Running head: CARE PLAN 1

PRNU 105

Care plan: Sprained ankle

Daffney Jones

Vancouver Island University

CARE PLAN

Nursing assessment

Objective

19-year-old female presents left ankle that is swollen, red, warm to touch, with non-pitting

edema. Left ankle measures 26 cm from malleolus circumference. Right ankle measures 22cm

circumference. Pt. grimaces and stated “ouch” when ankle was palpated. Full ROM in both

knees. Decreased ROM in left ankle compared to right. Patient’s biceps and triceps are able to

resist opposing force. Sharp and dull sensations were differentiated above and below the injury

and were consistent with uninjured side. Dorsalis pedis pulse is equal and 2+ on both right and

left. Capillary refill is equal to 3 seconds. BP 125/85mmHg recorded on the left arm in high

fowlers position. BPM 105. Pt. has unsteadied gait that was noticed when she had to walk in with

her friend supporting her left side. Pt. arrived with no shoe on left ankle. Patient has no known

allergies.

Subjective

Patient states “6/10 on the pain scale.” Pain started 1 hour ago. Patient states “it feels better

when my ankle is lifted up and feels worse when I have to put weight on it.” Patient describes

pain as “throbbing in left ankle.” Patient took an ibuprofen 30 minutes ago. Patient twisted ankle

while playing soccer patient states “I strained my ankle last year playing basketball too.”

Nursing diagnosis

“Impaired walking” (NANDA-I NURSING DIAGNOSIS 2012-2014) related to inflammation of

the ankle as evidenced by redness, swelling, edema, warm to touch, tenderness, inability to bear

weight on the left ankle and support needed from a friend to walk.
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Goal #1

Patient has reduced pain to 3/10 in the next hour as evidenced by patient statement and

decreased blood pressure to 120/80mmHg

Goal #2

Patient will demonstrate two step gait and proper technique for axillary crutch use 1 hour after

her pain is brought down to 3/10. She will also verbalize why it is important to have four fingers

width between the top of the crutch and her axillae.

Implementation #1

“Application of cold” (Williams & Hopper, 2015, p. 160).

Rational #1

“Cold can reduce swelling, bleeding, and pain when used to treat a new injury” (Williams &

Hopper, 2015, p.160).

Implementation #2 “NSAID’s are prescribed” (Williams & Hopper, 2015, p.1060) as per

doctor’s order and administered prn.

Rationale #2

“NSAID’s are used for several days until the pain is diminished” (Williams & Hopper, 2015. p.

1060).

Implementation #3

“Assess pain based on patients report [every thirty minutes]” (Williams & Hopper, 2015, p. 165).
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Rationale #3

“Patient’s pain is defined as what the patient says it is, when the patient says it is occurring”

(William & Hopper, 2015, p. 165).

Implementation #4

“Refer patient to physiotherapist [for 15-minute axillary crutch lesson]” (Taylor et al, 2015, p.

1079).

Rational #4

“Axillary crutches are used to provide support for patients who have temporary restrictions on

ambulation” (Taylor et al, 2015, p.1079).

Evaluation

Patient was able to verbalize pain levels and her pain was decreased to a 3/10 within 1 hour.

Patients BP decreased to 120/80 mmHG. Patient was able to demonstrate proper form with

axillary crutches as evidenced by a two-step gait without forcing the top of the crutch into the

axillae and verbalized that she could damage nerves if she leans her axillae on the top of the

crutches.

Nursing assessment #2

Objective

19-year-old female presents left ankle that is swollen, red, warm to touch, with non-pitting

edema. Left ankle measures 26 cm from malleolus circumference. Right ankle measures 22cm

circumference. Pt. grimaces and stated “ouch” when ankle was palpated. Full ROM in both

knees. Decreased ROM in left ankle compared to right. Patient’s biceps and triceps are able to
CARE PLAN

resist opposing force. Sharp and dull sensations were differentiated above and below the injury

and were consistent with uninjured side. Dorsalis pedis pulse is equal and 2+ on both right and

left. Capillary refill is equal to 3 seconds. BP 125/85mmHg recorded on the left arm in high

fowlers position. BPM 105. Pt. has unsteadied gait that was noticed when she had to walk in with

her friend supporting her left side. Pt. arrived with no shoe on left ankle. Patient has no known

allergies.

Subjective

Patient states “6/10 on the pain scale.” Pain started 1 hour ago. Patient states “it feels better when

my ankle is lifted up and feels worse when I have to put weight on it.” Patient describes pain as

“throbbing in left ankle.” Patient took an ibuprofen 30 minutes ago. Patient twisted ankle while

playing soccer patient states “I strained my ankle last year playing basketball too.”

Nursing Diagnosis

“Acute pain” (NANDA-I DIAGNOSIS 2012-2014) related to inflammation as evidenced by

redness, swelling, edema, tenderness and grimacing when ankle is palpated, and patient

statement that pain is 6/10 on pain scale.

Goal #1

Patient will understand how to reduce pain, at home, as evidenced by verbalization of RICE

(rest, ice, compression and elevation) protocol in the next hour.

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Goal #2

Patient will have decreased pain and relaxed state as evidenced by a pulse rate of 70 BPM a pain

rating of 2/10, and the ability to successfully complete a five-minute imagery therapy in the next

30 minutes.

Implementation #1

“Research the subject to be taught [RICE]” (Taylor et al, 2015, p. 492).

Rationale #1

“Nurses cannot teach information and skills to patients if they themselves lack the information

and skills to be taught” (Taylor et al, 2015, p. 493).

“Extensive information is easily accessible online, along with handouts, books, and journal

articles available in many nursing units” (Taylor et al, 2015, p. 492).

Implementation #2

“Demonstration of [RICE] techniques” (Taylor et al, 2015, p. 494).

“Practice session [of RICE technique]” (Taylor et al, 2015, p. 494).

Rationale #2

“Education experts agree that using a variety of teaching strategies enhances learning” (Taylor et

al, 2015, p.493).

Implementation #3

“Assist patients to begin to achieve a relaxation response by focusing on [her] breathing”

(Taylor et al, 2015, p. 740).

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Rationale #3

“A relaxation technique is frequently used to prepare the mind and body before beginning an

imagery session” (Taylor et al, 2015, p. 741).

Implementation #4

Talk patient through a five-minute imagery session.

Rationale #4

“Guided imagery focuses on evoking pleasant images to replace negative or stressful feelings

and to promote relaxation” (Taylor et al, 2015, p. 741).

Evaluation

Patient demonstrated how to accomplish RICE and verbalizes that it is used to reduce pain and

swelling in her injury. Patient states that her pain is down to 2/10 and has a heart rate of 70 Bpm:

she states “I feel more relaxed after the imagery: it took my mind off of my ankle for a few

minutes!”