I- Introduction

A fracture is a break in the continuity of bone and is defined according to its type
and extent. Fractures occur when the bone is subjected to stress greater that it can absorb.
Fractures are caused by direct blows, crushing forces, sudden twisting motions, and even
extreme muscle contractions. When the bone is broken, adjacent structures are also
affected, resulting in soft tissue edema, hemorrhage into the muscles and joints, joint
dislocation, ruptured tendons, severed nerves, and damaged blood vessels. Body organs
maybe injured by the force that cause the fracture or by the fracture fragments.
There are different types of fractures and these include, complete fracture,
incomplete fracture, closed fracture, open fracture and there are also types of fractures
that may also be described according to the anatomic placement of fragments,
particularly if they are displaced or nondisplaced. Such as greenstick fracture, depressed
fracture, oblique fracture, avulsion, spinal fracture, impacted fracture, transverse fracture
and compression fracture.
A comminuted fracture is one that produces several bone fragments and a closed
fracture or simple fracture is one that not cause a break in the skin. Comminuted fracture
at the Right Femoral Neck is a fracture in which bones of the Right Femoral Neck has
splintered to several fragments.
By choosing this condition as a case study, the student nurse expects to broaden
her knowledge understanding and management of fracture, not just for the fulfillment of
the course requirements in medical-surgical nursing. It is very important for the nurses
now a day to be adequately informed regarding the knowledge and skill in managing
these conditions since hip fracture has a high incidence among elderly people, who have
brittle bones from osteoporosis (particularly women) and who tend to fall frequently.
Often, a fractured hip is a catastrophic event that will have a negative impact on the
patients life style and quality of life. There are two major types of hip fracture.
Intracapsular fractures are fractures of the neck of the femur, Extracapsular fracture are
fractures of the trochanteric region and of the subtrocanteric region. Fractures of the neck
of the femur may damage the vascular system that supplies blood to the head and the
neck of the femur, and the bone may die. Many older adults experience hip fracture that
1

student nurse need to insure recovery and to attend their special need efficiently and
effectively. True the knowledge of this condition, a high quality of care will be provided
to those people suffering from it.

II. Objectives
General Objectives:
After three day of student nurse-patient interaction, the patient and the significant
others will be able to acquire knowledge, attitudes and skills in preventing complications
of immobility.
Specific Objectives:
A. STUDENT-NURSE CENTERED
After 8 hours of student nurse-patient interaction, the student nurse will be able
to:
1. state the history of the patient.
2. identify potential problems of patient
3. review the anatomy and physiology of the organ affective
4. discuss the pathophysiology of the condition.
5. identify the clinical and classical signs and symptoms of the condition.
6. implement holistic nursing care in the care of patient utilizing the nursing
process.
7. impart health teachings to patient and family members to care of patient with
fracture.
B. PATIENT-CENTERED
After 8 hours of student nurse-patient interaction, the patient and the significant
others will be able to:
1. explain the goals of the frequent position changes.
2. enumerate the position for proper body alignment.
3. discuss the different therapeutic exercises.
4. practice the different kinds of range of motion.
5. participate attentively during the discussion.

III. Nursing Assessment

1. Personal History
1.1 Patients Profile
Name: Mrs. Torralba, Lourdes
Age: 89 years old
Sex: Female
Civil Status: Widow
Religion: Roman Catholic
Date and time of admission; March 13, 2008 at 10:10 am
Room No.: Room 425, Cebu Doctors University Hospital
Complaints: Pain the right hip
Impression or Diagnosis: Fracture Close-Comminuted: Femoral Right Neck
General Osteoporosis
Breast Cancel (Right)
Diabetes Mellitus Type II
Physician: Dr. F. Vicuna, Dr. E. Lee, Dr. N. Uy, Dr. Ramiro
Hospital No: 216 426
1.2. Family and Individual Information, Social and Health History
Mrs. Torralba, Lourdes who resides in 8 Acacia St. Camputhaw Lahug, Cebu City,
Cebu Province with 9 successful children ( 6 boys and 3 girls) was admitted to Cebu
Doctors University Hospital for further management of the condition.
Mrs. Torralba is a college graduate and shes previously working as an assistant of her
husband ( Mr. Rodrigo Torrralba ) a doctor.
The patient was diagnosed to have Breast Cancer (Right) last 2006 with bone
metastasis and on chemotherapy with aromasin.

Two days prior to admission, the patient was standing and was about to open up
he umbrella when she got out of balance and landed on her right hip.And had experienced
limitation of movement on the right hip. The patient was then admitted due to the
persistence of pain.
The patient was previously hospitalized due to infected wound at the right ankle
last 2002. No familial history of hypertension and bronchial asthma but is positive to
diabetes mellitus of paternal side. Has no known food and drug allergies. The patient is
non-smoker non-alcoholic beverages drinker.
1.3. Level of Growth and Development
1.3.1. Normal Growth and Development at particular stage Older Adult ( 65
Years old to death)
Physical Development
Perception of well-being can define quality of life. Understanding the older adults
perception about health status is essential for accurate assessment and development of
clinically relevant interventions. Older adults concepts of health generally depend on
personal perceptions of functional ability. Therefore older adults engaged in activities of
daily living usually consider themselves healthy, whereas those whose activities are
limited by physical, emotional or social impairments may perceive themselves as ill.
There are frequently observed physiological changes in order adults that are
called normal. Finding these normal changes during and assessment is not an expected.
These physiological changes are not always pathological processes in themselves, but
they may make older adults more vulnerable to some common clinical conditions and
diseases. Some older adults experience all of these physiological changes, and others only
experience only a few. The body changes continuously with age, and specific effects on
particular older adults depend on health, lifestyle, stressors and environmental conditions.

Cognitive Development
Intellectual capacity includes perception, cognitive, memory, and learning.
Perception, or the ability to interpret the environment, depends on the acuteness of the
senses. If the aging persons senses are impaired, the ability to perceive the environment
and react appropriately is diminished. Perceptual capacity may be affected by changes in
the nervous system as well. Cognitive ability, or the ability to know, is related to the
perceptual ability.
Changes in cognitive structure occur as a person ages. It is believe that there is a
progressive loss of neurons. In addition, blood flow to the brain decreases, the meaninges
appear to thicken, and brain metabolism slows. As yet, little is known about the effect of
these physical changes on the cognitive functioning of the older adult. Older people need
addition time for learning, largely because of the problem of retrieving information.
Motivation is also important. Older adults have more difficulty than younger ones in
learning information they do not consider meaningful. It is suggested that the older
person mentally active to maintain cognitive ability at the highest possible level. Life
long mental activity, particularly verbal activity, helps the older person retain the high
level of cognitive function and may help maintain a long-term memory. Cognitive
impairment that interferes with normal life is not considered part of normal aging. A
decline in intellectual abilities that interferes with social or occupational functions should
always be regarded as abnormal.
Psychosocial Development
According to Erikson, the developmental task at this time is ego integrity versus
despair. People who attain ego integrity view with a sense of wholeness and derive
satisfaction from past accomplishment. They view death as an acceptable completion.
According to Erikson, people who develop integrity accept ones one and only life
style. By contrast, people who despair often believe they have made poor choices during
life and wish they have made poor choices during life and wish they could live life over.
Robert Butler sees integrity and bringing serenity and wisdom, and despair as resulting in
6

the inability to accept ones fate. Despair gives rise of frustration, this couragement, and a
sense that ones life has been worthless.
Moral Development
According to Kohlberg, moral development is completed in the early adult years.
Most old people stay at Kohlbergs conventional development, and some are at the
preconventional level. An elderly person at the preconventional level obeys roles to avoid
pain and the displeasure of others. At stage one, a person defines good and bad in relation
to self, whereas older persons at stage 7 may act to meet anothers need as well as their
own. Elderly people at the conventional level follow societys rules of conduct to
expectation of others.
Emotional Development
Well-adjusted aging couples usually thrive on companionship. Many couples rely
increasingly on their mates for this company and may have few outside friends. Great
bonds if affection and closeness can develop during this period of aging together and
nurturing each other. When a mate dies, the remaining partner inevitably experiences
feelings of loss, emptiness, and loneliness. Many are capable and manage to live alone;
however, reliance, on younger family members increases as age advances and in health
occurs. Some widows and widower remarry, particularly the latter, because the widowers
are less inclined than widows to maintain a household.
Spiritual Development
Murray and Zentner write that the elderly person with a mature religious outlook
striver to incorporate views of theology and religious action into thinking. Elderly people
can contemplate new religious and philosophical views and try to understand ideas
missed previously or interpreted differently. The elderly person also derives a sense of
worth by sharing experiences or views. In contrast, the elderly person who has not
7

matured spiritually may not matured spiritually may feel impoverishment or despair as
the drive for economic and professional success wares.
Psychosexual Development
Sex drives persist into the 70s, 80s, and 90s, provided that the health is good
and an interested partner is available. Interest in sexual activity in old age depends, in
large measure, on interest earlier in life. That is, people who are sexually active in young
and middle adulthood will remain active during their later years. However, sexual activity
does become less frequent. Many factors may play a rate in the ability of an elderly
person to engage in sexual activity. Physical problems such as diabetes, arthritis, and
respiratory conditions affect energy or the physical ability to participate in sexual activity.
Changes in the gonads of elderly women result from diminished secretion of the
ovarian hormones. Some changes, such as the shrinking of the uterus, and ovaries, go
unnoticed. Other changes are obvious. The breasts atrophy, and lubricating vaginal
secretions are reduced. Reduced natural lubrication is the cause of painful intercourse,
which often necessities the use of lubricating jellies.
3.1.2. Ill Person at the Particular Age of Patient
The older fracture patients showed a higher prevalence of chronic brain syndrome,
they were in poorer physical state and their skinfold thickness was less. They also had
more unrecognized visual disorders. Those who were younger had a higher prevalence of
stroke than comparable controls.
The type of fall leading to the fracture varied with agetripping was the
commonest cause in the younger patients and drop attacks in the older. Both stroke and
partial sightedness were associated with falls due to loss of balance. The older patients
had a very high prevalence of pyramidal tract abnormality associated with chronic brain
syndromeand it appears that these demented patients fall not because of mental
confusion but because of associated motor abnormalities.
Ertra-capsular fractures occur in older patients. They are more likely to have a
history of falls but previous fracture is equally common at this age in the fracture and
control series.
8

2. Diagnostic Test

Diagnostic test

Normal values

Patients
Result

Significance

Hemoglobin

14.0-17.5 g/dL

9.1

Hematocrit

41.5-50.4%

28.8

- Decreased-various anemias, with

excessive fluid intake.
-Decreased-severe anemias

WBC

4.4-11.0x10^ g/uL

5.32

-Normal

RBC

4.5-5.9x10^ g/uL

2.8

-Decreased- all anemias and leukemia,

when blood volume has been restored.

Mean Corpuseular
Hemoglobin

27.5-33.2 pg

32.7

-Normal

Mean Cell Volume

(MCA)

80-96 fL

103.6

-Increased-macrocytic anemia

Mean Corpuseular
Hemoglobin

33.4-35.5 %

32

-Decrease-severe hypochronic anemia

Platelet

150,000-450,000

387

-Normal

Differential Count

40-70 %

67

-Normal

Neutropihl

0-1 %

-Normal

Basophil

0-5 %

-Normal

Eosinophil

0-8%

09

Monocyte

20-40%

20

-Increase-viral infection, collagen and

hemolytic disorders
-Normal
Source:
Brunner and Suddarths. Textbook of
Medical-Surgical Nursing.10th Edition
Volume 2. page 2214-2215

Serum

3.6-5

4.7

-Normal

Potassium

6.7-1.5

6.6

Creatinine

8.4-10.2

8.2

-Decreased-Muscular atrophy, anemia,

leukemia
-Decreased-vitamin D. deficiency

April 10, 2008

Complete Blood
Count

Lympocyte

10

Calcium

1.2-2.2

1.0

-Decreased-anemia, malnutrition

Protein

3.3-5.5

2.9

-Decreased-no clinical significance

Albumen

2.9

Globulin

6.8

5.8

-Increased-chronic infection, multiple

myeloma
-Decreased-malnutrition

Total Protein

65-110

145

-Increased-diabetes mellitus

GCT(50gms)

8-35 u/mL

20

-Normal
Source:
Brunner and Suddarths. Textbook of
Medical-Surgical Nursing.10th Edition
Volume 2.page
2217,2219,2221,2224,2229,2230,2232

PBS

65-110

118

-Increased-diabetes mellitus
Source:
Brunner and Suddarths. Textbook of
Medical-Surgical Nursing.10th Edition
Volume 2.page 2230,2233,

Uric acid

2.5-7.5

4.4mg/dL

-Normal
Source:
Brunner and Suddarths. Textbook of
Medical-Surgical Nursing.10th Edition
Volume 2.page 2225,

Bleeding time-sim

2.3-9.5

6.31
min.-sec.

-Normal

Clotting time

5-15

10.41
min.-sec.

-Normal

Prothombin time

10-13

13.8 sec.

-Increased-deficiency of factors I, II,

V, VII, and X, fat malabsorption

% activity

70-120

96.2 %

INR

<1.2

1.03

11

-Normal
-Normal
Source: Brunner and Suddarths.
Textbook of Medical-Surgical

Nursing.10th Edition Volume 2.page

2214
Urinalysis
Macroscopic
Examination
Color

Yellow

Yellow

-Normal

Appearance

Clear

Clear

-Normal

Plt

4.5-7.8

6.0

-Normal

Specific gravity

1.003-1.029

1.010

-Normal

Protein

Negative

Trace

Glucose

Negative

Trace

-Glomerular disease, nephritic

syndrome
-Diabetes mellitus

Ketones

Negative

Negative

-Normal

Blood

Negative

Negative

-Normal

Leukocytes

Negative

Negative

-Normal

Nitrite

Negative

Negative

-Normal

Bilirubin

Negative

Negative

-Normal

Urohilinogen

Normal

0.2 eu/dL

-Normal

RBC/hpf

0-5

0-2/hpf

-Normal

WBC/hpf

0-5

0-2/hpf

-Normal

Bacteria

Present

Few

-Normal

Mucus threads

Present

Few

-Normal

Amorphous Urates

Present

Few

-Normal

Blood cell

Negative

Few

Indicates renal or urinary tract disease

Microscopic
Examination

12

Source:
Brunner and Suddarths. Textbook of
Medical-Surgical Nursing.10th Edition
Volume 2.page 2224,2225

13

3. Present Profile of Functional Health Patterns

Profile of Functional Health Patterns
3.1. Health Perception / Health Management Pattern
The patient described her usual health before to be fair and body is strong but now
she considered it to be poor and weak. This is because of the limited movements she felt,
the inability to walk or stand and difficulty in moving the extremities due to the fracture
of her right femoral neck. Before the admission, the patient eats more foods rich in fats,
sugar or glucose and cholesterol in their meals and she drinks plenty of water everyday.
During the patients hospitalization, her diet was changed to low fat and low cholesterol
diet because she was diagnosed of having diabetes mellitus type II. The patients
attending physician encourages her to take more of calcium and Vitamin D in order for
her bones to become stronger. The patient is non-smoker and non-alcoholic drinker and
she has no known allergies.
3.2. Nutritional / Metabolic Pattern
The patients usual food intake before the hospitalization includes fish, meat,
vegetables, fruits, chicken and especially foods rich in fats, sugar/glucose and cholesterol.
She consumes more than 8 glasses of water a day. Her maintenance meds were Aromasin,
Fosamax, Centrum and Caltrate. Now the patient was advised by her attending physician
to restrict foods that can aggravate her condition. The patient was also encourage to take
more of Calcium and Vitamin D in order for her bones to become stronger. The patient
doesnt smoke or drink alcoholic beverages, has no known allergies. There is a change in
her appetite now; she often eats a little only each meal.

14

3.3. Elimination Pattern

Before, the patient can freely go to the C.R. to void or defecate but now that shes
hospitalized she was advised to wear diaper for her to have difficulty in standing and
walking. There is no burning sensation during ur4ination and her stool is brownish
formed stool.
3.4. Activity-Exercise Pattern
The patient before hospitalized wakes up early in the morning for her to have fine
walking around their house as her exercise. She usually guided her grandsons and
granddaughters, but now, shes just on bed lying assisted by her private nurses and
CDUH health care providers.
3.5. Cognitive/ Perceptual Pattern
The patient before, can hear, smell, taste and feel well and correctly but the
patient cannot read her newspaper without her eyeglasses just the same as now. She
speaks slowly English, Tagalog and Bisaya languages as of now but before she speaks
fluently all of those languages. She easily communicates, understands questions,
instructions and be able to follow and answer them correctly.
3.6. Rest/ Sleep Pattern
Before the hospitalization, the patient usually sleeps late at night at around 10
oclock pm and wakes up early in the morning at 6 oclock am with an hour of sleep of 8
hours. Now, she usually sleeps early at night (8-9 oclock pm) and wakes up at around 7
oclock am with an hour of sleep of 10 hours. The patient usually stays in bed and read
newspapers sometimes, she cant take a nap in the afternoon due to her REHAB CARE.

15

3.7. Self- Perception Pattern

The patients most concern about right now is her rehabilitation care. The patient
wants to stay at the hospital until she improves her mobility so she would be able to stand
and walk all alone by herself. The patient never loses the support of her children even if
they were not there physically and also her private nurses.
Through this, she maybe able to cope up easily from her unhealthy condition. The
treatment, managements, medications and all out care rendered by the hospital to the
patient assured her for the improvement of her condition.
3.8. Sexuality/ Reproduction
The patients husband just recently died. Now, the patient does not allow anyone
to see her getting undressed, changing diaper, changing clothes because she believes that
as a woman, it should be keep as private.
3.9. Coping- Stress Tolerance Pattern
The patient usually makes her decision as for now since her children were busy in
their work abroad, but they make sure they never forget to support and help their mother
recover from illness. Sometimes, the patient usually shares her concerns to her private
nurses and of course also to the student nurses. She usually reads newspaper for her to be
more relaxed.
3.10. Value-Belief Pattern
The patient find source strength and hope with God and her loved ones. God is
very much important to the patient. Before, she usually goes to church together with her
other children. They were not involved in any religious organizations or practices. The
patient knows how to pray and praise God for all the nice things he had given.

16

3.11. Relationship Pattern

The patient understands more on English and Bisaya languages but a little only in
Tagalog language. The patient was living all by herself with her private nurses but
sometimes, her grandchildren will come over to visit her. She never uses the support of
her children even if they were away from their mother they always make sure that their
mother is safe and secure. The patient can easily communicate, cooperate, listen and
follow instructions easily.

17

4. Pathophysiology and Rationale

4.1 Normal Anatomy and Physiology of Organ/ System Affected

The word skeleton comes from the Greek word meaning dried- up body, our
internal framework is so beautifully designed and engineered and it puts any modern
skyscraper to shame. Strong, yet light, it is perfectly adapted for its functions of body
protection and motion. Shaped by an event that happened more than one million years
ago when a being first stood erect on hind legs our skeleton is a tower of bones
arranged so that we can stand upright and balance ourselves. The skeleton is subdivided
into three divisions: the axial skeleton, the boned that form the longitudinal axis of the
body, and the appendicular skeleton, the bones of the limbs and girdles. In addition to
bones, the skeletal system includes joints, cartilages, and ligaments (fibrous cords that
bind the bones together at joints). The joints give the body flexibility and allow
18

movement to occur. Besides contributing to body shape and form, or bones perform
several important body functions such as support, protection, movement, storage and
blood cell formation.
Classification of Bones
The diaphysis, or shaft, makes up most of the bones length and is composed of
compact bone. The diaphysis is covered and protected by a fibrous connective tissue
membrane, the periosteum. Hundreds of connective tissue fibers, called Sharpeys fibers,
secure the periosteum to the underlying bone. The epiphyses are the ends of the long
bone. Each epiphyses consist of a thin layer of compact bone enclosing the area filled
with spongy bone. Articular cartilage, instead of periosteum, covers its external surface.
Because the articular cartilage is glassy hyaline cartilage, it provides a smooth, slippery
surface that decreases friction at joint surfaces.
In adult bones, there is a thin line of bony tissue spanning the epiphyses that looks
a bit different from the rest of the bone in that area. This is the epiphyseal line. The
epiphyseal line is a remnant of the epiphyseal plate (a flat plate of hyaline cartilage) seen
in young, growing bone. Epiphyseal plates cause the lengthwise growth of the long bone.
By the end of puberty, when hormones stop long bone growth, epiphyseal plates have
been completely replaced by bone, leaving the epiphyseal lines to mark their previous
location.
In adults, the cavity of the shaft is primarily a storage area for adipose (fat) tissue.
It is called the yellow marrow, or medullary, in infants this areas forms blood cells, and
red marrow is found these. In adult bones, red marrow is confined to the cavities of
spongy bone of flat bones and the epiphyses some long bones.
Bone is one of the hardest materials in the body, and although relatively light in
weight, it has a remarkable ability to resist tension and other forces acting on it. Nature
has given us an extremely strong and exceptionally simple (almost crude) supporting
system without up mobility. The calcium salts deposited in the matrix bone its hardness,
whereas the organic parts (especially the collagen fibers) provide for bones flexibility
and great tensile strength.
19

The femur, or thigh bone, is the only bone in the thigh. It is the heaviest, strongest
bone in the body. Its proximal end has a ball-like head, a neck, and greater and lesser
trochanters (separrsted anteriorly by the intertrochanteric line and posteriorly by the
intertrochanteric crest). The trochanters, intertrochanteric crest and the gluteal tuberosity,
located on the shaft, all serve us sites for muscle attachment. The head of the femur
articulates with acetabulum of the hip bone in a deep, secure socket. However, the neck
of the femur is a common fracture site, especially in old age.
The femur slants medially as it runs downward to joint with the leg bones; this
brings the knees in line which the bodys center of gravity. The medial course of the
femur is more noticeable in females because of the wider female pelvis. Distally on the
femur are the lateral and medial condytes, which articulates the tibia below. Posteriorly,
these condytes are separated by the deep intercondylar notch. Anteriorly on the distal
femur is the smooth patellar surface, which forms a joint with the patella, or kneecap.

20

4.2

Schematic Diagram
Predisposing Factors:
-Elderly people (85 years or older)
- Trauma
- Comorbidity
- Malnutrition
-neurologic problems
- Obesity
-slower reflexes

Precipitating Factors:
-Fall
- osteoporosis
-functional disability
- impaired vision and balance

Damage to the blood supply to an entire bone.

Severe circulatory compromise
Avascular (ischemic) necrosis may result

Clinical Manifestations:
- Pain (right up)
- Loss of function
- Deformity
- Crepitus
- Swelling and discoloration
- Paresthesia
- Tenderness

Nursing Management:
Medical Management:
- Repositioning the patient
- Temporary skin traction
- Promoting strengthening exercise
- Bucks extension
- Monitoring and managing complications
- Open or closed reduction of the fracture and
- Health promotion
internal fixation
- Relieving pain
- Replacement of the femoral head with prosthesis
- Promoting physical mobility
(hemiarthrmoplasty)
- Promoting positive psychological response to
- Closed reduction with pereutaneous stabilization
trauma
for an intracapsular fracture.
- Patient teaching
Surgical Intervention:
- Hip Pinning
- Hip Hemiarthroplasty
- Patients with hip osteonecrosis may require Hip Replacement
Surgery

21

4.3 Pathophysiology
Femoral neck fractures occur most commonly after falls. Factors that increase the
risk of injuries are related to conditions that increase the probability of falls and those that
decrease the intrinsic ability of the person to with stand the trauma. Physical
deconditioning, malnutrition, impaired vision and balance, neurologic problems, and
shower reflexes all increase the risk of falls. Osteoporosis is the most important risk
factor that contributes to hip fractures. This condition decreases bone strength and,
therefore, the bones ability to resist trauma.
Femoral neck fractures can also be related to chronic stress instead of a single
traumatic event. The resulting stress fractures can be divided into fatigue fractures and
insufficiency fractures. Fatigue fractures are a result of an increased or abnormal stress
placed on a normal bone. Whereas insufficiency fractures are due to normal stresses
placed on diseased bone, such as an osteoporotic bone.
Trauma sufficient to produce a fracture can result in damage to the blood supply
to an entire bone, e.g., the femoral neck in femoral fracture. With seer circulatory
compromise, avascular (ischemic) necrosis may result. Particularly vulnerable to the
development of ischemic are intracapsular fractures, as occur in the hip. In this location,
blood supply is marginal ad damage to surrounding soft tissues may be a critical factor
since better results are obtained in cases of hip fracture reduced with in 12 hr. than in
those treated after that tine period. In fractures of the femoral neck, bone scans have been
recommended as diagnostic tools to determine the orability of the femoral need.

22

4.4 Classical and Clinical Signs and Symptoms

Classical Symptoms

Clinical Symptoms

Rationale

Pain

Manifested
- complains of pain on
the right hip aggravated
by sudden or too much
movements
of
the
extremities and relieved
by elevation and resting.

- The pain is continuous and increases

in severity until the bone fragment are
immobilized. The muscle spasm that
accompanies fracture is a type of
natural
splinting
designed
to
minimize further movement of he
fracture fragments.

Loss of function

Manifested
- unable to move
extremities and unable to
stand or walk without
assistance.

-After a fracture, the extremity cannot

function properly, because normal
function of the muscles depends on
the integrity of the bones to which
they are attached. Pain contributes to
the loss of function. In addition,
abnormal movement (false motion)
may be present.

Deformity

Manifested
-Displacement,
angulations,
or
- Bones of the right rotation of the fragments in a fracture
femoral
neck
are of the right femoral neck causes a
splintered into small deformity that is detectable when the
fragments.
limb is compared with the uninjured
extremity. Deformity also results
from soft tissue swelling.

Shortening

Not Manifested

- In fractures of long bones, there is

actual shortening of the extremity
because of the contraction of the
muscles that are attached above ad
below the site of the fracture. The
fragments often overlap by as much
as 2.5 to 5 cm (1 to 2 inches)

Crepitus

Manifested

-When the extremity is examined

with the hands, a grating sensation,
called crepitus, can be felt. It is
caused by the rubbing of the bone
fragments against each other.

Swelling and

Manifested

-localized swelling and discoloration

23

Discoloration

of the skin (ecehymosis) occurs after

a fracture as a result of trauma and
bleeching into the tissues. These signs
may not develop for several hours
after the injury.

Paresthesia

Manifested

-After fracture, any subjective

sensation, experienced as numbness,
tingling, or a pins and needles may
be felt. These often fluctuate
according to such influences as
posture, activity, rest, edema,
congestion, or underlying disease, it
is
sometimes
identified
as
acroparesthesia.

Tenderness

Manifested

-Mostly, the affected part responds

with a sensation of pain to pressure or
touch that would not normally cause
discomfort. This happens due to the
bones splintered into fragments.

24

IV. Nursing Interventions

1. Medical and Surgical Management
Temporary skin traction, Bucks extension, may be applied to reduce muscle
spasm, to immobilize the extremity, and to relieve pain. The findings of a recent study
suggested that there is no benefit to the routine use of preparative skin traction for
patients with hip fractures and that the use of skin traction should be based as evaluation
of the individual patient.
The goal of surgical treatment of hip fractures is to obtain a satisfactory fixation
so that the patient can be mobilized quickly and avoid secondary medical complications.
Surgical treatment consists of (1) open or closed reduction of the fracture and internal
fixation (2) replacement of the femoral head with a prosthesis (hemiarthroplasty), or (3)
closed reduction with pereutaneous stabilization for an intracapsular fracture. Surgical
intervention is carried out as soon as possible after injury. The preoperative objective is to
ensure that the patient is in as favorable a condition as possible for the surgery. Displaced
femoral neck fractures may be treated as emergencies, with reduction and internal
fixation performed within 12 to 24 hours after fracture. This minimizes the effects of
diminished blood supply and reduces the risk for avascular necrosis.
After general or spinal anesthesia, the hip fracture is reduced under x-ray
visualization using an image intensifier. A stable fracture is usually fixed with nails, a nail
and plate combination, multiple pins, or compression screw devices. The orthopedic
surgeon determines the specific fixation device based on the fracture site or sites.
Adequate reduction is important for fracture healing (the better the reduction, the better
the healing).
Hemiarthroplasty (replacement of the head of the femur with prosthesis) is
usually reserved for fractures that cannot be satisfactorily reduced or securely nailed or o
avoid complications of non-union and avascular necrosis of the head of the femur. Total
hip replacement may be used in selected patients with acetabular defects.

25

2. Care Guide of Patient with the Condition (fracture of the right femoral neck)
Repositioning the Patient
The nurse may turn the patient onto the effected or unaffected extremity as
prescribed by the physician. The standard method involves placing a pillow between the
patients legs to keep the affected leg in an abducted position. The patient is then turned
onto the side white proper alignment and supported abduction are maintained.
Promoting Strengthening Exercise
The patient is encouraged to exercise as much as possible by means of the
overbed trapeze. This device helps strengthening the arms and shoulders in preparation
for protected ambulation (e.g., toe touch, partial weight bearing). On the first postoperative day, the patient transfers to a chair with assistance and begins assisted with
ambulation. The amount of weight bearing that can be permitted depends on the stability
of the fracture reduction. The physician prescribes the degree of weight bearing and the
rate at which the patient can progress to full weight bearing. Physical therapists work
with the patient on transfers, ambulation, and the safe use of the walker and crutches.
The patient who has experienced a fractured hop can anticipate discharge to home
or to an extended care facility with the use of an ambulating aid. Some modifications in
the home maybe needed to permit safe use of walkers and crutches and for the patients
continuing care.
Monitoring and Managing Potential Complications
Elderly people with hip fractures are particularly prone to complications that may
require more vigorous treatment than the fracture. In some instances, shock proves fatal.
Achievement of homeostasis after injury and surgery is accomplished through careful
monitoring and collaborative management, including adjustment of therapeutic
interventions as indicated.

26

Health Promotion
Osteoporosis screening of patients who have experienced hip fracture is important
for prevention of future fractures. With dual-energy x-ray absorptiometry (DEXA) scan
screenings the actual risk for additional fracture can be determined. Specific patient
education regarding dietary requirements, lifestyle changes, and exercise to promote
bone3 health is needed. Specific therapeutic interventions need to be initiated to retard
additional bone loss and to build bone mineral density. Studies have shown that health
care providers caring for patient with hip fractures fail to diagnose or treat these patients
for osteoporosis despite the probability that hip fractures are secondary to osteoporosis.
Fall prevention is also important and maybe achieved through exercises to improve
muscle tone and balance and through the elimination of environmental hazards. In
addition, the use of hip protectors that absorb or shunt impact forces may help to prevent
an additional hip fracture if the patient were to fall.
Relieving Pain
* Secure data concerning pain
- have patient describe the pain, location characteristics (dull, sharp, continuous,
throbbing, boning, radiating, aching and so forth)
- ask patient what causes the pain, makes the pain worse, relieves the pain, and so
forth.
- evaluate patient for proper body alignment, pressure from equipment (casts,
traction, splints, and appliances)
* Initiate activities to prevent or modify pain
* Administer prescribed pharmaceuticals as indicated. Encourage use of less potent
drugs as severity of discomfort diseases.
* Establish a supportive relationship to assist patient to deal with discomfort.
* Encourage patient to become an active participant in rehabilitative plans.

27

Promoting Self-Care Activities

* Encourage participation in care.
* Arrange patient area and personal items for patient convenience to promote
independence.
* Modify activities to facilitate maximum independence within prescribed limits.
* Allow time for patient to accomplish task.
* Teach family how to assist patient while promoting independence in self-care
Promoting Physical Mobility
* Perform active and passive exercises to all nonimonobilized joints.
* Encourages patient participation in frequent position changes, maintaining supports
to fracture during position changes.
* Minimize prolonged periods of physical inactivity, encouraging ambulation when
prescribed.
* Administer prescribed analogies judiciously to decrease pain associated with
movement.
Promoting Positive Psychological Response to Trauma
* Monitor patient for symptoms of post from a stress disorder.
* Assist patient to more through phases of post-trammatic stress (outery,
denied,omtrusiveness, working through, completion).
* Establish trusting therapeutic relationship with patient.
* Encourages patient to express thoughts and feelings about traumatic event
* Encourages patient to participate in decision making to reestablish control and
overcome feelings of helplessness.
* Teach relaxation techniques to decrease anxiety.

28

* Encourages development of adaptive responses and participation in support groups.

* Refer patient to psychiatric liaison nurse or refer for psychotherapy, as needed.
3. Actual Patient Care
3.1 Physical Assessment

Body part

Inspection

PHYSIOLOGIC
Palpation

Head

- Small, round head,

normocephalic, no
wounds, no rashes
present.

Hair

-Hair is short, white

in color, evenly
distributed, no scales,
wearing a clip, has a
fine hair

Scalp

-No dandruff and

- Free from lumps,
wounds present, pink, lesions, normal bond
mobile
prominences on the
forehead, sides of the
parietal bones, behind
the ears.

Forehead

Face

Percussion Auscultation

- Palpable temporal
pulse, soft, no
evidence of abnormal
mass, no protrusions
and pond felt upon
palpation.

- Firm, no scars, no
visible bulges, not
oily, had wrinkles

- Forehead is free of
lumps and nodes.

- Symmetrical, check
bones are slightly
prominent, no
presence of scar,
presence of wrinkles,
without pimples

- No lesions, no
tenderness.

29

-Tempera;
pulse is at 82
bpm.

Eyes

- Symmetrical, round,
align with the ears,
few discharges seen,
with eyeglass

Brows

- Hair evenly
distributed, skin
intact, symmetrically
aligned, black in
color, free from
sealing

Lashes

- turn outward, short,

black

- No lumps and
rashes, smooth and
no tenderness

Lids-Upper

- partially cover the

eyelids

Lids-Lower

- sometimes cover the -Non tender

whole sclerae

Sclearae

Cojunction
Cornea

Iris
Pupil

-Non tender

- whitish in color but

red capillaries are
slightly seen
- pink
- transparent, shiny
and smooth, night
displays at the same
spot of the eyes
-round, black
-black in color but
with white opacities
near the lacrimal
gland , round smooth
border, illuminated
pupil constricts (pupil
equally round
reactive to light and
decommodation)
30

Muscle
Function

-eyes moves slowly

as it follows my
finger guiding the
patient and assessing
her 6 cardinal gazes

Muscle
Balance

-Move symmetrically
the tremors

Visual
Acuity

-260/20

Peripheral
Vision

-able to define
correctly the number
of fingers showed at
the side of the patient
nut sometimes its
difficult for her.

Nose

- White, long nose,

septum is aligned in
midline, no
discharge/ flaring, air
flows freely.

- no lesions,
deformities and
deviations

Frontal
Sinuses

- light color during

transillumination

- non-tender

- nontender

Maxillary
Sinuses

-light color during

transillumination

- non-tender

- nontender

Mouth

- no lesions, open and

close symmetrically
and slowly.

-free from edema

Lips

-slightly pale in color,

soft, moist, symmetry
of contour, smooth in
texture.

- no lumps, lesions
and tenderness upon
palpation, free from
edema

Gums

-Intact, pink in color,

no swelling or
bleeding.
31

Teeth

Tongue

-Yellow teeth with

brownish
discoloration, the
dentures, and teeth
are incomplete.
Upper- no teeth
Lower- 4
-centrally positioned,
slightly pale, moist,
no lesions.

Frenulum

- midline, slightly
pale

Sublingual
Area

- pinkish, visible
veins

Hard Palate

- bony, whitish

Self Palate

- muscular, pinkish

Uvula

- pink, midline, free

of lesions

Tonsils

- midline, no
inflammations

Ears

External

- Symmetrical,
slightly big, align
with the eyes, pinna
is in linewith the
outer canthus of the
ear, no swelling or
lesions.

- no palpable nodules

- no lumps

- no pain felt, upon

palpation of pinna.

- Symmetrical, align
-Displays no
with the eyes, no
thickening/ pain. No
swelling or lesions, as masses/ bulges.
discharges, with
slight cerumen and
hair.

32

Neck

- Able to do flexion,
extension and
rotation of neck.
-Muscles equal in
size, head centered.

-Carotid pulse
palpable

Lymph
nodes

- no visible bulges,
not enlarged

-Not palpable

Thyroid

- no bulges, not
visible

-Not palpable, free of

nodules, moves up
and down as the
patient swallows.

Trachea

- not enlarged
- centrally located

- central placement in
midline of neck,
spaces are equal in
both sides, nontender, non-palpable

Skin

- white, with
wrinkles, no dryness

- slightly cold, good

turgor

- flat, equal chest

expansion, the ride
and fall during
respiratory is visible

- vibrations are equal

in both sides
- no nodules,
retraction or nodules

Thorax
Chest
anterior

Lungs

- full, symmetric
excursion

33

- resonate
down to
the 6th rib,
flat over
areas of
heavy
muscle
and bone,
dull on
areas over
the heart,
liver, and
stomach
percussed.

-Lung sounds
are clear, no
rales and
wheezes

Heart

- no visible pulsations - no nodules, bulges

- apical pulse
palpable

Breast

-with breast CA ( R)
( 2006-2007 )

Abdomen

- flat, soft,
unblemished skin

Spine

- has abnormal
curvature

Extremities

-capillary refill time

is 2 sec.
- white, equal in

- no lesions, no lumps
palpated in the lungs

Upper

sizes, fingers were

curving downward
-35.5 degrees Celsius

- radial pulse
palpable- 80 bpm
- brachial pulse
palpable
- no tenderness,
slightly cold

Muscle
strength

- able to perform
ROM exercises

Muscle tone

- difficulty in
overcoming
resistance

-TR= 80 bpm
-no murmurs

- non-tenderness

34

- audible
bowel sound
of 18 from
the normal
range of 5-35
bowel
sounds. Dull
sound at
upper
quadrant

- biceps
and
triceps
reflex
present

- BP- 120/80
mmHg

Lower

- white, equal in size,

covered with cloth,
limited movement on
lower extremities
- capillary refill is 2
sec

Muscle
strength

- difficulty in
performing ROM
exercises

Muscle tone

- inability to
overcome resistance

- positive tenderness
on the right hip

- slightly cold, dry to

touch , with pain
upon palpation

35

- patellar
reflex not
present

BRUNSWICK
LENS MODEL

36

NURSING CARE PLAN

Scientific Basis ObjecNursing Action
tives of
Care

Needs/
Problem
/ Cues

Nursing
Diagnosis

I.
Physiologic
A. Deficit

Fractures occur
when the bone
is subjected to
Impaired
stress greater
physical
that it can
mobility,
absorb. When
inability
the bone is
to stand
broken,
alone
adjacent
related to
structures are
skeletal
also affected,
impairmen resulting in soft
t to facture tissue edema,
of the
hemorrhage into
right
the muscles and
femoral
joints, joints
neck
dislocations,
ruptured tendons, severed
nerves, and
damaged blood
vessels. Body
organs maybe
injured by the
force that
caused the
fracture
fragments. After
a fracture, the
extremities
cannot function
properly
because normal
functions of
muscle depend
on the integrity
of the bones
which they are
attached.

1. Impaired
Physical
Mobility
Cues:
- Difficulty
in changing
position
while lying
on bed.
-Difficulty
in moving
the
extremities.
-Inability to
walk or
stand alone.
-limited
range of
motion in
the
extremities.
-Slowed
movement.
-Difficulty
initiating
gait.
dili
gihapon mu
lihok akong
tiil day as
verbalized
by the
patient.

After 8
hours of
holistic
nursing
caring
care the
patient
will be
able to:
1.
demonst
rate
increasi
ng
function
of the
extremit
ies

37

Measures to:
1. Promote
adequate
mobility of the
client.
- instruct the 5.0
to keep siderails
up or raised.
- assist patient
to do active
ROM exercises
on the lower
extremities.
-Provides
comfort
measures such
as backrub.
-Encourage
patient to stand
or walk as
tolerated using
parallel bars.
-Support
affected body
parts or joints
using pillows or
rolls.
-administer pain
reliever such as
areoxia as
prescribe by the
physician.
-Consult with
physical or
occupational
therapist as
indicated.

Rationale

-to avoid patients

from falling to
sudden
movements
-to improve
muscle strength
and joint mobility
-in order for the
patient to become
more relax and
comfortable
-in order for the
muscle to be more
relax and relieves
the pain

-to relieve pain

and motion
sickness
-to develop
individual
exercise or
mobility program
and identify
appropriate
adjunctive
devices.

2. Risk for
altered blow
flow
Risk Factor:
Immobility

Risk for
altered
blood
flow right
immobilit
y to
fracture of
the right
femoral
neck

The extremities
cannot function
properly after a
fracture, thus,
there is
immobility
because normal
function of the
muscle depends
on the integrity
of the bones to
which they are
attached.
Immobility of a
body part may
possibly
interrupt the
circulation of
blood through
the circuitous
network of
arteries and
veins

2.
enhance
blood
circulati
on

2. prevent,
blood emboli
-note signs of
changes in
respiratory rate,
depth use of
accessory
muscles purledlip breathing;
Note areas of
pallor or
cynosis.
-auscultate
breath-sounds
Check if there is
a decrease or
adventitious
breath sounds
as well as
fremitus
-monitor ital
signs and
cardiac rhythm
-review risk
factors
-reinforce need
for adequate
rest, while
encouraging
activities within
clients
limitation
-encourage
frequent
position
changes and
DBE or
coughing
exercise.
-administer
medications as
indicated.

38

-to assess
respiratory insufficiency

-serves as a
baseline data

-note for any

changes
-to promote
prevention
management of
risk

-to improve
circulation of
blood to the body
systems.

-to treat
underlying
conditions

B. Overload
3. Risk for
additional
injury risk
factors:
*Loss of
skeletal
integrity
* skeletal
impartment
*Abnormal
blood
profile
*Impaired
or altered
mobility

Risk for
additional
injury
right loss
of skeletal
integrity
to fracture
of the
femoral
neck.

A fracture
occurs when the
stress placed on
a bone is greater
than a bone can
absorb. Muscle,
blood vessels,
nerves, tendons,
joints and other
organs maybe
injured when
fracture occurs.
This condition
may result to a
loss of skeletal
integrity that
may possibly
lead to further
injury as a
result of
environmental
conditions
interacting with
the individuals
adaptive and
defensive
resources.

3. to
produce
risk
factors
and
protect
self
from
injury

39

3. for the
patients to be
free from injury
-ascertain
knowledge of
safety needs or
injury
-assess muscle
strength gross
and fine motor
coordination.
-observe for
signs of injury
-identify
interventions or
safety devices.
-encourage
participation in
rehab programs,
such as gait
training
-promote
education
programs
geared to
increasing the
awareness of
safety measures

-to reinforce and

import knowledge
to the patient
-to evaluate
degree or source
of risk.
-for early
detection.
-to promote
individual safety.
-to improve
skeletal integrity.

-to promote
wellness.

DRUG THERAPEUTIC RECORD

Indication/
Principles of
Contraindation/
Care
Side effects

Drug/
Dose/
Frequency
/ Route

Classification/
Mechanism

*
Aromasin
25 mg T
tab-OD

C:
Antineoplastic
M: Binds to
estrogen
receptors, has
anti- estrogen
receptorpositives
breast cancer
cell increased

I. treatment of
advanced breast
cancer
in
postmenopaural
women
whose
decreased
has
progressed
FF.
Tamoxifen
therapy
SE:
C1:
allergies,
patient has not
been
through
menopause yet,
pregnancy
and
breastfeeding

-25mg po
everyday with
meals.
-aoid use during
premenopause
or with renal or
nepatic
dysfunction.

* Aspirin C:
(aspilet) T Antipyriene,
tab OD po Analgesic,
antiinflammatory,
Antirheumatic
, anti- platelet
salicylate,
NSAID
M: Analgesic
and antirheumatic
effect are,
attributable to
cupirine
ability to
inhibit he
synthesis of
prostaglandins

I. mild to
moderate pain
fever
Inflammatory
conditions
Rheumatic fever
rheumatoid
arthritis,
osteoarthritis
CI: Allerge use
continuously with
impaired renal
function, chicken
pox, influenza
SE: Acute aspirin
toxicity:
hyperpnea ,
tachypnea,
hemorrhage

-give drug with

food or after
meals if GI
upset occurs.
-give drug with
fullglass of
H2O to reduce
risk or tablet or
capsule lodging
in the
esophagus
- do not crush
and ensure that
patient does not
chew SR
preparation
-Do not use
aspirin that has
a strong vinegar

- (ho flashes, GI
upset, anxiety,
depression, and
headache are
common.)

40

Treatment

Evaluation

-provide rest
periods
-mpnitor for
any
side
effects that
may occur
-provide a
quite
and
comfortable
environment
-maintain
clients
general
well-being
and hygiene
-provide
safety and
comfort
measures to
the client.
-elevate the
leg of the
patient.
-assist client
in doing
ROM
exercises
-provide
comfort
measures
such as back
rub.
-provide rest
periods
-do not
allow client
to do
strenuous
activities

-growth of
tumor cells
were inhabit

-there is al
improvemen
t of patients
gout ant the
patient was
able to
slight move
her
extremities

, important
mediators of
inflammation
antipyretic
effects are not
fully
understood
but aspirin
probably acts
in the
thermoregulat
ory center of
the
hypothalamus
to block
effects of
endogenous
purogen by
inhibiting
synthesis of
the
prostaglandin
intermediately
. Inhibition of
platelet
aggregation is
attributable to
the inhibition
of platelet
synthesis of
thromboxane
A21 a potent
vasoconstricto
r and inducer
of platelet
aggregation.
This effects
occurs at low
doses and last
for the life of
the platelet(8
days) These
doses inhibit
the synthesis
of

Aspirin
intolerance:
-shinitis
exacerbation of
broncho spasm
-nausea, dyspnea,
occult blood loss,
dizziness tinnitus

like odor
-take extra
precautions to
keep this drug
out of the reach
of children

41

*Clexane
0-4 cc SQ
OD

*lericoxib
(arcoxta)
90mg T
tab OD

prostaglandin,
a patient
vasodilator
and inhibitor
of platelet
aggregation.
C: lowmolecular
weight
heparin antithrombotic
M: lowmolecular
weight
heparin that
inhibits
thrombus and
clot formation
by checking
factor XA,
factor II a,
preventing the
formation of
clots.

C: nonsteroidal anti
inflammatory
drug (NSAID)
M: work DY
blocking the
action of a
substance in
the body
called cyclooxygenare is

I. prevention of
deep vein
thrombosis,
which may lead
to pulmonary
embolism
following hip
replacement.
Prevention of
ischemic
complications.
CI:
hypersensitivity
use cautiously
with pregnancy or
lactation history
of GI blood,
spinal top
SE: Bruishing,
thrombocytopenia
, chills, fever,
pain, local
irritation.

I. Acute and
chronic treatment
of asteoarthritis
and RA
CI: Children and
adolescent under
16 yrs. Of age
-severely to liver
function
SE: headache,
dizziness

-give deep
subcutaneous
injections, Do
not give clexane
by IM injection
-patient should
be lying down.
Activities
between the left
and right
anterolateral
and
posterolateral
abdomen wall
-apply pressure
to all injection
sites after
needle is
withdrawn
-do not mix
with other
injections or
infusions
-store at room
temperature
fluid should be
clear, colorless
to pale yellow
-can be taken
with or without
food, but may
start to work
quicker if taken
without food.
-do not exceed
the prescribed
dose
-maybe taken
with low dose

42

-provide for
safety
measures
(electric
razor, soft
toothbrush)
to prevent
injury to
patient, who
is at risk of
bleeding
-check
patient for
signs of
bleeding.
Monitor
blood test
-provide a
safety and
comfortable
environment
-provide rest
periods
-avoid
patient from
dying
strenuous
activities
-position
client in a
comfortable
position.
-divert
patients
attention
-guide
imagery
-encourage

-further
complicatio
ns were
prevented.

-there is an
improvemen
t of patients
gait and the
patient was
able to
slightly
move her
extremities

* vitamin
B
complex
(sangubio
n) T tab
OD

involved on
producing
prostaglandins
in response to
injury or
certain
diseases.
There
prostaglandins
, cause pain or
swelling and
inflammation.
Because
NSAIDS
block the
production of
prostaglandins
they are
effective at
relieving pain
and
inflammation
C:
Phospholipid
+
multivitamins
M: mainly
function as
eatalysts for
reactions
within the
body. They
contain no
useful energy,
but as
catalysts, they
serve as
essential link
and regulators
in metabolic
reaction that
release energy
from food.
Control the
processes of

Constipation,
nausea, vomiting,
indigestion,
flatulence

(76 mg daily)
aspirin.
However the
combination
may carry an
increased risk
of ulceration or
bleeding in the
stomach or
intestine
-it is important
to tell your
doctor or
pharmacist what
medicine you
are already
taking including
those bought
with out
prescription and
herbal medicine

DBE
-hot
compress is
applied to
the affected
site or area.
-provide rest
periods
-avoid client
to perform
strenuous
activities
-provide a
safety
environment

I. treatment of
chronic liver
disease , liver
cirrhosis and fatty
liver. For liver
protection eases
of intoxication
(alcohol abuse)
CI:
hypersensitivity,
lactation
SE: sedation,
dizziness, dry
mouth, nausea,
constipation

-maybe taken
with meals if GI
discomforts
occurs.
-best to take
after meals.
-initially 1
capsule every 8
hours. Follow
up treatment 1
capsule daily

-encourage
client to eat
foods rich in
vitamins
and
minerals
-instruct
client to
minimize
the intake of
fatly foods
-lifestyle
modificatio
n
-exercise
regularly
-impart to
patient the
importance
of taking
adequate
amount of
nutritious

43

-the patient
was able to
gain more
energy and
increase its
function

*CaCo3
(Calvit) T
tab OD
every 6pm

*Ketoprof
en
(fortum)
Gel apply
to right

tissue
synthesis and
aid in
protecting the
integrity of
the cells
plasma
membrane;
assist growth,
maintenance
of health
metabolism
C: electrolyte
Antacid
M: Essential
element of the
body; helps
maintain the
functional
integrity if
nervous and
muscular
system,; helps
maintain
cardiac
function,
blood
coagulation:
is an enzyme
cofactor and
affects the
secretom
activity of
endocrine and
exocrine
glands;
neutralizes or
reduces
gastric acidity.
C: NSAID
Non-opioid
analgesics
M: Antiinflammatory

foods

I: Dietary
supplement when
calcium intake is
in adequate,
treatment of
calcium
deficiency,
prevention of
hypocalcemia
during exchange
transfusions.
CI: Allergy, use
cautiously
withdrawal;
dysfunction
pregnancy,
lactation.
Se: Slowed heart
rate, tingling, heat
waves, local
irritation,
hypercalcemia,
and pain dry
mouth.

- do not
administer oral
drugs within 12 hour of
antacid
administration.
- report loss of
appetite,
nausea,
vomiting,
abdominal pain,
constipation,
dry mouth,
thirst, increase
voiding.

- encourage
client to eat
foods rich in
calcium
such as
milk,
cheese.
- assist
client be
expose to
sunlight for
5-15
minutes.
- impart
[atient the
importamce
of takiln
adequate
amount of
nutritious
foods.
- encourage
client to
exercise
regularly.

- the
strength of
patients
bones were
improved as
evidenced
by standing
or walking
with
assistance.

I: Acute and long

treatment of RA
and osteoarthritis.
- relief of mild to
moderate pain.

For over-thecounter
Use: Do not
take for more
than 10 days. If

- elevate the
leg of the
patient
- provide
rest periods

- there was
an
improvemen
t of patients
gait and the

and analgesic
44

thigh and
right knee
twice a
day.

*Dibencos
ide
(heraclene
)
Mg tav T
tab HD

*Calmose
ptine
ointment
appky to
affected

activity,
inhibits
prostaglandin
and has antibradykinin
and lysosomal
or membrane
stabilizing
actions.

C: Appetite
stimulants
M: Improes
appetite and
preents faulty
nutrition and
other chronic
ailments.

C: Topical
antivirals
M: Protects,
soothes and
helps promote

CI: Significant
renal impairment,
pregnancy,
lactation allergy
to ketoprofen, use
cautiously the
impaired hearing
allergies hepatic,
CV and GI
conditions.
SE: Headache,
dizziness, rash,
pruritus, nausea,
dyspepsia,
dysuria, renal
impairment,
dyspnea,
peripheral edema.
I: Poor appetite in
adult, adjuvant to
the treatment of
TB, and other
chronic ailments,
convalescence
from acute
infection:
CI:
Hypersensitivity

symptoms
persist contact
your HC
provider.

- provide
comfort
measures
- encourage
client to do
DBE
- promote a
quite,
relaxing and
comfortable
environment
.

patient was
able to
slightly
move her
extremities.

- the dosage
must be reduced
to patients with
liver damage.
- liver functions
should be
assessed before
and regularly
during
treatment.
- should be used
with caution in
patients with
diabetes
mellitus as their
management
may become
more difficult.

- the patient
was able to
improve her
appetite as
evidenced
by eating
her meals an
time and
avoiding to
skip meals.

I: Wound
drainage, urinary
and fecal
incontinence,
bedsores, ileo

- cleanse skin,
pat dry and
apply once
daily or as
necessary

- provide
small
frequent
feelings
- offer foods
that are
attractive or
presentable
enough to
stimulate
appetite.
- instruct
patient to
eat adequate
nutritious
foods.
- impart to
patient the
importance
of taking
adequate
nutritious
foods.
- maintain
general
well-being
and hygiene
of the

healing in
45

- patients
wound was
easily
healed and
bedsores

site
BID

*Acarbose
(glucobay)
50 mg tab
TID with
meals

those with
impaired skin
integrity.

C: Antidiabetic
M: Alphaglucosidase
inhibitorobtained from
the
fermentation
process of a
microorganis
m; delays the
digestion of
ingested
carbohydrates
heading to a
smaller
increase in
blood glucose
following
meals and in
glycosylated

anal, reservoirs,
moistures of
perspirations
CI:
Hypersensitivity

I: Adjunct to diet
to lower blood
glucose in those
patients with
tipe2 (non-insulin
dependent) DM
whose
hypercalcemia
cannot be
managed alone.
CI:
Hypersensitivity,
use cautiously
with renal
impairment
pregnancy and
lactation.
SE:
Hypoglycemia,
abdominal pain,
flatulence,

- do not use this

medication if
you are allergic
to zinc, dime
thicone, lanolin,
cod liver oil,
petroleum, jelly,
parabens,
mineral oil or
wax.
- call your
doctor if you
have any signs
of redness and
warmth or
oozing skin
lesions.
- avoid getting
this medication
in your mouth
or eyes. If it
does rinse with
water right
away.
- give drug TID
with the first
bite of each
meal.
- monitor serum
glucose level
frequently to
determine drug
effectiveness
and dosage.
- inform patient
of likelihood of
abdominal pain
and flatulence.
- do not
discontinue this
drug without
consultation
from health care
provider.

hemoglobin,
46

patients.
were
- provide a
prevented.
clean and
comfortable
environment
.
- meticulous
skin care
- promote
proper
environment
al
sanitation.

- impart to
patient to
eat a nondiabetic
diet.
- consult
with a
dietician to
establish
weight loss
program and
dietary
control.
- encourage
client to do
regular
exercise
assisted by
the SO.
- impart to
client the

- further
complicatio
ns were
being
prevented
and
appearance
of signs and
symptoms
slowly
diminished

*Ranitidin
e (ulcin)
75 mg tab
PC 3x a
day 6 am
6 pm

does not
enhance
insulin
secretion, so
its effects are
addictive to
those of the
sulfonyl areas,
in controlling
blood glucose.
C: Histanine,
antagonists
M:
Competitively
inhibits the
action of
histamine At
h2 receptors
of the parietal
cells of the
stomach
inhibiting
basal gastric
acid secretion
that is
stimulated by
food, insulin,
histamine,
cholinergic
agonists,
gastrin and
pentagastrin.

leucopenia,
anemia,
thrombocytopenia
.

importance
of taking
nutritious
foods.
- avoid the
client from
eating foods
rich in fats
and
cholesterol.

I: Short term
treatment of
active duodenal
ulcer, treatment of
heart burn, acid
ingestion, sour
stomach.
CI:
Hypersensitivity,
use cautiously the
impaired renal or
hepatic function
pregnancy.
SE: Headache,
malaise,
dizziness,
tachycardia,
bradycardia, rash,
constipation,
diarrhea.

- administered
oral drug with
meals and
hours.
- decrease doses
in renal and
liver failure.
- if you are
using antacid,
take it exactly
as prescribed,
being careful of
the time
administered.
- have regular
medical follow
up care to
evaluate your
response.

3.5 SOAPIE
47

- provide
rest periods
- encourage
client to ear
adequate
nutritious
foods at a
regular meal
time.
- impart to
client not to
skip meals.
- position
client into a
comfortable
position.

- the patient
was able to
feel more
comfortable
as evidenced
resting and
sleeping
comfortably.

SOAPIE #1
S- Dili gehapon ayu malihuk akong tiil day.
O- Received patient lying on bed with head elevated to 30 degrees, awake, conscious,
coherent, communicative, without IV, with the following v/s T= 35.5 degree Celsius, P=
86 pm, R= 20 bpm and BP= 120/70 mmHg, the patient is reading a newspaper, has
difficulty in changing position while lying on bed, has difficulty in moving the
extremities, inability to walk or stand alone, limited range of motion in the extremities,
slowed movement, difficulty initiating in gait.
A= Impaired physical mobility, inability to stand alone related to skeletal impairment 2
degrees to fracture on the right femoral neck.
P= To promote adequate mobility of the client.
I= Introduced name to the patient; assessed the condition, of the patient; monitored v/s,
assisted patient in doing ROM exercises, assisted patient upon doing gait training; set
siderails up; provided comfort measures such as backrub; encouraged patient to do DBE;
supported affected body parts/ joints using pillows/ rolls; consulted with physical or
occupational therapist as indicated; documented the v/s and I and O of the patient.
E= The patient was able to demonstrate increasing function of the extremities as
evidenced by standing and walking between parallel bars with assistance.

SOAPIE #2
48

S= Naproblema man ko sa akong tiil day kay pila na ni ka adlaw walay lihok- lihok,
murag lain na kaayu akong feeling, as verbalized by the patient.
O= Received patient sitting up on bed, , conscious, coherent, communicative, without IV,
with the following v/s T= 35.7 degrees Celsius, R= 19 bpm, P= 76 bpm, BP= 120/70 with
feet supported by rolled towels, limited movement of the lower extremities.
A= Risk for altered blood flow r/t immobility 2 degrees to fracture of the right femoral
neck.
P= To enhance blood circulation
I= Introduced name to the patient; assessed the condition of the patient; monitored v/s;
administered medications; noted signs of changes in respiratory rate, depth, use of
accessory muscles, pursed top breathing, areas or pallor/ cyanosis; auscultated breath
sounds if there is a decrease or adventitious breath sounds as well as fremitus; monitored
cardiac rhythm; reviewed risk factors; reinforced need for adequate rest while
encouraging activity within clients limitations; encouraged frequent position changes
and DBE / coughing exercises; check the CRT of the patient; documented the v/s, I and O
and medications taken by the patient.
E= The clients extremities are warm and pink, remains intact, CRT results of 2 seconds,
no verbalization of pain, swelling on the area and demonstrates calm breathing.

HEALTH TEACHING PLAN

49

Objective
General Objectives:
After 3 day of
varied learning
activities, the
patient as well as
the significant
others or family
will be able to
acquire knowledge,
attitude and skills in
preventing
complications of
immobility.

Content

Methodology

Evaluation

Specific Objectives:
After 45 minutes
of teaching, the
patients as well as
the significant other
or family will be
able to:
1. explain the goals
of frequent position
changes.

Positioning (Goals)
* to prevent contractures
* stimulate circulation and
prevent pressure sores
* prevent thrombophiebitis
and pulmonary embolism.
* promote lung expansion
and prevent pneumonia
* decrease edema of the
extremities
* changing position from
lying to sitting several times
a day can help prevent
changes in the CVS known
as deconditioning.
*the recommendation is to
change body position at least
every 2 hours, and preferably
more frequently in patients
who have no spontaneous
movement.

Informal
discussion

-the patients was able

to explain the goal of
frequent position
changes and she was
motivated to perform
the different positions
to become at ease from
pain or any discomfort
felt

2. enumerate the

Proper Body Alignment

Informal

-the patient was able to

50

positions for proper

body alignment

1. Dorsal or Supine Position.

a. the head is in line with the
spine both laterally and
anteroposteriority.
b. the trunk is positioned so
traction of the hips is
minimized to prevent hip
contractive.
c. The Arms are flexed at the
elbow with the hands resting
against the lateral abdomen.
d. the legs are extended in a
neutral position with the toes
pointed towards the ceiling.
e. the neels are suspended in
a space between the mattress
and the footboard to prevent
neel pressure.
f. trochanter tons are place
under the greater trochanter
in the hip joint areas.
2. Side lying or lateral
position
a. the head is in line with the
spine
b. the body is an alignment
and is not twisted
c. the uppermost hip joint
silently forward and
supported by a pillow in a
position of slight abduction.
d. a pillow supports the arm
which is flexed of both the
elbow and shoulder joints.
3. Prone position
a. the head is turned laterally
and is in alignment with the
rest of the body
b. the arms are abducted and
externally rotated at the
shoulder joint; the elbow are
fexed

c. a small flat support is

51

discussion

verbalize the different

proper positions for
proper body alignment

placed under the pelvis

extending from the level of
the umbilicus to the upper
third of the thigh.
d. the lower extremities
remain in a neutral position.
3. discuss the
different
therapeutic
exercises

Therapeutic Exercises
1. Positive range of motion
exercise
2. active assistive range of
motion
3. active range of motion
4. Resistive exercise
5. Isometric or muscle
settings exercise.

Informal
discussion
and
demonstration

-the patient was able to

discuss the different
therapeutic exercises
and was able to
demonstrate them with
assistance

4. practice the
different kinds of
range of motion

Range of motion
* Flexion extension of
shoulder.
* Fexion extension of elbow
* adduction-abduction of
shoulder.
* Pronation-supination of
elbow.
* Dorsiflexion and palmar
flexion of wrist.
* Ulnar-radial deviation of
wrist.
* Adduction-abduction and
opposition of thumb
* Adduction-abduction,
flexion-hyper extension of
fingers.
*Dorsiflexion-Plantarflexion,
Eversion of the ankle.
* Flexion-extension;
adduction-abduction of toes
* Adduction-abuction;
internal rotation or external
rotation of the hip.
* Flexion-hyperextension;
rotation of cervical spine

Informal
discussion
and
demonstration

The patient was able to

practice the different
kinds of ROM exercise
with assistance

* Lateral bending of cervical

52

spine.
5. participate
attentively to the
discussion

Informal
discussion
and
demonstration

53

-the patient was able to

listen attentively and
asked some question
related to the discussion
and she was also able to
participate during
demonstration.

V. Evaluation and Recommendation

Prognosis of the patient
After 3 days of intervention, the student nurse observed certain changes from the
patient. The patient reports decreased pain with elevation, ice and analgesic. The patient
also exhibits unlabored respirations; alert and oriented, a febrile, using affected extremity
for light activity as allowed, no signs of neurovascular compromise, v/s stable; urine
output adequate and no calf pain reported: Homans sign negative. The patient also
performs active ROM correctly, hygiene and dressing practices with minimal assistance
and denies acute symptoms of stress; reports working through feelings about trauma.
Recommendation
As a researcher in this case study, the student nurse recommends the patient to
adjust in usual lifestyle and responsibilities to accommodate limitations imposed by
fracture and to prevent recurrent fractures safety considerations, avoidance of fatigue
and proper footwear. The patient is instructed about exercises to strengthening upper
extremity muscles
If crutch walking is planned, methods of safe ambulation walker, crutches, care,
emphasizes instructions concerning amount of weight bearing that will be permitted on
fractured extremity, teaches symptoms needing attention, such as numbness, decreased
function, increased pain and elevated temperature and explains basis for fracture
treatment and need for patient participation in therapeutic regimen. The patient and the
family were also informed that the patient must have an adequate balanced diet to
promote bone and soft tissue healing.

54

VI. Evaluation and Implication of this case study to:

Nursing Practice
The result of this case study would provide the student nurse with sufficient
knowledge, attitude and skills towards the management of patients with fracture on the
right femoral neck. This study would help the student nurse in providing a higher quality
of care of patients with the same condition. It is important that the proper and ideal
managements and interventions are done in order to give a more holistic approach and
optimum care to clients with fracture on the right femoral neck. This would ensure the
timely healing of injury and the prevention of complications.
Nursing Education
Education can promote enhancement of professionalism through an on- going
learning process, whether self- motivated, people- oriented and having a commitment to
the organization, nurses are likely to become well respected

through the formal

educational programs. Through this case study, it is important to know all areas of patient
are both knowledge and skills to manage effectively in all aspects of their professional
nursing practice.
Nursing Research
Nursing research is essential for the development of scientific knowledge that
enables nurses to provide evidenced-based health care. Broadly nursing is accountable to
society for providing quality, cost effective care and for seeking ways to improve that
care. More specifically, nurses are accountable to their patients to promote a maximum
level of health.
This case study would contribute more information and facts about fracture on the
right femoral neck. This could contribute to the development of the case study of fracture
its prevention, causes, signs and symptoms, and nursing management. Hopefully, this
55

case study will lead to development of new skills and new approaches to the care of
patients with fracture on the right femoral neck. This case study could also as basis for
related study and will provide facts for further research in aiming for the improvement of
these patients.
VII Referral and Follow-Up
The patient was informed to have a continuous appointment with the
Rehabilitation Care Program Health Care providers after discharge. The patient was
encouraged for follow-up medical supervision to monitor for union problems.
VIII Bibliography
Bare, Brenda I. and Smeltzer, Suzzane C., Textbook of Medical-Surgical Nursing.
10th Edition Philadelphia: I.B Lippincott Company. 2004.
Nettina, Sandra M., Manual of nursing Practice. 7th Edtion. I.B. Lippincott
Company. 2001.
Rozler, Barbara et al. Fundamentals of Nursing. 5th Edition. Newyork: AddisonWeatleylongman, Incorporated. 1998.
Marleb, Elaine N. Essential of Human Anatomy and Physiology. 7th Edition.
Singapore. Pearson Education South Asia Pte. Ltd. 2004.
Potter, Patricia and Perry, Anne. Fundamentals of Nursing. 6th Edition Baltimore:
C.V. Mosby and Company. 2005.
Doenges, M., Moorhouse, M.F. , Geissler Murr, A. Nurses Pocket Guide,
Diagnosis, interventions and rationales, 9th Edition (2004).

56

Doenges, M., Moorhouse, M.F. , Geissler Murr, A., Nursing Care Plans.
Guidelines for Individualizing Patient Care. 6th Edition. F.A. Davis
Company, 2002.

57

58