KATHMANDU UNIVERSITY

LUMBINI MEDICAL COLLEGE AND TEACHING HOSPITAL

NURSING PROGRAMME
TANSEN-7, PARVAS, PALPA

NURSING CARE PLAN ON:

“Fracture Open III A, Complete Comminuted

Displaced Femur left”

SUBMITTED TO: SUBMITTED BY:

Ms. Chandra Kumari Garbuja Bipana Surkhali
Lecturer Roll no: 23
LMCTH B.SC Nursing 2nd Year
8th batch, LMCTH

Date of submission: 12th July, 2020

A. Demographic Data of the patient
Patient Identification:
Name : Phulman Sunar
Age/Sex : 38 years/ Male
Address : Chapakot, Syanja
Education : Iliterate
Occupation : Agriculture
Ethnicity : Dalit
Marital status : Married

Inpatient details:
Ward : Orthopedic Ward
Bed no : 205
Inpatient number : 235325
Hospital number : 76031343
Date of Admission : 2020-10-4
Provisional Diagnosis : Open Fracture Femur Left
Final diagnosis : Fracture Open III A, Complete Comminuted Displaced Femur left
Day of Hospitalization : 5 days
Date of discharge : 2020-10-9
Operative Procedure : 90ᴏ to 90ᴏ Distal Femoral Pin Skeletal Traction System

B. Chief complaints
I. At the time of admission on date 2020/10/4
Pain and numbness sensation on the left thigh since last 9 hours

C. History of present illness

Mr. Phulman Sunar, a 63 year old male from Chapakot, Syangja was presented to LMTCH for
management of gunshot wound post initial management of injury at a community hospital. He
was apparently well 9 hours back when he got shot in the mid-lateral portion of his left during a
riot while buying grocery at local vegetable market. He felt extreme pain and subsequently
developed numbness throughout his left leg and noticed he was shot with the bullet deeply
penetrating the bone. Patient was taken by an ambulance for an emergency care at United
Mission Hospital; the nearest community hospital. Patient underwent bullet extraction at the
hospital’s operation theatre.
After that, he was referred to LMCTH on ambulance with proper maintenance of limb
immobility for further management of his condition and was put on 90º to 90º Distal Femoral Pin
Skeletal Traction System.
D. PATIENT ASSESSMENT
1) Consciousness level and orientation: Patient was fully conscious and well oriented to
time, place and person.
2) Vital sign:
Temperature = 97.4 degree Fahrenheit
Pulse = 70 bpm, regular with good volume, and no radio radial delay
Respiration = 20 b/m, regular
Blood pressure = 120/80 mm of Hg
Spo2 = 96 % in room air

3) Activities of daily living-

A. Feeding:
 Mode of food intake: Oral
 Appetite status: good
 Types of food taking: Normal diet
 Amount of food intake: Inadequate
 Any dietary restriction: No any dietary restriction

B. IV fluid: NS III pint over 24 hours

C. Elimination:
 Bowel habit: regular bowel habit
 Bladder habit: irregular bowel habit

D. Sleeping pattern:
 Inadequate sleep
 4 hours at night
 No day time sleeping

4) Mobility: Abnormal
5) Status of personal hygiene: Maintained
6) Anxiety: Present
7) Pain: Present
8) Edema: Present, unilateral and local
9) Others : - loss of skin integrity
E. LIST OF NURSING DIAGNOSIS

Actual Nursing Diagnosis

a) Acute pain related to post surgical incision movement of bone fragments and edema as
evidenced my verbal report of pain and alteration in muscle tone.

b) Ineffective Tissue Perfusion: Peripheral related to injury or traction therapy hypovolemia

secondary to excessive blood loss as evidenced by altered sensation and diminished
peripheral pulses.

c) Impaired physical mobility related to skeletal impairment and discomfort secondary to

femur fracture as evidenced by inability to move purposefully within the physical
environment and decreased muscle strength during neuromuscular examination.

d) Impaired skin integrity related to insertion of traction pins and puncture injury as
evidenced by invasion of body structures and destruction of skin layers.

e) Anxiety related to change in health status as evidenced by irritability and restlessness.

f) Disturbed sleep pattern related to abnormal physiological symptoms and changes in

environment as evidenced by general tiredness and verbal report of difficulty falling
asleep.

Potential Nursing Diagnosis

a) Risk for Peripheral Neurovascular dysfunction related to direct vascular injury, tissue
trauma and excessive edema.

b) Risk for trauma related to movement of bone fragments and weakness.

c) Risk for Deficient Fluid Volume related to hemorrhage and shock.

d) Risk for infection related to loss of skin integrity, traumatized tissue and skeletal
traction.

e) Risk for Disuse Syndrome related to injury and immobilization.

 NURSING CARE PLAN
Sn Assessment Nursing Goals and Planning Rationale Implementation Evaluation
diagnosis expected
outcome
1 Subjective Acute  Pt. will Assess and record the Influences the Assessed and record the My set goals
data: pain verbalize patient’s level of pain effectiveness of patient’s level of pain were
Patient says, related to relief of pain. utilizing pain intensity interventions. Many utilizing pain intensity achieved as
“I am post  Pt. will rating scale & note relieving factors, including the rating scale & noted patient was
feeling surgical demonstrate and aggravating factors, and level of anxiety, may relieving & aggravating able to
intense pain incision ability to nonverbal pain cues such as affect the perception factors. Pain scale= verbalize
in my left movemen participate in changes in vital signs, of pain. 8/10 relief from
leg” t of bone activities with emotions, and behavior. pain and
fragment minimal Maintain immobilization of Relieves pain and Maintained demonstrate
Objective s and complaints of affected part by means of prevents immobilization of relaxation
data: edema as discomfort. bed rest, cast, splint, bone displacement and affected part by bed rest, techniques
On evidence  Pt. will traction. extension of tissue cast, splint, and traction. along with
assessment d my demonstrate injury. participation
of patient verbal use Elevate and support injured Promotes venous Elevate and support in activities
pain scale report of of relaxation s extremity. return, decreases injured extremity. with least
was 9/10. pain and kills and edema, and may discomfort
-Decreased alteration diversional reduce pain. within 2
muscle tone in muscle activities as Avoid use of plastic sheets Can increase Avoided use of plastic days of
and tone. indicated for and pillows under limbs in discomfort by sheets and pillows under nursing
strength. individual cast enhancing heat limbs in cast. intervention.
-edema on situation. production in the
unilateral drying cast.
affected Administer pain medication Promotes muscle Administered tab
limb. as needed & before relaxation and reduce ibuprofen 200 mg BD
-numbness. procedure. pain. as prescribed.
Reassess the level and Monitor effectiveness Pain scale was reduced
intensity of pain and of intervention to 6 and pt. verbalized
changes related to pain. provided. reduced pain sensation.
Sn Assessment Nursing Goals & Planning Rationale Implementation Evaluation
. diagnosis expected
outcomes
2 Subjective Ineffective  Pt. identifies Assess for the signs Early detection of sign & Assessed for vital My set
data: Tissue factors that of decreased tissue symptoms facilitates quick, signs, peripheral objectives
Patient says, Perfusion: improve perfusion & effective management. pulse, saturation, were
“I am feeling Peripheral circulation. contributing factors pallor, cyanosis & achieved as
numbness on related to  Pt. identifies related to impaired Temperature. pt.
my left injury or blood flow. O2 saturation was maintained
necessary
limb.” traction decreased i.e. 85%. maximum
lifestyle
therapy Promote passive Exercise prevents venous Assisted in passive tissue
changes.
Objective hypovolemia ROM exercises as per stasis and further circulatory ROM exercises. perfusion as
data: secondary to  Pt. exhibits tolerance. compromise. evidenced
On excessive growing Avoid resting cast on Can cause denting/ Avoided resting cast by regular
observation blood loss as tolerance to hard surfaces or sharp flattening of the cast and on hard surfaces or pulse & pt
o2 saturation evidenced activity. edges. consequent pressure sores. sharp edges. was able to
of patient by altered  Pt maintains Elevate edematous Elevation improves venous Elevate edematous identify
was sensation maximum legs as ordered & return & minimizes edema. legs as ordered & factors
decreased to and tissue ensure there is no Pressure under knee limits ensured no pressure improving
85% in left diminished perfusion. pressure under knee. venous circulation. under knee. circulation
limb. peripheral within 24
-diminished pulses.  Pt. engages in Encourage smoking Smoking release Encouraged pt. to
hours of
cessation. catecholamine resulting in cease smoking.
femoral behaviors or nursing
vasoconstriction &
pulse as actions to intervention.
ineffective tissue perfusion.
compared to improve
tissue Administer It reduces blood viscosity & Administered Tab
right limb. antiplateletes as coagulation. Clopidogrel 75mg
perfusion.
prescribed. BD as prescription.
Reassess To evaluate effectiveness of There were no
neurovascular status intervention provided & symptoms of
and symptoms of replan as needed. neurovascular
impaired circulation. compromise.
Sn Assessment Nursing Goals & Planning Rationale Implementation Evaluation
diagnosis expected
outcomes
3 Subjective Impaired  Pt. will Assess degree of To provide nursing Assessed the degree of My set goals
data: physical maintain immobility due to intervention accordingly immobility produced were
Patient says, mobility mobility at injury /treatment & considering patients by injury/ treatment & achieved as
“I am related to the highest note patient’s perception & practice. noted patient’s patient was
feeling skeletal possible perception of perception of able to
difficulty in impairment level. immobility. immobility. maintain
changing and discomfort  Pt. will Teach or assist with Increases blood flow to Taught patient passive maximum
position and secondary to maintain active & passive ROM muscles & bone to ROM exercises of mobility &
performing femur fracture position of exercises of affected & improve muscle tone, affected and strength &
my tasks” as evidenced function. unaffected extremities. preserve joint mobility; unaffected extremities. able resume
by inability to  Pt will prevent atrophy. activities
Objective move increase with least
Encourage use of Contract muscles without Encouraged use of
data: purposefully strength/fu discomfort
isometric exercises bending joints or moving isometric exercises
On within the nction of within 2
starting with the limbs helping to maintain starting with the
observation physical affected days of
unaffected limb. muscle strength & mass. unaffected limb.
patient environment body parts. nursing
seemed and decreased Provide and assist with Early mobility reduces Provide and assist intervention.
weak muscle
 Pt will
the use of mobility aids complications of bed rest with the use of walker
-difficulty in strength during demonstrat
and encourage early (phlebitis) and promotes and emphasized early
performing neuromuscular e
mobility. healing and normalization mobility.
ADLs examination. techniques
of organ function.
independent that enable
ly resumption Reposition periodically Prevents or reduces the Repositioned &
-decreased of and encourage incidence of skin and encouraged coughing
strength activities. coughing and deep- respiratory complications & deep-breathing
breathing exercises. exercises.
Reassess the degree of To monitor the Mobility was
mobility. effectiveness of care. improved.
Sn Assessment Nursing Goals & Planning Rationale Implementation Evaluation
diagnosis expected
outcomes
4 Objective Risk for Pt will Assess capillary return, Detect the signs & Assess capillary return, My set
data: Peripheral maintain skin color, and warmth symptoms earlier & skin color, and warmth objectives
On Neurovascula tissue distal to the fracture, prevent complication by distal to the fracture, were
observation r dysfunction perfusion as vital signs, edema and appropriate intervention. vital signs, edema and achieved as
there was related to evidenced by pulse. pulse. pulse=50 b/m. patient was
decreased direct palpable Perform neurovascular Impaired feeling, Performed able to
femoral vascular pulses, skin assessments, noting numbness, increased neurovascular maintain
pulse injury, tissue warm/dry, changes in motor and pain occurs when assessments, noting adequate
unilaterally trauma and normal sensory function. circulation is changes in motor and tissue
on affected excessive sensation, inadequate/ nerves are sensory function. perfusion
limb along edema. usual damaged.
with edema sensorium, Remove jewelry & May restrict circulation Removed tight clothes
and color stable vital tight clothes from when edema occurs. from affected limb.
change. signs, and affected limb.
adequate Maintain elevation of Promotes venous Maintained elevation of
urinary output injured extremities. drainage and decreases injured limb at 90
for the edema. degree.
individual Encourage patient to Enhances circulation Encouraged patient for
situation. routinely exercise and reduces pooling of routine exercise of
digits and joints distal blood, especially in the digits and joints.
to the injury. lower extremities.
Administer IV fluids Maintains circulating Administered NS III
and blood products as volume, enhancing pint over 24 hours as
needed. tissue perfusion. prescribed.
Reassess neurovascular To measure There was no signs
function. effectiveness of care potential complication.
given.
Sn Assessment Nursing Goals and Planning Rationale Implementation Evaluation
diagnosis expected outcomes

5 Objective Risk for  Client will Maintain bed rest or Provides stability, Maintained bed as My set goals
data: trauma maintain limb rest as reducing the possibility indicated. Provided were
On related to stabilization and indicated. Provide of disturbing alignment support of joints above achieved as
observation movement of alignment of support of joints and muscle spasms, and below fracture site patient was
pt. seems bone fracture. above and below which enhances while moving and able to
weak & fragments  Client will fracture site, healing. turning. maintain
lethargic. and display callus especially when maximum
He couldn’t weakness. formation/begin moving and turning. possible
bear his ning union at Secure a bed & A soft or sagging Secured a bed using stabilization
weight on fracture site as mattress properly. mattress may deform mattress and raised &
his own. appropriate. cast, or interfere with side rails. demonstrated
Also he  Client will the pull of traction. proper
needed demonstrate Use sufficient Failure to properly Used sufficient techniques to
assistance body mechanics personnel during support limbs in casts personnel during maintain
for walking, that promote lifting & positioning may cause the cast to lifting & positioning body
turning and stability at the patient. break. patient. mechanics.
performing fracture site. Ascertain that all Ensures that traction Rechecked the devices
activities. clamps and device setup is functioning and clamps within
are functional. properly to avoid certain interval.
interruption of fracture
approximation.
Maintain a neutral Prevents unnecessary Maintained a neutral
position of affected movement and position of affected
part with sandbags, disruption of part with sandbags,
splints, trochanter alignment. splints, trochanter roll
roll and footboard. and footboard.
Teach patient on To reduce possibility Taught patient on
proper body of potential fall injury proper body
mechanics and and trauma. mechanics
alignment with less maintenance and
effort. alignment with less
effort.
Reassess the To evaluate the Patient showed
neuromuscular status effectiveness of increased muscular
and muscle strength. nursing intervention strength & no trauma/
provided as replan as was seen during period
per need. of hospitalization.

The End!!!!