Help on care plan

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My scenario has a 57 old female admitted to ER with a fractured leg secondary to MVA. VS -T 98.8 P 95 RR 24 b/P 145/89 she is AAO*3 complained of severe pain (8) right leg was given medication and reported relief (2). It's 1 am and the pt has not slept since admission she communicates she is use to it, feeling tired, falling asleep anywhere". She often had to have cuban coffee to stay alert as she often had to work with heavy machinery at a plant. I need a diagnosis, sub&obj goals and interventions. I have done the following diagnosis sleep deprivation r/t inadequate sleep hygiene aeb feeling tired and falling asleepbeverwhere" obj fracture right leg, sub use to it, feeling tired, falling asleep everywhere" i believe the pt is sleep deprived and she needs sleep for her fracture to heal, her body needs recuperation i have some intervention such as assess for fatigue, anxiety, encouraging restriction of cafeeine and encouraging a light snack and teach relaxation techn such as soft music but i need someones elses opinion. It would be helpful if they have other suggestions on what tbey would do, thank u

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My first thought was Acute Pain for diagnosis. I know you stated she had relief from pain med, but I am assuming the pain will return. Regardless, you said her pain is still a 2, so you could implement other interventions, such as positioning, relaxation techniques.

The other diagnosis that goes along with sleep deprivation is Readiness for Enhanced Sleep. The diagnosis would depend on whether she has a readiness to learn. If so, then it would be educating the pt. regarding relaxation, reducing caffeine, and the other interventions that you mentioned. I think your diagnosis of Sleep Deprivation is fine. You could also use the Fatigue diagnosis.

Lastly, you may want to consider the Anxiety diagnosis. Afterall, she did just go through a traumatic event (MVA) and may be anxious. Hope this helps.

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My scenario has a 57 old female admitted to ER with a fractured leg secondary to MVA. VS -T 98.8 P 95 RR 24 b/P 145/89 she is AAO*3 complained of severe pain (8) right leg was given medication and reported relief (2). It's 1 am and the pt has not slept since admission she communicates she is use to it, feeling tired, falling asleep anywhere". She often had to have cuban coffee to stay alert as she often had to work with heavy machinery at a plant. I need a diagnosis, sub&obj goals and interventions. I have done the following diagnosis sleep deprivation r/t inadequate sleep hygiene aeb feeling tired and falling asleepbeverwhere" obj fracture right leg, sub use to it, feeling tired, falling asleep everywhere" i believe the pt is sleep deprived and she needs sleep for her fracture to heal, her body needs recuperation i have some intervention such as assess for fatigue, anxiety, encouraging restriction of cafeeine and encouraging a light snack and teach relaxation techn such as soft music but i need someones elses opinion. It would be helpful if they have other suggestions on what tbey would do, thank u

I don't have a careplan book handy but maybe you do a dx of "pain related to injury as evidence by patient states pain is 10/10." Interventions could be something like assess pt's pain level Q??hrs, admin pain meds, monitor vitals."

You could maybe do a psychosocial with something like "anxiety related to MVA or hospital stay as evidence by pt states she's anxious/worried about being in hospital?? Interventions could be something like, stay with patient, assess pt's level of anxiety, teach relaxation techniques.

Hope that helps a little.

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Specializes in ER,OR, PACU, Corrections.

You might try Alteration in Health Maintenance r/t inadequate health practices such as unhealthy life style (her major lack of proper sleep habits). Sounds as if she may have set up an abnormal sleep pattern for herself. You would assess the contributing factors to sleep pattern and initiate health promoting behaviors such as reducing caffeine intake and sleep promoting techniques. Also, one question that I had was if the MVA was caused by her falling asleep? Good luck.

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Specializes in Rural Health.

I haven't done Care Plans for a few years... but for her sleep deprivation can you refer her for a sleep study as an intervention.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

on the student forums of allnurses we have this thread to help students with writing care plans:

https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

care planning is problem solving. we use the nursing process which consists of 5 steps to help us problem solve. the steps are to be followed in sequence.

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology

  • fractured leg secondary to mva

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data

  • severe pain (8) right leg with relief (2) after medication
  • has not slept since admission - says she is use to it, feeling tired, falling asleep anywhere - often had to have cuban coffee to stay alert as she often had to work with heavy machinery at a plant

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

  • acute pain r/t traumatic injury aeb pain in right leg of 8 on a scale of 0 to 10
  • insomnia r/t anxiety aeb has not been able to sleep since admission
    • this used to be called disturbed sleep pattern. patient's problem is that she could fall asleep anywhere. well, she just went through a trauma. i wouldn't be able to fall asleep either! would you? i'd be re-living the accident in my mind, thinking about my car. . .
    • you could also use, anxiety r/t situational crisis aeb insomnia

    [*]deficient knowledge, fracture care r/t lack of information

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I know this won't help but I will never miss having to do another care plan.

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To Datetonite

Thank you very much, i thought the same things too but the prof said it had something to do with sleep I love ur suggestion, thank you very much

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Specializes in med/surg, telemetry, IV therapy, mgmt.
I know this won't help but I will never miss having to do another care plan.

How long have you been licensed and working? Care plans are required by federal law in the chart of every Medicare patient. That is one reason why students learn to do them in school. The other reason is to learn how to think critically in order to pass the NCLEX A third reason is to help learn about medical disease and nursing care.

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Specializes in med/surg, telemetry, IV therapy, mgmt.
To Datetonite

Thank you very much, i thought the same things too but the prof said it had something to do with sleep I love ur suggestion, thank you very much

Follow what your instructor wants you to do. When I answer care plan questions I follow the NANDA guidelines. Your instructors may want you to follow another way of determining the nursing problems. It is all good as long as you are following a rational way of thinking.

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