case study weh

8/8/2019 Case Study Weh

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I. Patients DataA. General DataName: Patient PalabiroAddress: Dura, Tarlac City

Age: 26

Sex: Male

Birth Date: December 13, 1983

Religion: Roman Catholic

Nationality: Filipino

Civil status: Single

Rank in the family: 4th

son

Date of Admission: July 31, 2010Order of Admission: emergency repair on his right leg

Attending Physician: Dr. Relem Jessie

B. Chief complaint:Sudden pain in the right extremities of the patient due to the trauma from a motor cycle accident

C. Presence illness status:Presence of fracture on right leg to tibia up to fibula

D. Past Health Status:Childhood illness fever and chicken pox

Immunization only once, BCG on his first shotMajor illness None

Allergy None

E. Family AssessmentMember Relation Age Sex Occupation Educational

Attainment

1st

son

2nd

son

3rd

son

5th daughter

6th

son

Mother

Father

Brother

Brother

Brother

Sister

Brother

Mother

Father

36

34

32

24

22

53

60

Male

Male

Male

Female

Male

Female

Male

Construction

None

None

None

None

Housewife

Farmer

High school

High school

High school

High school

High school

Elementary

High school


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F. System Review1. Health Perception Pattern:

Pt. Perception about Health: ang buhay parela-relax langPt. Perception about illness: Buwisit yan sa Buhay

Pt. Perception about Health maintenance and habit: Basta Walang problema, ayos

Compliance w/ prescribe Medication: No Reaction

2. Nutritional Metabolic Pattern:Food: mostly Leafy Vegetable and rarely on fish and meat

Water: pt. consumed 10 glasses of water every day

Beverage: Mostly, the Pt. consumes Liquor and beer

3. Elimination patternBowel:Habits: plain naked during defecation

Odor: Aromatic

Consistency: Thick

Laxative use: none

Bladder:

Color: Dark orange

Odor: Aromatic

Alteration: none

4. Activity Exercise Pattern:Feeding - 0 Dressing - II Grooming II

Bathing - II Toileting - II Cooking - IV

Bed mobility - II Home Maintenance - III Other - 0

Legend:

0 Full careI Need for Equipment

II Need for Assistance

III Both

IV Dependent


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5. Cognitive perceptual pattern:Hearing: no use of equipment

Vision: no use of equipment

Sensory perceptual: to his opinion its okay

Learning style: responsive but no reaction about the topic

6. Sleeping rest pattern:Special sleeping problem: None

Hours of sleep: in day, he sleeps in 3 hours but in night he sleeps 11 hours

Alteration: none

Sleeping aids: none

7. Self Perception pattern:Felling about his current health status: kawawa naman akoDescription about his self: palabiro

Capabilities and weakness: malakas ako sa lahat pero hindi sa babae

Decription about Self Worth: sobrang halaga ko sa sarili ko noh

8. Role Relation pattern:Description about his role in the family: Wala nakahiga lang ako

Description about his role in the Work: no answer due to him has any any work at all

Description about his role in the Social Community: wala tambay lang ako

9. Sexual Reproduction PatternContraceptive: noneSexual Activity: none

Reproductive Problem: none

History of sex abuse: none

10. Coping stress tolerance Pattern:Perception about Stress: Pt. has no idea of stress because on his state that he only serve as a tambay

Coping Activities During Stress: none

11. Value Belief Pattern:Value Belief: none, the patient belief only him self

Religion and spiritual Belief: none because pt. is rarely go to church and belief about the bibleG. Herodo-familial Illness

Paternal illness: none

Maternal illness: none


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H. Developmental History:Theorist Age of the pt. Sex Pt. description

Erickson On the grade 1 day as he stated Male nung bata ako hnd ako halos takotsa tatay ko,alam mu n medyo

matapang na ako noon

Freud 11 years old Male Medyo pinagpa2ntasiyaan ko

noon mga klasse ko nun

Piaget 15 years old Male bad boy ako noon,sakit nga daw

kami ng ulo

Kohlberg 15 years old Male wala akong masyadong ginagawa

noon na matino eh

fowler On his present age Male Hay tanda kong to medyo hindi

na ako naniniwala kung minsan

II. Physical Assessment1. General Survey:Pt. is on bed with a presence of dressing on his right leg with an positive mood but no proper gaits and posture

Vital Signs:

Bp: mmhg

PR: Cpm

RR: Bpm

T: C

2. Head, hair and face:Pt. has a normocephalic and in round shape with a presence of hematoma on the right eye and papule on the fore head3. Eyes:Pt. eye has a normal vision, with no vision aid required and also pupil reacted on light but there is a presence of hematoma on the peri-orbital of

his right eye

4. NosePt. nose is symmetrical and no anomalies and masses, no discharge and also the color is paired to the skin color

5. EarsPt. ears is symmetrical and a lined with each other, no presence of discharge and masses


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6. Mouth and throatPt. mouth is symmetrical with an occurrence of burses in the upper lip and has a dark scaly lips, tenderness occur on the lips but not on the inner

mouth and throat

7. Neck and lymph nodes:Pt. neck is symmetrical and with tenderness of the lymph nodes

8. Skin and mucus membranePt. skin is in color dark brown with a masses on the forehead and a presence of hematoma on the right peri-orbital with dry mucosa on the lips

and eyes and most fully dry skin

9. NailsPt. nail is in fleshy color appropriate to the mucus membrane with a normal capillary refill and no abnormalities

10. Thorax and lungs:Pt. has a normal RR and no presence of abnormal sound in the lung and the chest wall is in normal range of 2:111. Cardio-VascularPt. has a normal rate with no anomalies but presence of barchycardia

12. Breast and axillaPt. breast is symmetrical and no masses has been palpated

13. AbdomenPt. abdomen is flat and round and presence of burborigmus found and no other abnormal sound detected

14. Extremities:Pt. Extremities is all normal except on his right lower leg due to the fracture

15. Neuro-carnial nervesAll nerves are functioning well16. Rectal and analNot asses

17. GenitalNot asses

III. Personal and Social History:a. Habit and vices: sleeping mostlyb. Caffeine: 1 cup per dayc. Smoke: 1 pack per dayd. Alcohol: 5 bottle per drinking sessione. Drugs: nonef. Lifestyle: always relax and inactiveg. Social affiliation: drinking session and palanith. Rank in the Family: 4th soni. Educational attainment: high school graduate

IV. Environmental healthhistory:Pt. stated that in there community there are always fight seen and prone to chismosa area


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V. Introduction of the diseaseBone fracture

yIs 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 termed pathological fracture.

Types:

Closed (simple) fractures

Are those in which the skin is intact.

Open (compound) fractures

Involve wounds that communicate with the fracture, or where fracture hematoma is exposed, and may

thus expose bone to contamination.Other types:

Complete fracture: A fracture in which bone fragments separate completely.

Incomplete fracture: A fracture in which the bone fragments are still partially joined.

Linear fracture: A fracture that is parallel to the bone's long axis.

Transverse fracture: A fracture that is at a right angle to the bone's long axis.

Oblique fracture: A fracture that is diagonal to a bone's long axis.

Spiral fracture: A fracture where at least one part of the bone has been twisted.

Comminuted fracture: A fracture in which the bone has broken into a number of pieces.

Compacted fracture: A fracture caused when bone fragments are driven into each other.

Signs and Symptoms

Local pain

Local bleeding

Local swelling

Deformity or dislocation

Symptoms of associated nerve damage: Numbness; Paralysis

Loss of pulse below fracture

Complication

y Bleedingy Hemorrhagey Shocky Deathy Circulatory problems


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y EmbolismDiagnostic test and treatment

y Physical examinationy X-raysy Computed tomography scanPain management

Ibuprofen has been found to be equally effective as the combination of acetaminophen and codeine.

Immobilization

Since bone healing is a natural process which will most often occur, fracture treatment aims to ensure the best possiblefunction of the injuredpart after healing.

Surgical procedure

Bone grafting

-repairing of the damage bone

Electrical bone growth stimulation or osteostimulation

-Has been attempted to speed or improve bone healing.


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VI. Anatomy PhysiologyFibula

y Although this bone runs parallel to the Tibia, it doesnt actually carry much weight. Instead, it acts as a stabilizer. It articulates with the Tibiaand the Talus. Its inferior end (Lateral Malleolus) is the bone that sticks out on the outside of the ankle. The Fibula can be found on the

lateral side (outside) of the lower leg.

Tibia

y The Tibia articulates with the Femur (upper leg) and the Talus (Ankle). This bone carries all the bodys weight. It is the main bone of the lowerleg and can be found on the more medial side of the leg.

Lower leg fractures include fractures of the tibia and fibula. Of these two bones, the tibia is the only weightbearing bone. Fractures of the

tibia generally are associated with fibula fracture, because the force is transmitted along the interosseous membrane to the fibula.The skin and subcutaneous tissue are very thin over the anterior and medial tibia and as a result of this, a significant number of fractures to

the lower leg are open. Even in closed fractures, the thin, soft tissue can become compromised. In contrast, the fibula is well covered by soft

tissue over most of its course with the exception of the lateral malleolus.

The tibia and fibula articulate at the proximal tibia-fibular syndesmosis.

Fractures of the tibia can involve the tibial plateau, tibial tubercle, tibial eminence, proximal tibia, tibial shaft, and tibial plafond.


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This are the common fracture in tibia associated with the fracture of the fibula:

Tibial plateau fractures. Line drawings of Schatzker types I, II, and III tibial plateau fractures. Type I consists of a wedge fracture of the lateral

tibial plateau, produced by low-force injuries. Type II combines the wedge fracture of the lateral plateau with depression of the lateralplateau. Type III fractures are classified as those with depression of the lateral plateau but no associated wedge fracture.

Tibial plateau fractures. Line drawings of Schatzker types IV, V,

and VI tibial plateau fractures. Type IV is similar to type I fracture, except that it involves the medial tibial plateau as opposed to the lateral

plateau. Greater force is required to produce this type of injury. Type V fractures are termed bicondylar and demonstrate wedge fractures of

both the medial and lateral tibial plateaus. Finally, type VI fractures consist of a type V fracture along with a fracture of the underlying

diaphysis and/or metaphysis.

Reference:

y Lippincott William and willcot medical-surgical booky Nursingcrib.comy eMedicine.comy WrongDiagnosis.comy Google.com.ph


10/22

VII. Pathophysiology

Motorcycle accident occur

Sudden impact traumatize the right leg of the patient

Trauma, break down the skeletal cells on the right tibia and fibula and also cut the skin of the patient

Break down May causes cracking and breaking of the tibia and fibula

Disposition bone, fragment and point edge of the cracked or break tibia and fibula, causes injury to the arteries and nerves

Sudden accumulation of blood in the fractured site that may causes enlargement on the traumatize leg

Signs and Symptom


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VIII. Laboratory and Diagnostic ResultHematology Result

Date: August 01, 2010

Patient: ----------------

Physician: Mendoza

Test Result Reference Range

WBC: 15.4 G/L

LYM: 2.3 R2 14.7 % L

*MID: 0.6 3.9 % M

GRAN: 12.5 81.4 % G

4.1 10.9 G/L

0.6 4.1 10.0 58.5 % L

0.0 1.8 0.1 24.0 % M

2.0 7.8 37.0 92.0 % G

RBC: 4.77 T/L

HCB: 103. g/L

HCT: .327 L/L

MCV: 68.5 fL

MCH: 21.6 PG

MCHC: 315. g/L

4.20 6.30 T/L

1.20- 180. g/L

.370 - .510 L/L

80.0 97.0 fL

26.0 32.0 PG

310. 360. g/L

PLT: 189. G/L 140 440 G/L

Significance:

Based on the result, the increase of WBC and GRAN indicates about a invasion of Microorganism; this is a way of our body to defend it self from

microbes, in the other hand the sudden decrease of HCB, HCT, MCV, and MCH is indicating an episode of bleeding, this factor factors are affectedduring blood lost.


12/22

IX. Drug StudyGeneric name: Ketorolac

Brand Name: Ketorolac

Drug Classification: analgesic, anti-inflammatory and anti-Pyretic

Dosage: 2 ml per IV push

Indication: post-op pain and hyperthermia

Mechanism of action Side effect and Adverse

Reaction

Contraindication Nursing Consideration

- Inhibits prostaglandin

synthesis, producing

peripherally mediatedanalgesia

- Also has antipyretic and

anti-inflammatory

properties.

- CNS:

1) drowsiness

2) abnormal thinking3) dizziness

4) euphoria

5) headache-

- RESP:

1) asthma

2) dyspnea

- CV:

1) edema

2) pallor3) vasodilation

- GI:

1) GI Bleeding

2) abnormal taste

3) diarrhea

4) dry mouth

5) dyspepsia

6) GI pain

7) nausea- GU:

1) oliguria

2) renal toxicity

3) urinary frequency

- DERM:

1) pruritis

2) purpura

3) sweating

- Hypersensitivity

- Cross-sensitivity with

other NSAIDs mayexistPre- or perioperative

use

- Known alcohol

intoleranceUse cautiously

in:

1) History of GI bleeding

2) Renal impair-ment

(dosage reduction may be

required)3) Cardiovascular disease

- Patients who have asthma, aspirin-induced allergy, and nasal polyps

are at increased risk for developing hypersensitivity reactions. Assess

for rhinitis, asthma, and urticaria.- Assess pain (note type, location, and intensity) prior to and 1-2 hr

following administration.

- Ketorolac therapy should always be given initially by the IM or IV

route. Oral therapy should be used only as a continuation of

parenteral therapy.

- Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs,

acetaminophen, or other OTC medications without consulting health

care professional.

- Advise patient to consult if rash, itching, visual disturbances, tinnitus,weight gain, edema, black stools, persistent headche, or influenza-like

syndromes (chills,fever,muscles aches, pain) occur.

- Effectiveness of therapy can be demonstrated by decrease in

severity of pain. Patients who do not respond to one NSAIDs may

respond to another.


13/22

4) urticaria

- HEMAT:

1) prolonged bleeding

time

- LOCAL:

1) injection site pain

- NEURO:

1) paresthesia

- MISC:

1) allergic reaction,

anaphylaxis


14/22

Generic name: Cefuroxime Sodium

Brand Name: Cefuroxime

Drug Classification: anti-infective; antibiotic; second-generation cephalosporin

Dosage: 5 ml every one IV Push

Indication: for the other cephalosporins, although as a second-generation it is less susceptible to Beta-lactamase and so may have greater activity

against Haemophilus influenzae, Neisseria gonorrhoeae and Lyme disease.


Reaction


Inhibit any microorganism

during invasion

Diarrhea, nausea,

vomiting,

headaches/migraines,

dizziness and abdominalpain.

Hypersensitivity to

cephalosporins.

y Determine history of hypersensitivity reactions tocephalosporins, penicillins, and history of

allergies, particularly to drugs, before therapy is

initiated.y Lab tests: Perform culture and sensitivity tests

before initiation of therapy and periodically

during therapy if indicated. Therapy may be

instituted pending test results. Monitor

periodically BUN and creatinine clearance.

y Inspect IM and IV injection sites frequently forsigns of phlebitis.

y Report onset of loose stools or diarrhea.Although pseudomembranous colitis (see Signs &Symptoms, Appendix F) rarely occurs, this

potentially life-threatening complication should

be ruled out as the cause of diarrhea during and

after antibiotic therapy.

y Monitor for manifestations of hypersensitivity(see Appendix F). Discontinue drug and report

their appearance promptly.

y Monitor I&O rates and pattern: Especiallyimportant in severely ill patients receiving highdoses. Report any significant changes.


15/22

Generic name:ranitidine hydrochloride

Brand Name: Ranitidine

Drug Classification: GASTROINTESTINAL AGENT; ANTISECRETORY (H2-RECEPTOR ANTAGONIST)

Dosage:

Indication: Short-term treatment of active duodenal ulcer. Most patients heal within 4 weeks. Studies available to date have not assessed the

safety of Ranitidine in uncomplicated duodenal ulcer for periods of more than 8 weeks.


Reaction


Potent anti-ulcer drug that

competitively and

reversibly inhibits

histamine action at H2-receptor sites on parietal

cells, thus blocking gastric

acid secretion. Indirectly

reduces pepsin secretion

but appears to have

minimal effect on fasting

and postprandial serum

gastrin concentrations or

secretion of gastricintrinsic factor or mucus

None y Symptomaticresponse to therapy

with Ranitidine does

not preclude thepresence of gastric

malignancy.

y Since Ranitidine isexcreted primarily by

the kidney, dosage

should be adjusted in

patients with

impaired renal

functiony Rare reports suggest

that Ranitidine may

precipitate acute

porphyric attacks in

patients with acute

porphyria. Ranitidine

should therefore be

avoided in patients

with a history of acute

porphyria.

y Potential toxicity results from decreased clearance(elimination) and therefore prolonged action; greatest in

the older adult patients or those with hepatic or renal

dysfunction.

y Lab tests: Periodic liver functions. Monitor creatinineclearance if renal dysfunction is present or suspected.

When clearance is


16/22

Generic name:metronidazole

Brand name: Metronidazole

Drug Classification: Anti-infectives,Anti-protozoals

Dosage: 2.5 ml per IV push

Indication: Amebicide in the management of amebic dysentery

Mechanism of action Side effect and Adverse Reaction Contraindication Nursing Consideration

Disrupts DNA and protein synthesis in

susceptible organisms

Bactericidal, or amebicidal action

CNS: seizures, dizziness, headache

GI: abdominal pain, anorexia,

nausea, diarrhea, dry mouth, furry

tongue, glossitis, unpleasant taste,

vomiting

Hematologic: leukopenia Skin: rashes, urticaria

hypersensitivity Administer with food or milk to minimize GI

irritation. Tablets may be crushed for

patients with difficulty swallowing.

May cause dizziness or light-headedness.

Caution patient or other activities requiringalertness until response to medication is

known.

Inform patient that medication may cause

an unpleasant metallic taste.

Inform patient that medication may cause

urine to turn dark.

Advise patient to consult health care

professional if no improvement in a few

days or if signs and symptoms of

superinfection (black furry overgrowth on

tongue; loose or foul-smelling stools

develop).


17/22

Generic name:Gentamicin

Brand name:Gentamicin

Drug Classification: antiinfective; aminoglycoside antibiotic

Dosage: IV/IM 2 mg/kg followed by 1.5 mg/kg q8hIndication:Parenteral use restricted to treatment of serious infections of GI, respiratory, and urinary tracts, CNS, bone, skin, and soft tissue (including

burns) when other less toxic antimicrobial agents are ineffective or are contraindicated. Has been used in combination with other antibiotics. Also

used topically for primary and secondary skin infections and for superficial infections of external eye and its adnexa.

Mechanism of action Side effect and Adverse Reaction Contraindication Nursing Consideration

Broad-spectrum aminoglycoside

antibiotic derived

fromMicromonospora

purpurea. Action is usuallybacteriocidal.

Special Senses: Ototoxicity (vestibular

disturbances, impaired hearing),

optic neuritis. CNS: neuromuscular

blockade: skeletal muscle weakness,apnea, respiratory paralysis (high

doses); arachnoiditis (intrathecal

use). CV: hypotension or

hypertension. GI: Nausea, vomiting,

transient increase in AST, ALT, and

serum LDH and bilirubin;

hepatomegaly, splenomegaly.

Hematologic: Increased or decreased

reticulocyte counts;granulocytopenia, thrombocytopenia

(fever, bleeding tendency),

thrombocytopenic purpura, anemia.

Body as a Whole: Hypersensitivity

(rash, pruritus, urticaria, exfoliative

dermatitis, eosinophilia, burning

sensation of skin, drug fever, joint

pains, laryngeal edema, anaphylaxis).

Urogenital: Nephrotoxicity:proteinuria, tubular necrosis, cells or

casts in urine, hematuria, rising BUN,

nonprotein nitrogen, serum

creatinine; decreased creatinine

clearance.

History of hypersensitivity to or toxic

reaction with any aminoglycoside

antibiotic. Safe use during pregnancy

(category C) or lactation is notestablished

Dosages are generally adjusted to

maintain peak serum gentamicin

concentrations of 4 10 g/mL, and

trough concentrations of 12 g/mL.Peak concentrations above 12 g/mL

and trough concentrations above 2

g/mL are associated with toxicity.

Draw blood specimens for peak

serum gentamicin concentration 30

min1h after IM administration, and

30 min after completion of a 3060

min IV infusion. Draw bloodspecimens for trough levels just

before the next IM or IV dose. Use

nonheparinized tubes to collect

blood.


18/22

X. List of Identified Problem according to priorityBased on my own arrangement, I will priorities the ff:

y Acute pain r/t muscle spasm and movement of bone fragment secondary to tissue traumay Impaired physical mobility r/t neuromuscular/skeletal impairmenty Risk for infection r/t open wound present on the affected area


19/22

XI. Nursing Care PlanCues Scientific

Background

Nursing Diagnosis Plan Intervention Rationale Evaluation

S:

ang sakit ng

Nabunggong paa

ko

O:

-grimace noted

-body weakness

-pain rate at 7/10

-irritability- self-focus behavior

The remaining

fragment of bones

in the Fractured

area gives an

internal trauma

that leads to

muscular spasm as

an action of our

body that triggersthe pain receptor

on the fracture site

Acute pain R/T

muscular spasm and

movement of bone

fragment secondary to

tissue trauma

After 2 hr. of

rendering nursing

intervention,

patient will relief

from pain and to

avoid any afflicted

trauma as

necessary

-Instruct to have a

complete bed rest

as needed

-Asses pain scale

-Administer

Analgesic As order

-Encourage to do

any devertional

activities like

playing card game,

watching TV and

Etc.

-advice watcher to

stand by at the side

of the patient

during in pain

- to promote

quicker bone

healing and

avoidance for any

bone fragment

motility

-to asses the Level

of pain

-stimulate theprostaglandine to

produce peripheral

mediated analgesia

-to divert the

attention and

stimulant of the

pain

-serves as support

to lift up and

psychologically

decreases the level

of pain

Goal met, patients

pain sca subsided at

7/10 to 5/10 and

also avoided any

tissue trauma


20/22

Cues Scientific

Background


S:ang hirap palang

igalaw tong paa

ko,pag gumagalw

kasi masakit

O:

-limited moved

noted

-slow and

uncoordinativemovement noted

-lack of implied

activity during day

time

-with an functional

level of 3

Due to nerveddamage, nerve on

the affected side

has no proper

coordinative

stimulation and

movement but it

just trigger the pain

receptor during any

movement at all

Impaired physicalmobility r/t

neuromuscular/skeletal

impairment

After 2 months ofrendering nursing

care, patient will

understand the

situation regarding

to his treatment,

safety measure and

risk about his

condition and

enable to recoveryhis activity as

quickly and

necessary

-provide relaxationof the affected

extremities

-use the un affected

side for making any

activity even on bed

-assist patient in all

of his/her daily

activity

-if the patient is for

any orthopedic

procedure, explain

The significance of

the procedure

-encourage to

increase intake of

calcium

-to promote bonehealing

-to promote semi-

independent

encouraging

-to avoid any

mistake that may

lead to server

problem-to orient the

patient about the

quickest way to

recover

-calcium promotes

growth and

development of the

bones

Goal met, as daypast by the patient

recovers quickly

and can walk with

the use of

equipment or none


21/22

Cues Scientific

Background


O:-Open Wound

-Stasis on the

Affected side

A presence of anportal of exit and a

stasis with moisture

of the discharge of

the wound may lead

to high tendency of

getting a infection

Risk for infection r/topen wound present

on the affected area

After 1 hr. ofrendering

collaborative

teachings, the pt.

will respond and

understand the

teaching regarding

to his condition

-teach pt. aboutclean and dry

wound care

-advise pt. to

control his

environment

-advise pt. to

complete his

medication mostlyanti-bacterial

-alternate position

changing in the

affected side

-to avoid moisturein the wound

-a high tendency of

avoiding infection is

to maintain clean

surrounding

-to ensure the

avoidance of the

infection

-avoid bedsore

Goal met, the pt. isresponsive and

understand well all

the teachings


22/22

XII. On-going AppraisalBased on my one day observation, the patient is determine to recover as soon as possible because he is getting bored when he stay at the

hospital

XIII. Discharge Plan:This are interventions and teaching that the pt. needed in home recovery state:

y Teach pt. for early ambulationy Teach pt for increase calcium intakey Teach pt. about less over work on the affected sidey Advise for completing the home regimeny Teach pt. about proper wound carey Advice about the monthly check up regarding about his right leg

case study weh

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