Republic of the Philippines

University of Northern Philippines

Tamag, Vigan City

College of Nursing

A Case Study on: Open Fracture Type III B Comminuted on Right patella, Compound displacement, lateral condyle femur

In partial fulfilment Of the requirements Of the course

Nursing Care Management 104: Curative and Rehabilitative Nursing Care Related Learning Experience

Manila Affiliation-Philippine Orthopedic Center Presented to: Raymund Christopher L. De la Pea, R.N. R.M. M.A.N Clinical Instructor Presented by:

Mckinley P. Cabuena BSN-III Daffodil

April 15, 2012

TABLE OF CONTENTS PAGE FRONTPAGE TABLE OF CONTENTS I. II. INTRODUCTION AND OBJECTIVES PATIENTS PERSONAL DATA ii i

(NURSING HISTORY OF PAST AND PRESENT ILLNESS) III. IV. V. VI. PEA/RSON ASSESSMENT DIAGNOSTIC PROCEDURE ANATOMY AND PHYSIOLOGY PATHOPHYSIOLOGY A. ALGORITHM B. EXPLANATION MANAGEMENT A. MEDICAL-SURGICAL B. NURSING CARE PLAN C. PROMOTIVE AND PREVENTIVE DRUG STUDY DISCHARGE PLAN UPDATES ORGANIZATION BIBLIOGRAPHY

VII.

VIII. IX. X. XI. XII.

I.INTRODUCTION An open fracture is one where there is a communication between the fracture and the outside world, an associated laceration. This has implications in terms of the management of this type of fracture, in that wound sepsis must be suspected. Recently there has been a move away from referring to this type of fracture as compound, since abbreviation of this in notes to com. leads to confusion with comminuted fracture. An open fracture may communicate with the outside world from without, an injury from the external world has exposed bone, or from within, bone is pointing through the skin. The former is more serious because there is likelihood that contamination - dirt, bits of clothing - has also been forced into the tissues. Grading is important in determining the management of open fractures: Minor / Grade I - small punctate wound less than 1 cm associated with low velocity trauma. Minimal soft tissue injury. No crushing. No comminution. Moderate / Grade II - wounds which are extensive in length and width but with relatively little soft tissue damage, and only moderate crushing or comminution. Major / Grade III - wounds of moderate or massive size with considerable soft tissue injury and/or foreign body contamination: III A - sufficient soft tissue to cover the fracture III B - insufficient tissue to cover the fracture; also periosteal stripping and severe comminution III C - arterial damage requiring repair. Degree of soft tissue damage not considered.

Less than 2% wound infection in grade I; more than 10% in grade II. High velocity injuries are III B or III C although the external wound may be small. A patella fracture is an injury to the kneecap. The kneecap is one of three bones that make up the knee joint. The patella is coated with cartilage on its undersurface and is important in providing strength of extension (straightening) of the knee joint. An undisplaced fracture of patella takes around 4-6 weeks of immobilization in a cast to heal, while a displaced fracture requires surgical treatment followed by quadriceps strengthening exercises for complete rehabilitation. A patella fracture most often occurs from a fall onto the kneecap. When the fracture occurs due to this type of direct trauma, there is often damage to the overlying skin, and because of the limited amount of soft tissue this can easily become an open fracture. Patella fractures can also occur when the quadriceps muscle is contracting but the knee joint is straightening (a socalled "eccentric contraction"). When the muscle pulls forcefully in this manner, the patella can fracture. Patient X was admitted at Philippine Orthopedic Center last April 2, 2012 due to wound on right knee secondary to motor vehicular accident having an initial diagnosis of open fracture type III B with comminuted patellar fracture, displaced lateral condyle of right femur.

II.OBJECTIVES OF THE STUDY General Objectives: On the completion of this study, I, the student nurse will be able to: Have more comprehensive understanding about the patients condition which is open fracture Type III B with comminuted patellar fracture; Apply nursing care appropriately with proper knowledge, attitude and skills in caring for my patient; Establish a therapeutic communication relationship between the client and student nurse in a more efficient exchange of information to determine patients needs.

Specific Objectives: I, the student nurse will be able to: Describe the common characteristics, manifestations and complication of open fractures; Know the past and present history of the client in conjunction with present illness; To assess the condition of the client through the use of PEARSON Assessment; To relate the significance of laboratory results and values in response to the clients current illness; To present the Anatomy and Physiology of the system involved in relation to patients condition; Identify the action, indication, contraindications, dosage, frequency, adverse effects, and nursing considerations in drug administration; To present nursing care plans formulated specifically for the client to recognize effectiveness of regimen and interventions; Recognize the medical and surgical management related to the patient as well as the promotive and preventive management; Formulate a comprehensive discharge plan, health teachings and updates to the client to promote continuous wellness and disease recuperation and rehabilitation.

cg IV.HISTORY OF PAST AND PRESENT ILLNESS

Past Health History Patient X is a 27 year old male client, born on November 18, 1984 and eldest among the 3 siblings. According to the patient, he had common childhood illnesses such as cough and colds but he had completed his immunizations as evidenced by a BCG scar on his right deltoid area. Since he is working as a waiter, he had undergone several tests to make sure he is physically fit for the work. He claimed to have an adequate sleep and rest period, with at least 30 minutes of exercise every morning by jogging. He claimed drinking occasionally and smokes a pack of cigarette a day. He also claimed having allergy to sea foods but no known allergy to drugs. With regards to the familial history, his father was diagnosed with Hypertension as well as his aunt with Diabetes Mellitus. They are both taking maintenance medications as prescribed by the doctor. He was never hospitalized prior to admission and he claimed not having a regular visit at the doctor for physical examinations and check-up because of insufficient time as he claimed.

Present Health History According to the patient, he was from his work and rode as a passenger on a single motorcycle when they stumbled on a rock and crashed on the road. He was first rushed Pasay General Hospital primarily but was endorsed to Philippine Orthopedic Center, conscious complaining of a painful wound on his right knee. Upon physical examination, he has an avulsion on his right knee, with visible deformity noted, with initial vital signs as follows: BP: 140/100, Temp: 36.6, RR: 20, PR: 93, having an initial diagnosis of Open Fracture type III B, with comminuted fracture on right patella, and compound displacement of the right lateral condyle of femur. He was admitted on April 2, 2012 at 12:05am, initially hooked with D5LRS 1L and wound debridement was done on fracture site as an initial management. Medications were ordered as follows: Penicillin G 5mL IV q6, Tramadol 50mg IV q8 for pain, Paracetamol 300mg IV q4, Cefuroxime 750mg IV q8, Ketorolac 30mg IV q6, and Etocoxib 120mg per tab OD. Initial blood examination showed a marked increase in Leukocytes as a suggestive for infection. On April 8, 2012, he was subjected to application of Spanning External Fixator on his Right knee and lab values prior to OR reflects a marked decrease in hemoglobin and Hematocrit levels that shows impending loss of blood supply and oxygenation in the affected site. Debridement was also done on the wound site to remove the dead tissues and facilitate faster healing process. To check the extent of impending infection, Gram-Staining of the wound was done which showed presence of RBC and WBC on the wound, with noted few gram (+) cocci singly with no spore forming bacilli. On April 11, 2012, he was confined to bed with a Spanning External fixator, with an IVF of D5LRS 1L hooked on his right metacarpal vein. Upon assessment initial vital signs were taken as follows: BP- 120/90, T-36.0, PR- 88, and RR-23. He claimed having a minimal pain with a pain scale of 3/10, with noted swelling on post-op site, with intact dry dressing and drain connected with no drainage noted. He was conscious and coherent, conversant. He claimed having adequate rest periods with no sleep disturbances. On April 12, 2012, initial vital signs were taken as follows: BP-120/80, T-36.2, PR-87, and RR-22. He had no complaints of pain in the post-operative site but still with limited bed mobility.

PEARSON ASSESSMENT Parameters P S Y C H O S O C I A L Day 1 (April 11, 2012) -Patient X is a 27 year old male -Presently residing at 2177 San Andres Extension, Sta. Ana, Manila -Roman Catholic and a Filipino citizen -works as a waiter at Alabang Country Club -He was admitted last April 2, 2012 @ 12:05am due to wound at right knee Conscious, coherent, and conversant Ericksons Psychosocial Theory: Intimacy Vs. Day 2 (April 12, 2012) -Patient X is a 27 year old male -Presently residing at 2177 San Andres Extension, Sta. Ana, Manila -Roman Catholic and a Filipino citizen -works as a waiter at Alabang Country Club -He was admitted last April 2, 2012 @ 12:05am due to wound at right knee Conscious, coherent, and conversant Ericksons Psychosocial Theory: Intimacy Vs.

Isolation

Isolation

E L I M I N A T I O N

-urinates and defecates on bed pan -voided approximately 500mL during the time of exposure -with straw colored urine as claimed -with no noted discomfort in urination -(-) BM -(-) Vomiting -with no noted diaphoresis E X E R C I S E -with limited bed mobility -performs assistive ROM exercises as instructed -sleeps for at least 8 hours a day -takes a nap occasionally as claimed -with no noted sleep disturbances -with noted snoring -stays on Male Service Ward B under pink service of Dr. Melvin Valera -with no side rails on bed -SO assists patient in activities -with Spanning external fixator with no drainage noted -with allergies to sea foods as claimed -no known allergies to medications -Medications: Penicillin G 5mL IV q6, Tramadol 50mg IV q8 for pain, Paracetamol 300mg IV q4, Cefuroxime 750mg IV q8, Ketorolac 30mg IV q6, and Etocoxib 120mg per tab OD

-urinates and defecates on bed pan -voided approximately 200mL during the time of exposure -with straw colored urine as claimed -with no noted discomfort in urination -(-) BM -(-) Vomiting -with no noted diaphoresis -with limited bed mobility -performs assistive ROM exercises as instructed -sleeps for at least 8 hours a day -takes a nap occasionally as claimed -with no noted sleep disturbances -with noted snoring -stays on Male Service Ward B under pink service of Dr. Melvin Valera -with no side rails on bed -SO assists patient in activities -with Spanning external fixator with no drainage noted -with allergies to sea foods as claimed -no known allergies to medications -Medications: Penicillin G 5mL IV q6, Tramadol 50mg IV q8 for pain, Paracetamol 300mg IV q4, Cefuroxime 750mg IV q8, Ketorolac 30mg IV q6, and Etocoxib 120mg per tab OD

A C T I V I T Y

a n d

S A F E T Y

O X Y G E N A T I O N N U T R I T I O N

- with well ventilated room - RR: 23cpm -PR: 88 bpm -BP: 120/90mmhg -with no complaints of DOB or SOB as claimed -no dyspnea noted -with normal capillary refill time (2-3secs.) -no noted cyanosis of nail beds and sclera -with an ongoing IVF of D5LRS 1L infusing well -on DAT diet -drinks at least 1L of fluids a day as claimed -with good appetite -with no difficulty of swallowing as claimed

- with well ventilated room - RR: 23cpm -PR: 87 bpm -BP: 120/80mmhg -with no complaints of DOB or SOB as claimed -no dyspnea noted -with normal capillary refill time (2-3secs.) -no noted cyanosis of nail beds and sclera -with an ongoing IVF of D5LRS 1L infusing well -on DAT diet -drinks at least 1L of fluids a day as claimed -with good appetite -with no difficulty of swallowing as claimed

DIAGNOSTIC EXAMINATIONS Ideal Examinations Physical exam: Painful swelling (edema) and bruising (ecchymosis) may be present around the patella. Extending or bending the knee may prove painful or impossible, depending upon the degree of bone displacement or associated injury to tendons and ligaments surrounding the knee. Nevertheless, the ability to bend or extend the knee does not rule out a patellar fracture. Following serious accidents, associated injuries may be present, which may include injuries to the hip or spine.

Tests: Standard x-rays with special views of the patella are usually sufficient to diagnose a patellar fracture. CT scan may be necessary for more difficult cases where x-rays are not definitive. Patella fractures themselves generally do not require MRI evaluation, but associated injuries to nearby tendons and ligaments may need to be evaluated by MRI studies. A standard xray of the unaffected (contralateral) knee may prove helpful by providing a comparison. Aspiration of fluid from the affected knee may be performed both to relieve pain and to check for the presence of fat, which often indicates the presence of a fracture. Actual Examinations Complete Blood Count (04-02-12) COMPONENTS Hemoglobin Mass Hematocrit Leukocytes Segmenters Lymphocytes Monocytes Eosinophils Platelet Count Blood Type MCV MCH MCHC RESULT 155 0.47 22.4 0.60 0.13 0.02 0.02 432 A+ 82 31 34 82-89 28-32 32-38 NORMAL NORMAL NORMAL NORMAL VALUES 127-183g/L 0.37-0.54 4.5-10 0.50-0.60 0.40-0.50 0.00-0.07 0.00-0.05 150-400 IMPLICATION NORMAL NORMAL INCREASED NORMAL DECREASED NORMAL NORMAL INCREASED

Complete Blood Count (04-08-12) COMPONENTS Hemoglobin Mass Hematocrit Leukocytes Segmenters Lymhocytes Monocytes Eosinophils Platelet Count Blood Type RESULT 113 0.34 14.9 0.55 0.45 0.04 0.02 256 A+ NORMAL VALUES 127-183g/L 0.37-0.54 4.5-10 0.50-0.60 0.40-0.50 0.00-0.07 0.00-0.05 150-400 DECREASED INCREASED NORMAL NORMAL NORMAL NORMAL NORMAL IMPLICATIONS

MCV MCH MCHC

87 28 36

82-89 28-32 32-38

NORMAL NORMAL NORMAL

Indications and Implications: The complete blood count or CBC test is used as a broad screening test to check for such disorders as anemia, infection, and many other diseases. It is actually a panel of tests that examines different parts of the blood and includes the following: White blood cell (WBC) count is a count of the actual number of white blood cells per volume of blood. Both increases and decreases can be significant. White blood cell differential looks at the types of white blood cells present. There are five different types of white blood cells, each with its own function in protecting us from infection. The differential classifies a person's white blood cells into each type: neutrophils (also known as segs, PMNs, granulocytes, grans), lymphocytes, monocytes, eosinophils, and basophils. Red blood cell (RBC) count is a count of the actual number of red blood cells per volume of blood. Both increases and decreases can point to abnormal conditions. Hemoglobin measures the amount of oxygen-carrying protein in the blood. Hematocrit measures the percentage of red blood cells in a given volume of whole blood. The platelet count is the number of platelets in a given volume of blood. Both increases and decreases can point to abnormal conditions of excess bleeding or clotting. Mean platelet volume (MPV) is a machine-calculated measurement of the average size of your platelets. New platelets are larger, and an increased MPV occurs when increased numbers of platelets are being produced. MPV gives your doctor information about platelet production in your bone marrow. Mean corpuscular volume (MCV) is a measurement of the average size of your RBCs. The MCV is elevated when your RBCs are larger than normal (macrocytic), for example in anemia caused by vitamin B12 deficiency. When the MCV is decreased, your RBCs are smaller than normal (microcytic) as is seen in iron deficiency anemia or thalassemias. Mean corpuscular hemoglobin (MCH) is a calculation of the average amount of oxygencarrying hemoglobin inside a red blood cell. Macrocytic RBCs are large so tend to have a higher MCH, while microcytic red cells would have a lower value.

Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the average concentration of hemoglobin inside a red cell. Decreased MCHC values (hypochromia) are seen in conditions where the hemoglobin is abnormally diluted inside the red cells, such as in iron deficiency anemia and in thalassemia. Increased MCHC values (hyperchromia) are seen in conditions where the hemoglobin is abnormally concentrated inside the red cells, such as in burn patients and hereditary spherocytosis, a relatively rare congenital disorder. Red cell distribution width (RDW) is a calculation of the variation in the size of your RBCs. In some anemias, such aspernicious anemia, the amount of variation (anisocytosis) in RBC size (along with variation in shape poikilocytosis) causes an increase in the RDW

Gram- Staining (04-07-12)

Specimen: Wound RESULT: RBC; (+) WBC; Few gram (+) cocci, singly; no spore-forming bacilli. Indication: Gram- Staining is a microbiological procedure that categorizes bacteria based on physical and chemical structure of their outer surface. This procedure is commonly used for detection and identification of bacteria that may infect the area.

ANATOMY AND PHYSIOLOGY OF THE ORGANS INVOLVED The thigh, leg, and foot constitute the lower limb. The bones of the lower limbs are considerably larger and stronger than comparable bones of the upper limbs because the lower limbs must support the entire weight of the body while walking, running, or jumping. Figure 1 illustrates features of the 30 bones of each lower limb.

The patella is flat, triangular bone, situated on the front of the knee-joint. It is usually regarded as a sesamoid bone, developed in the tendon of the Quadriceps femoris, and resembles these bones (1) in being developed in a tendon; (2) in its center of ossification presenting a knotty or tuberculated outline; (3) in being composed mainly of dense cancellous tissue. It serves to protect the front of the joint, and increases the leverage of the Quadriceps femoris by making it act at a greater angle. It has an anterior and a posterior surface three borders, and an apex. Surfaces.The anterior surface is convex, perforated by small apertures for the passage of nutrient vessels, and marked by numerous rough, longitudinal stri. This surface is covered, in the recent state, by an expansion from the tendon of the Quadriceps femoris, which is continuous below with the superficial fibers of the ligamentum patell. It is separated from the integument by a bursa. The posterior surface presents above a smooth, oval, articular area, divided into two facets by a vertical ridge; the ridge corresponds to the groove on the patellar surface of the femur, and the facets to the medial and lateral parts of the same surface; the lateral facet is the broader and deeper. Below the articular surface is a rough, convex, non-articular area, the lower half of which gives attachment to the ligamentum patell; the upper half is separated from the head of the tibia by adipose tissue. Borders.The base or superior border is thick, and sloped from behind, downward, and forward: it gives attachment to that portion of the Quadriceps femoris which is derived from the Rectus femoris and Vastus intermedius. The medial and lateral borders are thinner and converge below: they give attachment to those portions of the Quadriceps femoris which are derived from the Vasti lateralis and medialis. Apex.The apex is pointed, and gives attachment to the ligamentum patell. Structure.The patella consists of a nearly uniform dense cancellous tissue, covered by a thin compact lamina. The cancelli immediately beneath the anterior surface are arranged parallel with it. In the rest of the bone they radiate from the articular surface toward the other parts of the bone. PATHOPHYSIOLOGY I.ALGORITHM

CAUSE: Motor Vehicular Accident

Direct trauma to the leg and patella

Inflammation and swelling occurs in the area due to release of histamine, kinins and bradykinins to compensate invasion of microorganisms and further wound destruction

Tissue destruction and laceration occurs Bone destruction occurs due to direct pressure on the area that precedes to fracture, displacement or dislocation Bleeding occurs in the open wound area

Blood vessels and marrow of the bone becomes disrupted Spasms and contractions occur in the area of injury

Clinical Manifestations: Pain Deformity Avulsion Loss of sensation Crepitus Swelling and discoloration

Explanation Since trauma was due to motor vehicular accident that had caused great impact and pressure to the body most especially in the leg, fracture of the patellar bone took place. As an initial reaction, inflammation is occurring massively to compensate trauma thereby releasing chemicals that trigger activation of the immune response to fight against foreign bodies. Moreover, massive tissue destruction was obviously seen, causing bleeding and pain in the area that is precipitated by movement and other factors. Since there is bleeding, the blood vessels thereby constrict to prevent further bleeding, impairing its normal function to supply blood to the area. Since the bone was destroyed, the bone marrow was destroyed causing impaired in vital functioning such as hematopoeisis that may precede to low levels of RBCs in the body, that may compromise tissue oxygenation. Spastic sensations occur in the surrounding muscles of the fracture, as a result of compensating further blood loss and pain sensation. Signs and symptoms manifest as follows to confirm fracture: pain in the area, deformity, avulsion, loss of sensation, numbness, crepitus and marked swelling and discoloration. MEDICAL AND SURGICAL MANAGEMENT IDEAL MEDICAL MANAGEMENT Early, systemic, wide-spectrum antibiotic therapy is necessary for the treatment of open fractures. The bead pouch technique delivers antibiotics locally and prevents secondary

wound contamination. The open fracture wound should be thoroughly dbrided. To avoid the complication of gas gangrene, the wound should not be closed. Extensive soft-tissue damage may necessitate the use of local or free flaps. Techniques of fracture stabilization depend on the anatomic location of the fracture and the characteristics of the injury. Early bone grafting and supplemental procedures may be needed to achieve healing. Management of the infected open fracture is based on radical dbridement, skeletal stabilization, microbial-specific antibiotics, soft-tissue coverage, and reconstruction of bone defects. Antibiotics were administered for 48-hour intervals and were repeated with subsequent wound debridement. They concluded the most important variable in reducing wound infection was utilizing delayed wound closure rather than primary closure. Patzakis and Wilkins retrospectively reviewed their experience with various antibiotic regimens including penicillin, cephalothin, and cefamandole as well as a control arm with no antibiotics. Assess for circulatory impairment (cyanosis, coldness, mottling, decreased peripheral pulses, positive blanch sign, edema not relieved by elevation, pain or cramping). Assess for neurologic impairment (lack of sensation or movement, pain, or tenderness, or numbness and tingling). Administer analgesic medications. Explain fracture management to the child and family. Depending on the type of break and its location, repair (by realignment or reduction) may be made by closed or open reduction followed by immobilization with a splint, traction or a cast. Maintain skin integrity and prevent breakdown. Institute appropriate measures for cast and appliance care.

ACTUAL MEDICAL MANAGEMENT Pharmacologic Therapy DOSAGE 5mL 50mg 300mg 750mg 30mg 120mg ROUTE IV IV IV IV IV Oral FREQUENCY Every 6 hours Every 8 hours Every 4 hours Every 8 hours Every 6 hours Once a day INDICATION Antibacterial Pain reliever Antipyretic Antibacterial Antibacterial Pain reliever

NAME OF DRUG Penicillin G Tramadol Paracetamol Cefuroxime Ketorolac Etocoxib

Intravenous fluids were also given to adjunct cell nourishment and prevent dehydration and compensate to any blood lost. On DAT diet but as much as possible it should have balance and adequate protein intake to facilitate faster wound healing. Calcium-rich foods such as dairy products, milk, and vegetables to facilitate faster bone regeneration and healing. Since the patient has Spanning external fixator, complete bed rest and safety must be ensured so as to prevent aggravation of the condition, displacement and further dysfunction of the fixator.

IDEAL SURGICAL MANAGEMENT Treatment of patellar fractures is determined by displacement. Non-displaced fractures are typically treated without surgery (conservative treatment) by splinting the knee in extension (straight) for 4 to 6 weeks. Since the patella does not bear weight, there is no weight bearing restriction. Crutches, canes, or a walker may be used to aid in walking. Exercise of other leg muscles is encouraged while wearing the splint. After 4 to 6 weeks when the fracture is considered healed, physical therapy to regain range of motion is begun.

Displaced fractures of the patella are treated surgically to stabilize the fragments. Metal pins, screws, wires, or plates may be used to hold pieces of bone together. In cases in which too much bone has shattered, a partial or complete removal (excision) of the patella itself (patellectomy) may be performed. Surgeons generally retain as much of the original patella as possible to aid the knee in maintaining strength.

Following surgery, the knee usually will be immobilized in a brace. Weight bearing and walking are permitted as tolerated as soon as possible after surgery. Exercises to strengthen important muscles of the leg are begun immediately and range of motion exercises are begun at 4 to 6 weeks after surgery. A healed fracture and a strong quadriceps muscle permit a return to vigorous activity in 6 months. The management of these fractures is essentially the same as for patellar fractures without associated prosthetic arthoplasty. If the fracture is minimally displaced or nondisplaced, conservative treatment is recommended. Significantly displaced fractures with disruption of the extensor mechanism should be operated upon if possible. The actual procedure performed will depend upon the condition of the bone. If the fracture is amenable to fixation and the prosthesis is not loose, simply fixing the fracture should be considered. However, if the prosthesis is loose, a decision must be made as to whether the fracture can be fixed, followed by reinsertion of a prosthesis, or whether patellectomy may not be the best solution

ACTUAL SURGICAL MANAGEMENT Tension Bond Wiring Application (4-02-12) - modified anterior tension band technique is indicated for both transverse and comminuted fractures of the patella; - for maximal strength, wires are placed on tension surface of bone (anterior surface), as compared to circumferential cerclage wiring; - frx fragments are opposed from tension of the figure of 8 wire passed thru insertions of the quadriceps tendon and patellar ligament; - remember Sharpey's fibers provide the strongest site of fixation; - two K wires or 4 mm cancellous lag scres are incorporated into figure of 8 wire to augment anchorage of cerclage wire; - if there is too much comminution for secure ORIF, but a major (usually superior) fragment with a substantial amount of normal articular cartilage is present, partial patellectomy is the appropriate approach; -Pre- Operative considerations: - position patient supine w/ bump under knee; - equipment: several large towel clamps, 14 gauge needle, 20 and 22 gauge wire, and K wires; - be sure to explain to the patient that eventual hardware removal may be necessary due to pain; - Incision: - approached via a midline longitudinal incision or a transverse incision; - transverse incision gives more cosmetic result, esp in young patients; - be careful to avoid areas of contused skin or abrasions; - soft tissue overlying patella is often injured from direct compression or abrasion at the time of the fracture; - large fracture hematoma frequently develops, further compromising soft tissues; -Exposure: - expose entire anterior surface of patella, and the quadriceps and patellar tendon; - expose fracture & identify any defect in the extensor mechanism;

- defects in retinaculum will extend several cm medially or laterally, or both; - therefore extend exposure with a medial parapatellar capsular incision for a short distance proximally and medially. - need enough release to allow adequate palpation & partial visualization of frx site to ensure anatomical reduction of the articular surface; - look for osteochondral fragments, esp in trochlear groove; - it is not necessary to create a large medial arthrotomy, such as would be necessary for eversion and full visualization of the articular surface - small arthrotomy can be closed after fixation; * before proceding, place simple sutures in the torn retinaculum on either side of the fracture, and clamp the suture ends (do not tie); - the sutures are not tied at this point, becuase this would interfere w/ visualization of the fracture fragments; - placing sutures across the torn retinaculum will facilitate their repair, after the fracture has been fixed; - Reduction: - integrity of the fragments is evaluated; - often there is comminution that was not recognized on the radiographs; - decision regarding whether to proceed with an ORIF, partial patellectomy, or total patellectomy is then re-evaluated; - ORIF of transverse fractures with little or no comminution are most amenable to treatment with open reduction and internal fixation; - two large towel clips may assist w/ the reduction; - frx w/ small amount of comminution can often be first converted to a simple transverse frx by lag-screw fixation of comminuted portion; - provisional stabilization of the fracture can usually be obtained with one or two bonereduction forceps or with K wires; - once articular reduction is assured, proceed w/ hardware insertion; Wound Debridement -medical removal of dead, damaged or infected tissue to improve the healing potential of the healthy tissues. Indications: To prevent bacterial growth and multiplication in the wound that may cause further complications. If there is an excessive inflammatory response, which results from the presence of necrotic bodies that may worsen the condition. Application of Spanning External Fixator (04-08-12) In this kind of reduction, holes are drilled into uninjured areas of bones around the fracture and special bolts or wires are screwed into the holes. Outside the body, a rod or a curved piece of metal with special ball-and-socket joints joins the bolts to make a rigid support. The fracture can be set in the proper anatomical configuration by adjusting the ball-and-socket joints. Since the bolts pierce the skin, proper cleaning to prevent infection at the site of surgery must be performed. Installation of the external fixator is performed in an operating room, normally under general anesthesia. Removal of the external frame and bolts usually requires special wrenches and can be done with no anesthesia in an office visit. External fixation is usually used when internal fixation is contraindicated- often to treat open fractures, or as a temporary solution.

External fixation is also used in limb lengthening. People with short limbs can have, for example, legs lengthened. In most cases the thigh bone (femur) is cut diagonally in a surgical procedure under anesthesia. External fixator pins or wires (as above) are placed each side of the 'man made fracture' and the external metal apparatus is used to very gradually push the two sides of the bone apart millimeter by millimeter day by day and week by week. Bone is extremely clever tissue and will gradually grow into the small gap created by this 'distraction' technique. Such a process can take many months. In most cases it may be necessary for the external fixator to be in place for many weeks or even months. Most fractures heal in between 6 and 12 weeks. However, in complicated fractures and where there are problems with the healing of the fracture this may take longer still. It is known that bearing weight through fracture by walking on it, for example, with the added support of the external fixator frame actually helps fractures to heal.

PROMOTIVE AND PREVENTIVE MANAGEMENT PROMOTIVE Encourage increase intake of protein rich foods such as lean meat, fish, vegetables to facilitate faster wound healing and tissue regeneration. Include also Calcium-rich foods such as dairy products to facilitate faster bone mineralization and faster bone remodeling.

Increase Vitamin C and Zinc intake found in green leafy vegetables and fruits to boost immune system and resist against infection. Encourage assistive ROM exercises in bed to prevent development of complications such as pneumonia and atelectasis, contractures and to promote proper lung expansion and ventilation. Encourage adherence to prescribed medications to meet the desired therapeutic outcome and faster recuperation from the disease. Encourage aseptic and proper wound care to promote faster wound healing.

PREVENTIVE Prevent circulatory impairment by assessing pulses, color and temperature, and by reporting changes immediately. Prevent nerve compression syndromes by testing sensation and motor function, including subjective symptoms of pain, muscular weakness, burning sensation, limited ROM, and altered sensation. Correct alignment to alleviate pressure if appropriate, and notify the health care provider. Prevent compartment syndrome by assessing for muscle weakness and pain out of proportion to injury. Early detection is critical to prevent tissue damage. Causes of compartment syndrome include tight dressings or casts, haemorrhage. trauma, burns and surgery. Treatment entails pressure relief, which sometimes require performing a fasciotomy. Prevent infection, including osteomyelitits, bys using infection control measures Prevent renal calculi by encouraging fluids, monitoring I&O, and mobilizing the client as much as possible. Prevent pulmonary emboli by carefully monitoring with multiple fractures. Emboli generally occur within the first 24 hours.

DISCHARGE PLAN CRITERIA

MEDICATIONS

-Encourage adherence to prescribed pharmacologic regimen. -Note dosage, route, frequency, action, contraindication and side effects of drugs to prevent misuse and abuse and to achieve therapeutic level of therapy.

EXERCISE

TREATMENT

HEALTH TEACHINGS

-Engage in passive-assistive range of motion exercises to promote proper circulation, prevent contractures and complications associated with immobility. -Encourage participation in Isometric exercises to develop muscle strength through contractions without any vigorous movement. This way muscle strength is gradually built up while minimizing the risk of further damage. -Encourage collaboration with a Physical Therapist to start Rehabilitative Regimen. Pain Management -Provide non-pharmacologic interventions such as application of warm compress in the area to decrease swelling. -Position the affected site to comfort level, resting on the bed to allow relaxation and prevent spasms. -Take prescribed pain-relievers to ease the pain. -Encourage vigilant adherence to prescribed therapeutic regimen to prevent relapse. -Instruct strict aseptic technique in wound cleaning providing Povidone Iodine solution in disinfecting wound. -Encourage high-protein intake and high in Vitamin C and Zinc to facilitate faster wound healing as well as bone ossification and regeneration. -Encourage bed rest to preserve energy and to prevent movement of affected extremity. -The patient is instructed to go back at the hospital for follow up check-up, evaluation and additional information regarding management of condition. -Encourage high-protein diet which is found in lean meat, vegetables, fishes and eggs to facilitate faster wound healing process. -Encourage increase in calcium intake found in milk, dairy products to help the bones in ossification and faster remodeling. -Encourage increase intake of Vitamin C and Zinc found in fruits to boost immune system and resist against infections.

OUT-PATIENT DEPARTMENT DIET

CUES Subjective: Sumasakit paminsan minsan pero ngayon konti na lang. Noong una masakit talaga sobra as verbalized by the patient Objective: Limited range of motion Inability to purposely move within the environme nt Decreased muscle strength

NURSING DIAGNOSIS Problem: Impaired Physical Mobility Etiology: r/t pain secondary to immobilization Signs & Symptoms: Limited range of motion Inability to purposely move within the environme nt Decreased muscle strength

SCIENTIFIC BACKGROUND

NURSING INERVENTIONS Independent: Trauma 1. Assess degree of Goal: After, the patient immobility produced Tissue destruction will regain and by injury and and bone fracture maintain mobility at the treatment and note highest possible level clients perception of immobility Inflammation and Objectives: 2. Encourage swelling in the Maintain participation in area position of diversional activities. function Maintain a stimulating Increase Muscle spasms environment strength and and pain in the function of area 3. Instruct client in affected and active, or assist with compensatory Decreased muscle passive ROM body parts strength exercises of affected and unaffected Demonstrate extremities techniques that Limited enable movement as a 4. Encourage use of resumption of compensatory isometric exercises, activities, mechanism to starting with the especially ADL avoid pain unaffected limb Verbalize 5. Provide footboard and understanding trochanter as of the situation appropriate and individual treatment 6. Place in supine regimen and position periodically

GOALS & OBJECTIVES April 11, 2012

RATIONALE

EVALUATION April 11, 2012

1. Client may be restricted by self-view out of proportion with actual physical limitations, requiring information and interventions to promote progress toward wellness 2. Provides opportunity for release of energy, refocuses attention, enhances clients sense of self-control and self-worth, and aids in reducing social isolation 3. Increases blood flow to muscles and bone to improve muscle tone; maintain joint mobility; and prevent contractures, atrophy, and calcium resorption from disuse 4. Isometrics contract muscles without bending joints or

Level of Attainment:

Evidences:

safety measures

if possible when traction is used to stabilize lower limb fractures 7. Assist with and encourage self-care activities such as bathing, shaving and oral hygiene 8. Monitor BP with resumption of activity. Note reports of dizziness 9. Reposition periodically and encourage coughing and deep breathing exercises 10. Encourage increased fluid intake of 23L/day within cardiac tolerance 11. Provide diet high in proteins, carbohydrates, vitamins, minerals 12. Increase the amount of fiber in the diet. Limit gas-forming

moving limbs and help maintain muscle strength and mass 5. Useful in maintaining functional position of extremities and preventing complications 6. Reduce risk of flexion contracture of hip 7. Improves muscle strength and circulation, enhances client control in situation, and promotes self-directed wellness 8. Postural hypotension is a common problem following prolonged bedrest 9. Prevents incidence of skin and respiratory complications 10. Keeps the body well hydrated, decreasing risk of urinary infection and stone formation, and helps to

foods Dependent: 1. Consult with physical or occupational therapist or rehabilitation therapist 2. Refer to dietician or nutrition team, as indicated 3. Initiate bowel program stool softeners , enema or laxatives as indicated 4. Refer to psychiatric clinical nurse specialist or therapist as indicated

prevent constipation 11. For rapid healing 12. Adding bulk to stool helps prevent constipation. Gasforming foods may cause abdominal distention 1. Useful in creating aggressive individualized activity or exercise program 2. Client with fractures may have special considerations 3. Important to promote regular bowel evacuation and prevent constipation 4. Client may require more intensive treatment to deal with reality of current condition

CUES Subjective: Sumasakit paminsan minsan pero ngayon konti na lang. Noong una masakit talaga sobra as verbalized by the patient Objective: Pain scale of 5/10 Narrowe d focus Alternati on in muscle tone Limited range of motion

NURSING DIAGNOSIS Problem: Acute Pain Etiology: r/t presence of immobility device secondary to physical injury of the soft tissues and nerve trauma Signs & Symptoms: Pain scale of 5/10 Narrowe d focus Alternati on in muscle tone

SCIENTIFIC BACKGROUND Trauma

GOALS & OBJECTIVES April 11, 2012

Tissue destruction and Goal: After, the bone fracture patient will verbalize relief of pain Inflammation and swelling in the area Objectives: Display relaxed manner, able to participate in activities, and sleep and rest appropriately Irritation of nerve endings and stimulation of pain receptors Demonstrate use of relaxation skills and diversional activities

NURSING INERVENTIONS Independent: 1. Maintain immobilization of affected part by means of bed rest. 2.Elevate and support injured extremity

RATIONALE 1.Relieves pain and prevents bone displacement/extension of tissue injury 2.Promotes venous return, decreases edema, and may reduce pain 3.Can increase discomfort by enhancing heat production in the drying cast 4.Maintains body warmth due to pressure of bed linens on affected parts 5.Influences choice of, and monitors effectiveness of interventions

EVALUATION April 11, 2012 Level of Attainment:

Evidences:

Disruption of blood supply, vasoconstriction and destruction of marrow in the bone

3.Avoid use of plastic sheets/pillows under the limbs 4.Elevate bed covers and keep linens off toes 5. Evaluate and document reports of pain or discomfort, noting location and characteristics. Note nonverbal pain cues, such as changes in vital signs and behaviors 6.Encourage client to discuss problems related to injury 7.Perform and supervise

PAIN

6.Helps alleviate anxiety 7. Maintains strength and mobility of

passive or active ROM exercises 8.Provide alternative comfort measures (massage, backrub or position changes) 9.Provide emotional support and encourage use of stress management techniques (DBE, guided imagery, therapeutic touch. Dependent: 1.Administer medications, as indicated 2.Maintain continuous IV. Maintain safe and effective infusions and equipment

unaffected muscles and facilitates resolution of inflammation I injured tissues. 8.Improves general circulation; reduces areas of local pressure and muscle fatigue 9.Promotes sense of control and may enhance coping abilities in the management of the stress of traumatic injury and pain 1.Given to reduce pain and muscle spasms 2.Permit early mobilization and physical therapy