Fractures Nursing Care Plan

Definition

A fracture is a traumatic injury interrupting bone continuity.

TYPES:

• Closed simple, uncomplicated fractures – do not cause a break in the skin.
• Open compound, complicated fractures – involve trauma to surrounding tissue and break in the skin.
• Incomplete fractures– are partial cross-sectional breaks with incomplete bone disruption.
  
• Complete fractures – are complete cross-sectional breaks severing the periosteum.
• Comminuted fractures – produce several breaks of the bone, producing splinters and fragments.
• Greenstick fractures – break one side of a bone and bend the other.
• Spiral (torsion) fractures – involve a fracture twisting around the shaft of the bone.
• Transverse fractures – occur straight across the bone.
• Oblique fractures – occur at an angle across the bone (less than a transverse)

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Risk Factors

• From crushing force or direct blow
• Sudden twisting motion; persons with osteoporosis are at a particular risk
• Extremely forceful muscle contraction can cause fractures
• Pathological fractures result from a weakness in bone tissue, which may be caused by neoplasm or a malignant growth

Pathophysiology

Fracture occurs when stress placed on a bone exceeds the bone’s ability to absorb it.

Stages of normal fracture healing include:

• Inflammation
• Cellular proliferation
• Callus formation
• Callus ossification
• Mature one remodeling

Potential complications of fracture include:

• Life-threatening systemic fat embolus, which most commonly develops within 24 to 72 hours after fracture.
• Compartment syndrome, which is a condition involving increased pressure and constriction of nerves and vessels within an atomic compartment.
• Nonunion of the fracture side
• Arterial damage during treatment
• Infection and possibly sepsis
• Hemorrhage, possibly leading to shock

Assessment/Clinical Manifestations/Signs And Symptoms

• Pain
• Edema
• Tenderness
• Abnormal movement and crepitus
• Loss of function
• Ecchymoses
• Visible deformity
• Paresthesias and other sensory abnormalities

Laboratory and diagnostic study findings

• Radiographs and other imaging studies may identify the site and type of fracture.

Medical Management

The principles of fracture treatment include reduction, immobilization and regaining of normal function and strength through rehabilitation.

• The fracture is reduced “setting” the bone using a closed method (manipulation and manual traction (e.g. splint or cast) or an open method (surgical placement of internal fixation devices like pins, wires, screws, plates and nails) to restore the fracture fragments to anatomic alignment and rotation. The specific method depends on the nature of the fracture.
• After the fracture has been reduced, immobilization holds the bone in correct position and alignment until union occurs. Immobilization is accomplished by external or internal fixation.
• Function is maintained and restored by controlling swelling by elevating the injured extremity and applying ice as prescribed.
• Restlessness, anxiety, and discomfort are controlled using a variety of approaches (e.g. reassurance, position changes, pain relief strategies, including analgesic agents).
• Isometric and muscle-setting exercises are done to minimize disuse atrophy and to promote circulation.
• With internal fixation, the surgeon determines the amount of movement and weight-bearing stress the extremity can withstand and prescribed the level of activity.

Nursing Diagnosis

• Pain related to fracture, soft tissue damage, muscle spasm, and surgery
• Impaired physical mobility related to fractured hip
• Impaired skin integrity related to surgical incision
• Risk for impaired urinary elimination related to immobility
• Risk for disturbed thought process related to age, stress of trauma, unfamiliar surroundings, and drug therapy
• Risk for ineffective coping related to injury, anticipated surgery, and dependence
• Risk for impaired home maintenance related to fractured hip and impaired mobility

Nursing Management

1. Prevent infection
   • Cover any breaks in the skin with clean or sterile dressing.
2. Provide care during client transfer.
   • Immobilize a fractured extremity with splint in the position of the deformity before moving the client; avoid strengthening the injured body part if a joint is involved.
   • Support the affected body part above and below fracture site when moving the client.
3. Provide client and family teaching.
   • Explain prescribed activity restrictions and necessary lifestyle modification because of impaired mobility.
   • Teach the proper use of assistive devices, as indicated.
4. Administer prescribed medications, which may include opioid or nonopioid analgesics and prophylactic antibiotics for an open fracture.
5. Prevent and manage potential complications.
   • Observe for symptoms of life-threatening fat embolus, which may include personality change, restlessness, dyspnea, crackles, white sputum, and petechaie over the chest and buccal membranes. Assist with respiratory support, which must be instituted early.
   • Observe for symptoms of compartment syndrome, which include deep, unrelenting pain; hard edematous muscle; and decreased tissue perfusion with impaired neurovascular assessment findings.
   • Monitor closely for signs and symptoms of other complications.
6. Patient education regarding different factors that affect fracture healing
7. Factors that enhance fracture healing
   • Immobilization of fracture fragments
   • Maximum bone fragment contact
   • Sufficient blood supply
   • Proper nutrition
   • Exercise: weight bearing for long bones
   • Hormones: growth hormone, thyroid, calcitonin, vitamin D, anabolic steroids
8. Factors that inhibit fracture healing
   • Extensive local trauma
   • Bone loss
   • Inadequate immobilization
   • Space or tissue between bone fragments
   • Infection
   • Local malignancy
   • Metabolic bone disease (Paget’s disease)
   • Irradiated bone (radiation necrosis)
   • Avascular necrosis
   • Intra-articular fracture (synovial fluid contains fibrolysins, which lyse the initial clot and retard clot formation)
   • Age (elderly persons heal more slowly)
   • Corticosteroids (inhibit the repair rate)