Muscle spasms-risk for peripheral neurovascular dysfunction

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Justin Jones has just been admitted to an orthopedic unit after an automobile accident in which he was driving. He is 80 years old and has been living at home alone. Justin Jones has a history of Type 2 DM and osteoarthritis. He has casts and traction on both legs and a cast on one arm. He is receiving morphine sulfate intravenously via PCA pump. The admitting nurse wrote the following diagnoses and goals on the plan of care.

The nursing diagnosis is acute pain secondary to musculoskeletal trauma (arms, legs, body) and muscle spasms-risk for Peripheral Neurovascular Dysfunction secondary to casts/traction.

GOALS/EXPECTED OUTCOMES

Demonstrates correct use of PCA pump
Rates pain not higher than 4 on a scale of 1 to 10 at all times
Peripheral pulses palpable
Fingers and toes warm
Fingers and toes without pallor or cyanosis
No edema of fingers and toes
Capillary refill less than 3 seconds

1. What general knowledge will you need to care for this client?

2. What is one thing you could do to ensure Justin Jones' safety while managing his acute pain? List two more things you need to know about Mr. Jones to begin his discharge planning.

3. What is another nursing diagnosis you might want to include for Justin Jones?

4. Rewrite the goals/expected outcomes for Acute Pain so that they will have all the required components. Assume that today's date is November 10.

5. What beliefs, values, biases, or emotional responses might interfere with your ability to provide the best care to Justin Jones?

Reference no: EM133483802

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