CHAPTER 1

INTRODUCTION
1.1. Background
Traffic accidents are serious health problem throughout the world, the
same problem is also faced by Indonesia. Traffic accidents are the number 3 killer
in Indonesia. With the increasingly rapid advances in traffic both in terms of the
number of road users, the number of users of vehicles, the number of users of
transport services, road network and increasing the speed of the vehicle then the
majority of fractures were traffic accidents. There was 79.8% consequences
caused by traffic accidents is a fracture. A fracture, also referred to as a bone
fracture,it is a medical condition where the continuity of the bone broke. A
significant percentage of bone fractures occur because of high force impact or
stress; however, a fracture may also be the result of some medical conditions
which weaken the bones, for example osteoporosis, some cancers or osteogeneris
imperfecta. A fracture caused by a medical condition is known as a pathological
fracture. Fracture or broken bone is a break of continuity of bone tissue and / or
cartilage which is generally caused by excessive pressure. Trauma that causes a
broken bone can be a traumatic direct and indirect trauma. The open fracture is
a fracture where there is a relationship with the outside environment through the
skin resulting in bacterial contamination causing complications such as
infection.A single fracture means that one fracture only has occurred and
multiple fractures refer to more than one fracture occurring in the same bone.
Fractures are termed complete if the break is completely through the bone and
described as incomplete or "greenstick" if the fracture occurs partly across a
bone shaft. This latter type of fracture is often the result of bending or crushing
forces applied to a bone.
World Health Organization (WHO) notes that in 2005 there were more
than 7 million people die due to accidents and incidents around 2 million people
experience a physical disability. One of the incidents of accidents is high enough
that the incidence of lower limb fractures, approximately 46.2% of the incidents
of accidents that occur. Number of patients experienced a fracture in the United
States about 25 million people in a year .When researchers conduct a preliminary
study in the department of surgery. Base on Adam Malik Hospitals data, in
March 2010 there were 8 cases of fracture. Fractures of the femur is the highest
1

incidence. Based on the observations of researchers a number of patients with a

chief complaint of pain often encountered, especially in patients with fractures.
Information gleaned from the research room nurse at the time, to cope with the
pain felt by the patient is given analgesics alone and was never given a cold
compress by nurses to cope with the pain felt by the patient. Cold compress is one
form of action to be considered independently of nurses especially in patients who
experience pain fracture.
Fracture is a potential or actual threat to the integrity of the person will
experience physiological and psychological disorders that can cause a pain
response. The pain is a subjective state in when a person shows discomfort
verbally and non-verbally. Person's response to pain is influenced by emotions,
the level of awareness, cultural background, past experiences of pain and
understanding pain. Pain interfere with a person's ability to rest, concentration,
and usual activities (Engram, 1999). Fracture also can lead to some complication
condition like bleeding, gangrene, secondary hemorrage, chronic osteomyelitis,
delayed union, non union and malunion, joint stiffness septic shock until death.
So those phenomena make us as a nurse intererest to make a paper about
fracture and the nursing care plan base on number morbidity and also mortality
caused by fracture complication.
1.2. Purpose
The purpose of this paper is :
1. Understand the definition, etiology, pathogenesis, clinical manifestations,
diagnosis, treatment and prognosis of open fractures.
2. Understand the nursing care process in Fractures begin in nursing
assessment,

Nursing

diagnoses,

List

of

Nursing

interventions,

implementations and then evaluate the nursing care.

CHAPTER 2
DISCUSSION
2.1. Anatomy Physiology of Musculoscletal system
1. Structure of the sceletal system
The body contains 206 bone, which divided into two major categories ries:
2

the axial and appendicular skeletons. Bones are very good assortment in the
form or size, but they still have the same structure. The outermost layer called
the perriosteum where there are blood vessels and nerves. Layer under the
perriosteum of the bone with thread binding collagen called Sharpen thread
that goes into the bone called the cortex. Because of the cortex are hard and
thick so-called compact bone. The cortex is composed of solid and composed
in a very strong structural units called Haversian system. Bone consists of
three cells, namely osteoblasts, osteocytes and osteoclasts. Osteoblasts are
bone forming cells under the new bone. Osteocytes are osteoblasts that of
the matrix. While osteoclasts are cells with the bone crusher reabsorb bone
cells are damaged or old. Bone cells is bound by elements of the so-called
extra cellular matrix. This matrix is formed by the threads of collagen,
protein , carbohydrates, minerals and ground substance (gelatin) which
serves as a medium in the diffusion of nutrients, oxygen, and metabolic waste
between the bone with blood vessels. In addition, it contains organic calcium
salts (calcium and phosphate) that causes the hard bone (Ignatavicius, 1995).
2. Long bones
Is a long cylindrical bone where the round ends and often withstand heavy
loads (Ignatavicius, 1995). Long bones consist of epiphyseal, cartilage,
diaphysis, periosteum, and medullary bone. Epiphysis (bone ends) are the
attachment points of tendons and joints affect stability. Diaphysis is the main
part of the long bones that provide structural bone. Metaphysical wide part of
the long bone between the epiphysis and diaphysis. This is an area
metaphysical bone growth during infancy (Black, et al, 1993).
3. Function of skeletal system
Bone give form to the body, support various tissues and organs and permit
movement by providing attachment for tendons and ligaments. The skull and
ribcage, for example, provide support for the brain, special senses and lungs.
Movement of the body is permitted by the articulation of joints and their
attached

muscles.

Bone

protecs

the

hematopoietic

system,

which

manufactures blood cells. The marrow cavities within various bones serve as
site for blood cell information. In adult, blood cell form in marrow cavities in
the skull, vertebrae, ribs, sternum, shoulder, and pelvis. There are two types
of bone marrow: yellow and red. The yellow marrow is found in the shaft of
long bones and extends into the Haversian systems. Yellow marrow is
3

connective tissue composed fat cells. Yellow marrow does not produce blood
cell, except during times of increasing blood cell need. Red marrow has the
same hematopoietic function (manufactures red and white blood cells). Red
marrrowis located in cancellous bone spaces, found in flat bones. Bone also
provide a cruical portion of mineral balance. Bones store and release minerals
for celluler metabolism (Black, 1993).
Bone function according to Donna D (1993) are:
1 ) Giving the power to the body frame .
2 ) The place of attachment of the muscle .
3 ) Protect vital organs .
4 ) Place of manufacture blood cells .
5 ) The storage of mineral salts
2.2. Defenition of Fracture
A fracture is defined as a break or disruption in the continuity of a bone. With a
fracture, injury to surrounding soft tissue also occurs. The severity of soft tissue
injury depends on location and severity of the break (Linton,2012).
1. Classification of Fractures (Smeltzer, 2002)
a. Complete fracture is a fracture in the midline and usually a shift.
b. Incomplete fracture is fracture that occurs only in a portion of the bone
diameter.
c. Closed fracture is fracture which does not cause tearing of the skin.
d. Open fractures is fractures with an injury to the skin or mucous membranes to
bone fracture.
e. Greenstick : a fracture in which one side of a broken bone while the other
f.
g.
h.
i.
j.

bends
Transversal: fracture along the midline of the bone
Oblique: fracture makes an angle with the center line of the bone
Spiral: twisting around the stem of bone fracture
Comminuted: bone fracture with broken into several fragments
Avulsion: fracture pulls bone and other tissues away from the point of

attachment.
k. Compressed: the bone is crushed.
l. Impacted: the broken bone ends are forced into each other.
m. Depressed: the broken bone is forced inward.
2.3. Etiology
Fractures are ruptures of living tissue and normally are the result of trauma or, less
commonly, stress and fatigue (stress fracture) or an underlying disease (pathologic
fracture). Fractures are most commonly caused by trauma to the bone, especially as a
result of automobile accidents and falls. Bone desease such as bone cancer also can
4

lead to a fracture (Bullock, 2000; Linton, 2012).

2.4. Pathophysiology
Any of the 206 bones in the body can be fractured. A fracture occurs when the bone is
subjected to more kinetic energy than it can absorb. Fractures may result from a direct
blow, a crushing force (compression), a sudden twisting motion (torsion), a severe
muscle contraction, or disease that has weakened the bone (called a stress or
pathologic fracture). Two basic mechanisms produce fractures: direct force and
indirect force. With direct force the kinetic energy is applied at or near the site of the
fracture. The bone cannot withstand the force. With indirect force, the kinetic energy
is transmitted from the point of impact to a site where the bone is weaker. The
fracture occurs at the weaker point (LeMone, 2008).

2.5. Sign and Symptoms (Smeltzer, 2002)

1. Pain
Immediately, severe pain is felt at the time of injury. After injury, pain may result
from muscle spasm, overriding of this fractured ends of the bone, of damage to
adjacent structures.
2. Deformity
Strong muscle pull may cause bone fragment to override; therefore aligment and
contour changes occur, such as (1) angulation, rotation, and limb shortening;(2)
Bone despression; or (3) altered curves in the injured site, especially when
compared with the opposite site. Swelling (edema) may appear rapidly from
localization of serous fluid at the fracture site and extravasation of blood into
adjacent tissues. Bruising (ecchymosis) may result from subcutaneous bleeding.
Muscle spasms-involuntary muscle contractions near the fracture-may occur.
3. Tenderness
Tenderness over the fracture site is due to underlying injuries.
4. Impaired sensation(numbness)
Sensation may be impaired as a result of nerve damage or nerve entrapment from
edema, bleeding, or bony fragments.
5. Loss Of Normal Function
Normal Function may be lost because of instability of the fractured bone, pain, or
5

muscle spasm.
6. Paralysis
Paralysis may be caused by nerve damage.
7. Crepitius
Crepitus result from broken bone ends rubbing together. Grating sensations or
sounds are felt or head if the injured part is moved.
8. Hypovolemic shock
Hypovolemic shock may result from blood loss or other injuries.
2.6. Complications of fractures (Linton 2012)
Complications of fractures and surgical management include neurologic and/or
vascular injury, CS, infection, thromboembolic events, avascular necrosis, and
posttraumatic arthritis.
1. Neurologic and vascular injury
Neurologic and vascular injuries can occur in any fracture and are more likely in
cases with increasing fracture deformity. Peripheral nerve injury is suspected if a
patient experiences motor or sensory deficiencies. Management of neurologic
injury involves immediate reduction of the fracture and possible nerve
exploration, with subsequent follow-up to assess whether or not neurologic
function returns.
2. Compartment syndrome
Compartment Syndrome occurs when tissue pressure exceeds perfusion pressure
in a closed anatomic space. This condition can occur in any compartment, such as
the hand, forearm, upper arm, abdomen, buttock, thigh, and leg, but it most
commonly occurs in the anterior compartment of the leg.
3. Infection
Complications of surgical intervention include local infection in the form of
cellulitis or osteomyelitis and systemic infection in the form of sepsis. Early
recognition of a local infection may prevent the development of sepsis and, thus,
decrease patient morbidity. The most common pathogen is Staphylococcus
aureus. Other pathogens include group A streptococci, coagulase-negative
staphylococci, and enterococci. Appropriate antibiotics should be administered if
an infection is suspected. Serial C-reactive protein and erythrocyte sedimentation
6

rate measurements should be obtained and may be used to assess treatment

response to antibiotics. If infection cannot be eradicated with antibiotics, I&D of
the surgical wound may be necessary, with removal of orthopedic hardware, but
only if the hardware is not performing its role.
4. Thromboembolic events
Thromboembolic events may occur after orthopedic trauma with prolonged
patient immobilization. Patients with significant fractures who are immobile for
10 days or longer have a 67% incidence of thrombosis.
5. Avascular necrosis
Avascular necrosis (AVN) is caused by disruption of the blood supply to a region
of bone. Revascularization of the avascular bone can lead to nonunion, bone
collapse, or degenerative changes. AVN is most commonly associated with
fractures of the femoral head and neck, scaphoid, talar neck and body, and
proximal humerus.
6. Delayed union.
Delayed union is defined as a fracture that has not healed after a reasonable time
period (the time in which it was expected to heal) has passed.
7. Nonunion
Nonunion is defined as a fracture with no possible chance of healing, no matter
how long the initial treatment is carried out. Risk factors for nonunion are
summarized in the Table. Management consists of treatment of the cause of the
nonunion and can include eradication of infection, stabilization of the fracture,
removal of interfering soft tissues, bone grafting, and medical/nutritional
modifications of comorbidities.
8. Malunion
Malunion is defined as healing of bone in an unacceptable position in any plane,
which leads to a disability for the patient, cosmesis, or the potential for the
development of posttraumatic arthritis. Treatment involves surgical correction of
the anatomic abnormality.
2.7. Treatment (Smeltzer, 2002)
1. Fracture Reduction
a. Closed Reduction: nonsurgical realignment of the bones that returns them to
their previous anatomic position.
7

b. Open Reduction: a surgical procedure in which an incision is made at the

fracture site.
c. Traction: application of a pulling force to an injured or disease part of the
body or an extremity while countertraction pulls in the opposite direction.
2. Fracture Immobilization
a. Casts: temporary circumferential immobilization device. Casting is a
common treatment following closed reduction.
b. External Fixation: metallic device composed of metal pins that are inserted
into the bone and attached to external rods to stabilize the fracture while it
heals.
c. Internal Fixation: internal fixation device (pins, plates, intramedullary rods,
and metal and bioabsorbable screws) are surgically inserted at the time of
realignment.
3. Drug Therapy
Patient with fracture experience varying degrees of pain associated with
muscle spasms. Central and peripheral muscle relaxants, such as carisoprodol
(soma), cyclobenzaprine (flexeril), or methocarbamol (robaxin), may be
prescribed for relief of pain associated with muscle spasms.
In an open fracture the threat of tetanus can be reduced with tetanus and
diphtheria toxoid or tetanus immunoglobulin for the patient who has not been
previously immunized. Bone penetrating antibiotics, such as a cephalosporin
(cefazolin), are use prophylactically.
2.8. Nursing Care
1. Assessment
Assessment is the first step of nursing process. it is necessary for the nurse to
recognize more about clients problems in order to give the right nursing
implementation for clients. The success of nursing process which will be given to
the clients is depend on this step.
a. Patient identity
It Includes name, sex, age, address, religion, race, education, and occupation.
b. Chief Complaint
The most chief complaint of fracture is pain. Pain can be acute or chronic. It
can be identified by the five attributes of pains symptoms to obtain a complete
assessment of the client's pain. There are :
P (provokes)

including

environmental

factors,

personal

activities,
8

emotional reactions, or other circumstance that may have contributed to the

pain.
Q (Quality)

: what is it like ?

R (Region): where is it ? does it radiate ?

S (Severity)

: how bad is it ?

T (Time) : when did (does) it start ? how long did (does) it last ? how often
did (does) it come?
c. History of present illness
Data collection of HPI is help us to determine the cause of the fracture and the
chronology of the occurrence of the illness.
d. Past nursing history
There are some illness that might cause of or exacerbate the fracture. Such as
diabetes mellitus.
e. Family health history
Familys illness which is associated with bone disease is one of the
predisposing factors of fractures, such as diabetes and osteoporosis that are
common in some breeds, and bone cancer which tends to be genetically
( Ignatavicius , Donna D , 1995 ).
f. Activity/ rest
1) Weakness
2) Fatigue
3) Gait and/ or mobility problems
4) Generalized weakness
5) Restriction or loss of function of affected part; may be immediate, because
of the fracture, or develop secondarily from tissue swelling, pain
6) Weakness of affected extremity
7) Range of motion (ROM) deficits
g. Circulation
1) Hypertension, occasionally seen as a response to acute pain or
2) anxiety, or hypotension from severe blood loss
3) Tachycardia, stress response, hypovolemia
4) Pulse diminished or absent distal to injury in extremity
5) Delayed capillary refill
9

6) Pallor of affected part

7) Tissue swelling
8) Bruising or hematoma mass at site of injury
h. Elimination
1) Hematuria
2) Sediment in urine
3) Changes in output, acute renal failure (ARF) with major skeletal muscle
damage
i. Neurosensory
1) Loss of or impaired motion or sensation
2) Muscle spasms worsening over time
3) Numbness or tingling (paresthesias)
4) Local musculoskeletal deformities, abnormal angulation, posture changes,
shortening of limbs, rotation, or crepitation
5) Muscle spasms
6) Visible weakness or loss of function
7) Giving way or collapse, locking of joints, dislocations
8) Agitationmay be related to pain, anxiety, or other trauma
j. Pain/ discomport
1) Sudden severe pain at time of injurymay be localized to the area of tissue
or skeletal damage and then become more diffuse; however, can diminish
on immobilization
2) Absence of painsuggests nerve damage
3) Muscle-aching pain
4) Muscle spasms or cramping following immobilization
5) Guarding or distraction behaviors
6) Restlessness
7) Self-focus
k. Safety
1) Circumstances of incident may not support type of injury incurred may be
suggestive of abuse
2) Use of alcohol or other drugs
3) Skin lacerations
10

4) Tissue avulsion
5) Bleeding
6) Color changes of skin
7) Localized swelling may increase gradually or suddenly
8) Presence of risk factors for falling age, osteoporosis, dementia, arthritis,
other chronic conditions; preexisting unrecognized fracture
2. Nursing Diagnosis
a. Acute pain related to Muscle spasms; Movement of bone fragments, edema,
and injury to the soft tissue; Traction, immobility device.
Evaluation criteria :
Pain level : Verbalize relief of pain; Display relaxed manner, able to
participate in activities, and sleep and rest appropriately.
Pain control

: Demonstrate use of relaxation skills and diversional activities,

as indicated for individual situation.

Interventions :
1) Maintain immobilization of affected part by means of bedrest, cast, splint,
and traction (Relieves pain and prevents bone displacement/extension of
tissue injury).
2) Elevate and support injured extremity (Promotes venous return, decreases
edema, and may reduce pain)
3) Avoid use of plastic sheets/pillows under limbs in cast (Can increase
discomfort by enhancing heat production in the drying cast)
4) Elevate bed covers and keep linens off toes (Maintains body warmth
without discomfort due to pressure of bedclothes on affected parts)
5) Evaluate and document reports of pain or discomfort, noting location and
characteristics, including intensity (scale of 010), relieving, and
aggravating factors. Note nonverbal pain cues, such as changes in vital signs
and emotions or behavior. Listen to reports of family member/significant
other (SO) regarding clients pain. (Influences choice of, and monitors
effectiveness of, interventions. Many factors, including level of anxiety,
may affect perception of and reaction to pain. Note: Absence of pain
expression does not necessarily mean lack of pain)
6) Encourage client to discuss problems related to injury (Helps alleviate
anxiety. Client may feel need to relive the accident experience)

11

7) Perform and supervise passive or active ROM exercises (Maintains strength

and mobility of unaffected muscles and facilitates resolution of
inflammation in injured tissues)
8) Provide alternative comfort measures, for example, massage, back rub, or
position changes (Improves general circulation; reduces areas of local
pressure and muscle fatigue)
9) Provide emotional support and encourage use of stress management
techniques

progressive

relaxation,

deepbreathing

exercises,

and

visualization or guided imagery; provide therapeutic touch. (Refocuses

attention, promotes sense of control, and may enhance coping abilities in the
management of the stress of traumatic injury and pain, which is likely to
persist for an extended period)
10) Administer medications, as indicated: opioid and nonopioid analgesics,
such as morphine, meperidine (Demerol), or hydrocodone (Vicodin);
injectable and oral nonsteroidal anti-inflammatory drugs (NSAIDs), such
as ketorolac (Toradol) or ibuprofen (Motrin); and/or muscle relaxants, such
as cyclobenzaprine (Flexeril) or carisoprodol (Soma). (Given to reduce
pain and/or muscle spasms. Studies of Toradol have shown it to be
effective in alleviating bone pain, with longer action and fewer side effects
than opioid agents)
11) Maintain continuous intravenous (IV) or patient-controlled analgesia
(PCA) using peripheral, epidural, or intrathecal routes of administration.
Maintain safe and effective infusions and equipment (Optimal pain
management is essential to permit early mobilization and physical therapy
and to maintain adequate blood level of analgesia, preventing fluctuations
in pain relief with associated muscle tension or spasms)
b. Risk for peripheral neurovascular dysfunction related to Reduction or
interruption of blood flow; Direct vascular injury, tissue trauma, excessive
edema, thrombus formation; Hypovolemia
Evaluation criteria : Maintain tissue perfusion as evidenced by palpable pulses;
warm, dry skin; normal sensation; usual sensorium; stable vital signs; and
adequate urinary output for individual situation.
Intervention :
1) Evaluate presence and quality of peripheral pulse distal to injury via
palpation or Doppler. Compare with uninjured limb. (Decreased or absent
12

pulse may reflect vascular injury and necessitates immediate medical

evaluation of circulatory status)
2) Assess capillary return, skin color, and warmth distal to the fracture.
(Return of color should be rapid (35 seconds). White, cool skin indicates
arterial impairment. Cyanosis suggests venous impairment.)
3) Maintain elevation of injured extremity(ies) unless contraindicated by
confirmed presence of compartment syndrome. (Promotes venous drainage
and decreases edema)
4) Monitor vital signs (Inadequate circulating volume compromises systemic
tissue perfusion)
5) Perform neurovascular assessments, noting changes in motor and sensory
function. Ask client to localize pain or discomfort. (Impaired feeling,
numbness, tingling, and increased or diffuse pain occur when circulation to
nerves is inadequate or nerves are damaged.)
6) Monitor Hgb/Hct and coagulation studies, such as prothrombin time (PT).
(Assists in calculation of blood loss and needs and effectiveness of
replacement therapy. Coagulation deficits may occur secondary to major
trauma, in presence of fat emboli, or during anticoagulant therapy)
7) Administer IV fluids and blood products as needed. Administer
medications, as indicated: Low-molecular-weight heparin or heparinoids,
such as enoxaparin (Lovenox), dalteparin (Fragmin), or fondaparinux
(Arixtra), if indicated. (Maintains circulating volume, enhancing tissue
perfusion. Anticoagulants may be given prophylactically to reduce threat of
deep venous thrombus)
8) Apply antiembolic hose, or sequential pressure hose or compression boots,
as indicated. (Decreases venous pooling and may enhance venous return,
thereby reducing risk of thrombus formation.)
c. Impaired physical mobility related to Neuromuscular skeletal impairment, pain
or discomfort, restrictive therapies limb immobilization Psychological
immobility
Evaluation criteria :
Regain and maintain mobility at the highest possible level.
Maintain position of function.
Increase strength and function of affected and compensatory body parts.
Demonstrate techniques that enable resumption of activities, especially
activities of daily living (ADLs).
13

Interventions :
1) Assess degree of immobility produced by injury and/or treatment and note
clients perception of immobility (Client may be restricted by self-view or
self-perception out of proportion with actual physical limitations, requiring
information and interventions to promote progress toward wellness.)
2) Instruct client in active, or assist with passive, ROM exercises of affected
and unaffected extremities. (Increases blood flow to muscles and bone to
improve muscle tone; maintain joint mobility; and prevent contractures,
atrophy, and calcium resorption from disuse.)
3) Place in supine position periodically if possible when traction is used to
stabilize lower limb fractures. (Place in supine position periodically if
possible when traction is used to stabilize lower limb fractures.)
4) Assist with and encourage self-care activities such as bathing, shaving, and
oral hygiene (Assist with and encourage self-care activities such as bathing,
shaving, and oral hygiene)
5) Monitor blood pressure (BP) with resumption of activity (Postural
hypotension is a common problem following prolonged bed rest and may
require specific interventions, such as tilt table with gradual elevation to
upright position)
6) Reposition periodically and encourage coughing and deep breathing
Exercises (Prevents or reduces incidence of skin and respiratory
complicationsdecubitus ulcer, atelectasis, or pneumonia.)
7) collaborative : Consult with physical or occupational therapist and/or
rehabilitation specialist (Useful in creating aggressive individualized
activity or exercise program)
d. Impaired skin/ tissue integrity related to Puncture injury; compound fracture;
surgical repair; insertion of traction pins, wires, screws; Altered sensation,
circulation; accumulation of excretions or secretions; Physical immobilization.
Evaluation criteria :
Verbalize relief of discomfort.
Demonstrate behaviors or techniques to prevent skin breakdown and facilitate
healing, as indicated.
Achieve timely wound or lesion healing, if present
Interventions :
1) Examine the skin for open wounds, foreign bodies, rashes, bleeding,
discoloration, duskiness, and/or blanching. (Provides information regarding
14

skin circulation and problems that may be caused by application and/or

restriction of cast, splint, or traction apparatus, or edema formation that
may require further medical intervention)
2) Reposition frequently. (Lessens constant pressure on same areas and
minimizes risk of skin breakdown. Use of trapeze may reduce risk of
abrasions to elbows and heels)
3) Provide wound care by wet cast care
e. Risk for infection related to broken skin, traumatized tissues, environmental
exposure Invasive procedures, skeletal traction
Evaluation criteria :
Achieve timely wound healing, be free of purulent drainage or erythema, and
be afebrile
Interventions :
1) Inspect the skin for preexisting irritation or breaks in continuity (Pins or
wires should not be inserted through skin infections, rashes, or abrasions
may lead to bone infection.)
2) Provide sterile pin and wound care according to protocol, and exercise
meticulous hand washing. (May prevent cross-contamination and
possibility of infection.)
3) Observe wounds for formation of bullae, crepitation, bronze discoloration
of skin, and frothy or fruity-smelling drainage. (Signs suggestive of gas
gangrene infection)
4) Monitor vital signs. Note presence of chills, fever, and malaise, and any
changes in mentation (Hypotension and confusion may be seen with gas
gangrene; tachycardia, chills, and fever reflect developing sepsis)
5) Collaborative : Monitor laboratory/diagnostic studies

15

CHAPTER 3
CLOSING
3.1 Conclusion
Fracture is an interruption in the continuity of a bone tissue purposively and there are
some degree of destruction, interferences with the blood supply and disturbance of muscle
activity at the site of injury. It is may be caused by direct or indirect violence and gives the
manifestation such as painful, deformity, abnormal movement, and ecchymosis. Then
there are some treatment that can be given to the patient whom is fracture. There are two
treatments, operative and non operatif. Nonoperative consists of casting and traction (skin
and skeletal traction).
3.2 Suggestion
This paper is expected to be useful for nursing students to be able to improve their English
in nursing

BIBLIOGRAPHY

Bullock, B.L & Henze, R.L 2000, Focus in Pathophysiology, Lippincot, Philadelphia.
LeMone, P & Burke K 2008, Medical Surgical Nursing: Critical Thinking in Client Care, 4th
edn, Pearson International, New Jersey.
Linton, A.D 2012, Introduction to Medical Surgical Nursing, Elsevier Saunders, St. Louis
Missouri.
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Smeltzer, Suzanne C. & Bare. 2002. Buku Ajar Keperawatan Medikal Bedah vol. 3. EGC :
Jakarta
Doenges, Marilynn E. dkk. 2006. Nursing Care Plans Guidelines for Individualizing Client
Care Across the Span. Davis Plus : Philadelphia.

17