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Liceo de Cagayan University College of Nursing RN Pelaez Boulevard

Submitted as partial fulfillment in the subject N104 RLE A case study on A client with a right knee Fixator

Submitted by: Franklin Macabada

Submitted to: Mrs. Glenda Demafeliz RN, MN

February 18, 2013

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3 8 9 15 19 22 27 29 35 35 36

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I.Introduction A. Overview of the Case Client Taw-asan, Bobby is a CAA from the 23IB, 4ID, PA stationed at San Fernando Bukidnon. On October 24, 2012 there was a grenade explosion at the city hall of San Fernando where he was stationed. It exploded near his feet where he was sent hurtling. Shrapnel were imbedded on his stomach which prompted him to be taken to Malabalay Provincial Hospital for Emergency ExLap. His left side wasnt badly hurt which for him is surprising because he sustained most of his damage to his right side particularly on his right knee. B. Objective The objective in making this case study is to identify and understand the problem of my patient which is a fixator on the right knee and to determine what the specific actions should be done and rendered to my patient. Having this kind of case study is a privilege for me because it would be a good learning process by adding new knowledge and concept about different kinds of diseases that may be present in some patients. By making this case study I can identify the disease step by step, its nature on how this disease occur, and nursing actions that would be appropriate for the patient.

C. SCOPE and LIMITATIONS of the STUDY The study was conducted at Camp Evangelista Service Hospital Cagayan de Oro City in which observation, analyzing and understanding the patients condition was done. We were given two (2) days to conduct the study. The study is also limited to the condition of the patient which is having a fixator on his right knee. The study focuses only on obtaining the patients profile, health history and present health condition; assessing, recording, and gathering of pertinent data about the patient. Estimating the nursing needs and coping capacity of the patient; finding the primary health problems of the patient and the appropriate nursing interventions to solve the condition of the patient. The objectives, nursing care plans, drug study and evaluation for the patient was also done in this study.
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II. Database and History A. Database Client Taw-asan, Bobby a 40 yr old male from San Fernando Bukidnon. A CAA in the Philippine Army. Was admitted to CESH after being transferred from MPH after undergoing E ExLap due to grenade wounds after an attack on the city hall of san Fernando, bukidnon. He was admitted for orthopedic recuperation at CESH.

Health History Family Health History According to client Taw-asan; Hypertension is a heredofamilial trait. His father had suffered from it. Past Health History Client Taw-asan underwent emergency exploratory laparotomy at Malabalay Provincial Hospital on October of 2012 Present Health History Grenade Blast Injury NOI: Gunshot Injury DOI: 24, Ocotber 2012 POI: San Fernando, Bukidnon TOI: 2100H Patient Taw-asan sustained injury when a grenade exploded at the city hll. Underwent E ExLap at Bukidnon Provincial Hospital and was transferred to CESH for further Orthopedic Management.

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Name of Patient: Bobby A. Taw-asan Body Measurements: Weight: 60 lbs Height: 4 feet 9 inches Date of Assessment: Feb 13, 2013

Vital Signs upon Assessment: Temp: 36.4 C PR: 81 bpm RR: 19 cpm BP: 120/80 mmHg

EENT [ ] Impaired Vision [ ] Impaired Hearing [ ] Blind [ ] Deaf [ ] Pain [ ] Reddened [ ] Burning [ ] Edema [ ] Drainage [ ] Lesions [ ] Gums [ ] Teeth

Assess Eyes, Ears, Nose, and throat for any abnormalities [X] No Problem RESPIRATORY [ ] Asymmetrical [ ] Tachypnea [ ] Apnea [ ] Rales [ ] Cough [ ] Barrel Chest

[ ] Bradypnea [ ] Shallow [ ] Orthopnea [ ] Labored

[ ] Rhonchi [ ] Sputum [ ] Diminished [ ] Dyspnea [ ] Wheezing [ ] Pain [ ] Cyanotic

Assess respiration, rate, rhythm, depth, pattern, breath sounds, comfort. [ x ] No Problem CARDIOVASCULAR [ ] Arrhythmia [ ] Edema [ ] Tingling [ ] Tachycardia [ ] Numbness [ ] Diminished Pulse [ ] Fatigue [ ] Irregular [ ] Bradycardia [ ] Mur-mur [ ] Absent Pulse [ ] Pain

Assess heart sounds, rate, rhythm, pulse, blood pressure, circulation, fluid retention, comfort [ X] No Problem GASTROINTESTINAL [ ] Obese [ ] Distension [ ] Mass [ ] Dysphagia [ ] Rigidity [ ] Pain

Assess abdomen, bowel habits, swallowing, bowel sounds, comfort. [X] No Problem GENITO URINARY and GYNE [ ] Pain [ ] Urine Color [ ] Vaginal Bleeding [ ] Hematuria [ ] Discharges [ ] Nocturia Page | 5

Assess Urine frequency, control, color, odor, comfort, Gyne Bleeding, Discharges . [X] No Problem NEUROLOGIC [ ] Paralysis [ ] Vertigo [ ] Stuporous [ ] Tremors [ ] Unsteady [ ] Seizure [ ] Lethargic [ ] Confused [ ] Vision [ ] Grip [ ] Comatose

Assess motor function, sensation, LOC, Strength, Grip, gait, coordination, Speech [X] No Problem MUSCULOSKELETAL and SKIN [ ] Appliance [ ] Prosthesis [X] Wound [ ] Echymosis [X] Stiffness [ ] Swelling [ ] Itching [ ] Lesions [ ] Petechiae [ ] Poor Turgor [ ] Atrophy [ ] Hot [ X] Drainage

[ ] Cool [ ] Deformity [X] Pain

[ ] Rash [ ] Skin Color [ ] Flushed [ ] Diaphoretic [ ] Moist

Assess mobility, motion gait, alignment, joint function, Skin color, texture, turgor, integrity [ ] No Problem Place an (X) in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure if appropriate, using (X). Scars

Scars ExLap Scar

Drainage/ Pain from fixator on d/3rd femur


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SUBJECTIVE COMMUNICATION: [ ] Hearing Loss Comments:


[ ] Glasses

[ ] Languages

[ ] Visual Changes Ok pa man akong panan aw. [ ] Contact [ ] Hearing Aide [X] Denied Wala pa gani ko magLens [ ] Speech Difficulties

antipara As verbalized by the client. Pupil Size: R_3mm _ L _3mm__ Bilaterally equal Reaction: _Pupils Equally Round and Reactive to Light Accomodation OXYGENATION: [ ] Dyspnea Comments: Respiration: [ x ] Regular [ ] Irregular The rise and fall of the chest is symmetric

[ ] Smoking History Di man pod ko gapanigarilyo Describe: [ ] Cough [ ] Sputum [X] Denied . As verbalized by the client.

R: Symmetric to left; full chest expansion L: Symmetric to right; full chest expansion

CIRCULATION: [ ] Chest Pain [ ] Leg Pain [ ] Numbness of extremities [X ] Denied Comments: Heart Rhythm: [x] Regular [ ] Irregular

Wala man magsakit akong Ankle Edema: No ankle edema________________ dughan As verbalized by the Pulse client. Right Left Car + + Rad + + DP + + Fem* + +


Pulses on both left and right are present and palpable

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NUTRITION: Diet: Full (Increased Protein) [ ]N [ ]V Comments:

[ ] Dentures

[X ] None Full X Incomplete With Patient

Character Not applicable [ ] Recent change in weight, appetite [ ] Swallowing difficulty [X ] Denied ELIMINATION: Usual bowel pattern: Once a day [ ] Constipation Remedy Not applicable Date of last BM Feb, 15, 2013 [ ] Diarrhea Character

Ok ra man pod hinuon Upper akong pagkaon As verbalized by the client. Lower

[ ] Urinary Frequency

Comments: No

Bowel sounds: abdominal_Normoactive 5X_ uponAbdominal Distention: Present: [ ]Yes [X ]No

[ ] Urgency [ ] Dysuria [ ] Hematuria [ ] Incontinence [ ] Polyuria [ ] Foly in place [X] Denied

tenderness palpation.

Urine: Color: Odor: Yellowish Non-foul & non

Consistency: Clear cloudy

MGT. OF HEALTH & ILLNESS: [ ] Alcohol [X] Denied Briefly describe the patients ability to follow

Amount & Frequency

treatments (diet, meds, etc.) for chronic problems (if

Dili ko ga inom. as verbalized by the client present). SBE Last Pap Smear: Not applicable Client was keen to ask questions about her disease and describe it as well. She follows the regimen given to her. ___ SKIN INTEGRITY: [ ] Dry [ ] Itching Comments: [X] Dry [ ] Cold [X ] Warm Page | 8 [ ] Pale

LMP: Not applicable

Naa koy samad ibabaw sa [ ] Flushed

[X] Other [ ] Denied

akong tuhod . As verbalized by [ ] Moist the client.

[ ] Cyanotic

*Rashes, ulcers, decubitus (describe size, *location, drainage): Ulceration noted 5 inches above right knee, outer aspect. Nearly healed 2 inches in diameter. ACTIVITY/SAFETY : [ ] Convulsion [ ] Dizziness [X] motion of joints Comments: [ ] Level of Consciousness and Orientation

Mag lisod pako ug lihok saThe client is awake and coherent and oriented akoong tuhod, ug tunob sa __ Gait: __ Walker Cane X Other: Crutches

Limitedakong tiil As verbalized by the __ Gait: Steady client. __ Gait: X Unsteady: [ ] Sensory and motor losses in face or extremities:

Limitation ability to: [X ] Ambulate [X ] Bathe Self [ ] Other [ ] Denied


No sensory and motor loses on face and extremities noted. [X] Range of Motion Limitations: Right knee unable to be bent, right leg can support at least 5 kgs of weight.

COMFORT/SLEEP/AWAKE: [X ] Pain Location:5 Comments: inches Mag ngotngot [X] Facial Grimaces ang [X] Guarding

above right knee Frequency: Daily Remedies: Compress Elevation [ ] Nocturia [ ] Sleep Difficulties

akong tuhod kung I [X] Other Signs of Pain: bend jud naku ug ayoTender to pressure during cleaning

Warm as verbalized by the [ ] Siderail release form signed (60+ years) and client. Not applicable

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[ ] Denied COPING: Occupation: Cafgu in the Philippine Army Observe non-verbal behavior: Client is keen with current condition an seems to have Adapted to the routines

Members of household: 6 Members

Most supportive person: Vilma Taw-asan

The person and his phone number that can Be reached anytime: 09164680517

SPECIAL PATIENT INFORMATION (USE LEAD PENCIL) __NA____Daily Weight 02/13/13 BP q Shift ___ NA ____Neurovs ___ NA ____CVP/SG. Reading Date ordered Diagnostic/ Laboratory Exams Dec 12, 2012 Jan 12, 2013 Blood Chem Ultrasound NA Dec 13 Jan 13 10/24/13 PNSS 1L NA NA 01/13/13 __ NA______PT/OT__________ __ NA _____Irradiation ___ NA _____Urine Test_________ __ NA ____24 hour Urine Collection I.V. Blood Fluids/ Date Disc.

Date Done Date Ordered

Hematology: Increased WBC: Indicative of infection Decreased Hemoglobin: Decreased circulating blood X-ray: Normal Chest x-ray finding Normal Right Leg finding

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IV. DEVELOPMENTAL DATA The term growth and development both refers to dynamic process. Often used interchangeably, these terms have different meanings. Growth and development are interdependent, interrelated process. Growth generally takes place during the first 20 years of life; development continues after that. Growth: 1. Physical change and increase in size. 2. It can be measured quantitatively. 3. Indicators of growth include height, weight, bone size, and dentition. 4. Growth rates vary during different stages of growth and development. 5. The growth rate is rapid during the prenatal, neonatal, infancy and adolescent stages and slows during childhood. 6. Physical growth is minimal during adulthood. Development: 1. Is an increase in the complexity of function and skill progression. 2. It is the capacity and skill of a person to adapt to the environment. 3. Development is the behavioral aspect of growth.

Eriksons Stages of Psychosocial Development Theory

Erikson's psychosocial crisis stages life stage / relationships / issues basic virtue and second named strength (potential positive outcomes from each crisis) Hope and Drive maladaptation / malignancy (potential negative outcome - one or the other from unhelpful experience during each crisis)

(syntonic v dystonic) 1. Trust v Mistrust infant / mother / feeding and being comforted, teething, sleeping toddler / parents / bodily functions, toilet training, muscular control, walking preschool / family / exploration and discovery, adventure and play schoolchild / school, teachers, friends, neighbourhood / achievement and accomplishment adolescent / peers, groups, influences / resolving identity and direction, becoming a grownSensory Distortion / Withdrawal

2. Autonomy v Shame & Doubt 3. Initiative v Guilt

Willpower and SelfControl Purpose and Direction

Impulsivity / Compulsion

Ruthlessness / Inhibition

4. Industry v Inferiority

Competence and Method

Narrow Virtuosity / Inertia

5. Identity v Role Confusion

Fidelity and Devotion

Fanaticism / Repudiation

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6. Intimacy v Isolation

young adult / lovers, friends, work connections / intimate relationships, work and social life mid-adult / children, community / 'giving back', helping, contributing

Love and Affiliation

Promiscuity / Exclusivity

7. Generativity v Stagnation

Care and Production

Overextension / Rejectivity

Client Taw-asanis on the 7th stage Generativity vs Stagnation. Even though he is a battle casualty, he is still trying to provide up to his best for his children. He might as well have retired already since he is a battle casualties but he has decided to care for his family more avoiding stagnation.

Havinghurst Developmental Stages Havighurst identified Six Major Stages in human life covering birth to old age.

Infancy & early childhood (Birth till 6 years old) Middle childhood (613 years old) Adolescence (1318 years old) Early Adulthood (1930 years old) Middle Age (30-60years old) Later maturity (60 years old and over)

From there, Havighurst recognized that each human has three sources for developmental tasks. They are:

Tasks that arise from physical maturation: Learning to walk, talk, control of bowel and urine, behaving in an acceptable manner to opposite sex, adjusting to menopause. Tasks that arise from personal values: Choosing an occupation, figuring out ones philosophical outlook. Tasks that have their source in the pressures of society: Learning to read, learning to be responsible citizen.

The developmental tasks model that Havighurst developed was age dependent and all served pragmatic functions depending on their age. In the middle years, from about thirty to about fifty-five, men and women reach the peak of their influence upon society, and at the same time the society makes its maximum demands upon them for social and civic responsibility. It is the period of life to which they have looked forward during their adolescence and early adulthood. And the time passes so quickly during these full and active middle Page | 12

years that most people arrive at the end of middle age and the beginning of later maturity with surprise and a sense of having finished the journey while they were still preparing to commence it. The biological changes of ageing, which commence unseen and unfelt during the twenties, make themselves known during the middle years. Especially for the woman, the latter years of middle age are full of profound physiologically-based psychological change. The developmental tasks of the middle years arise from changes within the organism, from environmental pressure, and above all from demands or obligations laid upon the individual by his own values and aspirations. Client Taw-asan belongs to the middle age group. He has already accepted the biological changes in him and has set himself as the role model for his teenage children since his wife has passed away. Piagets Stage Theory of Cognitive Development Swiss biologist and psychologist Jean Piaget (1896-1980) observed his children (and their process of making sense of the world around them) and eventually developed a four-stage model of how the mind processes new information encountered. He posited that children progress through 4 stages and that they all do so in the same order. These four stages are:

Sensorimotor stage (Birth to 2 years old). The infant builds an understanding of himself or herself and reality (and how things work) through interactions with the environment. It is able to differentiate between itself and other objects. Learning takes place via assimilation (the organization of information and absorbing it into existing schema) and accommodation (when an object cannot be assimilated and the schemata have to be modified to include the object. Preoperational stage (ages 2 to 4). The child is not yet able to conceptualize abstractly and needs concrete physical situations. Objects are classified in simple ways, especially by important features. Concrete operations (ages 7 to 11). As physical experience accumulates, accommodation is increased. The child begins to think abstractly and conceptualize, creating logical structures that explain his or her physical experiences. Formal operations (beginning at ages 11 to 15). Cognition reaches its final form. By this stage, the person no longer requires concrete objects to make rational judgments. He or she is capable of deductive and hypothetical reasoning. His or her ability for abstract thinking is very similar to an adult.

Client Taw-asan has long past this stage. He has already established his formal operation skills and has already started passing it down to his children already.

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Freudian psychosexual development Stage Age Range Erogenous zone Consequences of psychologic fixation Orally aggressive: chewing gum and the ends of pencils, etc. Orally Passive: smoking, eating, kissing, oral sexual practices. Oral stage fixation might result in a passive, gullible, immature, manipulative personality. Anal retentive: Obsessively organized, or excessively neat Anal expulsive: reckless, careless, defiant, disorganized, coprophiliac Oedipus complex (in boys and girls); according to Sigmund Freud. Electra complex (in girls); according to Carl Jung. Latency Genital 6puberty Puberty death Dormant sexual feelings Sexual interests mature Sexual unfulfillment if fixation occurs in this stage. Frigidity, impotence, unsatisfactory relationships


Birth1 year



13 years

Bowel and bladder elimination


36 years


Genital stage The fifth stage of psychosexual development is the genital stage that spans puberty and adult life, and thus occupies most of the life of a man and of a woman; its purpose is the psychologic detachment and independence from the parents. The genital stage affords the person the ability to confront and resolve his or her remaining psychosexual childhood conflicts. As in the phallic stage, the genital stage is centered upon the genitalia, but the sexuality is consensual and adult, rather than solitary and infantile. The psychological difference between the phallic and genital stages is that the ego is established in the latter; the person's concern shifts from primary-drive gratification (instinct) to applying secondary process-thinking to gratify desire symbolically and intellectually by means of friendships, a love relationship, family and adult responsibilities. Actually client Taw-asan has also passed this stage with grace as I may say. Even though raising children on your own can be quite a daunting task but he is still able to manage and provide for his family as well.

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V. Pathophysiology
A bone fracture (sometimes abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a break in the continuity of the bone. A bone fracture can be the result of high force impact or stress, or trivial injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.

Grenade Explosion Injury to femur/fracture transverse, oblique, spiral or comminuted Restricted / loss of function of affected part Tissue swelling, bruising or hematoma mass at site of injury Breakage in skin Shock

Bleeding from damaged ends of bone & from surrounding soft tissue

Increased diameter of thigh due to continuous loss of blood

Hypertension (occasionally seen as a response to acute pain / anxiety) or Hypotension (severe blood loss) Tachycardia (stress response, hypovolemia)

Fatigue, weakness (e.g. affected extremity or generalized)

Gait and/or mobility problems

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VI. Drug Study

Mechanism of Action Generic Name: Tramadol Dosage: 50mg Frequency: Brand name: Ultram Q6 Route: PO Classification: Analgesic Binds to -opiate receptors in the CNS causing inhibition of ascending pain pathways, altering the perception of and response to pain; also inhibits the reuptake of norepinephrine and serotonin, which also modifies the ascending pain pathway. Management of pain in the operation site. Hypersensitivity to tramadol, opioids, or any component of the formulation; opioiddependent patients; acute intoxication with alcohol, hypnotics, centrally-acting analgesics, opioids, or psychotropic drugs Dizziness Nausea Drowsiness Dry mouth Constipation Headache Sweating Vomiting Itching Rash Visual disturbances Vertigo Inform client that medication may cause CNS depression and/or respiratory depression, particularly when combined with other CNS depressants Instruct patient to report cravings to physician immediately. Tell patient that driving or operating machinery should be avoided until the effect of drug wears off. Indication Contraindication Adverse Reactions Nursing Implication

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Mechanism of Action Generic Name: CALCIUM SUPPLEMENT/ VITAMIN D ORAL Brand name: Citracal + D Dosage: 1 cap Frequency: OD Route: PO Calcium plays a very important role in the body. It is necessary for normal functioning of nerves, cells, muscle, and bone. Classification: Vitamin supplemet If there is not enough calcium in the blood, then the body will take calcium from bones, thereby weakening bones. Vitamin D helps your body absorb calcium and phosphorus.



Adverse Reactions

Nursing Implication

This combination medication is used to prevent or treat low blood calcium levels in people who do not get enough calcium from their diets.

heart/blood vessel disease, kidney stones, kidney disease, certain immune system disorder (sarcoidosis), liver disease, certain bowel diseases (Crohn's disease, Whipple's disease), little or no stomach acid (achlorhydria), low levels of bile, untreated phosphate imbalance.

serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.

=Monitor for hypercalcemia =Monitor for hyperphospathemia

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Mechanism of Action Generic Name: Ascorbic Acid Brand name: Vitamin C Dosage: 500 mg 2 tabs Frequency: OD Route: Classification: Vitamin Supplement PO Essential vitamin believed to be important for synthesis of cellular components, catecholamines, steroids, and carnitine.



Adverse Reactions

Nursing Implication

Prophylaxis and treatment of scurvy and as a dietary supplement. Increases protection mechanism of the immune system, thus supporting wound healing. Necessary for wound healing and resistance to infection.

Use of sodium ascorbate in patients on sodium restriction; use of calcium ascorbate in patients receiving digitalis. Safety during pregnancy (category C) or lactation is not established.

GI: Nausea, vomiting, heartburn, diarrhea. Hematologic: Acute hemolytic anemia (patients with deficiency of G6PD); sickle cell crisis. CNS: Headache (high doses). Urogenital: Urethritis, dysuria, crystalluria (high doses). Other: Mild soreness at injection site; dizziness and temporary faintness with rapid IV administration.

Assessment & Drug Effects Lab tests:

Periodic Hct & Hgb, serum electrolytes. Monitor for S&S

of acute hemolytic anemia, sickle cell crisis. Patient & Family Education Take large doses of vitamin C in divided amounts because the body uses only what is needed at a particular time and excretes the rest in urine. Megadoses can

interfere with absorption of vitamin B12. Note: Vitamin C increases the absorption of iron when taken at the same time as iron-rich foods.

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Mechanism of Action Generic Name: Ferrous sulfate Brand name: Dosage: 1tab Frequency: OD Route: Classification: Iron Preparation PO Elevates the serum iron concentration which then helps to form High or trapped in the reticuloendothelial cells for storage and eventual conversion to a usable form of iron.



Adverse Reactions

Nursing Implication

Prevention and treatment of iron deficiency anemias. Dietary supplement for iron.

Hypersensitivity Severe hypotension.

Dizziness N&V Nasal Congestion Dyspnea Hypotension CHF MI Muscle cramps Flushing

Advise patient to take medicine as prescribed. Caution patient to make position changes slowly to minimize orhtostatic hypotension. Instruct patient to avoid concurrent use of alcohol or OTC medicine without consulting the physician. Advise patient to consult physician if irregular heartbeat, dyspnea, swelling of hands and feet and hypotension occurs. Inform patient that angina attacks may occur 30 min. after administration due reflex tachycardia.

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VII. MEDICAL MANAGEMENT October 31, 2012 0835H >Please admit to Ortho Ward = Admission order by doctor >Monitor VS q 4 = For baseline vitals >May have general liquids and soft diet for lunch = For nourishment and not to stress GI tract too much >Present IVF D5LR 200cc @ 30 gtts/min = Present fluid replacement >IVF to ff: D5LR 1 L @ 20 gtts/min =Present IVF reduced speed >Meds: Tramadol 50 mg slow iv q6 = Management of pain >Ranitdine 50 g IV q8 within 24 hrs = To allow the GI tract to rest >Ciprofloxacin 1 gm IV ANST (-) = antibiotic for transient skin infection due to E ExLap >Refer accordingly = Refer for any unusualities November 02, 2012 0855H >May have DAT =Diet change to as tolerated >D/C Ranitidine IV & Tramadol IV =Meds are slowly switched from IV to PO >IVF to ff: D5LR 1 L @ 10 gtts/min =current IVF speed decreased
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>May give Tramadol 50 mg PO q6 for pain =For pain management November 10, 2012 1125h>For ORIF of right Femur tomorrow PM =For Open Reduction with Internal Fixator on right knee November 11, 2012 1822H>To recovery room =Post operative recovery November 12, 2012 2042H > Morphine 2 mg + Buspirone 10 g in 10 cc PNSS given via EC =For pain management >Morphine precaution pls =For strict monitoring on and during morphine activation levels November 14, 2012 >For passive ROM exercises =To help with mobilization of affected knee November 16, 2012 0845H >Terminate IVF when consumed = Discontinue IVF once consumed >D/C IV meds once IVF is terminated, switch to PO =Continuation of medication via PO >Daily wound dressing =Daily cleaning of wound November 21, 2012 0850H >For removal of skin staples today =To allow the adhesion and healing of the surgical wound November 25, 2012 0940H >Continue assisted Rom exercises =For improvement of muscle tone November 30, 2012 0949H >FeSO4 1 tab OD =Increase RBC health December 10, 2012 1145H >For removal of remaining skin staples and sutures =To allow the adhesion and healing of the surgical wound
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December 12, 2012 1002H

>May transfer to regular ward =To facilitate healing and monitoring

January 28, 2013 0935H

>May do crutch ambulation, non-weight bearing R leg =To facilitate ambulation

February 03, 2012 1618h

>Daily wound dressing =Daily cleaning of wound >Continue assisted Rom exercises =For improvement of muscle tone

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Cues Nursing Diagnoses Impaired skin integrity Objectives Interventions Rationale Evaluation

Subjective data: Objective data: Incision wound with discharges 5 inches above Right knee

At the end of the shift client will verbalize increase of comfort on affected knee

- Daily wound dressing done

-To maintain optimum sterility and promote healing - Promotes circulation and prevents undue pressure on skin and tissues. - To promote comfort and maintain optimum circulation - To avoid discomfort and skin breakdown These measures promote comfort and reduce risk of irritation and skin breakdown. - Prominences have little subcutaneous fat and are prone to breakdown; using padding and pillows may help promote skin integrity.

- Turned/ Repositioned patient at least every 2 hours.

At the end of the shift client verbalized increase of comfort on affected knee

- Encouraged use of soft, loose cotton clothing.

- Used preventive skin care devices such as pillows and padding. - Kept patients skin dry and clean.

- Protected bony prominences with pillows and padding.

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Cues Subjective data: Sakit pa ang gi operahan, labi na kung pugson nako as verbalized by client Objective data: - Pain scale 9/10 - (+) Facial grimaces - Elevated BP 130/85

Nursing Diagnoses Pain R/T postsurgical incision

Objectives At the end of 2 hours of NI the client will manifest a decrease in pain scale from 9 to 2/10 or lower

Interventions -Asses the clients perception, level of understanding and needs

Rationale -To identify and assess the different nursing interventions to be done -To assess the effectiveness of NI and obtain baseline VS for future comparison -Because pain is highly subjective -To provide comfort -To alleviate pain

Evaluation -After 2 hours of NI client was able to verbalize relief from pain; 2/10 pain scale

-Obtain clients baseline including pain scale


-Encourage client to verbalize any discomfort -Position in comfortable position -Administer Tramadol 50 mg PRN for pain

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Cues Subjective data: Dili na jud ko komportable diri as verbalized by client Objective data: >Pale & weak looking >Restless & irritable >With limited movements noted.

Nursing Diagnoses Impaired Comfort Medical Condition

Objectives At the end of 8 hours, client will verbalize increase in comfort and reduction of anxiety

Interventions - Allowed patient verbalize pain. to

Rationale - Pain is subjective that can only be felt by the person affected - Promotes relaxation and helps refocus attention.

Evaluation At the end of 8 hours, client verbalized increase in comfort and reduction of anxiety


Provided nonpharmacologic comfort measures such as repositioning, back rub and divertional activities. - Encouraged use of stress management skills or complementary therapies such as guided imagery and therapeutic touch. - Taught to do deep breathing exercise and instructed to do it along with the other interventions when the pain starts. - Instructed relatives to stay with the patient at most times.

- Enables patient to participate actively in nondrug treatment of pain and enhances sense of control.

- Increases lung expansion, reduces muscle tension, enhances circulation and decreases pain perception.

- To reduce anxiety and enhance patients coping skills which in turn, decreases pain.

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Actual Nursing Intervention Taw-asan, Bobby

0700H Post-op Wound

February 14, 2013

D> With post-op wound @ R knee with wet & intact dressing with minimal secretions. A> Daily wound dressing done aseptically; leg slightly elevated; advised to keep wound covered at all times & avoid touching with bare hands; Encouraged intake of vitamin c rich foods; ROM exercises done within tolerable levels. R> Still with post-op wound; dressing dry and intact 0700H Post-op Pain

D> Sakit siya gamay kay ako gi exercise as verbalized; pain scale of 5/10 A> Applied warm compress; taught deep breathing & relaxation techniques; advised to ambulate with crutches on non-weight bearing leg; encouraged to verbalize any discomfort. R> Still in pain; with scale of 3/10

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Taw-asan, Bobby
0700H Post-op Wound

February 14, 2013

D> With post-op wound @ R knee with wet & intact dressing with minimal secretions. A> Daily wound dressing done aseptically; leg slightly elevated; advised to keep wound covered at all times & avoid touching with bare hands; Encouraged intake of vitamin c rich foods; ROM exercises done within tolerable levels. R> Still with post-op wound; dressing dry and intact 0700H Post-op Pain

D> Sakit siya gamay kay ako gi exercise kaganina as verbalized; pain scale of 9/10 A> Applied warm compress; taught deep breathing & relaxation techniques; advised to ambulate with crutches on non-weight bearing leg; encouraged to verbalize any discomfort. R> Still in pain; with scale of 2/10

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VIII. REFERRALS AND FOLLOW-UP: Outpatient (check-up): Instructed the patient to abide to her routine check-up with Dr. Lagapa at CESH once discharged. Encouraged the patient as well to report any unusual findings that he might have observed.

IX: EVALUATION AND IMPLICATIONS: This care study enables us to further our learning association with disease condition of the patient. From it, we have gained knowledge in the progression of the disease and the reaction of the body to maintain homeostasis and how eventually it causes harm. Through this, we actually improved our understanding and skills in the management of the patient through the experiences weve had in implementing our care. It also enhanced our confidence in intervening because of the input gained form our research. Case studies are a way of getting familiar or get acquainted not only with the patient but also on his or her condition. It provides concrete examples of how the theoretical knowledge learned during lectures was applied. How the concepts of the various disease condition were manifested through the client. It allows the opportunity to facilitate the acquisition of knowledge through the experiences gained in management and in caring for the patient. As a result, it is a must that case studies should be made not just for requirement purposes but also for the pursuit of knowledge. In general, the case study promoted learning through the research and actual experiences and made us more knowledgeable in caring for the patient and that can really be used in our chosen field.

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X. Bibliography Books: 120 Diseases (The essential Guide to more than 120 Medical Conditions, syndromes, and diseases) by Prof. Peter Abrahams 2007 pp. 46-47; 74-75; 190-195 Essentials of pathophysiology by Carol Mattson Porth Rn, MSN, PhD pp. 366-399; 705-721; 1034-1037 Manual of Nursing Practice by Lippincott 10thed. pp. 454-462; 910-932; 1087-1088 Portable Rn 3rd edition by Lippincott 2006 pp. 214-216; 226-228; 236-238 Nursing Care Plans, Nursing diagnosis and intervention by Gulanick/Myers 6th ed pp. 301-305; 777-782; 1050-1062


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