Orif Case Study

ST. PAUL UNIVERSITY, QUEZON CITYNURSING DEPARTMENT

FRACTURE AT RIGHT FEMUR - ORIF[CASE STUDY]

ST. PAUL HOSPITAL, CAVITE

MS. JENIFFER LUALHATI

SAKAMOTO, KAREN S.

Nov. 24, 2008

I. INTRODUCTION

We as a student nurses, wellness of the patient is the primary objective. And the best way to

promote these is by means of actualization.

Fracture is any break in the continuity of bone. In some cases, a bone may fracture without

visibly breaking. Fractures occur when the bone is subjected to stress greater than it can

absorb. It can be caused by a direct blow, crushing force, sudden twisting motion, or even

extreme muscle contraction. When the bone is broken, adjacent structures are also affected,

resulting in soft tissue edema, hemorrhage into the muscles and joints, joint dislocations,

ruptured tendons, severed nerves, and damaged blood vessels. Body organs may be injured by

the force that caused the fracture or by the fracture fragments. And according to the physician

the kind of fracture that Mr. M.C experience is comminuted fracture that the bone splinters at the

site of impact, and smaller bone fragments lie between the two main fragments.

Femur is the largest and strongest bone and has a good blood supply. Because of this and its

protective surrounding muscle, the shaft requires a large amount of force to fracture. Once a

fracture does occur, this same protective musculature usually is the cause of displacement,

which commonly occurs with femoral shaft fractures. Orthopedic surgeons often encounter

femur fractures because these fractures most often result from high-energy trauma, one must

have a high index of suspension for complications or other injuries like vehicular accident that

experience by Mr.M.C. While a variety of treatment options exist for a fracture that is associated

to injury.

We have chosen Mrs. M.C with the case of fracture, comminuted at the distal third right femur

because the patient showed willingness and interest to learn and understand about her

condition. We also want to know, and understand more about his case.

General Objectives:

At the end of the study or learning, the level 3 nursing students will be able to rectify, expound,

and relate all ideas or perception to the nursing approach in doing valid and outmost care with

the patient experiencing Fracture in the right Femur and undergone ORIF procedure.

Specific Objectives:

the level 3 student nurses will be capable of:

1. Proposing the overall assessment findings with the patient experiencing Fracture in the right

Femur.

2. Expounding thoroughly and articulately the anatomy and physiology of the systems involved

in Fracture.

3. Providing illustration and explanation of the pathophysiology of the Fracture in the right

Femur with regards to the patient.

4. Devising a well planned, with the principle of SMART a comprehensive nursing care plan that

is applicable to the patient with Fracture in the right Femur.

5. Inculcating health teachings for the patient to follow and be in great help for his condition.

6. Elucidating and discuss the rationale of the different nursing interventions to the patient and

to the family as well.

7. Evaluate the effectiveness and accuracy of the outcome of the nursing interventions.

8. Providing the needed information or knowledge to attain a healthy living.

II. PERSONAL DATA

Name: Mr. MGC

Address: # 334 Hugo Perez Trece Martires Cavite

Birthday: August 18, 1979

Age: 29

Birthplace: Cavite

Nationality: Filipino

Case #: 012744

Room #: 303-C

Hosp. #: 3322

Attending Physician:

Dr. B, Dr. A, Dr. Barr, Dr. G

How admitted:

Via Stretcher

Admission Date & hour:

November 13, 2008

04:30 AM

In case of emergency, please notify:

MRS. MC

Relation: Wife

Contact # : 09164295484

III. Nursing Assessment

A. Nursing History (Gordon’s Functional Health Pattern)

Clinical Manifestations Mr. M felt numb over his lower extremity during the said vehicular

accident and all he could feel that certain time is his wound.

Health Perception /

Health Management

Health to Mr. M is important to him because he cannot afford not to

work since he is newly married. He sees to it that he does not get sick.

He has no previous hospitalization and no family history of any

disease or abnormality.

Nutritional / Metabolic He likes to eat vegetables and seldom eats fish and meats.

Elimination He doesn’t have a hard time voiding and defecating. He defecates

once a day. He said that it was normal for him.

Activity / Rest He doesn’t have enough hours of sleep. He sleeps 6 – 7 hours a day

because he works from 8am – 5pm Tuesday to Sunday. His work is

far from where they are living.

Cognitive / Perception His sense of smell and hearing is normal. There’s no problem but his

eyes are color blinded.

Self Perception / Self-

concept

Mr. M felt embarrassed and at the same time, ashamed because of

what happened to him. He felt sad because he will not be able to work

for their living because of his present condition. He is also sad and

depressed because he will be having a hard time doing his usual

routine. He used to play basketball when he has time and design

stickers.

Role / Relationship Mr. M is second among six siblings. They have no conflicts among

relatives or family members. Mr. M and his wife understand each other

and care for each other.

Sexuality/Reproductive Mr. M recently got married so they will be having a hard time in making

children because of his condition. They were planning already to have

children but they didn’t expect to have this situation.

Coping/Stress

Tolerance

Mr. M cope his stress by talking to his friends, to his wife or fixing his

motorcycle. Mr. M has no vices. He doesn’t smoke and he doesn’t

drink alcohols.

Values/Beliefs Mr. M follow the belief of not sweeping at night because the good luck

will go away.

B. Physical Assessment

Patient has posterior bandage of the right Femur, has pale pink nail beds on the right foot, and complained of pain in the operative site but unfortunately, we failed to ask for the pain scale and we did not have enough time to further assess and handle the patient.

C. Medical History

For his past medication, we also failed to get information from the patient because we did not have enough time and to handle the patient.

IV. History of Present Illness

2 days prior to surgery, Mr. M was on his way home at night from work via motor vehicle. There

was a road construction in the highway. He assumed that the construction truck was way far

from the excavated hole so he regulated his speed to find out that the hole was directly after the

truck. He couldn’t swerve to the other lane because there were fast cars so he fell under the

hole.

V. Anatomy and Physiology

The femur or thigh bone is the only bone in the thigh. It is the heaviest and

strongest bone in the body. Its proximal end has a ball-like head, a neck

and greater and lesser trochanters. The head of the femur articulates with

the acetabulum of the hip bone in a deep secure socket.

Skeletal muscles are formed when the muscles are

attached to the skeleton or bone, which move the

limbs and other parts of the body.

The muscle that is attached to the femur is known to be the Quadriceps

group, which is consisted of the rectus femoris and three vastus muscles.

All four muscles insert into tibial tuberosity via patellar ligament.

VI. Pathophysiology

VII. Medical Management

A. X-RAY

Patient was diagnosed of Fracture at the distal 3rd right Femur

B. PRE-OP MEDICATIONS

1) ketorolac tromethamineAction: Inhibit prostaglandin synthesis, to produce anti-inflammatory, analgesic, antipyretic effects.

Indication: short-term management of moderately severe, acute pain (for single-dose treatment or multiple-dose treatment)

2) cefuroximeAction: Second-generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.

Indication: For bone or joint infection ; Perioperative prevention

3) ranitidineAction: Competitively inhibits action of histamine on the H2 at receptor sites of parietal cells, decreasing gastric acid secretion.

Indications: For active duodenal and gastric ulcer, maintenance therapy for duodenal or gastric ulcer, pathologic hypersecretory conditions, GERD, erosive esophagitis and heartburn.

4) Metoclopromide hydrochlorideAction: Stimulates motility of upper GI tract, increases lower esophageal sphincter tone and blocks dopamine receptors at the chemoreceptor trigger zone.

Indication: To prevent or reduce postoperative nausea and vomiting.

5) ParacetamolAction: Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating center.

C. HEMATOLOGY

Lab ResultsHEMOGLOBIN Date: 11/12/08 10:16 pm Release: 11/12/08 10:37 pmHemoglobinNV: 140-175g/L RESULT: 139g/L

HematocritNV: 0.41-0.50 RESULT: 0.41 HEMATOLOGY DATE: 11/13/08 4:50am Release: 11/13/08 5:22 am Hemoglobin Mass ConcentrationNV: 12-17 gms% RESULT: 13gms% Erythrocyte, Volume Fraction (Hct)NV: 40-45 % RESULT: 39%

VIII. Surgical Procedure

An incision is made in the right thigh, exposing the fractured part of the bone. The right femur

(fractured bone) is then holed, so that the orthopedic surgeon would be able to put the

reconstruction nail into the medullary canal. Then nail were attached to secure the femoral

fracture. The screws were attached to fixate the rod

IX. Nursing Care Plan

Assessment Diagnosis Inference Planning Interventions Rationale

Subjective

“Sumasakitat kumikirot

anginoperahansakin,” asVerbalized

by the patient.

Objective

Pain scale: (?) – failed

to get

c incisionon the R

femur(ORIF-treated)

c posteriorbandage on

R femur

Acute Pain

Related toSurgery incision

on R femur

Internalfixation

devices to hold the bone

fragment in position

Internal bleeding

Blood is associated to

swelling

It cause Acute pain

Short-term Goal

After 4 hours of

nursinginterventions,the patient:

◊ verbalizesminimizedfeeling of

pain

◊ verbalizesmethods thatprovide relief

◊demonstratesuse of

relaxationskills &

diversionalactivities asindicated forhis situation

Monitor vital signs Q15 until stable and check

and change dressing if needed.

Encourage ambulation

or even minimal

movement of

unaffected part.

Adjust bandage if constricted and advise to elevate R

leg.

Instruct and demonstrate of how to do

a deep breathing exercise.

Alterations to normal may be a sign of

infection.Moistened

dressings are favorable site

for microorganism

to culture.

◊ To divert attention on

pain and increases circulation.

◊This is to prevent

Diminished circulatory &

nerve function and to control swelling of the

site.

◊Help to promote

circulation, relaxation of

muscles.

-Unable to evaluate due to we were not able to handle and talk to the patient again.


Subjective

◊ “Medyo di pa akomakakilos ng gaya

dati dahil sa nakakabitsa akin” as verbalized

Objective

◊ c internal fixator@ R leg

Impaired physical

mobility of the

lower extremity related tointernal

fixator @ R femur

ORIF procedur

e

Bleeding from

damaged ends ofbone &

fromsurrounding tissue

Stimulates intenseinflammat

oryresponse

Pain

Impaired physical immobility of the lower R extremity

Short Term Goal

◊ After 3 days ofnursing

interventions,the patient will demonstrate

properexercises of the

unaffected lower extremity

◊ Assist and demonstrate in doing exercises for the unaffected lower extremity.

◊Encouragedprogressive activitiesaccording to level offatigue

◊Necessary to regain normal mobility of leg to speed recovery.

◊ Increase patient’sUse of affected leg.



Objective

◊ Portal of entry of micro-

organism because of

surgical incision

◊ Another portal of entry via dressings is poorly dressed.

Risk for infection related to

inadequate primary

defenses such as

broken skin and

traumatized tissues.

ORIF procedure

Internal & external bleeding

Healing process of tissues will take quite a

long time

Leaving the tissues partially

open

There is a point of

entry for the micro-

organism to enter

Short Term Goal

After 2 days ofNursing interventions, the patient will be able to demonstrate techniques to prevent risk of infections.

◊ Stress proper hand hygiene by all caregivers between clients.

◊ Educate to Maintain sterile technique

◊ Emphasize necessity of taking antivirals / antibiotics as directed.

◊ It is a first line of defense against infections and help minimize cross contamination

◊ To minimize accumulation of bacteria and to maintain asepsis.

◊ Premature discontinuation of treatment when client begins to feel well may result in return of infection and potentiate drug resistant strains.


X. HEALTH EDUCATION

1. Explain basis for fracture treatment and need for patient participation in therapeutic regimen.

2. Promote adjustment of usual lifestyle and responsibilities to accommodate limitations

imposed by fracture.

3. Instruct the patient to actively exercise joints above and below the immobilized fracture at

frequent intervals.

4. After removal of immobilizing device, have the patient start active exercises and continue with

isometric exercises.

5. Instruct the patient on exercises to strengthen upper extremity muscles if crutch, walking is

planned.

6. Instruct the patients in methods of safe ambulation-walker, crutcher, and cane.

7. Emphasize instruction concerning amount of weight bearing that will be permitted on

fractures extremity.

8. Discuss prevention of recurrent fracture; review safety consideration, avoidance of fatigue,

proper foot wear.

9. Encourage follow-up medical supervision to monitor for bone union problems.

10. Teach the patient to recognize and report symptoms needing attention, such as numbness,

decrease function, increase pain, or elevated temperature.

11. Encourage the patient to follow an adequate balance diet to promote bone and soft tissue

healing.

XI. CONCLUSION

Towards the end of the case study or learning, the level 3 nursing students were able to,

proposed the overall assessment findings with the patient experiencing a Fracture, comminuted

at the distal third right femur and expounded thoroughly and articulately the anatomy and

physiology of the systems involved. They were able to illustrate and explain the pathophysiology

of the Fracture, comminuted at the distal third right femur with regards to the patient, devised a

well planned, with the principle of SMART a comprehensive nursing care plan that is applicable

to the patient with Fracture, comminuted at the distal third right femur, inculcated health

teachings and elucidated and discuss the rationale of the different nursing interventions to the

patient and to the family as well. After proving the interventions, they evaluated the

effectiveness and accuracy of the outcome.

Orif Case Study

Documents

Transcript of Orif Case Study