First case study..ever.

[AhN10]

So I just wanted to see if someone could help me by telling me if I am on the right track..

we were given a case study of..."The patient is a 33 year old male who is diagnosed with a compound fracture of the left femur after falling three feet off a ladder at his home. He sustained no other injury from the fall. The patient underwent surgery to reduce the fracture and stabilize the femur with insertion of internal devices (screws). He is now admitted post-operatively to the orthopedic unit.

I was given the question of identifying the priority nursing diagnosis according to the book, which the top 3 were given 1. Acute pain related to compound fracture of left femur 2. Impaired physical mobility related to bed rest and fractured left femur and 3. Risk for peripheral neurovascular dysfunction related to unstable bones and swelling.

I just wanted to make sure I was on the right track with my thought process. Although acute pain seems to be important, number two seems to outweigh it to me.

Impaired physical mobility related to bed rest seems to be the winner. We have not had a lecture on nursing diagnosis (its this week, but they wanted us to start early). It seems to be that with the immobility the patient is going to sustain is a greater potential health risk (skin break down, impaired muscle movement, risk for DVT's)

I may be completely off track..but any help would be appreciated! :)

[SilleLu]

Nice job giving your thoughts and not just asking for an answer :)

So you did explain the risks of impaired physical mobility, let's explore the other two...what could happen with neurovascular dysfunction? acute pain? How quickly can all of these progress to serious complications?

[AhN10]

Thank yall so much for helping!

So I was thinking about it and now I think that the priorty diagnosis should be risk for peripheral neurovascular dysfunction.

Although impaired mobility is important due to the possibility of a DVT or skin breakdown and then infection that to me has more steps in order to get there vs a fat embolism with peripheral neurovascular dysfunction.

Impried mobility --> risk for DVT ---> developed ---> risk for PE

vascular dysfunction ---> fat embolism ---> possible death/serious health hazard

There is also compartment syndrome as another possible complication.

I will definitely look into that NANDA book! Thank you for the recommendation, everything helps!

Soooo..am I on the "best" right track now lol.

[SilleLu]

You're getting there! Try looking into the neurovascular issue a little more...what would happen if blood flow to the extremity is impaired? How do you assess this? (hint: lots of 'P' words!)

[AhN10]

I think I just lost myself now. lol

The P's :) Unrelenting Pain, pallor, parasthesias (abnormal sensation, prickling, tingling "pins and needles" caused by pressure on or damage to peripheral nerves), and paresis (muscle weakness) --> all indicators of compartment syndrome.

The question I was given is 1. Identify the priority nursing diagnosis 2. Identify 3 nursing interventions and explain rationale 3. How would I evaluate the outcome of the interventions

So.. 1. Risk for peripheral neuromuscular dysfunction: related to unstable bones and swelling (do they normally want you to explain why? ) Sorry for all of the questions but they haven't given us much insight.

Interventions-

1. Peripheral Sensation Management- Check pulses distal to the injury and compare with the unaffected side. Asses for pain, pallor, paresthesias and paresis which can be indicators for compartment syndrome. Check application and function of corrective device, compartment syndrome can also result from improper casting or splinting. Position extremity in the correct alignment with each position change, this ensures appropriate alignment.

2. Joint Mobility- Since the patient will be on bed rest and immobile, continuing regular strengthening exercise will decrease the risk for atrophy of unaffected limbs and ensure continuous circulation throughout the body while promoting comfort and well being

3. Prevention of DVT's and PE's - Monitor pt for signs of DVT's which include pain, deep tenderness, swelling, apply compression stockings. DVT's and PE's can be fatal therefor the patient needs to be monitored closely

Evaluation- Still kind of unsure about this. Does this ever get easier?!

[la_chica_suerte85, BSN, RN]

Yes, it gets easier and you are SO heading in the right direction. Usually "risk for" Dxs are not the first priority. They are potential problems but, in the post-op setting there are other things that are important, too. I would stick with acute pain as the #1 priority with the risk for being at the back of the list. Without any other data, it's difficult to justify anything else. The patient could be nauseated, which would be an important Dx, especially because the risk for aspiration is high and the patient is immobile and might not be able or willing to turn, deep breathe and cough yet, especially if the pain is bad enough. Circulation is a tough one since those pressure dressings are exactly what the name says. Once you start doing these on an actual patient, prioritization becomes much clearer.

I actually had a pt in a similar situation and I believe Acute Pain was my first one (maybe Ineffective Tissue Perfusion r/t circulatory stasis, decreased coughing, decreased deep breathing was first, it's been a LOOOOOONG time) and then some psychosocial one was my 3rd (it HAD to be). Anyway, I'm rambling and don't believe I can offer anything else. Good luck! You're already off to a fantastic start! You have no clue how hard priorities are for some students.

[jessicaparks2511]

There's a book called all in one care plans and it outlines the dx, interventions, and goals based on unit (med surf, pediatrics, ob, and psych). It's awesome. I also use Mosby's guide to nursing diagnoses.