Running Head: NURSING CASE STUDY/BONE FRACTURE DIP/2017/00451 1

Nursing Case Study:

A Patient with a Case of Closed Comminuted Distal Tibial Fracture (Rt.) with 1/3rd Distal Fibular Fracture, Plafond Fracture of the Right

Tibia and L1 Burst Fracture

Kinley Dorji (DIP/2017/00451)

GNM 2nd Year, 2st Semester

Faculty of Nursing and Public Health

NURSING CASE STUDY/BONE FRACTURE DIP/2017/00451 2

Registration Number: DIP/2017/00451

Category: GNM 2nd Year, 2nd Semester

Ward/Unit: Orthopedic Ward

Period of Placement: 9th-23rd March, 2019

Date of Planning of Care/Examination: 18th March, 2019

General Objectives: Enable students to understand principles and applications of the nursing process; by developing
skills in complete health assessment, planning, implementation and evaluation of the nursing care
with holistic approach supported by scientific rationales.
NURSING CASE STUDY/BONE FRACTURE DIP/2017/00451 3

CLIENT IDENTIFICATION

Name: Tobgay

Age/Gender: 51/Male

Care of Guardian with Contact No.: Karma (Wife) Phone No.: Not Available

Date & Time of Admission: 15th January, 2019 at 3:13 AM

Local Address: NPPF Colony, Thimphu

Permanent Address: Tarithang, Gelephu

Ward and Bed No.: Orthopedic Ward, B24

Hospital Registration No.: 51982

SOCIO-ECONOMIC STATUS

Marital Status: Married

No. of Children/Siblings: 4 (Four sons)

Level of Education: Uneducated

Occupation: School Caretaker

Type of House: Simple 1 storey house

Total Income (Monthly): Less than Nu. 9000/-

NURSING CASE STUDY/BONE FRACTURE DIP/2017/00451
HEALTH ASSESSMENT
A. History Taking
Chief Complaints:
History of Present Illness:
History of Past Illness:
Family Health History:
Personal History:
Reproductive History:
4
Back pain for 2 weeks.
Immobility of lower limbs for 2 weeks.
Pain at the lower legs for 2 weeks.
Prior to admission, the patient accidentally fell from a tree with a height equivalent to a 2 storey house and
sustained damage on his both legs and on his back injuring the lumber L1 vertebrae of the vertebral column. The
patient was semi-conscious after the fall and was back to full consciousness 2 weeks after his referral to
JDWNRH from Gelephu CRRH.
The patient has no past history of any major or minor illnesses such as osteoporosis, osteomyelitis, osteogenesis
imperfecta or rickets which may lead to a pathological fracture. And the patient does not have any past medical
history of being diagnosed with hypertension, heart diseases or diabetes.
The patient has no family history of any major or minor health conditions such as hypertension, cancers, heart
diseases and diabetes.
Prior to admission, patient sleeps well but after admission and also after the surgery, the patient complains of
disturbed sleep patterns due to pain at both of his injured legs with the fact that magnitude of pain was from the
right leg. Patient has a hobby of playing sports like archery and has a good taste for traditional things. Patient does
not consume or smoke tobacco products. Patient has a past habit of drinking alcohol at regular basis but has
stopped drinking alcohol recently. The patient is a Buddhist and follows the religion with sincerity.
The patient has a good sexual urge and libido. The patient has no record of being infected with any kind of
sexually transmitted diseases such as HIV, AIDS, Gonorrhoea, HPV, Hepatitis B and Syphilis. The patient voids
well but due to his immobility he is unable to go to the toilet and void, and thus needs assistance while accessing
the toilet for voiding. The patient has no pain, itching or discharge during urination. According to the attendant,
the patient urinates well with a frequency of 3-4 times daily.
NURSING CASE STUDY/BONE FRACTURE DIP/2017/00451 5

B. Physical Examination

B.1. General Head to Toe Examination

Areas Assessed Evaluation Areas Assessed Evaluation Areas Assessed Evaluation

General Appearance Head Nose
General Well-being: Normal Skull: Skull looks normal Rashes: Absent
Cooperation: Cooperative with no deformities. Bleeding: Absent
Mental status: Intelligent Headache: Absent Blockage: No blockage of the
Nutrition: Well nourished Injury: No injury to the head. nose.
Body built: Average
Height: Cannot stand Face Mouth
Weight: Cannot stand Swelling: No swelling Smell: No foul smell present
BMI: Cannot stand Rashes: Absent Toothache: Absent
Pallor: Absent Swelling: Absent
Vital Signs Sore throat: Absent
BP: 110/70 mmHg Neck Central cyanosis: Absent
(Normal range: 90/60 Neck stiffness: Absent Dehydration: Hydrated
– 120/80 mmHg.) Jugular vein: Not engorged. Sore throat: Absent
Pulse rate: 79 bpm Carotid pulsations: Normal Change in voice: No change in voice
(Normal range: 60 - Thyroid gland: Not enlarged Dehydration: Hydrated
100 bpm) Lymph nodes: Not enlarged
Respiration rate: 18 cpm Skin
(Normal range: 12-18 Eye Colour: Brown
cpm) Colour: Brown (Normal) Swelling: Absent
Temperature: 37.7 οC Redness/Yellow: Absent Sores: Absent
(Normal range: 36.5- Discharge: Absent Rashes: Absent
37.3 οC) Blurred vision: Absent Itching: No itching
SpO2: 95% Pupil: Reactive Ulcers: No ulcers
(Normal range: Loss of sensation: No loss of sensation
95-100%) Ears
Discharge: No discharge. Hand and Nail
Head Hearing problems: Mild hearing Deformities: Absent
Hair: No loss of hair, No problems due to aging Palmar erythema: Absent
itching and No rashes Vertigo: Absent Koilonychia: Absent
observed. Tinnitus: Present
NURSING CASE STUDY/BONE FRACTURE DIP/2017/00451 6

Areas Assessed Evaluation Areas Assessed Evaluation Areas Assessed Evaluation

Hand and Nail Upper Extremities Lower Extremities
Leukonychia: Absent Edema: Absent Edema: No edema
Peripheral cyanosis: Absent Distended veins: Absent
Clubbing: Absent Deformities: Absent Distended veins: Absent
Sores: Absent Deformities: Absent
Sores: Absent
Fractures: Present at the left and
right lower extremity

B.2. Systemic Examination of Musculoskeletal System

Method Used Positive Findings

Inspection General appearance: The patient looks calm but suffers from acute pain from the fracture of both the lower left and right
leg.

Mobility: The patient is unable to ambulate or move himself due to the fracture of both the left and right leg.

Symmetry: Upper and lower extremities maintain symmetry with no major deformities of the bones of any of the body
parts. The patient has a open incision due to the recent surgery of correction of the fracture.

Deformity: Absent

Presence of incision site left after a surgical repair is detected and the incision site looks dry.
Palpation Bone tenderness: Except for both the left and right lower extremity, no bone tenderness is detected. Due to the fracture of
the distal part of the tibia and 1/3rd part of the distal fibula, there is a presence of bone tenderness at the distal part of the left
leg and also there is a plafond fracture of the left tibia.

Fractures: Closed comminuted distal tibial fracture with 1/3rd distal fibular fracture which is fixed with distal locking plate,
left plafond fracture of the tibia which is fixed with clover leaf and L1 burst fracture.

Inflammation and swelling of the areas around fracture site is observed.

NURSING PROCESS/BONE FRACTURE DIP/2017/00451 7

LABORATORY INVESTIGATIONS

Hematology Report:

Examination requested: Complete Blood Count

Date: 8th March, 2019
Test Name Result Normal Range Units
White Blood Cell 6.23 4.0-10.0 10^3/ul
Lymphocyte % 31.6 20-40 %
Monocyte % 5.5 1-9 %
Neut/Gran % 50.6 40-60 %
Eosinophil % 12.0 H 0-5 %
Basophil % 0.3 0-2 %
Lymphocyte # 1.97 1.5-4.0 10^3/ul
Monocyte # 0.34 0.2-0.8 10^3/ul
Neut/Gran # 3.15 2.0-7.2 %
Eosinophil # 0.75 H 0-0.4 10^3/ul
Basophil # 0.02 0-0.2 10^3/ul
Red Blood Cell 5.24 4.50-6.48 10^6ul
Hematocrit 44.3 39-50 %
Hemoglobin 14.1 14.0-18.4 g/dl
Platelet 269 150-450 10^3/ul

Biochemistry Report:

Examination requested: Renal Function Test

Date: 15th March, 2019
Test Name Result Normal Range Units
Urea 27 15-45 mg/dL
Creatinine 0.5 L 0.6-1.3 mg/dL
Sodium 144 133-146 mEq/dL
Potassium 4.3 3.8-5.4 mEq/dL
Chloride 97 96-110 mEq/dL
NURSING PROCESS/BONE FRACTURE DIP/2017/00451 8

Examination requested: Liver Function Test

Date: 15th March, 2019
Test Name Result Normal Range Units
SGOT (AST) 17 5-40 IU/L
ALT 24 5-40 IU/L
Alkaline Phosphatase 139 H 40-129 IU/L
Total Bilirubin 1.1 0.1-1.2 mg/dl
Direct Bilirubin 0.32 H <0.2 mg/dl

Microbiology Report

Examination requested: Bacteriology Report

Date: 9th March, 2019
Specimen No.: P-0404
Specimen type: Pus
Organism: No growth
Gram stain/ Microscopy: No polymorphs seen
Gram stain (Bacteria): No bacteria seen

Reported by Ragunath Sharma

X-Ray Report:

Report 1

Status: Pre-operative phase

X-ray No.: 1188
Date: 15th Jan, 2019
Type: Anterior-posterior and lateral view of the right leg.

Findings: Comminuted fracture of the distal tibia is detected and a fracture of 1/3rd of the distal fibula is also detected. Comminuted fracture
has resulted to 2 bone fragments. From AP view, the part of the tibia below the fracture site is deviated away towards the medial
side of the body.
NURSING PROCESS/BONE FRACTURE DIP/2017/00451 9

Report 2

Status: Pre-operative phase

X-ray No.: 1444
Date: 15th Jan, 2019
Type: Anterior-posterior and lateral view of the left leg.

Findings: A plafond fracture of the distal tibia of left leg is detected. The fracture is mostly seen at the articular regions of the tibia.

Report 3

Status: Post-operative phase

X-ray No.: 2411
Date: 28th Jan, 2019
Type: Anterior-posterior and lateral view of the right leg.

Findings: A Distal Locking plate approximately measuring about 15 cm is fixed at the fractured tibial region with 10 screws and the
fractured site fixed accordingly through the locking plate.

Report 4

Status: Post-operative phase

X-ray No.: 2412
Date: 28th Jan, 2019
Type: Anterior-posterior and lateral view of the left leg.

Findings: A Cloverleaf plate measuring almost more than 12 cm is fixed along the fractured 1/3rd distal part of the left tibia and the fractured
site is fixed accordingly through this plate with 9 screws in place.
NURSING PROCESS/BONE FRACTURE DIP/2017/00451 10

MEDICAL DIAGNOSIS

Bone Fracture:

A bone fracture (sometimes abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a partial or complete break in the continuity of the bone. In more severe cases, the bone may
be broken into several pieces. A bone fracture may be the result of high force impact or stress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such as
osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.

Types of Fractures:

 Complete fracture: A fracture in which bone fragments separate completely.

 Incomplete fracture: A fracture in which the bone fragments are still partially joined.
 Linear fracture: A fracture that is parallel to the bone’s long axis.
 Transverse fracture: A fracture that is at a right angle to the bone’s long axis.
 Oblique fracture: A fracture that is diagonal to a bone’s long axis.
 Spiral fracture: A fracture where at least one part of the bone has been twisted.
 Comminuted fracture: A fracture in which the bone has broken into a number of pieces.
 Compacted fracture: A fracture caused when bone fragments are driven into each other.

Type of Fracture of the Patient: Closed Comminuted distal tibial fracture with 1/3rd distal fibular fracture of left leg, Plafond/Pilon fracture of the left tibia and Burst L1 fracture of the
patient’s vertebrae.
NURSING PROCESS/BONE FRACTURE DIP/2017/00451 11

TREATMENTS

Surgical Repair of Fracture:

Open Reduction-Internal Fixation (ORIF) with the use of Clover Leaf plate and Distal Locking plate

Open Reduction Internal Fixation (ORIF) involves the implementation of implants to guide the healing process of a bone, as well as the open reduction, or setting, of the bone. Open reduction
refers to open surgery to set bones, as is necessary for some fractures. Internal fixation refers to fixation of screws and/or plates, intramedullary bone nails (femur, tibia, and humerus) to enable or
facilitate healing. Rigid fixation prevents micro-motion across lines of fracture to enable healing and prevent infection, which happens when implants such as plates (e.g. dynamic compression
plate) are used. Open Reduction Internal Fixation techniques often are used in cases involving serious fractures such as comminuted or displaced fractures or, in cases where the bone otherwise
would not heal correctly with casting or splinting alone.

Cloverleaf is a system used in fractures of the distal tibia and proximal humerus especially in pilon or plafond fractures. These plates are fixed by both cortical and cancellous screws. Locking
plates are fracture fixation devices with threaded screw holes, which allow screws to thread through the hole and function as a fixed-angle device. These plates may have a mixture of holes that
allow placement of both locking and traditional non-locking screws.

Wound Debridement which involves the medical removal of dead, damaged or infected tissue to improve the healing potential of the remaining healthy tissue is also done since the incision
wounds after the surgery is still not yet healed properly. Surgical debridement or "sharp" debridement and laser debridement under anesthesia are the fastest methods of debridement. They are
very selective, meaning that the person performing the debridement has complete control over which tissue is removed and which is left behind. Surgical debridement can be performed in the
operating room or bedside, depending on the extent of the necrotic material and a patient's ability to tolerate the procedure. The surgeon will typically debride tissue back to viability, as determined
by tissue appearance and the presence of blood flow in healthy tissue
NURSING PROCESS/BONE FRACTURE DIP/2017/00451 12

Drugs for Treatment:

S.I. No. Drugs Drug Action Side Effects Nursing Responsibilities.

1 Name: Gentamicin Gentamicin is a bactericidal Dizziness, Vertigo, Ensure adequate hydration of
Type: Injection antibiotic that works by Hearing loss, patient before and during therapy.
Dose: 240 mg irreversibly binding the 30S Numbness, Muscle Monitor hearing with long term
Route: I.V. subunit of the bacterial twitching or weakness, therapy, ototoxicity may occur.
Frequency: O.D. ribosome, negatively impacting breathing difficulties Monitor RFTs, CBC. Serum drug
protein synthesis. and decreased urination. levels during long term therapy.
2 Name: Paracetamol The drug is a non-steroidal Low fever with Assess patient’s fever or pain.
Type: Tablet anti-inflammatory drug which nausea, stomach pain Assess allergic reactions if any
Dose: 500 mg acts by inhibiting the enzyme and loss of appetite, from the drug prescribed to the
Route: Oral cyclo-oxygenase which dark urine, clay patient. Teach patient to
Frequency: Q.I.D. produces pain producing colored stools or recognize signs and symptoms of
substances. jaundice. chronic overdose: bleeding,
bruising, fever, sore throat.
3 Name: Diclofenac Sodium The drug has analgesic, anti- Indigestion, gas, Evaluate therapeutic response by
Type: Injection inflammatory and antipyretic stomach pain, nausea, assessing pain, joint stiffness, joint
Dose: 75 mg properties. It involves the vomiting, diarrhoea, swelling and mobility. Do not
Route: I.M. inhibition of cyclo-oxygenase constipation, headache, breastfeed while on this drug.
Frequency: STAT and is a potent inhibitor of dizziness, drowsiness, Avoid alcohol or other CNS
prostaglandin synthesis in vitro. increased blood pressure depressants.
and increased sweating.
4 Name: Thiamine Thiamine combines with Nausea, sweating, Record patient’s dietary history
Type: Tablet adenosine triphosphate (ATP) to feeling warm, mild rash carefully as an essential part of
Dose: 75 mg from coenzyme, thiamine or itching, feeling vitamin replacement therapy. Body
Route: Oral pyrophosphate (thiamine restless. requirement of thiamine is directly
Frequency: B.D. diphosphate, cocarboxylase) proportional to carbohydrate intake
which is necessary carbohydrate and metabolic rate.
metabolism.
 NURSING PROCESS/BONE FRACTURE DIP/2017/00451 13

PATHOPHYSIOLOGY OF FRACTURE

Nonmodifiable:
Personal history of fracture as
an adult
History of fracture in first
degree relative
Female sex
Advanced age
Osteoblastic activity is immediately
stimulated, both intraosseous and periosteal
from osteoproginenitor cell.
TRAUMA
Bone Breakage
Death of bone cells
Bleeding typically occurs
around the site and into the
soft tissues surrounding the
bone. The soft tissues are
usually damaged by the
injury.
Modifiable:
Current cigarette smoking
Low body weight
Estrogen Deficiency
Early menopause (45 years old)
or bilateral ovariectomy
Prolonged premenstrual
amenorrhea
Low Calcium Intake
Alcoholism
Recurrent falls
Inadequate physical activity
Poor health/Frailty
Disruption in fracture hematoma due to
displaced and comminuted bone.

Fixation or proper bone alignment is

Immature new bone or callus is formed. Intense Inflammatory Reaction
needed to facilitate bone healing.

Fibrin clot is soon reabsorbed and the Vasodilation

new bone cells are slowly remodeled to Open Reduction Internal Fixation
from true bone. Intramedullary Nailing Interlocking
Increased blood flow to the area of injury Femur Left, Open Reduction Internal
Fixation Wiring Patellar Left
True bone replaces callus and is slowly
calcified. (Several weeks to few months) Accumulation of leukocytes and mast cells.
Screws, Wires, Rods, Nails or
other fixation apparatuses hold
Phagocytosis and removal of dead cell debris both ends of broken bone together

A fibrin clot (fracture hematoma) forms at the break Stress on the opposed of the broken bones,
and acts as a new network to which new cells can which accelerates osteoblastic activity at
adhere. the break leading to hastened normal bone
healing
NURSING PROCESS/BONE FRACTURE DIP/2017/00451 14

The natural process of healing a fracture starts when the injured bone and surrounding tissues bleed, forming a fracture Hematoma. The blood coagulates to form a blood clot situated between the
broken fragments. Within a few days blood vessels grow into the jelly-like matrix of the blood clot. The new blood vessels bring phagocytes to the area, which gradually remove the non-viable
material. The blood vessels also bring fibroblasts in the walls of the vessels and these multiply and produce collagen fibres. In this way the blood clot is replaced by a matrix of collagen.
Collagen’s rubbery consistency allows bone fragments to move only a small amount unless severe or persistent force is applied.

At this stage, some of the fibroblasts begin to lay down bone matrix (calcium hydroxyapatite) in the form of insoluble crystals. This mineralization of the collagen matrix stiffens it and transforms
it into bone. In fact, bone is a mineralized collagen matrix; if the mineral is dissolved out of bone, it becomes rubbery. Healing bone callus is on average sufficiently mineralized to show up on X-
ray within 6 weeks in adults and less in children. This initial “woven” bone does not have the strong mechanical properties of mature bone. By a process of remodeling, the woven bone is replaced
by mature “lamellar” bone. The whole process can take up to 18 months, but in adults the strength of the healing bone is usually 80% of normal by 3 months after the injury.
NURSING PROCESS/BONE FRACTURE DIP/2017/00451 15

COMPARISON OF CASE AND THEORY

Case Theory
Causes Fall injury from 2 storey tree. Trauma
Accident (RTA)
Fall injuries
Pathological fracture
Risk Factors Poor health/Frailty Current cigarette smoking
Inadequate physical activity Low body weight
Recurrent falls Estrogen Deficiency
Alcoholism Low Calcium Intake
Low body weight Alcoholism
Recurrent falls
Inadequate physical activity
Poor health/Frailty
Signs and Symptoms Pain Pain
Swelling Edema
Immobility Deformity
Bruising/ecchymosis Tenderness
Tenderness Loss of function
Impaired sensation/ numbness Bruising/ecchymosis
Hypovolemic shock
Impaired sensation/numbness
Diagnostic Investigation History and Physical Examination History and Physical Examination
X-ray X-ray
CT/MRI
Bone scan
Treatments Surgically inserted metal rods and plates Splints
Pain relief Braces
Plaster Cast
Traction
Surgically inserted metal rods and plates
Pain relief
NURSING PROCESS/BONE FRACTURE DIP/2017/00451
NURSING CARE PLANS (1 of 5)
S.I. No. Nursing Diagnosis Nursing Goals/
Expected Outcomes
1 Acute Pain related to Goal:
movement of bone Patient will describe
fragments, satisfactory pain control
inflammation, and at a level less than 3 to 4
injury to the soft tissue on a rating scale of 0 to
from fracture as 10 prior to discharge.
evidenced by:
Expected Outcomes:
Subjective data: - Verbalize relief of
“I feel the pain pain.
radiating through my -Display relaxed
left leg and it’s quite manner; able to
difficult to cope with participate in activities,
the pain,” as sleep/rest appropriately.
verbalized by the -Demonstrate use of
patient. relaxation skills and
diversional activities as
Objective data: indicated for individual
-Guarding/ protective situation.
behaviour. -Patient uses
-Mild tenderness and pharmacological and
erythema from the non-pharmacological
affected part of the leg. pain-relief strategies.
-Patient displays
improvement in mood,
coping.
Nursing Intervention
-Maintain immobilization of
affected part by means of bed
rest, cast, splint, traction.
-Elevate and support injured
extremity.
-Investigate any reports of
unusual or sudden pain or
deep, progressive, and poorly
localized pain unrelieved by
analgesics.
-Administer medications as
indicated: Narcotic and non-
narcotic analgesics,
injectable and oral
nonsteroidal anti-
inflammatory drugs
(NSAIDs) or muscle
relaxants.
-Report to the physician
when interventions are
unsuccessful and ineffective.
16
Scientific Rationale Evaluation
-Relieves pain and prevents The patient
bone displacement and describes a
extension of tissue injury. satisfactory pain
control at a level
-Promotes venous return, less than 3-4 and
decreases edema, and may can now
reduce pain. demonstrate use of
relaxation skills and
-May signal developing diversional
complications (infection, activities as
tissue ischemia, indicated for
compartmental syndrome). individual situation.
-Given to reduce pain or
muscle spasms.
Effectiveness of pain
medications must be
evaluated individually
because it is absorbed and
metabolized differently by
patients.
-Patients who demand pain
medications at more
frequent intervals than
prescribed may actually
require higher doses or
more potent analgesics.
NURSING PROCESS/BONE FRACTURE DIP/2017/00451 17

NURSING CARE PLANS (2 of 5)

S.I. No. Nursing Diagnosis Nursing Goals/ Nursing Intervention Scientific Rationale Evaluation
Expected Outcomes

2 Impaired Physical Goal: -Execute passive or active -Exercise enhances Patient can now
Mobility related to loss Patient will be able to assistive ROM exercises to increased venous return, walk to the toilet
of skeletal integrity perform simple ADLs all extremities. prevents stiffness, and with assistance of
(fractures) of the left without assistance and maintains muscle strength his crutch and has
lower extremity as have learned to and stamina. no major
evidenced by: ambulate with an assist complications in
of a crutch prior to -Let the patient accomplish -Healthcare providers and performing his
Subjective data: discharge. tasks at his or her own pace. significant others are often simple ADLs.
“I have under gone a Do not hurry the patient. in a hurry and do more for
surgery after my Expected outcomes: Encourage independent patients than needed.
fracture and now it -Patient is able to activity as able and safe. Thereby slowing the
hurts a lot, and perform simple ADLS. patient’s recovery and
because of the pain -Patient is able to reducing his or her
and the tenderness, ambulate with/without confidence.
I’m unable to walk,” assistance.
as verbalized by the -Patient demonstrates -Encourage use of isometric -Isometrics contract
patient. measures to increase exercises starting with the muscles without bending
mobility. unaffected limb. joints or moving limbs and
Objective data: -Patient demonstrates help maintain muscle
-Inability to move the use of adaptive strength and mass.
purposefully within devices to increase
the physical mobility. -Provide and assist with -Early mobility reduces
environment -Patient uses safety mobility by means of complications of bed rest
-Requires assistance measures to minimize wheelchair, walker, crutches (phlebitis) and promotes
while doing ADLs and potential for injury. or canes as soon as possible. healing and normalization
ambulation. -Increase Instruct in safe use of of organ function. Learning
-Presence of fracture at strength/function of mobility aids. the correct way to use aids
the left lower affected and is important to maintain
extremity. compensatory body optimal mobility and
parts. patient safety.
NURSING PROCESS/BONE FRACTURE DIP/2017/00451 18

NURSING CARE PLANS (3 of 5)

S.I. No. Nursing Diagnosis Nursing Goals/ Nursing Intervention Scientific Rationale Evaluation
Expected Outcomes

3 Impaired Skin Goal: -Keep a sterile dressing -This technique reduces the The patient has a
Integrity related to The patient will technique during wound care. risk for infection healthy intact skin
surgical repair: maintain a healthy and and does not
insertion of fixation complete intact skin -Wet thoroughly the -Saturating dressings will complain of any
apparatuses (IM prior to discharge. dressings with sterile normal ease the removal by dermal irritations
Nailing) as evidenced saline solution before loosening adherents and and can now
by: Expected outcomes: removal. decreasing pain, demonstrate proper
-Demonstrate and healthy
Subjective data: behaviours to prevent - Assess changes in body -Fever is a systemic measures to
“I feel pain, itchiness skin breakdown. temperature, specifically manifestation of maintain proper
and swelling around -The patient will increased in body inflammation and may skin integrity.
the incision wounds maintain a good range temperature. indicate the presence of
from the surgery I of motion and activity infection.
went through,” as tolerance.
verbalized by the - Patient reports any -Administer antibiotics as Wound infections may be
patient. altered sensation or pain ordered. managed well and more
at site of tissue efficiently with topical
Objective data: impairment. agents, although
-Incision wounds from -Patient demonstrates intravenous antibiotics may
the surgical repair. understanding of plan to be indicated.
-Bleeding from the heal tissue and prevent
incision sites. injury. -Tell patient to avoid rubbing -Wound infections may be
-Mild swelling and -Patient describes and scratching. Provide managed well and more
tenderness around the measures to protect and gloves or clip the nails if efficiently with topical
incision sites. heal the tissue, including necessary. agents, although
wound care. intravenous antibiotics may
be indicated.

-Encourage a diet that meets -A high-protein, high-

nutritional needs. calorie diet may be needed
to promote healing.
NURSING PROCESS/BONE FRACTURE DIP/2017/00451 19

NURSING CARE PLANS (4 of 5)

S.I. No. Nursing Diagnosis Nursing Goals/ Nursing Intervention Scientific Rationale Evaluation
Expected Outcomes

4 Risk for Infection Goal: - Inspect the skin for pre- - Pins or wires should not The patient now
related to risk factors The patient will achieve existing irritation or breaks in be inserted through skin practices proper
such as impaired skin timely wound healing, continuity. infections, rashes, or handwashing
integrity and be free of purulent abrasions (may lead to bone techniques and
insufficient knowledge drainage or erythema, infection). practices measures
to avoid exposure to and be afebrile prior to to prevent infection
pathogens as discharge. -Provide sterile wound care -May prevent cross- and has sufficient
evidenced by the according to protocol, and contamination and knowledge on
presence of incisions Expected outcomes: exercise meticulous hand possibility of infection. preventing
from the surgical -Patient remains free of washing infections.
repair. infection, as evidenced
by normal vital signs -Instruct patient not to touch -Minimizes opportunity for
and absence of signs and the insertion sites. contamination.
symptoms of infection.
-Early recognition of -Observe wounds for -Signs suggestive of gas
infection to allow for formation of bullae, gangrene infection.
prompt treatment. crepitation, and bronze
-Patient will discoloration of skin, frothy
demonstrate meticulous or fruity-smelling drainage.
hand washing technique.
-Assess muscle tone, -Muscle rigidity, tonic
reflexes, and ability to speak. spasms of jaw muscles, and
dysphagia reflect
development of tetanus.

-Investigate abrupt onset of -May indicate development

pain and limitation of of osteomyelitis.
movement with localized
edema and erythema in
injured extremity.
NURSING PROCESS/BONE FRACTURE DIP/2017/00451 20

NURSING CARE PLANS (5 of 5)

S.I. No. Nursing Diagnosis Nursing Goals/ Nursing Intervention Scientific Rationale Evaluation
Expected Outcomes

5 Risk for Fall related to Goal: -Maintain bed rest or limb -Provides stability, The patient now
loss of skeletal The patient will relate rest as indicated. Provide reducing possibility of uses safety
integrity (fractures) as controlled falls or no support of joints above and disturbing alignment and measures to prevent
evidenced by: falls prior to discharge. below fracture site, muscle spasms, which falls and trauma of
especially when moving and enhances healing. any kind, and also
Subjective data: Expected Outcomes: turning. has adequate
“I am unable to a walk -Patient will not sustain knowledge on
independently and falls. -Support fracture site with -Prevents unnecessary proper use of
perform simple tasks -Patient will intent to pillows or folded blankets. movement and disruption assistive
due to the fracture of use safety measures to Maintain neutral position of of alignment. Proper mechanical devices
my leg,” as verbalized prevent falls. affected part with sandbags, placement of pillows also for preventing falls.
by the patient. -Patient will splints, trochanter roll, and can prevent pressure
demonstrate selective footboard. deformities in the drying
Objective data: prevention measures to cast.
-Inability to move prevent falls.
purposefully within -Patient and caregiver -Teach patient on the proper -This will prevent the
the physical will implement and safe use of the crutch. patient from falling off
environment strategies to increase while using the crutch.
-Requires assistance safety and prevent falls
while doing ADLs and in the home. -Familiarize the patient to the -The patient must get used
ambulation. layout of the room. to the layout of the room to
-Presence of fracture at avoid tripping over.
the left lower
extremity. -Advice the patient -Provides further
attendants to assist the reassurance for the patient
patient whenever the patient in preventing the patient
is ambulating with the help from sustaining falls.
of a crutch or wheelchair.
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HEALTH EDUCATION

1. Educate the patient to seek care immediately if:

 The patient’s leg feels warm, tender, and painful which may look swollen and red.
 The pain in the patient’s injured leg gets worse even after the patient takes rest and medicine.
 The patient’s leg or toes are numb.
 The skin or toes of the patient’s injured leg become swollen, cold, or blue.

2. Educate the patient to inform the physician or bone specialist if:

 The patient has a fever.
 The patient’s implant felt bent or deformed.
 There are new blood stains or a bad smell coming from the surgical sites.
 The patient has new or worsening trouble moving the leg.
 The patient has questions or concerns about the condition or care.

3. Prescription pain medicine may be given to the patient and should be explained to the patient on how to take this medicine safely.

4. Educate the patient on self-care:

 Rest the leg as directed and avoid activities that cause leg pain.
 Elevate the leg above the level of the heart as often. This will help decrease swelling and pain. The leg should be propped on pillows or blankets to keep it elevated comfortably.
 Use crutches or a walker as directed. Crutches will help the patient walk and take some weight off the injured leg while it heals.
 Physical therapy may be recommended. A physical therapist teaches exercises to help improve movement and strength, and to decrease pain.
NURSING PROCESS/BONE FRACTURE DIP/2017/00451 22

References

Belleza, M. (2016). Fracture nursing care management. Retrieved from https://nurseslabs.com/category/nursing-notes/medical-surgical-nursing/fracture-nursing-care-management/

Faculty of Nursing and Public Health. (2014). Nursing practical manual: nursing procedures checklist and guidelines. Thimphu: Druk Printers.

Gordon, M. (2010). Nursing Diagnosis: Process and application, Fifth Edition. St. Louis: Mosby.

McLatchie, G., Borley, N. & Chikwe, J. (2007). Oxford handbook of clinical surgery. United Kingdom: Oxford University Press.

Nancy. (2005). Stephanie’s principles and practice of nursing. (Vol. 2) India: N.R. Publishing House.

Pathophysiology of fracture. (2014). Retrieved from https://www.scribd.com/pathophysiology_of_fracture/

Seaback, W. W. (2006). Nursing process: concepts and application. Canada: Thomson Delmar Learning.

Smeltzer, S.C. and Bare, B.G. (2004). Brunner and Suddarth's textbook of medical surgical nursing. 10th edition. Philadelphia: Lippincott Williams & Wilkins.