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CAPITOL UNIVERSITY

COLLEGE OF NURSING

A CASE STUDY ON

Open Reduction Internal Fixation of Distal

Fibular Fracture

IN PARTIAL FULFILLMENT OF

RELATED LEARNING EXPERIENCE 70

GROUP 3

Submitted to:

Ms. Jessele Janioso, RN, MN

Submitted by:

Kwesi Gem L. Yasay

Jocef Ian D. Rama

Clients Profile.

I.1 BIOGRAPHICAL DATA

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- Patient X is a 54 year old, female, Married, a Roman Catholic, presentlyresiding at Cagayan de Oro City.

2. CHIEF COMPLAINT

- Patient was admitted at Capitol University Medical City (CUMC) with a chiefcomplaint of distal fibular fracture.

3. HISTORY OF PRESENT ILLNESS

- Patient X had a fracture in her right distal fibula due to a slip accident.

4. WHAT HAPPENED DURING THE OPERATION?

- Pre-operative antibiotics, +/- interscalene block

General endotracheal anesthesia

Modified beach-chair position. All bony prominences well padded.

Examination under anesthesia of affected shoulder.

Prep and drape in standard sterile fashion. Have a well-padded height adjustable

Mayo stand or shoulder positioner available to hold the arm during the case.

Deltopectoral incision from just medial to AC joint to just lateral to the proximal

edge of the biceps muscle belly.

Identify deltopectoral interval (interval can be found by palpating medial edge of

deltoid insertion into clavicle or finding fat layer in interval surrounding cephalic

vein.)

Preserve cephalic vein by ligating any branches to deltoid and taking the cephalic

vein and its surrounding tissues medially.

Incise clavipectoral fascia adjacent to the conjoined tendon up to the

coracoacromial ligament.

Release upper 1/3 of pectoralis tendon if needed for exposure.

Ensure the anterior humeral circumflex vessels are protected and preserved.

Identify the long head of the biceps tendon and ensure that it is preserved

thoughtout the case.

Identify the fracture fragments. The key to identifying the various components is

the long head of the biceps tendon. The lesser tuberosity and subacapularis

tendon are medial to the long head tendon. The greater tuberosity and

supraspinatus are lateral. Generally splinting the rotator interval between thetuberosities provides adequate exposure to the proximal humerus.

Mobilize the tuberosity fragments. Tag them with suture as needed.

Gently identify the humeral head fragment, being careful to avoid any

neurovascular injury. Confirm that the head fragment is not split or impacted and

the cartilage is intact.

Reduce that fragments into anatomic position. The humeral head can usually be

reduced by externally rotation the arm and gentle pushing and rotating the head

into its anatomic position.

The fragments are then anatomically reduced and temporarily fixed using k-wires

or suture. Placing a non-absorbable #5 suture in a figure-8 fashion is oftenbeneficial to maintain the reduction during plate placement and also serves

additional fixation.

Place a proximal humeral plate as selected in the preoperative plan using AO

technique and as instructed in the manuctures technique guide.

Pack allograft bone chips / demineralized bone graft as needed to improve

healing.

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Repair the rotator interval.

Irrigate.

Close in layers.

ANATOMY & PHYSIOLOGY

In human anatomy, the femur is the longest and largest bone. Along with the temporal

bone of the skull, it is one of the two strongest bones in the body. The average adult

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male femur is 48 centimeters (18.9 in) in length and 2.34 cm (0.92 in) in diameter and

can support up to 30 times the weight of an adult.

It forms part of the hip joint (at the acetabulum) and part of the knee joint, which is

located above. There are four eminences, or protuberances, in the human femur: the

head, the greater trochanter, the lesser trochanter, and the lower extremity. They

appear at various times from just before birth to about age 14. Initially, they are joined to

the main body of the femur with cartilage, which gradually becomes ossified until the

protuberances become an integral part of the femur bone, usually in early

adulthood.The shaft of femur is cylindrical with a rough line on its posterior surface

(linea aspera).The intercondylar fossa is present between the condyles at the distal end

of the femur. In addition to the intercondylar eminence on the tibial plateau, there is both

an anterior and posterior intercondylar fossa (area), the sites of anterior cruciate and

posterior cruciate ligament attachment, respectively

Perioperative Management

SCRUB NURSE

Pre-operative Responsibilities

1. Assist with the preparation of the room for the designated surgical procedure,

including gathering supplies for the procedure.

2. Scrub, dry hands, gown, and glove.

3. Assist person scrubbed in first position with:

a. Setting up back table, mayo, and basinsb. Arrangement of instruments

c. Preparation of suture and needles

d. Preparation and counting sponges

e. Arrangement and preparation of other necessary items

f. Gowning and gloving surgeon and assistants

g. Assist with draping

h. Arrangement of sterile field

Intra-operative Responsibilities

1. During the procedure, progress from double-scrubbed position. Train self to keepeyes on field, and learn steps of procedure.

2. Begin developing methods of anticipating needs of surgeon and assistant.

3. After closing the skin:

a. Assist with care of instruments and counts if necessary

b. Care of specimen

c. Assist with dressing of wound

Post-operative Responsibilities

1. After the completion of the Procedure:

a. Assist with the gathering of all materials used during the procedure

b. Discard items as necessary being careful to discard sharp items in designated

placesc. Return all items to respective aread. Assist with cleaning of roome. Clean the

materials used properly and arrange them after drying2. Perform any duties which will

speed up the surgical procedure to follow in that room .

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CIRCULATING NURSE

Pre-operative Responsibilities

1. Care for the patient before surgery by:

a. Greeting patient and assist nurse with identification

b. Checking patient's chart, preparation, etc.

2. Prepare the room by:

a. Obtaining instruments, supplies, and equipment for the designated operativeprocedure

b. Opening unsterile supplies

c. Assisting in gowning

d. Observing breaks in sterile technique

e. Assisting anesthesiologist as necessary

f. Assisting with skin preparation and positioning

g. Assisting with forming of the sterile field

3. Count the instruments, sharps and sponges before the procedure and confirm with

scrub nurse.

Intra-operative Responsibilities

1. During the Procedure:

a. Remain in room and dispense materials as necessary

b. Observe procedure as closely as possible

c. Begin establishing method of anticipating needs of surgical team

d. Care of specimen as indicated

e. Care of operative records as indicated

2. Before the closing of the organ or peritoneum, count all instruments, sharps and

sponges and confirm with scrub nurse.

3. Inform the surgeon and assistant surgeon of a report of the instruments.

Post-operative Responsibilities

1. Properly document all the necessary information on the patients chart.

2. Assist in the cleaning of the Operation Room as necessary.

Prior to operation:

A careful history and physical examination are performed to exclude the

possibility of other gastrointestinal diseases that may mimic biliary colic, such as

peptic ulcer disease or reflux esophagitis.

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When the diagnosis of acute cholecystitis is suspected the patient should receive

nothing by mouth; however, nasogastric suction usually can be reserved for

patients who are vomiting or have ileus and abdominal distention.

Care for the patient before surgery by:a. Greeting patient and assist nurse with

identification. Checking patient's chart, preparation, etc.2. Prepare the room by:a.

Obtaining instruments, supplies, and equipment for the designated operative

procedure. Opening unsterile supplies. Assisting in gowning. Observing breaks in

sterile technique. Assisting anesthesiologist as necessary. Assisting with skin

preparation and positioning. Assisting with forming of the sterile field. Count the

instruments, sharps and sponges before the procedure and confirm with

scrubnurse.

Intra-operative Responsibilities

1. During the Procedure:

a. Remain in room and dispense materials as necessary

b. Observe procedure as closely as possible

c. Begin establishing method of anticipating needs of surgical team

d. Care of specimen as indicated

e. Care of operative records as indicated

2. Before the closing of the organ or peritoneum, count all instruments, sharps and

sponges and confirm with scrub nurse.

3. Inform the surgeon and assistant surgeon of a report of the instruments.

Post-operative Responsibilities

1. Properly document all the necessary information on the patients chart.

2. Assist in the cleaning of the Operation Room as necessary.

Prior to operation:

A careful history and physical examination are performed to exclude the

possibility of other gastrointestinal diseases that may mimic biliary colic, such as

peptic ulcer diseaseor reflux esophagitis.

When the diagnosis of acute cholecystitis is suspected the patient should

receivenothing by mouth; however, nasogastric suction usually can be reserved

for patientswho are vomiting or have ileus and abdominal distention.

Intravenous fluids are given to correct volume depletion and any electrolyte

imbalancesare measured and corrected. Monitor and regulate IVFs

The nurse instructs the patient about the need to avoid smoking to enhance

pulmonaryrecovery postoperatively and avoid respiratory complications. It is also

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important toinstruct the patient to avoid the use of aspirin and other agents that

can alter coagulationand other biochemical process

On of the most important responsibility of the nurse is to let the patient sign an

informedconsent regarding the surgery.

The patient is given anaesthesia prior to surgery and the patient is under NPO.

During the operation

Monitoring the vital signs of the patient is one of the responsibilities of the nurse

duringthe surgery.

Assisting the anesthesia care provider during induction of general anesthesia

Ensuring adequate oxygenation and hydration

After the operation

After recovery, the nurse places the patient in the low fowlers position. IV fluids

may begiven and nasogastric suction may be given to relieve abdominaldistention. Water andother fluids are given in about 24hours, and soft diet is

started when bowel soundsreturned.

Placing warm blankets on the patient to enhance comfort and preserve the

patient'sbody temperature

Assessing the patient's vital signs, oxygen saturation level, level of

consciousness,circulation, pain, IV site, fluid rate, and hydration status, as well

as the status of thesurgical site and dressing and all related monitoringequipment

The nurse helps in relieving the pain by instructing the patient regarding proper

positioning.

The nurse helps in improving the respiratory status by instructing the patient

regardingdeep breathing exercises.

The nurse also provides skin care like cleaning the incision part and providing

cleandressing following a strict aseptic technique

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The nurse instructs the patient about the medications that are prescribed by

thephysician

Discussing recommended follow-up management with the physician and the

surgeon

Pathophysiology

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V-Surgical Instruments used in Palatoplasty Procedure

A Deaverretractor (manual) is used to retract deep abdominal or chest incisions. Available in variouswidths.

A Richardson retractor (manual) is used to retract deep abdominal or chest incisions

An Army-Navyretractor(manual) is used to retract shallow or superficial incisions. Other names:

USA, US Army.

A malleable or ribbon retractor (manual) is used to retract deep wounds. May be bent to variousshapes.

Cutting and Dissecting InstrumentsStraight Mayo scissors - Used to cut suture and supplies. Also known as: Suture scissors.

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Curved Mayo scissors - Used to cut heavy tissue (fascia, muscle, uterus, and breast). Available in regularand long sizes.

Metzenbaum scissors (A) - Used to cut delicate tissue. Available in regular and long sizes.

Clamping and Occluding Instruments

A hemostat is used to clamp blood vessels or tagsutures. Its jaws may be straight or curved.Other names: crile, snap or stat.

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A mosquito is used to clamp small bloodvessels. Its jaws may be straight or curved.

A Kelly is used to clamp larger vessels andtissue. Available in short and long sizes.Other names: Rochester Pean.

A burlisheris used to clamp deep bloodvessels. Burlishers have two closed fingerrings. Burlishers with an open finger ring are calledtonsil hemostats.Other names: Schnidt tonsil forcep, Adsonforcep.

Kelly, hemostat, mosquito (left to right)

A right angle is used to clamp hard-to-reach

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vessels and to place sutures behind or around avessel. A right angle with a suture attached is calleda "tie on a passer." Other names: Mixter.

A hemoclip applier with hemoclips applies metalclips onto blood vessels and ducts which will remainoccluded.

Grasping and Holding Instruments Are used to hold tissue, drapes or sponges.

An Allis is used to grasp tissue. Available in shortand long sizes. A "Judd-Allis" holds intestinaltissue; a "heavy allis" holds breast tissue.

A Babcock is used to grasp delicate tissue(intestine, fallopian tube, ovary). Available in shortand long sizes.

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A Kocheris used to grasp heavy tissue. May alsobe used as a clamp. The jaws may be straight orcurved. Other names: Ochsner.

A Foerster sponge stick is used to graspsponges. Other names: sponge forcep.

A dissectoris used to hold a peanut.

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A Backhaus towel clip is used to hold towels anddrapes in place. Other name: towel clip.

Pick ups, thumb forceps and tissue forceps areavailable in various lengths, with or without teeth,and smooth or serrated jaws.

Russian tissue forceps are used to grasp tissue.

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DeBakey forceps are used to grasp delicatetissue, particularly in cardiovascular surgery.

Adson pick ups are either smooth: used to graspdelicate tissue; or with teeth: used to grasp theskin. Other names: Dura forceps.

Bone file- smoothing bone

Parkes rasp-cutting bone

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Mini-Liston bone cutting forceps- cutting bone