Introduction

Patient L.R., a 19 year old male living at San Pedro Laguna was admitted to Jose Reyes Memorial Medical Hospital last January 23, 2012. Patient L.R. as well as his family have no history of hypertension, diabetes mellitus and have no known allergies to any drug or food. Present history of illness. Two days prior to admission, patient L.R. together with his friends was walking in the street when a drunken motorcycle driver lost his balance and hit his right leg. After two days, he was brought to the Jose Reyes Memorial Medical Hospital complaining of severe pain and bleeding and was diagnosed with Fracture Open type III-A complete displaced proximal 3rd tibia left.

Anatomy and Physiology

The tibia is the inner and thicker of the two lower leg bones. It is the supporting bone of the lower leg and runs parallel to the narrower lower leg bone, the fibula, to which it is attached by ligaments. The tibia, or shinbone, articulates with the condyles of the femur , or upper leg bone, and the head of the fibula above, and with the talus and the distal end of the fibula below. It has an expanded upper end, a smaller lower end, and a shaft. At the upper end are the lateral and medial condyles (sometimes called medial and lateral tibial plateaus), which articulate with the lateral and medial condyles of the femur, the lateral and medial semi lunar cartilages intervening. Separating the upper articular surfaces of the tibial condyles are anterior and posterior intercondylar areas; lying between these areas is the intercondylar eminence. The lateral condyle possesses on its lateral aspect a circular articular facet for the head of the fibula. The medial condyle shows a groove on its posterior aspect for the insertion of the semi membranosus muscle. The shaft of the tibia is triangular in cross section, presenting three borders and three surfaces. Its anterior and medial borders, with the medial surface between them, are subcutaneous. The anterior border is prominent and forms the shin. At the junction of the anterior body with the upper end of the tibia is the tuberosity, which receives the attachment of the ligamentum patellae. The anterior border becomes rounded below, where it becomes continuous with the medial malleolus. The lateral and interosseous border gives attachment to the interosseous membrane. The posterior surface of the shaft shows an oblique line, the soleal line. Below the soleal line avertical ridge passes downward, dividing the posterior surface into medial and lateral areas. The lower end of the tibia is slightly expanded and on its inferior aspect shows a saddle-shape darticular surface for the talus. The lower end of the tibia shows a wide, rough depression on its lateral surface for articulation with the fibula.

Pathophysiology Predisposing Factors: Vehicular accident Trauma Slower reflexes Precipitating Factors: Fall Functional disability

Fracture of the Right and Left Leg

Stimulates inflammatory response

Limited range of motion

Clinical Manifestations: - Pain - Impaired physical mobility - Deformity - Swelling - Bleeding

Nursing Management: - Repositioning the patient - Promoting strengthening exercise - Monitoring and managing complications - Health promotion

Medical Management: - Tramadol 50mg - Paracetamol 300mg - Cefuroxime 750mg

Surgical Management: Short leg posterior mold Debridement External fixator

PERSON ASSESSMENT Date of assessment: February 15, 2012 Assessment Psychosocial 1. Significant others 2. Coping mechanism 2.1. Problem focused 2.2. Emotion focused 3. Religion 4. Primary language 5. Occupation Education 6. General appearance 7. Orientation Mother Talks to her mother Interpretation

Roman Catholic Tagalog None College undergraduate Electrical Engineering Neat Oriented

Alert and awake with appropriate responses Normal Normal

8. Memory 9. Speech 9.1. Volume 9.2. Rate 9.3. Amount 10. Non-verbal behavior Elimination 1. Stool 1.1. Consistency 1.2. Amount 1.3. Color 2. Urine 2.1. Quantity 2.2. Color 2.3. Odor 2.4. daily 3. Toileting ability Rest and Activity 1. Current activity 2. ADL s

Can recall past and recent experiences Clear Clear pitch Moderate More than needed Scratches his head

Talkative Slightly shy

Once a week Hard Many Brown 20ml/hr Yellow Aromatic 6x /day Uses diaper

Constipated

Normal

Reading newspaper, chatting with his mother and the other patients.

3. Sleep 3.1. Sleep history 3.1.1.Usual bedtime 3.1.2.Usual waking time 4. Body frame 5. Muscle 5.1. Strength

Difficulty maintaining asleep 7:00-9:00pm No regular waking time Medium frame Grade 3

Able to overcome gravity but not resistance

5.2. Tone 6. Motor function 6.1. Gross

6.2. Fine 7. Range 8. Pain relief measures Safety environment 1. Allergies 2. Eyes vision 3. 4. 5. 6. Hearing Skin Mucous membrane Temperature

Normal gross motor function in all extremity except for right lower leg Active ROM Normal fine motor function Normal except for the his right lower leg Intake of analgesics No known allergies to any food or drug. Myopia or nearsightedness Normal Due to vehicular accident Normal Normal

(-) Perceives distant objects to be blurry. Can hear clearly Dry; (+) wound Moist 36.8C

Oxygenation 1. Activity intolerance 2. Airway clearance 3. Respiration 4. Lung sound 5. Nails 6. Capillary refill 7. Blood pressure Nutrition 1. Hospital diets 2. Fluid intake 3. IVF 4. Height and weight 5. Skin turgor

Clear airway 15 Clear Pinkish 1-2 seconds 110/70

Normal Normal Normal Normal Normal Normal

Diet as tolerated Water and softdrinks D5LR 1L 5 10 ; 72.7kg Moist

Can normally digest foods Can tolerate liquids Normal Normal

Management Course in the ward Assessment 02-15-12 > Awake and coherent lying on bed > Good appetite > Good wound healing > No pain Diet IVF Medication Doctor s order Nursing Responsibility Health Teaching done as follows: y Increase oral fluid intake to promote hydration and decrease constipation y Comply with his vitamins to increase his hgb level y Perform ROM on unaffected part to prevent atrophy y Eliminate bowel daily to decrease constipation.

On diet as tolerated

D5LR 1L x 30 gtts/min.

Tramadol

50mg IV q8H For severe pain 750mg IV q8H ANST(-) 300mg IV q4H For fever 38.4C 500mg tab q4H for fever 37.8C

Cefuroxime

Paracetamol

FeSO4

1tab TID

Drug study

Generic Name (Brand)

Classifica tion

Dose Frequency Route

Action

Indication

Contraindicatio n

Nursing Responsibility

Tramadol (Tramacet )

analgesic

50mg q 8hr IVP

Treat moderate to moderately severe pain and most types of neuralgia, including trigeminal neuralgia.

Used to treat moderate to moderately severe pain and most types of neuralgia, including trigeminal neuralgia. It has been suggested that tramadol could be effective for alleviating symptoms of depression, anxiety, and phobias.

Health professionals have not yet fully endorsed of its use on a large scale for these disorders, although it may be used when other treatments have failed (under the supervision of a psychiatrist).

Should the check the patients name, the correct route, dosage, and frequency of the medicine that should be given.

Generic Name (Brand)

Classificati on

Dose Frequenc y Route

Action

Indication

Contraindicatio n

Nursing Responsibility

Cefuroxim e (Ceftin,Zi nacef)

cephalosp orin

750mg q 8hr IVP

Decreases or control the infection.

Less susceptible to beta lactamase and have greater activity against Haemophilu s Influenzae, gonorrhea and Lyme disease.

If the drug was tolerated it can cause diarrhea, nausea, vomiting, headache, or migraines, dizziness and abdominal pain.

Should thecheck thepatients name,the correctroute, dosage,and frequencyof themedicine thatshould begiven.

Generic Name (Brand)

Classificati on

Dose Frequenc y Route

Action

Indication

Contraindicati on

Nursing Responsibility

Acetamin ophen (Paraceta mol)

antipyretic s, nonopioid analgesics

300mg q 4 hr

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

Mild pain Fever

Excessive use can damage multiple organs such as liver and kidney Should check first the temperature before giving the medicine and after 1530mins. Recheck the temperature of the patient, should also check for the patients name, right route, dosage and frequency of the medicines.

Should check first the temperature before giving the medicine and after 15-30 mins. Recheck the temperature of the patient, should also check for the patients name, right route, dosage and frequency of the medicines.

Laboratory Results Diagnostic test January 23,2012 Complete Blood Count Normal values Patient s Result Significance

Hemoglobin

135-180g/L

107

Hematocrit WBC RBC

0.40-.54 5-10x10^12/L 4.6-6.42x10^12/L

0.32 12.09 3.50

- Decreased-various anemias, with excessive fluid intake. - decrease -Increase presence of infection -decreased

Mean Corpuscular Hemoglobin Mean Cell Volume (MCV)

27-31g/L

30

-normal

80-96 fL

80

-normal

Platelet

150-450x10^9/L

243

-Normal

Differential Count Neutropihl Lympocyte 40-70 % 20-40% 82.1 10.7 -increased -Decreased

Serum January 23,2012 Potassium Creatinine Sodium

3.41-4.81mmol/L 23-68Umol/L 135-143

3.78 66.07 137.30

-Normal -normal - normal

Nursing Care Plan Assessment Diagnosis Background Knowledge Subjective: Paputol-putol yung tulog naming dito kasimaya t maya may mga pumapasok natao eh. Disturbed Sleeping Patterns related to interruptions for therapeutics, monitoring Objective: Presence of eye bags. Weakness and restlessness. Taking nap when there is a chance or if there is a freetime. Yawning and other generated awakening and excessive stimulation (noise and lighting) Sleep is required After 1 to provide energy for physical and mental activities. Sleep patterns can be affected by the environment especially in hospital care settings. The patients experience sleep disturbances secondary to the noisy, bright environment, frequent monitoring and treatments, sharing of room with another, use of medications, night shift rotations that change Explain necessity of disturbances day of nursing interventi on the patient will achieve optimal amount of sleep as evidenced by verbalizati on of feeli ng rested and decrease the presence of eye bags. Do as much care as possible without waking up the client and do as much care as possible while the client is still awake. Observe and obtain feedbacks regarding on the usual sleeping pattern, bedtime routine and the usual number of hours of sleep and rest. Assess sleep pattern disturbances that are associated with the environment. -High percentage of sleep disturbances can affect the recovery of the patient. -To determine usual sleeping pattern and to compare if there are any After 1 day of nursing intervention the patient was able to achieved optimal amount of sleep as evidenced by verbalization o f feeling rested and decreased presence of Planning Intervention Rationale Evaluation

improvement eye bags. s on the sleeping pattern of the patient. -To avoid disturbance during sleep, and also to maximize the sleep and rest of the client. -For the

one s circadian r hythms, acute illness and emotional problems as fear or anxiety. Disruption in the individual s usual diurnal pattern of sleep and wakefulness may be temporary. However, there disruptions may result in both subjective distress and impairment in functional abilities.

for monitoring Vital Signs and care when hospitalized.

patient to have an understandin g of the importance of care being done to her and to minimize the complaints.

Discharge Plan Medications: Acetaminophen (paracetamol)- antipyretic drug Tramadol pain Cephalosporins (Cefuroxime)- antibiotic FeSO4

Exercise: Encourage ROM exercises /mild exercises to promote good circulation Treatment:     Get enough rest Advised to comply to all prescribed medications Well balanced diet Passive ROM

Health Teaching:  Teach the patient about medication management of signs and symptoms of worsening pain, and when to contact a health care provider.   Teach family member how to do ROM exercise Instruct the family member to provide a safe and quiet environment and not to leave the pt alone. Diet Well balanced diet Eat foods rich in fiber to relieve constipation Eat foods rich in protein for good wound healing Out-Patient  Follow up check up with the physician when the pt had lost of appetite, experiencing severe pain and development of restless sleep . Discharge Goals    Fractured stabilized Pain controlled Complication prevented

 

Condition,prognosis and therapeutic regimen understood. Plan in place to meet needs after discharged. Bibliography

http://www.scribd.com/ferrerjohnoliver/d/22785275-Nursing-Care-Plan-Distrubed-Sleeping-Pattern http://www.scribd.com/doc/19492007/drug-study-for-cefuroxime-tramadol-paracetamol-and-ncp-forpost-thoracostomy http://www.scribd.com/doc/54209452/Anatomy-and-Physiology-of-Tibia-and-Fibula