I- 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
extreme muscle contractions. 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
maybe injured by the force that cause the fracture or by the fracture fragments.

There are different types of fractures and these include, complete fracture,
incomplete fracture, closed fracture, open fracture and there are also types of fractures
that may also be described according to the anatomic placement of fragments,
particularly if they are displaced or nondisplaced. 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.
Often, a fractured hip is a catastrophic event that will have a negative impact on the
patient’s life style and quality of life. There are two major types of hip fracture.
 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 efficiently 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 able

to:
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. implement holistic nursing care in the care of patient utilizing the nursing
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 significant
others 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 History
1.1 Patient’s Profile

Name: Mrs. Torralba, Lourdes

Age: 89 years old
Sex: Female
Civil Status: Widow
Religion: Roman Catholic
Date and time of admission; March 13, 2008 at 10:10 am
Room No.: Room 425, Cebu Doctors’ University Hospital
Complaints: Pain the right hip
Impression or Diagnosis: Fracture Close-Comminuted: Femoral Right Neck

General Osteoporosis
Breast Cancel (Right)
Diabetes Mellitus Type II

Physician: Dr. F. Vicuna, Dr. E. Lee, Dr. N. Uy, Dr. Ramiro

Hospital No: 216 426
1.2. 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
Cebu Doctors’ University Hospital for further management of the condition.

Mrs. Torralba is a college graduate and she’s previously working as an assistant of her
husband ( Mr. Rodrigo Torrralba ) a doctor.
The patient was diagnosed to have Breast Cancer (Right) last 2006 with bone
metastasis and on chemotherapy with aromasin.

Two days prior to admission, the patient was standing and was about to open up
he umbrella when she got out of balance and landed on her right hip.And had experienced
limitation of movement on the 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 ankle
last 2002. No familial history of hypertension and bronchial asthma but is positive to
diabetes mellitus of paternal side. Has no known food and drug allergies. The patient is
non-smoker non-alcoholic beverages drinker.

1.3. Level of Growth and Development

1.3.1. Normal Growth and Development at particular stage Older Adult ( 65
Years old to death)
Physical Development

Perception 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 are
limited by physical, emotional or social impairments may perceive themselves as ill.

There are frequently observed physiological changes in order adults that are
called normal. Finding these “normal” changes during and assessment is not an expected.
These physiological changes are not always pathological processes in themselves, but
they may make older adults more vulnerable to some common clinical conditions and
diseases. Some older adults experience all of these physiological changes, and others only
experience 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 Development

Intellectual capacity includes perception, cognitive, memory, and learning.

Perception, or the ability to interpret the environment, depends on the acuteness of the
senses. If the aging person’s senses are impaired, the ability to perceive the environment
and react appropriately is diminished. Perceptual capacity may be affected by changes in
the 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 meaninges
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. Life
long 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 “one’s one and only life
style”. 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 one’s fate. Despair gives rise of frustration, this couragement, and a
sense that one’s life has been worthless.
Moral Development

According to Kohlberg, moral development is completed in the early adult years.

Most old people stay at Kohlberg’s 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 person’s at stage 7 may act to meet another’s need as well as their
own. Elderly people at the conventional level follow society’s 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 experiences
feelings 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 Development

Sex drives persist into the 70’s, 80’s, and 90’s, provided that the health is good
and an interested partner is available. Interest in sexual activity in old age depends, in
large 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 vaginal
secretions 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 skinf

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 age—tripping 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 abnormality associated with chronic brain
syndrome—and it appears that these demented patients fall not because of mental
confusion but because of associated motor abnormalities.

Ertra-capsular fractures occur in older patients. They are more likely to have a
history of falls but previous fracture is equally common at this age in the fracture and
control series.

2. Diagnostic Test
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 patient’s hospitalization, her diet was changed to low fat and low cholesterol
diet because she was diagnosed of having diabetes mellitus type II. The patient’s
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 patient’s 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 Caltrate. 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
doesn’t smoke or drink alcoholic beverages, has no known allergies. There is a change in
her appetite now; she often eats a little only each meal.

3.3. Elimination Pattern

 Before, the patient can freely go to the C.R. to void or defecate but now that
she’s
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, she’s just on bed lying assisted by her private nurses and
CDUH health care providers.

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, Tagalog and Bisaya 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 10
o’clock pm and wakes up early in the morning at 6 o’clock am with an hour of sleep of 8
hours. Now, she usually sleeps early at night (8-9 o’clock pm) and wakes up at around 7
o’clock am with an hour of sleep of 10 hours. The patient usually stays in bed and read
newspapers sometimes, she can’t take a nap in the afternoon due to her REHAB CARE.

3.7. Self- Perception Pattern

 The patient’s 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 maybe 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 patient’s husband just recently died. Now, the patient does not allow anyone
to see her getting undressed, changing diaper, changing clothes because she believes that
as 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 be more 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 Bisaya languages but a little only in
Tagalog 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.

4. Pathophysiology and Rationale

4.1 Normal Anatomy and Physiology of Organ/ System Affected

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
appendicular 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 diaphysis, or shaft, makes up most of the bones length and is composed of
compact bone. The diaphysis is covered and protected by a fibrous connective tissue
membrane, the periosteum. Hundreds of connective tissue fibers, called Sharpey’s 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. Articular 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 a bit different from the rest of the bone in that area. This is the epiphyseal line. The
epiphyseal 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 previous
location.

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 fibers) provide for bone’s 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 (separrsted anteriorly by the intertrochanteric line and posteriorly by
the intertrochanteric 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 body’s 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

4.2
Schematic Diagram

Predisposing Factors:
Precipitating Factors:
-Elderly people (85 years or older) -Fall
- Trauma - osteoporosis
- Comorbidity -functional disability
- Malnutrition - impaired vision and balance
-neurologic problems
- Obesity
-slower reflexes

4.3 Pathophysiology

Femoral neck fractures occur most commonly after falls. Factors that increase the

risk of injuries are related to conditions that increase the probability of falls and those that

decrease the intrinsic ability of the person to with stand the trauma. Physical

deconditioning, malnutrition, impaired vision and balance, neurologic problems, and

shower reflexes all increase the risk of falls. Osteoporosis is the most important risk
factor that contributes to hip fractures. This condition decreases bone strength and,

therefore, the bones ability to resist trauma.

Femoral neck fractures can also be related to chronic stress instead of a single

traumatic event. The resulting stress fractures can be divided into fatigue fractures and

insufficiency fractures. Fatigue fractures are a result of an increased or abnormal stress

placed on a normal bone. Whereas insufficiency fractures are due to normal stresses

placed on diseased bone, such as an osteoporotic bone.

Trauma sufficient to produce a fracture can result in damage to the blood supply

to an entire bone, e.g., the femoral neck in femoral fracture. With seer circulatory

compromise, avascular (ischemic) necrosis may result. Particularly vulnerable to the

development of ischemic are intracapsular fractures, as occur in the hip. In this location,

blood supply is marginal ad damage to surrounding soft tissues may be a critical factor

since better results are obtained in cases of hip fracture reduced with in 12 hr. than in

those treated after that tine period. In fractures of the femoral neck, bone scans have been

recommended as diagnostic tools to determine the orability of the femoral need.

IV. Nursing Interventions

1. Medical and Surgical Management

Temporary skin traction, Buck’s extension, may be applied to reduce muscle spasm, to

immobilize the extremity, and to relieve pain. The findings of a recent study suggested that there is no
benefit to the routine use of preparative skin traction for patients with hip fractures and that the use of skin

traction should be based as evaluation of the individual patient.

The goal of surgical treatment of hip fractures is to obtain a satisfactory fixation so that the

patient can be mobilized quickly and avoid secondary medical complications. Surgical treatment consists of

(1) open or closed reduction of the fracture and internal fixation (2) replacement of the femoral head with a

prosthesis (hemiarthroplasty), or (3) closed reduction with pereutaneous stabilization for an intracapsular

fracture. Surgical intervention is carried out as soon as possible after injury. The preoperative objective is

to ensure that the patient is in as favorable a condition as possible for the surgery. Displaced femoral neck

fractures may be treated as emergencies, with reduction and internal fixation performed within 12 to 24

hours after fracture. This minimizes the effects of diminished blood supply and reduces the risk for

avascular necrosis.

After general or spinal anesthesia, the hip fracture is reduced under x-ray visualization using an

image intensifier. A stable fracture is usually fixed with nails, a nail and plate combination, multiple pins,

or compression screw devices. The orthopedic surgeon determines the specific fixation device based on the

fracture site or sites. Adequate reduction is important for fracture healing (the better the reduction, the

better the healing).

Hemiarthroplasty (replacement of the head of the femur with prosthesis) is usually reserved for

fractures that cannot be satisfactorily reduced or securely nailed or o avoid complications of non-union and

avascular necrosis of the head of the femur. Total hip replacement may be used in selected patients with

acetabular defects.

2. Care Guide of Patient with the Condition (fracture of the right femoral neck)
Repositioning the Patient

The nurse may turn the patient onto the effected or unaffected extremity as prescribed by the

physician. The standard method involves placing a pillow between the patient’s legs to keep the affected

leg in an abducted position. The patient is then turned onto the side white proper alignment and supported

abduction are maintained.

Promoting Strengthening Exercise

The patient is encouraged to exercise as much as possible by means of the overbed trapeze. This

device helps strengthening the arms and shoulders in preparation for protected ambulation (e.g., toe touch,

partial weight bearing). On the first post- operative day, the patient transfers to a chair with assistance and

begins assisted with ambulation. The amount of weight bearing that can be permitted depends on the

stability of the fracture reduction. The physician prescribes the degree of weight bearing and the rate at

which the patient can progress to full weight bearing. Physical therapists work with the patient on transfers,

ambulation, and the safe use of the walker and crutches.

The patient who has experienced a fractured hop can anticipate discharge to home or to an

extended care facility with the use of an ambulating aid. Some modifications in the home maybe needed to

permit safe use of walkers and crutches and for the patient’s continuing care.

Monitoring and Managing Potential Complications

Elderly people with hip fractures are particularly prone to complications that may require more

vigorous treatment than the fracture. In some instances, shock proves fatal. Achievement of homeostasis

after injury and surgery is accomplished through careful monitoring and collaborative management,

including adjustment of therapeutic interventions as indicated.

Health Promotion

Osteoporosis screening of patients who have experienced hip fracture is important for prevention

of future fractures. With dual-energy x-ray absorptiometry (DEXA) scan screenings the actual risk for

additional fracture can be determined. Specific patient education regarding dietary requirements, lifestyle

changes, and exercise to promote bone3 health is needed. Specific therapeutic interventions need to be

initiated to retard additional bone loss and to build bone mineral density. Studies have shown that health

care providers caring for patient with hip fractures fail to diagnose or treat these patients for osteoporosis

despite the probability that hip fractures are secondary to osteoporosis. Fall prevention is also important

and maybe achieved through exercises to improve muscle tone and balance and through the elimination of
 environmental hazards. In addition, the use of hip protectors that absorb or shunt impact forces may help to

prevent an additional hip fracture if the patient were to fall.

Relieving Pain
* Secure data concerning pain
- have patient describe the pain, location characteristics (dull, sharp, continuous,
throbbing, boning, radiating, aching and so forth)
- ask patient what causes the pain, makes the pain worse, relieves the pain, and so
forth.
- evaluate patient for proper body alignment, pressure from equipment (casts,
traction, splints, and appliances)
* Initiate activities to prevent or modify pain
* Administer prescribed pharmaceuticals as indicated. Encourage use of less potent

drugs as severity of discomfort diseases.

* Establish a supportive relationship to assist patient to deal with discomfort.

* Encourage patient to become an active participant in rehabilitative plans.

Promoting Self-Care Activities

* Encourage participation in care.
* Arrange patient area and personal items for patient convenience to promote

independence.

* Modify activities to facilitate maximum independence within prescribed limits.

* Allow time for patient to accomplish task.

* Teach family how to assist patient while promoting independence in self-care

Promoting Physical Mobility

* Perform active and passive exercises to all nonimonobilized joints.
* Encourages patient participation in frequent position changes, maintaining supports
to fracture during position changes.
* Minimize prolonged periods of physical inactivity, encouraging ambulation when
prescribed.
* Administer prescribed analogies judiciously to decrease pain associated with
movement.
Promoting Positive Psychological Response to Trauma
* Monitor patient for symptoms of post from a stress disorder.
* Assist patient to more through phases of post-trammatic stress (outery,

denied,omtrusiveness, working through, completion).

* Establish trusting therapeutic relationship with patient.

* Encourages patient to express thoughts and feelings about traumatic event

* Encourages patient to participate in decision making to reestablish control and
overcome feelings of helplessness.
* Teach relaxation techniques to decrease anxiety.
* Encourages development of adaptive responses and participation in support groups.
* Refer patient to psychiatric liaison nurse or refer for psychotherapy, as needed.