Presented by: Stephanie Artifice and Jette Olbo

Right tibia and fibula fracture from road accident CASE SCENARIO LEGEND
Presenting Condition
Fracture in right tibia and fibula

History of Presenting Condition

PREDISPOSING
PREDISPOSING RISK FACTORS Mr. Z, 68 years old is admitted to the surgical ward due to a road accident that caused him to have a fracture in RISK FACTORS
FACTORS
FACTORS Previous fracture right tibia and fibula. He underwent surgery for the fractures as advised by the physician. He complaints of pain at
Old age Road accident
the fractured site. Upon assessment, the nurse noticed that he is exhibiting exertional dyspnea because of the
discomfort he felt on the fracture sites and he is having trouble turning position when following instructions.The
NURSING
nurse attempted to do a passive range of motion but he has limitations and muscle weakness. His postural gait is PATHOPHYSIOLOGY
DIAGNOSIS
not stable and he prefers lying on his bed all the time. He cannot perform his activity of daily living (AOL) like
Force of impact on femur disturbs the union of the bone
bathing and toileting and needs assistance from his family members.

Vital Signs: NURSING

COMPLICATIONS
INTERVENTIONS
BP - 90/65 mmHg
RR - 28 cpm
PR - 98 bpm
T - 37.2 C
SIGN AND MEDICAL
Blood loss Nonunion of bones Trauma
SYMPTOMS MANAGEMENT
Past Medical History
No significant past medical history.
ORIF left femoral fracture 7 years ago following fall from bicycle

Pre-Operation DIAGNOSTIC TOOL HEALTH TEACHINGS

Hypotension Angulation Swelling
- Complains of pain at fractured site
- Trouble turning positions
- Limited ROM and muscle weakness, and postural gait is unstable.

Post-Operation
NURSING Tachycardia Overriding of bone
INTERVENTIONS Tachypnea
Hypovolmic Shock DIAGNOSTIC TOOL Muscle spasm - Have rested in the PACU
ends
- Understand and accepted the outcome.
INDEPENDENT - Successful fixation of the fractured tibia and fibula.
- Assess vital signs (Blood Pressure, Pulse Rate, Respiratory Rate,
Medical History and Temperature and Oxygen Saturation).
Physical Exams Laboratory Results: - Assess patients?presence of pain and discomfort on the injured area. Guide Questions:
X-ray
RBC - 2.97 mm3 Tenderness What are the different risk factors for the different
Blood Test Through pain rating, 0 as no pain and 10 as extremely painful.
Hgb - 9.2 g/dL Broken skin conditions?
CT Scan - Assess the patient's consciousness to know if the patient is suffering from
Hct - 27 %
MRI Scan other complications. Relate the signs and symptoms to the pathologic
RDW - 15.5 %
Vital Signs: - Evaluate pain regularly every 2 hours noting characteristics, location, and processes found in the condition.
BP - 90/65 mmHg Acute pain related to intensity (0?10 scale).
RR - 28 cpm fractured bones and What are the primary characteristics and
Pain - Emphasize the patient's responsibility for reporting pain/relief of pain
damaged soft tissue assessment parameters of the disturbances?
PR - 98 bpm completely.
on the right leg
T - 37.2 C Open fracture - Note presence of anxiety or fear, and relate with the nature of and
What are the different medical and nursing
preparation for procedure. management approaches for the condition?
- Provide additional comfort measures such as blankets and positioning if
needed.
Decreased function - Encourage use of relaxation techniques: deep-breathing exercises,
guided imagery, visualization, music.
Restoration of bone to normal alignment DEPENDENT
- Administer analgesics as prescribed by the physician.

Pre-operative Measures:
Obtain signed consent
NPO status INDEPENDENT
Assess the appearance, odor, size, drainage and color to address - Assess vital signs (Blood Pressure, Pulse Rate, Respiratory Rate,
properly the wound with fracture. Temperature and Oxygen Saturation).
Maintain aseptic technique in cleaning the wound. - Assess the patient?s level of understanding of the current situation and its
Change dressing and bandage after cleaning and when soiled.
impact on life.
Reinforce patient's knowledge on surgical procedure
- Assess the affected site for bleeding and pain.
Secure blood for possible blood transfusion Impaired physical - Speak to the patient in a low tone voice. Be attentive and devote time to
Provide psychological support mobility related to loss
Administration of antibiotics at least 60 minutes prior to surgery. Limited movement of listening to the patient.
of integrity of bone - Provide factual information about what is happening.
Administration of analgesics as necessary for pain. the affected part
Transport patient to OR and endorse to OR nurse structures or fractures - Explain the procedure to be done and assure that everything will be fine.
of the bone - Encourage verbalization of feelings, fears, and anxiety.
- Assist the patient to learn and encourage use of stress management skills,
such as relaxation techniques, visualization, guided imagery, and
deep-breathing exercises.
Intra operative - Provide positive reinforcement for efforts. Use soothing words of
encouragement.
- Empower the patient; assure her that she is in control.

Skin preparation

Surgical incision

Promotes wound Improved venous and Internal Fixation

healing lymph return

Decreased tissue Open reduction

Stages of bone healing swelling

Decreased muscle Local irritation of the Wound irrigation and removal of tissues and
Inflammatory stage tissues débridement foreign material
(1 - 3 days) spasm

Medullary nailing
Fixation and alignment and Screws for a long
Fibrocartilage formation of the bones oblique or spiral
(3 days - 1 weeks) fracture.

Callus formation Closing of the incision

- Education is necessary for those patients discharged to home-based or community
(2 - 6 weeks)
settings with fractures and casts and should include recognition of the unique - Temperature is monitored at regular intervals, and the patient is monitored for signs of infection.
characteristics of acute compartment syndrome (increasing, refractory pain and - Assess the wound dressing and bandage for appearance, drainage, color and odor.
neurovascular manifestations). - Provide wound care and administration of antibiotics to prevent the occurrence of infection.
- Teach patients how to do exercises that help strengthen their legs and regain their - The nurse should frequently assess pain and neurovascular status of the affected limb and report any negative
changes. Ossification Risk for Infection
function.
- The limb should be maintained in a functional position at the level of the heart to promote optimal blood flow. (3 weeks - 6 months)
- Teach patients in getting out of bed and walk 2 to 3 times a day to help with blood flow.
- Educate about exercises to maintain the health of unaffected muscles and to increase - Pain management is essential and is accomplished with opioid analgesia, as prescribed.
the strength of muscles needed for transferring and for using assistive devices such as - Careful assessment of intake and output and urinalysis could alert the nurse to the development of
crutches, walkers, and special utensils. rhabdomyolysis.
- Educate how to use assistive devices safely. - The nurse provides emotional support and encouragement to the patient and encourages adherence to the Consolidation and Risk for infection
- Provide plans to help patients modify the home environment as needed and to ensure HEALTH TEACHINGS Post-op Care: remodeling related to tissue
treatment regimen.
safety, such as removing floor rugs or anything that obstructs walking paths throughout (6 weeks - 1 year) trauma and invasive
- The orthopedic surgeon evaluates the progression of bone healing with periodic x-rays.
the house. procedure on the right
- Nurses provide non-pharmacological intervention to alleviate pain manifestations through therapeutic listening, leg
- Educate patient to intake calcium vitamins and milk to strengthen the bones and allow
bone growth. initiation of relaxation techniques and behavior modification, and referral for rehabilitation therapy.
- Patient education includes self-care, medication information, monitoring for potential - The extremity is elevated to minimize edema and allow venous return for 3-5 days after surgery for
complications, and the need for continuing health care supervision. immobilization.
- Fracture healing and restoration of strength and mobility may take an average of 6 to 8 - Rehabilitation initiated early can improve circulation to the affected area and maximize function. Start doing small
weeks, depending on the quality of the patient?s bone tissue. It may take many months things and minimal exercise as tolerated by the body at 5-6 days after surgery. INDEPENDENT
for a severe fracture of a long bone to heal from 3-12 months depending on the - Assess Vital signs (Blood pressure, pulse rate, respiratory rate,
- Depression and anxiety are often associated with severe pain disorders; therefore, the nurse should accompany
severity of the fracture. Exercises to help with muscle strength and range of motion will
the patient with their needs, provide emotional support and allow the expression of feelings. temperature and Partial pressure of oxygen), especially the temperature
be needed.
- Provide instructions when to contact the primary provider for emergent follow-up. - Assist patients in getting out of bed and walk 2 to 3 times a day to help with blood flow. to monitor elevated temperature as a sign of infection.
- Assess and note any signs and symptoms of infection to address
immediately.
- Perform skin preparation to reduce the number of microorganisms that
Emergency occur at will cause infection.
Home - Adhere to facility infection control, sterilization, and aseptic policies and
procedures.
- Maintain dependent gravity drainage of indwelling catheter to monitor
urine output.
Call the doctor if you are not getting better or you have:
- During the procedure identify breaks in aseptic technique and resolve
- Pain that does not get better with medicine
- Redness, swelling, more pain, a lot of bleeding, or discharge from the incision immediately on occurrence.
site - Contain contaminated fluids and materials in specific sites in the
- Signs of infection, such as fever and chills operating room, and dispose of them according to hospital protocol.
- Numbness or tingling at the injury site DEPENDENT
- A cast that feels too tight
- Administer antibiotics as prescribed by the physician 60 minutes before
- Red skin around a cast
the procedure.
- Itching under a cast that does not go away
- Chalky white, blue, or black skin color in the fingers, toes, arm, or leg COLLABORATIVE
- Surgeons apply dressing and bandage after the procedure.