I- Introduction A fracture is a break in the continuity of bone and is defined a

ccording to its type and extent. Fractures occur when the bone is subjected to s
tress greater that it can absorb. Fractures are caused by direct blows, crushing
forces, sudden twisting motions, and even extreme muscle contractions. When the
bone is broken, adjacent structures are also affected, resulting in soft tissue
edema, hemorrhage into the muscles and joints, joint dislocation, ruptured tend
ons, severed nerves, and damaged blood vessels. Body organs maybe injured by the
force that cause the fracture or by the fracture fragments. There are different
types of fractures and these include, complete fracture, incomplete fracture, c
losed fracture, open fracture and there are also types of fractures that may als
o be described according to the anatomic placement of fragments, particularly if
they are displaced or nondisplaced. Such as greenstick fracture, depressed frac
ture, oblique fracture, avulsion, spinal fracture, impacted fracture, transverse
fracture and compression fracture. A comminuted fracture is one that produces s
everal bone fragments and a closed fracture or simple fracture is one that not c
ause a break in the skin. Comminuted fracture at the Right Femoral Neck is a fra
cture in which bones of the Right Femoral Neck has splintered to several fragmen
ts. By choosing this condition as a case study, the student nurse expects to bro
aden her knowledge understanding and management of fracture, not just for the fu
lfillment of the course requirements in medical-surgical nursing. It is very imp
ortant for the nurses now a day to be adequately informed regarding the knowledg
e and skill in managing these conditions since hip fracture has a high incidence
among elderly people, who have brittle bones from osteoporosis (particularly wo
men) and who tend to fall frequently. Often, a fractured hip is a catastrophic e
vent that will have a negative impact on the patient’s life style and quality of
life. There are two major types of hip fracture. Intracapsular fractures are fr
actures of the neck of the femur, Extracapsular fracture are fractures of the tr
ochanteric region and of the subtrocanteric region. Fractures of the neck of the
femur may damage the vascular system that supplies blood to the head and the ne
ck of the femur, and the bone may die. Many older adults experience hip fracture
that 1
student nurse need to insure recovery and to attend their special need efficient
ly and effectively. True the knowledge of this condition, a high quality of care
will be provided to those people suffering from it.
2
II. Objectives General Objectives: After three day of student nurse-patient inte
raction, the patient and the significant others will be able to acquire knowledg
e, attitudes and skills in preventing complications of immobility. Specific Obje
ctives: A. STUDENT-NURSE CENTERED After 8 hours of student nurse-patient interac
tion, the student nurse will be able to: 1. state the history of the patient. 2.
identify potential problems of patient 3. review the anatomy and physiology of
the organ affective 4. discuss the pathophysiology of the condition. 5. identify
the clinical and classical signs and symptoms of the condition. 6. implement ho
listic nursing care in the care of patient utilizing the nursing process. 7. imp
art health teachings to patient and family members to care of patient with fract
ure. B. PATIENT-CENTERED After 8 hours of student nurse-patient interaction, the
patient and the significant others will be able to: 1. explain the goals of the
frequent position changes. 2. enumerate the position for proper body alignment.
3. discuss the different therapeutic exercises. 4. practice the different kinds
of range of motion. 5. participate attentively during the discussion.
3
III. Nursing Assessment 1. Personal History 1.1 Patient’s Profile Name: Mrs. Tor
ralba, Lourdes Age: 89 years old Sex: Female Civil Status: Widow Religion: Roman
Catholic Date and time of admission; March 13, 2008 at 10:10 am Room No.: Room
425, Cebu Doctors’ University Hospital Complaints: Pain the right hip Impression
or Diagnosis: Fracture Close-Comminuted: Femoral Right Neck General Osteoporosi
s Breast Cancel (Right) Diabetes Mellitus Type II Physician: Dr. F. Vicuna, Dr.
E. Lee, Dr. N. Uy, Dr. Ramiro Hospital No: 216 426 1.2. Family and Individual In
formation, Social and Health History Mrs. Torralba, Lourdes who resides in 8 Aca
cia St. Camputhaw Lahug, Cebu City, Cebu Province with 9 successful children ( 6
boys and 3 girls) was admitted to Cebu Doctors’ University Hospital for further
management of the condition. Mrs. Torralba is a college graduate and she’s prev
iously working as an assistant of her husband ( Mr. Rodrigo Torrralba ) a doctor
. The patient was diagnosed to have Breast Cancer (Right) last 2006 with bone me
tastasis and on chemotherapy with aromasin.
4
Two days prior to admission, the patient was standing and was about to open up h
e umbrella when she got out of balance and landed on her right hip.And had exper
ienced limitation of movement on the right hip. The patient was then admitted du
e to the persistence of pain. The patient was previously hospitalized due to inf
ected wound at the right ankle last 2002. No familial history of hypertension an
d bronchial asthma but is positive to diabetes mellitus of paternal side. Has no
known food and drug allergies. The patient is non-smoker non-alcoholic beverage
s drinker. 1.3. Level of Growth and Development 1.3.1. Normal Growth and Develop
ment at particular stage Older Adult ( 65 Years old to death) Physical Developme
nt Perception of well-being can define quality of life. Understanding the older
adults perception about health status is essential for accurate assessment and d
evelopment of clinically relevant interventions. Older adults concepts of health
generally depend on personal perceptions of functional ability. Therefore older
adults engaged in activities of daily living usually consider themselves health
y, whereas those whose activities are limited by physical, emotional or social i
mpairments may perceive themselves as ill. There are frequently observed physiol
ogical changes in order adults that are called normal. Finding these “normal” ch
anges during and assessment is not an expected. These physiological changes are
not always pathological processes in themselves, but they may make older adults
more vulnerable to some common clinical conditions and diseases. Some older adul
ts experience all of these physiological changes, and others only experience onl
y a few. The body changes continuously with age, and specific effects on particu
lar older adults depend on health, lifestyle, stressors and environmental condit
ions.
5
Cognitive Development Intellectual capacity includes perception, cognitive, memo
ry, and learning. Perception, or the ability to interpret the environment, depen
ds on the acuteness of the senses. If the aging person’s senses are impaired, th
e ability to perceive the environment and react appropriately is diminished. Per
ceptual capacity may be affected by changes in the nervous system as well. Cogni
tive ability, or the ability to know, is related to the perceptual ability. Chan
ges in cognitive structure occur as a person ages. It is believe that there is a
progressive loss of neurons. In addition, blood flow to the brain decreases, th
e meaninges appear to thicken, and brain metabolism slows. As yet, little is kno
wn about the effect of these physical changes on the cognitive functioning of th
e older adult. Older people need addition time for learning, largely because of
the problem of retrieving information. Motivation is also important. Older adult
s have more difficulty than younger ones in learning information they do not con
sider meaningful. It is suggested that the older person mentally active to maint
ain cognitive ability at the highest possible level. Life long mental activity,
particularly verbal activity, helps the older person retain the high level of co
gnitive function and may help maintain a long-term memory. Cognitive impairment
that interferes with normal life is not considered part of normal aging. A decli
ne in intellectual abilities that interferes with social or occupational functio
ns should always be regarded as abnormal. Psychosocial Development According to
Erikson, the developmental task at this time is ego integrity versus despair. Pe
ople who attain ego integrity view with a sense of wholeness and derive satisfac
tion from past accomplishment. They view death as an acceptable completion. Acco
rding to Erikson, people who develop integrity accept “one’s one and only life s
tyle”. By contrast, people who despair often believe they have made poor choices
during life and wish they have made poor choices during life and wish they coul
d live life over. Robert Butler sees integrity and bringing serenity and wisdom,
and despair as resulting in 6
the inability to accept one’s fate. Despair gives rise of frustration, this cour
agement, and a sense that one’s life has been worthless. Moral Development Accor
ding to Kohlberg, moral development is completed in the early adult years. Most
old people stay at Kohlberg’s conventional development, and some are at the prec
onventional level. An elderly person at the preconventional level obeys roles to
avoid pain and the displeasure of others. At stage one, a person defines good a
nd bad in relation to self, whereas older person’s at stage 7 may act to meet an
other’s need as well as their own. Elderly people at the conventional level foll
ow society’s rules of conduct to expectation of others. Emotional Development We
ll-adjusted aging couples usually thrive on companionship. Many couples rely inc
reasingly on their mates for this company and may have few outside friends. Grea
t bonds if affection and closeness can develop during this period of aging toget
her and nurturing each other. When a mate dies, the remaining partner inevitably
experiences feelings of loss, emptiness, and loneliness. Many are capable and m
anage to live alone; however, reliance, on younger family members increases as a
ge advances and in health occurs. Some widows and widower remarry, particularly
the latter, because the widowers are less inclined than widows to maintain a hou
sehold. Spiritual Development Murray and Zentner write that the elderly person w
ith a mature religious outlook striver to incorporate views of theology and reli
gious action into thinking. Elderly people can contemplate new religious and phi
losophical views and try to understand ideas missed previously or interpreted di
fferently. The elderly person also derives a sense of worth by sharing experienc
es or views. In contrast, the elderly person who has not 7
matured spiritually may not matured spiritually may feel impoverishment or despa
ir as the drive for economic and professional success wares. Psychosexual Develo
pment Sex drives persist into the 70’s, 80’s, and 90’s, provided that the health
is good and an interested partner is available. Interest in sexual activity in
old age depends, in large measure, on interest earlier in life. That is, people
who are sexually active in young and middle adulthood will remain active during
their later years. However, sexual activity does become less frequent. Many fact
ors may play a rate in the ability of an elderly person to engage in sexual acti
vity. Physical problems such as diabetes, arthritis, and respiratory conditions
affect energy or the physical ability to participate in sexual activity. Changes
in the gonads of elderly women result from diminished secretion of the ovarian
hormones. Some changes, such as the shrinking of the uterus, and ovaries, go unn
oticed. Other changes are obvious. The breasts atrophy, and lubricating vaginal
secretions are reduced. Reduced natural lubrication is the cause of painful inte
rcourse, which often necessities the use of lubricating jellies. 3.1.2. Ill Pers
on at the Particular Age of Patient The older fracture patients showed a higher
prevalence of chronic brain syndrome, they were in poorer physical state and the
ir skinfold thickness was less. They also had more unrecognized visual disorders
. Those who were younger had a higher prevalence of stroke than comparable contr
ols. The type of fall leading to the fracture varied with age—tripping was the c
ommonest cause in the younger patients and ‘drop attacks’ in the older. Both str
oke and partial sightedness were associated with falls due to loss of balance. T
he older patients had a very high prevalence of pyramidal tract abnormality asso
ciated with chronic brain syndrome—and it appears that these demented patients f
all not because of mental confusion but because of associated motor abnormalitie
s. Ertra-capsular fractures occur in older patients. They are more likely to hav
e a history of falls but previous fracture is equally common at this age in the
fracture and control series. 8
2. Diagnostic Test
9
Diagnostic test April 10, 2008 Complete Blood Count Hemoglobin Hematocrit WBC RB
C Mean Corpuseular Hemoglobin Mean Cell Volume (MCA) Mean Corpuseular Hemoglobin
Platelet Differential Count Neutropihl Basophil Eosinophil Monocyte Lympocyte
Normal values
Patient’s Result
Significance
14.0-17.5 g/dL 41.5-50.4% 4.4-11.0x10^ g/uL 4.5-5.9x10^ g/uL 27.5-33.2 pg 80-96
fL 33.4-35.5 % 150,000-450,000 40-70 % 0-1 % 0-5 % 0-8% 20-40%
9.1 28.8 5.32 2.8 32.7 103.6 32 387 67 0 4 09 20
- Decreased-various anemias, with excessive fluid intake. -Decreased-severe anem
ias -Normal -Decreased- all anemias and leukemia, when blood volume has been res
tored. -Normal -Increased-macrocytic anemia -Decrease-severe hypochronic anemia
-Normal -Normal -Normal -Normal -Increase-viral infection, collagen and hemolyti
c disorders -Normal Source: Brunner and Suddarth’s. Textbook of Medical-Surgical
Nursing.10th Edition Volume 2. page 2214-2215 -Normal -Decreased-Muscular atrop
hy, anemia, leukemia -Decreased-vitamin D. deficiency
Serum Potassium Creatinine
3.6-5 6.7-1.5 8.4-10.2
4.7 6.6 8.2 10
Calcium Protein Albumen Globulin Total Protein GCT(50gms)
1.2-2.2 3.3-5.5 2 6.8 65-110 8-35 u/mL
1.0 2.9 2.9 5.8 145 20
-Decreased-anemia, malnutrition -Decreased-no clinical significance -Increased-c
hronic infection, multiple myeloma -Decreased-malnutrition -Increased-diabetes m
ellitus -Normal Source: Brunner and Suddarth’s. Textbook of Medical-Surgical Nur
sing.10th Edition Volume 2.page 2217,2219,2221,2224,2229,2230,2232 -Increased-di
abetes mellitus Source: Brunner and Suddarth’s. Textbook of Medical-Surgical Nur
sing.10th Edition Volume 2.page 2230,2233,
PBS
65-110
118
Uric acid
2.5-7.5
4.4mg/dL
-Normal Source: Brunner and Suddarth’s. Textbook of Medical-Surgical Nursing.10t
h Edition Volume 2.page 2225, -Normal -Normal -Increased-deficiency of factors I
, II, V, VII, and X, fat malabsorption -Normal -Normal Source: Brunner and Sudda
rth’s. Textbook of Medical-Surgical
Bleeding time-sim Clotting time Prothombin time % activity INR
2.3-9.5 5-15 10-13 70-120 <1.2
6.31 min.-sec. 10.41 min.-sec. 13.8 sec. 96.2 % 1.03
11
Nursing.10th Edition Volume 2.page 2214 Urinalysis Macroscopic Examination Color
Appearance Plt Specific gravity Protein Glucose Ketones Blood Leukocytes Nitrit
e Bilirubin Urohilinogen Microscopic Examination RBC/hpf WBC/hpf Bacteria Mucus
threads Amorphous Urates Blood cell 0-5 0-5 Present Present Present Negative 0-2
/hpf 0-2/hpf Few Few Few Few 12 -Normal -Normal -Normal -Normal -Normal Indicate
s renal or urinary tract disease Yellow Clear 4.5-7.8 1.003-1.029 Negative Negat
ive Negative Negative Negative Negative Negative Normal Yellow Clear 6.0 1.010 T
race Trace Negative Negative Negative Negative Negative 0.2 eu/dL -Normal -Norma
l -Normal -Normal -Glomerular disease, nephritic syndrome -Diabetes mellitus -No
rmal -Normal -Normal -Normal -Normal -Normal
Source: Brunner and Suddarth’s. Textbook of Medical-Surgical Nursing.10th Editio
n Volume 2.page 2224,2225
13
3. Present Profile of Functional Health Patterns Profile of Functional Health Pa
tterns 3.1. Health Perception / Health Management Pattern The patient described
her usual health before to be fair and body is strong but now she considered it
to be poor and weak. This is because of the limited movements she felt, the inab
ility to walk or stand and difficulty in moving the extremities due to the fract
ure of her right femoral neck. Before the admission, the patient eats more foods
rich in fats, sugar or glucose and cholesterol in their meals and she drinks pl
enty of water everyday. During the patient’s hospitalization, her diet was chang
ed to low fat and low cholesterol diet because she was diagnosed of having diabe
tes mellitus type II. The patient’s attending physician encourages her to take m
ore of calcium and Vitamin D in order for her bones to become stronger. The pati
ent is non-smoker and non-alcoholic drinker and she has no known allergies. 3.2.
Nutritional / Metabolic Pattern The patient’s usual food intake before the hosp
italization includes fish, meat, vegetables, fruits, chicken and especially food
s rich in fats, sugar/glucose and cholesterol. She consumes more than 8 glasses
of water a day. Her maintenance meds were Aromasin, Fosamax, Centrum and Caltrat
e. Now the patient was advised by her attending physician to restrict foods that
can aggravate her condition. The patient was also encourage to take more of Cal
cium and Vitamin D in order for her bones to become stronger. The patient doesn’
t smoke or drink alcoholic beverages, has no known allergies. There is a change
in her appetite now; she often eats a little only each meal.
14
3.3. Elimination Pattern Before, the patient can freely go to the C.R. to void o
r defecate but now that she’s hospitalized she was advised to wear diaper for he
r to have difficulty in standing and walking. There is no burning sensation duri
ng ur4ination and her stool is brownish formed stool. 3.4. Activity-Exercise Pat
tern The patient before hospitalized wakes up early in the morning for her to ha
ve fine walking around their house as her exercise. She usually guided her grand
sons and granddaughters, but now, she’s just on bed lying assisted by her privat
e nurses and CDUH health care providers. 3.5. Cognitive/ Perceptual Pattern The
patient before, can hear, smell, taste and feel well and correctly but the patie
nt cannot read her newspaper without her eyeglasses just the same as now. She sp
eaks slowly English, Tagalog and Bisaya languages as of now but before she speak
s fluently all of those languages. She easily communicates, understands question
s, instructions and be able to follow and answer them correctly. 3.6. Rest/ Slee
p Pattern Before the hospitalization, the patient usually sleeps late at night a
t around 10 o’clock pm and wakes up early in the morning at 6 o’clock am with an
hour of sleep of 8 hours. Now, she usually sleeps early at night (8-9 o’clock p
m) and wakes up at around 7 o’clock am with an hour of sleep of 10 hours. The pa
tient usually stays in bed and read newspapers sometimes, she can’t take a nap i
n the afternoon due to her REHAB CARE.
15
3.7. Self- Perception Pattern The patient’s most concern about right now is her
rehabilitation care. The patient wants to stay at the hospital until she improve
s her mobility so she would be able to stand and walk all alone by herself. The
patient never loses the support of her children even if they were not there phys
ically and also her private nurses. Through this, she maybe able to cope up easi
ly from her unhealthy condition. The treatment, managements, medications and all
out care rendered by the hospital to the patient assured her for the improvemen
t of her condition. 3.8. Sexuality/ Reproduction The patient’s husband just rece
ntly died. Now, the patient does not allow anyone to see her getting undressed,
changing diaper, changing clothes because she believes that as a woman, it shoul
d be keep as private. 3.9. Coping- Stress Tolerance Pattern The patient usually
makes her decision as for now since her children were busy in their work abroad,
but they make sure they never forget to support and help their mother recover f
rom illness. Sometimes, the patient usually shares her concerns to her private n
urses and of course also to the student nurses. She usually reads newspaper for
her to be more relaxed. 3.10. Value-Belief Pattern The patient find source stren
gth and hope with God and her loved ones. God is very much important to the pati
ent. Before, she usually goes to church together with her other children. They w
ere not involved in any religious organizations or practices. The patient knows
how to pray and praise God for all the nice things he had given.
16
3.11. Relationship Pattern The patient understands more on English and Bisaya la
nguages but a little only in Tagalog language. The patient was living all by her
self with her private nurses but sometimes, her grandchildren will come over to
visit her. She never uses the support of her children even if they were away fro
m their mother they always make sure that their mother is safe and secure. The p
atient can easily communicate, cooperate, listen and follow instructions easily.
17
4. Pathophysiology and Rationale 4.1 Normal Anatomy and Physiology of Organ/ Sys
tem Affected
The word skeleton comes from the Greek word meaning “dried- up body”, our intern
al framework is so beautifully designed and engineered and it puts any modern sk
yscraper to shame. Strong, yet light, it is perfectly adapted for its functions
of body protection and motion. Shaped by an event that happened more than one mi
llion years ago – when a being first stood erect on hind legs – our skeleton is
a tower of bones arranged so that we can stand upright and balance ourselves. Th
e skeleton is subdivided into three divisions: the axial skeleton, the boned tha
t form the longitudinal axis of the body, and the appendicular skeleton, the bon
es of the limbs and girdles. In addition to bones, the skeletal system includes
joints, cartilages, and ligaments (fibrous cords that bind the bones together at
joints). The joints give the body flexibility and allow 18
movement to occur. Besides contributing to body shape and form, or bones perform
several important body functions such as support, protection, movement, storage
and blood cell formation. Classification of Bones The diaphysis, or shaft, make
s up most of the bones length and is composed of compact bone. The diaphysis is
covered and protected by a fibrous connective tissue membrane, the periosteum. H
undreds of connective tissue fibers, called Sharpey’s fibers, secure the periost
eum to the underlying bone. The epiphyses are the ends of the long bone. Each ep
iphyses consist of a thin layer of compact bone enclosing the area filled with s
pongy bone. Articular cartilage, instead of periosteum, covers its external surf
ace. Because the articular cartilage is glassy hyaline cartilage, it provides a
smooth, slippery surface that decreases friction at joint surfaces. In adult bon
es, there is a thin line of bony tissue spanning the epiphyses that looks a bit
different from the rest of the bone in that area. This is the epiphyseal line. T
he epiphyseal line is a remnant of the epiphyseal plate (a flat plate of hyaline
cartilage) seen in young, growing bone. Epiphyseal plates cause the lengthwise
growth of the long bone. By the end of puberty, when hormones stop long bone gro
wth, epiphyseal plates have been completely replaced by bone, leaving the epiphy
seal lines to mark their previous location. In adults, the cavity of the shaft i
s primarily a storage area for adipose (fat) tissue. It is called the yellow mar
row, or medullary, in infants this areas forms blood cells, and red marrow is fo
und these. In adult bones, red marrow is confined to the cavities of spongy bone
of flat bones and the epiphyses some long bones. Bone is one of the hardest mat
erials in the body, and although relatively light in weight, it has a remarkable
ability to resist tension and other forces acting on it. Nature has given us an
extremely strong and exceptionally simple (almost crude) supporting system with
out up mobility. The calcium salts deposited in the matrix bone its hardness, wh
ereas the organic parts (especially the collagen fibers) provide for bone’s flex
ibility and great tensile strength. 19
The femur, or thigh bone, is the only bone in the thigh. It is the heaviest, str
ongest bone in the body. Its proximal end has a ball-like head, a neck, and grea
ter and lesser trochanters (separrsted anteriorly by the intertrochanteric line
and posteriorly by the intertrochanteric crest). The trochanters, intertrochante
ric crest and the gluteal tuberosity, located on the shaft, all serve us sites f
or muscle attachment. The head of the femur articulates with acetabulum of the h
ip bone in a deep, secure socket. However, the neck of the femur is a common fra
cture site, especially in old age. The femur slants medially as it runs downward
to joint with the leg bones; this brings the knees in line which the body’s cen
ter of gravity. The medial course of the femur is more noticeable in females bec
ause of the wider female pelvis. Distally on the femur are the lateral and media
l condytes, which articulates the tibia below. Posteriorly, these condytes are s
eparated by the deep intercondylar notch. Anteriorly on the distal femur is the
smooth patellar surface, which forms a joint with the patella, or kneecap.
20
4.2
Schematic Diagram
Predisposing Factors: -Elderly people (85 years or older) - Trauma - Comorbidity
- Malnutrition -neurologic problems - Obesity -slower reflexes Precipitating Fa
ctors: -Fall - osteoporosis -functional disability - impaired vision and balance
Damage to the blood supply to an entire bone. Severe circulatory compromise Avas
cular (ischemic) necrosis may result
Clinical Manifestations: - Pain (right up) - Loss of function - Deformity - Crep
itus - Swelling and discoloration - Paresthesia - Tenderness
Nursing Management: Medical Management: - Repositioning the patient - Temporary
skin traction - Promoting strengthening exercise - Buck’s extension - Monitoring
and managing complications - Open or closed reduction of the fracture and - Hea
lth promotion internal fixation - Relieving pain - Replacement of the femoral he
ad with prosthesis - Promoting physical mobility (hemiarthrmoplasty) - Promoting
positive psychological response to - Closed reduction with pereutaneous stabili
zation trauma for an intracapsular fracture. - Patient teaching Surgical Interve
ntion: - Hip Pinning - Hip Hemiarthroplasty - Patients with hip osteonecrosis ma
y require Hip Replacement Surgery
21
4.3 Pathophysiology Femoral neck fractures occur most commonly after falls. Fact
ors that increase the risk of injuries are related to conditions that increase t
he probability of falls and those that decrease the intrinsic ability of the per
son to with stand the trauma. Physical deconditioning, malnutrition, impaired vi
sion and balance, neurologic problems, and shower reflexes all increase the risk
of falls. Osteoporosis is the most important risk factor that contributes to hi
p fractures. This condition decreases bone strength and, therefore, the bones ab
ility to resist trauma. Femoral neck fractures can also be related to chronic st
ress instead of a single traumatic event. The resulting stress fractures can be
divided into fatigue fractures and insufficiency fractures. Fatigue fractures ar
e a result of an increased or abnormal stress placed on a normal bone. Whereas i
nsufficiency fractures are due to normal stresses placed on diseased bone, such
as an osteoporotic bone. Trauma sufficient to produce a fracture can result in d
amage to the blood supply to an entire bone, e.g., the femoral neck in femoral f
racture. With seer circulatory compromise, avascular (ischemic) necrosis may res
ult. Particularly vulnerable to the development of ischemic are intracapsular fr
actures, as occur in the hip. In this location, blood supply is marginal ad dama
ge to surrounding soft tissues may be a critical factor since better results are
obtained in cases of hip fracture reduced with in 12 hr. than in those treated
after that tine period. In fractures of the femoral neck, bone scans have been r
ecommended as diagnostic tools to determine the orability of the femoral need.
22
4.4 Classical and Clinical Sign’s and Symptoms Classical Symptoms Pain Clinical
Symptoms Manifested - complains of pain on the right hip aggravated by sudden or
too much movements of the extremities and relieved by elevation and resting. Ma
nifested - unable to move extremities and unable to stand or walk without assist
ance. Rationale - The pain is continuous and increases in severity until the bon
e fragment are immobilized. The muscle spasm that accompanies fracture is a type
of natural splinting designed to minimize further movement of he fracture fragm
ents. -After a fracture, the extremity cannot function properly, because normal
function of the muscles depends on the integrity of the bones to which they are
attached. Pain contributes to the loss of function. In addition, abnormal moveme
nt (false motion) may be present.
Loss of function
Deformity
Manifested -Displacement, angulations, or - Bones of the right rotation of the f
ragments in a fracture femoral neck are of the right femoral neck causes a splin
tered into small deformity that is detectable when the fragments. limb is compar
ed with the uninjured extremity. Deformity also results from soft tissue swellin
g. Not Manifested - In fractures of long bones, there is actual shortening of th
e extremity because of the contraction of the muscles that are attached above ad
below the site of the fracture. The fragments often overlap by as much as 2.5 t
o 5 cm (1 to 2 inches) -When the extremity is examined with the hands, a grating
sensation, called crepitus, can be felt. It is caused by the rubbing of the bon
e fragments against each other. -localized swelling and discoloration 23
Shortening
Crepitus
Manifested
Swelling and
Manifested
Discoloration
of the skin (ecehymosis) occurs after a fracture as a result of trauma and bleec
hing into the tissues. These signs may not develop for several hours after the i
njury. Manifested -After fracture, any subjective sensation, experienced as numb
ness, tingling, or a “pins and needles” may be felt. These often fluctuate accor
ding to such influences as posture, activity, rest, edema, congestion, or underl
ying disease, it is sometimes identified as acroparesthesia. -Mostly, the affect
ed part responds with a sensation of pain to pressure or touch that would not no
rmally cause discomfort. This happens due to the bones splintered into fragments
.
Paresthesia
Tenderness
Manifested
24
IV. Nursing Interventions 1. Medical and Surgical Management Temporary skin trac
tion, Buck’s extension, may be applied to reduce muscle spasm, to immobilize the
extremity, and to relieve pain. The findings of a recent study suggested that t
here is no benefit to the routine use of preparative skin traction for patients
with hip fractures and that the use of skin traction should be based as evaluati
on of the individual patient. The goal of surgical treatment of hip fractures is
to obtain a satisfactory fixation so that the patient can be mobilized quickly
and avoid secondary medical complications. Surgical treatment consists of (1) op
en or closed reduction of the fracture and internal fixation (2) replacement of
the femoral head with a prosthesis (hemiarthroplasty), or (3) closed reduction w
ith pereutaneous stabilization for an intracapsular fracture. Surgical intervent
ion is carried out as soon as possible after injury. The preoperative objective
is to ensure that the patient is in as favorable a condition as possible for the
surgery. Displaced femoral neck fractures may be treated as emergencies, with r
eduction and internal fixation performed within 12 to 24 hours after fracture. T
his minimizes the effects of diminished blood supply and reduces the risk for av
ascular necrosis. After general or spinal anesthesia, the hip fracture is reduce
d under x-ray visualization using an image intensifier. A stable fracture is usu
ally fixed with nails, a nail and plate combination, multiple pins, or compressi
on screw devices. The orthopedic surgeon determines the specific fixation device
based on the fracture site or sites. Adequate reduction is important for fractu
re healing (the better the reduction, the better the healing). Hemiarthroplasty
(replacement of the head of the femur with prosthesis) is usually reserved for f
ractures that cannot be satisfactorily reduced or securely nailed or o avoid com
plications of non-union and avascular necrosis of the head of the femur. Total h
ip replacement may be used in selected patients with acetabular defects.
25
2. Care Guide of Patient with the Condition (fracture of the right femoral neck)
Repositioning the Patient The nurse may turn the patient onto the effected or u
naffected extremity as prescribed by the physician. The standard method involves
placing a pillow between the patient’s legs to keep the affected leg in an abdu
cted position. The patient is then turned onto the side white proper alignment a
nd supported abduction are maintained. Promoting Strengthening Exercise The pati
ent is encouraged to exercise as much as possible by means of the overbed trapez
e. This device helps strengthening the arms and shoulders in preparation for pro
tected ambulation (e.g., toe touch, partial weight bearing). On the first postop
erative day, the patient transfers to a chair with assistance and begins assiste
d with ambulation. The amount of weight bearing that can be permitted depends on
the stability of the fracture reduction. The physician prescribes the degree of
weight bearing and the rate at which the patient can progress to full weight be
aring. Physical therapists work with the patient on transfers, ambulation, and t
he safe use of the walker and crutches. The patient who has experienced a fractu
red hop can anticipate discharge to home or to an extended care facility with th
e use of an ambulating aid. Some modifications in the home maybe needed to permi
t safe use of walkers and crutches and for the patient’s continuing care. Monito
ring and Managing Potential Complications Elderly people with hip fractures are
particularly prone to complications that may require more vigorous treatment tha
n the fracture. In some instances, shock proves fatal. Achievement of homeostasi
s after injury and surgery is accomplished through careful monitoring and collab
orative management, including adjustment of therapeutic interventions as indicat
ed.
26
Health Promotion Osteoporosis screening of patients who have experienced hip fra
cture is important for prevention of future fractures. With dual-energy x-ray ab
sorptiometry (DEXA) scan screenings the actual risk for additional fracture can
be determined. Specific patient education regarding dietary requirements, lifest
yle changes, and exercise to promote bone3 health is needed. Specific therapeuti
c interventions need to be initiated to retard additional bone loss and to build
bone mineral density. Studies have shown that health care providers caring for
patient with hip fractures fail to diagnose or treat these patients for osteopor
osis despite the probability that hip fractures are secondary to osteoporosis. F
all prevention is also important and maybe achieved through exercises to improve
muscle tone and balance and through the elimination of environmental hazards. I
n addition, the use of hip protectors that absorb or shunt impact forces may hel
p to prevent an additional hip fracture if the patient were to fall. Relieving P
ain * Secure data concerning pain - have patient describe the pain, location cha
racteristics (dull, sharp, continuous, throbbing, boning, radiating, aching and
so forth) - ask patient what causes the pain, makes the pain worse, relieves the
pain, and so forth. - evaluate patient for proper body alignment, pressure from
equipment (casts, traction, splints, and appliances) * Initiate activities to p
revent or modify pain * Administer prescribed pharmaceuticals as indicated. Enco
urage use of less potent drugs as severity of discomfort diseases. * Establish a
supportive relationship to assist patient to deal with discomfort. * Encourage
patient to become an active participant in rehabilitative plans.
27
Promoting Self-Care Activities * Encourage participation in care. * Arrange pati
ent area and personal items for patient convenience to promote independence. * M
odify activities to facilitate maximum independence within prescribed limits. *
Allow time for patient to accomplish task. * Teach family how to assist patient
while promoting independence in self-care Promoting Physical Mobility * Perform
active and passive exercises to all nonimonobilized joints. * Encourages patient
participation in frequent position changes, maintaining supports to fracture du
ring position changes. * Minimize prolonged periods of physical inactivity, enco
uraging ambulation when prescribed. * Administer prescribed analogies judiciousl
y to decrease pain associated with movement. Promoting Positive Psychological Re
sponse to Trauma * Monitor patient for symptoms of post from a stress disorder.
* Assist patient to more through phases of post-trammatic stress (outery, denied
,omtrusiveness, working through, completion). * Establish trusting therapeutic r
elationship with patient. * Encourages patient to express thoughts and feelings
about traumatic event * Encourages patient to participate in decision making to
reestablish control and overcome feelings of helplessness. * Teach relaxation te
chniques to decrease anxiety.
28
* Encourages development of adaptive responses and participation in support grou
ps. * Refer patient to psychiatric liaison nurse or refer for psychotherapy, as
needed. 3. Actual Patient Care 3.1 Physical Assessment PHYSIOLOGIC Palpation - P
alpable temporal pulse, soft, no evidence of abnormal mass, no protrusions and p
ond felt upon palpation.
Body part Head
Inspection - Small, round head, normocephalic, no wounds, no rashes present.
Percussion Auscultation
Hair
-Hair is short, white in color, evenly distributed, no scales, wearing a clip, h
as a fine hair -No dandruff and - Free from lumps, wounds present, pink, lesions
, normal bond mobile prominences on the forehead, sides of the parietal bones, b
ehind the ears. - Firm, no scars, no visible bulges, not oily, had wrinkles - Sy
mmetrical, check bones are slightly prominent, no presence of scar, presence of
wrinkles, without pimples - Forehead is free of lumps and nodes. - No lesions, n
o tenderness. -Tempera; pulse is at 82 bpm.
Scalp
Forehead
Face
29
Eyes
- Symmetrical, round, align with the ears, few discharges seen, with eyeglass -
Hair evenly distributed, skin intact, symmetrically aligned, black in color, fre
e from sealing - turn outward, short, black - partially cover the eyelids -Non t
ender - No lumps and rashes, smooth and no tenderness
Brows
Lashes Lids-Upper Lids-Lower Sclearae
- sometimes cover the -Non tender whole sclerae - whitish in color but red capil
laries are slightly seen - pink - transparent, shiny and smooth, night displays
at the same spot of the eyes -round, black -black in color but with white opacit
ies near the lacrimal gland , round smooth border, illuminated pupil constricts
(pupil equally round reactive to light and decommodation) 30
Cojunction Cornea
Iris Pupil
Muscle Function
-eyes moves slowly as it follows my finger guiding the patient and assessing her
6 cardinal gazes -Move symmetrically the tremors -260/20 -able to define correc
tly the number of fingers showed at the side of the patient nut sometimes its di
fficult for her. - White, long nose, septum is aligned in midline, no discharge/
flaring, air flows freely. - light color during transillumination -light color
during transillumination - no lesions, open and close symmetrically and slowly.
-slightly pale in color, soft, moist, symmetry of contour, smooth in texture. -I
ntact, pink in color, no swelling or bleeding. 31 - no lesions, deformities and
deviations
Muscle Balance Visual Acuity Peripheral Vision
Nose
Frontal Sinuses Maxillary Sinuses Mouth
- non-tender - non-tender -free from edema
- nontender - nontender
Lips
- no lumps, lesions and tenderness upon palpation, free from edema
Gums
Teeth
-Yellow teeth with brownish discoloration, the dentures, and teeth are incomplet
e. Upper- no teeth Lower- 4 -centrally positioned, slightly pale, moist, no lesi
ons. - midline, slightly pale - pinkish, visible veins - bony, whitish - muscula
r, pinkish - pink, midline, free of lesions - midline, no inflammations - Symmet
rical, slightly big, align with the eyes, pinna is in linewith the outer canthus
of the ear, no swelling or lesions. - no pain felt, upon palpation of pinna. -
no lumps - no palpable nodules
Tongue
Frenulum Sublingual Area Hard Palate Self Palate Uvula Tonsils Ears
External
- Symmetrical, align -Displays no with the eyes, no thickening/ pain. No swellin
g or lesions, as masses/ bulges. discharges, with slight cerumen and hair.
32
Neck
- Able to do flexion, extension and rotation of neck. -Muscles equal in size, he
ad centered. - no visible bulges, not enlarged - no bulges, not visible
-Carotid pulse palpable
Lymph nodes Thyroid
-Not palpable -Not palpable, free of nodules, moves up and down as the patient s
wallows. - central placement in midline of neck, spaces are equal in both sides,
nontender, non-palpable - slightly cold, good turgor
Trachea
- not enlarged - centrally located
Skin Thorax Chest anterior
- white, with wrinkles, no dryness
- flat, equal chest expansion, the ride and fall during respiratory is visible
- vibrations are equal in both sides - no nodules, retraction or nodules - full,
symmetric excursion - resonate down to the 6th rib, flat over areas of heavy mu
scle and bone, dull on areas over the heart, liver, and stomach percussed. -Lung
sounds are clear, no rales and wheezes
Lungs
33
Heart
- no visible pulsations - no nodules, bulges - apical pulse palpable -with breas
t CA ( R) ( 2006-2007 ) - flat, soft, unblemished skin - non-tenderness
-TR= 80 bpm -no murmurs
Breast Abdomen
- audible bowel sound of 18 from the normal range of 5-35 bowel sounds. Dull sou
nd at upper quadrant
Spine Extremities
- has abnormal curvature -capillary refill time is 2 sec. - white, equal in size
s, fingers were curving downward -35.5 degrees Celsius - no lesions, no lumps pa
lpated in the lungs - radial pulse palpable- 80 bpm - brachial pulse palpable -
no tenderness, slightly cold - biceps and triceps reflex present - BP- 120/80 mm
Hg
Upper
Muscle strength Muscle tone
- able to perform ROM exercises - difficulty in overcoming resistance
34
Lower
- white, equal in size, covered with cloth, limited movement on lower extremitie
s - capillary refill is 2 sec - difficulty in performing ROM exercises - inabili
ty to overcome resistance
- positive tenderness on the right hip
Muscle strength Muscle tone
- slightly cold, dry to touch , with pain upon palpation
- patellar reflex not present
35
BRUNSWICK LENS MODEL
36
Needs/ Problem / Cues I. Physiologic A. Deficit 1. Impaired Physical Mobility Cu
es: - Difficulty in changing position while lying on bed. -Difficulty in moving
the extremities. -Inability to walk or stand alone. -limited range of motion in
the extremities. -Slowed movement. -Difficulty initiating gait. “dili gihapon mu
lihok akong tiil day” as verbalized by the patient.
Nursing Diagnosis
NURSING CARE PLAN Scientific Basis ObjecNursing Action tives of Care After 8 hou
rs of holistic nursing caring care the patient will be able to: 1. demonst rate
increasi ng function of the extremit ies Measures to: 1. Promote adequate mobili
ty of the client. - instruct the 5.0 to keep siderails up or raised. - assist pa
tient to do active ROM exercises on the lower extremities. -Provides comfort mea
sures such as backrub. -Encourage patient to stand or walk as tolerated using pa
rallel bars. -Support affected body parts or joints using pillows or rolls. -adm
inister pain reliever such as areoxia as prescribe by the physician. -Consult wi
th physical or occupational therapist as indicated.
Rationale
Fractures occur when the bone is subjected to Impaired stress greater physical t
hat it can mobility, absorb. When inability the bone is to stand broken, alone a
djacent related to structures are skeletal also affected, impairmen resulting in
soft t to facture tissue edema, of the hemorrhage into right the muscles and fe
moral joints, joints neck dislocations, ruptured tendons, severed nerves, and da
maged blood vessels. Body organs maybe injured by the force that caused the frac
ture fragments. After a fracture, the extremities cannot function properly becau
se normal functions of muscle depend on the integrity of the bones which they ar
e attached.
-to avoid patients from falling to sudden movements -to improve muscle strength
and joint mobility -in order for the patient to become more relax and comfortabl
e -in order for the muscle to be more relax and relieves the pain
-to relieve pain and motion sickness -to develop individual exercise or mobility
program and identify appropriate adjunctive devices.
37
2. Risk for altered blow flow Risk Factor: Immobility
Risk for altered blood flow right immobilit y to fracture of the right femoral n
eck
The extremities cannot function properly after a fracture, thus, there is immobi
lity because normal function of the muscle depends on the integrity of the bones
to which they are attached. Immobility of a body part may possibly interrupt th
e circulation of blood through the circuitous network of arteries and veins
2. enhance blood circulati on
2. prevent, blood emboli -note signs of changes in respiratory rate, depth use o
f accessory muscles purledlip breathing; Note areas of pallor or cynosis. -auscu
ltate breath-sounds Check if there is a decrease or adventitious breath sounds a
s well as fremitus -monitor ital signs and cardiac rhythm -review risk factors -
reinforce need for adequate rest, while encouraging activities within clients li
mitation -encourage frequent position changes and DBE or coughing exercise. -adm
inister medications as indicated.
-to assess respiratory insufficiency
-serves as a baseline data
-note for any changes -to promote prevention management of risk
-to improve circulation of blood to the body systems.
-to treat underlying conditions
38
B. Overload 3. Risk for additional injury risk factors: *Loss of skeletal integr
ity * skeletal impartment *Abnormal blood profile *Impaired or altered mobility
Risk for additional injury right loss of skeletal integrity to fracture of the f
emoral neck.
A fracture occurs when the stress placed on a bone is greater than a bone can ab
sorb. Muscle, blood vessels, nerves, tendons, joints and other organs maybe inju
red when fracture occurs. This condition may result to a loss of skeletal integr
ity that may possibly lead to further injury as a result of environmental condit
ions interacting with the individuals adaptive and defensive resources.
3. to produce risk factors and protect self from injury
3. for the patients to be free from injury -ascertain knowledge of safety needs
or injury -assess muscle strength gross and fine motor coordination. -observe fo
r signs of injury -identify interventions or safety devices. -encourage particip
ation in rehab programs, such as gait training -promote education programs geare
d to increasing the awareness of safety measures
-to reinforce and import knowledge to the patient -to evaluate degree or source
of risk. -for early detection. -to promote individual safety. -to improve skelet
al integrity.
-to promote wellness.
39
Drug/ Classification/ Dose/ Mechanism Frequency / Route * Aromasin 25 mg T tab-O
D C: Antineoplastic M: Binds to estrogen receptors, has anti- estrogen receptorp
ositives breast cancer cell increased
DRUG THERAPEUTIC RECORD Indication/ Principles of Contraindation/ Care Side effe
cts I. treatment of advanced breast cancer in postmenopaural women whose decreas
ed has progressed FF. Tamoxifen therapy SE: C1: allergies, patient has not been
through menopause yet, pregnancy and breastfeeding -25mg po everyday with meals.
-aoid use during premenopause or with renal or nepatic dysfunction. - (ho flash
es, GI upset, anxiety, depression, and headache are common.)
Treatment
Evaluation
* Aspirin C: (aspilet) T Antipyriene, tab OD po Analgesic, antiinflammatory, Ant
irheumatic , anti- platelet salicylate, NSAID M: Analgesic and antirheumatic eff
ect are, attributable to cupirine ability to inhibit he synthesis of prostagland
ins
I. mild to moderate pain fever Inflammatory conditions Rheumatic fever rheumatoi
d arthritis, osteoarthritis CI: Allerge use continuously with impaired renal fun
ction, chicken pox, influenza SE: Acute aspirin toxicity: hyperpnea , tachypnea,
hemorrhage
-give drug with food or after meals if GI upset occurs. -give drug with fullglas
s of H2O to reduce risk or tablet or capsule lodging in the esophagus - do not c
rush and ensure that patient does not chew SR preparation -Do not use aspirin th
at has a strong vinegar
-provide rest periods -mpnitor for any side effects that may occur -provide a qu
ite and comfortable environment -maintain client’s general well-being and hygien
e -provide safety and comfort measures to the client. -elevate the leg of the pa
tient. -assist client in doing ROM exercises -provide comfort measures such as b
ack rub. -provide rest periods -do not allow client to do strenuous activities
-growth of tumor cells were inhabit
-there is al improvemen t of patients gout ant the patient was able to slight mo
ve her extremities
40
, important mediators of inflammation antipyretic effects are not fully understo
od but aspirin probably acts in the thermoregulat ory center of the hypothalamus
to block effects of endogenous purogen by inhibiting synthesis of the prostagla
ndin intermediately . Inhibition of platelet aggregation is attributable to the
inhibition of platelet synthesis of thromboxane A21 a potent vasoconstricto r an
d inducer of platelet aggregation. This effects occurs at low doses and last for
the life of the platelet(8 days) These doses inhibit the synthesis of
Aspirin intolerance: -shinitis exacerbation of broncho spasm -nausea, dyspnea, o
ccult blood loss, dizziness tinnitus
like odor -take extra precautions to keep this drug out of the reach of children
41
*Clexane 0-4 cc SQ OD
prostaglandin, a patient vasodilator and inhibitor of platelet aggregation. C: l
owmolecular weight heparin antithrombotic M: lowmolecular weight heparin that in
hibits thrombus and clot formation by checking factor XA, factor II a, preventin
g the formation of clots.
I. prevention of deep vein thrombosis, which may lead to pulmonary embolism foll
owing hip replacement. Prevention of ischemic complications. CI: hypersensitivit
y use cautiously with pregnancy or lactation history of GI blood, spinal top SE:
Bruishing, thrombocytopenia , chills, fever, pain, local irritation.
*lericoxib (arcoxta) 90mg T tab OD
C: nonsteroidal anti inflammatory drug (NSAID) M: work DY blocking the action of
a substance in the body called cyclooxygenare is
I. Acute and chronic treatment of asteoarthritis and RA CI: Children and adolesc
ent under 16 yrs. Of age -severely to liver function SE: headache, dizziness
-give deep subcutaneous injections, Do not give clexane by IM injection -patient
should be lying down. Activities between the left and right anterolateral and p
osterolateral abdomen wall -apply pressure to all injection sites after needle i
s withdrawn -do not mix with other injections or infusions -store at room temper
ature fluid should be clear, colorless to pale yellow -can be taken with or with
out food, but may start to work quicker if taken without food. -do not exceed th
e prescribed dose -maybe taken with low dose
-provide for safety measures (electric razor, soft toothbrush) to prevent injury
to patient, who is at risk of bleeding -check patient for signs of bleeding. Mo
nitor blood test -provide a safety and comfortable environment -provide rest per
iods -avoid patient from dying strenuous activities -position client in a comfor
table position. -divert patient’s attention -guide imagery -encourage
-further complicatio ns were prevented.
-there is an improvemen t of patient’s gait and the patient was able to slightly
move her extremities
42
* vitamin B complex (sangubio n) T tab OD
involved on producing prostaglandins in response to injury or certain diseases.
There prostaglandins , cause pain or swelling and inflammation. Because NSAIDS b
lock the production of prostaglandins they are effective at relieving pain and i
nflammation C: Phospholipid + multivitamins M: mainly function as eatalysts for
reactions within the body. They contain no useful energy, but as catalysts, they
serve as essential link and regulators in metabolic reaction that release energ
y from food. Control the processes of
Constipation, nausea, vomiting, indigestion, flatulence
(76 mg daily) aspirin. However the combination may carry an increased risk of ul
ceration or bleeding in the stomach or intestine -it is important to tell your d
octor or pharmacist what medicine you are already taking including those bought
with out prescription and herbal medicine -maybe taken with meals if GI discomfo
rts occurs. -best to take after meals. -initially 1 capsule every 8 hours. Follo
w up treatment 1 capsule daily
DBE -hot compress is applied to the affected site or area. -provide rest periods
-avoid client to perform strenuous activities -provide a safety environment
I. treatment of chronic liver disease , liver cirrhosis and fatty liver. For liv
er protection eases of intoxication (alcohol abuse) CI: hypersensitivity, lactat
ion SE: sedation, dizziness, dry mouth, nausea, constipation
-encourage client to eat foods rich in vitamins and minerals -instruct client to
minimize the intake of fatly foods -lifestyle modificatio n -exercise regularly
-impart to patient the importance of taking adequate amount of nutritious
-the patient was able to gain more energy and increase its function
43
tissue synthesis and aid in protecting the integrity of the cells plasma membran
e; assist growth, maintenance of health metabolism *CaCo3 C: electrolyte (Calvit
) T Antacid tab OD M: Essential every 6pm element of the body; helps maintain th
e functional integrity if nervous and muscular system,; helps maintain cardiac f
unction, blood coagulation: is an enzyme cofactor and affects the secretom activ
ity of endocrine and exocrine glands; neutralizes or reduces gastric acidity. C:
NSAID *Ketoprof Non-opioid en analgesics (fortum) M: AntiGel apply inflammatory
to right and analgesic
foods
I: Dietary supplement when calcium intake is in adequate, treatment of calcium d
eficiency, prevention of hypocalcemia during exchange transfusions. CI: Allergy,
use cautiously withdrawal; dysfunction pregnancy, lactation. Se: Slowed heart r
ate, tingling, heat waves, local irritation, hypercalcemia, and pain dry mouth.
- do not administer oral drugs within 12 hour of antacid administration. - repor
t loss of appetite, nausea, vomiting, abdominal pain, constipation, dry mouth, t
hirst, increase voiding.
- encourage client to eat foods rich in calcium such as milk, cheese. - assist c
lient be expose to sunlight for 5-15 minutes. - impart [atient the importamce of
takiln adequate amount of nutritious foods. - encourage client to exercise regu
larly.
- the strength of patient’s bones were improved as evidenced by standing or walk
ing with assistance.
I: Acute and long treatment of RA and osteoarthritis. - relief of mild to modera
te pain.
For over-thecounter Use: Do not take for more than 10 days. If
- elevate the leg of the patient - provide rest periods
- there was an improvemen t of patient’s gait and the
44
thigh and right knee twice a day.
activity, inhibits prostaglandin and has antibradykinin and lysosomal or membran
e stabilizing actions.
*Dibencos ide (heraclene ) Mg tav T tab HD
C: Appetite stimulants M: Improes appetite and preents faulty nutrition and othe
r chronic ailments.
CI: Significant renal impairment, pregnancy, lactation allergy to ketoprofen, us
e cautiously the impaired hearing allergies hepatic, CV and GI conditions. SE: H
eadache, dizziness, rash, pruritus, nausea, dyspepsia, dysuria, renal impairment
, dyspnea, peripheral edema. I: Poor appetite in adult, adjuvant to the treatmen
t of TB, and other chronic ailments, convalescence from acute infection: CI: Hyp
ersensitivity
symptoms persist contact your HC provider.
- provide comfort measures - encourage client to do DBE - promote a quite, relax
ing and comfortable environment .
patient was able to slightly move her extremities.
- the dosage must be reduced to patient’s with liver damage. - liver functions s
hould be assessed before and regularly during treatment. - should be used with c
aution in patient’s with diabetes mellitus as their management may become more d
ifficult.
*Calmose ptine ointment appky to affected
C: Topical antivirals M: Protects, soothes and helps promote healing in
I: Wound drainage, urinary and fecal incontinence, bedsores, ileo
- cleanse skin, pat dry and apply once daily or as necessary
- provide small frequent feelings - offer foods that are attractive or presentab
le enough to stimulate appetite. - instruct patient to eat adequate nutritious f
oods. - impart to patient the importance of taking adequate nutritious foods. -
maintain general well-being and hygiene of the
- the patient was able to improve her appetite as evidenced by eating her meals
an time and avoiding to skip meals.
- patient’s wound was easily healed and bedsores
45
site BID
those with impaired skin integrity.
anal, reservoirs, moistures of perspirations CI: Hypersensitivity
*Acarbose (glucobay) 50 mg tab TID with meals
C: Antidiabetic M: Alphaglucosidase inhibitorobtained from the fermentation proc
ess of a microorganis m; delays the digestion of ingested carbohydrates heading
to a smaller increase in blood glucose following meals and in glycosylated hemog
lobin,
I: Adjunct to diet to lower blood glucose in those patient’s with tipe2 (non-ins
ulin dependent) DM whose hypercalcemia cannot be managed alone. CI: Hypersensiti
vity, use cautiously with renal impairment pregnancy and lactation. SE: Hypoglyc
emia, abdominal pain, flatulence,
- do not use this medication if you are allergic to zinc, dime thicone, lanolin,
cod liver oil, petroleum, jelly, parabens, mineral oil or wax. - call your doct
or if you have any signs of redness and warmth or oozing skin lesions. - avoid g
etting this medication in your mouth or eyes. If it does rinse with water right
away. - give drug TID with the first bite of each meal. - monitor serum glucose
level frequently to determine drug effectiveness and dosage. - inform patient of
likelihood of abdominal pain and flatulence. - do not discontinue this drug wit
hout consultation from health care provider.
patients. were - provide a prevented. clean and comfortable environment . - meti
culous skin care - promote proper environment al sanitation.
- impart to patient to eat a nondiabetic diet. - consult with a dietician to est
ablish weight loss program and dietary control. - encourage client to do regular
exercise assisted by the SO. - impart to client the
- further complicatio ns were being prevented and appearance of signs and sympto
ms slowly diminished
46
*Ranitidin e (ulcin) 75 mg tab PC 3x a day 6 am – 6 pm
does not enhance insulin secretion, so its effects are addictive to those of the
sulfonyl areas, in controlling blood glucose. C: Histanine, antagonists M: Comp
etitively inhibits the action of histamine At h2 receptors of the parietal cells
of the stomach inhibiting basal gastric acid secretion that is stimulated by fo
od, insulin, histamine, cholinergic agonists, gastrin and pentagastrin.
leucopenia, anemia, thrombocytopenia .
importance of taking nutritious foods. - avoid the client from eating foods rich
in fats and cholesterol. - administered oral drug with meals and hours. - decre
ase doses in renal and liver failure. - if you are using antacid, take it exactl
y as prescribed, being careful of the time administered. - have regular medical
follow up care to evaluate your response. - provide rest periods - encourage cli
ent to ear adequate nutritious foods at a regular meal time. - impart to client
not to skip meals. - position client into a comfortable position. - the patient
was able to feel more comfortable as evidenced resting and sleeping comfortably.
I: Short term treatment of active duodenal ulcer, treatment of heart burn, acid
ingestion, sour stomach. CI: Hypersensitivity, use cautiously the impaired renal
or hepatic function pregnancy. SE: Headache, malaise, dizziness, tachycardia, b
radycardia, rash, constipation, diarrhea.
3.5 SOAPIE 47
SOAPIE #1 S- “ Dili gehapon ayu malihuk akong tiil day”. O- Received patient lyi
ng on bed with head elevated to 30 degrees, awake, conscious, coherent, communic
ative, without IV, with the following v/s T= 35.5 degree Celsius, P= 86 pm, R= 2
0 bpm and BP= 120/70 mmHg, the patient is reading a newspaper, has difficulty in
changing position while lying on bed, has difficulty in moving the extremities,
inability to walk or stand alone, limited range of motion in the extremities, s
lowed movement, difficulty initiating in gait. A= Impaired physical mobility, in
ability to stand alone related to skeletal impairment 2 degrees to fracture on t
he right femoral neck. P= To promote adequate mobility of the client. I= Introdu
ced name to the patient; assessed the condition, of the patient; monitored v/s,
assisted patient in doing ROM exercises, assisted patient upon doing gait traini
ng; set siderails up; provided comfort measures such as backrub; encouraged pati
ent to do DBE; supported affected body parts/ joints using pillows/ rolls; consu
lted with physical or occupational therapist as indicated; documented the v/s an
d I and O of the patient. E= The patient was able to demonstrate increasing func
tion of the extremities as evidenced by standing and walking between parallel ba
rs with assistance.
SOAPIE #2 48
S= “Naproblema man ko sa akong tiil day kay pila na ni ka adlaw walay lihok- lih
ok, murag lain na kaayu akong feeling”, as verbalized by the patient. O= Receive
d patient sitting up on bed, , conscious, coherent, communicative, without IV, w
ith the following v/s T= 35.7 degrees Celsius, R= 19 bpm, P= 76 bpm, BP= 120/70
with feet supported by rolled towels, limited movement of the lower extremities.
A= Risk for altered blood flow r/t immobility 2 degrees to fracture of the righ
t femoral neck. P= To enhance blood circulation I= Introduced name to the patien
t; assessed the condition of the patient; monitored v/s; administered medication
s; noted signs of changes in respiratory rate, depth, use of accessory muscles,
pursed top breathing, areas or pallor/ cyanosis; auscultated breath sounds if th
ere is a decrease or adventitious breath sounds as well as fremitus; monitored c
ardiac rhythm; reviewed risk factors; reinforced need for adequate rest while en
couraging activity within client’s limitations; encouraged frequent position cha
nges and DBE / coughing exercises; check the CRT of the patient; documented the
v/s, I and O and medications taken by the patient. E= The client’s extremities a
re warm and pink, remains intact, CRT results of 2 seconds, no verbalization of
pain, swelling on the area and demonstrates calm breathing.
HEALTH TEACHING PLAN 49
Objective General Objectives: After 3 day of varied learning activities, the pat
ient as well as the significant others or family will be able to acquire knowled
ge, attitude and skills in preventing complications of immobility. Specific Obje
ctives: After 45 minutes of teaching, the patients as well as the significant ot
her or family will be able to: 1. explain the goals of frequent position changes
.
Content
Methodology
Evaluation
Positioning (Goals) * to prevent contractures * stimulate circulation and preven
t pressure sores * prevent thrombophiebitis and pulmonary embolism. * promote lu
ng expansion and prevent pneumonia * decrease edema of the extremities * changin
g position from lying to sitting several times a day can help prevent changes in
the CVS known as deconditioning. *the recommendation is to change body position
at least every 2 hours, and preferably more frequently in patients who have no
spontaneous movement. Proper Body Alignment 50
Informal discussion
-the patients was able to explain the goal of frequent position changes and she
was motivated to perform the different positions to become at ease from pain or
any discomfort felt
2. enumerate the
Informal
-the patient was able to
positions for proper body alignment
1. Dorsal or Supine Position. a. the head is in line with the spine both lateral
ly and anteroposteriority. b. the trunk is positioned so traction of the hips is
minimized to prevent hip contractive. c. The Arms are flexed at the elbow with
the hands resting against the lateral abdomen. d. the legs are extended in a neu
tral position with the toes pointed towards the ceiling. e. the neels are suspen
ded in a space between the mattress and the footboard to prevent neel pressure.
f. trochanter tons are place under the greater trochanter in the hip joint areas
. 2. Side lying or lateral position a. the head is in line with the spine b. the
body is an alignment and is not twisted c. the uppermost hip joint silently for
ward and supported by a pillow in a position of slight abduction. d. a pillow su
pports the arm which is flexed of both the elbow and shoulder joints. 3. Prone p
osition a. the head is turned laterally and is in alignment with the rest of the
body b. the arms are abducted and externally rotated at the shoulder joint; the
elbow are fexed
discussion
verbalize the different proper positions for proper body alignment
c. a small flat support is 51
placed under the pelvis extending from the level of the umbilicus to the upper t
hird of the thigh. d. the lower extremities remain in a neutral position. 3. dis
cuss the different therapeutic exercises Therapeutic Exercises 1. Positive range
of motion exercise 2. active assistive range of motion 3. active range of motio
n 4. Resistive exercise 5. Isometric or muscle settings exercise. Range of motio
n * Flexion extension of shoulder. * Fexion extension of elbow * adduction-abduc
tion of shoulder. * Pronation-supination of elbow. * Dorsiflexion and palmar fle
xion of wrist. * Ulnar-radial deviation of wrist. * Adduction-abduction and oppo
sition of thumb * Adduction-abduction, flexion-hyper extension of fingers. *Dors
iflexion-Plantarflexion, Eversion of the ankle. * Flexion-extension; adduction-a
bduction of toes * Adduction-abuction; internal rotation or external rotation of
the hip. * Flexion-hyperextension; rotation of cervical spine * Lateral bending
of cervical 52 Informal discussion and demonstration -the patient was able to d
iscuss the different therapeutic exercises and was able to demonstrate them with
assistance
4. practice the different kinds of range of motion
Informal discussion and demonstration
The patient was able to practice the different kinds of ROM exercise with assist
ance
spine. 5. participate attentively to the discussion Informal discussion and demo
nstration -the patient was able to listen attentively and asked some question re
lated to the discussion and she was also able to participate during demonstratio
n.
53
V. Evaluation and Recommendation Prognosis of the patient After 3 days of interv
ention, the student nurse observed certain changes from the patient. The patient
reports decreased pain with elevation, ice and analgesic. The patient also exhi
bits unlabored respirations; alert and oriented, a febrile, using affected extre
mity for light activity as allowed, no signs of neurovascular compromise, v/s st
able; urine output adequate and no calf pain reported: Homan’s sign negative. Th
e patient also performs active ROM correctly, hygiene and dressing practices wit
h minimal assistance and denies acute symptoms of stress; reports working throug
h feelings about trauma. Recommendation As a researcher in this case study, the
student nurse recommends the patient to adjust in usual lifestyle and responsibi
lities to accommodate limitations imposed by fracture and to prevent recurrent f
ractures – safety considerations, avoidance of fatigue and proper footwear. The
patient is instructed about exercises to strengthening upper extremity muscles I
f crutch walking is planned, methods of safe ambulation – walker, crutches, care
, emphasizes instructions concerning amount of weight bearing that will be permi
tted on fractured extremity, teaches symptoms needing attention, such as numbnes
s, decreased function, increased pain and elevated temperature and explains basi
s for fracture treatment and need for patient participation in therapeutic regim
en. The patient and the family were also informed that the patient must have an
adequate balanced diet to promote bone and soft tissue healing.
54
VI. Evaluation and Implication of this case study to: Nursing Practice The resul
t of this case study would provide the student nurse with sufficient knowledge,
attitude and skills towards the management of patients with fracture on the righ
t femoral neck. This study would help the student nurse in providing a higher qu
ality of care of patients with the same condition. It is important that the prop
er and ideal managements and interventions are done in order to give a more holi
stic approach and optimum care to clients with fracture on the right femoral nec
k. This would ensure the timely healing of injury and the prevention of complica
tions. Nursing Education Education can promote enhancement of professionalism th
rough an on- going learning process, whether self- motivated, people- oriented a
nd having a commitment to the organization, nurses are likely to become well res
pected through the formal educational programs. Through this case study, it is i
mportant to know all areas of patient are both knowledge and skills to manage ef
fectively in all aspects of their professional nursing practice. Nursing Researc
h Nursing research is essential for the development of scientific knowledge that
enables nurses to provide evidenced-based health care. Broadly nursing is accou
ntable to society for providing quality, cost effective care and for seeking way
s to improve that care. More specifically, nurses are accountable to their patie
nts to promote a maximum level of health. This case study would contribute more
information and facts about fracture on the right femoral neck. This could contr
ibute to the development of the case study of fracture – its prevention, causes,
signs and symptoms, and nursing management. Hopefully, this 55
case study will lead to development of new skills and new approaches to the care
of patient’s with fracture on the right femoral neck. This case study could als
o as basis for related study and will provide facts for further research in aimi
ng for the improvement of these patients. VII – Referral and Follow-Up The patie
nt was informed to have a continuous appointment with the Rehabilitation Care Pr
ogram Health Care providers after discharge. The patient was encouraged for foll
ow-up medical supervision to monitor for union problems. VIII – Bibliography Bar
e, Brenda I. and Smeltzer, Suzzane C., Textbook of Medical-Surgical Nursing. 10t
h Edition Philadelphia: I.B Lippincott Company. 2004. Nettina, Sandra M., Manual
of nursing Practice. 7th Edtion. I.B. Lippincott Company. 2001. Rozler, Barbara
et al. Fundamentals of Nursing. 5th Edition. Newyork: AddisonWeatleylongman, In
corporated. 1998. Marleb, Elaine N. Essential of Human Anatomy and Physiology. 7
th Edition. Singapore. Pearson Education South Asia Pte. Ltd. 2004. Potter, Patr
icia and Perry, Anne. Fundamentals of Nursing. 6th Edition Baltimore: C.V. Mosby
and Company. 2005. Doenges, M., Moorhouse, M.F. , Geissler – Murr, A. “ Nurses
Pocket Guide”, Diagnosis, interventions and rationales, 9th Edition (2004).
56
Doenges, M., Moorhouse, M.F. , Geissler – Murr, A., “ Nursing Care Plans”. Guide
lines for Individualizing Patient Care. 6th Edition. F.A. Davis Company, 2002.
57
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