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Nursing Service Training Section Clinical Case Analysis

The patient is a male who was admitted to the Philippine Orthopedic Center with a fracture of the right femoral shaft after falling from a swing. He has no significant past medical history or allergies. Diagnostic imaging confirmed the fracture. His treatment includes immobilization, pain medications, antibiotics, and surgery may be needed for implanting fixation devices. Nursing care focuses on pain management, immobilizing the injured leg, medication administration, and monitoring for complications.

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Bernadeth Labrador
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238 views

Nursing Service Training Section Clinical Case Analysis

The patient is a male who was admitted to the Philippine Orthopedic Center with a fracture of the right femoral shaft after falling from a swing. He has no significant past medical history or allergies. Diagnostic imaging confirmed the fracture. His treatment includes immobilization, pain medications, antibiotics, and surgery may be needed for implanting fixation devices. Nursing care focuses on pain management, immobilizing the injured leg, medication administration, and monitoring for complications.

Uploaded by

Bernadeth Labrador
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Republic of the Philippines Department of Health PHILIPPINE ORHTOPEDIC CENTER Maria Clara corBanaweSts.

Quezon City NURSING SERVICE TRAINING SECTION CLINICAL CASE ANALYSIS Name: Lavilla, Julia Address: Plaridelbulacan/ San idelfonsoBulacan Date Admitted: Feb. 14, 2013 Dr.Incharge: Dr.Suguitan Diagnosis: Fracture Close complete displaced medial 3rd femoral shaft- right NURSING HISTORY: History of present illness: Prior to admission last February 14, 2013, after attending his class, while in his way home he saw a swing hanging on a tree. He played at the swing and accidentally he fall that result to injury. The patient was immediately brought to Philippine Orthopedic Center and is accompanied by relative with chief complaint of the deformity of right lower extremity. Past medical history: The patient hasnt been hospitalized before. Also he has no known food and drug allergies.

PATHOPHYSIOLOGY:

Stress placed on a bone, exceeds the bone ability to absorb it Injury in the bone Disruption in the continuity of bone Disruption of muscle and blood vessels attached to the ends of the bone Soft tissue damage Bleeding Hematoma forms in medullary canal Bone tissue surround the fractured site dies Inflammatory response

DIAGNOSTIC PROCEDURE: Bone Radiography Bone radiography are used to evaluate extremity pain or discomfort due to trauma, bone abnormalities, or fluid within a joint. Serial skeletal xrays are used to evaluate growth pattern. Radiation emitted from the x-ray machine passes through the patient onto a photographic plate or x-ray film. X-rays pass through air freely and are mostly absorbed. Skeletal x-rays are used to evaluate extremity pain or discomfort due to trauma, bone abnormalities, or fluid within a joint. Serial skeletal x-rays are used to evaluate growth pattern. Radiation emitted from the x-ray machine passes through the patient onto a photographic plate or x-ray film. X-rays pass through air freely and are mostly absorbed. Thus this procedure determines location and extent of fractures/trauma, may reveal preexisting and yet undiagnosed fractures. Bone scans, tomograms, computed tomography (CT)/magnetic resonance imaging (MRI) scans help visualize fractures, bleeding, and soft-

tissue damage; differentiates between stress/trauma fractures and bone neoplasms. MEDICAL MANAGEMENT:

Antibiotics, particularly if the skin is broken and the possibility for infection is high Bed rest Casting of the affected limb Pain control medications Surgically implanted fixation devices such as plates, rods or screws Traction

NURSING CARE PLAN

Assessment Pain related to tissue trauma secondary to fracture S: Medyo bali ko.. as verbalized O: >with balanced skeletal traction >with swelling on the right leg >with difficulty of turning

Planning At the end of nursing interventions, the client will report progressive pain and relief after pain-relief measures.

Interventions >Immobilize as possible,

Evaluation

the After the nursing using client verbalizes

injured part as much interventions, the splints as indicated. reduction of pain. >Teach the client to change slowly. >Elevate the injured extremity unless contraindicated. >Investigate medications other measures. pain or relief position

masakit pa yun reduction of

not relieved by pain

DRUGSTUDY

Drug name Paracet amol

Mechanism of action Inhibits the synthesis of the prostaglandin that may serve as mediators of pain and fever, primarily in the CNS. Has no significant antiinflammatory properties or GI toxicity.

Indication

Contraindic atrion

Adverse Reaction

Nursing Considerations overall status alcohol

Mild

pain Hypersensiti vity paracetamol

GI: Hepatic >Assess health and usage. hepatotoxi city (overdose)

and fever

to failure,

>Assess amount, frequency and drugs type of

GU:

Renal

failure

taken in patients self-medication, especially OTC drugs. >For assess and 60 following administration. pain, type, intensity minutes

Hematolog y: Neutropeni a, pancytope nia, leucopenia

location, density prior to and 30-

Dermatolo gic: and urticaria rash

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