Fractures are broken bones. Fractures can occur from trauma such as motor vehicle accidents or falls, age-related conditions like osteoporosis, or overuse such as stress fractures in athletes.
In this article:
- Types of Fractures
- Fracture Healing
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Impaired Physical Mobility
- Impaired Walking
- Ineffective Tissue Perfusion
- Risk For Constipation
Types of Fractures
Fractures are classified in several ways and may include the following:
- Open (compound) vs. Closed (simple): An open fracture penetrates through the skin, while a closed fracture does not.
- Displaced vs. Non-displaced: If the ends of the broken bone are misaligned, this is considered displaced. If the broken bone remains in alignment, it is non-displaced.
Fractures can also be classified by the pattern of break, such as:
- Greenstick: Frequently seen in children when the bone bends and cracks but does not break through completely.
- Comminuted: The bone is shattered in multiple places.
- Transverse: The break is in a straight line across the bone.
- Spiral: The fracture occurred in a spiral around the bone.
- Oblique: The break is diagonal.
- Compression: The bone is crushed.
- Hairline: Also known as a stress fracture, it is characterized by a small crack in the bone.
Fracture Healing
Fractures heal in three stages:
- Inflammatory stage: Inflammatory cells immediately migrate to the fracture site, and a hematoma forms to begin the framework for bone healing. This phase can last up to two weeks.
- Reparative stage: New fibrous tissue and cartilage form a soft callus to rejoin the bone ends. This phase takes 2-3 weeks.
- Remodeling stage: The soft callus undergoes mineralization and hardens. Osteoclasts absorb old bone tissue, while osteoblasts deposit new cells to form, strengthen, and shape new bones. This phase can take months or even years.
The rate at which a fracture heals depends on individual factors, such as age and health. Children heal from fractures faster than adults because their bones are covered in a protective connective tissue (periosteum) that quickly supplies blood to the area to heal damaged cells. The periosteum thins as we age, offering less support.
Nursing Process
Nurses may care for patients with fractures in many settings, such as emergency departments, urgent care centers, or inpatient units following surgical repairs. Fractures can be minor, only requiring splinting, or major, such as a hip, neck, or femur fracture, requiring surgery, inpatient care, and months of recovery. Nurses assist with pain control, physical rehabilitation, infection prevention, wound care, and discharge planning.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to fractures.
Review of Health History
1. Determine the nature of the injury.
Most often, traumas such as falls, car accidents, or sports injuries result in fractures. However, overuse or repetitive activities like running can contribute to certain fractures.
2. Assess the presence of pain.
A fracture often causes sudden pain due to damage in the nerves in that area. The patient may describe a sharp, stabbing pain that intensifies with pressure or movement of the bone. Ask the patient to rate the pain.
3. Identify the patient’s risk factors.
The following factors increase the risk of fractures:
- Advancing age
- History of fractures
- Low body weight
- Malnutrition
- Vitamin D deficiency
- Calcium deficiency
- Smoking
- Long-term alcohol use
- Female gender
- Sedentary lifestyle
4. Review the patient’s medical history.
The following medical conditions increase the risk of fractures:
- Osteoporosis
- Arthritis
- Cancer
- Paget’s disease
- Chronic kidney failure
- Thyroid disorders
- Diabetes
- Gastrointestinal disorders that disrupt nutrient absorption
5. Review the medication list.
Certain drugs may impact bone health:
- Corticosteroids are the most well-known medication for contributing to bone loss.
- Long-term use of selective serotonin reuptake inhibitors (SSRIs) may weaken bones.
- Proton pump inhibitors may disrupt the absorption of calcium.
- Some antidiabetic medications are associated with an increased risk of fractures.
- Antiseizure drugs can disrupt how our bodies process vitamin D.
- Hormonal drugs that lower testosterone or estrogen increase the risk of osteoporosis.
6. Track the surgical history.
It is especially important to review for a history of orthopedic procedures that will offer insight into past fractures, implanted rods or pins, or joint replacements.
7. Note the patient’s occupational history.
Occupations that include manual labor, such as construction, utilizing heavy machinery, or mining, are at a higher risk for injuries or falls resulting in fractures. The nurse may need to educate the patient on safety precautions.
Physical Assessment
1. Conduct a physical examination.
Fractures sometimes cause obvious deformities, or in the case of an open fracture, the bone protrudes through the skin. Severe swelling around a joint, bruising or discoloration, and the inability to bear weight or move the joint are additional signs of fractures.
2. Assess the neurovascular status of the affected area.
The nurse should assess the neurovascular status surrounding the injured area by palpating peripheral pulses, assessing capillary refill, monitoring skin temperature and color, and testing motor function.
3. Monitor for compartment syndrome.
Compartment syndrome is a serious complication of fractures that can result in permanent nerve damage if not recognized and treated. The nurse should remain aware of pain that is disproportionate to the injury, reports of numbness or tingling, and the presence of “wood-like” tension in the muscle.
Diagnostic Procedures
1. Anticipate an X-ray.
An X-ray will confirm a fracture and identify the extent of the injury.
2. Consider further testing.
The following tests can provide a more detailed picture of the fracture and the surrounding tissue compared to an X-ray.
- Magnetic resonance imaging (MRI) can assess for damage beyond bone, including ligaments or cartilage.
- A CT scan offers detailed imaging of muscles and organs in the area.
- A bone scan uses a radioactive tracer injected into the body to highlight bone abnormalities, including fractures, tumors, or infections.
3. Recommend bone density testing.
Patients at risk for fractures or with a history of fractures should receive bone mineral density (BMD) testing via a DEXA scan to assess bone strength.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions related to fractures.
1. Assess the ABCs of life.
Since many fractures occur as a result of a traumatic injury, prioritize airway, breathing, and circulation. Once the patient is stabilized, the nurse can focus on treating the fracture.
2. Manage any bleeding.
Assess the presence of active bleeding. Stop the bleeding by applying pressure to the fracture site using a clean bandage for immediate first aid. Prevent shock by positioning the patient in a Trendelenburg position (supine position with the head lowered and legs elevated).
3. Immobilize the fractured area.
Repositioning an out-of-place bone or attempting to realign it is not recommended. Splint the area above and below the fracture. For a non-displaced fracture, a splint, brace, or walking boot may be the only necessary intervention to allow the bone to heal.
4. Apply ice.
Use cold packs to reduce swelling and ease pain. Limit ice application to 20 minutes at a time.
5. Promote rest and educate on activity restrictions.
The patient should be instructed to rest and prevent bearing weight or using the extremity in the immediate recovery phase. Activity restrictions are dependent on the degree of injury and treatment required.
6. Relieve the pain.
Over-the-counter pain medications such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) reduce swelling and relieve discomfort. In the inpatient setting, the nurse may administer narcotics for severe pain and prior to/following surgery.
7. Elevate the affected area.
Elevate the fractured limb above the level of the heart with pillows to facilitate venous return.
8. Instruct on assistive devices.
Teach the patient how to use prescribed assistive devices such as crutches or a sling.
9. Apply traction.
The nurse may be responsible for implementing traction, which is a system of pulleys and weights that assist in realigning bones. This can be used before or after surgery.
10. Prepare the patient for possible surgery.
Surgery may be needed to realign the bone, replace a damaged joint with a prosthesis (arthroplasty), perform bone grafting, or insert rods, plates, screws, or pins.
11. Monitor incisions and perform wound care.
Following surgery, the nurse will need to monitor incisions closely for signs of infection (erythema, warmth, drainage), keep the incision clean and dry, and change dressings as ordered.
12. Refer the patient to a dietitian.
A dietitian can provide proper nutrition counseling, especially if the patient’s fracture is due to weakening of bones, malnutrition, and vitamin deficiency.
13. Educate on cast care.
The patient with a fracture may receive a cast to immobilize the bone for weeks or months. Educate the patient to keep the cast dry (cover with a plastic bag during showers or baths), not to stick anything inside the cast, and alert the provider to increasing pain, tightness, burning, or inability to move fingers/toes.
14. Refer the patient to physical or occupational therapy.
Physical or occupational therapy may be necessary for some patients to rebuild their strength and function.
15. Educate on strategies to prevent fractures.
Not all fractures can be prevented, such as with a motor vehicle accident, but older adults or those with osteoporosis can reduce their risk through the following methods:
- Removing fall hazards in the home
- Utilizing canes or walkers if needed
- Supplementing with vitamin D and calcium
- Participating in regular physical activity
Nursing Care Plans
Once the nurse identifies nursing diagnoses for a fracture, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for fractures.
Acute Pain
Acute pain with a fracture results from injury to the surrounding tissues, muscles, and nerves.
Nursing Diagnosis: Acute Pain
Related to:
- Bone displacement
- Compromised tissue
- Muscle spasms
- Edema
As evidenced by:
- Verbalization of pain
- Guarding behavior
- Facial grimacing or crying
- Diaphoresis
- Restlessness
- Distracted behavior
- Tachypnea, tachycardia, and increased blood pressure
Expected outcomes:
- Patient will report pain of 2/10 or less by discharge.
- Patient will display signs of comfort as evidenced by resting with eyes closed and vital signs within normal limits.
- Patient will utilize nonpharmacologic pain relief measures.
Assessment:
1. Assess for pain.
Using appropriate pain scales based on age and cognitive level (numeric, Wong-Baker FACES, FLACC) assess the severity of pain. The nurse should also assess the location, characteristics, and frequency of pain.
2. Monitor vital signs.
An elevated blood pressure and heart rate is a normal response to pain. These vital signs should improve once appropriate pain measures are instituted.
3. Assess pain relief.
After administering pain medications, the nurse should follow up within an hour to assess the effectiveness of medications or interventions.
Interventions:
1. Administer analgesics.
Acute fractures usually warrant narcotic pain relief which may be oral or IV. NSAIDs such as Ibuprofen or Naproxen treat inflammation and are often given in conjunction with narcotics.
2. Provide alternative comfort measures.
Patients should not rely solely on medication. Implement alternative measures that alleviate the patient’s pain such as ice packs, heat, massage, distraction, and controlled breathing.
3. Support the injured area.
A fractured extremity should remain elevated to reduce swelling. Utilize splints or traction devices as ordered. Immobilize the fractured area and follow weight-bearing instructions to promote healing.
4. Instruct on medications at discharge.
Patients should be instructed to not take pain medications more frequently than prescribed. If the dose ordered is not controlling their pain they should contact their provider. Instruct on other precautions with narcotics such as not operating vehicles, and possible side effects such as drowsiness, dizziness, nausea, and constipation.
Impaired Physical Mobility
Fractures impair the ability to ambulate, complete ADLs, and increase the risk of falls and other injuries.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Loss of integrity of bone structure
- Pain
- Prescribed activity restrictions
- Reluctance to initiate movement
- Deconditioning
As evidenced by:
- Reports of pain
- Unwillingness to move
- Limited ROM
- Decreased muscle strength
Expected outcomes:
- Patient will increase ambulation distance and participation in ADLs as tolerated.
- Patient will demonstrate techniques to support movement.
- Patient will remain free from falls or injury while ambulating.
Assessment:
1. Assess the degree of physical limitation.
Physical immobility will depend on the location and severity of the fracture as well as pain and swelling. Interventions will be determined based on what the patient can and cannot do for themselves
2. Assess for pain or other psychological concerns.
Pain and discomfort will prevent the patient from moving. Depression and anxiety may also prevent purposeful movement. Delays in movement will only further exacerbate pain and may lead to contractures and loss of muscle strength and tone.
3. Assess for a support system.
At discharge, the patient’s mobility will dictate further needs. If the patient does not have capable caregivers then they may require a short-term stay at a rehabilitation facility or in-home care.
Interventions:
1. Encourage independence.
The patient should be encouraged to do as much for themselves as possible. Even patients confined to a bed can assist with turning themselves and should be encouraged to perform ADLs such as feeding or washing their face if possible.
2. Premedicate before movement.
The nurse should anticipate pain and premedicate before potentially painful activities such as PT sessions or complete bed baths. This will help relax the patient and improve their ability to perform exercises.
3. Collaborate with PT/OT.
Hip fractures, spinal fractures, or other serious fractures may require PT or OT to assist with safe movement. These specialists can teach patients how to use canes, crutches, and other devices as well as instruct on exercises to strengthen muscles.
4. Encourage the use of assistive devices and equipment.
Any equipment that will support safe movement such as bedside commodes, grab bars, walkers, or scooters should be utilized.
Impaired Walking
Fractures occurring in the lower extremities can cause impaired mobilization and decreased physical function, making it difficult for the patient to ambulate.
Nursing Diagnosis: Impaired Walking
Related to:
- Pain
- Fracture
- Fear of falling
- Physical deconditioning
- Insufficient muscle strength
- Poor knowledge of mobility strategies
As evidenced by:
- Difficulty ambulating on an incline/decline
- Difficulty ambulating a required distance
- Difficulty ambulating on an uneven surface
- Difficulty navigating curbs
- Difficulty climbing stairs
Expected outcomes:
- Patient will demonstrate independent walking.
- Patient will demonstrate safe ambulation using assistive devices as needed.
Assessment:
1. Assess the patient’s extent of immobility.
Patients with severe lower extremity fractures may require rehabilitation before walking is possible. In older adults, the nurse may obtain a baseline level of mobility to prepare appropriate interventions.
2. Assess the patient’s pain.
Pain in patients with fractures is a contributing factor to the patient’s motivation to walk.
3. Assess barriers that contribute to the patient’s ability to walk.
If the fracture occurred due to a fall, the patient may be hesitant to walk. This is especially true in older adults with poor balance or other barriers such as vision or hearing problems.
Interventions:
1. Encourage progressive mobilization.
Ensure early ambulation when allowed and gradually increase mobility, such as sitting on the edge of the bed, transferring to a chair, and then standing and eventually walking.
2. Assist in providing range of motion exercises.
Exercise is essential to prevent deconditioning, increase circulation, and preserve joint and muscle function.
3. Premedicate before walking.
Patients in pain may require an analgesic before participating in physical therapy or walking. Keep in mind that some medications, like narcotics, can cause drowsiness, dizziness, and orthostatic hypotension, which increase the risk of falls.
4. Encourage the use of assistive devices for ambulation.
The use of walkers and crutches can help with the ambulation of patients with fractures. In the inpatient setting, the nurse may utilize a gait belt to aid the patient in walking and prevent falls.
Ineffective Tissue Perfusion
Fractures can disrupt tissue perfusion if damage occurs to blood vessels or complications arise that affect blood flow and tissue oxygenation.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Vascular damage
- Bone displacement
- Compartment syndrome
- Delayed healing/non-union of fracture
- Bleeding
- Thrombosis
- Ischemia
- Infection
As evidenced by:
- Absent or decreased peripheral pulses
- Impaired motor function
- Edema
- Pallor
- Extreme pain
- Paresthesia
Expected outcomes:
- Patient will demonstrate adequate tissue perfusion as evidenced by palpable pulses and skin temperature and color within normal parameters.
- Patient will verbalize signs of delayed wound healing and complications that require immediate evaluation.
Assessment:
1. Assess and monitor pulses at the fracture site.
Diminished or absent pulses indicate ineffective tissue perfusion, which can lead to ischemia. This finding requires immediate evaluation and intervention.
2. Assess skin characteristics at the fractured site.
Initial swelling and bruising at the fracture site are expected. Continue to monitor for pallor, changes in skin temperature, or worsening swelling that indicates a potential complication.
3. Monitor for complications.
Serious complications of fractures related to ineffective tissue perfusion may include internal or external bleeding, compartment syndrome, or thromboembolism. The nurse should monitor for signs of shock, neurovascular changes, and unusual swelling, discoloration, or warmth to the extremities.
Interventions:
1. Assist in surgical intervention or splinting.
Surgical intervention is often indicated to help with realigning fractured bones with the use of rods, plates, or pins. For mild fractures, splints or braces may be adequate. The goal is to realign the bones, allowing blood vessels and osteoblasts to form new bone growth.
2. Inspect the cast and affected extremity frequently.
If a cast is applied, frequently monitor for paresthesia, edema, or poor motor function that can indicate pressure on the nerves and muscles, compromising tissue perfusion.
3. Elevate the affected extremity unless contraindicated.
Elevating the fractured site can help promote venous return and perfusion and reduce swelling.
4. Administer an anticoagulant.
If the patient sustained a lower extremity fracture, compression sleeves will be contraindicated to prevent venous thromboembolism. If the patient is immobilized or physical movement is limited, an oral or injected anticoagulant may be prescribed to prevent DVT.
5. Encourage smoking cessation.
Smoking constricts blood vessels and limits blood flow, which can have a negative impact on the bone healing process.
Risk For Constipation
Opioids used for pain will cause constipation as they slow down gastric emptying and peristalsis. Untreated constipation can have uncomfortable and serious consequences.
Nursing Diagnosis: Risk For Constipation
Related to:
- Immobility
- Opioid use
- Change in eating pattern
- Insufficient fluid intake
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred, and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- Patient will have a solid bowel movement at least every 3 days.
- Patient will report no straining or discomfort with defecation.
- Patient will implement 2 measures to prevent constipation.
Assessment:
1. Auscultate bowel sounds.
Assess for the presence, location, and characteristics of bowel sounds.
2. Assess the patient’s normal bowel pattern.
Not everyone has a bowel movement daily. Bowel movements every 2-3 days are considered normal as long as the patient is not experiencing discomfort.
Interventions:
1. Administer stool softeners or laxatives.
The most common side effect of opioid medications is constipation. When prescribed these medications a stool softener should be used prophylactically in conjunction. For severe constipation, enemas may be required.
2. Educate on the risk and prevention of constipation.
Educate that patient that constipation is increased due to their immobility and use of opioids (if taking). Stool softeners should be taken before constipation occurs to prevent impaction or serious complications such as a bowel obstruction.
3. Increase fluids.
Fluids keep stools soft and easier to pass. Patients should drink plenty of water (if not contraindicated) as well as juices such as prune juice. Hot beverages like tea also stimulate bowel movements.
4. Increase mobility as tolerated.
Immobility from fractures can also slow down peristalsis. While the patient must first follow activity instructions, once the patient may safely ambulate or exercise, this should be encouraged.
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