Fractures are broken bones. Fractures can occur from trauma such as motor vehicle accidents, age-related conditions like osteoporosis, or from overuse such as stress fractures in athletes.
There are also different kinds of fractures. Here are some examples:
- Open (compound) fracture. Bone has broken through the skin.
- Closed fracture. The bone does not puncture through the skin.
- Greenstick fracture. Frequently seen in children when the bone has bent but does not break.
- Comminuted fracture. The bone is shattered in multiple places.
Nursing Process
Nurses may care for patients with fractures in many settings such as emergency departments, urgent care centers, or inpatient units following surgical repairs. Fractures can be minor such as a broken toe only requiring splinting or major such as a hip, neck, or femur fracture requiring surgery, inpatient care, and months of recovery. Nurses assist with pain control, overcoming activity limitations, preventing further complications, and discharge planning.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for a fracture, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for fractures.
Acute Pain
Acute pain with a fracture results from injury to the surrounding tissues, muscles, and nerves.
Nursing Diagnosis: Acute Pain
Related to:
- Bone displacement
- Compromised tissue
- Muscle spasms
- Edema
As evidenced by:
- Verbalization of pain
- Guarding behavior
- Facial grimacing or crying
- Diaphoresis
- Restlessness
- Distracted behavior
- Tachypnea, tachycardia, and increased blood pressure
Expected Outcomes:
- Patient will report pain of 2/10 or less by discharge
- Patient will display signs of comfort as evidenced by resting with eyes closed and vital signs within normal limits
- Patient will utilize nonpharmacologic pain relief measures
Assessment:
1. Assess for pain.
Using appropriate pain scales based on age and cognitive level (numeric, Wong-Baker FACES, FLACC) assess the severity of pain. The nurse should also assess the location, characteristics, and frequency of pain.
2. Monitor vital signs.
An elevated blood pressure and heart rate is a normal response to pain. These vital signs should improve once appropriate pain measures are instituted.
3. Assess pain relief.
After administering pain medications, the nurse should follow up within an hour to assess the effectiveness of medications or interventions.
Interventions:
1. Administer analgesics.
Acute fractures usually warrant narcotic pain relief which may be oral or IV. NSAIDs such as Ibuprofen or Naproxen treat inflammation and are often given in conjunction with narcotics.
2. Provide alternative comfort measures.
Patients should not rely solely on medication. Implement alternative measures that alleviate the patient’s pain such as ice packs, heat, massage, distraction, and controlled breathing.
3. Support the injured area.
A fractured extremity should remain elevated to reduce swelling. Utilize splints or traction devices as ordered. Immobilize the fractured area and follow weight-bearing instructions to promote healing.
4. Instruct on medications at discharge.
Patients should be instructed to not take pain medications more frequently than prescribed. If the dose ordered is not controlling their pain they should contact their provider. Instruct on other precautions with narcotics such as not operating vehicles, and possible side effects such as drowsiness, dizziness, nausea, and constipation.
Impaired Physical Mobility
Fractures impair the ability to ambulate, complete ADLs, and increase the risk of falls and other injuries.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Loss of integrity of bone structure
- Pain
- Prescribed activity restrictions
- Reluctance to initiate movement
- Deconditioning
As evidenced by:
- Reports of pain
- Unwillingness to move
- Limited ROM
- Decreased muscle strength
Expected Outcomes:
- Patient will increase ambulation distance and participation in ADLs as tolerated
- Patient will demonstrate techniques to support movement
- Patient will remain free from falls or injury while ambulating
Assessment:
1. Assess the degree of physical limitation.
Physical immobility will depend on the location and severity of the fracture as well as pain and swelling. Interventions will be determined based on what the patient can and cannot do for themselves
2. Assess for pain or other psychological concerns.
Pain and discomfort will prevent the patient from moving. Depression and anxiety may also prevent purposeful movement. Delays in movement will only further exacerbate pain and may lead to contractures and loss of muscle strength and tone.
3. Assess for a support system.
At discharge, the patient’s mobility will dictate further needs. If the patient does not have capable caregivers then they may require a short-term stay at a rehabilitation facility or in-home care.
Interventions:
1. Encourage independence.
The patient should be encouraged to do as much for themselves as possible. Even patients confined to a bed can assist with turning themselves and should be encouraged to perform ADLs such as feeding or washing their face if possible.
2. Premedicate before movement.
The nurse should anticipate pain and premedicate before potentially painful activities such as PT sessions or complete bed baths. This will help relax the patient and improve their ability to perform exercises.
3. Collaborate with PT/OT.
Hip fractures, spinal fractures, or other serious fractures may require PT or OT to assist with safe movement. These specialists can teach patients how to use canes, crutches, and other devices as well as instruct on exercises to strengthen muscles.
4. Encourage the use of assistive devices and equipment.
Any equipment that will support safe movement such as bedside commodes, grab bars, walkers, or scooters should be utilized.
Risk For Constipation
Opioids used for pain will cause constipation as they slow down gastric emptying and peristalsis. Untreated constipation can have uncomfortable and serious consequences.
Nursing Diagnosis: Risk For Constipation
Related to:
- Immobility
- Opioid use
- Change in eating pattern
- Insufficient fluid intake
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred yet and the goal of nursing interventions is aimed at prevention.
Expected Outcomes:
- Patient will have a solid bowel movement at least every 3 days
- Patient will report no straining or discomfort with defecation
- Patient will implement 2 measures to prevent constipation
Assessment:
1. Auscultate bowel sounds.
Assess for the presence, location, and characteristics of bowel sounds.
2. Assess the patient’s normal bowel pattern.
Not everyone has a bowel movement daily. Bowel movements every 2-3 days are considered normal as long as the patient is not experiencing discomfort.
Interventions:
1. Administer stool softeners or laxatives.
The most common side effect of opioid medications is constipation. When prescribed these medications a stool softener should be used prophylactically in conjunction. For severe constipation, enemas may be required.
2. Educate on the risk and prevention of constipation.
Educate that patient that constipation is increased due to their immobility and use of opioids (if taking). Stool softeners should be taken before constipation occurs to prevent impaction or serious complications such as a bowel obstruction.
3. Increase fluids.
Fluids keep stools soft and easier to pass. Patients should drink plenty of water (if not contraindicated) as well as juices such as prune juice. Hot beverages like tea also stimulate bowel movements.
4. Increase mobility as tolerated.
Immobility from fractures can also slow down peristalsis. While the patient must first follow activity instructions, once the patient may safely ambulate or exercise, this should be encouraged.
References
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
- Sizar O, Genova R, Gupta M. Opioid-Induced Constipation. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493184/
- Throckmorton, T. W. (2021, August). Fractures (Broken Bones) – OrthoInfo – AAOS. OrthoInfo. Retrieved March 10, 2022, from https://orthoinfo.aaos.org/en/diseases–conditions/fractures-broken-bones/
- Types of Fractures. (n.d.). The Orthopedic Institute at Southwest Health. Retrieved March 10, 2022, from https://www.orthopedic-institute.org/fracture-care/types-of-fractures/
