Fracture on Femur

Group "C" Case Presentation

Open Type III-S

Complete Comminuted Fracture D3-L

Femur

Reasons for choosing the Case:

•We chose this case because it requires a broader scope of research which will benefit

us.•We chose this case to learn orthopedic in

advance.•To have a study to share to our fellow

student.

Background Knowledge:

A Fracture is a break in the continuity of bone and is defined according to its type and extent. Fractures occur when the bone is subjected to stress greater than it can absorb. Fractures are cause by direct blows, crushing forces, sudden twisting motions, extreme muscle contractions. When the bone is broken, adjacent structures are also affected, resulting in soft tissue edema, hemorrhage into muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels. Body organs maybe injured by the force that cause the fracture or by fracture fragments.

TYPES OF FRACTURE

Greenstick fracture: an incomplete fracture in which the bone is bent. This type occurs most often in children.

Transverse fracture: a fracture at a right

angle to the bone's axis.

Oblique fracture:a fracture in which the

break has a curved or sloped pattern.

•Comminuted fracture: a fracture in which the

bone fragments into several pieces.

•An impacted fracture :• is one whose ends are driven into each other. This is commonly seen in arm fractures in children and is sometimes known as a buckle fracture. Other types of fracture are pathologic fracture, caused by a disease that weakens the bones, and stress fracture, a hairline crack.

•A depressed fracture: results from a force that drives a

piece of bone down. This fracture may effect the outer table of the skull, the inner table, or both if the force is strong and localized. This is a depressed fracture on the left parietal part of a skull.

An avulsion fracture: is a bone fracture which

occurs when a fragment of bone tears away from the main mass of bone as a result of physical trauma.

•An uncomplicated closed: fracture/simple fracture in

which the fractured ends of the bone do not break the skin.

•A spiral fracture (also called a torsion fracture):

is a bone fracture in which the bone has been twisted apart.

•A compression fracture: occurs when the normal

vertebral body of the spine is squished, or compressed, to a smaller height.

•Compound fracture: A fracture in which the

bone is sticking through the skin. Also called an open fracture.

Skeletal Tractions:

Morbidity &

Mortality

Most prevalent among the extremes of ages.Infants and Elderly.

Patients Profile

Name: MCAge: 57 years oldDate of Birth: July 7, 1952Status: WidowedNationality: FilipinoReligion: Roman CatholicHome Address: Batasan Hills Quezon CityDate of Admission: December 24, 2009Time of Admission: 8:15 amAdmitting Diagnosis: Fx Open III-S Complete Comminuted D3-L Femur

Past Medical History

•High blood•Asthma•Breast Mass at Lateral aspect of the left Breast

Present Medical History

GORDONS 11 TYPOLOGY OF

FUNCTIONAL HEALTH PATTERNS

BEFORE HOSPITALIZATION

DURING HOSPITALIZATION

A.)HEALTH MANAGEMENT PATTERNS

® what is your past illnesses?®what do you do whenever you got sick?®how do you maintain your good health?®how often do you go to the doctor to have medical check-up?

“asthma at UTI”

“umiinom lang ng gamot”

“kumakain lang ng mga gulay at prutas”

“pumupunta ako sa center , tuwing nakakaramdam lang ako ng sakit”



B.)SELF-PERCEPTION PATTERN ®how do you describe yourself? ®your moods? ®how many times do you take a bath in a day? ®how many times do you brush your teeth in a day?

“malakas, abala sa mga gawaing bahay”“madaldal, palatawa at palabiro”“dalawang beses sa isang araw”“hindi na ako nagtotoothbrush, wala na akong ngipin, mumog- mumog lang”

“ito nakahiga lang, walang silbi”“naging maiinitin ang ulo”“hindi na ako nakakaligo,punas-punas lang”“mga isang beses lang”



C.) NUTRITIONAL-METABOLIC PATTERN ®what are the foods you usually eat? ®how many times do you eat in a day? ®how many times do you drink water in a day?

“kanin,gulay at mga fruits”“tatlong beses sa isang araw”“mga apat –anim na beses sa isang araw”

“kung ano lang ang nirarasyon dito tulad ng kanin, pansit at tinapay”“ganun pa din, tatlong beses pa din”“mga apat –anim na beses”



D.)ELIMINATION PATTERN ®how many times do you defecate in a day? ®any discomfort?

®how many times do you urinate in a day?

®any discomfort? ®how many times do you change your diapers in a day?

“isang beses sa isang araw”“wala naman”

“ mga tatlo o apat na beses sa isang araw”

“wala naman”

“isang beses lang din”

“wala”

“ngayon, naka diapers kasi ako, mga dalawang beses”“wala naman”“dalawang beses”



E.)ACTIVITY- EXERCISE PATTERN ®what are the things you usually do?

®hobbies?

®exercise?

“nag aalaga ng mga apo ko, gumagawa ng mga gawaing bahay at naglalabada”“nanunuod ng T.V, nag-aalaga ng mga apo”“Tumatakbo-takbo”

“ito nakahiga lang, pautos utos lang, nahihirapan na akong gumalaw-galaw”“ditto nakikinig ng music sa cellphone ng anak ko”“dito paunat unat lang”



F.)SLEEP-REST PATTERN ®usual no. of hours of sleep and rest @ night? ®at day time?

®how do you relax yourself?

“siyam na oras”

“hindi ako natutulog sa hapon”“nanunod lang ng t.v”

“walong oras”

“Mga dalawang oras”

“nakahiga lang dito”



G.)ROLE- RELATIONSHIP PATTERN ®do you have close family ties? ®how do you bond with each other?

®who do you talk most often? ®how do you bond with your neighborhood?

“oo”

“kumakain ng sama-sama, nagkwekwentuhan at nagtatawanan””yung mga anak ko at mga kapitbahay ko”“super bonding kami, puro tawanan, kwentuhan”

“oo”

“wala na eh”

“yung anak kong ngababantay sa akin, mga pasyente din dito at mga bantay nila”“wala na eh”



H.)COPING-STRESS PATTERN ®what are things that made you angry? ®what do you do whenever you got angry? ®how do you feel towards the death of your son- in law? ®have you accepted about the death? ®how do you handle this?

”kapag nag aaway ang mga apo ko”“nagsesermon, nilalabas ang galit, salita ng salita”

“kapag iniiwanan nila ako dito sa hospital”“wala lang, hindi kumikibo”

“malungkot, masama ang loob”“hindi pa masyado, nalulungkot ako kasi namatay ang manugang ko at hanggang ngayon di pa nahuhuli ang pumatay”“nagdadasal, pinapasa diyos ko na lang”



I.)VALUE BELIEF PATTERN ®are you religious?

“oo” “oo”

Patient’s General Appearance

Date Performed: January 18, 2010Time: 9:00 am Name: MCAge: 57 years oldPrimary Language: TagalogHeight: 5’3’’Weight: 54 kgVital Signs:

BP- 110/80 mmHgTemp- 36.9 CO

PR- 82 BPMRR- 22 CPM

Assessment

•Hair Color- Black and White•Body Build- Proportionate•Overall hygiene and

grooming- Clean and neat•Note Body and Breath Odor- No Body odor; No Breath

odor

•Signs of distress in posture or facial Expression

- no distress noted•Note obvious signs of Health/

Illness- Weak and with fractured at left

Leg•Client’s Attitude- Cooperative and able to follow

instructions

•Client’s affect/mood; appropriateness of the responses

- Appropriate to situation•Quantity of Speech, Quality and

Organization- understandable, clear tone;

exhibits thought association•Relevance and organization of

thoughts- makes sense; has sense of

reality

Course in the ward

Doctor’s Order Nursing Responsibilities

1) Maintain Tractions

Inspect Integrity of Tractions Inspect for Infections Daily wound Dressing Educate Patient for proper

immobilization2) Safety Ensure Client’s Safety

Side rail’s Up for safety Put Client’s belongings within

reach Educate significant others about

safety precautions3) Refer for OR schedule Assess patient’s financial status

Refer for Social service( PCSO, Phil Health)

Educate patient regarding operation

Anatomy and Physiology

(Skeletal System)

The skeleton has six main functions:•Support- It provides the framework which supports the body and maintain its shape. •Movement- The bones are the levers that help the body move in different directions and in different ways.•Protection•The skeleton protects many vital organs

Cranium protects the brain.Ribs/Sternum protects the lungs, heart and some digestive organs.Pelvis protects and supports the digestive and reproductive organs.Spinal column protects the spine.

•Blood cell productionInside of the long bones in our bodies, there is a cavity that is filled with a substance called Bone Marrow. In this tissue, new blood cells are produced, and damaged blood cells are repaired. Red bone marrow produces red blood cells, white blood cells and other blood elements.The skeleton is the site of hematopoiesis, which takes place in red bone marrow. Marrow is found in the center of long bones.

•StorageMineral is a substance that the body needs to carry out all of our bodily functions like thinking, breathing and moving around. One of the minerals that the body needs is calcium. Calcium is a major part of bone, and this is where the body stores its calcium.•Endocrine regulationBone cells release a hormone called osteocalcin, which contributes to the regulation of blood sugar (glucose) and fat deposition. Osteocalcin increases both the insulin secretion and sensitivity, in addition to boosting the number of insulin-producing cells and reducing stores of fat.

Fractured femur with plate and screws

Pathophysiology

Trauma/Injury

Hematoma formation and Inflammation

Cellular Proliferation

Precallus Formation (2-

6 weeks)

Callus Formation (3-

6 months)

Laboratory Results

Hematology Dec. 24 Jan. 4 Normal UnitsWBC 22.1 15.9 5-10 Adults

9-20 New bornX109/L

Hemoglobin 119 95 140-170 M 120-140 F

gm/L

Hematocrit 0.367 0.28 0.45-0.50 M0.38-0.48 F

%

Neutrophils 0.86 0.46 0.31-0.76 Adult 0.40-0.50 Newborn

%

Lymphocytes 0.11 0.30 0.24-0.44 Adult 0.31-0.60 New

born

%

Monocytes 0.02 0.02 0.00-0.06 Adult %Eosinophils - 0.20 0.02-0.04 %Basophils - 0.02 0.00-0.01 %Bands 0.01 - 0.02-0.04 %Platelet Adequate 182 150-450 X109/LMCV 90.8 86.2 80-100 FlMCH 29.5 29.4 27-31 PgMCHC 325 341 320-360 g/LRDW 13.2 12.8 11.0-14.6 %

Serology Results Findings Units

Glucose 4.8 3.9 mmol/L

N Cholesterol 4.4 0.0-5.2 mmol/L

LDL Cholesterol 3.3 2.6-4.1 mmol/L

Triglycerides 0.94 0.4-1.7 mmol/L

HDL-Cholesterol 0.64 0.91-1.56 mmol/L

Blood Urea Nitrogen

4.9 2.5-6.1 mmol/L

Creatinine 78 53-115 umol/L

Sodium 138 135-148 mmol/L

potassium 3.7 3.5-5.3 mmol/L

Drug Study

Brand and Generic Name

Action Uses/ Indication

Contraindication

Side effects Nursing Consideration

Tramadol(Dolotral, Milador)

Centrally acting analgesic not chemically related to opioids but binds to mu-opioid receptors and inhibits reuptake of norepinephrine and serotonin

Used for moderate to severe pain

Hypersensitivity, acute intoxication with alcohol, hypnotics, centrally acting analgesics

Vasodilation, dizziness/ vertigo, headache, stimulation, anxiety, confusion and sleep disorder

-Assess patient pain( location and types)-Assess for hypersensitivity reaction: rash and pruritus-Monitor for possible drug induced adverse reaction CNS;stimulation dizziness,vertigo,headache,CV:vasodilationGI:nausea

Azyth (Azythromycin)

Binds to the P site of 50s bacterial ribosomal subunits thereby inhibiting protein synthesis.Treatment of infection in skin and soft tissues.

Treatment of infection of respiratory tract , skin and skin structure,and sexually transmitted disease cause by susceptible organisms

Hypersensitivityto azithromycin or or any macrolide antibiotic

Hypersensitivity reaction such as: skin redness with or without itching photosensitivity, joint pains

Assess for sign symptoms of infection :fever, drainage, sore throat increased WBC count positive specimen culture

Band Name and Generic Name

Action Uses/ indication Contraindication Side effects Nursing consideration

Cefradine(drug maker’s Biotech cefradine)

Inhibits mucopeptide synthesis in bacterial cell wall

Infection caused by susceptible strains of staphylococci, streptopneumonia and E-coli

Patients with history of shock, hypersensitivity to any ingredients and to cephem-type antibiotics

GI disturbances hypersensitivity reactions.

-hypersensitivity to drugs-monitor for positive response to antibiotic therapy-monitor for signs of infections

Losartan (bepzar,lifezar)

Selectively blocks the binding at angoitensin II to receptor sites in many tissues especially the vascular smooth muscles and adrenal glands. This prevents the vasoconstricting and aldestosterone secreting of angoitensin II on these tissue

Treatment of hypertension ,in heart failure and myocardial infarction,

Pregnancy, breast feeding, hypokalemia

Dizziness, dose-related orthostatic hypotension.impaired renal function and rarely ,rash,angioedema and raised alanine.

-assess BP , Monitor for possible drug reaction-assess patient’s and family knowledge of drug therapy

Ferrous SulfateBrotesol,feosol Spansule,Fer-in-sol

Provides elemental iron, an essential component in formation of hemoglobin in red blood cell development.

Prevention and treatment of iron-deficiency anemia

Hypersensitivity to any ingredients,hemosiderosis, hemolytic anemia.

Alteration and abdominal pain with nausea, vomiting diarrhea or constipation.

Obtain baseline assessment of iron deficiency before starting therapy -evaluate hemoglobin, hematocrit and reticulocyte count during therapy.-monitor for adverse reaction.-increase-assess diet nutrion

Nursing Care Plan

Assessment Nursing diagnosis

Planning Intervention Rationale Evaluation

Subjective ;Nahihirapan akong gumalaw galaw”Objective:-Facial grimace-presence of skeletal traction-limited range of motion-limited ability to perform gross motor skills-difficulty in turning-V/S taken:T-36.9 CPR-81 bpmRR-21 cpmBP-110/70 mmHg

Impaired physical mobility r/t musculoskeletal impairment

After the nursing intervention there will be:a.)regain/maintain mobility at the highest possible level

b.)maintain position of function

c.)increase strength/functions of affected and compensatory body parts

d.)demonstrate techniques that enable resumption of activities

1.observe px’s functional ability: document and report any changes using functional level scale2.ensure comfort measures by padding extremities prone to skin break down.3.implement ROM exercises every shift4.promote progressive mobilization to maximum within limits of px’s tolerance for pain5.instruct the px and family members in ROM exercises, transfers, skin inspection and ability regimen6.encourage px to discuss feelings and concerns about altered state of mobility

-Changes may indicate progressively decline or improvement-this measures prevent skin breakdown-This prevents joint contracture and muscle atrophy-maintain muscle tone and prevents complication of immobility-to reduce anxiety and promote compliance-to control minimize effects on immobility.

After the nursing intervention there was:a.)regained/maintained mobility at the highest possible level

b.)maintained position of function

c.)increased strength/functions of affected and compensatory body parts

d.)demonstration techniques that enable resumption of activities



Subjective:“ no verbal cues”Objective:-(+) open fracture@ the left lower femur-(+)skeletal traction@ the left tibia-(+)open gun shot wound @ the left lower femur-(+) edema @ the wounded site-(+) immobility-decreased hemoglobin:95m/L-V/S taken:T-36.9 CPR-81 bpmRR-21 cpmBP-110/70 mmHg

Impaired skin integrity r/t open fracture @ the lower femur as manifested by open gun shot wound @ the left lower femur

At the end of 2 weeks of nursing intervention:a) patient will

exhibit in evidence of skin breakdown

b) Patient will regain skin integrity

c) Patient will demonstrate skill in care of wound

d) Patient will perform skin care routine

1. inspects skin every shift-describe and document skin condition and report changes.2. assists with general hygiene and comfort measures3. Administer pain medication and monitor its effectiveness.4. use of foam mattress, red cradle or other devices5.maintain infection control standards6.change position at least every 2 hours7.instruct patient and family members in skin care regimen

-this provides evidence of effectiveness of skin care regimen-to promote comfort and sense of well being.-patient needs pain relief to maintain health- to avoid potential for infection-to reduce risk of spreading disease- reduce pressure and promoteCirculation-to encourage compliance

At the end of 2 weeks of nursing intervention:

a.) patient was exhibit in evidenced of skin breakdownb.)Patient was regained skin integrityc.)Patient was demonstrated skill in care of wound

d.)Patient was perform skin care routine



Subjective:“mas gusto ko magpasemento na lang kaysa magpaopera ng binti ko”Objective:-facial grimace-poor eye contact-restlessness-unmotivated to learn-economic status

Knowledge deficit r/t difficulty understanding disease process and its effect on own self care

After the 8 hour shift the px will;a.)express understanding of disease process, medication regimen and treatment planb.)px will make informed choices when addressing health care problems and self care deficitsc.)px will demonstrate ability to effectively implement chosen health strategy

1. consider old px life experience when developing teaching plan 2.provide quiet, calm environment for learning.3.limit length of each teaching’s session.4.ask if the px wants to learn new or additional information. If not discuss why.5. set aside time during each session for answering questions and clarifying information.

-new information is easier to assimilate if it is built on existing knowledge.-to enable px to process information w/o distraction from background noise or stress.-to avoid information overload-open discussion helps to identify barriers to learning and determine-older px may need affirmation that knowledge she possesses is current and correct. Discussion may also stimulate exchange of ideas and further learning.

After the 8 hour shift the px was;a.)expressed understanding of disease process, medication regimen and treatment planb.)px was informed choices when addressing health care problems and self care deficitsc.)px was demonstrate ability to effectively implement chosen health strategy

Assessment Nursing Diagnosis


Subjective:“ no verbal cues”Objective:-(+) open fracture@ the left lower femur-(+)skeletal traction@ the left tibia-(+)open gun shot wound @ the left lower femur-(+) edema @ the wounded site-(+) immobility-decreased hemoglobin:95m/L-Decreased hematocrit:0.25-V/S taken:T-36.9 CPR-81 bpmRR-21 cpmBP-110/70 mmHg

Risk for infection r/t open fracture as manifested by open gunshot wound @ the left femur

At the end of 2 weeks of nursing intervention there will be:a.)reduce risk of infectionb.)px will maintain good personal hygienec.)results of laboratory studies won’t indicate infection

1.wash hands before and after providing care2.monitor WBC count, as ordered and promptly report abnormal values.3.instruct client in proper personal hygiene 4.follow facility’s infection control policy5.use aseptic technique when performing invasive procedures.6. ensure adequate nutritional intake

-hand washing is the single best way to avoid spreading of pathogens-decreased production of WBC indicates infection-to reduce risk for infection-to minimize risk of nosocomial infection-to minimize risk of inducing pathogens-To promote healing

At the end of 2 weeks of nursing intervention there was:a.)reduced risk of infectionb.)px was maintained good personal hygienec.)results of laboratory studies won’t indicate infection



Subjective;“nalulungkot ako kasi namatay ang manugang ko at hanggang ngayon di pa nahuhuli ang pumatay”Objective:-poor eye contact-tearfulness-facial tension-facial blushing-restlessness-feelings if anger-V/S taken:T-36.9 CPR-81 bpmRR-21 cpmBP-110/70 mmHg

Anxiety r/t situational crises and hospitalization

After of 8 hour nursing intervention the patient will able:a) appear

relaxed and report anxiety reduced to a manageable level

b) verbalize awareness of feelings of anxiety

1. spend time with patient convey a willingness to listen, offer verbal reassurance 2. give px clear, concise explanation of anything about to occur. avoid information overload: an anxious px cant assimilate many details.3.listen attentively: allow px to express feelings verbally4. Identify and reduce many environmental stressors as possible.5.include px in decisions related to care when feasible.6.support family members in coping with px’s anxious behavior7.allow extra visiting periods with family if this seems to allay anxiety.

-specific amount of uninterrupted non-care related time spent with anxious px build trust-Anxiety may impair px’s cognitive abilities-This may allow px to identify anxious behaviors and discover some of anxiety -Anxiety often results from lack of trust on the environment-anxious px may mistrust own abilities: involvement in decision making may reduce anxious behaviors.-involving family members in process of reassuranc4 and explanation allays- this allows px and family to support each other according to their abilities and at their own race.

After of 8 hour nursing intervention the patient was:

a.)appeared relaxed and report anxiety reduced to a manageable level

b.)verbalize awareness of feelings of anxiety

THANK’S MA’AM

Fracture on Femur

Documents

bone fracture

open fracture

stress fracture

depressed fracture

fracture fragments

fracturesimple fracture

torsion fracture

incomplete fracture