Pathophysiology
This is a clinical discussion report of the case of the patient named Peter Bowman. The report comprises pathophysiology of his fractures, the order of nursing intervention, and rationale behind the nursing intervention and pathophysiology. The report will help in the interpretation of abnormal observation, findings, objective and subjective assessment of patient conditions.
Peter Bowman is a thirty-eight (38) year old male. His occupation is plumbing. He has just been brought to the Emergency Department with the help of an ambulance after he fell off from his roof. Initially, his X-Ray was conducted which displayed a fracture in his left femur and fractures to his left second and fourth ribs. He denied loss of consciousness at the trauma site of the fall as well as hitting off his head.
Pathophysiology is defined as distortion in the function or organ structure of an individual secondary to any illness, trauma or disease. It is a combination of pathology and physiology. Pathology is a medical branch which elaborates the specific conditions during the prevalence of an illness and physiology which is a discipline of biology referring to the mechanisms in operation inside an organism (McGurk, 2012).
The patient presented to the Emergency Department after a fall from the roof, which resulted in the fractures of ribs and a fractured femur. The patient presented this way because he fell stressing primarily on his left side and due to direct and sudden force the patient’s ribs and femur bone on his left got fractured. He also had grazes (breaking of the surface of the skin) to back, forehead, and left elbow reflects that the patient slipped to some distance on the trauma site after falling on the ground. There were bruises (skin discoloration without any skin break) on the patient’s body which indicates some internal tissue damage. Bone fracture is the result of a huge amount of stress, or a physical injury.
Rationale behind the patient’s symptoms
The patient exhibited following symptoms like pain in his left leg, edema and bruising in the left leg. In this case, the patient’s left leg pain and swelling were due to inflammation of the cells and break in the continuity of periosteum or endosteum. Edema in the neighboring tissues and muscle spasms at the injury site are the result of a distortion in the normal physiology of femur tissues and muscles. He also complained about bilateral chest pain and has shallow breathing with high respiration rate due to rib fractures.
Rationale behind the patient’s symptoms
The femur is known as the strongest, heaviest and longest bone of the human body and crucial for proper ambulatory motion. There are three types fractures associated with femur: spiral/transverse, committed, and open (Liu, 2015). The femoral bone is a tube type with the cardinal bow, continuing from the lower trochanter to the flexure of the femur condyles. The femur is subjected to various forces while ambulation such as bending, torsional forces and weight bearing (Brown, & Walters, 2012). The stress from these tissues may lead to an abduction malformation to the proximal part of the femoral shaft and subtrochanteric femoral fractures. The iliopsoas links to the lower trochanter causing flexion deformity in the same part. Distally, the big adductor muscle binds to the medial part, causing deformity in the apex lateral often seen in some distal femoral fracture. Femur comprises vascular supply tissues which receive the blood through the profunda femoral artery, therefore, regulates the supply of nutrients and blood in the body (Fawthrop, 2015). The periosteal circulation is important for the healing of the fracture.
The patient in this case study reported left leg pain of intensity 7 out of 10 is attributed to deformity in the structure and musculature of his femur. The patient is unable to put weight on his leg, as there is a deformity in the broken leg which appears shorter than the other limb. Another reason is bruising and pushing up of bony pieces into the skin causing discomfort, pain and ambulatory problems (Fawthrop, 2015). The femur of the patient sustained fracture causing a break of the ordinary mechanisms of blood and nutrients flow and further disturbing healing process. Fracture of femur shows the probable chance of blood loss into the thigh. The above-mentioned symptoms of patient weakened the strength of his thigh bone to bear his weight completely leading to pain while ambulating. Inflammation of the trauma site cells caused leg swelling in the patient.
Fractured Ribs: The ribs protect underlying structures and organs. The upper three ribs are guarded by the bony structure of forelimb. Clavicle, scapula, and humerus with their muscle bonding act as a barrier to the rib injury. Fracture in scapula, sternum, first or second rib indicates major risk for vessels of the head, spinal cord, neck, and lungs. These fractures are a consequence of a direct force or blow (Šobak, 2014). Rib fractures are the most common injury sustained after blunt chest physical injury, covering the majority of thoracic injuries from non-penetrating injuries. The fracture associated with first and the second rib signifies high index of vessel injury (Brown, & Walters, 2012). It causes pain during motion and impairs oxygenation, ventilation and effective coughing.
Femoral fracture
Here the patient reported left side chest pain due to the injury caused to his internal vessels related to second and fourth rib fractures. He suffered an average loss of blood per rib i.e. 100-150 ml. The middle ribs from fourth to ninth sustain most of the blunt trauma, which tends to push the ribs towards the thorax increasing the probability of hemothorax or a pneumothorax due to penetration of fractured ribs and hence, the fracture of the patient’s fourth rib pushed his ribs inwards leading to pneumothorax. The”paradoxical motion” arises when the normal movements of the chest are reversed, causing increase in the work and pain during breathing. This is the reason why Peter complains about pain in his left side of the chest (Le, 2015).
The abnormal findings of the patient are lower O2 stats i.e. 90% (The normal level: 94% to 99%) is due to hypoventilation, which causes the reduction in the oxygen intake by the lungs due to multiple broken ribs. The broken rib might compromise ventilation due to various mechanisms and pain due to rib fractures can cause atelectasis, and respiratory splinting. Multiple rib fractures also called as flail chest disturbs the normal diaphragmatic and costovertebral muscle excursion, causing insufficient ventilation. Pneumothorax and hemothorax originate from trauma, such as fall which occurs when there is an entry of air into the pleural cavity from outside of the cavity of the chest. Difficulty in breathing or labored breathing (shallow), on the injury side secondary to tension pneumothorax and it is also the reason of elevated pressure in jugular venous, muffled sounds of the heart. It is also the cause of the drop in oxygen saturation level of the patient. A tension pneumothorax occurs due to a puncture in the lung due to fractured ribs. Respiration is shallow and weak secondary to rib fracture and the shift of the mediastinum and trachea towards the unaffected side secondary to elevated air pressure.
The patient has high respiration rate to manage the decreased tidal volume for maintaining normal volume. The reason for the rapid respiration rate (RR is 12-20 per minute) can also be attributed to the blood clot in the lungs, and stress or anxiety attacks secondary to rib fracture and femur fracture. Heart rate (normal heart rate is 60-100 beats a minute) of Peter was 120 which is faster because of hypertension, imbalance in vasoconstriction and vasodilation, and circulation of markers of inflammation. (Berry, & Miller, 2008).
Fractured Ribs
The left foot is cool, non-diaphoretic, and pale because of disruption in the blood vessels resulting in a slow blood flow, pain, and peripheral neuropathy (such as numbness and tingling) due to fracture or sciatica nerve injury (Fawthrop, 2015).
Nursing intervention can be explained as the care and treatment given to the patient to recover his medical illness or injury, and these were prescribed for the patient. The patient was taken to the ED for the provision of treatment at the proper time as any delay can result in further complications of the patient’s injury. Chest X-ray was obtained initially to rule out any other intrathoracic injuries or risks. Nursing care plan or will follow the problems and symptoms described by the patient. The evaluation of vital signs such as blood pressure, respiration rate, heart rate, blood Oxygen saturation, and the temperature is the key elements of patient care. They determine the treatment protocols to be given to the patient and to take for their appropriate life-saving decisions. It helps to narrow down the solution of clinical problems (“vital measurements,” 2016). Here, the goal is to treat trauma patients by conducting a primary survey (Duch, & Møller, 2015).
These are the interventions ordered by the doctor after primary survey: The patient was administered morphine 7.5 mg IV STAT for pain management. The patient was given Oxygen therapy to increase O2 saturation level to normal. The patient administered 0.9% Sodium Chloride IL IV over 30 minutes. Then, the patient was inserted with indwelling urinary catheters (IDC) and to record hourly urine measures. Finally, the patient was placed in a different sitting called high fowler’s position for early mobilization.
Pain Management: Alleviation of pain is necessary for adequate ventilation in the patient by using narcotics. The patient administered 7.5 mg of IV morphine for the treatment of pain. It is also known as opioid (narcotic) analgesics. It works by changing the way the brain reacts to pain receptors (Wight, & King, 2014).
Oxygen therapy: Providing Oxygen therapy to maintain O2 stats to 96% or 99%. Lower O2 stats will lower the function of body cells. Thus, extra oxygen is provided to the patient to regulate proper cell functioning, followed by regular assessment of vital signs on fixed interval of time.
Electrolyte balance: Next the patient was delivered a litter of IV fluids which was prescribed to treat the patient’s sodium depletion or isotonic dehydration (extracellular). Intravenous fluids are the fastest way to restore body electrolytes as it is directly given into the veins (Interiano, 2012).
Nursing Interventions
Insertion of an IDC (Indwelling urinary catheter): It is used to evaluate the urological condition which includes the level of urinary output or any abnormalities related due to ongoing injury or medication and fluids given to the patient (Lim, & Sirichai, 2016).
Sitting in the high fowler’s position: Fowler’s position is the position when the head of the patient’s bed is elevated at 30, 45, and 90 degree, which are divided into different types of fowler’s position are low, standard, semi and high. In this case the patient was suggested to sit high fowler’s position body where the body lies between 60 to 90 degrees angle. The legs of the patient may be bent or straight in this position. It is used at the time of feeding the patient or radiology, grooming, or when the patient is facing breathing problems. The goal of this intervention is to maintain the proper circulation, avoid constriction, nerve damage, and avoiding pressure on the chest cavity. It helps the patient in proper chest expansion and oxygenation (Ellis, 2013).
The linking of interventions and pathophysiology is important for proper recovery and correct treatment of the patient. It also assists to know the unknown associated injury. Vital signs evaluation on regular interval of time is important to keep an eye on the disappearance patient symptoms (Lim, & Sirichai, 2016). The patient was provided with O2 therapy would help in the recovery of the patient’s fracture and increasing the oxygen saturation to 96% as the patient examination revealed low O2 stats secondary to the rib fracture. The patient was unable to take proper oxygen due to pain in his ribs which could be overcome by oxygen therapy, thereby helping in the recovery of oxygen levels of the body. Sitting in the high fowler’s position is essential for eliminating the problems of high respiration rate and shallow breathing in the patient due to second and fourth rib fractures. It will help in recovery of the vessel or intrathoracic damage in the patient. The patient can be prevented and treated for his pneumothorax or hemothorax caused by penetration of fractured rib pieces. The patient was administered 7.5 mg of IV morphine to assist in the alleviation of his left leg pain and chest pain by altering the way brain cell receptor response to the pain. Since, the femur is the strongest bone, which supports the body during an ambulatory motion and overcoming anxiety (Shah, 2015). The patient suffered internal vascular damage due to multiple trauma fractures resulted in electrolyte deficits in the patient’s body after fall and associated injuries which were treated by delivering a litter of IV fluids of 0.9% Sodium chloride. The electrolytic imbalance is attributed to breaking in the perpetuity of the blood vessels and capillaries (“Age-friendly nursing interventions in the management of older people in emergency departments,” 2012). Regaining back electrolytic balance will support in proper circulation of nutrient molecules and blood. The patient was inserted an Indwelling catheter to help in diagnosis of urological abnormalities such as incontinence or other. It is to determine any risk of urinary malfunction secondary to the femur fractures and its associated injuries (Ellis, 2013).
Conclusion
Conclusion
This clinical representation discussion report helped in learning of clinical nursing guidelines to be followed while treating ED fracture (trauma) patient. In this report nurse assists the patient Peter Bowman to treat and recover his injury after arriving in the emergency department after he sustained left femur fracture and second and fourth rib fractures secondary to fall. This report underlines the fact that how important is the understanding of the pathophysiology of the fractures or disease or injury for nurse for preparing a rational nursing care plan for early patient’s convalescence. The nurse should know the priorities or order of care plan prescribed to the patient in the ED and the role or detection of appropriate abnormal assessment. The above report emphasizes the need to for the nurse to understand the rationale and linking of a patient’s care with the patient’s symptoms. It elaborated the nursing management and guidelines to deal with patients having multiple fractures and will help in treating successive patients.
Reference
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