Question

Patient: Marilyn Jones

Medical Diagnosis: Lower Leg Fracture-Compartment Syndrome

Brief Summary: This case presents a post-surgical patient following an open reduction with internal fixation (ORIF) of a left tibia-fibula fracture. The student will be expected to conduct a basic assessment including a pain scale, recognize complications (compartment syndrome), and intervene appropriately.

Marilyn Jones is a 45-year-old female who suffered a left mid-shaft tibia-fibula fracture when she slipped on icy stairs this morning. She was taken to surgery for an open reduction with internal fixation (ORIF). She returned from surgery at 1:45 p.m. with a below-the-knee ace/splint dressing. Vital signs have been stable, and neurovascular checks have been within normal range. She has an IV of Lactated Ringer's infusing at 75 mL/hour and is tolerating liquids well without nausea. Her diet could probably be advanced to regular dinner this evening. A family member has been with her at the bedside throughout the day. She began complaining of pain shortly after returning from surgery and was given morphine 6 mg IV at 2:15 p.m. She is now on every-30-minute postoperative vital signs. Last vital signs were BP: 130/82, HR: 88, RR: 16.

1.   What would be a priority nursing diagnosis(in PES format) for this patient based on the scenario?

2.   What would be a risk nursing diagnosis(PES format) for this patient?

3.   What would be a short term goal?

4.   What would be a long term goal?

Answer 1