Comprehensive Fracture Care Plan for Nursing Students
Evidence-based nursing diagnoses, interventions, and outcomes for optimal fracture management
Understanding Fractures: The Foundation
What is a Fracture?
A fracture is a break or disruption in the continuity of a bone, which can range from a small crack to a complete break with multiple fragments. Fractures occur when the applied force exceeds the strength of the bone.
Types of Fractures
- Closed (Simple): Bone breaks but doesn’t pierce the skin
- Open (Compound): Bone breaks through the skin, increasing infection risk
- Comminuted: Bone breaks into multiple fragments
- Greenstick: Incomplete fracture where one side breaks and the other bends
- Transverse: Break is perpendicular to the bone’s long axis
- Oblique: Fracture line is at an angle to the bone’s axis
- Spiral: Fracture that twists around the bone, usually from rotational force
- Impacted: Broken ends are driven into each other
- Pathological: Occurs in diseased bone with minimal trauma
Remember Fracture Types: “COST GIP”
- Closed/Compound
- Oblique/Open
- Spiral/Simple
- Transverse
- Greenstick
- Impacted
- Pathological
The Healing Process of Fractures
| Stage | Timeline | Process |
|---|---|---|
| Inflammatory Phase | 0-5 days | Hematoma formation between bone fragments; inflammatory cells migrate to the site |
| Soft Callus Phase | 5-14 days | Fibroblasts produce collagen fibers that bridge the fracture; chondroblasts produce cartilage |
| Hard Callus Phase | 14-45 days | Osteoblasts replace cartilage with woven bone, forming a hard callus |
| Remodeling Phase | 45 days to years | Woven bone is replaced by lamellar bone; excess callus is resorbed and bone returns to original shape |
Clinical Pearl
The rate of fracture healing varies significantly based on factors including patient age, nutritional status, comorbidities, and fracture location. Weight-bearing bones typically heal faster due to greater blood supply and increased osteoblastic activity.
The Nursing Process in Fracture Management
Nursing Process Flow in Fracture Care
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation
Key Assessment Areas: “FRACTURE”
- Functional mobility assessment
- Range of motion evaluation
- Appearance of the affected area
- Circulation, sensation, and movement
- Tissue integrity around fracture site
- Understanding of patient about care
- Risk factors for complications
- Emotional response to injury
Comprehensive Nursing Care Plans for Fractures
1. Acute Pain
Nursing Diagnosis: Acute Pain related to tissue trauma, bone displacement, muscle spasm, and treatment procedures.
Assessment Findings:
- Verbal reports of pain (using pain scale)
- Guarding of affected area
- Facial grimacing, crying
- Altered vital signs (increased BP, pulse)
- Restlessness, inability to concentrate
- Muscle tension and spasms
| Nursing Interventions | Rationales |
|---|---|
| 1. Assess pain using a standardized pain scale at regular intervals and before/after interventions. | Establishes baseline and evaluates effectiveness of pain management strategies. Subjective pain experience requires consistent measurement. |
| 2. Administer prescribed analgesics on schedule rather than PRN for acute phase. | Maintaining therapeutic blood levels of medication provides better pain control than allowing pain to escalate before treatment. |
| 3. Position the affected limb with proper alignment and support using pillows. | Proper positioning reduces muscle tension, prevents strain on the fracture site, and promotes comfort. |
| 4. Apply cold therapy to affected area for first 24-48 hours as ordered. | Cold reduces bleeding, swelling, inflammation, and provides local anesthetic effect through nerve desensitization. |
| 5. Teach non-pharmacological pain management techniques (guided imagery, relaxation breathing). | Complementary approaches can reduce anxiety, distract from pain, and enhance effect of medications. |
| 6. Elevate the affected extremity above heart level when appropriate. | Elevation reduces edema by promoting venous return, thereby reducing pressure and pain at the fracture site. |
Expected Outcomes:
- Patient reports reduced pain levels (below 4 on a 0-10 scale) within 24-48 hours
- Patient demonstrates effective use of non-pharmacological pain relief methods
- Patient shows decreased physical manifestations of pain
- Patient maintains proper positioning of affected area
- Patient verbalizes understanding of pain management plan
2. Impaired Physical Mobility
Nursing Diagnosis: Impaired Physical Mobility related to pain, immobilization devices, prescribed movement restrictions, and decreased muscle strength.
Assessment Findings:
- Limited range of motion in affected limb/area
- Inability to move purposefully within physical environment
- Reluctance to attempt movement
- Compromised coordination
- Presence of immobilizing devices (cast, splint, traction)
- Decreased muscle strength and endurance
| Nursing Interventions | Rationales |
|---|---|
| 1. Assess level of mobility, strength, and functional limitations. | Establishes baseline and determines appropriate interventions and realistic goals for mobility progression. |
| 2. Perform passive ROM exercises to unaffected joints and active ROM for uninvolved extremities. | Maintains joint mobility, prevents contractures, maintains muscle tone, and prevents complications of immobility. |
| 3. Assist with mobility using appropriate assistive devices (walker, crutches, cane) based on fracture location. | Promotes safe mobility, prevents falls, and facilitates independence while protecting the healing fracture. |
| 4. Teach and supervise proper transfer techniques and weight-bearing status as prescribed. | Ensures patient safety, prevents re-injury, and promotes proper healing through adherence to weight-bearing restrictions. |
| 5. Implement an isometric exercise program for affected limb when appropriate. | Maintains muscle tone and strength without compromising fracture alignment, preparing for rehabilitation phase. |
| 6. Assess and monitor for complications of immobility (pressure injuries, DVT, constipation). | Early identification of complications allows for prompt intervention and prevention of secondary issues. |
Expected Outcomes:
- Patient demonstrates safe use of prescribed assistive devices
- Patient maintains muscle strength in unaffected extremities
- Patient adheres to prescribed weight-bearing restrictions
- Patient performs self-care activities at maximum level of independence
- Patient demonstrates proper body mechanics during transfers and mobility
- Patient remains free from complications of immobility
3. Risk for Peripheral Neurovascular Dysfunction
Nursing Diagnosis: Risk for Peripheral Neurovascular Dysfunction related to fracture, edema, treatment modalities (cast, splint, traction), and compartment syndrome.
Risk Factors:
- Mechanical compression from edema or tight casts
- Vascular injury associated with fracture
- Increased compartmental pressure
- Improper positioning of affected extremity
- Fractures in areas with significant neurovascular structures
Remember the “5 P’s” of Neurovascular Assessment
- Pain – Out of proportion, increased with passive movement
- Pallor – Color changes in extremity
- Pulse – Diminished or absent distal pulse
- Paresthesia – Numbness, tingling
- Paralysis – Motor deficit (late sign)
| Nursing Interventions | Rationales |
|---|---|
| 1. Perform comprehensive neurovascular assessment (5 P’s) every 1-2 hours initially, then every 4 hours as condition stabilizes. | Early detection of neurovascular compromise allows for timely intervention before permanent damage occurs. |
| 2. Assess capillary refill, skin temperature, sensation, and movement in digits distal to injury. | These assessments provide critical information about peripheral circulation and nerve function that may be compromised by the fracture or treatment. |
| 3. Elevate affected extremity above heart level using pillows. | Elevation promotes venous return, reduces edema, and decreases pressure on neurovascular structures. |
| 4. Monitor for signs of compartment syndrome (severe pain, pain with passive stretch, paresthesia, pressure, pallor, paralysis). | Compartment syndrome is a medical emergency requiring immediate intervention to prevent permanent tissue damage. |
| 5. Ensure casts/splints are not restrictive; monitor for proper fit. | Tight immobilization devices can compromise circulation and nerve function, particularly as edema fluctuates. |
| 6. Teach patient to report “CRAP” symptoms immediately: Increased Coldness, Redness, Altered sensation, or Pain. | Patient education enables early reporting of critical changes that may indicate neurovascular compromise. |
Expected Outcomes:
- Patient maintains adequate peripheral circulation evidenced by normal capillary refill (<3 seconds)
- Patient demonstrates normal sensation and movement in digits distal to injury
- Distal pulses remain palpable and equal to unaffected side
- Patient promptly reports changes in sensation, color, or temperature
- Patient remains free from signs of compartment syndrome
4. Risk for Impaired Skin Integrity
Nursing Diagnosis: Risk for Impaired Skin Integrity related to immobilization, pressure from casts/splints, decreased mobility, and altered sensation.
Risk Factors:
- Prolonged immobility
- Pressure from immobilization devices
- Moisture trapped under casts
- Friction during transfers
- Decreased sensation below fracture site
- Poor nutritional status affecting wound healing
- Presence of external fixation pins or surgical incisions
| Nursing Interventions | Rationales |
|---|---|
| 1. Perform comprehensive skin assessment every shift, paying special attention to pressure points and cast/splint edges. | Regular assessment allows for early identification of skin breakdown and implementation of preventive measures. |
| 2. Pad bony prominences and cast edges with soft materials as needed. | Padding reduces pressure and friction at vulnerable areas, preventing skin breakdown. |
| 3. Teach proper cast care: keep cast dry, avoid inserting objects under cast, use hair dryer on cool setting if cast becomes slightly damp. | Maintaining cast integrity and dryness prevents skin maceration, irritation, and breakdown underneath. |
| 4. Implement a turning schedule every 2 hours for bed-bound patients. | Regular repositioning relieves pressure on tissues, promotes circulation, and prevents pressure injuries. |
| 5. Assess for and address cast syndrome: odor, drainage, hot spots, pain under cast. | These signs may indicate skin breakdown, infection, or pressure areas under the cast requiring immediate attention. |
| 6. For external fixation pins, perform pin site care according to protocol (typically cleansing with chlorhexidine or saline). | Proper pin site care reduces infection risk and maintains skin integrity around insertion points. |
Expected Outcomes:
- Patient’s skin remains intact without evidence of pressure, friction, or moisture-related damage
- Cast/splint areas remain clean, dry, and odorless
- Pin sites remain clean without signs of infection (redness, drainage, tenderness)
- Patient demonstrates understanding of skin care and cast/splint precautions
- Patient maintains adequate nutrition and hydration to support skin integrity
5. Deficient Knowledge
Nursing Diagnosis: Deficient Knowledge related to unfamiliarity with fracture management, home care requirements, activity restrictions, and complication prevention.
Assessment Findings:
- Verbalization of inadequate understanding of condition or treatment
- Incorrect demonstration of techniques (transfers, assistive device use)
- Questioning about restrictions and timelines
- Anxiety about self-care management
- Failure to follow prescribed treatment plan
- Multiple requests for information repetition
Teaching Strategy
Use the “Teach-Back” method: Ask patients to explain or demonstrate what you’ve taught them in their own words. This method helps identify gaps in understanding and ensures effective learning.
| Nursing Interventions | Rationales |
|---|---|
| 1. Assess patient’s current knowledge, learning needs, preferences, and barriers. | Establishes baseline and tailors teaching to individual needs and learning style, improving knowledge retention. |
| 2. Provide comprehensive education about fracture healing process, expected timeline, and follow-up requirements. | Understanding the healing process promotes adherence to treatment plan and realistic expectations of recovery. |
| 3. Demonstrate and obtain return demonstration of proper assistive device use, transfers, weight-bearing technique. | Physical demonstration enhances learning of psychomotor skills and ensures safe practice at home. |
| 4. Teach warning signs requiring medical attention: increased pain, fever, cast/splint problems, changes in sensation/movement. | Early recognition of complications facilitates prompt intervention and prevents serious sequelae. |
| 5. Provide written instructions with illustrations for home care, exercise program, and activity progression. | Written materials reinforce verbal instruction and serve as reference after discharge when retention may decrease. |
| 6. Include family members/caregivers in education sessions when appropriate. | Support system involvement enhances adherence to treatment plan and provides assistance with care activities. |
Expected Outcomes:
- Patient verbalizes understanding of fracture condition and healing process
- Patient demonstrates correct use of assistive devices and proper body mechanics
- Patient explains weight-bearing restrictions and activity limitations
- Patient identifies warning signs requiring medical attention
- Patient demonstrates proper cast/immobilization device care
- Patient verbalizes understanding of follow-up care schedule
6. Risk for Infection
Nursing Diagnosis: Risk for Infection related to open fracture, surgical intervention, external fixation devices, and compromised skin integrity.
Risk Factors:
- Disruption of skin barrier in open fractures
- Presence of surgical incisions and hardware
- External fixation pins penetrating skin
- Compromised circulation to injured area
- Inadequate wound care techniques
- Environmental contamination at time of injury
- Compromised immune system or chronic diseases
Evidence-Based Practice
Early administration of antibiotics within 3 hours of an open fracture reduces infection rates by up to 59%. The current recommendation is for antibiotic administration within 1 hour when possible.
| Nursing Interventions | Rationales |
|---|---|
| 1. Maintain strict aseptic technique during wound care, dressing changes, and pin site care. | Aseptic technique minimizes introduction of pathogens to susceptible tissues, reducing infection risk. |
| 2. Administer prescribed antibiotics at scheduled intervals to maintain therapeutic levels. | Prophylactic or therapeutic antibiotics help prevent or treat infection by maintaining consistent blood levels of the antimicrobial agent. |
| 3. Assess wound sites and pin sites for signs of infection (redness, warmth, swelling, increased pain, purulent drainage). | Early detection of infection allows for prompt intervention before infection becomes established or spreads. |
| 4. Monitor vital signs, particularly temperature, for signs of systemic infection. | Fever may indicate systemic infection; changes in vital signs can provide early warning of developing sepsis. |
| 5. Maintain proper pin site care: cleanse with chlorhexidine or prescribed solution, keep dressings clean and dry. | Pin sites provide direct access to bone and deep tissues; proper care reduces colonization and infection risk. |
| 6. Monitor laboratory values (WBC, CRP, ESR) for infection indicators as ordered. | Elevated inflammatory markers can indicate developing infection before clinical signs become apparent. |
Expected Outcomes:
- Wounds and surgical sites remain free from signs of infection
- Patient maintains normal temperature and vital signs
- Pin sites remain clean without excessive drainage, redness, or pain
- Laboratory values remain within normal ranges or trending toward normal
- Patient demonstrates proper wound care and pin site care techniques
- Patient verbalizes understanding of infection signs requiring medical attention
7. Disturbed Body Image
Nursing Diagnosis: Disturbed Body Image related to physical changes, functional limitations, visible immobilization devices, and potential for long-term disability.
Assessment Findings:
- Verbalization of negative feelings about body or appearance
- Refusal to participate in care or look at affected area
- Social withdrawal or isolation
- Hiding affected body part (e.g., under clothing)
- Expressions of fear regarding permanent changes
- Preoccupation with loss of function or prior abilities
- Changes in social interaction patterns
| Nursing Interventions | Rationales |
|---|---|
| 1. Establish therapeutic relationship and encourage expression of feelings about body changes and limitations. | Open communication allows patient to process feelings about altered appearance and function, facilitating adaptation. |
| 2. Provide accurate information about expected physical changes and timeline for recovery. | Realistic expectations reduce anxiety and help patient understand temporary versus permanent changes. |
| 3. Assist with grooming and appearance-enhancing activities within limitations. | Maintaining appearance in areas unaffected by injury enhances self-esteem and normalcy. |
| 4. Encourage gradual involvement in care of affected body part. | Direct involvement promotes acceptance of changes and increases sense of control over recovery. |
| 5. Suggest clothing adaptations to accommodate casts/external fixators while maintaining style preferences. | Creative adaptations (e.g., side-snap pants, oversized clothing) allow for normal appearance despite immobilization devices. |
| 6. Refer to support groups or counseling if body image disturbance significantly impacts function or mood. | Peer support and professional guidance can assist with adjustment and coping strategies for significant body image issues. |
Expected Outcomes:
- Patient expresses feelings regarding changed body appearance and function
- Patient participates in self-care of affected body part
- Patient maintains social interactions and activities at maximum level possible
- Patient verbalizes realistic expectations about recovery and body appearance
- Patient displays adaptive coping strategies for temporary or permanent changes
- Patient demonstrates decreased preoccupation with physical limitations
8. Self-Care Deficit
Nursing Diagnosis: Self-Care Deficit (bathing, dressing, toileting, feeding) related to impaired mobility, pain, and presence of immobilization devices.
Assessment Findings:
- Inability to independently complete ADLs
- Difficulty manipulating clothing, bathing supplies
- Challenges with hygiene maintenance
- Balance difficulties during self-care activities
- Limited reach and range of motion affecting self-care
- Safety concerns during self-care activities
Remember “ADAPT” for Self-Care Support
- Assess individual capabilities and limitations
- Develop realistic goals for independence
- Assistive devices to facilitate self-care
- Progressive increase in self-participation
- Teach adaptive techniques for daily activities
| Nursing Interventions | Rationales |
|---|---|
| 1. Assess level of independence using functional assessment tools (e.g., Barthel Index). | Standardized assessment provides objective baseline to measure progress and identify specific areas requiring assistance. |
| 2. Provide adaptive equipment based on specific deficits (long-handled sponge, shower chair, dressing aids, raised toilet seat). | Appropriate assistive devices compensate for temporary limitations and promote maximum independence. |
| 3. Teach energy conservation techniques (sitting while performing tasks, organizing supplies within reach). | Conserving energy allows patient to complete more self-care activities without excessive fatigue. |
| 4. Collaborate with occupational therapy for specialized ADL training. | Occupational therapists provide expertise in adaptive techniques and equipment to maximize independence in daily activities. |
| 5. Establish a self-care routine that progressively increases patient participation. | Gradual progression to independence builds confidence and prevents frustration while ensuring safety. |
| 6. Teach methods for protecting casts/surgical sites during bathing (plastic covering, commercial cast protectors). | Maintaining cast integrity while performing hygiene activities prevents complications and supports healing. |
Expected Outcomes:
- Patient demonstrates increasing independence in self-care activities
- Patient uses adaptive equipment correctly and safely
- Patient maintains adequate hygiene despite limitations
- Patient verbalizes satisfaction with level of independence
- Patient demonstrates proper cast/wound protection during self-care
- Patient identifies resources for continued assistance if needed
9. Risk for Constipation
Nursing Diagnosis: Risk for Constipation related to immobility, opioid analgesics, changes in routine, and inadequate fluid/fiber intake.
Risk Factors:
- Decreased physical activity due to mobility restrictions
- Use of opioid pain medications
- Disruption of normal bowel routine
- Inadequate fluid intake
- Dietary changes during hospitalization/recovery
- Difficulty accessing toilet facilities due to mobility limitations
- Lack of privacy for elimination
Evidence-Based Practice
Research demonstrates that proactive bowel protocols for patients on opioid therapy reduce constipation rates by up to 70%. Implementing preventive measures is more effective than treating established constipation.
| Nursing Interventions | Rationales |
|---|---|
| 1. Assess normal bowel pattern and establish baseline. | Understanding patient’s normal elimination pattern allows for early detection of changes and appropriate intervention. |
| 2. Implement preventive bowel regimen when opioid analgesics are initiated. | Proactive management prevents opioid-induced constipation which is easier than treating established constipation. |
| 3. Encourage fluid intake of at least 2000-2500 mL daily unless contraindicated. | Adequate hydration softens stool and facilitates normal elimination. |
| 4. Promote high-fiber diet (20-35g daily) through food choices and/or supplements. | Dietary fiber adds bulk to stool, stimulates peristalsis, and promotes regular elimination. |
| 5. Ensure privacy and comfortable positioning during toileting. | Physical and psychological comfort during elimination facilitates natural bowel function. |
| 6. Monitor and document bowel movements including frequency, consistency, color, and amount. | Regular monitoring allows for early intervention if constipation develops despite preventive measures. |
Expected Outcomes:
- Patient maintains regular bowel elimination pattern
- Patient reports soft, formed stools without straining
- Patient consumes adequate fluid and fiber intake daily
- Patient experiences no abdominal discomfort or distention
- Patient verbalizes understanding of constipation prevention strategies
- Patient demonstrates proper use of prescribed stool softeners/laxatives if needed
10. Anxiety
Nursing Diagnosis: Anxiety related to acute injury, unfamiliar environment, uncertainty about recovery, potential lifestyle changes, and financial concerns.
Assessment Findings:
- Verbalization of concerns and worries
- Increased tension, restlessness, irritability
- Focus on potential negative outcomes
- Sleep disturbances
- Physiological responses (increased HR, RR, BP)
- Difficulty concentrating on instruction
- Expressed concern about impact on work, family roles
| Nursing Interventions | Rationales |
|---|---|
| 1. Assess level and source of anxiety using standardized tools and therapeutic communication. | Identifying specific anxiety triggers allows for targeted interventions and helps distinguish between normal concern and pathological anxiety. |
| 2. Provide clear, accurate information about condition, treatment plan, and recovery timeline. | Knowledge reduces fear of the unknown and corrects misconceptions that may increase anxiety. |
| 3. Teach progressive muscle relaxation, guided imagery, and deep breathing techniques. | These techniques activate the parasympathetic nervous system, countering physiological stress responses. |
| 4. Encourage expression of feelings and concerns; validate emotional responses as normal. | Validation normalizes anxiety as a common response to injury and promotes emotional processing. |
| 5. Maintain a calm, supportive environment with consistent caregivers when possible. | Environmental stability and familiar faces reduce situational anxiety during hospitalization. |
| 6. Refer to appropriate resources for practical concerns (social worker, financial counselor, vocational rehabilitation). | Addressing concrete stressors like financial or work issues reduces overall anxiety burden. |
Use “CALM” for Anxiety Management
- Clarify concerns and provide accurate information
- Acknowledge feelings as valid and normal
- Listen actively without rushing
- Minimize stressors in environment and teach coping skills
Expected Outcomes:
- Patient verbalizes decrease in anxiety levels
- Patient demonstrates effective use of coping strategies
- Patient exhibits reduced physical signs of anxiety
- Patient expresses realistic expectations about recovery
- Patient reports improved sleep patterns
- Patient participates in treatment decisions and care activities
Integrated Fracture Management: Putting It All Together
Comprehensive Fracture Care Flowchart
Initial Assessment
Type of fracture, neurovascular status, pain level
Type of fracture, neurovascular status, pain level
Immediate Management
Immobilization, pain control, neurovascular monitoring
Immobilization, pain control, neurovascular monitoring
Ongoing Assessment
Care plan implementation, complications monitoring
Care plan implementation, complications monitoring
Rehabilitation Phase
Progressive mobility, strengthening, self-care
Progressive mobility, strengthening, self-care
Discharge Planning
Education, home safety, follow-up care
Education, home safety, follow-up care
Clinical Pearls for Fracture Management
Pain Management Timing
Administer pain medication 30 minutes before physical therapy or dressing changes to maximize comfort and participation.
Cast Care
Petal the edges of casts with moleskin or tape to prevent skin irritation and breakdown at pressure points.
Circulation Checks
Compare the affected extremity with the unaffected side during neurovascular checks to establish a clear baseline for each patient.
DVT Prevention
Even with immobilized extremities, ankle pumps and isometric exercises can help prevent venous stasis and reduce DVT risk.
References and Further Reading
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.).
- Bulechek, G. M., Butcher, H. K., Dochterman, J. M., & Wagner, C. M. (2018). Nursing interventions classification (NIC) (7th ed.). Elsevier.
- Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). NANDA International nursing diagnoses: Definitions and classification, 2018-2020 (11th ed.). Thieme.
- Maher, A. B., Salmond, S. W., & Pellino, T. A. (2019). Orthopaedic nursing (5th ed.). Springer Publishing Company.
- Moorhead, S., Swanson, E., Johnson, M., & Maas, M. L. (2018). Nursing outcomes classification (NOC) (6th ed.). Elsevier.
- National Institute for Health and Care Excellence. (2022). Fractures (complex): Assessment and management. NICE guideline [NG37].
- Schoen, D. C. (2020). Adult orthopaedic nursing. Lippincott Williams & Wilkins.
- World Health Organization. (2021). Global report on falls prevention in older age. WHO Press.