A CASE STUDY OF A PATIENT WITH COMMINUTED FRACTURE CLOSED DISTAL THIRD FEMUR

A Case Study Presented to the Faculty of the College of Nursing Cebu Normal University

In Partial Fulfillment of the Requirements in Medical-Surgical Nursing (NCM 105)

By Macayan, Jellou Ray M.

October 2011

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ACKNOWLEDGEMENT

I would like to express my heartfelt gratitude to all those who helped me in making this case study a possibility. First of all I would like to thank the almighty God for giving me the strength and courage to complete this research even when faced with challenges, boredom and indiscretions. To Miss Bertilia F. Pragados for giving me the permission to make this case in the first instance, to do the necessary research work and for the constant reminders and pointers you have given me for this studythank you mam! Also I would also like to extend my sincere thanks to Miss Elaiza R. Cabunoc of the Vicente Sotto Memorial Medical Center Radiology Department for the kind accommodation and for allowing me to recover patients diagnostic files. I would also like to take this opportunity to thank my fellow researcher Miss Emy Jane Pilapil, Cherish Cyrill, Oraiz and Miss Sonia Rufa Singson and Miss Cybelle Caramba whose help, stimulating suggestions and encouragement inspired me in all the time of research for and writing of this case study and mostly for the company upon gathering relevant information for the study. I am also deeply indebted to my co-researcher Miss Alona Minque who looked closely at the final version of the case study for English style and grammar, correcting both and offering suggestions for improvement. And most especially, I would like to give my special thanks to my family whose patient love enabled me to complete this work.

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TABLE OF CONTENTS Page Title Page--------------------------------------------------------------------------------------------------------- i Acknowledgement --------------------------------------------------------------------------------------------- ii Table of Contents ---------------------------------------------------------------------------------------------- iii List of Figures --------------------------------------------------------------------------------------------------- v Chapter 1 Introduction ------------------------------------------------------------------------------------- 1 Chapter 2 - Patients Profile Background/History --------------------------------------------------------------------------------- 3 Patients Vitae ---------------------------------------------------------------------------------------- 4 Functional Health Patterns ------------------------------------------------------------------------ 4 Physical Assessment ------------------------------------------------------------------------------- 5 Chapter 3 - Anatomy and Physiology --------------------------------------------------------------------- 8 Chapter 4 - Psychopathophysiology Schematic Diagram -------------------------------------------------------------------------------- 15 Narrative ---------------------------------------------------------------------------------------------- 16 Chapter 5 - Management Medical Laboratory Procedures ---------------------------------------------------------------- 18 Diagnostic Procedures ---------------------------------------------------------------- 19 Drug Study ------------------------------------------------------------------------------- 21 Surgical ----------------------------------------------------------------------------------------------- 21 Nursing Summary of Nursing Problems --------------------------------------------------- 22 Individualized Nursing Care Plan -------------------------------------------------- 22 FDAR Charting ------------------------------------------------------------------------- 25 Discharge Summary with Collaborative Nursing Function ------------------- 25

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Chapter 6 - Evaluation and Recommendation ------------------------------------------------------- 29 Bibliography ------------------------------------------------------------------------------------------------------ 31 Appendices ------------------------------------------------------------------------------------------------------- 32 APPENDIX A (Physical assessment) ----------------------------------------------------------- 33 APPENDIX B (Hematologic studies) ------------------------------------------------------------ 39 APPENDIX C (Urinalysis) -------------------------------------------------------------------------- 41 APPENDIX D (Coagulation Profile) ------------------------------------------------------------- 42 APPENDIX E (X-ray Report) ---------------------------------------------------------------------- 43 APPENDIX F (Drug Studycelecoxib) --------------------------------------------------------- 45 APPENDIX G (Drug Studytramadol) --------------------------------------------------------- 46 APPENDIX H (Drug Studycefuroxime) ------------------------------------------------------ 47 APPENDIX I (NCP day 1) ------------------------------------------------------------------------- 48 APPENDIX J (NCP day 2) ------------------------------------------------------------------------ 51 APPENDIX K (NCP day 3) ----------------------------------------------------------------------- 53 APPENDIX L (FDAR day 1) ---------------------------------------------------------------------- 55 APPENDIX M (FDAR day 2) --------------------------------------------------------------------- 56 APPENDIX N (FDAR day 3) ---------------------------------------------------------------------- 57 APPENDIX O (Approval for Case Study) ----------------------------------------------------- 58 APPENDIX P (Approval for Final Printing and Book Binding of Case Study) ------- 59 Curriculum Vitae ----------------------------------------------------------------------------------------------- 60

LIST OF FIGURES Page Figure 1 - Upper extremity of right femur viewed from behind and above ------------------------- 8 Figure 2 - Right femur. Anterior surface --------------------------------------------------------------------10 Figure 3 - Right femur. Posterior surface ------------------------------------------------------------------ 12 Figure 4 - Pathophysiology of fracture (schematic diagram) ------------------------------------------ 15

CHAPTER I INTRODUCTION Being broken opens the door to a possibility--change. When you get hurt and broken inside, you try to heal yourself to be the same old person. But you really cant be that same person anymore. A part of you has changed. A broken bone is like a part of self that you knew is the same but just cant recognize anymore. Its still the same bone. Yet, during the process of healing, it seems to change. A fracture is a break in the continuity of bone and is defined according to its type and extent. 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 (Brunners and Suddarths 2004). 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 non displaced. Such as greenstick fracture, depressed fracture, oblique fracture, avulsion, spinal fracture, impacted fracture, transverse fracture and compression fracture. A comminuted fracture is one that produces several bone fragments and a closed fracture or simple fracture is one that does not cause a break in the skin. Comminuted fracture at the Right Distal Third Femur is a fracture in which bones of the distal portion of the femur has splintered to several fragment. The patient would then experience tremendous pain at the site of

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the fracture, swelling around the area and it may become warm to the touch. Typically the patient cannot bear any weight on the fracture without experiencing significant pain. Femur fracture affects almost 13 million Americans, and one of the leading fractures in the Philippines making it the most common form of fracture. The incidence of femoral fractures is reported as 1-1.33 fractures per 10,000 population per year (1 case per 10,000 population). In Vicente Sotto Memorial Medical Center, there are total of 56 patients out of 94 are diagnosed with femoral fracture within the duration of care, the estimated incidence rate in the said institution is about 60%. In individuals younger than 25 years and those older than 65 years, the rate of femoral fractures is 3 fractures per 10,000 populations annually. The incidence of femoral injuries and fractures increases in elderly patients. Primarily, this case was chosen because of its rapidly increasing incidence in the locality, most cases in the Orthopedic Ward Vicente Sotto Memorial Medical Center involves fracture in the femoral bones and it is inevitable for us nurses to care for these type of patient. It is very important for the nurses nowadays to be adequately informed regarding the knowledge and skill in managing these conditions, Through the knowledge of this condition, a high quality of care will be provided to those people is suffering from symptoms and complications of fracture. Generally, the purpose of this study is to generate knowledge about fracture and how it affects a person physiologically, emotionally, psychologically and spiritually. Moreover, this case study aims to: (a) gather information about clients past and present condition: (b) assess predisposing and precipitating factors that caused such disease condition; (c) determine anatomic and physiologic functions that contributes to the disease; (d) know the Pathophysiology of the clients condition; (e) determine medical and surgical interventions base on clients assessment and laboratory results; (f) and also identify appropriate nursing interventions to promote wellness for the patient.

CHAPTER II I. Background/History

History of Present Illness Few hours prior to admission, around 1 pm while driving a motorbike on the way home, the patient was outbalanced while turning due to darkness of the way and because of drunkenness, the patient sustained injury in right thigh, had multiple abrasions on anterior and posterior lower extremity, tenderness on the right leg prompted patient to consult Vicente Sotto Memorial Medical Center Emergency Room for medical advice and decided to admit for medical intervention and surgical operation. He was admitted on Ward 8 (Orthopedic ward) last July 6, 2011, around 11:03 pm under the care of Dr. Dominic Vicua, He has a chief complaint of Vehicular accident with an admitting diagnosis of Fractured Closed Distal Third Femur Right Comminuted. Physical assessment revealed the following findings, (+) pain on right foot radiating upward, multiple abrasions and hematoma on right lower extremity, limitation of movement noted and has the following vital signs; Temperature (36.7C), Pulse rate (62 bpm), Respiratory rate (21 cpm), Blood Pressure (130/90 mm Hg). Laboratory procedures done to the patient are Urinalysis and Complete Blood Count, Diagnostic procedures done were X-ray Skull APL, Cervical Spine APL, Chest PA, Right Hand APLO, Pelvis AP, Right Thigh APL and right Knee APL. Medication given is Celecoxib 200 mg PRN for pain. History of Past Illness The patient hasnt been hospitalized before and claims to undergo wound suturing due to another vehicular accident in Carajay District Hospital year 2001, Claims to have a family history of Hypertension and Diabetes Mellitus on paternal side, No known food and drug allergies, (-)

smoking, (+) alcohol, (+) drugs, usually eats Rice, Fish, Vegetables, Beef And Pork, not involved in any social activity, sleeps at 10 pm and wakes at 7 am, sexually active (3x weekly). I. Patients Vitae Mr. T.B.M, 32 years old, Male, Married, Currently residing in Carajay, Lapu-Lapu City, Cebu with wife and 3 children (2 boys and a girl), Born on October 23, 1978 in Carajay, LapuLapu City, Roman Catholic, Filipino, Worked at City hall resigned after election, currently unemployed and sells chicken, Graduated Associate Criminology can speak Tagalog and Cebuano, weighs 79 kilograms and has a height of 5 feet and 5 inches. II. Functional Health Patterns Patient was observed to be compliant with medication regimen, use of health-promotion activities such as regular exercise (Passive and active ROM exercises), Patient understood the purpose of medical intervention and surgical operation such as placement of traction as evidenced by keeping affected part immobilized as possible and minimizing movement and for nutritional and metabolic, the patient has no food restrictions, typical daily food intake includes Rice, Fish, Vegetables, Beef And Pork, no swallowing difficulties, Patient states to minimize eating as possible to minimize discomfort and inconvenience during bowel movement, skin lesions on right posterior leg noted, weight is 76 kg and height is 55ft, abdominal assessment reveals distension, noted 5 gurgles upon checking bowel sounds, no dehydration noted, for elimination the patients bowel movement is once every 2 days, he able to defecate without difficulty, constipation noted, dark brown hard stools noted, urination is 6-8 times daily, no pain upon urination noted, slightly cloudy, yellow colored urine noted. The Patient is unable to ambulate due to leg fracture, does passive ROM exercise on unaffected foot with wife and active ROM exercise on upper extremities, patient is unable to do some ADLs due restriction of mobility but constantly repositions itself on bed as instructed by nurse or wife. Patient usually sleeps at 910 pm and wakes at 6 am, patient states some discomfort during sleeping in the hospital which caused by light, pain, noise and constant vital signs monitoring. Patient is able to rest every after

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meal since the patient is on bed always. Patient is able understand and follow directions, retain information, make decisions, and solves problems as evidenced by taking medications religiously on indicated time on his own, Able to taste appropriately when food is given, no hearing difficulty, able to read newsprints, able to smell appropriately. Patient feels bad about self and blames himself in the accident, patient frequently becomes angry and annoyed about the restrictions and limitation in his activities. Patient is able to maintain eye contact, is assertive and has long attention span, able to communicate cooperatively with nurse. Patient acknowledges being a husband and father of 3 children, lives with family and interacts with family member appropriately, states that income is sufficient for their family needs, is not involved with any social groups but has close relationship with neighbors. Development of sexual characteristics are appropriate with age, patient states he is sexually active (3x weekly) and has no difficulty having sex, doesnt use any contraception. Patient states that he drinks alcohol most of the time and takes drugs (not specified) when he is stressed, states that his family is always with him when he has problem and it really helped him to handle stress appropriately. Patient is Roman Catholic and states that keeping spirituality within the family is important and enforced in his family. Goes to church every Sunday with family. III. Physical Assessment Head is normocephalic, symmetric, round, erect, midline with incision on parietal area, no involuntary movement noted, Facial features are symmetrical, temporal artery elastic and non tender, anicteric sclera, pupils are midline with each eyeballs, pale conjunctiva, eye movement symmetric and smooth in 6 directions, Ears are normal in size bilaterally 4 cm, both are aligned with inner canthus of the eye, no discharges, tenderness or lesions noted, lips are dry and pale, complete set of teeth noted, no dysphagia or ulcerations noted on oral cavity, lymph nodes are non tender and movable. Respiratory rate is 21 cycles per minute with normal depths, no nasal flaring, use of accessory muscles noted, no adventitious sounds are auscultated, bronchial sounds heard on trachea and thorax, Bronchovesicular sounds heard over the major bronchi and around the upper sternum, Vesicular sounds heard at peripheral lung fields. Chest expansion of 5 cm bilaterally noted. Systolic blood pressure of 130 and diastolic blood pressure of 90 noted

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bilaterally while lying. Apical pulse is regular with a rate of 66 beats per minute, pedal pulses is regular and bilaterally equal with a rate of 66 beats minute, no neck vein distension noted. Anterior chest is uniform in color with smooth texture no edema, tenderness, discoloration or nodules palpated, the ratio of anteroposterior diameter to transverse diameter is 2:1, scapula are non protruding, spinous process appear straight and thorax appears symmetric with ribs sloping downward, breast are symmetrical, not engorged or enlarged, nipples are dark brown and equal in size bilaterally. Abdomen is symmetric and slightly rounded with a large tattoo on midline, umbilical skin tones are similar to surrounding abdominal skin tones, umbilicus is midline at lateral line, bowel sounds are heard as intermittent, soft clicks and gurgles at a rate of 5 per minute, slightly rigid due to decreased bowel movement, no tenderness noted. Bladder is not palpable when not full, dull thud heard upon percussion of full bladder, urinates daily with a rate of 6-8 times approximately 700cc per day, urine color is yellow with a consistency of slightly cloudy. Joint are non tender, no swelling or bulging of fluid, knees symmetric, hollows present on both sides of the patella, lower leg aligned with upper leg. Full range of motion on upper extremity and marked limitation of range of motion on lower extremity. Facial movements are symmetrical, smiles, frowns, puff out cheeks, wrinkles forehead and shows teeth without difficulty, has full control on movements upper extremity while limited on lower extremity, sensory functions are equal on both sides, balance is not assessed due to mobility restrictions, patient is able to perform finger to nose test, reflexes are hypoactive on upper extremities (+). Able to identify the scent presented on each nostril. Able to read newsprint 14 inches away with full visual fields. Eyelid covers 2mm of the iris, eyes move in a smooth coordinated motion, pupils are both reactive and responsive to light accommodation. Eyes move in a smooth coordinated motion in an upward and downward motion. Reflection of light on the corneas are in the same spot indicating parallel alignment approximately 3mm from inner canthus, temporal and masseter muscles contact bilaterally. Lateral movements of eyeballs are smooth and in coordinated motion. Facial movements are symmetrical, smiles, frowns, puff out cheeks, wrinkles forehead and shows teeth without difficulty, movements are symmetrical, able to identify sweet and salty flavor. Able to hear whispered voice 1 meter away with both ears. Gag reflex is intact, able to identify sour and

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bitter taste Uvula and soft palate rise bilaterally on phonation, no hoarseness of voice noted. Strong and symmetric contractions of Trapezius muscle and there is strong contraction of Sternocleidomastoid muscle on the side opposite the turned face upon turning against resistance. Tongue movement is symmetric and smooth and bilateral strength is apparent.

CHAPTER III

FIGURE 1. Upper extremity of right femur viewed from behind and above. The femur, or thigh bone, is the only bone in the thigh. It is the heaviest, strongest bone in the body. Its proximal end has a ball-like head, a neck, and greater and lesser trochanters (separated anteriorly by the intertrochanteric line and posteriorly by the intertrochanteric crest). The trochanters, intertrochanteric crest and the gluteal tuberosity, located on the shaft, all serve us sites for muscle attachment. The head which is globular and forms rather more than a hemisphere, is directed upward, medialward, and a little forward, the greater part of its convexity being above and in front. Its surface is smooth, coated with cartilage in the fresh state, except over an ovoid depression, the fovea capitis femoris, which is situated a little below and behind the center of the head, and gives attachment to the ligamentum teres. The neck is a flattened pyramidal process of bone, connecting the head with the body, and forming with the latter a wide angle opening medialward. The angle is widest in infancy, and

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becomes lessened during growth, so that at puberty it forms a gentle curve from the axis of the body of the bone. In the adult, the neck forms an angle of about 125 with the body, but this varies in inverse proportion to the development of the pelvis and the stature. In the female, in consequence of the increased width of the pelvis, the neck of the femur forms more nearly a right angle with the body than it does in the male. The angle decreases during the period of growth, but after full growth has been attained it does not usually undergo any change, even in old age; it varies considerably in different persons of the same age. It is smaller in short than in long bones, and when the pelvis is wide. In addition to projecting upward and medialward from the body of the femur, the neck also projects somewhat forward; the amount of this forward projection is extremely variable, but on an average is from 12 to 14. The neck is flattened from before backward, contracted in the middle, and broader laterally than medially. The vertical diameter of the lateral half is increased by the obliquity of the lower edge, which slopes downward to join the body at the level of the lesser trochanter, so that it measures one-third more than the antero-posterior diameter. The medial half is smaller and of a more circular shape. The anterior surface of the neck is perforated by numerous vascular foramina. Along the upper part of the line of junction of the anterior surface with the head is a shallow groove, best marked in elderly subjects; this groove lodges the orbicular fibers of the capsule of the hip-joint. The posterior surface is smooth, and is broader and more concave than the anterior: the posterior part of the capsule of the hip-joint is attached to it about 1 cm. above the intertrochanteric crest. The superior border is short and thick, and ends laterally at the greater trochanter; its surface is perforated by large foramina. The inferior border, long and narrow, curves a little backward, to end at the lesser trochanter. The trochanters are prominent processes which afford leverage to the muscles that rotate the thigh on its axis. They are two in number, the greater and the lesser.

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FIGURE 2. Right femur. Anterior surface. The Greater Trochanter (trochanter major; great trochanter) is a large, irregular, quadrilateral eminence, situated at the junction of the neck with the upper part of the body. It is directed a little lateralward and backward, and, in the adult, is about 1 cm. lower than the head. It has two surfaces and four borders. The lateral surface, quadrilateral in form, is broad, rough, convex, and marked by a diagonal impression, which extends from the postero-superior to the antero-inferior angle, and serves for the insertion of the tendon of the Glutus medius. Above the impression is a triangular surface, sometimes rough for part of the tendon of the same muscle, sometimes smooth for the interposition of a bursa between the tendon and the bone. Below and behind the diagonal impression is a smooth, triangular surface, over which the tendon of the Glutus maximus plays, a bursa being interposed. The medial surface, of much less extent than the lateral, presents at its base a deep depression, the trochanteric fossa (digital fossa), for the insertion of the tendon of the Obturator externus, and above and in front of this an impression for the insertion of the Obsturator internus and Gemelli. The superior border is free; it is thick and

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irregular, and marked near the center by an impression for the insertion of the Piriformis. The inferior border corresponds to the line of junction of the base of the trochanter with the lateral surface of the body; it is marked by a rough, prominent, slightly curved ridge, which gives origin to the upper part of the Vastus lateralis. The anterior border is prominent and somewhat irregular; it affords insertion at its lateral part to the Glutus minimus. The posterior border is very prominent and appears as a free, rounded edge, which bounds the back part of the trochanteric fossa. The Lesser Trochanter (trochanter minor; small trochanter) is a conical eminence, which varies in size in different subjects; it projects from the lower and back part of the base of the neck. From its apex three well-marked borders extend; two of these are abovea medial continuous with the lower border of the neck, a lateral with the intertrochanteric crest; the inferior border is continuous with the middle division of the linea aspera. The summit of the trochanter is rough, and gives insertion to the tendon of the Psoas major. A prominence, of variable size, occurs at the junction of the upper part of the neck with the greater trochanter, and is called the tubercle of the femur; it is the point of meeting of five muscles: the Glutus minimus laterally, the Vastus lateralis below, and the tendon of the Obturator internus and two Gemelli above. Running obliquely downward and medialward from the tubercle is the intertrochanteric line (spiral line of the femur); it winds around the medial side of the body of the bone, below the lesser trochanter, and ends about 5 cm. below this eminence in the linea aspera. Its upper half is rough, and affords attachment to the iliofemoral ligament of the hip-joint; its lower half is less prominent, and gives origin to the upper part of the Vastus medialis. Running obliquely downward and medialward from the summit of the greater trochanter on the posterior surface of the neck is a prominent ridge, the intertrochanteric crest. Its upper half forms the posterior border of the greater trochanter, and its lower half runs downward and medialward to the lesser trochanter. A slight ridge is sometimes seen commencing about the middle of the intertrochanteric crest, and reaching vertically downward for about 5 cm. along the back part of the body: it is called the linea quadrata, and gives attachment to the Quadratus femoris and a few

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fibers of the Adductor magnus. Generally there is merely a slight thickening about the middle of the intertrochanteric crest, marking the attachment of the upper part of the Quadratus femoris.

FIGURE 3. Right femur. Posterior surface. The body, almost cylindrical in form, is a little broader above than in the center, broadest and somewhat flattened from before backward below. It is slightly arched, so as to be convex in front, and concave behind, where it is strengthened by a prominent longitudinal ridge, the linea aspera. It presents for examination three borders, separating three surfaces. Of the borders, one, the linea aspera, is posterior, one is medial, and the other, lateral. The linea aspera (FIGURE 3.) is a prominent longitudinal ridge or crest, on the middle third of the bone, presenting a medial and a lateral lip, and a narrow rough, intermediate line. Above, the linea aspera is prolonged by three ridges. The lateral ridge is very rough, and runs

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almost vertically upward to the base of the greater trochanter. It is termed the gluteal tuberosity, and gives attachment to part of the Glutus maximus: its upper part is often elongated into a roughened crest, on which a more or less well-marked, rounded tubercle, the third trochanter, is occasionally developed. The intermediate ridge or pectineal line is continued to the base of the lesser trochanter and gives attachment to the Pectineus; the medial ridge is lost in the intertrochanteric line; between these two a portion of the Iliacus is inserted. Below, the linea aspera is prolonged into two ridges, enclosing between them a triangular area, the popliteal surface, upon which the popliteal artery rests. Of these two ridges, the lateral is the more prominent, and descends to the summit of the lateral condyle. The medial is less marked, especially at its upper part, where it is crossed by the femoral artery. It ends below at the summit of the medial condyle, in a small tubercle, the adductor tubercle, which affords insertion to the tendon of the Adductor magnus. From the medial lip of the linea aspera and its prolongations above and below, the Vastus medialis arises; and from the lateral lip and its upward prolongation, the Vastus lateralis takes origin. The Adductor magnus is inserted into the linea aspera, and to its lateral prolongation above, and its medial prolongation below. Between the Vastus lateralis and the Adductor magnus two muscles are attachedviz., the Glutus maximus inserted above, and the short head of the Biceps femoris arising below. Between the Adductor magnus and the Vastus medialis four muscles are inserted: the Iliacus and Pectineus above; the Adductor brevis and Adductor longus below. The linea aspera is perforated a little below its center by the nutrient canal, which is directed obliquely upward. The other two borders of the femur are only slightly marked: the lateral border extends from the antero-inferior angle of the greater trochanter to the anterior extremity of the lateral condyle; the medial border from the intertrochanteric line, at a point opposite the lesser trochanter, to the anterior extremity of the medial condyle. The anterior surface includes that portion of the shaft which is situated between the lateral and medial borders. It is smooth, convex, broader above and below than in the center. From the upper three-fourths of this surface the

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Vastus intermedius arises; the lower fourth is separated from the muscle by the intervention of the synovial membrane of the knee-joint and a bursa; from the upper part of it the Articularis genu takes origin. The lateral surface includes the portion between the lateral border and the linea aspera; it is continuous above with the corresponding surface of the greater trochanter, below with that of the lateral condyle: from its upper three-fourths the Vastus intermedius takes origin. The medial surface includes the portion between the medial border and the linea aspera; it is continuous above with the lower border of the neck, below with the medial side of the medial condyle: it is covered by the Vastus medialis.

CHAPTER IV Pathophysiology

Fracture Precipitating factors: Behavior Lifestyle Occupation Environment Traumatic Force Applied To the Right Lower Extremity Risk factors Physical Trauma Due to Motorbike Accident Pre disposing factors: Age Gender

Multiple Abrasions and the Distal 3rd Femur Bone Is Broken Into Fragments (Comminuted)

Nerve at the site of fracture damaged

Fibrous Connective Tissue or Periosteum And Blood Vessels in the Cortex Marrow, And Surrounding Soft Tissues Are Disrupted and Damaged.

Muscle spasm due Fractured bone

Numbness

Bleeding Occurs From the Damaged Bone and From the Neighboring Soft Tissues

Pain and Tenderness

Formation of blood clot Hematoma Stimulation of the Inflammatory Response Pain, Swelling, Redness, Heat, Loss of Function

Limitation of ROM, Mobility and Reduction of ADLSs FIGURE 4. Pathophysiology of fracture (schematic diagram)

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A fracture is a break in the continuity of bone and is according to its type and extent. Fractures occur when the bone is subjected to stress greater than 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 hemorrhage into the muscles and joints, joint ruptured tendons, severed nerves, and damaged blood, organs may be injured by the force that caused the fracture fragments. The severity of the fracture, therefore, depends on the strength of the impact, the position of the bone when it was hit, and what type of bone has been affected. This is why bones can break in many different ways. The different cases of broken bones could be compound fractures, closed fractures, stress fractures, and fractures caused by pathological diseases such as osteoporosis. The above schema shows a comminuted type of fracture this type of fracture occurs when a bone has been broken into a number of pieces. Modifiable Risk factors for this type of fracture is the same as any other fracture which includes behavior such drunk driving which is the actual etiological factor for patients accident, lifestyle which basically relates to the nutritional intake, smoking habits and other activity that would affect the bodys bone integrity and calcium levels, Occupation and environment involving sun exposure and etc., other factors which are non modifiable includes Age caused by increased degeneration of bones as age also increases and Gender which mainly is caused by interplay of hormones in the body. In the above schema, the fracture is caused by a motorbike accident causing physical trauma in the right lower extremity, the accident also caused multiple abrasions and comminuted fracture in the distal 3rd femur. Broken bone fragments affects the nerve endings in the surrounding area causing numbness and muscle spasm leading to pain and tenderness thus causing the limitation of Range Of Motion and mobility disabling the patient to perform some activities of daily living. The above schema also shows the natural process of healing of a fracture which starts when the injured bone and surrounding tissues bleed, forming a Hematoma. The blood

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coagulates to form a blood clot situated between the broken fragments. Within a few days blood vessels grow into the jelly-like matrix of the blood clot. The new blood vessels

bring phagocytes to the area, which gradually remove the non-viable material. The blood vessels also bring fibroblasts in the walls of the vessels and these multiply and produce collagen fibers. In this way the blood clot is replaced by a matrix of collagen. Collagen's rubbery consistency allows bone fragments to move only a small amount unless severe or persistent force is applied. Throughout the process of bone healing the bodys inflammatory response is stimulated which is manifested by Pain, Swelling, Redness, Heat, Loss of Function and subsequently adds to the limitation Range Of Motion and mobility.

CHAPTER V MEDICAL MANAGEMENT Laboratory procedures Hematology One of the most important laboratory procedures for patient with fracture is complete blood count or hematology. Hematology is the study of the cellular elements of the blood, the production of these elements, and the physiological derangements that affect their functions. It is also concerned with blood volume, the flow properties of blood, and the physical relationships of red cells and plasma. Changes in blood components may be evidenced by a patient with fracture such as in Hematocrit it 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. Abnormal results during the actual complete blood count result of the patient (see appendix B) includes increased white blood cell count which is 11.9x10^9/L over a normal value of 4.8-10.8x10^9/L this indicates a normal stress response after trauma or it may also that there is an undergoing infection in the fracture site. Mean Corpuscular Hemoglobin which is 32.7 pg over a normal value of 27-31 pg which indicates macrocytic anemia, this could be not directly related to the diagnosis and also an increased basophil and monocyte which indicates bacterial infection and inflammation.

Urinalysis Routine urinalysis is one of the most widely ordered laboratory procedures, is used for basic screening purposes. It is a group of tests that evaluate the kidneys ability to selectively excrete and reabsorb substances while maintaining proper water balance. The results can provide valuable information regarding the overall health of the patient and the patients response to disease and treatment. The urine dipstick has a number of pads on it to indicate various

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biochemical markers. Urine pH is an indication of the kidneys ability to help maintain balanced hydrogen ion concentration in the blood. Specific gravity is a reflection of the concentration ability of the kidneys. Urine protein is the most common indicator of renal disease, although there are conditions that can cause benign proteinuria. Glucose is used as an indicator of diabetes. The presence of ketones indicates impaired carbohydrate metabolism. Hemoglobin indicates the presence of blood, which is associated with renal disease. Urine samples for routine analysis are best collected first thing in the morning. Urine that has accumulated in the bladder overnight is more concentrated, thus allowing detection of substances that may not be present in more dilute random samples. The sample should be examined within 1 hour of collection. If this is not possible, the sample may be refrigerated until it can be examined. Failure to observe these precautions may lead to invalid results. According to the patients actual urinalysis results (see appendix C) it showed that all of the parameters evaluated during the analysis are within normal values.

Coagulation profile The coagulation proteins respond to blood vessel injury in a chain of events. The intrinsic and extrinsic pathways of secondary hemostasis are a series of reactions involving the substrate protein fibrinogen, the coagulation factors (also known as enzyme precursors or zymogens), nonenzymatic cofactors (Ca2+), and phospholipids. The factors were assigned Roman numerals in the order of their discovery, not their place in the coagulation sequence. Alterations may occur because of blood loss, multiple transfusions, or liver injury. The specimen for this laboratory procedure is a Whole blood in a completely filled 5-mL blue-top (sodium citrate) tube. According to the patients actual results (see appendix D) all of the parameters evaluated during the coagulation profile fall within normal range.

Diagnostic procedures Bone Radiography

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Bone radiography are used to evaluate extremity pain or discomfort due to trauma, bone abnormalities, or fluid within a joint. Serial skeletal x-rays are used to evaluate growth pattern. Radiation emitted from the x-ray machine passes through the patient onto a photographic plate or x-ray film. X-rays pass through air freely and are mostly absorbed. skeletal x-rays are used to evaluate extremity pain or discomfort due to trauma, bone abnormalities, or fluid within a joint. Serial skeletal x-rays are used to evaluate growth pattern. Radiation emitted from the x-ray machine passes through the patient onto a photographic plate or x-ray film. X-rays pass through air freely and are mostly absorbed. Thus this procedure determines location and extent of fractures/trauma, may reveal preexisting and yet undiagnosed fractures. Bone scans, tomograms, computed tomography (CT)/magnetic resonance imaging (MRI) scans help visualize fractures, bleeding, and soft-tissue damage; differentiates between stress/trauma fractures and bone neoplasms. According to the patients actual diagnostic result (see appendix E) abnormal findings found in the x rays includes soft tissue swelling in the parieto-occipital region this was found out through Skull APL, Straightening of the cervical spine due to muscle spasm which was evident on cervical spine APL, Comminuted fracture, distal third, right femur with soft tissue swelling evident on thigh right APL and knee right APL. Arthrogram An arthrogram evaluates the cartilage, ligaments, and bony structures that compose a joint. After local anesthesia is administered to the area of interest, a fluoroscopically guided Small-gauge needle is inserted into the joint space. Fluid in the joint space is aspirated and sent to the laboratory for analysis. Contrast medium is inserted into the joint space to outline the soft tissue structures and the contour of the joint. After brief exercise of the joint, radiographs or magnetic resonance images (mris) are obtained. Arthrograms are used primarily for assessment of persistent, unexplained joint discomfort. Area of application includes shoulder, elbow, wrist, hip, knee, ankle, temporomandibular joint. This test is indicated for patients with fracture, evaluate pain, swelling, or dysfunction of a joint monitor disease progression. Normal findings are Normal bursae, menisci, ligaments, and articular cartilage of the joint (note: the cartilaginous surfaces

21
and menisci should be smooth, without evidence of erosion, tears, or disintegration) Abnormal findings can be found out in patients with Fracture, Arthritis, Cysts Diseases of the cartilage (chondromalacia),Injury to the ligaments Drug study The only drug prescribed to the patient is Celecoxib 200mg 1tab OD prn for pain. An analgesic drug and has anti-inflammatory activities related to inhibition of the COX-2 enzyme, which is activated in inflammation to cause the signs and symptoms associated with inflammation; does not affect the COX-1 enzyme, which protects the lining of the GI tract and has blood clotting and renal functions. This is given to the patient if patient is experiencing headache to manage pain. Before giving the medication, the nurse should (a) check patients history of allergies, renal impairment, impaired hearing, and hepatic and CV conditions if any; (b) check skin color and lesions; (c) check CBC, LFTs, renal function tests, serum electrolytes; (d) monitor vital signs; and (e) assess patients pain score. During the giving of drug, the nurse should: (a) administer drug with food or after meals; (b) establish safety measure if CNS or visual disturbances occur; and (c) document giving of drug. After giving of drug, the nurse should: (a) Provide comfort measures to reduce pain such as positioning, environmental control; (b) Instruct patient to take drug with food to prevent GI upse; (c) Instruct patient to take only the prescribed dosage; do not increase dosage; (d) Tell patient that he may experience adverse effects such as dizziness and drowsiness; and (e) Tell patient to report experience of sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers, changes in vision promptly.

SURGICAL MANAGEMENT Open Reduction Internal Fixation An open reduction and internal fixation (ORIF) is a type of surgery used to fix broken bones. This is a two-part surgery. First, the broken bone is reduced or put back into place. Next, an internal fixation device is placed on the bone; this can be screws, plates, rods, or pins used to hold the broken bone together. This surgery is done to repair fractures that would not heal correctly with casting or splinting alone. Before the surgery is done the patient has to undergo the

22
following exams: Physical examination which is to check your blood circulation and nerves affected by the broken bone, X-ray, CT scan, Blood tests, and Tetanus shot which depends on the type of fracture and if your immunization is current. General anesthesia may be used. It will block any pain and keep you asleep during the surgery. It is given through an IV (needle in your vein) in your hand or arm. In some instances, a spinal anesthetic, or more rarely a local block, may be used to numb only the area where the surgery will be done. This will depend on where the fracture is located and the time it will take to perform the procedure. Each ORIF surgery differs based on the location and type of fracture. In general, a breathing tube may be placed to help you breathe while you are asleep. Then, the surgeon will wash your skin with an antiseptic and make an incision. Next, the broken bone will be put back into place. Next, a plate with screws, a pin, or a rod that goes through the bone will be attached to the bone to hold the broken parts together. The incision will be closed with staples or stitches. A dressing and/or cast will then be applied.

NURSING MANAGEMENT Summary of nursing problems: 1. Acute pain related to movement of bone fragments secondary to comminuted fracture. 2. Impaired Physical Mobility related to musculoskeletal impairment secondary to prescribed restrictive therapies. (traction) 3. Risk for Trauma (additional injury) related to loss of skeletal integrity and improper placement of traction weights.

Individualized Nursing Care Plan Upon the first day of interaction to the patient the researcher was able to formulate the nursing problems and prioritized as to the most critical nursing focus which is acute pain related to movement of bone fragments secondary to comminuted fracture. Objective findings that could support the formulated problem include; Received patient lying on bed with head elevated, awake, conscious, coherent, communicative, with foam traction at right foot, with pain score of 7

23
out of 10, grimaced face noted, irritability observed, restlessness noted, limited range of motion observed and with a subjective cue of :ngol-ngol kaayu ang ako bali as verbalized. Short term goal formulated includes after 5 hours of nursing intervention the patient will be able to verbalize pain relief as evidenced by decreased pain score. Long term goal formulated includes after 3 days of nursing intervention, the patient will be able to, verbalize and demonstrate techniques that provide pain relief and demonstrate effective use of relaxation techniques as indicated for individual situation after assessment and goal planning the interventions were made which includes assessment level of pain, location, character, and aggravating factor to rule out for worsening of underlying conditions and development of complication and prevent occurrence. Observation for non-verbal cues of pain because they may not be congruent with verbal reports and may prompt change in locus of intervention, Provision of comfort measures as possible such as touch therapy, repositioning, use of cold/heat packs, constant interaction, quiet environment and calm activities which maximizes use of non-pharmacological techniques for pain relief, Instruction in and encouragement of usage of relaxation techniques such as focused breathing and imaging to distract patients attention and thus reduce tension, Encouragement in engaging in diversional activities such as socialization with other patients or listening to music which is also used distract attention and reduce tension, Health teaching about non-pharmacological pain management to promote self control and management of pain. Dependent and Collaborative nursing management includes Administration of analgesics as to a maximum as needed as indicated by individual situation to maintain acceptable level of pain, Instruction patient in use of transcutaneous electrical nerve stimulation units when ordered to maintain acceptable level of pain and comfort and lastly referral to occupational/physical therapy program to promote active role partcipation and enhanced self-control. During the second day of care, the researcher was to formulate the following nursing care plan with a nursing focus of Impaired Physical Mobility related to musculoskeletal impairment secondary to prescribed restrictive therapies. (traction), this problem problem was identified through analysis of the objective findings which includes, received patient lying on bed with head elevated to 30 degrees, awake, conscious, coherent, communicative, with foam traction at right

24
foot, the patient is reading a newspaper, has difficulty in changing position while lying on bed, has difficulty in moving the extremities, inability to walk or stand alone, limited range of motion in the extremities, slowed movement, difficulty in initiating gait and subjective cue maglisod man jud kog lihok sa ako lawas as verbalized. Short term goal is After 5 hours of nursing intervention, the patient will be able to perform activities of daily living at the level of functional capabilities. Long term goal includes After 3 days of nursing intervention; the patient will be able to demonstrate and verbalize proper exercises of the lower extremities & can perform activities of daily living with minimal assistance. Nursing interventions that were formulated include provision of normal range of motion exercises and function of lower extremity which necessary to regain normal mobility of leg to speed up recovery, Encouragement of progressive activities according to level of functional capability to increase patients use of affected leg. instruct and encourage use of overhead trapeze in mobilizing in the bed to obtain sense of control during movement, encouragement in participation in self-care, occupational/diversional/ recreational activities to enhances self concept and sense of independence, Identification of energy conserving techniques for ADLs which limits fatigue and maximizes participation in intervention, encouragement adequate intake of fluid and nutrition to promote well-being and energy production, provision of proper skin care to decrease risk for decubitus ulcer formation. Collaborative and dependent nursing interventions include administration medications as needed prior to activity for pain relief to permit maximal effort and involvement in activity and lastly consultation with Occupational therapy as needed to maintain continuity of care after discharge. Third and last nursing care plan for the patient includes a nursing problem which is Risk for Trauma (additional injury) related to loss of skeletal integrity and improper placement of traction weights, this was formulated upon analysis of objective findings which includes received patient lying on bed with head elevated, awake, conscious, coherent, communicative, with foam traction at right foot, absence of side rails noted, traction weights placed of walkways, absence of bed padding noted, high placement of bed observed, seen SO frequently leaving the patient and subjective cue :dali ra masabod sa mga mangagi kanang baton a gbitay. As verbalized, short term goal formulated is those After 4 hours of nursing intervention, the patient will be able to

25
verbalize understanding of condition and recognize need for prevention of injuries and a long term goal of After 3 days of nursing intervention, the patient will be able to demonstrate appropriate lifestyle changes to reduce risk for injury and maintain condition without additional injury and decrease risk for trauma. Nursing interventions formulated for this nursing problem includes Identification of factors related to individual situation and identify extent of risk which nfluence the scope and intensity of interventions to manage safety, notification of clients decisionmaking ability and level of cognition including functional capability cause this can affects clients ability to protect self and influences choice of interventions and teaching, Implementation interventions regarding safety issues includes: orientation to environment, keep bed in low position, pad bed edges as possible, provide adequate area lighting and assist with moving or turning using trapeze becausefailure to accurately assess, intervene and/or refer these these issues can place patients at needless risk and create negligence issues for healthcare practitioner, provision quiet environment and reduced stimulation as possible this can help limit confusion or overstimulation, placement traction weights at appropriate location away from passageways as possible, to prevent moving the weights causing disaligment of bone fragments. Collaborative and Dependent nursing interventions includes assistance with treatment of underlying medical/surgical conditions to improve cognition/thinking process. Focused charting On the first day of actual care to the patient the researcher utilized the formulated nursing care plan and derived to the focus Acute pain with supporting data of received patient lying on bed with head elevated to 30 degrees, awake, conscious, coherent, communicative, without IV, with the following v/s T= 35.5 degree Celsius, P= 86 pm, R= 20 bpm and BP= 120/70 mmHg, with foam traction at right foot, with pain score of 7 out of 10, grimaced face noted, irritability observed, restlessness noted, limited range of motion observed, ngol-ngol kaau ang akong bali dong. As verbalized. Actions made included; Introduced name to the patient, assessed level of pain, character and location, monitored v/s, positioned properly on bed with head slightly elevated, Due medications (analgesics) administered as ordered, encouraged to engage in diversional activities such as socialization with others, provided comfort measures such as

26
backrub, encouraged patient to do DBE; supported affected body parts/ joints using pillows/ rolls, consulted with physical or occupational therapist as indicated, documented the v/s and I and O of the patient. After the shift :wa na kaayu sakit ang ako bali dong. As verbalized, pain score decreased from 7out of 10 to 3 out of 10. On the second day of nursing care the formulated nursing problem for the charting focuses on Impaired physical mobility with supporting data of received patient lying on bed with head elevated to 30 degrees, awake, conscious, coherent, communicative, without IV, with the following v/s T= 35.5 degree Celsius, P= 86 pm, R= 20 bpm and BP= 120/70 mmHg, with foam traction at right foot, the patient is reading a newspaper, has difficulty in changing position while lying on bed, has difficulty in moving the extremities, inability to walk or stand

alone, limited range of motion in the extremities, slowed movement, difficulty in initiating gait. maglisod man ko ug lihok dong. As verbalized. Interventions done includes; Introduced name to the patient, assessed the condition of the patient; monitored v/s, positioned properly on bed with head slightly elevated, assisted patient in doing ROM exercises, assisted patient upon doing gait training, instructed in proper use of overhead trapeze, provided comfort measures such as backrub, encouraged patient to do DBE; supported affected body parts/ joints using pillows/ rolls, consulted with physical or occupational therapist as indicated, documented the v/s and I and O of the patient after the interaction the patient functionality of the extremities was able to demonstrate increasing

as evidenced by turning on bed without assistance and

effective usage of overhead trapeze For the last day of care to the patient the researcher utilized the formulated nursing care plan intended for that day which is Risk for additional injury with supporting data of received patient lying on bed with head elevated, awake, conscious, coherent, communicative, without IV, with the following v/s T= 37 degree Celsius, P= 62 pm, R= 21 bpm and BP= 130/70 mmHg, with foam traction at right foot, absence of side rails noted, traction weights placed of walkways, absence of bed padding noted, high placement of bed observed, seen SO frequently leaving the patient, dali raman masabaod ang kanang mga bato. As verbalized, interventions done includes; Introduced name to the patient, assessed the condition of the patient, instructed SO to

27
stay with patient as much as possible, implemented interventions regarding safety issues such as orientation of patient to environment, keeping bed in low position, providing adequate area lighting and padding of side rails as possible, monitored v/s, positioned properly on bed with head slightly elevated, assisted patient in doing ROM exercises, assisted patient upon doing gait training, instructed in proper use of overhead trapeze, provided comfort measures such as backrub, encouraged patient to do DBE; supported affected body parts/ joints using pillows/ rolls, consulted with physical or occupational therapist as indicated, documented the v/s and I and O of the patient after the interaction the patient was able to demonstrate behaviors to promote safety, SO was seen staying with patient most of the time.

Discharge summary This is a case of T.B.M, 32 years old, male, married, from Carajay, Lapu-Lapu City, Cebu, he was admitted on Vicente Sotto Memorial Medical Center ward 8 (orthopedic ward) last July 6, 2011, around 11:03 pm under the care of Dr. Dominic Vicua, he has a chief complaint of Vehicular accident with an admitting diagnosis of fractured closed distal third femur, right, comminuted. For the discharge instructions, the researcher focused on home care management , the researcher stressed to the patient the importance of continuing prescribed medication even after discharge for continuity of care and optimal recovery from condition and recovery, also taught patient and significant other patient about mechanism of action, dosage, frequency, side effects and adverse reaction of medication prescribed to increase patient and significant others knowledge about medication thus increasing compliance, advised patient to have daily exercise as tolerated such as morning walks assisted by a significant other ,Taught about appropriate exercise that can be used by patient such as passive exercise on the lower or affected extremity and active exercise on the upper extremity, advised patient to take a bath daily and wash hands frequently and also advise the significant others to do the same to prevent spread of infection, taught about signs of infection and when to call for medical emergency, encourage to have

28
emergency hotline numbers and transportation facilities ready in case of emergency and advised to return immediately if the following signs occur severe pain, swelling, headache, redness, or frequent light-headedness, encouraged to eat a well balanced diet including high protein and high calcium for faster bone remodelling and tissue repair which can be found in the following foods; meat products, egg, milk and other dairy products especially eating green leafy vegetables, also encouraged to have supplementary vitamins and minerals and lastly encouraged to strengthen spirituality within the family by attending to mass together and praying together. At the end of the shift the patient is still in.

29

CHAPTER VI EVALUATION AND RECOMMENDATION

I.

Extent of Goal Achievement

After 3 days of intervention, the student nurse observed certain changes from the patient. On the first day of interaction the patient reports decreased pain with elevation, ice and analgesic and also the patient was able to demonstrate effective use of relaxation techniques as evidenced by decreased recurrence of pain perception. On the second day of interaction changes observed to the patient include regaining of the patients previous range of motion in the leg & demonstrates proper exercises for the lower extremities. He also does some ADL without discomfort. On the third and final day on interaction the patient was seen demonstrating appropriate lifestyle changes to reduce risk for injury such as asking for help from SO upon moving and using trapeze effectively when turning. The patient also exhibits unlabored respirations; alert and oriented, afebrile, using affected extremity for light activity as allowed, no signs of neurovascular compromise, vital signs are stable; urine output adequate and no calf pain reported: Homans sign negative., hygiene and dressing practices with minimal assistance and denies acute symptoms of stress; reports working through feelings about trauma.

II. Recommendation As a researcher in this case study, the student nurse recommends the patient to adjust in usual lifestyle and responsibilities to accommodate limitations imposed by fracture and to prevent recurrent fractures safety considerations, avoidance of fatigue and proper footwear. The patient is instructed about exercises to strengthening upper extremity muscles If crutch walking is planned, methods of safe ambulationwalker, crutches, care, emphasizes instructions concerning amount of weight bearing that will be permitted on fractured extremity, teaches symptoms needing attention, such as numbness, decreased function, increased pain and elevated temperature and explains basis for fracture treatment and need for patient participation in

30

therapeutic regimen. The patient and the family were also informed that the patient must have an adequate balanced diet to promote bone and soft tissue healing.

Nursing Practice The result of this case study would provide the student nurse with sufficient knowledge, attitude and skills towards the management of patients with fracture on the right femoral neck. This study would help the student nurse in providing a higher quality of care of patients with the same condition. It is important that the proper and ideal managements and interventions are done in order to give a more holistic approach and optimum care to clients with fracture on the right femoral neck. This would ensure the timely healing of injury and the prevention of complications.

Nursing Education Education can promote enhancement of professionalism through an on- going learning process, whether self- motivated, people- oriented and having a commitment to the organization, nurses are likely to become well respected through the formal educational programs. Through this case study, it is important to know all areas of patient are both knowledge and skills to manage effectively in all aspects of their professional nursing practice.

Nursing Research Nursing research is essential for the development of scientific knowledge that enables nurses to provide evidenced-based health care. Broadly nursing is accountable to society for providing quality, cost effective care and for seeking ways to improve that care. More specifically, nurses are accountable to their patients to promote a maximum level of health.

31
BIBLIOGRAPHY Book sources: Bare, Brenda I. and Smeltzer, Suzzane C., Textbook of Medical-Surgical Nursing. 10th Edition Philadelphia: I.B Lippincott Company. 2004. Deglin, J. and Vallerand, A. 2005. Davis Drug Guide 9th edition, Philadelphia; F.A davis Doenges, M., Moorhouse, M.F. , Geissler Murr, A. Nurses Pocket Guide, Diagnosis, interventions and rationales, 9th Edition (2004). Doenges, M., Moorhouse, M.F. , Geissler Murr, A., Nursing Care Plans. Guidelines for Individualizing Patient Care. 6th Edition. F.A. Davis Company, 2002. Nettina, Sandra M., Manual of nursing Practice. 7th Edtion. I.B. Lippincott Company. 2001. Rozler, Barbara et al. Fundamentals of Nursing. 5th Edition. Newyork: AddisonWeatleylongman, Incorporated. 1998. Marieb, Elaine N. Essential of Human Anatomy and Physiology. 7th Edition. Singapore. Pearson Education South Asia Pte. Ltd. 2004. Potter, Patricia and Perry, Anne. Fundamentals of Nursing. 6th Edition Baltimore: C.V. Mosby and Company. 2005. Internet Sources: Aukerman, Douglas F, MD, Ho, Sherwin SW, MD, (30 Oct 2008), Femur Injuries and Fractures, Retrieved august 21, 2011 from http://emedicine.medscape.com/article/90779Cluett, Jonathan, M.D., (August 21, 2005), Femur Fracture, Retrieved September 18, 2011 from http://orthopedics.about.com/od/brokenbones/a/femur.htm Crist, Brett D. MD; Della Rocca Gregory J., MD, PhD; Murtha, Yvonne M. MD, (July 2008), Treatment of Acute Distal Femur Fractures, Retrieved September 18, 2011 from http://www.orthosupersite.com/view.aspx?rid=2979 Keany, James E, MD, FACEP, Kulkarni Rick, MD (2011, January), Femur Fracture, Retrieved August 21, 2011, from http://emedicine.medscape.com/article/824856-overview.

Appendices

33
APPENDIX A

Cebu Normal University

College of Nursing

APPROVAL FOR CASE STUDY

Name of Student: Macayan, Jellou Ray M. Semester: First Semester This is to certify that the student is approved to take the case of T.B.M (Initials of Patient) With diagnosis of Fractured Closed, Distal 3rd Femur, Right, Comminuted (Write the full diagnosis)

Year and Section: IV-B Academic Year: 2011-2012

In Ward VIII (Orthopedic Ward) as subject for case study in the undergraduate level.

Name and signature of Clinical Instructor: Mrs. Bertilia F. Pragados BSN, RN Date of approval: ___________________

APPENDIX B

34

Cebu Normal University

College of Nursing
APPROVAL FOR FINAL PRINTING AND BOOK BINDING OF CASE STUDY

Name of Student: Macayan, Jellou Ray M. Semester: First Semester

Year and Section: IV-B Academic Year: 2011-2012

This is to certify that the case study has underwent final checking and is approved for final printing and book binding as partial fulfilment for the requirements for graduation.

Name and signature of Clinical Instructor: Mrs. Bertilia F. Pragados BSN, RN Date of approval: __________________

35
APPENDIX C Physical assessment (actual)

Cebu Normal University

College of Nursing Cebu City NURSING ADMISSION AND ASSESSMENT Name of Student: Jellou Ray M. Macayan Name of Clinical Instructor: Bertilia F. Pragados A. General Admission Information Name of Patient: T.B.M, Date: July 6, 2011 TPR: T- 37, P- 62 Property:
R- 21

Clinical Assignment: WARD VIII (orthopedic ward) Inclusive Dates:

Age: Time:
11:03 pm

32 years old ERUF

Sex:

Male

Mode:
55 Ft

Allergies: no known allergies Diet:

Diet As Tolerated

BP: 130/70 mmhg HT: NONE NONE

WT: /

79 kg.

Sleeping Habits:

sleeps at 10 pm and wakes at 7 am

CBC: Yes NONE

No

Urinalysis: Yes Dentures Watch Money

/ No NONE NONE

Glasses Prosthesis Other NONE

Contact Lenses NONE Ring

Valuable to Business Office

NONE

Physical Appearance: Client appears to be on his stated chronological age, sexual development is appropriate for age, observed no upper
clothing, prominent tattoo noted on abdomen, unkempt appearance noted, diaphoresis noted, complexion is even, foam traction noted at right foot

Behavior Exhibited:

client is cooperative during the interaction and purposive in his actions, openness noted during conversation with life

experiences, mild anxiety noted, affect is appropriate with occasion, speech is clear, moderately paced and culturally appropriate.

Content of Conversation: patient- centered; topic was focused on patients profile, perception of reason for admission, present condition,
patients history of past and present illness, educational and cultural background.

Dr. Dominic Vicua M.D. Physician In-charge B. Admission Interview

36 1. Patients perception of reason for admission:

Patient verbalizes that reason for admission was because he sustained a

fracture on his lower extremity nabali akong paa as verbalized

2. Patients symptoms as he/she sees them: ngol-ngol kaayu og hapdos kung masabod ang akong balias verbalized by the pt.
3. Problems in daily living created by symptoms (as patient views them)
Patent is unemployed so he helps in raising his children and also in chicken business and because of this condition he can longer attend to this job.

4. Past Medical History (especially as it relates to P.I.)

a. Medical b. Surgical c. Allergies d. Medication

hasnt been hospitalized before

wound suturing 2001 Carajay District Hospital-ER

no known allergies

Celecoxib 200mg 1 tablet prn for pain,

e. Traumatic Injuries f. Orthopedic

NONE

Vehicular accident 2001 Carajay District hospital ER wound suturing

g. Other (psychiatric, etc.) NONE

5. Habits:

a. b. c.
running

Smoking Eating

non-smoker

Alcohol drinks

3x weekly

Drugs

occasionally(as

verbalized Breakfast, Lunch And Supper: Rice, vegetables, fish, beef, pork and water

Social Activity Rest/Sleeping Sexual

none but is a basketball player in their place previously

Physical Exercise walking and

d. e. f.

usually sleeps at 10pm and wakes up at 7 am, at 2pm patient takes a nap and wakes at 3 or 4 pm.

active, 3 times weekly as verbalized

Elimination

bowel movement: once daily

urination: 8-10 times daily

6. Social Economic History:

a. Native Language

Cebuano and Tagalog

37 b. Education c. Occupation
college level (graduate of associate criminology)

unemployed, sells chicken and also a landlord

d. Financial Status (what is the impact of current hospitalization)

Patient used their family to pay for the finances and also lends money from their friends around the neighborhood for additional financial assistance

e. Civil Status: f. Living Situation:

Married / Lives alone

Single

Divorced

Widow

Lives with others (specify) lives with wife and 3 children (2 sons and a daughter 7. Family History: Heart Disease, Cancer, TB, Mental Illness and Others (specify)
Paternal- (+) Hypertension, (+) Diabetes Mellitus

8. Primary Physicians Admitting Diagnosis (indicate P = Probable and C= Confirmed)

P- FRACTURE CLOSED RIGHT FEMUR C- FRACTURE, CLOSED, DISTAL 3RD FEMUR, RIGHT, COMMINUTED

C. Nursing Review of Systems (circle the appropriate symptoms) 1. HEENT: Headaches Hearing loss Eye pain Eye infection Sinus pain Facial pain Sore throat Nasal-tracheal pain

Visions Blurring Bleeding gums Other NONE

Diplopia Epistaxis Dentures

2. CARDIO-RESPIRATORY: Chest pain (site) NONE

Chest pain with exertion Nocturnal dyspnea Known murmur Pleuritic pain Last X-ray JULY 6, 2011 3. GASTRO-INTESTINAL: Thirst Heartburn Abdominal pain Hemorrhoids Hernia 4. GENITO-URINARY: Nausea Difficulty Swallowing Jaundice Other: NONE Vomiting Flatulence Diarrhea Hematemesis Constipation Tarry stool Dyspnea on exertion Edema Cough Sputum Diaphoresis Hypertension Hemoptysis EKG NONE Palpitation

38
Dysuria Nocturia Polyuria Burning Male Genital Tract: Pain Other Frequency Hematuria Urgency Stones Lesions NONE Testicular swelling NONE

a.

Penile discharges NONE NONE NONE NONE

Last Serology Test 5. MUSCULO-SKELETAL: Muscle pain Joint swelling Redness Other NONE X-rays 6. NERVOUS: Convulsions Tremor Muscle atrophy EEG NONE Other NONE Syncope Speech difficulty Extremity pain Neck pain Sprains

Joint pain Stiffness Deformity

Back pain Limited motion

Fractured Right Femur

Dizziness Limp paralysis

Vertigo Paresthesia

7. ENDOCRINE: Goiter Exopthalmos Change in body contour 8. EMOTIONAL: Anxiety Anger Depression Frustration Fear Other (specify) Tremor Voice change Infidelity Heat or Cold intolerance Polydipsia Other NONE

Notes: patient is angry, depressed and frustrated about his condition and blames himself for driving while drunk.

D. Nursing Observation 1. HEENT a. Symmetry Head is normocephalic, symmetric, round, erect, midline with incision on parietal area, no involuntary movement noted b. Eyes and Pupils Facial features are symmetrical, temporal artery elastic and non tender, , pupils are midline with each eyeballs c. Ears Normal in size bilaterally 4 cm, both are aligned with inner canthus of the eye, no discharges, tenderness or lesions noted

d. Mouth and Throat lips are dry and pale, complete set of teeth noted, no dysphagia or ulcerations noted on oral cavity

39 e. Lymph nodes lymph nodes are non tender and movable

2. RESPIRATORY a. Depth and Rate Respiratory rate is 21 cycles per minute with normal depths, no nasal flaring use of accessory muscles noted

b. Breath sounds No adventitious sounds are auscultated, bronchial sounds heard on trachea and thorax, Bronchovesicular
sounds heard over the major bronchi and around the upper sternum, Vesicular sounds heard at peripheral lung fields

c. Chest expansion Chest expansion of 5 cm bilaterally noted

3. CARDIO-VASCULAR a. Blood Pressure (R) 130/90 mm Hg (L) 130/90 mm Hg Lying 130/90 mm Hg b. Apical pulse rate and regularity regular with a rate of 66 beats per minute

Standing 130/90 mm Hg

c. Pedal pulses rate per minute (R) 66 beats minute d. Neck vein distention
no neck vein distension noted

(L)

66 beats minute

4. CHEST a. Anterior chest

uniform in color with smooth texture no edema, tenderness, discoloration or nodules palpated

b. Posterior chest

anteroposterior diameter ratio to transverse diameter is 2:1, scapula are non protruding, spinous process appear straight and thorax appears symmetric with ribs sloping downward

c. Breasts breast are symmetrical, not engorged or enlarged, nipples are dark brown and equal in size bilaterally. 1. Breasts and Axillae symmetrical, not engorged or enlarged, nipples are dark brown and equal in size bilaterally 2. Anterior Thorax Bowel sounds are heard as intermittent, soft clicks and gurgles at a rate of 5 per minute 3. Posterior Thorax Slightly rigid due to decreased bowel movement, no tenderness noted

5. GASTRO-INTESTINAL a. Bowel Sounds

series of intermittent soft clicks and gurgles heard upon auscultation with a rate of 5 per minute. slightly rigid to decreased bowel movement, no tenderness noted

b.

Tenderness or rigidity

6. URINARY a. Bladder

Bladder is not palpable when not full, dull thud heard upon percussion of full bladder, urinates daily with a rate of 6-8 times approximately 700cc per day, urine color is yellow with a consistency of slightly cloudy

7. SKELETAL a. Joints Joints are non tender, no swelling or bulging of fluid

b. Range of motion Full range of motion on upper extremity and marked limitation of range of motion on lower extremity

40
8. NEURO a. Motor Function 1. Facial Movements are symmetrical, smiles, frowns, puff out cheeks, wrinkles forehead and shows teeth without difficulty

2. Extremities

has full control on movements upper extremity while limited on lower extremity

b. Sensory Function (equal or not equal) sensory functions are equal on both sides
c. Equilibrium 1. Balance
balance is not assessed due to mobility restrictions

2. Finger to nose patient is able to perform finger to nose test

d. Reflexes ( equal or not equal) 1. Knees hypoactive (+)

Arms hypoactive (+)

9. CRANIAL NERVE FUNCTION a. Olfactory nerve: (sensory) 1. Sense of smell (coffee, vailla, etc.) 1.1 Anosmia Able to identify the scent presented on each nostril

1.2 Hyperosmia

Able to identify the scent presented on each nostril

b. Optic nerve: (sensory) 1. Sense of vision (snellens chart, newspaper) 1.1 Myopia Able to read newsprint 14 inches away with full visual fields

1.2 Hyperopia
c.

Able to read newsprint 14 inches away with full visual fields

Oculomotor: (motor) 1. Extra-ocular movements/Pupil reaction to light

1.1 Right eye Eyelid covers 2mm of the iris, PERRLA

d. Trochlear: (motor)

1.2 Left eye Eyelid covers 2mm of the iris, PERRLA

1. Assess direction of gaze, upward and downward movement of eyeball

eyes move in a smooth coordinated motion, Eyes move in a smooth coordinated motion in an upward and downward motion

e. Trigeminal nerve: (Sensory and motor) 1. Presence of corneal reflexes

1.1 Right eye blinks coordinately
Blinks bilaterally upon introduction of cotton to outer canthus

1.2 Left eye blinks coordinately

2. Ability to clench teeth able to clench teeth, temporal and masseter muscles contact bilaterally
f. Abducens: (motor) 1. Assess direction of gaze, lateral movements of the eyeballs 1.1 Right eye smooth and in coordination with left eye 1.2 Left eye smooth and in coordination with right eye

41
g. Facial: (Sensory and motor) 1. Sense of taste: Using back of tongue 1.1 Salty
able to identify taste

1.2 Sweet able to identify taste

2. Facial expression 2.1 Smile 2.3 Frown

able symmetrically

2.2 Puff out cheeks

able symmetrically

able symmetrically

2.4 Raise lower eyebrows able symmetrically

h. Auditory nerve: (motor) 1. Sense of hearing 1.1 Right ear Able to hear whispered voice 1 meter away i. Glossopharyngeal: (Sensory and motor) 1. Sense of taste: Using back of tongue 1.1 Salty Able identify taste 1.2 Sweet Able identify taste 1.2 Left ear Able to hear whispered voice 1 meter away

2. Ability to swallow (Use tongue blade to elicit gag reflex)

Able, Gag reflex is intact

j.

Vagus: (Sensory and motor)

1. Hoarseness of voice no hoarseness of voice noted 2. Sensation of pharynx

Uvula and soft palate rise bilaterally on phonation

Let patient say ah and observe(movement of palate and pharynx) k. Spinal accessory: (motor) 1. Movement of: 1.1 Head strong contraction of Sternocleidomastoid muscle on the side opposite the turned face upon turning agains
resistance muscle

1.2 Shoulder Strong and symmetric contractions of Trapezius

l.

Hypoglossal: (motor)

1. Able to stick tongue to midline Tongue movement is symmetric and smooth and bilateral strength is apparent.
10. EMOTIONAL

a. b. c.

Communication client is cooperative and is open in sharing information to the nurse Mood/Effect mood is appropriate for action, feels awful for the finaces they have to pay for. Behavior client is cooperative and can maintain eye contact during interaction

E. Knowledge of Illness

42 1. Learning Limitations patient knows about condition and the medical intervention given inclusing reason for temporary immobilization
of lower extremities and also the cause of his disability

2. Learning needs the patient needs to learn the importance of avoiding driving while he is drunk and also the patient needs to know the
seriousness of his condition

F. Nursing Impressions
Admitted a case of T.B.M., 32 years old, male, married, from Carajay, Lapu-lapu city, due to vehicular accident causing a sustained injury in right thigh with a chief complaint of pain and multiple abrasions on the lower extremities, After further evaluations the patient was diagnosed with fractured, closed distal 3rd femur right, comminuted.

G. Nursing Problems (in priority)

1. 2. 3. 4. Acute pain related to muscle spasms and movement of bone fragments. Impaired physical mobility related to restrictive therapies including foam traction and complete bed rest. Self-care deficit; Bathing/Hygiene/Feeding/Toileting related to decreased muscle control Risk for impaired gas exchange related to altered blood flow , fat or blood emboli. Risk for neurovascular dysfunction related to interruption of blood flow and tissue trauma

5.

H. Discharge Planning

1. Probable Date 2. Destination

July 27, 2011

Carajay, Lapu-Lapu city, Cebu

3. Transportation Taxi 4. Agencies and Equipment involved 5. Diet

Vicente Sotto Memorial Medical Center, Carajay District Hospital, Traction, (Foam)

diet as tolerated including high protein and calcium food

6. Medications Celecoxib 200mg 1 tablet if experiencing pain 7. Persons responsible for patient Wife, 2 sons and a daughter 8. Family conference
Scheduled a home visit with client

9. Anticipated problems Patient is at risk for fall, ulceration atrophy due to decreased muscle control and utilization 10. Home visit
done by public health nurse

43
APPENDIX D Hematologic studies (ACTUAL)

Republic of the Philippines Department of Health Regional Health office no.7 Vicente Sotto Memorial Medical Center B. Rodriguez St., Cebu City

Hematologic studies
NAME: T.B.M WARD: VII (orthopedic ward) PHYSICIAN: Dr. Dominic Vicua Blood component Hemoglobin Hematocrit WBC RBC Mean Corpuscular Hgb Mean (MCV) MCHC RDW MPV Platelet Cell Volume Normal values 140-180 g/L 42%-52% 4.8-10.8x10^9/L 4.70-6.10x10^12/L 27-31 pg 80-94 fl 330-370 g/L 11-16 fl 7.2-11.1 fl 150-450x10^9/L CASE NUMBER: 11-261262 DATE RENDERED: 7- 7-11

Actual results 156 g/L 47% 11.9x10^9/L 4.78x10^12/L 32.7 pg 97 fl 336 g/L 12.9 fl 7.4 fl 248x10^9/L

Significance Within normal range Within normal range Increased (infection) Within normal range Increased (macrocytic anemia) Within normal range Within normal range Within normal range Within normal range Within normal range

Clinical Significance:
Abnormal results during the actual complete blood count result of the patient includes increased white blood cell count which is 11.9x10^9/L over a normal value of 4.8-10.8x10^9/L this indicates a normal stress response after trauma or it may also that there is an undergoing infection in the fracture site. Mean Corpuscular Hemoglobin which is 32.7 pg over a normal value of 27-31 pg which indicates macrocytic anemia.

DIFFERRENTIAL WBC count:

44
Neutrophil Lymphocyte Monocyte Eosinophil Basophil Clinical Significance: The abnormal findings in the WBC differential count includes and increased monocyte which is indicative of a bacterial maybe because of the trauma to the patients extremities during the fracture and also an increased basophil which is indicative of inflammation as evidenced by the swelling on the lower extremities of the patient. 40-70% 19-48% 3-9% 0-7% 0-2% 67.10% 21.10% 10.60% .70% .40% Within normal range Within normal range Increased (bacterial infection) Within normal range Increased (inflammation)

APPENDIX E Urinalysis (ACTUAL)

Republic of the Philippines Department of Health Regional Health office no.7 Vicente Sotto Memorial Medical Center B. Rodriguez St., Cebu City

Urinalysis

45
NAME: T.B.M WARD: VII (orthopedic ward) PHYSICIAN: Dr. Dominic Vicuna COMPONENT Color Transparency Specific gravity Ph Glucose Protein RBC WBC Amorphous urates Mucus threads ACTUAL RESULTS yellow Slightly cloudy 1.025 6.5 Negative (-) Negative (-) 0-2/hpf 0-4/hpf rare few CASE NUMBER: 11-261262 DATE RENDERED: 7- 7-11

SIGNIFICANCE normal normal Within normal range Within normal range normal normal Within normal range Within normal range Normal normal

Clinical Significance: all of the parameters evaluated are within normal range.

APPENDIX F Coagulation profile (ACTUAL)

Republic of the Philippines Department of Health Regional Health office no.7 Vicente Sotto Memorial Medical Center B. Rodriguez St., Cebu City

Coagulation profile
NAME: T.B.M WARD: VII (orthopedic ward) PHYSICIAN: Dr. Dominic Vicuna Component PTT control Control % activity Control INR PT control % activity INR Results 14.8 seconds 102% 1.12 14.1 seconds 110.1% 1.06 CASE NUMBER: 11-261262 DATE RENDERED: 7- 7-11

Normal values 12.3-15.3 seconds 12.8-15.8 seconds -

Significance Within normal range

Within normal range

46

Clinical Significance: all of the parameters evaluated are within normal range.

APPENDIX G X-ray report (ACTUAL)

Republic of the Philippines Department of Health Regional Health office no.7 Vicente Sotto Memorial Medical Center B. Rodriguez St., Cebu City

X-RAY REPORT
NAME: T.B.M WARD: VII (orthopedic ward) PHYSICIAN: Dr. Dominic Vicua SKULL APL Findings: The cranial vault is intact, the sella turcica is intact, there is no evidence of fracture, bone erosion nor bone destruction, no abnormal intracranial calcifications is noted, there is a soft tissue swelling in the parieto-occipital region. Impression: Soft tissue swelling in the parieto-occipital region. CASE NUMBER: 11-261262 DATE RENDERED: 7- 18-11

CERVICAL SPINE APL Findings: The vertebra is normal in height, density, texture and modelling. There is no evidence of

47
fracture, bone erosion nor bone destruction. The pre-vertebral soft tissue space is within normal limits. The normal cervical lordosis is absent. Impression: Straightening of the cervical spine due to muscle spasm.

CHEST PA Findings: Both lung fields are clear. Heart is normal in size and shape. The trachea is at midline. Both hemidiaphragms are sharp and distinct. The osseous thoracic cage showed no bony abnormality. Impression: No significant chest findings.

PELVIS AP Findings: The bones normal in density, texture and modeling, there is no evidence of fracture, bone erosion nor bone destruction, both hip and sacro-iliac joint are within normal limits. Impression: Normal bones and joints of the hips

HAND RIGHT APLO Findings: The bones normal in density, texture and modeling, there is no evidence of fracture, bone erosion nor bone destruction. The joint spaces are within normal limits. Impression: Normal bones and joints of the right hand.

THIGH RIGHT APL Findings: There is a comminuted fracture in the distal third of the right femur with surrounding soft tissue swelling, the rest of the bone are normal in density, texture and modeling. Impression: Comminuted fracture, distal third, right femur with soft tissue swelling.

KNEE RIGHT APL Findings: There is a comminuted fracture in the distal third of the right femur with surrounding soft tissue swelling, the rest of the bone are normal in density, texture and modeling. Impression: Comminuted fracture, distal third, right femur with soft tissue swelling

48

APPENDIX H (Drug Study) Celecoxib

49

APPENDIX I(drug study) Tramadol

50

APPENDIX H (drug study) Cefuroxime axetil

51

51

APPENDIX I NCP day 1 (actual)

Cebu Normal University College of Nursing Cebu City Mission-Vision: Care Using Knowledge and Compassion NURSING CARE PLAN
NCP Scoring 10pts Nursing Diagnosis (at least 5 references) 2pts Defining Characteristics Outcome 3pts Intervention 1pt 3pts Bibliography 1pt

Clients Name: T.B.M Age: _32 y/o Sex: Male Civil Status: _Married Religion: R. Catholic Allergies: Food: No Known food allergies Drug: No Known drug allergies Diet: Diet as tolerated Date of Admission: July 6, 2011 measures Diagnosis: Fracture, Closed, Distal 3rd Femur, Right, Comminuted _________________________________________________________

Patient Care Classification: (Please Check) ____/______ Wholly Compensatory: Pts. therapeutic care is accomplished by nurse ___ ___ Partially Compensatory: Pts. performs some self-care measures __________ Supportive Educative: Pts. accomplishes self- care Clinical Division and Bed No.: Ward VII (orthopedic ward) bed 21 Name of Physician: Dr. Dominic Vicua Name of Student: Macayan, Jellou Ray M.

DEFINING CHARACTERISTICS Nursing Diagnosis: Acute pain related to movement of bone fragments secondary to comminuted fracture. Subjective:ngol-ngol kaayu ang ako bali as verbalized. Objective: Received patient lying on bed with head elevated, awake, conscious, coherent,

EXPECTED OUTCOME CRITERIA SHORT TERM: After 5 hours of nursing intervention the patient will be able to verbalize pain relief as evidenced by decreased pain score LONG TERM: After 3 days of nursing intervention, the patient will be able to: - Verbalize and demonstrate techniques that provide pain

INTERVENTION AND RATIONALE I-Assess level of pain, location, character, and aggravating factors R-To rule out for worsening of underlying conditions and development of complication and prevent occurrence. S-Doenges, et. Al 2008, p 501 I-Observe for non-verbal cues of pain R-Observation may not be congruent with verbal reports and

BEHAVIORAL OUTCOME SHORT TERM After 5 hours of nursing intervention: wa na kaayu sakit ang ako bali dong. As verbalized, pain score decreased from 7out of 10 to 3 out of 10. LONG TERM: After 3 days of nursing intervention the patient was

52
communicative, with foam traction at right foot, with pain score of 7 out of 10, grimaced face noted, irritability observed, restlessness noted, limited range of motion observed relief. Demonstrate effective use of relaxation techniques as indicated for individual situation. may prompt change in locus of intervention. S-Doenges, et. Al 2008, p 501 I-Provide comfort measures as possible such as touch therapy, repositioning, use of cold/heat packs, constant interaction, quiet environment and calm activities R-maximizes use of nonpharmacological techniques for pain relief S-Doenges, et. Al 2008, p 501 I-Instruct in and encourage use of relaxation techniques such as focused breathing and imaging. R-to distract attention and thus reduce tension S-Doenges, et. Al 2008, p 501 I-Encourage to engage in diversional activities such as socialization with other patients or listening to music. R-To distract attention and reduce tension. S-Doenges, et. Al 2008, p 501 I- Taught patient about nonpharmacological pain management. R-to promote self control and management of pain. S-Doenges, et. Al 2008, p 501 Dependent/ Collaborative: I-Administer analgesics as to a maximum as needed as indicated R-to maintain acceptable level of pain able to demonstrate effective use of relaxation techniques as evidenced by decreased recurrence of pain perception.

Laboratory: None significant

Theoretical Basis: According to Doenges, Moorhouse and Murr, acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in such tissue damage (international association for the study of pain). It is a sudden of slow onset of any intensity from mild to severe with an anticipated

53
predictable end and a duration of less than 6 months. Pain is explained as a combination of physiologic phenomena in addition to a psychosocial aspect that influence pain perception (Melzack and Wall,1965) Pain is also described as transient, tissue injury, trauma related, burn, iatrogenic or chronic neuropathic (Weber and Kelley 2007) S-Doenges, et. Al 2008, p 502 I-Instruct client in use of transcutaneous electrical nerve stimulation units when ordered. R-To maintain acceptable level of pain and comfort. S-Doenges, et. Al 2008, p 502 I-Refer to occupational/physical therapy program. R-Promotes active role and enhances self-control.

54

APPENDIX J NCP day 2 (actual)

Cebu Normal University College of Nursing Cebu City Mission-Vision: Care Using Knowledge and Compassion NURSING CARE PLAN

NCP Scoring 10pts Nursing Diagnosis (at least 5 references)

2pts

Defining Characteristics Outcome

3pts

Intervention 1pt

3pts Bibliography

1pt

Clients Name: T.B.M Age: _32 y/o Sex: Male Civil Status: _Married Religion: R. Catholic Allergies: Food: No Known food allergies Drug: No Known drug allergies Diet: Diet as tolerated Date of Admission: July 6, 2011 measures Diagnosis: Fracture, Closed, Distal 3rd Femur, Right, Comminuted _________________________________________________________

Patient Care Classification: (Please Check) ____/______ Wholly Compensatory: Pts. therapeutic care is accomplished by nurse ___ ___ Partially Compensatory: Pts. performs some self-care measures __________ Supportive Educative: Pts. accomplishes self- care Clinical Division and Bed No.: Ward VII (orthopedic ward) bed 21 Name of Physician: Dr. Dominic Vicua Name of Student: Macayan, Jellou Ray M.

DEFINING CHARACTERISTICS Nursing Diagnosis: Impaired Physical Mobility related to musculoskeletal impairment secondary to prescribed restrictive therapies. (traction) Subjective: maglisod man jud kog lihok sa ako lawas as verbalized. Objective: Received patient lying on bed

EXPECTED OUTCOME CRITERIA SHORT TERM GOAL: After 5 hours of nursing intervention, the patient will be able to perform activities of daily living at the level of functional capabilities.

INTERVENTION AND RATIONALE I-provision of normal range of motion exercises and function of lower extremity. R- Necessary to regain normal mobility of leg to speed recovery I-Encourage progressive activities according to level of functional capability. R-Increase patients

BEHAVIORAL OUTCOME SHORT TERM: After 5 hours of nursing intervention, the patient was able to demonstrate effective use of trapeze in mobilizing and repositioning on bed. LONG TERM: After 3 days of nursing intervention, goal is met through

LONG TERM GOAL: After 3 days of nursing intervention,

55
with head elevated to 30 degrees, awake, conscious, coherent, communicative, with foam traction at right foot, the patient is reading a newspaper, has difficulty in changing position while lying on bed, has difficulty in moving the extremities, inability to walk or stand alone, limited range of motion in the extremities, slowed movement, difficulty in initiating gait THEORETICAL BASIS: Physical mobility, the capability of movement, is necessary for the health and well-being of all Persons, Hogue (1984) identified mobility as the most important functional ability that determines the degree of independence and health care needs. Fracture Foam traction Decreased control of extremities Restriction of purposeful movement Impaired physical mobility the patient will be able to demonstrate and verbalize proper exercises of the lower extremities & can perform activities of daily living with minimal assistance. use of affected leg. I-instruct and encourage use of overhead trapeze in mobilizing in the bed. R-To obtain sense of control during movement. S- Doenges et. Al. page 459 I-encourage participation in self-care, occupational/diversional/ recreational activities. R-enhances self concept and sense of independence. S- Doenges et. Al. page 459 I-Identify energy conserving techniques for ADLs. R-Limits fatigue and maximizes participation S- Doenges et. Al. page 459 I-Encourage adequate intake of fluid and nutrition. R-Promotes well-being and energy production. S- Doenges et. Al. page 459 I-Provide proper skin care R-To decrease risk for decubitus ulcer S- Doenges et. Al. page 459 Collaborative/dependent: I-Administer medications as needed prior to activity for pain relief R-To permit maximal effort and involvement in activity. S-Doenges et. Al. page 460 I-Consult with Occupational therapy as ordered. the regaining of the patients previous range of motion in the leg & demonstrates proper exercises for the lower extremities. He also does some ADL without discomfort.

56
R-To maintain continuity of care after discharge. S- Doenges et. Al. page 459

APPENDIX K

57

NCP day 3 (actual)

Cebu Normal University College of Nursing Cebu City Mission-Vision: Care Using Knowledge and Compassion NURSING CARE PLAN

NCP Scoring 10pts Nursing Diagnosis (at least 5 references)

2pts

Defining Characteristics Outcome

3pts

Intervention 1pt

3pts Bibliography

1pt

Clients Name: T.B.M Age: _32 y/o Sex: Male Civil Status: _Married Religion: R. Catholic Allergies: Food: No Known food allergies Drug: No Known drug allergies Diet: Diet as tolerated Date of Admission: July 6, 2011 Diagnosis: Fracture, Closed, Distal 3rd Femur, Right, Comminuted _________________________________________________________

Patient Care Classification: (Please Check) ____/______ Wholly Compensatory: Pts. therapeutic care is accomplished by nurse ___ ___ Partially Compensatory: Pts. performs some self-care measures _____Supportive Educative: Pts. accomplishes self- care measures Clinical Division and Bed No.: Ward VII (orthopedic ward) bed 21 Name of Physician: Dr. Dominic Vicua Name of Student: Macayan, Jellou Ray M.

DEFINING CHARACTERISTICS

EXPECTED OUTCOME CRITERIA

INTERVENTION AND RATIONALE

BEHAVIORAL OUTCOME

58
Nursing Diagnosis: Risk for Trauma (additional injury) related to loss of skeletal integrity and improper placement of traction weights. Subjective:dali ra masabod sa mga mangagi kanang baton a gbitay. As verbalized Objective: Received patient lying on bed with head elevated, awake, conscious, coherent, communicative, with foam traction at right foot, absence of side rails noted, traction weights placed of walkways, absence of bed padding noted, high placement of bed observed, seen SO frequently leaving the patient. LABORATORY: None Significant SHORT TERM: After 4 hours of nursing intervention, the patient will be able to verbalize understanding of condition and recognize need for prevention of injuries. LONG TERM: After 3 days of nursing intervention, the patient will be able to: - Demonstrate appropriate lifestyle changes to reduce risk for injury. - Maintain condition without additional injury and decrease risk for trauma. I-Identify factors related to individual situation and identify extent of risk. R-Influences scope and intensity of interventions to manage safety. S-Doenges et. Al. 2000 p718 I-Note clients decision-making ability and level of cognition including functional capability. R-Affects clients ability to protect self and influences choice of interventions and teaching. S-Doenges et al. 2000 p718 I-Implement interventions regarding safety issues includes: -orient client to environment. -keep bed in low position. -pad bed edges as possible. -provide adequate area lighting -assist with moving/turning using trapeze R-Failure to accurately assess, intervene and/or refer these these issues can place patients at needless risk and create negligence issues for healthcare practitioner S-Doenges et. Al 2000 p 718 I-Provide quiet environment and reduced stimulation as possible. R-helps limit confusion or overstimulation. S-Doenges et. Al 2000 p 718 I-Place traction weights at appropriate location away from passageways as possible. R-To prevent moving the weights SHORT TERM: After 8 hours of nursing intervention: salamat kayo dong, nakasabot nako ngano delikado jud na ako ni ilihok lihok ako tiilas verbalized.

LONG TERM: After 3 days of nursing intervention: -the patient was seen demonstrating appropriate lifestyle changes to reduce risk for injury such as asking for help from SO upon moving and using trapeze effectively when turning. - The patient is free from additional injury at the end of the duration of care.

THEORETICAL BASIS: A fracture occurs when the stress placed on a bone is greater than a bone can absorb. Muscle, blood vessels, nerves, tendons, joints and other organs maybe injured when fracture occurs. This condition may result to a loss of skeletal integrity that may possibly lead to further

59
injury as a result of environmental conditions interactions with the patients adaptive and defensive resources. causing disaligment of bone fragments. S-Doenges et. Al 2000 p 718 Collaborative/Dependent: I-assist with treatment of underlying medical/surgical conditions. R-To improve cognition/thinking process

60
APPENDIX L Focused Charting Day 1 Republic of the Philippines Department of Health Regional Health office no.7 Vicente Sotto Memorial Medical Center B. Rodriguez St., Cebu City NURSES PROGRESS NOTES

Date 7/18/11

Time

10:00A M

F Focus Acute pain

D Data A Action R - Response

D - received patient lying on bed with head elevated to 30

degrees, awake, conscious, coherent, communicative, without IV, with the following v/s T= 35.5 degree Celsius, P= 86 pm, R= 20 bpm and BP= 120/70 mmHg, with foam traction at right foot, with pain score of 7 out of 10, grimaced face noted, irritability observed, restlessness noted, limited range of motion observed, ngol-ngol kaau ang akong bali dong. As verbalized. A - Actions made included; Introduced name to the patient, assessed level of pain, character and location, monitored v/s, positioned properly on bed with head slightly elevated, Due medications (analgesics) administered as ordered, encouraged to engage in diversional activities such as socialization with others, provided comfort measures such as backrub, encouraged patient to do DBE; supported affected body parts/ joints using pillows/ rolls, consulted with physical or occupational therapist as indicated, documented the v/s and I and O of the patient. R - :wa na kaayu sakit ang ako bali dong. As verbalized, pain score decreased from 7out of 10 to 3 out of 10.

Surname: M Given Name: T APPENDIX M Focused Charting Day 2

Age: 32 years old Ward: VIII (orthopedic ward)

Sex: Male Bed No: 21

Case No:

Republic of the Philippines Department of Health Regional Health office no.7 Vicente Sotto Memorial Medical Center B. Rodriguez St., Cebu City NURSES PROGRESS NOTES

61

Date 7/19/11

Time 10:00AM

F - Focus Impaired physical Mobility

D Data A Action R - Response

D - received patient lying on bed with head elevated to 30

degrees, awake, conscious, coherent, communicative, without IV, with the following v/s T= 35.5 degree Celsius, P= 86 pm, R= 20 bpm and BP= 120/70 mmHg, with foam traction at right foot, the patient is reading a newspaper, has difficulty in changing position while lying on bed, has difficulty in moving the extremities, inability to walk or stand alone, limited range of motion in the extremities, slowed movement, difficulty in initiating gait. maglisod man ko ug lihok dong. As verbalized. A - Introduced name to the patient, assessed the condition of the patient; monitored v/s, positioned properly on bed with head slightly elevated, assisted patient in doing ROM exercises, assisted patient upon doing gait training, instructed in proper use of overhead trapeze, provided comfort measures such as backrub, encouraged patient to do DBE; supported affected body parts/ joints using pillows/ rolls, consulted with physical or occupational therapist as indicated, documented the v/s and I and O. R - patient was able to demonstrate increasing functionality of the extremities as evidenced by turning on bed without assistance and effective usage of overhead trapeze. Sex: Male Bed No: 21 Case No:

Surname: M Given Name: T

Age: 32 years old Ward: VIII (orthopedic ward)

APPENDIX N Focused Charting Day 3 Republic of the Philippines Department of Health Regional Health office no.7 Vicente Sotto Memorial Medical Center B. Rodriguez St., Cebu City NURSES PROGRESS NOTES

Date 7/20/11

Time 10:00AM

F - Focus Risk for additional Injury

D Data A Action R - Response

D - Received patient lying on bed with head elevated,

awake, conscious, coherent, communicative, without IV, with the following v/s T= 37 degree Celsius, P= 62 pm,

62
R= 21 bpm and BP= 130/70 mmHg, with foam traction at right foot, absence of side rails noted, traction weights placed of walkways, absence of bed padding noted, high placement of bed observed, seen SO frequently leaving the patient, dali raman masabaod ang kanang mga bato. As verbalized A - Introduced name to the patient, assessed the condition of the patient, instructed SO to stay with patient as much as possible, implemented interventions regarding safety issues such as orientation of patient to environment, keeping bed in low position, providing adequate area lighting and padding of side rails as possible, monitored v/s, positioned properly on bed with head slightly elevated, assisted patient in doing ROM exercises, assisted patient upon doing gait training, instructed in proper use of overhead trapeze, provided comfort measures such as backrub, encouraged patient to do DBE; supported affected body parts/ joints using pillows/ rolls, consulted with physical or occupational therapist as indicated, documented the v/s and I and O of the patient. R - the patient was able to demonstrate behaviors to promote safety, SO was seen staying with patient most of the time Surname: M Given Name: T Age: 32 years old Ward: VIII (orthopedic ward) Sex: Male Bed No: 21 Case No:

CURRICULUM VITAE

PERSONAL INFORMATION Name Year & Section Adviser Provincial Address City Address Telephone No. Cell no. E-mail Address : : : : : : : : Jellou Ray M. Macayan BSN 4-B Mrs. Lagrimas Elizon P-6, Urbiztondo Street, Poblacion, Barobo, Surigao Del Sur Block 24, Lot 10, La Aldea, Buena Mactan, Lapu-lapu city 2386882 09239855653 bk_addicted@yahoo.com

63
Birthday : July, 1, 1991

EDUCATIONAL BACKGROUND Elementary School Year Secondary School Year Tertiary School Year AFFILIATIONS Position Member : : Organization Nightingale Student Council : : Cebu Normal University 2008-present : : Barobo National high School 2004-2008 : : Barobo Central Elementary School 1998-2004