Case Study- Fracture

I- Introduction 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. 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 nondisplaced. 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 not cause a break in the skin. Comminuted fracture at the Right Femoral Neck is a fracture in which bones of the Right Femoral Neck has splintered to several fragments. By choosing this condition as a case study, the student nurse expects to broaden her knowledge understanding and management of fracture, not just for the fulfillment of the course requirements in medical-surgical nursing. It is very important for the nurses now a day to be adequately informed regarding the knowledge and skill in managing these conditions since hip fracture has a high incidence among elderly people, who have brittle bones from osteoporosis (particularly women) and who tend to fall frequently. Often, a fractured hip is a catastrophic event that will have a negative impact on the patient’s life style and quality of life. There are two major types of hip fracture. Intracapsular fractures are fractures of the neck of the femur, Extracapsular fracture are fractures of the trochanteric region and of the subtrocanteric region. Fractures of the neck of the femur may damage the vascular system that supplies blood to the head and the neck of the femur, and the bone may die. Many older adults experience hip fracture that 1

student nurse need to insure recovery and to attend their special need efficiently and effectively. True the knowledge of this condition, a high quality of care will be provided to those people suffering from it.

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II. Objectives General Objectives: After three day of student nurse-patient interaction, the patient and the significant others will be able to acquire knowledge, attitudes and skills in preventing complications of immobility. Specific Objectives: A. STUDENT-NURSE CENTERED After 8 hours of student nurse-patient interaction, the student nurse will be able to: 1. state the history of the patient. 2. identify potential problems of patient 3. review the anatomy and physiology of the organ affective 4. discuss the pathophysiology of the condition. 5. identify the clinical and classical signs and symptoms of the condition. 6. implement holistic nursing care in the care of patient utilizing the nursing process. 7. impart health teachings to patient and family members to care of patient with fracture. B. PATIENT-CENTERED After 8 hours of student nurse-patient interaction, the patient and the significant others will be able to: 1. explain the goals of the frequent position changes. 2. enumerate the position for proper body alignment. 3. discuss the different therapeutic exercises. 4. practice the different kinds of range of motion. 5. participate attentively during the discussion.

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III. Nursing Assessment 1. Personal History 1.1 Patient’s Profile Name: Mrs. Torralba, Lourdes Age: 89 years old Sex: Female Civil Status: Widow Religion: Roman Catholic Date and time of admission; March 13, 2008 at 10:10 am Room No.: Room 425, Cebu Doctors’ University Hospital Complaints: Pain the right hip Impression or Diagnosis: Fracture Close-Comminuted: Femoral Right Neck General Osteoporosis Breast Cancel (Right) Diabetes Mellitus Type II Physician: Dr. F. Vicuna, Dr. E. Lee, Dr. N. Uy, Dr. Ramiro Hospital No: 216 426 1.2. Family and Individual Information, Social and Health History Mrs. Torralba, Lourdes who resides in 8 Acacia St. Camputhaw Lahug, Cebu City, Cebu Province with 9 successful children ( 6 boys and 3 girls) was admitted to Cebu Doctors’ University Hospital for further management of the condition. Mrs. Torralba is a college graduate and she’s previously working as an assistant of her husband ( Mr. Rodrigo Torrralba ) a doctor. The patient was diagnosed to have Breast Cancer (Right) last 2006 with bone metastasis and on chemotherapy with aromasin.

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Two days prior to admission, the patient was standing and was about to open up he umbrella when she got out of balance and landed on her right hip.And had experienced limitation of movement on the right hip. The patient was then admitted due to the persistence of pain. The patient was previously hospitalized due to infected wound at the right ankle last 2002. No familial history of hypertension and bronchial asthma but is positive to diabetes mellitus of paternal side. Has no known food and drug allergies. The patient is non-smoker non-alcoholic beverages drinker. 1.3. Level of Growth and Development 1.3.1. Normal Growth and Development at particular stage Older Adult ( 65 Years old to death) Physical Development Perception of well-being can define quality of life. Understanding the older adults perception about health status is essential for accurate assessment and development of clinically relevant interventions. Older adults concepts of health generally depend on personal perceptions of functional ability. Therefore older adults engaged in activities of daily living usually consider themselves healthy, whereas those whose activities are limited by physical, emotional or social impairments may perceive themselves as ill. There are frequently observed physiological changes in order adults that are called normal. Finding these “normal” changes during and assessment is not an expected. These physiological changes are not always pathological processes in themselves, but they may make older adults more vulnerable to some common clinical conditions and diseases. Some older adults experience all of these physiological changes, and others only experience only a few. The body changes continuously with age, and specific effects on particular older adults depend on health, lifestyle, stressors and environmental conditions.

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Cognitive Development Intellectual capacity includes perception, cognitive, memory, and learning. Perception, or the ability to interpret the environment, depends on the acuteness of the senses. If the aging person’s senses are impaired, the ability to perceive the environment and react appropriately is diminished. Perceptual capacity may be affected by changes in the nervous system as well. Cognitive ability, or the ability to know, is related to the perceptual ability. Changes in cognitive structure occur as a person ages. It is believe that there is a progressive loss of neurons. In addition, blood flow to the brain decreases, the meaninges appear to thicken, and brain metabolism slows. As yet, little is known about the effect of these physical changes on the cognitive functioning of the older adult. Older people need addition time for learning, largely because of the problem of retrieving information. Motivation is also important. Older adults have more difficulty than younger ones in learning information they do not consider meaningful. It is suggested that the older person mentally active to maintain cognitive ability at the highest possible level. Life long mental activity, particularly verbal activity, helps the older person retain the high level of cognitive function and may help maintain a long-term memory. Cognitive impairment that interferes with normal life is not considered part of normal aging. A decline in intellectual abilities that interferes with social or occupational functions should always be regarded as abnormal. Psychosocial Development According to Erikson, the developmental task at this time is ego integrity versus despair. People who attain ego integrity view with a sense of wholeness and derive satisfaction from past accomplishment. They view death as an acceptable completion. According to Erikson, people who develop integrity accept “one’s one and only life style”. By contrast, people who despair often believe they have made poor choices during life and wish they have made poor choices during life and wish they could live life over. Robert Butler sees integrity and bringing serenity and wisdom, and despair as resulting in 6

the inability to accept one’s fate. Despair gives rise of frustration, this couragement, and a sense that one’s life has been worthless. Moral Development According to Kohlberg, moral development is completed in the early adult years. Most old people stay at Kohlberg’s conventional development, and some are at the preconventional level. An elderly person at the preconventional level obeys roles to avoid pain and the displeasure of others. At stage one, a person defines good and bad in relation to self, whereas older person’s at stage 7 may act to meet another’s need as well as their own. Elderly people at the conventional level follow society’s rules of conduct to expectation of others. Emotional Development Well-adjusted aging couples usually thrive on companionship. Many couples rely increasingly on their mates for this company and may have few outside friends. Great bonds if affection and closeness can develop during this period of aging together and nurturing each other. When a mate dies, the remaining partner inevitably experiences feelings of loss, emptiness, and loneliness. Many are capable and manage to live alone; however, reliance, on younger family members increases as age advances and in health occurs. Some widows and widower remarry, particularly the latter, because the widowers are less inclined than widows to maintain a household. Spiritual Development Murray and Zentner write that the elderly person with a mature religious outlook striver to incorporate views of theology and religious action into thinking. Elderly people can contemplate new religious and philosophical views and try to understand ideas missed previously or interpreted differently. The elderly person also derives a sense of worth by sharing experiences or views. In contrast, the elderly person who has not 7

matured spiritually may not matured spiritually may feel impoverishment or despair as the drive for economic and professional success wares. Psychosexual Development Sex drives persist into the 70’s, 80’s, and 90’s, provided that the health is good and an interested partner is available. Interest in sexual activity in old age depends, in large measure, on interest earlier in life. That is, people who are sexually active in young and middle adulthood will remain active during their later years. However, sexual activity does become less frequent. Many factors may play a rate in the ability of an elderly person to engage in sexual activity. Physical problems such as diabetes, arthritis, and respiratory conditions affect energy or the physical ability to participate in sexual activity. Changes in the gonads of elderly women result from diminished secretion of the ovarian hormones. Some changes, such as the shrinking of the uterus, and ovaries, go unnoticed. Other changes are obvious. The breasts atrophy, and lubricating vaginal secretions are reduced. Reduced natural lubrication is the cause of painful intercourse, which often necessities the use of lubricating jellies. 3.1.2. Ill Person at the Particular Age of Patient The older fracture patients showed a higher prevalence of chronic brain syndrome, they were in poorer physical state and their skinfold thickness was less. They also had more unrecognized visual disorders. Those who were younger had a higher prevalence of stroke than comparable controls. The type of fall leading to the fracture varied with age—tripping was the commonest cause in the younger patients and ‘drop attacks’ in the older. Both stroke and partial sightedness were associated with falls due to loss of balance. The older patients had a very high prevalence of pyramidal tract abnormality associated with chronic brain syndrome—and it appears that these demented patients fall not because of mental confusion but because of associated motor abnormalities. Ertra-capsular fractures occur in older patients. They are more likely to have a history of falls but previous fracture is equally common at this age in the fracture and control series. 8

2. Diagnostic Test

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Diagnostic test

Normal values

Patient’s Result

Significance

Hemoglobin

14.0-17.5 g/dL

9.1

Hematocrit

41.5-50.4%

28.8

- Decreased-various anemias, with excessive fluid intake. -Decreased-severe anemias

WBC

4.4-11.0x10^ g/uL

5.32

-Normal

RBC

4.5-5.9x10^ g/uL

2.8

-Decreased- all anemias and leukemia, when blood volume has been restored.

Mean Corpuseular Hemoglobin

27.5-33.2 pg

32.7

-Normal

Mean Cell Volume (MCA)

80-96 fL

103.6

-Increased-macrocytic anemia

Mean Corpuseular Hemoglobin

33.4-35.5 %

32

-Decrease-severe hypochronic anemia

Platelet

150,000-450,000

387

-Normal

Differential Count

40-70 %

67

-Normal

Neutropihl

0-1 %

0

-Normal

Basophil

0-5 %

4

-Normal

Eosinophil

0-8%

09

Monocyte

20-40%

20

-Increase-viral infection, collagen and hemolytic disorders -Normal Source: Brunner and Suddarth’s. Textbook of Medical-Surgical Nursing.10th Edition Volume 2. page 2214-2215

Serum

3.6-5

4.7

-Normal

Potassium

6.7-1.5

6.6

Creatinine

8.4-10.2

8.2

-Decreased-Muscular atrophy, anemia, leukemia -Decreased-vitamin D. deficiency

April 10, 2008 Complete Blood Count

Lympocyte

10

Calcium

1.2-2.2

1.0

-Decreased-anemia, malnutrition

Protein

3.3-5.5

2.9

-Decreased-no clinical significance

Albumen

2

2.9

Globulin

6.8

5.8

-Increased-chronic infection, multiple myeloma -Decreased-malnutrition

Total Protein

65-110

145

-Increased-diabetes mellitus

GCT(50gms)

8-35 u/mL

20

-Normal Source: Brunner and Suddarth’s. Textbook of Medical-Surgical Nursing.10th Edition Volume 2.page 2217,2219,2221,2224,2229,2230,2232

PBS

65-110

118

-Increased-diabetes mellitus Source: Brunner and Suddarth’s. Textbook of Medical-Surgical Nursing.10th Edition Volume 2.page 2230,2233,

Uric acid

2.5-7.5

4.4mg/dL

-Normal Source: Brunner and Suddarth’s. Textbook of Medical-Surgical Nursing.10th Edition Volume 2.page 2225,

Bleeding time-sim

2.3-9.5

6.31 min.-sec.

-Normal

Clotting time

5-15

10.41 min.-sec.

-Normal

Prothombin time

10-13

13.8 sec.

-Increased-deficiency of factors I, II, V, VII, and X, fat malabsorption

% activity

70-120

96.2 %

INR