that she to do wound
The patient said that understand about diabetes care to the
does not knowledge and how to prevent it patient
about vascular injury 3. Dodiscussion
and its complication. The care giver said that she about the
can do wound care if the disease and how
OD: patient goes home to care about the
The patient and care The patient said that he disease
giver look confuse understand about his
when the nurse ask to disease.
discuss about
patients disease. OD:
The patient and care giver
look cooperative and can
answer the nurse questions
about fracture and vascular
injury.