case study poc

7/28/2019 Case Study POC

1/23

Republic of the Philippines

University of Northern Philippines

Tamag, Vigan City

College of Nursing

A Case Study on: Open Fracture Type III B Comminuted on Right patella, Compound

displacement, lateral condyle femur

In partial fulfilment

Of the requirements


2/23

TABLE OF CONTENTS

PAGE

FRONTPAGE i

TABLE OF CONTENTS ii

I. INTRODUCTION AND OBJECTIVESII. PATIENTS PERSONAL DATA

(NURSING HISTORY OF PAST AND PRESENT ILLNESS)

III. PEA/RSON ASSESSMENTIV. DIAGNOSTIC PROCEDUREV. ANATOMY AND PHYSIOLOGY

VI. PATHOPHYSIOLOGYA. ALGORITHMB. EXPLANATION

VII. MANAGEMENTA. MEDICAL-SURGICALB NURSING CARE PLAN


3/23

I.INTRODUCTION

An open fracture is one where there is a communication between the fracture and theoutside world, an associated laceration. This has implications in terms of the management of this

type of fracture, in that wound sepsis must be suspected. Recently there has been a move away

from referring to this type of fracture as compound, since abbreviation of this in notes to com.

leads to confusion with comminuted fracture. An open fracture may communicate with theoutside world from without, an injury from the external world has exposed bone, or from within,

bone is pointing through the skin. The former is more serious because there is likelihood that

contamination - dirt, bits of clothing - has also been forced into the tissues.

Grading is important in determining the management of open fractures: Minor / Grade I - small punctate wound less than 1 cm associated with low velocity

trauma. Minimal soft tissue injury. No crushing. No comminution.

Moderate / Grade II - wounds which are extensive in length and width but with relativelylittle soft tissue damage, and only moderate crushing or comminution.

Major / Grade III - wounds of moderate or massive size with considerable soft tissueinjury and/or foreign body contamination:

III A - sufficient soft tissue to cover the fracture III B - insufficient tissue to cover the fracture; also periosteal stripping and severe

i ti


4/23

II.OBJECTIVES OF THE STUDY

General Objectives:

On the completion of this study, I, the student nurse will be able to:

Have more comprehensive understanding about the patients condition which is openfracture Type III B with comminuted patellar fracture;

Apply nursing care appropriately with proper knowledge, attitude and skills in caring formy patient;

Establish a therapeutic communication relationship between the client and student nursein a more efficient exchange of information to determine patients needs.

Specific Objectives:

I, the student nurse will be able to:

Describe the common characteristics, manifestations and complication of open fractures;

Know the past and present history of the client in conjunction with present illness; To assess the condition of the client through the use of PEARSON Assessment; To relate the significance of laboratory results and values in response to the clients

current illness;

To present the Anatomy and Physiology of the system involved in relation to patientsditi


5/23

Present Health History

According to the patient, he was from his work and rode as a passenger on a single

motorcycle when they stumbled on a rock and crashed on the road. He was first rushed Pasay

General Hospital primarily but was endorsed to Philippine Orthopedic Center, conscious

complaining of a painful wound on his right knee. Upon physical examination, he has anavulsion on his right knee, with visible deformity noted, with initial vital signs as follows: BP:

140/100, Temp: 36.6, RR: 20, PR: 93, having an initial diagnosis of Open Fracture type III B,

with comminuted fracture on right patella, and compound displacement of the right lateral

condyle of femur. He was admitted on April 2, 2012 at 12:05am, initially hooked with D5LRS1L and wound debridement was done on fracture site as an initial management. Medications

were ordered as follows: Penicillin G 5mL IV q6, Tramadol 50mg IV q8 for pain, Paracetamol

300mg IV q4, Cefuroxime 750mg IV q8, Ketorolac 30mg IV q6, and Etocoxib 120mg per tabOD. Initial blood examination showed a marked increase in Leukocytes as a suggestive for

infection.

On April 8, 2012, he was subjected to application of Spanning External Fixator on hisRight knee and lab values prior to OR reflects a marked decrease in hemoglobin and Hematocrit

levels that shows impending loss of blood supply and oxygenation in the affected site.Debridement was also done on the wound site to remove the dead tissues and facilitate faster

healing process. To check the extent of impending infection, Gram-Staining of the wound wasdone which showed presence of RBC and WBC on the wound, with noted few gram (+) cocci

singly with no spore forming bacilli.

On April 11, 2012, he was confined to bed with a Spanning External fixator, with an IVF


6/23

Isolation Isolation

E

L

I

M

IN

A

T

I

O

N

-urinates and defecates onbed pan

-voided approximately

500mL during the time ofexposure

-with straw colored urine as

claimed

-with no noted discomfortin urination

-(-) BM

-(-) Vomiting-with no noted diaphoresis

-urinates and defecates onbed pan

-voided approximately

200mL during the time ofexposure

-with straw colored urine as

claimed

-with no noted discomfortin urination

-(-) BM

-(-) Vomiting-with no noted diaphoresis

A E

C X

T a E

I n R

V d C

-with limited bed mobility

-performs assistive ROM

exercises as instructed-sleeps for at least 8 hours a

-with limited bed mobility

-performs assistive ROM

exercises as instructed-sleeps for at least 8 hours a


7/23

O

X

YG

E

N

A

T

I

O

N

- with well ventilated room

- RR: 23cpm-PR: 88 bpm

-BP: 120/90mmhg-with no complaints of

DOB or SOB as claimed

-no dyspnea noted-with normal capillary refill

time (2-3secs.)

-no noted cyanosis of nailbeds and sclera

- with well ventilated room

- RR: 23cpm-PR: 87 bpm

-BP: 120/80mmhg-with no complaints of

DOB or SOB as claimed

-no dyspnea noted-with normal capillary refill

time (2-3secs.)

-no noted cyanosis of nailbeds and sclera

N

U

T

R

I

T

I

O

N

-with an ongoing IVF ofD5LRS 1L infusing well

-on DAT diet

-drinks at least 1L of fluids

a day as claimed-with good appetite

-with no difficulty of

swallowing as claimed

-with an ongoing IVF ofD5LRS 1L infusing well

-on DAT diet

-drinks at least 1L of fluids

a day as claimed-with good appetite

-with no difficulty of

swallowing as claimed


8/23

Tests: Standard x-rays with special views of the patella are usually sufficient to diagnose a

patellar fracture. CT scan may be necessary for more difficult cases where x-rays are not

definitive. Patella fractures themselves generally do not require MRI evaluation, but associatedinjuries to nearby tendons and ligaments may need to be evaluated by MRI studies. A standard x-

ray of the unaffected (contralateral) knee may prove helpful by providing a comparison.

Aspiration of fluid from the affected knee may be performed both to relieve pain and to checkfor the presence of fat, which often indicates the presence of a fracture.

Actual Examinations

Complete Blood Count (04-02-12)

COMPONENTS RESULT NORMAL VALUES IMPLICATION

Hemoglobin Mass 155 127-183g/L NORMAL

Hematocrit 0.47 0.37-0.54 NORMAL

Leukocytes 22.4 4.5-10 INCREASED

Segmenters 0.60 0.50-0.60 NORMAL

Lymphocytes 0.13 0.40-0.50 DECREASED

Monocytes 0.02 0.00-0.07 NORMAL
http://www.mdguidelines.com/x-rayhttp://www.mdguidelines.com/computerized-tomographyhttp://www.mdguidelines.com/magnetic-resonance-imaginghttp://www.mdguidelines.com/aspirationhttp://www.mdguidelines.com/pain-in-limbhttp://www.mdguidelines.com/pain-in-limbhttp://www.mdguidelines.com/aspirationhttp://www.mdguidelines.com/magnetic-resonance-imaginghttp://www.mdguidelines.com/computerized-tomographyhttp://www.mdguidelines.com/x-ray


9/23

MCV 87 82-89 NORMAL

MCH 28 28-32 NORMAL

MCHC 36 32-38 NORMAL

Indications and Implications:

The complete blood count or CBC test is used as a broad screening test to check for suchdisorders as anemia, infection, and many other diseases. It is actually a panel of tests that

examines different parts of the blood and includes the following:

White blood cell (WBC) count is a count of the actual number of white blood cells pervolume of blood. Both increases and decreases can be significant.

White blood cell differential looks at the types of white blood cells present. There are fivedifferent types of white blood cells, each with its own function in protecting us from

infection. The differential classifies a person's white blood cells into each

type: neutrophils (also known as segs, PMNs, granulocytes,

grans), lymphocytes, monocytes, eosinophils, and basophils.

Red blood cell (RBC) count is a count of the actual number of red blood cells per volume ofblood Both increases and decreases can point to abnormal conditions
http://labtestsonline.org/understanding/conditions/anemiahttp://labtestsonline.org/understanding/analytes/wbchttp://labtestsonline.org/understanding/analytes/differentialhttp://labtestsonline.org/glossary/neutrophilhttp://labtestsonline.org/glossary/lymphocytehttp://labtestsonline.org/glossary/monocytehttp://labtestsonline.org/glossary/eosinophilhttp://labtestsonline.org/glossary/basophilhttp://labtestsonline.org/understanding/analytes/rbchttp://labtestsonline.org/understanding/analytes/rbchttp://labtestsonline.org/glossary/basophilhttp://labtestsonline.org/glossary/eosinophilhttp://labtestsonline.org/glossary/monocytehttp://labtestsonline.org/glossary/lymphocytehttp://labtestsonline.org/glossary/neutrophilhttp://labtestsonline.org/understanding/analytes/differentialhttp://labtestsonline.org/understanding/analytes/wbchttp://labtestsonline.org/understanding/conditions/anemia


10/23

Specimen: Wound

RESULT: RBC; (+) WBC; Few gram (+) cocci, singly; no spore-forming bacilli.

Indication: Gram- Staining is a microbiological procedure that categorizes bacteria based onphysical and chemical structure of their outer surface. This procedure is commonly used fordetection and identification of bacteria that may infect the area.


11/23

The patella is flat, triangular bone, situated on the front of the knee-joint. It is usuallyregarded as a sesamoid bone, developed in the tendon of the Quadriceps femoris, and resembles


12/23

Direct trauma to the leg and patella

Inflammation and swelling

occurs in the area due torelease of histamine, kinins

and bradykinins tocompensate invasion of

microorganisms and further

wound destruction

Tissue destruction and lacerationoccurs

Bone destruction occurs due to

direct pressure on the area thatprecedes to fracture, displacement

or dislocation

Bleeding occurs in the open wound

area

Blood vessels and marrow of the bonebecomes disrupted

Spasms and contractions occur in the

area of injury


13/23

wound contamination. The open fracture wound should be thoroughly dbrided. To avoid

the complication of gas gangrene, the wound should not be closed. Extensive soft-tissue

damage may necessitate the use of local or free flaps. Techniques of fracture stabilizationdepend on the anatomic location of the fracture and the characteristics of the injury. Early

bone grafting and supplemental procedures may be needed to achieve healing.

Management of the infected open fracture is based on radical dbridement, skeletal

stabilization, microbial-specific antibiotics, soft-tissue coverage, and reconstruction ofbone defects.

Antibiotics were administered for 48-hour intervals and were repeated with subsequentwound debridement. They concluded the most important variable in reducing wound

infection was utilizing delayed wound closure rather than primary closure. Patzakis andWilkins retrospectively reviewed their experience with various antibiotic regimens

including penicillin, cephalothin, and cefamandole as well as a control arm with no

antibiotics.

Assess for circulatory impairment (cyanosis, coldness, mottling, decreased peripheralpulses, positive blanch sign, edema not relieved by elevation, pain or cramping).

Assess for neurologic impairment (lack of sensation or movement, pain, or tenderness, ornumbness and tingling).

Administer analgesic medications. Explain fracture management to the child and family. Depending on the type of break

and its location, repair (by realignment or reduction) may be made by closed or open

reduction followed by immobilization with a splint, traction or a cast.

Maintain skin integrity and prevent breakdown. Institute appropriate measures for castand appliance care


14/23

Displaced fractures of the patella are treated surgically to stabilize the fragments. Metalpins, screws, wires, or plates may be used to hold pieces of bone together. In cases in

which too much bone has shattered, a partial or complete removal (excision) of thepatella itself (patellectomy) may be performed. Surgeons generally retain as much of theoriginal patella as possible to aid the knee in maintaining strength.

Following surgery, the knee usually will be immobilized in a brace. Weight bearing andwalking are permitted as tolerated as soon as possible after surgery. Exercises to

strengthen important muscles of the leg are begun immediately and range of motion

exercises are begun at 4 to 6 weeks after surgery. A healed fracture and a strongquadriceps muscle permit a return to vigorous activity in 6 months.

The management of these fractures is essentially the same as for patellar fractureswithout associated prosthetic arthoplasty. If the fracture is minimally displaced or non-

displaced, conservative treatment is recommended. Significantly displaced fractures with

disruption of the extensor mechanism should be operated upon if possible. The actualprocedure performed will depend upon the condition of the bone.

If the fracture is amenable to fixation and the prosthesis is not loose, simply fixing thefracture should be considered. However, if the prosthesis is loose, a decision must bemade as to whether the fracture can be fixed, followed by reinsertion of a prosthesis, or

whether patellectomy may not be the best solution

ACTUAL SURGICAL MANAGEMENT
http://www.mdguidelines.com/reduction-of-fracture-or-dislocationhttp://www.mdguidelines.com/reduction-of-fracture-or-dislocation


15/23

- defects in retinaculum will extend several cm medially or laterally, or both;

- therefore extend exposure with a medial parapatellar capsular incision for a short distance

proximally and medially.- need enough release to allow adequate palpation & partial visualization of frx site to ensure

anatomical reduction of the articular surface;

- look for osteochondral fragments, esp in trochlear groove;

- it is not necessary to create a large medial arthrotomy, such as would be necessary foreversion and full visualization of the articular

surface - small arthrotomy can be closed after fixation;

* before proceding, place simple sutures in the torn retinaculum on either side of the fracture,

and clamp the suture ends (do not tie);- the sutures are not tied at this point, becuase this would interfere w/ visualization of the

fracture fragments;

- placing sutures across the torn retinaculum will facilitate their repair, after the fracturehas been fixed;

- Reduction:- integrity of the fragments is evaluated;

- often there is comminution that was not recognized on the radiographs;- decision regarding whether to proceed with an ORIF, partial patellectomy, or total

patellectomy is then re-evaluated;- ORIF of transverse fractures with little or no comminution are most amenable to treatment

with open reduction and internal fixation;

- two large towel clips may assist w/ the reduction;


16/23

External fixation is also used in limb lengthening. People with short limbs can have, forexample, legs lengthened. In most cases the thigh bone (femur) is cut diagonally in a

surgical procedure under anesthesia. External fixator pins or wires (as above) are placedeach side of the 'man made fracture' and the external metal apparatus is used to very

gradually push the two sides of the bone apart millimeter by millimeter day by day and

week by week. Bone is extremely clever tissue and will gradually grow into the small gap

created by this 'distraction' technique. Such a process can take many months. In most

cases it may be necessary for the external fixator to be in place for many weeks or even

months. Most fractures heal in between 6 and 12 weeks. However, in complicated

fractures and where there are problems with the healing of the fracture this may take

longer still. It is known that bearing weight through fracture by walking on it, forexample, with the added support of the external fixator frame actually helps fractures to

heal.


17/23

Increase Vitamin C and Zinc intake found in green leafy vegetables and fruits to boost

immune system and resist against infection.

Encourage assistive ROM exercises in bed to prevent development of complications suchas pneumonia and atelectasis, contractures and to promote proper lung expansion andventilation.

Encourage adherence to prescribed medications to meet the desired therapeutic outcomeand faster recuperation from the disease.

Encourage aseptic and proper wound care to promote faster wound healing.

PREVENTIVE

Prevent circulatory impairment by assessing pulses, color and temperature, and byreporting changes immediately.

Prevent nerve compression syndromes by testing sensation and motor function, includingsubjective symptoms of pain, muscular weakness, burning sensation, limited ROM, and

altered sensation. Correct alignment to alleviate pressure if appropriate, and notify the

health care provider.

Prevent compartment syndrome by assessing for muscle weakness and pain out ofproportion to injury. Early detection is critical to prevent tissue damage.

Causes of compartment syndrome include tight dressings or casts, haemorrhage.trauma, burns and surgery.


18/23

MEDICATIONS -Encourage adherence to prescribed pharmacologic regimen.

-Note dosage, route, frequency, action, contraindication and

side effects of drugs to prevent misuse and abuse and toachieve therapeutic level of therapy.

EXERCISE -Engage in passive-assistive range of motion exercises to

promote proper circulation, prevent contractures andcomplications associated with immobility.

-Encourage participation in Isometric exercises to develop

muscle strength through contractions without any vigorousmovement. This way muscle strength is gradually built up

while minimizing the risk of further damage.

-Encourage collaboration with a Physical Therapist to start

Rehabilitative Regimen.

TREATMENT Pain Management

-Provide non-pharmacologic interventions such as applicationof warm compress in the area to decrease swelling.

-Position the affected site to comfort level, resting on the bedto allow relaxation and prevent spasms.-Take prescribed pain-relievers to ease the pain.

HEALTH TEACHINGS -Encourage vigilant adherence to prescribed therapeutic

regimen to prevent relapse.

-Instruct strict aseptic technique in wound cleaning providing


19/23

CUES NURSINGDIAGNOSIS

SCIENTIFICBACKGROUND

GOALS &OBJECTIVES

NURSINGINERVENTIONS

RATIONALE EVALUATION

Subjective:

Sumasakitpaminsan minsanpero ngayon konti

na lang. Noong

una masakittalaga sobra as

verbalized by thepatient

Objective:

Limitedrange of

motion

Inability topurposely

movewithin the

environme

nt

Decreasedmuscle

strength

Problem: ImpairedPhysical Mobility

Etiology:

r/t pain secondary

to immobilizationSigns &

Symptoms:

Limitedrange of

motion

Inability topurposelymove

within theenvironme

nt

Decreasedmuscle

strength

Trauma

Tissue destruction

and bone fracture

Inflammation andswelling in the

area

Muscle spasms

and pain in thearea

Decreased muscle

strength

Limited

movement as acompensatory

mechanism toavoid pain

April 11, 2012

Goal: After, the patientwill regain and

maintain mobility at the

highest possible level

Objectives:

Maintainposition of

function

Increasestrength andfunction of

affected andcompensatory

body parts

Demonstratetechniques thatenable

resumption ofactivities,

especially ADL

Verbalizeunderstandingof the situation

and individualtreatment

regimen and

Independent:1. Assess degree of

immobility producedby injury and

treatment and note

clients perception of

immobility

2. Encourageparticipation indiversional activities.

Maintain astimulating

environment

3. Instruct client inactive, or assist with

passive ROMexercises of affectedand unaffected

extremities

4. Encourage use ofisometric exercises,starting with the

unaffected limb

5. Provide footboard andtrochanter as

appropriate

6. Place in supineposition periodically

1. Client may berestricted by self-viewout of proportion with

actual physical

limitations, requiringinformation and

interventions topromote progress

toward wellness

2. Provides opportunityfor release of energy,

refocuses attention,enhances clients sense

of self-control andself-worth, and aids in

reducing socialisolation

3. Increases blood flowto muscles and bone to

improve muscle tone;maintain joint

mobility; and preventcontractures, atrophy,

and calcium resorption

from disuse

4.

Isometrics contractmuscles without

bending joints or

April 11, 2012

Level ofAttainment:

Evidences:


20/23

safety measures if possible whentraction is used to

stabilize lower limb

fractures

7. Assist with andencourage self-care

activities such asbathing, shaving and

oral hygiene

8. Monitor BP withresumption of

activity. Note reports

of dizziness

9. Repositionperiodically and

encourage coughing

and deep breathingexercises

10.Encourage increasedfluid intake of 2-3L/day within cardiac

tolerance

11.Provide diet high inproteins,carbohydrates,

vitamins, minerals

12.Increase the amountof fiber in the diet.Limit gas-forming

moving limbs and helpmaintain muscle

strength and mass

5. Useful in maintainingfunctional position ofextremities and

preventingcomplications

6. Reduce risk of flexioncontracture of hip

7. Improves musclestrength andcirculation, enhances

client control insituation, and

promotes self-directed

wellness8. Postural hypotension

is a common problem

following prolonged

bedrest

9. Prevents incidence ofskin and respiratory

complications

10.Keeps the body wellhydrated, decreasing

risk of urinaryinfection and stoneformation, and helps to


21/23

foods

Dependent:

1. Consult withphysical or

occupationaltherapist or

rehabilitationtherapist

2. Refer to dieticianor nutrition team,

as indicated

3. Initiate bowelprogramstool

softeners , enemaor laxatives as

indicated

4. Refer topsychiatricclinical nurse

specialist ortherapist as

indicated

prevent constipation

11.For rapid healing12.Adding bulk to stool

helps preventconstipation. Gas-

forming foods maycause abdominal

distention

1. Useful in creatingaggressive

individualizedactivity or exercise

program

2. Client withfractures may have

specialconsiderations

3. Important topromote regularbowel evacuation

and prevent

constipation

4. Client may requiremore intensive

treatment to deal

with reality ofcurrent condition


22/23

CUES NURSING

DIAGNOSIS

SCIENTIFIC

BACKGROUND

GOALS &

OBJECTIVES

NURSING

INERVENTIONS

RATIONALE EVALUATION

Subjective:

Sumasakitpaminsan

minsan perongayon konti na

lang. Noong unamasakit talaga

sobra asverbalized by

the patient

Objective:

Painscale of

5/10

Narrowed focus

Alternation in

muscle

tone

Limitedrange of

motion

Problem: Acute

Pain

Etiology:r/t presence of

immobilitydevice

secondary tophysical injury

of the softtissues and nerve

traumaSigns &

Symptoms:

Painscale of5/10

Narrowed focus

Alternation in

muscle

tone

Trauma

Tissue destruction and

bone fracture

Inflammation and

swelling in the area

Disruption of blood

supply,vasoconstriction and

destruction of marrowin the bone

Irritation of nerve

endings andstimulation of pain

receptors

PAIN

April 11, 2012

Goal: After, the

patient will verbalizerelief of pain

Objectives:

Displayrelaxed

manner, ableto participate

in activities,and sleep and

rest

appropriately

Demonstrateuse of

relaxationskills and

diversional

activities

Independent:

1. Maintainimmobilization of

affected part by means ofbed rest.

2.Elevate and support

injured extremity

3.Avoid use of plastic

sheets/pillows under the

limbs

4.Elevate bed covers and

keep linens off toes

5. Evaluate and documentreports of pain or

discomfort, noting

location andcharacteristics. Notenonverbal pain cues, such

as changes in vital signs

and behaviors

6.Encourage client todiscuss problems related

to injury

7.Perform and supervise

1.Relieves pain and

prevents bonedisplacement/extension of

tissue injury

2.Promotes venous return,

decreases edema, and

may reduce pain

3.Can increase discomfortby enhancing heat

production in the drying

cast

4.Maintains body warmth

due to pressure of bed

linens on affected parts

5.Influences choice of,and monitors

effectiveness of

interventions

6.Helps alleviate anxiety

7. Maintains strengthand mobility of

April 11, 2012

Level of

Attainment:

Evidences:


23/23

passive or active ROM

exercises

8.Provide alternativecomfort measures

(massage, backrub or

position changes)

9.Provide emotional

support and encourageuse of stress management

techniques (DBE, guidedimagery, therapeutic

touch.

Dependent:

1.Administermedications, as

indicated

2.Maintain continuousIV. Maintain safe andeffective infusions

and equipment

unaffected musclesand facilitates

resolution ofinflammation I injured

tissues.

8.Improves general

circulation; reducesareas of local pressure

and muscle fatigue

9.Promotes sense ofcontrol and may

enhance copingabilities in the

management of thestress of traumatic

injury and pain

1.Given to reduce pain

and muscle spasms

2.Permit early

mobilization and physical

therapy

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