91340851 case-study-ortho-final

Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINESTamag, Vigan City

College of Nursing

A CASE ANALYSIS

On

Fracture closed complete displaced proximal phalanges

In Partial Fulfillmentof the Requirements of the Course,

NCM 103 (Philippine Orthopedic Center Duty)

Presented to:MRS. VIRGINIA R. RUBIO, RN,MAN, Ed.D

Clinical Instructor

Presented by:CHEZKA MARIE PALOLABSN – III BROMELIADS

ANGELICA MARIE RAFANANBSN-III GAZANIA

CASE STUDY GRADING SHEET FOR NCM

PARAMETERS PERCENTAGE%

ACTUALGRADE

I. Introduction & Objectives 5II. Personal DataIII. Nursing History of Past and Present

Illness

5

IV. PEARSON Assessment 15V. Diagnostic Proceduresa. Idealb. Actual

5

VI. Anatomy & Physiology 5VII. Pathophysiology

Algorithm Explanation

15

VIII. Managementa. Medicalb. Surgicalc. NCP with Evaluationd. Promotive and Preventive Management

5

205

IX. Drug Study 5X. Discharge Planning 5XI. Updates 5

XII. ORGANIZATION 2.5XIII. BIBLIOGRAPHY 2.5

TOTAL 100

REMARKS:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Mrs. Virginia R. Rubio, RN, MAN, Ed. D

Clinical Instructor

Table of Contents

Introduction & Objectives ……………………………………………………………………………………………….. 1 - 2

History of Past and Present Illness ……………………………………………………………………………………

PEARSON Assessment ……………………………………………………………………………………………………………..

Diagnostic Procedure:

a. Ideal …………………………………………………………………………………………………………….b. Actual …………………………………………………………………………………………………………….

Anatomy & Physiology …………………………………………………………………………………………………………….

Pathophysiology:

a. Algorithm …………………………………………………………………………………………………………….b. Explanation …………………………………………………………………………………………………………….

Management:

a. Medical Ideal ………………………………………………………………………………………………… Actual …………………………………………………………………………………………………

b. Surgical ……………………………………………………………………………………………………………..c. Nursing Care Plan …………………………………………………………………………………………………d. Promotive & Preventive Management …………………………………………………………..

Drug Study …………………………………………………………………………………………………………………………..

Discharge Planning ………………………………………………………………………………………………………………

Update ………………………………………………………………………………………………………………………………………..

I. INTRODUCTION:

The World Health Organization defines health as the state of complete physical, mental

and social well being and not merely the absence of a disease. This implies that to be healthy,

an individual must be free from any factors that bring disequilibrium or imbalance within his

body, his thought processes and the way he relates with the people around him and to his

environment.

Likewise, a disease is a departure from the state of health caused by an interruption or

modification of any of the vital functions of the different systems of the body. It is

characterized by a definite manifestation called sign or symptom.

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.

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 nondisplaced. 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 not cause a break in the skin.

Patient X is a 16 year old male from 265 Sauyo, Cabuyao, Novaliches, Quezon City who

was admitted for the first time to Philippine Orthopedic Center with a chief complaints of pain

at the left foot secondary to vehicular accident. Further assessment reveals fracture closed

complete displaced proximal phalanges 5th, 1st, 2nd, 3rd metatarsals head of 2nd metatarsals left

fracture closed medial malleolus left.

As the student-nurse assigned to care for Pt. X for 2 duty days, I have observed his

condition and identified some of his health needs. Although my contribution to the patient’s

recovery may be insignificant, witnessing my patient’s condition improving is a very fulfilling

experience. But more than the feeling of fulfillment, I felt that I was an instrument of God in

trying to bring back wholeness in X’s life no matter how insignificant it may be.

OBJECTIVES

After completing this case study, the student-nurse will be able to obtain appropriate

knowledge, skills and attitude in caring for a patient with bone injury particularly to a patient with

metatarsal closed frature. This is manifested by the student’s ability:

1. To present accurately the patient’s profile.

2. To obtain a comprehensive past, present and family history of patient’s illness.

3. To assess the health status of the patient using the cephalocaudal method and organize cues for

Nursing Care Plan.

4. To know the different diagnostic examinations (ideal and actual) related to the patient’s case

and understand the purpose and limitation of each examination.

5. To study the results/outcome of the diagnostic procedures that the patient has undergone and

explain how these are related to the case of the patient.

6. To discuss the anatomy and physiology of the organ involved in the case.

7. To illustrate through a schematic diagram the pathophysiology of the patient’s case and explain

the mechanism that is involved.

8. To present the medical and surgical management done to the patient.

9. To formulate a practical and realistic plan of care for the patient through:

a. systematic organization of the subjective and the objective cues related to the case.

b. identifying and prioritizing nursing diagnoses using the PES format (Problem-Etiology-

Signs/Symptoms) and according to NANDA.

c. analysis of the pathophysiology of the identified diagnosis based on the presentation of

the patient

d. formulating appropriate nursing objectives following the SMART criteria.

e. planning for independent, dependent and collaborative interventions and explaining the

rationale for every intervention done.

f. evaluating the degree of achievement for all the objectives set at the beginning of the

intervention.

10. To make a list of the different drugs taken and is presently taking by the patient with their

corresponding dosages, mechanisms of action, side/adverse effects and nursing responsibilities.

11. To formulate a Discharge Plan covering the following areas: METHOD (Medications, Exercises,

Treatments, Health Teachings, Out-Patient Department and Diet).

PATIENT’S PROFILE

Personal data

Name: Michael Caguindagan Salac

Address: 265 Sauyo Cabuyao, Novaliches, Quezon City

Age: 16y/o

Sex: Male

Birthday: April 24, 1996

Birthplace: Arayat, Pampanga

Civil Status: Single

Religion: Roman Catholic

Nationality: Filipino

Clinical data

Date and time of Admission: April 10, 2012 @ 1:00 pm

Physician-in-Charge: Dr. Melvin Valera

Chief Complaints: Pain at the left foot secondary to vehicular accident

Medical Diagnosis: Fracture closed complete displaced proximal

phalanges 5th, 1st, 2nd, 3rd metatarsals head of 2nd

metatarsals left fracture closed medial malleolus

left.

NURSING HISTORY OF PAST AND PRESENT ILLNESS

I.PAST ILLNESS

Patient X claimed that he has no major hospitalizations yet.

When he was 3 months old, he had bronchial asthma and lasted for 8 years. He had his

last attack when he was 10 years old. According to the patient, he completed his immunizations

(BCG, OPV, DPT, etc.). Like every children, he also experienced fever, cough and colds, bruises,

scratches and minor wounds. In these cases, he takes paracetamol for fever, applies betadine

for wound and neozep for cough and colds. he has no drug allergies.

II.PRESENT ILLNESS

Patient X, a 16 year old male from 265 Sauyo Cabuyao, Novaliches, Quezon City was

admitted to Philippine Orthopedic Center with a Chief Complaints of pain at the left foot

secondary to vehicular accident. Further assessment reveals fracture closed complete displaced

proximal phalanges fifth, first, second, third metatarsals, head of second metatarsal left

fracture closed medial malleolus left. It was about 2:00 pm on April 9, 2012 when the incident

happened. According to Patient X, he was on his way home when unfortunately, he was hit by

SUV and his left foot was crushed.

In POC, further tests were done to the patient as he was not responding to regular

treatment regimen. X-ray revealed the exact area of fracture and hematologic exams for any

occurrence of microorganisms and inflammation and site of fracture.

The patient is under the observation of Dr. Valera. She underwent fastecotomy with

slipper mold. While recovering, Pt X is taking the following medications:

Cefuroxime 750mg, IV q8 for infection.

Paracetamol 150mg 1tab IV q4 for temperature >38. 8 degree Celsius for fever

Celecoxib 200mg q12 for pain.

Ketorolac 15mg IV q6 for mild pain

Tramadol 50mg q6 for pain

Ranitidine 25mg q8 for duodenal ulcer

Ferrous sulfate tab OD for anemia

He underwent different diagnostic procedures such as Complete Blood Count and X-ray.

He is about 4 days confined at the hospital already and he had an improved condition. He

claimed that the pain decreased compared to his first confinement, swelling also decreased and

mobility of fractured area improved.

IV. PEARSON ASSESSMENT

DATES April 12, 2012 April 13, 2012

PSYCHOSOCIAL

Identity vs Role Confusion

16 year old , male

Single, a student

Lives at

Roman Catholic, Filipino

Basic needs are met such as

providing health teachings and

morning care.

Kept comortable and rested.

c swelling at the left ankle and

metatarsals.

c tolerable pain at the swollen

left ankle and metatarsals.

c elastic bandage applied at the

left ankle and metatarsals.

c open wound at the anterior

aspect of the metatarsal area as

claimed by the patient’s mother.

Weak in appearance

Conscious and coherent

Basic needs are met such as

providing health teachings and

morning care.

Kept comortable and rested.

c swelling at the left ankle and

metatarsals.

c tolerable pain at the swollen

left ankle and metatarsals.

c elastic bandage applied at the

left ankle and metatarsals.

c open wound at the anterior

aspect of the metatarsal area as

claimed by the patient’s

mother.

Conscious and conversant.

ELIMINATION

Urinates frequently

Urinates with assistance.

(-) BM

Urine output:

(-) vomiting

Urinates frequently

Urinates with assistance.

(-) BM

Urine output:

(-) vomiting

ACTIVITY &

REST

There is dizziness upon doing

some ADL’s as claimed by the

patient.

Able to have enough sleep for 7-8

hours.

c limited movements due to the

condition of the patient.

Weak in appearance

Able to sleep for 8 hours.

Still c limited movements due

to the condition of the patient.

Conversant

Active

Changed positions frequently.

Changed positions frequently

SAFETY

s allergies

c elastic bandage applied at the

let ankle and metatarsals.

c open wound at the anterior

aspect of the metatarsal area as

claimed by the patient’s mother.

Wound dressed at times.

Clean and ventilated room

No side rails

s allergies

c soiled elastic bandage applied

at the left ankle and

metatarsals.

c open wound at the anterior

aspect of the metatarsal area as

claimed by the patient’s

mother.

Wound dressed at times.

Clean and ventilated room

No side rails

OXYGENATION

RR: 30 cpm

PR: 99 bpm

(-) DOB

c an IV of D5LRS 1L x 12 hours

inserted at right cephalic vein

regulated to 20-21 gtts/min.

RR: 29 cpm

PR: 97 bpm

(-) DOB

c an IVF of D5LRS 1L x 12 hours

inserted at the right cephalic

vein regulated to 20-21

gtts/min.

NUTRITION

on DAT diet

c fair appetite

c an IVF of D5LRS 1L x 12 hours

inserted at the right cephalic

vein regulated to 20-21

gtts/min.

There is enough fluid intake.

Ate meals at the right time.

Needs assistance when eating

still on DAT diet

c good appetite

c an IVF of D5LRS 1L x 12 hours

inserted at the right cephalic

vein regulated to 20-21

gtts/min.

Increased fluid intake.

Increased intake of fruits rich in

Vit. C.

Ate meals at the right time.

Still needs assistance when

eating.

VI. ANATOMY AND PHYSIOLOGY

Any of the five long bones of thefoot (hind feet in quadrupeds), which collectively make up the metatarsus. They are analogous to the metacarpals of the hand. The metarsals articulate at one end with the tarsals (ankle bones) and at the other with thephalanges (toe bones). The metatarsals are numbered from the medial side (ossa metatarsalia I.-V.); each presents for examination a body and two extremities.

Common characteristics of the metatarsal bones

The body is prismoid in form, tapers gradually from the tarsal to the phalangeal extremity, and is curved longitudinally, so as to be concave below, slightly convex above. The base or posterior extremity is wedge-shaped, articulating proximally with the tarsal bones, and by its sides with the contiguous metatarsal bones: its dorsal and plantar surfaces are rough for the attachment of ligaments. The head or anterior extremity presents a convex articular surface, oblong from above downward, and extending farther backward below than above. Its sides are flattened, and on each is a depression, surmounted by a tubercle, for ligamentous attachment. Its plantar surface is grooved antero-posteriorly for the passage of the flexor tendons, and marked on either side by an articular eminence continuous with the terminal articular surface.

Characteristics of the individual metatarsal bones

The first metatarsal bone is remarkable for its great thickness, and is the shortest of the metatarsal bones. The body is strong, and of well-marked prismoid form. The base presents, as a rule, no articular facets on its sides, but occasionally on the lateral side there is an oval facet, by which it articulates with the second

VII. Pathophysiology

A. AlgorithmVehicular accident

metatarsal. Its proximal articular surface is of large size and kidney-shaped; its circumference is grooved, for the tarsometatarsal ligaments, and medially gives insertion to part of the tendon of the Tibialis anterior; its plantar angle presents a rough oval prominence for the insertion of the tendon of the Peronæus longus. The head is large; on its plantar surface are two grooved facets, on which glide sesamoid bones; the facets are separated by a smooth elevation.

The second metatarsal bone is the longest of the metatarsal bones, being prolonged backward into the recess formed by the three cuneiform bones. Its base is broad above, narrow and rough below. It presents four articular surfaces: one behind, of a triangular form, for articulation with the second cuneiform; one at the upper part of its medial surface, for articulation with the first cuneiform; and two on its lateral surface, an upper and lower, separated by a rough non-articular interval. Each of these lateral articular surfaces is divided into two by a vertical ridge; the two anterior facets articulate with the third metatarsal; the two posterior (sometimes continuous) with the third cuneiform. A fifth facet is occasionally present for articulation with the first metatarsal; it is oval in shape, and is situated on the medial side of the body near the base.

The third metatarsal bone articulates proximally, by means of a triangular smooth surface, with the third cuneiform; medially, by two facets, with the second metatarsal; and laterally, by a single facet, with the fourth metatarsal. This last facet is situated at the dorsal angle of the base

The fourth metatarsal bone is smaller in size than the preceding; its base presents an oblique quadrilateral surface for articulation with the cuboid; a smooth facet on the medial side, divided by a ridge into an anterior portion for articulation with the third metatarsal, and a posterior portion for articulation with the third cuneiform; on the lateral side a single facet, for articulation with the fifth metatarsal.

The fifth metatarsal bone is recognized by a rough eminence, the tuberosity, on the lateral side of its base. The base articulates behind, by a triangular surface cut obliquely in a transverse direction, with the cuboid; and medially, with the fourth metatarsal. On the medial part of its dorsal surface is inserted the tendon of the Peronæus tertius and on the dorsal surface of the tuberosity that of the Peronæus brevis. A strong band of the plantar aponeurosis connects the projecting part of the tuberosity with the lateral process of the tuberosity of the calcaneus. The plantar surface of the base is grooved for the tendon of the Abductor digiti quinti, and gives origin to the Flexor digiti quinti brevis.

Patient was hit by SUV

X-ray

Bleeding occurs

Swelling and InflammationPain, loss of function, deformity, crepitus, swelling and discoloration

Interventions Fasciotomy with slipper mold

Left metatarsal received direct violent trauma

Break on the proximal 5th phalanges and 1st, 2nd,3rd metatarsals without communication on the outside.

Bone splintered into several fragments

Muscles are destroyed and undergo muscle spasm which pulls the fragments in different positions

Blood vessel and marrow of the bone re disrupted

Tissues are damaged

B. Explanation:

Trauma is the most common cause of fracture. The trauma is caused by vehicular accident. The amount and direction of the force will vary from accident to accident resulting from violent direct trauma, either comminuted or multiple muscles are attached to the bones. Ones the bones are destroyed, muscles tend to go through spasm which is the reason why the splintered fragment of the bones move away or will be scattered. In this case, the 5th proximal phalanges of the metatarsal and so with the 1st, 2nd, rd metatarsal are damaged. The proximal bone is displaced due to muscle spasm. Blood vessels and the bone marrows are also destroyed due to the trauma. Tissue damage causes bleeding. Aside from bleeding, inflammation occurs followed by pain, deformity, loss of function, crepitus, swelling and discoloration.

Fasciotomy with slipper mold was done to the patient to reduce pressure and facilitate circulation on the left foot.

VIII. MANAGEMENT

MEDICAL MANAGEMENT

IDEAL ACTUAL

For immediate treatment, you have to elevate the injured foot and put an ice pack over it. If the person can go to the nearest hospital he must use crutches and not try to walk unsupported. For non-operative treatment, the doctor may recommend stiff soled shoe or casting the foot to make it more secured and make the healing faster. For medium to severe foot fractures, the doctor will advise the patient to use non-weight bearing cast for more than a month. This is the healing time. The most important treatment is to rest your foot. This means avoiding any exercise or activity that may have caused your stress fracture. Elevating your foot can help to relieve pain. Your doctor may also suggest that you take simple painkillers such as paracetamol or non-steroidal anti-inflammatory painkillers such as ibuprofen. Special shoes are available to help to immobilise the fracture and support your foot so that you are able to walk. If pain is severe, your doctor may suggest that you have a below-the-knee plaster cast until the fracture is healed.

A posterior mold was applied last April 9, 2012 on his left ankle to immobilize the affected part and to reduce further fracture or damage. This also helps in healing of the fracture if surgery is not needed.

Intravenous therapy is used to replace fluids, electrolytes and nutrient loses, anti-infectives, blood products and dyes. Hypertonic fluids are solutions having an osmotic pressure greater than that of the solution with which it is compared.

An IVF of D5LRS has been inserted at his left metacarpal vein that runs for 12 hours at 20-21 gtts/min. It aids in hydrating the patient and maintain balance in his fluids and electrolytes in his body.

Analgesics are medications used to relieve pain. The two basic categories o analgesics are opioids and the non-opioids. Opioids are a natural or synthetic morphine-like substance responsible for reducing severe pain. While non-opioids act at the peripheral nervous

Fracture Reduction

Fracture reduction refers to restoration of the fracture fragments to anatomic alignment and positioning. Either closed reduction or open reduction may be used to reduce fracture. The specific method selected depends on the nature of the fracture; however, the underlying principles are the same. Usually, the physician reduces a fracture as soon as possible to prevent loss of elasticity from the tissues through infiltration by edema or hemorrhage. in most cases, fracture reduction becomes more difficult as the injury begins to heal.

Before fracture reduction and immobilization, the patient is prepared for the procedure; consent for the procedure is obtained, and an analgesic is administered as prescribed. Anesthesia may be administered. The injured extremity must be handled gently to avoid additional damage.

Closed reduction

In most instances, closed reduction is accomplished by bringing the bone fragments into snstomic alignment through manipulation and manual traction. The extremity is held in the aligned position while the physician applies a cast, splint, or other device. Reduction under anesthesia with percutaneous pinning may also be used. The immobilizing device maintains the reduction and stabilizes the extremity for bone healing. X-rays are obtained to verify that the bone fragments are correctly aligned.

Traction (skin or skeletal) may be used until the patient is physiologically stable to undergo surgical fixation.

system.

Ketorolac is an NSAID that interferes with prostaglandin biosynthesis by inhibiting cyclooxygenase pathway or arachidonic acid metabolism; also acts as potent inhibitor or platelet aggregation. It is for moderately severe acute joint pain. It is administered intravenously every 6 hours with a dosage of 750mg.

Tramadol is an opioid analgesic that inhibits reuptake of serotonin and norepinephrine in CNS. It is for moderate to moderately severe pain. It is administered orally ever 6 hours with a dosage of 50mg.

Celecoxib is a COX-2 inhibitor that exhibits anti-inflammatory, analgesic, and antipyretic action due to inhibition of COX-2 enzyme. It is administered orally every 12 hours or for pain with a dosage of 200mg.

Paracetamol is an analgesic and antipyretic, its action is unclear but pain relief may result from inhibition of prostaglandin synthesis in CNS, with subsequent blockage of pain impulses. Fever reduction may result from vasodilation and increased peripheral blood flow in hypothalamus, which dissipates heat and lowers body temperature. It is administered intravenously every 4 hours for temp. ≥ 38.80c with a dosage of 250mg.

The antibiotics’ primary goal of antimicrobial therapy is to assist the body’s deenses in eliminating the pathogens. Medications that accomplish this goal by killing bacteria are called bactericidal.

Cefuroxime is a second-generation cephalosphorin that interferes with bacterial cell-wall synthesis and division by binding to cell wall, causing cell to die. Active against gram-negative and gram-positive bacteria, with expanded activity against gram-negative bacteria. It is administered intravenously every 8 hours with a dosage of 750mg.

Histamine2-Receptor Antagonist block the stimulation of gastric acid secretion and are use to treat peptic ulcer.

Ranitidine is a histamine2-receptor antagonist that reduces gastric acid secretion and increases gastric mucus and bicarbonate production, creating a protective coating on gastric mucosa. It is administered orally every 8 hours with a dosage of 25mg.

Mineral supplements are used to maintain and replenish loss of minerals in the body.

Ferrous sulfate is a mineral supplement that facilitates O2 transport via haemoglobin. It is used as iron source as it replaces iron found in haemoglobin, myoglobin and other enzymes. It is administered orally 1 tablet, once a day.

SURGICAL MANAGEMENT

IDEAL ACTUAL

Surgery for metatarsal fractures is usually done as an outpatient. You will require a general anesthetic or spinal anesthetic. The surgery is called open reduction and internal fixation, or ORIF.

During the surgery one or more incisions will be made over the area of the fracture, usually 2 - 3 inches in length. The fractured bone ends

Fasciotomy or fasciectomy is a surgical procedure where the fascia is cut to relieve tension or pressure (and treat the resulting loss ofcirculation to an area of tissue or muscle). Fasciotomy is a limb-saving procedure when used to treat acute compartment syndrome. It is also sometimes used to treat chronic compartment stress syndrome. The procedure has a very

are exposed, and then put back together, or “reduced”. The bones are then held together with some combination of screws, wires or plates.

The reason to do surgery is to put the bones and joints back together as close as possible to how they were before the injury.

Day of SurgeryAt the end of the surgical procedure the wound is stitched-up, and covered. A short leg plaster splint is applied. That dressing gives support to the foot, holding it securely. That should be left in place until I change it at the first post-operative office visit.

You will be given crutches at the surgery center, and I want you to not put any weight on that leg during the first 6 weeks. Do not walk on the splint.

Post-operative CourseDealing with post-operative pain will be your major concern for the first few days.

Most people find that for the first few days after surgery their foot will feel better if it is elevated. Generally, if you let it hang down for any period of time it will throb and you may have more swelling. You can put it into whatever position feels best, but usually that will be elevated with a pillow under the foot.

Most patients have swelling about the surgical area that lasts for about 4 months after surgery. You should not resume athletic activities for about 4 months after surgery.

Final ResultsThe goal of the surgery is to leave you with a painless foot that will allow normal activities. You should be able to regain full strength and power in the leg and ankle, and have no restriction of motion. Some patients will have some mild soreness still. Some will notice discomfort when the weather changes. It will usually take 6 – 9 months to reach maximum improvement.

high rate of success, with the most common problem being accidental damage to a nearby nerve.

Process

Fasciotomy in the limbs is usually performed by a surgeon under general or regional anesthesia. An incision is made in the skin, and a small area of fascia is removed where it will best relieve pressure.

Plantar fasciotomy is an endoscopic procedure. The doctor makes two small incisions on either side of the heel. An endoscope is inserted in one incision to guide the doctor. A tiny knife is inserted in the other. A portion of the fascia near the heel is removed. The incisions are then closed.

In addition to scar formation, there is a possibility that the surgeon may need to use a skin graft to close the wound. Sometimes when closing the fascia again in another surgical procedure, the muscle is still too large to close it completely. A small bulge is visible, but is not harmful.

PROMOTIVE AND PREVENTIVE MANAGEMENT

Relieving Pain

Affected part should immobilize with a splint to decrease pain and muscle spasm. Handle the affected area with great care and gentleness because wounds are frequently

very painful. Elevation reduces swelling and associated discomfort. Pain is controlled with prescribed analgesics and other pain- reducing techniques.

Improving Physical Mobility

Immobilization devices and avoidance of stress on the bone. Patient must understand the rationale for the activity restrictions. Encourage full participation in ADLs within the physical limitations to promote general

well-being.

Controlling the Infectious Process

Monitor response to antibiotic therapy. Observe for evidence of phlebitis, infection, and infiltration in the IV access. Ensure adequate circulation. Maintain needed immobility. Comply with weight- bearing restrictions. Change dressings using aseptic technique to promote healing and to prevent cross-

contamination. A diet high in protein and Vitamin C promotes healing. Encourage adequate hydration.

X. DISCHARGE PLAN

MEDICATIONS

Since patient MCS isn’t yet discharged from

the hospital, he can take his medications from

the hospital to their home. He is going to

maintain his mediations like his antibiotics,

pain relievers and multivitamins inorder or

him to boost his healing process.

ENVIRONMENT

Upon discharge of the patient, he should be in

a safe and sound environment. It’s significant

others is advised to lower the patient’s risk for

further fracture by assessing the home for fall

hazards. And he should be also in a clean

environment.

TREATMENT

The patient should take simple painkillers such

as paracetamol or non-steroidal anti-

inflammatory painkillers such as ibuprofen.

Another one is wound dressing. It is done to

prevent infection and to address the proper

treatment of the post-surgical wound of the

patient.

HEALTH TEACHINGS

The patient is adviced to have an adequate

calcium and Vit. D to avoid further bone

breakage. Another is by exercisig to

strengthen his bones and improve balance.

And he should have a balance diet to promote

wound healing.

OPD

The patient should attend his follow-up check

up inorder for the physician to see the

progress of the patient and to advise him what

to do.

DIET

The patient has no restrictions when it comes

to diet but he should increase his intake in

calcium and Vit. D specially when he had

undergone a surgery. He can have these two

by supplements or by the foods he eats

everyday. Vit. C should also be increased in his

diet for better wound repair and to boost his

immune system.

XI. UPDATES: Metatarsal Stress Fracture Treatment & Management

Acute PhaseRehabilitation Program

Physical TherapyThe patient should rest from the offending activity. Immobilization is recommended for comfort, with use of a postoperative (wooden-soled) shoe or short CAM Walker (Bird and Cronin, Inc, Eagan, Minn). It is important to apply ice and elevate the foot to minimize pain and swelling. If there is marked pain or minimal evidence of healing for stress fractures of the second or third metatarsals, a short-leg walking cast can be used until there is radiographic evidence of healing.

Recreational Therapy

During the respite period from the offending activity, the patient may maintain fitness by cycling, aqua-running, or resistance training by using equipment that does not involve the affected area.

Surgical Intervention

Stress fractures of the second or third metatarsals rarely require surgical intervention. Most of these fractures heal uneventfully, and nonunion is rare. However, stress fractures of the fifth-metatarsal base are more problematic. Displacement of these fractures tends to increase with continued weight bearing. The treatment options are 2-fold as follows:

Less-active patients should be non-weight bearing in a short-leg cast for 6-8 weeks or until there is radiographic evidence of healing. If an established nonunion develops, screw fixation and/or bone grafting may be required.[16]

For active patients, early intramedullary screw fixation, with or without bone grafting, is often recommended.

Consultations

Consult an orthopedic surgeon for fifth-metatarsal fractures or for second- or third-metatarsal fractures that do not demonstrate radiographic healing after 6 weeks.

Recovery Phase

Rehabilitation Program

Physical Therapy

During the recovery phase, the patient may progress to weight bearing as tolerated, initially in a wooden-soled shoe, and then in a comfortable shoe.

Recreational Therapy

Aqua-running, swimming, or bicycling may be continued to maintain physical fitness.

Other Treatment (Injection, manipulation, etc.)

Albisetti et al reported their experience with diagnosing and treating stress fractures at the base of the second and third metatarsals in young ballet dancers from 2005-2007.[17] Of 150 trainee ballet dancers, 19 had stress fractures of the metatarsal bone bases. All of the dancers were recommended to rest, but external shockwave therapy (ESWT) was also used in 18 and electromagnetic fields (EMF) and low-intensity ultrasonography was used in 1, with good results in each case.[17]

Albisetti advised the best approach to metatarsal stress fractures is early diagnosis with clinical examination and radiologic studies such as x-ray and MRI. The investigators also noted ESWT led to good results, with a relatively short time of rest from the patients' activities and a return to dancing without pain.[17] However, further study is warranted given the small study size and that all but one of the young dancers received ESWT.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The patient may be allowed to gradually return to his or her sport with a slow build-up in intensity and duration, with regular rest intervals. No more than a 10% increase in intensity or duration should be allowed from week to week. Any pain recurrence should prompt a rest period, followed by resuming the activity at a lower level.

Recreational Therapy

The patient may resume running with a slow increase in duration and intensity of the workouts (ie, no more than a 10% increase in intensity or duration per week).

Surgical Intervention

Patients who continue to have painful nonunion fractures are candidates for surgical intervention.[16] A fibrous nonunion that is not painful and does not limit the patient's functional abilities may be left alone.

Consultations

An orthopedic surgeon should be consulted in cases in which there is radiographic evidence of nonunion or prolonged pain.

XII. BIBLIOGRAPHY:

Website:

Metatarsal Stress Fracture Treatment & ManagementAuthor: Andrew D Perron, MD; Chief Editor: Sherwin SW Ho, MDhttp://emedicine.medscape.com/article/85746-treatment

Metatarsal fractures. http://www.patient.co.uk/health/Metatarsal-Fractures.htm, http://bonesfracture.com/metatarsal-fracture-treatment-metatarsal-bone-fracture-surgery-fractured-metatarsal-healing-time-recovery-types-symptoms-and-causes/, http://www.physioroom.com/injuries/ankle_and_foot/metatarsal_fracture_full.php

http://www.daviddarling.info/encyclopedia/M/metatarsal.html http://www.nlm.nih.gov/medlineplus/ency/article/001224.htm

Books:

Nursing Care Plan 8th Edition by Marilyn E. Doenges, Mary Frances Moorhouse & Alice C. Murr

PDR Nurse’s Drug Handbook 2008 Edition by George R. Spratto and Adrienne L. Woods

Fracture reduction. Textbook of Medical-Surgical Nursing Twelvth Edition by Brunner and Suddadrth Vol. 2.

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