Case Study Orthopedic

Fracture: Open I Tibia Fibula (R) Lacerated Wounded Leg Individual Case Study on Philippine Orthopedic Center

Nursingcasestudy.blogspot.com

I.

INTRODUCTION The case was about a 6-year-old male who had an open fracture on his right lower leg, which he incurred while crossing the street and was accidentally, bumped by a jeepney. He was brought on a stretcher accompanied by relatives on POC referred by Ospital ng San Jose Del Monte for debridement and for an external fixator. Admitted on Aug 7, 2007. A fracture is a break in the continuity of bone. It is defined according to type and extent. Fractures occur when the bone is subjected to stress greater that it can absorb. A direct blow, crushing force, sudden twisting motion, or even extreme muscle contraction can cause fractures. Bones can fracture as a result of direct trauma or indirect trauma. Direct trauma consists of direct force applied to the bone; direct mechanisms include tapping fractures (eg, bumper injury), penetrating fractures (eg, gunshot wound), and crush fractures. Indirect trauma involves forces acting at a distance from the fracture site. Indirect mechanisms include tension (traction), compressive, and rotational forces. In the case of the patient he had a direct trauma (bumped by a jeepney) where he had an open wound fracture, where his right lower leg was affected especially the tibia and fibula. I, a student nurse, will study on this particular case for familiarization of fractures as well as execution of nursing skills in orthopedic cases rendering care to a patient. a. Objectives After successful accomplishment of this case presentation, the students will be able to: 

Discuss the anatomy and physiology of the skeletal system that are directly affected in the fracture and relate the concepts to the actual situation of the patient. In this case the bones (phalanges) in the foot.



Explain the pathophysiology of a fracture.



Determine the nursing priorities and nursing management requisite and executable in a foot fracture, and incorporate these in the creation of a pertinent nursing care plan



Distinguish the different pharmacological actions of the drugs involved in the treatment of a fracture, and identify the nursing considerations that must be employed



Formulate relevant health teachings and outpatient care for a patient with a fracture.

II.

NURSING ASSESSMENT a. Personal Data Patient’s Name: R.L. Age: 6 y/o Sex: Male Address: Sapang Palay Bulacan Civil Status: Single Nationality: Filipino Religion: Catholic Admission Date: Aug 07, 2007 Chief complaint: Lacerated Wound Right Leg Clinical impression: Open I Tibia Fibula (R) Leg Lacerated Wound Attending physician: Dr. Mutia

b. History of Past Illness The patient had complete immunization during her childhood. Non-hypertensive, non-diabetic, non-asthmatic, no heart and circulation problems such as chest pain, weakness, shortness of breath, slurred speech or problems with vision. No allergies from aspirin and no history of stomach ulcers or bleeding. No past hospitalizations occurred until present. c. History of Present Illness The patient had an accident while crossing the street, accidentally he didn’t noticed the jeepney approaching from behind him. He was bumped by the jeepney and sustained a direct trauma on his right leg. His tibia and fibula sustained an open wound fracture. The patient was then immediately rushed in Ospital ng San Jose Del Monte, was then x-rayed and had the result Open I Tibia Fibula (R) Leg. The orthopedic surgeon referred for his debridement and fixator to POC and was admitted Aug 07, 2007. d. Psychosocial History The patient was a male 6-year-old prep from Bulacan City. The client is active in class, do homework and studies well. The client’s diet generally involved a variety of home-cooked / home prepared. He had a good appetite. During weekends he plays with his neighbors usual for a child’s play age.

e. Family History The patient’s parents were both still living. The father is an electrician and mother is a housewife. Parents had no established health problem. They were both negative for having diabetes. Eldest of 3 children, youngest is 2 years old.

f.

Physical Examination/Assessment Patient’s Name: R.L. Age: 6 y/o Sex: Male Address: Sapang Palay Bulacan Civil Status: Single Chief complaint: Lacerated Wound Right Leg Clinical impression: Open I Tibia Fibula (R) Leg Lacerated Wound Aug 07, 2007: T – 38.1°C PR – 100 bpm RR—20 bpm BP – 120/70 mmHg Aug 08, 2007: T – 37.4°C PR – 97 bpm RR—19 bpm BP – 120/70 mmHg HEAD The skull is rounded with parietal prominence and smooth in contour. The skull is free of any nodules, masses and depressions. The hair is thick, straight, black and shiny with equal distribution. Portions of the scalp have no dandruff. No lesions are noted. EYES Patient did not wear eyeglasses and disclaimed having vision problems. The general character of his face was calm and attentive. He had moderately thin eyebrows with rounded eyes that lied symmetrical to the nose. No discharges were noted on both eyes. The conjunctiva appeared lustrous pink, while the sclera looked white. The pupils were black and equally round. They were reactive to light, showing constriction and dilation capabilities when stimulated by illuminating at different distances. EARS The patient did not have any family history of hearing problems or any ear problems. The auricles or pinna are aligned with the outer canthus of the eyes, did not possess any deformities, lumps and lesions. No swelling and discharge were observed in the external canal. Client had no history of hearing problem. Her auditory acuity was good as he was very sensitive and responsive to sounds produced at varying distances. NOSE The nose was flat but symmetrical in shape. No inflammation, flaring, and lesions were present. The internal mucosa was dry and void of any discharges. MOUTH The outer lips were pink and relatively moist, showing no signs of pallor or cyanosis. The interior of the lips were smooth, moist and light pink. No lesions, edema, and ulcerations were found. The gums and tongue likewise looked pink and moist. The tonsils were intact and un-inflamed. NECK The neck muscles (sternocleidomastoid and trapezius muscles) did not have any swelling or masses. Head movements are coordinated, smooth and without any discomfort. The neck was symmetrical in shape with no mass palpated along the lymph nodes. The neck muscles demonstrated strength with the client’s ability to push his head against an antagonizing force of a hand. THORAX & LUNGS

The patient had no history of major respiratory ailments. He did not develop difficulties in breathing. His breath sounds were auscultated and showed absence of wheezing, rales, and stridor. The respiratory rates were 20 and 22 breaths per minute on April 18 and 19, respectively. HEART The patient alleged having no history of heart disorders. His heart sounds were auscultated and was found free from murmurs. His pulse rates were 80 and 69 beats per minute on April 18 and 19, respectively. ABDOMEN The abdominal contour was not protuberant when in standing position. The abdomen was flat and soft upon palpation and revealed no abdominal bowel sounds. Thise were no scars, lesions, and hisnias marked. EXTREMITIES The hands and wrists were intact with complete sets of fingers. No swelling and redness was evident. Client was easily & painlessly able to perform range of motion exercises with his hands and wrists. The elbows showed no swelling and deformities. Patient had no problems extending and flexing his forearms. Decreased Range of Motion on the right leg, swelling, open wound and deformation found on the right leg. The rest of the legs and feet of the left side were unaffected and demonstrated ability to perform range of motion exercises. NEUROLOGICAL EXAMINATION Patient was alert and well oriented with the time, place and people he was involved with. He was a little bit shy but vocal about his emotions and feelings. Fear of the procedure. Inspite of shyness, was able to communicate and interact well, and was very accommodating in answering questions.

III.

ANATOMY & PHYSIOLOGY OF THE SKELETAL SYSTEM (TIBIA AND FIBULA)

IV.

PATHOPHYSIOLOGY / SYMPTOMATOLOGY

RISK FACTORS

In the case of the client the major risk factor was trauma where he was accidentally bumped by a jeepney

Osteoporosis, Exercise and Sports Injury, Dental Emergencies, Perinatal Problems, Overuse, Trauma

AFFECTED PART

In the case of the client specifically open I tibia fibula right leg.

Bones of Lower Right Leg

The client had a open wound fracture. DISEASE PROCESS

Signs and symptoms (Book Med Surgcial Nursing Lipincott Williams and Wilkins 10 ed.) 





Experiences muscle spasm and continuos pain that increases in severity until bone fragments are immobilized Loss of function, deformity, abnormal movement, and shortening of the extremity may be noted. Crepitus, local swelling, and discoloration may be seen.

Diagnostic Tests (Med Surgical Nursig Saunders 6th ed.) 





Tomography – can be used to locate bone destruction, small cavities, foreign bodies, and lesions overshadowed by other structures. Bone Scans – images of the skeleton are taken after radioisotopes is injected intravenously and allowed to migrate to bone. Radiography – x-ray examinations obtaining a plain film, usually an anteroposterior or lateral view, possibly both.

FRACTURE

Signs and symptoms experienced by the patient   

Felt extreme pain. Can’t move his right leg and had an open wound . The right leg is swelling.

Diagnostic Tests done on the patient 

X-Ray – was done to the patient upon rushed to Ospital ng San Jose Del Monte

Treatment (Illustrated Manual of Nursing Practice Springhouse)

Treatment on Patient 

 



Drug Therapy Surgery – arthroscopic surgery, open reduction and internal fixation, amputation, laminectomy and spinal fusion, joint replacement, etc. Non-surgical Treatments – closed reduction, immobilization

Nursing Management (Illustrated Manual of Nursing Practice Springhouse) Patient preparation. If the patient will be receiving a general anesthetic, instruct him not to eat after midnight. Tell him he’ll receive a sedative before surgery. If appropriate, explain how traction can reduce pain, relieve spasms, and maintain alignment while he awaits surgery. Mention that he’ll need to wear a bandage, sling, or cast postoperatively to immobilize the fracture or dislocation

Debridement and fixation – procedure involves debridement and a fixator to fix the fractured bone.

Nursing Management for the patient: Witnessed consent for procedure signed and secured Needed materials supplies and material prepared. (fixator) Explanation of procedure was explained. Skin preparation was done. Post care rendered. Back to room and on Diet as Tolerated.

Five phases of fracture healing are the following (Frost, 1989): 1. 2. 3. 4. 5.

Fracture and inflammatory phase Granulation tissue formation Callus formation Lamellar bone deposition Remodeling

Injury involves the actual fracture to the bone, including insult to bone marrow, periosteum, and local soft tissues. Various biochemical signaling substances are involved in the formation of the granulation tissue stage, lasting roughly 2 weeks. Within 7 days, the body forms granulation tissue between the fracture fragments. The most important stage in fracture healing is the inflammatory phase and subsequent hematoma formation. It is during this stage that the cellular signaling mechanisms work via chemotaxis and an inflammatory mechanism to attract the cells necessary to initiate the healing response. During callus formation, cell proliferation and differentiation begin to produce osteoblasts and chondroblasts in the granulation tissue. The osteoblasts and chondroblasts synthesize the

extracellular organic matrices of woven bone and cartilage respectively, and then the newly formed bone is mineralized. This stage requires 4-16 weeks. During the fourth stage, the meshlike callus of woven bone is replaced by lamellar bone, which is organized parallel to the axis of the bone. The final stage involves remodeling of the bone at the site of the healing fracture by various cellular types such as osteoclasts. The final 2 stages require 1-4 years. Patients who have poor prognostic factors in terms of fracture healing are at increased risk for complications of fracture healing such as nonunion, malunion, osteomyelitis, and chronic pain. Patient factors influencing fracture healing Factors Ideal Age (Farmer, 1984) Youth Trauma (Schemling, 1995) Single limb Medications (Giannoudis, 2000) None Social factors (Kwiatkowski, 1996) Local factors (Mollitt, 2002) Type (Rockwood, 1996) Nutrition (Hernandez-Avila, 1991)

Nonsmoking

Problematic Advanced age (>40 y) Multiple traumatic injuries Nonsteroidal antiinflammatory drugs (NSAIDs), corticosteroids Smoking

No infection Closed fracture, neurovascularly intact Well nourished

Local infection Open fracture with poor blood supply Poor nutrition

There were no signs of infection just swelling. It was a closed fracture and no skin break and the patient was well nourished.

V.

NURSING MANAGEMENT Name of Patient: R.L. Age: 6 y/o Sex : male Religion: Catholic

Date admitted: Aug 07, 2007 Chief complaint: Diagnosis:

Action

Rationale

Immediate assessment includes airway, breathing and circulation. Monitor the vital signs until they are within normal limits and stable.

• To assess the overall general condition of the patient post anaesthetic.

Monitor the patient for signs and symptoms of neurovascular compromise comparing findings to the unaffected limb.

• Careful monitoring enables early detection.

a) Check for diminished or absent pedal pulses.

Surgical trauma causes swelling and edema, which can compromise circulation and compress nerves.

b) Check for capillary refill time. > 3 seconds

Prolonged capillary refill time points to diminished capillary perfusion

c) Observe for pallor, blanching, cyanosis, and coolness of extremity.

These signs may indicate compromised circulation.

d) Check for complaints of abnormal sensations, e.g. tingling and numbness.

These symptoms may result from nerve compression.

e) Observe for increased pain not controlled by medication.

Tissue and nerve ischaemia produces a deep, throbbing unrelenting pain.

Monitor intravenous infusions and continue according to prescription of surgeon or anaesthetist.

• The patient’s status of hydration needs to be monitored to prevent electrolyte imbalance or circulatory overload.

Assess the patient’s level of pain control and administer analgesia as prescribed. Ensure that if a patient controlled analgesia device (P.C.A.) is used, the corresponding hospital policy is followed. It is important for the patient to obtain effective pain relief in order to start an early programme of both limb and deep breathing exercises in relative comfort

• To monitor the effectiveness of the prescribed analgesia. Pain management is very important to prevent vicious cycles of pain, tension and anxiety that breeds more pain and equally important prevents participation in physiotherapy and self care.

Action

Rationale

The patient’s Waterlow Score is assessed. Specifically assess skin over bony prominences (sacrum, trochanters, scapulae, elbows, heels, inner and outer knees, inner and outer malleolus and back of head). Areas where skin is stretched tautly over bony prominences are at a greater risk of breakdown, because the possibility of ischaemia to skin is high due to compression of skin capillaries between a hard surface (i.e. mattress, chair) and the bone.The decision to nurse the patient on a pressure-relieving mattress will depend upon the nurse’s clinical judgement and the patient’s condition.

• These measures help to minimise the risk of complications of skin breakdown. Frequent repositioning is required to alleviate pressure pain and discomfort. A thorough skin assessment should be carried out each time the patient is repositioned.

The wound dressing is monitored for oozing from the incision site. If the patient has a portovac, observe the drainage from the wound through the portovac drains and record appropriately.

• Careful monitoring enables early detection of complications. Hypertension and vasospasm during surgery can result in temporary haemostasis and can result in delayed bleeding (Griffen 1999).

The leg and the external fixator must be moved as a unit and the amount of support required by the nurse is determined by the patient’s ability to control the leg during the move. The patient should use the overhead monkey pole to assist with body position changes.

• To prevent pain on movement, and to maintain correct alignment.

Pin-sites and wounds must be constantly observed for signs of infection: Observations should include determining pin stability, assessing skin tension at insertion site, noting colour, odour and characteristics of any drainage. Pin-sites should be attended to under strict aseptic technique, initially daily or more often as required.

• Prophylactic antibiotics are administered to prevent infection.

Continuously assess the patient for signs and symptoms of: Deep Venous Thrombosis (D.V.T.) Positive Homans Sign Swelling of leg, Tenderness in calf.

• Early detection and treatment.

DRUG STUDY

DATE ORDERED 7-7-7

MEDICATION AND TREATMENT Generic Name: Amikacin Sulfate Brand Name: Amikin Classification: Aminoglycosides

ACTION Inhibits protein synthesis by binding directly to the 30S ribosomal subunit. Generally bactericidal.

50mg/ml IM / IV infusion Q12

V.

INDICATION Serious infections caused by pseudomonas aeruginosa

NURSING CONSIDERATION Used cautiously in impaired renal function Obtain culture sensitivity tests before first dose. Weigh patient and obtain baseline renal function studies before therapy begins.

EVALUATION

PROGNOSIS * Tibia and fibula fractures Prognosis is generally good yet is dependent on degree of soft-tissue injury and bony comminution. Prognosis is good for isolated fibula fractures. MEDICATIONS Analgesics -- Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures. Toxoids -- This agent is used for tetanus immunization. Booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

EXERCISE Consult with the patient’s doctor and physical therapist to coordinate rehabilitation orders (exercise, Range of motion) and teaching. Describe the gait teach and explain the reason why to do the exercise. Then demonstrate the gait as necessary. Assist how to use his crutches. Three point gait – patient who can bear only partial or no weight on one leg. Instruct her to advance both crutches 6 to 8 inches (15 to 20 cm) along with the involved leg. Then tell her to bring the uninvolved leg forward and to bear the bulk of her weight on the crutches but some of it on the involved leg, if possible. Stress the importance of taking steps of equal length and duration with no pauses. Teach the patient using crutches to get up from a chair, tell her to hold both crutches in one hand, with the tips resting firmly on the floor. Then, instruct him to push from the chair with her free hand, supporting herself with the crutches. To sit down, the patient reverses the process, tell her to support herself with the crutches in one hand and lower herself with the other. Teach the patient to ascend stairs using the three point gait, tell her to lead with the uninvolved and to follow with both the crutches and the involved leg. To descend stairs, he should lead with the crutches and the involved leg and follow with the good leg. TREATMENT Prehospital Care: * Addressed airway, breathing, and circulation. * Checked and documented neurovascular status. * Applied sterile dressing to open wounds. * Apply gentle traction to reduce gross deformities; splint the extremity. * Administer parenteral analgesics for an isolated extremity injury in a hemodynamically stable patient. Emergency Department Care: * Open fractures must be diagnosed and treated appropriately. Tetanus had been updated and appropriate antibiotics given. This should involve antistaphylococcal coverage and consideration of an aminoglycoside for more severe wounds. Orthopedics consulted for emergent debridement and wound care. Fractures with tissue at risk for opening protected to prevent further morbidity.

* Compartment syndrome can develop in fractures of the lower leg. Signs of compartment syndrome include crescendo symptoms, pain with passive movement of involved muscles, paresthesias, pallor, and a very late finding is pulselessness. o If compartment syndrome is suspected, obtain an emergent orthopedic consult and measure compartment pressures. Compartment syndrome must be treated promptly with an emergency surgical fasciotomy. If untreated, the increased compartment pressures can cause ischemia and necrosis of the structures within that facial compartment and permanent disability. * Tibial plateau fracture o Immobilize nondisplaced fractures and have the patient remain nonweightbearing. o Obtain an orthopedic consultation for displaced (depressed) fractures, which require open reduction and internal fixation. Articular depression of greater than 3 mm may be considered for surgery. * Proximal tibia fractures o Surgically repaired proximal tibia fractures include external fixation, plating, and intramedullary nailing.

HYGIENE Instruct patient or family member in bathing and hygiene techniques. Have one of them demonstrate it under supervision. Instructions to a family member can be given in writing. Return demonstration identifies problem areas and increases self-confidence. Use of bedpan or urinal at bedside during night if the patient doesn’t want to go up in the dark to go to the bathroom. OUT-PATIENT CARE Client should be reminded about his follow-up care with the physician after one week. Give referral on health care delivery system such as physical therapist near to her location.

DIET Diet as Tolerated was ordered by the physician to the patient. Stress the importance of a high-carbohydrate and high-protein diet for adequate healing, and then assist the client in making food choices as necessary. SOCIAL ACTIVITIES Patient will stay home, he can invite and accommodate friends at his home. He can’t still go to school until proper instructions given by the doctor that he can go to school already.