NCP: Nursing Care Plans for Bronchiectasis

Bronchiectasis is a chronic pulmonary disease characterized by permanent abnormal dilatation and destruction of the elastic and muscular components of the walls of major bronchi and bronchioles. The disease has three forms: cylindrical (fusiform), varicose, and saccular (cystic). It affects people of both sexes and all ages. Chief clinical features of the disease are cough, daily mucus hypersecretion, Dyspnea, and recurrent respiratory tract infections, which may be accompanied by Hemoptysis

Causes Bronchiectasis

The primary etiology in the development of ordinary acquired Bronchiectasis is inflammatory destruction of the elastic tissue, smooth muscle, and cartilage of bronchial walls usually due to severe preceding infection(s). Fewer cases are caused by genetic or immune deficiencies or result from inhalation injury. Bronchiectasis results from conditions associated with repeated damage to bronchial walls and with abnormal mucociliary clearance, which causes a breakdown of supporting tissue adjacent to the airways. Such conditions include:

Predisposing factors:

Bronchopulmonary infection— Mycobacterium species, bacterial (e.g., Staphylococcus aureus, Bordetella pertussis, Klebsiella pneumoniae, H. influenza ), viral (e.g., measles, HIV, adenovirus, influenza), fungal (histoplasmosis, coccidiomycosis), recurrent aspiration pneumonia. Bronchial obstruction—foreign body aspiration, lung or bronchogenic neoplasm, airway nodules, hilar adenopathy (e.g., sarcoidosis), mucus impaction (e.g., allergic bronchopulmonary aspergllosis), broncholith, external compression by vascular aneurysm. Immunodefi ciency states—hypogammaglobulinemia, IgG subclass deficiency, selective IgA deficiency. Other congenital syndromes—cystic fibrosis, alpha1-antitrypsin deficiency, primary ciliary dyskinesia (e.g., Kartagener’s syndrome), Young’s syndrome (azoospermia and chronic sinopulmonary infections). Inhalation injury—smoke, ammonia, sulfur or nitrogen dioxide. Rheumatologic disease—rheumatoid arthritis, Sjogren’s syndrome Anatomic defects—bronchomalacia, Swyer-James syndrome, bronchial cartilage deficiency (Williams-Campbell syndrome), tracheobronchomegaly (Mounier-Kuhn syndrome)

Complications Bronchiectasis

Hemoptysis occurs in nearly 50% of patients with bronchiectasis (Mysliwiec & Pina, 1999); major pulmonary hemorrhage and death from exsanguination are rare (Swartz, 1998). Empyema, lung abscess, and pneumothorax are serious but rare complications of acute infections in bronchiectasis (Luce, 1994). Progressive respiratory insuffi ciency and cor pulmonale complicate severe bronchiectasis associated with deteriorating pulmonary function and hypoxemia.

TREATMENT FOR BRONCHIECTASIS

Medical interventions 

Inhaled bronchodilators may be helpful in diffuse small airway disease; beta adrenergic agents dilate airways and improve ciliary activity (Swartz, 1998).

Antimicrobial therapy for treatment of acute infectious exacerbations is based on results of sputum gram stain and culture. Corticosteroids reduce the airway infl ammatory response in bronchiectasis. Oxygen therapy is prescribed as indicated for patients with hypoxemia at rest, during sleep, and/or with activity. Gamma globulin replacement for immunoglobulin defi ciency may be effective in reducing the frequency and severity of sinopulmonary infections (George et al., 1995). Effective reduction and removal of bronchial secretions by a variety of available methods is critical in patients with bronchiectasis. The approach selected should be based upon an individual’s self-care abilities, motivation, breath control, neuromuscular status, preferences, needs, and financial resources (Langenderfer, 1998). Effective cough Percussion and postural drainage Autogenic drainage Positive expiratory pressure (PEP) therapy Flutter valve Vest therapy Humidifi cation (by cold water, jet nebulizers) as an adjunct to chest physiotherapy enhanced sputum production (Conway, Fleming, Perring, & Holgate, 1992). Aerosolized recombinant human DNase may lyse the DNA that causes the sputum to be highly viscous. Initial studies for cystic fibrosis are promising, but this therapy is not FDA approved in non-CF bronchiectasis (O’Donnell, Barker, Ilowite, & Fick, 1998; Wills et al., 1996). Non-invasive intermittent positive pressure ventilation (NIPPV) is an alternative to tracheostomy for respiratory failure due to advanced bronchiectasis.

Surgical intervention

Surgical resection

Lung or heart-lung transplantation

Nursing assessment for Bronchiectasis 

Patient’s history of recurrent bronchopulmonary infections and symptoms of chronic productive cough are hallmark features of bronchiectasis. Pain and dyspnea are also common. The history of acute, even if delayed, onset of bronchiectasis can sometimes be traced to a defi nite illness, pneumonia, or aspiration event in patients with postobstructive or infectious bronchiectasis. Those patients with underlying congenital or immune disorders usually demonstrate a more insidious disease onset (Luce, 1994). Cough is present in 90% of patients (Nicotra et al., 1995). Daily (often purulent) sputum production occurs in 75% of patients and varies in volume from 10–500 ml (Nicotra et al., 1995). Pleuritic chest pain represents distended peripheral airways or distal pneumonitis adjacent to a visceral pleural surface. This symptom occurs in 50% of bronchiectasis patients (Barker, 2002). Repeated episodes of fever, pleurisy, and/or sinusitis are also common. Weakness, dyspnea, and weight loss are seen in patients during infectious exacerbations or those with extensive disease. The St. George’s Respiratory Questionnaire (SGRQ) has been validated as a useful tool for assessment of health-related quality of life in patients with bronchiectasis (Wilson, Jones, O’Leary, Cole, & Wilson, 1997). Test items are divided into three major areas: symptomatology; activity tolerance; and impact of the condition on daily life including employment, need for medications, and sense of control or panic over one’s health.

Physical examination findings are neither sensitive nor specific for bronchiectasis. Crackles are the most common adventitious auscultatory finding, followed in frequency by wheezing, rhonchi, and a pleural friction rub (Barker, 2002; Mysliwiec & Pina, 1999; Nicotra et al., 1995). Digital clubbing is rare (Barker, 2002; Mysliwiec & Pina, 1999). Nasal polyps and sinusitis may also be evident (Luce, 1994). Patients may have fetid breath chronically or solely during episodes of purulent sputum production. Generalized weight loss and use of accessory muscles accompany severe disease.

Diagnostic Test for Bronchiectasis 

Radiographic imaging studies are the principal diagnostic tools for Bronchiectasis (chest roentgenogram, non-contrast computed tomography (HRCT) and spiral volumetric scans.

Bronchoscopy is used to examine airways for obstructing tumors or foreign bodies, to evaluate the degree and site of hemoptysis, and to detect or remove inspissated secretions (Barker & Bardana, 1988; George, Matthay, Light, & Matthay, 1995).

Functional assessment of the bronchiectasis patient includes pulmonary function testing with spirometry and lung volumes, and arterial blood gas analysis.

Laboratory studies are important in the diagnosis and follow-up of patients:

• The complete blood count with cell differential may reveal leukocytosis or increased neutrophil levels during acute exacerbations; anemia may be present in chronic infections (Swartz,1998). 
• Quantitative serum immunoglobulin levels of IgA, IgM, IgE, IgG 
• Sputum smear reveals large numbers of white blood cells and both gram-positive and gram-negative organisms 
• Sweat chloride testing is used to screen for cystic fibrosis in young adults with no identifiable predisposing cause for bronchiectasis. 
• Aspergillus titers are indicated when an Aspergillus organism is cultured or if radiographic exam (chest X-ray or HRCT) demonstrates central bronchiectasis (Barker & Bardana, 1988). 

Nursing Diagnosis That Could Be Found In Patient with Bronchiectasis

Common nursing diagnosis found in nursing care plans for Bronchiectasis:

• Impaired gas exchange related to ventilation–perfusion inequality 
• Ineffective airway clearance related to bronchoconstriction, increased mucus production, ineffective cough, bronchopulmonary infection, and other complications 
• Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction and airway irritants 
• Self-care deficits related to fatigue secondary to increased work of breathing and insufficient ventilation and oxygenation 
• Activity intolerance due to fatigue, hypoxemia, and ineffective breathing patterns 
• Ineffective coping related to reduced socialization, anxiety, depression, lower activity level, and the inability to work 
• Deficient knowledge about self-management to be performed at home. 

Sample nursing care plans Bronchiectasis:

NURSING DIAGNOSE	INTERVENTION	RATIONALE	EVALUATION
Impaired gas exchange related to ventilation perfusion inequality	a.    Administer bronchodilators as prescribed: ·      Inhalation is the preferred route. ·      Observe for side effects: tachycardia, dysrhythmias, central nervous system excitation, nausea, and vomiting. ·      Assess for correct technique of metered-dose inhaler (MDI) administration. b.  Evaluate effectiveness of nebulizer or MDI treatments. ·      Assess for decreased shortness of breath, decreased wheezing or crackles, loosened secretions, decreased anxiety. ·      Ensure that treatment is given before meals to avoid nausea and to reduce fatigue that accompanies eating. c.    Instruct and encourage patient in diaphragmatic breathing and effective coughing. d.    Administer oxygen by the method prescribed. ·      Explain rationale and importance to patient. ·      Evaluate effectiveness; observe for signs of hypoxemia. Notify physician if restlessness, anxiety, somnolence, cyanosis, or tachycardia is present. ·      Analyze arterial blood gases and compare with baseline values. When arterial puncture is performed and a blood sample is obtained, hold puncture site for 5 minutes to prevent arterial bleeding and development of ecchymoses. ·      Initiate pulse oximetry to monitor oxygen saturation. ·      Explain that no smoking is permitted by patient or visitors while oxygen is in use.	a.    Bronchodilators dilate the airways. The medication dosage is carefully adjusted for each patient, in accordance with clinical response. b.    Combining medication with aerosolized bronchodilators is typically used to control bronchoconstriction in an acute exacerbation. Generally, however, the MDI with spacer is the preferred route (less cost and time to treatment). c.    These techniques improve ventilation by opening airways to facilitate clearing the airways of sputum. Gas exchange is improved and fatigue is minimized. d.   Oxygen will correct the hypoxemia. Careful observation of the liter flow or the percentage administered and its effect on the patient is important. If the patient has chronic CO2 retention, excessive oxygen could suppress the hypoxic drive and respirations. These patients generally need low-flow oxygen rates of 1 to 2 L/min. Periodic arterial blood gases and pulse oximetry help to evaluate adequacy of oxygenation. Smoking may render pulse oximetry inaccurate because the carbon monoxide from cigarette smoke also saturates hemoglobin.	1.    Verbalizes need for bronchodilators and for taking as prescribed 2.    Evidences minimal side effects; heart rate near normal, absence of dysrhythmias, normal mentation 3.    Reports a decrease in dyspnea 4.    Shows an improved expiratory flow rate 5.    Uses and cleans respiratory therapy equipment as applicable 6.    Demonstrates diaphragmatic breathing and coughing 7.    Uses oxygen equipment appropriately when indicated ·         Evidences improved arterial blood gases or pulse oximetry ·         Demonstrates correct technique for use of MDI
Ineffective airway clearance related to bronchoconstriction, increased mucus production, ineffective cough, bronchopulmonary infection, and other complications	a.     Adequately hydrate the patient. b.     Teach and encourage the use of diaphragmatic breathing and coughing techniques. c.    Assist in administering nebulizer or MDI. d.    If indicated, perform postural drainage with percussion and vibration in the morning and at night as prescribed. e.    Instruct patient to avoid bronchial irritants such as cigarette smoke, aerosols, extremes of temperature, and fumes. f.     Teach early signs of infection that are to be reported to the clinician immediately: 1.      Increased sputum production 2.      Change in color of sputum 3.      Increased thickness of sputum 4.      Increased shortness of breath, tightness in chest, or fatigue Increased coughing 5.      Fever or chills       g.       Administer antibiotics as prescribed.         h.      Encourage patient to be immunized against influenza and Streptococcus pneumoniae.	a.    This ensures adequate delivery of medication to the airways. b.    Uses gravity to help raise secretions so they can be more easily expectorated or suctioned. c.    Bronchial irritants cause bronchoconstriction and increased mucus production, which then interferes with airway clearance.     d.   Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of the person with emphysema. Early recognition is crucial.    e.    Antibiotics may be prescribed to prevent or treat infection. f.    People with respiratory conditions are prone to respiratory infections and are encouraged to be immunized.	1.     Verbalizes need to drink fluids 2.     Demonstrates diaphragmatic breathing and coughing 3.     Performs postural drainage correctly 4.     Coughing is minimized 5.     Does not smoke 6.     Verbalizes that pollens, fumes, gases, dusts, and extremes of temperature and humidity are irritants to be avoided 7.     Identifies signs of early infection 8.     Is free of infection (no fever, no change in sputum, lessening of dyspnea) 9.     Verbalizes need to notify health care provider at the earliest sign of infection 10. Verbalizes need to stay away from crowds or people with colds in flu season 11. Discusses flu and pneumonia vaccines with clinician to help prevent infection
Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction, and airway irritants	a.     Teach patient diaphragmatic and pursedlip breathing. b.     Encourage alternating activity with rest periods. Allow patient to make some decisions (bath, shaving) about care based on tolerance level. c.     Encourage use of an inspiratory muscle trainer if prescribed.	a.    Helps patient prolong expiration time and decreases air trapping. With these techniques, patient will breathe more efficiently and effectively. b.   Pacing activities permits patient to perform activities without excessive distress. c.    Strengthens and conditions the respiratory muscles.	1.     Practices pursed-lip and diaphragmatic breathing and uses them when short of breath and with activity 2.     Shows signs of decreased respiratory effort and paces activities 3.     Uses inspiratory muscle trainer as prescribed
Self-care deficits related to fatigue secondary to increased work of breathing and insufficient ventilation and oxygenation	a.    Teach patient to coordinate diaphragmatic breathing with activity (eg, walking, bending). b.    Encourage patient to begin to bathe self, dress self, walk, and drink fluids. Discuss energy conservation measures. c.    Teach postural drainage if appropriate.	a.    This will allow the patient to be more active and to avoid excessive fatigue or dyspnea during activity. b.   As condition resolves, patient will be able to do more but needs to be encouraged to avoid increasing dependence. c.    Encourages patient to become involved in own care. Prepares patient to manage at home.	1.    Uses controlled breathing while bathing, bending, and walking 2.    Paces activities of daily living to alternate with rest periods to reduce fatigue and dyspnea 3.    Describes energy conservation strategies 4.    Performs same self-care activities as before 5.    Performs postural drainage correctly
Activity intolerance due to fatigue, hypoxemia, and ineffective breathing patterns	a.     Support patient in establishing a regular regimen of exercise using treadmill and exercycle, walking, or other appropriate exercises, such as mall walking. 1.    Assess the patient’s current level of functioning and develop exercise plan based on baseline functional status. 2.    Suggest consultation with a physical therapist or pulmonary rehabilitation program to determine an exercise program specific to the patient’s capability. Have portable oxygen unit available if oxygen is prescribed for exercise.	a.    Muscles that are deconditioned consume more oxygen and place an additional burden on the lungs. Through regular, graded exercise, these muscle groups become more conditioned, and the patient can do more without getting as short of breath. Graded exercise breaks the cycle of debilitation.	1.     Performs activities with less shortness of breath 2.     Verbalizes need to exercise daily and demonstrates an exercise plan to be carried out at home 3.     Walks and gradually increases walking time and distance to improve physical condition 4.     Exercises both upper and lower body muscle groups
Ineffective coping related to reduced socialization, anxiety, depression, lower activity level, and the inability to work	Help the patient develop realistic goals.    Encourage activity to level of symptom tolerance.  Teach relaxation technique or provide a relaxation tape for patient. Enroll patient in pulmonary rehabilitation program where available.	a.       Developing realistic goals will promote a sense of hope and accomplishment rather than defeat and hopelessness.      b.      Activity reduces tension and decreases degree of dyspnea as patient becomes conditioned.      c.       Relaxation reduces stress, anxiety, and dyspnea and helps patient to cope with disability.      d.      Pulmonary rehabilitation programs have been shown to promote a subjective improvement in a patient’s status and selfesteem as well as increased exercise tolerance and decreased hospitalizations.	1.    Expresses interest in the future 2.    Participates in the discharge plan 3.    Discusses activities or methods that can be performed to ease shortness of breath 4.    Uses relaxation techniques appropriately 5.    Expresses interest in a pulmonary rehabilitation program
Deficient knowledge about self-management to be performed at home.	a.     Help patient understand short- and longterm goals. 1.    Teach the patient about disease, medications, procedures, and how and when to seek help. 2.    Refer patient to pulmonary rehabilitation. Give strong message to stop smoking. Discuss smoking cessation strategies. Provide information about resource groups	a.    Patient needs to be a partner in developing the plan of care and needs to know what to expect. Teaching about the condition is one of the most important aspects of care; it will prepare the patient to live and cope with the condition and improve quality of life. b.   Smoking causes permanent damage to the lung and diminishes the lungs’ protective mechanisms. Air flow is obstructed and lung capacity is reduced. Smoking increases morbidity and mortality and is also a risk factor for lung cancer.	1.     Understands disease and what affects it 2.     Verbalizes the need to preserve existing lung function by adhering to the prescribed program 3.     Understands purposes and proper administration of medications 4.     Stops smoking or enrolls in a smoking cessation program 5.     Identifies when and whom to call for assistance

Patient Teaching & Home Health Guidance 

Patient Teaching & Home Health Guidance for Patient With Bronchiectasis. Bronchiectasis is a chronic pulmonary disease characterized by permanent abnormal dilatation and destruction of the elastic and muscular components of the walls of major bronchi and bronchioles. The disease has three forms: cylindrical (fusiform), varicose and saccular (cystic). It affects people of both sexes and all ages. Chief clinical features of the disease are cough, daily mucus hypersecretion, Dyspnea, and recurrent respiratory tract infections, which may be accompanied by Hemoptysis. 

Patient Teaching & Home Health Guidance for Patient with Bronchiectasis: 

• Instruct on early signs of pulmonary or sinus infection: change in amount or color of sputum or nasal drainage, Hemoptysis, increased Dyspnea, fever, chills, fatigue, headache, chest pain. 
• Emphasize importance of completing full course of antimicrobial therapy to prevent relapse or development of resistant strains of organisms; include education on proper delivery of intravenous and/or aerosolized antibiotics. 
• Teach patient and significant other effective airway clearance techniques to remove secretions and optimize ventilation. In addition to postural drainage and chest percussion, the patient may be instructed on proper use of the Flutter or PEP devices. The Vest is an alternative to chest percussion. 
• Encourage the patient to drink plenty of fluids to thin secretions and aid expectoration 
• Educate on avoidance of potential lung irritants: secondhand smoke, dust, noxious fumes, occupational exposures, and respiratory infections. 
• Instruct the patient to avoid air pollutants and people with known upper respiratory tract infections. 
• Inform patient of variety of pharmacologic and non-pharmacologic smoking cessation strategies and aids. 
• If appropriate, advise the patient to stop smoking because it stimulates secretions and irritates the airways.

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Nursing Care Plan for Bone Fractures

A fracture, or discontinuity of the bone, is the most common type of bone lesion. Normal bone can withstand considerable compression and shearing forces and, to a lesser extent, tension forces. A fracture occurs when more stress is placed on the bone than it is able to absorb.

A bone fracture is a medical condition in which there is a break in the continuity of the bone. A bone fracture can be the result of high force impactor stress, or trivial injury as a result of certain medical conditions that weaken the bones, such asosteoporosis, bone cancer, or osteogenesis imperfecta, where the fracture is then termedpathological fracture. (http://en.wikipedia.org/wiki/Bone_fracture)

Cause for Bone Fractures Bone Fractures Grouped according to cause, fractures can be divided into three major categories:

1. Fractures caused by sudden injury The most common fractures result from major trauma, such as a fall on an outstretched arm, a skiing or motor vehicle accident, and child, spouse, or elder abuse (shown by multiple or repeated episodes of fractures). The force causing the fracture may be direct, such as a fall, or indirect, such as a massive muscle contraction or trauma transmitted along the bone. For example, the head of the radius or clavicle can be fractured by the indirect forces that result from falling on an outstretched hand. 
2. Fatigue or stress fractures A fatigue fracture results from repeated wear on a bone. Pain associated with overuse injuries of the lower extremities, especially posterior medial tibial pain, is one of the most common symptoms that physically active persons, such as runners, experience Stress fractures in the tibia. 
3. Pathologic fractures. A pathologic fracture is fracture that occurs when the normal integrity and strength of bone have been compromised by invasive disease or destructive processes or tumors. Fractures of this type may occur spontaneously with little or no stress. The underlying disease state can be local, as with infections, cysts, or tumors, or it can be generalized, as in osteoporosis, Paget’s disease, or disseminated tumors. 

Classification of Bone Fractures Fractures usually are classified according to: Location Type Direction or pattern of the fracture line.

Fragment position

• Angulated, Bone fragments are at an angle to each other 
• Avulsed, Bone fragments are pulled from normal position by muscle spasms, muscle contractions, or ligament resistance 
• Comminuted, Bone breaks into many small pieces 
• Displaced, Bone fragments separate and are deformed Impacted, A bone fragment is forced into another bone or bone fragment 
• Nondisplaced, After the fracture, two sections of the bone maintain normal alignment 
• Overriding, Bone fragments overlap, thereby shortening the total length of the bone
• Segmental 

Fracture line

• Linear Fracture line is parallel to the axis of the bone 
• Longitudinal Fracture line extends longitudinally but not parallel to the axis of the bone 
• Oblique Fracture line crosses the bone at a 45-degree angle to the axis of the bone 
• Spiral Fracture line coils around the bone 
• Transverse Fracture line forms a 90-degree angle to the axis of the bone 

A fracture of the long bone is described in relation to its position in the boneproximal, midshaft, and distal. Other descriptions are used when the fracture affects the head or neck of a bone, involves a joint, or is near a prominence such as a condyle or malleolus. The type of fracture is determined by its communication with the external environment, the degree of break in continuity of the bone, and the character of the fracture pieces.10

A fracture can be classified as open or closed. When the bone fragments have broken through the skin, the fracture is called an open or compound fracture. In a closed fracture, there is no communication with the outside skin.

The degree of a fracture is described in terms of a partial or complete break in the continuity of bone. A greenstick fracture, which is seen in children, is an example of a partial break in bone continuity and resembles that seen when a young sapling is broken. This kind of break occurs because children’s bones, especially until approximately 10 years of age, are more resilient than the bones of adults.

The character of the fracture pieces may also be used to describe a fracture. A comminuted fracture has more than two pieces. A compression fracture, as occurs in the vertebral body, involves two bones that are crushed or squeezed together. A fracture is called impacted when the fracture fragments are wedged together. This type usually occurs in the humerus, often is less serious, and usually is treated without surgery. Segmental fracture Bone fractures occur in two areas next to each other with an isolated section in the center

The direction of the trauma produces a certain configuration or pattern of fracture. Reduction is the restoration of a fractured bone to its normal anatomic position. The pattern of a fracture indicates the nature of the trauma and provides information about the easiest method for reduction. Linear fractures, Fracture line is parallel to the axis of the bone Transverse fractures are caused by simple angulatory forces. A spiral fracture results from a twisting motion, or torque. A transverse fracture is not likely to become displaced

Treatment for Bone Fractures

The primary goals of treatment are to return the injured limb to maximal function, to prevent complications, and to obtain the best possible cosmetic results. Emergency treatment consists of splinting the limb above and below the suspected fracture where it lies, applying a cold pack, and elevating the limb, all of which reduce edema and pain. A severe fracture that causes blood loss calls for direct pressure to control bleeding. The patient with a severe fracture may also need fluid replacement (including blood products) to prevent or treat hypovolemic shock.

Treatment Options for Bone Fractures

Treatment Options to set a Bone Fractures depends on the location and severity of the injury. To heal a bone fractures properly, the fractured bone must be realigned. The most common realignment procedures are: Immobilization using a cast or splint Setting of bone through surgery. Advantages of surgery include: early mobility of injured bone and some use of the injured bone within weeks rather than months. After the bone is realigned properly, medication and rehabilitation will help the recovery process. Medication is used to lessen the pain. Rehabilitation prevents stiffness. Rehabilitation involves light movement of the tissues surrounding the injury. It helps increase blood flow which will aid the healing process.

Nonoperative Management

Until comparatively recently, nonoperative treatment was the only method of treating fractures and severe soft tissue injuries, but the introduction of anesthesia, antibiotics, improved surgical implants, and better operative techniques has changed the treatment of many fractures. The process of change continues, and probably fewer fractures will be managed nonoperatively as the functional benefits of operative treatment become more apparent to both surgeons and patients.

TRACTION: Skeletal Traction, Spinal Traction,

CASTS Braces

Slings, Bandages, and Support Strapping skeletal traction skeletal traction

Operative Management

When closed reduction is impossible, open reduction during surgery use to reduces and immobilizes the fracture by means of rods, plates, or screws

• Plating 
• Intramedullary Nailing 
• Kirschner wires 
• External Fixation 
• Arthroplasty 
• Amputations 

Complications for Bone Fractures

Possible complications of fractures include arterial damage, nonunion, fat embolism, infection, shock, avascular necrosis, and peripheral nerve damage. Acute Compartment Syndrome Nonunions and Bone Defects Nursing diagnosis for bone fractures

Nursing diagnosis for bone fractures determine by data that we found in nursing assessment: Nursing Assessment nursing care plans for bone fractures

Assessment on patient’s history usually reveals what caused the fracture, major trauma, such as a fall on an outstretched arm, a skiing or motor vehicle accident, or elder abuse. The patient typically reports pain that increases with movement and an inability to move the part of the arm or leg distal to the injury. The severity of the pain depends on the fracture type. The patient may also complain of a tingling sensation distal to the injury, possibly indicating nerve and vessel damage.

Inspection may disclose soft-tissue edema, an obvious deformity or shortening of the injured limb, and discoloration over the fracture site. Open fractures produce an obvious skin wound and bleeding. Gentle palpation usually reveals warmth, crepitus and, possibly, dislocation. Numbness distal to the injury and cool skin at the end of the extremity may indicate nerve and vessel damage. Auscultation may reveal loss of pulses distal to the injury, an indication of possible arterial compromise or nerve damage.

Palpation pulses in distal of the fracture to detect injury to blood vessels, which is a surgical emergency

Diagnostic tests for Bone Fractures

Anteroposterior and lateral X-rays of the suspected fracture, as well as X-rays of the joints above and below it, confirm the diagnosis. Angiography can reveal concurrent vascular injury. MRI or CT Scan of spine if suspect a bone tumor or compression of spinal cord Bone densitometry can predict an increased risk of osteoporosis usually in pathologic fractures Blood tests

Nursing Care Plans for Bone Fractures. Common nursing diagnosis for bone fractures:

• Acute pain, 
• Anxiety, 
• Bathing or hygiene self-care deficit, 
• Fear, 
• Impaired physical mobility, 
• Ineffective coping, 
• Ineffective role performance, 
• Ineffective tissue perfusion: Peripheral, 
• Risk for deficient fluid volume, 
• Risk for disuse syndrome, 
• Risk for infection, 
• Risk for injury, 
• Risk for [additional] Trauma. 

Nursing Goals Nursing Care Plans for Bone Fractures

Pain controlled. Prevented or minimized Complications Fracture stabilized. Condition, prognosis, and therapeutic regimen understood. Plan in place to meet needs after discharge. Nursing Care Plans for Bone Fractures with nursing diagnosis Acute pain

Sample Nursing Care Plans For bone Fracture with nursing diagnosis Pain Acute

NURSING DIAGNOSIS	INTERVENTIONS	EVALUATION
Acute Pain related to Muscle spasms Movement of bone fragments, edema, and injury to the soft tissue Traction, immobility device Stress, anxiety	·       Perform a comprehensive assessment of pain including location, characteristics, onset/duration, frequency, quality, severity ·       Maintain immobilization of affected part ·       Elevate and support injured extremity ·       Perform and supervise passive or active ROM exercises ·       Suggest diversional activities appropriate for client’s age, physical abilities, and personal preferences ·       Administer medications, as indicated.	·       Verbalize relief of pain. ·       Follow prescribed pharmacologic regimen ·       Display relaxed manner, able to participate in activities, and sleep and rest appropriately ·       Demonstrate use of relaxation skills and diversional activities, as indicated for individual situation

Patient Teaching Discharge and Home Healthcare Guidelines for Fractures Patient 

Teaching Discharge and Home Health care Guidelines for fractures patient. To prevent complications of prolonged immobility, encourage the patient to participate in physical and occupational therapy as prescribed. Verify that the patient has demonstrated safe use of assistive devices such as wheelchairs, crutches, walkers, and transfers. Teach the patient the purpose, dosage, schedule, precautions, and potential side effects, interactions, and adverse reactions of all prescribed medications. Review with the patient all follow-up appointments that are arranged. If home care is necessary, verify that appropriate arrangements have been completed. 

• Help the patient set realistic goals for recovery. 
• Show the patient how to use his crutches properly. 
• Tell the patient with a cast to report immediately signs of impaired circulation (skin coldness, numbness, tingling, or discoloration). 
• Warn the patient against getting the cast wet, and instruct him not to insert foreign objects under the cast. Teach the patient to exercise joints above and below the cast as ordered. 
• Tell the patient not to walk on a leg cast or foot cast without the physician’s permission. 
• Emphasize the importance of returning for follow-up care.

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