Need help writing my first nursing diagnosis.

[dw-71]

Mr. O. Meyer is a 35-year old man who was admitted via the Emergency Room for a broken leg and a possible myocardial infarction (heart attack) yesterday. He fell one story from a scaffold at his construction site yesterday for unexplained reasons. His current vital signs are Temperature 100.2, Pulse 100 and slightly irregular. Respiratory rate is 20 without difficulty or shortness of breath. Breath sounds are clear. He is currently on complete bed rest. His skin is warm and dry. He has some abrasions on his face, shoulders and back. He has not had a bath since admission and there are some areas that need to be cleaned. He has a splint on his left leg that is fractured. His leg is elevated on a pillow and there is ice to his ankle area. His toes are non-swollen, pink and warm to the touch. When the nurse compresses his toes, they blanch but capillary refill occurs instantaneously. Mr. Meyer is on a regular diet and ate 80% of his breakfast. He is taking liquids without difficulty and drank about 500 cc's since 6 am. He has an IV infusing at 125 cc's per hour. He is using a urinal without difficulty. His urine is clear and yellow. His urine output was 1000 ccs in the last 8 hours. He has not had a Bowel Movement since yesterday. He is alert and oriented to person, place and time. He reports pain from the muscle spasms as an "8" on a 0 (no pain) to 10 (maximum pain) scale. He denies any chest pain. He is attached to a cardiac monitor and the rate and rhythm are within normal limits. He has an order for Tylenol with Codeine for pain every 3-4 hours as needed. He last took it about 5 hours ago for leg pain. He reports no allergies. He is worried about not being able to go back to work since he is the sole support for his family. His wife is unemployed and takes care of their 2 pre-school aged children. She is visiting and his mother-in-law is watching the children.

Create 3 nursing diagnoses for this patient: include at least one physical problem and one psychosocial problem. Diagnose one actual problem and one potential problem. Prioritize this patient's top 2 emergent problems. Use the Problem - Etiology - Symptoms format.

Write one goal for each of the nursing diagnoses in question 4. Use a 3-part format for each goal.

Write 3 nursing interventions; one directed toward each nursing diagnosis/goal.

Discuss how you will evaluate achievement of the goals that have been set.

Here is what I have/think:

1. Pain r/t left leg fracture and muscle spasms AEB reports leg pain an 8 on 0-10 scale.

Mr. M's pain will be relieved within 30 min. after medication, positioning and applying ice AEB reports pain is relieved.

Provide adequate pain relief using medication and other comfort measures such as elevating affected leg as needed, applying ice, positioning q 2 hrs and encourage range-of-motion exercises of unaffected limbs.

I am stuck on 2 & 3, I'm thinking Risk for infection or Risk for additional injury for #2.

For the psychosocial problem Anxiety or risk for Situational low self-esteem/powerlessness due to him being unable to work.

I'm having difficulties on how to write the Risk for diagnosis.

Any help is appreciated!!!