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 ex t re me
m u sc l e c on t ra c ti on s . W he n t he b o n e i s b ro ke n , a dj ac e n t st r uc t u re s a re a l s o
aff ected, 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. Th e re a re d i ff e re nt t yp e s of fr ac t u re s an d t he se i nc l u de , co m p l e t e
f ra c tu re , incomplete fracture, closed fracture, open fracture and there are also
types of fractures t h a t m a y a l s o b e d e s c r i b e d a c c o r d i n g t o t h e a n a t o m i c
p l a c e m e n t o f f r a g m e n t s , particularly if they are displaced or non displaced. 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. O fte n, a f ra ct u re d hi p i s a c at a st ro p h i c e ve n t t ha t w i l l ha ve a
n e g a ti ve i m pa c t o n th e p a ti e n t s l i fe s ty l e a n d q ua l i ty of l i fe . T he re a re tw o
m aj or t y pe s of h i p fr ac t u re . 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 student nurse need to insure
recovery and to attend their special need effi ciently and effectively. True the
knowledge of this condition, a high quality of care will be provided to those people suffering
from it.

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 ableto:
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 . i m p l e m e n t h o l i s t i c n u r s i n g c a re i n t h e c a r e o f p a t i e n t u t i l i z i n g
t h e n u r s i n g 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 significantothers 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.

III. Nursing Assessment

1. Personal History1.1
Patients Profile Name: Mrs. Torralba, LourdesAge: 89 years old Sex: FemaleCivil Status:
WidowReligion: Roman Catholic Date and time of admission; March 13, 2008 at 10:10 am
Room No.: Room 425, Vicente sotto memorial medical center Complaints: Pain the right hip
Impression or Diagnosis: Fracture Close-Comminuted: Femoral Right Neck
Physician: Dr. F. Vicuna, Dr. E. Lee, Dr. N. Uy, Dr. RamiroHospital No: 216 4261.2. 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 CebuDoctors University Hospital for further management of the
condition.Mrs. Torralba is a college graduate and shes previously working as an assistant of
her husband ( Mr. Rodrigo Torrralba ) a doctor.The patient was diagnosed
Two days prior to admission, the patient was standing and was about to open uphe umbrella
when she got out of balance and landed on her right hip.And had experiencedlimitation of
movement on th e 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 anklelast
2002. No familial history of hypertension and bronchial asthma but is positive todiabetes
mellitus of paternal side. Has no known food and drug allergies. The patient isnon-smoker
non-alcoholic beverages drinker.1.3. Level of Growth and Development1.3.1. Normal Growth
and Development at particular stage Older Adult ( 65Years old to death)Physical
DevelopmentPerception 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

arelimited by physical, emotional or social impairments may perceive themselves as ill.There

are frequently observed physiological changes in order adults that arecalled normal. Finding
these normal changes during and assessment is not an expected.These physiological
changes are not always pathological processes in themselves, butthey may make older
adults more vulnerable to some common clinical conditions anddiseases. Some older adults
experience all of these physiological changes, and others onlyexperience only a few. The
body changes continuously with age, and specific effects on particular older adults depend
on health, lifestyle, stressors and environmental conditions.

Cognitive DevelopmentIntellectual capacity includes perception, cognitive, memory,

and learning.Perception, or the ability to interpret the environment, depends on the
acuteness of thesenses. If the aging persons senses are impaired, the ability to
perceive the environmentand react appropriately is diminished. Perceptual capacity
may be affected by changes inthe 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 meanings 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. Lifelong 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 ones one and only lifestyle. 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 the inability to accept
ones fate. Despair gives rise of frustration, this couragement, and a sense that
ones life has been worthless. Moral Development According to Kohlberg, moral
development is completed in the early adult years. Most old people stay at
Kohlbergs 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 persons at stage 7 may act to meet anothers need as well as
their own. Elderly people at the conventional level follow societys 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 experiencesfeelings 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
matured spiritually may not matured spiritually
may feel impoverishment or despair as the drive for economic and professional
success wares. Psychosexual Developments drives persist into the 70s, 80s, and
90s, provided that the health is good and an interested partner is available. Interest
in sexual activity in old age depends, enlarge 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 vaginalsecretions
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 skin
old 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 agetripping 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 abnormalityassociated
with chronic brain syndromeand it appears that these demented patients fall not
because of mental confusion but because of associated motor abnormalities. Extracapsular fractures occur in older patients. They are more likely to have history of
falls but previous fracture is equally common at this age in the fracture and control
series.

3. Present Profile of Functional Health Patterns Profile of Functional Health Patterns

3.1. Health Perception / Health Management Pattern
The patient described her usual health before to be fair and body is strong but now she
considered it to be poor and weak. This is because of the limited movements she felt, the
inability to walk or stand and difficulty in moving the extremities due to the fracture of her
right femoral neck. Before the admission, the patient eats more foods rich in fats, sugar or
glucose and cholesterol in their meals and she drinks plenty of water everyday. During the
patients hospitalization, her diet was changed to low fat and low cholesteroldiet because
she was diagnosed of having diabetes mellitus type II. The patients attending physician
encourages her to take more of calcium and Vitamin D in order for her bones to become
stronger. The patient is non-smoker and non-alcoholic drinker and she has no known
allergies.
3.2. Nutritional / Metabolic Pattern The patients usual food intake before the hospitalization
includes fish, meat, vegetables, fruits, chicken and especially foods rich in fats,
sugar/glucose and cholesterol. She consumes more than 8 glasses of water a day. Her
maintenance meds were Aromasin,Fosamax, Centrum and Cultrate. 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. There is a change in here appetite now; she often eats a little only each meal.14
3.3. 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 ur4ination and her stool is
brownish formed stool.
3.4. 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 S.O.
3.5. Cognitive/ Perceptual Pattern The patient before, can hear, smell, taste and feel well and
correctly but the patient cannot read her newspaper without her eyeglasses just the same as
now. She speaks slowly English, Tagalong and Biscayan languages as of now but before she
speaks fluently all of those languages. She easily communicates, understands questions,
instructions and be able to follow and answer them correctly.
3.6. Rest/ Sleep Pattern Before the hospitalization, the patient usually sleeps late at night at
around 10oclock pm and wakes up early in the morning at 6 oclock am with an hour of
sleep of 8hours. Now, she usually sleeps early at night (8-9 oclock pm) and wakes up at
around 7oclock am with an hour of sleep of 10 hours. The patient usually stays in bed and
read newspapers sometimes, she cant take a nap in the afternoon due to her REHAB CARE.
3.7. Self- Perception Pattern The patients most concern about right now is her rehabilitation
care. The patient wants to stay at the hospital until she improves her mobility so she would
be able to stand and walk all alone by herself. The patient never loses the support of her

children even if they were not there physically and also her private nurses. Through this, she
may be able to cope up easily from her unhealthy condition. The treatment, managements,
medications and all out care rendered by the hospital to the patient assured her for the
improvement of her condition.
3.8. Sexuality/ Reproduction The patients husband just recently died. Now, the patient does
not allow anyone to see her getting undressed, changing diaper, changing clothes because
she believes thetas a woman, it should be keep as private.
3.9. Coping- Stress Tolerance Pattern The patient usually makes her decision as for now
since her children were busy in their work abroad, but they make sure they never forget to
support and help their mother recover from illness. Sometimes, the patient usually shares
her concerns to her private nurses and of course also to the student nurses. She usually
reads newspaper for her to bemire relaxed.
3.10. 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.
3.11. Relationship Pattern The patient understands more on English and Biscayan languages
but a little only intaglio language. The patient was living all by herself with her private
nurses but sometimes, her grandchildren will come over to visit her. She never uses the
support of her children even if they were away from their mother they always make sure
that their mother is safe and secure. The patient can easily communicate, cooperate, listen
and follow instructions easily.
The word skeleton comes from the Greek word meaning dried- up body, our internal
framework is so beautifully designed and engineered and it puts any modern skyscraper to
shame. Strong, yet light, it is perfectly adapted for its functions of body protection and
motion. Shaped by an event that happened more than one million years ago when a being
first stood erect on hind legs our skeleton is a tower of bones arranged so that we can
stand upright and balance ourselves. The skeleton is subdivided into three divisions: the
axial skeleton, the boned that form the longitudinal axis of the body, and the appendicle
skeleton, the bones of the limbs and girdles. In addition to bones, the skeletal system
includes joints, cartilages, and ligaments (fibrous cords that bind the bones together at
joints). The joints give the body flexibility and allow movement to occur. Besides contributing
to body shape and form, or bones perform several important body functions such as support,
protection, movement, storage and blood cell formation. Classification of Bones The
diathesis, or shaft, makes up most of the bones length and is composed of compact bone.
The diathesis is covered and protected by a fibrous connective tissue membrane, the
periosteum. Hundreds of connective tissue fibbers, called Sharpes fibers,secure the
periosteum to the underlying bone. The epiphyses are the ends of the long bone. Each
epiphyses consist of a thin layer of compact bone enclosing the area filled with spongy bone.
Particular cartilage, instead of periosteum, covers its external surface.Because the articular
cartilage is glassy hyaline cartilage, it provides a smooth, slippery surface that decreases
friction at joint surfaces. In adult bones, there is a thin line of bony tissue spanning the
epiphyses that looks bit different from the rest of the bone in that area. This is the epiphysis
line. Theepiphyseal line is a remnant of the epiphyseal plate (a flat plate of hyaline cartilage)

seen in young, growing bone. Epiphyseal plates cause the lengthwise growth of the long
bone. By the end of puberty, when hormones stop long bone growth, epiphyseal plates have
been completely replaced by bone, leaving the epiphyseal lines to mark their
previouslocation.In adults, the cavity of the shaft is primarily a storage area for adipose (fat)
tissue. It is called the yellow marrow, or medullary, in infants this areas forms blood cells,
and red marrow is found these. In adult bones, red marrow is confined to the cavities of
spongy bone of flat bones and the epiphyses some long bones. Bone is one of the hardest
materials in the body, and although relatively light in weight, it has a remarkable ability to
resist tension and other forces acting on it. Nature has given us an extremely strong and
exceptionally simple (almost crude) supporting system without up mobility. The calcium salts
deposited in the matrix bone its hardness, whereas the organic parts (especially the collagen
fibbers) provide for bones flexibility and great tensile strength.
The femur, or thigh bone, is the only bone in the thigh. It is the heaviest, strongest bone in
the body. Its proximal end has a ball-like head, a neck, and greater and lesser trochanters
(separated anteriorly by the intertrochanteric line and posteriorly by theintertrochanteric
crest). The trochanters, intertrochanteric crest and the gluteal tuberosity,located on the
shaft, all serve us sites for muscle attachment. The head of the femur articulates with
acetabulum of the hip bone in a deep, secure socket. However, the neck of the femur is a
common fracture site, especially in old age. The femur slants medially as it runs downward
to joint with the leg bones; this brings the knees in line which the bodys center of gravity.
The medial course of the femur is more noticeable in females because of the wider female
pelvis. Distally on the femur are the lateral and medial condytes, which articulates the tibia
below. Posteriorly,these condytes are separated by the deep intercondylar notch. Anteriorly
on the distal femur is the smooth patellar surface, which forms a joint with the patella, or
kneecap.

Defining
characteristics

Nursing
diagnosis

Scientific
basis

Expected
outcome

Nursing
intervention

Rationale

Difficulty
in
changing
position while
lying on bed.Difficultyin
movingtheextre
mities.-Inability
to
walk
or
stand
alone.limitedrange of
motion
intheextremitie
s.Slowedmoveme
nt.Difficultyinitiati
nggait.diligiha
pon
mulihok
akongtiil day
as
verbalized
by the patient

Impaired
physical
mobility,
inability
to
standalon
e related
to skeletal
impairme
nt
to
facture of
the right
femoral
neck

Fractures
occur
when
the bone is
subjected to
stress greater
that it can
absorb. When
the bone is
broken,
adjacent
structures are
also affected,
resulting
in
soft
tissue
edema,
hemorrhage
in
to
the
muscles and
joints, joints
dislocations,
ruptured tendons,
severed
nerves, and
damaged
blood
vessels. Body
organs
maybe
injured by the
force
that
caused
the
fracture
fragments.
After
a
fracture, the
extremities
cannot
function
properly
because
normal
functions of
muscle
depend
on
the integrity
of the bones
which
they

After
8hours
nursepatient
interventio
n
the
patient will
be able to:
Demonstra
te
increasing
Function
of the
extremities

-Promote
adequate
mobility
of
the client.

to avoid patients
from falling to
sudden
movements

- instruct the
to keep side
rails up or
raised.

-to
improve
muscle strength
and joint mobility

assist
patient to do
active ROM
exercises on
the
lower
extremities.
-Provides
comfort
measures
such
as
backrub.
-Encourage
patient
to
stand
or
walk
as
tolerated
using
parallel bars.
-Support
affected
body parts
or
joints
using pillows
or rolls.
-administer
pain reliever
such
as
areoxia
as
prescribe by
the
physician.
-Consult
with physical
or

-in order for the

patient to become
more relax and
comfortable

-in order for the

muscle
to
be
more relax and
relieves the pain
-to relieve pain
and
motion
sickness

-to
develop
individual
exercise
or
mobility program
and identify
Appropriate
adjunctive
devices

are attached

Defini
ng
chara
cteris
tics

Nursing
diagnosis

Nursing
diagnosis

Outcomes

occupational
therapist as
indicated

Intervention

Rationale

2.
Risk
for alt
ered
blowfl
owRis
k
Facto
r:Imm
obilit
y

Risk
for
altered
bloodflow
rightimmo
bility
tofracture
of
the
rightfemo
ralneck

Defining
characteristi
cs

The
extremitiescann
ot
function properl
y
after
afracture,
thus,there
isimmobility bec
ause
normalfunction
of
themuscle
dependson the
integrityof
the
bones towhich
they
areattached.Im
mobility
of
a body
part
may possiblyint
errupt
thecirculation
of blood
throughthe
circuitousnetwor
k
of arteries
andveins

Nursing
diagnosis

Scientific
basis

Enhance
circulation

Outcomes

blood

2. prevent, blood
emboli-note
signs of changes
inrespiratory
rate,depth
use
of accessorymus
cles
purled-lip
breathing; Note
areas
of pallor
or cynosis.auscultate breat
h-soundsCheck if
there
isa
decrease
or adventitious b
reath soundsas
well asfremitusmonitor italsigns
andcardiac
rhythm-review
risk factorsreinforce needfor
adequaterest,
whileencouragin
gactivities
withinclientslimit
ationencouragefreque
nt positionchang
es
andDBE
or coughingexerc
ise.-administer m
edications
asindicated

Interventions

to
assessrespira
tory
insufficiencyserves
as
a baseline
data-note for
anychangesto
promote prev
entionmanag
ement
of risk -to
improvecircul
ation
of blood
to
the
bodysystems.
-to
treatunderlyi
ngconditions

Rationale

Risk
for additiona
l
injury
risk factors:
Loss
of skeletal
integrity*
skeletal
impartment*
Abnormal bl
ood

Risk
for additio
nalinjuryri
ght lossof
skeletalint
egrityto
fractureof
thefemor
alneck

A
fracture
occurs when
the
stress
placed on a
bone
is
greater than a
bone
can
absorb.
Muscle, blood
vessels,nerves
,
tendons, joints
and
other organs
maybe injured
when fracture
occurs.
This
condition may
result to a loss
of
skeletal
integrity that
may possibly
lead
to
further injury
as a result
of environmen
tal conditions
interacting
with
the
individuals
adaptive and
defensive
resources

to produce
risk factors
and protec
t
self
from
injury

for the patients to be

free from injury
-ascertain knowledge
of safety
needs
or injury
-assess
muscles
trength gross and fine
motor coordination.
-observe for signs of
injury
-identify interventions
or safety devices.
-encourage participati
on in rehab programs,
such as gaittraining
Promote
education programs
geared to increasing
the
awareness
of safety measures

to
reinforce
and
import
knowledge to
the patient
-to evaluate
degree
or
source
of
risk.
-for
early
detection.
-to promote
individual
safety.
-to
improve
skeletal
integrity.
-to promote
wellness