COLLEGE OF NURSING

Silliman University
Dumaguete City

Case Analysis on Open Fracture

Submitted to: Asst. Prof. Mary Nathalie Cata-al

Submitted by: Paez, April Mae
Perez, Catherine
Pileo, Eimereen

Vision:
A leading Christian Institution committed to total human development for the well-being of society and environment.
Mission:
Infuse into academic learning the Christian faith anchored on the gospel of Jesus Christ; provide an environment where Christian
fellowship and relationship can be nurtured and promoted.
Provide opportunities and excellence in every dimension of the University life in order to strengthen character, competence and faith.
Instill in all members of the University, community an enlightened social consciousness and a deep sense of justice and compassion.
Promote unity among people and contribute to national development

Letter for Application

Silliman University
College of Nursing
Dumaguete City
June 30, 2014
Asst. Prof. Mary Nathalie Cata-al, RN, MN
Clinical Instructor (Surgery) - Level III section A3
Silliman University
Dumaguete City 6200
Dear Maam Cata-al,
We are third year students of Silliman University College of Nursing who are presently assigned in Surgery Rotation, 2 nd floor, Silliman University Medical Center
Foundation Inc. We would like to apply for a case presentation on Open Fracture, a condition of our client Mr. Rodel Aparecio Ledesma, 37 years old from Calayugan, Valencia,
with a diagnosis of Open fracture at Right leg as compliance for our requirements in NCM 103- Surgery Rotation. Furthermore we would like to conduct this case study to expand
our knowledge, skills and positive attitude to the nursing care of clients with similar diagnosis.
Hoping for a positive response to our request, Thank You and God bless.
Respectfully Yours,

Eimereen Lei Mher Pileo

student nurse

Catherine Perez
student nurse

April Mae Paez

student nurse

Noted by:

Asst. Prof. Mary Nathalie Cata-al, RN, MN

Clinical Instructor

Table of Contents
I.
II.
III.
IV.
V.
VI.
VII.

VIII.

IX.
X.
XI.

Case Description .6
Demographic Data...8
Genogram ...10
Growth and Development12
Anatomy and Physiology.15
Concept Map ...23
Medical Management
A. Pharmacology 29
B. Laboratory exams ..30
C. Nursing Procedures 32
Nursing Management
A. FHP .....33
B. NCP 41
Summary of Nursing Diagnoses ...49
Journal readings 51
References .56

Case Description and

Objectives

CASE DESCRIPTION
This case deals with the care of a 37 year old man from Calayugan, Valencia, Negros Oriental, Philippines. He was admitted in Silliman University Medical
Center Foundation Inc. on June 21, 2014 at 6:10 am due to motor vehicle accident with open fracture on the right leg. Mr. Ledesma was diagnosed with
fracture, open at the right leg.
This case analysis contains the Demographic data of our client, its genogram, growth and development, the Anatomy and Physiology of the organ systems
affected during our care, Gordons Functional Health Patterns, Nursing Care Plans, Laboratory exams and results, The pathophysiology of open fracture and
the nursing and medical management of the condition.
Objectives
Central Objectives:
At the end of our case presentation, the learners shall be able to acquire sufficient knowledge regarding open fracture, develop their skills in the care of
patients with similar conditions, and develop a positive attitude towards the holistic care of patients with open fracture through the understanding of the
theories and pathophysiology of the condition.
Specific Objectives
Given sufficient time and ample resources learners shall be able to:
-

Have thorough understanding on the pathophysiology of open fracture

Define common terms and concepts related to the condition presented in the case analysis
Review the Anatomy and Physiology of the integumentary system and skeletal system
Enumerate at least 3 priority nursing diagnosis with appropriate nursing interventions
Obtain familiarity on various medications, their respective classifications, actions, indications, contraindications, adverse effects and nursing
considerations when administering these medications
Know the significance of the nurses role in the care of a patient with open fracture
Objectively evaluate the case analysis through a socialized discussion

DEMOGRAPHIC PROFILE

Demographic Data
Patients name: R.A.L
Age: 37 years old
Sex: Male
Civil Status: Married
Occupation: Seaman
Highest Educational Attainment: AFP
Address: Calayugan, Valencia, Negros Oriental
Religion: Catholic
Date & Time of Admission: June 21, 2014(6:10 AM)
Nationality: Filipino
Chief Complaint(s): Mutiple physical injuries secondary to MVA (motor vehicle accident)
Doctor in charge: Danilo V. Olegario, MD

Family History by Genogram

10

Genogram

80
HTN

69
HTN
DM

66

64

HTN

HTN

80

80
DM

61
HTN

80

A&W

43

41
HTN

HTN

44

41

39

A&W

A&W

A&W

40
A&W

CLIENT
37, PNA,
A&W

66
HTN

64
AST

61
A&W

HTN

59
A&W

57
A&W

44
A&W

33
A&W

LEGEND
= Male

A&W= Alive and well

AST= Asthma
PNA= Pneumonia
DM= Diabetic Mellitus
HTN= Hypertension

=Female

= Deceased

11

GROWTH AND DEVELOPMENT

Growth and Development

12

Patient R.A.L is 37 y/o and is considered middle adulthood (20-40 y/o). During this stage, most young people leave home, complete their education, and begin
full-time work. Their major concerns are developing a career; forming an intimate partnership; and marrying, rearing children, or establishing other lifestyles.
Psychosocial Development
Erik Erikson
The developmental task is achieving a sense of intimacy while avoiding isolation. There is a need to make personal commitments to others. If unable to or afraid to do this, they
may become isolated or self-absorbed.
Robert Havighurst
The developmental task are selecting a mate, learning to live with a marriage partner, starting a family, rearing a children, getting started in an occupation, taking on a civic
responsibilities, and finding a congenial social group.
Nelson and Barry
The characteristics are the separation from parents, exploration of new identities for self, personal discovery and self-discovery, and high-risk behavior (Emerging adults tend to be
high-risk takers, placing their high-functioning bodies at substantial risk of serious injuries)
Geroge Vaillant : Adaptation to use
Age of Consolidation (20-40): Consolidating career; strengthening marriage; not questioning goals
Daniel Levinson: Life structure
Culminating phase of early adulthood (33-45): Building a second adult life structure
Culminating the life structure for early adulthood (33-40): Settling down and Becoming ones own man
Roger Gould: Developmental themes
22-34 y/o Is what I am the only way for me to be?
They demonstrates independent competence while overcoming failures and realizes mortality and concern for failure
The social clock (Bernice Neugarten, 1968, 1979)
There are age-graded expectations for life events, such as beginning a first job, getting married, birth of the first child, buying a home, and retiring. An important cultural and
generational influence on adult development and a cultural-set-timetable that establishes when various events and behavior in life are appropriately called for being on time or off
time can profoundly affect self-esteem. When evaluating family and occupational attainments, people often ask, how am I doing for my age?
The triangular theory of love
Cognitive Development

13

Jean Piagets Theory (The formal operations stage)

She believed that formal operations continue throughout adulthood. There is the use of intuition, insight and hunches and the development of significant scientific thoughts. They
have the ability to think in abstract thoughts and to comprehend and balance arguments by both logic and emotion. Young adults are more quantitatively advanced in their thinking
in the sense that they have more knowledge than adolescents.
Warnier Schlaes Theory (The Achieving Stage)
People must adopt their cognitive skills to situations, such as marriage and employment, that have profound implications over long term goals. They focus less on acquiring
knowledge but more on applying it in everyday life.
Giselle Labouvie-Vleis Theory
This is from adolescent;s ideal world of possibility to pragmatic thought. Logic becomes a tool to solve real-world problems. There is acceptance of inconsistencies as part of life .
this develops ways of thinking that thrives on imperfection and compromise
In 30-40 years old, family and work expands and the cognitive capacity to juggle many responsibilities simultaneously improves. Creativity often peaks.
Moral Development
Lawrence Kohlbers Theory
Level III Post Conventional/ Principled level
Stage 5: The Social Contact Orientation
There is a standards of behavior which is based on adhering to laws that protect the welfare and rights of others. The personal values and oinions are recognized and violating the
rights of others are avoided
Stage 6: Universal-Ethical Principle Orientation
The person has developed moral standard based on universal human rights. When faced with a conflict between law and conscience, person will follow conscience, even though
the decision might involve personal risk
Spiritual Development
James Fowler
Stage 4: Individuative-reflexive faith (Early-Middle 20s or beyond)
Adults who reach this post conventional stage examine their faith critically and think out their own beliefs. Since young adults are concerned with intimacy, movement into this
stage is often triggered by divorce, death of friend or stressful environment.

14

Anatomy and Physiology

15

ANATOMY AND PHYSIOLOGY OF THE INTEGUMENTARY SYSTEM

The skin is the largest organ of the body, accounting for about 15% of the total adult body weight. It performs many vital functions, including protection against
external physical, chemical, and biologic assailants, as well as prevention of excess water loss from the body and a role in thermoregulation. The skin is continuous,
with the mucous membranes lining the bodys surface (Kanitakis, 2002).
The integumentary system is formed by the skin and its derivative structures. The skin is composed of three layers: the epidermis, the dermis, and subcutaneous
tissue (Kanitakis, 2002). The outermost level, the epidermis, consists of a specific constellation of cells known as keratinocytes, which function to synthesize
keratin, a long, threadlike protein with a protective role. The middle layer, the dermis, is fundamentally made up of the fibrillar structural protein known as collagen.
The dermis lies on the subcutaneous tissue, or panniculus, which contains small lobes of fat
cells known as lipocytes. The thickness of these layers varies considerably, depending on the
geographic location on the anatomy of the body. The eyelid, for example, has the thinnest
layer of the epidermis, measuring less than 0.1 mm, whereas the palms and soles of the feet
have the thickest epidermal layer, measuring approximately 1.5 mm. The dermis is thickest on
the back, where it is 3040 times as thick as the overlying epidermis (James, Berger, & Elston,
2006).

Functions of the Integumentary System

The skin and its derivatives perform a variety of functions that affect body metabolism
and prevent external factors from upsetting body homeostasis. Given its superficial location it
is our most vulnerable organ system, exposed to bacteria, abrasion, temperature extremes, and
harmful chemicals.
Protection
Chemical Barriers
The chemical barriers include skin secretions and melanin. Although the skins surface teems with bacteria, the low pH of skin secretions, or the so-called
acid mantle, retards their multiplication. In addition, many bacteria are killed outright by bactericidal substances in sebum. Skin cells also secrete a natural antibiotic
called human defensin that literally punches holes in bacteria, making them look like sieves. Wounded skin releases large quantities of protective peptides called

16

cathelicidins that are particularly effective in preventing infection by group A streptococcus bacteria. As discussed earlier, melanin provides a chemical pigment
shield to prevent UV damage to the viable skin cells.
Physical/Mechanical Barriers
Physical, or mechanical, barriers are provided by the continuity of skin and the hardness of its keratinized cells. As a physical barrier, the skin is a
remarkable compromise. A thicker epidermis would be more impenetrable, but we would pay the price in loss of suppleness and agility. Epidermal continuity works
hand in hand with the acid mantle to ward off bacterial invasion. The waterproofing glycolipids of the epidermis block the diffusion of water and water-soluble
substances between cells, preventing both their loss from and entry into the body through the skin. Substances that do penetrate the skin in limited amounts include
(1) lipid-soluble substances, such as oxygen, carbon dioxide, fat-soluble vitamins (A, D, E, and K), and steroids; (2) oleoresins (ole-o-rezinz) of certain plants,
such as poison ivy and poison oak; (3) organic solvents, such as acetone, dry-cleaning fluid, and paint thinner, which dissolve the cell lipids; (4) salts of heavy
metals, such as lead and mercury; and (5) drug agents called penetration enhancers that help ferry other drugs into the body.

Biological Barriers
Biological barriers include the Langerhans (dendritic) cells of the epidermis, macrophages in the dermis, and DNA itself. Langerhans cells are active
elements of the immune system. For the immune response to be activated, the foreign substances, or antigens, must be presented to specialized white blood cells
called lymphocytes. In the epidermis, it is the Langerhans cells that play this role. Dermal macrophages constitute a second line of defense to dispose of viruses and
bacteria that have managed to penetrate the epidermis. They, too, act as antigen presenters. Although melanin provides a fairly good chemical sunscreen, DNA
itself is a remarkably effective biologically based sunscreen. Electrons in DNA molecules absorb UV radiation and transfer it to the atomic nuclei, which heat up
and vibrate vigorously. However, since the heat dissipates to surrounding water molecules instantaneously, the DNA converts potentially destructive radiation into
harmless heat.
Body Temperature Regulation
The body works best when its temperature remains within homeostatic limits. Like car engines, we need to get rid of the heat generated by our internal
reactions. As long as the external temperature is lower than body temperature, the skin surface loses heat to the air and to cooler objects in its environment, just as a
car radiator loses heat to the air and other nearby engine parts.
Under normal resting conditions, and as long as the environmental temperature is below 3132C (8890F), sweat glands continuously secrete unnoticeable
amounts of sweat [about 500 ml (0.5 L) of sweat per day]. When body temperature rises, dermal blood vessels dilate and the sweat glands are stimulated into
vigorous secretory activity. Sweat becomes noticeable and can account for the loss of up to 12 L of body water in one day. Evaporation of sweat from the skin

17

surface dissipates body heat and efficiently cools the body, thus preventing overheating.
When the external environment is cold, dermal blood vessels constrict. This causes the warm blood to bypass the skin temporarily and allows skin
temperature to drop to that of the external environment. Once this has happened, passive heat loss from the body is slowed, thus conserving body heat.
Cutaneous Sensation
The skin is richly supplied with cutaneous sensory receptors, which are actually part of the nervous system. The cutaneous receptors are classified as
exteroceptors (ekster-o-septorz) because they respond to stimuli arising outside the body. For example, Meissners corpuscles (in the dermal papillae) and Merkel
discs allow us to become aware of a caress or the feel of our clothing against our skin, whereas Pacinian corpuscles (in the deeper dermis or hypodermis) alert us to
bumps or contacts involving deep pressure. Hair follicle receptors report on wind blowing through our hair and a playful tug on a pigtail. Painful stimuli (irritating
chemicals, extreme heat or cold, and others) are sensed by free nerve endings that meander throughout the skin.

Metabolic Functions
When sunlight bombards the skin, modified cholesterol molecules circulating through dermal blood vessels are converted to a vitamin D precursor, and
transported via the blood to other body areas to play various roles in calcium metabolism. For example, calcium cannot be absorbed from the digestive tract without
vitamin D. Besides synthesizing the vitamin D precursor, the epidermis has a host of other metabolic functions. It makes chemical conversions that supplement
those of the liverfor example, keratinocyte enzymes can (1) disarm many cancer-causing chemicals that penetrate the epidermis; (2) convert some harmless
chemicals into carcinogens; and (3) activate some steroid hormones; for instance, they can transform cortisone applied to irritated skin into hydrocortisone, a potent
anti-inflammatory drug. Skin cells also make several biologically important proteins, including collagenase, an enzyme that aids the natural turnover of collagen
(and deters wrinkles).
Blood Reservoir
The dermal vascular supply is extensive and can hold large volumes of blood (about 5% of the bodys entire blood volume). When other body organs, such
as vigorously working muscles, need a greater blood supply, the nervous system constricts the dermal blood vessels. This shunts more blood into the general
circulation, making it available to the muscles and other body organs.
Excretion
Limited amounts of nitrogen-containing wastes (ammonia, urea, and uric acid) are eliminated from the body in sweat, although most such wastes are
excreted in urine. Profuse sweating is an important avenue for water and salt (sodium chloride) loss.
Homeostatic Imbalances of Skin
When skin rebels, it is quite a visible revolution. Loss of homeostasis in body cells and organs reveals itself on the skin, sometimes in startling ways. The

18

skin can develop more than 1000 different conditions and ailments. The most common skin disorders are bacterial, viral, or yeast infections. A number of these are
summarized in Related Clinical Terms. Less common, but far more damaging to body well-being, are skin cancer and burns, considered next.

ANATOMY AND PHYSIOLOGY OF THE SKELETAL SYSTEM

Skeleton is subdivided into two divisions: the axial skeleton, the bones that form from 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.
Function of the bones
1. Support bones, the steel girders and
concrete of the body, form the internal
supports and anchors all soft organs. The bones
pillars to support the body trunk when we stand,
supports the thoracic wall.
2. Protection bones protect soft body organs. For
bone of the skull providing a snug enclosure for
one to head a soccer ball without worrying about
The vertebrae surround the spinal cord, and the
protect the vital organs of the thorax
3. Movement skeletal muscles, attached to bones
use the bones as levers to move the body and its
we can walk, swim, throw a ball and breathe.
4. Storage fat is stored in the internal cavities
5. Blood cell formation blood cell formation,
occurs within the bone marrow cavities of

reinforced
framework that
of the legs act as
and the rib cage
example the fused
the brain, allowing
injuring the brain.
rib cage helps
by the tendons,
parts. As a result,

hemotopoiesis,
certain bones.

19

Classification of Bones
The adult skeleton composed of 206 bones. There are two basic types of osseous, or bone, tissue: compact bone is dense and looks smooth and
homogeneous. Songy bone is composed of small needlelike pieces of bone and lots of open space.
Bone come in many size and shapes and they are classified according to shape into four groups:
Long bones longer than they are wide, they have a shaft with heads at both ends. Long bones are mostly compact bone. All the bones of the limbs, except the
wrist and ankle bones, are long bones.
Short bones cube-shaped and contain mostly spongy bone. The bones of the wrist and ankle are short bones. Sesamoid bones, which were form within tendons,
are a special type of short bone. The best-known example are the patella or kneecap.
Flat bones are thinned, flattened and usually curved. They have two thin layers of compact bone sandwiching a layer of spongy bone between them. Most bones
of the skull, the ribs , and the sternum are flat bones.
Irregular bones bones that do not fit one of the preceeding categories. The vertebrae, which make up the spinal column and the hip bones fall into this group.
Bone Formation, Growth and Remodeling
The skeleton is formed from two of the strongest and most
body, cartilage and bone. In embryos, the skeleton is primarily
but in the young child most of the cartilage has been replaced by
only in isolated areas such as the bridge of the nose, pats of the ribs,

supportive tissues in the

made of hyaline cartilage,
bone. Cartilage remains
and the joints.

Except for flat bones, which from fibrous membranes, most

bones develop using
hyaline cartilage structures as their models. Most simply, this
process of bone formation
or ossification, involves two major phases. First, the hyaline
cartilage model is
completely covered with bone matrix(a bone collar) by
bone0forming cells called
osteoblasts. So, for a short period, the fetus has cartilage bones enclosed by bony bones. Then, the enclosed hyaline cartilage model is digested away, opening
up a medullary cavity within the newly formed bone. Most hyaline cartilage models have been converted to bone except for two regions, the articular cartilage and
the epiphyseal plates. The articular cartilage persist for life, reducing friction at the joint surfaces. The epiphyseal plates provide for longitudinal growth of the long
bones during childhood. New cartilage is formed continuously on the external face of the articular cartilage and on the epiphyseal plate surface that is farther away
from the medullary cavity. At the same time, the old cartilage abutting the internal face of the articular cartilage and the medullary cavity is broken down and
replaced by bony matrix. Growing bones also must be widen as they lengthen. Osteoblasts, in the periosteum add bone tissue to the external face of the diaphysis as
osteoclasts in the endosteum remove bone from the inner face of the diaphysis wall. Since these two processes occur at about the same rate, the circumference of the
long bone expands and the bone widens. This process by which bones increase in diameter is called appositional growth. This process of long-bone growth is

20

controlled by hormones, most importantly growth hormones and, during puberty, the sex hormones. It ends during adolescents, when the epiphyseal plates are
completely converted to bone.
Bone is dynamic and active tissue. Bnes are remodeled continually in response to change in two factors: (1) calcium levels in the blood, (2) the pull of
gravity and muscles on the skeleton. When blood calcium levels drop below homeostatic levels, the parathyroid glands. PTH activates osteoclasts, giant bonedestroying cells in bones, to break down bone matrix and release calcium ions into the blood. On the other hand, when blood calcium levels are too high, calcium is
deposited in the bone matrix as hard calcium salts.
Bone remodeling is essential if bones are to retain normal proportions and strength during long-bone growth as the body increases in size and weight. It also
accounts for the fact that bones become thicker and form large projections to increase their strength in areas where bulky muscles are attached. At such sites,
osteoblasts lay down new matrix and become trapped within it. (once they are trapped they become osteocytes, or mature bone cells) on the other hand, the bones of
bedridden or physically inactive people tend to lose mass and to atrophy because they are no longer subjected to stress.
A fracture is treated by reduction, which is the realignment of the broken bone ends. In closed reduction, the bone ends are coaxed back into their normal
position by the physicians hands. In open reduction, surgery is performed and the bone ends are secured together with pins or wires. After the broken bone is
reduced, it is immobilized by the cast or traction to allow the healing process to begin. The healing time for a simple fractures is 6 to 8 weeks, but it is much longer
for large bones and for the bones of elderly people.
Intramembranous Ossification
Flat bones, such as the bones of the skull, are examples of intramembranous bones. In intramembranous ossification, bones develop between sheets of
fibrous connective tissue. Here, cells derived from connective tissue cells become osteoblasts located in ossification centers. The osteoblasts secrete the organic
matrix of bone. This matrix consists of mucopolysaccharides and collagen fibrils. Calcification occurs when calcium salts are added to the organic matrix. The
osteoblasts promote calcification, or ossification, of the matrix. Ossification results in the trabeculae of spongy bone. Spongy bone remains inside a flat bone. The
spongy bone of flat bones, such as those of the skull and clavicles (collarbones), contains red bone marrow.
A periosteum forms outside the spongy bone. Osteoblasts derived from the periosteum carry out further ossification. Trabeculae form and fuse to become
compact bone. The compact bone forms a bone collar that surrounds the spongy bone on the inside.
Endochondral Ossification
Most of the bones of the human skeleton are formed by endochondral ossification. During endochondral ossification, bone replaces the cartilaginous models
of the bones. Gradually, the cartilage is replaced by the calcified bone matrix that makes these bones capable of bearing weight.
Bone Repair
Repair of a bone is required after it breaks or fractures. Fracture repair takes place over a span of several months in a series of four steps:

21

1. Hematoma. After a fracture, blood escapes from ruptured blood vessels and forms a hematoma (mass of clotted blood) in the space between the broken bones. The
hematoma forms within 6 to 8 hours.
2. Fibrocartilaginous callus. Tissue repair begins, and a fibrocartilaginous callus fills the space between the ends of the broken bone for about three weeks.
3. Bony callus. Osteoblasts produce trabeculae of spongy bone and convert the fibrocartilage callus to a bony callus that joins the broken bones together. The bony
callus lasts about three to four months.
4. Remodeling. Osteoblasts build new compact bone at the periphery. Osteoclasts absorb the spongy bone, creating a new medullary cavity.
In some ways, bone repair parallels the development of a bone except that the first step, hematoma, indicates that injury has occurred. Further, a fibrocartilaginous
callus precedes the production of compact bone.

22

CONCEPT MAP

23

Predisposing Factors

Precipitating Factors:

Age ( middle adulthood)

Gender (male)

Hazardous Place
Fatigue

Motor Vehicle Accident

Integumentary System Functions:
Protect from heat, sunlight injury
and infection; regulate body
temperature; control fluid loss;
secretions; sensations; stores
water, fats and vitamin D

Traumatic Injury

Increase pressure or force on

the bone

X-ray
Fracture, Open at Right leg
Debridement
Efficacy of hydrosurgical
debridement and nanocrystalline
silver dressings for infection
prevention type 2 and 3 open
fracture
Timing issue in open fracture

Break in the right leg

Broken skin with

bone protruding

Musculoskeletal system functions:

protection and support,
movement; give shape; produce
blood cells; store Ca and
Phosphorus; produce heat

Assess degree of mobility or treatment and

note perception of immobility
Assist active/ passive ROM
Encourage and assist for self-care activities

24

Disruption of periosteum,
blood vessels and soft tissues

Blood coming from an open wound

decreased LOC, pain, headache,
vomiting

Bleeding around the site and

into the soft tissues
surrounding the bone

Decrease RBC (3.1/cumm)

Decrease Hemoglobin 8.7gm%
Decrease Hematocrit 26.80%
Blood Transfusion

Ranitidine 50mg IVTT q 8

vasonconstriction

Release of chemical mediators

Cefuroxime 75mg IVTT q 8
Ranitidine 50mg IVTT q 8
Keterolac 35mg IVTT q 8

Increase WBC 13,

200/cumm

Vasodilation

Increased blood flow to

the area of injury

Intense inflammatory reaction

Chemotactic Factor

Migration to injured part

Fever T= 38.3 C

V/S monitoring q 4
Pulse oximter
Catheterization
Administration of IVF
Administration of medications

Increased vascular
permeability

Contraction of smooth
muscles

Exudate formation

BP: 180/90 mmHg

Diphenhydramine
25mg IVTT

Margination
Redness
Heat

Decrease oncotic
pressure

Increased pressure
on nerve endings

Diapedesis

25

Swelling

Pain

Chemotaxis

Demerol 50 mg IVTT q 6
Nubain 10mg IVTT

Phagocytosis

A fibrin clot forms at the break

and acts as a network to which
new cells can adhere

Acute pain r/t

irritation of soft
tissues

Loss of function

Impaired physical mobility r/t musculoskeletal

impairment secondary to open fracture; Right leg
Activity intolerance r/t weakness on the right leg
secondary to open fracture at Right Leg
Assess perceived limitations to activity
weakness and degree of assistance
Assist to stand or move about
Provide rest period and positive atmosphere
Promote comfort measures
Encourage to use relaxation techniques

1. Monitor V/S
2. Obtain clients
assessment of pain w/c
includes location, onset,
frequency, quality,
intensity and
precipitating factors
3. Provide comfort
measure such as deep
breathing exercise,
repositioning and
relaxation technique
4. Provide hot and cold
compress
5. Teach to increase intake
of Vit. C
6. Administer analgesic
medications as ordered

Disruption in fracture
hematoma

Granulation tissue to
osteoid
Disruption in fracture
hematoma

Fixation or proper bone

alignment
26

Osteoblastic activity at the

break

Osteoblast activity is
immediately stimulated

Immature new bone or

callus is formed

Ossification

Consolidation

Fibrin clot is soon reabsorbed and

the new bone cells are slowly
remodelled to form true bone

Legend:
Manifestations -------------------

True bone replaced callus and is

slowly calcified several weeks few
months

Journal

---------------------------

Medical Managements -----Nursing Procedures -----------Anatomy and Physiology ----Laboratory Results --------------Nursing Diagnosis ---------------Nursing Interventions ----------27

Medical Management

28

Medical Management:
Pharmacology
Medication
Ranitidine 50mg IVTT q 8o

Ketorolac (Kelinen) 35mg IVTT q 8o

Cefuroxime (Jectral) 75mg IVTT q AD
Demerol 50mg IVTT q 6o
Panecoxib (Dynastat) 40mg IVTT q 12o

Diphenhydramine 25mg slow IVTT

Nalbuphine (Nubain) 10mg IVTT

Action
Competitively inhibits the action of histamine at the
histamine2 (H2) receptors of the parietal cells of the stomach,
inhibiting basal gastric acid secretion and gastric acid
secretion that is stimulated by food, insulin, histamine,
cholinergic agonists, gastrin, and pentagastrin.
Inhibits prostaglandin synthesis, producing peripherally
mediated analgesia. Also has antipyretic and antiinflammatory properties.
Bactericidal: inhibits synthesis of bacterial cell wall, causing
cell death
Relief of moderate to severe pain, pre-op medication,
support of anesth & obstet analgesia.
Short-term treatment of acute & post-op pain. May be used
pre-op to prevent or reduce post-op pain; can reduce opioid
requirements when used concomitantly.
Competitively blocks the effects of histamine at H1 receptor
sites, has atropine-like, antipruritic, and sedative effects.
Nalbuphine acts as an agonist at specific opioid receptors in
the CNS to produce analgesia, sedation but also acts to cause
hallucinations and is an antagonist at receptors.

correlation
Was given to counteract the adverse effects of blood
transfusion like chills or fever.

Was given to our patient because of pain experienced

from his injury and fever. Also to help from the
inflammation of the open wound.
This drug was given to our patient because of infection
which was manifested by his WBC fluctuating at 13,200
cumm.
This drug is given to our patient because of pain
experienced due to operation on the right leg.
This drug is given to our patient because of pain
experienced due to operation.
The patient has high BP and this is to slow down the
effects of smooth muscles thus the effect of sedatives-like
occurs.
This drug is given to our patient because of pain
experienced due to operation.

29

LABORATORY RESULTS
Date and time done: 6/21/2014 3:30pm

TEST

NORMAL
VALUES

RESULT

Hemoglobin

12-14 gm%

8.70 gm%

Hematocrit

37-44 vol%

26.80 vol%

RBC

4.6-6.2 M/cumm

3.1M/cumm

WBC

4.5-11T/cumm

13200/cumm

SIGNIFICANCE
Oxygen carrying pigment and main
component of RBC
Measures total amount of hemoglobin in
peripheral blood
Volume of RBC (packed cell volume) found
in 100ml of blood
Concentration of RBC from total blood
volume
Combined measure of the size, capacity and
number of cells present in the blood, and
along with the hemoglobin value, established
the presence and severity of anemia.
Primary Function: carry oxygen from the
lungs to the tissues around your body
a key player in getting waste carbon dioxide
from your tissues to your lungs, where it can
be breathed out.
Primary function: to fight infection and react
against other foreign bodies, particles or
tissue

RATIONALE
Decrease in hemoglobin indicates
blood loss
Decrease in hematocrit indicates blood
loss or hemorrhage

Decrease in RBC indicates blood loss

or excessive bleeding

Increase in WBC indicates

leukocytosis, infection, inflammation,
or tissue necrosis

30

URINALYSIS:
Physical and chemical exam:
Color: yellow
Transparency: hazy
Specific gravity: 1.020
Glucose: trace bilirubin ketone
Protein: 1+
pH: 6.0
Physicians Order:
Multiple Physical
Absolute NPO
IVF Plain LR 1L 140cc/hr

PROCEDURES

CORRELATION

Debridement of the right leg

Removes the dead, damaged, or infected tissue of the fracture to

improve the healing potential of the remaining healthy tissues
Reduces the risk of infection

Blood Transfusion

To replace blood lost during the accident and the surgery and
elevates the RBC, hematocrit and hemoglobin level

X-ray

Identified or diagnosed the broken bone or fracture

Dressing plaster

To keep the wound free of infection and to reduce or eliminate all

potential factors inhibiting natural healing

31

COLLERATION
NURSING PROCEDURES

Vital Signs taking q 4H

A quick and efficient way of monitoring a clients condition or identifying the problems
and evaluating a clients response to interventions and also, this is one way to monitor
the clients temperature since he experienced fever.

Administration of medications as ordered

Help the patient to recover faster

Pulse oximeter

It gives a reading of the percentage of hemoglobin that is saturated with oxygen (SaO2)

Catheterization

To drain urine

Administration of IVF

To reduce dehydration from being NPO

32

FUNCTIONAL HEALTH PATTERN

(FHP)

33

COLLEGE OF NURSING
Silliman University
Dumaguete City
Part I. Demographic Information
Name: Ledesma, Rodel Aparecio

Civil Status: Married

Sex: Male

Educational Attainment: College graduate

Address: Calayugan, Valencia

Religion: Roman Catholic

Occupation: Seaman

Room and Bed No.: Hallway

Doctor(s) in Charge: Danilo V. Olegano, MD

Nationality: Filipino

Chief Complaint(s): Vomiting, headache, pallor, bone protruding, pain and bleeding

Date & Time of Admission: June 21, 2014 6:10am

Diagnosis: Fracture, Open, Right leg

General Impression of client (appearance upon first contact):
Sleeping on bed with Intravenous fluid, linens wrinkled, bedside is a bit messy and has no strong odor.
Part II. Functional Health Patterns
USUAL HEALTH PATTERNS
1. Health Perception- Health Management
Patter
Verbalize by the wife:
general health has been good.
Experienced colds seldom and takes
over the counter drugs
Exercise daily at 5am and finishes at

INITIAL APPRAISAL

Verbalize by the wife:

okay-okay na sya kaysa atong una
namong abot dire na grabe kayo siya.
Maglisod jud siya ug gimok tungod aning
iya opera

ONGOING APPRAISAL

Patient verbalized:
Okay-okay nako gamay pero sakit-sakit
japun akong tiil
Dili pa nako magimok
sakit pa kaau ako tiil tungod sa opera
Rated pain as 8 in a range of 1-10 where 1 is

34

7am as health maintenance

Doesnt drink alcoholic beverages,
smoke and use drugs.
Never had an accident but was
hospitalized due to pneumonia last
2013.
Follows order and suggestion from
medical team
No maintenance medications

least pain and 10 is the most pain

Had an accident last Saturday at dawn
Facial grimacing still noted and gets easily
Verbalized, sakit kaau ako tiil tungod sa
irritated
opera
Rated pain as 8 in a range of 1-10 where 1 Medication:
Raniticidone 50mg IVT q8 6-2-10pm
is least pain and 10 is the most pain
Ketorolac (Keliner) 35mg IVT q8 6-2-10pm
Facial grimacing noted and gets easily
Demerol 50mg IVTT q6 x 2 dose 11am
irritated
2am-10am-6pm
Experienced complete transverse open
Panecoxib
(Dynastat)
40mg IVTT q12 x 2 doses
fracture, has bruises
6pm-6am
Drinks medication to relieve injury and
Diphenhydramine 25mg slow IVTT
pain
Nalbuphine (Nubain) 10mg IVTT
Medications:
Raniticidine 50mg IVT q8 6-2-10pm
There was no laboratory results for this day.
Ketorolac (Keliner) 35mg IVT q8 6-2-10pm
Demerol 50mg IVTT q6 x 2 dose 11am
2am-10am-6pm
Panecoxib (Dynastat) 40mg IVTT q12 x 2 doses
6pm-6am
Diphenhydramine 25mg slow IVTT
Nalbuphine (Nubain) 10mg IVTT
Laboratory Results:
Prothombine time 12.2
Hemoglobin 8.70gm %
Hematocrit 26.80
WBC 13, 200 /cumm
Segmented 82
Lymphocyte 10
Eosonophil 3
Monocyte 5
Basophil 0
RBC 4.7
Creatinine 1.10mg/dl

35

BUN 17.00
Sodium 139.10
Potassium 3.50
Sgpt/Alt 16. 00
Diagnosis: Open Fracture, right leg
2. Nutrition Metabolic Pattern
Kinds of Food
Breakfast:
Rice
Egg
Fish
Coffee
Water
Lunch:
Rice
Chicken
Soup
Water
Snacks:
Bread
Coffee
Water
Dinner:
Rice
Fish
Water

Quantity
2cups
1pc.
2pcs.
1cup
2glasses
2cups
2pcs
1bowl
2glasses
3pcs
2cups
2 glasses
2cups
2pcs.
2 glasses

Kinds of Food
Breakfast:
Rice
Ham
Banana
Water
Lunch:
Rice
Chicken
Water
Royal

Quantity
1cup
1pc.
1pc.
1/2cup

Kinds of Food
Breakfast:
Rice
Chicken
Banana
Water

1cup
1pc
1/2glass
1 glass

Has good appetite

No diet restrictions, no allergies
Skin is moist and warm to touch
Has skin problems, no lesions
No dental problems, extracted 2 molars
T= 38.3 PR= 74bpm RR= 20cpm Bp=
120/70mmHg
IV at 48gtts/min

Quantity
1cup
1pc.
1pc.
1/2cup

Has good appetite

Skin is moist and warm to touch
No dental problems, extracted 2 molars
T= 36.9 PR= 70bpm RR= 22cpm Bp=
110/70mmHg
IV at 44gtts/min

Takes Vitamin C
Good appetite
No diet restrictions, no allergies
Wounds heal well
No skin problems, no lesions

36

No dental problems, extracted 2 molars

3.

Elimination Pattern
Defecated 3-5 times a weak
Brown in color, form and no discomforts
Urinates 4-6times a day, clear no discomforts
Perspire a lot especially during exercise but
no strong odor

Has not defecated for 2 days

Has catheter
Has 1000ml of urine collected from last
night to 4pm
Perspires a little
Yellow urine color
UA Lab Results:
Color: yellow
Transparency: Hazy
S. G. :1.020
Glucose: traco Bilirubin Ketone

4. Activity Exercise Pattern

Verbalized by the wife:
Verbalized by the wife:
Maglisod jud siya og gimok tungod sa iya
Exercises daily at 5-7 in the morning though
opera
jogging.
Dili siya kabuhat sa iya mga gusto kay walay
kusoog iya tiil.
Goes to school
Has contemplated surgical procedure; open
Spend spare time watching television
fracture; right leg
Perceived ability for:
Has dressing on the right leg and its
Feeding: level 0
surroundings
Bathing: level 0
Toileting: level 0
Inability to move purposefully and
Bed mobility: level 0
independently
Dressing: level 0
No movement seen on the right leg
Gen. mobility: level 0
Breathing pattern is normal
Home maintenance: level 0
Perceived ability for:
Grooming: level 0
Feeding: level 1
Cooking: level 0
Bathing: level 3
Shopping: level 0
Toileting: level 3
Bed mobility: level 3

Has not defecated for 3 days

Has catheter
Has 750ml of urine collected from 12am to
10am
Perspires a little
Yellow urine color
No UA Lab results for this day

Verbalized by the wife:

Maglisod japon siya og gimok tungod sa
iya opera
Dili siya kabuhat sa iya mga gusto kay walay

kusoog iya tiil.

Dressings on the right leg and its

surroundings still noted
Inability to move purposefully and
independently
No movement seen on the right leg
Breathing pattern is normal
Perceived ability for:
Feeding: level 1
Bathing: level 3
Toileting: level 3
Bed mobility: level 3
Dressing: level 3
Gen. mobility: level 3

37

5.

Sleep Rest Pattern

Onset: 8-9pm
Awakening: 5am
Ready for activity after sleep as verbalized
by the wife
Rest time: after lunch
Feeling well rested after rest

6.

Cognitive Perceptual Pattern

No hearing and vision difficulty
Doesnt wear eye glasses
No change in memory
Learn things easily

7. Self Perception/ Self- Concept Pattern

Verbalized by the wife:
He feels good with his self

Dressing: level 3
Gen. mobility: level 3
Home maintenance: level N/A
Grooming: level 3
Cooking: N/A
Shopping: N/A
Muscle strength of 1/5 where 0 has no
contractions and 5 has movements against
gravity with full resistance

Home maintenance: level N/A

Grooming: level 3
Cooking: N/A
Shopping: N/A
Muscle strength same as 1/5 where 0 has no
contractions and 5 has movements against
gravity with full resistance

Sleep onset: 9pm

Sleep pattern disturbance due to giving of
medications
Wasnt able to rest well

Doesnt use sleeping pills

Sleep pattern disturbed due to giving of
medications
Wasnt able to rest well

No hearing and vision difficulty

Doesnt wear eye glasses
No change in memory
Learn things easily
Can talk properly as verbalized by the
wife
Has decrease attention span due to pain

No hearing and vision difficulty

Doesnt wear eye glasses
No change in memory
Learn things easily
Responds and speaks properly
Has decrease attention span due to pain

He feels sad about it, but we just

He accepts and understand the situation

38

8.

feels depressed and angry when there is

problem, financially and with the
children
we talk about the problem to solve it

Role-relationship Pattern
Dialects spoken at him is Cebuano
Lives with her wife and 2 children
Turns to his wife when he needs help with
anything
Decision making is done by both husband
and wife
No difficulties in relating with her family

9. Sexuality- Reproduction
Has been using contraceptives
No problems with his partner
Has 2 children
Feels happy being a man with a
family
Still shows affection
Sexually active due to schooling and
work
10. Coping-Stress Management
Always make decisions with his wife
No big change or losses in the past
years
Can tolerate stress
Watches television when stressed in
order to relax

understand the situation, we cant do

anything about it as verbalized by the
wife.

His work is affected

Decision making is done by his wife

His wife is always at his bedside ready to
attend to his needs
His role of being a father is affected
Sometimes visited by relatives

His wife always at his bedside ready to

attend to his needs
His role of being a father and his work is
affected
Sometimes visited by relatives

Wife is taking care of him; attentive to his

needs like in feeding and buying of
medications needed
Still shows affection
Not sexually active due to hospitalization

Feels that this hospitalization is very

stressful but the wife is doing its best in
helping his husband in coping up
Wife is the most helpful in talking things
over

Wife is taking care of him; attentive to his

needs like in feeding and buying of
medications needed
Still shows affection
Not sexually active due to hospitalization

Not use of always lying in bed but his wife is

doing its best in helping his husband in
coping up
Wife is the most helpful in talking things
over

39

11. Value-Belief
Finds God as a source of strength
God and religion are important to
them
Verbalized by the wife that praying
relieves the difficulties in them that
arises.
Finds time to hear mass every Sunday
Fearful and praises God

Finds God as a source of strength

Prays with his wife in the hospital
Considers religion as most important to
them
Still fearful and praises God in spite of his
condition

Finds God as a source of strength

Consider religion as most important thing
Prays with his wife in hospital
Praying to gain more strength
Still fearful and praises God in spite of his
condition

40

NURSING CARE PLAN

(NCP)

41

COLLEGE OF NURSING
Silliman University
Dumaguete City
NURSING CARE PLAN

CUES/EVIDENCES
Subjective:

Verbalized sakit
kaau ako tiil
tungod sa opera.

NURSING
DIAGNOSIS
Acute pain r/t
irritation of the soft
tissue secondary to
open fracture, right
leg

OBJECTIVES
Within our 2-day care, the
client will manifest lessen
pain as evidenced by:

Verbalization of
ability to cope with
incompletely
relieved pain

Verbalization of
method that lessens
pain

Objective:

Rated pain as 8 in
the range of 1-10
where 1 is atleast
pain and 10 is the
most pain.
Facial grimacing
Easily irritated

Demonstration of
use of relaxation
skills and
diversional
activities

INTERVENTIONS

RATIONALE

Independent:
1. Monitor vital
signs.

1. An information
baseline
comparison from
previous data and
llterations from
normal maybe
signs of infection.

2. Obtain clients
assessment of
pain which
includes location,
onset, frequency,
quality, intensity
and precipitating
factors. Reassess
each time pain is
reported.

2. To rule out
worsening of
underlying
condition or
development of
complications.

3. Observe
nonverbal cues or
behaviors.

3. Observations may
or may not be
congruent with
verbal reports.
According to
Dorothy Johnson,
he indicated the
behavioral system

EVALUATION
Goal met:
Within our care, he was able
to:

Verbalized ability
to cope with
incompletely
relieved pain

Verbalized method
that lessens pain

Demonstrated use
of relaxation skills
and diversional
activites

42

and its subsystems

and that behaviors
play a role in the
work of all helping
professionals.
4. Encourage patient
to verbalize pain.

4. Promotes
cooperation from
the client.

5. Encourage
diversional
activities (radio,
socialization with
others).

5. To divert attention
from pain.

6. Provide comfort
measures such as
deep breathing
exercises,
repositioning and
relaxation
techniques.

6. This promotes
relaxation and
reduces muscle
tension or spasm,
redistribute
pressure on body
parts and helps
patient focus on
non pain related
subjects.

7. Provide
application of hot
and cold
compress.

7. To relieve pain in
the muscle area.

8. Give health
teaching to
increase intake of

8. To promote
healing of wound.

43

vitamin C.
9. Manipulate the
environment to
promote periods
of uninterrupted
rest.

9. This promotes
health and well
being. According
to Florence
Nightingale, she
focuses on the
environment and
her belief that
energy for healing
or improvement
comes from within
the person.
Moreover, the
environment
should be quiet,
clean and well
ventilated

Collaborative:

10. Administer
analgesic
medications as
ordered.

10. To minimize
clients pain and
this is to comply
the physicians
order.

44

CUES/EVIDENCES
Subjective:
Maglisod jud siya
ug gimok tungod sa
iya opera as
verbalized by the
wife
Dili ko ganahan
mugimok tungod sa
sakit sa akong
opera, as
verbalized by the
client
Objecives:
has dressing on its
right leg
inability to move
purposefully and
independently
Muscle strength of
1/5

NURSING DIAGNOSIS
Impaired physical
mobility r/t
musculoskeletal
impairment secondary to
open fracture; Right leg

OBJECTIVES
Within our 5-hour care, the
client will improve physical
mobility as evidenced by:
Perform physical
activity with
assistance or any
assistive devices as
needed
Demonstrate
techniques or
behaviors that
enable resumption
of activities
Maintain increase
strength and
function of affected
or compensatory
body part
Verbalize
understanding of
situation and
individual treatment
regimen and safety
measures
Demonstrate muscle
strength of at least
3/5

INTERVENTIONS
Independent:
1. Assess degree of
mobility produced
by injury or
treatment and note
patient perception
of immobility
2. Encourage
participation on
diversion or
recreational
activities.

3. Assist in active or
passive range of
motion exercises
of affected and
unaffected
extremities.
|
vide footboard

RATIONALE
1. Patient may be restricted by
self-view or self-perception
out of proportion with actual
physical limitations
requiring interventions to
promote progress toward
wellness.
2. Provide opportunity for
release of energy, refocuses
attention, enhances patients
self control or self-worth and
self-efficacy and aids in
reducing social isolation.
According to Alberta
Bendwas self-efficacy
theory, it is the expectation
that one can master a
situation and produce a
positive outcome.
3. Increases blood flow to
muscles and bone to improve
muscle tone, maintain joint
mobility; prevent
contractures or atrophy.

EVALUATION
Goal partially met:
Within our care, the client
was able to:

4. Useful in maintaining
functional position of
extremities, preventing
complication. According to
self-care theory of Dorothea
Orem, nurses have to supply
care when the patients
cannot provide care to

Not performed
physical activity
with assistance or
any assistance
devices
Not demonstrated
techniques or
behaviors that
enable resumption
of activities
Partially increase
strength and
function of affected
or compensatory
body part
Verbalized
understanding of
situation and
individual treatment
regimen and safety
measures
Not demonstrated
muscle strength of
at lest 3/5

45

themselves.
4. Encourage and
assist with self
care activities (e.g.
sponge bath,
mouth care)

Collaborative
Refer to a physical
therapist as
indicated

5. Improves muscle strength

and circulation , enhances
patient control in situation
and promote self-directed
wellness. According to
Dorothea Orem, we as
nurses should provide care
when patients cannot
provide care to themselves.
Patients may require more
intensive treatment to deal
with current condition and
prolonged immobility

46

CUES/EVIDENCES

NURSING
CUES/EVIDENCES
DIAGNOSIS

Subjective:
The wife verbalized,
Dili siya kabuhat sa
iya mga gusto kay
walay kusoog iya
tiil.
Objectives:
Presence of dressing
on the right leg
No movements seen
on the right leg
Inability to perform
activities:
Bathing=3
Dressing=3
Toileting= 3
Bed mobility=3
Grooming= 3
Feeding= 1

Activity Intolerance
related to weakness on the
right leg secondary to
open fracture, right leg

OBJECTIVES

At the end of our 5 hour

nursing care, the patient
will be able to improve
activity tolerance;
response to energyconsuming movements as
evidenced by:
Use of identified
techniques to
enhance activity
tolerance
Participate
willingly in
necessary/ desired
activities
Report
measurable
increase in
activity tolerance

INTERVENTIONS
Independent:
Assess clients
perceived limitations
to an activity
Assess client on
weakness
Assess the client on
the degree of
assistance or use of
equipment
Assist the patient to
stand and move about
Provide a rest period
during an activity
Provide positive
atmosphere, while
acknowledging
difficulty of the
situation for the client

Promote comfort
measures and provide

RATIONALE

Provides comparative
baseline and information
about needed education
or intensions regarding
quality of life
Symptoms may be result
of or contribute to
intolerance of activity
To determine a current
status and needs
associates with
participation in needed/
desired activities
To protect client from
injury
To reduce fatigue
Helps to minimize
frustration and
rechanneling energy.
According to Florence
Nightingale, she focus on
environment and her
belief that the energy for
healing or improvement
comes from within the
person is certainly
applicable by any of the
helping professionals
To enhance ability to
participate in activities.
According to Jean

EVALUATION
Goal partially met:
At the end of our
nursing care, the patient
was able to:
1. Used identifies
techniques to
enhance activity
tolerance
2. 2. Participate
willingly in
necessary/
desired
activities
3. Partially
reported
measurable
increase in
activity
tolerance

47

a relief of pain

Instruct client to give

responses to the
activity and recognizes
signs and symptoms
Give client
information about
daily and weekly
progress
Encourage to maintain
positive attitude and to
use relaxation
technique
Teach about
appropriates safety
measures and
demonstrate
Collaborative:
Refer to other
disciplines, such as
exercise physiologist
psychological
counseling and
physical therapist

Watson, who emphasis

caring, including her
carative factors.
Indicate need to alter
activity level
To sustain motivation

To enhance sense of
well-being
To prevent injuries

To develop individually
appropriate therapeutic
regimens

48

Summary of nursing diagnoses

49

Acute pain r/t irritation of the soft tissue secondary to open fracture, open right leg
Impaired physical mobility r/t musculoskeletal impairment secondary to open fracture; Right leg
Activity Intolerance related to weakness on the right leg secondary to open fracture, right leg
Increased risk of hypovolemia and shock related to trauma and bleeding
Impaired skin integrity related to surgical repair
Self-care deficit related to decreased strength/endurance
Anxiety related to symptoms of disease and fear of the unknown
Knowledge deficit related to information unfamiliarity
Risk for Infection related to traumatized tissues
Risk for impaired gas exchange related to altered blood flow
Risk for peripheral neurovascular dysfunction related to tissue trauma
Risk for trauma related to skeletal integrity

50

Related Journal Readings

51

Journal Readings
Journal Readings # 1

Efficacy of hydrosurgical debridement and nanocrystalline silver dressings for infection

prevention in type II and III open injuries
Based on the article that I had read, the aim of the study was to retrospectively evaluate the clinical and culture-positive infection rates of open
Gustilo/Anderson type II and III fractures using a protocol nanocrystalline silver wound dressing and hydrosurgical debridement. Retrospective case series through
chart review on all type II and III open fractures were treated using a novel protocol from December 2005 to March 2008. All Gustilo/Anderson grade II and III
open fractures were treated with a novel protocol at a Level I trauma centre. Open Gustilo/Anderson grade II and III fractures were acutely stabilized in the trauma
centre/emergency department, while a nanocrystalline silver dressing was placed within the wound. Debridement using hydrosurgical scalpel and gravity irrigation
was performed within 6 to 8 hours of injury. Cultures were obtained prior to definitive fixation. The primary outcome measurements were positive cultures and
clinical infection rates. Seventeen patients met inclusion criteria. Mean age (335) and injury severity score (127) were gathered. There were 4 grade II open
fractures (235%), 11 grade IIIA (647%) and 2 grade IIIB open fractures (118%). The mean time to intravenous antibiotics was 615 minutes. The mean time to
initial debridement/irrigation was 2221 minutes. The average number of surgical procedures was 235 with a mean length of stay of 118 days. Six patients
developed positive cultures from the traumatic wounds, five were contaminants. One clinical infection was found (methicillin-resistant Staphylococcus aureus). The
overall clinical infection rate in this series was 59% (1/17). The only infection was in a Gustilo/Anderson grade II fracture. There were no infections in the more
high-energy Gustilo/Anderson grade IIIA and IIIB fractures compared with the Gustilo/Anderson control of 4-42%. We conclude that this novel protocol for openfracture treatment is a promising intervention. A further prospective randomized clinical study is warranted.

52

REACTION:

As we all know, open fractures present a unique challenge for the surgeons as two critical issues must be addressed. There is bacterial contamination at the
fracture site which commonly originates from the skin and environment and presents a major barrier to healing. Therefore, open fractures are at great risk of
infection and delayed union particularly in the setting of high-energy trauma.
It is good to know that there is such thing as gold standard for prevention of infection of open fractures and that is early antibiotic prophylaxis followed by
urgent debridement and irrigation (D & I) and stabilization. Silver has been used in modern medicine for nearly two centuries as an effective antimicrobial agent and
this has been shown to be cytotoxic for keratinocytes and fibroblasts; however, the cytotoxicity of silver depends on the method of application compared with
nanocrystalline silver dressings. Clinically, silver has been used mainly as a liquid (silver nitrate) or incorporated in cream (silver sulphadiazine) for the
management of burn wounds and the prevention of associated burn asepsis. Since our generation is improving and is now having new technologies for the better
good, Im happy that a nanocrystalline silver dressing has been developed to prevent wound adhesion, limit nosocomial infection, control bacterial growth and that
this could facilitate burn wound care. Through this, our patients will not experience these things if doctors would use nanocrystalline silver in their treatment.
According to the article, the treatment of open fractures with the use of nanocrystalline silver dressings and hydrosurgical debridement decreases clinical infection
rates compared with historical controls. However, hydrosurgical debridement and nanocrystalline silver dressings have been separately used in different areas for
the management of necrotic and burn wounds but have not been described as an approach to manage open fractures.

53

Journal Readings # 2

Timing issue in open fractures debridement: a review article

Open fracture constitute a major trauma mostly sustained by young adults during high-energy injuries. Management of long bone open fractures is a very
complex issue and is often complicated by nonunion and deep infection being among the most devastating and difficult to cure. It is generally recommended that
wound debridement and stabilization of open fractures should be performed as early as possible, preferably within 68 h on the basis of historical comment and
laboratory data. The rationale for this rule is believed to originate from Freidrichs historical study of guinea pigs. The literature lacks strong evidence addressing
the primary issue of timing and delay on the incidence of deep infection and nonunion in open fractures. In the light of the actual literature regarding this topic, it
seems that time to debridement of open fractures is not a prognostic factor of infection as well as nonunion.

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REACTION:
This piece is all about the time of surgical debridement and its relationship to the infection rate. The infection rate will be affected by either early or late
debridement. We clearly understood its main ideas but partially on the opinion and the supporting ideas. We chose this article because it has interesting thoughts. It
also said that if an open fracture without debridement stays more than 8 hours, then the bacteria replicates, thus it will lead to infection.
A lot of people have infections due to late debridement; however, if the debridement will be started early, then there would be a reduced risk of infection.
Wound debridement and stabilization of open fractures should be performed as early as possible, preferably 6-8 hours. The article was convincing because it relates
our case which is open fracture. Unfortunately, there are some points that overemphasize which are for me considered as irrelevant. But, it is well-researched
because the authors are Alberto Jorge-Mora, Juan Rodriguez-Martin, and Juan Pretell-Mazzini and it was well presented in a balanced way.
This article is helpful for people to be aware of how time is important when performing surgical debridement for open fractures. However, we havent
experienced being fractured, so we cant relate this to our experience but well relate this to our patients case. About our patient, few hours after the injury, he was
able to go to SUMC directly and was given care. He was examined in the X-ray and was operated through debridement. We also chose this because we are
interested and we now realized that time of debridement can affect the condition of the injury and to the body. It didnt bother or annoy us because this can be really
helpful not just to our case presentation but also to our duty in surgery.

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References
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Pillitteri, A. Maternal & child health nursing: care of the childbearing & childrearing family. 3rd ed. Vol. 2. Lippincott

Journal Sources:
Efficacy of hydrosurgical debridement and nanocrystalline silver dressings for infection prevention in type II and III open injuries. Retrieved from
http://web.a.ebscohost.com/Legacy/Views/static/html/Error.htm?aspxerrorpath=/ehost/detail/detail
Jorge-Mora, A., Rodriguez-Martin, J. & Pretell-Mazzini, J. (April 4 2012). Timing issue in open fracture debridement: a review article. Retrieved from
http://link.springer.com/article/10.1007%2Fs00590-012-0970-7

Internet Sources:

Broken bone. Retrieved from: https://ufhealth.org/broken-bone 2 Aug 2014

Open fractures. Retrieved from: http://orthoinfo.aaos.org/topic.cfm?topic=A005822 Aug 2014
Pathophysiology of fracture. Retrieved from: http://www.scribd.com/doc/102257963/Pathophysiology-of-Fracture 2 Aug 2014
What happens when a person bleeds. Retrieved from: http://www.stepsforliving.hemophilia.org/basics-of-bleeding-disorders/what-happens-when-a-person-bleeds
2 Aug 2014

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