University of Baguio

Fracture, Closed Complete Displaced,

Middle Third Femur Right

A Case Study
Presented to the Faculty of
School of Nursing
In partial fulfillment of the requirement
For the subject NCENL04

By:

Abance, Syndi Claire

Balicao, Jenny Claire
Boado, Marvin Jay
Cruz, Edzel
Doclisen, Brenda
Garcia, Denrick
Hizon, Rhauzen Jean
Mojica, Thea Mayla
Negradas, Kathleen Jane
Pasigian, Nicole
Santiago, Fevy Shane
Sison, Lei Sho

Juvy E. Carame, RN, MAN

Clinical Instructor
March 2018
 TABLE OF CONTENTS

TITLE PAGE ---------------------------------------------- i

TABLE OF CONTENTS -------------------------------------- ii

ACKNOWLEDGEMENT --------------------------------------- iii

CHAPTERS:

I.INTRODUCTION ------------------------------------------ 1

A. BRIEF DESCRIPTION ---------------------------------- 1

B. GOAL AND OBJECTIVES -------------------------------- 2

II. PATIENT`S PROFILE ----------------------------------- 3

A. BIOGRAPHICAL DATA

B. HISTORY OF MEDICAL ILLNESS

III. 13 AREAS OF ASSESSMENT ----------------------------- 5

IV. ANATOMY AND PHYSIOLOGY ----------------------------- 10

V.PATHOPHYSIOLOGY -------------------------------------- 13

A. SCHEMATIC DIAGRAM

B. NARRATIVE

VI. LABORATORY RESULTS --------------------------------- 16

VII. NURSING CARE MANAGEMENT --------------------------- 20

A. NURSING PROCESS -----------------------------------26

a. LIST OF IDENTIFIED PROBLEMS

b. PRIORITIZATION WITH JUSTIFICATION

c. NURSING CARE PLAN 2 ACTUAL 1 POTENTIAL/RISK --- 23

B. DRUG STUDY/MEDICATION --------------------------- 29

VIII. SUMMARY OF CARE --------------------------------- 31

IX. CONCLUSION ---------------------------------------- 32

X. RECOMMENDATION ------------------------------------- 33

XI. REFERENCES ---------------------------------------- 34

 ACKNOWLEDGEMENT

The BSN III section NCA group would like to express

their sincerest gratitude to those people who helped them in

the accomplishment of this study, without these people this

case study would not have been possible:

To the Father Almighty, for the gift of life, for the

daily providence, for giving us the strength, divine

guidance, wisdom and inspiration in our quest in the field

of our chosen course. We would like to extend our whole

heartedly the gratitude and praise to ever loving and

merciful God for touching and bringing together those people

who literally shared their abundant resources, talents,

skill and effort for the completion of the study.

To our beloved families, for their continuous and

unending support, for their unwavering love, care and

motivation.

To Baguio General Hospital and Medical Center for

giving us the opportunity to have our related learning

experience.

To our clinical instructor, Juvy E. Carame, RN, MAN who

professionally taught us the proper things to do, forbearing

and tirelessly guided us throughout the rotation, we

extremely express our heartfelt gratitude.

To the patient, their significant others for giving us

their time and patience to answer our questions. Their

cooperation in giving us enough information to fulfill the

study is much appreciated

 CHAPTER I: INTRODUCTION

The BSN III students of University of Baguio, Group 1

of section NCA had their Clinical Duty at the Orthopedics

Department of Baguio General Hospital and Medical Center

under the supervision of Mrs. Juvy Carame, RN MAN last March

22-24,2018 in a 3-11 shift.

A. BRIEF DEFINITION

During their clinical duty at the said department the

group were exposed to different orthopedic cases but the

group choose this case, pathologic fracture. A pathologic

fracture occurs when a bone breaks in an area that was

already weakened by another disease. When the bone is

weakened by some underlying medical condition, the

individual becomes more susceptible to fracture. Causes of

weakened bone include osteoporosis, tumors, infection, and

certain inherited bone disorders. And these are just a few

causes; there are dozens of diseases and conditions that can

lead to a pathologic fracture. Fractures of the bone come in

many shapes and types. The reason a fracture is called

pathologic is that the bone was weakened even before an

injury occurred. Sometimes pathologic fractures are obvious,

and other times it is not as clear that there was a problem

preceding the injury. The medical diagnosis of the chosen

case was Pathologic Femur Fracture. The client fell that led

to injury on her right thigh.

According to World Health Organization, falls are the

second leading cause of accidental or unintentional injury

deaths worldwide. Each year an estimated 646,000 individuals

die from falls globally of which over 80% are in low-and

middle-income countries.

Adults older than 65 years of age suffer the greatest

number of fatal falls. 37.3 million falls that are severe

enough to require medical attention occur each year. On the

Philippines the death rate of fall injuries is 4.75 and

ranked as 99th worldwide that causes death and ranked 32 in

the Philippines.

B. GOAL AND OBJECTIVES:

GENERAL OBJECTIVES:

1. To gain and share knowledge regarding appropriate care

regarding the case.

2. To improve our nursing skills in handling patient with

the kind of disease.

3. To ensure that the client receives the proper care and

comfort.

SPECIFIC OBJECTIVES:

1. To understand the pathophysiology of the disease.

2. To identify the possible cause and effects of the

disease.

3. To understand the medical intervention of the disease and

be able to provide the appropriate nursing intervention.

4. To able to prevent further problems by rendering

appropriate nursing interventions.

CHAPTER II: PATIENT’S PROFILE

A. BIOGRAPHICAL DATA

Name: Patient X

Age: 52

Gender: Female

Birthday: October 9, 1965

Address: Casabaan Sur, Binalonan, Pangasinan

Nationality: Filipino

Religion: Roman Catholic

Civil Status: Widow

Date of Admission: March 14, 2018

Time of Admission: 1:15pm

Admitting Diagnosis: Fracture, closed complete displaced,

middle third femur right

Chief Complaint: Right thigh pain

B. MEDICAL HISTORY

Patient’s CT scan report shows scattered tiny nodular

opacities are seen in both upper lobes and there are also

linear densities with dilated bronchioles in the medial

segment of the middle lobe and inferior lingual segment of

the upper lobe. The CT scan images reveal a closed,

complete, oblique, over riding fracture of the distal third

diaphysis of the right femur. The distal fractured segment

is superior-laterally displaced. Tiny fractured segment are

seen adjacent to the fracture deformity. Soft tissue

swelling is seen in the distal aspect of the thigh.

HISTORY OF THE PRESENT ILLNESS:

 3 days prior to admission, patient had history of fall

with her right thigh with associated pain and gross

deformity on the injured part. Patient was then unable to

ambulate. Patient was immediately brought to a local

institution wherein she was admitted and initially managed

but patient opted to transfer to hospital of choice hence

was referred to our institution for further care and

management.

CHAPTER III: 13 AREAS OF ASSESSMENT

 I. Psycho-Social Status

The patient is a 52-year-old, female, widow. She is

currently residing at Casabaan Sur, Binalonan, Pangasinan.

She is responsive and cooperative. Under the Psychosocial

Development theory of Erik Erikson, she is under the stage

of Adulthood, which is the Generativity versus Stagnation.

With virtue of care and has a significant relationship of

households and workmates.

II. Mental and Emotional Status

The patient is oriented to person, place and time. She can

identify things or names being asked. She is able to read

and write and can speak in Tagalog, English and Ilocano. She

can recall recent and remote memories she experienced.

Patient once verbalized during an intervention that she is

depressed and she already wants to go home because she

misses her family so much.

III. Environmental Status

The patient is confined at Baguio General Hospital- Medical

Center in a service section. The patient is in skeletal

traction at right femur and she is located in bed number 14,

it is three to four meters away from the nurses’ station and

five to six meters away from the comfort room. The ward is

well lighted & ventilated, has accessible bedside table,

chairs and trashcan.

IV. Sensory Status

 A. Sense of Sight

The patient has a pink palpebral conjunctiva. Her left

sclera appears red due to the accident she experienced. On

the other hand, patient reported that she can distinguish

objects at specified distance and has clear vision.

B. Sense of Taste

Patient was examined using variety of food, which tastes

salty, bitter, sweet and sour. She was able to differentiate

each other.

C. Sense of Hearing

On Auditory assessment, the voice whisper test was used.

Words were whispered and the patient was instructed to

repeat the words that were whispered. The intervention was

then repeated to the other ear.

D. Sense of Smell

The patient’s nose is in the midline of the face and is

symmetrical. She can distinguish smell of alcohol from

cologne. The nostrils are patent and there were no

secretions noted.

E. Sense of Touch

During an intervention, the patient was instructed to close

her eyes and tell what she feels when she was going to be

pinched. The patient responded and stated that the pinch is

painful. Moreover, patient was able to distinguish warm from

cold sensation.
 V. Motor Status

5/5 5/5

1/5 5/5

The patient’s motor status is 5/5 in her both upper

extremities and left lower extremity. While her right lower

extremity is with 1/5 motor status in which there is a

muscle contraction seen or identified during palpation, but

it is insufficient to produce joint motion even with

elimination of gravity. Moreover, the patient is in skeletal

traction in her right femur due to fracture caused by an

accident.

VI. Nutritional Status

The patient was able to consume all the food that was served

and it was also observed that she was able to consumed at

least one liter of water during the shift.

VII. Elimination Status

The patient’s urine characteristic is yellowish in color,

usually 500-800 cc levels. While her feces elimination is

once during the shift, with a characteristic of brownish in

color. Also, she has a type 3 to type 4 consistencies

according to Bristol stool chart.

VIII. Fluid and Electrolytes Status

The patient is hooked on a Plain normal saline solution for

sixteen hours at her left hand. On the second day of

admission, the Intravenous Fluid was removed and changed to

Heplock. She has an estimated water intake of 1000Ml during

the shift.

IX. Circulatory Status

During the shift, patient’s pulse rate ranges from 60-80

beats per minute taken at radial pulse and also an oxygen

saturation of 93% - 97%. Capillary refill ranges from 2-3

seconds. Patient’s blood pressure is within the range of

130/90 to 110/70 mm Hg.

X. Respiratory Status

The patient’s respiratory rate ranges from 19 to 21 breaths

per minute during the shift and no reports of difficulty of

breathing and use of accessory muscles.

XI. Temperature Status

The patient’s body temperature ranges from 36.5 to 37.2

degree Celsius taken via axillary.

XII. Integumentary Status

The patient is with Heplock at her left hand. Her skin is

brown, has good skin turgor. There was no history of skin

allergy, no presence of tattoo and bed sore noted. Her hair

is long, about 15-18 inches in length and well groomed.

XIII. Comfort and Rest Status

The patient doesn’t usually sleep for about 8-10 hours

during the night. During the shift, she verbalized that she

usually gets only 3-4 hours of sleep. She was mostly seen

unable to sleep, restless, and will wake up when there are

verbal cues such as monitoring of vital signs and

administration of medications, and when pain is felt. The

patient also verbalized that sometimes she cannot rest or

sleep due to the environmental noise.

 CHAPTER IV. ANATOMY AND PHYSIOLOGY

FEMUR

The femur, or thighbone, is the longest, heaviest, and

strongest bone in the entire human body. The femurs support

all of the body’s weight during many activities, such as

running, jumping, walking, and standing. Extreme forces also

act upon the femur thanks to the strength of the muscles of

the hip and thigh that act on the femur to move the leg. The

femur is classified structurally as a long bone and is a

major component of the appendicular skeleton. On its

proximal end, the femur forms a smooth, spherical process

known as the head of the femur. The head of the femur forms

the ball-and-socket hip joint with the cup-shaped acetabulum

of the coxal (hip) bone. The rounded shape of the head

allows the femur to move in almost any direction at the hip,

including circumduction as well as rotation around its axis.

Just distal from the head, the femur narrows considerably to

form the neck of the femur. The neck of the femur extends

laterally and distally from the head to provide extra room

for the leg to move at the hip joint, but the thinness of

the neck provides a region that is susceptible to fractures.

At the end of the neck, the femur turns about 45

degrees and continues distally and slightly medially toward

the knee as the body of the femur. At the top of the body of

the femur on the lateral and posterior side is a large,

rough bony projection known as the greater trochanter. Just

medial and distal to the greater trochanter is a smaller

projection known as the lesser trochanter. The greater and

lesser trochanters serve as a muscle attachment sites for

the tendons of many powerful muscles of the hip and groin

such as the iliopsoas group, gluteus medius, and adductor

longus. The trochanters also widen and strengthen the femur

in a critical region of high stresses due to external trauma

and the force of muscle contractions.

On its distal end, the femur forms the knee joint with

the tibia of the lower leg. The distal end of the body of

the femur widens significantly above the knee to form the

rounded, smooth medial and lateral condyles. The medial and

lateral condyles of the femur meet with the medial and

lateral condyles of the tibia to form the articular surfaces

of the knee joint. Between the condyles is a depression

called the intercondylar fossa that provides space for the

anterior cruciate ligament (ACL) and posterior cruciate

ligament (PCL), which stabilize the knee along its

anterior/posterior axis.
 CHAPTER V: PATHOPHYSIOLOGY

A. SCHEMATIC:

Predisposing Factors: Precipitating Factors:

 Age  Environmental
 Gender Factors

Stress placed on a bone, exceeds

the bone ability to absorb it.

Injury in the bone

Fractured/ Displaced middle 3rd of

right Femur bone

Lab Results:

 Low Hemoglobin
 High level LDH
 Fractured Femur
DRUGS: NCP:

 Tramadol  Acute Pain

 Risk For
Injury
Formation of blood
 Disturbed
clots
Sleep Pattern

Collagen Matrix replaces

Blood Clots

Osteoblast

Remodeling (Bone
Healing
B. NARRATIVE:

Patient X has a precipitating factors that is

environment where she works and where she lives and its

predisposing factors is age and gender. The client was

walking down the stairs in their place and suddenly fell

down until she reached the road or the highway. So then was

referred to the hospital. With this, patient X had a

disturbed sleep pattern, acute pain and risk for infection.

This then resulted that stress placed on a bone, exceeds the

bone ability to absorb it.

The natural process of healing a fracture starts when

the injured bone and surrounding tissues bleed, forming a

fracture Hematoma. The blood coagulates to form a blood clot

situated between the broken fragments. Within a few days

blood vessels grow into the jelly-like matrix of the blood

clot. The new blood vessels bring phagocytes to the area,

which gradually remove the non-viable material. The blood

vessels also bring fibroblasts in the walls of the vessels

and these multiply and produce collagen fibers.

In this way the blood clot is replaced by a matrix

of collagen. Collagens rubbery consistency allows bone

fragments to move only a small amount unless severe or

persistent force is applied. At this stage, some of the

fibroblasts begin to lay down bone matrix (calcium

hydroxyapatite) in the form of insoluble crystals. This

mineralization of the collagen matrix stiffens it and

transforms it into bone.

 In fact, bone is a mineralized collagen matrix; if the

mineral is dissolved out of bone, it becomes rubbery months

after the injury. For example, any form of nicotine hinders

the process of bone healing, and adequate nutrition

(including calcium intake) will help the bone healing

process. Weight-bearing stress on bone, after the bone

has healed sufficiently to bear the weight, also builds bone

strength. The bone shards can also embed in the muscle

causing great pain. Although there are theoretical concerns

about NSAIDs slowing the rate of healing, there is no

enough evidence to warrant withholding the use of this type

analgesic in simple fractures.

So in this, the patient was diagnosed with a pathologic

fracture at the right femur as evidenced by the lab results,

diagnostic test and was given drug that is tramadol.

CHAPTER VI: LABORATORY RESULTS

COMPLETE BLOOD COUNT

TEST NAME RESULTS REFERENCE RANGE

Hemoglobin 113 120-160g/L

Hematocrit 0.34 0.37-0.47L/L

DIFFERENTIAL COUNT

Lymphocytes 18% 20-40%

RBC Count 3.56 4.04-5.48 10^12/L

INTERPRETATION:

Low Hemoglobin count:

The patient has a low hemoglobin count, which means she

is anemic or has a low red blood cell count. Hemoglobin’s

role in the blood is to transport oxygen from the lungs to

the body’s tissues and returns carbon dioxide from the

tissues back to the lungs. She has a high WBC count because

there is an infection present.

Low hematocrit count:

A low hematocrit with low RBC count and low hemoglobin

indicates anemia. Hematocrit is the proportion, by volume of

the blood that consists of red blood cells. She has a high

neutrophil because it is caused by chemotherapy, leukemia,

radiation therapy or sepsis, and high neutrophils caused by

stress and bacterial infections.

Low Lymphocytes Count:

Lymphocytes are the second most abundant immune system

cell, and typically respond to bacterial infections As a

result, if they are Decreased it indicates a bacterial

infection for the patient.

Low RBC Count:

Blood or red cell loss that occurs suddenly or over

time and diseases and conditions that decrease red blood

cell production in the bone marrow will result in a low RBC

count. Some causes of a low RBC count are anemia and trauma.

Chemistry

TEST NAME RESULTS REFERENCE RANGE

LDH 326 U/L 81-234 U/L

INTERPRETATION:

High levels of LDH indicate some form of tissue damage.

High levels of more than one isoenzyme may indicate more
than one cause of tissue damage. For example, a patient
with pneumonia could also have a heart attack. Extremely
high levels of LDH could indicate severe disease or multiple
organ failure.

CT SCAN RESULT FORM

INTERPRETATION:

CT SCAN REPORT: Multiple axial tomographic section of

the thorax without IV Contrast was obtained.

CHEST:

The CT images reveal the following findings:

Scattered tiny nodular opacities are seen in both upper

lobes.
There also linear dense with dilated bronchioles in the
medial segment of the middle lobe and inferior lingular
segment of the upper lobe.

No evidence of pulmonary nodules or masses.

No pleural effusion or pleural thickening.

The Heart and vessels are unremarkable.

There no enlarged lymph nodes.

Degenerative changes are noted in the evaluable vertebrae.

No lytic or blastic lesions.

The Visualized upper abdominal structures appear

unremarkable.

IMPRESSION:

ABOVE FINDINGS IN THE LUNGS MAY RELATE TO INFECTIOUS

PROCESS SUCH AS PULMONARY TUBERCULOSIS WITH FIBROSIS AND

TRACTION BRONCHIECTASIS IN THE MIDDLE LOBE AND INFERIOR

LINGULA.

-NO EVIDENCE OF PULMONARY NODULES OR MEDIASTINAL

LYMPHADENOPATHIES.

RIGHT FEMUR:

CT SCAN REPORT: Multiple axial tomographic sections of

the right femur without contrast media and bone window were

observed.

The CT images reveal a closed, complete, oblique,

overriding fracture of the distal third diaphysis of the

right femur. The distal fractured segment is supero-

laterally displaced. Tiny fractured segments are seen

adjacent to the fracture deformity. Soft tissue swelling is

seen in the distal aspect of the thigh.

Bony fragments are also seen in the antero-superior aspect

of the right patella.

No lytic or sclerotic osseous changes.

The visualized joint spaces are maintained.

The rest of the soft tissues are unremarkable.

IMPRESSION:

- Closed, complete, overriding fracture, right distal femur

with adjacent soft tissue swelling

- Bony fragments in the anterosuperior aspect of right

patella, possibly a fracture.

CHAPTER VII: NURSING CARE MANAGEMENT

A. Nursing process

List of identified problems (actual and potential/risk)

A1. Actual Nursing Problems

 Acute Pain related to fracture, closed complete

displaced, sand injury to the middle 3rd femur right

 Disturb Sleeping Pattern

A2. Potential Nursing Problems

 Risk for infection related to wound

B. Prioritization

Nursing Rank Justification

Diagnosis

Acute Pain 1st According to

related to Maslow’s hierarchy

fracture, closed of human needs

complete that this problem

displaced, sand will received the

injury to the 1st highest

middle 3rd femur prioritization.

right This is one of the

strongest needs

because if the

person were

deprived of all

needs, the

physiological

One will come

first in the

person’s search

for satisfaction.
 It might cause

unpleasant sensory

and emotional

experience arising

from actual

problem or

potential tissue

damage or

described in terms

of damage. Pain is

signal that

something is wrong

and existing

whenever the

person says it

does.

Disturb Sleeping 2nd This nursing

Pattern diagnosis will

received 2nd

Prioritization

because this may

cause further

weakness/stress

that will not

contribute in

achieving fast

recovery of the

patient and may

lead to alteration
 of immune system.

Enough time of

sleep is necessary

for the healing

process of the

patient’s bone

fracture.

Risk for This is the 3rd

infection prioritized
3rd
related to wound nursing diagnosis

because according

to the rule, risk

problem should

prioritized least,

because actual

problem should

solve first.
 VIII. Summary of Care

We, The students of University of Baguio NCA group 1

who had a duty in Baguio General Hospital and Medical Center

at Orthopedic ward who had a case of Fracture, Closed

Complete Displaced, Middle 3rd Femur Right were able to gain

knowledge about the said case. We were able to check the

vital signs of our patient from the day that she was

admitted to monitor and to avoid sudden complications. The

health care team gave her medication for her case such as

Tramadol. Intravenous Fluid and clients input and output was

also monitored to avoid any imbalance from the client’s

fluid and electrolyte levels.

With proper knowledge, we were able to prevent further

problems about this case and we had already the chance to

identify all possible cause of this case.

 CHAPTER IX: CONCLUSION

During our duty at the medical 3rd floor ward, our

group gained and shared knowledge towards to what the most

appropriate method of care should be given to clients such

as ours, improved our nursing skills towards clients with

such conditions, and ensured that our client received the

outmost proper care and comfort during her stay. As such

during the making of this case study our group understood on

how these kinds of diseases is caused and how it affects the

body. We also learned its pathophysiology, the medical

intervention of this disease to provide the appropriate

nursing interventions, and on how to prevent further

complications by rendering the appropriate nursing

interventions.
 CHAPTER X: RECOMMENDATIONS

We, the group NCA1 of the University of Baguio would like to

recommend the following:

 To the Student Nurses to continue providing their

skills and knowledge to their patients. Giving all the

proper interventions each patient needs.

 To the University of Baguio – School of Nursing to

continue sending their nursing students to different

hospital affiliates to continue nurturing and broaden

their skills and knowledge to become a globally

competitive nurse in the future.

 To Baguio General Hospital and Medical Center to

continue offering their institution as a training area

for student nurses to be able to gain experience in the

hospital setting and also to the BGHMC staff to

continue helping and supporting the student Nurses

assigned on different clinical areas in molding them to

become a better nurse in the future.

 To the patient and significant others to continue their

treatment and medications for the betterment of their

health.

 To the future researchers of this study to continue

searching for new discoveries, devices and treatments

that could help in the management of this case.

 CHAPTER XI: REFERENCE

http://www.worldlifeexpectancy.com/country-health-

profile/philippines

http://www.who.int/mediacentre/factsheets/fs344/en

https://www.verywell.com

www.innerbody.com/image_skelfov/skel25_new.html

https://labtestsonline.org/condition/

https://emidicine.medscape.com/article/overview