CASE STUDY: A client on a balanced skeletal traction

You are caring for a 19 year-old male who is being treated at the male BST ward for 6 weeks now. He resides in Caloocan City, and is the second child of 5 siblings.

Health History

Mr. A was admitted 6 weeks ago after sustaining a fractured right tibia from a vehicular accident. He was riding a tricycle when it lost control while cruising. They tricycle allegedly had tumbled three times and he fell on his side. Next thing he knew, his right leg was dangling, and he felt sharp pain on his leg and knee afterwards. A balanced skeletal traction was applied on his right leg in the hospital, and he was told that he should recuperate in about 8-9 weeks.

Mr. A has been taking his antibiotics and pain reliever ever since he was confined. He however complains that he is getting mildly anxious with his long hospital stay, and gets relief when people talk to him. Currently, he says that he is not that anxious, but he his extremely uncomfortable because he has not had a full bath for 2 weeks now, and nurses during the shift are just giving him a sponge bath. He also verbalizes difficulty in moving about in the bed, and sometimes feels pain on his butt. With regard to his affected leg, he says that it’s not that painful as before, although it still feels painful if he does not take his pain relievers on time.

Physical Exam

You then inspect the affected leg. It is attached to a balanced skeletal traction. The weights hang freely, and there are no knots in the ropes. His body is aligned to the weight applying the traction. The pin site is dry and intact, with minimal purulent drainage. It is mildly swollen and pinkish I color. Upon palpation of his right foot, he tells you that it feels a little numb, and he finds it a bit difficult moving his toes. You also observe that the client gets irritable when he tries to reach for the trapeze and attempt to move.

The client’s vital signs are within normal limits during the whole shift.

Mechanics You are entitled to get more subjective and objective data. However, you are only limited to 10

questions and 10 objective parameters, because the client becomes irritable when assessment takes too long.

Identify 2 nursing diagnoses based on the given data. State your diagnoses with their etiologies. Formulate a short-term plan (For the whole shift) with at least 3 outcome criteria. Formulate a long-term plan (For 1 week) with at least 3 outcome criteria. For each plan, state at least 4 interventions with their corresponding rationale.

Point Distribution Assessment = 3 pts (Total = 6 pts) Evaluation = 3 pts (Total = 6 pts) Diagnosis = 3 pts each (Total = 6 pts) Plan = 3 pts each (Total = 12 pts) Interventions = 4 pts (Total = 16 pts) Rationale = 4 pts/intervention (Total = 16 pts)