CASE STUDY

By: Baquiran, Joan D. Group E BSN 4Y-2

NURSING CARE OF CLIENTS WITH MUSCULOSKELETAL DISORDERS

INTRODUCTION

Our patient named Bulanon, Chandy, lives at B16 Lupang Arinda Taytay, Rizal. His birthday was February 21, 1990. At the age of 21 years old, he admitted at Philippine Orthopedic Center due to his diagnosis of Patellar Tendon Avulsion. He was driving at the road of Taguig, C6 with his friend while he was drunk, he suddenly, didn't see a gutter that cause his accident. His right knee was scratch by the gutter and he took many scratches to his body. He admitted at Philippine Orthopedic Center last February 14, 2012. With the diagnosis of Crushed Patellar Tendon Avulsed Right. Avulsion means fragments tend to be small bone fragments. They are often at the ends of long bones and tend to be adjacent to joints. Anywhere that there is a tendon or ligament attachment is a potential site for an avulsion fracture. Common avulsion fractures are the ulna styloid fracture (associated with a Colles fracture) and fractures of the base of the 5th metatarsal associated with ankle inversion injuries. An avulsion fracture occurs when an injury causes a ligament or tendon to tear off (avulse) a small piece of a bone to which it's attached. The mechanism is usually a tension force which pulls the avulsed fragment off the bone.

PATHOPHYSIOLOGY
Unilateral traumatic avulsions of the patellar tendon tend to occur when a violent contraction of the quadriceps is resisted by the flexed knee (eg, while landing after a jump). The estimated force required to disrupt the extensor mechanism has been reported to be as high as 17.5 times body weight. In the flexed knee position, the patellar tendon sustains greater stress than the quadriceps tendon, and the tensile load is much higher at the insertion sites than in the mid substance of the tendon. Therefore, the patellar tendon most commonly ruptures near its proximal end, off the inferior pole of the patella. Since considerable force is needed to avulsed a healthy tendon, it is likely that avulsions occur in areas of preexisting disease.

HISTORY
Past and Present Medical History Mr. Bulanon doesn't have past medical history, but we're going to discuss about his present illness. According to him, this is the first time Mr. Bulanon had been admitted into this hospital (Philippine Orthopedic Center). On his first admission into this hospital he had undergone repair of patellar tendon. He had experienced accident and injuries, because his job is prone to accident particularly vehicular accident. As for his present illness, he was admitted into this hospital because of crushed patellar tendon avulsed,he was admitted last February 14, 2012. He was been diagnosed with patellar tendon avulsed. The doctor advised him to take CoAmoxiclav, and Multimeeds.

NURSING PHYSICAL ASSESSMENT

Skin Uniformity of color ................................................................................................ NORMAL Presence of edema .................................................................................................. NORMAL Lesions ................................................................ Has lesions on his side due to his accident Skin moisture.......................................................................................................... NORMAL Skin temperature ................................................................................................... NORMAL Skin The skin springs ............................................................................................ NORMAL Nails Fingernail plate .................................................................................................... NORMAL Fingernail and toenail bed color ........................................................................... NORMAL Fingernail and toenail texture .............................................................................. NORMAL Tissue surrounding nails ..................................................................................... NORMAL Skull Size, shape, symmetry ........................................................................................ NORMAL Presence of nodules, masses, and depressions .................................................... NORMAL Scalp Color and appearance .............................................................................. NORMAL Areas of tenderness ............................................................................................ NORMAL

HAIR Evenness of growth, thickness or thinness ........................................................... NORMAL Texture, and oiliness over the scalp ..................................................................... NORMAL FACE Facial features, symmetry of facial ..................................................................... NORMAL EYEBROWS Hair distribution, alignment, skin, quality, and movement .................................. NORMAL EYELASHES Hair distribution and direction of curl ... .............................................................. NORMAL EYELIDS Surface Skin intact, no Skin intact ......................................................................... NORMAL EXTERNAL EAR CANAL Cerumen, skin lesions, pus, blood ......................................................................... NORMAL HEARING ACUITY Response to normal voice tones ............................................................................. NORMAL NOSE Deviations in Normal voice tones Color is the same ........................................... NORMAL

MOUTH LIPS Symmetry of contour, color, and texture ........................................... NORMAL TEETH Color, number and condition, and presence of dentures ................... NORMAL TONGUE/FLOOR OF THE MOUTH Color and texture of the mouth floor and frenulum .......................... NORMAL Texture, movement and base of the tongue ........................................ NORMAL Presence of nodules, lumps, or excoriated areas ................................ NORMAL From neck, down to his hip, is normal. But for his knee down to his foot, it has lesions due to his accident happened on him.

RELATED TREATMENT

Nonsurgical Treatment
Very small, partial tears respond well to nonsurgical treatment. Immobilization. Your doctor may recommend you wear a knee immobilizer or brace. This will keep your knee straight to help it heal. You will most likely need crutches to help you avoid putting all of your weight on your leg. You can expect to be in a knee immobilizer or brace for 3 to 6 weeks. Physical therapy. Specific exercises can restore strength and range of motion. While you are wearing the brace, your doctor may recommend exercises to strengthen your quadriceps muscles. Straightleg raises are often prescribed. As time goes on, your doctor or therapist will unlock your brace. This will allow you to move more freely with a greater range of motion. You will be prescribed more strengthening exercises as you heal.

Surgical Treatment
Most people require surgery to regain the most function in their leg. Surgical repair reattaches the torn tendon to the kneecap. People who require surgery do better if the repair is performed early after the injury. Early repair may prevent the tendon from scarring and tightening in a shortened position. Hospital stay. Tendon repairs are sometimes done on an outpatient basis. Most people do stay in the hospital at least one night after this operation. Whether or not you will need to stay overnight will depend on your medical needs. The surgery may be performed with regional (spinal) anesthetic or with a general anesthetic (breathing tube). It cannot be done under local anesthesia.

ASESSMENT

DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Subjective: "Nadisgrasya ako sa motor at tumama ako sa gutter. Lasing kasi ako nun, kaya di ko namalayan na tatama ako sa gutter." as verbalized by the patient.

Increased risk of hypovolemia and shock related to trauma and bleeding. Increased risk of bone inflammation related to open fracture. Increased risk of fat embolism related to fracture of the long bones. Increased risk of severe fluid, electrolyte, and metabolic imbalances related to injury or inflammation.

Short term goal: After 3 hours of nursing intervention, the patient will increase comfort, decrease pain. Long term goal: After 1 day of nursing intervention, the patient will know how to take care of himself while driving a motorcycle.

Provide fracture fixation.

To prevent following injury of tissues. Provides an objective measure of the client's condition. For early detection of possible infection.

Short term goal: After 3 hours of nursing intervention, the patient now increase comfort, decrease pain. Long term goal: After 1 day of nursing intervention, the patient knows how to take care of himself while driving a motorcycle.

Monitor fluids input and output continuously.

Monitor clients vital signs.

Objective: PR - 93 bpm RR - 17 cpm BP - 120/90 mmHg Temp - 36.8 C Pain Swelling Lesions

Administer IV therapy, analgesics, antibiotics, and other medications as prescribed.

For the client's safety and regularity of his injured leg.

Pain and immobility related to diagnosis of fracture. Increased risk of respiratory, cardiovascular, bowel, and skin complications related to a long period of immobility. Anxiety related to the symptoms of disease and fear of the unknown.

Provide care to client with cast

To observe skin for irritation and site of skeletal traction insertion for signs of infection; use aseptic technique when cleaning the site of insertion. To prevent pressure sores. To decrease anxiety and to obtain cooperation.

Provide appropriate skin care. Provide emotional support to client, explain all procedures.