This case presentation aims to identify and determine the general heath problems and needs of the patient

with an admitting diagnosis of Open Complete Comminuted Fracture at the left tibia, fibula. This presentation also intends to help patient promote health and medical understanding of such condition through the application of the nursing skills. Specific

To raise the level of awareness of patient on health problems that he may encounter. To facilitate patient in taking necessary actions to solve and prevent the identified problems on his own. To help patient in motivating him to continue the health care provided by the health workers. To render nursing care and information to patient through the application of the nursing skills.

A fracture is any break in the continuity of bone. Fractures are named according to their severity, the shape or position of the fracture line, or even the physician who first described them. It is defined according to type and extent. In some cases, a bone may fracture without visibly breaking. Fractures occur when the bone is subjected to stress greater than it can absorb. It can be caused by a direct blow, crushing force, sudden twisting motion, or even extreme muscle contraction. When the bone is broken, adjacent structures are also affected, resulting in soft tissue edema, hemorrhage into the muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels. Body organs may be injured by the force that caused the fracture or by the fracture fragments. Among the common kinds of fractures are the following:

Open (compound) fracture: The broken ends of the bone protrude through the skin. Conversely, a closed (simple) fracture does not break the skin. Comminuted fracture: The bone splinters at the site of impact, and smaller bone bone fragments lie between the two main fragments. Greenstick fracture: A partial fracture in which one side of the bone is broken and the other side bends; occurs only in children, whose bones are not yet fully ossified and contain more organic material than inorganic material Impacted fracture: One end of the fractured bone is forcefully driven into the interior of the other. Potts fracture: A fracture of the distal end of the lateral leg, with one serious injury of the distal tibial articulation. Colles fracture: A fracture of the distal end of the lateral forearm in which the distal fragment is displaced posteriorly.

Fractures may also be described according to anatomic placement of fragments, particularly if they are displaced or nondisplaced. Injuries to the skeletal structure may vary from a simple linear fracture to a severe crushing injury. The type and location of the fracture and the extent of damage to surrounding structures determine the therapeutic management. Maximum functional recovery is the goal of management.

The most common fracture below the knee is one of the tibia and fibula that results from a direct blow, falls with the foot in a flexed position, or a violent twisting motion. Fractures of the tibia and fibula often occur in association with each other. The patient presents with pain, deformity, obvious hematoma, and considerable edema. Frequently, these fractures are open and involve severe soft tissue damage because there is little subcutaneous tissue in the area. The signs and symptoms of a fracture include unnatural alignment, swelling, muscle spasm, tenderness, pain and impaired sensation and decreased mobility. The position of the bone segments is determined by the pull of attached muscles, gravity, and the direction and magnitude of the force that caused the fracture. ANATOMY AND PHYSIOLOGY Lower Limb Each lower limb has 30 bones in four locations: (1) the femur in the thigh; (2) the patella; (3) the tibia and fibula in the leg; (4) and the 7 tarsals in the tarsus, the 5 metatarsals in the metatarsus, and the 14 phalanges in the foot. The femur, or thigh bone, is the longest , heaviest and strongest bone in the body. Its proximal end articulates the acetabulum of the hip bone. Its distal end articulates with the tibia and patella. The patella, or kneecap, is a small, triangular bone located anterior to the knee joint. It is a sesamoid bone that develops in the tendon of the quadriceps femoris muscle.The patella functions to increase the leverage of the tendon of the quadriceps femoris muscle, to maintain position of the tendon when the knee is bent, and to protect the knee joint. The tibia, or shin bone, is the larger, medial, weight-bearing bone of the leg. The tibia articulates at its proximal end with the femur and fibula, and its distal end with the fibula and the talus bone of the ankle. An interosseous bone connects the tibia and fibula. The fibula is parallel and lateral to the tibia, but it is considerably smaller than the tibia. The proximal end, the head of the fibula, articulates with the inferior surface of the lateral condyle of the tibia below the level of the knee joint to form the proximal tibiofibular joint. The distal end has a projection called the lateral malleolus that articulates with the talus bone of the ankle. The tarsus is the proximal region of the foot and consists of seven tarsal bones. They include the talus and calcaneus, the cuboid, the three cuneiform bones called the first, second, and third cuneiforms. The metatarsus is the intermediate region of the foot and consists of five metatarsal bones numbered I to V, from the medial to the lateral position. The first metatarsal is thicker than the others because it bears more weight. The phalanges comprise the distal component of the foot and resemble those of the hand both in number and arrangement. They are numbered I to V being with the great toe, which is medial.

NURSING ASSESSMENT Present Health History The patient, F. L., is a victim of nature-insinuated accident. The incident happened in the morning of July 6, 2006 wherein F.L. and 3 of his friends are having their lunch at a mountain slope in their place. A large branch of tree hit him at the back and at the same time another struck him at his left leg. Immediately he was brought to a hospital in Cabanatuan. Treatments were done such as Closed Tube Thoracotomy due to the impact of the branch on his posterior chest; wound cleaning and wound dressing for the injury he obtained from the impact at his left leg. He noticed that the healthcare providers in the said hospital did nothing but to clean his wounds and replace the dressing, so he decided to transfer to another hospital. On July 29, 2006 he was admitted by Dr. Geronilla at the East Avenue Medical Center wherein his admitting diagnosis is Open Complete Comminuted Fracture at the left tibia, fibula. The following day, July 30 at exactly 3:50pm he had undergone an operation conducted by Dr. Tagaba and was given a spinal anesthesia by Dr. Sangcate. The operation performed was Debridement Impaction and Application of External Fixator at the left tibia. Past Health History Prior to his hospitalization at Cabanatuan and Quezon City, he had no records or medical history of being admitted with any disease to any other hospital. Family Health History No hereditary disease can be attributed from his mother side, but his father died of asthma. Other than the latter, no other hereditary disease from both of his parents are within the patients knowledge. Demographic Data | Physical Assessment and General Appearance | Head to Toe Assessment Gordons Functional Health Pattern Health-Perception/ Health Management Pattern The patient is almost generally the same as how every Filipino seeks health assistance. Without any problem regarding his health, he would not approach health workers not unless it is lifethreatening. Although he was not hospitalized prior to his current illness, the patient has the proper perception whether he is being treated correctly as with the management done to him at the hospital in Cabanatuan. Nutritional/ Metabolic Pattern

The patient eats three times a day. He says that he eats a balanced diet. Although he is not fond of eating fish, he loves to eat vegetables such as okra and is fond of munching fruits like bananas and catmon. He usually drinks coffee every morning. He prefers to drink water than carbonated beverages. During his hospital stay, he is instructed with diet as tolerated. Elimination Pattern According to the patient, when he is at home or even at work he usually defecates for at least once a day, same as with his stay in the hospital. He urinates more frequently (average of 4 times daily) during his stay at the hospital than the time prior to his admission. Activity/ Exercise Pattern For his leisure time, the patient likes to have drink with friends. He often does this almost once a week, drinking a glass or two of gin or brandy. Aside from drinking, he is also fond of smoking cigarette, consuming almost 10 sticks a day. He started drinking and smoking almost 5 years ago. He is not fond of playing physical games. He implied that he would rather watch television and court a girl. Sleep-rest Pattern The patient sleeps for an average of 8 hours per day before his confinement. During his hospital stay, he usually sleeps for 4 hours and takes nap in the afternoon. He had a difficulty of moving around the bed due to the external fixator attached to his leg. Cognitive/ Perceptual Pattern From his point of view, he has a good memory. He says that he can still remember things of great importance especially with regards to his family and loved ones. His hearing ability is also in normal condition and so does his sense of sight. Self Perception/ Self-Concept Pattern The patient says that he is very much comfortable with his body image prior to his injury. Even if his left leg is injured, he still feels optimistic about regaining his old functionality and image. Role/ Relationship Pattern He still lives with his mother and performs his obligations as a son. The patient did not confirm that he is into an intimate relationship right now. Sexuality & Reproductive Pattern Being 5th among children of six wherein 5 of them are female and him, the only male among them, he managed to have a stable gender identity during his growing years.

Coping/ Stress-tolerance Pattern As part of his stress-tolerance activity, the patient likes to listen to soothing music to relieve him from anxiety. He also smokes for that matter and often he relaxes his body by taking a time off his work and spending time with his friends. Value/ Belief Pattern The patient is a Roman Catholic, but not really the type of follower who goes to the church every Sunday to hear mass. He makes his decision in accordance to his principles in life and how he perceives it. Medical & Surgical Management As in the case of the patient in this study, the operation performed was Debridement Impaction & Application of External Fixator at the left tibia. The principles of fracture treatment include reduction, immobilization, and regaining of normal function and strength through rehabilitation. In an open fracture, there is a risk of tetanus, gas gangrene and osteomyelitis. The objectives of management are to prevent infection of the wound, soft tissue and bone and to promote healing of soft tissue and bone. Debridement and irrigation is used to remove anaerobic organisms. Devitalized bone fragments are removed. The fracture is then carefully reduced and stabilized by external fixator. Intravenous antibiotics are prescribed to prevent or treat infection. Fracture treatment involves realigning the bone fragments (reduction) close to their normal or anatomic position and holding the fragments in place (immobilization) so that bone union can occur. Reduction of a fracture refers to the restoration of the fracture fragments to anatomic alignment and rotation. In most cases, fracture reduction becomes more difficult as the injury begins healing. The specific method used on the nature of the fracture in this case is closed reduction. Open reduction is a method is used if the bone is fragmented or difficult to reduce, and may requires screws and a plate to hold the fragments in place. The doctor makes a cut in the skin covering the break to expose the bone fragments. The bone fragments are moved into their normal position, and screws, a plate with screws, or a rod may be used to hold the realigned bones in place. Extremely severe fractures may require placement of a natural or artificial bone graft. The doctor closes the incision with stitches, and a splint, dressings, plus a splint or cast may also be used to protect the area. After the fracture has been reduced, the bone fragments must be immobilized, or held in correct position and alignment, until union occurs. Immobilization is accomplished by external. Methods of external fixation include bandages, casts, splints, continuous traction, and external fixators. External fixators are used to manage open fractures with soft tissue damage. They provide stable support for severe comminuted fractures while permitting active treatment of damaged soft tisuues. The fracture is reduced, aligned and immobilized by a series of pins inserted in the bone. Pin postions is maintained through attachment to a portable frame. The fixator facilitates patient comfort, early mobility,

and active exercise of adjacent uninvolved joints. Complications related to disuse and immobility are minimized. Open complete comminuted fracture of the tibia, as in the case of the patient, was treated with external fixation. Hip, foot and knee exercises are encouraged within the limits of the immobilizing device. Partial weight bearing is begun when prescribed and is progressed as the fracture heals in 4 to 8 weeks. Reduction and immobilization are maintained as prescribed to promote bone and soft tissue healing. Swelling is controlled by elevating the injured extremity and applying ice as prescribed. Neurovascular status is monitored, and surgeon is advise if signs of neurovascular compromise are identified. Reassurance, position changes and pain relief strategies controls feeling of restlessness, anxiety and discomfort. Isometric and muscle-setting exercises are encouraged to minimize disus atrophy and to promote circulation. Participation in activities of daily living is encouraged to promote independent functioning and self-esteem. Gradual resumption of activities is promoted within the therapeutic prescription. Discharge Plan M edication Intake of pain relievers in case the site is in pain. E conomic The use of nonpharmacotherapy such as exercises and elevation of lower extremity to control edema and pain are encouraged to avoid further expenditure on medication. T reatment Management of such condition would include proper therapy and exercises of the extremities, intake of pain relievers as prescribed and dietary supplements as well. H ygiene Advise to follow proper body hygiene and to maintain cleanliness on site. This would promote less risk for infection. O ut Patient/ Follow-up In cases wherin pain beyond limits of discomfort can be felt, advise to report to physician or surgeon immediately. Uncontrolled swelling and pain, cool and pale toes, signs of infection, loose fixators must be immediately reported to the physician for proper management. D iet

Instruct to eat foods that are rich in protein, dietary fiber, carbohydrates, Vitamins A & C to promote wound healing. Evaluation Conclusion The patient in this study had undergone debridement impaction and application of external fixator at the lest tibia. He had a tibial fracture last July 6 due to a blunt injury froma foreign object fall. He was transferred from a hospital at Cabanatuan to East Avenue Medical Center to seek for further advise and proper treatment of his case. Proper nursing care such as pain relief using nonpharmacotherapy and administration of prescribed drugs were done to promote comfort. Hygiene was also strictly implemented to avoid risk for infection. Nursing assistance was also given to help him in his activities of daily living. Health teaching is a very important role on the part of the nurses. This is of great significance to the knowledge deficit of patients regarding health and illness. Recommendation Strict compliance to the medical treatment, health teachings and medical check-up is advised. With proper nutrition and conformity to the medications & therapy, recovery would be easier and faster. Definition Of Terms Debridement removal of foreign material and devitalized tissue from a wound Edema excessive accumulation of fluid in the tissue spaces, due to increased trabsudation of of the fluid from the capillaries Fracture a break in a bone usually caused by trauma Impaction a condition in which one fragment of a fractured bone is driven into another and is fixed in that position Open reduction a reduction performed after making an incision through the soft parts in order to expose the fracture or dislocation