| Complication | Assessment | Analysis/Nursing Diagnosis | Nursing Care Plan/Implementation | Evaluation/Outcome Criteria |
|---|
| Shock (see Physiological Integrity) |
| Thrombophlebitis (see Physiological Integrity) |
| Fat emboli: serious, potentially life-threatening complication in which pressure changes in interior of fracture force molecules of fat from marrow into systemic circulation; may cause problems in respiratory or nervous system; seen most frequently onthird day after multiple fractures, fractures of long bones, or comminuted fracture | - Subjective data: dyspnea, severe chest pain; confusion, agitation; decrease in level of consciousness; numbness; feeling faint; history of diabetes, obesity
- Objective data: cyanosis; pupillary changes; muscle twitching; petechiae—chest, buccal cavity, axilla, conjunctiva, soft palate; extremities—pallor, cold; shock; vomiting
| - Risk for injury related to fat emboli
- Altered tissue perfusion related to fat emboli
|  Position: high Fowler’s to relieve respiratory symptoms- Administer oxygen STAT, to relieve anoxia and reduce surface tension of fat globules
- Institute respiratory support measures, as ordered—IPPB, respiratory assistive devices: be prepared for CPR in event of respiratory failure
- Monitor vital signs, cardiac monitor, q15 min during acute episode and prn (shock/cardiac failure possible)
- Obtain baseline data and monitor level of consciousness, neurological signs q15 min during acute episode and prn (neurological involvement possible)
- Administer parenteral fluids, as ordered: IV alcohol, blood and fluid replacements
- Administer medications as ordered: corticosteroids; digitalis; aminophylline; heparin sodium
- DO NOT RUB ANY LEG CRAMPS, BUT REPORT IMMEDIATELY
| - Client alert
- Pain relieved
- Respiratory, cardiac, and neurological systems have no permanent damage
|
| Nerve compression: pressure on nerve in affected area from edema, dislocation of bone, or immobilization apparatus; if pressure not relieved, permanent paralysis can result | - Subjective data: discomfort, pain, referred pain; burning, tingling, “stinging sensation”; numbness, altered sensation, inability to distinguish touch
- Objective data: limited movement; muscle weakness; paralysis; reflexes—diminished, irritable, or absent; color changes related to impaired circulation
| - Pain related to pressure on nerve
- Potential for physical injury related to pressure on nerve
- Impaired tissue perfusion related to impaired circulation
- Impaired physical mobility related to joint contracture, numbness
| - Monitor for potential signs q1h for first 48 hr; neurovascular assessment q12h and prn as condition indicates (circulation, sensation, and motion [CSM])
 Elevate affected limb; flex hand or foot of affected extremity; passive and active ROM exercises- Be prepared to cut cast or remove constrictions if signs of impairment exist
- Begin active ROM exercises to unaffected extremities
- Use footboard to prevent footdrop
- Encourage use of trapeze if applicable
- isometric exercises, as ordered
- Ambulation, weight bearing as ordered, support casts
| - Sensation, motor function are normal
- No complications noted
|
| Avascular necrosis/circulatory impairment: interference with normal circulation to affected area due to interruption of blood vessel, pressure on the vessel from dislocation, edema, or immobilization devices; results of impaired circulation lead to discomfort and, if not corrected, necrosis of tissue and bone due to lack of oxygen supply | - Subjective data: tenderness; pain, especially on passive motion
- Objective data: edema, swelling in affected area; decreased color, temperature, mobility; bleeding from wound
| - Risk for altered peripheral tissue perfusion related to vessel damage
| - Monitor for potential signs q1h for first 48 hr; blanching, coolness, edema; palpate pulse above and below injury, report absent pulse or major discrepancies STAT
- Elevate affected limb to decrease edema
- Report to physician if signs persist
- Be prepared to assist with bivalving of casts, or cut cast to relieve pressure
- Monitor size of drainage stains on casts; measure accurately and report if size increases
| - Circulation adequate to limb, to prevent tissue damage
|
| Infection | - Subjective data: pain
- Objective data: elevated temperature and pulse: erythema—discoloration of surrounding skin; edema—sudden, local induration; drainage—thin, watery, foul-smelling exudate; crepitus (may be indicative of gas gangrene); with cast—warm area, foul smell
| - Risk for injury related to tissue destruction
- Altered peripheral tissue perfusion related to swelling
| - Monitor vital signs, drainage
- Ensure client has had prophylactic tetanus toxoid
- May have prophylactic antibiotics ordered if wound was contaminated at time of injury
- Instruct client not to touch open wound or pin sites or put anything inside cast (could interrupt skin integrity and become potential source of infection)
| - No infection or heals with no serious complications
|
| Delayed union/nonunion: failure of bone to heal within normal time related to lack of use, inadequate circulation, other complicating medical conditions such as diabetes or poor nutrition | - Subjective data: pain
- Objective data: lack of callus formation on x-ray: poor alignment
| - Risk for injury related to poor healing of bone fracture
- Impaired physical mobility related to lower-limb fractures
- Dressing/grooming bathing/hygiene, self-care deficit related to upper-limb fracture
| - Maintain immobilization and alignment of affected limb
- Maintain adequate nutrition
- Avoid trauma to affected limb
- Monitor for circulatory or infection complication
 Dietary instructions regarding foods containing calcium and protein necessary for bone healing
| - Bone heals
- No complications noted
- Pain decreased
- Ambulation and self-care return to preinjury status
|
| Skin breakdown (related to cast) | - Subjective data: pain
- Objective data: temperature and pulse elevated; erythema; edema—cast edges, exposed distal portion of limb, limb area within cast; drainage and foul odor from break in skin (may be under cast and stain through or exit at ends of cast); crepitus (crackling sound could indicate gas gangrene); hyperactive reflexes
| - Impaired skin integrity related to cast trauma
| - If open wound: verify tetanus administration; monitor site through cast window, change dressing daily and prn
- Apply lotion or cornstarch to exposed skin ( no powder)
- Petal-tape edges of cast to reduce irritation
- Inspect skin for irritation, edema, odor, drainage—q2h initially, then q3h
- Instruct client not to place any object under cast because skin abrasions may lead to decubitus ulcers
- Promote drying of cast by leaving it uncovered and exposed to air for 48 hr; use no plastic
- Prevent indenting casts with fingertips or hard surface: place on pillows; use palms of hands when positioning affected limb
- Avoid excessive padding of Thomas’ splint in groin area—padding traps moisture, may lead to skin breakdown
| |
| Duodenal distress (with spica cast): spica cast incorporates the trunk and affected limb and can cause respiratory or abdominal distress when edema is present under the cast or cast is too tight to allow for normal body functions | - Subjective data: anorexia, nausea, abdominal pain
- Objective data: duodenal distress, vomiting, distention, cast too tight
| - Ineffective breathing related to pressure from cast
- Pain related to abdominal distress from pressure
- Fear related to cast constriction
| - Place on firm mattress; use bedboards if necessary to reduce muscle spasm
- Maintain warmth by covering uncasted areas
- Avoid turning for first 8 hr; when turning: use enough personnel to logroll; do not use bar between legs as turning device; support chest with pillows
- Monitor for signs of respiratory distress: increased respirations, apprehension
- Monitor for signs of duodenal distress: vomiting, distention; if these signs occur: place in prone position; have cast bivalved; may need NG tube; monitor for fluid imbalance
- Protect cast with nonabsorbent material during elimination
| - Complications avoided or detected early enough to prevent serious damage
|