WORLD CITI COLLEGES

960 Aurora Blvd., Quezon City

Case Study

Closed Comminuted Fracture of Femur

GONZALES, Jahada

(BSN- IV C4)

I. Introduction

J.D, 10 years old client was admitted on June 22, 2010 with chief complaint of multiple injuries secondary to vehicular accident. Medical Diagnosis are fracture closed complete subtrochanteric femur right; fractures closed complete distal femur right; mass concurve fracture right leg; anemia probable secondary to internal bleeding from fracture site.

A break or a crack in a bone is known as a fracture. Fractures can affect any bone in the body. Bones can fracture in a number of different ways. A simple (or closed) fracture is a clean break to the bone that does not damage any surrounding tissue or break through the skin. A compound (or open fracture) is when the surrounding soft tissue and skin is damaged. This kind of fracture is more serious as there is a higher risk of infection.

Healthy bones are extremely strong and usually able to withstand strong forces. However, if a force is too great or the bone is abnormal it can fracture. As you get older your bones become weaker and you become more prone to falls and fractures. One in two women and one in five men will have a fracture after the age of 50.

Young children get different types of fractures, because their bones are more elastic. They also have growth plates at the ends of the bones, which can be damaged. Growth plates are the areas of growing bone at the end of long bones in children and adolescents.

Fractures are usually a result of an accident such as a bad fall or car crash. Quezon City had a total number of traffic accidents in the metro area with a whopping 17,292, which is a 28.37 percentage share. For all of 2006 there were 123 fatal accidents and 3,209 non-fatal accidents with 13,960 properties damaged in Quezon City. The time it takes for a bone to heal depends on the type of fracture, where it is and if it is an open or closed fracture. It is a gradual process and can take anything from a few weeks to a few months.

By choosing this condition as a case study, the student nurse expects to broaden her knowledge understanding and management of fracture, not just a requirement in duty in POC. It is very important for the nurses now a day to be adequately informed regarding the knowledge and skill in managing these conditions since femur fracture related to car accident is high in incidence.

Objectives:

After successful accomplishment of this case study, the student will be able to:

A. Cognitive:

a.1. Identify the suitable nursing theory for the case and apply its concepts in delivering nursing care to a patient with Closed femur Fractures.

a.2. Discuss the anatomy and physiology of the Closed Femur Fractures.

a.3. Assess the history particularly recent patient’s Illnesses.

B. Psychomotor:

b.1 Demonstrate appropriate measures to assist patients with Closed Femur Fracture

b.2 Show a paradigm of the pathophysiology and etiology of Closed femur Fracture

b.3 Create relevant health teachings and the outpatient care for a patient with Closed Femur Fracture

C. Affective:

c.1. Explain the pathophysiology and etiology of Closed Femur Fracture

c.2. Integrate knowledge and skills to deliver an effective nursing care.

A. Theoretical Framework

The nursing theory that is applicable for fracture is the nursing theory of Dorothea Orem’s Self Care deficit. The theory essentially defines the need for nursing care. This need occurs whenever a person experiences some limitation or deficit which interferes with their ability to maintain self-care. Further, the theory delineates the various interactions which should occur between a nurse and a patient.

The client has traction in his left leg. He is advised for immobilization thus he is dependent on the nurse to provide care for him. Nursing care

includes assisting in eating, personal hygiene,

II. NURSING ASSESSMENT:

A. Personal data:

NAME: J. D

GENDER: Male

ADDRESS: Payatas, Quezon City

AGE: 10 y/o

DATE OF BIRTH: April 9, 1999PLACE OF BIRTH: Payatas, Quezon City

CITIZENSHIP: Filipino

RELIGION: Roman Catholic

CHIEF COMPLAINT/S: Multiple injuries secondary to vehicular accident

DATE ADMITTED: June 26, 2010

ATTENDING PHYSICIAN/S: Dr. G

B. HISTORY OF PRESENT ILLNESS

Prior to admission Patient J.D and his friends are playing in the streets when a

delivery truck arrived, they decided to ride at the running truck when he slipped off and

fall at the trucks wheels. The wheels hit his right femur and injured him. He was

immediately brought to hospital and referred here at Philippine Orthopaedic Center with

an admitting diagnosis of fracture closed complete subtrochanteric femur right; fractures

closed complete distal femur right; mass concurve fracture right leg; anemia probable

secondary to internal bleeding from fracture site.

C. HISTORY OF PAST ILLNESS

The client has no known childhood illness. He rarely get sick. Fever was

managed by taking in paracetamol, coughs and colds were managed by Solmux

and Plenty of rest as a form of management for these conditions.

D. FAMILY HISTORY

Both sides of client’s family has no known serious illness.

E. SOCIAL HISTORY

The Client is in 5th grade at payatas elementary school. He is an average student

and He loves to play with his friends after school and even weekends. From the 5

sibllings he is consider the eldest. He is rarely seen at home helping his parents;

he is always out with his friends playing at the streets.

F. HEAD TO TOE ASSESSMENT

Head to Toe Assessment

Skin

General skin color is brownish with darker shades of brown in area

exposed to the sun. Skin is dry and no lesions were found.

Nails (fingernails and toenails)

Nail beds are pinkish in color.

Head

The skull was smoothly contoured. There is a presence of scar in his left

temporal.

Hair

The hair was evenly distributed, thick, straight and black

Eyes

The client was blind on his right eye and is experiencing blurry vision on

his left eye. The eyebrows are evenly distributed. Has positive corneal reflex on

the left eye.

Nose

The patient’s nose was symmetric and patent nostrils. No discharge or

flaring. It has uniform color. Air moves freely as the client’s breathes through the

nares.

Ears

The patient’s color of the ear was same color as facial skin. Pinna recoils

after it is folded. The hearing acuity is good.

Mouth

The patient has no halitosis. His lips are dry and choppy.

Neck

The neck is smooth in movement with no discomfort.

Chest

Symmetrical chest expansion; Respiratory Rate is 18 cpm.

Heart

Normal cardiac rhythm. Cardiac Rate is 91 bpm.

Abdomen

The patient has a flabby, soft abdomen. He has 2 scars in the right lower

quadrant.

Extremities

Upper Extremities

The patient’s lower extremities are symmetrical, has smooth coordinated

movements and has a palpable pulse. The patient has a complete set of fingers.

Lower Extremities

The patient’s lower extremities are symmetrical, has smooth coordinated

movements there is a pin pricking pain on left leg and has weakness on both

sides. The patient has a complete set of fingers.

PATTERNS OF DAILY LIVING

Daily Activity Before Assessment

Sleeping Pattern

Patient had no problem in getting adequate sleep and rest. He was able to get 7 to 8 hours of uninterrupted sleep. He usually sleep at 8o’clock in the evening and awake at 4 o’clock in the morning. He naps at least one hour in the afternoon.

Elimination

Bowel The patient had no problem with his bowel patterns. His typical pattern was once a day particularly every morning.

Urine

He claimed to have no difficulty in defecation. His stool is firm and brown in color.Patient claimed to have no difficulty in voiding. Patient’s voiding pattern was usually 7times a day with urine appearing light yellow in color.

Nutritional Intake

Patient had relatively good appetite, although he consciously limited himself on eating sugars and fats. He was watchful in his diet and preferred home cooked food containing vegetables meat with moderate rice. He refrained using food flavourings and additives and uses less salt when preparing meals.He could finish

three meals in a day with snacks in the afternoon.

He was able to drink 8 to 9 glasses of water per day.

Hygiene The patient was able to maintain proper hygiene. He takes a bath twice a day; in the morning and before bedtime. He changes clothing everyday.He brushes his teeth thrice a day.

Level of Competency

Before Illness During Hospitalization

A. Physical J.D is a very active child. He is in 5th grade. After school he plays with his friends and his siblings. He usually plays tags at the streets. He seems restless. He can run very fast especially when he race with his friends.

During his confinement, J.D can no longer do his usual activities. He is strictly for immobilization. To relive boredom he usually play with his soldier toy using his hands.

COMPETENCIES DEVELOPMENT

B. Emotional J.D is very friendly child. He has a lot of friends in school and at their neighborhood. He is very optimistic and love to be around with people.

During his hospitalization, J.D seems bored and lonely. He was uncomfortable answering questions but he seems polite.

C. Social J.D has a good relationship with people. He is very friendly and sociable. He actively participate in school activities and their barangay activities.

His only social interaction is his mother and the patients in the ward. He doesn’t want to be visited by his friends because he thinks that they will only laugh at him.

E. Spiritual His family rarely goes to church but they have an altar at home. They sometimes prayed together. J.D is not interested in praying rather he wants to play outside with his friends.

His was silent most of the time. According to him, he prayed to Jesus when he feels pain and he prayed for his recovery, he wanted to walk again. Her mother prayed with him.

ANATOMY AND PHYSIOLOGY

The thigh bone, extending from the hip to the knee of four- and two-legged vertebrates, including humans. The femur is the largest, longest, and strongest bone of the humanskeleton. Its rounded, smooth head fits into a socket in thepelvis called the acetabulum to form the hip joint (an example of a ball-and-socket joint). The head of the femur is joined to the bone shaft by a narrow piece of bone known as the neck of the femur. The neck of the femur is a point of structural weakness and a common fracture site. The lower end of the femur hinges with the tibia (shinbone) to form the knee joint. 

The femur can be felt through the skin at two sites. At the lower end, the bone is enlarged to form two lumps called the condyles that distribute the weight-bearing load on the knee joint. On the outer side of the upper end of the femur is a protuberance called the greater trochanter. The gluteus and psoas muscles are inserted on the greater and lesser trochanter, respectively. The lateral and medial epicondyles articulate with the tibia and the trochlear groove accommodates the patella (kneecap). 

PATHOPHYSIOLOGY

NON- MODIFIABLE RISK FACTORS: MODIFIABLE RISK FACTORS:

- Accidents - Prolonged standing, walking, or running- Lytic lesions

o Cancerous metastasis

o Paget disease

o Bone cysts

- Osteoporosis

CLINICAL MANIFESTATION BY THE BOOK

-Pain,  - Point tenderness - Pallor, - pulse loss, -Paresthesia, - Paralysis. - Deformity -Swelling, -Discoloration,  -Crepitus, and -Loss of limb function.  -Numbness and tingling, -Mottled cyanosis, -Cool skin at the end of the extremity, -Loss of pulses distal to the injury

Damage to the blood supply to an entire bone.

Severe circulatory compromise

Avascular (ischemic) necrosis may result

CLINICAL MANIFESTATION BY THE PATIENT

- Pain - Pallor - Pulse loss - Pulse loss - Paralysis - Swelling - Discoloration - Loss of limb function - Numbness and tingling - Cool skin at the end of the extremity - Loss of pulses distal to the injury

DIAGNOSTICS EXAMS BY THE BOOK:

X-RAY

DIAGNOSTICS EXAMS BY THE CLIENT:

X-RAY

Hematology

TREATMENT BY THE BOOK:

Nonsteroidal anti-inflammatory agents (NSAIDs)

TREATMENT BY THE CLIENT:

Nonsteroidal anti-inflammatory agents (NSAIDs)

-Ibruprofen

LABORATORY EXAMINATION/S

DRUG STUDY

DATE ORDERED

MEDICATION ACTION INDICATION NURSING CONSIDERATION

September 10,2009 to May 12,2010

Amlodipine

10 mg/ 1 tab

OD

Lowering high blood pressure helps prevent strokes, heart attacks, and kidney problems. Amlodipine is called a calcium channel blocker. It works by relaxing blood vessels so blood can flow more easily.

used with or without other medications to treat high blood pressure (hypertension).

Take this medication by mouth, usually once daily with or without food or as directed by your doctor.

If used for angina, this medication must be taken regularly to be effective. It should not be used to treat angina when it occurs. Use other medications (e.g.,

sublingual nitroglycerin) to relieve an angina attack as directed by your doctor. Consult your doctor or pharmacist for details.

Lyrica

75mg/1tab

OD

used to treat Nerve Pain after Herpes, Diabetic Complication causing Injury to some Body Nerves, Additional Medication to Treat Partial Seizures, Disorder characterized by Stiff, Tender & Painful Muscles

to treat pain caused by nerve damage due to diabetes and shingles (herpes zoster) infection. It is also used to treat pain in people with fibromyalgia.

Take this medication by mouth, usually twice or three times a day, or as directed by your doctor. You may take it with or without food. When you start this medication, your dosage will probably need to be increased slowly by your doctor to reduce side effects, especially dizziness or drowsiness. Your dosage is based on your medical condition and response to therapy.

Metformin

500 mg / tab

1tab

BID

It works by helping to restore your body's proper response to the insulin you naturally produce, and by decreasing the amount of sugar that your liver makes and that your stomach/intestines absorb.

used with a proper diet and exercise program to control high blood sugar in people with type 2 diabetes (non-insulin-dependent diabetes). Controlling high blood sugar helps prevent kidney damage, blindness, nerve problems, loss of limbs, and sexual function problems

Take this medication by mouth, usually twice a day with meals or as directed by your doctor. Drink plenty of fluids while taking this medication unless otherwise directed by your doctor.

September 23, 2009

Vitamin-B complex

1 tab

OD

Vitamins are important building blocks of the body and help keep you in good health.

a multivitamin product used to treat or prevent vitamin deficiency due to poor diet, certain illnessAes

Take this medication by mouth, usually once daily or as directed. Follow all directions on the product package, or take as directed by your doctor. Do not take more than the recommended

dosage.

Constipation, diarrhea, or upset stomach may occur. These effects are usually temporary and may disappear as your body adjusts to this medication.

DISCHARGE PLANNING

Prognosis

The patient progress depends on its condition and the size of the tumor it

is possible that full recovery can be attain and there is 50% chance that the

tumor will completely disappear thru the treatment that the patient has

undergone.

Upon Discharge A.M will adhere to the following instructions:

M - Advised to the take medicine religiously on time

Amlodipine 10 mg 1 tab/ once a day

Vitamin B Complex 1 tab/ once a day

Metformin 500mg 1 tab/ twice a day

E – Enumerated safe measures to prevent accidental falls like removing

unnecessary rags inside the house, avoiding wet floors etc.

T – Radiotherapy and Medication for maintenance

H – Advice to perform daily exercise

O – Advice to come back at Neurosurgery OPD for follow up check-up/ 1 week

after discharge

D – Advice to avoid too much sweet in his diet

Advice to eat high protein diet

Advice small frequent feeding

S – Encourage to attend religious activities like Sunday mass