Professional Documents
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Patho On Fracture
Patho On Fracture
Deformity
Crepitus
Immobility
Deformity Loss of Function
Nursing Management: - Assess client's level of tolerance in moving - Assist client upon moving without mobilizing the affected leg. -Perform ROM exercises that the client can only tolerate. - Tell Client to frequently wiggle toes. - Encourage use of relaxation techniques - Give health teachings on the importance of ROM esp. on the affected leg as tolerated.
Nursing Management: -Evaluate presence/ quality of peripheral pulse distal to injury via palpation and compare with uninjured limb. - Assess capillary return, skin color, and warmth distal to the fracture. - Note reports of pain extreme for type of injury or increased pain on passive movement of extremity, muscle tension/tenderness, and change in pulse quality distal to injury. Do not elevate extremity. - Note signs of general pallor/cyanosis, cool skin, changes in mentation. -Test sensation of femoral nerve by
mentation. -Test sensation of femoral nerve by pitch/ pinprick in the dorsal web . - Immobilie or support the affected body part to prevent pressure and injury.
LEGEND:
Predisposing/Precipitating Factors
Pathophysiology of the disease condition Clinical Manifestations Nursing Diagnosis Nursing Management Medical Management Pharmacologic Management Complications
FRACTURE
Predisposing Factors: - Age - Gender - Nutrition
Close
Inflammatory Response Localization of serous fluid at fractured site Subcutaneous bleeding Initial Vasoconstriction Bruising Vasodilation Edema Increased Vascular Permeability
Swelling
Risk for peripheral Neuromuscular Dysfunction related to reduction of blood flow, direct vascular injury & tissue trauma secondary to motor vehicular accident.
Hyperemia
Redness
Heat
Edema
urn, skin color, o the fracture. n extreme for eased pain on f extremity, rness, and ity distal to e extremity.
Pain
kin, changes in
moral nerve by
Altered sleeping patt related to pain felt on left leg and thigh due open, complete fract secondary to moto vehicular accident
FRACTURE
Precipitating Factors: - People Working with heights - People engaging in high risk sports - Motor vehicular Accident - Fall - Direct blow
Risk for infection re inadequate primary broken skin, traum tissues, environmenta due to presence of
Open
Infection
Damaged muscle Skeletal Traction with 7 kgs. Pull fragments out of position Muscle Spasm Numbness Deformity Pain
Degeneration of nerve c
Altered comfort: Acute pain related to presence of skeletal traction as manifested by reports of pain on left leg.
Edema
Pain
Nursing Management: -Allow/ provide an avenue of expression of what the client feels at the moment and also about the accident. - Provide non-pharmacologic measures like: breathing exercises & guided imagery - Provide emotional support to the client.
Altered sleeping pattern related to pain felt on the left leg and thigh due to open, complete fracture secondary to motor vehicular accident.
- Provide emotional support to the client. -Maintain immobilization of affected part by means of traction. -Ask patient to rate pain in a scale of 0-10 where 10 is the most painful and 0 as no pain. -Document reports of pain or discomfort, noting location and characteristics, including intensity.
Risk for infection related to inadequate primary defenses: broken skin, traumatized tissues, environmental exposure due to presence of skeletal traction.
Nursing Management: -Inspect the skin for preexisting irritation or breaks in the continuity. -Assess skin area that is affected, noting reports of increased pain/burning sensation or presence of edema, erythema, foul odor or drainage. -Provide wound care according to protocol & exercise strict handwashing. -Instruct client not to touch or scratch wound -Monitor vital signs. (esp. temperature) -Do nail care. Impaired skin or tissue integrity related to open, complete fracture and presence of skeletal traction on left leg secondary to MVA.
Nursing Managemen - Examine wound fo discoloration and an abdominal findings. -Palpate taped tissu and document any t and pain. - Provide skin care. -Change dressing as -Keep bed linens free wrinkles and foreign -Maintain adequate nutritional status.
Decreased perfusi
Absence of reflexes
Impaired Tissue
Impaired physical mobility related to presence of skeletal traction on left leg due to open, complete fracture secondary to MVA.
Nursing Management: - Assess client's level of tolerance in moving - Assist client upon moving without mobilizing the affected leg. -Perform ROM exercises that the client can only tolerate.
the client can only tolerate. - Tell Client to frequently wiggle toes. - Encourage use of relaxation techniques - Give health teachings on the importance of ROM esp. on the affected leg as tolerated.
Nursing Management: Examine wound for bleeding, discoloration and any other abdominal findings. Palpate taped tissue daily and document any tenderness and pain. Provide skin care. Change dressing as needed. Keep bed linens free from wrinkles and foreign matter. Maintain adequate nutritional status.
Decreased platelets
Decreased RBC
Decreased WBC
Decreased perfusion
Ischemia
Hemorrhage
Impaired healing
Compartment Syndrome
Fat Embolism
Infection
Paralysis Pulselessness
exudate
Inflammatory Response
Formation of Hematoma
Fibrocatilage
Callus formation
Ossification
Consolidation
Remodelling
BONE HEALS
Deformity
Loss of Function
Nursing Management: - Assess client's level of tolerance in moving - Assist client upon moving without mobilizing the affected leg. -Perform ROM exercises that the client can only tolerate. - Tell Client to frequently wiggle toes. - Encourage use of relaxation techniques - Give health teachings on the importance of ROM esp. on the affected leg as tolerated.
Nursing Management: -Evaluate presence/ qua peripheral pulse distal to palpation and compare uninjured limb. - Assess capillary return, and warmth distal to th - Note reports of pain ex type of injury or increase passive movement of ex muscle tension/tenderne change in pulse quality d injury. Do not elevate ex - Note signs of general pallor/cyanosis, cool skin in mentation. -Test sensation of femora pitch/ pinprick in the do - Immobilie or affected body part to pr pressure and injury.
LEGEND:
Predisposing/Precipitating Factors
Pathophysiology of the disease condition Clinical Manifestations Nursing Diagnosis Nursing Management Medical Management Pharmacologic
Predisposing Facto
Nursing Management: Evaluate presence/ quality of peripheral pulse distal to injury via palpation and compare with uninjured limb. Assess capillary return, skin color, and warmth distal to the fracture. Note reports of pain extreme for type of injury or increased pain on passive movement of extremity, muscle tension/tenderness, and change in pulse quality distal to injury. Do not elevate extremity. Note signs of general pallor/cyanosis, cool skin, changes in mentation. Test sensation of femoral nerve by pitch/ pinprick in the dorsal web . Immobilie or support the affected body part to prevent pressure and injury.
Risk for peripheral Neuromuscular Dysfunction related to reduction of blood flow, direct vascular injury & tissue trauma secondary to motor vehicular accident.
FRACTURE
Predisposing Factors: - Age - Gender - Nutrition
Close
Open
Disruption of the surrounding tissues, peristeum, blood vessel and nerve supply
Inflammatory Response
Initial Vasoconstriction
Vasodilation
Vasodilation
capilllary/Vascular Permeability
Hyperemia
Redness
Heat
Edema
Pain
Precipitating Factors: - People Working with heights - People engaging in high risk sports - Motor vehicular Accident - Fall - Direct blow
exerted on it
d vessel and
Infection
Pain
Nursing Management: -Allow/ provide an avenue of expression of what the client feels at the moment and also about the accident. - Provide non-pharmacologic measures like: breathing exercises & guided imagery - Provide emotional support to the client. -Maintain immobilization of affected part by means of traction. -Ask patient to rate pain in a scale of 0-10 where 10 is the most painful and 0 as no pain. -Document reports of pain or discomfort, noting location and characteristics, including intensity.
Risk for infection related to inadequate primary defenses: broken skin, traumatized tissues, environmental exposure due to presence of skeletal traction.
Nursing Management: -Inspect the skin for preexisting irritation or breaks in the continuity. -Assess skin area that is affected, noting reports of increased pain/burning sensation or presence of edema, erythema, foul odor or drainage. -Provide wound care according to protocol & exercise strict handwashing. -Instruct client not to touch or scratch wound -Monitor vital signs. (esp. temperature) -Do nail care.
Numbness
Absence of reflexes
Impaired physical mobility related to presence of skeletal traction on left leg due to open, complete fracture secondary to MVA.
Nursing Management: - Assess client's level of tolerance in moving - Assist client upon moving without mobilizing the affected leg. -Perform ROM exercises that the client can only tolerate. - Tell Client to frequently wiggle toes. - Encourage use of relaxation techniques - Give health teachings on the importance of ROM esp. on the affected leg as tolerated.
Impaired skin or tissue integrity related to open, complete fracture and presence of skeletal traction on left leg secondary to MVA.
Nursing Management: - Examine wound for bleeding, discoloration and any other abdominal findings. -Palpate taped tissue daily and document any tenderness and pain. - Provide skin care. -Change dressing as needed. -Keep bed linens free from wrinkles and foreign matter. -Maintain adequate nutritional status.
Decreased platelets
Decreased perfusion
Ischemia
Ischemia
Hemorrhage
muscle mass
Necrosis
Tissue death
Compartment Syndro
sing Management: client's level of e in moving lient upon moving mobilizing the affected
Decreased platelets
Decreased RBC
Decreased WBC
Hemorrhage
Impaired healing
Shock
Fracture complications
Compartment Syndrome
Fat Embolism
Infection
Inflammatory Response
Formation of Hematoma
Fibrocatilage
Callus formation
Ossification
Consolidation
Remodelling
BONE HEALS