Frectal XD

7/28/2019 Frectal XD

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I- Introduction

A fracture is a break in the continuity of bone and is defined according to its type

and extent. Fractures occur when the bone is subjected to stress 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 tendons, 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, closed fracture, open fracture and there are also types of fractures

that may also be described according to the anatomic placement of fragments,

particularly if they are displaced or nondisplaced. Such as greenstick fracture, depressed

fracture, oblique fracture, avulsion, spinal fracture, impacted fracture, transverse fracture

and compression fracture.

A comminuted fracture is one that produces several bone fragments and a closed

fracture or simple fracture is one that not cause a break in the skin. Comminuted fracture

at the Right Femoral Neck is a fracture in which bones of the Right Femoral Neck has

splintered to several fragments.By choosing this condition as a case study, the student nurse expects to broaden

her knowledge understanding and management of fracture, not just for the fulfillment of

the course requirements in medical-surgical nursing. It is very important for the nurses

now a day to be adequately informed regarding the knowledge and skill in managing

these conditions since hip fracture has a high incidence among elderly people, who have

brittle bones from osteoporosis (particularly women) and who tend to fall frequently.

Often, a fractured hip is a catastrophic event that will have a negative impact on the

patients life style and quality of life. There are two major types of hip fracture.

Intracapsular fractures are fractures of the neck of the femur, Extracapsular fracture are

fractures of the trochanteric 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

neck of the femur, and the bone may die. Many older adults experience hip fracture that

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student nurse need to insure recovery and to attend their special need efficiently and

effectively. True the knowledge of this condition, a high quality of care will be provided

to those people suffering from it.

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II. Objectives

General Objectives:

After three day of student nurse-patient interaction, the patient and the significant

others will be able to acquire knowledge, attitudes and skills in preventing complications

of immobility.

Specific Objectives:

A. STUDENT-NURSE CENTERED

After 8 hours of student nurse-patient interaction, 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 holistic nursing care in the care of patient utilizing the nursing

process.

7. impart health teachings to patient and family members to care of patient with

fracture.

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.

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III. Nursing Assessment

1. Personal History

1.1 Patients Profile

Name: Mrs. Torralba, 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 Osteoporosis

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 Information, Social and Health History

Mrs. Torralba, Lourdes who resides in 8 Acacia 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 shes previously 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

metastasis and on chemotherapy with aromasin.

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Two days prior to admission, the patient was standing and was about to open up

he umbrella when she got out of balance and landed on her right hip.And had experienced

limitation of movement on the right hip. The patient was then admitted due to the

persistence of pain.

The patient was previously hospitalized due to infected wound at the right ankle

last 2002. No familial history of hypertension and 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 beverages drinker.

1.3. Level of Growth and Development

1.3.1. Normal Growth and Development at particular stage Older Adult ( 65

Years old to death)

Physical Development

Perception of well-being can define quality of life. Understanding the older adults

perception about health status is essential for accurate assessment and development 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 healthy, whereas those whose activities are

limited by physical, emotional or social impairments may perceive themselves as ill.

There are frequently observed physiological changes in order adults that are

called normal. Finding these normal changes 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 adults experience all of these physiological changes, and others only

experience only a few. The body changes continuously with age, and specific effects on

particular older adults depend on health, lifestyle, stressors and environmental conditions.

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Cognitive Development

Intellectual capacity includes perception, cognitive, memory, and learning.

Perception, or the ability to interpret the environment, depends on the acuteness of the

senses. If the aging persons senses are impaired, the ability to perceive the environment

and react appropriately is diminished. Perceptual capacity may be affected by changes in

the nervous system as well. Cognitive ability, or the ability to know, is related to the

perceptual ability.

Changes 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, the meaninges

appear to thicken, and brain metabolism slows. As yet, little is known about the effect of

these physical changes on the cognitive functioning of the older adult. Older people need

addition time for learning, largely because of the problem of retrieving information.

Motivation is also important. Older adults have more difficulty than younger ones in

learning information they do not consider meaningful. It is suggested that the older

person mentally active to maintain cognitive ability at the highest possible level. Life

long mental activity, particularly verbal activity, helps the older person retain the high

level of cognitive function and may help maintain a long-term memory. Cognitive

impairment that interferes with normal life is not considered part of normal aging. A

decline in intellectual abilities that interferes with social or occupational functions should

always be regarded as abnormal.

Psychosocial Development

According to Erikson, the developmental task at this time is ego integrity versus

despair. People who attain ego integrity view with a sense of wholeness and derive

satisfaction from past accomplishment. They view death as an acceptable completion.

According to Erikson, people who develop integrity accept ones one and only life

style. 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 could live life over.

Robert Butler sees integrity and bringing serenity and wisdom, and despair as resulting in

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the inability to accept ones fate. Despair gives rise of frustration, this couragement, and a

sense that ones life has been worthless.

Moral Development

According to Kohlberg, moral development is completed in the early adult years.

Most old people stay at Kohlbergs conventional development, and some are at the

preconventional 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 and bad in relation

to self, whereas older persons at stage 7 may act to meet anothers need as well as their

own. Elderly people at the conventional level follow societys rules of conduct to

expectation of others.

Emotional Development

Well-adjusted aging couples usually thrive on companionship. Many couples rely

increasingly on their mates for this company and may have few outside friends. Great

bonds if affection and closeness can develop during this period of aging together and

nurturing each other. When a mate dies, the remaining partner inevitably experiences

feelings of loss, emptiness, and loneliness. Many are capable and manage to live alone;

however, reliance, on younger family members increases as age advances and in health

occurs. Some widows and widower remarry, particularly the latter, because the widowers

are less inclined than widows to maintain a household.

Spiritual Development

Murray and Zentner write that the elderly person with a mature religious outlook

striver to incorporate views of theology and religious action into thinking. Elderly people

can contemplate new religious and philosophical views and try to understand ideas

missed previously or interpreted differently. The elderly person also derives a sense of

worth by sharing experiences or views. In contrast, the elderly person who has not

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matured spiritually may not matured spiritually may feel impoverishment or despair as

the drive for economic and professional success wares.

Psychosexual Development

Sex drives persist into the 70s, 80s, and 90s, 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 factors may play a rate in the ability of an elderly

person to engage in sexual activity. 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

unnoticed. Other changes are obvious. The breasts atrophy, and lubricating vaginal

secretions are reduced. Reduced natural lubrication is the cause of painful intercourse,

which often necessities the use of lubricating jellies.

3.1.2. Ill Person at the Particular Age of Patient

The older fracture patientsshowed a higher prevalence of chronic brain syndrome,

they werein poorer physical state and their skinfold thickness was less.They also had

more unrecognized visual disorders. Those whowere younger had a higher prevalence of

stroke than comparablecontrols.

The type of fall leading to the fracture varied with agetrippingwas the

commonest cause in the younger patients and dropattacksin the older. Both stroke and

partial sightednesswere associated with falls due to loss of balance. The olderpatients

had a very high prevalence of pyramidal tract abnormalityassociated with chronic brain

syndromeand it appearsthat these demented patients fall not because of mental

confusionbut because of associated motor abnormalities.

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Ertra-capsular fractures occur inolder patients. They are morelikely to have a

history of falls but previous fracture is equallycommon at this age in the fracture and

control series.

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2. Diagnostic Test

Diagnostic test Normal values Patients

Result

Significance

April 10, 2008Complete Blood

Count

Hemoglobin

Hematocrit

WBC

RBC

Mean Corpuseular

Hemoglobin

Mean Cell Volume

(MCA)

Mean Corpuseular

Hemoglobin

Platelet

Differential Count

Neutropihl

Basophil

Eosinophil

Monocyte

Lympocyte

Serum

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%

3.6-5

9.1

28.8

5.32

2.8

32.7

103.6

32

387

67

0

4

09

20

4.7

- Decreased-various anemias, with

excessive fluid intake.-Decreased-severe anemias

-Normal

-Decreased- all anemias and leukemia,

when blood volume has been restored.

-Normal

-Increased-macrocytic anemia

-Decrease-severe hypochronic anemia

-Normal

-Normal

-Normal

-Normal

-Increase-viral infection, collagen andhemolytic disorders

-Normal

Source:Brunner and Suddarths. Textbook of

Medical-Surgical Nursing.10th Edition

Volume 2. page 2214-2215

-Normal

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Potassium

Creatinine

Calcium

Protein

Albumen

Globulin

Total Protein

GCT(50gms)

PBS

Uric acid

Bleeding time-sim

Clotting time

Prothombin time

% activity

6.7-1.5

8.4-10.2

1.2-2.2

3.3-5.5

2

6.8

65-110

8-35 u/mL

65-110

2.5-7.5

2.3-9.5

5-15

10-13

70-120

6.6

8.2

1.0

2.9

2.9

5.8

145

20

118

4.4mg/dL

6.31

min.-sec.

10.41

min.-sec.

13.8 sec.

96.2 %

-Decreased-Muscular atrophy,

anemia, leukemia-Decreased-vitamin D. deficiency

-Decreased-anemia, malnutrition

-Decreased-no clinical significance

-Increased-chronic infection, multiple

myeloma

-Decreased-malnutrition

-Increased-diabetes mellitus

-NormalSource:

Brunner and Suddarths. Textbook ofMedical-Surgical Nursing.10th EditionVolume 2.page

2217,2219,2221,2224,2229,2230,2232

-Increased-diabetes mellitus

Source:

Brunner and Suddarths. Textbook of

Medical-Surgical Nursing.10th EditionVolume 2.page 2230,2233,

-Normal

Source:Brunner and Suddarths. Textbook of

Medical-Surgical Nursing.10th Edition

Volume 2.page 2225,

-Normal

-Normal

-Increased-deficiency of factors I, II,

V, VII, and X, fat malabsorption

-Normal

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INR

UrinalysisMacroscopic

Examination

Color

Appearance

Plt

Specific gravity

Protein

Glucose

Ketones

Blood

Leukocytes

Nitrite

Bilirubin

Urohilinogen

Microscopic

Examination

RBC/hpf

WBC/hpf

Bacteria

Mucus threads


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Amorphous Urates

Blood cell

Present

Negative

Few

Few

-Normal

Indicates renal or urinary tract disease

Source:

Brunner and Suddarths. Textbook of

Medical-Surgical Nursing.10th

EditionVolume 2.page 2224,2225

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3. Present Profile of Functional Health Patterns

Profile of Functional Health Patterns

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 inability to walk or stand and difficulty in moving the extremities due to the fracture

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 plenty of water everyday.

During the patients hospitalization, her diet was changed to low fat and low cholesterol

diet because she was diagnosed of having diabetes mellitus type II. The patients

attending physician encourages her to take more of calcium and Vitamin D in order for

her bones to become stronger. The patient is non-smoker and non-alcoholic drinker and

she has no known allergies.

3.2. Nutritional / Metabolic Pattern

The patients usual food intake before the hospitalization includes fish, meat,

vegetables, fruits, chicken and especially foods 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 Caltrate. 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 Calcium and Vitamin D in order for her bones to become

stronger. The patient doesnt 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.

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3.3. Elimination Pattern

Before, the patient can freely go to the C.R. to void or defecate but now that shes

hospitalized she was advised to wear diaper for her to have difficulty in standing and

walking. There is no burning sensation during ur4ination and her stool is brownish

formed stool.

3.4. Activity-Exercise Pattern

The patient before hospitalized wakes up early in the morning for her to have fine

walking around their house as her exercise. She usually guided her grandsons and

granddaughters, but now, shes just on bed lying assisted by her private 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

patient cannot read her newspaper without her eyeglasses just the same as now. She

speaks slowly English, Tagalog and Bisaya languages as of now but before she speaks

fluently all of those languages. She easily communicates, understands questions,

instructions and be able to follow and answer them correctly.

3.6. Rest/ Sleep Pattern

Before the hospitalization, the patient usually sleeps late at night at around 10

oclock pm and wakes up early in the morning at 6 oclock am with an hour of sleep of 8

hours. Now, she usually sleeps early at night (8-9 oclock pm) and wakes up at around 7

oclock am with an hour of sleep of 10 hours. The patient usually stays in bed and read

newspapers sometimes, she cant take a nap in the afternoon due to her REHAB CARE.

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3.7. Self- Perception Pattern

The patients most concern about right now is her rehabilitation care. The patient

wants to stay at the hospital until she improves 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 physically and also her private nurses.

Through this, she maybe able to cope up easily from her unhealthy condition. The

treatment, managements, medications and all out care rendered by the hospital to the

patient assured her for the improvement of her condition.

3.8. Sexuality/ Reproduction

The patients husband just recently 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 should 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 from illness. Sometimes, the patient usually shares her concerns to her private

nurses 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 strength and hope with God and her loved ones. God is

very much important to the patient. Before, she usually goes to church together with her

other children. They were 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.

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3.11. Relationship Pattern

The patient understands more on English and Bisaya languages but a little only in

Tagalog language. The patient was living all by herself 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 from their mother they always make sure that their

mother is safe and secure. The patient can easily communicate, cooperate, listen and

follow instructions easily.

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4. Pathophysiology and Rationale

4.1 Normal Anatomy and Physiology of Organ/ System Affected

The word skeleton comes from the Greek word meaning dried- up body, our

internal framework is so beautifully designed and engineered and it puts any modern

skyscraper 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 million 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. The skeleton is subdivided

into three divisions: the axial skeleton, the boned that form the longitudinal axis of the

body, and the appendicular skeleton, the bones 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

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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, makes 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. Hundreds of connective tissue fibers, called Sharpeys fibers,

secure the periosteum to the underlying bone. The epiphyses are the ends of the long

bone. Each epiphyses consist of a thin layer of compact bone enclosing the area filled

with spongy bone. Articular cartilage, instead of periosteum, covers its external surface.

Because the articular cartilage is glassy hyaline cartilage, it provides a smooth, slippery

surface that decreases friction at joint surfaces.

In adult bones, 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. The

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 growth, epiphyseal plates have

been completely replaced by bone, leaving the epiphyseal lines to mark their previous

location.

In adults, the cavity of the shaft is primarily a storage area for adipose (fat) tissue.

It is called the yellow marrow, or medullary, in infants this areas forms blood cells, and

red marrow is found 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 materials 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 without up mobility. The calcium salts deposited in the matrix bone its hardness,

whereas the organic parts (especially the collagen fibers) provide for bones flexibility

and great tensile strength.

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The femur, or thigh bone, is the only bone in the thigh. It is the heaviest, strongest

bone in the body. Its proximal end has a ball-like head, a neck, and greater and lesser

trochanters (separrsted anteriorly by the intertrochanteric line and posteriorly by the

intertrochanteric crest). The trochanters, intertrochanteric crest and the gluteal tuberosity,

located on the shaft, all serve us sites for muscle attachment. The head of the femur

articulates with acetabulum of the hip bone in a deep, secure socket. However, the neck

of the femur is a common fracture 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 bodys center of gravity. The medial course of the

femur is more noticeable in females because of the wider female pelvis. Distally on the

femur are the lateral and medial condytes, which articulates the tibia below. Posteriorly,

these condytes are separated by the deep intercondylar notch. Anteriorly on the distal

femur is the smooth patellar surface, which forms a joint with the patella, or kneecap.

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4.2 Schematic Diagram

Predisposing Factors: Precipitating Factors:

-Elderly people (85 years or older) -Fall

- Trauma - osteoporosis- Comorbidity -functional disability

- Malnutrition - impaired vision and balance

-neurologic problems

- Obesity

-slower reflexes

Damage to the blood supply to an entire bone.

Severe circulatory compromise

Avascular (ischemic) necrosis may result

Surgical Intervention:- Hip Pinning

- Hip Hemiarthroplasty

- Patients with hip osteonecrosis may require Hip Replacement

Surgery

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Clinical Manifestations:

- Pain (right up)

- Loss of function

- Deformity

- Crepitus- Swelling and discoloration

- Paresthesia

- Tenderness

Nursing Management:- Repositioning the patient

- Promoting strengthening exercise

- Monitoring and managing complications

- Health promotion

- Relieving pain

- Promoting physical mobility

- Promoting positive psychological response to

trauma

Medical Management:- Temporary skin traction

- Bucks extension

- Open or closed reduction of the fracture and

internal fixation

- Replacement of the femoral head with prosthesis

(hemiarthrmoplasty)

- Closed reduction with pereutaneous stabilization

for an intracapsular fracture.


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4.3 Pathophysiology

Femoral neck fractures occur most commonly after falls. Factors that increase the

risk of injuries are related to conditions that increase the probability of falls and those that

decrease the intrinsic ability of the person to with stand the trauma. Physical

deconditioning, malnutrition, impaired vision and balance, neurologic problems, and

shower reflexes all increase the risk of falls. Osteoporosis is the most important risk

factor that contributes to hip fractures. This condition decreases bone strength and,

therefore, the bones ability to resist trauma.

Femoral neck fractures can also be related to chronic stress instead of a single

traumatic event. The resulting stress fractures can be divided into fatigue fractures and

insufficiency fractures. Fatigue fractures are a result of an increased or abnormal stress

placed on a normal bone. Whereas insufficiency fractures are due to normal stresses

placed on diseased bone, such as an osteoporotic bone.

Trauma sufficient to produce a fracture can result in damage to the blood supply

to an entire bone, e.g., the femoral neck in femoral fracture. With seer circulatory

compromise, avascular (ischemic) necrosis may result. Particularly vulnerable to the

development of ischemic are intracapsular fractures, as occur in the hip. In this location,

blood supply is marginal ad damage 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

recommended as diagnostic tools to determine the orability of the femoral need.

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4.4 Classical and Clinical Signs and Symptoms

Classical Symptoms Clinical Symptoms Rationale

Pain

Loss of function

Deformity

Shortening

Crepitus

Swelling and

Manifested

- complains of pain onthe right hip aggravated

by sudden or too much

movements of the

extremities and relievedby elevation and resting.

Manifested- unable to move

extremities and unable to

stand or walk withoutassistance.

Manifested

- Bones of the right

femoral neck aresplintered into small

fragments.

Not Manifested

Manifested

Manifested

- The pain is continuous and increases

in severity until the bone fragment areimmobilized. The muscle spasm that

accompanies fracture is a type of

natural splinting designed to

minimize further movement of hefracture fragments.

-After a fracture, the extremity cannotfunction properly, because normal

function of the muscles depends on

the integrity of the bones to whichthey are attached. Pain contributes to

the loss of function. In addition,

abnormal movement (false motion)may be present.

-Displacement, angulations, or

rotation of the fragments in a fracture

of the right femoral neck causes adeformity that is detectable when the

limb is compared with the uninjured

extremity. Deformity also resultsfrom soft tissue swelling.

- In fractures of long bones, there is

actual shortening of the extremitybecause of the contraction of the

muscles that are attached above ad

below the site of the fracture. Thefragments often overlap by as much

as 2.5 to 5 cm (1 to 2 inches)

-When the extremity is examined

with the hands, a grating sensation,

called crepitus, can be felt. It iscaused by the rubbing of the bone

fragments against each other.

-localized swelling and discoloration

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Discoloration

Paresthesia

Tenderness

Manifested

Manifested

of the skin (ecehymosis) occurs after

a fracture as a result of trauma andbleeching into the tissues. These signs

may not develop for several hours

after the injury.

-After fracture, any subjective

sensation, experienced as numbness,tingling, or a pins and needles may

be felt. These often fluctuate

according to such influences as

posture, activity, rest, edema,congestion, or underlying disease, it

is sometimes identified as

acroparesthesia.

-Mostly, the affected part respondswith a sensation of pain to pressure ortouch that would not normally cause

discomfort. This happens due to the

bones splintered into fragments.

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IV. Nursing Interventions

1. Medical and Surgical Management

Temporary skin traction, Bucks extension, may be applied to reduce muscle

spasm, to immobilize the extremity, and to relieve pain. The findings of a recent study

suggested that there 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 evaluation

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) open or closed reduction of the fracture and internal

fixation (2) replacement of the femoral head with a prosthesis (hemiarthroplasty), or (3)

closed reduction with pereutaneous stabilization for an intracapsular fracture. Surgical

intervention 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 reduction and

internal fixation performed within 12 to 24 hours after fracture. This minimizes the

effects of diminished blood supply and reduces the risk for avascular necrosis.

After general or spinal anesthesia, the hip fracture is reduced under x-ray

visualization using an image intensifier. A stable fracture is usually fixed with nails, a

nail and plate combination, multiple pins, or compression screw devices. The orthopedic

surgeon determines the specific fixation device based on the fracture site or sites.

Adequate reduction is important for fracture healing (the better the reduction, the better

the healing).

Hemiarthroplasty (replacement of the head of the femur with prosthesis) is

usually reserved for fractures that cannot be satisfactorily reduced or securely nailed or o

avoid complications of non-union and avascular necrosis of the head of the femur. Total

hip replacement may be used in selected patients with acetabular defects.

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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 unaffected extremity as

prescribed by the physician. The standard method involves placing a pillow between the

patients legs to keep the affected leg in an abducted position. The patient is then turned

onto the side white proper alignment and supported abduction are maintained.

Promoting Strengthening Exercise

The patient is encouraged to exercise as much as possible by means of the

overbed trapeze. This device helps strengthening the arms and shoulders in preparation

for protected ambulation (e.g., toe touch, partial weight bearing). On the first post-

operative day, the patient transfers to a chair with assistance and begins assisted 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 bearing. Physical therapists work

with the patient on transfers, ambulation, and the safe use of the walker and crutches.

The patient who has experienced a fractured hop can anticipate discharge to home

or to an extended care facility with the use of an ambulating aid. Some modifications in

the home maybe needed to permit safe use of walkers and crutches and for the patients

continuing care.

Monitoring and Managing Potential Complications

Elderly people with hip fractures are particularly prone to complications that may

require more vigorous treatment than the fracture. In some instances, shock proves fatal.

Achievement of homeostasis after injury and surgery is accomplished through careful

monitoring and collaborative management, including adjustment of therapeutic

interventions as indicated.

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Health Promotion

Osteoporosis screening of patients who have experienced hip fracture is important

for prevention of future fractures. With dual-energy x-ray absorptiometry (DEXA) scan

screenings the actual risk for additional fracture can be determined. Specific patient

education regarding dietary requirements, lifestyle changes, and exercise to promote

bone3 health is needed. Specific therapeutic 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 osteoporosis despite the probability that hip fractures are secondary to osteoporosis.

Fall prevention is also important and maybe achieved through exercises to improve

muscle tone and balance and through the elimination of environmental hazards. In

addition, the use of hip protectors that absorb or shunt impact forces may help to prevent

an additional hip fracture if the patient were to fall.

Relieving Pain

* Secure data concerning pain

- have patient describe the pain, location characteristics (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 prevent or modify pain

* Administer prescribed pharmaceuticals as indicated. Encourage 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.

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Promoting Self-Care Activities

* Encourage participation in care.

* Arrange patient area and personal items for patient convenience to promote

independence.

* Modify 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 during position changes.

* Minimize prolonged periods of physical inactivity, encouraging ambulation when

prescribed.

* Administer prescribed analogies judiciously to decrease pain associated with

movement.

Promoting Positive Psychological Response 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 relationship 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 techniques to decrease anxiety.

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* Encourages development of adaptive responses and participation in support groups.

* Refer patient to psychiatric liaison nurse or refer for psychotherapy, as needed.

3. Actual Patient Care

3.1 Physical Assessment

PHYSIOLOGIC

Body part Inspection Palpation Percussion Auscultation

Head

Hair

Scalp

Forehead

Face

- Small, round head,normocephalic, no

wounds, no rashes

present.

-Hair is short, white

in color, evenly

distributed, no scales,

wearing a clip, has afine hair

-No dandruff and

wounds present, pink,mobile

- Firm, no scars, novisible bulges, not

oily, had wrinkles

- Symmetrical, check

bones are slightly

prominent, nopresence of scar,

presence of wrinkles,

without pimples

- Palpable temporalpulse, soft, no

evidence of abnormal

mass, no protrusionsand pond felt upon

palpation.

- Free from lumps,

lesions, normal bondprominences on the

forehead, sides of theparietal bones, behind

the ears.

- Forehead is free oflumps and nodes.

- No lesions, no

tenderness.

-Tempera;pulse is at 82

bpm.

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Eyes

Brows

Lashes

Lids-Upper

Lids-Lower

Sclearae

Cojunction

Cornea

Iris

Pupil

- Symmetrical, round,

align with the ears,

few discharges seen,with eyeglass

- Hair evenly

distributed, skin

intact, symmetrically

aligned, black incolor, free from

sealing

- turn outward, short,

black

- partially cover the

eyelids

- sometimes cover the

whole sclerae

- whitish in color butred capillaries are

slightly seen

- pink

- transparent, shinyand smooth, night

displays at the same

spot of the eyes

-round, black

-black in color butwith white opacities

near the lacrimal

gland , round smoothborder, illuminated

pupil constricts (pupil

equally roundreactive to light and

decommodation)

- No lumps and

rashes, smooth and

no tenderness

-Non tender

-Non tender

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Muscle

Function

Muscle

Balance

Visual

Acuity

Peripheral

Vision

Nose

Frontal

Sinuses

Maxillary

Sinuses

Mouth

Lips

Gums

-eyes moves slowly

as it follows my

finger guiding thepatient and assessing

her 6 cardinal gazes

-Move symmetrically

the tremors

-260/20

-able to define

correctly the numberof fingers showed atthe side of the patient

nut sometimes its

difficult for her.

- White, long nose,

septum is aligned in

midline, nodischarge/ flaring, air

flows freely.

- light color during

transillumination

-light color during

transillumination

- no lesions, open andclose symmetrically

and slowly.

-slightly pale in color,

soft, moist, symmetry

of contour, smooth intexture.

-Intact, pink in color,no swelling or

bleeding.

- no lesions,

deformities and

deviations

- non-tender

- non-tender

-free from edema

- no lumps, lesions

and tenderness upon

palpation, free fromedema

- non-

tender

- non-

tender

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Teeth

Tongue

Frenulum

Sublingual

Area

Hard Palate

Self Palate

Uvula

Tonsils

Ears

External

-Yellow teeth with

brownish

discoloration, thedentures, and teeth

are incomplete.Upper- no teeth

Lower- 4

-centrally positioned,slightly pale, moist,

no lesions.

- midline, slightly

pale

- pinkish, visible

veins

- bony, whitish

- muscular, pinkish

- pink, midline, free

of lesions

- midline, no

inflammations

- Symmetrical,

slightly big, align

with the eyes, pinna

is in linewith theouter canthus of the

ear, no swelling or

lesions.

- Symmetrical, align

with the eyes, noswelling or lesions, as

discharges, with

slight cerumen andhair.

- no palpable nodules

- no lumps

- no pain felt, upon

palpation of pinna.

-Displays no

thickening/ pain. Nomasses/ bulges.

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Neck

Lymph

nodes

Thyroid

Trachea

Skin

Thorax

Chest

anterior

Lungs

- Able to do flexion,

extension androtation of neck.

-Muscles equal in

size, head centered.

- no visible bulges,

not enlarged

- no bulges, not

visible

- not enlarged- centrally located

- white, withwrinkles, no dryness

- flat, equal chest

expansion, the ride

and fall duringrespiratory is visible

-Carotid pulse

palpable

-Not palpable

-Not palpable, free of

nodules, moves up

and down as thepatient swallows.

- central placement inmidline of neck,

spaces are equal inboth sides, non-tender, non-palpable

- slightly cold, goodturgor

- vibrations are equal

in both sides

- no nodules,retraction or nodules

- full, symmetricexcursion

- resonatedown to

the 6th rib,

flat over

areas ofheavy

muscle

and bone,dull on

areas over

the heart,liver, and

stomach

percussed.

-Lung soundsare clear, no

rales and

wheezes

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Heart

Breast

Abdomen

Spine

Extremities

Upper

Musclestrength

Muscle tone

- no visible pulsations

-with breast CA ( R)

( 2006-2007 )

- flat, soft,unblemished skin

- has abnormal

curvature

-capillary refill time

is 2 sec.

- white, equal in

sizes, fingers were

curving downward

-35.5 degrees Celsius

- able to performROM exercises

- difficulty inovercoming

resistance

- no nodules, bulges

- apical pulsepalpable

- non-tenderness

- no lesions, no lumps

palpated in the lungs

- radial pulse

palpable- 80 bpm

- brachial pulsepalpable

- no tenderness,

slightly cold

- biceps

and

tricepsreflex

present

-TR= 80 bpm

-no murmurs

- audiblebowel sound

of 18 from

the normal

range of 5-35bowel

sounds. Dull

sound atupper

quadrant

- BP- 120/80

mmHg

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Lower

Muscle

strength

Muscle tone

- white, equal in size,covered with cloth,

limited movement on

lower extremities

- capillary refill is 2sec

- difficulty in

performing ROM

exercises

- inability to

overcome resistance

- positive tendernesson the right hip

- slightly cold, dry to

touch , with pain

upon palpation

- patellar

reflex not

present

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BRUNSWICKLENS MODEL

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NURSING CARE PLAN

Needs/Problem

/ Cues

NursingDiagnosis

Scientific Basis Objec-tives of

Care

Nursing Action Rationale

I.PhysiologicA. Deficit

1. Impaired

PhysicalMobility

Cues:

- Difficultyin changing

position

while lyingon bed.

-Difficulty

in movingthe

extremities.

-Inability to

walk orstand alone.

-limited

range of

motion inthe

extremities.-Slowed

movement.

-Difficulty

initiatinggait.

dili

gihapon mulihok akong

tiil day as

verbalizedby the

patient.

Impaired

physical

mobility,inability

to stand

alonerelated to

skeletal

impairment to facture

of the

rightfemoral

neck

Fractures occurwhen the boneis subjected to

stress greater

that it can

absorb. Whenthe bone is

broken,

adjacentstructures are

also affected,

resulting in softtissue edema,

hemorrhage into

the muscles andjoints, joints

dislocations,

ruptured ten-

dons, severednerves, and

damaged blood

vessels. Body

organs maybeinjured by the

force thatcaused the

fracture

fragments.

After a fracture,the extremities

cannot function

properlybecause normal

functions of

muscle dependon the integrity

of the bones

which they areattached.

After 8hours ofholistic

nursing

caring

care thepatient

will be

able to:1.

demonst

rateincreasi

ng

functionof the

extremit

ies

Measures to:1. Promoteadequate

mobility of the

client.

- instruct the 5.0to keep siderails

up or raised.

- assist patientto do active

ROM exercises

on the lowerextremities.

-Provides

comfortmeasures such

as backrub.

-Encourage

patient to standor walk as

tolerated using

parallel bars.

-Supportaffected body

parts or jointsusing pillows or

rolls.

-administer pain

reliever such asareoxia as

prescribe by the

physician.-Consult with

physical or

occupationaltherapist as

indicated.

-to avoid patientsfrom falling to

sudden

movements-to improve

muscle strength

and joint mobility

-in order for the

patient to becomemore relax and

comfortable

-in order for the

muscle to be morerelax and relieves

the pain

-to relieve pain

and motionsickness

-to develop

individual

exercise ormobility program

and identify

appropriateadjunctive

devices.

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2. Risk foraltered blow

flow

Risk Factor:Immobility

Risk foraltered

blood

flow right

immobility to

fracture ofthe right

femoral

neck

The extremitiescannot function

properly after a

fracture, thus,

there isimmobility

because normalfunction of the

muscle depends

on the integrity

of the bones towhich they are

attached.

Immobility of abody part may

possiblyinterrupt thecirculation of

blood through

the circuitousnetwork of

arteries and

veins

2.enhance

blood

circulati

on

2. prevent,blood emboli

-note signs of

changes in

respiratory rate,depth use of

accessorymuscles purled-

lip breathing;

Note areas of

pallor orcynosis.

-auscultate

breath-soundsCheck if there is

a decrease oradventitiousbreath sounds

as well as

fremitus-monitor ital

signs and

cardiac rhythm

-review riskfactors

-reinforce need

for adequaterest, while

encouraging

activities withinclients

limitation

-encourage

frequentposition

changes and

DBE orcoughing

exercise.

-administer

medications as

indicated.

-to assess

respiratory in-

sufficiency

-serves as a

baseline data

-note for any

changes

-to promoteprevention

management of

risk

-to improve

circulation ofblood to the body

systems.

-to treat

underlying

conditions

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B. Overload

3. Risk foradditional

injury risk

factors:

*Loss ofskeletal

integrity* skeletal

impartment

*Abnormal

bloodprofile

*Impaired

or alteredmobility

Risk foradditional

injury

right loss

of skeletalintegrity

to fractureof the

femoral

neck.

A fractureoccurs when the

stress placed on

a bone is greater

than a bone canabsorb. Muscle,

blood vessels,nerves, tendons,

joints and other

organs maybe

injured whenfracture occurs.

This condition

may result to aloss of skeletal

integrity thatmay possiblylead to further

injury as a

result ofenvironmental

conditions

interacting with

the individualsadaptive and

defensive

resources.

3. toproduce

risk

factors

andprotect

selffrom

injury

3. for thepatients to be

free from injury

-ascertain

knowledge ofsafety needs or

injury-assess muscle

strength gross

and fine motor

coordination.-observe for

signs of injury

-identifyinterventions or

safety devices.-encourageparticipation in

rehab programs,

such as gaittraining

-promote

education

programsgeared to

increasing the

awareness ofsafety measures

-to reinforce and

import knowledgeto the patient

-to evaluate

degree or source

of risk.

-for early

detection.

-to promoteindividual safety.

-to improveskeletal integrity.

-to promote

wellness.

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DRUG THERAPEUTIC RECORD

Drug/Dose/

Frequency

/ Route

Classification/Mechanism

Indication/Contraindation/

Side effects

Principles ofCare

Treatment Evaluation

*Aromasin

25 mg T

tab-OD

* Aspirin

(aspilet) Ttab OD po

C:Antineoplastic

M: Binds to

estrogen

receptors, hasanti- estrogen

receptor-

positivesbreast cancer

cell increased

C:

Antipyriene,Analgesic,

anti-inflammatory,

Antirheumatic

, anti- platelet

salicylate,NSAID

M: Analgesic

and anti-rheumatic

effect are,

attributable tocupirine

ability to

inhibit hesynthesis of

prostaglandins

I. treatment ofadvanced breast

cancer in

postmenopaural

women whosedecreased has

progressed

FF. Tamoxifentherapy

SE:

C1: allergies,patient has not

been through

menopause yet,pregnancy and

breastfeeding

I. mild to

moderate painfever

Inflammatoryconditions

Rheumatic fever

rheumatoid

arthritis,osteoarthritis

CI: Allerge use

continuously withimpaired renal

function, chicken

pox, influenzaSE: Acute aspirin

toxicity:

hyperpnea ,tachypnea,

hemorrhage

-25mg poeveryday with

meals.

-aoid use during

premenopauseor with renal or

nepatic

dysfunction.

- (ho flashes, GI

upset, anxiety,depression, and

headache are

common.)

-give drug with

food or aftermeals if GI

upset occurs.-give drug with

fullglass of

H2O to reduce

risk or tablet orcapsule lodging

in the

esophagus- do not crush

and ensure that

patient does notchew SR

preparation

-Do not useaspirin that has

a strong vinegar

-provide restperiods

-mpnitor for

any side

effects thatmay occur

-provide a

quite andcomfortable

environment

-maintainclients

general

well-beingand hygiene

-provide

safety and

comfortmeasures to

the client.

-elevate the

leg of thepatient.

-assist clientin doing

ROM

exercises

-providecomfort

measures

such as backrub.

-provide rest

periods-do not

allow client

to dostrenuous

activities

-growth oftumor cells

were inhabit

-there is al

improvement of patients

gout ant thepatient was

able to

slight move

herextremities

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, important

mediators ofinflammation

antipyretic

effects are not

fullyunderstood

but aspirinprobably acts

in the

thermoregulat

ory center ofthe

hypothalamus

to blockeffects of

endogenouspurogen byinhibiting

synthesis of

theprostaglandin

intermediately

. Inhibition of

plateletaggregation is

attributable to

the inhibitionof platelet

synthesis of

thromboxaneA21 a potent

vasoconstricto

r and inducer

of plateletaggregation.

This effects

occurs at lowdoses and last

for the life of

the platelet(8days) These

doses inhibit

the synthesisof

Aspirin

intolerance:-shinitis

exacerbation of

broncho spasm

-nausea, dyspnea,occult blood loss,

dizziness tinnitus

like odor

-take extraprecautions to

keep this drug

out of the reach

of children

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*Clexane

0-4 cc SQOD

*lericoxib(arcoxta)

90mg T

tab OD

prostaglandin,

a patientvasodilator

and inhibitor

of platelet

aggregation.C: low-

molecularweight

heparin anti-

thrombotic

M: low-molecular

weight

heparin thatinhibits

thrombus andclot formationby checking

factor XA,

factor II a,preventing the

formation of

clots.

C: non-steroidal anti

inflammatory

drug (NSAID)M: work DY

blocking the

action of asubstance in

the body

called cyclo-oxygenare is

I. prevention of

deep veinthrombosis,

which may lead

to pulmonary

embolismfollowing hip

replacement.

Prevention ofischemic

complications.CI:hypersensitivity

use cautiously

with pregnancy orlactation history

of GI blood,

spinal top

SE: Bruishing,thrombocytopenia

, chills, fever,

pain, localirritation.

I. Acute andchronic treatment

of asteoarthritis

and RACI: Children and

adolescent under

16 yrs. Of age-severely to liver

function

SE: headache,dizziness

-give deep

subcutaneousinjections, Do

not give clexane

by IM injection

-patient shouldbe lying down.

Activities

between the leftand right

anterolateralandposterolateral

abdomen wall

-apply pressureto all injection

sites after

needle is

withdrawn-do not mix

with other

injections orinfusions

-store at room

temperaturefluid should be

clear, colorless

to pale yellow

-can be takenwith or without

food, but may

start to workquicker if taken

without food.

-do not exceedthe prescribed

dose

-maybe takenwith low dose

-provide for

safetymeasures

(electric

razor, soft

toothbrush)to prevent

injury to

patient, whois at risk of

bleeding-checkpatient for

signs of

bleeding.Monitor

blood test

-provide a

safety andcomfortable

environment

-provide restperiods

-avoid

patient fromdying

strenuous

activities

-positionclient in a

comfortable

position.-divert

patients

attention-guide

imagery

-encourage

-further

complications were

prevented.

-there is animprovemen

t of patients

gait and thepatient was

able to

slightlymove her

extremities

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* vitamin

B

complex(sangubio

n) T tab

OD

involved on

producingprostaglandins

in response to

injury or

certaindiseases.

Thereprostaglandins

, cause pain or

swelling and

inflammation.Because

NSAIDS

block theproduction of

prostaglandinsthey areeffective at

relieving pain

andinflammation

C:

Phospholipid

+multivitamins

M: mainly

function aseatalysts for

reactions

within thebody. They

contain no

useful energy,

but ascatalysts, they

serve as

essential linkand regulators

in metabolic

reaction thatrelease energy

from food.

Control theprocesses of

Constipation,

nausea, vomiting,indigestion,

flatulence

I. treatment of

chronic liver

disease , livercirrhosis and fatty

liver. For liver

protection easesof intoxication

(alcohol abuse)

CI:hypersensitivity,

lactation

SE: sedation,

dizziness, drymouth, nausea,

constipation

(76 mg daily)

aspirin.However the

combination

may carry an

increased riskof ulceration or

bleeding in thestomach or

intestine

-it is important

to tell yourdoctor or

pharmacist what

medicine youare already

taking includingthose boughtwith out

prescription and

herbal medicine

-maybe taken

with meals if GI

discomfortsoccurs.

-best to take

after meals.-initially 1

capsule every 8

hours. Followup treatment 1

capsule daily

DBE

-hotcompress is

applied to

the affected

site or area.-provide rest

periods-avoid client

to perform

strenuous

activities-provide a

safety

environment

-encourage

client to eat

foods rich invitamins

and

minerals-instruct

client to

minimizethe intake of

fatly foods

-lifestyle

modification

-exercise

regularly-impart to

patient the

importanceof taking

adequate

amount ofnutritious

-the patient

was able to

gain moreenergy and

increase its

function

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*CaCo3

(Calvit) T

tab ODevery 6pm

*Ketoprofen

(fortum)

Gel applyto right

tissue

synthesis andaid in

protecting the

integrity of

the cellsplasma

membrane;assist growth,

maintenance

of health

metabolismC: electrolyte

Antacid

M: Essentialelement of the

body; helpsmaintain thefunctional

integrity if

nervous andmuscular

system,; helps

maintain

cardiacfunction,

blood

coagulation:is an enzyme

cofactor and

affects thesecretom

activity of

endocrine and

exocrineglands;

neutralizes or

reducesgastric

acidity.

C: NSAIDNon-opioid

analgesics

M: Anti-inflammatory

I: Dietary

supplement when

calcium intake isin adequate,

treatment ofcalciumdeficiency,

prevention of

hypocalcemiaduring exchange

transfusions.

CI: Allergy, use

cautiouslywithdrawal;

dysfunction

pregnancy,lactation.

Se: Slowed heart

rate, tingling, heatwaves, local

irritation,

hypercalcemia,

and pain drymouth.

I: Acute and longtreatment of RA

and osteoarthritis.

- relief of mild tomoderate pain.

- do not

administer oral

drugs within 1-2 hour of

antacidadministration.- report loss of

appetite,

nausea,vomiting,

abdominal pain,

constipation,

dry mouth,thirst, increase

voiding.

For over-the-counter

Use: Do not

take for morethan 10 days. If

foods

- encourage

client to eat

foods rich incalcium

such asmilk,cheese.

- assist

client beexpose to

sunlight for

5-15

minutes.- impart

[atient the

importamceof takiln

adequate

amount ofnutritious

foods.

- encourage

client toexercise

regularly.

- elevate theleg of the

patient

- providerest periods

- the

strength of

patientsbones were

improved asevidencedby standing

or walking

withassistance.

- there wasan

improvemen

t of patientsgait and the

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thigh and

right kneetwice a

day.

*Dibencoside

(heraclene

)Mg tav T

tab HD

*Calmoseptine

ointment

appky toaffected

and analgesic

activity,inhibits

prostaglandin

and has anti-

bradykininand lysosomal

or membranestabilizing

actions.

C: Appetitestimulants

M: Improes

appetite andpreents faulty

nutrition and

other chronic

ailments.

C: Topicalantivirals

M: Protects,

soothes andhelps promote

CI: Significant

renal impairment,pregnancy,

lactation allergy

to ketoprofen, use

cautiously theimpaired hearing

allergies hepatic,CV and GI

conditions.

SE: Headache,

dizziness, rash,pruritus, nausea,

dyspepsia,

dysuria, renalimpairment,

dyspnea,peripheral edema.I: Poor appetite in

adult, adjuvant to

the treatment ofTB, and other

chronic ailments,

convalescence

from acuteinfection:

CI:

Hypersensitivity

I: Wounddrainage, urinary

and fecal

incontinence,bedsores, ileo

symptoms

persist contactyour HC

provider.

- the dosagemust be reduced

to patients with

liver damage.- liver functions

should be

assessed before

and regularlyduring

treatment.

- should be usedwith caution in

patients with

diabetesmellitus as their

management

may become

more difficult.

- cleanse skin,pat dry and

apply once

daily or asnecessary

- provide

comfortmeasures

- encourage

client to do

DBE- promote a

quite,relaxing and

comfortable

environment

.

- providesmall

frequent

feelings- offer foods

that are

attractive or

presentableenough to

stimulate

appetite.- instruct

patient to

eat adequatenutritious

foods.

- impart to

patient theimportance

of taking

adequatenutritious

foods.

- maintaingeneral

well-being

and hygieneof the

patient was

able toslightly

move her

extremities.

- the patientwas able to

improve her

appetite asevidenced

by eating

her meals an

time andavoiding to

skip meals.

- patientswound was

easily

healed andbedsores

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site

BID

*Acarbose(glucobay)

50 mg tab

TID withmeals

healing in

those withimpaired skin

integrity.

C: Anti-diabetic

M: Alpha-

glucosidaseinhibitor-

obtained from

thefermentation

process of a

microorganis

m; delays thedigestion of

ingested

carbohydratesheading to a

smaller

increase inblood glucose

following

meals and inglycosylated

anal, reservoirs,

moistures ofperspirations

CI:

Hypersensitivity

I: Adjunct to dietto lower blood

glucose in those

patients withtipe2 (non-insulin

dependent) DM

whosehypercalcemia

cannot be

managed alone.

CI:Hypersensitivity,

use cautiously

with renalimpairment

pregnancy and

lactation.SE:

Hypoglycemia,

abdominal pain,flatulence,

- do not use this

medication ifyou are allergic

to zinc, dime

thicone, lanolin,

cod liver oil,petroleum, jelly,

parabens,mineral oil or

wax.

- call your

doctor if youhave any signs

of redness and

warmth oroozing skin

lesions.- avoid gettingthis medication

in your mouth

or eyes. If itdoes rinse with

water right

away.

- give drug TIDwith the first

bite of each

meal.- monitor serum

glucose level

frequently todetermine drug

effectiveness

and dosage.

- inform patientof likelihood of

abdominal pain

and flatulence.- do not

discontinue this

drug withoutconsultation

from health care

provider.

patients.

- provide aclean and

comfortable

environment

.- meticulous

skin care- promote

proper

environment

alsanitation.

- impart topatient to

eat a non-

diabeticdiet.

- consult

with adietician to

establish

weight loss

program anddietary

control.

- encourageclient to do

regular

exerciseassisted by

the SO.

- impart toclient the

were

prevented.

- furthercomplicatio

ns were

beingprevented

and

appearanceof signs and

symptoms

slowly

diminished

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*Ranitidin

e (ulcin)75 mg tab

PC 3x a

day 6 am 6 pm

hemoglobin,

does notenhance

insulin

secretion, so

its effects areaddictive to

those of thesulfonyl areas,

in controlling

blood glucose.

C: Histanine,antagonists

M:

Competitivelyinhibits the

action ofhistamine Ath2 receptors

of the parietal

cells of thestomach

inhibiting

basal gastric

acid secretionthat is

stimulated by

food, insulin,histamine,

cholinergic

agonists,gastrin and

pentagastrin.

leucopenia,

anemia,thrombocytopenia

.

I: Short termtreatment of

active duodenal

ulcer, treatmentof heart burn, acid

ingestion, sourstomach.CI:

Hypersensitivity,

use cautiously theimpaired renal or

hepatic function

pregnancy.

SE: Headache,malaise,

dizziness,

tachycardia,bradycardia, rash,

constipation,

diarrhea.

- administered

oral drug withmeals and

hours.

- decrease dosesin renal and

liver failure.- if you areusing antacid,

take it exactly

as prescribed,being careful of

the time

administered.

- have regularmedical follow

up care to

evaluate yourresponse.

importance

of takingnutritious

foods.

- avoid the

client fromeating foods

rich in fatsand

cholesterol.

- providerest periods

- encourage

client to earadequate

nutritiousfoods at aregular meal

time.

- impart toclient not to

skip meals.

- position

client into acomfortable

position.

- the patient

was able tofeel more

comfortable

as evidencedresting and

sleepingcomfortably.

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3.5 SOAPIE

SOAPIE #1

S- Dili gehapon ayu malihuk akong tiil day.

O- Received patient lying on bed with head elevated to 30 degrees, awake, conscious,

coherent, communicative, without IV, with the following v/s T= 35.5 degree Celsius, P=

86 pm, R= 20 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,

slowed movement, difficulty initiating in gait.

A= Impaired physical mobility, inability to stand alone related to skeletal impairment 2

degrees to fracture on the right femoral neck.

P= To promote adequate mobility of the client.

I= Introduced name to the patient; assessed the condition, of the patient; monitored v/s,

assisted patient in doing ROM exercises, assisted patient upon doing gait training; set

siderails up; provided comfort measures such as backrub; encouraged patient to do DBE;

supported affected body parts/ joints using pillows/ rolls; consulted with physical or

occupational therapist as indicated; documented the v/s and I and O of the patient.

E= The patient was able to demonstrate increasing function of the extremities as

evidenced by standing and walking between parallel bars with assistance.

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SOAPIE #2

S= Naproblema man ko sa akong tiil day kay pila na ni ka adlaw walay lihok- lihok,

murag lain na kaayu akong feeling, as verbalized by the patient.

O= Received patient sitting up on bed, , conscious, coherent, communicative, without IV,

with 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 right femoral

neck.

P= To enhance blood circulation

I= Introduced name to the patient; assessed the condition of the patient; monitored v/s;

administered medications; noted signs of changes in respiratory rate, depth, use of

accessory muscles, pursed top breathing, areas or pallor/ cyanosis; auscultated breath

sounds if there is a decrease or adventitious breath sounds as well as fremitus; monitored

cardiac rhythm; reviewed risk factors; reinforced need for adequate rest while

encouraging activity within clients limitations; encouraged frequent position changes

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 clients extremities are warm and pink, remains intact, CRT results of 2 seconds,

no verbalization of pain, swelling on the area and demonstrates calm breathing.

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HEALTH TEACHING PLAN

Objective Content Methodology Evaluation

General Objectives:

After 3 day ofvaried learning

activities, thepatient as well asthe significant

others or family

will be able to

acquire knowledge,attitude and skills in

preventing

complications ofimmobility.

Specific Objectives:After 45 minutes

of teaching, the

patients as well asthe significant other

or family will be

able to:

1. explain the goals

of frequent position

changes.

Positioning (Goals)

* to prevent contractures

* stimulate circulation and

prevent pressure sores* prevent thrombophiebitis

and pulmonary embolism.* promote lung expansion

and prevent pneumonia

* decrease edema of the

extremities* changing position from

lying to sitting several times

a day can help preventchanges in the CVS known

as deconditioning.

*the recommendation is tochange body position at least

every 2 hours, and preferably

more frequently in patientswho have no spontaneous

movement.

Informal

discussion

-the patients was able

to explain the goal of

frequent position

changes and she wasmotivated to perform

the different positionsto become at ease from

pain or any discomfort

felt

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2. enumerate the

positions for properbody alignment

Proper Body Alignment

1. Dorsal or Supine Position.a. the head is in line with the

spine both laterally and

anteroposteriority.

b. the trunk is positioned sotraction of the hips is

minimized to prevent hipcontractive.

c. The Arms are flexed at the

elbow with the hands resting

against the lateral abdomen.d. the legs are extended in a

neutral position with the toes

pointed towards the ceiling.e. the neels are suspended in

a space between the mattressand the footboard to preventneel pressure.

f. trochanter tons are place

under the greater trochanterin the hip joint areas.

2. Side lying or lateral

position

a. the head is in line with thespine

b. the body is an alignment

and is not twistedc. the uppermost hip joint

silently forward and

supported by a pillow in aposition of slight abduction.

d. a pillow supports the arm

which is flexed of both the

elbow and shoulder joints.3. Prone position

a. the head is turned laterally

and is in alignment with therest of the body

b. the arms are abducted and

externally rotated at theshoulder joint; the elbow are

fexed

Informal

discussion

-the patient was able to

verbalize the differentproper positions for

proper body alignment

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3. discuss the

different

therapeutic

exercises

4. practice the

different kinds of

range of motion

c. a small flat support is

placed under the pelvisextending from the level of

the umbilicus to the upper

third of the thigh.

d. the lower extremitiesremain in a neutral position.

Therapeutic Exercises

1. Positive range of motion

exercise

2. active assistive range ofmotion

3. active range of motion

4. Resistive exercise5. Isometric or muscle

settings exercise.

Range of motion

* Flexion extension of

shoulder.* Fexion extension of elbow

* adduction-abduction of

shoulder.

* Pronation-supination ofelbow.

* Dorsiflexion and palmar

flexion of wrist.* Ulnar-radial deviation of

wrist.

* Adduction-abduction andopposition of thumb

* Adduction-abduction,

flexion-hyper extension of

fingers.*Dorsiflexion-Plantarflexion,

Eversion of the ankle.

* Flexion-extension;adduction-abduction of toes

* Adduction-abuction;

internal rotation or externalrotation of the hip.

* Flexion-hyperextension;

rotation of cervical spine

Informal

discussion

and

demonstration

Informal

discussion

anddemonstration


discuss the different

therapeutic exercises

and was able todemonstrate them with

assistance

The patient was able to

practice the different

kinds of ROM exercisewith assistance

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5. participate

attentively to the

discussion

* Lateral bending of cervical

spine.

Informal

discussion

anddemonstration


listen attentively and

asked some questionrelated to the discussion

and she was also able toparticipate during

demonstration.

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V. Evaluation and Recommendation

Prognosis of the patient

After 3 days of intervention, the student nurse observed certain changes from the

patient. The patient reports decreased pain with elevation, ice and analgesic. The patient

also exhibits unlabored respirations; alert and oriented, a febrile, using affected extremity

for light activity as allowed, no signs of neurovascular compromise, v/s stable; urine

output adequate and no calf pain reported: Homans sign negative. The patient also

performs active ROM correctly, hygiene and dressing practices with minimal assistance

and denies acute symptoms of stress; reports working through feelings about trauma.

Recommendation

As a researcher in this case study, the student nurse recommends the patient to

adjust in usual lifestyle and responsibilities to accommodate limitations imposed by

fracture and to prevent recurrent fractures safety considerations, avoidance of fatigue

and proper footwear. The patient is instructed about exercises to strengthening upper

extremity muscles

If crutch walking is planned, methods of safe ambulation walker, crutches, care,

emphasizes instructions concerning amount of weight bearing that will be permitted on

fractured extremity, teaches symptoms needing attention, such as numbness, decreased

function, increased pain and elevated temperature and explains basis for fracture

treatment and need for patient participation in therapeutic regimen. The patient and the

family were also informed that the patient must have an adequate balanced diet to

promote bone and soft tissue healing.

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VI. Evaluation and Implication of this case study to:

Nursing Practice

The result of this case study would provide the student nurse with sufficient

knowledge, attitude and skills towards the management of patients with fracture on the

right femoral neck. This study would help the student nurse in providing a higher quality

of care of patients with the same condition. It is important that the proper and ideal

managements and interventions are done in order to give a more holistic approach and

optimum care to clients with fracture on the right femoral neck. This would ensure the

timely healing of injury and the prevention of complications.

Nursing Education

Education can promote enhancement of professionalism through an on- going

learning process, whether self- motivated, people- oriented and having a commitment to

the organization, nurses are likely to become well respected through the formal

educational programs. Through this case study, it is important to know all areas of patient

are both knowledge and skills to manage effectively in all aspects of their professional

nursing practice.

Nursing Research

Nursing research is essential for the development of scientific knowledge that

enables nurses to provide evidenced-based health care. Broadly nursing is accountable to

society for providing quality, cost effective care and for seeking ways to improve that

care. More specifically, nurses are accountable to their patients 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 contribute to the development of the case study of fracture

its prevention, causes, signs and symptoms, and nursing management. Hopefully, this

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case study will lead to development of new skills and new approaches to the care of

patients with fracture on the right femoral neck. This case study could also as basis for

related study and will provide facts for further research in aiming for the improvement of

these patients.

VII Referral and Follow-Up

The patient was informed to have a continuous appointment with the

Rehabilitation Care Program Health Care providers after discharge. The patient was

encouraged for follow-up medical supervision to monitor for union problems.

VIII Bibliography

Bare, Brenda I. and Smeltzer, Suzzane C., Textbook of Medical-Surgical Nursing.

10th 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: Addison-

Weatleylongman, Incorporated. 1998.

Marleb, Elaine N. Essential of Human Anatomy and Physiology. 7th Edition.

Singapore. Pearson Education South Asia Pte. Ltd. 2004.

Potter, Patricia and Perry, Anne. Fundamentals of Nursing. 6 th 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).

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