NURSING MANAGEMENT OF A PATIENT WITH CLOSE FRACTURE

A CASE STUDY PRESENTED TO THE OUR LADY OF FATIMA UNIVERSITY COLLEGE OF NURSING VALENZUEA CITY

BY: YAP JOHN JOSHUA M.

MS.VILMA MIGUEL, RN, MAN Clinical instructor

INTRODUCTION

PATIENT PROFILE

PATIENT NAME AGE SEX BED NUMBER HOSPITAL NUMBER BLOOD TYPE ADDRESS DATE OF BIRTH OCCUPATION

M.A.DC 8 MALE 34 713421 O+ Sto.Nino Gov.Pascual Malabon Dec,12,2003 student

DATE OF ADMISSION DIAGNOSIS

FEB,12,2012 Fractured closed complete

FAMILY MEDICAL HISTORY

MOTHER

FATHER

M.A.DC
PAST MEDICAL HISTORY: ACCORDING TO DOES NOT HAVE ANY PAST MEDICAL HISTORY

PRESENT MEDICAL HISTORY: PTA . FALL INJURE ABOUT 3Ft HIGh

C.C: SWELLING AND TENDERNESS AT RIGHT ELBOW

Anatomy and Physiology

A bone fracture is a medical condition in which there is a break in the continuity of the bone. A bone fracture can be the result of high force impact or stress, or trivial injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture. When outside forces are applied to bone it has the potential to fail. Fractures occur when bone cannot withstand those outside forces. Fracture, break, or crack all mean the same thing. One term is not better or worse than another. The integrity of the bone has been damaged and the bone structure fails and a fracture occurs. (Wedro, 2012) Broken bones hurt for a variety of reasons including: the nerve endings that surround bones contain pain fiber. These fibers may become irritated when the bone is broken or bruised; broken bones bleed, and the blood and associated swelling causes pain; and muscles that surround the injured area may go into spasm when they try to hold the broken bone fragments in place, and these spasms may cause further pain. (Wedro, 2012)

GENERAL SIGNS AND SYMPTOMS OF FRACTURE

1. Pain at or near the seat of fracture. 2. Tenderness of discomfort on gentle pressure over the affected area. 3. Swelling about the seat of fracture. Swelling frequently render it difficult to perceive other signs of fracture and care must be taken therefore not to treat the condition as a less serious injury. 4. Loss or power; the injured part cannot be moved normally 5. Deformity of the limb; the limb may assume an unnatural position and be mis-shapen. The contracting muscles may cause the broken ends of the bone to override, thereby producing shortening of the limp. 6. Irregularity of the bone. If the fracture is near the skin the irregularity of the bone may be felt. 7. Crepitus (bony grating) may be heard or felt. 8. Unnatural movement at the seat of the fracture.

TYPES OF FRACTURES

Open fracture: An open fracture is a fracture where the broken bone is exposed. That is dangerous because of increased chances of infection. It is also called compound fracture.

Closed fracture: Also known as simple fracture, a closed fracture is a fracture where the bone is broken, but the skin is intact.

Complete fracture: The two pieces of the bone, resulting from the fracture, completely separate from each other.

Incomplete fracture: In this, the two pieces of bone, resulting from the fracture do not completely separate from each other; the bone pieces are still joined to some extent. This happens when the crack (or fracture) does not traverse along the entire width of the bone.

Multi-fragmentary fracture: In this the bone splits into multiple pieces.

Compression fracture: A compression fracture is a closed fracture that occurs when two or more bones are forced against each other. It commonly occurs to the bones of the spine and may be caused by falling into a standing or sitting position, or a result of advanced osteoporosis.

Avulsion fracture: An avulsion fracture is a closed fracture where a piece of bone is broken off by a sudden, forceful contraction of a muscle. This type of fracture is common in athletes and can occur when muscles are not properly stretched before activity. This fracture can also because of an injury.

Impacted fracture: An impacted fracture is similar to a compression fracture, yet it occurs within the same bone. It is a closed fracture which occurs when pressure is applied to both ends of the bone, causing it to split into two fragments that jam into each other. This type of fracture is common in car accidents and falls.

Stress fracture: It is a common overuse injury. It is most often seen in athletes who run and jump on hard surfaces such as runners, ballet dancers and basketball players.

Linear fracture: In this the fracture is parallel to the bone's long axis.

Transverse fracture: In this the fracture is at a right angle to the bone's long axis.

Oblique fracture: In this the fracture is diagonal to a bone's long axis.

Spiral fracture: In this at least one part of the bone has been twisted.

Comminuted fracture: In this the fracture results in several fragments.

Compacted fracture: In this the fracture is caused when bone fragments are driven into each other.

MEDICAL THERAPY
Fractures are broken bones. Fractures cause pain and make it difficult or impossible to use the part of the body that is injured. The treatment of a fracture depends upon the type and location of the fracture, if there are other injuries, and how serious those injuries are. The goal of treatment is to have a completely healed well-aligned bone that functions well. The bone should not be deformed and should look good when healed. The treatment should allow the person to go back to work as soon as possible. The broken pieces must be put back into the correct position and kept in proper alignment until healing is completed. The types of treatment include: y y y y y y closed reduction traction open reduction and internal fixation external fixation casts and splints and functional casts or braces

X-rays - help determine the proper diagnosis and type of treatment. Sometimes fractures do not affect bone alignment and only require protection of the bone with a splint or cast while it heals. However, if the fractured bone is not lined up correctly, it may need to be reduced. This means re-aligning the bone. A closed reduction re-aligns a bone by manipulation without surgery. Sometimes it is not possible for the provider to get the bones in the right position with a closed reduction. If this happens, traction can be put on the bones to gently pull them into position. Traction is usually used for a short period of time and before other forms of treatment are used.

PATHOPHYSIOLOGY
NON MODIFIABLE FACTORS

Direct trauma to the bone and tissue due to fall about 3FT high

BLEEDING OCCURS FROM THE DAMAGE ENDS OF THE BONE FROM THE NEIGBORING SOFT TISSUE.

When a bone is broken, the periosteum and blood vessel in the cortex, marrow, and surroundingsoft tissue are disrupted

>irregularity of the bone >unnatural movement of the site

A CLOT (HEMATOMA) FORMS WITHIN THE MEDULLARY CANAL, BETWEEN THE FRACTURE ENDS OF THE BONE AND BENEATH THE PERIOSTEUM

BONE TISSUE IMMIDIATELY ADJACENT TO FRACTURE DIES

NECROTIC TISSUE ALONG WITH ANY DEBRIS IN THE FRACTURE AREA STIMULATES AN INTENSE INFLAMMATORY RESPONSE

PAIN NEAR THE SEAT OF THE FRACTURE

TENDERNESS OF DISCOMFORT ON GENTLE PRESSURE OVER AFFECTED AREA

SWELLING ABOUT THE SEAT OF FRACTURE

WITHIN 48 HOURS AFTER THE INJURY , VASCULAR TISSUE INVADES THE FRACTURE AREA FROM SURROUNDING SOFT TISSUE AND THE MARROW CAVITY , AND BLOOD FLOW TO THE ENTIRE BONE IS INCREASED. AS THE REPAIR PROCESS CONTINUES REMODELING OCCURS DURING WHICH UNNECESSARY CALLUS IS RESORBED AND TRABECULAE ARE FORMULATED A LONG LINES OF STRESS

P-E-R-S-O-N Assessment
Psychosocial ASSESSMENT Father Feb. 16, 2012 INTERPRETATION Members of the family will help the client to cope up easier and better to his condition. Instead of minding the pain that he is experiencing, he listens to music to ease the pain. The patient is in calm and accepting mood.

1. Significant Others

2. Coping mechanism 2.1 Problem- Focused

Sublimation

2.2 Emotional-Focused

Calm

3. Religion

Roman Catholic

4. Primary Language

Tagalog

God is the one who give him strength and confidence to face his trials. Tagalog is the medium of communication between the client and the student nurse. The client is a grade 3 level

5. Occupation 6. Education 7. General Apperance

Student elementary He have dirty nails has scars in his elbow and feet and has a splint in his right arm

8. Orientation

Oriented in time, place and person

He was able to recognize the day, the hospital and himself. He is in stable mental capability.

9. Memory

Intact Short term and Long term memory

He can still remember the recent events and the past events including the accident he dealt with.

10. Speech a. Volume

Soft

The patient is conserving his

b. Rate c. Amount

Slowed Answer when questioned only

energy and cannot talk much due to mild pain on his right arm.

11. Non-Verbal Behavior

In good eye contact when questioned Facial grimace

He seems to be uncomfortable and in pain.

Elimination 1. Stool a. Consistency and Shape b. Amount c. Color Undetermined Brownish-yellowish Formed stool According to the client, it has been 1 week after the operation before he defecates.

2. Urine a. Quantity b. Color FC Yellowish The yellowish color is due to the medications rendered to the client. c. Odor d. Clarity 3. Toileting Ability Aromatic Clear The patient can go to the Comfort room so whenever he feels the urgency, he is just the one to go in the comfort room

Rest and Activity 1. Current Activity Level The patient can walk but cant move his right arm he is slightly active

2. ADLs

Upon waking up, the client usually takes his breakfast .He also play in his cellphone when he feels bores.

3. Sleep a. Sleep history Usual bedtime Usual waking time 8pm 7 am The patient has difficulty in sleeping due to hot environment that he is experiencing.

4. Body Frame

5. Muscle a. Strength b. Tone Normal Flaccid The muscle of the patient is in fair condition except for the right arm

6. Motor function a. Gross Capable of extension and flexion of extremities except for right arm still limited.

He can do his ADL by his own. b. Fine 7. Range of Motion Active ROM He can do work by his own

8. Pain Relief Measures

playing Listens to music in cellphone when he is in pain.

He diverts his attention to suppress pain.

Safe Environment 1. Allergies No known allergy

2. Eyes/Vision

Pink palpable conjunctiva (anicteric sclerae)

Normal sensory and motor function

3. Hearing 4. Skin

Can recognize voices Warm and moist Due to hot environment

5. Mucous Membrane

Moist Mucous Membrane

Patient is well hydrated

6. Temperature

T: 36. 2C at auxillary temperature

The patient is afebrile.

Oxygenation Activity Tolerance Limited activity in his right arm only Airway Clearance No secretion present in the airway of the client Respiration RR: 22 cycles/minute The patient has slightly increase in respiration but does not show any signs of hypoxemia or difficulty in breathing. Lung Sounds (-) abnormal lung sounds

Nails Capillary Refill Blood Pressure

Dirty and long

Normal in shape

Nutrition Hospital diet On diet as Tolerated Eaten full meal well

Fluid intake

Can drink fluid

Drink almost 1500 ml/ day

IVFs Skin Turgor

No IVF Good skin Turgor Signs of good hydration

COURSE IN THE WARD

FEB.15.2012 THURSDAY
Assessment Diet IVF Laboratory Exam Medication Doctors Orders Nursing Responsibilities

Awake

Maintaine d on diet as tolerated

No ongoin g IVF

No medication where given

There is no doctors order

Encouraged increased fluid intake to promote hydration.

Instructed to do Deep Breathing Exercise to alleviate pain and promote relaxation. Advised to Play games in cell phone to relieved boredom.

FEB.16.2012 FRIDAY
Assessment Diet IVF Laboratory Exam Medication Doctors Orders Nursing Responsibilities

Conscious

Maintaine d on diet as tolerated

No ongoing IVF

No medication where given

There is no doctors order.

Encouraged increased fluid intake to promote hydration.

Instructed to do Deep Breathing Exercise to alleviate pain and promote relaxation. Advised to play games in cell phone to relieved boredom. Encouraged to do ROM to the Unaffected side to prevent muscle atrophy