case study poc
TRANSCRIPT
-
7/28/2019 Case Study POC
1/23
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
-
7/28/2019 Case Study POC
2/23
TABLE OF CONTENTS
PAGE
FRONTPAGE i
TABLE OF CONTENTS ii
I. INTRODUCTION AND OBJECTIVESII. PATIENTS PERSONAL DATA
(NURSING HISTORY OF PAST AND PRESENT ILLNESS)
III. PEA/RSON ASSESSMENTIV. DIAGNOSTIC PROCEDUREV. ANATOMY AND PHYSIOLOGY
VI. PATHOPHYSIOLOGYA. ALGORITHMB. EXPLANATION
VII. MANAGEMENTA. MEDICAL-SURGICALB NURSING CARE PLAN
-
7/28/2019 Case Study POC
3/23
I.INTRODUCTION
An open fracture is one where there is a communication between the fracture and theoutside 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 theoutside 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 relativelylittle soft tissue damage, and only moderate crushing or comminution.
Major / Grade III - wounds of moderate or massive size with considerable soft tissueinjury 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
i ti
-
7/28/2019 Case Study POC
4/23
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 openfracture Type III B with comminuted patellar fracture;
Apply nursing care appropriately with proper knowledge, attitude and skills in caring formy patient;
Establish a therapeutic communication relationship between the client and student nursein 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 patientsditi
-
7/28/2019 Case Study POC
5/23
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 anavulsion 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 D5LRS1L 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 tabOD. 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 hisRight 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 wasdone 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
-
7/28/2019 Case Study POC
6/23
Isolation Isolation
E
L
I
M
IN
A
T
I
O
N
-urinates and defecates onbed pan
-voided approximately
500mL during the time ofexposure
-with straw colored urine as
claimed
-with no noted discomfortin urination
-(-) BM
-(-) Vomiting-with no noted diaphoresis
-urinates and defecates onbed pan
-voided approximately
200mL during the time ofexposure
-with straw colored urine as
claimed
-with no noted discomfortin urination
-(-) BM
-(-) Vomiting-with no noted diaphoresis
A E
C X
T a E
I n R
V d C
-with limited bed mobility
-performs assistive ROM
exercises as instructed-sleeps for at least 8 hours a
-with limited bed mobility
-performs assistive ROM
exercises as instructed-sleeps for at least 8 hours a
-
7/28/2019 Case Study POC
7/23
O
X
YG
E
N
A
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 nailbeds and sclera
- 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 nailbeds and sclera
N
U
T
R
I
T
I
O
N
-with an ongoing IVF ofD5LRS 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 an ongoing IVF ofD5LRS 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
-
7/28/2019 Case Study POC
8/23
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 associatedinjuries to nearby tendons and ligaments may need to be evaluated by MRI studies. A standard x-
ray 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 checkfor the presence of fat, which often indicates the presence of a fracture.
Actual Examinations
Complete Blood Count (04-02-12)
COMPONENTS RESULT NORMAL VALUES IMPLICATION
Hemoglobin Mass 155 127-183g/L NORMAL
Hematocrit 0.47 0.37-0.54 NORMAL
Leukocytes 22.4 4.5-10 INCREASED
Segmenters 0.60 0.50-0.60 NORMAL
Lymphocytes 0.13 0.40-0.50 DECREASED
Monocytes 0.02 0.00-0.07 NORMAL
http://www.mdguidelines.com/x-rayhttp://www.mdguidelines.com/computerized-tomographyhttp://www.mdguidelines.com/magnetic-resonance-imaginghttp://www.mdguidelines.com/aspirationhttp://www.mdguidelines.com/pain-in-limbhttp://www.mdguidelines.com/pain-in-limbhttp://www.mdguidelines.com/aspirationhttp://www.mdguidelines.com/magnetic-resonance-imaginghttp://www.mdguidelines.com/computerized-tomographyhttp://www.mdguidelines.com/x-ray -
7/28/2019 Case Study POC
9/23
MCV 87 82-89 NORMAL
MCH 28 28-32 NORMAL
MCHC 36 32-38 NORMAL
Indications and Implications:
The complete blood count or CBC test is used as a broad screening test to check for suchdisorders 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 pervolume of blood. Both increases and decreases can be significant.
White blood cell differential looks at the types of white blood cells present. There are fivedifferent 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 ofblood Both increases and decreases can point to abnormal conditions
http://labtestsonline.org/understanding/conditions/anemiahttp://labtestsonline.org/understanding/analytes/wbchttp://labtestsonline.org/understanding/analytes/differentialhttp://labtestsonline.org/glossary/neutrophilhttp://labtestsonline.org/glossary/lymphocytehttp://labtestsonline.org/glossary/monocytehttp://labtestsonline.org/glossary/eosinophilhttp://labtestsonline.org/glossary/basophilhttp://labtestsonline.org/understanding/analytes/rbchttp://labtestsonline.org/understanding/analytes/rbchttp://labtestsonline.org/glossary/basophilhttp://labtestsonline.org/glossary/eosinophilhttp://labtestsonline.org/glossary/monocytehttp://labtestsonline.org/glossary/lymphocytehttp://labtestsonline.org/glossary/neutrophilhttp://labtestsonline.org/understanding/analytes/differentialhttp://labtestsonline.org/understanding/analytes/wbchttp://labtestsonline.org/understanding/conditions/anemia -
7/28/2019 Case Study POC
10/23
Specimen: Wound
RESULT: RBC; (+) WBC; Few gram (+) cocci, singly; no spore-forming bacilli.
Indication: Gram- Staining is a microbiological procedure that categorizes bacteria based onphysical and chemical structure of their outer surface. This procedure is commonly used fordetection and identification of bacteria that may infect the area.
-
7/28/2019 Case Study POC
11/23
The patella is flat, triangular bone, situated on the front of the knee-joint. It is usuallyregarded as a sesamoid bone, developed in the tendon of the Quadriceps femoris, and resembles
-
7/28/2019 Case Study POC
12/23
Direct trauma to the leg and patella
Inflammation and swelling
occurs in the area due torelease of histamine, kinins
and bradykinins tocompensate invasion of
microorganisms and further
wound destruction
Tissue destruction and lacerationoccurs
Bone destruction occurs due to
direct pressure on the area thatprecedes to fracture, displacement
or dislocation
Bleeding occurs in the open wound
area
Blood vessels and marrow of the bonebecomes disrupted
Spasms and contractions occur in the
area of injury
-
7/28/2019 Case Study POC
13/23
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 stabilizationdepend 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 ofbone defects.
Antibiotics were administered for 48-hour intervals and were repeated with subsequentwound debridement. They concluded the most important variable in reducing wound
infection was utilizing delayed wound closure rather than primary closure. Patzakis andWilkins 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 peripheralpulses, positive blanch sign, edema not relieved by elevation, pain or cramping).
Assess for neurologic impairment (lack of sensation or movement, pain, or tenderness, ornumbness 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 castand appliance care
-
7/28/2019 Case Study POC
14/23
Displaced fractures of the patella are treated surgically to stabilize the fragments. Metalpins, 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 thepatella itself (patellectomy) may be performed. Surgeons generally retain as much of theoriginal patella as possible to aid the knee in maintaining strength.
Following surgery, the knee usually will be immobilized in a brace. Weight bearing andwalking 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 strongquadriceps muscle permit a return to vigorous activity in 6 months.
The management of these fractures is essentially the same as for patellar fractureswithout associated prosthetic arthoplasty. If the fracture is minimally displaced or non-
displaced, conservative treatment is recommended. Significantly displaced fractures with
disruption of the extensor mechanism should be operated upon if possible. The actualprocedure performed will depend upon the condition of the bone.
If the fracture is amenable to fixation and the prosthesis is not loose, simply fixing thefracture should be considered. However, if the prosthesis is loose, a decision must bemade 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
http://www.mdguidelines.com/reduction-of-fracture-or-dislocationhttp://www.mdguidelines.com/reduction-of-fracture-or-dislocation -
7/28/2019 Case Study POC
15/23
- 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 foreversion 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 fracturehas 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;
-
7/28/2019 Case Study POC
16/23
External fixation is also used in limb lengthening. People with short limbs can have, forexample, 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 placedeach 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, forexample, with the added support of the external fixator frame actually helps fractures to
heal.
-
7/28/2019 Case Study POC
17/23
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 suchas pneumonia and atelectasis, contractures and to promote proper lung expansion andventilation.
Encourage adherence to prescribed medications to meet the desired therapeutic outcomeand 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 byreporting changes immediately.
Prevent nerve compression syndromes by testing sensation and motor function, includingsubjective 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 ofproportion to injury. Early detection is critical to prevent tissue damage.
Causes of compartment syndrome include tight dressings or casts, haemorrhage.trauma, burns and surgery.
-
7/28/2019 Case Study POC
18/23
MEDICATIONS -Encourage adherence to prescribed pharmacologic regimen.
-Note dosage, route, frequency, action, contraindication and
side effects of drugs to prevent misuse and abuse and toachieve therapeutic level of therapy.
EXERCISE -Engage in passive-assistive range of motion exercises to
promote proper circulation, prevent contractures andcomplications associated with immobility.
-Encourage participation in Isometric exercises to develop
muscle strength through contractions without any vigorousmovement. 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.
TREATMENT Pain Management
-Provide non-pharmacologic interventions such as applicationof warm compress in the area to decrease swelling.
-Position the affected site to comfort level, resting on the bedto allow relaxation and prevent spasms.-Take prescribed pain-relievers to ease the pain.
HEALTH TEACHINGS -Encourage vigilant adherence to prescribed therapeutic
regimen to prevent relapse.
-Instruct strict aseptic technique in wound cleaning providing
-
7/28/2019 Case Study POC
19/23
CUES NURSINGDIAGNOSIS
SCIENTIFICBACKGROUND
GOALS &OBJECTIVES
NURSINGINERVENTIONS
RATIONALE EVALUATION
Subjective:
Sumasakitpaminsan minsanpero ngayon konti
na lang. Noong
una masakittalaga sobra as
verbalized by thepatient
Objective:
Limitedrange of
motion
Inability topurposely
movewithin the
environme
nt
Decreasedmuscle
strength
Problem: ImpairedPhysical Mobility
Etiology:
r/t pain secondary
to immobilizationSigns &
Symptoms:
Limitedrange of
motion
Inability topurposelymove
within theenvironme
nt
Decreasedmuscle
strength
Trauma
Tissue destruction
and bone fracture
Inflammation andswelling in the
area
Muscle spasms
and pain in thearea
Decreased muscle
strength
Limited
movement as acompensatory
mechanism toavoid pain
April 11, 2012
Goal: After, the patientwill regain and
maintain mobility at the
highest possible level
Objectives:
Maintainposition of
function
Increasestrength andfunction of
affected andcompensatory
body parts
Demonstratetechniques thatenable
resumption ofactivities,
especially ADL
Verbalizeunderstandingof the situation
and individualtreatment
regimen and
Independent:1. Assess degree of
immobility producedby injury and
treatment and note
clients perception of
immobility
2. Encourageparticipation indiversional activities.
Maintain astimulating
environment
3. Instruct client inactive, or assist with
passive ROMexercises of affectedand unaffected
extremities
4. Encourage use ofisometric exercises,starting with the
unaffected limb
5. Provide footboard andtrochanter as
appropriate
6. Place in supineposition periodically
1. Client may berestricted by self-viewout of proportion with
actual physical
limitations, requiringinformation and
interventions topromote progress
toward wellness
2. Provides opportunityfor release of energy,
refocuses attention,enhances clients sense
of self-control andself-worth, and aids in
reducing socialisolation
3. Increases blood flowto muscles and bone to
improve muscle tone;maintain joint
mobility; and preventcontractures, atrophy,
and calcium resorption
from disuse
4.
Isometrics contractmuscles without
bending joints or
April 11, 2012
Level ofAttainment:
Evidences:
-
7/28/2019 Case Study POC
20/23
safety measures if possible whentraction is used to
stabilize lower limb
fractures
7. Assist with andencourage self-care
activities such asbathing, shaving and
oral hygiene
8. Monitor BP withresumption of
activity. Note reports
of dizziness
9. Repositionperiodically and
encourage coughing
and deep breathingexercises
10.Encourage increasedfluid intake of 2-3L/day within cardiac
tolerance
11.Provide diet high inproteins,carbohydrates,
vitamins, minerals
12.Increase the amountof fiber in the diet.Limit gas-forming
moving limbs and helpmaintain muscle
strength and mass
5. Useful in maintainingfunctional position ofextremities and
preventingcomplications
6. Reduce risk of flexioncontracture of hip
7. Improves musclestrength andcirculation, enhances
client control insituation, and
promotes self-directed
wellness8. Postural hypotension
is a common problem
following prolonged
bedrest
9. Prevents incidence ofskin and respiratory
complications
10.Keeps the body wellhydrated, decreasing
risk of urinaryinfection and stoneformation, and helps to
-
7/28/2019 Case Study POC
21/23
foods
Dependent:
1. Consult withphysical or
occupationaltherapist or
rehabilitationtherapist
2. Refer to dieticianor nutrition team,
as indicated
3. Initiate bowelprogramstool
softeners , enemaor laxatives as
indicated
4. Refer topsychiatricclinical nurse
specialist ortherapist as
indicated
prevent constipation
11.For rapid healing12.Adding bulk to stool
helps preventconstipation. Gas-
forming foods maycause abdominal
distention
1. Useful in creatingaggressive
individualizedactivity or exercise
program
2. Client withfractures may have
specialconsiderations
3. Important topromote regularbowel evacuation
and prevent
constipation
4. Client may requiremore intensive
treatment to deal
with reality ofcurrent condition
-
7/28/2019 Case Study POC
22/23
CUES NURSING
DIAGNOSIS
SCIENTIFIC
BACKGROUND
GOALS &
OBJECTIVES
NURSING
INERVENTIONS
RATIONALE EVALUATION
Subjective:
Sumasakitpaminsan
minsan perongayon konti na
lang. Noong unamasakit talaga
sobra asverbalized by
the patient
Objective:
Painscale of
5/10
Narrowed focus
Alternation in
muscle
tone
Limitedrange of
motion
Problem: Acute
Pain
Etiology:r/t presence of
immobilitydevice
secondary tophysical injury
of the softtissues and nerve
traumaSigns &
Symptoms:
Painscale of5/10
Narrowed focus
Alternation in
muscle
tone
Trauma
Tissue destruction and
bone fracture
Inflammation and
swelling in the area
Disruption of blood
supply,vasoconstriction and
destruction of marrowin the bone
Irritation of nerve
endings andstimulation of pain
receptors
PAIN
April 11, 2012
Goal: After, the
patient will verbalizerelief of pain
Objectives:
Displayrelaxed
manner, ableto participate
in activities,and sleep and
rest
appropriately
Demonstrateuse of
relaxationskills and
diversional
activities
Independent:
1. Maintainimmobilization of
affected part by means ofbed rest.
2.Elevate and support
injured extremity
3.Avoid use of plastic
sheets/pillows under the
limbs
4.Elevate bed covers and
keep linens off toes
5. Evaluate and documentreports of pain or
discomfort, noting
location andcharacteristics. Notenonverbal pain cues, such
as changes in vital signs
and behaviors
6.Encourage client todiscuss problems related
to injury
7.Perform and supervise
1.Relieves pain and
prevents bonedisplacement/extension of
tissue injury
2.Promotes venous return,
decreases edema, and
may reduce pain
3.Can increase discomfortby 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
6.Helps alleviate anxiety
7. Maintains strengthand mobility of
April 11, 2012
Level of
Attainment:
Evidences:
-
7/28/2019 Case Study POC
23/23
passive or active ROM
exercises
8.Provide alternativecomfort measures
(massage, backrub or
position changes)
9.Provide emotional
support and encourageuse of stress management
techniques (DBE, guidedimagery, therapeutic
touch.
Dependent:
1.Administermedications, as
indicated
2.Maintain continuousIV. Maintain safe andeffective infusions
and equipment
unaffected musclesand facilitates
resolution ofinflammation I injured
tissues.
8.Improves general
circulation; reducesareas of local pressure
and muscle fatigue
9.Promotes sense ofcontrol and may
enhance copingabilities in the
management of thestress of traumatic
injury and pain
1.Given to reduce pain
and muscle spasms
2.Permit early
mobilization and physical
therapy