Demographic Data

Name: Mrs. C.A. Address: Doldol, Bacong, Negros Oriental Sex: Female Age: 69 yrs. old Birth date: Dec. 3, 1942 Place of Birth: Doldol, Bacong, Negros Oriental Nationality: Filipino Marital Status: Married Religion: Roman Catholic Education: Elementary Graduate Occupation: Housewife Health Insurance: Philhealth Physician: Dr. C.U.P Source and Realibility: 20% patients chart; 75% patient; 5% significant others.

CHIEF COMPLAINT
nagsakit naman akong tuo nga tiil, ug akong kamot ky maoy natukon nako pagkahulog nako, sakit naman siya malihok as verbalized by the patient.

HISTORY OF PRESENT ILLNESS

Prior to the incident which causes the fracture, the client wanted to out to there garage to have some exercise, before opening the door, she tries to reach out to the doorknob but unfortunately she was not able to hold it and her left leg fell in there stairs.

PAST HEALTH HISTORY

The client has no known childhood illnesses. Her past hospitalizations was when he delivered her child in a cesarean section last 1975, last 2009 because of her eye operation, and the latest is last September 11, 2011 because of fall. The client has no known allergies and she her maintenance medication is insulin for about 3 years. She has no recent travel and she was not involved in any military service.

PSYCHOLOSOCIAL HISTORY
Typical day

Wakes at 6:00 am took her breakfast and at around 7:00 he takes fine walking around there house as her exercise. At around 9:00 am, he washes clothes and do light household chores. At around 11:30, she takes her lunch, & watches tv. At around 1:00 pm she takes a nap until 3:00 PM. At around 5:00 she watches the tv and at 6:30 she takes her dinner, then from 7:00 until 9:30 she watches tv and she retires to bed at 10 pm.

Nutritional / Metabolic Pattern

The patients usual food intake before the hospitalization includes fish, meat, vegetables, fruits, chicken. She consumes more than 8 glasses of water a day. Now the patient was advised by her attending physician to restrict foods that can aggravate her condition. The patient was also encourage to take more of Calcium and Vitamin D in order for her bones to become stronger. The patient doesnt smoke or drink alcoholic beverages, has no known allergies Elimination Pattern

Before, the patient can freely go to the C.R. to void or defecate but now that shes hospitalized she was advised to wear diaper for her to have difficulty in standing and walking. There is no burning sensation during urination and her stool is brownish formed stool. Activity-Exercise Pattern

The patient before hospitalized wakes up early in the morning for her to have fine walking around their house as her exercise. She usually guided her grandsons and granddaughters, but now, shes just on bed lying assisted by her significant others. Rest/ Sleep Pattern

Before the hospitalization, the patient usually sleeps late at night at around 10 oclock pm and wakes up early in the morning at 6 oclock am with an hour of sleep of 8 hours. Now, she usually sleeps early at night (8-9 oclock pm) and wakes up at around 7 oclock am with an hour of sleep of 10 hours. Sexuality/ Reproduction

The patient state that she is not sexually active. Since she is already old and shes already happy with there life. Coping- Stress Tolerance Pattern

The patient usually makes her decision as for now since her children were busy in their work, but they make sure they never forget to support and help their mother recover from illness. Sometimes, the patient usually shares her concerns to them and to her husband. She usually watch tv for her to be more relaxed.

Value-Belief Pattern

The patient find source strength and hope with God and her loved ones. God is very much important to the patient. Before, she usually goes to church together with her other children. They were not involved in any religious organizations or practices. The patient knows how to pray and praise God for all the nice things he had given. Relationship Pattern

The patient understands more on English and Bisaya languages but a little only in Tagalog language. The patient was living with her children and has a good relationship with them. Her children supported them and they always make sure that their mother is safe and secure. The patient can easily communicate, cooperate, listen and follow instructions easily.

FOCUS ASSESSMENT:
Musculoskeletal System UPPER Extremities
-capillary refill time is 2 sec. -fingers were curving downward - able to perform ROM exercises in the right arm and leg - difficulty in overcoming resistance. - radial pulse palpable- 80 bpm - brachial pulse palpable - no tenderness, slightly cold - biceps and triceps reflex present at the left arm -right arm has a cast

LOWER EXTREMITIES
-limited movement on lower extremities esp in the left leg - capillary refill is 2 sec - difficulty in performing ROM exercises - inability to overcome resistance - positive tenderness on the right hip - slightly cold, dry to touch , with pain upon palpation

DEFINITION:
A bone fracture is a medical condition in which there is a break in the continuity of the bone. A bone fracture can be the result of high force impact or stress, or trivial injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.
In orthopedic medicine, fractures are classified in various ways. Historically they are named after the doctor who first described the fracture conditions. However, there are more systematic classifications in place currently. All fractures can be broadly described as:

Closed (simple) fractures are those in which the skin is intact Open (compound) fractures involve wounds that communicate with the fracture, or where fracture hematoma is exposed, and may thus expose bone to contamination. Open injuries carry a higher risk ofinfection.

Other considerations in fracture care are displacement (fracture gap) and angulation. If angulation or displacement is large, reduction (manipulation) of the bone may be required and, in adults, frequently requires surgical care. These injuries may take longer to heal than injuries without displacement or angulation.

Compression fractures usually occurs in the vertebrae, for example when the front portion of a vertebra in the spine collapses due to osteoporosis (a medical condition which causes bones to become brittle and susceptible to fracture, with or without trauma).

Other types of fracture are:

Complete fracture: A fracture in which bone fragments separate completely. Incomplete fracture: A fracture in which the bone fragments are still partially joined. In such cases, there is a crack in the osseous tissue that does not completely traverse the width of the bone.[1] Linear fracture: A fracture that is parallel to the bone's long axis. Transverse fracture: A fracture that is at a right angle to the bone's long axis. Oblique fracture: A fracture that is diagonal to a bone's long axis. Spiral fracture: A fracture where at least one part of the bone has been twisted. Comminuted fracture: A fracture in which the bone has broken into a number of pieces. Impacted fracture: A fracture caused when bone fragments are driven into each other.

CAUSES:
Bones are some of the strongest tissues in your body. If an impact or a force is stronger than the
strength of the bone on which it is acting, then a fracture may result. The most common causes of fracture are falls, motor vehicle accidents, and a weakening of the bone called osteoporosis.

MANIFESTATIONS:
The five Ps pain, pulse, pallor, paresthesia, and paralysis are seen with all types of fractures. Swelling around the broken bone area

Bruises will appear in due time after the bone is fractured Bleeding when there is an open fracture Severe pain in the injured area Failure of free movements for the injured body part Inability to move the fractured limb when there is nerve damage Deformity when there is the displacement of the bone

DIAGNOSTIC EXAMS:
X-rays: Radiographs remain the most important tool for diagnosing and treating fractures. Routine x-ray evaluation of suspected fractures should always include both anteroposterior and lateral views. On a single view, the characteristic displacement, discontinuity in contour, or altered alignment of a fracture may be hidden because of overlap or projection. When standard views are equivocal, as sometimes occurs with minimally displaced spiral fractures, oblique views can be helpful. Fractures may be missed if the x-ray shows too small an area. A patient complaining of thigh and knee pain, for instance, may actually have a hip fracture causing referred pain; unless x-rays of the entire femur are taken, the fracture may be missed. Computed tomography: Although not routinely needed, computed tomography is a useful adjunct to plain x-rays in several circumstances. It allows visualization of occult fractures, particularly in areas difficult to image with xrays because of overlying bony structures (eg, the cervical spine). Computed tomography helps in determining the extent of articular surface disruption in joint fractures and in assessing suspected pathologic fractures for bone destruction and soft tissue masses. Magnetic resonance imaging: In special circumstances, magnetic resonance imaging offers advantages, providing excellent tomography, soft tissue contrast, and spatial resolution using noninvasive and nonionizing radiation technology. Magnetic resonance imaging helps in evaluating pathologic fractures and in diagnosing osteonecrosis and osteomyelitis, both of which can mimic fractures. Often, magnetic resonance imaging can show occult fractures before an x-ray can detect them. Magnetic resonance imaging cannot directly show calcification or bone mineral and thus does not visualize bone structure as well as x-ray or computed tomography. Bone scan: Total-body scanning, using 99mTc-labeled pyrophosphate or similar radioactive analogs, is performed to detect focal injury to bone from any cause. Uptake occurs wherever new bone forms, which can occur in response to infection, arthritis, tumor, or fracture. Occult fractures not yet visible on x-ray can often be detected on bone scan 3 to 5 days after injury. Patients with suspected pathologic fractures require bone scans for evaluation of metastatic and metabolic bone disease, which involve areas other than the fracture site. Blood tests: Fractures, especially those of the hip, can result in substantial bleeding into soft tissues. The most widely used clinical test for evaluating blood loss from fractures is hematocrit measurement. A 3 mL/dL drop in hematocrit corresponds to the loss of roughly 500 mL (1 u.) of blood in a normally hydrated patient. Patients with acutebleeding or dehydration may initially have a falsely normal or elevated hematocrit; when intravascular volume is replenished with IV fluids, hematocrit will fall. Since elderly patients are often at high risk for developing myocardial ischemia, their RBC volume should not be allowed to drop below a level that maintains sufficient oxygen-carrying capacity. A low or falling hematocrit can also warn of a serious underlying medical condition with important implications in the fracture patient. Serum alkaline phosphatase rises when bone turnover increases. This occurs with normal fracture healing as well as with malignancy and metabolic abnormality.

NURSING MANAGEMENT:
1. Provide emergency management when situation warrants, for a new fracture. Assess the five Ps. Determine the mechanism of injury. Immobilize the part. Move injured parts as little as possible. Cover any open wounds with a sterile, or clean dressing. Reassess the five Ps. Apply traction if circulatory compromise is present. Elevate the injured limb, if possible. Apply cold to the injured area. Call emergency medical services. 2. Assess for circulatory impairment (cyanosis, coldness, mottling, decreased peripheral pulses, positive blanch sign, edema not relieved by elevation, pain or cramping). 3. Assess for neurologic impairment (lack of sensation or movement, pain, or tenderness, or numbness and tingling). 4. Administer analgesic medications. 5. Explain fracture management to the child and family. Depending on the type of break and its location, repair (by realignment or reduction) may be made by closed or open reduction followed by immobilization with a splint, traction or a cast. 6. Maintain skin integrity and prevent breakdown. Institute appropriate measures for cast and appliance care. 7. Prevent Complications Prevent circulatory impairment by assessing pulses, color and temperature, and by reporting changes immediately. Prevent nerve compression syndromes by testing sensation and motor function, including subjective symptoms of pain, muscular weakness, burning sensation, limited ROM, and altered sensation. Correct alignment to alleviate pressure if appropriate, and notify the health care provider. Prevent compartment syndrome by assessing for muscle weakness and pain out of proportion to injury. Early detection is critical to prevent tissue damage. Causes of compartment syndrome include tight dressings or casts, hemorrhage. trauma, burns and surgery. Treatment entails pressure relief, which sometimes require performing a fasciotomy. 8. Prevent infection, including osteomyelitits, bys using infection control measures. 9. Prevent renal calculi by encouraging fluids, monitoring I&O, and mobilizing the child as much as possible. 10. Prevent pulmonary emboli by carefully monitoring adolescents and children with multiple fractures. Emboli generally occur within the first 24 hours.

SURGICAL MANAGEMENT
- Temporary skin traction - Bucks extension - Open or closed reduction of the fracture and internal fixation - Replacement of the femoral head with prosthesis (hemiarthrmoplasty) - Closed reduction with pereutaneous stabilization for an intracapsular fracture. - Hip Pinning -Hip Hemiarthroplasty -Patients with hip osteonecrosis may require Hip Replacement Surgery

Pathophysiology
Predisposing Factors: -Elderly people - Trauma Precipitating Factors: -Fall - impaired vision and balance

Injury in the bone

Disruption in the continuity of bone

Disruption of muscle and blood vessels attached to the ends of the bone

Soft tissue damage

Bleeding

Hematoma forms in medullary canal

Bone tissue surround the fractured site dies

Clinical Manifestations: - Pain (right up) - Loss of function - Deformity - Crepitus - Swelling and discoloration - Paresthesia - Tenderness

Nursing Management: - Repositioning the patient - Promoting strengthening exercise Monitoring and managing complications - Health promotion - Relieving pain - Promoting physical mobility - Promoting positive psychological response to trauma

Medical Management: - Temporary skin traction - Bucks extension - Open or closed reduction of the fracture and internal fixation - Replacement of the femoral head with prosthesis (hemiarthrmoplasty) - Closed reduction with pereutaneous stabilization for an intracapsular fracture.

ST. PAUL UNIVERSITY DUMAGUETE COLLEGE OF NURSING S.Y. 2011-2012

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN RELATED LEARNING EXPERIENCE (RLE)

A CASE ANALYSIS ON: FRACTURE

Submitted to: Mrs. Gerah P. Valle, R.N. Clinical Instructor

Submitted by: Banquerigo, Cherylee D.

Date Submitted: September 28,2011