ANGELES UNIVERSITY FOUNDATION

Angeles City, Pampanga

COLLEGE OF NURSING

FRACTURE CLOSED COMPLETE DISPLACED MIDDLE

THIRD FEMUR RIGHT SECONDARY TO FALL
CASE STUDY – ORTHOPEDIC WARD

SUBMITTED BY:
ADVINCULA, KRIZZIA MAE
BALA, JESSICA
CATACUTAN, JESSE
MALAYAO, PEETCHEE
PANGILINAN, RAIDIS NAOMI
TAMANGAN, KLAYNE ERIKA
BSN III-A: GROUP 5

SUBMITTED TO:
MA. TERESA CABANAYAN RN, MN
CLINICAL INSTRUCTOR

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I. INTRODUCTION
As rugged as our bodies are, they are often susceptible to painful and disabling
injuries such as strains, sprains, dislocations and fractures. Fractures are simply a break in
a bone caused by forces that exceed the strength of the osseous tissue in the bone. Although
bones may break spontaneously, as occurs in osteomalacia and osteomyelitis, most
fractures are caused by a trauma that places excessive stress on a bone. Fractures occur
more often in men than women up to the age of 45 and are most often associated with sports,
work, and motor vehicle accident injuries. Among the elderly, women suffer more fractures
than men due to the increased incidence of osteoporosis associated with the hormonal
changes of menopause.

Fracture is defined as a break in the continuity of a bone. A break occurs when

force is applied that exceeds the intensity of compressive strength of the bone. The incidence
of fractures varies for individual bones according to age and gender, with the highest of
incidence of fractures in young males and older persons. As a result of trauma from vehicular
accident, the leg is particularly affected.

Closed fracture or simple fracture is defined as the break in the bone which has no
communication to the outside. Complete fracture is defined as break across the entire section
of bone, dividing it into distinct parts. Displaced fracture is defined as fragments out of the
normal position at the fracture site.

In a recent study entitled “Acute Management of Open Fractures: An Evidence-

Based Review” done in Texas last November 2015, its results revealed that the acute
management of open fractures remains a challenge to orthopedic surgeons. There is strong
evidence that prophylactic antibiotics (eg, a first generation cephalosporin) should be
administered as soon as possible to reduce the risk of deep infection. Urgent operative
irrigation and debridement is the standard of care, usually performed during daytime hours
by an experienced team. The goals of surgery are to achieve thorough debridement, bone
stabilization, and restoration of the soft tissue envelope. Multiple fixation techniques are
available, each with its advantages and disadvantages. The role of adjunctive therapies, such

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as antibiotic-impregnated devices, rhBMP-2, and NPWT between serial debridements is
emerging. (Journal of Orthopedics, 2015).

Another study entitled “Healing Complications Are Common After Locked Plating for
Distal Femur Fractures” done in Iowa said that locking plates have become the most
commonly used method to fix fractures of the distal femur. However, factors that lead to
successful fracture healing have not been carefully studied. They evaluated the rate of
healing of a consecutive case series of distal femur fractures treated with the plates and
assessed the effect of multiple patient and treatment variables. Callus was measured
quantitatively to assess whether the healing outcome and construct stiffness affect the
amount of callus formed. They concluded that their study, when combined with published
studies, indicates some patients experience healing difficulties, including nonunion, delayed
union, and hardware failure, when fractures of the distal femur are treated with locking plates.
Fractures that fail to heal usually maintain alignment and form less callus, suggesting callus
inhibition rather than hardware failure is the primary problem. Mechanical factors such as
implant and construct stiffness may play a role in callus inhibition, but at this stage, the
optimal mechanical environment for a distal femur fracture treated with locking implants
remains uncertain.

Falls are the second leading cause of accidental or unintentional injury deaths
worldwide. Each year an estimated 646 000 individuals die from falls globally of which over
80% are in low- and middle-income countries. Adults older than 65 years of age suffer the
greatest number of fatal falls. Though not fatal, approximately 37.3 million falls severe
enough to require medical attention occur each year. Such falls are responsible for over 17
million DALYs (disability-adjusted life years) lost. The largest morbidity occurs in people aged
65 years or older, young adults aged 15–29 years and children aged 15 years or younger.
While nearly 40% of the total DALYs lost due to falls worldwide occurs in children, this
measurement may not accurately reflect the impact of fall-related disabilities for older
individuals who have fewer life years to lose. In addition, those individuals who fall and suffer
a disability, particularly older people, are at a major risk for subsequent long-term care and

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institutionalization. On the other hand, they occur in approximately 74, 664 persons in the
Philippines with a population of 86, 241,697.

As nursing students involved in the medical field, we are concerned in the

diagnosis and in coming across with several diseases among the patients. Generally, in
acquiring knowledge, one must get involved with the patient in gathering information of the
actual illness itself. We decided to accomplish a case study about fracture in order to have a
more extensive understanding about it. More so, we would like to know the manifestations
that are present in the patient, in what circumstances these will occur, what complications
may arise if no management will be implemented, as well as the new health interventions
appropriate for the disease. We have also chosen it to be our case so that we can apply the
lessons that we are discussing in our lecture about the fracture together with its risk factors,
signs and symptoms, diagnostic procedures, medical or surgical management, and nursing
interventions.

This study will serve as a vehicle for better understanding and for proper attitude
and actions to take for the prevention of this disease. With that, we felt that this experience
would reinforce our knowledge, which will help us give the best patient care possible in the
event that we will be encountering patients with similar diagnoses in the future.

Objectives
 Nurse Centered
a. Short Term

At the completion of this case study, the student nurse shall have:

 Explained the purpose and objectives of the study to the patient.

 Gathered information in a systematic manner in order to determine the health-related
needs of the patient.
 Gathered information to further assess the patient. The information includes:
demographic data, socio-economic, cultural and environmental factors, family health and
history, and history of past and present disease condition.

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 Assessed patient status/condition, namely: presence of signs and symptoms, and other
abnormal changes that are manifested by the patient through physical examination,
observation, or direct interview.
 Reviewed, obtained and identified the requisition of different laboratory and diagnostic
procedures done to the patient, as well as the medications administered to the patient.
 Identified nursing responsibilities to each diagnostic procedures and medical
management.
 Planned holistic care to enhance, modify, and support the health patterns of the client's
system in various health factors/determinants.

b. Long Term

At the completion of this case study, the student nurse shall have:

 Defined what is fracture.

 Identified current trends about fracture.
 Identified statistics (international and local) regarding fracture.
 Identified different diagnostic and laboratory procedures with their indications and nursing
responsibilities.
 Become more familiar of the structure and the function of the affected system or organ
and relate the alterations in the anatomy and physiology with the manifestations of the
patient.
 Identified modifiable and non-modifiable factors and how it can affect or bring about the
mentioned disease.
 Identified signs and symptoms and explain its occurrence.
 Identified the different medical management regarding the disease of the patient such as
the IVFs, oxygen therapy, nebulization; drugs; diet; activity/exercise together with their
general action and indications for the patient.
 Identified if there are any surgical management or special procedures for the mentioned
disease.
 Identified and prioritized nursing care plans (NCP) including their independent, dependent
and interdependent interventions.

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 Performed therapeutic nursing interventions and communication in order to implement
the nursing care plan effectively.
 Utilized critical thinking in order to learn new skills and knowledge that are vital in the
management of a patient.

 Patient Centered
a. Short Term

At the completion of this case study, the patient shall have:

 Verbalized understanding about the disease condition.

 Discussed the development of the disease condition from the initial signs and symptoms
manifested up to the time she was admitted in the hospital.
 Identified factors that contributes in the acquisition of the disease.
 Cooperated during physical assessment to determine abnormal changes.
 Cooperated to the nursing interventions provided by the student nurses.
 Participated willingly in the treatment regimen.

b. Long Term

At the completion of this case study, the patient shall have:

 Built trusting relationship with students and other health care team in order to cooperate
well and give information that are needed and important in the completion of this case
study.
 Cooperated in taking the necessary actions to solve the identified problems.
 Gained new knowledge and demonstrated compliance on treatment management and
health teachings rendered by the students and other health personnel.
 Learned the basic and appropriate nursing interventions or treatment plan in relation with
her disease.
 Demonstrated behavioral change after implementing the care plan.
 Demonstrated improvement of the health status.

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I. NURSING PROCESS
A. ASSESSMENT

1. PERSONAL HISTORY

a. Demographic data

To preserve the privacy and confidentiality of our patient, the group purposely
concealed the patient’s identity and instead referred to her as Patient Lee throughout the
course of this study.

Patient Lee is a 29-year-old female, Filipino citizen, married, born in Mexico,

Pampanga on September 24, 1988. Patient Lee lives in Mexico, Pampanga with her
husband and 3 children. Her mother served as the informant who had provided the
necessary data needed in this study.

At the time of the assessment, Patient Lee was admitted in a tertiary hospital in
San Fernando, Pampanga last January 22, 2018 at 7:00 in the evening. Her chief complaint
was fall with an admitting diagnosis of Fracture Closed Complete Displaced Middle Third
Femur Right Secondary to Fall.

b. Socio-Economic and Cultural Factors

b.1 Income and expenses

Patient Lee is married, and blessed with 3 children. Her eldest is female, 11 years
old, who is currently Grade 5, the 2nd child is female, 9 years old, who is currently Grade 3,
and the youngest is male, 2 years old and haven’t yet attended school. Patient Lee is a
housewife but her husband works in a bukid as a farmer with consistent pay of ₱300 per
day.
The family has an estimated income of ₱9,000 per month. According to National
Economic Development Authority (NEDA), they should have at least ₱2,873.33 when the
total monthly income is divided to its members for them to be considered not poor. Since
there are 5 members within the family, their family is considered as poor. Here’s the
breakdown of the expenses of the family:

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 Expenses (monthly)
Food ₱6,200
Electricity ₱700
Total: ₱6,900

Based from the table of the breakdown of expenses of the family, they have monthly
income of ₱9,000. They spend ₱6,200 for their foods such as vegetables, fish, and meat,
and ₱700 for the electricity. According to Patient Lee, their monthly income is just enough
for their monthly expenses. They are either spending the remaining money for the school
supplies of their children or save them up. But according to Patient Lee, they do not have
savings for medication purposes, they either borrow money from her mother or from their
neighbors. With regards to their food preparation, Patient Lee is the one who buys their food
from the market which to be consume weekly and she also the one who cooks for their
family.

b.2 Educational attainment

According to Patient Lee, she was not able to finish high school. She just finished
1st year high school because she doesn’t want to study anymore and also because of
financial problem. She mentioned the school she attended, it was located in Mexico,
Pampanga. The school she attended when she was in elementary was located also in
Mexico, Pampanga.
b.3 Religious Affiliation
Patient Lee and her family are Roman Catholic. Although they are not totally active
with church activities and attending mass, as a family, they practice praying together before
eating and sleeping.

b.4 Cultural factors affecting health of the family

When a family member feels some sort of pain, or any other ailments such as
fever, cough, and flu, they seek help first in the nearest health center to get treated. But they
also seek help to some manghihilot if they experience pain such as back pain. And according
to Patient Lee, they also self-medicate other mild illness. They usually use Paracetamol for

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fever, Neozep for colds, and Biogesic for headache. She also mentioned that to treat cough,
they use 4 pieces of oregano by boiling it. They use the squeezed liquid or decoction of
oregano leaves. But if these conditions are not treated, they will already go to a hospital for
a check-up.
c. Environmental Factors
Patient Lee lives in a bungalow, studio-type house. Their house is made up of
concrete materials. Their house has a total floor area of 10 sqm. The family’s total space
requirement is 3 for Patient Lee, 3 for her husband, 1.5 for her 1st child, 1.5 for her 2nd
child, and 1.5 for her 3rd child which is equal to 10.5. Therefore, the total space requirement
is more than the total floor area (10.5 sqm > 10 sqm). With this, there is an inadequate living
space. She said that there is not enough air coming through the house. She also mentioned
that it’s quite hot inside their house because their ceiling is too low. They have 2 windows
and 1 door. They don’t have comfort room. They use the comfort room of Patient Lee’s
mother adjacent to their house. But when someone is using her mother’s comfort room, they
do wrap and throw for defecating and throw it in the river near their house. They do not have
drainage system. Their water supply is from pitcher pump which they use for washing
dishes, laundry, bathing and cooking. They also use it as a source of their drinking water.
They do not boil it, instead, they drink it directly. And when the family has left over food they
just leave it at their table and will eat later, and because they do not have refrigerator to use
as their storage for food.

With regards to their food, Patient Lee is the one who buys their food from the
market such as vegetables, fish, and meat which to be consume weekly. She also buys
foods at the sari-sari store near their house. Regarding their garbage disposal, their
community provides a free garbage collecting service every Monday of the week.

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2. FAMILY HEALTH-ILLNESS HISTORY (Genogram)

PATERNAL SIDE MATERNAL SIDE

Grandfather Grandfather Grandmother

Grandmother
X 76 y/o 73 y/o
With right side femur
Diabetes Living Living
fracture due to fall

Auntie Auntie Uncle

Father Auntie Uncle Uncle Uncle
50 y/o 47 y/o 43 y/o
56 y/o 54 y/o 53 y/o 49 y/o 45 y/o
with DM

Uncle Auntie Auntie Mother Uncle Auntie Auntie Uncle

59 y/o 57 y/o 55 y/o 53 y/o 51 y/o 49 y/o 47 y/o 45 y/o

Brother Sister Patient Lee

33 y/o 31 y/o Fracture Closed
Complete Displaced
Middle 3rd Femur Right
Secondary to Fall

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 With regards to Patient Lee’s genogram, on the paternal side, her
grandfather died of complication in Diabetes while her grandmother has fracture on
her right femur due to fall. Her father is the eldest child, alive, and he doesn’t have
any problem with his health. Same as through with her father’s siblings, the second,
third, fourth, fifth, seventh and eight siblings of her father do not have any known
disease condition. But the sixth sibling of her father who is now 47 years old has
Diabetes and is taking maintenance drug for more than 10 years.

On the other hand, on the maternal side, her grandfather and her
grandmother are both living with no known disease. All of the siblings of her mother
are living and don’t have any known disease condition.

Patient Lee is the youngest among 3 siblings. All of her siblings are living
and has no known disease.

3. HISTORY OF PAST ILLNESS

According to Patient Lee, she had a complete immunization status. When
asked about her past illness during childhood, she stated that she experienced
German Measles for about 3-4 days and they did not provide any intervention for it.
They just let it to subside. When asked when was the time she experienced German
Measles, she was not able to recall the date of its occurrence. Patient Lee also
mentioned that when she was in elementary, she had mumps and put tina or blue ink
because it was their practice to put it on an affected part but she was not able to
remember the specific date it occurred. She also experiences headache, fever, cough,
and colds. As a management, she just buys over the counter drugs such as Biogesic
or Neozep. She also mentioned that, during her pregnancy with her 3 children, she
didn’t manifest any signs and symptoms that could complicated the pregnancies and
that delivered her babies healthy in a Normal Spontaneous Delivery.

4. HISTORY OF PRESENT ILLNESS

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 According to Patient Lee, last January 22, 2018, it was morning when the
incident happened. She was riding a bicycle and roamed around near their place until
a child walked in front of her while she was biking and she tried to dodge it to prevent
her hitting the child that eventually led to falling from the bicycle and fell from an area
of cemented ground and has debris of stones. At 10:30 in the morning, she was rushed
to the health center near their house and she was given Tetanus toxoid with 2 doses
and 2 skin tests. According to her, they put a box, that serves as a splint, to the affected
part of the femur. Then later on, she was transferred to a tertiary hospital in San
Fernando, Pampanga for further assessment with her injured leg. She had x-ray (right
thigh and knee anteroposterior lateral and pelvis anteroposterior) on January 22, 2018
and there they have identified that she had a fracture on her right femur.

5. PHYSICAL EXAMINATION

Upon Admission (Lifted from the Chart)

January 22, 2018 (done by the doctor)

Chief Complaint: Fall

General Survey: conscious, coherent,

Skin: (-) pallor, (-) jaundice
Lungs: chest expansion: symmetrical
auscultation: clear
Heart: precordium: adynamic
rhythm: normal
(-) murmur
Abdomen: flat, normoactive bowel sounds, soft, non-tender
Extremities: pulse: full and equal
Vital signs: T: 37ºC
PR: 90 bpm
RR: 28 cpm
BP: 100/70 mmHg

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First NPI (February 01, 2018 - Thursday) 6-2 shift (done by student nurses)

Vital Signs:
T: 36.1 ºC
PR: 107 bpm
RR: 16 cpm
BP: 130/90 mmHg

Skin: Her skin has a light brown skin complexion. Her temperature is in normal
range, 36.1. She has rashes all over her stomach, back and some in upper and
lower extremities. Also, there are bruises on left elbow and lower extremities.

Hair: Her hair is straight black in color, has thin strands and evenly distributed. She
has no presence of dandruff or any infestations.

Nails: Her nails are pinkish in color but dirty with capillary refill of 2 seconds.

Face: She has symmetric facial movement.

Neck Muscles: Her neck is at the midline with controlled movements.

Lymph nodes: No lumps are noted.
Eyebrows: Hairs of the eyebrow are black and are evenly distributed.
Eyelashes: They are short and are curved slightly outward. Its color is also same
with her eyebrows.

Eyes: She has black pupils and are slightly smaller in size. They have a smooth
border, and are flat round. Pupils constrict when looking at near object and dilate at
far object.

Eyelids: They close symmetrically and involuntary blinks are present.

Ears: They are symmetrical and brown in color. They recoil as they are folded.

Nose: Her nose has the same color as to the face. There were no noted nasal
discharges.

13
 Lip, Buccal mucosa: She has symmetrical lips and surrounding tissue in net
position with smiling. No lesions, swelling, or drooping observed --- lips are pinkish
in color, moist, smooth without lesions and no ulcers. She has pinkish oral mucosa.
Teeth and Gum: She has missing teeth both upper and lower, gum noted as pink
in color.
Tongue and Floor of the Mouth: Her tongue is in the central of position, with
minimal whitish coating, able to protrude tongue no seen lesion on her tongue. The
floor of the mouth appears moist and smooth.
Antherior and Posterior Thorax: She has symmetrical chest, respiration pattern is
unlabored, with anterior-posterior to lateral diameter 1:2 ratio, shape and position of
the sternum is on midline, level with ribs lungs are clear upon auscultation.
Abdomen: Her skin color in the abdomen is the same color as the extremities; flat
and symmetrical; no tenderness, rigid stomach.
Upper Extremities: Symmetrical in shape, firm, smooth, coordinated muscle
movement, absence of tenderness, lesions, and deformities.

Lower extremities: She has skeletal traction at right leg with counterweight
hanging freely, her right leg felt some pain, no edema noted for the both leg

Musculoskeletal: All reflexes are within the normal range, normal structures noted
in the bones. Except in the affected part of the patient (right femur) that needed
to be align properly through the traction.

CRANIAL NERVE ASSESSMENT

Cranial Nerves Assessment Normal Patient Lee’s

Technique Response Response
Cranial Nerve I: The student nurse Patient Lee will be She was able to
Olfactory asked Patient Lee to able to identify the identify the scent of
(Sensory) close both of her eyes different aromas alcohol and
and asked to identify presented with perfume with her
Smell aromas, such as eyes closed. eyes closed.
alcohol and perfume.
Cranial Nerve II: The student nurse Patient Lee will be She was able to
Optic asked Patient Lee to able to identify read clearly the

14
(Sensory) identify words/ prints some prints and words through a
Vision central and from a paper. words. paper.
peripheral
Cranial Nerve III: Patient Lee was asked Pupils react to She elicited
Oculomotor to look straight. With light and pupillary
(Motor) the use of a penlight, accommodation. constriction when
Eye elevation and the light was focused the light strikes and
papillary constriction on the left and right eye papillary dilation
and was removed to when the penlight
determine any changes was turned off. Her
on the pupil size. pupils constricted
when she was
asked to look at a
penlight at a far
distance. he was
able to open and
close her eyelids
properly.
Cranial Nerve IV: Patient Lee was asked Eyes will be able She managed to
Trochlear to follow the direction of to move on follow the
(Motor) the penlight in an oblique direction movement of the
Downward and lateral oblique direction without moving penlight. She has
eye movements without moving her her head. complete range of
head. motion with her eye
movement. Both
eyes movement
were seen.
Cranial Nerve V: Student nurses made Patient Lee will be She was able to feel
Trigeminal use of clean cotton able to feel the and identify sharp
(Sensory/Motor) wisp and gently stroked stimulation of the and dull. She also
Motor: Temporal and Patient Lee’s outer light touch. She elicited blinking
Masseter muscles
canthus of the eye to will be able to reflex. She was able
contractibility stimulate corneal chew and open to feel the stroke of
reflex. Student nurse her mouth. cotton when the
Sensory: All asked Patient Lee to student nurse wiped
sensations for entire chew and open her the cotton in both
face, scalp, cornea, mouth. side of her cheeks.
and nasal and oral She was able to
cavities open her mouth and
chew.
Cranial Nerve VI: Student nurse asked Eyes will be able She was able to
Abducens (Motor) Patient Lee to follow to move in lateral follow the
the direction of the movement of the

15
Lateral eye penlight in lateral movement without penlight on both
movement movement without moving the head. sides of her face.
moving the head.
Cranial Nerve VII: Student nurse asked Patient Lee will be She was able to
Facial Patient Lee to raise her able to raise perform the
eyebrows, smile, frown eyebrows, frown, instructions and has
Sensory: Taste and show teeth. She and smile and symmetrical facial
(anterior 2/3 of the was also asked to show teeth. She movements both
tongue) identify taste on the tip will be able to side of her face.
of the tongue such as identify taste on She was able to
Motor: Facial orange juice. the tip of the identify the taste of
Expression tongue such as orange juice.
orange juice.
Cranial Nerve VIII: Student nurse placed a Patient Lee will be She was able to
Vestibulocochlear/A watch near the ears able to hear the hear the tick of the
coustics (Sensory) and asked Patient Lee ticking watch. She wrist watch on both
Hearing (cochlear) if she could hear the will be able to ears.
Balance (vestibular) watch tick. For the stand erect and
balance, the student walk in balance. The student
nurse instructed nurses did not
Patient Lee to walk. able to do this
procedure
because of the
skeletal traction
put into her.
Cranial Nerve IX: Student nurse asked Patient Lee will be She was able to say
Glossopharyngeal Patient Lee to say “Ah”. able to elicit “Ah”.
(Sensory/Motor) upward movement
Swallow, gag reflex, of soft palate when
vocalization, mouth is opened.
posterior pharynx
muscles
Cranial Nerve X: The student nurse Patient Lee will be She showed no
Vagus asked Patient Lee to able to swallow difficulty when
(Sensory/Motor) swallow and asked her and speak without swallowing.
Swallow, gag reflex, a question. hoarseness.
vocalization, cough

16
Cranial Nerve XI: Student nurse asked Patient Lee will be She didn’t have
Accessory Patient Lee to move able to shrug difficulty in moving
(Motor) her head from side to shoulders and her head from side
Trapezius and side and asked her to move head from to side and was able
sternocleidomastoid elevate her shoulders side to side to elevate her
movement: shoulder against the resistance against applied shoulders against
elevation and lateral introduced by the resistance. resistance of the
head rotation student nurse. hands of the
student nurse.
Cranial Nerve XII: The student nurse Patient Lee will be She can move her
Hypoglossal asked Patient Lee to able to protrude tongue up and
(Motor) move her tongue from tongue and move down, and side to
Tongue movement side to side and in and it from side to side. side as instructed.
out.

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Second NPI (February 02, 2018 - Friday) 6-2 shift (done by student nurses)

Vital Signs:
T: 36.1 ºC
PR: 88 bpm
RR: 20 cpm
BP: 120/80 mmHg

Skin: Her skin has a light brown skin complexion. Her temperature is in normal
range, 36.1. She has rashes all over her stomach, back and some in upper and
lower extremities. Also, there are bruises on left elbow and lower extremities.

Hair: Her hair is straight black in color, has thin strands and evenly distributed. She
has no presence of dandruff or any infestations.

Nails: Her nails are pinkish in color but dirty with capillary refill of 2 seconds.

Face: She has symmetric facial movement.

Neck Muscles: Her neck is at the midline with controlled movements.

Lymph nodes: No lumps are noted.
Eyebrows: Hairs of the eyebrow are black and are evenly distributed.
Eyelashes: They are short and are curved slightly outward. Its color is also same
with her eyebrows.

Eyes: She has black pupils and are slightly smaller in size. They have a smooth
border, and are flat round. Pupils constrict when looking at near object and dilate at
far object.

Eyelids: They close symmetrically and involuntary blinks are present.

Ears: They are symmetrical and brown in color. They recoil as they are folded.

Nose: Her nose has the same color as to the face. There were no noted nasal
discharges.

18
 Lip, Buccal mucosa: She has symmetrical lips and surrounding tissue in net
position with smiling. No lesions, swelling, or drooping observed --- lips are pinkish
in color, moist, smooth without lesions and no ulcers. She has pinkish oral mucosa.
Teeth and Gum: She has missing teeth both upper and lower, gum noted as pink
in color.
Tongue and Floor of the Mouth: Her tongue is in the central of position, with
minimal whitish coating, able to protrude tongue no seen lesion on her tongue. The
floor of the mouth appears moist and smooth.
Antherior and Posterior Thorax: She has symmetrical chest, respiration pattern is
unlabored, with anterior-posterior to lateral diameter 1:2 ratio, shape and position of
the sternum is on midline, level with ribs lungs are clear upon auscultation.
Abdomen: Her skin color in the abdomen is the same color as the extremities; flat
and symmetrical; no tenderness, rigid stomach.
Upper Extremities: Symmetrical in shape, firm, smooth, coordinated muscle
movement, absence of tenderness, lesions, and deformities.

Lower extremities: She has skeletal traction at right leg with counterweight
hanging freely, her right leg felt some pain, no edema noted for the both leg

Musculoskeletal: All reflexes are within the normal range, normal structures noted
in the bones. Except in the affected part of the patient (right femur) that needed
to be align properly through the traction.

CRANIAL NERVE ASSESSMENT

Cranial Nerves Assessment Normal Patient Lee’s

Technique Response Response
Cranial Nerve I: The student nurse Patient Lee will be She was able to
Olfactory asked Patient Lee to able to identify the identify the scent of
(Sensory) close both of her eyes different aromas alcohol and
and asked to identify presented with perfume with her
Smell aromas, such as eyes closed. eyes closed.
alcohol and perfume.
Cranial Nerve II: The student nurse Patient Lee will be She was able to
Optic asked Patient Lee to able to identify read clearly the

19
(Sensory) identify words/ prints some prints and words through a
Vision central and from a paper. words. paper.
peripheral
Cranial Nerve III: Patient Lee was asked Pupils react to She elicited
Oculomotor to look straight. With light and pupillary
(Motor) the use of a penlight, accommodation. constriction when
Eye elevation and the light was focused the light strikes and
papillary constriction on the left and right eye papillary dilation
and was removed to when the penlight
determine any changes was turned off. Her
on the pupil size. pupils constricted
when she was
asked to look at a
penlight at a far
distance. She was
able to open and
close her eyelids
properly.
Cranial Nerve IV: Patient Lee was asked Eyes will be able She managed to
Trochlear to follow the direction of to move on follow the
(Motor) the penlight in an oblique direction movement of the
Downward and lateral oblique direction without moving penlight. She has
eye movements without moving her her head. complete range of
head. motion with her eye
movement. Both
eyes movement
were seen.
Cranial Nerve V: Student nurses made Patient Lee will be She was able to feel
Trigeminal use of clean cotton able to feel the and identify sharp
(Sensory/Motor) wisp and gently stroked stimulation of the and dull. She also
Motor: Temporal and Patient Lee’s outer light touch. She elicited blinking
Masseter muscles
canthus of the eye to will be able to reflex. She was able
contractibility stimulate corneal chew and open to feel the stroke of
reflex. Student nurse her mouth. cotton when the
Sensory: All asked Patient Lee to student nurse wiped
sensations for entire chew and open her the cotton in both
face, scalp, cornea, mouth. side of her cheeks.
and nasal and oral She was able to
cavities open her mouth and
chew.
Cranial Nerve VI: Student nurse asked Eyes will be able She was able to
Abducens (Motor) Patient Lee to follow to move in lateral follow the
the direction of the movement of the

20
Lateral eye penlight in lateral movement without penlight on both
movement movement without moving the head. sides of her face.
moving the head.
Cranial Nerve VII: Student nurse asked Patient Lee will be She was able to
Facial Patient Lee to raise her able to raise perform the
eyebrows, smile, frown eyebrows, frown, instructions and has
Sensory: Taste and show teeth. She and smile and symmetrical facial
(anterior 2/3 of the was also asked to show teeth. She movements both
tongue) identify taste on the tip will be able to side of her face.
of the tongue such as identify taste on She was able to
Motor: Facial orange juice. the tip of the identify the taste of
Expression tongue such as orange juice.
orange juice.
Cranial Nerve VIII: Student nurse placed a Patient Lee will be She was able to
Vestibulocochlear/A watch near the ears able to hear the hear the tick of the
coustics (Sensory) and asked Patient Lee ticking watch. She wrist watch on both
Hearing (cochlear) if she could hear the will be able to ears.
Balance (vestibular) watch tick. For the stand erect and
balance, the student walk in balance. The student
nurse instructed nurses did not
Patient Lee to walk. able to do this
procedure
because of the
skeletal traction
put into her.
Cranial Nerve IX: Student nurse asked Patient Lee will be She was able to say
Glossopharyngeal Patient Lee to say “Ah”. able to elicit “Ah”.
(Sensory/Motor) upward movement
Swallow, gag reflex, of soft palate when
vocalization, mouth is opened.
posterior pharynx
muscles
Cranial Nerve X: The student nurse Patient Lee will be She showed no
Vagus asked Patient Lee to able to swallow difficulty when
(Sensory/Motor) swallow and asked her and speak without swallowing.
Swallow, gag reflex, a question. hoarseness.
vocalization, cough

21
Cranial Nerve XI: Student nurse asked Patient Lee will be She didn’t have
Accessory Patient Lee to move able to shrug difficulty in moving
(Motor) her head from side to shoulders and her head from side
Trapezius and side and asked her to move head from to side and was able
sternocleidomastoid elevate her shoulders side to side to elevate her
movement: shoulder against the resistance against applied shoulders against
elevation and lateral introduced by the resistance. resistance of the
head rotation student nurse. hands of the
student nurse.
Cranial Nerve XII: The student nurse Patient Lee will be She can move her
Hypoglossal asked Patient Lee to able to protrude tongue up and
(Motor) move her tongue from tongue and move down, and side to
Tongue movement side to side and in and it from side to side. side as instructed.
out.

22
Third NPI (February 08, 2018 - Thursday) 6-2 shift (done by student nurses)

Vital Signs:
T: 36.4 ºC
PR: 88 bpm
RR: 20 cpm
BP: 120/80 mmHg

Skin: Her skin has a light brown skin complexion. Her temperature is in normal
range, 36.4ºC.

Hair: Her hair is straight black in color, has thin strands and evenly distributed. She
has no presence of dandruff or any infestations.

Nails: Her nails are pinkish in color but dirty with capillary refill of 2 seconds.

Face: She has symmetric facial movement.

Neck Muscles: Her neck is at the midline with controlled movements.

Lymph nodes: No lumps are noted.
Eyebrows: Hairs of the eyebrow are black and are evenly distributed.
Eyelashes: They are short and are curved slightly outward. Its color is also same
with her eyebrows.

Eyes: She has black pupils and are slightly smaller in size. They have a smooth
border, and are flat round. Pupils constrict when looking at near object and dilate at
far object.

Eyelids: They close symmetrically and involuntary blinks are present.

Ears: They are symmetrical and brown in color. They recoil as they are folded.

Nose: Her nose has the same color as to the face. There were no noted nasal
discharges.

Lip, Buccal mucosa: She has symmetrical lips and surrounding tissue in net
position with smiling. No lesions, swelling, or drooping observed --- lips are pale in
color, moist, smooth without lesions and no ulcers. She has pale oral mucosa.

23
 Teeth and Gum: She has missing teeth both upper and lower, gum noted as pink
in color.
Tongue and Floor of the Mouth: Her tongue is in the central of position, with
minimal whitish coating, able to protrude tongue no seen lesion on her tongue. The
floor of the mouth appears moist and smooth.
Antherior and Posterior Thorax: She has symmetrical chest, respiration pattern is
unlabored, with anterior-posterior to lateral diameter 1:2 ratio, shape and position of
the sternum is on midline, level with ribs lungs are clear upon auscultation.
Abdomen: Her skin color in the abdomen is the same color as the extremities; flat
and symmetrical; no tenderness, rigid stomach.
Upper Extremities: Symmetrical in shape, firm, smooth, coordinated muscle
movement, absence of tenderness, lesions, and deformities.

Lower extremities: No edema noted for the left leg, and slightly edematous with
intact dressing on surgical site (right femur)

Musculoskeletal: All reflexes are within the normal range, normal structures noted
in the bones. Except in the affected part of the patient (right femur) due to the
postop surgical procedure on February 07, 2018.

CRANIAL NERVE ASSESSMENT

Cranial Nerves Assessment Normal Patient Lee’s

Technique Response Response
Cranial Nerve I: The student nurse Patient Lee will be She was able to
Olfactory asked Patient Lee to able to identify the identify the scent of
(Sensory) close both of her eyes different aromas alcohol and
and asked to identify presented with perfume with her
Smell aromas, such as eyes closed. eyes closed.
alcohol and perfume.
Cranial Nerve II: The student nurse Patient Lee will be She was able to
Optic asked Patient Lee to able to identify read clearly the
(Sensory) identify words/ prints some prints and words through a
Vision central and from a paper. words. paper.
peripheral

24
Cranial Nerve III: Patient Lee was asked Pupils react to She elicited
Oculomotor to look straight. With light and pupillary
(Motor) the use of a penlight, accommodation. constriction when
Eye elevation and the light was focused the light strikes and
papillary constriction on the left and right eye papillary dilation
and was removed to when the penlight
determine any changes was turned off. Her
on the pupil size. pupils constricted
when she was
asked to look at a
penlight at a far
distance. She was
able to open and
close her eyelids
properly.
Cranial Nerve IV: Patient Lee was asked Eyes will be able She managed to
Trochlear to follow the direction of to move on follow the
(Motor) the penlight in an oblique direction movement of the
Downward and lateral oblique direction without moving penlight. She has
eye movements without moving her her head. complete range of
head. motion with her eye
movement. Both
eyes movement
were seen.
Cranial Nerve V: Student nurses made Patient Lee will be She was able to feel
Trigeminal use of clean cotton able to feel the and identify sharp
(Sensory/Motor) wisp and gently stroked stimulation of the and dull. She also
Motor: Temporal and Patient Lee’s outer light touch. She elicited blinking
Masseter muscles
canthus of the eye to will be able to reflex. She was able
contractibility stimulate corneal chew and open to feel the stroke of
reflex. Student nurse her mouth. cotton when the
Sensory: All asked Patient Lee to student nurse wiped
sensations for entire chew and open her the cotton in both
face, scalp, cornea, mouth. side of her cheeks.
and nasal and oral She was able to
cavities open her mouth and
chew.
Cranial Nerve VI: Student nurse asked Eyes will be able She was able to
Abducens (Motor) Patient Lee to follow to move in lateral follow the
Lateral eye the direction of the movement without movement of the
movement penlight in lateral moving the head. penlight on both
movement without sides of her face.
moving the head.

25
Cranial Nerve VII: Student nurse asked Patient Lee will be She was able to
Facial Patient Lee to raise her able to raise perform the
eyebrows, smile, frown eyebrows, frown, instructions and has
Sensory: Taste and show teeth. She and smile and symmetrical facial
(anterior 2/3 of the was also asked to show teeth. She movements both
tongue) identify taste on the tip will be able to side of her face.
of the tongue such as identify taste on She was able to
Motor: Facial orange juice. the tip of the identify the taste of
Expression tongue such as orange juice.
orange juice.
Cranial Nerve VIII: Student nurse placed a Patient Lee will be She was able to
Vestibulocochlear/A watch near the ears able to hear the hear the tick of the
coustics (Sensory) and asked Patient Lee ticking watch. She wrist watch on both
Hearing (cochlear) if she could hear the will be able to ears.
Balance (vestibular) watch tick. For the stand erect and
balance, the student walk in balance. The student
nurse instructed nurses did not
Patient Lee to walk. able to do this
procedure
because of the
postop surgical
procedure of her
affected leg (right
femur).
Cranial Nerve IX: Student nurse asked Patient Lee will be She was able to say
Glossopharyngeal Patient Lee to say “Ah”. able to elicit “Ah”.
(Sensory/Motor) upward movement
Swallow, gag reflex, of soft palate when
vocalization, mouth is opened.
posterior pharynx
muscles
Cranial Nerve X: The student nurse Patient Lee will be She showed no
Vagus asked Patient Lee to able to swallow difficulty when
(Sensory/Motor) swallow and asked her and speak without swallowing.
Swallow, gag reflex, a question. hoarseness.
vocalization, cough

26
Cranial Nerve XI: Student nurse asked Patient Lee will be She didn’t have
Accessory Patient Lee to move able to shrug difficulty in moving
(Motor) her head from side to shoulders and her head from side
Trapezius and side and asked her to move head from to side and was able
sternocleidomastoid elevate her shoulders side to side to elevate her
movement: shoulder against the resistance against applied shoulders against
elevation and lateral introduced by the resistance. resistance of the
head rotation student nurse. hands of the
student nurse.
Cranial Nerve XII: The student nurse Patient Lee will be She can move her
Hypoglossal asked Patient Lee to able to protrude tongue up and
(Motor) move her tongue from tongue and move down, and side to
Tongue movement side to side and in and it from side to side. side as instructed.
out.

27
Fourth NPI (February 09, 2018 - Friday) 6-2 shift (done by student nurses)

Vital Signs:
T: 36.3°C
PR: 88 bpm
RR: 19 cpm
BP: 120/80 mmHg

Skin: Her skin has a light brown skin complexion. Her temperature is in normal
range, 36.3ºC.

Hair: Her hair is straight black in color, has thin strands and evenly distributed. She
has no presence of dandruff or any infestations.

Nails: Her nails are pinkish in color but dirty with capillary refill of 2 seconds.

Face: She has symmetric facial movement.

Neck Muscles: Her neck is at the midline with controlled movements.

Lymph nodes: No lumps are noted.
Eyebrows: Hairs of the eyebrow are black and are evenly distributed.
Eyelashes: They are short and are curved slightly outward. Its color is also same
with her eyebrows.

Eyes: She has black pupils and are slightly smaller in size. They have a smooth
border, and are flat round. Pupils constrict when looking at near object and dilate at
far object.

Eyelids: They close symmetrically and involuntary blinks are present.

Ears: They are symmetrical and brown in color. They recoil as they are folded.

Nose: Her nose has the same color as to the face. There were no noted nasal
discharges.

Lip, Buccal mucosa: She has symmetrical lips and surrounding tissue in net
position with smiling. No lesions, swelling, or drooping observed --- lips are pale in
color, moist, smooth without lesions and no ulcers. She has pale oral mucosa.

28
 Teeth and Gum: She has missing teeth both upper and lower, gum noted as pink
in color.
Tongue and Floor of the Mouth: Her tongue is in the central of position, with
minimal whitish coating, able to protrude tongue no seen lesion on her tongue. The
floor of the mouth appears moist and smooth.
Antherior and Posterior Thorax: She has symmetrical chest, respiration pattern is
unlabored, with anterior-posterior to lateral diameter 1:2 ratio, shape and position of
the sternum is on midline, level with ribs lungs are clear upon auscultation.
Abdomen: Her skin color in the abdomen is the same color as the extremities; flat
and symmetrical; no tenderness, rigid stomach.
Upper Extremities: Symmetrical in shape, firm, smooth, coordinated muscle
movement, absence of tenderness, lesions, and deformities.

Lower extremities: No edema noted for the left leg, and slightly edematous with
intact dressing on surgical site (right femur)

Musculoskeletal: All reflexes are within the normal range, normal structures noted
in the bones. Except in the affected part of the patient (right femur) due to the
postop surgical procedure on February 07, 2018.

CRANIAL NERVE ASSESSMENT

Cranial Nerves Assessment Normal Patient Lee’s

Technique Response Response
Cranial Nerve I: The student nurse Patient Lee will be She was able to
Olfactory asked Patient Lee to able to identify the identify the scent of
(Sensory) close both of her eyes different aromas alcohol and
and asked to identify presented with perfume with her
Smell aromas, such as eyes closed. eyes closed.
alcohol and perfume.
Cranial Nerve II: The student nurse Patient Lee will be She was able to
Optic asked Patient Lee to able to identify read clearly the
(Sensory) identify words/ prints some prints and words through a
Vision central and from a paper. words. paper.
peripheral

29
Cranial Nerve III: Patient Lee was asked Pupils react to She elicited
Oculomotor to look straight. With light and pupillary
(Motor) the use of a penlight, accommodation. constriction when
Eye elevation and the light was focused the light strikes and
papillary constriction on the left and right eye papillary dilation
and was removed to when the penlight
determine any changes was turned off. Her
on the pupil size. pupils constricted
when she was
asked to look at a
penlight at a far
distance. she was
able to open and
close her eyelids
properly.
Cranial Nerve IV: Patient Lee was asked Eyes will be able She managed to
Trochlear to follow the direction of to move on follow the
(Motor) the penlight in an oblique direction movement of the
Downward and lateral oblique direction without moving penlight. She has
eye movements without moving her her head. complete range of
head. motion with her eye
movement. Both
eyes movement
were seen.
Cranial Nerve V: Student nurses made Patient Lee will be She was able to feel
Trigeminal use of clean cotton able to feel the and identify sharp
(Sensory/Motor) wisp and gently stroked stimulation of the and dull. She also
Motor: Temporal and Patient Lee’s outer light touch. She elicited blinking
Masseter muscles
canthus of the eye to will be able to reflex. She was able
contractibility stimulate corneal chew and open to feel the stroke of
reflex. Student nurse her mouth. cotton when the
Sensory: All asked Patient Lee to student nurse wiped
sensations for entire chew and open her the cotton in both
face, scalp, cornea, mouth. side of her cheeks.
and nasal and oral She was able to
cavities open her mouth and
chew.
Cranial Nerve VI: Student nurse asked Eyes will be able She was able to
Abducens (Motor) Patient Lee to follow to move in lateral follow the
Lateral eye the direction of the movement without movement of the
movement penlight in lateral moving the head. penlight on both
movement without sides of her face.
moving the head.

30
Cranial Nerve VII: Student nurse asked Patient Lee will be She was able to
Facial Patient Lee to raise her able to raise perform the
eyebrows, smile, frown eyebrows, frown, instructions and has
Sensory: Taste and show teeth. She and smile and symmetrical facial
(anterior 2/3 of the was also asked to show teeth. She movements both
tongue) identify taste on the tip will be able to side of her face.
of the tongue such as identify taste on She was able to
Motor: Facial orange juice. the tip of the identify the taste of
Expression tongue such as orange juice.
orange juice.
Cranial Nerve VIII: Student nurse placed a Patient Lee will be She was able to
Vestibulocochlear/A watch near the ears able to hear the hear the tick of the
coustics (Sensory) and asked Patient Lee ticking watch. She wrist watch on both
Hearing (cochlear) if she could hear the will be able to ears.
Balance (vestibular) watch tick. For the stand erect and
balance, the student walk in balance. The student
nurse instructed nurses did not
Patient Lee to walk. able to do this
procedure
because of the
postop surgical
procedure of her
affected leg (right
femur).
Cranial Nerve IX: Student nurse asked Patient Lee will be She was able to say
Glossopharyngeal Patient Lee to say “Ah”. able to elicit “Ah”.
(Sensory/Motor) upward movement
Swallow, gag reflex, of soft palate when
vocalization, mouth is opened.
posterior pharynx
muscles
Cranial Nerve X: The student nurse Patient Lee will be She showed no
Vagus asked Patient Lee to able to swallow difficulty when
(Sensory/Motor) swallow and asked her and speak without swallowing.
Swallow, gag reflex, a question. hoarseness.
vocalization, cough

31
Cranial Nerve XI: Student nurse asked Patient Lee will be She didn’t have
Accessory Patient Lee to move able to shrug difficulty in moving
(Motor) her head from side to shoulders and her head from side
Trapezius and side and asked her to move head from to side and was able
sternocleidomastoid elevate her shoulders side to side to elevate her
movement: shoulder against the resistance against applied shoulders against
elevation and lateral introduced by the resistance. resistance of the
head rotation student nurse. hands of the
student nurse.
Cranial Nerve XII: The student nurse Patient Lee will be She can move her
Hypoglossal asked Patient Lee to able to protrude tongue up and
(Motor) move her tongue from tongue and move down, and side to
Tongue movement side to side and in and it from side to side. side as instructed.
out.

32
7. DIAGNOSTIC AND LABORATORY PROCEDURES

DIAGNOSTICS DATE ORDERED INDICATION(S) OR PURPOSE(S) RESULTS

LABORATORY DATE RESULT(S)
PROCEDURES

Right Thigh APL Date Ordered: This test was done to the patient to Based on the diagnosis of the
01-22-18 detect abnormalities within the patient which is the fracture closed
body. A femur x-ray is a safe and complete displaced middle third
Pelvis AP painless test that uses a small femur right secondary to fall,
Date Result In: amount of radiation to make an confirmatory test is the femur x-ray
image of a person's upper leg (the but then it is not attached on the
Right Knee APL Not attached on the
chart area between the hip and knee). chart.
During the examination, an x-ray
machine sends a beam of radiation
through the upper leg, and an
image is recorded on special film or
a computer. This image shows the
soft tissues and the bone in the
upper leg, which is called the femur.
A femur X-ray can help find the
cause of symptoms such as pain,
limp, tenderness, swelling, or
deformity of the upper leg. It can
detect a broken bone, and after a
broken bone has been set, it can

33
help determine whether the bone is
in satisfactory alignment.

The AP pelvis view is part of

a pelvic series examining the iliac
crest, sacrum, proximal femur,
pubis, ischium and the great pelvic
ring. It is of considerable
importance in the management of
severely injured patients presenting
to emergency departments.

Knee APL x-ray is a specialized

projection to assess the knee
joint, distal femur, proximal tibia
and fibula and the patella. And to
assess the bony structure of the
knee and specifically to define the
presence of fractures and also to
assess for degenerative disease
within the joint.

34
NURSING RESPONSIBILITIES:

Before:
 Explain to the patient that x-ray assess a particular anatomy.
 Tell the patient that she does not need to restrict food and fluids.
 Describe the test, including who will perform it and when it will take place.
 Provide a gown without snaps, and instruct the patient to remove jewelry and other metallic objects that may be
in the x-ray field.

During:
 If the x-ray is done at the bedside, place contraptions as far from the x-ray field as possible.

After:
 If the test is done at the bedside, reposition the patient comfortably. Otherwise, no special care is required.

35
DIAGNOSTIC/ DATE GENERAL SPECIFIC RESULTS NORMAL ANALYSIS AND
LABORATORY ORDERED INDICATION VALUES INTERPRETATION
INDICATION
PROCEDURES OF RESULTS
DATE
RESULT(S)
IN

White blood Date White blood cells This test was 15.75 4-10 The result was
cells (WBCs) Ordered: (WBCs), also called used to detect if above the normal.
leukocytes, are the she has presence This indicates that
01-31-18
cells of the immune of infection. she has presence
system that are of infection.
involved in protecting
Date Result
the body against both
in:
infectious disease
01-31-18 and foreign invaders.

Neutrophils Date Neutrophils are a type This test was 72.8 50-70 The result was
Ordered: of phagocyte and are done to detect if above the normal.
normally found in the she has the This indicates that
01-31-18
bloodstream. During presence of there is a presence
the beginning (acute) infection or an of inflammation,
phase of inflammation particularly as a
Date Result
inflammation, process. result of bacterial
in:
particularly as a result infection.
01-31-18 of bacterial infection,
neutrophils are one of

36
 the first-responders of
inflammatory cells to
migrate towards the
site of inflammation.

Lymphocytes Date Lymphocytes produce This test was 21.2 20-40 The result was in
Ordered: antibodies and other done to detect if normal range. This
chemicals she has the indicates that the
01-31-18 responsible for
presence of body could already
destroying
microorganisms. infection because fight infection and
it participates in has the ability to
Date Result
humoral response recognize antigens,
in:
which also produce
01-31-18 indicates the antibodies, and
presence of destroy cells that
infection and play could cause
an important and damage.
integral role in the
body’s defense
mechanism.

Monocytes Date Monocytes are a type This test was 5.6 3-12 The result was
Ordered: of white blood cell that done to detect normal. This
fights off bacteria, abnormal or indicates that there
01-31-18
viruses and fungi. immature cells are enough
Originally formed in and can diagnose monocytes in the
the bone marrow, they an infection, body for their

37
 Date Result are released into our inflammation, or functions of
in: blood and tissues. an immune phagocytosis to
When certain germs system disorder. fight off bacteria,
01-31-18
enter the body, they viruses and fungi.
quickly rush to the site
for attack.

Eosinophils Date Eosinophil count is a This test was 8.1 0.5-5.0 The result was
Ordered: type of blood test that done to detect above the normal.
measures the quantity inflammation This indicates that
01-31-18
of eosinophils in your related to patient was linked
body. An eosinophil is allergies. to allergies on
a type of white blood January 29, 2018.
Date Result
cell. An eosinophil
in:
count typically
01-31-18 becomes active when
you have certain
allergic diseases,
infections, and other
medical conditions

Basophils Date Basophil is a type This test was 0.3 0.0-1.0 The result was
Ordered: of white blood done to detect if normal. This
cell present in the she has the indicates that there
01-31-18
blood. Basophils help presence of are enough
protect the body infection. basophils in the
against disease and body for their

38
 Date Result infections by eating function of
in: some types of phagocytosis to
bacteria, foreign fight off bacteria,
01-31-18
substances, and other and other foreign
cells. substances.

Red Blood Date RBC count, also This test was 4.43 4-5.50 The result was in
Cell Ordered: called an erythrocyte done to evaluate normal range which
count, is part of a the oxygen indicates that the
01-31-18 complete blood count. carrying capacity patient’s blood is
It’s used to detect the of the blood and to adequate in
number or red blood determine if the carrying oxygen
Date Result cells in microliter, or oxygen within the throughout the
in: cubic millimeter of body is adequate. body.
whole blood.
01-31-18

Hemoglobin Date Hemoglobin is the This test was 12.6 12-16 The result was in
Ordered: protein molecule in done to evaluate normal range which
red blood cells that the oxygen indicates that the
01-31-18
carries oxygen from carrying capacity patient’s blood is
the lungs to the body's of the blood and to adequate in
tissues and returns determine if the carrying oxygen
Date Result
carbon dioxide from oxygen within the throughout the
in:
the tissues back to the body is adequate. body.
01-31-18 lungs.

39
Hematocrit Date Hematocrit is the This test was 42.3 40-54 The result was in
Ordered: volume percentage done to determine normal range which
(%) of red blood cells the percentage of indicates that the
01-31-18
in blood. Blood is red blood cells patient’s blood is
composed mainly of (RBCs) in the adequate in
red blood cells and blood. carrying oxygen
Date Result
white blood cells throughout the
in:
suspended in an body.
01-31-18 almost clear fluid
called serum. The
hematocrit test
indicates the
percentage of blood
by volume that is
composed of red
blood cells.

Platelet Date Platelet is also called This test was 431 150-450 The result was
Ordered: thrombocytes are a done to detect the normal. This
component of blood clotting ability of indicates that she
01-31-18
whose function (along the body of patient has adequate
with the coagulation which depends on amount of platelet
factors) is to stop the number of to provide
Date Result
bleeding by clumping platelets coagulation as
in:
and clotting blood circulating in the evidenced by
01-31-18 vessel injuries. blood stream. normal number of
Platelets have no cell platelets circulating
nucleus: they are

40
 fragments of in the blood stream.
cytoplasm that are
derived from the
megakaryocytes ] of
the bone marrow, and
then enter the
circulation.

MCV Date Mean corpuscular This test was 88.7 80-100 The result was
Ordered: volume (MCV) is the done to determine normal. This
average volume of if the size of the indicates that
01-31-18
red cells in a red blood cells is patient has an
specimen. MCV is being affected. average volume of
elevated or red blood cells and
Date Result
decreased in still normal to
in:
accordance with deliver oxygen.
01-31-18 average red cell size.

MCH Date MCH stands for Mean This test was 28.5 27-34 The result was
Ordered: Corpuscular done to check normal which
Hemoglobin, and is a whether there is means that the
01-31-18 still enough
calculation of the level of oxygen-
amount of
average amount of hemoglobin in carrying
hemoglobin each red blood hemoglobin inside
Date Result
contained within each cell that carries a red blood cell is
in:
of a person's red oxygen to the adequate to supply
blood cells. body. of oxygen to

41
 01-31-18 Hemoglobin is the tissues.
protein that carries
oxygen from the lungs
to the cells of the body
through the
bloodstream.

MCHC Date MCHC measures the This test was 32.1 32-36 The result was
Ordered: average done for the normal which
concentration of calculation of the means that there is
01-31-18 hemoglobin in red
average normal level of
blood cells.
concentration of concentration of
hemoglobin inside hemoglobin inside
a red blood cell. a red blood cell.
Date Result This also indicates
in: that there is
adequate oxygen-
01-31-18
carrying capacity of
the blood.

42
 The result was
RDW-CV Date Red cell distribution This test was 13.1 11-16
normal. This
Ordered: width (RDW) is a done to detect the
indicates that she
parameter that clotting ability of
01-31-18 has normal
measures variation in the body of patient
variation in red
red blood cell size or which depends on
blood cell size or
red blood cell volume. the number of
red blood cell
RDW is elevated in platelets
volume.
Date Result accordance with circulating in the
in: variation in red cell blood stream.
size (anisocytosis), ie,
01-31-18
when elevated RDW
is reported on
complete blood count,
marked anisocytosis
(increased variation in
red cell size) is
expected on
peripheral blood
smear review.

RDW-SD Date Red cell distribution This test was 41.3 35-56 The result was
Ordered: width (RDW) is a done to detect the normal. This
parameter that clotting ability of indicates that she
01-31-18
measures variation in the body of patient has normal
red blood cell size or which depends on variation in red
red blood cell volume. the number of blood cell size or

43
 RDW is elevated in platelets red blood cell
accordance with circulating in the volume.
Date Result
variation in red cell blood stream.
in:
size (anisocytosis), ie,
01-31-18 when elevated RDW
is reported on
complete blood count,
marked anisocytosis
(increased variation in
red cell size) is
expected on
peripheral blood
smear review.

44
NURSING RESPONSIBILITIES:

Before:

 Explain test procedure. Explain that slight discomfort may be felt when the skin is punctured.
 Encourage to avoid stress if possible because altered physiologic status influences and changes normal
hematologic values.
 Inform the patient is not required and necessary.
 Obtain drug history and medical conditions that may alter the test results

During:

 Apply manual pressure and dressings over puncture site on removal.

 Maintain aseptic technique.
 Assist the technician if necessary.

After:

 Apply pressure / pressure dressing to the puncture site.

 Monitor the puncture site for oozing or hematoma formation.
 Instruct to resume normal activities and may resume the patient’s specified diet (low salt, low fat diet).
 Document the time and the procedure done.

45
8. ANATOMY AND PHYSIOLOGY

The femur is also called the thigh bone and is the longest and strongest bone of the body.
It is composed of upper end, lower end and a shaft.

The upper and bears a rounded head, whereas the lower end is widely expanded to from
two large condyles. The head is directed medially. The cylindrical shaft is convex
forwards.

Upper end of Femur

The upper end of the femur includes the head, the neck, the greater trochanter, the lesser
trochanter, the intertrochanteric line, and the intertrochanteric crest.

46
Head of Femur

Head articulates with acetabulum to form a hip joint. It is more than half a sphere, and is
directed medially, upwards and slightly forwards.

Fovea is a roughened pit just below and behind the center of the head. Head, in its most
part is covered by cartilage.

Neck of Femur

Neck is about is about 3-3.5 cm long and connects head with shaft. The neck forms an
angle with shaft, known as neck shaft angle and is about 125 in adults [lesser in females].
The angle facilitates movements of the hip joint. Femoral neck is strengthened by a
thickening of bone called the calcar femoral present along its concavity.

The neck has two borders and two surfaces

The upper border, concave and horizontal, meets the shaft at the greater trochanter. The
lower border, straight and oblique, meets the shaft near the lesser trochanter.

The anterior surface is flat and meets the shaft at the inter- chanteric line. Anterior surface
of femoral neck is entirely inter- capsular. Upper part of this surface may be covered by
articular cartilage.

The posterior surface is convex from above downwards and concave from side to side. It
meets the shaft at the intertrochanteric crest. It is not intracapsular in its lower lateral part.

Antecersion is the angle formed between the transverse axis of the upper and lower ends
of the femur. It is about 15 degrees.

Greater Trochanter

Greater trochanter is a large quadrangular prominence located at the upper part of the
junction of the neck with shaft. The upper border of the trochanter lies at the level of the
center of the head.

The greater trochanter has an upper border with an apex, and 3 surfaces
(anterior, medial and lateral). The apex is the in- turned posterior part of the posterior
border. The anterior surface is rough in its lateral part. The medial surface presents a
rough impression, above and a deep trochanteric fossa, below. The lateral surface is
crossed by an oblique ridge directed downwards and forwards.

Lesser Trochanter

47
It is a conical eminence directed medially and backwards from the junction of the posterior
part of the neck with the shaft.

Intertrochanteric Line

It marks the junction of neck with the femur. It is a roughened ridge from anterosuperior
angle of the greater trochanter (as a tubercle), and is continuous below with the spiral line
in front of the lesser trochanter.

Spiral line is
a curved line with its superior end adjacent to the lessertrochanter, nearly continuous wit
h the intertrochanteric line, andconverging inferiorly with the pectineal line to form the m
edial lip of the linea aspera.

It forms the medial boundary of the distal attachment of the iliacus muscle. The spiral
line winds round the shaft below the lesser trochanter to reach the posterior surface of
the shaft.

Intertrochanteric Crest

It marks the junction of the posterior surface of the neck with the shaft of the femur. It is
smooth rounded ridge which begins above at the posterior superior angle of the greater
trochanter and ends at the lesser trochanter. The rounded elevation, a little above its
middle is called the quadrate tubercle.

Shaft of Femur

The shaft is almost a cylindrical structure wide superiorly and inferiorly and narrowest in
the middle. It is convex forwards and is directed obliquely downwards and medially.

48
The shaft in middle one-third has three borders -medial, lateral and posterior.
The medial and lateral borders are rounded and ill- defined, but the posterior border is in
the form of a broad roughened ridge, called the linea aspera. Linea aspera is an important
landmark in orthopedics surgeries involving reduction of femoral fractures.

The Linea aspera has distinct medial and lateral lips. The medial and lateral surfaces are
directed more backwards than to sides.

The shaft possesses 3 surfaces as well – anterior, medial and lateral.

In upper on third of the shaft he two lips of the Linea aspera diverge wide to form an
additional posterior surface and four borders (medial, lateral, spiral line and the lateral hip
of the gluteal tuberosity) and 4 surfaces (anterior, medial, lateral and posterior).

The gluteal tuberosity is a broad roughened ridge on the lateral part of the posterior
surface.

Similarly, the two lips of the Linea aspera diverge in lower one third and enclose an
additional, popliteal surface. Thus this part of the shaft has four border (medial, lateral,
supracondylar line and lateralsupracondylar line) 4 surfaces (anterior, medial, lateral and
popliteal). The medial border and medial supracondylar line meet inferiorly to obliterate
the medial surface.

49
Lower End of Femur

The lower end of the femur is wide and expanded. It has two large condyles
– medial and lateral. Anteriorly, the two condyles are united and are in a line with the front
of the shaft. Posteriorly, they are separated by a deep gap, termed the interocondylar
fossa or intercondylar notch, and project backwards much beyond the plane of the
popliteal surface.

The lateral condyle is flat laterally, less prominent than medialcondyle and stouter than it.
It has a prominence called the lateralepicondyle. Below it lies the popliteal groove with
deeper anterior part and a shallower posterior part.

Medial condyle is convex medially. It also bears a prominent point called

the medial epicondyle. Adductor tubercle is a projection posterosuperior to the epicondyle
which serves as an important landmark. The epiphyseal line for the lower end of the
femur passes through it.

Interondylar fossa or notch separates the lower and posterior parts of the two condyles.
Intercondylar line separates notch from the popliteal surface. Anteriorly, the notch is
limited by patellar articular surface.

The two condyles are partially covered by a large articular surface. Anteriorly, the
condyles articulate with patella and this articualtion extends more on the lateral condyle
than on the medial.Between the two condyles, the surface is grooved vertically. Two faint
grooves separate the patellar articualtion surface from tibial surfaces. Tibial articulation
surface over the lateral condyle is short and straight anteroposteriorly whereas the part
over the medial condyle is longer and is convex medially.

50
Attachments on the Femur
Head of Femur

The fovea on the head of the femur provides attachment to the ligament of the head
(round ligament, or ligamentum teres).

Greater Trochanter

 The piriformis is inserted into the apex

 The gluteus minimus is inserted into the rough lateral part of the anterior surface
 The obturator internus and the two gemelli are inserted into the upper rough
impression on the medial surface
 The obturator externus is inserted into the trochanteric fossa
 The gluteus medius is inserted into the ridge on the lateralsurface.
 The trochanteric bursa of the gluteus medius lies in front of the ridge, and the
trochanteric bursa of the gluteus maximus lies behind the ridge.

Lesser Trochanter

 The psoas major is inserted on the apex and medial part of the rough anterior
surface.
 The iliacus is inserted on the anterior surface of the base of the trochanter, and on
the area below.
 Gluteus minimus bursa lies deep to the upper horizontal fibrres of the adductor
magnus.

Intertrochanteric Line

Following structures attach to intertrochanteric line

 Capsular ligament of the hip joint

 Iliofemoral ligament in its upper part
 Lower band of the iliofemoral ligament in its lower part
 Highest fibres of the vastus lateralis from the upper end
 Highest fibres of the vastus medialis from the lower end
 Quadratus femoris attached on quadrate tubercle

Shaft of Femur

 The medial and popliteal surfaces are bare [ Except for part of gastrocnemius
origin on the popliteal surface]
 Vastus intermedius – upper three fourths of the anterior and lateral surfaces.
 Articularis genu – just below the vastus intermedius.

51
  Vastus lateralis – upper part of the intertrochanteric line, anterior
and inferior borders of the greater trochanter, the lateral lip of the gluteal
tuberosity, and the upper half of the lateral lip of the line aspera.
 Vastus medialis – Lower part of the intertrochanteric line, the spiral line,
the medial lip of the linea aspera, and the upper one –fourth of
the medial supracondylar line.
 Gluteal tubersosity receives insertion of deeper fibres of the lower half of the
gluteus maximus
 Adductor longus – Medial lip of the linea aspera between the vastus medialis and
the adductor brevis and magnus
 Adductor brevis is inserted into a line extending from the lesser trochanter to the
upper part of the linea aspera, behind the pectineus and the upper part of the
adductor longus.
 Adductor magnus is inserted into the medial margin of the gluteal tuberosity, the
linea aspera, the medial superacondylar line, and the adductor tubercle
 Pectineus is inserted on a line extending from the lesser trochanter to the linea
aspera.
 Short head of the biceps femoris arises from the lateral lip of the linea aspera
between the vastus lateralis and the adductor magnus, and from the upper two –
thirds of the lateralsuperacondylar line
 Medial and lateral intermuscular septa are attached to the lips of the linea aspera
and to the supracondylar line. These septae separate the extensor muscles from
the adductor medially, and from the flexors laterally. The lower end of
the lateralsupracondylar line gives origin to the plantaris above and the upper part
of the lateral head of the gastrocnemius below.
 The popliteal surface is covered with fat and forms the floor of the popliteal
fossa. Medial head of the gastrocnemius extends to the popliteal surface just
above the medial condyle.

Lateral Condyle

 Fibular collateral ligament of the knee attaches to the lateralepicondyle.

 The popliteus aries from the deep anterior part of the popliteal groove. When the
knee is flexed the tendon of this muscle lies in the shallow posterior part of the
grove.
 The muscular impression near the lateral epicondyle gives origin to
the lateral head of the gastrocnemius.

Medial Condyle

 Tibial collateral ligament of the knee – medial epicondyle

 Hamstring part of the adductor magnus – adductor tubercle

52
Intercondylar Notch

 Anterior cruciate ligament – posterior part of the medial surface of

the lateral condyle.
 The intercondylar line provides attachment to the capsular ligament and laterally
to the oblique popliteal ligamemt.
 The infrapatellar synovial fold is attached to the anterior border of the
intercondylar fossa.

53
 A. PLANNING (Nursing Care Plan)

NCP#1: ACUTE PAIN

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED

EXPLANATION OUTCOME

Subjective: Acute Pain In cases of Short Term: Monitor skin color These are usually Short Term:
Ø fracture, pain is After 4 hours of and vital signs. altered in pain. The patient’s pain
continuous and nursing scale shall have
Note when pain To medicate
Objective: increasing in interventions, the decreased from
occurs (e.g. with prophylactically, as
The patient severity until bone patient’s pain scale appropriate 7/10 to 4/10.
ambulation, every
manifested: fragments are will decrease from
evening).
 Pain scale of immobilized. 7/10 to 4/10.
7/10 Tissue damage Provide comfort To promote
 Guarding releases chemical measures such as nonpharmacologica
mediators, such as Long Term: l pain management Long Term:
behavior repositioning and
 Positioning to prostaglandins, After 4 days of quiet environment. The patient shall
avoid pain bradykinin, nursing have reported
 Irritability serotonin, interventions, the Instruct in and To distract attention that pain is
 Reduced substance p, and patient will be able encourage use of and reduce tension already relieved
interaction with histamine. These to report that pain relaxation and verbalized
people substances then is already relieved techniques such sense of control
activate and will also as deep breathing. of response to
The patient may nociceptors, verbalize sense of Review acute situation.
To reduce concern
manifest: resulting in control of response procedures and of the unknown and
 Changes in transduction, or to acute situation. expectations associated muscle
appetite the generation of including when tension
 Sleep pattern an action potential. treatment may
disturbance Then the cause pain.
transmission of
 Restlessness Encourage To prevent fatigue
action potential
 Diaphoresis adequate periods
moves from the

54
Vital Signs: site of injury along of rest and sleep.
T: 36.1ºC afferent nerve
Provide firm To reduce pressure
PR: 107 bpm fibers to
mattress, small in inflamed or
RR: 16 cpm nociceptors at the
pillow. Elevate painful joints.
BP: 130/90 mmHg spinal cord.
linen with bed
- G Release of other
cradle as needed.
u neurotransmitters
a carry the action Apply ice cold Cold may relieve
r potential across packs when pain and swelling
d the cleft to the during acute
indicated.
episodes.
i dorsal horn of the
n spinal cord, from
h where it ascends Encourage To promote
a the spinothalamic mobility of the circulation and
tract to the extremities. Assist prevent excessive
thalamus and the tissue pressure
with ROM
midbrain. Finally, exercises.
from the thalamus,
fibers send the
nociceptive Administer Necessary for
message to the medications treatment of the
somatosensory underlying cause
(particularly
cortex, parietal analgesics) as
lobe, frontal lobe, prescribed.
and the limbic
system, where the
third nociceptive Provides sustained
Assist with
process heat to reduce pain
physical therapist.
perception occurs. and improve ROM
Perception, the of affected joints
conscious
experience of pain,

55
involves both the
sensory and
affective
components of
pain.

56
 NCP#2: IMPAIRED PHYSICAL MOBILITY

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED

EXPLANATION OUTCOME

Subjective: Impaired Fractures occur Short Term: Present a safe These measures Short Term:
Ø physical mobility when the bone is After 4 hours of environment. Bed promote a safe, The patient shall
related to loss of subjected to stress nursing rails up, bed in down secure environment have verbalized
Objective: integrity of bone greater than it can interventions, the position, important and may reduce understanding of
structures absorb. When the patient will be able item close by. risk for falls. situation and
The patient (fracture) bone is broken, to verbalize individual
manifested: adjacent structures understanding of Execute passive or Exercise enhances treatment
 Limited range are also affected, situation and active assistive increased venous regimen and
of motion in resulting in individual treatment ROM exercises to return, prevents safety measures.
the right lower dislocations, regimen and safety all extremities. stiffness and
extremity ruptured blood measures. maintains muscle
noted vessels, bleeding strength. It avoids
 Limited ability from damaged ends Long Term: contracture Long Term:
to perform of bone and After 4 days of deformation. The patient shall
gross or fine surrounding tissue. nursing have
motor skills Then will stimulate interventions, the Turn and position Position changes demonstrated or
 Difficulty in inflammatory patient will be able the patient every 2 optimize circulation participated in
changing response and to demonstrate or hours or as needed. to all tissue and ADL’s and desired
position increased capillary participate in ADLs relieve pressure. activities, and
 Difficulty in permeability, then and desired maintained or
moving the there will be fluid and activities, and Offer diversional Diversional activity increased
affected cellular exudation, maintain or activities. helps in refocusing strength and
extremity and pain will occur increase strength attention and function of
 With skeletal which leads to and function of promotes coping affected leg.
traction on the impaired physical affected leg. with limitations.
right leg with mobility.
counter Explain to the This allows patient
weights patient the need to to have sense of

57
 hanging freely call for help. control and lowers
fear of being left
The patient may alone.
manifest:
 Dyspnea Set goals with This enhances
 Fatigue patient for sense of
 Weakness cooperation in anticipation of
 Postural activities or progress and
instability/ gait exercises and improvement and
changes position changes. gives some sense
of control or
Vital Signs: independence.
T: 36.1ºC
PR: 107 bpm Provide the patient Rest periods are
RR: 16 cpm of rest periods in essential to
BP:130/90 between activities. conserve energy.
mmHg Consider energy- The patient must
saving techniques. learn and accept
his/her limitations.

Teach the patient in A safe environment

maintaining home will help prevent
atmosphere injury related to
hazard-free and falls. Home
safe. modification can
help the patient
maintain a desired
level of functional
independence and
reduce fatigue with
activity.

58
Support affected To maintain
leg using pillows. position and
function and reduce
risk of pressure
ulcers

Encourage deep Reduces stress

breathing exercises levels and helps to
and relaxation divert attention
technique. from pain

59
 NCP#3: IMPAIRED SKIN INTEGRITY

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED

EXPLANATION OUTCOME

Subjective: Impaired Skin Skin is the primary Short Term: Assess blood To provide Short Term:
Ø Integrity related defense of the body; After 4 hours of supply and comparative The patient shall
to presence of It protects the body nursing sensation of skin baseline and have identified
Objective: traction and against infections interventions, the surfaces and opportunity for behaviors or
The patient prolonged and diseases patient will be able affected area on a timely intervention techniques to
manifested: immobility brought about by the to identify regular basis. when problems are prevent skin
invasion of microbes
 Dry skin behaviors or noted breakdown or
in the body. Due to
 Itchiness techniques to injury.
the fracture of the To clarify\y
 Redness prevent skin Determine client’s
patient which is intervention needs
around the caused by fall, there breakdown or level of discomfort.
and priorities
affected body will be impaired injury.
part physical mobility.
This will cause Long Term: Long Term:
After 4 days of Perform routine To monitor The patient shall
Vital Signs: pressure on soft
nursing skin inspections. progress of wound have displayed
T: 36.1ºC tissues between
bony prominences interventions, the healing timely healing of
PR: 107 bpm
RR: 16 cpm which will compress patient will be able wound without
BP:130/90 capillaries and to display timely complication.
mmHg occlude blood flow. If healing of wound Keep the area To assist body’s
the pressure will not without clean and dry, natural process of
be relieved, there complication. carefully dress repair
can be microthrombi wounds, support
formation and
incision.
occlusion in
capillaries and blood
flow which can To protect the
disrupt the skin Apply appropriate
wound and for
resulting in disruption dressing or wound
wound healing
of skin causing coverings

60
impaired skin Maintain For faster wound
integrity. appropriate healing
moisture
environment for
particular wound.

Reposition client on To enhance

regular schedule, understanding and
involving client in cooperation
reasons for and
decisions about
times and
positions.

Use appropriate To reduce pressure

padding devices. on, and enhance
circulation to,
compromised
tissues

Encourage PROM To promote

exercises. circulation and
reduce risks
associated with
immobility

61
 NCP#4: DISTURBED SLEEPING PATTERN

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED

EXPLANATION OUTCOME

Subjective: Disturbed First, tissue damage Short Term: Assess client's To determine the Short Term:
“Di ako Sleeping Pattern releases chemical After 4 hours of sleep patterns and etiology of the The patient shall
makatulog nang related to pain in mediators, such as nursing usual bedtime disturbance have identified
maayos kasi right leg and prostaglandins, interventions, the rituals and appropriate
masakit yung sa discomfort due to bradykinin, patient will identify incorporate these interventions to
paa ko, kaya the skeletal serotonin, substance appropriate into the plan of promote sleep.
napuyat ako” as traction as P, and histamine. interventions to care.
verbalized by the
evidenced by These substances promote sleep.
patient.
irritability and then activate Provide measures Simple measures
Objective: frequent yawning nociceptors, Long Term: to take before can increase quality Long Term:
The patient during resulting in After 4 days of bedtime to assist of sleep. The patient shall
manifested: assessment transduction, or the nursing with sleep. have reported
 Irritability generation of an interventions, the improved sleep
 Frequent action potential. patient will be able Provide pain relief Clients have and increased
yawning Then the to report improved shortly before reported that sense of well-
during transmission of sleep and bedtime and uncomfortable being and feeling
assessment action potential increased sense of position client positions and pain rested.
 Fatigued moves from the site well-being and comfortably for are common factors
Appearance of injury along feeling rested. sleep. of sleep
 Dark circle afferent nerve fibers disturbance.
under eyes to nociceptors at the
spinal cord. Release Keep environment Excessive noise
The patient may of other quiet. causes sleep
manifest: neurotransmitters deprivation.
 Restlessness carry the action
 Difficulty in potential across the
arousal cleft to the dorsal Teach some These guidelines
horn of the spinal guidelines for good on sleep hygiene

62
 Altered cord, from where it sleep hygiene to have been shown to
mental status ascends the improve sleep effectively improve
spinothalamic tract to habits. quality of sleep.
the thalamus and the
midbrain. Finally, Instruct patient to This reduces the
Vital Signs:
from the thalamus, follow as consistent energy required for
T: 36.1ºC
fibers send the a daily schedule for adaptation to
PR: 107 bpm
nociceptive message sleeping and changes.
RR: 16 cpm
to the arising as possible.
BP:130/90
somatosensory
mmHg
cortex, parietal lobe, Instruct to avoid Gastric digestion
frontal lobe, and the heavy meals can disturb sleep.
limbic system, where before sleeping.
the third nociceptive
process perception Prepare patient for This promotes
occurs. Perception, necessary minimal interruption
the conscious anticipated in sleep or rest.
experience of pain, interruptions or
involves both the disruptions.
sensory and affective
components of pain. Position to an To alleviate
Pain following appropriate discomfort and
fracture has been position. improve sleep
associated with
sleep disturbance. Minimize sleep- To promote
The patient’s sleep disrupting factors readiness for sleep
will be disturbed and provide and improve sleep
when she clustered care. duration and quality
experiences pain
when she tends to
move during the
night.

63
C. IMPLEMENTATION

1. MEDICAL MANAGEMENT

a. IVF, NGT feeding, TPN, IFC

MEDICAL DATE ORDERED GENERAL INDICATIONS OR CLIENT’S

MANAGEMENT DESCRIPTION PURPOSES RESPONSE TO THE
DATE PERFORMED
TREATMENT TREATMENT
DATE CHANGED

Date Ordered:
Plain Normal Saline Plain Normal Saline It was prescribed to Patient responded well
Solution (PNSS) 1L January 22, 2018 Solution in an isotonic replace fluid lost and to the treatment and
x 30 gtts/min volume expander. It is a electrolytes of the received the nutrients
source of water and body to prevent needed by the body
Date Performed: electrolyte replacement. It dehydration as well such as water, sodium
January 22, 2018 – is also used with the as IV medication and chloride. She did
January 27, 2018 administration of blood administration. not experience any
transfusions. potential IVF therapy
related complications.
Date Discontinued: The patient was kept
hydrated as evidenced
January 27, 2018 by absence of dryness
of skin during the 4
days of nurse-patient
interaction.

64
NURSING RESPONSIBILITIES:

Before:

 Verify the patient.

 Verify the doctor’s order indicating the type of solution and the amount to be administered.
 Assess patient’s vital signs.

During:

 Regulate the IVF as ordered.

 Check for the patency of the line.
 Check the infusion rate.
 Monitor the level of the fluid.
 Watch closely for signs and symptoms of fluid overload.

After:

 Check regulation of IVF regularly and maintain appropriate infusion rate.

 Give the patient some instructions regarding proper care and limitation of movement on the insertion site to keep the
cannula in place.
 Maintain patient’s IV line, watch for irritation in the insertion site.
 Document the procedure done.

65
 MEDICAL DATE ORDERED GENERAL INDICATIONS OR CLIENT’S
MANAGEMENT DESCRIPTION PURPOSES RESPONSE TO THE
DATE PERFORMED
TREATMENT TREATMENT
DATE CHANGED

Date Ordered:
Plain Lactated Lactated Ringer's is a It was prescribed to Patient responded well
Ringer’s Solution February 07, 2018 sterile solution for fluid replace fluid lost by to the treatment and
(PLRS) 1L x 30 and electrolyte the body to prevent received the nutrients
gtts/min replenishment. It restores dehydration. needed by the body.
Date Performed: fluid and electrolyte She did not experience
February 07, 2018 balances, produces any potential IVF
diuresis, and acts as therapy related
February 08, 2018 alkalizing agent (reduces complications. The
acidity). patient was kept
hydrated as evidenced
Date Discontinued: by absence of dryness
February 08, 2018 of skin during the 4
days of nurse-patient
interaction.

66
NURSING RESPONSIBILITIES:

Before:

 Verify the patient.

 Verify the doctor’s order indicating the type of solution and the amount to be administered.
 Assess patient’s vital signs.

During:

 Regulate the IVF as ordered.

 Check for the patency of the line.
 Check the infusion rate.
 Monitor the level of the fluid.
 Watch closely for signs and symptoms of fluid overload.

After:

 Check regulation of IVF regularly and maintain appropriate infusion rate.

 Give the patient some instructions regarding proper care and limitation of movement on the insertion site to keep the
cannula in place.
 Maintain patient’s IV line, watch for irritation in the insertion site.
 Document the procedure done.

67
 MEDICAL DATE ORDERED GENERAL INDICATIONS OR CLIENT’S RESPONSE
MANAGEMENT DESCRIPTION PURPOSES TO THE TREATMENT
DATE PERFORMED
TREATMENT
DATE CHANGED

Date Ordered:
D5W 500mL + 250 Dextrose 5% in Water It was prescribed to The patient was free
mg Tramadol x 20 February 07, 2018 (D5W) with Tramadol replace fluid lost by from dehydration or
ugtts/min raises total fluid volume. It the body to prevent was kept hydrated as
is also helpful in dehydration. evidenced by absence
Date Performed: rehydrating and excretory of dryness of skin
February 07, 2018 purposes and reduce during the 4 days of
gastric acid. nurse-patient
February 08, 2018 interaction. The
Tramadol was also
effective as evidenced
Date Discontinued: by decreased pain
February 08, 2018 scale from 7/10 to 4/10
on February 08, 2018.

68
NURSING RESPONSIBILITIES:

Before:

 Verify the patient.

 Verify the doctor’s order indicating the type of solution and the amount to be administered.
 Assess patient’s vital signs.

During:

 Regulate the IVF as ordered.

 Check for the patency of the line.
 Check the infusion rate.
 Monitor the level of the fluid.
 Watch closely for signs and symptoms of fluid overload.

After:

 Check regulation of IVF regularly and maintain appropriate infusion rate.

 Give the patient some instructions regarding proper care and limitation of movement on the insertion site to keep the
cannula in place.
 Maintain patient’s IV line, watch for irritation in the insertion site.
 Document the procedure done.

69
 MEDICAL DATE ORDERED GENERAL INDICATIONS OR CLIENT’S
MANAGEMENT DESCRIPTION PURPOSES RESPONSE TO THE
DATE PERFORMED
TREATMENT TREATMENT
DATE CHANGED

Date Ordered:
Heparin lock (Hep- Heparin Lock, or Hep This is used to keep The patient complied
lock) January 27, 2018 Lock, is an intravenous IV catheters open with the heplock and it
February 08, 2018 (IV) catheter that is and flowing freely served as an
threaded into a peripheral which is viable for alternative in using IV
vein, and flushed with days longer than a and a patent route for
Date Performed: heparin. They are held in traditional IV. It is IV medications.
place with tape in order to used episodically for
January 27, 2018 – administer drugs and fluid or medication
February 06, 2018 fluids without injecting infusions.
February 08, 2018 patients multiple times
unnecessarily.
February 09, 2018

Date Discontinued:
February 07, 2018

70
NURSING RESPONSIBILITIES:

Before:

 Check health care provider’s order to insert a heparin lock.

 Wash hands and put on clean gloves.
 Check client’s identification bracelet.
 Explain procedure and reason for inserting heparin lock to client.
 Prepare supplies at bedside.

During:
 Place heparin lock.
 Open sterile package with needleless adapter heparin lock.
 For existing IV, loosen IV tubing and remove.
 Screw heparin lock into hub of tubing.
 To check for patency, remove cap from one-way valve following vigorous scrubbing with alcohol at the connection
site. Connect needleless Leur-locking syringe to the valve. Inject solution into IV site per protocol, using gentle
pulsating motions to create turbulence. Remove syringe and replace sterile cap at end of tubing.

After:
 Check for bleeding.
 Check for swelling on the injection site.
 Check for patency of heparin lock.

71
 MEDICAL DATE ORDERED GENERAL INDICATIONS OR CLIENT’S
MANAGEMENT DESCRIPTION PURPOSES RESPONSE TO THE
DATE PERFORMED
TREATMENT TREATMENT
DATE CHANGED

Date Ordered:
Indwelling Foley It is a small, flexible tube It was ordered to Patient complains
Catheter (IFC) February 07, 2018 that can be inserted empty bladder slight discomfort upon
through the urethra and completely prior and insertion of the
into the bladder, allowing during surgery and catheter. The patient’s
Date Performed: urine to drain. The urethra maintenance of urine was drained and
February 07, 2018 – is the tube that carries bladder her output was
February 09, 2018 urine from the bladder out decompression. It monitored. She was
of the body. was also ordered to able to urinate through
facilitate accurate the catheter with
measurement of the yellow color urine
urinary output. amounting to 1400cc
on February 08, 2018
and 400cc on
February 09, 2018.

72
NURSING RESPONSIBILITIES:

Before:

 Check the physician order: Check all parts of the order for accuracy.
 Explain to the patient the purposes/ indications of the procedure.
 Prepare all the equipment needed such as sterile catheter, pair of gloves, antiseptic solution, drapes, forceps,
water soluble, lubricant, urine receptacle, specimen container, syringe with distilled water, flashlight.
 Wash hands and observe appropriate infection control procedures.

During:

 Place client in appropriate position and drape all areas except the perineum.
 Water sterile gloves.
 Attached catheter to collection bag.
 Attached the prefilled syringed to the indwelling catheter inflation hub and test the balloon.
 Lubricate the catheter.
 Cleanse the meatus.
 Insert the catheter firmly 2 to 3 ingest from the tip. Check for urine output.
 Inflate the balloon.
 Secure catheter on patient’s thigh with hypo allergic tape.

73
After:

 Instruct the patient never to pull the catheter.

 Check if there are no kinks or twist on the tubing.
 Empty the drainage bag regularly.
 Monitor for signs and symptoms of urinary tract infection such as fever, chills, turbid urine, itching the redness
on perineal area and elevation of WBC.
 Keep the urine drainage bag below the level of the bladder.
 Record the date/time the foley catheter was inserted; patient’s reaction, the consistency and amount of urine.

74
b. Drugs

GENERAL
NAME OF DATE ORDERED ROUTE OF SPECIFIC CLIENT’S
ACTION
DRUGS ADMINISTRATION INDICATION OR RESPONSE TO
DATE GIVEN FUNCTIONAL PURPOSE THE
DOSAGE AND
CLASS MEDICATION
DATE CHANGED FREQUENCY OF
MECHANISM OF WITH ACTUAL
ADMINISTRATION SIDE EFFECT
ACTION

Generic Name: Date Ordered: Route: IV General Action: It was prescribed The patient’s pain
Analgesic for the scale was
Tramadol January 22, 2018 Dosage: 50 mg
management of decreased from
February 07, Frequency: Every moderate to 7/10 to 4/10 on
Mechanism of
2018 8 hours for pain severe pain. February 08,
Brand Name: action:
2018.
Ultram It is thought to
bind to opioid
Date Given:
receptor and
January 22, 2018 inhibit reuptake of
norepinephrine
February 07, and serotonin.
2018

75
Generic Name: Date Ordered: Route: Oral General Action: It was prescribed The patient’s pain
Dosage: 200 NSAID for the scale was
Celecoxib January 23, 2018
mg/cap management of decreased from
Frequency: Twice moderate to 7/10 to 4/10 on
a day for pain Mechanism of
Brand Name: Date Given: action: severe pain. February 08,
2018.
Celebrex January 23, 2018 It is thought to
inhibit
– February 09,
prostaglandin
2018 synthesis,
impeding
cyclooxygenase-
2, to produce anti-
inflammatory,
analgesic, and
antipyretic effects.

Generic Name: Date Ordered: Route: Oral General Action: It was prescribed The patient did
Dosage: 50 Antihistamine because the not manifest
Diphenhydramine January 30, 2018
mg/cap patient anymore allergic
Frequency: Every experienced reactions or
8 hours PRN Mechanism of
Brand Name: Date Given: action: rashes on body rashes on her
and body on body and face on
Benadryl January 30, 2018 It competes with
histamine for H1- January 30, 2018. February 05,
receptor sites. It 2018.
prevents, but

76
 doesn’t reverse,
histamine-
mediated
responses,
particularly those
of the bronchial
tubes, GI tract,
uterus and blood
vessels.

Generic Name: Date Ordered: Route: IV General Action: It was prescribed The patient didn’t
before and during experience signs
Cefazolin February 07, Dosage: 1g Antibiotic
Frequency: Every certain operation of infection after
2018
8 hours to help prevent her operation on
Mechanism of
Brand Name: action: infection after her February 07,

Date Given: operation on 2018 as

Ancef It exerts its action
by penetrating February 07, evidenced by
February 07,
bacterial cells 2018. normal
2018 - February readily and
temperature on
09, 2018 interfering with
the synthesis of February 08 and
vital cell wall 09, 2018. She
components, displayed timely
which leads to cell
death; wound of healing
bactericidal. and inflammation
on her right leg

77
 was reduced.

Generic Name: Date Ordered: Route: IV General Action: It was prescribed The patient didn’t
to prevent ulcer experience signs
Ranitidine February 07, Dosage: 50 mg Antiulcer
Frequency: Once and to decrease and symptoms of
2018
on NPO gastric acid ulcer.
Mechanism of
Brand Name: action: production while

Date Given: the patient is on

Zantac It competitively
inhibits action of NPO.
February 07,
histamine at H2-
2018 – February receptor sites of
08, 2018 parietal cells,
decreasing
gastric acid
production.
Date
Discontinued:

February 08,
2018

Generic Name: Date Ordered: Route: IV General Action: It was prescribed The patient’s pain
for the scale was
Paracetamol February 07, Dosage: 900 mg Analgesic
Frequency: Every Antipyretic management of decreased from
2018
Brand Name: 6 hours x 5 doses mild to moderate 7/10 to 4/10 on
pain and to February 08,

78
Tylenol Mechanism of prevent 2018. She didn’t
action: occurrence of experience fever
Date Given:
It is thought to fever. as evidenced by
February 07, produce
normal
analgesia by
2018 temperature on
inhibiting
prostaglandin and February 08 and
other substances 09, 2018.
that sensitize pain
receptors. Drug
may relieve fever
through central
action in the
hypothalamic
heat-regulating
center.

79
NURSING RESPONSIBILITIES:

Before:
 Check doctor’s order.
 Verify patient.
 Check the condition of the patient before administering the drug.
 Explain the importance of the drug to the patient.

During:
 Be alert for signs of reactions of the medication.
 Discontinue drug if hypersensitivity reactions occur.

After
 Note the patient’s reaction to the drug.
 Instruct patient to report adverse reactions promptly.
 Document.

80
c. Diet

CLIENT’S
TYPE OF DIET DATE ORDERED GENERAL INDICATION/S SPECIFIC RESPONSE
DATE STARTED DESCRIPTION OR PURPOSE/S FOODS TAKEN AND/ OR
DATE CHANGED REACTION TO
THE DIET
Nothing per Date Ordered: It is an instruction This diet was None The patient
orem (NPO) February 07, 2018 advising that the indicated for the complied with the
patient is patient before and diet and was able
Date Started: prohibited from after surgery to to rest her
February 07, 2018 ingesting food, prevent aspiration gastrointestinal
– February 08, beverage, or by nausea and tract before she
2018 medicine, who is vomiting, which will undergo a
about to undergo occurs when procedure. The
Date Changed: surgery or special stomach contents patient
February 08, 2018 diagnostic enter the lungs, responded well to
procedures potentially the diet as
requiring that the blocking airflow evidenced by the
digestive tract be and putting prevention of
empty or who is patients at risk for aspiration by
unable to tolerate pulmonary nausea and
food and fluids by aspiration. vomiting.

81
 mouth for some
reason.

Diet as Date Ordered: Diet as tolerated It was prescribed Lugaw The patient was
Tolerated (DAT) February 08, 2018 is being ordered to the patient for able to tolerate
by the physician increased body foods. She was
Date Started: when the patient resistance, regaining her
February 08, 2018 can tolerate muscle strength strength as
February 09, 2018 nutritious foods and regular evidenced by
considering her functioning of the absence of
condition and if body. weakness on
will not cause any February 08 and
further 09, 2018.
complication to
the patient. It is
used for patients
requiring no
dietary
modification.

82
NURSING RESPONSIBILITIES:

Before:
 Check the doctor’s order for the type of diet given.
 Explain to the patient the advantages and disadvantage of the prescribed diet.
 Explain to the patient the indication and importance of the therapeutic regimen ordered by doctor.
 Explain the importance of compliance to the diet given.

During:

 The nurse should make sure that the patient complies with the diet ordered by the doctor.
 Emphasize strict compliance to the diet given.
 Apply the diet to the right patient and make sure that the patient follows the diet.

After:
 Monitor the vital signs of the patient.
 Stress out the importance compliance to the prescribed diet.
 Encourage the patient to eat nutritious foods that Lee help him to regain his strength.
 Document.

83
d. Activity/Exercise

DATE ORDERED
ACTIVITY/ GENERAL INDICATION/S OR CLIENT’S
EXERCISE DATE STARTED DESCRIPTION PURPOSE/S RESPONSE AND/ OR
REACTION TO THE
DATE CHANGED ACTIVITY/EXERCISE

Flat on bed Date Ordered: It is a back-lying It was indicated to The patient complied
position similar to immobilize the with the order and was
January 22, 2018
dorsal recumbent but fractured leg of the
the head and patient and let it rest for able to regain the
shoulders are not it to be able to gain its strength of her
Date Started: elevated. Just like normal function and
fractured leg gradually.
dorsal recumbent, this strength.
January 22, 2018 –
position provides
February 09, 2018
comfort in general for
patients recover after
some types of
operation. Arms
should be abducted
from the body and
straight with slight
flexion. Hands should
rest comfortably in a
flat position with
fingers open. The hips
knees are properly
aligned.

84
Turn side to side Date Ordered: Lateral aspects of the It was ordered to The patient expressed
lower scapula and relieve pressure on relief from
January 22, 2018 lower ileum support sacrum and heels, to
most of the body prevent pressure uncomfortable feeling
weight every 2 hours. ulcers, and to promote of wellness on lower
Date Started: circulation and
back and sacral area.
peristaltic movement.
January 22, 2018 –
There were also no
February 09, 2018
bed sores present.

Passive Range of Date Ordered: This exercise is to It was prescribed for The patient verbalized
Motion Exercise reduce stiffness, the patient to help sense of comfort and
February 08, 2018 prevent deformities improve joint function
and help keep joints and this can help keep can already sit on her
flexible. The range of her joints flexible, bed but with the
Date Started: motion is the normal reduce pain, and
assistance of her
amount the joints can improve balance and
February 08, 2018
be moved in certain strength. mother.
February 09, 2018 directions.

85
NURSING RESPONSIBILITIES:
Before:

 Check for doctor’s order for prescribed activity.

 Assess patient to determine functional level.
 Determine if patient is capable of doing the task.

During:

 Position patient properly.

 Attend to the patient’s need.

After:
 Note the response of the patient to the treatment regimen.
 Monitor patient frequently.
 Document procedure and findings.
 Report to physician any untoward reaction of the patient.

86
SURGICAL MANAGEMENT

BUCK’S TRACTION

It is an orthopedic procedure that applies traction to the lower extremity with the
hips and the knees extended. It is used in the treatment of hip and knee contractures, in
postoperative positioning and immobilization, and in disease processes of the hip and the
knee. The traction force is delivered through a traction boot or skin traction in a straight
line. This form of skin traction to the lower limb provides for straight pull through a single
pulley attached to a crossbar at the foot of the bed. The limb in traction lies parallel to the
bed. The foot of the bed is routinely elevated to provide counter traction and to keep the
patient from being pulled down to the foot of the bed. This type of traction may be
unilateral, involving one leg, or bilateral, involving both legs. It can be applied with
adhesive tape secured with an elastic bandage and attached to a pulley and weight.

Nursing Responsibilities:

 Check alignment of the leg to maintain a straight line of pull from the rope attached
to the spreader bar to the pulley mounted on the foot of the bed.
 Check the bandage wrappings and tape or moleskin strips to be sure that they are
adhering properly and have not slipped downward.
 The traction apparatus shall be maintained at all times so that the alignment of
pull is correct.
 Report immediately if any part of the wrappings or traction apparatus appears to
be out of place.
 Perform neurovascular, sensory, motor assessments, and document as ordered.
 The patient is usually not allowed to turn and must remain flat on his back.

87
Intramedullary Nailing Femur Right

An intramedullary rod, also known as an intramedullary nail (IM nail) or inter-

locking nail or Küntscher nail (without proximal or distal fixation), is a metal rod forced into
the medullary cavity of a bone. IM nails have long been used to treat fractures of long
bones of the body.

The surgery was done on February 07, 2018 which started at 6:12 pm and ended
at 7:8 pm. Epidural and spinal anesthesia were administered. The patient was on supine
position. Povidone 10% and 70% alcohol were provided as solutions. Indwelling foley
catheter was inserted with yellow color urine draining 200cc. IVFs of PNSS 1L x 10
gtts/min on right hand and PLRS 1L x 30 gtts/min on left forearm were ordered. Incision
was on the lateral aspect right thigh.

This surgery is performed by the Orthopedic Surgeon in the Operating Room under
general anesthesia. The surgeon will make an incision near the hip joint in order to insert
a rigid rod (intramedullary nail) through the femur. The rod is fixed by screws at both ends
and will keep the bone stable in order to ensure proper healing. In most cases, neither a
cast nor brace will be required post-surgery. Your child will be able to move his hip, knee
and ankle on the operated side. The joints will remain flexible and muscle strength will
be maintained.

The hip will be swollen and you will notice small incisions on the side. Depending
on the fracture pattern, your child will be permitted to walk on the affected leg. In some
instances, weight bearing on the affected leg is not permitted for up to six weeks. Once
the fracture has healed, the rod will remain within the femur and is typically not removed.

Client’s Response to the Operation

88
 After the operation, Patient Leehas been complaining about slight headache, and
back pain. She cannot do anything by herself and needs the assistance of others. It has
also constrained her in doing her usual activities but she is managing the pain by resting
and taking analgesics. She has been eating well and has neither difficulty of swallowing
nor loss of appetite.

Nursing Responsibilities:

Prior During After

 Inform the patient of  Bring any medications,  Provide necessary

what is happening and irrigation fluids, or dressings.
provide support. surgical supplies that
are requested to  Medications should be
 A sedative maybe operating field, using taken as per the
useful to relieve the sterile technique. prescription of the
anxiety of surgery.  Perform surgical doctor.
counts of sponges,
 Painkillers and sharps, and  Ensure to take the
antibiotics may be instruments per entire course of
prescribed before the institutional policy antibiotic.
procedure. before closure of the
 If there are any signs
uterus, peritoneum and
. skin incision. A count is of infection such as
fever, pain, or
also conducted when a
discharge, consult the
change in surgical staff
doctor immediately.
takes place.
 Remove gloves and
discard in proper trash
receptacle. Perform
hand hygiene and
apply clean gloves.

89
2. NURSING MANAGEMENT (Actual FDAR)

February 01, 2018: Thursday

F: Impaired Skin Integrity

D: Received patient lying on bed in semi-fowler’s position, awake, conscious, oriented to

time, place, and person, with heplock on left hand, with skeletal traction on right femur
with counter traction hanging freely, with dry skin, itchiness, redness around affected body
part. Vital signs as follows: T- 36.1ºC, PR- 107 bpm, RR- 16 cpm, BP-130/90 mmHg.

A:

 Inspected skin for changes in color or turgor

 Monitored hydration of skin and mucous membranes
 Encouraged adequate rest
 Assisted the patient in her comfortable position
 Provided skin care
 Kept linens dry and wrinkle-free
 Encouraged to keep fingernails short
 Provided comfort measures
 Emphasized proper hygiene

R: The patient identified behaviors or techniques to prevent skin breakdown or injury.

90
February 02, 2018: Friday

F: Impaired Physical Mobility

D: Received patient sitting on bed, awake, conscious, oriented to time, place, and person,
with skeletal traction on right femur with counter traction hanging freely, with limited range
of motion on the right lower extremity, with limited ability to perform gross or fine motor
skills, slowed movement, and with difficulty in turning. Vital signs as follows: T- 36.1°C; P-
88bpm; R- 20cpm; BP- 120/80 mmHg.

A:

 Established therapeutic relationship

 Assessed and recorded vital signs
 Taught preventive measures to prevent fall such as always raised the side rails
 Encouraged to do isometric or passive range of motion exercises
 Encouraged to do deep breathing exercises and do relaxation techniques
 Encouraged to support the affected leg with pillow

R: The patient maintained position of function and increased strength of the affected body
part.

91
February 08, 2018: Thursday

F: Altered Comfort

D: Received patient lying on bed in semi-fowler’s position, awake, conscious, oriented to

time, place, and person, with indwelling foley catheter connected to a urine bag
amounting 1400cc with yellow color urine, with dry and intact dressing covered with
elastic bandage on the right leg, the patient is irritable and with difficulty of turning or
moving, always turns side to side, and with limited range of motion on the right lower
extremity. Vital signs as follows: T- 36.4°C; P- 88bpm; R- 20cpm; BP- 120/80 mmHg.

A:

 Established therapeutic relationship

 Assessed and recorded vital signs
 Encouraged adequate rest
 Provided comfort and safety measures like raising side rails
 Provided comfort such as rubbing/ touching her hand
 Assisted the patient in her comfortable position

R: The patient verbalized sense of comfort, participated in individual treatment regimen

and complied to health teachings and safety measures given to increase comfort.

92
February 09, 2018: Friday

F: Disturbed Sleep Pattern

D: Received patient lying on bed in semi-fowler’s position, awake, oriented to time, place
and person, with an intact heplock on the left hand, with an indwelling foley catheter
connected to a urine bag amounting 400cc with yellow color urine, with dry and intact
dressing covered with elastic bandage on the right leg, the patient reported being awake
and dissatisfaction with sleep, and not feeling well rested because her right leg is
pulsating and with tingling sensation at night until dawn, with limited range of motion on
the right lower extremity, and with difficulty of turning. Vital signs as follows: T- 36.3°C; P-
88bpm; R- 19cpm; BP- 120/80 mmHg.

A:

 Established therapeutic relationship

 Assessed and monitored vital signs
 Encouraged adequate rest
 Listened to reports of sleep quality
 Observed for physical signs of fatigue like restlessness and drooping of eyes
 Assisted patient in her comfortable position
 Provided comfort measures and safety measures like raising of side rails
 Identified factors known to interfere with sleep

R: The patient reported sense of well-being and feeling rested.

93
D. EVALUATION

1. Clients Daily Progress Chart

DAYS ADMISSION 01-30- 01-31- 02-01- 02-02- 02-07- 02-08- 02-09-

18 18 18 18 18 18 18
01-22-18
Nursing Problems
1. Acute Pain √ √ √ √ √ √ √ √
2.Impaired Physical Mobility √ √ √ √ √ √ √ √
3. Impaired Skin Integrity √ √ √ √ √ √ √
4. Disturbed Sleeping Pattern
√ √ √ √ √ √

Vital Signs
 Temperature 37.0 36.1 36.1 36.4 36.6
 Pulse
90 107 88 88 88
Rate
 Respiratory Rate 28 16 20 30 19
 Blood Pressure 100/70 130/90 120/80 120/80 120/80

Diagnostic and Laboratory

Procedures
CBC with platelet count
12.6
 Hemoglobin 42.3
 Hematocrit

94
 RBC count 4.43
 MCV 88.7
 MCH
 MCHC 28.5
 WBC count 32.1
 Neutrophils
15.75
 Lymphocytes
 Monocytes 72.8
 Eosinophils 21.2
 Platelet count
 RDW-CV 5.6
 RDW-SD 8.1
431
13.1
41.3
Medical Management
IVF
 PNSS √ √
 PLRS
√ √ √
 D5W
√ √ √
Heplock √ √ √
Indwelling Foley Catheter
√ √

95
Drugs
Tramadol √
Celecoxib √ √ √ √
Diphenhydramine
√
Ranitidine √
Cefazolin √ √
Paracetamol √

Diet
NPO √
DAT √ √ √ √ √ √ √

Exercise
Flat on bed √ √ √ √ √ √ √ √
Urn side to side √ √ √ √ √ √ √ √
PROM Exercise √ √ √ √ √ √ √ √

96
II. SUMMARY OF FINDINGS
 Fractures are common. They occur when the physical force exerted on the bone is
stronger than the bone itself. Your risk of fracture depends. Broken bones are very
common in childhood, although children’s fractures are generally less complicated than
fracture in adults.
 Fractures can range in severity from minor inconveniences to severe, life-threatening
injuries that take months or years for full recovery. Improper treatment of fractures can
even lead to debilitating changes to the body’s strength and mobility.

 Fractures commonly happen because of car accidents, falls, or sports injuries. Other
causes are low bone density and osteoporosis, which cause weakening of the bones.
 Common types of fractures include:

 Closed fracture or simple fracture is defined as the break in the bone

which has no communication to the outside.
 Complete fracture is defined as break across the entire section of bone,
dividing it into distinct parts.
 Displaced fracture is defined as fragments out of the normal position at the
fracture site.

 The student nurses have learned in this case study the different types of fractures,
risk factors that predisposed the client to such condition, and the management for
such condition. Knowing the risk factors that may lead to this condition and imparting
them may help individuals to be more aware of their safety and be aware of the
consequences of having fractures.

III. CONCLUSION
In light with the findings of the conducted study, the researchers were able to draw
their conclusions.

A fractured femur is a breakage in the thigh bone (femur), the longest, strongest
and heaviest bone in the human body. The strength and size of the femur means that
under typical circumstances, a large force or extensive trauma is needed in order to result
in a fracture. Motor vehicle accidents and falls are examples of common accidents that

97
result in a fractured femur. Conversely, femur fractures that occur after low-energy trauma
suggest the presence of some type of underlying bone condition.

Symptoms of a fractured femur can include severe pain, bleeding, deformity of the
leg, tissue swelling, and being unable to move your leg. Blood loss can be severe and
may lead to hypovolemic shock. In some cases, bone fragments may protrude from the
skin. Fractures of the femur are commonly associated with traumatic circumstances that
may result in injuries to other areas of the body as well.

Fracture reduction and immobilization: Reduce fractures to near-anatomic alignment

by using in-line traction, which reduces pain and helps prevent hematoma formation. Hold
reduction by a traction device (eg, Hare, Buck) or long-leg posterior splint. Traction is
often required to hold the femur out to length because of contraction of large muscle mass
in the thigh.

IV. RECOMMENDATION
Based on the findings that were presented and the conclusions that were made,
the student nurses have the following recommendations which were formulated:

To the Department of Health, that they may have programs in promoting the health
and well-being of the people to stop the increasing incidence of the disease in the country
and so that people will have the right knowledge and skills in managing the situation.

To the Nursing Practice, that they may implement current knowledge about
fractureinto clinical practice to reduce the number of fracture cases.
To the people affected by the disease, that they may be informed of the
management for the said disease, that they may cooperate with the DOH and other health
care providers in solving the problem regarding the prevalence of fracture. They should
be watchful of the things that could aggravate the condition and the things that could
lessen its effect and promote timely and safe healing and firmly conform to the treatment
regimen and follow the doctor’s counsel regarding the condition at all cost.

98
 To the health care professionals, that they may be able to be conscious of the signs
and symptoms of the disease so that at the first strike of the manifestations, preventive
actions and management can be provided to prevent further complications.

To the student nurses, that they may have improved education regarding the
condition so they can be vigilant in providing first aid measures, appropriate nursing
interventions and applicable health teachings provided to clients having the condition.

To the future researchers, that they may continue to strive and find advancement
regarding the condition, updating skills and treatments that would help in the betterment
of those patients having the condition.

V. LEARNING DERIVED
Nurses also do research and this case study is a form of it. In order to have
evidence-based practice, we need evidence. And with the knowledge and hands-on
experience, we can theorize, structure studies, and collect evidence that leads to better
care. The goal of nursing research is to achieve better care standards and applications
for patients and families. As we do this case study, we learned ways on how the disease
condition can be acquired, prevented and treated. With this, we aimed to reduce morbidity
and gets patient healthy again. It is also important for us to build rapport and work closely
with the patient and his family to find out how to treat them better.
Advincula, Krizzia Mae

In this rotation, I’ve learned a lot about fractures and their risk factors and the
appropriate medical management for them. I was able to enhance my communicating
and assessment skills within our rotation. This is just because we interacted with our
patient every duty and we stayed at their bedside to ensure to attend to their needs. This
rotation made me realize to appreciate the life that God has given me because accidents
may happen anytime.

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 In making this case study, made me realize how essential teamwork, cooperation
and understanding is when working together. It is not easy having to divide all the work
and rely on each other’s works but in my situation, I believe all my groupmates showed
eagerness to finish this case study on time. I learned to appreciate them all and all our
combined efforts.
Bala, Jessica

Throughout this rotation, I enjoyed the ortho surgery. It gives us the highlights of
our lecture in which our clinical instructor had tackled last time. I did not realize how ortho
ward would look like but because of this experience, I hope it will bring out something
good from me. I enjoyed every bit of experience and knowledge and I hope I can learn
more. This case study helps us to give more knowledge about ortho that we didn’t know
before and that is a good thing for us students.
Catacutan, Jesse

Through this case study, I was able to understand a lot of useful information about
the disease condition. It helped me to gain knowledge and understanding of the disease.
I was also able to be aware about the importance of the early treatment when signs and
symptoms exist. It is beneficial to us to have an early case study like this so that in the
future, if I Rosario encounter a patient with the same condition, I have knowledge and
skills about it and won’t be clueless. If that’s the case, I can provide the proper care for
my patient without any doubt. It is important for a student nurse to have knowledge, skills,
and attitude.
Malayao, Peetchee

In this case study, I have learned so much starting from building a whole new
communication with my group all the way down to learning about the condition.
Communication is the key when it comes to a group effort. The amount of time and effort
put into a project shows the effort and the willingness of a group that wants to pass as a
whole. My group may have its ups and downs, but we always get our acts together and

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think of a way to get everything done. I’m glad to say I have gotten close with my group
and look forward to working with them for the rest of the year.
Pangilinan, Raidis Naomi

Doing this case study was a different learning experience because of the bonding
we had similar to that of the family and at the same time, doing our task and working as
a team. It was a different accomplishment for we are able to view and learn an actual
condition of a patient. In doing this case study, I think, there are important things that a
student nurse must have or possess. Some of these are initiative, passion, effort, patience
and availability to socialize or communicate with other people. These are necessary for
you to have a successful working relationship not only with your groupmates but as well
as with the patient we are handling.

Handling a patient with such condition, I realized how important it is to always take
care of your body and take good care of your health. Studying the case of our patient,
gave us student nurses the opportunity to enhance our knowledge and skills in rendering
holistic nursing care to the patient. With every disease comes with risks and we never
know what outcomes may take place so it is our job as nurses to help in every way we
can to prevent complications and for the patient to follow a regimen in order to restore
health and become an ideally healthy individual.
Tamangan, Klayne Erika

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VI. BIBLIOGRAPHY

Books:

Gary A. & Kevin T. (2003). Anatomy and Physiology. Fifth Edition. Mosby Publishing, Inc.
St. Louis, Missouri 63146

Website:

http://bestpractice.bmj.com/best-practice/monograph/45/basics/pathophysiology.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4786904/

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