VEHICULAR ACCIDENT

A Nursing Care Plan

Presented to
Sir Karl Christian Golucan
Clinical Instructor
Saint Louis University

In Partial Fulfillment of
The Course Requirement
For Related Learning Experience
Payward Room
By:
BSN IV Group A1
Balingway,Beverly D.

February 7,2015

Name: De Ocampo,Nestor C.

Sex: Male

Birthday:04/22/1957 Age: 57 years old

Place of Birth: Nueva Ecija
Address: 195,Bongabon 28 Nueva Ecija
Civil Status: Married
Nationality: Filipino
Religion: Roman Catholic
Dialect: Tagalog, Ilocano
Educational Attainment: College Graduate
Date of Admission:01/104/2015

B.

Chief Complaint(s)
Continious Pain on the wound site

C.

History of present illness:

The Patient was apparently well until 1 day prior to admission, the patient had

motor vehicular accident. The patient fell on a concrete ground hitting his left side of the
body; thus, abrasions and open wounds were seen on his left hand and leg. The patient
was brought to a nearby community hospital by the people who witnessed the
accident.He felt pain on the left side specifically on the hip area.X ray revealed fracture
on the site and debridement was done. The patient felt weak and felt continious pain on
the wound site; thus, sought consultation to this institution; hence, the admission.

D. Past History:
The patient has no known previous hospitalizations. The patient verbalized that he had
not experienced any major illness or accident that required hospitalization before. The
patient only verbalized to have experienced common illnesses such as cough and colds,
body aches, and fever. He has no allergies to food; he states that he has no specific
preference for food. He also added that he has no allergies to drugs and environmental
changes. The patient claims to be completely immunized as a child. He also verbalized
that they utilize over-the-counter drugs like paracetamol, and neozep to cure common

illnesses such as cough and colds, fever, and body ache. The patients childhood history
reveals that the patient had chicken pox and measles.

Family History
There is family history of hypertension under his fathers side. He denies family
history of bronchial asthma, Diabetes Mellitus, Cardiac Arrest, Arthritis, CVD, CAD,
congenital anomalies/abnormalities, cancer, and PTB. Deceased family members died
of old age as verbalized by patient.

Social and Environmental History

The patient is 57 y/o currently self-employed. Patient lives with his wife and
daughter and is served by helpers in their house. There is nothing much he can do at
home since there are people assigned to complete the house chores as stated by the
patient. The patient has a harmonious relationship with his wife and his daughter as
stated by the patient. Patient lives along a non-congested neighborhood in an owned
house, with 3 rooms and 4 occupants. Source of water for domestic purpose comes
from a deep well nearby house. Drinking water is mineral water. Their garbage is
collected regularly every week. Toilet is flush type.

GORDONS FUNCTIONAL PATTERNS

A. Health Perception Health Management Pattern
The patient has no known previous hospitalizations. The patient
verbalized that he had not experienced any major illness or accident that
required hospitalization before. The patient only verbalized to have experienced
common illnesses such as cough and colds, body aches, and fever. The patient
claims to be completely immunized as a child. He also verbalized that they utilize
over-the-counter drugs like paracetamol, and neozep to cure common illnesses
such as cough and colds, fever, and body ache. The patients childhood history
reveals that the patient had chicken pox and measles. The patient doesnt
smoke. The patient doesnt drink any kind of liquor. The patient has no known
allergies to food and drugs. The patient perceives his health fairly. The patient
has no regular basis for exercise but follows prescribed regimen. Patient seeks
help of the doctor whenever he feels there is a problem in his health. There was
no regular basis for check up.
B. Nutritional Metabolic Pattern
The patient weighs 66 kilogram and there were no weight fluctuations for
the last 6 months. The patient is on full diet regularly. The patient has normal
appetite and no food preference. The patient needs minimal assistance when.
The patient has pink buccal cavity and moist, no inflammations noted. Patient
has no dentures. Patient has an ongoing IVF of PNSS 1 Liter infuse for 12 hours
infusing well on the right arm. Skin is pinkish brown in color, warm to touch, dry,
good skin turgor, no edema, intact (for the non affected side). The clients meals
include rice, green leafy vegetables, and fruits. The patient does not skip meals.
There was a regular time for eating breakfast, lunch, dinner and snacks. The
patient eats heavy breakfast, lunch and dinner. The patient has no vitamin or any
kind of supplementation. The patient has also no difficulty in chewing and
swallowing.

C. Elimination Pattern
Patient usually has his bowel elimination every morning. He defecates
once everyday. The patient did not experience constipation or diarrhea. The
patient usually urinates 3 -4 x daily. The patient did not experience dysuria,
incontinence or hematuria. There were no any assistive devices connected to the
patient. Abdomen was symmetrical and protruded. The patient has a normal
bowel sound which is 12 per minute. Upon palpations, patients abdomen was
soft and no tenderness. Characteristics of bowel and urine are still the same as
for the normal stool and urine of the patient.
D. Activity Exercise Pattern
The patient has no musculoskeletal anomalies. There were no tremors,
and swelling. Self Care Ability:

0 Independent

1 Assistive Device
2 Assistance From Others
3 Assistance from person and equipment
4 Dependent/ Unable
ACTIVITIES
0
1
2
3
4
Eating
X
Bathing
X
Dressing
X
Toileting
X
Bed Mobility
X
Transferring
X
Ambulating
X
Stairs
X
The patient has assistive devices such as walker or cane.. Patient has
normal posture, no deformities. Patients pulse rate is normal which is 90bpm
(normal = 60-100 bpm). Upon inspection, patient has symmetrical chest and
respirations were regular and normal with absence of adventitious breath
sounds.

E. Sleep Rest Pattern

The patient usually sleeps at 9:00 pm and wakes 6:00 am daily. The
patient usually has 8-9 hours of sleep. The patient takes 1.5 hour to 2 hours nap
in the afternoon everyday. Patient has no bedtime rituals. The patient has no
difficulty in waking up.
F. Cognitive Perceptual Pattern
The patient is conscious and coherent. The patients affectation is flat.
The patient is oriented to time, person, and place. The patient has long term
memory loss. Pupils are equal in size and brisk in reaction. Patients reflexes are
normal. Patient has 5/5 muscle strength on upper extremities and 4/5 on the right
lower extremity and 3/5 on the left lower extremity. Patient has no tingling
sensation. Patient complains for pain in the left hip area, rated as 4, 10 as the
highest. The patient has no abnormalities on his 5 senses. The patient is able to
communicate, speak,

and articulate. The patient is able to make decisions

easily. The patient stated that pain affects his habits and activities.
G. Self Perception Self Concept Pattern
Patients appearance is calm. Patients level of anxiety is 2 from scale of
0-10. Face is not reddened. Voice quality is loud. Patient answers questions
readily. Patient views himself as positive. The patient does not foresee his
condition as a future problem to his body image and structure. The patient
manifests no body disturbances.
H. Role Relationship Pattern
The patient lives with his family in a house of 3 rooms and 4 occupants.
He lives with his wife and daughters. The patient is self-employed. The patient
has his wife and 2 daughters as his support system. Patient has a good
relationship with his family members and relatives. The patient perceived no
changes in usual role. Social activities are limited due to pain upon execution.

I.

Sexuality Reproductive

The patient is 57 years old and is a male. Patient has no history of

prostate problems. No history of penile discharges. Patient denies on the history
of sexual transmitted diseases.
J. Coping Stress Tolerance Pattern
Patient is usually not stressed. Watching television is done to relieve any
stress felt. The patient has no major concerns on his hospitalization.
K. Value Belief Pattern
The patient is a roman catholic. Patient denies on religious restrictions.
Patient believes that prayers help much.

DIAGNOSTIC TESTS
TEST
CBCP

X-ray

RESULTS
Elevated WBC
12x10^9/L
Hgb = 142 g/L
Hct = 0.427 %
MCV = 84.4
MCH = 28 pg
MCHC = 332 g/L
None yet

NORMAL VALUES
5-10x10^9/L
120-170
0.4-0.54
76-96
27-32
320-360
N/A

PATHOPHYSIOLOGY

RATIONALE
To indicate or to know
presence of infection
and assess for blood
loss and function of
components of blood.
To indicate presence
of fractures or injuries.

Vehicular Accident
Patient Fell off his tricycle
Patient fell of on the concrete ground hitting his left side of the body
Increase Friction and Pressure on the skin
Damaging the layers of the skin
Open Wounds/ Abrasions Destroyed First line of defense against microbes
Stimulate the hypothalamus to produce prostaglanding-releasing hormone
Production of prostaglandin
Risk for
Infection

Stimulation of free nerve endings

Pain will enter the substancia gelatinosa
Cerebral Cortex for crude interpretation of pain
Hypothalamus for the specific interpretation of pain
Aggravated by movement
Patient not able to tolerate ADLs
Requiring assistance

Pain related to tissue

trauma secondary to
vehicular accident
Activity Intolerance
related to pain upon
movement

Sources:
Medical-Surgical Nursing Textbook by Brunner and Suddarth 11th edition, p.635
Medical Surgical Nursing by Black and Hawks 7th edition p.1842

PROBLEM PRIORITIZATION

LIST OF PRIORITIZED PROBLEMS

Actual:
Activity Intolerance related to pain upon movement
Pain Related to tissue trauma secondary to vehicular accident
Potential:
Risk for Infection
PRIORITIZATION OF PROBLEMS:
Classification
(Under
Maslows
Hierarchy of
Needs)

Subclassification
(Under
OFFTERAS)

Problem

Justification

actual problem
Activity

Physiologic
Patients
Verbalization
(actual problem)

Potential problem

Activity
Intolerance
related to
pain upon
movement

Pain
related to
tissue
trauma
secondary
to
vehicular
accident

Risk
for
Infection

According
to
OFFTERAS,
activity is the priority need to be
satisfied That is why the
problem related to activity is
the first to be prioritized ant
according to the patient, the
cause of his activity intolerance
is because of the pain.

Pain is the second prioritized

problem because it is the
patients secondary complaint.

Since risk for infection is a

potential
problem,
it
is
prioritized last.