Fractured Femur-case Pres

UNIVERSAL COLLEGE OF NURSING

8273 Dr. A. Santos Avenue, Parañaque City Telefax 8298615/8204276

Open Type III-S Complete Comminuted Fracture D3-L Femur

A Case Study Submitted to: Helen Ferriols. MAN Clinical Instructor East Avenue Medical Center

In Partial fulfillment of the Requirements in the Related Learning Experience Baquilar, Lorielyn D. Caloza, Anivill B. Cantor, Christopher C. De Vega, Joyce M. Echevarria, Adora S. Lovedioro, Vergel C. Lozada, Rose Ann Shayne F. Madredeo, Ronalyn B. Natividad, Brian C. Pring, Bernardino L. Salvador, Charles V.

Group C BSN III

Reasons for choosing the Case:

• • •

We choose this case because it requires a broader scope of research which will benefit us We chose this case to learn orthopedic in advance To have a study to share to our fellow student

Background Knowledge 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 than it can absorb. Fractures are cause by direct blows, crushing forces, sudden twisting motions, extreme muscle contractions. When the bone is broken, adjacent structures are also affected, resulting in soft tissue edema, hemorrhage into muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels. Body organs maybe injured by the force that cause the fracture or by fracture fragments. TYPES OF FRACTURE ➢ Greenstick fracture: an incomplete fracture in which the bone is bent. This type occurs most often in children.

➢ Transverse angle to the bone's axis.

fracture: a fracture at a right

➢ Oblique fracture: a fracture in which the break has a curved or sloped pattern.

➢ Comminuted the bone

fracture: a fracture in which fragments into several pieces.

➢ An impacted fracture is one whose ends are driven into each other. This is commonly seen in arm fractures in children and is sometimes known as a buckle fracture. Other types of fracture are pathologic fracture, caused by a disease that weakens the bones, and stress fracture, a hairline crack

➢ A depressed fracture results from a force that drives a piece of bone down. This fracture may effect the outer table of the skull, the inner table, or both if the force is strong and localized. This is a depressed fracture on the left parietal part of a skull.

➢ An avulsion fracture is a bone fracture which occurs when a fragment of bone tears away from the main mass of bone as a result of physical trauma

➢ An uncomplicated fracture in the bone do not

closed fracture/simple which the fractured ends of break the skin.

➢ A spiral fracture (also called a torsion fracture) is a bone fracture in which the bone has been twisted apart

➢ A compression fracture occurs when the normal vertebral body of the spine is squished, or compressed, to a smaller height

➢ Compound fracture: A fracture in which the bone is sticking through the skin. Also called an open fracture.

Skeletal Tractions

Patients Profile Name:

MC

Age:

57 years old

Date of Birth:

July 7, 1952

Status:

Widowed

Nationality:

Filipino

Religion:

Roman Catholic

Home Address:

Batasan Hills Quezon City

Date of Admission:

December 24, 2009

Time of Admission: 8:15 am Admitting Diagnosis: Fx Open III-S Complete Comminuted D3-L Femur

Past Medical History •

Highblood

•

Asthma

•

Breast Mass at Lateral aspect of the left Breast

Patient’s General Appearance

Date Performed: Time:

January 18, 2010 9:00 am

Name: MC Age: 57 years old Primary Language: Tagalog Height: 5’3’’ Weight: 54 kg Vital Signs: BP- 110/80 mmHG Temp- 36.9 C PR- 82 BPM RR- 22 Assessment: • • • • • • • • • •

Hair Color - Black and White Body Build - Proportionate Overall hygiene and grooming - Clean and neat Note Body and Breath Odor - No Body odor; No Breath odor Signs of distress in posture or facial Expression - no distress noted Note obvious signs of Health/ Illness - Weak and with fractured at left Leg Client’s Attitude - Cooperative and able to follow instructions Client’s affect/mood; appropriateness of the responses - Appropriate to situation Quantity of Speech, Quality and Organization - understable, clear tone; exhibits thought association Relevance and organization of thoughts - makes sense; has sense of reality

Physical Assessment PARTS TO BE

OBSERVATION

MEASUREMENT

NORMAL

INTERPRETATION

ASSESSED I. Gross general appearance

FINDINGS

1.1 Height

1.6 m

Normal

1.2 Weight

54 kg

Normal

1.3 Body Build 1.4 Posture/ Gait 1.5 Skin Color 1.6 Personal Hygiene/ Grooming 1.7 Body Breath Odor 1.8 Nutritional Status 1.9 Age appropriateness 1.10 Sensory status

fair skin color

normal posture

Ectomorphic

fair skin color

Normal

Normal

Normal

neat and clean no foul smelling odor BMI: 18.524.9

No Body and Breath Odor

Normal Normal

BMI: 21.1

Appropriate to Age Normal

Her face is Appropriate to her age Well developed

Well developed Normal

2. Physiologi cal Cues 2.1 Temperature

36.9 C

2.2 Pulse

Normal

82 bpm

36.5-37.5 C 60-100 bpm 16-22 cpm

2.3 Respiration

22 cpm

120/80 mmhg

Normal

2.4 Blood Pressure

110/80 mmHG

Normal

Normal

3. Behavior 3.1 Verbal (Speech-quality; quantity; coherence; relevance; pattern; organization of thought) 3.2 Non-verbal Body language Gesture Movement Facial expression Attitude Affect/ mood Appropriateness of response

HEAD TO TOE PHYSICAL EXAMINATION Head 1. Skull

-good speech quality -understable, clear tone; exhibits thought association

- good speech quality -organized the thought

Normal

-can response to a body language -can do facial expression

-can response to a body language -can do facial expression -

Normal

TECHNIQUE

NORMAL / STANDARD

ACTUAL FINDINGS

ANALYSIS

Palpation Size, shape, contour, any lumps, deformities

-rounded -smooth skull contour -absence of nodules or masses

-symmetrical in shape -smooth skull contour -absence of nodules or masses

Normal

2. Scalp / hair

Inspection Appearance, hair color, distribution, texture, presence of lice, nits and dandruff

-hair evenly distributed -hair black in color -silky hair -no presence of nits and lice -no presence of tenderness

-even distribution of hair -black and white hair color -silky -no presence of nits and lice -not tender

Normal

3. Face

Inspection Note symmetry,

-rounded; symmetric or

-rounded -symmetric

Normal

shape, expression, Appearance and movements 4. Eyes/Vision

Eye Structures a. Eyeball - note Any protrusion

slightly asymmetric facial features -symmetric facial movements

facial movements

-no protrusion

-no protrusion -symmet rical closeness of lids -no secretion

b. Lid margins Observe scaling Secretions, position, Symmetry, ability to blink and frequency

-lids close symmetrically -no secretion -symmetrical -15-20 blinks/min

c. Conjunctiva note color, appearance

-transparent; shiny, smooth, and pink or red

d. Sclera – note Color, appearance

-sclera appears white in color

e. Pupils – size, Shape, symmetry, Reaction to light, and accommodation

-pupil equally round reactive to light accommodation (PERRLA)

f. Eyebrows/lashes Color, symmetry, quantity of hair, placement

Normal Normal

-symmetrical -can blinks 16/min

-evenly distributed hair -black and white in color -symmetrically aligned -curled slightly outward

-pinkish in color -shiny -white in color -pupil equally round

Normal

Normal

Normal -even distribution of hair -black and white -aligned symmetrical

Normal

-coordinates by movement

g. Eye movement in all directions -both eyes coordinated (cardinal movement/s)

Normal

5. Ears/hearing

a. Pinna Inspection Parallelism, size, shape, appearance, placement. Palpation Palpate for firmness of the cartilage and for tenderness. b. External canal Inspection Check color, appearance, and any discharge.

e. Hearing acuity Whisper from clients ear at a distance of 2 feet away from the clients back

-symmetrical; aligned with outer canthus of eye, about 10 from verical

-symmetrical Normal

-firm -not tender

Normal

- grayish an in color -wet cerumen

Normal

-able to hear ticking in both ears -normal voice tone (audible)

-able to hear on both ears

Normal

-mobile, firm, and not tender; pinna recoils after it is folded -grayish tan color -presence of wet cerumen in various shades of brown -no discharge

6. Nose

Inspection Placement, discharges and Patency

-symmetric and straight -no discharge -air moves freely as the client breaths through the nares

-midline alignment -no discharge -air moves freely

Normal

7. Mouth / lips

Inspection Color, shape, moisture and symmetry, appearance

-uniform pink color -soft, moist, smooth texture -symmetry of contour -ability to purse lips

-pinkish in color -soft, moist, smooth -ability to purse lips

Normal

-pink gums -moist, firm texture to gums -no retraction of gums

-pinkish in color -firm and moist

Gums Color, appearance

Teeth

-smooth, white,

Normal

Color, arrangement, general condition, breath Tongue Size, color, shape, symmetry, moisture, movement Palate – Hard / soft Color, texture, shape

8. Cheeks

9. Neck

shinny tooth enamel,

Normal -pink color -moves freely -moist; slightly rough -symmetrically aligned -lighter pink hard palate -light pink, smoothsoft palate -more irregular texture -symmetrical in shape

Soft Palate – (w/ penlight) pink, smooth uvula in midline

-pink in color -uvula positioned in midline of soft palate

Oropharynx / tonsil Color, texture, elicit gag reflex present Inspection Color, appearance

-pink and smooth posterior wall -gag reflex present

(Inspection) Symmetry, position, movement (chin to chest, ear to shoulder)

(Palpation) Palpate for lumps,

-No more Tooth

-pinkish -symmetrical -moist Normal -pinkish in color -smooth -symmetry of the shape

Normal

-pinkish -uvula present in midline -pinkish -smooth -presence of gag reflex

Normal

-pink in color

-Fair color

Normal

-symmetrical (muscles equal in size) -coordinated, smooth movements with no discomfort -complete range of motion

-head centered

Normal

-lymph nodes not palpable

Normal

10. Chest Anterior

nodes, tenderness (Inspection) Note symmetry, color, deformities, breathing pattern (Palpation) Any lumps, masses

Posterior

Inspection Symmetry, retractions, deformities

Palpate for vocal (tactile) fremitus

-not palpable -skin intact -quiet, rhythmic and effortless respirations

-rhythmic respirations

Normal

-no masses

-chest wall intact -spinal column is straight -right and left shoulders and hips are at the same height -bilateral symmetry of vocal fremitus

Auscultate Breath sounds 11. Heart

Inspection Check for lifts, heaves, pulsation Palpation 2nd ICS (right) Aortic valve 2nd ICS (left) pulmonic valve th 5 ICS (left sternal border) tricuspid mid-clavicular – below the nipple) apical Auscultation Check cardiac rate at apical area Inspect Jugular Veins for distention

12. Breast

Inspection

-vasicular and bronchovesicular breath sounds -complete pulsation of the heart, normal heart sound

-normal heart rate -usually heard at all sites -no distention -veins not visible

Normal

Normal

Normal

Size, Shape, symmetry, color, any dimpling, discharges in the nipples Palpation Note any mumps, masses, tenderness, (clockwise borders inward) 13. Abdomen

Inspection Color, contour, symmetry, skin integrity, scars

-no tenderness, masses/nodules

Normal

-Presence of Breast Mass(7x5 cm) at Lateral Aspect of the Left Breast

Abnormal

-unblemished skin; uniform in color; symmetric contour

Normal

Auscultate for bowel sounds, vascular sounds, peritoneal friction rub

-audible bowel sound -absence of arterial bruits -absence of friction rub

Normal

Palpation Palpate 4 quadrants, note areas of tenderness, lumps, masses, distention in circular motion using finger pads.

-no tenderness; relax abdomen with smooth, consistent tension

Percussion Percuss 4 quadrants from LQD clockwise, note any tympany or dullness

14. Upper Extremities

-skin uniform in color; skin smooth and intact; no nipple discharge

Inspection Symmetry, size, length, deformities, skin

Normal

-tympany over the stomach and gas filled bowels, dullness especially over the liver and spleen, or a full bladder -equal in size, both side of the body

Normal

-symmetrical

Normal

lesions, scars, ROM movement

15. Lower Extremities

Hands Size, number of fingers, color of nail, capillary refill, hygiene movement Inspection Symmetry, size, length, deformities, hair distribution, scars, lesions, movement (flexion, extension, rotation) Feet Inspection Color, symmetry, deformities, number of toes, scars, lesions, hygiene. Movement (flexion, extension, rotation)

-range of motion varies

-able to return capillary refill within 2-3 seconds -5 fingers in 1 hand

Normal

-no deformities, no skin lesion and scars

-presence of Gun shot wound at Left femur

Abnormal

-fair skin color -no scars/lesions -can extend, flex and rotate -skin intact

-fair skin color -presence of gun shot wound at Left femur -can’t extend and flex Left Leg

-5 fingers in 1 hand -pinkish color, able to return after the capillary refill

Abnormal

Course in the ward

Doctor’s Order

Nursing Responsibilities

1) Maintain Tractions

• • • •

Inspect Integrity of Tractions Inspect for Infections Daily wound Dressing Educate Patient for proper immobilization

1) Safety

• • • •

Ensure Client’s Safety Side rail’s Up for safety Put Client’s belongings within reach Educate significant others about safety precautions

• •

1) Refer for OR schedule

•

Assess patient’s financial status Refer for Social service( PCSO, Phil Health) Educate patient regarding operation

Anatomy and Physiology Skeletal System The skeleton has six main functions

• Support- It provides the framework which supports the body and maintain its shape. • Movement- The bones are the levers that help the body move in different directions and in different ways.

• Protection The skeleton protects many vital organs • • • • .

Cranium protects the brain. Ribs/Sternum protects the lungs, heart and some digestive organs. Pelvis protects and supports the digestive and reproductive organs. Spinal column protects the spine.

• Blood cell production Inside of the long bones in our bodies, there is a cavity that is filled with a substance called Bone Marrow. In this tissue, new blood cells are produced, and damaged blood cells are repaired. Red bone marrow produces red blood cells, white blood cells and other blood elements.

The skeleton is the site of hematopoiesis, which takes place in red bone marrow. Marrow is found in the center of long bones.

• Storage Mineral is a substance that the body needs to carry out all of our bodily functions like thinking, breathing and moving around. One of the minerals that the body needs is calcium. Calcium is a major part of bone, and this is where the body stores its calcium.

• Endocrine regulation Bone cells release a hormone called osteocalcin, which contributes to the regulation of blood sugar (glucose) and fat deposition. Osteocalcin increases both the insulin secretion and sensitivity, in addition to boosting the number of insulin-producing cells and reducing stores of fat.

Fractured femur with plate and screws

Laboratory Results

Hematology WBC

Dec. 24 22.1

Jan. 4 15.9

Hemoglobin

119

95

Hematocrit

0.367

0.28

Neutrophils

0.86

0.46

Lymphocytes

0.11

0.30

0.02 0.01 Adequate 90.8 29.5 325 13.2

0.02 0.20 0.02 182 86.2 29.4 341 12.8

Monocytes Eosinophils Basophils Bands Platelet MCV MCH MCHC RDW

Serology Glucose N Cholesterol LDL Cholesterol Triglycerides HDL-Cholesterol Blood Urea Nitrogen Creatinine Sodium potassium

Results 4.8 4.4 3.3 0.94 0.64 4.9 78 138 3.7

Normal 5-10 Adults 9-20 New born 140-170 M 120-140 F 0.45-0.50 M 0.38-0.48 F 0.31-0.76 Adult 0.40-0.50 Newborn 0.24-0.44 Adult 0.31-0.60 New born 0.00-0.06 Adult 0.02-0.04 0.00-0.01 0.02-0.04 150-450 80-100 27-31 320-360 11.0-14.6

Findings 3.9 0.0-5.2 2.6-4.1 0.4-1.7 0.91-1.56 2.5-6.1 53-115 135-148 3.5-5.3

Units X109/L gm/L % % % % % % % X109/L Fl Pg g/L %

Units mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L umol/L mmol/L mmol/L