Lina Clinical Reasoning Case Study 2022

Nursing Care Plan
Lina Case Study

Clinical Reasoning Cycle
step 5
Based on the patient situation and the nursing diagnosis – the following
SMART Goals are established :-
• GOAL 1 – Achieving increased mobility. [from immobilization to mobilization to ambulatory phase]. Time – 4-5 weeks
• GOAL 2 - Pain relief– Line has low pain and bone pain due to L2 fracture). Goal is to be achieved in 1- 2weeks. Assessment
– Numerical Pain Rating Scale [NPRS], VAS [Visual Analogous Scale].
• GOAL 3 – Fall prevention – Goal is to be achieved within 1-2 weeks. The Measurement/evaluation - Fall Risk Assessment
Tool.
• GOAL 4 : Functional Independence – Lina has self care deficits, cognitive deficits and functional restriction. For
measurement and evaluation - Functional Independence Measurement (FIM) tool. Time – 3- 5 weeks.
Picture link -
https://www2.aofoundation.org/wps/portal/!ut/p/a1/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2DDbz9_UMMDRyDXQ3dw9wMDAzMjYEKIvEocDQnTr8BDuBoQEh_Q
W5oKAD4ENaS/dl5/d5/L2dJQSEvUUt3QS80SmlFL1o2XzJPMDBHSVMwS09PVDEwQVNFMUdWRjAwMDcz/?
showPage=redfix&bone=Spine&segment=TraumaThoracolumbar&classification=53-B2&treatment=&method=Posterior%20short%20segment%20fixation%20with%20pedicle
%20screws&implantstype=&approach=&redfix_url=1417448419953

Clinical Reasoning Cycle step 6
NURSING INTERVENTIONS to manage COMPRESSION FRACTURE L2 with OSTEOPOROSIS:
Objective Intervention Clinical
rationale
Expected
clinical
outcome
1. Maintaining immobilization,
preventing contractures and
maintaining muscle strength
(around hip and limbs)
[in immobilization phase] (Holla et
al., 2017).
Aiding the subject with slings and
braces
• The braces and slings will aid in
immobilization and faster healing of
fracture (Baumgarten et al., 2018).
Improved stabilization of the joints
and healing of the fracture.
2. Developing functional mobility
[in mobilization phase]
ADL and mobility training • Promoting mobility and ADL in
the patient with help in
improvement of functional
independence (de Souto Barreto
et al., 2017).
Improved mobility and bone
growth.
3. Pain management (in the fracture
and surrounding area)
Administering the prescribed pain
reliever medication at proper times
of the day.
• Low back pain ( of muscular origin)
and bone pain ( due to fracture) can be
treated by administering the analgesics.
Reduced pain.
4. Preventing falls and re-
traumatization
Observation and supervision of
patient environment
• Monitoring and assessing for risks in
the patient environment will prevent
falls ( in the ambulatory phase) Improved functional walking.
5. Maintaining the nutrition status
of the patient
Fat and cholesterol free diet must
be given. Providing a diet rich in
vitamin, minerals, carbohydrates is
crucial to faster healing of the
patient.
Reduced cholesterol and fat in the
diet will improve high blood
pressure.
Better nutrition will promote bone
growth and treat osteoporosis.
Improved nutritional status of bone
and body.
.