CAPITOL UNIVERSITY COLLEGE OF NURSING

A CASE STUDY ON

Open Reduction Internal Fixation of Distal Fibular Fracture

IN PARTIAL FULFILLMENT OF RELATED LEARNING EXPERIENCE 70 GROUP 3

Submitted to: Ms. Jessele Janioso, RN, MN

Submitted by: Kwesi Gem L. Yasay Jocef Ian D. Rama

Clients Profile.

I.
1 BIOGRAPHICAL DATA

- Patient X is a 54 year old, female, Married, a Roman Catholic, presently residing at Cagayan de Oro City. 2. CHIEF COMPLAINT - Patient was admitted at Capitol University Medical City (CUMC) with a chief complaint of distal fibular fracture.

3. HISTORY OF PRESENT ILLNESS - Patient X had a fracture in her right distal fibula due to a slip accident. 4. WHAT HAPPENED DURING THE OPERATION? - Pre-operative antibiotics, +/- interscalene block
General endotracheal anesthesia Modified beach-chair position. All bony prominences well padded. Examination under anesthesia of affected shoulder. Prep and drape in standard sterile fashion. Have a well-padded height adjustable Mayo stand or shoulder positioner available to hold the arm during the case. Deltopectoral incision from just medial to AC joint to just lateral to the proximal edge of the biceps muscle belly. Identify deltopectoral interval (interval can be found by palpating medial edge of deltoid insertion into clavicle or finding fat layer in interval surrounding cephalic vein.) Preserve cephalic vein by ligating any branches to deltoid and taking the cephalic vein and its surrounding tissues medially. Incise clavipectoral fascia adjacent to the conjoined tendon up to the coracoacromial ligament. Release upper 1/3 of pectoralis tendon if needed for exposure. Ensure the anterior humeral circumflex vessels are protected and preserved. Identify the long head of the biceps tendon and ensure that it is preserved thoughtout the case. Identify the fracture fragments. The key to identifying the various components is the long head of the biceps tendon. The lesser tuberosity and subacapularis tendon are medial to the long head tendon. The greater tuberosity and supraspinatus are lateral. Generally splinting the rotator interval between the tuberosities provides adequate exposure to the proximal humerus. Mobilize the tuberosity fragments. Tag them with suture as needed. Gently identify the humeral head fragment, being careful to avoid any neurovascular injury. Confirm that the head fragment is not split or impacted and the cartilage is intact. Reduce that fragments into anatomic position. The humeral head can usually be reduced by externally rotation the arm and gentle pushing and rotating the head into its anatomic position. The fragments are then anatomically reduced and temporarily fixed using k-wires or suture. Placing a non-absorbable #5 suture in a figure-8 fashion is often beneficial to maintain the reduction during plate placement and also serves additional fixation. Place a proximal humeral plate as selected in the preoperative plan using AO technique and as instructed in the manuctures technique guide. Pack allograft bone chips / demineralized bone graft as needed to improve healing.

 Repair the rotator interval. Irrigate. Close in layers.

ANATOMY & PHYSIOLOGY

In human anatomy, the femur is the longest and largest bone. Along with the temporal bone of the skull, it is one of the two strongest bones in the body. The average adult

male femur is 48 centimeters (18.9 in) in length and 2.34 cm (0.92 in) in diameter and can support up to 30 times the weight of an adult. It forms part of the hip joint (at the acetabulum) and part of the knee joint, which is located above. There are four eminences, or protuberances, in the human femur: the head, the greater trochanter, the lesser trochanter, and the lower extremity. They appear at various times from just before birth to about age 14. Initially, they are joined to the main body of the femur with cartilage, which gradually becomes ossified until the protuberances become an integral part of the femur bone, usually in early adulthood.The shaft of femur is cylindrical with a rough line on its posterior surface (linea aspera).The intercondylar fossa is present between the condyles at the distal end of the femur. In addition to the intercondylar eminence on the tibial plateau, there is both an anterior and posterior intercondylar fossa (area), the sites of anterior cruciate and posterior cruciate ligament attachment, respectively Perioperative Management SCRUB NURSE Pre-operative Responsibilities 1. Assist with the preparation of the room for the designated surgical procedure, including gathering supplies for the procedure. 2. Scrub, dry hands, gown, and glove. 3. Assist person scrubbed in first position with: a. Setting up back table, mayo, and basins b. Arrangement of instruments c. Preparation of suture and needles d. Preparation and counting sponges e. Arrangement and preparation of other necessary items f. Gowning and gloving surgeon and assistants g. Assist with draping h. Arrangement of sterile field Intra-operative Responsibilities 1. During the procedure, progress from double-scrubbed position. Train self to keep eyes on field, and learn steps of procedure. 2. Begin developing methods of anticipating needs of surgeon and assistant. 3. After closing the skin: a. Assist with care of instruments and counts if necessary b. Care of specimen c. Assist with dressing of wound Post-operative Responsibilities 1. After the completion of the Procedure: a. Assist with the gathering of all materials used during the procedure b. Discard items as necessary being careful to discard sharp items in designated placesc. Return all items to respective aread. Assist with cleaning of roome. Clean the materials used properly and arrange them after drying2. Perform any duties which will speed up the surgical procedure to follow in that room.

CIRCULATING NURSE Pre-operative Responsibilities 1. Care for the patient before surgery by: a. Greeting patient and assist nurse with identification b. Checking patient's chart, preparation, etc. 2. Prepare the room by: a. Obtaining instruments, supplies, and equipment for the designated operative procedure b. Opening unsterile supplies c. Assisting in gowning d. Observing breaks in sterile technique e. Assisting anesthesiologist as necessary f. Assisting with skin preparation and positioning g. Assisting with forming of the sterile field 3. Count the instruments, sharps and sponges before the procedure and confirm with scrub nurse. Intra-operative Responsibilities 1. During the Procedure: a. Remain in room and dispense materials as necessary b. Observe procedure as closely as possible c. Begin establishing method of anticipating needs of surgical team d. Care of specimen as indicated e. Care of operative records as indicated 2. Before the closing of the organ or peritoneum, count all instruments, sharps and sponges and confirm with scrub nurse. 3. Inform the surgeon and assistant surgeon of a report of the instruments. Post-operative Responsibilities 1. Properly document all the necessary information on the patients chart. 2. Assist in the cleaning of the Operation Room as necessary. Prior to operation:

A careful history and physical examination are performed to exclude the possibility of other gastrointestinal diseases that may mimic biliary colic, such as peptic ulcer disease or reflux esophagitis.

 When the diagnosis of acute cholecystitis is suspected the patient should receive nothing by mouth; however, nasogastric suction usually can be reserved for patients who are vomiting or have ileus and abdominal distention.

Care for the patient before surgery by:a. Greeting patient and assist nurse with identification. Checking patient's chart, preparation, etc.2. Prepare the room by:a. Obtaining instruments, supplies, and equipment for the designated operative procedure. Opening unsterile supplies. Assisting in gowning. Observing breaks in sterile technique. Assisting anesthesiologist as necessary. Assisting with skin preparation and positioning. Assisting with forming of the sterile field. Count the instruments, sharps and sponges before the procedure and confirm with scrubnurse.

Intra-operative Responsibilities 1. During the Procedure: a. Remain in room and dispense materials as necessary b. Observe procedure as closely as possible c. Begin establishing method of anticipating needs of surgical team d. Care of specimen as indicated e. Care of operative records as indicated 2. Before the closing of the organ or peritoneum, count all instruments, sharps and sponges and confirm with scrub nurse. 3. Inform the surgeon and assistant surgeon of a report of the instruments. Post-operative Responsibilities 1. Properly document all the necessary information on the patients chart. 2. Assist in the cleaning of the Operation Room as necessary. Prior to operation:

A careful history and physical examination are performed to exclude the possibility of other gastrointestinal diseases that may mimic biliary colic, such as peptic ulcer diseaseor reflux esophagitis. When the diagnosis of acute cholecystitis is suspected the patient should receivenothing by mouth; however, nasogastric suction usually can be reserved for patientswho are vomiting or have ileus and abdominal distention. Intravenous fluids are given to correct volume depletion and any electrolyte imbalancesare measured and corrected. Monitor and regulate IVFs The nurse instructs the patient about the need to avoid smoking to enhance pulmonaryrecovery postoperatively and avoid respiratory complications. It is also

important toinstruct the patient to avoid the use of aspirin and other agents that can alter coagulationand other biochemical process

On of the most important responsibility of the nurse is to let the patient sign an informedconsent regarding the surgery.

The patient is given anaesthesia prior to surgery and the patient is under NPO. During the operation

Monitoring the vital signs of the patient is one of the responsibilities of the nurse duringthe surgery.

Assisting the anesthesia care provider during induction of general anesthesia

Ensuring adequate oxygenation and hydration After the operation

After recovery, the nurse places the patient in the low fowlers position. IV fluids may begiven and nasogastric suction may be given to relieve abdominal distention. Water andother fluids are given in about 24hours, and soft diet is started when bowel soundsreturned. Placing warm blankets on the patient to enhance comfort and preserve the patient'sbody temperature

Assessing the patient's vital signs, oxygen saturation level, level of consciousness,circulation, pain, IV site, fluid rate, and hydration status, as well as the status of thesurgical site and dressing and all related monitoring equipment The nurse helps in relieving the pain by instructing the patient regarding proper positioning.

The nurse helps in improving the respiratory status by instructing the patient regardingdeep breathing exercises.

The nurse also provides skin care like cleaning the incision part and providing cleandressing following a strict aseptic technique

 The nurse instructs the patient about the medications that are prescribed by thephysician Discussing recommended follow-up management with the physician and the surgeon

Pathophysiology

V-Surgical Instruments used in Palatoplasty Procedure A Deaver retractor (manual) is used to retract deep abdominal or chest incisions. Available in various widths.

A Richardson retractor (manual) is used to retract deep abdominal or chest incisions

An Army-Navy retractor (manual) is used to retract shallow or superficial incisions. Other names:

USA, US Army.

A malleable or ribbon retractor (manual) is used to retract deep wounds. May be bent to various shapes.

Cutting and Dissecting Instruments Straight Mayo scissors - Used to cut suture and supplies. Also known as: Suture scissors.

Curved Mayo scissors - Used to cut heavy tissue (fascia, muscle, uterus, and breast). Available in regular and long sizes.

Metzenbaum scissors (A) - Used to cut delicate tissue. Available in regular and long sizes.

Clamping and Occluding Instruments A hemostat is used to clamp blood vessels or tag sutures. Its jaws may be straight or curved. Other names: crile, snap or stat.

A mosquito is used to clamp small blood vessels. Its jaws may be straight or curved.

A Kelly is used to clamp larger vessels and tissue. Available in short and long sizes. Other names: Rochester Pean.

A burlisher is used to clamp deep blood vessels. Burlishers have two closed finger rings. Burlishers with an open finger ring are called tonsil hemostats. Other names: Schnidt tonsil forcep, Adson forcep.

Kelly, hemostat, mosquito (left to right)

A right angle is used to clamp hard-to-reach

vessels and to place sutures behind or around a vessel. A right angle with a suture attached is called a "tie on a passer." Other names: Mixter.

A hemoclip applier with hemoclips applies metal clips onto blood vessels and ducts which will remain occluded.

Grasping and Holding Instruments Are used to hold tissue, drapes or sponges. An Allis is used to grasp tissue. Available in short and long sizes. A "Judd-Allis" holds intestinal tissue; a "heavy allis" holds breast tissue.

A Babcock is used to grasp delicate tissue (intestine, fallopian tube, ovary). Available in short and long sizes.

A Kocher is used to grasp heavy tissue. May also be used as a clamp. The jaws may be straight or curved. Other names: Ochsner.

A Foerster sponge stick is used to grasp sponges. Other names: sponge forcep.

A dissector is used to hold a peanut.

A Backhaus towel clip is used to hold towels and drapes in place. Other name: towel clip.

Pick ups, thumb forceps and tissue forceps are available in various lengths, with or without teeth, and smooth or serrated jaws.

Russian tissue forceps are used to grasp tissue.

DeBakey forceps are used to grasp delicate tissue, particularly in cardiovascular surgery.

Adson pick ups are either smooth: used to grasp delicate tissue; or with teeth: used to grasp the skin. Other names: Dura forceps.

Bone file- smoothing bone

Parkes rasp-cutting bone

Mini-Liston bone cutting forceps- cutting bone