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PRESENTATION

EVRMC

ORTHOPEDIC

WARD

FEBRUARY 24, 2016

9:00AM-12:00NN

Brain

Injury

Medical Diagnosis

:

Traumatic Brain Injury

Psychiatric Diagnosis

:

To be considered Neurocognitive

Disorder

with

due to Traumatic Brain Injury

Behavioural Disturbances

Traumatic Brain Injury from alleged MVC

TBI

is generally

the

result of

a sudden,

violent blow or jolt to the head. The brain is

launched into a collision course with the inside of the skull, resulting in possible bruising of the brain, tearing of nerve fibers and bleeding.

TBI severity varies enormously depending on which part of the brain is affected, whether it occurred in a specific location or

Epidemiology

TBI is a leading cause of death and disability

around

the

globe

and

presents

major health cause of

a

worldwide

problem.

social,

is

economic,

and

It

the number

one

coma. It plays the leading role in disability due to trauma, and is the leading cause of brain damage in children and young adults .

Epidemiology

Findings on the frequency of each level

of severity definitions

vary

based

on

the

and

methods used in

studies. A World Health Organization

study estimated that between 70 and

90%

of

head

injuries

that

receive

treatment

are mild,

and

a

US study

and

found

that

moderate

severe

NURSING

ASSESME

Patient’s Profile

Name: Gonzaga, Gerardo Age: 61 years old Sex: Male Occupation: Carpenter Civil Status: Married

Religion: Roman Catholic Address: Brgy. Hibucawan, Jaro, Leyte Nationality: Filipino No. of Children: 4 Work of Wife: Housewife

Date of Admission: February 13, 2017 Time of admission: 7:00 PM Admitting Physician: Dr. Jay Stephen Cantay Admitting Diagnosis: Traumatic Brain Injury from altered MVA Source of Data: Patient and

HEALTH

HISTORY

PRESENT HEALTH HISTORY

He

was

going

home

from

work when another motorcycle bumped on his rear side. That one vehicle came into contact with another. According to the patient, his head bumped into the road cement.

He was immediately brought in to Jaro Municipal Health Office and was referred to Eastern Visayas Regional Medical Center for further evaluation at 7:00 PM last February 13, 2017 and was examined by Dr. Jay Stephen Cantay, hence admission.

PAST MEDICAL HISTORY

Patient

claimed

that

he

was

hospitalized at Carigara District Hospital due to hypertension last December 2016. Before admission, he added that he was already been prescribed with Metropolol and took it once a day. He confirmed that no other hospitalization was

FAMILY HEALTH HISTORY

Patient claimed of heredo- familial disease of asthma on his maternal side and hypertension on his paternal side. No other known heredo- familial disease noted.

GORDON’S FUNCTIONAL HEALTH PATTERN

HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

Before

admission,

patient

G

describes his health as “okay man la, nakakatrabaho man gihap bis amo na

it akon According

edad”

to

him,

as verbalized.

he

eats

three

times a day in order for him to get rid and to prevent diseases.

During

admission,

patient describes

his

health as

“alkanse na ha

kinabuhi kay waray na kita

dong”.

there

He

claimed

were

medications

that

that

some

they

He

stated

that

due

to

his

condition, it would be hard for him

to take care of himself and children as well. Patient added that he had complains of vision deficit but not

able

to

instead

seek proper eye care but

he

just

bought an

eyeglasses, “ gilid-gilid ko man la gipalit dong” as verbalized.

NUTRITIONAL-METABOLIC

PATTERN Before admission, patient

GG eats three

times a day

and

snacks

twice

a

day.

Patient consumed 1-2 litre of water per day. He stated that his appetite was good

and

he

has

no

food

Patient claimed that he does

not

take

any

supplemental

vitamins prior to admission.

Currently,

Patient

was

prescribed to Diet as Tolerated but he claimed that his appetite has changed.

ELIMINATION PATTERN

Before admission, patient GG claimed that he defecates once a day without experiencing discomforts usually in the morning with a brown colored stool and is well-formed. He also stated that he voids three times a day with yellow colored urine. No pain when voiding as he claimed.

During admission, patient claimed that he defecates once every two to three days with a hard stool. He also added that he voids via catheter and does not feel any urge to urinate.

SLEEP-REST PATTERN

Before admission, patient claimed that he sometimes worked 7 days per week. Patient verbalizes “okay man la dong, makapahuway man gihap ak”. He rated his tiredness as 5 out of 10. Patient also added that he usually sleeps at 9 to 10 PM and wakes up 4:30 in the morning. He does not use any sleeping aids and does not have any difficulties when sleeping.

Currently,

experiences

patient

disturbed

sleeping pattern because

of

such

some interruptions

as

giving

medications and noise in

the surroundings. He

ACTIVITY-EXERCISE PATTERN

Before admission, patient works as a carpenter. “ang mga baskog man ang patrabahuon sa mga lisud2x dong” as verbalized by the patient so he rated his tiredness as 5 out of 10 with 10 the most tiring. He stated that he can do his activities of daily living.

During admission, he claimed that

his activities of daily

living

is

already limited

due

to

his

condition and relies on his wife in his self care. Patient verbalizes

that

di

man kaayo ko

makalihok2x dong. Makuri gihap ngan ma’ol-ol kung maglihok akon tuda”.

COGNITIVE-EXERCISE PATTERN

He

claimed

that

he

has

some

complaints of difficulty concentrating

and

reading on small letters.

He

added that he does not seek proper

eye medical care yet bought an eyeglasses, “gilid-gilid ko man la gipalit dong” as patient verbalizes.

Patient

claimed

that

when

using

the

eyeglasses,

experienced

he

headache.

Patient

can

speak

and

understand Waray-waray, Cebuano, Tagalog and a

SELF PERCEPTION PATTERN

Patient

claimed

that

he

is

concerned about the financial sources for his hospital bills. “ ako la an may trabaho ha amon dong, mayda ako anak na pulis pero bago paman la hiya naka sulod” as stated by the patient.

ROLE RELATIONSHIP PATTERN

Patient claimed that he is living with his wife and four children. He also added that he usually decides for his family until the accident happened.

During

confinement,

he

is

accompanied by his wife and stays with him most of the time.

SEXUALITY-RELATIONSHIP PATTERN

Patient GG claimed that he was married at the age of 23. They were married for 15 years and got separated. Patient now has a common-law-wife and they have 4 children. They are now living for almost 21 years.

COPING-STRESS MANAGEMENT PATTERN

Patient

claimed

that

his

mother died at the age of 93 last December 2016. He stated that there is nothing he would

like to change

in

his

self.

He

also

added

that

when

he

is

stressed,

he

usually

seeks

VALUE-BELIEF SYSTEM PATTERN

Patient claimed that

he

is

a

Roman

Catholic. He stated that “diri man ako makasimba kada dominggo dong labi na kung may trabaho pero mutuo ngan nagsalig ako ha Ginoo, priority ko man gihap it pagsimba”. The patient also added that there are no practices that affect his hospitalization. He claimed that a strong faith in God will accounts for his fast progress.

Skin

  • - Abrasion lesion observed on both wrist

  • - Abrasion lesion observed on left scapular area

  • - Abrasion lesion observed on lower left lumbar area

  • - Skin turgor of 3 sec

Nails

-CRT of 3 sec

Head

  • - Wound lesion observed in the left occipital area with 4 stitsches

  • - Tenderness noted

Eyes

  • - Periorbital Hematoma noted on both eyes

  • - Subconjuctival haemorrhage on right eye noted

Chest

  • - Lesion observed on left breast; nontender; with complaints of episodic tenderness

Date

Diagnostic

Normal

Patients

Significant Findings

Test

Results

Results

Feb.

Hemoglobin

130–180

120g/L

Decreased in all anemias in

13,

count

g/L

leukemia,

2017

and after hemorrhage

Hematocrit

42%–52%

35 %

Decreased in severe

count

anemias, anemia of pregnancy, acute massive blood loss

 

4.6–6.2 ×

4.23×

Decreased in various

Red Blood Cell Count

1012/L

1012/L

anemias, pregnancy, severe or prolonged hemorrhage, and with excessive fluid intake

White blood

4.5–11 ×

18.55

Increased in presence of

Cell Count

109/L

infections

Date

Feb. 15, 2017

Diagnostic

Test

Significant

Findings

Computed

Tomography

-Contusions, Frontal and Left cerebellum -Left Occipital Bone Fracture -Minor Hemosinus, Left Maxillary

DRUG

RISPERIDONE, 2mg, 1tab Oral, Hours of sleep

CLASSIFICATION

INDICATION

SIDE EFFECTS

NURSING

RESPONSIBILITIE

THERAPEUTIC

CLASS:

Antipsychotic

PHARMACOLOGIC

CLASS:

Benzisozole dermative

MECHANISM OF ACTION:

Blocks dopamine and 5h2 receptors in the brain.

Schizophrenia, Irritability, including aggression, self injury and temper tantrums associated with an autistic disorder.

CONTRAINDICA

TION:

Hypersensitive to drug and in breastfeeding women

CNS:

parkinsonism, suicide attempt, somnolence, agitation, anxiety, dizziness, fever, impaired concentration, abnormal thinking, dreaming tremor, fatigue, depression

CV: tachycardia, orthostatic hypotension, peripheral

S

BEFORE:

Obtained baseline BP and monitored

DURING:

Advised to avoid alcohol while taking this drug

AFTER:

Advised patient to avoid alcohol Provided O2 when necessary Warned

DRUG

CLASSIFICATION

INDICATION

SIDE EFFECTS

GI: constipation,

nausea, vomiting, abdominal pain, anorexia, dry mouth, increased saliva, diarrhea, GU: urinary incontinence, increased urination, abnormal orgasm, vaginal dryness Metabolic: weight gain, hyperglycemia , weight loss

Musculoskeletal:

arthralgia, back

pain, limb pain, myalgia

Respiratory:

dyspnea, coughing,

NURSING

RESPONSIBILITIE

S

Monitored for S/S of overdose (Drowsiness, sedation, tachycardia, hpn, EPS, seizures Instructed to do DBE Encourage Oral hygiene Advised patient high fiber diet Instructed patient to elevate feet if not contraindicated

U

DIAZEPAM, 5mg, 1 tablet/ day, oral, hours of sleep

U

RESPONSIBILITIE

S

THERAPEUTIC

CLASS:

Anxiolytic

PHARMACOLOGIC

CLASS:

Benzodiazepine

MECHANISM OF ACTION:

Probably potential the effects of GABA, depress the CNS and supress the spread of seizure activity

-Anxiety -Muscle Spasm -Tetanus

CONTAINDICATION:

-Hypersensitive to drug or soya protein -Experiencing shock and coma -Acute angle closure glaucoma -Caution in patient with liver or renal impairment, depression, history of substance abuse

CNS: drowsiness, dysarthria, slurred speech, tremor, transient amnesia, fatigue, ataxia, headache, insomnia, paradoxical anxiety, hallucination, minor changes in EEG pattern CV: CV collapse, bradycardia, hypotension EENT: diplopia, blurred vision GI: constipation, diarrhea with rectal pain GU: urinary incontinence & retention

BEFORE:

-Monitored V/S and BP -Assessed for hypersensitivity

DURING:

-Warned patient to avoid activities that require alertness -Instructed SO to assist & provided safety to patient

-Advised increased fiber diet & avoid alcohol

AFTER:

-Monitored for dizziness, ataxia, mental state changes -Instructed patient

DRUG

CEFTRIAXONE, 500mg , IVTT every 24 hours (8am-

8pm)

CLASSIFICATION

INDICATION

SIDE EFFECTS

NURSING

RESPONSIBILITIE

S

THERAPEUTIC

CLASS:

Antibiotic

PHARMACOLOGIC

CLASS:

Third Generation Cephalosporin, Pregnancy risk category B

MECHANISM OF ACTION:

Inhibits cell wall synthesis, promoting osmotic instability, usually baactericidal

-Perioperative prevention -UTI, septicaemia, skin structure infection

CONTRAINDICATIO

N:

-Hypersensitive to dry or other cephalosporin -Cautiously in patient hypersensitive to penicillin -Cautiously in breast feeding women

GI:

pseudomembranou

s colitis, diarrhea

HEMA:

Eosinophilia, thrombocytosis, leukopenia SKIN: pain, induration, rash

OTHER:

hypersensitivity

reactions,

anaphylaxis

- Instructed patient to report discomfort

at IV site

  • - Tell patient to report adverse

reactions promptly

  • - Educated and

informed about the

adverse reactions

  • - Tell patient to

notify prescriber if having loose stools

  • - Assessed for pain

  • - Administered pain meds. As prescribed by the physician

DRUG

CLASSIFICATION

INDICATION

SIDE EFFECTS

NURSING

RESPONSIBILITIE

S

Mannitol 100ml

THERAPEUTIC

-To reduce

CNS: seizures,

BEFORE:

IVTT every 12

CLASS:

intraocular or

dizziness,

hours (8 am- 8pm)

Diuretic

intracranial

headache, fever

DURING:

PHARMACOLOGIC

pressure or cerebral edema

CV: edema, thrombophlebitis,

-To relieve thirst, give frequent

CLASS:

-To prevent oliguria

hypotension,

mouth care or

Osmotic diuretic

or acute renal

hypertension,

fluids

MECHANISM OF ACTION:

failure -Oliguria

heart failure, tachycardia, vascular overload

-Emphasized importance of drinking only the

Increases osmotic

CONTRAINDICATIO

EENT: blurred

amount of fluids

pressure

N:

vision, rhinitis

ordered.

glomerular filtrate, thus inhibiting

-Hypersensitive to drug

GI: thirst, dry mouth, nausea,

AFTER:

tubular reabsorption of H2O and electrolytes. It elevates plasma osmolarity and

-Anuria, active intracranial bleeding, severe dehydration, metabolic edema

vomiting, diarrhea GU: urine retention META: dehydration SKIN: local pain, urticaria OTHERS: thirst,

-Monitored vital sign and intake and output -Instructed patient to promptly report adverse reactions

increased H2O flow into extracellular

chill

and discomfort at I.V. site.

DRUG

CLASSIFICATION

INDICATION

SIDE EFFECTS

NURSING

RESPONSIBILITIE

S

Ketorolac

THERAPEUTIC

Short – term

CONTRAINDICATIO

CNS: Headache,

Renal

Tromethamine 10

CLASS:

management of ain

dizziness,

impairment,

ml IVTT every 8

NSAID

(up to 5days)

insomnia, fatigue,

Impaired

hours (8 am- 4pm- 12 am)

PHARMACOLOGIC

Ophthalmic: Relief of ocular itching

tinnitus, ophthalmologic

hearing, allergies,

CLASS:

due to seasonal

effects.

hepatic,

NSAID

conjunctivitis and

DERMATOLOGIC:

Skin color and

THERAPEUTIC

relief of postoperative

Rash, pruritus, sweating, dry

lesions, orientation,

ACTIONS:

inflammation and

mucous

reflexes,

Anti – inflammatory and analgesics activity; inhibits prostaglandins and

pain after cataract surgery.

membranes, GI: Nausea, dyspepsia, GI pain, diarrhea, vomiting,

peripheral sensation, clotting times, CBC,

leukotriene

NS:

constipation,

adventitious

synthesis.

Contraindicated with significant renal impairment, during labor and

flatulence, hepatic impairment. GU: Dysuria, renal impairment

sounds Be aware that patient may be at risk for CV

 

delivery , lactation;

HEMATOLOGIC:

events, GI

patients wearing soft contact lenses

Bleeding, decreased Hgb and

bleeding, renal toxicity, monitor

DRUG

CLASSIFICATION

INDICATION

SIDE EFFECTS

active peptic ulcer disease or GI, bleeding; hypersensitivity to ketorolac; as prophylactic analgesics before major surgery; treatment of perioperative pain in CABG; suspected or confirmed cerebrovascular bleeding; hemorrhagic diathesis, incomplete hemostasis, high risk of bleeding; use with probenecid, pentoxyphylline.

NURSING

RESPONSIBILITIE

S

Protect drug vials from light. Administer every 6 hours to maintain serum levels and control pain.

DRUG

Ranitidine Hydrochloride IVTT 25mg every 8 hours (8am- 4pm-

12am)

CLASSIFICATION

INDICATION

SIDE EFFECTS

THERAPEUTIC

CLASS:

Antiulcer

PHARMACOLOGIC

CLASS:

Histamine – 2 anatagonist

THERAPEUTIC

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,

Short – term treatment of active duodenal ulcer. Maintenance therapy for duodenal ulcer at reduced dosage. Short – term treatment of GERD. Short – term treatment and maintenance therapy of active, benign gastric ulcer. Treatment and maintenance of healing of erosive

CNS: Headcahe, malaise, dizziness, insomnia, vertigo. CV: Tachycardia, bradycardia

DERMATOLOGIC:

Rash, alopecia GI: Constipation, diarrhea, nausea,

vomiting,

abdominal

pain,hepatitis. GU: Impotence or decreased libido

HEMATOLOGIC:

Leukopenis, granulocytopenia, thrombocytopenia LOCAL: Pain at IM site local burning

or itching at IV site

OTHER:

NURSING

RESPONSIBILITIE

S

Instruct patient not to take new medication w/o consulting physician Instruct patient to take as directed and do not increase dose Allow 1 hour between any other antacid and ranitidine Avoid excessive alcohol Assess patient for epigastric or abdominal pain and frank or occult blood in the stool,

DRUG

CLASSIFICATION

INDICATION

SIDE EFFECTS

CONTRAINDICATIO

N:

Contraindicated with allergy to ranitidine, lactation.

NURSING

RESPONSIBILITIE

S

Inform patient that it may cause drowsiness or dizziness Inform patient that increased fluid and fiber intake may minimize constipation Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health care professional

DRUG

Dexamethasone Sodium Sulphate IVTT 10mg every 8 hours (8am- 4pm-

12am)

CLASSIFICATION

INDICATION

SIDE EFFECTS

THERAPEUTIC

CLASS:

Anti – inflammatory

PHARMACOLOGIC

CLASS:

Corticosteroid

MECHANISM OF ACTION:

Suppresses edema, fibrin deposition, capillary dilation, leukocyte migration, capillary proliferation, and collagen deposition.

Hypercalcemia associated with cancer Cancer chemotheraphy – induced nausea and vomiting. Cerebral edema associated with brain tumor, craniotomy, or head injury. Ulcerative colitis, acute exacerbations of MS, and palliation in some leukemias and lymphomas.

CNS: Seizures, vertigo, headaches, insomnia, mood swings, depression, psychosis, intracerebral haemorrhage, cataracts, glaucoma. CV: Hypertension, heart failure, necrotizing angiitis. ENDOCRINE:

Growth retardation, decreased carbohydrate tolerance, diabetes mellitus GI: Peptic or esophageal ulcer, pancreatitis,

NURSING

RESPONSIBILITIE

S

Tell patient to shake suspension well before use. Teach patient how to instill drops. Advise him to wash hands before and after applying solution, and warn him not to touch tip of dropper to eye or surrounding tissue. Tell patient to apply light finger pressure on lacrimal sac for 1 minute after

DRUG

CLASSIFICATION

INDICATION

SIDE EFFECTS

CONTRAINDICATIO

HEMATOLOGIC:

NS:

Contraindicated in patient’s hypersensitivity to drug or its ingredients. Drug contain sulphite. Contraindicated in those with ocular tuberculosis or acute superficial herpes simplex (dendritic keratitis), varicella, or other fungal or viral diseases of cornea and conjunctiva; in patients with acute, purulent, untreated

Fluid and electrolyte disturbances, increase blood sugar, glycosuria,

increase serum cholesterol.

HYPERSENSITIVI

TY: Anaphylactoid or hypersensitivity reactions.

MUSCULOSKELET

AL: Muscle weakness, loss of

muscle mass. Osteoporosis, spontaneous fractures OTHER: Impaired wound healing, petechiae,

NURSING

RESPONSIBILITIE

S

Warn patient not to use leftover drug for new eye inflammation; doing so may cause serious problems.

Cues

Nursing

Objectives

Intervention

Rationale

Evaluation

Diagnosis

Subjective:

“Maul-ol tak bali ha Dong”

tiil

Objective:

-Limited Range of Motion noted -Guarding behavior noted upon moving leg -Slowed movement noted -Rate of dependence (3) three -Requires help from another person and equipment device

Impaired physical mobility related

General :

   

to loss of integrity of leg bone structures

After 4 days of holistic nursing care, the patient will be able to reach OLOF.

Scientific Basis:

 

Fractures occur when the bone

Specific:

1.Encouraged significant others to reposition patient every 2 hours

  • 1. To promote optimal level of functioning

is

subjected

to

stress

greater

After 8 hours of student nurse-

2.

Supported affected body part with soft

2. To maintain position of function and reduce

that

it

can

absorb.

When

patient interaction, the patient will

 
   

linen

risk of pressure ulcers

the bone

is

broken,

adjacent

be able to demonstrate a decrease

3.

Encouraged participation in self care

  • 3. To enhance sense of independence

structures

are

also

affected,

rate of dependence from 3 to 2

4.

Provided safety measures

  • 4. To ensure safety

resulting in soft tissue edema,

5.

Administered meds as prescribed

  • 5. To relieve pain pharmacologically

hemorrhage

into

the

muscles

(ketorolac)

and joints,

joints

dislocations,

6.

Scheduled activity with adequate rest

  • 6. To reduce fatigue

ruptured

ten-dons,

severed

Source : Nurses Pocket

periods

nerves,

and

damaged

blood

7.

Encouraged adequate intake of fluids and

  • 7. To prevent constipation

vessels.

Body organs

may

be

Guide12th edition Doenges,

foods high in fiber

injured by the force that caused the fracture fragments. After a fracture, the extremities cannot

Moorhouse, Murr FUNDAMENTALS OF NURSING POTTER AND PERRY 8TH Edition

8.

Check for skin integrity for signs of

redness and tissue ischemia (especially over ears, shoulders, elbows, sacrum, hips, heels,

  • 8. Routine inspection of the skin (especially over

bony prominences) will allow for prevention or early recognition and treatment of pressure

because

normal

functions

ankles, and toes)

ulcers

of muscle depend on the

MEDICAL AND SURGICAL

9.

Note elimination status (e.g., usual

  • 9. Immobility promotes constipation, decreasing

integrity of the bones which they are attached.

NURSING BRUNNER AND SUDDARTHS 10TH Edition

pattern, present patterns, signs of constipation)

the motility of the gastrointestinal tract

GOAL UNMET.

Still patient requires help from another person and equipment device

Cues

Subjective:

“Maul-ol tak bali ha tiil Dong”

Objective:

Limited Range of Motion noted Guarding behavior noted upon moving leg Slowed movement noted Rate of dependence (3) three Requires help from another person and

  • i t d

i

Nursing

Diagnosis

Impaired physical mobility related to loss of integrity of leg bone structures

Scientific Basis

Fractures occur when the bone is

subjected to stress greater that it can absorb. When the bone is

broken,

adjacent

structures are

also affected, resulting in soft

tissue edema,

hemorrhage into

the muscles and joints,

joints

dislocations, ruptured ten-dons,

Body

injured

caused

organs

by

the

the

may

be

force that

fracture

fragments. After a fracture,

the extremities cannot

because normal functions

of muscle

depend

on

the

integrity of the bones which

Objectives

General :

After 4 days of holistic nursing care, the patient will be able to reach OLOF.

Specific

After 8 hours of student nurse- patient interaction, the patient will be able to demonstrate a

Intervention

Rationale

1.Encouraged

significant

others to reposition patient

1. To promote optimal level of functioning

every 2 hours

 

2.

To

maintain

position

of

2. Supported affected body

function and reduce

risk

of

part with soft linen

pressure ulcers

 

3. Encouraged participation in

3.

To

enhance

sense

of

self care 4. Raised side rails up

independence 4. To ensure safety

 

Intervention

Rationale

5. Administered meds as

  • 5. To

relieve

pain

prescribed (ketorolac)

pharmacologically

6. Scheduled activity with

  • 6. To reduce fatigue

adequate rest periods 7. Encouraged adequate intake of fluids and foods high in fiber

  • 7. To prevent constipation

8.

Check

for

skin

8. Routine inspection of

integrity

redness

for

signs

of the skin (especially over

and

tissue bony prominences) will

ischemia

(especially allow for prevention or

over

ears,

shoulders,

elbows,

sacrum,

hips,

heels, ankles, and toes)

early recognition and treatment of pressure ulcers

Intervention

Rationale

  • 9. Note

elimination 9.

Immobility

status

(e.g.,

usual

promotes

pattern,

present constipation,

patterns,

signs

constipation)

of decreasing the motility of the gastrointestinal tract

Evaluation

GOAL UNMET

Still patient requires help from another person and equipment device

Cues

Nursing

Objectives

Intervention

Rationale

Evaluation

Diagnosis

Subjective :

Makapoy it ak lawas”

Objective:

Fatigue related to disturbed sleeping pattern

Scientific Basis:

General :

After 4 days of holistic nursing care, the patient will be able to reach optimum leaving of functioning

-Lethargic noted -Lack of energy noted

-Slowed

movement

noted -Limited mobility noted

-Fatigue rate of 7 out of

10,

as

10

as

the

highest

 

Sleep restores our body’s energy needs. People with decreased sleep may or will manifest decreased energy level as evidenced by lethargy and increased need for sleep

Specific:

After 8 hours of student nurse-patient interaction, the patient will be able to verbalize and demonstrate a fatigue rate of 4-5

  • 1. Provided adequate rest

  • 2. Supported affected body

part with soft linen

Source : Nurses Pocket Guide12th edition Doenges, Moorhouse, Murr FUNDAMENTALS OF NURSING POTTER AND PERRY 8TH Edition MEDICAL AND SURGICAL NURSING BRUNNER AND SUDDARTHS 10TH Edition

3.Instructed to avoid caffeine containing foods and drinks

  • 4. Provided safety measures

  • 5. Scheduled activity with

adequate rest periods

1.To promote optimal level of functioning

2. To maintain position of function and reduce risk of pressure ulcers

  • 3. To promote adequate sleep

  • 4. To ensure safety

  • 5. To reduce fatigue

GOAL MET.

Patient demonstrated and verbalizes decrease fatigue rate of 5.

Cues

Nursing Diagnosis

Objectives

 

Intervention

Rationale

Evaluat

   

ion

Subjective :

Acute pain related to Left Leg Fracture

General :

 

Maol-ol tak bali ha tiil Dong

After

4 days

of

holistic nursing

 
 

Scientific Basis:

care,

the patient will

be able

to

Objective:

Unpleasant sensory and emotional

REFERENCE: FUNDAMENTALS OF

reach OLOF.

 

-Guarding behavior noted Pain scale of 5/10

experiencing from actual tissue damage; sudden or slow onset with pain intensity from

Specific:

mild to severe with an anticipated or

After 8 hours of student nurse-

1. Instructed in and encouraged

  • 1. To distract attention and

GOAL Partially

C- sharp stabbing pain

predictable end and a duration of less than 6

use of Deep Breathing Exercise

reduce tension

  • 3. To report pain immediately

MET.

O-upon exertion of force on affected leg L-fractured site at Left lower leg D-2-3 min

months. Fractures occur when the bone is subjected to stress greater that it can absorb. When the bone is broken, adjacent structures are

patient interaction, the patient will be able to verbalize a decreased pain intensity to 3-4

2. Provided hot and warm compress at interval frequency 3.Encouraged verbalization of

2. to reduce pain via non pharmacologic use

Patient demonstrated a pain scale of

5/10

E- more movement of leg D-deep breathing

also affected, resulting in soft tissue edema,

feelings 4. Administered pain relievers

  • 4. To reduce pain via

R-not A-none

hemorrhage into the muscles and joints, joints dislocations, ruptured ten-dons, severed nerves, and damaged blood vessels. Body organs may be injured by the force that caused the fracture fragments. After a fracture, the extremities cannot because normal functions

Source : Nurses Pocket Guide12th edition Doenges, Moorhouse, Murr FUNDAMENTALS OF

as ordered 5. Positioned at comfort 6.Maintain immobilization of affected part by means of bed rest and mold

pharmacologic use 5.To reduce tension 6.Relieves pain and prevents bone displacement and extension of tissue injury.

of muscle depend on the integrity of the bones which they are attached.

NURSING, MEDICAL AND SURGICAL NURSING

NURSING POTTER AND PERRY 8TH Edition MEDICAL AND SURGICAL NURSING BRUNNER AND SUDDARTHS 10TH Edition

 

Cues

Subjective :

Maol-ol tak bali ha tiil Dong

Objective:

Guarding behavior noted Pain scale of 5/10

C- sharp stabbing pain O-upon exertion of force on affected leg L-fractured site at Left lower leg D- 2-3 min E- more movement of leg R-deep breathing R-not A-none

Nursing Diagnosis

Acute pain related to Left Leg Fracture

Scientific Basis

• Unpleasant sensory and emotional experiencing from actual tissue damage; sudden or slow onset with pain intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months.

•Fractures occur when the bone is subjected to stress greater that it can absorb. When the bone is broken, adjacent structures are also affected, resulting in soft tissue edema, hemorrhage into the muscles and joints, joints dislocations, ruptured ten-dons, severed nerves, and damaged blood vessels. Body organs may be injured by the force that caused the fracture fragments. After a fracture, the extremities cannot because normal functions of muscle depend on the integrity of the bones

Objectives

General :

After 4 days of holistic nursing care, the patient will be able to reach OLOF.

Specific:

After 8 hours of student nurse- patient interaction, the patient will be able to verbalize a decreased pain intensity to 3-4

Intervention

Rationale

1.Provided adequate rest 2. Supported affected body part with soft linen 3.Instructed to avoid caffeine containing foods and drinks

1.To promote optimal level of functioning 2. To maintain position of function and reduce risk of pressure ulcers 3. To promote adequate sleep

Intervention

Rationale

4. Provided safety

  • 4. To ensure safety

measures 5. Scheduled activity with 5. To reduce fatigue adequate rest periods

6. Administered prescribed meds (ketorolac)

  • 6. To aid pharmacologically

Evaluation

GOAL Partially MET.

Patient demonstrated a pain scale of 5/10

Cues

Nursing

Objectives

Intervention

Rationale

Evaluation

Diagnosis

Subjective:

“Diri ako nahingaturog hin tuhay” as verbalized by the patient

Disturbed sleep pattern related to discomfort resulting from current illness or injury

SCIENTIFIC BASIS:

Objective:

Sleep is required to

provide energy for physical and mental

  • - Change in normal sleep pattern

  • - activities . The sleep

Restlessness

  • - wake cycle is complex ,

Irritability

  • - Slowed reaction

consisting of different

  • - stages of

Lethargy

  • - consciousness , rapid

Disoriented

  • - Decreased number of hours of sleep 3-

eye movement. As persons age, the

  • 4 amount of time spent in REM diminishes. The amount of sleep that individuals require varies with age and personal characteristics such disruption may result in both subjective distress and apparent impairment in function abilities. Discomfort also contributes in changes in environment health and routine. REFERENCE: FUNDAMENTALS OF NURSING

General: After 4 days of holistic student nurse patient interaction the patient will be able to achieve optimum level of functioning.

Specific:

-After 8 hrs. of student-

nurse patient interaction the patient will be able to demonstrate an increased number of hours of sleep 6-7 hours

  • 1. Observed or

obtained feedback from client regarding visual sleeping routines, number of hours of sleep. 2 Provided calm and quiet environment.

  • 3. Instructed client or

SO to avoid caffeinated drinks like cola and coffee.

  • 4. Positioned client

comfortably. 5.Encouraged deep breathing exercises. 6.Refered to physician or sleep specialist as indicated

  • 1. To determine usual

sleep pattern and provide a comparative baseline .

  • 2. helps to promote

conducive atmosphere

for rest full sleep.

  • 3. May irritate the

bladder which can cause diuresis over stimulation prevents client from falling asleep, delays client falling asleep and

shortens the REM part of sleep.

  • 4. To promote rest.

  • 5. For relaxation

technique. 6.For specific interventions and or therapies, including medications, biofeedback

GOAL PARTIALLY MET.

The patient demonstrated an increased number of hours of sleep 5-6 hours

 

Focus Charting

 

Date and Time

Focus Problem

 

Data

 

Action

Response

February 20, 2017

Disturbed

sleeping

Received

patient

on

-Vital Signs taken and

Kept watched

12:00 pm

pattern

bed

sleeping

with

recorded

  • - Change in normal

Intravenous

Fluid

of

-Intake and Output

sleep pattern

Plain

Non-Saline

Monitored

  • - Restlessness

Solution

1

 

liter

980

-Positioned patient

  • - Irritability

mL level at 30drops/

comfortably

  • - Slowed reaction

minute

infusing

well

-supported affected

  • - Lethargy

at

right

arm,

with

leg with soft linen

  • - Disoriented

Long

Leg

Posterior

-encouraged

Mold

Left, with Foley

adequate intake of

Bag

Catheter

fluids

and nutritious

attached

to

Urobag

foods

infusing well; Diri ako

-encouraged to do

nahingaturog

 

hin

deep breathing

tuhay” as verbalized

exercises

 

by

the

patient;

-adequate

rest

lethargic

 

noted;

provided

disoriented

to

time

-balanced

activity

and lace noted;

with rest periods -bed side care done

 
 

-Instructed client or

SO

to

avoid

caffeinated drinks like cola and coffee.

Date

Focus

Data

Action

Respons

and

Problem

e

Time

Februar

Impaire

-Received patient

-Vital Signs taken and

Kept

y 22,

d

on bed sleeping

recorded

watched

2017

Physical

with Intravenous

-Intake and Output Monitored

1:00

Mobility

Fluid of Plain Non-

-Positioned patient

pm

Saline Solution 1 liter kept set sterile, with Long Leg Posterior Mold Left, with Foley Bag Catheter attached to Urobag infusing well; masakit akun tiil kun gikikiwa” as verbalized by the patient.

comfortably -supported affected leg with soft linen -encouraged adequate intake of fluids and nutritious foods -encouraged to do deep breathing exercises -adequate rest provided -balanced activity with rest periods -bed side care done

Date

Focus

and

Problem

Data

Action

Respon

Time

se

Februa

Self Care

-Received

patient

-Vital Signs taken and

-kept

ry 23,

Deficit

on

bed sleeping

recorded

watche

2017

with

Intravenous

-Intake and Output monitored

d

1:00

Fluid of Plain Non-

-positioned patient

pm

Saline Solution

1

comfortably

liter

kept

set

-assisted on wound dressing

sterile, with Long

-supported affected leg with

Leg Posterior Mold

soft linen

Left, with

Foley

-encourage to do Deep

Bag

Catheter

Breathing Exercise

attached

to

-adequate rest provided

Urobag

infusing

-performed bed bath

well;

-emphasized the importance

Inability

to

bath

of bed bath

self noted; guarding

-safety provided

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