ST.

PAUL UNIVERSITY, QUEZON CITY

NURSING DEPARTMENT

FRACTURE AT RIGHT FEMUR - ORIF

[CASE STUDY]
ST. PAUL HOSPITAL, CAVITE

MS. JENIFFER LUALHATI

SAKAMOTO, KAREN S.

Nov. 24, 2008

I. INTRODUCTION

We as a student nurses, wellness of the patient is the primary objective. And the best way to
promote these is by means of actualization.

Fracture is any break in the continuity of bone. In some cases, a bone may fracture without
visibly breaking. Fractures occur when the bone is subjected to stress greater than it can
absorb. It can be caused by a direct blow, crushing force, sudden twisting motion, or even
extreme muscle contraction. When the bone is broken, adjacent structures are also affected,
resulting in soft tissue edema, hemorrhage into the muscles and joints, joint dislocations,
ruptured tendons, severed nerves, and damaged blood vessels. Body organs may be injured by
the force that caused the fracture or by the fracture fragments. And according to the physician
the kind of fracture that Mr. M.C experience is comminuted fracture that the bone splinters at the
site of impact, and smaller bone fragments lie between the two main fragments.
Femur is the largest and strongest bone and has a good blood supply. Because of this and its
protective surrounding muscle, the shaft requires a large amount of force to fracture. Once a
fracture does occur, this same protective musculature usually is the cause of displacement,
which commonly occurs with femoral shaft fractures. Orthopedic surgeons often encounter
femur fractures because these fractures most often result from high-energy trauma, one must
have a high index of suspension for complications or other injuries like vehicular accident that
experience by Mr.M.C. While a variety of treatment options exist for a fracture that is associated
to injury.

We have chosen Mrs. M.C with the case of fracture, comminuted at the distal third right femur
because the patient showed willingness and interest to learn and understand about her
condition. We also want to know, and understand more about his case.
General Objectives:
At the end of the study or learning, the level 3 nursing students will be able to rectify, expound,
and relate all ideas or perception to the nursing approach in doing valid and outmost care with
the patient experiencing Fracture in the right Femur and undergone ORIF procedure.

Specific Objectives:
the level 3 student nurses will be capable of:
1. Proposing the overall assessment findings with the patient experiencing Fracture in the right
Femur.
2. Expounding thoroughly and articulately the anatomy and physiology of the systems involved
in Fracture.
3. Providing illustration and explanation of the pathophysiology of the Fracture in the right
Femur with regards to the patient.
4. Devising a well planned, with the principle of SMART a comprehensive nursing care plan that
is applicable to the patient with Fracture in the right Femur.
5. Inculcating health teachings for the patient to follow and be in great help for his condition.
6. Elucidating and discuss the rationale of the different nursing interventions to the patient and
to the family as well.
7. Evaluate the effectiveness and accuracy of the outcome of the nursing interventions.
8. Providing the needed information or knowledge to attain a healthy living.
II. PERSONAL DATA

Name: Mr. MGC

Address: # 334 Hugo Perez Trece Martires Cavite
Birthday: August 18, 1979
Age: 29
Birthplace: Cavite
Nationality: Filipino

Case #: 012744
Room #: 303-C
Hosp. #: 3322

Attending Physician:
Dr. B, Dr. A, Dr. Barr, Dr. G
How admitted:
Via Stretcher
Admission Date & hour:
November 13, 2008
04:30 AM

In case of emergency, please notify:

MRS. MC
Relation: Wife
Contact # : 09164295484
III. Nursing Assessment

A. Nursing History (Gordon’s Functional Health Pattern)

Clinical Manifestations Mr. M felt numb over his lower extremity during the said vehicular
accident and all he could feel that certain time is his wound.
Health Perception / Health to Mr. M is important to him because he cannot afford not to
Health Management work since he is newly married. He sees to it that he does not get sick.
He has no previous hospitalization and no family history of any
disease or abnormality.
Nutritional / Metabolic He likes to eat vegetables and seldom eats fish and meats.
Elimination He doesn’t have a hard time voiding and defecating. He defecates
once a day. He said that it was normal for him.
Activity / Rest He doesn’t have enough hours of sleep. He sleeps 6 – 7 hours a day
because he works from 8am – 5pm Tuesday to Sunday. His work is far
from where they are living.
Cognitive / Perception His sense of smell and hearing is normal. There’s no problem but his
eyes are color blinded.
Self Perception / Self- Mr. M felt embarrassed and at the same time, ashamed because of
concept what happened to him. He felt sad because he will not be able to work
for their living because of his present condition. He is also sad and
depressed because he will be having a hard time doing his usual
routine. He used to play basketball when he has time and design
stickers.
Role / Relationship Mr. M is second among six siblings. They have no conflicts among
relatives or family members. Mr. M and his wife understand each other
and care for each other.
Sexuality/Reproductive Mr. M recently got married so they will be having a hard time in making
children because of his condition. They were planning already to have
children but they didn’t expect to have this situation.
Coping/Stress Mr. M cope his stress by talking to his friends, to his wife or fixing his
Tolerance motorcycle. Mr. M has no vices. He doesn’t smoke and he doesn’t
drink alcohols.
Values/Beliefs Mr. M follow the belief of not sweeping at night because the good luck
will go away.
B. Physical Assessment

Patient has posterior bandage of the right Femur, has pale pink nail beds on the right foot, and
complained of pain in the operative site but unfortunately, we failed to ask for the pain scale and
we did not have enough time to further assess and handle the patient.
 C. Medical History

For his past medication, we also failed to get information from the patient because we did not
have enough time and to handle the patient.

IV. History of Present Illness

2 days prior to surgery, Mr. M was on his way home at night from work via motor vehicle. There
was a road construction in the highway. He assumed that the construction truck was way far
from the excavated hole so he regulated his speed to find out that the hole was directly after the
truck. He couldn’t swerve to the other lane because there were fast cars so he fell under the
hole.

V. Anatomy and Physiology

The femur or thigh bone is the only bone in the thigh. It is the heaviest and strongest bone in the
body. Its proximal end has a ball-like head, a neck and greater and lesser trochanters. The head
of the femur articulates with the acetabulum of the hip bone in a deep secure socket.

Skeletal muscles are formed when the muscles are attached to the skeleton
or bone, which move the limbs and other parts of the body.

The muscle that is attached to the femur is known to be the Quadriceps

group, which is consisted of the rectus femoris and three vastus muscles.
All four muscles insert into tibial tuberosity via patellar ligament.

VI. Pathophysiology
VII. Medical Management
A. X-RAY

Patient was diagnosed of Fracture at the distal 3rd right Femur

B. PRE-OP MEDICATIONS

1) ketorolac tromethamine
Action: Inhibit prostaglandin synthesis, to produce anti-inflammatory, analgesic,
antipyretic effects.

Indication: short-term management of moderately severe, acute pain (for single-dose

treatment or multiple-dose treatment)

2) cefuroxime
Action: Second-generation cephalosporin that inhibits cell-wall synthesis, promoting
osmotic instability; usually bactericidal.

Indication: For bone or joint infection ; Perioperative prevention

3) ranitidine
Action: Competitively inhibits action of histamine on the H2 at receptor sites of parietal
cells, decreasing gastric acid secretion.

Indications: For active duodenal and gastric ulcer, maintenance therapy for duodenal or
gastric ulcer, pathologic hypersecretory conditions, GERD, erosive esophagitis and
heartburn.

4) Metoclopromide hydrochloride
Action: Stimulates motility of upper GI tract, increases lower esophageal sphincter tone
and blocks dopamine receptors at the chemoreceptor trigger zone.

Indication: To prevent or reduce postoperative nausea and vomiting.

5) Paracetamol
Action: Thought to produce analgesia by blocking pain impulses by inhibiting synthesis
of prostaglandin in the CNS or of other substances that sensitize pain receptors to
stimulation. The drug may relieve fever through central action in the hypothalamic heat-
regulating center.

C. HEMATOLOGY

Lab Results
HEMOGLOBIN Date: 11/12/08 10:16 pm
Release: 11/12/08 10:37 pm
Hemoglobin
NV: 140-175g/L RESULT: 139g/L

Hematocrit
NV: 0.41-0.50 RESULT: 0.41
HEMATOLOGY DATE: 11/13/08 4:50am
Release: 11/13/08 5:22 am

Hemoglobin Mass Concentration

NV: 12-17 gms% RESULT: 13gms%

Erythrocyte, Volume Fraction (Hct)

NV: 40-45 % RESULT: 39%
VIII. Surgical Procedure

An incision is made in the right thigh, exposing the fractured part of the bone. The right femur
(fractured bone) is then holed, so that the orthopedic surgeon would be able to put the
reconstruction nail into the medullary canal. Then nail were attached to secure the femoral
fracture. The screws were attached to fixate the rod
IX. Nursing Care Plan

Assessment Diagnosis Inference Planning Interventions Rationale

Subjective Acute Internal Short-term Monitor vital Alterations to

Pain fixation Goal signs Q15 normal may
“Sumasakit Related to devices to hold After 4 hours until stable be a sign of
at kumikirot Surgery the bone of and check infection.
ang incision fragment in nursing and change Moistened
inoperahan on R position interventions, dressing if dressings are
sakin,” as femur the patient: needed. favorable site
Verbalized for
by the Internal bleeding ◊ verbalizes microorganism
patient. minimized to culture.
feeling of
pain Encourage ◊ To divert
Objective Blood is ambulation attention on
associated to ◊ verbalizes or even pain and
Pain scale: swelling methods that minimal increases
(?) – failed provide relief movement circulation.
to get of
◊demonstrates unaffected
c incision It cause Acute use of part.
on the R pain relaxation
femur skills &
(ORIF- diversional Adjust ◊This is to
treated) activities as bandage if prevent
indicated for constricted Diminished
c posterior his situation and advise circulatory &
bandage on to elevate R nerve function
R femur leg. and to control
swelling of the
site.

Instruct and ◊Help to

demonstrate promote
of how to do circulation,
a deep relaxation of
breathing muscles.
exercise.

-Unable to evaluate due to we were not able to handle and talk to the patient again.
 Assessment Diagnosis Inference Planning Interventions Rationale

Subjective Impaired ORIF Short Term ◊ Assist and ◊Necessary

physical procedur Goal demonstrate to regain
◊ “Medyo di pa ako mobility of e in doing normal
makakilos ng gaya the ◊ After 3 days of exercises for mobility of
dati dahil sa nakakabit lower nursing the leg to speed
sa akin” as verbalized extremity Bleeding interventions, unaffected recovery.
related to from the patient will lower
internal damaged demonstrate extremity.
Objective fixator @ ends of proper
R femur bone & exercises of the ◊Encouraged ◊ Increase
◊ c internal fixator from unaffected progressive patient’s
@ R leg surroundi lower extremity activities Use of
ng tissue according to affected leg.
level of
fatigue
Stimulate
s intense
inflammat
ory
response

Pain

Impaired
physical
immobilit
y of the
lower R
extremity

-Unable to evaluate due to we were not able to handle and talk to the patient again.
 Assessment Diagnosis Inference Planning Interventions Rationale

Objective Risk for ORIF Short Term ◊ Stress ◊ It is a first

infection procedure Goal proper hand line of
◊ Portal of related to hygiene by defense
entry of inadequate After 2 all caregivers against
micro- primary days of between infections and
organism defenses Internal & Nursing clients. help minimize
because of such as external intervention cross
surgical broken bleeding s, the contamination
incision skin and patient will
traumatize Healing be able to ◊ Educate to ◊ To minimize
◊ Another d tissues. process of demonstrat Maintain accumulation
portal of tissues will e sterile of bacteria
entry via take quite a techniques technique and to
dressings is long time to prevent maintain
poorly risk of asepsis.
dressed. infections.

Leaving the ◊ Emphasize ◊ Premature

tissues necessity of discontinuatio
partially taking n of treatment
open antivirals / when client
antibiotics as begins to feel
directed. well may
There is a result in return
point of of infection
entry for the and potentiate
micro- drug resistant
organism to strains.
enter

-Unable to evaluate due to we were not able to handle and talk to the patient again.

X. HEALTH EDUCATION
1. Explain basis for fracture treatment and need for patient participation in therapeutic regimen.
2. Promote adjustment of usual lifestyle and responsibilities to accommodate limitations
imposed by fracture.
3. Instruct the patient to actively exercise joints above and below the immobilized fracture at
frequent intervals.
4. After removal of immobilizing device, have the patient start active exercises and continue with
isometric exercises.
5. Instruct the patient on exercises to strengthen upper extremity muscles if crutch, walking is
planned.
6. Instruct the patients in methods of safe ambulation-walker, crutcher, and cane.
7. Emphasize instruction concerning amount of weight bearing that will be permitted on
fractures extremity.
8. Discuss prevention of recurrent fracture; review safety consideration, avoidance of fatigue,
proper foot wear.
9. Encourage follow-up medical supervision to monitor for bone union problems.
10. Teach the patient to recognize and report symptoms needing attention, such as numbness,
decrease function, increase pain, or elevated temperature.
11. Encourage the patient to follow an adequate balance diet to promote bone and soft tissue
healing.

XI. CONCLUSION
Towards the end of the case study or learning, the level 3 nursing students were able to,
proposed the overall assessment findings with the patient experiencing a Fracture, comminuted
at the distal third right femur and expounded thoroughly and articulately the anatomy and
physiology of the systems involved. They were able to illustrate and explain the pathophysiology
of the Fracture, comminuted at the distal third right femur with regards to the patient, devised a
well planned, with the principle of SMART a comprehensive nursing care plan that is applicable
to the patient with Fracture, comminuted at the distal third right femur, inculcated health
teachings and elucidated and discuss the rationale of the different nursing interventions to the
patient and to the family as well. After proving the interventions, they evaluated the
effectiveness and accuracy of the outcome.