胫骨开放性骨折护理查房英语范文

胫骨开放性骨折护理查房英语范文
Nursing Round Note for Open Tibial Fracture.
Patient: [Patient's name]
Medical Record Number: [Medical record number]
Date of Admission: [Date of admission]
Date of Injury: [Date of injury]
Assessment:
Chief Complaint: Open tibial fracture.
History of Present Illness:
The patient is a [age]-year-old [sex] who sustained an open tibial fracture on [date of injury]. The patient was [mechanism of injury], resulting in a [location] open
fracture of the [bone(s)]. The wound was initially managed with [initial management]. The patient was transferred to our facility for further care.
Past Medical History:
[List of past medical history, if any]
Medications:
[List of current medications, if any]
Allergies:
[List of allergies, if any]
Social History:
[Pertinent social history, if any]
Physical Examination:
Vital Signs:
Temperature: [Temperature]
Pulse: [Pulse]
Respirations: [Respirations]
Blood pressure: [Blood pressure]
General:
Alert and oriented x 3。

No acute distress.
Skin:
Open wound on the [location] aspect of the [limb]
Wound is [size] cm in length and [depth] cm in depth.
Wound edges are [description of wound edges]
Wound bed is [description of wound bed]
There is [amount] of drainage from the wound.
The surrounding skin is [description of surrounding skin]
Musculoskeletal:
Deformity of the [limb]
Tenderness to palpation over the [bone(s)]
Crepitus over the [bone(s)]
Limited range of motion of the [joint(s)]
Neurovascular:
Sensation is intact to the [level]
Motor function is intact to the [level]
Pulses are palpable in the [location]
Capillary refill time is less than 2 seconds. Other:
[Any other relevant physical exam findings]
Diagnostic Studies:
X-ray: [Findings of X-ray]
CT scan: [Findings of CT scan, if performed] MRI: [Findings of MRI, if performed]
Nursing Diagnosis:
Risk for infection related to open wound.
Acute pain related to fracture and wound.
Impaired physical mobility related to fracture and wound.
Risk for compartment syndrome related to swelling and edema.
Nursing Interventions:
Monitor the wound for signs of infection, such as redness, swelling, drainage, and pain.
Cleanse the wound with [solution] and dress the wound with [dressing].
Administer antibiotics as prescribed.
Elevate the [limb] to promote venous return and reduce swelling.
Apply ice to the [limb] to reduce pain and swelling.
Administer pain medication as prescribed.
Assist with range of motion exercises as tolerated.
Monitor for signs of compartment syndrome, such as pain, paresthesias, and decreased pulses.
Educate the patient on wound care and infection prevention.
Evaluation:
The patient's wound is clean and free of infection. The patient is experiencing minimal pain.
The patient is able to move the [limb] without difficulty.
The patient is at low risk for compartment syndrome.
The patient is educated on wound care and infection prevention.
Plan:
Continue to monitor the wound for signs of infection.
Continue to cleanse and dress the wound as prescribed.
Continue to administer antibiotics as prescribed.
Continue to elevate the [limb] and apply ice to reduce swelling.
Continue to administer pain medication as prescribed.
Continue to assist with range of motion exercises.
Continue to monitor for signs of compartment syndrome.
Continue to educate the patient on wound care and
infection prevention.
Discharge the patient with instructions on wound care, infection prevention, and follow-up appointments.。