Case Study

Case Study
Care of Infants and Children Practicum NURS 3051P
Submitted by: Daniel Orji Cheche
Submitted to: Mrs. Cynthia Guild
Submitted on: May 21, 2015

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Table of Contents
Page #
Introduction

Preface

Data collection/Complete Health History.

Bio data
Chief complaints
History of present illness
Medical history
Family history
Lifestyle
Socioeconomic history
Environmental history
Psychological
Complete Physical Assessment

Analysis of Data Collected-

10

Gordons Typology of 11 Functional Health Patterns

*Health perception/Health Management
*Nutritional/Metabolic
*Elimination
*Activity/Exercise
*Cognitive/Perceptual
*Roles/Relationships
*Self-Perception/Self concept
*Coping/Stress
*Value/Belief
*Medication/History
*Nursing Physical assessment

Comparing the data.

14

Actual and potential problems.

18

Implementation/Evaluation

17

Nursing Care Plan

Teaching Plan

Recommendations

22

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Appendix A..
-

24

Bone diagram Fig 1.1

Types of Fractures Fig1.2
Traction Fig 1.3
Traction Fig 1.4
Closed Fracture of femur Fig 1.5
Wong-Baker FACES Pain Rating Scale Fig. 2.1

References..

Introduction

26

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The skeletal system comprises of all the bones in the body along with the tissues such as
tendons, ligaments and cartilage that connects them. There are four types of bones: long, short
flat, and irregular. The long bones, especially the femur and tibia, are subjected to the most of
the

load

during

activities

and

are

crucial

for

skeletal

mobility.

(http://www.bonefixator.com/long_bone/anatomy_1.html) Bones, joints, cartilages and ligaments

make up the skeletal system. The anatomy of the long bones consists of the diaphysis, epiphysis,
the periosteum metaphysis and epiphyseal growth plate. Fig. 1.1 During childhood, new cartilage
is continuously formed, the older cartilage becomes ossified and bone replaces cartilage. The
process of ossification begins in the embryo and continues until the child is 18 or 21 years old.
Damage to these components of the bone can cause major problems in bone growth and healing
(Hockenberry & Wilson, 2011). A Ffractures is a break in the can be defined as any break in the
continuity of the bon and is defined according to the type and extent. e. Fractures occur when
the bone is subjected to stress greater that it can absorb. Fractures are caused by direct blows,
crushing forces, sudden twisting motions, and even extreme muscle contractions. When the bone
is broken, adjacent structures are also affected, resulting in soft tissue edema, hemorrhage into
the muscles and joints, joint dislocation, ruptured tendons, severed nerves, and damaged blood
vessels. Body organs maybe injured by the force that cause the fracture or by the fracture
fragments.
There are different types of fractures and these include, complete fracture, incomplete
fracture, closed fracture, open fracture and there are also types of fractures that may also be
described according to the anatomic placement of fragments, particularly if they are displaced or
nondisplaced. Such as greenstick fracture, depressed fracture, oblique fracture, avulsion, spinal
fracture, impacted fracture, transverse fracture and compression fracture. Fig 1.2

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Fractures occur when the bone is subjected to stress greater than it can absorb (Smeltzer et al,
2010). Fractures are a common injury at any age, but most likely occur in children and in the
elderly. They can be caused by direct blows, crushing forces, and sudden twisting motions which
can come about from motor vehicle injuries sports or fall from heights. Types of fractures
include: open, closed, incomplete, complete, displaced and comminuted. Fig 1.2 It is manifested
by generalized swelling, pain and tenderness, and limited use to the affected part. X-rays are
used to examine the specific area of the broken bone. Therapeutic management goals are to reestablish alignment and length of the bony fragment (reduction), to retain alignment and length
(immobilization), to restore function to the injured parts and to prevent further injury
(Hockenberry &Wilson). When bone fragments cannot be reduced with simple traction and
stabilization with a cast, the extended bulling force obtained with continuous traction may be
required. The use of traction is the direct application of such forces to produce equilibrium to the
fracture site. A forward force (traction) is produced by attaching weight to the distal bone
fragment. This force is balanced by the backward force of the muscle pull (countertraction) and
the frictional force between the patient and the bed (Hockenberry & Wilson, 2011). (Fig 1.3 and
1.4)
By choosing this condition as a case study, It is expcted expects to broaden my
knowledge understanding and management of fracture, not just for the fulfillment of the course
requirements in pediactric nursing. It is very important for nurses in general to be adequately
informed regarding the knowledge and skill in managing these condition.

Through the

knowledge acquired with this study of this condition, a higher quality of care will be provided to
minors suffering from it.

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Preface
I would like to thank the Ana Jacqueline P.s parents mother and Ana Jacqueline P.
herself for letting allowing me do a case study based on her injury pf her fractured femur. I
would also like to extend my gratitude to the Pediatric Ward at Karl Heusner Memorial Hospital
(KHMH) at the Pediatric Ward for allowing me to observe and train me to along withhaving
excellentexceptional and capablecompetent nurses who are committed to providing holistic care
to their young patients. It was a great learning experience to be ablve to be working honor
working alongside them and gaining new practical knowledge on Pediatrics and Nnursing care. I
would like to extend my thanks to Mrs. Cynthia Guild for being a motherly and patient instructor
alongside with Ms. Dawn Elliot who guided helped me and mentored me through the practicum
period and assisting me with any and all questions I had in regards to this unit. when I got stuck
in my care plans. Im coming out of thisfininshg this unit of Pediatric care with new enhanced
knowledge and better capabilities in my nursing skills in order for me to be a good nurse to
children whenever I become certified after my studiesto better myself to become a great nurse.

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I.

Data Collection/ Complete Health History

i.
Biodata:

Ana Jacqueline P. (Jackie) is a foursix year-old minor female minor residing in Benque Viejo
del Carmen in theBiscayne Village, CayoBelize District. She sought medical help alongside her
motherParents, Mr and Mrs. LP, after being transferred from the San Ignacio Hospital. The minor
is single, with a Catholic upbringing. According to her mother, whenever they are in need of
medical care, they would normally usually go to Benque Ladyville Healthcare Cener Polyclinic
where it is her husband who takes care of the medical bills whenever there is a medical problem
with the family.
ii.

Chief complaint

LSs Jackies reason to be at the Karl Heusner Memorial Hospital is because of a closed fracture
to the right femur. Example can be seen in Fig. 1.5
iii.

History of Present illness

Mrs. LS P describes that on March Saturday April 182, 20145 her daughter was playing with a
group of children near a tree near their homeanother little girl, who ran behind her daughter and
pushed her in frontthen she suddenly heard a commotion outside along with someone crying.
When she went outside, she saw her daughter on the ground crying. When she investigated, she

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learnt that her daughter had climb a tree and feel,, causing her to feel intense pain on her right
leg. When she went to get her daughter, tThe child was sprawled rolling on the ground, unable
to get up, with her leg in an abnormal position and crying with pain. It all happened so suddenly.
This is the first time that LS Jackie has a sustained a severe injury or broken bones. Two Any
previous visit to the healthcare center would have been due to immunizations shots or severe
influenza symptoms. years ago, LS twisted her hand but it only needed bandaging and rest. The
complete fracture is located in the right femur. The child stated that the fall hurt a lot and that
her leg looked twistedweird Her mother described that the site of the injury was really highly
inflamed, bruised and and red. Presently, LS Jackie has traction with weight to help the process
of healing and keep the leg straight. LS Jackie complains of pain to the right leg whenever the
weights are lifted. However, and during the night when she has nightmares and begins to cry.
Presently, she is able to sit up in bed with no pain though.
iv.

Medical history

Medical history for this patient goes as follows: In the past, as aforementioned, the patient had
twisted her hand but did not require hospital stay to treat the injury to the handThere has been no
instances in which the patient had sustain any serious injury to her person. Her mother says
explained that she her daughter is not a sickly person and only does not get sick very often, but
catches the flu once in a whileoccasionally.

When she was admitted at Accident and

&Eergency (A&E), she was given Voltaren 20 mg IV stat and

Pethidine 20 mg IV stat.

Diclofenac 18 mg IV was later added by the physician. Currently, LS Jackie is being given
Tylenol suspension 180 mg as needed every 8 hours for pain. All these are pain medications. Her
mother says LS Jackie does not suffer from any allergies she is aware of.

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v.

Family history

Mrs. LP P stated that no other member of her family has suffered a fracture like this. She can
only recall her grandfather (LSs great grandfather) who also had a fractured femur and had to
wear a cast as well. Other than him, none of her immediate family has suffered from broken
bones. The only medical ailments the family sufferes from is high blood pressure from Jackies
father side of the family and diabetes from the mothers side of the family. However no one in
her immediate family is suffering from this currently.
vi.

Lifestyle

On a typical day, LS Jackie wakes up and has breakfast of bread and buttereither cereal or
Belizean style breakfasts of fry jacks, beans, egg and cheese. She attends her local primary
school named kinder gardenBiscayne Government School.During For her school break at
schoolbreaks, she usually takes a sandwichhas sandwich or a piece of local fruit in season at the
time. or cheese dip. For lunch at home she has rice and beansvarious Belizean style lunches,
most commonly Rice and beans with juice and. Finally at for dinner she usually eats beans with
flour tortillas and sometimes accompanied with fried eggs with sausage. As the mother, LP Mrs.
P buys the family groceries and cooks for her family. There is no known food allergy to LS
Jackie according to her. There is no difficulty for LS Jackie to perform her basic activities of
self-care prior to her fractured femur.
vii.

Socioeconomic history

Ms. LP confides that she used to believe in the mal de ojo or evil eye in which a child
presents with on and off fever and to cure this, an egg has to be passed over the childs body to
cure it. She states that she no longer believes in that custom though. LSJackie and her family

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live resides in their own home which was inheried from Mrs. P grandparents some years ago.
given to them by her father. Ms. LPThe mother went to reached up to highschool and worked for
a while before meeting her hustabnd starting started an family, she is a stay at home mother. Mr.
P also went to highschool and currently is employed as a stevedore at Port in Belize City and has
to go to work several days at a time to load off ships. Jackie is currently in primary school and
LS with her other siblings and cousins. is still in kinder garden. She noted that the village is
fairly safe and that murders and robberies are not common in the area where the reside. also
states that their neighborhood is safe. Cases of murder or robbery are not heard around where she
lives. It is very safe. When asked questioned about Jackies care and wellbeing when she returns
home with the injured leg, the mother advised that she will care for it s advise by te hospital.
Also if there is any complications, she will be able to seek assistance from the Ladyville
Heathcare Center. what will happen when LS returns home with her injured leg, she says that
she could always seek medical help at Benque Poly Clinic whenever necessary.
viii.

Environmental history

In BenqueBiscayne Village, Mrs. LP says states that they do not have they have potable water.
So most villagers, like themselves have created a Well pump to divert water in the home. Also,
for drinking purposes, they have two huge vats which collects rain water on the property but they
drink rain water from their tank. Their bathroom is inside the house with sewage. There are no
complaints of any infestation of rats or insects except for the occasional roach and mosquitoes
present. She states that there is a carpentry shop right next to their house that makes furniture but
makes a lot of noise and saw dust. She is concerned about this for her children at home during
the rainy season due which can causes cases of malaria and dengue. She notes that her husband
would occasionally clear the bushes near their property and clear up any places which can harbor

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the mosquitoes.because she has a baby boy at home still breastfeeding and she doesnt like him
to inhale the dust from the carpentry shop and have to hear the noise from it. They have already
told the owners to move, but they have yet to do so.
ix.

Psychological

Mrs. P advises that she has been receiving emotional and financial support from her family
members along with other village members while staying in the hospital. Family members call
her and little LS every day from the hospital to see how she is doing. Mr. LP checks with the
mother every day to talk with Jackie and provide support to her over the phone. s husband calls
every day to talk to his little girl.Since he has to work, Mrs. P has to stay with Jackie during her
stay at KHMH and Mr. P comes and checks during the week on them. Mrs P mother has been
taking care of the other two older children at home while she is caring for Jackie. Since they live
in Benque, only she has been staying with her child but her husband and mother provide support
to her over the phone. Jackie is very eager to return home and recover in order to go back to
school. Her classmates have sents cards and treats to encourage her to get better and return to
school. Therefore, it would seem that the physcological state of Jackie is one that is upbeat, with
exception of the occasional onset pain when the skin traction that will return once ina while.
They own a plantain chips business in which they have to fry chips every day to sell plus the
father works, hence the reason LP is the only one staying with her child at Karl Heusner. LS is
very eager to go home. Every day she shows signs of recovery by being able to sit up in bed
despite the skin traction and cries less. She is a happy child.

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x.

12

Physical assessment of the client (Patients mother answered the questions

regarding the physical assessment-subjective data)

Generally, patient maintains good weight and eats well. She has not noticed that LSs clothes are
getting tighter due to weight gain. She is a fairly healthy child that does not get sick as often as in
the past. Presently she has not gotten any high fevers. Her skin is warm and smooth. She sweats
because the room is hot and the fan does not provide enough breeze. There is itching of the skin
under the bandages and it gets worse when the weather is really hot. Her neck is not stiff or
enlarged and does not hurt. She has no difficulty swallowing. Eyes and ears are healthy
according to mother. No eye vision problems or difficulty hearing. She states that she has taught
her children good hygiene; she brushes her teeth before going to school and going to sleep. She
does not have rotten teeth, no problems with gum bleeding. LSs breathing is normal and has
never had shortness of breath when she plays or does daily activities. She has never gotten
pneumonia. Her breasts have not started developing yet. She states that she does have shyness
when exposing herself and finds it difficult to change with other patients in the room because
there are not curtains to provide privacy. She has never had any chest pain or discomfort relating
to her cardiovascular assessment. She has good appetite and does not have nausea or vomiting
due to her fractured femur. There is no diarrhea that she has noticed and she has normal bowel
movements. She has not had any fainting spells or headaches. No aches of bones except for the
fractured femur which is swollen and causes pain when moved. Her mother states that LS is a
fairly healthy child with no serious illnesses until now.
ANALYSIS OF DATA COLLECTED
ORGANIZING THE DATA

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1.

13

Gordons Typology of 11 Functional Health Patterns

I.

Health Perception/Health Management

Patient has generally good health prior to injury. From the interview gathered, patient
does not suffer from allergies with food or medications. Their living environment is
stable, free from harm except for the carpentry shop which is a risk factor for
breathing problems due to the saw dust generated from it. Patient practices good selfcare hygiene, has good relationship with parents and siblings and has a positive
outlook in getting better and going home. Parents have good support systems from
family members to assist with stress of mother being away from home and away from

II.

her other children.

Nutritional/Metabolic
Patient has good appetite and tolerates food 100% every day when served. Patient
eats sufficient amount of carbohydrates, lipids and nutrients from 24 hour intake
described by mother during a typical day. She does engage in some snacking but it is
not interfere with her 3 meals a day. She usually drinks about two 1 liter bottles of
water a day. Her sleep/wake normal patterns range from getting up around 7 in the

III.

morning and going to sleep around 8 at night (11 hours of sleep).

Elimination
Bowel movements are regular everyday consisting of moist, soft stools. There are no
urine incontinence problems with patient. Presently, LS has to wear pampers because
she cannot move from the bed. Mother changes pampers whenever soiled. Patient

IV.

drinks sufficient amount of water every day. Mother says LS has never had UTIs.
Activity/Exercise
Patient is a 4 year old active child who engages in play whether at home or at her
kinder garden. Mother describes her as an active child who rides her bike at times
under supervision. She is not lethargic when at home. Presently, she is able to move

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her left leg and arms and sits up in bed. Range of motion exercises are sometimes
V.

done.
Cognitive/Perceptual
LS is a bright child. At the ward, she engages in conversation with mother and with
other patients. She reads books and plays with her toys on the bed. Mother states she
is attending kinder garden and will enter a Nazarene school upon completion of
kinder garden. LS is aware of her fractured leg and responds to questions asked by

VI.

nurse and mother.

Roles/Relationships
Patient has strong attachment bond to mother but does not shy away from interaction
with medical staff and other patients and visitors. Seems outgoing and will participate

VII.

in play activities initiated by nurse and mother.

Self-Perception/Self concept
Patient seems to be at ease at the ward. Mother states that she is potty trained but at
the moment must urinate and stool in pampers due to skin traction to right leg. She is
able to brush her teeth and comb her hair on her own. Appearance seems calm and

VIII.

relaxed with no signs of anxiety on her features.

Coping/Stress
Patient seems to be coping well to situation. Mother discusses that she feels a little
worried that they have to stay at Karl Heusner. She had previously asked for a transfer
back to the San Ignacio Community Hospital since it is much closer to their home in
Benque. She is also still breast feeding her baby but has been unable to do so for the
past 2 weeks due to her being too far away. Doctor Roberts, LSs doctor, informed
that the patient could not go back and must stay at Belize City. There is stress to
separation of the mother with the rest of her children. Patient has episodes of
nightmares where she suddenly awakes and starts crying. Mother interprets this as she
remembering the accident. Patient also cries and complains when the leg is in pain or

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itches. Patient was assessed using Wong-Bakers FACES Pain rating scale and scored
IX.

a 3 using 0-5 coding. See Fig. 2.1

Value/Belief
Other than old beliefs in the mal de ojo, patient and mother do not seem to have
other cultural beliefs. Other health beliefs LP practices is putting on sweaters and
covering the head when the weather gets cold, washing hands after using the
bathroom, practicing good oral hygiene and regular baths. They relate their faith to

X.

the Catholic church and have a strong belief in God.

Medication/History
Nil allergies to medication referred by mother. Upon admission to Accident and
Emergency, patient was given Pethidine 20 mg IV stat, and Voltaren 20 mg IV stat.
Currently, patient is being given a Tylenol suspension of 7.5 cc for pain whenever it is
needed. All medications prescribed are pain medications to alleviate swelling and

XI.

pain to right leg.

Nursing Physical assessment

In regards to the physical assessment of LS, patient is conscious and alert lying in supine
position in bed with skin traction to the right leg with weights. With regards to skin, hair and
nails, there is no signs of cyanosis or jaundice. Skin is light brown with even pigmentation.
Skin is warm to touch, firm, smooth and even with no tenting. No scars visible. Hair is brown
and straight which is evenly distributed with no alopecia. The scalp is free of lesions or scars.
Nails have a pink undertone with good capillary refill less than 3 seconds. For the Head, neck
and lymph nodes assessment1s, face is symmetrical with ears aligning with canthus of the
eyes. Smile is even, eyebrows rise equally, no rhythmic bobbing or abnormalities with the
head and neck. There is no swelling of the lymph nodes below the jaw and
sternocleidomastoid upon palpation. Patient has good range of motion of the neck. Thyroid
gland is not enlarged, nil bulges. Eyes and ears assessment tests adequate. Patient is able to

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follow the direction of the tip of the pen with eyes only, there is no tenderness when
palpating the eyelids and ears. With regards to the abdomen assessment, abdomen is
symmetrical with nil bulges or masses observed. Umbilicus is protruded. Upon percussion,
dullness is heard over solid organs and hollow sounds over the intestines. Upon palpation,
there is no tenderness voiced by client when doing light and deep palpation. The assessment
of the respiratory system shows that respiration is adequate with symmetric chest rise,
posterior chest has even pigmentation as well as anterior chest. Upon auscultation, breath
sounds are normal with no crackles with good chest expansion. When assessing the
cardiovascular system, the head is kept steady, eyes are not bulging. Lips are pink and not
cyanosed. Oral mucosa pink and hydrated. Ear lobes are smooth with no bilateral earlobe
creases. Fingers are pink and even, nil clubbing observed. Respiratory pattern is even and
regular with no retractions. Legs are even in color and smooth. There is edema to the right
thigh and is painful upon mobilization. Carotid pulses are strong and bounding. Upon
auscultation of the heart, heart sounds are rhythmic with no murmurs. Extremities are well
perfused and hydrated with good capillary refill less than 3 seconds. Overall, client is in good
health except for the closed fracture to the right leg. No abnormalities observed in any of the
other body systems.

COMPARING THE DATA

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Table 1: Timeline of events in LSs injury

Patient has been showing gradual reduced levels of pain from initial admission and assessment
up to the present. Patient scored a 5 on Wong-Bakers FACES pain assessment tool initially,
scored a 3 last week and is presently scoring a 1. There is definite improvement in the patients
ability to sit up in bed and assist in changing clothes and pampers.

Fig. 2.1 Patients current pain rating to the right femur

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Vital signs have been consistent and without presence of an infection. Patient is seen and
evaluated by Dr. Roberts and Dr. Parham on a daily basis to assess condition. X-rays have been
taken of the initial injury and how it has been aligning with the help of the skin traction with
weights. Last x-ray taken indicated femur is well aligned but must still be kept of traction to keep
promoting callus formation. Since patient is 4 years old, bone healing is characteristically rapid
because of the thickened periosteum and generous blood supply. In early childhood, healing
times for a femoral fracture can take up to 4 weeks (Hockenberry & Wilson, 2011). LS has been
at the ward for 18 days still and Dr. Roberts has ordered 2 more weeks of being in traction. Bone
healing in any age group is greatly influenced by the patients general health. LS does not have
any other illness presently to hinder her healing. Mother should be educated on the importance of
a balanced diet to promote stronger bones and good development of childs body.
Strengths of LSs family include having a good support system in terms of taking the time out to
take care of LS and father staying at home to take care of the other children and to keep their
business running. Her grandmother is also helping take care of the other children. Weaknesses
could be that there is only communication through the phone to the rest of the family in Benque.
No other family members have come to relieve LP of taking care of her daughter. In another of
point of view, LSs injury is an opportunity for the family to grow closer when they help each
other out. LS will become closer to her mother, and vice versa. Father will have the opportunity
to see what it feels to take care of the rest of the family on his own, and he could be more
understanding to his wife. Financial strain of LSs injury may decrease the familys resources,
other siblings could feel neglected since attention is on LS for the moment, and both parents can
be feeling guilt over having failed to protect their child. Other opportunities to educate other
members of the community on fractures and timeframe of bone healing could come to LSs

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family so that they could educate other families to supervise when their children are playing and
try to prevent injuries to their childrens bones.

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Table 2: Nursing
interventions related to data
gathered

20

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21

ACTUAL AND POTENTIAL PROBLEMS

In order of priority
Actual: a. Impaired physical mobility- LS is unable to move the right femur and whole right
leg because of the skin traction with weights to the foot of bed. She is able to move her toes but
has impaired physical mobility to change positions on the bed. She is kept in a supine position,
but she is able to sit up in bed now that she is not experiencing as much pain as before. She needs
assistance in bathing herself and changing clothes. She requires the assistance of her mother. The
nurse helps in changing the bed linens without disturbing the traction.
b. Acute pain- LS is not having as much pain as she had at the beginning of the injury
however there is still pain present whenever she moves the leg suddenly or when she is being
changed and bed linens are being changed. The right leg is still tender to touch and edematous.
Patient is being given 7.5cc of Tylenol for pain management. Patient starts complaining and
crying that it hurts whenever she feels the pain.
Potential: c. Risk for disuse syndrome- Patient is at risk for disuse syndrome since she is not
ambulating and not able to do range of motion exercises to affected leg. Patient is limited to
staying in bed, so muscle strength is at risk to be reduced. Inactive muscle loses strength at a rate
of 3% per day (Hockenberry & Wilson, 2011). Immobility can also affect the circulation to the
skin during inactivity and can cause edema. Friction from the straps and bandages could cause
skin breakdown.

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IMPLEMENTATION/EVALUATION

22

Nursing Care Plan 14/03/2014

Assessment

Nursing Diagnosis

Objective data:
-Patient lying in supine
position in bed
-respiratory
effort
adequate
-skin warm to touch and
hydrated
-oral mucosa pink and
hydrated
-Abdomen soft and
palpable, non-tender
-Extremities
well
perfused, capillary refill
less than 3 seconds.
-right leg on skin
traction with weights,
immobilized with sand
bags
around
leg,
edematous and tender
Subjective Data:
-patient
cries
when
moved when bed linens
are being changed and
when she wakes up from
a bad dream, and voices
pain
-Patient cannot bathe on
her own, requires help of
mother to be sponged in

Actual:
Impaired physical mobility
related to bone injury to
right femur as evidenced by
inability to move out of bed
to bathe due to skin traction
with weights to right leg

Acute pain related to bone

injury to right femur as
evidenced by client voicing
pain felt to right leg and
being tender to touch
Potential
Risk for disuse syndrome
related to bone injury to
right femur

Goals/Objectives

Interventions/Rationale

Long term goal:

I. Impaired Physical Mobility
At the end of 3 days, 1.Assist in changing pampers and
bed linens-helps patient since she
patient will be able to:
cannot move much without
feeling pain (collaborative-nurse
1.Pull herself up to and mother)
assist mother during 2.Do range of motion exercisesbathing and when bed helps strengthens muscles of legs
linens are being changed and arms (independent-nurse)
according to level of 3.Provide books, and toys within
tolerance
reach-keeps patient entertained
and not feel bored of staying in
Short term goal:
bed (collaborative-nurse and
At the end of the 8 hour mother)
shift, patient will be 4.Keep right leg in tractionable to:
promotes correct alignment and
healing of bone (collaborative2.Voice that she feels doctor and nurse)
little pain or is free of 5.Provide skin care by keeping
pain to right leg when skin clean and dry-helps maintain
she moves
skin integrity and reduces risk of a
break in the skin (independentnurse)
3.Move
unaffected
limbs to do range of
II.
Acute pain
motion exercises to 1. Assess level of pain using
reduce risk of disuse Wong-Bakers pain assessment
syndrome
tool-helps to see level of pain
patient is feeling (independent)

Outcomes
At the end of 3 days,
patient was able to:
1.Pull herself up in bed to
assist during bed baths and
changing
of
linens
according to level of
tolerance
At the end of the 8 hour
shift, patient was able to:
2.Voice that she felt little or
no pain to right leg when
she moved
3.move unaffected limbs
and do range of motion
exercises and therefore
reduced the risk of disuse
syndrome

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bed
-Patient is quiet and
calm when she has
books to read and TV to
watch.

2. Administer Tylenol every 8

hours or when needed-analgesics
help control pain (Dependent on
doctors orders)
3.Monitor vital signs for increase
in pulse which would indicate
pain (independent)
4.keep toys and books within
reach so patients focus will be on
the stimuli and not on the pain
(independent-mother)
5.Provide comfort to child by
talking soothingly so she can relax
when she is having pain
(collaborative-nurse and mother)
III.

Risk for disuse

syndrome
1.Initiate range of motion
exercises to encourage adequate
circulation (independent)
2.Massage pressure area points to
prevent bed sores (collaborativenurse and mother)
3.Encourage patient to wiggle
toes, sit up, and stretch as
tolerated
(collaborative-doctor,
nurse and mother)
4.Educate mother on disuse
syndrome so she can move childs
limbs when nurse is not around
(independent-nurse)

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24

TEACHING PLAN
TOPIC: Fractures and traction
VENUE: Patients bedside AUDIENCE: Mother and
patient
DATE: March 14, 2014
DURATION: 30 minutes
THE PURPOSE: To educate the patient and mother on impaired physical mobility, pain
management and how to do range of motion exercises
STATEMENT OF OVERALL GOAL: Patient and mother will understand the reasons why
traction is placed, and how to manage patient in traction
OBJECTIVES

CONTENT
OUTLINE

At the end of the

discussion, patient
and mother will be
able to:
1.Describe what is a
fracture and the
types of fractures
and how traction
therapy works

1.What is a
fracture?

2.Identify type of
fracture patient
suffered by looking
at patients x-rays
3.Adapt to patient
having to stay on
traction for 2 more
weeks and how to
manage pain
4. Describe disuse
syndrome and how
to do range of
motion exercises to
prevent it

METHOD
OF
INSTRUCTIO
N

DiscussionExplain traction
care-understand
2. What are the
the therapy,
different types
of fractures that maintain
traction,
can occur?
maintain
3. treatment of
alignment
fractures-cast or (check after
traction
patient moves),
and prevent
4.Medications
skin breakdown
available:
Tylenol,
Voltaren,
Pethidine-for
pain
management

go in depth by
demonstrating
the correct
ways of doing
range of motion
5.Disuse
exercises and
syndrome
have mother
6.Questions and perform a
answers at end
return
of presentation demonstration

Recommendations

TIME
ALLOTED
FOR EACH
OBJECTIVE

5 minutes for
each objective
and time left
will be for
demonstration
and questions
& answers

RESOURCES/
TEACHING
AIDS

METHOD OF
EVALUATION

Visual aids:
Pictures of the
types of
fractures
Patients X-ray
Demonstration

When the nurse

finishes
discussion,
patient and
mother are able
to identify type
of fracture
patient
sustained,
understand
which pain
medications are
given and how
they work, and
how to initiate
range of motion
exercises to
prevent disuse
syndrome.

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25

After evaluating the data compiled, some recommendations to patient and family can be
given. Possible ways to improve the situation of the family could be that other family members
should come and help the mother of taking care of the child. Undoubtedly, LP is having difficulty
being the only one who has to stay with the child because she voices that her baby is still
breastfeeding and her breasts are getting tender from not breastfeeding. In the meantime also, she
is also worried about her other children and how things are at home. It would be recommended to
have someone else come to help her at least for 2 or 3 days so she can go back home. LS is doing
very well in the past days. All that is left to do is wait 2 more weeks so the skin traction can be
discontinued. Dr. Roberts could then put on a cast or transfer her to the San Ignacio Community
Hospital so she can be closer to home. LS also needs more books and toys so that she does not
get bored about having to stay immobilized.
Interventions from the nursing care plan were met and the patients needs were prioritized
according to the needs that were most outstanding. Range-of motion exercises are still being
done and client is able to sit up in bed and move other limbs to promote circulation. Patients
right leg is still in traction and care is done to see that the leg is always aligned and that the
weights are hanging freely. If patient is in pain, Tylenol is given to help alleviate it.
When patient is discharged and taken back home, bed rest and care should be taken so
that leg does not become injured again. The child must not strain the right leg with excessive
running or other physical activities. Follow up care with the doctor should be done as scheduled
for x-rays to see that the bone continues healing. If there is any vomiting or shortness of breath
after being discharged, parents should be advised to seek immediate medical help at the nearest
health center. Patient should keep taking her pain medications as prescribed by the doctor as
well. The mother should be encouraged to freely ask any questions she might have regarding

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26

future appointments or how to better take care of her child once she is back home. At the same
time the nurse should provide accurate and understandable information on all topics related to
the injury. The teaching plan for this patient should help minimize the lack of knowledge on the
patients injury.

Appendix

Case Study

Fig. 1.1 Parts of the bone

Fig. 1.2 Types of fractures

Fig. 1.4 Traction with weights

Fig 1.3 Application of traction to maintain equilibrium

27

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Fig. 1.4 example of a fractured femur

Fig 2.1 Wong-Bakers FACES pain assessment tool

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29

References
Hockenberry, M., Wilson, D., (2011). Wongs Nursing Care of Infants and Children. (9th
ed.) St. Louis, MO: Mosby.

Smeltzer, S., Bare, B., Hinkle, J., Cheever, K., (2010). Brunner and Suddarths Textbook of
Medical Surgical Nursing. (12th ed.). Philadelphia, PA: Lippincott Company

Pinelo, L., Personal Communication. (2014).

Long bone anatomy references

1. Perren SM. Physical and biological aspects of fracture healing
with special reference to internal fixation. Clinical Orthopaedics
& Related Research, 1979(138): p. 175-96.
2. Manolagas SC. Editorial: Cell Number Versus Cell Vigor--What
Really Matters to a Regenerating Skeleton? Endocrinology,
1999. 140(10): p. 4377-4381.