Case Study-Ortho Final

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Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City

College of Nursing

A CASE ANALYSIS

On

Fracture closed complete displaced proximal phalanges

In Partial Fulfillment

of 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 PALOLA

BSN III BROMELIADS

ANGELICA MARIE RAFANAN

BSN-III GAZANIA

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CASE STUDY GRADING SHEET FOR NCM

PARAMETERS PERCENTAGE

%

ACTUAL

GRADE

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. PathophysiologyAlgorithmExplanation

15

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

5

20

5

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

XII. ORGANIZATION 2.5

XIII. BIBLIOGRAPHY 2.5

TOTAL 100

REMARKS:

____________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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

Clinical Instructor

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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 ..

Bibliography

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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 closedfracture 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 patients

recovery may be insignificant, witnessing my patients condition improving is a very fulfilling

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

trying to bring back wholeness in Xs 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 students ability:

1. To present accurately the patients profile.2. To obtain a comprehensive past, present and family history of patients 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 patients caseand understand the purpose and limitation of each examination.

5. To study the results/outcome of the diagnostic procedures that the patient has undergone andexplain 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 patients 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 ofthe 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 theintervention.

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

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PATIENTS 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.

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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.

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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 asproviding health teachings and

morning care.

Kept comortable and rested. c swelling at the left ankle andmetatarsals.

c tolerable pain at the swollenleft ankle and metatarsals.

c elastic bandage applied at theleft ankle and metatarsals.

c open wound at the anterioraspect of the metatarsal area as

claimed by the patients 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 andmetatarsals.

c tolerable pain at the swollenleft ankle and metatarsals.

c elastic bandage applied at theleft ankle and metatarsals.

c open wound at the anterioraspect of the metatarsal area as

claimed by the patients

mother.

Conscious and conversant.

ELIMINATION Urinates frequently Urinates with assistance. (-) BM Urine output: (-) vomiting

Urinates frequently Urinates with assistance. (-) BM Urine output: (-) vomiting

ACTIVITY & There is dizziness upon doingsome ADLs as claimed by the

patient.

Able to have enough sleep for 7-8hours.

c limited movements due to thecondition of the patient.

Able to sleep for 8 hours. Still c limited movements due

to the condition of the patient.

Conversant Active Changed positions frequently.

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REST Weak in appearance Changed positions frequently

SAFETY s allergies c elastic bandage applied at the

let ankle and metatarsals.

c open wound at the anterioraspect of the metatarsal area as

claimed by the patients 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 anterioraspect of the metatarsal area as

claimed by the patients

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.

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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 oneend 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 attachmentof 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

metatarsal. Its proximal articular surface is of large size and

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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 Peronus 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 singlefacet, 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 thelateral 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 Peronus tertius and on the dorsal surface of the

tuberosity that of the Peronus brevis. A strong band of the

plantar aponeurosis connects the projecting part of the tuberositywith 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.

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VII. Pathophysiology

A. AlgorithmVehicular accident

Patient was hit by SUV

X-ray

Bleeding occurs

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

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

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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 nearesthospital 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 importanttreatment 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 iscompared.

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

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Fracture Reduction

Fracture reduction refers to restoration of

the fracture fragments to anatomicalignment 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. inmost 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 positionwhile 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.

responsible for reducing severe pain. While

non-opioids act at the peripheral nervous

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 bodys deenses in

eliminating the pathogens. Medications that

accomplish this goal by killing bacteria are

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called bactericidal.

Cefuroxime is a second-generation

cephalosphorin that interferes with bacterialcell-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 thestimulation 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

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

oftissue or muscle). Fasciotomy is a limb-

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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

are exposed, and then put back together, or

reduced. The bones are then held together

with some combination ofscrews, 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 Surgery

At 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 notwalk on the splint.

Post-operative Course

Dealing 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 mayhave 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 Results

The 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

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

high rate of success, with the most commonproblem 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. Sometimeswhen 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.

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some mild soreness still. Some will notice

discomfort when the weather changes. It will

usually take 6 9 months to reach maximum

improvement.

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.

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X. DISCHARGE PLAN

MEDICATIONSSince patient MCS isnt 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. Its significant

others is advised to lower the patients risk for

further fracture by assessing the home for fall

hazards. And he should be also in a clean

environment.

TREATMENTThe 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 TEACHINGSThe 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.

OPDThe 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.

DIETThe 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

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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 Phase

Rehabilitation Program

Physical Therapy

The patient should rest from the offending activity. Immobilization is recommended forcomfort, 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 theaffected 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.

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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 returnto 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

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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, MD

http://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 & AliceC. Murr

PDR Nurses Drug Handbook 2008 Edition by George R. Spratto and Adrienne L.Woods

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

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