UNIVERSAL COLLEGE OF NURSING

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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 fracture: a fracture at a right

angle to the bone's axis.

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

➢ Comminuted fracture: a fracture in which

the bone 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 closed fracture/simple

fracture in which the fractured ends of
the bone do not 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: January 18, 2010
Time: 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 FINDINGS
I. Gross general
appearance

1.1 Height 1.6 m Normal

1.2 Weight 54 kg Normal

1.3 Body Build normal Ectomorphic

posture
1.4 Posture/ Gait Normal

1.5 Skin Color fair skin color Normal

fair skin color
1.6 Personal Normal
neat and clean
Hygiene/
Grooming
no foul
1.7 Body Breath Normal
No Body and smelling odor
Odor
Breath Odor BMI: 18.5-
24.9
1.8 Nutritional
BMI: 21.1 Normal
Status
Appropriate
to Age
1.9 Age
Her face is Normal
appropriateness
Appropriate to her Well
age developed
1.10 Sensory status
Well developed Normal

2. Physiologi
cal Cues

2.1 Temperature 36.9 C 36.5-37.5 C Normal

60-100 bpm
2.2 Pulse 82 bpm 16-22 cpm Normal

2.3 Respiration 22 cpm 120/80 mmhg Normal

2.4 Blood 110/80 mmHG Normal

Pressure
 3. Behavior -good speech - good speech Normal
quality quality
3.1 Verbal -understable, clear -organized the
(Speech-quality; tone; exhibits thought
quantity; thought
coherence; association
relevance;
pattern;
organization of
thought)
3.2 Non-verbal
Body language -can response to a -can response Normal
Gesture body language to a body
Movement -can do facial language
Facial expression expression -can do facial
Attitude expression
Affect/ mood -
Appropriateness
of response

HEAD TO TOE TECHNIQUE NORMAL / ACTUAL ANALYSIS

PHYSICAL STANDARD FINDINGS
EXAMINATION
Head Palpation -rounded -symmetrical Normal
1. Skull Size, shape, -smooth skull in shape
contour, any contour -smooth skull
lumps, deformities -absence of nodules contour
or masses -absence of
nodules or
masses

2. Scalp / hair Inspection -hair evenly -even Normal

Appearance, hair distributed distribution of
color, distribution, -hair black in color hair
texture, presence -silky hair -black and
of lice, nits and -no presence of nits white hair
dandruff and lice color
-no presence of -silky
tenderness -no presence
of nits and
lice
-not tender

3. Face Inspection -rounded; -rounded Normal

Note symmetry, symmetric or -symmetric
 shape, expression, slightly asymmetric facial
Appearance and facial features movements
movements -symmetric facial
movements

4. Eyes/Vision Eye Structures

a. Eyeball - note -no protrusion -no protrusion Normal
Any protrusion -symmet
rical
b. Lid margins -lids close closeness of Normal
Observe scaling symmetrically lids
Secretions, -no secretion -no secretion
position, -symmetrical
Symmetry, ability -15-20 blinks/min
to blink and -symmetrical
frequency -can blinks
16/min
c. Conjunctiva -transparent; shiny,
note color, Normal
smooth, and pink or -pinkish in
appearance red color
-shiny

d. Sclera – note -sclera appears -white in

Color, appearance color Normal
white in color
-pupil equally
e. Pupils – size, round
Shape, symmetry, -pupil equally round
Reaction to light, Normal
reactive to light
and -even
accommodation
accommodation distribution of
(PERRLA)
hair
f. Eyebrows/lashes -black and
Color, symmetry, white
-evenly distributed
quantity of hair, -aligned
hair
placement symmetrical
-black and white in Normal
color
-symmetrically
aligned -coordinates
-curled slightly by movement
outward

g. Eye movement
in all directions
-both eyes
coordinated
(cardinal
movement/s) Normal
5. Ears/hearing a. Pinna -symmetrical; -symmetrical
Inspection aligned with outer Normal
Parallelism, size, canthus of eye,
shape, appearance, about 10 from
placement. verical

Palpation -firm
Palpate for -mobile, firm, and -not tender Normal
firmness of the not tender; pinna
cartilage and for recoils after it is
tenderness. folded - grayish an in
b. External canal
color
Inspection -grayish tan color -wet cerumen Normal
Check color, -presence of wet
appearance, and cerumen in various
any discharge. shades of brown
-no discharge

e. Hearing acuity
Whisper from -able to hear ticking -able to hear
clients ear at a in both ears on both ears Normal
distance of 2 feet -normal voice tone
away from the (audible)
clients back

6. Nose Inspection -symmetric and -midline Normal

Placement, straight alignment
discharges and -no discharge -no discharge
Patency -air moves freely as -air moves
the client breaths freely
through the nares

7. Mouth / lips Inspection -uniform pink color -pinkish in Normal

Color, shape, -soft, moist, smooth color
moisture and texture -soft, moist,
symmetry, -symmetry of smooth
appearance contour -ability to
-ability to purse lips purse lips

-pink gums
-moist, firm texture -pinkish in
Gums to gums color
-no retraction of Normal
Color, appearance -firm and
gums moist

Teeth -smooth, white,

 Color, shinny tooth -No more
arrangement, enamel, Tooth
general condition, Normal
breath
Tongue -pink color
Size, color, shape, -moves freely -pinkish
symmetry, -moist; slightly -symmetrical
moisture, rough -moist
movement -symmetrically Normal
aligned

Palate – Hard / -lighter pink hard -pinkish in

soft palate color
Color, texture, -light pink, smooth- -smooth
shape soft palate -symmetry of
-more irregular the shape
texture Normal
-symmetrical in
shape
-pinkish
-uvula present
Soft Palate – -pink in color in midline
(w/ penlight) -uvula positioned in
pink, smooth uvula midline of soft -pinkish
in midline palate -smooth
-presence of Normal
Oropharynx / -pink and smooth gag reflex
tonsil posterior wall
Color, texture, -gag reflex present
elicit gag reflex
present
8. Cheeks Inspection -pink in color -Fair color Normal
Color, appearance

9. Neck (Inspection)
Symmetry, -symmetrical -head Normal
position, (muscles equal in centered
movement (chin to size)
chest, ear to -coordinated,
shoulder) smooth movements
with no discomfort
-complete range of
motion

(Palpation) -lymph nodes not

palpable Normal
Palpate for lumps,
 nodes, tenderness -not palpable
10. Chest (Inspection)
Anterior Note symmetry, -skin intact -rhythmic Normal
color, deformities, -quiet, rhythmic and respirations
breathing pattern effortless
respirations
(Palpation)
Any lumps,
masses -no masses
Posterior
Inspection
Symmetry,
retractions, -chest wall intact
deformities -spinal column is
straight
-right and left
shoulders and hips
are at the same
Palpate for vocal height
(tactile) fremitus
-bilateral symmetry
of vocal fremitus
Auscultate
Breath sounds -vasicular and
bronchovesicular
breath sounds
11. Heart Inspection -complete pulsation Normal
Check for lifts, of the heart, normal
heaves, pulsation heart sound
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 -normal heart rate
-usually heard at all Normal
Inspect sites
Jugular Veins for
distention -no distention
-veins not visible Normal

12. Breast Inspection

 Size, Shape, -skin uniform in Normal
symmetry, color, color; skin smooth
any dimpling, and intact; no nipple
discharges in the discharge
nipples
Palpation -Presence of
Note any mumps, -no tenderness, Breast Abnormal
masses, masses/nodules Mass(7x5 cm)
tenderness, at Lateral
(clockwise borders Aspect of the
inward) Left Breast

13. Abdomen Inspection

Color, contour, -unblemished skin; Normal
symmetry, skin uniform in color;
integrity, scars symmetric contour

Auscultate for -audible bowel Normal

bowel sounds, sound
vascular sounds, -absence of arterial
peritoneal friction bruits
rub -absence of friction
rub

Palpation -no tenderness;

Palpate 4 relax abdomen with Normal
quadrants, note smooth, consistent
areas of tension
tenderness, lumps,
masses, distention
in circular motion
using finger pads.

Percussion
Percuss 4
quadrants from
LQD clockwise,
note any tympany -tympany over the
stomach and gas Normal
or dullness
filled bowels,
dullness especially
over the liver and
spleen, or a full
bladder
14. Upper Inspection
Extremities Symmetry, size, -equal in size, both -symmetrical Normal
length, side of the body
deformities, skin
 lesions, scars, -range of motion
ROM movement varies

-able to return
Hands capillary refill
Size, number of -5 fingers in 1 hand within 2-3 Normal
fingers, color of -pinkish color, able seconds
nail, capillary to return after the -5 fingers in 1
refill, hygiene capillary refill hand
movement
15. Lower Inspection
Extremities Symmetry, size, -no deformities, no -presence of
length, skin lesion and Gun shot Abnormal
deformities, hair scars wound at Left
distribution, scars, femur
lesions, movement
(flexion,
extension,
rotation)

Feet
Inspection
Color, symmetry,
deformities, -fair skin color -fair skin Abnormal
number of toes, -no scars/lesions color
scars, lesions, -can extend, flex -presence of
hygiene. and rotate gun shot
Movement -skin intact wound at Left
(flexion, femur
extension, -can’t extend
rotation) and flex Left
Leg
 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 Dec. 24 Jan. 4 Normal Units
WBC 22.1 15.9 5-10 Adults X109/L
9-20 New born
Hemoglobin 119 95 140-170 M gm/L
120-140 F
Hematocrit 0.367 0.28 0.45-0.50 M %
0.38-0.48 F
Neutrophils 0.86 0.46 0.31-0.76 Adult %
0.40-0.50
Newborn
Lymphocytes 0.11 0.30 0.24-0.44 Adult %
0.31-0.60 New
born
Monocytes 0.02 0.02 0.00-0.06 Adult %
Eosinophils - 0.20 0.02-0.04 %
Basophils - 0.02 0.00-0.01 %
Bands 0.01 - 0.02-0.04 %
Platelet Adequate 182 150-450 X109/L
MCV 90.8 86.2 80-100 Fl
MCH 29.5 29.4 27-31 Pg
MCHC 325 341 320-360 g/L
RDW 13.2 12.8 11.0-14.6 %

Serology Results Findings Units

Glucose 4.8 3.9 mmol/L
N Cholesterol 4.4 0.0-5.2 mmol/L
LDL Cholesterol 3.3 2.6-4.1 mmol/L
Triglycerides 0.94 0.4-1.7 mmol/L
HDL-Cholesterol 0.64 0.91-1.56 mmol/L
Blood Urea Nitrogen 4.9 2.5-6.1 mmol/L
Creatinine 78 53-115 umol/L
Sodium 138 135-148 mmol/L
potassium 3.7 3.5-5.3 mmol/L