THEORETICAL BACKGROUND

OF FIBULAR TIBIA FRACTURE (CRURIS)

A. CONCEPT OF DISEASE
1. Anatomy and Physiology Overview

Picture 1. Anatomy Fibular Tibia

1) Tibia (shin)
This bone includes the long bones, so it consists of three parts:
 Epiphysis proximalis (upper end)
This section widens transversally and has a superior joint surface on
each condylus, the medial condylus and lateral condylus. In the
middle there is an elevation called eminenta intercondyloidea.
 Diaphysis (corpus)
In the cross section is a triangle with a peak facing face, so that the
corpus has three sides, namely anterior margo (on the face), medial
margin (on the medial) and interristsea crista (lateral) which limits
lateral facies, posterior facies and medial facies The medial condition
is directly under the skin and anterior margin next to the proximal.
 Epiphysis distalis (lower end)
Medially this part is strong protruding and is called the medial
malleolus (ankle). The distal epiphysis has three plains of joints,
namely the vertical joint plate (articular melleolaris facies),
horizontal joints (inferior articular facies) and lateral joints (fibularis
incisures).
2) Fibula

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 It is a long, slender bone, located lateral to the tibia. Rounded
Epiphysis proximalis is called the fibulae capitulum. Proximal tapering
towards apex. In the capitulum there are two plains of joints called the
fibular capitulli articidal facies, for jointed with the tibia. In the corpus
there are four crista, namely, lateral crista, anterior crista, medial crista
and crista interosssea. There are three plains, namely lateral facies, medial
facies and posterior facies. In the distal lateral to rounded into the lateral
malleolus.
According to Long, B.C, bone function in general is:
1) Hold body tissue and give shape to the body frame.
2) Protect body organs (example: skull protects brain)
3) For movement (the muscle attaches to the bone to contract and move).
4) A warehouse for storing minerals (eg calcium and phosphorus)
5) Hematopoiesis (the place for making red blood cells in the bone marrow).
According to Price, Sylvia Anderson, bone growth and metabolism are
affected by minerals and hormones:
1) Calcium and bone phosphorus contain 99% of the body's calcium and
90% phosphorus. Calcium and phosphorus concentrations are maintained
in inverse relationships, calcitonin and parathyroid hormones work to
maintain balance.
2) Calcitonin is produced by the thyroid gland where thyrocalsitonin also
has an effect to reduce osteoclast activity, to see increased osteoblast
activity and the longest is to prevent new osteoclast formation.
3) Vitamin D affects bone deposition and absorption. Large amounts of
vitamin D can cause bone absorption as seen in high levels of parathyroid
hormone. If there is no vitamin D, parathyroid hormone will not cause
bone absorption while vitamin D in small amounts helps classification of
bones by increasing absorption of calcium and phosphate by the small
intestine.
4) Parathyroid hormone, has a direct effect on bone minerals which causes
calcium and phosphate to be absorbed and move through the serum.
Increased levels of parathyroid hormone slowly cause an increase in the
number and activity of osteoclasts resulting in demineralization. Increased
serum calcium levels in hyperparathyroidism can lead to kidney stone
formation.

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 5) Growth Hormone (growth hormone), secreted by the anterior lobe of the
pituitary gland which is responsible for increasing bone length and
determining the number of bone matrices formed before puberty.
6) Gluicocorticoids, adrenal glucocorticoids regulate protein metabolism.
This hormone can increase or decrease catabolism to reduce or increase
the matrix of bone organs and assist in regulation of calcium absorption
and phosphorus from the small intestine.
7) Estrogen stimulates osteoblast activity. Decreasing estrogen after
menopause reduces the activity of osteoblasts which causes a decrease in
the bone organ matrix. Bone classification has an effect on osteoporosis
that occurs in women before age 65 but it is the organic matrix that is the
cause of osteoporosis.
2. Definition

Picture 2. Fibular Tibia Fracture (Cruris)

Fractures or fractures are the breakdown of continuity of bone and
cartilage tissue which is generally caused by forced ruda.
The cruris fracture is a breakdown of bone continuity and is
determined according to the type and extent, occurring in the tibia and fibula
bone. Fractures occur when the bone is subjected to greater stress than can be
absorbed.
The cruric fracture is a condition of disconnection of the tibia and
fibula bone. In clinical conditions, fractures of the cruris can be closed and
fractures open when accompanied by damage to the soft tissues (muscles,
skin, nerve tissue, blood vessels) so as to allow a connection between broken
bone fragments and outside air caused by an injury from direct trauma that
about the foot. (Muttaqin, 2008)
There are four main categories of fractures:
1) Incomplit

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 Fractures that only involve crossed sections of bone.
2) Complit
The fracture line involves the entire crossing of the bone and bone
fragments usually change or shift (shift from the normal position).
3) Closed
The fracture does not expand and does not cause tearing of the skin.
4) Open (compound)
The bone fragment extends beyond the muscle and there is injury to the
skin which is divided into 3 degrees:
Degree 1: less than 1 cm wound, slight soft tissue damage, no crushing,
simple fracture or mild comminution and minimal
contamination.
Degree 2: lacerations of more than 1 cm, soft tissue damage, not
extensive, moderate comminutive fractures, and moderate
contamination.
Degree 3: extensive soft tissue damage (skin, muscle, and neurovascular
structure) and high degree of contamination.
3. Etiology
According to (Rasjad, 2009) the most important cause of fibular tibia
fracture is caused by a blow that bends the knee joint and rips the medial
ligament of the joint, a direct impact on the tibia such as a traffic accident,
and fragility of the bone structure. The causes of known fractures are as
follows:
1) Direct trauma
Fractures caused by a direct impact on bone tissue such as a traffic
accident, falling from a height, and the impact of hard objects by direct
force.
2) Indirect (indirect) trauma
Fractures that are not caused by a direct impact, but rather caused by an
excessive burden on bone or muscle tissue, for example as in sportsmen
or gymnasts who use only one hand to support their body weight.
3) Pathological trauma
Fractures caused by disease processes such as osteomyelitis,
osteosarcoma, osteomalacia, cushing syndrome, cortisone / ACTH
complications, osteogenesis imperfecta (congenital disorders that affect
osteoblast formation). Occurs because of weak and easily broken bone
structure.

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 a. Osteoporosis occurs because the speed of bone reabsorption exceeds
the speed of bone formation, so that the bones become porous and
brittle and can experience fractures.
b. Osteomilitis is a bone and bone marrow infection caused by pyogen
bacteria where microorganisms originate from focus elsewhere and
circulate through blood circulation.
c. Ostheartritis is caused by damaged or thinning joint pads and
cartilage
4. Signs and Symptoms
The clinical manifestations of fibular tibia fracture are:
1) Great pain in the fracture area, and increases when pressed / touched.
2) Not able to move legs.
3) Deformity occurs due to changes in the position of bone fragments. Can
form angles because of the pressure of unification and imbalance of
muscle drive. It can also shorten lower extremity because of the pull of
the lower extremity muscle when the fragments slip and overlap with
other bones. And it can also occur rotationally due to unbalanced pulling
by the muscle attached to the bone fragment so that the fracture fragment
rotates out of its normal longitudinal axis.
4) The presence of crepitus (palpable by the presence of bone rattle) is
caused by friction between one fragment and another.
5) Ecchymosis or subcutaneous bleeding caused by damage to blood vessels
so that blood seeps under the skin around the skin area.
6) Swelling and discoloration of the skin due to extravasation of blood and
tissue fluid around the fracture area.
5. Pathophysiology
Fractures can occur due to trauma / involuntary so that they can cause
open and closed wounds. Open wound fractures make it easier for
microorganisms to enter the wound and will cause infection.
In the fracture can result in the breakdown of continuity of joint tissue,
bone even the skin in the open fracture so as to stimulate the surrounding
nociseptor to release histamine, bradykinin and prostatglandin which will
stimulate A-delta fibers to deliver pain stimulation to the spinal cord, then
delivered by fibers afferent nerves that enter the spinal through the "dorsal
root" and synapse on the dorsal horn. Pain impulses cross the rear in the
interneurons and continue with the ascending spinal pathway, the
spinothalamic tract (STT) and spinoreticuler tract (SRT). STT is a

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discriminatory system and carries information about the nature and location of
the stimulus to the thalamus then to the cortex to be interpreted as pain.
Pain can stimulate the autonomic nervous system to activate
norepinephrine, hope msimpatis is stimulated to activate RAS in the
hypothalamus to activate the work of organs so that REM decreases causing
sleep disturbances.
As a result of the pain causing limitations of movement
(immobilization) due to increased pain when moved and pain also causes
reluctance to move, including toiletening, causing faecal buildup in the colon.
Colon reabsorbs faecal fluid so that faeces become dry and hard and
constipation arises.
Immobilization itself results in a variety of problems, one of which is
pressure sores, which are injuries to the skin due to suppression that is too
long in the bone promenence area.
Structural changes that occur in the body and feelings of threat to body
integrity, are psychological stressors that can cause anxiety.
Disconnection of the continuity of joint or bone tissue can result in
neuro vascular injury resulting in edema also resulting in changes in the
alveolar membrane (capillary) so that lung enlargement occurs and then there
is damage to gas exchange, resulting in shortness of breath as compensation
for the body to meet oxygen needs.

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6. Pathway

7. Supporting Diagnostic
1) Rongent examination: Determine the area or location at least 2 times the
projection, anterior, posterior lateral.
2) Bone CT scan, MRI program: To clearly see the area that is damaged.
3) Arteriogram (if vasculer damage occurs)
4) Capillary blood count
 HT may increase (hema concentration) increases or decreases.
 Increased creatinine, drug trauma, increased keratin in the kidneys.
5) Ca calcium levels, Hb
8. Medical Management
The basic concepts that must be considered when dealing with
fractures are recognition, reduction, retention, and rehabilitation.
1) Recognition / Introduction
The history of the incident must be clear to determine the diagnosis and
subsequent actions.
2) Reduction / Manipulation / Reposition
That is an attempt to manipulate bone fragments so that they return to
their original state optimally. The reduction method is divided into:

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a. Closed Reduction; done by returning bone fragments to their position
(the edges are interconnected). The equity is maintained in the
desired position while the cast, splint or other tool. The
immobilization tool will maintain reduction and stabilize the
extremities for bone healing. X-rays must be done to find out whether
the bone fragments are in the correct alignment.
b. Traction; a tool that can be used to pull fractured limbs to straighten
bones. The weight of traction is adjusted for muscle spasms that
occur.
 Skin traction is to pull the fractured part of the bone by putting
plaster directly on the skin to maintain the shape, helping to
cause muscle spasm in the injured part and is usually used for
short periods (48-72 hours).
 Skeletal traction is traction used to straighten injured bones and
long joints to maintain traction, severing pins (wires) into the
bone.
 Maintenance traction is a continuation of traction, advanced
strength can be given directly to the bone with wire or pins.
c. Open reduction: performed by surgically reduced bone fragments.
Internal fixation devices in the form of pins, wires, screws, nail plates,
or metal bars are used to maintain bone fragments in their position
until solid bone healing occurs. This tool can be placed on the side of
the bone or directly into the bone marrow cavity, the tool maintains
strong approximation and fixation for bone fragments.
 OREF (External Open Reduction Fixation) is an open reduction
with internal fixation where the bone is transfixed above and
below the fracture, the screw or wire is transfused in the proximal
and distal part and then connected to one another with a stem.
This external fixation is used to treat open fractures with soft
tissue damage. This tool provides stable support for communitive
fractures (crushed or crushed). The attached pin is maintained so
that its position is maintained, then linked to the frame. This
fixation provides a sense of comfort for patients who have
damaged bone fragments.
 ORIF (Open Reduction Internal Fixation) is a method of
managing fractures by means of open reduction surgery and
internal fixation where an incision is carried out at the site of

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 injury and is found along the anatomic plane where the fracture
occurs.
3) Retention / Immobilization
An attempt is made to hold the bone fragments back optimally.
Fracture immobilization. After the fracture is reduced, the bone
fragments must be immobilized, or maintained in the correct
alignment position until unification occurs. Immobilization can be
done by external or internal fixation. External fixation methods
include bandages, casts, splints, continuous traction, pins and cast
techniques, or external fixators. Metal implants can be used for
internal fixation which acts as an internal splint to immobilize
fractures.
4) Rehabilitation
Aim to restore as much functional activity as possible to avoid
atrophy or contractures. If conditions permit, exercises must be
started to maintain limb strength and mobilization.
9. Bone Healing Process
1) Hematoma or Inflammatory Stage (1-3 days)
Hematomas are formed from blood originating from torn blood vessels.
Hematoma is wrapped by surrounding soft tissues (periosteum and
muscle). This happens around 1-2 x 24 hours.
2) Proliferation Stage (3 days - 2 weeks)
Cells proliferate from the inner layer of the periosteum around the fracture.
These cells become precursors of osteoblasts, and will grow towards bone
fragments. Proliferation also occurs in bone marrow tissue.
3) Kallus Stage (2-6 weeks)
Osteoblasts form soft bones (kallus) and give rigiditation to fractures. If
you see the kallus mass on X-ray it means the fracture has fused.
4) Ossification Stage / hardened soft tissue (3 weeks-6 months)
The Kallus hardens and closes the fractal hole (fracture gap) between the
periosteum and the cortex attaches the fragment. And gradually the bones
become mature. Union bones that can be ascertained by X-ray are said to
have occurred when there is no movement with light stress and no
tenderness with pressure directly on the direct area.
5) Consolidation and Remodeling Phase (6 months - 1 year)

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 Unnecessary kallus is removed / reabsorbed from the recovered bone. The
process of reabsorption and storage of bone along the fracture line
provides bone strength in holding all loads.
10. Complications
1) Initial complications;
Compartemant Syndrome: This complication is very dangerous because it
can cause lower ecstatic vascularization disorders which can threaten the
survival of lower extremities. The mechanism of tibial fracture is intra-
compartmental bleeding, this will cause intracompartment pressure to rise,
causing backflow of venous blood to be disrupted. This will cause edema.
In the presence of edema, intracompartment pressure rises to the end so
high that it clogs arteries in the intracompartment. Symptoms of lower
extremity pain and paraesthesia, pain will increase if the finger is moved
passively. If this lasts long enough paralyzes can occur in the extensor
hallusis longus muscles, extensor digitorum longus and anterior tibial.
2) Complications for a long time:
 Malunion: In a situation where a broken bone has healed in a
position that is not supposed to. Malunion is bone healing
characterized by increasing levels of strength and deformity.
 Delayed Union: is a healing process that continues to run at a
slower speed than normal. Delayed union is a fracture failure
consolidating according to the time it takes the bone to connect.
This is caused by a decrease in blood supply to the bone.
 Non Union: is a fracture failure consolidating and producing a
complete, strong, and stable connection after 6-9 months. Non-
union is characterized by excessive movement on the side of the
fracture that forms a fake joint or pseuardoarthrosis. This is also
caused by poor blood flow.

B. NURSING CARE PLAN

1. Assessment
a. Medical History
1) Main complaint
In general, the main complaint in the case of a fracture is pain. The
pain can be acute or chronic depending on the duration of the attack.
To obtain a complete assessment of client pain, use:

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  Provoking Incident: is there an event that becomes a factor of
precipitation pain.
 Quality of Pain: what kind of pain a client feels or describes. Is it
like burning, pulsing, or piercing.
 Region: radiation, relief: whether the pain can subside, whether
the pain spreads or spreads, and where pain occurs.
 Severity (Scale) of Pain: how far the pain is felt by the client, can
be based on the pain scale or the client explains how far the pain
affects the ability of its function.
 Time: how long the pain lasts, when, does it get worse at night or
during the day.
2) Current medical history:
Assess the chronology of the trauma that causes cruris fractures, what
help is obtained, whether it has been treated at a shaman or broken
bone. In addition, by knowing the mechanism of the occurrence of
accidents, nurses can find out other injuries. The presence of knee
trauma is indicated by proximal tibial fracture. The angulation trauma
will cause a converse or short type of fracture, while rotational trauma
will cause a spiral type. The main cause of fracture is a land traffic
accident.
3) Past medical history:
In some circumstances, clients who have sought treatment from a
traditional midwife often experience union malls. Certain diseases
such as bone cancer or cause pathological fractures so that the bones
are difficult to connect. In addition, diabetic clients with sores are very
at risk of developing acute and chronic osteomyelitis and diabetes
inhibits bone healing.
4) Family medical history:
Family disease associated with cruris fractures is one of the
predisposing factors for fractures, such as osteoporosis that often
occurs in several offspring and bone cancer which tends to be
genetically inherited.
2. Physical Examination
Divided into two, namely general examination (generalized status) to
get a general description and local examination (localist). This is necessary to
be able to carry out total care because there is a tendency where specialization
only shows a narrower area but is more profound.

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1) General condition:
 Awareness of the patient: apathy, sopor, coma, anxiety, compost
depends on the client's condition.
 Pain, disease conditions: acute, chronic, mild, moderate, severe and in
cases of fractures usually acute.
 Vital signs are not normal because there are disorders of both function
and form.
2) Systemically from head to genetal:
 Integumentary system: There is erytema, temperature around the area
of increased trauma, swelling, edema, tenderness.
 Head: There are no disorders, namely, normo cephalik, symmetrical,
no protrusion, no headache.
 Neck: There is no disturbance that is symmetrical, there is no
protrusion, there is swallowing reflex.
 Face: The face appears to hold pain, others have no changes in
function or form. There are no lesions, symmetrical, not edema.
 Eyes: There are no disorders such as the conjunctiva not anemic
(because there is no bleeding)
 Ears: Tests whisper or weber are still normal. There are no lesions or
tenderness.
 Nose: No deformity, no respiratory nostrils.
 Mouth and pharynx: There is no enlargement of the tonsils, the gums
don't bleed, the oral mucosa is not pale.
 Thorax: There is no intercostae muscle movement, symmetrical chest
movements.
 Lungs: Inspection, breathing increases, whether or not regular
depends on the history of the client's disease associated with the
lungs; Palpation, same or symmetrical movements, fermitus feels the
same; Percussion, sonor sound, no erup or other additional sounds;
Auscultation, normal breath sounds, no wheezing, or other additional
sounds such as stridor and ronchi.
 Heart: Inspection, does not appear heart jaundice; Palpation, the pulse
increases, the iktus is not palpable; Auscultation, single S1 and S2
sounds, no murmur.
 Abdomen: Inspection, flat, symmetrical, no hernia; Palpation, tugor
is good, there is no muscular defands, the liver is not palpable;

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 Percussion, the sound of thympani, there is a reflection of fluid
waves; Auscultation, normal intestinal peristalsis 20 times / minute.
 Inguinal-Genetalia-Anus: No hernia, no lymphatic enlargement, no
difficulty with bowel movements.
3) Musculoskeletal system
a. Look (inspection)
 Cictriks (both natural and artificial scarring such as scars).
 Cape au lait spot (birth mark).
 Fistulae.
 Color redness or blueness or hyperpigmentation.
 Lumps, swelling, or basins with unusual (abnormal) things.
 Position and form of extremity (deformity)
 Road position (gait, when entering the examination room)
b. Feel (palpation)
At the time of palpation, the position of the patient is repaired first
starting from the neutral position (anatomical position). Basically this
is an examination that provides two-way information, both examiners
and clients. What needs to be noted is:
 Changes in temperature around trauma (warm) and skin moisture.
 If there is swelling, is there fluctuations or edema especially
around the joints.
 Tenderness (tenderness), crepitus, note the location of the
abnormality (1/3 proximal, middle, or distal). Muscle: tone at the
time of relaxation or contraction, a lump found on the surface or
attached to the bone. In addition, neurovascular status was also
examined. If there is a lump, then the nature of the lump needs to
be described its surface, consistency, movement of the base or
surface, pain or not, and its size.
c. Move
After checking the feel, then proceed with moving the extremities
and note whether there are complaints of pain in the movement.
Recording of the scope of this movement is necessary, in order to be
able to evaluate the conditions before and after. Joint movements are
recorded with degrees, from each direction of movement starting
from point 0 (neutral position) or in metric size.

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 This check determines whether there is a movement disorder
(mobility) or not. The movements seen are active and passive
movements.
3. Supporting Diagnostic
1) X-ray examination
2) Bone CT scan, MRI tomogram
3) Arteriogram (if vasculer damage occurs)
4) Capillary blood count
5) Levels of calcium Ca, Hb
4. Nursing Diagnosis
1) Acute pain r.t muscle spasm, movement of bone fragments, edema, soft
tissue injury, traction installation, stress / anxiety.
2) Risk for peripheral neurovascular dysfunction r.t decreases blood flow
(vascular injury, edema, thrombus formation).
3) Impaired gas exchange r.t changes in blood flow, embolism, alveolar /
capillary membrane changes (interstitial, pulmonary edema, congestion).
4) Impaired physical mobility r.t neuromuscular skeletal damage, pain,
restrictive therapy (immobilization).
5) Impaired skin integrity r.t open fracture, installation of traction (pen, wire,
screw).
6) Risk for infection r.t the inability of primary defense (skin damage, soft
tissue taruma, invasive procedures / bone traction).
5. Nursing Intervention
No Nursing Dx Goals & Criteria Intervention Rationale
Results
1 Acute pain r.t  Goals: The client 1. Maintain immobilisation 1. Reducing pain and
muscle spasm, says the pain is of the affected part with preventing
movement of reduced or lost. bed rest, casts, stabs and malformations
bone  Criteria: Clients / or traction. 2. Increases venous
fragments, will show relaxed 2. Elevate the position of return, reduces edema /
edema, soft actions, be able to the affected limb. pain.
tissue injury, participate in 3. Do and monitor passive / 3. Maintain muscle
traction activities, sleep, active motion exercises. strength and improve
installation, rest properly, 4. Take action to improve vascular circulation.
stress / anxiety show the use of comfort (massage, 4. Promotes general
relaxation skills change of position) circulation, relieves

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 and therapeutic 5. Teach the use of pain areas of local pressure
activities as management techniques and muscle fatigue.
indicated for (deep breathing 5. Turns attention to pain,
individual exercises, visual improves control of
situations. imagination, disional pain that may last a
activities) long time.
6. Do cold compresses 6. Reduces edema and
during the acute phase reduces pain.
(the first 24-48 hours) as 7. Reducing pain through
needed. central and peripheral
7. Collaboration of giving pain inhibitory
analgesics as indicated. mechanisms.

2 Risk for  Goals: The client 1. Encourage clients to 1. Promotes blood

peripheral will show good routinely practice circulation and
neurovascular neurovascular moving the fingers / prevents joint
dysfunction r.t function. distal joints of injury. stiffness.
decreases  Criteria: Akral 2. Avoid circulation 2. Prevent venous stasis
blood flow warm, not pale restrictions due to and as a clue to the
(vascular and syanosis, can excessive pressure / need to adjust the
injury, edema, move actively. spalk. tight / spalk tightness.
thrombus 3. Maintain a high 3. Increases venous
formation). extremity injury unless drainage and
there is a decreases edema
contraindication to the except in the presence
presence of of a blockage of
compartment syndrome. arterial flow which
4. Give anticoagulant causes a decrease in
drugs (warfarin) if perfusion.
needed. 4. May be given as a
5. Monitor the quality of prophylactic attempt
peripheral pulse, to reduce venous
capillary flow, skin thrombus.
color and the warmth of 5. Evaluate the
distal skin injury, development of client
compare with the problems and the

15
 normal side. need for interventions
according to the
client's
circumstances.

3 Impaired gas  Goals: The client 1. Instruct / help deep 1. Promotes alveolar
exchange r.t will show that breathing exercises and ventilation and
changes in oxygenation effective cough perfusion.
blood flow, needs are met exercises. 2. Reposition increases
embolism,  Criteria: No 2. Do and teach changes in secretion drainage
alveolar / shortness of a safe position and decreases
capillary breath, no according to the pulmonary
membrane cyanosis of blood circumstances of the 3. Prevent blood clots in
changes gas analysis client. thromboembolic
(interstitial, within normal 3. Collaboration of conditions.
pulmonary limits administration of Corticosteroids have
edema, anticoagulant drugs shown success in
congestion). (warvarin, heparin) and preventing /
corticosteroids as overcoming fat
indicated. embolism.
4. Analyze the 4. Decrease in PaO2 and
examination of blood increase in PCO2
gases, hemoglobin, indicates disruption
calcium, LEDs, fat and of gas exchange;
platelets. anemia,
5. Evaluate the frequency hypocalcemia,
of breathing and increased LED and
breathing effort, note lipase levels, blood
the presence of stridor, fat and decreased
use of accessory platelets are often
respiratory muscles, associated with fat
retinal retraction and embolism.
central cyanosis. 5. The presence of
tachypnea, dyspnea
and mental changes is
an early sign of

16
 respiratory
insufficiency, it may
indicate early stage
pulmonary embolism.

4 Impaired  Goals: Clients 1. Maintain the 1. Focus attention,

physical implementation of increase your sense
can increase /
mobility r.t therapeutic recreational of self control / self-
maintain mobility
neuromuscular activities (radio, esteem, help reduce
skeletal at the highest newspapers, friends / social isolation.
damage, pain, family visits) according 2. Promotes
level which may
restrictive to the circumstances of musculoskeletal
be able to
therapy the client blood circulation,
(immobilizatio maintain a 2. Help passive range of maintains muscle
n) motion exercises in tone, maintains joint
functional
sick and healthy motion, prevents
position to
extremes according to contractures / atrophy
improve strength the client's and prevents calcium
circumstances. reabsorption due to
/ function that is
3. Give a foot support, immobilization.
sick and
roll the trochanter / 3. Maintain the
compensate for hand as indicated. functional position of
4. Help and encourage the limb.
body parts.
self-care (cleanliness / 4. Increase the
 Criteria: Clients elimination) according independence of
can show to the circumstances of clients in self-care
the client. according to the
techniques that
5. Change position conditions of client
enable activities periodically according limitations.
to the circumstances of 5. Reducing the
the client. incidence of skin and
6. Push / maintain fluid respiratory
intake of 2000-3000 ml complications
/ day. (pressure sores,
7. Give the TKTP diet. atelectasis,
8. Collaboration with pneumonia)

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 physiotherapy as 6. Maintain adequate
indicated. hydration, prevent
urinary
complications and
constipation.
7. Adequate calories
and protein are
needed for the
healing process and
maintain the
physiological
functions of the
body.
8. Collaboration with
physiotherapists
needs to develop
individual physical
activity programs.

5 Impaired skin  Goals: The client 1. Maintain a comfortable 1. Reducing the risk of
integrity r.t declares lost and safe bed (dry, wider skin damage /
open fracture, inconvenience clean, tight loom, lower abrasion.
installation of  Criteria: Clients elbow pads, heels). 2. Increases peripheral
traction (pen, show technical 2. Massage the skin, circulation and
wire, screw) behavior to especially the increases the skin
prevent skin protrusion area of the and muscular weight
damage / bone and the distal area of the pressure that is
facilitate healing of stiffness / casts. relatively constant in
as indicated, 3. Protect the skin and immobilization.
achieve wound casts on the perianal 3. Prevent disruption of
healing according area skin and tissue
to time / healing 4. Observation of the state integrity due to
of lesions occur of the skin, press cast / faecal contamination.
weight against the skin, 4. Assess the
pen / traction insertion. development of client
5. Keep the skin dry and problems.

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 clean. 5. Continuous wet skin
6. Advise the client to use triggers irritation that
thin, dry clothes that leads to dikubitus.
absorb sweat and are 6. Prevent skin irritation
free of wrinkles. and improve
7. Collaboration in giving evaporation.
foam and wind beds. 7. Prevents over-
suppression of tissues
that can limit cellular
perfusion, thereby
reducing tissue
ischemia.

6 Risk for  Goals: Clients 1. Perform sterile pen care 1. Prevent secondary
infection r.t the achieve healing and wound care infections and
inability of wounds according to the accelerate wound
primary according to protocol. healing.
defense (skin time. 2. Teach clients to 2. Minimizing
damage, soft  Criteria: Free maintain the sterility of contamination.
tissue taruma, purulent drainage pen insertion. 3. Broad-spectrum or
invasive or erythema and 3. Collaboration with specific antibiotics
procedures / fever tetanus antibiotics and can be used
bone traction) toxoids as indicated. prophylactically,
4. Analysis of laboratory preventing or
results (Complete overcoming
blood count, LED, infections. Tetanus
culture and wound / toxoid to prevent
serum / bone tetanus infection.
sensitivity) 4. Leukocytosis usually
5. Observation of vital occurs in the process
signs and signs of local of infection, anemia
inflammation in the and increased LED
wound. can occur in
osteomyelitis.
Culture to identify
infectious organisms.

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 5. Evaluating the
development of client
problems.

20
 BIBLIOGRAPHY

E. Oswari. 2011. Bedah dan Perawatannya ,cetakan VI. Jakarta: EGC

Keliat Anna Budi, SKp, MSC. 2010. Proses Keperawatan. Jakarta: EGC
Muttaqin.A. & Sari. K. 2008. Asuhan keperawatan perioperatif, Konsep, Proses dan
Aplikasi. Jakarta: Salemba Medika.
Priharjo Rasional. 2009. Perawatan Nyeri Untuk Paramedis, edisi revisi. Jakarta:
EGC.
Rasjad Chaeruddin, Ph. D. Prof. 2009. Ilmu Bedah Orthopedi, cetakan IV. Makassar:
Bintang Lamumpatue.
Reksoprodjo.S. 2010. Kumpulan Kuliah Ilmu Bedah. Bagian Ilmu Bedah. Jakarta:
Fakultas Kedokteran UI.

Approve by,
Clinical Instructor Clinical Teacher

( _____ ) (Ahmad Juliadi,Ns.,M.Kep)

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