A CASE STUDY OF A PATIENT WITH COMMINUTED FRACTURE
CLOSED DISTAL THIRD FEMUR
A Case StudyPresented to
the Faculty of the College of NursingCebu Normal University
In Partial Fulfillmentof the Requirements in
Medical-Surgical Nursing(NCM 105)
By
Macayan, Jellou Ray M.
October 2011
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ACKNOWLEDGEMENT
I would like to express my heartfelt gratitude to all those who helped me in making this
case study a possibility.
First of all I would like to thank the almighty God for giving me the strength and courage
to complete this research even when faced with challenges, boredom and indiscretions.
To Miss Bertilia F. Pragados for giving me the permission to make this case in the first
instance, to do the necessary research work and for the constant reminders and pointers you
have given me for this study—thank you mam!
Also I would also like to extend my sincere thanks to Miss Elaiza R. Cabunoc of the
Vicente Sotto Memorial Medical Center Radiology Department for the kind accommodation and
for allowing me to recover patient’s diagnostic files.
I would also like to take this opportunity to thank my fellow researcher Miss Emy Jane
Pilapil, Cherish Cyrill, Oraiz and Miss Sonia Rufa Singson and Miss Cybelle Caramba whose
help, stimulating suggestions and encouragement inspired me in all the time of research for and
writing of this case study and mostly for the company upon gathering relevant information for the
study.
I am also deeply indebted to my co-researcher Miss Alona Minque who looked closely at
the final version of the case study for English style and grammar, correcting both and offering
suggestions for improvement.
And most especially, I would like to give my special thanks to my family whose patient
love enabled me to complete this work.
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TABLE OF CONTENTS
Page
Title Page--------------------------------------------------------------------------------------------------------- i
Acknowledgement --------------------------------------------------------------------------------------------- ii
Table of Contents ---------------------------------------------------------------------------------------------- iii
List of Figures --------------------------------------------------------------------------------------------------- v
Chapter 1 – Introduction ------------------------------------------------------------------------------------- 1
Chapter 2 - Patient’s Profile
Background/History --------------------------------------------------------------------------------- 3
Patient’s Vitae ---------------------------------------------------------------------------------------- 4
Functional Health Patterns ------------------------------------------------------------------------ 4
Physical Assessment ------------------------------------------------------------------------------- 5
Chapter 3 - Anatomy and Physiology --------------------------------------------------------------------- 8
Chapter 4 - Psychopathophysiology
Schematic Diagram -------------------------------------------------------------------------------- 15
Narrative ---------------------------------------------------------------------------------------------- 16
Chapter 5 - Management
Medical
Laboratory Procedures ---------------------------------------------------------------- 18
Diagnostic Procedures ---------------------------------------------------------------- 19
Drug Study ------------------------------------------------------------------------------- 21
Surgical ----------------------------------------------------------------------------------------------- 21
Nursing
Summary of Nursing Problems --------------------------------------------------- 22
Individualized Nursing Care Plan -------------------------------------------------- 22
FDAR Charting ------------------------------------------------------------------------- 25
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Discharge Summary with Collaborative Nursing Function ------------------- 25
Chapter 6 - Evaluation and Recommendation ------------------------------------------------------- 29
Bibliography ------------------------------------------------------------------------------------------------------ 31
Appendices ------------------------------------------------------------------------------------------------------- 32
APPENDIX A (Physical assessment) ----------------------------------------------------------- 33
APPENDIX B (Hematologic studies) ------------------------------------------------------------ 39
APPENDIX C (Urinalysis) -------------------------------------------------------------------------- 41
APPENDIX D (Coagulation Profile) ------------------------------------------------------------- 42
APPENDIX E (X-ray Report) ---------------------------------------------------------------------- 43
APPENDIX F (Drug Study—celecoxib) --------------------------------------------------------- 45
APPENDIX G (Drug Study—tramadol) --------------------------------------------------------- 46
APPENDIX H (Drug Study—cefuroxime) ------------------------------------------------------ 47
APPENDIX I (NCP day 1) ------------------------------------------------------------------------- 48
APPENDIX J (NCP day 2) ------------------------------------------------------------------------ 51
APPENDIX K (NCP day 3) ----------------------------------------------------------------------- 53
APPENDIX L (FDAR day 1) ---------------------------------------------------------------------- 55
APPENDIX M (FDAR day 2) --------------------------------------------------------------------- 56
APPENDIX N (FDAR day 3) ---------------------------------------------------------------------- 57
APPENDIX O (Approval for Case Study) ----------------------------------------------------- 58
APPENDIX P (Approval for Final Printing and Book Binding of Case Study) ------- 59
Curriculum Vitae ----------------------------------------------------------------------------------------------- 60
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LIST OF FIGURES
Page
Figure 1 - Upper extremity of right femur viewed from behind and above ------------------------- 8
Figure 2 - Right femur. Anterior surface --------------------------------------------------------------------10
Figure 3 - Right femur. Posterior surface ------------------------------------------------------------------ 12
Figure 4 - Pathophysiology of fracture (schematic diagram) ------------------------------------------ 15
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CHAPTER I
INTRODUCTION
Being broken opens the door to a possibility--change. When you get hurt and broken
inside, you try to heal yourself to be the same old person. But you really can’t be that same
person anymore. A part of you has changed. A broken bone is like a part of self that you knew is
the same but just can’t recognize anymore. It’s still the same bone. Yet, during the process of
healing, it seems to change.
A fracture is a break in the continuity of bone and is defined according to its type and
extent. Fractures occur when the bone is subjected to stress greater that it can absorb. Fractures
are caused by direct blows, crushing forces, sudden twisting motions, and even extreme muscle
contractions. When the bone is broken, adjacent structures are also affected, resulting in soft
tissue edema, hemorrhage into the muscles and joints, joint dislocation, ruptured tendons,
severed nerves, and damaged blood vessels. Body organs maybe injured by the force that cause
the fracture or by the fracture fragments (Brunner’s and Suddarth’s 2004).
There are different types of fractures and these include, complete fracture, incomplete
fracture, closed fracture, open fracture and there are also types of fractures that may also be
described according to the anatomic placement of fragments, particularly if they are displaced or
non displaced. Such as greenstick fracture, depressed fracture, oblique fracture, avulsion, spinal
fracture, impacted fracture, transverse fracture and compression fracture.
A comminuted fracture is one that produces several bone fragments and a closed
fracture or simple fracture is one that does not cause a break in the skin. Comminuted fracture at
the Right Distal Third Femur is a fracture in which bones of the distal portion of the femur has
splintered to several fragment. The patient would then experience tremendous pain at the site of
the fracture, swelling around the area and it may become warm to the touch. Typically the patient
cannot bear any weight on the fracture without experiencing significant pain.
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Femur fracture affects almost 13 million Americans, and one of the leading fractures in
the Philippines making it the most common form of fracture. The incidence of femoral fractures is
reported as 1-1.33 fractures per 10,000 population per year (1 case per 10,000 population). In
Vicente Sotto Memorial Medical Center, there are total of 56 patients out of 94 are diagnosed with
femoral fracture within the duration of care, the estimated incidence rate in the said institution is
about 60%. In individuals younger than 25 years and those older than 65 years, the rate of
femoral fractures is 3 fractures per 10,000 populations annually. The incidence of femoral injuries
and fractures increases in elderly patients.
Primarily, this case was chosen because of its rapidly increasing incidence in the locality,
most cases in the Orthopedic Ward Vicente Sotto Memorial Medical Center involves fracture in
the femoral bones and it is inevitable for us nurses to care for these type of patient. It is very
important for the nurses nowadays to be adequately informed regarding the knowledge and skill
in managing these conditions, Through the knowledge of this condition, a high quality of care will
be provided to those people is suffering from symptoms and complications of fracture.
Generally, the purpose of this study is to generate knowledge about fracture and how it
affects a person physiologically, emotionally, psychologically and spiritually. Moreover, this case
study aims to: (a) gather information about client’s past and present condition: (b) assess
predisposing and precipitating factors that caused such disease condition; (c) determine anatomic
and physiologic functions that contributes to the disease; (d) know the Pathophysiology of the
client’s condition; (e) determine medical and surgical interventions base on client’s assessment
and laboratory results; (f) and also identify appropriate nursing interventions to promote wellness
for the patient.
CHAPTER II
I. Background/History
History of Present Illness
Few hours prior to admission, around 1 pm while driving a motorbike on the way home,
the patient was outbalanced while turning due to darkness of the way and because of
drunkenness, the patient sustained injury in right thigh, had multiple abrasions on anterior and
posterior lower extremity, tenderness on the right leg prompted patient to consult Vicente Sotto
Memorial Medical Center Emergency Room for medical advice and decided to admit for medical
intervention and surgical operation. He was admitted on Ward 8 (Orthopedic ward) last July 6,
2011, around 11:03 pm under the care of Dr. Dominic Vicuňa, He has a chief complaint of
Vehicular accident with an admitting diagnosis of Fractured Closed Distal Third Femur Right
Comminuted.
Physical assessment revealed the following findings, (+) pain on right foot radiating
upward, multiple abrasions and hematoma on right lower extremity, limitation of movement noted
and has the following vital signs; Temperature (36.7˚C), Pulse rate (62 bpm), Respiratory rate (21
cpm), Blood Pressure (130/90 mm Hg).
Laboratory procedures done to the patient are Urinalysis and Complete Blood Count,
Diagnostic procedures done were X-ray Skull APL, Cervical Spine APL, Chest PA, Right Hand
APLO, Pelvis AP, Right Thigh APL and right Knee APL. Medication given is Celecoxib 200 mg
PRN for pain.
History of Past Illness
The patient hasn’t been hospitalized before and claims to undergo wound suturing due to
another vehicular accident in Carajay District Hospital year 2001, Claims to have a family history
of Hypertension and Diabetes Mellitus on paternal side, No known food and drug allergies, (-)
smoking, (+) alcohol, (+) drugs, usually eats Rice, Fish, Vegetables, Beef And Pork, not involved
in any social activity, sleeps at 10 pm and wakes at 7 am, sexually active (3x weekly).
I. Patient’s Vitae
Mr. T.B.M, 32 years old, Male, Married, Currently residing in Carajay, Lapu-Lapu City,
Cebu with wife and 3 children (2 boys and a girl), Born on October 23, 1978 in Carajay, Lapu-
Lapu City, Roman Catholic, Filipino, Worked at City hall resigned after election, currently
unemployed and sells chicken, Graduated Associate Criminology can speak Tagalog and
Cebuano, weighs 79 kilograms and has a height of 5 feet and 5 inches.
II. Functional Health Patterns
Patient was observed to be compliant with medication regimen, use of health-promotion
activities such as regular exercise (Passive and active ROM exercises), Patient understood the
purpose of medical intervention and surgical operation such as placement of traction as
evidenced by keeping affected part immobilized as possible and minimizing movement and for
nutritional and metabolic, the patient has no food restrictions, typical daily food intake includes
Rice, Fish, Vegetables, Beef And Pork, no swallowing difficulties, Patient states to minimize
eating as possible to minimize discomfort and inconvenience during bowel movement, skin
lesions on right posterior leg noted, weight is 76 kg and height is 5’5’ft, abdominal assessment
reveals distension, noted 5 gurgles upon checking bowel sounds, no dehydration noted, for
elimination the patient’s bowel movement is once every 2 days, he able to defecate without
difficulty, constipation noted, dark brown hard stools noted, urination is 6-8 times daily, no pain
upon urination noted, slightly cloudy, yellow colored urine noted. The Patient is unable to
ambulate due to leg fracture, does passive ROM exercise on unaffected foot with wife and active
ROM exercise on upper extremities, patient is unable to do some ADL’s due restriction of mobility
but constantly repositions itself on bed as instructed by nurse or wife. Patient usually sleeps at 9-
10 pm and wakes at 6 am, patient states some discomfort during sleeping in the hospital which
caused by light, pain, noise and constant vital signs monitoring. Patient is able to rest every after
meal since the patient is on bed always. Patient is able understand and follow directions, retain
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information, make decisions, and solves problems as evidenced by taking medications religiously
on indicated time on his own, Able to taste appropriately when food is given, no hearing difficulty,
able to read newsprints, able to smell appropriately. Patient feels bad about self and blames
himself in the accident, patient frequently becomes angry and annoyed about the restrictions and
limitation in his activities. Patient is able to maintain eye contact, is assertive and has long
attention span, able to communicate cooperatively with nurse. Patient acknowledges being a
husband and father of 3 children, lives with family and interacts with family member appropriately,
states that income is sufficient for their family needs, is not involved with any social groups but
has close relationship with neighbors. Development of sexual characteristics are appropriate with
age, patient states he is sexually active (3x weekly) and has no difficulty having sex, doesn’t use
any contraception. Patient states that he drinks alcohol most of the time and takes drugs (not
specified) when he is stressed, states that his family is always with him when he has problem and
it really helped him to handle stress appropriately. Patient is Roman Catholic and states that
keeping spirituality within the family is important and enforced in his family. Goes to church every
Sunday with family.
III. Physical Assessment
Head is normocephalic, symmetric, round, erect, midline with incision on parietal area, no
involuntary movement noted, Facial features are symmetrical, temporal artery elastic and non
tender, anicteric sclera, pupils are midline with each eyeballs, pale conjunctiva, eye movement
symmetric and smooth in 6 directions, Ears are normal in size bilaterally 4 cm, both are aligned
with inner canthus of the eye, no discharges, tenderness or lesions noted, lips are dry and pale,
complete set of teeth noted, no dysphagia or ulcerations noted on oral cavity, lymph nodes are
non tender and movable. Respiratory rate is 21 cycles per minute with normal depths, no nasal
flaring, use of accessory muscles noted, no adventitious sounds are auscultated, bronchial
sounds heard on trachea and thorax, Bronchovesicular sounds heard over the major bronchi and
around the upper sternum, Vesicular sounds heard at peripheral lung fields. Chest expansion of 5
cm bilaterally noted. Systolic blood pressure of 130 and diastolic blood pressure of 90 noted
bilaterally while lying. Apical pulse is regular with a rate of 66 beats per minute, pedal pulses is
6
regular and bilaterally equal with a rate of 66 beats minute, no neck vein distension noted.
Anterior chest is uniform in color with smooth texture no edema, tenderness, discoloration or
nodules palpated, the ratio of anteroposterior diameter to transverse diameter is 2:1, scapula are
non protruding, spinous process appear straight and thorax appears symmetric with ribs sloping
downward, breast are symmetrical, not engorged or enlarged, nipples are dark brown and equal
in size bilaterally. Abdomen is symmetric and slightly rounded with a large tattoo on midline,
umbilical skin tones are similar to surrounding abdominal skin tones, umbilicus is midline at lateral
line, bowel sounds are heard as intermittent, soft clicks and gurgles at a rate of 5 per minute,
slightly rigid due to decreased bowel movement, no tenderness noted. Bladder is not palpable
when not full, dull thud heard upon percussion of full bladder, urinates daily with a rate of 6-8
times approximately 700cc per day, urine color is yellow with a consistency of slightly cloudy.
Joint are non tender, no swelling or bulging of fluid, knees symmetric, hollows present on both
sides of the patella, lower leg aligned with upper leg. Full range of motion on upper extremity and
marked limitation of range of motion on lower extremity. Facial movements are symmetrical,
smiles, frowns, puff out cheeks, wrinkles forehead and shows teeth without difficulty, has full
control on movements upper extremity while limited on lower extremity, sensory functions are
equal on both sides, balance is not assessed due to mobility restrictions, patient is able to
perform finger to nose test, reflexes are hypoactive on upper extremities (+). Able to identify the
scent presented on each nostril. Able to read newsprint 14 inches away with full visual fields.
Eyelid covers 2mm of the iris, eyes move in a smooth coordinated motion, pupils are both
reactive and responsive to light accommodation. Eyes move in a smooth coordinated motion in
an upward and downward motion. Reflection of light on the corneas are in the same spot
indicating parallel alignment approximately 3mm from inner canthus, temporal and masseter
muscles contact bilaterally. Lateral movements of eyeballs are smooth and in coordinated motion.
Facial movements are symmetrical, smiles, frowns, puff out cheeks, wrinkles forehead and shows
teeth without difficulty, movements are symmetrical, able to identify sweet and salty flavor. Able to
hear whispered voice 1 meter away with both ears. Gag reflex is intact, able to identify sour and
bitter taste Uvula and soft palate rise bilaterally on phonation, no hoarseness of voice noted.
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Strong and symmetric contractions of Trapezius muscle and there is strong contraction of
Sternocleidomastoid muscle on the side opposite the turned face upon turning against resistance.
Tongue movement is symmetric and smooth and bilateral strength is apparent.
CHAPTER III
FIGURE 1. Upper extremity of right femur viewed from behind and above.
The femur, or thigh bone, is the only bone in the thigh. It is the heaviest, strongest bone
in the body. Its proximal end has a ball-like head, a neck, and greater and lesser trochanters
(separated anteriorly by the intertrochanteric line and posteriorly by the intertrochanteric crest).
The trochanters, intertrochanteric crest and the gluteal tuberosity, located on the shaft, all serve
us sites for muscle attachment.
The head which is globular and forms rather more than a hemisphere, is directed upward,
medialward, and a little forward, the greater part of its convexity being above and in front. Its
surface is smooth, coated with cartilage in the fresh state, except over an ovoid depression, the
fovea capitis femoris, which is situated a little below and behind the center of the head, and gives
attachment to the ligamentum teres.
The neck is a flattened pyramidal process of bone, connecting the head with the body,
and forming with the latter a wide angle opening medialward. The angle is widest in infancy, and
becomes lessened during growth, so that at puberty it forms a gentle curve from the axis of the
body of the bone. In the adult, the neck forms an angle of about 125° with the body, but this
varies in inverse proportion to the development of the pelvis and the stature. In the female, in
consequence of the increased width of the pelvis, the neck of the femur forms more nearly a right
angle with the body than it does in the male. The angle decreases during the period of growth,
but after full growth has been attained it does not usually undergo any change, even in old age; it
varies considerably in different persons of the same age. It is smaller in short than in long bones,
and when the pelvis is wide.
In addition to projecting upward and medialward from the body of the femur, the neck
also projects somewhat forward; the amount of this forward projection is extremely variable, but
on an average is from 12° to 14°. The neck is flattened from before backward, contracted in the
middle, and broader laterally than medially. The vertical diameter of the lateral half is increased
by the obliquity of the lower edge, which slopes downward to join the body at the level of the
lesser trochanter, so that it measures one-third more than the antero-posterior diameter. The
medial half is smaller and of a more circular shape. The anterior surface of the neck is perforated
by numerous vascular foramina. Along the upper part of the line of junction of the anterior surface
with the head is a shallow groove, best marked in elderly subjects; this groove lodges the
orbicular fibers of the capsule of the hip-joint. The posterior surface is smooth, and is broader and
more concave than the anterior: the posterior part of the capsule of the hip-joint is attached to it
about 1 cm. above the intertrochanteric crest. The superior border is short and thick, and ends
laterally at the greater trochanter; its surface is perforated by large foramina. The inferior border,
long and narrow, curves a little backward, to end at the lesser trochanter.
The trochanters are prominent processes which afford leverage to the muscles that rotate
the thigh on its axis. They are two in number, the greater and the lesser.
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FIGURE 2. Right femur. Anterior surface.
The Greater Trochanter (trochanter major; great trochanter) is a large, irregular,
quadrilateral eminence, situated at the junction of the neck with the upper part of the body. It is
directed a little lateralward and backward, and, in the adult, is about 1 cm. lower than the head. It
has two surfaces and four borders. The lateral surface, quadrilateral in form, is broad, rough,
convex, and marked by a diagonal impression, which extends from the postero-superior to the
antero-inferior angle, and serves for the insertion of the tendon of the Glutæus medius. Above the
impression is a triangular surface, sometimes rough for part of the tendon of the same muscle,
sometimes smooth for the interposition of a bursa between the tendon and the bone. Below and
behind the diagonal impression is a smooth, triangular surface, over which the tendon of the
Glutæus maximus plays, a bursa being interposed. The medial surface, of much less extent than
the lateral, presents at its base a deep depression, the trochanteric fossa (digital fossa), for the
insertion of the tendon of the Obturator externus, and above and in front of this an impression for
the insertion of the Obsturator internus and Gemelli. The superior border is free; it is thick and
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irregular, and marked near the center by an impression for the insertion of the Piriformis. The
inferior border corresponds to the line of junction of the base of the trochanter with the lateral
surface of the body; it is marked by a rough, prominent, slightly curved ridge, which gives origin to
the upper part of the Vastus lateralis. The anterior border is prominent and somewhat irregular; it
affords insertion at its lateral part to the Glutæus minimus. The posterior border is very prominent
and appears as a free, rounded edge, which bounds the back part of the trochanteric fossa.
The Lesser Trochanter (trochanter minor; small trochanter) is a conical eminence, which
varies in size in different subjects; it projects from the lower and back part of the base of the neck.
From its apex three well-marked borders extend; two of these are above—a medial continuous
with the lower border of the neck, a lateral with the intertrochanteric crest; the inferior border is
continuous with the middle division of the linea aspera. The summit of the trochanter is rough,
and gives insertion to the tendon of the Psoas major.
A prominence, of variable size, occurs at the junction of the upper part of the neck with the
greater trochanter, and is called the tubercle of the femur; it is the point of meeting of five
muscles: the Glutæus minimus laterally, the Vastus lateralis below, and the tendon of the
Obturator internus and two Gemelli above. Running obliquely downward and medialward from the
tubercle is the intertrochanteric line (spiral line of the femur); it winds around the medial side of
the body of the bone, below the lesser trochanter, and ends about 5 cm. below this eminence in
the linea aspera. Its upper half is rough, and affords attachment to the iliofemoral ligament of the
hip-joint; its lower half is less prominent, and gives origin to the upper part of the Vastus medialis.
Running obliquely downward and medialward from the summit of the greater trochanter on the
posterior surface of the neck is a prominent ridge, the intertrochanteric crest. Its upper half forms
the posterior border of the greater trochanter, and its lower half runs downward and medialward
to the lesser trochanter. A slight ridge is sometimes seen commencing about the middle of the
intertrochanteric’ crest, and reaching vertically downward for about 5 cm. along the back part of
the body: it is called the linea quadrata, and gives attachment to the Quadratus femoris and a few
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fibers of the Adductor magnus. Generally there is merely a slight thickening about the middle of
the intertrochanteric crest, marking the attachment of the upper part of the Quadratus femoris.
FIGURE 3. Right femur. Posterior surface.
The body, almost cylindrical in form, is a little broader above than in the center, broadest
and somewhat flattened from before backward below. It is slightly arched, so as to be convex in
front, and concave behind, where it is strengthened by a prominent longitudinal ridge, the linea
aspera. It presents for examination three borders, separating three surfaces. Of the borders, one,
the linea aspera, is posterior, one is medial, and the other, lateral.
The linea aspera (FIGURE 3.) is a prominent longitudinal ridge or crest, on the middle
third of the bone, presenting a medial and a lateral lip, and a narrow rough, intermediate line.
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Above, the linea aspera is prolonged by three ridges. The lateral ridge is very rough, and runs
almost vertically upward to the base of the greater trochanter. It is termed the gluteal tuberosity,
and gives attachment to part of the Glutæus maximus: its upper part is often elongated into a
roughened crest, on which a more or less well-marked, rounded tubercle, the third trochanter, is
occasionally developed. The intermediate ridge or pectineal line is continued to the base of the
lesser trochanter and gives attachment to the Pectineus; the medial ridge is lost in the
intertrochanteric line; between these two a portion of the Iliacus is inserted. Below, the linea
aspera is prolonged into two ridges, enclosing between them a triangular area, the popliteal
surface, upon which the popliteal artery rests. Of these two ridges, the lateral is the more
prominent, and descends to the summit of the lateral condyle. The medial is less marked,
especially at its upper part, where it is crossed by the femoral artery. It ends below at the summit
of the medial condyle, in a small tubercle, the adductor tubercle, which affords insertion to the
tendon of the Adductor magnus.
From the medial lip of the linea aspera and its prolongations above and below, the
Vastus medialis arises; and from the lateral lip and its upward prolongation, the Vastus lateralis
takes origin. The Adductor magnus is inserted into the linea aspera, and to its lateral prolongation
above, and its medial prolongation below. Between the Vastus lateralis and the Adductor magnus
two muscles are attached—viz., the Glutæus maximus inserted above, and the short head of the
Biceps femoris arising below. Between the Adductor magnus and the Vastus medialis four
muscles are inserted: the Iliacus and Pectineus above; the Adductor brevis and Adductor longus
below. The linea aspera is perforated a little below its center by the nutrient canal, which is
directed obliquely upward.
The other two borders of the femur are only slightly marked: the lateral border extends
from the antero-inferior angle of the greater trochanter to the anterior extremity of the lateral
condyle; the medial border from the intertrochanteric line, at a point opposite the lesser
trochanter, to the anterior extremity of the medial condyle. The anterior surface includes that
portion of the shaft which is situated between the lateral and medial borders. It is smooth, convex,
14
broader above and below than in the center. From the upper three-fourths of this surface the
Vastus intermedius arises; the lower fourth is separated from the muscle by the intervention of
the synovial membrane of the knee-joint and a bursa; from the upper part of it the Articularis genu
takes origin. The lateral surface includes the portion between the lateral border and the linea
aspera; it is continuous above with the corresponding surface of the greater trochanter, below
with that of the lateral condyle: from its upper three-fourths the Vastus intermedius takes origin.
The medial surface includes the portion between the medial border and the linea aspera; it is
continuous above with the lower border of the neck, below with the medial side of the medial
condyle: it is covered by the Vastus medialis.
CHAPTER IV
Pathophysiology
FIGURE 4. Pathophysiology of fracture (schematic diagram)
FractureFracture
Traumatic Force Applied To the Right Lower ExtremityTraumatic Force Applied To the
Right Lower Extremity
NumbnessNumbness
Multiple Abrasions and the Distal 3rd Femur Bone Is Broken Into Fragments (Comminuted)Multiple Abrasions and the Distal 3rd Femur
Bone Is Broken Into Fragments (Comminuted)
Physical Trauma Due to Motorbike Accident
Physical Trauma Due to Motorbike Accident
Bleeding Occurs From the Damaged Bone and From the Neighboring Soft TissuesBleeding Occurs From the Damaged Bone and From
the Neighboring Soft Tissues
Precipitating factors:
Behavior
Lifestyle
Occupation
Environment
Precipitating factors:
Behavior
Lifestyle
Occupation
Environment
Fibrous Connective Tissue or Periosteum And Blood Vessels in the Cortex Marrow, And Surrounding Soft
Tissues Are Disrupted and Damaged.
Fibrous Connective Tissue or Periosteum And Blood Vessels in the Cortex Marrow, And Surrounding Soft
Tissues Are Disrupted and Damaged.
Risk factorsRisk factors Pre disposing
factors:
Age
Gender
Pre disposing factors:
Age
Gender
Pain, Swelling, Redness, Heat, Loss of FunctionPain, Swelling, Redness, Heat, Loss of Function
Stimulation of the Inflammatory ResponseStimulation of the Inflammatory Response
HematomaHematoma
Formation of blood clotFormation of blood clot
Nerve at the site of fracture damaged
Nerve at the site of fracture damaged
Muscle spasm due Fractured
bone
Muscle spasm due Fractured
bone
Limitation of ROM, Mobility and Reduction of ADLS’sLimitation of ROM, Mobility and Reduction of ADLS’s
Pain and TendernessPain and
Tenderness
A fracture is a break in the continuity of bone and is according to its type and extent.
Fractures occur when the bone is subjected to stress greater than it can absorb. Fractures are
caused by direct blows, crushing forces, sudden twisting motions, and even extreme muscle
contractions. When the bone is broken, adjacent structures are also affected resulting in soft
hemorrhage into the muscles and joints, joint ruptured tendons, severed nerves, and damaged
blood, organs may be injured by the force that caused the fracture fragments. The severity of the
fracture, therefore, depends on the strength of the impact, the position of the bone when it was
hit, and what type of bone has been affected. This is why bones can break in many different
ways. The different cases of broken bones could be compound fractures, closed fractures, stress
fractures, and fractures caused by pathological diseases such as osteoporosis. The above
schema shows a comminuted type of fracture this type of fracture occurs when a bone has been
broken into a number of pieces.
Modifiable Risk factors for this type of fracture is the same as any other fracture which
includes behavior such drunk driving which is the actual etiological factor for patient’s accident,
lifestyle which basically relates to the nutritional intake, smoking habits and other activity that
would affect the body’s bone integrity and calcium levels, Occupation and environment involving
sun exposure and etc., other factors which are non modifiable includes Age caused by increased
degeneration of bones as age also increases and Gender which mainly is caused by interplay of
hormones in the body.
In the above schema, the fracture is caused by a motorbike accident causing physical
trauma in the right lower extremity, the accident also caused multiple abrasions and comminuted
fracture in the distal 3rd femur. Broken bone fragments affects the nerve endings in the
surrounding area causing numbness and muscle spasm leading to pain and tenderness thus
causing the limitation of Range Of Motion and mobility disabling the patient to perform some
activities of daily living.
The above schema also shows the natural process of healing of a fracture which starts
when the injured bone and surrounding tissues bleed, forming a Hematoma. The blood
17
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 fibers. 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.
Throughout the process of bone healing the body’s inflammatory response is stimulated which is
manifested by Pain, Swelling, Redness, Heat, Loss of Function and subsequently adds to the
limitation Range Of Motion and mobility.
CHAPTER V
MEDICAL MANAGEMENT
Laboratory procedures
Hematology
One of the most important laboratory procedures for patient with fracture is complete
blood count or hematology. Hematology is the study of the cellular elements of the blood, the
production of these elements, and the physiological derangements that affect their functions. It is
also concerned with blood volume, the flow properties of blood, and the physical relationships of
red cells and plasma. Changes in blood components may be evidenced by a patient with fracture
such as in Hematocrit it may be increased (hemoconcentration) or decreased (signifying
hemorrhage at the fracture site or at distant organs in multiple trauma). Increased white blood cell
(WBC) count is a normal stress response after trauma. Abnormal results during the actual
complete blood count result of the patient (see appendix B) includes increased white blood cell
count which is 11.9x10^9/L over a normal value of 4.8-10.8x10^9/L this indicates a normal stress
response after trauma or it may also that there is an undergoing infection in the fracture site.
Mean Corpuscular Hemoglobin which is 32.7 pg over a normal value of 27-31 pg which indicates
macrocytic anemia, this could be not directly related to the diagnosis and also an increased
basophil and monocyte which indicates bacterial infection and inflammation.
Urinalysis
Routine urinalysis is one of the most widely ordered laboratory procedures, is used for
basic screening purposes. It is a group of tests that evaluate the kidneys’ ability to selectively
excrete and reabsorb substances while maintaining proper water balance. The results can
provide valuable information regarding the overall health of the patient and the patient’s response
to disease and treatment. The urine dipstick has a number of pads on it to indicate various
biochemical markers. Urine pH is an indication of the kidneys’ ability to help maintain balanced
hydrogen ion concentration in the blood. Specific gravity is a reflection of the concentration ability
of the kidneys. Urine protein is the most common indicator of renal disease, although
there are conditions that can cause benign proteinuria. Glucose is used as an indicator of
diabetes. The presence of ketones indicates impaired carbohydrate metabolism. Hemoglobin
indicates the presence of blood, which is associated with renal disease.
Urine samples for routine analysis are best collected first thing in the morning. Urine that
has accumulated in the bladder overnight is more concentrated, thus allowing detection of
substances that may not be present in more dilute random samples. The sample should be
examined within 1 hour of collection. If this is not possible, the sample may be refrigerated until it
can be examined. Failure to observe these precautions may lead to invalid results.
According to the patients actual urinalysis results (see appendix C) it showed that all of
the parameters evaluated during the analysis are within normal values.
Coagulation profile
The coagulation proteins respond to blood vessel injury in a chain of events. The intrinsic
and extrinsic pathways of secondary hemostasis are a series of reactions involving the substrate
protein fibrinogen, the coagulation factors (also known as enzyme precursors or zymogens),
nonenzymatic cofactors (Ca2+), and phospholipids. The factors were assigned Roman numerals
in the order of their discovery, not their place in the coagulation sequence. Alterations may occur
because of blood loss, multiple transfusions, or liver injury. The specimen for this laboratory
procedure is a Whole blood in a completely filled 5-mL blue-top (sodium citrate) tube.
According to the patient’s actual results (see appendix D) all of the parameters evaluated
during the coagulation profile fall within normal range.
Diagnostic procedures
Bone Radiography
Bone radiography are used to evaluate extremity pain or discomfort due to trauma, bone
abnormalities, or fluid within a joint. Serial skeletal x-rays are used to evaluate growth pattern.
Radiation emitted from the x-ray machine passes through the patient onto a photographic plate or
20
x-ray film. X-rays pass through air freely and are mostly absorbed. skeletal x-rays are used to
evaluate extremity pain or discomfort due to trauma, bone abnormalities, or fluid within a joint.
Serial skeletal x-rays are used to evaluate growth pattern. Radiation emitted from the x-ray
machine passes through the patient onto a photographic plate or x-ray film. X-rays pass through
air freely and are mostly absorbed. Thus this procedure determines location and extent of
fractures/trauma, may reveal preexisting and yet undiagnosed fractures.
Bone scans, tomograms, computed tomography (CT)/magnetic resonance imaging (MRI)
scans help visualize fractures, bleeding, and soft-tissue damage; differentiates between
stress/trauma fractures and bone neoplasms.
According to the patients actual diagnostic result (see appendix E) abnormal findings
found in the x rays includes soft tissue swelling in the parieto-occipital region this was found out
through Skull APL, Straightening of the cervical spine due to muscle spasm which was evident on
cervical spine APL, Comminuted fracture, distal third, right femur with soft tissue swelling evident
on thigh right APL and knee right APL.
Arthrogram
An arthrogram evaluates the cartilage, ligaments, and bony structures that compose a
joint. After local anesthesia is administered to the area of interest, a fluoroscopically guided
Small-gauge needle is inserted into the joint space. Fluid in the joint space is aspirated and sent
to the laboratory for analysis. Contrast medium is inserted into the joint space to outline the soft
tissue structures and the contour of the joint. After brief exercise of the joint, radiographs or
magnetic resonance images (mris) are obtained. Arthrograms are used primarily for assessment
of persistent, unexplained joint discomfort. Area of application includes shoulder, elbow, wrist,
hip, knee, ankle, temporomandibular joint. This test is indicated for patients with fracture, evaluate
pain, swelling, or dysfunction of a joint monitor disease progression. Normal findings are Normal
bursae, menisci, ligaments, and articular cartilage of the joint (note: the cartilaginous surfaces
and menisci should be smooth, without evidence of erosion, tears, or disintegration) Abnormal
findings can be found out in patients with Fracture, Arthritis, Cysts Diseases of the cartilage
(chondromalacia),Injury to the ligaments
21
Drug study
The only drug prescribed to the patient is Celecoxib 200mg 1tab OD prn for pain. An
analgesic drug and has anti-inflammatory activities related to inhibition of the COX-2 enzyme,
which is activated in inflammation to cause the signs and symptoms associated with
inflammation; does not affect the COX-1 enzyme, which protects the lining of the GI tract and has
blood clotting and renal functions. This is given to the patient if patient is experiencing headache
to manage pain. Before giving the medication, the nurse should (a) check patient’s history of
allergies, renal impairment, impaired hearing, and hepatic and CV conditions if any; (b) check
skin color and lesions; (c) check CBC, LFTs, renal function tests, serum electrolytes; (d) monitor
vital signs; and (e) assess patient’s pain score. During the giving of drug, the nurse should: (a)
administer drug with food or after meals; (b) establish safety measure if CNS or visual
disturbances occur; and (c) document giving of drug. After giving of drug, the nurse should: (a)
Provide comfort measures to reduce pain such as positioning, environmental control; (b) Instruct
patient to take drug with food to prevent GI upse; (c) Instruct patient to take only the prescribed
dosage; do not increase dosage; (d) Tell patient that he may experience adverse effects such as
dizziness and drowsiness; and (e) Tell patient to report experience of sore throat, fever, rash,
itching, weight gain, swelling in ankles or fingers, changes in vision promptly.
SURGICAL MANAGEMENT
Open Reduction Internal Fixation
An open reduction and internal fixation (ORIF) is a type of surgery used to fix broken
bones. This is a two-part surgery. First, the broken bone is reduced or put back into place. Next,
an internal fixation device is placed on the bone; this can be screws, plates, rods, or pins used to
hold the broken bone together. This surgery is done to repair fractures that would not heal
correctly with casting or splinting alone. Before the surgery is done the patient has to undergo the
following exams: Physical examination which is to check your blood circulation and nerves
affected by the broken bone, X-ray, CT scan, Blood tests, and Tetanus shot which depends on
the type of fracture and if your immunization is current. General anesthesia may be used. It will
22
block any pain and keep you asleep during the surgery. It is given through an IV (needle in your
vein) in your hand or arm. In some instances, a spinal anesthetic, or more rarely a local block,
may be used to numb only the area where the surgery will be done. This will depend on where
the fracture is located and the time it will take to perform the procedure. Each ORIF surgery
differs based on the location and type of fracture. In general, a breathing tube may be placed to
help you breathe while you are asleep. Then, the surgeon will wash your skin with an antiseptic
and make an incision. Next, the broken bone will be put back into place. Next, a plate with
screws, a pin, or a rod that goes through the bone will be attached to the bone to hold the broken
parts together. The incision will be closed with staples or stitches. A dressing and/or cast will
then be applied.
NURSING MANAGEMENT
Summary of nursing problems:
1. Acute pain related to movement of bone fragments secondary to comminuted fracture.
2. Impaired Physical Mobility related to musculoskeletal impairment secondary to prescribed
restrictive therapies. (traction)
3. Risk for Trauma (additional injury) related to loss of skeletal integrity and improper
placement of traction weights.
Individualized Nursing Care Plan
Upon the first day of interaction to the patient the researcher was able to formulate the
nursing problems and prioritized as to the most critical nursing focus which is acute pain related
to movement of bone fragments secondary to comminuted fracture. Objective findings that could
support the formulated problem include; Received patient lying on bed with head elevated,
awake, conscious, coherent, communicative, with foam traction at right foot, with pain score of 7
out of 10, grimaced face noted, irritability observed, restlessness noted, limited range of motion
observed and with a subjective cue of :”ngol-ngol kaayu ang ako bali” as verbalized. Short term
goal formulated includes after 5 hours of nursing intervention the patient will be able to verbalize
23
pain relief as evidenced by decreased pain score. Long term goal formulated includes after 3
days of nursing intervention, the patient will be able to, verbalize and demonstrate techniques that
provide pain relief and demonstrate effective use of relaxation techniques as indicated for
individual situation after assessment and goal planning the interventions were made which
includes assessment level of pain, location, character, and aggravating factor to rule out for
worsening of underlying conditions and development of complication and prevent occurrence.
Observation for non-verbal cues of pain because they may not be congruent with verbal reports
and may prompt change in locus of intervention, Provision of comfort measures as possible such
as touch therapy, repositioning, use of cold/heat packs, constant interaction, quiet environment
and calm activities which maximizes use of non-pharmacological techniques for pain relief,
Instruction in and encouragement of usage of relaxation techniques such as focused breathing
and imaging to distract patients attention and thus reduce tension, Encouragement in engaging in
diversional activities such as socialization with other patients or listening to music which is also
used distract attention and reduce tension, Health teaching about non-pharmacological pain
management to promote self control and management of pain. Dependent and Collaborative
nursing management includes Administration of analgesics as to a maximum as needed as
indicated by individual situation to maintain acceptable level of pain, Instruction patient in use of
transcutaneous electrical nerve stimulation units when ordered to maintain acceptable level of
pain and comfort and lastly referral to occupational/physical therapy program to promote active
role partcipation and enhanced self-control.
During the second day of care, the researcher was to formulate the following nursing care
plan with a nursing focus of Impaired Physical Mobility related to musculoskeletal impairment
secondary to prescribed restrictive therapies. (traction), this problem problem was identified
through analysis of the objective findings which includes, received patient lying on bed with head
elevated to 30 degrees, awake, conscious, coherent, communicative, with foam traction at right
foot, the patient is reading a newspaper, has difficulty in changing position while lying on
bed, has difficulty in moving the extremities, inability to walk or stand alone, limited range
of motion in the extremities, slowed movement, difficulty in initiating gait and subjective cue
24
“maglisod man jud kog lihok sa ako lawas” as verbalized. Short term goal is After 5 hours of
nursing intervention, the patient will be able to perform activities of daily living at the level of
functional capabilities. Long term goal includes After 3 days of nursing intervention; the patient
will be able to demonstrate and verbalize proper exercises of the lower extremities & can perform
activities of daily living with minimal assistance. Nursing interventions that were formulated
include provision of normal range of motion exercises and function of lower extremity which
necessary to regain normal mobility of leg to speed up recovery, Encouragement of progressive
activities according to level of functional capability to increase patient’s use of affected leg.
instruct and encourage use of overhead trapeze in mobilizing in the bed to obtain sense of control
during movement, encouragement in participation in self-care, occupational/diversional/
recreational activities to enhances self concept and sense of independence, Identification of
energy conserving techniques for ADL’s which limits fatigue and maximizes participation in
intervention, encouragement adequate intake of fluid and nutrition to promote well-being and
energy production, provision of proper skin care to decrease risk for decubitus ulcer formation.
Collaborative and dependent nursing interventions include administration medications as needed
prior to activity for pain relief to permit maximal effort and involvement in activity and lastly
consultation with Occupational therapy as needed to maintain continuity of care after discharge.
Third and last nursing care plan for the patient includes a nursing problem which is Risk
for Trauma (additional injury) related to loss of skeletal integrity and improper placement of
traction weights, this was formulated upon analysis of objective findings which includes received
patient lying on bed with head elevated, awake, conscious, coherent, communicative, with foam
traction at right foot, absence of side rails noted, traction weights placed of walkways, absence of
bed padding noted, high placement of bed observed, seen SO frequently leaving the patient and
subjective cue :”dali ra masabod sa mga mangagi kanang baton a gbitay”. As verbalized, short
term goal formulated is those After 4 hours of nursing intervention, the patient will be able to
verbalize understanding of condition and recognize need for prevention of injuries and a long
term goal of After 3 days of nursing intervention, the patient will be able to demonstrate
appropriate lifestyle changes to reduce risk for injury and maintain condition without additional
25
injury and decrease risk for trauma. Nursing interventions formulated for this nursing problem
includes Identification of factors related to individual situation and identify extent of risk which
nfluence the scope and intensity of interventions to manage safety, notification of clients decision-
making ability and level of cognition including functional capability cause this can affects client’s
ability to protect self and influences choice of interventions and teaching, Implementation
interventions regarding safety issues includes: orientation to environment, keep bed in low
position, pad bed edges as possible, provide adequate area lighting and assist with moving or
turning using trapeze becausefailure to accurately assess, intervene and/or refer these these
issues can place patients at needless risk and create negligence issues for healthcare
practitioner, provision quiet environment and reduced stimulation as possible this can help limit
confusion or overstimulation, placement traction weights at appropriate location away from
passageways as possible, to prevent moving the weights causing disaligment of bone fragments.
Collaborative and Dependent nursing interventions includes assistance with treatment of
underlying medical/surgical conditions to improve cognition/thinking process.
Focused charting
On the first day of actual care to the patient the researcher utilized the formulated nursing
care plan and derived to the focus Acute pain with supporting data of received patient lying on
bed with head elevated to 30 degrees, awake, conscious, coherent, communicative, without IV,
with the following v/s T= 35.5 degree Celsius, P= 86 pm, R= 20 bpm and BP= 120/70 mmHg,
with foam traction at right foot, with pain score of 7 out of 10, grimaced face noted, irritability
observed, restlessness noted, limited range of motion observed, “ngol-ngol kaau ang akong bali
dong”. As verbalized. Actions made included; Introduced name to the patient, assessed level of
pain, character and location, monitored v/s, positioned properly on bed with head slightly
elevated, Due medications (analgesics) administered as ordered, encouraged to engage in
diversional activities such as socialization with others, provided comfort measures such as
backrub, encouraged patient to do DBE; supported affected body parts/ joints using pillows/
rolls, consulted with physical or occupational therapist as indicated, documented the v/s and I
26
and O of the patient. After the shift :”wa na kaayu sakit ang ako bali dong”. As verbalized, pain
score decreased from 7out of 10 to 3 out of 10.
On the second day of nursing care the formulated nursing problem for the charting
focuses on Impaired physical mobility with supporting data of received patient lying on bed with
head elevated to 30 degrees, awake, conscious, coherent, communicative, without IV, with the
following v/s T= 35.5 degree Celsius, P= 86 pm, R= 20 bpm and BP= 120/70 mmHg, with foam
traction at right foot, the patient is reading a newspaper, has difficulty in changing position
while lying on bed, has difficulty in moving the extremities, inability to walk or stand
alone, limited range of motion in the extremities, slowed movement, difficulty in initiating gait. “
maglisod man ko ug lihok dong”. As verbalized. Interventions done includes; Introduced name to
the patient, assessed the condition of the patient; monitored v/s, positioned properly on bed with
head slightly elevated, assisted patient in doing ROM exercises, assisted patient upon doing gait
training, instructed in proper use of overhead trapeze, provided comfort measures such as
backrub, encouraged patient to do DBE; supported affected body parts/ joints using pillows/
rolls, consulted with physical or occupational therapist as indicated, documented the v/s and I
and O of the patient after the interaction the patient was able to demonstrate increasing
functionality of the extremities as evidenced by turning on bed without assistance and
effective usage of overhead trapeze
For the last day of care to the patient the researcher utilized the formulated nursing care
plan intended for that day which is Risk for additional injury with supporting data of received
patient lying on bed with head elevated, awake, conscious, coherent, communicative, without IV,
with the following v/s T= 37 degree Celsius, P= 62 pm, R= 21 bpm and BP= 130/70 mmHg, with
foam traction at right foot, absence of side rails noted, traction weights placed of walkways,
absence of bed padding noted, high placement of bed observed, seen SO frequently leaving the
patient, “dali raman masabaod ang kanang mga bato”. As verbalized, interventions done
includes; Introduced name to the patient, assessed the condition of the patient, instructed SO to
stay with patient as much as possible, implemented interventions regarding safety issues such as
orientation of patient to environment, keeping bed in low position, providing adequate area
27
lighting and padding of side rails as possible, monitored v/s, positioned properly on bed with head
slightly elevated, assisted patient in doing ROM exercises, assisted patient upon doing gait
training, instructed in proper use of overhead trapeze, provided comfort measures such as
backrub, encouraged patient to do DBE; supported affected body parts/ joints using pillows/
rolls, consulted with physical or occupational therapist as indicated, documented the v/s and I
and O of the patient after the interaction the patient was able to demonstrate behaviors to
promote safety, SO was seen staying with patient most of the time.
Discharge summary
This is a case of T.B.M, 32 years old, male, married, from Carajay, Lapu-Lapu City,
Cebu, he was admitted on Vicente Sotto Memorial Medical Center ward 8 (orthopedic ward) last
July 6, 2011, around 11:03 pm under the care of Dr. Dominic Vicuṅa, he has a chief complaint of
Vehicular accident with an admitting diagnosis of fractured closed distal third femur, right,
comminuted.
For the discharge instructions, the researcher focused on home care management , the
researcher stressed to the patient the importance of continuing prescribed medication even after
discharge for continuity of care and optimal recovery from condition and recovery, also taught
patient and significant other patient about mechanism of action, dosage, frequency, side effects
and adverse reaction of medication prescribed to increase patient and significant other’s
knowledge about medication thus increasing compliance, advised patient to have daily exercise
as tolerated such as morning walks assisted by a significant other ,Taught about appropriate
exercise that can be used by patient such as passive exercise on the lower or affected extremity
and active exercise on the upper extremity, advised patient to take a bath daily and wash hands
frequently and also advise the significant others to do the same to prevent spread of infection,
taught about signs of infection and when to call for medical emergency, encourage to have
emergency hotline numbers and transportation facilities ready in case of emergency and advised
to return immediately if the following signs occur severe pain, swelling, headache, redness, or
28
frequent light-headedness, encouraged to eat a well balanced diet including high protein and high
calcium for faster bone remodelling and tissue repair which can be found in the following foods;
meat products, egg, milk and other dairy products especially eating green leafy vegetables, also
encouraged to have supplementary vitamins and minerals and lastly encouraged to strengthen
spirituality within the family by attending to mass together and praying together. At the end of the
shift the patient is still in.
CHAPTER VI
EVALUATION AND RECOMMENDATION
I. Extent of Goal Achievement
After 3 days of intervention, the student nurse observed certain changes from the patient. On
the first day of interaction the patient reports decreased pain with elevation, ice and analgesic and
also the patient was able to demonstrate effective use of relaxation techniques as evidenced by
decreased recurrence of pain perception. On the second day of interaction changes observed to
the patient include regaining of the patient’s previous range of motion in the leg & demonstrates
proper exercises for the lower extremities. He also does some ADL without discomfort. On the
third and final day on interaction the patient was seen demonstrating appropriate lifestyle
changes to reduce risk for injury such as asking for help from SO upon moving and using trapeze
effectively when turning. The patient also exhibits unlabored respirations; alert and oriented,
afebrile, using affected extremity for light activity as allowed, no signs of neurovascular
compromise, vital signs are stable; urine output adequate and no calf pain reported: Homan’s
sign negative., hygiene and dressing practices with minimal assistance and denies acute
symptoms of stress; reports working through feelings about trauma.
II. Recommendation
As a researcher in this case study, the student nurse recommends the patient to adjust in
usual lifestyle and responsibilities to accommodate limitations imposed by fracture and to prevent
recurrent fractures – safety considerations, avoidance of fatigue and proper footwear. The patient
is instructed about exercises to strengthening upper extremity muscles If crutch walking is
planned, methods of safe ambulation–walker, crutches, care, emphasizes instructions concerning
amount of weight bearing that will be permitted on fractured extremity, teaches symptoms
needing attention, such as numbness, decreased function, increased pain and elevated
temperature and explains basis for fracture treatment and need for patient participation in
therapeutic regimen. The patient and the family were also informed that the patient must have an
adequate balanced diet to promote bone and soft tissue healing.
Nursing Practice
The result of this case study would provide the student nurse with sufficient knowledge, attitude
and skills towards the management of patients with fracture on the right femoral neck. This study
would help the student nurse in providing a higher quality of care of patients with the same
condition. It is important that the proper and ideal managements and interventions are done in
order to give a more holistic approach and optimum care to clients with fracture on the right
femoral neck. This would ensure the timely healing of injury and the prevention of complications.
Nursing Education
Education can promote enhancement of professionalism through an on- going learning process,
whether self- motivated, people- oriented and having a commitment to the organization, nurses
are likely to become well respected through the formal educational programs. Through this case
study, it is important to know all areas of patient are both knowledge and skills to manage
effectively in all aspects of their professional nursing practice.
Nursing Research
Nursing research is essential for the development of scientific knowledge that enables nurses to
provide evidenced-based health care. Broadly nursing is accountable to society for providing
quality, cost effective care and for seeking ways to improve that care. More specifically, nurses
are accountable to their patients to promote a maximum level of health.
31
BIBLIOGRAPHY
Book sources:
Bare, Brenda I. and Smeltzer, Suzzane C., Textbook of Medical-Surgical Nursing. 10th
Edition Philadelphia: I.B Lippincott Company. 2004.
Deglin, J. and Vallerand, A. 2005. Davis’ Drug Guide 9th edition, Philadelphia; F.A davis
Doenges, M., Moorhouse, M.F. , Geissler – Murr, A. “ Nurses Pocket Guide”, Diagnosis,
interventions and rationales, 9th Edition (2004).
Doenges, M., Moorhouse, M.F. , Geissler – Murr, A., “ Nursing Care Plans”. Guidelines
for Individualizing Patient Care. 6th Edition. F.A. Davis Company, 2002.
Nettina, Sandra M., Manual of nursing Practice. 7th Edtion. I.B. Lippincott Company.
2001.
Rozler, Barbara et al. Fundamentals of Nursing. 5th Edition. Newyork: Addison-
Weatleylongman, Incorporated. 1998.
Marieb, Elaine N. Essential of Human Anatomy and Physiology. 7th Edition. Singapore.
Pearson Education South Asia Pte. Ltd. 2004.
Potter, Patricia and Perry, Anne. Fundamentals of Nursing. 6th Edition Baltimore: C.V.
Mosby and Company. 2005.
Internet Sources:
Aukerman, Douglas F, MD, Ho, Sherwin SW, MD, (30 Oct 2008), Femur Injuries and
Fractures, Retrieved august 21, 2011 from http://emedicine.medscape.com/article/90779-
Cluett, Jonathan, M.D., (August 21, 2005), Femur Fracture, Retrieved September 18,
2011 from http://orthopedics.about.com/od/brokenbones/a/femur.htm
Crist, Brett D. MD; Della Rocca Gregory J., MD, PhD; Murtha, Yvonne M. MD, (July
2008), Treatment of Acute Distal Femur Fractures, Retrieved September 18, 2011 from
http://www.orthosupersite.com/view.aspx?rid=2979
Keany, James E, MD, FACEP, Kulkarni Rick, MD (2011, January), Femur Fracture,
Retrieved August 21, 2011, from http://emedicine.medscape.com/article/824856-overview.
Appendices
33
APPENDIX A
Cebu Normal UniversityCollege of Nursing
APPROVAL FOR CASE STUDY
Name of Student: Macayan, Jellou Ray M. Year and Section: IV-BSemester: First Semester Academic Year: 2011-2012
This is to certify that the student is approved to take the case of
T.B.M
(Initials of Patient)
With diagnosis of
Fractured Closed, Distal 3 rd Femur, Right, Comminuted
(Write the full diagnosis)
In Ward VIII (Orthopedic Ward) as subject for case study in the undergraduate level.
Name and signature of Clinical Instructor:
Mrs. Bertilia F. Pragados BSN, RN
Date of approval: ___________________
34
APPENDIX B
Cebu Normal UniversityCollege of Nursing
APPROVAL FOR FINAL PRINTING AND BOOK BINDING OF CASE STUDY
Name of Student: Macayan, Jellou Ray M. Year and Section: IV-BSemester: First Semester Academic Year: 2011-2012
This is to certify that the case study has underwent final checking and is approved for final printing and
book binding as partial fulfilment for the requirements for graduation.
Name and signature of Clinical Instructor:
Mrs. Bertilia F. Pragados BSN, RN
Date of approval: __________________
35
APPENDIX C Physical assessment (actual)
Cebu Normal UniversityCollege of Nursing
Cebu City
NURSING ADMISSION AND ASSESSMENT
Name of Student: Jellou Ray M. Macayan Clinical Assignment: WARD VIII (orthopedic ward)
Name of Clinical Instructor: Bertilia F. Pragados Inclusive Dates:
A. General Admission Information
Name of Patient: T.B.M, Age: 32 years old Sex: Male
Date: July 6, 2011 Time: 11:03 pm Mode: ERUF Allergies: no known allergies
TPR: T- 37, P- 62 R- 21 BP: 130/70 mmhg HT: 5’5 Ft WT: 79 kg. Diet: Diet As Tolerated
Sleeping Habits: sleeps at 10 pm and wakes at 7 am CBC: Yes / No Urinalysis: Yes / No
Property: Glasses NONE Contact Lenses NONE Dentures NONE
Prosthesis NONE Ring NONE Watch Money NONE
Other NONE
Valuable to Business Office NONE
Physical Appearance: Client appears to be on his stated chronological age, sexual development is appropriate for age, observed no upper
clothing, prominent tattoo noted on abdomen, unkempt appearance noted, diaphoresis noted, complexion is even, foam traction noted at
right foot
Behavior Exhibited: client is cooperative during the interaction and purposive in his actions, openness noted during conversation with life
experiences, mild anxiety noted, affect is appropriate with occasion, speech is clear, moderately paced and culturally appropriate.
Content of Conversation: patient- centered; topic was focused on patient’s profile, perception of reason for admission, present condition,
patient’s history of past and present illness, educational and cultural background.
Dr. Dominic Vicuña M.D.
Physician In-charge
B. Admission Interview
36
1. Patient’s perception of reason for admission: Patient verbalizes that reason for admission was because he sustained a
fracture on his lower extremity “nabali akong paa” as verbalized
2. Patient’s symptoms as he/she sees them: “ngol-ngol kaayu og hapdos kung masabod ang akong bali”as verbalized by the pt.
3. Problems in daily living created by symptoms (as patient views them)
Patent is unemployed so he helps in raising his children and also in chicken business and because of this condition he can longer
attend to this job.
4. Past Medical History (especially as it relates to P.I.)
a. Medical hasn’t been hospitalized before
b. Surgical wou nd suturing – 2001 – Carajay District Hospital-ER
c. Allergies no known allergies
d. Medication Celecoxib 200mg 1 tablet prn for pain,
e. Traumatic Injuries Vehicular accident – 2001 – Carajay District hospital ER – wound suturing
f. Orthopedic NONE
g. Other (psychiatric, etc.) NONE
5. Habits:
a. Smoking non-smoker Alcohol drinks 3x weekly Drugs occasionally(as verbalized
b. Eating Breakfast, Lunch And Supper: Rice, vegetables, fish, beef, pork and water
c. Social Activity none but is a basketball player in their place previously Physical Exercise walking and running
d. Rest/Sleeping usually sleeps at 10pm and wakes up at 7 am, at 2pm patient takes a nap and wakes at 3 or 4 pm.
e. Sexual active, 3 times weekly as verbalized
f. Elimination bowel movement: once daily urination: 8-10 times daily
37
6. Social Economic History:
a. Native Language Cebuano and Tagalog
b. Education college level (graduate of associate criminology)
c. Occupation unemployed, sells chicken and also a landlord
d. Financial Status (what is the impact of current hospitalization)
Patient used their family to pay for the finances and also lends money from their friends around the neighborhood for
additional financial assistance
e. Civil Status: Married / Single Divorced Widow
f. Living Situation: Lives alone
Lives with others (specify) lives with wife and 3 children (2 sons and a daughter
7. Family History: Heart Disease, Cancer, TB, Mental Illness and Others (specify)
Paternal- (+) Hypertension, (+) Diabetes Mellitus
8. Primary Physician’s Admitting Diagnosis (indicate P = Probable and C= Confirmed)
P- FRACTURE CLOSED RIGHT FEMUR
C- FRACTURE, CLOSED, DISTAL 3 RD FEMUR, RIGHT, COMMINUTED
C. Nursing Review of Systems (circle the appropriate symptoms)1. HEENT: Headaches Hearing loss Visions Diplopia
Eye pain Eye infection Blurring EpistaxisSinus pain Facial pain Bleeding gums DenturesSore throat Nasal-tracheal pain Other NONE
2. CARDIO-RESPIRATORY: Chest pain (site) NONE
Chest pain with exertion Dyspnea on exertionNocturnal dyspnea Edema Hypertension PalpitationKnown murmur Cough Sputum HemoptysisPleuritic pain DiaphoresisLast X-ray JULY 6, 2011 EKG NONE
3. GASTRO-INTESTINAL:
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Thirst Nausea Vomiting HematemesisHeartburn Difficulty Swallowing Flatulence ConstipationAbdominal pain Jaundice Diarrhea Tarry stoolHemorrhoids Hernia Other: NONE
4. GENITO-URINARY:
Dysuria Polyuria Frequency UrgencyNocturia Burning Hematuria Stones
a. Male Genital Tract: Penile discharges NONE Lesions NONEPain NONE Testicular swelling NONEOther NONE
Last Serology Test NONE
5. MUSCULO-SKELETAL:
Muscle pain Extremity pain Joint pain Back painJoint swelling Neck pain Stiffness Limited motionRedness Sprains DeformityOther NONE X-rays Fractured Right Femur
6. NERVOUS:
Convulsions Syncope Dizziness VertigoTremor Speech difficulty Limp paralysis ParesthesiaMuscle atrophyEEG NONE Other NONE
7. ENDOCRINE:
Goiter Tremor Heat or Cold intoleranceExopthalmos Voice change PolydipsiaChange in body contour Infidelity Other NONE
8. EMOTIONAL:
Anxiety Depression FearAnger Frustration Other (specify)
Notes: patient is angry, depressed and frustrated about his condition and blames himself for driving while drunk.
D. Nursing Observation1. HEENT
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a. Symmetry Head is normocephalic, symmetric, round, erect, midline with incision on parietal area, no involuntary movement noted
b. Eyes and Pupils Facial features are symmetrical, temporal artery elastic and non tender, , pupils are midline with each eyeballs
c. Ears Normal in size bilaterally 4 cm, both are aligned with inner canthus of the eye, no discharges, tenderness or lesions noted
d. Mouth and Throat lips are dry and pale, complete set of teeth noted, no dysphagia or ulcerations noted on oral cavity
e. Lymph nodes lymph nodes are non tender and movable
2. RESPIRATORYa. Depth and Rate Respiratory rate is 21 cycles per minute with normal depths, no nasal flaring use of accessory muscles noted
b. Breath sounds No adventitious sounds are auscultated, bronchial sounds heard on trachea and thorax, Bronchovesicular
sounds heard over the major bronchi and around the upper sternum, Vesicular sounds heard at peripheral lung fields
c. Chest expansion Chest expansion of 5 cm bilaterally noted
3. CARDIO-VASCULARa. Blood Pressure (R) 130/90 mm Hg (L) 130/90 mm Hg Lying 130/90 mm Hg Standing 130/90 mm Hg b. Apical pulse rate and regularity regular with a rate of 66 beats per minute
c. Pedal pulses rate per minute (R) 66 beats minute (L) 66 beats minute
d. Neck vein distention no neck vein distension noted
4. CHESTa. Anterior chest uniform in color with smooth texture no edema, tenderness, discoloration or nodules palpated
b. Posterior chest anteroposterior diameter ratio to transverse diameter is 2:1, scapula are non protruding, spinous process
appear straight and thorax appears symmetric with ribs sloping downward
c. Breasts breast are symmetrical, not engorged or enlarged, nipples are dark brown and equal in size bilaterally.
1. Breasts and Axillae symmetrical, not engorged or enlarged, nipples are dark brown and equal in size bilaterally
2. Anterior Thorax Bowel sounds are heard as intermittent, soft clicks and gurgles at a rate of 5 per minute
3. Posterior Thorax Slightly rigid due to decreased bowel movement, no tenderness noted
5. GASTRO-INTESTINALa. Bowel Sounds series of intermittent soft clicks and gurgles heard upon auscultation with a rate of 5 per minute.
b. Tenderness or rigidity slightly rigid to decreased bowel movement, no tenderness noted
6. URINARYa. Bladder Bladder is not palpable when not full, dull thud heard upon percussion of full bladder, urinates daily with a rate of 6-8
times approximately 700cc per day, urine color is yellow with a consistency of slightly cloudy
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7. SKELETALa. Joints Joints are non tender, no swelling or bulging of fluid
b. Range of motion Full range of motion on upper extremity and marked limitation of range of motion on lower extremity
8. NEURO
a. Motor Function1. Facial Movements are symmetrical, smiles, frowns, puff out cheeks, wrinkles forehead and shows teeth without difficulty
2. Extremities has full control on movements upper extremity while limited on lower extremity
b. Sensory Function (equal or not equal) sensory functions are equal on both sides
c. Equilibrium1. Balance balance is not assessed due to mobility restrictions
2. Finger to nose patient is able to perform finger to nose test
d. Reflexes ( equal or not equal)
1. Knees hypoactive (+) Arms hypoactive (+)
9. CRANIAL NERVE FUNCTIONa. Olfactory nerve: (sensory)
1. Sense of smell (coffee, vailla, etc.)1.1 Anosmia Able to identify the scent presented on each nostril
1.2 Hyperosmia Able to identify the scent presented on each nostril
b. Optic nerve: (sensory)
1. Sense of vision (snellen’s chart, newspaper)1.1 Myopia Able to read newsprint 14 inches away with full visual fields
1.2 Hyperopia Able to read newsprint 14 inches away with full visual fields
c. Oculomotor: (motor)
1. Extra-ocular movements/Pupil reaction to light
1.1 Right eye Eyelid covers 2mm of the iris, PERRLA 1.2 Left eye Eyelid covers 2mm of the iris, PERRLA
d. Trochlear: (motor)
1. Assess direction of gaze, upward and downward movement of eyeball
eyes move in a smooth coordinated motion, Eyes move in a smooth coordinated motion in an upward and downward motion
e. Trigeminal nerve: (Sensory and motor)
1. Presence of corneal reflexes Blinks bilaterally upon introduction of cotton to outer canthus
1.1 Right eye blinks coordinately 1.2 Left eye blinks coordinately
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2. Ability to clench teeth able to clench teeth, temporal and masseter muscles contact bilaterally
f. Abducens: (motor)
1. Assess direction of gaze, lateral movements of the eyeballs
1.1 Right eye smooth and in coordination with left eye 1.2 Left eye smooth and in coordination with right eye
g. Facial: (Sensory and motor)
1. Sense of taste: Using back of tongue
1.1 Salty able to identify taste 1.2 Sweet able to identify taste
2. Facial expression
2.1 Smile able symmetrically 2.2 Puff out cheeks able symmetrically
2.3 Frown able symmetrically 2.4 Raise lower eyebrows able symmetrically
h. Auditory nerve: (motor)
1. Sense of hearing
1.1 Right ear Able to hear whispered voice 1 meter away 1.2 Left ear Able to hear whispered voice 1 meter away
i. Glossopharyngeal: (Sensory and motor)
1. Sense of taste: Using back of tongue
1.1 Salty Able identify taste 1.2 Sweet Able identify taste
2. Ability to swallow (Use tongue blade to elicit gag reflex)
Able, Gag reflex is intact
j. Vagus: (Sensory and motor)
1. Hoarseness of voice no hoarseness of voice noted
2. Sensation of pharynx Uvula and soft palate rise bilaterally on phonation
Let patient say “ah” and observe(movement of palate and pharynx)
k. Spinal accessory: (motor)
1. Movement of:
1.1 Head strong contraction of Sternocleidomastoid muscle on the side opposite the turned face upon turning agains
resistance 1.2 Shoulder Strong and symmetric contractions of Trapezius
muscle
l. Hypoglossal: (motor)
1. Able to stick tongue to midline Tongue movement is symmetric and smooth and bilateral strength is apparent.
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10. EMOTIONAL
a. Communication client is cooperative and is open in sharing information to the nurse
b. Mood/Effect mood is appropriate for action, feels awful for the finaces they have to pay for.
c. Behavior client is cooperative and can maintain eye contact during interaction
E. Knowledge of Illness
1. Learning Limitations patient knows about condition and the medical intervention given inclusing reason for temporary immobilization
of lower extremities and also the cause of his disability
2. Learning needs the patient needs to learn the importance of avoiding driving while he is drunk and also the patient needs to know the
seriousness of his condition
F. Nursing Impressions
Admitted a case of T.B.M., 32 years old, male, married, from Carajay, Lapu-lapu city, due to vehicular accident causing a sustained
injury in right thigh with a chief complaint of pain and multiple abrasions on the lower extremities, After further evaluations the patient was
diagnosed with fractured, closed distal 3 rd femur right, comminuted.
G. Nursing Problems (in priority)
1. Acute pain related to muscle spasms and movement of bone fragments.
2. Impaired physical mobility related to restrictive therapies including foam traction and complete bed rest.
3. Self-care deficit; Bathing/Hygiene/Feeding/Toileting related to decreased muscle control
4. Risk for impaired gas exchange related to altered blood flow , fat or blood emboli.
5. Risk for neurovascular dysfunction related to interruption of blood flow and tissue trauma
H. Discharge Planning
1. Probable Date July 27, 2011
2. Destination Carajay, Lapu-Lapu city, Cebu
3. Transportation Taxi
4. Agencies and Equipment involved Vicente Sotto Memorial Medical Center, Carajay District Hospital, Traction, (Foam)
5. Diet diet as tolerated including high protein and calcium food
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6. Medications Celecoxib 200mg 1 tablet if experiencing pain
7. Persons responsible for patient Wife, 2 sons and a daughter
8. Family conference Scheduled a home visit with client
9. Anticipated problems Patient is at risk for fall, ulceration atrophy due to decreased muscle control and utilization
10. Home visit done by public health nurse
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APPENDIX DHematologic studies (ACTUAL)
Republic of the PhilippinesDepartment of Health
Regional Health office no.7Vicente Sotto Memorial Medical Center
B. Rodriguez St., Cebu City
Hematologic studies
NAME: T.B.M CASE NUMBER: 11-261262WARD: VII (orthopedic ward) DATE RENDERED: 7- 7-11PHYSICIAN: Dr. Dominic Vicuña
Blood component Normal values Actual results Significance
Hemoglobin 140-180 g/L 156 g/L Within normal range
Hematocrit 42%-52% 47% Within normal range
WBC 4.8-10.8x10^9/L 11.9x10^9/L Increased (infection)
RBC 4.70-6.10x10^12/L 4.78x10^12/L Within normal range
Mean Corpuscular Hgb 27-31 pg 32.7 pg Increased (macrocytic anemia)
Mean Cell Volume
(MCV)
80-94 fl 97 fl Within normal range
MCHC 330-370 g/L 336 g/L Within normal range
RDW 11-16 fl 12.9 fl Within normal range
MPV 7.2-11.1 fl 7.4 fl Within normal range
Platelet 150-450x10^9/L 248x10^9/L Within normal range
Clinical Significance:
Abnormal results during the actual complete blood count result of the patient includes increased white
blood cell count which is 11.9x10^9/L over a normal value of 4.8-10.8x10^9/L this indicates a normal
stress response after trauma or it may also that there is an undergoing infection in the fracture site. Mean
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Corpuscular Hemoglobin which is 32.7 pg over a normal value of 27-31 pg which indicates macrocytic
anemia.
DIFFERRENTIAL WBC count:
Neutrophil 40-70% 67.10% Within normal range
Lymphocyte 19-48% 21.10% Within normal range
Monocyte 3-9% 10.60% Increased (bacterial infection)
Eosinophil 0-7% .70% Within normal range
Basophil 0-2% .40% Increased (inflammation)
Clinical Significance:
The abnormal findings in the WBC differential count includes and increased monocyte which is
indicative of a bacterial maybe because of the trauma to the patients extremities during the fracture and
also an increased basophil which is indicative of inflammation as evidenced by the swelling on the lower
extremities of the patient.
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APPENDIX EUrinalysis (ACTUAL)
Republic of the PhilippinesDepartment of Health
Regional Health office no.7Vicente Sotto Memorial Medical Center
B. Rodriguez St., Cebu City
Urinalysis
NAME: T.B.M CASE NUMBER: 11-261262WARD: VII (orthopedic ward) DATE RENDERED: 7- 7-11PHYSICIAN: Dr. Dominic Vicuna
COMPONENT ACTUAL RESULTS SIGNIFICANCE
Color yellow normal
Transparency Slightly cloudy normal
Specific gravity 1.025 Within normal range
Ph 6.5 Within normal range
Glucose Negative (-) normal
Protein Negative (-) normal
RBC 0-2/hpf Within normal range
WBC 0-4/hpf Within normal range
Amorphous urates rare Normal
Mucus threads few normal
Clinical Significance: all of the parameters evaluated are within normal range.
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APPENDIX FCoagulation profile (ACTUAL)
Republic of the PhilippinesDepartment of Health
Regional Health office no.7Vicente Sotto Memorial Medical Center
B. Rodriguez St., Cebu City
Coagulation profile
NAME: T.B.M CASE NUMBER: 11-261262WARD: VII (orthopedic ward) DATE RENDERED: 7- 7-11PHYSICIAN: Dr. Dominic Vicuna
Component Results Normal values Significance
PTT control 14.8 seconds 12.3-15.3 seconds Within normal range
Control % activity 102% -
Control INR 1.12 -
PT control 14.1 seconds 12.8-15.8 seconds Within normal range
% activity 110.1% -
INR 1.06 -
Clinical Significance: all of the parameters evaluated are within normal range.
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APPENDIX GX-ray report (ACTUAL)
Republic of the PhilippinesDepartment of Health
Regional Health office no.7Vicente Sotto Memorial Medical Center
B. Rodriguez St., Cebu City
X-RAY REPORT
NAME: T.B.M CASE NUMBER: 11-261262WARD: VII (orthopedic ward) DATE RENDERED: 7- 18-11PHYSICIAN: Dr. Dominic Vicuña
SKULL APL
Findings: The cranial vault is intact, the sella turcica is intact, there is no evidence of fracture, bone
erosion nor bone destruction, no abnormal intracranial calcifications is noted, there is a soft tissue swelling
in the parieto-occipital region.
Impression: Soft tissue swelling in the parieto-occipital region.
CERVICAL SPINE APL
Findings: The vertebra is normal in height, density, texture and modelling. There is no evidence of
fracture, bone erosion nor bone destruction. The pre-vertebral soft tissue space is within normal limits.
The normal cervical lordosis is absent.
Impression: Straightening of the cervical spine due to muscle spasm.
CHEST PA
Findings: Both lung fields are clear. Heart is normal in size and shape. The trachea is at midline. Both
hemidiaphragms are sharp and distinct. The osseous thoracic cage showed no bony abnormality.
Impression: No significant chest findings.
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PELVIS AP
Findings: The bones normal in density, texture and modeling, there is no evidence of fracture, bone
erosion nor bone destruction, both hip and sacro-iliac joint are within normal limits.
Impression: Normal bones and joints of the hips
HAND RIGHT APLO
Findings: The bones normal in density, texture and modeling, there is no evidence of fracture, bone
erosion nor bone destruction. The joint spaces are within normal limits.
Impression: Normal bones and joints of the right hand.
THIGH RIGHT APL
Findings: There is a comminuted fracture in the distal third of the right femur with surrounding soft tissue
swelling, the rest of the bone are normal in density, texture and modeling.
Impression: Comminuted fracture, distal third, right femur with soft tissue swelling.
KNEE RIGHT APL
Findings: There is a comminuted fracture in the distal third of the right femur with surrounding soft tissue
swelling, the rest of the bone are normal in density, texture and modeling.
Impression: Comminuted fracture, distal third, right femur with soft tissue swelling
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APPENDIX H (Drug Study)Celecoxib
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APPENDIX I(drug study)Tramadol
52
APPENDIX H (drug study)Cefuroxime axetil
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APPENDIX I NCP day 1 (actual)
Cebu Normal UniversityCollege of Nursing
Cebu CityMission-Vision: Care Using Knowledge and Compassion
NURSING CARE PLAN
Client’s Name: T.B.M Patient Care Classification: (Please Check)Age: _32 y/o Sex: Male Civil Status: _Married Religion: R. Catholic ____/______ Wholly Compensatory: Pts. therapeutic care is Allergies: Food: No Known food allergies accomplished by nurse Drug: No Known drug allergies ___ ___ Partially Compensatory: Pts. performs some self-care Diet: Diet as tolerated measuresDate of Admission: July 6, 2011 __________ Supportive Educative: Pts. accomplishes self- care measuresDiagnosis: Fracture, Closed, Distal 3 rd Femur, Right, Comminuted Clinical Division and Bed No.: Ward VII (orthopedic ward) bed 21 _________________________________________________________ Name of Physician: Dr. Dominic Vicuña
Name of Student: Macayan, Jellou Ray M.
DEFINING CHARACTERISTICS
EXPECTED OUTCOME CRITERIAINTERVENTION AND
RATIONALEBEHAVIORAL OUTCOME
Nursing Diagnosis: Acute pain related to movement of bone fragments secondary to comminuted fracture.
Subjective:”ngol-ngol kaayu ang ako bali” as verbalized.
Objective: Received patient lying on bed with head elevated, awake, conscious,
SHORT TERM:After 5 hours of nursing intervention the patient will be able to verbalize pain relief as evidenced by decreased pain score
LONG TERM:After 3 days of nursing intervention, the patient will be able to:
- Verbalize and demonstrate techniques that provide pain
I-Assess level of pain, location, character, and aggravating factorsR-To rule out for worsening of underlying conditions and development of complication and prevent occurrence.S-Doenges, et. Al 2008, p 501I-Observe for non-verbal cues of pain R-Observation may not be congruent with verbal reports and
SHORT TERMAfter 5 hours of nursing intervention:“wa na kaayu sakit ang ako bali dong”. As verbalized, pain score decreased from 7out of 10 to 3 out of 10.
LONG TERM:After 3 days of nursing intervention the patient was
NCP Scoring 10pts Defining Characteristics 3pts Intervention 3ptsNursing Diagnosis 2pts Outcome 1pt Bibliography 1pt (at least 5 references)
52
coherent, communicative, with foam traction at right foot, with pain score of 7 out of 10, grimaced face noted, irritability observed, restlessness noted, limited range of motion observed
Laboratory:None significant
Theoretical Basis:According to Doenges, Moorhouse and Murr, acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in such tissue damage (international association for the study of pain). It is a sudden of slow onset of any
relief.- Demonstrate effective use of
relaxation techniques as indicated for individual situation.
may prompt change in locus of intervention.S-Doenges, et. Al 2008, p 501I-Provide comfort measures as possible such as touch therapy, repositioning, use of cold/heat packs, constant interaction, quiet environment and calm activitiesR-maximizes use of non-pharmacological techniques for pain reliefS-Doenges, et. Al 2008, p 501I-Instruct in and encourage use of relaxation techniques such as focused breathing and imaging.R-to distract attention and thus reduce tensionS-Doenges, et. Al 2008, p 501I-Encourage to engage in diversional activities such as socialization with other patients or listening to music.R-To distract attention and reduce tension.S-Doenges, et. Al 2008, p 501I- Taught patient about non-pharmacological pain management.R-to promote self control and management of pain.S-Doenges, et. Al 2008, p 501
Dependent/ Collaborative:I-Administer analgesics as to a maximum as needed as indicatedR-to maintain acceptable level of
able to demonstrate effective use of relaxation techniques as evidenced by decreased recurrence of pain perception.
53
intensity from mild to severe with an anticipated predictable end and a duration of less than 6 months. Pain is explained as a combination of physiologic phenomena in addition to a psychosocial aspect that influence pain perception (Melzack and Wall,1965)Pain is also described as transient, tissue injury, trauma related, burn, iatrogenic or chronic neuropathic (Weber and Kelley 2007)
painS-Doenges, et. Al 2008, p 502I-Instruct client in use of transcutaneous electrical nerve stimulation units when ordered.R-To maintain acceptable level of pain and comfort.S-Doenges, et. Al 2008, p 502I-Refer to occupational/physical therapy program.R-Promotes active role and enhances self-control.
54
APPENDIX J NCP day 2 (actual)
Cebu Normal UniversityCollege of Nursing
Cebu CityMission-Vision: Care Using Knowledge and Compassion
NURSING CARE PLAN
Client’s Name: T.B.M Patient Care Classification: (Please Check)Age: _32 y/o Sex: Male Civil Status: _Married Religion: R. Catholic ____/______ Wholly Compensatory: Pts. therapeutic care is Allergies: Food: No Known food allergies accomplished by nurse Drug: No Known drug allergies ___ ___ Partially Compensatory: Pts. performs some self-care Diet: Diet as tolerated measuresDate of Admission: July 6, 2011 __________ Supportive Educative: Pts. accomplishes self- care measuresDiagnosis: Fracture, Closed, Distal 3 rd Femur, Right, Comminuted Clinical Division and Bed No.: Ward VII (orthopedic ward) bed 21 _________________________________________________________ Name of Physician: Dr. Dominic Vicuña
Name of Student: Macayan, Jellou Ray M.
DEFINING CHARACTERISTICS
EXPECTED OUTCOME CRITERIA
INTERVENTION AND RATIONALEBEHAVIORAL
OUTCOMENursing Diagnosis: Impaired Physical Mobility related to musculoskeletal impairment secondary to prescribed restrictive therapies. (traction)
Subjective: “maglisod man jud kog lihok sa ako lawas” as verbalized.
SHORT TERM GOAL:After 5 hours of nursing intervention, the patient will be able to perform activities of daily living at the level of functional capabilities.
I-provision of normal range ofmotion exercises andfunction of lowerextremity.R- Necessary to regainnormal mobility of legto speed recoveryI-Encourageprogressive activities
SHORT TERM:After 5 hours of nursing intervention, the patient was able to demonstrate effective use of trapeze in mobilizing and repositioning on bed.
LONG TERM:
NCP Scoring 10pts Defining Characteristics 3pts Intervention 3ptsNursing Diagnosis 2pts Outcome 1pt Bibliography 1pt (at least 5 references)
55
Objective: Received patient lying on bed with head elevated to 30 degrees, awake, conscious, coherent, communicative, with foam traction at right foot, the patient is reading a newspaper, has difficulty in changing position while lying on bed, has difficulty in moving the extremities, inability to walk or stand alone, limited range of motion in the extremities, slowed movement, difficulty in initiating gait
THEORETICAL BASIS:Physical mobility, the capability of movement, is necessary for the health and well-being of all Persons, Hogue (1984) identified mobility as the most important functional ability that determines the degree of independence and health care needs.
Fracture
Foam traction
Decreased control of extremities
LONG TERM GOAL:◊ After 3 days ofnursing intervention,the patient will be able to demonstrate andverbalize properexercises of the lowerextremities & canperform activities ofdaily living withminimal assistance.
according to level of functional capability.R-Increase patient’suse of affected leg.I-instruct and encourage use of overhead trapeze in mobilizing in the bed.R-To obtain sense of control during movement.S- Doenges et. Al. page 459I-encourage participation in self-care, occupational/diversional/ recreational activities.R-enhances self concept and sense of independence.S- Doenges et. Al. page 459I-Identify energy conserving techniques for ADL’s.R-Limits fatigue and maximizes participationS- Doenges et. Al. page 459I-Encourage adequate intake of fluid and nutrition.R-Promotes well-being and energy production.S- Doenges et. Al. page 459I-Provide proper skin care R-To decrease risk for decubitus ulcerS- Doenges et. Al. page 459
Collaborative/dependent:I-Administer medications as needed prior to activity for pain reliefR-To permit maximal effort and involvement in activity.
After 3 days ofnursing intervention,goal is met throughthe regaining of thepatient’s previousrange of motion in theleg & demonstratesproper exercises forthe lower extremities.He also does some ADL without discomfort.
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Restriction of purposeful movement
Impaired physical mobility
S-Doenges et. Al. page 460I-Consult with Occupational therapy as ordered.R-To maintain continuity of care after discharge.S- Doenges et. Al. page 459
57
APPENDIX K NCP day 3 (actual)
Cebu Normal UniversityCollege of Nursing
Cebu CityMission-Vision: Care Using Knowledge and Compassion
NURSING CARE PLAN
Client’s Name: T.B.M Patient Care Classification: (Please Check)Age: _32 y/o Sex: Male Civil Status: _Married Religion: R. Catholic ____/______ Wholly Compensatory: Pts. therapeutic care is Allergies: Food: No Known food allergies accomplished by nurse Drug: No Known drug allergies ___ ___ Partially Compensatory: Pts. performs some self-care Diet: Diet as tolerated measuresDate of Admission: July 6, 2011 _____Supportive Educative: Pts. accomplishes self- care measuresDiagnosis: Fracture, Closed, Distal 3 rd Femur, Right, Comminuted Clinical Division and Bed No.: Ward VII (orthopedic ward) bed 21 _________________________________________________________ Name of Physician: Dr. Dominic Vicuña
Name of Student: Macayan, Jellou Ray M.
DEFINING CHARACTERISTICSEXPECTED OUTCOME
CRITERIAINTERVENTION AND RATIONALE
BEHAVIORAL OUTCOME
NCP Scoring 10pts Defining Characteristics 3pts Intervention 3ptsNursing Diagnosis 2pts Outcome 1pt Bibliography 1pt (at least 5 references)
58
Nursing Diagnosis: Risk for Trauma (additional injury) related to loss of skeletal integrity and improper placement of traction weights.
Subjective:”dali ra masabod sa mga mangagi kanang baton a gbitay”. As verbalized
Objective:Received patient lying on bed with head elevated, awake, conscious, coherent, communicative, with foam traction at right foot, absence of side rails noted, traction weights placed of walkways, absence of bed padding noted, high placement of bed observed, seen SO frequently leaving the patient.
LABORATORY:
None Significant
THEORETICAL BASIS:A fracture occurs when the stress placed on a bone is greater than a bone can absorb. Muscle, blood vessels, nerves, tendons, joints and other organs maybe injured when fracture occurs. This condition may result to a loss of skeletal integrity that may possibly
SHORT TERM:After 4 hours of nursing intervention, the patient will be able to verbalize understanding of condition and recognize need for prevention of injuries.
LONG TERM:After 3 days of nursing intervention, the patient will be able to:
- Demonstrate appropriate lifestyle changes to reduce risk for injury.
- Maintain condition without additional injury and decrease risk for trauma.
I-Identify factors related to individual situation and identify extent of risk.R-Influences scope and intensity of interventions to manage safety.S-Doenges et. Al. 2000 p718I-Note clients decision-making ability and level of cognition including functional capability.R-Affects client’s ability to protect self and influences choice of interventions and teaching.S-Doenges et al. 2000 p718I-Implement interventions regarding safety issues includes:-orient client to environment.-keep bed in low position.-pad bed edges as possible.-provide adequate area lighting -assist with moving/turning using trapezeR-Failure to accurately assess, intervene and/or refer these these issues can place patients at needless risk and create negligence issues for healthcare practitionerS-Doenges et. Al 2000 p 718I-Provide quiet environment and reduced stimulation as possible.R-helps limit confusion or overstimulation.S-Doenges et. Al 2000 p 718I-Place traction weights at appropriate location away from passageways as possible.R-To prevent moving the weights
SHORT TERM:After 8 hours of nursing intervention:“salamat kayo dong, nakasabot nako ngano delikado jud na ako ni ilihok lihok ako tiil”as verbalized.
LONG TERM:After 3 days of nursing intervention:-the patient was seen demonstrating appropriate lifestyle changes to reduce risk for injury such as asking for help from SO upon moving and using trapeze effectively when turning.
- The patient is free from additional injury at the end of the duration of care.
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lead to further injury as a result of environmental conditions interactions with the patients adaptive and defensive resources.
causing disaligment of bone fragments.S-Doenges et. Al 2000 p 718
Collaborative/Dependent:I-assist with treatment of underlying medical/surgical conditions.R-To improve cognition/thinking process
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APPENDIX LFocused Charting Day 1
Republic of the PhilippinesDepartment of Health
Regional Health office no.7Vicente Sotto Memorial Medical Center
B. Rodriguez St., Cebu City
NURSES PROGRESS NOTES
Date Time F – Focus D – Data A – Action R - Response
7/18/11 10:00AM Acute pain D - received patient lying on bed with head elevated to 30
degrees, awake, conscious, coherent, communicative,
without IV, with the following v/s T= 35.5 degree Celsius,
P= 86 pm, R= 20 bpm and BP= 120/70 mmHg, with
foam traction at right foot, with pain score of 7 out of 10,
grimaced face noted, irritability observed, restlessness
noted, limited range of motion observed, “ngol-ngol kaau
ang akong bali dong”. As verbalized.
A - Actions made included; Introduced name to the
patient, assessed level of pain, character and location,
monitored v/s, positioned properly on bed with head
slightly elevated, Due medications (analgesics)
administered as ordered, encouraged to engage in
diversional activities such as socialization with others,
provided comfort measures such as backrub, encouraged
patient to do DBE; supported affected body parts/ joints
using pillows/ rolls, consulted with physical or
occupational therapist as indicated, documented the v/s
and I and O of the patient.
R - :”wa na kaayu sakit ang ako bali dong”. As verbalized,
pain score decreased from 7out of 10 to 3 out of 10.
Surname: M Age: 32 years old Sex: Male Case No:
Given Name: T Ward: VIII (orthopedic ward) Bed No: 21
APPENDIX M
61
Focused Charting Day 2
Republic of the PhilippinesDepartment of Health
Regional Health office no.7Vicente Sotto Memorial Medical Center
B. Rodriguez St., Cebu City
NURSES PROGRESS NOTES
Date Time F - Focus D – Data A – Action R - Response
7/19/11 10:00AM Impaired physical D - received patient lying on bed with head elevated to 30
Mobility degrees, awake, conscious, coherent, communicative,
without IV, with the following v/s T= 35.5 degree Celsius,
P= 86 pm, R= 20 bpm and BP= 120/70 mmHg, with
foam traction at right foot, the patient is reading a
newspaper, has difficulty in changing position while
lying on bed, has difficulty in moving the
extremities, inability to walk or stand alone, limited range
of motion in the extremities, slowed movement, difficulty
in initiating gait. “ maglisod man ko ug lihok dong”. As
verbalized.
A - Introduced name to the patient, assessed the
condition of the patient; monitored v/s, positioned properly
on bed with head slightly elevated, assisted patient in
doing ROM exercises, assisted patient upon doing gait
training, instructed in proper use of overhead trapeze,
provided comfort measures such as backrub, encouraged
patient to do DBE; supported affected body parts/ joints
using pillows/ rolls, consulted with physical or
occupational therapist as indicated, documented the v/s
and I and O.
R - patient was able to demonstrate increasing
functionality of the extremities as evidenced by
turning on bed without assistance and effective usage of
overhead trapeze.
Surname: M Age: 32 years old Sex: Male Case No:Given Name: T Ward: VIII (orthopedic ward) Bed No: 21
APPENDIX N
62
Focused Charting Day 3
Republic of the PhilippinesDepartment of Health
Regional Health office no.7Vicente Sotto Memorial Medical Center
B. Rodriguez St., Cebu City
NURSES PROGRESS NOTES
Date Time F - Focus D – Data A – Action R - Response
7/20/11 10:00AM Risk for additional D - Received patient lying on bed with head elevated,
Injury awake, conscious, coherent, communicative, without IV,
with the following v/s T= 37 degree Celsius, P= 62 pm,
R= 21 bpm and BP= 130/70 mmHg, with foam traction at
right foot, absence of side rails noted, traction weights
placed of walkways, absence of bed padding noted, high
placement of bed observed, seen SO frequently leaving
the patient, “dali raman masabaod ang kanang mga bato”.
As verbalized
A - Introduced name to the patient, assessed the
condition of the patient, instructed SO to stay with patient
as much as possible, implemented interventions
regarding safety issues such as orientation of patient to
environment, keeping bed in low position, providing
adequate area lighting and padding of side rails as
possible, monitored v/s, positioned properly on bed with
head slightly elevated, assisted patient in doing ROM
exercises, assisted patient upon doing gait training,
instructed in proper use of overhead trapeze, provided
comfort measures such as backrub, encouraged patient
to do DBE; supported affected body parts/ joints using
pillows/ rolls, consulted with physical or occupational
therapist as indicated, documented the v/s and I and O of
the patient.
R - the patient was able to demonstrate behaviors to
promote safety, SO was seen staying with patient most of
the time
Surname: M Age: 32 years old Sex: Male Case No:Given Name: T Ward: VIII (orthopedic ward) Bed No: 21
63
CURRICULUM VITAE
PERSONAL INFORMATION
Name : Jellou Ray M. Macayan
Year & Section : BSN 4-B
Adviser : Mrs. Lagrimas Elizon
Provincial Address : P-6, Urbiztondo Street, Poblacion, Barobo, Surigao Del Sur
City Address : Block 24, Lot 10, La Aldea, Buena Mactan, Lapu-lapu city
Telephone No. : 2386882
Cell no. : 09239855653
E-mail Address : [email protected]
Birthday : July, 1, 1991
EDUCATIONAL BACKGROUND
Elementary
School : Barobo Central Elementary School
Year : 1998-2004
Secondary
School : Barobo National high School
Year : 2004-2008
Tertiary
School : Cebu Normal University
Year : 2008-present
AFFILIATIONS
Position : Organization
Member : Nightingale Student Council