LICEO DE CAGAYAN UNIVERSITY

College of Nursing
Rodolfo N. Pelaez Blvd., Carmen,
Cagayan de Oro City

In partial fulfillment of the requirements

In NCM 501-202
Related Learning Experience

A Care Study

On
BONE FRACTURE

Submitted to:
DANTE DIADULA, RN

Submitted by:

Mertalla, Mary Joy G.

March 12, 2010

1
 TABLE OF CONTENTS

Page
Ι. Introduction 3 - 4

α. Overview of the case

β . Objective of the case
c. Scope and Limitation
ΙΙ. Health history 5 - 6

α. Profile of Patient
β . Past Medical History
χ . History of Present illness and Chief Complaint
ΙΙ Ι. Developmental Data
6-7
Ις. Medical Management 8 - 11
α. Medical Orders and rationale
β . Drug study

ς. Pathophysiology with anatomy & physiology 12 - 19

ςΙ. Nursing Assessment (System Review & Nsg. Assessment II) 20 - 24

ςΙ Ι. Nursing Management
25 - 29
α. Ideal Nursing Management
β . Actual Nursing Management
ςΙ Ι Ι . Discharge planning
30
IX. Evaluation and Prognosis 30 - 31
X. Bibliography 32

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Introduction
A. Overview of the case

A fracture usually results from traumatic injury to a bone, causing the continuity
of bone tissues or bony cartilage to be disrupted or broken. Fracture classifications
include simple or compound and incomplete or complete. Simple fractures (often called
"closed") are not obvious as the skin has not been ruptured and remains intact.
Compound fractures (commonly called "open") break the skin, exposing bone and
causing additional soft tissue injury and possible infection. A single fracture means that
one fracture has occurred, and multiple fractures refer to more than one fracture
occurring in the same bone. Fractures are termed complete if the break is completely
through the bone and described as incomplete or "greenstick" if the fracture occurs
partly across a bone shaft. This latter type of fracture is often the result of bending or
crushing forces applied to a bone.

Fractures are also named according to the specific part of the bone involved and
the nature of the break. Identification of a fracture line can further classify fractures.
Types include linear, oblique, transverse, longitudinal, and spiral fractures. Fractures can
be further subdivided by the positions of bony fragments and are described as
comminuted, non-displaced, impacted, overriding, angulated, displaced, avulsed, and
segmental. Additionally, an injury may be classified as a fracture-dislocation when a
fracture involves the bony structures of any joint with associated dislocation of the same
joint.

The exact number of fractures sustained in the United States each year is not
known as many are not treated. Experts estimate the number of fractures at between 10
and 20 million. People of all ages and races experience fractures. Broken bones are

3
slightly more common among children due to their increased level of activity and among
older people due to their lack of exercise and inadequate intake of calcium.

This study is an opportunity for us student nurses to gain insights about fracture
on the distal phalanx. This will help us as student nurses to develop empathy for the
patients with this kind of case, know the impact of this condition and sharpen our ability
to care for our patient. Gathered data about our patient, brief anatomy and physiology,
including the care that we were able to render to our patient during days of exposure in
the Station 1 of Doctor Sabal Hospital, Inc.

B. Objective of the case

The objective of this study is as follows;

• Trace the disease process which is related to the actual condition of the patient.
• Recognize the medical care of the client and know the significance of the medical
managements rendered.
• Recognize the significance of all diagnostic tests given to the patient.
• Formulate and implement an effective nursing care plan especially designed for
patient’s problems as identified in the nursing assessment.

C. Scope and Limitation

This case presentation involves patient Bones who was diagnosed Fracture on
rd
the right distal phallanx digit right foot. The scope and limitation of this study are as
follows:
 Patient’s history and background
 Predisposing and precipitating factors as manifested by the patient
 Anatomy, Physiology and Pathophysiology of fracture on the distal phallanx 3rd
digit right foot.
 Nursing and Medical management during the confinement period
 Discharge plan, referrals and evaluation of the study
 Assessment of patient is inclusive only from February 16-17,20010

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 II. Health history
A. Profile of Patient

Name : Patient Fracture

Address : Topaz St.,Gusa Cagayan de Oro City
Birthday : 1994
Age : 15 years old
Gender : Male
Religion : Roman Catholic
Nationality : Filipino
Civil Status : single
Educational Attainment : high school
Date of Admission: February 12, 2010
Time of Admission: 10:25 am
Allergy : No known food and drug allergy
AP : Dr. Yacapin
Chief Complaint: swelling and tenderness on the right foot
Diagnosis : Fracture distal phalanx 3rd digit right foot.

Vital Signs Assessment:

Temperature: 37.1 °C
Pulse Rate: 84 bpm
Respiratory Rate: 24cpm cpm
Blood Pressure: 110/70mmHg
Height: 5’ 6’’
Weight: 135lbs

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 A. Past Medical History
The patient was not been hospitalized before prior to his admission. He was a
basketball player with height of 5’8’’. He seldom had complains regarding his health. The
minor ones’ are cough, colds and headache. His father had hypertension which makes
him a candidate for acquiring hypertension while on his mother’s side, there were no
heredo-familial disease identified.

B. History of Present illness and Chief Complaint

The patient is a 15 year-old male who is a roman catholic is presently residing at
Topaz St.,Gusa Cagayan de Oro City
According to the patient, six days prior to his admission he was outbalanced
while playing basketball. He fell into a concrete floor which causes an injury to his right
foot. The patient then complained of pain and was given with mefenamic acid 1 tab by
his mother. Two days prior to admission, an x-ray of the patient’s right foot was done.
Then on Feb 12, 2010 at 10:25 in the morning the patient came at the emergency room
of Northern Mindanao Medical Center with a chief complain of swelling and tenderness
on the right foot. Hence the patient was admitted and was scheduled for an operation on
the 15th day of February.

III. Developmental Data

Growth is defined as a quantitative (measurable) increase in size of the whole or

any of its parts, such as the height and weight. On the other hand, development is a
qualitative increase in capacity of functioning, like learning new skills and intelligence.
Theories of development provide a framework for thinking about human growth,
development, and learning.

6
Sigmund Freud’s Psychosexual Theory

The fifth and last stage of psychosexual development, the genital stage, lasts
from puberty, about the twelfth year of age, and onwards. It actually continues until
development stops, which is ideally in the eighteenth year of age, when adulthood starts.
This stage represents the major portion of life

The patient was not that detached from his parents since he was just 13 years
old. The patient was also shy on letting someone see his genital and it was evident while
we were removing his catheter.

Erik Erikson’s Psychosocial Theory

Adolescence (12 to 19 years)

• Psychosocial Crisis: Identity vs. Role Confusion

The client now was very conscious with what he appears to others. This was
evident by the way he carried himself while he was admitted. The client was also
beginning to build his own career especially on being a basketball player and at the
same time he was also making sure that he balances it with his studies.

Robert Havighurst’s Developmental Task Theory

(Ages 12-18)

The patient was achieving new and more mature relations with age mates and
both sexes. He was also achieving a masculine social role. He uses his body effectively
by engaging to various sports especially basketball. He also developed a sense of
emotional independence towards his family. He also acquired a set of ethical system
which he now uses as a guide to his behavior.

Jean Piaget’s Theory of Cognitive Development

7
Formal operational stage

The patient was able to draw conclusions from the information available. Also,
the patient was able to understand such things as love and values.

IV. Medical Management

A. Medical Orders and rationale

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 DATE ORDER RATIONALE
Feb 12, 2009 Please admit to room of choice
under the care of Dr. Yacapin.
10:30 AM Prob. Swelling of the right foot distal For documentation
phalanx 3rd digit
TPR q 4 hr To monitor any alterations and
Monitor v/s q 4 hr deviations in patients’ vital
measurement
DAT The best diet of choice
Infuse with D5LR @ 20gtts/min. For fluid replacement
Lab: X-ray of the right foot APO – For diagnostic purposes
taken outside lab
Schedule for open reduction pinning For ducomentation
3rd & 4th metatarsal foot under
spinal anesthesia today.
Secure consent For legal purposes
Cefazolin 500 mg IV 1hr anst (-) Antibiotic drug
Post op Orders To RR s/p on pinning right foot For documentation
Morphine precautions for 24 hr
DAT once fully awake Diet of choice
Flat on bed until 12:00 MN then may Ta avoid vomiting/after effects
turn to sides. of the drugs
v/s q 5 min x 2 hr then q hr For monitoring
IVF D5LR 1L @ 30 gtts/min IVF of choice for fluid
IVF to ff – D5LR 1L @ SR replacement
Meds: Cefazolin 1 g IV q 8hr For drug therapy
Ketorolac 30 mg PO OD after 5 Hal
I & O q 4hr
Feb 13, 2010 Pls give metodopramide 10 mg IVT > To prevent vomiting
now then q 8 hr PRN for vomiting
12:10 AM
(+) vomiting 2X in
small amt
02/14/09 Te Anetoxal 0.5 ml/M 2. Anti-tetanus vaccine
To continue ff meds 3. To facilitate hospital
Cefuroxime 500 g 1 tab BID PO discharge
Meloxican 15 g 1 tab OD PO 4. Home medications –
1. TCB after 3 days for ff-up check- antibiotic treatment
up. 5. For follow-up check-up
B. Drug study

Name of Drug Generic Ketorolac Tromethamine (Toradol)

(Brand)
Date Ordered 02/12/10
Classification Analgesic

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Dose / Frequency Route 30 mg IV
Mechanism of Action It inhibits synthesis of prostaglandins and is a peripherally
acting analgesic. Ketorolac does not have any known
effects on opiate receptors.
Specific Indication Short-term management of pain
Contraindication Hypersensitivity to ketorolac, individuals with complete or
partial syndrome of nasal polyps, angioedema, and
bronchospastic reaction to aspirin or other NSAID
Side Effects / Toxic Drowsiness, dizziness, headache, nausea, dyspepsia, GI
Effects pain, hemorrhage, edema, sweating, pain at injection site.
Nursing Precaution  Report promptly any signs or symptoms of GI
ulceration and bleeding during long term therapy.
 Note: Possible CNS adverse effects
 Do not use other NSAIDS while taking this drug.

Name of Drug Generic Cefazolin Sodium (Ancef)

(Brand)
Date Ordered 02/13/10
Classification Antibiotic
Dose / Frequency Route 1g IV q 8 hr
Mechanism of Action Preferentially binds to one or more of penicillin-binding
proteins (PBP) located on cell walls of susceptible
organisms. This inhibits third and final stage of bacterial
cell wall synthesis, thus killing the bacterium.
Specific Indication Severe infection of soft tissue and bone.
Contraindication Hypersensitivity to any cephalosporin and related
antibiotics.
Side Effects / Toxic Anaphylaxis, fever, eosinophilia, superinfections, seizure,
Effects Diarrhea, abdominal cramps, urticaria
Nursing Precaution  Report promptly any signs or symptoms of super
infection.
 Report signs of hemostatic defects: ecchymoses,
petechiae, nosebleed.

Name of Drug Generic Cefuroxime Sodium (Zinacef)

(Brand)
Date Ordered 02/13/10
Classification Cephalosposin Antibiotic
Dose / Frequency Route 500 g 1 tab BID PO
Mechanism of Action Resistance against beta-lactamase-producing strains
exceeds that of first generation cephalosporins.

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 Antimicrobial spectrum of activity resembles that of
cefonocid. Preferentially binds to one or more of the
penicillin binding proteins located on cell wall synthesis,
thus killing the bacterium.
Specific Indication Infectious caused by susceptible organisms in the skin
structures.
Contraindication Hypersensitivity to any cephalosporin and related
antibiotics.
Side Effects / Toxic pain, burning, superinfections, antibiotic-associated colitis,
Effects rash, pruritus, urticaria, increased serum creatinine and
BUN, decreased creatinine clearance.
Nursing Precaution  Report loose stools or diarrhea promptly.
 Report any signs and symptoms of
hypersensitivity.

Name of Drug Generic Tetanus toxoid

(Brand)
Date Ordered 02/14/10
Classification Vaccines, Antisera & Immunologicals
Dose/Frequency/Route 0.5 cc deep IM
Mechanism of Action The tetanus toxin initially binds to peripheral nerve
terminals. It is transported within the axon and across
synaptic junctions until it reaches the central nervous
system. There it becomes rapidly fixed to gangliosides at
the presynaptic inhibitory motor nerve endings, and is
taken up into the axon by endocytosis. The effect of the
toxin is to block the release of inhibitory neurotransmitters
(glycine and gamma-amino butyric acid) across the
synaptic cleft, which is required to check the nervous
impulse. If nervous impulses cannot be checked by
normal inhibitory mechanisms, it produces the generalized
muscular spasms characteristic of tetanus. The toxin
appears to act by selective cleavage of a protein
component of synaptic vesicles, synaptobrevin II, and this
prevents the release of neurotransmitters by the cells.
Specific Indication Booster vaccination against diphtheria, tetanus &
pertussis for individuals
Contraindication Encephalopathy of unknown aetiology occurring w/in 7
days following previous vaccination w/ pertussis-
containing vaccine. Transient thrombocytopenia or
neurological complications following an earlier
immunisation against diphtheria &/or tetanus. IV
administration.

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SideEffects/ToxicEffects This medication may cause irritation, redness, swelling,
warmth, itching, bruising, pain and a hard lump at the
injection site which lasts a few days up to a week. Other
side effects include low grade fever, muscle or joint aches,
general body discomfort, flushing or itching. If these
symptoms continue or become bothersome, inform your
doctor.
Nursing Precaution Postpone administration in patients w/ acute severe febrile
illness.

Name of Drug Generic meloxicam (Mobic)

(Brand)
Date Ordered 02/13/10
Classification megestrol acetae
Dose / Frequency Route 15 g 1 tab BID PO
Mechanism of Action thought to reduce the inflammation and pain by inhibiting
prostaglandin synthesis of the enzymes cycloxygenase.
Specific Indication osteoarthritis.
Contraindication Hypersensitivity to any drug.
Side Effects / Toxic pain, burning, superinfections, antibiotic-associated colitis,
Effects rash, pruritus, urticaria, increased serum creatinine and
BUN, decreased creatinine clearance.
Nursing Precaution  Report loose stools or diarrhea promptly.
 Report any signs and symptoms of
hypersensitivity.

V. Pathophysiology with anatomy & physiology

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 There are 5 main bone types in the human skeleton. Long bones, short bones,
flat bones, irregular bones and sesamoid bones. A sixth type known as “Wormian”
bones is also found, which are found during growth of the skull in children,

• long bones are the main lever arms of the appendecular skeleton, such bones
are the femur, humerous and (Despite their relative length) the phalanges in the
finger.
• Short bones are very strong and are very good at resisting deformation through
shock. As such, they are found in the wrist and foot (Carpals and Tarsals
respectively) as this is where the loads on the body are normally applied,
through walking, running, or lifting and throwing.
• Flat bones are, as their name describes, relatively flat. They provide protection
for organs, and offer attachment points for muscles. These are found on the
body as the Skull, pelvis and sternum.
• Irregular bones are not specific to any one function, and are found in a variety of
roles within our bodies, they are found in the face, but probably more
importantly, in the spinal column.
• sesamoid bones are small and oval, and are located within tendons to aid its
motion around a joint, the obvious of these being the knee-cap, or patella.

These varieties in size and shape are all due to the different functions these
bones carry out. However, they all follow a similar structure, a variation on a theme.
They must all be strong enough to support us, and light-weight enough so we can
move. This is achieved by having the hardest area of bone, called compact bone, on the
outside, forming a rigid cylinder called the Diaphysis, and looser, spongy tissue, known
as cancellous bone inside the head. Between the cancellous bone and the interior of the
shaft, or Medullar cavity, are plates. These Epiphyseal plates are part of the
development process of the bone, and are discussed in more detail later.

Within the medullar cavity is yellow bone marrow. This is where vital minerals,
and calcium are stored. Red marrow is found within the cancellous bone at each end,
and this manufactures red blood cells. On the very outside of the bone is found the
periosteum. This is a protective layer round the bones, that provides the attachment for
ligaments and tendons. At the point of contact with other bones is found Articular

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cartilage. This provides a frictionless, cushioning coating to prevent the bones from
wearing each other away. Failure of the cartilage is what causes arthritis.

Skeletal Development

In the fetus, the skeleton is first laid down as cartilage, but as development
continues, it is replaced by bone in a process known as ossification. This is a complex
process involving the gradual removal of cartilage by cells from outside which invade it;
other cells of a different kind then follow and lay down the bone which eventually
replaces the cartilage that has been removed.

In an X-ray of a bone, it is possible to see where cartilage is still present (At the
Epiphyseal plates), these are the places where growth in length is still taking place, and
it is possible to estimate a child’s age from the size of these regions.

Because children have a greater percentage of cartilage in their bones than

adults, their bone structure is significantly more flexible than adults. This means that, in
the event of a fracture, the bone will bend and splinter, rather than snap. In the case of
exercise and sport, the bones must not be over loaded, or else longitudinal growth may
be reduced, resulting in pain, and stunted growth in later life. Weight training should not
be carried out by children until their development has slowed. It is not the age, or size of
the child that is important, rather than their developmental stage.

Synovial Joints.

At any point in the body, where two bones meet, there will be a joint of sorts. The most
common joint is the Synovial joint. These joints are freely moving, and allow efficient
transfer of muscular force from one muscle to bone and to bone.
There are a number of different types of Synovial joint, these are typically...

• Ball and Socket: For example, at the femur-hip interface. This is where the head
of the bone fits into a socket on the other bone, allowing a wise range of motion,
in a number of axes.

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 • Hinge joints: As their name indicates, these joints provide movement in one
plane, like a door hinge. Found at the join between humerous and ulna (loosely
speaking)
• Pivot joints: These allow rotation of one bone around another, such as where the
radius and the ulna meet.
• Condyliond: Also known as Ellipsoid joints, this is where curved facia meet,
offering movement in a number of planes. Found in the fingers.
• Gliding joints: Found between two flat parts of bone, and allow little lateral
movement only. Found between the Carpals in the hands.
• Saddle joints: These joints allow a greater range of movement than condyloid
joints, yet are similar in shape, the most well known example is at the base of the
thumb.

The ends of the bones in Synovial joints are shaped to fit each other in such a
way as to limit their movement in the directions required. Range and direction of
movement is aided and controlled by ligaments that attach the bones together. On the
surface of the bone is the Articular cartilage, which aids movement, and reduces wear
on the bone face. Surrounding the whole joint is the “Joint Capsule”. This contributes to
the control and stability of the joint, along with the ligaments. It is attached to the
periosteum, tough and stretch resistant. Within this capsule is the Synovial membrane
from which the joint gets its name. This secretes Synovial fluid into the joint, which aids
in reducing friction. Between tendons and bone, in certain joints, little pads known as
bursae can be found. These offer a “bridge” for the tendon to move over, reducing
friction and wear between the tendon and the bone itself.

As was mentioned in the description of the structure of the joint, the shape of fit
of the bones and the tendons restrict mobility of the joint to within required constraints.
There are a number of other factors that also affect the range of motion, or ROM, of a
joint. The most obvious restrictions are structural, bony protrusions around the joint, like
where the point of the elbow fouls the humerous, limiting its movement. The joint
structure itself, with the ligaments, joint capsule and face of bones.

Temperature plays a major role in ROM. Quite simply, the warmer the joint is,
the greater its ROM will be, this places great emphasis on doing a proper warm-up

1
before exercise. Stretching is important to athletes. This is because as muscles
become more and more trained, they tend to shorten slightly, thus restricting mobility.
However, good muscle structure also add to the stability of many joints, like the knee.
As we age, our body’s ability to function decreases. this includes flexibility. Older
people don’t have the same strength as the young.

Individual bone structure

Compact bone or (Cortical bone)

The hard outer layer of bones is composed of compact bone tissue, so-called
due to its minimal gaps and spaces. This tissue gives bones their smooth, white, and
solid appearance, and accounts for 80% of the total bone mass of an adult skeleton.
Compact bone may also be referred to as dense bone.

Trabecular bone

Filling the interior of the organ is the trabecular bone tissue (an open cell porous
network also called cancellous or spongy bone), which is composed of a network of rod-
and plate-like elements that make the overall organ lighter and allowing room for blood

1
vessels and marrow. Trabecular bone accounts for the remaining 20% of total bone
mass but has nearly ten times the surface area of compact bone.

Cellular structure

There are several types of cells constituting the bone;

• Osteoblasts are mononucleate bone-forming cells that descend from

osteoprogenitor cells. They are located on the surface of osteoid seams and
make a protein mixture known as osteoid, which mineralizes to become bone.
Osteoid is primarily composed of Type I collagen. Osteoblasts also manufacture
hormones, such as prostaglandins, to act on the bone itself. They robustly
produce alkaline phosphatase, an enzyme that has a role in the mineralisation of
bone, as well as many matrix proteins. Osteoblasts are the immature bone cells.

• Bone lining cells are essentially inactive osteoblasts. They cover all of the
available bone surface and function as a barrier for certain ions.
• Osteocytes originate from osteoblasts that have migrated into and become
trapped and surrounded by bone matrix that they themselves produce. The
spaces they occupy are known as lacunae. Osteocytes have many processes
that reach out to meet osteoblasts and other osteocytes probably for the
purposes of communication. Their functions include to varying degrees:
formation of bone, matrix maintenance and calcium homeostasis. They have also
been shown to act as mechano-sensory receptors—regulating the bone's
response to stress and mechanical load. They are mature bone cells.

• Osteoclasts are the cells responsible for bone resorption (remodeling of bone to
reduce its volume). Osteoclasts are large, multinucleated cells located on bone
surfaces in what are called Howship's lacunae or resorption pits. These lacunae,
or resorption pits, are left behind after the breakdown of the bone surface.
Because the osteoclasts are derived from a monocyte stem-cell lineage, they are
equipped with phagocytic like mechanisms similar to circulating macrophages.
Osteoclasts mature and/or migrate to discrete bone surfaces. Upon arrival, active
enzymes, such as tartrate resistant acid phosphatase, are secreted against the
mineral substrate.

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Formation

The formation of bone during the fetal stage of development occurs by two
processes: Intramembranous ossification and endochondral ossification.

Intramembranous ossification mainly occurs during formation of the flat bones of

the skull; the bone is formed from mesenchyme tissue. The steps in intramembranous
ossification are:

1. Development of ossification center

2. Calcification
3. Formation of trabeculae
4. Development of periosteum

Endochondrial ossification

Endochondral ossification, on the other hand, occurs in long bones, such as

limbs; the bone is formed from cartilage. The steps in endochondral ossification are:

1. Development of cartilage model

2. Growth of cartilage model
3. Development of the primary ossification center
4. Development of the secondary ossification center
5. Formation of articular cartilage and epiphyseal plate

Endochondral ossification begins with points in the cartilage called "primary

ossification centers." They mostly appear during fetal development, though a few short
bones begin their primary ossification after birth. They are responsible for the formation
of the diaphyses of long bones, short bones and certain parts of irregular bones.
Secondary ossification occurs after birth, and forms the epiphyses of long bones and the
extremities of irregular and flat bones. The diaphysis and both epiphyses of a long bone
are separated by a growing zone of cartilage (the epiphyseal plate). When the child
reaches skeletal maturity (18 to 25 years of age), all of the cartilage is replaced by bone,
fusing the diaphysis and both epiphyses together (epiphyseal closure).

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Bone marrow

Bone marrow can be found in almost any bone that holds cancellous tissue. In
newborns, all such bones are filled exclusively with red marrow , but as the child ages it
is mostly replaced by yellow, or fatty marrow. In adults, red marrow is mostly found in the
marrow bones of the femur, the ribs, the vertebrae and pelvic bones.

Remodeling

Remodeling or bone turnover is the process of resorption followed by

replacement of bone with little change in shape and occurs throughout a person's life.
Osteoblasts and osteoclasts, coupled together via paracrine cell signalling, are referred
to as bone remodeling units.

Purpose

The purpose of remodeling is to regulate calcium homeostasis, repair micro-

damaged bones (from everyday stress) but also to shape and sculpture the skeleton
during growth.

Calcium balance

The process of bone resorption by the osteoclasts releases stored calcium into
the systemic circulation and is an important process in regulating calcium balance. As
bone formation actively fixes circulating calcium in its mineral form, removing it from the
bloodstream, resorption actively unfixes it thereby increasing circulating calcium levels.
These processes occur in tandem at site-specific locations.

Repair

Repeated stress, such as weight-bearing exercise or bone healing, results in the

bone thickening at the points of maximum stress (Wolff's law). It has been hypothesized
that this is a result of bone's piezoelectric properties, which cause bone to generate
small electrical potentials under stress.[3]

1
 Pathophysiology

Definition: A fracture is a complete or incomplete break in a bone resulting from the

application of excessive force.

Predisposing factor Precipitating factor

Age (teen angers who are active on sports) Lifestyle (basketball player)
Gender (male) Slippery surface

Trauma

Skeletal instability Soft

tissue injury

Loss of weight support

Bleeding

Loss of attachment for muscle and ligaments

Joint motion disabled

Muscle contractions

Inflammatory response vasodilatation

Increased capillary permeability

Protein and granulocytes leak into tissue

Edema

Blood clots at injured sites

Granulation tissue invades clots

Reticuloendothelial cells remove debris

Calcium goes into solution

New capillaries grow into clot

New bone cells form

Callus formation

S/S: Initial dull pain, bruising, swelling

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 VI. Nursing Assessment (System Review & Nsg. Assessment II)

NURSING SYSTEM REVIEW CHART

NAME of PATIENT: Patient D Date: July 5, 2009
Pulse: 85 bpm BP: 110/70 mmhg Temp: 36.2 C Height: 5’6’ Weight: 135lbs

EENT:
[ X] Impaired Vision [ ] Blind [ ] Pain [ ] Reddened
[ ] Drainage [ ] Gums [ ] Hard of Hearing
[ ] Deaf [ ] Burning [ ] Edema [ ] Lesion
[ ] Teeth [ ] No P,roblem
- impaired vision, pt
Assess Eyes, Ears Nose, and Throat for Abnormalities. wears eye glasses

RESPIRATORY SYSTEM:
[ ] Asymmetric [ ] Tachypnea [ ] Apnea [ ] Rales - vomited in small
[ ] Cough [ ] Barrel Chest [ ] Bradypnea amount
[ ] Shallow [ ] Rhonchi [ ] Sputum [ ] Diminished [ ] Dyspnea
[ ] Orthopnea [ ] Labored [ ] Wheezing
[ ] Pain [ ] Cyanotic[X ] No Problem
Assess Resp. Rate, Rhythm, Depth, Pattern, - Skin is cold
Breath Sounds, and Comfort.

CARDIO VASCULAR:
[ ] Arrhythmia [ ] Tachycardia [ X ] Numbness
- Urinary catheter
[ ] Diminished Pulses [ ] Edema [ ] Fatigue [ ] Irregular in place – decreased
[ ] Bradycardia [ ] Murmur [ ] Tingling [ ] Absent Pulses urine output
[ ] Pain [ ] No Problem
Assess Heart Sounds, Rate, Rhythm, Pulse,
Blood Pressure, Circulation, Fluid Retention, and Comfort.
- Numbness on the
GASTRO - INTESTINAL TRACT:
[ ] Obese [ ] Distention [ ] Mass [ ] Dysphagea lower left extremity
[ ] Rigidly[ ] Pain [ X ] No Problem
Assess Abdomen, Bowel Habits, Swallowing, - Fracture on the
Bowel Sounds, and Comfort.
distal phallanx 3rd
GENITO - URINARY AND GYNE: digit right foot
[ ] Pain [ ] Urine Color [ ] Vaginal Bleeding
[ ] Hematuria [ ] Discharge [ ] Nocturia [X] No Problem
Assess Urine Frequency, Control, Color, - Confused and
Odor, Comfort, Gyne-Bleeding and Discharge. weak
NEURO:
[ ] Paralysis [ ] Stuporus [ ] Unsteady [ ] Seizures
[ ] Lethargic [ ] Comatose [ ] Vertigo [ ] Tremors
[X] Confused [ ] Vision [ ] Grip [ ] No Problem
Assess Motor Function, Sensation, LOC, Strength,
Grip, Gait, Coordination, Orientation and Speech. - IVF of D5LR 1L
@ 30gtts/min
MUSCULOSKELETAL and SKIN:
[ ] Appliance [ ] Stiffness [ ] Itching [ ] Petechiae [ ] Hot
[ ] Drainage [ ] Prosthesis [ ] Swelling [ ] Lesion
[ ] Poor Turgor [ X ] Cool [ ] Deformity [ ] Wound
[ ] Rash [ ] Skin Color [ ] Flushed [ ] Atrophy [ ] Pain
[ ] Ecchymosis [ ] Diaphoretic [ ] Moist [ ] No Problem
Assess Mobility, Motion, Gait, Alignment,
Joint Function, Skin Color, Texture, Turgor, and Integrity.

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 Place an (X) in the area of abnormality. Indicate the location of the problem in the figure if appropriate, using (X).
NURSING SYSTEM REVIEW CHART
NAME of PATIENT: Patient D Date: July 6, 2009
Pulse: 84bpm BP: 120/80 mmhg Temp: 37.1C Height: 5’8’’ Weight: 79 kg

EENT:
[X] Impaired Vision [ ] Blind [ ] Pain [ ] Reddened
[ ] Drainage [ ] Gums [ ] Hard of Hearing
[ ] Deaf [ ] Burning [ ] Edema [ ] Lesion
[ ] Teeth [ ] No P,roblem
Assess Eyes, Ears Nose, and Throat for Abnormalities.

RESPIRATORY SYSTEM:
[ ] Asymmetric [ ] Tachypnea [ ] Apnea [ ] Rales
[ ] Cough [ ] Barrel Chest [ ] Bradypnea
[ ] Shallow [ ] Rhonchi [ ] Sputum [ ] Diminished [ ] Dyspnea - Skin still cool
[ ] Orthopnea [ ] Labored [ ] Wheezing
[ ] Pain [ ] Cyanotic[X ] No Problem
Assess Resp. Rate, Rhythm, Depth, Pattern,
Breath Sounds, and Comfort.

CARDIO VASCULAR:
[ ] Arrhythmia [ ] Tachycardia [ ] Numbness Pain
[ ] Diminished Pulses [ ] Edema [ ] Fatigue [ ] Irregular
[ ] Bradycardia [ ] Murmur [ ] Tingling [ ] Absent Pulses
[ ] Pain [X] No Problem
Assess Heart Sounds, Rate, Rhythm, Pulse,
Blood Pressure, Circulation, Fluid Retention, and Comfort.

GASTRO - INTESTINAL TRACT:

[ ] Obese [ ] Distention [ ] Mass [ ] Dysphagea
[ ] Rigidly[ ] Pain [X] No Problem
Assess Abdomen, Bowel Habits, Swallowing,
Bowel Sounds, and Comfort.

GENITO - URINARY AND GYNE:

[ ] Pain [ ] Urine Color [ ] Vaginal Bleeding
[ ] Hematuria [ ] Discharge [ ] Nocturia [ X ] No Problem
Assess Urine Frequency, Control, Color,
Odor, Comfort, Gyne-Bleeding and Discharge.

NEURO:
[ ] Paralysis [ ] Stuporus [ ] Unsteady [ ] Seizures
[ ] Lethargic [ ] Comatose [ ] Vertigo [ ] Tremors
[ ] Confused [ ] Vision [ ] Grip [X] No Problem
Assess Motor Function, Sensation, LOC, Strength, - IVF of D5LR 1L
Grip, Gait, Coordination, Orientation and Speech.
@ 30 gtts/min
MUSCULOSKELETAL and SKIN:
[ ] Appliance [ ] Stiffness [ ] Itching [ ] Petechiae [ ] Hot
[ ] Drainage [ ] Prosthesis [ ] Swelling [ ] Lesion
[ ] Poor Turgor [ X ] Cool [ ] Deformity [ ] Wound
[ ] Rash [ ] Skin Color [ ] Flushed [ ] Atrophy [ ] Pain
[ ] Ecchymosis [ ] Diaphoretic [ ] Moist [ ] No Problem
Assess Mobility, Motion, Gait, Alignment,
Joint Function, Skin Color, Texture, Turgor, and Integrity.

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 Place an (X) in the area of abnormality. Indicate the location of the problem in the figure if appropriate, using (X).
NUSING ASSESSMENT 2

SUBJECTIVE OBJECTIVE
COMMUNICATION
[ ] hearing loss [X] glasses [ ]languages
Comments: “Naa koy daot sa
[X] visual changes [ ] contact lens [ ] hearing aide
akong mata, sukad pa grade 6
[ ]denied R L
ga-suot nako ug eye glass.”
Pupil size: 2-3 mm 2-3 mm
Reaction: Pupil equally round reactive to light and
accommodation
OXYGENATION:
[ ]dyspnea Resp. [X]regular [ ]irregular
Comments: “Wala man ko
[ ]smoking history Describe: difficulty in breathing with crackles
galisod ug ginhawa, wala pa
None sound
pud ko gapanigarilyo.”
[ ] cough
[ ]sputum R: symmetrical to the left side
[ ]denied L: symmetrical to the right side

CIRCULATION
Comments: “Murag Heart rhythm [X] regular [ ] irregular
[ ]chest pain giputlan kog tiil, dili
[ ] leg pain nako kayo mabati-an Carotid Radial Dorsal pedis femoral
[X] numbness of extremities akong tiil-kadtong R: 83 84 86 +
[ ] denied bag-o gi-operahan.” L: 80 83 84 +
Comments: Pulses are palpable and heart rhythm
is regular.

*if applicable
NUTRITION:
Diet: Diet as tolerated Comments: “Wala [ ]dentures [x]none
man na-usab ako
[ ] N [X] V timbang. Wa pud ko Full partial with patient
Character ga-lisod ug tulon.” Upper [] [] []
[ ] recent change in weight Lower [] [] []
and appetite
[ ] swallowing difficulty
[ ]denied
ELIMINATION
Bowel sounds: Audible bowel sounds – gargling
Usual bowel pattern urinary frequency sound
Once a day 2-3 times a day
[ ]constipation [ ]urgency Abdominal Distention
Remedies: NA [ ]dysuria Present [ ] yes [ ] No
Date of last BM [ ] hematuria Urine (color, consistency, odor)
July 5, 2009 [ ] incontinence yellowish color .
[ ] diarrhea [ ] polyuria
Character: [X] foly in place
Brown colored stool

MGT. OF HEALTH & ILLNESS: Briefly, describe the patient’s ability to follow
[ ] alcohol [X]denied treatments (diet, meds, etc.) for chronic health
none problems (if present).
The patient was able to follow strict

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[ ] SBE last Pap smear: NA compliance to the prescribed medication.
LMP: NA
SKIN INTEGRITY:
[ ] dry Comments: “man akong [ ] dry [X]cold [ ] pale
[ ] itching panit, tug-naw lang siya [ ] flushed [ ]warm [ ]moist [ ]cyanotic
[X]other kay tungod sa aircon”
[ ] denied *rashes, ulcers, decubitus (describe size, location,
drainage) : No rashes and ulcers noted

ACTIVITY/SAFETY:
[ ] convulsion [] LOC and Orientation: the client conscious and
[ ] dizziness Comments: “Dili oriented to time, place and person
[x] limited motion of joints pajud ko ka-lakaw, [ ] Gait [ ] walker [ ] care [X] others
Limitation in ability to dili pa pud ko ka-
[X] ambulate ligo nga ako ra [x] steady [ ] unsteady
[X] bathe self karon” [ ]Sensory and motor losses in face or extremities
[ ] other No problems observed in the patients sensory
[ ] denied and motor function

[ ] ROM limitations: The patient is on complete

bed rest at the moment but he could perform
ROM exercises of the shoulders and hands
COMFORT/SLEEP/AWAKE:
[ x] pain (location, Comments: “ galisod ko ug [x ] facial grimace
frequency, tulog, kai ga ngot-ngot man sa [x ] guarding
remedies) kasakit akong tiil” [ x] other signs of pain moaning
[ ] nocturia [ ] side rail release form signed (60 + years)
[x ] sleep difficulties NONE
[ ] denied

COPING:
None observable behavior: patient able to
Occupation: NA maintain eye to contact during assessment
Members of household: 5 members
Most supportive person: mother

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 VII. Nursing Management
a. Ideal Nursing Management

1. Impaired physical mobility related to fracture on the right distal phallanx 3rd digit.

Interventions Rationale

1. Maintain neutral positioning of hip.  Prevents stress at the site of fixation.

2. Use trochanter roll.  Minimizes external rotation.
3. Place pillow between legs when  Supports leg; prevent adduction
turning.  Encourages patient’s active
4. Instruct and assist in position participation while preventing stress on
changes and transfers. hip fixation.
5. Instruct in and supervise isometric,  Strengthens muscle needed for walking.
quadriceps-setting, and gluteal-
setting exercises.

2. Impaired skin integrity related to surgical incision

Goal: achieves timely wound healing

Interventions Rationale
1. Monitor vital signs  Temperature, pulse, and respiration
increase in response to infection.
(Magnitude of response may be
minimal in elderly patients.)
2. Perform aseptic dressing changes.  Avoids introducing infectious
organisms.
3. Assess wound appearance and  Red, swollen, draining incision is
character of drainage. indicative for infection.
4. Assess report of pain.  Pain may be due to wound
hematoma, possible locus of

2

5. Administer prophylactic antibiotic if
prescribed, and observe for side
effects.
3. Fluid volume deficit related to active fluid loss
Goal: maintain fluid volume at a functional level.
Interventions
1. Keep fluids within clients reach and
encourage frequent intake.
3. Control humidity and ambient air
temperature.
3. Maintain accurate I & O and weight
daily.
4. Administer medication (antiemetics) as
indicated.
5. Establish 24-hour fluid replacement
needs and routes to be used.
infection, which needs to be
surgically evacuated.
 Antibiotics reduce the risk for
infection.
Rationale
 To make fluids available for the
patient.
 To reduce elevated metabolic rate.
 To compare and monitor progress.
 To limit gastric losses
 Prevent peaks/ valleys in fluid level.
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 b. Actual Nursing Management

S “ Dili pako maka-kaya ug tindog kung dili ko tabangan, lisod pa ilakaw”

- Lethargy
- Decreased performance
O - Lack of energy

Fatigue related to poor physical condition as evidenced by fracture on the right

A distal phalanx.
At the end of 2 days, the client will be able to demonstrate measurable increase in
P physical activity.
1. Rest periods were given to the patient.
2. Head of bed was kept elevated.
I 3. Assisted during ambulation.
4. Assisted in Self Care.

At the end of 2 days the client was able to demonstrate measurable increase in
E physical activity.

S No available subjective data

- Inadequate primary defenses
O - Broken and traumatized tissue at the right foot
- Invasive procedure
Risk for infection related to tissue destruction as evidenced by a fracture on the
A right distal phalanx.
At the end of 30 minutes, the client will be able to identify interventions to reduce
P the risk of infections.
1. Both the client and the caregiver performed hand washing meticulously.
2. Emphasized limitations of visitors to the area.
I 3. Aseptic technique was properly maintained.
4. Encouraged to practice proper hygiene.
At the end of 30 minutes, the patient was able to understand and identify
E intervention to reduce infection.

2
S “Dili pa ko makalakaw ug tarong pero malihuk-lihok na naku akong tiil”, as
verbalized by the patient.
O  Slowed movement
 Limited range of motion at the lower extremities
 Gait changes
A Impaired physical mobility related to fractured on the right distal phallanx.

P Long term: At the end of 1 month, the client will be able to participate in
activities of daily living and desired activities.
Short term: At the end of 20 minutes, the client will be able to verbalize
understanding of situation and engage in therapeutic positioning.
I Independent:
1. The affected body part was supported by a pillow to keep it elevated.
2. Wound dressing was also done aseptically.
3. The client was encouraged to participate in self-care to enhance
sense of independence.
4. assisted in position changes and transfers.
Dependent:
5. The client was also advised to visit his physician for his follow-up check-
up.
E Short term: After 20 minutes the client was able verbalized understanding of
situation and engaged in therapeutic positioning.

S “Unsa na kaha ang itsura sa akong panit karon human og opera”, as

verbalized by the patient.
O  Surgical incision on the right foot
 Destruction of skin layers
 Cool skin
A Impaired skin integrity related to surgical incision on the right foot.

P Long term: At the end of 1 month, the clients wound will be able to display a
timely wound healing.

2
I Independent:
1. The area was kept clean and dry.
2. The area was kept elevated.
3. The client was encouraged to increase intake of protein for tissue
repair.
4. Encouraged for early ambulation and ROM exercises.
Dependent:
5. Wound dressing was also implemented.
E The goal was not properly evaluated due to time constraints.

VIII. Discharge planning

MEDICATION  The patient was instructed to religiously comply with his home
medications
Cefuroxime 500 g 1 tab BID PO
Meloxican 15 g 1 tab OD PO
EXERCISE Instructed to perform ROM exercises to enhance blood circulation.
Also, walking is advised with the use of crutches.
TREATMENT  Proper hygiene measures was also imparted
 Encouraged with adequate nutrition and rest.
 Encourage to elevate the foot to facilitate venous return to the heart

2
 OUT PATIENT  After discharged, client was instructed to return after 3 days to
the clinic for follow-up checkup, X-ray and physical exam
DIET Health teachings on DIET gave emphasis on:
 Increase intake of foods with calorie and calcium rich for bone
regeneration.
 Increase fluid intake appropriate for age at least 1500mL per
day
 Instructed to increase protein intake such as meat and fish for
tissue repair.

IX. Evaluation and Prognosis

As future professional health care providers, it is vital in our part to always see to
it that we have identified the health problem of our patient, which is significant in our
nursing field, somehow I were able to identify various nursing diagnosis and
implemented possible effective nursing care to our patient, which gave sense of
accomplishment in our part as student nurse. Eventually, we should be cautious at all
times in giving care to the patient and should always bear in mind that we are dealing
with life. And must always be compassionate and provide holistic approach.
This study will serve as a reference material in rendering competent care to our
client especially those with similar situation. Through this, we will be able to develop our
knowledge as well as our skills and attitudes in applying the prescribed procedure to
improve the health status of the patient.
This study will act as a baseline as well as a guide for coming up with a good,
reliable, accurate and comprehensive research paper dealing with issues commonly
experienced by patient in the hospital setting. This may aid the researchers to widen the
scope of the study in relation to more or less similar cases.
The case study paved way for researcher to identify and determine issues
related to bone fracture

3
 Bibliography

Kozier, Erb, Berman, Snyder, FUNDAMENTALS OF NURSING, 7th edition

published by Pearson Education Inc. Copyright 2004,

Wilson, Shannon, Stang, NURSES DRUG GUIDE 2004, Philippine edition

published by PEARSON EDUCATION SOUTH ASIA PTE LTD. Copyright
@ 2004, volume 1 & 2, pp.86- 89, 270- 271

Joyce Young Jonhson, R, PhD, Handbook for Brunner & Suddarth’s:

TEXTBOOK OF MEDICAL- SURGICAL NURSING, 19th edition copyright
@ 2004 by Lippincott Williams & Wilkins

Smeltzer, Bare, Brunner & Suddarth’s, TEXTBOOK OF MEDICAL –SURGICAL

NURSING, 10th edition, volume 1

Marilynn E. Doenges, RN, BSN, MA, CS, Mary Frances Moorhouse, RN, BSN,
CRRN, CLNC, NURSING CARE PLANS: Guidelines for Individualizing
Patient Care, 6 edition, copyright @2002 by F.A. Davis Company,
pp.304- 328