Pointers and tips appreciated :)

[NightNurseRN13]

2nd semester nursing student here. I had assessment today and I have a full day tomorrow to finish the paperwork so I figured I would again post here and see if anyone can point out where I'm lacking or what I may be missing or even how to word something in a more professional manner.

So quick report on my pt.

60 yr old male came into hospital after a MVC, has fractured femur, fractured radius, fractured C5

He is on spinal precautions and fall precautions

He is on hypoglycemia protocol even though no history of diabetes.

He is on Bowel and Bladder training management even though he is continent (I'm thinking to prevent skin breakdown since he needs a slide board to be transferred)

He has OT, PT and recreational therapy consults and has been on the rehab floor for 14 days.

Here is my concept map in order by priority:

Impaired mobility r/t musculoskeletal alterations AEB: multiple fractures, pre-cast on radius, unsteady gait, non-weight bearing on Lt. leg, spinal precautions, slide board for transfer and decreased ROM

Acute pain rt trauma AEB: grimace with movement, verbalized pain of 4 on scale of 1-10, decreased ROM

risk for falls r/t complex factors: unsteady gain, multiple fractures, pain, medications, pre-cast, falls precautions, decreased lower extremity strength, decreased ROM

risk for ineffective tissue perfusion r/t complex factors: risk of DVT, trauma, hospitlization, impaired mobility, decreased ROM, pre-cast, decreased activity, decreased hemoglobin, TEDs

Risk for unstable blood Glucose level r/t recent history of elevated glucose secondary to Hypoglycemia managment

Activity intolerance r/t complex factors AEB: weakness, unsteady gait, pain, multiple fractures, decreased ROM, non-weight bearing on lt. leg, musculoskeletal impairment

imapired bed mobility r/t impaired ability to properly turn AEB: slide board used for transfer, spinal precautions, fractured C5, decreased ROM

disturbed body image r/t injury AEB: pt. verbalized hope to return back to work, multiple fractures, imapired functioning compared to before accident

risk for infection r/t complex factors: in the hospital, trauma, pain, pressure, imapired mobility, decreased hemoglobin

Risk for constipation r/t complex factors: decreased activity, emotional stress, colace, bowel training management, decreased ROM, pain

Risk for impaired skin integrity r/t complex factors: impaired mobility, bowel and bladder training, pre-cast, friction, pressure, shear, decreased ROM, decreased ability to preform ADL's

Here are my 3 required intervention sheets with goals:

1. Impaired mobility r/t musculoskeletal alterations:

General goal: Pt. will gradually increase mobility as tolerated by end of shift

Behavioral outcome objective: The pt. will be free of complications associated with impaired mobility throughout todays shift

Interventions:

1. monitor and record pt. ability to tolerate activity (tells nurse how much pt. can tolerate and what goals to set)

2. ensure pt. continues to use TEDs while admitted (promotes venous return preventing DVT's)

3. assist pt. with ROM exercises if unable to ambulate (prevents contractures)

4. encourage and observe pt. use of incentive spirometer (to make sure IS is being used properly and to set goals for pt)

5. assit pt. with ambulation as tolerated (immobility is the cause of many unwanted issues, as listed on concept map)

6. assess pt. for cause of immobility (may be due to physical, psychological or motivational issues)

7. monitor pt. vital signs before and after ambulation/exercise (shows signs of distress, improvement or decline)

8. assess pt. pain before and after activity (pt is more willing to participate in activity if pt. knows pain will be addressed)

2. Acute pain r/t trauma

General goal: pt. will verbalize and rate pain level throughout shift

behavior outcome objective: pt. will use a self report pain tool to identify current pain level and establish a comfort goal when initally interviewed by 0900

Interventions:

1. determine if pt. is experience any pain at initial interview (provides data for pain management

2. assess pain level in pt. using the 1-10 pain scale (determines if pt. can use a self-report tool)

3. Assess pt. pain routinely at frequent intervals (will show if pain managment is effective

4. ask pt. what best relieves his pain (will be able to continue that pain management)

5. ask pt. if interested in trying different pain relief techniques (may help to relive pain even further and educate patient as to non pharmalogical pain management alternatives)

6. prevent pain during procedures if possible (prevents further unnessary pain

7. explain the pt. the pain management approach (gives pt. opportunity to include his ideas and willingness to try new techniques)

3. Risk for falls r/t complex factors

general goal: pt. will remain free from falls by end of shift

Behvaior outcome objective: the pt. will become oriented to environment further to minimize the risk of falls throughout shift

interventions:

1. complete fall risk assessment (is a valid reliable tool and informs nurse to what extreme they need to intervene)

2. screen pt. for balance and mobility skills (determines pt. abilities and then plan for ways to improve problem areas)

3. when ambulating pt. use walker and/or gait belt (prevent serious complications if fall were to occur)

4. make sure bed wheels are locked at all times (prevents falls)

5. make sure pt. has skid free slippers (provides traction/prevents falls)

6. orientate pt. to environment (allows pt. to become familar with environment and to avoid obstacles)

7. encourage pt. to use assistive devices (added support and prevention of falls)

8. provide adequate lighting when appropriate (allows pt. to see where they are going and to avoid obstacles)