FRACTURE CLOSED COMPLETE MIDDLE 3RD FEMUR LEFT

Chapter I

INTRODUCTION

A femur fracture is a crack or complete break in the bone of your thigh. A

significant amount of force is required to fracture this large bone. The fracture can be

caused by direct or indirect trauma. Direct trauma involves a forceful blow to the thigh.

Indirect trauma involves twisting the thigh or a violent muscle contraction.

With its large size, the femur can fracture in many different areas. Fractures of

the head of the femur are commonly associated with hip dislocations. Femoral neck

fractures usually result from minor trips or falls. This kind of break is most common in

women following menopause, when bones can become more fragile. Trochanteric

fractures occur primarily in young and middle-aged people, usually from direct trauma

such as a blow.

Femur fractures vary based on the type of injury that was sustained, the way the

bone was fractured and the location of the fracture. The femur shaft is divided into three

parts and the location of injuries may include: Proximal femur fractures involve the upper

portion of the bone, next to the hip joint; femoral shaft fractures involve the middle

portion of the bone and are usually very severe injuries; Supracondylar femur fractures

involve the area just above the knee and are considered uncommon.

In addition, femur fractures may be categorized by the type of injury, which may

include: A transverse fracture is a straight line across the shaft of the femur; An oblique

fracture is an angled line or break; A spiral fracture is a fracture that encircles the femur

shaft; A comminuted fracture occurs when the bone has broken into several pieces; A
displaced fracture occurs when the bone fragments on each side of the break are not

aligned; An open or compound fracture occurs when bone fragments may puncture the

skin, also damaging surrounding muscles and tendons.

Fractures are commonly obvious, since femoral fractures are often caused by

high energy trauma. Signs of fracture include swelling, deformity, and shortening of the

leg. Extensive soft-tissue injury, bleeding, and shock are common. The most common

symptom is severe pain, which prevents movement of the leg.

Complications of fractures may either be acute or chronic. Hypovolemic shock

resulting from hemorrhage is more frequently noted in trauma patients with pelvic

fractures and in patients with displaced or open femoral fractures. After fracture of long

bones and or pelvic bones, or crush injuries, fat emboli may develop. Compartment

syndrome in an extremity is a limb-threatening condition that occurs when perfusion

pressure falls below tissue pressure within a closed anatomic compartment.

To determine the presence of fracture, the following diagnostic tools are used. X-

ray examination determines location and extent of fractures/trauma, may reveal

preexisting and yet undiagnosed fracture(s). Bone scans, tomograms, computed

tomography (CT)/magnetic resonance imaging (MRI) scans visualizes fractures,

bleeding, and soft-tissue damage; differentiates between stress/trauma fractures and

bone neoplasms. Arteriograms may be done when occult vascular damage is suspected.

Complete blood count (CBC): Hematocrit (Hct) may be increased (hemoconcentration)

or decreased (signifying hemorrhage at the fracture site or at distant organs in multiple

trauma). Increased white blood cell (WBC) count is a normal stress response after

trauma. Urine creatinine (Cr) clearance; Muscle trauma increases load of Cr for renal

clearance. Coagulation profile; Alterations may occur because of blood loss, multiple

transfusions, or liver injury.

Nursing interventions of the fractured areas include instructing the patient

regarding proper methods to control edema and pain. It is important to teach exercises

to maintain the health of the unaffected muscles and to increase the strength of muscles

needed for transferring and for using assistive devices. Plans are made to help the

patients modify the home environment to promote safety such as removing any
obstruction in the walking paths around the house. In addition, wound irrigation and

debridement are initiated as soon as possible and the affected extremity is elevated to

minimize edema.

According to the World Health Organization (WHO), 4967 femur fractures – 4644

from the United States and 323 from other countries. The included patients from the

United States had a mean age of 38 years and 59% of them were male. Most (57%) of

the included patients were the victims of road motor vehicle accidents.

According to the Department of Health (DOH) Philippine claims from 2010 –

2015 revealed that 66.46% of hip fractures were surgically treated. The total number of

claims doubled between 2012 and 2016; the number of claims for femoral fractures

increased fourfold in this period.

The overall prevalence of femoral fractures in La Union was 2.4% in females

and 11.0% in males. This translates that motor vehicles users are at risk for fractures. In

order to optimize utilization of health care resources in the community, there’s no better

way to do this than to initiate primary and secondary preventive measures among at risk

individuals.

STUDENT-CENTERED OBJECTIVES:

After 2-3 days of rendering holistic nursing care, the student will be able:

1. To comprehend the risk factors, complications and nursing considerations for the

client.

2. To observe and identify potential complications and how to initiate appropriate

preventive or corrective actions.

3. To provide health teachings to the client for continuity of care to the client.

4. To provide nursing care that can contribute to the optimum health status of the client.
 Chapter II

NURSING HEALTH HISTORY

I. Biographic Data

The client’s name is D.P.M. He was born on May 14, 1995. He is 24 years old.

He is a full-blooded Filipino and a Roman Catholic. He lives in San Juan, La Union.

Patient is a Highschool graduate and works as a corn delivery/harvester man.

II. Reasons for Seeking Health Care

Patient D.P.M. was under the influence of alcohol and patient hit a bridge in San

Juan, La Union. He was having an intermittent, localized, dull aching pain with a pain

scale of 7/10 on fracture site elicited on movement of left lower extremities.

III. Family Health History

Patient D.P.M. stated that he has no known familial health problems both on his

maternal and paternal side.

IV. History of Present Health Concern

One day prior to admission, patient D.P.M. went on a drinking session/spree with

his friends after work. Driving under the influence of alcohol at midnight, patient D.P.M.

felt asleep and accidentally hit a bridge in San Juan, La Union.

V. Past Health History

 Patient had no history of asthma, hypertension, diabetes mellitus, coronary artery

disease, arthritis or malignancies. No noted allergies to drugs or foods. Patient has no

history of vehicular accidents and hospitalizations other than having common cough and

colds.

VI. Lifestyle and Health Practices

A. Description of a Typical Day

Patient D.P.M. typically wakes up around 5:00 to 6:00 in the morning. Patient

immediately gets out of bed to urinate and pray before he starts his day. He usually eats

his lunch at 12:30 to 1:00 p.m. as he has to finish all his tasks for the day. He takes a

nap after lunch and spends the rest of his afternoon collecting corn harvests and

delivering it to the warehouse. He eats his dinner by 6:00-7:00 p.m. together with his

family and watch his favorite TV show at night. He then prepares to bed around 10:00-

11:00 p.m.

B. Nutrition and Weight Management

Patient D.P.M. usually eats 3-4 meals a day. His breakfast typically consists of

coffee and bread. He has his usual cup of rice with viands of a variety of seafood, meat,

poultry and dry beans products for lunch or dinner. The source of their drinking water

comes from a water shop. He usually defecates once in the morning and has regular

bowel movement.

C. Activity Level and Exercise

Patient D.P.M. has an active lifestyle. His routines are mainly engaging on

activities that mostly require physical work. He also stated that he regularly exercise to

be physically fit.

D. Sleep and Rest

Patient D.P.M. has a regular sleeping pattern but sometimes tend to have troubles

in sleeping. He often sleeps around 10:00 to 11:00 p.m. and wakes up around 5:00 am

to 6:00 a.m. Thus, having 8 to 10 hours of sleep every day.

E. Medications and Substance Use

 Patient D.P.M. doesn’t have maintenance medications. He treats his common

illnesses such as cough and colds with OTC medicines when home remedy of

calamansi water is not effective for him. He is knowledgeable about the use of herbal

medicines but he believes that some illnesses should be treated with pharmacotherapy.

F. Self-concept and Self-care pattern

Patient D.P.M. verbalized concerns about his age because he feels like he is

being left out from other people at his age. He hasn’t finished his college degree and he

feels like he is just going to be a plain “corn harvester and delivery guy.” However, he

stated that even though he feels that way, he still takes care of himself physically and

make sure that he still has a role in society by giving his best at work for his self-

development and family.

G. Social Activities

Patient D.P.M. often stays at work and mingles frequently with his friends.

Furthermore, he likes to socialize with his neighbors and often talks to them about daily

life issues.

H. Role-Relationship Pattern

Patient D.P.M. doesn’t want to make any relationships with any opposite sex yet

because he believes that he still needs to improve himself and focus on providing

financial support to his family.

I. Values and Beliefs

Patient D.P.M. is a Roman Catholic and usually attends the mass on Sundays.

However, there are times that he has to work overtime and has no other choice but to

skip the Sunday service and just offer his prayers in the comfort of their home. Patient

still has superstitious beliefs related to medical concerns as he still believes in quack

doctors but is also open-minded about the field of medical science.

J. Education and/or Work

Patient shyly confessed that he never finished College and has no other means

of income besides working as a corn harvester and delivery guy.

 K. Stress Level and Coping Style

Patient’s stress stems from the fact that he is at his age when he is supposed to

be more financially capable and successful in his career of choice but has no proper

education and means to do so. He lets his family know that he does not want to enroll in

college because he does not want to be a burden to his family in terms of financial

aspect. He just copes by offering prayers and asking the Almighty’s guidance not only

for himself but for his family’s sake as well.

L. Environmental Living Sanitation

Patient D.P.M. and his family lives in a bungalow house in San Juan, La Union.

Their house is near the Barangay Hall and Basketball Court. Their source of water for

bath is from deep well and buys their drinking water from the drinking water station

nearby. The space of their house is enough for the family and has pretty good green

cover. However, some of their neighbors cook using fire woods and create some noise

especially on the weekends. Patient D.P.M.’s household has a water-sealed,

sewer/septic tank toilet facility that is exclusively used by the household. They have a

good garbage segregation system in their community and garbage collection takes place

every Wednesdays and Sundays.

VII. Developmental Task

According to Erik Erikson’s Psychosocial Development: Stage 6, Intimacy vs.

Isolation

Intimacy versus isolation is the sixth stage of Erik Erikson's theory of

psychosocial development. This stage takes place during young adulthood between the

ages of approximately 18 to 40 yrs. During this period, the major conflict centers on

forming intimate, loving relationships with other people. During this period, we begin to

share ourselves more intimately with others. We explore relationships leading toward

longer-term commitments with someone other than a family member. Successful

completion of this stage can result in happy relationships and a sense of commitment,

safety, and care within a relationship. Avoiding intimacy, fearing commitment and
relationships can lead to isolation, loneliness, and sometimes depression. Success in

this stage will lead to the virtue of love.

This stage is currently what patient D.P.M. belongs to as he is at the time of his

life wherein he is able to form intimate relationships with others. He mentioned that this

stage of his life is crucial because prior to forming commitments or relationships with

others, he must have self-development and show that he is financially capable to

support his future partner. However, he said that despite not being able to have a more

comfortable life due to lack of educational background and stable job, he is willing to

work on himself and eventually form a good relationship with his future partner.

Chapter III
PHYSICAL ASSESSMENT

Last February 21, 2020 at around 8 in the morning, a Cephalocaudal Physical

Examination to patient D.P.M. was conducted.

General Appearance and Behavior

During the interview and observation, patient is awake and looking weak. He was

lying on the bed with a skeletal traction on his left leg. His initial vital signs were:

Temperature of 37.5℃, Respiration Rate of 18 breaths per minute, Heart Rate of 102

beats per minute and Oxygen Saturation of 99%.

Skin, Hair and Nails

Skin is brown in color and with no lesions on the skin. Skin is slightly cold to

touch and skin turgor brings back for about 2-3 seconds. The hair is black in color,

smooth and equally distributed. Blackish discoloration of some nails are present. Upon

assessing, patient has a capillary refill of around 2 seconds.

Head, Neck and Lymph Nodes

Head is normocephalic, symmetric, and has full range of motion. Face is

normally symmetric and proportionate. Movements are equal bilaterally. The neck is
located midline but has presence of neck vein engorgement. There were no lesions or

mass noted. The trachea is in midline.

Mouth, Throat, Nose and Sinuses

The lips are pink but blackish and dry. No ulcerations or lesions noted. The

tongue moves freely and non-tender. The client possesses pink gums. Tonsils are easily

seen. Nose is in midline, no nasal obstructions and both nares are patent. No bone and

cartilage deviation noted on palpation. No tenderness noted on palpation. No tenderness

is palpated over sinuses.

Eyes and Eyebrows

The eyebrows are symmetrically aligned and equal in movement. Eyelashes are

equally distributed and curled slightly outward. Eyelids close symmetrically. There is no

swelling, discharge or lesions of eyelids. Eyeballs are symmetrically aligned but appears

sunken. Pupils are equally round, reactive to light and accommodation.

Ears

Ears are equal in size and similar to one another. The pinna recoils after folded.

There is no swelling and tenderness palpated. No foul discharges. Patient can respond

to sounds.

Thorax and Lungs

The chest is normal in diameter. The chest contour is symmetrical, and the spine

is vertically aligned. Chest has noted abrasions. The chest wall is intact, no tenderness

or no masses noted. Chest expansion is present and no noted adventitious sounds were

auscultated.

Heart

Heart has a strong and regular rhythm of 102 beats per minute. No heart

murmurs or extra heart sounds heard.

Abdomen
 The abdomen wall moves posteriorly in a symmetrical fashion with inspiration.

The umbilicus was centrally located and inverted. There is no lesions, no dilated veins

and no visible pulsations noted. On light palpation, palpable mass, rigidity, or pain on the

surface was not noted. On percussion, there is no dullness noted. On auscultation,

normal bowel sound consisting of clicks and gurgles for 5-30 per minute is present.

Upper and Lower extremities

Both upper and lower extremities are normal in terms of size but upper

extremities are darker in color. Abrasions were seen on both right and left arms.

Patient’s left leg has abrasions and an Open Reduction External Fixation (OREF) was

noted on his lower leg. Swelling was also noted on patient’s left thigh.

Genitalia

Not assessed

Neurologic

The client is coherent but appears weak. Patient is able to spontaneously open

eyes and to verbal command. The patient understands what the procedure is intended

for and is able to respond to some questions correctly. Patient obeys command intended

for motor response but has limitations on his lower extremities due to his skeletal

traction. His Glasgow coma scale for her eye response is 4, verbal response is 5 and

motor response is scored as 5.

 Chapter IV

ANATOMY AND PHYSIOLOGY

The musculoskeletal system (also known as the locomotor system) is an organ

system that gives animals (including humans) the ability to move, using the muscular
and skeletal systems. It provides form, support, stability, and movement to the body. The

musculoskeletal system is made up of the body’s bones (the skeleton), muscles,

cartilage, tendons, ligaments, joints, and other connective tissue that supports and binds

tissues and organs together.

Its primary functions include supporting the body, allowing motion, and protecting

vital organs. The bones of the skeletal system provide stability to the body analogous to

a reinforcement bar in concrete construction. Muscles keep bones in place and also play

a role in their movement. To allow motion, different bones are connected by articulating

joints, and cartilage prevents the bone ends from rubbing directly onto each other.

The skeletal portion of the system serves as the main storage system for calcium

and phosphorus. The importance of this storage is to help regulate mineral balance in

the bloodstream. When the fluctuation of minerals is high, these minerals are stored in

bone; when it is low, minerals are withdrawn from the bone. The skeleton also contains

critical components of the hematopoietic (blood production) system. Located in long

bones are two distinctions of bone marrow: yellow and red. The yellow marrow has fatty

connective tissue and is found in the marrow cavity. In times of starvation, the body uses

the fat in yellow marrow for energy.

The red marrow of some bones is an important site for hematopoeisis or blood

cell production that replaces cells that have been destroyed by the liver. Here, all

erythrocytes, platelets, and most leukocytes form in bone marrow from where they

migrate to the circulation.

Muscles contract (shorten) to move the bone attached at the joint. Skeletal

muscles are attached to bones and arranged in opposing groups around joints. Muscles

are innervated—the nerves conduct electrical currents from the central nervous system

that cause the muscles to contract. Three types of muscle tissue exist in the body.

These are skeletal, smooth, and cardiac muscle.

Only skeletal and smooth muscles are considered part of the musculoskeletal

system.
Skeletal muscle is involved in body locomotion. Examples of smooth muscles include

those found in intestinal and vessel walls. Cardiac and smooth muscle are characterized

by involuntary movement (not under conscious control). Cardiac muscles are found in

the heart.

A tendon is a tough, flexible band made of fibrous connective tissue, and

functions to connect muscle to bone. Joints are the bone articulations allowing

movement. A ligament is a dense, white band of fibrous elastic tissue. Ligaments

connect the ends of bones together in order to form a joint. These help to limit joint

dislocation and restrict improper hyperextension and hyperflexion. Also made of fibrous

tissue are bursae. These provide cushions between bones and tendons and/or muscles

around a joint.

Chapter VI

LAB RESULTS

Date Requested: February 21, 2020

HEMATOLOGY

PARAMETER RESULT UNIT REF RANGE INTERPRETATION

Hemoglobin 139 g/L 120-160 NORMAL

Hematocrit 0.41 L/L 0.37-0.47 NORMAL

Erythrocytes 4.4 x10^9/L 4.0-5.4 NORMAL

WBC 11.78 x10^9/L 4.0-10.0 Response to an infection

or inflammatory
condition
Neutrophils 81.20 % 55.0-65.0 This is a sign that your
body has an infection
 Lymphocytes 28.2 % 25.0-35.0 NORMAL

Monocytes 7.4 % 3.0-6.0 Normal immune

response to an event
such as infection
Eosinophil 0.40 % 2.0-4.0 Result of intoxication
from alcohol or
excessive production of
cortisol
Basophils 0.7 % 0.0-1.0 NORMAL

Platelet Count 356 x10^9/L 150-450 NORMAL

Date Verified: February 17, 2020

Exam: X-Ray

Interpretation:

Left Thigh Cross Table Lateral:

Follow-up study to the one done on February 15, 2020 shows better AP alignment of the

complete transverse fracture involving the middle third of the left femur with chipped

fragment, seen in the AP view.

Posterior displacement is observed on the cross table lateral view.

Other visualized bones appear intact.

Pelvis:

Symmetrical iliac alae, Shenton’s lines and pelvic ring.

No fracture or dislocation.
The bilateral sacroiliac joints, hip joints and symphysis pubis are not widened.

A small calcific density is seen adjacent the right hip joint.

Chapter IX

EVALUATION

All the data written in this case study are gathered by means of interview,

assessments and observations as well as from the patient’s data. Patient D.P.M. was

rushed to Ilocos Training and Regional Medical Center last February 15, 2020 due to

multiple physical injury and femoral fracture that is described as closed, complete and

displaced. Upon admission, he was diagnosed by his physician, Dr. J.V.O. with Fracture

Closed Complete Middle 3rd Femur Left. Patient underwent a diagnostic test of Complete

Blood Count (CBC) and X-Ray. Patient was given medications such as Tramadol,

Cefazolin and Co-Amoxiclav.

We, the assigned student nurses for patient D.P.M. were able to handle his case

last February 20, 2020. On the first day of our encounter with the patient, we were able

to have good nurse-patient relationship. We monitored his vital signs as well as given his

medications he needed. We also considered important nursing considerations given to

the patient such as applying ice compress every 2 hours and making sure he is

positioned at moderate back rest. Aside from that, we were also able to impart health

teaching for our patient and family members for continuity of care as well as informing
him of the importance of proper hygiene, clean environment and avoidance of strenuous

tasks that might predispose his traction with infections.

The knowledge of the diagnosed condition of the client particularly its risk and

management has improved since our first encounter as observed on the feedback that

we have provided to check for the understanding of the health teachings we have

imparted as well as his being able to have mobilization on his upper extremities and

countermeasures for the prevention of pressure ulcers as well as risks for infections.

However, the assurance that the parents of the client that continuity of care will be

applied is not guaranteed.

Patient D.P.M. was discharged on February 27, 2020 and was given health

teachings on prevention of infection.

Health teachings were also imparted about the administration of medications.

Follow-up check was never encountered.

In conclusion, this case study helped us achieve our student objectives of first,

being able to identify the problem of the patient and to be able to learn more about

Femoral Fractures. We were able to identify risk factors and complications of the said

musculoskeletal-related problem. Furthermore, we were able to establish one of the

necessary nursing roles- which is building rapport with our client and being able to

provide the necessary nursing care our patient needs for the optimum quality of his

health. In addition, we were able to share our knowledge to our patient and family for

continuity of care. Finally, this case study helped us, student nurses to understand the

essence of working as a team as this is one of the tasks we must remember to abide for

the better progress of student-patient relationship.