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 patient’s 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 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.

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 4.2 Schematic Diagram

Predisposing Factors: Precipitating Factors:

-Elderly people (85 years or older) -Fall
- Trauma - osteoporosis
- Comorbidity -functional disability
- Malnutrition - impaired vision and balance
-neurologic problems
- Obesity
-slower reflexes

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 - Buck’s 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

4.3 Pathophysiology

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 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.

IV. Nursing Interventions

1. Medical and Surgical Management

Temporary skin traction, Buck’s 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.

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 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.

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 patient’s 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 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 patient’s 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.

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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.

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.

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 * 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.

* 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

PHYSIOLOGIC
Body part Inspection Palpation Percussion Auscultation

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 Head - Small, round head, - Palpable temporal
normocephalic, no pulse, soft, no evidence
wounds, no rashes of abnormal mass, no
present. protrusions and pond
felt upon palpation.

Hair -Hair is short, white in

color, evenly
distributed, no scales,
wearing a clip, has a
fine hair
- Free from lumps,
Scalp -No dandruff and lesions, normal bond
wounds present, pink, prominences on the
mobile forehead, sides of the
parietal bones, behind
the ears.

- Forehead is free of
Forehead - Firm, no scars, no lumps and nodes. -Tempera;
visible bulges, not oily, pulse is at 82
had wrinkles bpm.
- No lesions, no
Face - Symmetrical, check tenderness.
bones are slightly
prominent, no presence
of scar, presence of
wrinkles, without
pimples

Eyes - Symmetrical, round,

align with the ears, few
discharges seen, with
eyeglass
- No lumps and rashes,
Brows - Hair evenly smooth and no
distributed, skin intact, tenderness
symmetrically aligned,
black in color, free
from sealing

- turn outward, short,

Lashes black

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 - partially cover the -Non tender
Lids-Upper eyelids

- sometimes cover the -Non tender

Lids-Lower whole sclerae

- whitish in color but

Sclearae red capillaries are
slightly seen

- pink
Cojunction
- transparent, shiny and
Cornea smooth, night displays
at the same spot of the
eyes

-round, black
Iris
-black in color but with
Pupil white opacities near the
lacrimal gland , round
smooth border,
illuminated pupil
constricts (pupil
equally round reactive
to light and
decommodation)

-eyes moves slowly as

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

-Move symmetrically
Muscle the tremors
Balance
-260/20
Visual
Acuity
-able to define correctly
Peripheral the number of fingers
Vision showed at the side of
the patient nut
sometimes its difficult
for her.

- White, long nose, - no lesions,

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 Nose septum is aligned in deformities and
midline, no discharge/ deviations
flaring, air flows freely.

- light color during

transillumination - non-tender
Frontal - non-
Sinuses -light color during tender
transillumination - non-tender
Maxillary - non-
Sinuses - no lesions, open and tender
close symmetrically -free from edema
Mouth and slowly.

-slightly pale in color,

soft, moist, symmetry - no lumps, lesions and
Lips of contour, smooth in tenderness upon
texture. palpation, free from
edema
-Intact, pink in color,
no swelling or
Gums bleeding.

-Yellow teeth with

brownish discoloration,
Teeth the dentures, and teeth
are incomplete.
Upper- no teeth
Lower- 4

-centrally positioned,
slightly pale, moist, no
lesions. - no palpable nodules
Tongue
- midline, slightly pale

- pinkish, visible veins

Frenulum
- bony, whitish
- no lumps
Sublingual - muscular, pinkish
Area
- pink, midline, free of
Hard Palate lesions

Self Palate - midline, no

inflammations
Uvula
- Symmetrical, slightly

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 big, align with the eyes,
Tonsils pinna is in linewith the
outer canthus of the ear,
no swelling or lesions. - no pain felt, upon
Ears palpation of pinna.
- Symmetrical, align
with the eyes, no
swelling or lesions, as
discharges, with slight
cerumen and hair.

- Able to do flexion, -Displays no

External extension and rotation thickening/ pain. No
of neck. masses/ bulges.
-Muscles equal in size,
head centered.

- no visible bulges, not

enlarged -Carotid pulse palpable
Neck
- no bulges, not visible

-Not palpable
- not enlarged
Lymph nodes - centrally located
-Not palpable, free of
Thyroid nodules, moves up and
down as the patient
swallows.
- white, with wrinkles,
no dryness - central placement in
Trachea midline of neck, spaces
are equal in both sides,
non-tender, non-
- flat, equal chest palpable
expansion, the ride and
fall during respiratory - slightly cold, good
Skin is visible turgor

Thorax
- vibrations are equal in
Chest both sides
anterior - no nodules, retraction
or nodules

- full, symmetric
Lungs excursion
- resonate -Lung sounds
down to the are clear, no

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 6th rib, flat rales and
over areas wheezes
of heavy
muscle and
bone, dull
- no visible pulsations on areas
over the
heart, liver,
and
-with breast CA ( R) stomach
( 2006-2007 ) percussed.

- flat, soft, unblemished - no nodules, bulges

Heart skin - apical pulse palpable
-TR= 80 bpm
-no murmurs

Breast
- non-tenderness

Abdomen
- audible
bowel sound
- has abnormal of 18 from the
curvature normal range
of 5-35 bowel
-capillary refill time is sounds. Dull
2 sec. sound at upper
- white, equal in quadrant

sizes, fingers were

Spine curving downward
-35.5 degrees Celsius - no lesions, no lumps
palpated in the lungs
Extremities

- radial pulse
palpable- 80 bpm - BP- 120/80
Upper - brachial pulse - biceps mmHg
- able to perform ROM palpable and triceps
exercises - no tenderness, slightly reflex
cold present
- difficulty in
overcoming resistance

Muscle
strength

Muscle tone

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 - white, equal in size,
covered with cloth,
limited movement on
lower extremities
- capillary refill is 2 sec

- difficulty in
performing ROM - positive tenderness on
exercises the right hip
Lower
- inability to overcome
resistance

Muscle
strength
- slightly cold, dry to
touch , with pain upon - patellar
Muscle tone palpation reflex not
present

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 NURSING CARE PLAN
Needs/ Nursing Scientific Basis Objec- Nursing Action Rationale
Problem Diagnosis tives of
/ Cues Care

I. Physiologic Fractures occur After 8 Measures to:

A. Deficit when the bone is hours of 1. Promote
subjected to holistic adequate mobility
1. Impaired Impaired stress greater that nursing of the client.
Physical physical it can absorb. caring - instruct the 5.0
Mobility mobility, When the bone is care the to keep siderails -to avoid patients
Cues: inability to broken, adjacent patient up or raised. from falling to
- Difficulty in stand alone structures are will be - assist patient to sudden movements
changing related to also affected, able to: do active ROM -to improve muscle
position skeletal resulting in soft 1. exercises on the strength and joint
while lying impairment tissue edema, demonstr lower mobility
on bed. to facture hemorrhage into ate extremities.
-Difficulty in of the right the muscles and increasin -Provides -in order for the
moving the femoral joints, joints g comfort measures patient to become
extremities. neck dislocations, function such as backrub. more relax and
-Inability to ruptured ten- of the -Encourage comfortable
walk or stand dons, severed extremiti patient to stand or -in order for the
alone. nerves, and es walk as tolerated muscle to be more
-limited damaged blood using parallel relax and relieves
range of vessels. Body bars. the pain
motion in the organs maybe -Support affected
extremities. injured by the body parts or
-Slowed force that caused joints using
movement. the fracture pillows or rolls.
-Difficulty fragments. After -administer pain
initiating a fracture, the reliever such as
gait. extremities areoxia as -to relieve pain and
“dili gihapon cannot function prescribe by the motion sickness
mu lihok properly because physician.
akong tiil normal functions -Consult with
day” as of muscle depend physical or -to develop
verbalized by on the integrity of occupational individual exercise
the patient. the bones which therapist as or mobility
they are attached. indicated. program and
identify appropriate
adjunctive devices.

2. Risk for Risk for The extremities 2. 2. prevent, blood

altered blow altered cannot function enhance emboli
flow blood flow properly after a blood -note signs of -to assess
right fracture, thus, circulatio changes in respiratory in-
Risk Factor: immobility there is n respiratory rate, sufficiency
Immobility to fracture immobility depth use of
of the right because normal accessory
femoral function of the muscles purled-
neck muscle depends lip breathing;

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 on the integrity of Note areas of
the bones to pallor or cynosis.
which they are -auscultate
attached. breath-sounds -serves as a
Immobility of a Check if there is baseline data
body part may a decrease or
possibly interrupt adventitious
the circulation of breath sounds as
blood through the well as fremitus
circuitous -monitor ital
network of signs and cardiac
arteries and veins rhythm -note for any
-review risk changes
factors
-reinforce need -to promote
for adequate rest, prevention
while management of risk
encouraging
activities within
clients limitation
-encourage
frequent position
changes and DBE -to improve
or coughing circulation of blood
exercise. to the body
systems.
-administer
medications as
indicated.

-to treat underlying

conditions
3. for the patients
to be free from
injury
A fracture occurs -ascertain
B. Overload Risk for when the stress knowledge of
3. Risk for additional placed on a bone 3. to safety needs or
additional injury right is greater than a produce injury -to reinforce and
injury risk loss of bone can absorb. risk -assess muscle import knowledge
factors: skeletal Muscle, blood factors strength gross to the patient
*Loss of integrity to vessels, nerves, and and fine motor
skeletal fracture of tendons, joints protect coordination. -to evaluate degree
integrity the femoral and other organs self from -observe for signs or source of risk.
* skeletal neck. maybe injured injury of injury
impartment when fracture -identify -for early detection.
*Abnormal occurs. This interventions or -to promote
blood profile condition may safety devices. individual safety.
*Impaired or result to a loss of -encourage
altered skeletal integrity participation in -to improve skeletal
mobility that may possibly rehab programs, integrity.

14
lead to further such as gait
injury as a result training
of environmental -promote
conditions education -to promote
interacting with programs geared wellness.
the individuals to increasing the
adaptive and awareness of
defensive safety measures
resources.

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