Diploma in Nursing

8/8/2019 Diploma in Nursing

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DIPLOMA IN NURSING

CASE STUDY SEMESTER 6

TITLE:

CLOSE FRACTURE OF MIDSHARF RIGHT

FEMUR

NAME : ERNINA JOHNIOUSID NO : 03-200901-00391

GROUP : 1

INTAKE : JANUARY 2009

CI NAME : MDM NANCY LO


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CONTENT

TITLE

A. INTRODUCTION OF THE CASE PATIENT

1.1 Patient information data

1.2 History of present injury

1.3 Patient progress notes

B. INTRODUCTION OF THE CASE STUDY

2.1 Definition

2.2 Types of fracture

2.3 Causes

2.4 Clinical manifestation

2.5 Immediate Managment

2.6 Medical managment

2.7 Complication

C. NURSING CARE PLAN

3.1 Nusing diagnosis & intervention

3.2 Health education

3.3 Discharge plan

SUMMARRY

CONCLUSION

REFERENCE


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A. INTRODUCTION OF THE CASE PATIENT

1.1 Patient information data

Name : Mr. X-ray

Ic no : 031119-12-1371

Sex : Male

Age : 7 years

Race : Murut

Religion : Kristian

Address : Kg. saga

Nationality : Malaysia

Social status : NIL

Allergic : NIL

Date of addmission : 15 October 2010

Date of discharge : 20 October 2010


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1.2 History of present injury

Patient fall from the tree and he cannot stand up.after that he feels right leg very

painful and swelling.He parents bring to the hospital and after take x-ray he diagnosis is

close fracture midsharft of right femur.


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1.3 Patient progress notes

15 / 10 / 2010 ( On Addmission)

7.30 PM

Admitted by Dr. B, A&E warded at 7.30 pm on streacher and thomas splint,case

escorted by PPK.Patient complaint swelling and pain in the right leg.

Vital sign

BP : 118 / 82

Pulse : 112

Temp : 37.5 0c

Spo2 : 97%

Plan

1. Splinting2. BUSE3. Tab. PCM 250 mg4.

X-ray

10 PM

Patient complain pain and cannot sleep well.

Blood pressure high and level of pain is 6.

BP : 123 / 89

Plan

1. Tab. PCM 250 mg

2. Admitted in children ward

Reacheck BP after 30 minutes BP : 109 / 79


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16 / 10 / 2010

8 AM

Close Fracture Midsharf of Femur

- No active complaint- Sleep well- No SOBPlan

1. Monitor vital sign2. KIV antibiotic3. On skin traction today

Vital sign

BP : 101 / 80

Pulse : 102

Temp : 37.1 0c

Spo2 : 98%

10 AM

- On skin traction 2 kg with thomas splint- On medication- Allow orally- Monitor pain score- Arrangment physiotherapyMedication

1. Tab PCM 250 mg


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17 / 10/ 2010

8 AM

- Cont skin traction 2 kg- No complaint- Sleep well- Off medication10 AM

- Patient comfort, tolerance orally well- No skin breakdown- Positioning 2 hourlyVital sign

BP : 98 / 68

Pulse : 105

Temp : 36.80c

Spo2 : 98%

Physiotherapy noted

- No active c/o today- Patient sitting on the bed, alert and coperative- Both upper limb actively more- No coughing noted- Breathing pattern (symmetrical & diaphramatic)


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18 / 10/ 2010

8 AM

- Cont skin traction 2 kg- No complaint- Sleep well10 AM


BP : 100 / 78

Pulse : 98

Temp : 36.60c

Spo2 : 99%

Physiotherapy noted



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19 / 10/ 2010

8 AM



BP : 99 / 75

Pulse : 115

Temp : 37.70c

Spo2 : 99%

Fever today and tepid sponging apply

Repet temperature after 30 minuts

Temp : 36.9oc

Physiotherapy noted



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20 / 10/ 2010

8 AM


- Patient comfort, tolerance orally well- No skin breakdown- Positioning 2 hourly- Discharge today- Go to hospital Keningau to do POPVital sign

BP : 108 / 70 mmHg

Pulse : 106

Temp : 36.70c

Spo2 : 96%


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B. INTRODUCTION OF THE CASE STUDY

Fractures of the femur are common childhood injuries and among the most common

causes of hospitalization for pediatric orthopedic injuries. The strong blood supply of

the fracture femur allows for rapid healing and generally favorable outcomes. The

treatment for fractures fracture varies based on the child's age and injury with a trend

towards operative stabilization.

Several observational studies have identified a bimodal age distribution for fractures

femur with peaks in the toddler age group, where falls are the predominant cause of

injury, and in the adolescent age group, where motor vehicle collisions cause most of the

fractures. Across all age groups, boys have higher rates of femoral shaft fractures than

girls.

Fracture femur is one of the most common fracture treated at tertiary level centre's

requiring adequate radiological assistance. Providing distal locking zig arm support in

the nail has made it possible to treat fracture femur at primary level with acceptable

locking, without the additional support with added benefits on surgeons part of less

expertise, less surgery time, and good to excellent union rates and at the same time on

patients part, avoidance of radiological exposure, being economical availability at the

next door itself.

Complications were the same as seen with closed interlocking nail involving limb length

discrepancy malrotoation infection with added complication failure to lock distal end in

few cases.

Mortality from a femur fracture has been estimated at 1 per 600 patients but is most

often due to associated injuries sustained as a result of high energy.


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2.1 Definition

A break in the femur bone. The femur is also known as the thighbone and is the main

bone that runs from the knee to the hip. It is one of the body's strongest bones in the

body and a lot of force is required to break it. A fractured femur is also known as afemoral fracture.


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2.2 Types of fracture

Transverse Oblique Spiral Angulated Displaced Angulated & displaced


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2.3 Causes

Direct traumay Accidenty

Falls Pressure

y Esp. In athletics Pathological fracture

y Decrease of density of the bones Others

y Osteoporosisy Pagets disease


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2.4 Clinical manifestation

Pain Loss of normal function Obvious deformity Excessive motion at sites Crepitus/grating sounds (crakling sounds produced by rubbing of the bones) Soft tissue edema Warmth over injured area Ecchymosis of the skin surrounding injured area (bluish black discoloration)

of the skin

Loss of the sensation/ paralysis distal to injury

Signs of shock Evidence of fracture on x-ray film


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2.5 Immediate Managment

Splinting & body alignment Elevation of body part Application of cold packs (1st 24 hours) to reduce hemorrhage, edema & pain Observe f0r change in colour, sensation & body temperature of injury part Observe for signs of shock


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2.6 Medical managment

Analgesics are given to treat the pain Antibiotics when there is open fracture or surgical intervention Maintenance of fragments in correct alignment thourgh immobilization Tetanus to toxoid IM ATT Prevention of excessive loss of joint mobility & muscle tone

Secondary managment

Optimal reduction (replace bone fragments in their correct anatomyposition)* Manual manipulation/closed reduction (traction pressure applied to

distal fragment

* Traction (application of the pulling force as means of contracting

the nautral tension in the tissue)

* Open reduction (surgical intervation that may use internal fixation

device

Immobilization*Traction skin traction, skeletal traction

*Internal fixation pins, screw,wires


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Skin Traction


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2.7 Complication

Hypovolemic shock* Control must be rapid

* Blood for grouping and X match (GXM)

* IV-Hartmans, N/saline , Gelofundine

* Vital signs monitoring

* Blood transfusion

Fat embolism (24-72 hours)* Microglobules of fat from the bone marrow at the fracture sites normally

Femoral shaft and pelvis

* Contributing factors can also be the excessive movement of fracture sites

Sign & Symptoms1.Respiratory Insufficiency

- Increased respiratory rate (Tachypnea)

- Use of accessory muscles

- Tachycardia, fever, chest pain

2.Petechial haemorrhage into the skin expecially at axilla, anterior chest wall

and conjunctiva

Knee stiffness* Early surgery and mobilization

* Gradual knee bending exercises

Wound infection* Common in compound fracture & surgical wound

Osteomyelitis* Inflammation of the bone


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C. NURSING CARE PLAN

3.1 Nusing diagnosis & intervention

Nursing diagnosis Goal Intervention Evaluation

Pain related to

fracture

Patient pain will be

reduce.

1.Monitor level of

pain with pain

score.

2. Administer

analgesics as

ordered by doctor

to relieve pain.

3.Advise patient to

rest in bed.

4.Less movement

5.Inform doctor if

pain no less.

Patient verbalized

less pain.

Observe facial

expression.

Level of pain less

from 10 to 0.

Anxiety related to

fracture

Patient verbalized

no anxiety.Sleep pattern and

appetite good.

1.Assess the severity

of the anxiety.2.Explain to patient

recarding process

to fracture.

3.Give spiritual

support.

4.Collaborate with

family members

to give emotional

support.

Patient verbalized

less anxiety.Observed sleep

pattern and apptiet.


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Nursing diagnosis Goals Intervention Evaluation

Potential impaired

skin integrity

related to

immobility

Patient skin remain

intact no signs of

skin breakdown.

1.Assess condition

of skin for

breakdown.

2.Relieve pressure

by using ripple

bed, gloves filled

with water.

3.Maintain personal

hygiene.

4.Protect the skin

from moisture by

applying.

protective cream.

5.Change position

of patient 2

hourly.

Skin condition

normal.

Knowledge deficit

related to fracture

Patient will be able

explain the nature

of the fracture,

treatment and

complication.

Patient give Good

feedback when ask

the question.

1.Assess the depth

of knowledge.

2.Explain the

patient the

process and

effect of the

treatment.

3.Encourge patient

And family to ask

Question.

4.Give health talk

Repeatedly.

Patient understand

about the fracture

and treatment.


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3.2 Health education

Less movement Don't try to realign the bone or push a bone that's sticking out back inWhen use cast

Always keep the cast clean and dry If the cast become very loose as the swelling goes down, call the doctor

Especially if the cast is rubbing againts the skin

Cover the cast with a plastic bag or wrap the cast to bath.Avoid shower Do not lean on or push on the cast, it may break Do not try to remove cast


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3.3Discharge planName : Mr. X -ray

Age : 7 years

Ward : Children ward

Sex : Male

Race : Murut

Date of addmission : 15 / 10 / 2010 @ 7.30 PM

Date of discharge : 20 / 10 / 2010 @ 2 PM

Diagnosis

Close fracture midshaft of right femur

No medication prescribed

Transfer to hospital Keningau to do POP

Follow up clinic appointment at 18 / 11 / 2010


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CONCLUSION

The femur is the most commonly fractured long bone. It is undisputed that majority of

these fractures can be satisfactorily treated by close inter locking nail.

Femoral fractures in nonambulating infants are generally felt to be attributable to abuse

in the absence ofsignificant traumaor underlying organic pathology. The investigation

of such fractures includes a report to appropriate social service and law enforcement

agencies, and legal involvement.

This paper describes nonambulatoryinfants who sustained identical midsharftl femoral

metaphyseal fractures extending through the growth plate after playing in an infant

stationary activity center called an Exersaucer. It is possible that the twisting motion

provided by the Exersaucer

(Evenflo, Picqua, OH) might be consistent with the

generationofforces necessary to cause these fractures.


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REFERENCE

1. Pati BN , Bansal VP , Krisnan LG , Ahmed A , Garg S . Interlocking nail offemur. A review of 90 classes. Ind J Orthop. 2001, 35: 1, 49-51.

2.

Clawson DK, Smith RF, Hansen ST. Closed intramedullary nailing of the femur.J Bone JointSurg (Am). 1971;50:681-69.

3. Hunter, JB. Femoral shaft fractures in children. Injury 2005; 36 Suppl 1:A864. Loder, RT ,ODonnell, PW ,Feinberg, JR. Epidemiology and mechanisms of

Femur fracture in children. J Pediatr Orthop 2006;26:561.

5. Rewers, A, et al. Childhood femur fracture, associated injuries , andsociodemographic risk factor; a population-based study. Pediatrics 2005;

115;e543


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Summarry Patient

Mr. X-ray was addmitted to A&E department on 15 october 2010 with complaint pain

and swelling at right leg.During in A&E department the patient vital sign was taken BP

118 / 82 mmHg, Pulse rate 112/min and spo2 97%.During at home this patient no takeanything medication.

Mr. X-ray was admitted at children ward by Dr. B around 7.30 am.1st day Mr. X-ray in

the ward he still in the pain.ain the ward treatments and investigation has taken.Nursing

care have been done to this patient.This patient no have special treatment bescause he

no complaint pain and allow orally.Vital sign is normal.

This patient on skin traction and no complain pain.Patient stable and

comfortable.Patient discharge because transfer to hospital Keningau to do POP.

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Diploma in Nursing