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com/nursing-care-plans-for-bone-fractures/ NCP: Nursing Care Plan for Bone Fractures

Posted by lifenurses on March 20, 2010

A fracture, or discontinuity of the bone, is the most common type of bone lesion. Normal bone can withstand considerable compression and shearing forces and, to a lesser extent, tension forces. A fracture occurs when more stress is placed on the bone than it is able to absorb. 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 impactor stress, or trivial injury as a result of certain medical conditions that weaken the bones, such asosteoporosis, bone cancer, or osteogenesis imperfecta, where the fracture is then termedpathological fracture. (http://en.wikipedia.org/wiki/Bone_fracture) Cause for Bone Fractures Bone Fractures Grouped according to cause, fractures can be divided into three major categories:

Fractures caused by sudden injury

The most common fractures result from major trauma, such as a fall on an outstretched arm, a skiing ormotor vehicle accident, and child, spouse, or elder abuse (shown by multiple or repeated episodes of fractures). The force causing the fracture may be direct, such as a fall, or indirect, such as a massive muscle contraction or trauma transmitted along the bone. For example, the head of the radius or clavicle can be fractured by the indirect forces that result from falling on an outstretched hand.

Fatigue or stress fractures

A fatigue fracture results from repeated wear on a bone. Pain associated with overuse injuries of the lower extremities, especially posterior medial tibial pain, is one of the most common symptoms that physically active persons, such as runners, experience Stress fractures in the tibia.

Pathologic fractures.

A pathologic fracture is fracture that occurs when the normal integrity and strength of bone have been compromised by invasive disease or destructive processes or tumors. Fractures of this type may occur spontaneously with little or no stress. The underlying disease state can be local, as with infections, cysts, or tumors, or it can be generalized, as in osteoporosis, Pagets disease, or disseminated tumors. Classification of Bone Fractures Fractures usually are classified according to:

Location Type Direction or pattern of the fracture line.

Fragment position

Angulated, Bone fragments are at an angle to each other Avulsed, Bone fragments are pulled from normal position by muscle spasms, muscle contractions, or ligament resistance Comminuted, Bone breaks into many small pieces Displaced, Bone fragments separate and are deformed Impacted, A bone fragment is forced into another bone or bone fragment Nondisplaced, After the fracture, two sections of the bone maintain normal alignment Overriding, Bone fragments overlap, thereby shortening the total length of the bone Segmental

Fracture line

Linear Fracture line is parallel to the axis of the bone Longitudinal Fracture line extends longitudinally but not parallel to the axis of the bone Oblique Fracture line crosses the bone at a 45-degree angle to the axis of the bone Spiral Fracture line coils around the bone Transverse Fracture line forms a 90-degree angle to the axis of the bone

A fracture of the long bone is described in relation to its position in the boneproximal, midshaft, and distal. Other descriptions are used when the fracture affects the head or neck of a bone, involves a joint, or is near a prominence such as a condyle or malleolus. The type of fracture is determined by its communication with the external environment, the degree of break in continuity of the bone, and the character of the fracture pieces.10 A fracture can be classified as open or closed. When the bone fragments have broken through the skin, the fracture is called an open or compound fracture. In a closed fracture, there is no communication with the outside skin. The degree of a fracture is described in terms of a partial or complete break in the continuity of bone. Agreenstick fracture, which is seen in children, is an example of a partial break in bone continuity and resembles that seen when a young sapling is broken. This kind of break occurs because childrens bones, especially until approximately 10 years of age, are more resilient than the bones of adults. The character of the fracture pieces may also be used to describe a fracture. A comminuted fracture has more than two pieces. A compression fracture, as occurs in the vertebral body, involves two bones that are crushed or squeezed together. A fracture is called impacted when the fracture fragments are wedged together. This type usually occurs in the humerus, often is less serious, and usually is treated without surgery. Segmental fracture Bone fractures occur in two areas next to each other with an isolated section in the center The direction of the trauma produces a certain configuration or pattern of fracture. Reduction is the restoration of a fractured bone to its normal anatomic position. The pattern of a fracture indicates the nature of the trauma and provides information about the easiest method for reduction. Linear fractures, Fracture line is parallel to the axis of the bone Transverse fractures are caused by simple angulatory forces. A spiral fracture results from a twisting motion, or torque. A transverse fracture is not likely to become displaced Nursing Care Plans for Fractures Nursing Diagnosis for Fractures Treatment for Bone Fractures The primary goals of treatment are to return the injured limb to maximal function, to prevent complications, and to obtain the best possible cosmetic results. Emergency treatment consists of splinting the limb above and below the suspected fracture where it lies, applying a cold pack, and elevating the limb, all of which reduce edema and pain. A severe fracture that causes blood loss calls for direct pressure to control bleeding. The patient with a severe fracture may also need fluid replacement (including blood products) to prevent or treat hypovolemic shock. Treatment Options for Bone Fractures Treatment Options to set a Bone Fractures depends on the location and severity of the injury. To heal a bone fractures properly, the fractured bone must be realigned. The most common realignment procedures are:

Immobilization using a cast or splint Setting of bone through surgery. Advantages of surgery include: early mobility of injured bone and some use of the injured bone within weeks rather than months.

After the bone is realigned properly, medication and rehabilitation will help the recovery process. Medication is used to lessen the pain. Rehabilitation prevents stiffness. Rehabilitation involves light movement of the tissues surrounding the injury. It helps increase blood flow which will aid the healing process.

Nonoperative Management

Until comparatively recently, nonoperative treatment was the only method of treating fractures and severe soft tissue injuries, but the introduction of anesthesia, antibiotics, improved surgical implants, and better operative techniques has changed the treatment of many fractures. The process of change continues, and probably fewer fractures will be managed nonoperatively as the functional benefits of operative treatment become more apparent to both surgeons and patients.
1. 2. 3. TRACTION: Skeletal Traction, Spinal Traction, CASTS Braces Slings, Bandages, and Support Strapping

Operative Management When closed reduction is impossible, open reduction during surgery use to reduces and immobilizes the fracture by means of rods, plates, or screws
1. 2. 3. 4. 5. 6. Plating Intramedullary Nailing Kirschner wires External Fixation Arthroplasty Amputations

Complications for Bone Fractures Possible complications of fractures include arterial damage, nonunion, fat embolism, infection, shock,avascular necrosis, and peripheral nerve damage. Acute Compartment Syndrome Nonunions and Bone Defects Nursing diagnosis for bone fractures Nursing diagnosis for bone fractures determine by data that we found in nursing assessment : Nursing Assessment nursing care plans for bone fractures Assessment on patients history usually reveals what caused the fracture, major trauma, such as a fall on an outstretched arm, a skiing or motor vehicle accident, or elder abuse. The patient typically reports pain that increases with movement and an inability to move the part of the arm or leg distal to the injury. The severity of the pain depends on the fracture type. The patient may also complain of a tingling sensation distal to the injury, possibly indicating nerve and vessel damage. Inspection may disclose soft-tissue edema, an obvious deformity or shortening of the injured limb, and discoloration over the fracture site. Open fractures produce an obvious skin wound and bleeding. Gentle palpation usually reveals warmth, crepitus and, possibly, dislocation. Numbness distal to the injury and cool skin at the end of the extremity may indicate nerve and vessel damage. Auscultation may reveal loss of pulses distal to the injury, an indication of possible arterial compromise or nerve damage. Palpation pulses in distal of the fracture to detect injury to blood vessels, which is a surgical emergency Diagnostic tests for Bone Fractures

Anteroposterior and lateral X-rays of the suspected fracture, as well as X-rays of the joints above and below it, confirm the diagnosis. Angiography can reveal concurrent vascular injury. MRI or CT Scan of spine if suspect a bone tumor or compression of spinal cord Bone densitometry can predict an increased risk of osteoporosis usually in pathologic fractures Blood tests Acute pain Anxiety Bathing or hygiene self-care deficit Fear Impaired physical mobility Ineffective coping Ineffective role performance Ineffective tissue perfusion: Peripheral

Risk for deficient fluid volume Risk for disuse syndrome Risk for infection Risk for injury

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Nursing Care Plan to the Client with Fractures of the Extremities and Extremities Surgery

Nursing Assessment 1. Assess for history of the injury, presence of factors that may cause pathologic fractures (osteoporosis, osteomyelitis, neoplastic diseases, etc.). 2. Assess presence of signs of fracture (edema, pain, loss of motion, crepitus, extremity disproportion or abnormal positioning). 3. Assess presence of signs and symptoms of soft tissues involvement (swelling, hemorrhage, impaired sensation in the extremity). 4. Assess extremity for presence of open fracture and severe external hemorrhage. 5. Assess vital signs, fluid balance and urine output. 6. Assess diagnostic tests and procedures for abnormal values. 7. Assess routine preoperative history. Nursing Diagnosis 1. Increased risk of hypovolemia and shock related to trauma and bleeding. 2. Increased risk of bone inflammation related to open fracture. 3. Increased risk of fat embolism related to fracture of the long bones. 4. Increased risk of severe fluid, electrolyte, and metabolic imbalances related to injury or inflammation. 5. Pain and immobility , related to diagnosis of fracture.

6. Increased risk of respiratory, cardiovascular, bowel, and skin complications related to a long period of immobility. 7. Anxiety related to the symptoms of disease and fear of the unknown. Nursing Plan and Interventions Goals 1. Increase comfort, decrease pain. 2. Prevent avoidable injury. 3. Prevent complications of immobility. 4. Provide optimal bone and wound healing. 5. Then surgical intervention prescribed, prevent postoperative complications. 6. Decreased anxiety with increased knowledge. Interventions 1. Provide emergency care if requires (hemostasis, respiratory care, prevention of shock). 2. Provide fracture fixation to prevent following injury of tissues. 3. Observe signs of fat embolism (especially during first 48 hours after the fracture). 4. Monitor fluids input and output continuously, insert IV catheter, urinary catheter. 5. Monitor clients vital signs. 6. Monitor clients laboratory tests results for abnormal values. 7. Administer IV therapy, analgesics, antibiotics, and other medications as prescribed.

8. Prepare client and his family for surgical intervention if required. 9. For client after surgical intervention provide routine postoperative care and teach about possible postoperative complications. 10. Provide care to client with cast (observe signs of circulatory impairment change in skin color and temperature, diminished distal pulses, pain and swelling of the extremity; protect the cast from damage). 11. Provide care to client in traction (check the weights are hanging freely, observe skin for irritation and site of skeletal traction insertion for signs of infection; use aseptic technique when cleaning the site of insertion). 12. In case of hip fracture and hip replacement maintain the adduction of the affected extremity. 13. Provide respiratory exercises to prevent lung complications. 14. Observe for signs of thrombophlebitis, report immediately. 15. Provide appropriate skin care to prevent pressure sores. 16. Encourage fluid intake and high-protein, high-vitamin, highcalcium diet. 17. Teach the client appropriate crutch-walking techniques . 18. Provide emotional support to client, explain all procedures to decrease anxiety and to obtain cooperation. 19. Instruct client regarding fracture healing process, diagnostic procedures, treatment and its complications, home care, daily activities, diet, restrictions and follow-up. Evaluation 1. Reports increased comfort, decreased pain. 2. No evidence of respiratory, vascular or skin complications of immobility.

3. Maintains stable vital signs, fluid and metabolic balance, nutritional state. 4. Has sufficient fracture healing rate. 5. Laboratory tests results shows no abnormalities. 6. No postoperative complications, or treatment complications. 7. Learned of crutch-walking, taking care of himself then possible. 8. Demonstration of understanding of fracture healing process, diagnostic and treatment procedures, trauma prevention, and need for follow-up.