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
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