81105552 a Case Study of Patient With Com Minuted Fracture Distal Third Femur

A CASE STUDY OF A PATIENT WITH COMMINUTED FRACTURE

CLOSED DISTAL THIRD FEMUR

A Case StudyPresented to

the Faculty of the College of NursingCebu Normal University

In Partial Fulfillmentof the Requirements in

Medical-Surgical Nursing(NCM 105)

By

Macayan, Jellou Ray M.

October 2011

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ACKNOWLEDGEMENT

I would like to express my heartfelt gratitude to all those who helped me in making this

case study a possibility.

First of all I would like to thank the almighty God for giving me the strength and courage

to complete this research even when faced with challenges, boredom and indiscretions.

To Miss Bertilia F. Pragados for giving me the permission to make this case in the first

instance, to do the necessary research work and for the constant reminders and pointers you

have given me for this study—thank you mam!

Also I would also like to extend my sincere thanks to Miss Elaiza R. Cabunoc of the

Vicente Sotto Memorial Medical Center Radiology Department for the kind accommodation and

for allowing me to recover patient’s diagnostic files.

I would also like to take this opportunity to thank my fellow researcher Miss Emy Jane

Pilapil, Cherish Cyrill, Oraiz and Miss Sonia Rufa Singson and Miss Cybelle Caramba whose

help, stimulating suggestions and encouragement inspired me in all the time of research for and

writing of this case study and mostly for the company upon gathering relevant information for the

study.

I am also deeply indebted to my co-researcher Miss Alona Minque who looked closely at

the final version of the case study for English style and grammar, correcting both and offering

suggestions for improvement.

And most especially, I would like to give my special thanks to my family whose patient

love enabled me to complete this work.

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TABLE OF CONTENTS

Page

Title Page--------------------------------------------------------------------------------------------------------- i

Acknowledgement --------------------------------------------------------------------------------------------- ii

Table of Contents ---------------------------------------------------------------------------------------------- iii

List of Figures --------------------------------------------------------------------------------------------------- v

Chapter 1 – Introduction ------------------------------------------------------------------------------------- 1

Chapter 2 - Patient’s Profile

Background/History --------------------------------------------------------------------------------- 3

Patient’s Vitae ---------------------------------------------------------------------------------------- 4

Functional Health Patterns ------------------------------------------------------------------------ 4

Physical Assessment ------------------------------------------------------------------------------- 5

Chapter 3 - Anatomy and Physiology --------------------------------------------------------------------- 8

Chapter 4 - Psychopathophysiology

Schematic Diagram -------------------------------------------------------------------------------- 15

Narrative ---------------------------------------------------------------------------------------------- 16

Chapter 5 - Management

Medical

Laboratory Procedures ---------------------------------------------------------------- 18

Diagnostic Procedures ---------------------------------------------------------------- 19

Drug Study ------------------------------------------------------------------------------- 21

Surgical ----------------------------------------------------------------------------------------------- 21

Nursing

Summary of Nursing Problems --------------------------------------------------- 22

Individualized Nursing Care Plan -------------------------------------------------- 22

FDAR Charting ------------------------------------------------------------------------- 25

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Discharge Summary with Collaborative Nursing Function ------------------- 25

Chapter 6 - Evaluation and Recommendation ------------------------------------------------------- 29

Bibliography ------------------------------------------------------------------------------------------------------ 31

Appendices ------------------------------------------------------------------------------------------------------- 32

APPENDIX A (Physical assessment) ----------------------------------------------------------- 33

APPENDIX B (Hematologic studies) ------------------------------------------------------------ 39

APPENDIX C (Urinalysis) -------------------------------------------------------------------------- 41

APPENDIX D (Coagulation Profile) ------------------------------------------------------------- 42

APPENDIX E (X-ray Report) ---------------------------------------------------------------------- 43

APPENDIX F (Drug Study—celecoxib) --------------------------------------------------------- 45

APPENDIX G (Drug Study—tramadol) --------------------------------------------------------- 46

APPENDIX H (Drug Study—cefuroxime) ------------------------------------------------------ 47

APPENDIX I (NCP day 1) ------------------------------------------------------------------------- 48

APPENDIX J (NCP day 2) ------------------------------------------------------------------------ 51

APPENDIX K (NCP day 3) ----------------------------------------------------------------------- 53

APPENDIX L (FDAR day 1) ---------------------------------------------------------------------- 55

APPENDIX M (FDAR day 2) --------------------------------------------------------------------- 56

APPENDIX N (FDAR day 3) ---------------------------------------------------------------------- 57

APPENDIX O (Approval for Case Study) ----------------------------------------------------- 58

APPENDIX P (Approval for Final Printing and Book Binding of Case Study) ------- 59

Curriculum Vitae ----------------------------------------------------------------------------------------------- 60

v

LIST OF FIGURES

Page

Figure 1 - Upper extremity of right femur viewed from behind and above ------------------------- 8

Figure 2 - Right femur. Anterior surface --------------------------------------------------------------------10

Figure 3 - Right femur. Posterior surface ------------------------------------------------------------------ 12

Figure 4 - Pathophysiology of fracture (schematic diagram) ------------------------------------------ 15

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CHAPTER I

INTRODUCTION

Being broken opens the door to a possibility--change. When you get hurt and broken

inside, you try to heal yourself to be the same old person. But you really can’t be that same

person anymore. A part of you has changed. A broken bone is like a part of self that you knew is

the same but just can’t recognize anymore. It’s still the same bone. Yet, during the process of

healing, it seems to change.

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 that it can absorb. Fractures

are caused by direct blows, crushing forces, sudden twisting motions, and even extreme muscle

contractions. When the bone is broken, adjacent structures are also affected, resulting in soft

tissue edema, hemorrhage into the muscles and joints, joint dislocation, ruptured tendons,

severed nerves, and damaged blood vessels. Body organs maybe injured by the force that cause

the fracture or by the fracture fragments (Brunner’s and Suddarth’s 2004).

There are different types of fractures and these include, complete fracture, incomplete

fracture, closed fracture, open fracture and there are also types of fractures that may also be

described according to the anatomic placement of fragments, particularly if they are displaced or

non displaced. Such as greenstick fracture, depressed fracture, oblique fracture, avulsion, spinal

fracture, impacted fracture, transverse fracture and compression fracture.

A comminuted fracture is one that produces several bone fragments and a closed

fracture or simple fracture is one that does not cause a break in the skin. Comminuted fracture at

the Right Distal Third Femur is a fracture in which bones of the distal portion of the femur has

splintered to several fragment. The patient would then experience tremendous pain at the site of

the fracture, swelling around the area and it may become warm to the touch. Typically the patient

cannot bear any weight on the fracture without experiencing significant pain.

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Femur fracture affects almost 13 million Americans, and one of the leading fractures in

the Philippines making it the most common form of fracture. The incidence of femoral fractures is

reported as 1-1.33 fractures per 10,000 population per year (1 case per 10,000 population). In

Vicente Sotto Memorial Medical Center, there are total of 56 patients out of 94 are diagnosed with

femoral fracture within the duration of care, the estimated incidence rate in the said institution is

about 60%. In individuals younger than 25 years and those older than 65 years, the rate of

femoral fractures is 3 fractures per 10,000 populations annually. The incidence of femoral injuries

and fractures increases in elderly patients.

Primarily, this case was chosen because of its rapidly increasing incidence in the locality,

most cases in the Orthopedic Ward Vicente Sotto Memorial Medical Center involves fracture in

the femoral bones and it is inevitable for us nurses to care for these type of patient. It is very

important for the nurses nowadays to be adequately informed regarding the knowledge and skill

in managing these conditions, Through the knowledge of this condition, a high quality of care will

be provided to those people is suffering from symptoms and complications of fracture.

Generally, the purpose of this study is to generate knowledge about fracture and how it

affects a person physiologically, emotionally, psychologically and spiritually. Moreover, this case

study aims to: (a) gather information about client’s past and present condition: (b) assess

predisposing and precipitating factors that caused such disease condition; (c) determine anatomic

and physiologic functions that contributes to the disease; (d) know the Pathophysiology of the

client’s condition; (e) determine medical and surgical interventions base on client’s assessment

and laboratory results; (f) and also identify appropriate nursing interventions to promote wellness

for the patient.

CHAPTER II

I. Background/History

History of Present Illness

Few hours prior to admission, around 1 pm while driving a motorbike on the way home,

the patient was outbalanced while turning due to darkness of the way and because of

drunkenness, the patient sustained injury in right thigh, had multiple abrasions on anterior and

posterior lower extremity, tenderness on the right leg prompted patient to consult Vicente Sotto

Memorial Medical Center Emergency Room for medical advice and decided to admit for medical

intervention and surgical operation. He was admitted on Ward 8 (Orthopedic ward) last July 6,

2011, around 11:03 pm under the care of Dr. Dominic Vicuňa, He has a chief complaint of

Vehicular accident with an admitting diagnosis of Fractured Closed Distal Third Femur Right

Comminuted.

Physical assessment revealed the following findings, (+) pain on right foot radiating

upward, multiple abrasions and hematoma on right lower extremity, limitation of movement noted

and has the following vital signs; Temperature (36.7˚C), Pulse rate (62 bpm), Respiratory rate (21

cpm), Blood Pressure (130/90 mm Hg).

Laboratory procedures done to the patient are Urinalysis and Complete Blood Count,

Diagnostic procedures done were X-ray Skull APL, Cervical Spine APL, Chest PA, Right Hand

APLO, Pelvis AP, Right Thigh APL and right Knee APL. Medication given is Celecoxib 200 mg

PRN for pain.

History of Past Illness

The patient hasn’t been hospitalized before and claims to undergo wound suturing due to

another vehicular accident in Carajay District Hospital year 2001, Claims to have a family history

of Hypertension and Diabetes Mellitus on paternal side, No known food and drug allergies, (-)

smoking, (+) alcohol, (+) drugs, usually eats Rice, Fish, Vegetables, Beef And Pork, not involved

in any social activity, sleeps at 10 pm and wakes at 7 am, sexually active (3x weekly).

I. Patient’s Vitae

Mr. T.B.M, 32 years old, Male, Married, Currently residing in Carajay, Lapu-Lapu City,

Cebu with wife and 3 children (2 boys and a girl), Born on October 23, 1978 in Carajay, Lapu-

Lapu City, Roman Catholic, Filipino, Worked at City hall resigned after election, currently

unemployed and sells chicken, Graduated Associate Criminology can speak Tagalog and

Cebuano, weighs 79 kilograms and has a height of 5 feet and 5 inches.

II. Functional Health Patterns

Patient was observed to be compliant with medication regimen, use of health-promotion

activities such as regular exercise (Passive and active ROM exercises), Patient understood the

purpose of medical intervention and surgical operation such as placement of traction as

evidenced by keeping affected part immobilized as possible and minimizing movement and for

nutritional and metabolic, the patient has no food restrictions, typical daily food intake includes

Rice, Fish, Vegetables, Beef And Pork, no swallowing difficulties, Patient states to minimize

eating as possible to minimize discomfort and inconvenience during bowel movement, skin

lesions on right posterior leg noted, weight is 76 kg and height is 5’5’ft, abdominal assessment

reveals distension, noted 5 gurgles upon checking bowel sounds, no dehydration noted, for

elimination the patient’s bowel movement is once every 2 days, he able to defecate without

difficulty, constipation noted, dark brown hard stools noted, urination is 6-8 times daily, no pain

upon urination noted, slightly cloudy, yellow colored urine noted. The Patient is unable to

ambulate due to leg fracture, does passive ROM exercise on unaffected foot with wife and active

ROM exercise on upper extremities, patient is unable to do some ADL’s due restriction of mobility

but constantly repositions itself on bed as instructed by nurse or wife. Patient usually sleeps at 9-

10 pm and wakes at 6 am, patient states some discomfort during sleeping in the hospital which

caused by light, pain, noise and constant vital signs monitoring. Patient is able to rest every after

meal since the patient is on bed always. Patient is able understand and follow directions, retain

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information, make decisions, and solves problems as evidenced by taking medications religiously

on indicated time on his own, Able to taste appropriately when food is given, no hearing difficulty,

able to read newsprints, able to smell appropriately. Patient feels bad about self and blames

himself in the accident, patient frequently becomes angry and annoyed about the restrictions and

limitation in his activities. Patient is able to maintain eye contact, is assertive and has long

attention span, able to communicate cooperatively with nurse. Patient acknowledges being a

husband and father of 3 children, lives with family and interacts with family member appropriately,

states that income is sufficient for their family needs, is not involved with any social groups but

has close relationship with neighbors. Development of sexual characteristics are appropriate with

age, patient states he is sexually active (3x weekly) and has no difficulty having sex, doesn’t use

any contraception. Patient states that he drinks alcohol most of the time and takes drugs (not

specified) when he is stressed, states that his family is always with him when he has problem and

it really helped him to handle stress appropriately. Patient is Roman Catholic and states that

keeping spirituality within the family is important and enforced in his family. Goes to church every

Sunday with family.

III. Physical Assessment

Head is normocephalic, symmetric, round, erect, midline with incision on parietal area, no

involuntary movement noted, Facial features are symmetrical, temporal artery elastic and non

tender, anicteric sclera, pupils are midline with each eyeballs, pale conjunctiva, eye movement

symmetric and smooth in 6 directions, Ears are normal in size bilaterally 4 cm, both are aligned

with inner canthus of the eye, no discharges, tenderness or lesions noted, lips are dry and pale,

complete set of teeth noted, no dysphagia or ulcerations noted on oral cavity, lymph nodes are

non tender and movable. Respiratory rate is 21 cycles per minute with normal depths, no nasal

flaring, use of accessory muscles noted, no adventitious sounds are auscultated, bronchial

sounds heard on trachea and thorax, Bronchovesicular sounds heard over the major bronchi and

around the upper sternum, Vesicular sounds heard at peripheral lung fields. Chest expansion of 5

cm bilaterally noted. Systolic blood pressure of 130 and diastolic blood pressure of 90 noted

bilaterally while lying. Apical pulse is regular with a rate of 66 beats per minute, pedal pulses is

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regular and bilaterally equal with a rate of 66 beats minute, no neck vein distension noted.

Anterior chest is uniform in color with smooth texture no edema, tenderness, discoloration or

nodules palpated, the ratio of anteroposterior diameter to transverse diameter is 2:1, scapula are

non protruding, spinous process appear straight and thorax appears symmetric with ribs sloping

downward, breast are symmetrical, not engorged or enlarged, nipples are dark brown and equal

in size bilaterally. Abdomen is symmetric and slightly rounded with a large tattoo on midline,

umbilical skin tones are similar to surrounding abdominal skin tones, umbilicus is midline at lateral

line, bowel sounds are heard as intermittent, soft clicks and gurgles at a rate of 5 per minute,

slightly rigid due to decreased bowel movement, no tenderness noted. Bladder is not palpable

when not full, dull thud heard upon percussion of full bladder, urinates daily with a rate of 6-8

times approximately 700cc per day, urine color is yellow with a consistency of slightly cloudy.

Joint are non tender, no swelling or bulging of fluid, knees symmetric, hollows present on both

sides of the patella, lower leg aligned with upper leg. Full range of motion on upper extremity and

marked limitation of range of motion on lower extremity. Facial movements are symmetrical,

smiles, frowns, puff out cheeks, wrinkles forehead and shows teeth without difficulty, has full

control on movements upper extremity while limited on lower extremity, sensory functions are

equal on both sides, balance is not assessed due to mobility restrictions, patient is able to

perform finger to nose test, reflexes are hypoactive on upper extremities (+). Able to identify the

scent presented on each nostril. Able to read newsprint 14 inches away with full visual fields.

Eyelid covers 2mm of the iris, eyes move in a smooth coordinated motion, pupils are both

reactive and responsive to light accommodation. Eyes move in a smooth coordinated motion in

an upward and downward motion. Reflection of light on the corneas are in the same spot

indicating parallel alignment approximately 3mm from inner canthus, temporal and masseter

muscles contact bilaterally. Lateral movements of eyeballs are smooth and in coordinated motion.

Facial movements are symmetrical, smiles, frowns, puff out cheeks, wrinkles forehead and shows

teeth without difficulty, movements are symmetrical, able to identify sweet and salty flavor. Able to

hear whispered voice 1 meter away with both ears. Gag reflex is intact, able to identify sour and

bitter taste Uvula and soft palate rise bilaterally on phonation, no hoarseness of voice noted.

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Strong and symmetric contractions of Trapezius muscle and there is strong contraction of

Sternocleidomastoid muscle on the side opposite the turned face upon turning against resistance.

Tongue movement is symmetric and smooth and bilateral strength is apparent.

CHAPTER III

FIGURE 1. Upper extremity of right femur viewed from behind and above.

The femur, or thigh bone, is the only bone in the thigh. It is the heaviest, strongest bone

in the body. Its proximal end has a ball-like head, a neck, and greater and lesser trochanters

(separated anteriorly by the intertrochanteric line and posteriorly by the intertrochanteric crest).

The trochanters, intertrochanteric crest and the gluteal tuberosity, located on the shaft, all serve

us sites for muscle attachment.

The head which is globular and forms rather more than a hemisphere, is directed upward,

medialward, and a little forward, the greater part of its convexity being above and in front. Its

surface is smooth, coated with cartilage in the fresh state, except over an ovoid depression, the

fovea capitis femoris, which is situated a little below and behind the center of the head, and gives

attachment to the ligamentum teres.

The neck is a flattened pyramidal process of bone, connecting the head with the body,

and forming with the latter a wide angle opening medialward. The angle is widest in infancy, and

becomes lessened during growth, so that at puberty it forms a gentle curve from the axis of the

body of the bone. In the adult, the neck forms an angle of about 125° with the body, but this

varies in inverse proportion to the development of the pelvis and the stature. In the female, in

consequence of the increased width of the pelvis, the neck of the femur forms more nearly a right

angle with the body than it does in the male. The angle decreases during the period of growth,

but after full growth has been attained it does not usually undergo any change, even in old age; it

varies considerably in different persons of the same age. It is smaller in short than in long bones,

and when the pelvis is wide.

In addition to projecting upward and medialward from the body of the femur, the neck

also projects somewhat forward; the amount of this forward projection is extremely variable, but

on an average is from 12° to 14°. The neck is flattened from before backward, contracted in the

middle, and broader laterally than medially. The vertical diameter of the lateral half is increased

by the obliquity of the lower edge, which slopes downward to join the body at the level of the

lesser trochanter, so that it measures one-third more than the antero-posterior diameter. The

medial half is smaller and of a more circular shape. The anterior surface of the neck is perforated

by numerous vascular foramina. Along the upper part of the line of junction of the anterior surface

with the head is a shallow groove, best marked in elderly subjects; this groove lodges the

orbicular fibers of the capsule of the hip-joint. The posterior surface is smooth, and is broader and

more concave than the anterior: the posterior part of the capsule of the hip-joint is attached to it

about 1 cm. above the intertrochanteric crest. The superior border is short and thick, and ends

laterally at the greater trochanter; its surface is perforated by large foramina. The inferior border,

long and narrow, curves a little backward, to end at the lesser trochanter.

The trochanters are prominent processes which afford leverage to the muscles that rotate

the thigh on its axis. They are two in number, the greater and the lesser.

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FIGURE 2. Right femur. Anterior surface.

The Greater Trochanter (trochanter major; great trochanter) is a large, irregular,

quadrilateral eminence, situated at the junction of the neck with the upper part of the body. It is

directed a little lateralward and backward, and, in the adult, is about 1 cm. lower than the head. It

has two surfaces and four borders. The lateral surface, quadrilateral in form, is broad, rough,

convex, and marked by a diagonal impression, which extends from the postero-superior to the

antero-inferior angle, and serves for the insertion of the tendon of the Glutæus medius. Above the

impression is a triangular surface, sometimes rough for part of the tendon of the same muscle,

sometimes smooth for the interposition of a bursa between the tendon and the bone. Below and

behind the diagonal impression is a smooth, triangular surface, over which the tendon of the

Glutæus maximus plays, a bursa being interposed. The medial surface, of much less extent than

the lateral, presents at its base a deep depression, the trochanteric fossa (digital fossa), for the

insertion of the tendon of the Obturator externus, and above and in front of this an impression for

the insertion of the Obsturator internus and Gemelli. The superior border is free; it is thick and

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irregular, and marked near the center by an impression for the insertion of the Piriformis. The

inferior border corresponds to the line of junction of the base of the trochanter with the lateral

surface of the body; it is marked by a rough, prominent, slightly curved ridge, which gives origin to

the upper part of the Vastus lateralis. The anterior border is prominent and somewhat irregular; it

affords insertion at its lateral part to the Glutæus minimus. The posterior border is very prominent

and appears as a free, rounded edge, which bounds the back part of the trochanteric fossa.

The Lesser Trochanter (trochanter minor; small trochanter) is a conical eminence, which

varies in size in different subjects; it projects from the lower and back part of the base of the neck.

From its apex three well-marked borders extend; two of these are above—a medial continuous

with the lower border of the neck, a lateral with the intertrochanteric crest; the inferior border is

continuous with the middle division of the linea aspera. The summit of the trochanter is rough,

and gives insertion to the tendon of the Psoas major.

A prominence, of variable size, occurs at the junction of the upper part of the neck with the

greater trochanter, and is called the tubercle of the femur; it is the point of meeting of five

muscles: the Glutæus minimus laterally, the Vastus lateralis below, and the tendon of the

Obturator internus and two Gemelli above. Running obliquely downward and medialward from the

tubercle is the intertrochanteric line (spiral line of the femur); it winds around the medial side of

the body of the bone, below the lesser trochanter, and ends about 5 cm. below this eminence in

the linea aspera. Its upper half is rough, and affords attachment to the iliofemoral ligament of the

hip-joint; its lower half is less prominent, and gives origin to the upper part of the Vastus medialis.

Running obliquely downward and medialward from the summit of the greater trochanter on the

posterior surface of the neck is a prominent ridge, the intertrochanteric crest. Its upper half forms

the posterior border of the greater trochanter, and its lower half runs downward and medialward

to the lesser trochanter. A slight ridge is sometimes seen commencing about the middle of the

intertrochanteric’ crest, and reaching vertically downward for about 5 cm. along the back part of

the body: it is called the linea quadrata, and gives attachment to the Quadratus femoris and a few

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fibers of the Adductor magnus. Generally there is merely a slight thickening about the middle of

the intertrochanteric crest, marking the attachment of the upper part of the Quadratus femoris.

FIGURE 3. Right femur. Posterior surface.

The body, almost cylindrical in form, is a little broader above than in the center, broadest

and somewhat flattened from before backward below. It is slightly arched, so as to be convex in

front, and concave behind, where it is strengthened by a prominent longitudinal ridge, the linea

aspera. It presents for examination three borders, separating three surfaces. Of the borders, one,

the linea aspera, is posterior, one is medial, and the other, lateral.

The linea aspera (FIGURE 3.) is a prominent longitudinal ridge or crest, on the middle

third of the bone, presenting a medial and a lateral lip, and a narrow rough, intermediate line.

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Above, the linea aspera is prolonged by three ridges. The lateral ridge is very rough, and runs

almost vertically upward to the base of the greater trochanter. It is termed the gluteal tuberosity,

and gives attachment to part of the Glutæus maximus: its upper part is often elongated into a

roughened crest, on which a more or less well-marked, rounded tubercle, the third trochanter, is

occasionally developed. The intermediate ridge or pectineal line is continued to the base of the

lesser trochanter and gives attachment to the Pectineus; the medial ridge is lost in the

intertrochanteric line; between these two a portion of the Iliacus is inserted. Below, the linea

aspera is prolonged into two ridges, enclosing between them a triangular area, the popliteal

surface, upon which the popliteal artery rests. Of these two ridges, the lateral is the more

prominent, and descends to the summit of the lateral condyle. The medial is less marked,

especially at its upper part, where it is crossed by the femoral artery. It ends below at the summit

of the medial condyle, in a small tubercle, the adductor tubercle, which affords insertion to the

tendon of the Adductor magnus.

From the medial lip of the linea aspera and its prolongations above and below, the

Vastus medialis arises; and from the lateral lip and its upward prolongation, the Vastus lateralis

takes origin. The Adductor magnus is inserted into the linea aspera, and to its lateral prolongation

above, and its medial prolongation below. Between the Vastus lateralis and the Adductor magnus

two muscles are attached—viz., the Glutæus maximus inserted above, and the short head of the

Biceps femoris arising below. Between the Adductor magnus and the Vastus medialis four

muscles are inserted: the Iliacus and Pectineus above; the Adductor brevis and Adductor longus

below. The linea aspera is perforated a little below its center by the nutrient canal, which is

directed obliquely upward.

The other two borders of the femur are only slightly marked: the lateral border extends

from the antero-inferior angle of the greater trochanter to the anterior extremity of the lateral

condyle; the medial border from the intertrochanteric line, at a point opposite the lesser

trochanter, to the anterior extremity of the medial condyle. The anterior surface includes that

portion of the shaft which is situated between the lateral and medial borders. It is smooth, convex,

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broader above and below than in the center. From the upper three-fourths of this surface the

Vastus intermedius arises; the lower fourth is separated from the muscle by the intervention of

the synovial membrane of the knee-joint and a bursa; from the upper part of it the Articularis genu

takes origin. The lateral surface includes the portion between the lateral border and the linea

aspera; it is continuous above with the corresponding surface of the greater trochanter, below

with that of the lateral condyle: from its upper three-fourths the Vastus intermedius takes origin.

The medial surface includes the portion between the medial border and the linea aspera; it is

continuous above with the lower border of the neck, below with the medial side of the medial

condyle: it is covered by the Vastus medialis.

CHAPTER IV

Pathophysiology

FIGURE 4. Pathophysiology of fracture (schematic diagram)

FractureFracture

Traumatic Force Applied To the Right Lower ExtremityTraumatic Force Applied To the

Right Lower Extremity

NumbnessNumbness

Multiple Abrasions and the Distal 3rd Femur Bone Is Broken Into Fragments (Comminuted)Multiple Abrasions and the Distal 3rd Femur

Bone Is Broken Into Fragments (Comminuted)

Physical Trauma Due to Motorbike Accident

Physical Trauma Due to Motorbike Accident

Bleeding Occurs From the Damaged Bone and From the Neighboring Soft TissuesBleeding Occurs From the Damaged Bone and From

the Neighboring Soft Tissues

Precipitating factors:

Behavior

Lifestyle

Occupation

Environment

Precipitating factors:

Behavior

Lifestyle

Occupation

Environment

Fibrous Connective Tissue or Periosteum And Blood Vessels in the Cortex Marrow, And Surrounding Soft

Tissues Are Disrupted and Damaged.

Fibrous Connective Tissue or Periosteum And Blood Vessels in the Cortex Marrow, And Surrounding Soft

Tissues Are Disrupted and Damaged.

Risk factorsRisk factors Pre disposing

factors:

Age

Gender

Pre disposing factors:

Age

Gender

Pain, Swelling, Redness, Heat, Loss of FunctionPain, Swelling, Redness, Heat, Loss of Function

Stimulation of the Inflammatory ResponseStimulation of the Inflammatory Response

HematomaHematoma

Formation of blood clotFormation of blood clot

Nerve at the site of fracture damaged

Nerve at the site of fracture damaged

Muscle spasm due Fractured

bone

Muscle spasm due Fractured

bone

Limitation of ROM, Mobility and Reduction of ADLS’sLimitation of ROM, Mobility and Reduction of ADLS’s

Pain and TendernessPain and

Tenderness

A fracture is a break in the continuity of bone and is according to its type and extent.

Fractures occur when the bone is subjected to stress greater than it can absorb. Fractures are

caused by direct blows, crushing forces, sudden twisting motions, and even extreme muscle

contractions. When the bone is broken, adjacent structures are also affected resulting in soft

hemorrhage into the muscles and joints, joint ruptured tendons, severed nerves, and damaged

blood, organs may be injured by the force that caused the fracture fragments. The severity of the

fracture, therefore, depends on the strength of the impact, the position of the bone when it was

hit, and what type of bone has been affected. This is why bones can break in many different

ways. The different cases of broken bones could be compound fractures, closed fractures, stress

fractures, and fractures caused by pathological diseases such as osteoporosis. The above

schema shows a comminuted type of fracture this type of fracture occurs when a bone has been

broken into a number of pieces.

Modifiable Risk factors for this type of fracture is the same as any other fracture which

includes behavior such drunk driving which is the actual etiological factor for patient’s accident,

lifestyle which basically relates to the nutritional intake, smoking habits and other activity that

would affect the body’s bone integrity and calcium levels, Occupation and environment involving

sun exposure and etc., other factors which are non modifiable includes Age caused by increased

degeneration of bones as age also increases and Gender which mainly is caused by interplay of

hormones in the body.

In the above schema, the fracture is caused by a motorbike accident causing physical

trauma in the right lower extremity, the accident also caused multiple abrasions and comminuted

fracture in the distal 3rd femur. Broken bone fragments affects the nerve endings in the

surrounding area causing numbness and muscle spasm leading to pain and tenderness thus

causing the limitation of Range Of Motion and mobility disabling the patient to perform some

activities of daily living.

The above schema also shows the natural process of healing of a fracture which starts

when the injured bone and surrounding tissues bleed, forming a Hematoma. The blood

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coagulates to form a blood clot situated between the broken fragments. Within a few days blood

vessels grow into the jelly-like matrix of the blood clot. The new blood vessels

bring phagocytes to the area, which gradually remove the non-viable material. The blood vessels

also bring fibroblasts in the walls of the vessels and these multiply and produce collagen fibers. In

this way the blood clot is replaced by a matrix of collagen. Collagen's rubbery consistency allows

bone fragments to move only a small amount unless severe or persistent force is applied.

Throughout the process of bone healing the body’s inflammatory response is stimulated which is

manifested by Pain, Swelling, Redness, Heat, Loss of Function and subsequently adds to the

limitation Range Of Motion and mobility.

CHAPTER V

MEDICAL MANAGEMENT

Laboratory procedures

Hematology

One of the most important laboratory procedures for patient with fracture is complete

blood count or hematology. Hematology is the study of the cellular elements of the blood, the

production of these elements, and the physiological derangements that affect their functions. It is

also concerned with blood volume, the flow properties of blood, and the physical relationships of

red cells and plasma. Changes in blood components may be evidenced by a patient with fracture

such as in Hematocrit it may be increased (hemoconcentration) or decreased (signifying

hemorrhage at the fracture site or at distant organs in multiple trauma). Increased white blood cell

(WBC) count is a normal stress response after trauma. Abnormal results during the actual

complete blood count result of the patient (see appendix B) includes increased white blood cell

count which is 11.9x10^9/L over a normal value of 4.8-10.8x10^9/L this indicates a normal stress

response after trauma or it may also that there is an undergoing infection in the fracture site.

Mean Corpuscular Hemoglobin which is 32.7 pg over a normal value of 27-31 pg which indicates

macrocytic anemia, this could be not directly related to the diagnosis and also an increased

basophil and monocyte which indicates bacterial infection and inflammation.

Urinalysis

Routine urinalysis is one of the most widely ordered laboratory procedures, is used for

basic screening purposes. It is a group of tests that evaluate the kidneys’ ability to selectively

excrete and reabsorb substances while maintaining proper water balance. The results can

provide valuable information regarding the overall health of the patient and the patient’s response

to disease and treatment. The urine dipstick has a number of pads on it to indicate various

biochemical markers. Urine pH is an indication of the kidneys’ ability to help maintain balanced

hydrogen ion concentration in the blood. Specific gravity is a reflection of the concentration ability

of the kidneys. Urine protein is the most common indicator of renal disease, although

there are conditions that can cause benign proteinuria. Glucose is used as an indicator of

diabetes. The presence of ketones indicates impaired carbohydrate metabolism. Hemoglobin

indicates the presence of blood, which is associated with renal disease.

Urine samples for routine analysis are best collected first thing in the morning. Urine that

has accumulated in the bladder overnight is more concentrated, thus allowing detection of

substances that may not be present in more dilute random samples. The sample should be

examined within 1 hour of collection. If this is not possible, the sample may be refrigerated until it

can be examined. Failure to observe these precautions may lead to invalid results.

According to the patients actual urinalysis results (see appendix C) it showed that all of

the parameters evaluated during the analysis are within normal values.

Coagulation profile

The coagulation proteins respond to blood vessel injury in a chain of events. The intrinsic

and extrinsic pathways of secondary hemostasis are a series of reactions involving the substrate

protein fibrinogen, the coagulation factors (also known as enzyme precursors or zymogens),

nonenzymatic cofactors (Ca2+), and phospholipids. The factors were assigned Roman numerals

in the order of their discovery, not their place in the coagulation sequence. Alterations may occur

because of blood loss, multiple transfusions, or liver injury. The specimen for this laboratory

procedure is a Whole blood in a completely filled 5-mL blue-top (sodium citrate) tube.

According to the patient’s actual results (see appendix D) all of the parameters evaluated

during the coagulation profile fall within normal range.

Diagnostic procedures

Bone Radiography

Bone radiography are used to evaluate extremity pain or discomfort due to trauma, bone

abnormalities, or fluid within a joint. Serial skeletal x-rays are used to evaluate growth pattern.

Radiation emitted from the x-ray machine passes through the patient onto a photographic plate or

20

x-ray film. X-rays pass through air freely and are mostly absorbed. skeletal x-rays are used to

evaluate extremity pain or discomfort due to trauma, bone abnormalities, or fluid within a joint.

Serial skeletal x-rays are used to evaluate growth pattern. Radiation emitted from the x-ray

machine passes through the patient onto a photographic plate or x-ray film. X-rays pass through

air freely and are mostly absorbed. Thus this procedure determines location and extent of

fractures/trauma, may reveal preexisting and yet undiagnosed fractures.

Bone scans, tomograms, computed tomography (CT)/magnetic resonance imaging (MRI)

scans help visualize fractures, bleeding, and soft-tissue damage; differentiates between

stress/trauma fractures and bone neoplasms.

According to the patients actual diagnostic result (see appendix E) abnormal findings

found in the x rays includes soft tissue swelling in the parieto-occipital region this was found out

through Skull APL, Straightening of the cervical spine due to muscle spasm which was evident on

cervical spine APL, Comminuted fracture, distal third, right femur with soft tissue swelling evident

on thigh right APL and knee right APL.

Arthrogram

 An arthrogram evaluates the cartilage, ligaments, and bony structures that compose a

joint. After local anesthesia is administered to the area of interest, a fluoroscopically guided

Small-gauge needle is inserted into the joint space. Fluid in the joint space is aspirated and sent

to the laboratory for analysis. Contrast medium is inserted into the joint space to outline the soft

tissue structures and the contour of the joint. After brief exercise of the joint, radiographs or

magnetic resonance images (mris) are obtained. Arthrograms are used primarily for assessment

of persistent, unexplained joint discomfort. Area of application includes shoulder, elbow, wrist,

hip, knee, ankle, temporomandibular joint. This test is indicated for patients with fracture, evaluate

pain, swelling, or dysfunction of a joint monitor disease progression. Normal findings are Normal

bursae, menisci, ligaments, and articular cartilage of the joint (note: the cartilaginous surfaces

and menisci should be smooth, without evidence of erosion, tears, or disintegration) Abnormal

findings can be found out in patients with Fracture, Arthritis, Cysts Diseases of the cartilage

(chondromalacia),Injury to the ligaments

21

Drug study

The only drug prescribed to the patient is Celecoxib 200mg 1tab OD prn for pain. An

analgesic drug and has anti-inflammatory activities related to inhibition of the COX-2 enzyme,

which is activated in inflammation to cause the signs and symptoms associated with

inflammation; does not affect the COX-1 enzyme, which protects the lining of the GI tract and has

blood clotting and renal functions. This is given to the patient if patient is experiencing headache

to manage pain. Before giving the medication, the nurse should (a) check patient’s history of

allergies, renal impairment, impaired hearing, and hepatic and CV conditions if any; (b) check

skin color and lesions; (c) check CBC, LFTs, renal function tests, serum electrolytes; (d) monitor

vital signs; and (e) assess patient’s pain score. During the giving of drug, the nurse should: (a)

administer drug with food or after meals; (b) establish safety measure if CNS or visual

disturbances occur; and (c) document giving of drug. After giving of drug, the nurse should: (a)

Provide comfort measures to reduce pain such as positioning, environmental control; (b) Instruct

patient to take drug with food to prevent GI upse; (c) Instruct patient to take only the prescribed

dosage; do not increase dosage; (d) Tell patient that he may experience adverse effects such as

dizziness and drowsiness; and (e) Tell patient to report experience of sore throat, fever, rash,

itching, weight gain, swelling in ankles or fingers, changes in vision promptly.

SURGICAL MANAGEMENT

Open Reduction Internal Fixation

An open reduction and internal fixation (ORIF) is a type of surgery used to fix broken

bones. This is a two-part surgery. First, the broken bone is reduced or put back into place. Next,

an internal fixation device is placed on the bone; this can be screws, plates, rods, or pins used to

hold the broken bone together. This surgery is done to repair fractures that would not heal

correctly with casting or splinting alone. Before the surgery is done the patient has to undergo the

following exams: Physical examination which is to check your blood circulation and nerves

affected by the broken bone, X-ray, CT scan, Blood tests, and Tetanus shot which depends on

the type of fracture and if your immunization is current. General anesthesia may be used. It will

22

block any pain and keep you asleep during the surgery. It is given through an IV (needle in your

vein) in your hand or arm. In some instances, a spinal anesthetic, or more rarely a local block,

may be used to numb only the area where the surgery will be done. This will depend on where

the fracture is located and the time it will take to perform the procedure. Each ORIF surgery

differs based on the location and type of fracture. In general, a breathing tube may be placed to

help you breathe while you are asleep. Then, the surgeon will wash your skin with an antiseptic

and make an incision. Next, the broken bone will be put back into place. Next, a plate with

screws, a pin, or a rod that goes through the bone will be attached to the bone to hold the broken

parts together. The incision will be closed with staples or stitches. A dressing and/or cast will

then be applied.

NURSING MANAGEMENT

Summary of nursing problems:

1. Acute pain related to movement of bone fragments secondary to comminuted fracture.

2. Impaired Physical Mobility related to musculoskeletal impairment secondary to prescribed

restrictive therapies. (traction)

3. Risk for Trauma (additional injury) related to loss of skeletal integrity and improper

placement of traction weights.

Individualized Nursing Care Plan

Upon the first day of interaction to the patient the researcher was able to formulate the

nursing problems and prioritized as to the most critical nursing focus which is acute pain related

to movement of bone fragments secondary to comminuted fracture. Objective findings that could

support the formulated problem include; Received patient lying on bed with head elevated,

awake, conscious, coherent, communicative, with foam traction at right foot, with pain score of 7

out of 10, grimaced face noted, irritability observed, restlessness noted, limited range of motion

observed and with a subjective cue of :”ngol-ngol kaayu ang ako bali” as verbalized. Short term

goal formulated includes after 5 hours of nursing intervention the patient will be able to verbalize

23

pain relief as evidenced by decreased pain score. Long term goal formulated includes after 3

days of nursing intervention, the patient will be able to, verbalize and demonstrate techniques that

provide pain relief and demonstrate effective use of relaxation techniques as indicated for

individual situation after assessment and goal planning the interventions were made which

includes assessment level of pain, location, character, and aggravating factor to rule out for

worsening of underlying conditions and development of complication and prevent occurrence.

Observation for non-verbal cues of pain because they may not be congruent with verbal reports

and may prompt change in locus of intervention, Provision of comfort measures as possible such

as touch therapy, repositioning, use of cold/heat packs, constant interaction, quiet environment

and calm activities which maximizes use of non-pharmacological techniques for pain relief,

Instruction in and encouragement of usage of relaxation techniques such as focused breathing

and imaging to distract patients attention and thus reduce tension, Encouragement in engaging in

diversional activities such as socialization with other patients or listening to music which is also

used distract attention and reduce tension, Health teaching about non-pharmacological pain

management to promote self control and management of pain. Dependent and Collaborative

nursing management includes Administration of analgesics as to a maximum as needed as

indicated by individual situation to maintain acceptable level of pain, Instruction patient in use of

transcutaneous electrical nerve stimulation units when ordered to maintain acceptable level of

pain and comfort and lastly referral to occupational/physical therapy program to promote active

role partcipation and enhanced self-control.

During the second day of care, the researcher was to formulate the following nursing care

plan with a nursing focus of Impaired Physical Mobility related to musculoskeletal impairment

secondary to prescribed restrictive therapies. (traction), this problem problem was identified

through analysis of the objective findings which includes, received patient lying on bed with head

elevated to 30 degrees, awake, conscious, coherent, communicative, with foam traction at right

foot, the patient is reading a newspaper, has difficulty in changing position while lying on

bed, has difficulty in moving the extremities, inability to walk or stand alone, limited range

of motion in the extremities, slowed movement, difficulty in initiating gait and subjective cue

24

“maglisod man jud kog lihok sa ako lawas” as verbalized. Short term goal is After 5 hours of

nursing intervention, the patient will be able to perform activities of daily living at the level of

functional capabilities. Long term goal includes After 3 days of nursing intervention; the patient

will be able to demonstrate and verbalize proper exercises of the lower extremities & can perform

activities of daily living with minimal assistance. Nursing interventions that were formulated

include provision of normal range of motion exercises and function of lower extremity which

necessary to regain normal mobility of leg to speed up recovery, Encouragement of progressive

activities according to level of functional capability to increase patient’s use of affected leg.

instruct and encourage use of overhead trapeze in mobilizing in the bed to obtain sense of control

during movement, encouragement in participation in self-care, occupational/diversional/

recreational activities to enhances self concept and sense of independence, Identification of

energy conserving techniques for ADL’s which limits fatigue and maximizes participation in

intervention, encouragement adequate intake of fluid and nutrition to promote well-being and

energy production, provision of proper skin care to decrease risk for decubitus ulcer formation.

Collaborative and dependent nursing interventions include administration medications as needed

prior to activity for pain relief to permit maximal effort and involvement in activity and lastly

consultation with Occupational therapy as needed to maintain continuity of care after discharge.

Third and last nursing care plan for the patient includes a nursing problem which is Risk

for Trauma (additional injury) related to loss of skeletal integrity and improper placement of

traction weights, this was formulated upon analysis of objective findings which includes received

patient lying on bed with head elevated, awake, conscious, coherent, communicative, with foam

traction at right foot, absence of side rails noted, traction weights placed of walkways, absence of

bed padding noted, high placement of bed observed, seen SO frequently leaving the patient and

subjective cue :”dali ra masabod sa mga mangagi kanang baton a gbitay”. As verbalized, short

term goal formulated is those After 4 hours of nursing intervention, the patient will be able to

verbalize understanding of condition and recognize need for prevention of injuries and a long

term goal of After 3 days of nursing intervention, the patient will be able to demonstrate

appropriate lifestyle changes to reduce risk for injury and maintain condition without additional

25

injury and decrease risk for trauma. Nursing interventions formulated for this nursing problem

includes Identification of factors related to individual situation and identify extent of risk which

nfluence the scope and intensity of interventions to manage safety, notification of clients decision-

making ability and level of cognition including functional capability cause this can affects client’s

ability to protect self and influences choice of interventions and teaching, Implementation

interventions regarding safety issues includes: orientation to environment, keep bed in low

position, pad bed edges as possible, provide adequate area lighting and assist with moving or

turning using trapeze becausefailure to accurately assess, intervene and/or refer these these

issues can place patients at needless risk and create negligence issues for healthcare

practitioner, provision quiet environment and reduced stimulation as possible this can help limit

confusion or overstimulation, placement traction weights at appropriate location away from

passageways as possible, to prevent moving the weights causing disaligment of bone fragments.

Collaborative and Dependent nursing interventions includes assistance with treatment of

underlying medical/surgical conditions to improve cognition/thinking process.

Focused charting

On the first day of actual care to the patient the researcher utilized the formulated nursing

care plan and derived to the focus Acute pain with supporting data of received patient lying on

bed with head elevated to 30 degrees, awake, conscious, coherent, communicative, without IV,

with the following v/s T= 35.5 degree Celsius, P= 86 pm, R= 20 bpm and BP= 120/70 mmHg,

with foam traction at right foot, with pain score of 7 out of 10, grimaced face noted, irritability

observed, restlessness noted, limited range of motion observed, “ngol-ngol kaau ang akong bali

dong”. As verbalized. Actions made included; Introduced name to the patient, assessed level of

pain, character and location, monitored v/s, positioned properly on bed with head slightly

elevated, Due medications (analgesics) administered as ordered, encouraged to engage in

diversional activities such as socialization with others, provided comfort measures such as

backrub, encouraged patient to do DBE; supported affected body parts/ joints using pillows/

rolls, consulted with physical or occupational therapist as indicated, documented the v/s and I

26

and O of the patient. After the shift :”wa na kaayu sakit ang ako bali dong”. As verbalized, pain

score decreased from 7out of 10 to 3 out of 10.

On the second day of nursing care the formulated nursing problem for the charting

focuses on Impaired physical mobility with supporting data of received patient lying on bed with

head elevated to 30 degrees, awake, conscious, coherent, communicative, without IV, with the

following v/s T= 35.5 degree Celsius, P= 86 pm, R= 20 bpm and BP= 120/70 mmHg, with foam

traction at right foot, the patient is reading a newspaper, has difficulty in changing position

while lying on bed, has difficulty in moving the extremities, inability to walk or stand

alone, limited range of motion in the extremities, slowed movement, difficulty in initiating gait. “

maglisod man ko ug lihok dong”. As verbalized. Interventions done includes; Introduced name to

the patient, assessed the condition of the patient; monitored v/s, positioned properly on bed with

head slightly elevated, assisted patient in doing ROM exercises, assisted patient upon doing gait

training, instructed in proper use of overhead trapeze, provided comfort measures such as

backrub, encouraged patient to do DBE; supported affected body parts/ joints using pillows/

rolls, consulted with physical or occupational therapist as indicated, documented the v/s and I

and O of the patient after the interaction the patient was able to demonstrate increasing

functionality of the extremities as evidenced by turning on bed without assistance and

effective usage of overhead trapeze

For the last day of care to the patient the researcher utilized the formulated nursing care

plan intended for that day which is Risk for additional injury with supporting data of received

patient lying on bed with head elevated, awake, conscious, coherent, communicative, without IV,

with the following v/s T= 37 degree Celsius, P= 62 pm, R= 21 bpm and BP= 130/70 mmHg, with

foam traction at right foot, absence of side rails noted, traction weights placed of walkways,

absence of bed padding noted, high placement of bed observed, seen SO frequently leaving the

patient, “dali raman masabaod ang kanang mga bato”. As verbalized, interventions done

includes; Introduced name to the patient, assessed the condition of the patient, instructed SO to

stay with patient as much as possible, implemented interventions regarding safety issues such as

orientation of patient to environment, keeping bed in low position, providing adequate area

27

lighting and padding of side rails as possible, monitored v/s, positioned properly on bed with head

slightly elevated, assisted patient in doing ROM exercises, assisted patient upon doing gait

training, instructed in proper use of overhead trapeze, provided comfort measures such as

backrub, encouraged patient to do DBE; supported affected body parts/ joints using pillows/

rolls, consulted with physical or occupational therapist as indicated, documented the v/s and I

and O of the patient after the interaction the patient was able to demonstrate behaviors to

promote safety, SO was seen staying with patient most of the time.

Discharge summary

This is a case of T.B.M, 32 years old, male, married, from Carajay, Lapu-Lapu City,

Cebu, he was admitted on Vicente Sotto Memorial Medical Center ward 8 (orthopedic ward) last

July 6, 2011, around 11:03 pm under the care of Dr. Dominic Vicuṅa, he has a chief complaint of

Vehicular accident with an admitting diagnosis of fractured closed distal third femur, right,

comminuted.

For the discharge instructions, the researcher focused on home care management , the

researcher stressed to the patient the importance of continuing prescribed medication even after

discharge for continuity of care and optimal recovery from condition and recovery, also taught

patient and significant other patient about mechanism of action, dosage, frequency, side effects

and adverse reaction of medication prescribed to increase patient and significant other’s

knowledge about medication thus increasing compliance, advised patient to have daily exercise

as tolerated such as morning walks assisted by a significant other ,Taught about appropriate

exercise that can be used by patient such as passive exercise on the lower or affected extremity

and active exercise on the upper extremity, advised patient to take a bath daily and wash hands

frequently and also advise the significant others to do the same to prevent spread of infection,

taught about signs of infection and when to call for medical emergency, encourage to have

emergency hotline numbers and transportation facilities ready in case of emergency and advised

to return immediately if the following signs occur severe pain, swelling, headache, redness, or

28

frequent light-headedness, encouraged to eat a well balanced diet including high protein and high

calcium for faster bone remodelling and tissue repair which can be found in the following foods;

meat products, egg, milk and other dairy products especially eating green leafy vegetables, also

encouraged to have supplementary vitamins and minerals and lastly encouraged to strengthen

spirituality within the family by attending to mass together and praying together. At the end of the

shift the patient is still in.

CHAPTER VI

EVALUATION AND RECOMMENDATION

I. Extent of Goal Achievement

After 3 days of intervention, the student nurse observed certain changes from the patient. On

the first day of interaction the patient reports decreased pain with elevation, ice and analgesic and

also the patient was able to demonstrate effective use of relaxation techniques as evidenced by

decreased recurrence of pain perception. On the second day of interaction changes observed to

the patient include regaining of the patient’s previous range of motion in the leg & demonstrates

proper exercises for the lower extremities. He also does some ADL without discomfort. On the

third and final day on interaction the patient was seen demonstrating appropriate lifestyle

changes to reduce risk for injury such as asking for help from SO upon moving and using trapeze

effectively when turning. The patient also exhibits unlabored respirations; alert and oriented,

afebrile, using affected extremity for light activity as allowed, no signs of neurovascular

compromise, vital signs are stable; urine output adequate and no calf pain reported: Homan’s

sign negative., hygiene and dressing practices with minimal assistance and denies acute

symptoms of stress; reports working through feelings about trauma.

II. Recommendation

As a researcher in this case study, the student nurse recommends the patient to adjust in

usual lifestyle and responsibilities to accommodate limitations imposed by fracture and to prevent

recurrent fractures – safety considerations, avoidance of fatigue and proper footwear. The patient

is instructed about exercises to strengthening upper extremity muscles If crutch walking is

planned, methods of safe ambulation–walker, crutches, care, emphasizes instructions concerning

amount of weight bearing that will be permitted on fractured extremity, teaches symptoms

needing attention, such as numbness, decreased function, increased pain and elevated

temperature and explains basis for fracture treatment and need for patient participation in

therapeutic regimen. The patient and the family were also informed that the patient must have an

adequate balanced diet to promote bone and soft tissue healing.

Nursing Practice

The result of this case study would provide the student nurse with sufficient knowledge, attitude

and skills towards the management of patients with fracture on the right femoral neck. This study

would help the student nurse in providing a higher quality of care of patients with the same

condition. It is important that the proper and ideal managements and interventions are done in

order to give a more holistic approach and optimum care to clients with fracture on the right

femoral neck. This would ensure the timely healing of injury and the prevention of complications.

Nursing Education

Education can promote enhancement of professionalism through an on- going learning process,

whether self- motivated, people- oriented and having a commitment to the organization, nurses

are likely to become well respected through the formal educational programs. Through this case

study, it is important to know all areas of patient are both knowledge and skills to manage

effectively in all aspects of their professional nursing practice.

Nursing Research

Nursing research is essential for the development of scientific knowledge that enables nurses to

provide evidenced-based health care. Broadly nursing is accountable to society for providing

quality, cost effective care and for seeking ways to improve that care. More specifically, nurses

are accountable to their patients to promote a maximum level of health.

31

BIBLIOGRAPHY

Book sources:

Bare, Brenda I. and Smeltzer, Suzzane C., Textbook of Medical-Surgical Nursing. 10th

Edition Philadelphia: I.B Lippincott Company. 2004.

Deglin, J. and Vallerand, A. 2005. Davis’ Drug Guide 9th edition, Philadelphia; F.A davis

Doenges, M., Moorhouse, M.F. , Geissler – Murr, A. “ Nurses Pocket Guide”, Diagnosis,

interventions and rationales, 9th Edition (2004).

Doenges, M., Moorhouse, M.F. , Geissler – Murr, A., “ Nursing Care Plans”. Guidelines

for Individualizing Patient Care. 6th Edition. F.A. Davis Company, 2002.

Nettina, Sandra M., Manual of nursing Practice. 7th Edtion. I.B. Lippincott Company.

2001.

Rozler, Barbara et al. Fundamentals of Nursing. 5th Edition. Newyork: Addison-

Weatleylongman, Incorporated. 1998.

Marieb, Elaine N. Essential of Human Anatomy and Physiology. 7th Edition. Singapore.

Pearson Education South Asia Pte. Ltd. 2004.

Potter, Patricia and Perry, Anne. Fundamentals of Nursing. 6th Edition Baltimore: C.V.

Mosby and Company. 2005.

Internet Sources:

Aukerman, Douglas F, MD, Ho, Sherwin SW, MD, (30 Oct 2008), Femur Injuries and

Fractures, Retrieved august 21, 2011 from http://emedicine.medscape.com/article/90779-

Cluett, Jonathan, M.D., (August 21, 2005), Femur Fracture, Retrieved September 18,

2011 from http://orthopedics.about.com/od/brokenbones/a/femur.htm

Crist, Brett D. MD; Della Rocca Gregory J., MD, PhD; Murtha, Yvonne M. MD, (July

2008), Treatment of Acute Distal Femur Fractures, Retrieved September 18, 2011 from

http://www.orthosupersite.com/view.aspx?rid=2979

Keany, James E, MD, FACEP, Kulkarni Rick, MD (2011, January), Femur Fracture,

Retrieved August 21, 2011, from http://emedicine.medscape.com/article/824856-overview.

Appendices

33

APPENDIX A

Cebu Normal UniversityCollege of Nursing

APPROVAL FOR CASE STUDY

Name of Student: Macayan, Jellou Ray M. Year and Section: IV-BSemester: First Semester Academic Year: 2011-2012

This is to certify that the student is approved to take the case of

T.B.M

(Initials of Patient)

With diagnosis of

Fractured Closed, Distal 3 rd Femur, Right, Comminuted

(Write the full diagnosis)

In Ward VIII (Orthopedic Ward) as subject for case study in the undergraduate level.

Name and signature of Clinical Instructor:

Mrs. Bertilia F. Pragados BSN, RN

Date of approval: ___________________

34

APPENDIX B

Cebu Normal UniversityCollege of Nursing

APPROVAL FOR FINAL PRINTING AND BOOK BINDING OF CASE STUDY

Name of Student: Macayan, Jellou Ray M. Year and Section: IV-BSemester: First Semester Academic Year: 2011-2012

This is to certify that the case study has underwent final checking and is approved for final printing and

book binding as partial fulfilment for the requirements for graduation.

Name and signature of Clinical Instructor:

Mrs. Bertilia F. Pragados BSN, RN

Date of approval: __________________

35

APPENDIX C Physical assessment (actual)

Cebu Normal UniversityCollege of Nursing

Cebu City

NURSING ADMISSION AND ASSESSMENT

Name of Student: Jellou Ray M. Macayan Clinical Assignment: WARD VIII (orthopedic ward)

Name of Clinical Instructor: Bertilia F. Pragados Inclusive Dates:

A. General Admission Information

Name of Patient: T.B.M, Age: 32 years old Sex: Male

Date: July 6, 2011 Time: 11:03 pm Mode: ERUF Allergies: no known allergies

TPR: T- 37, P- 62 R- 21 BP: 130/70 mmhg HT: 5’5 Ft WT: 79 kg. Diet: Diet As Tolerated

Sleeping Habits: sleeps at 10 pm and wakes at 7 am CBC: Yes / No Urinalysis: Yes / No

Property: Glasses NONE Contact Lenses NONE Dentures NONE

Prosthesis NONE Ring NONE Watch Money NONE

Other NONE

Valuable to Business Office NONE

Physical Appearance: Client appears to be on his stated chronological age, sexual development is appropriate for age, observed no upper

clothing, prominent tattoo noted on abdomen, unkempt appearance noted, diaphoresis noted, complexion is even, foam traction noted at

right foot

Behavior Exhibited: client is cooperative during the interaction and purposive in his actions, openness noted during conversation with life

experiences, mild anxiety noted, affect is appropriate with occasion, speech is clear, moderately paced and culturally appropriate.

Content of Conversation: patient- centered; topic was focused on patient’s profile, perception of reason for admission, present condition,

patient’s history of past and present illness, educational and cultural background.

Dr. Dominic Vicuña M.D.

Physician In-charge

B. Admission Interview

36

1. Patient’s perception of reason for admission: Patient verbalizes that reason for admission was because he sustained a

fracture on his lower extremity “nabali akong paa” as verbalized

2. Patient’s symptoms as he/she sees them: “ngol-ngol kaayu og hapdos kung masabod ang akong bali”as verbalized by the pt.

3. Problems in daily living created by symptoms (as patient views them)

Patent is unemployed so he helps in raising his children and also in chicken business and because of this condition he can longer

attend to this job.

4. Past Medical History (especially as it relates to P.I.)

a. Medical hasn’t been hospitalized before

b. Surgical wou nd suturing – 2001 – Carajay District Hospital-ER

c. Allergies no known allergies

d. Medication Celecoxib 200mg 1 tablet prn for pain,

e. Traumatic Injuries Vehicular accident – 2001 – Carajay District hospital ER – wound suturing

f. Orthopedic NONE

g. Other (psychiatric, etc.) NONE

5. Habits:

a. Smoking non-smoker Alcohol drinks 3x weekly Drugs occasionally(as verbalized

b. Eating Breakfast, Lunch And Supper: Rice, vegetables, fish, beef, pork and water

c. Social Activity none but is a basketball player in their place previously Physical Exercise walking and running

d. Rest/Sleeping usually sleeps at 10pm and wakes up at 7 am, at 2pm patient takes a nap and wakes at 3 or 4 pm.

e. Sexual active, 3 times weekly as verbalized

f. Elimination bowel movement: once daily urination: 8-10 times daily

37

6. Social Economic History:

a. Native Language Cebuano and Tagalog

b. Education college level (graduate of associate criminology)

c. Occupation unemployed, sells chicken and also a landlord

d. Financial Status (what is the impact of current hospitalization)

Patient used their family to pay for the finances and also lends money from their friends around the neighborhood for

additional financial assistance

e. Civil Status: Married / Single Divorced Widow

f. Living Situation: Lives alone

Lives with others (specify) lives with wife and 3 children (2 sons and a daughter

7. Family History: Heart Disease, Cancer, TB, Mental Illness and Others (specify)

Paternal- (+) Hypertension, (+) Diabetes Mellitus

8. Primary Physician’s Admitting Diagnosis (indicate P = Probable and C= Confirmed)

P- FRACTURE CLOSED RIGHT FEMUR

C- FRACTURE, CLOSED, DISTAL 3 RD FEMUR, RIGHT, COMMINUTED

C. Nursing Review of Systems (circle the appropriate symptoms)1. HEENT: Headaches Hearing loss Visions Diplopia

Eye pain Eye infection Blurring EpistaxisSinus pain Facial pain Bleeding gums DenturesSore throat Nasal-tracheal pain Other NONE

2. CARDIO-RESPIRATORY: Chest pain (site) NONE

Chest pain with exertion Dyspnea on exertionNocturnal dyspnea Edema Hypertension PalpitationKnown murmur Cough Sputum HemoptysisPleuritic pain DiaphoresisLast X-ray JULY 6, 2011 EKG NONE

3. GASTRO-INTESTINAL:

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Thirst Nausea Vomiting HematemesisHeartburn Difficulty Swallowing Flatulence ConstipationAbdominal pain Jaundice Diarrhea Tarry stoolHemorrhoids Hernia Other: NONE

4. GENITO-URINARY:

Dysuria Polyuria Frequency UrgencyNocturia Burning Hematuria Stones

a. Male Genital Tract: Penile discharges NONE Lesions NONEPain NONE Testicular swelling NONEOther NONE

Last Serology Test NONE

5. MUSCULO-SKELETAL:

Muscle pain Extremity pain Joint pain Back painJoint swelling Neck pain Stiffness Limited motionRedness Sprains DeformityOther NONE X-rays Fractured Right Femur

6. NERVOUS:

Convulsions Syncope Dizziness VertigoTremor Speech difficulty Limp paralysis ParesthesiaMuscle atrophyEEG NONE Other NONE

7. ENDOCRINE:

Goiter Tremor Heat or Cold intoleranceExopthalmos Voice change PolydipsiaChange in body contour Infidelity Other NONE

8. EMOTIONAL:

Anxiety Depression FearAnger Frustration Other (specify)

Notes: patient is angry, depressed and frustrated about his condition and blames himself for driving while drunk.

D. Nursing Observation1. HEENT

39

a. Symmetry Head is normocephalic, symmetric, round, erect, midline with incision on parietal area, no involuntary movement noted

b. Eyes and Pupils Facial features are symmetrical, temporal artery elastic and non tender, , pupils are midline with each eyeballs

c. Ears Normal in size bilaterally 4 cm, both are aligned with inner canthus of the eye, no discharges, tenderness or lesions noted

d. Mouth and Throat lips are dry and pale, complete set of teeth noted, no dysphagia or ulcerations noted on oral cavity

e. Lymph nodes lymph nodes are non tender and movable

2. RESPIRATORYa. Depth and Rate Respiratory rate is 21 cycles per minute with normal depths, no nasal flaring use of accessory muscles noted

b. Breath sounds No adventitious sounds are auscultated, bronchial sounds heard on trachea and thorax, Bronchovesicular

sounds heard over the major bronchi and around the upper sternum, Vesicular sounds heard at peripheral lung fields

c. Chest expansion Chest expansion of 5 cm bilaterally noted

3. CARDIO-VASCULARa. Blood Pressure (R) 130/90 mm Hg (L) 130/90 mm Hg Lying 130/90 mm Hg Standing 130/90 mm Hg b. Apical pulse rate and regularity regular with a rate of 66 beats per minute

c. Pedal pulses rate per minute (R) 66 beats minute (L) 66 beats minute

d. Neck vein distention no neck vein distension noted

4. CHESTa. Anterior chest uniform in color with smooth texture no edema, tenderness, discoloration or nodules palpated

b. Posterior chest anteroposterior diameter ratio to transverse diameter is 2:1, scapula are non protruding, spinous process

appear straight and thorax appears symmetric with ribs sloping downward

c. Breasts breast are symmetrical, not engorged or enlarged, nipples are dark brown and equal in size bilaterally.

1. Breasts and Axillae symmetrical, not engorged or enlarged, nipples are dark brown and equal in size bilaterally

2. Anterior Thorax Bowel sounds are heard as intermittent, soft clicks and gurgles at a rate of 5 per minute

3. Posterior Thorax Slightly rigid due to decreased bowel movement, no tenderness noted

5. GASTRO-INTESTINALa. Bowel Sounds series of intermittent soft clicks and gurgles heard upon auscultation with a rate of 5 per minute.

b. Tenderness or rigidity slightly rigid to decreased bowel movement, no tenderness noted

6. URINARYa. Bladder Bladder is not palpable when not full, dull thud heard upon percussion of full bladder, urinates daily with a rate of 6-8

times approximately 700cc per day, urine color is yellow with a consistency of slightly cloudy

40

7. SKELETALa. Joints Joints are non tender, no swelling or bulging of fluid

b. Range of motion Full range of motion on upper extremity and marked limitation of range of motion on lower extremity

8. NEURO

a. Motor Function1. Facial Movements are symmetrical, smiles, frowns, puff out cheeks, wrinkles forehead and shows teeth without difficulty

2. Extremities has full control on movements upper extremity while limited on lower extremity

b. Sensory Function (equal or not equal) sensory functions are equal on both sides

c. Equilibrium1. Balance balance is not assessed due to mobility restrictions

2. Finger to nose patient is able to perform finger to nose test

d. Reflexes ( equal or not equal)

1. Knees hypoactive (+) Arms hypoactive (+)

9. CRANIAL NERVE FUNCTIONa. Olfactory nerve: (sensory)

1. Sense of smell (coffee, vailla, etc.)1.1 Anosmia Able to identify the scent presented on each nostril

1.2 Hyperosmia Able to identify the scent presented on each nostril

b. Optic nerve: (sensory)

1. Sense of vision (snellen’s chart, newspaper)1.1 Myopia Able to read newsprint 14 inches away with full visual fields

1.2 Hyperopia Able to read newsprint 14 inches away with full visual fields

c. Oculomotor: (motor)

1. Extra-ocular movements/Pupil reaction to light

1.1 Right eye Eyelid covers 2mm of the iris, PERRLA 1.2 Left eye Eyelid covers 2mm of the iris, PERRLA

d. Trochlear: (motor)

1. Assess direction of gaze, upward and downward movement of eyeball

eyes move in a smooth coordinated motion, Eyes move in a smooth coordinated motion in an upward and downward motion

e. Trigeminal nerve: (Sensory and motor)

1. Presence of corneal reflexes Blinks bilaterally upon introduction of cotton to outer canthus

1.1 Right eye blinks coordinately 1.2 Left eye blinks coordinately

41

2. Ability to clench teeth able to clench teeth, temporal and masseter muscles contact bilaterally

f. Abducens: (motor)

1. Assess direction of gaze, lateral movements of the eyeballs

1.1 Right eye smooth and in coordination with left eye 1.2 Left eye smooth and in coordination with right eye

g. Facial: (Sensory and motor)

1. Sense of taste: Using back of tongue

1.1 Salty able to identify taste 1.2 Sweet able to identify taste

2. Facial expression

2.1 Smile able symmetrically 2.2 Puff out cheeks able symmetrically

2.3 Frown able symmetrically 2.4 Raise lower eyebrows able symmetrically

h. Auditory nerve: (motor)

1. Sense of hearing

1.1 Right ear Able to hear whispered voice 1 meter away 1.2 Left ear Able to hear whispered voice 1 meter away

i. Glossopharyngeal: (Sensory and motor)

1. Sense of taste: Using back of tongue

1.1 Salty Able identify taste 1.2 Sweet Able identify taste

2. Ability to swallow (Use tongue blade to elicit gag reflex)

Able, Gag reflex is intact

j. Vagus: (Sensory and motor)

1. Hoarseness of voice no hoarseness of voice noted

2. Sensation of pharynx Uvula and soft palate rise bilaterally on phonation

Let patient say “ah” and observe(movement of palate and pharynx)

k. Spinal accessory: (motor)

1. Movement of:

1.1 Head strong contraction of Sternocleidomastoid muscle on the side opposite the turned face upon turning agains

resistance 1.2 Shoulder Strong and symmetric contractions of Trapezius

muscle

l. Hypoglossal: (motor)

1. Able to stick tongue to midline Tongue movement is symmetric and smooth and bilateral strength is apparent.

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10. EMOTIONAL

a. Communication client is cooperative and is open in sharing information to the nurse

b. Mood/Effect mood is appropriate for action, feels awful for the finaces they have to pay for.

c. Behavior client is cooperative and can maintain eye contact during interaction

E. Knowledge of Illness

1. Learning Limitations patient knows about condition and the medical intervention given inclusing reason for temporary immobilization

of lower extremities and also the cause of his disability

2. Learning needs the patient needs to learn the importance of avoiding driving while he is drunk and also the patient needs to know the

seriousness of his condition

F. Nursing Impressions

Admitted a case of T.B.M., 32 years old, male, married, from Carajay, Lapu-lapu city, due to vehicular accident causing a sustained

injury in right thigh with a chief complaint of pain and multiple abrasions on the lower extremities, After further evaluations the patient was

diagnosed with fractured, closed distal 3 rd femur right, comminuted.

G. Nursing Problems (in priority)

1. Acute pain related to muscle spasms and movement of bone fragments.

2. Impaired physical mobility related to restrictive therapies including foam traction and complete bed rest.

3. Self-care deficit; Bathing/Hygiene/Feeding/Toileting related to decreased muscle control

4. Risk for impaired gas exchange related to altered blood flow , fat or blood emboli.

5. Risk for neurovascular dysfunction related to interruption of blood flow and tissue trauma

H. Discharge Planning

1. Probable Date July 27, 2011

2. Destination Carajay, Lapu-Lapu city, Cebu

3. Transportation Taxi

4. Agencies and Equipment involved Vicente Sotto Memorial Medical Center, Carajay District Hospital, Traction, (Foam)

5. Diet diet as tolerated including high protein and calcium food

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6. Medications Celecoxib 200mg 1 tablet if experiencing pain

7. Persons responsible for patient Wife, 2 sons and a daughter

8. Family conference Scheduled a home visit with client

9. Anticipated problems Patient is at risk for fall, ulceration atrophy due to decreased muscle control and utilization

10. Home visit done by public health nurse

44

APPENDIX DHematologic studies (ACTUAL)

Republic of the PhilippinesDepartment of Health

Regional Health office no.7Vicente Sotto Memorial Medical Center

B. Rodriguez St., Cebu City

Hematologic studies

NAME: T.B.M CASE NUMBER: 11-261262WARD: VII (orthopedic ward) DATE RENDERED: 7- 7-11PHYSICIAN: Dr. Dominic Vicuña

Blood component Normal values Actual results Significance

Hemoglobin 140-180 g/L 156 g/L Within normal range

Hematocrit 42%-52% 47% Within normal range

WBC 4.8-10.8x10^9/L 11.9x10^9/L Increased (infection)

RBC 4.70-6.10x10^12/L 4.78x10^12/L Within normal range

Mean Corpuscular Hgb 27-31 pg 32.7 pg Increased (macrocytic anemia)

Mean Cell Volume

(MCV)

80-94 fl 97 fl Within normal range

MCHC 330-370 g/L 336 g/L Within normal range

RDW 11-16 fl 12.9 fl Within normal range

MPV 7.2-11.1 fl 7.4 fl Within normal range

Platelet 150-450x10^9/L 248x10^9/L Within normal range

Clinical Significance:

Abnormal results during the actual complete blood count result of the patient includes increased white

blood cell count which is 11.9x10^9/L over a normal value of 4.8-10.8x10^9/L this indicates a normal

stress response after trauma or it may also that there is an undergoing infection in the fracture site. Mean

45

Corpuscular Hemoglobin which is 32.7 pg over a normal value of 27-31 pg which indicates macrocytic

anemia.

DIFFERRENTIAL WBC count:

Neutrophil 40-70% 67.10% Within normal range

Lymphocyte 19-48% 21.10% Within normal range

Monocyte 3-9% 10.60% Increased (bacterial infection)

Eosinophil 0-7% .70% Within normal range

Basophil 0-2% .40% Increased (inflammation)

Clinical Significance:

The abnormal findings in the WBC differential count includes and increased monocyte which is

indicative of a bacterial maybe because of the trauma to the patients extremities during the fracture and

also an increased basophil which is indicative of inflammation as evidenced by the swelling on the lower

extremities of the patient.

46

APPENDIX EUrinalysis (ACTUAL)

Republic of the PhilippinesDepartment of Health

Regional Health office no.7Vicente Sotto Memorial Medical Center

B. Rodriguez St., Cebu City

Urinalysis

NAME: T.B.M CASE NUMBER: 11-261262WARD: VII (orthopedic ward) DATE RENDERED: 7- 7-11PHYSICIAN: Dr. Dominic Vicuna

COMPONENT ACTUAL RESULTS SIGNIFICANCE

Color yellow normal

Transparency Slightly cloudy normal

Specific gravity 1.025 Within normal range

Ph 6.5 Within normal range

Glucose Negative (-) normal

Protein Negative (-) normal

RBC 0-2/hpf Within normal range

WBC 0-4/hpf Within normal range

Amorphous urates rare Normal

Mucus threads few normal

Clinical Significance: all of the parameters evaluated are within normal range.

47

APPENDIX FCoagulation profile (ACTUAL)

Republic of the PhilippinesDepartment of Health

Regional Health office no.7Vicente Sotto Memorial Medical Center

B. Rodriguez St., Cebu City

Coagulation profile

NAME: T.B.M CASE NUMBER: 11-261262WARD: VII (orthopedic ward) DATE RENDERED: 7- 7-11PHYSICIAN: Dr. Dominic Vicuna

Component Results Normal values Significance

PTT control 14.8 seconds 12.3-15.3 seconds Within normal range

Control % activity 102% -

Control INR 1.12 -

PT control 14.1 seconds 12.8-15.8 seconds Within normal range

% activity 110.1% -

INR 1.06 -

Clinical Significance: all of the parameters evaluated are within normal range.

48

APPENDIX GX-ray report (ACTUAL)

Republic of the PhilippinesDepartment of Health

Regional Health office no.7Vicente Sotto Memorial Medical Center

B. Rodriguez St., Cebu City

X-RAY REPORT

NAME: T.B.M CASE NUMBER: 11-261262WARD: VII (orthopedic ward) DATE RENDERED: 7- 18-11PHYSICIAN: Dr. Dominic Vicuña

SKULL APL

Findings: The cranial vault is intact, the sella turcica is intact, there is no evidence of fracture, bone

erosion nor bone destruction, no abnormal intracranial calcifications is noted, there is a soft tissue swelling

in the parieto-occipital region.

Impression: Soft tissue swelling in the parieto-occipital region.

CERVICAL SPINE APL

Findings: The vertebra is normal in height, density, texture and modelling. There is no evidence of

fracture, bone erosion nor bone destruction. The pre-vertebral soft tissue space is within normal limits.

The normal cervical lordosis is absent.

Impression: Straightening of the cervical spine due to muscle spasm.

CHEST PA

Findings: Both lung fields are clear. Heart is normal in size and shape. The trachea is at midline. Both

hemidiaphragms are sharp and distinct. The osseous thoracic cage showed no bony abnormality.

Impression: No significant chest findings.

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PELVIS AP

Findings: The bones normal in density, texture and modeling, there is no evidence of fracture, bone

erosion nor bone destruction, both hip and sacro-iliac joint are within normal limits.

Impression: Normal bones and joints of the hips

HAND RIGHT APLO

Findings: The bones normal in density, texture and modeling, there is no evidence of fracture, bone

erosion nor bone destruction. The joint spaces are within normal limits.

Impression: Normal bones and joints of the right hand.

THIGH RIGHT APL

Findings: There is a comminuted fracture in the distal third of the right femur with surrounding soft tissue

swelling, the rest of the bone are normal in density, texture and modeling.

Impression: Comminuted fracture, distal third, right femur with soft tissue swelling.

KNEE RIGHT APL

Findings: There is a comminuted fracture in the distal third of the right femur with surrounding soft tissue

swelling, the rest of the bone are normal in density, texture and modeling.

Impression: Comminuted fracture, distal third, right femur with soft tissue swelling

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APPENDIX H (Drug Study)Celecoxib

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APPENDIX I(drug study)Tramadol

52

APPENDIX H (drug study)Cefuroxime axetil

51

APPENDIX I NCP day 1 (actual)

Cebu Normal UniversityCollege of Nursing

Cebu CityMission-Vision: Care Using Knowledge and Compassion

NURSING CARE PLAN

Client’s Name: T.B.M Patient Care Classification: (Please Check)Age: _32 y/o Sex: Male Civil Status: _Married Religion: R. Catholic ____/______ Wholly Compensatory: Pts. therapeutic care is Allergies: Food: No Known food allergies accomplished by nurse Drug: No Known drug allergies ___ ___ Partially Compensatory: Pts. performs some self-care Diet: Diet as tolerated measuresDate of Admission: July 6, 2011 __________ Supportive Educative: Pts. accomplishes self- care measuresDiagnosis: Fracture, Closed, Distal 3 rd Femur, Right, Comminuted Clinical Division and Bed No.: Ward VII (orthopedic ward) bed 21 _________________________________________________________ Name of Physician: Dr. Dominic Vicuña

Name of Student: Macayan, Jellou Ray M.

DEFINING CHARACTERISTICS

EXPECTED OUTCOME CRITERIAINTERVENTION AND

RATIONALEBEHAVIORAL OUTCOME

Nursing Diagnosis: Acute pain related to movement of bone fragments secondary to comminuted fracture.

Subjective:”ngol-ngol kaayu ang ako bali” as verbalized.

Objective: Received patient lying on bed with head elevated, awake, conscious,

SHORT TERM:After 5 hours of nursing intervention the patient will be able to verbalize pain relief as evidenced by decreased pain score

LONG TERM:After 3 days of nursing intervention, the patient will be able to:

- Verbalize and demonstrate techniques that provide pain

I-Assess level of pain, location, character, and aggravating factorsR-To rule out for worsening of underlying conditions and development of complication and prevent occurrence.S-Doenges, et. Al 2008, p 501I-Observe for non-verbal cues of pain R-Observation may not be congruent with verbal reports and

SHORT TERMAfter 5 hours of nursing intervention:“wa na kaayu sakit ang ako bali dong”. As verbalized, pain score decreased from 7out of 10 to 3 out of 10.

LONG TERM:After 3 days of nursing intervention the patient was

NCP Scoring 10pts Defining Characteristics 3pts Intervention 3ptsNursing Diagnosis 2pts Outcome 1pt Bibliography 1pt (at least 5 references)

52

coherent, communicative, with foam traction at right foot, with pain score of 7 out of 10, grimaced face noted, irritability observed, restlessness noted, limited range of motion observed

Laboratory:None significant

Theoretical Basis:According to Doenges, Moorhouse and Murr, acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in such tissue damage (international association for the study of pain). It is a sudden of slow onset of any

relief.- Demonstrate effective use of

relaxation techniques as indicated for individual situation.

may prompt change in locus of intervention.S-Doenges, et. Al 2008, p 501I-Provide comfort measures as possible such as touch therapy, repositioning, use of cold/heat packs, constant interaction, quiet environment and calm activitiesR-maximizes use of non-pharmacological techniques for pain reliefS-Doenges, et. Al 2008, p 501I-Instruct in and encourage use of relaxation techniques such as focused breathing and imaging.R-to distract attention and thus reduce tensionS-Doenges, et. Al 2008, p 501I-Encourage to engage in diversional activities such as socialization with other patients or listening to music.R-To distract attention and reduce tension.S-Doenges, et. Al 2008, p 501I- Taught patient about non-pharmacological pain management.R-to promote self control and management of pain.S-Doenges, et. Al 2008, p 501

Dependent/ Collaborative:I-Administer analgesics as to a maximum as needed as indicatedR-to maintain acceptable level of

able to demonstrate effective use of relaxation techniques as evidenced by decreased recurrence of pain perception.

53

intensity from mild to severe with an anticipated predictable end and a duration of less than 6 months. Pain is explained as a combination of physiologic phenomena in addition to a psychosocial aspect that influence pain perception (Melzack and Wall,1965)Pain is also described as transient, tissue injury, trauma related, burn, iatrogenic or chronic neuropathic (Weber and Kelley 2007)

painS-Doenges, et. Al 2008, p 502I-Instruct client in use of transcutaneous electrical nerve stimulation units when ordered.R-To maintain acceptable level of pain and comfort.S-Doenges, et. Al 2008, p 502I-Refer to occupational/physical therapy program.R-Promotes active role and enhances self-control.

54

APPENDIX J NCP day 2 (actual)

Cebu Normal UniversityCollege of Nursing

Cebu CityMission-Vision: Care Using Knowledge and Compassion

NURSING CARE PLAN

Client’s Name: T.B.M Patient Care Classification: (Please Check)Age: _32 y/o Sex: Male Civil Status: _Married Religion: R. Catholic ____/______ Wholly Compensatory: Pts. therapeutic care is Allergies: Food: No Known food allergies accomplished by nurse Drug: No Known drug allergies ___ ___ Partially Compensatory: Pts. performs some self-care Diet: Diet as tolerated measuresDate of Admission: July 6, 2011 __________ Supportive Educative: Pts. accomplishes self- care measuresDiagnosis: Fracture, Closed, Distal 3 rd Femur, Right, Comminuted Clinical Division and Bed No.: Ward VII (orthopedic ward) bed 21 _________________________________________________________ Name of Physician: Dr. Dominic Vicuña

Name of Student: Macayan, Jellou Ray M.

DEFINING CHARACTERISTICS

EXPECTED OUTCOME CRITERIA

INTERVENTION AND RATIONALEBEHAVIORAL

OUTCOMENursing Diagnosis: Impaired Physical Mobility related to musculoskeletal impairment secondary to prescribed restrictive therapies. (traction)

Subjective: “maglisod man jud kog lihok sa ako lawas” as verbalized.

SHORT TERM GOAL:After 5 hours of nursing intervention, the patient will be able to perform activities of daily living at the level of functional capabilities.

I-provision of normal range ofmotion exercises andfunction of lowerextremity.R- Necessary to regainnormal mobility of legto speed recoveryI-Encourageprogressive activities

SHORT TERM:After 5 hours of nursing intervention, the patient was able to demonstrate effective use of trapeze in mobilizing and repositioning on bed.

LONG TERM:

NCP Scoring 10pts Defining Characteristics 3pts Intervention 3ptsNursing Diagnosis 2pts Outcome 1pt Bibliography 1pt (at least 5 references)

55

Objective: Received patient lying on bed with head elevated to 30 degrees, awake, conscious, coherent, communicative, with foam traction at right foot, the patient is reading a newspaper, has difficulty in changing position while lying on bed, has difficulty in moving the extremities, inability to walk or stand alone, limited range of motion in the extremities, slowed movement, difficulty in initiating gait

THEORETICAL BASIS:Physical mobility, the capability of movement, is necessary for the health and well-being of all Persons, Hogue (1984) identified mobility as the most important functional ability that determines the degree of independence and health care needs.

Fracture

Foam traction

Decreased control of extremities

LONG TERM GOAL:◊ After 3 days ofnursing intervention,the patient will be able to demonstrate andverbalize properexercises of the lowerextremities & canperform activities ofdaily living withminimal assistance.

according to level of functional capability.R-Increase patient’suse of affected leg.I-instruct and encourage use of overhead trapeze in mobilizing in the bed.R-To obtain sense of control during movement.S- Doenges et. Al. page 459I-encourage participation in self-care, occupational/diversional/ recreational activities.R-enhances self concept and sense of independence.S- Doenges et. Al. page 459I-Identify energy conserving techniques for ADL’s.R-Limits fatigue and maximizes participationS- Doenges et. Al. page 459I-Encourage adequate intake of fluid and nutrition.R-Promotes well-being and energy production.S- Doenges et. Al. page 459I-Provide proper skin care R-To decrease risk for decubitus ulcerS- Doenges et. Al. page 459

Collaborative/dependent:I-Administer medications as needed prior to activity for pain reliefR-To permit maximal effort and involvement in activity.

After 3 days ofnursing intervention,goal is met throughthe regaining of thepatient’s previousrange of motion in theleg & demonstratesproper exercises forthe lower extremities.He also does some ADL without discomfort.

56

Restriction of purposeful movement

Impaired physical mobility

S-Doenges et. Al. page 460I-Consult with Occupational therapy as ordered.R-To maintain continuity of care after discharge.S- Doenges et. Al. page 459

57

APPENDIX K NCP day 3 (actual)

Cebu Normal UniversityCollege of Nursing

Cebu CityMission-Vision: Care Using Knowledge and Compassion

NURSING CARE PLAN

Client’s Name: T.B.M Patient Care Classification: (Please Check)Age: _32 y/o Sex: Male Civil Status: _Married Religion: R. Catholic ____/______ Wholly Compensatory: Pts. therapeutic care is Allergies: Food: No Known food allergies accomplished by nurse Drug: No Known drug allergies ___ ___ Partially Compensatory: Pts. performs some self-care Diet: Diet as tolerated measuresDate of Admission: July 6, 2011 _____Supportive Educative: Pts. accomplishes self- care measuresDiagnosis: Fracture, Closed, Distal 3 rd Femur, Right, Comminuted Clinical Division and Bed No.: Ward VII (orthopedic ward) bed 21 _________________________________________________________ Name of Physician: Dr. Dominic Vicuña

Name of Student: Macayan, Jellou Ray M.

DEFINING CHARACTERISTICSEXPECTED OUTCOME

CRITERIAINTERVENTION AND RATIONALE

BEHAVIORAL OUTCOME

NCP Scoring 10pts Defining Characteristics 3pts Intervention 3ptsNursing Diagnosis 2pts Outcome 1pt Bibliography 1pt (at least 5 references)

58

Nursing Diagnosis: Risk for Trauma (additional injury) related to loss of skeletal integrity and improper placement of traction weights.

Subjective:”dali ra masabod sa mga mangagi kanang baton a gbitay”. As verbalized

Objective:Received patient lying on bed with head elevated, awake, conscious, coherent, communicative, with foam traction at right foot, absence of side rails noted, traction weights placed of walkways, absence of bed padding noted, high placement of bed observed, seen SO frequently leaving the patient.

LABORATORY:

None Significant

THEORETICAL BASIS:A fracture occurs when the stress placed on a bone is greater than a bone can absorb. Muscle, blood vessels, nerves, tendons, joints and other organs maybe injured when fracture occurs. This condition may result to a loss of skeletal integrity that may possibly

SHORT TERM:After 4 hours of nursing intervention, the patient will be able to verbalize understanding of condition and recognize need for prevention of injuries.

LONG TERM:After 3 days of nursing intervention, the patient will be able to:

- Demonstrate appropriate lifestyle changes to reduce risk for injury.

- Maintain condition without additional injury and decrease risk for trauma.

I-Identify factors related to individual situation and identify extent of risk.R-Influences scope and intensity of interventions to manage safety.S-Doenges et. Al. 2000 p718I-Note clients decision-making ability and level of cognition including functional capability.R-Affects client’s ability to protect self and influences choice of interventions and teaching.S-Doenges et al. 2000 p718I-Implement interventions regarding safety issues includes:-orient client to environment.-keep bed in low position.-pad bed edges as possible.-provide adequate area lighting -assist with moving/turning using trapezeR-Failure to accurately assess, intervene and/or refer these these issues can place patients at needless risk and create negligence issues for healthcare practitionerS-Doenges et. Al 2000 p 718I-Provide quiet environment and reduced stimulation as possible.R-helps limit confusion or overstimulation.S-Doenges et. Al 2000 p 718I-Place traction weights at appropriate location away from passageways as possible.R-To prevent moving the weights

SHORT TERM:After 8 hours of nursing intervention:“salamat kayo dong, nakasabot nako ngano delikado jud na ako ni ilihok lihok ako tiil”as verbalized.

LONG TERM:After 3 days of nursing intervention:-the patient was seen demonstrating appropriate lifestyle changes to reduce risk for injury such as asking for help from SO upon moving and using trapeze effectively when turning.

- The patient is free from additional injury at the end of the duration of care.

59

lead to further injury as a result of environmental conditions interactions with the patients adaptive and defensive resources.

causing disaligment of bone fragments.S-Doenges et. Al 2000 p 718

Collaborative/Dependent:I-assist with treatment of underlying medical/surgical conditions.R-To improve cognition/thinking process

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APPENDIX LFocused Charting Day 1

Republic of the PhilippinesDepartment of Health

Regional Health office no.7Vicente Sotto Memorial Medical Center

B. Rodriguez St., Cebu City

NURSES PROGRESS NOTES

Date Time F – Focus D – Data A – Action R - Response

7/18/11 10:00AM Acute pain D - received patient lying on bed with head elevated to 30

degrees, awake, conscious, coherent, communicative,

without IV, with the following v/s T= 35.5 degree Celsius,

P= 86 pm, R= 20 bpm and BP= 120/70 mmHg, with

foam traction at right foot, with pain score of 7 out of 10,

grimaced face noted, irritability observed, restlessness

noted, limited range of motion observed, “ngol-ngol kaau

ang akong bali dong”. As verbalized.

A - Actions made included; Introduced name to the

patient, assessed level of pain, character and location,

monitored v/s, positioned properly on bed with head

slightly elevated, Due medications (analgesics)

administered as ordered, encouraged to engage in

diversional activities such as socialization with others,

provided comfort measures such as backrub, encouraged

patient to do DBE; supported affected body parts/ joints

using pillows/ rolls, consulted with physical or

occupational therapist as indicated, documented the v/s

and I and O of the patient.

R - :”wa na kaayu sakit ang ako bali dong”. As verbalized,

pain score decreased from 7out of 10 to 3 out of 10.

Surname: M Age: 32 years old Sex: Male Case No:

Given Name: T Ward: VIII (orthopedic ward) Bed No: 21

APPENDIX M

61

Focused Charting Day 2

Republic of the PhilippinesDepartment of Health

Regional Health office no.7Vicente Sotto Memorial Medical Center

B. Rodriguez St., Cebu City

NURSES PROGRESS NOTES

Date Time F - Focus D – Data A – Action R - Response

7/19/11 10:00AM Impaired physical D - received patient lying on bed with head elevated to 30

Mobility degrees, awake, conscious, coherent, communicative,

without IV, with the following v/s T= 35.5 degree Celsius,

P= 86 pm, R= 20 bpm and BP= 120/70 mmHg, with

foam traction at right foot, the patient is reading a

newspaper, has difficulty in changing position while

lying on bed, has difficulty in moving the

extremities, inability to walk or stand alone, limited range

of motion in the extremities, slowed movement, difficulty

in initiating gait. “ maglisod man ko ug lihok dong”. As

verbalized.

A - Introduced name to the patient, assessed the

condition of the patient; monitored v/s, positioned properly

on bed with head slightly elevated, assisted patient in

doing ROM exercises, assisted patient upon doing gait

training, instructed in proper use of overhead trapeze,

provided comfort measures such as backrub, encouraged

patient to do DBE; supported affected body parts/ joints

using pillows/ rolls, consulted with physical or

occupational therapist as indicated, documented the v/s

and I and O.

R - patient was able to demonstrate increasing

functionality of the extremities as evidenced by

turning on bed without assistance and effective usage of

overhead trapeze.

Surname: M Age: 32 years old Sex: Male Case No:Given Name: T Ward: VIII (orthopedic ward) Bed No: 21

APPENDIX N

62

Focused Charting Day 3

Republic of the PhilippinesDepartment of Health

Regional Health office no.7Vicente Sotto Memorial Medical Center

B. Rodriguez St., Cebu City

NURSES PROGRESS NOTES

Date Time F - Focus D – Data A – Action R - Response

7/20/11 10:00AM Risk for additional D - Received patient lying on bed with head elevated,

Injury awake, conscious, coherent, communicative, without IV,

with the following v/s T= 37 degree Celsius, P= 62 pm,

R= 21 bpm and BP= 130/70 mmHg, with foam traction at

right foot, absence of side rails noted, traction weights

placed of walkways, absence of bed padding noted, high

placement of bed observed, seen SO frequently leaving

the patient, “dali raman masabaod ang kanang mga bato”.

As verbalized

A - Introduced name to the patient, assessed the

condition of the patient, instructed SO to stay with patient

as much as possible, implemented interventions

regarding safety issues such as orientation of patient to

environment, keeping bed in low position, providing

adequate area lighting and padding of side rails as

possible, monitored v/s, positioned properly on bed with

head slightly elevated, assisted patient in doing ROM

exercises, assisted patient upon doing gait training,

instructed in proper use of overhead trapeze, provided

comfort measures such as backrub, encouraged patient

to do DBE; supported affected body parts/ joints using

pillows/ rolls, consulted with physical or occupational

therapist as indicated, documented the v/s and I and O of

the patient.

R - the patient was able to demonstrate behaviors to

promote safety, SO was seen staying with patient most of

the time

Surname: M Age: 32 years old Sex: Male Case No:Given Name: T Ward: VIII (orthopedic ward) Bed No: 21

63

CURRICULUM VITAE

PERSONAL INFORMATION

Name : Jellou Ray M. Macayan

Year & Section : BSN 4-B

Adviser : Mrs. Lagrimas Elizon

Provincial Address : P-6, Urbiztondo Street, Poblacion, Barobo, Surigao Del Sur

City Address : Block 24, Lot 10, La Aldea, Buena Mactan, Lapu-lapu city

Telephone No. : 2386882

Cell no. : 09239855653

E-mail Address : [email protected]

Birthday : July, 1, 1991

EDUCATIONAL BACKGROUND

Elementary

School : Barobo Central Elementary School

Year : 1998-2004

Secondary

School : Barobo National high School

Year : 2004-2008

Tertiary

School : Cebu Normal University

Year : 2008-present

AFFILIATIONS

Position : Organization

Member : Nightingale Student Council