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A fracture is a complete or incomplete disruption in the continuity of bone structure and

is dened according to its type and extent. Fractures occur when the bone is subjected to stress
greater than it can absorb. Fractures may be caused by direct blows, crushing forces, sudden
twisting motions, and extreme muscle contractions. When the bone is bro- ken, adjacent
structures are also affected, resulting in soft tissue edema, hemorrhage into the muscles and
joints, joint dislocations, ruptured tendons, severed nerves, and dam- aged blood vessels. Body
organs may be injured by the force that caused the fracture or by fracture fragment.
There are different types of fractures and these include, complete fracture, incomplete
fracture, closed fracture, comminuted fracture and open fracture. A complete fracture involves
a break across the entire cross- section of the bone and is frequently displaced. An incomplete
involves a break through only part of the cross-section of the bone. A comminuted fracture is
one that produces several bone fragments. A closed fracture or simple fracture is one that
does not cause a break in the skin. An open fracture is one in which the skin or mucous
membrane wound extends to the fractured bone. Fractures may also be described according to
the anatomic placement of fragments. Such as, avulsion, comminuted, compression, depressed,
open, pathologic, epiphyseal, greenstick, impacted, oblique, spiral, simple, stress and
The clinical signs and symptoms of a fracture include acute pain, loss of function,
deformity, shortening of the extremity, crepitus, and localized edema and ecchymosis. The pain
is continuous and increases in severity until the bone fragments are immobilized. The muscle
spasms that accompany a fracture begin within 20 minutes after the injury and result in more
intense pain than the patient re- ports at the time of injury. The muscle spasms can minimize
further movement of the fracture fragments or can result in further bony fragmentation or
misalignment. After a fracture, the extremity cannot function properly because normal function
of the muscles depends on the integrity of the bones to which they are attached. Pain
contributes to the loss of function. In addition, abnormal movement (false motion) may be
present. Displacement, angulation, or rotation of the fragments in a fracture of the arm or leg
causes a deformity that is detectable when the limb is compared with the uninjured extremity.
There is actual shortening of the extremity because of the compression of the fractured bone.
Sometimes muscle spasms can cause the distal and proximal site of the fracture to overlap,
causing the extremity to shorten. When the extremity is gently palpated, a crumbling sensation,
called crepitus, can be felt. It is caused by the rubbing of the bone fragments against each
other. Localized edema and ecchymosis occur after a fracture as a result of trauma and
bleeding into the tissues. These signs may not develop for several hours after the injury or may
develop within an hour, depending on the severity of the fracture.
Accurate evaluation and diagnosis of orthopedic problems requires advanced medical
training. Orthopedic surgeons are highly skilled in the use of the diagnostic procedures to reach
a proper diagnosis. After a complete physical examination, medical history profile, and
discussion of symptoms, patients may undergo one or more appropriate diagnostic test.
Imaging of suspected fracture usually begins with plain radiography (x-ray). Although x-ray will
reveal most fractures, subtle fractures and some stress fractures may not be visible
immediately on x-ray. If symptoms of fracture persist, an occult (or hidden) fracture is
suspected. Follow-up x-rays may show a fracture due to loss of bone around the fracture site
during the healing process. However, if plain x-rays continue to be negative but clinical
suspicion remains, further imaging tests such as, magnetic resonance imaging [MRI], or
computed tomography [CT]) are warranted.
The medical management of fracture includes the following: Reduction of fractures
which refers to restoration of the fracture fragments to anatomic alignment and positioning.
Either closed reduction or open reduction may be used to reduce a fracture. Usually, the
physician reduces a fracture as soon as possible to prevent loss of elasticity from the tissues
through inltration by edema or hemorrhage. Before fracture reduction and immobilization,
the patient is prepared for the procedure; consent for the procedure is obtained, and an
analgesic is administered as prescribed. Anesthesia may be administered. The injured extremity
must be handled gently to avoid additional damage. Immobilization after the fracture has been
done, the bone fragments must be immobilized and maintained in proper position and
alignment until union occurs. Immobilization may be accomplished by external or internal
xation. Reduction and immobilization are maintained as prescribed to promote bone and soft
tissue healing. Edema is controlled by elevating the injured extremity and applying ice as pre-
scribed. Neurovascular status (circulation, motion and sensation) is monitored routinely, and
the orthopedic surgeon is notied immediately if signs of neurovascular compromise develop.
The nursing management includes the following: Immediately after injury, if a fracture is
suspected, it is important to immobilize the body part before the patient is moved. Adequate
splinting is essential. Joints proximal and distal to the fracture must be immobilized to prevent
movement of fracture fragments. Immobilization of the long bones of the lower extremities
may be accomplished by bandaging the legs together, with the unaffected extremity serving as
a splint for the injured one. In an upper extremity injury, the arm may be bandaged to the
chest, or an injured forearm may be placed in a sling. The neurovascular status distal to the
injury should be assessed both before and after splinting to determine the adequacy of
peripheral tissue perfusion and nerve function. With an open fracture, the wound is covered
with a sterile dressing to prevent contamination of deeper tissues. No at- tempt is made to
reduce the fracture, even if one of the bone fragments is protruding through the wound. Splints
are applied for immobilization.
We chose fracture as our case study because it will help our group in understanding the
disease process of the patient. This would also help us in identifying the primary needs of the
patient with fracture. By identifying such needs and health problems of our patient, we will be
able to formulate an individualized care plan that would address these needs and problems
effectively which can help the patient to recover faster and maintain a holistic sense of wellness
even while in the hospital.

General Objectives:
We, the student nurses of the Medical Colleges of Northern Philippines, aim to develop
essential as well as skilful orthopaedic nursing care which is based on the better and effective
approach that will serve as a catalyst to promote health, reduce illness and complications and
to restore the normal body function of the patient. We are also up to in knowing the nature of
the disease and on how to manage it in such a way that it would be therapeutic to the patient

Specific Objectives:
By the end of this whole rotation, we, the student nurses of MCNP, will be able to:
1. To trace the pathophysiology of fractures.
2. To identify factors that contributes to the development of fractures.
3. To enhance our ability to manage the said disease in regards to their cultural beliefs and
4. To develop an independent and collaborative work together with the medical health
team members.
5. To prioritize things which are essential in assessing and developing proper interventions
in treating or alleviating the illness.
6. To improve the use of the nursing process that would include assessment, diagnosis,
planning, implementation and evaluation into a more useful and more effective
in doing the patients care.
7. To apply the core and fundamental systematic approach of the nursing profession in
promoting health unto the clients.

AGE: 43
DATE OF BIRTH: February 1, 1971
BIRTH PLACE: Pangasinan
ADDRESS: Ipil- ipil Zamboanga City
WEIGHT: 87 kg
DIALECT: Ilocano
RELIGION: Roman Catholic
OCCUPATION: Philippine Army
CHIEF COMPLAINT: Pain on left upper and lower extremities
DATE OF ADMISSION: February 09, 2014
INITIAL DIAGNOSIS: Fracture closed comminuted displaced femur open comminuted of
proximal 3
and M/ 3
tibia fibula (L) fracture open comminuted displaced of displaced M/3

of D/3
radius w/na (L) fracture close complete transverse shaft metacarpal
SURGICAL PROCEDURES DONE: Debridement thigh, and leg (L)
Debridement forearm (L) w/ application of external fixation, radius (L) and IM pinning ulna (L)
debridement hand (L) with ORIF (pinning) 4
and 5
metacarpal, (L) debridement thigh (L) with
application of external Fixation, Femur (L)


The femur, or thigh bone, is the longest, heaviest, and strongest bone in the entire
human body. All of the bodys weight is supported by the femurs during many activities, such as
running, jumping, walking, and standing. Extreme forces also act upon the femur thanks to the
strength of the muscles of the hip and thigh that act on the femur to move the leg. The femur is
classified structurally as a long bone and is a major component of the appendicular skeleton.
On its proximal end, the femur forms a smooth, spherical process known as the head of the
femur. The head of the femur forms the ball-and-socket hip joint with the cup-shaped
acetabulum of the coxal (hip) bone. The rounded shape of the head allows the femur to move
in almost any direction at the hip, including circumduction as well as rotation around its axis.
Just distal from the head, the femur narrows considerably to form the neck of the femur. The
neck of the femur extends laterally and distally from the head to provide extra room for the leg
to move at the hip joint, but the thinness of the neck provides a region that is susceptible to
At the end of the neck, the femur turns about 45 degrees and continues distally and
slightly medially toward the knee as the body of the femur. At the top of the body of the femur
on the lateral and posterior side is a large, rough bony projection known as the greater
trochanter. Just medial and distal to the greater trochanter is a smaller projection known as the
lesser trochanter. The greater and lesser trochanters serve as a muscle attachment sites for the
tendons of many powerful muscles of the hip and groin such as the iliopsoas group, gluteus
medius, and adductor longus. The trochanters also widen and strengthen the femur in a critical
region of high stresses due to external trauma and the force of muscle contractions.
The distal end of the body of the femur widens significantly above the knee to form the
rounded, smooth medial and lateral condyles. The medial and lateral condyles of the femur
meet with the medial and lateral condyles of the tibia to form the articular surfaces of the knee
joint. Between the condyles is a depression called the intercondylar fossa that provides space
for the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL), which stabilize
the knee along its anterior/posterior axis.
The tibia is the inner and thicker of the two long bones in the lower leg. It is also called
the shin bone. Its upper end is expanded into medial and lateral condyles, which have concave
surfaces and unite with the condyles of the femur. The tibia is the supporting bone of the lower
leg and runs parallel to the other, smaller bone (the fibula) to which it is attached by ligaments.
The front of the tibia, or tibial tuberosity, lies just below the skin and can easily be felt. The
tibial tuberosity is a region on the bone where muscles and tendons attach (or an apophysis).
The upper end joins the femur to form the knee joint, and the lower end forms part of the ankle
joint. On the inside of the ankle, the tibia widens and sticks out to form a large bony
prominence called the medial malleolus. On the outside of the ankle is a protrusion called the
lateral malleolus, which is sometimes called the ankle bone, and is the most common area for
ankle sprains. The lateral meniscus of the knee is a thick, crescent-shaped piece of cartilage that
acts as padding. It lies between the joint where the femur and tibia articulate (come in contact
with each other) on the outside of the knee. Likewise, the medial meniscus lies in the joint on
the inside of the knee. The menisci are vital to absorbing shock from the knees, as well as
providing lubrication and stabilization. Therefore, every attempt is made to repair (and more
recently even to replace) worn or injured menisci.
The radius is the shorter of the two long bones of the forearm. The other is the ulna.
The radius is the bone on the thumb side of the arm. The shaft of the radius has a broad base
that joins the lower end of the ulna and the upper bones of the wrist at a large process called
the radial styloid. The disk-shaped head of the radius, which is smaller than the base, joins the
lower end of the humerus (bone in the upper arm) to form the elbow joint.


Stress placed on a bone, exceeds the bone ability to absorb it

Injury in the bone

Disruption in the continuity of bone

Disruotion of muscle and blood vessels attached to the ends of the bone

Soft tissue damage


Hematoma forms in medullary canal

Bone tissue surround the fractured site dies

Inflammatory Response

Personal history of fracture as an
History of fracture in first degree
Advanced age

Vehicular Accident
Current cigarette smoking
Low body weight
Estrogen Deficiency
Early menopause (45 years old) or
bilateral ovariectomy
Prolonged premenstrual
Low Calcium Intake
Recurrent falls
Inadequate physical activity
Poor health/Frailty

Increased blood circulation around the infected area

The site of inflammation dilate

Allowing the larger cells of the blood to pass

There is large supply of proteins

Increase body heat
Sign and symptoms of inflammatory response: Red and Warm skin
Painful site

History of Present Illness
Six days prior to admission, Mr. R.B. was riding a motorcycle with his wife in a curve
highway. He accidentally collided with an elf truck head on. Immediate pain was noted on his
left upper and lower extremities. Patient also sustained multiple avulsed wound and lacerated
wounds. Patient was brought to a private hospital where debridement and closure of the
wounds were done. X ray was also done revealing multiple fractures on left upper and lower
Few hours prior to admission, the patient was transferred to a station hospital then
evacuated in our institution hence this admission.

History of Past Illness
Patient R.B has no known allergy to any food or medications. He cant recall if he received
any vaccines or immunizations during his childhood and no scar of BCG vaccine in his deltoid
both in right and left. The patient experienced childhood illnesses such as measles, chicken pox
but he cannot recall if he experienced mumps. No past history of any confinement or
hospitalization because of any diseases or vehicular accidents. He does not have any
medication for maintenance. He stated that he is healthy and uses over the counter
medications such as alaxan for pain, paracetamol for fever, solmux for cough and neozep for
colds. He does not use any vitamin supplement.

Family Health History
The patient is the youngest among six siblings. No family history of diabetes mellitus, drug
addiction/drug dependency, asthma and cancer. His mother is still alive and healthy as the
patient says mas malakas pa sakin nanay ko eh. His father died due to natural death but he
stated that his father has undiagnosed hypertension before. He also added that when his father
had his blood pressure monitored usually twice a month the BP is continuously high but his
father has no complains of headache and dizziness. His father takes antihypertensive
medication when he feels to take too.

According to the patient being healthy is tantamount to being able to perform his role
unaided and being strong. He stated that he is compliant with regards to his health as he says
Sundalo ako kaya kailangan laging malusog saka libre naman ang mga gamot bakit hindi ko pa
susundin. He also claims that whenever he experiences common diseases such as fever, cough
and body ache, he prefer to use non pharmacological management such as sponge bath and
increasing fluid intake for fever, drinking of lemonade for cough and body massage for pain.
When these nonpharmacological treatments are not affective then he uses over the counter
drugs such as alaxan for pain, paracetamol for fever and solmux for cough. When all of these
seem not working then he will consult the physician immediately.
According to the patient being unable to do something which he usually does(ADLs) is similar
to not being healthy as what he is experiencing right now as he says pati nga pagpapalit ng
damit ko ay hindi ko na magawa. The patient has an external fixation due to the fractured right
lower and upper extremities and on heplock. He stated that he is more compliant now with the
time of taking oral medication, he follows the do(s) and dont(s) on the treatment and
procedures guidelines. He is given antibiotics and pain reliever as prescribed by his physician.
His wound and the insertion site of external fixation devices are regularly cleaned and
frequently changed wound dressing. The patient is stationary on bed, cant walk nor move by
his own.
Patient eats three times a day with snacks in between. His breakfast usually composed of a
cup of coffee, 1 to 2 cups of rice and vegetable salad or fried fish. For his lunch and dinner he
usually consumes 2 to 4 cups of rice, 2 to 4 glass of water and vegetable cooked in fish sauce
(dinengdeng). The patient prefers water and fruit juices for his beverage and he seldom eats
meat. During his early adulthood years he admits that he is a drunkard. He can drink 16 bottles
of pale pilsen in one night. But 10 years ago he stops drinking alcohol because his wife
requested it, but he still drinks liquor occasionally in a maximum of 1 bottle. He does not take
any vitamin supplement. No difficulty in chewing and swallowing. His weighs 87 kg and standof
59 tall.
Patient eats what the staff of the dietary department offered him. His regular breakfast is a
cube size of meat or a piece of fried fish, a piece of banana or slice of fruit and a cup of rice. His
lunch and dinner usually composed of 1 cup of rice with a vegetable and fried fish as viand. He
usually drinks approximately 1.5 liters of water per day. He seldom drinks coffee. No difficulty
in chewing and swallowing. He has difficulty in feeding himself by his own because one of his
fractured arm and he cannot sit by his own so supervision and assistance is needed.
The patient stated that he usually urinates 3 to 5 times a day with an amount of
approximately 700 to 1200 ml a day, with a light yellow to amber color and aromatic odor. No
episodes of painful and difficulty in voiding. The patient regularly defecates once or twice a day
with yellow orange to light brown color, bulky in consistency and no difficulties in defecating.
He does not use enema, suppositories and laxative to aid in defecation.
The patient was catheterized in Zamboanga Syudad Medical Center but after a week the
catheter was removed. According to the patient he suffered burning and painful urination with
blood and pus in the urine but due to increasing of fluid intake and antibiotics given, this
episodes of burning and painful urination did not last longer. Currently according to him, his
urinating and defecating habits, frequency and routine including the color and consistency of
the feces and the color, odor of the urine are the same as what he has before the
hospitalization. The only difference now is that he urinates in urinal and defecates in a bedpan
with assistance of the SO.
As a soldier the patient need to be physically fit and to maintain this fitness the patient
usually do jogging 2 to 3 times a week or do sit ups and push ups. According to him doing this
work outs makes him feel better. Every day he needs to stand for 4 hours, as part of his work
during his regular duty at the command post. His hobbies are playing basketball and chess. He
often serves as VIP escorts of higher officers of the AFP.

The patient got a fracture on the right arm, leg and thigh. Due to this condition the patient
cannot do his routine activities or exercises. He just follow the advised of the physician to at
least do isometric exercises in his lower right leg and do ROM active assistive on her right arm.
He entertains himself by chatting to his roommates, watching tv and listening to music.
According to him when he was still in the battlefield, he cant sleep that good because he
need to be half awake at all times, as what he said that Mindanao is Mindanao there is no safe
place for a soldier like them. Although he is half awake at all times during night he still feels that
he is well rested. He takes daytime nap during his free time. He does not use any sleeping pills,
no special rituals before sleeping. He preferred to sleep with lights off.
According to him, he sleeps most hours of the day during his first month in the hospital to
divert the pain and to rest after episodes of severe pain. He takes several daytime naps.
Although he slept a lot he still feels unrested. Currently according to the patient he sleeps 8 to
10 hours a day. He feels well rested because his sleep is uninterrupted throughout the night. He
does not use any sleeping pills and no rituals to aid in sleeping.
The patient has no problem with his senses, can remember recent memories such as what
is the content of her breakfast today and he can remember remote memories such as who is
the first female president of the Philippines. The patient stated that he has no problem in
perception of things, can reason out himself and happenings, he can think clearly and can
decide critically related situation. No episodes of forgetfulness and hearing or seeing things that
are not seen by others.
The patient has no problem with his five senses. The patient is in pain with pain scale of 5/10.
No changes in the cognitive status and perception ability of the patient. According to him there
are no changes as what he had before hospitalization and what he has during hospitalization.

The client perceived himself as a loving father, a good provider and a great and faithful
husband. He is satisfied on her body figure and appearance. According to him even though he
has his own family, he still gives financial support to his parents. He stated that he loves to chat
with others and he rarely gets into trouble or conflicts with other people because he settles
misunderstanding quickly. He also stated that he is very independent and a wide minded
individual. He prioritizes what his wifes opinions on every matter.

The client had a multiple fracture in the left extremities (arm and leg) on external fixation,
cant move freely but is still positive on his life despite his condition. According to him, maybe it
will take time before he can walk again but he is considering this as a blessing because after
discharge he can stay longer on his family and be a more hands on father in terms of
disciplining them and teaching them how to be a good person. According to him, after
discharge he will file his retirement.
The patient manages stress in the work area by sleeping or listening to music. He rarely open
work related stress to his wife because he does not want his wife to worry. According to him
sleeping gives him the time to think on what to do. When the stress is somehow personal
involving the family, then that is the time they sit together as a couple and settle the problem.
He stated that during decision making his wife do almost the final decision.
According to the patient this is one of the most severe stress he and his family had undergone
so far in his entire life because he and his wife are both are in the hospital, with fracture in the
extremities and unable to ambulate with their own. The patient manages stress and boredom
by chatting to the person near his bed (roommate), but the most effective so far that can
remove his stress is when he speaks to his two children. The moment he hears the voice of her
two children soothes his worry and stress.

According to the patient he assumes the role of being the main financial supporter, but his
wife do almost the budgeting, decision making and disciplining their two children. He also says
that he is always the foundation and main structure of the family; he protects his wife and
children to any harm and provides them the emotional and financial needs they needed. He
also says that he is a supportive brother to his siblings and understanding son to his parents. He
had never been into conflicts with his parents because as a son he needs to bend his head
forward to his parents, as a way of giving respects. According to the patient they have a
misunderstanding with his elder brother because of financial issue. In being a citizen, according
to him even if he is not that rich he chose to serve the country and the people of this country
with utmost loyalty and honesty. He believes that during his 23 years in service he has been a
good soldier.

He is still the main financial provider. He says that temporarily, he cant perform his full duty
as a father due to his condition but he stated that he is trying to compensate by always calling
and talking to his children, giving them reminders and checking them at all times. The conflict
between him and his elder brother was resolved during the first week of hospitalization, his
elder brother went to visit him and personally say sorry to him which according to the patient
was one of the good things that happen after the accident.

The patient is satisfied with his sexuality being a man. He believes that he fulfills the role of a
man. According to him to be able to provide for your own family and be independent in life is
one of the characteristics of being a man. According to him he had been circumcise at the age
of 10 in their province. He had his coitarche at the age of 21 to his wife. He has no known STDs
and any reproductive related diseases. The patient is still sexually active at the age of 44.
The patient says being able to be strong despite what happened and be the foundation and
strength of my family is still tantamount to being a great man.

Patient is a Roman Catholic. He believes in miracle and has a great faith in God despite his busy
schedule. He seldom go to church with his family but he often prays on his own for the
protection of his family. He believes that everything happens for a purpose.
Patients faith in God has been increased. He prays more often to God that he and his wife can
recover faster and that may his children and family be safe always. He also claims that the
accident is a punishment for earning money through the tears and sweat of other people
because he has a business of lending money with interest.

Date and
Focus Progress Notes
April 28, 2014
7:00 am to
3:00 pm
Acute pain
related to
Received lying on bed awake and oriented, with uniplanar
external fixator on left thigh, left leg and left arm.
Pain Scale of 5/10
Facial grimacing

Maintained immobilization of affected part by
means of bed rest
Provided comfort measures such as
repositioning the patient
Encouraged diversional activities such as
watching television
Instructed to use relaxation techniques such as
deep breathing exercise
Administered Celecoxib as ordered
Encouraged adequate rest periods

The patient verbalized pain relief and displayed
relaxed appearance.

Date and
Focus Progress Notes
April 29, 2014
7:00 am to
3:00 pm
Infection Received lying on bed awake and oriented, with uniplanar
external fixator on left thigh, left leg and left arm.
Increased ESR: 64mm/hr
Presence of pus in the urine
Presence of pus in the wounds

Stressed proper hand hygiene by all caregivers
between therapies/ client.
Assisted in daily wound care and observed sterile
technique at all times when possible.
Changed wound dressing, as indicated using proper
sterile technique.
Instructed to avoid scratching the wound by any
unclean object or bare hands.
Encouraged patient to eat high in protein and
vitamin C rich food.
Administered ascorbic acid as ordered
Administered antibiotic as ordered

The patient was able to identify and implement
ways to prevent further complications.

Date and
Focus Progress Notes
April 29, 2014
7:00 am to
3:00 pm
Received lying on bed awake and oriented, with uniplanar
external fixator on left thigh, left leg and left arm.
inability to move
limited range of motion

Assisted with active/passive range of motion exercises
of both affected and unaffected extremities
Encouraged use of isometric exercises starting with the
unaffected limb.
Encouraged self-care activities such as bathing
Assisted with mobility by means of wheelchair, as soon
as possible. Instructed in safe use of mobility aids.
Supported affected body parts or joints using pillows
Schedule activities with adequate rest periods
Identified energy conserving techniques for activities
The patient was able to maintain position of function as
evidenced by absence of contractures, foot drop,
decubitus and so forth.


Advised and educated the patient regarding the importance of taking the prescribed
take home medications, the proper way of administering the drug at the right time, right route
and right dosage. Instructed to finish course of therapy even when signs and symptoms
disappeared early and do not abruptly discontinue the drug without consultation to the
healthcare provider to prevent rebound effects.
Tramadol 500mg
Celecoxib 200mg/tablet
Cefepine 750mg TIV BID
Piperacillin sodium and tazobactam sodium

Encourage range of motion exercises like flexion and extension of the arms and legs.
Encouraged the patient to ambulate as tolerated and avoid heavy lifting on the left arm.
Instruct the patient to follow the treatment regimen especially the medications
prescribed. Have a regular consultation with the physician and report any unusual signs of
infection such as presence of pus in wounds, fever etc.

Stressed the importance of proper hygiene like hand washing, tooth brushing and
bathing, to prevent further complications and also precautionary measures such as using gloves
when cleaning the wounds.

The client must do follow up care to note any improvement in his condition and for
continued treatment.

Advised patient to increase fluid intake within cardiac tolerance and to eat foods rich in
protein and Vitamin C to promote faster healing.

Advised patient to continue believing in God and thanking Him for the blessings of life,
and to participate in religious activities to strengthen his faith.