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I. INTRODUCTION

Head injury can be defined as any alteration in mental or physical functioning related to a blow to the head. Loss of consciousness does not need to occur

always. Head injuries are exclusive from other kinds of body injuries because the wounds are not always visible and it is difficult to assess just what kind of damage

has been sustained to the brain in terms of symptomatic problems post-injury.

Head injuries are caused by motor vehicle accidents account for an estimated 28% of traumatic brain injuries; sports/physical activity account for 20%;

assaults/ violence are responsible for 9%; 43% are due to "other" reasons. However, when considering those brain injuries severe enough to require hospitalization,

virtually half (49%) are caused by motor vehicle accidents.

The severity of head injuries is most commonly classified by the initial post resuscitation Glasgow Coma Scale (GCS) score, which generates a numericalsummed score for eye, motor, and verbal abilities. Traditionally, a score of 13-15 indicates mild injury, a score of 9-12 indicates moderate injury, and a score of 8 or

less indicates severe injury.

There are three primary degrees of head injury which range from mild to severe. A mild head injury is the most difficult to detect because it is common for

the injured person to not even realized they've been injured and may not seek treatment. Even a minor blow to the head may result in a mild head injury; some

concussions would be considered a mild TBI. Indicators of a mild head injury being present are brief unconsciousness, headaches, persistent or unusual fatigue,

irritability, a confused feeling or some memory loss. Decreased concentration or bouts of depression after a blow to the head may also indicate a mild head injury

has occurred. Sometimes there may be physical signs as well such as a loss of balance or sensitivity to the senses, such as light or noises.

If a person has experienced a moderate head injury t

he symptoms are characterized as including the same ones as a mild head injury, but with additional

problems. Moderate head injuries include a loss of consciousness which may have lasted anywhere from several minutes to hours. In addition the injured person

may feel levels of confusion and exhibit uncharacteristic behavioral, physical or cognitive differences that were not present prior to the injury. In addition to the

physical symptoms that are exhibited in a mild head injury.

A severe head injury includes a loss of consciousness for over six hours or when the injured person has fallen into a coma. This unconsciousness can last

for many days or result in a persistent vegetative state with little or no response. Severe head injuries are hard to predict because recovery strides can range from

significant degrees of recuperation to minimal progress depending on the nature of the injury.

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With any degree of head injury it is important to get immediate medical treatment. Early intervention has been proven to result in a better prognosis post

injury. A person who has sustained a head injury may experience significant changes which include behavioral, physical or emotional differences and may not

behave the same way they did pre-injury.

In the United States, there are 2 million Traumatic Brain Injuries each year (One every 15 seconds).500, 000 of these injuries require hospital

admission. Every 5 minutes someone dies from a head injury.140, 000 people each year.75, 000 - 100,000 in the U.S. Over half of the deaths occur at the time of theincident or within two hours of hospitalization. Every 5 minutes someone becomes permanently disabled due a head injury. 70,000 - 90,000 of those who survivewill have lifelong disabilities.2, 000 more will live in a persistent vegetative state.Men in the United States are nearly twice as likely to be hospitalized with brain

injury as women. This male predominance is found worldwide. Approximately half of the patients admitted to a hospital for head injury are aged 24 years oryounger.

While in the Philippines, Philippine National Police reported about 15,000 traffic accidents in 2006 meaning that there are on average of 41 trafficaccidents per day. These accidents result in 674 fatalities, 3,767 injuries and 10,623 instances of property damage .The report concluded that most traffic accidents

are caused mainly by driver errors. In 2006 for example, 4,182 (27%) of car accidents were caused by driver error. The said vehicle accident can caused Headinjuries to the victim especially the driver and the passengers. Head injury data are difficult to compare internationally for multiple reasons, including

inconsistencies and complexities of diagnostic coding.

Reason for Choosing such Case Study

This study of a client with Moderate Head Injury intends to provide and share information to:

Allow nursing students to help them picture and foresee patients experiencing Moderate Head Injury and to guide them on how to apply patient-

centered nursing interventions.

Individuals and to other people who are interested on what types of management are applicable and appropriate when experiencing the disease.

Objectives

General Objective:

To be able to discuss problems encountered by a patient having Moderate head injury and bring in with the proper nursing care or management thatwill advance the progress the recovery of the patient.

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Specific Objectives:

A.1 Client-centered objectives:

1. To gain sufficient knowledge about the condition he had experienced.

2. To increase the awareness of the patient with regard to the possible complications.

3. To provide appropriate information on self-care activities using health teachings.

4. To give proper nursing interventions to the patient and his situation.

5. To be able to impart knowledge about the prevention of aggravation of the said condition to the patient.

A.2 Student-centered objectives:

1. To attain familiarity with regard to signs and symptoms of the condition

2. To obtain the necessary information regarding the patients condition through physical examination

3. To analyze the medications that was given to the patient in the entire course of treatment

4. To identify the patients health care needs through the analysis of the date gathered.

5. To be able to make an appropriate nursing care plan who had Moderate Head Injury

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II. NURSING HEALTH HISTORY

A. Demographic Data

Name: K.P.

Age: 22 years oldGender: Male

Address: Carmensita, Florida Blanca, PampangaDate of Birth: April 16, 1989

Nationality: FilipinoReligion: Roman Catholic

Educational Attainment: High School Undergraduate (1st year)Occupation: Farmer

Health Care Financing/Usual Source of Health Care: PhilHealthDate/Time of Admission: September 12, 2011 02:00 AM

Date of Discharge: September 26, 2011Admitting Physician: Dr. Naguit

Admitting Diagnosis: Moderate Head Injury t/c ICH, Complete Open Fracture at Left Patella

Hospital Number: 332019

B. Chief Complaint:

Vehicular accident, (+) to alcohol, (+) multiple abrasion on abdomen & L arm, (+) dizziness, (+) fracture, Glasgow Coma Scale (GCS) 10, E-3 V-2 M-5

C. Present History of Illness:

Last September 11, 2011, the client went to a friends house to celebrate his birthday around 4 in the afternoon. It was already 12 midnight when the clientand a friend of his went out to buy more bottles of brandy to the nearest convenience store riding his motorcycle. On their way, they crashed with another

motorcycle. Both parties were drunk, the other driver was dead on the spot and the others, including the client were brought immediately to the nearest hospital, Sto.

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Cristo Hospital, a secondary hospital that provided them first aid. They were advised to transfer the client immediately to a tertiary hospital and were then brought to

JBLMGH by an ambulance - unconscious. Upon the arrival of his Aunt, he gained some consciousness and upon initial assessment he was positive of alcohol breath

and dizziness. Signed consent was obtained and surgical management was done on the Emergency Room. He has a fracture with a long leg posterior mold on his

left lower extremity due to vehicular accident he had encountered. Intravenous fluid and oxygen inhalation was initiated and he was then transferred to the surgery

ward.

D. Past History of Illness:

The patients Aunt was the one who took care of them ever since, acts as a real mother and a friend as well. She said that the immunization of K.P. was complete.

She also said that he has no noted chronic disease and allergies. His childhood illnesses include chickenpox, the client was 14 years old then and their remedy to it

was going to barangay health clinic to have some medicines and advice for fast healing recovery, the chickenpox lasted for a week. The client has been hospitalized

for the first time in his life.

E. Family History of Illness:

KPs extended family members are in optimal health condition for the past 3 weeks. In the patients maternal side, his grandmother suffered from Breast Cancer.

Aside from the above mentioned, his one brother, uncle and aunt has Asthma. On the contrary, GPs father, as well as his uncle on the maternal side are both

hypertensive.

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GENOGRAM

FATHER SIDE MOTHER SIDE

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LEGEND:

MALE

FEMALE

HYPERTENSION

CANCER

DECEASED

PATIENT

ASTHMA

RP

62

WT

49

TT 59

UP 61FP

63

OP 62

DP

65

MD

63

SP

53

SP

61

EP 26

VP

24

MP

68

EP

28

KP

22EP

15

EP

32

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F. Functional Health Patterns

PRIOR TO ADMISSION DURING HOSPITALIZATION

1. HealthPerception/Health ManagementPattern

Patient KP seemed to be a healthy person becauseaccording to his Auntie, he doesnt easily acquire colds. Andonce he gets cold or fever he takes herbal medicines which

are readily available on their backyard. He is fond of eatingvegetables rather than meat products and drinks a lot of water.

The patient was unconscious upon interview and cannot participatewell. He needs some rest and energy since it is onlyl 3days ago duringthe accident.

2. NutritionalMetabolicPattern

The patients usual daily food intake was composed ofcoffee, breads, fish, pork and chicken. He drinks about eight

to ten glasses of fluids a day, more on water (1920-2400ml).

He doesnt have any eating discomforts and when he has a

wound, it heals timely and normally.

Upon admission, the patient was under NPO diet for 3 days (Sept 11-13, 2011). He is NPO due to lack of energy to eat and he is always

sleeping previously. Then on September 14, 2011, his diet shifted toDAT with SAP.

Sept. 11,

2011

Sept.12,

2011

Sept.13,

2011

Breakfast NPO NPO NPO

Lunch NPO NPO NPO

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Dinner NPO NPO NPO

3. EliminationPattern

The patient had no difficulty in defecation. It occurs 1-2times a day.

The patient had no difficulty in urinating. He urinates for

at least 10 times in a day.

Frequency Color/Consistency Discomfor

t

Remarks

BowelElimination 1-2times/day light brown ordark brown,

formed stool

Nodiscomfort Normal

Urination 5-8

times/day

Clear or Yellow No

discomfort

Normal

During hospitalization, he was not yet able to defecate. His stool

output was zero since admission.

Regarding his urination, he was catheterized for 3days now and he is

still on FC. Urine was dark yellow in color.

There is no excessive perspiration and odor problem noted.

Frequenc

y

Color/Consistency Discomfort Remarks

BowelElimination

None N/A N/A N/A

Urination 1250cc/day

Dark yellow Nodifficulty

inurinating

Normal

4. Activity-Exercise Pattern

The client considers doing household chores as a form of

exercise. He often goes to farm for some farming activities,after that he usually goes home immediately, eats, takes a

bath and stays outside their house. He has lots of friends tochat with and plays cards to kill their boredom. He loves

The patient was still resting in bed and cannot move easily due to

fracture on his left leg . He is sleeping all day long for fast healing andrecovery.

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biking, one form of exercise and hobby.

TIME ACTIVITY

4:00am

4:30am

4:40am6:50am7:00am

9:00am12:00nn

1:00pm2:00pm

5:00pm6:00pm

6:30pm

8:30pm

9:00pm

9:30pm

Wake up

Wash up

FarmingBreakfastTake a bath

Standby with his friends/playingLunch

Watching TVRest at home

MeriendaTake a nap

Visit a friends houseWatch TV or texting

Dinner

Watch TV or chat with hisbrothers & Wash upSleep

0 Feeding 0 Bathing 0 Toileting

0 Bed Mobility 0 Dressing 0 Grooming

0 General Mobility

0 Completely Able - Activity completed under ordinary

circumstances without modification, and within reasonable

time. (A "reasonable time" involves an amount of time theindividual feels is acceptable to complete the task and an

amount which does not interfere with completing other tasks,

II Feeding II Bathing I Toileting

II Bed Mobility II Dressing II Grooming

II General Mobility

0 Completely Able - Activity completed under ordinary circumstances

without modification, and within reasonable time. (A "reasonable time"involves an amount of time the individual feels is acceptable to complete

the task and an amount which does not interfere with completing other

tasks, as well as the professional judgment of the case manager based on

the individual's age, health condition, (e.g. arthritis) and situation.

I Able with Aids/Difficulty - Activity completed with prior preparation or

under special circumstances, or with assistive devices or aids, or beyond a

reasonable time.

II Able with Helper - Activity completed only with help or assistance of

another person, or under another person's supervision by cuing. Individual

performs at least half the effort to complete the activity.

II

I

Unable - Individual assists minimally (less than half of effort), or is totally

dependent.

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as well as the professional judgment of the case manager

based on the individual's age, health condition, (e.g. arthritis)

and situation.

I Able with Aids/Difficulty - Activity completed with prior

preparation or under special circumstances, or with assistive

devices or aids, or beyond a reasonable time.

II Able with Helper - Activity completed only with help or

assistance of another person, or under another person's

supervision by cuing. Individual performs at least half the

effort to complete the activity.

II

I

Unable - Individual assists minimally (less than half of effort),

or is totally dependent.

5. Sleep-RestPattern

Approximately, the patient has 7-8 hours of sleep and will

just get up on bed at night when he has the urge to urinate.

His brother reported that he can go back to sleep easily. Heusually takes a nap in the afternoon for about 30minutes to 1hour.

Date Sleep Nap Total Quality

Sept.8,2011

7 hrs 1hour 8 hours Invigorated

Sept.9,

2011

6 hrs 30mins 7 hours Invigorated

Sept.10,2011

6 hrs 1 hour 7 hours Invigorated

The patient sleep well due to his condition, the hospital environment.

He usually sleeps for 7-8 hours only.

Date Sleep Nap Total Quality

Sept.11,2011

6 hrs 1hour 7 hours sufficient

Sept.12,

2011

7 hrs 30mins 7

hours

sufficient

Sept.13,2011 6 hrs 20mins 6 hours &20mins

sufficient

6. Cognitive

PerceptualPattern

The patient has no hearing or viewing difficulty. His

perceptual pattern was still good.

The patient has no hearing difficulty but cannot talk sensibly due to

his moderate head injury that affects him now. His thinking ability wasaffected.

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7. Self-Perception/Self-ConceptManagement

Not applicable. Disorientation and altered level of consciousness noted uponinterview.

8. Role-

RelationshipPattern

The client lives with his family together with his 2

brothers and auntie. The family structure is extended.

Sometimes they experience difficulty in handling financialproblems but they usually talk it over and find ways to solveit.

The client cant speak accordingly and appropriately, he is very

difficult to handle. He cannot assume his responsibility as a part of their

household due to hospitalization.

9. Sexuality-ReproductivePattern

The client is still single, no girlfriend and doesnt talk toomuch about this with his brothers or other family members.

The client is still single. Disorientation and altered level ofconsciousness noted upon interview

10. Coping StressTolerancePattern

The client wasnt tensed most of the time. He can easily

cope with the different changes on around him. When there isa problem, he seeks comfort and advice from his Aunt,

brothers or a good friend. He is working on their farm so thathe doesnt feel stress most of the time.

The client is not aware of his current status on the hospital, he talks

when he is awake, but it is not appropriate to the situation. He needsmore rest and compliance to treatment regimen for fast recovery.

11. Value-BeliefPattern

The client and his family is a Roman Catholic. They trust

and believe in God knowing that He is the one who gives

them their everyday needs. They pray every night and neverfail to attend mass every Sunday.

His family still has faith in God and is confident that He will help himin his recovery. Personal perception regarding this is not noted due to

clients disorientation.

G. Growth and Development

Theories Stages Justification

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ERIK ERIKSONS THEORY OFSOCIOEMOTIONAL

Intimacy is a close personal relationship while isolation isthe fact of being alone and separated from others.

Indicators of negative resolution include impersonalrelationship career or lifestyle.

His brother stated that though there are problems and

other difficulties arise, still, they still want to be with

their family at the end of the day.

PIAGETS STAGE OF COGNITIVEDEVELOPMENT

FORMAL OPERATION(12-ADULTHOOD)

During this final stage of cognitive development, children became capable of what Piaget terms hypothetico-

deductive reasoning. That is, when faced with a problem,young people can formulate a general theory that includes

all possible factors. In addition, persons who reach thestage of formal operations demonstrate prepositional

reasoning. They can assess the logical validity of verbalassertions, even when these refer to possibilities rather

than to events in real world

His brother thinks that KP can handle problems

maturely as of the moment.

FOWLERS STAGES OF SPIRITUALDEVELOPMENT

Stage of Individuative-Reflective

It begins in a radical shift from dependence on

others spiritual beliefs to development of their own.

Individuals are no longer defined by the groups to which

they belong. Instead, they choose beliefs, values and

relationships important to their self-fulfillment.

They obtained positivity that even if their family

encounter problems, they immediately pray, and ask

the help, guidance and strength to God. They have an

optimistic view of life no matter what happens as

mentioned above, there is always hope and they keep

moving forward.

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PHYSICAL ASSESSMENT

Name: Patient KP Date of Assessment: Sept. 21, 2011Age: 22 years old

Sex: Male Vital signs:BP: 120/70 mmHgT: 37.0CP: 62 bpmR: 22 cpm

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AREA TO BE ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS

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General Survey

a. BODY BUILT, Inspection Varies with lifestyle Proportionate Normal

b. POSTURE AND GAIT, STANDING Inspection Relaxed, erect posture, coordinated

movement

Uncoordinated body movements Abnormal, due to

present condition

c. OVERALL HYGIENE AND GROOMING Inspection Clean, neat Clean and Neat Normal

d. BODY AND BREATH ODOR Inspection No body or breath odor No body odor, no foul breath odor Normal

e. SIGNS OF DISTRESS Inspection No signs Signs of distress noted Abnormal, due to

perception about

the injury

f. OBVIOUS SIGNS OF HEALTH/ILLNESS Inspection Healthy appearance Unhealthy Appearance Abnormal, due to

presence of injury

g. ATTITUDE Inspection Cooperative Uncooperative Abnormal, due to

present condition

h. MOOD AND APPROPRIATENESS OF

RESPONSES

Inspection Appropriate to the situation Inappropriate to the situation Abnormal, due to

altered level of

consciousness

i. QUANTITY AND QUALITY OF SPEECH Inspection Understandable, moderate pace, exhibits

thought association

Not understandable, exhibits

thought dissociations

Abnormal, due to

altered level of

consciousness

j. RELEVANCE AND ORGANIZATION OFTHOUGHTS

Inspection Logical sequence, makes sense The patient wasnt able to giverelevant thoughts and information

Abnormal, due toaltered level of

consciousness

1. INTEGUMENTARY (SKIN)

a. COLOR AND UNIFORMITY OF COLOR

b. EDEMA

c. SKIN LESIONS

Inspection Varies from light to deep brown, genera lly

uniform in color except in areas exposed to

the sun; no edema; Freckles, some

birthmarks, some fat and raised nevi

Not uniform in color(ecchymosis on

left patella),with abrasions and

bruises on the anterior and posterior

thorax & on the left and right arm

Abnormal due to

injury

d. MOISTURE Palpation Moisture in skin folds and axillae Moisture in skin folds and axillae Normal

e. TEMPERATURE Palpation Uniform within normal range Varies in temperature Abnormal due to

present condition

f. SKIN TURGOR Palpation When pinched, skin brings back to previous

state

Poor skin turgor on lef t patel la Abnormal due to

injury

(NAILS)

a. FINGERNAIL PLATE SHAPE Inspection Convex curvature, angle between nail and

nail bed of about 160 degrees

Convex curvature Normal

b. FINGERNAIL AND TOENAIL BED COLOR Inspection Pink in light-skinned clients; dark-skinned

clients may have brown or black

pigmentation in longitudinal streaks

Pink nail beds and prompt refill

time

Normal

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III. ANATOMY AND PHYSIOLOGY

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NEUROLOGIC ASSESSMENT

Glasgow Coma Score

Eye Opening (E) Verbal Response (V) Motor Response (M)

3 2 5

TEMPERATURE 36.5-37.5 C 36.7C Normal

PULSE RATE Range: 60-100 bpm 62 bpm Normal

RESPIRATORY RATE Range: 12-20 cpm 22 cpm Normal

BLOOD PRESSURE 120/80 mmHg 120/ 70 mmHg Normal

HEIGHT Varies with lifestyle 57 Normal

WEIGHT Varies with lifestyle 60 kg Normal

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The Brain

CONTUSION

The BrainThe brain, when fully developed, is a large organ which fills the cranial cavity. Early in its development the brain becomes divided into three parts known as the

forebrain, the midbrain and the hindbrain. The forebrain is the largest part and is called the cerebrum; it is divided into the right and left hemispheres by a deeplongitudinal fissure. The separation is complete t the front and back but in the center, the hemispheres are joined by a broad band of nerve fibres called the

corpus callosum. The outer layer of the cerebrum is called the cerebral cortex and is composed of grey matter (cell bodies) thrown into numerous folds orconvolutions called gyri, separated by fissures called sulci. This enables the surface area of the brain, and therefore the number of cell bodies, to be increased

greatly. The general pattern of the gyri and sulci is the same in all humans; three main sulci divide each hemisphere into four lobes, each named after the skull boneunder which it lies. The central sulcus runs downwards and forwards from the top of the hemisphere to a point just above the lateral sulcus; the lateral sulcus runs

backwards from the lower part of the front of the brain and the parieto-occipital sulcus runs downwards and forwards for a short way from the upper posterior partof the hemisphere. The lobes of the hemispheres are the frontal lobe, lying in front of the central sulcus and above the lateral sulcus; the parietal lobe lying between

the central sulcus and the parieto-occipital sulcus and above the line of the lateral sulcus; the occipital lobe, which forms the back of the hemisphere and the

temporal lobe lying below the lateral sulcus and extending back to the occipital lobe. The area lying immediately in front of the central sulcus between is known asthe pre-central gyrus and is the motor area from which arise many of the motor fibres of the central nervous system. Immediately behind the central sulcus lies thesensory area, called the post-central gyrus, in the cells of which several kinds of sensation are interpreted. Longitudinal section of a hemisphere shows grey matter

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(cell bodies)on the outside and white matter (nerve fibres) forming the interior. The nerve fibres connect one part of the brain with the other parts and with the spinal

cord, but within the white matter groups of nerve cells can be seen forming areas of grey matter. These areas of grey matter are called cerebral nuclei.

The main function of these areas is coordination of movement and posture of the body: disorders affecting these areas cause jerky movements andunsteadiness. The cavities within the brain are called ventricles. There are two lateral ventricles, a central third ventricle and a fourth ventricle between the

cerebellum and the pons. All are filled with cerebrospinal fluid. The midbrain lies between the forebrain and the hindbrain. It is about 2cm in length and consistsof two stalk-like bands of white matter called the cerebral peduncles, which convey impulses passing to and from the brain and spinal cord, and four small

prominences called the quadrigeminal bodies, which are concerned with sight and hearing reflexes. The pineal body lies between the two upper quadrigeminalbodies. The hindbrain has three parts:

1. The pons, which lies between the midbrain above and the medulla oblongata below. It contains fibres which carry impulses upwards and downwards and somewhich communicate with the cerebellum.

2. The medulla oblongata lies between the pons above and the spinal cord below. It contains the cardiac and respiratory centres which are also known as the vitalcentres and which control the heart and respiration.

3. The cerebellum projects backwards beneath the occipital lobes of the cerebrum. It is connected to the midbrain, the pons and the medulla oblongata by threebands of fibres called the superior, middle and inferior cerebellar peduncles respectively. The cerebellum is responsible for the coordination of muscular activity,

control of muscle tone and maintenance of posture. It is continuously receiving sensory impulses concerning the degree of stretch in muscles, the position of jointsand information from the cerebral cortex. It sends information to the thalamus and the cerebral cortex. The midbrain, the pons and the medulla have many functions

in common and together re often known as the brain stem. This area also contains the nuclei from which originate the cranial nerves.

PLEURAL EFFUSION

The pleura is a double-layered membrane that covers the lungs and the inside of the thoracic cavities. The parietal pleura is adherent to the inside of the chest walland the thoracic surface of the diaphragm. It remains detached from the adjacent structures in the mediastinum and is continuous with the visceral pleura, which is

adherent to the lung, covering each lobe and passing into the fissures that separate them. The pleural space plays an important role in respiration by coupling themovement of the chest wall with that of the lungs in two ways:

1. A relative vacuum in the space keeps the visceral and parietal pleura in close proximity.2. The small volume of pleural fluid, which has been calculated at 0.13 ml/kg of body weight and the normal circumstances, serves as a lubricant to facilitate

movement of the pleural surface against each other in the course of respirations. This small volume of fluid is maintained through the balance of hydrostatic andoncotic pressure and lymphatic drainage, disturbance of which may lead to pathology. An abnormal collection of this pleural fluid in the pleural spaces more than

0.13 ml/kg of bodyweight is called, pleural effusion.

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This can either be a result from a systemic disorders or local diseases. Systemic disorders include heart failure, liver or renal diseases and connective disorders, like

rheumatoid arthritis and systemic lupus erythematosus (SLE). Local diseases include pneumonia, atelectasis, tuberculosis, lung cancer, and trauma. Pleural Effusionis not often a primary disease process; it is usually a secondary to other processes as mentioned above.

FRACTURE

The word skeleton comes from the Greek word meaning dried- up body, our internal framework is so beautifully designed and engineered and it puts any modern

skyscraper to shame. Strong, yet light, it is perfectly adapted for its functions of body protection and motion. Shaped by an event that happened more than onemillion years ago when a being first stood erect on hind legs our skeleton is a tower of bones arranged so that we can stand upright and balance ourselves. The

skeleton is subdivided into three divisions: the axial skeleton, the boned that form the longitudinal axis of the body, and the appendicular skeleton, the bones of thelimbs and girdles. In addition to bones, the skeletal system includes joints, cartilages, and ligaments (fibrous cords that bind the bones together at joints). The joints

give the body flexibility and allow 18 movement to occur. Besides contributing to body shape and form, or bones perform several important body functions such assupport, protection, movement, storage and blood cell formation.

Classification of Bones

The diaphysis, or shaft, makes up most of the bones length and is composed of compact bone. The diaphysis is covered and protected by a fibrous connective tissuemembrane, the periosteum. Hundreds of connective tissue fibers, called Sharpeys fibers, secure the periosteum to the underlying bone. The epiphyses are the ends

of the long bone. Each epiphyses consist of a thin layer of compact bone enclosing the area filled with spongy bone. Articular cartilage, instead of periosteum,covers its external surface. Because the articular cartilage is glassy hyaline cartilage, it provides a smooth, slippery surface that decreases friction at joint surfaces.

In adult bones, there is a thin line of bony tissue spanning the epiphyses that looks a bit different from the rest of the bone in that area. This is the epiphyseal line.The epiphyseal line is a remnant of the epiphyseal plate (a flat plate of hyaline cartilage) seen in young, growing bone. Epiphyseal plates cause the lengthwise

growth of the long bone. By the end of puberty, when hormones stop long bone growth, epiphyseal plates have been completely replaced by bone, leaving theepiphyseal lines to mark their previous location. In adults, the cavity of the shaft is primarily a storage area for adipose (fat) tissue. It is called the yellow marrow, or

medullary, in infants this areas forms blood cells, and red marrow is found these. In adult bones, red marrow is confined to the cavities of spongy bone of flat bonesand the epiphyses some long bones.

Bone is one of the hardest materials in the body, and although relatively light in weight, it has a remarkable ability to resist tension and other forces acting on it.

Nature has given us an extremely strong and exceptionally simple (almost crude) supporting system without up mobility. The calcium salts deposited in the matrixbone its hardness, whereas the organic parts (especially the collagen fibers) provide for bones flexibility and great tensile strength.

The patella, or kneecap, is one of three bones, along with the tibia (shin bone) and femur (thigh bone), that make up the knee joint. All of these bones are covered

with a layer of cartilage at points where their surfaces come into contact. Furthermore, the patella is wrapped within a tendon. This tendon connects the quadricepsmuscle of the thigh to the shin bone (tibia) below the knee joint.

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The patella is important functionally because it increases the leverage of the knee joint. From a mechanical perspective, the patella allows for an increase of about

30% in strength of extension (kicking) of the leg at the knee joint.

IV. THE PATIENT AND HIS ILLNESS

A. Pathophysiology

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B. Review of Systems

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Systems of a human body work in union with one another, failure of a system can cause alterations in other system function. Neurologic level refers to the

lowest level at which sensory and motor functions are normal. Below the neurologic level there is:

Nervous System

altered level of consciousness,

temporary amnesia

irrational behavior

altered spatial relation & orientation

Musculoskeletal System-

limited ROM,

suppress RAS

decreased wakefulness

Cardiovascular System

decreased blood flow

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increased PaCO2

Destruction of blood vessels

Hemorrhage

ecchymosis

necrosis at damaged end of the bone, muscles and surrounding tissue

increased WBC

Endocrine System-

release of prostaglandins that leads to swelling

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C. Laboratory Test

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Diagnostic

Laboratory

Procedure

Date

Ordered

and Date

result

Indications or Purpose Result Normal Values Analysis and

Interpretation of

the results

Nursing

Responsibilities

Blood

Chemistry

Sept. 12,

2011

Blood chemistry tests are

often ordered prior to

surgery or a procedure to

examine the general

health of a patient. This

blood test, commonly

referred to as a Chem 7

because it looks at 7

different substances

found in the blood, is

routinely performed after

surgery as well.

RBS 7.53 mmol/L

BUN 5.0 mmol/L

Creatinine 90.7 umol/L

3.85-9.0 mmol/L

4.1-6.1 mmol/L

60-120 umol/L

Analysis/

Interpretation

Normal

Fluid replacement

Rapidadministration of

intravenous fluidsand electrolytes

helps support theblood pressure.

Monitor input and

output.

Electrolytes Actual Findings

Sodium 144 mmol/L

Potassium 3.89 mmol/L

Chloride 105 mmol/L

Normal Findings

136-145 mmol/L

3.5-5.0 mmol/L

101-111 mmol/L

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Diagnostic

Laboratory

Procedure

Date

Ordered

and Date

result

Indications or Purpose Result Normal Values Analysis and

Interpretation of

the results

Nursing

Responsibilities

Blood

Chemistry

Sept. 21,

2011

Blood chemistry tests are

often ordered prior to

surgery or a procedure to

examine the general

health of a patient. This

blood test, commonly

referred to as a Chem 7

because it looks at 7

different substances

found in the blood, is

routinely performed after

surgery as well.

Creatinine 74.7 umol/L M : 60-120 umol/L

F : 58-100umol/L

Normal

Fluid replacement

Rapidadministration of

intravenous fluidsand electrolytes

helps support theblood pressure.

Monitor input and

output.

Electrolytes Actual Findings

Sodium 144.1 mmol/L

Potassium 3.89 mmol/L

Chloride 105.4 mmol/L

Normal Findings136-145 mmol/L

3.5-5.0 mmol/L

101-111 mmol/L

Analysis/

Interpretation

Diagnostic

Laboratory

Date

Ordered

Indications or Purpose Result Normal Values Analysis and

Interpretation of the

Nursing Responsibilities

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Laboratory

Procedure

Ordered

and

Date

result

Interpretation of the

results

CBC Sept.

12,

2011

The CBC provides valuable

information about the blood

and to some extent the bone

marrow, which is the blood-

forming tissue. The CBC isused for the following

purposes:

as a preoperative test to

ensure both adequateoxygen carrying capacity

and hemostasis

to identify persons who

may have an infection

to diagnose anemia

to identify acute andchronic illness, bleeding

tendencies, and white bloodcell disorders such as

leukemia

to monitor treatment foranemia and other blood

diseases

to determine the effects ofchemotherapy and radiation

therapy on blood cellproduction

Components Actual

Findings

HGB 122

HCT 0.36

WBC count 24.5

Neutrophils .84

Lymphocytes .16

Platelet count 268

Normal Findings

125-175

0.40-0.52

5.10x10 /L

0.45-0.65

0.20-0.35

150-400x10 /L

Analysis/

Interpretation

Decreased

Decreased

Increased-

Inflammatory

response

Increased WBC

Administer

antibiotics asordered

Instruct clientand significantothers to practice

infection controltechnique

The nurse should

carefully assess the patient with a low

hematocrit forhis/her ability to

tolerate physicalactivity. After

blood loss, plasmavolume is usually

replaced withinseveral hours. As a

result, the patientwith a low

hematocrit caused by hemorrhag

may have a normal blood pressure. If

there is not enoughfluid to shift from

the interstitial andintracellular spaces

into the vascularspace, the blood

pressure will falland the patient will

show signs ofshock.

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V. THE PATIENT AND HIS CARE

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Diagnostic

Laboratory

Procedure

Date

Ordered

and Date

result

Indications or Purpose Result Normal Values Analysis and

Interpretation of the

results

Nursing

Responsibilities

Chest X-ray Sept. 15,

2011

Chest x-rays are used to

visualise the lung fields,

and rule out pathology.

Chest x-rays are also

used to visualise air and

fluid levels within the

lung fields. These can be

evident in stab chests and

other traumatic injuries.

Most chest x-rays should

be done erect, and this is

very important whenlooking for air and fluid

levels which cannot be

seen well on a supine

chest x-ray. Patients who

present with traumatic

injuries have

a pneumothorax ( air in

the lungs) and this is an

important indication for a

chest x-ray.

Shows haziness in left

hemothorax due to hydrothorax.

True cardiac size cannot be

ascertained.

Aorta is unremarkable.

Left chest tube is in placed.

No other findings of note.

The lungs look normal in

size and shape, and the lung

tissue looks normal. No

growths or other masses can

be seen within the lungs.

The heart looks normal in

size, shape, and the heart

tissue looks normal. The

blood vessels leading to and

from the heart also are

normal in size, shape, and

appearance.

No abnormal collection of

fluid or air is seen, and no

foreign objects are seen.

All tubes, catheters, or other

medical devices are in their

correct positions in the chest.

Theres haziness in left

hemothorax due to

hydrothorax. No other

findings noted.

Brought patient

to the x-ray

department with

safety

precautions

given. To secure

results.

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A. Medical Management

1. Intravenous Fluid

Medical

Management

DATE

ORDERED/

DATE

CHANGED

GENERAL

DESCRIPTION

INDICATION AND

PURPOSES

CLIENT RESPONSE

TO THE

TREATMENT

NURSING RESPONSIBILITIES

Intravenous

Fluid

Of 0.9 NaCl

(PNSS)

1L, regulated at

30-31gtts/min

September

12,2011

Isotonic

(sameosmolarity as

our bodyfluids.

Normal saline

is a sterile,non-pyrogenic

solution forfluid

electrolytereplenishment

.

Used to replace

fluids indehydration, go

with bloodtransfusions,

hyponatremia, andburn victims.

It is indicated as asource of water

and electrolytes.

The patient developed

limited movement due

to the inserted IV; also,

he displays proper

hydration that can be

seen through moist skin

mucus membranes.

BEFORE:

Check for the doctors order.

Verify for what kind of solution tobe infused, and what the regulation

is.

Explain the importance of therapy

to the client.

Select the most appropriate site and

type of cannula for a particular

patient. Assess and prepare the IV site.

Prime the IV tubing.

Apply tourniquet

DURING:

Provide aseptic technique

Assess for the IV tubing patency.

Secure the IV tubing.

Monitor I and O.

Monitor for signs and symptoms ofIV therapy.

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AFTER:

Check for clients response to thetherapy.

Do after care on all the materials.

Check for skin irritations.Document procedures done

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2. Oxygenation

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1. Drugs

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TREATMENT DATE ORDERED/DATE CHANGED

GENERAL DESCRIPTION INDICATIONS ANDPURPOSES

CLIENTSRESPONSE TO

THE TREATMENT

NURSING RESPONSIBILITIE

OxygenInhalation

(O2 2-3 LPM vianasal cannula)

September 12, 2011 It delivers low

concentration of oxygen

(24% to 45%) at flowrates of 2-3 L per minute,in this minimal O2 is

required.

Oxygen therapy is

a key treatment in

respiratory care. The purpose is to

increase oxygen

saturation intissues where the

saturation levelare too low due to

illness or injury.

The patient

experience

improvebreathingpattern.

The patientlessen

difficulty ofbreathing.

PRIOR:

1. Assess vital signs for baseline

2. Determine the need for oxygetherapy and verify the doctorsorder.

3. Place cautionary signs readingSmoking: Oxygen in Use on

door or at the foot of the bed.

DURING:1. Monitor patient condition.

2. Frequently check thehumidifier.

AFTER:1. Check the patient nares and ea

any signs of irritation.

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GENERIC NAME/

BRANDNAME

DATE ORDERED/

DATE

CHANGED

ROUTE OF

ADMINISTRATION,

DOSAGE,

FREQUENCY

CLASSIFICATION,

MECHANISMSOF

ACTION

INDICATIONS/

PURPOSES

CLIENTS

RESPONSE TO

SIDEEFFECTS

NURSING

RESPONSIBILITIES

Generic Name:

MANNITOL

Brand Name:

Osmitol

Resectisol

September 12,

2011

150mg

TIV

Q8

Classification:

Osmotic diuretic

Action:

Increases the osmotic

pressure of glomerular

filtrate, which inhibits

tubular reabsorption of

water and electrolytes

and increases urinary

output.

Mannitol is indicated

for reduction of

increasedintracranial pressure

associated with

cerebral edema;

promoting urinary

excretion of toxic

substances.

The client did not

experience any

adverse effectssuch as dizziness

and seizures, but he

whined about

having occasional

headaches.

BEFORE:

Check the

doctors order

Check the

expiration date,integrity and sterility of

the drug.

DURING:

Be sure toadminister the drug at

the right patient, rightroute, right dosage, and

at the right time.

AFTER:

Check the vitalsign

Check for the

adverse effect such as

seizures, heart failure,

blurred vision.

Watch out for

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excessive fluid loss and

sign and symptom of

hypovolemia and

dehydration.

GENERIC NAME/BRANDNAME

DATE ORDERED/DATE

CHANGED

ROUTE OFADMINISTRATION,

DOSAGE,

FREQUENCY

CLASSIFICATION,MECHANISMSOF

ACTION

INDICATIONS/PURPOSES

CLIENTSRESPONSE TO

SIDEEFFECTS

NURSINGRESPONSIBILITIES

Generic Name:

KETOROLAC

Brand Name:

Kortezor

Toradol

September 12,

2011

30mg

TIV

Q6

Classification:

Analgesic

Anti-inflammatory

Antipyretic

Action:

Inhibits prostaglandin

synthesis by inhibition

of cyclo-oxygenate

enzyme. It also

inhibits leukotriene

synthesis, help

stabilize lysosomal

membranes and exert

ant-bradykinin

activity.

Ketorolac is

indicated for short

term management of

moderate to severe

acute post-operative

pain.

The client was

relieved and was

able to attain

tolerable level of

pain.

BEFORE:

Check the

doctors order

Check theexpiration date,

integrity and sterility of

the drug.

DURING:

Be sure to

administer the drug at

the right patient, right

route, right dosage, and

at the right time.

AFTER:

Check the vital

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sign

Check for theadverse effect such as

nausea, GI disturbance

and rash.

Watch out for

excessive fluid loss andsign and symptom of

anaphylactoid reactions

NAME OFDRUG

DATEORDERED/DATE

CHANGED

ROUTE OFADMINISTRATION,

DOSAGE,FREQUENCY

CLASSIFICATION,MECHANISM OF

ACTION

INDICATION/PURPOSE

CLIENTSRESPONSE,

SIDE EFFECTS

NURSINGRESPONSIBILITY

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GenericName:RANITIDINE

Brand Name:ZANTAC

Date ordered:

September 12,2011

50 mg

TIVQ8

Classification:

Anti-refluxH2 Receptor Blocker

Mechanism of Action:

Competitively inhibits the

action of histamine at theH2 receptors of the

parietal cells of the

stomach, inhibiting basalgastric acid secretion and

gastric acid secretion thatis stimulated by food,

insulin, histamine,cholinergic agonist,

gastrin, and pentagastrin.

Short-termtreatment of

active duodenalulcer

Maintenance

therapy for

duodenal ulcerat reduceddosage

Short-term

treatment ofactive, benign

gastric ulcer

Prevention foracid aspiration

Abdominal pain

did not occur.BEFORE

Check the Doctorsorder

Check the expirationdate, integrity and

sterility of the drug.

DURING

Be sure to administer

the drug at the Rightpatient, Right route,

Right dosage, and atthe Right time.

AFTER

Check the vital signCheck for the adverse

effect such as fever,headache dizziness,

insomnia , tremors

NAME OFDRUG

DATEORDERED/DATE

CHANGED

ROUTE OFADMINISTRATION,

DOSAGE,FREQUENCY

CLASSIFICATION,MECHANISM OF

ACTION

INDICATION/PURPOSE

CLIENTSRESPONSE, SIDE

EFFECTS

NURSINGRESPONSIBILITY

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Generic Name:CEFUROXIME

Brand Name:CEFUROXIME

Date ordered:

September 12,2011

750mg

TIV

Q8

Classification:

Cephalosporin 2nd

generation

Action:

Second generationcephalosporin that inhibit

cell-wall synthesis,promoting osmotic

instability; usuallybactericidal

Prophylaxis for

infection

Pain is felt upon

administering IVinjection

PRIOR

1. Assess patient forcontraindication.

2. Assess for baselinedata.

3. Have vitamin K

readily available in caseof hypoprothrombinemoccurs.

DURING

1.Reconsitute 1gram w10 or more ml of sterile

water

AFTER1. Instruct patient to

avoid alcohol for 3days

after drug administratiobecause serious reactionoften occur.

2. Tell patient that hemay experience someside effects brought upo

by the drug.

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NAME OF

DRUG

DATE

ORDERED/

DATE

CHANGED

ROUTE OF

ADMINISTRATION,

DOSAGE,

FREQUENCY

CLASSIFICATIO

N,

MECHANISM OF

ACTION

INDICATION/

PURPOSE

CLIENTS

RESPONSE,

SIDE EFFECTS

NURSING

RESPONSIBILITY

Generic

Name:CELECOXIB

Brand Name:

CELEBREX

September 12,2011 200 mg/cap

BID

Classification:

Anti-rheumatic;

Mechanism of

Action:

Exhibits anti-

inflammatory,

analgesic and anti-

pyretic action due to

inhibition of COX-2

enzyme

Acute pain

RheumatoidArthritis

May prevent

rheumatoid Arthritisand it will decrease

pain due to

inflammation

BEFORE:

Check doctorsorder

Check theexpiration date,

integrity andsterility of thedrug.

Instruct patient

to take drug withfood or milk

DURING: Be sure to

administer thedrug at the Right

patient, Rightroute, Right

dosage, and atthe

Right time

AFTER:

Advise patient to

immediatelyreport bloody

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stools, vomitingof blood.

Tell patient to

avoid aspirinand other

NSAIDs (suchas Ibuprofen and

naproxen)during therapy.

NAME OFDRUG

DATEORDERED/DATE

CHANGED

ROUTE OFADMINISTRATION,

DOSAGE,FREQUENCY

CLASSIFICATION,MECHANISM OF

ACTION

INDICATION/PURPOSE

CLIENTSRESPONSE, SIDE

EFFECTS

NURSINGRESPONSIBILITY

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GENERIC

NAME:Tetanus Toxoid

Date ordered:

September 12,2011

0.5 ml

IM

Classification:

Immunizing agent

General Action:

Maintenance of

active immunity and

booster effect inpotential exposure.Promotes immunity to

tetanus by producingof antitoxin.

For prevention of

tetanus, diphtheria, andpertussis, adolescents

and adults arerecommended to

receive a one-time

booster dose of Tdap.

Pain is felt upon

administering IMinjection

PRIOR

1. Assess patient forcontraindication.

2. Assess for baselinedata.

3. Tell patient that he

may experience sideeffects brought about bythe drug.

DURING

1. Administer thedrug slowly.

AFTER

1. Instruct him to reportintolerable side effects

as prompt intervention

could be done.2. Instruct him to reportadverse effects that he

may experience

2. Diet

Type of dietDate

Started

Date

Change

General

Description

Indication/Purposes

Specific

foods/fluids

taken

Client Response Nursing Responsibilities

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NPO(Nothing

Per Orem)

09/12/11 09/14/11 An instructionmeaning to

withhold oralfoods and fluids,

but for patientswho will

undergo

laboratoryexamination, the

physician will

allow smallamount of fluid

intake for oralmedication

This diet isusually ordered

for client whoundergo to

laboratoryexamination to

provide a

accurate results.

NONE Feels hunger andthirst, appears

weak.

Prior

-asses the level of understanding of thepatient

-Explain the importance of followingstrictly NPO diet in terms that the client

can understand and then evaluate

During

-Strictly monitor clients behavior infollowing NPO diet

Post

-Educate the client of what kind of food

he can eat after NPO diet

DAT( diet as

tolerated)with SAP

(strict

aspiration

precaution)

09/14/11 (until

discharge)

It is a diet that

allows thepatient to eat all

types/kinds of

foods as long as

the client can

tolerate it.

Instructed

following ageneral liquid

diet for better

source of good

nutrition.

Meatloaf or

cheese,hardboiledegg,

pandesalWater

Nilagangbaboy, rice,

waterManok (with

soup), gulay

(repolyo,

petchay), rice,

water

Relieved hunger Prior

-Asses the level of understanding of thepatient

-Explain that immediate shifting offoods from NPO to General Fluids to

DAT without undergoing soft diet canresult to constipation, thats why we

need to emphasize eating first softfoods before eating any solid foods

During

-Strictly monitor clients behavior infollowing DAT diet

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Check for the effectiveness

of exercise to the client

Type of Exercise GeneralDescription

Indications/Purpose

Clients response to theactivity/ exercise

Nursing responsibility

Range of Motion To move jointsincluding upper and

lower extremities incertain manner to

promote goodcirculation.

These exercises reducestiffness and help keep

your joints flexible.The "range-of-motion"

is the normal amountyour joints can be

moved in certaindirections. If your

joints are very painfuland swollen, move

them gently throughtheir range of motion

Prior to hospitalization:

The client can easily perform

this type of exercise without

any hesitation because he

doesnt feel any weakness in

terms of his physical abilities.

During Hospitalization:

During hospitalization the

client cant perform those

activities that he can perform

before, because he experience

pain and discomfort.

Prior:

Encourage the client to dothe said exercise.

Assess for clientscapacity in performing the

exercise.

Explain the importance of

exercise for the client.

During:

If needed, assist client

while performing theexercise

Monitor clients condition

while doing it.

Check if the client isperforming the exercise

correctly.

After:

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Check for the effectiveness of

exercise to the client

PRIORITIZATION OF NURSING CARE PLAN

Nursing Diagnoses Priority Justification

1. Ineffective cerebral tissue perfusion High Circulation must be dealt first to stabilize the clients

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condition.

2. Altered sensory perception High

Altered sensory perception was given the second

highest priority because according to Maslows

hierarchy of needs, a person must me physiologically

capacitated to be able to function well and so, anyalterations of such must be addressed promptly.

3. Impaired physical mobility Medium Alteration in mobility affects the clients general

movement and ADL.

4. Acute Pain Low Acute pain was given the fourth priority because

when resolved, it could enhance the capability of the

patient to adhere to his treatment regimen

5. Risk for Infection Low It does not need immediate intervention because our

nursing intervention here is to watch for the signs ofinfection or any complication.

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Nursing Care Plan

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

BACKGROUND

PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective IneffectiveCerebral tissue

Vehicular accident SHORT TERM:

After 1 hour of nursingintervention, the

INDEPENDENT:

>note presence of conditionthat can affect multiple

SHORT TERM:

Goal met. After 1 hourof nursing intervention,

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>

Objective

> altered level of

consciousness

>words are

inappropriate to

the situation

GCS: 10 (E:3,V:2,

M:5)

BP: 110/80

PR: 79

RR: 21

T: 36.6C

Perfusion related

to interruption of

blood flow in the

brain secondary to

moderate head

injury.

Contusion

Ruptured blood vessels

Decreased blood flow

Ineffective cerebral

tissue perfusion

Altered level of

consciousness

relatives of the client

will be able to verbalize

understanding of

condition, therapy

regimen, side effects of

medications, and when

to contact health care

provider.

LONG TERM:

After 1-2 weeks of

nursing intervention, the

client will be able to

demonstrate increased

perfusion as individually

appropriate.

system (brain injury)

>identify changes related to

systemic or peripheral

alterations in circulations

(altered mental status)

>elevate head of the bed and

maintain head/neck in

midline or neutral position

>monitor vital signs and

mental status, I&O

>encourage discussion of

feelings regarding

prognosis/long term effects

of condition

>demonstrate/ encourage use

of relaxationactivities/techniques

DEPENDENT:

>administer medications

(steroids, diuretics), as

ordered

COLLABORATIVE:

>assist with treatment of

underlying condition, as

indicated

>to promotecirculation/ venous

drainage

>to decrease tension

level

>used to decreased

edema

>to improve tissue

perfusion

the relatives of the client

was able to verbalized

understanding of

condition, therapy

regimen, side effects of

medications, and when

to contact health care

provider.

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Objective cues:

disorientation in

time,place

restless/irritable

anxietylevel of

7/10

confusio

n

persisten

tlyasking

questions

brain tissue

(parietal lobe)

Neurologic deficits

Altered special

relation & orientation

bruises

improve

physicalcondition

Specific objectives:

reduce level ofanxiety

reduce risk forfall/further

injury

re-orient the

client on time,place

Long term:

After 2 weeks

of nursing

intervention, the

patient will be able to

gain his normal

memory as manifested

by:

orientation in

time, family,place, name

Vital signs

Raise the side-rails

Keep acomfortable & less

stimulatingenvironment

Promoterelaxational/

diversionalactivities like:

music therapy, etc.

Close watch withsignificant others

improvementof condition

To promotesafety

To reduce thelevel of

anxiety & topromote

relaxation

To promote

relaxation &to divert

patientsattention

To securepatients

safety & keepthe patient

oriented/updated of the

bruises

improvedphysical

condition

Specific objectives:

reduced levelof anxiety

reduced risk forfall/further

injury

re-oriented the

client on time,place

Goal met

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Dependent:

Administermedication as

ordered

situation

To lessen

anxiety

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

BACKGROUND

PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective

>

Objective

> fracture on left

Impaired physical

mobility related to

musculoskeletal

impairment

secondary to

vehicular

accident.

Vehicular accident

Open complete fracture

at left patella

Inflammatory response

SHORT TERM:

After 1 hour of nursing

intervention, the client

will be able to verbalize

understanding of

situation and individual

treatment regimen and

safety measures, as

manifested by responses

to intervention/teaching

and actions performed.

INDEPENDENT:

>note situations such as

surgery, fractures,

amputations, tubings.

>support affected body part

using pillows, foot supports.

>re-position the client from

side to side every 2 hours

>provide regular skin care to

>it may restrict

movement

>to maintain position of

function and reduce

risk of pressure ulcers

>to prevent bed sores

>to prevent risk of

SHORT TERM:

Goal met. After 1 hour

of nursing intervention,

the client was able to

verbalized understanding

of situation and

individual treatment

regimen and safety

measures, as manifested

by responses to

intervention/teaching

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foot

>long leg

posterior mold on

left foot

>inability to stand

without assistance

>limited range of

motion on lower

extremities

Swelling and pain

Limited range of

motion

Impaired physical

mobility

LONG TERM:

After 2-3 weeks of

nursing intervention, the

client will be able to

increase strength and

function of affected or

compensatory body part.

include pressure area

management

>provide for safety measures

as indicated by individual

situation, including fall

prevention

>encourage adequate intakeof fluids/nutritious foods

>involve the client and SO

in care, assisting them to

learn ways of managing

problems of immobility

>demonstrate use of

standing aids and mobility

devices such as crutches,

walker, and have the

client/care provider

demonstrate knowledge

about safe use of device.

DEPENDENT:

>administer medication prior

to activity as needed for pain

relief

COLLABORATIVE:

>assist with treatment ofunderlying condition causing

infection

>to prevent risk for fall

and injury

>promotes well-being

and maximizes energyproduction

>promotes

independence and

enhances safety

>to permit maximal

effort/involvement in

activity

and actions performed.

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i d f i

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pain or dysfunction

VI. DISCHARGE PLANNING

1. General Condition of the Patient upon Discharge

The patient, upon discharge, is in a fair amount of pain (scale of 2) and with a dry and occluded dressing at the fracture site. The patient

is conscious with vital signs of BP-110/60; RR-22cpm; PR-80bpm; T-37.

2. Discharge Planning using METHODS

MEDICINE

The patient was advised to take the prescribed oral medications continuously and/or as needed. These medicines are:

Cefalexin

Dosage: 500 mg cap

Frequency: every 6 hours for 1 week

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N rsing Responsibilities;

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Nursing Responsibilities;

- Give drug with meals; arrange for small, frequent meals if GI complications occur.

- Complete the full course of this drug even if you feel better

Mefenamic Acid

Dosage: 500 mg cap

Frequency: prn

Nursing Responsibilities:

o Instruct patient to avoid alcohol (includes wire, beer, and liquor) when taking this medicine since it can cause

increase in stomach irritation.

o Use with caution if the patient has a weakened heart. It may cause increased shortness of breath or weight gain.

o Avoid aspirin, aspirin-containing products, other pain medicines, other thinners (warfarin, ticlopidine, and

clopidogrel), garlic, ginseng, gingko, and vitamin E while taking. Talk with healthcare provider.

EXERCISE

Post-operative exercise must be done by the patient; he should start with simple ones and gradually advance to exercises that are morestrenuous. These exercises are done to restore muscle tone as well as improve circulation, and regain strength.

ANKLE CIRCLES to enhance circulation

Make 10 circles with your ankles clockwise, and then repeat counterclockwise.

Do the ankle circles in different position such as sitting, lying, etc.

Repeat circular pattern 3-5 times.

TREATMENT

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The client was advised to perform self monitoring of his intake and output (e g amount and color of the stool) which can be the guide in

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The client was advised to perform self monitoring of his intake and output (e.g. amount and color of the stool), which can be the guide in

knowing if his gastrointestinal system is properly functioning. In addition, the client was instructed to perform hand washing regularly and to clean the

incision site using the proper wound care methods until it is completely healed.

HEALTH TEACHING

The client must know about the following:

Continue taking of oral medications

Have a rest, and try to get a good night sleep to avoid fatigue

For his hygiene: he is allowed to take shower and cleanse the incision site with betadine.

OUT-PATIENT

The client is required to see his attending physician for the following check-up on October 03, 2011 at the Jose B. Lingad Memorial General

Hospital. The check-up usually includes assessing the condition of his incision, intake and input, and checking for any necessary laboratory test. This

check-up is also an opportunity for the patient and his significant others to discuss problems and to consider if any further referrals and necessary for the

client.

DIET

The client was advised to have a:

High protein diet- for the development of muscles and fast wound healingEx. Meat, tofu, dairy products, fish

Increased fluid intake- for hydration and to prevent constipationEx. 2-3 quarts of fluid a day (water, orange juice)

Rich in Vitamin C, protein, iron- for faster wound healingEx. Orange, guava, green leafy vegetables

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High fiber foods- to prevent constipation and to avoid too much pressure on the affected area in the intestines

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High fiber foods- to prevent constipation and to avoid too much pressure on the affected area in the intestines.

Ex. Green leafy vegetables, papaya

SAFETY

The client was advised to avoid strenuous activities within three weeks after his operation to avoid too much pressure on the fracture site that can

increase the probability of having an infection. In addition, he was advised to perform hand washing regularly.

VII. CONCLUSION

As future nurses we should have the knowledge and skills on how to deal properly in every patient. We should give the appropriate care and

intervention that will prevent further complications. Through this study we able to gain the importance of proper management on a patient who had a moderate

head injury since it may lead to more serious conditions if it is not properly managed or treated. Also, we were able to help out and be familiarized to medicalmanagements made, its benefits and side effect to patient during the entire course of treatment. Furthermore as a group, we were be able to help others to understand

and know more about head injuries and ways to prevent and manage its signs and symptoms.

Regarding the patient, we could say that we have been an effective healthcare providers. We have imparted information on how the patient can take care of

his condition.

VIII. BIBLIOGRAPHY

http://braininjury.blogs.com/braininjury/2006/09/cdc_brain_injur.htmlhttp://www.wrongdiagnosis.com/c/concussion/deaths.htm

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http://www.wrongdiagnosis.com/c/concussion/prevalence.htm

http://braininjury.blogs.com/braininjury/2006/09/cdc_brain_injur.htmlhttp://www.wrongdiagnosis.com/c/concussion/deaths.htmhttp://braininjury.blogs.com/braininjury/2006/09/cdc_brain_injur.htmlhttp://www.wrongdiagnosis.com/c/concussion/deaths.htmhttp://www.wrongdiagnosis.com/c/concussion/prevalence.htmhttp://www.wrongdiagnosis.com/c/concussion/prevalence.htm

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http://www.wrongdiagnosis.com/c/concussion/prevalence.htm

focus on pathophysiology, Author: barbara l. bullock, reet l. henza, page 964essentials of pathophysiology, Author: thomas j. nowak, A.Gordon handford, page 554

http://books.google.com.ph/books?id=WSP6wdD_8MEC&pg=PA377&lpg=PA377&dq=parasympathetic+nervous+system+in+abdominal+distention&source=bl&ots=wK4GjR4_Ts&sig=qGpN2yh

MyZki146o3hMQ9XwAuQw&hl=tl&ei=PNlHTevNJJOXceCX9Y8D&sa=X&oi=book_result&ct=result&resnum=5&ved=0CDoQ6AEwBA#v=onepage&q=parasympathetic%20nervous%20system%20in%20abdominal%20distention&f=false

Colbert, Ankney, Lee, Principles of Anatomy and Physiology, An Interactive Journey, Pearson Education South Asia Pte Ltd 2007

Marieb, Elaine (2007) Essentials of Anatomy and PhysiologyKozier, Erb, Berman, Snyder, Fundamentals of Nursing 7 th and 8th Edition, Pearson Education South Asia Pte Ltd 2007/2008Huether, Sue E. and Kathryn C. McCane 2nd Edition, Understanding Pathophysiology

Marilyn E. Doenges, Nursing Pocket Guide 11 th Edition, LA Davis Company, Philadelphia Pennsylvania 2006Nursing 2006 Drug Handbook 26th Edition, Lippincott Williams and Wilkins

Suzanne C. Smeltzer and Brenda G. Bare, Brunner and Suddarths Textbook of Medical-Surgical Nursing 10 th Edition, Volume 1, Lippincott

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http://www.wrongdiagnosis.com/c/concussion/prevalence.htmhttp://books.google.com.ph/books?id=WSP6wdD_8MEC&pg=PA377&lpg=PA377&dq=parasympathetic+nervous+system+in+abdominal+distention&source=bl&ots=wK4GjR4_Ts&sig=qGpN2yhMyZki146o3hMQ9XwAuQw&hl=tl&ei=PNlHTevNJJOXceCX9Y8D&sa=X&oi=book_result&ct=result&resnum=5&ved=0CDoQ6AEwBA#v=onepage&q=parasympathetic%20nervous%20system%20in%20abdominal%20distention&f=falsehttp://books.google.com.ph/books?id=WSP6wdD_8MEC&pg=PA377&lpg=PA377&dq=parasympathetic+nervous+system+in+abdominal+distention&source=bl&ots=wK4GjR4_Ts&sig=qGpN2yhMyZki146o3hMQ9XwAuQw&hl=tl&ei=PNlHTevNJJOXceCX9Y8D&sa=X&oi=book_result&ct=result&resnum=5&ved=0CDoQ6AEwBA#v=onepage&q=parasympathetic%20nervous%20system%20in%20abdominal%20distention&f=falsehttp://books.google.com.ph/books?id=WSP6wdD_8MEC&pg=PA377&lpg=PA377&dq=parasympathetic+nervous+system+in+abdominal+distention&source=bl&ots=wK4GjR4_Ts&sig=qGpN2yhMyZki146o3hMQ9XwAuQw&hl=tl&ei=PNlHTevNJJOXceCX9Y8D&sa=X&oi=book_result&ct=result&resnum=5&ved=0CDoQ6AEwBA#v=onepage&q=parasympathetic%20nervous%20system%20in%20abdominal%20distention&f=falsehttp://books.google.com.ph/books?id=WSP6wdD_8MEC&pg=PA377&lpg=PA377&dq=parasympathetic+nervous+system+in+abdominal+distention&source=bl&ots=wK4GjR4_Ts&sig=qGpN2yhMyZki146o3hMQ9XwAuQw&hl=tl&ei=PNlHTevNJJOXceCX9Y8D&sa=X&oi=book_result&ct=result&resnum=5&ved=0CDoQ6AEwBA#v=onepage&q=parasympathetic%20nervous%20system%20in%20abdominal%20distention&f=falsehttp://www.wrongdiagnosis.com/c/concussion/prevalence.htmhttp://books.google.com.ph/books?id=WSP6wdD_8MEC&pg=PA377&lpg=PA377&dq=parasympathetic+nervous+system+in+abdominal+distention&source=bl&ots=wK4GjR4_Ts&sig=qGpN2yhMyZki146o3hMQ9XwAuQw&hl=tl&ei=PNlHTevNJJOXceCX9Y8D&sa=X&oi=book_result&ct=result&resnum=5&ved=0CDoQ6AEwBA#v=onepage&q=parasympathetic%20nervous%20system%20in%20abdominal%20distention&f=falsehttp://books.google.com.ph/books?id=WSP6wdD_8MEC&pg=PA377&lpg=PA377&dq=parasympathetic+nervous+system+in+abdominal+distention&source=bl&ots=wK4GjR4_Ts&sig=qGpN2yhMyZki146o3hMQ9XwAuQw&hl=tl&ei=PNlHTevNJJOXceCX9Y8D&sa=X&oi=book_result&ct=result&resnum=5&ved=0CDoQ6AEwBA#v=onepage&q=parasympathetic%20nervous%20system%20in%20abdominal%20distention&f=falsehttp://books.google.com.ph/books?id=WSP6wdD_8MEC&pg=PA377&lpg=PA377&dq=parasympathetic+nervous+system+in+abdominal+distention&source=bl&ots=wK4GjR4_Ts&sig=qGpN2yhMyZki146o3hMQ9XwAuQw&hl=tl&ei=PNlHTevNJJOXceCX9Y8D&sa=X&oi=book_result&ct=result&resnum=5&ved=0CDoQ6AEwBA#v=onepage&q=parasympathetic%20nervous%20system%20in%20abdominal%20distention&f=false