Fracture Slide Basis

University of Perpetual Help System Laguna-Isabela Campus
Minante 1, Cauayan City, Isabela
College of Nursing
FRACTURE: CLAVICLE FRACTURE (L)
A Case Study
Presented To
The Faculty of the College of Nursing
University of Perpetual Help System Isabela Campus
Minante Uno, Cauayan City, Isabela
In Partial Fulfilment
of the Requirements for the subject
Maternal and Child Health Nursing – Acute and Chronic (NCM 109)
Submitted by:
Constantino, King Aldus J.
Submitted to:
Ms. Joanne Sison RN, MSN
Ms. Amie Jane Padolina, RN, MSN
Dr. Prince Llyod Cruz
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TABLE OF CONTENTS
I. Case Overview
II. Patient’s Profile
III. General Survey
IV. Nursing History
V. Gordon’s Functional Health Pattern
VI. Physical Assessment
VII. Neurological Assessment
VIII. Diagnostic and Laboratory Tests
IX. Anatomy and Physiology
X. Pathophysiology
XI. Course in the Ward
XII. Nursing Care Plan
XIII. Drug Study
XIV. Discharge Planning
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CASE OVERVIEW
A fracture is a break in the bone. An open or complicated fracture occurs when a
shattered bone punctures the skin. Fractures are usually caused by vehicle accidents, falls, or
sports injuries. Low bone density and osteoporosis are two more reasons of bone weakness.
Stress fractures, which are extremely minute fissures in the bone, can be caused by overuse.
A fracture, like a crack or a break, is a fractured bone. A bone can be totally or partly broken in a
variety of ways (crosswise, lengthwise, in multiple pieces).
TYPES OF FRACTURES
Despite being rigid, bones can flex or give somewhat in response to an external stimulus.
Bones will, however, break if the force is too severe, much as a plastic ruler will if it is twisted
too far.
The force that broke the bone often determines how serious a fracture is. The bone may
fracture rather than completely shatter if the breaking threshold has just been slightly surpassed.
The bone may break if the force is too great, such in a car accident or from a bullet.
An open fracture occurs when the bone fractures in a way that bone pieces protrude
through the skin or when a wound extends all the way to the shattered bone. Because once the
skin is ruptured, infection can develop in both the wound and the bone, this sort of fracture is
extremely severe.
Common types of fractures include:
 Open fracture (compound fracture): The bone pokes through the skin and can be seen.
Or a deep wound exposes the bone through the skin.
 Closed fracture (simple fracture). The bone is broken, but the skin is intact.
 Fractures have a variety of names. Here is a list of types that may happen:
 Greenstick. This is an incomplete break. A part of the bone is broken, causing the other
side to bend.
 Transverse. The break is in a straight line across the bone.
 Spiral. The break spirals around the bone. This is common in a twisting injury.
 Oblique. The break is diagonal across the bone.
 Compression. The bone is crushed. This causes the broken bone to be wider or flatter in
appearance.
 Comminuted. The bone has broken into 3 or more pieces. Fragments are present at the
fracture site.
 Segmental. The same bone is broken in 2 places, so there is a "floating" piece of bone.
 Avulsion. The bone is broken near a tendon or ligament. A tendon or ligament pulls off a
small piece of bone.
CAUSES OF FRACTURES
The most common causes of fractures are:
 Trauma. A fall, motor vehicle accident, or tackle during a football game can all result in
fractures.
 Osteoporosis. This disorder weakens bones and makes them more likely to break.
 Overuse. Repetitive motion can tire muscles and place more force on bone. This can
result in stress fractures. Stress fractures are more common in athletes.
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Fractures can also be caused by diseases that weaken the bone. This includes osteoporosis or
cancer in the bones.
RISK FACTORS OF DEVELOPING FRACTURES
Risk factors that should also be considered include smoking, weight loss, family history,
decreased physical activity, alcohol or caffeine use, or low calcium and vitamin D intake.
 Smoking. Smoking is a risk factor for fracture because of its impact on hormone levels.
 Alcohol. Drinking alcohol in excess can influence bone structure and mass. Research
published by the National Institute on Alcohol Abuse and Alcoholism indicates that
chronic heavy drinking during a person’s earlier years can compromise bone quality and
may increase the risk of bone loss—and potential fractures—even after drinking has
stopped.
 Steroids. (corticosteroids) are often prescribed to treat chronic inflammatory conditions,
such as rheumatoid arthritis, inflammatory bowel disease and chronic obstructive
pulmonary disease (COPD).
 Rheumatoid Arthritis. In this debilitating autoimmune disease—which strikes two to
three times more women than men—the body attacks healthy cells and tissues around the
joints, resulting in severe joint and bone loss.
 Other Chronic Disorders. Celiac disease, Crohn’s disease, and ulcerative colitis, are
often linked to bone loss which can be accelerated by their frequent and necessary
treatment with steroids.
 Diabetes. patients with Type 1 diabetes often have low bone density, though researchers
are not sure why. Typical onset of Type 1 diabetes is in childhood when bone mass is
building, and some sufferers also have celiac disease.
 Previous Fracture. Previous Low Impact Fractures doubles the risk of having another
fracture.
 Family History. Family history of hip fracture increases the risk of hip fractures in their
children.
SIGNS AND SYMPTOMS OF FRACTURES

Symptoms of a fracture vary depending on its location, a person’s age and general health,
and the severity of the injury.
However, people with a bone fracture will typically experience some of the following:
 Pain
 Swelling
 Bruising
 Discolored skin around the affected area
 Protrusion of the affected area at an unusual angle
 Inability to put weight on the injured area
 Inability to move the affected area
 A grating sensation in the affected bone or joint
 Bleeding if it is an open fracture
In more severe cases, a person may experience:
 Dizziness
 Faintness or lightheadedness
 Nausea
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DIAGNOSTICS
How are fractures identified?
A thorough health history will be taken by your healthcare practitioner (including asking how the
injury happened). You'll also have a physical examination. Testing for a fracture could involve:
 X-ray. A diagnostic test that uses invisible electromagnetic energy beams to make
pictures of internal tissues, bones, and organs on film.
 MRI. An imaging test that uses large magnets, radiofrequencies, and a computer to make
detailed pictures of structures within the body.
 CT scan. This is an imaging test that uses X-rays and a computer to make detailed
images of the body. A CT scan shows details of the bones, muscles, fat, and organs.
COMPLICATIONS OF FRACTURES
Some complications (such as blood vessel and nerve damage, compartment syndrome, fat
embolism, and infections) occur during the first hours or days after the injury. Others (such as
problems with joints and healing) develop over time.
 Blood vessel damage

 Nerve damage
 Pulmonary embolism
 Fat embolism
 Compartment syndrome
 Infections
 Joint problems
 Uneven limbs
 Osteonecrosis
TREATMENTS OF FRACTURES
The goal of treatment is to put the pieces of bone back in place, control the pain, give the
bone time to heal, prevent complications, and restore normal use of the fractured area.
Treatment may include:
 Splint or cast. This immobilizes the injured area to keep the bone in alignment. It protects
the injured area from motion or use while the bone heals.
 Medicine. This may be needed to control pain.
 Traction. This is the use of a steady pulling action to stretch certain parts of the body in a
certain direction. Traction often uses pulleys, strings, weights, and a metal frame attached
over or on the bed. The purpose of traction is to stretch the muscles and tendons around the
broken bone. This helps the bone ends to align and heal.
 Surgery. Surgery may be needed to put certain types of broken bones back into place.
Sometimes internal fixation devices (metal rods or pins located inside the bone) or external
fixation devices (metal rods or pins located outside of the body) are used to hold the bone
fragments in place while they heal.
 Fractures can take months to heal as broken bones “knit” back together when new bone is
formed between the broken parts.
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MEDICATIONS
Drugs used to treat fractures are generally nonsteroidal anti-inflammatory drugs
(NSAIDs), analgesics, and anxiolytics.
STATISTICS
According to the study conducted by Li-Yu, Juliet T. 2007, There was no report of
osteoporosis among the 50 to 59 years old individuals. The overall prevalence of osteoporosis in
adult Filipinos 60 to 69 years of age was 0.8% while those beyond 70 years old was 2.5 percent.
The overall prevalence of fractures was 11.3 percent in females and 9.0 percent in males. Using
the heel pixi, the overall prevalence of low bone mass was 65.2 percent in females and 70.0
percent in males. Using the OSTA, 37.5 percent of female’s vs 45.16 percent of males were in
the low risk group, 44.8 percent of female’s vs 41.9 percent of males were identified to be at
intermediate risk while 17.6 percent of female’s vs 12.9 percent of males were at high risk for
osteoporosis.
PATIENT’S PROFILE
NAME: Patient X
AGE: 53 years old
ADDRESS: San Francisco, Alicia
BIRTHDATE: 08/02/1969
SEX: Male
CIVIL STATUS: Married
RELIGION: Roman Catholic
WEIGHT: 62kg
HEIGHT: 159
BMI:
GENERAL SURVEY: The patient is on-going D5NSS @ 30gtts/min.
Patient is awake, conscious and coherent. On
the left upper clavicle, the patient complained
of swelling and soreness. On the patient's
right leg, there are sutures.
CHIEF COMPLAINT: Swelling shoulder (L)
DIAGNOSIS: Fracture clavicle (L)
VITAL SIGNS
BLOOD PRESSURE 170/100
RESPIRATORY RATE 20
HEART RATE 88
TEMPERATURE 36.2°C
O2 99%
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GENERAL SURVEY
Patient X is a male 53 years old born on 08/02/1969, residing at San Francisco, Alicia.
During the general survey, the patient is on-going D5NSS @ 30gtts/min. Patient is awake,
conscious and coherent. On the left upper clavicle, the patient complained of swelling and
soreness while on the patient's right leg, there are pain felt because of sutures.
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NURSING HISTORY
I. Present History
In the case of patient X, the left clavicle of the patient had swelled five hours before
admission. The patient complained of a lesion on his right leg and pain in his left shoulder. The
patient's vital signs are all within normal range, with the exception of his elevated blood pressure
of 170/100.
II. Past Medical History
Patient X never had any significant illnesses, although he did have a cough and a fever
that were treated with over-the-counter medicines and herbal medicines. The patient has never
undergone surgery or been hospitalized. The patient receives a COVID-19 vaccination as well as
booster doses.
III. Family History
Patient’s X who resides in San Francisco, Alicia have no history of the disorders in their
families. Whereas the patient has hypertension, it is controlled with medication. The patient
never had any major issues. The patient's wife has diabetes and hypertension, while their middle
child, an adult, exhibits decrescendo crescendo osteoporosis symptoms.
IV. Familial Diseases
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GORDON’S FUNCTIONAL HEALTH PATTERN

HEALTH NORMS AND
NARRATIVE REMARKS
PATTERN STANDARDS
Health The client was asked “Ano po Health is defined in many Risk for injury related
Perception – ang masasabi niyo sa ways. It is not merely the to increased WBC
Health kalusugan niyo ngayon?” The absence of disease, but secondary to fractured
Management client states “Medyo mahina includes aspects of physical, clavicle
Pattern ako ngayon kasi naaksidente mental, social, and emotional
(Describes ako. Hindi ko po magalaw ang well-being. In a positive Risk for infection
client’s kamay ko at kaka-tahi lang model of health, the definition related to surgical
perceived itong sugat sa paa ko.” includes factors such as incision.
pattern of health strength, resilience,
and well-being When asked “May past resources, potentials, and
and how health hospitalization po ba kayo, capabilities rather than
is managed) allergies sa gamot at pagkain, focusing just on pathology.
past surgeries?” The client Health involves a
states “Wala naman po, wala biopsychosocial perspective
naman akong mga allergies sa (Pender et al, 2011).
gamot o sa pagkain.”.
A person who has good
He was asked “May tinitake po physical health is likely to
ba kayong gamot o have bodily functions and
maintenance po? The client processes working at their
states “Meron po” as added peak. This is not only due not
“Losartan po para sa only to an absence of disease.
hypertension ko”. Regular exercise, balanced
nutrition, and adequate rest
The patient was asked, “Paano all contribute to good health.
niyo po hinahandle ang sarili https://bit.ly/3llRhIH
niyo po kapag may sakit po
kayo? Saan po kayo
pumupunta?” He answered,
“Sa RHU po ako pumupunta
kasi libro don”
Nutritional – The client was asked “May Eating vegetables every day Readiness for enhanced
Metabolic sinusunod po ba kayong diet?” is important for health. They fluid balance
Pattern the client states “Hindi ako provide essential vitamins,
(Describes masiyado sa karne ang minerals, and other nutrients, Readiness for enhanced
pattern of food kinakain ko madalas mga such as antioxidants and nutrition
and fluid gulay kasi mura at yun lang fiber. https://bit.ly/39BYaD6
consumption madalas ang nakakayanan
relative to namin.” People with healthy eating
metabolic need patterns live longer and are
and pattern He was asked “May mga ayaw at lower risk for serious
indicators of at gusto po ba kayong mga health problems.
local nutrient pagkain at kung may mga https://bit.ly/3sJ3TNW
supply) allergies po ba kayo, ano po
ang mga ito” the client states Eating a balanced diet that's
“Hindi ako mapili sa pagkain low in high glycemic
kaya wala rin akong carbohydrates and processed
masasabing ayaw kong foods can help your immune
pagkain, madalas kami kumain system fight off the virus.
ng gulay. At wala akong https://bit.ly/3sJ4xLy
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allergies ser”
According to the World
Health Organization, a well-
balanced diet is essential for
optimal health and nutrition.
It protects against diseases
such as heart disease,
diabetes, and cancer. A
healthy diet should include a
wide variety of foods and a
reduction in salt, carbs,
saturated fats, and trans-fats
obtained from industrial
processes.
Elimination The client was asked “Ilang Urinating 4 to 10 times a day Readiness for enhanced
Pattern beses po kayong umiihi sa is considered healthy if it urinary elimination
(Describes isang araw? The client states, does not affect day-to-day
pattern of “Dalawang beses ser” life. Most people pee 6 or 7
excretory times every 24 hours. Peeing
function (bowel, When the client is asked, between 4 and 10 times daily
bladder, urine “Kapag po ba umiihi kayo may may be considered healthy if
etc…) kulay po ba ito o may amoy po the frequency does not
ba? The client states “Wala interfere with the person's
naman po itong kulay at wala quality of life.
rin po itong amoy.”
The common value for urine
He was asked “Kapag po pH is 6.0–7.5Trusted Source
dumudumi kayo, nahihirapan for most people, but any value
po ba kayo? The client states, within the 4.5–8.0 range is
“Hindi po ako nahihirapang generally not a cause for
dumumi.” concern. The pH scale runs
from 1 to 14, with 1 being the
most acidic and 14 the most
basic.
https://bit.ly/3Psp2pn
Activity – Rest The client was asked about his Regular physical activity can Ineffective activity
Pattern exercises or what type of improve your muscle strength intolerance related to
(Describes exercise he is doing or any and boost your endurance. immobility secondary to
pattern of problem during exercise, the Exercise delivers oxygen and fractured bone
exercise, client states “Yung exercise ko nutrients to your tissues and
activity, leisure, po siguro bago ako na-hospital helps your cardiovascular
and recreation) ay ang pagtratrabaho ko. Nag system work more efficiently.
aararo ako, nagbubugat ng And when your heart and
mabibigat, ngayon ang lung health improve, you
problema ko lang siguro ay have more energy to tackle
nahihirapan po akong daily chores.
maglakad at tumayo dahil sa https://mayocl.in/3G2cYXB
tahi ko dahil nakakaramdam
po ako ng sakit sa tahi ko at
yung sa balikat ko.”
Cognitive – The client was asked “Mabilis To help us understand Acute pain related to
Perceptual po ba kayong makalimot, The information about the world fractured bone
Pattern client states “Hindi naman po around us and interact safely
(Describes ako makakalimutin” with our environment, as the
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ability to sensory information we

comprehend and The client was asked. “May receive is vast and
use information problema po ba kayo sa complicated.
and on the pandinig niyo? nanlalabo po https://bit.ly/3Mx5wq6
sensory ba ang patingin niyo? Sa pang-
functions) amoy ngay po?” The client Cognitive change as a normal
answered, “Wala naman po process of aging has been
akong mga problema sa mga well documented in the
ganyan, ang problema ko lang scientific literature. Some
po ay yung balikat ko cognitive abilities, such as
pagkatapos ng aksidente tapos vocabulary, are resilient to
yung sa paa ko na katatahi brain aging and may even
lang kaya medyo hindi ko improve with age. Other
muna ilalakad” He also added, abilities, such as conceptual
“Masakit po kasi lalong-lalo reasoning, memory, and
na yang sa balikat ko” processing speed, decline
gradually over time.
https://bit.ly/3PwHDAT
Sleep – Rest The client was asked, “Ilang A good night’s sleep is just Readiness for enhanced
Pattern oras kayo natutulog sa isang as important as regular sleep
(Describes araw?” He answered, “Mga 8- exercise and a healthy diet. A
patterns of 9 oras” peaceful bedtime routine
sleep, rest, and When the client was asked sends a powerful signal to
relaxation) “Anong oras po kayo your brain that it’s time to
natutulog?” He answered wind down and let go of the
“Mga 9 po ako natutulog at day’s stresses. Sometimes
nagigising po ako mga 7 ng even small changes to your
umaga.” environment can make a big
difference to your quality of
When the client was asked, sleep.
“Pag hapon anong oras https://bit.ly/3My6EJV
natutulog?” He answered
“Kapag hapon po hindi ako National Sleep Foundation
masiyado natutulog sa hapon guidelines advise that healthy
ser, mga Saturday at Sunday adults need between 7 and 9
lang.” hours of sleep per night.
Babies, young children, and
When is the client asked teens need even more sleep to
“Gumagamit ba ng gamot na enable their growth and
pampatulog?” He answered development. People over 65
“Wala akong iniinom na should also get 7 to 8 hours
gamot” per night.
When is the client is asked https://bit.ly/3Prgjns
“Anong nararamdaman niyo
pagkagising niyo? “Relax
ako.”
Self-perception The client was asked “Sa Self-awareness make positive Fear related to surgical
– Self-concept tingin niyo po ano ang opinyon behavioral changes that can intervention
Pattern niyo sa sarili niyo” He replied lead to greater personal and
(Describes “Mabait naman akong tao, interpersonal success. Self-
person’s kaya hindi ko na masiyado knowledge is also considered
attitudes toward pinagbayad yung nakabunggo an important quality for a
self, including saakin, gumawa nalang kami mental health professional.
identity, body ng kasulutan.” Self-awareness is considered
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image, and as an important tool to

sense of self- When the client was asked develop a therapeutic
worth. “Kuntento ba kayo sa sarili relationship with patients for
niyo?” He answered therapeutic healing. It is
“Kontento naman ako, gusto important for nurses to know
ko sana walang magkasakit at themselves well and it
humaba pa ang buhay ultimately helps them to build
naming.” a therapeutic environment of
caring and healing.
The client is also asked, “Ano https://bit.ly/3NnKnP3
naman po ang perception niyo
sa sarili niyo in terms of Insecurities feed mental
physical?”. The client health issues like depression,
answered, “Okay naman, pogi low self-esteem, and anxiety.
pa rin naman pero may brace They are also often a
na nilagay si doctora, habang contributing factor to eating
hindi pa ako naooperahan.” disorders and substance use
disorders.
When the client was asked, https://bit.ly/3sFWDST
“Ano po nararamdaman niyo
tungkol sa kalagayan niyo Planning is a cycle of
po?”. The client verbalized, defining objectives, creating
“Siyempre takot ako kasi techniques, and sketching out
ooperahan daw ako.” errands and timetables to
achieve the goals. It is the
way toward choosing in detail
how to accomplish something
before you begin to do it.
Planning begins after dreams,

requirements, wants and
thoughts take birth
throughout everyday life. In
each part of our lives,
planning plays a significant
job.
https://bit.ly/3MmQmU9
Role – The client was asked, “Ano Within a family, each person Readiness for enhanced
Relationship ang ginagawa mo para sa takes on a unique role and set family processes
Pattern pamilya?”. The client of responsibilities. For the
(Describes verbalized “Ang role ko sa family to develop supportive
pattern of role pamilya ko kasi ako lang yung relationships, healthy
engagements nagtratrabaho. Ngayon at communication, mutual
and naaksidente ako, baka hindi respect and teamwork, it's
relationships) muna ako important for each member to
makakapagtrabaho.” understand roles and
responsibilities. Old people
The client is asked, “Kung can help the family grow in
ikaw ay nasa ospital sino ang positive directions.
gumagawa ng iyong https://bit.ly/3Loe29j
responsabilidad?” He
answered. “Ang gumagawa ng
mga responsinbilidad ay yung
panganay kong anak”
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The client was asked “Lahat ba

ng miyembro ng pamilya
kooperatiba?” He answered.
“Lahat sila nagiging
kooperatiba”
The client was asked. “Sino

ang gumagawa ng desisyon sa
pamilya” “Yung asawa ko ang
madalas gumawa ng desisyon”
Sexuality – The client was asked, Sex is a normal, healthy part Readiness for enhanced
Reproductive “Kamusta naman po ang of life. It should be fun and sexual patterns
Pattern reproductive system niyo? Mag pleasurable for you and your
(describes naging problema po ba noon?” partner. But it can also be
client’s pattern The client stated, “Wala risky if you or your partner
of satisfaction naman akong naging do certain things that could
and problema.” spread disease or cause
dissatisfaction physical or emotional
with sexuality distress.
pattern, https://wb.md/3LpJVyj
describes
reproductive Aging changes in the male
patterns) reproductive system occur
primarily in the testes.
Testicular tissue mass
decreases. The level of the
male sex hormone,
testosterone decreases
gradually. There may be
problems getting an erection.
https://bit.ly/3z293sD
Coping – Stress When the client is asked, Effective stress management Readiness for enhance
Tolerance “Kapag may problema po helps you break the hold coping
(Describes kayo, ano po ang iyong stress has on your life, so you
client’s pattern ginagawa niyo?” can be happier, healthier,
of satisfaction The client responded, “Kapag more productive, and
and may problema ako mentally healthy.
dissatisfaction pinaguusapan naming mag https://bit.ly/3MmPxe1
with sexuality asawa.” Being aware of our own
pattern, warning signs of stress or
describes When the client was asked, mental ill health not only
reproductive “Anong opinion niyo kapag ensures we look after
patterns) umiiyak kayo?” The client ourselves more effectively,
responded “Hindi ako madalas but also enhances our
umiyak pero kung umiyak man emotional intelligence and
ako siguro baka may nagawa will result in higher empathy
silang mali saakin.” towards others. The
anticipation of something
When the client was asked, good is really powerful.”
“Anong opinyon niyo kapag Having a list of things, you're
galit kayo?” The client committed to doing, even if
responded “Syempre kapag you don't know when you'll do
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galit ako linalabas ko nalang them, is in itself soothing. Yet

pero hindi naman ako planning does more than give
nanununtok o nananakit, basta us something to anticipate. It
nagagalit lang ako lalo na can also help quell anxiety by
kapag makulit ang anak ko.” dealing with cognitive
clutter.
https://bit.ly/3LpTZHt
Value – Belief When the client is asked, “Ano Values and beliefs reflect our Readiness for enhance
Pattern po ang religion niyo? Ano po senses of right and wrong. spiritual well-being
(Describes ang spiritual o religious They help us grow and
pattern of values practice po na importante po develop. Individual values
and beliefs, para sainyo?” The client reflect how we live our life
including stated, “Catholic ako and what we consider
spiritual and /or naniniwala ako sa diyos. Ang important for our own self
goals that guide importante siguro yung pag interests. Individual values
choices or punta namin sa simbahan, include enthusiasm,
decisions) tuwing semana santa. Hindi creativity, humility, and
man kami makapag simba personal fulfillment.
tuwing linggo ang importante https://bit.ly/3yPGdeG
yung mga apo at anak ko
makadiyos” Good health is an important
enabler of positive family and
The client was asked, “Wala community life. It enabled
naman bawal sa relihiyon people to participate in and
niyo? He answered “Wala contribute to society in
namang bawal” different ways.
https://bit.ly/3yPGn5M
The client was asked, “Kapag
kailangan niya ng dugo, okay Principles are important for
lang ba na Salinan kayo ng the governing actions and the
dugo?” He answered “Oo” operation of techniques in
any field education. For the
individual, a principle, when
it is understood and accepted,
serves in important ways to
guide his reflective thinking
and his choice of activities or
actions.
https://bit.ly/39BA7Uw
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PHYSICAL ASSESSMENT
BODY METHODS FINDINGS INTERPRET RATIONALE
PARTS ATION
Head Inspection - Head is NORMAL Naturally, the normal head shape
symmetrically when viewed from above should
rounded with no look similar to an egg, slightly
lesions and wider at the back than the front.
infestations
Palpation - No presence of Normal head appearance has no
tenderness or lesions and tenderness and no
masses. signs of abnormalities around the
head
Scalp and Inspection - Hair color is Due to Aging Balding is due to androgenetic
Hair Palpation black and shows alopecia, more commonly known
slight balding as male pattern baldness, which is
- Scalp is clean, a hereditary condition. It can affect
free from men of all ages, and may even
masses, lumps start before the age of 21.
and dandruff.
Face Inspection - No presence of NORMAL The face is symmetric or slightly
abnormalities asymmetric; palpebral fissures
equal in size; symmetric nasolabial
folds.
Palpation - No presence of The face of the client appeared
tenderness or smooth and has uniform
masses. consistency and with no presence
of nodules or masses.
Eyes Inspection - Skin in both NORMAL Normal eyes have eyelashes point
eyelids is outwards and the eyelids will open
without redness, and close easily. The white part of
swelling, or the eye, the sclera, with the
lesions. overlying conjunctiva, is not red
- Eyeballs are and inflamed. The cornea is bright
symmetrically and clear. The pupil is black and
aligned round. If the pupil and iris are well
- Conjunctiva is seen, this confirms that the cornea
clear must be clear. The conjunctiva is
smooth
Palpation - No masses or NORMAL Normal eyes have no bulging or
bulging masses and there’s no indication or
exophthalmos or bulging in the
eyes.
Ears Inspection - Ears are equal in NORMAL Many variations in size and shape
size exist within the label of "normal
ear", but in general, the normal ear
is one which all the structures
(helix, antihelix, tragus, antitragus,
scaphoid/triangular fossa, and
external auditory canal) are all
present and well formed.
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Palpation - No masses NORMAL Normal ears upon palpations are

free from tenderness, lesions and
masses.
Nose Inspection - Normal breaths NORMAL Normal findings might be
Palpation in both nostrils. documented, nose is symmetrical
Percussion No presence of with no discoloration, swelling or
malformations. Nasal mucosa is
discharge and
pinkish red with no
tenderness. discharge/bleeding, swelling,
- Frontal and malformations or foreign bodies.
maxillary sinuses No sinus pain noted. Nose is
are non-tender to patent with good air flow.
palpate
- Sinuses are non-
tender to
percuss.
Mouth Inspection - Lips is smooth NORMAL In a healthy mouth, the tissues are
and pinkish. No pink, firm and moist. If you have a
suspected lesions healthy mouth, your breath will
smell pleasant or neutral. Healthy
gums are firm and pink, not red or
white.
Palpation - No masses on NORMAL Upper and lower gums. They
tongue and gums should appear symmetrical, moist
and pinkish, with well-defined
margins. Dark-skinned people may
have a melanotic line along the
gum margin. And healthy dorsal
tongue is symmetrical, pink, moist,
and slightly rough from the
papillae, possibly with a thin,
whitish coating.
Neck Inspection - Neck is NORMAL The trachea should be midline, and
symmetric there should not be any noticeable
- Normal neck enlargement of lymph nodes or the
movement thyroid gland with normal range of
- Prominent neck motion.
vessels
Palpation - No masses or NORMAL Lymph nodes, if palpable, should
lumps be round and movable and should
not be enlarged or tender
Breast and Palpation - No masses upon NORMAL Upon palpation normal bilateral
Axillary palpation. breasts are symmetrical, no tender,
no suspicious masses, skin or
nipple changes or
lymphadenopathy.
Thorax Inspection - Symmetrical NORMAL Side to side symmetric chest
(Anterior and respiratory effort shape. Distance from the front to
Posterior) without uses of the back of the chest (anterior-
posterior diameter) less than the
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accessory size of the chest from side to side

muscle. (transverse diameter
Palpation - No tenderness, Is used to evaluate the symmetry
pain and unusual and extent of thoracic movement
sensation. during inspiration. Is usually
symmetrical and is at least 2.5
centimeters between full
expiration and full inspiration
Percussion - There is The bronchial breath sounds over
resonance upon the trachea has a higher pitch,
percussion. louder, inspiration and expiration
are equal and there is a pause
between inspiration and
expiration.
Auscultation - Upon There is no high-pitched whistling
auscultation, sound that happens when
there’s no breathing through swollen,
adventitious constricted airways. It most often
occurs during exhalations.
sounds.
Lungs Percussion - Normal NORMAL Resonant percussion note: heard
(Anterior/Post resonance over over a normal air-filled lung. Dull
erior) lung tissue. percussion note (the sound heard
over solid tissues)
Auscultation - Absence of Absence of loud, high-pitched
adventitious bronchial breath sounds over the
sounds. trachea. Medium pitched
bronchovesicular sounds over the
mainstream bronchi, between the
scapulae, and below the clavicles.
Soft, breezy, low-pitched vesicular
breath sounds over most of the
peripheral lung fields.
Heart Inspection - The apical pulse NORMAL The external chest is normal in
(Precordium), is visible appearance without lifts, heaves,
Anterior or thrills. PMI is not visible and is
Chest palpated in the 5th intercostal
space at the midclavicular line
Palpation - Upon palpation Palpation includes assessing the
there is no arterial pulse, measuring blood
vibrations pressure, palpating any thrills on
the chest, and palpating for the
point of maximal impulse. Arterial
pulse: When palpating the arterial
pulse, the examiner should be able
to gather the rate, rhythm, and
characteristics.
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Auscultation - No extra heart Normal S1 and S2, with regular

sounds and rate and rhythm. S2 > S1 at the
murmurs heard. base, S1 > S2 at apex. No splitting
of the heart sounds heard. No
murmur.
Abdomen Inspection - Smooth skin NORMAL Abdomen is soft, symmetric, and
without lesions non-tender without distention.
There are no visible lesions or
scars.
Auscultation - Gurgling bowel NORMAL Abdomen is soft, symmetric, and
sound every 5-10 non-tender without distention.
minutes There are no visible lesions or
scars.
Percussion - Tympanic sound The anterior gas-filled abdomen
over air-filled normally has a tympanic sound to
stomach/intestin percussion, which is replaced by
al section. dullness where solid viscera, fluid,
or stool predominate. The flanks
are duller as posterior solid
structures predominate, and the
right upper quadrant is somewhat
duller over the liver.
Palpation - No tenderness Abdomen is soft, symmetric, and
and masses non-tender without distention
Genitourinary Inspection - Rounded contour NORMAL Flat or rounded contour
- No visible (protuberant in children until age
lesions 4)
Palpation - Absence of pain, Normal findings should include no
tenderness and pain, tenderness and mass upon
mass palpation. In addition, during
- No urgency, palpation patient shall not
frequency or complain of any urgency or
retention retention to urinate
Extremities Inspection - Fractured Due toFractures typically cause swelling,
(Upper) clavicle clavicular
but swelling may take hours to
- Swelling fracture
develop and, in some types of
shoulder fractures, is very slight. When
- Presence of muscles around the injured area try
wound to hold a broken bone in place,
- Broken skin muscle spasms may occur, causing
additional pain. Bruises appear
when bleeding occurs under the
skin.
Palpation - Misshaped The bone pokes through the skin
clavicle and can be seen, or a deep wound
- Protruding bone exposes the bone through the skin.
(closed fracture) Closed fracture (also called simple
fracture). The bone is broken, but
the skin is intact.
(Lower) Inspection - Symmetric and Due to surgical Extremities are atraumatic in
equal in length. incision appearance without tenderness or
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- Swelling leg deformity. Extremities are without

- Sutured skin is swelling or erythema. Full range
present. of motion is noted to all joints.
Palpation - Sutured skin is No signs of deformities and
present. lesions in extremities
Skin Inspection - Temperature: NORMAL Normal skin color varies from

36.7°C white to pink, and to yellow,
brown, and black. In the different
ethnic groups, there are
pronounced variations in skin,
head hair, and body hair.
Palpation - Absence of Skin temperature is the
lesions and temperature of the outermost
masses on the surface of the body. Normal
surface of the human skin temperature on the
skin and warm to trunk of the body varies between
touch. 33.5 and 36.9 °C (92.3 and 98.4
°F), though the skin’s temperature
is lower over protruding parts, like
the nose, and higher over muscles
and active organs.
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NEUROLOGICAL ASSESSMENT
NAME CLASSIFICATION MAJOR FUNCTIONS FINDINGS
I. Olfactory Sensory - Smell - Can identify and smell
scent while eyes are
closed
II. Optic Sensory - Vision (acuity and field - Signs of visual
of vision); pupil impairment
reactively to light and - Can read and can
accommodation match colors
(efferent impulse)
III. Oculomotor Motor - Eyelid elevation; most - Both pupils constrict
EOMs; pupil size and - Symmetric eye
reactivity (efferent movement
impulse)
IV. Trochlear Motor - EOM (turns eyes - Equal pupil size

downward and laterally) - normal movement of
the upper eyelids
V. Trigeminal Both - Chewing, facial and - Eyes naturally blink
mouth sensation, corneal when cotton wisp
reflex (sensory) lightly touched the
cornea
VI. Abducens Motor - EOM (turns eyes - Turns eyes laterally
laterally) - No presence of
strabismus
VII. Facial Both - Facial expression; taste, - There is facial grimace
corneal reflex (motor), upon inspection.
eyelid and lip closure
VIII. Sensory - Hearing; equilibrium - Maintained balanced
Acoustic/Vestibular without stepping
cochlear sideways
IX. Both - Gaggling and - Swallowing intact
Glossopharyngeal swallowing (sensory);
taste
X. Vagus Both - Gaggling and - Gag reflex intact
swallowing (motor);
speech (phonation)
XI. Spinal Motor - Shoulder movement; - Symmetrically aligned
Accessory head rotation
XII. Hypoglossal Motor - Tongue movement; - Normal tongue
speech (articulation) movement
DIAGNOSTIC AND LABORATORY TESTS

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HEMATOLOGY (September 30, 2022)
NORMAL NORMAL
PARAMETER RESULT PARAMETER RESULT
VALUES VALUES
WBC 4.0-10.0x10^/L 15.9 HGB Male 12.0-16.0g/L 15.1
Lymphocyte 20.0-40.0% 20.0 Female 11.0-15.0g/L
Monocyte 3.0-15.0% 10.0 HCT Male 40.0-54.0% 52.2
Granulocyte 50.0-70.0% 70.0 Female 37.0-47.0%
RBC 3.50-5.00x10^12/L 6.55 Platelet 100-300x10^9L 216
SARS-CoV-2) RAPID ANTIGEN (Ag) TEST (July 04. 2022)

BRAND: CLUNGENE
NASOPHARYNGEAL SWAB
TESTED RESULT
Novel Corona Virus (SARS CoV-2) NEGATIVE
ROENTGENOGRAPHIC REPORT
NAME: CAOILE, DENIWIN A. XRAY NUMBER: 22-1258

AGE/SEX: 53Y/M EXAM DATE: September 30, 2022
Examination: LEFT SHOULDER AP

Radiological Findings:
 There is a comminuted fracture involving the midshaft of the left with inferior
 displacement of the distal fractured segment.
 No lytic or sclerotic lesions noted.
 Included soft tissues and joint spaces are intact.
Examination: RIGHT LEG APL
Radiological Findings:
 There is a non-displaced fracture in the lateral tibial condyle
 No lytic or sclerotic lesions noted.
 Included soft tissues and joint spaces are intact
ANATOMY AND PHYSIOLOGY

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The human skeletal system consists of all of the bones, cartilage, tendons, and ligaments
in the body. Altogether, the skeleton makes up about 20 percent of a person’s body weight. An
adult’s skeleton contains 206 bones. Children’s skeletons actually contain more bones because
some of them, including those of the skull, fuse together as they grow up.
There are also some differences in the male and female skeleton. The male skeleton is
usually longer and has a high bone mass. The female skeleton, on the other hand, has a broader
pelvis to accommodate for pregnancy and child birth. Regardless of age or sex, the skeletal
system can be broken down into two parts, known as the axial skeleton and the appendicular
skeleton.
Each shoulder girdle, or pectoral girdle, consists of two bones – a clavicle and a scapula.
 Humerus and Scapula-Skeletal System Anatomy and Physiology for Nurses

 Clavicle. The clavicle, or collarbone, is a slender, doubly curved bone; it attaches to the
manubrium of the sternum medially and to the scapula laterally, where it helps to form
the shoulder joint; it acts as a brace to hold the arm away from the top of the thorax and
helps prevent shoulder dislocation.
 Scapulae. The scapulae, or shoulder blades, are triangular and commonly called “wings”
because they flare when we move our arms posteriorly.
 Parts of the scapula. Each scapula has a flattened body and two important processes- the
acromion and the coracoid.
 Acromion. The acromion is the enlarged end of the spine of the scapula and connects
with the clavicle laterally at the acromioclavicular joint.
 Coracoid. The beaklike coracoid process points over the top of the shoulder and anchors
some of the muscles of the arm; just medial to the coracoid process is the large
suprascapular notch, which serves as a nerve passageway.
 Borders of the scapula. The scapula has three borders- superior, medial (vertebral), and
lateral (axillary).
 Angles of the scapula. It also has three angles- superior, inferior, and lateral; the glenoid
cavity, a shallow socket that receives the head of the arm bone, is in the lateral angle.
Factors to free movement of the shoulder girdle. Each shoulder girdle attaches to the
axial skeleton at only one point- the sternoclavicular joint; the loose attachment of the scapula
allows it to slide back and forth against the thorax as muscles act; and, the glenoid cavity is
shallow, and the shoulder joint is poorly reinforced by ligaments. Connected along their length
by an interosseous membrane, two bones, the tibia and fibula, form the skeleton of the leg.
 Tibia. The tibia, or shinbone, is larger and more medial; at the proximal end, the medial
and lateral condyles articulate with the distal end of the femur to form the knee joint.
 Tibial tuberosity. The patellar (kneecap) ligament attaches to the tibial tuberosity, a
roughened area on the anterior tibial surface.
 Medial malleolus. Distally, a process called medial malleolus forms the inner bulge of the
ankle.
 Anterior border. The anterior surface of the tibia is a sharp ridge, the anterior border, that
is unprotected by the muscles; thus, it is easily felt beneath the skin.
 Fibula. The fibula, which lies along the tibia and forms joints with it both proximally and
distally, is thin and sticklike; the fibula has no part in forming the knee joint.
 Lateral malleolus. Its distal end, the lateral malleolus, forms the outer part of the ankle.
PATHOPHYSIOLOGY
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COURSE IN THE WARD
DATE DOCTOR’S ORDER RATIONALE NURSING

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RESPONSIBILITIES
9/30/22  Please admit to  For further  Admit the patient as
10 AM ROC monitoring, ordered.
 TPR every shift and management, and  Nurse is responsible to
record evaluation of explain the procedure
 CBC, X-RAY patient’s condition. to the patients.
shoulder (L) lower  To protect the  Teach patients a low
extremity (R), patients. purine diet will
ERG.  Ensures an ongoing typically center around
communication fruits, vegetables, and
 Secure consent for
process between you whole grains. The diet
admission
and your health care will minimize the
 IVF: D5NSS at 30
provider. consumption of red
gtts/min
 Help prevent and meat, seafood.
control the amount  Inspect for IV site for
of fluid around your swelling, redness, and
heart, lungs, or in pain.
your legs.
 To prevent or treat
dehydration.  Verify doctor’s order.
 Explain test procedure.
 The purpose of Explain test procedure.
diagnostic Check for expiration
technology is to date. Check for the
provide information religion of the patient.
DIAGNOSTICS: Check for blood type.
that will improve
 CBC, X-RAY  Inform the patient
patient outcome.
 Used to diagnose about the laboratory
fractured bones or exams.
joint dislocation.  Fill-out necessary
10/02/22 request forms.
11 AM  Inform the laboratory
MEDICATIONS:
 Cefuroxime 750mg  To treat bacterial department about the
IV q8 infections in many exams.
 Ketorolac IV now different parts of the  Follow-up results and
ANST body. attached it to the
 ATS (+) ANST  To relieve patient’s chart.
moderately severe
pain  Observe 10 Rights of
 Used to treat mild to drug administration:
 Celecoxib 200mg moderate pain and 1. Right drug
1amp BID help relieve 2. Right dosage
 T-Toxoid symptoms of 3. Right patient
 Tetagam P 250mg arthritis 4. Right route
IM  Used to prevent 5. Right time
 Cefuroxime 1-tab tetanus 6. Right recording
BID  To treat bacterial 7. Right approach
infections in many 8. Right refuse
different parts of the 9.Right documentation
body 10.Right to assessment
and history.
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NURSING CARE PLAN (1)

NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
SUBJECTIVE DATA: Acute pain related to SHORT TERM: Independent: Independent: SHORT TERM:
“Masakit po banda sa fractured bone After 30 minutes of After 30 minutes of
balikad ko” as nursing intervention, 1. Established rapport 1. To ensure nursing intervention,
verbalized by the patient will compliance of the patient will
patient demonstrate use of patient demonstrate use of
relaxation skills and relaxation skills and
OBJECTIVE DATA: patient will display 2. Assess and monitor 2. To obtain patient will display
C – Stabbing pain signs of comfort as vital signs COLDSPA, to also signs of comfort as
O – Started prior to the evidenced by resting assess the exact evidenced by resting
accident. with eyes closed and location of abdominal with eyes closed and
L – Pain on the left vital signs within pain. vital signs within
shoulder normal limits 3. Ascertain normal limits
D – 3 days 3. To improve coping
understanding of
hospitalization, pain LONG TERM: mechanisms in dealing LONG TERM:
individual needs
still occurs. After 3 days of nursing with the stress of pain. After 3 days of nursing
S – Pain scale: 9/10 interventions, patient 4. Promote and 4. To prepare better interventions, patient
P – The pain is felt will utilize provide a calm and for will utilize
when the patient is nonpharmacologic activities and nonpharmacologic
quiet environment. manage discomfort pain relief measures
standing and lying on pain relief measures
the site of fractured. and verbalize relief of mentally. and verbalize relief of
A – (+) Facial pain. 5. Provide comfort pain.
grimace, (+) Guarding measures and non- 5. To promote
behavior, Irritability pharmacologic pain distraction and
management. decrease pain.
V/S TAKEN AS 6. Plan rest periods 6. Rest increases
FOLLOWS: and create a conducive coping abilities by
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BP: 100/70 environment for reducing fatigue and

PR: 83 sleeping and resting. conserving energy.
RR: 26
T: 36 7. Instruct on 7. Patients should be
SPO2: 97% medications at instructed to not take
discharge. pain medications more
frequently than
Dependent: prescribed.
1. Administer Dependent:
pharmacologic pain 1. To reduce the pain
management as felt by the patient.
ordered.
2. Administer
medications as 2. To prevent
ordered. symptoms of fracture.
3. Support the injured 3. Utilize splints or

area. traction devices as
ordered.
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ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTION
SUBJECTIVE DATA: Ineffective tissue SHORT TERM: Independent: Independent: SHORT TERM:
“Tasa-tasang dugo yung perfusion related to upper Within 15 mins of 1. Established rapport 1. To ensure compliance Within 15 mins of
naidudumi ko” as GI bleeding as evidenced nursing intervention, of the patient nursing intervention,
verbalized by the patient. by hematochezia patient maintains patient maintains
maximum tissue 2. Alterations in the blood maximum tissue
perfusion to vital organs, 2. Assess and monitor pressure and pulse rate perfusion to vital organs,
OBJECTIVE DATA: as evidenced by warm vital signs which may indicate the as evidenced by warm
- Pallor and dry skin, present and presence of bleeding. and dry skin, present and
- Presence of blood in the strong peripheral pulses, strong peripheral pulses,
stool. and vitals within patient’s 3. To determine the risk and vitals within patient’s
- Diarrhea normal range factors and bleeding normal range
- Abdominal pain 3. Assess the client’s history of the client.
history of bleeding.
LONG TERM: LONG TERM:
V/S TAKEN AS After 2 days of nursing 4. Help eliminate anxiety After 2 days of nursing
FOLLOWS: intervention, patient will associated with the intervention, patient will
BP: 100/70 be able to demonstrate 4. Explain all procedures surgery. be able to demonstrate
PR: 83 effective tissue perfusion and treatments. effective tissue perfusion
RR: 26 as evidenced by 5. Early assessment as evidenced by
T: 36 hemoglobin and 5. Teach patient to facilitates immediate hemoglobin and
SPO2: 97% hematocrit within normal recognize the signs and treatment. hematocrit within normal
limits symptoms that need to be limits
reported to the nurse.
Dependent:
Dependent: 6. To make up for blood
6. Administer fluids, and fluid loss and to keep
blood, and electrolytes as GI circulation and
prescribed. cellular function intact
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7. These will lessen fluid

loss and neutralize
7. Administer prescribed stomach acid hopefully
medications preventing further
irritation of the GI
mucosa.
8. To determine the
location and cause of GI
8. Prepare for endoscopy bleeding
or surgery.
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ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
SUBJECTIVE DATA: Deficient fluid volume SHORT TERM: Independent: Independent: SHORT TERM:
“Naninilaw ang kutis related to GI Within 15 mins of 1. Established rapport 1. To ensure Within 15 mins of
ko parang wala akong hemorrhage as nursing intervention, compliance of the nursing intervention,
dugo” as verbalized by evidenced by patient will be able to patient patient will be able to
the patient. decreased skin turgor maintain adequate maintain adequate
fluid volume as 2. Assess and monitor 2. Alterations in the fluid volume as
evidenced by stable vital signs blood pressure and evidenced by stable
OBJECTIVE DATA: vital signs, balanced pulse rate which may vital signs, balanced
- Pallor intake and output, and indicate the presence intake and output, and
- Decreased skin capillary refill <3 of bleeding. capillary refill <3
turgor seconds. seconds.
- Capillary refill <5 3. Assess nutritional 3. To determine the
seconds status I&O that may have an LONG TERM:
LONG TERM:
After 2 days of adverse impact on fluid After 2 days of nursing
nursing intervention, intake. intervention, patient is
V/S TAKEN AS patient is normovolemic as
4. Monitor intake and
FOLLOWS: normovolemic as 4. To monitor patient’s evidenced by systolic
output
BP: 100/70 evidenced by systolic fluid volume BP greater than or
PR: 83 BP greater than or 5. Evaluate lab results. accurately. equal to 90 mm HG
RR: 26 equal to 90 mm HG 5. Low levels of Hgb (or patient’s baseline),
T: 36 (or patient’s baseline), and Hct signal blood and normal skin
SPO2: 97% and normal skin 6. Urge the patient to loss. turgor.
turgor. drink the prescribed 6. To treat fluid deficit.
amount of fluid.
Dependent:
7. Start intravenous Dependent:
therapy as prescribed. 7. To replenish the
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fluids and electrolytes

lost.
8. Administer blood
transfusion as 8. To increase the
prescribed. hemoglobin level and
treat anemia and
hypovolemia related to
9. Administer GI bleeding.
prescribed medications 9. To prevent the
symptoms of GI
bleeding
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SUBJECTIVE DATA: Ineffective breathing SHORT TERM: Independent: Independent: SHORT TERM:
“Nahihirapan akong pattern related to Within 30 mins of 1. Established rapport 1. To ensure Within 30 mins of
huminga” as abnormal respiratory nursing intervention, compliance of the nursing intervention,
verbalized by the rate. patient maintains an patient patient maintains an
patient. effective breathing effective breathing
pattern, as evidenced 2. Assess and monitor 2. To obtain baseline pattern, as evidenced
V/S TAKEN AS by relaxed breathing at vital signs especially data parameters. by relaxed breathing at
FOLLOWS: normal rate and depth respiratory rate. normal rate and depth
BP: 100/70 and absence of 3. Position the patient 3. To permit maximum and absence of
PR: 83 dyspnea. with proper body lung excursion and dyspnea.
RR: 26 alignment and chest expansion.
T: 36 LONG TERM: comfortable position. LONG TERM:
SPO2: 97% After 2 days of After 2 days of nursing
nursing intervention, 4. Auscultate breath 4. This is to detect intervention, patient’s
patient’s respiratory sounds, chest, and lung decreased or respiratory rate
rate remains within sounds. adventitious breath remains within
established limits. established limits.
sounds.
5. Encourage frequent 5. Ensure the patient
rest periods and teach the rests between
patient to pace activity. strenuous activities.
6. Encourage small
nutritious frequent meals. 6. This prevents
crowding of the
7. Promote ventilation. diaphragm.
7. Moving air can

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Dependent: decrease feelings of air

1. Administer hunger.
medications as indicated Dependent:
1. To improve patient
2. Provide respiratory outcomes.
medications and standby
oxygen, per doctor’s 2. To relax the airway
orders. smooth muscles and
cause bronchodilation
to open air passages.

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SUBJECTIVE DATA: Ineffective breathing SHORT TERM: Independent: Independent: SHORT TERM:
“Nanghihina po ako” pattern related to At the end of the span 1. Established rapport 1. To ensure Within 30 mins of
as verbalized by the abnormal respiratory of care, the patient will compliance of the nursing intervention,
patient. rate. be able to verbalize patient patient maintains an
less feeling of fatigue effective breathing
V/S TAKEN AS and be able to fully 2. Assess and monitor 2. To obtain baseline pattern, as evidenced
FOLLOWS: perform his or her vital signs especially data parameters. by relaxed breathing at
BP: 100/70 daily tasks with ease. respiratory rate. normal rate and depth
PR: 83 and absence of
RR: 26 LONG TERM: 3. Assess the level of 3. To identify the need dyspnea.
T: 36 After 2 days of fatigue. for further assistance in
SPO2: 97% nursing intervention, doing their activities of LONG TERM:
the patient will also be daily living. After 2 days of nursing
able to demonstrate intervention, patient’s
and apply efficient 4. Teach the patient 4. So, patient will not respiratory rate
ways to conserve his and the caregiver about be overwhelmed with remains within
or her energy to energy-saving established limits.
work.
prevent further fatigue. techniques.
5. Provide comfort 5. These may reduce

such as judicious touch nervous energy that
or massage, and cool lead to relaxation.
showers.
6. Aid the patient 6. Promoting
develop habits to relaxation before sleep
promote effective and providing for
rest/sleep patterns. several hours of
uninterrupted sleep can
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contribute to energy
restoration.
7. Encourage the 7. To help the body’s

patient to need rest and red blood cells to
sleep as they can and deliver enough
avoid doing any oxygenated blood.
strenuous activities
that might trigger
fatigue. 8. Spicy food is a
8. Instruct the patient known gastric irritant
to avoid spicy food that upsets the gastric
that might upset their lining and stomach
stomach further.
Collaborative:
Collaborative: 1. If the patient is
1. Collaborate patients inactive in
to a nutritionist to gastrointestinal
ensure that the daily bleeding, they are
food and nutritional advised not to eat dark-
intake are achieved. colored food to
differentiate blood in
the feces.
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DRUG STUDY (1)

Drug Name Mechanism Dosage Indication Contraindication Adverse effects Nursing Interventions
Generic Semisynthetic third- 1-gram IV q12 Infections Hypersensitivity Body as a Whole:  Tell patient if there’s
name: generation ANST caused by to cephalosporins Pruritus, fever, any signs of bleeding.
Ceftriaxone cephalosporin susceptible and related chills, pain,  Tell patient to loosen
antibiotic. stools or diarrhea
Moderate to organisms in antibiotics; induration at IM
promptly.
Preferentially binds to Severe lower pregnancy injection site;
Brand one or more of the Infections respiratory phlebitis (IV site).
name: penicillin-binding Adult: IV/IM tract, skin and GI: Diarrhea,
proteins (PBP) located 1–2 g q12– skin abdominal cramps,
Rocephin
on cell walls of 24h (max: 4 structures, pseudomembranous
susceptible organisms. g/d) urinary tract, colitis, biliary
This inhibits third and bones and sludge. Urogenital:
final stage of bacterial joints; also Genital pruritus;
cell wall synthesis, intra- moniliasis.
thus killing the abdominal
bacterium. infections,
pelvic
inflammatory
disease,
uncomplicated
gonorrhea,
meningitis,
and surgical
prophylaxis.
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DRUG STUDY (2)

Generic Prototype of the 300 mg IV Chronic, Patient in whom CNS: Headache,  Tell patient to notify
name: propionic acid NSAIDs every 6hrs symptomati urticaria, severe dizziness, light- physician immediately of
Paracetamol (cox 1) inhibitor with c rhinitis, headedness, passage of dark tarry
nonsteroidal anti- Adult: PO rheumatoid bronchospasm, anxiety, stools, "coffee ground"
inflammatory activity 200–400 mg arthritis and angioedema, nasal emotional lability, emesis, frankly bloody
and significant t.i.d. or q.i.d. osteoarthriti polyps are fatigue, malaise, emesis, or other GI
antipyretic and (max: 1200 s; relief of precipitated by drowsiness, distress, as well as blood
analgesic properties. mg/d) mild to aspirin or anxiety, or protein in urine, and
Blocks prostaglandin moderate other NSAIDs; confusion, onset of skin rash,
synthesis. Ibuprofen pain; active peptic ulcer, depression, pruritus, jaundice.
activity also includes primary bleeding aseptic  Tell patient to not self-
modulation of T-cell dysmenorrh abnormalities. meningitis. medicate with ibuprofen if
function, inhibition of ea; CV: taking prescribed drugs or
inflammatory cell reduction of Hypertension, being treated for a serious
chemotaxis, decreased fever. palpitation, condition without
release of superoxide congestive heart consulting physician.
radicals, or increased failure (patient  Tell patient do not take
scavenging of these with marginal aspirin concurrently with
compounds at cardiac function); ibuprofen.
inflammatory sites. peripheral edema.  Tell patient to avoid
Special Senses: alcohol and NSAIDs
Amblyopia unless otherwise advised
nephrotoxicity, by physician. Concurrent
decreased use may increase risk of
creatinine GI ulceration and bleeding
clearance.
College of Nursing
tendencies.
DRUG STUDY (3)

Generic Rebamipide is 100mg tab 1tab to treat Rebamipide is Significant:  Tell patient that
name: postulated to increase 3x a day stomach contraindicated in Dizziness, this drug may
Rebamipide prostaglandin E2 in ulcers, peptic patients with drowsiness, cause drowsiness
gastric mucosa and ulcers, gastric known history of thrombocytopenia, or dizziness, if
elevate gastric ulcers. It is drug leucopenia, affected, do not
mucous, gastric also used to hypersensitivity. hypersensitivity and drive or operate
anaphylactoid machinery.
mucosal blood flow treat stomatitis
reactions  Tell patient may
and secretion of (mouth ulcers)
Gastrointestinal be taken with or
gastric alkaline. It also and dry eyes. disorders: without food.
stimulates gastric Peptic ulcers Constipation, dry
mucosal cell growth are sores that mouth, diarrhoea,
and decreases gastric develop on the nausea, vomiting,
mucosa injury. inner lining of heartburn,
the intestine abdominal pain,
and stomach. belching, sensation
of abdominal
enlargement, taste
abnormality.
Investigations:
Increased AST,
ALT, alkaline
phosphatase, or
BUN levels.
College of Nursing
DRUG STUDY (4)

Generic name: Azithromycin is a 500mg tab Azithromycin Hypersensitivity to Significant:  Monitor liver
Azithromycin macrolide antibiotic on1c a day is used to treat macrolide antibiotics. Myasthenia gravis. function values
under the azalide certain History of hepatic Ear and labyrinth and blood count
group. It inhibits bacterial dysfunction/cholestatic disorders: Deafness. with differential.
Brand name: RNA-dependent infections, jaundice following Eye disorders: Perform culture
protein synthesis by such as previous antibiotic Pruritus, burning, and susceptibility
Azemax stinging of the eye testing before
binding to the 50s bronchitis; use.
or ocular initiating therapy.
ribosomal subunit, pneumonia;
discomfort, sticky  Counsel patients
preventing the sexually eye sensation, being treated for
translocation of transmitted foreign body STDs about
peptide chains. diseases sensation appropriate
(STD); and (ophthalmic). precautions and
infections of Gastrointestinal additional
the ears, lungs, disorders: therapy.
sinuses, skin, Diarrhoea,  Culture site of
throat, and vomiting, infection before
reproductive abdominal pain, therapy.
organs. nausea, flatulence,
dyspepsia,
dysgeusia. Skin and
subcutaneous tissue
disorders: Pruritus,
rash.
College of Nursing
DRUG STUDY (5)

Generic Inhibits proton pump 80mg + 90ml Used to treat Hypersensitive to :  Monitor liver
name: activity by binding to PNSS x heartburn and drug or its function values
Omeprazole hydrogen-potassium 10mins for 72 indigestion components; and blood count
adenosine hours Rilpivirine- with differential.
triphosphatase, located containing Perform culture
Brand name: at secretory surface of products and susceptibility
testing before
Zolnevar gastric parietal cells,
initiating therapy.
to suppress gastric
 Counsel patients
acid secretion being treated for
STDs about
appropriate
precautions and
additional therapy.
 Culture site of
infection before
therapy.
College of Nursing
DRUG STUDY (6)

Generic Acetylcysteine 600mg tab Adjuvant therapy Hypersensitivity CNS: Dizziness,  Tell patient to report
name: Exflem probably acts by dissolve in ½ in patients with to acetylcysteine; drowsiness. GI: difficulty with
disrupting disulfide glass of water abnormal, viscid, patients at risk of Nausea, clearing the airway
linkages of once a day @ or inspissated gastric vomiting, or any other
Brand name: mucoproteins in H-S mucous secretions hemorrhage. stomatitis, respiratory distress.
Acetycystein purulent and in acute and hepatotoxicity  Tell patient to report
Adult Dose: 1 nausea, as an
e nonpurulent chronic (urticaria).
effervescent antiemetic may be
secretions. bronchopulmonary
tablet once a Respiratory: indicated.
diseases, and in  Note: Unpleasant
day, Bronchospasm,
pulmonary odor of inhaled drug
preferably in rhinorrhea,
complications of becomes less
the evening. burning sensation
cystic fibrosis and noticeable with
Or, as in upper
surgery, continued use.
prescribed by respiratory
tracheostomy, and
a physician. passages,
atelectasis. Also
epistaxis.
used in diagnostic
bronchial studies
and as an antidote
for acute
acetaminophen
poisoning.
College of Nursing
DRUG STUDY (7)

Generic Tranexamic acid is 1gm IV now Tranexamic acid History of Gastrointestinal  Monitor for signs and
name: an antifibrinolytic (sometimes convulsions; disorders: symptoms of
Tranexamic agent that inhibits shortened to txa) acquired Nausea, hypersensitivity
acid the breakdown of is a medicine that disturbances of vomiting, reactions, convulsions,
fibrin clots. It blocks controls bleeding. colour vision. diarrhoea, thrombotic events, and
the lysine binding It helps your Severe renal abdominal pain. ureteral obstruction.
sites of plasminogen blood to clot and impairment. General
Brand
and impairs the is used for Concomitant use disorders and  May be taken with or
name:
endogenous nosebleeds and with combined administration without food.
Antranex fibrinolytic process, heavy periods. If hormonal site conditions:
thus preserving and you're having a contraceptives. Fatigue.
stabilising the fibrin tooth taken out, Musculoskeletal
matrix structure. using tranexamic and connective
acid mouthwash tissue disorders:
can help stop Musculoskeletal
bleeding. pain, back pain,
muscle cramps
or spasm,
arthralgia.
College of Nursing
College of Nursing
DISCHARGE PLANNING
I. MEDICATIONS
 Take medicine until it's finished or until your doctor says it's okay to stop.
 Don't take medicines prescribed for another person.
 Take the prescribed dose at the same time each day (use a memory aid such as meals,
bedtime, charts, or pill boxes).
II. EXERCISE
Exercise Rationale
Walk as much as tolerated. This improves blood flow and speeds wound
healing. Ask when you can return to your
usual activities, such as work. Slowly do more
each day.
III. TREATMENT
Treatment Rationale
Take medications prescribed by the physician. Taking your medicine as prescribed or
medication adherence is important for
controlling chronic conditions, treating
temporary conditions, and overall long-term
health and well-being.
Have enough rest. To promote healing.
IV. HEALTH TEACHING
Health Teaching Rationale

Eat small meals more often while your A compound in chili peppers called capsaicin
digestive system heals. Avoid or limit caffeine may cause burning diarrhea, potentially
and spicy foods. Also avoid foods that cause initiating light rectal bleeding
heartburn, nausea, or diarrhea.
Do not drink alcohol Alcohol can cause ulcers and esophageal
varices. Esophageal varices are swollen blood
vessels in your esophagus. Over time the
blood vessels become weak and may bleed.
Do not smoke Nicotine and other chemicals in cigarettes and

cigars can increase your risk for ulcers.
Teach patient to drink plenty of water and To prevent constipation.
caffeine-free fluids.
Limit or do not take NSAIDs NSAIDs can increase your risk for ulcers and
GI bleeding.
College of Nursing
Manage GI conditions as directed Examples of GI conditions include

gastroesophageal reflux, peptic ulcer disease,
and ulcerative colitis. Take all medicines for
these conditions as directed.
V. OUTPATIENT FOLLOW-UP
Outpatient Follow-up Rationale

Return to the clinic for follow-up visit about To assess the incision site if healing or
two weeks after surgery. infection occurs.
Contact your healthcare provider if: Symptoms of GI bleeding may return.
 You have nausea or are vomiting.
 You have heartburn.
 You have questions or concerns about
your condition or care.
Follow up with your healthcare provider as These tests can make sure you do not have
directed: more bleeding.
 You may need to return for a
colonoscopy, endoscopy, or other tests.
VI. DIET
Diet Rationale
Add fats slowly. For fats aids in bile secretion.
High-protein food intake. Aids in healing.
VII. SPIRITUAL CARE
Spiritual Care Rationale

Encourage the client and her family to seek This will strengthen their spiritual life and not
emotional, physical, and mental strength from easily give up when problems arise.
God.
PROGNOSIS
The patient's significant other brought him to Southern Isabela Medical Hospital and
Clinic. According to his wife, the patient had been having diarrhea with presence of bright red
stool possibly blood. Subsequently after the hospital's treatment and diagnosis, the patient is still
at the hospital scheduled for laparoscopy. September 23, 2022

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University of Perpetual Help System Laguna-Isabela Campus

Minante 1, Cauayan City, Isabela

FRACTURE: CLAVICLE FRACTURE (L)

SIGNS AND SYMPTOMS OF FRACTURES

 Blood vessel damage

GORDON’S FUNCTIONAL HEALTH PATTERN

ability to sensory information we

image, and as an important tool to

Planning begins after dreams,

The client was asked “Lahat ba

The client was asked. “Sino

galit ako linalabas ko nalang them, is in itself soothing. Yet

Palpation - No masses NORMAL Normal ears upon palpations are

accessory size of the chest from side to side

Auscultation - No extra heart Normal S1 and S2, with regular

- Swelling leg deformity. Extremities are without

Skin Inspection - Temperature: NORMAL Normal skin color varies from

IV. Trochlear Motor - EOM (turns eyes - Equal pupil size

DIAGNOSTIC AND LABORATORY TESTS

HEMATOLOGY (September 30, 2022)

SARS-CoV-2) RAPID ANTIGEN (Ag) TEST (July 04. 2022)

NAME: CAOILE, DENIWIN A. XRAY NUMBER: 22-1258

Examination: LEFT SHOULDER AP

Examination: RIGHT LEG APL

ANATOMY AND PHYSIOLOGY

 Humerus and Scapula-Skeletal System Anatomy and Physiology for Nurses

COURSE IN THE WARD

DATE DOCTOR’S ORDER RATIONALE NURSING

NURSING CARE PLAN (1)

BP: 100/70 environment for reducing fatigue and

3. Support the injured 3. Utilize splints or

NURSING CARE PLAN (2)

7. These will lessen fluid

NURSING CARE PLAN (3)

fluids and electrolytes

NURSING CARE PLAN (4)

7. Moving air can

Dependent: decrease feelings of air

NURSING CARE PLAN (5)

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

5. Provide comfort 5. These may reduce

7. Encourage the 7. To help the body’s

DRUG STUDY (1)

DRUG STUDY (2)

DRUG STUDY (3)

DRUG STUDY (4)

DRUG STUDY (5)

DRUG STUDY (6)

DRUG STUDY (7)

IV. HEALTH TEACHING

Health Teaching Rationale

Do not smoke Nicotine and other chemicals in cigarettes and

Manage GI conditions as directed Examples of GI conditions include

Outpatient Follow-up Rationale

VII. SPIRITUAL CARE

Spiritual Care Rationale

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