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SCHOLARLY ASSIGNMENT: CONCEPT MAP

Kushanvir Gill
820 420 024
NURS 252: Complex Issues and Patient Safety
February 5, 2016

13 year old, female with no past medical history. 8 hours post insertion of intramedullary rod for left femur fracture with Vitals
35.6, 66, 10, 100/60, 96% on 2L via NP. Distal Surgical site with adequate pedal pulse. Patient drowsy with difficulty answering
questions about pain.

Risk for trauma

Risk for post-surgical complications

Respiratory
depression

Interventions
-Place the patient
in a high
fowlers position
to facilitate
breathing and
lung expansion.
-Administer
oxygen as
ordered.
- Monitor for
labored
respirations,
cyanosis and
cold and clammy
skin.

- Monitor rate,
rhythm, depth,
and effort of
respirations to
determine need
for additional
respiratory
support
-Position should
be changed
every 1-2 hours
to allow full
chest expansion
and increase
perfusion of both
lungs.

Risk for deep vein


thrombosis R/T
immobility

Altered state of
consciousness

Interventions

Interventions

- Assess for signs


of venous
thromboembolis
m, such as
redness, swelling,
warm
extremities,
edema, pain,
tachypnea,
dyspnea and
restlessness.

-Monitor
neurological
status,
including level
of
consciousness,
pupillary
reactions and
motor and
sensory
function using
Glasgow coma
scale.

- Encourage early
ambulation to
maintain muscle
contractions and
adequate vascular
flow.

- Avoid pressure
under knees from
bed or pillows to
avoid pressure on
veins,
constriction of
circulation, or
pooling and stasis
of blood.

-Assist the
patient to optimal
body position for
passive or active
joint movement
to prevent
dislocation and
other
complications.
-Administer

- Monitor
respiratory
status and
maintain a
patent airway
because
increased CO2
levels increase
cerebral edema.
-Maintain NPO
status until
consciousness
returns.
-Monitor signs
for restlessness
or agitation to
get cues for
pain.
-Maintain the
clients safety
by putting side
rails up.

Risk for
injury

Interventions
-Provide assistive
devices such as
cane, walker or
wheelchair for
ambulation to
prevent falls.
-Assist patient to
sit on side of bed to
facilitate postural
adjustments.
-Assist patient with
ambulation to
promote mobility.
-Collaborate with
physiotherapist to
develop and
execute an exercise
program to
increase patients
compliance and
promote continuity
of exercise.
- Get an order to
administer pain
medication as a
control measure
before beginning
exercise to
decrease
discomfort from
exercise and
increase patients
participation.

Risk for
infection
Interventions

Impaired physical
mobility R/T
neuromuscular
skeletal impairment

Interventions

-Note and record

-Have the call bell

the type, amount,


colour, consistency
and odour of
drainage.

in reach to assist the


client.

-Notify doctor for


any excessive or
abnormal drainage
and significant
changes in vital
signs. (Such as
increased in
temperature)
- Instruct the patient
on how to care for
the incision during
bathing or
showering to avoid
infection.

-Inspect the incision


site for redness,
swelling, or signs of
dehiscence or
evisceration to
avoid
complications.

-Once the dressing


is removed after 48
hours clean the area
around the incision
with an appropriate
cleaning solution
and aseptic

- Assess for
abdominal
distension, presence
of flatus or stool,
bowel sounds, or
nausea and
vomiting to
determine if
paralytic ileus is
present.

-Monitor for
circulation,
movement and
sensation of
affected extremity
to detect possible
complication of
peripheral vascular
function.
-Provide trapeze for
movement in bed to
reduce
complications of
immobility.
-Monitor skin and
bony prominences
for early signs of
skin breakdown.
-Administer
appropriate skin
care at friction and
pressure points to
prevent skin
breakdown.

References
Lewis, S. L., Dirksen, S. R., Bucher, L., Heitkemper, M. M., & Camera, I. M. (2014). MedicalSurgical Nursing In Canada . Toronto: Elsevier Canada.
McLeod, A. (2204). British Journal of Nursing. Traumatic injuries to the head and spine 2:
nursing considerations, 1041-1049.
Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal Child
Nursing Care In Canada. Toronto: Elsevier Canada.