Need help to identify 2 potential actual problems

  1. Hey im doing a assignment on this following case study and I need to identify 2 actual or potential nursing problems/diagnosis, I have already picked one, which is patient is at risks for fall due to fractured femur...and the interventions are( move items closer to patient and respond to call bell asap) but im having trouble to identify another nursing problem for this case study, could I say pt is at risks for developing fat embolism due to long bone fracture and evidenced acute respiratory distress syndrome and im not too sure what my interventions would be... anyway here is the case study, any help would be appreciated

    25-year-old male Mr X was admitted at 2000hrs following a motor vehicle accident the previous evening. His leg was trapped for several hours prior to extraction from his vehicle by the emergency services.
    He sustained a fracture to the mid-shaft of his R) femur and has extensive bruising of the surrounding tissue.
    Mr x has not had any oral food or fluids since this accident due to nausea and is now fasting while he waits for investigation and theatre.

    CNS: Mr Davis is alert and orientated, pain initially 7/10 is now 4/10 since commencement of morphine PCA at 0200hrs. Pt grimacing on movement.
    CVS: Bp currently 100/65 P 105 T 37.3. ECG sinus tachycardia. IV cannula inserted in emergency R) cubital fossa.
    Resp: RR 24, O2 sat 98% on 6 l via Hudson mask.
    GIT: Remains nauseated, metoclopramide 10 mg administered IV with minimal effect. Currently NBM. weight approx. 90kgs. IVT in progress N/saline 100ml/hr. Bowel sounds present.
    GUT: IDC inserted in ed, urine output 500mls since admission. WTU - Amber, pH 5.0, blood trace, SG 1.005, ketones trace.
    Musculoskeletal/skin: Currently rest in bed with leg in Donway splint.
    Neuro, - foot cool to touch, strong pulses, increased pain on passive movement. Patient last rolled 0300hrs for pressure area care.
    Medical plan: remain NBM for CT scan prior to theatre this am.
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  2. Visit Walrus93 profile page

    About Walrus93

    Joined: Apr '18; Posts: 8; Likes: 2
    from AU

    20 Comments

  3. by   Cricket183
    Think along the lines of what you would need to watch for in someone whose leg was trapped for an extended period of time? What are you going to be assessing? What is a possible life-threatening or limb-threatening complication from this type of injury? What do his GUT symptoms mean? This is more than a femur fracture...
  4. by   Walrus93
    compartment syndrome?
  5. by   Cricket183
    Definitely a possibility and what would your nursing diagnosis be for that? Compartment syndrome is the medical complication you need to worry about but what are the nursing diagnosis that go along with that?

    But also don't miss the bigger picture here. The urine is amber colored. What could be happening in the body to cause this? Think about the mechanism of injury. The leg was trapped in a crushed car for an extended period of time. Your patient has extensive bruising to the surrounding area. The femur is broken. Think of the anatomy of that area of the body. What do you have a lot of in that area? How would that then relate to the GUT findings?
  6. by   Walrus93
    The diagnosis for the increasing risk of department syndrome are: his leg was trapped for a several hours, he is currently using a Donway splint, which is adding extra pressure to the leg muscles and he has extensive bruising of the surrounding tissue. the interventions would be elevate the leg, and change to a more appropriate traction for his leg?

    as for his urine the only thing i can think of is that he might be dehydrated?
  7. by   Cricket183
    Not dehydration. Look at the specific gravity. If he was dehydrated, you would expect it to be elevated.

    Think about what proteins could be breaking down in the body because of the injury that would cause amber (tea-colored) urine and what systemic problems this might cause. Think of the anatomy of your thigh. What is the most abundant type of tissue for most people there?
    Last edit by Cricket183 on Apr 17
  8. by   Walrus93
    Honestly I have no idea, I dont think I have been taught anything about that yet... but what do you think of my interventions for compartment syndrome does it make sense to you? thanks the goal of cuz to be reduce the risks for department syndrome for the pt and the expected health outcome is Mr X risks of developing a compartment syndrome will decease after interventions are implemented
  9. by   Cricket183
    I sent you a PM.
  10. by   Walrus93
    Hi sorry I cant reply to pms
    Hey thank you so much this really help, I dont know how to thank you haha thanks for putting the time commenting and sending me the message! but let say one of my nursing problem is Rhabdomylosis, how would I type it as a nursing problem and the nursing goal/ expected health outcome? I know the intervention would be monitor compartment syndrome and monitor fluid balance ?
  11. by   amoLucia
    how about simple pain management?
  12. by   ThePsychWhisperer
    Quote from Walrus93
    Hi sorry I cant reply to pms
    Hey thank you so much this really help, I dont know how to thank you haha thanks for putting the time commenting and sending me the message! but let say one of my nursing problem is Rhabdomylosis, how would I type it as a nursing problem and the nursing goal/ expected health outcome? I know the intervention would be monitor compartment syndrome and monitor fluid balance ?
    If you don't have a copy of the Nursing Diagnosis handbook, I highly suggest you get one. You cannot technically write a nursing diagnosis for rhabdomyolysis or compartment syndrome, as these are medical diagnoses. You can, however, write diagnoses related to the rhabdo and the compartment syndrome, such as "At risk for pain (or actual pain) r/t rhabdo/compartment syndrome," "Risk for neurovascular dysfunction r/t compartment syndrome," etc. amoLucia has also given you a few good ideas.
    After you get your diagnoses, how will you treat them? What would be optimal yet reasonable outcomes? A Dx handbook will help you with all of this.
    Last edit by ThePsychWhisperer on Apr 17
  13. by   MilliePieRN
    If I were a nursing instructor, I'd be annoyed that you chose risk for falls when you have this sick of patient. Everyone is a risk for falls. This person is in respiratory distress and I'd want you to acknowledge that. Don't always choose the easiest answer when there are other obvious, more in depth choices.
  14. by   Expert_01
    I sent you a PM.

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