Saint Louis University

Baguio City
School of Nursing
S.Y 2018-2019

II. Demographic Data

This is the case of NWR, 41 years old male, Filipino Roman Catholic, single and a construction worker, who
is born on June 21, 1977 in Pozorubio, Pangasinan and is currently residing in Loakan, Baguio City,
admitted for the first time on September 2 2018. The informant is the patient with reliability of 85%. He is
currently admitted in the surgical ward room 233 bed 2of Saint Louis University Hospital of the Sacred
Heart, Baguio City.
III. Medical History

1.) History of present Illness or condition

The patient was apparently well until approximately 16 hours prior to admission, the patient had history
of fall from the second floor of a currently constructed house near Loakan, Baguio City. The patient fell and
landed on his arms. The patient was apparently drinking alcohol with his co-workmates before the said
incident with at least 3 bottles of gin. The patient cannot recall events prior to fall but claimed to have had
no quarrels with his co-work mates. The patient had associated symptoms of limitation of movement of
arms, dizziness, weakness and pain on the arms but no signs and symptoms of headache, nausea and
vomiting, change of sensorium nor loss of consciousness. The patient was then rushed to the emergency
room of this SLUSHS, hence admission.

2.) Past Medical History

Patient had no history of hypertension, diabetes, asthma, stroke, pulmonary tuberculosis, cancer nor
heart disease. The patient had no history of recent hospitalization nor surgeries in the past. The patient’s
childhood vaccinations were claimed to be complete but there were no any other recent vaccinations.

3.) Family History

 Saint Louis University
Baguio City
School of Nursing
S.Y 2018-2019

There is no familial history of hypertension, stroke, asthma, heart disease, cancer, dementia, nor
pulmonary tuberculosis as recalled by the patient.

4.) Social and Environmental History

The patient is currently residing in a small apartment in a congested neighborhood full of pine trees
with one toilet which is a flush type. The patient is also a smoker of 5 pack years and an alcoholic of
approximately 3 bottles of gin once a week for about 10years. The patient’s drinking water from a mineral
water an indicated that the garbage is segrated and collected at least once a week. There is no recent
history of travel. The patient has no preference on food but exercises through work and chores at home.

IV. Course of Confinement

Problems Diagnost Significance Medicatio Indication Nursing Nursing Interventions
Identified ics/ / Findings ns Diagnosis
Laborato
ry
 Saint Louis University
Baguio City
School of Nursing
S.Y 2018-2019

Pain Pelvic AP pelvic X-ray Tetanus tetanus Toxoid is Acute pain Determine possible
used to prevent
x-ray can help find toxoid IV 1 related to causes of pain. Note
tetanus (also
the cause of ampule known as lockjaw). physical injury location of surgical
symptoms Tetanus is a procedure. Assess pain
such as pain, serious illness that characteristics (PQRST)
causes
swelling, or
convulsions
deformity in (seizures) and
the pelvic, severe muscle
hip, or upper spasms that can
leg regions, be strong enough
to cause bone
and can Ketorolac
fractures of the
detect broken 30 mg q8 spine.
bones after hours It works by
an injury. blocking your
body's production
of certain natural
substances that
cause
inflammation. This
effect helps to
decrease swelling,
pain, or fever.
V. Assessment Tool
VI. Pathophysiology

Precipitating factors: Predisposing factors

- Pushed by someone that cause fall - Fall
- Male - Alcoholism
-
 Saint Louis University
Baguio City
School of Nursing
S.Y 2018-2019

Patient arrives from ER

Fracture on both forearms Hematoma on right orbital area

Pain, loss of function, swelling, redness

Risk for injury Fracture, open bilateral wrist

Identify interventions to prevent or Wrist AP bilateral x-rayApplied pressure to wound with sterile bandage,
reduce infections - CBC applied ice packs to limit swelling and help relieve
= assess changes in skin color and - UA pain
surgical site
= emphasize hand hygiene
Acute pain related to physical injury
= cleanse incision sites with
Went to OR for
Verbalize non-pharmacological woundthat
methods debridement and pinning on
appropriate antimicrobial solution
bilateral wrist.
provide relief of pain
= maintain hydration
= Determine possible causes of pain
= Note location of surgical procedure
Transport to surgery ward with elastic bandage
= Assess pain characteristics (PQRST)
wrapped around both wrist and intact arm sling
= Encourage verbalization of feelings about
pain
=Encourage comfort measures like changing of
position
VII. Nursing Diagnosis and Justification
 Saint Louis University
Baguio City
School of Nursing
S.Y 2018-2019

Problem Identified Justification

Acute pain 1. According to the Comfort Theory of Katherine Kolcaba,
comfort is an immediate desirable outcome of nursing care and
since the client is experiencing pain, the client’s comfort is
impaired and must be addressed first since it is also an actual
problem.

Risk for Infection 2. According to King’s Goal Attainment Theory, it describes

as a dynamic, interpersonal relationship in which a patient
grows and develops to attain certain goals. Since the goal of a
nurse is to provide holistic care to the clients, then it is
important to devoid the client of any things that may harm his
health with also the participation of the patient.

Impaired Physical mobility According to Parse’s Human Becoming Theory, the goal of
nursing care is to focus on the quality of life of the client. Since
the client has limited movements due to his injuries, he has an
impaired standard of health and comfort. This is also an actual
problem which should be addressed.

Impaired skin integrity According to Paterson and Zderad’s Humanistic Theory, the
theory looks at each patient as an individual who needs
personalized care. This is also an actual problem which should
be addressed
 Saint Louis University
Baguio City
School of Nursing
S.Y 2018-2019

VIII. NCP Proper

Assessment Explanation Objectives Nursing Rationale Evaluation
of problem Intervention
 Saint Louis University
Baguio City
School of Nursing
S.Y 2018-2019

S: A fracture is STO Determine Acute pain Short term:

“Sumasakit the medical After the end of possible follows an injury > Fully met since
kamay pag term for a shift the client causes of pain the client is
ginagalaw ko” broken bone. will be able to: Verbalize non-
Verbalize non- Note location Can influence pharmacological
Fractures are
O: 3rd day post pharmacologica of surgical post op pain methods that
common; the provide relief of
op wound average l methods that procedure
pain
debridement and person has provide relief of
pinning of two during a pain PQRST pain
Assess pain
bilateral wrist lifetime. They
LTO: characteristics method is
With intact arm occur when valuable tool to
After 72 hours (PQRST)
sling and elastic the physical describe, Long term:
of nursing
bandage force exerted determine and > Partially met
intervention the
wrapped around on the bone is Encourage assess patient because client still
client will be
both wrists stronger than verbalization pain. has pain rated as
Pain rated as able to:
the bone itself. Report pain is of feelings Evaluate coping 6/10 characterized
5/10 about pain activities as stabbing located
Acute pain is a relieved
characterized as at the right forearm
physiological Demonstrate
stabbing located Encourage aggravated by
response that use of
at the right comfort movement and
warns us of relaxation skills
forearm measures like relieved by resting
danger. The
aggravated by changing of
process of
movement and position
nociception
relieved by
describes the
resting To prevent
normal Encourage
Nursing fatigability that
processing of adequate rest
Diagnosis:
 Saint Louis University
Baguio City
School of Nursing
S.Y 2018-2019

Acute pain r/t pain and the can impair ability

physical injury responses to Discuss s/o on to manage pain
noxious stimuli ways to assist Family members
that are client o pain may provide
damaging or management assistance to pain
potentially management to
damaging to reduce muscle
normal tissue. tension.
Saint Louis University
Baguio City
School of Nursing
S.Y 2018-2019
 Saint Louis University
Baguio City
School of Nursing
S.Y 2018-2019

NCP II
ASSESSMENT EXPLANATION OF THE OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
PROBLEM
S: Last sept 3 Risk for infection is defined Short term: 1. Assess and - Patients with Short term:
naoperahan as the state in which an After 30 mins of monitor poor nutritional > Fully met since
akosa kanang individual is at risk to be nursing nutritional status may be the client is
kamay” invaded by an interventions, status and unable to complacent of
opportunistic or the patient will weight muster a prescribed
rd
O: 3 day post pathogenic agent from verbalize in his cellular immune regimen of care.
op wound endogenous or exogenous own words the response to
debridement sources. Since the client willingness to pathogens
and pinning of has multiple lesions and follow-up making them Long term:
bilateral wrist breaks in the skin wherein prescribed susceptible to > Partially met
With intact arm the skin is the first line of regimen. 2. Assess infection. since the client
sling and elastic defense of the body immunization - People with has vital signs
bandage against harmful Long term: status and incomplete of:
wrapped around microoganisms, the client After 3 days of history immunizations BP: 180/100
both wrists is susceptible to infections. nursing may not have PR: 75
intervention, the sufficient RR: 24
Reference: patient will acquired active T: 36.7
https://nurselabs.com/risk- remain free of 3. Monitor for immunity.
for-infection/ infection, as signs of - These are the
evidenced by redness, classic signs of
 Saint Louis University
Baguio City
School of Nursing
S.Y 2018-2019

normal vital swelling, infection.

signs and increased pain,
symptoms of purulent
infection discharge, etc. - Restricting
Nursing 4. Maintain a quiet visitation
Diagnosis: environment reduces the
Risk for infection and limit visitors transmission of
pathogens
5. Maintain - Aseptic
asepsis for technique
wound care decreases the
changes of
transmitting or
spreading
pathogens to
the patient.
Interrupting the
chain of
infection along
the chain of
infection is an
effective to
6. Offer fluids of at prevent
least 2000-3000 infection.
mL of water per -
day, unless - Fluids promote
contraindicated diluted urine
and frequent
Saint Louis University
Baguio City
School of Nursing
S.Y 2018-2019

emptying of
bladder-
7. Teach SO and reducing the
visitors proper stasis of urine,
handwashing in turn, reduces
risk for bladder
infection
- Patient and SO
can spread
8. Encourage infection from
intake of one part of the
protein-rich and body to
calorie-rich another-
foods handwashing
9. Encourage reduces these
coughing and risks
deep breathing - Helps support
exercises; the immune
frequent system
position responsiveness
changes - Helps reduce
stasis of
secretions in
the lungs and
the bronchial
tree. When
stasis occurs,
pathogens can
 Saint Louis University
Baguio City
School of Nursing
S.Y 2018-2019

cause upper
respiratory tract
infections and
pneumonia

CASE PRESENTATION

SUBMITTED TO:
PULIDO, FLORENCE
SUBMITTED BY:
CABATBAT, WYEN
ALTUNA, VENICE PAMELA
BRILLANTES, KAREN
FERRER, ELYZE DIANETTE
BSN III- A1
DATE:
SEPTEMBER 18. 2018
 Saint Louis University
Baguio City
School of Nursing
S.Y 2018-2019

CASE PRESENTATION

SUBMITTED TO:
PULIDO, FLORENCE
SUBMITTED BY:
CABATBAT, WYEN
ALTUNA, VENICE PAMELA
BRILLANTES, KAREN
FERRER, ELYZE DIANETTE
BSN III- A1
DATE:
SEPTEMBER 18. 2018