NEW ERA UNIVERSITY

COLLEGE OF NURSING

CASE STUDY:
Fracture, Open III A,
Compound
rd
Comminuted Distal 3
Tibia, Left

Presented by:
Brosas, Myko B.
BSN-NEU
I.INTRODUCTION

A bone fracture is a medical condition in which there is a break in the continuity

of bone. One of its types is an open fracture in which a broken bone penetrates the
skin. This is an important distinction because when a broken bone penetrates the skin
there is a need for immediate treatment, and an operation is often required to clean the
area of the fracture. Furthermore, because of the risk of infection, there are more often
problems associated with healing when a fracture is open to the skin. Open fractures
are typically caused by high-energy injuries such as car crashes, falls, or sports-related
injuries. Open fractures often require immediate surgery to clean the area of the injury.
Because of the break in the skin, debris and infection can travel to the fracture location,
and lead to a high rate of infection in the bone.

This type of fracture usually takes longer to heal because of the extent of injury
to the bone and the surrounding soft-tissues. Type III-A open fracture has a wound
larger than 10 cm, with severe contamination and severe crushing component. Open
fractures also have a high rate of complications including infection and non-union.

This case focuses on an 11 year old female, patient KA who was admitted last
August 15, 2010 at Philippine Orthopedic Center and has an admitting diagnosis of
Fracture, Open III A Compound Comminuted Distal 3rd Tibia, left. The patient was
handled by a 4th year nursing student with the supervision of Prof. Elizabeth Raymundo.

This case study covers a wide variety of significant and relevant information
such as the demographic profile, nursing history, pathophysiology,
laboratory/diagnostic study and also the drug study that is needed for the case
analysis.
 I. Objectives:

By the end of the intended period for the gathering of clients’ information and
interviews, the student aims to:

General

• To relate the knowledge that the student has learned in related learning
experience based on standard principles.
• To broaden the scope of skills in devising interventions in relation to specific
case of the patient.

Specific

A. Knowledge

• Analyze all the data gathered from the client, particularly the health history, chief
complaint, signs and symptoms of the disease the client encountered, drugs taken
by client, and laboratory examinations held.
• Present and understand the underlying pathophysiology in relation to the
anatomy and physiology of the client’s case for the incorporation of nursing
interventions.

B. Skills

• Plan for appropriate nursing interventions to be implied to the client for

improvement of the disease process or if not the factors affecting the disease
process.
• Implement effective and efficient appropriate nursing interventions after gaining the
client’s trust and cooperation.
• Evaluate the client’s response to the nursing interventions provided for knowing
the effectiveness of the nursing interventions given.
C. Attitude

• Develop discipline and camaraderie among members of the group through

assigning different responsibilities and tasks accordingly.
• Support and establish teamwork within the group in dealing with this activity.

III.BIOGRAPHIC DATA

Child’s name: PATIENT KA

Address: Caloocan City

Date of birth: March 21, 1999

Age: 11 years old

Sex: Female

Race: Asian

Religious Orientation: Roman Catholic

Date of Admission: August 15, 2010

Ward: Children’s Ward

Medical Diagnosis: Fracture, Open III A Compound Comminuted Distal 3rd Tibia, Left

Health care Financing and Usual Source of Medical Care: Hospital

IV.NURSING HISTORY

A. History of Present Illness

Few hours prior to admission, the client was riding a motorcycle when it was hit by an
owner- type jeep. The accident threw the client overboard and hit her left thigh and leg. It
caused laceration of the client’s left thigh and leg. Soon after, the client was brought to a
hospital at Caloocan city. The client was referred to Philippine Orthopedic Center for further
management and treatment. During the client’s admission, the client undergone CBC and she
was given medications for pain and was operated on her left lower extremity. The client was
then ordered by her physician to be on a balanced skeletal traction.

B. Past Medical History

The client had cough and colds in the past. According to the client’s father, she had
completed her immunization during her childhood. The client does not take any vitamin
supplements. She had no allergies to food or medications. This incident was the first injury
she has experienced. This was her first time to be admitted to a hospital.

C. Family History of Illness

Father:
Has history of
DM in the
family
 Mother:
Has
asthma

Patient:
N/A

The client’s father has history of diabetes mellitus in the family while her mother has
asthma.

V.ANATOMY AND PHYSIOLOGY:

THE SKELETAL SYSTEM

The Skeletal System serves many important functions; it provides the shape and
form for our bodies in addition to supporting, protecting, allowing bodily movement,
producing blood for the body, and storing minerals.

Functions:

Its 206 bones form a rigid framework to which the softer tissues and organs of
the body are attached. Vital organs are protected by the skeletal system. The brain is
protected by the surrounding skull as the heart and lungs are encased by the sternum
and rib cage. Bodily movement is carried out by the interaction of the muscular and
skeletal systems. For this reason, they are often grouped together as the musculo-
skeletal system. Muscles are connected to bones by tendons. Bones are connected to
each other by ligaments. Where bones meet one another is typically called a joint.
Muscles which cause movement of a joint are connected to two different bones and
contract to pull them together. An example would be the contraction of the biceps and a
relaxation of the triceps. This produces a bend at the elbow. The contraction of the
triceps and relaxation of the biceps produces the effect of straightening the arm.

Blood cells are produced by the marrow located in some bones. An average of
2.6 million red blood cells is produced each second by the bone marrow to replace
those worn out and destroyed by the liver. Bones serve as a storage area for minerals
such as calcium and phosphorus. When an excess is present in the blood, buildup will
occur within the bones. When the supply of these minerals within the blood is low, it will
be withdrawn from the bones to replenish the supply.

Divisions of the Skeleton

The human skeleton is divided into two distinct parts:

The axial skeleton consists of bones that form the axis of the body and support and
protect the organs of the head, neck, and trunk. It consists of:

• The Skull
• The Sternum
• The Ribs
• The Vertebral Column

The appendicular skeleton is composed of bones that anchor the appendages to the
axial skeleton. It consists of:

• The Upper Extremities

• The Lower Extremities
• The Shoulder Girdle
• The Pelvic Girdle--(the sacrum and coccyx are considered part of the vertebral
column)

Types of Bone

The bones of the body fall into four general categories: long bones, short bones,
flat bones, and irregular bones. Long bones are longer than they are wide and work as
levers. The bones of the upper and lower extremities (ex. humerus, tibia, femur, ulna,
metacarpals, etc.) are of this type. Short bones are short, cube-shaped, and found in
the wrists and ankles. Flat bones have broad surfaces for protection of organs and
attachment of muscles (ex. ribs, cranial bones, bones of shoulder girdle). Irregular
bones are all others that do not fall into the previous categories. They have varied
shapes, sizes, and surfaces features and include the bones of the vertebrae and a few
in the skull.

Bone Composition
 Bones are composed of tissue that may take one of two forms - compact and
spongy bone. Most bones contain both types. Compact bone is dense, hard, and forms
the protective exterior portion of all bones. Spongy bone is inside the compact bone and
is very porous (full of tiny holes). Spongy bone occurs in most bones. The bone tissue
is composed of several types of bone cells embedded in a web of inorganic salts
(mostly calcium and phosphorus) to give the bone strength, and collagenous fibers and
ground substance to give the bone flexibility.
VII. DIAGNOSTIC/LABORATORY STUDIES

PROCEDURE DATE DONE INDICATION OF NORMAL ACTUAL SIGNIFICANCE OF THE

THE TEST VALUES FINDINGS FINDINGS

Hematology September 18, The complete blood Below the normal

2010 count (CBC) is a range
screening test, used Segmenters 0.40
to diagnose and = 0,50-0.70 Low levels of segmenters
manage numerous may indicate infection.
diseases. It can This means that there
reflect problems with
are few band cells in an
fluid volume (such as
attempt to fight infection.
dehydration) or loss
of blood. It can show (Lippincott Manual of
abnormalities in the
nursing Practice
production, life span,
and destruction of
Diagnostic tests by
blood cells. It can Lippincott Williams
Lymphocyte p.46)
reflect acute or
chronic infection, s = 0.20- 0.48
allergies, and 0.40
problems with
Above the normal
clotting.
range

An elevated lymphocyte
count indicates that the
body’s resistance to fight
infection has
substantially increased.

(Lippincott Manual of
nursing Practice
Diagnostic tests by
Lippincott Williams p.
 VI.PATHOPHYSIOLOGY:

Factor:
• Trauma
or
accident

Traumatic injury Blood vessels

Compression of
results into breakage become ruptured
nerve endings
w/in the area of bone.

bleeding
Pain Extremity Inflammator
bends y process
occur

Results to loss
of function Results to
and deformity swelling and
tenderness

Blood coagulates between broken

fragments

Fibrin network forms and

changes into granulation
tissue

Osteoblasts produce
osteoids

Osteoids form a bridge across a

fracture site

Minerals are deposited in the

osteoid which forms callus

Fracture ends knit Remodeling

together occurs
 VIII. DRUG STUDY

DRUG BRAND PHARMACOLOG INDICATION/ ADVERSE DESIRED NURSING

ORDER NAME IC ACTION CONTTRAINDICATI REACTION ACTION RESPONSIBILITIES
ON
Cefazolin Ceptaz Bactericidal: I: Treatment of CNS: To treat • Advise relatives
500 mg TIV q Inhibits synthesis infections caused by headache, infection. to maintain normal
8 ˚ for 3 of bacterial cell staphylococcus dizziness, fluid intake of the
days ANST wall, causing cell aureus. lethargy client while using
(-) death. GI: nausea, this medication.
CI: Contraindicated vomiting, • Advise the
with allergy to diarrhea, relatives to report if
cephalosporins or anorexia, severe diarrhea and
penicillins. abdominal difficulty of
pain,flatulenc breathing occurs to
e the client.
GU: • Instruct relatives
nephrotoxicity to report signs of
superinfection:
black "furry"
tongue, white
patches in mouth,
foul-smelling stools,
vaginal itching or
discharge.
Amikacin Bactericidal: I: Used to initiate CNS: lethargy, To treat • Advise the
100 mg TIV q Inhibits cell wall treatment when a hallucinations, infection. relatives to report if
12o x 5 days synthesis of staphylococci seizures severe diarrhea,
Paracetamol Thought to I: infection
The drugisis Hematologic:
ANST (-) sensitive GI: glossitis, To decrease • difficulty
Advise of
parents
250 mg/tab q produce indicated for Hemolytic temperature that
breathing, for
Antibiotic organisms suspected. gastritis, drug is short
rashes
6o analgesia and increased anemia term use only.
causing cell stomatitis, and mouth sores
prn for fever reduce temperature. Leukopenia • occur.
Warn patient that
death. CI: Contraindicated sore mouth
temp ≥ 37.8 ˚ temperature by Neutropenia dosages or the
with allergy to • Advise
c inhibiting CI:cephalosporins or Hepatic: unprescribed long
synthesis of Contraindicated in Jaundice relatives to finish
term
entire coursecause
penicillins. use can
prostaglandin patient Metabolic: of
liver damage.
Antipyretic in CNS. hypersensitive to Hypoglecemia therapy for the
drug. Skin: client.
Rash

Ibuprofen 200 It works by blocking I: Indicated for CNS: lethargy, For relief of • Advise the
mg q 8˚ for the action of a relief of mild to hallucinations, mild pain. relatives to report if
pain substance in the moderate pain. seizures severe diarrhea,
body called cyclo- GI: glossitis, difficulty of
oxygenase. CI: Contraindicated gastritis, breathing, rashes and
to patient’s with stomatitis, mouth sores occur.
sore mouth • Advise the
hypersensitivity to
drug. relatives to finish
entire course of
therapy for the client.
IX. NURSING CARE PLAN
 CUES NURSING BACKGROUND GOALS AND NURSING RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTIONS
Subjective:
“Minsan sumasakit Acute Pain r/t It is described as After an hour of 1.Accept patient’s Pain is a subjective After an hour of
pa rin ‘yung sa may mechanical an unpleasant nursing feeling of pain. experience and cannot nursing
bandang bali ko.” injury. sensory and interventions, the Acknowledge the be felt by others interventions,
emotional client will be able pain experience and the client has
experience arising
Objective: to show signs of convey acceptance shown signs of
from actual or
- shifting back and pain relief. of patient’s response pain relief
potential tissue
forth damage or to pain • The
- grimace described in terms client has
- client reassured by of such damage. 2.Observe non- Observations may be stopped
occasional touching In cases of verbal cues/pain the only indicator crying
fracture, pain is behaviors and other present when client is and has
continuous and defining unable to verbalize stayed
increasing until characteristics. calm
bone fragments • Underlyi
are immobilized. 3.Monitor skin These are usually ng cause
color/temperature altered in acute pain of
and VS which may help in the client’s
management of the hyperther
problem. mia was
attention,
4.Provide comfort Promote non- thus
measures (touch, pharmacological pain treated.
parent’s presence) management

5.Provide To distract attention and

diversional activities reduce tension.
(TV, etc.)

6.Administer Analgesics are

analgesics, as medications that
indicated and as reduces pain
ordered
 Subjective: Impaired skin Mechanical injury Long Term: 1.Assess skin Provide baseline Goals Met:
After 3-4 days
“Iyan ‘yung sugat integrity may result into a lesion/wound for data helpful in
of nursing
ko, unti-unti na related to break in the interventions,
size, shape, the management After 3-4 days
gumagaling.” mechanical continuity of skin consistency, of wound. of nursing
the client will show healing
injury due to intensity of texture, interventions,
of wounds without signs and
Objective: secondary to trauma. temperature, and the client has
symptoms of complication
shown healing of
surgery hydration.
wounds without
-wound in the left Short term: signs and
thigh After 6-8 hrs of 2.Keep the area This assists symptoms of
nursing clean/dry, body’s natural complication
interventions of carefully dress process of
nursing wounds, support repair. After 6-8 hrs of
interventions, incision, prevent nursing
the client will: infection, and interventions of
• Have reduced risk of stimulate nursing
further impairment of circulation to interventions,
skin integrity surrounding areas. the client:
• Patient’s caregivers • Have
will have full 3.Use appropriate reduced risk
understanding & skill barrier dressings, To protect the of further
in care of wound wound coverings, wound and/or impairment
skin-protective surrounding of skin
agents. tissues. integrity
• Patient’s
4.Use appropriate To reduce caregivers
padding devices pressure had full
when indicated. on/enhance understandin
circulation to g & skill in
compromised care of
tissues wound.
5.Provide This provides a
optimum nutrition positive nitrogen
including vitamins balance to aid in
and increased skin/tissue
protein intake healing and to
maintain general
good health
6.Follow body To reduce risk for
substance isolation further infection
precaution; use
clean gloves &
clean dressing for
wound care.
Practicing proper
hand washing
before & after
wound care.
X.PROPOSED DISCHARGE PLAN

Medications- to take at home

• Emphasize to the significant others the importance of taking the medications as

prescribed.

Exercise

• Advise the significant others that the patient may return to regular activity.

Treatments

• Encourage the significant others to cleanse and change the dressing of the
incision site.
• Have follow- up check ups to maintain proper health function.
• Advise the significant others to consult doctor and health care provider if
symptoms persist including dysuria, hematuria, anuria and swelling, pain or
drainage from the incision site.

Health Teachings

• Advise the significant others to inspect and observe for any changes on the
incision site.
• With regards to the take home medications, inform the significant others for any
side effects of prescribed meds and how to handle them.
• Teach the significant others when to contact their primary care provider if any
signs and symptoms of allergic reaction occur.

Out patient follow-up

• Advised the significant others to have a regular medical evaluation with primary
health provider.
• Follow-up a schedule by the doctor or physician.

Diet

• Instruct the SO that the client may resume to regular diet.

• Advise the SO to prepare healthy and nutritious foods like fruits and vegetables.

Spiritual

• Advised the SO to maintain and increase trust and faith to God.