Basic Nursing 1st Edition by Judith Wilkinson, Leslie Treas

Exercise 3

Refer to Meet Your Patient, at the beginning of the chapter. State whether each of Mr. Ivanos's goals was a short-term or a long-term goal.
Meet Your Patient
Ben Ivanos has just been admitted to an orthopedic unit after a motorcycle accident. Mr. Ivanos is 24 years old and normally healthy; he takes no medications. He has casts and traction on both legs and a cast on one arm. He is receiving morphine sulfate intravenously via a patient-controlled analgesia (PCA) pump. Imagine that you are an orthopedic nurse and must plan care for Mr. Ivanos. You rank the following nursing diagnoses as highest priority:
1. Acute Pain secondary to musculoskeletal trauma (arms, legs, body) and muscle spasms
2. Risk for Peripheral Neurovascular Dysfunction secondary to casts/traction.
You write the following desired outcomes (goals) on the care plan:
Goals for diagnosis 1
Demonstrates correct use of PCA pump.
Rates pain not higher than 4 on a scale of 1 to 10 at all times.
Goals for diagnosis 2
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
These goals will guide you in choosing nursing interventions for relieving Mr. Ivanos's pain and preventing peripheral neurovascular dysfunction. When the nursing shift changes, the written care plan provides directions for the new caregivers so that they will continue to focus on Mr. Ivanos's most important needs.