FUNCTIONAL NURSING

A Case Study

On

Fracture, Closed, Galeazzi, Left

Submitted by: Alforque, Mary Leonilyn Golo, Rio Cornell Guinita, Marie Lourneth Hijara, Raymond Largo, Delight Grace GROUP 3A TEAM 2

Submitted to: Mr. Esperidion Corvera

INTRODUCTION

A fracture is a break in the continuity of the bone. This is commonly manifested by pain, loss of function, deformity, shortening of the extremity, crepitus, local swelling and discoloration. It is defined according to its type and extent. One type is the Galeazzi fracture.

Definition The Galeazzi fracture-dislocation, is an injury pattern involving a radial shaft fracture with associated dislocation of the distal radioulnar joint (DRUJ); the injury disrupts the forearm axis joint. The Galeazzi fracture injury pattern was first described in 1842, by Cooper, 92 years before Galeazzi reported his results. Ricardo Galeazzi (1866-1952), an Italian surgeon at the Instituto de Rachitici in Milan, was known for his extensive work experience on congenital dislocation of the hip. In 1934, he reported on his experience with 18 fractures with the above-described pattern as a compliment to the Monteggia lesion. Such fractures have since become synonymous with his name. In 1941, Campbell termed the Galeazzi fracture the "fracture of necessity," because it necessitates surgical treatment Causes It is usually caused by direct blows and falls. Incidence Galeazzi fractures account for 3-7% of all forearm fractures. They are seen most often in males. Although Galeazzi fracture patterns are reportedly uncommon, they are estimated to account for 7% of all forearm fractures in adults. Prognosis Adults tend to have poor results with closed reduction. In adults, nonsurgical treatment of the injury results in persistent or recurrent dislocations of the distal ulna. Manifestations Pain and soft-tissue swelling are often present at the distal-third radial fracture site and at the wrist joint.

Patients Profile A case of J.M.D., 21 years old, male, Catholic, admitted for the first time in Vicente Sotto Memorial Medical Center last January 5, 2012 at 7:50 PM with chief complaints of fracture of the left forearm from a motorvehicular accident and was diagnosed with Fx, Closed, Galeazzi left. As surgical intervention, Emergency Open Reduction and Internal Fixation Plating of the left radius were done on January 25, 2012. No past surgeries aside from abovementioned. No past illnesses with significance to present condition. There is history of hypertension on paternal side and none on the maternal side. Client smokes several sticks per day for 3 years and consumes beer and hard drinks occasionally for the same number of years. Client is currently on diet as tolerated. There are no known food and drug allergies.

History of Present Illness 2 days prior to admission, client was driving a motorcycle on a muddy road in Bogo when the he lost balance, fell and used his left arm to support his body weight, causing the fracture. He was initially brought to Bogo District Hospital and was referred to Vicente Sotto Memorial Medical Center for intervention, thus this admission.

Focused Physical Assessment Cardiovascular Blood pressure reading is at 130/90 mmHg and a strong, steady pulse of 80 bpm. Capillary refill time of affected area is 1 second. No bluish discoloration and edema of fingers and clubbing of nails noted. Musculoskeletal Client is 1 day S/P Emergency ORIF plating of the left radius with elastic bandage in place. There is a pain score of 5/10 and 11/10 upon movement. Ranges of motion on both upper extremities are limited with an IVF of 2 PNSS 1L at 20 gtts/min hooked on right arm. There are no tingling sensations or numbness on affected area. Can feed and change positions in bed independently. Toileting, bathing and ambulation requires assistance from other people. No other unusualities. Elimination Client hasnt defecated since 2 days ago. He voids clear, dark yellow urine of 4-5 times a day. No difficulties noted.

ANATOMY AND PHYSIOLOGY

Anatomy of the Hand & Wrist The hand is composed of many small bones called carpals, metacarpals and phalanges. The two bones of the lower arm -the radius and theulna -- meet at the hand to form the wrist.

The Median and Ulnar nerves are the major nerves of the hand, running the length of the arm to transmit electrical impulses to and from the brain to create movement and sensation.

PATHOPHYSIOLOGY Tension exceed bone tensile strength

Fracture

Pain

Cessation of normal function and range of motion

Inflammatio n

The Galeazzi fracture-dislocation, as shown in the image below, is an injury pattern involving a radial shaft fracture with associated dislocation of the distal radioulnar joint (DRUJ); the injury disrupts the forearm axis joint.

This anteroposterior radiograph demonstrates a classic Galeazzi fracture: a short oblique or transverse fracture of the radius with associated dislocation of the distal ulna. The dislocation results from the disruption of the DRUJ (distal radio-ulnar joint). Note the prominence of the distal ulna (ulna positive variance).

ACTUAL LABORATORIES

Complete Blood Count CBC WBC Hgb Hct MCV MCH RBC MCHC RDW MPV Platelet Count Differential Count Neutrophil Lymphocytes Monocyte Eosinophil Basophil Blood Typing Blood Type RH Coagulation time Bleeding time

Result 7.80 137 0.42 89.0 29.40 4.67 331 14.40 6.90 248.00

Unit 10^9/L g/L L/L Fl Pg 10^12/L g/l Fl Fl 10^9/L

Reference 4.8-10.8 140-180 .42-.52 80-94 27-31 4.7-6.10 330-370 11-16 7.2-11.1 150-400

58.00 29.90 10.10 4.80 0.2 B Pos (+) 334 241

% % % % %

40-74 19-48 13-9 0-7 0-2 -

mins mins

Coagulation Component Prothrombin Time Control Control % Act Control INR Patient % Activity INR

Result 15.1 93.8 1.040 12.6 133.4 0.84

Unit Secs % Secs %

Reference 13.2-16.2 13.2-16.2 -

Urinalysis Color: Yellow Transparency: Clear Specific Gravity: 1.030 pH: 5.0 Glucose: (-) CHON: (-) RBC: 0-1/hpf WBC: 0-1/hpf Cast Crystals Calcium Oxalate Miscellaneous Structures Squamous cells Bacteria Mucus Threads

Moderate Rare Few Few

IDEAL LABORATORIES Imaging Studies Radiographs The diagnosis of a Galeazzi fracture is confirmed on radiographic examination. Standard anteroposterior (AP) and true lateral forearm views are obtained, which must include an AP or a posteroanterior (PA) view, as well as a lateral view, of the wrist, along with AP and lateral views of the elbow. Radiographs of the contralateral extremity can be obtained for comparison. Plain radiographic findings suggestive of injury to the DRUJ are as follows:  Fracture at the ulnar styloid base  Widening of the DRUJ space on an AP radiograph  Dislocation of the radius relative to the ulna on a true lateral radiograph, which is obtained with the shoulder abducted 90  Shortening of the radius by more than 5 mm relative to the distal ulna Assessment of DRUJ integrity is often difficult using plain radiography alone. A bilateral, axial computed tomography (CT) scan of the forearm is the preferred imaging study for diagnosing DRUJ disruption.

MEDICAL MANAGEMENT Pharmacologic Therapy Tramadol (Ultram) is a narcotic-like pain reliever. Tramadol is used to treat moderate to severe pain. Extended-release forms are used to treat moderate to severe chronic pain when treatment is needed around the clock. It is classified under pregnancy category C. The client is prescribed with Tramadol 50mg IVTT every 6hrs in order to provide pain relief of skeletal impairment and surgical trauma as evidenced by complaints of acute moderate pain which occur intermittently. Drug must not be given if the client is intoxicated with alcohol, street drugs, sedatives, and anxiolytics. Extreme precaution must also be observed when giving drug to clients with history of drug or alcohol addiction, epilepsy, and head injury, a metabolic disorder, or taking an antidepressant, muscle relaxant, narcotic, or antipsychotic. Adverse reactions to watch out for include agitation, hallucinations, fever, tachycardia, hyperreflexia, fainting, seizure, loss of coordination, and shallow breathing. Ketorolac (Toradol) is in a group of drugs called nonsteroidal anti-inflammatory drugs (NSAID). Ketorolac works by reducing hormones that cause inflammation and pain in the body. It is classified under pregnancy category C. It is used short-term (5days or less) to treat moderate to severe pain. Patients indication is to provide relief of severe pain verbally reported and noted through manifestations of irritability, restlessness, facial grimace, and guarded movement. Administration of medication must strictly follow prescribed dosage, route, and timing, which is, Ketorolac 15mg IVTT every 6hrs. Prior to beginning of therapy, client must be screened for drug contraindications such as hypersensitivity, severe kidney disease, and a bleeding disorder. Throughout the course of therapy, client must be instructed to avoid taking any over-the-counter cold, allergy, or pain medication without medical consultation. Moreover, the nurse must watch out for signs of allergic reactions and other serious side effects such as chest pain, shortness of breath, black, bloody or tarry stools, hemoptysis, swelling or rapid weight gain, and oliguria. Cefazolin (Ancef) is a cephalosphorin antibiotic, under pregnancy category B. It works by fighting bacteria in your body. Cefazolin injection is used to treat many kinds of bacterial infections, including severe or life-threatening forms. Client is prescribed with Cefazolin 1gm IVTT every 8hrs in order to prevent prosthetic bone infection secondary to putting on of implants during surgery to facilitate healing of fracture. Before initiating therapy, skin testing must be done to rule out allergic reactions to the drug. Client must also be assessed for signs of infection, such as fever, pain, warmth, redness, and swelling. Serious side effects side effects to watch out for include bloody or watery diarrhea, skin rash, easy bruising or bleeding, sore throat, and seizure. Client must be instructed to immediately report the occurrence of untoward drug reactions.

Gentamicin (Garamycin) is an aminoglycoside antibiotic, used to treat many type of bacterial infections, particularly those caused by Gram-negative organisms. Client is given Gentamicin 80mg IVTT every 8hrs to provide bactericidal action towards susceptible microorganisms. Prior to beginning of therapy, skin testing must be done to rule out any possibilities of an allergic reaction. Client must also be screened for kidney disease, hearing loss, Parkinsons disease, or a neuromuscular disorder such as myasthenia gravis. Throughout the course of therapy, proper route, dosage, and timing of drug administration must be observed. Also, nurse must watch out for the occurrence of any adverse drug reactions including oliguria, ringing in the ears, dizziness, vertigo, numbness, skin tingling, muscle twitching, seizures, severe watery diarrhea and abdominal cramps.

SURGICAL MANAGEMENT Actual The client underwent ORIF plating radius and pinning distal ulnar left. Open Reduction Internal Fixation (ORIF) is a method of surgically repairing a fractured bone. Generally, this involves either the use of plates and screws or an intramedullary rod to stabilize the bone. Open reduction refers to the method wherein the fracture fragments are exposed surgically by dissecting the tissues. The reduction is currently maintained by the application of internal implants. Complications of ORIF include malunion and infection, which usually occur in operations done without enough caution. Success of this surgical procedure depends on the reduction of the radius and distal radio-ulnar joint and the restoration of the forearm axis. Ideal Galeazzi fractures are best treated with open reduction of the radius and the distal radio-ulnar joint. It has been called the fracture of necessity, because it necessitates open surgical treatment in the adult. Nonsurgical treatment results in persistent or recurrent dislocations of the distal ulna. However, in skeletally immature patients such as children, the fracture is typically treated with closed reduction. Closed reduction is a method used for treating fractures in which the physician manipulates the fractured bones from the outside of the body to correctly position them without making an incision to access the site of the fracture. Once the fragments are reduced, the reduction is maintained by application of casts, traction or held by implants which may in turn be internal or external. It is very important to verify the accuracy of reduction by clinical tests and x-ray, especially in the case with joint dislocations.

NURSING MANAGEMENT

Acute Pain related to presence of discomfort in left arm secondary to surgical procedure done The clients subjective cue: Sakit pa ayo akong kamot Objective clues include: received lying on bed; conscious; coherent; with ongoing # 4 PNSS 1L @ 30 gtts per minute infusing well at right hand; reported discomfort in post-operative site; 2 days post-op; guarded behavior noted; limited movements observed; facial grimace noted; and a pain score of 5 over 10. The expected outcome criteria after 8 hours of nursing interventions, the client will be able to verbalize even slight relief of pain and demonstrate interventions to control and manage such discomforts. And after 3 days of nursing interventions, client will be able to continue demonstrating the use of relaxation techniques and diversional activities, as indicated and report that pain and discomfort is relieved. Promotive independent nursing interventions include: promoting comfort measures as non-pharmacological pain management; encouraging use of relaxation techniques to distract attention and reduce tension, providing adequate rest periods to reduce fatigue. Preventive independent nursing interventions include: noting location of surgical sites as this can influence the amount of postoperative discomforts experienced by the client; obtaining clients assessment of discomfort and reassessing each time it occurs to rule out worsening of any underlying condition or possible complications; using pain rating scale appropriate for age and condition in obtaining intensity/ severity of pain; accepting and acknowledging clients description of pain as this is a subjective experience and cannot be felt by others. Curative independent nursing interventions include: monitoring vital signs to watch for any changes; administering pain medications as prescribed to provide pain relief; providing oxygen as necessary if dyspnea occurs, most importantly, strictly instruct client to not to strain during defecation as these may increase .pressure in the rectal wall. Rehabilitative independent nursing interventions include: referring to physician promptly if any unusualities occur for prompt treatment and management; and instructing client to continue adhering to prescribed therapeutic regimen management.

Impaired physical mobility related to skeletal impairment and presence of pain The clients subjective cue: Dili ko ganahan maglihok-lihok. Sakit pa gud. Objective clues include: received lying on bed; conscious; coherent; with ongoing # 4 PNSS 1 L @ 30 gtts per minute infusing well at right hand; diminished ability to perform motor skills observed; slowed movements noted; difficulty turning and rising up on bed observed. The expected outcome criteria after 8 hours of nursing interventions, the client will be able to participate in activities of daily living and desired activities. After 2-3 days of nursing interventions, the client will be able to demonstrate techniques that enable resumption of activities. Promotive independent nursing interventions include: encouraging participation in self-care, diversional/recreational activities to enhance self-concept; encouraging adequate fluid intake of fluids/ nutritious foods to promote well-being and maximizes energy production; encouraging communication between significant others and client to build on success of interventions. Preventive independent nursing interventions include: noting situations such as surgery, fractures, or amputation that may restrict movements of client; identifying energy-conserving techniques for activities of daily living to limit ftigue and maximize participation; and providing for safety measures to prevent client injury. Curative independent nursing interventions include: instructing client in use of side rails, trapeze for position changes and transfers; administering medications prior to activity as needed for pain relief to permit maximal effort/ involvement in activity; supporting affected body parts/ joints using pillows, foot supports to maintain position of function and reduce risk of pressure ulcers. Rehabilitative independent nursing interventions include: consulting with physical/occupational therapist to develop individual exercise / mobility programs; and instructing client to report any unusualities promptly to physician.

Impaired skin Integrity related to alteration in the integumentary system secondary to surgical procedure done The clients subjective cue: Na-operahan ko sa akong kamot. Objective clues include: received lying on bed; conscious; with ongoing # 4 PNSS 1 L @ 30 gtts per minute infusing well on right hand; with elastic bandage on left arm over armsling; reports of itchiness in bandaged arm; status post debridement. The expected outcome criteria after 8 hours of nursing interventions, the client will be able to demonstrate techniques in maintaining good and proper hygienic measures and participate in prevention measures and treatment program. Promotive independent nursing interverventions to achieve short term goal include: teaching client and significant others techniques to protect integrity of the skin, care of lesions and wounds in order to promote wellness and timely wound healing; discussing important measures for early detection of skin changes and for complications; ascertaining attitudes of client about condition and noting misconceptions to identify areas to be addressed in teaching plans. Preventive independent nursing interventions include: advising to keep nails short and teaching about the importance of proper hygiene to prevent infection and keep the body clean; instructing client to turn to sides every two hours to prevent formation of pressure ulcers; and changing dressings and bandages regularly to prevent having reservoir of microorganisms and prevent itching. Curative independent nursing interventions include: advising client to keep bed linens clean and dry since moisture potentiates skin breakdown; encouraging client to stay on bed to avoid bleeding and overexertion to the post-op area; and encouraging client to consume foods that are high in fibers, protein and vitamins necessary for wound healing as tolerated to provide balanced nutrition for an individual and easy defecation; and facilitating medication administration (e.g. antibiotiotics, ointment) for faster wound healing. Rehabilitative independent nursing interventions include: reporting promptly to physician for any unusualities; referring to dietitian for nutritional treatment and instructing to have follow-up check-up as indicated.

Activity Intolerance related to generalized weakness

The clients subjective cue: Dili pa nako kaya maglihok-lihok. Objective cues include: received lying on bed; conscious; lethargic; with ongoing # 4 PNSS 1 L @ 30 gtts per minute infusing well at right hand; listlessness observed; diminished activity level noted; frequent lying on bed noted. The expected outcome criteria after 8 hours of nursing interventions, the client will be able to participate willingly in necessary/desired activities. And after 3 days of nursing interventions, client will be able to use identified techniques to enhance activity tolerance. Promotive independent nursing interventions include: noted presence of factors contributing to fatigue that may affect clients actual and perceived ability to participate with activities; increase activity levels gradually to conserve energy; and, promote comfort measures and provide relief of pain to enhance ability to participate in activities. Preventive independent nursing interventions include: adjusting activities to prevent overexertion; assisting with activities and providing client with the usei of assistive devices to protect client from injury; and assessing cardiopulmonary response to physical activity to note progressing/accelerating of degree of fatigue. Curative independent nursing interventions include: monitoring vital signs/ cognitive signs to watch for signs of changes and unusualities; provide/ monitor response to supplemental oxygen and medications if dyspnea occurs upon doing activities. Rehabilitative independent nursing interventions include: instructing client to continue adhering to prescribed therapeutic regimen; reporting promptly to physician for any unusualities; plan for progressive increase of activity level to increase activity tolerance.

Self-care Deficit related to musculoskeletal impairment and weakness

The clients subjective cue: Dili ko kaligo nga ako ra use. Objective cues include: received lying on bed; conscious; coherent; with ongoing # 4 PNSS 1 L @ 30 gtts per minute infusing well at right hand; inability o wash body without assistance; inability to manipulate clothings without assistance. The expected outcome criteria after 8 hours of nursing interventions, the client will be able to perform self-care activities within level of own ability. After 2-3 days of nursing interventions, the client will be able to demonstrate techniques to meet self-care needs. Promotive independent nursing interventions include: providing for communication among those involved in caring for or existing with client to enhance coordination and continuity of care; showing sufficient time for client to accomplish tasks to fullest extent of ability to promote independence and enhance cooperation; reviewing safety concerns to promote client safety. Preventive independent nursing interventions include: providing assistive devices to aid in mobility; identifying energy-saving behaviors to prevent fatigue and unnecessary energy expenditures; providing adequate rest periods to prevent faigue that may hinder performance. Curative independent nursing interventions include: assisting with meeting clients needs when he is unable to do so to assist in dealing with situation; render bed bath if unable to ambulate to bathroom to assist in activities of daily living; administering pain medications, as indicated to alleviate pain that may be a hindrance to performance of ADLs. Rehabilitative independent nursing interventions include: assisting with necessary adaptations to accomplish ADLs to encourage client to build on successes; encouraging significant other to offer assistance when needed to maximize participation and involvement in patient care.