Care Plan for Fracture

Category / Primary Body System

• Musculoskeletal System

Problem

• Patient is at risk for complications due to fracture.

Goal

• Patient will have no complications related to fracture (e.g., dislocation) within 90 days.

Plan/Approach

1. Pain Management

   • Administer pain medications as ordered
   • Monitor and document pain levels
   • Educate on non-pharmacological pain relief methods

2. Monitoring and Assessment

   • Perform necessary blood tests (Labs as ordered)
   • Facilitate orthopedic consultations
   • Arrange for PT/OT evaluations and implement prescribed exercises
   • Assist with repositioning for comfort and prevent pressure ulcers
   • Ensure proper use of immobilization devices (e.g., sling)
   • Monitor cast for signs of complications (e.g., skin breakdown)
   • Regularly assess CSM of affected extremities

Rationale

1. Pain Management
   • Effective pain control improves patient comfort and facilitates participation in rehabilitation activities, essential for recovery.
2. Monitoring and Assessment
   • Regular monitoring and appropriate specialist consultations help detect and address complications early, ensuring optimal healing and preventing further injury.
   • PT/OT involvement promotes mobility and prevents stiffness, enhancing functional recovery.
   • Proper repositioning and cast care prevent pressure ulcers and skin complications, ensuring patient comfort and reducing infection risk.
   • Monitoring CSM ensures early detection of circulatory or nerve issues, allowing for timely intervention.

Actions

1. Pain Management

   • Administer prescribed analgesics at specified intervals.
   • Use a standardized pain scale (e.g., Numeric Rating Scale) to assess pain before and after medication.
   • Teach the patient about using ice, elevation, and relaxation techniques to manage pain.

2. Monitoring and Assessment

   • Schedule and conduct necessary blood tests as per physician's orders.
   • Coordinate with the orthopedic specialist for regular consultations and follow-up on recommendations.
   • Organize PT/OT sessions and assist the patient in performing prescribed exercises.
   • Reposition the patient every 2 hours or as needed, using pillows and supports.
   • Instruct the patient and caregivers on the correct use of the sling or other immobilization devices.
   • Inspect the cast daily for tightness, cracks, or wetness and educate the patient on proper cast care.
   • Assess the affected limb for circulation, sensation, and movement regularly, documenting and reporting any changes immediately.