Breaking of the femur

False movement of the injured bone

Deformity

Extravasation of blood to surrounding tissue Skeletal Traction with 7 kgs.

Crepitus

Immobility
Deformity Loss of Function

Nursing Management: - Assess client's level of tolerance in moving - Assist client upon moving without mobilizing the affected leg. -Perform ROM exercises that the client can only tolerate. - Tell Client to frequently wiggle toes. - Encourage use of relaxation techniques - Give health teachings on the importance of ROM esp. on the affected leg as tolerated.

Impaired physical mobility related to loss of integrity of bone structures,

Nursing Management: -Evaluate presence/ quality of peripheral pulse distal to injury via palpation and compare with uninjured limb. - Assess capillary return, skin color, and warmth distal to the fracture. - Note reports of pain extreme for type of injury or increased pain on passive movement of extremity, muscle tension/tenderness, and change in pulse quality distal to injury. Do not elevate extremity. - Note signs of general pallor/cyanosis, cool skin, changes in mentation. -Test sensation of femoral nerve by

mentation. -Test sensation of femoral nerve by pitch/ pinprick in the dorsal web . - Immobilie or support the affected body part to prevent pressure and injury.

LEGEND:

Predisposing/Precipitating Factors

Pathophysiology of the disease condition Clinical Manifestations Nursing Diagnosis Nursing Management Medical Management Pharmacologic Management Complications

FRACTURE
Predisposing Factors: - Age - Gender - Nutrition

Inability of the bone to absorb too much pressure

Break in the continuity of the bone

Close

Disruption of the surrounding tissues, nerve supply

Increased capillary permeability

Inflammatory Response Localization of serous fluid at fractured site Subcutaneous bleeding Initial Vasoconstriction Bruising Vasodilation Edema Increased Vascular Permeability

Extravasation of blood to surrounding tissue

Swelling

quality of al to injury via

Risk for peripheral Neuromuscular Dysfunction related to reduction of blood flow, direct vascular injury & tissue trauma secondary to motor vehicular accident.

Hyperemia

outpouring of plasma, blood to the site.

Redness

Heat

Edema

urn, skin color, o the fracture. n extreme for eased pain on f extremity, rness, and ity distal to e extremity.

Increased pressure irritation o nerve endings

Pain

kin, changes in

moral nerve by

moral nerve by dorsal web . rt the affected t pressure and

Altered sleeping patt related to pain felt on left leg and thigh due open, complete fract secondary to moto vehicular accident

FRACTURE
Precipitating Factors: - People Working with heights - People engaging in high risk sports - Motor vehicular Accident - Fall - Direct blow

Risk for infection re inadequate primary broken skin, traum tissues, environmenta due to presence of

to absorb too much pressure exerted on it

n the continuity of the bone

Cefuroxime 50 tab BID p.o.

Open

nding tissues, peristeum, blood vessel and nerve supply

Undergone a minor surgery- suture of his left thigh with L.A.

Infection

Damaged muscle Skeletal Traction with 7 kgs. Pull fragments out of position Muscle Spasm Numbness Deformity Pain

Damaged Peripheral Nerves

Degeneration of nerve c

reased Vascular Permeability

tpouring of plasma, blood to the site.

Altered comfort: Acute pain related to presence of skeletal traction as manifested by reports of pain on left leg.

Edema

creased pressure irritation of nerve endings

Pain

Nursing Management: -Allow/ provide an avenue of expression of what the client feels at the moment and also about the accident. - Provide non-pharmacologic measures like: breathing exercises & guided imagery - Provide emotional support to the client.

Tramadol 50mg capsule TID p.o.

Altered sleeping pattern related to pain felt on the left leg and thigh due to open, complete fracture secondary to motor vehicular accident.

- Provide emotional support to the client. -Maintain immobilization of affected part by means of traction. -Ask patient to rate pain in a scale of 0-10 where 10 is the most painful and 0 as no pain. -Document reports of pain or discomfort, noting location and characteristics, including intensity.

Risk for infection related to inadequate primary defenses: broken skin, traumatized tissues, environmental exposure due to presence of skeletal traction.

Cefuroxime 50 mg tab BID p.o.

Nursing Management: -Inspect the skin for preexisting irritation or breaks in the continuity. -Assess skin area that is affected, noting reports of increased pain/burning sensation or presence of edema, erythema, foul odor or drainage. -Provide wound care according to protocol & exercise strict handwashing. -Instruct client not to touch or scratch wound -Monitor vital signs. (esp. temperature) -Do nail care. Impaired skin or tissue integrity related to open, complete fracture and presence of skeletal traction on left leg secondary to MVA.

Nursing Managemen - Examine wound fo discoloration and an abdominal findings. -Palpate taped tissu and document any t and pain. - Provide skin care. -Change dressing as -Keep bed linens free wrinkles and foreign -Maintain adequate nutritional status.

Damaged Peripheral Nerves

Degeneration of nerve cells

Decreased blood vol

Decreased perfusi

Loss of muscle control

Poor muscle tone

Absence of reflexes

Loss of muscle mass

Activity Intolerance/ impaires physical mobility

Impaired Tissue

Impaired physical mobility related to presence of skeletal traction on left leg due to open, complete fracture secondary to MVA.

Nursing Management: - Assess client's level of tolerance in moving - Assist client upon moving without mobilizing the affected leg. -Perform ROM exercises that the client can only tolerate.

the client can only tolerate. - Tell Client to frequently wiggle toes. - Encourage use of relaxation techniques - Give health teachings on the importance of ROM esp. on the affected leg as tolerated.

Nursing Management: Examine wound for bleeding, discoloration and any other abdominal findings. Palpate taped tissue daily and document any tenderness and pain. Provide skin care. Change dressing as needed. Keep bed linens free from wrinkles and foreign matter. Maintain adequate nutritional status.

Rupture of blood vessel

Decreased blood volume

Decreased platelets

Decreased RBC

Decreased WBC

Decreased perfusion

Greater risk for bleeding

Palllor, weakness, fatigue

Decreased body protection

Ischemia

Hemorrhage

Impaired healing

Necrosis Shock Tissue death Fracture complications

Impaired Tissue Integrity

Compartment Syndrome

Fat Embolism

Infection

6 P's: Paresthesia Pain Pressure Pallor Paralysis Pulselessness

Altered mental status Tachycardia Tachypnea Hypoxemia

Elevated Temp. Rapid pulse thin, watery, extremely-foul smelling exudate

Paralysis Pulselessness

exudate

Inflammatory Response

Formation of Hematoma

Fibrocatilage

Callus formation

Ossification

Consolidation

Remodelling

BONE HEALS

Breaking of the femur

False movement of the injured bone

Deformity

Crepitus Immobility Loss of

Skeletal Traction with 7 kgs.

Loss of Function

Nursing Management: - Assess client's level of tolerance in moving - Assist client upon moving without mobilizing the affected leg. -Perform ROM exercises that the client can only tolerate. - Tell Client to frequently wiggle toes. - Encourage use of relaxation techniques - Give health teachings on the importance of ROM esp. on the affected leg as tolerated.

Impaired physical mobility related to loss of integrity of bone structures,

Nursing Management: -Evaluate presence/ qua peripheral pulse distal to palpation and compare uninjured limb. - Assess capillary return, and warmth distal to th - Note reports of pain ex type of injury or increase passive movement of ex muscle tension/tenderne change in pulse quality d injury. Do not elevate ex - Note signs of general pallor/cyanosis, cool skin in mentation. -Test sensation of femora pitch/ pinprick in the do - Immobilie or affected body part to pr pressure and injury.

LEGEND:

Predisposing/Precipitating Factors

Pathophysiology of the disease condition Clinical Manifestations Nursing Diagnosis Nursing Management Medical Management Pharmacologic

Pharmacologic Management Complications

Predisposing Facto

Traction with 7 kgs.

Nursing Management: Evaluate presence/ quality of peripheral pulse distal to injury via palpation and compare with uninjured limb. Assess capillary return, skin color, and warmth distal to the fracture. Note reports of pain extreme for type of injury or increased pain on passive movement of extremity, muscle tension/tenderness, and change in pulse quality distal to injury. Do not elevate extremity. Note signs of general pallor/cyanosis, cool skin, changes in mentation. Test sensation of femoral nerve by pitch/ pinprick in the dorsal web . Immobilie or support the affected body part to prevent pressure and injury.

Risk for peripheral Neuromuscular Dysfunction related to reduction of blood flow, direct vascular injury & tissue trauma secondary to motor vehicular accident.

FRACTURE
Predisposing Factors: - Age - Gender - Nutrition

Inability of the bone to absorb too much pressure exerted on it

Break in the continuity of the bone

Close

Open

Disruption of the surrounding tissues, peristeum, blood vessel and nerve supply

Inflammatory Response

Skeletal with 7 kgs.

Initial Vasoconstriction

Vasodilation

Increased capilllary/Vascular Permeability

Vasodilation

capilllary/Vascular Permeability

Hyperemia

outpouring of plasma, blood to the site.

Redness

Heat

Edema

Increased pressure irritation of nerve endings

Pain

Precipitating Factors: - People Working with heights - People engaging in high risk sports - Motor vehicular Accident - Fall - Direct blow

exerted on it

d vessel and

Undergone a minor surgery- suture of his left thigh with L.A.

Infection

Damaged muscle Skeletal Traction with 7 kgs.

Pull fragments out of position

Muscle Spasm Numbness Deformity

Pain

Altered comfort: Acute pain related to muscle spasm

Nursing Management: -Allow/ provide an avenue of expression of what the client feels at the moment and also about the accident. - Provide non-pharmacologic measures like: breathing exercises & guided imagery - Provide emotional support to the client. -Maintain immobilization of affected part by means of traction. -Ask patient to rate pain in a scale of 0-10 where 10 is the most painful and 0 as no pain. -Document reports of pain or discomfort, noting location and characteristics, including intensity.

Tramadol 50mg capsule TID p.o.

Risk for infection related to inadequate primary defenses: broken skin, traumatized tissues, environmental exposure due to presence of skeletal traction.

Cefuroxime 50 mg tab BID p.o.

Nursing Management: -Inspect the skin for preexisting irritation or breaks in the continuity. -Assess skin area that is affected, noting reports of increased pain/burning sensation or presence of edema, erythema, foul odor or drainage. -Provide wound care according to protocol & exercise strict handwashing. -Instruct client not to touch or scratch wound -Monitor vital signs. (esp. temperature) -Do nail care.

Damaged Peripheral Nerves

Degeneration of nerve cells

Numbness

Loss of muscle control

Poor muscle tone

Absence of reflexes

Loss of muscle mass

Activity Intolerance/ impaires physical mobility

Impaired physical mobility related to presence of skeletal traction on left leg due to open, complete fracture secondary to MVA.

Nursing Management: - Assess client's level of tolerance in moving - Assist client upon moving without mobilizing the affected leg. -Perform ROM exercises that the client can only tolerate. - Tell Client to frequently wiggle toes. - Encourage use of relaxation techniques - Give health teachings on the importance of ROM esp. on the affected leg as tolerated.

Impaired skin or tissue integrity related to open, complete fracture and presence of skeletal traction on left leg secondary to MVA.

Nursing Management: - Examine wound for bleeding, discoloration and any other abdominal findings. -Palpate taped tissue daily and document any tenderness and pain. - Provide skin care. -Change dressing as needed. -Keep bed linens free from wrinkles and foreign matter. -Maintain adequate nutritional status.

Decreased blood volume

Decreased platelets

Decreased perfusion

Greater risk for bleeding

Ischemia

Ischemia

Hemorrhage

muscle mass

Necrosis

Tissue death

Impaired Tissue Integrity

Compartment Syndro

sing Management: client's level of e in moving lient upon moving mobilizing the affected

m ROM exercises that t can only tolerate. ent to frequently

6 P's: Paresthesia Pain Pressure Pallor Paralysis Pulselessness

age use of relaxation

ealth teachings on the nce of ROM esp. on the leg as tolerated.

Rupture of blood vessel

Decreased platelets

Decreased RBC

Decreased WBC

Greater risk for bleeding

Palllor, weakness, fatigue

Decreased body protection

Hemorrhage

Impaired healing

Shock

Fracture complications

Compartment Syndrome

Fat Embolism

Infection

6 P's: Paresthesia Pain Pressure Pallor Paralysis Pulselessness

Altered mental status Tachycardia Tachypnea Hypoxemia

Elevated Temp. Rapid pulse thin, watery, extremely-foul smelling exudate

Inflammatory Response

Formation of Hematoma

Fibrocatilage

Callus formation

Ossification

Consolidation

Remodelling

BONE HEALS