Global City Innovative College

College of Nursing and International Health Studies

CASE STUDY
MAXILLARY FRACTURE SECONDARY TO VEHICULAR ACCIDENT (MOTORCYCYLE)

Presented to: PSUPT Michelle Arban RN, MAN Presented by: BSN-416 Group D2 Tabingo, Ma, Leona Angela P. Talledo, Amor Marie E. Tauro, Akhiro S. Tolledo, John Ralph S. Yanto, Czarina Marie S.

August 11, 2010 Philippine National Police General Hospital (PNPGH)

/jrst2010/

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Table of Contents
Introduction -Yanto, Czarina Marie S. • General Objectives -Yanto, Czarina Marie S. • Nursing History -Tabingo, Ma, Leona Angela P. • Physical Assessment -Tabingo, Ma, Leona Angela P. • Anatomy and Physiology -Tauro, Akhiro S. • Pathophysiology of the Disease -Tolledo, John Ralph S. Laboratory Examinations/ Diagnostic Procedures -Tauro, Akhiro S. • Course in the ward -Tolledo, John Ralph S. • Nursing Care Plan -Yanto, Czarina Marie S. • Drug Study -Talledo, Amor Marie E. •

INTRODUCTION
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Tripod Fracture is a facial fracture involving the three supports of the malar prominence, the arch of the zygomatic bone, the zygomatic process of the frontal bone, and the zygomatic process of the maxillary bone. The zygoma makes up a large portion of the lateral orbital wall and floor. Fractures are important as they can alter orbital volume. The facial bones form 4 transverse and 4 paired vertical buttresses which support facial function and define the form of the face. Zygomaticomaxillary complex fractures involve the upper transverse maxillary (along the zygomaticotemporal suture and zygomaticomaxillary suture) and the lateral vertical maxillary buttress (along the zygomaticomaxillary and zygomaticofrontal sutures). ZMC fractures usually involve all three of the sutures allowing for the term “tripod” fractures. Tripod fractures or zygomaticomaxillary complex fractures are the second most common type of fracture on the skull which it is about 40% of all facial fracture. It has a much higher percentage of tripod fracture in males(80%) than in women 20%) and majority of them ages 20-30 years old due to their lifestyle. The leading cause of tripod fracture is vehicular accidents, which is about 70% of all case. Tripod fracture is so called because of separation of three major attachments of the zygoma to the rest of the face. It is caused usually by a direct blow to the body of zygoma which makes up a large portion of the lateral orbital wall and floor. The zygomaticomaxillary complex (ZMC) plays a key role in the structure, function, and aesthetic appearance of the facial skeleton. It provides normal cheek contour and separates the orbital contents from the temporal fossa and the maxillary sinus. This fracture will generally cause contour abnormalities of all three of the lines of Dolan. It also has a role in vision and mastication. The ZMC provides lateral globe support necessary for binocular vision. The zygomatic arch is the insertion site for the masseter muscle and protects the temporalis muscle and the coronoid process. The patient in this study underwent vehicular accident (motorcycle) that’s why he has suffered from Tripod Fracture. Open Reduction Internal Fixation was the procedure performed to him. According to the Knight and North classification nationwide, Among 70 patients with tripod fractures, 14 patients (20%) underwent 1-point fixation technique through lateral brow incisions. Preoperative and postoperative displacements of the infraorbital rim were radiologically measured. Of these patients, 7 cases (50%) were type III, 6 cases (43%) were type IV, and 1 case (7%) was type V Simple fracture of the infraorbital rim was seen in 10 patients (71%), and comminuted fracture was seen in 4 patients (29%). In 11 patients, zygomaticofrontal sutures were fixed with square microplates with 4 holes and 0.5 mm in thickness, and straight miniplates with 4 holes and 1.0 mm in thickness were used in 3 patients. Of 14 tripod fractures, 6 (43%) were associated with floor fractures. Seven had displacement of the infraorbital rim (range, 2.0-7.6 mm; mean, 4.6 ± 0.8 mm), and the other 7 had no displacement of the infraorbital rim. After surgery, step deformities of the infraorbital rims were improved (range, 0.1-3.8 mm; mean, 1.4 ± 0.5 mm). All 14 patients were satisfied with their postoperative appearance. Indications for using 1-point fixation of the tripod fracture are (1) minimal or moderate displacement of the infraorbital rim in the tripod fracture of the zygoma, (2) no ocular signs of diplopia or enophthalmos, and (3) comminuted infraorbital rim fractures where internal fixation is difficult. Signs and symptoms of experienced by the patient

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Therapeutic interventions include application of local cold packs. Fig. An ophthalmic examination may be required to rule out extensive intraocular trauma (eg. palpating the infraorbital fracture. optic nerve injuries. observing the patient demonstrate limited eye movement in the upward gaze. 1: Illustration showing the fracture of our patient 4 .* Hematoma * Abbrasion * Decreased ocular movement. the fractured side will appear flat). and noting swelling in the injured area. administration of regional anesthesia for pain. and * Edema Zygomatic fractures are diagnosed clinically by looking down at the patient's face from above and behind (ie. Surgeons also examine the patient for evidence of a CSF leak caused by a fractured cribriform plate. and open or closed reduction of die fracture site. eyelid. or global lacerations). lacrimal.

the group wanted to add additional information and knowledge regarding the case as well as enhancing their skills in proper nursing care for their future patients. 5 .Reason for Studying: The group chose this case Tripod Fracture because it is new in their vocabulary and as a students and learners.

OBJECTIVES General Objective: This case presentation aims to identify and determine the general heath problems and needs of the patient with an admitting diagnosis of Tripod Fracture. • • 6 . Affective: o Help patient in motivating him to continue the health care provided by health workers o Help the patient to recover from the disease. o To gain knowledge about zygomaticomaxilly complex fracture Psychomotor: o Recognize skill appropriate to nursing responsibilities for tripod fracture patient o Render nursing care through proper application of nursing intervention to patient with tripod fracture o To learn how to manage and take care of patients with tripod fracture. to: • Cognitive: o Identify different types of diagnostic procedures and medical management necessary for treatment of tripod fracture o Trace the pathophysiology of tripod fracture based on signs and symptoms manifested by patient o Determine the action of drugs used on tripod fracture. the group formulated their specific objectives as follows. This presentation also intends to help patient promote health and medical understanding of such condition through the application of the nursing skills Specific Objectives: In line with our general objective. o Give health education to patient.

alert and grimace does not show pain 7 . Rinconada Educational Attainment: College Graduate Occupation: Police officer Father: RL Mother: LL Sex: Male Birthday: September 6.Nursing History Patient’s Profile Source of Information: Patient himself Name: RL Place of Birth: Camarines Sur Address: Camarines Sur Civil Status: Married Nationality: Filipino Religion: Roman Catholic Dialect: Tagalog. 2010 Time of Admission: 9:30 am Place of Admission: Philippine National Police General Hospital Mode of Admission: Ambulatory Accompanying Person: Mother Chief Complaint: Maxillary fracture related to Vehicular Accident Admitting Diagnosis: Maxillary fracture Left secondary to Vehicular accident (Motorcycle) General Survey: Patient was awake. 1983 Age: 26 years old Initial Data on Admission Date of Admission: July 17.

He noticed that his gums got injured. RL. OPV and measles. during that time was wearing a regular helmet. He immediately received first aid care.Initial Vital Signs: Temperature: 36. RL’s partner brought him in the tricycle station and asked the driver to bring him to Iriga City Lourdes Hospital.2 C Respiratory Rate: 20cpm Pulse Rate: 89bpm Blood pressure: 140/100mmHg History of Present Illness Two weeks before the admission. This resulted him to dodge his motorcycle against the stray dog. They are 3 in the family. While on their way. they came to pass a dark intersection in which he barely saw a stray dog crossing. HEPA B. RL and his partner was called by their senior officer to report on duty around 11:00 pm. especially his mother. Both of his parents have history of hypertension. Psycho-social Data RL fully understands why he was in the hospital and he also understands what his condition was vehicular accident that’s why he was injured. He has a 2 month old baby boy. His mother and his family serve as support systems for him. He lives by himself since his wife’s job is assigned far from their home. Past Medical History RL never experienced hospitalization due to any accidents or injury. His attending physician advised him to seek medical care from other institution since they lack advance medical equipments so he went to PNPGH to seek 2nd opinion about his condition. They rode separate motorcycles going to work. DPT. 8 . she was the one who attend to the needs of RL. He had immunizations for BCG. and for three days he was having epistaxis. but upon dodging his face hit the speedometer. He was also given anti tetanus serum as a prophylaxis and pain relievers during that time. Family History The type of family that they have is Nuclear.

with his eyesight nor with his memory capacity. His wife used to take contraceptive pills 9 During Hospitalization He knows that he will recover soon from the operation. 3. He still has strong faith to God Analysis & Interpretation Patient shows positive attitude towards his condition this may lead to faster recovery 2. He is a good son to his parents and a good sibling to his brothers and sisters He doesn’t have any problem with hearing. RL says that he is happily married to his wife of 10 months and that he is a loving father 2 month old son. he 4. They ask existential questions. with his eyesight nor with his memory capacity His sex life is not active for a month He is very eager to go back to his normal life. LL. He was delivered via NSD in a hospital and there was no feto-maternal complication. Role Perception He says he cannot attend to his responsibilities at home since he’s in the hospital but still hoping for fast recovery to go back to his job and family He still doesn’t have any problem with hearing. and at this age they form an identity as an adult in the family and in the work world. young adults think about partnering with another person for a long-term relationship. Sexuality reproductive .Birth/Developmental History RL was born to a G8P8 mother with a regular prenatal check up to a health center. At the age of 26 he is considered as a young adult. Gordon’s Functional Pattern of Health Care Patterns of Health 1. RL was the fourth child among the siblings of Mr. Cognitive Perceptual Pattern This will help him not to totally change his perception about his self since after the accident He’s willing to wait for his wife. He has strong faith to God and has a positive will in almost every aspects of his life. RL & Ms. Self Perception Prior to hospitalization He lives by himself since his wife’s job from their home.

Value Belief Pattern He believes in God. or sometimes he watches TV or a movie Because he’s in the hospital he cannot drink anymore. Rest and Activity Pattern Sleeps 6 hours when he doesn’t have any duty but sleeps 4 hours when he’s on duty. He values his religion This can promote faster recovery 7. He eats 3 vegetables. He doesn’t have any difficulty in urinating or defecating His operation affected his elimination pattern but was relieved by applying warm & cold compress and by eating high fiber diet 8. His nap takes 3 hours. Coping Stress Tolerance Pattern Whenever he’s under stress he goes out with friends to drink. Elimination Pattern He defecates at least 2 times a day and urinates at least 2 times a day. Having a little difficulty in sleeping position because he is being cautious with his face lesions 6. He eats 3 times a day and times a day and He eats a balanced diet. now since he is hospitalized but he’s fine with it. He still values his religion The first few hours after the operation he had difficulty in urinating and defecating but was relieved through warm and cold compress and by eating foods high in fiber Sleeps 8 hours a day and naps about 3 hours. Rest is very essential for faster recovery 9. Nothing much has changed with his sleeping pattern. He just talks to his mom or to his fellow patients when he feels stress He still believes in God. This will promote faster recovery 5. and then stopped up until now. His viand is His viand is consisting of meat and consisting of meat and vegetables. Eats balanced diet.before their marriage. Nutritional – Metabollic Pattern Eats balanced diet. This will help him feel comfortable with his hospitalization since 10 . perceives that sex can wait and he can divert his interest into other activities Even if he’s in the hospital he still finds ways of how to cope up with stress.

Activity and Exercise Pattern His work is in lined with exercise. He doesn’t have any soap preference snacks 2 times a day. 5 months prior to hospitalization he had to have a tooth pasta. Hygiene and Comfort He takes a bath about 2 times a day. more than 10 glasses of water his preference of food didn’t totally changed’ He takes a bath once a He’s comfortable with day with the the pattern of bathing assistance of his he has. He doesn’t have time for exercise since lesions are still present. His snacks are consisting of pancit and banancue. mother 11. more than 10 glasses of water and 1 cup of coffee each day. Doesn’t take any vitamins or supplements. He drinks 2 glasses of juice. Health Perception and Health management Experienced hospitalization because of the accident He’s prone to other diseases since he does not take any vitamins or supplements Nurse’s Impressions of client Patient was awake. 10. He jogs 2 times a week for about 2 hours and occasionally plays basketball for about an hour. This might slow his metabolic rate since under hospitalization 12. He drinks 2 glasses of juice. alert and grimace does not manifest pain Finding’s Significant to Nursing Care: 11 .snacks 2 times a day. Doesn’t have any past medical.

Physical Assessment Date Assessed: August 9. pallor. tissue destruction and invasive materials introduced to the patients’ affected part. due to accident Has normal skin in the lower turgor. no ulcer. AREA ASSESSED SKIN METHOD OF NORMAL EXAMINATION FINDINGS Inspection >Color: depends on Palpation race. jaundice. Patient shows an abrasion on his right & left upper extremities. soft. no leision. erythema. rashes >Texture: smooth. 2010 Time Assessed: 4:00 pm Initial Vital Signs: Temperature: 37 C Pulse Rate: 85bpm Respiratory Rate: 17cpm Blood pressure: 140/100mmHg General Survey: The patient is awake. scar. slightly rough with presence of scars 12 . Patient has bandage placed over and around his head. Hypothermia related to trauma and exposure to cool environment as manifested by shivering. with D5LR at 30 gtts/min hooked at his left hand. extremities & upper extremities >Soft. Facial grimace shows blunt affect and he is cooperative. petichiae. papule.Maxillary Fracture related to vehicular accident Nursing Diagnosis: 1. Impaired Skin Integrity related to destruction of skin layers or tissues as evidenced by disruption of skin surface and invasion of affected body structure. Risk for Infection related to inadequate primary defenses as evidenced by traumatized tissue. 2. body temperature below normal range and cool skin 3. macule ACTUAL ANALYISIS AND FINDINGS INTERPRETATION >Brown Skin shows presence presence of of lesions and scars scars & lesions due to the accident. whitish pink to a brown shade to black No cyanosis. sitting on the chair beside the bed. Left part of the face has grade 1 edema.

slightly curved with edema on upward left eyelid. Patient has to be extra cautious on his upper part of his head due to the sutures after the operation Vision and other parts of the eye is not affected by the sugery but still feels pain on the lower part of the left eye due to suture 13 . distributed Evenly distributed >Black. not dry >Temperature: Warm to touch >Color: Pinkish >Shape: Convex curvature >Texture: Smooth >Capillary Refill: 2-3 seconds >Color: Depends on race. nodules. depression >No pain upon palpation >Normal turgor skin >Moist and not dry >Warm to touch >Pinkish >Convex curvature >Smooth >2 seconds >Black >Evenly distributed >Thick Normal nails upon inspection and palpation Has normal distribution and texture of hair EYES Inspection Palpation >Neither brittle nor dry >Round. Symmetrical. evenly black(varies). black.NAIL Inspection Palpation HAIR Inspection HEAD Inspection Palpation >Turgor: skins snaps back immediately when pinched >Moisture: moist. black. round. brown. fontanelles are closed >No mass. burgundy >Distribution: Evenly distributed. >No Ptosis. curved >Eyelashes: upward black(varies). coarse or smooth >Moisture: neither brittle nor dry >Normocephalic. nodules >Presence of pain pain due to suture >Face is >Face is symmetrical asymmetrical due to left side edema >Symmetrical >Symmetrical >Eyebrows: >Symmetrical. fontanelles are closed >No palpable mass. no sign of alopecia >Texture: thick or thin.

parallel. no visible materials >grayish Black. covers the whole eye. >Pupil: Equally round. with discoloration. parallel with the symmetrical eyes >Same color with >Brown the complexion >Auricles has firm >Auricles has cartilage firm cartilage >No redness of >No redness of Ears are normal upon inspection and palpation. There’s no presence of lesion and no erythema With normal discharges as well 14 .>Eyelids: Covers small part of the eye when open. equally round. No Ptosis unequal coverage of eyeballs due to edema >Conjunctiva: pink >Pink palpebral and moist conjunctiva >Cornea: Transparent smooth >Transparent and and smooth >Sclera: white. no visible materials. reactive to light accommodation (PERRLA) >grayish black. no minute foreign matter capillaries >Iris: brown (varies). no presence of pigmentation. reactive to light accommodation >Visual Acuity: >20/20 Vision Clear vision >Eyes move freely >Ocular >Presence of movement: Eyes suture under the moves freely left eye EARS Inspection Palpation >Bean shaped. >Bean shaped. no >White.

pearly pearly gray gray >Hearing acuity: >Able to hear Able to hear clearly clearly NOSE SINUSES & Inspection Palpation >Nose in middle symmetrical the >In the midline Presence of tenderness and and on the left sinuses due symmetrical to swelling. >No discharges >No nasal flaring >Both nares are patent >No discharges >No nasal flaring >Both nares are patent >No bone and >No bone and cartilage deviation cartilage deviation >No tenderness >Presence of upon palpation tenderness upon palpation >Nasal septum is in >Nasal septum the midline is in the midline >Nasal mucosa is pink >No tenderness and swelling of the paranasal sinuses >Nasal mucosa pink >Presence of tenderness and swelling of left 15 . membrane: flat. translucent.earlobes >No lesion >No tenderness upon palpation of auricles and mastoid process earlobes >No lesion >No tenderness upon palpation of auricles and no tenderness on the mastoid process >No discharges or >No discharges lesion on ear canal or lesion on ear canal >Some cerumen >Presence of may be present cerumen >Tympanic >Flat. transluscent.

pinkish. moist >Gums: pinkish. no lesion inspect since patient is having a hard time to open his mouth >Tonsils: pinkish. white to yellowish in color. > with pain and no swelling tenderness upon palpation. > wasn’t able to no lesion. moist >Tongue: Pinkish. No edema. pinkish.MOUTH Inspection >Lips: symmetrical. no edema >wasn’t able to inspect since patient is having a hard time to open his mouth > wasn’t able to inspect since patient is having a hard time to open his mouth >wasn’t able to inspect since patient is having a hard time to open his mouth The patient has difficulty in opening his mouth due to the surgery >Buccal mucosa. > wasn’t able to pinkish. of teeth: 28. hard and soft palate: Pinkish. does not move freely >Mandible: Moves smoothly. no pain and tenderness upon palpation >In the midline >In the midline The client has limited >No visible masses >No visible range of motion since or lumps masses or lumps he has to be very extra NECK Inspection Palpation 16 . no dental carries sinuses >Moist. no receding gums. moves patient is having freely a hard time to open his mouth >Uvula: midline. no swelling >Teeth: no. in the inspect since midline. no gum bleeding.

wheezing. scoliosis. and auscultation 17 . tachypnea. No signs of inspection Normal upon inspection. scoliosis. tachypnea & bradypnea >No retractions >No adventitious breath sounds >PR: 75bpm >No tachycardia and bradycardia >No dysrhythmia >No lift or heaves >No heart murmurs All lymph nodes are normal upon inspection and palpation. lordosis >Respiratory Rate: 12 – 25 cpm >No dyspnea. lordosis >RR: 17cpm >No dyspnea. palpation. stridor) >Pulse Rate: 75 – 120 bpm >No tachycardia and bradycardia >No dysrhythmia >No lift or heaves >No heart murmurs >Brown >Symmetrical >No kyphosis. percussion and auscultation HEART Inspection Palpation Auscultation Normal upon inspection.>No tenderness >No tenderness upon palpation upon palpation >Trachea is in the >Trachea is midline palpable and in the midline >Moves freely >Moves freely >ROM: Full range >ROM: there’ a limited range of motion due to surgery >Not palpable >Not palpable >Non tender >Non tender cautious with the sutures on his head LYMPHNODE Inspection Palpation THORAX LUNGS & Inspection Palpation Percussion Auscultation >Same as skin color >Symmetrical >No kyphosis. palpation. bradypnea >No retractions >No adventitious breath sounds (crackles.

no of motion crepitus >Oriented with >Oriented with Upon inspection. no areas of of lesion and tenderness abrasion on upper and lower extremities Warm to touch >Warm to touch >ROM: moves >ROM: there is freely. percussion and auscultation Normal upon inspection Upon inspection. with time. rounded >No tenderness upon palpation >Audible. place situation. friction >No bruit. patient is well oriented situation person.ABDOMEN Inspection Auscultation Palpation Percussion >Same as skin color >No lesion >Flat. situation. moves in no limited range full range. soft gurgling sound (5 gurgling sound to 20 seconds) >No bruit. abrasion and scars are present. soft. instructions and follow commands instructions and commands 18 . palpation. can very cooperative. rounded >No tenderness upon palpation GENITORECTAL Inspection URINARY EXTREMITIES Inspection Palpation >Same as skin color >Presence of scars >Flat. NEUROLOGIC SYSTEM Inspection >No lesion. no hematuria. rubs friction rubs ion >Urinary: no >Urinary: no hematuria. These are mostly caused by the motorcycle accidents. soft >Audible. no difficulty urinating. no urinary nocturia and incontinence urinary incontinence >Whitish pink to a >Brown brown shade to black >Equal on both >Equal on both sides sides >Hair evenly >Hair evenly distributed distributed Normal upon inspection. presence of lesion. place. person. time. place. >with presence masses. can follow >Alert. Alert and >Alert. lump. time. soft. difficulty no nocturia and urinating.

The axial skeleton transmits the weight from the head. anchors muscles. which is located in the neck and serves as the point of attachment for the tongue. does not articulate with any other bones in the body. The biggest bone in the body is the femur in the upper leg. Most of the body weight is located in back of the spinal column which therefore has the erectors spinae muscles and a large amount of ligaments attached to it resulting in the curved shape of the spine.>Makes eye contact with the examiner >Cranial nerves are intact >Makes eye contact with the examiner >Cranial nerves are all intact Anatomy and Physiology Anatomy and physiology The skeletal system The human skeleton consists of both fused and individual bones supported and supplemented by ligaments. and protects organs such as the brain. the trunk. being supported by muscles and ligaments. lungs and heart. The hyoid bone. and the upper extremities down to the lower extremities at the hip joints. Axial skeleton The axial skeleton (80 bones) is formed by the vertebral column (26). It serves as a scaffold which supports organs. Conclusive research cited by the American Society for Bone Mineral Research (ASBMR) demonstrates that weight-bearing exercise stimulates bone growthOnly the 19 . The 366 skeletal muscles acting on the axial skeleton position the spine. and the head. and the skull (22 bones and 7 associated bones). Not all bones are interconnected directly: There are three bones in each middle ear called the ossicles that articulate only with each other. and the smallest is the stapes bone in the middle ear. tendons. the thoracic cage (12 pairs of ribs and the sternum). the skeleton comprises around 14% of the total body weight. allowing for big movements in the thoracic cage for breathing. and is therefore responsible for the upright position of the human body. muscles and cartilage. Fused bones include those of the pelvis and the cranium. and half of this weight is water. In an adult.

where the lower margins of the orbits and the upper borders of the ear canals are all in a horizontal plane. this does not always equate to a natural posture in life. supporting the tongue. However. they have little in common with each other. or the system of membranes which envelops the central nervous system. one occipital bone. The Human skull The adult skull is normally made up of 22 bones. 20 . Their functions are to make locomotion possible and to protect the major organs of locomotion. as it does not articulate with any other bones. which are air-filled cavities lined with respiratory epithelium. the upper limbs (60). Except for the mandible. the skulls of other species. and reproduction. This is the position where the subject is standing and looking directly forward. The exact functions of the sinuses are unclear. but is also unexpectedly light. or they may be important in improving the resonance of the voice. The skull is a protector of the brain. to form an attachment for muscles of the neck and trunk. The hyoid bone. Appendicular skeleton The appendicular skeleton (126 bones) is formed by the pectoral girdles (4). Non weight-bearing activity. the comparatively small brain-case is surrounded by large sinuses which reduce the weight. a protective vault surrounding the brain. is usually not considered as part of the skull either. Encased within the temporal bones are the six ear ossicles of the middle ears. the sinuses are extensive. the arachnoid mater and the pia mater. Other than being classified together. has no effect on bone growth. They are known as the dura mater. Eight bones — including one frontal. For comparison. the bones supporting the face. In humans. are the three membranes which surround the structures of the nervous system. which also lines the large airways. The skull contains the sinus cavities. Fourteen bones form the splanchnocranium. may sometimes be studied in the Frankfurt plane. the pelvic girdle (2). The elephant skull needs to be very large. all of the bones of the skull are joined together by sutures. In some animals. and the lower limbs (60). notably primates and hominids. two parietals. digestion. including swimming and cycling. excretion. one sphenoid. they may contribute to decreasing the weight of the skull with a minimal decrease in strength.parts of the skeleton that are directly affected by the exercise will benefit. the anatomical position for the skull is the Frankfurt plane. rigid articulations permitting very little movement. The meninges. such as the elephant. though these are not part of the skull. two temporals and one ethmoid — form the neurocranium (braincase).

which are attached to the skeleton at various sites on bones. and provide attachment points for the muscles that produce facial expressions. form the prominences of the cheeks and part of the lateral margins of the orbits. e. The mandible. Movement The joints between bones permit movement. Two lacrimal bones form part of the medial wall of each orbit. the only skull bone that is able to move.g. Two maxillae form the upper jaw. form openings for the passage of food. water. and provides anchorage for the 16 lower teeth. Functions: Support The skeleton provides the framework which supports the body and maintains its shape. and link all other facial bones apart from the mandible (lower jaw). some allowing a wider range of movement than others.Facial bones The 14 (mainly 7 on each side) facial bones form the framework of the face. and the intercostal muscles the lungs would collapse. Two zygomatic bones (cheekbones). contain sockets for the 16 upper teeth. and vision. Two inferior nasal conchae form part of the lateral wall of the nasal cavity. taste. Without the ribs. Movement is powered by skeletal muscles. provide cavities for the sense organs of smell. articulates with the temporal bone allowing the mouth to open and close. and joints provide the principal mechanics for movement. anchor the teeth. Two nasal bones form the bridge of the nose. bones. all coordinated by the nervous system. Two palatine bones from the posterior side walls of the nasal cavity and posterior part of the hard palate. and air. 21 . the ball and socket joint allows a greater range of movement than the pivot joint at the neck. The pelvis and associated ligaments and muscles provide a floor for the pelvic structures. Muscles. The vomer forms part of the nasal septum. costal cartilages.

However. spine. bones are not entirely made of calcium. The ilium and spine protect the digestive and urogenital systems and the hip. The vertebrae protect the spinal cord. and sternum protect the lungs. 22 . The carpals and tarsals protect the wrist and ankle respectively. Storage Bone matrix can store calcium and is involved in calcium metabolism.Protection The skeleton protects many vital organs: • • • • • • • The skull protects the brain. in addition to boosting the number of insulin-producing cells and reducing stores of fat. The clavicle and scapula protect the shoulder. and the middle and inner ears. Blood cell production The skeleton is the site of haematopoiesis. which contributes to the regulation of blood sugar (glucose) and fat deposition. The rib cage.but a mixture of chondroitin sulfate and hydroxyapatite. the latter making up 70% of a bone. Marrow is found in the center of long bones. Endocrine regulation Bone cells release a hormone called osteocalcin. the eyes. which takes place in red bone marrow. The patella and the ulna protect the knee and the elbow respectively. and bone marrow can store iron in ferritin and is involved in iron metabolism. heart and major blood vessels. Osteocalcin increases both the insulin secretion and sensitivity.

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Modifiable Factors . -CT Scan of the Facial Bones -X-ray -Blood test (CBC) 24 Management: Surgery ORIF.Nutritional Status -Activity/ Stress -Occupation PATHOPHYSIOLOGY Trauma /Accident Non-modifiable Factors -Age -Gender -Genetics Break in the continuity of the bone Destruction of organic & inorganic matters Nerve function at the site of the fracture temporarily lost Numbness Surrounding muscles become flaccid Outcome if surgery is not performed Continuous bleeding Shock Fractured bone reduced Muscle spasm & contractions of the surrounding muscles Facial Pain Death Poor Circulation Tripod Fracture Signs & Symptoms: -Epistaxis -Facial Pain -Facial swelling -Loss of facial sensation Outcome upon Surgery Loss of blood to the bone Bone tissue dies Bone will collapse Cyanosis Pallor -Maxillary Fracture will be manage -Bone put back into place -Internal fixation device helps to hold bone together Bone Necrosis Diagnostic Exam.Open Reduction & Internal Fixation .

68 0.53 0.34-0.05 Bleeding time: 1min & 45seconds Clotting time:4 mins and 15 seconds Blood type: “B+” 25 .Laboratory Examination & Diagnostic Procedure Regaspi.40 7.40-0.36 0.05-0.51 4.01-0. normal 139.3 Differential Count results 0.07 result Analysis interpretation normal normal normal Analysis interpretation normal normal A low number of monocytes in the blood (monocytopenia) can occur in response to the release of toxins into the blood by certain types of bacteria (endotoxemia).59 0.02 Reference range Segmenters Lymphocytes Monocytes 0. Rolando Male July 19.22-0. as well as in people receiving chemotherapy or corticosteroids.0 0.07 0.23-9.12 Eosinophils Stab Basophil 0. 2010 HEMATOLOGY Complete Blood Count reference ranges Hemoglobin Hematocrit Wbc count 137-175 0.

left . result/s verified. Soft tissue contusion at the left cheek area with mucosal thickening in the left maxillary sinus The optic globes. Mid zygomatic arch with minimal depression.20sec Analysis interpretation normal normal PROTHROMBIN TIME Reference Range Result PT patient PT control % Activity INR 10.13.32 Result 31. 26 . specimen sent to lab.31.10 12. nasal bones. lens. The inferior rectus is minimally thickened.Seen and examined this date by Pedro A. 2010 CT scan of the Facial Bones Multiple plain axial images reveal the ff findings: Anterior and Lateral walls of the left maxillary sinus with moderate to severe depression Inferior orbital rim and anterior orbital floor with minimal depression. maxilla and mandibles are intact.July 19.D July 19. Nacional M.14 11.0. optic nerves and rest of the extraocular muscles are intact The rest of the orbits.30 11.30 26. 2010 Physically Examined Impression/ Dx: (+) fracture maxilla.10sec 32. 2010 HEMATOLOGY Partial thromboplastin Reference Range PTT patient PTT Control 25.44. Tuesday July 13.28.80 % Analysis interpretation normal normal Note: Specimen rechecked. paranasal sinuses.32.

preoperative checklist rechecked at OR suite and placed patient comfortable at OR >Latest Blood pressure 90/60mmHg.COURSE IN THE WARD Date & Shift August 2. 27 Management to Patient Patient Response >Patient follows the instructions given by the nurse >Patient was already informed with regards the operation > Patient follows the instructions given by the nurse >Patient doing a deep breathing exercise >Patient has a sign of improvement >Patient chills due to the effect of anesthesia . Pulse Rate 82bpm. 2010 3:00-11:00pm 1500H >For OR tomorrow morning under general anesthesia >OR and anesthesia materials completed tracium (atracium) 3 pcs. Blood pressure of 110/80 mmHg >Consent and request for surgery secured. For delivery tomorrow morning by ORIF 1600H >NPO post midnight >Routine oral and body hygiene prior to OR >IVF D5LR to run at 30gtts/min >Pre-meds at OR August 03. 2010 7:00am-3:00pm 0700H >received by stretcher with IVF of D5LR 1 liter infusing well at the right hand.

transfer via stretcher 1645H >Monitoring of V/S q15 until stable >Monitoring of I &O and record every shift >With O2 inhalation at 2-3Lpm via nasal cannula for 2 hours >Suction secretion as necessary >Encourage patient deep breathing exercise >IVF to follow D5LR to run at 30gtts/min >Medication: -Ketorolac -Tramadol -Ceftriaxone >Remove foley catheter tomorrow 6:00am 3:00-11:00pm 1740H >In from OR status post ORIF under GA per stretcher. patient head is packed with dressing and elastic roller bandage. with 02 inhalation via nasal cannula at 2 Lpm. with ongoing IVF D5LR at 600cc level Regulated at 30gtts/min infusing well. afebrile >Vital signs BP=140/90mmHg P=86bpm R=16cpm >Patient keep comfortable in bed >Patient is stable 28 .

2010 7:00am-3:00pm 1030H >May have DAT >May sit on bed >May ambulate >Patient shows signs of recovery >Patient vomits two times >Patient flat on bed >Patient keep comfortable and rested 29 .>Skin testing done of Ceftriaxone 2000H >02 inhalation removed >Vital signs monitored q15 2100H >Tramadol 100mg TIV Negative result for skin test 2200H >Ceftriaxone 1gram through slow IV push August 04.

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