FRACTURE
I. UNDERSTANDING
Fractures are the normal breakup of a bone or cartilage caused by violence. (E. Oerswari, 1989: 144).
A fracture or broken bone is the dissolution of continuity of bone or cartilage tissue which is generally caused by rudapaksa (Mansjoer, 2000: 347).
Closed fracture is when there is no fracture relations with the outside world. Open fracture is a bone fragment extends past the muscle and skin, where the potential for infection (Sjamsuhidajat, 1999: 1138).
Fractures of the femur is cut off the continuity of femoral stem that can result from direct trauma (traffic accidents, falls from height), and more usually experienced by adult males. Fractures in this area can cause considerable bleeding, resulting in a fall in shock pendertia (Faculty of medicine, 1995:543)
Olecranon fracture is a fracture that occurred at the elbow caused by direct violence, usually accompanied by kominuta and other fractures or anterior dislocation of the joints (Faculty of medicine, 1995:553).
II. Etiology
According to Sachdeva (1996), the cause of fracture can be divided into three, namely:
a. Traumatic injury
Traumatic injury to the bone can be caused by:
1) direct injury means a direct blow to the bone so that bone pata spontaneously. Beatings and transverse fractures usually cause damage to the skin above it.
2) Injury indirect means direct blow away from the location of impact, for example, fell by the hand berjulur and cause fracture of the clavicle.
3) Fractures caused by a sudden contraction of the muscles hard strong.
b. Pathological fracture
In this case the bone damage caused by the disease process in which minor trauma can cause fractures can also occur in the following circumstances:
1) bone tumor (benign or malignant): new tissue growth uncontrolled and progressive.
2) Infections such as osteomyelitis: can occur as a result of acute infection or may arise as a progressive process, slow and painful illness.
3) rickets: a bone disease caused by deficiency of vitamin D which affects all other skeletal tissue, usually caused by dietary deficiency, but can sometimes be caused by failure of absorption of vitamin D or because of intake of calcium or low phosphate.
c. Spontaneously: the bone caused by continuous stress on diseases such as polio and who served dikemiliteran.
III. CLASSIFICATION femoral fracture
a. Closed fracture (closed), when there was no correlation between bone fragments with the outside world.
b. Open fracture (open / compound), if there is a relationship between bone fragemen with the outside world because of the need on the skin, open fractures were divided into three degrees, namely:
1) First Degree
- Less than 1 cm wound
- A little soft tissue damage with no signs of injury shattered.
- A simple fracture, analyze the transversal, or cumulative obliq light.
- Contamination of light.
2) Second Degree
- Laceration more than 1 cm
- Damage to soft tissue, not extensive, avulse
- Fractures community is.
3) Third Degree
Damage extensive soft tissue structures including skin, muscle and neurovaskuler and a high degree of contamination.
c. Complete fracture
• Broken bones at the midline and usually experience the shifting (shifting from the normal position).
d. Incomplete fracture
• Fracture occurs only on a portion of the center line of the bone.
e. Special type of fracture
a) The broken line
1) Outline transverse fracture
2) Outline obliq pata
3) Outline a spiral fracture
4) Compression Fractures
5) avulsion fracture
b) The broken line
1) Fractures komunitif more than one fracture line and interconnected.
2) segmental fracture of more than one fracture line but interrelated
3) a multiple fracture lines more than one broken bone but at different times.
c) Sliding-not shift
Fracture complications patali not shift the line but the two fragments did not shift.
Fracture shifted, the shift fracture fragments are also called in the location of fragments (Smeltzer, 2001:2357).
IV. Pathophysiology
Wound healing process consists of several phases, namely:
1. Phase hematum
• Within 24 hours resulting hemorrhage, edema, fractures around hematume
• After 24 hours the blood supply around the fracture increases
2. Phase of granulation tissue
• There was 1-5 days after injury
• At this stage the product is active phagositosis neorosis
• Itematome transformed into granulation tissue containing new blood vessels and osteoblasts fogoblast.
3. Callus formation phase
• There was a 60-10 harisetelah injury
• Granulation callus shape changes
4. Phase ossificasi
• Begin at 2-3 weeks after the fracture to heal
• permanent callus eventually formed bone stiff with calcium salt deposits that unites the broken bone
5. Consolidation phase and remadelling
• Within 10 weeks is more appropriate form of callus is formed by osteoblasts and osteuctas oksifitas (Black, 1993: 19).
V. SIGNS AND SYMPTOMS
1. Deformity
Muscle strength cause blistering power of the bone fragments to move from his place of balance and contur changes occur such as:
a. Bone shortening rotation
b. Suppression of bone
2. Swelling: edema emerge quickly from the scene and ekstravaksasi blood in the tissue adjacent to the fracture
3. Echumosis of Bleeding Subculaneous
4. Involunters spasm muscle spasm near the fracture
5. Tenderness / tenderness
6. Pain may be caused by muscle spasm moved from its place and bone damage in areas adjacent structures.
7. Loss of sensation (numbness, nerve damage may occur from / bleeding)
8. Abnormal movements
9. Hypovolemic shock results from blood loss
10. Krepitasi (Black, 1993: 199).
VI. EXAMINATION SUPPORT
1. X-ray images
To find the location of fracture and fracture line directly
Knowing the place and type of fracture
Usually taken before and after surgery and periodically during the healing process
2. Tomography bone score, score C1, Mr1: can be used to identify soft tissue damage.
3. Artelogram suspected when there is vascular damage
4. HT complete blood count may increase (hemokonsentrasi) or menrurun (significant bleeding at the fracture side or distant organs at multiple trauma)
Increasing the number of SDP is the normal stress response after trauma
5. Coagulation profile changes can occur at multiple transfusions of blood loss or injury to the liver (Doenges, 1999: 76).
VII. Management of
1. Fracture Reduction
Manipulation or closed reduction, surgical manipulation of non-manual rearrangement of the bone fragments of previously autonomous position.
open reduction is the improvement of overall alignment of the bone incision surgery, often include internal viksasi against fracture with wires, screws intramedulasi rod pin plates, and nails. Type the location of fracture depends on the age of the client.
Traction equipment:
o skin traction is usually for short-term treatment
o muscle traction or surgery is usually for long-term period.
2. Fracture Immobilization
dressing (plaster)
External Fixation
Internal Fixation
Selection Faction
3. Fraction open
surgical debridement and irigrasi Surgery
tetanus immunization
prophylactic antibiotic therapy
Immobilization (Smeltzer, 2001).
Management in Nursing
I. ASSESSMENT
Assessment is the first step in the process of nursing and basic overall (Boedihartono, 1994: 10).
Post op patient assessment frakture Olecranon (Doenges, 1999) include:
a. Circulation
Symptoms: a history of heart problems, GJK, pulmonary edema, peripheral vascular disease, or vascular stasis (increased risk of thrombus formation).
b. Ego integrity
Symptoms: feelings of anxiety, fear, anger, apathy; multiple stress factors, such as financial, relationship, lifestyle.
Mark: can not break, the increase in tension / sensitive excitatory; sympathetic stimulation.
c. Food / liquids
Symptoms: pancreatic insufficiency / DM, (predisposition to hypoglycemia / ketoacidosis), malnutrition (including obesity), dry mucous membranes (barring entry / preoperative fasting period).
d. Respiratory
Symptoms: infections, chronic conditions / coughing, smoking.
e. Security
Symptoms: allergic / sensitive to drugs, food, duct tape, and solutions; Immune Deficiency (peningkaan sitemik risk of infection and delay healing); The emergence of cancer / cancer therapy, the latest; family history of malignant hyperthermia / reaction to anesthesia; History hepatic disease (the effects of detoxification drugs and can alter coagulation); History of blood transfusions / transfusion reactions.
Signs: menculnya an exhausting process of infection; fever.
f. Counseling / Learning
Symptoms: pengguanaan anticoagulation, steroids, antibiotics, antihypertensive, cardiotonic glokosid, antidisritmia, bronchodilator, diuretics, decongestants, analgesics, antiinflammatory, anticonvulsant or tranquilizer and also the-counter medicines or recreational drugs. The use of alcohol (risk of kidney damage, affecting coagulation and anastesia choice, and also the potential for post-operative withdrawal).
II. Nursing Diagnosis
Nursing diagnosis is a unification of the problem real or potential patients based on data already collected (Boedihartono, 1994: 17).
Nursing diagnoses that appeared in the post-op patients with fractures (Wilkinson, 2006) include:
1. Pain associated with the dissolution of bone tissue, bone fragment movement, edema and tissue injury, traction equipment / immobilization, stress, anxiety
2. Activity intolerance related to dyspnea, weakness / fatigue, lack of oxygenation edekuatan, anxiety, and disruption of sleep patterns.
3. Damage to skin integrity related to pressure, changes in metabolic status, damage and decreased sensation circulation have been proven by injury / ulceration, weakness, weight loss, poor skin turgor, there is necrotic tissue.
4. Physical mobility barriers associated with pain / discomfort, damage muskuloskletal, activity restriction therapy, and decreased strength / resistance.
5. Risk of infection associated with stasis of body fluids, depressed inflammatory response, invasive procedures and pathways penusukkan, injury / damage to skin, surgical incision.
6. Lack of knowledge challenged condition, prognosis and treatment needs related to cognitive limitations, lack of exposure / recall, misinterpretation of information.
III. INTERVENTION AND IMPLEMENTATION
Intervention is preparing a plan of nursing actions to be undertaken to address the problem in accordance with nursing diagnosis (Boedihartono, 1994:20)
Implementation is the embodiment of management and nursing care plans that have been prepared at the planning stage (Effendi, 1995:40).
And implementation of nursing intervention that appears in patients with post-op frakture Olecranon (Wilkinson, 2006) include:
1. Pain is a sensory and emotional experience of an unpleasant and an increase due to actual or potential tissue damage, is described in terms of such damage; awitan suddenly or slowly from heavy samapai light intensity to the end that can be anticipated or foreseen and duration of less than six months.
Objective: The pain can be diminished or lost.
Criteria Results: - Pain is reduced or lost
- The client looked calm.
Intervention and Implementation:
a. Do approach the client and family
R / client relationships and create a cooperative family
b. Assess the level of intensity and frequency of pain
R / level of pain intensity and frequency showed pain scale
c. Explain to the client's cause of pain
R / provide an explanation will add to knowledge about the client's pain.
d. Observation of vital signs.
R / to know the client's progress
e. Work collaboratively with medical teams in providing analgesic
R / is a dependent nursing actions, which serves to block the analgesic pain stimulation.
2. Intolerance is an activity of an individual's circumstances are not sufficient to have physiological or psychological energy to endure or to meet the needs or daily activities as desired.
Objective: The patient has enough energy to move.
Criteria results: - behavior appeared to meet the needs of self-ability.
- Patient is able to express do some activities without assistance.
- Coordination of muscle, bone and other limbs good.
Intervention and Implementation:
a. Plan for adequate rest periods.
R / reduce activities that are not needed, and the energy collected can be used for optimal activity secar necessary.
b. Provide training activities gradually.
R / stages that are given to help the process slow activity by saving energy but the right destination, early mobilization.
c. Aids in meeting the needs of patients as required.
R / reduce the energy consumption to the power of patients recover.
d. After the exercises and activities to examine the response of the patient.
R / maintain the possibility of an abnormal response of the body as a result of the exercise.
3. Damage to skin integrity is the state of someone who experienced a change of skin is not desirable.
Goal: Achieve wound healing at the appropriate time.
Results Criteria: - no signs of infection such as pus.
- Not clean the wound moist and not dirty.
- Vital signs within normal limits or tolerable.
Intervention and Implementation:
a. Assess the skin and wound identification at the stage of development.
R / know how far the development of wound ease in doing the right thing.
b. Assess the location, size, color, smell, and the number and type of wound fluid.
R / identify the severity of the injury will facilitate the intervention.
c. Monitor the increase in body temperature.
R / increased body temperature that can be identified as the process of inflammation.
d. Provide wound care with aseptic technique. Dressing the wound with sterile gauze and dry, use paper tape.
R / Aseptic technique helps speed wound healing and prevent infection.
e. If recovery does not occur collaboration further action, such as surgical debridement.
R / so that foreign objects or infected tissue is not widespread in other areas of normal skin.
f. After surgical debridement, change dressings as needed.
R / bandage can be replaced once or twice a day depending on the condition of severe / her no injury, to prevent infection.
g. Collaboration antibiotics as indicated.
R / antibiotics to kill microorganisms useful in areas at risk of pathogen infection.
4. Barriers of physical mobility is a limitation in self-reliance, physical movement that is useful from a limb or body or more.
Objective: The patient will indicate the optimal level of mobility.
Criteria results: - appearance of a balanced ..
- Perform movement and displacement.
- To maintain optimal mobility that can be in tolerance, with the following characteristics:
0 = fully independent
1 = need a hearing aid.
2 = requires assistance from others for assistance, supervision, and teaching.
3 = needs help from others and hearing aid.
4 = dependence; not participate in the activity.
Intervention and Implementation:
g. Assess the need for health services and the need for equipment.
R / identify the problem, facilitate the intervention.
h. Determine the level of patient motivation in doing the activity.
R / affect the assessment of the ability of the activity due to the inability or unwillingness to do.
i. Teach and monitor patients in the use of hearing aids.
R / rate limits the ability of optimal activity.
j. Teach and support patients in active and passive ROM exercises.
R / maintain / increase strength and muscle endurance.
k. Collaboration with a physical or occupational therapist.
R / as suaatu planning resources to develop and maintain / improve patient's mobility.
5. Infection risks associated with inadequate peripheral defenses, changes in circulation, high blood sugar levels, invasive procedures and skin damage.
Objective: The infection does not occur / controlled.
Criteria results: - no signs of infection such as pus.
- Not clean the wound moist and not dirty.
- Vital signs within normal limits or tolerable.
Intervention and Implementation:
a. Monitor vital signs.
R / identify the signs of inflammation, especially when the body temperature increases.
b. Perform wound care with aseptic technique.
R / control the spread of pathogenic microorganisms.
c. Perform maintenance on inpasif procedures such as intravenous lines, catheters, wound drainage, etc..
R / to reduce the risk of nosocomial infection.
d. If there are signs of infection collaboration for blood tests, such as hemoglobin and leukocytes.
R / decrease in Hb and increased number of normal leukocytes can occur due to the infection process.
e. Collaboration for the administration of antibiotics.
R / antibiotics to prevent growth of pathogenic microorganisms.
6. Lack of knowledge about the condition, prognosis and treatment needs related to cognitive limitations, lack of exposure / recall, misinterpretation of information.
Objective: The patient expressed an understanding of the conditions, procedures and effects of the treatment process.
Criteria Results - perform the necessary procedures and explain the reason of an action.
- Start the necessary lifestyle changes and participate in treatment regimens.
Intervention and Implementation:
a. Assess the level of knowledge of the client and family about her illness.
R / find out how much experience and knowledge of the client and family about her illness.
b. Give an explanation to the client about his illness and his condition now.
R / to know the disease and his present condition, the client and his family will feel calm and reduce anxiety.
c. Instruct clients and family to watch his diet.
R / diet and proper diet helps the healing process.
d. Request for repeat clients and their families back on material that has been given.
R / find out how deep understanding of clients and families and assess the success of the action taken.
IV. EVALUATION
Addalah evaluation stage in the process of nursing in which the level of success in achieving the goals of nursing are assessed and the need to modify goals or set of nursing interventions (Brooker, 2001).
Evaluation is expected in the post operative patients with fractures were:
1. Pain can be reduced or lost after the act of nursing.
2. Patients have enough energy to move.
3. Achieving wound healing at the appropriate time
4. Patients will indicate the optimal level of mobility.
5. Infection does not occur / controlled
6. Patients expressed an understanding of the conditions, procedures and effects of the treatment process.
REFERENCES
Black, Joyce M. 1993. Medical Surgical Nursing. W.B Sainders Company: Philadelphia
Boedihartono, 1994, in Hospital Nursing Process. EGC: Jakarta.
Brooker, Christine. 2001. Pocket Dictionary of Nursing. EGC: Jakarta.
Brunner and Suddarth, 2002, Medical Surgical Nursing, 3rd Edition, EGC, Jakarta
Doenges, Marilyn E. 1999. Nursing Care Plans, 3rd Edition. EGC: Jakarta.
E. Oerswari 1989, Surgery and Treatment, PT Gramedia. Jakarta
Nasrul, Effendi. 1995. Introduction to Nursing Process. EGC. Jakarta.
Sjamsuhidajat, R and Wim de Jong. 1998. IMU Surgery Textbook, Revised edition. EGC: Jakarta
Wilkinson, Judith M. 2006. Nursing Diagnosis Pocket Book, 7th edition. EGC: Jakarta.
Smeltzer, Suzanne C. 2001. Medical Surgical Nursing Textbook of Brunner & Suddarth, 8th Edition. EGC: Jakarta.
Faculty of medicine. 1995. Collection of Surgical Science Lecture. Binarupa alphabet: Jakarta
