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A CASE STUDY OF A PATIENT WITH COMMINUTED FRACTURE CLOSED DISTAL THIRD FEMUR

A Case Study Presented to the Faculty of the College of Nursing Cebu Normal University

In Partial Fulfillment of the Requirements in Medical-Surgical Nursing (NCM 105)

By Macayan, Jellou Ray M.

October 2011

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ACKNOWLEDGEMENT

I would like to express my heartfelt gratitude to all those who helped me in making this case study a possibility. First of all I would like to thank the almighty God for giving me the strength and courage to complete this research even when faced with challenges, boredom and indiscretions. To Miss Bertilia F. Pragados for giving me the permission to make this case in the first instance, to do the necessary research work and for the constant reminders and pointers you have given me for this study—thank you mam! Also I would also like to extend my sincere thanks to Miss Elaiza R. Cabunoc of the Vicente Sotto Memorial Medical Center Radiology Department for the kind accommodation and for allowing me to recover patient’s diagnostic files. I would also like to take this opportunity to thank my fellow researcher Miss Emy Jane Pilapil, Cherish Cyrill, Oraiz and Miss Sonia Rufa Singson and Miss Cybelle Caramba whose help, stimulating suggestions and encouragement inspired me in all the time of research for and writing of this case study and mostly for the company upon gathering relevant information for the study. I am also deeply indebted to my co-researcher Miss Alona Minque who looked closely at the final version of the case study for English style and grammar, correcting both and offering suggestions for improvement. And most especially, I would like to give my special thanks to my family whose patient love enabled me to complete this work.

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TABLE OF CONTENTS Page Title Page--------------------------------------------------------------------------------------------------------- i Acknowledgement --------------------------------------------------------------------------------------------- ii Table of Contents ---------------------------------------------------------------------------------------------- iii List of Figures --------------------------------------------------------------------------------------------------- v Chapter 1 – Introduction ------------------------------------------------------------------------------------- 1 Chapter 2 - Patient’s Profile Background/History --------------------------------------------------------------------------------- 3 Patient’s Vitae ---------------------------------------------------------------------------------------- 4 Functional Health Patterns ------------------------------------------------------------------------ 4 Physical Assessment ------------------------------------------------------------------------------- 5 Chapter 3 - Anatomy and Physiology --------------------------------------------------------------------- 8 Chapter 4 - Psychopathophysiology Schematic Diagram -------------------------------------------------------------------------------- 15 Narrative ---------------------------------------------------------------------------------------------- 16 Chapter 5 - Management Medical Laboratory Procedures ---------------------------------------------------------------- 18 Diagnostic Procedures ---------------------------------------------------------------- 19 Drug Study ------------------------------------------------------------------------------- 21 Surgical ----------------------------------------------------------------------------------------------- 21 Nursing Summary of Nursing Problems --------------------------------------------------- 22 Individualized Nursing Care Plan -------------------------------------------------- 22 FDAR Charting ------------------------------------------------------------------------- 25 Discharge Summary with Collaborative Nursing Function ------------------- 25

43 APPENDIX F (Drug Study—celecoxib) --------------------------------------------------------.58 APPENDIX P (Approval for Final Printing and Book Binding of Case Study) ------.55 APPENDIX M (FDAR day 2) --------------------------------------------------------------------.53 APPENDIX L (FDAR day 1) ---------------------------------------------------------------------.51 APPENDIX K (NCP day 3) ----------------------------------------------------------------------.Evaluation and Recommendation ------------------------------------------------------.59 Curriculum Vitae ----------------------------------------------------------------------------------------------.57 APPENDIX O (Approval for Case Study) ----------------------------------------------------.48 APPENDIX J (NCP day 2) -----------------------------------------------------------------------.46 APPENDIX H (Drug Study—cefuroxime) -----------------------------------------------------.31 Appendices ------------------------------------------------------------------------------------------------------.29 Bibliography -----------------------------------------------------------------------------------------------------.56 APPENDIX N (FDAR day 3) ---------------------------------------------------------------------.iv Chapter 6 .60 .39 APPENDIX C (Urinalysis) -------------------------------------------------------------------------.47 APPENDIX I (NCP day 1) ------------------------------------------------------------------------.32 APPENDIX A (Physical assessment) ----------------------------------------------------------.45 APPENDIX G (Drug Study—tramadol) --------------------------------------------------------.33 APPENDIX B (Hematologic studies) -----------------------------------------------------------.41 APPENDIX D (Coagulation Profile) ------------------------------------------------------------.42 APPENDIX E (X-ray Report) ---------------------------------------------------------------------.

Anterior surface --------------------------------------------------------------------10 Figure 3 .8 Figure 2 .v LIST OF FIGURES Page Figure 1 .Right femur. Posterior surface -----------------------------------------------------------------.Pathophysiology of fracture (schematic diagram) -----------------------------------------.Right femur.12 Figure 4 .Upper extremity of right femur viewed from behind and above ------------------------.15 .

complete fracture. A broken bone is like a part of self that you knew is the same but just can’t recognize anymore. incomplete fracture. resulting in soft tissue edema. particularly if they are displaced or non displaced. hemorrhage into the muscles and joints. closed fracture. But you really can’t be that same person anymore. Fractures occur when the bone is subjected to stress greater that it can absorb. and damaged blood vessels. open fracture and there are also types of fractures that may also be described according to the anatomic placement of fragments. depressed fracture. and even extreme muscle contractions. Body organs maybe injured by the force that cause the fracture or by the fracture fragments (Brunner’s and Suddarth’s 2004). There are different types of fractures and these include. impacted fracture. Such as greenstick fracture.CHAPTER I INTRODUCTION Being broken opens the door to a possibility--change. transverse fracture and compression fracture. you try to heal yourself to be the same old person. joint dislocation. oblique fracture. crushing forces. during the process of healing. ruptured tendons. The patient would then experience tremendous pain at the site of . adjacent structures are also affected. severed nerves. Comminuted fracture at the Right Distal Third Femur is a fracture in which bones of the distal portion of the femur has splintered to several fragment. A comminuted fracture is one that produces several bone fragments and a closed fracture or simple fracture is one that does not cause a break in the skin. It’s still the same bone. spinal fracture. avulsion. it seems to change. sudden twisting motions. Fractures are caused by direct blows. When you get hurt and broken inside. A part of you has changed. When the bone is broken. A fracture is a break in the continuity of bone and is defined according to its type and extent. Yet.

(d) know the Pathophysiology of the client’s condition.33 fractures per 10. swelling around the area and it may become warm to the touch. (c) determine anatomic and physiologic functions that contributes to the disease. (f) and also identify appropriate nursing interventions to promote wellness for the patient. psychologically and spiritually. Typically the patient cannot bear any weight on the fracture without experiencing significant pain. this case was chosen because of its rapidly increasing incidence in the locality. The incidence of femoral fractures is reported as 1-1. In individuals younger than 25 years and those older than 65 years.2 the fracture. Moreover. a high quality of care will be provided to those people is suffering from symptoms and complications of fracture. emotionally. . (e) determine medical and surgical interventions base on client’s assessment and laboratory results. the estimated incidence rate in the said institution is about 60%. It is very important for the nurses nowadays to be adequately informed regarding the knowledge and skill in managing these conditions. and one of the leading fractures in the Philippines making it the most common form of fracture. Primarily. The incidence of femoral injuries and fractures increases in elderly patients. In Vicente Sotto Memorial Medical Center. there are total of 56 patients out of 94 are diagnosed with femoral fracture within the duration of care. the purpose of this study is to generate knowledge about fracture and how it affects a person physiologically. most cases in the Orthopedic Ward Vicente Sotto Memorial Medical Center involves fracture in the femoral bones and it is inevitable for us nurses to care for these type of patient.000 populations annually. Generally.000 population per year (1 case per 10. Femur fracture affects almost 13 million Americans. the rate of femoral fractures is 3 fractures per 10.000 population). Through the knowledge of this condition. this case study aims to: (a) gather information about client’s past and present condition: (b) assess predisposing and precipitating factors that caused such disease condition.

Blood Pressure (130/90 mm Hg). limitation of movement noted and has the following vital signs. (+) pain on right foot radiating upward. Physical assessment revealed the following findings. Right Hand APLO. Cervical Spine APL. Right Thigh APL and right Knee APL. Claims to have a family history of Hypertension and Diabetes Mellitus on paternal side. Diagnostic procedures done were X-ray Skull APL. the patient sustained injury in right thigh. around 11:03 pm under the care of Dr. had multiple abrasions on anterior and posterior lower extremity. Pelvis AP. Respiratory rate (21 cpm). Temperature (36. Pulse rate (62 bpm). tenderness on the right leg prompted patient to consult Vicente Sotto Memorial Medical Center Emergency Room for medical advice and decided to admit for medical intervention and surgical operation. No known food and drug allergies. 2011. multiple abrasions and hematoma on right lower extremity. He has a chief complaint of Vehicular accident with an admitting diagnosis of Fractured Closed Distal Third Femur Right Comminuted. around 1 pm while driving a motorbike on the way home. Medication given is Celecoxib 200 mg PRN for pain. Dominic Vicuňa. He was admitted on Ward 8 (Orthopedic ward) last July 6. the patient was outbalanced while turning due to darkness of the way and because of drunkenness. Background/History History of Present Illness Few hours prior to admission.7˚C). Chest PA. (-) . History of Past Illness The patient hasn’t been hospitalized before and claims to undergo wound suturing due to another vehicular accident in Carajay District Hospital year 2001.CHAPTER II I. Laboratory procedures done to the patient are Urinalysis and Complete Blood Count.

Male. Graduated Associate Criminology can speak Tagalog and Cebuano. Cebu with wife and 3 children (2 boys and a girl). skin lesions on right posterior leg noted. noted 5 gurgles upon checking bowel sounds. urination is 6-8 times daily. I. T.4 smoking. Vegetables. Married. Worked at City hall resigned after election. does passive ROM exercise on unaffected foot with wife and active ROM exercise on upper extremities. the patient has no food restrictions. usually eats Rice. sleeps at 10 pm and wakes at 7 am. Lapu-Lapu City. Patient usually sleeps at 910 pm and wakes at 6 am.B. Patient states to minimize eating as possible to minimize discomfort and inconvenience during bowel movement. not involved in any social activity. Filipino. dark brown hard stools noted. (+) drugs. currently unemployed and sells chicken. Born on October 23. 32 years old. LapuLapu City. Roman Catholic. patient states some discomfort during sleeping in the hospital which caused by light. noise and constant vital signs monitoring. weighs 79 kilograms and has a height of 5 feet and 5 inches. for elimination the patient’s bowel movement is once every 2 days. Currently residing in Carajay. abdominal assessment reveals distension. (+) alcohol. Beef And Pork. II. Patient understood the purpose of medical intervention and surgical operation such as placement of traction as evidenced by keeping affected part immobilized as possible and minimizing movement and for nutritional and metabolic. constipation noted. weight is 76 kg and height is 5’5’ft. patient is unable to do some ADL’s due restriction of mobility but constantly repositions itself on bed as instructed by nurse or wife. no dehydration noted. use of health-promotion activities such as regular exercise (Passive and active ROM exercises). The Patient is unable to ambulate due to leg fracture. slightly cloudy. Fish.M. no swallowing difficulties. pain. Fish. Beef And Pork. sexually active (3x weekly). 1978 in Carajay. no pain upon urination noted. Vegetables. yellow colored urine noted. Functional Health Patterns Patient was observed to be compliant with medication regimen. typical daily food intake includes Rice. Patient’s Vitae Mr. Patient is able to rest every after . he able to defecate without difficulty.

is assertive and has long attention span. pale conjunctiva. Patient states that he drinks alcohol most of the time and takes drugs (not specified) when he is stressed. retain information. Chest expansion of 5 cm bilaterally noted. Respiratory rate is 21 cycles per minute with normal depths. no adventitious sounds are auscultated. Facial features are symmetrical. make decisions. is not involved with any social groups but has close relationship with neighbors. both are aligned with inner canthus of the eye. midline with incision on parietal area. Able to taste appropriately when food is given. lips are dry and pale. no nasal flaring. Patient is able understand and follow directions. Vesicular sounds heard at peripheral lung fields. III. temporal artery elastic and non tender. states that income is sufficient for their family needs. pupils are midline with each eyeballs. lymph nodes are non tender and movable. no involuntary movement noted. able to read newsprints. bronchial sounds heard on trachea and thorax. and solves problems as evidenced by taking medications religiously on indicated time on his own. anicteric sclera. Patient acknowledges being a husband and father of 3 children. symmetric. no dysphagia or ulcerations noted on oral cavity. Ears are normal in size bilaterally 4 cm.5 meal since the patient is on bed always. Development of sexual characteristics are appropriate with age. patient frequently becomes angry and annoyed about the restrictions and limitation in his activities. tenderness or lesions noted. no hearing difficulty. Bronchovesicular sounds heard over the major bronchi and around the upper sternum. states that his family is always with him when he has problem and it really helped him to handle stress appropriately. Systolic blood pressure of 130 and diastolic blood pressure of 90 noted . Goes to church every Sunday with family. patient states he is sexually active (3x weekly) and has no difficulty having sex. no discharges. Patient is Roman Catholic and states that keeping spirituality within the family is important and enforced in his family. complete set of teeth noted. able to smell appropriately. able to communicate cooperatively with nurse. lives with family and interacts with family member appropriately. erect. Patient is able to maintain eye contact. Physical Assessment Head is normocephalic. Patient feels bad about self and blames himself in the accident. eye movement symmetric and smooth in 6 directions. doesn’t use any contraception. use of accessory muscles noted. round.

able to identify sweet and salty flavor. dull thud heard upon percussion of full bladder. the ratio of anteroposterior diameter to transverse diameter is 2:1. wrinkles forehead and shows teeth without difficulty. Lateral movements of eyeballs are smooth and in coordinated motion. puff out cheeks. sensory functions are equal on both sides. puff out cheeks. no tenderness noted. frowns. eyes move in a smooth coordinated motion. Bladder is not palpable when not full. patient is able to perform finger to nose test. balance is not assessed due to mobility restrictions. Facial movements are symmetrical. nipples are dark brown and equal in size bilaterally. hollows present on both sides of the patella. Able to read newsprint 14 inches away with full visual fields. tenderness. Anterior chest is uniform in color with smooth texture no edema.6 bilaterally while lying. movements are symmetrical. frowns. reflexes are hypoactive on upper extremities (+). pedal pulses is regular and bilaterally equal with a rate of 66 beats minute. Full range of motion on upper extremity and marked limitation of range of motion on lower extremity. breast are symmetrical. discoloration or nodules palpated. Apical pulse is regular with a rate of 66 beats per minute. Able to hear whispered voice 1 meter away with both ears. soft clicks and gurgles at a rate of 5 per minute. urinates daily with a rate of 6-8 times approximately 700cc per day. temporal and masseter muscles contact bilaterally. slightly rigid due to decreased bowel movement. Abdomen is symmetric and slightly rounded with a large tattoo on midline. Reflection of light on the corneas are in the same spot indicating parallel alignment approximately 3mm from inner canthus. Eyelid covers 2mm of the iris. knees symmetric. Gag reflex is intact. not engorged or enlarged. no swelling or bulging of fluid. able to identify sour and . Eyes move in a smooth coordinated motion in an upward and downward motion. umbilicus is midline at lateral line. has full control on movements upper extremity while limited on lower extremity. no neck vein distension noted. smiles. spinous process appear straight and thorax appears symmetric with ribs sloping downward. urine color is yellow with a consistency of slightly cloudy. Joint are non tender. smiles. lower leg aligned with upper leg. scapula are non protruding. umbilical skin tones are similar to surrounding abdominal skin tones. Facial movements are symmetrical. wrinkles forehead and shows teeth without difficulty. Able to identify the scent presented on each nostril. bowel sounds are heard as intermittent. pupils are both reactive and responsive to light accommodation.

no hoarseness of voice noted. Strong and symmetric contractions of Trapezius muscle and there is strong contraction of Sternocleidomastoid muscle on the side opposite the turned face upon turning against resistance. Tongue movement is symmetric and smooth and bilateral strength is apparent. .7 bitter taste Uvula and soft palate rise bilaterally on phonation.

except over an ovoid depression. The neck is a flattened pyramidal process of bone. The angle is widest in infancy. The trochanters. intertrochanteric crest and the gluteal tuberosity. strongest bone in the body. the greater part of its convexity being above and in front. is directed upward. and gives attachment to the ligamentum teres. It is the heaviest. Its proximal end has a ball-like head.CHAPTER III FIGURE 1. The head which is globular and forms rather more than a hemisphere. The femur. and greater and lesser trochanters (separated anteriorly by the intertrochanteric line and posteriorly by the intertrochanteric crest). and forming with the latter a wide angle opening medialward. connecting the head with the body. all serve us sites for muscle attachment. and . Upper extremity of right femur viewed from behind and above. a neck. and a little forward. is the only bone in the thigh. located on the shaft. medialward. coated with cartilage in the fresh state. the fovea capitis femoris. which is situated a little below and behind the center of the head. Its surface is smooth. or thigh bone.

Along the upper part of the line of junction of the anterior surface with the head is a shallow groove. so that it measures one-third more than the antero-posterior diameter. which slopes downward to join the body at the level of the lesser trochanter. in consequence of the increased width of the pelvis. but this varies in inverse proportion to the development of the pelvis and the stature. The vertical diameter of the lateral half is increased by the obliquity of the lower edge.9 becomes lessened during growth. so that at puberty it forms a gentle curve from the axis of the body of the bone. the neck of the femur forms more nearly a right angle with the body than it does in the male. its surface is perforated by large foramina. They are two in number. and is broader and more concave than the anterior: the posterior part of the capsule of the hip-joint is attached to it about 1 cm. to end at the lesser trochanter. In the female. but after full growth has been attained it does not usually undergo any change. the amount of this forward projection is extremely variable. and when the pelvis is wide. and broader laterally than medially. The medial half is smaller and of a more circular shape. but on an average is from 12° to 14°. it varies considerably in different persons of the same age. The posterior surface is smooth. long and narrow. The anterior surface of the neck is perforated by numerous vascular foramina. best marked in elderly subjects. In addition to projecting upward and medialward from the body of the femur. the greater and the lesser. The angle decreases during the period of growth. In the adult. even in old age. and ends laterally at the greater trochanter. It is smaller in short than in long bones. The superior border is short and thick. contracted in the middle. curves a little backward. The trochanters are prominent processes which afford leverage to the muscles that rotate the thigh on its axis. above the intertrochanteric crest. . the neck forms an angle of about 125° with the body. The neck is flattened from before backward. the neck also projects somewhat forward. this groove lodges the orbicular fibers of the capsule of the hip-joint. The inferior border.

in the adult. Above the impression is a triangular surface. Below and behind the diagonal impression is a smooth. situated at the junction of the neck with the upper part of the body. quadrilateral in form. The medial surface. is broad. rough. over which the tendon of the Glutæus maximus plays. and. for the insertion of the tendon of the Obturator externus. The lateral surface. convex. It is directed a little lateralward and backward. and above and in front of this an impression for the insertion of the Obsturator internus and Gemelli. presents at its base a deep depression. the trochanteric fossa (digital fossa). and marked by a diagonal impression. and serves for the insertion of the tendon of the Glutæus medius. is about 1 cm. quadrilateral eminence. It has two surfaces and four borders. it is thick and . lower than the head. The superior border is free. great trochanter) is a large.10 FIGURE 2. irregular. Anterior surface. of much less extent than the lateral. which extends from the postero-superior to the antero-inferior angle. a bursa being interposed. sometimes rough for part of the tendon of the same muscle. Right femur. sometimes smooth for the interposition of a bursa between the tendon and the bone. triangular surface. The Greater Trochanter (trochanter major.

The inferior border corresponds to the line of junction of the base of the trochanter with the lateral surface of the body. and reaching vertically downward for about 5 cm. Its upper half forms the posterior border of the greater trochanter. and is called the tubercle of the femur. it is the point of meeting of five muscles: the Glutæus minimus laterally. and gives attachment to the Quadratus femoris and a few . and gives origin to the upper part of the Vastus medialis. and the tendon of the Obturator internus and two Gemelli above. which gives origin to the upper part of the Vastus lateralis. The anterior border is prominent and somewhat irregular. small trochanter) is a conical eminence. rounded edge. and affords attachment to the iliofemoral ligament of the hip-joint. From its apex three well-marked borders extend. of variable size. The Lesser Trochanter (trochanter minor. A prominence. prominent. below this eminence in the linea aspera. the Vastus lateralis below. two of these are above—a medial continuous with the lower border of the neck. The posterior border is very prominent and appears as a free. the inferior border is continuous with the middle division of the linea aspera. occurs at the junction of the upper part of the neck with the greater trochanter. and its lower half runs downward and medialward to the lesser trochanter. along the back part of the body: it is called the linea quadrata. and marked near the center by an impression for the insertion of the Piriformis. A slight ridge is sometimes seen commencing about the middle of the intertrochanteric’ crest. the intertrochanteric crest. its lower half is less prominent. it affords insertion at its lateral part to the Glutæus minimus. a lateral with the intertrochanteric crest. and ends about 5 cm. which varies in size in different subjects. Running obliquely downward and medialward from the tubercle is the intertrochanteric line (spiral line of the femur). it is marked by a rough. and gives insertion to the tendon of the Psoas major.11 irregular. Running obliquely downward and medialward from the summit of the greater trochanter on the posterior surface of the neck is a prominent ridge. which bounds the back part of the trochanteric fossa. slightly curved ridge. Its upper half is rough. below the lesser trochanter. it projects from the lower and back part of the base of the neck. it winds around the medial side of the body of the bone. The summit of the trochanter is rough.

Right femur. The linea aspera (FIGURE 3. and runs . Of the borders. It presents for examination three borders. and concave behind. marking the attachment of the upper part of the Quadratus femoris. lateral. and the other. The body. The lateral ridge is very rough.) is a prominent longitudinal ridge or crest. Posterior surface. is posterior. the linea aspera. Generally there is merely a slight thickening about the middle of the intertrochanteric crest. the linea aspera. one. almost cylindrical in form. where it is strengthened by a prominent longitudinal ridge. and a narrow rough. intermediate line. It is slightly arched. so as to be convex in front. presenting a medial and a lateral lip. separating three surfaces. is a little broader above than in the center. FIGURE 3. on the middle third of the bone. broadest and somewhat flattened from before backward below.12 fibers of the Adductor magnus. one is medial. Above. the linea aspera is prolonged by three ridges.

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almost vertically upward to the base of the greater trochanter. It is termed the gluteal tuberosity, and gives attachment to part of the Glutæus maximus: its upper part is often elongated into a roughened crest, on which a more or less well-marked, rounded tubercle, the third trochanter, is occasionally developed. The intermediate ridge or pectineal line is continued to the base of the lesser trochanter and gives attachment to the Pectineus; the medial ridge is lost in the intertrochanteric line; between these two a portion of the Iliacus is inserted. Below, the linea aspera is prolonged into two ridges, enclosing between them a triangular area, the popliteal surface, upon which the popliteal artery rests. Of these two ridges, the lateral is the more prominent, and descends to the summit of the lateral condyle. The medial is less marked, especially at its upper part, where it is crossed by the femoral artery. It ends below at the summit of the medial condyle, in a small tubercle, the adductor tubercle, which affords insertion to the tendon of the Adductor magnus. From the medial lip of the linea aspera and its prolongations above and below, the Vastus medialis arises; and from the lateral lip and its upward prolongation, the Vastus lateralis takes origin. The Adductor magnus is inserted into the linea aspera, and to its lateral prolongation above, and its medial prolongation below. Between the Vastus lateralis and the Adductor magnus two muscles are attached—viz., the Glutæus maximus inserted above, and the short head of the Biceps femoris arising below. Between the Adductor magnus and the Vastus medialis four muscles are inserted: the Iliacus and Pectineus above; the Adductor brevis and Adductor longus below. The linea aspera is perforated a little below its center by the nutrient canal, which is directed obliquely upward. The other two borders of the femur are only slightly marked: the lateral border extends from the antero-inferior angle of the greater trochanter to the anterior extremity of the lateral condyle; the medial border from the intertrochanteric line, at a point opposite the lesser trochanter, to the anterior extremity of the medial condyle. The anterior surface includes that portion of the shaft which is situated between the lateral and medial borders. It is smooth, convex, broader above and below than in the center. From the upper three-fourths of this surface the

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Vastus intermedius arises; the lower fourth is separated from the muscle by the intervention of the synovial membrane of the knee-joint and a bursa; from the upper part of it the Articularis genu takes origin. The lateral surface includes the portion between the lateral border and the linea aspera; it is continuous above with the corresponding surface of the greater trochanter, below with that of the lateral condyle: from its upper three-fourths the Vastus intermedius takes origin. The medial surface includes the portion between the medial border and the linea aspera; it is continuous above with the lower border of the neck, below with the medial side of the medial condyle: it is covered by the Vastus medialis.

CHAPTER IV Pathophysiology

Fracture Precipitating factors: Behavior Lifestyle Occupation Environment Traumatic Force Applied To the Right Lower Extremity Risk factors Physical Trauma Due to Motorbike Accident Pre disposing factors: Age Gender

Multiple Abrasions and the Distal 3rd Femur Bone Is Broken Into Fragments (Comminuted)

Nerve at the site of fracture damaged

Fibrous Connective Tissue or Periosteum And Blood Vessels in the Cortex Marrow, And Surrounding Soft Tissues Are Disrupted and Damaged.

Muscle spasm due Fractured bone

Numbness

Bleeding Occurs From the Damaged Bone and From the Neighboring Soft Tissues

Pain and Tenderness

Formation of blood clot Hematoma Stimulation of the Inflammatory Response Pain, Swelling, Redness, Heat, Loss of Function

Limitation of ROM, Mobility and Reduction of ADLS’s FIGURE 4. Pathophysiology of fracture (schematic diagram)

This is why bones can break in many different ways.16 A fracture is a break in the continuity of bone and is according to its type and extent. In the above schema. The blood . and even extreme muscle contractions. depends on the strength of the impact. and what type of bone has been affected. organs may be injured by the force that caused the fracture fragments. sudden twisting motions. The different cases of broken bones could be compound fractures. closed fractures. When the bone is broken. Modifiable Risk factors for this type of fracture is the same as any other fracture which includes behavior such drunk driving which is the actual etiological factor for patient’s accident. the accident also caused multiple abrasions and comminuted fracture in the distal 3rd femur. Occupation and environment involving sun exposure and etc. and fractures caused by pathological diseases such as osteoporosis. forming a Hematoma. The above schema shows a comminuted type of fracture this type of fracture occurs when a bone has been broken into a number of pieces. The above schema also shows the natural process of healing of a fracture which starts when the injured bone and surrounding tissues bleed. Fractures occur when the bone is subjected to stress greater than it can absorb. therefore. Broken bone fragments affects the nerve endings in the surrounding area causing numbness and muscle spasm leading to pain and tenderness thus causing the limitation of Range Of Motion and mobility disabling the patient to perform some activities of daily living. The severity of the fracture. stress fractures.. severed nerves. crushing forces. joint ruptured tendons. other factors which are non modifiable includes Age caused by increased degeneration of bones as age also increases and Gender which mainly is caused by interplay of hormones in the body. adjacent structures are also affected resulting in soft hemorrhage into the muscles and joints. the fracture is caused by a motorbike accident causing physical trauma in the right lower extremity. Fractures are caused by direct blows. the position of the bone when it was hit. and damaged blood. smoking habits and other activity that would affect the body’s bone integrity and calcium levels. lifestyle which basically relates to the nutritional intake.

. Loss of Function and subsequently adds to the limitation Range Of Motion and mobility. Collagen's rubbery consistency allows bone fragments to move only a small amount unless severe or persistent force is applied. In this way the blood clot is replaced by a matrix of collagen. Heat. which gradually remove the non-viable material. Within a few days blood vessels grow into the jelly-like matrix of the blood clot. Swelling.17 coagulates to form a blood clot situated between the broken fragments. Throughout the process of bone healing the body’s inflammatory response is stimulated which is manifested by Pain. The new blood vessels bring phagocytes to the area. Redness. The blood vessels also bring fibroblasts in the walls of the vessels and these multiply and produce collagen fibers.

7 pg over a normal value of 27-31 pg which indicates macrocytic anemia. the flow properties of blood. and the physical relationships of red cells and plasma. It is a group of tests that evaluate the kidneys’ ability to selectively excrete and reabsorb substances while maintaining proper water balance. Mean Corpuscular Hemoglobin which is 32. is used for basic screening purposes.9x10^9/L over a normal value of 4. The results can provide valuable information regarding the overall health of the patient and the patient’s response to disease and treatment. the production of these elements. this could be not directly related to the diagnosis and also an increased basophil and monocyte which indicates bacterial infection and inflammation. It is also concerned with blood volume. Changes in blood components may be evidenced by a patient with fracture such as in Hematocrit it may be increased (hemoconcentration) or decreased (signifying hemorrhage at the fracture site or at distant organs in multiple trauma). Abnormal results during the actual complete blood count result of the patient (see appendix B) includes increased white blood cell count which is 11. Increased white blood cell (WBC) count is a normal stress response after trauma.8x10^9/L this indicates a normal stress response after trauma or it may also that there is an undergoing infection in the fracture site. and the physiological derangements that affect their functions.8-10. Urinalysis Routine urinalysis is one of the most widely ordered laboratory procedures.CHAPTER V MEDICAL MANAGEMENT Laboratory procedures Hematology One of the most important laboratory procedures for patient with fracture is complete blood count or hematology. The urine dipstick has a number of pads on it to indicate various . Hematology is the study of the cellular elements of the blood.

the sample may be refrigerated until it can be examined. Urine that has accumulated in the bladder overnight is more concentrated. Coagulation profile The coagulation proteins respond to blood vessel injury in a chain of events. multiple transfusions. or liver injury. not their place in the coagulation sequence. Diagnostic procedures Bone Radiography . Urine protein is the most common indicator of renal disease. The intrinsic and extrinsic pathways of secondary hemostasis are a series of reactions involving the substrate protein fibrinogen. The factors were assigned Roman numerals in the order of their discovery. If this is not possible. According to the patient’s actual results (see appendix D) all of the parameters evaluated during the coagulation profile fall within normal range. which is associated with renal disease. nonenzymatic cofactors (Ca2+). The specimen for this laboratory procedure is a Whole blood in a completely filled 5-mL blue-top (sodium citrate) tube. and phospholipids. Glucose is used as an indicator of diabetes. Urine samples for routine analysis are best collected first thing in the morning. Failure to observe these precautions may lead to invalid results. the coagulation factors (also known as enzyme precursors or zymogens). The sample should be examined within 1 hour of collection.19 biochemical markers. Specific gravity is a reflection of the concentration ability of the kidneys. thus allowing detection of substances that may not be present in more dilute random samples. According to the patients actual urinalysis results (see appendix C) it showed that all of the parameters evaluated during the analysis are within normal values. Alterations may occur because of blood loss. although there are conditions that can cause benign proteinuria. Urine pH is an indication of the kidneys’ ability to help maintain balanced hydrogen ion concentration in the blood. Hemoglobin indicates the presence of blood. The presence of ketones indicates impaired carbohydrate metabolism.

According to the patients actual diagnostic result (see appendix E) abnormal findings found in the x rays includes soft tissue swelling in the parieto-occipital region this was found out through Skull APL. ligaments. right femur with soft tissue swelling evident on thigh right APL and knee right APL. hip. tomograms. Arthrogram An arthrogram evaluates the cartilage. or dysfunction of a joint monitor disease progression. Normal findings are Normal bursae. After local anesthesia is administered to the area of interest. Contrast medium is inserted into the joint space to outline the soft tissue structures and the contour of the joint. menisci. computed tomography (CT)/magnetic resonance imaging (MRI) scans help visualize fractures. Radiation emitted from the x-ray machine passes through the patient onto a photographic plate or x-ray film. temporomandibular joint. a fluoroscopically guided Small-gauge needle is inserted into the joint space. bone abnormalities. elbow. ankle. evaluate pain. swelling. and articular cartilage of the joint (note: the cartilaginous surfaces . Serial skeletal x-rays are used to evaluate growth pattern. bone abnormalities. differentiates between stress/trauma fractures and bone neoplasms. and soft-tissue damage. bleeding. wrist. or fluid within a joint. and bony structures that compose a joint.20 Bone radiography are used to evaluate extremity pain or discomfort due to trauma. Fluid in the joint space is aspirated and sent to the laboratory for analysis. or fluid within a joint. Arthrograms are used primarily for assessment of persistent. Bone scans. Area of application includes shoulder. radiographs or magnetic resonance images (mris) are obtained. This test is indicated for patients with fracture. Radiation emitted from the x-ray machine passes through the patient onto a photographic plate or x-ray film. Thus this procedure determines location and extent of fractures/trauma. Straightening of the cervical spine due to muscle spasm which was evident on cervical spine APL. Comminuted fracture. After brief exercise of the joint. distal third. skeletal x-rays are used to evaluate extremity pain or discomfort due to trauma. may reveal preexisting and yet undiagnosed fractures. unexplained joint discomfort. knee. Serial skeletal x-rays are used to evaluate growth pattern. X-rays pass through air freely and are mostly absorbed. ligaments. X-rays pass through air freely and are mostly absorbed.

Injury to the ligaments Drug study The only drug prescribed to the patient is Celecoxib 200mg 1tab OD prn for pain. This surgery is done to repair fractures that would not heal correctly with casting or splinting alone. After giving of drug. (c) Instruct patient to take only the prescribed dosage. impaired hearing. SURGICAL MANAGEMENT Open Reduction Internal Fixation An open reduction and internal fixation (ORIF) is a type of surgery used to fix broken bones. During the giving of drug. this can be screws. and (e) assess patient’s pain score. which protects the lining of the GI tract and has blood clotting and renal functions. or pins used to hold the broken bone together. the nurse should (a) check patient’s history of allergies. and (e) Tell patient to report experience of sore throat. (b) Instruct patient to take drug with food to prevent GI upse. This is a two-part surgery. Before the surgery is done the patient has to undergo the . the broken bone is reduced or put back into place. environmental control. Cysts Diseases of the cartilage (chondromalacia). (b) check skin color and lesions. renal function tests. or disintegration) Abnormal findings can be found out in patients with Fracture. This is given to the patient if patient is experiencing headache to manage pain. which is activated in inflammation to cause the signs and symptoms associated with inflammation. swelling in ankles or fingers. An analgesic drug and has anti-inflammatory activities related to inhibition of the COX-2 enzyme. the nurse should: (a) administer drug with food or after meals. and (c) document giving of drug.21 and menisci should be smooth. the nurse should: (a) Provide comfort measures to reduce pain such as positioning. do not increase dosage. (b) establish safety measure if CNS or visual disturbances occur. Next. renal impairment. plates. changes in vision promptly. an internal fixation device is placed on the bone. (d) monitor vital signs. First. without evidence of erosion. Before giving the medication. does not affect the COX-1 enzyme. (c) check CBC. serum electrolytes. and hepatic and CV conditions if any. itching. fever. rash. rods. tears. Arthritis. LFTs. weight gain. (d) Tell patient that he may experience adverse effects such as dizziness and drowsiness.

a spinal anesthetic. Individualized Nursing Care Plan Upon the first day of interaction to the patient the researcher was able to formulate the nursing problems and prioritized as to the most critical nursing focus which is acute pain related to movement of bone fragments secondary to comminuted fracture. conscious. CT scan. and Tetanus shot which depends on the type of fracture and if your immunization is current. It will block any pain and keep you asleep during the surgery. Acute pain related to movement of bone fragments secondary to comminuted fracture. Then. a breathing tube may be placed to help you breathe while you are asleep. with pain score of 7 . General anesthesia may be used. It is given through an IV (needle in your vein) in your hand or arm. The incision will be closed with staples or stitches. or more rarely a local block. the broken bone will be put back into place. 2. a pin. NURSING MANAGEMENT Summary of nursing problems: 1. Next.22 following exams: Physical examination which is to check your blood circulation and nerves affected by the broken bone. A dressing and/or cast will then be applied. awake. the surgeon will wash your skin with an antiseptic and make an incision. Next. (traction) 3. Blood tests. Objective findings that could support the formulated problem include. with foam traction at right foot. communicative. Impaired Physical Mobility related to musculoskeletal impairment secondary to prescribed restrictive therapies. Received patient lying on bed with head elevated. In general. Risk for Trauma (additional injury) related to loss of skeletal integrity and improper placement of traction weights. This will depend on where the fracture is located and the time it will take to perform the procedure. In some instances. Each ORIF surgery differs based on the location and type of fracture. X-ray. a plate with screws. or a rod that goes through the bone will be attached to the bone to hold the broken parts together. coherent. may be used to numb only the area where the surgery will be done.

use of cold/heat packs. quiet environment and calm activities which maximizes use of non-pharmacological techniques for pain relief. limited range of motion observed and with a subjective cue of :”ngol-ngol kaayu ang ako bali” as verbalized. character. Health teaching about non-pharmacological pain management to promote self control and management of pain. this problem problem was identified through analysis of the objective findings which includes. and aggravating factor to rule out for worsening of underlying conditions and development of complication and prevent occurrence. Provision of comfort measures as possible such as touch therapy. with foam traction at right . verbalize and demonstrate techniques that provide pain relief and demonstrate effective use of relaxation techniques as indicated for individual situation after assessment and goal planning the interventions were made which includes assessment level of pain. communicative. coherent. grimaced face noted. During the second day of care. irritability observed. Instruction in and encouragement of usage of relaxation techniques such as focused breathing and imaging to distract patients attention and thus reduce tension. received patient lying on bed with head elevated to 30 degrees. conscious. awake. Dependent and Collaborative nursing management includes Administration of analgesics as to a maximum as needed as indicated by individual situation to maintain acceptable level of pain. the patient will be able to. restlessness noted. constant interaction. Long term goal formulated includes after 3 days of nursing intervention. Instruction patient in use of transcutaneous electrical nerve stimulation units when ordered to maintain acceptable level of pain and comfort and lastly referral to occupational/physical therapy program to promote active role partcipation and enhanced self-control. repositioning. Encouragement in engaging in diversional activities such as socialization with other patients or listening to music which is also used distract attention and reduce tension.23 out of 10. (traction). Observation for non-verbal cues of pain because they may not be congruent with verbal reports and may prompt change in locus of intervention. Short term goal formulated includes after 5 hours of nursing intervention the patient will be able to verbalize pain relief as evidenced by decreased pain score. the researcher was to formulate the following nursing care plan with a nursing focus of Impaired Physical Mobility related to musculoskeletal impairment secondary to prescribed restrictive therapies. location.

communicative. seen SO frequently leaving the patient and subjective cue :”dali ra masabod sa mga mangagi kanang baton a gbitay”. has difficulty in changing position while lying on bed. Short term goal is After 5 hours of nursing intervention. encouragement in participation in self-care. instruct and encourage use of overhead trapeze in mobilizing in the bed to obtain sense of control during movement. high placement of bed observed.24 foot. traction weights placed of walkways. the patient will be able to demonstrate and verbalize proper exercises of the lower extremities & can perform activities of daily living with minimal assistance. the patient will be able to perform activities of daily living at the level of functional capabilities. this was formulated upon analysis of objective findings which includes received patient lying on bed with head elevated. Long term goal includes After 3 days of nursing intervention. Collaborative and dependent nursing interventions include administration medications as needed prior to activity for pain relief to permit maximal effort and involvement in activity and lastly consultation with Occupational therapy as needed to maintain continuity of care after discharge. As verbalized. occupational/diversional/ recreational activities to enhances self concept and sense of independence. Nursing interventions that were formulated include provision of normal range of motion exercises and function of lower extremity which necessary to regain normal mobility of leg to speed up recovery. with foam traction at right foot. inability to walk or stand alone. Third and last nursing care plan for the patient includes a nursing problem which is Risk for Trauma (additional injury) related to loss of skeletal integrity and improper placement of traction weights. conscious. Identification of energy conserving techniques for ADL’s which limits fatigue and maximizes participation in intervention. absence of bed padding noted. absence of side rails noted. difficulty in initiating gait and subjective cue “maglisod man jud kog lihok sa ako lawas” as verbalized. the patient will be able to . provision of proper skin care to decrease risk for decubitus ulcer formation. slowed movement. awake. the patient is reading a newspaper. short term goal formulated is those After 4 hours of nursing intervention. Encouragement of progressive activities according to level of functional capability to increase patient’s use of affected leg. has difficulty in moving the extremities. limited range of motion in the extremities. encouragement adequate intake of fluid and nutrition to promote well-being and energy production. coherent.

coherent. provide adequate area lighting and assist with moving or turning using trapeze becausefailure to accurately assess. As verbalized. intervene and/or refer these these issues can place patients at needless risk and create negligence issues for healthcare practitioner. Collaborative and Dependent nursing interventions includes assistance with treatment of underlying medical/surgical conditions to improve cognition/thinking process. Nursing interventions formulated for this nursing problem includes Identification of factors related to individual situation and identify extent of risk which nfluence the scope and intensity of interventions to manage safety. assessed level of pain. Actions made included. with the following v/s T= 35. Implementation interventions regarding safety issues includes: orientation to environment. P= 86 pm. limited range of motion observed. R= 20 bpm and BP= 120/70 mmHg. placement traction weights at appropriate location away from passageways as possible. Introduced name to the patient. with foam traction at right foot. character and location. to prevent moving the weights causing disaligment of bone fragments. pad bed edges as possible. encouraged to engage in diversional activities such as socialization with others.25 verbalize understanding of condition and recognize need for prevention of injuries and a long term goal of After 3 days of nursing intervention. keep bed in low position. provided comfort measures such as . restlessness noted. with pain score of 7 out of 10. provision quiet environment and reduced stimulation as possible this can help limit confusion or overstimulation. conscious. monitored v/s. irritability observed. communicative. notification of clients decisionmaking ability and level of cognition including functional capability cause this can affects client’s ability to protect self and influences choice of interventions and teaching. awake. grimaced face noted. “ngol-ngol kaau ang akong bali dong”. without IV. Focused charting On the first day of actual care to the patient the researcher utilized the formulated nursing care plan and derived to the focus Acute pain with supporting data of received patient lying on bed with head elevated to 30 degrees. Due medications (analgesics) administered as ordered. the patient will be able to demonstrate appropriate lifestyle changes to reduce risk for injury and maintain condition without additional injury and decrease risk for trauma.5 degree Celsius. positioned properly on bed with head slightly elevated.

absence of side rails noted. documented the v/s and I and O of the patient. encouraged patient to do DBE. As verbalized. interventions done includes. conscious. P= 86 pm. pain score decreased from 7out of 10 to 3 out of 10. Introduced name to the patient. communicative. with the following v/s T= 37 degree Celsius. without IV. absence of bed padding noted. conscious. assisted patient in doing ROM exercises. monitored v/s.5 degree Celsius. limited range of motion in the extremities. As verbalized. slowed movement. traction weights placed of walkways. high placement of bed observed. inability to walk or stand alone. awake. difficulty in initiating gait. assisted patient upon doing gait training. “ maglisod man ko ug lihok dong”. provided comfort measures such as backrub. awake. “dali raman masabaod ang kanang mga bato”.26 backrub. coherent. As verbalized. with foam traction at right foot. P= 62 pm. Introduced name to the patient. consulted with physical or occupational therapist as indicated. R= 20 bpm and BP= 120/70 mmHg. documented the v/s and I and O of the patient after the interaction the patient functionality of the extremities was able to demonstrate increasing as evidenced by turning on bed without assistance and effective usage of overhead trapeze For the last day of care to the patient the researcher utilized the formulated nursing care plan intended for that day which is Risk for additional injury with supporting data of received patient lying on bed with head elevated. positioned properly on bed with head slightly elevated. seen SO frequently leaving the patient. assessed the condition of the patient. supported affected body parts/ joints using pillows/ rolls. coherent. communicative. encouraged patient to do DBE. consulted with physical or occupational therapist as indicated. supported affected body parts/ joints using pillows/ rolls. instructed in proper use of overhead trapeze. instructed SO to . has difficulty in moving the extremities. After the shift :”wa na kaayu sakit ang ako bali dong”. R= 21 bpm and BP= 130/70 mmHg. with foam traction at right foot. without IV. On the second day of nursing care the formulated nursing problem for the charting focuses on Impaired physical mobility with supporting data of received patient lying on bed with head elevated to 30 degrees. assessed the condition of the patient. the patient is reading a newspaper. Interventions done includes. with the following v/s T= 35. has difficulty in changing position while lying on bed.

providing adequate area lighting and padding of side rails as possible. supported affected body parts/ joints using pillows/ rolls. monitored v/s. the researcher stressed to the patient the importance of continuing prescribed medication even after discharge for continuity of care and optimal recovery from condition and recovery. Lapu-Lapu City. married. dosage. the researcher focused on home care management . Discharge summary This is a case of T.Taught about appropriate exercise that can be used by patient such as passive exercise on the lower or affected extremity and active exercise on the upper extremity. 32 years old.B. advised patient to have daily exercise as tolerated such as morning walks assisted by a significant other . consulted with physical or occupational therapist as indicated. around 11:03 pm under the care of Dr. he has a chief complaint of Vehicular accident with an admitting diagnosis of fractured closed distal third femur. advised patient to take a bath daily and wash hands frequently and also advise the significant others to do the same to prevent spread of infection. SO was seen staying with patient most of the time. positioned properly on bed with head slightly elevated. from Carajay.M. taught about signs of infection and when to call for medical emergency. instructed in proper use of overhead trapeze. documented the v/s and I and O of the patient after the interaction the patient was able to demonstrate behaviors to promote safety. provided comfort measures such as backrub. assisted patient in doing ROM exercises. implemented interventions regarding safety issues such as orientation of patient to environment. right. comminuted.27 stay with patient as much as possible. male. frequency. also taught patient and significant other patient about mechanism of action. Cebu. 2011. side effects and adverse reaction of medication prescribed to increase patient and significant other’s knowledge about medication thus increasing compliance. For the discharge instructions. encourage to have . he was admitted on Vicente Sotto Memorial Medical Center ward 8 (orthopedic ward) last July 6. encouraged patient to do DBE. assisted patient upon doing gait training. Dominic Vicuṅa. keeping bed in low position.

milk and other dairy products especially eating green leafy vegetables. meat products. egg. . or frequent light-headedness.28 emergency hotline numbers and transportation facilities ready in case of emergency and advised to return immediately if the following signs occur severe pain. encouraged to eat a well balanced diet including high protein and high calcium for faster bone remodelling and tissue repair which can be found in the following foods. also encouraged to have supplementary vitamins and minerals and lastly encouraged to strengthen spirituality within the family by attending to mass together and praying together. headache. redness. At the end of the shift the patient is still in. swelling.

29 .

Recommendation As a researcher in this case study. He also does some ADL without discomfort. increased pain and elevated temperature and explains basis for fracture treatment and need for patient participation in . afebrile. decreased function. II. urine output adequate and no calf pain reported: Homan’s sign negative. vital signs are stable. hygiene and dressing practices with minimal assistance and denies acute symptoms of stress. the student nurse recommends the patient to adjust in usual lifestyle and responsibilities to accommodate limitations imposed by fracture and to prevent recurrent fractures – safety considerations. such as numbness.CHAPTER VI EVALUATION AND RECOMMENDATION I. ice and analgesic and also the patient was able to demonstrate effective use of relaxation techniques as evidenced by decreased recurrence of pain perception. care. using affected extremity for light activity as allowed. the student nurse observed certain changes from the patient. The patient also exhibits unlabored respirations. On the first day of interaction the patient reports decreased pain with elevation. crutches. methods of safe ambulation–walker. On the third and final day on interaction the patient was seen demonstrating appropriate lifestyle changes to reduce risk for injury such as asking for help from SO upon moving and using trapeze effectively when turning. emphasizes instructions concerning amount of weight bearing that will be permitted on fractured extremity. avoidance of fatigue and proper footwear. alert and oriented. no signs of neurovascular compromise. On the second day of interaction changes observed to the patient include regaining of the patient’s previous range of motion in the leg & demonstrates proper exercises for the lower extremities. reports working through feelings about trauma. Extent of Goal Achievement After 3 days of intervention. The patient is instructed about exercises to strengthening upper extremity muscles If crutch walking is planned.. teaches symptoms needing attention.

30 therapeutic regimen.oriented and having a commitment to the organization. Broadly nursing is accountable to society for providing quality.motivated. Nursing Practice The result of this case study would provide the student nurse with sufficient knowledge. . people. it is important to know all areas of patient are both knowledge and skills to manage effectively in all aspects of their professional nursing practice. nurses are accountable to their patients to promote a maximum level of health. Through this case study. whether self. This would ensure the timely healing of injury and the prevention of complications. More specifically. Nursing Education Education can promote enhancement of professionalism through an on. The patient and the family were also informed that the patient must have an adequate balanced diet to promote bone and soft tissue healing.going learning process. It is important that the proper and ideal managements and interventions are done in order to give a more holistic approach and optimum care to clients with fracture on the right femoral neck. This study would help the student nurse in providing a higher quality of care of patients with the same condition. cost effective care and for seeking ways to improve that care. nurses are likely to become well respected through the formal educational programs. Nursing Research Nursing research is essential for the development of scientific knowledge that enables nurses to provide evidenced-based health care. attitude and skills towards the management of patients with fracture on the right femoral neck.

Rozler. 6th Edition Baltimore: C. Femur Injuries and Fractures. 5th Edition.orthosupersite.F.A davis Doenges. 7th Edtion. from http://emedicine. Retrieved September 18. Fundamentals of Nursing. Deglin. 2002. M. Lippincott Company. Yvonne M. Ltd. A. Diagnosis. Brenda I. 10th Edition Philadelphia: I. 7th Edition. Murtha. (August 21.com/article/824856-overview. and Vallerand. Elaine N. Barbara et al.com/article/90779Cluett. January). M. MD (2011. (July 2008). Davis’ Drug Guide 9th edition. 2004. interventions and rationales. 2011 from http://orthopedics.htm Crist. MD.D. 2001. MD. Pearson Education South Asia Pte. Jonathan. 6th Edition. 2011 from http://www. FACEP.medscape.B.com/od/brokenbones/a/femur.. Femur Fracture. Singapore. Essential of Human Anatomy and Physiology. .. 2011 from http://emedicine. Retrieved august 21.F. Guidelines for Individualizing Patient Care. MD. Incorporated. Potter. M. F. Retrieved September 18. (30 Oct 2008).. Patricia and Perry.. .B Lippincott Company. Fundamentals of Nursing.A. 2005). Brett D. M. James E. Davis Company. Kulkarni Rick. 1998. I. M.V. F. Manual of nursing Practice. Femur Fracture. 2011. Moorhouse. Retrieved August 21. Sandra M. Moorhouse. Della Rocca Gregory J. Treatment of Acute Distal Femur Fractures. 2005. MD. PhD. Douglas F. Mosby and Company.. J. Geissler – Murr. Ho. 2005. Geissler – Murr. Marieb.medscape. Textbook of Medical-Surgical Nursing. “ Nurses Pocket Guide”.. . Nettina. MD. 2004. Internet Sources: Aukerman.about. Suzzane C. Doenges.com/view.31 BIBLIOGRAPHY Book sources: Bare. “ Nursing Care Plans”. 9th Edition (2004). Philadelphia. Sherwin SW. Newyork: AddisonWeatleylongman. Anne.aspx?rid=2979 Keany. and Smeltzer. A. MD.. A.

Appendices .

Pragados BSN. RN Date of approval: ___________________ APPENDIX B . Bertilia F. Right.33 APPENDIX A Cebu Normal University College of Nursing APPROVAL FOR CASE STUDY Name of Student: Macayan.B.M (Initials of Patient) With diagnosis of Fractured Closed. Comminuted (Write the full diagnosis) Year and Section: IV-B Academic Year: 2011-2012 In Ward VIII (Orthopedic Ward) as subject for case study in the undergraduate level. Name and signature of Clinical Instructor: Mrs. Jellou Ray M. Semester: First Semester This is to certify that the student is approved to take the case of T. Distal 3rd Femur.

Jellou Ray M. Semester: First Semester Year and Section: IV-B Academic Year: 2011-2012 This is to certify that the case study has underwent final checking and is approved for final printing and book binding as partial fulfilment for the requirements for graduation. Bertilia F. Name and signature of Clinical Instructor: Mrs.34 Cebu Normal University College of Nursing APPROVAL FOR FINAL PRINTING AND BOOK BINDING OF CASE STUDY Name of Student: Macayan. Pragados BSN. RN Date of approval: __________________ .

centered. affect is appropriate with occasion. Sleeping Habits: sleeps at 10 pm and wakes at 7 am CBC: Yes NONE No Urinalysis: Yes Dentures Watch Money / No NONE NONE Glasses Prosthesis Other NONE Contact Lenses NONE Ring Valuable to Business Office NONE Physical Appearance: Client appears to be on his stated chronological age. moderately paced and culturally appropriate. P. openness noted during conversation with life experiences. Content of Conversation: patient. mild anxiety noted. 2011 TPR: T. Physician In-charge B. foam traction noted at right foot Behavior Exhibited: client is cooperative during the interaction and purposive in his actions. General Admission Information Name of Patient: T. perception of reason for admission. Dominic Vicuña M. patient’s history of past and present illness.21 Clinical Assignment: WARD VIII (orthopedic ward) Inclusive Dates: Age: Time: 11:03 pm 32 years old ERUF Sex: Male Mode: 5’5 Ft Allergies: no known allergies Diet: Diet As Tolerated BP: 130/70 mmhg HT: NONE NONE WT: / 79 kg.M.35 APPENDIX C Physical assessment (actual) Cebu Normal University College of Nursing Cebu City NURSING ADMISSION AND ASSESSMENT Name of Student: Jellou Ray M.37.B. speech is clear. complexion is even. sexual development is appropriate for age. unkempt appearance noted.62 Property: R. educational and cultural background. observed no upper clothing. Dr. prominent tattoo noted on abdomen. topic was focused on patient’s profile. Date: July 6.D. Admission Interview . Pragados A. present condition. Macayan Name of Clinical Instructor: Bertilia F. diaphoresis noted.

Habits: a.) a. beef. 3 times weekly as verbalized Elimination bowel movement: once daily urination: 8-10 times daily 6. 3. usually sleeps at 10pm and wakes up at 7 am. Medical b. Patient’s symptoms as he/she sees them: “ngol-ngol kaayu og hapdos kung masabod ang akong bali”as verbalized by the pt.36 1. running Smoking Eating non-smoker Alcohol drinks 3x weekly Drugs occasionally(as verbalized Breakfast. c. Other (psychiatric. at 2pm patient takes a nap and wakes at 3 or 4 pm.I. Surgical c. Native Language Cebuano and Tagalog . Traumatic Injuries f. Allergies d. Past Medical History (especially as it relates to P. f. 4. fish. Orthopedic NONE Vehicular accident – 2001 – Carajay District hospital ER – wound suturing g. Medication hasn’t been hospitalized before wound suturing – 2001 – Carajay District Hospital-ER no known allergies Celecoxib 200mg 1 tablet prn for pain. vegetables. Lunch And Supper: Rice. Problems in daily living created by symptoms (as patient views them) Patent is unemployed so he helps in raising his children and also in chicken business and because of this condition he can longer attend to this job. etc. e. b. pork and water Social Activity Rest/Sleeping Sexual none but is a basketball player in their place previously Physical Exercise walking and d. active. e.) NONE 5. Social Economic History: a. Patient’s perception of reason for admission: Patient verbalizes that reason for admission was because he sustained a fracture on his lower extremity “nabali akong paa” as verbalized 2.

Civil Status: f. CARDIO-RESPIRATORY: Chest pain (site) NONE Chest pain with exertion Nocturnal dyspnea Known murmur Pleuritic pain Last X-ray JULY 6. 2011 3. DISTAL 3RD FEMUR. Financial Status (what is the impact of current hospitalization) Patient used their family to pay for the finances and also lends money from their friends around the neighborhood for additional financial assistance e. sells chicken and also a landlord d. (+) Diabetes Mellitus 8. Mental Illness and Others (specify) Paternal. TB. HEENT: Headaches Hearing loss Eye pain Eye infection Sinus pain Facial pain Sore throat Nasal-tracheal pain Visions Blurring Bleeding gums Other NONE Diplopia Epistaxis Dentures 2. Cancer.(+) Hypertension. Nursing Review of Systems (circle the appropriate symptoms) 1. CLOSED. Occupation college level (graduate of associate criminology) unemployed.FRACTURE. GASTRO-INTESTINAL: Thirst Heartburn Abdominal pain Hemorrhoids Hernia 4. Primary Physician’s Admitting Diagnosis (indicate P = Probable and C= Confirmed) P.37 b. Education c. RIGHT.FRACTURE CLOSED RIGHT FEMUR C. Living Situation: Married / Lives alone Single Divorced Widow Lives with others (specify) lives with wife and 3 children (2 sons and a daughter 7. GENITO-URINARY: Nausea Difficulty Swallowing Jaundice Other: NONE Vomiting Flatulence Diarrhea Hematemesis Constipation Tarry stool Dyspnea on exertion Edema Cough Sputum Diaphoresis Hypertension Hemoptysis EKG NONE Palpitation . COMMINUTED C. Family History: Heart Disease.

EMOTIONAL: Anxiety Anger Depression Frustration Fear Other (specify) Tremor Voice change Infidelity Heat or Cold intolerance Polydipsia Other NONE Notes: patient is angry. no involuntary movement noted b. ENDOCRINE: Goiter Exopthalmos Change in body contour 8. round. MUSCULO-SKELETAL: Muscle pain Joint swelling Redness Other NONE X-rays 6. symmetric. Penile discharges NONE NONE NONE NONE Last Serology Test 5. temporal artery elastic and non tender. complete set of teeth noted. no dysphagia or ulcerations noted on oral cavity . erect. HEENT a. D. tenderness or lesions noted d. . no discharges. both are aligned with inner canthus of the eye. Mouth and Throat lips are dry and pale. Symmetry Head is normocephalic. pupils are midline with each eyeballs c. NERVOUS: Convulsions Tremor Muscle atrophy EEG NONE Other NONE Syncope Speech difficulty Extremity pain Neck pain Sprains Joint pain Stiffness Deformity Back pain Limited motion Fractured Right Femur Dizziness Limp paralysis Vertigo Paresthesia 7. Eyes and Pupils Facial features are symmetrical. depressed and frustrated about his condition and blames himself for driving while drunk. Ears Normal in size bilaterally 4 cm. midline with incision on parietal area. Nursing Observation 1.38 Dysuria Nocturia Polyuria Burning Male Genital Tract: Pain Other Frequency Hematuria Urgency Stones Lesions NONE Testicular swelling NONE a.

CARDIO-VASCULAR a. Pedal pulses rate per minute (R) 66 beats minute d. urine color is yellow with a consistency of slightly cloudy 7. spinous process appear straight and thorax appears symmetric with ribs sloping downward c. Neck vein distention no neck vein distension noted (L) 66 beats minute 4. Chest expansion Chest expansion of 5 cm bilaterally noted 3. nipples are dark brown and equal in size bilaterally 2. no tenderness noted 5. Anterior chest uniform in color with smooth texture no edema. Apical pulse rate and regularity regular with a rate of 66 beats per minute Standing 130/90 mm Hg c. Breath sounds No adventitious sounds are auscultated. urinates daily with a rate of 6-8 times approximately 700cc per day. SKELETAL a. Anterior Thorax Bowel sounds are heard as intermittent. Bowel Sounds series of intermittent soft clicks and gurgles heard upon auscultation with a rate of 5 per minute. Range of motion Full range of motion on upper extremity and marked limitation of range of motion on lower extremity . tenderness. 1. Tenderness or rigidity 6. Posterior Thorax Slightly rigid due to decreased bowel movement.39 e. not engorged or enlarged. dull thud heard upon percussion of full bladder. Bladder Bladder is not palpable when not full. URINARY a. CHEST a. Breasts and Axillae symmetrical. Lymph nodes lymph nodes are non tender and movable 2. Posterior chest anteroposterior diameter ratio to transverse diameter is 2:1. no tenderness noted b. soft clicks and gurgles at a rate of 5 per minute 3. slightly rigid to decreased bowel movement. discoloration or nodules palpated b. Blood Pressure (R) 130/90 mm Hg (L) 130/90 mm Hg Lying 130/90 mm Hg b. GASTRO-INTESTINAL a. Bronchovesicular sounds heard over the major bronchi and around the upper sternum. scapula are non protruding. Joints Joints are non tender. Vesicular sounds heard at peripheral lung fields c. not engorged or enlarged. no swelling or bulging of fluid b. bronchial sounds heard on trachea and thorax. Breasts breast are symmetrical. RESPIRATORY a. no nasal flaring use of accessory muscles noted b. Depth and Rate Respiratory rate is 21 cycles per minute with normal depths. nipples are dark brown and equal in size bilaterally.

Trigeminal nerve: (Sensory and motor) 1. Eyes move in a smooth coordinated motion in an upward and downward motion e. PERRLA 1. Olfactory nerve: (sensory) 1.40 8. Extra-ocular movements/Pupil reaction to light 1.1 Right eye Eyelid covers 2mm of the iris. Balance balance is not assessed due to mobility restrictions 2.1 Myopia Able to read newsprint 14 inches away with full visual fields 1. NEURO a. Assess direction of gaze.2 Hyperosmia Able to identify the scent presented on each nostril b. Sense of vision (snellen’s chart. Sense of smell (coffee. Assess direction of gaze. puff out cheeks.1 Right eye blinks coordinately Blinks bilaterally upon introduction of cotton to outer canthus 1. Extremities has full control on movements upper extremity while limited on lower extremity b.2 Left eye blinks coordinately 2. Reflexes ( equal or not equal) 1.2 Left eye smooth and in coordination with right eye . Able to read newsprint 14 inches away with full visual fields Oculomotor: (motor) 1.1 Anosmia Able to identify the scent presented on each nostril 1. frowns.) 1. Ability to clench teeth able to clench teeth.2 Hyperopia c. etc. newspaper) 1. Presence of corneal reflexes 1. temporal and masseter muscles contact bilaterally f. Trochlear: (motor) 1. Equilibrium 1. CRANIAL NERVE FUNCTION a. wrinkles forehead and shows teeth without difficulty 2.2 Left eye Eyelid covers 2mm of the iris. Optic nerve: (sensory) 1. Finger to nose patient is able to perform finger to nose test d. Sensory Function (equal or not equal) sensory functions are equal on both sides c. smiles. upward and downward movement of eyeball eyes move in a smooth coordinated motion. lateral movements of the eyeballs 1. Abducens: (motor) 1. vailla. Facial Movements are symmetrical. Motor Function 1. Knees hypoactive (+) Arms hypoactive (+) 9.1 Right eye smooth and in coordination with left eye 1. PERRLA d.

2 Shoulder Strong and symmetric contractions of Trapezius l. Gag reflex is intact j.1 Salty able to identify taste 1. Facial: (Sensory and motor) 1. Spinal accessory: (motor) 1. Sense of taste: Using back of tongue 1.2 Sweet Able identify taste 1. feels awful for the finaces they have to pay for.2 Left ear Able to hear whispered voice 1 meter away 2. Hypoglossal: (motor) 1.2 Sweet able to identify taste 2. Able to stick tongue to midline Tongue movement is symmetric and smooth and bilateral strength is apparent. Ability to swallow (Use tongue blade to elicit gag reflex) Able.4 Raise lower eyebrows able symmetrically h. 10. Hoarseness of voice no hoarseness of voice noted 2.3 Frown able symmetrically 2. Vagus: (Sensory and motor) 1. Sense of hearing 1. Knowledge of Illness . Auditory nerve: (motor) 1. Sensation of pharynx Uvula and soft palate rise bilaterally on phonation Let patient say “ah” and observe(movement of palate and pharynx) k. Behavior client is cooperative and can maintain eye contact during interaction E.41 g. Facial expression 2. Glossopharyngeal: (Sensory and motor) 1.1 Smile 2.1 Right ear Able to hear whispered voice 1 meter away i.1 Head strong contraction of Sternocleidomastoid muscle on the side opposite the turned face upon turning agains resistance muscle 1.2 Puff out cheeks able symmetrically able symmetrically 2. b. Sense of taste: Using back of tongue 1.1 Salty Able identify taste 1. c. Movement of: 1. Communication client is cooperative and is open in sharing information to the nurse Mood/Effect mood is appropriate for action. EMOTIONAL a.

Bathing/Hygiene/Feeding/Toileting related to decreased muscle control Risk for impaired gas exchange related to altered blood flow . Persons responsible for patient Wife. due to vehicular accident causing a sustained injury in right thigh with a chief complaint of pain and multiple abrasions on the lower extremities. Transportation Taxi 4. After further evaluations the patient was diagnosed with fractured. 2. 3. Acute pain related to muscle spasms and movement of bone fragments. ulceration atrophy due to decreased muscle control and utilization 10. 2011 Carajay.M. 32 years old. Anticipated problems Patient is at risk for fall. Traction. Diet Vicente Sotto Memorial Medical Center. (Foam) diet as tolerated including high protein and calcium food 6. Probable Date 2.. Discharge Planning 1. Learning Limitations patient knows about condition and the medical intervention given inclusing reason for temporary immobilization of lower extremities and also the cause of his disability 2. Lapu-lapu city. Impaired physical mobility related to restrictive therapies including foam traction and complete bed rest.42 1. Nursing Problems (in priority) 1. from Carajay. Carajay District Hospital. Nursing Impressions Admitted a case of T. Medications Celecoxib 200mg 1 tablet if experiencing pain 7. comminuted. closed distal 3rd femur right. Family conference Scheduled a home visit with client 9. Destination July 27. Learning needs the patient needs to learn the importance of avoiding driving while he is drunk and also the patient needs to know the seriousness of his condition F. Cebu 3. married. H. Lapu-Lapu city. G. Agencies and Equipment involved 5. 4. male. Risk for neurovascular dysfunction related to interruption of blood flow and tissue trauma 5. fat or blood emboli.B. Self-care deficit. Home visit done by public health nurse . 2 sons and a daughter 8.

78x10^12/L 32.10x10^12/L 27-31 pg 80-94 fl 330-370 g/L 11-16 fl 7.9 fl 7. Dominic Vicuña Blood component Hemoglobin Hematocrit WBC RBC Mean Corpuscular Hgb Mean (MCV) MCHC RDW MPV Platelet Cell Volume Normal values 140-180 g/L 42%-52% 4.4 fl 248x10^9/L Significance Within normal range Within normal range Increased (infection) Within normal range Increased (macrocytic anemia) Within normal range Within normal range Within normal range Within normal range Within normal range Clinical Significance: Abnormal results during the actual complete blood count result of the patient includes increased white blood cell count which is 11. Rodriguez St.43 APPENDIX D Hematologic studies (ACTUAL) Republic of the Philippines Department of Health Regional Health office no. Cebu City Hematologic studies NAME: T.8-10.2-11.7 pg 97 fl 336 g/L 12.8-10.7 Vicente Sotto Memorial Medical Center B.7-11 Actual results 156 g/L 47% 11.70-6..9x10^9/L 4.1 fl 150-450x10^9/L CASE NUMBER: 11-261262 DATE RENDERED: 7.M WARD: VII (orthopedic ward) PHYSICIAN: Dr.9x10^9/L over a normal value of 4. DIFFERRENTIAL WBC count: .B.7 pg over a normal value of 27-31 pg which indicates macrocytic anemia. Mean Corpuscular Hemoglobin which is 32.8x10^9/L 4.8x10^9/L this indicates a normal stress response after trauma or it may also that there is an undergoing infection in the fracture site.

40% Within normal range Within normal range Increased (bacterial infection) Within normal range Increased (inflammation) APPENDIX E Urinalysis (ACTUAL) Republic of the Philippines Department of Health Regional Health office no. Rodriguez St.10% 10.44 Neutrophil Lymphocyte Monocyte Eosinophil Basophil Clinical Significance: The abnormal findings in the WBC differential count includes and increased monocyte which is indicative of a bacterial maybe because of the trauma to the patients extremities during the fracture and also an increased basophil which is indicative of inflammation as evidenced by the swelling on the lower extremities of the patient.7 Vicente Sotto Memorial Medical Center B..60% . Cebu City Urinalysis . 40-70% 19-48% 3-9% 0-7% 0-2% 67.70% .10% 21.

3 seconds 12.B.1% 1. Dominic Vicuna Component PTT control • Control % activity • Control INR PT control • % activity • INR Results 14.8 seconds 102% 1.8-15.1 seconds 110.3-15.025 6.06 CASE NUMBER: 11-261262 DATE RENDERED: 7.M WARD: VII (orthopedic ward) PHYSICIAN: Dr. Rodriguez St.45 NAME: T.M WARD: VII (orthopedic ward) PHYSICIAN: Dr. APPENDIX F Coagulation profile (ACTUAL) Republic of the Philippines Department of Health Regional Health office no.7-11 Normal values 12.8 seconds - Significance Within normal range Within normal range .12 14. Cebu City Coagulation profile NAME: T.7 Vicente Sotto Memorial Medical Center B.B. Dominic Vicuna COMPONENT Color Transparency Specific gravity Ph Glucose Protein RBC WBC Amorphous urates Mucus threads ACTUAL RESULTS yellow Slightly cloudy 1.7-11 SIGNIFICANCE normal normal Within normal range Within normal range normal normal Within normal range Within normal range Normal normal Clinical Significance: all of the parameters evaluated are within normal range.5 Negative (-) Negative (-) 0-2/hpf 0-4/hpf rare few CASE NUMBER: 11-261262 DATE RENDERED: 7..

texture and modelling. Rodriguez St. Cebu City X-RAY REPORT NAME: T.B.M WARD: VII (orthopedic ward) PHYSICIAN: Dr. APPENDIX G X-ray report (ACTUAL) Republic of the Philippines Department of Health Regional Health office no. Dominic Vicuña SKULL APL Findings: The cranial vault is intact.46 Clinical Significance: all of the parameters evaluated are within normal range. bone erosion nor bone destruction. there is no evidence of fracture. Impression: Soft tissue swelling in the parieto-occipital region. CASE NUMBER: 11-261262 DATE RENDERED: 7. the sella turcica is intact.18-11 CERVICAL SPINE APL Findings: The vertebra is normal in height. There is no evidence of . density.. there is a soft tissue swelling in the parieto-occipital region.7 Vicente Sotto Memorial Medical Center B. no abnormal intracranial calcifications is noted.

right femur with soft tissue swelling. texture and modeling. distal third. Impression: Comminuted fracture. distal third. there is no evidence of fracture. texture and modeling. KNEE RIGHT APL Findings: There is a comminuted fracture in the distal third of the right femur with surrounding soft tissue swelling. both hip and sacro-iliac joint are within normal limits. The joint spaces are within normal limits. The pre-vertebral soft tissue space is within normal limits. Impression: Normal bones and joints of the hips HAND RIGHT APLO Findings: The bones normal in density. THIGH RIGHT APL Findings: There is a comminuted fracture in the distal third of the right femur with surrounding soft tissue swelling. the rest of the bone are normal in density. right femur with soft tissue swelling . there is no evidence of fracture. texture and modeling. Impression: No significant chest findings. The trachea is at midline. The osseous thoracic cage showed no bony abnormality. bone erosion nor bone destruction. CHEST PA Findings: Both lung fields are clear. Heart is normal in size and shape. Both hemidiaphragms are sharp and distinct. bone erosion nor bone destruction. Impression: Straightening of the cervical spine due to muscle spasm.47 fracture. Impression: Normal bones and joints of the right hand. bone erosion nor bone destruction. Impression: Comminuted fracture. the rest of the bone are normal in density. texture and modeling. PELVIS AP Findings: The bones normal in density. The normal cervical lordosis is absent.

48 APPENDIX H (Drug Study) Celecoxib .

49 APPENDIX I(drug study) Tramadol .

50 APPENDIX H (drug study) Cefuroxime axetil .

51 .

Al 2008. Jellou Ray M. Comminuted _________________________________________________________ Patient Care Classification: (Please Check) ____/______ Wholly Compensatory: Pts. and aggravating factors R-To rule out for worsening of underlying conditions and development of complication and prevent occurrence. Objective: Received patient lying on bed with head elevated. As verbalized.care Clinical Division and Bed No. LONG TERM: After 3 days of nursing intervention the patient was . EXPECTED OUTCOME CRITERIA SHORT TERM: After 5 hours of nursing intervention the patient will be able to verbalize pain relief as evidenced by decreased pain score LONG TERM: After 3 days of nursing intervention. Catholic Allergies: Food: No Known food allergies Drug: No Known drug allergies Diet: Diet as tolerated Date of Admission: July 6. location. Closed. p 501 I-Observe for non-verbal cues of pain R-Observation may not be congruent with verbal reports and BEHAVIORAL OUTCOME SHORT TERM After 5 hours of nursing intervention: “wa na kaayu sakit ang ako bali dong”.Verbalize and demonstrate techniques that provide pain INTERVENTION AND RATIONALE I-Assess level of pain. awake. et. conscious. accomplishes self.B.51 APPENDIX I NCP day 1 (actual) Cebu Normal University College of Nursing Cebu City Mission-Vision: Care Using Knowledge and Compassion NURSING CARE PLAN NCP Scoring 10pts Nursing Diagnosis (at least 5 references) 2pts Defining Characteristics Outcome 3pts Intervention 1pt 3pts Bibliography 1pt Client’s Name: T. Right. Dominic Vicuña Name of Student: Macayan. DEFINING CHARACTERISTICS Nursing Diagnosis: Acute pain related to movement of bone fragments secondary to comminuted fracture. pain score decreased from 7out of 10 to 3 out of 10. coherent. 2011 measures Diagnosis: Fracture.M Age: _32 y/o Sex: Male Civil Status: _Married Religion: R.: Ward VII (orthopedic ward) bed 21 Name of Physician: Dr. S-Doenges. therapeutic care is accomplished by nurse ___ ___ Partially Compensatory: Pts. Subjective:”ngol-ngol kaayu ang ako bali” as verbalized. Distal 3rd Femur. character. performs some self-care measures __________ Supportive Educative: Pts. the patient will be able to: .

constant interaction. limited range of motion observed relief. restlessness noted. Al 2008. with foam traction at right foot.Taught patient about nonpharmacological pain management. Moorhouse and Murr. Al 2008. irritability observed. p 501 I. S-Doenges. et. grimaced face noted. et. may prompt change in locus of intervention. Al 2008. Al 2008. R-to distract attention and thus reduce tension S-Doenges.52 communicative. It is a sudden of slow onset of any intensity from mild to severe with an anticipated . Al 2008. p 501 Dependent/ Collaborative: I-Administer analgesics as to a maximum as needed as indicated R-to maintain acceptable level of pain able to demonstrate effective use of relaxation techniques as evidenced by decreased recurrence of pain perception. et. p 501 I-Provide comfort measures as possible such as touch therapy. - Laboratory: None significant Theoretical Basis: According to Doenges. p 501 I-Encourage to engage in diversional activities such as socialization with other patients or listening to music. use of cold/heat packs. repositioning. S-Doenges. with pain score of 7 out of 10. R-to promote self control and management of pain. quiet environment and calm activities R-maximizes use of nonpharmacological techniques for pain relief S-Doenges. p 501 I-Instruct in and encourage use of relaxation techniques such as focused breathing and imaging. Demonstrate effective use of relaxation techniques as indicated for individual situation. et. et. R-To distract attention and reduce tension. S-Doenges. acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in such tissue damage (international association for the study of pain).

. Pain is explained as a combination of physiologic phenomena in addition to a psychosocial aspect that influence pain perception (Melzack and Wall. R-Promotes active role and enhances self-control. trauma related. et. et. R-To maintain acceptable level of pain and comfort. Al 2008. S-Doenges. Al 2008. p 502 I-Refer to occupational/physical therapy program.53 predictable end and a duration of less than 6 months. tissue injury. p 502 I-Instruct client in use of transcutaneous electrical nerve stimulation units when ordered. iatrogenic or chronic neuropathic (Weber and Kelley 2007) S-Doenges. burn.1965) Pain is also described as transient.

Objective: Received patient lying on bed EXPECTED OUTCOME CRITERIA SHORT TERM GOAL: After 5 hours of nursing intervention. R-Increase patient’s BEHAVIORAL OUTCOME SHORT TERM: After 5 hours of nursing intervention. therapeutic care is accomplished by nurse ___ ___ Partially Compensatory: Pts.M Age: _32 y/o Sex: Male Civil Status: _Married Religion: R. 2011 measures Diagnosis: Fracture. Dominic Vicuña Name of Student: Macayan. Comminuted _________________________________________________________ Patient Care Classification: (Please Check) ____/______ Wholly Compensatory: Pts. Catholic Allergies: Food: No Known food allergies Drug: No Known drug allergies Diet: Diet as tolerated Date of Admission: July 6. R. Jellou Ray M.care Clinical Division and Bed No. goal is met through LONG TERM GOAL: ◊ After 3 days of nursing intervention. performs some self-care measures __________ Supportive Educative: Pts.Necessary to regain normal mobility of leg to speed recovery I-Encourage progressive activities according to level of functional capability.: Ward VII (orthopedic ward) bed 21 Name of Physician: Dr. (traction) Subjective: “maglisod man jud kog lihok sa ako lawas” as verbalized. Right. . Closed. accomplishes self. the patient will be able to perform activities of daily living at the level of functional capabilities. the patient was able to demonstrate effective use of trapeze in mobilizing and repositioning on bed. DEFINING CHARACTERISTICS Nursing Diagnosis: Impaired Physical Mobility related to musculoskeletal impairment secondary to prescribed restrictive therapies. LONG TERM: After 3 days of nursing intervention. Distal 3rd Femur.54 APPENDIX J NCP day 2 (actual) Cebu Normal University College of Nursing Cebu City Mission-Vision: Care Using Knowledge and Compassion NURSING CARE PLAN NCP Scoring 10pts Nursing Diagnosis (at least 5 references) 2pts Defining Characteristics Outcome 3pts Intervention 1pt 3pts Bibliography 1pt Client’s Name: T. INTERVENTION AND RATIONALE I-provision of normal range of motion exercises and function of lower extremity.B.

R-To obtain sense of control during movement. awake. R-enhances self concept and sense of independence. R-Limits fatigue and maximizes participation S. page 460 I-Consult with Occupational therapy as ordered. page 459 Collaborative/dependent: I-Administer medications as needed prior to activity for pain relief R-To permit maximal effort and involvement in activity. limited range of motion in the extremities. He also does some ADL without discomfort. page 459 I-Identify energy conserving techniques for ADL’s. the capability of movement. inability to walk or stand alone.Doenges et. has difficulty in changing position while lying on bed. R-Promotes well-being and energy production. Al. Hogue (1984) identified mobility as the most important functional ability that determines the degree of independence and health care needs.Doenges et. S. the regaining of the patient’s previous range of motion in the leg & demonstrates proper exercises for the lower extremities. slowed movement.Doenges et. page 459 I-Encourage adequate intake of fluid and nutrition. . I-instruct and encourage use of overhead trapeze in mobilizing in the bed. S-Doenges et. has difficulty in moving the extremities. difficulty in initiating gait THEORETICAL BASIS: Physical mobility. S. page 459 I-Provide proper skin care R-To decrease risk for decubitus ulcer S. is necessary for the health and well-being of all Persons. occupational/diversional/ recreational activities. Al. use of affected leg.55 with head elevated to 30 degrees. coherent. with foam traction at right foot. S. Al. communicative. Al. Al. the patient is reading a newspaper.Doenges et. page 459 I-encourage participation in self-care.Doenges et. Fracture Foam traction Decreased control of extremities Restriction of purposeful movement Impaired physical mobility the patient will be able to demonstrate and verbalize proper exercises of the lower extremities & can perform activities of daily living with minimal assistance. Al. conscious.

Al. page 459 APPENDIX K .Doenges et. S.56 R-To maintain continuity of care after discharge.

performs some self-care measures _____Supportive Educative: Pts. accomplishes self. Jellou Ray M.care measures Clinical Division and Bed No. Right. Catholic Allergies: Food: No Known food allergies Drug: No Known drug allergies Diet: Diet as tolerated Date of Admission: July 6. Dominic Vicuña Name of Student: Macayan.: Ward VII (orthopedic ward) bed 21 Name of Physician: Dr. DEFINING CHARACTERISTICS EXPECTED OUTCOME CRITERIA INTERVENTION AND RATIONALE BEHAVIORAL OUTCOME . therapeutic care is accomplished by nurse ___ ___ Partially Compensatory: Pts. Distal 3rd Femur.M Age: _32 y/o Sex: Male Civil Status: _Married Religion: R.57 NCP day 3 (actual) Cebu Normal University College of Nursing Cebu City Mission-Vision: Care Using Knowledge and Compassion NURSING CARE PLAN NCP Scoring 10pts Nursing Diagnosis (at least 5 references) 2pts Defining Characteristics Outcome 3pts Intervention 1pt 3pts Bibliography 1pt Client’s Name: T. Closed.B. Comminuted _________________________________________________________ Patient Care Classification: (Please Check) ____/______ Wholly Compensatory: Pts. 2011 Diagnosis: Fracture.

coherent. nakasabot nako ngano delikado jud na ako ni ilihok lihok ako tiil”as verbalized. nerves. As verbalized Objective: Received patient lying on bed with head elevated. Al. blood vessels. 2000 p718 I-Note clients decision-making ability and level of cognition including functional capability. -keep bed in low position. S-Doenges et. Muscle. intervene and/or refer these these issues can place patients at needless risk and create negligence issues for healthcare practitioner S-Doenges et. R-helps limit confusion or overstimulation. . LABORATORY: None Significant SHORT TERM: After 4 hours of nursing intervention. the patient will be able to verbalize understanding of condition and recognize need for prevention of injuries.The patient is free from additional injury at the end of the duration of care. high placement of bed observed. the patient will be able to: . tendons. traction weights placed of walkways. Subjective:”dali ra masabod sa mga mangagi kanang baton a gbitay”. I-Identify factors related to individual situation and identify extent of risk. absence of bed padding noted. LONG TERM: After 3 days of nursing intervention: -the patient was seen demonstrating appropriate lifestyle changes to reduce risk for injury such as asking for help from SO upon moving and using trapeze effectively when turning. R-To prevent moving the weights SHORT TERM: After 8 hours of nursing intervention: “salamat kayo dong. . -pad bed edges as possible. R-Influences scope and intensity of interventions to manage safety. Al 2000 p 718 I-Place traction weights at appropriate location away from passageways as possible.Demonstrate appropriate lifestyle changes to reduce risk for injury. THEORETICAL BASIS: A fracture occurs when the stress placed on a bone is greater than a bone can absorb. LONG TERM: After 3 days of nursing intervention. -provide adequate area lighting -assist with moving/turning using trapeze R-Failure to accurately assess. joints and other organs maybe injured when fracture occurs.Maintain condition without additional injury and decrease risk for trauma. R-Affects client’s ability to protect self and influences choice of interventions and teaching. communicative. awake.58 Nursing Diagnosis: Risk for Trauma (additional injury) related to loss of skeletal integrity and improper placement of traction weights. Al 2000 p 718 I-Provide quiet environment and reduced stimulation as possible. with foam traction at right foot. S-Doenges et al. absence of side rails noted. conscious. This condition may result to a loss of skeletal integrity that may possibly lead to further . seen SO frequently leaving the patient. S-Doenges et. 2000 p718 I-Implement interventions regarding safety issues includes: -orient client to environment.

Al 2000 p 718 Collaborative/Dependent: I-assist with treatment of underlying medical/surgical conditions. causing disaligment of bone fragments.59 injury as a result of environmental conditions interactions with the patients adaptive and defensive resources. R-To improve cognition/thinking process . S-Doenges et.

without IV.60 APPENDIX L Focused Charting Day 1 Republic of the Philippines Department of Health Regional Health office no. Due medications (analgesics) administered as ordered.Actions made included. coherent. documented the v/s and I and O of the patient. R . R= 20 bpm and BP= 120/70 mmHg. character and location. A . Rodriguez St. Rodriguez St.received patient lying on bed with head elevated to 30 degrees. Introduced name to the patient. conscious. Surname: M Given Name: T APPENDIX M Focused Charting Day 2 Age: 32 years old Ward: VIII (orthopedic ward) Sex: Male Bed No: 21 Case No: Republic of the Philippines Department of Health Regional Health office no. provided comfort measures such as backrub. encouraged patient to do DBE. Cebu City NURSES PROGRESS NOTES . monitored v/s. “ngol-ngol kaau ang akong bali dong”. awake. supported affected body parts/ joints using pillows/ rolls.7 Vicente Sotto Memorial Medical Center B. limited range of motion observed.:”wa na kaayu sakit ang ako bali dong”.. restlessness noted. consulted with physical or occupational therapist as indicated.Response D . irritability observed. with pain score of 7 out of 10. with the following v/s T= 35. P= 86 pm.5 degree Celsius. with foam traction at right foot. assessed level of pain..7 Vicente Sotto Memorial Medical Center B. positioned properly on bed with head slightly elevated. pain score decreased from 7out of 10 to 3 out of 10. As verbalized. As verbalized. grimaced face noted. communicative. encouraged to engage in diversional activities such as socialization with others. Cebu City NURSES PROGRESS NOTES Date 7/18/11 Time 10:00A M F – Focus Acute pain D – Data A – Action R .

conscious.Response D . P= 86 pm. has difficulty in changing position while lying on bed. positioned properly on bed with head slightly elevated.Focus Impaired physical Mobility D – Data A – Action R . provided comfort measures such as backrub. coherent.patient was able to demonstrate increasing functionality of the extremities as evidenced by turning on bed without assistance and effective usage of overhead trapeze. P= 62 pm. Rodriguez St. assisted patient in doing ROM exercises.Response D . communicative.Introduced name to the patient. the patient is reading a newspaper. monitored v/s. assisted patient upon doing gait training. awake. without IV. limited range of motion in the extremities. .5 degree Celsius. R . encouraged patient to do DBE. with foam traction at right foot..received patient lying on bed with head elevated to 30 degrees. A .Received patient lying on bed with head elevated. instructed in proper use of overhead trapeze.7 Vicente Sotto Memorial Medical Center B.61 Date 7/19/11 Time 10:00AM F . inability to walk or stand alone. supported affected body parts/ joints using pillows/ rolls. consulted with physical or occupational therapist as indicated. difficulty in initiating gait. awake. communicative. conscious. coherent. As verbalized. with the following v/s T= 37 degree Celsius.Focus Risk for additional Injury D – Data A – Action R . has difficulty in moving the extremities. R= 20 bpm and BP= 120/70 mmHg. without IV. Sex: Male Bed No: 21 Case No: Surname: M Given Name: T Age: 32 years old Ward: VIII (orthopedic ward) APPENDIX N Focused Charting Day 3 Republic of the Philippines Department of Health Regional Health office no. assessed the condition of the patient. documented the v/s and I and O. Cebu City NURSES PROGRESS NOTES Date 7/20/11 Time 10:00AM F . “ maglisod man ko ug lihok dong”. slowed movement. with the following v/s T= 35.

high placement of bed observed. instructed in proper use of overhead trapeze. assessed the condition of the patient. SO was seen staying with patient most of the time Surname: M Given Name: T Age: 32 years old Ward: VIII (orthopedic ward) Sex: Male Bed No: 21 Case No: CURRICULUM VITAE PERSONAL INFORMATION Name Year & Section Adviser Provincial Address City Address Telephone No. absence of side rails noted. with foam traction at right foot.Introduced name to the patient. Lot 10. “dali raman masabaod ang kanang mga bato”. keeping bed in low position.the patient was able to demonstrate behaviors to promote safety. absence of bed padding noted. positioned properly on bed with head slightly elevated.62 R= 21 bpm and BP= 130/70 mmHg. Macayan BSN 4-B Mrs. traction weights placed of walkways. R . instructed SO to stay with patient as much as possible. Buena Mactan. La Aldea. consulted with physical or occupational therapist as indicated. implemented interventions regarding safety issues such as orientation of patient to environment. providing adequate area lighting and padding of side rails as possible. documented the v/s and I and O of the patient. Poblacion.com . monitored v/s. supported affected body parts/ joints using pillows/ rolls. Lapu-lapu city 2386882 09239855653 bk_addicted@yahoo. encouraged patient to do DBE. E-mail Address : : : : : : : : Jellou Ray M. provided comfort measures such as backrub. Cell no. Lagrimas Elizon P-6. seen SO frequently leaving the patient. assisted patient upon doing gait training. Surigao Del Sur Block 24. assisted patient in doing ROM exercises. Urbiztondo Street. As verbalized A . Barobo.

63 Birthday : July. 1991 EDUCATIONAL BACKGROUND Elementary School Year Secondary School Year Tertiary School Year AFFILIATIONS Position Member : : Organization Nightingale Student Council : : Cebu Normal University 2008-present : : Barobo National high School 2004-2008 : : Barobo Central Elementary School 1998-2004 . 1.