Republic of the Philippines

PALAWAN POLYTECHNIC COLLEGE INC.

Manalo Extension, Puerto Princesa City
Bachelor of Science in Nursing

CASE OVERVIEW
OF

LEFT LEG FRACTURE

SUBMITTED TO:
MA’AM CAROL CAYABO, RN
Clinical Instructor

SUBMITTED BY:
ALEJAH MAE A. REY, SN

BSN3-B CALISTA ROY

Table of Contents
Title Page…………………………………………………………………………….i
Table of Contents……………………………………………………………………ii
Introduction (Nursing Theory)………………………………………………………iii
CHAPTER 1: ASSESSMENT
Nursing Health History………………………………………………………..I
Physical Examination………………………………………………………….II
Diagnostic procedure…………………………………………………………..III
Anatomy and Physiology……………………………………………………...IV
Pathophysiology/Disease……………………………………………………...V
CHAPTER II: PLANNING
List of Prioritized Nursing Diagnosis………………………………………….VI
Nursing Care Plan……………………………………………………………..VII
CHAPTER III: IMPLEMENTATION
Medical management………………………………………………………….VIII
Drug Study…………………………………………………………………….IX
Treatment……………………………………………………………………...X
Diet……………………………………………………………………………XI
Activity/Exercise……………………………………………………………...XII
Surgical management………………………………………………………….XIII
Client Daily Progress Chart ………………………………………………….XIV
CHAPTER IV: EVALUATION
Medication
Exercise
Treatment
Healing Teaching
Out-Patient Department
Diet
Spirituality
References

INTRODUCTION
 The musculoskeletal system is composed of the bones, joints, muscles, rendors,
ligaments, and bursae of the body. The major function of this system are to support
and protect the body and foster movement of the extremities. The components of this
system are highly integrated; therefore, disease in or injury to one component
adversely affects others. For instance, an infection in a joint (e.g., septic arthritis)
causes degeneration of the articular surfaces of the bones within the joint and local
muscle atrophy.

STRUCTURE and FUNCTION of the SKELETAL SYSTEM

There are 206 bones in the human body, divided into four categories classified by
their shape: long, short, flat, and irregular. The long bones are found in the upoer and
lower extremities (e.g., the femur). Long bones ate shaped like rods of shafts with
rounded ends. The shaft known as the diaphysis, is primarily cortical bone (compact
bone) The ends of the long bones, called epiphyses, are primarily cancelous bone
(trabecular bone). During childhood and adolescence, there is a layer of cartilage
known as the epiphyseal plate, or growth plate, that separates the epiphysis from the
diaphysis. The epiphyseal plate nurtures and facilitates longitudinal growth. The
epiphyseal plate is calcified in adults. The ends of long bones are covered at the joints
by articular cartilage, which is tough, elastic, and avascular tissue.

The Patient with an External Fixator

External fixator devices are used to manage fractures with large amounts of soft
tissue damage. Complicated fractures of the humerus, forearm, femur, tibia, and
pelvis are also managed with external skeletal fixators. There are also used to correct
defects, treat nonunion, and lengthen limbs. Their use has increased in recent years
with advances in orthopedic trauma care. The fixator provides skeletal stability for
severe comminuted (crushed or splintered) fractures while permitting active treatment
of extensive soft tissue damage.
External fixation is a technique that involves the surgical insertion of pins through
the skin and soft tissues intro and through the bone. A metal external frame is attached
to these pins and is designed to hold the fracture in proper alignment to enable the
healing occur (Kani, Porrino, &Chew, 2020). Advantages of external fixation,
compared to other modes of treatment, include immediate fracture stabilization,
minimization of blood loss (in comparison to internal fixation), increased patient
comfort, improved wound care, promotion of early mobilization and weight bearing
on the affected limb, and active exercise of adjacent uninvolved joints (AAOS
2019d). The disadvantages are an increased risk for pin site loosening and infection,
which can lead to osteomyelitis, septic arthritis, and progressive pain (Sayed,
Mohammed, Mostafa, et al., 2019).

Nursing Theory

According to Dorothea Orem, delivery of patient care based on theoretical principles

can promote successful practice. Orem's Self-Care Nursing Theory offers direction for
the practitioner in the ambulatory surgery setting. In this model, the nurse assists
clients by acting for, teaching, guiding, supporting, and providing a developmental
environment. Levels of care range from performing total care to educating the patient
and family. Promoting self-care as soon as feasible is the goal of the ambulatory care
plan. Consequently, self-care deficits created during surgery and anesthesia must be
overcome so that the patient is dismissed from the ambulatory setting with the ability
to meet self-care needs. Her theory defined Nursing as “The act of assisting others in
the provision and management of self-care to maintain or improve human functioning
at the home level of effectiveness.” It focuses on each individual’s ability to perform
self-care, defined as “the practice of activities that individuals initiate and perform on
their own behalf in maintaining life, health, and well-being.”

Self-Care Theory
Dorothea Orem’s Self-Care Deficit Theory focuses on each “individual’s ability to
perform self-care, defined as ‘the practice of activities that individuals initiate and
perform on their own behalf in maintaining life, health, and well-being.'” The Self-
Care or Self-Care Deficit Theory of Nursing is composed of three interrelated
theories: (1) the theory of self-care, (2) the self-care deficit theory, and (3) the theory
of nursing systems, which is further classified into wholly compensatory, partially
compensatory and supportive-educative. It is discussed further below.

Dorothea Orem’s Self-Care Deficit Theory

There are instances wherein patients are encouraged to bring out the best in them
despite being ill for a period of time. This is very particular in rehabilitation settings,
in which patients are entitled to be more independent after being cared for by
physicians and nurses. Between 1959 and 2001, Dorothea Orem developed the Self-
Care Nursing Theory or the Orem Model of Nursing. It is considered a grand nursing
theory, which means the theory covers a broad scope with general concepts applicable
to all instances of nursing.

Nursing (The theory of the nursing system)

Nursing is an art through which the practitioner of nursing gives specialized
assistance to persons with disabilities, making more than ordinary assistance
necessary to meet self-care needs. The nurse also intelligently participates in the
medical care the individual receives from the physician.

CHAPTER 1: ASSESSMENT
A. Nursing Health History
Functional Health Before During After
Pattern Hospitalization Hospitalization Hospitalization
Health Exercise every Taking medication Continuously
perception/Health morning and as prescribed by taking medication
management taking attending prescribed by his
multivitamins for physician and attending
boosting restricted to take physician for
immunity some vitamins that wound healing
can cause
excessive bleeding
Nutritional Metabolic According to SO, Patient Begin eating
Mr. De Belen has taking/eating nutritious and
a vices of recommended healthy foods on
drinking alcohol food at the a regular basis
and smoking hospital (daily and taking
cigarettes prepared meal by vitamins to boost
sometimes a dietitian). Immunity and for
faster recovery

Elimination Patient’s Patient’s His elimination’s

elimination is on elimination is still amount still the
regular basis and on regular basis same.
with in normal and with in normal
range. range but his stool
is in a soft texture
(1500L/24hrs).
Activity-Exercise Client always Patient always on Patient’s
perform daily bed, sleeping, condition
activity such as lying on bed the improved, he was
walking, running, whole day and able to move his
hiking and unable to walk left lower leg
adventure. properly on his without assistance
own because of and ready for
his leg fracture discharge
Cognitive-Perceptual He’s usually a He always want to He became more
happy, joyful and rest and avoiding friendly and
talkative kind of social approachable
person communication specially to
because he only hospital’s staffs
wants to rest
Sleep-Rest Has a sleep Excessive Back to his
routine from sleeping/sleeping
usually sleep
11:30pm to 8am all day hours routine
from 11:30pm to
8am
Self-perception/Self Mama’s boy and He prefer the Sweet to his
conception described by presence of his family and friends
mother as a mother only
responsible,
caring and selfless
 eldest brother and
child
Role-Relationship Eldest child. Visited by his Family became
Parents always friends and other more caring and
shows their love family member provide more
and support attention for his
fast recovery
Sexuality/Reproductive N/A N/A N/A

Coping/Stress Drink alcohol and His parents Avoiding vices

tolerance smoke when he handled his because it is
can’t handle his situation well and restricted by his
problem and they make sure physician
stress that everything
will be okay. They
don’t want him to
be stressed
Value-Belief Always go to Wasn’t able to Attending church
church every attend any church every Sunday and
Sunday and gathering and continued to
attending every activity attend church
church activities activities

Physical Examination

General Health (Appearance and Mental Status)

SKIN
Patient’s skin is soft, smooth, pale in color, no signs of irritation

HAIR
Hair is well comb, dry, no scalp dandruff

NAILS
Patient’s nail is short and no dirt

SKULL AND FACE

Symmetrical and no signs of abnormalities

EYE STRUCTURE AND VISUAL ACTUITY

Equal, round with color black pupil, brown iris, and reactive to light

EARS AND HEARING

No abnormalities observed

NOSE AND SINUSES

No signs of congestion

MOUTH AND OROPHARYNX

Patient is able to swallow their own secretions. No abnormalities observed

NECK
Trachea is in mid-line, no enlargement of lymph nodes and thyroid gland

THORAX AND LUNGS

Clear breath sounds bilaterally, no crackles or wheezes

HEART AND CENTRAL VESSELS

Regular rate and rhythm, pulse beats normally. No abnormalities observed

PERIPHERAL VASCULAR SYSTEM

Normal pulse, fast wound healing in lower left leg, no gangrene, pallor

BREAST AND AXILLAE

Nipples, breast tissue,and areas around the breast look normal and are normal in size
and shape

ABDOMEN
Non-tender and firm

MUSCULOSKELETAL
Patient’s posture is unbalanced and gait while walking is abnormal. Joints and
muscles on left leg are asymmetrical but no signs of swelling, redness, and leg
deformity.

NEUROLOGICAL SYSTEM
Patient is alert and oriented. Cranial nerves are i ntact and symmetrical. Reflexes are
normal
FEMALE GENITALS AND INGUINAL AREA
No abnormalities observed

RECTUM AND ANUS

No abnormalities observed

Diagnostic Procedure
Name of the Date ordered Normal values Values Interpretation
Procedure obtained and Analysis
CRP (CRP) is a
glycoprotein
C-Reactive 11/06/2023 0.00-5.00 51.17mg/L produced
Protein mg/L by the liver in
response to
acute
inflammation.
CRP
disappears
from the serum
rapidly when
inflammation
has
subsided. The
inflammatory
process and its
association
with ath
erosclerosis
make the
presence of
CRP, as
detected by
highly sensi
tive CRP
assays, a
potential mark
er for coronary
artery disease.
It is
believed that
the
inflammatory
process may
instigate the
conver
sion of a stable
plaque to a
weak
er one that can
rupture and
 occlude an
artery.

CBC
Hemoglobin 11/06/2023 140-180g/L 101 g/L The protein
hemoglobin is
found in red
blood cells. Red
blood cells carry
oxygen
throughout your
body. If you
have a disease
that affects you.
Hemoglobin is
the capacity of
your body to
produce red
blood cells.
Levels may fall.
Low
hemoglobin
levels can
indicate a
number of
diseases

Hematocrit 11/06/2023 0.400-0.540 % 0.306 % A hematocrit

test is a simple
blood test used
to determine the
percentage of
red blood cells
in your blood.
Red blood cells
are required
because
Circulate
oxygen
throughout your
body. Low or
high hematocrit
levels may
indicate blood
disorders or
other medical
conditions.

Red cell count 11/06/2023 4.60-600 /L 3.45 /L RBC

production in
healthy adults
takes place in
 the
bone marrow
of the
vertebrae, pel
vis, ribs,
sternum, skull,
and proxi
mal ends of the
femur and
humer
us. Production
of RBCs is
regulated
by a hormone
called
erythropoie
tin which is
produced and
secreted
by the kidneys.
Normal RBC
devel
opment and
function are
depen
dent on
adequate levels
of vitamin
B12, folic acid,
vitamin E, and
iron.

white cell 11/06/2023 4.3-10.00 /L 13.94 /L A high white

count blood cell
(WBC) count
can be caused
by a number of
different
diseases. White
blood cells are
an essential
component of
the body's
immune system.
These cells aid
in the fight
against
infection, the
healing of
injuries, and the
recovery. When
a bone marrow
 disorder that
produces an
excess of white
blood cells also
produces an
excess of red
blood cells, this
occurs

Anatomy and Physiology

The musculoskeletal system provides protection for vital organs, including the brain,
heart, and lungs; serves as a framework to support body structures; and makes
mobility possible. Muscles and tendons hold the bones together, and joints allow the
body to move. They also move to produce heat that helps maintain the body
temperature. Movements facilitates the return of deoxygenated blood to the right side
of the heart by massaging the venous vasculature.

Pathophysiology

PREDISPOSING FACTOR
PRECIPITATING FACTOR
 Poor environment (rough road,
small road space, lack of street  Host inadequate ( irresponsible
lights). driver, driving under the
 Work influence of alcohol).
 Age  Stray dogs
 Sex
 Poor response of
previous administration
Failure of primary prevention
Poor response of
 Road signs
ambulatory vehicle
 Vehicle gear (knee pad, helmet)

Poor emergency services and Poor state of fixed facilitate

High RTA’s
pre-hospital care

Failure of secondary
prevention Failure of tertiary prevention
 Pre-care trauma  Hospital care

High road traffic morbidities and mortalities

CHAPTER II
List of Prioritized Nursing Diagnosis
Nursing Number Supporting Data Justification
Diagnosis of
Priorities
Acute pain related 1 - Facial Grimace According to Dorothea
to post surgical - Guarding Orem, delivery of patient
incision behaviour care based on theoretical
- Pain Scale 6/10 principles can promote
- Elevated BP successful practice. Orem's
130/100 Self-Care Nursing Theory
- Debridement offers direction for the
Impaired skin 2 - Surgical incision practitioner in the
integrity related to - Disruption of skin ambulatory surgery setting.
physical surface Her theory defined Nursing
demanding as “The act of assisting
Impaired physical 3 - Weakness others in the provision and
mobility related to - Slow movement management of self-care to
physical - Difficulty in maintain or improve human
reconditioning turning functioning at the home
- Facial grimace level of effectiveness.” It
when moving focuses on each individual’s
Risk for infection 4 - Surgical incision ability to perform self-care,
related to surgery - Guarding position defined as “the practice of
Decrease activity 5 - Weak in activities that individuals
tolerance related appearance initiate and perform on their
to insufficient - Cannot perform own behalf in maintaining
muscle mass ADL’s alone life, health, and well-being.”

Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Objective data: Impaired After 8 hrs INDEPENDENT: After 8hrs of
skin integrity of nursing nursing
- Fracture over related to intervention, - Keep the area intervention,
bony surgical the patient clean and dry, patient was able
prominence incision will be able address rashes to:
- intact OREF to: and inflammation,
with suction and provide - Free from any
drainage/VAC - Identify protective signs of
- Wet dressing individual measures. infection
risk factors - assess the - Shows
-↓BP - Display overall condition knowledge in
100/80mmHg timely of the skin the technique
-RR 20 healing - Monitored VS on preventing
- PR 66 bpm lesion or and recorded the risk of
- T 36.2˚C wounds infection
- O2 99% without DEPENDENT: - proper wound
complication healing and
- Establish - Administer absence of
infection medication as exudes, foul
prevention prescribed by the odor and pain
measures physician
and
treatment

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective data: Impaired After 8hrs of INDEPENDENT: After 8hrs of
physical nursing nursing
“Hindi ko pa rin mobility intervention, - Provide comfort intervention,
talaga sya related to patient will - Assess patient’s patient was able
magalaw ng physical be able to: SO knowledge of to:
maayos pero reconditioning immobility and
nagagalaw - Move about it’s implication - Perform
naman yung within - Assess degree of physical activity
mga daliri ko” environment mobility produced independently or
as verbalized by as needed or by injury with assist as
the patient desired needed
within limits DEPENDENT:
Objective data: of ability or - Keep the leg
with elevated as
- Intact OREF appropriate prescribed by the
with suction adjuncts physician
drainage/VAC - Verbalize
- PS 6/10 understandin
- Wet dressing g of situation
or risk factors
and safety
measures

CHAPTER III: IMPLEMENTATION

A. Medical Management
1. Drug Studies
Date Name Classific Dose, Mechanism Contraindi Side Nursing
orde of the ation route of action cation effect responsib
red Drug and and ilities
indicatio freque
n ncy
Ketorol 30mg Used to Drowsi - Assess
oact IV relieve ness, pain (note
q6hr moderately abnorm type,
severe pain al location
after thinkin and
surgery. g, intensity)
dizzines prior to 1-
Anti- s, 2hr
pyretic and asthma, following
anti- dyspnea administr
inflammato , GI ation
ry bleedin - Assess
properties g, renal for
toxicity rhinitis,
, dry asthma
mouth, amd
diarrhea urticaria
,
edema,
pallor

Date Name Classific Dose, Mechanis Contraindic Side Nursing

order of the ation and route m of ation effect responsibi
ed Drug indicatio and action lities
n freque
ncy
Trama 50mg Tramadol Seizures Assess
dol IV works dir , type,
q6hr ectly on dizzines location
opioid s, and
receptors headach intensity
in the e, of pain
central stimulati before and
nervous on, 2-3hr
system confusio (peak)
and n, after
reduces euphoria administra
feelings , tion
of pain malaise,
by nervous
interrupti ness,
 ng the sleep
way disorder,
nerves weaknes
signal s
pain
between
the brain
and the
body.

2. Treatment
NAME OF TREATMENT INDICATION/PURPOSE NURSING
RESPONSIBILITY
N/A N/A N/A

3. Diet
(Diet As Tolerated)
MEAL SERVING
Breakfast - 1 serving of scrambled egg with tomato,
1 cup of rice, 1 glass of hot chocolate, 1
glass of water
Snack (If needed) - 1 chocomucho biscuit, 2 glasses of
water
Lunch - 1 serving of fish sauce (sinigang), 2
cups of rice, 3 glasses of water
Snack (If needed) - 1 bottle of coffee jelly
Dinner - 1 serving of chicken adobo, 1cup of
rice, 2 glasses of water

Brief Description
Regular diet, also known as general, normal, or full diet, was previously known as
DAT (diet as tolerated). A typical diet includes grains, vegetables, fruits, dairy
products, as well as meat, fish, and beans. Designed for the adult patient who does not
require any dietary changes.
Purpose
Diet as tolerated indicates that the gastrointestinal tracts is tolerating food and
is ready for advancement to the next stage.
 Nursing Responsibilities
Nurses have the knowledge and responsibility to ensure that the nutritional needs of
their patients and clients are met. It is critical to provide nutrition screening and
appropriate nutrition advice in order to improve healthy eating and the health results
that follow. Non-communicable diseases are frequently linked to modifiable risk
factors.

4. Activity/Exercise
Type of Procedure/Steps Use of Restrictions Rationale
activity equipment
allowed to be
continued
Walking Take a small step Clipart Avoid long To provide
at a time to crutches distance well-lighted
exercise leg pathway and environment
muscles slippery and avoid the
surfaces occurrence of
injury. To
ensure clients
safety

5. Surgical management

Post operative
- Frequently examine the incision site to monitor the wound healing process.
- Manage wound dressings.
- Counsel patients on wound care

Client’s Daily Progress Chart

Diagnostic Diet Activity Medication Treatment Surgery
Procedure

Admission
Day 1 IFC DAT N/A Ketorolac N/A N/A
30mg IV
q6hrs
Amlodipine
1mg/tab
OD

Day 2 Debridement DAT N/A Tramadol N/A OREF

50mg IV
q6hrs
Amlodipine
1mg/tab
OD

Day 3 N/A DAT N/A Cefuroxime N/A N/A

500mg/tab
BID
Ketorolac
30mg IV
q6hrs

Day 4 N/A DAT N/A Cefuroxime N/A N/A

500mg/tab
BID
Celecoxib
250mg/tab
BID for 6
days
Ketorolac
30mg IV
q6hrs

Day 5 N/A DAT Walking Paracetamol N/A N/A

300mg IV
STAT
Telmisartan
80mg/tab
OD
Cefuroxime
500mg/tab
BID

Day N/A DAT Walking Telmisartan N/A N/A

80mg/tab
OD
 Day 6 N/A DAT Walking Cefuroxime N/A N/A
500mg

CHAPTER IV: IMPLEMENTATION

Medication

Name of Dosage Route Time Curative Side

Drug and effects effects
Frequency

Cefuroxim 500mg Oral or TID To treat Nausea,

e by q8hrs certain vomiting,
mouth infections dizziness,
caused by diarrhea,
bacteria and body
prevent swelling
bacterial
growth
Headache,
Ibuprofen 500mg Oral or As Manage dizziness,
by needed/ pain, fever drowsiness,
mouth when in and fatigue and
pain inflammation restless
sleep, thirst
and
sweating,
tingling or
numbness
in hands
and feet,
ringing in
the ears,
blurred
vision and
eye
irritation,
fluid
retention
and ankle
swelling.

Exercise
Type of Procedure/Steps Use of Restrictions Rationale
activity equipment
allowed to be
continued
Walking Take a small step Clipart Avoid long To provide
at a time to crutches distance well-lighted
exercise leg pathway and environment
muscles slippery and avoid the
surfaces occurrence of
injury. To
ensure clients
safety

Treatment
NAME OF TREATMENT INDICATION/PURPOSE NURSING
RESPONSIBILITY
N/A N/A N/A

Health Teaching
 Explain to the patient the importance of self-care, such as getting enough rest/sleep
and eating healthy foods.
 Instruct the patient not to overwork the body and to do only light chores during the
day, especially after discharge.
 Explain to the patient the importance of self-care, such as getting enough rest/sleep
and eating healthy foods.
 Follow all instructions and look after yourself
 Make sure to always do the hand-hygiene before touching the leg part with OREF to
avoid infection
 Wound dressing every after 24hrs
 Proper intake of cefuroxime 500mg orally every 8hours after meal for 7 days
 Take Ibuprofen 500mg orally as needed
 Avoid walking in a slippery surfaces to prevent any accidents like falling

Out-patient Department

Name of the Room No. Date and Time Name of

Doctor Institution
Vick Roland L. N/A January 10, 2024 PMMGH
Ladica, M.D. 10:00 am

Diet
(Diet As Tolerated)
MEAL SERVING
Breakfast - 1 serving of scrambled egg with tomato,
1 cup of rice, 1 glass of hot chocolate, 1
glass of water
Snack (If needed) - 1 chocomucho biscuit, 2 glasses of
water
Lunch - 1 serving of fish sauce (sinigang), 2
cups of rice, 3 glasses of water
Snack (If needed) - 1 bottle of coffee jelly
Dinner - 1 serving of chicken adobo, 1cup of
rice, 2 glasses of water

Brief Description
Regular diet, also known as general, normal, or full diet, was previously known as
DAT (diet as tolerated). A typical diet includes grains, vegetables, fruits, dairy
products, as well as meat, fish, and beans. Designed for the adult patient who does not
require any dietary changes.

Contraindicated
Avoid fatty foods and salty foods (process foods, soda, drinks that contains alcohol).

Spirituality
 Encourage to continue seeking God’s presence and guidance
 Emphasize the importance of prayers in healing
 Encourage to continue attending church gathering every Sunday
 Encourage to have a positive thinking
 Encourage to continue praying to God
REFERENCES