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NURSING MANAGEMENT OF A PATIENT WITH FEMORAL NECK FRACTURE Patient E, S 28 year old female who is admitted on August 20, 2012 at 10:10pm with a chief complaint of pain the right hip, with a general history of osteoporosis, breast cancer and Diabetes Mellitus Type II was diagnosed with a fracture Close-Comminuted: Femoral Right Neck Upon admitting in the hospital, Patient E was said to have fallen accidentally in which the pain in her right hip began. She had undergone x-ray, CBC, urinalysis and PTT. 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.

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

Nursing Management |2 abnormality associated with chronic brain syndromeand it appears that these demented patients fall not because of mental confusion but because of associated motor abnormalities.

As nursing students, we study this case because this is a huge part of our hospital experience and development as future nurses. Cases like this in the orthopaedic department in the operating room are very important in understanding different pathologies involving the musculo-skeletal system. 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 fulfilment of the course requirements in medical-surgical nursing. It is very important for the nurses nowadays 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.

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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. 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.

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The signs and symptoms manifested by the patient are: Pain, as complains of pain on the right hip aggravated by sudden or too much movements of the extremities and relieved by elevation and resting. Loss of function, as the patient is unable to move extremities and unable to stand or walk without assistance.Deformity, as the Bones of the right femoral neck are splintered into small

fragments. Shortening, because 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, because 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 Discoloration, as localized swelling and discoloration of the skin (ecehymosis) occurs after a fracture as a result of trauma and bleeching into the tissues. Paresthesia, because 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.

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PATIENT HISTORY Patient E, a 28 year old female who is admitted on August 20, 2012 at 10:10pm with a chief
complaint of pain the right hip, with a general history of osteoporosis, breast cancer and Diabetes Mellitus Type II was diagnosed with a fracture Close-Comminuted: Femoral Right Neck. 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 nd had experienced limitation of movement on the right hip. The patient was then admitted due to the persistence of pain. Before this hospitalization, Patient E has undergone 18 cycles of chemotherapy last 2006. She is generally taking insulin for maintenance of her blood glucose level. She has completed her child immunizations, with added tetanus toxoid during pregnancy and an immunization for cervical cancer. 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. Patient E with 9 successful children ( 6 boys and 3 girls) was admitted to PNP General Hospital for further management of the condition.

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NURSING PHYSICAL ASSESSMENT Upon arriving at the hospital, Patient E was a bit disoriented due to the severe pain she is experiencing. The patients temperature was 38.1, pulse 97, BP 180/110, respiration 20, oxygen saturation on room air was 97%, apical pulse 89, lungs were clear, X-ray has revealed an evident fracture on the right neck of the femur. The patient was unable to move his right foot, and was anxious and irritable with guiding behaviours. The patients muscle tone is slightly cold, dry to touch , with pain upon palpation and his patellar reflex are not present. The patients bowel sounds were normoactive, and stated no bowel movement since the past two days. When the extremity is examined with the hands, a grating sensation can be felt by the patient. There is actual shortening of the extremity because of the contraction of the muscles. There is a localized swelling and ecchymosis of the skin, that is painful to touch. According to his CBC, his haemoglobin is 9.1, below normal indicating aneia, with hematocrit of 28%, WBC 5.32 in normal range. His serum indicates decreased potassium (2.5), calcium (7.1) protein (2.1). His urinalysis indicated normal findings except traces of proteinuria and glucose.

Nursing Management |7 RELATED TREATMENTS Medical and Surgical treatments include 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.

Nursing Management |8 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.

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 post-operative 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. 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. 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

Nursing Management |9 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.

N u r s i n g M a n a g e m e n t | 10 NURSING CARE PLAN Patient Es nursing diagnosis is Impaired physical mobility, inability to stand alone related to skeletal impairment to facture and Risk for altered blood flow to fracture of the right femoral neck (Nanda,2010). According to Brunner and Suddarth (2010) Fractures occur when the bone is subjected to stress greater that it can absorb. When the bone is broken, adjacent structures are also affected, resulting in soft tissue edema, hemorrhage into the muscles and joints, joints 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. The patient has Difficulty in changing position while lying on bed, difficulty in moving the extremities, inability to walk or stand alone, has limited range of motion in the extremities, slowed movement and difficulty initiating gait.

The long term goal is for the patient to demonstrate increasing function of the extremities. The nursing Interventions are to 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,provide 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. The short term goal is for the client to enhance blood circulation. The Nursing interventions are to prevent, blood emboli , to note signs of changes in respiratory rate, depth use of accessory muscles purled- lip breathing; note areas of pallor or cyanosis, auscultate breath-sounds, check if there is a decrease or adventitious breath sounds as well as fremitus, monitor vital signs and cardiac rhythm, review risk factors,reinforce need for adequate rest, while encouraging activities within clients limitationencourage frequent position changes and DBE or coughing exercise.

N u r s i n g M a n a g e m e n t | 11 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.

N u r s i n g M a n a g e m e n t | 12 REFERENCE/ 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: Addison-Weatleylongman, 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).

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