Nursing Process for an Orthopedic Patient

Abstract

A nursing care plan is a tool that the nursing team uses to communicate with each other regarding the treatment of the patient. It also promotes continuity of care as one of the patient’s rights in the Patient Rights Charter in South Africa. The purpose of this chapter is to look at the needs of an orthopedic patient and to create a nursing care plan. Once the problems of the patient have been identified, the expected outcome will be formulated and nursing interventions will be implemented. This will provide a framework on how the treatment plan of the patient should be structured. There are many academic books with standardized nursing care plans for surgical nursing. In orthopedic wards, even if two patients are admitted for the same orthopedic condition, their nursing care plan will not be the same. Their treatment should be individualized. There are many factors that will affect the nursing care plan of an individual patient such as age, if the patient has any comorbidities and the patient’s attitude towards rehabilitation and treatment.

1. Introduction

Nursing care plan is a written document that has information regarding the condition of the patient, nursing diagnoses, expected outcomes, as well as the nursing interventions [1, 2, 3]. There are five steps of nursing process that need to be followed before a nursing care plan is formulated, namely assessment, nursing diagnosis, outcomes, implementation and evaluation [4]. After emergency management and treatment of an orthopedic patient with fractures, the nursing management and treatment of the patient will be based on the individual problem or injury that is presented by the patient. As the Orthopedics Unit is a specialty unit, an individualized nursing care should be formulated instead of a standardized nursing care.

2. Assessment

Assessment is the first step in delivering nursing care. A nurse must collect and analyze data in a systematic manner. A health assessment is a term used to describe a process whereby a nurse identifies the needs of a patient by doing a comprehensive physical examination of the patient and obtaining the health history of the patient [5].

A brief history is essential in order to assess the mechanism of injury and to raise suspicion of other, less apparent injuries such as a pathological fracture where the skeletal system is weakened by a disease. If the violence has been minimal and hardly sufficient to have caused a fracture, then this may arouse a suspicion that the fractured bone has been weakened by a disease or previous damage, for example, a pathological fracture. The mechanism of injury and the mode of application are frequently important to determine additional injury. Taking the occupation of the patient into account is frequently helpful in planning rehabilitation and recuperative efforts once the fracture has been managed. Activity level before injury directs the type of treatment given for a specific injury. Deformity and swelling must be carefully evaluated physically so that complications can be avoided. It is vitally important that the neurovascular status of the extremity be carefully evaluated to avoid long-term or permanent damage to limbs. The neurovascular integrity of the extremity, or lack thereof; should be documented. Integrity of the skin should be monitored as well. Care must be taken to ensure that there is no breakdown of the skin in the area of the fracture site.

There are four types of health assessments that are done in the health care setting, which are further discussed in the following sections:

2.1 Initial assessment or head-to-toe assessment

Initial assessment is done by a nurse who is admitting the patient. This nurse must obtain biographical information about the patient and also details of past medical history, surgical history as well as social history [6]. The reason for this is to make a correct diagnosis when diagnosing an orthopedic patient because most orthopedics conditions are specific to certain demographics; for example, rickets (vitamin D deficiency), sickle cell disease, and slipped capital femoral epiphysis are all pediatric conditions which means they are age specific and multiple myeloma affects people who are much older. Race and ethnicity also play a role in certain musculoskeletal conditions. Asian women, as well as women who are menopausing, are more likely to be diagnosed with osteoporosis. Finding out whether a patient smokes or not will affect the patient’s diagnosis because smoking delays fracture healing [6] and affects the patient’s response to analgesics.

2.2 Focused assessment

Focused assessment is a close examination of a disease. In nursing, the focused assessment is involved in relieving pain and stabilizing the condition of the patient, especially when the medical diagnosis is fully understood. Focused assessment also helps the nurse to identify a problem in a patient in order to formulate a specific plan related to the main problem that she is focusing on. A patient who is diagnosed with a tibia fracture might complain of shortness of breath and chest pains. The nurse will then focus on monitoring the vital signs of the patient, checking neurovascular compromise, and monitoring that patient for fat embolism syndrome [6].

2.3 Emergency assessment

During admission, a patient may have low hemoglobin, that is a hemoglobin of less than 8 g/dl. That patient may need a blood transfusion that will be prescribed by an orthopedic surgeon and administered by a professional nurse. This forms part of emergency assessment. Also, a patient with low peripheral saturation, which is SATS of below 94% on room air or an unresponsive orthopedic patient, will also need emergency attention. Patients might need emergency resuscitation for a number of reasons. It might be pulmonary embolus or fat embolus (life-threatening conditions). Different health care workers, for example, orthopedic surgeons, nephrologists, cardiologists and nurse professionals, will perform different emergency assessments until the patient is stabilized [6].

2.4 On-going or time-lapsed assessment

Nurses take care of the patients for a longer period based on the initial diagnosis or problem that patients presented with on admission. In this assessment, the patient is constantly evaluated monitoring his or her progress and response to treatment. Patient progress or lack thereof will be noted on the patient’s file through a document called nursing progress chart. A care plan will be formulated using the needs and problems that the patient will be presenting during their hospital stay. This can last for months.

The nurse personnel will need to continuously gather and interpret information from the patient in order to meet the needs of the patient and act accordingly [6].

3. Diagnosis

The nurse will use her knowledge, skills and experience to diagnose a patient [1]. The diagnoses may also reflect the causes of the illness that the patient would be presenting with at an orthopedic ward. A patient, for example; might complain of falling and sustaining a fracture of a neck or femur. If the patient has a history of prostate cancer, the nurse will make an initial diagnosis of a pathological fracture (when a bone has been weakened by a disease), and the plan of treatment will differ from someone presenting with a fracture after falling without any prior medical history.

4. Planning

Planning is a process whereby the goals and outcomes are formulated to impact patient care. These goals should bring a positive outcome in the life and well-being of the patient. A care plan should be unique to an individual patient. No two care plans should look the same even if the patients present with a similar condition.

Outcome statements should contain five components that are easily remembered using the SMART mnemonic (Table 1) [7].

Specific	Outcome statement should state precisely what it is to be accomplished. They must not be ambiguous.
Measurable/meaningful	Measurable outcomes have numeric parameters for judging whether the outcome was met, for example, administer, identify, verbalize and have absence of.
Attainable/action-oriented	Outcome statement should be written so that there is a clear action to be taken by the patient. They must also be possible to achieve.
Results-oriented/realistic	Realistic outcomes consider the patient's physical and mental condition, their cultural and spiritual values, beliefs and preferences. They should be within reach. They should be achievable with available resources for the patient, nursing staff and the health care setting.
Timely	Outcomes statements should include the time frame for evaluation, for example, within 24 hours, by discharge, and throughout hospitalization. There should be a starting date and end date for outcomes.

Table 1.

SMART mnemonic.

5. Implementation

Implementation means actually doing what, as a nurse, you have outlined and set out to do in your nursing care plan [8]. This is a nursing intervention stage. This is where a nurse administers analgesics, elevates the affected limb, collaborates with a physical therapist to mobilize the patient from bed to chair, etc.

6. Evaluation

This is the final stage of the nursing process [8]. If a nurse has provided an intervention to the patient, they must come back and evaluate if it did bring a positive outcome to the patient. For example, did elevating the affected limb reduce swelling? The nursing care plan may be changed depending on the evaluated condition of the patient.

7. Fractures

7.1 Definition

A fracture is a break in the continuity of the cortical and/or cancellous bone.

7.2 Causes

1. Physical trauma e.g. motor vehicle accident, falling from height

2. Overuse e.g. sport injuries

3. Health condition e.g. metastatic bone disease

7.3 Types of fractures

1. Closed fracture

2. Open fracture

3. Greenstick fracture

4. Hairline fracture

5. Avulsion

6. Compression fracture

Some fractures are classified by their pattern, for example, oblique fracture, transverse fracture and longitudinal fracture, and others are diagnosed by their pattern of not breaking the bone in a straight line such as greenstick fractures, segmental fractures, spiral fractures and comminuted fractures [9].

7.4 Signs and symptoms of fractures

A sign is an objective, observable phenomenon that can be identified by another person, in this case, a nurse. A symptom is an effect noticed and experienced only by the person who has the condition, and this is where, as a nurse, you will get your subjective data. Subjective data is largely reported by the patient.

7.4.1 Altered comfort

Patient will complain of pain on the fractured site. Depending on the time of presentation at the clinic, the level of pain will range from moderate to severe. The patients’ response to pain is not the same. There are many factors that affect the patient’s response to pain such as language barrier and analgesic that a patient has taken, for example, Grand Pa headache powder (which is not recommended by any South African government hospital due to its side effects on the gastrointestinal tract), cultural belief or anxiety and expectations of patient regarding pain.

7.4.2 Inability to use the limb

Postinjury, the patient may or may not be able to move the limb or put weight on the limb.

7.4.3 Diminished sensation

Numbness or tingling sensation can be experienced by the patient in the affected area. This could be due to a nerve injury.

7.4.4 Altered normal limb alignment

Postinjury, the bone may position incorrectly, causing poor alignment. Bones may be angulated (bent), rotated (twisted), translated or displaced, which may be described as a position shift or limb length discrepancy (LLD or difference in length of the bone).

7.4.5 Edema

A fracture will cause swelling. There is an increased flow of blood to a fractured area, which causes more fluid to pass through the affected area. The soft tissues will subsequently be inflamed.

7.4.6 Increased warmth

Not all fractures will lead to infection, but if increased warmth is noted on the affected limb, this may be a sign of infection, especially on compound fractures.

7.4.7 Crepitus

This is a grating sound that can occur when two bone ends or fragments move or rub against each other.

7.4.8 Ecchymosis

Bruising will be caused by leaking blood vessels underneath the skin of the affected limb. The color may be brown, black or blue [9].

8. Complications of fractures

1. Fat embolism

2. Vascular injuries

3. Nerve damage

4. Pulmonary embolism

5. Thromboembolism

6. Compartment syndrome

7. Infection

8. Shock

9. Reaction to internal fixation devices

10. Limb length discrepancy

11. Osteonecrosis

12. Reflex sympathetic dystrophy

13. Non-union, mal-union and delayed union

14. Amputation [9].

9. Nursing priorities for patients with fractures

1. Patient should be pain-free.

2. Fracture should be immobilized with a splint or traction.

3. Prevent and control infection in case of an open fracture.

4. Provision of adequate nutrition especially high protein diet for wound and bone healing.

5. Allay fear and anxiety.

6. Give health education on exercising and prevention of falls and refracture.

10. General principles of nursing care

1. Body parts must be in alignment.

2. Prevent foot drop.

3. Logrolling body is moved as one unit using two or more individuals, aligning with pillows, blankets, etc.

4. Circulatory/neurovascular checks “The 6P’s.”

   • Pulselessness

   • Pallor

   • Pain

   • Paresthesia

   • Paralysis

   • Poikilothermia

11. Discharge goals

1. Patient should be able to administer medication, that is, analgesics as well as anticoagulants, on their own

2. Patient should be able to perform activities of daily living

3. Patient should be able to take the prescribed diet

4. Patient should be able to come for wound review and/or follow-up X-rays

12. Nursing diagnosis

The nursing diagnoses should include pain management, risk of infection and mobility problems. These nursing diagnoses provide a guide for developing and implementing individual nursing interventions that aim to optim ize patient care (Table 2).

Acute pain related to: Trauma Muscle spasms Movement of bone fragments Soft tissue damage Inflammation and swelling As evidenced by: Guarding behavior Verbalization or reports of pain Antalgic positioning to avoid pain Facial grimacing Restlessness

Table 2.

Common nursing diagnoses associated with fractures.

12.1 Acute pain

12.2 Impaired physical mobility

Impaired physical mobility can be temporary (fractured tibia/fibula), permanent (spinal cord injury) or worsening (multiple myeloma) (Table 3).

Impaired physical mobility may be caused by, that is, “related to”: Loss of integrity of the bone Neuromuscular impairment Pain Reluctance to initiate movement Prescribed restrictions or immobilizers etc. Looking back at the signs and symptoms of fractures is where a nurse will obtain the “as evidenced by”: Verbalization of pain and discomfort with mobilizing Refusal to mobilize Limited range of motion Uncoordinated movements Contractures of limbs

Table 3.

Common nursing diagnoses associated with fractures.

13. Other common nursing diagnoses for fractures

1. Anxiety

2. Impaired skin integrity

3. Risk for infection

4. Risk for compartment syndrome

5. Risk for hypovolemic shock/risk for deficient fluid volume

6. Self-care deficit

7. Ineffective coping

8. Ineffective peripheral tissue perfusion

9. Risk for injury

10. Risk for additional trauma

11. Risk for disuse syndrome

12. Knowledge deficit

14. Desired/expected outcomes

1. Expected outcomes for acute pain in a patient with a fracture

2. The patient will show an increased comfort level

3. The patient will verbalize non-pharmacological strategies to relieve pain

4. Patient will reach a tolerable pain level maximum 2 on a scale of 1–10 within 48 hours after receiving pain medication

5. Patient will verbalize relief of pain

6. Patient will display a relaxed manner, able to participate in activities and sleep and rest appropriately

15. Nursing interventions

15.1 Nursing intervention categories

15.1.1 Independent

These are nursing tasks that requires only one nurse who independently provides the treatment intervention without assistance from other staff members. An example is of this is a nurse administering medication to a patient [10].

15.1.2 Dependent

These are nursing tasks that require a direct order or permission from a doctor such as prescribing medication, Plaster of Paris, and urinary catheter as well as providing negative pressure wound therapy [10].

15.1.3 Interdependent or collaborative

These tasks require the medical team to care for a patient and depend on orders from physicians and Orthopedics trained nursing practitioners. For example, in a patient with a neck or femur fracture whereby a doctor will prescribe medication, the nurse will administer it and apply skin weight traction, and a physical therapist helps with rehabilitation of the patient [10].

15.2 Types of nursing interventions

15.2.1 Health promotion

Nurses can provide health education to quit smoking as it delays fracture healing and to eat a healthy diet and exercise healing to promote wound healing. Patient can also be advised to reduce alcohol intake and to avoid mixing prescribed medication together with traditional medicine from inyanga or isangoma [10].

15.2.2 Disease prevention

Disease prevention aims at reducing the risk of developing specific illnesses and diseases. If you work on a computer, take breaks to avoid conditions like carpal tunnel syndrome [10].

15.2.3 Treatment

Treatment aims to manage and treat existing health problems. The most common treatment nurses provide is pain control. Nurses administer analgesics and anti-hypertensives, reposition patients four hourly, provide ice packs for edematous limbs and joints, and elevate injured extremities [10].

15.2.4 Rehabilitation

Assisting the patient to mobilize from bed to chair after surgery such as ORIF (open reduction and internal fixation) of the tibia or fibula is part of rehabilitation for the patient (Table 4) [10].

Acute pain; Smile at the patient to make the environment as comfortable as possible. Explain procedure to the patient to allay any anxiety. Provide calm, quiet environment. Promotes effects of analgesics and to decrease any form of stimuli. Monitor pain intensity every 2 hours. Utilize appropriate method of assessment (e.g., numeric pain scales (0–10), behavior assessment). Pain is subjective in nature, and only the patient can fully describe it. Evaluate and document reports of pain or discomfort, noting location and characteristics, including intensity. Consider non-pharmacological treatment (RICE therapy), for example, ice packs to reduce swelling. Produce immobilization of affected limb by bedrest, back slab, POP and traction. This relieves pain and prevents further tissue injury. Elevate affected extremity above heart level. This promotes venous return, decreases swelling and reduces pain. Avoid the use of plastic linen savers and pillows under the limb in cast. It increases pain by enhancing heat in the drying cement. Elevate bed linen and keep it away from patient’s toes using a bed cradle. This helps with keeping the limb warm without causing more pain to the patient with the heaviness of bed linen. Reposition the limb. Maintain alignment with pillows or a folded blanket. This helps stimulate blood circulation. Administer pain medication as prescribed. Response to pain and pain medication differs from patient to patient. Monitor vital signs at least every 4 hours while awake. Detects early changes.

Impaired physical mobility; Assess degree of immobility produced by the fracture. Patient may be restricted by self-perception disproportionate to the physical limitations. Educate the patient regarding proper use of assistive devices. Maintains muscle tone and prevents complications of immobility. Provide progressive mobilization as tolerated. Schedule increased mobilization on a daily basis. Medicate for pain as needed, especially before activity. Pain interferes with ability to ambulate by inhibiting muscle movement. Perform ROM exercises (passive, active, and functional) of affected and unaffected extremities every 2 hours. Increases circulation, maintains muscle tone and prevents joint contractures. Implement measures to prevent falls, such as keeping bed in low position, wearing appropriately fitting shoes or non-skid slippers. Basic safety measures. A patient on traction to stabilize the fracture should be placed on a supine position. It reduces the risk of flexion contracture on the hip. Maintain adequate nutrition with the assistance of a dietician. Provides nutrients for energy and prevents protein loss due to immobility. Observe for complications of immobility (e.g., constipation, muscle atrophy, pressure injuries and orthostatic hypotension). Allows early detection and prevention of complications. Assist and encourage the patient with self-care activities such as bathing. Improves muscle strength and circulation. Encourage diversional and recreational activities such as reading newspapers, watching TV, personal possessions (smartphones with social media such as Facebook, X, Instagram and TikTok), and family visits. Provides opportunity to focus patient’s attention elsewhere and enhance patient’s sense of self control. Include the patient and family or significant other in carrying out plan of care. Allows time for practice under supervision. Increases likelihood of effective management of therapeutic regimen. Assist with mobility with crutches, wheelchair, walking frame and initiate physical therapy and/or occupational therapy as soon as possible. Reduces complications of bedrest.

Table 4.

Nursing interventions [11].

16. Rationale

In most cases, nurses are not required to write rationale in the nursing care plan. The rationales for interventions mentioned above have been highlighted in italics. Rationale is statement that explains why a certain intervention was done. A nurse must use her critical thinking skills to explain the rationale; for example, elevate the lower limb of a patient with a cushion to reduce swelling. Rationales are specific to the individual patients. It happens that sometimes a patient will not exhibit any swelling before an operation, but the swelling will be noticed operatively, so the nursing care plan of that patient will change, and the reason for elevation will be stated under rationale. Also, repositioning the patient four hours a day can be used as an example. The rationale would be to promote circulation, prevent pressure injuries, which are one of the complications of fractures, and to prevent respiratory problems such as pneumonia (Table 5).

Evaluation

Acute pain; Patient verbalizes relief of pain. Patient follows prescribed pharmacological regimen. Patient displays relaxed manner, is able to participate in activities and sleeps appropriately. Demonstrates use of relaxation exercises. Impaired physical mobility; Patient’s mobility will be improved Pain and discomfort decreased Independence restored Physical mobility will be stabilized Patient satisfaction

Table 5.

Evaluation of acute pain and impaired physical mobility.

17. Health education

Preserving skeletal health may involve:

1. Avoiding falls

2. Taking calcium supplements

3. Getting enough vitamin D

4. Avoiding carbonated beverages (phosphates deplete bone)

5. Getting regular exercise.

18. Examples of nursing care plan in an orthopedics setting

18.1 Clinical nursing document progress report-nursing care plan: A patient with multiple myeloma

No*	Need list
1	Comfort	5
2	Mobility	6
3		7
4		8
When admitting a patient ensure the Nursing Care Plan is done……; The needs and/or the problems that are identified above are clearly described in the diagnosis and prioritized; Clear expected outcomes are written; Nursing interventions are clear; The patient’s reactions to interventions are evaluated and documented on the CMJAH1114/6			Use the same need names/numbers initially allocated on the needs list; Delete solved needs by crossing out their numbers alongside; Do not re-use deleted numbers, unless a solved need is re-activated; Nursing Care Plan should be done on admission, when patients condition changes and as the needs arise.
Nursing diagnosis	Expected outcome		Nursing intervention
Self-care deficit evidenced by patient being fully dependent on nursing staff	Patient will improve participation in activities of daily living by the end of this week		Encourage patient to perform as much self-care as condition allows; Assist patient with tasks that a patient cannot perform; Assist patient in becoming independent and functioning
Impaired physical mobility related to pain evidenced by patient being unable to walk unaided	Patient will increase physical mobility and demonstrate safe use of assistive devices a day after starting physical therapy		Mobilize the joint above and joint below the wound gently; Promote daily physical therapy program by collaborating with physical therapist; Do passive exercises
Risk for infection related to impaired immune system functioning	Patient will obtain negative results from cultured specimen; Patient will exhibit absence of fever and chills throughout admission		Implement measures to reduce the risk of infection such as maintaining hand-washing techniques when handling the patient; Adhere to universal precautions; Maintain adequate fluid intake; Avoid invasive procedures such as catheterization
Risk for bleeding related to excessive losses through normal routes	Patient will take measures to prevent bleeding and will recognize signs of bleeding; Patient will not experience bleeding as evidenced by normal pressure, normal hemoglobin levels and desired coagulation profile during hospitalization		Monitor patient’s vital signs; Look for signs of orthostatic hypotension; Check stools and urine for occult blood; Assess skin and mucous membrane for signs of petechiae, bruising hematoma formation or oozing of blood; Monitor hematocrit and hemoglobin; Educate patient about precautionary measures to prevent tissue trauma or disruption of normal clotting mechanisms; Use soft brittle toothbrush and non-abrasive toothpaste; avoid use of toothpicks and dental floss; Avoid rectal suppositories, rectal thermometers, enemas and tampons; Limit straining with bowel movements, forceful nose-blowing; Monitor for skin necrosis
DATE: 2023/03/19 TIME: 13 h 05 NAME: P.B.S Mbatha SIGNATURE: RANK: Professional Nurse Specialty( Orthopaedics)

Name of Patient:……………………Hospital/Reg no:……………………

Ward:……………………Doctor:……………………Page: 01

Diagnosis: Multiple Myeloma

18.2 Clinical nursing document progress report-nursing care plan: A patient with right subtrochanteric fracture and right fibula fracture

No*	Need list
1	Comfort	5
2	Mobility	6
3		7
4		8
When admitting a patient ensure the nursing care plan is done……; The needs and/or the problems that are identified above are clearly described in the diagnosis and prioritized; Clear expected outcomes are written; Nursing interventions are clear; The patient’s reactions to interventions are evaluated and documented on the CMJAH1114/6			Use the same need names/numbers initially allocated on the needs list; Delete solved needs by crossing out their numbers alongside; Do not re-use deleted numbers, unless a solved need is re-activated; Nursing Care Plan should be done on admission, when patients condition changes and as the needs arise.
Nursing diagnosis	Expected outcome		Nursing intervention
Risk for infection evidenced by elevated temperature	Patient will show absence of infection during admission; Patient will report absence of drainage from the wound pre-and post-operatively; Patient will report normal temperature and exhibit no swelling during admission		Use strict aseptic technique when changing the dressings; Provide thorough skin care; Administer antipyretic as prescribed by collaborating with Medical team; Monitor patient’s response to antipyretic
Altered comfort related to inflammation and swelling evidenced by blisters on the fracture site	Reports no discomfort with movement 30 minutes post administration of analgesic; Patient will verbalize his pain; as less than 7/10 during; therapy by the end of this week		Elevate the affected area to reduce swelling and discomfort; Collaborate with medical team to administer analgesic; Monitor neurovascular status four hourly
DATE: 2024/01/02 TIME: 13 h 05 NAME: P.B.S Mbatha SIGNATURE: RANK: Professional Nurse Specialty-Orthopedics

Name of Patient:……………………Hospital/Reg no:……………………

Ward:……………………Doctor:……………………Page: 01

Diagnosis: Right subtrochanteric fracture and right fibula fracture

18.3 Clinical nursing document progress report-nursing care plan: A patient with right neck of fracture and open fracture left tibia postexternal fixation

No*	Need list
1	Comfort	5	Skin integrity
2	Mobility	6	Rest and Sleep
3	Nutrition	7	Psychosocial needs
4	Elimination	8	Safety
When admitting a patient ensure the nursing care plan is done……; The needs and/or the problems that are identified above are clearly described in the diagnosis and prioritized; Clear expected outcomes are written; Nursing interventions are clear; The patient’s reactions to interventions are evaluated and documented on the CMJAH1114/6			Use the same need names/numbers initially allocated on the needs list; Delete solved needs by crossing out their numbers alongside; Do not re-use deleted numbers, unless a solved need is re-activated; Nursing Care Plan should be done on admission, when patients condition changes and as the needs arise.
Nursing diagnosis	Expected outcome		Nursing intervention
Risk for movement of bone fragments and additional trauma related to loss of skeletal integrity	Patient will maintain stabilization and alignment of fractures while on traction		Maintain bedrest or limb rest as indicated. Provide support for joints above and below fracture site, especially when moving and turning; Support fracture site with pillows or folded blankets. Maintain neutral position of affected part with sandbags, splints, trochanter roll or footboard; Evaluate splinted extremity for edema resolution.; Maintain position and integrity of traction; Assess integrity of external fixation device; Position client so that appropriate pull is maintained on the long axis of the bone; Review follow-up or control x-rays.; Initiate and maintain bone rehabilitation that is, early ambulation
Acute pain related to; muscle spasms evidenced by protective behavior	Patient will verbalize relief of pain 30 minutes postadministration of analgesics; Patient will display a relaxed manner, will be able to participate in activities, and sleep and rest appropriately by the end of the week		Maintain immobilization of affected part by means of bedrest, cast, splint and traction.; Elevate and support injured extremity.; Evaluate and document reports of pain or discomfort, noting location and characteristics, including intensity (scale of 0–10), relieving and aggravating factors; Encourage patient to discuss problems related to injury.; Explain procedures before beginning them.; Administer medication before care activities. Let the patient know it is important to request medication before pain becomes severe.; Perform and supervise passive or active ROM exercises.
Knowledge deficit related to new diagnosis	The patient will verbalize an understanding of the disease process within a day of receiving Health Education		Identify the patient’s best methods for learning.; Initiate teaching when patient is most amenable to receiving information; Provide relevant information only.; Provide an environment conducive to learning.; Explain each procedure as it is being done, and give the rationale for procedure and the patient’s role.; Provide the patient with enough opportunity to ask questions, for example; Teach about the importance of taking antibiotics as prescribed; Educate about signs and symptoms of neurovascular compromise; Educate about principles of infection control and wound care
Anxiety threat or change in role status and health status	Patient will demonstrate absence of physiological signs and; symptoms of anxiety after explanation by nursing personnel		Give the patient an opportunity to verbalize perception of situation that is causing anxiety.; Explain all procedures and rationales for the procedure in clear, concise, simple terms.
Risk for all problems associated with bed rest: pressure ulcers, pneumonia, constipation, urinary stasis, DVT	Patient will not experience any orthopedic complications throughout admission		Do four hourly neurovascular checks; Maintain body alignment; Instruct patient on what to report, for example, pain that is disproportionate to injury; Check weights and pulleys; Provide adequate time and privacy during elimination; Encourage patient to eat all prescribed diet
DATE: TIME: NAME: P.B.S Mbatha SIGNATURE: RANK: Professional Nurse Specialty-Orthopedics

Name of Patient: Hospital/Reg no: Ward: Doctor: Page: 01

Diagnosis: Right neck of femur fracture and open fracture left tibia postexternal fixation.

18.4 Clinical nursing document progress report-nursing care plan: A patient with a spinal cord injury

No*	Need list
1	Comfort	5	Elimination
2	Mobility	6	Skin Integrity
3	Hygiene	7	Psychosocial
4	Nutrition	8	Rest
When admitting a patient ensure the nursing care plan is done……; The needs and/or the problems that are identified above are clearly described in the diagnosis and prioritized; Clear expected outcomes are written; Nursing interventions are clear; The patient’s reactions to interventions are evaluated and documented on the CMJAH1114/6			Use the same need names/numbers initially allocated on the needs list; Delete solved needs by crossing out their numbers alongside; Do not re-use deleted numbers, unless a solved need is re-activated; Nursing Care Plan should be done on admission, when patients condition changes and as the needs arise.
Nursing diagnosis	Expected outcome		Nursing intervention
Disturbed sensory perception related to psychological stress evidenced by motor incoordination	Patient will recognize sensory impairments and identify behaviors to compensate for deficits by the end of the week		Assess and document sensory function or deficit, progressing from area of deficit to neurologically intact area; Protect from bodily harm; Assist patient to recognize and compensate for alterations in sensation; Explain procedures before and during care, identifying the body part involved; Provide tactile stimulation, touching patient in intact sensory areas; Position patient to see surroundings and activities; Provide uninterrupted sleep and rest periods; Note presence of exaggerated emotional responses
Altered comfort related to physical injury evidenced by burning pain below level of injury	Will report relief or control of pain 30 minutes postadministration of analgesics		Assess for presence of pain.; Help patient to identify and quantify pain; Evaluate increased irritability, muscle tension, restlessness, unexplained vital sign changes; Assist in identifying precipitating factors; Provide comfort measures, for example, warm or cold packs; Encourage use of relaxation techniques; Administer medication as indicated by collaborating with a Medical team
Risk for grief related to loss of feelings of inadequacy	Patient will begin to process through recognized stages of grief, focusing on 1 day at a time and identifying ways to appropriately cope with grief		Identify signs of grieving; Note lack of communication or emotional response, absence of questions; Provide simple, accurate information to patient; Do not give false reassurance while providing emotional support; Encourage expression of feelings; Encourage expression of sadness, grief, guilt and fear assist patient in verbalizing feelings about situation, avoiding judgment about what is expressed; Note comments indicating that the patient is expecting to walk shortly and is bargaining with God; Focus on present needs, for example, ROM, exercises and skin care; Identify the use of manipulative behavior and reactions to caregivers; Encourage the patient to take control when possible; Accept expressions of anger and hopelessness; Set limits on unacceptable behavior when necessary, for example, abusive language; Note loss of interest in living, sleep disturbance and suicidal thoughts; Arrange visit by individual similarly affected as appropriate; Consult with or refer to psychiatric/mental health nurse, social worker, psychologist and psychiatrist
Ineffective breathing pattern evidenced by use of accessory muscles to breathe	Patient will maintain adequate ventilation and demonstrate appropriate behavior to support respiratory effort; Patient will demonstrate an effective breathing pattern as evidenced by normal; breath sounds and normal arterial blood gases		Assess respiratory function by asking the patient to do deep breathing exercises; Note the presence and absence of spontaneous effort and quality of respirations; Auscultate breath sounds; Note strength and effectiveness of cough; Observe skin color for cyanosis; Assess for abdominal distension and muscle spasm; Maintain patent airway by keeping the head in neutral position; Suction as necessary; Administer oxygen therapy; Assist with the use of respiratory adjuncts and aggressive chest percussions in collaboration with physiotherapist
Risk for Impaired Skin Integrity related to altered metabolic state	Patient will participate to level of ability to prevent skin breakdown by the end of this week		Inspect all skin areas, noting capillary blanching and refill, redness, swelling; Encourage continuation of regular exercise program; Avoid and limit injection of medication below the level of injury; Massage and lubricate skin with lotion, for example, Zinc and castor oil ointment; Reposition frequently; Wash and dry skin, especially in high-moisture areas; Keep linen dry and free of wrinkles and crumbs
Risk for Autonomic Dysreflexia related to Spinal cord injury at T7 or above	Patient will cooperate with the care plan to prevent development of dysreflexia and will also be able to recognize triggers of dysreflexia by the end of the week		Identify and monitor precipitating risk factors; Observe signs and symptoms of syndrome such as changes in vital signs and paroxysmal hypertension, tachycardia and bradycardia; Stay with patient during episode; Monitor BP frequently; Elevate head of the bed; Eliminate causative stimulus as such as bladder distention; Inform patient of warning signs and how to avoid them; Perform ROM (active or passive) every 4 hours; Keep the patient warm; Monitor intake and output; Provide appropriate skin care
Impaired urinary elimination related to disruption in bladder innervation evidenced by bladder distension, incontinence and overflow	Patient will verbalize understanding of condition and maintain balanced intake and output with clear odor-free urine by the end of today		Assess voiding pattern; Compare fluid intake with urine output; Palpate for bladder distension and observe for overflow; Encourage 2 liters of fluid intake daily; Begin bladder retraining as per ward protocol when appropriate; Observe for cloudy or bloody urine and foul odor; Cleanse perineal area and keep dry; Refer for further evaluation of the bladder; Keep the bladder deflated by means of indwelling catheter initially.; Begin intermittent catheterization program when appropriate; Measure residual urine
Constipation related to disturbance of innervation to bowel and rectum evidenced by loss of ability to evacuate bowel voluntarily	Patient will re-establish satisfactory bowel elimination pattern in 24 hours		Auscultate bowel sounds, noting location and characteristics; Observe abdominal distension if bowel sounds are decreased or absent; Note reports of nausea, the onset of vomiting; Record frequency, characteristics and amount of stool; Check for the presence of impaction; Establish regular daily bowel program; Encourage a well-balanced diet that includes bulk and roughage and increased fluid intake; Assist and encourage exercise and activity within individual ability; Observe incontinence and help patient relate incontinence change in diet or routine; Restrict intake of caffeine; Provide skin care; Collaborate with dietician and nutritional team
Situational low self-esteem related to situational crisis evidenced by fear of rejection and negative feelings about the body	Patient will verbalize acceptance of self in situation		Acknowledge difficulty in determining degree of functional incapacity and a chance of functional improvement; Listen to patient’s comments and responses to situation; Assess dynamics of patient; Encourage family to treat patient as normally as possible; Provide accurate information; Discuss the meaning of loss or change with patient; Accept patient, show concern for individual as a person; Give positive reinforcements; Include patient in care, allow patient to make decisions and participate in self-care activities as possible; Be alert to sexually oriented jokes, flirting or aggressive behavior; Be aware of own feelings and reaction to patient’s sexual anxiety; Refer for counseling
Risk for trauma evidenced by instability of spinal column	Patient will maintain proper alignment of the spine without further damage to spinal cord		Maintain bed rest and immobilization devices such as sandbags, traction, halo, hard and soft cervical collar and braces; Check external stabilization device, for example, skeletal traction apparatus; Elevate head of the bed as indicated; Check weights for ordered traction; Reposition at intervals using for turning and support
Impaired physical mobility related to neuromuscular impairment evidenced by inability to purposefully move	Patient will increase the strength of unaffected body parts by the end of the week		Continually assess motor function by requesting patient to perform certain actions such as shrugging shoulders, spreading fingers, squeezing and releasing examiner’s hands; Provide means to summon help (Bell system); Perform and assist with full ROM exercises on all extremities and joint, using slow, smooth movements; Maintain ankles at 90 degrees with footboard; Elevate lower extremities at intervals when in chair; Assess for edema of feet and ankles; Plan activities to provide uninterrupted rest periods; Monitor BP before and after activity; Change position slowly; Prepare for weight-bearing activities like the use of tilt table for upright position; Encourage use of relaxation techniques; Inspect skin daily and provide skin care.; Assist and encourage pulmonary hygiene like deep breathing, coughing and suctioning; Assess for swelling, redness and muscle tension in the calf; Investigate sudden onset of dyspnea and cyanosis and other signs of respiratory distress; Collaborate with physiotherapist and occupational therapist; Administer muscle relaxants and anti-spasticity agents as indicated.

Name of Patient:.........Hospital/Reg no:.........Ward:....Doctor:................Page: 01

Diagnosis: Spinal Cord Injury

19. Conclusion

All nursing programs teach the basics of nursing care plan. This promotes effective communication within the nursing team and improves patient care. Nursing care plan needs practice. It is not something that one can learn once and be perfect on formulating it. It should be concise but realistic, correlate with the patient’s condition, and vary from time to time depending on the condition of the patient. As part of patient’s records, continuity of care is maintained with a nursing care plan.

Acknowledgments

The author would like to express her gratitude to all the orthopedic surgeons at the Charlotte Maxeke Johannesburg Academic Hospital for their support to the orthopedics nursing team.

Conflict of interest

The author declares no conflict of interest.