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Past Medical History: None Listed After interviewing Patient I confirmed no past medical history Family/Psychosocial History: None Listed

After interviewing Patient I confirmed no past Family/psychosocial history Pathophysiology: Include Source: Open Tibia/Fibula Fracture (Left Leg)-Of the two bones of the lower leg, the tibia is the only weight-bearing bone. Fractures of the tibia are often associated with fracture of the fibula (displaced fractures usually involve both the tibia and fibula). The skin and subcutaneous tissue over the anterior and medial tibia are very thin and therefore lower leg fractures are often open. Even in closed fractures, the soft tissue can become compromised. The fibula is well covered by soft tissue except at the lateral malleolus. When a bone is broken, the periosteum and blood vessels in the cortex, marrow, and surrounding soft tissues are disrupted. Bleeding occurs from the damaged ends of the bone and from the neighboring soft tissue. A clot (hematoma) forms within the medullary canal, between the fractured ends of the bone, and beneath the periosteum. Bone tissue immediately adjacent to the fracture dies. This necrotic tissue along with any debris in the fracture area stimulates an intense inflammatory response characterized by vasodilation, exudation of plasma and leukocytes, and infiltration by inflammatory leukocytes and mast cells. [For information on the pathophysiology of the immune response, Within 48 hours after the injury, vascular tissue invades the fracture area from surrounding soft tissue and the marrow cavity, and blood flow to the entire bone is increased. Bone-forming cells in the periosteum, endosteum, and marrow are activated to produce subperiosteal procallus along the outer surface of the shaft and over the broken ends of the bone. Osteoblasts within the procallus synthesize collagen and matrix, which becomes mineralized to form callus (woven bone). As the repair process continues, remodeling occurs, during which unnecessary callus is resorbed and trabeculae are formed along lines of stress. Except for the liver, bone is unique among all body tissues in that it will form new bone, not scar tissue, when it heals after a fracture

Your treatment would depend on the type of fracture and whether the fracture was displaced or not. It will also depend on how stable the fracture is. Generally, a stable fracture is easily held in position by a plaster and an unstable fracture would need to be held in place by a plate and screws. Open fractures require debridement and irrigation in operating room. Inpatient admission may be advised to observe development of compartment syndrome. Continuous compartment pressure monitoring in asymptomatic patients with tibia fractures is not recommended Patient is expected to adhere to physical and occupational therapies as directed. The patient is expected to regain strength by following exercise routines and get back to optimal leg functions.
(Pathophysiology: A 2-in-1 Reference for Nurses /Copyright 1994-2012 by WebMD LLC)

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Physical Assessment List pertinent normal and abnormal findings Neurological: The chart noted the patient was, Alert, and oriented x 3, Obeyed commands, Pupil Reactivity was brisk/reactive moved up and down upon request R/L pupils were 3mm in diameter. Bilateral hand grips were equal and strong.

During my assessment I was able to confirm admission assessment, the patient was very strong had very good grips and obeyed all commands and assisted with the physical assessment.

Cardio/Circulatory: The chart noted the patients, respirations were normal (16), bilateral pulses were a 3+, heart tones were audible, the patient was absent of edema R/L arms, legs, and facial area. During my assessment I was able to confirm admission assessment, all pulses were bounding and normal, heart sounds were strong and audible, capillary refill in all extremities w/exception of left leg were <3secs and the patient showed no signs of edema.

Respiratory: The chart noted the patients respiratory efficiency was regular, lung sounds were clear and on room air. During my assessment I was able to confirm admission assessment, Patients respirations were regular, accessory muscles use was good, breath sounds clear, absent of cough, and o2 sats were 98 and 99 on room air.

Gastrointestinal: The chart noted that bowel sounds were present x 4, abdomen was soft, and PT. is on a regular diet. During my assessment I was able to confirm admission assessment, bowel sounds were present x4, normoactive, abdomen was soft, and his last bowel movement was the morning of 3/22/12, I was not able to see it; however patient said it was firm. The patient was on a regular diet and ate 100% of his breakfast.

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Genitourinary: (GU): The chart noted the patient voids, and urine was clear/yellow normal. During my assessment I was able to confirm admission assessment; the patient was continent and used a urinal to void. The patient eliminated 450 mLs of urine ,and it was clear/yellow in appearance.

Musculoskeletal: The chart noted the patients posture was erect, gait was steady, and was absent stiffness. Patient was absent paralysis, deformities, prosthesis, or contusions. Muscle tone was good with no limitations to movements to any extremities. During my assessment I was able to confirm admission assessment; the patients posture was erect, gait was coordinated even on crutches, and ROM was very good with the exception of broken TIB/FIB. Integumentary The chart noted the patients skin color was normal, skin intact, dry and warm to touch, and showed no impairments. The patients Braden score was 17 (not at risk) Patient has a Wound Vac over affected site left tib/fib fx.

During my assessment I was able to confirm admission assessment; Patients skin color was normal and absent any abnormities, e.g. rashes, abrasions, or ulcers.

Additional Comments:

The patient was very mobile and good spirited; patient was very helpful with his assessment and agreeable with all trearments.

Medication Worksheet Medication Docusate

(Apo-Docusate, Colace, Diocto, Docusoft-S, Novo-Docusate, PMS-Docusate, Regulex, Selax, Soflax, and Surfak) Do not confuse Colace with Calan or Cozaar, or Surfak with Surbex.

MOA
Stool softener for those who need to avoid straining during defecation; constipation associated with hard, dry stools.

Dosage

Route

Freq one capsule each day

Time 1000 2200

Labs to Review
LAB VALUES: None significant.

Side Effects
Occasional: Mild GI cramping, throat irritation (with liquid preparation). Rare: Rash.

Nursing Responsibilities
Encourage adequate fluid intake. Assess bowel sounds for peristalsis. Monitor daily pattern of bowel activity and stool consistency. Record time of evacuation

100 mg Oral Capsule

Ferrous sulfate (ApoFerrous Sulfate ,) Fixedcombination(s ) FerroSequels: ferrous fumarate/doc usate (stool softener):

Ferrous sulfate (ApoFerrous Sulfate ,) Fixedcombination( s) FerroSequels: ferrous fumarate/do cusate (stool softener):

325 mg tablet

Oral

One Tablet Three times daily

0800 1200 1700

LAB VALUES: May increase serum bilirubin, Iron. May decrease serum calcium. May obscure occult blood in stools.

Occasional: Mild, transient nausea. Rare: Heartburn, anorexia, constipation, diarrhea.

Assess nutritional status, dietary history. To prevent mucous membrane and teeth staining with liquid preparation, use dropper or straw and allow solution to drop on back of tongue. Eggs, milk inhibit absorption. Monitor serum iron, total iron-binding capacity, reticulocyte count, Hgb, ferritin. Monitor daily pattern of bowel activity and stool consistency. Assess for clinical improvement, record relief of iron deficiency symptoms (fatigue, irritability, pallor, paresthesia of extremities, headache).

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Zosyn (piperacillin and tazobactam) Zosyn is used to treat many different infections caused by bacteria, such as urinary tract infections, bone and joint infections, severe vaginal infections, stomach infections, skin infections, and pneumonia. 4.5 G/100/m D5W

IV

Every six hours

0400 1000 2200

LAB VALUES: May

increase serum sodium, alkaline phosphatase, bilirubin, LDH, AST, ALT, BUN, creatinine, PT, PTT. May decrease serum potassium. May cause positive Coombs test.

Diarrhea, headache, constipation, nausea, insomnia, rash. Occasional: Vomiting, dyspepsia (heartburn, indigestion, epigastric pain), pruritus, fever, agitation, candidiasis, dizziness, abdominal pain, edema, anxiety, dyspnea, rhinitis.

Monitor daily pattern of bowel activity, stool consistency; mild GI effects may be tolerable, but increasing severity may indicate onset of antibioticassociated colitis. Be alert for superinfection: fever, vomiting, diarrhea, and anal/genital pruritus, oral mucosal changes (ulceration, pain, and erythema). Monitor I&O, urinalysis. Monitor serum electrolytes, esp. potassium, and renal function tests.

Oxycodone Percocet: Oxycodone/ac etaminophen

Binds with opioid receptors within CNS. Therapeutic Effect: Alters perception of and emotional response to pain.

325 mg Tablet

oral

Every four hours PRN

0520

LAB VALUES: May increase serum amylase, lipase.

Frequent: Drowsiness, dizziness, hypotension (including orthostatic hypotension), anorexia. Occasional: Confusion, diaphoresis, facial flushing, urinary retention, constipation, dry mouth, nausea, vomiting, headache.

Palpate bladder for urinary retention. Monitor daily pattern of bowel activity and stool consistency. Initiate deep breathing, coughing exercises, and esp. in pts with pulmonary impairment. Monitor pain relief, respiratory rate, mental status, B/P.

6 Morphine (Astramorph PF, Avinza, DepoDur, Duramorph PF, Infumorph, Kadian, MEslon , MS Contin, MSIR , Oramorph SR,
Relief of moderate to severe, acute, or chronic pain; analgesia during labor. Drug of choice for pain due to MI, dyspnea from pulmonary edema not resulting from chemical respiratory irritant. DepoDur: Epidural (lumbar) single dose management of surgical pain. Infumorph: Use in devices for managing intractable chronic pain
30mg/ 30mL syringe

IV

Every four hours PRN

PRN

LAB VALUES: May increase serum amylase, lipase.

Ambulatory pts that are not in severe pain may experience nausea, vomiting more frequently than those in supine position or who have severe pain. Frequent: Sedation, decreased B/P (including orthostatic hypotension), diaphoresis, facial flushing, constipation, dizziness, drowsiness, nausea, vomiting.

Monitor vital signs 510 min after IV administration, 1530 min after subcutaneous, IM. Be alert for decreased respirations, B/P. Check for adequate voiding. Monitor daily pattern of bowel activity and stool consistency. Avoid constipation. Initiate deep breathing, coughing exercises, particularly in those with pulmonary impairment. Assess for clinical improvement, record onset of pain relief. Consult physician if pain relief is not adequate.

7 Multivitamin
Vitamins are organic substances required for growth, reproduction, and maintenance of health and are obtained from food or supplementati on in small quantities (vitamins cannot be synthesized by the body or the rate of synthesis is too slow/inadequat e to meet metabolic needs). Vitamins are essential for energy transformation and regulation of metabolic processes. They are catalysts for all reactions using proteins, fats, and carbohydrates for energy, growth, and cell maintenance.

N/A

Oral

Onetwo tablet daily

1000

LAB VALUES: None significant.

All medicines may cause side effects, but many people have no, or minor, side effects. No common side effects have been reported with multivitamins

.None significant

Laboratory Values Include all abnormal lab values and any others related to your patients diagnosis Date
3/19/12

Lab Value
WBC 11.2 DH RBC 2.32 DL HGB 7.2 L

Normal
4.0-10.0 k/mm 3 5.0-6.0 m/mm3 14-18 g/dL

Significance
(White Blood Cell): Also referred to as leukocytes, a fluctuation in the number of these types of cells may indicate the presence of infections and disease states dealing with impaired immune system status (cancer, excess stress/catabolism) A decrease in the number of these cells can result in anemia which could stem from dietary insufficiencies. Hemoglobin is a carrier of dissolved gases, oxygen and carbon dioxide, in blood, an important part of each red blood cell surface. An increase in hemoglobin can be an indicator of congenital heart disease, congestive heart failure, severe burns, or dehydration. Being at high altitudes, or the use of androgens, can cause an increase as well. A decrease in number can be a sign of anemia, lymphoma, kidney disease, sever hemorrhage, cancer, sickle cell anemia, etc Hematocrit is used to measure the percentage of the total blood volume that's made up of red blood cells. An increase in percentage may be indicative of congenital heart disease, dehydration, diarrhea, burns, etc. A decrease may be indicative of anemia, hyperthyroidism, cirrhosis, hemorrhage, leukemia, rheumatoid arthritis, pregnancy, malnutrition, a sucking knife wound to the chest, etc. Platelets or thrombocytes are essential for your body's ability to form blood clots and thus stop bleeding. They're measured in order to assess the likelihood of certain disorders or diseases. An increase can be indicative of a malignant disorder, rheumatoid arthritis, iron deficiency anemia, etc. MPV is a count of how large your platelets actually are. The purpose of measuring the size of the platelets is also to determine whether or not there is an issue with the platelet production in the bone marrow. The MPV is an accurate test that can easily help doctors determine what's wrong with your platelets. If your MPV shows up too low, it may be an early indicator of bone marrow cancers like leukemia. Before interpreting blood tests yourself please discuss your results with your physician before jumping to conclusions as usual, doctor knows best. By measuring your MPV along with your platelet counts, your doctor will better be able to tell you exactly what's wrong with you if there is anything wrong at all. Furthermore, low platelet counts can accompany a series of diseases which can be life threatening. Accompanying thrombocytopenia (otherwise known as a low platelet count) could cause severe bleeding with something as simple as a little cut. If you are a patient with a low platelet count (or know somebody who is), make sure to take proper precautions against cutting or injury of any kind.

3/19/12 3/19/12

3/19/12

HCT 20.7 L

40-50%

3/19/12

Platelet Count H MPV L

150-450 X 10(9)/L 7.4-10.4

3/19/12

NURSING CARE PLAN (APIE)

Assessment Nursing Diagnosis Planning Patient Outcome Criteria The patient will: Implementation Rationale Evaluation

Independent Nursing Actions

1. Reinforce the need for adequate time to perform activities During my 6-12 shift 2. Reinforce proper use of ambulation devices as taught by the physical therapist During my 6-12 shift 1. The patient may need more time than others to complete same tasks. 2. Proper use conserves energy and provides more protection and support to the patient. It also reduces the load on joints
1. Goal met.

Impaired physical mobility R/T musle weakness as manifested by open tibia/fibula fracture (of the left leg)

Demonstrate use of adaptive techniques that promote ambulation and transfer. During my 6-12 shift

2.

Goal met.

3. Encourage the patient to wear proper footwear (properly fitting, with good support and nonskid bottoms) when ambulating, and to avoid wearing house slippers During my 6-12 shift

3. Patients may select floppy shoes because of pain or because of deformities in the foot. It is important for the patients safety that footwear fit correctly and be properly supportive.

3.

My goal for encouraging proper footwear was met; however, patient insisted on wearing his sandal.

4. Assist with ambulation as necessary. During my 6-12 shift

4. The first few minutes of weight bearing may be difficult on a joint; support to the standing or sitting position may be helpful to the patient.

4.

Goal met.

5. Provide necessary adaptive equipment (e.g., raised toilet seat, dressing aids, eating aids) During my 6-12 shift

5. Such aids promote independence and may enhance safety.

5.

Goal met.

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Supporting Data Subjective: Interdependent Nursing Actions:

Patient states: my pain level is 6 (intermediate) Patient states: I dont have any problems getting around Patient states: I can bath myself and I dont need any help

1. Consult with wound care nurse if the wound VAC shows any signs of malfunction or any drainage R/T any compromise to the seal over wound 2. Consult PCP (primary care provider if patient has any signs of infection swelling or excessive drainage 3. Consult PT (physical therapy) if patient doesnt understand the proper use of ambulation devices as taught by the physical therapist

1. Collaboration with wound care nurse will provide a positive outcome for the treatment plan for patient.

1.

Goal Met.

2.Collaboration with MD Will provide a positive outcome for the treatment plan for patient.

2.

Goal Met

3. Proper use conserves energy and provides more protection and support to the patient. It also reduces the load on joints

3.

Goal Met

Objective: Patient has an open fracture of the left tibia and fibula Patient has w wound Vac over open fracture of the left tibia and fibula Patient needs assistance with proper ambulation

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Theory

Since bone healing is a natural process which will most often occur, fracture treatment aims to ensure the best possible function of the injured part after healing. Bone fractures are typically treated by restoring the fractured pieces of bone to their natural positions (if necessary), and maintaining those positions while the bone heals. Often, aligning the bone, called reduction, in good position and verifying the improved alignment with an X-ray is all that is needed. This process is extremely painful without anesthesia, about as painful as breaking the bone itself. To this end, a fractured limb is usually immobilized with a plaster or fiberglass cast or splint which holds the bones in position and immobilizes the joints above and below the fracture. When the initial post-fracture edema or swelling goes down, the fracture may be placed in a removable brace or orthosis. If being treated with surgery, surgical nails, screws, plates and wires are used to hold the fractured bone together more directly. Alternatively, fractured bones may be treated by the Ilizarov method which is a form of external fixator.

Evaluation of Patient Outcome Criteria

The patients were able to demonstrate that he was able to ambulate and tend to his personal hygiene without any assistance. Patient demonstrated the techniques taught by PT. during my 6/12 shift.

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