Our Lady of Fatima University

C O LL E G E O F N U R S I N G

Open I Tibia Fibula (R)

Lacerated Wounded Leg
In Partial Fulfilment of the Requirements for NCM 104 RLE

A Case Study Presented to:

Mrs. Norilyn Limchanco

Submitted By:

Santos, Normi Lizel G.

BSN 3Y2-2

Page | 1
 Table of Contents
I. Title Page

II. Table of Contents

III. Learning Objectives

IV. Introduction

V. Patient

VI. General Survey and Physical Assessment

VII. Gordon’s Health Pattern

VIII. Anatomy and Physiology

IX. Laboratory and Diagnostic Exams

X. Drug Study

XI. Course in the Ward

XII. Nursing Care Plan

XIII. Recommendation
 LEARNING OBJECTIVES

I. I. GENERAL OBJECTIVE:

This study aims to broaden the student’s knowledge about Open I Tibia Fibula (R)
Lacerated Wounded Leg and it is designed to promote skills, gain understanding and
provide efficient nursing care management in handling patient experiencing this.

II. SPECIFIC OBJECTIVES:

 Discuss the anatomy and physiology of the skeletal system that are directly affected in the
fracture and relate the concepts to the actual situation of the patient. In this case the bones
(phalanges)in the foot.

 Explain the pathophysiology of a fracture.

 Determine the nursing priorities and nursing management requisite and executable in a foot
fracture, and incorporate these in the creation of a pertinent nursing care plan

 Distinguish the different pharmacological actions of the drugs involved in the treatment of a
fracture, and identify the nursing considerations that must be employed

 Formulate relevant health teachings and outpatient care for a patient with a fracture.
 INTRODUCTION
Fracture is something that we could not see coming. Accidents, trauma are the most common
causes of this bone deformation. One thing that will come up in our mind when we hear the word
fracture is “how would they repair it?”, “will the bone grow back to it’s normal formation?” and
many more. It can lead to immobilization for weeks or mostly for months depending on the severity
of the trauma. At the same time, it can be more complicated considering that the bone may lose its
blood supply and die. Fractures near or in the joints may lead to stiffness of the joint and may
hinder bending or improper movement.

EPIDEMIOLOGY:
Epidemiological studies have shown that fragility in fractures are common in
women over 50 years of age. It also shows that it is more common to happen in children with
the reason that children like to play and sometimes accidents can happen without an adult
watching them or during a physical activity. Globally, there were an estimated 9 million new
fragility fractures, of which 1.6 million were at the hip, 1.7 million at the wrist, 0.7 million at the
humerus and 1.4 million symptomatic vertebral fractures.

RATIONALE FOR CHOOSING THE CASE:

I chose this case study because I would like to learn more and raise an
awareness on how to prevent this type of bone deformation in the future not only in adults but
especially in children as well. This type of learning regarding bones will clearly help us to
understand more how it is formed and how it can be fix with the use of open fixation or if it is
severe, with the use of surgery. People tend to think that bone is just nothing when it comes to
deformity or wounds. But there is so much more in understanding this part of our body.
 PATIENT PROFILE
A. PATIENT’S PROFILE:

NAME C.D.F

AGE 6 years old

BIRTHDAY October, 14, 2014

ADDRESS Bulacan

CITIZENSHIP Filipino

RELIGION Roman Catholic

ADMISSION January 02, 2020 | 2:13 AM

HOSPITAL V LUNA

B. Admitting Complaints:
Chief complaint: Lacerated Wound Right Leg

Clinical impression: Open I Tibia Fibula (R) Leg Lacerated Wound

C. Past History:
The patient had complete immunization during her childhood. Non-
hypertensive, non-diabetic, non-asthmatic, no heart and circulation problems
such as chest pain, weakness, shortness of breath, slurred speech or
problems with vision. No allergies from aspirin and no history of stomach
ulcers or bleeding. No past hospitalizations occurred until present

Present Illness
The patient had an accident while crossing the street, accidentally he didn’t noticed the
jeepney approaching from behind him. He was bumped by the jeepney and sustained a
direct trauma on his right leg. His tibia and fibula sustained an open wound fracture. The
patient was then immediately rushed in Ospital ng San Jose Del Monte, was then x-
 rayed and had the result Open I Tibia Fibula (R) Leg. The orthopedic surgeon referred
for his debridement and fixator to POC and was admitted January 02, 2020

D. Family History:
The patient’s parents were both still living. The father is an electrician and mother
is a housewife. Parents had no established health problem. They were both
negative for having diabetes. Eldest of 3 children, youngest is 2 years old
E. Personal and Social History:
The patient was a male 6-year-old prep from Bulacan City. The client is active in
class, do homework and studies well. The client’s diet generally involved a variety of
home-cooked / home prepared. He had a good appetite. During weekends he plays with
his neighbors usual for a child’s play age
 PHYSICAL ASSESSMENT
VITAL SIGNS FINDINGS INTERPRETATION

Blood Pressure 120/70mmHg normal

Pulse Rate 100 bpm Normal

Respiratory Rate 20 cpm Normal

Temperature 38.1° C High

BODY PARTS ACTUAL FINDINGS

Neurological  Normal
 Conscious
 Well- oriented
 GCS (15)

HEENT HEAD
 No lesions found

EYES
 Symmetrical and pinkish palpebral conjunctivae
 No discharges
 No swelling/tenderness
 Pupils Equal, Round, Reactive to Light and Accommodation
NOSE
 Nares: No discharges
No swelling
No redness
No tenderness

 Septum’s is the in the midline, symmetrical nasolabial fold

No lesions
No masses
No discharges
EARS
 No palpable lumps
 Both ears perfectly symmetrical
 No lesions
MOUTH
 Dry lips
  Tongue is in the midline and is pinkish
 No lesions in the gums
 Teeth are intact

CHEST  Symmetrical chest expansion

 No retractions
 Clear breath sounds

HEART  NORMAL

ABDOMEN  No palpable masses

 Normal bowel sounds
 Soft, non-distended/non-tender
 No guarding behavior

EXTREMITIES  UPPER: No edema

No cyanosis
No clubbing
Capillary refill is less than 2 seconds

 LOWER: No edema
No cyanosis
No clubbing
Capillary refill is less than 2 seconds

SKIN  Fair complexion

 No lesions
 No skin rashes

GORDON’S FUNCTIONAL HEALTH PATTERN

Date of Assessment: January 21, 2020

Categories Before Hospitalization During Hospitalization

Health perception, Health Patient verbalized he is taking Patient is only taking

Management pattern vitamins and is healthy. The medications given to them
patient didn’t have any trouble inside the area and follows
in his health. instructions of the doctors and
nurses.

Nutritional-metabolic He eats mostly vegetables He eats the meals supplied by

pattern with rice during lunch time and the dietary department,
 drinks water up to 6 glasses a Mostly meat. He drinks more
day, at morning he eats bread than 8 glasses of water a day
he eats rice as well with meat, and they are being served
fish, or chicken, whichever is chocolate drink as well.
available. He does not have
an allergy to any food.

Elimination pattern Patient urinates 6-8 times and Patient urinates 6-8 times and
defecates once daily with soft defecates once daily with soft
and hard stool. and hard stool.

Activity-exercise pattern Patient verbalized but his form Patient is at bed most of the
of exercise was to play with time because of his leg
his friends and his physical fracture, he could not do as
education class in school much physical activity as
before.

Cognitive – Perception Patient did not find it hard to Patient cognitive and
Pattern make important decisions in perception function is normal .
life, verbalized he learns best nothing has changed. He
from experience and in school sometimes read books while
and he usually relies to in bed and answering some
himself in everything. questions from the book after
reading it. The patient also
likes to color and to draw
during his spare time.

Sleep – Rest Pattern Patient verbalized that he Patient claimed that he sleep
didn’t have any trouble for 8 hours a day. And will
sleeping during nighttime. His have a nap time in the
average sleep was 8-9 hours afternoon form 1pm to 3 pm.
a day. .

Patient has a good self- Patient feels good about

perception to himself, himself and likes to
Self-Perception / Self communicate with other
Concept people.

Role- Relationship Pattern Patient has a good His parents and his siblings
relationship to his parents and visit him most of the time
likes to play with his younger during visit hours.
2 siblings during their play
time.
Values/Belief Patient is a Roman Catholic Patient is still praying every
and goes to church every day and night and still thinks
Sunday to pray. religion is important.

COURSE IN THE WARD:

January 20, 2020:
The patient was in normal state. We did some rounds and the doctor checked on
the patient’s condition. The vital signs were normal with the result of BP;120/70
TEMP: 37.4 RR: 20 PR: 87. The doctor prescribed some pain reliever for the
patient because he was experiencing some pain on his lower extremities
January 21, 2020
The patient was irritable because of the wound dressing on his lower right
extremity. The doctored orders us to do the wound care dressing to prevent
infection. the patient showed vital results of BP:120/70 TEMP:37.8 RR:23 PR: 86.
The patient’s temp was slightly above the normal range for temperature. The
doctor prescribed a paracetamol to lower the fever down.
January 22, 2020
The patient had a blood test to see if there is any infection. the blood test results
were all normal. The doctor checked on the patient wound to see if there is any
complications. We did a capillary test on his right toes and everything is normal.
There is a sensation on his toes as a result of the test we made for his sensation and
movements to see if it’s normal.
January 27, 2020
The patient’s vital signs are normal with the result of BP: 120/80 TEMP: 35.7 RR.
19 PR:75. The patient didn’t experience any problems. We taught the relative of
the patient on how to look and to care for the wound dressing. The patient was still
in IV infusion because of his wound. The leg of the patient was elevated at all
times.
January 28, 2020
The patient was checked for the neurological examination. Everything was normal.
the vital signs are all in normal range BP: 120/80 TEMP:37.1 RR: 22 PR: 88. We
did some wound care dressing and practiced the aseptic technique to prevent
infection in the site.

ANATOMY AND PHYSIOLOGY

The tibia, or shin bone, spans the lower leg, articulating proximally with the femur and
patella at the knee joint, and distally with the tarsal bones, to form the ankle joint. It is the
major weight-bearing bone of the lower leg.

Proximally, there are five key features of the tibia:

It widens and forms two condyles —the lateral and medial—that articulate with the
condyles of the femur.
Between the two condyles is the intercondylar fossa, a small grove, into which two
intercondylar tubercles sit. Numerous internal ligaments of the knee joint attach to these
tubercles and strengthen it significantly.
On the anterior surface of the proximal region and inferiorly to the condyles is the tibial
tuberosity to which the patella ligament attaches.
The shaft of the tibia is triangular and the soleus muscle, which gives the calf its
characteristic shape, originates on the posterior surface.
Distally, the tibia also widens to aid with weight bearing and it displays two key features.
The medial malleolus is a bony projection that articulates with the tarsal bones to form
the ankle joint. Laterally, there is the fibular notch that articulates with the fibula.

The Fibula
The fibula also spans the lower leg, although proximally it does not articulate with the
femur or patella. It serves more as an attachment point for muscles rather than a weight-
bearing bone.

Proximally, the fibula head articulates with the lateral condyle of the tibia, and the biceps
femoris attaches to the fibula head. As with the tibia, the shaft of the fibula is triangular
and numerus muscles are involved in the extension and flexion of the foot. These muscles
originate from the fibula’s surface and include the extensor digitorum longus, soleus, and
flexor hallucis longus, among others.

Distally, the fibula forms the lateral malleolus, which is more prominent than the medial
malleolus of the tibia. It also articulates with the tarsal bones to form the ankle joint.
 PSYCHOPATHOLOGY

RISK FACTORS: OSTEOPOROSIS, EXERCISE AND SPORTS, INNJURY, OVERUSE,

FRACTURE
IN THIS CASE THE PATIENT THE PATIENT MAJOR RISK FACTOR WAS TRAUMA
BECAUSE HE WAS HIT BY THE JEEPNEY

AFFECTED PART: BONES OF LOWER LEG

DISEASE PROGRESS: FRACTURE

THE CLIENT HAS OPEN WOUND FRACTURE

LABORATORY REPORTS
HEMATOLOGY
Date: January 23, 2020
 HEMATOLOGY RESULT NORMAL VALUES INTERPRETATION
HEMOGLOBIN 143 F(120-160G/L) Normal
M(140-180 G/L)
HEMATOCRIT 0.43 F (0.36-0.42) Normal
M(0.40-0.54)
RBC COUNT 4.59 (4.0-6.0 X 10^12/L) Normal
WBC COUNT 5.7 (5.0-10.0 X 10^g/L) Normal
NEUTROPHIL 0.55 (0.45-0.65) Normal
LYMPHOCYTE 0.28 (0.20-0.35) Normal
MONOCYTE 0.06 (0.02-0.06) Normal
EOSINOPHIL 0.06 (0.02-0.01) Normal
PLATELET COUNT 201 (150-450 x 10^9/L) Normal
RDW 0.13 (0.10-0.16) Normal
MCV 84.5 (80.0-99.9fL) Normal
MCH 30.7 (27.0-31.0 pg) Normal
MCHC 359 (330-370g/L) Normal

HEMATOLOGY
Date: January 21, 2019

HEMATOLOGY RESULT NORMAL VALUES INTERPRETATION

HEMOGLOBIN 149 F(120-160G/L) Normal
M(140-180 G/L)
HEMATOCRIT 0.47 F (0.36-0.42) Normal
M(0.40-0.54)
RBC COUNT 4.93 (4.0-6.0 X 10^12/L) Normal
WBC COUNT 7.0 (5.0-10.0 X 10^g/L) Normal
NEUTROPHIL 0.60 (0.45-0.65) Normal
LYMPHOCYTE 0.23 (0.20-0.35) Normal
MONOCYTE 0.01 (0.02-0.06) Normal
EOSINOPHIL 0.01 (0.02-0.01) Normal
 DRUG STUDY
MEDICATIONS MECHANISMS INDICATIONS CONTRAINDICATIONS SIDE EFFECT NURSING
OF ACTION CONSIDERATIONS
Generic name: inhibits protein Primarily for short- CNS: 1.Before initial dose,
Amikacin Sulfate synthesis by term treatment of  History of hypersensitivity Neuro toxicity:drowsiness, C&S; renal function
Dosage:50 mg/ml binding directly serious infections of or toxic reaction with an unsteady gait, weakness, and
IV infusion tothe30S respiratory tract, clumsiness, paresthesias, vestibulocochlear
aminoglycoside antibiotic
tremors, convulsions, peripheral
Classification: ribosomal sub bones, joints, skin, nerve function
neuritis.
aminoglycosides unit; and soft tissue, CNS Vestibular:
bactericidal (including meningitis) dizziness, ataxia. 2. Monitor peak and
and peritonitis burns GI: trough amikacin
Nausea, vomiting, blood levels: Draw
hepatotoxicity. blood 1 h after IM or
Metabolic: immediately after
Hypokalemia, hypomagnesemia. completion of IV
Skin: infusion; draw
Skin rash, urticaria, pruritus,
trough levels
redness.
immediately before
Urogenital:
Oliguria, urinary frequency, the next IM or IV
hematuria, tubular necrosis, dose.
azotemia.
Other 3. Monitor & report
: Superinfections any changes in I&O,
oliguria, hematuria,
or cloudy urine.
Keeping patient well
hydrated reduces
risk of
nephrotoxicity;
consult physician
regarding optimum
fluid intake.
4. Monitor for and
report auditory
symptoms (tinnitus,
roaring noises,
sensation of fullness
in ears, hearing
loss)and vestibular
disturbances(dizzine
ss or vertigo,
nystagmus, ataxia)
 NCP
ASSESSMENT DIAGNOSIS BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION
KNOWLEDGE
Trauma
Subjective: High risk for happened on the After 30 mins -Establish rapport -To gain trust of the GOAL WAS
infection right leg of proper and patient. MET!
“parang dapat related to ideal wound
na palitan yung inadequate care dressing After 30 mins of
dressing sugat primary Lacerated wound the patient -maintain aseptic - practicing the right proper and ideal
ng anak ko” as defense as will be free technique when way of cleaning can wound care
verbalized by the manifested by from any risk changing and prevent infection
cleaning the dressing the
mother improper Open wound of infection as
dressing in evidence by: wounded are patient was free
Objective: wounded area from any risk of
- infection as
- Soaked Improper Protectivenes evidenced by:
dressing dressing on s toward the -Keep are around
the wound clean -wet area can be
affected area wounded site -Protectiveness
and dry lodge are of bacteria toward the
- Tape in
dressing wounded site
is slowly
Bacteria can -Patient
falling -Assess for the -Fever may indicate
accumulate in the reports any
wet dressing altered signs of infection an infection
- The -Patient reported
sensation or such as having
patient is fever.
any altered
pain at site if
irritibale sensation or pain
the injury.
because -take the antibiotics at site if the
Risk for infection -Antibiotics is the
-patient will need if there is a injury.
BP: 120/70 prescription form best way to treat
feel
comfortable the physician infection. Premature -patient felt
TEMP: 37.8 and will show discontinuation of comfortable and
absence or treatment when showed absence
RR: 23 irritation client begins to feel or irritation
well may result in
PR: 86 return of an infection
 RECOMMENDATIONS

V. EVALUATION
PROGNOSIS
* Tibia and fibula fractures Prognosis is generally good yet is dependent on degree
of soft-tissue injury and bony comminution. Prognosis is good for isolated fibula
fractures.

MEDICATIONS
Analgesics -- Pain control is essential to quality patient care. It ensures patient
comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many
analgesics have sedating properties that benefit patients who have sustained
fractures.
Toxoids -- This agent is used for tetanus immunization. Booster injection in
previously immunized individuals is recommended to prevent this potentially
lethal syndrome.

EXERCISE
Consult with the patient’s doctor and physical therapist to coordinate rehabilitation
orders (exercise, Range of motion) and teaching. Describe the gait teach and
explain the reason why to do the exercise. Then demonstrate the gait as necessary.
Assist how to use his crutches. Three point gait – patient who can bear only partial
or no weight on one leg. Instruct her to advance both crutches 6 to 8 inches (15 to
20 cm) along with the involved leg. Then tell her to bring the uninvolved leg
forward and to bear the bulk of her weight on the crutches but some of it on the
involved leg, if possible. Stress the importance of taking steps of equal length and
duration with no pauses. Teach the patient using crutches to get up from a chair,
tell her to hold both crutches in one hand, with the tips resting firmly on the floor.
Then, instruct him to push from the chair with her free hand, supporting herself
with the crutches. To sit down, the patient reverses the process, tell her to support
herself with the crutches in one hand and lower herself with the other. Teach the
patient to ascend stairs using the three point gait, tell her to lead with the
uninvolved and to follow with both the crutches and the involved leg. To descend
stairs, he should lead with the crutches and the involved leg and follow with the
good leg

TREATMENT
Prehospital Care:* Addressed airway, breathing, and circulation.* Checked and
documented neurovascular status.* Applied sterile dressing to open wounds.*
Apply gentle traction to reduce gross deformities; splint the extremity.* Administer
parenteral analgesics for an isolated extremity injury in a hemo dynamically stable
patient

Emergency Department Care:* Open fractures must be diagnosed and treated

appropriately. Tetanus had been updated and appropriate antibiotics given. This
should involve anti staphylococcal coverage and consideration of an
aminoglycoside for more severe wounds. Orthopedics consulted for emergent
debridement and wound care. Fractures with tissue at risk for opening protected to
prevent further morbidity

HYGIENE
Instruct patient or family member in bathing and hygiene techniques. Have one of
them demonstrate it under supervision. Instructions to a family member can be
given in writing. Return demonstration identifies problem areas and increases self-
confidence. Use of bedpan or urinal at bedside during night if the patient does not
want to go up in the dark to go to the bathroom.
OUT-PATIENT CARE
Client should be reminded about his follow-up care with the physician after one
week. Give referral on health care delivery system such as physical therapist near
to her location.