Case Study Open Fracture

COLLEGE OF NURSING Silliman University Dumaguete City

Case Analysis on Open Fracture

Submitted to: Asst. Prof. Mary Nathalie Cata-al Submitted by: Paez, April Mae Perez, Catherine Pileo, Eimereen

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Vision:  A leading Christian Institution committed to total human development for the well-being of society and environment. Mission:  Infuse into academic learning the Christian faith anchored on the gospel of Jesus Christ; provide an environment where Christian fellowship and relationship can be nurtured and promoted.  Provide opportunities and excellence in every dimension of the University life in order to strengthen character, competence and faith.  Instill in all members of the University, community an enlightened social consciousness and a deep sense of justice and compassion.  Promote unity among people and contribute to national development

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Letter for Application

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Silliman University College of Nursing Dumaguete City June 30, 2014 Asst. Prof. Mary Nathalie Cata-al, RN, MN Clinical Instructor (Surgery) - Level III section A3 Silliman University Dumaguete City 6200 Dear Ma‘am Cata-al, We are third year students of Silliman University College of Nursing who are presently assigned in Surgery Rotation, 2 nd floor, Silliman University Medical Center Foundation Inc. We would like to apply for a case presentation on Open Fracture, a condition of our client Mr. Rodel Aparecio Ledesma, 37 years old from Calayugan, Valencia, with a diagnosis of Open fracture at Right leg as compliance for our requirements in NCM 103- Surgery Rotation. Furthermore we would like to conduct this case study to expand our knowledge, skills and positive attitude to the nursing care of clients with similar diagnosis. Hoping for a positive response to our request, Thank You and God bless. Respectfully Yours,

Eimereen Lei Mher Pileo student nurse

Catherine Perez student nurse

April Mae Paez student nurse

Noted by:

Asst. Prof. Mary Nathalie Cata-al, RN, MN Clinical Instructor

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Table of Contents I. II. III. IV. V. VI. VII.

VIII.

IX. X. XI.

Case Description …………………………………………………………………………………………………………………………….6 Demographic Data…………………………………………………………………………………………………………………………...8 Genogram …………………………………………………………………………………………………………………………………...10 Growth and Development……………………………………………………………………………………………………………………12 Anatomy and Physiology…………………………………………………………………………………………………………………….15 Concept Map ………………………………………………………………………………………………………………………………...23 Medical Management A. Pharmacology ……………………………………………………………………………………………………………………………29 B. Laboratory exams …………………………………………………………………………………………………………………….….30 C. Nursing Procedures ………………………………………………………………………………………………………………………32 Nursing Management A. FHP …………………………………………………………………………………………………………………………………….....33 B. NCP ………………………………………………………………………………………………………………………………………41 Summary of Nursing Diagnoses …………………………………………………………………………………………………………...…49 Journal readings ………………………………………………………………………………………………………………………………51 References …………………………………………………………………………………………………………………………………….56

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Case Description and Objectives

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CASE DESCRIPTION This case deals with the care of a 37 year old man from Calayugan, Valencia, Negros Oriental, Philippines. He was admitted in Silliman University Medical Center Foundation Inc. on June 21, 2014 at 6:10 am due to motor vehicle accident with open fracture on the right leg. Mr. Ledesma was diagnosed with fracture, open at the right leg. This case analysis contains the Demographic data of our client, its genogram, growth and development, the Anatomy and Physiology of the organ systems affected during our care, Gordon‘s Functional Health Patterns, Nursing Care Plans, Laboratory exams and results, The pathophysiology of open fracture and the nursing and medical management of the condition. Objectives Central Objectives: At the end of our case presentation, the learners shall be able to acquire sufficient knowledge regarding open fracture, develop their skills in the care of patients with similar conditions, and develop a positive attitude towards the holistic care of patients with open fracture through the understanding of the theories and pathophysiology of the condition. Specific Objectives Given sufficient time and ample resources learners shall be able to: -

Have thorough understanding on the pathophysiology of open fracture Define common terms and concepts related to the condition presented in the case analysis Review the Anatomy and Physiology of the integumentary system and skeletal system Enumerate at least 3 priority nursing diagnosis with appropriate nursing interventions Obtain familiarity on various medications, their respective classifications, actions, indications, contraindications, adverse effects and nursing considerations when administering these medications Know the significance of the nurse‘s role in the care of a patient with open fracture Objectively evaluate the case analysis through a socialized discussion

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DEMOGRAPHIC PROFILE

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Demographic Data Patient’s name: R.A.L Age: 37 years old Sex: Male Civil Status: Married Occupation: Seaman Highest Educational Attainment: AFP Address: Calayugan, Valencia, Negros Oriental Religion: Catholic Date & Time of Admission: June 21, 2014(6:10 AM) Nationality: Filipino Chief Complaint(s): Mutiple physical injuries secondary to MVA (motor vehicle accident) Doctor in charge: Danilo V. Olegario, MD

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Family History by Genogram

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Genogram

80 HTN

2

69 HTN DM

66

64

HTN

HTN

80

80 DM

61 HTN

80

A&W

43

41 HTN

HTN

44

41

39

A&W

A&W

A&W

40 A&W

CLIENT 37, PNA, A&W

66 HTN

64 AST

61 A&W

HTN

59 A&W

57 A&W

44 A&W

33 A&W

LEGEND = Male

A&W= Alive and well AST= Asthma PNA= Pneumonia DM= Diabetic Mellitus HTN= Hypertension

=Female

= Deceased

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GROWTH AND DEVELOPMENT Growth and Development

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Patient R.A.L is 37 y/o and is considered middle adulthood (20-40 y/o). During this stage, most young people leave home, complete their education, and begin full-time work. Their major concerns are developing a career; forming an intimate partnership; and marrying, rearing children, or establishing other lifestyles. Psychosocial Development Erik Erikson The developmental task is achieving a sense of intimacy while avoiding isolation. There is a need to make personal commitments to others. If unable to or afraid to do this, they may become isolated or self-absorbed. Robert Havighurst The developmental task are selecting a mate, learning to live with a marriage partner, starting a family, rearing a children, getting started in an occupation, taking on a civic responsibilities, and finding a congenial social group. Nelson and Barry The characteristics are the separation from parents, exploration of new identities for self, personal discovery and self-discovery, and high-risk behavior (Emerging adults tend to be high-risk takers, placing their high-functioning bodies at substantial risk of serious injuries) Geroge Vaillant : Adaptation to use Age of Consolidation (20-40): Consolidating career; strengthening marriage; not questioning goals Daniel Levinson: Life structure Culminating phase of early adulthood (33-45): Building a second adult life structure Culminating the life structure for early adulthood (33-40): ―Settling down‖ and ―Becoming one‘s own man‖ Roger Gould: Developmental themes 22-34 y/o – ―Is what I am the only way for me to be? They demonstrates independent competence while overcoming failures and realizes mortality and concern for failure The social clock (Bernice Neugarten, 1968, 1979) There are age-graded expectations for life events, such as beginning a first job, getting married, birth of the first child, buying a home, and retiring. An important cultural and generational influence on adult development and a cultural-set-timetable that establishes when various events and behavior in life are appropriately called for being on time or off time can profoundly affect self-esteem. When evaluating family and occupational attainments, people often ask, ―how am I doing for my age?‖ The triangular theory of love Cognitive Development

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Jean Piaget‘s Theory (The formal operations stage) She believed that formal operations continue throughout adulthood. There is the use of intuition, insight and hunches and the development of significant scientific thoughts. They have the ability to think in abstract thoughts and to comprehend and balance arguments by both logic and emotion. Young adults are more quantitatively advanced in their thinking in the sense that they have more knowledge than adolescents. Warnier Schlae‘s Theory (The Achieving Stage) People must adopt their cognitive skills to situations, such as marriage and employment, that have profound implications over long term goals. They focus less on acquiring knowledge but more on applying it in everyday life. Giselle Labouvie-Vlei‘s Theory This is from adolescent;s ideal world of possibility to pragmatic thought. Logic becomes a tool to solve real-world problems. There is acceptance of inconsistencies as part of life . this develops ways of thinking that thrives on imperfection and compromise In 30-40 years old, family and work expands and the cognitive capacity to juggle many responsibilities simultaneously improves. Creativity often peaks. Moral Development Lawrence Kohlber‘s Theory Level III – Post Conventional/ Principled level Stage 5: The Social Contact Orientation There is a standards of behavior which is based on adhering to laws that protect the welfare and rights of others. The personal values and oinions are recognized and violating the rights of others are avoided Stage 6: Universal-Ethical Principle Orientation The person has developed moral standard based on universal human rights. When faced with a conflict between law and conscience, person will follow conscience, even though the decision might involve personal risk Spiritual Development James Fowler Stage 4: Individuative-reflexive faith (Early-Middle 20‘s or beyond) Adults who reach this post conventional stage examine their faith critically and think out their own beliefs. Since young adults are concerned with intimacy, movement into this stage is often triggered by divorce, death of friend or stressful environment.

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Anatomy and Physiology

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ANATOMY AND PHYSIOLOGY OF THE INTEGUMENTARY SYSTEM The skin is the largest organ of the body, accounting for about 15% of the total adult body weight. It performs many vital functions, including protection against external physical, chemical, and biologic assailants, as well as prevention of excess water loss from the body and a role in thermoregulation. The skin is continuous, with the mucous membranes lining the body‘s surface (Kanitakis, 2002). The integumentary system is formed by the skin and its derivative structures. The skin is composed of three layers: the epidermis, the dermis, and subcutaneous tissue (Kanitakis, 2002). The outermost level, the epidermis, consists of a specific constellation of cells known as keratinocytes, which function to synthesize keratin, a long, threadlike protein with a protective role. The middle layer, the dermis, is fundamentally made up of the fibrillar structural protein known as collagen. The dermis lies on the subcutaneous tissue, or panniculus, which contains small lobes of fat cells known as lipocytes. The thickness of these layers varies considerably, depending on the geographic location on the anatomy of the body. The eyelid, for example, has the thinnest layer of the epidermis, measuring less than 0.1 mm, whereas the palms and soles of the feet have the thickest epidermal layer, measuring approximately 1.5 mm. The dermis is thickest on the back, where it is 30–40 times as thick as the overlying epidermis (James, Berger, & Elston, 2006).

Functions of the Integumentary System The skin and its derivatives perform a variety of functions that affect body metabolism and prevent external factors from upsetting body homeostasis. Given its superficial location it is our most vulnerable organ system, exposed to bacteria, abrasion, temperature extremes, and harmful chemicals. Protection Chemical Barriers The chemical barriers include skin secretions and melanin. Although the skin‘s surface teems with bacteria, the low pH of skin secretions, or the so-called acid mantle, retards their multiplication. In addition, many bacteria are killed outright by bactericidal substances in sebum. Skin cells also secrete a natural antibiotic called human defensin that literally punches holes in bacteria, making them look like sieves. Wounded skin releases large quantities of protective peptides called

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cathelicidins that are particularly effective in preventing infection by group A streptococcus bacteria. As discussed earlier, melanin provides a chemical pigment shield to prevent UV damage to the viable skin cells. Physical/Mechanical Barriers Physical, or mechanical, barriers are provided by the continuity of skin and the hardness of its keratinized cells. As a physical barrier, the skin is a remarkable compromise. A thicker epidermis would be more impenetrable, but we would pay the price in loss of suppleness and agility. Epidermal continuity works hand in hand with the acid mantle to ward off bacterial invasion. The waterproofing glycolipids of the epidermis block the diffusion of water and water-soluble substances between cells, preventing both their loss from and entry into the body through the skin. Substances that do penetrate the skin in limited amounts include (1) lipid-soluble substances, such as oxygen, carbon dioxide, fat-soluble vitamins (A, D, E, and K), and steroids; (2) oleoresins (o″le-o-rez′inz) of certain plants, such as poison ivy and poison oak; (3) organic solvents, such as acetone, dry-cleaning fluid, and paint thinner, which dissolve the cell lipids; (4) salts of heavy metals, such as lead and mercury; and (5) drug agents called penetration enhancers that help ferry other drugs into the body.

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Biological Barriers Biological barriers include the Langerhans‘ (dendritic) cells of the epidermis, macrophages in the dermis, and DNA itself. Langerhans‘ cells are active elements of the immune system. For the immune response to be activated, the foreign substances, or antigens, must be presented to specialized white blood cells called lymphocytes. In the epidermis, it is the Langerhans‘ cells that play this role. Dermal macrophages constitute a second line of defense to dispose of viruses and bacteria that have managed to penetrate the epidermis. They, too, act as antigen ―presenters.‖ Although melanin provides a fairly good chemical sunscreen, DNA itself is a remarkably effective biologically based sunscreen. Electrons in DNA molecules absorb UV radiation and transfer it to the atomic nuclei, which heat up and vibrate vigorously. However, since the heat dissipates to surrounding water molecules instantaneously, the DNA converts potentially destructive radiation into harmless heat. Body Temperature Regulation The body works best when its temperature remains within homeostatic limits. Like car engines, we need to get rid of the heat generated by our internal reactions. As long as the external temperature is lower than body temperature, the skin surface loses heat to the air and to cooler objects in its environment, just as a car radiator loses heat to the air and other nearby engine parts. Under normal resting conditions, and as long as the environmental temperature is below 31–32°C (88–90°F), sweat glands continuously secrete unnoticeable amounts of sweat [about 500 ml (0.5 L) of sweat per day]. When body temperature rises, dermal blood vessels dilate and the sweat glands are stimulated into vigorous secretory activity. Sweat becomes noticeable and can account for the loss of up to 12 L of body water in one day. Evaporation of sweat from the skin

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surface dissipates body heat and efficiently cools the body, thus preventing overheating. When the external environment is cold, dermal blood vessels constrict. This causes the warm blood to bypass the skin temporarily and allows skin temperature to drop to that of the external environment. Once this has happened, passive heat loss from the body is slowed, thus conserving body heat. Cutaneous Sensation The skin is richly supplied with cutaneous sensory receptors, which are actually part of the nervous system. The cutaneous receptors are classified as exteroceptors (ek″ster-o-sep′torz) because they respond to stimuli arising outside the body. For example, Meissner‘s corpuscles (in the dermal papillae) and Merkel discs allow us to become aware of a caress or the feel of our clothing against our skin, whereas Pacinian corpuscles (in the deeper dermis or hypodermis) alert us to bumps or contacts involving deep pressure. Hair follicle receptors report on wind blowing through our hair and a playful tug on a pigtail. Painful stimuli (irritating chemicals, extreme heat or cold, and others) are sensed by free nerve endings that meander throughout the skin.

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Metabolic Functions When sunlight bombards the skin, modified cholesterol molecules circulating through dermal blood vessels are converted to a vitamin D precursor, and transported via the blood to other body areas to play various roles in calcium metabolism. For example, calcium cannot be absorbed from the digestive tract without vitamin D. Besides synthesizing the vitamin D precursor, the epidermis has a host of other metabolic functions. It makes chemical conversions that supplement those of the liver—for example, keratinocyte enzymes can (1) ―disarm‖ many cancer-causing chemicals that penetrate the epidermis; (2) convert some harmless chemicals into carcinogens; and (3) activate some steroid hormones; for instance, they can transform cortisone applied to irritated skin into hydrocortisone, a potent anti-inflammatory drug. Skin cells also make several biologically important proteins, including collagenase, an enzyme that aids the natural turnover of collagen (and deters wrinkles). Blood Reservoir The dermal vascular supply is extensive and can hold large volumes of blood (about 5% of the body‘s entire blood volume). When other body organs, such as vigorously working muscles, need a greater blood supply, the nervous system constricts the dermal blood vessels. This shunts more blood into the general circulation, making it available to the muscles and other body organs. Excretion Limited amounts of nitrogen-containing wastes (ammonia, urea, and uric acid) are eliminated from the body in sweat, although most such wastes are excreted in urine. Profuse sweating is an important avenue for water and salt (sodium chloride) loss. Homeostatic Imbalances of Skin When skin rebels, it is quite a visible revolution. Loss of homeostasis in body cells and organs reveals itself on the skin, sometimes in startling ways. The

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skin can develop more than 1000 different conditions and ailments. The most common skin disorders are bacterial, viral, or yeast infections. A number of these are summarized in Related Clinical Terms. Less common, but far more damaging to body well-being, are skin cancer and burns, considered next.

ANATOMY AND PHYSIOLOGY OF THE SKELETAL SYSTEM Skeleton is subdivided into two divisions: the axial skeleton, the bones that form from the longitudinal axis of the body, and the appendicular skeleton, the bones of the limbs and girdles. In addition to bones the skeletal system includes joints, cartilages, and ligaments (fibrous cords that bind the bones together at joints)/ the joints give the body flexibility and allow movement to occur. Function of the bones 1. Support – bones, ―the steel girders‖ and concrete‖ of the body, form the internal supports and anchors all soft organs. The bones pillars to support the body trunk when we stand, supports the thoracic wall. 2. Protection – bones protect soft body organs. For bone of the skull providing a snug enclosure for one to head a soccer ball without worrying about The vertebrae surround the spinal cord, and the protect the vital organs of the thorax 3. Movement – skeletal muscles, attached to bones use the bones as levers to move the body and its we can walk, swim, throw a ball and breathe. 4. Storage – fat is stored in the internal cavities 5. Blood cell formation – blood cell formation, occurs within the bone marrow cavities of

―reinforced framework that of the legs act as and the rib cage example the fused the brain, allowing injuring the brain. rib cage helps by the tendons, parts. As a result,

hemotopoiesis, certain bones.

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Classification of Bones The adult skeleton composed of 206 bones. There are two basic types of osseous, or bone, tissue: compact bone is dense and looks smooth and homogeneous. Songy bone is composed of small needlelike pieces of bone and lots of open space. Bone come in many size and shapes and they are classified according to shape into four groups: Long bones – longer than they are wide, they have a shaft with heads at both ends. Long bones are mostly compact bone. All the bones of the limbs, except the wrist and ankle bones, are long bones. Short bones – cube-shaped and contain mostly spongy bone. The bones of the wrist and ankle are short bones. Sesamoid bones, which were form within tendons, are a special type of short bone. The best-known example are the patella or kneecap. Flat bones – are thinned, flattened and usually curved. They have two thin layers of compact bone sandwiching a layer of spongy bone between them. Most bones of the skull, the ribs , and the sternum are flat bones. Irregular bones – bones that do not fit one of the preceeding categories. The vertebrae, which make up the spinal column and the hip bones fall into this group. Bone Formation, Growth and Remodeling The skeleton is formed from two of the strongest and most body, cartilage and bone. In embryos, the skeleton is primarily but in the young child most of the cartilage has been replaced by only in isolated areas such as the bridge of the nose, pats of the ribs,

supportive tissues in the made of hyaline cartilage, bone. Cartilage remains and the joints.

Except for flat bones, which from fibrous membranes, most bones develop using hyaline cartilage structures as their ―models‖. Most simply, this process of bone formation or ossification, involves two major phases. First, the hyaline cartilage model is completely covered with bone matrix(a bone collar) by bone0forming cells called osteoblasts. So, for a short period, the fetus has cartilage ―bones‖ enclosed by ‗bony‘ bones. Then, the enclosed hyaline cartilage model is digested away, opening up a medullary cavity within the newly formed bone. Most hyaline cartilage models have been converted to bone except for two regions, the articular cartilage and the epiphyseal plates. The articular cartilage persist for life, reducing friction at the joint surfaces. The epiphyseal plates provide for longitudinal growth of the long bones during childhood. New cartilage is formed continuously on the external face of the articular cartilage and on the epiphyseal plate surface that is farther away from the medullary cavity. At the same time, the old cartilage abutting the internal face of the articular cartilage and the medullary cavity is broken down and replaced by bony matrix. Growing bones also must be widen as they lengthen. Osteoblasts, in the periosteum add bone tissue to the external face of the diaphysis as osteoclasts in the endosteum remove bone from the inner face of the diaphysis wall. Since these two processes occur at about the same rate, the circumference of the long bone expands and the bone widens. This process by which bones increase in diameter is called appositional growth. This process of long-bone growth is

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controlled by hormones, most importantly growth hormones and, during puberty, the sex hormones. It ends during adolescents, when the epiphyseal plates are completely converted to bone. Bone is dynamic and active tissue. Bnes are remodeled continually in response to change in two factors: (1) calcium levels in the blood, (2) the pull of gravity and muscles on the skeleton. When blood calcium levels drop below homeostatic levels, the parathyroid glands. PTH activates osteoclasts, giant bonedestroying cells in bones, to break down bone matrix and release calcium ions into the blood. On the other hand, when blood calcium levels are too high, calcium is deposited in the bone matrix as hard calcium salts. Bone remodeling is essential if bones are to retain normal proportions and strength during long-bone growth as the body increases in size and weight. It also accounts for the fact that bones become thicker and form large projections to increase their strength in areas where bulky muscles are attached. At such sites, osteoblasts lay down new matrix and become trapped within it. (once they are trapped they become osteocytes, or mature bone cells) on the other hand, the bones of bedridden or physically inactive people tend to lose mass and to atrophy because they are no longer subjected to stress. A fracture is treated by reduction, which is the realignment of the broken bone ends. In closed reduction, the bone ends are coaxed back into their normal position by the physician‘s hands. In open reduction, surgery is performed and the bone ends are secured together with pins or wires. After the broken bone is reduced, it is immobilized by the cast or traction to allow the healing process to begin. The healing time for a simple fractures is 6 to 8 weeks, but it is much longer for large bones and for the bones of elderly people. Intramembranous Ossification Flat bones, such as the bones of the skull, are examples of intramembranous bones. In intramembranous ossification, bones develop between sheets of fibrous connective tissue. Here, cells derived from connective tissue cells become osteoblasts located in ossification centers. The osteoblasts secrete the organic matrix of bone. This matrix consists of mucopolysaccharides and collagen fibrils. Calcification occurs when calcium salts are added to the organic matrix. The osteoblasts promote calcification, or ossification, of the matrix. Ossification results in the trabeculae of spongy bone. Spongy bone remains inside a flat bone. The spongy bone of flat bones, such as those of the skull and clavicles (collarbones), contains red bone marrow. A periosteum forms outside the spongy bone. Osteoblasts derived from the periosteum carry out further ossification. Trabeculae form and fuse to become compact bone. The compact bone forms a bone collar that surrounds the spongy bone on the inside. Endochondral Ossification Most of the bones of the human skeleton are formed by endochondral ossification. During endochondral ossification, bone replaces the cartilaginous models of the bones. Gradually, the cartilage is replaced by the calcified bone matrix that makes these bones capable of bearing weight. Bone Repair Repair of a bone is required after it breaks or fractures. Fracture repair takes place over a span of several months in a series of four steps:

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1. Hematoma. After a fracture, blood escapes from ruptured blood vessels and forms a hematoma (mass of clotted blood) in the space between the broken bones. The hematoma forms within 6 to 8 hours. 2. Fibrocartilaginous callus. Tissue repair begins, and a fibrocartilaginous callus fills the space between the ends of the broken bone for about three weeks. 3. Bony callus. Osteoblasts produce trabeculae of spongy bone and convert the fibrocartilage callus to a bony callus that joins the broken bones together. The bony callus lasts about three to four months. 4. Remodeling. Osteoblasts build new compact bone at the periphery. Osteoclasts absorb the spongy bone, creating a new medullary cavity. In some ways, bone repair parallels the development of a bone except that the first step, hematoma, indicates that injury has occurred. Further, a fibrocartilaginous callus precedes the production of compact bone.

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CONCEPT MAP

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Predisposing Factors  

Precipitating Factors:  

Age ( middle adulthood) Gender (male)

Hazardous Place Fatigue

Motor Vehicle Accident Integumentary System Functions: Protect from heat, sunlight injury and infection; regulate body temperature; control fluid loss; secretions; sensations; stores water, fats and vitamin D

Traumatic Injury

Increase pressure or force on the bone

X-ray Fracture, Open at Right leg Debridement Efficacy of hydrosurgical debridement and nanocrystalline silver dressings for infection prevention type 2 and 3 open fracture Timing issue in open fracture

Break in the right leg

Broken skin with bone protruding

Musculoskeletal system functions: protection and support, movement; give shape; produce blood cells; store Ca and Phosphorus; produce heat

Assess degree of mobility or treatment and note perception of immobility Assist active/ passive ROM Encourage and assist for self-care activities

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Disruption of periosteum, blood vessels and soft tissues

Blood coming from an open wound decreased LOC, pain, headache, vomiting

Bleeding around the site and into the soft tissues surrounding the bone

  

Decrease RBC (3.1/cumm) Decrease Hemoglobin 8.7gm% Decrease Hematocrit 26.80% Blood Transfusion

Ranitidine 50mg IVTT q 8

vasonconstriction

Release of chemical mediators  Cefuroxime 75mg IVTT q 8  Ranitidine 50mg IVTT q 8  Keterolac 35mg IVTT q 8

 Increase WBC 13, 200/cumm

Vasodilation

Increased blood flow to the area of injury

Intense inflammatory reaction

Chemotactic Factor

Migration to injured part

 Fever T= 38.3 C

V/S monitoring q 4 Pulse oximter Catheterization Administration of IVF Administration of medications

Increased vascular permeability

Contraction of smooth muscles

Exudate formation

 BP: 180/90 mmHg

Diphenhydramine 25mg IVTT

Margination Redness Heat

Decrease oncotic pressure

Increased pressure on nerve endings

Diapedesis

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Swelling

Pain

Chemotaxis

Demerol 50 mg IVTT q 6 Nubain 10mg IVTT

Phagocytosis

A fibrin clot forms at the break and acts as a network to which new cells can adhere

Acute pain r/t irritation of soft tissues

Loss of function

Impaired physical mobility r/t musculoskeletal impairment secondary to open fracture; Right leg Activity intolerance r/t weakness on the right leg secondary to open fracture at Right Leg Assess perceived limitations to activity weakness and degree of assistance Assist to stand or move about Provide rest period and positive atmosphere Promote comfort measures Encourage to use relaxation techniques

1. Monitor V/S 2. Obtain client’s assessment of pain w/c includes location, onset, frequency, quality, intensity and precipitating factors 3. Provide comfort measure such as deep breathing exercise, repositioning and relaxation technique 4. Provide hot and cold compress 5. Teach to increase intake of Vit. C 6. Administer analgesic medications as ordered

Disruption in fracture hematoma

Granulation tissue to osteoid Disruption in fracture hematoma

Fixation or proper bone alignment 26

Osteoblastic activity at the break

Osteoblast activity is immediately stimulated

Immature new bone or callus is formed

Ossification

Consolidation

Fibrin clot is soon reabsorbed and the new bone cells are slowly remodelled to form true bone

Legend: Manifestations -------------------

True bone replaced callus and is slowly calcified several weeks – few months

Journal

---------------------------

Medical Managements -----Nursing Procedures -----------Anatomy and Physiology ----Laboratory Results --------------Nursing Diagnosis ---------------Nursing Interventions ----------27

Medical Management

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Medical Management: Pharmacology Medication Ranitidine 50mg IVTT q 8o

Ketorolac (Kelinen) 35mg IVTT q 8o Cefuroxime (Jectral) 75mg IVTT q AD Demerol 50mg IVTT q 6o Panecoxib (Dynastat) 40mg IVTT q 12o

Diphenhydramine 25mg slow IVTT

Nalbuphine (Nubain) 10mg IVTT

Action Competitively inhibits the action of histamine at the histamine2 (H2) receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin, and pentagastrin. Inhibits prostaglandin synthesis, producing peripherally mediated analgesia. Also has antipyretic and antiinflammatory properties. Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death Relief of moderate to severe pain, pre-op medication, support of anesth & obstet analgesia. Short-term treatment of acute & post-op pain. May be used pre-op to prevent or reduce post-op pain; can reduce opioid requirements when used concomitantly. Competitively blocks the effects of histamine at H1 receptor sites, has atropine-like, antipruritic, and sedative effects. Nalbuphine acts as an agonist at specific opioid receptors in the CNS to produce analgesia, sedation but also acts to cause hallucinations and is an antagonist at µ receptors.

correlation Was given to counteract the adverse effects of blood transfusion like chills or fever.

Was given to our patient because of pain experienced from his injury and fever. Also to help from the inflammation of the open wound. This drug was given to our patient because of infection which was manifested by his WBC fluctuating at 13,200 cumm. This drug is given to our patient because of pain experienced due to operation on the right leg. This drug is given to our patient because of pain experienced due to operation. The patient has high BP and this is to slow down the effects of smooth muscles thus the effect of sedatives-like occurs. This drug is given to our patient because of pain experienced due to operation.

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LABORATORY RESULTS Date and time done: 6/21/2014 3:30pm

TEST

NORMAL VALUES

RESULT

Hemoglobin

12-14 gm%

8.70 gm%

Hematocrit

37-44 vol%

26.80 vol%

RBC

4.6-6.2 M/cumm

3.1M/cumm

WBC

4.5-11T/cumm

13200/cumm

SIGNIFICANCE  Oxygen carrying pigment and main component of RBC  Measures total amount of hemoglobin in peripheral blood  Volume of RBC (packed cell volume) found in 100ml of blood  Concentration of RBC from total blood volume  Combined measure of the size, capacity and number of cells present in the blood, and along with the hemoglobin value, established the presence and severity of anemia.  Primary Function: carry oxygen from the lungs to the tissues around your body  a key player in getting waste carbon dioxide from your tissues to your lungs, where it can be breathed out.  Primary function: to fight infection and react against other foreign bodies, particles or tissue

RATIONALE  Decrease in hemoglobin indicates blood loss  Decrease in hematocrit indicates blood loss or hemorrhage

 Decrease in RBC indicates blood loss or excessive bleeding

 Increase in WBC indicates leukocytosis, infection, inflammation, or tissue necrosis

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URINALYSIS: Physical and chemical exam: Color: yellow Transparency: hazy Specific gravity: 1.020 Glucose: trace – bilirubin – ketone Protein: 1+ pH: 6.0 Physician’s Order: Multiple Physical Absolute NPO IVF Plain LR 1L 140cc/hr

PROCEDURES

CORRELATION

Debridement of the right leg

Removes the dead, damaged, or infected tissue of the fracture to improve the healing potential of the remaining healthy tissues Reduces the risk of infection

Blood Transfusion

To replace blood lost during the accident and the surgery and elevates the RBC, hematocrit and hemoglobin level

X-ray

Identified or diagnosed the broken bone or fracture

Dressing plaster

To keep the wound free of infection and to reduce or eliminate all potential factors inhibiting natural healing

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COLLERATION NURSING PROCEDURES



Vital Signs taking q 4H



A quick and efficient way of monitoring a client‘s condition or identifying the problems and evaluating a client‘s response to interventions and also, this is one way to monitor the client‘s temperature since he experienced fever.



Administration of medications as ordered



Help the patient to recover faster



Pulse oximeter



It gives a reading of the percentage of hemoglobin that is saturated with oxygen (SaO2)



Catheterization



To drain urine



Administration of IVF



To reduce dehydration from being NPO

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FUNCTIONAL HEALTH PATTERN (FHP)

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COLLEGE OF NURSING Silliman University Dumaguete City Part I. Demographic Information Name: Ledesma, Rodel Aparecio

Civil Status: Married

Sex: Male

Educational Attainment: College graduate

Address: Calayugan, Valencia

Religion: Roman Catholic

Occupation: Seaman

Room and Bed No.: Hallway

Doctor(s) in Charge: Danilo V. Olegano, MD

Nationality: Filipino

Chief Complaint(s): Vomiting, headache, pallor, bone protruding, pain and bleeding

Date & Time of Admission: June 21, 2014 6:10am

Diagnosis: Fracture, Open, Right leg General Impression of client (appearance upon first contact): Sleeping on bed with Intravenous fluid, linens wrinkled, bedside is a bit messy and has no strong odor. Part II. Functional Health Patterns USUAL HEALTH PATTERNS 1. Health Perception- Health Management Patter Verbalize by the wife:  ―general health has been good.‖  ―Experienced colds seldom and takes over the counter drugs‖  ―Exercise daily at 5am and finishes at

INITIAL APPRAISAL

Verbalize by the wife:  ―okay-okay na sya kaysa atong una namong abot dire na grabe kayo siya.‖  Maglisod jud siya ug gimok tungod aning iya opera‖

ONGOING APPRAISAL

Patient verbalized:  ―Okay-okay nako gamay pero sakit-sakit japun akong tiil‖  ―Dili pa nako magimok‖  ―sakit pa kaau ako tiil tungod sa opera‖  Rated pain as 8 in a range of 1-10 where 1 is

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

7am‖ as health maintenance  ―Doesn‘t drink alcoholic beverages, smoke and use drugs.‖  ―Never had an accident but was hospitalized due to pneumonia last 2013.‖  ―Follows order and suggestion from medical team‖ No maintenance medications

 

least pain and 10 is the most pain ―Had an accident last Saturday at dawn‖  Facial grimacing still noted and gets easily Verbalized, ―sakit kaau ako tiil tungod sa irritated opera‖  Rated pain as 8 in a range of 1-10 where 1  Medication: Raniticidone 50mg IVT q8 6-2-10pm is least pain and 10 is the most pain Ketorolac (Keliner) 35mg IVT q8 6-2-10pm  Facial grimacing noted and gets easily Demerol 50mg IVTT q6 x 2 dose 11am irritated 2am-10am-6pm  Experienced complete transverse open Panecoxib (Dynastat) 40mg IVTT q12 x 2 doses fracture, has bruises 6pm-6am  Drinks medication to relieve injury and Diphenhydramine 25mg slow IVTT pain Nalbuphine (Nubain) 10mg IVTT  Medications: Raniticidine 50mg IVT q8 6-2-10pm  There was no laboratory results for this day. Ketorolac (Keliner) 35mg IVT q8 6-2-10pm Demerol 50mg IVTT q6 x 2 dose 11am 2am-10am-6pm Panecoxib (Dynastat) 40mg IVTT q12 x 2 doses 6pm-6am Diphenhydramine 25mg slow IVTT Nalbuphine (Nubain) 10mg IVTT  Laboratory Results: Prothombine time – 12.2 Hemoglobin – 8.70gm % Hematocrit – 26.80 WBC – 13, 200 /cumm Segmented – 82 Lymphocyte – 10 Eosonophil – 3 Monocyte – 5 Basophil – 0 RBC – 4.7 Creatinine 1.10mg/dl

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BUN – 17.00 Sodium – 139.10 Potassium – 3.50 Sgpt/Alt – 16. 00  Diagnosis: Open Fracture, right leg 2. Nutrition – Metabolic Pattern Kinds of Food Breakfast: Rice Egg Fish Coffee Water Lunch: Rice Chicken Soup Water Snacks: Bread Coffee Water Dinner: Rice Fish Water     

Quantity 2cups 1pc. 2pcs. 1cup 2glasses 2cups 2pcs 1bowl 2glasses 3pcs 2cups 2 glasses 2cups 2pcs. 2 glasses

Kinds of Food Breakfast: Rice Ham Banana Water Lunch: Rice Chicken Water Royal       

Quantity 1cup 1pc. 1pc. 1/2cup

Kinds of Food Breakfast: Rice Chicken Banana Water

1cup 1pc 1/2glass 1 glass

   

Has good appetite No diet restrictions, no allergies Skin is moist and warm to touch Has skin problems, no lesions No dental problems, extracted 2 molars T= 38.3 PR= 74bpm RR= 20cpm Bp= 120/70mmHg IV at 48gtts/min



Quantity 1cup 1pc. 1pc. 1/2cup

Has good appetite Skin is moist and warm to touch No dental problems, extracted 2 molars T= 36.9 PR= 70bpm RR= 22cpm Bp= 110/70mmHg IV at 44gtts/min

Takes Vitamin C Good appetite No diet restrictions, no allergies Wounds heal well No skin problems, no lesions

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

No dental problems, extracted 2 molars

3.    

Elimination Pattern Defecated 3-5 times a weak Brown in color, form and no discomforts Urinates 4-6times a day, clear no discomforts Perspire a lot especially during exercise but no strong odor

     

Has not defecated for 2 days Has catheter Has 1000ml of urine collected from last night to 4pm Perspires a little Yellow urine color UA Lab Results: Color: yellow Transparency: Hazy S. G. :1.020 Glucose: traco – Bilirubin – Ketone

4. Activity Exercise Pattern Verbalized by the wife: Verbalized by the wife:  ―Maglisod jud siya og gimok tungod sa iya  ―Exercises daily at 5-7 in the morning though opera‖ jogging.‖  ―Dili siya kabuhat sa iya mga gusto kay walay kusoog iya tiil.‖  Goes to school  Has contemplated surgical procedure; open  Spend spare time watching television fracture; right leg  Perceived ability for:  Has dressing on the right leg and its Feeding: level 0 surroundings Bathing: level 0 Toileting: level 0  Inability to move purposefully and Bed mobility: level 0 independently Dressing: level 0  No movement seen on the right leg Gen. mobility: level 0  Breathing pattern is normal Home maintenance: level 0  Perceived ability for: Grooming: level 0 Feeding: level 1 Cooking: level 0 Bathing: level 3 Shopping: level 0 Toileting: level 3 Bed mobility: level 3

     

Has not defecated for 3 days Has catheter Has 750ml of urine collected from 12am to 10am Perspires a little Yellow urine color No UA Lab results for this day

Verbalized by the wife:  ―Maglisod japon siya og gimok tungod sa iya opera‖  ―Dili siya kabuhat sa iya mga gusto kay walay 

kusoog iya tiil.‖

Dressings on the right leg and its surroundings still noted  Inability to move purposefully and independently  No movement seen on the right leg  Breathing pattern is normal  Perceived ability for: Feeding: level 1 Bathing: level 3 Toileting: level 3 Bed mobility: level 3 Dressing: level 3 Gen. mobility: level 3

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5.     

Sleep Rest Pattern Onset: 8-9pm Awakening: 5am ―Ready for activity after sleep‖ as verbalized by the wife Rest time: after lunch Feeling well rested after rest

6.    

Cognitive Perceptual Pattern No hearing and vision difficulty Doesn‘t wear eye glasses No change in memory Learn things easily

7. Self Perception/ Self- Concept Pattern Verbalized by the wife:  ―He feels good with his self‖

Dressing: level 3 Gen. mobility: level 3 Home maintenance: level N/A Grooming: level 3 Cooking: N/A Shopping: N/A  Muscle strength of 1/5 where 0 has no contractions and 5 has movements against gravity with full resistance

Home maintenance: level N/A Grooming: level 3 Cooking: N/A Shopping: N/A  Muscle strength same as 1/5 where 0 has no contractions and 5 has movements against gravity with full resistance

 

Sleep onset: 9pm Sleep pattern disturbance due to giving of medications Wasn‘t able to rest well

  

Doesn‘t use sleeping pills Sleep pattern disturbed due to giving of medications Wasn‘t able to rest well



No hearing and vision difficulty Doesn‘t wear eye glasses No change in memory Learn things easily ―Can talk properly‖ as verbalized by the wife Has decrease attention span due to pain

     

No hearing and vision difficulty Doesn‘t wear eye glasses No change in memory Learn things easily Responds and speaks properly Has decrease attention span due to pain



―He feels sad about it, but we just



He accepts and understand the situation



    

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 

8.     

―feels depressed and angry when there is problem, financially and with the children‖ ―we talk about the problem to solve it‖

Role-relationship Pattern Dialects spoken at him is Cebuano Lives with her wife and 2 children Turns to his wife when he needs help with anything Decision making is done by both husband and wife No difficulties in relating with her family

9. Sexuality- Reproduction  Has been using contraceptives  No problems with his partner  Has 2 children  Feels happy being a man with a family  Still shows affection  Sexually active due to schooling and work 10. Coping-Stress Management  Always make decisions with his wife  No big change or losses in the past years  Can tolerate stress  Watches television when stressed in order to relax

   

  

 

understand the situation, we can‘t do anything about it‖ as verbalized by the wife.



His work is affected

Decision making is done by his wife His wife is always at his bedside ready to attend to his needs His role of being a father is affected Sometimes visited by relatives



His wife always at his bedside ready to attend to his needs His role of being a father and his work is affected Sometimes visited by relatives

Wife is taking care of him; attentive to his needs like in feeding and buying of medications needed Still shows affection Not sexually active due to hospitalization



Feels that this hospitalization is very stressful but the wife is doing its best in helping his husband in coping up Wife is the most helpful in talking things over



 

 



Wife is taking care of him; attentive to his needs like in feeding and buying of medications needed Still shows affection Not sexually active due to hospitalization

Not use of always lying in bed but his wife is doing its best in helping his husband in coping up Wife is the most helpful in talking things over

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11. Value-Belief  Finds God as a source of strength  God and religion are important to them  Verbalized by the wife that praying relieves the difficulties in them that arises.  Finds time to hear mass every Sunday  Fearful and praises God

   

Finds God as a source of strength Prays with his wife in the hospital Considers religion as most important to them Still fearful and praises God in spite of his condition

    

Finds God as a source of strength Consider religion as most important thing Prays with his wife in hospital Praying to gain more strength Still fearful and praises God in spite of his condition

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NURSING CARE PLAN (NCP)

41

COLLEGE OF NURSING Silliman University Dumaguete City NURSING CARE PLAN

CUES/EVIDENCES Subjective: 

Verbalized ―sakit kaau ako tiil tungod sa opera.‖

NURSING DIAGNOSIS Acute pain r/t irritation of the soft tissue secondary to open fracture, right leg

OBJECTIVES Within our 2-day care, the client will manifest lessen pain as evidenced by: 

Verbalization of ability to cope with incompletely relieved pain



Verbalization of method that lessens pain

Objective: 

 

Rated pain as 8 in the range of 1-10 where 1 is atleast pain and 10 is the most pain. Facial grimacing Easily irritated



Demonstration of use of relaxation skills and diversional activities

INTERVENTIONS

RATIONALE

Independent: 1. Monitor vital signs.

1. An information baseline comparison from previous data and llterations from normal maybe signs of infection.

2. Obtain client‘s assessment of pain which includes location, onset, frequency, quality, intensity and precipitating factors. Reassess each time pain is reported.

2. To rule out worsening of underlying condition or development of complications.

3. Observe nonverbal cues or behaviors.

3. Observations may or may not be congruent with verbal reports. According to Dorothy Johnson, he indicated the behavioral system

EVALUATION Goal met: Within our care, he was able to: 

Verbalized ability to cope with incompletely relieved pain



Verbalized method that lessens pain



Demonstrated use of relaxation skills and diversional activites

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and its subsystems and that behaviors play a role in the work of all helping professionals. 4. Encourage patient to verbalize pain.

4. Promotes cooperation from the client.

5. Encourage diversional activities (radio, socialization with others).

5. To divert attention from pain.

6. Provide comfort measures such as deep breathing exercises, repositioning and relaxation techniques.

6. This promotes relaxation and reduces muscle tension or spasm, redistribute pressure on body parts and helps patient focus on non pain related subjects.

7. Provide application of hot and cold compress.

7. To relieve pain in the muscle area.

8. Give health teaching to increase intake of

8. To promote healing of wound.

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vitamin C. 9. Manipulate the environment to promote periods of uninterrupted rest.

9. This promotes health and well being. According to Florence Nightingale, she focuses on the environment and her belief that energy for healing or improvement comes from within the person. Moreover, the environment should be quiet, clean and well ventilated

Collaborative:

10. Administer analgesic medications as ordered.

10. To minimize client‘s pain and this is to comply the physician‘s order.

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CUES/EVIDENCES Subjective:  ―Maglisod jud siya ug gimok tungod sa iya opera‖ as verbalized by the wife  “Dili ko ganahan mugimok tungod sa sakit sa akong opera‖, as verbalized by the client Objecives:  has dressing on its right leg  inability to move purposefully and independently  Muscle strength of 1/5

NURSING DIAGNOSIS Impaired physical mobility r/t musculoskeletal impairment secondary to open fracture; Right leg

OBJECTIVES Within our 5-hour care, the client will improve physical mobility as evidenced by:  Perform physical activity with assistance or any assistive devices as needed  Demonstrate techniques or behaviors that enable resumption of activities  Maintain increase strength and function of affected or compensatory body part  Verbalize understanding of situation and individual treatment regimen and safety measures  Demonstrate muscle strength of at least 3/5

INTERVENTIONS Independent: 1. Assess degree of mobility produced by injury or treatment and note patient perception of immobility 2. Encourage participation on diversion or recreational activities.

3. Assist in active or passive range of motion exercises of affected and unaffected extremities. | vide footboard

RATIONALE 1. Patient may be restricted by self-view or self-perception out of proportion with actual physical limitations requiring interventions to promote progress toward wellness. 2. Provide opportunity for release of energy, refocuses attention, enhances patient‘s self control or self-worth and self-efficacy and aids in reducing social isolation. According to Alberta Bendwa’s self-efficacy theory, it is the expectation that one can master a situation and produce a positive outcome. 3. Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility; prevent contractures or atrophy.

EVALUATION Goal partially met: Within our care, the client was able to: 







 4. Useful in maintaining functional position of extremities, preventing complication. According to self-care theory of Dorothea Orem, nurses have to supply care when the patients cannot provide care to

Not performed physical activity with assistance or any assistance devices Not demonstrated techniques or behaviors that enable resumption of activities Partially increase strength and function of affected or compensatory body part Verbalized understanding of situation and individual treatment regimen and safety measures Not demonstrated muscle strength of at lest 3/5

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themselves. 4. Encourage and assist with self care activities (e.g. sponge bath, mouth care)

Collaborative  Refer to a physical therapist as indicated

5. Improves muscle strength and circulation , enhances patient control in situation and promote self-directed wellness. According to Dorothea Orem, we as nurses should provide care when patients cannot provide care to themselves.  Patients may require more intensive treatment to deal with current condition and prolonged immobility

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CUES/EVIDENCES

NURSING CUES/EVIDENCES DIAGNOSIS

Subjective:  The wife verbalized, ―Dili siya kabuhat sa iya mga gusto kay walay kusoog iya tiil.‖ Objectives:  Presence of dressing on the right leg  No movements seen on the right leg  Inability to perform activities: Bathing=3 Dressing=3 Toileting= 3 Bed mobility=3 Grooming= 3 Feeding= 1

Activity Intolerance related to weakness on the right leg secondary to open fracture, right leg

OBJECTIVES

At the end of our 5 hour nursing care, the patient will be able to improve activity tolerance; response to energyconsuming movements as evidenced by:  Use of identified techniques to enhance activity tolerance  Participate willingly in necessary/ desired activities  Report measurable increase in activity tolerance

INTERVENTIONS Independent:  Assess client‘s perceived limitations to an activity  Assess client on weakness  Assess the client on the degree of assistance or use of equipment  Assist the patient to stand and move about  Provide a rest period during an activity  Provide positive atmosphere, while acknowledging difficulty of the situation for the client

 Promote comfort measures and provide

RATIONALE

 Provides comparative baseline and information about needed education or intensions regarding quality of life  Symptoms may be result of or contribute to intolerance of activity  To determine a current status and needs associates with participation in needed/ desired activities  To protect client from injury  To reduce fatigue  Helps to minimize frustration and rechanneling energy. According to Florence Nightingale, she focus on environment and her belief that the energy for healing or improvement comes from within the person is certainly applicable by any of the helping professionals  To enhance ability to participate in activities. According to Jean

EVALUATION Goal partially met: At the end of our nursing care, the patient was able to: 1. Used identifies techniques to enhance activity tolerance 2. 2. Participate willingly in necessary/ desired activities 3. Partially reported measurable increase in activity tolerance

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a relief of pain

 Instruct client to give responses to the activity and recognizes signs and symptoms  Give client information about daily and weekly progress  Encourage to maintain positive attitude and to use relaxation technique  Teach about appropriates safety measures and demonstrate Collaborative:  Refer to other disciplines, such as exercise physiologist psychological counseling and physical therapist

Watson, who emphasis caring, including her carative factors.  Indicate need to alter activity level  To sustain motivation

 To enhance sense of well-being  To prevent injuries

 To develop individually appropriate therapeutic regimens

48

Summary of nursing diagnoses

49

           

Acute pain r/t irritation of the soft tissue secondary to open fracture, open right leg Impaired physical mobility r/t musculoskeletal impairment secondary to open fracture; Right leg Activity Intolerance related to weakness on the right leg secondary to open fracture, right leg Increased risk of hypovolemia and shock related to trauma and bleeding Impaired skin integrity related to surgical repair Self-care deficit related to decreased strength/endurance Anxiety related to symptoms of disease and fear of the unknown Knowledge deficit related to information unfamiliarity Risk for Infection related to traumatized tissues Risk for impaired gas exchange related to altered blood flow Risk for peripheral neurovascular dysfunction related to tissue trauma Risk for trauma related to skeletal integrity

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Related Journal Readings

51

Journal Readings Journal Readings # 1

Efficacy of hydrosurgical debridement and nanocrystalline silver dressings for infection prevention in type II and III open injuries Based on the article that I had read, the aim of the study was to retrospectively evaluate the clinical and culture-positive infection rates of open Gustilo/Anderson type II and III fractures using a protocol nanocrystalline silver wound dressing and hydrosurgical debridement. Retrospective case series through chart review on all type II and III open fractures were treated using a novel protocol from December 2005 to March 2008. All Gustilo/Anderson grade II and III open fractures were treated with a novel protocol at a Level I trauma centre. Open Gustilo/Anderson grade II and III fractures were acutely stabilized in the trauma centre/emergency department, while a nanocrystalline silver dressing was placed within the wound. Debridement using hydrosurgical scalpel and gravity irrigation was performed within 6 to 8 hours of injury. Cultures were obtained prior to definitive fixation. The primary outcome measurements were positive cultures and clinical infection rates. Seventeen patients met inclusion criteria. Mean age (33·5) and injury severity score (12·7) were gathered. There were 4 grade II open fractures (23·5%), 11 grade IIIA (64·7%) and 2 grade IIIB open fractures (11·8%). The mean time to intravenous antibiotics was 61·5 minutes. The mean time to initial debridement/irrigation was 222·1 minutes. The average number of surgical procedures was 2·35 with a mean length of stay of 11·8 days. Six patients developed positive cultures from the traumatic wounds, five were contaminants. One clinical infection was found (methicillin-resistant Staphylococcus aureus). The overall clinical infection rate in this series was 5·9% (1/17). The only infection was in a Gustilo/Anderson grade II fracture. There were no infections in the more high-energy Gustilo/Anderson grade IIIA and IIIB fractures compared with the Gustilo/Anderson control of 4-42%. We conclude that this novel protocol for openfracture treatment is a promising intervention. A further prospective randomized clinical study is warranted.

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REACTION:

As we all know, open fractures present a unique challenge for the surgeons as two critical issues must be addressed. There is bacterial contamination at the fracture site which commonly originates from the skin and environment and presents a major barrier to healing. Therefore, open fractures are at great risk of infection and delayed union particularly in the setting of high-energy trauma. It is good to know that there is such thing as gold standard for prevention of infection of open fractures and that is early antibiotic prophylaxis followed by urgent debridement and irrigation (D & I) and stabilization. Silver has been used in modern medicine for nearly two centuries as an effective antimicrobial agent and this has been shown to be cytotoxic for keratinocytes and fibroblasts; however, the cytotoxicity of silver depends on the method of application compared with nanocrystalline silver dressings. Clinically, silver has been used mainly as a liquid (silver nitrate) or incorporated in cream (silver sulphadiazine) for the management of burn wounds and the prevention of associated burn asepsis. Since our generation is improving and is now having new technologies for the better good, I‘m happy that a nanocrystalline silver dressing has been developed to prevent wound adhesion, limit nosocomial infection, control bacterial growth and that this could facilitate burn wound care. Through this, our patients will not experience these things if doctors would use nanocrystalline silver in their treatment. According to the article, the treatment of open fractures with the use of nanocrystalline silver dressings and hydrosurgical debridement decreases clinical infection rates compared with historical controls. However, hydrosurgical debridement and nanocrystalline silver dressings have been separately used in different areas for the management of necrotic and burn wounds but have not been described as an approach to manage open fractures.

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Journal Readings # 2

Timing issue in open fractures debridement: a review article

Open fracture constitute a major trauma mostly sustained by young adults during high-energy injuries. Management of long bone open fractures is a very complex issue and is often complicated by nonunion and deep infection being among the most devastating and difficult to cure. It is generally recommended that wound debridement and stabilization of open fractures should be performed as early as possible, preferably within 6–8 h on the basis of historical comment and laboratory data. The rationale for this rule is believed to originate from Freidrich‘s historical study of guinea pigs. The literature lacks strong evidence addressing the primary issue of timing and delay on the incidence of deep infection and nonunion in open fractures. In the light of the actual literature regarding this topic, it seems that time to debridement of open fractures is not a prognostic factor of infection as well as nonunion.

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REACTION: This piece is all about the time of surgical debridement and its relationship to the infection rate. The infection rate will be affected by either early or late debridement. We clearly understood its main ideas but partially on the opinion and the supporting ideas. We chose this article because it has interesting thoughts. It also said that if an open fracture without debridement stays more than 8 hours, then the bacteria replicates, thus it will lead to infection. A lot of people have infections due to late debridement; however, if the debridement will be started early, then there would be a reduced risk of infection. Wound debridement and stabilization of open fractures should be performed as early as possible, preferably 6-8 hours. The article was convincing because it relates our case which is open fracture. Unfortunately, there are some points that overemphasize which are for me considered as irrelevant. But, it is well-researched because the authors are Alberto Jorge-Mora, Juan Rodriguez-Martin, and Juan Pretell-Mazzini and it was well presented in a balanced way. This article is helpful for people to be aware of how time is important when performing surgical debridement for open fractures. However, we haven‘t experienced being fractured, so we can‘t relate this to our experience but we‘ll relate this to our patient‘s case. About our patient, few hours after the injury, he was able to go to SUMC directly and was given care. He was examined in the X-ray and was operated through debridement. We also chose this because we are interested and we now realized that time of debridement can affect the condition of the injury and to the body. It didn‘t bother or annoy us because this can be really helpful not just to our case presentation but also to our duty in surgery.

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References Book Sources: Black, J. M., Hawks, J. H. & Keene, A. M. (2001). Medical-surging nursing: clinical management for positive outcomes 6th ed. Saunders Lewis, S. M., Heitkemper, M. M. & Dirksen, S.R. (2004). Medical-Surgical Nursing: Assessment and management of clinical problems 6th ed. Missouri, St. Louis. Marieb, E.N. (1995). Human anatomy and physiology 3rd ed. The Benjamin/Cummings Publishing Company, Inc. Pillitteri, A. Maternal & child health nursing: care of the childbearing & childrearing family. 3rd ed. Vol. 2. Lippincott

Journal Sources: Efficacy of hydrosurgical debridement and nanocrystalline silver dressings for infection prevention in type II and III open injuries. Retrieved from http://web.a.ebscohost.com/Legacy/Views/static/html/Error.htm?aspxerrorpath=/ehost/detail/detail Jorge-Mora, A., Rodriguez-Martin, J. & Pretell-Mazzini, J. (April 4 2012). Timing issue in open fracture debridement: a review article. Retrieved from http://link.springer.com/article/10.1007%2Fs00590-012-0970-7

Internet Sources:

Broken bone. Retrieved from: https://ufhealth.org/broken-bone 2 Aug 2014 Open fractures. Retrieved from: http://orthoinfo.aaos.org/topic.cfm?topic=A005822 Aug 2014 Pathophysiology of fracture. Retrieved from: http://www.vbook.pub.com/doc/102257963/Pathophysiology-of-Fracture 2 Aug 2014 What happens when a person bleeds. Retrieved from: http://www.stepsforliving.hemophilia.org/basics-of-bleeding-disorders/what-happens-when-a-person-bleeds 2 Aug 2014

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