Rib Fracture Nursing Care Plans Diagnosis and Interventions
Rib Fracture NCLEX Review and Nursing Care Plans
Rib fracture, or a broken rib, is a type of fracture that accounts for at least 12 percent of all cases of broken bones. The rib cage is a bony structure made up of the sternum (breast bone), 24 rib bones divided into 12 pairs, and cartilage attached to the thoracic region of the spinal column.
The rib cage’s primary functions are to protect the chest cavity organs, notably the heart and the lung, facilitate breathing by allowing the lungs to expand and fill up with air, and to provide structural support for the upper structures of the body.
The first three rib pairs are considered the hardest to break, while the last two rib pairs–ribs 11 and 12–are more difficult to break due to their position and structural mobility.
Rib fractures happen when one of the bones or cartilages making up the rib cage is cracked or broken, usually due to receiving a direct, heavy blow to the chest.
Common causes of these include vehicular accidents, assault injuries (e.g. gunshot wounds), falls and sports-related injuries. Though they can be painful, most cases of rib fractures recover without developing complications through appropriate assessment and management.
Signs and Symptoms of Rib Fracture
When any of the ribs are fractured, severity of the injury can range from a crack to the rib breaking into several pieces. Patients with rib fractures may experience:
- Mild to severe pain that worsens while breathing or moving. Patients experiencing pain while performing what can be considered a causative action that can potentially result in rib microfracture (such as swinging a golf club) should be considered for rib fractures even if there is no presenting difficulty of breathing yet.
- Tenderness around the chest area that is painful to touch, often with presence of bony crepitus, or crunching or grating, squeaking sounds, when palpating site of injury
- Diminished or abnormal breath sounds, which may be indicative of pulmonary complications
Causes and Risk Factors of Rib Fracture
Rib fractures can occur traumatically or atraumatically. Traumatic rib fractures are caused by blunt trauma to the chest area, which can occur during vehicular accidents, falls, sports-related injuries and even repeated, severe coughing.
Atraumatic rib fractures, or fractures not caused by direct force to the chest, are caused by weakness in the bone structure, as seen in patients with bone diseases and cancer, causing them to break more easily.
Those patient groups who are especially at risk for rib fractures include:
- Patients with bone diseases, such as osteoporosis
- Patients with cancer, especially if the tumor is located in a rib or those with metastatic cancers
- Athletes who play contact sports, such as basketball or American football, or sports involving repetitive movements that can cause wear and microtrauma to the chest area, such as rowing or golf.
- Elderly patients, who are especially prone to falls
Since children have more elastic ribs than adults, they do not develop fractured ribs as often. Therefore, a pediatric patient presenting rib fractures should be assessed for possible child abuse.
Complications of Rib Fracture
A broken rib can put the chest organs it is supposed to protect at risk. When a patient has a rib fracture, they are evaluated for signs of possible complications, including:
- Ruptured blood vessels, such as the aorta, that can cause internal bleeding
- Damage to the lungs, such as punctured lungs that can lead to chest wall deformities like pneumothorax or hemothorax.
- Damage to other organs. While the two lowest ribs are less likely to break than the rest of the rib cage due to their mobility, when they do fracture, the neighboring organs such as the kidneys, liver and spleen, can also get damaged.
- Flail chest. A potentially fatal complication for a fractured rib is developing a flail chest. Flail chest is a type of rib injury when at least three rows of ribs have two or more fractures per rib, causing the affected segment to not expand or contract in sync with the rest of the chest wall. Signs and symptoms of a flail chest include severe pain and an uneven rising or falling of the chest while breathing. Flail chest is considered a medical emergency with a mortality rate between 10 to 15 percent.
Diagnosis of Rib Fracture
In order to determine if a patient has a fractured rib, the doctor will first conduct a physical exam by assessing the chest area for signs of trauma or injury, including bruising or visible chest wall deformities.
Palpation of the chest area may reveal bony tenderness or pain to touch. The doctor may also use a stethoscope to check for irregular breath sounds and assess for low oxygen levels (hypoxia) if the patient is complaining about breathing problems.
Diagnosing rib fractures can be done with a thorough physical exam and history taking, and usually will not need additional imaging studies. However, for patients with complicated rib fractures, several diagnostic exams can also be ordered, such as:
- X-Rays. Most fractures can already be identified by x-rays. They can also screen for collapsed lungs, a potential and fatal rib fracture complication. X-Rays are also needed to diagnose certain rib fracture complications, including flail chest.
- Ultrasounds. Ultrasound readings can help doctors in diagnosing whether a particular fracture is caused by trauma or an underlying pathologic condition; as well as help identify potential rib fracture complications.
- CT Scans. Considered as the gold standard for rib fracture diagnosis, however CT Scans are used for more than identifying fractures in patients with known chest trauma. While some fractures not clearly visible on x-rays or ultrasounds may appear more defined in a CT scan, these fractures may present minimal to no clinical significance. CT scans are more often done on rib fracture patients to rule out possible blood vessel damage or other internal injuries
- MRI. Like CT scans, MRIs can be used to identify organ and soft tissue damage as well as fine fractures. However, they are less preferred for stress-related bone fractures compared to bone scans, as resulting images can be more difficult to interpret and MRIs are generally more expensive and less effective than bone scans.
- Bone scans. Usually the more preferred diagnostic exam to provide additional imaging for stress fractures if needed, useful in identifying weakness in bone structure, including fractures. However, they also expose patients to more radiation, and may not even be necessary to conduct for most cases of rib fractures.
Treatment for Rib Fractures
Most uncomplicated cases of rib fractures can be treated on an outpatient basis, and heal on their own after at least six months.
Inpatient management may be needed for patients with multiple rib fractures, displaced ribs or patients with additional organ or blood vessel injury. Elderly patients are especially vulnerable to complications like pneumonia and will require closer monitoring.
Treating rib fractures may involve the following interventions:
- Medications. Oral pain relievers are prescribed to help the patient breathe more comfortably and relieve pain. Injectable analgesia such spinal nerve blocks may also be given if oral pain relievers are insufficient. Placing ice or cold compresses on the injured area is advised to reduce the swelling.
- Breathing exercises. Because of the tenderness and pain that usually occur when breathing while with rib fractures, patients tend to alleviate the discomfort through shallow breathing. However, this increases the risk for patients to develop complications such as lung collapse (atelectasis) or pneumonia. To prevent this, aside from pain management, doctors will also prescribe performing regular breathing exercises and provide patient education on proper deep breathing techniques. Use of a spirometry is also recommended to help encourage patient compliance.
- Physical therapy. As with other fractures, providing adequate periods of rest is important to help the bones heal. However, patients should also be encouraged to have equally adequate amounts of mild to moderate activity to prevent pneumonia. Activities that can add pressure to the chest and further aggravate the fractured rib should be avoided, including crunches, lifting, pushing or pulling heavy objects.
- Prevention and management of complications. Injuries to other organs like hemothorax or pneumothorax should also be treated, especially if the patient is for surgical management for their rib fractures. While rib fractures typically heal well on their own, complete recovery may be prolonged depending on the severity of any additional organ injuries sustained. These complications should usually be managed first before a patient’s rib fracture can be managed surgically, if necessary.
- Surgery. If conventional, non-invasive treatments are not enough, surgical management can be considered to stabilize rib fractures using titanium plates. Surgical management is necessary for patients with flail chest, which is considered a medical emergency. Other possible rib fracture patients for surgery may be those with chest wall deformity, or experiencing severe chest pain unrelieved by medication that interfere with normal breathing and can lead to respiratory failure.
- Avoiding tib taping. Splinting or binding of the ribs to alleviate pain associated with rib fractures was once common practice. But studies found that rib taping encouraged shallow breathing which puts patients at risk for further complications, and is no longer recommended.
Nursing Considerations for Rib Fractures
Care for patients with rib fractures is generally the same with care for patients with other types of bone injuries. Nursing priorities for these patients include:
- promoting healing of fractured ribs
- ensuring that patients maintain adequate breathing, airway and circulation
- managing pain
- preventing complications commonly associated with chest injuries, such as atelectasis and pneumonia
Nursing Diagnosis for Rib Fractures
Rib Fracture Nursing Care Plan 1
Nursing Diagnosis: Acute Pain related to chest muscle spasms, broken bone fragments, tissue injury, edema, and/or anxiety, secondary to rib fracture as evidenced by pain scale rating, descriptions of pain quality (e.g. throbbing), grimacing, guarding behaviors, and symptoms of exertion and autonomic manifestations of pain
Patient will verbalize relief or lessening of experienced pain, will no longer demonstrate grimacing or expressions of pain, and reduced guarding behaviors, will be able to perform activities of daily living with no to minimal discomfort, and will be able to understand and demonstrate activities and techniques to help manage pain and discomfort
|Rib Fracture Interventions||Rationale|
|Assess severity and quality of patient’s pain. Record according to pain severity (use pain scales such as numerical pain scale, the FACES scale, or the FLACC scale), the quality and description of the pain, and any aggravating or relieving factors that affect perception of pain.||Creating a database on a patient’s pain experience can serve as a basis for intervention and a baseline to measure effectiveness of pain management.|
|Monitor for other signs and symptoms accompanying the pain. Report and record any untoward manifestations indicative of a possible complication.||Signs and symptoms such as abnormal vital signs, fever, chills and difficulty breathing are complications that may be due to infection, especially for post-operative patients.|
|Provide adequate periods of rest.||Bed rest can help relieve moderate pain and promote healing.|
|Avoid binding a rib fracture injury site.||Binding a rib fracture injury site can encourage improper breathing technique and cause complications|
|Provide alternative comfort measures such as cold compress, massage, position changes, and diversionary activities (watching TV, listening to music, meditation and guided imagery, etc.)||Comfort measures can help relieve local pressure and improve circulation in the affected area. Diversionary activities can help divert patient focus and minimize perception of pain.|
|Assess the patient’s current pain medication regimen. Schedule patient’s activities in consideration of the effectiveness of pain medications. Ideally, patient’s pain medication should be given before care activities or therapeutic exercises||It is important to evaluate the effectiveness of current pain medication and the need to re-evaluate therapeutic regimen or patient’s physical condition if pain relief is consistently not achieved. Giving pain medication prior to any activity will help patients become better prepared and encourage compliance.|
|Remind the patient to ask for medication if pain becomes too severe, or to inform the nurse if the current medication is no longer able to regulate pain.||To emphasize the importance of pain management for patient comfort and to avoid breathing becoming compromised by the pain|
|Ensure that patient-controlled analgesia (PCA) access is patent, infusing well and is adequately maintained.||PCA access should be well-maintained to prevent fluctuations in pain relief and exacerbation, which can lead to muscle tension and spasms. Compromised access sites can also put patients at risk for developing infection.|
Rib Fracture Nursing Care Plan 2
Nursing Diagnosis: Deficient Knowledge related to unfamiliarity with the diagnosis as evidenced by questions regarding rib fractures, possible misinformation or unawareness regarding disease process
Patient will be able to verbalize understanding of current condition, possible complications and the rationale behind medications and interventions for treatment, and will be able to demonstrate compliance to prescribed medications and treatments outlined in their care plan
|Rib Fracture Interventions||Rationale|
|Discuss with the patient their condition’s pathology, causative and risk factors, prognosis and the contents of their care plan.||To provide the patient with information on their current condition and enable them to create informed decisions about their healthcare.|
|Provide education on the patient’s medication regimen. Assess for and address potential drug-drug interactions with patient’s prescribed medications prior to having rib fractures.||To prevent potential adverse reactions and complications resulting from non-compliance to medication or drug to drug interactions with previous prescribed medications.|
|Assess effectiveness of any analgesics being taken and consider further assessment if current pain medication is ineffective.||Managing pain is especially important to rib fracture patients to prevent complications associated with ineffective breathing patterns due to pain-induced difficulty of breathing. Ineffective pain management may prompt a need to re-evaluate current pain medications being used or to consider other pain management options.|
|Educate the patient on limitations in mobility while still with rib fracture. List down activities that patient will require assistance with while still under treatment (e.g. heavy lifting, pushing or pulling objects), and advise patient to avoid movements that can aggravate their current injury||To ensure that the patient will be aware of their current physical limitations and prepare the patient on how to deal with them while still healing.|
|Educate the patient on possible ways to prevent recurrence of rib fractures, such as:|
Avoid or limit participation in contact sports and recommending use of protective equipment; provide resources and education to prevent falls; advise elderly patients to have constant companions to prevent injuries; and ensure adequate rest periods for patients who cannot avoid activities involving repeated movement that can cause stress injuries (i.e. athletes)
|To provide rib fracture time to heal and prevent recurrence of rib injury.|
|Discuss with the patient the importance of attending follow-up appointments as scheduled. Advise to watch out for any untoward signs and symptoms that will require reassessment.||To enable monitoring of healing progression for rib fractures and effectiveness of current treatment plan. The patient should monitor for possible complications such as fever, chills, increased or unmanageable pain, dizziness or difficulty breathing.|
Rib Fracture Nursing Care Plan 3
Risk for Ineffective Breathing Pattern
Patient will be able to have regulated, normal breathing pattern, maintain respiratory rates and oxygen saturation levels within normal limits, will be able understand and verbalize importance of maintaining proper breathing techniques, and will be able to actively participate and collaborate during activities to facilitate adequate breathing patterns
|Rib Fracture Interventions||Rationale|
|Assess and monitor respiratory rate, breathing depth and oxygen saturation levels, auscultate for abnormal breath sounds, and note for any signs of exertion or difficulty of breathing (i.e. breathing assisted by accessory muscles)||Consistently monitoring the patient’s breathing pattern will enable prompt intervention should there be early signs of ineffective breathing pattern or respiratory distress.|
|Determine aggravating and relieving factors for ineffective breathing patterns.||Knowing what can cause ineffective breathing patterns in fractured rib patients (usually pain) can help prepare both the nurse and patient to prevent future episodes.|
|Educate the patient on the importance of maintaining an adequate breathing pattern.||Maintaining deep breathing is important for rib fracture patients to prevent lung collapse and pneumonia.|
|Encourage the patient to do deep breathing exercises and advise prescription of incentive spirometry, if possible. Provide pain relievers prior to exercises as indicated.||Prevent complications related to ineffective breathing patterns and to maintain adequate oxygenation. Use of incentive spirometry can provide data on the effectiveness of the patient’s deep breathing exercises and encourage compliance. Preemptively provide pain relief prior to exercises to reduce or prevent occurrence of pain.|
|Encourage adequate rest periods between activities.||Ensure that the patient has enough rest periods to give the body time to recover from therapeutic activities and to heal their injuries.|
Rib Fracture Nursing Care Plan 4
Impaired Physical Mobility
Nursing Diagnosis: Impaired Physical Mobility related to neuromuscular skeletal impairment secondary to rib fracture, as evidenced by verbalizations of pain, possible limited range of motion in moving upper body or extremities
The patient will be able to attain optimal level of mobility, and to be able to carry on activities of daily living as unimpededly as possible.
|Rib Fracture Interventions||Rationale|
|Assess the extent of the patient’s limited movement, and patient’s perception of their limited ROM.||Establish baseline data on the extent of the patient’s limitations, the maximum possible attainable ROM, and how likely the patient will be compliant to activities to promote return to optimal ROM.|
|Educate the patient on performing active ROM, or how to participate in active-passive ROM exercises. For stress injury rib fractures, caution should be observed to limit the repeated movement that caused the micro injury that may lead to the fracture in the first place.||Performing ROM exercises improve mobility, strengthen muscle tone, and improve blood flow to the upper extremities. Active patient participation encourages the patient to take charge of their healthcare and their compliance.|
|Educate the patient to limit strenuous or weight bearing activities on the upper extremities while their rib fracture injuries are still healing. Provide assistance in activities as necessary.||Lifting heavy weights, pushing, pulling, or overexertion of upper extremities can worsen rib cage damage and delay healing. Advise activities in moderation.|
|Ensure adequate pain control and encourage the patient to verbalize any pain or discomfort that may limit mobility and physical activity. Encourage deep breathing exercises and to maintain a regular breathing pattern.||Attain optimal pain management to encourage the patient to remain active and prevent pulmonary complications like pneumonia.|
Rib Fracture Nursing Care Plan 5
Nursing Diagnosis: Self-Care Deficit related to physical limitations and pain secondary to rib fracture as evidenced by inability to fulfill activities of daily living such as bathing, dressing and toileting.
Desired Outcome: The patient will be able to demonstrate activities of daily living to the best of his abilities.
|Rib Fracture Interventions||Rationale|
|Determine the limitations of the patient regarding self-care.||Determining baseline information regarding the self-care needs of the patient aids the healthcare provider in formulating appropriate care plans for the patient.|
|Formulate with the patient an efficient exercise regimen that targets the particular activity deficit of the patient.||Patients who have rib fractures will require a well-formulated exercise regimen in order to regain muscle integrity and autonomy in self-care.|
|Involve the relatives or significant others on how they can assist with the patient’s self-care needs.||Active participation of the patient’s significant others decreases reliance on skilled home service and reinforces the prescribed therapeutic regimen.|
|Ensure that the patient complies with the ordered adequate pain management.||Poorly managed pain could result in limited attempts to move and therefore increase struggle in performing activities of daily living.|
|Coordinate and refer the patient to occupational therapists as indicated, including the use of assistive devices.||Coordination with specialists can improve the patient’s ability in performing activities of daily living.|
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Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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