Step-by-step explanation
4) Nursing NANDA nursing diagnoses of the patient with cast.
• Knowledge deficit related to the treatment
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• Pain related to the surgical incision pain and musculoskeletal disorder.
• Impaired physical mobility related to the cast.
• Self-care deficit: bathing/hygiene, feeding, dressing/grooming, or toileting due to restricted mobility.
• Impaired skin integrity related to lacerations and abrasions
• Risk for peripheral neurovascular dysfunction related to physiologic responses to injury and compression effect of cast
• Risk of infection i.e. hypostatic pneumonia relate to immobility.
• Anxiety related to disease process.
5) What goals did you assign to each of the NANDA nursing diagnoses?
• knowledge of the treatment regimen,
• Relief of pain.
• improved physical mobility.
• Achievement of maximum level of self-care.
• Healing of lacerations and abrasions.
• maintenance of adequate neurovascular function, and absence of complications.
6) What priority nursing actions apply to the case study (Saunders document along with page number) as applies.
EXPLAINING THE TREATMENT REGIMEN
The patient is informed of the purpose and expectations of the prescribed plaster cast and possible complications that may arise. This knowledge will promote the patient's to participate actively in adherence to the treatment program. It is important to help the patient understand what to expect when they have the cast i.e. sensations (eg, heat from the hardening reaction of the plaster) and that the body part will be immobilized after casting
RELIEVING PAIN
Evaluate the type of pain whether musculoskeletal or incision pain, Patient should be able to indicate the exact site of pain and describe the character and intensity of the pain to help determine its cause. Most pain can be relieved by elevating the involved part, applying cold as prescribed, and administering usual dosages of analgesics.
Immobilize the limb incase the pain is associated with the disease process (eg, fracture) i. Elevate the limb incase pain is due to edema that is associated with trauma, surgery, or bleeding into the tissues or prescribed, intermittent application of cold. Ice bags (one-third to one-half full) or cold application devices are placed on each side of the cast making sure not to indent the cast.
IMPROVING MOBILITY
Every joint that is not immobilized should be exercised and moved through its range of motion to maintain function. If the patient has a leg cast, the nurse encourages toe exercises.
PROMOTING HEALING OF SKIN ABRASIONS
Clean any visible lacerations or abrasions. observes the patient for systemic signs of infection, odors from the cast, and purulent drainage staining the cast. It is important to notify the physician if any of these occurs.
MAINTAINING ADEQUATE NEUROVASCULAR FUNCTION
Swelling and edema are natural responses of the tissue to trauma and surgery. The patient may complain that the cast is too tight. Vascular insufficiency and nerve compression due to unrelieved swelling can result in compartment syndrome. The nurse monitors circulation, motion, and sensation of the affected extremity, assessing the fingers or toes of the casted extremity and comparing them with those of the opposite extremity. Normal findings include minimal swelling, minimal discomfort, pink color, warm to touch, rapid capillary refill response, normal sensations, and ability to exercise fingers or toes. The nurse encourages the patient to move fingers or toes hourly when awake to stimulate circulation.
MONITORING AND MANAGING POTENTIAL COMPLICATIONS
• Compartment Syndrome
• Pressure ulcers.
• Disuse syndrome.
Promoting home and community based care by encouraging the patient to ambulate and take control of their self care.
b. Assessment data (from the case study)
• Kathy Gestalt is a young lady 33yr-old in good general health status.
• She is on second day post-op open right Tibia/Fibula fracture, She still has complains of the pain on the fracture or the incision site.
• She has plaster cast in placed on right lower leg you have to assess the neurovascular status, numbness, edema of toes, degree and location of swelling, bruising and skin abrasions.
• No known allergies.
• Her Vital signs -Temp 98.4, BP 116/76, P 96, RR 20, SaO2 99%. and are within normal range with no signs of infection or underlying health condition like HTN.
• She is in normal mental status and cooperative but anxious as she is worried about scarring and is reluctance regarding walking on leg.
• She is normal feeds and the diet is well tolerated.
• She is on early ambulation training on how to use of Crutches
c. 3 priority NANDA nursing diagnoses
1. Knowledge deficit related to the treatment regime.
2. Pain related to musculoskeletal disorder.
3. Impaired physical mobility related to the cast.
d. Goal
1. Knowledge of the treatment regimen.
2. Relieve pain.
3. Improved physical mobility.
e. Interventions.
• Explaining treatment regimen, pathologic problems purpose and expectations.
• Relieve pain by giving the prescribed treatment, elevating the involved part, applying cold compressors as prescribed.
• Improving mobility, immobilized joints should be exercised and moved through its range of motion to maintain function.
• Promote healing of skin abrasions by dressing the wounds, give prescribed antibiotics and monitor any signs of infection i.e. fever, odor from the cast, purulent discharge staining the cast and notify the doctor.
• Maintain adequate neurovascular function by performing frequent regular assessment of neuro vascular status by monitoring circulation, motion and sensation of the toes
• Monitoring and managing potential complications by preventing increased tissue pressure which may cause compartment syndrome, pressure ulcers or disuse syndrome.
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