1

INTRODUCTION
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 nondisplaced. Such as greenstick fracture,
depressed fracture, oblique fracture, avulsion, spinal fracture, impacted fracture,
transverse fracture and compression fracture.
comminuted fracture is one that produces several bone fragments and a
closed fracture or simple fracture is one that not causes a break in the skin.
Comminuted fracture at the Left Proximal Middle 3rd Femur is a fracture in which bones
has splintered into several fragments. Often, a fractured bone is a catastrophic event
that will have a negative impact on the patient's life style and quality of life.
s we apply this condition to my patient, she has fracture in the proximal part of
the femur caused by vehicular accident. She is Raiza Marie Tungol Nuque, a 4 years
old child from 44--Reyes P-3 Lower Bicutan, Taguig City. She was admitted at
Philippine Orthopedic Center last March 5, 2011 with a chief complaint of pain in the
thigh and leg. The patient was under the supervision of Dra. palisoc.




2

OBJECTIVES
eneral Objectives:
fter student nurse-patient interaction, the patient and the significant others will
be able to acquire knowledge, attitudes and skills in preventing complications of
immobility such as bed sores, pneumonia, deep vein thrombosis, atelectasis, etc. in
order to improve patient's condition.
Specific Objectives:
1. To gather patient's information and to know past and present history of the
patient
2. To have knowledge about the disease of the patient
3. Review the anatomy and physiology of the organ affected
4. Discuss the pathophysiology of the condition
5. To identify the signs & symptoms of the condition manifested by the patient
6. To provide holistic care appropriate for the patient's condition
7. To impart health teaching to the patient and family members of how to care
for a patient with fracture












3

PATIENT'S PROFILE
Name: Raiza Marie Tungol Nuque
Address: 44--Reyes P-3 Lower Bicutan Taguig City
Age: 4 years old
Sex: Female
CiviI Status: Child
ReIigion: Roman Catholic
NationaIity: Filipino
Date and Time of Admission: March 5, 2011 @ 6:00 pm
Room No.: Cubicle 5 @ Children's Ward
CompIaints: Pain at the left thigh with swelling
Impression or Diagnosis: Fracture Close-Comminuted Proximal Middle
3
rd
Femur Left
Physician: Dr. palisoc
Institution: Philippine Orthopedic Center







4

ISTORY OF PAST AND PRESENT ILLNESS

. PST HSTORY
ccording to the patient's mother, Raiza had experienced minor illnesses like
common colds, fever and coughs. nd whenever she had this signs and
symptoms, it was relieved by OTC drugs that are being bought by her mother.
Her mother added that she never been hospitalized before the accident
happened.
B. PRESENT HSTORY
Few hours prior to admission, Raiza's mother was washing their clothes while she
was playing with her scooter outside their house at 44--Reyes P-3 Lower Bicutan,
Taguig City when suddenly a jeepney reached her place and allegedly hit her feet.
Raiza sustained multiple abrasions on her left and right lower extremities and felt pain
on her right thigh. So, her mother immediately brought her to the Philippine Orthopedic
Center and was subsequently admitted.
During the admission day, she undergone X-ray, Complete Blood Count,
Prothrombin Time and Physical ssessment. The X-ray reveals the location and
severity of the affected bone. On the other hand, the CBC reveals low hematocrit count-
0.31, increase leukocyte count of 22.20 x 109/L, low Hemoglobin of 98 g/L, and
increased Platelet count of 605 x 10^9/L. The Prothrombin time of the patient is 16.5
seconds which is increased. nd lastly, the physical exam reveals multiple abrasions in
both lower extremities and swelling at the right thigh.








5

PEARSON ASSESSMENT

March 29, 2011 TUESDY
7-8 am
March 30, 2011 WEDNESDY
9-10 am
pril 1, 2011 FRDY
7-8 am

- my patient's name is Raiza Marie
Tungol Nuque, a 4 years old girl
who lives at Lower Bicutan, Taguig
City.
- admitted last March 5, 2011 @
6pm with chief complaint of pain on
her thigh.
- verbal response: responded well,
answers questions properly, and
was oriented.
- motor response: responded well
at upper extremities, right leg is
hard to flex.
- with wound covered with sterile
gauze and cleansed with hydrogen
peroxide on her right leg.
- abrasions found on her feet.

- received patient lying on bed,
conscious and coherent
- verbal response: responded well,
answers questions properly and
was oriented.
- no complaints of pain or other
problems noted.

- received patient sitting on
wheelchair with 1 Spica Cast,
conscious and coherent.
- with complaint of itchiness inside
the applied cast.
6

- psychosocial development:
PRE-SCHOOL (nitiative VS. uilt)
URNE OUTPUT:
>Frequency: 1 slightly soaked
diaper
>Color: yellowish output
>Transparency: turbid

BOWEL ELMNTON:
>Frequency: 1
>Consistency: formed
>Color: yellowish-brown output

- No perspiration noted during the
shift
URNE OUTPUT:
>Frequency: 1 diaper
>Color: yellowish output
>Transparency: turbid

BOWEL ELMNTON:
>Frequency: 0
>Consistency: --
>Color: --
URNE OUTPUT:
>Frequency: 0
>Color: --
>Transparency: --

BOWEL ELMNTON:
>Frequency: 0
>Consistency: --
>Color: --



7

CTVTES:
- limited movement due to traction
applied.
- assisted by the mother during
hygiene time and elimination.
- assisted by mother in changing
clothes.
- she don't want to eat rice.

REST ND SLEEP:
- she slept 10 hours last night.
- comfortable when sleeping.
- with one pillow under the head.
- with 6-8 hours of sleep with
waking-up pattern.
- with frequent nap at day time.
CTVTES:
- limited movement due to traction
applied.
- assisted by the mother during
hygiene time and elimination.
- assisted by mother in changing
clothes.
- she has good appetite, eats rice.
- talking actively with other patients
and to the student nurse.
- active in drawing and interpreting
it to me.
REST ND SLEEP:
- she slept 11 hours last night.
- comfortable when sleeping.
- with one pillow under the head.
- with 6-8 hours of sleep with
waking-up pattern.
CTVTES:
- limited movement due to cast
applied
- assisted by the mother during
hygiene time and elimination, and
wound cleaning.
- assisted by mother in changing
clothes.
- active and jolly.

REST ND SLEEP:
- she slept 7 hours last night.
- uncomfortable due to fibreglass
cast that has applied last night.
- with complaint of itchiness.
- with 6-8 hours of sleep with
waking-up pattern.
8

- BLOOD TYPE: "O

- TEMP: 36 C/xilla
- RR: 30 cpm
- HERT RTE: 134 bpm
- No known allergies to any foods
and medications.
- no side rails.

-MEDCTONS:
~Multivitamins + ron Syrup 5ml
OD

- BLOOD TYPE: "O
- TEMP: 36.2 C/xilla
- RR: 33 cpm
- HERT RTE: 137 bpm
- No known allergies to any foods
and medications.
- no side rails.

-MEDCTONS:
~Multivitamins + ron Syrup 5ml
OD

- BLOOD TYPE: "O
- TEMP: 36 C/xilla
- RR: 31 cpm
- HERT RTE: 132 bpm
- No known allergies to any foods
and medications.
- no side rails.

-MEDCTONS:
~Multivitamins + ron Syrup 5ml
OD

9

- RR:30 (normal range)
- HR: 134 bpm
- Capillary refill- 2 sec.
- No O
2
supplementation
- No nasal discharges.
- No nasal polyps.
- RR:33 (normal range)
- HR: 137 bpm
- Capillary refill- 2 sec.
- No O
2
supplementation
- No nasal discharges.
- No nasal polyps.
- RR:31 (normal range)
- HR: 132 bpm
- Capillary refill- 2 sec.
- No O
2
supplementation
- No nasal discharges.
- No nasal polyps.
- Diet as tolerated
- Doesn't want rice
- no VF attached
- PRESCRBED: high calorie &
high calcium and junk foods
- PREFFERED: high fat
- RESTRCTED: none
- Diet as tolerated
- no VF attached
- PRESCRBED: high calorie &
high calcium
- PREFFERED: high calorie & fat
- RESTRCTED: none
- Diet as tolerated
- no VF attached
- PRESCRBED: high calorie &
high calcium
- PREFFERED: high fat & calorie
- RESTRCTED: none
10

ACTUAL DIAGNOSTIC EXAMS

HEMTOLOY
PArAMETERS NORMAL 1ST LAST INDICATION
Hemoglobin
Mass
127-183g/L 97 129 Before, the hemoglobin is decrease
which may indicate various anemias,
pregnancy,
severe or prolonged hemorrhage,
and with excessive fluid intake at
present it is normal already
Hematocrit 0.37-0.54 0.31 0.40 Before it is Decreased, may indicate
severe anemias, anemia, acute
massive blood loss, but now it is in the
normal range
Leukocyte
Count
4.5-10x10^9/L 25.9 7.20 Before it is increased, may indicate
acute infections,trauma or surgery,
leukemia,
malignant disease, necrosis; decreased
with viral infections, bone marrow
suppression, primary bone marrow
disease, but now it is already in the
normal range
Defferential
Count

Segmenters 0.50-0.70 0.45 Normal
Lymphocytes 0.20-0.40 0.40 Normal
Monocytes 0.00-0.07 0.04 Normal
Eosinophils 0.00-0.05 0.11 increased may indicate allergy, parasitic
disease, collagen disease, subacute
infections;

Reticulocytes 0.5-2%
Platelet Count 150-
400x10^9/L
629 377 ncreased may indicate malignancy,
myeloproliferative disease, rheumatoid
arthritis,
and postoperatively; about 50% of
patients with unexpected increase of
platelet count will be found to have a
malignancy, at present is is noe on its
normal range
Coaglation
Studies

Prothrombin
Time
11-15secs 16.5 12 Prolonged by deficiency of factors , ,
V, V, and X, fat malabsorption,severe
liver disease, coumaDin anticoagulant
therapy. Present cbc shows normal
Prothrombin time
% 70-120
11

ctivity
ctive PTT
RH typing
CRP
Semi-
quantitative
CRP
<6mg/L
MCV 82-92fL 86 Normal
MCH 28-32 28 Normal
MCHC 32-38% 32 Normal
BIood type: "o















IDEAL DIAGNOSTIC PROCEDURES
12

COMPLETE BLOOD COUNT- s used as a broad screening test to check for such
disorders as anemia, infection, and many other disease
Many patients will have baseline CBC tests to help determine their general health
status. f they are healthy or they have cell populations that are within normal limits,
then they may not require another CBC until their health status changes or until their
doctor feels taht it is necessary.

PARAMETERS NORMAL
Hemoglobin Mass 127-183g/L
Hematocrit 0.37-0.54
Leukocyte Count 4.5-10x10^9/L
Defferential Count
Segmenters 0.50-0.70
Lymphocytes 0.20-0.40
Monocytes 0.00-0.07
Eosinophils 0.00-0.05
Reticulocytes 0.5-2%
Platelet Count 150-400x10^9/L
Coaglation Studies
Prothrombin Time 11-15secs
% 70-120
ctivity
ctive PTT
RH typing
CRP
Semi-quantitative CRP <6mg/L
MCV 82-92fL
MCH 28-32
MCHC 32-38%
X-RAY/RADIOGRAP- is a non-invasive medical test that helps physicians diagnose
and treat medical conditions. maging with x-rays involves exposing a part of the body to
13

a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays
are the oldest and most used frequently used form of medical imaging.
O are important in evaluating patients with musculoskeletal disorders. Bone films
determine bone density, texture, erosion and changes in bone relationships.
Multiple x-ray views are needed for full assessment of the structure being
examined. X-ray of the cortex of the bone reveals the presence of any widening,
narrowing, and signs of irregularity. Joint x-rays will reveal the presence of fluid,
irregularity, spur formation, narrowing and changes in the joint structure.

URINALYSIS- is a used as a screening and/or diagnostic tool because it can help
detect substances or cellular material in the urine associated with different metabolic
and kidney disorders. t is ordered widely and routinely to detect any abnormalities that
require follow up. Often, substances such as protein or glucose will begin to appear in
the urine before patients are aware that they may have a problem. t is used to detect
urinary tract infections and other disorders of the urinary tract. n patients with acute or
chronic conditions, such as kidney disease, the urinalysis may be ordered at intervals
as a rapid method to help monitor organ function, status, and response to treatment.
COMPUTED TOMOGRAPY SCAN AND MAGNETIC RESONANCE IMAGING- it
shows the extent of the fracture damage, how the fragment of the bone is misaligned,
shows the soft tissue around the bone which help to detect injury to nearby tendons and
ligaments, shows evidence of cancer, shows swelling or bruising within the bone, shows
occult fractures before they appear on x-rays.
O CT SCAN- shows in detail a specific plane of involved bone. t can be useful in
orthopedic diagnosis by revealing tumors of the soft tissue or injuries to the
ligaments or tendons. t is helpful in identifying the location and the extent f
fractures in areas difficult to define like the acetabulum. Studies may be
performed with or without contrast and last about an hour.
O MRI- is a non-invasive, special imaging technique that uses magnetic fields,
radiowaves, and computers to demonstrate abnormalities such as tumors,
narrowing of tissue pathways through bone of soft tissue as muscle, tendon, and
cartilage. Because an electromagnetic is used, patient with any metal implants,
braces or facemakers are not allowed for this procedure.

BONE SCANNING- imaging procedure that involves use of radioactive substance
called technetium- 99 labelled pyrophosphate. Occult fractures are detected 3-5 days
after the injury. f pathogenic fracture is suspected bone scan help to check the
problems of the bones, ones that might not be producing symptoms
14

O Reflex the degree to which the matrix of the bone takes up a bone seeking
radioactive isotope that is injected into the system. The scan is done 4-6 hours
after the isotope injection.




















Anatomy &
physioIogy

15

The femur is a long bone whose axis of movement is well outside of its
substance for most of its length. The thigh bone, extending from the hip to the knee of
four- and two-legged vertebrates, including humans. The femur is the largest, longest,
and strongest bone of the human skeleton. ts rounded, smooth head fits into a socket
in the pelvis called the acetabulum to form the hip joint (an example of a ball-and-socket
joint). The head of the femur is joined to the bone shaft by a narrow piece of bone
known as the neck of the femur. The neck of the femur is a point of structural weakness
and a common fracture site. The lower end of the femur hinges with the tibia (shinbone)
to form the knee joint.

The femur can be felt through the skin at two sites. t the lower end, the bone is
enlarged to form two lumps called the condyles that distribute the weight-bearing load
on the knee joint. On the outer side of the upper end of the femur is a protuberance
called the greater trochanter. The gluteus and psoas muscles are inserted on the
greater and Iesser trochanter, respectively. The IateraI and mediaI epicondyIes
articulate with the tibia and the trochIear groove accommodates the patella (kneecap).
CompIete fracture lines involves entire cross-section of the bone, and bone fragments
are usually displaced.
CIosed the fracture does not extend trough the skin.
16

Comminuted fracture a fracture in which the bone is broken into more than two
pieces. crushing force is usually responsible and there is often extensive injury to
surrounding soft tissues.


















PATOPYSIOLOGY
Vehicular accident

17

Patient was hitted by a jeepney

Thigh received direct violent trauma

Middle third bone of the femur breaks across the entire cross section
X-RY
Bone splintered into several fragments

Muscles are destroyed and undergo muscle spasm which pulls the fragments in
different positions

Blood vessels and marrow of the bone are disrupted

Tissues are damaged

Bleeding occurs

nflammation

Pain, deformity, loss functions, shortening of the leg, crepitus, swelling and discoloration
NTERVENTONS

Steinman Pin nsertion via eneral naesthesia 90-90 traction


1 HP SPC CST
EXPLANATION
Trauma is the most common cause of fracture. The trauma is caused by
vehicular accidents. The amount and direction of the force will vary from accident to
accident resulting from violent direct trauma are either comminuted or multiple. Muscles
are attached to the bones, once the bones are destroyed, muscles tend to go through
spasm which is the reason why the splintered fragments of the bone moves away or will
18

be scattered, in this case , the middle third of the femur is damaged, the proximal bone
is displaced due to muscle spasm. Blood vessels and the bone marrows are also
destroyed due to trauma occurred, tissue damage causes bleeding. side from
bleeding, inflammation occurs. Pain, deformity, loss function, shortening of the leg,
crepitus, swelling and discoloration occurs.
nsertion of Steinman pin is done. Skeletal Traction was also applied to the
patient, specifically 90-90 traction for more than a month and applied a cast,
specifically 1 Hip Spica cast.





















MANAGEMENT
MEDICAL AND SURGICAL MANAGEMENTS
a. MEDCL MNEMENT

19

1. TRCTON
O is the act of pulling and drawing which is associated with counter traction.
O This is used to keep aligned while the fracture heals. n array of ropes, pulleys,
and weights are used to continuously pull on the limb.
O Skeletal Traction is used using Steinman pin with holder
O 90-90 is used, and it is indicated for fracture f the proximal 3
rd
of the femur
O The patient is under 4lbs traction weight bag
O She is under traction for more than a month.

2. CST
O s made by wrapping rolls of plaster or fiberglass strip that harden once wetted.
Plaster often used for the initial cast when a displaced fracture is being treated
O Fiberglass cast is applied to the patient
O 1 hip spica cast was applied to affected area.

3. MEDCTONS
O CO-MOXCLV
O PRCETMOL 250mg, 5ml q 4 hours for temperature of more than 37.8C
O SCORBC CD SYRUP 5ml


b. SURCL MNEMENT

IDEAL
O OPEN REDUCTION INTERNAL FIXATION- the fracture fragments are reduced
through the use of internal fixation devices in the form of metallic pins, wire,
screws, plates, nails or rods, which maybe attach to the sides of bone or inserted
through the bony fragments or directly into the medullary cavity of the bone.

ACTUAL
O STEINMAN PIN INSERTION- Steinman pin is inserted t the left distal third femur
by Dr. Badies under eneral naesthesia. V sedation by Dr. Yabyabin.






PROMOTIVE AND PREVENTIVE MANAGEMENT

. PROMOTVE MNEMENT

O Provide a safe and conducive environment for fast recovery which is free from
sources of stress which may cause anxiety and potential pathogens which may
cause infection.
20

O Encourage and assist in passive range of motion exercises to prevent stiffness

and increase the strength of the muscles not only of the affected but of the
unaffected limbs as well.
O Encourage patient to eat protein-rich food to promote wound healing.
O nstruct patient to avoid unnecessary movement of the fractured extremity
O Observe aseptic technique in caring for the wound


B. PREVENTVE MNEMENT

O void playing alone outside the house and without supervision
O Refrain from overusing the affected lower extremities to prevent another fracture
and further complications
O Encourage intake of high calorie and high calcium diet to help faster recovery
O Observe motor vehicles around the patient's environment
O Let patient play in a motor vehicle free area to avoid accident
O Exercise the unaffected extremities to sustain strength







21

Nursing care pIan

CUES DIAGNOSIS ANALYSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective:

"Nahihirapan na
nga siya eh, gusto
na daw umuwi.
s verbalized by
the patient's
mother.

Objective:

>Limited ROM
>Decreased
muscle strength
and control
>Unable to walk
due to traction
applied
>With fair skin
>With Steinmann
pin inserted at
proximal middle
3
rd
of the
femur(90-90
traction)
>No signs of
swelling at
Steinmann pin site

P- mpaired
physical mobility
related to pain and
discomfort and
physiologic
immobility
E- Pain and
discomfort and
physiologic
immobility
S- s evidenced
By:

>Limited ROM
>Decreased
muscle strength
and control
>Unable to walk
due to traction
applied
>With fair skin
>With Steinmann
pin inserted at
proximal middle
3
rd
of the
femur(90-90
traction)
>No signs of

Vehicular accident



Strong force
causes femoral
fracture and
muscle spasm



Damage bone
nerve ending



mpaired Physical
Mobility

fter 4 hours of
rendering
appropriate
nursing
interventions, the
client will improve
muscle strength
and do some
range of motions
on the extremities
to prevent atrophy.

INDEPENDENT:
>sses degree of
immobility produced by
injury/treatment and
note client's perception
of immobility.





>Encourage
participation in
diversional/recreational
activities such as
drawing, playing toys
on bed. Maintain
stimulating
environment; such as
radio, TV, newspapers,
personal
possessions/pictures,
clock Calendar visits,
from family/friends.



>nstruct client


>Client may be
restricted by self-
perception out of
proportion with
actual physical
limitations
requiring
interventions to
promote progress
toward wellness.

>Provides
opportunity for
release of energy,
refocuses
attention,
enhances client's
sense of control
and aids in
reducing social
isolation.







GOAL MET
fter 4 hours of
rendering
appropriate
nursing
interventions, the
client
demonstrated
increase muscle
strength as
evidenced by
demonstrating
some range of
motion exercises
on the extremities.
22

>Needs
assistance in
doing DL's.


swelling at
Steinmann pin site
>Needs
assistance in
doing DL's.

in/assist with
active/passive ROM
exercises of affected
and unaffected
extremities.







>Encourage of
isometric
exercises starting with
the unaffected limb.





>Provide footboard,
wrist splints,
trochanter/hand rolls
as appropriate.




>Place in supine
position periodically if
possible when traction
is used to stabilized


>ncreases blood
flow to muscles
and bone to
improve muscle
tone and maintain
joint mobility,
prevent
contractures and
atrophy and
calcium resorption
from disuse.


>sometrics
contract muscles
without bending
joints or moving
limbs and help
maintain muscle
strength and mass.


>Useful in
maintaining
functional position
of extremities,
hands/feet and
preventing
complications.

>Reduces risk of
23

lower limb fractures.

>nstruct in/encourage
use of trapeze and
"position for lower
limb fractures.












>ssist with self care
activities (e.g., bathing,
brushing.)








>Monitor blood
pressure with
resumption of activity.
Note reports of
flexion contracture
of femur.



>Facilitates
movement during
hygiene/ skin care
and linen changes,
reduces discomfort
of remaining flat in
bed. Post position
involves placing
the injured foot flat
on the Bed with
the knee bent
while grasping the
trapeze and lifting
the body off the
bed.

>mproves muscle
strength and
circulation,
enhances client's
respiratory function
and prevents
complications such
as respiratory
pneumonia, etc.


>Postural
24

dizziness.





>Reposition
periodically and
encourage coughing or
breathing exercises.



>uscultate bowel
sounds. Monitor
elimination habits and
provide for regular
bowel routine. Place
on bedside commode,
if feasible, or use
fracture pan. Provide
privacy.






>Perform a thorough
assessment of client's
condition prior to
bowel habits.

hypotension is a
common problem
following
prolonged bed rest
and may require
specific
interventions
(gradual elevation
to upright position).

>Prevents and
reduces incidence
of skin and
respiratory
complications.


>Bed rest, use of
analgesics and
changes in dietary
habits can slow
peristalsis and
produce
constipation.
Nursing measures
that facilitate
elimination may
prevent
complications.


>To help in tissue
repair.
25

>Encourage increased
fluid intake to 2000-
3000 mL/day.






>Provide diet high in
proteins,
carbohydrates,
vitamins and minerals.














Constipations in
orthopedic clients
is a major issue
and needs
immediate and
ongoing attention.



>Keeps the body
well hydrated,
decreasing risk of
urinary infection,
stone formation
and helps prevent
constipation.


>n the presence
of musculoskeletal
injuries, early good
feeding is needed
as nutrients
required for
healing are rapidly
depleted. This can
have a profound
effect on muscle
mass, tone and
strength. Protein
foods increase
contents in small
bowel, resulting in
26

>ncrease the amount
of roughage/fiber in
the diet. Limit gas
forming foods.






Collaborative:

>Consult with
physical/occupational
therapist and/or
rehabilitation
specialist.








>Refer to
dietician/nutrition team
gas formation and
constipation.
Therefore,
gastrointestinal
function should be
fully restores
before protein
foods and
increased.

>dding bulk to
stool helps prevent
constipation. as
forming foods can
cause abdominal
distention
especially in
presence of
decreased
intestinal mobility.



>Used in creating
aggressive
individualized
activity program.
Client may require
log term
assistance with
movement,
strengthening and
weight-bearing
27

as indicated.








>nitiate bowel
program (stool
softeners, enemas,
laxatives) as indicated.



>Refer to psychiatric
clinical nurse
specialist/therapist as
indicated.
activities as well as
use of adjuncts.

>Clients with
fractures
especially when
associated with
trauma may have
special nutritional
considerations to
maximize healing
of bones and
tissues.


>mportant to
promote regular
bowel evacuation
and prevent
constipation.


>Client may
require more
intensive treatment
to delay with reality
of current
condition,
prolonged
immobility, and
perceived loss of
control.

28

Drug study
NAME OF
DRUG
DOSAGE &
FREQUENCY
ACTION INDICATION CONTRAINDICATION ADVERSE &
SIDE EFFECTS
NURSING
RESPONSIBILITIES
29

1. CEFOLN 250mg V
NST(-) as
loading dose
- bind to
bacterial cell
wall membrane,
causing cell
death.
- treatment of
skin and skin
structure
infections
(including burn
wounds), bone
and joint
infections.
- hypersensitivity to
cephalosphorins
- serious sensitivity to
penicillins
- CNS: seizures (
doses)
- :
pseudomembranous
colitis, diarrhea,
nausea, vomiting,
cramps
- DERM: rashes,
urticaria
- HEMT: blood
dyscrasias,
hemolytic anemia
- ssess patient for
infection (V/S:
appearance of wound,
urine and stool, WBC)
at beginning & during
therapy.
- Before initiating
therapy, obtain a
history to determine
previous use of and
reactions to penicillins
or cephalosphorins.
Persons with a
negative history of
penicillin sensitivity
may still have an
allergic response.
2. BUPROFEN 250mg/ 5ml 5ml
BD PRN for
pain
- inhibits
prostaglandin
synthesis.
-decreased pain
and
inflammation
- reduction of
fever.
- mild to
moderate pain
or
dysmenorrhea
- lowering of
fever.
- hypersensitivity
- active bleeding or
ulcer disease.
- CNS: headache,
dizziness,
drowsiness, psychic
disturbances
- EENT: amblyopia,
blurred vision,
tinnitus
- CV: arrhythmias,
edema
- : bleeding,
hepatitis,
constipation,
dyspepsia, nausea,
vomiting, abdominal
discomfort
- U: cystitis,
- assess pain (note
type, location, &
intensity) prior to and
1-2 hr following
administration.
- advise client to take
ibuprofen with a full
glass of water and to
remain in an upright
position for 15-30 min
after administration.
-
30

hematuria, renal
failure
- DERM: rashes
- HEMT: blood
dyscarias,
prolonged bleeding
time
3. PRCETMOL 250mg/ 5ml 5ml
q 4 for T> 37.8
C
- inhibits the
synthesis of
prostaglandins
that may serve
as mediators of
pain and fever,
primarily in the
CNS
- analgesia
- antipyresis
- mild pain
- fever
- previous
hypersensitivity
- products containing
alcohol, aspartame,
saccharin, sugar, or
tartrazine should be
avoided in patients who
have hypersensitivity or
intolerance to this
compounds.
- : hepatic failure,
hepatotoxicity
(overdose)
- U: renal failure
(high doses/chronic
use)
- DERM: rash,
uticaria
- assess overall health
status and alcohol
usage before
administering
acetaminophen.
Malnourished patients
or chronic alcohol
abusers are at higher
risk of developing
hepatotoxicity with
chronic use of usual
doses of this drug.
- FEVER: assess
fever; note presence
of associated signs
(diaphoresis,
tachycardia, etc.)
4. SCORBC
CD SYRUP
5ml syrup OD - For delayed
fracture or
wound healing
- treatment &
prevention of
Vit. C deficiency
- tartrazine
hepersensitivity
- CNS: drowsiness,
fatigue, headache,
insomnia
- : cramps,
diarrhea, hearturn,
nausea, vomiting
- U: kidney stones
- DERM: flushing
- follow 10 rights of
drug administration
- document any signs
of over dose such as
decrease level of
consciousness, etc.
31

5.
MULTVTMNS
+ RON SYRUP
5ml Syrup &
hold ascorbic
acid
- prevents and
treat nutritional
vitamin ad
mineral
deficiency.
ncrease body
resistance
against disease.
- abdominal
discomfort,
epigastric distress,
reactions, peptic
ulcerations,
headache, nausea,
vertigo.

- take detailed drug
history prior to
initiation of therapy.
Observe signs of
allergic response in
those with aspirin or
NSD sensitivity. Lab
test should be done.
Monitor therapeutic
effectiveness.

32

DISCARGE PLANNING
O Multivitamins iron syrup
O Calcium 1 tab od x 30 days
O Follow strict medication compliance
O void not following schedules of medication to
prevent drug-resistance
O Follow proper order dose of drugs to achieve drug
reactions
O void OTC drugs that is not prescribed by the
physician
O Passive Rom exercises:
- Simple stretching
- Moving he affected leg
- Circular motion of the affected foot`
- Have rest periods during physical activities
- Do deep breathing exercises
O Strict medication compliance
O ntake of vitamin c and d to strengthen immune
system and in helping bone growth
O ssistance of the family for physical therapy or
activities of the patient
O Continuous passive rom exercises

O Strict medication compliance do physical therapy
and passive rom exercises
O Promote proper wound cleaning
O Promote hand washing to prevent infection
O Promote proper nutrition
O ntake of vitamin c and d to strengthen immune
system and in helping bone growth
O Monitor signs and symptoms of infection
O Monitor complications
O o for follow-up check up and update health by
going to regular check-up
O Continue medications as prescribed by the doctor






33

O Diet as tolerated
O ncrease Calcium and protein intake







O nstruct patient to keep his wound dressing clean
and dry
O Monitor signs and symptoms of infections
O Monitor for complications
O nstruct patient to have passive range of motion
exercise
O nstruct patient to ask assistance when doing such
things
O nstruct patient not to go outside the house when
alone
O nstruct patient to avoid areas with lot of motor
vehicles
O nstruct patient to see motor vehicles around her

















UPDATES
34

Three-Quarters of ip Fracture Patients Are Vitamin D Deficient, Indian Study

ReveaIs
$cienceDaily (Dec. 13, 2010) New Delhi researchers show that vitamin D levels may
be a useful index for the assessment of hip fracture risk in elderly people.

study in New Delhi ndia has revealed high rates of vitamin D deficiency among
hip fracture patients, confirming the conclusions of similar international studies which
point to vitamin D deficiency as a risk factor for hip fracture.
group of 90 hip fracture patients was compared to a matched control group of
similar age, sex and co-morbidity. Of the patients who had suffered hip fractures, 76.7%
were shown to be vitamin D deficient as measured by serum 25(OH)D levels of less
than 20 ng/ml. n addition, 68.9% had elevated PTH levels. n comparison, only 32.3%
of the controls had vitamin D deficiency and 42.2% had elevated PTH levels (secondary
hyperparathyroidism).
Vitamin D deficiency has been linked to the pathogenesis of osteoporosis and is
increasingly thought to play a role in muscle strength, certain cancers, multiple sclerosis
and diabetes. Vitamin D levels are very low in the ndian population in all age groups,
and could be explained by skin pigmentation, traditional clothing and the avoidance of
sunlight.
The results of the New Delhi study confirm that serum 25 (OH)D levels may be a
useful index for the assessment of risk of hip fracture in elderly people.
The study (OC13) was presented at the OF Regionals -- 1st sia-Pacific
Regional Osteoporosis Meeting being held in Singapore from December 10-13, 2010.










BibIiography
35

O BOOKS
Bare, Brenda . and Smeltzer, Suzzane C., Textbook of Medical-Surgical
Nursing. 10
th
Edition Philadelphia: .B Lippincott Company. 2004.

Nettina, Sandra M., Manual of nursing Practice. 7
th
Edtion. .B. Lippincott
Company. 2001.

Rozler, Barbara et al. Fundamentals of Nursing. 5
th
Edition. Newyork: ddison-
Weatleylongman, ncorporated. 1998.

Marleb, Elaine N. Essential of Human natomy and Physiology. 7
th
Edition.
Singapore. Pearson Education South sia Pte. Ltd. 2004.

Potter, Patricia and Perry, nne. Fundamentals of Nursing. 6
th
Edition Baltimore:
C.V. Mosby and Company. 2005.

Doenges, M., Moorhouse, M.F. , eissler Murr, . " Nurses Pocket uide,
Diagnosis, interventions and rationales, 9
th
Edition (2004).

Doenges, M., Moorhouse, M.F. , eissler Murr, ., " Nursing Care Plans.
uidelines for ndividualizing Patient Care. 6
th
Edition. F.. Davis
Company, 2002.

O INTERNET

http://www.scribd.com/doc/19800479/Case-Study-Fracture

http://www.britannica.com/bps/media-view/101308/0/1/0

http://www.pediatric-orthopedics.com/Topics/Bones/Femur/femur.html