Introduction
Jodie Rush, born in 2004, was rushed to the emergency room in the morning after breaking her right ankle while skiing. This paper provides an in-depth analysis of the holistic care of a client with an ankle fracture, using objective and subjective diagnostic findings as a reference point. The discussion includes three client or nursing diagnoses, along with related interventions and concepts. In addition, two safety concepts are explained, emphasizing basic safety precautions to protect customers. Finally, the importance of nursing interventions in improving patient outcomes is emphasized.
Subjective and Objective Assessment Findings
Subjective Assessment Findings
Jodi has a history of asthma and uses an inhaler when needed. When Jodi arrived, the pain was 10/10 severe, and they gave her morphine for pain relief. Jody also received an ondansetron injection to induce diarrhea before being taken to the operating room. A urinary tube is inserted because it is difficult to drain the bed. Jodi’s parents have arrived at the hospital and are now waiting in the operating room.
Objective Assessment Findings
Jody’s preoperative vital signs were recorded: temperature 37.5°C (99.5°F), heart rate 89/min, respirations 18/min, blood pressure 128/89 mmHg, and SpO2 98 on room air. The antepartum stool was 400 mL of pure white urine. Physical examination revealed clear lung sounds, normal S1 and S2 heart sounds, a soft and opaque abdomen, pale skin, and a dry, slightly flushed, and bandaged cheek. Peripheral pulse was +2 bilaterally, and capillary refill was detected in less than 2 seconds. Considering Jodi’s current condition, after recovery from spinal surgery under general anesthesia, it is necessary to monitor ventilation, breathing, and blood flow carefully. General anesthesia for this condition and circulatory problems from spinal failure increases the likelihood of Jodie using a breathing tube.
Three Client Problems/Nursing Diagnoses, Interventions, and Rationales
Problem One
Nursing Diagnosis
The client faces significant safety concerns regarding injury prevention, especially for spinal fractures requiring surgery under general anesthesia. This condition greatly increases the chance of falling and exacerbating the current injury. Therefore, comprehensive measures should be taken immediately to ensure customers’ safety.
Intervention
Follow the client’s requested comprehensive safety procedures to reduce the risk of injury. This includes installing bed rails to provide physical barriers and assistive devices such as walkers or crutches to improve mobility and stability. To better monitor ambulance operations and facilitate safe operations.
Rationale
Bed rails are an important safety feature to prevent accidental falls and injuries. Assistive devices provide great assistance during exercise, effectively reducing the risk of falling and improving stability. The walker can play an important role in ensuring the client’s safety by assisting with movement control.
Problem Two
Nursing Diagnosis
The client demonstrates changes in physiological state related to tissue integrity, as evidenced in various situations. An ankle fracture that requires surgery first indicates structural deterioration of the joint, which affects the integrity of the tissue around the fracture site.
Intervention
Prioritize interventions focused on wound healing and infection prevention to address compromised tissue integrity. This includes proper wound care, cleaning the wound with appropriate antibiotics, and using open dressings to promote healing. Also, check the wound site regularly for any signs of infection, such as swelling, discharge, or discharge, so that immediate intervention can be performed if necessary.
Rationale
Proper wound care is important to maintain tissue integrity and promote healing. Thoroughly cleaning the wound and applying a clean dressing reduces the risk of infection and helps the wound heal faster. Regular monitoring can detect signs of infection early and provide prompt intervention to prevent complications and achieve a positive outcome. This intervention effectively addresses the client’s physical conditions related to tissue integrity and improves overall health and well-being.
Problem Three
Nursing Diagnosis
The client’s physical condition is experiencing significant changes, mainly due to the loss of mobility due to the fractured spine. This fracture severely limits the client’s ability to move freely and independently, requiring active intervention to address and reduce mobility-related problems.
Intervention
A multidisciplinary approach is needed to optimize movement within injury-induced restrictions. Use techniques that provide comfort and stability to facilitate joint alignment and reduce the risk of pressure sores caused by prolonged immobility. Incorporate various movement exercises into the client’s care plan to move together, build mobility, maintain strength, and improve joint mobility.
Rationale
Joint recognition techniques are important for joint alignment and for preventing pressure ulcers, common complications of chronic osteoarthritis. By regularly adjusting the client’s position, pressure is redistributed, thereby reducing the risk of tissue damage and promoting skin integrity.
Safety Considerations
Fall Prevention
If the client has a reduced range of motion due to an ankle fracture, there is a risk of falling. Measures such as bed rest, assistive devices, and supervised ambulation are critical to reduce this risk and ensure client safety.
Infection Control
With minor injuries and rib fractures on the forehead, which require surgical repair, infection control is critical. Strict adherence to wound care, surgical antibiotics, and regular monitoring for signs of infection are important to prevent complications and achieve optimal healing.
Importance of the Nursing Interventions
The importance of nursing interventions, especially in situations such as hip fractures, cannot be overstated. These interventions are critical for several reasons. Nursing interventions are designed to improve patient outcomes. Interventions aim to prevent problems associated with the client’s condition.
For example, fall prevention and infection control measures help reduce the risk and help prevent further harm to patients (Rortveit et al., 2020). Moreover, these interventions help improve patient comfort and satisfaction. Nursing interventions help improve comfort and satisfaction by promptly and effectively addressing client needs. Measures that reduce pain, aid mobility, and ensure a safe posture can significantly improve the patient experience.
In addition, nursing intervention plays an important role in early integration and rehabilitation. Nurses use strategies to promote mobility and independence to facilitate the healing process and the client’s transition to normal functioning (Rortveit et al., 2020). This intervention puts patient safety first. Precautions such as preventing falls, controlling infections, and medication management are taken to protect clients from harm and ensure care safety.
References
Rortveit, K., Saetre Hansen, B., Joa, I., Lode, K., & Severinsson, E. (2020). Qualitative evaluation in nursing interventions—A review of the literature. Nursing Open, 7(5), 1285–1298.