Complex Nursing Care: Assessment, Interventions, and Education

Running head: COMPLEX NURSING CARE.
Complex Nursing Care
Name of student
Institutional affiliation

COMPLEX NURSING CARE.
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Assessment 1 Part 1- Complex Patient Plan of Care
Student Name: ____________________ Student ID: ________________ Case Study Patient:
_______________________
Patient/Nursing Problem Patient Assessment Data Optimal Patient
Outcome/Goal
Acute pain related to the bone
fracture, soft tissue damage,
movement of bone fragments,
devices applied for
immobility, muscle spasms
due to the injury.
Patient verbalizes pain rating
it at 9 in a scale of 1-10
Patient has facial grimaces
Patient is restless with an
increased heartrate of 120
beats/min.
Patient guards the place of
injury
Patient verbalizes relief of
pain,
Patient demonstrates
calmness, rests and sleeps.
Patient demonstrates normal
heartrate ranging 60-100
beats per minute.
Impaired skin and tissue
integrity related to oblique
fracture of the femur, open
and displaced fracture of the
tibia, compromised blood
circulation, reduced physical
Patient reports of pain in the
left leg
Presence of broken skin and
destroyed tissues.
Displaced bones and tissues
Patient demonstrates
alleviation from the
discomfort
Patient demonstrates wound
and bone healing promptly
Patient acquires practices

COMPLEX NURSING CARE.
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mobility, insertion of nails
and screws during the surgery
promoting healing e.g
immobility of the injured
limb.
Risk for wound infection
related to impaired defense
mechanism due to broken
skin, damaged tissues, open
and dirty wound, surgical
procedure and insertion of
foreign materials.
Presence of an open and dirty
wound
Damaged tissues and
fractured bone
Compromised blood supply
Presence of broken skin
Introduction of foreign nails
and screws
Patient to remain free of
infection as evidenced by
vital signs which are within
normal ranges.
Patient demonstrates proper
techniques of handwashing
and preventive measures
(Siddiqui et al., 2017).
Patient demonstrates wound
and bone healing
Diminished physical mobility
relatedto restrictive nature of
fracture management; limb
immobilization, pain on
movement, discomfort,
impairment of the muscle and
skeletal tissue.
Presence of surgical
restrictive modalities to
movement
Pain on movement.
Loss of muscle control.
Impaired range of motion
activities.
Patient demonstrates ability
to maintain active limb
movement and demonstrate
muscle control and strength.
Patient demonstrates normal
range of movements
Patient demonstrates
techniques and practices
towards attaining normal
function (Gómez-Barrena et

COMPLEX NURSING CARE.
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al., 2015).
Risk for falls and physical
trauma related to limb
weakness, impaired
neuromuscular function, pain
on attempted movement,
presence of traction and
reduced range of motion.
Presence of fractures and
displaced bone
Pain during movement
Presence of displaced bone
fragments
Limited ability to move
Patient demonstrates maintain
o control and stabilization of
fractures (Ramos, Travasso
and Carvalho, 2018).
Patient displays formation of
callus and bone union as
expected.
Patient demonstrates body
mechanics towards improving
stability of the fracture.
Risk for peripheral
neurovascular dysfunction
related to compromised blood
flow, injury to blood vessels,
injury to soft tissue and
excessive bleeding
Presence of broken and
destroyed tissues
Excessive bleeding due to the
injured tissues and blood
vessels
Compromised blood supply
to the periphery
Patient demonstrates normal
tissue perfusion confirmed by
presence of normal and
palpable peripheral pulses,
pink and warm skin, normal
sensation of the extremities
and stable vital observations
(Opacic et al., 2016).