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ADMISSION/FINAL DIAGNOSIS: Fractured Closed Complete Displaced

Subtrochanteric Area Left Femur

I. HEALTH HISTORY

A. DEMOGRAPHIC DATA

1. Client’s name or initial: RSL

2. Gender: Female
3. Age, Birthdate and Birthplace: 81 y/o, May 29, 1929, Zamboanga
4. Marital Status: Widowed
5. Race and Nationality: Filipino
6. Religion: Catholic
7. Address, Telephone Number: Cavite
8. Educational Background: high school graduate
9. Occupation:N/A
10. Usual Source of Medical Care: hospital, clinics, self-medication

B. SOURCE AND RELIABLITY OF INFORMATION

Primary information was provided by the client’s daughter, who seems
reliable.
Secondary information was gathered from the patient’s chart.

C. REASONS FOR SEEKING CARE / CHIEF COMPLAINTS

According to daughter:
“Nadulas kasi siya noon. Tapos, ayan na, may bali na pala yung sa
balakang nya nung pinatingin namin. Nagdadaing na sya non na masakit ung
may balakang nya tapos hindi na nya naigagalaw mapahanggang ngayon.”

 Fractured Left Femur

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 Hip pain
 Immobility of lower extremity

D. HISTORY OF PRESENT ILLNESS / PRESENT HEALTH

The client has always been roaming around days prior to admission, when
the client accidentally tripped on the dry floor last September 15, 2010. Aside
from that, no other illnesses have been noted. As of November 23, 2010, the
patient was still in the ICU with a GCS score of 6 as evidenced by spontaneous
eye movement with no motor and verbal reflexes to any stimulus. The patient
also shown positive signs and symptoms of cough, yellowish phlegm and grade 2
bed sore. Suctioning and frequent changing of body position was done to
alleviate patient’s discomfort.

E. PAST MEDICAL HISTORY / PAST HEALTH

The client’s daughter stated that it is the first time of the client to be
admitted in the hospital, so it was also the first time to diagnose her health.
According to the daughter it is the client’s first accident, because the client just
experiences some simple insect bites and scratches. And this is the worst one.
The daughter also stated that they rarely go for a check up but they have no
hesitations to go to hospital or to a physician if there is a severe case happens
such as very severe pain and fever. The daughter said that the client doesn’t have
had any minor or major operations at all. The client’s daughter also verbalized that
she was not well informed about the client’s immunizations and vaccine, because
she was not able to recognize it. Client has an obstetric history of G2P2
T2P0A0L2M0. She delivered both of her children through a vaginal spontaneous
delivery. On her previous pregnancy, no complication was identified. Age at
menarche was not able to determine by the daughter. Client has menopause
when she was 45 y/o According to the daughter, the client doesn’t have any
noticeable allergy whether drugs or medications, food allergies or environmental
allergens.
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F. FAMILY HISTORY

unknown unknown

SLR
83 60yo
Fractured left Femur Accident

56 52 46 54
A/W HTN DM A/W

21
A/W

25 15
A/W A/W

LEGEND

patient

male

female

Deceased
female

Deceased
male
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The client was born May 29, 1929 and was blessed to have two offsprings
both female and married, one with hypertension and the other with diabetes
mellitus, both with offsprings all alive and well. Unfortunately, her daughter can no
longer recall the history of her grandparents. The client live together with her
daughter– the elder offspring who attends all needs of the patient. According to
her daughter, her father died due to accident.

G. SOCIO-ECONOMIC

As seen in the table above, two members of the family have the capability
to earn income with the total of 30,000.00Php. The client’s daughter stated that
the she is the one who manages and budgets their money, because she is the
one who goes to the market and the one who pays for their monthly consumed
water and electricity using her daughter’s income and husband’s income. They
can buy necessary foods for the family, for them to have complete meal and for
their everyday needs. But according to her it is quite small for the whole family
that is why some of their relatives help them in some expenses. Client’s daughter
said that they did not earned enough money to sustain all the hospital bills of her
mother that’s why she is asking help in some of their relatives and husband’s
relatives.

H. DEVELOPMENTAL HISTORY

At the client’s age she is at the Late Adulthood stage, it is the Ego Integrity
vs. Despair stage. She is 82 years old. In this stage, a person has the Virtue of
Wisdom. In this stage, as people grow older and become senior citizens they
tend to slow down their productivity and explore life as a retired person. It is
during this time that they contemplate their accomplishments and are able to
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develop integrity if they see their selves as leading a successful life. If they see
their life as unproductive, or feel that they did not accomplish their life goals, they
become dissatisfied with life and develop despair, often leading to depression
and hopelessness.
The final developmental task is retrospection: people look back on their
lives and accomplishments. They develop feelings of contentment and integrity if
they believe that they have led a happy, productive life. They may instead
develop a sense of despair if they look back on a life of disappointments and
unachieved goals. , On her age, what she usually ask is "Have I lived a full life?”
On the client’s part, she is able accomplish her goals, because she do built her
own family and let her children finish studies and that’s fulfilling for her.

I. REVIEW OF SYSTEMS AND PHYSICAL EXAMINATION

1. ROS AND PE

SYSTEM PE
a. General -received pt aslying on bed, awake, assuming supine position
with a score of 6 in GCS as evidenced by spontaneous eye
movement with blinking but no motor and verbal response to
touch or painful stimulus.

- endomorphic body build

- there is marked immobility of both upper and lower

extremities

- with NGT intact, attached at right nare of the nose

-with ET attached to MV in AC mode with FiO 2 of 35%, 0.25
Tidal Volume, Rate Patient BPM of 20, I:E Ratio of 1: 4.0 and
Inspiratory Flow Rate of 40LPM.
-with attached cardiac monitor
-with number 26 PNSS 1L x 48 @100cc level hours hooked at
cephalic vein, infusing well with 5-6gtts/min
-with IFC attached to urine bag draining 400cc of light yellow
colored urine

-vital signs:
BP: 130/60
PR: 71
RR: 20
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Temp: 37. 1
b. Integument Inspection
-skin looks shiny with desquamation at the palmar area.
-nails are symmetrical in appearance, though nail looks pale
on hands and feet

-hair is color white, thin and is scarcely distributed

upon the head area

(+)grade 3 pitting edema on both forearms, the right forearm

with redness
(+) grade pressure ulcer at the lumbar area

Palpation
Skin warm to touch with 37.1 C
Pood skin turgor
c. Head Inspection
-head is normocephalic.
-facial features are symmetrical
(-) lesions

Palpation
Fine hair texture
d. Eyes Inspection
-eyes are symmetrical in appearance
-bulbar conjunctiva is clear with tiny vessels
-scarce whitish eyelashes
--iris brownish in color
-sclera is yellowish

(-) PERRLA – the pupils do not constrict when light was

focused on it and remained at 2.5mm in diameter
(+)arcus senilis
e. Ears Inspection
-ears are symmetrical, bilateral and equal size in appearance.
(-)lesions
(+) scarce amount of yellowish flaky cerumen

Palpation
(-)tenderness
f. Nose and Inspection
Sinuses -with intact NGT attached on right nare of nostrils
-nose symmetrical in appearance.
(-) nasal flaring
(-)discharge
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Palpation
(-) tenderness
g. Mouth and Inspection
Throat -with ET tube attached to MV in AC mode
-lips, gums and mucosa are pink, tongue is pink and is quite
dry.
-teeth is no longer complete only 2 remains at the front area
(+)dental carries
h. Neck Inspection
-Neck does not move.
(-) jugular vein distention

Palpation
-palpable submandibular bilateral lymph nodes
i. Breast and Inspection
Axillary -breast is flat
-areola color is light brown in color
-scarce axillary hair are no longer present
j. Respiratory Inspection
-with attached ET to MV in AC mode
-chest is symmetrical in expantion
-sternum is at midline and is straight

(-)chest lesions
(+)productive cough
(+)yellow frothy sputum upon suctioning
(-) use of accessory muscles

RR:20cpm

Auscultation
(+)crackles on both lung fields
k. Cardiovascular Inspecion
with cardiac monitor

(-)clubbing of fingers
(+) varicose veins on lower extremities
0-3 seconds capillary refil

Palpation
Pulse irregular in rhythm
Grade 2 in strength
PR: 71bpm

Auscultation
(-)murmurs
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l. Gastrointestinal Inspection
-flat abdomen
-sunken umbilicus

Auscultation
- bowel sounds (10 times per minute) heard as soft clicks and
gurgles
- patent NGT; with borborygmic sound in ingestion of air
l. Urinary Inspection
-with indwelling foley catheter
(+) light yellow colored urine
m. Genitalia Not done
n. Musculoskeletal Inspection
(+)immobility of upper and lower extremities
(+)body weakness
(+)limited ROM with the aid of assistance of relatives
o. Neurologic Inspection
-GCS score of 6 as evidenced by spontaneous eye movement
with blinking but no motor and verbal response to touch
stimulus or even at pain stimulus

Motor function
-no movement
p. Hematologic Inspection
Capillary refill of 3 seconds
(-)bleeding
(+)inflammation on edematous right forearm
(+)edema on right and left forearm
(+)palpable lymph nodes
q. Endocrine (-)diaphoresis
(-)exopthalmos

2. LABORATORY STUDIES / DIAGNOSTICS

Procedure/Date Indication Normal Actual Nursing
Findings Findings Responsibilities
Chest X-Ray PA Is a projection Impression: -check doctor’s
Nov. 7, 2010 radiograph of -PTB involving order
the chest used both upper -explain client
to diagnose lungs the procedure
conditions progressing
affecting the from previous
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chest, its study with

contents, and volume loss,
nearby right
structures. -interstitial
Chest pneumonia
radiographs and/or TB
are among the endobronchial
most common spread lower
films taken, lung
being -atheromatous
diagnostic of aorta
many -pleuro
conditions diaphragmatic
reaction, right
-minimal
pleural effusion
vs thickening
-degenerative
changes of the
spine

Hematology Hemoglobin 123-253 104 L -check doctor’s

Nov. 06, 2010 Hematocrit 0.36 – 0.45 0.32 L order
- obtain informed
WBC 5.0 – 10.0 6.6x109/L concent
x109/L - assess pt. for
Differential allergy to iodine
Count Post-Procedure:
Segmenters 0.35-0.66 0.77 H - assess pt. for
Lymphocytes 022 – 0.40 0.15 L signs of bleeding
Eosinopils 0.01 – 0.04 0.05 H /adverse reaction
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Monocytes 0.04-0.04 0.02 L to the dye

Stab Cells - assess the
affected
extremity for any
change in
sensorimotor
function

3. OTHER ASSESMENT TOOLS

a. Functional Level Code

Comprehensive Actual
Date Taken Actual Result
Content /Legend

Nov. 30, 2010 (See Table below) Level 5

LEGEND FUNCTIONAL LEVEL CODE

LEVEL 1 FULL SELF CARE
LEVEL 2 REQUIRES USE OF REQUIREMENTS OR DEVICE
REQUIRES ASSISTANCE OR SUPERVISION FROM ANOTHER
LEVEL 3
PERSON
REQUIRES ASSISTANCE OR SUPERVISION FROM ANOTHER
LEVEL 4
PERSON OR DEVICE
LEVEL 5 IS DEPENDENT AND DOES NOT PARTICIPATE

The client is no longer moving. She receives device support for her
breathing, IVF for hydration, NGT feeding for nutrition, relatives for moving and
nurses for clinical procedures.

b. Scale for Muscle Strength

Comprehensive Actual
Date Taken Actual Result
Content /Legend
Nov. 30, 2010 (See Table below) 2
Rating Explanation Strength Classification
5 Active motion against full resistance Normal
4 Active motion against some resistance Slight Weakness
3 Active motion against gravity Average Weakness
Passive ROM (gravity removed and
2 Poor ROM
assisted by examiner
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1 Slight flicker of contraction Severe Weakness

0 No Muscular contraction Paralysis
There is poor in the client’s ROM. The client no longer moves, and if she moves,
it is very seldom, and is due to assistance of other.

c. Pulse Amplitude Scale

Comprehensive Actual
Date Taken Actual Result
Content /Legend

0 = absent
1+ = Weak
Nov. 30, 2010 2+ = Normal 4+
3+ = Increased
4+ = Bounding

The pulse amplitude scale result is 4+, because the beating of the pulse is
bounding, yet irregular in rhythm. She usually have a pulse rate of 70bpm.

d. Glassgow Coma Scale

Comprehensive Actual
Date Taken Actual Result
Content /Legend

Spontaneous--open with blinking

at baseline (4points)

Opens to verbal command,

Eye speech, or shout (3points)
Nov. 30, 2010 Opening 4
Response Opens to pain, not applied to face
(2points)

None (1point)

Verbal Oriented (5points) 1

Response
Confused conversation, but
able to answer questions
(4points)
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Inappropriate responses, words

discernible (3points)

Incomprehensible
speech(2points)

None(1point)

Obeys commands for

movement(6points)

Purposeful movement to
painful stimulus(5points)

Withdraws from pain(4points)

Motor 1
Response Abnormal (spastic) flexion,
decorticate posture (3points)

Extensor (rigid) response,

decerebrate posture(2points)

None(1point)

The client had a score of 6 in GCS as evidenced by spontaneous eye movement

and blinking but then, there are no verbal and motor response. No verbal response
because a mechanical ventilator is attached to the client, therefore inhibiting verbal
process of the client, as for motor response, the client does not exhibit motor response
whether to touch or pain stimulus, there is just tears flowing down the client’s eyes when
the procedure is quite painful.

J. FUNCTIONAL ASSESSMENT (including ADL)

According to daughter

A. Health Perception – Health Management

The client has been said healthy before the admission occurred. Seldom getting
sick and used to roam around place to place in their compound. She is fund of making
use of herbal leaves when it comes to managing health illnesses, such as oregano for
cough.
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B. Self-esteem, Self concept, Self-Perception Management

The client usually seems to feel good about herself. Very lively and is close to
the neighbors and to family members, always smiling and is very accommodating. As
for the present situation it is said that it can be felt that the client is very lonely.

C. Activity – Exercise Pattern

Functional level code is at level 4 requiring personal and device assistance. At
present, she needs the mechanical ventilator assisting her breathing, the relatives
when changing body positioning and for hygienic matters. Exercising has not been a
habit of the patient ever since.

D. Sleep – Rest Pattern

Usually, by 6pm, the client is already asleep. Lying down makes her sleepy and
wakes up by 3am the other day or earlier the next day. Taking afternoon naps also is a
for of her rest. At present, the client is, most of the time, asleep.

E. Nutritional / Elimination Pattern

Client does not take any as her vitamins. She is picky on foods because she only
have 2 teeth to grind the meal so she preferred something soft like fish. At present, the
source of nutrition of the patient was via the 1600kcal OF with 6-8 egg whites as
ordered by the physician. The client was catheterized and bowel is still present.

F. Sexuality-Reproductive Pattern
The client only had two children when her husband left their family. At 45 the
client was menopaused.

G. Interpersonal Relationships
The client was a disciplinarian mother by words. She is at peace with her
neighbors, maintains a communication with her offsprings and is more relaxed with
someone, either offspring or grandchildren by his side.

H. Coping and Stress Management/ Tolerance Pattern

The client has high tolerance to events occurring to her life. She does not get
angry much and always forgives. Even at present, she is tolerating the pain she is
feeling and hangs on to live.

I. Personal Habits
The client does not have vices, alcohol intake, smoking, drug misuse/abuse
during her younger years as she is having the time of her life enjoying youth.
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J. Environmental Hazards
Housing and neighborhood is safe according to the client’s daughter, because
the client is at peace with their neighbors. She lives together with her offsprings in a
compound, grandchildren and in-laws. There is easy access for transportation because
there are numerous tricycles that pass along their area.

II. PROBLEM LIST

A. ACTUAL
Problem Problem Date Date Resolved /
no. Identified Remarks
1 Ineffective Airway Clearance Nov. 30 ---
2 Impaired Gas Exchange Nov. 30 ---
3 Imbalanced Nutrition: Less than Nov.30 ---
body requirements
4 Excess fluid volume Nov.30 ---
5 Impaired tissue integrity Nov.30 ---
6 Impaired physical mobility Nov.30 ---

B. HIGH RISK
Problem Problem Date Identified
no.
1 Risk for Nov. 30
Infection
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IV. ANATOMY AND PHYSIOLOGY

The human skeleton consists of both fused and individual bones supported and

supplemented by ligaments, tendons,muscles and cartilage. It serves as a scaffold
which supports organs, anchors muscles, and protects organs such as
the brain, lungs and heart. The biggest
bone in the body is the femur in the thigh,
and the smallest is the stapes bone in
the middle ear. In an adult, the skeleton
comprises around 30-40% of the total
body weight,[1] and half of this weight is
water.
Fused bones include those of
the pelvis and the cranium. Not all bones
are interconnected directly: there are three
bones in each middle ear called
the ossicles that articulate only with each
other. The hyoid bone, which is located in
the neck and serves as the point of
attachment for the tongue, does not
articulate with any other bones in the
body, being supported by muscles and
ligaments.

Development
Early in gestation, a fetus has a
cartilaginous skeleton from which the long
bones and most other bones gradually
form throughout the remaining gestation
period and for years after birth in a
process called endochondral ossification.
The flat bones of the skull and
the clavicles are formed from connective
tissue in a process known
as intramembranous ossification,
and ossification of the mandible occurs in
the fibrous membrane covering the outer
surfaces of Meckel's cartilages. At birth a
newborn baby has over 300 bones, whereas on average an adult human has 206
bones[2] (these numbers can vary slightly from individual to individual). The difference
comes from a number of small bones that fuse together during growth, such as
the sacrum and coccyx of the vertebral column.
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Organization
There are 206 bones in the adult human skeleton, a number which varies between
individuals and with age - newborn babies have over 270 bones some of which fuse
together into a longitudinal axis, the axial skeleton, to which theappendicular skeleton is
attached.

Function
The skeleton serves 6 major functions.

Support
The skeleton provides the framework which supports the body and maintains its shape.
The pelvis and associated ligaments and muscles provide a floor for the pelvic
structures. Without the ribs, costal cartilages, and the intercostal muscles the lungs
would collapse.
Movement
The joints between bones permit movement, some allowing a wider range of movement
than others, e.g. the ball and socket joint allows a greater range of movement than the
pivot joint at the neck. Movement is powered by skeletal muscles, which are attached to
the skeleton at various sites on bones. Muscles, bones, and joints provide the principal
mechanics for movement, all coordinated by the nervous system.

Protection
The skeleton protects many vital organs:
 The skull protects the brain, the eyes, and the middle and inner ears.
 The vertebrae protects the spinal cord.
 The rib cage, spine, and sternum protect the lungs, heart and major blood
vessels.
 The clavicle and scapula protect the shoulder.
 The ilium and spine protect the digestive and urogenital systems and the hip.
 The patella and the ulna protect the knee and the elbow respectively.
 The carpals and tarsals protect the wrist and ankle respectively.

Blood cell production
The skeleton is the site of haematopoiesis, which takes place in red bone marrow.
Marrow is found in the center of long bones.

Storage
Bone matrix can store calcium and is involved in calcium metabolism, and bone
marrow can store iron in ferritin and is involved in iron metabolism. However, bones are
not entirely made of calcium,but a mixture of chondroitin sulfate and hydroxyapatite, the
latter making up 70% of a bone.

Endocrine regulation
Bone cells release a hormone called osteocalcin, which contributes to the regulation
of blood sugar (glucose) and fat deposition. Osteocalcin increases both
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the insulin secretion and sensitivity, in addition to boosting the number of insulin-

producing cells and reducing stores of fat

Sex-based differences
There are many differences between the male and female human skeletons. Most
prominent is the difference in the pelvis, owing to characteristics required for the
processes of childbirth. The shape of a female pelvis is flatter, more rounded and
proportionally larger to allow the head of a fetus to pass. Men tend to have slightly
thicker and longer limbs and digit bones (phalanges), while women tend to have
narrower rib cages, smaller teeth, less angular mandibles, less pronounced cranial
features such as the brow ridges and external occipital protuberance (the small bump at
the back of the skull), and the carrying angle of the forearm is more pronounced in
females. Females also tend to have more rounded shoulder blades.

V. PATHOPHYSIOLOGY
Introduction

Background
This article discusses fractures of the femoral diaphysis. For proximal femur fractures
(subtrochanteric to femoral head), see the article Fractures, Hip. For fractures of the
distal femur (supracondylar to condylar), see the article Fractures, Knee.

The femur is the largest and strongest bone and has a good blood supply. Because of
this and its protective surrounding muscle, the shaft requires a large amount of force to
fracture. Once a fracture does occur, this same protective musculature usually is the
cause of displacement, which commonly occurs with femoral shaft fractures.

As with many orthopedic injuries, neurovascular complications and pain management

are the most significant issues in patients who come to the ED. The rich blood supply,
when disrupted, can result in significant bleeding. Open fractures have added potential
for infection.

The 3 types of femoral shaft fractures are as follows:

 Type I - Spiral or transverse (most common)

 Type II - Comminuted
 Type III - Open

Associated injuries are common.

Anteroposterior radiograph of a femoral-shaft fracture in a 19-year-old

man.
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Pathophysiology
Diaphyseal fractures result from significant force transmitted from a direct blow or from
indirect force transmitted at the knee.

Pathologic fractures may occur with relatively little force. These may be the result of
bone weakness from osteoporosis or lytic lesions.

Mortality/Morbidity
Morbidity and mortality rates have been reduced in femoral shaft fractures, mainly as
the result of changes in methods of fracture immobilization. Current therapies allow for
early mobilization, thus reducing the risk of complications associated with prolonged
bed rest.

Clinical

History:

 In older persons, hip fracture most often results from a simple fall; in a small
percentage, it occurs spontaneously in the absence of a fall.
 Patient complains of pain and inability to move the hip.
 With stress fractures in young athletes and nondisplaced fractures, patient may
complain of pain in hip or knee and may be ambulatory.
 Patient may have a history of other osteoporotic fractures, such as Colles or
vertebral fractures.

Physical:

 In patients who experienced trauma, perform a primary survey and stabilize as

needed.
 Take a detailed secondary survey because of the high likelihood of other
associated injuries. As many as 69% of patients with femoral head fracture-
dislocations had major associated injuries, including other extremity injuries,
intra-abdominal or intrapelvic injuries, neck injuries, and head injuries.
 Pay particular attention to vital signs and secondary manifestations of shock such
as changes in skin, mental status, and urine output. Hip fractures are associated
with blood volume losses of up to 1500 cc.
 Inspect and palpate for deformity, hematoma formation, laceration, and
asymmetry.
 Observe the natural position of the extremity, as this alone often indicates the
type of injury the patient has sustained.
 Femoral head fracture: Most often, this occurs as a result of hip dislocation;
therefore, the position of the extremity is abduction, external rotation, and flexion
or extension for anterior dislocation. With posterior dislocation (most common
type), the extremity is held in an adducted and internally rotated position.
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 Femoral neck fracture: Extremity is held in a slightly shortened, abducted, and

externally rotated position, unless the fracture is only a stress fracture or severely
impacted. In this case, the hip is held in a natural position.
 Intertrochanteric fracture: Extremity is held in a markedly shortened and
externally rotated position.
 Subtrochanteric fracture: Proximal femur usually is held in a flexed and externally
rotated position.
 Trochanteric fracture
 No deformities are noted on observation.
 Apply lateral to medial pressure on hips through greater trochanters.
 In assessing range of motion (ROM), first test external and internal rotation with
extremity in extension. If the patient has a fracture, especially a displaced one,
the remainder of ROM exam is extremely painful, of limited diagnostic use, and
potentially dangerous. If the patient has pain with the initial ROM exam, obtain x-
ray prior to completing.
 Perform a detailed distal neurovascular exam.
 If patient is a trauma victim, assess for pelvic fracture by stressing pelvis
anteriorly to posteriorly through iliac crests and symphysis pubis, and laterally to
medially through iliac crests.
Physical

 Conduct a thorough examination to rule out associated injury. Hip fractures and
ligamentous knee injuries commonly are observed in association.
 At the site of fracture, tenderness on examination and visible deformity typically
are noted.
 The extremity may appear shortened, and crepitus may be noted with movement.
 The thigh is often swollen secondary to hematoma formation.
 Perform a thorough vascular examination on the extremity. Signs of vascular
compromise should prompt arteriography and a vascular surgery consult.
Physical signs of arterial injury include the following:
o Expanding hematoma
o Absent or diminished pulses
o Progressive neurologic deficits in a closed fracture
 Because of extensive blood supply to the musculature surrounding the femur,
diaphyseal fractures may be associated with significant blood loss (ie, 1 L or
more) and resulting tachycardia and hypotension.
 Test distal neurologic function, though examination is frequently unreliable
because of the amount of pain associated with these fractures. Nerve injury is
rare because of protective surrounding musculature.

Risk factors:
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 Race: Incidence of hip fracture is 2-3 times greater in whites than in nonwhites,
primarily because of the increased rate of osteoporosis in whites.

 Sex:
 Rate of hip fracture is 2-3 times greater in women than in men. At least 75% of all
hip fractures occur in women.
 Lifetime risks of hip fracture in white women and men are 15% and 5%,
respectively.
 Femoral neck fractures are more frequent in women than men by about 4:1.
Intertrochanteric fractures are more frequent in women than men by about 5:1

 Age:
 Rate of hip fracture increases with age; after age 50 years, it doubles with each
decade. Nearly 50% of all hip fractures occur in adults older than 80 years. Hip
fracture at a young age is not common and is usually the result of a major
traumatic event or, rarely, is related to bone pathology.
 Femoral head fractures are more common in younger patients, because the
same mechanism of injury is more likely to cause femoral neck fracture in older
persons.
 Trochanteric fractures are uncommon and affect younger patients more often
than older persons.
 Femoral neck fractures are rare in younger patients; the average age is 74-78
years.
 Intertrochanteric fractures also are rare in younger patients; the average age is
75-81 years.
 Subtrochanteric fractures have a bimodal age distribution and are seen most
often in those aged 20-40 years in association with high-energy trauma and in
patients older than 60 years.

Causes:

 in young persons, trauma associated with significant kinetic energy is required to

cause a hip fracture. For example, 75% of all femoral head fractures, more
common among young patients, occur as a result of motor vehicle accidents.
 In older persons, more than 90% of these fractures result from trauma or torsion
associated with a minor fall. They also can occur in the absence of an obvious
traumatic event.
 Osteoporosis greatly increases risk of fracture.
 Other risk factors for hip fracture include the following:
 Dementia
 Cigarette smoking
 Institutional living
 Maternal history of hip fracture
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 Previous hip fracture

 Previous Colles or vertebral fracture attributed to osteoporosis
 Physical inactivity
 Low body weight
 Tall stature
 Alcohol abuse
 Impaired vision
 Use of psychotropic medications and drugs that decrease bone mass, including
furosemide, corticosteroids, thyroid hormone, phenobarbital, and phenytoin

VI. MEDICAL-SURGICAL MANAGEMENT (Curative)

1. Procedure

Procedure/Date Indication/ Analysis Nursing

Responsibilities
suctioning The need to remove - The primary
accumulated pulmonary
responsibility for
secretions as evidenced
by one of the following: suctioning shall be
4.1.1 Coarse breath
assumed by the nurse to
sounds by auscultation or
'noisy' breathing be performed
4.1.2 Increased peak
whenever necessary; a
inspiratory pressures
during volume-controlled physician's order is not
mechanical ventilation or
required. Patient
decreased tidal volume
during pressure- assessment shall be
controlled ventilation.
performed to determine
4.1.3 Patient's inability to
generate an effective the need for appropriate
spontaneous cough.
suctioning.
4.1.4 Visible secretions in
the airway - suctioning patients
4.1.5 Changes in
immediately
monitored flow and
pressure graphics prior to and following
4.1.6 Suspected
treatments to perform
aspiration of gastric or
upper airway secretions - hyperoxygenated before
4.1.7 Clinically apparent
and after all forms of
increased work of
breathing suctioning either by
4.1.8 Deterioration of
encouragement to deep
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arterial blood gas values breathe, or by ambu bag

4.1.9 Radiologic changes
with 100% oxygen setup
consistent with retention
of pulmonary secretions if not
4.2 The need to obtain a
contraindicated.
sputum specimen to rule
out or identify pneumonia
or other pulmonary
infection or for sputum
cytology
4.3 The need to maintain
the patency and integrity
of the artificial airway
4.4 The need to stimulate
a patient cough in
patients unable to cough
effectively secondary to
changes in mental status
or the influence of
medication
4.5 Presence of
pulmonary atelectasis or
consolidation, presumed
to be associated with
secretion retention
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2. Pharmatherapeutics/ Medicines

GN (BN) Indication (Client Specific) Nursing Responsibilities

Classification Stock Dosage and Frequency

> Aspirin is used for the

GENERIC NAME: treatment of inflammation,
aspirin
fever, and pain that results
BRAND NAMES: from many forms of arthritis,
Aspirin including rheumatoid arthritis,
juvenile arthritis, systemic
Classication: lupus erythematosus,
Acetylsalicylic acid ankylosing spondylitis,
Reiter's syndrome, and
Tablets: caplets and osteoarthritis, as well as for
tablets: 325mg, soft tissue injuries, such as
500mg; enteric tendinitis and bursitis. Aspirin
coated (safety also is used for rapid relief of
coated) caplets and mild to moderate pain and
tablets: 325mg, fever in other inflammatory
500mg. conditions. Because aspirin
inhibits the function of
platelets for prolonged
periods of time, it is used for
reducing the risk of strokes
and heart attacks.
DOSAGE
Tablets: 80 mg tab
OD pc
Peptamen® [powd]
Peptide based diet for > Mix well with water
Classification: patients w/ impaired GI
Enteral/Nutritional function. Appropriate also for >Do not over infuse
> Aspirin should be
stored at room
temperature, 20-25 C
(68-77 F), in a sealed
container, avoiding
moisture
> The most common side
effects of aspirin involve
the gastrointestinal
system and ringing in the
ears. With respect to the
gastrointestinal system, it
can cause ulcerations,
abdominal burning, pain,
cramping, nausea,
gastritis, and even
serious gastrointestinal
bleeding and liver
toxicity. Sometimes,
ulceration and bleeding
can occur without any
abdominal pain. Black
tarry stools, weakness,
and dizziness upon
standing may be the only
signs of internal bleeding.
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Products those w/ fat malabsorption

requiring a low fat diet; > If in NGT; the NGT
Per 100 g Fat 18.5 g, provides total nutrition support should be patent to avoid
protein 18 g,
via tube-feeding or oral aspiration
carbohydrate 57.2 g, administration; 1st choice
vit A 1,900 iu, vit D after trauma, surgery at the
130 iu, vit E 13 iu, vit
ICU.
K 23 mcg, vit C 65
mg, vit B1 0.93 mg, 6 scoops in one glass H2O
vit B2 1.1 mg, niacin
13 mg, vit B6 1.9 mg,
folic acid 250 mcg,
pantothenic acid 6.5
mg, vit B12 3.7 mcg,
biotin 190 mcg,
choline 210 mg,
taurine 37 mg,
carnitine 37 mg, Na
365 mg, K 580 mg,
Cl 467 mg, Ca 370
mg, phosphorus 325
mg, Mg 186 mg,
manganese 1,235
mcg, Fe 5.6 mg,
iodine 46 mcg,
copper 0.65 mg, Zn
6.5 mg, selenium 19
mcg, chromium 19
mcg, molybdenum
56 mcg. Energy: 465
kCal.
Dosage
5 scoops or 43 g in
170 mL water
providing 200 kcal.
Tube feeding: Can
be fed full strength &
often full rate from
day 1 to provide max
nutritional support
Bactroban Ointment®
> Primary skin infections eg
> Avoid contact w/ eyes
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impetigo, folliculitis,
Classification: furunculosis & ecthyma.
Topical Antibiotics Secondary infections eg
infected eczema, infected
Apply bid-tid for up to traumatic lesions including
10 days. abrasions, insect bites, minor
wounds & burns. Bacterial
contamination prophylaxis.
>pt’s indication:TID
or prolonged use.
Caution use in moderate
or severe renal
impairment. . Pregnancy.
> has an adverse
reaction of Burning
sensation, stinging,
itching. Cutaneous
sensitization reactions.
> using of Sterile gloves
when applying

VII. PROGRESS NOTES

Day # 1
During the first day of contact with the patient, the client was lying
Date: supinely on bed and with no movements demonstrated. The client had
November many contraptions, NGT, ET, IVF, IFC and had a score of 6 in GCS.
23, 2010 The upper extremities are edematous and the right forearm appears
inflamed.
Time: There are 2 pressure sores at the lumbar area of the patient, the one
2pm-10pm which is already healed and the other one which is still under treatment.
The client often cries prior to suctioning, and coughs out frequently.
Nurse-patient-relative interaction was done with the patient immediately
after endorsement. Vital signs was monitored and recorded. Adequate
rest periods were also given to the patient. The patient was closely
monitored for suctioning and for osteurized feeding. Intake and output
was also monitored and recorded.
Day # 2
During the second day of contact with the patient, there is no difference
Date: than that of the first day. All the contraptions were still attached, the
November forearms are still edematous with the right forearm inflamed. Pressure
24, 2010 sores were cleansed every night. Nurse-patient-relative interaction was
done, vital signs taken and recorded, done feeding and suctioning,
Time: intake and output monitored and recorded.
2pm-10pm

Day # 3
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On the third day of contact with the patient, there is still no difference
Date: than that of the first day. All the contraptions were still attached, the
November forearms are still edematous with the right forearm inflamed. Pressure
30, 2010 sores were cleansed every night. Nurse-patient-relative interaction was
done, vital signs taken and recorded, done feeding and suctioning,
intake and output monitored and recorded.
Time:
2pm-10pm
Day # 4
On the fourth day of contact with the patient, there is still no difference
Date: than that of the first day. All the contraptions were still attached, the
December forearms are still edematous with the right forearm inflamed. Pressure
01, 2010 sores were cleansed every night. Nurse-patient-relative interaction was
done, vital signs taken and recorded, done feeding and suctioning,
Time: intake and output monitored and recorded.
2pm-10pm
Day # 5
On the fifth day of contact with the patient, all contraptions were still
Date: attached, inflamed right forearm already resolved but there still remains
December edema on the upper extremities. Pressure sore was cleansed. Nurse-
07, 2010 patient-relative interaction was done, vital signs taken and recorded,
done feeding and suctioning, intake and output monitored and
Time: recorded.
2pm-10pm

VIII. DISCHARGE HEALTH TEACHING PLANS

Content Strategy
1. Compliance Medication Follow up checkups
-On medication, the
Diet -Prescribed medications of client will be given the
the physician should be list of prescribed
Exercise taken. medications listed on a
table with columns of the
Activity Changes medication name,
-In rehabilitating Soft foods specific time of the day
with low fat is prescribed for the medication needed
the client to be taken, frequency of
taking medication and
until when the
-Use of anti septic solution medication should be
on wound cleaning taken. Also, this will
contain the dos and
don’ts that are needed to
be followed to prevent

Follow-up/ Check-up Consultation to the
physician will be scheduled
one week after the client
was discharged in a time
flexible for the client’s
schedule.
Client will be advised to
consult doctor for any
problems or complications
encountered.
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severe reaction.
-Diet plans with
modification of low fat
diet will be listed as well
as the foods allowed to
be consumed and the
foods needed to be
limited.
Step by step procedure
of proper wound care will
be provided in a list
adjusted to the client’s
preferred language.
Pictures will be included
in the pamphlet where
the procedure is listed.
-A personal/common
prayer will be told
together with the patient
for fast recovery.
Evaluation of effective
ness of the medication to
the client by monitoring
the result
-A consultation schedule
will be provided as well
as list of the signs of
infection and
complication that may
need immediate medical
attention if observed.
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IX. SUMMARY OF CLIENT’S STATUS OR CONDITION AS OF LAST DAY OF CONTACT

Date: December 7, 2010

On the last day of contact, there is quite an improvement in the client’s condition.The
client was lying supinely on bed and with no movements demonstrated. The client still
have many contraptions, NGT, ET, IVF, IFC and had a score of 6 in GCS. The upper
extremities are less edematous - grade 2, and the right forearm no longer appears
inflamed. There are still 2 pressure sores at the lumbar area of the patient, the one
which is already healed and the other one which is still under treatment.

_________________________ __________________________
Signature above PRINTED NAME Signature above PRINTED NAME
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