Nursing Care Plan on Fractures

Fractures are broken bones. Fractures can occur from trauma such as motor vehicle accidents, age-related conditions like osteoporosis, or from overuse such as stress fractures in athletes. 

There are also different kinds of fractures. Here are some examples: 

• Open (compound) fracture. Bone has broken through the skin. 
• Closed fracture. The bone does not puncture through the skin. 
• Greenstick fracture. Frequently seen in children when the bone has bent but does not break. 
• Comminuted fracture. The bone is shattered in multiple places. 

Nursing Process

Nurses may care for patients with fractures in many settings such as emergency departments, urgent care centers, or inpatient units following surgical repairs. Fractures can be minor such as a broken toe only requiring splinting or major such as a hip, neck, or femur fracture requiring surgery, inpatient care, and months of recovery. Nurses assist with pain control, overcoming activity limitations, preventing further complications, and discharge planning.

Nursing Assessment

Nursing assessment for fractures focuses on identifying the type and severity of the injury, evaluating complications, and planning effective care. Here are the key components:

1. Health History Review

• Assess the mechanism of injury (e.g., fall, trauma, or accident).
• Identify any pre-existing conditions like osteoporosis or bone disorders.
• Review the patient’s pain history, including onset, location, and intensity.

2. Physical Examination

• Observe for visible deformities, swelling, or bruising at the fracture site.
• Assess for pain or tenderness that worsens with movement or pressure.
• Check for loss of function or limited range of motion in the affected area.
• Evaluate for numbness or tingling, which may indicate nerve involvement.

3. Circulatory and Neurological Assessment

• Monitor for signs of impaired circulation, such as pale or cool skin, weak pulses, or delayed capillary refill.
• Perform a neurovascular check to assess sensation and motor function.

4. Diagnostic Procedures

• Review X-rays or imaging studies to confirm the type and location of the fracture.
• Conduct blood tests if needed to evaluate for infection or other complications.

Nursing Interventions

Nursing interventions for fractures focus on managing pain, promoting healing, and preventing complications. Here are some key interventions:

1. Pain Management

• Administer prescribed analgesics such as NSAIDs or opioids to alleviate pain.
• Use cold compresses to reduce swelling and discomfort.
• Encourage positioning and elevation of the affected limb to minimize edema.

2. Immobilization and Alignment

• Apply splints, casts, or traction to stabilize the fracture and promote proper alignment.
• Monitor for signs of compartment syndrome, such as increased pain or swelling.
• Educate patients on avoiding pressure on the immobilized area.

3. Infection Prevention

• Clean and dress any open wounds to prevent infection.
• Monitor for signs of infection, such as redness, warmth, or discharge.
• Administer antibiotics if prescribed for open fractures.

4. Nutritional Support

• Encourage a diet rich in calcium and vitamin D to support bone healing.
• Promote hydration to maintain overall health.
• Address any nutritional deficiencies that may delay recovery.

5. Mobility and Rehabilitation

• Assist with physical therapy to restore strength and range of motion.
• Encourage early ambulation as appropriate to prevent complications like blood clots.
• Provide mobility aids such as crutches or walkers for safe movement.

6. Patient Education

• Teach patients and caregivers about fracture care and signs of complications.
• Provide guidance on rehabilitation exercises to improve recovery.
• Address emotional concerns related to mobility limitations and lifestyle changes.

Nursing Care Plans

Once the nurse identifies nursing diagnoses for a fracture, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for fractures.

Acute Pain

Acute pain with a fracture results from injury to the surrounding tissues, muscles, and nerves.

Nursing Diagnosis: Acute Pain

Related to:

• Bone displacement 
• Compromised tissue 
• Muscle spasms 
• Edema

As evidenced by:

• Verbalization of pain 
• Guarding behavior 
• Facial grimacing or crying 
• Diaphoresis 
• Restlessness 
• Distracted behavior 
• Tachypnea, tachycardia, and increased blood pressure

Expected Outcomes:

• Patient will report pain of 2/10 or less by discharge 
• Patient will display signs of comfort as evidenced by resting with eyes closed and vital signs within normal limits 
• Patient will utilize nonpharmacologic pain relief measures  

Assessment:

1. Assess for pain.
Using appropriate pain scales based on age and cognitive level (numeric, Wong-Baker FACES, FLACC) assess the severity of pain. The nurse should also assess the location, characteristics, and frequency of pain.

2. Monitor vital signs.
An elevated blood pressure and heart rate is a normal response to pain. These vital signs should improve once appropriate pain measures are instituted.

3. Assess pain relief.
After administering pain medications, the nurse should follow up within an hour to assess the effectiveness of medications or interventions.

Interventions:

1. Administer analgesics.
Acute fractures usually warrant narcotic pain relief which may be oral or IV. NSAIDs such as Ibuprofen or Naproxen treat inflammation and are often given in conjunction with narcotics.

2. Provide alternative comfort measures.
Patients should not rely solely on medication. Implement alternative measures that alleviate the patient’s pain such as ice packs, heat, massage, distraction, and controlled breathing.

3. Support the injured area.
A fractured extremity should remain elevated to reduce swelling. Utilize splints or traction devices as ordered. Immobilize the fractured area and follow weight-bearing instructions to promote healing.

4. Instruct on medications at discharge.
Patients should be instructed to not take pain medications more frequently than prescribed. If the dose ordered is not controlling their pain they should contact their provider. Instruct on other precautions with narcotics such as not operating vehicles, and possible side effects such as drowsiness, dizziness, nausea, and constipation.

Impaired Physical Mobility

Fractures impair the ability to ambulate, complete ADLs, and increase the risk of falls and other injuries.

Nursing Diagnosis: Impaired Physical Mobility

Related to:

• Loss of integrity of bone structure 
• Pain 
• Prescribed activity restrictions 
• Reluctance to initiate movement 
• Deconditioning 

As evidenced by:

• Reports of pain 
• Unwillingness to move 
• Limited ROM 
• Decreased muscle strength 

Expected Outcomes:

• Patient will increase ambulation distance and participation in ADLs as tolerated 
• Patient will demonstrate techniques to support movement 
• Patient will remain free from falls or injury while ambulating 

Assessment:

1. Assess the degree of physical limitation.
Physical immobility will depend on the location and severity of the fracture as well as pain and swelling. Interventions will be determined based on what the patient can and cannot do for themselves

2. Assess for pain or other psychological concerns.
Pain and discomfort will prevent the patient from moving. Depression and anxiety may also prevent purposeful movement. Delays in movement will only further exacerbate pain and may lead to contractures and loss of muscle strength and tone.

3. Assess for a support system.
At discharge, the patient’s mobility will dictate further needs. If the patient does not have capable caregivers then they may require a short-term stay at a rehabilitation facility or in-home care.

Interventions:

1. Encourage independence.
The patient should be encouraged to do as much for themselves as possible. Even patients confined to a bed can assist with turning themselves and should be encouraged to perform ADLs such as feeding or washing their face if possible.

2. Premedicate before movement.
The nurse should anticipate pain and premedicate before potentially painful activities such as PT sessions or complete bed baths. This will help relax the patient and improve their ability to perform exercises.

3. Collaborate with PT/OT.
Hip fractures, spinal fractures, or other serious fractures may require PT or OT to assist with safe movement. These specialists can teach patients how to use canes, crutches, and other devices as well as instruct on exercises to strengthen muscles.

4. Encourage the use of assistive devices and equipment.
Any equipment that will support safe movement such as bedside commodes, grab bars, walkers, or scooters should be utilized.

Risk For Constipation

Opioids used for pain will cause constipation as they slow down gastric emptying and peristalsis. Untreated constipation can have uncomfortable and serious consequences. 

Nursing Diagnosis: Risk For Constipation

Related to:

• Immobility 
• Opioid use 
• Change in eating pattern 
• Insufficient fluid intake 

Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred yet and the goal of nursing interventions is aimed at prevention.  

Expected Outcomes:

• Patient will have a solid bowel movement at least every 3 days 
• Patient will report no straining or discomfort with defecation 
• Patient will implement 2 measures to prevent constipation 

Assessment:

1. Auscultate bowel sounds.
Assess for the presence, location, and characteristics of bowel sounds.

2. Assess the patient’s normal bowel pattern.
Not everyone has a bowel movement daily. Bowel movements every 2-3 days are considered normal as long as the patient is not experiencing discomfort.

Interventions:

1. Administer stool softeners or laxatives.
The most common side effect of opioid medications is constipation. When prescribed these medications a stool softener should be used prophylactically in conjunction. For severe constipation, enemas may be required.

2. Educate on the risk and prevention of constipation.
Educate that patient that constipation is increased due to their immobility and use of opioids (if taking). Stool softeners should be taken before constipation occurs to prevent impaction or serious complications such as a bowel obstruction.

3. Increase fluids.
Fluids keep stools soft and easier to pass. Patients should drink plenty of water (if not contraindicated) as well as juices such as prune juice. Hot beverages like tea also stimulate bowel movements.

4. Increase mobility as tolerated.
Immobility from fractures can also slow down peristalsis. While the patient must first follow activity instructions, once the patient may safely ambulate or exercise, this should be encouraged.

Nursing Diagnoses and Rationales for Fracture

1. Acute Pain

Rationale: Fractures often result in significant pain due to bone disruption, soft tissue injury, and muscle spasms. Assessing the patient’s pain levels, providing pain relief through medications, and implementing non-pharmacological interventions such as ice application, elevation, and relaxation techniques can help manage pain. Regularly reassessing pain and adjusting the pain management plan as needed is crucial for effective pain control.

2. Impaired Physical Mobility

Rationale: A fracture can impair the patient’s ability to move the affected limb and perform daily activities. Assessing mobility limitations, providing assistive devices, and implementing range-of-motion exercises can help improve mobility. Encouraging the patient to participate in physical therapy and adhere to a rehabilitation plan can also enhance recovery and restore function.

3. Risk for Infection

Rationale: Fractures, especially open fractures, can increase the risk of infection due to potential contamination and impaired blood supply to the injured area. Assessing signs of infection, maintaining a clean and sterile environment, and administering prophylactic antibiotics as prescribed can help prevent infection. Educating the patient on wound care and signs of infection to watch for is also essential.

4. Risk for Peripheral Neurovascular Dysfunction

Rationale: Fractures can compromise vascular and nerve function, leading to complications such as compartment syndrome or nerve damage. Assessing the neurovascular status of the affected limb, including circulation, sensation, and movement, and monitoring for changes can help detect early signs of dysfunction. Prompt intervention and communication with the healthcare team are necessary to prevent permanent damage.

5. Impaired Skin Integrity

Rationale: Immobilization devices such as casts or splints can cause pressure sores and skin breakdown. Assessing the skin condition, ensuring proper fit and padding of immobilization devices, and educating the patient on skin care and monitoring are vital. Regularly repositioning the patient and inspecting the skin can help maintain skin integrity.

6. Deficient Knowledge

Rationale: Patients with fractures may lack knowledge about the injury, treatment plan, and self-care measures. Assessing the patient’s understanding, providing education on fracture management, and teaching proper use of assistive devices and home care practices can help address this knowledge deficit. Encouraging the patient to ask questions and seek clarification as needed is important for informed care.

7. Anxiety

Rationale: The experience of a fracture and its treatment can cause anxiety and emotional distress. Assessing the patient’s anxiety levels, providing emotional support, and teaching relaxation techniques can help manage anxiety. Encouraging the patient to express their fears and concerns and offering reassurance can also reduce anxiety.

8. Risk for Constipation

Rationale: Decreased mobility and use of pain medications can lead to constipation in patients with fractures. Assessing bowel function, encouraging a high-fiber diet, ensuring adequate hydration, and promoting physical activity within safe limits can help prevent constipation. Administering stool softeners or laxatives as prescribed may also be necessary.

9. Enhanced Coping

Rationale: Fractures can impact a patient’s ability to cope with their injury and its limitations. Assessing coping mechanisms, providing psychological support, and helping the patient identify positive coping strategies can enhance coping. Encouraging participation in support groups and therapy can also provide additional support.

10. Risk for Complications

Rationale: Fractures can lead to various complications, such as deep vein thrombosis, pulmonary embolism, or delayed union. Assessing risk factors, monitoring for signs and symptoms, and implementing preventive measures such as early mobilization, anticoagulant therapy, and patient education can help mitigate these risks. Regular follow-up and communication with the healthcare team are essential for early detection and management of complications.

REFERENCES

1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
2. Sizar O, Genova R, Gupta M. Opioid-Induced Constipation. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493184/
3. Throckmorton, T. W. (2021, August). Fractures (Broken Bones) – OrthoInfo – AAOS. OrthoInfo.  https://orthoinfo.aaos.org/en/diseases–conditions/fractures-broken-bones/
4. Types of Fractures. (n.d.). The Orthopedic Institute at Southwest Health. https://www.orthopedic-institute.org/fracture-care/types-of-fractures/
5. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. 
6. Forsh DA, Ferguson TA. Contemporary management of femoral neck fractures: the young and the old. Curr Rev Musculoskelet Med. 2012 Sep;5(3):214-21. doi: 10.1007/s12178-012-9127-x. PMID: 22628175; PMCID: PMC3535087.
7. Ghayoumi P, Kandemir U, Morshed S. Evidence based update: open versus closed reduction. Injury. 2015 Mar;46(3):467-73. doi: 10.1016/j.injury.2014.10.011. Epub 2014 Oct 14. PMID: 25554424.
8. Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
9. Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
10. Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
11. Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. 
12. Slobogean GP, Sprague SA, Scott T, Bhandari M. Complications following young femoral neck fractures. Injury. 2015 Mar;46(3):484-91. doi: 10.1016/j.injury.2014.10.010. Epub 2014 Oct 31. PMID: 25480307.

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