Casestudy Fracture

8/10/2019 Casestudy Fracture

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I -PATIENT ASSESMENT DATA BASE

A. GENERAL DATA

1. Patients Name: M.F.

2. Address: Sta. Maria, Pangasinan

3.

Age: 23 years old4. Sex: male

5. Birth date: February 9, 1990

6. Rank in the Family: husband and father of 2 children

7. Nationality: Filipino

8. Civil Status: married

9. Date of Admission: December 28, 2013

10.Order of Admission:

Admit patient to ward

NPO

V/S every 4 hours and recordRequest for:

CBC, CT, urinalysis

X-ray:

Skull

Right thigh

Pelvis

Right leg

Right forearm

Right arm

Right ankle

IVF: plain LRS 1 liter 200ml fast drip then every 8 hours

IV meds:

Cefuroxime 750mg Q12 hours (ANST)

Ketorolac 1amp Q8 hours (ANST)

Tetanus toxoid 4500 units (ANST)

11.Attending Physician: Dr. Olivar

12.Admitting diagnosis:

Closed fracture, right medial malleolusClosed fracture, right humerus


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Closed fracture, comminuted, right radius and ulna

Closed fracture, middle third, right femur

Lacerated wound:

Right knee

Right leg

Left frontal

B. CHIEF COMPLAINT: acute pain

C. HISTORY OF PRESENT ILLNESS: traumatic injury (vehicular accident)

D. PAST HEALTH HISTORY/STATUS:

Childhood Illness: chicken pox, cold and cough

Immunization: incomplete

Major Illness: none

Current Medications: none

Allergies: no known allergies

E. FAMILY ASSESMENT:

NAME RELATION AGE SEX OCCUPATION EDUCLATTAINMENT

K.F. wife 19 years old female housewife 1styear college

(education)

C.F. daughter 2 years old female

K.F. daughter 1 month old female


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F. SYSTEM REVIEW:

1. HEALTH PERCEPTION- HEALTH MANAGEMENT PATTERN

The purpose of it is to determine how the client perceives and manage her health

According to thepatient health is important but disgrasya ngarud di awan maaramidak ah

2. NUTRITIONAL -METABOLIC PATTERN

The purpose of this is to determine the clients dietary habits and metabolic needs.

The patients typical diet consist of the following:

Breakfast Lunch dinner

Tuyo (dried fish) fish Adobo (balun-balunan, chickenheads)

Egg Monggo rice

Kamote tops Gulay (dinengeng)

Rice rice

1 cup of coffee

Patient also added he drinks 8-10 8oz. cups of water, he doesnt smoke and doesnt drink alcoholic beverages

3. ELIMINATION PATTERN:

The purpose of this is to determine adequacy of function of the clients bowel and bladder elimination

Bowel Habits: once a day

Color: Yellow

Odor: Foul Odor

Consistency: varies

Bladder:

Frequency of urine: 4x a day

Characteristics of urine: increase urine output

Color: clear

Odor: Strong smell


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4. ACTIVITY PATTERNEXERCISE PATTERN

The purpose of this is to determine the clients activity of daily living

The patient stated, he can perform all his activities of daily living before his accident. Now that he is just lying on bed

his family does his ADLs for him

5.

COGNITIVEPERCEPTUAL PATTERN Purpose of these is to determine the functioning status of the 5 senses, vision, hearing, touch (including pain perception), taste

and smell. Devices and methods used to assist the client with deficits any of this 5 senses are assessed.

According to Mr. M.F., he can hear, smell, feel, taste, and see clearly. He doesnt use any device to help his senses

work.

6. SLEEPREST PATTERN

The purpose of this is to determine the clients perception of her sleep, relaxation and energy levels. Methods used to promote

relaxation and sleep is also assessed.

According to patient, he sleeps around 10:00 pm and wakes up at 3:00 am. He also takes an afternoon sleep after

lunch whenever he is not busy on his farm.

7. SELF- PERCEPTION AND SELF-CONCEPT PATTERN:

The purpose of this is to determine the clients perception of her identity, body image and self- worth. The clients behavior,

attitude and emotional patterns are assessed.

According to thepatient, although he cant perform his ADLs, he is not upset on his current situation because he has

his family that is always there for him.

8. ROLE-RELATIONSHIP PATTERN:

The purpose of this is to determine the clients perception of responsibilities and roles in the family, work and in social life.

The patient told that they live in a compound with 11 families and most of them are relatives. he also added, mayatmet ngem dadduma adda met apa

9. SEXUALITYREPRODUCTIVE PATTERN

The purpose of this is to determine the clients fulfillment of sexual activities and perceive level satisfaction.

The patient stated that, he doesnt have any problem in his sexuality or reproductive pattern. He never used or tried

any contraceptives before.

10.COPINGSTRESS TOLERANCE PATTERN

The purpose of this is to determine the areas and amount of stress in the clients life and the effectiveness of coping methods

used to deal with it.

The patient told that whenever he is stressed, agtagba-tagbet ti kayo pangsungrod


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11.VALUEBELIEF PATTERN

The purpose of this is to determine the clients life, values and goals, philosophical beliefs and spiritual beliefs that influence

her own choices and decisions.

According to the patient, he is an Iglesia ni Cristo by faith.

G.

DEVELOPMENTAL HISTORY

THEORIST AGE SEX DESCRIPTION PATIENT DESCRIPTION

Erik Erikson 23 Male Intimacy vs. isolation(+) lasting relationship or

commitment.

(-) isolation and a fear ofcommitment

During our interview,with his current situation,the patient answered myquestions without anyhesitations. He doesntisolate himself even hecant do his ADLs

because he has his family

and he admits that ithappened because of anaccident, and no one

should be blamed.

H. PHYSICAL ASSESSMENT

a. GENERAL SURVEY

1.Overall appearance and grooming: client is neat and well groomed.

2.

Actual height and weight: 57 in height and 75 kilograms BMI: 25.90

3.Symptoms of distress:

4.Posture, gait: lying on bed

5.Affect, mood: despite of the patient condition, he still manages to tell us the whole scenario how his accident happened.

b. VITAL SIGNS (initial)

BP: 110/70 mmHg

RR: 20 respirations per minute

PR: 75 beats per minute

TEMP: 37.1c


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c. REGIONAL EXAMutilize IPPA technique

1. Head, Skin, Hair, Nails: lacerated wound on the left forehead, stitched and covered with gauze.

The clients skin tone is brown. It is cold and moist. The skin turgor is good and do not have any signs of dehydration.

Hair is black and straight. No scalp lesions or flaking.

The clients nail shape is convex, not well-trimmed and slightly dirty. The nail is smooth and the nail bed is pink. The capillary

refill is within 3 seconds.

2. Eyes: patient has no complains of blurring of vision or any visual problems; the eye brows are evenly distributed. Eyelids have

effectively closure. The blink response is bilateral, eye balls are symmetrical, conjunctiva is pinkish, and the sclera is white.

The color of his eyes is brown, the shapes are equal, and it is uniform in color. Pupils are equal in size. Pupils are equally round

and reactive to light and accommodation.

3. Nose: The color of the clients nose is the same as the color of his face. His septum is in the midline. The mucosa is pink;

nostrils are both patent, no nasal flaring.

4. Ears:The color of the ear is brown, it is symmetrical. The pinna is symmetrical. The pinnas are elastic and recoil when folded.

The mastoid process is non-tender. No discharges noticed.

5. Mouth and throat:The lips is symmetrical and pink, the consistency is smooth, buccal mucosa is pink, the gums is pink, the

tongue is pink and it is smooth. The color of the hard and soft palate is pink and is intact. The tonsils are not inflamed. Uvula is in

the midline, gag reflex is present. The teeth have a complete set of 32 teeth.

6. Neck and lymph nodes:no pulsations visible, no thyroid enlargement upon palpation and inspection. No tenderness or

stiffness noted. No swollen lymph nodes.

7. Thorax and lungs:The color of the chest is brown. The chest expansion is symmetrical. Respiratory rhythm is regular.

Respiratory pattern is normal. When palpated she doesnt feet any tenderness. When percussed the sound is resonance. No

adventitious sound heard upon auscultation. Respiratory rate is 20 breaths per minute.

9. Cardiovascular:The rhythm is regular. No jugular vein distension. Heart rate is 75 beats per minute.


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10. Breast and axilla:symmetrical with no signs of dimpling or retraction. Nipples are equal in size, no lesions, no abnormal

discharges and tenderness.

11. Abdomen:Peristalsis is non-visible. The bowel sound normal: every 15-20 seconds. When percussed the sound is tympany.

When palpated he doesnt have any tenderness.

12. Extremities: skin color is the same as the other parts of the body which is brown. The client can resist force when asked to

resist (unaffected area). There is swelling on the affected site. The IV site is in his left arm.

13. Genitals:Not performed.

14. Rectum and anus: not performed.

15. Neurological/cranial nerves:

Olfactory:he is able to differentiate smell from that of an alcohol and perfume.

Optic:reacts on both sides.

Oculomotor: eyes move smoothly in a coordinated motion in all directions (the six cardinal fields).

Trochlear:Bilateral pupils constricts simultaneously when illuminated.

Trigeminal:temporal and masseter muscles contract bilaterally when chewing.

Abducens:pupils are equally rounded reactive to light and accommodation.

Facial nerve:patient is able to smile, frown, wrinkles forehead, shows teeth, puff out cheeks, purses lips, raises

eyebrows, and closes eyes against resistance in symmetrical movement.

Acoustic:patient is able to hear whispered words from 1-2 feet.

Glossopharyngeal: has no difficulty in swallowing.

Vagus:the gag reflex is present.

Spinal Accessory:there is symmetric, strong contraction of trapezius muscles when asked to shrug the shoulders

against resistance. There is also a strong contraction of sternocleidomastoid muscle on side opposite the turned face when

turning the head against resistance.

Hypoglossal:can move tongue and can swallow without difficulties.


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II- PERSONAL/SOCIAL HISTORY

A. HABITS / VICES

a. Caffeine: 1 cup of coffee everyday for breakfast

b. Smoking: no

c. Alcohol: no

d. Tea/juice: no

e. Soda: occasionally

f. Drugs: never used any prohibited or illegal drugs

III- ENVIONMENTAL HISTORY (LIVING/NEIGHBORHOOD/CIRCUMSTANCES)

According to the patient, their house is made of bamboo and tin roof located in a compound of 11 families. Their water source for drinking

is from a water pumping station. They live about 1 kilometer from the barangay hall and about 2 kilometers away from the market andtowns health center.


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IV- INTRODUCTION (RELATED TO THE DISEASE / CASE OF THE PATIENT)

FRACTURES

A fracture is a disruption or break in the continuity of the structure of bone. Traumatic injuries account for the

majority of fractures, although some fractures are secondary to a disease process (pathologic fractures from

cancer or osteoporosis).

Fractures can be classified as open (formerly called compound) or closed(formerly called simple) depending

on communication or noncommunication with the external environment. In an open fracture, the skin is

broken, exposing the bone and causing soft tissue injury. In closed fracture the skin has not been ruptured and

remains intact.

Fractures can also be classified as completeor incomplete.Fractures are termed completeif the break is completely through the bone and described

as incompleteif the fracture occurs partly a bone shaft but the bone is still in one piece. An incomplete fracture is often the result of bending or

crushing forces applied to a bone.

Fractures can also be described and classified according to the direction of the fracture line. Types include linear, oblique, transverse, longitudinal,

and spiral fractures.

Fractures can also be classified as displaced or nondisplaced. In a

displacedfracture the two ends of the broken bone are separated

from one another and out of their normal positions. Displaced

fractures are usually comminuted(more than two fragments) or

oblique.In a nondisplaced fracturethe periosteum is intact across

the fracture and the bone is still in alignment. Nondisplaced

fractures are usually transverse, spiral, or greenstick.

CLINICAL MANIFESTATIONS

Thepatients history indicates a mechanism of injury associated

with the clinical manifestations, including immediate localized

pain, decreased function, and inability to bear weight on or use the

affected area


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CLINICAL MANIFESTATIONS OF FRACTURE SIGNIFICANCE

Edema and swelling Unchecked bleeding, swelling, and edema in closed space can occlude circulation and

damage nerves.

Pain and tenderness Pain and tenderness encourage splinting of muscle around fracture with reduction in

motion of injured area.

Muscle spasm Muscle spasms may displace nondisplaced fracture or prevent it from reducing

spontaneously.Deformity Deformity is a cardinal sign of fracture; if uncorrected, it may result in problems with

bony union and restoration of function of injured part

Ecchymosis/contusion Ecchymosis may appear immediately after injury and may appear distal injury. Reassure

patient the process is normal and discoloration will eventually resolve.

Loss of function Fracture must be managed properly to ensure restoration of function to limb/part

Crepitation Crepitation may increase chance for nonunion if bone ends are allowed to moveexcessively. Micromovement of bone-end fragments (postfracture) assists in osteogenesis(new bone growth)

COLLABORATIVE CARE

The overall goals of fracture treatment are (1) anatomic realignment of bone fragments (reduction), (2) immobilization to maintain realignment,

and (3) restoration of normal or near normal function of the injures part.

DIAGNOSTIC:

History and physical examination

X-ray

CT scan, MRI

COLLABORATIVE THERAPY

FRACTURE REDUCATION

Manipulation

Closed reduction

Skin traction

Skeletal traction

Open reduction/internal fixation


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FRACTURE IMMOBILIZATION

Casting or splinting

Traction

External fixation

Internal fixation

OPEN FRACTURES

Surgical debridement and irrigation

Tetanus and diphtheria immunization

Prophylactic antibiotic therapy

Immobilization

NURSING MANAGEMENT

A brief history of the traumatic episode, mechanism of injury, and the position in which the victim was found can be obtained from thepatient or witnesses.

Document clinical finding before fracture treatment is initiated to avoid doubts about whether a problem discovered later was missed

during original examination or was caused by the treatment. Neurovascular assessment;peripheral vascular assessment(color, temperature, capillary refill, peripheral pulses and edema) and

peripheral neurologic assessment(sensation, motor function, and pain)

Assess an extremitys color (pink, pale, cyanotic) and temperature (hot, warm, cool, cold) in the area of the affected extremity. Compare pulses on both the unaffected and injured extremity to identify differences in rate and quality

Evaluate the ulnar, median, and radial nerves by assessing sensation and motor innervations in the upper extremity.

GOALS

Have physiologic healing with no associated complications.

Obtain satisfactory pain relief.

Achieve maximal rehabilitation potential.


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V- ANATOMY AND PHYSIOLOGY

A bone fracture is an injury or break in a bone. A bone breaks when there is a force which

a bone cannot withstand. There are many situations that can cause a bone fracture like a

fall or a car accident. The symptoms of a bone fracture depend on the type of bone that

was broken, or the damage to muscles, nerves, or blood vessels. Bone fractures also varyamong children and adults because childrens bones are more flexible than adults bones.

Adult's fractures heal slower than childrens fractures. Many people fracture at least one

bone during their lifetime.

Fractures are classified by the cause and nature of the initial break. A traumatic fracture is

one due to an initial injury. A pathologic fracture is one caused by a pre-existing

conditions or disease. An open fracture is one exposed to the outside world by a rupture to

the skin, while a closed fracture remains protected by the skin. Fractures can further be

classified by the size, orientation, and location of the break. Further classifications of bone

fractures include greenstick, transverse, fissured, oblique, comminuted, and spiral.

Greenstick fractures are incomplete and do not go completely through the entire bone.

Transverse fractures are completely across the bone while the break happens at a right

angle to the main axis of the bone. A fissure fracture is one of a longitudinal break that

does not go completely through the bone. An oblique fracture is one at an angle other than

90 degrees and usually goes completely through the bone. A comminuted fracture is one

that completely destroys the bone into smaller pieces. A spiral fracture is caused by

pressure when a bone is twisted and can cause a seemingly circular break in response to

such jagged motion. All of the above are few of the various types of fractures.


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VILABORATORY AND DIAGNOSTIC EXAMINATIONS

DATE: December 28, 2013

TYPE OF EXAMINATION: HEMATOLOGY

NORMAL VALUES RESULTS SIGNIFICANCERBC 4.69 - 6.13 x 10(12) /L 4.3 Decreased. Related to fracture,

production of RBC

HEMOGLOBIN 140 - 180g/L 129 Decreased. Blood loss

HEMATOCRIT 0.40 - 0.54 0.41 Normal

WBC COUNT 4-10 x 10(9)/L 16.9 Increased. Indicates blunt trauma

SEGMENTERS 0.500.70 0.65 Normal

LYMPHOCYTES 0.200.40 0.28 Normal

MONOCYTES 0.00.07 0.07 Normal

EOSINOPHILS 0.00.07 0.07

BLOOD TYPE O+

BLEEDING TIME 15 mins 210 NormalCLOTTING TIME 28 mins 320 Normal

DATE: January 3, 2014

TYPE OF EXAMINATION: HEMATOLOGY

NORMAL VALUES RESULTS SIGNIFICANCE

HEMOGLOBIN 140 - 180g/L 99 Decreased. Blood loss

HEMATOCRIT 0.40 - 0.54 0.32 Decreased. Blood loss


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VIIDRUG STUDY

GENERIC NAME: ketorolac

BRAND NAME: toradol

DRUG CLASSIFICATION: non-steroidal anti-inflammatory drug

DOSAGE: ketorolac 30mg slow IVP every 12 hours PRN for pain

INDICATION: Short-term management of moderately severe, acute pain for multiple-dose treatment

MECHANISM OF

ACTION

ADVERSE REACTIONS CONTRAINDICATIONS SIDE EFFECTS NURSING

CONSIDERATION

May inhibit prostaglandin

synthesis, to produce anti-

inflammatory, analgesic,

and antipyretic effects.

Arrhythmias, renal failure. Contraindicated in patients

hypersensitive to drug and

in those at risk for bleeding

Headache, dizziness,

drowsiness, sedation.

Edema, hypertension,

palpitations.

Assist with ambulation if

any of these side effects

occurs.

Advise patient to be alertfor signs and symptoms of

CV events (chest pain,

shortness of breath,

weakness, slurred speech)

and to seek medical

attention immediately if

they occur.

Tell patient to promptly

report edema and weight

gain.


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GENERIC NAME: chlorphenamine maleate

BRAND NAME:

DRUG CLASSIFICATION: antihistamine (alkylamine)

DOSAGE: 1amp IVP 30 minutes prior to blood transfusion

INDICATION: for allergic reaction during blood transfusion

MECHANISM OFACTION

ADVERSE REACTIONS CONTRAINDICATIONS SIDE EFFECTS NURSINGCONSIDERATIONS

Competes with histaminefor H1-receptor sites oneffector cells. Drug

prevents, but doesntreverse, histamine-mediated responses.

Contraindicated in patientshaving acute asthmaticattacks and in those withangle closure glaucoma,symptomatic prostatichyperplasia,

pyloroduodenalobstruction, or bladderneck obstruction

Drowsiness, sedation

Dry mouth

Raise side rails to preventpatient from falling

Give patient sips of water


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VII- LIST OF IDENTIFIED PROBLEM ACCORDING TO PRIORITY

Acute pain

Impaired physical mobility

Risk for ineffective tissue perfusion

Risk for pneumonia

Risk for constipation


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XI- NURSING CARE PLAN

ACUTE PAIN

ASSESSMENT NURSINGDIAGNOSIS

PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE:nurse sumasakit nanaman yun bali ko

Pain scale: 7/10

OBJECTIVE:-facial grimace

-crying

-complaints of pain

Pain related tofracture (movement of

bone fragments andmuscle spasms)

After 15-30 minutesof nursinginterventions, the

patient reportssatisfaction with painrelief measures with

pain scale from 7/102/10

Perform acomprehensiveassessment of pain toinclude location,characteristics, onset/duration, intensity orseverity of pain, and

precipitating factors

Teach the patient andwatcher the use ofnonpharmacologictechniques (e.g.,

relaxation, hot/coldapplication, andmassage) before,

after, and , if possibleduring painful

activities; before painoccurs or increases;

and along with otherpain relief measures

Provide patientoptimal pain reliefwith prescribedanalgesics such asketorolac

To plan appropriateinterventions

To reduce edema andpromote comfort

May inhibitprostaglandinsynthesis, to produceanti-inflammatory,analgesic, andantipyretic effects. Torelieve pain and

promote comfort.

After 30 minutes ofnursing interventions,the goal was fully metas evidenced by

patients reports withsatisfaction with painrelief measure and

pain scale decreased

from 7/10 to 2/10


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IMPAIRED PHYSICAL MOBILITY



OBJECTIVE:-limited ROM-decreasedmuscle strengthand/or control

Impaired physicalmobility loss ofintegrity of bonestructures, movementof bone fragments and

prescribed movementrestrictions

After 58hours of nursinginterventions,the patientexperiences no

complication ofimmobility

Assess ROM of unaffectedjoints and distal to theimmobilization device

Assess muscle strength in allextremities.

Perform flexion and extensionexercises to proximal and distal

joints of the affected extremity,when indicated.

Instruct patient not to scratchskin under the cast with any

objects

Position cast on pillows

Pad rough edges and tractionconnections

Instruct patient to direct coolair under cast

Apply ice for the first 24-36hours

Patients with casts willexperience some degree oflimited ROM to theaffected area. OptimalROM is critical for

movement and necessaryfor rehabilitation

The rehabilitationprogram will be geared

toward maximizing as

much strength as possiblein the affected orimmobilized extremity.

These exercises serve tomaintain mobility

To prevent skin injury andinfection

To lessen strain on otherbody parts.

To prevent skin irritationand breakdown of cast.

To decrease itching

To reduce swelling orinflammation

After 8 hours ofnursinginterventions thegoal was fullymet as evidenced

by increasedROM in

coordination toprescribedmovement

restrictions


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RISK FOR INEFFECTIVE TISSUE PERFUSION



OBJECTIVE:-immobility-presence of cast-inflammatory

process

Risk for ineffectivetissue perfusionrelated to vascularinsufficiency andnerve compression

After 1-2 hours ofnursinginterventions, the

patient experiencesno peripheral

neurovasculardysfunction

Perform acomprehensiveappraisal of peripheralcirculation (e.g. check

peripheral pulses,

edema, capillary refill,color, temperature or

extremity)

Prevent infection in

wounds with iodine

solution and cover itwith gauze

Maintain adequatehydration.

Support affected bodypart

Maintain position and

integrity of traction

Elevated limb 20degrees of greater above

the heart

To monitor fordiminished tissue

perfusion and planappropriateintervention.

To prevent further

edema and

inflammation, thismay contribute furtherto vascularinsufficiency and

nerve compression.

To prevent increasedblood viscosity.

To prevent pressureand injury

To prevent

compression of bloodvessels and nerves

To reduce edema bypromoting venous

return (note: ifcompartmentsyndrome is

suspected, elevate

extremity no higherthat heart level)

After 2 hours ofnursing interventions,the goal was metseeing that the patientdid not experience

peripheralneurovascular

dysfunction


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VIII- ONGOING APPRAISAL

The patients health status improved; decreased patients pain from his injury, increased his ROM and prevented the patient from

experiencing peripheral vascular dysfunction due to his condition

IX - DISCHARGE PLAN (HEALTH TEACHINGS)

For pain management, patient can take OTC oral analgesics and /or nonpharmacological techniques like positioning or hot/codl application

Teach patient and caregiver about proper cast care

o Do not get cast wet. Dry cast thoroughly after exposure to water.

o Do not remove any padding

o Do not insert objects onside cast. If itching occurs, use a hair dryer on cool setting or a fan to relieve itching.

o Do not bear weight on new cast for 48 hours (not all casts are made for weight bearing; check with health care provider when

unsure) Teach patient and caregiver about ROM exercises to maintain mobility and prevent contractures

Report signs of possible problems to health care provider

o Increase pain

o Swelling associated with pain and discoloration of toes or fingers

o Pain during movement

o Burning or tingling under cast

o Sores or foul odor under the cast

Keep appointment to have fracture and cast checked


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PANPACIFIC UNIVERSITY NORTH PHILIPPINESUrdaneta city, Pangasinan

Collegeof Nursing

CASE STUDY ON FRACTURES

Submitted by:Prince OMar R. Perez, BSN3

Submitted to:

Ms. Glecy C. Ventura, RN, MAN

Documents

Casestudy Fracture