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PERSONAL DATA

Name: Mr. PP
Age: 82 y/o
Sex: Male
Birthplace: Solano, Nueva Vizcaya
Birthday: 07-07-1928
Address: Solano, Nueva Vizcaya
Civil Status: Married
Occupation: None
Religion: Roman Catholic
Nationality: Filipino
Educational Attainment: Elementary Undergraduate
1st Wife: Deceased
2nd Wife: Mrs. AP
Age: 49
Occupation: None
Children: (1st Wife) 8

Attending Physician: Dr. Calata / Dr. Tagayuman


Type of Admission: New
Social Service Classification: C3
Date of Admission: November 28, 2010
Time of Admission: 11:30am
Ward: Surgery Ward
Room: 233 (Ortho)
Admitting Diagnosis: t/c Femoral Neck Fracture
Principal Diagnosis: Femoral Neck Fracture Right
Chief Complaint: mobility standing on his Right Lower Extremity,
pain @ inguinal area
HISTORY OF PAST ILLNESSES
According to the patient, he used to smoke 1 pack of cigarette a day. It started
when he was still an adolescent. Ten years ago, he was diagnosed to have Bronchial
Asthma, from then on, he stopped smoking. When he is experiencing an attack, he takes
Salbutamol via nebulization. He has been to hospital for about 1-2 times in every 2 years.
The factors that trigger his asthma are: allergens (dust, pollens, animal dander), irritants (smoke, strong
perfumes/odors, weather changes, cold air) and excessive exercise.

The patient also suffered from common colds, cough, and fever especially during
cold season. He usually takes OTC drugs such as Paracetamol.

HISTORY OF PRESENT ILLNESS


According patient, he had history of fall 1 month ago (October 29, 2010) from a
tricycle drove by his son when they were going to the cemetery, landing on his Right
Lower Extremity. Right after the accident, consult was done at MMG, x-ray done and
diagnostic to have Normal X-rays. Ten days after, patient experienced progressive pain
and decreased ROM to mobility standing on his Right Lower Extremity. Persistent of
above symptom prompted consult.
On November 28, 2010, 11:30am, he was admitted with complaint of inability
standing on his right lower extremity and pain at his inguinal area. His admitting
diagnosis: to consider Femoral Neck Fracture.
As claimed by the patient, he had only hypertension when he was admitted to the
hospital; his BP was 160/80. Medications given were Diclofenac Sodium 75mg IV q8,
NTG patch ACWL, Clonidine 150mg tab.

On November 29, Skin Traction was applied. December 6, the patient had Partial
Hip Replacement @ Right Femur, and Anthroplasty + Bone Cement @ Right Femur.

FAMILY HISTORY
According to the client, there were known history of Hypertension, Diabetes,
Heart Failure, Cancer and Asthma in their family.
BRIEF DESCRIPTION OF THE PRESENT ILLNESS

FRACTURE

A fracture is a break in the continuity of bone. It is defined according to type and


extent. Fractures occur when the bone is subjected to stress greater than it can absorb. A
direct blow, crushing, force, sudden twisting motion, or even extreme muscle contraction
can cause fractures. When the bone is broken, adjacent structures are also affected,
resulting in tissue edema, hemorrhage into the muscles and joints, joint dislocations,
ruptured tendons, served nerves, and damaged blood vessels. Body organs may be injured
by the force that caused the fracture or by the fracture fragments.

TYPES OF FRACTURES

• Complete fracture- break across the entire cross-section of the bone


• Incomplete fracture-break occurs through only part of the cross-section of bone
• Comminuted fractures-break with several bone fragments
• Closed fracture-does not produce a break in the skin
• Open fracture- break in which the skin wound extends to the fractured bone

CLINICAL MANIFESTATIONS

• Deformity
• Swelling
• Bruising
• Muscle spasm
• Pain
• Tenderness
• Loss of function
• Abnormal mobility and crepitus
• Neurovascular changes
• Shock

ASSESSMENT AND DIAGNOSTIC FINDINGS

The diagnosis of a fracture depends on the symptoms, the physical signs, and
radiographic examination. Usually the patient reports an injury to the area.

MEDICAL MANAGEMENT
EMERGENCY MANAGEMENT

• Immediately after injury, immobilize the body part before the patient is moved. If
an injured patient must be moved before splints can be applied, support the
extremity above and below the fracture site to prevent rotation or angular motion.
• Splint the fracture, including joints adjacent to the fracture, to prevent damage to
the soft tissue.
• Apply temporary, well-padded splints, firmly bandaged over clothing, to
immobilize the fracture.
• Assess neurovascular status distal to the injury to determine adequacy of the
peripheral tissue perfusion and neuro function. Be alert for paresthesia or
paralysis.
• Cover the wound of an open fracture with a clean dressing to prevent
contamination of deeper tissues.
BRONCHIAL ASTHMA

Bronchial asthma is a disease caused by increased responsiveness of the


tracheobronchial tree to various stimuli.
Bronchial asthma is a disease of the lungs in which an obstructive ventilation
disturbance of the respiratory passages evokes a feeling of shortness of breath. The cause
is a sharply elevated resistance to airflow in the airways. Despite its most strenuous
efforts, the respiratory musculature is unable to provide sufficient gas exchange. The
result is a characteristic asthma attack, with spasms of the bronchial musculature,
edematous swelling of the bronchial wall and increased mucus secretion. In the initial
stage, the patient can be totally symptom-free for long periods of time in the intervals
between the attacks. As the disease progresses, increased mucus is secreted between
attacks as well, which in part builds up in the airways and can then lead to secondary
bacterial infections. Bronchial asthma is usually intrinsic (no cause can be demonstrated),
but is occasionally caused by a specific allergy (such as allergy to mold, dander, dust).
Although most individuals with asthma will have some positive allergy tests, the allergy
is not necessarily the cause of the asthma symptoms.

Bronchial asthma triggers may include:

• Tobacco smoke
• Infections such as colds, flu, or pneumonia
• Allergens such as food, pollen, mold, dust mites, and pet dander
• Exercise
• Air pollution and toxins
• Weather, especially extreme changes in temperature
• Drugs (such as aspirin, NSAID, and beta-blockers)
• Food additives (such as MSG)
• Emotional stress and anxiety
• Singing, laughing, or crying
• Smoking, perfumes, or sprays
• Acid reflux

Signs and Symptoms of Bronchial Asthma

With bronchial asthma, you may have one or more of the following signs and symptoms:

• Shortness of breath
• Tightness of chest
• Wheezing
• Excessive coughing or a cough that keeps you awake at night

Diagnosing Bronchial Asthma

Because asthma does not always happen at the doctor's visit, it's important for you to
describe your asthma signs and symptoms to your doctor. You might also notice when
the symptoms occur such as during exercise, with a cold, or after smelling smoke.
Asthma tests may include:

• Spirometry: A lung function test to measure your breathing capacity and how well you
breathe. You will breathe into a device called a spirometer.
• Peak Expiratory Flow (PEF): Using a device called a peak flow meter, you forcefully
exhale into the tube to measure the force of air you can expend out of your lungs. Peak
flow monitoring can allow you to monitor your how well your asthma is doing at home.
• Chest X-Ray: Your doctor may do a chest X-ray to rule out any other diseases that may
be causing similar symptoms.
Treating Bronchial Asthma

Once diagnosed, your asthma doctor will recommend asthma medication (which can
include asthma inhalers and pills) and lifestyle changes to treat and prevent asthma
attacks. For example, long-acting anti-inflammatory asthma inhalers are often necessary
to treat the inflammation associated with asthma. These inhalers deliver low doses of
steroids to the lungs with minimal side effects if used properly. The fast-acting or
"rescue" bronchodilator inhaler works immediately on opening airways during an asthma
attack.

If you have bronchial asthma, make sure your doctor shows you how to use the inhalers.
Be sure to keep your rescue inhaler with you in case of an asthma attack or asthma
emergency. While there is no asthma cure yet, there are excellent asthma medications
that can help with preventing asthma symptoms and asthma support that can help you live
a normal, active life.

HYPERTENSION

The medical term for high blood pressure. High blood pressure and hypertension
are interchangeable terms used to describe blood traveling through the arteries at a
pressure that is consistently too high to maintain good health. Although hypertension
often causes no symptoms, it is dangerous. Left untreated, the disease can lead to severe
and possibly life-threatening damage to the heart, kidneys, and arteries.

Sometimes people with markedly elevated blood pressure may develop:

• headache,
• dizziness,
• blurred vision,
• nausea and vomiting, and
• chest pain and shortness of breath.

Blood pressure lower than 120/80 mmHg is considered normal. A person with
readings of 120-139/80-89 mmHg is considered to have prehypertension. Blood pressure
that is consistently over 140/90 mmHg indicates stage 1 hypertension. Blood pressure
above 160/100 mmHg is stage 2 hypertension.

CAUSES
Essential hypertension
Essential hypertension is the most prevalent hypertension type, affecting 90–95% of
hypertensive patients. Although no direct cause has been identified, there are many
factors such as sedentary lifestyle, smoking, stress, visceral obesity, potassium deficiency
(hypokalemia), obesity (more than 85% of cases occur in those with a body mass
index greater than 25), salt (sodium) sensitivity, alcohol intake, and vitamin D
deficiency that increase the risk of developing hypertension. Risk also increases
with aging, some inherited genetic mutations, and having a family history of
hypertension. An elevated level of renin, a hormone secreted by the kidney, is another
risk factor, as is sympatheticnervous system overactivity. Insulin resistance, which is a
component of syndrome X (or the metabolic syndrome), is also thought to contribute to
hypertension. Recent studies have implicated low birth weight as a risk factor for adult
essential hypertension.
Secondary hypertension
Secondary hypertension by definition results from an identifiable cause. This type is
important to recognize since it's treated differently to essential hypertension, by treating
the underlying cause of the elevated blood pressure. Hypertension results in the
compromise or imbalance of the pathophysiological mechanisms, such as the hormone-
regulating endocrinesystem, that regulate blood plasma volume and heart function. Many
conditions cause hypertension, some are common and well recognized secondary causes
such as Cushing's syndrome, which is a condition where the adrenal glands overproduce
the hormone cortisol. In addition, hypertension is caused by other conditions that cause
hormone changes such as hyperthyroidism, hypothyroidism (citation needed), and certain
tumors of the adrenal medulla (e.g., pheochromocytoma). Other common causes of
secondary hypertension include kidney disease, obesity/metabolic disorder, pre-
eclampsia during pregnancy, the congenital defect known as coarctation of the aorta, and
certain prescription and illegal drugs.

COMPLICATIONS

Hypertension is the most important risk factor for death in industrialized countries. It
increases hardening of the arteries thus predisposes individuals to heart disease,
peripheral vascular disease, and strokes. Types of heart disease that may occur include:
myocardial infarction, heart failure, and left ventricular hypertrophy

MANAGEMENT

• Weight reduction if overweight


• Reduce sodium intake
• Increase aerobic exercise
• Limit alcohol intake
• Maintain adequate intake of potassium
• Eat a diet rich in fruits, vegetables, and low-fat dairy products but reduced in
saturated and total fat
• Discontinue tobacco use

TEN WAYS TO CONTROL HYPERTENSION

1. Know your blood pressure. Have it checked regularly.


2. Know what your weight should be. Keep it at that level or below.
3. Do not use too much salt in cooking or at meals. Avoid salty foods.
4. Eat a low-fat diet according to American Heart Association recommendations.
5. Do not smoke cigarettes or use tobacco products.
6. Take your medicine exactly as prescribed. Do not run out of pills even for a single
day.
7. Keep appointments with the doctor.
8. Follow your doctor’s advice about exercise.
9. Make certain that your parents, brothers, sisters, and children have their blood
pressure checked regularly.
10. Live a normal life in every other way.
ANATOMY AND PHYSIOLOGY

The Lungs

(Pulmones)

The lungs are the essential organs of respiration; they are two in number, placed one on either
side within the thorax, and separated from each other by the heart and other contents of the
mediastinum (Fig. 970).
Each lung is conical in shape, and presents for examination an apex, a base, three borders, and
two surfaces.
The apex is rounded, and extends into the root of the neck, reaching from 2.5 to 4 cm. above
the level of the sternal end of the first rib.
The base is broad, concave, and rests upon the convex surface of the diaphragm, which
separates the right lung from the right lobe of the liver, and the left lung from the left lobe of the
liver, the stomach, and the spleen.

Surfaces.—The costal surface is smooth, convex, of considerable extent, and corresponds to the
form of the cavity of the chest, being deeper behind than in front.
Fissures and Lobes of the Lungs.—The left lung is divided into two lobes, an upper and a
lower, by an interlobular fissure, which extends from the costal to the mediastinal surface of the
lung both above and below the hilus. The superior lobe lies above and in front of this fissure,
and includes the apex, the anterior border, and a considerable part of the costal surface and the
greater part of the mediastinal surface of the lung. The inferior lobe, the larger of the two, is
situated below and behind the fissure, and comprises almost the whole of the base, a large portion
of the costal surface, and the greater part of the posterior border.
The right lung is divided into three lobes, superior, middle, and inferior, by two interlobular
fissures. One of these separates the inferior from the middle and superior lobes, and corresponds
closely with the fissure in the left lung. The middle lobe, the smallest lobe of the right lung, is
wedge-shaped, and includes the lower part of the anterior border and the anterior part of the base
of the lung.
Divisions of the Bronchi.
The right bronchus gives off, about 2.5 cm. from the bifurcation of the trachea, a branch for
the superior lobe. This branch arises above the level of the pulmonary artery, and is therefore
named the eparterial bronchus.
The left bronchus passes below the level of the pulmonary artery before it divides, and hence
all its branches are hyparterial; it may therefore be looked upon asequivalent to that portion of the
right bronchus which lies on the distal side of its eparterial branch.

FIG. 974– Partof a secondary lobule from the depth of a human lung, showing parts of several
primary lobules. 1, bronchiole; 2, respiratory bronchiole; 3, alveolar duct; 4, atria; 5, alveolar sac;
6, alveolus or air cell: m, smooth muscle; a, branch pulmonary artery; v, branch pulmonary
vein; s, septum between secondary lobules. Camera drawing of one 50 μ section. X 20 diameters.
(Miller.)
Each bronchiole divides into two or more respiratory bronchioles, with scattered alveoli, and
each of these again divides into several alveolar ducts, with a greater number of alveoli
connected with them. Each alveolar duct is connected with a variable number of irregularly
spherical spaces, which also possess alveoli, the atria. With each atrium a variable number (2–5)
of alveolar sacs are connected which bear on all parts of their circumference alveoli or air sacs.
(Miller.)
The alveoli are lined by a delicate layer of simple squamous epithelium, the cells of which are
united at their edges by cement substance. Outside the epithelial lining is a little delicate
connective tissue containing numerous elastic fibers and a close net-work of blood capillaries,
and forming a common wall to adjacent alveoli.
The pulmonary artery conveys the venous blood to the lungs.
The pulmonary capillaries form plexuses which lie immediately beneath the lining epithelium,
in the walls and septa of the alveoli and of the infundibula.
The pulmonary veins -open into the left atrium of the heart, conveying oxygenated blood to be
distributed to all parts of the body by the aorta.
The bronchial arteries supply blood for the nutrition of the lung; they are derived from the
thoracic aorta or from the upper aortic intercostal arteries, and, accompanying the bronchial
tubes, are distributed to the bronchial glands and upon the walls of the larger bronchial tubes and
pulmonary vessels.
The bronchial vein is formed at the root of the lung, receiving superficial and deep veins
corresponding to branches of the bronchial artery.
Nerves.—The lungs are supplied from the anterior and posterior pulmonary plexuses, formed
chiefly by branches from the sympathetic and vagus. The filaments from these plexuses
accompany the bronchial tubes, supplying efferent fibers to the bronchial muscle and afferent
fibers to the bronchial mucous membrane and probably to the alveoli of the lung. Small ganglia
are found upon these nerves.

The Skeletal System


The Skeletal System serves many important functions; it provides the shape and form for
our bodies in addition to supporting, protecting, allowing bodily movement, producing
blood for the body, and storing minerals.

Functions

Its 206 bones form a rigid framework to which the softer tissues and organs of the body
are attached.

Vital organs are protected by the skeletal system. The brain is protected by the
surrounding skull as the heart and lungs are encased by the sternum and rib cage.

Bodily movement is carried out by the interaction of the muscular and skeletal systems.
For this reason, they are often grouped together as the musculo-skeletal system. Muscles
are connected to bones by tendons. Bones are connected to each other by ligaments.
Where bones meet one another is typically called a joint. Muscles which cause movement
of a joint are connected to two different bones and contract to pull them together. An
example would be the contraction of the biceps and a relaxation of the triceps. This
produces a bend at the elbow. The contraction of the triceps and relaxation of the biceps
produces the effect of straightening the arm.

Blood cells are produced by the marrow located in some bones. An average of 2.6 million
red blood cells are produced each second by the bone marrow to replace those worn out
and destroyed by the liver.
Bones serve as a storage area for minerals such as calcium and phosphorus. When an
excess is present in the blood, buildup will occur within the bones. When the supply of
these minerals within the blood is low, it will be withdrawn from the bones to replenish
the supply.

Divisions of the Skeleton

The human skeleton is divided into two distinct parts:

Axial and Appendicular

The axial skeleton consists of bones that form the axis of the body and support and
protect the organs of the head, neck, and trunk.

The Skull
The Sternum
The Ribs
The Vertebral Column

The appendicular skeleton is composed of bones that anchor the appendages to the axial
skeleton.

The Upper Extremities


The Lower Extremities
The Shoulder Girdle
The Pelvic Girdle--(the sacrum and coccyx are considered part of the vertebral column)

The Pelvic Girdle

The Pelvic Girdle, also called the hip girdle, is composed to two coxal (hip) bones. The
coxal bones are also called the ossa coxae or innominate bones. During childhood, each
coxal bone consists of three separate parts: the ilium (denoted in purple above),
the ischium (denoted in red above), and the pubis (denoted in blue above). In an adult,
these three bones are firmly fused into a single bone. In the picture above, the coxal bone
on the left side has been divided into its component pieces while the right side has been
preserved.

In the back, these two bones meet on either side of the sacrum. In the front, they are
connected by a muscle called the pubic symphysis (denoted in green above).

The pelvic girdle serves several important functions in the body. It supports the weight of
the body from the vertebral column. It also protects and supports the lower organs,
including the urinary bladder, the reproductive organs, and the developing fetus in a
pregnant woman.
The pelvic girdle differs between men and woman. In a man, the pelvis is more massive
and the iliac crests are closer together. In a woman, the pelvis is more delicate and the
iliac crests are farther apart. These differences reflect the woman's role in pregnancy and
delivery of children. When a child is born, it must pass through its mother's pelvis. If the
opening is too small, a cesarean section may be necessary.

Types of Bone

The bones of the body fall into four general categories: long bones, short bones, flat
bones, and irregular bones. Long bones are longer than they are wide and work as levers.
The bones of the upper and lower extremities (ex. humerus, tibia, femur, ulna,
metacarpals, etc.) are of this type. Short bones are short, cube-shaped, and found in the
wrists and ankles. Flat bones have broad surfaces for protection of organs and attachment
of muscles (ex. ribs, cranial bones, bones of shoulder girdle). Irregular bones are all
others that do not fall into the previous categories. They have varied shapes, sizes, and
surfaces features and include the bones of the vertebrae and a few in the skull.

Bone Composition

Bones are composed of tissue that may take one of two forms. Compact, or dense bone,
and spongy, or cancellous, bone. Most bones contain both types. Compact bone is dense,
hard, and forms the protective exterior portion of all bones. Spongy bone is inside the
compact bone and is very porous (full of tiny holes). Spongy bone occurs in most bones.
The bone tissue is composed of several types of bone cells embedded in a web of
inorganic salts (mostly calcium and phosphorus) to give the bone strength, and
collagenous fibers and ground substance to give the bone flexibility

Heart Anatomy

9. Right Atrium
1. Right Coronary 10. Right Ventricle
2. Left Anterior Descending 11. Left Atrium
3. Left Circumflex 12. Left Ventricle
4. Superior Vena Cava 13. Papillary Muscles
5. Inferior Vena Cava 14. Chordae Tendineae
6. Aorta 15. Tricuspid Valve
7. Pulmonary Artery 16. Mitral Valve
17. Pulmonary Valve
8. Pulmonary Vein
Coronary Arteries

Because the heart is composed primarily of cardiac muscle tissue that continuously
contracts and relaxes, it must have a constant supply of oxygen and nutrients. The
coronary arteries are the network of blood vessels that carry oxygen- and nutrient-rich
blood to the cardiac muscle tissue.

The blood leaving the left ventricle exits through the aorta, the body’s main artery. Two
coronary arteries, referred to as the "left" and "right" coronary arteries, emerge from the
beginning of the aorta, near the top of the heart.

The initial segment of the left coronary artery is called the left main coronary. This blood
vessel is approximately the width of a soda straw and is less than an inch long. It
branches into two slightly smaller arteries: the left anterior descending coronary artery
and the left circumflex coronary artery. The left anterior descending coronary artery is
embedded in the surface of the front side of the heart. The left circumflex coronary artery
circles around the left side of the heart and is embedded in the surface of the back of the
heart.

Just like branches on a tree, the coronary arteries branch into progressively smaller
vessels. The larger vessels travel along the surface of the heart; however, the smaller
branches penetrate the heart muscle. The smallest branches, called capillaries, are so
narrow that the red blood cells must travel in single file. In the capillaries, the red blood
cells provide oxygen and nutrients to the cardiac muscle tissue and bond with carbon
dioxide and other metabolic waste products, taking them away from the heart for disposal
through the lungs, kidneys and liver.

When cholesterol plaque accumulates to the point of blocking the flow of blood through a
coronary artery, the cardiac muscle tissue fed by the coronary artery beyond the point of
the blockage is deprived of oxygen and nutrients. This area of cardiac muscle tissue
ceases to function properly. The condition when a coronary artery becomes blocked
causing damage to the cardiac muscle tissue it serves is called a myocardial infarction or
heart attack.

Superior Vena Cava

The superior vena cava is one of the two main veins bringing de-oxygenated blood from
the body to the heart. Veins from the head and upper body feed into the superior vena
cava, which empties into the right atrium of the heart.

Inferior Vena Cava

The inferior vena cava is one of the two main veins bringing de-oxygenated blood from
the body to the heart. Veins from the legs and lower torso feed into the inferior vena
cava, which empties into the right atrium of the heart.

Aorta

The aorta is the largest single blood vessel in the body. It is approximately the diameter
of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various
parts of the body.

Pulmonary Artery

The pulmonary artery is the vessel transporting de-oxygenated blood from the right
ventricle to the lungs. A common misconception is that all arteries carry oxygen-rich
blood. It is more appropriate to classify arteries as vessels carrying blood away from the
heart.

Pulmonary Vein

The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the
left atrium. A common misconception is that all veins carry de-oxygenated blood. It is
more appropriate to classify veins as vessels carrying blood to the heart.

Right Atrium

The right atrium receives de-oxygenated blood from the body through the superior vena
cava (head and upper body) and inferior vena cava (legs and lower torso). The sinoatrial
node sends an impulse that causes the cardiac muscle tissue of the atrium to contract in a
coordinated, wave-like manner. The tricuspid valve, which separates the right atrium
from the right ventricle, opens to allow the de-oxygenated blood collected in the right
atrium to flow into the right ventricle.

Right Ventricle

The right ventricle receives de-oxygenated blood as the right atrium contracts. The
pulmonary valve leading into the pulmonary artery is closed, allowing the ventricle to fill
with blood. Once the ventricles are full, they contract. As the right ventricle contracts, the
tricuspid valve closes and the pulmonary valve opens. The closure of the tricuspid valve
prevents blood from backing into the right atrium and the opening of the pulmonary valve
allows the blood to flow into the pulmonary artery toward the lungs.

Left Atrium

The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As
the contraction triggered by the sinoatrial node progresses through the atria, the blood
passes through the mitral valve into the left ventricle.

Left Ventricle

The left ventricle receives oxygenated blood as the left atrium contracts. The blood
passes through the mitral valve into the left ventricle. The aortic valve leading into the
aorta is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they
contract. As the left ventricle contracts, the mitral valve closes and the aortic valve opens.
The closure of the mitral valve prevents blood from backing into the left atrium and the
opening of the aortic valve allows the blood to flow into the aorta and flow throughout
the body.

Papillary Muscles

The papillary muscles attach to the lower portion of the interior wall of the ventricles.
They connect to the chordae tendineae, which attach to the tricuspid valve in the right
ventricle and the mitral valve in the left ventricle. The contraction of the papillary
muscles opens these valves. When the papillary muscles relax, the valves close.

Chordae Tendineae

The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in
the right ventricle and the mitral valve in the left ventricle. As the papillary muscles
contract and relax, the chordae tendineae transmit the resulting increase and decrease in
tension to the respective valves, causing them to open and close. The chordae tendineae
are string-like in appearance and are sometimes referred to as "heart strings."
Tricuspid Valve

The tricuspid valve separates the right atrium from the right ventricle. It opens to allow
the de-oxygenated blood collected in the right atrium to flow into the right ventricle. It
closes as the right ventricle contracts, preventing blood from returning to the right atrium;
thereby, forcing it to exit through the pulmonary valve into the pulmonary artery.

Mitral Valve/ Bicuspid Valve

The mitral valve separates the left atrium from the left ventricle. It opens to allow the
oxygenated blood collected in the left atrium to flow into the left ventricle. It closes as
the left ventricle contracts, preventing blood from returning to the left atrium; thereby,
forcing it to exit through the aortic valve into the aorta.

Pulmonary Valve

The pulmonary valve separates the right ventricle from the pulmonary artery. As the
ventricles contract, it opens to allow the de-oxygenated blood collected in the right
ventricle to flow to the lungs. It closes as the ventricles relax, preventing blood from
returning to the heart.

Aortic Valve

The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it
opens to allow the oxygenated blood collected in the left ventricle to flow throughout the
body. It closes as the ventricles relax, preventing blood from returning to the heart.

LABORATORY ANALYSIS

Name of patient: P.P. Date: 11/29/10


Age: 82 file no: 10-12198 surg

Radiologic Report
LS APL/ Right thigh APL/ Pelvis AP (11-28-10 / 11-29-10)

There are osteoporotic changes involving the visualized bone


Beginning degenerative changes with osteophytes involving the lumbar spine is noted
There is narrowing of L5-S1 disk space with marginal schlerosis involving the adjoining
and plates of L5 and L1 vertebrae
The line of weight bearing falls with is the sacral promontory
Pedicles and laminae are contact
There is complete fracture involving the neck of the right femur
The abdominal aorta is calcified
Paravertebral soft tissues are unremarkable.

Impression:
Osteoporotic changes visualized bones
Beginning degenerative changes with osteophytes, lumbar spine
Narrowing of L5- S1 disk space with marginal schlerosis involving the adjoining end
plates of L5 and L1 vertebrae, may be due to degeneratve disk disease
Complete fractures right femoral neck
Atherosclerotic abdominal aorta.

Urinalysis
(11/28/10)

Physical Analysis:
Color: yellow
Transparency: slightly turbid
Chemical changes: Microscopic Exam
Sugar- negative epithelial cells- pale
Protein- negative pus cells- 0.2 1hrt
Reaction- acidic RBC- negative
Specific gravity- 1.030 Bacteria- negative
Mucous/threads- positive
Easts- negative
Crystals- negative
Yeast cells- negative
Amorphore urates- rare
Amorphore phosphate- negative

Persistent P.E BP= 140/80


Decreased ROM right lower Extremities

Hematology
(11/28/10)

TEST RESULTS NORMAL UNITS INDICATION


VALUES
Hgb 145 120-180 g/L Normal
Hct .60 0.38- 0.55 % Increased
WBC 10.2 5-10x10 g/L Increased
Platelet 354 150-400x10 g/L Normal

DIFFERENTIAL COUNT:

Neutrophil .78 50-70 % Increased


Lymphocytes .20 20-40 % Normal
Monocytes .02 1-10 % Decreased

Glu-Crea Test

Patient Name: P. P.
Sample #: 11
Location: SW Sample Fluid: Serum
Priority: Positive
Segment: C centered 9:25 (11/29/10)
Position: l
Test Name Result Reference Interval Units Indication
GLU glucose 76 70-100 Mg/dL Normal
CREA Creatinine 1.0 0.6-1.3 Mg/dL Normal

Name of patient: P.P. Date: 12/2/10


Age: 82 File no: 10-12198 surg

Radiologic Report

CXR AP: (12/2/10)


There are linear densities in there apical area
Hear is enlarged
Aorta is calcified
The 6 costophrenic sulcus is blunted
Right cocostophrenic sulcus and the visualized bones are intact

Impression:
Parenchymal fibrosis, Right apex
Cardiomegaly
Atherosclerotic aorta
Pleural thickening, Left

Blood Transfusion

Name of Pt: P. P Hospital No: 269802


Ward: SW
Pt. Blood type: A
Type of cross matching: major

Source of blood: PRBC


Donor no: 2009-123164
Expiry Date: 12/13/10
Component: PRBC

Result of Cross matching: Compatible


No hemolysis

Date cross-matched: 12/5/10


Time crossmatched: 6;00 am/pm

Vital Signs Monitoring


TEMPERATU BLOOD RESPIRATI PULSE RATE
Before start of RE PRESSURE ON
transfuriosn RATE
36.8 130/80 23 88
15 minute after 36.8 130/80 22 89
start of transfusion
60 minutes after of 36.8 120/80 20 82
transfusion
At the end of 36.5 120/70 20 88
transfusion

Hematology
(12/07/10)

TEST RESULTS NORMAL UNITS INDICATION


VALUES
Hgb 105 120-180 g/L Decreased
Hct .31 0.38- 0.55 % Decreased
PERSON ASSESSMENT

PSYCHOSOCIAL
Pre Operative Assessment
Assessment Pathophysiological Basis
 Signifcant Others:
-Loving and Caring wife
 Coping Mechanism:
-Rest and Sleep
-Facing the problem
-Praying
 Religion
-Roman Catholic
 Primary Language:
-Ilocano
 Primary source of Health Care:
-Private Clinic
-Tertiary Hospitals
 Financial Resources related to Illness:
-With PhilHealth
-Asks help from children abroad
 Occupational/ Education:
-Retired Farmer
-Elementary Undergraduate (Grade 4)
 General Appearance:
-Dress for his age and according to
weather
-Speech relevant to the questions
asked
-Moderate tone of voice and speech
-Conscious and Coherent
 Orientation:
-Oriented to time, place and person
and event
 Affect:
-Appropriate
-Facial expression is congruent to his
mood
 Memory:
-No apparent problem with memory
(oriented to time, place, person and
event)
 Speech:
-Understandable
-Normal tone and Volume
 Non-verbal behavior:
-Grimace

ELIMINATION

 Stool:
-Frequency: once
-Pattern: every other day
-Consistency and shape: soft &
formed
-Color: brown
 Urine:
-Frequency: 3-4 times a day, 250 ml/
urination
-Color: yellow
-Clarity: slightly turbid
-Specific Gravity: 1.030 with 0.2 pus
cells

REST & ACTIVITY


 Current Activity Level: Due to presence of traction
-immobilize due to traction
 Activity of Daily Living:
-MUSCULOSKELETAL
Self-care Ability
0=Independent
1=Assistive Device
2=Assistance from others
3=assistance from person and
equipment
4=dependent/unable

Eating 2
Bathing 2
Dressing 2
Toileting 2
Bed Mobility 2
Transferring 2
Ambulating 4
Stairs 4

-unable to ambulate & needs minimal


assistance
 Sleep:
-7 hours/ day ( 9pm-4am)
 Body Frame:
-Mesomorph
 Posture & Gait:
-can’t be assessed properly (pt. is
immobilize due to presence of
traction)
 Coordination:
-no purposeful movements
-no tremors
 Muscle:
-No involuntary movements
 Motor Function:
-Gross: can flex and extend upper and
left lower extremities except right
lower extremity
-Fine: can pick up and hold objects
with the use of fingers
 Range of Motion:
-can adduct abduct upper extremities
-pronation & supination of arms
-unable to stand on his right lower
extremity
 Pain relief Measures:
-tries to sleep
-takes analgesic medications as prescribed
 Mobility:
-limited mobility due to traction

SAFE ENVIRONMENT
 Allergies/ Reaction:
-Medications, Food & Environment:
No known allergy
 Eyes/ Vision:
-not wearing eye glass or any contact
lenses
-no involuntary eye movements
 Hearing/ Hearing Aide
-response to normal voice tone
-doesn’t use any hearing aide
 Skin:
-Color:
Light brown in color
-Texture:
wrinkled skin
-Temperature:
warm skin
-Turgor:
good skin turgor, skin goes back
abruptly
-Edema:
no ascites & no edema noted
no lesion noted
 Mucous Membrane:
-Moist and intact
 Temperature:
36.8 C (axillary)
-More than the Normal range which
 Laboratory Analysis: indicates infection.
-WBC (Leukocytes): the secondary
defense
approximately 10,200/mm3

OXYGENATION
 Activity Tolerance:
-can perform and tolerate light
activities
-needs assistance with others
 Airway clearance:
-no secretions present in the nose -the patient has asthma, due to
-with presence of wheezes upon bronchoconstriction of airways
auscultation
 Respiratory Rate:
-16 cpm
 Lung Sounds: -the patient has asthma, due to
-presence of wheezes bronchoconstriction of airways
 Capillary Refill:
-with good capillary refill of 1-2
seconds
 Blood Pressure:
-110/80 mmHg

NUTRITION
 Hospital Diet/ Restrictions:
-on DAT
 IVF:
D5LR 1L x KVO, right metacarpal
 Tissue/Skin Turgor:
-good, goes back abruptly
 Ability to chew:
-cannot chew well due to teeth loss -due to poor oral hygiene practices and
 Ability to swallow: aging
-can swallow well
-can tolerate food well
-can drink and eat well
-no assistive device used
 Laboratory Analysis:
-Glucose and Creatinine within
normal level

PSYCHOSOCIAL
Post Operative Assessment

ASSESSMENT PATHOPHYSIOLOGICAL BASIS

Significant Others:
 Her loving wife is always ready to give
her a full support in everything that he
is doing

Coping Mechanism:
 The patient acts normally and perceives Patient uses these coping mechanisms
things around him in normal way that to decrease her anxiety with her present
he can cope to it. condition.

Religion:
 Roman Catholic

Primary Language:
 Ilocano , Tagalog
 These are the dialect he uses and also
his family members when
communicating

Primary Sources:
 Private clinic
 Veterance Regional Hospital
 These were the nearest health care
institutions they could seek for
immediate medical attention.

Financial Resources related to illness:


 Significant others
 Such financial resources can provide
him immediate access to seek health
care services.

Educational attainment/ Occupation:


 Farmer These are some of the observation
 Elementary Undergraduate evaluated during the visit that may
 Patient was unable to finish his picture the present condition of the
elementary education patient.
 An insufficient financial resources to
sustain his continuous education is a
burden to pursue his chosen career.

General appearance:
 Patient appears weak and pale
 With grimaces
 He is appropriate dressed for her age
and the weather
 Good eye contact
 Patient uses appropriate gestures such
as smiling.

Affect: Verbal concerns are appropriate with


 Blunted showing little or slow to his gestures
responds

Memory: The patient doesn’t experience any loss


Immediate: of memory.
>Able to recite number asked to
be recited in a span of second

Recent:
>He could remember what
happened during the past few days prior to his
operation
Remote:
>He could recall the time when
they married with his wife.

Orientation:
 Well oriented to time , place, person
and event.

Speech: The patient doesn’t experience any


 Voice quality is clear, slow, audible on speech defect
close distance with normal tone and
volume
 Understandable
Non-verbal behaviors are appropriate
Non-verbal Behaviors: with the patient’s response, emotions
 Nodding and to what he is trying to say
 Grimaces

ELIMINATION

ASSESSMENT PATHOPHYSIOLOGICAL BASIS


Stool:

 Frequency: Three to Four times a day


 Pattern: Every morning and anytime in The patient’s stool pattern, frequency
daytime and characters depends on the amount
 Consistency: soft, well formed of food and fluid taken.
 Color: Brownish
 Amount: moderate Normal color of stool.

Bladder

 Frequency: 2-3 times a day


Due to present condition of the patient,
 Quality per voiding: scanty he does not voids frequently.
 Color: Yellow amber
Frequency and duration of urination
depends on the quality of fluid intake.
Toilet ability

 Un able to do

REST AND ACTIVITY

ASSESSMENT PATHOPHYSIOLOGICAL BASIS

Current Activity Level:

 Almost of the time, the patient lies


on bed

Activity of Daily Living:

 Musculoskeletal
Self-care Ability
0=Independent
1=Assistive Device
2=Assistance from others
3=assistance from person and equipment
4=dependent/unable

Eating 2
Bathing 2
Dressing 2
Toileting 2
Bed Mobility 2
Transferring 2
Ambulating 4
Stairs 4

-unable to ambulate & needs minimal


assistance

Sleep:

 7-8 hours
 Nap:30 minutes
 Position: Semi fowlers position
 Characteristics of sleep: easily
awaken at night

Body frame:
 Mesomorph

Posture:
 Was not able to assess due to
inability to do the necessary
assessment

Motor Function:

 Fine : able to pick ballpen on


hand.
 Motor: able to extend, flex rotate,
adduct and abduct upper
extremities but not the lower
extremities.

Range of motion:
Legs:
 Unable to move

Arms:
 Full range of motion

SAFE AND ENVIRONMENT

ASSESSMENT PATHOPHYSIOLOGIC BASIS


Allergies:

 Medication: NONE
 Food: NONE
 Environment: NONE

Eyes/Vision:
 PERRLA: Pupils constrict when
looking at near objects and with
light ; pupils dilated when
looking at far objects.

 Glasses: NONE

Hearing:
No impairment on hearing ability and can
hear clearly what he hears.
 Use of hearing aid: NONE

Skin integrity:
Decrease circulating oxygenated blood to
 Color: Pale the peripheries causes the skin to become
pale.
Mucous membrane:

 Intact

Temperature

 36.5 Degree Celsius


 Route: Axilla

OXYGENATION

ASSESSMENT PATHOPHYSIOLOGIC BASIS

Airway clearance:

 Nose: Clear, no obstruction A clear airway passage promotes better


 Mouth: Clear, no obstruction flow of air.

Lung Sounds:

 Not assess
Respiration:

 Rhythm: regular to irregular


 RR: 23cpm
 Depth: deep and slow
 Semi- fowler position

Color: The heart has to pumps stronger in order to


supply body tissues with adequate amount
 Skin: Fair complex of oxygenated blood. Due to in adequate
oxygenation and circulation to the
 Nails: Pinkish
extermities
 Lips: Dry and pale

Pulse rate: 64bpm

 Location:Radial

Capillary Refill:

 Right upper extremities:1-2 secs


 Left upper extremities: 1-2 secs.
 Right lower extremeties: 2-3
secs
 Left lower extremities: 2-3
secs.

Blood Pressure:140/90mmHg

Oxygen therapy: NONE

NUTRITION

ASSESSMENT PATHOPHYSIOLOGIC BASIS

Diet/ Restriction:

 Low fat low salt The patient needs to reduce salt to prevent
water retention.

Reduction of fats also needed due to the


underlying conditions .
Height:

 5’4”

BMI:

 19.85kg/m2

Ability to chew or swallow:

 YES
He doesn’t have any difficulty chewing or
swallowing

Appetite:

 With good appetite, able to


consume half of the meal served.
COURSE IN THE WARD

1st day of hospitalization November 28,2010


IVF: D5LR 1L x 20 gtts/min The patient, 82 years old male was
Diet: NPO post dinner admitted at 11:30 am due to pain felt at
Assessment: right hip secondary to fall. He was seen by
 Conscious Dr. Calata with orders made and carried
 Coherent out, IVF inserted and admitted to surgery
 BP- 160/80 ward from ER with secured consent via
 With pain at injured area secondary stretcher with same IVF. He is for CBC,
to fall Blood Typing, pelvic x-ray, APL, 12L
Nursing intervention: ECG, CXR-PA, FBS, skin traction and was
 Performed head to toe assessment administered diclofenac sodium 75 mg IV
every 80 ANST(-).
 Monitored vital signs
 IVF inserted
 For ortho referral

2nd day of hospitalization November 29,2010


IVF:D5LR 1L x 20 gtts/min At 7 am skin traction is applied and
Diet: NPO maintained. Dr. Respicio made a new
Assessment: orders and carried out. He was refered to
 Awake CXR and to medicine from co-
 Inability to ambulate due to felt management. At 7 pm CXR plates sent to
pain x-ray department for official reading; result
Nursing intervention: is for referral to MROD. He had taken
 Monitored vital signs tramadol 50 mg IV immediately after the
 With hip pain doctor say so and if pain occur, salbutamol
 Plan for partial hip replacement neb. every 30 min. x 3 doses then every
after 6 hours, hydrocortisone 200mg
 Referred to medicine for co-
initially then 100 mg every 6 hr, seratide 12
management CP evaluation
mg 2 puff T.I.D., nezelin SR 20 mg tab
once a day, ceftriaxone 1 g IV every 8 hr
ANST, NTG patch ACW.

3rd and 4th day of hospitalization November 30- December 1, 2010


IVF:D5LR 1L x 20 gtts/min The patient maintained his skin traction and
Diet: NPO continuing his medications including
Assessment: tramadol whenever he felt pain.
 With bearable pain
Nursing intervention:
 Monitored and recorded vital signs

5th day of hospitalization December 2,2010


IVF:D5LR 1L x 20 gtts/min The patient maintained his skin traction
Diet: NPO intact. With doctor ordered for cp and
Assessment: continuing his medications
 Wound care done
 Hygiene emphasized
Nursing intervention:
 Monitored and recorded vital signs

6th day of hospitalization December 3,2010


IVF:D5LR 1L x 20 gtts/min The patient maintained his skin traction and
Diet: NPO medications. Dr. Respicio attached the
Assessment: chest x-ray official reading to chart, he had
 Fully awake no notes made and will follow up the
 With bearable pain patient later.
Nursing intervention:
 Monitored and recorded vital signs

7th day of hospitalization December 4,2010


IVF:D5PNSS 1L x 20 gtts/min The patient maintained his skin traction. At
Diet: NPO 9:15 am the patient cardiac risk index
Assessment: (CRI) III and re-evaluation done, seen and
 On bed, awake examined by Dr. Respicio. And at 11 am
 With intact skin traction the patient seen by Dr. Foronda with new
Nursing intervention: orders made, for hip replacement at right
 Monitored and recorded vital signs on Monday(12-06-10) and ordered to
 Monitored BP every 2 hours secure consent, to notify OR/ AOD and ask
 Secured consent to prepare 2 units of PRBC for OR use
with properly typed and cross matched and
 Advised watchers to seek for blood
forwarded to blood bank and instructed the
donors
watchers to seek for blood donors and he
was continuing his medications.

8th day of hospitalization December 5, 2010


IVF:D5PNSS 1L x 20 gtts/min Seen by Dr. Willie with some orders made.
Diet: NPO For OR/ hip replacement tomorrow,
Assessment: OR/AOD notified and secured consent, still
 With intact dressing of hip skin to prepare 2 unit of PRBC per OR use but
traction at 7 pm there is available 2 units PRBC at
Nursing intervention: blood bank but still to notify medicine of
 Monitored and recorded vital signs OR schedule and continuing his
 Wound care done medications.
 Kept comfortable

9th day of hospitalization December 6,2010


IVF:D5PNSS 1L x KVO For partial hip replacement at right today,
Diet: NPO-DAT once awake consent secured to OR per stretcher, at 1
Assessment: pm received from Surgical ward and
 Conscious assisted to OR table comfortably. Hooked
 Coherent to pulse oximeter (SPO-48%). Assisted to
 BP- 150/100mmHg LLDP then supine after induction. At 1:55
 PR- 86bmp pm SAB inducted by Dr. Pangda and then
 RR- 26cpm monitored BP (140/80 mmHg), IFC
 T- 37.60
inserted and connected to Urine Bag, skin
Nursing intervention: preparation done at operation site, sterile
drapes applied. At 2:15 pm, procedure
 Monitored and vital signs every 15
started by Dr. Foronda with Dr. Andiatico
min.
as assist with Miranda as scrub nurse with
 Monitored urine output sponges instruments and needles counted
 Oxygen at 3LMP complete and closing of incision site done
 IFC renewed at 4:15 pm procedure was ended with
 Secured consent dressing applied and the procedure was
 Oral hygiene encouraged done(partial hip arthroplasty + bone cement
at right). At 4:30 pm patient transferred to
PACU per stretcher with same IVF and
endorsed to NOD with latest BP of 140/80.
At 4:35 pm, In from OR per stretcher,
awake, coherent with intact positioning
dressing. Maintained flat on bed, oxygen
inhalation administered at 3LMP via nasal
cannula, V/S monitored every 5 min. with
ongoing post BT Hgb Hct type “A” after
the operation was administered and due at
3am of December 7, 2010. with LBP of
120/80 and no further complaint noted and
endorsed with continuity of care. At 10 pm,
the dressing was noted soaked and reffered
at once to Dra. Calata. Changed dressing
aseptically, pressure dressing applied but
no further bleeding noted with latest vital
signs of BP- 110/70mmHg, CR- 88bpm,
RR-20cpm. Continuing his medications but
he has an additional medicine of
ampicillin- sulbactam 1.5g IV.

10th day of hospitalization December 7, 2010


IVF:D5PNSS 1L x KVO For post –op x-ray of pelvis including hip
Diet: DAT joint at 11:30. No subjective complaints
Assessment: noted and endorsed to ward for continuity
 Awake of care. With bearable post- op pain and
 Conscious scaled 5 out of 10 and with intact and good
 Coherent dressing. Continuing his medications with
 Dry and intact surgical bandage at additional again of hydroxyzine+vial to his
surgical site medications for this day only.
 IFC intact draining freely
 BP- 120/80
 PR-88bpc
 RR- 20cpm
Nursing intervention:
 Monitored and recorded vital signs
 Kept well thermoregulated and
comfortable on bed
 Monitored for any fluctuations in
V/S
 Medication resumed

11th day of hospitalization December 8, 2010


IVF:D5PNSS 1L x KVO IC renewed aseptically and routine care
Diet: DAT done. Continuing his medications with
Assessment: ampicillin.
 Intact dressing
Nursing intervention:
 Monitored and recorded vital signs
 Wound care done
 Kept comfortable

12th -14th day of hospitalization December 9- 11, 2010


IVF:D5PNSS 1L x KVO No untoward complaints reported and kept
Diet: DAT the client rested. Help the client to
Assessment: mobilized from bed carefully. Continuing
 With intact dressing of hip skin his medications. On December 11 there is
traction an additional medication of FeSO4 and
 With bearable pain Colecoxib.
Nursing intervention:
 Monitored and recorded vital signs
 Wound care done
 Kept comfortable
 Daily bath advised
 Mobilization from bed with
assistance encourage

15th day of hospitalization December 12, 2010


IVF:D5PNSS 1L x KVO Kept the client rested and given clonidine
Diet: DAT for his high BP and has LBP of 140/90.
Assessment: Shift to oral medicines, cefuroxime 500
 With intact dressing of hip skin mg/ ampule 3x a day and celecoxib 200mg
traction 2x a day and ordered possible discharged
 With dizziness and unbalanced tomorrow instructed to come back on
chest pain (BP-180/100mmHg) December 16, 2010. the hydrocortisone and
Nursing intervention: nezeline was discontinued and added
 Monitored and recorded vital signs FeSO4 ,clonidine, cefuroxime and
 Wound care done colecoxib.
 Kept comfortable
 Mobilization from bed with
assistance encourage
 Administered clonidine 150 mg

16th day of hospitalization December 13, 2010


IVF:D5PNSS 1L x KVO May go home. At 2:48 pm bill was settled
Diet: DAT and at 3 pm the patient was discharged.
Assessment: With patient’s take home medicines for
 With intact dressing of hip skin continuing medications and these are
traction colecoxib, cefuroxime, and seratidine.
Nursing intervention:
 Monitored and recorded vital signs
 Wound care done
 Kept comfortable
 Daily bath advised
 Mobilization from bed with
assistance encourage