Care Plan

Student: Tatiana Novak Date: July 8, 2019

Course: NSG-320 CC Instructor: Professor Green

Clincial Site: Honor Health Deer Valley Client Identifier: J.T. Age: 23

Reason for Admission: Patient was admitted after as a level 1 trauma after a motor vehicle accident.

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

Bilateral femur and patella fractures, and rhabdomyolosis J.T.’s current clinical manifestations for femur and knee fractures
include: pain, inability to move legs, swelling, tenderness, bruising,
Pathophysiology: a bone fracture is a medical condition in where the
inability to walk
continuity of the bone is broken. The bone could be a complete fracture
which means it is broken in half or a partial fracture where the bone is still Clinical manifestations for rhabdomyolisis: tenderness and swelling
connected which a crack in it. Bilateral femur fractures indicates that both of the extremities
legs have broken femurs. Bilateral knee fractures means that both knees Expected clinical manifestations for femur and knee fractures:
are fractured.
- Obvious deformities of the leg
Rhabdomyolisis a serious syndrome due to a direct or indirect muscle
injury. It results from the death of muscle fibers and release of their Expected clinical manifestations for rhabdomyolisis:
contents into the bloodstream. - Muscle tenderness and swelling may be seen, but detectable
Risk factors: muscle swelling in the extremities generally develops, when
it occurs, with fluid repletion. Such swelling is much less
Fractures: extreme trauma and force, osteoporosis are major risk factors common on hospital admission. Muscle weakness may be
for potential fractures. present, depending upon the severity of muscle injury.
(Lewis, Bucher, Heitkemper, & Harding, 2017
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
Rhabdomyolisis: crush injury, overexertion, alcohol abuse and certain
medicines and toxic substances.

(Lewis, Bucher, Heitkemper, & Harding, 2017

Assessment Data
Subjective Data:

VS: 7/8/19 (0800) Labs: 7/8/19 (0403) Diagnostics:

T : 98.0 On next page. - Toxicology (7/4/19) – Positive for benzodiazapines
and THC
BP: 130/70
- Alcohol report (7/4/19) - 0.266
HR: 60 - Chest X-ray (7/4/19) – lft. 9th rib fracture
- Bilateral Femur X-ray (7/4/19) – bilateral femur
RR: 18
fractures
O2 Sat: 98% - CT chest and abdomen (7/5/19) – intermediate
density around fundus of gallbladder
7/8/19 (1300)
- Exploratoy Laparotomy (7/5/19) – small bowel
T : 97.5 perfusion, grade 2 splenic laceration
BP: 126/74
HR: 57

2
RR: 15 WBC (4-11): 7.1 WNL

O2 Sat: 100%
RBC (4-5): 2.49 RBC are decreased due to
the client’s loss of blood
from her fractures and
recent surgery

Hgb (14-18): 7.7 Hemoglobin levels are

low due to the client’s
blood loss from her
fractures and surgery.

Hct (39-50): 21.9 Hematocrit levels are low

due to the client’s blood
loss from her fractures and
surgery

Platelets (150-400): 95 Platelet levels are low due

to the amount of blood
loss the client
experienced.

Na+ (135-145): 139 WNL

K+ (3.5-5.0): 3.5 WNL

Ca2+ (8.5-10.2): 9.0 WNL

ALT (7-56): 71 These levels may be

elevated severely because
of the toxins like the
alcohol and THC in her
body.

AST (10-40): 116 elevated severely because

of the toxins like the

3
 alcohol and THC in her
body.

Bun (7-20): 12 WNL

Cr (0.2-1): 0.5 WNL

Glucose (70-110): 75 WNL

Creatinine Kinase (26- This major increase in CK

192): 5,422 is due to the patient
having rhabdomyolysis

4
Assessment: Orders:
Past medical history: - nonweight baring for lower extremities
- weight baring as tolerated for upper extremities
The patient also sustain these injuries during her accident
- incision and wound care
- Left 9th rib fracture - encourage coughing and deep breathing with splinting
- small bowel injury - fall precautions
- grade 2 splenic injury - diet changed to clear liquids
- continous 0.9% normal saline replacement
She has no other past medical history
Neuro
LOC: Alert, Oriented x 4, lethargic

Speech: Clear

Pupils: Brisk, reactive, Equal, Round, Regular, R size- 4 mm, L Size- 4 mm

Eyes: Open spontaneously

Affect: Cooperative

Skin
Color: Pink

Status: Intact, Warm, Dry

Wounds: location: abdomen, outer thigh by hip and on the outer knee

Drainage: moderate, serosanguineous

Staples

Dressing: clean, dry, and intact

5
 Resp
Oxygen Status: RA, O2 sats _98%_, Rate: 15

Lung sounds: Clear

Effort: unlabored

Cough: None

Sputum: None

MSK
Upper extremity Motor Response: Moves against resistance,

Strong, Equal

Lower Extremity Motor Response: Moves against resistance,

Weak, Equal,

Mobility: bedrest, non-weight baring

Assistive Devices: none

Fall Precautions: Yes

Cardio/Vascular
Heart rate: 57 bpm, Regular BP: 126/74

Heart tones: S1, S2

Pulses: Radial- Palpable, + 2

Pedal- Palpable, + 1

Capillary Refill: Brisk, <3 Sec,

Edema: upper- present +1; lower - present +2 (both non-pitting)

6
JVD: Absent

Hygiene
Status: Partial bath

Linens changed 7/8/19 @ 1445

** Include time and date completed

GI
Abdomen: Flat

Tenderness- yes from incision, soft

Bowel sounds: Normoactive

Last BM: Date- 7/4/19

Describe the color and consistency: “brown and soft. It was small”

Diet: Type- clear liquid diet

Percentage of Breakfast and lunch: 0% due to previously being NPO during the
day

Monitoring Lines/IVs
Peripheral IVs: Location- Rt. Upper arm Size- 20 gauge

0.9% normal saline infusing

JP Drain: location – RUQ color- pink output – 125 ml

7
 GU
Status: Voids

Urine: Clear, Yellow

Output amount: 400ml

Pain/Burning/Difficulty voiding- no

Pain
P (Precipitating factor): movement

Q (Quality): sharp, throbbing pain

R (Radiation/Region): “all over”

S (Severity): 8/10

T (Time): 1100

Goal: 4 /10

8
 Medications
ALLERGIES:

No known drug allergies

(Deglin, Vallerand, & Sanoski, 2015)
Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing
Effect Considerations
Enoxaparin (lovenox) 40 mg ` SubQ Daily The patient is using this Hematomas, increased bleeding, Assess client for
medication as a prophylaxis of hemorrhage, thrombocytopenia bleeding, bloody noses,
venous thrmbosus due to her melena, bleeding gums
immobilization. etc. Check aPPT levels
before administration of
the medication. Do not
push the air bubble out
of the prepackaged
syringe.
Escitalopram (lexapro) 10 mg PO Daily This medication is ues to treat Blurred vision, racing thoughts, Teach the patient to
anxiety in adults. feelings of extreme happiness or avoid taking NSAIDs
sadness, low levels of sodium and alcohol. Instruct the
patient to take their
missed dose as soon as
possible on the same
day. Tell the HCP if
patient becomes
pregnant because this
medication needs to be
tapered during the 3rd
trimester
Sodium chloride 0.9% 1000 ml IV Continuous This medication is being hung Edema, IV site irritateion, Assess fluid balance
for the patioent to be hervolemia, hypokalemia, (intake and output),
adequately hydrated and as hypernatremia assess daily weight.
treatment for rhabdomyolisis. Monitor serum sodium,
potassium, and chloride
concentrations. Explain
to patient the purspose

9
 of the infusion and why
it is continuous.
Acetaminophen (tylenol) 650 mg PO Q8h The client is on this pain Nausea, vomitting, headaches, Before adminstration of
medication for as a baseline insomnia, hypertension, this medicatoin, it is
pain controller. constipation, renal failure, rash. expected to look for
rashes periodically
throughout treatment.
Additional nursing
considerations include
assessing pain levels
before administration.
With this medication,
educate clients on
possible renal and liver
failure.
Oxycodone 5 mg PO PRN for The client has this pain Confusion, constipation, Assess respiratory rate
pain (4-6) medication to help control her sedation, respiratory depression and do not administer if
Q4h moderate pain level when it is a and bradycardia. below 10 respirations a
4-6 out of 10 on the pain scale. minute. Assess LOC
before administering
the medication. Also
assess pain level before
administering.
Oxycodone 10 mg PO PRN for The cleint has this pain Confusion, constipation, Assess respiratory rate
pain (7-10) medication to help control her sedation, respiratory depression and do not administer if
Q4h severe pain level when it is a 7- and bradycardia. below 10 respirations a
10 out of 10 on the pain scale. minute. Assess LOC
before administering
the medication. Also
assess pain level before
administering.
Morphine 4 mg IV push PRN Q4h The client is taking this Confusion, constipation, Assess respiratory rate
medication for breakthrough sedation, respiratory depression and do not administer if
pain to control the level of the and bradycardia. below 10 respirations a
client’s pain. minute. Assess LOC
before administering
the medication. Also
assess pain level before
administering.

10
Bisacodyl (Dulculax)
5 mg Oral Daily PRN This medication is taken when
the client is experiencing
constipation due to the pain
medication she is taking
Abdominal cramps, nausea,
diarrhea, and rectal burning.
Stop giving this
medication when the
client is experiencing
diarrhea. Assess for
bowel sounds and
abdominal distension.

Ondansetron (Zofran) 4 mg IV push PRN for Client was given this Headache, dizziness, Assess patient for
nausea and medication as a PRN constipation, abdominal pain, abdominal distension,
vomiting medication for Nausea/ dry mouth. n/v, and bowel sounds
Q6h vomiting. before administration.

Do not give if the

patient is not
experiencing n/v.
reassess to make sure
the medication has
worked and the patient
is no longer nauseous.

Nursing Diagnoses and Plan of Care

Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time-specific, Nursing or interprofessional Provide reason why intervention Was goal met? Revise the
reasonable, and attainable. interventions. is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Risk for peripheral neurovascular impairment related to multiple fractures.
This is the priority nursing diagnosis because we want to make sure this is prevented so that the patient can have a full recovery of both her legs.

Patient will maintain tissue
Client will maintain tissue perfusion by having palpable
perfusion. pulses, warm and dry skin, and
having normal sensation
1. Evaluate the presence of
quality peripheral pulses
four times a shift.
1. The presense of a
palpable or doppler
pulse indicated vascular
movement. If there is
1. Goal met. The nurse
assessed the patients
peripheral pulses
and found them
11

Secondary Nursing Diagnosis:
Acute pain related to bilateral femur and knee fractures as evidence by patient stating pain is eight out of ten on the pain scale.
This is secondary to the primary nursing diagnosis because pain is more uncomfortable for the patient but not potentially damage causing.
The client will have satisfactory
pain management.
throughout her stay in the
hosptial.
The client will verbalize pain
within her acceptable pain goal
of 3/10 by the end of shift.
2. Assess capillary refill in
the toes and surrouding
skin four times a shift.
3. Note edema or swelling
and if it becomes worse
or better every shift.
4. Instruct the patient to
inform the staff of pain
during passive movment
of the effected
extremities and if there is
tenderness with any
erythema (reddness).
(Phelps, Ralph, & Taylor, 2017).
1. Administer ordered pain
medication before pain reaches
its peak level. Use the pain
medication the client prefers.
an absence of the pulse palpable, four times
there can be vascular a shift.
injuries that need 2. Goal met. After
immediate medical assessing the
evaluation. peripheral pulses the
2. Brisk (< 3 secnds) nurse assessed
capillary refill indicated capillary refill four
proper oxygenation to times a shift to make
the limb. If there is a sure of adequate
increase in capillary oxygenation.
refill time there could 3. Goal met. The nurse
be vascular impairment. monitored for
3. An increase in edema increasing edema
can indicated the every shift.
presense of 4. Goal met. The
hemorrhage. patient informed the
4. Increased pain that is nurse of increase in
uncontrolled with the pain so that the
presense of tenderness nurse could assess
and redness can be a for life threatening
life threatening conditions.
condition, compartment
syndrome, that
necessary emergency
interventions.
(Phelps, Ralph, & Taylor, 2017).
1. By giving the prefered pain 1. Met. Patient is given
medication before the pain morphine because it does not
reaches its peak level will make her nauseous. Patient’s
maintain a lower pain level and pain medication was given
when she stated her pain was a
12
 2. Handle the lower extremities
carefully to decrease pain and
additional injury.
3. Return to patient in 30
minutes to check intervention
affectiveness.
(Phelps, Ralph, & Taylor,
2017).
Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socio-economic
status, cultural and spiritual preferences of the individual and focused on providing safe, evidence based care for the achievement of
quality client outcomes.”
keep it from becoming
unbearable for the patient.
2. Careful manipulation of the
right leg will prevent further
injury and pain. Leaving it in a
comfortable position will also
help the patient relax.
3. By returning to check if
interventions have been
affective will help build patient
trust and prevent the client
being in pain for prolonged
periods of pain.
(Phelps, Ralph, & Taylor,
2017).
6 out of 10 to prevent it from
getting worse.
2. Met. Pain was effectivey
controlled when manipulating
the lower extremities by leaving
it in the comfortable position.
3. Met. The nurse returned to
check on the patient 30 minutes
after administration of
interventions to make sure
patient’s pain remained low.
13
 Reference

Deglin, J., Vallerand, A., & Sanoski, C. (2015). Davis’s drug guide for nurses (15th ed.). Philadelphia, Penn.: F.A. Davis.

Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical surgical nursing (10th ed.). St. Louis, Missouri:

Elsevier.

Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks & Taylors nursing diagnosis reference manual (10th ed.) Philadelphia, PA: Wolters

Kluwer.

14