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 e x t r e m e m u s c l e c o n t r a c ti o n s . W h en t h e b o n e i s b r ok e n ,
a d j a c en t s t r u ct u r e s ar e a l s o 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. T h e r e a r e d i f f e r e n t
t y p e s o f f ra c tu r e s a n d t h e s e i n c l u d e , co m p l e te f r a c t u r e, 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 f t en , a f ra ct u r e d h i p i s a ca t a s tr o p h i c e v e n t t h a t w i l l h a v e a n e g a t i v e i m p a ct o n
t h e p a t i e n t ’ s l i f e s t y l e a n d q u al i t y o f l i f e . T h e r e a r e t w o m a j o r t yp e s o f h i p f r a ct u r e .
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 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. implement holistic nursing care in the car e 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
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

Patient’s 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 she’s 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 person’s 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 “one’s 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 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 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 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,
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 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
abnormalityassociated with chronic brain syndrome—and it appears that these demented patients fall
not because of mental confusion but because of associated motor abnormalities. Extra-capsular
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
patient’s hospitalization, her diet was changed to low fat and low cholesteroldiet 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 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
doesn’t 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 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 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 10o’clock pm
and wakes up early in the morning at 6 o’clock am with an hour of sleep of 8hours. Now, she usually sleeps early at
night (8-9 o’clock pm) and wakes up at around 7o’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 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 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 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 Sharpe’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. 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 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 (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 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.
Defining Nursing Scientific basis Expected Nursing Rationale
characteristics diagnosis outcome intervention
Difficulty in Impaired Fractures occur After 8hours -Promote to avoid patients from
changing position physical when the bone is nurse-patient adequate falling to sudden
while lying on bed.- mobility, subjected to intervention mobility of the movements
Difficultyin inability to stress greater the patient client.
movingtheextremit standalone that it can will be able
ies.-Inability to related to absorb. When to:
walk or stand skeletal the bone is Demonstrate - instruct the to -to improve muscle
alone.-limitedrange impairment broken, adjacent increasing keep side rails strength and joint
of motion to facture of structures are Function up or raised. mobility
intheextremities.- the right also affected, of the
Slowedmovement.- femoral resulting in soft extremities
Difficultyinitiatingg neck tissue edema,
ait.“diligihapon hemorrhage in -in order for the
mulihok akongtiil to the muscles - assist patient patient to become
day” as verbalized and joints, joints to do active more relax and
by the patient dislocations, ROM exercises comfortable
ruptured ten- on the lower
dons, severed extremities.
nerves, and -Provides -in order for the
damaged blood comfort muscle to be more
vessels. Body measures such relax and relieves the
organs maybe as backrub. pain
injured by the -Encourage -to relieve pain and
force that patient to stand motion sickness
caused the or walk as
fracture tolerated using
fragments. After parallel bars.
a fracture, the -Support
extremities affected body
cannot function parts or joints
properly using pillows or
because normal rolls.
functions of -administer -to develop individual
muscle depend pain reliever exercise or mobility
on the integrity such as areoxia program and identify
of the bones as prescribe by Appropriate
which they are the physician. adjunctive devices
attached -Consult with
physical or
occupational
therapist as
indicated
Definin Nursing Nursing diagnosis Outcomes Intervention Rationale
g diagnosis
charact
eristics

2. Risk Risk for The Enhance blood 2. prevent, blood to

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red bloodflow function properly of changes y in-sufficiency-
blowflo rightimmobi after afracture, inrespiratory serves as
wRisk lity thus,there rate,depth use a baseline data-
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neck dependson the areas of pallor ionmanagement
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bones towhich they auscultate breath- improvecirculati
areattached.Immobi soundsCheck if there on of blood to
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Defining Nursing Scientific basis Outcomes Interventions Rationale
characteristics diagnosis

Risk Risk A fracture occurs to produce for the patients to be free to reinforce and
for additional for addition when the stress from injury import
alinjuryright placed on a bone risk factors knowledge to
injury lossof is greater than a and protect -ascertain knowledge the patient
risk factors: skeletalinteg bone can absorb. of safety needs or injury
Loss of skeletal self from -to evaluate
rityto Muscle, blood
integrity* injury -assess muscles trength degree or source
fractureof vessels,nerves,
skeletal gross and fine of risk.
thefemoraln tendons, joints
impartment*Ab motor coordination.
eck and other organs
normal blood -for early
maybe injured -observe for signs of injury detection.
when fracture
occurs. This -identify interventions -to promote
condition may or safety devices. individual safety.
result to a loss of
-encourage participation in -to improve
skeletal integrity
rehab programs, such as skeletal integrity.
that may possibly
gaittraining
lead to
-to promote
further injury as a Promote
result education programs geared wellness
of environmental to increasing the awareness
conditions of safety measures
interacting with
the individuals
adaptive and
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resources