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 organsmaybe 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 fracturesthat may also be described according to the anatomic placement of fragments,particularly if they are displaced or nondisplaced. Such as greenstick fracture, depressedfracture, oblique fracture, avulsion, spinal fracture, impacted fracture, transverse fractureand compression fracture. A comminuted fracture is one that produces several bone fragments and a closedfracture 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 hassplintered to several fragments. By choosing this condition as a case study, the student nurse expects to broadenher knowledge understanding and management of fracture, not just for the fulfillment ofthe course requirements in medical-surgical nursing. It is very important for the nursesnow a day to be adequately informed regarding the knowledge and skill in managingthese conditions since hip fracture has a high incidence among elderly people, who havebrittle 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 thepatients 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 arefractures of the trochanteric region and of the subtrocanteric region.

Fractures of the neckof the femur may damage the vascular system that supplies blood to the head and the neck of the femur, and the bone may die. 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. 3

III. Nursing Assessment 1. Patients Profile Name: XXX Age: 6y/o Birthday: November 17, 2005 Sex: Female Civil Status: Single Religion: Roman Catholic Date and time of admission: November 14, 2011 Complaints: Pain in the left thigh Impression or Diagnosis: Fracture Close Complete P3 Femur Left Intervention: Steinmann pin insertion Left thigh Physician: Dr. Alitagtag Hospital No: 677097

GENERAL INFORMATION Patient is a 6 year old Female, Baptist. Grade 1 student. HISTORY OF PRESENT ILLNESS/ INJURY Few hours patient was playing on the second floor of their house when the floor informant claim for experience for experience severe pain with left thigh deformity and irritability to ambulate. PAST MEDICAL HISTORY Immunization are with her age. No major illness. PERSONAL AND SOCIAL HISTORY Patient is the youngest of 3 siblings. PHISICAL EXAMINATION General Survey y Alert y Coherent y Not in distress Other Physical Exam (+) swelling Deformity in Left deformity (+) tenderness Left thigh

Moral Development According to Kohlberg, moral development is completed in the early adult years.Most old people stay at Kohlbergs conventional development, and some are at thepreconventional level. An elderly person at the preconventional level obeys roles to avoidpain and the displeasure of others. At stage one, a person defines good and bad in relationto self, whereas older persons at stage 7 may act to meet anothers need as well as theirown. Elderly people at the conventional level follow societys rules of conduct toexpectation 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 70s, 80s, and 90s, 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 agetripping was the commonest cause in the younger patients and drop attacks in the older. Both stroke and partial sightedness were associated with falls due to loss of balance. The older patients had a very high prevalence of pyramidal tract abnormality associated with chronic brain syndromeand 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 ahistory of falls but previous fracture is equally common at this age in the fracture andcontrol series. 8

3.3. Elimination Pattern Before, the patient can freely go to the C.R. to void or defecate but now that shes hospitalized she was advised to wear diaper for her to have difficulty in standing and walking. There is no burning sensation during ur4ination and her stool is brownish formed stool. 3.4. Activity-Exercise Pattern The patient before hospitalized wakes up early in the morning for her to have fine walking around their house as her exercise. She usually guided her grandsons and granddaughters, but now, shes just on bed lying assisted by her 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 thepatient cannot read her newspaper without her eyeglasses just the same as now. Shespeaks slowly English, Tagalog and Bisaya languages as of now but before she speaksfluently all of those languages. She easily communicates, understands questions,instructions and be able to follow and answer them correctly. 3.6. Rest/ Sleep Pattern Before the hospitalization, the patient usually sleeps late at night at around 10oclock pm and wakes up early in the morning at 6 oclock am with an hour of sleep of 8hours. Now, she usually sleeps early at night (8-9 oclock pm) and wakes up at around 7oclock am with an hour of sleep of 10 hours. The patient usually stays in bed and readnewspapers sometimes, she cant take a nap in the afternoon due to her REHAB CARE. 15 3.7. Self- Perception Pattern

The patients most concern about right now is her rehabilitation care. The patientwants to stay at the hospital until she improves her mobility so she would be able to standand walk all alone by herself. The patient never loses the support of her children even ifthey were not there physically and also her private nurses. Through this, she maybe able to cope up easily from her unhealthy condition. Thetreatment, managements, medications and all out care rendered by the hospital to thepatient assured her for the improvement of her condition. 3.8. Sexuality/ Reproduction The patients husband just recently died. Now, the patient does not allow anyoneto see her getting undressed, changing diaper, changing clothes because she believes thatas 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 intheir work abroad, but they make sure they never forget to support and help their motherrecover from illness. Sometimes, the patient usually shares her concerns to her privatenurses and of course also to the student nurses. She usually reads newspaper for her to bemore relaxed. 3.10. Value-Belief Pattern The patient find source strength and hope with God and her loved ones. God isvery much important to the patient. Before, she usually goes to church together with herother children. They were not involved in any religious organizations or practices. Thepatient knows how to pray and praise God for all the nice things he had given. 16 3.11. Relationship Pattern The patient understands more on English and Bisaya languages but a little only inTagalog language. The patient was living all by herself with her private nurses butsometimes, her grandchildren will come over to visit her. She never uses the support ofher children even if they were away from their mother they always make sure that theirmother is safe and secure. The patient can easily communicate, cooperate, listen andfollow instructions easily.

movement to occur. Besides contributing to body shape and form, or bones performseveral important body functions such as support, protection, movement, storage andblood cell formation. Classification of Bones The diaphysis, or shaft, makes up most of the bones length and is composed ofcompact bone. The diaphysis is covered and protected by a fibrous connective tissuemembrane, the periosteum. Hundreds of connective tissue fibers, called Sharpeys fibers,secure the periosteum to the underlying bone. The epiphyses are the ends of the longbone. Eachepiphyses consist of a thin layer of compact bone enclosing the area filledwith spongy bone. Articular cartilage, instead of periosteum, covers its external surface.Because the articular cartilage is glassy hyaline cartilage, it provides a smooth, slipperysurface that decreases friction at joint surfaces. In adult bones, there is a thin line of bony tissue spanning the epiphyses that looksa bit different from the rest of the bone in that area. This is the epiphyseal line. Theepiphyseal line is a remnant of the epiphyseal plate (a flat plate of hyaline cartilage) seenin 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 havebeen completely replaced by bone, leaving the epiphyseal lines to marktheir 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 inweight, it has a remarkable ability to resist tension and other forces acting on it. Naturehas given us an extremely strong and exceptionally simple (almost crude) supportingsystem without up mobility. The calcium salts deposited in the matrix bone its hardness,whereas the organic parts (especially the collagen fibers) provide for bones flexibilityand great tensile strength. 19 The femur, or thigh bone, is the only bone in the thigh. It is the heaviest, strongestbone in the body. Its proximal end has a ball-like head, a neck, and greater and lessertrochanters

(separrsted 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 femurarticulates with acetabulum of the hip bone in a deep, secure socket. However, the neckof 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; thisbrings the knees in line which the bodys center of gravity. The medial course of thefemur is more noticeable in females because of the wider female pelvis. Distally on thefemur are the lateral and medial condytes, which articulates the tibia below. Posteriorly,these condytes are separated by the deep intercondylar notch. Anteriorly on the distalfemur is the smooth patellar surface, which forms a joint with the patella, or kneecap. 20

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. 22

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 asprescribed by the physician. The standard method involves placing a pillow between thepatients legs to keep the affected leg in an abducted position. The patient is then turnedonto 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 theoverbed trapeze. This device helps strengthening the arms and shoulders in preparationfor 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 withambulation. The amount of weight bearing that can be permitted depends on the stabilityof the fracture reduction. The physician prescribes the degree of weight bearing and therate at which the patient can progress to full weight bearing. Physical therapists workwith 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 homeor to an extended care facility with the use of an ambulating aid. Some modifications inthe home maybe needed to permit safe use of walkers and crutches and for the patientscontinuing 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 promotebone3 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 healthcare 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 improvemuscle tone and balance and through the elimination of environmental hazards. Inaddition, the use of hip protectors that absorb or shunt impact forces may help to preventan 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. 27 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.

VI. Evaluation and Implication of this case study to: Nursing Practice The result of this case study would provide the student nurse with sufficient knowledge, attitude and skills towards the management of patients with fracture on the right femoral neck. This study would help the student nurse in providing a higher quality of care of patients with the same condition. It is important that the proper and ideal managements and interventions are done in order to give a more holistic approach and optimum care to clients with fracture on the right femoral neck. This would ensure the timely healing of injury and the prevention of complications. Nursing Education

Education can promote enhancement of professionalism through an on- goinglearning process, whether self- motivated, people- oriented and having a commitment tothe organization, nurses are likely to become well respectedthrough the formaleducational programs. Through this case study, it is important to know all areas of patientare both knowledge and skills to manage effectively in all aspects of their professionalnursing practice. Nursing Research Nursing research is essential for the development of scientific knowledge thatenables nurses to provide evidenced-based health care. Broadly nursing is accountable tosociety for providing quality, cost effective care and for seeking ways to improve thatcare. More specifically, nurses are accountable to their patients to promote a maximumlevel of health. This case study would contribute more information and facts about fracture on theright femoral neck. This could contribute to the development of the case study of fracture its prevention, causes, signs and symptoms, and nursing management. Hopefully, this case study will lead to development of new skills and new approaches to the care ofpatients with fracture on the right femoral neck. This case study could also as basis forrelated study and will provide facts for further research in aiming for the improvement ofthese patients. VII Referral and Follow-Up The patient was informed to have a continuous appointment with theRehabilitation Care Program Health Care providers after discharge. The patient wasencouraged for follow-up medical supervision to monitor for union problems.