CAPITOL MEDICAL CENTER COLLEGES

COLLEGE OF NURSING

IN PARTIAL FULFILLMENT OF THE REQUIREMENT

NURSING CARE MANAGEMENT

RELATED NURSING EXPERIENCE

IN THE CLINICAL ROTATION AT CAPITOL MEDICAL CENTER

SUBMITTED THE STUDY ON A 40 YEAR OLD MAN

DIAGNOSED WITH MULTIPLE ABRASION

SUBMITTED BY:
CHRISTIAN P. URETA

SUBMITTED TO:
MRS. ROSITA RETAMAR
 Nursing Health History

I. Personal Data

Name: Roberto Recato Talusan

Address: 12 Diamond st. Carmel 5 subd, Tandang Sora Quezon City

Age: 40 year old

Sex: Male

Civil Status: Married

Religion: Roman Catholic

Birthday: June 06, 1969

Birthplace: Quezon City

Room No: 536

Hospital No: 334120

Attending Physician: Dr. Clemente

Medical Diagnosis: Multiple Abrasion

Chief Complaint: Body pain

II. Medical History

A. Chief Complaint

The patient complained of body pain after the accident

upon going to the emergency room of CMC.

B. History of Present Illness

Patient was riding a motrocycle when a jeepney allergedly

hit him causing him to be out of control of the said vehicle. (-)
LOC, (-) vomiting , consult at ER and

C. Past Medical History

The patient experience a vehicular accident in the year

2007. He had stitches in his left arm and his head.

D. Family Medical History

The patient is negative in Diabetes Mellitus, Asthma,

Hypertension Allergy and Cancer. However, the patient had a
family history of heart disease from his father.

E. Social History
 The patient is a smoker having 10sticks a day and an
alcoholic beverage drinker. He drinks about 18 bottles of beer
occasionally. He lives with his wife and 3 kids. The patient
spends his weekdays in the office and the weekends with his
family.

III.Physical Assessment
 Category Actual Findings Normal Findings Analysis

Head Symmetrical; Normocephalic; Everything is normal.

proportion to body; normal texture;
without masses; With proportional to body
stitches from previous
accident

Eyes Pale palpebral White sclera; pink Slight change in color due to
conjunctiva; Active conjunctiva age of patient but vision is
sclera normal.

Ears Brown in color; can No lesions; no Everything is normal and can

hear normally; no masses; no hear well.
lesions; no discharges; tenderness

Nose No swelling noted; No discharges; The patient’s nose is normal.

Airways are patent and parallel to midline;
free from obstruction no obstructions

Mouth Teeth are complete; no Present and good The patient’s mouth is
dentures; slightly dentition; no normal.
yellow in color; pink lesions; no swelling;
gums no infections

Neck Supple neck; no No lesions; active The patient’s anterior and

masses; anterior part of range of motion posterior neck is normal.
the neck suffered from
burn

Heart Normal heart sounds; Normal upstroke; Patient’s heart rhythm is

regular rhythm; no bilateral amplitude; within normal. 80bpm.
murmurs no bruits

Lungs No cough noted; Equal No resonant The patient’s lungs are

chest expansion; clear percussion; clear; normal. 18- 20 bpm
breath sounds normal breath
sounds

Abdomen Soft; flabby abdomen; No scars; no The patient’s abdomen is

non-tender; no masses; tenderness; no normal.
guarding behavior
when palpated

Extremities With edema; not equal No cyanosis; no The patient’s lower

strength; with lesions ; deformities; normal extremities suffered from the
nails are clean and nail findings accident, the right leg have
short; Cyanosis in the edema and the left leg is
right leg having hard time to move.
The patient’s upper
extremity is normal

Skin Brown in color; has Normal skin The patient’s skin is normal
lesions; warm and tenderness; no aside from the lesions in the
moist; lesions right leg.
IV. Gordon’s Pattern of Functioning
 Pattern of Before During Hospitalization Interpretation
Functoning Hospitalization
Health He describes her He easily coped up He followed what the
Perception – current health that with the procedures physician advised him
Health he feels healthy and takes care of to do like eating
Management without taking any himself with nutritious foods and
Pattern kind of vitamins. instructions. rehabilitation.
Nutrition He usually eats He lose his appetite He was able to easily
Metabolic three times a day in quite time because cope up with the diet
Pattern and considers of the accident but given to him and sees
himself healthy. He can eat well. it as a means to further
eats what he wants speed up her healing
to. process.
Elimination He does not have He was able to He eliminates normally
Pattern any problem during urinate and defecate during and before his
urination and with ease. There was hospitalization. He
defecation. He no catheter inserted does not have any
defecates everyday on him that made problems regarding his
(2x a day) urination difficult for elimination pattern.
him.
Activity – He usually leaves He spends his time He was able to
Exercise the house at around watching tv and maintain his fitness
Pattern 7am to go to work talking with his and comfort depending
and spends his day children when they on his state. He does
there. In the are in the hospital. what he feels
weekends, He stays comfortable to do.
at home and spends
the day with his
children. He
exercise when he
have time
Cognitive – He can see clearly He was well oriented He feels relaxed and
Perceptual without an aid of an with time and space. does not need any help
Pattern eyeglass. He hears He can still read and with his senses. He was
clearly and his other write. always responsive and
senses functions coherent during and
well. before his stay.
Self – He is happy just the He is depressed He feels comfortable
Perception way he is. because he can’t when his family is with
Pattern walk his left leg but him.
he will cope up with
his problem by
therapy and
rehabilitation

Sleep – Rest He usually sleeps He now sleeps about He does not experience
Pattern between 9pm to 12-13hours. He said any sleeping disorder
10pm. She wakes he is oversleeping. and maintains his
up at 6am. energy with frequent
sleeping. He also does
not have any problem
sleeping since he feels
relaxed most of the
time.
Role – He can easily His family is still able Even in his present
Relationship express her feelings to talk to him and he condition, he was still
Pattern to every member of is still able to perform able to perform his
the family. He his roles as their duties as a mother and
functions as a father and a loving a wife to his family. His
happy husband to husband. sickness was never a
his wife and a father hindrance to him and
to his children.\ to his family.
Sexuality – Hir sexual Since her Although they do have
Reproductive relationship with his confinement, she was coitus in their age,
Pattern wife is active. She not sexually active. they were still able to
does not have any have a loving
 V. Drug Study

Generic Brand Dosa Mechanism Indication Contra- Adverse Nsg.

Name Name ge s s Indications Reactionss Respon
.
Meperidine Demer 1 cap pain Used to asthma, Nervous Assess
ol reliever treat COPD, sleep System: Eu patient’
apnea, or phoria, s pain
moderate other dysphoria,
-to-severe breathing weakness,
pain. disorders; headache,
liver or agitation,
Used for kidney tremor,
purposes disease; uncoordina
underactive ted muscle
other
thyroid; movement
than curvature of s, severe
those the spine; convulsions
listed in a history of , transient
this head injury hallucinatio
or brain ns and
medicatio
tumor; disorientati
n guide. epilepsy or on, visual
other disturbance
seizure s.
disorder;
low blood Gastrointe
pressure; stinal: Dry
gallbladder mouth,
disease; constipatio
n, biliary
tract
spasm.

Cardiovasc
ular :
Flushing of
the face,
tachycardia
,
bradycardi
a,
palpitation,
hypotensio
n syncope.

Genitourin
ary: Urinar
y retention.

Allergic: Pr
uritus,
urticaria,
other skin
rashes,
wheal and
flare over
the vein
with
intravenou
s injection.
VI. Nursing Care Plan

Assessment Diagnosis Planning Intevention Rationale Evaluation

Data: Mr. T Acute pain Short Term Goal Independent Short Term Goal
40 y/old related to tissue After 3 hours of 1. Reassess each time 1. To rule out worsening After 3 hours of nursing
injury secondary nursing intervention pain occurs/is reported. of underlying intervention the patient had
Subjective: to vehicular the patient will be able Note and investigate condition/development of able to report pain is
Patient accident as to report pain is changes from previous complications. relieved/controlled and
verbalized: manifested by relieved/controlled reports. 2. Pain is a subjective verbalized pain intensity on
“Medyo masakit the signs and and verbalized pain 2. Acknowledge the pain experience and cannot be a scale of 7/10 to at least
pa ang katawan symptoms.. intensity on a scale of experience and convey felt by others. 3/10.
ko” 7/10 to at least 3/10. acceptance of client’s
• Pain scale response to pain. 3. Usually altered in acute
of 7 out of 10 3. Monitor skin color, pain
• Stabbing temperature and vital
pain signs
Objective:
• Pain in the
right foot 4. To promote
when touched 4. Provide comfor nonpharmacological pain
• Body pain Long Term Goal measures such as quiet management. Long Term Goal
After 2 days of environment 5. To distract attention After 2 days of
• Irritability
continuous nursing and reduce tension continuous nursing
expressive
intervention the 5. Instruct in/encourage intervention the patient had
behavior
patient will us of relaxation demonstrate use of
obeserved
demonstrate use of techiniques and 6. To prevent fatigue relaxation skills and
evidence of
relaxation skills and diversional activities such diversional activities, as
pain
diversional activities, as watching tv/CDs/tapes. indicated, for individual
• V/S taken
as indicated, for 6. Encourage adequate situation.
as follows:
individual situation. rest periods 1. Pain reliever
o BP-
Dependent
120/90 1. Administer medications
o R- as prescribed by the
21 physician.
o P-
85 e.g. Tramadol
o T-
36.5