Nursing Case Study Orthopedic Fracture

8/2/2019 Nursing Case Study Orthopedic Fracture

1/15

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Open I Tibia Fibula (R) Lacerated WoundedLeg[ } u ~ ~ [ il l ( ill[[~ ~[ i l l~~~(i l l @ ] [ i l l ~ D @ [ f l ]Individual Case Study on

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2/15

The case was about a 6-year-old male who had an open fracture on his right lowerleg, which he incurred while crossing the street and was accidentall , bum ed by ajeepney. He was brought on a stretche . .0. {@I,~ 0@r;:;;;;]by Ospital ng San Jose Del Monte for ~UU~[ ]~ UUUAdmitted on Aug 7, 2007.A fracture is a break in the continuity of bone. It is defined according to type andextent. Fractu res occur when the bone is subjected to stress greater that it can

D O n ~n nr?R!m~(Cjfti~~~~' sudden twisting motion, or even extremeUUUWU ~ ~~lOO~tlkes. Bones can fracture as a result of directtrau or indirect trauma. Direct trauma consists of direct force applied to the bone;direct mechanisms include tapping fractures (eg, bumper injury), penetratingfractures (eg, gunshot wound), and cr[lus flfmtures. Indirect trau~~lbv~~ forsesactin~ at a distance ~romthe frac~ure ~ . ~ ~ ~ 8 0 0 f M ~ ~ f f i l l : ; D @ 0 U i )(traction), compressive, and rotationa orces. ~In the case of the patient he had a direct trauma (bumped by a jeepney) where hehad an open wound fracture, where his right lower leg was affected especially thetibia and fibula.

l [ } u ~ ~ [fUrn [fCR~~~{].&ilr@lll~~rticular.case for famili~rization of fractu.res asf' CW~HJ~~xe~~~rs~'Sk~~~'~rthopedlc cases rendenng care to a patient.a. Objectives

After successful accomplishment o~~~Q~lil~@@DUUable to: Discuss the anatomy and physiology of the skeletal system thatare directly affected in the fracture and relate the concepts to the

[fu~~llil(]][f~~llil@~~Ql]@]~OO~he patient. In this case the bones (phalanges)

Explain the pathophysiology of a fracture .~ ~

ADetermine the nursiO .. . - . . ~ . ~ D @ O U i )requisite and execu~ )i~cture, Incorpora e~esein the creation of a pertinent nursing care plan

Distinguish the different pharmacological actions of the drugsinvolved in the treatment of a fracture, and identify the nursing[?)[fu~~[fUrn[f~~[fU~~~rn@j~rm~~tsmmmust be em~IOyed . . .- Formulate relevant health teachings and outpatient care for apatient with a fracture.


3/15

~[}u~~[ f f i_OO@~~QD@[f lJa. Personal Data

Patient's Name: RL.Age: 6 y/oSex: MaleAddress: Sapang Palay BulacanCivil Status: SingleNationality: FilipinoReligion: Catholic

Clinical impression: Open I Tibia Fibula (R) Leg Lacerated WoundAttending physician: Dr. Mutia

b. History of Past IllnessThe patient had complete immunization during her childhood. Non-hypertensive,non-diabetic, non-asthmatic, no heart and circulation problems such as chestpain, weakness, shortness of breath, slurred speech or problems with vision. Nof l : . " on o~ci.5rqrom s irin~nd no history of stomach ulcers or bleeding. No past

i 0 1 3 n @ @ l l i r n sent.c. History of Present Illness

The patient had an accident while ~r ruoomlOO~~aw~.~QD@@[f l Jnoticed the jeepney approaching from behind him. He was bumped by thejeepney and sustained a direct trauma on his right leg. His tibia and fibulasustained an open wound fracture. The patient was then immediately rushed inn - 0n 0 Ospital r e , 1 . ~ S .a. ~.e - e.1Mont.e,was then x-rayed and had the result Open I TibiaUU~Ullil(]][f~~~lJ~~~~,~~~~.referred for his debridement and fixator

d. Psychosocial HistoryThe patient was a male 6-year-old ~~~~~Q~Qr tJ@[f l Jclass, do homework and studies w~~e client's dietge";,~aIIY involved avariety of home-cooked f home prepared. He had a good appetite. Duringweekends he plays with his neighbors usual for a child's play age.

The patient's parents were both still living. The father is an electrician andmother is a housewife. Parents ha~~A~~~~ Jm~~ -both negative for having diabetes. ~m m ~ti i l l l ! f~~~~~~D@@[flJ


4/15

~[}u~~[illQJJ[[~~[ill~~QQJJ@][illQD@[fl]f. Physical Examination/Assessment

Patient's Name: R.L.Age: 6 yl oSex: MaleAddress: Sapang Palay BulacanCivil Status: SingleChief complaint Lacerated Wound Right Leg

G o 0~ Clinical~nne~~~~ I T ibia Fibula (R) Leg Lacerated Wound0 [illQJJ[[~D~~,~~~~lto~~ihm RR-20 bpm BP -120170 mmHgAug 08, 2007: I_- 37.4C PR-97 bpm RR-19 bpm BP -120170 mmHg

HEAD ~ R n r c \ 0 ~ ~The skull is rounded with parietal promin W I J . l J i . . l i l l J O O ~ ~ l l i ) . . . c lli1~D@OUUnodules, masses and depressions. The ~iS thick, straight, black an shiny with equaldistr ibution. Portions of the scalp have no dandruff. No lesions are noted.EYESPatient did not wear eyeglasses and disclaimed having vision problems. The general character of

[}u0~- - - - . D!!hiSface. soogcal andattg. t ive. He _.hadmoderately thin eyebrows with rou.nded eyes that l ied0 \ 0 ~nnr?;?D 0 . - - - ' 0 ~~ere noted on both eyes. The conjunctiva appearedUUWU ~ .. . .,. ~\i:eOWc:IJ.MUe. The pupils were black and equally round. Theywere- reac ive to light, showing constriction and dilation capabilities when stimulated by illuminating at

different distances.

~~eR:atientdidnot have anyfamilyhistorywh~1~ ~o~[~rDa~~~o~~~~@~e~@@llilUor pinna are aligned with the outer canthus of the eyes, did not possess any deformities, lumps andlesions. No swelling and discharge were observed in the external canal. Client had no history ofhearing problem. Her auditory acuity was good as he was very sensitive and responsive to soundsproduced at varying distances.

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The nose was flat but symmetrical in shape. No inflammation, flaring, and lesions were present.::~~t:rnal mucosa was dry and void of a~mMJWQJJ [[~~ [ill~~nQJJ@][illno@[fl]

The outer lips were pink and relatively moist, showing no signs of pallor or cyanosis. The interior ofthe lips were smooth, moist and light pink. No lesions, edema, and ulcerations were found. Thegums and tongue likewise looked pink and moist. The tonsils were intact and un-inf lamed.

~ G u 0 ~ ITU(illU'~D@i~~u~~(~~Q~~~~nd trapeziusmuscles) didnot have any swellingormasses. Head movements are coordinated, smooth and without any discomfort. The neck wass.ymmetrical in shape with no mass palPated~1 _ g~~ Iymph~o.d.e_. The. ne,ck..mus~l.sdemonstrated strength with the client's abilit .. ~M ..- . - .. ~. 0 @ r ,: 0 ; lhand. O U U W _ _ J5UU~D~OUUUTHORAX & LUNGS


5/15

~Gu~~[JiJ(l[][[~~~(OJ~n~_~~ij)atory ailments. He did not develop difficulties inbre~. His breath sounds were auscultated and showed absence of wheezing, rales, andstridor. The respiratory rates were 20 and 22 breaths per minute on April 18 and 19, respectively.

HEARTThe patient al leged having no history of heart disorders. His heart sounds were auscultated andwas found free from murmurs. His pulse rates were 80 and 69 beats per minute on April 18 and19, respectively.

[ } u D~ 0 ABDO~N dl ~ I0 [JiJ(l[] [ [ ~ D ~~~~~~lli) ~@llUUerant when in standing position. The abdomen was flat andsoft upon palpation and revealed no abdominal bowel sounds. Thise were no scars, lesions, andhisnias marked.

~ : : : n : ~ ~ : : wrists were i n t a c ttth c O ~ I ~ ~ ~ ~ f ~ ~ ~ ~ ~ @ I ~ ~ ~ ~ ~ ~ g D @ @ l l i i l levident. Client was easily & painlessly able to perform range of motion exercises with his handsand wrists. The elbows showed no swelling and deformities. Patient had no problems extendingand flexing his forearms. Decreased Range of Motion on the right leg, swelling, open wound anddeformation found on the right leg. The rest of the legs and feet of the left side were unaffected anddemonstrated ability to perform range of motion exercises.

u ~ ~[JiJ(ill[[~~~~IT@k~ff~nlliJUPatient was alert and well oriented with the time, place and people he was involved with. He was alittle bit shy but vocal about his emotions and feelings. Fear of the procedure. Inspite of shyness,was a b l e o communicate a n dnteract well~~ 1~J r n ~ ~ l ~ t i ~ @ T I ~ e @ ~ ~ n : @ @ l l i i l l


6/15

Intercondylareminence

Lateral condyle

Head of fibula

-t-t---InterosseousAnterior crest membrane J i ) @ ~ ~ ( i l l@ ]@ [ i l l ~ D @ D D U

Tibia -Fibula

Medialmalleolus

Lateralmalleolus

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7/15

RISK FACTORS Osteoporosis, Exercise and SportsInjury, Dental Emergencies,Perinatal Problems, Overuse,Trauma

accidentally bumped by a jeepneyIn the case of the client the major riskfactor was trauma where he was~[

o ",1

DAFFECTED PART Bones of Lower Right Leg In the case of the client specif ically open It ibia fibula right leg.

D

Signs and symptoms (Book MedSurgcial Nursing Lipincott Williamsand Wilkins 10ed.)

Experiences muscle spasmand continuos pain thatincreases in severity until bonefragments are immobilizedLoss of function, deformity,abnormal movement, andshortening of the extremitymay be noted.Crepitus, local swell ing, anddiscoloration mav be seen

DISEASE t FRACTURE~ 0 n PROCESS ~

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Diagnostic Tests (Med SurgicalNursig Saunders 6th ed.) .Tomography - can be used tolocate bone destruction, smallcavit ies, foreign bodies, andlesions overshadowed by otherstructures.Bone Scans - images of theskeleton are taken afterradioisotopes is injectedintravenously and allowed tomigrate to bone.-/ Radiography - x-rayexaminations obtaining a plainfilm, usually an anteroposterioror lateral view, possibly both.

The client had a open wound fracture.

o Signs and symptoms experiencedby the patient-/-/

Felt extreme pain.Can't move his right leg andhad an open wound.The right leg is swell ing.

Diagnost ic Tests done on thepatient-/ X-Ray - was done to the

patient upon rushed to Ospitalng San Jose Del Monte


8/15

Treatment (Il lustrated Manual ofNursing Practice Springhouse)if Drug Therapyif Surgery - arthroscopic

surgery, open reduction andinternal fixation, amputation,laminectomy and spinal fusion,joint replacement, etc.

if Non-surgical Treatments-closed reduction,immobilization[ f U ( i l l ~~~rrr-


9/15

Io lGumuilgI@ta?I~~lt ld l@ffB. (l~ cartilage. respectively, and then the newlyIf' ff,~one l~Wz~qJli lS sta~=V~-16 weeks.

Patients who have poor prognostic factors in terms of fracture healing are at increased riskoD_~~tllr~J~~~U1j~D~~nunion, malunion, osteomyelitis, and chronic

Patient factors influencing fracture healingFactors

Youthge (Farmer, 1984)Nonsteroidal anti-inflammatory drugs(NSAIDs), corticosteroidsSmoking

Trauma (Schemling, 1995) Single limb Multiple traumatic injuriesMedications (Giannoudis, 2000) None

Type (Rockwood, 1996) Closed fracture,neurovascularl

Local factors (1\1011itt,2002) No infection

Nutrition (Hernandez-Avila,1991

Well nourished


10/15

Name of Patient: R.L.Age: 6 y/ oSex: maleReligion: Catholic

Date admitted: Aug 07, 2007Chief complaint:~ l f { J ~ r r t 1 o ~? ~ D I T O ~ ~ n ~ @ ] I T O n o @ l l i m

Action RationaleImmediate assessment includes airway,breathing and circulation. Monitor the vital} u D ~ M ~ ~ rn r u ~ ~@ ( g j m ~ ~Monitor the patient for signs and symptoms ofneurovascular compromise comparingfindings to the unaffected limb.a) Check for diminished or absentpedal pulses.b) Check for capillary refi ll time. > 3 seconds

d) Check for complaints ofabnormal sensations, e.g.tingling and numbness.e) Observe for increased pain notcontrolled by medication.

To assess the overall generalcondition of the patient postmrruthetic.

Careful monitoring enablesearly det~WuD~[JlJ~u?~D[JlJ 0 ~ ~ ~ @ ]SUrgicaWrauma causes swell ing an~dema, whichcan compromise circulation and compress nerves.Prolonged capillary refill t ime points to diminishedcapillaryperfusionrffl~igns may indicate\X1M~mised circulation.

Tissue and nerve ischaemiaproduces a deep, throbbingunrelenting pain.b ~ ~ O J J ~ u u ~ o

surgeon or anaesthetist.

r,;i;~tient's status of~~19n needs to bemonitored to preventelectrolyte imbalance orcirculatory overload.

Assess the patient's level ofpain control and administeranalgesia as prescribed. Ensurethat if a patient controlledanalgesia device (P.C.A.) isused, the correspondingn - -Is ~~~ctsfollowed. is r!I. A~ lfU - - ~~ , - - . . -. ~ l 9 J I T O l ) o

- order to start an earlyprogramme of both limb anddee breath in exercises in relative comfort

o To monithe prescribed analgesia. Painmanagement is very importantto prevent vicious cycles ofpain, tension and anxiety thatbreeds more pain and equallyinmortant prevents@ i' ion in physiotherapyI care.


11/15

The patient's Waterlow Score is assessed.Specifically assess skin over bonyprominences (sacrum, trochanters, scapulae,elbows, heels, inner and outer knees, innerand outer malleolus and back of head). Areaswhere skin is stretched tautly over bonyprominences are at a greater risk ofbreakdown, because the possibility ofischaemia to skin is high due to compression

[}uD~iii~~ies betwe n a h d surfa i ~mattress will dep d upon the nurse's clinicaljudgement and the patient's condition.The wound dressing is monitored for oozingfrom the incision site. If the patient hasa portovac, observe the drainage from thewound through the portovac drainsand record appropriately.

The leg and the externalfixator must berf~!!:u a it and t~~:=~ : m r ; c m m ~ ~ U l j othe move. The ~t should use theoverhead monkey pole to assist with bodyosition chan es.Pin-sites and wounds must be constantlyobserved for signs of infection: Observationsshould include determining pin stability,assessing skin tension at insertion site, notingcolour, odour and characterist ics of anydrainage. Pin-sites should be attended tonder strict am tic techni ue ini iall dai

~ ; ~ ~ ~ ~ f i f i ~ ~ ~ r , ~ , t ; ~ ) ~ ~ $ ' ~surge~~~sult in temporary ha s asis ancan result in delayed bleeding (Griffen1999). To prevent pain on movement, and to maintaincorrect alignment.

@ l l i J U p r o P h Y l r o o I b R H ~ { ? ~ D l l i ) ( Q l ~ Q l l i J ~ 0 O l J Q o @ @ l l i J UadmlnlstJcJ~~~revent ~infection.

Continuously assess thepatient for signs and symptomsof: Deep Venous Thrombosis (D.v.T.)Positive Homans Sign Swelling of leg,Tenderness in calf.

Early detection and treatment.


12/15

DATE ORDERED MEDICATION AND ACTITREATMENT7-7-7 Generic Name:Amikacin Sulfate

Brand Name:Inhibits proteinsynthesis by bindingdirect ly to the 30Sribosomal subunit.

Serious infectionscaused bypseudomonasaeruginosa

Used cautiously inimpaired renalfunctionObtain culturesensitivity testsbefore first dose.50mg/milM IIVinfusion Q12 Weigh patient and~ G u D ~ ( i l l [ ( @ D U U @ @ ai~~1U Ubegins.

PROGNOSIS* Tibia and fibula fractures

~O~ITD~~;i1~rnd:@@U@pendent on degree of soft-tissue injuryandPrognosis is good for isolated fibula fractures.MEDICATIONSAnalgesics -- Pain control is essential to quality patient care. It ensures patientcomfort, promotes pulmonary toilet, and aids physical therapy regimens. Manyanalgesics have sedating properties that benefit patients who have sustained fractures.

~~rMm~~~n~~~~~~Zt~~~~~t~~~:~~I~j~~ti~;n~nrt~~~iOUSIY


13/15

Three point gait - patient who can bear only partial or no weight on oneleg. Instruct her to advance both crutches 6 to 8 inches (15 to 20 cm) along withrl:, o n h~~~g the uninvolved leg forward and to bear theuDu[[J(ill . g~ut some of it on the involved leg, if possible.Stress e importance of taking steps of equal length and duration with nopauses.

Teach the patient using crutc"~~~nYI?rJ~' ~~MCAhP.:l.chboth crutches in one hand, with the t ~ l I iW I t l ~ ~ li ll t f 1 ~lJlft.~tQJOUi)him to push from the chair with h r free hand, supp ing herself with thecrutches. To sit down, the patient reverses the process, tell her to support herselfwith the crutches in one hand and lower herself with the other.Teach the patient to ascend stairs using the three point gait, tell her tolead with the uninvolved and to follow with both the crutches and the involvedp[}u~~[[J~~_~fflf[? with the crutches and the involved leg and

TREATMENT

Prehospital Care:* Addressed airway, breathing, and circulation.t a t u s .* Apply gentle traction to reduce gross defof5\~IITO@~~I~~n(ill@][[JQo@OUi)* Administer parenteral analgesics fdf' an isolated ex~mity injury in ahemodynamically stable patient.

Emergency Department Care:~[}u~~~~~~~~[iiEI treated appropriately. Tetanus had been- updated and ua~ropriate antibiotics given. This should involve antistaphylococcalcoverage and consideration of an aminoglycoside for more severe wounds. Orthopedicsconsulted for emergent debridement and. ~oun~8m. Fractures with t~su~t ris'5-\for _

opening protected to prevent further morbld'ty.~lJlJDu[[J[ill[[~D[[J~~lJ[ill\ill@[[JUo@OUi)


14/15

~Gu~~~~~~ffij~~@@OffiJractures of the lower leg.Signs of compartment syndrome include crescendo symptoms, pain with passivemovement of involved muscles, paresthesia~ ffillor, and 0a veryAlat~findin~ is

pulselessness. ~lIlJ~U[JO(ill[[~~[JO~~~Q[]\9.J[JOuD@DDOo If compartment syndrome is suspected, obtain an emergent orthopedic consultand measure compartment pressures. Compartment syndrome must be treatedpromptly with an emergency surgical fasciotomy. If untreated, the increased

oD~B~~~~~~ and necrosis of the structures within that* Tibial plateau fracture

o Immobilize nondisplaced frac~D_[[.@~~@@W~@@OUi)nonweightbearing.o Obtain an orthopedic consultation for displaced (depressed) fractures, whichrequire open reduction and internal fixation. Articular depression of greater than 3 mm

o Surgically repaired proximal tibia fractures include external fixation, Rlating, andintramedullary nailing. ~ G u ~ ~ [JOQ[][~~ [JO~~nQ[]~ITiJnD@@DDO

HYGIENEGu~~llil(]][[~~[f8~@~b~@lliruer in bathing and hygiene techniques. Haveone of t~ demonstrate it under supervision. Instructions to a family member

can be given in writing. Return demonstration identifies problem areas andi n c r e a S ~ ~ e s ~ t ~ ~ ~ ~ ~ ~ ~ e ~ n n a lt b e d s ~ g ~ @ _ f lW @ ~ ~ Q B @ @ l l i 1 Uto go up in the dark to go to the bathro~'t:l

OUT-PATIENT CAR.E~GuD~[JOQJJ[[~DOOEiR@Qilll~B@~t his follow-up care with the physician after- onewee~

Give referral on health care delivery system such as physical therapistnear to her location.


15/15

1 o l [ } u ~ ~ U i J _ ~ 1 r i I 1 o l ~ 0 n n @ ] ~ l r i I n D ( Q ) r n n IIf' ~evas ~era'fedwas orffered by the physician to the patient. Stress theimportance of a high-carbohydrate and high-protein diet for adequate healing,and then assist the client in making food W I ' s as necassary. A r . ! l ASOCIAL ACTIVITIES ~ l n J ~ U i J ( i l l [ [ ~ ~ U i J ~ ~ ~ Q [ ] \ 9 . J U i J ~ D @ D D O

Patient will stay home, he can invite and accommodate friends at hishome, He can't still go to school until proper instructions given by the doctor that} u D ~ U i J ( i l l ~ ~ W l J ~ ~ @ f g J ~ I I T U ~ 6 @ D D O

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} u ~ ~ I T U ( i l l [ [ ~ ~ I T U @ ~ n Q [ ] @ J I T U n D @ D D O~ [ } u ~ ~ I T U ( i l l [ [ ~ ~ I T U ~ ~ n Q [ ] @ J I T U n D @ D D O

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Nursing Case Study Orthopedic Fracture

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