case analysis - fracture

7/29/2019 Case Analysis - Fracture

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DEMOGRAPHIC DATA

Patients Name: Espia, John Raphael

Age: 20 years old

Case Number: 734658

Civil Status: Single

Nationality: Filipino

Religion: Roman Catholic

Address: 368 Balagtas St. Asuncion, Tondo, Manila

Birthday: March 24, 1992

Birthplace: Bian, Laguna

Date of Admission: October 3, 2012

Diagnosis: Fracture, closed, complete comminuted, m3, femur R

Fracture, open 1, d3, tibia-fibula R

Physician: Dr. Reynes

NURSING HISTORY

General Information: J.R.E. is a 20 year old male patient coming in for R lower extremity pain.

Chief Complaint: R Thigh and R leg pain.

Present Illness:

Started 10 days PTA when the patient is riding a motorcycle with a drunk driver. They

got involved in a collision with a speeding jeepney throwing him off. He was rushed to a

hospital in Laguna and subsequently transferred to Batangas General Hospital and was placed

on traction before transferring to POC.

Past Medical History:

Patient sustained a tibial fracture on the R leg 10 years ago.

Family History:

(-) Hypertension

(-) Diabetes

Personal History:

He is a canteen service crew.

(+) Alcohol drinker

(+) Smoker - occasional

Physical Exam:

(+) Swelling deformity R thigh

(+) Swelling deformity R leg

(+) Less than 1 cm open wound R leg

Teodoro, Michelle Ann T.

Group 3

BSN 3


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PHYSICAL ASSESSMENT

BODY PART NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS/ASSESSMENT

HEAD Hair and Scalp

Cranium (Skull)

Face

Eyes and Vision

Ears andhearing

Nose

Mouth

NECK Muscles

- Hair evenly

distributed.

- Thick growth of hair.

- No presence of

infection.

- Amount of body hair

variable.

- Normocephalic.

- Absence of nodules or

masses.

- Symmetrical facial

features; palpebral

fissures equal in size.

- Symmetric facial

movements.

- Eyebrows and

Eyelashes evenly

distributed.

- Eyelids intact with

involuntary blinks perminute, and close

symmetrically.

- Bulbar conjunctiva is

transparent, sclera

appears to be white.

- Palpebral conjunctiva

is shiny, smooth and

reddish.

- Lacrimal gland/sac has

no edema and

tenderness-Cornea is transparent.

- Color same as facial

skin. Symmetrical.

- Mobile and firm pinna.

- Symmetric and

straight.

- No discharges, masses,

lesions.

- Uniform, pink in color,

moist and smooth in

texture.

- 32 adult teeth.

- Tongue pink in color,

moves freely.

- Muscles equal in size;

head centered.

- Hair evenly

distributed.

- Thick growth of hair.

- No presence of

infection.

- Amount of body hair

variable.

- Normocepalic.

- No nodules or masses

palpated.

- Symmetrical features

and facial movements.

- Hair evenly

distributed; equally

distributed.

- Eyelids intact.

- Transparent bulbar

conjunctiva. Sclera is

white.

- Shiny, smooth and

pale red/pink.

- No edema or

tenderness

- Transparent.

- Color same w/ facial

skin. Symmetrical.

- Presence of ear wax.

- Respond to sounds.

- Normal

- Uniform, dry in texture

- Tongue moves

symmetrically w/o

difficulty.

- Normal

- Dry lips indicates fluid

volume deficit.


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Lymph nodes Trachea

Thyroid Gland

Upper extremities Skin,

fingers/nails

Muscle strengthand tone.

Joints

Pulses

Chest and Back

Abdomen

Genitals

- Not palpable

- Central placement in

midline of neck; spaces

are equal on both sides.

- Not palpable.

- Color of skin is the

same w/ body color.

- Nails have smooth

texture, convex

curvature in shape.

- Nail beds slightly

pinkish in appearance,

with intact epidermis,

capillary refill in two

sec.

-Muscle size equal on

both sides of the body.

-No contractures and

tremors.-Muscle has equal

strength.

- No swelling. No

tenderness, crepitation

or nodules.

- Joints move smoothly.

- Present uponpalpation.

- Chest is symmetric,

spine is vertically

aligned, chest wall

intact; no tenderness;

no masses.

- Uniform in color,Symmetric contour

- No evidence of

enlargement of liver

and spleen.

- Audible bowel sounds,

bladder not palpable.

- Triangular distribution

of pubic hair. Pubic hair

intact.

- No inflammation,

swelling or discharges.

- Normal

- Normal

- Normal

- Skin is brown. Same

w/skin tone.

- Normal but longer and

dirty.

- Normal

- Normal

- Normal

- Pulse noted as 84 bpm

- Normal

- Normal

- Not examined.

- Due to the patients stay in

the hospital without regular

grooming.


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Lower extremities Skin

Muscle strengthand tone.

Joints

Toenails

- No abrasions.

- Smooth and

moisturized.

- No swelling or

redness.

- Uniform in color.

-Muscle size equal on

both sides of the body.

-No contractures and

tremors.

-Muscle has equal

strength.

- Able to move freely

- Color of skin is the

same w/ body color.

- Nails have smooth

texture, convexcurvature in shape.

- Nail beds slightly

pinkish in appearance,

with intact epidermis,

capillary refill in two

sec.

- R leg is in cast.

- Some visible parts

appears to be dry.

- (+) swelling on the R

leg.

- Limited ROM.

- R leg is in cast. L leg

appears to be normal.

- Limited ROM. Cannot

walk or go to another

place w/o wheelchair or

crutches.

- Nail beds on R leg

appears to be blanched.

- Due to fracture.

- Due to fracture.

- Due to poor circulation on

the casted leg.


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PATHOPHYSIOLOGY

The patient got involved in a vehicular accident 10 days PTA

Patient had fracture on the femur and tibia-fibula bone.

Swelling of the Right leg.

Was brought to the hospital and was put into traction.

Transferred to POC and had to put Steinmanns Pin and BST.

Patient was casted prior to discharge.

For closed possible open reduction nailing, tibia and fibula, femur early next year.

ANATOMY AND PHYSIOLOGY OF THE AFFECTED PART

Fracture, closed, complete comminuted, m3, femur R

The femur, or thigh bone, is the longest, heaviest and strongest bone in the body. Its

proximal end articulates the acetabulum of the hip bone. Its distal end articulates with the tibia

and patella.

The action of the gluteus medius has some tendency to pull the upper fragment

outward, and the strong pull of the abductor muscle group tends to cause outward bowing at

the point of fracture. In this fracture there is a general tendency to develop inward rotation of

the lower fragment and outward bowing.

Fracture, open 1, d3, tibia-fibula R

The tibia, or shin bone, is the larger, medial, weight-bearing bone of the leg. The tibia

articulates at its proximal end with the femur and fibula, and its distal end with the fibula and

the talus bone of the ankle.

(+) Comminuted

Fracture

(+) Fracture with

< 1cm open

wound

Femur Tibia and Fibula


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The fibula is parallel and lateral to the tibia, but it is considerably smaller than the tibia.

The proximal end, the head of the fibula, articulates with the inferior surface of the lateral

condyle of the tibia below the level of the knee joint to form the proximal tibiofibular joint.

In an open fracture, also called a compound fracture, the skin around the fracture site

has been punctured. Open fractures often involve much more damage to the surrounding

muscles, tendons, and ligaments. They have a higher risk for complications and take a longer

time to heal. Only the tibia bears weight, but fracture of the tibia is often associated with

fracture of the fibula because force is transmitted via the interosseous membrane that

connects the two bones.

DIAGNOSTIC PROCEDURE

CBC CT/BT PT SGOT/SGPT

MEDICAL MANAGEMENT

The patient takes Cefuroxime and Amikacin to prevent bacterial infection The patient also takes Etericoxib to relieve pain. He was also put into long leg circular cast.

SURGICAL MANAGEMENT

Steinmanns pin was inserted to the patient and was put into BST. The patient is scheduled for closed possible open reduction nailing tibia and fibula,

femur early next year.

NURSING CARE

Check patient vital sign. Offer bed bath/sponge bath to patient. Provide diversional activities. Assist patient in moving and transferring. Encourage increased fluid intake.


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DISCHARGE PLAN

Instruct patient to observe for signs and symptoms of bacterial infection. Instruct patient on how to properly use crutches. Help the patient to plan for changes in self-image and the potential for depression. Drug treatment

case analysis - fracture

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