INTRODUCTION Achilles tendon is named after Achilles: the ancient Greek hero of the Trojan War.

He was invulnerable except for one spot on his heel. After many adventures and victories he was killed by a narrow shot into his heel. That¶s why it was named after him. The Achilles tendon is also known as the heel tendon, heel cord or calcenean tendon. It is a fibrous tissue that connects the heel to the muscles of the lower leg: the calf muscle. Leg muscles are the most powerful muscle group in the body and the Achilles tendon is the thickest and strongest tendon in the body. Contracting the calf muscles pulls the Achilles tendon, which pushes the foot downward. This contraction enables standing, on the toes, walking, running and jumping. Each Achilles tendon is subject to a person¶s entire body weight with each step. Depending upon speed, stride terrain and additional weight being carried or push each Achilles tendon maybe subject to up to 3-12 times a person¶s body weight during a sprint or push off. Overuse, misalignment, improper footwear, medication side effects or accidents can result in Achilles tendon injuries. Undue strain results in over 230,000 achilles tendon injuries per year in the U.S. alone. One month ago, our patient had an accident. The buker bottles dropped in his foot that is why he had a cut on his posterior heel. He had a check-up to the doctor and the doctor sutured his wound and gave antibiotic.The patient was thinking that he would feel better. But After several weeks, he had a difficulty in walking and he felt pain in his posterior heel at the left side. He then decided to go to the doctor and complaint about it. The doctor advised him to have a repair on his left Achilles tendon. Last July 31, 2007 he took the surgery.

OBJECTIVES of THE STUDY At the end of this study, the NCM501204 group A12 students of Liceo de Cagayan University will be able to: 1. define Achilles tendon 2. Identify the developmental theory of the patient 3. Discuss the health history of the patient which include the family past medical history 4. Identify the history of present illness 5. Discuss the medical management of the disease 6. Show the physical assessment of the patient 7. Discuss the pathophysiology of the disease 8. Enumerate and discuss the nursing management

9. Identify the drugs administered to the patient 10. Discuss the discharge plan which includes the referral and follow-up

SCOPE and LIMITATION This study is limited only on the physical assessment of the patient which was conducted during our hospital exposure at x last x, 3-11 shift, since the patient was cared by the other group. All the data gathered we¶re only based on the interview with the patient, physical assessment and observations and from the chart of the patient.

PATIENT¶S PROFILE

NAME: AGE: SEX: BIRTHDAY: BIRTH PLACE: RELIGION: NATIONALITY: CIVIL STATUS: ADDRESS: OCCUPATION: NAME OF WIFE: OCCUPATION: x Filipino x

Mr. X x Male x

Roman Catholic

Married x

x Housewife

NUMBER OF CHILDREN: MONTHLY INCOME:

Three children P17, 000/month

DEVELOPMENTAL THEORIES
SIGMUND FRUED (1856-1939)

Psychosexual Theory Freud advanced a theory of personality development that centered on the effects of the sexual pleasure drive on the individual psyche. At particular points in the developmental process, he claimed, a single body part is particularly sensitive to sexual, erotic stimulation. These erogenous zones are the mouth, the anus, and the genital region. The child's libido centers on behavior affecting the primary erogenous zone of his age; he cannot focus on the primary erogenous zone of the next stage without resolving the developmental conflict of the immediate one. A child at a given stage of development has certain needs and demands, such as the need of the infant to nurse. Frustration occurs when these needs are not met; Overindulgence stems from such an ample meeting of these needs that the child is reluctant to progress beyond the stage. Both frustration and overindulgence lock some amount of the child's libido permanently into the stage in which they occur; both result in a fixation. If a child progresses normally through the stages, resolving each conflict and moving on, then little libido remains invested in each stage of development. But if he fixates at a particular stage, the method of obtaining satisfaction which characterized the stage will dominate and affect his adult personality. Stages of Psychosexual Theory y Oral (Birth to 1 year) Mouth is the center of pleasure Major source gratification and exploration

Security is primary need Fixation: Difficulty in trusting others, nail biting, and overeating y Anal (2-3 years) Anus and bladder are the center of pleasure Sensual satisfaction and self control A way of exerting independence Fixation: In this stage can result to obsessive-compulsive personality such as temper tantrums y Phallic (4-6 years) Fixation at the phallic stage develops a phallic character, which is reckless, resolute, self-assured, and narcissistic-excessively vain and proud. y Genital ( Puberty and after) Energy is directed toward attaining a mature sexual relationship. Our patient had three children.
ERIK ERIKSON

Psychosocial Theory Erikson believed that childhood is very important in personality development. He accepted many of Freud's theories, including the id, ego, and superego, and Freud's theory of infantile sexuality. But Erikson rejected Freud's attempt to describe personality solely on the basis of sexuality, and, unlike Freud, felt that personality continued to develop beyond five years of age.

All of the stages in Erikson's epigenetic theory are implicitly present at birth (at least in latent form), but unfold according to both an innate scheme and one's upbringing in a family that expresses the values of a culture. Each stage builds on the preceding stages, and paves the way for subsequent stages. Each stage is characterized by a psychosocial crisis, which is based on physiological development, but also on demands put on the individual by parents and/or society. Ideally, the crisis in each stage should be resolved by the ego in that stage, in order for development to proceed correctly. The outcome of one stage is not permanent, but can be altered by later experiences. Everyone has a mixture of the traits attained at each stage, but personality development is considered successful if the individual has more of the "good" traits than the "bad" traits. Stage:Generativity vs. Stagnation Generativity is the concern in establishing and guiding the next generation. Our patient belongs to middle adulthood in which creativity and concern for others was the positive indicator and he belongs to generativity versus stagnation. According to her nephew he was a good father to his children especially in guiding them to finish their
studies for them to have a better future. JEAN PIAGET

Cognitive Development Piaget¶s theory focuses on the development of cognition. Cognitive processes, such as abstract reasoning, problem solving, and intellectual growth. Develop gradually through the childhood years and reach a stable operational phase in adolescence that is subsequently refined through the childhood years. According to Piaget, cognitive development is an orderly, sequential process in which a variety of new experiences must exist before intellectual abilities can develop. Piaget proposed this theory of childhood cognitive development in 1969. Since that time, there have been many criticisms of Piaget¶s theory. Most notably, developmental psychologists debate whether children actually go through these four stages in the way that Piaget proposed, and further that not all children reach the formal operation stage. Despite this criticism, Piaget has had a major influence on all modern

developmental psychologists. In addition to his proposed idea that children¶s cognitive performance is directly related to the stage they are in, he proposed four major stages of development.

The Sensorimotor Period (birth to 2 years) Discovery of relationships between sensation and motor behavior. Preoperational Thought (2 to 6/7 years) Uses of symbols to represent objects internally, especially through language. Concrete Operations (6/7 to 11/12 years) Mastery of logic and development of rational thinking. Formal Operations (11/12 to adult) Persons who reach the formal operation stage are capable of thinking logically and abstractly. They can also reason theoretically. Piaget considered this the ultimate stage of development, and stated that although the children would still have to revise their knowledge base, their way of thinking was as powerful as it would get. Our group¶s patient is in the formal operation phase, wherein he uses rational thinking and reasoning is deductive and futuristic.
ROBERT HAVIGHURST

Developmental Task Theory He believed that learning is basic to life and that people continue to learn throughout life. He promoted the concept of developmental task, which he defines as a task which arises at or about a certain period in life of an individual, which leads to his happiness and success with later task, while failure leads to unhappiness in the individual, disapproval by the society, and difficulty with late task.

The developmental-task concept occupies middle ground between two opposed theories of education: the theory of freedom, the child will develop best if left as free as possible, and the theory of constraint, that child must learn to become a worthy, responsible adult through restraints imposed by his society. A developmental task is midway between an individual need and societal demand. It assumes an active learner interacting with an active social environment. The group¶s patient belongs to middle adulthood wherein he assisted the teenage children to become responsible especially his children.

Family History During our duty on x, We interviewed the patient. According to him the only illness that there family experienced was fever and colds. They don¶t have family history regarding worst diseases. Even if they have simple life they live a healthy lifestyle. Both side of the family, the mother and father side don¶t have any experience in worst diseases. History of Present illness A month PTA, our patient had an accident. He had a cut on his posterior left heel. He then went to MedinaEmergencyHospitaland had a check-up. The doctor sutured the wound and gave him antibiotic. One month PTA, he had a difficulty in waking and he felt pain in his posterior heel. He then decided to go to the doctor and complaint about it. The doctor advised him to have a surgery.

DEVELOPMENTAL THEORIES
SIGMUND FRUED (1856-1939)

Psychosexual Theory Freud advanced a theory of personality development that centered on the effects of the sexual pleasure drive on the individual psyche. At particular points in the developmental process, he claimed, a single body part is particularly sensitive to sexual, erotic stimulation. These erogenous zones are the mouth, the anus, and the genital region. The child's libido centers on behavior affecting the primary erogenous zone of his age; he cannot focus on the primary erogenous zone of the next stage without resolving the developmental conflict of the immediate one. A child at a given stage of development has certain needs and demands, such as the need of the infant to nurse. Frustration occurs when these needs are not met; Overindulgence stems from such an ample meeting of these needs that the child is reluctant to progress beyond the stage. Both frustration and overindulgence lock some amount of the child's libido permanently into the stage in which they occur; both result in a fixation. If a child progresses normally through the stages, resolving each conflict and moving on, then little libido remains invested in each stage of development. But if he fixates at a particular stage, the method of obtaining satisfaction which characterized the stage will dominate and affect his adult personality. Stages of Psychosexual Theory y Oral (Birth to 1 year) Mouth is the center of pleasure Major source gratification and exploration Security is primary need Fixation: Difficulty in trusting others, nail biting, and overeating y Anal (2-3 years)

Anus and bladder are the center of pleasure Sensual satisfaction and self control A way of exerting independence Fixation: In this stage can result to obsessive-compulsive personality such as temper tantrums y Phallic (4-6 years) Fixation at the phallic stage develops a phallic character, which is reckless, resolute, self-assured, and narcissistic-excessively vain and proud. y Genital ( Puberty and after) Energy is directed toward attaining a mature sexual relationship. Our patient had three children.
ERIK ERIKSON

Psychosocial Theory Erikson believed that childhood is very important in personality development. He accepted many of Freud's theories, including the id, ego, and superego, and Freud's theory of infantile sexuality. But Erikson rejected Freud's attempt to describe personality solely on the basis of sexuality, and, unlike Freud, felt that personality continued to develop beyond five years of age. All of the stages in Erikson's epigenetic theory are implicitly present at birth (at least in latent form), but unfold according to both an innate scheme and one's upbringing in a family that expresses the values of a culture. Each stage builds on the preceding stages, and paves the way for subsequent stages. Each stage is characterized by a psychosocial crisis, which is based on physiological development, but

also on demands put on the individual by parents and/or society. Ideally, the crisis in each stage should be resolved by the ego in that stage, in order for development to proceed correctly. The outcome of one stage is not permanent, but can be altered by later experiences. Everyone has a mixture of the traits attained at each stage, but personality development is considered successful if the individual has more of the "good" traits than the "bad" traits. Stage:Generativity vs. Stagnation Generativity is the concern in establishing and guiding the next generation. Our patient belongs to middle adulthood in which creativity and concern for others was the positive indicator and he belongs to generativity versus stagnation. According to her nephew he was a good father to his children especially in guiding them to finish their
studies for them to have a better future. JEAN PIAGET

Cognitive Development Piaget¶s theory focuses on the development of cognition. Cognitive processes, such as abstract reasoning, problem solving, and intellectual growth. Develop gradually through the childhood years and reach a stable operational phase in adolescence that is subsequently refined through the childhood years. According to Piaget, cognitive development is an orderly, sequential process in which a variety of new experiences must exist before intellectual abilities can develop. Piaget proposed this theory of childhood cognitive development in 1969. Since that time, there have been many criticisms of Piaget¶s theory. Most notably, developmental psychologists debate whether children actually go through these four stages in the way that Piaget proposed, and further that not all children reach the formal operation stage. Despite this criticism, Piaget has had a major influence on all modern developmental psychologists. In addition to his proposed idea that children¶s cognitive performance is directly related to the stage they are in, he proposed four major stages of development.

The Sensorimotor Period (birth to 2 years) Discovery of relationships between sensation and motor behavior. Preoperational Thought (2 to 6/7 years) Uses of symbols to represent objects internally, especially through language. Concrete Operations (6/7 to 11/12 years) Mastery of logic and development of rational thinking. Formal Operations (11/12 to adult) Persons who reach the formal operation stage are capable of thinking logically and abstractly. They can also reason theoretically. Piaget considered this the ultimate stage of development, and stated that although the children would still have to revise their knowledge base, their way of thinking was as powerful as it would get. Our group¶s patient is in the formal operation phase, wherein he uses rational thinking and reasoning is deductive and futuristic.
ROBERT HAVIGHURST

Developmental Task Theory He believed that learning is basic to life and that people continue to learn throughout life. He promoted the concept of developmental task, which he defines as a task which arises at or about a certain period in life of an individual, which leads to his happiness and success with later task, while failure leads to unhappiness in the individual, disapproval by the society, and difficulty with late task. The developmental-task concept occupies middle ground between two opposed theories of education: the theory of freedom, the child will develop best if left as free as possible, and the theory of constraint, that child must learn to become a worthy, responsible adult through restraints imposed by his society. A developmental task is

midway between an individual need and societal demand. It assumes an active learner interacting with an active social environment. The group¶s patient belongs to middle adulthood wherein he assisted the teenage children to become responsible especially his children.

Family History During our duty on x, We interviewed the patient. According to him the only illness that there family experienced was fever and colds. They don¶t have family history regarding worst diseases. Even if they have simple life they live a healthy lifestyle. Both side of the family, the mother and father side don¶t have any experience in worst diseases. History of Present illness A month PTA, our patient had an accident. He had a cut on his posterior left heel. He then went to MedinaEmergencyHospitaland had a check-up. The doctor sutured the wound and gave him antibiotic. One month PTA, he had a difficulty in waking and he felt pain in his posterior heel. He then decided to go to the doctor and complaint about it. The doctor advised him to have a surgery.

PATHOPHYSIOLOGY OF ACHILLES TENDON TRANSECTION
Definition:

Transection of the Achilles tendon is an injury which is characterized by a tear or cut of the tendon cause by a direct trauma. Achilles tendon is the one who connects the gastrocnemius muscle to the heel causing the foot to plantar flex. Predisposing factors: 
Age  Gender (Male)  Lifestyle

Precipitating factors:
>Trauma >Overstretching the tendons >Over pronation

LEFT ACHILLES TENDON SUFFERS TRAUMATIC INJURY Achilles tendon ruptures

Complete transection or the tendon was cut off

Retraction of the calf muscles into proximal calf

Inflammation or swelling and bleeding may occur
Pain²aching, stiffness, soreness, or tenderness²within the tendon

A gap or depression may be felt and seen in the tendon about 2 inches above the heel bone.

Bruising and weakness Standing on tiptoe and pushing off when walking will be impossible.

Difficulty of walking

DIAGNOSTIC EXAM

Blood chemistry

FBS

±

105.0 mg/dl (75-115 mg/dl) Hematology

Hg ± Hct ± WBC ±

12.6 g/dl ( 13-18g/dl) 44.3 g/dl ( 40-54 g/dl) 8110 (5,000-10,000 mm3)

Differential count: Neutrophils Lymphocytes Monocytes -

67 ( 50-70%) 27 ( 20-40%) 6 ( 3-8%)

MEDICAL MANAGEMENT

Doctor¶s Order July 30, 2007 1. Please admit under my service 2. Consent for admission 3. TPR every shift and record 4. Diet as tolerated 5. Incorporate all laboratory result and CP clearance done outside 6. Schedule for surgical repair of Achilles tendon tomorrow 7:30 am under spinal anesthesia. 7. Consent for procedure.

Rationale 1. To give medical attention. 2. For legal purposes and for proper consent of the procedure to be done. 3. To monitor the patient¶s condition. 4. To provide complete nourishment to the patient. 5. To determine if there are some abnormalities with lab results and for documentation. 6. To surgically repair the patient¶s Achilles tendon. 7. For legal purposes and for proper consent of the procedure to be done since it is an invasive procedure. 8. To prevent vomiting and aspiration during the operation. 9. To provide enough fluid and

8. Nothing per Orem after midnight. 9. Start D5LR 1 liter at 40gtts/min

10. Cephalexin 1 gram caplet P.O. with sip of water at 6 AM. July 31, 2007; 9:45 am Post-operative orders 1. To RR now ± Repair of tendon of Achilles, Left, under spinal anesthesia 2. Please monitor vital signs every 15 minutes until stable then every 1 hour for 10 hours then every 2 hours for 8 hours then every 4 hours. 3. Oxygen by mask at 5-6 Liters per minute for 2 hours. 4. Nothing per Orem temporarily, may have full diet at 2 PM.

electrolytes to the patient. 10. To prevent possible infection during the operation.

1. To surgically repair any abnormalities of the patient¶s tendon of Achilles. 2. To properly monitor the patient¶s condition after the operation.

5. IVF: D5LR 1 liter for 8 hours and D5NR 1 liter for 8 hours

3. To provide enough amount of oxygen to the patient. 4. To prevent vomiting and aspirations and to provide complete nourishment to the patient, so as to regain the patient¶s energy. 5. To replace fluid and electrolytes loss and for administration of IV medications

6. Medications: y Continue Cephalexin (Ceporex) y To prevent infection. An 1 gm caplet P.O. TID antibacterial drug. y Ketorolac 30mg IV every 8 y To relieve pain. hours (-) ANST for 3 doses. y Morphine was given per spinal. y To relieve pain but morphine Morphine precautions, please precautions should be observed watch out for hypotension, and Naloxone is to counter the nausea, vomiting, pruritus and effects of Morphine overdose. respiratory depression, refer for RR < 10 mins. May give Naloxone 0.2mg IV. y Tramadol HCL 100mg IV every y To relieve pain after the effect of 8 hours to PRN for breakthrough anesthesia subsided. pain. y Metoclopramide 10mg IV every y To prevent nausea and 8 hours PRN for nausea and vomiting. vomiting. y Diphenhydramine 50 mg IV y To relieve allergic reactions like every 8 hours PRN for severe severe pruritus. pruritus. 7. Flat on bed until 2 PM 7. For proper circulation of blood. 8. Please keep Left foot elevated. 8. To help decrease swelling. 9. Intake and Output every 4 hours 9. To monitor if the patient¶s kidney is

and record. 10. Refer accordingly. July 31, 2007 1. Present IVF to consume, presently at KVO rate. 2. Keep Left leg elevated always. 3. Start Mefenamic Acid (Ponstan) 500mg 1 cap TID after every meal (to start after dinner tonight). 4. Continue hot and cold compression for 15 minutes straight.

properly functioning. And for documentation. 10. To provide proper medical attention if there are unusualities. 1. For administration of IV medications. 2. To help decrease swelling. 3. To relieve pain.

4. To help reduce swelling.

Name of Drug Generic (Brand) Cephalexin (Ceporex)

Date Ordered

Classification

Dose/ Frequency/ Route 1gm Caplet P.O TID

Mechanism of Action

7-31-07

Cephalosporins

Firstgeneration cephalosporins that inhibits cell-wall synthesis, promoting osmotic instability, usually bactericidal.

Specific Indication (why drug is ordered) To prevent possible infection during the operation.

Contraindication

Side-Effects/ Toxic Effects

Nursing Precaution

Use cautiously in patients hypersensitive to penicillin because of possibility of cross- sensitivity with other betalactam antibiotics.

CNS: dizziness, headache, fatigue, confusion, hallucination, agitation. GI: nausea, anorexia, vomiting, diarrhea, gastritis, glossitis, dyspepsia, abdominal pain. GU: genital pruritus, candidiasis, vaginitis, intestinal nephritis. Hematologic: anemia. Musculoskeletal: arthritis, arthralgia, joint pain. Skin: maculopopular and erythematous rashes, urticaria. OTHERS: anaphylaxis. 

Ask patient about past reaction to cephalosporin or penicillin therapy before giving first dose.  Tell patient to notify prescriber if rash or sign and symptoms of super infection develop.

Name of Drug Generic (Brand) Ketorolac

Date Ordered

Classification

Dose/ Frequency/ Route 30mg IV every 8 hours

Mechanism of Action

Specific Indication (why drug is ordered) To relieve pain.

Contraindication

Side-Effects/ Toxic Effects

Nursing Precaution

7-31-07

Nonsteroidal Antiinflammatory Drugs

Unknown. May inhibit prostaglandin synthesis, to produce antiinflammatory, analgesic, and anti-pyretic effects.

Contraindicated as prophylactic analgesic before major surgery or intraoperatively when hemostasis is critical; and in patients currently receiving aspirin, an NSAID, or probenecid.

CNS: dizziness, headache, drowsiness sedation. CV: edema,hypertension, palpitation, arrthythmias. GI: nausea, GI pain, vomiting, diarrhea, dyspepsia, constipation, flatulence, stomatitis. Hematologic: decrease platelet adhesion, purpura, and prolonged bleeding time. Musculoskeletal: arthritis, arthralgia, joint pain. Skin: pruritus, rash, diaphoresis. OTHERS: pain at injection site. 

NSAID may mask signs and symptoms of infection because of their antipyretic and antiinflammatory actions.  Correct hypovolemia before giving ketorolac.

Name of Drug Generic (Brand)

Date Ordered

Classification

Dose/ Frequency/ Route

Mechanism of Action

Specific Indication (why drug is ordered)

Contraindication

Side-Effects/ Toxic Effects

Nursing Precaution

Tramadol Hydrochloride

7-31-07

Opioid analgesic

100mg IV every 8 hours prn

Unknown. A centrally acting synthetic analgesic compound not chemically related to opioids. Thought to bind to opioid receptors and inhibit reuptake of norepinephrine and serotonin.

To relieve pain after the effect of anesthesia subside.

Use cautiously in patients at risk for seizures or respiratory depression; in patients with increase intracranial pressure or head injury, acute abdominal conditions or renal or hepatic impairment; or in patients with physical dependence opiods.

CNS: dizziness, headache, vertigo, somnolence, CNS stimulation, asthenia, anxiety, confusion, coordination disturbance. CV: vasodilation. EENT: visual disturbance. GI: nausea, abdominal pain, vomiting, diarrhea, dyspepsia, constipation, flatulence, anorexia, dry mouth. Musculoskeletal: hypertonia. Respiratory: Respiratory depression. Skin: pruritus, rash, diaphoresis. 

Reassess patient¶s level of pain at least 30 minutes after administration.

Name of Drug Generic (Brand)

Date Ordered

Classification

Dose/ Frequency/ Route

Mechanism of Action

Specific Indication (why drug is ordered)

Contraindication

Side-Effects/ Toxic Effects

Nursing Precaution

Metoclopramide

7-31-07

Antiemetics

10mg IV every 8 hours prn

Stimulates motility of upper GI tract, increase lower esophageal sphincter tone, and blocks dopamine receptors at the chemoreceptor trigger zone.

To prevent postoperative nausea and vomiting.

Contraindicated in patients for whom stimulation of GI motility might be dangerous (those with hemorrhage, obstruction, or perforation).

CNS: restlessness, anxiety, drowsiness, fatigue, lassitude, fever, depression, confusion. CV: transient hypertension,hypotension. GU: urinary frequency, incontinence. GI: nausea, bowel disorder, diarrhea. Skin: rash, uticaria. Other: prolactin secretion, loss of libido. 

Monitor bowel sound.

Name of Drug Generic (Brand)

Date Ordered

Classification

Dose/ Frequency/ Route

Mechanism of Action

Specific Indication (why drug is

Contraindication

Side-Effects/ Toxic Effects

Nursing Precaution

ordered)

Diphenhydramine

7-31-07

Antihistamines

50mg IV every 8 hours prn

Competes with histamines for H1-receptor sites on effector cells. Prevents, but doesn¶t reverse, histaminesmediated responses, particularly those of smooth muscle of the bronchial tubes, GI tract, uterus, and blood vessels. Structurally related to local anesthetic, diphenhydramine provides local anesthesia and suppresses cough reflex.

To relieve allergic reactions like severe pruritus.

Use with caution in patients with prostatic hyperplasia, asthma, COPD, increase intraocular pressure, hyperthyroidism, CV disease, and hypertension.

CNS: restlessness, drowsiness, fatigue, confusion, insomnia, headache, vertigo. CV: palpitation, hypertension,hypotension, tachycardia. EENT: Diplopia, blurred vision, nasal congestion, tinnitus. GU: urinary frequency, urine retention. GI: nausea, vomiting, diarrhea, dry mouth, constipation. Skin: rash, uticaria. Other: anaphylactic shock. 

Stop drug 4 days before diagnosti c skin testing because antihista mine can prevent, reduce, or mask positive skin test respons e.

DRUG STUDY Name of Patient: Mr. X

Name of Drug Generic (Brand) Mefenamic Acid ( Ponstan)

Date Ordered

Classification

Dose/ Frequency/ Route 500mg 1cap TID

Mechanism of Action

7-31-07

Analgesic

Unknown. A centrally acting synthetic analgesic compound not chemically related to opioids. Thought to bind to opioid receptors and inhibit reuptake of norepinephrine and serotonin.

Specific Indication (why drug is ordered) To relieve pain.

Contraindication

Side-Effects/ Toxic Effects

Nursing Precaution

Use cautiously in patients at risk for seizures or respiratory depression; in patients with increase intracranial pressure or head injury, acute abdominal conditions or renal or hepatic impairment; or in patients with physical dependence opiods.

CNS: dizziness, headache, vertigo, somnolence, CNS stimulation, asthenia, anxiety, confusion, coordination disturbance. CV: vasodilation. EENT: visual disturbance. GI: nausea, abdominal pain, vomiting, diarrhea, dyspepsia, constipation, flatulence, anorexia, dry mouth. Musculoskeletal: hypertonia. Respiratory: Respiratory depression. Skin: pruritus, rash, diaphoresis 

Reassess patient¶s level of pain at least 30 minutes after administration

IDEAL NURSING MANAGEMENT NURSING DIAGNOSIS: Skin/Tissue Integrity, impaired: actual/risk for May be related to Puncture injury; compound fracture; surgical repair; insertion of traction pins, wires, screws Altered sensation, circulation; accumulation of excretions/secretions Physical immobilization Possibly evidenced by (actual) Reports of itching, pain, numbness, pressure in affected NURSING DIAGNOSIS: Pain, acute May be related to Movement of bone fragments, edema, and injury to the soft tissue immobility device Stress, anxiety Possibly evidenced by Reports of pain Distraction; self-focusing/narrowed focus; facial mask of pain Guarding, protective behavior; alteration in muscle tone; autonomic responses DESIRED OUTCOMES/EVALUATION CRITERIA²PATIENT WILL: Pain Level (NOC) Verbalize relief of pain. Display relaxed manner; able to participate in activities, sleep/rest appropriately. Pain Control (NOC) Demonstrate use of relaxation skills and diversional activities as indicated for individual situation. ACTIONS/INTERVENTIONS Pain Management (NIC) Independent Maintain immobilization of affected part by means of bed rest, cast, splint, traction. (Refer to ND: Trauma, risk for [additional].) Elevate and support injured extremity. RATIONALE

Relieves pain and prevents bone displacement/extension of tissue injury.

Promotes venous return, decreases edema, and may reduce pain. Can increase discomfort by enhancing heat production in the drying cast.

Avoid use of plastic sheets/pillows under limbs in cast.

Elevate bed covers; keep linens off toes.

Maintains body warmth without discomfort due to pressure of

bedclothes on affected parts.

Collaborative Apply cold/ice pack first 24±72 hr and as necessary. Routinely administered or PCA Maintain/monitor IV patient-controlled maintains adequate blood level of analgesia (PCA) using peripheral, analgesia, preventing fluctuations in epidural, or intrathecal routes of pain relief with associated muscle administration. Maintain safe and tension/spasms. effective infusions/equipment. NURSING DIAGNOSIS: Mobility, impaired physical May be related to pain/discomfort; restrictive therapies (limb immobilization) Possibly evidenced by Inability to move purposefully within the physical environment, imposed restrictions Reluctance to attempt movement; limited ROM Decreased muscle strength/control DESIRED OUTCOMES/EVALUATION CRITERIA²PATIENT WILL: Mobility Level (NOC) Regain/maintain mobility at the highest possible level. Maintain position of function. Increase strength/function of affected and compensatory body parts. Demonstrate techniques that enable resumption of activities. ACTIONS/INTERVENTIONS Independent Encourage participation in diversional/recreational activities. Maintain stimulating environment, e.g., radio, TV, newspapers, personal possessions/pictures, clock, calendar, and visits from family/friends. Instruct patient in/assist with active/passive ROM exercises of affected and unaffected extremities. RATIONALE

Provides opportunity for release of energy, refocuses attention, enhances patient¶s sense of self-control/selfworth, and aids in reducing social isolation.

Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility; prevent contractures/atrophy and calcium resorption from disuse.

Provide/assist with mobility by means of wheelchair, walker, crutches, and canes as soon as possible. Instruct in

Improves muscle strength and circulation, enhances patient control in

safe use of mobility aids.

situation, and promotes self-directed wellness. Keeps the body well hydrated, decreasing risk of urinary infection, stone formation, and constipation.

Provide diet high in proteins, carbohydrates, vitamins, and minerals, limiting protein content until after first bowel movement.

Collaborative Consult with physical/occupational therapist and/or rehabilitation specialist.

Adding bulk to stool helps prevent constipation. Gas-forming foods may cause abdominal distension, especially in presence of decreased intestinal motility.

/surrounding area Disruption of skin surface; invasion of body structures; destruction of skin layers/tissues DESIRED OUTCOMES/EVALUATION CRITERIA²PATIENT WILL: Tissue Integrity: Skin &Mucous Membranes (NOC) Verbalize relief of discomfort. Demonstrate behaviors/techniques to prevent skin breakdown/facilitate healing as indicated. Achieve timely wound/lesion healing if present. ACTIONS/INTERVENTIONS Independent Examine the skin for open wounds, foreign bodies, rashes, bleeding, discoloration, duskiness, blanching. RATIONALE Provides information regarding skin circulation and problems that may be caused by application and/or restriction of cast/splint or traction apparatus, or edema formation that may require further medical intervention. Reduces pressure on susceptible areas and risk of abrasions/skin breakdown.

Massage skin and bony prominences. Keep the bed linens dry and free of wrinkles. Place water pads/other padding under elbows/heels as indicated. Reposition frequently. Encourage use of trapeze if possible.

Lessens constant pressure on same areas and minimizes risk of skin breakdown. Use of trapeze may reduce risk of abrasions to elbows/heels.

Plaster cast application and skin care: Cleanse skin with soap and water. Rub gently with alcohol and/or dust with small amount of a zinc or stearate powder; Collaborative Provide foam mattress, sheepskins, flotation pads, or air mattress as indicated.

Provides a dry, clean area for cast application. Note: Excess powder may cake when it comes in contact with water/perspiration.

If area under tapes is tender, suspect skin irritation, and prepare to remove the bandage system. Maintains skin integrity.

Name of Patient:Mr. X Date July 31, 2007 S SOAPIE

³Sakit kayo akong tiil mam´ as verbalized by the patient. O  facial grimace  guarding behavior(supports the affected side while moving)

A Acute pain related to a cut on the Achilles tendon and surgical incision on the affected site as evidenced by facial grimace and guarding behavior upon movement or ambulation. P At the end of 30 minutes patient will be relieve from pain. I Independent:  Observed and documented the location, severity and character of pain. (To differentiate the cause of pain and to provide information about disease progression/resolution, development of complications and

effectiveness of intervention.)  Handled the affected extremity gently by supporting it when movement. (Movement could be very painful especially if the injured site is affected.)  Instructed the client on deep breathing exercises when experiencing pain. (To promote relaxation and lessen the pain he felt.)  Positioned for comfort and function with affected part slightly elevated, and assisted with frequent changes in position. (To provide comfort and promotes venous return, decreases edema and may reduced pain.) Dependent:  Administered with prescribed analgesics (Ketorolac 50 mg. IVTT q 8hrs. and Mefenamic Acid 500 mg. TID PO). (To relieved from pain.) E At the end of 1 hour patient verbalized relieved from pain.

Date July 31, 2007 S

SOAPIE

³Dili gyudnakumalihokaku wala nga tiilbusamaglisodko og tindog og lakaw kun ako ra´ as verbalized by the patient. O  Slow movement  Limited range of motion on the lower limbs  Difficulty in walking Impaired physical mobility related to Achilles tendon impairment and pain as evidenced by difficulty in ambulating. P At the end of 2 hours the patient will be able to verbalize understanding of the situation and demonstrate participation of the activities. I Independent:  Assisted in position changes and transfers. (Encourages patient to participate in moving while preventing stress on the affected site.)

A 

Provided with safety measures and supported when ambulating. (To avoid possibility of fall and subsequent injury.)  Taught on how to use the crutches and crutch walking. (To provide a method or assistive device when ambulating.)  Encouraged to perform the activity up to the maximum capacity within the limitations of the disability. (To maintain muscle strength without putting to much stress on the injured site.)  Taught and performed active Range of Motion exercises. (To promote joint mobility and maintain muscular strength.)

E At the end of 2 hours the patient was able to participate on the activity and able to performed exercises without compromising the affected site.

Date July 31, 2007 S

SOAPIE

³Gakatol-katol akong samad og medyohapdos´ as verbalized by the patient. O  itching on the site  redness  pain Risk for infection related to the wound during the injury and the post operative wound. P At the end of 1 hour we will be able to identify risk factors and interventions to reduce potential for infection and maintain a safe aseptic environment. I Independent:  Examined the wound for signs of infections. (To determine presence of infection especially on the surgical site.)  Performed aseptic wound dressing on the site. (To

A

reduced the risk of infection.)  Applied with sterile dressing. (To prevent environmental contamination of the wound.)  Encouraged to eat foods rich in Vitamin C like citrus fruits, oranges, etc...(To increased resistance from infections.) Dependent:  Administered with prescribed antibiotic (Cephalexin 1gm Caplet P.O TID). (May be given prophylactically for suspected infection or contamination.) E At the end of 1 hour we were able to provide specific interventions to reduce the risk of infection to our patient.

PROGNOSIS

Prognostic Indicators A. Onset of Illness B. Duration of Illness C. Attitude and willingness to take medications D. Mood and Effect E. Precipitating Factors F. Depressive feature G. Family support

Poor

Good X X X X X X X

RECOMMENDATION

The patient has good prognosis. Instruct the significant others or caregivers to give extra care of the long leg-walking or patellar-tendon-hearing cast. Give clear instruction to patient in restoring functions by controlling swelling through elevating the injured extremity and applying ice as prescribed.

Patient should also be taught to control restlessness, anxiety and discomfort such as giving reassurance, position changes and pain relief strategies including analgesic.

Moreover, isometric and muscle setting exercise are encouraged to promote circulation. However with internal fixation the attending physician determine the amount of movement and weight bearing stress the extremity can tolerate and prescribes the level of activity.

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