I .

OBJECTIVES

a. General

To develop the essential Skills, Knowledge, and Attitude in the care

of management of patient with Fracture and to have a better insight and

understanding about the disease

b. Specific Objectives

Given adequate opportunity, the students are expected to:

• Define “Fracture”.

• Identify clinical manifestations.

• Apply knowledge and skills that are significant or necessary prevention

for the so called disease.

• Implement planned intervention.

• Apply the different nursing intervention applicable to the care of

patient.

• Correlate the Laboratory findings on the patient current condition.

• Establish and maintain Nurse-Patient relationship.

• Evaluate the effective care of what you implemented and rendered.

II. PATIENT’S PROFILE

NAME: Mrs. C

AGE: 47 years old

SEX: Female

CIVIL STATUS: Married

BIRTHDATE: Feb. 20, 1962

BIRTH PLACE: Negros Occidental

ADRESS: Norte Candelaria, Quezon

NATIONALITY: Filipino

RELIGION: Roman Catholic

NAME OF SPOUSE: Mr. C

1
 BED NUMBER: 236

WARD: Surgery

DATE OF ADMISSION: February 27, 2009

TIME OF ADMISSION: 2:16 pm

DATE OF DISCHARGED: April 6, 2009

ATTENDING PHYSICIAN: Dr. Geronimo Badoza Ayala

TYPE OF OPERATION: Wound debridement with Application of Posterior Mold

on left Foot

III. HISTORY

a. Nursing History

ι. Chief complaint : Vehicular Accident

ι ι. Admitting Diagnosis: Infected wound Left Foot

ι ι ι . Physical Exam (cephalocaudal)

Table I

Body Part Normal Findings Actual Findings Analysis and

Interpretation
General • Conscious and • Conscious • Normal
Appearance coherent and coherent
• Ambulatory • Able to • Because foot is
Vital signs: ambulate a weigh
T- 36.5 – 37.4°C using bearing part of
P- 80- 100 bpm assistive the body. It
R- 16-30 bpm device like needs assistive
BP- 110/70- 120/80 crutches device
mmHg Vital signs:
T- 38.5°C • Temperature is
P- 92 bpm high due to
R- 22 bpm trauma
BP- 130/ 80 mm Hg
Head/ Skull • proportional to • Head is • Normal
the size of the proportion to
body the body and
no deformity
• round, with noted
prominences in
the • Generally • Normal
frontal area round, with
anteriorly & the prominences
occipital area in the frontal
posteriorly, and occipital
symmetrical in area.
all
planes, gently • No • Normal
curved tenderness
noted upon

2
 palpation.

Scalp or • scalp is white, • Scalp is white • Normal

Hair clean, free from and clean.
masses, lumps, No dandruff,
nits, no lice
dandruff & No lesions
lesions,
• with no areas of • No • Normal
tenderness tenderness
upon noted upon
palpation palpation
• hair is
black, evenly • With short • Normal
distributed & black hair
covers evenly
the whole scalp, distributed
thick & shiny
• No scars • Normal
noted

Face • oblong shaped, • oblong • Normal

symmetrical, smooth shaped,
& no involuntary • symmetrical,
muscle movements • & no
involuntary
muscle
movements
Eyes/ Vision • eyes are • Contour and • Normal
parallel symmetry in
& evenly size
placed,
symmetrical,
non protruding,

• Eyebrows • Normal
• Eyebrows Symmetrical
Symmetrical and in line
and in line with with each
each other. other.

• Maybe black, • Normal

• Black
brown or blond eyebrows
depending on evenly
race evenly distributed.
distributed • Due to
• With moist decrease
• both and pale hemoglobin
eyes are clear; conjunctiva level
sclera is white &
clear
• Normal
• iris are
• conjunctiva are proportional
shiny, moist, to the size of
transparent & the
salmon pink in eye, round &
color; symmetrical

3
 • Normal
• Pupil equally
• iris are reacted to
proportional light and
to the size of accommodati
the on.
eye, round & • Normal
symmetrical; • Equal
movements
of the eyes
• pupils
are from
pinpoint to
almost the size
of
the iris, round,
symmetrical,
constricts with
increasing light
&
accommodation
;
able to move
eyes in
full range of
direction

Nose • nose is in • Centrally • Normal

midline, located

• No Discharges. • No nasal • Normal

discharges

• No flaring alae • No nasal • Normal

nasi. flaring noted
Both nares are Presence of
patent. nasal hair
With good
passage of
air
• No tenderness
noted on • Normal
• No
palpation.
tenderness
noted upon
palpation.

• Nasal septum
in the mid line • Normal
and not • Nasal septum
perforated. in the mid line
and not
perforated.

• The nasal
mucosa is • Normal
pinkish to red in • The nasal

4
 color. mucosa is
(Increased pinkish.
redness
turbinates are
typical of
allergy).

Mouth/ Lips • lips are pinkish, • With pinkish • Normal

symmetrical, lip and moist lips
margin is well-
defined,
smooth &
moist;

• gums are • Gums are • Normal

pinkish, smooth, pinkish moist,
moist, no no swelling
swelling,
no retraction, no
discharge;

TEETH
• 32 teeth • With • Due to excess
are present, yellowish fluorine in
aligned, teeth drinking water.
with no dental • Taking several
caries; drinks like
• With coffee
incomplete • Due to
set of teeth excessive
smoking.

• Normal

• tongue is • Tongue is
pinkish, slightly centrally
rough on top, located.
smooth along Pinkish and
the moist. Freely
lateral margins, movable.
moist, shiny &
freely movable;
• Normal

• soft palate is • soft palate is

pinkish, smooth pinkish,
& smooth & • Normal
moist; moist;

• hard palate • hard palate

is slightly is slightly
pinkish; pinkish

Neck • proportional to • Neck is • Normal

the size of the proportional
body to the size of
& head, the body.
symmetrical
& straight,

5
 • no • no • Normal
palpable lumps, palpable
masses or lumps,
areas of masses or
tenderness areas of
tenderness

Chest • chest contour is • With • Normal

symmetrical, symmetrical
chest
expansion
• no lumps, no upon
masses, no breathing.
tender areas,
• No masses • Normal
• with
clear breath
sounds
• With normal • Normal
breath
sounds

• Normal • Normal
cardiac rate
75 bpm

• Normal • Normal
respiratory
rate 22 bpm

• With clear • Normal

breath
sounds
(bronchovesic
ular sound)

• Both breast • Normal

no masses
noted

Abdomen • abdominal skin • No scars • Normal

is unblemished,
no
scars,

• color is • color is not • Due to

uniform with the uniform with exposure to
body color, the sunlight
body color because of her
job

• abdomen is • abdomen is • Normal

rounded with rounded
symmetric
movements • with soft and • Normal

6
 caused non tender
by respiration; abdomen
upon
• umbilicus is palpation
concave
• umbilicus is • Normal
centrally
located and
concave

Upper • palms are • palms are • Normal

Extremities pinkish, warm, soft pinkish,
& elastic; warm, soft
& elastic

• nails are
transparent, smooth • with good
& convex with light capillary refill • Normal
pink nail beds & (2-3 secs.)
white translucent
tips;

• 5 fingers in
each hand; both
shoulders, arms, • 5 fingers in • Normal
elbows, hands & each hand;
wrists can be both
moved in different shoulders,
range of motion with arms,
relative ease; with elbows,
marks of petechial hands &
rash wrists can be
moved in
different
range of
motion with
relative ease

Lower • skin is smooth, • With wound • Due physical

Extremities fine hair is on her left injury that
evenly extremities results in an
distributed, and opening or
absence With swelling break of the
of varicose and pain skin
veins, noted

• Due to internal
• 5 toes bleeding or
in each foot, leakage of
sole & • With blood from an
dorsal surface is hematoma injury
smooth with noted on her
pink 5th digits of • To reduce
nail beds & left foot edema and
white
provide comfort
translucent tips;
both legs, • To cover the
knees,
wound to
ankles, & toes • Left foot

7
 can elevated with prevent
be moved in one pillow infection as
different range well as to
of
control
motion with
bleeding
relative • Dressing
ease. supported by
elastic
bandage
Genito • Normal urine • With • Normal
Urinary output ( 1,500 adequate
cc/ day) urine output
( 1,200
• No lesions cc/day) • Normal
noted
• With no
lesions noted • Due to
• With regular environment
bowel • With irregular factors
movement bowel
movement
• With no
discharges
noted • With no • Normal
discharges
noted

ι ϖ. Final Diagnosis: Open (compound) Fracture on Left Foot

b. Present Health History

i. 24 hours recall of events

February 23, 2009 the patient is tracking the road to the market at that
time. She was riding on a tricycle with a neighbor then, an accident happened. A
10 wheeler truck ahead of them loose its exterior wheel and hit their vehicle. The
patient jumped out off the tricycle. The tricycle turned around about 90 degrees
and unfornately the patient’s foot stucked in the middle; caught underneath the
wheels of the truck. The people who witnessed the accident quickly respond to
helped her. And due to the accident, she had her three days hospitalization in
Lucena United Doctors Hospital before she had transferred at Quezon Medical
Center (QMC). According to Mrs. C, her wound was not often to clean for three
consecutive days that caused infection to her open fracture. Out of 10 as the
highest pain scale, Mrs. C rated herself 7-8 upon scaling.

ii. Sign and Symptoms

- pain (9 out 10 as most painful) and swelling on left foot

- body malaise

8
 c. Past Medical History

The patient had never been hospitalized. She had chicken pox when she
was in 6th grade of elementary. She also had a measles, simple cough, and colds
during her childhood and later years. She is taking over the counter drugs such
as paracetamol, antibiotics, and herbal supplement to relieve her condition.

d. Family Health Background

According to figure I the patient’s grandfather and grandmother on her

mother side were both died because of old age, while on her father side, her
grandfather died due to different complications of rheumatism and her
grandmother died because of old age. The client’s father died due to different
complications of rheumatism and her mother is still alive. Our client had no past
chronic disease except cough, cold and fever that cause by the environment.
She is only hospitalized because of the vehicular accident happenned to her.

9
Grandfather,
Grandmother,8 Grandfather,
92 Grandmother,
9 84
87 (Died of old
(Died of old
(Rheumatism) age)
age) (Died of old
age)
di

Mother,64
Father,70
(Still alive and
(Rheumatism)
healthy)

Mrs. C, 47

(Patient)

Figure I

LEGEND:

- Male

- Female

- Patient

IV. NUTRITION

a. 24 hours food recall (PTA)

- There is a restriction diet specifically NPO (Nothing Per Orem)

upon hospitalization for about 3days. (Empty stomach is a
Standard Operating Procedure for the pt. who will undergo
operation)

b. Regular/Routine Diet

- The client eats variety of foods, either harvested to their mini

vegetable garden or it can be brought in the local market like fish,
meat, and eggs. But because of her status in life, their family
cannot have it all. So they only have one viand a day. She had
good appetite for all sorts of food and she had a good hydration.

10
 c. Input and output

- INPUT: Before hospitalization Mrs. C drinks more than 2 liters of

water a day and a matter of 4 glasses of coffee a day because of
the nature of her job and because of her habits.

- OUTPUT: She has a good bowel movement for about twice a day.
Urination is thrice a day.

- INPUT: PTA, due to doctor’s order of NPO, IVF serves as her

intake.

- OUTPUT: Sometimes there is no defecation for the whole day. And

when Mrs. C feels to defecate, there is a discomfort during feces
elimination. (Due to environmental factors and decrease physical
activity). And in urinary elimination it had a normal amount and
characteristics.

d. Vices and Habits

- Mrs. C’s habits are to plant vegetables, to water the planted

vegetables, to harvest different vegetables to their mini garden and
to do their house hold chores. With regards to her vices, SMOKING
is the only vice she can’t detach to herself. A matter of 5-6 sticks a
day.

V. Disease Entity

a. Definition

What is a fracture?

Fracture is a break in the continuity of bones and is defined according to its

type and extent. A fracture is a partial or complete break in the bone. When a
fracture occurs, it is classified as either open or closed:

• Open fracture - the bone exits and is visible through the skin, or where a
deep wound exposes the bone through the skin.
• Closed fracture - the bone is broken, but the skin is intact.

11
Fractures have a variety of names. Below is a listing of the common types that
may occur in all ages:

• Greenstick - incomplete fracture. The broken bone is not completely

separated.

Image I

• Transverse - the break is in a straight line across the bone.

Image II

• Spiral - the break spirals around the bone; common in a twisting injury.

Image III

• Oblique - diagonal break across the bone.

12
 Image IV

• Compression - the bone is crushed, causing the broken bone to be wider

or flatter in appearance.

Image V

• Comminuted - the break is in three or more pieces.

b. Etiology

- Fracture is most often cause by some type of trauma to a bone. This

trauma might occur as a result of direct blows, crushing forces, sudden twisting
motion, and extreme muscle contraction.

α. Stages of normal fractures healing includes:

• Inflammation

• Cellular proliferation

• Callus formation

• Callus ossification

• Mature bone remodeling

β . Potential complications of fracture include:

• Life-threatening systematic fat embolus, which most commonly

develops within 24 to 72 hours after fractures.

• Compartment syndrome, which is a condition involving increased

pressure and constriction of nerves and vessels within an atomic
compartment.

13
 • Nonunion of the fracture side.

• Arterial damage during treatment.

• Infection and possibly sepsis.

• Hemorrhage, possibly leading to shock.

χ . Occurrence/Epidemiology

Anybody can have a bone fracture. Those with low bone density
(osteoporosis), bone tumors, certain cancers, or a brittle bone disease called
osteogenesis imperfecta are at higher risks for bone fractures. Children and
adults who are extremely active and participate in contact sports are also more
likely to suffer bone fractures. After middle age, women are more likely than en to
suffer bone fractures because diseases that affect bone strength and because of
hormonal effect, that is why women needs calcium supplement at their middle
age due to decrease bone density which leads to Fracture.

Fracture occurs when the bone is subjected to stress greater than it can
absorb.

When the bone is broken, the soft tissues around the broken bone may
also be injured. The area around or below the fracture may feel numb or paralyze
due to loss of pulse in that area. And the adjacent structures are also affected,
resulting in soft tissue edema, hemorrhage into muscles and joints, joint
dislocation, ruptured tendons, severed nerves and damaged blood vessels. Body
organs may be injured by the force that cause fracture or by Fracture fragments.

In general, bone fracture results in pain, swelling and sometimes bruising

from internal bleeding. The patient cannot bear weight or pressure on the injured
area, and may be unable to move it without severe pain.

14
 δ. Anatomy and Physiology of the organ involved

Front view of a skeleton of an adult human

Image VI

The musculoskeletal system includes 206 bones which are connected at

joints. The joints are held together by ligaments and cushioned by cartilages.
Tendons attach muscles to the bones. It provides the shape and forms our
bodies in addition to supporting, protecting, allowing bodily movement, producing
blood for the body, and storing minerals.

The human skeleton consists of two (2) main divisions:

1. Axial body’s upright structure with 80 bones:

a. Skull

b. Vertebral column

c. Ribs

2. Appendicular – the body’s appendages with 126 bones:

15
 a. Arms

b. Hips

c. Legs

Four major types of bones. Their names reflect their shape:

1. Long bones

2. Short bones

3. Flat bones

4. Irregular bones

LONG BONES are typically longer than they are wide. As they rules have a shaft
with heads at both ends, long bones are mostly compact bone. All bones of the
limbs, except the wrist and ankles bones, are long bones.

SHORT BONES are generally cube-shaped and contain mostly spongy bone.
The bones of the wrist and ankle are short bones.

FLAT BONES are thin, flattened, and usually curbed. They have two thin layers
of compact bone sandwiching a layer of spongy bone between them. Most bones
of the skull, the ribs, and the sternum (breastbone) are flat bones.

IRREGULAR BONES are that do not fit of the preceding categories. The
vertebrae, which make up the spinal column and the hip bones fall into this
group. Some includes are:

a. Sesamoid- occurs in conjunction with tendon and points in the body where
pressure occurs.

b. Wormain- occur in cranial sutures

FUNCTION OF THE BONE

The skeleton has six main functions:

SUPPORT

The skeleton provides the framework which supports the body and maintains
its shape. The pelvis and associated ligaments and muscles provide a floor for
the pelvic structures. Without the ribs, costal cartilages, and the intercostals
muscles the lungs would collapse...much like a black hole.

16
 a. MOVEMENT

The joints between bones permit movement, some allowing a wider range of
movement than others, e.g. the ball and socket joint allows a greater range of
movement than the pivot joint at the neck. Movement is powered by skeletal
muscles, which are attached to the skeleton at various sites on bones. Muscles,
bones, and joints provide the principal mechanics for movement, all coordinated
by the nervous system.

PROTECTION

The skeleton protects many vital organs:

• The skull protects the brain, the eyes, and the middle and inner ears.
• The spine protects the spinal cord.
• The rib cage, spine, and sternum protect the lungs, heart and major blood
vessels.
• The clavicle and scapula protect the shoulder.
• The ilium and spine protect the digestive and urogenital systems and the
hip.
• The patella and the ulna protect the knee and the elbow respectively.
• The carpals and tarsals protect the wrist and ankle respectively.

BLOOD CELL PRODUCTION

The skeleton is the site of haematopoiesis, which takes place in red bone
marrow.

STORAGE

Bone matrix can store calcium and is involved in calcium metabolism, and
bone marrow can store iron in ferritin and is involved in iron metabolism.

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.

17
BONES OF THE LOWER LIMBS

Femur

adductor tubercle · patellar

surface · epicondyles (lateral,
lower extremity
medial) · condyles (lateral,
medial) · intercondylar fossa
Crus

Tibia lower extremity medial malleolus · fibular notch

Fibulahead · body · lateral malleolus
Other patella
Foot

calcaneus (sustentaculum tali, trochlear process) · talus (body, neck,

Tarsus
head) · navicular · cuboid · cuneiform (medial, intermediate, lateral)

Metatarsus1st metatarsal · 2nd · 3rd · 4th · 5th

Other phalanges of the foot

First Metatarsal Bone

Image VII

The first metatarsal bone is the bone in the body of the foot just behind
the big toe. It is remarkable for its great thickness, and is the shortest of the
metatarsal bones. The body is strong, and of well-marked prismoid form.

The base presents, as a rule, no articular facets on its sides, but

occasionally on the lateral side there is an oval facet, by which it articulates with
the second metatarsal.

Its proximal articular surface is of large size and kidney-shaped; its

circumference is grooved, for the tarsometatarsal ligaments, and medially gives
insertion to part of the tendon of the Tibialis anterior; its plantar angle presents a
rough oval prominence for the insertion of the tendon of the Peronæus longus.

18
 The head is large; on its plantar surface are two grooved facets, on which
glide sesamoid bones; the facets are separated by a smooth elevation.

Second metatarsal bone

Image VIII

The second metatarsal bone is the longest of the metatarsal bones,

being prolonged backward into the recess formed by the three bones. Its base is
broad above, narrow and rough below.

It presents four articular surfaces: one behind, of a triangular form, for

articulation with the second cuneiform; one at the upper part of its medial
surface, for articulation with the first cuneiform; and two on its lateral surface, an
upper and lower, separated by a rough non-articular interval.

Each of these lateral articular surfaces is divided into two by a vertical

ridge; the two anterior facets articulate with the third metatarsal; the two posterior
(sometimes continuous) with the cuneiform. A fifth facet is occasionally present
for articulation with the first metatarsal; it is oval in shape, and is situated on the
medial side of the body near the base. The second metatarsal base acts as a
"keystone" (like in an arch) for the lisfranc joint. The base of the metatarsal is
held firmly between the 1st & 3rd cuneiform.

19
Third metatarsal bone

Image IX

The third metatarsal bone articulates proximally, by means of a

triangular smooth surface, with the third cuneiform; medially, by two facets, with
the second metatarsal; and laterally, by a single facet, with the fourth metatarsal.

Fourth metatarsal bone

Image X

The fourth metatarsal bone is smaller in size than the third; its base
presents an oblique quadrilateral surface for articulation with the cuboid; a
smooth facet on the medial side, divided by a ridge into an anterior portion for
articulation with the third metatarsal, and a posterior portion for articulation with
the third cuneiform; on the lateral side a single facet, for articulation with the fifth
metatarsal.

20
Fifth metatarsal bone

Image XI

The fifth metatarsal bone is recognized by a rough eminence, the

tuberosity, on the lateral side of its base. The base articulates behind, by a
triangular surface cut obliquely in a transverse direction, with the cuboid; and
medially, with the fourth metatarsal.On the medial part of its dorsal surface is
inserted the tendon of the Peronæus tertius and on the dorsal surface of the
tuberosity that of the Peronæus brevis.

A strong band of the plantar aponeurosis connects the projecting part of

the tuberosity with the lateral process of the tuberosity of the calcaneus.The
plantar surface of the base is grooved for the tendon of the Abductor digiti quinti,
and gives origin to the Flexor digiti quinti brevis.

The base of the metatarsal is often injured and a particularly notorious

fracture is the fracture. Stress fractures are common in the fifth metatarsal
among athletes.

21
 FRACTURE

Vehicular Accident-(Mechanical)

Tissue & Bone injury

Destruction on muscle & Destruction on bone of the 2nd -

tissue integrity 5th metatarsal

Vascular Response

Increase Capillary Permeability

Redness (Rubor)
Fluid/Cellular exudation
Heat (Calor) accumulation

Exudates (serous)
Treatment Edema (Tumor)
Application of cold Treatment
compress
Pain (Dolor)
Application of
Application of ice packs
Impaired ice packs
Function Elevation of
Treatment affected area

Immobilization Immobilization
Bone repair
Elevation of affected Debridement
area Clot formation

Analgesic Callus formation Possible

Callus ossification complication
if fracture is
Treatment Bone remodelling not properly
managed:
Application of short
Hypovolemic
posterior mold
shock, fat
embolism and
compartment
syndrome

22
VI. PATHOPHYSIOLOGY

Fracture is a break in the continuity of bone and is defined according to its

type and extent. Fracture occurs when the bone is subjected to stress greater
than it can absorb. Fractures are caused by the direct blows, crushing forces,
sudden twisting motion, and extreme muscle contraction. When the bone is
broken, adjacent structures are also affected, resulting in soft tissue edema,
hemorrhage into the muscles and joints, joint dislocation, ruptured tendons,
severed nerves, and damaged blood vessels. Body organs may be injured by the
force that caused fracture or by fracture fragments.

In the case of patient Mrs. C, fracture of bone 2nd and 5th metatarsal of left
foot is due to vehicular accident (mechanical). This lead to tissue and bone
injury, destruction on muscle tissue integrity and destruction on bone of the 2nd –
5th metatarsal. Because of the injury, this leads to vascular response which
further increases capillary permeability. Inflammatory response is activated
which include redness, heat, fluid cellular exudate accomulation, edema, pain
and loss of function on the affected area. Those symptoms are treated with
application of cold compress, elevation of affected area, immobilization,
debridement, use of analgesic and application of short posterior mold.

When a bone is broken, blood vessels in the bone are also damaged. The
vessels bleed, and a clot forms in the damaged area. Two to three days after the
injury, blood vessels and cells from surrounding tissues begin to invade the clot.
Some of these cells produce a fibrous network of connective tissue between the
broken bone, which holds the bone fragments together and fills the gap between
the fragments. Other cell produce islets of cartilage in the fibrous network. The
zone of tissue repair between the two bone fragments is called a callus.

Osteoblasts enter the callus and begin forming cancellous bone.

Cancellous bone formation in the callus is usually complete four to six weeks
after the injury. Immobilization of the bone is critical up to this time because
movement will refracture and delicate new matrix. Subsequently, the cancellous
bone is slowly remodeled to form compact and cancellous bone, and the repair is
complete. Total healing of the fracture may require several months. If bone
healing occurs properly, the heal region.

On the other hand if fracture is not properly managed this lead to

complication like: hypovolemic shock due to massive bleeding, fat embolism
usually follows fracture of the long bones or muliple fracture and compartment
syndrome due to tight dressing and tight cast.

VII. MANAGEMENT

a. Medical and Surgical Management

Patient with Open Fractures

In an open fracture, there is a risk for osteomyelitis, tetanus, and gas

gangrene. The objectives of management are to prevent infection of the wound,
soft tissue, and bone and to promote healing of soft tissue and bone. The nurse
administers tetanus prophylaxis is indicated. Serial irrigation and debridement
are use to remove anaerobic organisms. Intraveneous (IV) antibiotics are
prescribed to prevent or treat infection. Analgesics are given for pain.

Prompt, through wound irrigation and debridement in the operating room

is necessary. The wound is cultured and devitalized bone fragment are removed.
The fracture is carefully reduced and stabilized by external fixation or
intramedullary nails. Any damage to blood vessels, soft tissue, muscles, nerves,
and tendons is treated.

With open fractures, primary wound closer is usually delayed. Heavily

contaminated wounds are left unsutured and dressed with sterile gauze to permit
edema and wound drainage. Wound irrigation and debridement may be
repeated, removing infected and devitalized tissue and increasing vascularity in
the region. After it has been determined that infection is not present, the wound is
close into five to seven days, and all dead space is obliterated and grafting of
autogenous skin or a flap.

The nurse elevates the extremity to minimize edema. It is important to

assess neurovascular status frequently. The nurse measures the patient’s
temperature at regular intervals and monitors the patient for signs of infection (or
instructs the patient or family to do so). In four to eight weeks, bone grafting may
be necessary to bridge bone defects and to stimulate bone healing.
PHARMACOLOGIC MANAGEMENT

Table II

NAME OF
NURSING
DRUG/ BRAND DOSAGES ACTION CONTRAINDICATION ADVERSE EFFECTS
MANAGEMENT
NAME

Paracetamol 500mg 1 tab; Inhibits the synthesis Previous hypersensitity. GI: hepatic; hepatoxicity >Right drug
of prostaglandins that Products containing alcohol , (overdose).
1 tab every 4 may serve as aspartame, saccharin, sugar or > Right dose
hours as needed medicators of pain tartrazine should be avoided in
Brand Name: > Right time
and fever. patient who have GU: renal failure (high dose/
Ibuprofen hypersensitivity or tolerance in chronic use). >Right route
those compounds
> Right patient

HEMAT: neutropenia, > Take a complete drug

pancytopenia, history of the patient

>Document drug you

adminstered
DERM: rash, urticaria
>Find out if the patient
has any allergy

>Assess fever, note

presence of associated
signs (diaphoresis,
tachycardia, and body
malaise).

>Monitor vital signs.

 TABLE III

NAME OF
NURSING
DRUG/ BRAND DOSAGES ACTION CONTRAINDICATION ADVERSE REACTION
MANAGEMENT
NAME

Cefuroxime 500mg 1 cap Bind to bacterial cell >Hypersensitivity to Seizures(high dose); diarrhea, >Right drug
thrice a day wall membrane, cephalosporins. jaundice, nausea, vomiting, cramps,
(8am, 1pm, 6pm) causing cell death; rashes, urticaria,alllergic reaction > Right dose
bactericidal action >Serious hypersensitivity to including anaphylaxis and serum
Brand Name: penicillins. > Right time
sickness, superinfection
Zinacef >Right route

> Right patient

>Assess the patient for

infection (vital signs;
appearance of wound;
WBC) at the beginning
and throughout the
therapy

>Before initiating
therapy, obtain history to
determine previous use
and reactions to
penicillins or
 cephalosporins. Persons
with a negative history of
penicillin sensitivity may
still have an allergic
response.

> Observe patient for

signs and symptoms of
anaphylaxis (rash,
pruritus, laryngeal
edema, wheezing).
Discontinue medication
and notify physician or
other health care
provider immediately if
these symptoms occur.

>Assess patient for renal

dysfunction and adjust
dose accordingly.

TABLE IV
 NAME OF
DRUG/ NURSING
DOSAGES ACTION CONTRAINDICATION ADVERSE EFFECT
BRAND MANAGEMENT
NAME

Tramadol 500mg 1 cap Binds to mu-opioid Hypersensitivity. Cross-sensitivity Seizures, headache, anxiety; >Right drug
thrice a day (8am, receptors. with opiods may occur. Patients confusion, malaise, nervousness,
1pm, 6pm) Decreased pain. who are acutely intoxicated with sleep disorder,constipation, nausea, > Right dose
Brand Name: alcohol, sedative/hypnotics, abdominal pain, anorexia, > Right time
centrally acting analgesics. dyspepsia
Tramal Patients who are physically >Right route
dependent on opioid analgesics.
> Right patient

>Assess type, location,

and intensity of pain
before and 2-3 hrs.
(peak) after
administration.

>Assess blood pressure

and respiratory rate
before and periodically
during administration.
Respiratory depression
has not occurred with
recommended doses.

>Assess previous
analgesic history.
Tramadol is not
recommended for
patients dependent on
opiods or who have
previously received
opiods for more than 1
week, may cause opioid
withdrawal symptoms.

>Monitor patient for

seizures. May occur with
the recommended
doses range. Risk is
increased with higher
doses and in patients
taking antidepressants
or other drugs that
decrease the seizure
threshold.
 TABLE V

NAME OF
NURSING
DRUG/ BRAND DOSAGES ACTION CONTRAINDICATION ADVERSE EFFECT
MANAGEMENT
NAME

Celecoxib 200mg twice a Has analgesic, anti- History allergic-type reaction to Dizziness, headache, insomnia, >Right drug
day (8am, 6pm) flammatory, and sulfonamides. History of asthma, abdominal pain, diarrhea,
antipyretic urticaria, or allergic-type reactions dyspepsia, nausea, rash,liative > Right dose

Brand Name: properties to aspirin or other NSAID’s. dermatitis > Right time

Celebrex >Right route

> Right patient

>Assess range of
motion,degree of
swelling, and painin
affected joints before
and periodically
throughout the therapy.
 TABLE VI

GENERIC
NAME/ NURSING
DOSAGES ACTION CONTRAINDICATION ADVERSE EFFECT
BRAND MANAGEMENT
NAME

Cloxacillin 500g IVP every Bind to bacterial cell Hypersensitivity to penicillin CNS:seizure, pseudomembranous >Right drug
6 hours (12nn, wall, leading to cell ( cross-sensitivity with colitis, diarrhea, nausea, drug
6pm, 12 mid, death. Resist the cephalosporin) enduced hepatitis, vomiting. > Right dose

Brand Name: 6am) action of penicillinase, > Right time

an enzyme capable of
Cloxapen inactivating penicillin. Derm: rash, urticaria, pain at IM >Right route
site, phebitis and IV site > Right patient

>Asess the patient for

MISC: allergic reactions including
anaphylaxis and serum sickness
infection ( vital signs)
appearance of
wound,urine and stool
(WBC)at beginning of
througthout therapy.

>Obtain a history before

initiating theraphy to
determine previous use
of and reactions of
 penicillin or
cephalosporins.

>Observe patient for

sign and symptoms of
anaphylaxis, rash,
pruritus, larnygheal
edema,wheezing,
abodominal pain
( discontinue the drug
and notify the physician
or other health care
immediately) if these
occur keep epinepherine
an antihistamine, and
resuscitation equipment
close by in the event of
an anaphylactic reaction.

>Assess vein for signs

of irritation and phlebitis.
Change IV site every 48
hrs. to prevent phelibitis.

TABLE VII

GENERIC DOSAGES ACTION CONTRAINDICATION ADVERSE EFFECT NURSING

NAME/ BRAND
MANAGEMENT
NAME

Ranitidine 300mg twice a Inhibits the action of Hypersensitivity. Cross-sensitivity CNS: confuson, dizziness, > Right patient
day (8am, 6pm) histamine at the H2 may occur some product contain drowsiness, hallucination, headache
for 4 weeks receptor site located alcohol and should be avoided in > Right dose
primarily in gastric patient with known intolerance. CV: arrythmias
Brand Name: > Right drug
parietal cell, Porphyria (ranitidine bismuth GI: altered taste black tongue,
Zantac resulting in inhibition citrate only). Some products constipation, dark stools, diarrhea, >Right route
of gastric acid contain aspartame and should be nausea > Right time
secretion. Healing avoided in patients with
and prevention of phenylketonuria. HEMAT: anemia >Assess for epigastric
ulcers. Decrease or abdominal pain and
symptoms of frank or occult blood in
gastroesophageal the stool, emesis, or
reflux. gastric aspirate.

>Assess geriatric and

debilitated patients
routinely for confusion.
Report promptly.

>Monitor V/S.

TABLE VIII

GENERIC DOSAGES ACTION CONTRAINDICATION ADVERSE EFFECT NURSING

 NAME/
BRAND MANAGEMENT
NAME

Ferrous 500mg 1 An essential mineral Primary hemochromatosis. Dizziness, seizures, headache, >Right drug
Sulfate capsule once a found in hemoglobin, Hemolitic anemias and other hypotension, tachycardia, nausea,
day (9am) myoglobin, and many anemias not due to iron deficiency. constipation, dark stools, epigastric > Right dose
enzymes. Parenteral Some products contain alcohol, pain, flushing, ueticaria, allergic > Right time
Brand Name: iron enters the blood tartrazine, or sulfites and should be reactions including anaphylaxis.
stream and organs of avoided in patients with known >Right route
Apo- Ferrous the reticuloendothelial intolerance or hypersensitivity.
Sulfate > Right patient
system (liver,spleen, Concurrent oral iron theraphy.
bone marrow), where >Asses nutritional
iron is separated out status and dietary
and becomes apart of history to determine
iron possible cause of
stores.prevention/treat amenia and nedd for
or iron deficiency. patient teaching.

>Assess bowel function

for constipation. Notify
physician or other
health care provider
and use appropirate
nursing maesures
should these
 occur.Observe patient
for sign and symptoms
of anaphylaxis, rash,
pruritus, larnygheal
edema,wheezing,
abodominal pain
( discontinue the drug
and notify the physician
or other health care
immediately) if these
occur keep
epinepherine an
antihistamine, and
resuscitation equipment
close by in the event of
an anaphylactic
reaction.

TABLE IX
 DROPS TO NURSING
IV FLUID ACTION CONTRAINDICATION ADVERSE EFFECT
CONSUME MANAGEMENT

Dextrose 5% 1000 mL runs for >Maintain and Solutions containing dextrose may febrile response, infection at the site >Make sure that the IVF
Lactated 8 hours replace body stores be contraindicated in patients with of injection, venous thrombosis or is well regulated.
Ringers (D5LR) of water, known allergy to corn or corn phlebitis extending from the site of
injection, extravasation, and >Check the IVF at
electrolytes, products.
hypervolemia. regular intervals.
vitamins, proteins,
and fat and calories. >Monitor the patient for
>Restores acid base any signs of edema on
balance. the injection site.

Addendum: Patient consumed 16 bottles of D5LR 1L during her confinement

 c. Nursing Management

In planning and implementing nursing care for the client with fracture the
nurse should consider the client’s response to the traumatic experience.
Although each client has individual needs, nursing care commonly focuses on
client problems with pain, impaired physical mobility, impaired tissue perfusion,
and neurovascular compromise.

The patient with nonunion has experienced an extended time in fracture

treatment and frequently becomes frustrated with prolonged therapy. The nurse
provides emotional support and encouragement to the patient and encourages
compliance with the treatment regimen. The orthopedic surgeon evaluates the
progression of bone healing with periodic x-rays.

Nursing care for the patient with bone debridement include pain
management, monitoring the patient for signs of infections at the sites, and
patient education. The nurse needs to reinforce information concerning the
objectives of the bone debridement, immobilization; non-weight bearing, wound
care, signs of infection, and follow-up care with orthopedic surgeon.

Basic Body Mechanics

Body Mechanics refers to the function of muscles and joints and the
application of the mechanical principles to the activities of the patient and the
nurse. By applying these principles a nurse can efficiently lift and turn patient
when given care without causing injury to her own body.

Nursing Care Goals

A. Permit Normal Functioning.

e.g. Eating is usually done in sitting position because the gravitational flow
assists the food in reaching the stomach.

B. Aids Healing.

The patient must also be positioned so that circulation is maintained, thus

aids healing. And must practice frequent isometric quadriceps exercises.

C. Prevent Complications and Deformities.

D. Relieve pain
VII. LABORATORY/DIAGNOSTIC EXAMINATION

FEBRUARY 28,2009

NORMAL
CBC RESULTS ANALYSIS/INTERPRETATION
VALUES
M: 14.0-
17.0g/dl Dietary deficiency/ malnutrition and
Hemoglobin 10.6
F: 12.0- anemia
15.0g/dl
M: 40-
50vol% Normal/ to determine viscosity of the
Hematocrit 32.1
F: 30-40vol blood
%
M: 4.6-
Indicate bacterial infection. Indicates
5.1uL
RBC 3.31 abnormal or deficient hemoglobin
F: 4.0-
content in RBC.
4.5uL
Indicate trauma, infection and
5,000-
WBC 18,760 inflammation. Indicates tissue
10,000
disruption
May indicate inflammation and tissue
Neutrophil 74.6 55-65 injury. Indicates in high level of stress
is placed in the body.

Lymphocyte 13.5 25-35 Indicates of infection

Eosinophils 2.7 1.0-5.0% Normal

150-400
Platelet 268 Normal
103/uL

Table X

MARCH 3, 2009

NORMAL
CBC RESULTS ANALYSIS/INTERPRETATION
VALUES
M: 14.0-
17.0g/dl Dietary deficiency/ malnutrition and
Hemoglobin 10.9
F: 12.0- anemia.
15.0g/dl
M: 40-
50vol%
Hematocrit 37.1 Normal
F: 30-40vol
%

5,000- Indicate trauma, infection, and

WBC 18,000
10,000 inflammation

Neutrophil 74 55-65 Indicate inflammation and tissue injury

Lymphocyte 27 25-35 Due to trauma; normal

Table XI

URINALYSIS

URINALYSIS RESULT RIGHT VALUE INTERPRETATION

Because of the effects of

Color Yellow Yellow amber
drugs; Normal

Because of the effects of

Transparency Slightly turbid Clear
drugs; Normal

Table XII

X RAY RESULT (April 3, 2009)

Follow- up X- RAY of the left foot shows the noted fracture segments, 2 nd
and 5th metatarsal, as previously noted not in proper anatomical alignment.

Some evidence of beginning callus formations noted.

Clinical correlation suggested.

LABORATORY STUDIES

COMPLETE BLOOD COUNT

HEMOGLOBIN

It is the principal component of the erythrocyte made up of a protein

(globin) and pigment (heme) which gives the RBC its red color. This test
evaluates blood loss, erythropoietics ability, anemia, and response to therapy.

• Increase level- indicates polycythemia vera, congestive heart failure

(CHF), congenital heart disease (CHD), dehydrations, severe burns or
polycythemia secondary to high altitudes. Indicates an above-average
concentration of oxygen-carrying protein in the blood. Indicates the body
may be making too many red blood cells.
 • Decrease level- indicates anemia from blood loss, dietary deficiency/
malnutrition, kidney disease, risk of heart attack and congestive heart
failure.

HEMATOCRIT

The volume of the red cells (erythtrocytes) in blood, expressed as fraction

of the total volume of the blood. The packed cell volume is determined by
centrifuging blood in a tube and measuring the height of the red cell column as a
fraction of the total.

• Increase level- indicates dehydration, burns, diarrhea and erythrocytosis

• Decrease level- indicates anemia from blood loss (hemorrhage),

destruction of red blood cells and malnutrition or specific diet deficiencies

RED BLOOD CELL

A blood cell containing the red pigment hemoglobin, the principal function
of which is the transport of oxygen. A mature erythrocyte has no nucleus and its
shape is that of biconcave disk, approximately 7millimicron in diameter.

• Increase level- indicates polycythemia

• Decrease level- indicates anemia from blood loss, abnormal destruction of

red blood cell, lack of substances needed for RBC production.

WBC

Leukocytes are the body’s primary defense against microorganism and

other substances foreign to the body. This blood test evaluates a number of
condition and different causes of alteration in the white blood cell count including
infection, inflammation, tissue necrosis and leukemic neoplasm.

• Increase level- this may indicate trauma, infection, inflammation,

hemorrhage, malignancies, toxins or serum sickness.

• Decrease level- may indicate autoimmune disease, bone marrow, drug

toxicity, bone marrow overwhelming infection.

NEUTROPHILS

Are the most abundant of the leukocytes. They are the body’s first line of
defense against invading microorganisms.

• Increase level- may indicate bacterial infection including gonorrhea,

myocardial infection, and metabolic disorder including rheumatic fever.
 • Decrease level- indicates infection including typhoid hepatitis, influenza,
tularemia, measles, and bone marrow depression.

EOSINOPHILS

• Increase level- indicates allergic response including fever, foods and

medication allergies, parasitic infection, asthma, amoebiasis, bone
marrow, lung cancer, skin disorder.

• Decrease level- indicates infections like typhoid, hepatitis, measles,

tularemia, influenza, mononucleosis, and due to administration of steroids

BASOPHILS

• Increase level- acute leukemia, and following surgery or trauma.

• Decrease level- allergic reactions, stress, allergy, parasitic disease, use of

corticosteriod.

LYMPHOCYTES

• Increase level- infectious monocyteosis, viral and some bacterial

infections, hepatitis,

• Decreases level- aplastic anemia, immuno deficiency including AIDS.

MONOCYTES

• Increase level- viral infections, parasitic disease, collagen and hemolytic

disorders

• Decrease level- use of corticosteriods, Human Immunovirus (HIV)

infections.

PLATELETS

Fragments of cells that participate in clotting. They initiate repair of blood

vessel walls.

• Increase level- indicates infection chronic inflammation, tissue damage

acute blood loss.

• Decrease level- indicates increase risk of bleeding. And may indicate

marrow depression like aplastic anemia, folic acid deficiency.