What could be the problem(s)?

Pain
The patient has requested pain medication every 4-6 hours throughout the night for pain of 9/10
indicating that the level of pain is severe and difficult to bear. Experiencing severe pain may prevent
the patient from effectively participating in any area of his recovery. This will lead to a delay in
healing and an increase in the risk for the development of other health issues.
Anxiety / Stress
The patient has several immobilizing injuries that resulted from an accident meaning that the change
in physical status was sudden and unexpected. Most individuals would be expected to experience
anxiety and/or stress in this kind of situation
Ineffective coping
The patient is cooperative but gets easily frustrated when assistance is needed indicating that the
patient is experiencing difficulty in accepting and coping with his current situation.
Impaired mobility
The patient has multiple fractures of both legs and the right arm, both his legs are in traction, and he
has a cast from his right wrist to the mid-upper arm greatly limiting his mobility.
Basic Care Assistance
The patient requires assistance with basic care including toileting, hygiene, and meal setup meaning
that he cannot meet these needs on his own.
Impaired family dynamics / Change in Life Role
The patient is a 27 year old married male who is the father of 2 preschool aged children. He is now
trying to recover from a number of mobility limiting injuries. He will likely be in the hospital for a
period of time and require additional recovery time following discharge. His roles as husband, father,
and bread-winner will need to be minimized during recovery.
Risk for infection
Both of patients legs are in traction, the insertion points of which are at risk for infection.
Risk for impaired skin integrity
Due to the patients limited mobility, he is at risk for developing skin breakdown due to prolonged
periods of increased pressure and decreased perfusion
Risk for nutritional deficit, constipation, and dehydration
Due to the patients decreased mobility, he may experience decreased appetite and intestinal
peristalsis; the patient may also decrease food and fluid intake in an attempt to decrease his need for
toileting assistance all of which may lead to the development of nutritional deficit, dehydration, and
constipation
NANDA

Acute pain R/T physical trauma AEB patient describes pain as a 9/10
Impaired physical mobility R/T
Self-care deficit: bathing, toileting, feeding, dressing
Risk for infection AEB
Risk for impaired skin integrity AEB physical immobilization

What would you assess?

Vital signs
Assessing vital signs at regular intervals allows you to note any changes in homeostasis and
signs of systemic infection
Pain
Assess pain level using the numerical (0 to 10) scale
Skin
Assess the skin for temperature, moisture, bruises, wounds, abrasions, and/or foreign bodies.
Lungs
Assess lung sounds for signs of secretion build up due to immobility
Gastrointestinal
Assess nutritional intake (24-hour recall) to determine risk for nutritional deficit and monitor
intake and output to assess for constipation
Urinary
Monitor intake and output to assess for dehydration
Musculoskeletal
Assess range of motion in mobile joints and strength in non-contraindicated muscle groups to
form a baseline
What should you do?

Administer pain medications as ordered in order to relieve pain

Request routine labs
Help patient adjust in bed as much as possible and develop adjustment schedule to prevent
skin breakdown
Keep skin clean and dry to prevent breakdown
Teach patient to take deep breaths and cough at regular intervals to prevent secretion build-up
in the lungs
Determine the patients favorite foods and request a dietary consult for appropriate nutritional
intake
Request a physical therapy consult to develop individualized exercise program to maintain
muscle tone
Request occupational therapy consult to increase the number of activities of daily living
performed by the patient
Encourage the family to visit and the patient to socialize
Provide the patient with entertainment by playing music or reading a book to improve mood
Request a social work consult to determine resources for family support like child care and
financial assistance
Request assistance from a case worker in coordinating the resources provided by the social
worker.
2

Plan of Care
Nursing Diagnosis (Nanda r/t): Acute pain related to physical trauma
As evidenced by (Supporting Data Patient/Family, Vitals, Labs / Results, Assessment):
Subjective: Pain severity rated as a 9 out of 10
Objective:

None

Short Term Goal: Client will show improved pain relief within two hours as evidenced by a
reported pain level of 5 out of 10
Long Term Goal: Client will achieve pain relief by discharge as evidenced by a reported pain
level of 2 out of 10
Nursing Interventions
Administer Tylenol or Demerol as
ordered for pain
Teach and encourage use of relaxation
techniques such as focused breathing
and imaging
Assist patient with repositioning every
2 hours as allowed by his condition and
the providers orders
Review procedures and expectations
including when treatment may cause
pain
Encourage verbalizations of feelings
about the pain such as concern about
tolerating pain

Scientific Principle / Rationale

Evaluation

Decrease clients pain severity

Numerical pain scale

To distract attention from pain and

reduce tension

Numerical pain scale

To reduce pain and tension

Numerical pain scale

To reduce concern of the unknown and

associated muscle tension
To evaluate coping abilities and identify
areas of additional concern

Body language (facial

expressions, eye
contact)
Body language (facial
expressions, eye
contact)