I.

INTRODUCTION

A bone fracture (sometimes abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a break in the continuity of the bone. A bone fracture can be the result of high force impact or stress, or trivial injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture. An arm fracture or broken arm involves breaking a bone in the arm. The most frequent breaks occur in one of the three main arm bones - the humerus, ulna or radius. A broken arm can limit a person's ability to carry out day-to-day tasks. It usually involves placing a plaster cast on it to hold it immobile while the bone heals. Frequent arm fractures or fractures that occur from minimal trauma may be a sign that there is a bone problem such as osteoporosis. The natural process of healing a fracture starts when the injured bone and surrounding tissues bleed, forming a fracture Hematoma. The blood coagulates to form a blood clot situated between the broken fragments. Within a few days, blood vessels grow into the jelly-like matrix of the blood clot. The new blood vessels bring phagocytes to the area, which gradually remove the non-viable material. The blood vessels also bring fibroblasts in the walls of the vessels and these multiply and produce collagen fibers. In this way the blood clot is replaced by a matrix of collagen. Collagen's rubbery consistency allows bone fragments to move only a small amount unless severe or persistent force is applied. At this stage, some of the fibroblasts begin to lay down bone matrix (calcium hydroxyapatite) in the form of insoluble crystals. This mineralization of the collagen matrix stiffens it and transforms it into bone. In fact, bone is a mineralized collagen matrix; if the mineral is dissolved out of bone, it becomes rubbery. Healing bone callus is on average sufficiently mineralized to show up on X-ray within 6 weeks in adults and less in children. This initial "woven" bone does not have the strong mechanical properties of mature bone. By a process of remodeling, the woven bone is replaced by mature "lamellar" bone. The whole process can take up to 18 months, but in adults the strength of the healing bone is usually 80% of normal by 3 months after the injury. Several factors can help or hinder the bone healing process. For example, any form of nicotine hinders the process of bone healing, and adequate nutrition (including calcium intake) will help the bone healing process. Weight-bearing stress on bone, after the bone has healed sufficiently to bear the weight, also builds bone strength. Although there are theoretical concerns about NSAIDs slowing the rate of healing, there is not enough evidence to warrant withholding the use of this type analgesic in simple fractures. We selected this study because we wanted to learn more about this condition, how it affects a person and how to give an appropriate nursing management for the patient. It is fascinating to learn more about the bone because it is important in our daily living. This is a case study of Mr. ADM, a 25 year old male who underwent an OR plating on left arm last January 25, 2011 at 10:04AM with a physicians diagnosis of Closed Incomplete Fracture Secondary to Vehicular Accident. He was assessed and admitted to Jose B. Lingad Memorial Regional Hospital.
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A. Objectives: General objectives Our case study aims to enhance the knowledge of nursing students who had or will encounter patient with an arm fracture and underwent an OR plating, build up skills to expand their skills as they have their practice in Orthopedic ward, and develop an optimistic outlook towards providing appropriate and holistic care of patient with this kind of condition through the understanding of the concepts of this study. Specific objectives Client-Centered: y y y y y To have a knowledge about his condition. To understand the health teachings with regards to the wound care after discharged in the hospital. To gain knowledge about post-operative complications To determine the complications of the patient fracture To cope up with his situation.

Student-Centered: y y y y To be able to evaluate the effectiveness of the plan of care. To be able to identify the risk factors that was related to fracture. To be able to learn how to establish rapport with our client and understand the case well. To be able to implement the plan of care to prevent complications.

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II. NURSING ASSESSMENT

A. Personal History Name: Mr. A.D.M. Age: 25 years old Birth date: 10 March 1985 Sex: Male marital status: Married Position in the family: Father of the family Address: Sta. Ursula Poetis, Guagua, Pampanga Nationality: Filipino Race: Asian Religion: Catholic Educational attainment: 2nd year high school Health care financing or usual source of medical care: personal renumeration Date of admission: January 25, 2011 Time of Admission: 10:04AM Date of Discharge: January 31, 2011 Final diagnosis: Closed Incomplete Fracture Secondary to Vehicular Accident B. Chief Complaint and Reason for visit Nabunggo ako ng malakas nung van tapos nasapol tong kaliwang

braso ko as verbalized by the patient.

C. History of past illness In his childhood years, the patient already had chicken pox and measles as well as intermittent episodes of common colds and cough. He said that his immunizations were complete. He also doesnt consult the doctor when he has mild illness like mild fever, cough and cold. He is just medicating himself. He use over-the-counter drugs. He also stated that he doesnt have any allergies to foods and drugs. He also stated that he doesnt have problems with his cardiovascular system and respiratory system. He told us that this is the second time he was admitted to the hospital due to vehicular accident.
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D. History of Present illness January 25, 2011, patient A.D.M., a 25 year old male was admitted to the hospital in complaint direct trauma on his left humerus due to vehicular accident. The patient had an accident while crossing the road; accidentally he didnt notice the van approaching from behind. He was bumped by the van and sustained a direct trauma on his left humerus. The patient was immediately rushed in the hospital, was then x-rayed and had the result of Close (L) humerus. The Orthopedic Surgeon referred for his debridement and fixator to POC.

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E. Family health illness history/ Genogram The patients siblings are in optimal health condition. In his paternal side, his grandmother was diagnosed with Hypertension and Diabetes Mellitus. On the other hand, our patients parents both have Hypertension. On the other hand, our patients grandparents passed away because of their old age.

Paternal Side

Maternal Side
-

LEGEND
Male

PS 68y/o

AS 65y/o

BC 70y/o

SC 65y/o

Female Client - Deceased - Hypertension - Diabetes Mellitus

BS 40 y/o

MS 40 y/o

ADM, 25y/o

AM 23 y/o

BM 22 y/o

CM 19 y/o

DM 17 y/o

EM 13 y/o

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F. Functional Health Pattern Gordons Functional Health Pattern

Prior to Hospitalization Functional Health Pattern I. Health Health Pattern Before Hospitalization

Perception The patient stated that he doesnt have problems noticed During his hospitalization the patient wasnt able to perform Management with regards to his health. He does smoke and takes 1 pack different activities because of his condition. He always takes his of cigarette per day. He drinks beer twice a week and medicine and follows the order of the doctor. consumed 2 bottles per drink. He doesnt believe in quack doctors. ADM defined healthy as being free from any illness and not being always hospitalized. On the other hand, he defined unhealthy as oftentimes having certain kind of illness.

II.

Nutritional Metabolic The patient usually eats rice and egg during breakfast; rice, ADMs diet doesnt change much with his condition. He still Pattern fish and vegetables for lunch; and, for supper, he eats rice gets the enough nutrients he needs. His physician ordered NPO vegetables, fish and meat. He eats snacks in between lunch diet before his operation. and supper, and before going to sleep. His snacks usually composed of bread, biscuit, and juice. Water (9-11 glasses Date Breakfast Lunch Dinner per day) is the fluid he usually intakes. He has no problem January 25, 1 bowl of 1 plate of 1 cup of with his appetite. He takes his multivitamin every day to 2011 porridge tindang adobong give his strength in his work. (approx. (tocino) sitaw Date Breakfast Lunch Dinner 250mL) 2 cups of rice 2 cups of 1glass of rice January 3 slices 2 cups rice 1 1/2 cup 2 glasses of 2 glasses of water 22, 2011 bread 1 serving rice water (approx. water (approx. 2 glasses sinigang 1 serving 240mL) (approx.240 240mL) of water na baboy chopseuy
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(approx. 240mL)

(containin g kangkong, okra, gabi and pork) 2 glasses of water (approx. 240 mL) 1 1/2 cup rice 2 pcs. medium sized fried tilapia 2 glasses of water (approx. 240 mL) 2 cups rice 1 serving chicken tinola bread 2 glasses of water (approx. 240 mL)

January 23, 2011

1 bowl sopas (approx. 200ml) 2 glasses of water (approx. 240 mL)

(containing cabbage, carrots, string beans, cauliflower, and chicken) 2 glasses of water (approx.300 mL 1 cup rice 1 serving nilagang baboy 2 glasses of water (approx. 240 mL)

mL)

January 26, 2011

NPO 1 cup of rice cup of adobong kangkong of

January 27, 2 pcs. Of 2 cups of rice 2011 pandesal 1 pc. Medium 1 glass of sized tilapia milk 1 cup of (approx. ginisa sa 200ml) saluyot
2 water (approx. 240 mL)

1 glass milk (approx. glasses of 200ml)

January 24, 2011

3 medium sized bread 1 glass of water (approx. 240 mL) 1 cup coffee (appox. 150ml)

1 cup rice 1 pc. medium sized fried bangus bread 2 glasses of water (approx. 240 mL)

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III.

Elimination Pattern

The patient has no problem in his urination and defecation. He urinates at least 6 times a day and defecates once a day. The client urinates 6 times a day and has the characteristic of yellow color, transparent, and aromatic odor. He has no difficulty in urinating and doesnt experience painful voiding. With regard to his bowel movement, he defecates twice a day and has the characteristic of brown color, formed, soft, cylindrical and aromatic odor. He has no difficulty in defecating.

The patients urination and defecation doesnt change the pattern prior to admission. His urine has yellow in color, transparent and aromatic odor while his bowel movement has brown in color, and hard stool. Date January 27, 2011 January 28, 2011 January 29, 2011

Urine Stool

3 1

3 1

3 1

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IV.

Activity Pattern

Exercise The patient plays basketball every day after his work. He uses walking as his exercise. During his spare time, he takes a nap and watch television with his daughter.

ADM cannot perform some activities vigorously and without the help of his wife. Most of his activities during hospitalization are required assistance or supervision from another person. Perceived ability for code level Level 0: Full self-care Level I: required use of equipment or device Level II: required assistance or supervision from another person Level III: required assistance or supervision from another person or device Level IV: is dependent and does not participate 0 feeding II bathing II toileting II bed mobility II dressing II grooming IIIgeneral mobility

Perceived ability for code level Level 0: Full self-care Level I: required use of equipment or device Level II: required assistance or supervision from another person Level III: required assistance or supervision from another person or device Level IV: is dependent and does not participate 0 feeding 0 bathing 0 toileting 0 bed mobility 0 dressing 0 grooming 0 general mobility 0 home maintenance

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Time A.M 6:00 7:30

Sat (January 22, 2011)

Sun (January 23, 2011) Walking Eating

Mon (January 24, 2011) Walking Eating Reading news paper Cleaning house Going to work

7-Day Activity Tue (January 25, 2011)

Wed (January 26, 2011)

Thurs (January 27, 2011) Walking Eating

Fri (January 28, 2011)

Walking Eating

Eating Reading news paper

Walking Eating Reading news paper

8:00

Reading news paper

Attending mass

Reading news paper Sleeping Reading news paper Sleeping

9:00 11:00 Playing with his daughter 12:00 Eating (Lunch) P.M 2:00 Sleeping 4:00 eating

Cleaning house Eating (Lunch) Sleeping Eating Eating (Lunch) Eating (Lunch) Eating (Lunch) Reading newspaper Eating Reading news paper Sleeping Eating (Lunch)

Eating & Watching T.V Eating (Dinner) Watching T.V

Reading news paper

6:00 7:30

Playing with his daughter Eating (Dinner)

Reading news paper Eating (Dinner) Eating (Dinner) Watching T.V Eating (Dinner)

eating (Dinner) Watching T.V Sleeping

9:00 10:00

Sleeping

Sleeping Sleeping Sleeping

AM 1:00 V. Sleep - Rest Pattern

Sleeping The patient regularly sleeps at least 9 hours a day. He sleeps at 9pm or 10pm to 6am. He has no sleeping disturbances. He takes a nap every afternoon usually one hour of sleep and the maximum is two. The client is satisfied to his hours of sleep. He relaxes himself by reading.

Sleeping Since the day when the patient was admitted to the hospital, he said that his hours of sleep were only 5 hours. He has sleeping disturbances after his surgical operation because of the pain he feels.

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Date January 22, 2011 January 23, 2011 January 24, 2011

# of sleep 8 8 8

# nap 1 1 0

Total 9 9 8

Quality invigorated invigorated invigorated

Date January 25, 2011 January 26, 2011 January 27, 2011 January 28, 2011

# of sleep 5 5 6 7

# nap 0 3 2 1

Total 5 8 8 8

Quality Not invigorated invigorated invigorated invigorated

VI.

Cognitive Perceptual ADMs senses appear to be in good shape. No difficulty When he was admitted to the hospital, theres no change on his Pattern was observed. he doesnt wear eyeglasses. There are no vision and hearing. He can easily catch up with what was his changes in her memory lately. He said that one of the wife was telling him. easiest ways to learn things is when he look at or read things for several times. However, he finds it difficult to remember a few things when he doesnt clearly understand it. Self-perception Self- The patient describes himself as a simple individual who He is a bit worried because he cant help his family to provide concept Pattern wants to have a good future his own family. Most of the their needs. He thinks that he cannot function well at present due time, he feels good about himself especially when he to his condition. doesnt encounter hardships. Even though his income is not that big, he still wanted to find a way to meet all of the needs of his family especially for the education of his daughter. He tries to cope with his current state of health by the help of his extended family members. Regular consultations with medical personnel regarding his condition help in the coping up process.
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VII.

VIII. Role relationship Pattern ADM lives following an extended family structure. He is the breadwinner and decision maker in the family, as he had said upon interview. Sometimes, they find it hard to handle some financial problems but they are eagerly trying to talk about it and finding ways on how to solve it. The patients

family doesnt depend on him for things. He has close friends and he feels part of neighborhood where he is living. IX. Sexuality - Reproductive The client has no difficulty with sexual desire, arousal, The client expected that his sexual functioning will be altered Pattern orgasm, etc. They use pills and condoms as a contraceptive. because of his condition. He thinks that they will abstain from They used to sexually interact thrice a week before he was having sex for this time. hospitalized. He doesnt experience any pain with sexual interaction. His first sexual intercourse was when he was 18 years old with multiple partners. Coping - Stress Pattern The client is not tensed when it comes to certain situations According to the patient, he was able to cope up easily with his that need immediate concern or action. He considers his present condition because his family and friends were always at family and his wife as the most important means to release his side to comfort him. any tension or stress that he feels through communication. He seeks for Gods supervision and asks help from his loved ones when difficult times arise. The client and his family is Roman Catholic. He doesnt believe in superstitions and quack doctors. They go to church every Sunday to thank God for all the blessings that theyve experiencing. Every night, he always prays to give praise and thanks to God. In addition, he reiterated that having an active spiritual life is important and it helps in making right, appropriate and just decisions in life. There are no religious practices that restrict them from approving certain medical procedures for their own sake. He wasnt able to go to the church because of his condition, but he always prays to God to take care of him and his family.

X.

XI.

Value Belief Pattern

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Growth and Development

STAGE Genital

THEORY DESCRIPTION FREUDS PSYCHOSEXUAL This stage marks the beginning DEVELOPMENT THEORY of adult sexual desires and behavior and marks the development of a strong interest in forming heterosexual relationships with people outside the family.

ACTUAL FINDINGS The client is separated from his parents but he doesnt show any untoward reaction with this situation because he knows that he has a supportive family that would help him not to be dependent to his parents. he can also decide for herself as well as for his family.

REMARKS NORMAL

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STAGE Intimacy vs Isolation

THEORY ERIKSONS PSYCHOSOCIAL DEVELOPMENT THEORY

DESCRIPTION Individuals are able to form close contacts and relationships with others and to share themselves with others.

ACTUAL FINDINGS The client has his own family. Hence, he built a sense of trust to his partner that will ensure the patient to be safe and secured. ADM understands that intimacy is not just a sexual relationship. He is aware that it involves mutual commitment and acceptance.

REMARKS NORMAL

STAGE Formal Operations Stage

THEORY PIAGETS COGNITIVE DEVELOPMENT THEORY

DESCRIPTION During this period, major terms of adult thought make their appearance. Thinking becomes abstract and symbolic.

ACTUAL FINDINGS The client falls in this stage because he became capable of logical thought and his reasoning skills was developed which can help him to resolve his problems. The client thinks rationally and finds a reason first before making a rational decision. he thinks the consequences of doing or not doing something and if it will benefit or harm his family or not.

REMARKS NORMAL

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STAGE Post Conventional (Level III)

THEORY KOHLBERGS MORAL DEVELOPMENT THEORY

DESCRIPTION Morality is based on agreement with others to serve the common good and protect the rights of individuals.

ACTUAL FINDINGS The client falls in this stage because he knows his responsibility for himself and others. He knows his limitations to protect himself as an individual. The client believes that everyone have their rights. He is very happy because he had the freedom to choose or decide. He says that if we will not violate others rights, surely people will respect us. Our patient is law-abiding citizen, he is very afraid to break any laws.

REMARKS NORMAL

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STAGE

THEORY  Westerhoffs Stages of Faith Development

CHARACTERISTICS Puts faith into personal and social action and is willing to stand up for what the individual believes even against the nurturing community.

Owned Faith

SIGNIFICANT BEHAVIOR According to the client, her way of being or behaving is based on what she believes. She takes responsibility for her personal faith. It becomes apart of her and impacts her decisions, choices, and actions

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III.

ANATOMY AND PHYSIOLOGY

Bony structure and joints

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The humerus is the (upper) arm bone. It joins with the scapula above at the shoulder joint (or glenohumeral joint) and with the ulna and radius below at the elbow joint. Elbow joint The elbow joint is the hinge joint between the distal end of the humerus and the proximal ends of the radius and ulna. The humerus cannot be broken easily. Its strength allows it to handle loading up to 300 lbs. Osteofascial compartments The arm is divided by a fascial layer (known as lateral and medial intermuscular septa) separating the muscles into two osteofascial compartments:
 

Anterior compartment of the arm Posterior compartment of the arm

The fascia merges with the periosteum (outer bone layer) of the humerus. The compartments contain muscles which are innervated by the same nerve and perform the same action. Two other muscles are considered to be partially in the arm:


The large deltoid muscle is considered to have part of its body in the anterior compartment. This muscle is the main abductor muscle of the upper limb and extends over the shoulder. The brachioradialis muscle originates in the arm but inserts into the forearm. This muscle is responsible for rotating the hand so its palm faces forward (supination).

Cubital fossa The cubital fossa is clinically important for venepuncture and for blood pressure measurement. It is an imaginary triangle with borders being:
    

Laterally, the medial border of brachioradialis muscle Medially, the lateral border of pronator teres muscle Superiorly, the intercondylar line, an imaginary line between the two epicondyles of the humerus The floor is the brachialis muscle The roof is the skin and fascia of the arm and forearm
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The structures which pass through the cubital fossa are vital. The order from which they pass into the forearm are as follows, from medial to lateral:
     

Median nerve, which starts to branch Brachial artery Tendon of the biceps brachii muscle Radial nerve Median cubital vein - this important vein is where venepuncture occurs. It connects the basilic and cephalic veins. Lymph nodes

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Nerve Supply

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The musculocutaneous nerve, from C5, C6, C7, is the main supplier of muscles of the anterior compartment. It originates from the lateral cord of the brachial plexus of nerves. It pierces thecoracobrachialis muscle and gives off branches to the muscle, as well as to brachialis and biceps brachii. It terminates as the anterior cutaneous nerve of the forearm. The radial nerve, which is from the fifth cervical spinal nerve to the first thoracic spinal nerve, originates as the continuation of the posterior cord of the brachial plexus. This nerve enters thelower triangular space (an imaginary space bounded by, amongst others, the shaft of the humerus and the triceps brachii) of the arm and lies deep to the triceps brachii. Here it travels with a deep artery of the arm (the profunda brachii), which sits in the radial groove of the humerus. This fact is very important clinically as a fracture of the bone at the shaft of the bone here can cause lesionsor even transections in the nerve. Other nerves passing through give no supply to the arm. These include:


The median nerve, nerve origin C5-T1, which is a branch of the lateral and medial cords of thebrachial plexus. This nerve continues in the arm, travelling in a plane between the biceps and triceps muscles. At the cubital fossa, this nerve is deep to the pronator teres muscle and is the most medial structure in the fossa. The nerve passes into the forearm. The ulnar nerve, origin C7-T1, is a continuation of the medial cord of the brachial plexus. This nerve passes in the same plane as themedian nerve, between the biceps and triceps muscles. At the elbow, this nerve travels posterior to the medial epicondyle of the humerus. This means that condylar fractures can cause lesion to this nerves.

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Blood supply and venous drainage

The main artery in the arm is the brachial artery. This artery is a continuation of the axillary artery. The point at which the axillary becomes the brachial is distal to the lower border of teres major. The brachial artery gives off an important branch, the profunda brachii (deep artery of the arm). This branching occurs just below the lower border of teres major. The brachial artery continues to the cubital fossa in the anterior compartment of the arm. It travels in a plane between the biceps and triceps muscles, the same as the median nerve and basilic vein. It is accompanied by venae comitantes (accompanying veins). It gives branches to the muscles of the anterior compartment. The artery is in between the median nerve and the tendon of the biceps muscle in the cubital fossa. It then continues into the forearm. The profunda brachii travels through the lower triangular space with the radial nerve. From here onwards it has an intimate relationship with the radial nerve. They are both found deep to the triceps muscle and are located on the spiral groove of the humerus. Therefore fracture of the bone may not only lead to lesion of the radial nerve, but also haematoma of the internal structures of the arm. The artery then continues on toanastamose with the recurrent radial branch of the brachial artery, providing a diffuse blood supply for the elbow joint. Veins The veins of the arm carry blood from the extremities of the limb, as well as drain the arm itself. The two main veins are the basilic and thecephalic veins. There is a connecting vein between the two, the median cubital vein, which passes through the cubital fossa and is clinically important for venepuncture (withdrawing blood).
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The basilic vein travels on the medial side of the arm and terminates at the level of the seventh rib. The cephalic vein travels on the lateral side of the arm and terminates as the axillary vein. It passes through the deltopectoral triangle, a space between the deltoid and the pectoralis major muscles.

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IV.

PATHOPHYSIOLOGY CLOSED INCOMPLETE FRACTURE

Risk factors: Nonmodifiable: Gender: Male Age: 25

Sudden Acute force (impacted) is imposed to forearm

Relaxed muscle and skin condition resilience showing more elasticity

Bracing and absorbing force Force overwhelm the substantial strength of radial bone Intact skin (closed type) Incomplete fracture does not produce complete separation of bone Permeability of capillary Inflammatory response Plasma leaks to tissue from the blood stream Mast cell release histamine

X-ray result: Incomplete fracture

Blood vessel dilatation

Swelling

Blood flow locally

Swelling tissue irritates nociceptors

Redness

Stimulates pain receptors

Pain

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V.

REVIEW OF SYSTEMS

Musculoskeletal System

The extremity cannot function properly because normal function of the muscles depends on the integrity of the bones to which they are attached. There is inability to move the fingers freely due to constricting cast. Swelling and pain were felt by the Client to the surgical incision of the arm. Limited ROM is present.

Integumentary System

The Clients skin barrier is disrupted. Pain and swelling are present into the laceration of the surgical site ( left arm). Skin abrasions are noted in different parts of the body and bruise was also found surrounding the left eye.

Circulation System

There is diminished circulation in the arm because of the constricting cast.

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VI.

PHYSICAL ASSESSMENT

Name: Patient ADM Normal

Age: 25 years old

Sex: Male

Date of Assessment: January 28, 1011

BMI: 20.34/

NORMAL FINDINGS TEMPERATURE PULSE RATE RESPIRATORY RATE BLOOD PRESSURE HEIGHT WEIGHT 36.5-37.5 C Range: 60-100 bpm Range: 12-20 cpm 120/80 mmHg Varies with lifestyle Varies with lifestyle

ACTUAL FINDINGS 37.50C 87 bpm 17 cpm 120/ 90 mmHg 57 60 kg

REMARKS Normal Normal Normal Normal Normal Normal

AREA TO BE ASSESSED General Survey

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

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a. BODY BUILT,

Inspection

Varies with lifestyle

Proportionate

Normal

b. POSTURE AND GAIT, STANDING

Inspection

Relaxed, erect posture, coordinated movement Clean, neat No body or breath odor

Erect posture and coordinated movement Clean and Neat No body odor, no foul breath odor No distress noted Healthy Appearance Cooperative Appropriate to the situation Understandable, exhibits thought association Has logical sequence, has sense of reality

Normal

c. OVERALL HYGIENE AND GROOMING d. BODY AND BREATH ODOR

Inspection Inspection

Normal Normal

e. SIGNS OF DISTRESS f. OBVIOUS SIGNS OF HEALTH/ILLNESS g. ATTITUDE h. MOOD AND APPROPRIATENESS OF RESPONSES i. QUANTITY AND QUALITY OF SPEECH

Inspection Inspection Inspection Inspection

No signs Healthy appearance Cooperative Appropriate to the situation

Normal Normal Normal Normal

Inspection

Understandable, moderate pace, exhibits thought association Logical sequence, makes sense

Normal

j. RELEVANCE AND ORGANIZATION OF THOUGHTS 1. INTEGUMENTARY (SKIN)

Inspection

Normal

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a. COLOR AND UNIFORMITY OF COLOR b. EDEMA c. SKIN LESIONS

Inspection

Varies from light to deep brown, generally uniform in color except in areas exposed to the sun; no edema; Freckles, some birthmarks, some fat and raised nevi

Brown in color, generally uniform except in areas exposed to the sun: no edema; birthmarks on left and right: abrasions and bruise on the left hand, abrasions on the right knee, tattoos on legs and shoulders; redness on the affected arm Moisture in skin folds and axillae Uniform within normal range Skin on the left arm is stretched and cannot be pinched

It indicates irritation of the skin

d. MOISTURE

Palpation

Moisture in skin folds and axillae

Normal

e. TEMPERATURE

Palpation

Uniform within normal range

Normal

f. SKIN TURGOR

Palpation

When pinched, skin brings back to previous state

Indicates a fracture on the left arm

(NAILS) a. FINGERNAIL PLATE SHAPE Inspection Convex curvature, angle between nail and nail bed of about 160 degrees Pink in light-skinned clients; dark-skinned clients may have brown or black pigmentation in longitudinal streaks Convex curvature Normal

b. FINGERNAIL AND TOENAIL BED COLOR

Inspection

Pallor on the left fingernail, delayed return of usual color

Circulatory impairment

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c. FINGERNAIL AND TOENAIL TEXTURE d. TISSUES SURROUNDING NAILS e. BLANCH TEST

Palpation Inspection Palpation

Smooth Intact epidermis Prompt return of pink or usual color. Normally 2-3 seconds.

Smooth Intact epidermis delayed return of usual color on left fingernail

Normal Normal Circulatory impairment

2. HEAD (SKULL) a. SIZE, SHAPE, SYMMETRY Inspection Rounded, smooth skull contour Rounded, smooth skull contour presence of abrasion on left forehead Normal

b. NODULES, MASSES, DEPRESSION

Palpation

Smooth, uniform consistency, absence of nodules/masses

Due to vehicular accident

(SCALP) a. COLOR AND APPEARANCE Inspection White, pinkish in color, no scales or lice No tenderness White, pinkish in color, no scales or lice No tenderness Normal

b. AREAS OF TENDERNESS (HAIR) a. EVENNESS OR DISTRIBUTION, THINNESS/THICKNESS (FACE)

Palpation

Normal

Inspection

Evenly distribution of hair

Evenly distribution of hair

Normal

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a. Facial features, symmetry of facial movements

Inspection

Symmetric or slightly asymmetric facial features, palpebral fissures equal in size, symmetric facial movements

Has bruises on left eye area

Due to vehicular accident

(EYES) 1 EYEBROWS a. HAIR DISTRIBUTION, ALIGNMENT, SKIN QUALITY AND MOVEMENT Inspection Hair evenly distributed, skin intact, eyebrows aligned, equal movement Hair evenly distributed, skin intact, eyebrows aligned, equal movement Normal

2. EYELASHES a. EVENNESS OF DISTRIBUTION & DIRECTION OF CURL 3. EYELIDS a. SURFACE CHARACTERISTICS, POSITION IN RELATION TO THE CORNEA, ABILITY TO BLINK AND FREQUENCY OF BLINKING Inspection Skin intact, no discharge, no discoloration, lids close symmetrically, approximately 15-20 involuntary blinks per minute, bilateral blinking When lids open, no visible sclera above cornea, and upper and lower borders of cornea are slightly covered
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Inspection

Equally distributed, curled slightly outward

Equally distributed, curled slightly outward

Normal

Skin intact, no discharge, no discoloration, lids close symmetrically, 17 involuntary blinks per minute

Normal

4. CONJUNCTIVA a. COLOR, TEXTURE, AND PRESENCE IN THE BULBAR CONJUNCTIVA Inspection Transparent, capillaries sometimes evident. Transparent, capillaries sometimes evident. Normal

b. COLOR, TEXTURE AND LESIONS IN THE PALPEBRAL CONJUNCTIVA 5. SCLERA a. COLOR AND CLARITY 6. CORNEA a. CLARITY

Inspection

Shiny, smooth, pink or red

Shiny, smooth, pink or red

Normal

Inspection

White, shiny

White, shiny

Normal

Inspection

Transparent, shiny and smooth, details of the iris are visible

Transparent, shiny and smooth, details of the iris are visible

Normal

7. IRIS a. SHAPE AND COLOR 8. PUPILS a. COLOR, SHAPE, SYMMETRY OR SIZE Inspection Black in color, equal in size, normally 3-7mm in diameter, round, smooth border Black in color, equal in size, smooth border Normal Inspection Round, the color varies Round and Black Normal

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(VISUAL ACIUTY) a. NEAR VISION b. LIGHT REACTION AND ACCOMMODATION Inspection Inspection Able to read newsprint Illuminated pupil constricts, nonilluminated constricts, pupils constrict when looking at near objects, pupils dilate when looking at far objects, pupils converge when near object is moved toward nose Able to read newsprint Illuminated pupil constricts, non-illuminated constricts, pupils constrict when looking at near objects, pupils dilate when looking at far objects, pupils converge when near object is moved toward nose Normal Normal

(LACRIMAL GLAND, SAC, AND NASOLACRIMAL DUCT) 1. LACRIMAL GLAND Inspection and palpation No edema or tenderness No edema or tenderness Normal

(EXTRAOCULAR MUSCLES) a. ALIGHMENT AND COORDINATION Inspection Both eyes coordinated, move in unison, with parallel alignment Both eyes coordinated, move in unison, with parallel alignment Normal

(VISUAL FIELDS a. PERIPHERAL FIELDS OF VISION Inspection When looking straight ahead, client can see objects in When looking straight ahead, client can see Normal

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periphery (EARS) 1. AURICLES a. COLOR SYMMETRY, SIZE AND POSITION Inspection Color same as facial skin, symmetric position on line drawn from lateral angle of eye to point where top part of auricle joins head is horizontal, imaginary line drawn from the top to the bottom of the ear, varies no more than 10 degrees from the vertical Mobile, firm, and not tender, pinna recoils after it is folded

objects in periphery

Color same as facial skin, symmetrical, aligned with the outer canthus of the eye, with two piercing on each ear

Normal

b. TEXTURE, ELASTICITY AND AREAS OF TENDERNESS

Palpation

Mobile, firm, and not tender, pinna recoils after it is folded

Normal

2. EXTERNAL EAR CANAL a. CERUMEN, SKIN LESIONS, PUS AND BLOOD Inspection Dry cerumen, grayish-tan color, or sticky, wet cerumen in various shades of brown With dry cerumen, no lesions, no pus or blood Normal

(HEARING ACUITY TEST) a. RESPONSE TO NORMAL VOICE TONES Inspection Normal voice tones audible Normal voice tones audible Normal

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b. WATCH TICK TEST

Inspection

Able to hear ticking on both ears

Able to hear ticking on both ears

Normal

(NOSE) a. DEVIATIONS IN SHAPE, SIZE/COLOR AND FLARING/DISCHARGE FROM NARES Inspection Symmetric in shape and straight, no discharge and flaring, uniform color, not tender, no lesions Symmetric in shape and straight, no discharge and flaring, uniform color, not tender, no lesions With lesions on left nares Normal

b. REDNESS, SWELLING, GROWTHS AND DISCHARGE

Inspection

Not tender, no lesions, no discharge

Due to vehicular accident Normal

c. NASAL SEPTUM BETWEEN THE NASAL CHAMBERS d. PATENCY OF BOTH NASAL CAVITIES

Inspection

Intact and in midline

Intact and in midline

Palpation

Air moves freely as the client breathes through the nares

Air moves freely as the client breathes through the nares Not tender, no lesions

Normal

e. TENDERNESS, MASSES, AND DISPLACEMENT OF BONE AND CARTILAGE (SINUSES) a. TENDERNESS (MOUTH)

Palpation

Not tender, no lesions

Normal

Palpation

Not tender

Not tender

Normal

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1. LIPS a. SYMMETRY OF CONTOUR, COLOR AND TEXTURE Inspection Uniform pink color, darker in dark-skinned people, soft, moist, smooth texture, symmetric contour, able to purse lips Dark in color, moist, smooth texture, soft, symmetric contour, able to purse lips Normal

2. BUCCAL MUCOSA a. COLOR, MOISTURE, TEXTURE AND PRESENCE OF LESIONS Inspection and palpation Uniform pink color, freckledbrown in color in dark-skinned clients, moist, smooth, soft, glistening and elastic texture Uniform pink color, moist, soft, glistening Normal

3. TEETH a. COLOR, NUMBER, CONDITION AND PRESENCE OF DENTURES 4. GUMS a. COLOR AND CONDITION Inspection Pink gums/bluish/dark patches in dark-skinned people, moist, firm texture, non retraction Pink gums, moist, firm texture Normal Inspection Smooth, white, shiny tooth enamel 21 adult teeth: white: smooth and intact dentures Normal

5. TONGUE/FLOOR OF THE MOUTH a. COLOR AND TEXTURE OF THE MOUTH FLOOR AND FRENULUM Inspection and palpation Smooth tongue, base with prominent veins, pink color, Smooth tongue base with prominent veins, pink Normal

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moist, slightly rough, pink color b. POSITION, COLOR, TEXTURE, MOVENMENT AND BASE OF THE TONGUE c. NODULES, LUMPS/EXCORIATED AREA Inspection and palpation Palpation- not performed Central position, moves freely

color, moist, slightly rough Central position, moves freely Smooth with no palpable nodules Normal

Smooth with no palpable nodules

Normal

(PALATES AND UVULA) a. COLOR, SHAPE, TEXTURE Inspection and Palpation Light pink, rough soft palate, hard palate with more irregular texture Position in midline of soft palate Light pink, rough soft palate, hard palate with more irregular texture Position in midline of soft palate Normal

b. POSITION AND MOBILITY

Inspection

Normal

(OROPHARYNX AND TONSILS) a. COLOR AND TEXTURE Inspection Pink and smooth posterior wall, no discharge, normal size Pink and smooth posterior wall, no discharge, normal size Pink and smooth, no discharge, normal size Present Normal

b. SIZE OF TONSIL, COLOR AND DISCHARGE

Inspection

Pink and smooth, no discharge, normal size Present

Normal

c. GAG REFLEX (NECK AND LYMPH NODES)

Normal

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1. LYMPH NODES a. TENDERNESS 2. TRACHEA a. PLACEMENT Inspection and palpation Central placement at the midline of the neck Central placement at the midline of the neck Normal Palpation Not palpable Not palpable Normal

3. THYROID GLAND a. SYMMETRY AND VISIBLE MASSES b. SMOOTHNESS AND AREAS OF ENLARGEMENT, MASSES/NODULES Inspection Palpation Not visible Lobes may not be palpated, if palpated, lobes are small, smooth, painless and rise freely with swallowing Not visible Lobes not be palpated, painless and rise freely with swallowing Normal Normal

(THORAX) 1. POSTERIOR THORAX a. SHAPE, SYMMETRY AND DIAMETER Inspection Anteroposterior diameter ratio is 1:2, chest symmetric Spine vertically aligned Uniform temperature, no tenderness, no masses Chest symmetric Normal

b. SPINAL ALIGNMENT c. TEMPERATURE, TENDERNESS, MASSES

Inspection Palpation

Spine vertically aligned Uniform temperature, no tenderness, no masses

Normal Normal

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d. RESPIRATORY EXCURSION

Inspection

Full and symmetric chest expansion Bilateral symmetry, fremitus is heard most clearly at the apex of the lungs

Full and symmetric chest expansion Bilateral symmetry, fremitus is heard most clearly at the apex of the lungs Percussion notes resonates except over the scapula Normal breath sounds

Normal

e. VOCAL FREMITUS

Palpation

Normal

f. PERCUSSION NOTES

Percussion

Percussion notes resonates except over the scapula Vesicular and bronchovesicular breath sounds

Normal

g. BREATH SOUNDS

Auscultation

Normal

1. ANTERIOR THORAX a. BREATHING PATTERNS Inspection Respirations are evenly spaced and effortless Uniform temperature, no tenderness and masses Full, symmetric chest expansion Respirations are evenly spaced and effortless Uniform temperature, no tenderness and masses Full, symmetric chest expansion Bilateral symmetry, fremitus is normally decreased over heart and breast tissues Normal

b. TEMPERATURE, TENDERNESS, MASSES

Palpation

Normal

c. RESPIRATORY EXCURSION

Inspection

Normal

d. VOCAL FREMITUS

Palpation

Bilateral symmetry, fremitus is normally decreased over heart and breast tissues

Normal

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e. TRACHEA

Auscultation

Bronchial and tubular breath sounds Vesicular and bronchovesicular breath sounds

Bronchial and tubular breath sounds Normal breath sounds

Normal

f. BREATH SOUNDS

Auscultation

Normal

(CARDIOVASCULAR) 1. AORTIC AND PULMONIC AREAS Inspection and palpation Inspection and palpation Inspection and palpation Inspection and palpation No pulsations No pulsations Normal

2. TRICUSPID AREA

No pulsations, no lifts or heave

No pulsations, no lifts or heave No lift/heave, palpable

Normal

3. APICAL AREA

No lift/heave, palpable

Normal

4. EPIGASTRIC AREA

Aortic pulsations

Aortic pulsations

Normal

(CAROTID ARTERIES) a. PALPATION Palpation Symmetric pulse volume, full pulsation, thrusting quality, quality remains same when client breathes, turns head and changes from sitting to supine position Symmetric pulse volume, full pulsation, thrusting quality, quality remains same when client breathes, turns head and changes from sitting to supine position Normal

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b. AUSCULTATION (JUGULAR VEINS) a. DISTENTION (BREAST AND AXILLAE) a. SIZE, SYMMETRY AND CONTOUR b. b. LOCALIZED DISCOLORATION/HYPERPIGMENTATI ON/ RETRACTION/DIMPLING LOCALIZED HYPERVASCULAR AREA, SWELLING/EDEMA c. AREOLA

Auscultation

No bruit sounds

No bruit sounds

Normal

Inspection

Veins not visible

Veins not visible

Normal

Inspection

Rounded shape, slightly unequal, generally symmetric; Skin uniform in color and intact

Breasts are even with the chest wall: skin uniform in color: skin smooth and intact

Normal

Inspection

Round, oval, bilaterally the same, color varies from light pink to dark brown Round, equal in size, similar in color, soft and smooth, both points in the same direction, no discharges except in pregnant or breastfeeding females No tenderness, masses/nodules

Round, oval, bilaterally the same, dark brown in color

Normal

d. NIPPLES

Inspection

Round, equal in size, similar in color, points in the same direction

Normal

e. AXILLARY, SUBCLAVICULAR AND SUPRACLAVICULAR LYMPH NODES (ABDOMEN)

Palpation

No tenderness, masses/nodules

Normal

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a. SKIN INTEGRITY

Inspection

Unblemished skin, uniform color

Unblemished skin, uniform color Rounded (convex) No evidence of enlargement of liver/spleen Symmetric contour Symmetric movements caused by respirations

Normal

b. ABDOMINAL CONTOUR c. ENLARGED LIVER AND SPLEEN

Inspection Inspection

Flat/rounded/scaphoid No evidence of enlargement of liver/spleen Symmetric contour Symmetric movements caused by respiration, visible peristalsis in very lean people, aortic pulsations in thin persons at epigastric area Audible bowel sounds, absence of arterial bruits, absence of friction rubs No tenderness, relaxed abdomen with smooth, consistent tension

Normal Normal

d. SYMMETRY OF CONTOUR e. ABDOMINAL MOVEMENTS

Inspection Inspection

Normal Normal

f. BOWEL SOUNDS, VASCULAR SOUNDS AND PERITONEAL FRICTION RUBS

Auscultation

Audible bowel sounds, absence of arterial bruits, absence of friction rubs No tenderness, relaxed abdomen with smooth, consistent tension

Normal

g. PALPATION

Palpation

Normal

(MUSCULOSKELETAL SYSTEM) 1. MUSCLES a. SIZE Inspection Equal on both sides swelling on the left arm Indicates a

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fracture b. CONTRACTURES c. FASCICULATIONS AND TREMORS d. TONICITY Inspection Inspection Palpation No contractures No fasciculation or tremors Normally firm No contractures No fasciculation or tremors Not firm Normal Normal Indicates a fracture Indicates a fracture

e. STRENGTH

Inspection

Equal strength on both sides

Less of normal strength on the left arm

2. BONES a. SKELETON FOR NORMAL STRUCTURES AND DEFORMITIES b. EDEMA/TENDERNESS Inspection No deformities No deformities Normal

Palpation

No tenderness, crepitation or nodules

With swelling and tenderness on the left arm

Indicates a fracture

3. JOINTS a. SWELLING Inspection No swelling With swelling on the left arm With tenderness noted, limited ROM on the left arm Indicates a fracture Indicates a fracture

b. TENDERNESS, SMOOTHNESS OF MOVEMENT, SWELLING, CREPITATION AND PRESENCE OF NODULE

Palpation

No tenderness, swelling, crepitation or nodules, joints move smoothly

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VII.

LABORATORY PROCEDURES

DIAGNOSTIC / LABORATORY PROCEDURE

DATE ORDERED and DATE RESULT IN

INDICATIONS or PURPOSE

RESULT

NORMAL VALUES

ANALYSIS AND INTERPRETATION OF THE RESULTS

NURSING RESPONSIBILITIES

PRIOR: y A white blood cell count is a determination of number of WBC or leukocytes/unit volume in a sample of venous blood. The test is used to detect infection or inflammation and also used to help monitor the bodys response to various treatments and to monitor bone marrow function, and to determine the need for further tests, such as differential count. Check if theres a doctors order for CBC y Explain the procedure to the patient and why it is needed y Give the patient a clean vial and instruct to void directly into the specimen bottle y Provide privacy DURING: y Use standard precaution and sterile technique when getting specimen y Apply pressure on the venipuncture site after withdrawing specimen\ AFTER: y Label the specimen

CBC (Complete Blood Count) y y y y WBC Count Lymphocytes Eosinophils Hemoglobin Hematocrit

Jan. 25, 2011 Jan 25,2011

6.7

M:510x109/L

Within normal range.

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y Hemoglobin is an important HGB component of red blood cells that carries oxygen and carbon dioxide 155 to and from tissues. The hemoglobin determination test is used to screen for diseases associated with anemia and in determining acid-base balance. The oxygen carrying capacity of the blood is also determined by the Hemoglobin concentration Measures the percentage of RBC Hct in a blood volume. The test is performed to help diagnose blood .43 disorders, such as polycythemia, anemia or abnormal dehydration, blood transfusion decisions for severe symptomatic anemias, and the effectiveness of those transfusions. The smallest formed elements in blood that promote blood clotting after an injury. The test is performed to determine if blood PLT 191 M: 140-170 F: 120 150 g/dL

container with name, age, date and time the specimen was obtained, room no., the doctor who ordered the specimen. Send the specimen to the laboratory immediately

Within normal range

M: 0.40 - Within normal range 0.60 F: 0.38 0.40

150 450 X10 /L

9

Within normal range condition.

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clots normally, evaluate platelet production, and to diagnose and monitor a severe increase or decrease in platelet count A small white blood cell (leukocyte) that plays a large role Lymphocytes in defending the body against disease. Evaluate bacterial and .44 viral infection, immune disease, leukemia, and ulcerative colitis

0.2-0.35

Above normal range

Jan. 25, 2011 Jan 25,2011

A n X-rayof the humerus is obtained to determine the extent of damage gthrough visualization of the bones.

Incomplete fracture is noted in proximal Normal humerus structure of Posterior mold cast is the humerus present.

1. Control 2. Activity 3. INR 4. Partial thromboplastin Time

13.0 70-100 % 0.8 1.2 34-45 sec

Prothrombin time 12-15 sec 74.3 % 1.14 38.7

Within normal range Within normal range Within normal range Within normal range

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VIII. MEDICAL MANAGEMENT

MEDICAL MANAGEMENT TREATMENT

DATE ORDERED/ DATE GENERAL INDICATIONS/ PERFORMED/ DESCRIPTION PURPOSE DATE CHANGE OR DC

CLIENTS NURSING RESPONSIBILITIES RESPONSE TO THE PROCEDURE

IVF (D5LR)

Date ordered/performed: Jan. 26, 2010

5% Dextrose Draws fluid out of in Lactated the interstitial Ringers compartments into Solution the vascular compartment, expanding vascular volume, in preparation for a surgical procedure

Client was comfortable after the IVF insertion; no negative reactions observed.

PRIOR: y Determined the type of solution to be infused. y The rate of flow or the time over which the infusion is to be completed. y Assess the vital signs, skin turgor. DURING: y Prepare the infusion set. y Spike the solution container. y Prime the tubing. y Perform aseptic technique. y Initiate the infusion. y Regulate the infusion. AFTER: y Document relevant data. y Monitor clients response. y Evaluate if IV flow is consistent with what ordered. y Assess the infusion site.
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MEDICAL MANAGEMENT TREATMENT

DATE ORDERED/ DATE PERFORMED/ GENERAL DATE CHANGE OR DESCRIPTION DC

INDICATIONS/ PURPOSE

CLIENTS NURSING RESPONSIBILITIES RESPONSE TO THE PROCEDURE

Date ordered/performed: Jan. 26, 2011 (3LPM via face Date discontinued: mask) Jan. 27, 2011 Oxygen therapy

Oxygen therapy is the y administration of oxygen as medical intervention. Oxygen is essential for cell metabolism, and in turn, for tissue oxygenation. y It is an administration of oxygen at concentration greater than that in room air to prevent hypoxemia and hypoxia.

Increases oxygen y saturation in tissues where the saturation levels are too low due to illness or injury. y Increases the amount of oxygen in the blood, reduces the extra work of the heart, and decreases shortness of breath

The patient PRIOR: was relieved y Check for the doctors order from including the flow rate of O2 difficulty of y Check and how to administer for breathing. the oxygen tank, humidifier, and the patient flow rate meter if they are demonstrates working. adequate oxygenation y Place no smoking sign at the head or foot of the bed.

DURING: y y y Assess for kinks and obstruction Secure the tubing, comfortably. Observe for moisture in the mask to prevent aspiration. Observe the pressure necrosis.

AFTER: y Check for clients response to the therapy.

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y y

Check for the skin irritation. Perform after care.

IX.

DRUG STUDY

Name of drug

of Date ordered, Route General action, administration, taken/given Indications/Purpose Classification, dosage, Mechanism of Action Date changed/ D/C frequency Classification: H2 RECEPTOR INDICATION BLOCKER GENERAL ACTION >anti-ulcer MECHANISM ACTION

Client response to the medication, Nursing Responsibilities actual side effects PRIOR Clients response 1. Assess patient for contraindication. 2. Assess for baseline data. 3. Tell patient that he may experience side effects brought about by the drug. DURING 1. Administer the drug slowly. AFTER 1. Instruct him to report intolerable side effects so as
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Generic Name: RANITIDINE Brand Name: ZANTAC

Date ordered: January 25, 2010

80 mg TIV Q8

>Short-term >no abdominal pain treatment of active duodenal ulcer

Maintenance Side effects OF > therapy for duodenal >abdominal ulcer at reduced constipation >Competitively dosage inhibits the action of histamine at the H2 >Short-term receptors of the treatment of active, parietal cells of the

pain,

stomach, inhibiting benign gastric ulcer basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonist, gastrin, and pentagastrin.

prompt intervention could be done. 2. Instruct him to report adverse effects that he may experience.

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Name of drug

Date ordered, Route of General action, taken/given administration, Classification, Indications/Purpose Date changed/ dosage, Mechanism of Action frequency D/C

Client response to the medication, Nursing Responsibilities actual side effects PRIOR

Generic Name: CELECOXIB Brand Name: CELEBREX

Date ordered: January 2010

200 mg PO 27, FOR PAIN

Classification: NONSTEROIDAL ANTIINFLAMMATORY DRUG GENERAL ACTION >Pain reliever

. Indication: >Management of acute pain.

Clients response >verbalized decreased pain felt

1. Take drug with food if GI upset occurs 2. Determine any GI bleed/ulcer history, sulfonamide allergy, aspirin and other NSAIDinduced asthma, urticaria, allergic type reaction 3. Monitor sign and symptoms 4. Assess for liver or renal dysfunction; reduce dose DURING 1. Take with foods; decreases stomach upset

MECHANISM ACTION

>Inhibits prostaglandin synthesis, primarily by inhibiting cyclooxygenase-2 thus decreasing inflammation.

Contraindications: Side Effects: >Contraindicated with allergies to sulfonamides, - headache - dizziness celecoxib, NSAID, or aspirin - insomnia - rash OF - nausea - abdominal pain y

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Name of Drug

Date ordered, taken/given Date changed/ D/C

Route of administration, dosage, frequency

General action, Classification, Mechanism of Action

Indications/Purpose

Client response to the medication, actual side effects

Nursing Responsibilities

Cefazolin

Date ordered: January 25, 2011 >1g. IV >1g. IV Bind to bacterial cell wall membrane, causing cell death. Treatment of: Skin & skin structure infections; pneumonia; urinary tract infections; bone & joint infections >No significant features seen >Normal Assess patient for infection (vital signs; appearance of surgical site, urine; WBC) at beginning and during therapy. Before initiating therapy, obtain a history to determine previous use of and reactions to penicillins or cephalosphorins. Persons with a negative history of penicillin sensitivity may still have an

Active against January 26, 2011 >1g IV q8 (-) ANST many gram-positive cocci including: >1g IV q8 (-) ANST Streptococcus pneumoniae, Group A beta-hemolytic streptococci; Penicillinasproducing staphylococci.

Therapeutic:

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Anti-infectives Pharmacologic: First generation cephalosphorins

allergic response. Obtain specimens for culture and sensitivity before initiating therapy. Observe patient for signs and symptoms of anaphylaxis (rash, pruritis, laryngeal edema, wheezing). Discontinue drug and notify physician or other health care professional immediately if these problems occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in case of anaphylactic reaction. Monitor site for thrombophlebitis (pain, redness, swelling). Change
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sites every 48-72 hr to prevent phlebitis. Instruct patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foulsmelling stools) and allergy. Instruct patient to notify health care professional if fever and diarrhea develop, especially if diarrhea contains blood, mucus, or pus. Advise not to treat diarrhea without consulting healthcare professional.

Date ordered,

Route of administration, dosage, frequency

General action, Classification, Mechanism of

Indications/Purpose

Client response to the medication, actual side effects

Nursing Responsibilities

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Name of Drug

taken/given Date changed/ D/C

Action

Promethazine

Date ordered: January 25, 2011

500mg+ATSO4 0.5mg (pre OR meds)

Selectively blocks H1 receptors, diminishing the effects of histamine on cells of the upper respiratory tract and eyes and decreasing the sneezing, mucus production, itching and tearing that accompany allergic reactions. blocks cholinergic receptors in the vomiting center that are believed to mediate the nausea and vomitting caused by gastric irritation.

Preoperative sedation, treatment and prevention of nausea and vomiting, adjunct to anesthesia and analgesia.

>sedated during OR >Client verbalizes that he was asleep and just remembered awake when he was already at the ward.

y y

Monitor BP, pulse and respiratory rate frequently. Assess level of sedation after administration. Assess patient for nausea and vomiting before and after administration. Administer each 25mg slowly over at least 1 hr. Do not give rectal supp or tabs to children younger than 2 years old because of risk of fetal respiratory depressions Give IM injections deep into muscle Do not administer SQ, tissue necrosis may occur
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Arteriospasms and gangrene of artery may occur when administered intra-arterially. Reduce dosage of barbiturates given concurrently within promethazine by least half. PRESCRIBED FOR: Promethazine is prescribed for treating nausea or vomiting, motion sickness, and allergic reactions and for sedation.

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Name of Drug

Date ordered, taken/given Date changed/ D/C

Route of administration, dosage, frequency

General action, Classification, Mechanism of Action

Indications/Purpose

Client response to the medication, actual side effects

Nursing Responsibilities

Lidocaine

Date ordered: January 25, 2010

(Not specified)

Anaesthetics - Local & General   

Available forms:  Direct injection 10, 20 mg/mL;  IV injection (admixture) 40, 100, 200 mg/mL; IV infusion2, 4, 8 mg/mL;  topical liquid 2.5%, 5%;  topical ointment 2.5%, 5%; t  opical cream 0.5%;

As >No pain felt while antiarrhythmic: on OR/procedure being done Management of Onset: 45-90 Sec.; acute ventricular Duration: 10-20 arrhythmias during Min.; Absorption: Readily cardiac surgery and absorbed from the GI MI (IV use). Use IM tract, mucous when IV membranes, damaged administration is not skin, inj sites, possible or when including muscle; ECG monitoring is poor through intact not available and the skin.; Distribution: Crosses danger of ventricular arrhythmias is great the placenta, bloodbrain barrier and (single-dose IM use, enters breast milk. for example, by Protein-binding: 66% paramedics in a ( 1-acid mobile coronary care glycoprotein).; unit) Metabolism: 90% hepatic; converted to monoethylglycinexyli dide and

>Monitor BP, pulse and respiratory rate frequently.

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 topical gel 0.5%, 2.5%;  topical spray 0.5%, 10%;  topical solution 2%, 4%;  topical jelly2%; injection 0.5%, 1%, 1.5%, 2%, 4%, 5%; patch varies

glycinexylidide. Firstpass metabolism is extensive, bioavailability after oral dose is approx 35%.;  Excretion: Via urine (<10% unchanged). Elimination half-life: biphasic; initial: 7-30 min; terminal: 1.5-2 hr (adults), 3.2 hr (infants, premature infants).

As anesthetic: Infiltration anesthesia, peripheral and sympathetic nerve blocks, central nerve blocks, spinal and caudal anesthesia, retrobulbar and transtracheal injection; topical anesthetic for skin disorders and accessible mucous membranes

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Name of Drug

Date ordered, taken/given Date changed/ D/C

Route of administration, dosage, frequency

General action, Classification, Mechanism of Action

Indications/Purpose

Client response to the medication, actual side effects

Nursing Responsibilities

Parecoxib

Date Ordered: Januray 26, 2011

40mg IV OD x 2doses

Nonsteroidal Antiinflammatory Drugs (NSAIDs) Parecoxib is the prodrug of valdecoxib. It has a very high selectivity for inhibiting cyclooxygenase-2 (COX2) mediated prostaglandin synthesis to reduce mediators of pain and inflammation. The selective inhibition of COX-2 is coupled with reduced GI toxicity, but associated increased risk for thrombotic events and renal impairment have been noted. Distribution:

Post-op pain

>Tolerable Pain is noted

Before initiating therapy, obtain a history to determine previous use of and reactions to NSAIDs.

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Plasma protein binding: approx 98%. Metabolism: Hydrolysed in the liver to its active metabolite, valdecoxib, and propionic acid; plasma half-life: 22 min. Excretion: Via urine; approx 70% of a dose appearing as inactive metabolites, <5% of a dose appears as unchanged valdecoxib in the urine. Trace amounts of unchanged drug in faeces. Elimination half-life: 8 hr.

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X.

NURSING PRIORITIZATION

Nursing Diagnosis

Prioritization

Rationale

Acute Pain

High Priority

Acute pain neither belongs to airway, breathing, nor circulation (ABCs) of the body. However, based on Maslows Hierarchy of Needs, physical aspects of an individual belong to safety and security needs, which is the second level. If pain is present in the body, an individual may not feel safe and might be anxious about his health condition. This is the reason why it is considered as a high priority problem.

Impaired Tissue Integrity

Medium Priority Skin integrity neither belongs to airway, breathing, nor circulation (ABCs) of the body although it can lead to infection when a deviation from normal occurs. For the moment, the nurse does not need to address this problem. In addition, based on Maslows Hierarchy of Needs, physical aspects of an individual belong to safety and security needs, which is the second level. Skin is a large part of it. This is the reason why it is
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Impaired Physical Mobility

Low Priority

considered as a medium priority problem.. Impaired physical mobility neither belongs to airway, breathing, nor circulation (ABCs) of the body. In addition, based on Maslows Hierarchy of Needs, physical mobility is linked with physical aspect (safety and security needs) of an individual. But for the moment, the nurse may not address this problem. This is the reason why it is considered as a low priority problem.

XI.

NURSING CARE PLAN

Cues

Nursing diagnosis

Scientific Knowledge

Planning Short term goal:

Implementation

Rationale

Evaluation Short term goal:

Acute pain related to Accident injury as evidenced Subjective cue: by verbal report of Makirot ang braso pain. ko, as verbalized by the patient. Arm fracture Objective cues: > Pain scale of 7 out of 10

After 4 to 6 hours Independent: of nursing intervention the > Noted location of patient will be able surgical procedures. to verbalize methods that provide relief.

Long term goal:

After 4 to 6 hours of nursing > this can influence intervention the the amount of patient was able to postoperative pain verbalize methods experienced. that provide relief. Goal met. > to rule out worsening of > Performed pain underlying condition. assessment each time
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> Facial grimace > Guarded behavior > Vital signs: BP- 120/90mmHg T- 37.5C PR- 87bpm RR- 17cpm Pain mediators activation Nociceptors activation

After 1 week of pain occurs. nursing intervention the client will be able to report that pain is > Accepted clients > Pain is a subjective relieved/ controlled. description of pain. experience and cannot be felt by others. > Observed for > Observations may/ nonverbal cues (e.g., may not be facial expression) congruent with verbal reports indicating need for further evaluation. > Monitored signs. vital > usually altered in acute pain.

Long term goal: After 1 week of nursing intervention the client was able to report that pain is relieved/ controlled. Goal met.

Irritation endings

of

nerve

Dependent: Acute pain to maintain > Administered > analgesics as acceptable level of indicated to maximal pain. dosage as needed. Reference: Reference: Brunner & Suddarths Textbook of Medical-Surgical Nurses Pocket Guide, Doenges, Moorhouse, Murr. pg. 388-391

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Nursing pg.220

Cues

Nursing diagnosis

Scientific Knowledge Accident

Planning

Implementation

Rationale

Evaluation

Subjective cue:

Impaired tissue integrity related to surgery as evidenced by damaged tissue.

Short term goal: After 2 to 3 hours of nursing Fracture intervention the client will be able to verbalize understanding of condition and Bleeding from causative factors. damaged ends of bone and from surrounding tissue Long term goal:

Independent: > Recorded size, > provides color, smell, comparative location, baseline. temperature, texture, of wounds if possible.

Short term goal:

Objective cues: > Damaged tissue (e.g., integumentary)

After 2 to 3 hours of nursing intervention the client was able to verbalize understanding of condition and > Inspected wounds causative factors. > promotes timely daily for changes. intervention/ revision Goal met. of plan of care. to > Promoted good > nutrition with healing. adequate protein and calorie intake, and vitamin supplements. facilitate Long term goal:

Impaired integrity

After 7 days of nursing intervention the client will be able tissue to demonstrate behavior changes to promote healing and > Practice aseptic technique for prevent cleaning and complications. dressing wounds

After 7 days of nursing intervention the client was able to demonstrate behavior changes to promote healing and prevent complications. Goal > reduces risk of met.
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> Promote mobility.

early cross- contamination.

> to circulation excessive pressure.

promote and tissue

Reference: Nurses Pocket Guide, Doenges, Moorhouse, Murr. pg. 561-564

Reference: Brunner & Suddarths Medical-Surgical Nursing pg. 2079s

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Cues

Nursing diagnosis

Scientific Knowledge

Planning Short term goal:

Implementation

Rationale

Evaluation

Subjective cue:

Impaired physical Accident mobility related to musculoskeletal impairment as evidenced by limited range of motion. Fracture

Objective cues: > Limited range of motion > Slowed movement > Engages in substitutions for movement (e.g., increased attention to others activity)

After 2 to 3 hours of nursing intervention the client will be able to verbalize understanding of situation/ risk factors and individual treatment regimen Bleeding from and safety measures. damaged ends of bone and from surrounding tissue Long term goal:

Independent: > Observed movement when client is unaware of observation.

> to note any incongruencies with Short term goal: reports of abilities. After 2 to 3 hours of nursing intervention the client was able to verbalize understanding of situation/ risk factors and individual treatment regimen and safety measures. Goal met.

> to maintain position of function and reduce risk of > Supported affected pressure ulcers. body part. (e.g., arm sling) > to include pressure area management.

> enhances self> Provided regular concept and sense of After 2 weeks of skin care. independence. nursing intervention the client will be able Stimulates intense to maintain strength inflammatory Encouraged > promotes welland function of > response participation in self- being and maximizes affected body part. care. energy production.

Long term goal: After 2 weeks of nursing intervention the client was able to maintain strength and function of affected body part. Goal met.

Edema

> Encouraged adequate intake of fluids/ nutritious foods.

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Reference: Pain . Nurses Pocket Guide, Doenges, Moorhouse, Murr. pg. 352-355

Impaired mobility

physical

Reference: Brunner & Suddarths Medical-Surgical Nursing pg. 2079

XII.

DISCHARGE PLANNING

GENERAL CONDITION OF THE CLIENT UPON DISCHARGE The client can tolerate light activities and was able to ambulate. MEDICATIONS The client was instructed to continue his oral medications: Celecoxib Ceafazolin
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y y

EXERCISES The client was instructed to ambulate and do light exercises. Ambulation is for normal circulation and light exercises to limit fatigue. TREATMENT The patient still advised to undergone oxygen therapy since his breathing is still not normal although he only has slight DOB. Also, he needs to monitor his laboratory tests and ECG results to know the progression of his illness. HEALTH TEACHING -Continuous intake of oral meds based on the doctors order -Manage Stress OUT-PATIENT The client is required to attend the follow-up check-up. It usually includes the visualization of his bones. DIET The client is on diet as tolerated. Rich in vitamin c, protein, iron- for the faster wound healing.

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XIII. Health Teachings

Goal: To help the patient understand fully what closed incomplete fracture is and how to manage it.

LERARNING OBJECTIVE/S After 30-45 hour of health teaching, the patient will be able to:

LEARNING CONTENT

METHOD OF INSTRUCTION Lecture-Discussion

TIME ALLOTMENT 30-45 minutes

RESOURCES

EVALUATION &

Smeltzer, S.C., Bare, Question B.G. Medical-Surgical AnswerNursing (10th ed. Vol. Explanation 2) Page 2079-2083

1.Verbalize understanding of what closed incomplete fracture is

Fracture is a break in the continuity of bone and is defined according to its type and content. Fractures occur when the bone is subjected to stress greater than it can absorb. Closed incomplete fracture involves a break only the part of the cross-section bone and doesnt cause a break in the skin.

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2.Enumerate causes of Causes of fracture fracture  direct blows  crushing forces  sudden twisting motions  extreme muscle contractions

3.Determine manifestations fracture

of

 

 

Pain, continuous and increases in severity until the bone fragments are immobilized. Loss of function, the extremity cannot function properly, because normal function of the muscles depends on the integrity of the bones to which they are attached. Deformity, displacement, angulations, or rotation of the fragments in a fracture of the arm or leg causes a deformity (either visible or palpable) that is detectable when the limb is compared with the uninjured extremity. Shortening, there is an actual shortening of the extremity because of the contraction of the muscles that are attached above and below the site of the fracture. Crepitus, a grating sensation upon examination of the extremity. Swelling and discoloration
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Management for closed incomplete fracture  4.Determine management for closed incomplete  fracture   Describe approaches to control swelling and pain (elevate extremity to heart level; take analgesics as prescribed) Consume diet to promote healing Avoid excessive use of injured extremity State indicators of complications to report promptly to physician

XIV. Conclusion

will encounter patient with an arm fracture and underwent an OR plating, As partial fulfillment of our requirement, we had learned so much in handling our client with an arm fracture and underwent an OR plating like giving the best care to the best way that we can. We attained and follow certain standards and rules to promote the nurse patient interaction. With this case study, we gain knowledge that we can surely use in the near future ahead. All we do to our client is the summary of what we have learned in lectures in school.. We do manage our time to give sufficient care to our beloved client. We believed that client is our work and we have the responsibility to attend to their needs and serve them as best as we can. We are able to provide health teaching about the proper health care to our client. We started having an interview by building trust to our client because at first, he doesnt like to share some information to us. But, as time goes by, we were able to let our client share some information that will be very useful in this case studies.

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XV.

References/Bibliography

Book References y y y y y y y y Fundamentals of Nursing, Process and Practice 7th edition By Barbara Kozier,Glenora Erb, Audrey Berman, Shirlee Synder Essentials of Pathophysiology Concepts of Altered Health Pathophysiology Medical-Surgical Nursing, Brunner and Sudarths 12th Edition Nursing Diagnosis Handbook 8th Edition PPD Drug Handbook, Lipincott Anatomy and Physiology 4th edition, Jane Marieb Nurses Pocket Guide, Diagnoses, Prioritized Interventions, and Rationales, Marilyn Doenges, Mary Frances Moorhouse, Alice C. Murr

Electronic References y y y www.davidnelson.md www.drugs.com www.wrongdiagnosis.com

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