Gap Non-Union Fracture Case Presentation

In Partial Fulfillment Of the Requirements In the Related Learning Experience
A Case Presentation On Gap non-union 5th Metacarpal Hand Left Status Post Application of Bone Spacer 5th Metacarpal Hand Left Bone Ankylosis Metacarpophalengeal Proximal and Distal Interphalengeal Joint Hand Left Submitted by Group 17 BSN 4A1-E Agbada, Ma.Vanessa. Alacantara, Donna Bella Aliwalas, Melody Aro, Carla Mariz Banares, Rommel Bas-awan, Christian Robinson V. Sison, Ma. Jay Jesusa. Suizo, Mary Grace Supilanas, Mark Anthony Villanueva, Rossie Villanueva, Vina Cherrie Faye
Submitted to: Cherry Aurora S. Panergo Clinical Instructor
Area of Affiliation: Armed Forces of the Philippines Medical Center Inclusive Duty Dates: April 18,19,20,25,26 and 27, 2011
TABLE OF CONTENTS
Page I. Introduction - - - - - - - - - - - - - - - - - - - - - -- - - - -- - - - - - - - 5
II.
Objectives
- - - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- - - -
III.
Patient Profile - - - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- -
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a. Biographic Data - -- - - - - -- - - - - - - - - - - - - - - - - - - - - - - b. Chief Complaint - - - - - - - - -- - - - - -- - - - - - - - - - - - - - - - c. History of Present Illness - - - - - - - - -- - - - - -- - - - - - - - - - d. Past History - - - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- Childhood Illness Childhood Immunization Allergies Hospitalization for Serious Illness Medications
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e. Family History of Illness - - - - - - -- - - - - -- - - - - - - - - - - - - - -------17 IV. Physical Assessment - - - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- - Head-to-toe-Assessment- - - - - - - - -- - - - - -- - - - - 18 18
V. Activities of Daily Living (Using Gordons Functional Pattern) - - - - -
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A. Health Perception and Management Pattern-----------------------------27 B. Nutritional Pattern----------------------------------------------------------------27 C. Elimination Pattern---------------------------------------------------------------27 D. Activity Exercise Pattern-----------------------------------------------------28 E. Sleep Rest Pattern---------------------------------------------------------------28 F. Cognitive- Perceptual Pattern-------------------------------------------------28 G. Self-Perception-Self-Concept Pattern--------------------------------------29 H. Role-Relationship Pattern------------------------------------------------------29 I. Sexuality-Reproductive Pattern------------------------------------------------29 J. Coping-Stress Tolerance Pattern---------------------------------------------29 K. Value-Belief Pattern--------------------------------------------------------------30 VI. Developmental Task (Ericksons Psychosocial Theory of Development) (Intimacy VS Isolation) - - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -VII. Laboratory/ Diagnostic Findings - - - - - - - -- - - - - -- - - - - - - - - - - - - 31 32
A. Chest X-ray - - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- - - - - B. Electrocardiogram - - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- C. Complete Blood Count - - - - - - - -- - - - - -- - - - - - - - - - - - - - - D. Fecalysis - - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- - - - - - - E. Urinalysis - - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- - - - - - - -
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VIII. Anatomy and Physiology - - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - A. Macro Anatomy of the Skeletal System: Anterior View and Posterior View - - - - - - - -- - - - - -- - - - - - B. Micro Anatomy of the Skeletal System: Outer Parts of the Hands - - - - - - - -- - - - - -- - - - - - - - - - - - - -
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C. Macro Physiology of the Skeletal System - - - - - - - -- - - - - -D. Micro Physiology of the Skeletal System
Cross Dissection of Internal Bone Structure the 5th Metacarpal - -
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IX. Pathophysiology - - -- - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- - - - X. Course in the Ward - - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- - - - XI. Nursing Care Plan A. Acute Pain - - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- - - - B. Disturbed Sleep Pattern - - - - - - -- - - - - -- - - - - - - - - - - - - C. Self- Care Deficit: Hygiene - - - - - - -- - - - - -- - - - - - - - - - - - XII. Drug Study A. Cefuroxime - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - B. Ketorolac - - - - - - -- - - - - -- - - - - - - - - - - ------------C. Tramadol - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - D. Ranitidine- - - - - -- - - - - - - - - - -- - - - - - - - - -----------E. Celecoxib - - - - - - -- - - - - -- - - - - - -
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XIII. Discharge Planning - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- - - - M-edication - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- - - - - - - - E-xercise/ Environment - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - T-reatment - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- - - - - - - - - H-ealth teaching - - - - - - - - - - - - - -- - - - - - - - - - - -- - - - - -- O-PD follow up - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- - - - - D-iet - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - S-piritual/ sexual - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- - - - - XIV. References - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- - - - - - - - - - -
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We are the 4th year nursing students of Group 17 from Our Lady of Fatima University. We are glad to have a traumatic type of
fracture as our case presentation because this case will gives us a new knowledge and information a lot of thing that we will need to adopt regarding orthopaedic nursing care. Our case study discussed, the definition of gap non-union type of fracture ,diagnosis, treatment, nursing interventions and complications. After accomplishing this case study, its a really big help and it will serve as a guide to become effective nurses if we encounter a patient with the same case because we all know how to manage and perform the effective care that will be needed by our patient. This is the medical diagnosis of our patient . Gap non-union 5 metacarpal Hand Left Status Post Application of bone spacer 5th metacarpal Hand Left bone ankylosis metacarpophalangeal proximal and distal interphalangeal joint hand left.
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A gap non-union on the fifth metacarpal on the left hand of our patient is a type of fracture that was caused by an injury that he acquired during the encounter with the rebels. Risk factors : Due to an injury Occupational hazards Clinical manifestations of fracture: Pain, aggravated by motion, tenderness Loss of motion Edema ( after 24 hours ) Shortening of the limb. Due to spasm of muscles Obvious deformity X-rays confirms fracture
Emergency management when fracture occurs: Immediately immobilize the injured part Joints proximal and distal to the fracture must be immobilize to prevent movement of fracture fragments.
Those arms maybe bandage to the chest or an injured forearm maybe placed in a sling. With an open fracture the wound is cover with a sterile dressing to prevent contact in deeper tissues.
Collaborative Management: Reduction o Open reduction with internal fixator ( ORIF ) = this is done through surgery that involves application of bone spacer, pins, wires, screws and plates to the affected bone o Do neurovascular checks o Prevent complications of mobility o Analgesics as prescribed. Care for Patient with Open reduction: Check dressings for bleeding and infection Assess LOC. Bleeding causes altered level of consciousness Elevate the affected extremity to prevent swelling Turn every 2 hours; turn to unoperative side only, to prevent pressure on the operative site. Implement measures to prevent thrombus formation o Abduction and adduction of the fingers on the affected area o Flexion of the fingers on the injured hands Observe for adequate bowel and bladder function Assist patient in getting in and out of bed on first and second post-op day. Assess the site for redness , drainage, tenderness and pain Help the patient become mobile within the prescribed weight-bearing limits. Encourage isometric and active exercises as tolerated Notify the physician if the signs of infection is present Diagnostic and laboratory exam / studies X- rays studies
o Bone x-rays determine bone density, texture, erosion and changes in bone relationships. X-rays study of the cortex of the bone reveals any widening, narrowing or signs of irregularity. Computed tomography Which maybe perform with or without the use of contrast agent, can reveal tumors of the soft tissue or injuries on ligaments or tendons. Bone scan o Is perfom to detect metastatic and primary bone tumors , osteomyelitis and some fractures and aseptic necrosis
Priority Nursing Diagnosis: Acute pain related to altered integrity of the fifth metacarpal bone secondary to surgery Self-care deficit related to inability to grasp objects secondary to amputation of the fifth phalanges Disturbed body image: changes in perception of self secondary to amputation of the fifth phalanges. Risk for peripheral neurovascular dysfunction; phantom limb pain related to amputation of the fifth phalanges of the left hand.
II. General Objectives A. Knowledge Our team used holistic approach to view our patient's totality. Our objectives include: Incorporating background knowledge to the actual patient care. It includes hypothetical principles regarding nursing care and hands-on nursing procedures to be performed for the patient's management of care, also remembering the normal values to be able to identify abnormalities and analyzing why it is happens and preventing foreseeable mistakes that could harm the patient's well-being. Specific Objectives: 1. Nursing Care Advocate for health promotion. Educate patients. Provide care and assistance. Help patient and their family to cope with illness. Performing relaxation techniques helps the patient to divert their condition. Encouraging the patient to respond in medication. Teaching the patient to perform daily exercises to maintain the health. Provide patient teaching, including self-care, medication information and monitoring for potential complications of the illness. 2. Medication Administration Informing the patient if he/she is unfamiliar with the medication. We should explain the intended action as well as any side effects or adverse effects that might occur. Check three times for safe medication administration. a) First check = Read the medication administration record and remove the medication(s) from the client's drawer. Verify that the client's name and room number match the (MAR). Compare the label of the medication against the MAR. If the dosage does not match the MAR, determine if you need to do a match calculation. b) Second check = While preparing the medication, look at the medication label and check against the MAR. c) Third check = Recheck the label on the container before returning to its storage place. Check the label on the medication against the MAR before opening the package at the bedside.
Calculate the medication accurately. Document each medication given, record the medication given, dosage, time, any complaints or assessments of the client and your signature. Evaluate the effects of the medication. Return to the client when the medication is expected to take effect (usually 30 minutes) to evaluate the effects of the medication on the client.
3. Physical Assessment Assessment in Muscles Inspect the muscles for size. Compare the muscles on one side of the body (specially the hand and arm) to the same muscles on the other side. For any discrepancies, measure the muscles with a tape. a) Normal findings = Equal size on both sides of the body b) Deviations from normal = atrophy ( a decrease in size ) or hypertrophy ( an increase in size ) amputate, asymmetry. o Inspect the muscles and tendons for contractures (shortening) a) Normal findings = No contractures b) Deviations from normal = Malposition of body parts o Inspect the muscles for tremors, for example by having the client hold the arms out in front of the body a) Normal findings = No tremors b) Deviations from normal = Presence of tremor o Palpate muscles at rest to determine muscle tonicity ( the normal condition of tension, or tone of a muscle at rest ) a) Normal findings = normally firm b) Deviations from normal = atonic ( lacking tone ) o Test muscle strength o Grasp strength: The patient grasps your index and middle fingers while you try to pull the fingers out. a) Normal findings = Equal strength on each body side b) Deviations from normal = 25 % or less of normal strength
0 = 0% or less of normal strength 1 = 10% of normal strength; no movement, contraction of muscle is palpable or visible. 2 = 25% of normal strength; full muscle movement against gravity with support. 3 = 50% of normal strength; normal movement against gravity. 4 = 75% of normal strength; normal full movement against gravity and against minimal resistance. 5 = 100% of normal strength; normal full movement against gravity and against full resistance. Assessment in Bones Inspect the skeleton for structure a) Normal findings = No deformities b) Deviations from normal = Bones misaligned o Palpate the bones to locate any areas of edema or tenderness a) Normal findings = No tenderness or swelling b) Deviations from normal = Presence of tenderness or swelling Assessment in Joints Inspect the joint for swelling. Palpate each joint for tenderness, smoothless of movement, swelling, crepitation and presence of nodules. a) Normal findings = No swelling, no tenderness, crepitation or nodules. b) Deviations from normal = One or more swollen joints, presence of tenderness, swelling, crepitation or nodules.
4. Infection Control o Teach proper hand hygiene ( e.g., handling foods, before eating, after toileting, before and after required home care treatment and after touching anybody substances such as wound drainage ) and related hygienic measures to all family members. o Instruct about proper administration of medication. o Promote nail care: Keep fingernails short and clean to eliminate rough edges, which can harbor microorganisms.
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o Placing the contaminated dressings and other disposable items containing body fluid that is being used by the patient according to the hospital waste disposal. o Perform sterile to sterile techniques. o Wear protective gear like face mask to prevent endogenous, exogenous infection. o Put the used needles in a puncture resistant container with a screw-top lid. Label so as not to discard in the garbage. o Using of disposable gloves when measuring the urine output of the patient. o Sanitizing of hands before and after handling the patient
B. Skills Group participation in performing basic nursing procedures such as the following: Monitoring vital signs such as pulse rate, respiratory rate, blood pressure and body temperature and the corresponding abnormalities and their interpretations. Performing proper medicine preparation and administration techniques, health teachings about nutritional diet, wound dressing changes and range of motions/exercises which can reduces the nurses comfort and so to the patient. Specific Objectives: 1. Monitoring vital signs Blood pressure: Normal BP not should be lesser or higher than 120/80 mmHg Hypertension stage 1 = 140-159 / 90-99 mmHg Hypertension stage 2 = >160 / >100 mmHg o S/sx of hypertension ( e.g., headache, ringing in the ears, flushing of face, nosebleeds, fatigue, bradycardia. ) o Interventions: Don't give excessive drinking water ( to reduce blood volume ) Proper positioning ( semi or high fowlers position ) Low salt ; Low fat diet Administering of antihypertensive drugs (e.g., Betablockers = Propranolol , Calcium-channel blockers = Verapamine Hypotension = < 120 / 80 mmHg
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o S/sx of hypotension ( e.g., dizziness, mental confusion, restlessness, cool and clammy skin, pale or cyanotic skin, tachycardia ) o Interventions : Proper positioning ( supine or trendelenburg's position ) for 10 minutes Administration of caffeine Record the client's pulse and blood pressure Body temperature : Normal human body temperature is about 36.5 - 37.2 C Pyrexia or hyperthermia = 38 C - 40 C o S/sx of hyperthermia ( e.g., increased heart rate, respiratory rate and depth, flushed and warm skin, sweating and possible dehydration ) o Interventions : Monitor vital signs Assess skin color and temperature Monitor WBC, hematocrit value and other pertinent laboratory reports for indications of infection and dehydration. Measure intake and output Provide oral hygiene to keep the mucous membranes moist. Perform a Tepid sponge bath to increase heat loss through conduction Administration of antipyretic drug ( e.g., Paracetamol ) Hypothermia = 35 C below o S/sx of hypothermia ( e.g., decreased body temperature and respiratory, severe shivering initially, feelings of cold and chills, pale, cool and waxy skin, decreased urinary output , disorientation ) o Interventions : Provide a warm environment Provide dry clothing Apply warm blankets Keep limbs close to the body Supply warm oral / intravenous fluids
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Pulse rate: The normal range for an adult is typically place at 60100 bpm. o An excessively fast heart rate (e.g., over 100 bpm in an adult ) is referred to as tachycardia. o A heart rate in an adult of less than 60 bpm is called bradycardia. Respiratory rate : The normal range is about 12-20 cpm. o Abnormally slow respirations are referred to as bradypnea. o Abnormally fast respirations are called tachypnea.
2. Measuring input and output o Instruct the client or family member to record urinary output. o Provide enough time for bladder emptying ( 10 minutes ) o Monitor urinary elimination including odor , volume and color. o Limit ingestion of bladder irritants ( e.g., colas, coffee, tea and chocolates ) o Instruct client to limit fluids for 2 to 3 hours before bedtime. o Catheterize for residual urine, as appropriate. o Instruct on a high-fiber diet, as appropriate o Asking the patient how many times they urinate and defecate from the time of our shift o Knowing the normal urine output when collecting the urine of the patient . o Document all gathered data by organizing it, including the time ( within the shif ) legible hand writing and error free . 3. Performing physical assessment o Appropriate interview skills an techniques using the 4 senses such as sight, hearing, touch and smell. o Identifying those aspects of a patient's physical, psychological and emotional state that indicated a need for nursing care. o Using of the devices that measures the availability of the specific part of the body to response to a stimuli. o Gaining the cooperation of the client is important for better physical assessment resullt . o Using of proper and appropriate measurable devices in performing physical assessment.
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C. Attitude Establishing rapport to facilitate an effective communication between the patient, his/her relatives, student nurses and the health care team staff to identify priority problems to be resolved in the care plan. 1. Effective communication with the patient. o Direct to the point attitude towards the patient. o Make the patient comfortable by simply smiling to them and using flowerable words. o Use language appropriate to the client's level of understanding. o Avoidance of speaking foul languages. o Wearing proper uniform o Using eye contact, self disclosure, open posture and giving the right distance when interacting with the patient. o Performing a health teaching regards to the patient's current condition. o Using appropriate verbal and non-verbal expressions in conveying messages and other expressions. o Using empathy not sympathy. o Avoiding false reassurance to the patient. 2. Effective communication with the health care team. o Establish open communication with the health care team and the student nurses. o Apply professionalism in any aspects of care for the patient with physicians, relatives and staff at all times. o Providing thorough explanations to provide directions to the main point of view. o Communicating client's need appropriately to the health care staff by reporting complete datas about the client's responds to medications and medical procedures. o Using appropriate language to avoid disrespect to the health care team. o Legibly documenting the patient's chart and other related documents. o Using proper referrals.
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o Validating practices to knowledgeable health care staff to prevent malpractice. 3. Effective communication with fellow group mates. o Project a positive image o To deligate responsibilities well by keeping them informed and updated about the patient's care and instructions given by the clinical instructor. o Acknowledge every team members efforts in accomplishing in group and individual task. o Adjusting to one's weakness through sharing resources that one does not have and plotting appropriate schedule to fit one's availability. o Maintaining professionalism throughout the rotation by going duty on time and maintaining proper decorum. o Absences during the meeting, not coming on designated time, lack of appropriate resources are the problems that we encounter during group works. We tend to anticipate those problems so we manage them by giving each other proper directions through text messaging to prevent delays and meet the deadline. o Encouraging each of team members to do the designated task to make our work accomplish. o Communicating any doubtful nursing practices to a reliable health care staff before performing it. o If confusion arises, clarify any miscommunication to health care providers.
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IIi. Patient Profile a. Biographic Data Name: J.B Rank: PFC(Private First Class) Address: Isabela Age: 29 yrs. old Sex: Male Birthday: Dec. 17, 1981 Civil status: Single Educational Attainment: High School Graduate Occupation: Soldier Nationality: Filipino Religion: Roman Catholic Mothers Name: Marilou Balmes Fathers Name: Bernardino Balmes Surgical Diagnosis: Gap non-union 5th Metacarpal Hand Left S/P Application of Bone Spacer 5th Metacarpal Hand Left Bone Ankylosis Metacarpophalengeal Proximal and Distal Interphalengeal Joint Hand Left Date of Admission: March 12, 2011 Time of Admission: 0811H Method of Transport: Per Ambulance Doctor-in-Charge: Captain Chua with Orthopedic Team A
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a. Chief Complaint Pain on 5th digit left hand
b. History of Present Illness Patient is a case of GSI 5 months prior to admission, when they were firing in a truck suddenly ambushed by NPA-New Peoples Army rebels. Patient sustained a single gunshot injury to his left digit hand. Patient was then brought to Abra provincial Hospital where in wound irrigation was done. Patient was there evacuated in an institution for further evaluation and management. c. History of Past Illness Childhood Illness During his childhood, the patient had Measles and Chickenpox only. Childhood Immunizations The patient did not complete his immunizations during his childhood. He only received anti polio. Allergies The patient had no allergies to any foods and drugs. Hospitalization for Serious Illnesses The patient brought to the hospital when he was a child because of Malaria Medications
1. Celecoxib 2. Cefuroxime sodium 3. Tramadol 4. Keterolac 5. Ranitidine Hydrochloride
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IV. Physical Assessment

Body parts Skull Measurements Palpation Norms Proportional to the size of the body, round, with prominences in the frontal area anterior and the occipital area posterior, symmetrical in all planes, gently curved. Actual findings Smooth absence of nodule or masses Smooth skull contour Analysis
Scalp
Inspection
White, clean, free from masses, lumps, scars, nits, dandruff and lesions.
The scalp are white and clean no masses or lumps, no lice or nits, no dandruff or lesion
Palpation Hair Inspection
No areas of tenderness Black evenly distributed and covers the whole scalp, thick, shiny, free from split ends. Coarse or fine Oblong Or oval, or square or heartshaped, symmetrical, facial expression that is dependent on the mood or true feelings, smooth and free from wrinkles, no involuntary muscle movements
No lump and tenderness of the scalp Uneven distribution of hair, thin hair
Palpation Face Inspection
No abnormalities observed Slightly asymmetric facial features noted
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Body parts Eyes
Measurements Inspection
Norms Parallel, unevenly placed, symmetrical, non protruding, with scant amount of secretions of both eyes black and clear Black, Evenly distributed and turned outward Black, symmetrical, thick, can raise lower brows without difficulty, evenly distributed and parallel to each other. Upper lids cover a small portion of the iris and the cornea and the sclera limbus, when the eyes are open when the eyes are closed, the lid meet completely. Symmetrical color is the same as the surrounding skin. No palpable mass Clear, without sackings, secretions, lacrimal duct opening, (puncta) are evident nasal ends of the upper and lower lids.
Actual findings No abnormalities observed
Analysis
Eye Lashes
Inspection
No abnormalities observed
Eyebrows
Inspection Inspection
Eyelids
Patient can blink normally
Palpation Inspection Lid margins
No palpable mass felt. No abnormalities observed
Palpebral fissure
Inspection Appear equal when the eyes open.
Appear equal when the eyes are open
Lower palpebral conjunctiva
Inspection
Salmon pink, shiny, moist and transparent
Pinkish in color, no lesion or nodules
Sclera Iris
White and clear Proportional to the size of the eye, round, black/brown, and symmetrical.
Sclera is white in color Black, symmetrical and round
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Body parts Pupils
Norms Able to move eyes in full range of motion or able to move in all direction. From pinpoint to almost the size of the iris, round, symmetrical, constrict with increasing light and accommodation.
Actual findings Round equal size pupils that reacts to lights and accommodation
Analysis
Eye movement Visual acuity
Able to move eyes in full range of motion or able to move in all direction. 20/20- distance from the chart - distance at which a normal eye can read Able to see 60 degrees superiorly, 90 degrees temporally, and 70 degrees inferiorly.
Both eyes coordination Able to read news print, books and letters
Field vision Ear
Able to see 60 degrees superiorly, 90 degrees temporally, and 70 degrees inferiorly Parallel, symmetrical, proportional to the size of the head, bean-shaped, helix is in line with the outer canthus of the eye, skin is the same color as the surrounding area, clean. Pinkish, clean, with scant amount of cerumen and a few cilia.
Client can able to see in the periphery Symmetrically align
Ear canal
Inspection
-Midline symmetrical and patent internal nares are clean, pinkish with few cilia nasal septum appears straight -With firm cartilage, clean pinkish (+) cilia seen Mobile firm not tender able to hear a whisper spoken 2 feet away
Hearing acuity
Inspection
Able to hear whisper spoken 2 feet away
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Body parts Nose
Norms Midline, symmetrical, and patent
Actual findings -No discharge or flaring, uniform in color -No tenderness
Analysis
Internal Nares Nasal Septum Lips
Inspection Inspection Inspection
Clean, pinkish, with few cilia Straight Pinkish, symmetrical, lip margin well defined, smooth and moist Straight -lips with no dryness cracking lesions or cyanosis, uniformed brown
Teeth
Inspection
32 permanent teeth, well-aligned, free from caries or filling, no halitosis Large, medium, red or pink, slightly rough on top, smooth along the lateral margins, moist, shiny, and freely movable At the center, symmetrical and freely movable
-wearing dentures , slightly yellowish in color
Tongue
Inspection
-pinkish in color, protrudes symmetrically, (-)swelling,(-)ulcers,(-)ulcers -uvula moves properly upward when the patients says ah -(+) gag reflex when the tongue depressor touches posterior pharynx No abnormalities observed No abnormalities observed -Slightly pink
Uvula
Inspection
Frenulum Cheeks (buccal mucosa) Palate: Soft
Inspection Inspection Inspection
Midline, straight and thin Pinkish, moist and smooth Pinkish, smooth and moist
Hard
Inspection
Slightly pinkish
Slightly pinkish
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Body Parts Voice
Measurements Inspection Palpation
Norms No hoarseness and well-modulated No palpable lumps,masses, or areas of tenderness Adam's apple palpable
Actual findings Normal voice tone No abnormalities observed
Analysis
Inspection Neck Palpation
Proportional to the size of the body and head, symmetrical, and straight No palpable lumps, masses, or areas of tenderness Adam's apple palpable
-(-)unrestrictive range of motion in the neck, no swelling, -No palpable mass noted
Neck Range of motion
Inspection
Freely movable without difficulty
Inspection Neck Muscular Strength Inspection THORAX & LUNGS ( ANTERIOR & POSTERIOR )
-Symmetrical and able to resist applied force ( both muscles ) -The chest contour is symmetrical and the chest is twice as wide as deep (anteroposterior diameter in a 1:2 ratio ). The spine is straight. Posteriorly the ribs tend to slope across and down. The ribs are prominent in a thin person. There is no bulging or retraction of the ICS during breathing. -The chest wall moves symmetrically during respiration
-Costal angel is not widened -No tenderness or masses
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Body Parts THORAX & LUNGS ( ANTERIOR & POSTERIOR )
Measurements Palpation
Norms -No lumps, masses, areas of tenderness. -Sides of the thorax expand symmetrically. The examiner's thumb separate approximately 3-5 cm. During excursion. -Vibrations are prominent over the areas near the bronchi. It increases with the intensity of the voice. Vibrations are strongest between the first and second ribs along the sternum anteriorly and between the scapulae posteriorly.
Actual findings
Analysis
-No areas of dullness
Percussion
-Percussion note varies with the thickness of the chest wall . -Resonance- sound creates by air fiiled lungs. It is clear, long,low pitch. -Dull- short, high, pitch, soft and thudding, heard over the heart. -Flat- absolute dullness;absence of air in the underlying tissue. -Tympany- moderately loud with musical quality with specific pitch. Quadrant of the abdomen.
-Normal breath sounds
Auscultation
Normal breath sounds differ in character depending on the area of the lung being auscultated. Bronchovesicular sounds- are mediumpitched sound or medium intensity, heard posteriorly between the scapulae. Vesicular sounds -are heard over the lung periphery. Bronchial sounds- are hollow high pitched
-Normal breath sounds
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Body Parts HEART
Norms No pulsations Abdominal aortic pulsations visible
Analysis
Palpation
Abdominal aortic pulsations palpable The 2 heart sounds are audible in all areas but loudest in the apical area. Cardiac rates range from 60-100 bpm
BREAST (MALE)
Inspection Palpation
Males: flat, symmetrical. If obese, may be slightly rounded. Color of the skin same with the abdomen, no retraction, no dimpling. No mass or lump, no areas of tenderness Lobular feel of glandular tissue is normal. The lower edge of the each breast may feel firm and hard. Warm to touch and smooth.
No abnormalities observed No abnormalities observed
AREOLA
Inspection
Round or oval, color darker than surrounding skin, symmetrical. For dark skinned clients, color is darker than other skin surfaces. No masses and areas of tenderness Round or inverted, equal in size, similar in color, nipples point in one direction, no discharge, no lesion, no dimpling, No crusting.
Palpation Inspection NIPPLES
No abnormalities observed No abnormalities observed
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Body Parts NIPPLES
Norms No masses, no tenderness and no discharge Skin is unblemished, no scars , color is uniform, flat, rounded (convex), or scaphoid (concave), symmetrical movements caused by respirations, aortic pulsations at epigastric area visible in thin persons, positioned midway between the xiphoid process and symphisis pubis, color is the same as the surrounding. There are clicks and gurgles, the frequency of which has been estimated at from 5-34 per minute. Occasionally, borborygmi (loud prolonged gurgles hyper peristalsis)the familiar stomach growling can be heard. Tympany predominates because of presence of air in the stomach and intestines. Percussion is dull at the livers lower boarder. Soft abdomen, no tenderness, no muscle guarding, no lumps or masses, organomegaly. Livers edge feels firm and non-tender. Skin color varies (pinkish, tan, darkbrown), symmetrical, fine hair evenly distributed, presence/ absence of visible veins.
Analysis
ABDOMEN
Inspection
-No abnormalities observed -rounded
Auscultation
Percussion
Palpation
UPPER EXTREMITIES Arms
Inspection
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Body Parts UPPER EXTREMITIES Arms
Norms Warm, dry, elastic; no areas of tenderness. Muscle appears equal with good muscle tone.
Analysis
Palms (Anterior & Posterior Surface)
Inspection
Palms pinkish (dorsal surface) warm; males-thick Nails are transparent, smooth and convex with nail beds and white translucent tips. Five fingers in each hands
No abnormalities observed No abnormalities observed 5 fingers on the right hand; 4 fingers on the Left hand Normal Capillary Refill Time (<3 seconds) on both hands The patient has undergone 5th metacarpal amputation due to severe damage to the said affected area.
Nails
Inspection
Palpation
As pressure is applied to the nail bed, appears white or blanched, and pink color returns immediately as pressure is released. Skin color varies (pinkish, tan, dark brown), skin is smooth, fine hair evenly distributed, absence of varicose veins, muscles symmetrical, length symmetrical.
Lower extremities Legs
Inspection
-no gross deformities - symmetrical body parts, -good body alignment, -no involuntary movement, -smooth gait, full range in motion, Normal Capillary Refill Time (<3 seconds) on both hands Actual findings No abnormalities observed Analysis
Palpation
Muscles appear equal, warm and with good muscle tone. Norms As pressure is applied, the nail bed appears white or blanched; pink color returns when pressure is released.
Body Parts Toes
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V. Activities of Daily Living (Using Gordons Functional Pattern)

FUNCTIONAL PATTERN BEFORE HOSPITALIZATION DURING HOSPITALIZATION INTERPRETATION
A.
Health Perception and Management Pattern
The client views the importance of health as very important. He ate a balanced diet and exercised daily so that he stayed healthy. Whenever he was sick the only thing he does was to break sweat like doing push-ups and jogging. He doesnt take any over-thecounter drugs. The patient ate balanced diet three times a day. It consists of fruits, meats, vegetables, and fish. He had no allergies to any food, drugs and environment.
For him, he considered his self as a healthy one even he was being hospitalized. He followed the doctors prescribed orders for medications and frequent diagnostic procedure followups.
The patients health perception change significantly due to his hospitalization.
B.
Nutritional Pattern
Before his scheduled surgery, the client was prescribed to be on NPO-nothing per orem for about 9 hours. Right after the surgery, the doctor ordered to ate the prescribed diet to resume his regular diet of fruits, meats, vegetables, and fish. STOOL OUTPUT: He defecated brownish/yellowish stool once a day without experiencing any discomfort URINE OUTPUT: He voided 4 times a day with light yellow urine in color. No foley catheter inserted during operation.
The patients nutritional status has changed depending on the need since he underwent several procedures which required diet changes as part of his management.
C. Elimination Pattern
STOOL OUTPUT: He defecated brownish/yellowish stool once a day without experiencing any discomfort. URINE OUTPUT: He voided 3-4 times a day, a light yellow in color.
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FUNCTIONAL PATTERN
BEFORE HOSPITALIZATION
DURING HOSPITALIZATION
INTERPRETATION
D. Activity-Exercise Pattern
He performed jogging, push-ups, situps, and pull ups as his daily exercise every morning. His job was a brave soldier to serve his country and countrymen.
He cannot performed jogging, push-ups, and pull-ups as his daily exercise every morning during hospitalization. For now walking was his exercise. The patient can get back to his work as soon as when the doctor recommended to do so. During his hospitalization, his sleeping hours was approximately 8 hours a day from 10pm to 6am.
The patient cannot perform such exercises because he is presently admitted due to fracture of the 5th metacarpal which resorted to its amputation and he is on his first day post operative.
E.
Sleep-Rest Pattern
When he was on duty, 2 hours was his sleeping hour a day per 24 hours. But when he was not on duty he sleeps at approximately 8 hours a day per 24 hours. He had no rest during day time and afternoon when he was on duty.
The patients sleep and rest patterns have changed because he is a patient which does not need him to be scheduled for duty as his routine activity before hospitalization.
F.
Cognitive-Perceptual Pattern
He started to read and write at the age of six. He can respond to verbal communications and understood by others. He answers correctly and properly whenever hes being questioned or asked by a health care provider. The technique of asking used by the health care provider was question and answer.
BEFORE HOSPITALIZATION
He can respond correctly, clearly and properly answer the questions being asked by the health care provider during hospitalization.
There were no changes in the cognitive and perceptual patterns of the patient.
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FUNCTIONAL PATTERN
DURING HOSPITALIZATION
INTERPRETATION
G. Self-Perception-Self-Concept Pattern
He sees his self as a responsible son to his parents and a kind brother to his siblings. Also a brave soldier to his country.
He still believes that he is a responsible son to his parents and a kind brother to his siblings. And also a brave soldier to his country. Even he was being hospitalized and now that his fifth digit was gone he said that life must goes on and dont lose hope. His monthly salary was the only way to support his expenses and family needs inspite the fact that he was being hospitalized. The patient still maintains his strong family ties and communication through calling and texting. He has a girlfriend, but he is not sexually active during his hospitalization.
There were no changes in his selfconcept pattern.
H. Role-Relationship Pattern
He is a son and provides some needs in the family. Has an intact relationship with the family and open with communication through calling and texting. He had a girlfriend. He has a good sexual behavior. He has a one year stable relationship. His current girlfriend was the seventh while he was the second boyfriend of his girlfriend. According to the patient the most stressful event that he had been experienced was when his mother died last 2008. Being busy to his work was the thing he does to cope up in this situation.
The patient can still support the expenses of the family and maintain his family relationship through cell phone communication (text messages and calling them).
I.
Sexuality-Reproductive Pattern
The patients sexual behavior has changed because of the limitations in his environment and due to his damaged finger (5th digit)
J.
Coping-Stress Tolerance Pattern
According to the patient, the most stressful event that ever happens to him during hospitalization was when he was admitted due to his gunshot wound in his left fifth metacarpal of his hand.
The patient can easily cope up with his problem which means he is well adjusting and adapting even during crisis/stress situations.
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BEFORE HOSPITALIZATION FUNCTIONAL PATTERN
DURING HOSPITALIZATION INTERPRETATION
He watched television and plays his cellular phone whenever he was under stressed. He can easily overcome his problems and immediately finds a solution to it.
He watched television and plays his cellular phone whenever he was under stressed. He can easily overcome his problems and immediately finds a solution to it.
K.
Value-Belief Pattern
He believes in God. He is a Roman Catholic. He goes to church every Sunday. In every operation they had, he always prays to God to guide him in their battle.
He strongly believed in God. He seldom goes to church during he has been hospitalized. Every Saturday or Sunday, he attended the mass and bible study in the institution. He always prayed at night. Sometimes he read the bible when he had his spare time. During he was being hospitalized, he thinks that he was dying, his thoughts belongs to those who had being left by him especially his family and girlfriend whenever he cannot survive to his condition.
After what happened to him, the patients faith in God became stronger and he always prayed to God before he sleeps.
VI. Developmental task
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Developmental task
Normal Age/Patients Age
Positive Task(Erickson)
Patients Positive Achieved task
Negative Task (Erickson)
Patient Negative Achieve task
Interpretation
Young Adulthood 18-35 years old
1.Establising close intimate relationship with other person
1.Social Isolation
Intimacy versus Isolation
1. ACHIEVED. He is afraid to lose someone that he loves for 1 year. His girlfriend didnt visit him in the hospital because she is taking her Masteral Degree.
The patient was not able to achieve the entire positive task by Erik Erickson because of his situation. He has many plans for his life about the future but his being hospitalized prevents him to accomplish those things.
Patient Age:29 years old
2.Making a commitment to that relationship, even in times of stress and sacrifice
2. Inability to maintain serious relationship with the opposite sex.
2. ACHIEVED. They relationship is 1 year according to the patient there way of communication is through Cell phone. Sometimes they have quarrel because of jealousy. The girl thinks that her boyfriend has other girl.
3.Accepting sexual behavior as desirable
3. ACHIEVED: He is open about any sexual concerns and portrays heroic deeds.
VII. Laboratory and Diagnostic Findings
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DATE 11 March 2011
PROCEDURE Chest X-ray Posterior and Anterior View
NORMS Chest should be clear of any enlargement, dilation of any blood vessels, free of any deformities such as obstructions and bleeding.
RESULT Lungs are clear, heart not enlarged, Aorta is not dilated, Diaphragm and sulci are intact. The rest of the visualized chest structures are unremarkable.
INTERPRETATION Normal
ANALYSIS
DATE 17 March 2011
PROCEDURE Electrocardiogram (ECG)
NORMS Normal Sinus Rhythm
RESULT Sinus Rhythm, Occasional Premature Ventricular contractions
INTERPRETATION Normal
ANALYSIS Sinus Rhythm occurs when the electrical impulses starts at a regular rate and rhythm in the sinus node and travels through the normal conduction pathway. Premature Ventricular Contractions occurs in healthy people taking caffeine, nicotine and alcohol
DATE
PROCEDURE
NORMS
RESULT
INTERPRETATION
ANALYSIS
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12 March 2011
Complete Blood Count (CBC) Hemoglobin Hematocrit Red Blood Cells White Blood Cells Platelet Count Segmenters Lymphocytes Monocytes Blood Indices: Mean Corpuscular Value Mean Corpuscular Hemoglobin Mean Corpuscular Hemoglobin Concentration Reticulocyte Count: Clotting Time Bleeding time Blood type: B+ 135-180g/m M: 0.35-0.51 M/F: 3.93-5.22x10 12/L 5.0-10.0x10 9/L 130-500x10 0.55-0.65 0.22-0.35 0.02- 0.10 80-100 FL 27-31 FL 31-36 g/dL 148 0.42 5.66 6.0 240 0.75 0.15 0.10 74.9 26.1 34.9 Normal Normal Increased Normal Normal Increased Decreased Normal Decreased Decreased Normal Possible anemia due to minimal blood loss due to open fracture Possible anemia due to minimal blood loss due to open fracture
Possible anemia due to minimal blood loss due to open fracture
Possible anemia due to minimal blood loss due to open fracture
1.5-9.5 min.
2 min 30 secs 1 min 30 secs
Normal Normal
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DATE 23 March 2011
PROCEDURE Urinalysis Urine Flow Cytometry Co;or Clarity Specific Gravity Chemical Analysis pH Protein Glucose Leukocytes Nitrates Ketones Urobilinogen Bilirubin
NORMS
RESULTS
INTERPRETATION
ANALYSIS
yellowish Clear 1.003-1.030
Light yellow Clear 1.005
Normal Normal Normal Possibly affected by the clients food intake of acid rich I foods like fruits and vegetables and foods rich in uric acid like organ meats.
50-60: acidic 70-90: Basic Negative Negative Negative Negative Negative Negative Negative NORMS 0-11 0-11 0-11 0-11 0-11 NORMS Brown-light brown Formed to semi-formed None None None None
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Acidic Normal Normal Normal Normal Normal Normal Normal
DATE
23 March 2011
PROCEDURE Urinalysis: Microscopic Analysis RBC WBC EC CAST BACT PROCEDURE Fecalysis Color of Stool Consistency RBC Pus cells Mucus Ova & Parasites
RESULTS 0 U/L 3 U/L 1 U/L 0 U/L 4 U/L RESULTS Light Brown Formed None None None None
INTERPRETATION Normal Normal Normal Normal Normal INTERPRETATION Normal Normal Normal Normal normal Normal
ANALYSIS
DATE
ANALYSIS
23 March 2011
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VIII. Anatomy and Physiology A. Macro- Anatomy of the Skeletal System
Figure 1: Anterior View
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FFigure 2: Posterior View
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B. Micro Anatomy of the Metacarpals.
Fig. 1.1 Outer Parts Of the Hands.
Fig. 1.2 Posterior Parts Of the hand
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Fig.1.3 Cross Dissection of Internal Bone Structure the 5th Metacarpal
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C. Macro- Physiology of the Skeletal System Skeletal System is the biological system providing support in living organisms. Skin, muscle and bones allow movement. Skin - pliable covering. Muscles do actual moving. Bones give anchor to move against. The skeleton functions not only as the support for the body but also in haematopoiesis, the manufacture of blood cells that takes place in bone marrow. This is why people who have cancer of the bone marrow almost always die. It is also necessary for protection of vital organs and is needed by the muscles for movement. a.Scapula- is the technical name for the shoulder blade. It is a flat, triangular bone that lies over the back of the upper ribs. The rear surface can be felt under the skin. It serves as an attachment for some of the muscles and tendons of the arm, neck, chest and back and aids in the movements of the arm and shoulder. It is well padded with muscle so that great force is required to fracture it. The back surface of each scapula is divided into unequal portions by a "spine." This spine leads to a "head," which bears two processes - the "acromion process" that forms the tip of the shoulder and a "coracoid process" that curves forward and down below the clavicle (collarbone). The acromion process joins a clavicle and provides attachments for muscles of the arm and chest muscles. The acromion is a bony prominence at the top of the shoulder blade. On the head of the scapula, between the processes mentioned above, is a depression called the "glenoid cavity." It joins with the head of the upper arm bone (humerus). b.Spine-The spine is a column of bone and cartilage that extends from the base of the skull to the pelvis. It encloses and protects the spinal cord and supports the trunk of the body and the head. The spine is made up of approximately thirtythree bones called "vertebrae." c.Vertebrae -Each pair of vertebrae is connected by a joint which stabilizes the vertebral column and allows it to move. d.Disk-Between each pair of vertebrae is a disk-shaped pad of fibrous cartilage with a jelly-like core, which is called the "intervertebral" disk - or usually just the "disk". These disks cushion the vertebrae during movement. The entire spine encloses and protects the spinal cord, which is a column of nerve tracts running from every area of the body to the brain. The vertebrae are bound together by two long, thick ligaments running the entire length of the spine and by smaller ligaments between each pair of vertebrae. The anterior longitudinal ligament consists of strong, dense fibers, located inside the bodies of the vertebrae. They span nearly the whole length of the spine, beginning with the second vertebrae
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(or "axis"), and extending to the sacrum. The ligament is thicker in the middle (or "thoracic" region). Some of the shorter fibers are separated by circular openings, which allow for the passage of blood vessels. Several groups of muscles are also attached to the vertebrae, and these control movements of the spine as well as to support it. Quasimodo, the central character of Victor Hugo's novel, "The Hunchback of Notre Dame," is probably the most famous of all real or fictional sufferers of "kyphosis," an abnormal, backward curvature of the spine. e. Humerus The humerus is the bone of the upper arm. a.Head-The smooth, dome-shaped head of the bone lies at an angle to the shaft and fits into a shallow socket of the scapula (shoulder blade) to form the shoulder joint. Below the head, the bone narrows to form a cylindrical shaft. It flattens and widens at the lower end and, at its base, it joins with the bones of the lower arm (the ulna and radius) to make up the elbow. i. Greater Tubercle And Lesser Tubercle- muscles originating or scapula attach to greater and lesser tubercle and holds the humerus to thje scapula. ii Deltoid Tuberosity- where in muscle attach Iii Epicondyles- upon the distal end of humerus just lateral to the condyles provide attachment sites from forearm muscles. f.Ligaments of The Sacrum- The sacrum, at the base of the vertebral column, is wedged between the coxal bones of the pelvis and is united to them by fibrocartilage at the "sacroiliac joints." The weight of the body is transmitted to the legs through the pelvic girdle at these joints. The a. Posterior Sacroiliac Ligament -at the front of the sacrum, which joins it to the ilium is called the "anterior sacroiliac ligament"; at the back, it is called the "." The coccyx, or tail bone, is attached by ligaments to the margins of the sacral hiatus (opening at the tip of the sacrum). These ligaments are called the "anterior" and "posterior sacrococcygeal ligaments." b.Sacrospinous-ligament is a thin, triangular sheet attached by its broad base to the lateral margins of the sacrum and coccyx, where its fibers are intermingled with those of the intrapelvic surface of the "sacrotuberous ligament," and by its apex to the spine of the ischium.
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c.Sacrotuberous Ligament -is a broad, flat fan-shaped complex of fibers stretching from the lower back spine of the ilium, the 4th and 5th transverse tubercles and the caudal part of the lateral margin of the sacrum and coccyx to the inner margin of the tuberosity of the ischium. The "iliolumbar ligament" connects the lower lumbar vertebra process to the ilium (the largest portion of the coxal bone). f. Forearm- has 2 bones a. Ulna- on the medial side of the forearm b. Radius- lateral side i Semi-lunar notch- that fits tightly over the end of the humerus forming most of the elbow joints. ii Olecranon Process- which can be felt as the point of the elbow. iii Choronoid Process- helps complete th grip of the ulna on the distal end of humerus iv Styloid Process- located on the medial side. g.Lower Leg And Ankle Ligaments a.Fibula -is the long, slender bone beside the tibia. Its ends are slightly enlarged into an upper head" and a lower "lateral malleolus." The head meets the fibula just below the lateral condyle; but it does not enter into the knee joint and does not bear any body weight. The ligaments which join the fibula to the front of the fibula are called the "anterior tibiofibular ligaments," and the "posterior tibiofibular ligaments" join them behind the knee. The lateral malleolus is joined to the ankle by the "anterior talofibular ligaments," and the "posterior talofibular ligaments." These ligaments form a prominence on the side of the ankle. b.Tibia-is the inner and thicker of the two long bones in the lower leg. It is also called the shin bone. Its upper end is expanded into "medial" and "lateral condyles," which have concave surfaces and unite with the condyles of the femur. The tibia is the supporting bone of the lower leg and runs parallel to the other, smaller bone (the fibula) to which it is attached by ligaments. The front of the tibia lies just below the skin and can easily be felt. The upper end joins the femur to form the knee joint, and the lower end forms part of the ankle joint. On the inside of the ankle, the tibia widens and sticks out to form a large bony prominence called the "medial malleolus." On the outside of the ankle is a
41
protrusion called the "lateral malleolus," which is sometimes called the ankle bone, and is the most common area for ankle sprains Ankles-The foot consists tarsals. a.Tarsal Bones," forming a group called the tarsus. These bones are arranged so that one of them, the "talus," can move freely where it joins the tibia and fibula (lower leg bones). This is known as the "head of the talus." The remaining tarsal bones are bound firmly together, forming a mass on which the talus rests. b.Calcaneus,. The other bones which compose the tarsus are the "" the largest of the ankle bones; the "talus;" the "navicular," the "cuboid," the "lateral cuneiform," the "intermediate cuneiform," and the "medial cuneiform." The "calcaneus," or heel bone, is located below the talus where it projects backward to form the base of the heel. It helps to support the weight of the body and provides an attachment for muscles that move the foot. f. Carpal Bones The skeleton of the wrist consists of eight small "carpal bones" that are firmly bound in two rows of four bones each. The resulting mass is the "carpus." The eight bones are the "pisiform," "triangular" or "triquetrum," the "pisiform," "lunate," and "scaphoid" on the upper end of the wrist, where it connects with ligaments and the lower arm bones, and the "hamate," "capitate," "trapezoid," and "trapezium" on the lower side of the hand by the "metacarpals," or first joint of thefingers. Condyles of The Humerus At the lower end of the humerus (upper arm bone) and the femur, there are two smooth condyles (rounded processes of the bone): a knob-like "capitulum" on the lateral side and a pulley-shaped "trochlea" in the middle. The capitulum unites with the radius (smaller lower arm bone) at the elbow, and the trochlea is a notch which joins ligaments to the head of the ulna (larger lower arm bone). Above the condyles on either side are "epicondyles," which provide attachments for muscles and ligaments of the elbow. The one toward the center of the arm is the "medial epicondyle," and the one to the side is the "lateral epicondyle." Clavicle The clavicle is the collarbone. There are two of these bones, each curved al little like an "f," that join the top of the breastbone (sternum) to the shoulder blade (scapula). The clavicles support the arms and transmit force from the arms into the central skeleton.
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The Coccyx The coccyx (or tail) is the lowest part of the vertebral column and is attached by ligaments to the margins of the sacral hiatus. When a person is sitting, pressure is exerted on the coccyx, and it moves forward, acting sort of like a shock absorber. Sitting down with too great a force may cause the coccyx to be fractured or dislocated. Femur The "femur" is the thigh bone, the longest bone in the body. The lower end joins the tibia (shin) to form the knee joint. The upper end is rounded into a ball (or "head" of the femur) that fits into a socket in the pelvis to form the hip joint. Just below the head is a constriction, or neck, and two large processes - an upper, lateral "greater trochanter" and a lower, medial "lesser trochanter." These processes provide attachments for muscles of the legs and buttocks. Femoral condyles are large, rounded bumps on the distal end of the femur. They articulate (come in contact) with the condyles of the tibia and form part of the knee joint. The neck of the femur gives the hip joint a wide range of movement, but it is a point of weakness and a common site of fracture. Fibula The fibula is the outer and thinner of the two long bones of the lower leg. It is much narrower than the other bone (the shin), to which it runs parallel and to which it is attached at both ends by ligaments. The upper end of the fibula does not reach the knee, but the lower end descends below the shin and forms part of the ankle. Its main function is to provide attachment for muscles. It doesn't give much support or strength to the leg, which explains why the bone can safely be used for grafting onto other bones in the body. Pelvis (or Os Coxa) The pelvis is a ring of bones in the lower trunk of the body, which is bounded by the coccyx (tail bone) and the hip bones. The pelvis protects abdominal organs such as the bladder, rectum and, in women, the uterus. The pelvis is made up of three hip bones, which are joined by rigid sacroilac joints to the sacrum at the back. The hip bones curve forward to join the pubic symphysis at the front. The symphysis pubis is a cartilaginous union between both sides of the pelvis anteriorly. It is significant during childbirth as it is capable of stretching to permit delivery. Attached to the pelvis are muscles of the abdominal wall, the buttocks, the lower back, and the insides and backs of the thighs. Each innominate bone is made up of three fused bones: the ilium, the ischium, and the pubis. Together they form the acetabulum which is a cup-like depression ball and socket joint.
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The ilium is the uppermost and largest and consists of a wide, flattened plate with a long curved ridge (called the "iliac crest") along its border. The pubis is the smallest pelvic bone. It extends forward from the ischium and around to the pubis symphysis, where it is joined to the other pubic bone by a tough, fibrous tissue. These three bones meet to form a cup-shaped cavity that make up the socket of the hip joint. There are many structural differences between the male and the female pelvis, most of which reflect the role of childbirth in the female. The male pelvis is larger and smaller inside with the pubis symphysis deeper and longer. The female, on the other hand, has a much more delicate, less prominent pelvis that is wider inside and the pubis symphysis shallow and shorter. These and other differences give testimony to the fact that childbirth is a feat of nature indeed. Ischium The "ramus" of the ischium is the thin, flattened part of the ischium (lowest part of the coxal bone), which ascends from the lower part of the body and joins the inferior ramus of the pubis - the junction being indicated in the adult by a raised line. The combined rami are sometimes called the "ischiopubic ramus." The ischium is the posterior inferior compart of the pelvis. Posteriorly, bony prominences form the ischial tuberosity or each side of the inner pelvis and support the body's weight in a sitting position. The large opening called the obturator foramen is formed by both the rami of the ischium together with the pubis and creates the opening that allows for the passage of major blood vessels and nerves to the legs and feet.
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D. Micro-Physiology of the Metacarpals (5th digit) Attached to the carpal bone and form the bony framework the hand of metacarpals is aligned with the five digits. The thumb and finger they are numbered 1-5 from the thumb to the little finger. The ends, or heads of 5 metacarpals are associate 1 with thumb and finger 5. The knuckles each fingers consist of three small bones. a.Phalanges-The phalanges are the small bones that make up the skeleton of the fingers, thumb and toes. Each finger and smaller toe has three phalanges; the thumb and big toe each have two. The phalange nearest the body of the hand or foot is call the i.Proximal Phalange- phalange near to the point of attachment to the carpal bones. ii Distal Phalange- distal carpal bones are fixed. The peripheral metacarpals (those of the thumb and little finger) form the sides of the cup of the palmar gutter and as they are brought together they deepen this concavity. iii Middle Phalange- The middle metacarpals are tihtly united to the carpus by intrinsic interlocking bone elements and their bases. iv Distal Phalanx of the Thumb- Metacarpal of the thumb far to the point of attachment of the phalanges. v. Proximal Phalanx Of Thumb- metacarpal bone near to the point of attachment of the phalanges.
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IX. Pathophysiology
Modifiable Risk Factors: > Occupational hazard in Military profession. > Alcohol > Accident > Falls
Non-Modifiable Risk Factors: > Age 18 56 yrs. Old > Gender: Male
Bullet striking the left hand 5th digit, wound occurs.
Barrel firmly pressed into the skin, there may be minimal soot and searing on the outside of the wound.
Deep penetration of smoke, burning, gun powder fragments and gases into depths of injury.
Exit wounds, round moves through the body it slows down and explodes within the tissue and surrounding muscle.
Slowing down of the projectile, it reaches the end of its trajectory it has to force harder to push through, may lead to fractures.
Patients Signs and Symptoms > Pain > Open wound left hand 5th metacarpal. > Limited movement on left hand and upper extremity > Moderate bleeding at left hand upper extremity Book based Signs and Symptoms > Severe Pain > Crepitus > Ischemia > Bleeding from open fracture.
Gap Non-Union 5th Metacarpal Left Hand Bony Ankylosis Metacarpal Proximal And Distal Joint.
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X. Course in the Ward
Month/Day
Course in the Ward
WEEK 1 MARCH 12-18 2011
Private first class of the Philippines army, 29 year male, J.B was admitted at exactly 0630H, accompanied by ward man on a stretcher under the service of Captain Chua and team A. Initial diagnosis was Gap non-union 5th Metacarpal hand left Status Post application of Bone Spacer 5th Metacarpal Hand Left Bone AnkylosisMetacarpophalengeal proximal and Distal Interphalengeal Joint Hand Left. He was conscious and coherent, and not in cardio pulmonary distress. Then informed consent for admission and management was secured. Admission tag was attached to chart of the patient. He was given diet as tolerated and vital signs was taken and recorded. The temperature was 37.2 C, the blood pressure 130/80 mmHg, pulse rate 92 beats per minute, and the respiratory rate was 20 cycles per minute. After taking the vital signs, the patient was put in comfortable position, and also orientation of ward rules and regulation was advised. The diagnostic procedure done for the patient was urinalysis, fecalysis,12-L ECG, chest x-ray and posterior and anterior view and also for further complete blood count with APC, blood typing. Also ordered CT Scan and x-ray of hand APO. The medication administered was Celecoxib 400 mg/tab. 1 tab OD for pain as needed.
WEEK 2 MARCH 19-25, 2011
Blood type is B+. Blood indices showed MCV was 74.9, MCH 26.1, MCHC 34.9, clotting time was 2 minutes and 30 sec, and bleeding time was 1 min and 30 sec. Blood ph was 6.0. The chest x-ray showed that lungs were clear, heart not enlarged, aorta is not dilated, diaphragm and sulci were intact. There were no significant chest findings. The complete blood count result showed there is an abnormality in the following: Hemoglobin was 148 g/L, hematocrit was 0.42 gm/L, RBC count was 5.66 U/L, WBC count 6.0, platelet count 240, segments 0.75, lymphocytes 0.15, and monocytes 0.10. ECG showed sinus rhythm with occasional premature ventricular contraction. Urine flow cytometry showed light yellow colored urine, clear and with specific gravity of 1.005. Fecalysis showed light brown stool with formed consistency.Patient has limitation of movement on his left hand.
WEEK 3 MARCH 26 APRIL 1, 2011
The patient was ordered for Operation and scheduling for amputation 5th digit hand(left finger). The consent was secured for the procedure. He was infused with D5LR 1L X 300 ml/min. He was started on Cefuroxime 750 mg/TIV. Oral care was routinely performed.
WEEK 4 APRIL 2-7,2011
Patient was returned to PACU. He was maintained on moderate bed rest. His vital signs were monitored every 15 minutes. His fluid input and output was also monitored. He was temporarily put on NPO when he first arrived at PACU. D5LR 1L X 30 IVF was infused. Medication given was Tramadol 100 mg IV initially then 150 mg IV every 6 hours.
WEEK 5 APRIL 8-14,2011
Patient was transferred to ward with anesthesia. IVF was just to consume. Celecoxib was started at 200 mg 1 tablet twice a day for pain. Patient was referred to next nurse on duty.
WEEK 6 APRIL 15-20, 2011
On the 15th, the patient was ordered by the anesthesia doctor to go to Post anesthesia care unit on Monday April 18, 2011.The patient was proceeding to operating room to amputate his 5 th digit left hand. Then informed consent procedure was signed and attached to the patients chart. The patient was informed NPO - post midnight, for venoclysis D5LR 1L x 30 gtts/min as well using an 18 gauge needle and blood set. Give Cefuroxime 750mg TIV prior to surgery, prepare for the operative site including perineal care. On the 18th they instructed to prepare the following: Midazolam 5mg IV c/o PACU, Nalbuphine 5mg IV c/o PACU, Ranitidine 50 mg IV every 8 hours once on NPO nothing per orem. With ongoingIVF of D5LR 1L @ 30 gtts/min using blood set with Gauge
47
18 needle. Followed up the availability of blood through laboratory but still for cross matching. Cefuroxime 750mg TIV was given ANST after negative skin test as initial dose. The entire pre operation check list was completed. Then the patient was transferred to PACU via wheel chair and endorse to the PACU nurse. Patient came back to ward 3A from O.R. Post - operative care was rendered on bed with the patient awake and responsive. With on-going IVF of D5LR 1L @ 30 gtts/min. Wound dressing was rendered to the patient on his left hand secured with elastic bandage by attending physician. The patient has limited movement on his left hand as assessed. Then monitored for the onset and severity of pain and vital signs were monitored and recorded. The post-operative pain of the patient was mild to moderate on his left hand on and of tolerable level with a scale of 5/10. Assessed for the degree of pain of the patient and encourage him to verbalized feelings about the pain. Advised him to limit the movement of his left hand. Pain reliever was given which isCelecoxib 200 mg/tab 5 tabs BID per orem. Then the pain scale was reduced to 3/10. WEEK 7 APRIL 21-28, 2011 Wound dressing was rendered on his left hand and secured it with elastic bandage which was dry and intact. On and off pain at the amputation site with the pain scale of 5/10. Patient was monitored for onset and severity of pain. Celecoxib 200mg/tab was given for the patient to relieve the pain. Advised him to limit his mobility on the affected left hand. Pain lessened from 5/10 to 3/10. Re-assessed the degree of mobility. And advised the patient to perform range of motion exercise to determine the degree.
48
XI. Nursing Care Plan Priority # 1: Acute Pain

ASSESSMENT Subjective: Sumasakit sya, tapos nawawala lang kapag umiiinom ako ng gamot as verbalized by the patient. Objective: 1. Taking ( drug, pain reliever, route, frequency done) TRAMADOL usual dosage is 50 100mg every 4-6 hours ROUTE - IV 2. Pain scale of 7/10 3. Expressive behavior of restlessness. 4. Sleep disturbances during procedures (giving medication, IV checking, endorsement) 5. Minimal swelling of his left hand fingers. 6. With 1 inch. Plaster bandage on his left hand. 7. Stayed only on his position when pain occurs. 8. Pain was subsiding when taking pain medication. 9. The left hand is shiny in textures compare to right not affected. 10. Irritability when pain occurs Vital signs; BP= 140/80 mmHg PR=70bpm RR=20cpm TEMP=35.9 c DIAGNOSIS Acute pain related to altered integrity of the 5th metacarpal bone at the left hand secondary to post surgical operation as evidenced by; Taking (drug, pain reliever. Route, frequency done), pain scale of 7/10, sleep disturbances during procedures (giving medications, IV checking, endorsement), minimal swelling of his left hand, With 1 inch plaster bandage on his left hand, stayed only on his position when pain occurs, pain was subsiding when taking pain medication, the left is shiny in textures compare to not affected hand, irritability when pain occurs. BACKGROUND STUDY OF DIAGNOSIS Acute pain( unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms such damaged) They were being ambushed by the New Peoples Army at the province of Abra and acquired his injury at fifth finger of his left hand by gunshot encountered. Comfort with the one of the nurses priority in caring for the clients who had undergone surgery. Pain management should be included. Unpleasant sensation postoperatively could result to patients discomfort which includes alteration in his activity of daily living. PLANNING STG: After of 2-4 hours of nursing intervention the patient will be able to report a decrease of pain from 7/10 to 3/10 pain scale. INTERVENTION Independent: 1. Use pain scale. 2. Note client attitude toward pain and pain medication. 3. Note when pain occurs. 1. To know what the pain scale is. 2. To help prevent the pain. 3. To promote pharmacological pain management. 4. To know the abnormal findings. 5. To know the knowledge and expectations about the pain management. 6. Usually altered in acute pain. 7. To determine if there is any bleeding in the site. 8. To reduce anxiety and pain. 1. Numeric pain scale was use. 2. Able to identify presence of pain. 3. Is able to verbalize advantages and disadvantages in taking pain medication. 4. Latest vital sign was stabled. 5. Gained knowledge and expectations about pain management. 6. Is able to verbalized feelings about pain. 7. Is able to know if theres any bleeding on the surgical site. 8. Clients gained knowledge how to handle painful experiences. 9. Able to monitored physical responses. RATIONALE EVALAUTION
4. Monitor skin color, temperature, and vital signs. 5. Ascertain clients knowledge and expectations about pain management. 6. Encourage verbalization of feelings about pain. 7. Note location of surgical procedure. 8. Teach the client about the nature of the impending painful experience. 9. Monitor physical responses; for example palpitation, rapid pulse, repetitive movement, pacing.
9. To determine the extent of pain sensation.
49
ASSESSMENT
DIAGNOSIS
BACKGROUND STUDY OF DIAGNOSIS
PLANNING
INTERVENTION 10. Teach the client the use non pharmacological techniques ( e.g. relaxation, music therapy, massage) Dependent: 1 Administer analgesics ordered. 2. Note clients for the locus of pain. 3. Note client attitudes toward and use of pain medicine. 4. Assist in through evaluation including neurological and psychological factors. 5 Determine analgesic selections (narcotics, non narcotics, NSAID) based on the type and severity of pain. 6. Institute safety precautions as appropriate if he receives narcotics analgesia. 7. Instruct the client to request prn pain medication before pain is severe.
RATIONALE 10. Factors that maybe precipitating or augmenting pain should be reduced or eliminated to enhance the overall pain 1. To prevent infection. 2. To maintain acceptable level of pain. 3. For management of severe persistent pain. 4. To assist the neurological and psychological factors.
EVALAUTION 10. Able to identified some non pharmacological techniques.
1. Able to administered analgesics. 2. Noted client locus of pain. 3. Able to identify presence of pain. 4. Established in assisting neurological and psychological factors. 5 Gained knowledge on what type of narcotics or pain medication can be used. 6. Established safety for the patient taking narcotics drugs. 7. The client is able to know when he must request for pain medication before it severe.
5 Various type of pain (acute, chronic, neuropathic, and no conceptive) requires different analgesia approach. 6. Side effects of opioids narcotics include drowsiness and sedation. 7. Severe pains are more difficult to control and increase the clients anxiety and fatigue. The preventive approach to pain management can reduce the total 24hr. analgesic dose
50
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION 8. Evaluate the effectiveness of analgesics at regular, frequent intervals after each administration and especially after initial doses, also observing for any s/sx of untoward effects. (Respiratory depression, nausea and vomiting, dry mouth and constipation). 9. Implements actions to decrease untoward effects of analgesics (example: constipation and gastric irritation) 10. Document client responses to analgesics and any untoward effects.
RATIONALE 8. The analgesic dose may not be adequate to raise the clients pain threshold or mat be causing intolerable or dangerous side effect or both.
EVALAUTION 8. Gained knowledge about those different side effects of the drugs he takes.
9. Constipation is common side effect of opioids narcotics and a treatment plan to prevent occurrence should be instituted at the beginning of analgesic therapy. 10. Documentation facilitates pain management by communicative effective and effective pain management strategies to the entire health care plan. 1. To identify possible pain management to suited for the patient. 2. To recognize the extent of pain on patient activity of daily living. 3. To prevent infection. 4. To maintain patient hygiene.
9. Able to decrease the side effects of analgesia.
10. Able to identified the clients response to analgesics.
Health teaching: 1. Review ways to lessen pain including techniques such as therapeutic touch and relaxation techniques. 2. Discuss impact of pain on lifestyle/independence and ways to maximized level of functioning. 3.Aseptic wound dressing. 4. Keep nails short. 1. Able to lessened pain, and gained learnings other techniques, such as relaxation techniques. 2. Clients had gained learnings in maximizing their level of functioning. 3. Accomplished proper wound dressing. 4. Able to kept nails short. .
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ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION 3 .Identify and discuss symptoms for w/o client needs to seek medical assistance/evaluation. 4. Refer to physical therapist is occupational as indicated. 5. Implement physical therapist exercise program in conjunction w/ the client and other team members. 6 .Use relaxation techniques acceptable to patients well being. 7. Emphasize to expect and report potential side effects of analgesics agents and their prevention and management. 8. Encourage participating in activities important to self and family. 9. Emphasize the importance of complying to prescribe pain medication. 10. Encourage adequate rest period.
RATIONALE 3. To provide timely interactions
EVALAUTION 3. Already discussed and identify symptoms for pain medication. 4 .Able to have his personal physical therapist for the improvement. 5. Was implemented those different exercise program with the patient and other team members 6 Able to know those foods that can help the client improving status. 7. Able to know what are those side effects of the drugs.
4. To identify assistive devices to facilitate independence in ADL's 5. Coordination of program enhances likeness of success.
6. To provide proper diet for the client. 7. Enable the patient to continue analgesia with other interruption because of side effects. 8. To promote activity of lifestyle.
8. Able to participate those important activities to himself and family. 9. Client compiled to those prescribed pain medications. 10. Client performed proper rest period like sleeping within6-8 hours.
9. To deliver efficient pain management. 10. To prevent fatigue.
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ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION Collaborative: 1. Assist or prepare for surgical procedures if indicated. 2. Review instructions from other members of the health care team and provide written copy. 5. Advise use only the prescribe medication. 6 .Use relaxation techniques acceptable to patients well being. 7. Emphasize to expect and report potential side effects of analgesics agents and their prevention and management. 8. Encourage participating in activities important to self and family. 9. Emphasize the importance of complying to prescribe pain medication. 10. Encourage adequate rest period.
RATIONALE
EVALAUTION
1. To improve peripheral circulation.
1. Able to assist the client if theres anything surgical procedures indicated 2. Reviewed instructions from other members of the health care team and provide written copy. 5. Able to know the advised medication only. 6.Gained learning on some relaxation techniques that the patient can performed. 7. Able to know what are those side effects of the drugs.
2. Provides clarification reinforcement and periodic review by client/caregivers.
5. To prevent possible dangerous drug interactions. 6. To relieve anxiety.
7. Enable the patient to continue analgesia with other interruption because of side effects. 8. To promote activity of lifestyle.
8. Able to participate those important activities to himself and family. 9. Client compiled to those prescribed pain medications. 10. Client performed proper rest period like sleeping within6-8 hours.
9. To deliver efficient pain management. 10. To prevent fatigue.
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ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION Independent: 1. Teach the client to specify pain by using PQRST method, position, quality, radiation, severity, during episodes of pain, and music therapy when pain sensation is being experiences 2. Teach the client in proper use of medication and proper dosage of it. 3. Establish a schedule for prescribed days to take and instruct to take the prescribe dosage only. 4. Encourage to verbalize feelings of pain wherever present with appropriate reports. 5. Advise to consult the physician when pain felt is recurrent and intractable. Dependent: 1. Ask the physician about medical concerns in taking pain relievers if not effective that turned out to be. 2. Communicate further assessments when differences from other data are found. 3. Documents proper assessments and reports to physician.
RATIONALE
EVALAUTION
1. To report pain.
1. Gain the knowledge about the PQRST method.
2. To prevents miss use of pain medication. 3. To prevent miss dosed of drugs.
2. Able to use other non pharmacological treatment to relief pain. 3. Able to know the the daily routine schedule in taking proper dosage of drugs. 4. Clients reports immediately when he experiencing pain. 5. Able to know the extent of pain.
4. To validate pain responses appropriately. 5. For appropriate interventions.
1. To determine the effectiveness of medications.
1. Is able to know the medical concerns in taking pain relievers. 2. Able to know the differences between normal and abnormal findings. 3. Report to the physician the different assessment and acquiring right information.
2. To modified care given.
3. To prevent miscommunications.
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ASSESSMENT
DIAGNOSIS
BACKGROUND OF THE STUDY
PLANNING
INTERVENTIONS 4. Assist with clients conferences to the physician concerning surgical condition. 5. Provide physician proper documentation about the clients response to pain medication and side effects experience. Collaborative: 1. Teach the clients significant others when ever pain arise to monitor vital signs about the clients responses to pain medications. 2. Assist in further assessments of factors precipitating pain about the patient as appropriate when pain resist such as psychological interventions and manifestations of pain. 3. Instruct the client in use of transcutaneous electrical stimulation unit when ordered. 4. Determine other alternative measures to relieve pain that is acceptable to patients culture and standard like massages, relaxation techniques, yoga etc.
RATIONALE 4. To established scheduled care plan.
EVALUATION 4. Gained knowledge concerning in his medical condition. 5. Provided physician proper documentation about the clients response to pain medication and side effects experienced.
5. To modify pharmacological interventions.
1. To obtain baseline data about clients responses to medications. 2. To determine other factors that precipitate pain.
1. Able to established stable vital singns.
2. Assisted in further assessments of factors precipitating pain about the patient as appropriate when pain resist such as psychological interventions and manifestations of pain 3. Instructed the client in use of transcutaneous electrical stimulation unit when ordered. 4. Performed some alternative measures to relieve pain such as relaxation techniques, yoga etc.
3. To relieve felt pain.
4. To identify options available according to patients resources.
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ASSESSMENT
DIAGNOSIS
BACKGROUND OF THE STUDY
PLANNING
INTERVENTIONS 5. Provide for individualized physical therapy, exercise program that can be continued by the client when discharge. Health teaching: 1. Instruct to follow prescribed medication schedule and take the only dosage prescribes whenever pain arises. 2. Educate about the effects and side effects prescribe medications and their possible interactions to different substance. 3. Recommend that the client and significant others to take time for themselves(bonding) 4. Identify community support groups/ sources to meet individual need.
RATIONALE 5. Promotes active not passive role.
EVALUATION 5. Client continued his individualized physical exercise.
1. To prevent medication overdose and under dose.
1. Client able to follow prescribed medication a ordered.
2. To monitor possible side effects.
2. Effects prescribed medications and their possible interactions to different substance had learned. 3. Client had time with significant others.
3. Provides opportunity to recognize and refocus on task and hand 4. Proper use of resources may reduce negative pattern of overdoing heavy activities then spending several days in bed recuperating. 5. Top prevent unexpected diagnosis drug to drug interactions and other similar effects
4. Gained community support groups that meet individual need.
5. Discuss potential hazards of unproven and /or non medical therapies/remedies.
5. Discussed potential hazards of unproved and or non medical therapies/remedies.
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XI. Nursing Care Plan Priority # 2: Disturbed Sleep Pattern

ASSESSMENT SUBJECTIVE: hindi ako makatulog ng maayos, lagi nalang may pumupunta para icheck ako as verbalized by the patient. OBJECTIVE 1.Patient sleep was less than 6 hours every day 2. Sleep disturbance 3. Decreased ability to function 4.Acute pain (Pain scale of 7/10) 5. Self induced impairment of normal pattern 6. Fatigue 7. Slowed reaction 8. Increase in irritability 9.Restlessness 10.Disorientation DIAGNOSIS Disturbed sleep pattern related to interruptions for therapeutic and monitoring procedures secondary to post operative surgery performed as manifested by patient sleep less than 6 hours every day, sleep disturbance, decreased ability to function, acute pain (Pain scale of 7/10), self induced impairment of normal pattern, fatigue, slowed reaction, increase in irritability, restlessness and disorientation. BACKGROUND OF THE STUDY Disturbed sleep pattern is time limited disruption of sleep amount and quality. The patient had underwent surgery, amputation of 5th digit of the left hand after infection 5th digit of the left hand after a gun shot from an ambushed of the NPA rebel. Then the post operative procedures that was done to monitor the condition every 1 hour, taking vital signs, medication administration, endorsement, changing or regulating the IVFs that caused his disturbance in the sleeping pattern. PLANNING STG: after 24 hours of nursing intervention, the patient will: 1. will be able to sleep adequately in 24 hours(6-8 hours) 2. Determine the contributing factors for sleep disturbance 3. Assess the environmental status for any contributing factors that may affect sleep.(e.g. noise, lighting, temperature, uncomfortable sleep environment) 4. Note any medical diagnosis that may affect sleep.(nocturia) 5. Note for any medications that may have effects in sleep pattern 6. Observe and obtain feedback from client regarding usual bedtime, routines, number of hours of sleep, time arising 7. Observe physical signs of fatigue (e.g. restlessness) INTERVENTIONS INDEPENDENT: 1.Monitor vital signs 1.To establish baseline data for further evaluation and to monitor for any sign of abnormalities. 2. For assessment of contributing factors 3. Assess for contributing factors 1.vital signs was monitored, RATIONALE EVALUATION
2. Contributing factors identified 3. Environmental status was assessed, patient was uncomfortable
4. Assess for contributing factor 5. Other medication has side effects that may alter sleep pattern 6.To determine usual pattern and provide comparative baseline
4. No medical diagnosis that may affect sleep 5.Theres no medication that may alter sleep pattern 6. Client able to verbalized those his regular routines in bedtimes. 7.Is able to know indications that tells if the client experiencing fatigue.
VITAL SIGNS: Temp: 35.9o C PR: 70bpm RR: 20cpm BP: 140/80 mmHg
7. To evaluate dysfunction
57
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION 8. Listen to clients subjective reports of sleep quality 9. Determine clients expectations of adequate sleep 10. Do chronological chart DEPENDENT: 1. Discuss with client alternative ways to aid sleep problem 2. Administer pain medications 1 hour before sleep as ordered 3. Discuss clients perception of need. 4. Provide information regarding causative factors of sleep disturbance 5. Assist in thorough evaluation including neurological and psychological factors 6. Encourage the patient to ask question, and provide concrete answer.
RATIONALE 8. To evaluate clients concerned regarding the problem. 9. Provides opportunity to address misconceptions/ unrealistic expectations. 10. To determine peak performance rhythm
EVALAUTION 8. Able to document the subjective report of client about sleep patterns. 9. Clients expectation was determined 10. Chart was done
1. For client knowledge in acquiring optimal sleep 2. To relive discomfort and take maximum advantage of sedative effect. 3. To identify priorities in conjunction of the patient 4. For knowledge of the patient on causative factors. 5. To assist the neurological and psychological factors. 6. To clarify information that the patient did not understand
1. Alternative ways was discussed with the client 2. Medication was taken by patient, pain relieved
3.Needs were discussed with the client 4. Causative factors was learned by the patient
5. Neurologic and psychologic factors was evaluated 6. Patient was able to asked questions and able to clarify it
58
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION 7. Assist client to develop individual program of relaxation 8. Assist client to develop schedules that take advantage of peak performance times as identified by chronobiological chart 9.Discuss with the client regarding his worries about loss of one of his digit hand 10. Discuss with client relaxation techniques(e.g. meditation) COLLABORATIVE: 1. Regular consultation to attending physician. 2. Collaborate with the nutritionist regarding the patients diet 3. Collaborate with the other health care team to arrange care to provide rest to client. 4. Refer to a psychologist for assessment of any psychological problem regarding amputation of one part of the body.
RATIONALE 7. For early detection to provide early intervention 8. To promote wellness to client
EVALAUTION 7. Client developed own program 8. Client was assisted in developing schedule
9. To assess the concerned of client regarding condition 10. For better wellness of client
9.Worries of client was discussed together with him 10. Relaxation techniques where discussed
1. For monitoring of patients condition 2. For nutritional status of the patient 3. For better and easier management for the clients condition 4.For psychological assessment
1. Regular consultation to attending physician. 2. Collaborated with the nutritionist regarding the patients diet 3. Collaborated with the other health care team to arrange care to provide rest to client. 4. Referred to a psychologist for assessment of any psychological problem regarding amputation of one part of the body.
59
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION 5. Collaborate to the pharmacy for right drug for the patient 6. Refer to support counsellor to help deal with psychological stressor. 7. Consult other health team for comprehensive assessment. 8. Encourage family counselling 9. Seek for the help of family in hygiene of patient. 10. Ask for cooperation of other health care members in keeping a quiet environment HEALTH TEACHINGS: 1. Explain the necessity of disturbances for monitoring VS and other care.
RATIONALE 5. For the drug of the patient 6. To know the present bone structure and note for any changes. 7. For further assessment of the patient 8. To help deal with concerns arising. 9. For hygiene of the patient 10. For calm environment of the patient
EVALAUTION 5. Collaborated to the pharmacy for right drug for the patient 6. Referred to support counsellor to help deal with psychological stressor. 7. Consulted other health team for comprehensive assessment. 8. Encouraged family counselling 9. Family helped the patient in hygiene 10. Other health care team cooperated
1. For clients understanding on procedures performed to him
1. Explained the necessity of disturbances for monitoring VS and other care. 2. Selected a space and time for teaching in which client and/or caregiver can focus regarding infection prevention
2. Select a space and time for teaching in which client and/or caregiver can focus regarding infection prevention
2. To provide effective teaching of health teachings
60
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION 3. Encouraged intake of protein and calorie-rich foods 4. Encourage patient in verbalizing feelings 5. Recommend inclusion of bedtime snacks (e.g. milk, juice, crackers). 6.Discuss with the client regarding his worries about loss of one of his digit hand 7. Discuss with client relaxation techniques(e.g. meditation) 8. Discuss with client environmental stimuli that affect his sleep 9. Recommend midmorning naps. 10. Discuss adult clients usual bedtime rituals, expectations for obtaining good sleep time
RATIONALE 3. This maintains optimal nutritional status 4.. Establish cooperation and rapport. 5. . To reduce sleep interference from hunger 6. To evaluate clients concerned about his condition 7. To promote wellness
EVALAUTION 3. Encouraged intake of protein and calorie-rich foods 4. Encouraged patient in verbalizing feelings 5. Inclusion of bedtime snacks (e.g. milk, juice, crackers) recommended. 6.Discussed with the client regarding his worries about loss of one of his digit hand 7. Discussed with client relaxation techniques 8. Discussed with client environmental stimuli that affect his sleep 9. Recommended midmorning naps. 10. Usual bedtime rituals, expectation was discussed with the client
8. For knowledge regarding causative factor 9. Naps in afternoon can disrupt normal sleep pattern 10. Provide information on clients management of the situation and identifies area that may modified
61
ASSESSMENT
DIAGNOSIS
PLANNING LTG: After 6 months of nursing interventions, The patient will: 1. report improvement in sleep/ rest pattern. 2. report increased sense of well being and feeling rested.
INTERVENTION INDEPENDENT: 1.Provide quiet environment and comfort information 2. Promote adequate physical exercise activity during day. 3. Explore other sleep aids 4. Manage controllable sleep-disrupting factors 5. Provide care for uninterrupted periods for rest, especially allowing for longer periods of sleep at night when possible DEPENDENT: 1. Evaluate for the use of medications and/or other drugs affecting sleep. 2. Review medications being taken and their effect on sleep, suggesting modifications in regimen. 3. Administer sedatives/other sleep medications, when indicated, nothing clients response.
RATIONALE
EVALAUTION
1. Promotes relaxation and readiness for sleep 2. To aid in stress control of energy. 3. For client to achieve optimum sleep 4. To provide more calm environment 5. For clients establish optimal sleep and relax pattern
1.Provided quiet environment and comfort information 2. Promoted adequate physical exercise activity during day. 3. Explored other sleep aids 4. Managed controllable sleep-disrupting factors 5. Care was done before the clients rest
1. To reduce risk for infection.
1. Evaluated for the use of medications and/or other drugs affecting sleep. 2. Reviewed medications being taken and their effect on sleep, suggesting modifications in regimen. 3. Administered sedatives/other sleep medications, when indicated, nothing clients response.
2. If medications are found to be interfering.
3. To reduce need for redosing during prime sleep hours.
62
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION 4. Review possibility of next day drowsiness/rebound insomnia and temporary memory loss. 5. Discuss use/appropriateness of OTC sleep medications/herbal supplements. Note possible side effects and drug interactions. COLLABORATIVE: 1. Refer to psychologist for Emotion assessment regarding amputated digit 2. Regular consultation to attending physician. 3. Collaborate with the family regarding effective successful coping mechanism. 4. Refer patient to support groups as needed.
RATIONALE 4. It may be associated with prescription sleep medications.
EVALAUTION 4. Reviewed possibility of next day drowsiness/rebound insomnia and temporary memory loss 5. Use of OTC sleep medications/herbal supplements was discussed. Possible drug effects noted.
5. To provide information to client regarding medication/ herbal supplement.
1.For assessment of emotional status
1. Emotion was assessed by the psychologist 2. Regular consultation to attending physician. 3. Collaborated with the family regarding effective successful coping mechanism. 4. Referred patient to support groups as needed. 5. Included significant whenever possible
2. For updates in any changes on the condition 3. For patient To reduce discomforts and to improve life. 4. These allow patient to interact with others who have similar problems or learning needs. 5. This encourages ongoing support for patient
5. Include significant whenever possible
63
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION HEALTH TEACHINGS: 1. Encourage client to develop plan to restrict caffeine, alcohol, and other stimulating substances from late/evening intake and avoid eating large evening/late-night meals. 2. Instructed client to get out of bed, leave bedroom, engage in relaxing activities if unable to fall asleep, and not return to bed until feeling sleepy. 3. Encourage patient to maintain positive attitude; suggest use of relaxation technique. 4. Encourage patient to involve self in exercise as part of wellness management for the whole person 5. Encourage expression of feelings contributing to/ resulting from condition.
RATIONALE
EVALAUTION
1. These factors are known to disrupt sleep patterns.
1. Client developed a plan to restrict caffeine, alcohol, and other stimulating substances from evening intake and avoided eating large latenight meals. 2. Client to got out of bed, leave bedroom, engaged in relaxing activities when he was unable to fall asleep.
2. For client to promote sleep on his own way
3. To enhance sense of well being.
3. Client maintain positive attitude and used relaxation technique 4. Patient was involved self in exercise as part of wellness management for the whole person 5. Patient expressed feelings contributing to/ resulting from condition.
4. To promote wellness.
5. To manage activities within individual limits.
64
XI. Nursing Care Plan Priority # 3: Self car Deficit

ASSESSMENT Subjective: Madalas di ko na nagagawa ang mga bagay na dapat kong gawin tulad ng pagligo magisa at pagaalaga sa akin sarili kinakailangan ko pa ng kasama dahik masakit ang kamay ko sa tuwing ginagalaw koas verbalized by the patient. Objective; 1. Asks assistance during mealtimes 2. Inability to open containers. 3. Inability to perform body hygiene. 4. Inability to carry out proper toileting. 5. 7/10 pain scale 6. Moderate Swelling of the left hand as evidenced by: s/symptoms. 7. Inability to get bath supplies 8. Inability to wash body 9. Inability obtain water source. 10. Inability to dry body. DIAGNOSIS Self -care deficit (H) related amputated/loss of body part 5th digit metacarpals secondary to recurrent infections as manifested to: Asks assistance during mealtimes, Inability to open containers, Inability to perform body hygiene, Inability to carry out proper toileting, 7/10 pain scale, moderate Swelling of the left hand ,Inability to get bath supplies, Inability to wash body ,Inability obtain water source, Inability to dry body. BACKGROUND STUDY OF DIAGNOSIS Self -care deficit impaired ability to perform or complete feeding, bathing/hygiene or toileting activities for one self. The client was shot during an encounter with the NPA on his left hand affecting the 5th phalange. Due to the severity of damaged to clients hand, and underwent amputation that makes the patient unable to perform activities PLANNING STG: After 2 weeks nursing interventions the patient will perform hygiene care with the reports of decreased episodes of pain INTERVENTION Independent: 1.Observe patient's ability and readiness to learn 1. Client developed a plan to restrict other stimulating substances from evening intake and avoided eating large latenight meals. 2. Client to got out of bed, leave bedroom, engaged in relaxing activities when he was unable to fall asleep. 3. Client maintain positive attitude and used relaxation technique 4. Patient was involved self in exercise as part of wellness management for the whole person 5. Patient expressed feelings contributing to/ resulting from condition. 6. To meet patients needs 1. The patient projects readiness to learn. RATIONALE EVALAUTION
2. Ascertain level of knowledge including anticipatory needs
2. Has sufficient know of his treatment
3. Assess motivation and willingness of patient and to learn
3.The patient exhibits willingness and motivating attitude to learn. 4. The patient has the ability to perform the desired care 5. Priority needs identified
4. Assess ability to learn or perform desired health-related care. 5. Identify priority of learning needs within the overall plan of care. 6.State objectives clearly in patients terms 7. Determine individual strength and skills of the patient. 8. Provide information relevant to the condition of the patient.
Vital signs; BP= 140/80 mmHg PR=70bpm RR=20cpm TEMP=35.9 c
6. Objectives were presented to the patient 7. individuals skills of the patients mood 8. Relevant information provided
7. To determine individual and skills of the patient.
8.To assess the clients motivation
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ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION 9. Identify information that needs to be remembered 10. Provide physical comfort for the learner.
RATIONALE 9. To establish the content to be included
EVALAUTION 9. Information that needs to be remembered were stressed 10. Comfort provided
Dependent: 1. Begin with information the at the patient does not know progressing from simple to complex) patient already knows and move to. 2. Establish objectives and goals for learning at the beginning of the session. 3. Provide information using various mediums (e.g., explanations, discussions, demonstrations, pictures, written instructions, computerassisted programs, and videotapes).
10. This allows patient to concentrate on what is being discussed or demonstrated.
1. Limits sense of overwhelming
1. Patients knowledge was assessed.
2. This allows learner to know what will be discussed and expected during the session. 3. Different people take in information in different ways.
2. Objectives were cleared to the patient.
3. Information provided Patient identified the most important
66
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION 4. Teach patient about the medication regimen 5. State the possible side effects of the drug. 6. Assist with the medication regimen as necessary encouraging timely use of medication.
RATIONALE 4. For patients understanding and compliance 5. For patients knowledge about the effects of the drug 6. To ensure the patient he follows the medication.
EVALAUTION 4. Patient understood medication regimen. 5. Patient Understood the side effects of the drug 6. Assisted with the medication regimen as necessary encouraging timely use of medication. 7. Ensured client receives attentive analgesic care.
7. Ensure client receives attentive analgesic care.
7. When he takes the medication the pain was relief therefore he can perform proper hygiene. 8. To meet the patients routine activities for maintaining health care
8. Assists patient to perform ADLs if he is unable to meet/perform independently
8.Able to assist during difficult procedures needing assistance such as bathing or changing bed linen 9. Provided for communication among those who are involved in caring/assisting the client. 10. Provided information regarding prevent of infection.
9. Provide for communication among those who are involved in caring/assisting the client. 10. Provide information regarding prevention of infection.
9. To enhances coordination and continuity.
10. To prevent infection
67
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION Collaborative: 1. Allow learner to identify what is most important to him or her.
RATIONALE
EVALAUTION
1. This clarifies learner expectations and helps the nurse match the information to be presented to the individuals needs. 2. Patient involvement improves compliance with health regimen and makes teaching and learning a partnership. 3. Matching the learners preferred style with the educational method will facilitate success in mastery of knowledge. 4. Patient brings many life experiences to each learning session. 5. Understanding past information is essential to acquiring new knowledge 6. For patients understanding and compliance
1. Patient identified the most important
2. Involve patient in writing specific outcomes for the teaching session, such as identifying what is most important
2. Patient cooperated
3. Determine patients learning style, especially if patient has learned and retained new information in the past. 4. Question patient regarding previous experience and health teaching. 5.Repeat and reinforce information during several brief sessions. 6. Discuss with the patient the significance of following the prescribed diet
3. Patients learning style was determined
4. Patients previous knowledge was assessed
5. Information reinforced unto
6. Prescribed diet was followed
68
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION 7. Determine patient or caregivers selfefficacy to learn and apply new knowledge.
RATIONALE 7. Self-efficacy refers to ones confidence in his or her ability to perform any task. A first step in teaching may be foster increased selfefficacy in the learners ability to learn the desired information or skills 8. The patients knowledge base may be influenced by cultural perceptions.
EVALAUTION 7. Efficacy determined and new knowledge was applied
8. Assess for the influence of cultural beliefs, norms, and values on the patients knowledge base. 9. Approach individuals with respect, warmth, and professional courtesy. 10. Evaluate client's learning through return demonstrations, verbalizations, or the application of skills to new situations. Health Teachings: 1.Provide instruction for specific topics.
8. Patients influence of cultural beliefs, norms, and values were assessed.
9. Instances of disrespect and lack of caring have special significance for individuals. 10. Presenting information along with examples of how to apply the information has been found more successful.
9. Approached individual professionally.
10. The patient performed return demonstration and verbalization
1.For patients understanding
1.Essential instructions provided 2. Community resources assessed.
2. Explore community resources.
2. To assess patients environmental resources
69
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION 3. Include significant others whenever possible. 4. Select a space and time for teaching in which client and/or caregiver can focus on information to be learned. 5. Refer patient to support groups as needed.
RATIONALE 3. This encourages ongoing support for patient 4. The home setting provides many distractions that may impair the ability of the client to learn.
EVALAUTION 3.Significant others were involved
4. Specific time was selected and both gained focus
5. These allow patient to interact with others who have similar problems or learning needs. 6.To promote wound healing 7. To prevent further injury. 8. To prevent safely.
5. The patient decided to join support group
6.Consume healthy diet 7. Demonstrate ability to transfer. 8. Use mobility and activity aids safely.
6.Consume d healthy diet 7. Demonstrated ability to transfer. 8. Used mobility and activity aids safely 9. Identified support group 10. Described approaches to control.
9. Identify support group.
9. To facilitate rehabilitation.
10. Describe approaches to control.
10. Take analgesic if prescribed,
70
ASSESSMENT
DIAGNOSIS
PLANNING LONG TERM GOALS: After 6 months nursing intervention the client will be able to perform self care independently.
INTERVENTION INDEPENDENT: 1.Allow sufficient time for client to accomplish tasks to fullest extent of ability.
RATIONALE
EVALAUTION
1.Assist the client to become aware of rights and responsibilities in health/healthcare and to asses own health strengths physical, emotional. 2. Support the client making health related decisions and assist in developing self-care practices and goals to promote. 3.Review/modify program periodically to accommodate changes in clients abilities.
1.Allowed sufficient time for client to accomplish tasks to fullest extent of ability.
2. Assist with necessary adaptations to accomplish ADLs.
2. Assisted with necessary adaptations to accomplish ADLs.
3. Promote clients/participation in problem identification and desired goals and decision making. 4. Plan time for listening to the clients feelings/concern.
3. Promoted clients/participation in problem identification and desired goals and decision making. 4. Planned time for listening to the clients feelings/concern.
4. Encourage keeping a journal of progress and practicing of independent living skills. 5.Review safety concerns, modify activities/ environment
5.Determine individual strength and skills of the client
5.Determined individual strength and skills of the client
71
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION DEPENDENT: 1.Ask the physician about medical concerns in taking pain relievers if not effective that turned out to be. 2. Communicate further assessments when differences from other datas are found. 3. Documents proper assessments and report to physician.
RATIONALE
EVALAUTION
1. To determine the effectiveness of medications.
1 Is able to know the medical concerns in taking pain reliever
2. To modified care given.
2. Able to know the differences between normal and abnormal findings. 3. Report to the physician the different assessment and acquiring right information. 4. Gained knowledge concerning in his medical condition. 5. Provided physician proper documentation about the clients response to pain medication and side effects experienced.
3. To prevent miss communications.
4. Assist with clients conferences to physician. 5. Provide physician proper documentation about the clients response to pain medication and side effects experience. COLLABORATIVE: 1. Assist with profession program.
4. To established scheduled care plan.
5. To modify pharmacological interventions.
1. To accomplish task to fullest extent of ability.
1. Assisted with profession program.
72
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION 2.Collaborate with rehabilitation professionals to identify obtain assistive devices. 3. Promote clients/ significant other participation in problem identification and desired goals and decision making. 4. Plan time for listening to the clients/significant others feeling concern. 5. Determine individual strength and skills of the client. HEALTH TEACHINGS: 1. Assist the client to become aware of rights and responsibilities in health/healthcare and to asses own health strengths physical, emotional.
RATIONALE 2. To encourage client to build on successes.
EVALAUTION 2.Collaborated with rehabilitation professionals to identify obtain assistive devices. 3. Promoted clients/ significant other participation in problem identification and desired goals and decision making. 4. Plan time for listening to the clients/significant others feeling concern. 5. Determined individual strength and skills of the client.
3. To enhance commitment to plan.
4. To discover barriers to participation in regimen and to work on problem. 5.To determine skills of client
1.To enhance capabilities and promote independence
1. Assisted the client to become aware of rights and responsibilities in health/healthcare and to asses own health strengths physical, emotional.
73
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION 2. Support the client making health related decisions and assist in developing selfscare practices and goals to promote. 3. Review/modify program periodically to accommodate changes in clients abilities.
RATIONALE 2. To promote independence daily life style.
EVALAUTION 2. Supported the client making health related decisions and assist in developing self care practices and goals to promote. 3. Reviewed/modify program periodically to accommodate changes in clients abilities. 4. Encouraged keeping a journal of progress and practicing of independent living skills. 5. Reviewed safety concerns. modify activities/ environment
3. To promote health care provider
4. Encourage keeping a journal of progress and practicing of independent living skills. 5. Review safety concerns. Modify activities/ environment.
4. To determine proximity of health care during emergency.
5. Provides clarification reinforcement and periodic review by client.
74
XII. Drug Study

DRUG NAME CLASSIFICATION MECHANISM OF ACTIONS Bactericidal: Inhibits synthesis of bacterial cell wall causing death. INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS Bone marrow depression (decreased WBC, decreased platelets, decreased Hct), nausea and vomiting, diarrhea, abdominal pain, anorexia, ranging from rash to fever to anaphylaxis. DRUG TO DRUG INETRACTIONS -Increased nephrotoxicity with aminoglycosides. -Increased bleeding effects with oral anticoagulants. -Risk of disulfiram like reaction with alcohol. NURSING CONSIDERATIONS -Culture infection and arrange for sensitivity tests before and during therapy if expected response is not seen. -Give oral drug with food to decrease GI upset and enhance absorption. -Discontinue if hypersensitivity reaction occurs.
1.
Cefuroxime sodium
Antibiotic
-Lower respiratory infections caused by S. pneumonia, S. aureus, E. coli, Klebsiella pneumonia, H. influenza, S. pyogenes -Dermatologic infections caused by S. aureus, S. pyogenes, E. coli, K pneumonia, Enterobacter. -Bone and joint infections due to S. aureus.
-Contraindicated with allergy to cephalosporins or penicillins. - Use cautiously with impaired renal or hepatic function.
75
DRUG NAME
CLASSIFICATION
MECHANISM OF ACTIONS Anti-inflammatory and analgesic activity inhibits prostaglandins and leukotriene synthesis
INDICATIONS
CONTRAINDICATIONS
ADVERSE EFFECTS Headache, dizziness, somnolence, insomnia, rash, nausea, bleeding, local burning.
DRUG TO DRUG INTERACTIONS -Increased risk of nephrotoxicity with other nephro-toxins. -Increased risk of bleeding with anticoagulants, aspirin.
NURSING CONSIDERATIONS -Be aware that patient may be at increased risk for CV events, GI bleeding, renal toxicity. -Protect drug vials from light -Administer every 6hrs to maintain serum levels and control pain.
2.
Ketorolac tromethamine
Antipyretic Nonopiod analgesic NSAID
Short term of pain management
Contraindicated with significant renal impairment, allergy to aspirin, concurrent use of NSAIDs, active peptic ulcer disease, hypersensitivity to ketorolac, as prophylactic analgesic before major surgery.
76
DRUG NAME
CLASSIFICATION
MECHANISM OF ACTIONS Binds tomu-opioid receptors and inhibits the reuptake of norepinephrine anrd serotonin; causes many effects similar to the opiods, dizziness, somnolence, nausea, constipation but does not have the respiratpry depressant effects.
INDICATIONS
CONTRAINDICATIONS
ADVERSE EFFECTS Sedation, dizziness or vertigo, headache, hypotension, sweating, nauseas and vomiting, potential for abuse anaphylactoid reactions.
DRUG TO DRUG INTERACTIONS -Decreased effectiveness with carbamazepine -Increased risk of tramadol toxicity with MAOIs or SSRIs.
NURSING CONSIDERATIONS Control environment if sweating or CNS effects occur.
3.
Tramadol hydrochloride
Analgesic Opioid analgesic
-Relief of moderate to moderately severe pain -Relief of moderate to severe chronic pain who need around the clock treatment for extended periods -Premature ejaculation; restless leg syndrome
-Contraindicated with allergy to tramadol or opioids or acute intoxication with alcohol, opioids, or psychoactive drugs. -Concomitant use of CNS depressants, MAOIs, SSRIs, TCAs, renal impairment, hepatic impairment.
77
DRUG NAME
CLASSIFICATION
MECHANISM OF ACTIONS Competitively inhibits the action of histamine at the H2 receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin, and pentagastrin.
INDICATIONS
CONTRAINDICATIONS
ADVERSE EFFECTS Head ache, rash, tachycardia, bradycardia, constipation, diarrhea, nausea and vomiting, abdominal pain, pain at IM site, local burning or itching at IV site.
DRUG TO DRUG INTERACTIONS -Increased effects of warfarin, TCAs, monitor patient closely and adjust dosage as needed.
NURSING CONSIDERATIONS -Administer oral drug with meals and at bed time. -Decrease doses in renal and liver failure. -Provide concurrent antacid therapy to relieve pain. -Administer IM dose undiluted, deep into large muscle group. -Arrange for regular follow-up, including blood tests to evaluate effect.
4.
Ranitidine hydrochloride
Histamine-2 (H2) antagonist
-Short term treatment of active duodenal ulcer -Maintenance therapy for duodenal ulcer at reduced dosage -Short-term treatment and maintenance therapy of active, benign gastric ulcer -Short-term treatment of GERD -Pathologic hypersecretory conditions -Treatment of erosive esophagitis -Treatment of heartburn, acid indigestion,sour stomach
-Contraindicated with allergy to ranitidine, lactation. -Use cautiously with impaired renal or hepatic function.
78
DRUG NAME 5. Celecoxib
CLASSIFICATION Analgesic NSAID Specific COX-2 enzyme inhibitor
MECHANISM OF ACTIONS Analgesics and antiinflammatory 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.
INDICATIONS -Management of acute pain. -Relief of signs and symptoms of ankylosing spondylitis.
CONTRAINDICATIONS Contraindicated with allergies to sulfonamides, celecoxib, NSAIDs, or aspirin; significant renal impairment.
ADVERSE EFFECTS Headache, dizziness, somnolence, insomnia, rash, dyspepsia, abdominal pain, fatigue, bone marrow depression.
DRUG TO DRUG INTERACTIONS -Increased risk of bleeding if taken concurrently with warfarin. Monitor patient closely and reduce warfarin dose as appropriate. -Increased lithium levels and toxicity. -Increased risk of GI bleeding with longterm alcohol use, smoking.
NURSING CONSIDERATIONS -Administer drug with food or after meals if GI upset occurs. -Establish safety measures if CNS or visual disturbances occur. -Arrange for periodic ophthalmologic examination during long term therapy. -Provide further comfort measures to reduce pain and to reduce inflammation.
79
XIII. Discharge planning M-edications: 1. Instruct the client to learn the names of the medications as well as their actions and possible adverse effects. Carry as complete list of all prescriptions, OTC over the counter medications and home remedies at all times. 2. Advise to keep all medications out of reach of children and pets. 3. The client to take the medications as only as prescribed. Educate immediately consult the nurse, pharmacist or primary care provider about any patients w/ the medications. 4. Always check the medications label to make sure the correct medication is being taken. 5. Request labels printed with larger type on medication containers if there is difficulty rending the label. 6. Check the expiration date and discard outdated medications by flushing them down the toilet. Do not throw the medication(s) into the trash. 7. If a dose or more is missed, do not take two or more doses; ask the pharmacist/primary care provider directions. 8. Never stop taking the medications w/o first discussing it with the primary. 9. Always check with the pharmacist before taking any non prescription medications can interact with the prescribed medication 10. Assist circuits and family members to set-up a medication plan to remember a schedule. Weekly pill containers or a written plan may be helpful. E-xercise: 1. Teach the specific performance of passive or assistive ROM exercises to maintain joint mobility of the left hand and fingers and active exercise of the whole body to maintaining muskuloskeletal function. 2. Discussed pain control measures required exercise like taking analgesics prior to activities as prescribed. 3. Provide a written schedule for the type, frequency and duration of exercises encourage the in use of a progress graph or chart to facilitate adherence with the therapy. 4. Discuss safety measures to avoid falls. If patient cannot climb staircases without grab bars keeping environment safety to prevent injury. 5. Intersperse rest periods activity periods to manage energy to prevent to energy to prevent fatigue. 6. Discuss ways to minimize fatigue such as performing activities more slowly and for shorter periods, resting more often and using more assistance as required. 80
7. Teach ways to increase energy foods, ensuring adequate rest and sleep, controlling pain staring feelings with a trusted listener. 8. Teach techniques to monitor activity tolerance as appropriate. 9. Avoidance of movements that cause pain on the postoperative site. 10. Provides appropriate information about assessing community resources home care agencies, physical and occupational therapy agencies, and movement programs and resources of adaptive equipment.
T-reatment: 1. Contract with the patient for participants in care of the amputated site to enhance to follow through. 2. Provide information and help client to know where and how to find to it on own which provides independence and encourages informed decision making. 3. Stress the importance of the clients knowledge and understanding of the need for treatment or medication as well as consequence of actions and choices to assist the client and significant others to develop strategies for dealing effectively with clients health condition. 4. Give information in manageable amounts using verbal, written and audio visual modes at level of clients ability concerning the treatment to facilitate learning. 5. Accept the client choice or point of view, even if it appears to be destructive. Avoid confrontation regarding beliefs to maintain open communication. 6. Have the client paraphrase the instruction information head, it validates the clients understanding and reveals misconceptions. 7. Establish graduated goals as necessary, ( e.g., patient wants to recover fast, may be willing to adjust his lifestyle according to the treatment regimen) may improve quality life, encouraging progression to more advanced goals. 8. Developed a system of self monitoring to provide a sense of control and enable the client to follow own progress and assist with making choices. 9. Emphasize important of grooming and personal hygiene and assist in developing skills to improve and dress for success. Looking best improves sense of self esteem and presenting a positive appearance enhances how others see the patient. 10. Emphasize the importance of compliance of medications. 81
H-ealth teachings: 1. The residual limb must be handled gently to promote wound healing whenever the dressing is change; aseptic technique is required to prevent wound infection and possible osteomyelitis. 2. Instruct the patient and family in wrapping the residual limb with elastic dressings and teach the patient of care for the residual limb after the incision is healed. 3. Encourage to look at, feel and then care for the residual limb to facilitate the acceptance of the loss of the body part. 4. Assist the patient to regain the previous level of independent, educate functioning. 5. Limit or avoid use of plastic materials (e.g rubber sheet, plastic linen savers) on the surgical site because moisture potentiates skin breakdown enhance circulation to compromised tissue. 6. Discuss the importance of early detection of skin changes/ other complications of amputation of the affected area. Teach client to avoid using alcohol or other CNS depressant while taking narcotic drugs. 7. Keep the area clean/dry carefully support the friction to prevent infection and stimulate circulation to surrounding areas to assist body's natural process of repair. 8. Periodic laboratory studies as ordered relative to general well being and status of the patient's specific health and status could provide pertinent data's about patient response treatment. 9. Provide support systems to reinforce negotiated behaviours. Encourage client to continue positive behaviours, especially if the client is beginning to see the benefit. 10. Provision of optimum nutrition and protein intake to provide (+) nitrogen to aid in health to maintain general good health.
OPD Follow-up: 1. advise the patient to follow-up health visit to evaluate this physical and psychosocial adjustments, 2. Remind the patient and family about the importance of continuing health production and screening test. 3. Report pain that is uncontrolled by analgesics and other pain managements techniques. 4. Encourage to participate in rehabilitation programs to regain functional independence. 5. Emphasize indicators of complications to report promptly to physician signs of local or systemic infections, residual limb breakdown. 6. Discuss the importance of keeping appointments to monitor healing and 82
recovery after surgery. 7. Instruct the patient to report promptly to the primary care provider any increasing redness, swelling, pain or discharge from the incision drain sites. 8. Periodic laboratory 9. Provide information about where describe medical equipment can be purchased, rented or obtained free of charge. How to access home and other services and where to obtain supplies such as dressings nutritional supplements. 10. Periodic preventive health assessments are necessary. Modifications in the plan of care are mode on the basis of such findings. D-iet: 1. Discuss foods high in specific nutrients required for healing such as protein, iron, calcium, vitamin C and mineral supplementation. 2. 2-3 liters of fluid a day if not contraindications maintain good hydration. 3. Discuss safe food preparation and preservation techniques as appropriate. 4. Reinforce hygiene handling at food and dishes such as wash yards, before preparing foods cook beef poultry and egg thoroughly, wash or peel raw fruits and vegetables and follow the rules keep hot foods hot and cold foods and when in doubt, throw it out to prevent food bone illness that may predispose patient to slow healing of the operated site. 5. If appropriate discuss ways to purchase low-cost nutritious foods like buying fruits and vegetables in surgeon. 6. Maintain weight in a healthy range. 7. Keep total fat intake within 20%-35% of total calories and less than 10%. from saturated fatty acids such as cooking meat by grilling, baking, boiling/ eat less meat cat more fish and bat plant sources of protein. 8. Consume less than 2,300mg of sodium/day and add rich foods. 9. Drink alcohol in moderation. 10. Do not change the patient diet significantly without consulting the healthcare provider since drug dosage may have based on the patient previous dietary intake.
83
Spirituality: 1. Encourage the patient to resume regular worship activities to hope and strengthen faith. 2. Participate in desired religious activities, contact w/ minister/ spiritual adviser to validate ones belief in an external. 3. They can provide support and strengthen the inner self. 4. Introspection in search for peace and harmony can carry over relationships w/ other and other ones outlook in life. 5. Relaxation and meditative activities (yoga, prayer) is helpful in promoting general well being and serve of connectedness w/ self /nature/cool. 6. Bibliotherapy, list of relevant resources study groups, prior nurse, poetry society, and possible websites for later reference/ self-faced learning and ongoing support.
S-exuality: 1. Encourage client to share thoughts/concerns with partner and clarify values/ impart of condition on gentle hugging and kissing is allowed for clients when they feel like it. Full sexual intercourse cannot be revealed until wound soreness and tenderness is relationship. 2. Provide sex education, explanation of normal sexual functioning when necessary. 3. Remind the patient that all health information is handled in a confidential manner. 4. Emphasize on responsible sexual behaviour to prevent sexually transmitted disease, the prevention of unwanted pregnancy and the avoidance of sexual harassment abuse. 5. Intimacy such as resolved approximately 2-4weeks.
84
XIV. REFERENCES I. INTRODUCTION: Baares, Rommel Books: Medical-Surgical Nursing 12th edition Lippincott, Williams & Wilkins II. OBJECTIVES: Baares, Rommel Books: Fundamentals of nursing 8th edition Concepts, Process, and Practice volume 2 2007 by B.Kozier and G. Erb Pearson Prentice Hall Upper saddle River New Jersey PATIENT PROFILE: Sison, Ma. Jay Jesusa S. Assessment of the patient Patient chart PHYSICAL ASSESSMENT: Alcantara, Donna Bella Book: Fundamentals of nursing 8th edition Concepts, Process, and Practice volume 2 2007 by B.Kozier and G. Erb Pearson Prentice Hall Upper saddle River New Jersey ACTIVITIES OF DAILY LIVING: Aro, Carla Mariz Assessment of the patient
III.
IV.
V.
VI. DEVELOPMENTAL TASK: Sison, Ma. Jay Jesusa S. E-reference: http://en.wikipedia.org/wiki/Erikson_stages_of_psychosocial_develo pment VI. LABORATORY/DIAGNOSTIC FINDINGS: Bas-awan, Christian Robinson Book: Kozier and Erbs: Fundamentals of nursing 8 th edition Concepts, Process, and Practice volume 1& 2, 2007 by B.Kozier and G. Erb Pearson Prentice Hall Upper saddle River New Jersey Brunner And Suddarths Medical Sugical Nursing 12th Edition Volume 1 & 2 by S. Smeltzes, B. Bare, J. Hinkle, K. Cheever. Wolters Kluwer, Lippincott Williams and Wilkins Volume 1 & 2
85
VIII. ANATOMY AND PHYSIOLOGY: Aliwalas, Melody Books:Essentials of ANATOMY and PHYSIOLOGY SIXTH EDITION by: Rod R. Seedy IX. E- reference: http://hes.ucfsd.org/gclaypo/skelweb/skel04.html
PATHOPHYSIOLOGY: Villanueva, Rossie E-reference: http://www.google.com.ph/search?hl=tl&client=firefoxa&rls=org.mozilla%3AenUS%3Aofficial&biw=986&bih=620&site=search&tbm=isch&sa=1 &q=injuries+of+the+5th+metacarpal+left+hand&btnG=Hanapin& aq=f&aqi=&aql=&oq= COURSE IN THE WARD: Suizo, Mary Grace Patients Chart NURSING CARE PLAN: Supilanas, Mark Anthony Book: Kozier and Erbs: Fundamentals of nursing 8 th edition Concepts, Process, and Practice volume 1& 2, 2007 by B.Kozier and G. Erb Pearson Prentice Hall Upper saddle River New Jersey Brunner And Suddarths Medical Sugical Nursing 12th Edition Volume 1 & 2 by S. Smeltzer B. Bare, J. Hinkle, K. Cheever. Wolters Kluwer, Lippincott Williams and Wilkins Volume 1 & 2 Nurses Pocket Guide: Diagnosis, Prioritized Interventions And Rationale by M. Doenges, M.F. Moorhouse, A. Murr 10 th edtion F.A. Davis Company . Philadelphia.
X. XI.
Villanueva, Vina Cherry Faye Book: Kozier, NANDA, Brunner Brunner And Suddarths Medical Sugical Nursing 12th Edition Volume 1 & 2 by S. Smeltzer B. Bare, J. Hinkle, K. Cheever. Wolters Kluwer, Lippincott Williams and Wilkins Volume 1 & 2 86
Agbada, Ma. Vanessa Book: Kozier and Erbs: Fundamentals of nursing 8th edition Concepts, Process, and Practice volume 1& 2, 2007 by B.Kozier and G. Erb Pearson Prentice Hall Upper saddle River New Jersey Brunner And Suddarths Medical Sugical Nursing 12th Edition Volume 1 & 2 by S. Smeltzer B. Bare, J. Hinkle, K. Cheever. Wolters Kluwer, Lippincott Williams and Wilkins Volume 1 & 2 Nurses Pocket Guide: Diagnosis, Prioritized Interventions And Rationale by M. Doenges, M.F. Moorhouse, A. Murr 10th edtion F.A. Davis Company . Philadelphia.
XII.
DRUG STUDY: Aro, Carla Mariz Books: 2010 Lippincotts Nursing Drug Guide, Amy Karch, Philadelphia, Baltimore, New York, London, Buenos Aires, Hong Kong, Sydney, Tokyo. DISCHARGE PLANNING: Bas-awan, Christian Robinson Book: Kozier and Erbs: Fundamentals of nursing 8th edition Concepts, Process, and Practice volume 1& 2, 2007 by B.Kozier and G. Erb Pearson Prentice Hall Upper saddle River New Jersey Brunner And Suddarths Medical Sugical Nursing 12th Edition Volume 1 & 2 by S. Smeltzer B. Bare, J. Hinkle, K. Cheever. Wolters Kluwer, Lippincott Williams and Wilkins Volume 1 & 2 Nurses Pocket Guide: Diagnosis, Prioritized Interventions And Rationale by M. Doenges, M.F. Moorhouse, A. Murr 10th edtion F.A. Davis Company . Philadelphia
XIII.
87

Gap Non-Union Fracture Case Presentation

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In Partial Fulfillment Of the Requirements In the Related Learning Experience

Submitted to: Cherry Aurora S. Panergo Clinical Instructor

e. Family History of Illness - - - - - - -- - - - - -- - - - - - - - - - - - - - -------17 IV. Physical Assessment - - - - - - - - -- - - - - -- - - - - - - - - - - - - - - - - - -- - Head-to-toe-Assessment- - - - - - - - -- - - - - -- - - - - 18 18

V. Activities of Daily Living (Using Gordons Functional Pattern) - - - - -

a. Chief Complaint Pain on 5th digit left hand

1. Celecoxib 2. Cefuroxime sodium 3. Tramadol 4. Keterolac 5. Ranitidine Hydrochloride

IV. Physical Assessment

Palpation Hair Inspection

Palpation Face Inspection

No abnormalities observed Slightly asymmetric facial features noted

Body parts Eyes

Actual findings No abnormalities observed

Patient can blink normally

Palpation Inspection Lid margins

No palpable mass felt. No abnormalities observed

Inspection Appear equal when the eyes open.

Appear equal when the eyes are open

Lower palpebral conjunctiva

Salmon pink, shiny, moist and transparent

Pinkish in color, no lesion or nodules

Sclera is white in color Black, symmetrical and round

Body parts Pupils

Eye movement Visual acuity

Field vision Ear

Client can able to see in the periphery Symmetrically align

Able to hear whisper spoken 2 feet away

Body parts Nose

Norms Midline, symmetrical, and patent

Actual findings -No discharge or flaring, uniform in color -No tenderness

Internal Nares Nasal Septum Lips

Inspection Inspection Inspection

-wearing dentures , slightly yellowish in color

Frenulum Cheeks (buccal mucosa) Palate: Soft

Inspection Inspection Inspection

Body Parts Voice

Measurements Inspection Palpation

Actual findings Normal voice tone No abnormalities observed

Inspection Neck Palpation

Neck Range of motion

Freely movable without difficulty

-Costal angel is not widened -No tenderness or masses

Body Parts THORAX & LUNGS ( ANTERIOR & POSTERIOR )

-No areas of dullness

-Normal breath sounds

-Normal breath sounds

Body Parts HEART

Norms No pulsations Abdominal aortic pulsations visible

Actual findings No abnormalities observed

No abnormalities observed No abnormalities observed

Palpation Inspection NIPPLES

No abnormalities observed No abnormalities observed

Body Parts NIPPLES

Actual findings No abnormalities observed

-No abnormalities observed -rounded

UPPER EXTREMITIES Arms

Body Parts UPPER EXTREMITIES Arms

Actual findings No abnormalities observed

Palms (Anterior & Posterior Surface)

Lower extremities Legs

Body Parts Toes

V. Activities of Daily Living (Using Gordons Functional Pattern)

Health Perception and Management Pattern