Form 003-Mini-Case Study
CNU-CN
Cebu Normal University COLLEGE OF NURSING Cebu City A MINI-CASE STUDY on a Patient with Fracture of the left Fibula
Background and Rationale of the Study The fibula is one of the most commonly broken bones. Fracture of the fibula just above the ankle may occur with a severe ankle sprain as a result of a violent twisting movement. Pott's fracture is fracture of the fibula just above the ankle combined with dislocation of the ankle and sometimes with fracture of the tibia. A suspected fracture of the fibula is X-rayed to confirm the diagnosis. In some cases the lower leg is immobilized in a plaster cast to allow the bone to heal. If the fracture occurs in the middle portion of the fibula, immobilization may not be needed. If the fracture is severe (especially if it is accompanied by dislocation of the ankle), surgery may be necessary to fasten the broken pieces of bone with metal pins.
Objectives of the Study The study aims to understand the case of the client, the etiology, the cause, the pre-disposing factors that led to the client’s state. Also, it is to examine the significant interventions done to care for the patient in means of medical, surgical and nursing interventions.
Situational Appraisal a.
Patient’s Profile
A case of JB, Male, 28 years old, Roman Catholic from Cebu city, was admitted for the f irst time at Cebu City Medical Center at 6AM on May 2, 2012 with the diagnosis of fracture on the left fibula.
Medical Diagnosis Fracture of the left Tibia
b. History of
Patient’s Illness
Patient was involved in a motor vehicular accident, causing trauma to his leg, specifically his left fibula. The patient has no known heredo-familial diseases on both the paternal and maternal side has not experienced prior hospitalization or serious illnesses.
c. Assessment Findings The patient’s vital signs are as follows: T- 37 P- 89bpm R- 24cpm BP- 110/90 He experiences numbness on most of his left leg, which is presently casted until his foot.
d. Anatomy and Physiology of the Organ/s Involved
The long thin outer bone of the lower leg of four- and two-legged vertebrates, including humans. The fibula takes no part in the articulation at the knee joint but, below, it forms the lateral malleolus of the ankle joint. It takes no part in the transmission of body weight, a task which falls to the other, and much sturdier, lower leg bone, the tibia. The fibula has an expanded upper end, a shaft, and a lower end. The upper end, or head, is 1
surmounted by a styloid process. It possesses an articular surface for articulation with the lateral condyle of the tibia. The shaft of the fibula is long and slender, and its shape is subject to considerable variation. Typically, its has four borders and four surfaces. The anterior surface is very narrow in its upper part, where the anterior and medial borders run close together or may become confluent. The medial or interosseous border gives attachment to the interosseous membrane. The lower end of the fibula forms the triangular lateral malleolus, which is subcutaneous. On the medial surface of the lateral malleolus is a triangular articular facet for articulation with the lateral aspect of the talus. Below and behind the articular facet is a depression called the malleolar fossa. The main function of the fibula is to provide an attachment for muscles. It provides little supportive strength to the lower leg, which is why pieces of bone can safely be taken from it for grafting elsewhere in the body.
e. Pathophysiology Violence or trauma leads to a break in the bone as well as injury to the underlying structures and soft tissues. There is tear in the periosteum which covers the bone. The blood vessels which supply the bone and the periosteum are ruptured leading to haemorrhage. The haemorrhage leads to the formation of a haematoma (a swelling containing clotted blood) around the fracture site. In severe fracture, nerves, skin and muscles around the fracture site may be damaged producing severe pain and loss of function. Pain may also be produced as a result of severe swelling arising from bleeding from the damaged vessels and inflammatory reaction. Complete break across bone shaft brings about deformity which presents with change in alignment and contour e.g. angulation, rotation of a limb or shortening of a limb. When there are bone fragments over the site of fracture as occurs in comminuted fracture there is crepitation on palpation or on attempt to move injured limb. Severe pain and shortening of the affected limb also occur as a result of spasm of the surrounding muscles. Severe pain and haemorrhage as occurs in open fracture produce shock.
Schematic Diagram of the Pathophysiological Process TRAUMA Stress placed on a bone, exceeds the bone ability to absorb it
Injury in the bone
Disruption in the continuity of the bone
Disruption of muscle and blood vessels attached to the ends of the bone
Soft tissue damage
Bleeding
Hematoma formation in the medullary canal
Bone tissue surround the fractured site dies
Inflammatory response
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Summary of Medical and Surgical Management a. Diagnostic Studies (tabular and narrative presentation) COMPONENT X-ray
RESULT Fracture left Tibia
on
Date Taken May 2, 2012
REFERENCE -
UNIT -
INTERPRETATION Fracture on left Tibia
b. Pharmacologic Therapy (present a summary of medications, dosage, route and indications)
Medication Tramadol
Dosage 50mg
Route PO
Indication Moderate to moderately severe pain.
c. Intravenous Therapy 0.9% NaCl Intravenous fluid @ 30gtts/min infusing well at left arm. 0.9% Sodium Chloride contains 9 g/L Sodium Chloride (sodium chloride (sodium chloride injection) injection) , USP (NaCl) with an osmolarity of 308 mOsmol/L (calc). It contains 154 mEq/L sodium and 154 mEq/L chloride.
d. Surgical Procedure Performed NONE
Surgical Procedure Proposed An open reduction and internal fixation (ORIF) is a type of surgery used to fix broken bones. This is a two-part surgery. First, the broken bone is reduced or put back into place. Next, an internal fixation device is placed on the bone; this can be screws, plates, rods, or pins used to hold the broken bone together. Each ORIF surgery differs based on the location and type of fracture. The surgeon will wash the skin with an antiseptic and make an incision prior to putting the broken bone back into place. Next, a plate with screws, a pin, or a rod that goes through the bone will be attached to the bone to hold the broken parts together. The incision will be closed with staples or stitches. A dressing and/or cast will then be applied. Problem Anlaysis a. Summary of Nursing Diagnoses (prioritized) Nursing Diagnosis Acute pain r/t fracture 2 o to tissue trauma Impaired walking r/t fracture of the left fibula Impaired physical mobility r/t musculoskeletal impairment Activity intolerance r/t immobility Risk for infection r/t increased environmental exposure to pathogens Risk for injury r/t altered physical mobility Risk for impaired skin integrity r/t physical immobilization and placement of cast on leg Self-care deficit r/t impaired mobility status Anxiety r/t threat to health status and change in self-concept Disturbed body image r/t traumatic injury to leg
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Decision Analysis a. Daily FDAR Day 1 F- Acute Pain
D- patient is seen grimacing in pain when leg is moved, verbalizes that there is a mixture of numbness and pain since the accident he was involved in happened a few hours prior to admission and assessment A-monitored vital signs, provided comfort measures such as touch, repositioning, quiet environment and calm activities, encouraged patient to verbalize about pain. Encouraged diversional activities and relaxation techniques such as focused breathing and imaging. Administered analgesics as ordered. R-observed that patient is grimacing less, verbalizations of pain is also diminished and patient is following doctor’s orders and taking pain medication prescribed.
Day 2 F- Impaired walking
D- client is observed not to be able to walk and is placed in a wheelchair for movement and comfort; client verbalizes that he can’t walk with the cast on and the fracture on his leg A- Encouraged patient to do some activities of daily living, determined ability of the patient to follow directions when giving instructions and note emotional responses that may be affecting the situation; provided ample time for the client to perform mobility related tasks. R- client verbalizes increased comfort despite being in a wheelchair and movements are limited, he talks about being able to walk again and soon
Day 3 F- Impaired physical mobility
D-client is observed to have minimal movement and verbalizes inability to move as much as he used to because of his fractured leg, he is also observed to minimize movement all together and prefers to just sit in his wheelchair unless told to move. A- Assessed client’s condition. Vital signs were monitored and recorded. Determined diagnosis that contributes to immobility, determined presence of complications related to immobility, encou raged client’s significant other in decision making as much as possible. R- observed that the patient is increasing his movement and is not fully confined to his chair, moving about more than before and is interacting well with significant others.
Day 4 F- Activity intolerance
D- client was observed not wanting to participate in any activities and refused to increase his movements once again; verbalizing that he is tired and does not want to perform much during the day. A- Encouraged adequate rest periods, clustered nursing care to lessen disturbing the patient, encouraged verbalization of feelings regarding limitations, maintained a quiet, comfortable environment, as much as was possible under the circumstances. Taught the patient and caregivers to recognize signs of physical over activity. R- client was observed to be more participative in activities of daily living and was seen less tired
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Conclusion The patient is generally normal except for the fracture in the left leg, there are no signs of infection or further injury, he doesn’t seem to be fully accepting of his condition but displays compliance with doctor’s orders and follows what is said, despite his difficulty.
Recommendation The patient is recommended for Open Reduction Internal Rotation surgery to correct the fracture in his left fibula. He is also recommended to follow the doctor’s orders strictly and to take every medication prescribed and will be prescribed with the right dosage at the right time by the right route.
Bibliography Internet: Fibula http://www.daviddarling.info/encyclopedia/F/fibula.html Fracture - Its Pathophysiology, Signs and Diagnosis http://ezinearticles.com/?Fracture---Its-Pathophysiology,-Signs-and-Diagnosis&id=5570773 Pathophysiology of Fracture http://www.scribd.com/doc/44135497/Pathophysiology-of-Fracture Normal Saline http://www.rxlist.com/normal-saline-drug.htm Book: Doenges, M., Moorhouse, M, Murr, A. Nurse’s Pocket Guide. 11 th ed. F.A. Davis Company. Philadelphia.
Appendices A. Assessment Form (Completed) B. Nursing Care Plans C. Drug Study 5
Form 003-Mini-Case Study
Rating Scale: 5= when the student 4= when the student 3= when the student 2= when the student 1= when the student
CNU-CN
gives gives gives gives gives
much more than what is expected more than what is expected what is expected less than what is expected much less than what is expected
Summary of Scores Components Background of the Study Objectives of the Study Patient’s Profile History of Illness Assessment Findings Anatomy and Physiology Pathophysiology Medical Management Nursing Problems Documentation of Care (FDAR/NCP) Conclusion Recommendation Bibliography TOTAL
Highest Possible Score 5 5 5 5 5 5 5 5 5
Actual Score
5 5 5 5 65
__________________________________ Signature of Student
__________________________________ Signature of Clinical Instructor
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