Question

Case Study B: Patient with Fractured Tibia (Unit IV) Due by April 26th

Mr. West, 26 years old, was admitted with left fractured tibia. He was taken to surgery and is now being transferred to the orthopedic unit. He has a long leg cast on the left leg. His post-op orders are transcribed to the nursing care plan:

VS q4h                     I&O Neurovascular checks (cric,. Movement, sensation, temp) q4h Elevate left leg on (1) pillow

1liter D5W q10h-discontinue when taking fluids well Teach crutch walking in AM

Diet Clear Liquids to Regular Medications    PCA-Dilaudid 0.2mg/hr

You are assigned to Mr. West as he is taken into his room. You noted that he is alert, left leg cast is damp and clean, and an IV is infusing into his right hand.

Prioritize the five nursing interventions as you would do them to take care of Mr. West. Write in the number in the box to identify the order of your interventions (#1=first intervention, #2=second intervention, etc.) and state an evidence-based rational for each intervention (cite your source)

                INTERVENTIONS           PRIORITY #                           RATIONALE_____     

Take vital signs
Neurovascular assessment of both extremities
Assess cast for dryness, signs, of drainage, and sharp edges
Use palms of hands to elevate cast on pillow
Teach isometric exercises
Check neuro status of right leg (CMST)

On the morning of the first post-op day, you noted that Mr. West is:

1. Requesting pain med
2. Left pedal pulses present, edema 2+
3. Capillary refill >2 sec, moves left toes
4. Taking fluids and voiding quantity sufficient
5. MD orders CPK, LDH, and SGOT

All of the following nursing diagnosis may apply to Mr. Jackson

Risk for injury, Deficient knowledge, Risk for infection, Risk for impaired skin integrity, Ineffective tissue perfusion, Impaired physical mobility, Fear, Pain, Activity intolerance, Impaired tissue integrity, Anxiety, risk for peripheral neurovascular dysfunction

1. Select the ONE nursing diagnosis above that is of priority at this time
2. Provide a rationale for your selection
3. List three nursing interventions that meet the needs of Mr. West

Mr. West refuses lunch and you assess:

c/o increased pain, especially with elevation of the leg, numbness and tingling, left pedal pulse weak, cool

Based on this new information, identify and write the priority problem in the box below. Then, starting with the small box labeled #1, prioritize the nursing intervention for this situation and identify your follow-up action plan for Mr. West.  

Priority Problem # 1 # 2 # 3 # 4 # 5 # 6 New Action Plan

Nursing Intervention:

A Take the vital signs   

B .Inform MD stat

C. Prepare to have cast bivalved

D. Ensure left extremity is at heart level

E. Monitor left pedal pulse

F. Stay with patient

Answer 1

First priority: Take vital signs/

Rationale: Vitals signs checking help us to know the basic health status of the patient and it also help the nurse to identify any deviations from the normal.

Second priorty:Elevate the cast on pillow;

Rationale;Tis will provode a comfortable possition tpo the patient.

Third priority;Assess the cast for dryness and check for any drangae or any sharp edges are there.

Rationale:This will help the nurse to knwo the condition of the surgica site. If it is dry without any leakage of blood, then the wound is healthy.

Fourth priority:Neurovascular assessment of both extremities and check for capillary refillemnt

Rationale; As the patient is unable to move his legs, there is achance of development of deep vein thrombosis. So, neuroassessmnet should be done

Fifth: Teach exercise;

Rationale: Since the patient is on continue bed rest they should be taught regarding the exercises to move small and frequent movements of te fingers of the legs. This will improve blood circulation and reduce the irsk of development of deep vein thrombosis.

Second Part:

1. Acute pain related to the surgical procedure as evidenced by patient compains of pain.

Interventions:a. Assess the level of pain with the help of pain chart raing scale.

b.Provide a comforatble posstion to the patient. Ask him whether he needs an extra pillow to support the surgical site.

c.. avoid use of plastic sheet which can increse heat

d. provide medications as per doctors order.

2. Risk for peripheral neurovascular dysfunction related to decrease blood flow as evidencedby the presence of edema on the leg

Interventions: a. assess the capillary return and skin color of the area.

b,Measure the injured area withnthe non injured area as it helpss to identify any further bleeding taking pace .

c. Check for any tenderness.

d. perform neurovascular assessments.

3.Impaired physical mobility related to neuromuscular impairment as evidenced by inablity to move.

Interventions: a.Assess the degree of immboilty and educationa and cultural practices of the patient so that the nurse can teach about the various exrcises.

b.ausculatate the bowel sounds as immobilsation can alter the elimination pattern.

c.monitor blood pressure as prolongeed immobilastion can lead to postural hypotension.

Third part:

Impaired skin integrity related to altered circulation as evidenced by the pedal pulse is weak.

The nursing interventions are;\

1. Take vital signs.

2. Monitir left pedal pulse.

4.Ensure left extremity is at heat level.

5. Inform MD stat

6. Prepare to have cast bivalved.

7 Stay with the patient.