Introduction

This case study is all about my analysis and evaluation in my clinical duty in
Orthopedic Ward about Femoral Fracture. A femur fracture, or broken
thighbone, is an extremely painful and dangerous injury. The femur is
one of the strongest bones in the body, and a break or fracture in the
femur bone is often caused by severe injury. Severe pain, swelling,
discomfort, physical deformity, and frequently the inability to walk are
signs of a femur fracture. A femur fracture is diagnosed after a physical
examination of the leg as well as imaging tests that may include X-rays
or CT scans. Imaging tests allow the physician to identify the exact
location of the fracture. Treatment for a femur fracture often includes
setting and immobilizing the leg, and in severe cases, surgery may be
required to ensure proper healing. There are two main types of
nonsurgical treatments for a femur fracture. The patient can be put on
bed rest, with weights and pulleys creating traction; or the patient can
be placed in a cast that extends from the rib cage to the toes. This case
study gives the students an opportunity and experience to assess and
evaluate the patient in an actual clinical setting.

a.2. Patient’s Profile

Name: GR

Age: 54

Sex: Male

Weight: 65kgs

Height: 5’7

Marital status: Married

Citizen: Filipino

Religion: Roman Catholic

 Blood Type: O+

Admitting Diagnosis: MPI sec to 1 Femoral Fracture Right

2 Lacerated wound, Right thigh

a.3. Nursing Health History

Chief Complaint
Patient GR often complain the pain at his area of fracture (femur fracture right) which is
caused by Vehicular Accident.

Present Illness

Patient GR, a 54-year-old Filipino male, was admitted to the Ilocos Training and Regional
Medical Center (ITRMC) on the evening of February 17, 2024. According to patient GR, they are
from their friend’s house before the accident happened. The patient was little bit drunk, and the
driver of the tricycle that they are riding is also a little bit drunk which is son of the patient.
Patient GR tells the story, that they try to avoid the four wheel car that they will meet, so the
driver of the tricycle tried to avoid the accident so he turned the steering wheel of the tricycle in
the opposite direction. They didn't crash into a car or anything but they bumped into a field
swhich was the cause of his fracture. The patient ran to Agoo hospital but was told that there is
no doctor in the hospital at that time so he was transferred to ITRMC. According to the patient,
a lot of blood was lost from him while he was being rushed to the hospital, so he was nervous
and he always said “ Maam tulungan dak, hanko kayan."

Past History

Medical History:

The patient has never been hospitalized before, but he has experienced coughing and colds,
which are typically treated at home.

Surgical History

The patient has no past surgery.

Medications

Cloxacillin 500mg, Gentamicin 1g, Vit C tab, Omeprazole 40mg, Lactulose 30mg,

Celecoxib 200mg, Tramadol 50mg, Paracetamol 600mg, Ofazonlin 1g/IV, Cefazolin

Allergies

Patient has no allergy to foods and medications

Family History

According to the patient, they don’t have any family health history. The patient define the
health status of their family as healthy because they don’t have and illnesses and when it comes
to food his parents often prepare a vegetables for them to eat. His father died at 82 year old
(2022) Patient GR don’t want to open this topic while we conducted the interview. His Mother,
who is living and is currently 84 year old, don’t have any illenessess.

Personal and Social History

The patient was graduated Criminology at Tuguegarao. He works as a tricycle driver

for almost 7years. According to the patient, he out at their home around 6:30 am,
his route is from Santo Tomas to Agoo only. In the afternoon, he picked up his wife
at the PCLU Agoo, because her wife is a vendor at the canteen of this school. They
were at their house at seven o’clock in the evening. The exercise pattern that he
always do is fetching a water from a well every morning. The patient does not
smoke and identified himself as an occasional drinker. The patient is a Roman
Catholic, and he is belong to the group officers of the Church, every Sunday he goes
to the church with his whole family. According to the patient, they stopped going to
church since he was admitted to the hospital, because of the accident that
happened to him. He serves every Sunday as one of the leaders who always lead in
the rosary prayer before the mass begin. He is currently residing at their own house
together with his mother, wife and their 6 kids.
Genogram
a.4. Nursing Health Assessment

Gordon’s 11 Functional Health Patterns

Before After
Hospitalization/ Hospitalization/ Interpretation
Diagnosis Diagnosis
1. Health Patients define The patient said that, The possibly reason
Perception health as being free he is scared to drive why patient have a
and from illness. Since he his tricycle again, cold and cough is
Management was young, he never because of the because of his work.
been go to hospital. incident that He is a tricycle driver
The patient stated happened to him. and sometimes he
that most often he While taking the took him until
have a cold and interview, I also ask evening to drive his
cough and it is the patient if he have tricycle. The patient
because when he go a complete admitted that he
to drive his tricycle at protective don’t use any
night to have a equipment when he protective gear like
income so that they is working, and he jacket , so because of
will have a money to said is no. that there is a
buy their needs. possibility that this is
one of the reason
why he is having a
cold and cough.
2. Nutritional The weighed 65kgs. At present, he The patient has no
Metabolic He has no problem weighed 64kgs with signs of
Pattern with his appetite, no BMI of 22.1 , normal. abnormalities on his
previous difficulty of He lost 1kg from his health, and the BMI
swallowing, nausea, previous admission of the patient is
vomiting and no at ITRMC last considered normal,
problem with February 17, 2024. however this is not
chewing. Patient Patient have a DAT affects his current
describe his regular diet while he is on situation.
meal as follows: the hospital which
breakfast- drink 1cup means, he can eat
of coffee, sometimes and drink as much as
milk, and eat a 2-3 he can tolerate
pcs of pandesal without becoming
Lunch- 3cups of rice, uncomfortable or
with 2 pcs of head of experiencing nausea.
bangus. But after his
Snacks- eat 3 pcs of operation, the
pandesal and drink 2 patient stated that
cups of water. he is not eating like
Dinner- 5cups of rice he used to, before
and 1 bowl of soup the operation.
 with vegetable.
Their family usually
prepare a
“dinengdeng” for
dinner because of his
old mother. The
patient often drink a
water since he is
always exposed to
direct sunlight when
he is working.
According to the
patient he always
have a bottle of
mineral water at his
tricycle. He
occasionally drink
alcohol since he was
30 years old.
3. Elimination Patient denies any He defecates 2-3 The patient has no
Pattern problem with times a week, formed problem with
defecation. He brown in color, had elimination but was
defecates twice or no constipation and given lactulose to
thrice a day, formed diarrhea. The avoid straining.
brown-yellow in measurement of his
color. He had history urine output is
of diarrhea, and use ranging to 300-
laxative. As to 800ml, and the color
urination the patient is light yellow. The
has no history of patient voids 5 times
UTI. He voids 3 times a day.
a day, and the color
of his urine is yellow.
4. Activity The patient stated The patient lifting a Incorporating
Exercise that, his routine in dumbbell weighed 5- activities like
Pattern the morning is 10kgs. So that his fetching water or
fetching a water from muscles will stretch lifting dumbbells
a well, he considered since he lay down
into one's routine
this as his exercise for how many days at
can contribute to a
because he always the hospital. The
doing this. physical therapist balanced approach
also helped the to physical fitness
patient to move his and a healthy
feet that have a lifestyle. This
fracture, every 10am routine will also
in the morning at the help the patient to
hospital, so that the have a fast
patient can easily
 walk again. recovery.
5. Sleep Rest Patient stated that The patient stated Fractures typically
Pattern he has no history of that he has 5-6 hours cause significant
lack of sleep. He of sleep and had a pain, especially
always had a 7-8 episodes of during the initial
hours of sleep at awakening. He often
stages after the
night and took a nap complained that he
injury. Pain can
for 1 hour by noon have a difficulty of
time before he sleeping because of interfere with the
continue his work. his fracture. ability to fall asleep
and stay asleep
throughout the
night. Even with
pain medication,
discomfort may
persist, particularly
when trying to find
a comfortable
sleeping position.
6. Cognitive
Perceptual
Pattern
7. Self-
Perception-
Self-Concept
Pattern
8. Role
Relationship
Pattern
9. Sexuality
Reproductive
10. Coping-Stress
Tolerance
Pattern
11. Value-Belief
Pattern