St.

Anthony College of Roxas City,

Capiz
San Roque Street Roxas City

A Case
Study
In
 Colles’
Fracture
Submitted to.
Mrs. Suzette Vela RN
Clinical Instructor

Submitted by:
Kara Angela Dumol
BSN 4C (group 4)

I. INTRODUCTION:

Colles’ fracture is a fracture of the radius, typically about 1 cm proximal to the

wrist. It usually results from a forceful, direct trauma, such as falling on an
outstretched hand. It is the most common wrist fracture. Because the ulna plays
no part in forming the wrist joint, the radius receives the brunt of the force.
Symptoms include local pain, numbness in the fingers, and limited mobility; if the
radius is displaced, it produces a classical dinner fork deformity of the wrist.
A Colles’ fracture often results in a shattering of the ends of the broken
bones. Initial treatment consists of splinting the wrist and forearm in the injured
position, gently applying ice over the injury, and calling for medical assistance.
With mild fractures, a closed reduction (non-surgical realignment of bones) may
be sufficient, but if the injury is more serious, surgical realignment may be
 required. It is particularly important to maintain the length of the radius. A poorly
treated Colles’ fracture can result in the radius shortening relative to the ulna and
can give rise to permanent loss of wrist rotation. After reduction, the injured wrist
is usually immobilized in a plaster of Paris cast, which leaves the fingers and
thumbs free so the muscles of the fingers, hand, and forearm can be exercised.
Immobilization is often lengthy (4-6 weeks). Most sports doctors advocate
aggressive rehabilitation, which includes an intensive exercise programme to
ensure maximum recovery. It may take 3-6 months before an athlete can return
to full activity.

II. OBJECTIVES

General

After this case study, I will be able to develop and gain more knowledge,
skills and attitudes in rendering care to the sick specifically to patients with a
bone fracture by applying the principles, theories and lessons that we have
earned for the preparation for this clinical exposure.

Specific:
• Cognitive

1. To be able to expand my knowledge about different kinds of fracture

and its affected sites.

2. To learn the different abnormalities manifested by the patient suffering

from these kind of fracture.
3. To be able to do a drug study, to learn the side effects, indication,
contraindication and nursing responsibility.
4. To be able to formulate nursing care plan according to the problem of
the patient.
5. To be able to formulate discharge planning in order to help and ensure
patient’s health improvement after discharge.

• Skills

1. To be able to take and learn more procedures.

2. To be able to conduct interview and to have a physical assessment to
the patient.
 3. To be able to gather more information about the patient’s condition
regarding his illness.
4. To be able to rank and prioritized problems.
5. To be able to perform nursing interventions and to evaluate if there
was any progress done to the patient

• Attitudes

1. To be able to establish trust and rapport with the patient.

2. To be able to have confidence in interacting with the patient and doing
procedures.
3. To be able to establish an effective nursing-patient interactions.
4. To be able to practice the Anthonian-Vincentian core values in
rendering care to the patient.
5. To be able to give importance to the said exposure that it may serve as
a challenge in facing various patients with different conditions and
enhanced management of skills, attitude and knowledge in handling
the clients.

III. Anatomy and Physiology

Every cell in the human body needs energy in order to function. The
body’s primary energy source is glucose, a simple sugar resulting from the
digestion of foods containing carbohydrates (sugars and starches). Glucose from
the digested food circulates in the blood as a ready energy source for any cells
that need it. Insulin is a hormone or chemical produced by cells in the pancreas,
an organ located behind the stomach. Insulin bonds to a receptor site on the
outside of cell and acts like a key to open a doorway into the cell through which
glucose can enter. Some of the glucose can be converted to concentrated
energy sources like glycogen or fatty acids and saved for later use. When there
is not enough insulin produced or when the doorway no longer recognizes the
insulin key, glucose stays in the blood rather entering the cells.
PANCREAS

Pancreas is an organ located behind the stomach and next to the liver and the
gall bladder. Pancreatic juices contain Enzymes, which help digest or break
down food proteins. Normally the juices leave the pancreas via a duct like
channel and join the common bile duct, which carries the secretions from the
gallbladder, and pour the mixture into the duodenal portion of the stomach.
IV. VITAL INFORMATION

Name: Mr. J.E

Age: 40 yrs. old
Sex: Male
Address: Burgos st. Ilawod Roxas, City
Civil Status: Married
Religion: Roman Catholic
Occupation: Driver
Date Admitted: November 21, 2010
Ward: Male Surgical Ward
Chief Complaints: Abdominal Pain
Impression/Admitting Diagnosis: Acute pancreatitis
Final Diagnosis: Acute pancreatitis
Attending Physician(s): Dr.

V. CLINICAL ASSESSMENT

A. Nursing History
 3 days prior to admission the patient experienced sudden onset of
abdominal pain, diffuse. 2 days PTA the patient still have the same abdominal
pain, this time was more severe and they monitored it. The patient is negative to
bladder change. Few hours PTA, the patient could not any more tolerate the
pain; He was brought to SACR.

B. Past Health Problem/Status

Mr. J.E has no history of past hospitalization. Sometimes he experienced

mild fever, coughs, and cold but manageable and treated with over the counter
drugs like paracetamol and solmux. He has no known allergies to food, drugs
and animals

C. Family Health History

Mr. S.M mother and father are healthy. They do not have nor had any
serious diseases. Her siblings are also healthy.

FAMILY GENOGRAM

M.M
Y.M 38 y.o
45 y.o health
healthy y

T.M
12 y.o M.M
health 11 y.o
y
healt
hy

DISEASE
HEALTHY F M PATIEN
M F D T
VI. BRIEF SOCIAL, CULTURAL AND RELIGIOUS
BACKGROUND

a. Educational Background
Mr. S.M is a grade 6 student in Saint Mary’s Academy of Capiz

b. Religious Practices
Mr. S.M grew from a religious family who strongly believes in the
existence of God and his words. He and his relatives go to mass every
Sunday and attend to any special occasion in the church.

d. Economic Status
Both of her parents are in working Japan and financially
supported their needs.

VII. CLINICAL INSPECTION

A. Vital Signs
Vital Signs upon admission: Vital Signs during our care:
BP- 130/80 mmHg BP- 110/70 mmHg
RR- 37 bmp RR- 27 bmp
AR- 87 bmp AR- 72 bmp
PR- 85 bmp PR- 75 bmp
TEMP. – 36.5°C TEMP. – 36.5°C

B. HEIGHT – 4’3”
WEIGHT – 42 kgs.
BMI – 20.18 (normal)

C. Physical Assessment
I. General Appearance
Mr. S.M complains pain in her right wrist. He appears weak and
uncomfortable. He has a long arm cast with arm sling on the right arm. He
lies at bed. Clothes are clean and neat.

II. Skin, Hair, Nails

• (+) swelling, (-) lump, (-) rash, (-) petechiae, (+) pallor
• Short, thick, and black in color, (-) lice, (-) dandruff
• Well-trimmed, (+) pale nail beds

III. Head, Face, and Lymphatics

• (-) headache, (+) dizziness,
• (-) pimples, (+) facial grimace, (-) moon face
• (-) palpable lymph nodes, (-) swelling

IV. Eyes, Ears, Nose, Mouth and Throat

• Eyes – (-) edema-papilledema (-) cataract, no eyeglasses, pupils are
black in color, (-) pale sclerae & conjunctiva, (+) pupils are equally
round and reactive to light and accommodation.
• Ears – Good auditory acquity, (-) lumps, (-) discharges, (-) infection
• Nose – (-) obstruction, (-) sinus inflammation, (-) discharges
• Mouth – (+) dry lips, (-) obstruction, no braces noted
• Throat – (-) tonsillitis, (-) sore throat (-) symmetric

V. Neck, Upper and Lower Extremities

• Neck – (-) enlargement of thyroid, (-) presence of lumps
• Upper Extremities & lower extremities – (+) weakness, (+) poor range of
motion

VI. Chest, Breasts, Axilla

• (-) chest pain,
• (-) hair, (-) lumps
• (-) lumps, (-) discharge
• Axilla – (-) lumps, (-) body odor

VII. Respiratory System

 • (-) pleural effusion, (-) cough, Nasal cavity is clear, no obstruction or
secretions noted.

VIII. Cardiovascular System

• (-) hypertension, (-) chest pain

IX. Gastrointestinal System

• (-) loss of appetite, (-) abdominal pain

X. Genitor-urinary System
• (+)decreased urinary output; urine output for 8 hours = 200 cc, (+) mild
pain upon urination, (+) hazy and tea-colored urine, (+) delayed
menstruation,
(+) distended bladder with generalized tenderness

XI. Musculoskeletal System

• (+) muscle pain, (+) fractures, (+) generalized body weakness

XII. General Appraisal

a. Speech And Language – Speaks in low calm voice. She can speak
Chinese, English, Hiligaynon and Tagalog.

b. Hearing – He can hear well and able to respond to questions actively.

c. Mental Status – Mr. S.M is alert and very cooperative, and answers
questions when asked.

d. Emotional Status – whenever procedures made and medication given he

does it cooperatively

VIII LABORATORY AND DIAGNOSTIC DATA

IHematology
Name and Date of Result Normal Values Significance of
Examination the abnormal
 result

Hemoglobin 147 g/L Male: 135 – 180 NORMAL.

Female: 120 - 160
Hematocrit 0.44 vol.fr Male: 0.40 – 0.54 NORMAL
Female: 0.37 – 0.47
Red Cell Count 5.13 million/uL 3.6-5 million/uL NORMAL

X-ray result

IMPRESSION:
• Fracture at distal radius and ulna

XI. PATHOPHYSIOLOGY
XII DISCHARGE PLANNING

A. Medications
 After long term of treatment the patient is required to take Celecoxib 1 tab
BID if pain and swelling occurs.

B. Exercise and activity

Encourage early ambulation, and deep breathing exercise. Adequate rest

is important to maintain progress toward full recovery and to avoid relapse
treatment. Normal activities may be resumed.

C. Home teaching

Clearly and specifically explain the nature of the disease, its course, and
the eventual prognosis of the condition to the patient and the parents and/or
caregivers. They need to understand that, while complete resolution is expected,
a small possibility exists for persistent disease, and that an even smaller
possibility exists for progression.

E. Out-patient follow-up

Encourage pt. that when he’s discharged, he must have a regular check-
up to his physician until it is needed.

F. Spiritually
Advised patient to pray to God always and so with the family, advised
them to pray together with the patient. God is the healer and reliever of all pains,
sufferings and diseases.