About
A partial or complete break in a bone.
Assess
Open wounds, bleeding, ecchymosis ( bruising), infection, decreased pulses distal to injury, pallor, numbness, tingling, increased temperature; Pain; increased risk of blood clots.
Complications
Infection- monitor for s/s of infection.
Acute compartmental syndrome- monitor for circulation to area distal to joint including pulses, pallor, warmth, pain, pressure, paralysis or parasthesias.
Impaired tissue integrity; pain; immobility
DVT; fat embolism syndrome- use prophylactic anticoagulants as ordered.
Diagnosis
- Acute pain related to trauma
- Impaired physical mobility related to trauma and limb immobilization
- Risk for impaired skin integrity related to presence of cast
Goals
- The client will identify adaptive techniques to accommodate for impaired mobility.
- The client will identify a pain level less than 4 on a zero to ten scale, zero being none and 10 being the worst imaginable.
- The client will identify signs and symptoms requiring immediate follow-up by health care provider.
Interventions
- Monitor client with limb injuries or surgeries for s/s of impaired circulation ( pain, pallor, decreased pulses, paralysis, and parasthesias).
- Monitor for complications, including hemorrhage and impaired tissue perfusion.
- Monitor for s/s of infection around injury ( temp, increased WBC's, pain, redness, edema, increased drainage, odor).
- Immobilize affected body part, as indicated.
- Prepare for surgery, casting, splinting as indicated.
- Administer pain medications prn as ordered.
- Teach client what to expect prior to, during, and after procedures.
- Teach patient how to use adaptive techniques to maintain mobility including crutches, walker as indicated.
- Monitor for signs/ symptoms of complications.
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