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Nursing Assessment Report

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Nursing Assessment Report 


Nursing Assessment Report


Institution Affiliation

Clinical Assessment

Historical and Physical Assessment

            The evaluation of a patient who suffers from femur fractures would require history reports, physical analyses and the causes of the breach. The historical assessment would focus on significant pain and elements like the inability to bear weight by the patient. Additionally, variables like shortening of the leg, bone injuries which include tibial shaft fractures and the extension of the fracture into distal femur (Juall, 2014). The above historical review would be anchored on traumatic femoral features.

            The historical report of the patient present that the patient had a fracture shaft femur. Additionally, the patient has chest pain and shortness of breath. The implication of the report; patient is suffering from trauma related femur fractures. Shortness of breath is critical and requires immediate addressing failure to which it may cost the life of the patient. The assessment would need a physical examination from head to toe to ensure all the parts of the body were not fractured (Juall, 2014). However, before the test, the following action plan will follow. In the assessment report information on causes of the breach will be vital. Additionally, any forms of treatment that the patient has been subjected to before in the course of the five days. 

Action Plan

            The nurse would require subjecting the patient to a ventilator to assist respiratory muscles and the lungs in breathing. A potential respiratory failure which requires immediate medical attention because it is highly life threatening if not responded to immediately (Juall, 2014). Failure to which, the effect would result in lack of air in and out of the lungs and thus the death of the patient.  Secondly, upon management of the situation, it will be necessary to offer pain medication, for example, the Anti-coagulants which are mainly used following traumatic fracture. Additionally, it will be required in operation treatment.

            The patient requires a stable fixation of the fracture to ensure the improvement of motion between the hip and the knee. The report on the fracture pattern will be provided through scans. Depending on severity of the situation, it may require surgery to correct any form of deformation of the bones. Additionally, the patient will require ambulatory aids, for example, the use of crutches in the initial stages of treatment. Pulmonary therapy will be resourceful to...


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