fractured femur case study

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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 ex t re me m u sc l e c on t ra c ti on s . W he n t he b o n e i s b ro ke n , a dj ac e n t st r uc t u re s a re a l s o aff ected, 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. Th e re a re d i ff e re nt t yp e s of fr ac t u re s an d t he se i nc l u de , co m p l e t e f ra c tu re , 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 fte n, a f ra ct u re d hi p i s a c at a st ro p h i c e ve n t t ha t w i l l ha ve a n e g a ti ve i m pa c t o n th e p a ti e n t’ s l i fe s ty l e a n d q ua l i ty of l i fe . T he re a re tw o m aj or t y pe s of h i p fr ac t u re . 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 effi ciently 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 . i m p l e m e n t h o l i s t i c n u r s i n g c a re i n t h e c a r e o f p a t i e n t u t i l i z i n g t h e n u r s i n g 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. Extracapsular 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 characteristics

Nursing diagnosis

Scientific basis

Expected outcome

Nursing intervention

Rationale

Difficulty in changing position while lying on bed.Difficultyin movingtheextre mities.-Inability to walk or stand alone.limitedrange of motion intheextremitie s.Slowedmoveme nt.Difficultyinitiati nggait.“diligiha pon mulihok akongtiil day” as verbalized by the patient

Impaired physical mobility, inability to standalon e related to skeletal impairme nt to facture of the right femoral neck

Fractures occur when the bone is subjected to stress greater that it can absorb. When the bone is broken, adjacent structures are also affected, resulting in soft tissue edema, hemorrhage in to the muscles and joints, joints dislocations, ruptured tendons, severed nerves, and damaged blood vessels. Body organs maybe injured by the force that caused the fracture fragments. After a fracture, the extremities cannot function properly because normal functions of muscle depend on the integrity of the bones which they

After 8hours nursepatient interventio n the patient will be able to: Demonstra te increasing Function of the extremities

-Promote adequate mobility of the client.

to avoid patients from falling to sudden movements

- instruct the to keep side rails up or raised.

-to improve muscle strength and joint mobility

assist patient to do active ROM exercises on the lower extremities. -Provides comfort measures such as backrub. -Encourage patient to stand or walk as tolerated using parallel bars. -Support affected body parts or joints using pillows or rolls. -administer pain reliever such as areoxia as prescribe by the physician. -Consult with physical or

-in order for the patient to become more relax and comfortable

-in order for the muscle to be more relax and relieves the pain -to relieve pain and motion sickness

-to develop individual exercise or mobility program and identify Appropriate adjunctive devices

are attached

Defini ng chara cteris tics

Nursing diagnosis

Nursing diagnosis

Outcomes

occupational therapist as indicated

Intervention

Rationale

2. Risk for alt ered blowfl owRis k Facto r:Imm obilit y

Risk for altered bloodflow rightimmo bility tofracture of the rightfemo ralneck

Defining characteristi cs

The extremitiescann ot function properl y after afracture, thus,there isimmobility bec ause normalfunction of themuscle dependson the integrityof the bones towhich they areattached.Im mobility of a body part may possiblyint errupt thecirculation of blood throughthe circuitousnetwor k of arteries andveins

Nursing diagnosis

Scientific basis

Enhance circulation

Outcomes

blood

2. prevent, blood emboli-note signs of changes inrespiratory rate,depth use of accessorymus cles purled-lip breathing; Note areas of pallor or cynosis.auscultate breat h-soundsCheck if there isa decrease or adventitious b reath soundsas well asfremitusmonitor italsigns andcardiac rhythm-review risk factorsreinforce needfor adequaterest, whileencouragin gactivities withinclientslimit ationencouragefreque nt positionchang es andDBE or coughingexerc ise.-administer m edications asindicated

Interventions

to assessrespira tory insufficiencyserves as a baseline data-note for anychangesto promote prev entionmanag ement of risk -to improvecircul ation of blood to the bodysystems. -to treatunderlyi ngconditions

Rationale

Risk for additiona l injury risk factors: Loss of skeletal integrity* skeletal impartment* Abnormal bl ood

Risk for additio nalinjuryri ght lossof skeletalint egrityto fractureof thefemor alneck

A fracture occurs when the stress placed on a bone is greater than a bone can absorb. Muscle, blood vessels,nerves , tendons, joints and other organs maybe injured when fracture occurs. This condition may result to a loss of skeletal integrity that may possibly lead to further injury as a result of environmen tal conditions interacting with the individuals adaptive and defensive resources

to produce risk factors and protec t self from injury

for the patients to be free from injury -ascertain knowledge of safety needs or injury -assess muscles trength gross and fine motor coordination. -observe for signs of injury -identify interventions or safety devices. -encourage participati on in rehab programs, such as gaittraining Promote education programs geared to increasing the awareness of safety measures

to reinforce and import knowledge to the patient -to evaluate degree or source of risk. -for early detection. -to promote individual safety. -to improve skeletal integrity. -to promote wellness

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