COLEGIO SAN AGUSTIN - BACOLOD

COLLEGE OF HEALTH AND ALLIED PROFESSIONS

NURSING PROGRAM
B.S. Aquino Drive, Bacolod City
Contact Number: (034) 434-2471
Local 162 Email Address:
csab.chap@gmail.com

PROBLEM BASED-LEARNING WRITTEN

REQUIREMENT 2ND SEMESTER AY 2022 –
2023
(LEVEL 3 & 4)
LEVEL: 3 GROUP #: 12
AREA OF ROTATION: Surgical Ward DATE: May 10 - 12, 2023

SUMMARY/OVERVIEW OF THE CASE:

Mrs. D., a 77-year-old Black American woman, was taken to the emergency room on a snowy
morning after falling onto her right hip. She claimed she was just checking the mail when she
slipped on the ice beneath the snow. Her physical examination revealed additional complications,
including osteoporosis which was why she is currently being treated with alendronate sodium
(Fosamax). Moreover, she also has a history of falls and was medically diagnosed as having an
extracapsular fracture. She was scheduled for an open reduction and internal fixation (ORIF)
surgery which will help with the fixation and alignment of the broken bones.

I. Patient’s Assessment
Subjective DATE/TIME
Data/s: The patient verbalized (Preoperative):
Patient
History “I just wanted to check the mail. I was making my way
down my front walk slowly. I had my good boots on but
there must have been ice under the snow and I slipped. It
all happened so fast I was up, I was down and here I am”.

“Every time I move, my right hip hurts.”

"My doctor had already identified osteoporosis as my

condition. I'm now taking Fosamax for it.”

"I had neck and back issues when my menopause began

at the age of 53.”

“My daughter and I had noticed a change in my posture

even before I was diagnosed with osteoporosis. But, since
being diagnosed, I've noticed that it worsens over time.”

(Postoperative)

“I can't properly move my right leg”

“Will I be able to walk once I'm discharged?”

“I find it difficult to move because of my surgery. I am

worried that I might need to reduce my physical activities.”

“I am scared that I won’t be able to recover from this”

 Objective
Data/s: Vital signs:
Physical
Assessment - BP: 110/70 mmHg (90/60-120/80 mmHg)
- RR: 15 cpm (12-18 cpm)
- PR: 90 bpm (60-100 bpm)
- TEMP: 37 °C (36.5 °C-37.3°C)
- O2 sat: 97% (95-100%)

Physical Assessment:

- Bruise on the right hip noted

- Sullen look noted
- Facial grimace noted
- Limited range of motion noted
- Hesitance to move due to fear of pain noted
- Pain scale - 5/10
- Weight - 75 kg
- Height - 5’5
Diagnostic - Pelvic X-ray
Studies and - Bone density test
Procedures

II. Pathophysiologic Basis: Illustrates: Definition, Concept of the

disease/procedure, Etiology, Pathophysiological Information

Osteoporosis is a metabolic bone

disease that, on a cellular level, results
from osteoclastic bone resorption not
compensated by osteoblastic bone
formation. This causes bones to
become weak and fragile, thus
increasing the risk of fractures. It
affects men and women of all races.
But white and Asian women,especially
older women who are past
menopause, are at highest risk.

In our patient, her physical history showed that she has osteoporosis which
explains why her bones are brittle other than the fact that she is old that led
her to have extracapsular fracture after she fell. Extracapsular fracture is a
fracture of the neck of the femur which occur outside the capsule of the hip
joint. It is most commonly a fracture of elderly, osteoporotic bone. She is
then scheduled for a Open reduction and internal fixation (ORIF) surgery. A
surgery used to stabilize and heal a broken bone. The surgeon will make an
incision in your hip to reach the injured bones. Then, the bones will be
realigned, or you might receive an implant to replace part of your bone or
joint. Metal hardware will hold the bones and joint together while your hip
heals. Hence, the reason why she cannot move for quite a period of time
since she is already at the old age and has a slow healing time for the
fractured bone. Therefore, she is currently in the state of immobility where
she couldn’t walk nor move and even perform her activities of daily living.

III. Analysis/Nursing Diagnosis: Formulation of Nursing Diagnosis based on the

Information gathered

NURSING DIAGNOSIS:
 - Impaired Physical Mobility related to extracapsular fracture

RATIONALE:

Osteoporosis, a musculoskeletal ailment that makes bones weak and brittle, was previously
discovered in our patient. Because of this condition, even minor pressures like coughing or
bending over might cause a fracture. Hip, wrist, and spine fractures brought on by osteoporosis
are the most frequent. Bone is a living tissue that undergoes continuous resorption and
replacement.Osteoporosis develops when the production of new bone is insufficient to counteract
the loss of existing bone. Men and women of various races are affected by it. The risk is greatest
for white and Asian women, particularly older women who have passed menopause. She was
found to have an extracapsular fracture in her right hip as a result of her previous medical history,
which contributed to her current fall. A bone fracture known as an extracapsular fracture can occur
close to a joint.Extracapsular fractures traverse the femur within the area of bone bounded by the
intertrochanteric line proximally, up to a distance of 5 cm from the distal part of the lesser
trochanter. Several classification methods have been proposed to define different types of
extracapsular fractures. In order to reach the damaged bones, our surgeon will create an incision
in the hip. Our patient is unfortunately unable to walk, move, or even carry out her everyday tasks
due to her immobility. The goal is for the patient to be able to function at an adequate and optimal
level once again.

IV. Nursing Therapeutic Plan Development and Implementation of Care

NURSING THERAPEUTIC PLAN
A. Plan for Health Promotion
A.1 Physiologic
1. Encourage patient to have physical
therapy if not contraindicated
IMPLEMENTATION OF CARE
A. Independent Nursing Care
A.1. Physiologic Care
1. Assess for impediments in mobility
Rationale: Identifying barriers to
mobility guides design of an optimal
treatment plan

2. Evaluate patient’s ability to

perform activities of daily living
efficiently and safely
Rationale: Restricted movements
influence the capacity to perform most
activities of daily living.

2. Encourage patient to use assistive 1. Provide patient with assistive

devices
3. Encourage patient to do muscle
exercises as able or when allowed
out of bed
4. Promote and Facilitate
ambulation when possible
5. Consume enough fluids and
electrolytes to prevent tissue
dehydration and to support
optimum organ and cellular
devices such as wheelchair, canes,
transfer bars, ets
Rationale: correct utilization of
assistive devices can enhance activity
and lessen
the dangers of fall
1. Assist patient in performing
muscle exercises
Rationale: adds to gaining enhanced
sense of balance and strengthens
compensatory body arts
early
1. Aid patients in each initial change
such as dangling legs, sitting in a
chair, ambulation.
Rationale: These movements keep
the patient as functionally working as
possible. Early mobility increases self
esteem about reacquiring
independence and reduces the chase
that debilitation will transpire.
1. Urge the patient to drink the
prescribed amount of fluid.
Rationale: Older patients have a
 function.
A.2. Psychosocial
1. Verbalize relief and reduced anxiety
and stress in any situations
2. Insist on the value of having a
support system and a solid
relationship with kin.
1. Give positive reinforcements during
activity.
A.3 Spiritual
1. Recognize and respect the patient's
religious conviction.
decreased sense of thirst and may
need ongoing reminders to drink.
2. Recommend other fluid sources.
Rationale: other fluid sources such
as flavored guillotine, frozen juice
bars, sports drinks can encourage the
patient to drink as it also facilitates
fluid replacement.
A.2. Psychosocial Care
1. Establish rapport by introducing
yourself and inform patient about
the procedures to be done
Rationale: To reduce anxiety and
increase cooperation.
1. Give information about the
patient’s current health status
Rationale: To reduce anxiety and
promote cooperation.
1. Provide emotional support
through verbal and non-verbal
communication.
2. Provide a safe space for the
patient by allowing them to
verbalize fears and feelings about
their current illness.
Rationale: This build a trusting
relationship with the patient
3. Allow the patient to communicate
with his/her family in a calm and
relaxing manner
Rationale: This assures the patient
that he/she has adequate support
4. Encourage patient in doing
activities by positive
reinforcements
Rationale: This boost patient’s self-
esteem
A.3 Spiritual Care
1. Check for the patient's own
cultural beliefs and norms.
Rationale: to avoid any
misunderstanding between the nurse
and patient
2. Take cues from the patient.
Rationale: When bringing up
spiritual health with patients,
understanding this may be a difficult
topic for them to discuss. Let them
lead the conversation and do not
press further than they want to share
3. Listen to a patient’s fears and
concerns without adding your
own stories.
Rationale: In an effort to empathize
with a patient who is telling their
story, it is easy for the nurse to start
adding personal examples from their
own life.
2. Show a spirit of spirituality.
3. Realize the significance of spiritual
guidance.
B. Plan for Health Restoration and
Maintenance
B.1 Pharmacologic
1. Alendronate Sodium (Fosamax)
- Dosage: Adults: 10 mg PO once daily
in the morning or 70 mg once weekly.
- Mechanism of Action:
Bisphosphonate binds to
hydroxyapatite crystals and inhibits
osteoclast-mediated bone resorption;
decreases mineral release and
collagen or matrix breakdown in bone.
- Indication: Prevention and treatment
of osteoporosis in postmenopausal
women, Paget's disease. Treatment of
glucocorticoid-induced osteoporosis.
B.2 Nutrition and Diet
1. Emphasize the importance of proper
and appropriate nutritional intake.
2. Ensure good hydration at all times.
1. Pray with the patient if requested
(or provide someone who will).
Rationale: Some nurses may feel
reluctant to pray with patients when
they are asked for various reasons.
They may feel underprepared,
uncomfortable, or unsure if they are
“allowed to.” Nurses are encouraged
to pray with their patients to support
their spiritual health, as long as the
focus is on the patient’s preferences
and beliefs, not the nurse’s.
1. Ask the patient how you can
support them spiritually.
Rationale: An important way to
assist a patient with their spiritual
health is to ask them what they need
to feel supported in their faith and
then try to accommodate their
requests, if possible.
2. Support patients within their own
faith tradition.
Rationale: Because patients can
sometimes feel as if they are a
captive audience, it is not
appropriate for the nurse to take this
opportunity to attempt to persuade a
patient towards a preferred religion
or belief system.
B. Interdependent Care
B.1. Pharmacologic
1. Give in at AM with a full glass of
water at least 30 minutes before the
first beverage, food, or medication of
the day.
2. Monitor serum calcium levels before,
during, and after therapy.
3. Ensure adequate vitamin D and
calcium intake.
4. Provide comfort measures if bone
pain returns.
5. Report twitching, muscle spasms,
dark-colored urine, severe diarrhea.
B.2. Nutrition and Diet
1. Encourage the patient to increase
adequate fluid intake unless
contraindicated.
Rationale: Fluid intake helps make
the stool soft and moist for easier
elimination.
2. Assess the patient’s food choices
by taking a nutritional history with
the participation of significant
others.
Rationale: Aside from physical
assessment, a comprehensive
understanding of the patient’s
nutritional history is necessary to

3. Identify food and fluids to be
included in the meal that are
appropriate for the patient.
B.3. Surgical Intervention
Open Reduction and Internal Fixation
(ORIF) Surgery
- Puts pieces of a broken bone into
place using surgery. Screws, plates,
sutures, or rods are used to hold the
broken bone together. An incision will
be made in the skin above the break.
The pieces of bone will be moved into
the right place. A plate with screws, a
pin, or a rod that goes through the
bone will be attached to the bone to
hold the broken parts together. The
incision will be closed with staples or
stitches and covered with bandages.
The area will be protected with a splint
or cast.
determine the degree of malnutrition
accurately, if present, and metabolic
energy needs. It is necessary to
assess their usual daily food intake
before improving patients’ dietary
habits or offering them nutritional
guidance.
3. Discourage caffeinated or
carbonated beverages.
Rationale: These beverages can
spoil the patient’s appetite by
decreasing hunger and can lead to
early satiety.
4. Offer high protein supplements
based on individual needs and
capabilities.
Rationale: Such supplements can
increase calories and protein without
conflict with voluntary food intake.
B.3 Surgical Intervention
PREOPERATIVE
1. Assess the patient’s vital signs.
Ask the patient to rate the pain
from 0 to 10, and describe the
pain he/she is experiencing.
Rationale: To create a baseline set
of observations for the patient. The
10-point pain scale is a globally
recognized pain rating tool that is
both accurate and effective.
2. Maintain immobilization of
affected parts by means of bed
rest, cast, splint, traction.
Rationale: Relieves pain and
prevents bone
displacement/extension of tissue
injury.
3. Elevate and support injured
extremity.
Rationale: Promotes venous return
decreases edema and may reduce
pain.
4. Explain procedure before
beginning them.
Rationale: Allows patients to
prepare mentally for activity and to
participate in controlling levels of
discomfort.
INTRAOPERATIVE
1. Intraoperative patient safety: ask
patient to lay down and position
patient to the proper position
appropriate to the surgery to be
performed
Rationale: Reduced risk of
complications or untoward outcomes
2. Inform patient or SO of nurse’s
intraoperative advocate role.
 Rationale: Develops trust and
rapport, decreasing fear of loss of
control in a foreign environment.
3. Tell patient anticipating local or
spinal anesthesia that drowsiness
and sleep occurs, that more
sedation may be requested and
will be given if needed, and that
surgical drapes will block view of
the operative field.
Rationale: Reduces concerns that
patient may “see” the procedure.
4. Compare surgery schedule,
patient identification band, chart,
and signed operative consent for
surgical procedure.
Rationale: Provides for positive
identification, reducing fear that
wrong procedure may be done.

POSTOPERATIVE

1. Promoting Patient Safety

Rationale: When transferred to the
stretcher, the patient should be
covered with blankets and secured
with straps above the knees and
elbows. These straps anchor the
blankets at the same time restrain
the patient should he or she pass
through a stage of excitement while
recovering from anesthesia. To
protect the patient from falls, side
rails should be raised.

2. Keep airway in place until the

patient is fully awake and tries to
eject it.
Rationale: The airway is allowed to
remain in place while the client is
unconscious to keep the passage
open and prevents the tongue from
falling back. When the tongue falls
back, airway passage obstruction will
result. Return of pharyngeal reflex,
noted when the patient regains
consciousness, may cause the
patient to gag and vomit when the
airway is not removed when the
patient is awake. Suction secretions
as needed.

3. Encourage most surgical patients

to ambulate as soon as possible.
Rationale: Remind patient of the
importance of early mobility in
preventing complications (helps
overcome fears).
V. Evaluation of the presented plan of Care

1. Goal Achieved. After providing the patient with appropriate nursing care, she was able to
perform activities with least amount of assistance as evidenced by:

Subjective:
“Thank you so much, Nurse! My range of motion is no longer that restricted. Although I am
still unable to perform some of my previous daily activities, I can notice some
improvements, such as being able to slowly walk to the bathroom to pee or poop on my
own."

Objective:
Scored 7 on the Scale of Basic Activities of Daily Living (ADL)
- Hygiene - Assistance for several parts of the body (2)
- Dressing - Needs assistance in choosing clothing, getting dressed, and remains partially
or completely undressed (2)
- Toileting - Needs to be accompanied - Needs assistance (1)
- Locomotion - Needs assistance (1)
- Continence - Continent (0)
- Meals - Needs assistance to cut meat or peel fruit (1)

2. Goal Achieved. After providing the patient with appropriate nursing care, she was able to
use learned methods to maximize independence as evidenced by:

Subjective:
"I've been using assistive devices ever since I learned how to do so. When I get out of
bed, I use the transfer bar, and when I want to walk around, I use a cane."

3. Goal Achieved. After providing the patient with appropriate nursing care, she was able to
verbalize increased feeling of strength as evidenced by:

Subjective:
“I'm gradually regaining my strength these days. I can finally get out of bed, unlike before
when I used to lay all day. I'm not as weak as I used to be. In my current situation, I am
now optimistic. I know that I will be able to recover and resume my previous activities in no
time.”

PREPARED BY:
GROUP 12 - BSN-3C
- GATILOGO, PAUL VINCENT
- NEGRITO, MARY JO
- PANISA, ALYSSA
- PINEDA, ABEGAIL
- RAMOS, ALEXIE ADRIANNE
- RESULA, AIRIEL MAE
- RIVERA, AZ
- VERGARA, ROSHANNE DANICA
- WALDATO, NINA YZABELLA

ENDORSED BY:

APPROVED BY:
REYMA MIJARES
MAGBANUA, RN, MAN DEAN