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I- Introduction

A fracture is a break in the continuity of bone and is defined according to its type
and extent. Fractures occur when the bone is subjected to stress greater that it can absorb.
Fractures are caused by direct blows, crushing forces, sudden twisting motions, and even
extreme muscle contractions. When the bone is broken, adjacent structures are also
affected, resulting in soft tissue edema, hemorrhage into the muscles and joints, joint
dislocation, ruptured tendons, severed nerves, and damaged blood vessels. Body organs
maybe injured by the force that cause the fracture or by the fracture fragments.
There are different types of fractures and these include, complete fracture,
incomplete fracture, closed fracture, open fracture and there are also types of fractures
that may also be described according to the anatomic placement of fragments,
particularly if they are displaced or nondisplaced. Such as greenstick fracture, depressed
fracture, oblique fracture, avulsion, spinal fracture, impacted fracture, transverse fracture
and compression fracture.
A comminuted fracture is one that produces several bone fragments and a closed
fracture or simple fracture is one that not cause a break in the skin. Comminuted fracture
at the Right Femoral Neck is a fracture in which bones of the Right Femoral Neck has
splintered to several fragments.
By choosing this condition as a case study, the student nurse expects to broaden
her knowledge understanding and management of fracture, not just for the fulfillment of
the course requirements in medical-surgical nursing. It is very important for the nurses
now a day to be adequately informed regarding the knowledge and skill in managing
these conditions since hip fracture has a high incidence among elderly people, who have
brittle bones from osteoporosis (particularly women) and who tend to fall frequently.
Often, a fractured hip is a catastrophic event that will have a negative impact on the
patient’s life style and quality of life. There are two major types of hip fracture.
Intracapsular fractures are fractures of the neck of the femur, Extracapsular fracture are
fractures of the trochanteric region and of the subtrocanteric region. Fractures of the neck
of the femur may damage the vascular system that supplies blood to the head and the
neck of the femur, and the bone may die. Many older adults experience hip fracture that

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student nurse need to insure recovery and to attend their special need efficiently and
effectively. True the knowledge of this condition, a high quality of care will be provided
to those people suffering from it.

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II. Objectives

General Objectives:
After three day of student nurse-patient interaction, the patient and the significant
others will be able to acquire knowledge, attitudes and skills in preventing complications
of immobility.

Specific Objectives:
A. STUDENT-NURSE CENTERED
After 8 hours of student nurse-patient interaction, the student nurse will be able
to:
1. state the history of the patient.
2. identify potential problems of patient
3. review the anatomy and physiology of the organ affective
4. discuss the pathophysiology of the condition.
5. identify the clinical and classical signs and symptoms of the condition.
6. implement holistic nursing care in the care of patient utilizing the nursing
process.
7. impart health teachings to patient and family members to care of patient with
fracture.
B. PATIENT-CENTERED
After 8 hours of student nurse-patient interaction, the patient and the significant
others will be able to:
1. explain the goals of the frequent position changes.
2. enumerate the position for proper body alignment.
3. discuss the different therapeutic exercises.
4. practice the different kinds of range of motion.
5. participate attentively during the discussion.

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III. Nursing Assessment

1. Personal History

1.1 Patient’s Profile

Name: Mrs. Torralba, Lourdes


Age: 89 years old
Sex: Female
Civil Status: Widow
Religion: Roman Catholic
Date and time of admission; March 13, 2008 at 10:10 am
Room No.: Room 425, Cebu Doctors’ University Hospital
Complaints: Pain the right hip
Impression or Diagnosis: Fracture Close-Comminuted: Femoral Right Neck
General Osteoporosis
Breast Cancel (Right)
Diabetes Mellitus Type II
Physician: Dr. F. Vicuna, Dr. E. Lee, Dr. N. Uy, Dr. Ramiro
Hospital No: 216 426

1.2. Family and Individual Information, Social and Health History

Mrs. Torralba, Lourdes who resides in 8 Acacia St. Camputhaw Lahug, Cebu City,
Cebu Province with 9 successful children ( 6 boys and 3 girls) was admitted to Cebu
Doctors’ University Hospital for further management of the condition.
Mrs. Torralba is a college graduate and she’s previously working as an assistant of her
husband ( Mr. Rodrigo Torrralba ) a doctor.
The patient was diagnosed to have Breast Cancer (Right) last 2006 with bone
metastasis and on chemotherapy with aromasin.

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Two days prior to admission, the patient was standing and was about to open up
he umbrella when she got out of balance and landed on her right hip.And had experienced
limitation of movement on the right hip. The patient was then admitted due to the
persistence of pain.
The patient was previously hospitalized due to infected wound at the right ankle
last 2002. No familial history of hypertension and bronchial asthma but is positive to
diabetes mellitus of paternal side. Has no known food and drug allergies. The patient is
non-smoker non-alcoholic beverages drinker.

1.3. Level of Growth and Development

1.3.1. Normal Growth and Development at particular stage Older Adult ( 65


Years old to death)

Physical Development

Perception of well-being can define quality of life. Understanding the older adults
perception about health status is essential for accurate assessment and development of
clinically relevant interventions. Older adults concepts of health generally depend on
personal perceptions of functional ability. Therefore older adults engaged in activities of
daily living usually consider themselves healthy, whereas those whose activities are
limited by physical, emotional or social impairments may perceive themselves as ill.
There are frequently observed physiological changes in order adults that are
called normal. Finding these “normal” changes during and assessment is not an expected.
These physiological changes are not always pathological processes in themselves, but
they may make older adults more vulnerable to some common clinical conditions and
diseases. Some older adults experience all of these physiological changes, and others only
experience only a few. The body changes continuously with age, and specific effects on
particular older adults depend on health, lifestyle, stressors and environmental conditions.

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Cognitive Development

Intellectual capacity includes perception, cognitive, memory, and learning.


Perception, or the ability to interpret the environment, depends on the acuteness of the
senses. If the aging person’s senses are impaired, the ability to perceive the environment
and react appropriately is diminished. Perceptual capacity may be affected by changes in
the nervous system as well. Cognitive ability, or the ability to know, is related to the
perceptual ability.
Changes in cognitive structure occur as a person ages. It is believe that there is a
progressive loss of neurons. In addition, blood flow to the brain decreases, the meaninges
appear to thicken, and brain metabolism slows. As yet, little is known about the effect of
these physical changes on the cognitive functioning of the older adult. Older people need
addition time for learning, largely because of the problem of retrieving information.
Motivation is also important. Older adults have more difficulty than younger ones in
learning information they do not consider meaningful. It is suggested that the older
person mentally active to maintain cognitive ability at the highest possible level. Life
long mental activity, particularly verbal activity, helps the older person retain the high
level of cognitive function and may help maintain a long-term memory. Cognitive
impairment that interferes with normal life is not considered part of normal aging. A
decline in intellectual abilities that interferes with social or occupational functions should
always be regarded as abnormal.

Psychosocial Development

According to Erikson, the developmental task at this time is ego integrity versus
despair. People who attain ego integrity view with a sense of wholeness and derive
satisfaction from past accomplishment. They view death as an acceptable completion.
According to Erikson, people who develop integrity accept “one’s one and only life
style”. By contrast, people who despair often believe they have made poor choices during
life and wish they have made poor choices during life and wish they could live life over.
Robert Butler sees integrity and bringing serenity and wisdom, and despair as resulting in

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the inability to accept one’s fate. Despair gives rise of frustration, this couragement, and a
sense that one’s life has been worthless.

Moral Development

According to Kohlberg, moral development is completed in the early adult years.


Most old people stay at Kohlberg’s conventional development, and some are at the
preconventional level. An elderly person at the preconventional level obeys roles to avoid
pain and the displeasure of others. At stage one, a person defines good and bad in relation
to self, whereas older person’s at stage 7 may act to meet another’s need as well as their
own. Elderly people at the conventional level follow society’s rules of conduct to
expectation of others.

Emotional Development

Well-adjusted aging couples usually thrive on companionship. Many couples rely


increasingly on their mates for this company and may have few outside friends. Great
bonds if affection and closeness can develop during this period of aging together and
nurturing each other. When a mate dies, the remaining partner inevitably experiences
feelings of loss, emptiness, and loneliness. Many are capable and manage to live alone;
however, reliance, on younger family members increases as age advances and in health
occurs. Some widows and widower remarry, particularly the latter, because the widowers
are less inclined than widows to maintain a household.

Spiritual Development

Murray and Zentner write that the elderly person with a mature religious outlook
striver to incorporate views of theology and religious action into thinking. Elderly people
can contemplate new religious and philosophical views and try to understand ideas
missed previously or interpreted differently. The elderly person also derives a sense of
worth by sharing experiences or views. In contrast, the elderly person who has not

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matured spiritually may not matured spiritually may feel impoverishment or despair as
the drive for economic and professional success wares.

Psychosexual Development

Sex drives persist into the 70’s, 80’s, and 90’s, provided that the health is good
and an interested partner is available. Interest in sexual activity in old age depends, in
large measure, on interest earlier in life. That is, people who are sexually active in young
and middle adulthood will remain active during their later years. However, sexual activity
does become less frequent. Many factors may play a rate in the ability of an elderly
person to engage in sexual activity. Physical problems such as diabetes, arthritis, and
respiratory conditions affect energy or the physical ability to participate in sexual activity.
Changes in the gonads of elderly women result from diminished secretion of the
ovarian hormones. Some changes, such as the shrinking of the uterus, and ovaries, go
unnoticed. Other changes are obvious. The breasts atrophy, and lubricating vaginal
secretions are reduced. Reduced natural lubrication is the cause of painful intercourse,
which often necessities the use of lubricating jellies.
3.1.2. Ill Person at the Particular Age of Patient
The older fracture patients showed a higher prevalence of chronic brain syndrome,
they were in poorer physical state and their skinfold thickness was less. They also had
more unrecognized visual disorders. Those who were younger had a higher prevalence of
stroke than comparable controls.
The type of fall leading to the fracture varied with age—tripping was the
commonest cause in the younger patients and ‘drop attacks’ in the older. Both stroke and
partial sightedness were associated with falls due to loss of balance. The older patients
had a very high prevalence of pyramidal tract abnormality associated with chronic brain
syndrome—and it appears that these demented patients fall not because of mental
confusion but because of associated motor abnormalities.
Ertra-capsular fractures occur in older patients. They are more likely to have a
history of falls but previous fracture is equally common at this age in the fracture and
control series.

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2. Diagnostic Test

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Diagnostic test Normal values Patient’s Significance
Result
April 10, 2008
Complete Blood
Count

Hemoglobin 14.0-17.5 g/dL 9.1 - Decreased-various anemias, with


excessive fluid intake.
Hematocrit 41.5-50.4% 28.8 -Decreased-severe anemias

WBC 4.4-11.0x10^ g/uL 5.32 -Normal

RBC 4.5-5.9x10^ g/uL 2.8 -Decreased- all anemias and leukemia,


when blood volume has been restored.

Mean Corpuseular 27.5-33.2 pg 32.7 -Normal


Hemoglobin

Mean Cell Volume 80-96 fL 103.6 -Increased-macrocytic anemia


(MCA)

Mean Corpuseular 33.4-35.5 % 32 -Decrease-severe hypochronic anemia


Hemoglobin

Platelet 150,000-450,000 387 -Normal

Differential Count 40-70 % 67 -Normal

Neutropihl 0-1 % 0 -Normal

Basophil 0-5 % 4 -Normal

Eosinophil 0-8% 09 -Increase-viral infection, collagen and


hemolytic disorders
Monocyte 20-40% 20 -Normal
Source:
Lympocyte Brunner and Suddarth’s. Textbook of
Medical-Surgical Nursing.10th Edition
Volume 2. page 2214-2215

Serum 3.6-5 4.7 -Normal

Potassium 6.7-1.5 6.6 -Decreased-Muscular atrophy, anemia,


leukemia
Creatinine 8.4-10.2 8.2 -Decreased-vitamin D. deficiency

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Calcium 1.2-2.2 1.0 -Decreased-anemia, malnutrition

Protein 3.3-5.5 2.9 -Decreased-no clinical significance

Albumen 2 2.9 -Increased-chronic infection, multiple


myeloma
Globulin 6.8 5.8 -Decreased-malnutrition

Total Protein 65-110 145 -Increased-diabetes mellitus

GCT(50gms) 8-35 u/mL 20 -Normal


Source:
Brunner and Suddarth’s. Textbook of
Medical-Surgical Nursing.10th Edition
Volume 2.page
2217,2219,2221,2224,2229,2230,2232

PBS 65-110 118 -Increased-diabetes mellitus


Source:
Brunner and Suddarth’s. Textbook of
Medical-Surgical Nursing.10th Edition
Volume 2.page 2230,2233,

Uric acid 2.5-7.5 4.4mg/dL -Normal


Source:
Brunner and Suddarth’s. Textbook of
Medical-Surgical Nursing.10th Edition
Volume 2.page 2225,

Bleeding time-sim 2.3-9.5 6.31 -Normal


min.-sec.

Clotting time 5-15 10.41 -Normal


min.-sec.

Prothombin time 10-13 13.8 sec. -Increased-deficiency of factors I, II,


V, VII, and X, fat malabsorption

% activity 70-120 96.2 % -Normal

INR <1.2 1.03 -Normal


Source: Brunner and Suddarth’s.
Textbook of Medical-Surgical

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Nursing.10th Edition Volume 2.page
2214
Urinalysis
Macroscopic
Examination

Color Yellow Yellow -Normal

Appearance Clear Clear -Normal

Plt 4.5-7.8 6.0 -Normal

Specific gravity 1.003-1.029 1.010 -Normal

Protein Negative Trace -Glomerular disease, nephritic


syndrome
Glucose Negative Trace -Diabetes mellitus

Ketones Negative Negative -Normal

Blood Negative Negative -Normal

Leukocytes Negative Negative -Normal

Nitrite Negative Negative -Normal

Bilirubin Negative Negative -Normal

Urohilinogen Normal 0.2 eu/dL -Normal

Microscopic
Examination

RBC/hpf 0-5 0-2/hpf -Normal

WBC/hpf 0-5 0-2/hpf -Normal

Bacteria Present Few -Normal

Mucus threads Present Few -Normal

Amorphous Urates Present Few -Normal

Blood cell Negative Few Indicates renal or urinary tract disease

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Source:
Brunner and Suddarth’s. Textbook of
Medical-Surgical Nursing.10th Edition
Volume 2.page 2224,2225

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3. Present Profile of Functional Health Patterns

Profile of Functional Health Patterns

3.1. Health Perception / Health Management Pattern

The patient described her usual health before to be fair and body is strong but now
she considered it to be poor and weak. This is because of the limited movements she felt,
the inability to walk or stand and difficulty in moving the extremities due to the fracture
of her right femoral neck. Before the admission, the patient eats more foods rich in fats,
sugar or glucose and cholesterol in their meals and she drinks plenty of water everyday.
During the patient’s hospitalization, her diet was changed to low fat and low cholesterol
diet because she was diagnosed of having diabetes mellitus type II. The patient’s
attending physician encourages her to take more of calcium and Vitamin D in order for
her bones to become stronger. The patient is non-smoker and non-alcoholic drinker and
she has no known allergies.

3.2. Nutritional / Metabolic Pattern

The patient’s usual food intake before the hospitalization includes fish, meat,
vegetables, fruits, chicken and especially foods rich in fats, sugar/glucose and cholesterol.
She consumes more than 8 glasses of water a day. Her maintenance meds were Aromasin,
Fosamax, Centrum and Caltrate. Now the patient was advised by her attending physician
to restrict foods that can aggravate her condition. The patient was also encourage to take
more of Calcium and Vitamin D in order for her bones to become stronger. The patient
doesn’t smoke or drink alcoholic beverages, has no known allergies. There is a change in
her appetite now; she often eats a little only each meal.

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3.3. Elimination Pattern

Before, the patient can freely go to the C.R. to void or defecate but now that she’s
hospitalized she was advised to wear diaper for her to have difficulty in standing and
walking. There is no burning sensation during ur4ination and her stool is brownish
formed stool.

3.4. Activity-Exercise Pattern

The patient before hospitalized wakes up early in the morning for her to have fine
walking around their house as her exercise. She usually guided her grandsons and
granddaughters, but now, she’s just on bed lying assisted by her private nurses and
CDUH health care providers.

3.5. Cognitive/ Perceptual Pattern

The patient before, can hear, smell, taste and feel well and correctly but the
patient cannot read her newspaper without her eyeglasses just the same as now. She
speaks slowly English, Tagalog and Bisaya languages as of now but before she speaks
fluently all of those languages. She easily communicates, understands questions,
instructions and be able to follow and answer them correctly.

3.6. Rest/ Sleep Pattern

Before the hospitalization, the patient usually sleeps late at night at around 10
o’clock pm and wakes up early in the morning at 6 o’clock am with an hour of sleep of 8
hours. Now, she usually sleeps early at night (8-9 o’clock pm) and wakes up at around 7
o’clock am with an hour of sleep of 10 hours. The patient usually stays in bed and read
newspapers sometimes, she can’t take a nap in the afternoon due to her REHAB CARE.

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3.7. Self- Perception Pattern

The patient’s most concern about right now is her rehabilitation care. The patient
wants to stay at the hospital until she improves her mobility so she would be able to stand
and walk all alone by herself. The patient never loses the support of her children even if
they were not there physically and also her private nurses.
Through this, she maybe able to cope up easily from her unhealthy condition. The
treatment, managements, medications and all out care rendered by the hospital to the
patient assured her for the improvement of her condition.

3.8. Sexuality/ Reproduction

The patient’s husband just recently died. Now, the patient does not allow anyone
to see her getting undressed, changing diaper, changing clothes because she believes that
as a woman, it should be keep as private.

3.9. Coping- Stress Tolerance Pattern

The patient usually makes her decision as for now since her children were busy in
their work abroad, but they make sure they never forget to support and help their mother
recover from illness. Sometimes, the patient usually shares her concerns to her private
nurses and of course also to the student nurses. She usually reads newspaper for her to be
more relaxed.

3.10. Value-Belief Pattern

The patient find source strength and hope with God and her loved ones. God is
very much important to the patient. Before, she usually goes to church together with her
other children. They were not involved in any religious organizations or practices. The
patient knows how to pray and praise God for all the nice things he had given.

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3.11. Relationship Pattern

The patient understands more on English and Bisaya languages but a little only in
Tagalog language. The patient was living all by herself with her private nurses but
sometimes, her grandchildren will come over to visit her. She never uses the support of
her children even if they were away from their mother they always make sure that their
mother is safe and secure. The patient can easily communicate, cooperate, listen and
follow instructions easily.

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4. Pathophysiology and Rationale

4.1 Normal Anatomy and Physiology of Organ/ System Affected

The word skeleton comes from the Greek word meaning “dried- up body”, our
internal framework is so beautifully designed and engineered and it puts any modern
skyscraper to shame. Strong, yet light, it is perfectly adapted for its functions of body
protection and motion. Shaped by an event that happened more than one million years
ago – when a being first stood erect on hind legs – our skeleton is a tower of bones
arranged so that we can stand upright and balance ourselves. The skeleton is subdivided
into three divisions: the axial skeleton, the boned that form the longitudinal axis of the
body, and the appendicular skeleton, the bones of the limbs and girdles. In addition to
bones, the skeletal system includes joints, cartilages, and ligaments (fibrous cords that
bind the bones together at joints). The joints give the body flexibility and allow

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movement to occur. Besides contributing to body shape and form, or bones perform
several important body functions such as support, protection, movement, storage and
blood cell formation.

Classification of Bones

The diaphysis, or shaft, makes up most of the bones length and is composed of
compact bone. The diaphysis is covered and protected by a fibrous connective tissue
membrane, the periosteum. Hundreds of connective tissue fibers, called Sharpey’s fibers,
secure the periosteum to the underlying bone. The epiphyses are the ends of the long
bone. Each epiphyses consist of a thin layer of compact bone enclosing the area filled
with spongy bone. Articular cartilage, instead of periosteum, covers its external surface.
Because the articular cartilage is glassy hyaline cartilage, it provides a smooth, slippery
surface that decreases friction at joint surfaces.
In adult bones, there is a thin line of bony tissue spanning the epiphyses that looks
a bit different from the rest of the bone in that area. This is the epiphyseal line. The
epiphyseal line is a remnant of the epiphyseal plate (a flat plate of hyaline cartilage) seen
in young, growing bone. Epiphyseal plates cause the lengthwise growth of the long bone.
By the end of puberty, when hormones stop long bone growth, epiphyseal plates have
been completely replaced by bone, leaving the epiphyseal lines to mark their previous
location.
In adults, the cavity of the shaft is primarily a storage area for adipose (fat) tissue.
It is called the yellow marrow, or medullary, in infants this areas forms blood cells, and
red marrow is found these. In adult bones, red marrow is confined to the cavities of
spongy bone of flat bones and the epiphyses some long bones.
Bone is one of the hardest materials in the body, and although relatively light in
weight, it has a remarkable ability to resist tension and other forces acting on it. Nature
has given us an extremely strong and exceptionally simple (almost crude) supporting
system without up mobility. The calcium salts deposited in the matrix bone its hardness,
whereas the organic parts (especially the collagen fibers) provide for bone’s flexibility
and great tensile strength.

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The femur, or thigh bone, is the only bone in the thigh. It is the heaviest, strongest
bone in the body. Its proximal end has a ball-like head, a neck, and greater and lesser
trochanters (separrsted anteriorly by the intertrochanteric line and posteriorly by the
intertrochanteric crest). The trochanters, intertrochanteric crest and the gluteal tuberosity,
located on the shaft, all serve us sites for muscle attachment. The head of the femur
articulates with acetabulum of the hip bone in a deep, secure socket. However, the neck
of the femur is a common fracture site, especially in old age.
The femur slants medially as it runs downward to joint with the leg bones; this
brings the knees in line which the body’s center of gravity. The medial course of the
femur is more noticeable in females because of the wider female pelvis. Distally on the
femur are the lateral and medial condytes, which articulates the tibia below. Posteriorly,
these condytes are separated by the deep intercondylar notch. Anteriorly on the distal
femur is the smooth patellar surface, which forms a joint with the patella, or kneecap.

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4.2 Schematic Diagram

Predisposing Factors: Precipitating Factors:


-Elderly people (85 years or older) -Fall
- Trauma - osteoporosis
- Comorbidity -functional disability
- Malnutrition - impaired vision and balance
-neurologic problems
- Obesity
-slower reflexes

Damage to the blood supply to an entire bone.

Severe circulatory compromise

Avascular (ischemic) necrosis may result

Clinical Manifestations:
- Pain (right up)
- Loss of function
- Deformity
- Crepitus
- Swelling and discoloration
- Paresthesia
- Tenderness

Nursing Management: Medical Management:


- Repositioning the patient - Temporary skin traction
- Promoting strengthening exercise - Buck’s extension
- Monitoring and managing complications - Open or closed reduction of the fracture and
- Health promotion internal fixation
- Relieving pain - Replacement of the femoral head with prosthesis
- Promoting physical mobility (hemiarthrmoplasty)
- Promoting positive psychological response to - Closed reduction with pereutaneous stabilization
trauma for an intracapsular fracture.
- Patient teaching
Surgical Intervention:
- Hip Pinning
- Hip Hemiarthroplasty
- Patients with hip osteonecrosis may require Hip Replacement
Surgery

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4.3 Pathophysiology

Femoral neck fractures occur most commonly after falls. Factors that increase the
risk of injuries are related to conditions that increase the probability of falls and those that
decrease the intrinsic ability of the person to with stand the trauma. Physical
deconditioning, malnutrition, impaired vision and balance, neurologic problems, and
shower reflexes all increase the risk of falls. Osteoporosis is the most important risk
factor that contributes to hip fractures. This condition decreases bone strength and,
therefore, the bones ability to resist trauma.
Femoral neck fractures can also be related to chronic stress instead of a single
traumatic event. The resulting stress fractures can be divided into fatigue fractures and
insufficiency fractures. Fatigue fractures are a result of an increased or abnormal stress
placed on a normal bone. Whereas insufficiency fractures are due to normal stresses
placed on diseased bone, such as an osteoporotic bone.
Trauma sufficient to produce a fracture can result in damage to the blood supply
to an entire bone, e.g., the femoral neck in femoral fracture. With seer circulatory
compromise, avascular (ischemic) necrosis may result. Particularly vulnerable to the
development of ischemic are intracapsular fractures, as occur in the hip. In this location,
blood supply is marginal ad damage to surrounding soft tissues may be a critical factor
since better results are obtained in cases of hip fracture reduced with in 12 hr. than in
those treated after that tine period. In fractures of the femoral neck, bone scans have been
recommended as diagnostic tools to determine the orability of the femoral need.

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4.4 Classical and Clinical Sign’s and Symptoms

Classical Symptoms Clinical Symptoms Rationale

Pain Manifested - The pain is continuous and increases


- complains of pain on in severity until the bone fragment are
the right hip aggravated immobilized. The muscle spasm that
by sudden or too much accompanies fracture is a type of
movements of the natural splinting designed to
extremities and relieved minimize further movement of he
by elevation and resting. fracture fragments.

Loss of function Manifested -After a fracture, the extremity cannot


- unable to move function properly, because normal
extremities and unable to function of the muscles depends on
stand or walk without the integrity of the bones to which
assistance. they are attached. Pain contributes to
the loss of function. In addition,
abnormal movement (false motion)
may be present.

Deformity Manifested -Displacement, angulations, or


- Bones of the right rotation of the fragments in a fracture
femoral neck are of the right femoral neck causes a
splintered into small deformity that is detectable when the
fragments. limb is compared with the uninjured
extremity. Deformity also results
from soft tissue swelling.

Shortening Not Manifested - In fractures of long bones, there is


actual shortening of the extremity
because of the contraction of the
muscles that are attached above ad
below the site of the fracture. The
fragments often overlap by as much
as 2.5 to 5 cm (1 to 2 inches)

Crepitus Manifested -When the extremity is examined


with the hands, a grating sensation,
called crepitus, can be felt. It is
caused by the rubbing of the bone
fragments against each other.

Swelling and Manifested -localized swelling and discoloration

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Discoloration of the skin (ecehymosis) occurs after
a fracture as a result of trauma and
bleeching into the tissues. These signs
may not develop for several hours
after the injury.

Paresthesia Manifested -After fracture, any subjective


sensation, experienced as numbness,
tingling, or a “pins and needles” may
be felt. These often fluctuate
according to such influences as
posture, activity, rest, edema,
congestion, or underlying disease, it
is sometimes identified as
acroparesthesia.

Tenderness Manifested -Mostly, the affected part responds


with a sensation of pain to pressure or
touch that would not normally cause
discomfort. This happens due to the
bones splintered into fragments.

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IV. Nursing Interventions

1. Medical and Surgical Management

Temporary skin traction, Buck’s extension, may be applied to reduce muscle


spasm, to immobilize the extremity, and to relieve pain. The findings of a recent study
suggested that there is no benefit to the routine use of preparative skin traction for
patients with hip fractures and that the use of skin traction should be based as evaluation
of the individual patient.
The goal of surgical treatment of hip fractures is to obtain a satisfactory fixation
so that the patient can be mobilized quickly and avoid secondary medical complications.
Surgical treatment consists of (1) open or closed reduction of the fracture and internal
fixation (2) replacement of the femoral head with a prosthesis (hemiarthroplasty), or (3)
closed reduction with pereutaneous stabilization for an intracapsular fracture. Surgical
intervention is carried out as soon as possible after injury. The preoperative objective is to
ensure that the patient is in as favorable a condition as possible for the surgery. Displaced
femoral neck fractures may be treated as emergencies, with reduction and internal
fixation performed within 12 to 24 hours after fracture. This minimizes the effects of
diminished blood supply and reduces the risk for avascular necrosis.
After general or spinal anesthesia, the hip fracture is reduced under x-ray
visualization using an image intensifier. A stable fracture is usually fixed with nails, a nail
and plate combination, multiple pins, or compression screw devices. The orthopedic
surgeon determines the specific fixation device based on the fracture site or sites.
Adequate reduction is important for fracture healing (the better the reduction, the better
the healing).
Hemiarthroplasty (replacement of the head of the femur with prosthesis) is
usually reserved for fractures that cannot be satisfactorily reduced or securely nailed or o
avoid complications of non-union and avascular necrosis of the head of the femur. Total
hip replacement may be used in selected patients with acetabular defects.

25
2. Care Guide of Patient with the Condition (fracture of the right femoral neck)
Repositioning the Patient

The nurse may turn the patient onto the effected or unaffected extremity as
prescribed by the physician. The standard method involves placing a pillow between the
patient’s legs to keep the affected leg in an abducted position. The patient is then turned
onto the side white proper alignment and supported abduction are maintained.

Promoting Strengthening Exercise

The patient is encouraged to exercise as much as possible by means of the


overbed trapeze. This device helps strengthening the arms and shoulders in preparation
for protected ambulation (e.g., toe touch, partial weight bearing). On the first post-
operative day, the patient transfers to a chair with assistance and begins assisted with
ambulation. The amount of weight bearing that can be permitted depends on the stability
of the fracture reduction. The physician prescribes the degree of weight bearing and the
rate at which the patient can progress to full weight bearing. Physical therapists work
with the patient on transfers, ambulation, and the safe use of the walker and crutches.
The patient who has experienced a fractured hop can anticipate discharge to home
or to an extended care facility with the use of an ambulating aid. Some modifications in
the home maybe needed to permit safe use of walkers and crutches and for the patient’s
continuing care.

Monitoring and Managing Potential Complications

Elderly people with hip fractures are particularly prone to complications that may
require more vigorous treatment than the fracture. In some instances, shock proves fatal.
Achievement of homeostasis after injury and surgery is accomplished through careful
monitoring and collaborative management, including adjustment of therapeutic
interventions as indicated.

26
Health Promotion

Osteoporosis screening of patients who have experienced hip fracture is important


for prevention of future fractures. With dual-energy x-ray absorptiometry (DEXA) scan
screenings the actual risk for additional fracture can be determined. Specific patient
education regarding dietary requirements, lifestyle changes, and exercise to promote
bone3 health is needed. Specific therapeutic interventions need to be initiated to retard
additional bone loss and to build bone mineral density. Studies have shown that health
care providers caring for patient with hip fractures fail to diagnose or treat these patients
for osteoporosis despite the probability that hip fractures are secondary to osteoporosis.
Fall prevention is also important and maybe achieved through exercises to improve
muscle tone and balance and through the elimination of environmental hazards. In
addition, the use of hip protectors that absorb or shunt impact forces may help to prevent
an additional hip fracture if the patient were to fall.

Relieving Pain

* Secure data concerning pain


- have patient describe the pain, location characteristics (dull, sharp, continuous,
throbbing, boning, radiating, aching and so forth)
- ask patient what causes the pain, makes the pain worse, relieves the pain, and so
forth.
- evaluate patient for proper body alignment, pressure from equipment (casts,
traction, splints, and appliances)
* Initiate activities to prevent or modify pain
* Administer prescribed pharmaceuticals as indicated. Encourage use of less potent
drugs as severity of discomfort diseases.
* Establish a supportive relationship to assist patient to deal with discomfort.
* Encourage patient to become an active participant in rehabilitative plans.

27
Promoting Self-Care Activities

* Encourage participation in care.


* Arrange patient area and personal items for patient convenience to promote
independence.
* Modify activities to facilitate maximum independence within prescribed limits.
* Allow time for patient to accomplish task.
* Teach family how to assist patient while promoting independence in self-care

Promoting Physical Mobility

* Perform active and passive exercises to all nonimonobilized joints.


* Encourages patient participation in frequent position changes, maintaining supports
to fracture during position changes.
* Minimize prolonged periods of physical inactivity, encouraging ambulation when
prescribed.
* Administer prescribed analogies judiciously to decrease pain associated with
movement.

Promoting Positive Psychological Response to Trauma

* Monitor patient for symptoms of post from a stress disorder.


* Assist patient to more through phases of post-trammatic stress (outery,
denied,omtrusiveness, working through, completion).
* Establish trusting therapeutic relationship with patient.
* Encourages patient to express thoughts and feelings about traumatic event
* Encourages patient to participate in decision making to reestablish control and
overcome feelings of helplessness.
* Teach relaxation techniques to decrease anxiety.

28
* Encourages development of adaptive responses and participation in support groups.
* Refer patient to psychiatric liaison nurse or refer for psychotherapy, as needed.

3. Actual Patient Care

3.1 Physical Assessment

PHYSIOLOGIC
Body part Inspection Palpation Percussion Auscultation

Head - Small, round head, - Palpable temporal


normocephalic, no pulse, soft, no
wounds, no rashes evidence of abnormal
present. mass, no protrusions
and pond felt upon
palpation.

Hair -Hair is short, white


in color, evenly
distributed, no scales,
wearing a clip, has a
fine hair

Scalp -No dandruff and - Free from lumps,


wounds present, pink, lesions, normal bond
mobile prominences on the
forehead, sides of the
parietal bones, behind
the ears.

Forehead - Firm, no scars, no - Forehead is free of -Tempera;


visible bulges, not lumps and nodes. pulse is at 82
oily, had wrinkles bpm.

Face - Symmetrical, check - No lesions, no


bones are slightly tenderness.
prominent, no
presence of scar,
presence of wrinkles,
without pimples

29
Eyes - Symmetrical, round,
align with the ears,
few discharges seen,
with eyeglass

Brows - Hair evenly - No lumps and


distributed, skin rashes, smooth and
intact, symmetrically no tenderness
aligned, black in
color, free from
sealing

Lashes - turn outward, short,


black

Lids-Upper - partially cover the -Non tender


eyelids

Lids-Lower - sometimes cover the -Non tender


whole sclerae

Sclearae - whitish in color but


red capillaries are
slightly seen

Cojunction - pink

Cornea - transparent, shiny


and smooth, night
displays at the same
spot of the eyes

Iris -round, black

Pupil -black in color but


with white opacities
near the lacrimal
gland , round smooth
border, illuminated
pupil constricts (pupil
equally round
reactive to light and
decommodation)

30
Muscle -eyes moves slowly
Function as it follows my
finger guiding the
patient and assessing
her 6 cardinal gazes

Muscle -Move symmetrically


Balance the tremors

Visual -260/20
Acuity

Peripheral -able to define


Vision correctly the number
of fingers showed at
the side of the patient
nut sometimes its
difficult for her.

Nose - White, long nose, - no lesions,


septum is aligned in deformities and
midline, no deviations
discharge/ flaring, air
flows freely.

Frontal - light color during - non-tender - non-


Sinuses transillumination tender

Maxillary -light color during - non-tender - non-


Sinuses transillumination tender

Mouth - no lesions, open and -free from edema


close symmetrically
and slowly.

Lips -slightly pale in color, - no lumps, lesions


soft, moist, symmetry and tenderness upon
of contour, smooth in palpation, free from
texture. edema

Gums -Intact, pink in color,


no swelling or
bleeding.

31
Teeth -Yellow teeth with
brownish
discoloration, the
dentures, and teeth
are incomplete.
Upper- no teeth
Lower- 4

Tongue -centrally positioned, - no palpable nodules


slightly pale, moist,
no lesions.

Frenulum - midline, slightly


pale

Sublingual - pinkish, visible - no lumps


Area veins

Hard Palate - bony, whitish

Self Palate - muscular, pinkish

Uvula - pink, midline, free


of lesions

Tonsils - midline, no
inflammations

Ears - Symmetrical, - no pain felt, upon


slightly big, align palpation of pinna.
with the eyes, pinna
is in linewith the
outer canthus of the
ear, no swelling or
lesions.

External - Symmetrical, align -Displays no


with the eyes, no thickening/ pain. No
swelling or lesions, as masses/ bulges.
discharges, with
slight cerumen and
hair.

32
Neck - Able to do flexion, -Carotid pulse
extension and palpable
rotation of neck.
-Muscles equal in
size, head centered.

Lymph - no visible bulges, -Not palpable


nodes not enlarged

Thyroid - no bulges, not -Not palpable, free of


visible nodules, moves up
and down as the
patient swallows.

Trachea - not enlarged - central placement in


- centrally located midline of neck,
spaces are equal in
both sides, non-
tender, non-palpable

Skin - white, with - slightly cold, good


wrinkles, no dryness turgor

Thorax

Chest - flat, equal chest - vibrations are equal


anterior expansion, the ride in both sides
and fall during - no nodules,
respiratory is visible retraction or nodules

Lungs - full, symmetric - resonate -Lung sounds


excursion down to are clear, no
the 6th rib, rales and
flat over wheezes
areas of
heavy
muscle
and bone,
dull on
areas over
the heart,
liver, and
stomach
percussed.

33
Heart - no visible pulsations - no nodules, bulges -TR= 80 bpm
- apical pulse -no murmurs
palpable

Breast -with breast CA ( R)


( 2006-2007 )

Abdomen - flat, soft, - non-tenderness - audible


unblemished skin bowel sound
of 18 from
the normal
range of 5-35
bowel
sounds. Dull
sound at
upper
quadrant

Spine - has abnormal


curvature

Extremities -capillary refill time - no lesions, no lumps


is 2 sec. palpated in the lungs
- white, equal in

Upper sizes, fingers were - radial pulse - biceps - BP- 120/80


curving downward palpable- 80 bpm and mmHg
-35.5 degrees Celsius - brachial pulse triceps
palpable reflex
- no tenderness, present
slightly cold

Muscle - able to perform


strength ROM exercises

Muscle tone - difficulty in


overcoming
resistance

34
Lower - white, equal in size, - positive tenderness
covered with cloth, on the right hip
limited movement on
lower extremities
- capillary refill is 2
sec

Muscle - difficulty in
strength performing ROM
exercises

Muscle tone - inability to - slightly cold, dry to - patellar


overcome resistance touch , with pain reflex not
upon palpation present

35
BRUNSWICK
LENS MODEL

36
NURSING CARE PLAN
Needs/ Nursing Scientific Basis Objec- Nursing Action Rationale
Problem Diagnosis tives of
/ Cues Care

I. Fractures occur After 8 Measures to:


Physiologic when the bone hours of 1. Promote
A. Deficit is subjected to holistic adequate
Impaired stress greater nursing mobility of the
1. Impaired physical that it can caring client.
Physical mobility, absorb. When care the - instruct the 5.0 -to avoid patients
Mobility inability the bone is patient to keep siderails from falling to
Cues: to stand broken, will be up or raised. sudden
- Difficulty alone adjacent able to: - assist patient movements
in changing related to structures are 1. to do active -to improve
position skeletal also affected, demonst ROM exercises muscle strength
while lying impairmen resulting in soft rate on the lower and joint mobility
on bed. t to facture tissue edema, increasi extremities.
-Difficulty of the hemorrhage into ng -Provides -in order for the
in moving right the muscles and function comfort patient to become
the femoral joints, joints of the measures such more relax and
extremities. neck dislocations, extremit as backrub. comfortable
-Inability to ruptured ten- ies -Encourage -in order for the
walk or dons, severed patient to stand muscle to be more
stand alone. nerves, and or walk as relax and relieves
-limited damaged blood tolerated using the pain
range of vessels. Body parallel bars.
motion in organs maybe -Support
the injured by the affected body
extremities. force that parts or joints
-Slowed caused the using pillows or
movement. fracture rolls.
-Difficulty fragments. After -administer pain -to relieve pain
initiating a fracture, the reliever such as and motion
gait. extremities areoxia as sickness
“dili cannot function prescribe by the
gihapon mu properly physician.
lihok akong because normal -Consult with -to develop
tiil day” as functions of physical or individual
verbalized muscle depend occupational exercise or
by the on the integrity therapist as mobility program
patient. of the bones indicated. and identify
which they are appropriate
attached. adjunctive
devices.

37
2. Risk for Risk for The extremities 2. 2. prevent,
altered blow altered cannot function enhance blood emboli
flow blood properly after a blood -note signs of -to assess
flow right fracture, thus, circulati changes in respiratory in-
Risk Factor: immobilit there is on respiratory rate, sufficiency
Immobility y to immobility depth use of
fracture of because normal accessory
the right function of the muscles purled-
femoral muscle depends lip breathing;
neck on the integrity Note areas of
of the bones to pallor or
which they are cynosis.
attached. -auscultate -serves as a
Immobility of a breath-sounds baseline data
body part may Check if there is
possibly a decrease or
interrupt the adventitious
circulation of breath sounds
blood through as well as
the circuitous fremitus
network of -monitor ital -note for any
arteries and signs and changes
veins cardiac rhythm
-review risk -to promote
factors prevention
-reinforce need management of
for adequate risk
rest, while
encouraging
activities within
clients
limitation
-encourage -to improve
frequent circulation of
position blood to the body
changes and systems.
DBE or
coughing
exercise.

-administer -to treat


medications as underlying
indicated. conditions

38
B. Overload
3. Risk for Risk for A fracture 3. to 3. for the
additional additional occurs when the produce patients to be
injury risk injury stress placed on risk free from injury
factors: right loss a bone is greater factors -ascertain -to reinforce and
*Loss of of skeletal than a bone can and knowledge of import knowledge
skeletal integrity absorb. Muscle, protect safety needs or to the patient
integrity to fracture blood vessels, self injury
* skeletal of the nerves, tendons, from -assess muscle -to evaluate
impartment femoral joints and other injury strength gross degree or source
*Abnormal neck. organs maybe and fine motor of risk.
blood injured when coordination.
profile fracture occurs. -observe for -for early
*Impaired This condition signs of injury detection.
or altered may result to a -identify -to promote
mobility loss of skeletal interventions or individual safety.
integrity that safety devices.
may possibly -encourage -to improve
lead to further participation in skeletal integrity.
injury as a rehab programs,
result of such as gait
environmental training
conditions -promote -to promote
interacting with education wellness.
the individuals programs
adaptive and geared to
defensive increasing the
resources. awareness of
safety measures

39
DRUG THERAPEUTIC RECORD
Drug/ Classification/ Indication/ Principles of Treatment Evaluation
Dose/ Mechanism Contraindation/ Care
Frequency Side effects
/ Route

* C: I. treatment of -25mg po -provide rest -growth of


Aromasin Antineoplastic advanced breast everyday with periods tumor cells
25 mg T M: Binds to cancer in meals. -mpnitor for were inhabit
tab-OD estrogen postmenopaural -aoid use during any side
receptors, has women whose premenopause effects that
anti- estrogen decreased has or with renal or may occur
receptor- progressed nepatic -provide a
positives FF. Tamoxifen dysfunction. quite and
breast cancer therapy comfortable
cell increased SE: - (ho flashes, GI environment
C1: allergies, upset, anxiety, -maintain
patient has not depression, and client’s
been through headache are general
menopause yet, common.) well-being
pregnancy and and hygiene
breastfeeding -provide
safety and
comfort
measures to
the client.
* Aspirin C: I. mild to -give drug with -elevate the -there is al
(aspilet) T Antipyriene, moderate pain food or after leg of the improvemen
tab OD po Analgesic, fever meals if GI patient. t of patients
anti- Inflammatory upset occurs. -assist client gout ant the
inflammatory, conditions -give drug with in doing patient was
Antirheumatic Rheumatic fever fullglass of ROM able to
, anti- platelet rheumatoid H2O to reduce exercises slight move
salicylate, arthritis, risk or tablet or -provide her
NSAID osteoarthritis capsule lodging comfort extremities
M: Analgesic CI: Allerge use in the measures
and anti- continuously with esophagus such as back
rheumatic impaired renal - do not crush rub.
effect are, function, chicken and ensure that -provide rest
attributable to pox, influenza patient does not periods
cupirine SE: Acute aspirin chew SR -do not
ability to toxicity: preparation allow client
inhibit he hyperpnea , -Do not use to do
synthesis of tachypnea, aspirin that has strenuous
prostaglandins hemorrhage a strong vinegar activities

40
, important Aspirin like odor
mediators of intolerance: -take extra
inflammation -shinitis precautions to
antipyretic exacerbation of keep this drug
effects are not broncho spasm out of the reach
fully -nausea, dyspnea, of children
understood occult blood loss,
but aspirin dizziness tinnitus
probably acts
in the
thermoregulat
ory center of
the
hypothalamus
to block
effects of
endogenous
purogen by
inhibiting
synthesis of
the
prostaglandin
intermediately
. Inhibition of
platelet
aggregation is
attributable to
the inhibition
of platelet
synthesis of
thromboxane
A21 a potent
vasoconstricto
r and inducer
of platelet
aggregation.
This effects
occurs at low
doses and last
for the life of
the platelet(8
days) These
doses inhibit
the synthesis
of

41
prostaglandin,
a patient
vasodilator
and inhibitor
of platelet
aggregation.
*Clexane C: low- I. prevention of -give deep -provide for -further
0-4 cc SQ molecular deep vein subcutaneous safety complicatio
OD weight thrombosis, injections, Do measures ns were
heparin anti- which may lead not give clexane (electric prevented.
thrombotic to pulmonary by IM injection razor, soft
M: low- embolism -patient should toothbrush)
molecular following hip be lying down. to prevent
weight replacement. Activities injury to
heparin that Prevention of between the left patient, who
inhibits ischemic and right is at risk of
thrombus and complications. anterolateral bleeding
clot formation CI: and -check
by checking hypersensitivity posterolateral patient for
factor XA, use cautiously abdomen wall signs of
factor II a, with pregnancy or -apply pressure bleeding.
preventing the lactation history to all injection Monitor
formation of of GI blood, sites after blood test
clots. spinal top needle is -provide a
SE: Bruishing, withdrawn safety and
thrombocytopenia -do not mix comfortable
, chills, fever, with other environment
pain, local injections or -provide rest
irritation. infusions periods
-store at room -avoid
temperature patient from
fluid should be dying
clear, colorless strenuous
to pale yellow activities
*lericoxib C: non- I. Acute and -can be taken -position -there is an
(arcoxta) steroidal anti chronic treatment with or without client in a improvemen
90mg T inflammatory of asteoarthritis food, but may comfortable t of patient’s
tab OD drug (NSAID) and RA start to work position. gait and the
M: work DY CI: Children and quicker if taken -divert patient was
blocking the adolescent under without food. patient’s able to
action of a 16 yrs. Of age -do not exceed attention slightly
substance in -severely to liver the prescribed -guide move her
the body function dose imagery extremities
called cyclo- SE: headache, -maybe taken -encourage
oxygenare is dizziness with low dose

42
involved on Constipation, (76 mg daily) DBE
producing nausea, vomiting, aspirin. -hot
prostaglandins indigestion, However the compress is
in response to flatulence combination applied to
injury or may carry an the affected
certain increased risk site or area.
diseases. of ulceration or -provide rest
There bleeding in the periods
prostaglandins stomach or -avoid client
, cause pain or intestine to perform
swelling and -it is important strenuous
inflammation. to tell your activities
Because doctor or -provide a
NSAIDS pharmacist what safety
block the medicine you environment
production of are already
prostaglandins taking including
they are those bought
effective at with out
relieving pain prescription and
and herbal medicine
inflammation
* vitamin C: I. treatment of -maybe taken -encourage -the patient
B Phospholipid chronic liver with meals if GI client to eat was able to
complex + disease , liver discomforts foods rich in gain more
(sangubio multivitamins cirrhosis and fatty occurs. vitamins energy and
n) T tab M: mainly liver. For liver -best to take and increase its
OD function as protection eases after meals. minerals function
eatalysts for of intoxication -initially 1 -instruct
reactions (alcohol abuse) capsule every 8 client to
within the CI: hours. Follow minimize
body. They hypersensitivity, up treatment 1 the intake of
contain no lactation capsule daily fatly foods
useful energy, SE: sedation, -lifestyle
but as dizziness, dry modificatio
catalysts, they mouth, nausea, n
serve as constipation -exercise
essential link regularly
and regulators -impart to
in metabolic patient the
reaction that importance
release energy of taking
from food. adequate
Control the amount of
processes of nutritious

43
tissue foods
synthesis and
aid in
protecting the
integrity of
the cells
plasma
membrane;
assist growth,
maintenance
of health
metabolism
*CaCo3 C: electrolyte I: Dietary - do not - encourage - the
(Calvit) T Antacid supplement when administer oral client to eat strength of
tab OD M: Essential calcium intake is drugs within 1- foods rich in patient’s
every 6pm element of the in adequate, 2 hour of calcium bones were
body; helps treatment of antacid such as improved as
maintain the calcium administration. milk, evidenced
functional deficiency, - report loss of cheese. by standing
integrity if prevention of appetite, - assist or walking
nervous and hypocalcemia nausea, client be with
muscular during exchange vomiting, expose to assistance.
system,; helps transfusions. abdominal pain, sunlight for
maintain CI: Allergy, use constipation, 5-15
cardiac cautiously dry mouth, minutes.
function, withdrawal; thirst, increase - impart
blood dysfunction voiding. [atient the
coagulation: pregnancy, importamce
is an enzyme lactation. of takiln
cofactor and Se: Slowed heart adequate
affects the rate, tingling, heat amount of
secretom waves, local nutritious
activity of irritation, foods.
endocrine and hypercalcemia, - encourage
exocrine and pain dry client to
glands; mouth. exercise
neutralizes or regularly.
reduces
gastric acidity.
C: NSAID
*Ketoprof Non-opioid I: Acute and long For over-the- - elevate the - there was
en analgesics treatment of RA counter leg of the an
(fortum) M: Anti- and osteoarthritis. Use: Do not patient improvemen
Gel apply inflammatory - relief of mild to take for more - provide t of patient’s
to right moderate pain. than 10 days. If rest periods gait and the
and analgesic

44
thigh and activity, CI: Significant symptoms - provide patient was
right knee inhibits renal impairment, persist contact comfort able to
twice a prostaglandin pregnancy, your HC measures slightly
day. and has anti- lactation allergy provider. - encourage move her
bradykinin to ketoprofen, use client to do extremities.
and lysosomal cautiously the DBE
or membrane impaired hearing - promote a
stabilizing allergies hepatic, quite,
actions. CV and GI relaxing and
conditions. comfortable
SE: Headache, environment
dizziness, rash, .
pruritus, nausea,
dyspepsia,
dysuria, renal
impairment,
C: Appetite dyspnea,
*Dibencos stimulants peripheral edema. - the dosage - provide - the patient
ide M: Improes I: Poor appetite in must be reduced small was able to
(heraclene appetite and adult, adjuvant to to patient’s with frequent improve her
) preents faulty the treatment of liver damage. feelings appetite as
Mg tav T nutrition and TB, and other - liver functions - offer foods evidenced
tab HD other chronic chronic ailments, should be that are by eating
ailments. convalescence assessed before attractive or her meals an
from acute and regularly presentable time and
infection: during enough to avoiding to
CI: treatment. stimulate skip meals.
Hypersensitivity - should be used appetite.
with caution in - instruct
patient’s with patient to
diabetes eat adequate
mellitus as their nutritious
management foods.
may become - impart to
more difficult. patient the
importance
of taking
adequate
nutritious
C: Topical foods.
*Calmose antivirals I: Wound - cleanse skin, - maintain - patient’s
ptine M: Protects, drainage, urinary pat dry and general wound was
ointment soothes and and fecal apply once well-being easily
appky to helps promote incontinence, daily or as and hygiene healed and
affected bedsores, ileo necessary of the bedsores
healing in

45
site those with anal, reservoirs, - do not use this patients. were
BID impaired skin moistures of medication if - provide a prevented.
integrity. perspirations you are allergic clean and
CI: to zinc, dime comfortable
Hypersensitivity thicone, lanolin, environment
cod liver oil, .
petroleum, jelly, - meticulous
parabens, skin care
mineral oil or - promote
wax. proper
- call your environment
doctor if you al
have any signs sanitation.
of redness and
warmth or
oozing skin
lesions.
- avoid getting
this medication
in your mouth
or eyes. If it
does rinse with
water right
C: Anti- away.
*Acarbose diabetic I: Adjunct to diet - give drug TID - impart to - further
(glucobay) M: Alpha- to lower blood with the first patient to complicatio
50 mg tab glucosidase glucose in those bite of each eat a non- ns were
TID with inhibitor- patient’s with meal. diabetic being
meals obtained from tipe2 (non-insulin - monitor serum diet. prevented
the dependent) DM glucose level - consult and
fermentation whose frequently to with a appearance
process of a hypercalcemia determine drug dietician to of signs and
microorganis cannot be effectiveness establish symptoms
m; delays the managed alone. and dosage. weight loss slowly
digestion of CI: - inform patient program and diminished
ingested Hypersensitivity, of likelihood of dietary
carbohydrates use cautiously abdominal pain control.
heading to a with renal and flatulence. - encourage
smaller impairment - do not client to do
increase in pregnancy and discontinue this regular
blood glucose lactation. drug without exercise
following SE: consultation assisted by
meals and in Hypoglycemia, from health care the SO.
glycosylated abdominal pain, provider. - impart to
flatulence, client the
hemoglobin,

46
does not leucopenia, importance
enhance anemia, of taking
insulin thrombocytopenia nutritious
secretion, so . foods.
its effects are - avoid the
addictive to client from
those of the eating foods
sulfonyl areas, rich in fats
in controlling and
blood glucose. cholesterol.
*Ranitidin C: Histanine, - administered - the patient
e (ulcin) antagonists I: Short term oral drug with - provide was able to
75 mg tab M: treatment of meals and rest periods feel more
PC 3x a Competitively active duodenal hours. - encourage comfortable
day 6 am inhibits the ulcer, treatment of - decrease doses client to ear as evidenced
– 6 pm action of heart burn, acid in renal and adequate resting and
histamine At ingestion, sour liver failure. nutritious sleeping
h2 receptors stomach. - if you are foods at a comfortably.
of the parietal CI: using antacid, regular meal
cells of the Hypersensitivity, take it exactly time.
stomach use cautiously the as prescribed, - impart to
inhibiting impaired renal or being careful of client not to
basal gastric hepatic function the time skip meals.
acid secretion pregnancy. administered. - position
that is SE: Headache, - have regular client into a
stimulated by malaise, medical follow comfortable
food, insulin, dizziness, up care to position.
histamine, tachycardia, evaluate your
cholinergic bradycardia, rash, response.
agonists, constipation,
gastrin and diarrhea.
pentagastrin.

3.5 SOAPIE

47
SOAPIE #1

S- “ Dili gehapon ayu malihuk akong tiil day”.

O- Received patient lying on bed with head elevated to 30 degrees, awake, conscious,
coherent, communicative, without IV, with the following v/s T= 35.5 degree Celsius, P=
86 pm, R= 20 bpm and BP= 120/70 mmHg, the patient is reading a newspaper, has
difficulty in changing position while lying on bed, has difficulty in moving the
extremities, inability to walk or stand alone, limited range of motion in the extremities,
slowed movement, difficulty initiating in gait.

A= Impaired physical mobility, inability to stand alone related to skeletal impairment 2


degrees to fracture on the right femoral neck.

P= To promote adequate mobility of the client.

I= Introduced name to the patient; assessed the condition, of the patient; monitored v/s,
assisted patient in doing ROM exercises, assisted patient upon doing gait training; set
siderails up; provided comfort measures such as backrub; encouraged patient to do DBE;
supported affected body parts/ joints using pillows/ rolls; consulted with physical or
occupational therapist as indicated; documented the v/s and I and O of the patient.

E= The patient was able to demonstrate increasing function of the extremities as


evidenced by standing and walking between parallel bars with assistance.

SOAPIE #2

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S= “Naproblema man ko sa akong tiil day kay pila na ni ka adlaw walay lihok- lihok,
murag lain na kaayu akong feeling”, as verbalized by the patient.

O= Received patient sitting up on bed, , conscious, coherent, communicative, without IV,


with the following v/s T= 35.7 degrees Celsius, R= 19 bpm, P= 76 bpm, BP= 120/70 with
feet supported by rolled towels, limited movement of the lower extremities.

A= Risk for altered blood flow r/t immobility 2 degrees to fracture of the right femoral
neck.

P= To enhance blood circulation

I= Introduced name to the patient; assessed the condition of the patient; monitored v/s;
administered medications; noted signs of changes in respiratory rate, depth, use of
accessory muscles, pursed top breathing, areas or pallor/ cyanosis; auscultated breath
sounds if there is a decrease or adventitious breath sounds as well as fremitus; monitored

cardiac rhythm; reviewed risk factors; reinforced need for adequate rest while
encouraging activity within client’s limitations; encouraged frequent position changes
and DBE / coughing exercises; check the CRT of the patient; documented the v/s, I and O
and medications taken by the patient.

E= The client’s extremities are warm and pink, remains intact, CRT results of 2 seconds,
no verbalization of pain, swelling on the area and demonstrates calm breathing.

HEALTH TEACHING PLAN

49
Objective Content Methodology Evaluation
General Objectives:
After 3 day of
varied learning
activities, the
patient as well as
the significant
others or family
will be able to
acquire knowledge,
attitude and skills in
preventing
complications of
immobility.

Specific Objectives:
After 45 minutes
of teaching, the
patients as well as
the significant other
or family will be
able to:

1. explain the goals Positioning (Goals) Informal -the patients was able
of frequent position * to prevent contractures discussion to explain the goal of
changes. * stimulate circulation and frequent position
prevent pressure sores changes and she was
* prevent thrombophiebitis motivated to perform
and pulmonary embolism. the different positions
* promote lung expansion to become at ease from
and prevent pneumonia pain or any discomfort
* decrease edema of the felt
extremities
* changing position from
lying to sitting several times
a day can help prevent
changes in the CVS known
as deconditioning.
*the recommendation is to
change body position at least
every 2 hours, and preferably
more frequently in patients
who have no spontaneous
movement.

2. enumerate the Proper Body Alignment Informal -the patient was able to

50
positions for proper 1. Dorsal or Supine Position. discussion verbalize the different
body alignment a. the head is in line with the proper positions for
spine both laterally and proper body alignment
anteroposteriority.
b. the trunk is positioned so
traction of the hips is
minimized to prevent hip
contractive.
c. The Arms are flexed at the
elbow with the hands resting
against the lateral abdomen.
d. the legs are extended in a
neutral position with the toes
pointed towards the ceiling.
e. the neels are suspended in
a space between the mattress
and the footboard to prevent
neel pressure.
f. trochanter tons are place
under the greater trochanter
in the hip joint areas.
2. Side lying or lateral
position
a. the head is in line with the
spine
b. the body is an alignment
and is not twisted
c. the uppermost hip joint
silently forward and
supported by a pillow in a
position of slight abduction.
d. a pillow supports the arm
which is flexed of both the
elbow and shoulder joints.
3. Prone position
a. the head is turned laterally
and is in alignment with the
rest of the body
b. the arms are abducted and
externally rotated at the
shoulder joint; the elbow are
fexed

c. a small flat support is

51
placed under the pelvis
extending from the level of
the umbilicus to the upper
third of the thigh.
d. the lower extremities
remain in a neutral position.

3. discuss the Therapeutic Exercises Informal -the patient was able to


different 1. Positive range of motion discussion discuss the different
therapeutic exercise and therapeutic exercises
exercises 2. active assistive range of demonstration and was able to
motion demonstrate them with
3. active range of motion assistance
4. Resistive exercise
5. Isometric or muscle
settings exercise.

4. practice the Range of motion Informal The patient was able to


different kinds of * Flexion extension of discussion practice the different
range of motion shoulder. and kinds of ROM exercise
* Fexion extension of elbow demonstration with assistance
* adduction-abduction of
shoulder.
* Pronation-supination of
elbow.
* Dorsiflexion and palmar
flexion of wrist.
* Ulnar-radial deviation of
wrist.
* Adduction-abduction and
opposition of thumb
* Adduction-abduction,
flexion-hyper extension of
fingers.
*Dorsiflexion-Plantarflexion,
Eversion of the ankle.
* Flexion-extension;
adduction-abduction of toes
* Adduction-abuction;
internal rotation or external
rotation of the hip.
* Flexion-hyperextension;
rotation of cervical spine

* Lateral bending of cervical

52
spine.

5. participate Informal -the patient was able to


attentively to the discussion listen attentively and
discussion and asked some question
demonstration related to the discussion
and she was also able to
participate during
demonstration.

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V. Evaluation and Recommendation

Prognosis of the patient

After 3 days of intervention, the student nurse observed certain changes from the
patient. The patient reports decreased pain with elevation, ice and analgesic. The patient
also exhibits unlabored respirations; alert and oriented, a febrile, using affected extremity
for light activity as allowed, no signs of neurovascular compromise, v/s stable; urine
output adequate and no calf pain reported: Homan’s sign negative. The patient also
performs active ROM correctly, hygiene and dressing practices with minimal assistance
and denies acute symptoms of stress; reports working through feelings about trauma.

Recommendation

As a researcher in this case study, the student nurse recommends the patient to
adjust in usual lifestyle and responsibilities to accommodate limitations imposed by
fracture and to prevent recurrent fractures – safety considerations, avoidance of fatigue
and proper footwear. The patient is instructed about exercises to strengthening upper
extremity muscles
If crutch walking is planned, methods of safe ambulation – walker, crutches, care,
emphasizes instructions concerning amount of weight bearing that will be permitted on
fractured extremity, teaches symptoms needing attention, such as numbness, decreased
function, increased pain and elevated temperature and explains basis for fracture
treatment and need for patient participation in therapeutic regimen. The patient and the
family were also informed that the patient must have an adequate balanced diet to
promote bone and soft tissue healing.

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VI. Evaluation and Implication of this case study to:

Nursing Practice

The result of this case study would provide the student nurse with sufficient
knowledge, attitude and skills towards the management of patients with fracture on the
right femoral neck. This study would help the student nurse in providing a higher quality
of care of patients with the same condition. It is important that the proper and ideal
managements and interventions are done in order to give a more holistic approach and
optimum care to clients with fracture on the right femoral neck. This would ensure the
timely healing of injury and the prevention of complications.

Nursing Education

Education can promote enhancement of professionalism through an on- going


learning process, whether self- motivated, people- oriented and having a commitment to
the organization, nurses are likely to become well respected through the formal
educational programs. Through this case study, it is important to know all areas of patient
are both knowledge and skills to manage effectively in all aspects of their professional
nursing practice.

Nursing Research

Nursing research is essential for the development of scientific knowledge that


enables nurses to provide evidenced-based health care. Broadly nursing is accountable to
society for providing quality, cost effective care and for seeking ways to improve that
care. More specifically, nurses are accountable to their patients to promote a maximum
level of health.
This case study would contribute more information and facts about fracture on the
right femoral neck. This could contribute to the development of the case study of fracture
– its prevention, causes, signs and symptoms, and nursing management. Hopefully, this

55
case study will lead to development of new skills and new approaches to the care of
patient’s with fracture on the right femoral neck. This case study could also as basis for
related study and will provide facts for further research in aiming for the improvement of
these patients.

VII – Referral and Follow-Up

The patient was informed to have a continuous appointment with the


Rehabilitation Care Program Health Care providers after discharge. The patient was
encouraged for follow-up medical supervision to monitor for union problems.

VIII – Bibliography

Bare, Brenda I. and Smeltzer, Suzzane C., Textbook of Medical-Surgical Nursing.


10th Edition Philadelphia: I.B Lippincott Company. 2004.

Nettina, Sandra M., Manual of nursing Practice. 7th Edtion. I.B. Lippincott
Company. 2001.

Rozler, Barbara et al. Fundamentals of Nursing. 5th Edition. Newyork: Addison-


Weatleylongman, Incorporated. 1998.

Marleb, Elaine N. Essential of Human Anatomy and Physiology. 7th Edition.


Singapore. Pearson Education South Asia Pte. Ltd. 2004.

Potter, Patricia and Perry, Anne. Fundamentals of Nursing. 6th Edition Baltimore:
C.V. Mosby and Company. 2005.

Doenges, M., Moorhouse, M.F. , Geissler – Murr, A. “ Nurses Pocket Guide”,


Diagnosis, interventions and rationales, 9th Edition (2004).

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Doenges, M., Moorhouse, M.F. , Geissler – Murr, A., “ Nursing Care Plans”.
Guidelines for Individualizing Patient Care. 6th Edition. F.A. Davis
Company, 2002.

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