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 organs maybe 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 fractures that may also be described according to the anatomic placement of fragments, 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. Often, a fractured hip is a catastrophic event that will have a negative impact on the patients 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 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 1

student nurse need to insure recovery and to attend their special need efficiently and effectively. True the knowledge of this condition, a high quality of care will be provided to those people suffering from it.

II. Objectives

General Objectives: After three day of student nurse-patient interaction, the patient and the significant others will be able to acquire knowledge, attitudes and skills in preventing complications of immobility.

Specific Objectives: A. STUDENT-NURSE CENTERED After 8 hours of student nurse-patient interaction, the student nurse will be 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.

III. Nursing Assessment

1. Personal History 1.1 Patients Profile

Name: John Romuald B. Amoroto Age: 13 years old Sex: Male Civil Status: Single Religion: Roman Catholic Date and time of admission; July 9,2011 at 12:00 am Chief Complaints: Mass on the left thigh Diagnosis: Fracture Femoral left Neck

Physician: Dr. Rotor/Besa

History of Patient History of present illness\injury: Two months prior to admission, patient was kicked at his left thigh that resulted to pain and progessed to become a limb with weakness of the left lower extremity. He sought consult at a local hospital after one week due to persistent pain and given pain medications that afforded slight relief, one month prior to admission, he consulted at another hospital and was worked up with an assessment of a bone tumor where x rays, MRI, and biopsy where done. Due to persistent pain and weakness his father opted to seek at Philippine Orthopedic center and he was assessed with a fracture on the left femur probably secondary to a malignant process and admitted due to anemia.

Past Medical History: >No previous hospitalization, >No surgery >No known comorbidities Family History >No history of cancer, Hypertension nor diabetes

Personal and social History: >No known allergies >immunization was not sure to be complete

Physical examination >general survey >patient conscious and coherent not in distress >not ambulatory and cachectic >42 cm mass of the left thigh that was tender limitation of motion on the left knee.

V/S BP: 90/60 mmhg RR: 126 PR:18 Temp:36 degree celcius Ht.: 160 cm Wt: 50 kg

Examination of systems >pale palpebral conjunctiva anicteric sclera, symmetrical chest expansion, clear breath sound, abdomen flat, soft and none tender

Laboratory exams

Diagnostic test

Result

Normal values

Hemoglobin mass Hematocrit Leukocytes Lymphocytes Monocytes Eosinophils Platelets Prothrombin time Actvated PTT CRP Urea Creatinine Alkaline phosphatase LDH SCE Total protein Albumin Globulin

118 0.36 7.70 0.29 0.05 0.15 332 13.9 25.9 Reactive 3.09 mmol/L 46.38 mmol/l 278.01 343.17 u/l 67.00g/L 30.00g/L 37.00g/L

127-183g/L 0.37-0.54 4.5-10x10g/L 0.20-0.40 0.00-0.07 0.00-0.05 150-400x10g/L 11-15 sec 22-45 sec

1.70-8.30 44.00-115.00 80.00-306.00 225.00-450.00 66.00-87.00 38.00-51.00 28.00-36.00

Pathophysiology and Rationale

Normal Anatomy and Physiology of Organ/ System Affected 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 appendicular 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 diaphysis, or shaft, makes up most of the bones length and is composed of compact bone. The diaphysis is covered and protected by a fibrous connective tissue membrane, the periosteum. Hundreds of connective tissue fibers, called Sharpeys 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. Articular 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 a bit different from the rest of the bone in that area. This is the epiphyseal line. The epiphyseal line is a remnant of the epiphyseal plate (a flat plate of hyaline cartilage) seen 7

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 previous location. 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 fibers) provide for bones 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 (separrsted anteriorly by the intertrochanteric line and posteriorly by the intertrochanteric 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 bodys 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.

Schematic Diagram
Predisposing Factors: -Elderly people (85 years or older) - Trauma - Comorbidity - Malnutrition -neurologic problems - Obesity -slower reflexes Precipitating Factors: -Fall - osteoporosis -functional disability - impaired vision and balance

Damage to the blood supply to an entire bone.

Severe circulatory compromise

Avascular (ischemic) necrosis may result

Clinical Manifestations: - Pain (right up) - Loss of function - Deformity - Crepitus - Swelling and discoloration - Paresthesia - Tenderness

Nursing Management: Medical Management: - Repositioning the patient - Temporary skin traction - Promoting strengthening exercise - Bucks extension - Monitoring and managing complications - Open or closed reduction of the fracture and - Health promotion internal fixation - Relieving pain - Replacement of the femoral head with - Promoting physical mobility prosthesis (hemiarthrmoplasty) - Promoting positive psychological response to - Closed reduction with pereutaneous stabilization trauma for an intracapsular fracture. - Patient teaching Surgical Intervention: - Hip Pinning - Hip Hemiarthroplasty - Patients with hip osteonecrosis may require Hip Replacement Surgery

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.

Nursing Interventions 1. Medical and Surgical Management Temporary skin traction, Bucks extension, may be applied to reduce muscle spasm, to immobilize the extremity, and to relievepain. The findings of a recent study suggested that there is no benefit to the routine use of preparative skin traction for

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patients with hip fractures and that the use of skin traction should be based as evaluation of the individual patient. The goal of surgical treatment of hip fractures is to obtain a satisfactory fixation so that the patient can be mobilized quickly and avoid secondary medical complications. Surgical treatment consists of (1) open or closed reduction of the fracture and internal fixation (2) replacement of the femoral head with a prosthesis (hemiarthroplasty), or (3) closed reduction with pereutaneous stabilization for an intracapsular fracture. Surgical intervention is carried out as soon as possible after injury. The preoperative objective is to ensure that the patient is in as favorable a condition as possible for the surgery. Displaced femoral neck fractures may be treated as emergencies, with reduction and internal fixation performed within 12 to 24 hours after fracture. This minimizes the effects of diminished blood supply and reduces the risk for avascular necrosis. After general or spinal anesthesia, the hip fracture is reduced under x-ray visualization using an image intensifier. A stable fracture is usually fixed with nails, a nail and plate combination, multiple pins, or compression screw devices. The orthopedic surgeon determines the specific fixation device based on the fracture site or sites. Adequate reduction is important for fracture healing (the better the reduction, the better the healing). Hemiarthroplasty (replacement of the head of the femur with prosthesis) is usually reserved for fractures that cannot be satisfactorily reduced or securely nailed or o avoid complications of non-union and avascular necrosis of the head of the femur. Total hip replacement may be used in selected patients with acetabular defects.

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 as prescribed by the physician. The standard method involves placing a pillow between the patients legs to keep the affected leg in an abducted position. The patient is then turned onto the side white proper alignment and supported abduction are maintained.

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Promoting Strengthening Exercise

The patient is encouraged to exercise as much as possible by means of the overbed trapeze. This device helps strengthening the arms and shoulders in preparation for protected ambulation (e.g., toe touch, partial weight bearing). On the first postoperative day, the patient transfers to a chair with assistance and begins assisted with ambulation. The amount of weight bearing that can be permitted depends on the stability of the fracture reduction. The physician prescribes the degree of weight bearing and the rate at which the patient can progress to full weight bearing. Physical therapists work with 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 home or to an extended care facility with the use of an ambulating aid. Some modifications in the home maybe needed to permit safe use of walkers and crutches and for the patients continuing 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 promote bone3 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 health 12

care 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 improve muscle tone and balance and through the elimination of environmental hazards. In addition, the use of hip protectors that absorb or shunt impact forces may help to prevent an 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.

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 13

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-traumatic 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. * Encourages development of adaptive responses and participation in support groups. * Refer patient to psychiatric liaison nurse or refer for psychotherapy, as needed.

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 14

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- going learning process, whether self- motivated, people- oriented and having a commitment to the organization, nurses are likely to become well respected through the formal

educational programs. Through this case study, it is important to know all areas of patient are both knowledge and skills to manage effectively in all aspects of their professional nursing practice.

Nursing Research

Nursing research is essential for the development of scientific knowledge that enables nurses to provide evidenced-based health care. Broadly nursing is accountable to society for providing quality, cost effective care and for seeking ways to improve that care. More specifically, nurses are accountable to their patients to promote a maximum level of health. This case study would contribute more information and facts about fracture on the right 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 of patients with fracture on the right femoral neck. This case study could also as basis for related study and will provide facts for further research in aiming for the improvement of these patients.

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VII Referral and Follow-Up

The patient was informed to have a continuous appointment with the Rehabilitation Care Program Health Care providers after discharge. The patient was encouraged for follow-up medical supervision to monitor for union problems.

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CASE STUDY
Fracture Femoral left Neck

Submitted by: Neveen Ann A. Castro

Submitted to: Mam Josephine Barnachea

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