CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

I. INTRODUCTION A. Definition Dislocation of the hip is a common injury to the hip joint. Dislocation occurs when the ballshaped head of the femur comes out of the cupshaped acetabulum set in the pelvis. This may happen to a varying degree. A dislocated hip is a condition that can either be congenital or acquired. And the dislocation can be posterior or anterior.

Nine out of ten hip dislocations are posterior. The affected limb will be shortened and internally rotated in this case. In an anterior dislocation the limb will not be lengthened as noticeably and will be externally rotated.

Congenital hip dislocation must be detected early when it can be easily treated by a few weeks of traction. If it is not detected, the child's hip may develop incorrectly seen when the child begins to walk. If one hip is affected the child will have a limp and lurch and with bilateral dislocation there will be a waddling gait. On physical exam, with the baby in the supine position, the examiner flexes the hips and knees both to 90 degrees, and, holding the knees, pushes gently downward, which may induce a posterior dislocation or subluxation. Keeping the baby in this 90 degree flexed position, the examiner then externally rotates the thighs. A normal infant will demonstrate no evidence of dislocation. It can also be detected with the Galeazzi test. Congenital hip dislocation is much more common in girls than boys.

Acquired hip dislocations are extremely painful and commonly occur during any kind of accidents. They may be treated by surgical realignment and traction.

CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

B. Morbidity and Mortality Hip dislocations are relatively uncommon during athletic events. Injuries to small joints (e.g., finger, wrist, ankle, and knee) are much more common. However, serious morbidity can be associated with hip dislocations, making careful and convenient diagnosis and treatment important for the sports medicine physician. Large-force traumas (e.g., motor vehicle accidents, pedestrians struck by automobiles, falling from trees/infrastructures) are the most common causes of hip dislocations. This type of injury is also associated with high-energy impact athletic events (e.g., football, rugby, water skiing, alpine skiing/snowboarding, gymnastics, running, basketball, race car driving, equestrian sports). Hip dislocations are either anterior or posterior, with posterior hip dislocations comprising the majority of traumatic dislocations. C. Incidence and Prevalence Congenital dislocation of the hip also occurs and is termed developmental dysplasia of the hip (DDH). The annual incidence of DDH is approximately 2-4 cases per 1000 births; approximately 80-85% of the affected individuals are girls.

D. Reasons for choosing the disease We choose posterior hip dislocation (right) particularly acquired dislocation as our case to be studied because we want each and all of us whether men or women in any ages to be aware of the possible complications of the disease and the management of patient with such musculoskeletal disorder.

CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

II. OBJECTIVES A. General Objectives Within 1 week of exposure at Philippine Orthopedic Center (POC) childrens ward, we, BSN IV-A Group 2 student nurses from World Citi Colleges (WCC) Antipolo campus aim to use our knowledge, skills, and attitude to render holistic care to our client as well as convey information with regards to the promotion and maintenance of health in order for our client to achieve possible wellness state and carry out activities of daily living.

B. Specific Objectives

Knowledge To identify the problem of the patient To formulate exact and effective nursing care plan to the patient To review the normal anatomy and physiology of the musculoskeletal system Skills To improve our ability to handle patient with Balance Skeletal Traction (BST) and to enhance our skills to the applications of our knowledge To provide health teachings and nursing interventions Attitude To establish good nurse-patient relationship with our client and to improve the level of our communications to our patient and staff nurses To build rapport with the patient

CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

III. SIGNIFICANCE OF THE STUDY

To patient with hip dislocation: To acquire necessary knowledge related to their health condition To be able to manage them when pain and abnormalities related to the disease occurs To be able to understand the treatment that the health care providers offer in their recovery process To promote prevention of complications

To staff nurses: To properly indentify the needs of the patient To be able to render nursing care and information to the patient through the application of the nursing skills To apply their knowledge and skills when caring to patients with hip dislocation

To nursing students: To properly assess the patients who are manifesting the disease To be knowledgeable in the treatment they are providing them To be able to provide more health teachings in the prevention of the disease

CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

IV. SCOPE AND DELIMITATIONS

We had our duty at Philippine Orthopedic Center (POC) childrens ward, in Banawe street Quezon City last August 13-17, 2012. We were able to assess the patients condition but only for 2 days and 1 hour each day, it is not really enough to assess due to lack of time but through keen observations we were able to interview for somehow the father of our patient and with the help of the patients chart and records. Another thing, our patient was not able to talk in neither tagalog nor English because he is pure bisaya. But fortunately, we are able to gather certain information needed to formulate this case study. The study lasted about 2 hours of exposure in total with the patient. Our client R.T. is suffering from acquired posterior hip dislocation (right) which we will be dealing with this study.

CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

V. NURSING HISTORY
Name: Age: Address: Sex: Weight: Height: Birthday: Birth Place: Religion: Date of Admission: Hospital #: Hospital Ward: Referred By: Referred To: Reason for Referral: Diagnosis: Chief Complaint: R.T. 8 Years Old Masbate City Male 33 Lbs/ 15 Kg 45 Inches February 4, 2004 Masbate Roman Catholic August 8, 2012 @ 2:30pm 722273 Cw-C3 Dr. Aujero Dr. Canete For evaluation and management of Seizure Episodes (08-12-12) Posterior Hip Dislocation (Right) Inability to walk

CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

A. HISTORY OF PRESENT ILLNESS Two weeks prior to consult, patient fell from a high tree. Patient was unable to ambulate/ walk since the incident. Consult was done with a manghihilot where massage and other unrecalled management were done. B. PAST MEDICAL HISTORY Unrecalled

C. PAST ILLNESS Unrecalled

D. FAMILY HISTORY (-) HPN (-) DM

E. PERSONAL & SOCIAL HISTORY: Patient is the 2nd child in a group of 5

Currently Grade 1 student Patient lives with father and grandmother in Masbate where mother resides in Metro Manila F. PHYSICAL EXAMINATION AND ASSESSMENT A. General Survey Carried by mother Not in cardio-respiratory distress

CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

B. Initial Vital Signs B/P: 100/60 mmHg RR: 25 cpm PR: 107 bpm Temp: 37.6 C

C. Other Physical Findings S: O: (+) LOM of the right hip towards all planes (+) tenderness on right hip Prominence of right hip Leg length discrepancy right shorter than left Inability to ambulate Right hip fixed in flexion, adduction (+) LOM of right hip towards all planes (+) Leg length discrepancy right shorter than left A: P: Posterior Hip Dislocation Right for BST (balance skeletal traction) right to aid reduction

CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

VII. THEORETICAL FRAMEWORK

Erik Erikson's Theory of Psychosocial Development Theory Erik Erikson's theory of psychosocial development is one of the best-known theories of personality in psychology. Much like Sigmund Freud, Erikson believed that personality develops in a series of stages. Unlike Freud's theory of psychosexual stages, Erikson's theory describes the impact of social experience across the whole lifespan. One of the main elements of Erikson's psychosocial stage theory is the development of ego identity. Ego identity is the conscious sense of self that we develop through social interaction. According to Erikson, our ego identity is constantly changing due to new experiences and information we acquire in our daily interactions with others. In addition to ego identity, Erikson also believed that a sense of competence motivates behaviors and actions. Each stage in Erikson's theory is concerned with becoming competent in an area of life. If the stage is handled well, the person will feel a sense of mastery, which is sometimes referred to as ego strength or ego quality. If the stage is managed poorly, the person will emerge with a sense of inadequacy. In each stage, Erikson believed people experience a conflict that serves as a turning point in development. In Erikson's view, these conflicts are centered on either developing a psychological quality or failing to develop that quality. During these times, the potential for personal growth is high, but so is the potential for failure.

CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

Psychosocial Stage 1 - Trust vs. Mistrust The first stage of Erikson's theory of psychosocial development occurs between birth and one year of age and is the most fundamental stage in life. Because an infant is utterly dependent, the development of trust is based on the dependability and quality of the child's caregivers. If a child successfully develops trust, he or she will feel safe and secure in the world. Caregivers who are inconsistent, emotionally unavailable, or rejecting contribute to feelings of mistrust in the children they care for. Failure to develop trust will result in fear and a belief that the world is inconsistent and unpredictable.

Psychosocial Stage 2 - Autonomy vs. Shame and Doubt The second stage of Erikson's theory of psychosocial development takes place during early childhood and is focused on children developing a greater sense of personal control. Like Freud, Erikson believed that toilet training was a vital part of this process. However, Erikson's reasoning was quite different than that of Freud's. Erikson believe that learning to control one's bodily functions leads to a feeling of control and a sense of independence. Other important events include gaining more control over food choices, toy preferences, and clothing selection. Children who successfully complete this stage feel secure and confident, while those who do not are left with a sense of inadequacy and self-doubt.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

Psychosocial Stage 3 - Initiative vs. Guilt During the preschool years, children begin to assert their power and control over the world through directing play and other social interactions. Children who are successful at this stage feel capable and able to lead others. Those who fail to acquire these skills are left with a sense of guilt, self-doubt, and lack of initiative.

Psychosocial Stage 4 - Industry vs. Inferiority This stage covers the early school years from approximately age 5 to 11. Through social interactions, children begin to develop a sense of pride in their accomplishments and abilities. Children who are encouraged and commended by parents and teachers develop a feeling of competence and belief in their skills. Those who receive little or no encouragement from parents, teachers, or peers will doubt their abilities to be successful.

Psychosocial Stage 5 - Identity vs. Confusion During adolescence, children explore their independence and develop a sense of self. Those who receive proper encouragement and reinforcement through personal exploration will emerge from this stage with a strong sense of self and a feeling of independence and control. Those who remain unsure of their beliefs and desires will feel insecure and confused about themselves and the future.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

Psychosocial Stage 6 - Intimacy vs. Isolation This stage covers the period of early adulthood when people are exploring personal relationships. Erikson believed it was vital that people develop close, committed relationships with other people. Those who are successful at this step will form relationships that are committed and secure. Remember that each step builds on skills learned in previous steps. Erikson believed that a strong sense of personal identity was important for developing intimate relationships. Studies have demonstrated that those with a poor sense of self tend to have less committed relationships and are more likely to suffer emotional isolation, loneliness, and depression.

Psychosocial Stage 7 - Generativity vs. Stagnation During adulthood, we continue to build our lives, focusing on our career and family. Those who are successful during this phase will feel that they are contributing to the world by being active in their home and community. Those who fail to attain this skill will feel unproductive and uninvolved in the world.

Psychosocial Stage 8 - Integrity vs. Despair This phase occurs during old age and is focused on reflecting back on life. Those who are unsuccessful during this stage will feel that their life has been wasted and will experience many regrets. The individual will be left with feelings of bitterness and despair.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

Those who feel proud of their accomplishments will feel a sense of integrity. Successfully completing this phase means looking back with few regrets and a general feeling of satisfaction. These individuals will attain wisdom, even when confronting death.

Based on Ericksons psychosocial developmental theory, R.T. in early school years classified under Industry vs. Inferiority which explains that the most important event are through social interactions, that children begin to develop a sense of pride in their accomplishments and abilities. And develop a feeling of competence and belief in their skills. Those who receive little or no encouragement from parents, teachers, or peers will doubt their abilities to be successful.

In the case of R.T., because of social interactions to his peers his sense of pride to do accomplishments and to prove his abilities he climb a high alateris tree.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

VIII. 13 Areas of Assessment I. Social Status Demographic Data R.T. is an 8-year old male, currently an elementary grade 1 student Born on February 4, 2004. He is the second child of the group of five. The family resides in Masbate City but his mother is currently working in metro manila She has 5 offspring, 2 are working already while the remaining are still studying.

Socio-Economic Factor R.T. belongs in an extended family, Roman Catholic and currently a grade 1 student, while his father is a construction worker and his mother is a kasambahay residing in Metro Manila. Their family income is 11,000.00 pesos below per month which according to his father, it is just enough to meet their basic needs and sometimes it lacks.

Environmental Factor R.T. resides in a medium size house made up of concrete and some plywood with 1 small room and 2 small windows, 1 in the kitchen and 1 in sala which resulted to poor ventilation. The house is located in a congested area in Masbate. Artesian well is their primary source of water. Their excreta disposal is with water carriage.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

Erick Ericksons Psychosocial Development Theory Psychosocial Stage 4 - Industry vs. Inferiority This stage covers the early school years from approximately age 5 to 11. Through social interactions, children begin to develop a sense of pride in their accomplishments and abilities. Children who are encouraged and commended by parents and teachers develop a feeling of competence and belief in their skills. Those who receive little or no encouragement from parents, teachers, or peers will doubt their abilities to be successful.

Based on Ericksons psychosocial developmental theory, R.T. in early school years classified under Industry vs. Inferiority which explains that the most important event are through social interactions, that children begin to develop a sense of pride in their accomplishments and abilities. And develop a feeling of competence and belief in their skills. Those who receive little or no encouragement from parents, teachers, or peers will doubt their abilities to be successful.

In the case of R.T., because of social interactions to his peers his sense of pride to do accomplishments and to prove his abilities he climb a high alateris tree.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

II. Mental Status R.T. is conscious and coherent, oriented to time and date, he is a grade 1 student and is able to read and write and follow instructions, able to maintain eye to eye contact. He is open is such a way that he will cry when he is hungry, thirsty and something that is aching, he just nod when we ask him. But he is unable to converse thoroughly with the student nurses because of language barrier, but he understands common Tagalog.

During assessment and interview, his father will translate all our questions about what really happened to him and he will able to tell the story, then his father will again translate. This shows that his memories are still intact.

III. Emotional Status Prior to hospitalization, according to the father of R.T., he is very cheerful; he loves to play with his neighbor children, brothers and sisters. After the accident, the first 5 days of hospitalization R.T. became very irritable and always cries due to pain, and cant able to talk as stated by the father.

IV. Sensory Perception Vision In assessing the vision, patient is instructed to look straight to observe the general appearance of his eyes.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

Eyes are almond in shape, irises are brownish in color, and scleras are whitish in color, eyebrows and eyelashes are equally distributed. His conjunctiva is pale and moist.

With the use of a penlight. Pupils are assessed; Pupils are equally round and reactive to light accommodation. The patient does not use eyeglasses or contact lenses.

Visual acuity is assessed by asking the patient to read the bisaya word written in a piece of paper with a approximately font size of 12 about 3 feet away from him, using the right eye first then left eye and then both eyes. Then test was repeated but this time it will be only 1 foot away from him using the same procedure. Different words were use written in different paper in every test. R.T. read all the samples during the test.

Smell Clients nose has no deviation in terms of shape and size; nose is pointed and with some discharges was seen during assessment due to his cold. Before the next procedure, permission was asked to the father of our patient, using a peel of orange, without the patients knowledge, we ask him to identify the sample by smelling. After smelling he did not identified the fruit. Test shows that there are obstructions identified in the sense of smell.

Hearing General appearance of R.T.s ears were parallel, symmetrically proportional to the size of the head, bean shaped, firm cartilage and with a presence of cerumen and in the outer part it is not clean.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

In assessing the hearing acuity of the patient, R.T. is instructed by his father to repeat the words that will be whisper at a distance of two feet away on the left ear first, then right ear after the test, she was able to repeat the whispered words.

Taste Patients lips were dry, symmetrical in shape; tongue is whitish in color, there is presence of tooth decays up and down, and with teeth loss, with signs of gingivitis due to presence of teeth decays, buccal areas are moist. We assess using a tongue depressor. To assess her sense of taste, Patient is asked to do some test. She was asked to taste a pinch of sugar without knowing the sample is. After the test R.T. identified the sample correctly as he stated matam-is.

Touch In assessing patients sense of touch, he was asked to close his eyes, and a piece of wet cloth was stroke to his upper extremities, and he stated matugnaw! that he felt a sensation of wet and cold on his skin.

V. Motor Ability

Before the accident, R.T. was an active child that he could do things that any other children do. He actually walks meters by meters everyday to go to school.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

In present situation, he is in Balance Skeletal Traction (BST) so when we instructed him to move his lower extremities and do isometric exercise (e.g. moving the fingers of the affected toe and relax and contract of the affected leg) but before that, we instructed first to do it on his unaffected leg.

VI. Temperature Date August 14, 2012 August 16, 2012 Time 2: 00 pm 2:00 pm Temperature 38.7 C 36.6 C Location axilla axilla

R.T. was febrile on August 14, 2012; temperature is at 38.7 C taken at Right axilla. And on August 16, 2012 R.T. was afebrile with 36.6 C also taken at Right axilla.

VII. Respiratory Status Date August 14, 2012 August 16, 2012 Time 2: 00 pm 2:00 pm RR cpm 24 17

On the first day of assessment, his chest expansion was symmetrical. But rhythm pattern is fast due to his condition, he is febrile and experiencing pain at that moment.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

He has an ineffective airway clearance due to colds that result to an ineffective breathing pattern.

Lungs were auscultated for adventitious sounds, after auscultation, no adventitious sounds were heard.

Second day of assessment, his chest expansion was symmetrical. Rhythm pattern is regular.

VIII. Circulatory Status Date August 14, 2012 August 16, 2012 Time 2: 00 pm 2:00 pm PR bpm 79 68

Taken at radial pulse, her capillary refill is within 2-3 seconds taken at right forefinger, and as indicated to his chart he is prescribed with ferrous sulfate and undergoing a nutritional program to manage malnutrition.

Pulse is not easily palpable.

Blood Pressure Date August 14, 2012 August 16, 2012 Time 2: 00 pm 2:00 pm BP 90/60 100/70

Blood pressure was taken at his left brachial artery, negative for peripheral edema.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

IX. Nutritional Status As we interview the father of R.T. he claimed that sometimes they just eat once a day only and if lucky, twice a day. Their normal viand is noodles. And as R.T. is in school, he always eats chichiria even when he is at home. Weight: 33 Lbs/ 15 Kg Height: 45 Inches

Formula: BMI = (Weight in Pounds / (Height in inches) x 703 Computation: BMI =33lbs/ (45inches) x 703 BMI = (33lbs/2025 inches) x 703 BMI =0.0162963 x 703 BMI = 11.46 BMI Categories:

Underweight = <18.5 Normal weight = 18.524.9 Overweight = 2529.9 Obesity = BMI of 30 or greater

Therefore, R.T. with a BMI of 11.46 is under the category of underweight.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

X. Elimination Status R.T. according to his father he defecates once a day without difficulty. He urinates 4 to 5 times a day. In his urinalysis urine is yellow in color transparency is hazy. During assessment he is diaper due to his condition and he is in balance skeletal traction.

XI. Reproductive System According to the father of R.T. he is not yet circumcised. XII. Physical Rest and Comfort Before hospitalization R.T. sleeps before 7 pm because they have no electricity and wakes up at 5 am to prepare to for school at 6 am. During hospitalization, most of the time R.T. is as sleeps due to no other activities to do. XIII. State of skin and appendages Skin As we assessed R.T. he has poor skin turgor, dry and dark in color. Hair Presences of dandruff were seen during assessment, no lice were seen, and patient has thin short straight hair. Nails During the assessment, nails are bluish and pale in color, no signs of clubbing, no excess nor lacking. Extremities The patient was assessed for edema or any inflammation in the affected area.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

IX. ANATOMY AND PHYSIOLOGY

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

Region The bones of the hip region are the hip bone (or innominate bone) and the femur (or thigh bone). Prominent palpable bony structures of the hip bone include the iliac crest, the anterior superior (ASIS) and posterior superior iliac spines (PSIS), the posterior inferior iliac spine (PIIS), the five or so tubercles and the lower lateral borders of the sacrum, and the ischial tuberosity ("sitting bone"). Proximally the femur is largely covered by muscles and, as a consequence, the greater trochanter is often the only palpable bony structure. Distally on the femur some more palpable bony structures are the condyles. Articulation

Radiograph of a healthy human hip joint The hip joint is a synovial joint formed by the articulation of the rounded head of the femur and the cup-like acetabulum of the pelvis. It forms the primary connection between the bones of the lower limb and the axial skeleton of the trunk and pelvis. Both joint surfaces are covered with a strong but lubricated layer called articular hyaline cartilage. The cuplike acetabulum forms at the union of

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

three pelvic bones the ilium, pubis, and ischium. The Y-shaped growth plate that separates them, the triradiate cartilage, is fused definitively at ages 1416. It is a special type of spheroidal or ball and socket joint where the roughly spherical femoral head is largely contained within the acetabulum and has an average radius of curvature of 2.5 cm. The acetabulum grasps almost half the femoral ball, a grip augmented by a ring-shaped fibrocartilaginous lip, the acetabular labrum, which extends the joint beyond the equator. The head of the femur is attached to the shaft by a thin neck region that is often prone to fracture in the elderly, which is mainly due to the degenerative effects of osteoporosis.

Muscles and movements The hip muscles act on three mutually perpendicular main axes, all of which pass through the center of the femoral head, resulting in three degrees of freedom and three pair of principal directions: Flexion and extension around a transverse axis (left-right); lateral rotation and medial rotation around a longitudinal axis (along the thigh); and abduction and adduction around a sagittal axis (forwardbackward) ; and a combination of these movements (i.e. circumduction, a compound movement in which the leg describes the surface of an irregular cone). It should be noted that some of the hip muscles also act on either the vertebral joints or the knee joint, that with their extensive areas of origin and/or insertion, different part of individual muscles participate in very different movements, and that the range of movement varies with the position of the hip joint. Additionally, the inferior and superior gemelli may be termed triceps coxae together with the obturator internus, and their function simply is to assist the latter muscle.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

The movement of the hip joint is thus performed by a series of muscles which are here presented in order of importance with the range of motion from the neutral zero-degree position indicated: Lateral or external rotation (30 with the hip extended, 50 with the hip flexed): gluteus maximus; quadratus femoris; obturator internus; dorsal fibers of gluteus medius and minimus; iliopsoas (including psoas major from the vertebral column); obturator externus; adductor magnus, longus, brevis, and minimus; piriformis; and sartorius. Medial or internal rotation (40): anterior fibers of gluteus medius and minimus; tensor fascia latae; the part of adductor magnus inserted into the adductor tubercle; and, with the leg abducted also thepectineus. Extension or retroversion (20): gluteus maximus (if put out of action, active standing from a sitting position is not possible, but standing and walking on a flat surface is); dorsal fibers of gluteus medius and minimus; adductor magnus; and piriformis. Additionally, the following thigh muscles extend the hip: semimembranosus, semitendinosus, and long head of biceps femoris. Flexion or anteversion (140): iliopsoas (with psoas major from vertebral column); tensor fascia latae, pectineus, adductor longus, adductor brevis, and gracilis. Thigh muscles acting as hip flexors: rectus femoris and sartorius. Abduction (50 with hip extended, 80 with hip flexed): gluteus medius; tensor fascia latae; gluteus maximus with its attachment at the fascia lata; gluteus minimus; piriformis; and obturator internus. Adduction (30 with hip extended, 20 with hip flexed): adductor magnus with adductor minimus; adductor longus, adductor brevis, gluteus maximus with its attachment at the gluteal

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

tuberosity; gracilis(extends to the tibia); pectineus, quadratus femoris; and obturator externus. Of the thigh muscles, semitendinosus is especially involved in hip adduction. Capsule The capsule attaches to the hip bone outside the acetabular lip which thus projects into the capsular space. On the femoral side, the distance between the head's cartilaginous rim and the capsular attachment at the base of the neck is constant, which leaves a wider extracapsular part of the neck at the back than at the front. The strong but loose fibrous capsule of the hip joint permits the hip joint to have the second largest range of movement (second only to the shoulder) and yet support the weight of the body, arms and head. The capsule has two sets of fibers: longitudinal and circular. The circular fibers form a collar around the femoral neck called the zona orbicularis. The longitudinal retinacular fibers travel along the neck and carry blood vessels.

Ligaments The hip joint is reinforced by five ligaments, of which four are extracapsular and one intracapsular. The extracapsular ligaments are the iliofemoral, ischiofemoral, and pubofemoral ligaments attached to the bones of the pelvis (the ilium, ischium, and pubis respectively). All three strengthen the capsule and prevent an excessive range of movement in the joint. Of these, the Y-shaped and twisted iliofemoral ligament is the strongest ligament in the human body. In the upright position, it prevents the trunk from falling backward without the need for muscular activity. In the sitting position, it becomes relaxed, thus permitting the pelvis to tilt backward into its sitting position. The ischiofemoral

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

ligament prevents medial rotation while the pubofemoral ligament restricts abduction in the hip joint. The zona orbicularis, which lies like a collar around the most narrow part of the femoral neck, is covered by the other ligaments which partly radiates into it. The zona orbicularis acts like a buttonhole on the femoral head and assists in maintaining the contact in the joint. The intracapsular ligament, the ligamentum teres, is attached to a depression in the acetabulum (the acetabular notch) and a depression on the femoral head (the fovea of the head). It is only stretched when the hip is dislocated, and may then prevent further displacement. It is not that important as a ligament but can often be vitally important as a conduit of a small artery to the head of the femur. This arterial branch is not present in everyone but can become the only blood supply to the bone in the head of the femur when the neck of the femur is fractured or disrupted by injury in childhood.

Blood Supply The hip joint is supplied with blood from the medial circumflex femoral and lateral circumflex femoral arteries, which are both usually branches of the deep artery of the thigh(profunda femoris), but there are numerous variations and one or both may also arise directly from the femoral artery. There is also a small contribution from a small artery in the ligament of the head of the femur which is a branch of the posterior division of the obturator artery, which becomes important to avoid avascular necrosis of the head of the femur when the blood supply from the medial and lateral circumflex arteries are disrupted (e.g. through fracture of the neck of the femur along their course). The hip has two anatomically important anastomoses, the cruciate and the trochanteric anastomoses, the latter of which provides most of the blood to the head of the femur. These anastomoses exist between the femoral artery or profunda femoris and the gluteal vessels.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

X. PATHOPHYSIOLOGY

Risk factors: Age Gender Weakness (malnutrition) Lack of safety education/precaution

Etiologic/causative factors Accident caused by: High alateris tree

Organ/system affected Skeletal and muscular system Inflammation of muscle and dislocation of bones Specifically on right posterior hip

Medical diagnosis Posterior Hip dislocation (right)

Laboratory/ diagnostic done x- ray

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

XI. NURSING MANAGEMENT A. Laboratory Test Name: R.T. COMPONENT Hemoglobin Mass Hematocrit Leukocyte Count Differential Count Segmenters Lymphocytes Monocytes Reticulocytes Platelet count Coagulation Studies Prothrombin Time % activity INR Activated PTT Blood Type RH Typing CRP Semi-quantitative CRP Reactive 24 < 6mg/L 22-45 secs 11-15 secs Clotting Time (Lee & White) Bleeding Time (Ivys Method) 5-15 mins 525 0.94 0.05 0.01 0.50-0.70 0.20-0.40 0.00-0.07 0.5-2.0% 150-400x10^9/L RBC Morphology ESR WESTERGREN METHOD Children 28 0-10 mm/hr RESULT (MALE) 140 0.47 37.10 Lab no. 61 NORMAL RANGE 127-183 g/L 0.37-0.54 4.5-10 x 109/L Date: 08/12/2012 COMPONENT RESULT NORMAL RANGE INDICES 98 82-92 fl MVC 29 28-32 pg MCH 30 32-38 % MCHC

1-7 mins

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

URINALYSIS

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B. Nursing Care Plan ASSESSMENT NURSING DIAGNOSIS - Acute pain r/t dislocation of right posterior hip with inflammation PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: R.T. is crying when we do bed bathing. makulog! Objective: -facial grimace -guarding behaviour -Pain Scale of 6 -Respiratory Rate: 24

After 4 hours of nursing intervention patient will decrease pain from pain scale of 6 to 4.

- determine and document presence of possible cause/s of pain. ** Inflammation in the affected site. - Observe signs of inflammation in the affected site.

- To rule out worsening of underlying condition

After 4 hours of nursing intervention patient decreased pain from pain scale of 6 to 4.

- Observations may or may not be congruent with verbal reports indicating need for further evaluation and an indication of infections. - Vital signs usually altered in acute pain. -repositioning and providing quiet environment promotes nonpharmacoligal pain management -for the management of pain.

Goal was met.

-Monitor clients vital signs. -provide comfort measures

-collaborate in treatment of underlying condition causing pain and proactive management of pain. Give analgesic (ibuprofen) as prescribed by the physician

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

SUBJECTIVE:

Hyperthermia r/t After 1 of pangalawang araw inflammation on site nursing intervention nya nang nilalagnat of the dislocation. patients as verbalized by the temperature will father of the patient. decrease from 38.7c to 36.5c OBJECTIVE: Temp: 38.7 c RR: 24 cpm Warm to touch Flushed skin

-maintain bed rest -promote surface cooling by means of tepid sponge bath -record all sources of fluid loss such as urine, vomiting and diarrhea - Evaluate the affected leg for inflammation or edema.

-to reduce metabolic demands and oxygen consumption -to decrease temperature by means through evaporation and conduction

-to monitor fluid and electrolyte loses

- Observations may or may not be congruent with verbal reports indicating need for further evaluation and an indication of infections. -to facilitate fast recovery

-administer antipyretic (paracetamol) as prescribed by doctor

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

C. Drug Study

Generic name Coamoxiclav : 312.5 mg/5mL 8mL q12h x 7days

Brand Name Amoclav

Classific ation Bacterici dal

Indication Lower respiratory tract infections, otitis media, sinusitis, skin & soft tissue infections, UTI, pre & post-surgical procedures, bone & joint, O&G infections, dental infections.

Contraindicati on History of penicillin hypersensitivity .

Mechanism Of action

Adverse reaction Allergic reactions - itching, rashes, fever angioneuroticoedema - anaphylaxis (1 in 50,000 to 100,000) Cross-allergy with other penicillins Partial cross-allergy with cephalosporins (10%) Hepatitis, cholestatic jaundice Erythema multiforme (including StevensJohnson) Toxic epidermal necrolysis; exfoliative dermatitis Diarrhea, vomiting Rashes Neutropenia Anaemia

Nursing considerations - Patients must ensure they take the full course of the medicine. - Assess respiratory status. - Observe for anaphylaxis. - Ensure that the patient has adequate fluid intake during any diarrhea attack. - The medicine must be taken in equal doses around the clock to maintain level in the blood.

Inhibits enzymes involved in formation of peptidoglycan layer of bacterial Superinfections cell wall involving No effect on Pseudomonas or human cell walls candida. Bactericidal; only Pregnancy & works on dividing lactation bacteria Well absorbed enterally Clavulanic acid inhibits bacterial -lactamase

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

Generic Name Acetaminophen (Paracetamol) 250mg/5ml 8ml q4h PRN for temperature 37.8C

Classification antipyretics, nonopioid analgesics

Mechanism of Action Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS

Specific Indication Mild pain Fever

Side Effects Hema: hemolytic anemia, neutropenia, leukopenia, pancytopenia. Hepa: jaundice Metabolic: hypoG GI: HEPATIC FAILURE, HEPATOTOXICITY (overdose)GU: renal failure (high doses/chronic use). Derm: rash, urticaria.

Nursing Implications BEFORE: ~ Advise parents or caregivers to check concentrations of liquid preparations. Errors have resulted in serious liver damage. ~ Assess fever; note presence of associated signs (diaphoresis, tachycardia, and malaise). DURING: ~ Adults should not take acetaminophen longer than 10 days and children not longer than 5 days unless directed by health care professional. ~ Advise mother or caregiver to take medication exactly as directed and not to take more than the recommended amount. AFTER: ~ Advise patient to consult health care professional if discomfort or fever is not relieved by routine doses of this drug or if fever is greater than 39.5C (103F) or lasts longer than 3 days.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

Drug name Ibuprofen 210mg/5mL 8mL BID PRN for pain

Action Unknown . May inhibit prostagla ndin synthesis, to produce antiinflamma tory, analgesic, and antipyreti c effects.

Indication Ibuprofen contains the active ingredient ibuprofen, which belongs to a group of medicines called nonsteroidal antiinflammatory drugs (NSAIDs). It works by blocking the action of a substance in the body called cyclo-oxygenase. Cyclo-oxygenase is involved in the production of various chemicals in the body, some of which are known as prostaglandins. Ibuprofen is therefore used to relieve pain and inflammation.

Adverse effects

Contraindication

CNS Contraindicated in patients Headache, dizziness, nervousness, aseptic meningitis. hypersensitive to drug and in those CV with angioedema, Peripheral edema, fluid syndrome of nasal retention, edema. polyps, or EENT bronchospastic Tinnitus reaction to aspirin GI or other NSAIDs. Epigastric distress, nausea, Contraindicated in occult blood loss, peptic pregnant women. ulceration, diarrhea, constipation, Use cautiously in abdominal pain, bloating, GI patients with GI fullness, dyspepsia, flatulence, disorders, history of heartburn, decreased appetite. peptic ulcer disease, GU cardiac Acute renal failure, azotemia, decompensation, cystitis, hematuria. hypertension, HEMATOLOGIC asthma, or intrinsic Plonged bleeding time, anemia, coagulation defects. neutropenia, pancytopenia, thrombocytopenia, aplastic anemia, leucopenia, agranulocystocis. METABOLIC Hypoglycemia, hyperkalemia. RESPIRATORY: Bronchospasm SKIN Pruritus, rash, urticaria, stevens Johnson syndrome.

Nursing Responsibility Tell patient to take with meals or milk to reduce adverse GI reactions. Note: Drug is available at OTC. Instruct patient not to exceed 1.2 g daily, and not to take for extended periods ( longer than 3 days for fever or longer than 10 days for pain) without consulting presciber. Teach patient to watch for and report to prescriber immediately signs and symptoms of GI bleeding, including blood in vomit, urine, or stool or coffee ground vomit, and black, tarry stool. Warn patient to avoid hazardous activities that require mental alertness until effects on CNS are known. Advise patient to wear sunscreen to avoid hypersensitivity to sunlight.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

Name of Drug

Classification

Mechanism of Action -Inhibits bacterial cell wall synthesis, rendering cell wall osmotically unstable, leading to cell death Indications: -Treatment of LRIT (e.g. bronchitis, pneumonia, bronchopneumonia, emphysema, lung abscess), skin and soft tissue infections. Pre-operative prophylaxis to reduce chance of postoperative surgical infections.

Adverse Reaction

Special Consideration

Nursing Responsibilities

Generic Name: Ceftriaxone 500mg IV q8 ANST (-)

Antimicrobial and Antiparasitic

-Leukopenia, serum sickness, anaphylaxis. Side Effects: -Phlebitis, rash, diarrhea, vomiting.

-Use with caution in patients with history of gastrointestinal disease. Nephrotoxicity has been reported following concomitant administration with aminoglycosides. Contraindications: -Hypersensitivity to cephalosporins and penicillins, lidocaine or any other local anaesthetic product of the amide type.

-Instruct patient to take medication as prescribed for the length of time ordered even if he feels better. -Teach patient to report sore throat, bruising, bleeding and joint pain. -Advise patient to watch out for perineal itching, fever, malaise, redness, pain, swelling, rash diarrhea.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

Drug name

Action / classification

Indication

Contraindication

Nursing responsibility

Trade name : Salbutamol Neb Generic name: Albuterol Sulfate q6

In low doses, acts relatively selectively at beta 2 adrenergic receptors to cause bronchodilation and vasodilation; at higher doses, beta 2 selectivity is lost, and the drug acts at beta 2 receptors to cause typical sympathomimetic cardiac effect. Anti asthmatic

Relief and prevention of brochospasm in patients with reversible obstructive airway disease. Inhalation: treatment of acute attacks of bronchospasm. Prevention of exercise-induced bronchospasm. Unlabeled use: adjunct in treating serious hyperkalemia in dialysis patients; seems to lower potassium concentration when inhaled by patients on hemodialysis.

Contraindicated with hypersensitivity to albuterol; tachyarrhythmias, tachycardia cause by digitalis intoxication. Use cautiously with diabetes mellitus; hyperthyroidism, history of seizure disorders.

Observe 10 rights in giving medications Use minimal doses for minimal periods; drug tolerance can occur with prolonged used. Prepare solution for inhalation by diluting 0.5 ml 0.5% solution with 2.5 ml normal saline ; deliver over 5 15 minuts by nebulization.

Do not exceed the recommended dosage; administer pressurized inhalation drug forms during second half of inspiration, because the airways are open wider and the aerosol distribution is more extensive.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

Name of Drug

Classification

Adverse effect

Indication

Contraindication

Nursing Consideration

Ascorbic acid syrup 8mL OD daily

Vitamins

GI: Nausea, vomiting, heartburn, diarrhea. Hematologic: Acute hemolytic anemia (patients with deficiency of G6PD); sickle cell crisis. CNS: Headache (high doses). Urogenital: Urethritis, dysuria, crystalluria (high doses). Other: Mild soreness at injection site; dizziness and temporary faintness with rapid IV administration.

Prophylaxis and treatment of scurvy and as a dietary supplement. Increases protection mechanism of the immune system, thus supporting wound healing. Necessary for wound healing and resistance to infection.

Use of sodium ascorbate in patients on sodium restriction; use of calcium ascorbate in patients receiving digitalis. Safety during pregnancy (category C) or lactation is not established.

Assessment & Drug Effects Lab tests: Periodic Hct & Hgb, serum electrolytes. Monitor for S&S of acute hemolytic anemia, sickle cell crisis. Patient & Family Education Take large doses of vitamin C in divided amounts because the body uses only what is needed at a particular time and excretes the rest in urine. Megadoses can interfere with absorption of vitamin B12. Note: Vitamin C increases the absorption of iron when taken at the same time as iron-rich foods.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

Drug Name and Dosage

Drug Classification and Action/s *Mineral for antianemia *Vital for hemoglobin regeneration, specifically it enables the RBC development and oxygen transport via hemoglobin *Pharmacokinetics: Absorption:5-30%intestines Distribution: PB:UK Metabolism: t: Uk Excretion: Urine, feces, bile *Pharmacodynamics: PO Onset: 4 days Peak: 7-14 days Duration: 3-4 mos

Indication

Nursing Consideration/s

Iron Brandnames: Ferrous sulfate syrup 8ml BID x 7 days

*To prevent and treat iron deficiency anemia

*Contraindicated in clients with hemolytic anemia, Peptic ulcer and Ulcerative colitis *Administer vitamins with food to prevent GI upset. *Caution on intake of chamomile, feverfew, peppermint and St. Johns wort for it interferes with the absorption of iron and other minerals. *Increadead effect of iron with viatmin C; decreaded effect of tetracycline, antacids, penicillamine *Inform clients of side-effects like nausea and vomiting, diarrhea, constipation,epigastric pain and refer to the attending nurse upon occurrence for management. *Monitor for adverse reactions like pallor and drowsiness.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

XII. DISCHARGE PLANNING/ PROGNOSIS

MEDICATIONS Co-amoxiclav 312.5 mg/5mL q12h x 7 days Ibufrofen 210 mg/5 mL for pain Paracetamol 250mg/5mL q4h PRN Ascorbic Acid syrup 8mL OD daily Ferrous Sulfate syrup 8mL BID daily

EXERCISE Deep breathing exercise ( can use every time in repositioning) Isometric exercise in lower extremities

TREATMENT antibiotic as prescribed by the doctor BST (balance skeletal traction)

HEALTH TEACHINGS Isometric exercise everyday for good blood circulation and reduce muscles spasms. Provide information about limitations and restrictions of active mobility.

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CASE STUDY: POSTERIOR HIP DISLOCATION (RIGHT)

Instruct the patient to maintain good personal hygiene to avoid possible infection in the infected area also for prevention of other complications.

OUT-PATIENT Continuous compliance to medications, treatment and drug regimen given by doctors Advised to continue with isometric exercises which are recommended to improve blood circulation and reduce muscle spasms. Remind the client to return to the nearest orthopedic center for a follow-up visit

DIET Patient was ordered to take some vitamins. o Ascorbic acid syrup 8mL OD daily o Ferrous Sulfate syrup 8mL BID x 7days Patient is under nutritional program to manage the malnutrition.

SPIRITUALITY Strengthen faith in God.

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