Access Millions of academic & study documents

Word Nur2356 Module 06 Assignment

Content type
User Generated
Subject
Nursing
School
Rasmussen University
Type
Homework
Showing Page:
1/3
Module 06 Care Map
Mr. Harry Roost is a 78-year old male being discharge after a fracture of his right tibia and
fibula. He has a long leg cast that he will need to wear for the next 8 weeks. The nurses
have observed him using a hanger to scratch the skin under the cast. The nurse have
reminded him each time that he is not to put anything down his cast. He also sits on the
side of the bed for long periods with his leg in a dependent position. He also gets up to go
to the bathroom without calling for help. The staff have observed him hopping to the
bathroom without using his crutches.
Subjective
-
Observed patient hopping
-
Patient is not using
crutches to ambulate
Subjective
-
Observed patient sitting
on edge of bed with leg in
dependent position
Subjective
-
Observed using hanger to
scratch skin under cast
Objective
-
The patient has a long leg
cast on the right leg
-
He is unable to ambulate
or bear weight on the
right leg
Objective
-
The patient has 2+
edema in the right foot
Objective
-
There is a superficial
laceration visible coming
out from the top of the
cast
Diagnostic
Diagnostic
Diagnostic
- Previous imaging showed
fracture of right tibia and fibia
- Patient denies any signs of
compartment or cast syndrome
N/A
Nursing Diagnosis
Nursing Diagnosis
Nursing Diagnosis
Impaired physical mobility,
cast-related (NANDA Nursing
Diagnosis, 2020).
Risk for peripheral
neuromuscular dysfunction
related to compression of
cast
Risk for impaired skin
integrity, related to foreign
body lacerations
SMART Goal
SMART Goal
SMART Goal

Sign up to view the full document!

lock_open Sign Up
Showing Page:
2/3
The patient will verbalize
understanding of safety
precautions and demonstrate
compliance in improving
stability.
The patient will be properly
monitored for peripheral
vascular dysfunction through
routine nursing checks and
preventative measures, like
elevation of the extremity, will
be performed.
The patient will be monitored
for signs of infection. The
patient will verbalize
understanding of other
means to treat discomfort.
Nursing Interventions
Nursing Interventions
Nursing Interventions
-
Evaluate the patients pain
and initiate pain relief if
indicated.
-
Encourage alternative
means of pain relief, like
distraction or relaxation
-
Promote isometric
exercises to strengthen
muscles restricted by the
cast
-
Encourage upper body
strengthening exercises
-
Teach patient about safety
precautions
-
Re-enforce physician
instructions on weight
bearing activities
-
Encourage participation in
self care activities
-
Encourage mobility using
the assistive devices
-
Elevate the right leg above
the heart
-
Monitor for signs of cast
syndrome, compartment
syndrome
-
Specifically, monitor and
report to physician any
abdominal pain,
hypertension, vomiting,
tachycardia which are signs
of cast syndrome
-
Monitor for worsening pain,
paresthesia, decrease in
pallor which are signs of
compartment syndrome
(Compartment syndrome,
2020).
-
Encourage him to call
physician immediately
should these concerns arise
-
Reinforce to the patient that
he cannot put foreign
objects down the cast.
-
Instruct the patient to keep
the cast try. Instruct him to
dry the cast with a blow
dryer on cool if it does get
wet.
-
Monitor for signs of
bruising, laceration, rashes,
ulceration, and other signs
of skin break down.
-
Monitor for hot spots
along cast, as these could
be signs of infection.
-
Encourage him to notify
provider should he have
concerns.
-
Teach him skin cares
technique for the exposed
leg.
References:

Sign up to view the full document!

lock_open Sign Up
Showing Page:
3/3

Sign up to view the full document!

lock_open Sign Up
Unformatted Attachment Preview
Module 06 – Care Map Mr. Harry Roost is a 78-year old male being discharge after a fracture of his right tibia and fibula. He has a long leg cast that he will need to wear for the next 8 weeks. The nurses have observed him using a hanger to scratch the skin under the cast. The nurse have reminded him each time that he is not to put anything down his cast. He also sits on the side of the bed for long periods with his leg in a dependent position. He also gets up to go to the bathroom without calling for help. The staff have observed him hopping to the bathroom without using his crutches. Subjective Subjective Subjective - Observed patient hopping - Observed patient sitting - Observed using hanger to on edge of bed with leg in scratch skin under cast - Patient is not using dependent position crutches to ambulate Objective Objective - The patient has a long leg - The patient has 2+ ...
Purchase document to see full attachment
User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.
Studypool
4.7
Indeed
4.5
Sitejabber
4.4

Similar Documents