WORLD CITI COLLEGES

960 Aurora Blvd., Quezon City

Case Study
Closed Comminuted Fracture of Femur

GONZALES, Jahada

(BSN- IV C4)
I. Introduction

J.D, 10 years old client was admitted on June 22, 2010 with chief complaint of
multiple injuries secondary to vehicular accident. Medical Diagnosis are
fracture closed complete subtrochanteric femur right; fractures closed
complete distal femur right; mass concurve fracture right leg; anemia probable
secondary to internal bleeding from fracture site.

A break or a crack in a bone is known as a fracture. Fractures can affect

any bone in the body. Bones can fracture in a number of different ways. A
simple (or closed) fracture is a clean break to the bone that does not damage
any surrounding tissue or break through the skin. A compound (or open
fracture) is when the surrounding soft tissue and skin is damaged. This kind of
fracture is more serious as there is a higher risk of infection.

Healthy bones are extremely strong and usually able to withstand strong
forces. However, if a force is too great or the bone is abnormal it can fracture.
As you get older your bones become weaker and you become more prone to
falls and fractures. One in two women and one in five men will have a fracture
after the age of 50.

Young children get different types of fractures, because their bones are
more elastic. They also have growth plates at the ends of the bones, which can
be damaged. Growth plates are the areas of growing bone at the end of long
bones in children and adolescents.

Fractures are usually a result of an accident such as a bad fall or car crash.
Quezon City had a total number of traffic accidents in the metro area with a
whopping 17,292, which is a 28.37 percentage share. For all of 2006 there
were 123 fatal accidents and 3,209 non-fatal accidents with 13,960 properties
damaged in Quezon City. The time it takes for a bone to heal depends on the
type of fracture, where it is and if it is an open or closed fracture. It is a
gradual process and can take anything from a few weeks to a few months.

By choosing this condition as a case study, the student nurse expects to

broaden her knowledge understanding and management of fracture, not just a
requirement in duty in POC. It is very important for the nurses now a day to
be adequately informed regarding the knowledge and skill in managing these
conditions since femur fracture related to car accident is high in incidence.
 Objectives:

After successful accomplishment of this case study, the student will be able to:

A. Cognitive:

a.1. Identify the suitable nursing theory for the case and apply its concepts in
delivering nursing care to a patient with Closed femur Fractures.

a.2. Discuss the anatomy and physiology of the Closed Femur Fractures.

a.3. Assess the history particularly recent patient’s Illnesses.

B. Psychomotor:

b.1 Demonstrate appropriate measures to assist patients with Closed Femur

Fracture

b.2 Show a paradigm of the pathophysiology and etiology of Closed femur

Fracture

b.3 Create relevant health teachings and the outpatient care for a patient with
Closed Femur Fracture

C. Affective:

c.1. Explain the pathophysiology and etiology of Closed Femur Fracture

c.2. Integrate knowledge and skills to deliver an effective nursing care.

A. Theoretical Framework

The nursing theory that is applicable for fracture is the nursing theory of
Dorothea Orem’s Self Care deficit. The theory essentially defines the need
for nursing care. This need occurs whenever a person experiences some
limitation or deficit which interferes with their ability to maintain self-care.
Further, the theory delineates the various interactions which should occur
between a nurse and a patient.

The client has traction in his left leg. He is advised for immobilization
thus he is dependent on the nurse to provide care for him. Nursing care
includes assisting in eating, personal hygiene,
 II. NURSING ASSESSMENT:

A. Personal data:

NAME: J. D
GENDER: Male
ADDRESS: Payatas, Quezon City
AGE: 10 y/o
DATE OF BIRTH: April 9, 1999
PLACE OF BIRTH: Payatas, Quezon City
CITIZENSHIP: Filipino
RELIGION: Roman Catholic
CHIEF COMPLAINT/S: Multiple injuries secondary to vehicular accident
DATE ADMITTED: June 26, 2010
ATTENDING PHYSICIAN/S: Dr. G

B. HISTORY OF PRESENT ILLNESS

Prior to admission Patient J.D and his friends are playing in the streets when a
delivery truck arrived, they decided to ride at the running truck when he slipped off and
fall at the trucks wheels. The wheels hit his right femur and injured him. He was
immediately brought to hospital and referred here at Philippine Orthopaedic Center with
an admitting diagnosis of fracture closed complete subtrochanteric femur right; fractures
closed complete distal femur right; mass concurve fracture right leg; anemia probable
secondary to internal bleeding from fracture site.
 C. HISTORY OF PAST ILLNESS

The client has no known childhood illness. He rarely get sick. Fever was
managed by taking in paracetamol, coughs and colds were managed by Solmux
and Plenty of rest as a form of management for these conditions.

D. FAMILY HISTORY

Both sides of client’s family has no known serious illness.

E. SOCIAL HISTORY

The Client is in 5th grade at payatas elementary school. He is an average student

and He loves to play with his friends after school and even weekends. From the 5
sibllings he is consider the eldest. He is rarely seen at home helping his parents;
he is always out with his friends playing at the streets.

F. HEAD TO TOE ASSESSMENT

Head to Toe Assessment

Skin

General skin color is brownish with darker shades of brown in area

exposed to the sun. Skin is dry and no lesions were found.

Nails (fingernails and toenails)

Nail beds are pinkish in color.

Head

The skull was smoothly contoured. There is a presence of scar in his left
temporal.

Hair
 The hair was evenly distributed, thick, straight and black

Eyes

The client was blind on his right eye and is experiencing blurry vision on
his left eye. The eyebrows are evenly distributed. Has positive corneal reflex on
the left eye.

Nose

The patient’s nose was symmetric and patent nostrils. No discharge or

flaring. It has uniform color. Air moves freely as the client’s breathes through the
nares.

Ears

The patient’s color of the ear was same color as facial skin. Pinna recoils
after it is folded. The hearing acuity is good.

Mouth

The patient has no halitosis. His lips are dry and choppy.

Neck

The neck is smooth in movement with no discomfort.

Chest

Symmetrical chest expansion; Respiratory Rate is 18 cpm.

Heart

Normal cardiac rhythm. Cardiac Rate is 91 bpm.

Abdomen
 The patient has a flabby, soft abdomen. He has 2 scars in the right lower
quadrant.

Extremities

Upper Extremities

The patient’s lower extremities are symmetrical, has smooth coordinated

movements and has a palpable pulse. The patient has a complete set of fingers.

Lower Extremities

The patient’s lower extremities are symmetrical, has smooth coordinated

movements there is a pin pricking pain on left leg and has weakness on both
sides. The patient has a complete set of fingers.

PATTERNS OF DAILY LIVING

Daily Activity Before

Assessment

Patient had no
problem in
getting
adequate
Sleeping sleep and rest.
Pattern He was able to
get 7 to 8
hours of
uninterrupted
sleep. He
usually sleep
at 8o’clock in
the evening
and awake at 4
o’clock in the
morning. He
naps at least
 one hour in the
afternoon.
Elimination

Bowel The patient

had no
problem with
his bowel
patterns. His
typical pattern
was once a
day particularly
every morning.
He claimed to
have no
difficulty in
defecation. His
stool is firm
and brown in
color.
Urine Patient
claimed to
have no
difficulty in
voiding.
Patient’s
voiding pattern
was usually 7
times a day
with urine
appearing light
yellow in color.

Nutritional Patient had

Intake relatively good
appetite,
although he
consciously
limited himself
on eating
sugars and
fats. He was
watchful in his
diet and
preferred
 home cooked
food containing
vegetables
meat with
moderate rice.
He refrained
using food
flavourings and
additives and
uses less salt
when
preparing
meals.
He could finish
three meals in
a day with
snacks in the
afternoon.

He was able to
drink 8 to 9
glasses of
water per day.

Hygiene The patient

was able to
maintain
proper
hygiene. He
takes a bath
twice a day; in
the morning
and before
bedtime. He
changes
clothing
everyday.
He brushes his
teeth thrice a
day.
Level of Before Illness
Competency
A. Physical J.D is a very active child. He is in
5th grade. After school he plays
with his friends and his siblings.
He usually plays tags at the streets.
He seems restless. He can run very
fast especially when he race with
his friends.
COMPETENCIES DEVELOPMENT
B. Emotional J.D is very friendly child. He has
a lot of friends in school and at
their neighborhood. He is very
optimistic and love to be around
with people.
C. Social J.D has a good relationship with
people. He is very friendly and
sociable. He actively participate in
school activities and their
barangay activities.
During Hospitalization
During his confinement, J.D can no
longer do his usual activities. He is
strictly for immobilization. To relive
boredom he usually play with his
soldier toy using his hands.
During his hospitalization, J.D seems
bored and lonely. He was
uncomfortable answering questions
but he seems polite.
His only social interaction is his
mother and the patients in the ward.
He doesn’t want to be visited by his
friends because he thinks that they will
only laugh at him.
E. Spiritual His family rarely goes to church
but they have an altar at home.
They sometimes prayed together.
J.D is not interested in praying
rather he wants to play outside
with his friends.
His was silent most of the time.
According to him, he prayed to Jesus
when he feels pain and he prayed for
his recovery, he wanted to walk again.
Her mother prayed with him.
ANATOMY AND PHYSIOLOGY

The thigh bone, extending from the hip to the knee of four- and two-
legged vertebrates, including humans. The femur is the largest, longest, and
strongest bone of the humanskeleton. Its rounded, smooth head fits into a socket in
thepelvis called the acetabulum to form the hip joint (an example of a ball-and-socket
joint). The head of the femur is joined to the bone shaft by a narrow piece of bone known
as the neck of the femur. The neck of the femur is a point of structural weakness and a
common fracture site. The lower end of the femur hinges with the tibia (shinbone) to
form the knee joint.

The femur can be felt through the skin at two sites. At the lower end, the bone is
enlarged to form two lumps called the condyles that distribute the weight-bearing load on
the knee joint. On the outer side of the upper end of the femur is a protuberance called
the greater trochanter. The gluteus and psoas muscles are inserted on the greater
and lesser trochanter, respectively. The lateral and medial epicondyles articulate with
the tibia and the trochlear groove accommodates the patella (kneecap).

PATHOPHYSIOLOGY
NON- MODIFIABLE RISK FACTORS: MODIFIABLE RISK
FACTORS:
 - Accidents - Prolonged standing, walking, or running
- Lytic lesions
o Cancerous metastasis
o Paget disease
o Bone cysts
- Osteoporosis

Damage to the blood

supply to an entire bone.

Severe circulatory
compromise

Avascular (ischemic)
necrosis may result

CLINICAL MANIFESTATION
CLINICAL MANIFESTATION BY THE PATIENT
BY THE BOOK
- Pain
- Pallor
-Pain,
- Pulse loss
- Point tenderness
- Pulse loss
- Pallor,
- Paralysis
- pulse loss,
- Swelling
-Paresthesia,
- Discoloration
- Paralysis.
- Loss of limb function
- Deformity
- Numbness and tingling
-Swelling,
- Cool skin at the end of the
-Discoloration,
extremity
-Crepitus, and
- Loss of pulses distal to the injury
-Loss of limb function.
-Numbness and tingling,
-Mottled cyanosis,
-Cool skin at the end of the extremity,
-Loss of pulses distal to the injury

DIAGNOSTICS EXAMS DIAGNOSTICS EXAMS

BY THE BOOK: BY THE
CLIENT:
 X-RAY
 X-RAY

 Hematology

TREATMENT BY THE BOOK: TREATMENT BY THE CLIENT:

 Nonsteroidal anti-inflammatory  Nonsteroidal anti-

agents (NSAIDs) inflammatory agents

(NSAIDs)
-Ibruprofen


 LABORATORY EXAMINATION/S

DRUG STUDY

DATE MEDICATION ACTION INDICATION NURSING

ORDERED CONSIDERATION
September Amlodipine Lowering high used with or Take this medication by
10,2009 to blood pressure without other mouth, usually once
May 10 mg/ 1 tab helps prevent medications to daily with or without
12,2010 strokes, heart treat high food or as directed by
OD
attacks, and kidney blood pressure your doctor.
problems. (hypertension).
Amlodipine is called If used for angina, this
a calcium channel medication must be
blocker. It works by taken regularly to be
relaxing blood effective. It should not
vessels so blood be used to treat angina
can flow more when it occurs. Use
easily. other medications (e.g.,
sublingual nitroglycerin)
to relieve an angina
attack as directed by
your doctor. Consult
your doctor or
pharmacist for details.

Lyrica used to treat Nerve to treat pain Take this medication by

Pain after Herpes, caused by mouth, usually twice or
75mg/1tab Diabetic nerve damage three times a day, or as
Complication due to diabetes directed by your doctor.
OD
causing Injury to and shingles You may take it with or
some Body Nerves, (herpes zoster) without food. When you
Additional infection. It is start this medication,
Medication to Treat also used to your dosage will
Partial Seizures, treat pain in probably need to be
Disorder people with increased slowly by your
characterized by fibromyalgia. doctor to reduce side
Stiff, Tender & effects, especially
Painful Muscles dizziness or drowsiness.
Your dosage is based on
your medical condition
and response to
therapy.
 Metformin It works by helping used with a Take this medication by
to restore your proper diet and mouth, usually twice a
500 mg / tab body's proper exercise day with meals or as
response to the program to directed by your doctor.
1tab
insulin you control high Drink plenty of fluids
BID naturally produce, blood sugar in while taking this
and by decreasing people with medication unless
the amount of type 2 diabetes otherwise directed by
sugar that your (non-insulin- your doctor.
liver makes and dependent
that your diabetes).
stomach/intestines Controlling
absorb. high blood
sugar helps
prevent kidney
damage,
blindness,
nerve
problems, loss
of limbs, and
sexual function
problems

September Vitamin-B Vitamins are a multivitamin Take this medication by

23, 2009 complex important building product used to mouth, usually once
blocks of the body treat or daily or as directed.
1 tab and help keep you prevent Follow all directions on
in good health. vitamin the product package, or
OD
deficiency due take as directed by your
to poor diet, doctor. Do not take
certain more than the
illnessAes recommended dosage.

Constipation, diarrhea,
or upset stomach may
occur. These effects are
usually temporary and
may disappear as your
body adjusts to this
medication.
DISCHARGE PLANNING

Prognosis

The patient progress depends on its condition and the size of the tumor it
is possible that full recovery can be attain and there is 50% chance that the
tumor will completely disappear thru the treatment that the patient has
undergone.

Upon Discharge A.M will adhere to the following instructions:

M - Advised to the take medicine religiously on time

− Amlodipine 10 mg 1 tab/ once a day

− Vitamin B Complex 1 tab/ once a day

− Metformin 500mg 1 tab/ twice a day

E – Enumerated safe measures to prevent accidental falls like removing

unnecessary rags inside the house, avoiding wet floors etc.

T – Radiotherapy and Medication for maintenance

H – Advice to perform daily exercise

O – Advice to come back at Neurosurgery OPD for follow up check-up/ 1 week

after discharge

D – Advice to avoid too much sweet in his diet

− Advice to eat high protein diet

 − Advice small frequent feeding

S – Encourage to attend religious activities like Sunday mass