Jose C.

Feliciano College Foundation

Dau Exit, NLEX, Dau Mabalacat Pampanga
Institute of Nursing, Midwifery and Nursing Aide
Academic Year 2011 2012

Debridement Suture
A Case Study
In Partial Fulfillment of the Course Requirement
In Related Learning Experience

Prepared by
Tuazon, Christine Jhoy Canlas
Mercado, Jennifer
BSN III

Prepared For
Mr. Erwin Pernia, RN
Instructor

TABLE OF CONTENTS

I.

II.

III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
XII.
XIII.

Introduction
A. Current trend
B. Reason for choosing the case
Nursing Assessment
A. Personal history
B. History of the past and present illness
C. Family Health illness
D. Physical Examination
Anatomy and Physiology
Pathophysiology
Medication
Diagnostic and Laboratory Procedure
Diet
IVF
Nursing Care Plan
SOAPIE
Discharge
Conclusion and Learning derived
Bibliography

I.

Introduction
A. Current trend
B. Reason for choosing the case
The reason why we choose our patient Mr. Damon as our subject for our case presentation is because his
medical diagnosis, which is S/P debridement suture, is a common condition. This study will provide us as
nursing student with concrete and significant information regarding the fracture condition with the emphasis
on the management and nursing care given to patients having the same diagnosis.
This also helps in enhancing the skills of the member of the health care team in disseminating
information to prevent the occurrence of the fracture, as well as early prevention of further complications when
the condition is already present.
Lastly, this study will contribute to the improvement of the standards of nursing practice and the quality
of care given to such patients, thereby keeping with latest trends in care management.

II.

Nursing Assessment
A. Personal history
Damon Salvatore, a 18 year old Filipino, was born on January 10, 1993, the 2 nd to the youngest among the
4 children of Mr. and Mrs. Salvatore both Filipino descent.
B. History of the past and present illness
According to his mother Mrs. Salvatore, Damon was never been admitted in hospital since he was a child
none of her children was admitted in the hospital only for now because of the accident Damon
encounter.
C. Family Health illness

D. Physical Examination

III.
IV.

Anatomy and Physiology

Pathophysiology

V.

Medication
Medication

Cefuroxime

Dosage/Route

Date ordered
Date
prescribed
Date given

Indication

Cefuroxime is
used to treat
certain
infections
caused by
bacteria, such
as bronchitis;
gonorrhea;
Lyme disease;
and infections
of the ears,
throat, sinuses,
urinary tract,
and skin.
Cefuroxime is
in a class of
medications

Client
response

called
cephalosporin
antibiotics. It
works by
stopping the
growth of
bacteria.
Antibiotics will
not work for
colds, flu, or
other viral
infections.
Ranitidine

Ranitidine is
used to treat
ulcers; gastro
esophageal
reflux disease
(GERD), a
condition in
which
backward flow
of acid from the
stomach causes
heartburn and
injury of the
food pipe
(esophagus);

and conditions
where the
stomach
produces too
much acid, such
as ZollingerEllison
syndrome.
Over-thecounter
ranitidine is
used to prevent
and treat
symptoms of
heartburn
associated with
acid
indigestion and
sour stomach.
Ranitidine is in
a class of
medications
called
H2 blockers. It
decreases the
amount of acid
made in the

stomach.
Tramadol

Tramadol is
used to relieve
moderate to
moderately
severe pain

Celecoxib

Celecoxib is a
nonsteroidal
antiinflammatory
drug (NSAID).
It works by
reducing
hormones that
cause
inflammation
and pain in the
body.
Celecoxib is
used to treat
pain or
inflammation
caused by many

conditions such
as arthritis,
ankylosing
spondylitis,
and menstrual
pain. Celecoxib
is also used in
the treatment of
hereditary
polyps in the
colon
Gentamycin

Gentamycin is
an antibiotic. It
fights bacteria
in the body.
Gentamycin is
used to treat
severe or
serious
bacterial
infections.

Ceftriaxone

Ceftriaxone
injection is
given before
certain types of
surgery to
prevent
infections that
may develop
after the
operation.
Ceftriaxone
injection is in a
class of
medications
called
cephalosporin
antibiotics. It
works by
killing bacteria.
Antibiotics will
not work for
colds, flu, or
other viral
infections.

Promethazine

Promethazine
is also used to
prevent and

control nausea
and vomiting
that may occur
after surgery,
and with other
medications to
help relieve
pain after
surgery.
Promethazine
is also used to
prevent and
treat motion
sickness.
Promethazine
helps control
symptoms, but
will not treat
the cause of the
symptoms or
speed recovery.
Promethazine
is in a class of
medications
called
phenothiazines
. It works by
blocking the

action of a
certain natural
substance in
the body.
Famotidine
Furosemide

VI.

Diagnostic and Laboratory Procedure

Diagnostic
Lab.
procedure

Indication

Date
ordered
Date result

Result

Normal
values

Hemoglobin

Hemoglobin is a
protein inside
red blood cells
that carries
oxygen. A
hemoglobin test

DO
DR- 6/24/11
DO
DR- 7/2/11
DO

164

M- 125-175
g/l
F- 115-155
g/l

77
92

Analysis/
interpretation

Hematocrit

reveals how
much
hemoglobin is in
a person's blood.
This information
can be used to
help physician's
diagnose and
monitor anemia
(a low
hemoglobin
level) and
polycythemia
vera (a high
hemoglobin
level).

DR- 7/6/11
DO
DR- 7/7/11
DO
DR- 7/12/11

Hematocrit is a

DO
DR- 6/24/11
DO
DR- 7/2/11
DO
DR- 7/6/11
DO
DR- 7/7/11
DO

blood test that

measures the
percentage of the
volume of whole
blood that is
made up of red
blood cells. This

104
115

.49
.23
.25
.28

M-0.40- 0.52
F- 0.38- 0.48

measurement

DR- 7/12/11

.34

DO
DR- 6/24/11
DO
DR- 7/2/11
DO
DR- 7/6/11
DO
DR- 7/12/11

19.1

depends on the
number of red
blood cells and
the size of red
blood cells.
The hematocrit
is almost always
ordered as part
of a complete
blood count.

WBC count

The WBC count

is used to
determine the
presence of an
infection
or leukemia. It is
also used to help
monitor the
bodys response
to various
treatments and to
monitor bone

10.6
10.0
7.1

5-10 x 10/
L

marrow function
.
Neutrophils

A neutrophils
test helps us
detect the levels
of neutrophils in
our body. These
neutrophils are
an integral part
of our immune
system and
through a
process called
chemotaxis; they
reach any place
where an
infection has
occurred. These
cells take about
an hour to reach
the site of
infection. In fact,
they are one of
the main
components of
pus and are to
blame for its

DO
DR- 6/24/11
DO
DR- 7/2/11
DO
DR- 7/6/11
DO
DR- 7/12/11

.88
.80
.80
.68

0.45-0.65

whitish color
Lymphocytes Leukocyte (white
blood cell) that
normally makes
up about 25% of
the total white
blood cell count
but can vary
widely.
Lymphocytes
occur in two
forms: B cells,
which produce
antibodies, and
T cells, which
recognize
foreign
substances and
process them for
removal.

DO
DR- 6/24/11
DO
DR- 7/2/11
DO
DR- 7/6/11
DO
DR- 7/12/11

.12

Platelet
count

DO
DR- 6/24/11
DO
DR- 7/6/11

275

To diagnose
a bleeding
disorder or
a bone marrow
disease

0.20-0.35

.20
.20
.32

540

150-400 x
10/L

VII.

Diet
Type of diet

General
description

Indication/Purpos
e

Date ordered
Date started
Date changed

Client
response

NPO

(Nothing per
Orem) No food
or liquid is
allowed to be
eaten by the
patient

>to reduce gastric

secretions related
to abdominal pain.
>to prevent
aspiration during
surgery.
>to eliminate
nausea and
vomiting

DO
DS
DC

Patient felt
hungry

DAT

(Diet as
tolerated)
introduction of
diet that can be
tolerated by
the patient and
the regular
foods that are
taken by the

>is only given

when client can
now tolerate any
food she desires
that is nutritious
>if this will not
lead to any
complications >

DO
DS
DC

Patient was
able to regain
nutrients and
strength.

patient

if the client needs

further monitoring
for lab test

VIII.
IVF
IX. Nursing Care Plan
X. SOAPIE
#1 (actual soapie)

S>
O > Received patient on bed in supine position conscious and coherent w/ ongoing IVF of D5LRs 1L @ 700 cc level
in the right hand infusing well regulated @ 30 31 gtts/min. v/s taken as follows
B/P- 120/80 RR- 21 PR- 77 Temperature 36.5
>Right leg w/ dry and intact dressing
> (-) pale skin
> (+) UO
> (-) bowel movement
> afebrile

A > Impaired physical mobility r/t musculoskeletal impairment

P > after 4 of NPI the patient will verbalize understanding of situation and individual treatment/safety measures

I > Established rapport

>v/s taken ad recorded
>due meds given
>determined diagnosis that contributes to immobility
>assessed movement
>Noted behavioral and emotional response
>instructed patient not to eat anything after 12 noon
>seen on rounds by Dr. Aldaba @ 7:30 am w/ orders and carried out
>NPO past 12 noon
>for emergency redebridement
>scene consent
>inform AROD for procedure
>Endorsed

E> After 4 of NPI goal met as evidenced of patient verbalized understanding of situation and individual
treatment/safety measures

#2
S>
O > received patient o supine position conscious and coherent w/ IVF of D5LRS 1L @ 500 cc level infusing well on the
right hand regulated @ 30-31 gtts/min v/s taken as follow:
B/P- 120/70 RR- 20 PR- 76 Temp. 36.8
A > risk for infection r/t inadequate primary defense manifested by broken skin
P > after 2 of nursing intervention the patient will gain knowledge in infection control as evidenced by discussing
the wound care.
I > established rapport
> v/s taken and recorded
> due meds. given
> wound care done @ 9 am
> observed for localized sign of infection
> instructed patient S.O to have proper hygiene when cleaning the wound/suture
> teached proper hygiene
> endorsed
E > goal met as evidenced by patient identified intervention to prevent or reduce risk of infection
XI.
Conclusion and Learning derived
XII.
Bibliography

http://wiki.answers.com/Q/Why_diet_as_tolerated_is_given_to_a_patient
http://wiki.answers.com/Q/What_is_NPO
http://www.surgeryencyclopedia.com/Fi-La/Hemoglobin-Test.html
http://www.nlm.nih.gov/medlineplus/ency/article/003646.htm
http://labtestsonline.org/understanding/analytes/wbc/tab/test
http://www.medicalhealthtests.com/blood-tests/neutrophils-blood-test.html
http://labtestsonline.org/understanding/analytes/cbc/tab/test
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601206.html
http://www.drugs.com/celecoxib.html
http://www.drugs.com/mtm/gentamicin.html