Medical-surgical Nursing Demystified

(^268) Medical-Surgical Nursing Demystified
NURSING DIAGNOSES

• Risk for impaired skin integrity


• Risk for activity intolerance


• Impaired physical mobility

NURSING INTERVENTION

• Monitor circulation: check peripheral pulses, capillary refill, and skin tem-
  perature distal to the break. Compromise of blood flow will diminish pulses,
  slow capillary refill and cause cool skin temperature. Compare bilateral areas
  for symmetry.


• Monitor vital signs: check for elevated pulse, low BP, and elevated respira-
  tory rate. The broken bone ends can lacerate a vessel causing internal bleed-
  ing; monitor for signs of shock. May see elevated temperature with infection
  from open fracture.


• Explain to the patient:
  
  
  • How to provide self-care—depending on the fracture area, the patient’s
    ability to care for himself or herself may be compromised.
  
  
  • The importance of performing range-of-motion exercise to maintain mus-
    cle tone in the areas not immobilized.
  
  
  • Not to insert anything into the cast. The padding may become dislodged,
    causing pressure points under the hard cast which would lead to skin
    breakdown. The skin integrity may also be broken when scratching under
    the cast, leading to an infection.
  
  
  
  

Gout

WHAT WENT WRONG?

This is a metabolic disorder in which the body does not properly metabolize

purine-based proteins. As a result, there is an increase in the amount of uric acid,

which is the end product of purine metabolism. As a result of hyperuricemia,

uricacid crystals accumulate in joints, most commonly the big toe (podagra),

causing pain when the joint moves. Uric acid is cleared from the body through

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