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INTRODUCTION

 Subtrochanteric fractures are fractures that occur in a zone extending from the lesser
trochanter to 5cm distal to the lesser trochanter, however extension into the
intertrochanteric region is common. These fractures are more difficult to treat as
compared to intertrochanteric fractures due to the powerful muscle forces acting on
the fragments as well as the tremendous stress that is normally placed through this
region. The proximal fragment is typically flexed, abducted, and externally rotated
while the distal fragment is typically adducted. When seen in young patients, they are
due to high energy trauma or pathologic fracture with 10% of high energy fractures
due to gun shot wounds.In the elderly, they are often related to osteoporosis. Fracture
may also occur at the site of screw placement for a femoral neck fracture if the
inferior screw is placed too low as this creates a cortical defect and stress riser.

I. Personal Data

Name: Kennyvic N. Unay

Birthdate: September 6, 2006

Address: Novaliches Q.C.

Room & Bed No.: Childrens Ward

Religion: Catholic

Age: 3 y.o.

Informant: William Unay (father)

Date: July , 2009

II. Nursing History

A. Chief Complaint:

 Acute Pain(Lateral Left femur Part)

B. History of present illness:

Fitrilyn C. Dalhani
WCC-QC D3
Individual Case Study
POC Page 1
 6 Days PTA- patients was reported to jump from a 2 feet cabinet in their
house, and afterwards was complaining of pain in the leg part.

C. Past Health History:

1. Patient has no previous hospitalization, and reported by the father that this is
the patients first to be brought to the hospital.

D. Pre-natal History:

a. Obstetric history :

• Patient’s mother is in her 26 year when she got pregnant for the second
time and gave birth to her second child which is patient K.U.

b. Was pregnancy planned?

• Pt. parents are married and the pregnancy was plan according to the pt.
father.

c. Discomfort & associated signs and symptoms during pregnancy?

• Mother reported that when she was pregnant with pt. K.U. she
experienced nausea and vomiting which is a normal sign and
symptoms of pregnant women.

E. Birth History:

• Patient was born in a Hospital(no particular) and was born through a


Normal spontaneous Delivery 40 weeks gestation, it was the mothers
G2P2.

F. Infancy & Childhood:

• Father of patient reported that K.U. is breastfed from birth till his 4
month of life, and bottlefed until 4 years of age and is introduced to
eating solid foods when patient K.U. is in his 8 month of age.

• Patients had her 1st tooth erupted when he is 8 months, crawled at 7


months of age and the first word that patient K.U Spoke is mama in
his 6 months of age.

Fitrilyn C. Dalhani
WCC-QC D3
Individual Case Study
POC Page 2
G. Medical Surgery

A. Immunization :

• Patient is immunized with BCG, OPV1, Hepa a1, Hepa b1, DPT1,
OPV2, Hepa a2, Hepa b2, DPT2, OPV3, Hepa a3, Hepa b3, Measles.
Although the mother cannot recall the date of when this vaccines are
given to his son but she assured us that this vaccines was given to his
son.

B. Illnesses:

C. Patients’ mother reported that as far as she could remember her son had
never experience a serious illness.

D. Present Medications:

• Present medications of patient K.U. are Co- amoxiclav which is an


antibiotic drug.

E. Hospitalization:

• Patient has no previous hospitalization

H. Family History

• Patient has no family history of diseases as reported by patients’


father.

I. Usual Patterns of Functioning:

1. Physical Activity

-when patient was admitted in the hospital patient was always playing
with his toys as reported by the patients’ father.

2. Food & Fluid Intake

Fitrilyn C. Dalhani
WCC-QC D3
Individual Case Study
POC Page 3
- patient loves to eat vegetables, and eat all kinds of food, he eats
at least 5 times a day, breakfast, lunch, dinner and eats his siesta twice
a day, patients father reported that his daughter commonly encounters
feeding problem particularly colic.

3. Sleep Pattern

- Reported by patients’ father that his son sleeps at least 9 hours a


day, patient K.U. sleeps at around 9 in the evening.

4. Elimination Pattern

Bowel

- Patients’ typical bowel pattern is 1- 2 times a day usually patient


defecates when he takes a bath.

Bladder

- Patient K. U. Voids several times a day, urine is yellow in


appearance.

5. Hygiene

- Patient as a 3 yr. old cannot maintain a personal hygiene by his


self, when taking a bath he is assisted by her mother, he takes a
bath twice a day, upon waking up and before sleeping.

J. CLINICAL APPRAISAL

A. General Physical Assessment:

Skin
 Pt. skin is fair in color, it is smooth in texture.
Head
 Patients anterior and posterior fontanels is both palpated closed, patients
scalp is seen clean and hair is black in color.
Eyes
 Pt. eyes are black in color, pinkish sclera, Conjunctiva is pale in color; she
had thick eyebrows with rounded eyes the lied symmetrical to the nose.
Nose

Fitrilyn C. Dalhani
WCC-QC D3
Individual Case Study
POC Page 4
 It is pointed and in shape, symmetrical nose holes the internal mucosa was
felt moist.
Ears
 Patients’ ears are symmetrical in shape with each other.
Mouth
 Patient’s lips is slightly pinkish in color, tongue is seen with reddish color,
pts. Gum is pinkish in appearance.
Neck
 Pts. Carotid pulse is palpable, Symmetrical size of neck to normal size of
neck shape.
Heart and Lungs

 Pts. Breathing pattern is constantly changing but in the normal range of a


child.

Abdomen

 Patients abdomen is slightly protruded

Upper Extremities

 Patients’ upper extremities are symmetrical with each other.

Lower Extremities

 Patients’ lower extremities are symmetrical with each other.

 Seen with Skin Traction (2 pounds)applied on the left leg.

Hemoglobin 114 125-160

RBC Count 3.87 4.00-5.50

Hematocrit 0.37 3.8-5.0

WBC Count 8.8 5.00-10.00

Neutrophil 0.77 0.40-0.60

Lymphocyte 0.18 0.20-0.40

Monocyte 0.04 0.02-0.08

Eosinophil 0.01 0.00-0.04

Nasophil 0.00-0.01

B. B. Teething Process

Fitrilyn C. Dalhani
WCC-QC D3
Individual Case Study
POC Page 5
Patient first teeth erupted when he was in her 8 months of age.

Laboratory Examination

Complete Blood Count

ANATOMY AND PHYSIOLOGY

The Skeletal System serves many important functions; it provides the shape and form for our bodies in
addition to supporting, protecting, allowing bodily movement, producing blood for the body, and storing
minerals.
Functions
Its 206 bones form a rigid framework to which the softer tissues and organs of the body are attached.
Vital organs are protected by the skeletal system. The brain is protected by the surrounding skull as the
heart and lungs are encased by the sternum and rib cage.

Fitrilyn C. Dalhani
WCC-QC D3
Individual Case Study
POC Page 6
Bodily movement is carried out by the interaction of the muscular and skeletal systems. For this reason,
they are often grouped together as the musculo-skeletal system. Muscles are connected to bones
by tendons. Bones are connected to each other by ligaments. Where bones meet one another is typically
called a joint. Muscles which cause movement of a joint are connected to two different bones and contract
to pull them together. An example would be the contraction of the biceps and a relaxation of the triceps.
This produces a bend at the elbow. The contraction of the triceps and relaxation of the biceps produces
the effect of straightening the arm.
Blood cells are produced by the marrow located in some bones. An average of 2.6 million red blood cells
are produced each second by the bone marrow to replace those worn out and destroyed by the liver.
Bones serve as a storage area for minerals such as calcium and phosphorus. When an excess is present in
the blood, buildup will occur within the bones. When the supply of these minerals within the blood is low,
it will be withdrawn from the bones to replenish the supply.
Divisions of the Skeleton
The human skeleton is divided into two distinct parts:
The axial skeleton consists of bones that form the axis of the body and support and protect the organs of
the head, neck, and trunk.
The Skull
The Sternum
The Ribs
The Vertebral Column
The appendicular skeleton is composed of bones that anchor the appendages to the axial skeleton.
The Upper Extremities
The Lower Extremities
The Shoulder Girdle
The Pelvic Girdle--(the sacrum and coccyx are considered part of the vertebral column)
Types of Bone
The bones of the body fall into four general categories: long bones, short bones, flat bones, and irregular
bones. Long bones are longer than they are wide and work as levers. The bones of the upper and lower
extremities (ex. humerus, tibia, femur, ulna, metacarpals, etc.) are of this type. Short bones are short,
cube-shaped, and found in the wrists and ankles. Flat bones have broad surfaces for protection of organs
and attachment of muscles (ex. ribs, cranial bones, bones of shoulder girdle). Irregular bones are all others
that do not fall into the previous categories. They have varied shapes, sizes, and surfaces features and
include the bones of the vertebrae and a few in the skull.
Bone Composition
Bones are composed of tissue that may take one of two forms. Compact, or dense bone, and spongy, or
cancellous, bone. Most bones contain both types. Compact bone is dense, hard, and forms the protective
exterior portion of all bones. Spongy bone is inside the compact bone and is very porous (full of tiny
holes). Spongy bone occurs in most bones. The bone tissue is composed of several types of bone
cells embedded in a web of inorganic salts (mostly calcium and phosphorus) to give the bone strength,
and collagenous fibers and ground substance to give the bone flexibility

Fitrilyn C. Dalhani
WCC-QC D3
Individual Case Study
POC Page 7
The thigh bone, extending from the hip to the knee of four- and two-legged vertebrates,
including humans. The femur is the largest, longest, and strongest bone of the humanskeleton. Its
rounded, smooth head fits into a socket in thepelvis called the acetabulum to form the hip joint
(an example of a ball-and-socket joint). The head of the femur is joined to the bone shaft by a
narrow piece of bone known as the neck of the femur. The neck of the femur is a point of
structural weakness and a common fracture site. The lower end of the femur hinges with
the tibia (shinbone) to form the knee joint.

The femur can be felt through the skin at two sites. At the lower end, the bone is enlarged to
form two lumps called the condyles that distribute the weight-bearing load on the knee joint. On
the outer side of the upper end of the femur is a protuberance called the greater trochanter. The
gluteus and psoas muscles are inserted on the greater and lesser trochanter, respectively. The
lateral and medial epicondyles articulate with the tibia and the trochlear groove accommodates
the patella (kneecap).

PATHOPHYSIOLOGY

 The subtrochanteric region of the femur, arbitrarily designated as the region between
the lesser trochanter and a point 5 cm distal, consists predominantly of cortical bone.
Healing in this region is predominantly through a primary cortical healing. Thus, the
fracture is quite slow to consolidate.4 In addition, this region is exposed to high stresses
during activities of daily living. Axial loading forces through the hip joint create a
large moment arm, with significant lateral tensile stresses and medial compressive
loads. In addition to the bending forces, muscle forces at the hip also create torsional
effects that lead to significant rotational shear forces. During normal activities of daily
living, up to 6 times the body weight is transmitted across the subtrochanteric region
of the femur.

DRUG STUDY
Date Ordered Medication Action Indication Nursing Diagnosis

1/16/09 G.N.: Paracetamol > thougth to produce > Mild fever or > Monitor and
B.N.:Acetaminophen analgesia by blocking pain prescription
Dosage: 240 mg pain impulses by products contain
Frequency: q6h inhibiting synthesis of acetaminophen be
R.O.A.: p.o. prostaglandin in the aware of this when
CNS or of other calculating total
substances that daily dose.

Fitrilyn C. Dalhani
WCC-QC D3
Individual Case Study
POC Page 8
senzitize pain receptors > Use liquid form
Pharmacologic Class: to stimulation. The for children and pts.
 Paraminophenol drug may relieve fever Who have difficulty
derivative through central action swallowing.
in the hypothalamic >in children don’t
heat regulating center. exceed 5 doses in
24 hours.
1/16/09 G.N.: Amoxicillin > Prevents bacteria > Lower > Before giving
B.N.: Augmentin cell- wall synthesis respiratory drugs ask pt. about
Dosage: 475 mg/5 ml during replication. tract allergic reaction to
Frequency: BID infections, skin penicillins.
R.O.A.: p.o. and skin > Give drug at least
structure 1 hr before a
infections and bacteriostatic
Pharmacologic Class:
UTI’s caused antibiotic.
 Aminopenicillin and
by susceptible
betalactamase
strains gram-
inhibitor.
positive and
gram- negative
organisms.

NURSING CARE PLAN

ASSESSMENT PLANNING INTERVENTION EVALUATION

Subjective: Within 8 hours of Independent: After 8 hours of


nursing nursing
“Nahihirapan siya 1. Do as much as care
interventions, the interventions, the
makabalik sa tulog as possible without
lalo na sa gabi.
patient must report waking client.
patient reported that
Nagigising kasi siya improvement of he was able to rest
kapagkumikirot yung sleep pattern. R: To minimize time for a longer period
paa niya.” as spent inside the of time.
verbalized by the patient’s room.
patients father.

2. Provide quiet
Objective: environment by
minimizing sound/
- Weakness noted noise produced during
nurse’s rounds.
- Patient is Irritable
R: to promote rest
- Patient is restless. periods

- Patient gives

Fitrilyn C. Dalhani
WCC-QC D3
Individual Case Study
POC Page 9
SHORT answers to
questions of the nurse.
3. Change linen if
needed.

R: clean linens
provide comfort to
NURSING patient.
DIAGNOSIS:

Disturbed Sleep
Subjective: Within 4 hours of good Independent: After four hours of good
Pattern r/t Wag mo nursing intervention the
 Ms. Ms. 4. GiveTSB
Followto patient nursing intervention
galawin hita
interruption for patient should be able to: and change clothing.
handwashing patient was able to:
niya, di pa kasi techniques
therapeutic, R: this willbefore
provide
magaling sugat  Prevent or reduce and after  Prevent or reduce
monitoring
niya eh and
as occurrence of comfort tohandling
patient occurrence of
laboratory
verbalized by infection in patients. infection in his
patients’ as
examinations patients Rationale: surgical
Father.
evidenced by the
surgical • Handwashing is wound.
Objective: wound. first- line defense
patient’s
 Patients of against
restlessness.
surgical wound nosocomial
in patients left infection.
subtrochanteric  Provide for
ASSESSMENT
femur. PLANNING INTERVENTION EVALUATION
wound
 Wet dressings
DISCHARGE SUMMARY isolation.
covering the Rationale:
patients • Reduce risk of
surgical cross
wound. contamination.
 Patient  Change dressing
experienced as needed/
difficulty in indicated
moving due to Rationale:
pain felt. • To keep surgical
 Patient seen with wound clean to
Skin Traction prevent infection.
(2  Encourage patient
pounds)applied ambulation,
on the left leg deep breathing
exercises,
coughing, and
Nursing diagnosis: position
 Risk for infection changes.
related to Rationale:
inadequate • Mobilization of
primary respiratory
defenses secretion.
secondary to Collaborative:
surgical  Administer/
wound. monitor
medication
regimen and
Fitrilyn C. Dalhani note clients’
WCC-QC D3 response.
Individual Case Study Rationale:
POC • To determine Page 10
effectiveness of
therapy/ presence
of the effect.
 Patient has a good progmosis for it only took a short period of time in
able for the patients subtrochanteric fracture to heal and patients was
discharge.

NURSING MA N A G E M E N T

a. Nur s i ng ca re of a patient w i t h a fracture, w h e t h e r casted or in traction, is


based u p o n prevention of complications wh i l e healing. By performing an accurate
n ur s i ng assessment on
a regular basis, t h e nur s i n g staff c a n m a n a g e t h e patient's pain
a n d pr e ve nt complications.

b. When assessing a patient w i t h a fracture, c h e c k t h e "5 P's"--pain, pul se,


pallor, paresthesia, a n d paralysis.

( 1 ) Pain. Determine w h e r e t h e pain is located a n d if it is wo r s e or better?


W orse ni ng pain may indicate increased ede ma, lack of adequate blood s u p p l y.
( 2 ) Puls e. Ch e c k t h e peripheral pulses, especially t h o s e distal to t h e
fracture site. Compare a ll pul ses w i t h t h o s e on t h e unaffected side. Pu lse s s h o u l
d be
str ong a n d e qua l.
( 3 ) Pallor. O bs e r ve t h e color a n d temperature of t h e skin, especially a r o u n d
t h e fracture site. Perform t h e capillary refill (blanching) test.
( 4 ) Paresthesia. E xa m i ne t h e injured area f o r increase or decrease in
sensation. C a n t h e patient detect tactile stimulation s u c h as a b l u n t t o u c h or
a s ha r p
pinprick? Does t h e patient complain of n u m b n e s s or tingling?
( 5) Paralysis. C he c k t h e patient's mobility. C a n he wiggle h i s toes a n d
fingers? C a n he m o v e hi s extremities?

c. Al l nur si ng assessment findings s h o u l d be d o c um e n te d in t h e patient's c h a r t


so t h a t comparison c a n be m a d e w i t h n o t e s m a d e at b o t h earlier a n d later dates.
In this w a y , t h e patient's progress c a n be followed a n d c h a n g e s in st atus a r e easily
recognized. In addition to t h e five P's menti on ed a bo ve, t h e patient's l e v el of
consciousness a n d temperature s h o u l d be c hec ke d regularly. M e n t a l stat us c h a n g e s
a n d temperature elevation c ou l d indicate t h e presence of infection. Reposition t h e
patient as nece ssar y to relieve pressure areas. Ch e c k a l l dressings, bandages, casts,
splints, a n d traction equipm ent to e n s u r e t h a t n o t h i n g is causing constriction or
pressure. Freque nt a n d t h o r o u g h checking a n d observation on t h e part of t h e
n ur s i ng staff will promote healing a n d p r e v e n t complications

Fitrilyn C. Dalhani
WCC-QC D3
Individual Case Study
POC Page 11