PERCEPTION AND COORDINATION: CLOSED SUPRACONDYLAR FRACTURE TYPE III SECONDARY TO FALL A CASE STUDY IN DAVAO REGIONAL HOSPITAL

APOKON, TAGUM CITY _____________________

A Case Study Presented To BSN-Students And Clinical Instructors

_____________________

In Partial Fulfilment for the Requirement of BSN 3 Related Learning Experience: Concept Perception and Coordination

By:

Van Kyssel R. Reyes

February 23, 2013

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Chapter I Background of the Study A supracondylar fracture is a fracture, usually of the distal humerus just above the epicondyles, although it may occur elsewhere. While relatively rare in adults it is one of the most common fractures to occur in children and is often associated with the development of serious complications. It may be of a flexion type or an extension type, depending upon the displacement of the distal fragment of bone. The most common type is extension type, accounting for 80% of all supracondylar fractures. The distal fragment is displaced posteriorly. Flexion type the least common variety is the distal fragment displacing anteriorly relative to the proximal segment. The displacements may present in one of a number of ways the posterior shift, posterior tilt, lateral or medial shift, proximal shift or internal rotation. This is the most common elbow fracture in children, about 60% of fractures in children. It is most common in children below 10, peak incidence is between the ages of 5-8 years of age. Primarily in children who are around age 7 years, which is often a period of maximum ligamentous laxity therefore, the elbow hyperextends when the child tries to catch himself or herself during a fall. The presenting complaint is that the child presents with history of a falling on an outstretched hand followed by pain, swelling and inability to move the affected elbow.

Other injuries of closed supracondylar is commonly brachial artery injury, if left untreated could lead to Volkmann's contracture which is permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers. On Philippines it is most common below 10 years, peak age 5-8 y.o. 80% of all pediatric distal humerus fractures, on the survey 2 is to 1 males prone on having this supracondylar fracture . Extension type accounts for 90-98% of all supracondylar fractures. On Davao Regional hospital there are patient who has fracture but not the same as supracondylar fracture, if there is the same case it is usually on the children since as the stated earlier it is most common to the children . This study aims to provide the readers information about the disease process of the case chosen by the researchers, its clinical manifestations, nursing,

pharmacological and medical interventions. This also provides a clear picture of the whole disease process through giving description about the manifestations of a real client and the management he had undergone.

OBJECTIVES Upon completion of this study and after data gathering, research and analysis, the researchers shall have devised objectives that will guide them for the proper understanding and fair interpretation of the case of their chosen patient and they will be able to: Gain knowledge about the disease process, predisposing factors, clinical manifestation and the disease management and gain skills and appropriate attitudes needed to function as a student nurse in the community. Be able to use the nursing process as framework for care of the patient and develop teaching plan and strategies appropriate for the goal attainment. Prevent and manage potential complications that might occur and emphasize health teachings and dietary instructions and restrictions as well as performing appropriate exercises

I.

Background of the Patient BIOGRAPHICAL DATA Name Address Age Occupation Admitting Physician : Patient sipat :Prk. 2 Tibanban, Gov. Genoroso Davao Oriental, Philippines : 6 years old : N/A : Dr. Louvette P. Donayre, M.D

Admitting Diagnosis : Closed Supracondylar Fracture Type III secondary to fall Religion Nationality : Roman Catholic : Filipino

Educational Attainment: Pupil Date/Time of Admission : 11/17/12 8:00 pm

CHIEF COMPLAINT Fall

HISTORY OF PRESENT ILLNESS At 4:30 pm of November 17, 2012 the patient was playing and eventually fall from an 8 ft. height causing the injury. His father and mother brought him to the nearest hospital on their place then they transferred him to Davao Regional Hospital at 8:00 pm.
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PAST MEDICAL AND NURSING HISTORY Patient received complete immunizations. He also experienced common illness such as colds, cough, and fever during his childhood. He did not undergone any surgery, no allergy and did not take any aspirin.

PERSONAL, FAMILY AND SOCIO-ECONOMIC HISTORY Patient sipat is an elementary pupil. His father and mother are both laborer. They have an income of Php 3,000 4,000 per month. His father has no vices and their family has no history of diabetes, hypertension, tuberculosis, bronchial asthma and malignancy.

PATIENT NEED ASSESSMENT Name : Patient sipat Age : 6 y.o. Sex : M Status : Child

Admission Date / Time

: Novenmber 17, 2012 / 8:00 pm____________ : Closed Supracondylar Fracture Tpe III

Admitting Medical Diagnosis secondary to fall Arrived on unit by Accompanied by *VS

: Wheel chair_________ : Mother : BP = 90/70 mmHg____ RR = 29 cpm_________

From : Emergency Room

CR = 110 bpm___ Temp. = 37 C__

Clients Perception of Reason for Admission: , Nahulog ni siya kay nisaka man ni siya sa pultahan ., as verbalized by the mother.____ How was the problem being managed at home? Medication taken at home : none_ :Supporting arm by splint_

PHYSIOLOGICAL NEEDS Oxygenation *BP : 90/70 mmHg__ *RR : 29 cpm__ *Lungs (per auscultation: character; lung sound; symmetry of chest expansion; breathing character and pattern): No adventitious sounds / clear lung sounds heard upon auscultation; equal rise and fall of chest / chest expansion and with normal depth of respiration; breathing in eupnic pattern.____ *Cardiac Status (per auscultation: sound, character; chest pain : Normal lub dubb sound is heard upon auscultation, no murmurs noted; no chest pain felt.__ *Capillary Refill : Capillary refill returns before 2 second upon blanching.___ *Skin Character and Color : Pallor, dry skin.___ *Life-supporting apparatus : IVF = D5LR 1L @ 55cc/hour . Temperature Maintenance *Temperature : 37 C__ *PR : 110 bpm__

*Skin Character: Upper and lower extremities normally warm to touch. Nutritional Fluids *Amt. of Food Consumed : Able to consume the meal served. ____ *Prescribed Diet : Diet as Tolerated

*Problem (nausea, vomiting: no. of times & amount): None *Eating Pattern (frequency, amount, character) : 3x a day; whole meal served. *Intake (IVF; fluid / water) : IVF = D5LR 1L @ 55cc/hour; H20 = 1000cc. Elimination *Last Bowel Movement (frequency, amount, character) : The patient has defecated for about 320 grams and has a brownish color.

*Normal Pattern : Once a day, every morning.______ *Urination (frequency, amount, character, sensation) : Able to urinate at least 4x a day with a yellowish colored urine; at least 100cc per urination.___ Rest and Sleep *Bed Time : 07:00 pm_____ *Waking Up : 05:00 am______

*Sleep (pattern, amount of sleep) : 10 hours every night, undisturbed. 1-2 hours sleep every afternoon. *Problem (as verbalized): none.__ Stimulation-Activity *Work : none_____________

*Recreation/Pastime: Playing with his brother *Hobbies / Vices : Cellphone game,watching television.

SAFETY AND SECURITY NEED Patient sipatfeels safe and secure in terms of his condition because of hisparents who took care of him and that these people will never leave him even though he has a skin traction. LOVE-BELONGING NEED

Patient sipat feels the love and belongingness from his family. They are always there for him. He was always being visited by hismother and father was always the one who took care of her in the hospital and even at home. SELF-ESTEEM NEED The patients situation is hard for him and for his family since he was a child then absent for almost 3 weeks, he will be having his operation also to reform his arm and his activity will be disturbed. SELF-ACTUALIZATION NEED The patient together with his family thinks positively and entrust to God everything. He feels accepted and loved by others and feels deep loving bonds with the people around him. PHYSICAL ASSESSMENT GENERAL SURVEY The patient is a 6-year old male, stands 3 ft in height and 16 kg. in weight, and with the following VS as monitored and recorded upon admission BP=90/70mmHg, PR=110bpm, RR=29cpm, Temp.=37C. He is conscious, coherent, and responsive to the questions asked and procedures done by the health care team providers.

 Date 11-17-12 11-18-12 11-18-12

VITAL SIGNS Shift 3-11 11-7 7-3 Time 8 pm 1:30 am 9:10 am Temp 37 36.8 36.4 BP 90/70 90/60 90/60 RR 29 28 25 PR 110 105 112 I ---------O ----U-1 S-0 U-1 S-1

11-18-12

3-11

6:40 pm

36.6

100/60

17

65

----

8:50 pm 11-19-12 11-19-12 11-19-12 11-20-12 11-20-12 11-20-12 11-20-12 11-21-12 11-21-12 11-22-12 11-22-12 11-22-12 11-7 7-3 3-11 11-7 7-3 3-11 11-7 7-3 3-11 11-7 7-3 3-11 1:15 am 9:20 am 6:05 pm 1:20 am 9:20 am 6:35 pm 1:20am 4:20 am 6:10 pm 6:30 am 9:00 am 6:30 pm

36 36.9 36.6 37.2 37 37.2 37.4 36.5 36.6 37.2 37 37.2 37.2

90/60 90/60 90/60 90/60 100/70 90/70 90/60 90/60 90/60 90/60 90/60 90/60 90/60

18 20 22 23 24 25 23 24 24 25 25 26 23

67 97 105 110 102 104 100 101 104 102 102 102 100

----------------------------------------

U-1 S-0 U- 1 S-0 U-1 S-0 U- 1 S-0 U-2 S-0. U-2 S-0 U-1 S-0 U- 1 S-0 U-1 S-1 U-1 S-0 U-1 S-0 U-1 S-0 U-1 S-0
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11-23-12 11-23-12

11-7 7-3

1:00 am 8:00 am

37.1 36.5

90/60 90/60

24 30

101 104

-------

U- 1 S-0 ---U-300cc

12:00 nn

36.4

90/60

28

102

H2O-500cc S- 2

11-23-12 11-24-12 11-24-12

3-11 11-7 7-3

5:00 pm 4:30 am 8:00 am

36 37.2 36.6

90/60 90/70 90/60

27 24 28

105 101 110

-------U-500cc

12:00 nn

37

90/60

26

105

H2O-700cc S-1

11-24-12 11-25-12 11-25-12 11-25-12 11-26-12 11-26-12 11-26-12 11-27-12 11-27-12 11-27-12 11-28-12 11-28-12 11-28-12 11-29-12

3-11 11-7 7-3 3-11 11-7 7-3 3-11 11-7 7-3 3-11 11-7 7-3 3-11 11-7

7:20 pm 3:10 am 9:30 am 6:15 pm 2:20 am 8:20 am 6:30 pm 1:30 am 9:00 am 7:20 pm 3:10 am 8:10 am 7:20 pm 2:10 am

36.7 36.6 36.4 37 36.7 37.2 36.4 36.5 36.2 36.7 36.6 37 36.5 36.5

90/70 100/60 100/70 90/70 90/60 90/60 90/60 90/70 90/60 90/70 100/60 90/60 90/70 90/60

28 24 26 23 24 26 25 27 23 28 24 27 24 25

102 104 108 100 101 104 105 104 101 102 104 102 107 102

-----------------------------------------

U-1 S-1 U-1 S-0 U-1 S-1 U-1 S-0 U-1 S-1 U-1 S-0 U-1 S-0 U-1 S-0 U-1 S-1 U-1 S-0 U-1 S-1 U-1 S-0 U-1 S-0 U-1 S-0
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11-29-12

7-3

8:00 am

36.5

90/60

30

110

----

---U-300cc

12:00 nn

36.3

90/60

28

104

H2O-750cc S-1

NUTRITIONAL STATUS The patient is 3ft. in height and weighs 16 kg. He is on Diet as Tolerated. He is able to consume the food served. He eats 3 meals a day with small snacks in between meals; able to consume 1000mL of water a day. With D5LR 1L @ 55cc/hour.

NEUROLOGIC STATUS Patient is alert, attentive, and follows commands. If asleep, he responds promptly to external stimulation and, once awake, remains attentive.

INTEGUMENTARY SYSTEM Skin is pale and slightly dry with brown patches. Hair is fine and evenly

distributed. With a short, clean and well-trimmed fingernails and toenails. HEENT (Head, Eyes, Ears, Nose and Throat) Head is normocephalic. Eyes has fine, coordinated movements and are symmetrical. Ears are patent and bilaterally hears sounds; both are symmetrical. Nose is midline, patent and sinuses are non-tender. Lips are moist; gums are pinkish, intact and non-bleeding with midline uvula and non-inflamed tonsils. Some teeth are missing and some have caries. Tongue is pink and even; dorsal surface rough with papillae.

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PULMONARY SYSTEM Clear lung sounds are heard upon auscultation. Chest is bilateral

symmetry in general shape. Theres an equal rise and fall of the chest and with normal depth of respiration. CARDIOVASCULAR SYSTEM Normal lub dubb sound is heard upon auscultation, with no chest pain felt. GASTROINTESTINAL SYSTEM Abdomen has an equal color as the rest of the body, hassoft and flat abdomen. Normal clicks heard upon auscultation 25 clicks per minute. MUSCULOSKELETAL SYSTEM Hands are medium in size, has supracondylar fracture at left arm, has overhead skin traction, bruises noted at left arm, skin is slightly dry but with no lesions noted. Right arm is able to move through active ROM. The size of the feet is about 4 inches; symmetrical in shape. Upper and lower extremities are normally warm to touch. Skin peeling on both hands and feet noted. GENITO-URINARY SYSTEM Patient urinates at least 4 times a day without difficulty with yellowish colored urine at about 100cc per urination.

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COURSE IN THE WARD

Date/Shift

Nurses Assessment

Nurses Intervention

Medical Management

11-17-12 3-11

Admitt ed this 6 years old; male ; awak e and respo nsive came in due to fall

V/S taken and recorded.

Laboratory exams requested (x-ray)

To obtain baseline data. Started with D5LR 1L regulated @ 55cc/hr. For venous access. To

done. obtain data and

baseline identify

abnormalities

and

underlying causes.

11-17-12 3-11

Received from ER per wheelchair;

V/S checked and recorded.

Per application of overhead skin traction.

To obtain baseline

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awake and responsive;

data.

To maintain limb aligned to the body surface and to prevent complication. On diet as tolerated. To maintain and continue tolerated diet.

11-17-12 11-7

Received on bed; awake and responsive; with #1 D5LR regulated @ 55cc/hr.

V/S checked and recorded

Still for overhead skin traction.

To obtain baseline data. Watched and cared for To identify appropriate interventions if there are unusualities.

To maintain limb aligned to the body surface and to prevent complication. On diet as tolerated To maintain and continue tolerated diet.

11-18-12 7-3

Received on bed; awake and

V/S checked and recorded.

Overhead skin traction a left arm.

To obtain baseline To maintain limb

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responsive; With D5LR @900cc regulated @55cc/hr

data.

aligned to the body surface and to prevent

Watched and cared for.

complication. On diet as tolerated. To maintain and continue tolerated diet. On diet as tolerated.

To identify appropriate interventions if there are unusualities.

11-18-12 3-11

Received patient on bed; awake and responsive; with IVF of D5LR @ 800cc level @55cc/hr.

V/S taken and recorded.

To obtain baseline To maintain and data. Due meds given. continue tolerated diet.

To treat underlying cause.

Watched and cared for.

To identify appropriate interventions if there are unusualities. 11-18-12 Received on V/S checked and

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11-7

bed; Awake. with IVF #1 D5LR @ 55cc/hr.

recorded. To obtain baseline data.

11-19-12 7-3

Received on bed; awake and responsive; on diet as tolerated; with IVF D5LR @900cc level regulated @55cc/hr.

V/S taken and recorded.

Maintain on overhead skin traction.

To obtain baseline data. Due available meds given.

To maintain limb aligned to the body surface and to prevent

To treat underlying complication. cause. refer to orthopedics.

11-19-12 3-11

Received on bed; awake and responsive; on moderate high back

V/S taken and recorded.

Maintain on overhead skin traction.

To obtain baseline data. Due available meds given.

To maintain limb aligned to the body surface and to prevent

rest. with IVF To treat underlying complication.

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#2 D5LR @700cc level regulated @55cc/hr.

cause.

On diet as tolerated.

Needs attended.

To maintain and continue tolerated diet.

To provide comfort. Health teachings rendered. To have accurate knowledge and prevent more complication.

11-19-12 11-7

On bed awake. with

V/S checked and recorded.

Overhead skin traction at left arm.

IVF #2 D5LR To obtain baseline @700cc level regulated @55cc/hr. 11-20-12 7-3 Received on bed; awake and responsive; on diet as tolerated. IVF #2 D5LR V/S monitored. data.

To maintain limb aligned to the body surface and to prevent complication.

To obtain baseline data. Due med given.

To treat underlying cause.

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@55cc/hr.

Kept safe and comfortable.

To provide security and comfort. Needs attended.

To provide comfort.

11-20-12 3-11

Received on bed; awake and responsive; on diet as tolerated. On moderate high back rest with IVF #3 D5LR @55cc/hr.

V/S checked and recorded.

To obtain baseline data. followed up meds and pending labs. Watched and monitored. To identify appropriate interventions if there are unusualities. Due meds given.

To treat underlying cause.

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11-21-12 11-7

Received on bed awake and responsive; IVF #4 D5LR @55cc/hr

V/S checked and recorded.

Overhead skin traction at left arm.

To obtain baseline To maintain limb data. Followed up meds and pending labs. To take medication and identify underlying cause. aligned to the body surface and to prevent complication. On diet as tolerated To maintain and continue tolerated Due available meds given. To treat underlying cause. diet.

Watched and cared for.

To provide comfort.

11-22-12 7-3

Received patient on bed; awake and

V/S taken and recorded.

Overhead skin traction at left arm.

To obtain baseline To maintain limb data. aligned to the body

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responsive; #4 D5LR 1L @55cc/hr.

surface and to prevent Follow up availability complication. of meds. To treat underlying cause. On diet as tolerated. To maintain and continue tolerated Health teachings rendered. To have accurate knowledge and prevent more complication. Watched and cared for. To provide comfort. diet.

11-22-12 3-11

Received on bed awake and responsive; with IVF #5 D5LR 1L @55cc/hr.

V/S checked and recorded.

Overhead skin traction at left arm.

To obtain baseline To maintain limb data. aligned to the body surface and to prevent Followed up pending meds. To take medication complication. On diet as tolerated.

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as ordered.

To maintain and continue tolerated

Needs attended.

diet.

To provide comfort.

Watched and cared for.

To identify appropriate interventions if there are unusualities. 11-22-12 11-7 On bed awake; D5LR @ 55cc/hr. V/S checked and recorded. Overhead skin traction at left arm.

To obtain baseline To maintain limb data. aligned to the body surface and to prevent Needs attended. complication. On diet as tolerated. Meds given. To maintain and

To provide comfort.

To treat underlying continue tolerated cause. diet.

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11-23-12 7-3

Received patient on bed; awake and responsive; IVF #5 D5LR 1L @ 55cc/hr.

V/S taken and recorded.

Overhead skin traction at left arm.

To obtain baseline To maintain limb data. Followed up of unavailability of meds. To take medication as ordered. aligned to the body surface and to prevent complication. On diet as tolerated. To maintain and continue tolerated Health teachings rendered. To have accurate knowledge and prevent more complication. Watched and cared for. diet.

11-23-12 3-11

Received patient on bed; awake and responsive; IVF #5 D5LR

V/S taken and recorded.

Overhead skin traction at left arm.

To obtain baseline To maintain limb data. Followed up of unavailability of aligned to the body surface and to prevent complication.

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500cc level regulated @ 55cc/hr.

meds. To take medication as ordered.

On diet as tolerated.

To maintain and continue tolerated

Watched and cared for.

diet.

To identify appropriate interventions if there are unusualities. 11-24-12 11-7 Received patient on bed; awake and responsive. V/S taken and recorded. Overhead skin traction at left arm.

To obtain baseline To maintain limb data. Needs attended. aligned to the body surface and to prevent complication. On diet as tolerated. To maintain and continue tolerated diet.

To provide comfort.

11-24-12 7-3

Received lying on bed;

V/S checked and recorded.

Overhead skin traction at left arm.

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responsive and coherent.

To obtain baseline To maintain limb data. aligned to the body surface and to prevent Health teachings imparted. To have accurate knowledge and prevent more complication. Provided with restful environment. To provide comfort. complication. On diet as tolerated. To maintain and continue tolerated diet.

11-24-12 3-11

Received on bed awake; responsive and coherent.

V/S checked and recorded.

Overhead skin traction at left arm.

To obtain baseline To maintain limb data. Due meds followed up. To treat underlying cause. aligned to the body surface and to prevent complication. On diet as tolerated. To maintain and Watched and cared for. To identify continue tolerated diet.

25

appropriate interventions if there are unusualities. 11-24-12 11-7 On bed; sleep. V/S checked and recorded. Overhead skin traction at left arm.

To obtain baseline To maintain limb data. Needs attended. aligned to the body surface and to prevent complication.

To provide comfort.

11-25-12 7-3

Received on bed; awake and responsive

V/S checked and recorded.

Overhead skin traction at left arm.

To obtain baseline To maintain limb data. aligned to the body surface and to prevent Watched and cared for. To identify appropriate interventions if there are unusualities. Health teachings imparted. complication.

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 To have accurate knowledge and prevent more complication. 11-25-12 3-11 Received on bed; awake and responsive. Seen by Dr. Donayre Due meds given. V/S monitored. Overhead skin traction at left arm kept limb aligned. To maintain limb aligned to the body

To obtain baseline data.

To treat underlying surface and to prevent cause. complication.

Watched and cared for.

To

identify

appropriate interventions if there

are unusualities.

11-25-12 11-7

Received on bed; awake and responsive

V/S checked and recorded.

Overhead skin traction at left arm.

To obtain baseline To maintain limb data. aligned to the body surface and to prevent

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Watched and cared for.

complication.

To

identify

appropriate interventions if there

are unusualities.

Health teachings imparted.

To have accurate knowledge and prevent more complication. 11-26-12 7-3 On bed; sleep. V/S checked and recorded. Overhead skin traction at left arm.

To obtain baseline To maintain limb data. aligned to the body surface and to prevent Needs attended. complication.

To provide comfort.

11-26-12 3-11

Received on bed; awake

V/S checked and recorded.

Overhead skin traction at left arm.

28

and responsive

To obtain baseline To maintain limb data. aligned to the body surface and to prevent Watched and cared for. To identify appropriate interventions if there are unusualities. Health teachings imparted. To have accurate knowledge and prevent more complication. complication.

11-26-12 11-7

Received lying on bed; responsive and coherent.

V/S checked and recorded.

Overhead skin traction at left arm.

To obtain baseline data.

To maintain limb aligned to the body surface and to prevent

Health teachings imparted.

complication. On diet as tolerated.

To have accurate

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knowledge and prevent more complication. Provided with restful environment. To provide comfort. 11-27-12 7-3 On bed; sleep. V/S checked and recorded.

To maintain and continue tolerated diet.

Overhead skin traction at left arm.

To obtain baseline To maintain limb data. aligned to the body surface and to prevent Needs attended. complication.

To provide comfort.

11-27-12 3-11

Received on bed; awake and responsive

V/S checked and recorded.

Overhead skin traction at left arm.

To obtain baseline To maintain limb data. aligned to the body surface and to prevent Watched and cared for. To identify appropriate interventions if there complication.

30

are unusualities. Health teachings imparted. To have accurate knowledge and prevent more complication. 11-27-12 11-7 Received lying on bed; responsive and coherent. Health teachings imparted. To have accurate knowledge and prevent more complication. Provided with restful environment. To provide comfort. 11-28-12 7-3 On bed; sleep. V/S checked and recorded. Overhead skin traction at left arm. V/S checked and recorded. Overhead skin traction at left arm.

To obtain baseline To maintain limb data. aligned to the body surface and to prevent complication. On diet as tolerated. To maintain and continue tolerated diet.

To obtain baseline To maintain limb

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data.

aligned to the body surface and to prevent

Needs attended.

complication.

To provide comfort.

11-28-12 3-11

Received on bed awake; Seen by Dr. Donayre.

V/S taken and recorded.

On diet as tolerated.

To obtain baseline To maintain and data. continue tolerated diet. Overhead skin traction at left arm. To maintain limb aligned to the body surface and to prevent complication. For pedia clearance.

11-28-12 11-7

Received on bed; awake and responsive; not in

V/S taken and recorded.

Overhead skin traction at left arm.

To obtain baseline To maintain limb data. aligned to the body surface and to prevent

32

respiratory distress;

Followed up pending lab request.

complication. For pedia approval clearance.

To identify abnormalities and underlying causes.

Needs attended and cared for.

To provide comfort.

11-29-12 7-3

Received on bed; awake and responsive.

V/S taken and recorded.

On diet as tolerated.

To obtain baseline To maintain and data. continue tolerated diet. Provided with calm and restful environment. To provide comfort. Overhead skin traction at left arm. To maintain limb aligned to the body surface and to prevent Needs attended. complication.

To provide comfort.

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Doctors Order Date 11-17-12 Time Order Please admit to orthowar under GS III Secure consent for admission Monitor VS q 4 DAT Start IVF with D5LR @ 55 cc/hr Labs: CBC, BT, Serum Electrolytes, Chest X-ray, X-ray left forearm. Medication: Paracetamol 200 mg IVTT q4 RTC Please apply overhead skin traction.

11-18-12

DAT Maintain skin traction Continue meds

11-19-12

DAT IVF D5LR @ 55 cc/hr Continue Meds Maintain skin traction Refer to ortho for definitive procedure.

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11-20-12

DAT IVF @ D5LR @ 55 cc/hr Continue Meds Monitor skin traction

11-21-12

DAT IVF @ D5LR @ 55 cc/hr Continue Meds Monitor skin traction

11-22-12

DAT IVF @ D5LR @ 55 cc/hr Continue Meds Monitor skin traction

11-23-12

DAT IVF @ D5LR @ 55 cc/hr Continue Meds Maintain skin traction

11-24-12

DAT Continue Meds Monitor skin traction

11-25-12

DAT Continue Meds Maintain skin traction

11-26-12

DAT

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 Continue Meds 11-27-12 DAT Continue Meds For pedia clearance 11-28-12 DAT Continue Meds 11-29-12 Pedia Notes Patient seen and examined, History on PE reviewed Cc: fall, pt. was accidentally fall while playing left arm (-) fever (-) cough. Skin traction at left arm. Closed supracondylar fracture type III secondary to fall. Rpt. CBC, PC, Protime, Rpt. S. elec. Rpt. CXR UA Please ref lab result once available

36

LABORATORY AND DIAGNOSTIC EXAMINATIONS Serum Electrolytes Date: November 17, 2012 LAB EXAM NORMAL RESULT RESULT INTERPRETA-TION The result is normal . Transmission of Tests that measure the nerve impulses can concentration of electrolytes are be altered and needed for both the diagnosis and lethargy, headache S. Sodium 135-148 mmol/L 139.4 management of renal, endocrine, and dizziness are acid-base, water balance, and many some signs and other conditions. Their importance symptoms for lies in part with the serious hyponatremia or consequences that follow from the hypernatremia. relatively small changes that The result is diseases or abnormal conditions normal.Contraction of may cause. (http://www. cardiac, skeletal and surgeryencyclopedia.com/CeS. Potassium 3.50-5.00 mmol/L 3.84 smooth muscles can Fi/Electrolyte-Tests.html#b be altered. Fatigue, ,November 29, 2012) muscle weakness and decreased bowel RATIONALE

37

motility are some signs and symptoms for hypokalemia or hyperkalemia. The result is normal. Bone strength and blood coagulation can be altered. Irritability, S. Calcium 1.13-1.32 mmol/L 1.21 anxiety and numbness are some signs and symptoms for hypocalcemia or hypercalcemia.

NORMAL VALUES Blood group --Hemoglobin 115-165 g/L

LAB EXAM

Hematology Date: November 17, 2012 RESULT INTERPRETATION B positive 118 --The result is normal.

RATIONALE

A complete blood count

Hemoglobin gives blood (CBC) gives important its red color and carries oxygen to the body through the blood. This may indicate anemia and pallor can be information about the kinds and numbers of cells in the blood, especially red blood cells , white blood cells , and platelets. A CBC helps

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observed. (http://en.wikipedia.org/ wiki/Hemoglobin, November 29, 2012) Hematocrit 0.35-0.55 0.34 The result is below normal. The hematocrit measures how much space in the blood is occupied by RBCs. A low hematocrit level is one of the clinical manifestations of anemia. It coincides with the pts low hgb level.(http://en.wikipedia .org/ wiki/Hematocrit November 29, 2012) Leucocytes 5.0-10.0 15.8 The result is above normal. Leukocytes or WBCs are indicators if there is infection in the body. WBC fights against infection so the

your doctor check any symptoms, such as weakness,fatigue, or bruising, you may have. A CBC also helps him or her diagnose conditions, such as anemia, infection, and many other disorders. (http://www.webmd.com/ato-z-guides/complete-bloodcount-cbc November 29, 2012)

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patient is at risk for infection. (http://en.wikipedia.org/ wiki/White_blood_cell, November 29, 2012) Monocytes 0.02-0.6 0.03 The result is normal. Monocytes are also a type of Leukocytes or WBC that fights infections. (http://en.wikipedia.org/ wiki/White_blood_cell, November 29, 2012) Neutrophils 0.55-0.65 0.85 The result is above normal.The most abundant type of white blood cells, elevated neutrophils usually mean there is an ongoing current bacterial infection. (http://answers.yahoo.c om/question/index?qid=

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20080208002214AAaul ts November 29,2012)

I.

Review of Anatomy and Physiology

Fig. 1 Diagram of the Anatomy of Human Skeletal System The skeletal system includes all of the bones and joints in the body. Each bone is a complex living organ that is made up of many cells, protein fibers, and minerals. The skeleton acts as a scaffold by providing support and protection for the soft tissues that make up the rest of the body. The skeletal system also provides attachment points for

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muscles to allow movements at the joints. New blood cells are produced by the red bone marrow inside of our bones. Bones act as the bodys warehouse for calcium, iron, and energy in the form of fat. Finally, the skeleton grows throughout childhood and provides a framework for the rest of the body to grow along with it. The skeletal system in an adult body is made up of 206 individual bones. These bones are arranged into two major divisions: the axial skeleton and the appendicular skeleton. The axial skeleton runs along the bodys midline axis and is made up of 80 bones in the skull, hyoid, auditory ossicles, ribs, sternum, and the vertebral column. The appendicular skeleton is made up of 126 bones in the upper and lower limbs and the pelvic and pectoral (shoulder) girdles.

Skull The skull is composed of 22 bones that are fused together except for the mandible. These 21 fused bones are separate in children to allow the skull and brain to grow, but fuse to give added strength and protection as an adult. The mandible remains as a moveable jaw bone and forms the only movable joint in the skull with the temporal bone. The bones of the superior portion of the skull are known as the cranium and protect the brain from damage. The bones of the inferior and anterior portion of the skull are known as facial bones and support the eyes, nose, and mouth. Hyoid and Auditory Ossicles The hyoid is a small, U-shaped bone found just inferior to the mandible. The hyoid is the only bone in the body that does not form a joint with any other bone it is a
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floating bone. The hyoids function is to help hold the trachea open and to form a bony connection for the tongue muscles.

Vertebrae 26 vertebrae form the vertebral column of the human body. They are named by region cervical (neck), thoracic (chest), lumbar (lower back), sacrum, and coccyx (tail bone). There are seven cervical vertebrae, twelve thoracic, five lumbar, one sacrum, and one coccyx.

Ribs and Sternum The sternum, or breastbone, is a thin, knife-shaped bone located along the midline of the anterior side of the thoracic region. The sternum connects to the ribs by thin bands of cartilage called the costal cartilage. Pectoral Girdle and Upper Limb The pectoral girdle connects the upper limbs (arms) to the axial skeleton and consists of the left and right clavicles and left and right scapulae. The humerus is the bone of the upper arm. It forms the ball and socket joint of the shoulder with the scapula and forms the elbow joint with the lower arm bones. The radius and ulna are the two bones of the forearm. Pelvic Girdle and Lower Limb Formed by the left and right hip bones, the pelvic girdle connects the lower limbs (legs) to the axial skeleton.

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The femur is the largest bone in the body and the only bone of the thigh (femoral) region. The femur forms the ball and socket hip joint with the hip bone and forms the knee joint with the tibia and patella. Commonly called the kneecap, the patella is special because it is one of the few bones that are not present at birth. The patella forms in early childhood to support the knee for walking and crawling. The tibia and fibula are the bones of the lower leg. The tibia is much larger than the fibula and bears almost all of the bodys weight. The fibula is mainly a muscle attachment point and is used to help maintain balance. The tibia and fibula form the ankle joint with the talus, one of the seven tarsal bones in the foot. The tarsals are a group of seven small bones that form the posterior end of the foot and heel. The tarsals form joints with the five long metatarsals of the foot. The each of the metatarsals forms a joint with one of the set of phalanges in the toes. Each toe has three phalanges, except for the big toe, which only has two phalanges. Types of Bones All of the bones of the body can be broken down into five types: long, short, flat, irregular, and sesamoid. Long bones are longer than they are wide and are the major bones of the limbs. Long bones grow more than the other classes of bone throughout childhood and so are responsible for the bulk of our height as adults. A hollow medullary cavity is found in the center of long bones and serves as a storage area for bone marrow. Examples of long bones include the femur, tibia, fibula, metatarsals, and phalanges.

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Short bones are about as long as they are wide and are often cubed or round in shape. The carpal bones of the wrist and the tarsal bones of the foot are examples of short bones. Flat bones vary greatly in size and shape, but have the common feature of being very thin in one direction. Because they are thin, flat bones do not have a medullary cavity like the long bones. The frontal, parietal, and occipital bones of the cranium - along with the ribs and hip bones - are all examples of flat bones. Irregular bones have a shape that does not fit the pattern of the long, short, or flat bones. The vertebrae, sacrum, and coccyx of the spine - as well as the sphenoid, ethmoid, and zygomatic bones of the skull - are all irregular bones. Finally, the sesamoid bones are formed after birth inside of tendons that run across joints. Sesamoid bones grow to protect the tendon from stresses and strains at the joint and can help to give a mechanical advantage to muscles pulling on the tendon. The patella and the pisiform bone of the carpals are the only sesamoid bones that are counted as part of the 206 bones of the body. Other sesamoid bones can form in the joints of the hands and feet, but are not present in all people. Parts of Bones The long bones of the body contain many distinct regions due to the way in which they develop. At birth, each long bone is made of three individual bones separated by hyaline cartilage. Each end bone is called an epiphysis (epi = on; physis = to grow) while the middle bone is called a diaphysis (dia = passing through). The epiphyses and diaphysis grow towards one another and eventually fuse into one bone.
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The region of growth and eventual fusion in between the epiphysis and diaphysis is called the metaphysis (meta = after). Once the long bone parts have fused together, the only hyaline cartilage left in the bone is found as articular cartilage on the ends of the bone that form joints with other bones. The articular cartilage acts as a shock absorber and gliding surface between the bones to facilitate movement at the joint

Skeletal System Physiology Support and Protection The skeletal systems primary function is to form a solid framework that supports and protects the body's organs and anchors the skeletal muscles. The bones of the axial skeleton act as a hard shell to protect the internal organs - such as the brain and the heart - from damage caused by external forces. The bones of the appendicular skeleton provide support and flexibility at the joints and anchor the muscles that move the limbs. Movement The bones of the skeletal system act as attachment points for the skeletal muscles of the body. Almost every skeletal muscle works by pulling two or more bones either closer together or further apart. Joints act as pivot points for the movement of the bones. The regions of each bone where muscles attach to the bone grow larger and stronger to support the additional force of the muscle. In addition, the overall mass and thickness of a bone increase when it is under a lot of stress from lifting weights or supporting body weight.

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Hematopoiesis Red bone marrow produces red and white blood cells in a process known as hematopoiesis. Red bone marrow is found in the hollow space inside of bones known as the medullary cavity. Children tend to have more red bone marrow compared to their body size than adults do, due to their bodys constant growth and development. The amount of red bone marrow drops off at the end of puberty, replaced by yellow bone marrow. Storage The skeletal system stores many different types of essential substances to facilitate growth and repair of the body. The skeletal systems cell matrix acts as our calcium bank by storing and releasing calcium ions into the blood as needed. Proper levels of calcium ions in the blood are essential to the proper function of the nervous and muscular systems. Bone cells also release osteocalcin, a hormone that helps regulate blood sugar and fat deposition. The yellow bone marrow inside of our hollow long bones is used to store energy in the form of lipids. Finally, red bone marrow stores some iron in the form of the molecule ferritin and uses this iron to form hemoglobin in red blood cells.

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Fig. 2 Diagram of the Anatomy of Supracondylar fracture Symptomatology Symptomatology Pain Actual Symptoms Implication Fracture is usually accompanied by a very severe pain. Pain from fracture is about the worst pain so far. The kind of pain sometimes is enough to make the patient go into a state of shock if not controlled. Article Source: http://EzineArticles.com/5570773 Damage can cause inflation. Vascular injury causing the swelling. Bruising Any internal damage will cause internal bleeding.

Swelling

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Inability to move

Any disease or disability that requires complete bed rest or extremely limits your activity is considered immobility. Patients who have had a stroke resulting in partial or complete spinal in

hemiparesis/paralysis, cord injury or resulting

paraplegia

quadriplegia,

fracture, or prolonged bed rest after surgery are considered

immobilized Deformity Deformity occurs especially with fracture of the limbs. The part below the affected limb can be rotated outwards or inwards. In some cases the affected limb is shorter than the second.

Article Source: http://EzineArticles.com/5570773 Shortening In fractures of long bones, there is actual shortening of the

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extremity because of the compression of the fractured bone. Article Source: (Brunner and Suddarth Medical Surgical Nursing vol. 2)

Etiology of the disease Etiology Trauma Actual Symptoms Implication Due to the resilience of the soft tissue of children, fractures occur more often than soft tissue injuries. Age ( 3 12 years old ) adult ( 60 years old) Age-related changes, such as decreases in bone strength and brain size, could make older riders more susceptible to injury. Impaired vision, delayed reaction time, and altered balance, all of

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which accompany the natural aging process, could contribute to crashes or mishaps. (http://www.livescience.com/11012oldermotorcycle-riders-injured.html)

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A. Written Pathophysiology Closed Supracondylar fracture Type III is a severe pain, it is not necessary to delay client to convey to the hospital and it needs immediate attention, Type 3 fracture needs surgery since it is fully displaced.This classification remains somewhat deficient in describing the mechanically important concept of the medial and lateral columns and their fracture involvement. It also is somewhat deficient in describing the level through which the fracture occurs in each column and related important surgical considerations. Local swelling, loss of function or abnormal movement of the affected part and deformities such as angulation, shortening or rotation of the part. Pain or local tenderness is normally present. This is due to a temporary loss of nerve function at the site of the fracture. Associated vascular injury causes swelling, pallor, pain, or numbness and pulselessness These signs may not develop for several hours after injury or may develop within an hour, depending on the severity of the fracture. patient fall from an 8 feet high door, causing the fracture at the distal humerus which was displaced and eventually causing vascular injury. The blood vessels also bring fibroblasts in the walls of the vessels and these multiply and produce collagen fibers. In this way the blood clot is replaced by a matrix of collagen. Collagens rubbery consistency allows bone fragments to move only a small amount unless severe or persistent force is applied. At this stage, some of the fibroblasts begin to lay down bone matrix (calcium hydroxyapatite) in the form of insoluble crystals. This mineralization of the collagen matrix stiffens it and transforms it into bone. In fact, bone is a mineralized collagen matrix; if the mineral is dissolved out of bone, it becomes rubbery. Causing the left arm to become immobilize.
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Traction (skin or skeletal) may be used until the patient is physiologically stable to undergo surgical fixation. Skin traction is used to control muscle spasm and to immobilize an area before surgery. Skin traction is accomplished by using weight and pull on traction tape or on a foam boot attached to the skin. The amount of weight applied must not exceed the tolerance of the skin.

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B. Diagram of Pathophysiology
Predisposing factor: Age (6-12 years old) Fall from an 8 (eight) ft. height. Fractured the distalhumerus Humerusdisplaced. Precipitating factor: Activity- (playing)

Vascular injury

The blood coagulates to form a blood clot situated between the broken fragments.

The blood vessels bring fibroblast in the walls of the vessels and these multiply and produce collagen f ibers. Fibroblasts begin to lay down bone matrix (Calcium hyroxyapatite) in the form of insoluble crystals. Mineralization of the collagen matrix stiffens it and transforms it into bone.

deformity, swelling, bruising, pain, impaired sensation

Immobility

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If treated: Nursing management: Health teachings Monitor Vital SignsCollaborative Laboratory test Medical management: Paracetamol 200 mg IVTT Overhead Skin Traction Surgery

If not treated: Infection Necrosis and loss of function

amputation

Exacerbation Poor prognosis Death

Good Prognosis:

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III. Nursing Care Management Date/Shift 11-23-12 7-3 Assessment S- maglisod pa man ko ug lihok-lihok dili pud ko makanaog diri sa higdaanan. as verbalized Need Nursing Diagnosis Impaired physical mobility related to overhead skin traction secondary to closed supracondylar fracture Objective of care After 6 hours of nursing care the patient will be able to: - Verbalize the importance of side lying. - Not complain for respiratory distress. - Verbalize pain free. - Understand importance of skin traction Nursing Intervention Dependent: Monitor Vital Signs Maintain Overhead skin traction. Independent: Assisted on normal range of motion. Positioned on Moderate High Back Rest. Rationale Evaluation Goal Met: After 6 hours of nursing care the patient was able to verbalized importance of side lying position magtakilid na ko usahay aron dili na singoton akong likod, respiratory distress not noted, verbalized pain free wala man naga sakit akong kamot, understand importance of skin traction bahalag dili ko makanaog diri sa higdaanan basta dili lang magsakit akong kamot as verbalized.

S E L F A C T - with overhead U skin traction at A left arm. L Rationale: - Bruise I Fall causing noted at Z injury to left arm A humerus results - Pain rate T to 7/10 I internal bleeding - V/S O from damage - BP -90/60 N/ ends of bone Temp- 37 ACTIVITY and from RR 28 surrounding PR- 110 tissue which stimulates intense inflammatory response that causes increased capillary

R- to provide baseline data R- to kept limb aligned to body. R- to avoid muscle sprain

R- to avoid respiratory distress

Assisted on side lying position. Health Teachings

R- to prevent bed sore. R- to gain knowledge.

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permeability and fluid/cellular exudation that leads to edema that causes pain to impaired function Ref: Mary Ellen Murray and Lesley D. Atkinson Understanding the Nursing Process in Changing Care Environment

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Date/Shift 11-23-12 7-3

Assessment

Need P H Y S I O L O G I C N E E D

O- with overhead skin traction at left arm. - Bruise noted at left arm - Pain rate 7/10 - V/S - BP -90/60 Temp- 37 RR 28 PR- 110

Nursing Diagnosis Risk for infection related to a site for organism invasion secondary to surgery. Rationale: Surgery there is break down of skin which gives opportunity for the bacteria and other pathogens to invade the body. The host is susceptible for infection because of the breakage of the bodys first line of defense. Ref: Mary Ellen Murray and Lesley D. Atkinson Understanding the Nursing Process in Changing Care Environment

Objective of care Within 2 days of nursing care the patient will demonstrate skin integrity: - Absence of swelling to the site - Absence of erythema - Dry and intact dressing will be noted

Nursing Intervention Dependent: - Monitor vital signs - Change dressing as ordered Independent: - Monitor IVF at desired rate. - Assess for signs of infection Observe handwashing frequently

Rationale

Evaluation After 2 days of nursing action, Goal met, the patient was able to demonstrate skin integrity as evidence by: - Absence of swelling to the site. - Absence of erythema - Dry and intact dressing is noted.

R- baseline data R- to keep wound dry and intact

R- maintain adequate hydration R- to prevent exacerbation of the disease - To prevent cross infection

Collaborative - Encourage watcher on frequent handwashing when giving direct care to the client

To prevent infection and promote aseptic technique

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Date/Shift 11-23-12 7-3

Assessment S- Mahadlok man ko inig human sa opera kay dili na kayo ko makadulaas verbalized. O- with overhead skin traction at left arm. - Bruise noted at left arm - Pain rate 7/10 - V/S - BP -90/60 Temp- 37 RR 28 PR- 110

Need S E L F E S T E E M N E E D

Nursing Diagnosis anxiety related to actual or perceived threat to biologic integrity Rationale: Fear of unknown is usually one of the factors greatly contributed to the anxiety of the person. When the health of the person is at risk or threatened anxiety will likely to occur Proper Ref: Mary Ellen Murray and Lesley D. Atkinson Understanding the Nursing Process in Changing Care Environment

Objective of care Within 2 days of nursing care the patient will be able to: Understand the importance of surgery Will verbalize decrease of nervousness. Differentiate real from imagined situation.

Nursing Intervention Dependent: - Monitor Vital Signs

Rationale

Evaluation After 2 days of nursing care, goal partially met as evidenced by patient was able to - understand the importance of surgery -verbalize decrease in nervousness magpaopera nalang jud ko para maayo ang akong bali naa man pud sila mama ug papa diri as verbalized.

For baseline data

Independent: - Established rapport.

Orient to environment using simple explanation Speaks slowly and calmly Encourage expression and feelings

To gain trust and cooperati on To easily understa nd the situation To gain cooperati on To note the decrease of anxiety

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B. Discharge Plan Medications -Educate family members concerning right drug administration as well as right time and dosage as prescribed. -Explain the relevance of taking prescribed medications for fast and better recovery. -Instruct patient and family to continue home medications as ordered: Medication Paracetamol Dose 200 mg Frequency Every 4 hours Time 2-6 10-2 6-10

Exercise -Explain the importance of exercise to alleviate the condition. -Educate patient and family to have the mindset of exercise, do at least one passive and active range of motion and physical chore each day. As little as 15 minutes of walking 3 time a week has a proven beneficial effect but never exercise that causes fatigue. -Remind patient and family on the warning signs of injury such as pain, bruise, swelling and redness. Treatment -Instruct patient to take medication and for family tobought medical regimen religiously as well as scheduled hospital visits for continuous monitoring. -Encourage to take Multivitamins for immunity. -Educate the patient to self-monitor blood sugar levels frequently at least before meals or at bedtime.

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Health Teachings -Educate patient on the importance of nutrition such ascalcium, iron and protein for his age. -Encourage regular exercise. -Make the patient and family understands the importance seeking medical help in case of any complications or abnormalities. Out-patient -Even without the presence of any health care member, the parents must still obey to bought the medications and the client must take his medications religiously. All health teachings rendered monitor his arm condition and avoid junk foods. - Encourage client and his parents to follow medical advice for follow-up check up 1 week after discharge. Diet -Teach patient to eat healthy foods in moderation on a regular schedule. Eating at the same times each day regulates. -Educate on the maintenance of healthy diet consisting of milk, dairy products, fruits, egg, vegetables, whole grains, fish, white meat and poultry

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C. PHARMACOLOGICAL MANAGEMENT
Date / Shift 1117-12 7-3 Generic Name P A R A C E T A M O L Brand Name ----Classification Antipyretic Mechanism of Action Reduces fever byacting directly onthe hypothalamiche at-regulatingcenter to causevasodilatio n andsweating, whichhelps dissipateheat. Siteand mechanismof action unclear Indication Analgesicantipyretic inpatients with aspirinallergy, hemostaticdisturb ances, bleedingdiathese s, upper GIdisease, gouty arthritis- Arthritis and rheumaticdisorder s involvingmusculo skeletal pain (butlacks clinically significantantirhe umatic and antiinflammatory effects)- Common cold, flu, otherviral and bacterialinfections with pain andfeverUnlabeled use:Prophylactic for childrenreceiving DPT vaccinationto reduce incidence Adverse Effect CNS: Headache CV: Chest pain,dyspnea, Myocardialdamage Whendoses of 58 g/dayare ingested daily forseveral weeks orwhen doses of 4g/day are ingestedfor 1 yr GI: Hepatictoxicity andfailure, jaundice GU: Acute kidney failure, renal tubularnecrosis Hematologic: Methemoglobinemia cyanosis;hemolytic anemiahematuria, anuria;neutropenia,leuco penia,pancytopenia,thro mbocytopenia,hypoglyce mia Hypersensitivity: Rash, fever Time and Dosage Every 4 RTC 200mg Nursing Consideration -Monitor liver function studies;may cause hepatic toxicity at doses>4g/day -Monitor renalfunction studies;albumin indicates nephritis -Monitor blood studies,especially CBC and pro-time if patient is onlong-term therapy. -Check I&O ratio;decreasing output may indicate renalfailure . -Assess for fever and pain-Assess hepatotoxicity:dark urine, clay-colored stools -Assess allergic reactions: rash,

Analgesic

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of fever and pain

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IV. SYNTHESES OF CLIENTS CONDITION/STATUS FROM ADMISSION TO PRESENT A. Conclusion After a gradual evaluation of the patients condition from the first day of our duty to the last, I came up with a conclusion that it is beyond doubt unpredictable as to what happens in the whole period of my nursing care. The overall condition of my patient was illustrated to have achieved a high level of wellness with the teamwork of the entire member of the health care team. B. Patients Prognosis
POOR FAIR GOOD JUSTIFICATION Patient has been admitted because of fall since November 17, 2012 and has a diagnosis of closed DURATION Supracondylar Fracture type III and still for OR scheduling during our last day of duty. November 29,2012. The patients condition became better than he was ONSET first admitted since the pain on his left arm didnt occur since the skin traction was maintained. The patient and his parents is willing to comply all WILLINGNESS medication and activities conducive to faster healing and recovery. The nature of the environment is conducive for ENVIRONMENT faster recovery because there is proper ventilation and the fan in the ward is near for him.

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C. Recommendations The following are the my suggestions for a faster therapeutic effect: To the patient -I encourage him to follow medical regimen by continuing medications as ordered by his attending physician. - Follow the health teachings rendered to him by the health care team. -Cooperate in everything that the health care team advises. To the family -I recommend to the patients immediate family members tofulfill the medical regimen that is ordered by the physician for faster recovery of their son. .-provide adequate support, care, love and understanding to the patients situation. -Develop knowledge about the patients recovery status to avoid further complications. follow the health teaching that was rendered to act upon their son need.

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V. EVALUATION OF THE OBJECTIVES OF THE STUDY After a step by step review on related topics on this case study, I hereby presenting my evaluation with relation to my main objectives that I affirmed at the start of this case study. Myself settled that I was able to meet the chosen case with sensible data gathered. Further documented related information that are important as I relate the nursing skills I have learned not only for this study but also for future references, and that I gained information about the case chosen and use them to function as student nurses in the community and I was able to use the nursing process as a framework for the care of my patient and for goal attainment and that is to prevent and manage potential complications. With sufficient effort, I have come up with this comprehensive case presentation that deals not only on the basic facts of the topic but also mysuccess in every detail directed to have an abundant yield.

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Bibliography A. Textbooks. 1. Elaine N. Marieb, R.N., Ph.D. Essentials of Anatomy and Physiology 6 th edition 2002. 2. Nurses Pocket Guide. Doenges Moorhouse Murr. 10th Edition. 2008. 3. Suzanne C. Smeltzer, et al. Brunner and Suddarths Textbook of Medical Surgical Nursing 11th edition. Vol. 1 and 2. 2010 4. Judith Hopfer Deglin and April Hazard Vallerand. Davis Drug Guide for Nurses 10th edition. 2007 5. Suzanne C. Smeltzer, et al. Brunner and Suddarths Textbook of Medical Surgical Nursing 10th edition. Vol. 1. 2004

B. Electronic Media 1. Rebello GN, Albright MB. Broken Bones: Common Pediatric Upper Extremity Fractures Part II. Orthopaedic Nursing. 2006;25(5):311-323. 2. Marquis CP, Cheung G, Dwyer JSM, Emery DFG. Supracondylar fractures of the humerus. Current Orthopaedics. 2008;22(1):62-69. 3. Jonathan Cluett, M.D., About.com Guide http://orthopedics.about.com/od/pediatricfractures/a/elbowfracture.htm

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