Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY Cabanatuan City COLLEGE OF NURSING PATIENT CARE

RECORD
Patients Name: ___________________ Ward: _________ Date: __________ Chief Complaint: __________________ Diagnosis: _____________________ HEALTH HISTORY I. Biographical Data:

Age: ____ Sex: ____ Citizenship: __________ Religion: ________ Birthdate: __________ Civil Status: _____ Educ. Attainment: _____________ Address: ______________________________________________________

II.

History of Present Illness

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ _______________________________________________ III. Past Health History

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ _______________________________________________ IV. Family Health History

______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

REVIEW OF SYSTEMS Patients Name: __________________________ Ward: ________________ Chief Complaint: _________________________ Diagnosis: _____________

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VITAL SIGNS oral rectal axilla BP: PSYCHOSOCIAL

Calm Anxious Cooperates with care Others NEURO Within normal level; WNL except for: LOC Orientation Memory deficit Sensory deficit Aids hearing vision Cranial nerve deficit Language deficit OTHERS

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GENITOURINARY o Within normal level; WNL except for: o Burning urgency dysuria hesitancy o Urinary incontinence o Anuric o Polyuria o Nocturia o Catheter o Drainage tubes Urine: (color)___________________ o Amount o Cloudy o Sediment o Heme GENITALIA o Discharge o OTHERS MUSCULOSKELETAL Within normal level; WNL except for: Ecchymosis Erythema Lesions Rashes Pressure ulcer/location ___________ Pressure relief device Incision location ___________ Drains Secretions Turgor OTHERS COMFORT Within normal level; WNL except for: Pain location Pain characteristics Receiving meds: type: ________________ OTHERS HYGIENE Shower Bath Mouthcare Pericare Antiembolic hose OTHERS PRECAUTIONS Falls Aspiration Neutropenia Suicide Airborne Radiation OTHERS

RESPIRATORY o Within normal level; WNL except for: o Irregular heart beat Shortness of breath dyspnea o Cough nasal flaring Breath sounds: o Unequal diminished o Coarse/rhonchi crackles o Artificial airway wheezes o OTHERS GASTROINTESTINAL o Within normal level; WNL except for: o NPO o DAT o TPN o NGT o Nausea o Vomiting o Dysphagia o Gas eructation o Regurgitation Abdomen: o Firm o Tender o Distended Bowel sounds o Hyperactive o Hypoactive o Absent Stool o No flatus o Fecal incontinence o Constipation o Diarrhea o OTHERS

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o o o o o

o o o o o o

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Name and Signature:

SUMMARY OF DIAGNOSTIC PROCEDURES DATE PROCEDURE SIGNIFICANT FINDINGS INFERENCE

NURSING CARE PLAN

PHILIPPINE ORTHOPEDIC CENTER Maria Clara corner Banawe Street, Quezon City HISTORY: February 9, 1945 1st organized as Philippine Civil Affairs Unit Hospital - Mandaluyong Emergency Hospital - 500 bed capacity National Orthopedic Hospital and Rehabilitation Medicine Center- 700 bed capacity RA 6786 November 29, 1989- Philippine Orthopedic Center Dr. Jose V. Delos Santos Dr. Teodoro R. Castro pioneer of POC present hospital director

Mission The POC is committed to deliver accessible and the highest quality orthopedic and rehabilitation and other related services that respond to the needs of Metro Manila community and other areas all over L,V & M. Vision We pledge to provide our patients with the utmost quality service through a caring and competent staff prepared to utilize world class technology Services 1. ER open 24h 2. OPD (8-5) a. Ortho trauma b. Adult recon.ortho c. Pediatric ortho d. Spine injury e. Head injury f. Microvascular sx g. Subspecialty (for patients with ortho problem) g1. neuron g2. uro g3. thoracocardio sx h. Dental services 3. Rehabilitative services a. PT b. OT c. Psych and vocational d. Prosthetic 4. Ancillary a. Radiology b. Laboratory 5. Special units a. RR b. Head injury c. Spinal surgery 6. Special projects

a. b. c. d.

Diabetes Pain Tumor Nutritional

NURSING STUDENT AFFILIATION PROGRAM Rationale: The care of the clients with orthopedic condition requires a special preparation and skill -provision of holistic client care General obj.: To apply classroom instructions to actual situations in each area Specific obj.: At the end of the affiliation, the students will be able to: 1. Identify the common ortho appliances/ equipment in the management of ortho pts. 2. Discuss the pathophysio, mgt and principles of care involved in any common ortho condition 3. Identify the materials used in application of traction and cast 4. Explain the importance of multidisciplinary approach to patient care 5. Demonstrate skills in the following ortho procedures: a. Traction application b. Assist in cast application c. Turning and positioning an ortho patient 6. Perform nursing care to patients with m-s disorders Clinical areas: Location Childrens ward 1st floor Northeast ward post op-female; 2nd floor Male service A post-op male; 2nd floor Male Traction ward 2nd floor Spinal ward 2nd floor Male service B male pts. w/o traction 3rd floor Female service ward 3rd floor; w/w/o traction Students activities: v/s tickler endorse to NOD morning care nursing care NPI Pin dressing BST Parts of the report Introduction Definition S/SX Pathophysio Dx exam Tx and Mgt Nsg care References Parts of Case study: Introduction Personal profile History- Past, Present, Family Laboratory work-up Ana and Physio Drug Study NCP Discharge Summary

ORTHOPEDIC the science and practice of correcting deformities caused by accident, stress, or trauma or caused by disease or disorder in the structure of the skeleton MUSCULOSKELETAL SYSTEM MS system provides the structure and leverage that permits mobility Bones of the skeletal system serve as reservoir for Ca and manufacturing facility for RBC, WBC, and platelets Alterations in MS system can result from tissue injury, bone fx, infections and tumors 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: 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) 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 FRACTURES Bones form the skeleton of the body and allow the body to be supported against gravity and to move and function in the world. Bones also protect some body parts, and the bone marrow is the production center for blood products. Bone is not a stagnant organ. It is the body's reservoir of calcium and is always undergoing change under the influence of hormones. Parathyroid hormone increases blood calcium levels by leeching calcium from bone, while calcitonin has the opposite effect, allowing bone to accept calcium from the blood. What causes a fracture? When outside forces are applied to bone it has the potential to fail. Fractures occur when bone cannot withstand those outside forces. Fracture, break, or crack all mean the same thing. One term is not better or worse than another. The integrity of the bone has been lost and the bone structure fails. Broken bones hurt for a variety of reasons including:

The nerve endings that surround bones contain pain fibers and and these fibers become irritated when the bone is broken or bruised.

Broken bones bleed, and the blood and associated swelling (edema) causes pain. Muscles that surround the injured area may go into spasm when they try to hold the broken bone fragments in place, and these spasms cause further pain.

Often a fracture is easy to detect because there is obvious deformity. However, at times it is not easily diagnosed. It is important for the physician to take a history of the injury to decide what potential problems might exist. Moreover, fractures don't always occur in isolation, and there may be associated injuries that need to be addressed. Fractures can occur because of direct blows, twisting injuries, or falls. The type of forces on the bone may determine what type of injury that occurs. Descriptions of fractures can be confusing. They are based on:

where in the bone the break has occurred, how the bone fragments are aligned, and

whether any complications exist.

Description: A break in the continuity of the margins of a bone When a force exceeds the compressive or tensile strength of the bone The first step in describing a fracture is whether it is open or closed. If the skin over the break is disrupted, then an open fracture exists. The skin can be cut, torn, or abraded (scraped), but if the skin's integrity is damaged, the potential for an infection to get into the bone exists. Since the fracture site in the bone communicates with the outside world, these injuries need to be cleaned out aggressively and many times require anesthesia in the operating room to do the job effectively. Next, there needs to be a description of the fracture line. Does the fracture line go across the bone (transverse), at an angle (oblique) or does it spiral? Is the fracture in two pieces or is it comminuted, in multiple pieces?

Finally, the fracture's alignment is described as to whether the fracture fragments are displaced or in their normal anatomic position. If the bones fragments aren't in the right place, they need to be reduced or placed back into their normal alignment

Causes: Stress, Trauma, Overuse, repeated wear Muscle spasm causes pain, swelling, tenderness Risk factors: Falls, motor vehicular accidents, sports Use of drugs that impair judgment Bone tumors Infection Signs and symptoms Obvious deformity Edema. Ecchymosis Redness Muscle spasm Management in care of fracture Recognition Reduction Retention Rehabilitation The Patient Undergoing Orthopedic Surgery Conditions that may be corrected by surgery: 1. 2. 3. 4. 5. unstabilized fracture deformity joint disease necrotic or infected tissue tumors

Frequent surgical procedure/s: 1. ORIF Open reduction the correction and alignment of the fracture after surgical dissection and exposure of the fracture 2. Closed reduction with internal fixation for fx: stabilization of reduced fx by the use of metal screws, plates, wires, nails and pins a. Arthroplasty repair of joint problems through the operating arthroscope or through open joint surgery b. Meniscectomy excision of a damaged joint fibrocartilage 3. Amputation for severe extremity conditions (gangrene, massive trauma) 4. Bone graft the placement of bone tissue to promote healing, stabilize and or to replace diseased bone. Ex.; autologous or homologous grafts 5. Tendon transfer the movement of tendon insertion to improve function 6. Fasciotomy the incision and diversion of the muscle fascia; to relieve muscle constriction, as in compartment syndrome, or to reduce fascia contracture Total joint arthroplasty or replacement the replacement of both articular surfaces within a joint with metal or synthetic materials Total hip arthroplasty the replacement of a severely damaged hip with an artificial joint. Indications: a. OA; RA; b. Femoral neck Fx c. Failed prosthesis d. Osteotomy e. Congenital hip disease

Prosthesis is mostly consist of a metal femoral component topped by a spherical ball fitted into a plastic acetabular socket

Complications; 1. dislocation 2. excessive wound drainage 3. thromboembolism 4. infection 5. heel pressure ulcer 6. avascular necrosis (bone death caused by loss of blood supply) Nursing Interventions: 1. Prevent dislocation of the hip prosthesis positioning the leg in abduction by the use of an abduction pillow between the legs or abduction splint 2. Patients hip is never flexed more than 90 degrees 3. Avoid crossing legs 4. The nurse does not elevate the head of the bed more than 60 degrees 5. The patient is also reminded not to flex the affected hip 6. Keep pressure off heel prevents pressure ulcer on heel 7. Support exercise regimen reconditioning exercises 8. For DVT, use elastic compression stocking to aid in venous blood return and prevent stasis 9. Change position and increase activity as prescribed activity promotes circulation and diminishes venous stasis 10. Use aseptic technique for dressing changes 11. Activity limitations (weight-bearing limits; hip precautions)

Hardware - A generic term that encompasses all metallic implants. By extension, it also includes nonmetallic materials associated with metallic components such as polyethylene components of joint prostheses. See implants. Implant - Any surgically placed, nonbiological material whose purpose is to promote healing of tissues or serve as a replacement of structures such as joints. Screws - One of the most commonly used orthopedic fixation devices. Screws are designed for different uses and for placement in different types of bone. Screws can be used as single standalone devices, as components of hardware constructs (e.g. plates with screws), or as separate devices complementing other hardware (e.g. interfragmentary screws and plates with screws for fracture fixation). Cancellous screw - A screw designed for placement in cancellous bone. The pullout strength of a screw is proportional to the amount of metal-bone contact. Because cancellous bone is porous, threads for cancellous bone screws have to be longer than for cortical screws to achieve the same degree of metal-bone contact and thus have the same pullout strength as cortical screws. Cortical screw - A screw designed for placement in cortical bone

Wires - The term can refer to thin diameter, fully flexible wires with minimal resistance to bending or thicker diameter wires, such as K-wires, that can be used as rigid fixation devices. K-wires - The commonly used designation for Kirschner wires. These are thin wires that used for a variety of purposes. They can act as fixation devices for small bones, as guide wires for insertion of cannulated nails, and as accessory components with external fixation devices. Arthroplasty - An operation that restore as far as possible the integrity and function of a joint. In general, an arthroplasty involves prosthetic replacement of one or both sides of a joint. A hemiarthroplasty involves replacement of only one side of a joint. A total joint arthroplasty involves replacement of both sides of a joint. A hemiarthroplasty may be unipolar of bipolar. Dynamic compression - The compression of a fracture by weight bearing and/or muscle contraction. Fracture fixations that employ dynamic compression include dynamic hip screws, anti-glide plates, dynamized tibial and femoral nails, and tension band wiring. Ender nail - Also referred to as an Ender rod. A smooth, flexible rod used for intramedullary fixation of long bone fractures. The nail is used for diaphyseal fractures in patients whose epiphyseal growth plates are still open. It is inserted through the metadiaphyseal region, avoiding the epiphyseal plate so that the growth of the bone is not impaired. Malunion healing of a fractured bone in a malaligned position Nonunion failure of fragments bone to heal together Delayed union prolongation of expected healing time for fx Contusion blunt force injury to soft tissue Disarticulation amputation through a joint Dislocation separation of joint surfaces Dysplasia dislocation; deformity; mis/malalignment Sprain injury to ligaments and other soft tissues at a joint Strain pulled muscle caused by overuse, overstretching or excessive stress RICE Rest, Ice, Compression, Elevation (management of contusions, strains and sprains) Avascular necrosis tissue death due to anoxia and diminished blood supply; nerve palsy may occur Phantom Limb Pain pain perceived as being in the amputated limb - caused by the severing of peripheral nerves
Phantom pain is pain that feels like it's coming from a body part that's no longer there. Doctors once believed this post-amputation phenomenon was a psychological problem, but experts now recognize that these real sensations originate in the spinal cord and brain The exact cause of phantom pain is unclear, but it appears to originate in the spinal cord and brain. During imaging scans such as magnetic resonance imaging (MRI) or positron emission tomography (PET) specific portions of the brain show activity when the person feels phantom pain. Many experts believe phantom pain may be at least partially explained as a response to mixed signals from the brain. After an amputation, areas of spinal cord and brain lose input from the missing limb and adjust to this detachment in unpredictable ways.

The result can mimic tangled wires and trigger the body's most basic message that something is not right: pain.

Some factors that may increase your risk of phantom pain include:

Pain before amputation. Some researchers have found that people who had pain in a limb before amputation are likely to have it afterward, especially immediately after amputation. This may be because the brain holds on to the memory of the pain and keeps sending pain signals, even after the limb is removed.

Stump pain. People who have persistent stump pain usually have phantom pain, too. Stump pain can be caused by a neuroma, an abnormal growth on damaged nerve endings that often results in painful nerve activity.

Poor-fitting artificial limb (prosthesis). Talk to your doctor to be sure you're putting your artificial limb on correctly and that it fits properly. If you think your artificial limb may not fit properly, or is causing pain, talk to your doctor.

Bone plates are surgical tools, which are used to assist in the healing of broken and fractured bones. The breaks are first set and then held in place using bone plates in situations where casts cannot be applied to the injured area. Bone plates are often applied to fractures occurring to facial areas such the nose, jaw or eye sockets. Repairs like this fall into an area of medicine known as osteosynthesis A bone plate system for fixing bone fractures includes a locking bone plate and a conically-shaped drilling sleeve. The bone plate has at least one threaded hole, and with the drilling sleeve screwed into the bone plate hole, a drill bit guided through the sleeve drills a hole into bone having a central axis angularly misaligned with the central axis of the bone plate hole. The angle between the drilled hole's central axis and the bone plate hole's central axis is equal to or less than the tolerance angle of the threads of the bone plate hole. This allows a bone plate screw to be imperfectly seated with respect to the bone plate hole and still screwed into the hole to lock the plate without jamming the screw head into the plate hole, while still allowing the screw to be screwed out if needed

Hip replacement (total hip replacement), is a surgical procedure in which the hip joint is replaced by a prosthetic implant. Replacing the hip joint consists of replacing both the acetabulum and the femoral head. Such joint replacement orthopaedic surgery generally is conducted to relieve arthritis pain or fix severe physical joint damage as part of hip fracture treatment. Hip replacement is currently the most successful and reliable orthopaedic operation with 97% of patients reporting improved outcome.

The acetabulum (pronounced /stbjulm/) is a concave surface of the pelvis. The head of the femur meets with the pelvis at the acetabulum, forming the hip joint. The word acetabulum means "little vinegar cup",

The femur head (Latin: caput femoris) is the highest part of the thigh bone (femur). It is supported by the neck of the femur. The head 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 ligament of head of femur. If there is a fracture of the neck of the femur, the blood supply through the ligament becomes crucial. In orthopedic surgery, the head of the femur is important because it can undergo avascular necrosis and consequent osteochondritis dissecans. The head is removed in total hip replacement surgery.

In human anatomy, the femur is the longest and largest bone. Along with the temporal bone of the skull, it is one of the two strongest bones in the body. The average adult male femur is 48 centimeters (18.9 in) in length and 2.34 cm (0.92 in) in diameter and can support up to 30 times the weight of an adult.[1] It forms part of the hip joint (at the acetabulum) and part of the knee joint, which is located above. There are four eminences, or protuberances, in the human femur: the head, the greater trochanter, the lesser trochanter, and the lower extremity Knee replacement, or knee arthroplasty, is a surgical procedure to replace the weightbearing surfaces of the knee joint to relieve the pain and disability of osteoarthritis. Knee replacement surgery can be performed as a partial or a total knee replacement.[2] In general, the surgery consists of replacing the diseased or damaged joint surfaces of the knee with metal and plastic components shaped to allow continued motion of the knee. The operation involves substantial postoperative pain, and includes vigorous physical rehabilitation. The recovery period is 6 weeks or longer and involves use of a walker and then a cane.[ Compartment syndrome: A condition in which there is swelling and an increase in pressure within a limited space (a compartment) that presses on and compromises blood vessels, nerves, and/or tendons that run through that compartment. Hence, the function of tissue within that compartment is compromised. Compartment syndromes usually involve the leg but can also occur in the forearm, arm, thigh, shoulder, and buttock. Some of the causes of increased pressure in compartment syndromes are trauma (for example, a fracture), too-tight wound dressings or casts,

hemorrhage (bleeding) into the compartment, or inflammation (carpal tunnel syndrome , for example). Symptoms of a compartment syndrome include numbness, tingling, pain or loss of movement in an extremity. Sequelae (the lasting effects) can include nerve compression, paralysis, contracture or even death. Treatment is to relieve the pressure; if symptoms are severe or prolonged, surgery may be needed.

Quiz # 1. POC Orientation. Do not write anything on this questionnaire. No erasure I. Write in your paper of what is being asked below: 1. Location of Philippine Orthopedic Center 2. Date the hospital was established 3. Chief of hospital 4. Chief Nurse 5. Head of Nursing Training Office 6. Nurse Supervisors of NTO (6-9) 7. 8. 9. 10. Give the indication of Balance Skeletal Traction 11. What is the countertraction in BST? 12. Principles of traction (12-15) 13. 14. 15. 16. Enumerate parts of the Balkan frame (16-20) 17. 18. 19. 20. 21. Clinical areas in POC (21-27) 22. 23. 24. 25. 26. 27. 28. Students Activities Goals and Objectives (28-30) 29. 30.

Prepared by: Lorelei S. Lorenzo,RN,MAN Clinical Instructor