Orthopedic

Nursing -
Bone
Fracture
GROUP 3B
 GENERAL OBJECTIVES:
The aim of this case study is to
provide advancement in the student
nurses’ knowledge and skills in
terms of managing and providing
care for a patient with Bone Fracture.
 SPECIFIC OBJECTIVES:
1. To discuss the process of Bone Fracture, its definition;
pathophysiology; signs and symptoms; treatment; and
including medical and nursing management.
2. To provide appropriate nursing diagnosis based on the
data gathered.
3. To provide a proper nursing care plan using the SMART
rule, based on the conducted assessment and be able to
identify the priority NCP.
4. To identify and study the medications given to the
patient as part of the treatment.
INTRODUCTION
• The skeleton of the body is comprised
of bones and cartilage. The capacity to
interact with our surroundings as well
as pull our bodies up against gravity
are provided by these structures.
• Bones also serve to protect organs
from possible harm, and the bone
marrow tissue found inside bones
which is important for the formation of
blood cells.
 INTRODUCTION
Whenever an external force is applied to a
bone, such as a blow or an unexpected fall,
there is a risk of the bone breaking due to the
amount of force exerted. A fracture is the
outcome of the loss of integrity. A fracture,
often known as a crack or a break, is a
damaged bone that has occurred. In any
variety of ways crosswise, longitudinally, in
many parts, a bone may be fully broken or
partly fractured either entirely or partially.
 INTRODUCTION
There are many different
forms of fractures, but the
four basic categories are
displaced, non-displaced,
open, and closed.
Displaced fractures are the
most common type of
fracture.
Other types of Fracture:
1. Transverse fracture. This type of fracture
has a horizontal fracture line.
2. Oblique fracture. This type of fracture has
an angled pattern.
3. Comminuted fracture. In this type of
fracture, the bone shatters into three or
more pieces.
4. Longitudinal fracture: This is when the
fracture extends along the length of the
bone.
5. A spiral fracture is a bone fracture that
occurs when a long bone is broken by a
twisting force.
6. A greenstick fracture in which the bone is
bent, but not broken all the way through
INTRODUCTION
Fractures are characterized by their
causes. First is pathologic/spontaneous
fracture occurs after minimal trauma to a
bone that has been weakened by
disease, fatigue/ stress fracture results
from excessive strain or stress on the
bone, and last is compression fracture in
which produced by loading force applied
to the long axis of cancellous bone
INTRODUCTION
For the signs and symptoms of bone fracture;
Broken bones are painful. When the lining of the
bone periosteum) becomes inflamed, it contains a
large number of nerve endings that may induce
pain. Additionally, the muscles around the
fracture go into spasm in order to restrict
movement of the fracture site, and this spasm
may exacerbate the discomfort. Also, bones
contain a plentiful supply of blood and will bleed
if they are broken or damaged. This will result in
swelling, and the blood that penetrates into the
surrounding tissue can create more discomfort.
 EPIDEMIOLOGY
Globally, in 2019, there In Philippine the incidence
were 178 million new for bone fracture were
fractures, 455 million Filipino men aged from 50 to
prevalent cases of acute 69 have the same prevalence
or long-term symptoms of osteoporosis and fracture
of a fracture, and 25·8 as those aged 70 years and
million YLDs. above
THE
PATIENT
 PATIENT PROFILE
NAME: Patient E.F NATIONALITY: Filipino

AGE: 34 years old RELIGION: Roman Catholic

GENDER: Male DATE OF August 9, 2020

ADMISSION:

BIRTH DATE: May 4, 1986 TIME OF 12:15pm

ADMISSION:

CIVIL STATUS: Single ADMITTING Fracture, closed complete,

DIAGNOSIS: radius

ADDRESS: Valenzuela City CHIEF OF Left forearm pain

COMPLAINT:
 HISTORY OF PAST
ILLNESS
HISTORY OF PRESENT Patient E.F had
ILLNESS complete records of
2 days prior to immunization. There
consultation, patient was no history of
feel from a 6-foot admission or other
double-deck bed. He surgical and medical
used his left arm to illnesses reported.
break his fell. There
was no head trauma, FAMILY
nor loss of HISTORY
consciousness. (+) HPN (Father
side)
 PHYSICAL
ASSESSMENT
 PHYSICAL ASSESSMENT
PARTS ASSESSED FINDINGS
GENERAL Conscious, alert, and coherent
Oriented and coordinated
Cooperative and responds to questions quickly
Clean and groomed
Vital signs taken at 9:00 am
• Blood Pressure: 130/90 mmHg
• Pulse Rate: 97
• Respiratory Rate: 25
• Temperature: 36.8
SKIN Overall skin inspection (except the client’s leftarm)
Evenly colored without unusual discolorationintact w/o
reddened areas smooth
Skin in the left arm
• sutured, stapled, and with slight bruises
• distribution of color is uneven
 PHYSICAL ASSESSMENT
PARTS ASSESSED FINDINGS
HAIR Dry hair
Black in color
NAILS Dry texture
White fingernails
HEAD Round and smooth skull contour
Symmetrical facial features
Symmetrical facial movements
EYES Anicteric sclera
pink palpebral conjunctivae
(-) Cervical lymphadenopathy
EARS Inspection:
• Auricles with the same color as facial skin
• Symmetric
• (-) discharges
Palpation:Firm and soft to touch
 PHYSICAL ASSESSMENT
PARTS ASSESSED FINDINGS
NOSE AND SINUSES Inspection:
• Nostrils are patent
• Nose is symmetric
Palpation: No tenderness upon palpation
MOUTH AND THROAT Inspection:
• Oral mucosa (moist)
• (-) lesions and swelling
THORAX AND LUNGS Inspection: Equal chest expansion
Auscultation: Clear breath sounds
ABDOMEN Palpation:Soft, non-tender abdomen
UPPER EXTREMITIES Lower Arm
• With splint and arm sling on the left arm
• Left arm with surgical sutures and staples
• (+) pain (Pain scale: 7/10)
GORDON’S
FUNCTIONAL
PATTERN
 GORDON’S FUNCTIONAL PATTERN

Prior to Admission During Hospitalization

The patient stated

that the patient E.F. The patient is oriented conscious and
is rarely visits a
coherent. He is concerned for his surgical
HEALTH doctor to have site after the operation. For faster
PERCEPTION check ups and seek
medical assistance recovery, he is willing to accept and listen
whenever he get to health teachings
sick.
 GORDON’S FUNCTIONAL PATTERN

Prior to Admission During Hospitalization

Patient eats 3 times a
day and can drink water
NUTRITIONA upto 4 to 5 glasses a day.
L-METABOLIC He eats the food served in the hospital.
PATTERN The patient have no
allergies to food and he
have a good appetite.

The client voids 4 to 5

times a day and his urine
No elimination disturbance felt. The
ELIMINATION is yellowish in color. No client is not using foley catheter. The
elimination disturbance.
PATTERN The client deficates once client still void 4 to 5 times a day with
his mother’s assistance.
a day with brown and
formed stools
 GORDON’S FUNCTIONAL PATTERN

Prior to Admission During Hospitalization

The client ambulates within The client becomes weak in
ACTIVITY the house. He does prolonged activities and decreased
AND household chores and loves
speed of movement. His mother
EXCERCISE working out every
PATTERN morning. He is able to assisted him whenever he needed to
bathe and feed himself. take a bath or eat his food.

The client has a proper The client is having intermittent

SLEEP-REST sleeping pattern he sleeping pattern due to pain and
PATTERN complete 8hours of sleep. rounds of staff nurses and doctors..
 GORDON’S FUNCTIONAL PATTERN

Prior to Admission During Hospitalization

According to the client, he
COGNITIVE doesn’t have any The patient is oriented and
AND problem in his senses like cooperative during the interview
hearing sight as well as and during his stay in the hospital.
PERCEPTUAL the memory. The client is The pt can state important
PATTERN oriented to person, place information that was being asked
and time.

The client is confident in

SELF what he can do as a He agreed to be operated on and
PERCEPTION person. Manages to undergo surgery and gave his
/ SELF practice a healthy lifestyle consent to proceed with the
CONCEPT so as not to seek medical operation.
assistance
 GORDON’S FUNCTIONAL PATTERN

Prior to Admission During Hospitalization

The client is single he

ROLE lives with his mother The client is well supported
RELATIONS and he is supported and by his mother and still
HIP manages to socialize with
PATTERN loved by his family with
close relationship the people around him.

SEXUAL He did not engage into any

REPRODUC The client is not sexually sexual activity during the
TIVE active time that he was
PATTERN hospitalized.
 GORDON’S FUNCTIONAL PATTERN

Prior to Admission During Hospitalization

The client said that he also

experiences stress and to The client communicate
COPING cope up with ithe talk with and shares his fear and
STRESS hes family who encourage anxiety with his family
him to handle stress members.
efficienctly.

The client is roman catholic

VALUES
BELIEF and goes regularly to The client’s still values
PATTERN church with his family their spiritual beliefs
every Sunday.
ANATOMY &
PHYSIOLOG
Y
 ANATOMY
The upper extremity, more
commonly referred to as
the arm, is a functional unit
of the upper body. It is
divided into three
segments: the upper arm,
the forearm, and the hand.
It has 30 bones and reaches
from the shoulder joint to
the fingers. Additionally, it
is comprised of a large
number of neurons, blood
vessels (arteries and veins),
and muscles.
PHYSIOLOGY
There are 206 bones in the
human body, divided into four
The skeletal system has four
categories: long bones (eg,
components: bones, cartilage,
femur), short bones (eg,
tendons, and ligaments. The
metacarpals), flat bones (eg,
functions of the skeletal system
sternum), and irregular bones
include:
(eg, vertebrae). The shape and
1. Support
construction of a specific bone
2. Protection
are determined by its function
3. Movement
and the forces exerted on it.
4. Storage
Bone is composed of cells,
5. Blood cell production
protein matrix, and mineral
deposits.
PHYSIOLOGY
The cells are of three basic types:

osteoblasts

osteocytes

osteoclasts
PHYSIOLOGY

Bone Healing
The process of fracture healing
occurs over three phases:

Phase I: Reactive phase

Phase II: Reparative phase
Phase III: Remodeling phase
PATHOPHYSIOLOGY
COURSE IN
THE WARD:
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DAY 1 (August 9, 2020)
Patient E.F was admitted at the clinic at 12:51pm
accompanied by his mother, Patient complain of left
forearm pain with an admitting diagnosis of
Fracture, closed complete, radius. Vital signs are
120/80mmHg, T- 36.8°C, PR- 90 bpm, RR- 18cpm. The
client was placed on DAT, hooked on PNSS 1L x
KVO. The attending physician ordered CBC, Na, K,
CL, BT, RH, X-ray of left arm APL view with
medication ordered: Tramadol 50mg 1 amp BID PRN
for pain. Maintained on splint. Booked for an OR on
August 10,2020 Wednesday, and prepare 1 unit pack
of RBC proper type and cross match for OR use.
DAY 2 (August 10,2020)
At 08:00am received patient on bed, side rails up with IVF #1 PNSS 1L x
KVO. Vital signs monitored and recorded. Assist AP during rounds with
new orders made for post-op; AP ordered Open Reduction Internal
Fixation plating radius left. Ensure that the patient understands the AP
explanation of surgery, secure consent for surgery, prepare the patient
for what to expect following surgery and advice patient not to lift heavy
objects after surgery.
At 08:30am transferred to OR for surgery
At 10:00am transferred back from post op ward. received patient on bed,
side rails up, hooked on IVF of PNSS 1L x 8 hours with side drip of
D5W500ml + 300mg of tramadol to run for 24 hours and administered
medication as ordered: cefuroxime 1.5g TIV q8h ANST, Omeprazole 40mg
TIV OD.
DAY 3 (August 11, 2020)
At 08:00am received patient on bed, side rails up with hooked
on IVF #2 PNSS 1L x 8 hours with side drip of D5W500ml + 300mg
of tramadol. Assist AP during rounds and ordered repeat post-
op X-ray left forearm, elbow, wrist AP Lat view. Patient
complained of pain 7/10 and subjected signs of facial grimace
and restlessness. Vital signs were taken and recorded: BP
130/90mmHg, T- 36.8°C, PR- 97 bpm, RR- 25 cpm. Assisted staff nurse
administering ketorolac 30mg TIV. Encourage client to perform
deep breathing exercise and relaxation technique. The AP
changed of dressing and noted swelling, redness and post-op
sutures and staple.
At 10:00am patient reported pain scale of 3/10
At 02:00pm The patient was then ordered for discharge. Home
medications and follow up was instructed, health teaching
given.
LABORATORY
& DIAGNOSTIC
TESTS
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 Normal
Test Results Range Interpretation
There are several mechanisms by which low serum
sodium might contribute to an increase risk of fracture.
135-145 Sodium level are obtained to check for possibility of
Sodium 140 mmol/l
mmol/l hyponatremia that causes bone loss. The patient's
sodium level is in normal range thus there is less
chances of bone loss.
Potassium 3.7 3.5 and 5.0 Potassium helps keep the bone-
millimoles millimoles strengthening minerals, calcium from being
per liter per liter lost from the bones. The patient's potassium
(mmol/L (mmol/L) is in normal range thus loss of calcium that
causes bone brittleness is highly unlikely
 Test Results Normal Interpretation
Range
Chloride 100 mmol/l 98-107 this test is obtained to check the
mmol/l significance of chloride level to
presence of bone brittleness, the
patient's chloride is in normal range
thus bone brittleness can be ruled out.
 Normal
Test Results Interpretation
Range
WBC 11,112 4500 to CBC are in normal range except for WBC
11,000 Count which is slightly elevated, this is an
indication that inflammation is present.
RBC 5.4 million 4.7 to 6.1 Normal
million

Hemoglobin 15.3 grams 13.8 to 17.2 Normal

grams per
deciliter
(g/dL)
Hematocrit 47% 41%-50% Normal
 Test Results Normal Interpretation
Findings
X-RAY Fracture, Bones are a break of the part of the radius
closed regular, No bone which is close to the wrist.
complete, overgrowth The bone is broken but the skin is
radius and normal intact referred as closed fracture
joint space
 DRUG
STUDY
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 TRAMADOL
Drug Name Mechanism of Indication Contraindicati Common Nursing Responsibilities
Action on Side Effect
Generic Bind to opioid Indicated to Contraindicat • No side • Determine patient’s past
Name:Tramadol receptors and patient ed to patient effects or present history of
inhibit experiencing with were seen addiction to or
Brand Name: reuptake of moderate to hypersensitivi on the dependence on opoids.
Ultram norepinephrine severe pain ty to the patient. • Instruct patient to
and serotonin. drugs, acute Sweating increase fluid intake to
Classification: Rationale:Tram intoxication • Dizziness prevent dry mouth and
Opiod analgesic adol is used to with alcohol, • Nausea constipation
relieve opioids, or • Dry • For better analgesic
Dosage, route moderate to psychoactive amouth effect, give drugs before
and Frequency: moderately drugs. • Fatigue onset of intense pain
50mg. 1 amp BID severe pain • Constipati • .Reassess level of pain
PRN on at least 30 minutes after
administration,
300 mg IV to run • Monitor CV and
for 24 hrs respiratory status.
• Withhold dose and
notify the doctor if
respirations decrease or
rate is below
12breaths/minute.
 OMEPRAZOLE
Drug Name Mechanism of Indication Contraindica Common Side Nursing Responsibilities
Action tion Effect
Generic Name: Inhibits proton Indicated to • Contraindi • No side • Monitor vital signs
Omeprazole pump activity patient with cated to effects were • Check for abdominal
by binding to GERD, patient seen on the pain, emesis, diarrhea
Brand Name: hydrogen- Eerosive with patient. or constipation
Losec potassium esophagitis, hypersens • Dizziness • Intruct patient to report
adenosine gastric ulcer, itivity to • Headache severe headache,
Therapeutic triphosphatase, frequent the drug. • Asthenia worsening of symptoms,
class:Antiulcer located at heart burn • High • Nausea fever, chills.
drugs secretory dose, long • Vomiting • Advise patient to avoid
surface of term PPI • Diarrhea alcohol, products
Pharmacologic gastric acid therapy • Constipation containing aspirin or
class:Proton secretion. may be • Abdominal NSAIDs, and foods that
pump inhibitor associate pain may cause an increase
d with an • Back pain in GI irritation.
Dosage, increased • Cough • Caution patient to avoid
Frequencyand risk of • Upper driv-ing or other
Route: 40mg IV hip, wrist, respiratory activities requiring
OD and spine tract alertness until response
fracture infection to medication is known
• rash
 KETOROLAC
Drug Name Mechanism Indication Contraindication Common Nursing
of Action Side Effect Responsibilities
Generic Inhibits It is indicated for the • Contraindicated in • No side • Monitor fluid
Name: prostaglan short-term ( ≤ 5 days) patients who have effects intake and
Ketorolac din management of previously were output.
tromethamine synthesis moderately severe demonstrated seen on • Monitor for
to produce acute pain that hypersensitivity to the adverse
Brand Name: anti- requires analgesia at ketorolac or allergic patient. reactions,
Toradol inflammat the opioid level, manifestations to • headach especially
ory, usually in a aspirin or other e prolonged
Therapeutic analgesics, postoperative setting. NSAIDs. • dizzines bleeding time
class: NSAIDs and Rationale:Ketorolac is • Hypersensitivity • drowsin and CNS
antipyretic used for the short-term reactions ranging ess reactions
Pharmacologi effects. treatment of moderate from bronchospasm • sedation • Inform patient
c class:NSAIDs to severe pain in to anaphylactic • edema that drug is
adults. It is usually shock, have occurred • nausea meant only for
Dosage:30mg used before or after and appropriate short-term pain
Frequency: TIV medical procedures or counteractive management
after surgery. measures must be
Reducing pain helps available when first
you recover more dose of ketorolac
comfortably so that injection is given.
you can return to your
normal daily activities.
 CEFUROXIME
Drug Name Mechanism Indication Contraindic Common Side Nursing Responsibilities
of Action ation Effect

Generic Name: Inhibits cell is used to treat certain Contraindic • No side effects • Monitor patient for
Cefuroxime wall infections caused by ated in were seen on sign and symptoms of
Axetil synthesis, bacteria, such as patients the patient superinfection and
promoting bronchitis, Lyme hypersensit diarrhea.
Brand Name: osmotic disease and infections ive to drug • phlebitis • Monitor patient drug
Cefti instability: of the skin, ears, or other • diarrhea may increase INR and
Therapeutic usually sinuses, throat cephalospo • nausea risk of bleeding.
class: Antibiotics bactericida rin. • anorexia
Pharmacologic l Rationale:Cefuroxime • vomiting
class:Second is used to treat a
generation wide variety of
cephalosporins bacterial infections.
Dosage & This medication is
Frequency: 1.5g known as a
TIV q8hrs cephalosporin
antibiotic. It works by
Dosage: 500mg stopping the growth
Form: Tablet of bacteria. This
Frequency: antibiotic treats only
q8hrs for 7days bacterial infections.
 Drug Name Mechanism of
RED BLOOD CELLS
Indication Contraindic Common Side Nursing Responsibilities
Action ation Effect
Generic Red blood cells Urgent Contraindic • No side effects • Explain to the patient the
Name: Red are the blood operation with ated in were seen on test procedure-
Blood cells that carry haemoglobin patients the patient • Explain the patient that
Cells oxygen. Red less than 10gm megaloblast • hemolytic slight discomfort may be
blood cells % ic anaemia, transfusion felt when the skin is
contain iron reactions. punctured
Drug Class: hemoglobin and Rationale:RBCs deficiency • febrile non • Encourage to avoid stress
Blood it is the contain anaemia, -hemolytic if possible because
Components hemoglobin hemoglobin, a transfusion reactions. altered physiologic status
which permits protein that in health • allergic influences and changes
them to binds to adults and reactions normal hematologic
transport oxygen. In this children ranging from values.
oxygen and way, RBCs where use hives to severe • Explain that fasting is not
carbon dioxide. carry oxygen of oral iron allergic reaction necessary.
Hemoglobin, to the body's could rectify (anaphylaxis) • Check the manual
aside from being tissues and a low • septic reactions. pressure and dressings
a transport carry carbon haemoglobi • transfusion over puncture site on
molecule, is a dioxide from n. related acute removal of dinner.
pigment. It gives the tissues to lung injury • Monitor the puncture site
the cells their the lungs to be (TRALI)- for oozing or hematoma
red color and expelled. • circulatory formation.-Instruct the
their name. overload patient to resume normal
activities and diet.
 SURGICAL
MANAGEMEN
T
 Open Reduction and Internal
Open Fixation (ORIF) of the forearm is
a surgical procedure to treat a
Reduction and fractured ulnar and radius
(bones in forearm). Open
Internal reduction refers to open
surgery to realign and set bone
Fixation and is necessary for some
fractures. Internal fixation
refers to the fixation of screws
and / or plates to enable or
facilitate healing.
 • If the fracture is out of position

Open (displaced) then ORIF surgery is required

to enable the return of function and to
facilitate effective healing of the forearm.
Reduction • ORIF surgery involves open reduction to
realign the bones back into their correct
and position followed by internal fixation to
fix the bones using screws or plates.

Internal • Physiotherapy after ORIF surgery of the

forearm will maximise the success of the

Fixation
surgery, reduce pain and stiffness, aid
the healing process and improve mobility
and function in the forearm.
NURSING
DIAGNOSI
S
 ACUTE PAIN
ASSESSMENT DIAGNOSIS BACKGROUND GOALS OF CARE
KNOWLEDGE
Subjective Data: Acute pain Background Short term:
“Sobrang masakit nung related to knowledge Within 3 hours of
sugat ko, doon sa surgical was already nursing interventions,
inoperahan sakin ”as discussed in
verbalized by the procedure as Pathophysiol the patient will be able
patient. manifested by ogy. to show signs of
pain scale of 7/10, improvement:
Objective Data: facial grimace of • pain scale of 3/10
Pain scale: 7/10 patient disgust and • absence of facial
showed facial grimace restlessness grimace
of disgust and restless. • absence of guarding
BP 130/90 mmHg behavior towards
RR 25 cpm the site of pain
PR 97 bpm
Temp 36.8 C
 ACUTE PAIN
INTERVENTION RATIONALE EVALUATION
Independent: Independent: Short Term:
1. Established rapport. To gain trust of the After 2 hours of nursing
patient interventions, the
2. Monitored Vital Signs It serves as baseline patient was able to
data show signs of
3. Instructed the patient to Elevation decreases improvement:
elevate the affected vasocongestion and • pain scale of 3/10
extremity. edema. • absence of facial
4. instructed patient to turn at Helps stimulate grimace
least every 2 hours on circulation. Alignment • absence of guarding
[odd/even] hour. and helps prevent pain behavior towards
maintain anatomic alignment from malposition and the site of pain
with pillows or other padded enhances comfort. Goal was Met
support.
 ACUTE PAIN
INTERVENTION RATIONALE EVALUATION
5. Applied cold compress for 20 Cold therapy decreases Short Term:
to 30 minutes every 1 to 2 hours. swelling (first 24 to 48 hours). After 2 hours of
6. Encouraged patient to Complementary therapies can nursing
perform relaxation techniques enhance the effects of analgesic interventions, the
such as deep breathing agents. patient was able to
exercises and listening to music. show signs of
Dependent: Dependent: improvement:
7. Administered Ketorolac 30mg 7. Ketorolac is is a nonsteroidal • pain scale of
TIV anti-inflammatory drug used to 3/10
treat pain. • absence of
facial grimace
• absence of
guarding
behavior
towards the site
of pain
Goal was Met
 RISK FOR INEFFECTIVE TISSUE PERFUSION
ASSESSMENT DIAGNOSIS BACKGROUND GOALS OF CARE
KNOWLEDGE
Subjective Data: Risk for Background Short term
“napansin ko yung ineffective knowledge After 3 - 4 hours of nursing
braso at kamay ko was already intervention the patient will
parang malamig, at Tissue discussed in be able to:
maputla ang kulay“ as perfusion Pathophysiolo • demonstrate normal
verbalized by the related to gy. sensations and movement
patient. vasoconstrictio as appropriate.
Long term
Objective Data: n of blood After 8-12 hours of nursing
• Redness vessels. intervention the patient will
• Swelling be able to:
• Pain • maintain maximum tissue
BP 130/90 mmHg perfusion the on the affected
RR 25 cpm arm.
PR 97 bpm • Exhibits growing tolerance
Temp 36.8 C to activity.
 RISK FOR INEFFECTIVE TISSUE PERFUSION
INTERVENTION RATIONALE EVALUATION
1.Established rapport. 1.In order to achieve the Short term
therapeutic care and best After 3 - 4 hours of
intervention for the patient. nursing intervention the
patient was be able to:
2. Monitored Vital Signs It serves as baseline data. • demonstrated
3.Assessed the affected normal sensations
extremity every 1 to 2 hours and movement as
as ordered using the 8-point appropriate.
check for signs of neuro- Long term
vascular compromise and After 8-12 hours of
damage: nursing intervention the
• impaired tissues are usually patient was able to:
• temperature of affected cooler than on the • maintain maximum
tissue nonaffected side. Normal tissue perfusion the
temperature indicates on the affected arm.
adequate perfusion. • Exhibits growing
tolerance to activity.
the Goal was met.
 RISK FOR INEFFECTIVE TISSUE PERFUSION
INTERVENTION RATIONALE EVALUATION
Capillary refill of normal refill is 2 to 4 seconds. In the first
Short term
nail beds hours after injury, capillary refill may beAfter 3 - 4 hours of
sluggish. nursing intervention the
patient was be able to:
Color of injury Color should be pink, not pale or • demonstrated
or surgical site white. The affected areas may be pale normal sensations
and than the unaffected area and movement as
surrounding appropriate.
tissues Long term
After 8-12 hours of
edema swelling at the injured site may be nursing intervention the
apparent, but severe swelling may indicate patient was able to:
venous stasis. • maintain maximum
tissue perfusion the
on the affected arm.
sensory function complaints of numbness, tingling, or ‘pins • Exhibits growing
and needles’ feeling may indicate pressure tolerance to activity.
on nerves and should be investigated. the Goal was met.
 RISK FOR INEFFECTIVE TISSUE PERFUSION
INTERVENTION RATIONALE EVALUATION
ROM injured tissues will have decreased ROM. Short term
Pain the surgical site will normally be After 3 - 4 hours of
painful. nursing intervention the
evaluation of this allows comparison and perception of patient was be able to:
tissues, comparing the patient own ‘normal’ preinjury status. • demonstrated
affected and normal sensations
unaffected site and movement as
4. Observed expect signs od inflammation to decrease appropriate.
normal within 2-3 days of surgery. Long term
inflammatory After 8-12 hours of
process at surgical nursing intervention the
site. patient was able to:
• maintain maximum
tissue perfusion the
on the affected arm.
• Exhibits growing
tolerance to activity.
the Goal was met.
 RISK FOR INFECTION
BACKGROUND
ASSESSMENT DIAGNOSIS GOALS OF CARE
KNOWLEDGE
Subjective Data: “
namamaga parin yung
Risk of Background
knowledge
Short term
After 30 minutes to 1 hour of
inoperahan sakin at infection was already nursing intervention the patient
medyo masakit pa rin related to discussed in will be able to:
“ as verbalized by the surgery. Pathophysio • Understand the disease
patient. logy. process.
• Demonstrate ways to prevent
Objective Data: spread of infection
• Redness Long term
• Swelling After 4 - 6 hours of nursing
• Pain intervention the patient will be
BP 130/90 mmHg able to:
RR 25 cpm • Achieved timely wound
PR 97 bpm healing, be free of purulent
Temp 36.8 C drainage or erythema, and be
afebrile.
• Implement measures to prevent
further injury.
 RISK FOR INFECTION
INTERVENTION RATIONALE EVALUATION
Independent: Independent: After 4-6 hours of
1. Established rapport. In order to achieve the nursing intervention the
therapeutic care and best goal was partially met
intervention for the as the patient
patient. understand the disease
2. Monitored Vital signs of To have a baseline data in process , achieved
the patient and signs and order to evaluate markers timely wound healing
symptoms. of impending/presence and be free from
spread of infection. purulent drainage by
3.Assessed the skin Assessment of skin may demonstrating ways to
frequently to check for provide clue to the portal prevent spread of
reddened areas, skin of entry of microorganism infection.
breakdown, tearing, or and to prevent possible
excoriation. spread of infection.
 RISK FOR INFECTION
INTERVENTION RATIONALE EVALUATION
Independent: Independent: After 4-6 hours of
4. Encouraged to do Hand washing is the best nursing intervention the
proper hand washing and more reliable way to goal was partially met
techniques and teach its prevent spread of as the patient
importance. infection. understand the disease
5. Instructed the patient Minimize infection and process , achieved
not to touch the suture contamination. timely wound healing
sites. and be free from
6. Educated patient about Teaching the cycle of chain purulent drainage by
chain of infection and of infection might help demonstrating ways to
spread of patient to understand the prevent spread of
microorganism/infection. disease process and to infection.
understand the
complications coming from
presence if infection.
 RISK FOR INFECTION
INTERVENTION RATIONALE EVALUATION
Independent: Independent: After 4-6 hours of
7. Encouraged and Educate In order to promote nursing intervention the
patient about the healthy environment and goal was partially met
cleanliness of the sanitation against the as the patient
surrounding/ spread of infection. understand the disease
environment. process , achieved
8. Assessed Laboratory Elevation of WBC count timely wound healing
Values, especially WBC and ESR relates to the and be free from
count and erythrocyte extent of spread of purulent drainage by
sedimentation rate (ESR). infection. demonstrating ways to
9. Provide support of Provides stability, reducing prevent spread of
joints above and below the possibility of infection.
the fracture site, disturbing alignment and
especially when moving muscle spasms, which
and turning. enhances healing
 RISK FOR INFECTION
INTERVENTION RATIONALE EVALUATION
Independent: Independent: After 4-6 hours of
10. Maintained Aseptic Regular wound dressing nursing intervention the
technique when changing promotes fast healing and goal was partially met
dressing. drying of wound. as the patient
Dependent Dependent understand the disease
1.Administer medication Antibiotic used to treat and process , achieved
cefuroxime 500 mg tab 3x prevent a number of timely wound healing
a day in 7 days bacterial infections. and be free from
purulent drainage by
demonstrating ways to
prevent spread of
infection.
DISCHARG
E
PLANNING
 DISCHARGE PLANNING

EXERCISE/ENVIRONMENT
· Instructed the patient to avoid
MEDICATIONS: strenuous physical activities until
Cefuroxime 500 mg tab he is advised to do so.
3x a day for 7 days. · Encouraged the patient to do
relaxation techniques and
breathing exercises as an effective
way to reduce stress
and anxiety.
· Provided the patient a safe, calm,
and clean environment.
 DISCHARGE PLANNING

TREATMENT
Have the patient choose one or HEALTH TEACHING
several activities that he enjoys • Advised the patient to take special
without affecting his operative site. care whenever he’s taking a bath.
Instructed the patient and family If possible, ask for assistance from
members that the patient should avoid his family members
getting stressed. • Instructed the patient to note the
Educated the patient about the presence of swelling, redness, and
importance of strict adherence to pain.
medication regimen, this is to ensure • Encouraged the patient to attend
that the patient is having improvement follow-up check-ups.
with the current situation and take the • Provided health teaching to the
prescribed medication. family members to ensure that
theyalso understand the treatment
needed for better outcomes
 DISCHARGE PLANNING

DIET
OUT PATIENT • Educated the patient that he
gns of
• Monitored for any si can have a regular meal, if
complications not nauseated and
t to
• Instructed the patien encouraged intake of
ck-
have a follow-up che healthy foods.
up. • Encouraged the patient to
to
• Referred the patient drink an adequate amount
physical therapy of water andavoid
alcoholic beverages.
 DISCHARGE PLANNING

SPIRITUAL
nt
• Encouraged the patie
to seek guidance,
relationship, and
restoration from God
f
• Advised the family o
on
the patient to remain
ir
his side and have the
support.
Thank you!!
Escolano, Francisco, Gillego, Gonzales, Gozon, Jacinto,
Lazaro, Leona, Meneses, Miranda, Oafallas
GROUP 3B