Fracture
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 (i.e., dislocation) for 90 days.
Plan/Approach:
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Pain Management:
- Step-by-Step Approach: Administer pain medications as ordered.
- Monitoring Strategies: Regularly assess pain levels using a standardized pain scale.
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Lab Monitoring:
- Step-by-Step Approach: Conduct labs as ordered to monitor for any signs of infection or other complications.
- Technological Aids: Utilize electronic health records (EHR) to track lab results.
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Specialist Consultations:
- Step-by-Step Approach: Arrange for orthopedic consult as ordered.
- Engagement in Diversional Activities: Encourage patient to engage in light activities that do not strain the affected area.
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Rehabilitation Services:
- Step-by-Step Approach: Provide PT/OT evaluation and treatment as ordered.
- Educational Efforts: Educate patient on the importance of rehabilitation exercises to promote healing.
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Positioning for Comfort:
- Step-by-Step Approach: Reposition patient in a position of comfort as indicated.
- Monitoring Strategies: Regularly assess patient’s comfort and make adjustments as needed.
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Supportive Devices:
- Step-by-Step Approach: Ensure patient wears a sling or other supportive devices as needed.
- Educational Efforts: Teach patient proper use and care of supportive devices.
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Cast and Wound Care:
- Step-by-Step Approach: Monitor cast, if any, for signs and symptoms of complications (i.e., skin breakdown) every shift.
- Monitoring Strategies: Regularly check the cast for tightness, integrity, and signs of pressure sores.
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Circulation, Sensation, and Movement (CSM):
- Step-by-Step Approach: Monitor CSM to affected extremities as needed.
- Technological Aids: Use tools like Doppler ultrasound if necessary to assess circulation.
Rationale:
- Pain Management: Effective pain control is essential for patient comfort and mobility.
- Lab Monitoring: Ensures timely detection of complications such as infection or delayed healing.
- Specialist Consultations: Provides expert evaluation and recommendations for treatment.
- Rehabilitation Services: Promotes physical recovery and prevents complications related to immobility.
- Positioning for Comfort: Reduces pain and prevents pressure sores.
- Supportive Devices: Supports fracture healing and prevents further injury.
- Cast and Wound Care: Prevents complications related to the cast and promotes skin integrity.
- Circulation, Sensation, and Movement (CSM): Ensures the affected extremity is receiving adequate blood flow and has normal sensation and movement.
Actions:
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Pain Management:
- Staff will administer pain medications as ordered.
- Staff will regularly assess pain levels.
-
Lab Monitoring:
- Staff will conduct labs as ordered and track results in the EHR.
-
Specialist Consultations:
- Staff will arrange for orthopedic consult as ordered.
-
Rehabilitation Services:
- Staff will provide PT/OT evaluation and treatment as ordered.
-
Positioning for Comfort:
- Staff will reposition the patient as needed to ensure comfort.
-
Supportive Devices:
- Staff will ensure the patient wears a sling or other supportive devices as needed.
- Staff will educate the patient on the proper use of these devices.
-
Cast and Wound Care:
- Staff will monitor the cast for signs and symptoms of complications every shift.
- Staff will check the cast for tightness, integrity, and signs of pressure sores.
-
Circulation, Sensation, and Movement (CSM):
- Staff will monitor CSM to the affected extremities as needed.
- Staff will use tools like Doppler ultrasound if necessary to assess circulation.