MODULE 1: CARE OF CLIENTS W/ PROBLEMS….

NCM 116

SECOND SEMESTER | AY. 2023-2024| PROF. LEE ANNE MONIQUE IBANA

FRACTURE 1. Traumatic – fracture due to

 A break/crack in the continuity of the direct/indirect violence
bone. - Fracture results from
mechanical injuries.
2 Mechanism - Due to abnormal
a. Direct - kinetic is applied at or near the excessive force
site of fracture. a. Direct Violence
b. Indirect - kinetic energy is transmitted b. Indirect Violence
from the point of impact to a site c. Muscular Violence
where a bone is weaker.
o Fall
CLASSIFICATION OF FRACTURE o Assault
A. Morphologically (appearance) o Accidental
a) Open – fracture/compound 2. Pathological – fracture for illness
fracture bone that breaks or disease.
through the skin. Local
b) Closed/Swipe Fracture – 1. Infection
does not penetrate thru skin 2. Tumors
o Benign
1. Transverse o Primary
o Fracture in which the bone
malignant
breaks across the shaft. o Metastatic tumors
o Bone cancer
2. Stellate
a. Inflammatory
o Line of fracture radiator for a
b. Metabolic
point c. Neoplastic
o Star shaped fracture d. Congenital

3. Oblique General
o Slanted across bone shaft  osteoporosis
 metabolic disease
4. Spiral  Paget's disease - chronic
o Twist around the shaft o d/o that causes bones to
casually twisting injury grow larger and becomes
weaker
5. Comminuted  osteogenesis infer infection
o When bone breaks into 3 or  genetic d/o that prevents the body for
more fragment building strong bones

6. Segmental C. ON THE BASIS OF STABILITY

o Two fractures in 1 bone
1. Complete - fracture that involves
7. Impacted Fracture the entire width of the bone
o Break where the ends are a) Impacted/Buckle Fracture
driven into each other b) Iron-impacted
Assessment
1. Did bone break through skin 2. Incomplete - partial fracture
2. Is the bone break completely broken a) Greenstick
or just part of it - most common in _____
3. Details of the fracture - one side is broken

B. Etiology – cause fracture

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 MODULE 1: CARE OF CLIENTS W/ PROBLEMS…. NCM 116

SECOND SEMESTER | AY. 2023-2024| PROF. LEE ANNE MONIQUE IBANA

 Smoking
D. ON PRESSURE OF WOUND  Associated Systemic
Illness
1. Simple/Closed - no skin breakage
COMPLICATION OF MUSCULOSKELETAL
2. Compound/Open - skin integrity TRAUMA
is intended 1. Compartment Syndrome
 P - pain - early signs
E. MISCELLANEOUS  P - Pallor - dusky/pale in color
1. Multiple Fracture  P - Paralysis - unable to move
2. Complicated Fracture  P - Paresthesia - feeling
- when the structure pins/needle
surrounding the site of  P - Poikilothermia - feeling
fracture is injured warm, check both extremities
- damaged veins,  P - Pulselessness - late sign,
arteries and nerve check the radial

MANIFESTATION "BROKEN" NURSING INTERVENTION

B - Bruising with pain & swelling 1. Notify Medical Doctor
R - Reduced Movement 2. Keep extremities at heart level
O - Odd appearance 3. Loosen/remove resistance/
K - "Krackling" sound - crepitus clothing
E - Edema, erythema on site - cast
N - Neurovascular impairment 4. Severe Cases - Fasciotomy
- pressure on the done by MD
nerve/vascular supply
to an extremely 2. FAT EMBOLISM SYNDROME
 Hypovolemic Shock - due to - Long bones fracture
blood loss  Signs and Symptom changes
 Ecchymosis - due to in mental status - confusion
extravasion of blood into  Restless - difficulty of
subcutaneous tissue breathing
 Increase RR
Signs and Symptoms Neurovascular  Petechial rash (chest, axilla,
Impairment upper arm)
 6 P's
 P - pain - heart, lungs, kidneys,
 P - Pallor eyes --- BRAIN
 P - Paralysis
 P - Paresthesia 3. DVT - blood clot form in one/deep
 P - Poikilothermia vein usually legs
 P - Pulselessness 4. Infection
5. Delayed Union and non-union
COMPILATION OF FRACTURE 6. Reflex sympathetic dystrophy
- 3 to 12 weeks - chronic conditions
1. Delayed Union Fracture - takes more characterized by
that used time to unite severe burning pain
- older person (arms, legs, hands
2. Non-union - fragments and not unite and feet)
3. Malunion - bone are heated but poor
in alignment TREATMENT:
Causes: A. EMERGENCY CARE
 Age A. Immobilize

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 MODULE 1: CARE OF CLIENTS W/ PROBLEMS…. NCM 116

SECOND SEMESTER | AY. 2023-2024| PROF. LEE ANNE MONIQUE IBANA

- correct alignment - the patient if applicable

- alleviate pain/pressure - increase fluid intake
- accelerate healing - increase protein
- stabilize the injury while - orthostatic Hypotension
traveling/transporting
C. CAST
a. Splinting - A rigid device applied to immobilize
- cardboard piece of wound the injured bones and promotes bone
(first aid) healing
- put paddling (if available for - apply with stable fracture
extra support)
 pulse - circulation and motor TYPES OF CAST
ability & sensation before 1. PLASTER CAST
applying the splint o made for gauze and plaster
 properly fit strips in water.
 pulse 2. SYNTHETIC CAST
o made for filter glass/plastic
b. Dressing strips
 sterile gauze o lighter than the plaster cast
 secure the bandage o dries in few minutes, but may
 applying the pressure around take a few hours to harden
the wound not over the bone fully.
to prevent bleeding 3. CAST BRACE
o made for hard plastic
c. Assessment of pulse, Movement, o soft pads inside the brace
and sensation
push against the injury
o brace is held in place by
B. REDUCTION (operation will be @ the
Velcro strips that can be
bedside)
removed
- for alignment/align bones in
4. SPLINT (half cast)
place
o made for slabs of plaster or
- perform to restore bone in
fiber glass that hold injury
Normal position
together
o bandage is wrapped around
[Link] REDUCTION (pushing/pulling)
injury to hold slabs in place
- exerting effort and fraction
o often used when swelling is
- we need anesthesia
present
- may apply fraction and casting
after
NURSING CARE
1. Check the Neurovascular status
2. OPEN REDUCTION INTERNAL FIXATION
- 6 P's (pain- early signs,
(ORIF)
pulselessness- late sign)
- require surgery
2. Check the infection.
- internal fixation used: wires,
3. Skin breakdown/skin integrity
pins, screw, plates and nails 4. Keep it dry.
- infection 5. Elevate cast above heart level
- decrease swelling
NURSING CARE 6. Use palm to touch cast to
1. Check the Neurovascular status; the 6P's. prevent indentation.
2. Check and assess the drainage.
- check the color and smell. D. TRACTION
3. Check the pressure/bed sore. - Attain realignment

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 MODULE 1: CARE OF CLIENTS W/ PROBLEMS…. NCM 116

SECOND SEMESTER | AY. 2023-2024| PROF. LEE ANNE MONIQUE IBANA

- prevent/reduce pain parallel rods using ropes,

- reduced using pulley and weight.
fraction/dislocation
MATERIALS:
1. MANUAL TRACTIONS a. Orthopedic Bed (with firm beds
 the hand directly applies mattress)
the pulling force/force the b. Bed elevation
traction. c. Balkan Frame/Cross Bar, Curve Bar,
 done by PT/ trained nurse Vertical, Horizontal, Diagonal Bars
d. Three Pulleys/Overhead Trapeze
BENEFITS: e. Traction Equipment
a. Relieve Spasm - Thomas splints
b. Relieve nerve - Pearson's attachment
compression - Rest Splints
c. Gently stretcher the - Steinman's Pin Holder Slings
cervical/lumbar spine
d. Improve mobilization Three ROPES (SUSPENSION, TRACTION &
e. Encourage relaxation THIGH ROPE)
 TRACTION WEIGHT - (10%
body weight)
1. SKIN TRACTION  SUSPENSION WEIGHT -
- exerting grabbing and pulling ( 1/2 of Traction weight)
force through patients skin  THIGH ROPE - foot pedal/rest
- usually short term (24-72°)
- less weight (usually 5-10
lbs/5-7 lbs) PRINCIPLES OF TRACTION
- uses tape, boots/ splints 1. Dorsal Recumbent Position
directly on skin 2. There must be a counter traction
- use operatively - -Patient
- use 1-3 days/temporary Traction/Weight
traction traction
3. There must be continued traction
Example: 4. The line of the pulley's should be in
 Buck's Traction for adults line with the line deformity
 Bryant's Traction for a. 1 - in the inguinal are
pediatrics b. 2 - in line with knee
c. 3 - in line with 1st and 2nd
NURSING CARE pulley
1. Check skin breakdown (q 2-4 hrs) 5. Avoid friction.
2. Monitor for pressure points - no knots along the
3. Non-adhesive - no use of adhesive pulley
tape 6. Weight should be HANGING FREELY
4. bandage/foams/stripes - no lifting
5. Skin adhesive - use of adhesive tape - no weight on the floor
attached to weight 7. Observe wear and tears of the bags
and rods.
2. BALANCE SUSPENSION TRACTION
- involves more than one force 3. SKELETAL TRACTION
of pull traction - Application of pulling force
- used to treat femur/upper leg through placement of pins in
fractures where traction is via the bones and weight
attached.

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 MODULE 1: CARE OF CLIENTS W/ PROBLEMS…. NCM 116

SECOND SEMESTER | AY. 2023-2024| PROF. LEE ANNE MONIQUE IBANA

- long bone fracture

E. SURGERY
NURSING CARE 1. EXTERNAL FIXATION
1. Infection  transfixing screw/tension wires that
2. PIN CARE (ONE PIN: ONE SWAB at pass through the bone above and
least every shift) below the fracture and attached to
3. Monitor pin loosening external frame.
INDICATION:
IN ALL TRACTION 1. Fracture is associated with severe
1. Need to ensure patient is in Current soft tissue damaged (including open
Position for bone alignment fracture) or those are comminuted.
2. Traction forces must be remained 2. Fracture around the joint that are
CONSTANT potentially suitable for internal fixation
3. Keep weight off the floor hanging but soft tissue are two swollen to
freely! Never lift the weight! allow surgery.
3. Patient with severe multiple injuries
ASSESSMENT - Bilateral Femoral Fracture;
1. Neurovascular status Fracture with bleeding.
 Pain: 4. Ununited Fracture - which can be
Analgesic/NSAIDS/Narcotics excised and compressed.
 Pulse: Assessing bilateral 5. Infection/infected fracture
 Poikilothermia
 Paralysis: "can you move COMPLICATION
this?" 1. Infection
 Parythermia: "can you feel 2. Damage to soft tissue and structure
this?" - inhibit movement
2. Alignment - need to know the anatomical
 Straight structures
 Supine 3. Over distraction
 Head on bed at least <30° - if there is no contact between
 Ropes- check the fragment’s union is
3. Weight - create tension unlikely.
- keep it hanging freely 2. INTERNAL FIXATION (ORIF)
4. Skin - Using of plates, nails, screams
 Skin breakdown and wires
 (straps/pins/sacrum)
 Pin site care INDICATION:
 Inspect (Skin infection) 1. Patient is compliant and reliable
 New drainage 2. With sufficient bone quality and present
 Redness around the pin? less complex fracture.
 Loosening of the pin? 3. Distal radial fracture
 Clean: one clean - one swab
Complication:
PATIENT EDUCATION 1. Infection - prevent it infection
1. infection - prevent infection  avoid touching of site
- avoid touching of site  keep it clean and dry
- keep it clean and dry  keep environment clean
- keep environment clean  DIET: high protein and Vitamin
- DIET: high protein, increased C
Vit. C (fruits and vegetables)  Increase Fluid Intake and
- Increase fluid Intake and Fiber Fiber
2. Alignment. 2. Alignment
3. Recheck the bleeding. 3. Recheck the bleeding

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 MODULE 1: CARE OF CLIENTS W/ PROBLEMS…. NCM 116

SECOND SEMESTER | AY. 2023-2024| PROF. LEE ANNE MONIQUE IBANA

10. Melch Type

F. ELECTRICAL BONE STIMULATION 11. Salter - Harris type
- stimulation of bone cells for - epiphyseal plate
rapid healing o S - straight
- increase signal cascades in o A - above
order to stimulate move robust o L - lower
and rapid healing o E - Everything
- 2 skin electrodes are placed o R - Crush
an each side of broken bone 12. Thomas-epstein type - hips
and low voltage passes a
II. INFLAMMATORY/INFECTIOUS DISEASE
small current between A. SPRAIN
electrodes - ligaments
- when we role ankles inusual
INDICATION:
 -non-healing (non-union) bone How to deal inflammation/swelling?

MEDICATION: 1. R - rest - avoid any activity that

1. Analgesic- moderate pain cause pain
killer /Narcotics - through pain killers I - ice - 20 mins 16 pack 3x a day
(opioids/morphine) C - compression -ankle braces,
 Paracetamol keep things long in place
 Acetaminophen E - elevation - decrease swelling,
decrease pain 20-30 mins 1-2
 Ibuprofen
times a day
2. Still Softener
- decrease constipation 2. Cross friction massage
- increase fluid intake and fiber 3. Exercises
3. Antacids a) sealed calf stretch
4. NSAIDS - passive ROM
- pain killer/anti-inflammatory - 3x 20 seconds hold 2-3 x a
- lesser Side effects compared day
to opioids b) ankle ABC 2-3 x a day
c) weight shift
5. Antibiotics
- 10-30 x a day , increased
6. Anticoagulants
elevation as tolerated
- blood thinner d) mini squats
- Prevent deep vein thrombosis - 30-90 x daily
7. Diet e) gastrocnemius stretch
- increase fluid intake and fiber - 3 x 20 sec hold 3 x daily
- Increase protein like egg, f) heal raises
chicken and etc. - 3 sets of 10-30 reps.

EPONYM B. SPRAIN
1. Barton's - radius - stretching injury muscle and
2. Cotton fracture - ankle tendon
3. Colles Fracture - Radius - ulna o R - rest
4. Malgaigne's Fracture o I - Ice
5. Monteggia's Fracture - double fracture o C - compression
6. Bennett's Fracture - base of the thumb o E- elevation
7. Galeazzi's Fracture - 3rd distal radius
o C - close - Colles  Prevention - stretching
o S - Smith
o G - 3rd distal GRADE LEVEL OF MUSCLE STRAIN
8. Pott's Fracture - fracture of the fibula  Grade 1
9. Gartland type

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 MODULE 1: CARE OF CLIENTS W/ PROBLEMS…. NCM 116

SECOND SEMESTER | AY. 2023-2024| PROF. LEE ANNE MONIQUE IBANA

- minimal, muscle fibers are slightly 3. Localized defect with stable bone
form 4. Diffuse infection with involvement of
- damage is minimal bone stability.
- 2-3 weeks to recover
 Grade 2 Medications: IV antibiotics (long term)
- 2-3 months to recover
- 50 % of the muscle fibers form Surgery Management:
 Grade 3 1. Debridement
- muscle fibers are completely form 2. Removal of the dead bone tissue
- 3 months- 1 year to recovery (sequestrectomy)
- severe pain and swelling 3. Combination of Debridement and
- require surgery administration of culture specific
antibiotic

C. CONTUSION Sx:
o trauma that damages blood vessels 1. Open the involucrum ( new bone)
underneath the skin 2. Remove the sequestrum (dead bone)
- falling 3. Saucerize the bone
- bumping - make sure a pathologic fracture is
- getting hit not created
- Stabilize the bone if needed
Treatment: (external fixator is prepared)
o R- rest if possible 4. Full cavity with bone hips cement
o I - ice - swelling and help heal mere spacer.
guidelines
Diagnostic Test
o C- compression bandage- decrease
1. MRI, Bone Scan, CT Scan
blood flow; decrease swelling and
2. UTZ
pain
3. Blood Test
o E- elevation - decrease blood flow,
 ESR - Electrolytes Sedimentation
decrease discoloration
Rate
 increase ESR - inflammation
D. OSTEOMYELITIS
- bone infection  WBC - increase WBC -
inflammation/infection
Other risk fracture 1. Blood and tissue culture - to identify
a) recent trauma specific antibodies
b) open fracture
c) orthopedic symptoms NURSING DIAGNOSIS AND MANAGEMENT
d) systemic disease (DM) 1. Risk for infection
- proper wound healing/cleaning
Initial signs and symptoms - DIET: Increase Vit. C and CHON
1. Bone pain - Administered of antibiotics as
2. Redness prescribed
3. Swelling 2. Hypertension
4. Fever - monitor vital signs q 4 hours
5. Increased WBC - TSB, increase Fluid Intake
- provide a cold environment;
Classifications: provide light clothing and bedding
1. Acute - usually within 2 weeks - Administer medication as
2. Subacute -for 4 weeks to several prescribed
months 3. Impaired physical mobility
3. Chronic - after several months - years - ensure safety
- Passive ROM
TYPES OF BONE INFECTION - No weight bearing activities to the
1. Medullary affected area
2. Superficial - maintain rest
4. Acute Pain

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 MODULE 1: CARE OF CLIENTS W/ PROBLEMS…. NCM 116

SECOND SEMESTER | AY. 2023-2024| PROF. LEE ANNE MONIQUE IBANA

- DBE/guided imagery  E - Elevated temperature fever

- relaxation techniques  R - Reduced/difficulty moving the
- immobilize/splints spine
- avoid manipulation of the involved  T - tenderness over the affected
area; handle the area gently vertebrae
- -pain relief as prescribed  E - Edema around the spine
E. POTT'S DISEASE  B - Back pain (especially with
 TB of the spine movement)
 Tuberculosis spondylitis  R - Radical Pain (radiating)
 David's Disease  A - Abscess Formation
 Pott's carries
 Pott's Curvature  P - Paraplegia
 O - Osteopenia (bone density loss)
Causative Agent: Mycobacterium tuberculosis  T - Tissue destruction visible in
- common site in spine imaging studies
- Percival Pott 1979 English Surgeon  S - Soft tissue swelling/inflammation
PATHOPHYSIOLOGY "Paraplegia" - late sign
[Link] in the lungs spreads hematogenously to - due to spinal column compression
the bone (spine) - paralysis (motor and sensory function)
l in lower half of the bones
Reaches the anterior portion of the vertebral
column 1. Inability to walk - legs
I 2. Incontinence/bone/bladder control
Bacteria proliferate with in the bone 3. Sexual dysfunction
I 4. Paresthesia
Immune cells respond to invasion
I Diagnostic test
GRANULOMA FORMATION (reaction of 1. Tuberculin skin test/ Mantoux
infection, inflammation, imitation or foreign Test/Purified Protein Derivative - M.
objects) TB
I - injected they ID tilo elicit
Formation of caseous necrosis cells death that immune response in patient
causes tissue to become "cheese like" in who have been expel to TB
appearance - 48 - 72° results
IA IB - 5-10 mm/raised/induration
A. Leads to destruction of trabecular bone (significant)
with in the vertebral column bodies - 4mm (insignificant) - BCE
Sign and symptoms
1. Loss of bone density PURPOSE:
2. Vertebral collapse 1. Indicate exposure to TB not
3. Gibbus formation necessarily active TB
B. Formation of Paravertebral abscess 2. presence of antibodies against
1. Local tissue formation Tubercle Bacilli
2. Compression of neural structure
2. ESR
Abscess+ vertebral collapse 3. ACID-FAST BACILLI - Sputum AFB
 (+) - detects presence of M. TB
Signs and Symptom
 (-) - 2months of TB treatment
1. Radiculopathy ( nerve not
compression)
DO'S
2. Myelopathy (spine column
- Rinse mouth with water only
compression)
- early morning collection
3. Paralysis (paraplegia)
- (deep breathing, cough deeply)
S/Sx = VERTEBRA POTS
DON'T
 V - Vertebral column deformity

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 MODULE 1: CARE OF CLIENTS W/ PROBLEMS…. NCM 116

SECOND SEMESTER | AY. 2023-2024| PROF. LEE ANNE MONIQUE IBANA

- Don't use mouthwash o E- ethambutol

- Don't brush o S - streptomycin
- Don't breakfast
Common S/E
4. Imaging 1. R- orange-red colored urine
a. X-RAY (temporary reversible)
- destruction of anterior portion of 2. I - peripheral neuritis
the vertebra - Inflammation nerve
- collapsed vertebral body - vit. B6
b. MRI/CT SCAN 3. P - hepatotoxicity
- detected imaging 4. E - optic neuritis
- gibbus formation - inflam. optic
- detects pressure of Abscess - Decreased VA
- spinal cord compression - Blurred vision

Surgical TX
1. Arthrodesis
Mgt. GOAL - referred as joint fission
1. Minimize Deformity - prone position - corrects the structural deformity
side lying (proper alignment) - done to conservative fx. fails
2. Building pts resistance - removal of interpretable
- Rest sleep disc/cartilage
- Diet : high CHON ; diet rich in - bone graft is inserted bet. the
vitamins and minerals such as bone
Vitamin C, D, Calcium |
bone are realigned and fixed together (fixator)
Immobilizing cervical |
- BRACES bone growth forming a single solid bone.
- SOMI (Sternal Occipital Mandibular
immobilize) 1. Joint eliminated
- provide control over flexion, extension, 2. Decreased bone pain
lateral and rotational movement of the 3. Improve stability in the affected area
spine (C2 -C5) vertebrae
[Link] Excision
 Upper Thoracic - Taylor's Brace - 6A
- Maintains spine in neutral position - prone
when sitting, standing or walking,
helps posture correction. How?
1. vertebral resection (removal) excision
 Lower Thoracic - Jenette’s Brace of structure within the body
- Control and support thoracic and - removal of infected vertebral body
lumbar spine, reduce pain and 2. Spinal reconstruction
present further injury - bone grafting
- autograft -self
 Lumbosacral - chairback brace - allograft - other
(waist trimmer) 3. Costotransversectomy and
- Short brace may provide low back anterolateral decompression
pain relief and spinal stability - Costotransversectomy - removal
especially after symptoms of costotransverse joint
- Decompression - Sx removal of
4. Control infxn - wound care structure that are
compressing/putting pressure to
• TB drugs the SC
o R-rifampicin
o I - isoniazid  correct the ribs to the transverse
o P- pyrazinamide process of the vertebrae
1. Incision

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SECOND SEMESTER | AY. 2023-2024| PROF. LEE ANNE MONIQUE IBANA

2. Joint removal
- access to the thoracic SC
3. Spinal decompression
- Goal: to decompress the SC

4. Laminectomy
- laminal removal
- bony arch on the back of vertebral that
covers/protect the SC
- removal creates move space with in
the spinal cord
- relieve pain in the SC

5. SURGICAL DRAINAGE
o drainage of the abscess -
decrease pressure
How:
1. Incision to expose the site of abscess
2. Abscess debridement and irrigation
3. Drain placement - catheter
- continue drainage

COMPLICATION:
1. Hypostatic Pneumonia
 settling fluids to a contain are of
the lungs due to immobility

Immobility
l
Decrease chest wall immobility
l
Impairs the ability to clear secretion in lungs
l
Mucus secretion pool in the airway
l
Attracts nutria
;
Pneumonia - HYPOSTATIC PNEUMONIA

2. Bed sore
- prolonged immobilization

 Mngt:
- change position q 2°
- dry skin moisturizer
- Linen dry and wrinkle free

3. Constipation
Reason:
1. Limited mobility
2. Paraplegia
3. Loss of appetite
4. Dehydration

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