Group "C" Case

Presentation
  
Open Type III - S
Complete
Comminuted
Fracture D3 - L
Femur
 Reasons for choosing the Case :

We chose this case because it requires a

broader scope of research which will benefit
us.
We chose this case to learn orthopedic in
advance.
To have a study to share to our fellow
student.
Background Knowledge :

A Fracture is a break in the continuity of

bone and is defined according to its type and
extent. Fractures occur when the bone is
subjected to stress greater than it can absorb.
Fractures are cause by direct blows, crushing
forces, sudden twisting motions, extreme muscle
contractions. When the bone is broken, adjacent
structures are also affected, resulting in soft
tissue edema, hemorrhage into muscles and
joints, joint dislocations, ruptured tendons,
severed nerves, and damaged blood vessels. Body
organs maybe injured by the force that cause
the fracture or by fracture fragments.
TYPES OF
FRACTURE
Greenstick fracture:
an incomplete fracture in
which the bone is bent. This
type occurs most often in
children.
Transverse fracture:
a fracture at a right
angle to the bone's axis.
Oblique fracture:
a fracture in which the
break has a curved or sloped
pattern.
•Comminuted fracture:
a fracture in which the bone
fragments into several pieces.
•An impacted fracture :
•is one whose ends are driven into
each other. This is commonly seen
in arm fractures in children and is
sometimes known as a buckle
fracture. Other types of fracture
are pathologic fracture, caused by
a disease that weakens the bones,
and stress fracture, a hairline
crack.
•A depressed fracture :
results from a force that drives a
piece of bone down.  This fracture may
effect the outer table of the skull,
the inner table, or both if the force
is strong and localized. This is a
depressed fracture on the left parietal
part of a skull.
An avulsion fracture :
is a bone fracture which occurs
when a fragment of bone tears away
from the main mass of bone as a
result of physical trauma.
•An uncomplicated closed :
fracture/simple fracture in
which the fractured ends of the
bone do not break the skin.
•A spiral fracture ( also
called a torsion
fracture ):
is a bone fracture in which
the bone has been twisted
apart.
•A compression fracture :
occurs when the normal
vertebral body of the spine is
squished, or compressed, to a
smaller height.
•Compound fracture :
A fracture in which the bone
is sticking through the skin.
Also called an open fracture.
Skeletal Tractions :
Morbidity
&
Mortality
Most prevalent among
the extremes of ages.
Infants and Elderly.
Patients Profile
Name: MC
Age: 57 years old
Date of Birth: July 7, 1952
Status: Widowed
Nationality: Filipino
Religion: Roman Catholic
Home Address: Batasan Hills Quezon
City
Date of Admission: December 24, 2009
Time of Admission: 8:15 am
Admitting Diagnosis: Fx Open III-S
Complete Comminuted D3-L Femur
Past Medical
History
•
•High blood
•Asthma
•Breast Mass at Lateral
aspect of the left Breast
Present Medical
History
GORDONS 11 TYPOLOGY
OF FUNCTIONAL HEALTH
PATTERNS
 BEFORE DURING HOSPITALIZATION
HOSPITALIZATION
A.)HEALTH MANAGEMENT
PATTERNS
® what is your past
illnesses? “asthma at UTI”
®what do you do
whenever you got “umiinom lang ng
sick? gamot”
®how do you
maintain your good “kumakain lang ng
health? mga gulay at prutas”
®how often do you
go to the doctor to “pumupunta ako sa
have medical check- center , tuwing
up? nakakaramdam lang
ako ng sakit”
 BEFORE DURING HOSPITALIZATION
HOSPITALIZATION

B.)SELF-PERCEPTION
PATTERN
®how do you
describe yourself? “malakas, abala sa “ito nakahiga lang,
®your moods? mga gawaing bahay” walang silbi”
®how many “madaldal, palatawa “naging maiinitin
times do you take a at palabiro” ang ulo”
bath in a “dalawang beses sa “hindi na ako
day? isang araw” nakakaligo,punas-
®how many times “hindi na ako punas lang”
do you brush your nagtotoothbrush, “mga isang beses
teeth in a day? wala na akong lang”
ngipin, mumog- mumog
lang”
 BEFORE DURING HOSPITALIZATION
HOSPITALIZATION

C.) NUTRITIONAL-
METABOLIC PATTERN
®what are the
foods you usually “kanin,gulay at mga “kung ano lang ang
eat? fruits” nirarasyon dito
®how many times “tatlong beses sa tulad ng kanin,
do you eat in a isang araw” pansit at tinapay”
day? “mga apat –anim na “ganun pa din,
®how many times beses sa isang araw” tatlong beses pa
do you drink water din”
in a day? “mga apat –anim na
beses”
 BEFORE DURING HOSPITALIZATION
HOSPITALIZATION

D.)ELIMINATION
PATTERN
®how many times “isang beses sa “isang beses lang
do you defecate in isang araw” din”
a day? “wala naman”
®any discomfort? “wala”
“ mga tatlo o apat
®how many times na beses sa isang “ngayon, naka
do you urinate in a araw” diapers kasi ako,
day? mga dalawang beses”
“wala naman” “wala naman”
®any discomfort? “dalawang beses”
®how many times
do you change your
diapers in a day?
 BEFORE DURING HOSPITALIZATION
HOSPITALIZATION

E.)ACTIVITY- EXERCISE
PATTERN
®what are the “nag aalaga ng mga “ito nakahiga lang,
things you usually apo ko, gumagawa ng pautos utos lang,
do? mga gawaing bahay nahihirapan na
at naglalabada” akong gumalaw-galaw”
“nanunuod ng T.V, “ditto nakikinig ng
®hobbies? nag-aalaga ng mga music sa cellphone
apo” ng anak ko”
“Tumatakbo-takbo” “dito paunat unat
®exercise? lang”
 BEFORE DURING HOSPITALIZATION
HOSPITALIZATION

F.)SLEEP-REST PATTERN
®usual no. of
hours of sleep and “siyam na oras” “walong oras”
rest @ night?
®at day time?
“hindi ako natutulog “Mga dalawang oras”
®how do you relax sa hapon”
yourself? “nanunod lang ng “nakahiga lang dito”
t.v”
 BEFORE DURING HOSPITALIZATION
HOSPITALIZATION

G.)ROLE- RELATIONSHIP
PATTERN
®do you have
close family ties? “oo” “oo”
®how do you bond
with each other? “kumakain ng sama- “wala na eh”
sama,
nagkwekwentuhan at
®who do you talk nagtatawanan”
most often? ”yung mga anak ko at “yung anak kong
®how do you bond mga kapitbahay ko” ngababantay sa akin,
with your “super bonding kami, mga pasyente din
neighborhood? puro tawanan, dito at mga bantay
kwentuhan” nila”
“wala na eh”
 BEFORE DURING HOSPITALIZATION
HOSPITALIZATION

H.)COPING-STRESS
PATTERN
®what are things ”kapag nag aaway ang “kapag iniiwanan nila
that made you mga apo ko” ako dito sa hospital”
angry? “nagsesermon, “wala lang, hindi
®what do you do nilalabas ang galit, kumikibo”
whenever you got salita ng salita”
“malungkot, masama ang
angry? loob”
®how do you feel “hindi pa masyado,
towards the death nalulungkot ako kasi
of your son- in law? namatay ang manugang ko
®have you at hanggang ngayon di
pa nahuhuli ang
accepted about the pumatay”
death? “nagdadasal, pinapasa
®how do you handle diyos ko na lang”
this?
 BEFORE DURING HOSPITALIZATION
HOSPITALIZATION

I.)VALUE BELIEF
PATTERN
®are you “oo” “oo”
religious?
Patient ’ s General
Appearance
Date Performed : January 18, 2010
Time : 9:00 am

Name : MC
Age : 57 years old
Primary Language : Tagalog
Height : 5’3’’
Weight : 54 kg
Vital Signs :
BP- 110/80 mmHg
Temp- 36.9 CO
PR- 82 BPM
RR- 22 CPM
Assessment
•Hair Color
- Black and White
•Body Build
- Proportionate
•Overall hygiene and grooming
- Clean and neat
•Note Body and Breath Odor
- No Body odor; No Breath odor
 •Signs of distress in posture or
facial Expression
- no distress noted
•Note obvious signs of Health/
Illness
- Weak and with fractured at left
Leg
•Client’s Attitude
- Cooperative and able to follow
instructions
 •Client’s affect/mood;
appropriateness of the responses
- Appropriate to situation
•Quantity of Speech, Quality and
Organization
- understandable, clear tone;
exhibits thought association
•Relevance and organization of
thoughts
- makes sense; has sense of
reality
Course in the
ward
Doctor’s Order Nursing Responsibilities
Maintain Tractions Inspect Integrity of Tractions

Inspect for Infections

Daily wound Dressing

Educate Patient for proper

immobilization
2) Safety Ensure Client’s Safety

Side rail’s Up for safety

Put Client’s belongings within reach

Educate significant others about

safety precautions
3) Refer for OR schedule Assess patient’s financial status

Refer for Social service( PCSO, Phil

Health)
Educate patient regarding operation
 Anatomy and
Physiology

( Skeletal System )
The skeleton has six main functions :
•Support - It provides the framework which
supports the body and maintain its shape.
•Movement - The bones are the levers that help
the body move in different directions and in
different ways.
•Protection
•The skeleton protects many vital organs
•Cranium protects the brain.
•Ribs/Sternum protects the lungs, heart and
some digestive organs.
•Pelvis protects and supports the
digestive and reproductive organs.
•Spinal column protects the spine.
•Blood cell production
Inside of the long bones in our bodies,
there is a cavity that is filled with a
substance called Bone Marrow. In this
tissue, new blood cells are produced, and
damaged blood cells are repaired. Red bone
marrow produces red blood cells, white blood
cells and other blood elements.
The skeleton is the site of hematopoiesis,
which takes place in red bone marrow. Marrow
is found in the center of long bones.
•Storage
Mineral is a substance that the body needs to
carry out all of our bodily functions like
thinking, breathing and moving around. One of the
minerals that the body needs is calcium. Calcium
is a major part of bone, and this is where the
body stores its calcium.
•Endocrine regulation
Bone cells release a hormone called osteocalcin,
which contributes to the regulation of blood sugar
(glucose) and fat deposition. Osteocalcin increases
both the insulin secretion and sensitivity, in
addition to boosting the number of insulin-
producing cells and reducing stores of fat.
Fractured femur with plate and
screws
Pathophysiology
Laboratory Results
Hematology Dec. 24 Jan. 4 Normal Units
WBC 22.1 15.9 5-10 Adults X109/L
9-20 New born
Hemoglobin 119 95 140-170 M gm/L
120-140 F
Hematocrit 0.367 0.28 0.45-0.50 M %
0.38-0.48 F
Neutrophils 0.86 0.46 0.31-0.76 Adult %
0.40-0.50
Newborn
Lymphocytes 0.11 0.30 0.24-0.44 Adult %
0.31-0.60 New
born
Monocytes 0.02 0.02 0.00-0.06 Adult %
Eosinophils - 0.20 0.02-0.04 %
Basophils - 0.02 0.00-0.01 %
Bands 0.01 - 0.02-0.04 %
Platelet Adequate 182 150-450 X109/L
MCV 90.8 86.2 80-100 Fl
MCH 29.5 29.4 27-31 Pg
MCHC 325 341 320-360 g/L
RDW 13.2 12.8 11.0-14.6 %
Serology Results Findings Units

Glucose 4.8 3.9 mmol/L

N Cholesterol 4.4 0.0-5.2 mmol/L

LDL Cholesterol 3.3 2.6-4.1 mmol/L

Triglycerides 0.94 0.4-1.7 mmol/L

HDL-Cholesterol 0.64 0.91-1.56 mmol/L

Blood Urea Nitrogen4.9 2.5-6.1 mmol/L

Creatinine 78 53-115 umol/L

Sodium 138 135-148 mmol/L

potassium 3.7 3.5-5.3 mmol/L

Drug Study
Brand and Action Uses/ Indication Contraindication Side effects Nursing
Generic Name Consideration
Tramadol Centrally acting Used for Hypersensitivity Vasodilation, -Assess patient pain(
(Dolotral , analgesic not moderate to , acute dizziness/ location and types)
Milador) chemically severe pain intoxication vertigo, -Assess for
related to with alcohol, headache, hypersensitivity
opioids but hypnotics, stimulation, reaction: rash and
binds to mu- centrally acting anxiety, pruritus
opioid receptors analgesics confusion and -Monitor for
and inhibits sleep disorder possible drug
reuptake of induced adverse
norepinephrine reaction
and serotonin CNS;stimulation
dizziness,vertigo,hea
dache,
CV:vasodilation
GI:nausea

Azyth Binds to the P Treatment of Hypersensitivity Hypersensitivity Assess for sign

(Azythromycin ) site of 50s infection of to azithromycin reaction such symptoms of
bacterial respiratory or or any as: skin redness infection :fever,
ribosomal tract , skin and macrolide with or without drainage, sore throat
subunits thereby skin antibiotic itching increased WBC count
inhibiting structure,and photosensitivity positive specimen
protein sexually , joint pains culture
synthesis. transmitted
Treatment of disease cause
infection in by susceptible
skin and soft organisms
tissues.
Band Name and Action Uses / Contraindicati Side effects Nursing
Generic Name indication on consideration

Cefradine Inhibits Infection caused Patients with GI disturbances -hypersensitivity

(drug maker’s mucopeptide by susceptible history of shock, hypersensitivity to drugs
Biotech synthesis in strains of hypersensitivity reactions. -monitor for
cefradine) bacterial cell staphylococci, to any positive
wall streptopneumonia ingredients and response to
and E-coli to cephem-type antibiotic
antibiotics therapy
-monitor for
signs of
infections

Losartan Selectively Treatment of Pregnancy, breast Dizziness, dose- -assess BP ,

(bepzar ,lifezar ) blocks the hypertension ,in feeding, related Monitor for
binding at heart failure hypokalemia orthostatic possible drug
angoitensin II and myocardial hypotension.impai reaction
to receptor infarction, red renal -assess patient ’s
sites in many function and and family
tissues rarely knowledge of
especially the ,rash,angioedema drug therapy
vascular smooth and raised
muscles and alanine.
adrenal glands.
This prevents
the
vasoconstricting
and
aldestosterone
secreting of
angoitensin II
on these tissue
Ferrous Provides Prevention Hypersensitiv Alteration Obtain
Sulfate elemental and treatment ity to any and abdominal baseline
Brotesol,feos iron, an of iron- ingredients,h pain with assessment of
ol essential deficiency emosiderosis, nausea, iron
Spansule,Fer- component in anemia hemolytic vomiting deficiency
in-sol formation of anemia. diarrhea or before
hemoglobin in constipation. starting
red blood therapy
cell -evaluate
development. hemoglobin,
hematocrit
and
reticulocyte
count during
therapy.
-monitor for
adverse
reaction.
-increase
-assess diet
nutrion
Nursing Care
Plan
Assessment Nursing diagnosis Planning Intervention Rationale Evaluation
Subjective ; Impaired physical After the nursing 1.observe px’s -Changes may After the nursing
Nahihirapan akong mobility r/t intervention there functional ability: indicate intervention there
gumalaw galaw” musculoskeletal will be: document and report progressively was:
Objective: impairment a.)regain/maintain any changes using decline or a.)regained/maintained
-Facial grimace mobility at the functional level improvement mobility at the
-presence of highest possible scale -this measures highest possible
skeletal traction level 2.ensure comfort prevent skin level
-limited range of b.)maintain position measures by padding breakdown b.)maintained position
motion of function extremities prone -This prevents of function
-limited ability to c.)increase to skin break down. joint contracture c.)increased
perform gross motor strength/functions 3.implement ROM and muscle atrophy strength/functions of
skills of affected and exercises every -maintain muscle affected and
-difficulty in compensatory body shift tone and prevents compensatory body
turning parts 4.promote complication of parts
-V/S taken: d.)demonstrate progressive immobility d.)demonstration
T-36.9 C techniques that mobilization to -to reduce anxiety techniques that
PR-81 bpm enable resumption maximum within and promote enable resumption of
RR-21 cpm of activities limits of px’s compliance activities
BP-110/70 mmHg tolerance for pain -to control
5.instruct the px minimize effects on
and family members immobility.
in ROM exercises,
transfers, skin
inspection and
ability regimen
6.encourage px to
discuss feelings
and concerns about
altered state of
mobility
Assessment Nursing diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired skin At the end of 2 1. inspects skin -this provides At the end of 2
“ no verbal cues” integrity r/t open weeks of nursing every shift-describe evidence of weeks of nursing
Objective: fracture @ the intervention: and document skin effectiveness of intervention:
-(+) open fracture@ lower femur as patient will condition and skin care regimen a.) patient was
the left lower manifested by open exhibit in evidence report changes. -to promote comfort exhibit in
femur gun shot wound @ of skin breakdown 2. assists with and sense of well evidenced of skin
-(+)skeletal the left lower Patient will regain general hygiene and being. breakdown
traction@ the left femur skin integrity comfort measures -patient needs pain b.)Patient was
tibia Patient will 3. Administer pain relief to maintain regained skin
-(+)open gun shot demonstrate skill medication and health integrity
wound @ the left in care of wound monitor its - to avoid potential c.)Patient was
lower femur Patient will effectiveness. for infection demonstrated skill
-(+) edema @ the perform skin care 4. use of foam -to reduce risk of in care of wound
wounded site routine mattress, red cradle spreading disease d.)Patient was
-(+) immobility or other devices - reduce pressure perform skin care
-decreased 5.maintain infection and promote routine
hemoglobin:95m/L control standards Circulation
-V/S taken: 6.change position at -to encourage
T-36.9 C least every 2 hours compliance
PR-81 bpm 7.instruct patient
RR-21 cpm and family members
BP-110/70 mmHg in skin care
regimen
Assessment Nursing diagnosis Planning Intervention Rationale Evaluation
Subjective: Knowledge deficit After the 8 hour 1. consider old px -new information is After the 8 hour
“mas gusto ko r/t difficulty shift the px will; life experience easier to shift the px was;
magpasemento na understanding a.)express when developing assimilate if it is a.)expressed
lang kaysa disease process and understanding of teaching plan built on existing understanding of
magpaopera ng binti its effect on own disease process, 2.provide quiet, knowledge. disease process,
ko” self care medication regimen calm environment -to enable px to medication regimen
Objective: and treatment plan for learning. process information and treatment plan
-facial grimace b.)px will make 3.limit length of w/o distraction from b.)px was informed
-poor eye contact informed choices each teaching’s background noise or choices when
-restlessness when addressing session. stress. addressing health
-unmotivated to health care 4.ask if the px -to avoid care problems and
learn problems and self wants to learn new information self care deficits
-economic status care deficits or additional overload c.)px was
c.)px will information. If not -open discussion demonstrate ability
demonstrate ability discuss why. helps to identify to effectively
to effectively 5. set aside time barriers to implement chosen
implement chosen during each session learning and health strategy
health strategy for answering determine
questions and -older px may need
clarifying affirmation that
information. knowledge she
possesses is
current and correct.
Discussion may also
stimulate exchange
of ideas and
further learning.
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Subjective: Risk for At the end of 1.wash hands -hand washing is At the end of
“ no verbal cues” infection r/t 2 weeks of before and after the single best 2 weeks of
Objective: open fracture as nursing providing care way to avoid nursing
-(+) open manifested by intervention 2.monitor WBC spreading of intervention
fracture@ the open gunshot there will be: count, as ordered pathogens there was:
left lower femur wound @ the left a.)reduce risk of and promptly -decreased a.)reduced risk
-(+)skeletal femur infection report abnormal production of of infection
traction@ the b.)px will values. WBC indicates b.)px was
left tibia maintain good 3.instruct client infection maintained good
-(+)open gun shot personal hygiene in proper -to reduce risk personal hygiene
wound @ the left c.)results of personal hygiene for infection c.)results of
lower femur laboratory 4.follow -to minimize risk laboratory
-(+) edema @ the studies won’t facility’s of nosocomial studies won’t
wounded site indicate infection infection indicate
-(+) immobility infection control policy -to minimize risk infection
-decreased 5.use aseptic of inducing
hemoglobin:95m/L technique when pathogens
-Decreased performing -To promote
hematocrit:0.25 invasive healing
-V/S taken: procedures.
T-36.9 C 6. ensure
PR-81 bpm adequate
RR-21 cpm nutritional
BP-110/70 mmHg intake
Assessment Nursing diagnosis Planning Intervention Rationale Evaluation
Subjective; Anxiety r/t After of 8 hour 1. spend time with -specific amount of After of 8 hour
“nalulungkot ako situational crises nursing patient convey a uninterrupted non- nursing
kasi namatay ang and hospitalization intervention the willingness to care related time intervention the
manugang ko at patient will able: listen, offer verbal spent with anxious patient was:
hanggang ngayon di appear relaxed and reassurance px build trust a.)appeared relaxed
pa nahuhuli ang report anxiety 2. give px clear, -Anxiety may impair and report anxiety
pumatay” reduced to a concise explanation px’s cognitive reduced to a
Objective: manageable level of anything about abilities manageable level
-poor eye contact verbalize awareness to occur. avoid -This may allow px b.)verbalize
-tearfulness of feelings of information to identify anxious awareness of
-facial tension anxiety overload: an anxious behaviors and feelings of anxiety
-facial blushing px cant assimilate discover some of
-restlessness many details anxiety
-feelings if anger . -Anxiety often
-V/S taken: 3.listen results from lack
T-36.9 C attentively: allow of trust on the
PR-81 bpm px to express environment
RR-21 cpm feelings verbally -anxious px may
BP-110/70 mmHg 4. Identify and mistrust own
reduce many abilities:
environmental involvement in
stressors as decision making may
possible. reduce anxious
5.include px in behaviors.
decisions related -involving family
to care when members in process
feasible. of reassuranc4 and
6.support family explanation allays
members in coping - this allows pxand
with px’s anxious family to support
behavior each other
7.allow extra according to their
visiting periods abilities and at
with family if this their own race.
seems to allay
anxiety.
THANK ’ S MA ’ AM