A fracture is a discontinuity or break in a bone. There are more than 150 fracture classifications. Five major ones are as follow:
1. Incomplete: Fracture involves only a portion of the cross-section of the bone. One side breaks; the other usually just bends (greenstick).
2. Complete: Fracture line involves entire cross-section of the bone, and bone fragments are usually displaced.
3. Closed: The fracture does not extend through the skin.
4. Open: Bone fragments extend through the muscle and skin, which is potentially infected.
5. Pathological: Fracture occurs in diseased bone (such as cancer, osteoporosis), with no or only minimal trauma.
Stable fractures are usually treated with casting. Unstable fractures that are unlikely to reduce may require surgical fixation.
CARE SETTING
Most fractures are managed at the community level. Although a number of the interventions listed here are appropriate for this population, this plan of care addresses more complicated injuries encountered on an inpatient acute medicalsurgical unit.
RELATED CONCERNS
Craniocerebral trauma (acute rehabilitative phase)
Pneumonia: microbial
Psychosocial aspects of care
Renal failure: acute
Spinal cord injury (acute rehabilitative phase)
Surgical intervention
Thrombophlebitis: deep vein thrombosis
Patient Assessment Database
Symptoms of fracture depend on the site, severity, type, and amount of damage to other structures.
ACTIVITY/REST
May report: Weakness, fatigue
Gait and/or mobility problems
May exhibit: Restricted/loss of function of affected part (may be immediate, because of the fracture, or develop secondarily from tissue swelling, pain)
Weakness (e.g., affected extremity or generalized)
CIRCULATION
May exhibit: Hypertension (occasionally seen as a response to acute pain/anxiety) or hypotension (severe blood loss)
Tachycardia (stress response, hypovolemia)
Pulse diminished/absent distal to injury in extremity
Delayed capillary refill, pallor of affected part
Tissue swelling, bruising, or hematoma mass at site of injury
ELIMINATION
May exhibit: Hematuria, sediment in urine, changes in output, acute renal failure (ARF) (with major skeletal muscle damage)
NEUROSENSORY
May report: Loss of/impaired motion or sensation
Muscle spasms, worsening over time
Numbness/tingling (paresthesias)
May exhibit: Local musculoskeletal deformities, e.g., abnormal angulation, posture changes, shortening of limbs, rotation, crepitation (grating sound with movement or touch), muscle spasms, visible weakness/loss of function
Giving way/collapse or locking of joints; dislocations
Agitation (may be related to pain/anxiety or other trauma)
Range-of-motion (ROM) deficits
PAIN/DISCOMFORT
May report: Sudden severe pain at the time of injury (may be localized to the area of tissue/skeletal damage and then become more diffuse; can diminish on immobilization); absence of pain suggests nerve damage
Muscle aching pain, spasms/cramping (after immobilization)
May exhibit: Guarding/distraction behaviors, restlessness
Self-focus
SAFETY
May report: Circumstances of incident that do not support type of injury incurred (suggestive of abuse)
May exhibit: Skin lacerations, tissue avulsion, bleeding, color changes
Localized swelling (may increase gradually or suddenly)
Use of alcohol or other drugs
Presence of fall-risk factors, e.g., age, osteoporosis, dementia, arthritis, other chronic conditions; preexisting (unrecognized) fracture
TEACHING/LEARNING
May report: Use of multiple medications (prescribed and over-the-counter [OTC]) with interactive effects
Discharge plan
DRG projected mean length of inpatient stay: femur 9.0 days; hip/pelvis, 6.7 days; all other, 2.5–5.0 if hospitalization required
May require temporary assistance with transportation, self-care activities, and homemaker/maintenance tasks
May require additional therapy/rehabilitation post discharge, or possible placement in assisted-living/extended-care facility for a period of time
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
X-ray examinations: Determines location and extent of fractures/trauma, may reveal preexisting and yet undiagnosed fracture(s).
Bone scans, tomograms, computed tomography (CT)/magnetic resonance imaging (MRI) scans: Visualizes fractures, bleeding, and soft-tissue damage; differentiates between stress/trauma fractures and bone neoplasms.
Arteriograms: May be done when occult vascular damage is suspected.
Complete blood count (CBC): Hematocrit (Hct) may be increased (hemoconcentration) or decreased (signifying hemorrhage at the fracture site or at distant organs in multiple trauma). Increased white blood cell (WBC) count is a normal stress response after trauma.
Urine creatinine (Cr) clearance: Muscle trauma increases load of Cr for renal clearance.
Coagulation profile: Alterations may occur because of blood loss, multiple transfusions, or liver injury.
NURSING PRIORITIES
1. Prevent further bone/tissue injury.
2. Alleviate pain.
3. Prevent complications.
4. Provide information about condition/prognosis and treatment needs.
DISCHARGE GOALS
1. Fracture stabilized.
2. Pain controlled.
3. Complications prevented/minimized.
4. Condition, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
1. Incomplete: Fracture involves only a portion of the cross-section of the bone. One side breaks; the other usually just bends (greenstick).
2. Complete: Fracture line involves entire cross-section of the bone, and bone fragments are usually displaced.
3. Closed: The fracture does not extend through the skin.
4. Open: Bone fragments extend through the muscle and skin, which is potentially infected.
5. Pathological: Fracture occurs in diseased bone (such as cancer, osteoporosis), with no or only minimal trauma.
Stable fractures are usually treated with casting. Unstable fractures that are unlikely to reduce may require surgical fixation.
CARE SETTING
Most fractures are managed at the community level. Although a number of the interventions listed here are appropriate for this population, this plan of care addresses more complicated injuries encountered on an inpatient acute medicalsurgical unit.
RELATED CONCERNS
Craniocerebral trauma (acute rehabilitative phase)
Pneumonia: microbial
Psychosocial aspects of care
Renal failure: acute
Spinal cord injury (acute rehabilitative phase)
Surgical intervention
Thrombophlebitis: deep vein thrombosis
Patient Assessment Database
Symptoms of fracture depend on the site, severity, type, and amount of damage to other structures.
ACTIVITY/REST
May report: Weakness, fatigue
Gait and/or mobility problems
May exhibit: Restricted/loss of function of affected part (may be immediate, because of the fracture, or develop secondarily from tissue swelling, pain)
Weakness (e.g., affected extremity or generalized)
CIRCULATION
May exhibit: Hypertension (occasionally seen as a response to acute pain/anxiety) or hypotension (severe blood loss)
Tachycardia (stress response, hypovolemia)
Pulse diminished/absent distal to injury in extremity
Delayed capillary refill, pallor of affected part
Tissue swelling, bruising, or hematoma mass at site of injury
ELIMINATION
May exhibit: Hematuria, sediment in urine, changes in output, acute renal failure (ARF) (with major skeletal muscle damage)
NEUROSENSORY
May report: Loss of/impaired motion or sensation
Muscle spasms, worsening over time
Numbness/tingling (paresthesias)
May exhibit: Local musculoskeletal deformities, e.g., abnormal angulation, posture changes, shortening of limbs, rotation, crepitation (grating sound with movement or touch), muscle spasms, visible weakness/loss of function
Giving way/collapse or locking of joints; dislocations
Agitation (may be related to pain/anxiety or other trauma)
Range-of-motion (ROM) deficits
PAIN/DISCOMFORT
May report: Sudden severe pain at the time of injury (may be localized to the area of tissue/skeletal damage and then become more diffuse; can diminish on immobilization); absence of pain suggests nerve damage
Muscle aching pain, spasms/cramping (after immobilization)
May exhibit: Guarding/distraction behaviors, restlessness
Self-focus
SAFETY
May report: Circumstances of incident that do not support type of injury incurred (suggestive of abuse)
May exhibit: Skin lacerations, tissue avulsion, bleeding, color changes
Localized swelling (may increase gradually or suddenly)
Use of alcohol or other drugs
Presence of fall-risk factors, e.g., age, osteoporosis, dementia, arthritis, other chronic conditions; preexisting (unrecognized) fracture
TEACHING/LEARNING
May report: Use of multiple medications (prescribed and over-the-counter [OTC]) with interactive effects
Discharge plan
DRG projected mean length of inpatient stay: femur 9.0 days; hip/pelvis, 6.7 days; all other, 2.5–5.0 if hospitalization required
May require temporary assistance with transportation, self-care activities, and homemaker/maintenance tasks
May require additional therapy/rehabilitation post discharge, or possible placement in assisted-living/extended-care facility for a period of time
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
X-ray examinations: Determines location and extent of fractures/trauma, may reveal preexisting and yet undiagnosed fracture(s).
Bone scans, tomograms, computed tomography (CT)/magnetic resonance imaging (MRI) scans: Visualizes fractures, bleeding, and soft-tissue damage; differentiates between stress/trauma fractures and bone neoplasms.
Arteriograms: May be done when occult vascular damage is suspected.
Complete blood count (CBC): Hematocrit (Hct) may be increased (hemoconcentration) or decreased (signifying hemorrhage at the fracture site or at distant organs in multiple trauma). Increased white blood cell (WBC) count is a normal stress response after trauma.
Urine creatinine (Cr) clearance: Muscle trauma increases load of Cr for renal clearance.
Coagulation profile: Alterations may occur because of blood loss, multiple transfusions, or liver injury.
NURSING PRIORITIES
1. Prevent further bone/tissue injury.
2. Alleviate pain.
3. Prevent complications.
4. Provide information about condition/prognosis and treatment needs.
DISCHARGE GOALS
1. Fracture stabilized.
2. Pain controlled.
3. Complications prevented/minimized.
4. Condition, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
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