Nursing Care Plans for Cruris Fracture

by Susanti Santalia, 1706039345, Medical Surgical Nursing III – A

Undergraduate Student - Faculty of Nursing Universitas Indonesia
[email protected]

Case 1:
A man, 24 years old was admitted to ER due to accident when he was riding. His foot was run on
by a car. The patient complaint of inability to stand, with 7-8 scale pain. Assessment findings:
compos mentis, (+) opened injury on cruris area and metatarsal with bleeding. BP: 100/60
mmHg, PR: 106x/mins, RR: 22x/mins.

Subjective Data Objective Data

Inability of standing after incident Compos mentis
Pain at wounded are = 7-8 scale Opened injury with bleeding on cruris &
metatarsal area
Patient feels that he cannot feel his leg* BP: 100/60 mmHg
Foot was run by a car PR: 106x/mins
RR: 22x/mins
Fracture of tibia and/or fibula; trauma*
Immobilization*
Mechanical compression (cast) *
Patient looked uncomfortable and holding
pain*
Vascular Trauma presence*

*: added data
I. Main Nursing Diagnosis: Risk for Peripheral Neurovascular Dysfunction
“Susceptible to disruption in the circulation, sensation, and motion of an extremity, which
may compromise health.”[ CITATION Her14 \l 1033 ]
Subjective Data Objective Data
Foot was run by a car Opened injury with bleeding on cruris &
metatarsal area
 Fracture of tibia and/or fibula; trauma*
Immobilization*
Mechanical compression (cast) *
BP: 100/60 mmHG (a bit low)

*: added data
Nursing Outcomes:
Tissue Perfusion: Peripheral [ CITATION Moo13 \l 1033 ]: Maintain tissue perfusion as evidenced
by palpable pulses; warm, dry skin; normal sensation; stable vital signs; and adequate urinary
output for individual situation.

Nursing Interventions:
Intervention Rationale
NIC: Circulatory Precautions
Independent
Assess client’s risk for development of Any client with severe fractures or multiple
venous thromboembolism (VTE) and acute fractures, especially of long bones (femur) is
compartment syndrome (ACS). at risk for VTE (including deep vein
thrombosis (DVT) and pulmonary embolus
(PE) particularly if long-term bedrest is
required. Clients with fractures of tibia or
femur can be at risk for ACS if they have
sustained severe tissue injury that resulted in
significant bleeding into a closed
compartment, compressed blood vessels such
as might occur with a crush injury, or surgery
to repair blood vessels with subsequent
reperfusion to a compartment. ACS can also
be a complication of circumferential
dressings, splints, or casts that are applied too
tightly.
Evaluate presence and quality of peripheral Decreased or absent pulse may reflect
pulse distal to injury via palpation. Compare vascular injury and necessitates immediate
with uninjured limb. medical evaluation of circulatory status. Be
aware that occasionally a pulse may be
palpated even though circulation is blocked
by a soft clot through which pulsations may
be felt. In addition, perfusion through larger
arteries may continue after increased
compartment pressure has collapsed the
arteriole and venule circulation in the muscle.
Assess capillary return, skin color, and Return of color should be rapid (3–5
warmth distal to the fracture. seconds). White, cool skin indicates arterial
impairment. Cyanosis suggests venous
impairment. Note: Peripheral pulses, capillary
refill, skin color, and sensation may be normal
even in the presence of compartment
syndrome because superficial circulation is
usually not compromised.
NIC: Circulatory Care: Arterial [or] Venous Insufficiency
Independent
Maintain elevation of injured extremity(ies) Promotes venous drainage and decreases
unless contraindicated by confirmed presence edema. Note: In presence of increased
of compartment syndrome. compartment pressure, elevation of the
extremity actually impedes arterial flow,
decreasing perfusion.
Casts or circumferential
Investigate sudden signs of limb ischemia, Fracture dislocations of joints, especially the
such as decreased skin temperature, pallor, knee, may cause damage to adjacent arteries,
and increased pain. with resulting loss of distal blood flow.
Collaborative
Administer IV fluids and blood products as Maintains circulating volume, enhancing
needed. tissue perfusion.
Administer medications, as indicated: Low- Maintains circulating volume, enhancing
molecular-weight heparin or heparinoids, tissue perfusion. Anticoagulants may be given
such as enoxaparin (Lovenox), dalteparin prophylactically to reduce threat of deep
(Fragmin), or fondaparinux (Arixtra), if venous thrombus
indicated.

Apply antiembolic hose or sequential pressure Decreases venous pooling and may enhance
hose or compression boots, as indicated. venous return, thereby reducing risk of
thrombus formation.

II. Nursing Diagnosis: Acute Pain related to Fractures

“Unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage (International Association for the Study of
Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or
predictable end, and with a duration of less than 3 months.” [ CITATION Her14 \l 1033 ]

Subjective Data Objective Data

 Inability of standing after incident Opened injury with bleeding on cruris &
metatarsal area
Pain at wounded are = 7-8 scale Patient looked uncomfortable and holding
pain*

*: added data
Nursing Outcomes:
Pain level:
1. Verbalize relief of pain, measured with pain scale from 1 to 10
2. Display relaxed cues and expression, able to participate in activities
Pain control: Demonstrate use of relaxation skills.

Nursing Interventions:
Intervention Rationale
NIC: Pain Management
Independent
Maintain immobilization of affected foot: Relieves pain and prevents bone
bedrest and cast displacement/extension of tissue injury.
Elevate and support injured extremity Promote venous return, decrease edema, and
may reduce pain.
Monitor, evaluate, and document pain or Monitoring effectiveness of intervention,
discomfort. Use scale. (0 to 10) influence interventions.
Do not forget to assess the PQRST.
Tell patient to express whenever the pain is Promotes comfort, enhance relaxation
intense, tell the patient the urge to tell before
pain is becoming more severe
Investigate any reports of unusual or sudden May signal complications in develop, such as
pain or deep, progressive, and unrelieved by infections, ischemia, or compartment
analgesics syndrome. (refer to main diagnosis)
Provide alternative comfort measures, for Improve general circulation; reduces areas of
example, massage, back rub, or position local pressure and muscle fatigue.
changes
Collaborative
Administer medications, as indicated: opioid Given to reduce pain and/or muscle spasms;
and nonopioid analgesics such as morphine, ketorolac (toradol) studies shown that it has
meperidine; injectable and oral NSAIDs, such more effective work with bone pain, with
as ketorolac or ibuprofen; and/or muscle longer action and fewer side effects than
relaxants such as cyclobenzaprine (flexeril) or opioid.
carisoprodol.
Maintain continuous IV or patient-controlled Optimal pain management is essential to
analgesia (PCA) using peripheral, epidural, or permit early mobilization and physical
 intrathecal routes of administration. therapy and to maintain adequate blood level
of analgesia, preventing fluctuations in pain
relief with associated muscle tension or
spasms

III. Nursing Diagnosis: Impaired Tissue Integrity

“Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle,
tendon, bone, cartilage, joint capsule, and/or ligament.” [ CITATION Her14 \l 1033 ]

Subjective Data Objective Data

Foot was run by a car Opened injury with bleeding on cruris &
metatarsal area
BP: 100/60 mmHg (a bit low)

Vascular Trauma presence*

*: added data
Nursing Outcomes:
Tissue Integrity: Skin & Mucous Membranes:
1. Verbalize relief of discomfort
2. Achieve timely wound or lesion healing.

Nursing Interventions:
Intervention Rationale
NIC: Skin Surveillance
Independent
Examine the skin for open wounds, foreign Provides information regarding skin
bodies, rashes, bleeding, discoloration, circulation and problems that may be caused
duskiness, and/or blanching. by application and/or restriction of cast,
splint, or traction apparatus, or edema
formation that may require further medical
intervention.
Provide specialty beds and Geomatts as Used for clients with a high risk of skin
indicated. breakdown or in whom long-term immobility
is expected.
Reposition frequently. Encourage use of Lessens constant pressure on same areas and
trapeze, if possible. If not able to turn minimizes risk of skin breakdown. Use of
independently, a turning schedule must be trapeze may reduce risk of abrasions to
maintained by the nurse. elbows and heels.
 Collaborative
Provide foam mattress, sheepskins, flotation Because of immobilization of body parts,
pads, or air mattress, as indicated. bony prominences other than those affected
by the casting may suffer from decreased
circulation.
Monovalve, bivalve, or cut a window in the Cutting or hinging the cast allows the release
cast, per protocol. of pressure and provides access for wound
and skin care.

IV. Nursing Diagnosis: Impaired Physical Mobility

“Limitation in independent, purposeful movement of the body or of one or more
extremities.” [ CITATION Her14 \l 1033 ]

Subjective Data Objective Data

Inability to stand after the accident Foot is having a fracture, being casted

Patient feels that he cannot feel his leg*

*: added data
Nursing Outcomes:
1. Mobility
- Regain and maintain mobility at the highest possible level.
- Demonstrate techniques that enable resumption of activities, especially activities of
daily living (ADLs).
2. Skeletal Function
- Maintain position of function
- Increase strength and function of affected and compensatory body parts
Nursing Interventions:
Intervention Rationale
NIC: Bedrest Care
Independent
Encourage participation in diversional or Provides opportunity for release of energy,
recreational activities. E.g: TV, Gadget, visits refocuses attention, enhances client’s sense of
from family and relatives self-control and self-worth, and aids in
reducing social isolation.
Assist with and encourage self-care activities Improves muscle strength and circulation,
such as bathing, shaving, and oral hygiene. enhances client control in situation, and
promotes self-directed wellness.
Instruct in, and encourage use of, trapeze and Facilitates movement during hygiene, skin
“post position” for lower limb fractures. care, and linen changes; reduces discomfort of
remaining flat in bed. “Post position” involves
placing the uninjured foot flat on the bed with
the knee bent while grasping the trapeze and
lifting the body off the bed.
Provide diet high in proteins, carbohydrates, In the presence of musculoskeletal injuries,
vitamins, and minerals, limiting protein early good feeding is needed as nutrients
content until after first bowel movement. required for healing are rapidly depleted.
Collaborative
Consult with physical or occupational Useful in creating aggressive individualized
therapist and/or rehabilitation specialist. activity or exercise program.
Refer to dietitian or nutrition team, as The client with fractures, especially when
indicated. associated with trauma, may have special
nutritional considerations; for example,
he or she may need enteral or parenteral
feedings to maximize healing of tissues and
bones.
Initiate bowel program—stool softeners, Important to promote regular bowel
enemas, or laxatives, as indicated. evacuation and prevent constipation.

References
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Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2013). Nursing Outcomes
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