Nursing Care Plan CASE SCENARIO: Femoral Shaft

Nursing Care Plan CASE SCENARIO: Femoral Shaft fracture Patient Details: Name: Ahamd Mohammed Age/Gender: 20-year-old, male Nationality: Emirati MRN: 0024777 Date of Birth: 10/7/2001 Date and Time of Admission: 28/10/2021 at 01:00 AM. Diagnosis: Femoral shaft fracture Mr. Ahmad was brought via ambulance to ED after sustaining high-speed motorcycle injury. He was accompanied by his brother, who stated in anger,” he should not race again with his friends, I will crash his motorbike!” Mr. Ahmad was shouting in pain, looked very pale, sweating, stressed, and fatigued. When moving him from the ambulance stretcher to AE bed, he stated” I cannot stand with my right leg, I have stabbing pain in my right thigh”. Multiple wounds was noted on his face and both arms. Upon initial physical examination, bruise, swelling and redness were visible in his right thigh. His right leg looked shorter than the left leg. The skin in his middle thigh was cold and tender upon touch. His initial vital signs were BP: 135/ 90 mmHg. Pulse: 190 bpm, SPO2: 96% on room air, Pain score 8/10. During the vascular examination, he reported numbness in his right leg and showed an absence of distal pules and a lack of tissue perfusion. “He had no past medical history and no allegories to any medication or food, my father and mother are known case of hypertension, and Ahmad’s current height is 170 cm, and his weight is 60 Kg as we measured them yesterday in the GEM” as stated by his brother upon taking patient history AE physician ordered for immediate right leg X-ray, blood tests, keep patient NPO for potential urgent surgery, administer analgesics, and apply long leg cast. Medication: Morphine 10MG, IV, STAT and PRN every 12 hours Perfalgan I g , IV, three times a day Dextrose 5%, 500 ml , IV Diclofenac 75mg 25 , IM, three times a day Diagnostic tests: Complete blood count and kidney function test, RBCs= 6.7 M/µL, WBCs= 12 K/µL, Hgb= 9.1 g/dL, Platelet= 178 x103/L, Creatinine: 4 mg/dL, BUN: 29 mg/dL. Chest X-ray Findings: Comminuted femoral shaft fracture of the right leg 1. List 5 diagnoses from systematic analysis that incorporates complete diagnostic statements in PES (Problem Etiology and Signs / Symptoms) format. include: -Objectives/Plan -Intervention/s – Evaluation -Assessment data: include objective and subjective data 2. REFERENCES: Use a variety of resources, like textbook or websites for your reference. Minimum three resources should be used. Below is an example of one diagnosis already done based on the case: Assessment data: pain related to lack of tissue perfusion in the right thigh secondary to motorcycle . Subjective data: Objective data: your assessment vital sign : BP: 135\90 mmhg . P: 190 bpm . SPO2 : 96% room air . W : 60 kg . H : 170 cm . patient stated ” I can’t stand stand with my right leg ” . ” I have a stabbing pain in my right thigh ” . Scale pain 8\10 . Patient is “Shouting in pain “. Patient skin very pale , nervous . Multiple wounds in his face and both arms . Bruis , swelling and redness In the light leg . Right leg shorter than the left leg . Shouting in pain . The skin in his middle thigh is cold and tender upon touch . Nursing diagnosis 1 Pain related to lack of tissue perfusion in the right thigh , secondary to motorcycle accident manifested by shouting in pain and pain scale 8\10 . Objectives/Plan After 3,4 hours I will able to relieve the pain from 8\10 to 2\10 . Intervention/s Place the patient in a 30 degree position . Give medication to relieve the pain . Divertional : put Quran . Vital sign monitoring . Psychological therapy and relaxation techniques. Evaluation Goalmet : the patient said that the pain has relieved because og the medication , the pain reduced 2 to 3\10 . Assessment data: Subjective data: Objective data: your assessment vital sign : BP: 135\90 mmhg . P: 190 bpm . SPO2 : 96% room air . W : 60 kg . H : 170 cm . patient stated ” I can’t stand stand with my right leg ” . ” I have a stabbing pain in my right thigh ” . Scale pain 8\10 . Patient is “Shouting in pain “. Patient skin very pale , nervous . Multiple wounds in his face and both arms . Bruis , swelling and redness In the light leg . Right leg shorter than the left leg . Shouting in pain . The skin in his middle thigh is cold and tender upon touch . LourdesDensing 2 hours ago Missing information: reference Shei18 60 minutes ago Missing information: You 59 minutes ago Tornetta III, P., Kain, M. S. H., & Creevy, W. R. (2007). Diagnosis of femoral neck fractures in patients with a femoral shaft fracture: improvement with a standard protocol. JBJS, 89(1), 39-43. Flynn, J. M., & Schwend, R. M. (2004). Management of pediatric femoral shaft fractures. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 12(5), 347-359. Stans, A. A., Morrissy, R. T., & Renwick, S. E. (1999). Femoral shaft fracture treatment in patients age 6 to 16 years. Journal of Pediat You 57 minutes ago *- List 5 diagnoses from systematic analysis that incorporates complete diagnostic statements in PES (Problem Etiology and Signs / Symptoms) format. include: -Objectives/Plan -Intervention/s – Evaluation -Assessment data: include objective and subjective data SCIENCE HEALTH SCIENCE NURSING NURSING 1430

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