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:

1. Pain Management:

   • Step-by-Step Approach: Administer pain medications as ordered.
   • Monitoring Strategies: Regularly assess pain levels using a standardized pain scale.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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:

1. Pain Management:

   • Staff will administer pain medications as ordered.
   • Staff will regularly assess pain levels.

2. Lab Monitoring:

   • Staff will conduct labs as ordered and track results in the EHR.

3. Specialist Consultations:

   • Staff will arrange for orthopedic consult as ordered.

4. Rehabilitation Services:

   • Staff will provide PT/OT evaluation and treatment as ordered.

5. Positioning for Comfort:

   • Staff will reposition the patient as needed to ensure comfort.

6. 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.

7. 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.

8. 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.