NURS 125

Nursing Care Plan

1. Briefly explain about the patient’s story including primary and secondary diagnosis. Describe patient’s signs and symptoms
related to primary diagnosis upon arrival:

M.H is a 45-year-old female who suffered a left mid-shaft tibia-fibula fracture when she slipped on icy stairs. She was taken to surgery for an
open reduction with internal fixation (ORIF). She returned from surgery at 1:45 p.m. with a below-the-knee ace/splint dressing. The primary
diagnosis was a lower leg fracture. A lower leg fracture is a complete or incomplete disruption in the continuity of bone structure of the tibia
and fibula. Fractures occur when the bone is subjected to stress greater than it can absorb like direct blows, crushing forces and sudden
twisting motions, and extreme muscle contractions. Clinical signs and symptoms of a fracture include acute pain, loss of function, deformity,
shortening of the extremity, crepitus, and localized edema and ecchymosis. “An open reduction with internal fixation is, through a surgical
approach, fracture fragments are anatomically aligned. Internal fixation devices like metallic pins, wires, screws, plates, nails, or rods may be
used to hold the bone fragments in position until solid bone healing occurs. These devices may be attached to the sides of bone, or they may be
inserted through the bony fragments or directly into the medullary cavity of the bone” (Hinkle & Cheever, 2018, p. 3169). M.H began
complaining of pain shortly after returning from surgery and was given morphine 6 mg IV at 2:15 p.m. Administration of morphine did not
relieve the patient’s pain, she reported 8/10 throbbing burning pain in the left leg, patient reports it feels like the bandage is too tight, and she
cannot move or feel her toes. This assessment led to secondary diagnosis of Compartment Syndrome.

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2. Pathophysiology of primary and secondary disease including signs and symptoms relation between primary and secondary disease:
A lower leg fracture occurs when the bone is subjected to stress greater than it can absorb like direct blows, crushing forces and sudden
twisting motions, and extreme muscle contractions. Clinical signs and symptoms of a fracture include acute pain, loss of function,
deformity, shortening of the extremity, crepitus, and localized edema and ecchymosis. The physician performs an open reduction with
internal fixation (ORIF) to prevent loss of elasticity from the tissues through infiltration by edema or hemorrhage. After the physician puts
a below-the-knee ace/splint dressing which is used to immobilize and support the body part in a functional position, and it allows for
natural swelling. However, compartment syndrome is more prevalent when soft tissue swelling occurs within a contained space. (Hinkle &
Cheever, 2018, p. 3015) Compartment syndrome is characterized by the elevation of pressure within an anatomic compartment that is
above normal perfusion pressure. Compartment syndrome arises from an increase in compartment volume, a decrease in compartment size
(e.g., from a restrictive cast), or aspects of both. When the pressure within an affected compartment rises above normal, perfusion to the
NURS 125 NCP__ Student Name: Date
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 tissues is impaired, causing cell death, which may lead to tissue necrosis and loss of limb. A patient with compartment syndrome reports
deep, throbbing, unrelenting pain, which is unrelieved by medications, seems disproportional to the injury, and intensifies with passive
ROM. Advanced compartment syndrome includes loss or diminished sensation and motor loss or weakness indicating nerve damage.
(Hinkle & Cheever, 2018, p. 3177-3178)
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3. Diagnostic studies for primary diagnosis to rule out diagnoses of the disease (including blood tests, diagnostic studies, diagnostic
procedure and …).
Which study was done for your patient?

computerized tomography (CT), magnetic resonance imaging (MRI) and X-ray to pinpoint the location of the break and determine the
extent of injury to any adjacent joints.1 Stryker Intra-Compartmental Pressure Monitor: measure tissue pressure by inserting a tissue
pressure-monitoring device into the muscle compartment (normal pressure is 8 mmHg or less). Prolonged pressure of more than 30 mmHg
can result in permanent dysfunction.2

4. Identify and prioritize 3 nursing diagnoses

Nursing diagnosis #1: Impaired tissue perfusion R/T restrictive dressing AEB left leg cyanotic, prolonged capillary refill, absent pedal pulse,
cannot move their toes and toes feel numb, patient reports bandage feels too tight, unrelieved pain with narcotics

Nursing diagnosis #2: Impaired walking R/T neuromuscular impairment AEB patient states they cannot move their toes and toes feel numb,
and reported pain of 8/10
Nursing diagnosis #3: Acute pain R/T restrictive dressing causing increased compartment pressure AEB reported pain 8/10, patient reports
bandage feels too tight, pain is not improving with pain meds, restlessness, diaphoresis, increased HR & RR

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 Collaborative care: Physical therapist individualize activity and exercise program to strengthen leg muscles for ambulation and
prevent muscle atrophy from disuse.

1
Broken leg. (2020, July 01). Retrieved February 26, 2021, from https://www.mayoclinic.org/diseases-conditions/broken-leg/diagnosis-treatment/drc-20370416

2
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's textbook of medical-surgical nursing. Philadelphia: Wolters Kluwer.

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  Patient/Family teaching: Teaching patient how to properly use assistive devices like walkers, crutches, canes. Modify home
environment as needed and to ensure safety, such as removing floor rugs or anything that obstructs walking paths throughout the
house.
 Discharge planning/ community referral(s): self-care, medication information, monitoring for potential complications, and the
need for continuing health care supervision

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 Prioritized Nursing Diagnoses

#1 Nursing Diagnosis: Impaired tissue perfusion R/T restrictive dressing AEB left leg cyanotic, prolonged capillary refill, absent pedal
pulse, cannot move their toes and toes feel numb, patient reports bandage feels too tight, unrelieved pain with narcotics,

Plan: Patient will have present pedal pulses, sensation in toes, and will be able to move toes within 2 minuets of loosening the dressing

Interventions Rationale Evaluation

(Pt’s response to individual interventions)
(include one teaching) APA = Author, year and page(s)

1. Assess skin texture, color,
temperature, capillary refill and
SpO2. Note the presence of hair,
ulcers, or gangrenous areas on
the legs or feet.
1. Thin, shiny, dry skin with hair loss; brittle 1.The patient’s leg was cyanotic, capillary
nails; and gangrene or ulcerations on toes and refill > 3 seconds, and skin was intact.
anterior surfaces of feet are seen in patients This indicated impaired tissue perfusion.
with arterial insufficiency. Assess for changes
which can indicate circulation problems. It
can also reveal if patient’s tissue perfusion is
improving or worsening.

(Doenges, et al., 2016, p. 881).

2. Loosen dressing and maintain
extremity at heart level
2. With arterial insufficiency, leg elevation
decreases arterial blood supply to the legs
while legs at level of the heart will promote
blood flow and arterial perfusion.
(Hinkle & Cheever, 2018, p. 3177)
2. After loosening the dressing, the
patient’s leg returned to normal color,
capillary refill was < 3 seconds and SpO2
98 % which indicated patients tissue
perfusion was improving

3. Administer O2 3. To promote optimal blood flow and 3. Normal skin color to leg, capillary refill
circulation, improve tissue & organ perfusion, < 3 seconds and SpO2 increased to 98%
and promote function

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 (Doenges, et al., 2016, p. 882).

4. Encourage early ambulation
4. Reduces venous pooling and enhances
venous return
(Doenges, et al., 2016, p. 882).
4.Was not able to observe however,
patient would show an improvement of
blood circulation to muscles and bone by
regaining normal skin color without
edema due to blood pooling

5. Educate patient on care of
dependent limbs and foot care
and ways to promote arterial
flow
5. When circulation is impaired, changes in
sensation place patients at risk for
development of lesions or ulcers that are slow
to heal
(Doenges, et al., 2016, p. 883).
5. Patient will demonstrate proper foot
care like wearing insulated socks, and
always wear shoes. Patient will know to
apply heating pad in abdomen to promote
arterial flow into the lower extremities

Status of Outcome: Met / Partially Met / Not Met

Patient had pulses in both legs, could feel and move toes within the 2 minuets of loosening the dressing on the left leg.

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#2 Nursing Diagnosis: Impaired walking R/T neuromuscular impairment AEB patient states they cannot move their left toes and toes
feel numb, and reported pain of 8/10, can not bear weight on left leg

Plan: The patient will be able to ambulate for 3 minuets around the room with the use of assistive devices in 2 hours

Interventions Rationale Evaluation

(Pt’s response to individual
(include one teaching) APA = Author, year and page(s) interventions)

1. Encourage gradual increase
in ambulation
1. It will help reduce leg pain
associated with walking and improve
stamina. Early mobility reduces
complications of bed rest like
pressure ulcers, development of
DVTs and PE, and promotes healing.
1. Was not able to observe however, I
would expect that the patient will be
free of DVTs, PE, and pressure ulcers.
Patient will be able to ambulate and
rest when pain returns and continue
ambulation when pain subsides.

(Doenges, et al., 2016, p. 941).

2. Monitor patient’s
cardiopulmonary and muscular
tolerance for walking
2. Increased pulse rate,
breathlessness, irregular heartbeat is
indicative of need to reduce level of
activity. Postural hypotension is a
common problem following
prolonged bed rest and require
specific interventions like slow
position changes.
(Doenges, et al., 2016, p. 941).
2. Was not able to observe however,
patient would be safe during
ambulation, if postural hypotension
was present, patient will hang feet over
bed to get up and ambulate. By
monitoring for signs of activity
intolerance, patient was not harmed
during ambulation and rested when she
couldn’t ambulate further.

3. Assist patient with active 3. Increase’s blood flow to muscles 3. Was not able to observe however,
and passive ROM exercises and bone to improve muscle tone, patient would not lose muscle strength
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 preserve joint mobility; prevent
contractures or atrophy and calcium
reabsorption from disuse
(Taylor, et al., 2019, p. 1163).
4. Reposition patient every two 4. Prevents pressure ulcers from
hours being in bed rest which causes
pressure on bony prominence
causing pressure ulcers.
(Doenges, et al., 2016, p. 882).
5. Educate patient on use of 5. Learning the correct way to use
assistive devices aids is important to maintain optimal
mobility and patient safety.
(Doenges, et al., 2016, p. 941).
Status of Outcome: Met / Partially Met / Not Met
The patient was able to walk around the room for 3 minuets with the use of a walker within the hour.
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and joint function. Patient’s exercises
will maintain the health of unaffected
muscles and to increase the strength of
muscles needed for transferring with
walker, crutches or cane.
4. Was not able to observe however,
patient would be free of pressure
ulcers. Skin was clean, dry and intact.
5. Patient will use assistive devices
safely and in the correct way to prevent
bearing weight on left leg and maintain
the patient’s independence to perform
ADLs
#3 Nursing Diagnosis: Acute pain R/T restrictive dressing causing increased compartment pressure AEB reported pain 8/10, patient reports
bandage feels too tight, pain is not improving with pain meds, restlessness, diaphoresis, increased HR (109) & RR (21) & BP (158/94)
Plan: Patient will report a pain of 6/10 within 5 minutes after loosening the restrictive dressing.
Interventions Rationale
(include one teaching) APA = Author, year and page(s)
1. Loosen the restrictive 1. Action will minimize pain because the pain is
dressing originating from a restrictive dressing delaying will
cause permanent nerve and muscle damage and
necrosis.
(Hinkle & Cheever, 2018, p. 3178)
2. Monitor BP, respirations and 2. Altered vitals due to pain. Helps monitor how the
heart rate patient’s condition is progressing either improving or
worsening by comparing it to the baseline vitals.
Baseline vitals were heart rate (109), BP 158/94, RR
(21), patient reported pain 8/10
(Doenges, et al., 2016, p. 603).
3. Administer pain medication 3. To maintain the patients “acceptable level of pain”
per doctor’s order
(Doenges, et al., 2016, p. 603).
4. Monitor for unusual or 4. signals developing complications like infection,
sudden pain or deep, tissue ischemia, compartmental syndrome, malunion,
progressive, and poorly nonunion, and fat embolism
localized pain unrelieved by
NURS 125 NCP Student Name________________
Evaluation
(Pt’s response to individual
interventions)
1. Patient reported pain 6/10 after
loosening the dressing.
2. After loosening the dressing, the
patient’s vitals decreased to heart rate
92, BP 142/86, RR 17, and a pain of
6/10 which indicated that the
intervention improved the patient’s
condition
3. The patient had been administered
Morphine 4mg IV push; however, the
patient reported the pain was the same
and it was unrelieved
4. After evaluation that the pain was
unrelieved by pain medications,
disproportional to injury, localized and
was due to feeling the dressing was too
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 analgesics. (Hinkle & Cheever, 2018, p. 3165) tight, it led to the loosening of the
dressing to prevent compartment
syndrome. The patient then reported
improved pain of 6/10

5. Educate patient on
nonpharmacological pain
management methods like
focused breathing, guided
imagery, and diversional
activities like watching TV.
5. Pain is unrelieved by narcotics. Therefore, patient
will do focus breathing exercises to relieve
hyperventilation (respiration of 27) due to pain and
restlessness, and decrease the pain
(Doenges, et al., 2016, p. 604).
5. The patient was be able to refocus
attention, control breathing, and was
able to manage the stress of injury and
pain. This help decreases respiration to
17, decrease restlessness and decreased
heart rate to 94.

Status of Outcome: Met / Partially Met / Not Met

The patient reported a pain of 6/10 in two minutes after loosening the restrictive dressing in the left leg.

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 References:
Broken leg. (2020, July 01). Retrieved February 26, 2021, from https://www.mayoclinic.org/diseases-conditions/broken-
leg/diagnosis-treatment/drc-20370416

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurses pocket guide: diagnoses, prioritized interventions, and
rationales. Philadelphia: F.A. Davis Company

Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's textbook of medical-surgical nursing. Philadelphia: Wolters
Kluwer.

Taylor, C., Lynn, P., & Bartlett, J. L. (2019). Fundamentals of nursing: the art and science of person-centered nursing care.
Philadelphia: Wolters Kluwer.

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 Neuro Pain Skin CV

Alert & O x 4 8/10 throbbing burning pain in the left leg. Normal skin turgor, skin cool to Initial: BP 158/94, HR 109 beats/min
Nothing makes the pain better; pain is worse touch and sweaty. Temp 99° F
Right pedal pulse is 110 per min regular
when someone touches it. The pain is localized,
Left leg is cyanotic with prolonged while left pedal pulse is absent.
and patient reports it feels like the bandage is
Resp capillary refill
too tight. The pain has been going on since she After loosening dressing: BP 142/86, HR
returned from surgery. Morphine 4mg IV push
Initial: Resp 21 Dressing on left leg is tight= 92
was administered but pain did not change loosened dressing
breaths/min, chest
moves normally
Pain rated 6/10 after bandage was loosened
bilaterally
SpO2: 95%
MS
After loosening
dressing: Resp: 17 5 Dimensions of Person Concept Map Patient cannot move toes on left leg,
SpO2 increased to 98%
toes feel numb

M.H No weight bearing on left leg post op

45-year-old female
GI Allergies: No known Allergies
Full code
Diet: Currently on Primary DX: Lower Leg Fracture Safety
liquids but can advance Secondar DX: Compartment Syndrome
Chief complaint: Throbbing burning pain in left leg 8/10, Prevent further complications like
to regular diet by the
unrelieved by narcotics malunion, nonunion, delayed union,
afternoon MH: No prior medical conditions, not on medications
avascular necrosis of bone, infection
Social history: Married, nonsmoker
Past surgical history: ORIF postop and compartment syndrome

Fall risk due to activity intolerance

GU

No deviations noted Sociocultural Intellectual Emotional Spiritual

Nonsmoker, Clear and concise speech, Restlessness due to pain Unknown

married to J.H formulated well-structured
sentences

Erikson’s Developmental Stage: Generativity vs Stagnation

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