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INTRODUCTION
A clavicle fracture is a bone fracture in the clavicle, or collarbone.Claviclefractures involve approximately 5% of all fractures seen in hospital emergency
admissions. Clavicles are the most common broken bone in the human body. It ismost often fractured in the middle third of its length. Children and infants areparticularly prone to it. Newborns often present clavicle fractures following adifficult delivery. After fracture of the clavicle, the sternocleidomastoid muscleelevates the proximal fragment of the bone. The trapezius muscle is unable tohold up the distal fragment owing to the weight of the upper limb, and thus theshoulder droops.
A rib fracture is a break orfracture in one or more of the bones making upthe rib cage. The middle ribs are the ones most commonly fractured. Fracturesusually occur from direct blows or from indirect crushing injuries. The weakest
part of a rib is just anterior to its angle, but a fracture can occur anywhere. Themost commonly fractured ribs are the 7th and 10th. Rib fractures are usuallyquite painful because the ribs have to move to allow forbreathing. Even a smallcrack can inflame a tendon and cripple an arm.Rib fractures can occur withoutdirect trauma and have been reported after sustained coughing and in varioussports for example, rowing and golf often in elite athletes. They can alsooccur as a consequence of diseases such as cancer or infections (pathologicalfracture).
Cirrhosis is a consequence of chronic liver disease characterized byreplacement of livertissue by fibrous scartissue as well as regenerative nodules
(lumps that occur as a result of a process in which damaged tissue isregenerated), leading to progressive loss of liver function. Cirrhosis is mostcommonly caused by alcoholism, hepatitis B and C, and fatty liver disease buthas many other possible causes. Some cases are idiopathic, i.e., of unknowncause.The word "cirrhosis" derives from Greek, meaning tawny (the orange-yellow colour of the diseased liver).
Diabetes mellitus type 2 or type 2 diabetes (formerly called [non-[insulin]]-dependent diabetes mellitus (NIDDM), or adult-onset diabetes) is a disorder thatis characterized by high blood glucose in the context of insulin resistance andrelative insulin deficiency.While it is often initially managed by increasingexercise and dietary modification, medications are typically needed as thedisease progresses. There are an estimated 23.6 million people in the U.S.(7.8% of the population) with diabetes with 17.9 million being diagnosed, 90% ofwhom are type 2.With prevalence rates doubling between 1990 and 2005, CDChas characterized the increase as an epidemic. Traditionally considered adisease of adults, type 2 diabetes is increasingly diagnosed in children in parallelto rising obesity rates due to alterations in dietary patterns as well as in life stylesduring childhood.
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http://en.wikipedia.org/wiki/Bone_fracturehttp://en.wikipedia.org/wiki/Claviclehttp://en.wikipedia.org/wiki/Childrenhttp://en.wikipedia.org/wiki/Infantshttp://en.wikipedia.org/wiki/Newbornshttp://en.wikipedia.org/wiki/Childbirthhttp://en.wikipedia.org/wiki/Sternocleidomastoid_musclehttp://en.wikipedia.org/wiki/Trapezius_musclehttp://en.wikipedia.org/wiki/Bone_fracturehttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Rib_cagehttp://en.wikipedia.org/wiki/Breathhttp://en.wikipedia.org/wiki/Coughhttp://en.wikipedia.org/wiki/Sporthttp://en.wikipedia.org/wiki/Rowing_(sport)http://en.wikipedia.org/wiki/Golfhttp://en.wikipedia.org/wiki/Sportspersonhttp://en.wikipedia.org/w/index.php?title=Pathological_fracture&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Pathological_fracture&action=edit&redlink=1http://en.wikipedia.org/wiki/Liverhttp://en.wikipedia.org/wiki/Diseasehttp://en.wikipedia.org/wiki/Tissue_(biology)http://en.wikipedia.org/wiki/Scarhttp://en.wikipedia.org/wiki/Nodule_(medicine)http://en.wikipedia.org/wiki/Alcoholismhttp://en.wikipedia.org/wiki/Hepatitis_Bhttp://en.wikipedia.org/wiki/Hepatitis_Chttp://en.wikipedia.org/wiki/Non-alcoholic_fatty_liver_diseasehttp://en.wikipedia.org/wiki/Idiopathichttp://en.wikipedia.org/wiki/Diabetes_mellitushttp://en.wikipedia.org/wiki/Metabolic_disorderhttp://en.wikipedia.org/wiki/Insulin_resistancehttp://en.wikipedia.org/wiki/Physical_exercisehttp://en.wikipedia.org/wiki/Dietinghttp://en.wikipedia.org/wiki/Centers_for_Disease_Control_and_Preventionhttp://en.wikipedia.org/wiki/Epidemichttp://en.wikipedia.org/wiki/Bone_fracturehttp://en.wikipedia.org/wiki/Claviclehttp://en.wikipedia.org/wiki/Childrenhttp://en.wikipedia.org/wiki/Infantshttp://en.wikipedia.org/wiki/Newbornshttp://en.wikipedia.org/wiki/Childbirthhttp://en.wikipedia.org/wiki/Sternocleidomastoid_musclehttp://en.wikipedia.org/wiki/Trapezius_musclehttp://en.wikipedia.org/wiki/Bone_fracturehttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Rib_cagehttp://en.wikipedia.org/wiki/Breathhttp://en.wikipedia.org/wiki/Coughhttp://en.wikipedia.org/wiki/Sporthttp://en.wikipedia.org/wiki/Rowing_(sport)http://en.wikipedia.org/wiki/Golfhttp://en.wikipedia.org/wiki/Sportspersonhttp://en.wikipedia.org/w/index.php?title=Pathological_fracture&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Pathological_fracture&action=edit&redlink=1http://en.wikipedia.org/wiki/Liverhttp://en.wikipedia.org/wiki/Diseasehttp://en.wikipedia.org/wiki/Tissue_(biology)http://en.wikipedia.org/wiki/Scarhttp://en.wikipedia.org/wiki/Nodule_(medicine)http://en.wikipedia.org/wiki/Alcoholismhttp://en.wikipedia.org/wiki/Hepatitis_Bhttp://en.wikipedia.org/wiki/Hepatitis_Chttp://en.wikipedia.org/wiki/Non-alcoholic_fatty_liver_diseasehttp://en.wikipedia.org/wiki/Idiopathichttp://en.wikipedia.org/wiki/Diabetes_mellitushttp://en.wikipedia.org/wiki/Metabolic_disorderhttp://en.wikipedia.org/wiki/Insulin_resistancehttp://en.wikipedia.org/wiki/Physical_exercisehttp://en.wikipedia.org/wiki/Dietinghttp://en.wikipedia.org/wiki/Centers_for_Disease_Control_and_Preventionhttp://en.wikipedia.org/wiki/Epidemic8/6/2019 204 GYNE Fracture Liver Cirrhosis DM
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B. Objectives of the Study
The study aims to further analyze a patients condition providing the
students of NCM501204 a definite idea on how it is to care for a patient with the
same disease condition and how to interconnect all the other laboratory and
significant findings of the physician to associate to the patients current state and
condition. Proper assessment and nursing interventions are also given priority to
emphasize the importance of nursing care to an ill patient. The study also has an
objective of assessing and assisting the patient from her present condition
towards the patients improvement in a higher level of wellness.
C. Scope and Limitation of the Study
The study covers 2 days of assessment and care during our exposure at
Cagayan de Oro Medical Center (COMC) and rendered our care to the patient at
Station 4 (Private room) these includes thorough assessment, giving of nursing
interventions, analyzing of the laboratory results, relating the disease condition to
the Anatomy and Physiology of the Human body and the Pathophysiology of the
disease.
The focus of the study is limited to the time that we had our duty at
COMC, the span of time for the assessment of the patient has limited since we
had only 2 days to assess and for our nursing interventions. Also the hand writing
of the doctors at the doctors order are not legible.
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II. PATIENTS PROFILE
Name: C.B.P
Age: 79 years old
Sex: Female
Birth date: January 12, 1930
Birth place: Zamboanga De l Sur
Occupation: Housewife
Income: 300 pesos/month
Civil status: Widower
Nationality: Filipino
Informant: Patient and SonsReligion: Roman Catholic
Address: Balucot, Tambulig, Zamboanga Del Sur
Number of children 5 children
CLINICAL PROFILE
Date of admission: August 1, 2009
Time of admission: 11:35 AM
Attending physician: Dr. Chang, Dr. Sison, Dr. Tia, Dr. Pagdilao
Chief Complaint: Body malaise
Admitting diagnosis: DM, Fracture Left 8th Rib minimally displaced
Fracture of Distal Left Clavicle
Diet: Soft Diabetic Diet
Vital Signs upon Assessment: BP: 140/80mmHg
T: 36.60 C
RR: 22 cpm
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PR: 85 bpm
Patients Health History
In 2008, patient C.B.P. was admitted at Cebu and was diagnosed to have
liver cirrhosis 2004, this is because of her diet since she was young, she was
fond of eating street foods. She had been on Godex and Essentiale Natural
Meds for several years.
History of Present Illness
A case of 79 year old, female, widower, Filipino fromBalucot, Tambulig,
Zamboanga Del Sur, was admitted at Cagayan de Oro Medical Center on august1, 2009 at exactly 11:35AM accompanied by her daugther. 2 weeks prior to
admission, the patient experienced a fall at there stairs (4 steps), she was
admitted at Zamboanga by then. Due to insufficiency of the equipments of their
hospital, her children decided to transfer her at COMC here in Cagayan de Oro
City and was diagnose DM, Fracture Left 8th Rib minimally displaced Fracture of
Distal Left Clavicle.
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III. GROWTH AND DEVELOPMENT
Developmental Task Theory of Robert Havighurst
A developmental task is a task which arises at or about a certain period in
the life of an individual.
Basing on Havighurst theory our patient C.B.P. belongs in the later
maturity 79 years old stage wherein she has adjusted to decreasing physical
strength and health and the patient also has settled for a reduced income.
Psychosexual Theory of Sigmund Freud
The psychosexual stage of Sigmund Freud has five developmental
periods during which the individual seeks pleasure from different areas of the
body associated with sexual feelings.
Basing in this theory, C.B.P. belongs to the genital stage wherein she has
already achieved sexual desires. She has five children. Fortunately, She has a
good personal relationship with her children. She has fully achieved the
implications of this stage because she was able to raise a family, making a livingand doing it independently apart from her parents. The value of decision making
has already matured in the patient, upon making many decisions for herself and
her family.
Psychosocial Theory of Erik Erickson
Erik Erickson envisioned life has a sequence of levels of achievements.
Each stage signals tasks that must achieved. He believed that the greater the
task achievement, the healthier the personality of the person. Failure to achieve
the tasks influences the persons ability to achieve the next tasks.
Basing on this theory, C.B.P. belongs to the maturity Stage wherein she
has already achieved sexual desires he has 5 children at present. The patient
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feels that she has already lived longer to see her children grow up and live a life
of their own. She thinks that she already has served her purpose in this life and
found uniqueness in the life that she is leading. She accepted that all life forms
has their own end and has accepted that sooner she will have to leave his
children behind, because she is open in the concept of death but she has also
fear from it.
Cognitive Theory of Jean Piaget
Cognitive development refers to how a person perceives, thinks, and
gains understanding of his or her world through the interaction and influence of
genetics and learning factors.Basing on this theory C.B.P. belongs to the Formal Operational Phase
wherein she has solved previously encountered problems in a logical manner
and has used rational thinking. This includes overcoming financial problems and
her personal family problems.
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IV. MEDICAL MANAGEMENT
A. Medical Orders and Rationale
Doctors Order RationaleAugust 1, 200911:35 AM
Pls. admit under the serviceof Dr. Chang
Secure consent of care
TPR q4
Soft Diabetic Diet
Labs: CBC, U/A, Chest x-rayPA view, Ultrasound of theliver and gallbladder,NA+ K+
Start venoclysis with PNSS IL @ 10gtts/min
O2 2-3L/min
Med: Celecoxib 200mg BID
Intake and output monitor qshift
August 2, 2009
8:00 AM Request for FBS, crea, NA+
K+
IVF to follow PNSS 1L atsame rate.
For proper management/care.
For legal purposes
To monitor any changes in TPR
Diet for patient to provide proper
nutritionTo determine deviation and to knowany abnormalities .
To provide fluid and electrolytes andserves as a channel for any drug thatcan be administer through it (IVTT).
Provide enough oxygen.
For management of moderate tosevere pain.
To determine fluid balance going in andout from the body.
To re-evaluate the values of the result.
To provide fluid and electrolytes andserves as a channel for any drug thatcan be administer through it (IVTT).
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For Rehabilitation
Informed Dr. Sison for co-management
Meds: Kalimate 2 sachets TID
NaHCO3 650mg 1 tab TID
Lactulose 30ml OD
Continue Celecoxib 200mgBID
Refer accordingly
August 3, 20098:50 AM
Side drip Aminoleban 500 @20cc/hr.
Repeat for FBS, crea, NA+K+
Continue Rehabilitation
Informed Dra. Tia for co-management
Turn to sides q 2 hours
Moderate high back rest
Provide footboardMeds: Amoxiclav 500 I tab TID
Itopride 50 mg TID
Pancreatin 50mg BID
For management of the fracture
For co-management
For electrolytes balance in the bodyAntacid; neutralize secreted acid.
Laxative: Prevent/treatment forconstipation.
Management of pain.
Refer any abnormalities/ anusualities.
For hepatic encelopathy due to chronicliver disease.
To monitor blood glucose level and toto check for electrolyte imbalance.
For proper managementFor co-management
To prevent bed sore.
To facilitate proper breathing
To provide comfort.
For lower tract infections.
To prevent nausea and vomiting.
For bloating and flatulence as inpancreatic insufficiency.
Refer any abnormalities/ anusualities.
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Refer accordingly
August 4, 20099:15AM
Ventolin 1 neb now
IVF to follow PNSS @10gtts/min
Treatment and prevention of asthma.
To provide fluid and electrolytes andserves as a channel for any drug thatcan be administer through it (IVTT).
DRUG STUDY
SODIUM BICARBONATE
Classification: Acidifiers and AlkalinizersDosage/route: 650mg TID , poMechanism of Action: Restores buffering capacity of the body and neutralizerexcess acid.Specific Indication: Cardiac Arrest, Metabolic Acidosis, Systemic or UrinaryAlkalinization and AntacidContraindications: Patients who are losing chlorides because of vomiting,continuous GI suction and in those receiving diuretics that producehypochloremic alkalosis. Oral sodium bicarbonate is contraindicated for patientswith acute ingestion of strong mineral acids.
Side Effects: Tetany, Edema, Gastric Distention, Belching, and Flatulence.Nursing Precaution: To avoid risk of alkalosis, obtain blood pH, partial pressure of arterial
oxygen, partial pressure of partial carbon dioxide, and electrolyte levels.Keep prescriber informed of laboratory results.
KALIMATE
Classification: ElectrolytesMechanism of Action: After administration of Kalimate via oral, calcium ion of
Kalimate is exchanged for potassium ion in the intestinal tract, particularly aroundthe colon, and Kalimate is excreted as unchanged polystyrene sulfonate resininto the feces without digestion and absorption. In consequence, potassium inthe intestinal tract is excreted outside the body.Dosage/route: 2 sachets TID, poSpecific Indication: Prevention & treatment of hyperkalemia resulting fromacute or chronic renal failure.Contraindications: Patients w/ intestinal obstruction & stenosis, constipation.
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Side Effects: Constipation, anorexia & nausea. Hypopotassemia.Nursing Precaution: Careful administration in patients with hyperparathyroidism(blood concentration of calcium may be increased by ion exchange) and patientswith multiple myeloma (blood concentration of calcium may be increased by ionexchange).
Important: Kalimate should be administered while measuring the serumpotassium and serum calcium levels regularly to prevent overdose. If anyabnormal findings are observed, appropriate measures eg, reduction of dose orwithdrawal of the drug should be taken.
FUROSEMIDE
Classification: Loop diuretic
Dosage/route: 40 mg BID, poMechanism of Action: Inhibits the reabsorption of sodium and chloride from theascending limb of the loop of Henle, leading to a sodium-rich diuresis.
Specific Indication: Furosemide is a "water pill" (diuretic) that increases theamount of urine you make, which causes your body to get rid of excess water.This drug is used to treat high blood pressure. Lowering high blood pressurehelps prevent strokes, heart attacks, and kidney problems. This medication alsoreduces swelling/fluid retention (edema) which can result from conditions such ascongestive heart failure, liver disease, or kidney disease. This can help toimprove symptoms such as trouble breathing.
Contraindications: Contraindicated with allergy to furosemide, sulfonamides;allergy to tartrazine (in oral solution); anuria, severe renal failure; hepatic coma;pregnancy; lactation.
Side Effects: CNS: Dizziness, vertigo, paresthesias, xanthopsia, weakness,headache, drowsiness, fatigue, blurred vision, tinnitus, irreversible hearing loss
CV: Orthostatic hypotension, volume depletion, cardiac arrhythmias,thrombophlebitis
Dermatologic: Photosensitivity, rash, pruritus, urticaria, purpura,exfoliative dermatitis, erythema multiforme
GI: Nausea, anorexia, vomiting, oral and gastric irritation, constipation,
diarrhea, acute pancreatitis, jaundice GU: Polyuria, nocturia, glycosuria, urinary bladder spasm Hematologic: Leukopenia, anemia, thrombocytopenia, fluid and
electrolyte imbalances, hyperglycemia, hyperuricemia Other: Muscle cramps and muscle spasms
Nursing Precaution: Use cautiously with SLE, gout, diabetes mellitus.
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Give early in the day so that increased urination will not disturb sleep. Administer with food or milk to prevent GI upset. Reduce dosage if given with other antihypertensives; readjust dosage
gradually as BP responds. Measure and record weight to monitor fluid changes.
CELECOXIB
Classification:Nonsteroidal Antiinflammatory drugMechanism of Action: This medication is a nonsteroidal anti-inflammatory drug(NSAID), specifically a COX-2 inhibitor, which relieves pain and swelling(inflammation). It is used to treat arthritis, acute pain, and menstrual pain anddiscomfort. Celecoxib is also used to decrease growths found in the intestines(colon polyps) of persons with a family history of this condition. This drug worksby blocking the enzyme in your body that makes prostaglandins. Decreasing
prostaglandins helps to reduce pain and swelling.Dosage/route: 200 mg BID, poSpecific Indication: Celecoxib is licensed for use in osteoarthritis, rheumatoidarthritis, acute pain, painful menstruation and menstrual symptoms, and toreduce the number of colon and rectal polyps in patients with familialadenomatous polyposis. It was originally intended to relieve pain whileminimizing the gastrointestinal adverse effects usually seen with conventionalNSAIDs. In practice, its primary indication is in patients who need regular andlong term pain relief: there is probably no advantage to using celecoxib for shortterm or acute pain relief over conventional NSAIDs. In addition, the pain reliefoffered by celecoxib is similar to that offered by paracetamol.[1]
Contraindications: Hypersensitivity including those in whom attacks ofangioedema, rhinitis and urticaria have been precipitated by aspirin, NSAIDs orsulfonamides. Severe hepatic impairment; severe heart failure; inflammatorybowel disease; peptic ulcer; renal impairment.Side Effects: The most common adverse effects are headache, abdominal pain,dyspepsia, diarrhea, nausea, flatulence, and insomnia. Other side effects includefainting, kidney failure, heart failure, aggravation of hypertension, chest pain,ringing in the ears, deafness, stomach and intestinal ulcers, bleeding, blurredvision, anxiety, photosensitivity, weight gain, water retention, flu-like symptoms,drowsiness and weakness.Nursing Precaution:
History of GI bleeding; renal/hepatic insufficiency; asthma or allergic disorders;hypertension; monitor haemoglobin or haematocrit levels for signs of anaemia.History of cerebrovascular disease or ischaemic heart disease.
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LACTULOSE
Classification: LaxativesMechanism of Action: Lactulose promotes peristalsis by producing an osmoticeffect in the colon with resultant distention. In hepatic encephalopathy, it reduces
absorption of ammonium ions and toxic nitrogenous compounds, resulting inreduced blood ammonia concentrations.Dosage/route: 30 ml ODSpecific Indication: Used to treat constipation.Contraindications: Galactosaemia, intestinal obstruction. Patients on lowgalactose diet.Side Effects: This medication may cause gas, belching or stomach cramps. Ifthese effects continue or become bothersome, inform your doctor. Notify yourdoctor if you develop any of these effects while taking this medication: diarrhea,nausea, vomiting. If you notice other effects not listed above, contact your doctoror pharmacist.
Nursing Precaution:Monitor electrolyte imbalance. Lactose intolerance; diabetics.
Laboratory Exams:
Urinalysis Date: August 1, 2009,
Test Result SignificanceColor Yellow Normal
Transparency Clear NormalPus cells 10-21hpf Normal
RBC 5-12hpf NormalEpithelium Few NormalAmorphous Few Normal
Complete Blood Count Date: August 1, 2009
Test Result Normal Value SignificanceWBC 10,800 5,000-
10,000/mm
Increase infection,dehydration, leukemia,trauma polycythemia vera
Hemoglobin 13.8 13.7-16.7 g/dl Hemoglobin is the main
transport of oxygen andcarbon dioxide in the blood.Hematocrit 38.7 40.5-49.7 vols% Increase in erythrocythosis,
dehydration and hemo-concentration associatedwith shock
Platelet Count Adequate 150,000- Platelets (also known asthrombocytes) are the
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450,000/mm smallest formed elements ofthe blood. They are vital tocoagulation of the blood toprevent excessive bleeding.
Differential Count
Lymphocytes 15 17.4-46.2% Depressed level mayindicate an exhaustedimmune system.
Monocyte 3 4.3-10.3% Low levels are indicative of agood state of health. .
Basophil 2.5 2-3% Basophilic activity is not fullyunderstood but it is known tocarry histamine, heparin,and serotonin.
Blood Chemistry Date: August 1, 2009
Test Result Normal Value SignificancePhosphorus 5.43 2.50-50.0mgs/dL Metastatic neoplasm to bonePotassium 6.0 3.5-5.5mEq/L Increase excess IV
administration, Potassium-sparing diuretics, infection,dehydration, acidosis, bloodtransfusion, burns and trauma
Glucose 422.7 60.00-110.0 Diabetes MellitusSodium 150.6 135-145mEq/L Increase dietary or IV intake
DI, Cushings syndrome,
increase swating.
Blood Chemistry Date: August 1, 2009
Result Normal Value SignificanceCalcium 4.03 8.10-
10.40mmol/L
Acute pancreatitis, nephrosis,
Creatinine 2.93 0.6-1.1 mg/dL Increase renal failure,muscular dystrophy,hyperthyroid, acromegaly,rhabdomyolysis
Chest X-RAY Date: August 2, 2009
ImpressionCardiomegaly, LV form
HEArt enlarged
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Pulmonary congestion
Minimal Pleural effusion, bilateral
Atherosclerosis aorta
Fracture left clavicle and left 8 th posterior rib
ULTRASOUND Date: August 2, 2009
Liver and GallbladderImpression:
Contracted liver
Gall stone with sludge
Ascites Minimal
V. ANATOMY AND PHYSIOLOGY
The Skeletal System serves many important functions; it provides theshape and form for our bodies in addition to supporting, protecting, allowingbodily movement, producing blood for the body, and storing minerals.
Its 206 bones form a rigid framework to which the softer tissues andorgans of the body are attached. Vital organs are protected by the skeletal
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system. The brain is protected by the surrounding skull as the heart and lungsare encased by the sternum and rib cage.
Bodily movement is carried out by the interaction of the muscular and skeletalsystems. For this reason, they are often grouped together as the musculo-
skeletal system. Muscles are connected to bones by tendons. Bones areconnected to each other by ligaments. Where bones meet one another istypically called a joint. Muscles which cause movement of a joint are connectedto two different bones and contract to pull them together. An example would bethe contraction of the biceps and a relaxation of the triceps. This produces abend at the elbow. The contraction of the triceps and relaxation of the bicepsproduces the effect of straightening the arm.
The Ribs
The ribs are thin, flat, curved bones that form a protective cage around theorgans in the upper body. They are comprised 24 bones arranged in 12 pairs.
The first seven bones are called the true ribs. These bones are connected to thespine (the backbone) in back. In the front, the true ribs are connected directly tothe breastbone or sternum by a strips of cartilage called the costal cartilage. Thenext three pairs of bones are called false ribs. These bones are slightly shorterthan the true ribs and are connected to the spine in back. However, instead ofbeing attached directly to the sternum in front, the false ribs are attached to the
lowest true rib. The last two sets of rib bones are called floating ribs. Floating ribsare smaller than both the true ribs and the false ribs. They are attached to thespine at the back, but are not connected to anything in the front. The ribs form akind of cage the encloses the upper body. They give the chest its familiar shape.
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The Shoulder Girdle
The Shoulder Girdle, also called the Pectoral Girdle, is composed of fourbones: two clavicles and two scapulae .
The clavicle, commonly called the collarbone, is a slender S-shaped bonethat connects the upper arm to the trunk of the body and holds the shoulder jointaway from the body to allow for greater freedom of movement.
PATHOPHYSIOLOGY
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Predisposing Factor Precipitating
Age (79 y.o)Liver cirrhosisDiabetes Mellitus
Unsafe externalenvironment
Body malaise,dyspnea, pain
Fall (4 steps stairs)
Rib fracture,clavicle frature
Impaired tissueperfussion
Increase bloodglucose level
Renin-angitensin-Aldosterone-system
activation
Liver unable to synthesizeprotein/amino acid
Low fat absorption
Low protein absorption
Pleural infusion
PAIN
Impaired
oxygenation
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NURSING ASSSESSMENT (System Review Chart) Date: August 2,2009
Age (79 y.o)Liver cirrhosisDiabetes Mellitus
Unsafe externalenvironment
Body malaise,dyspnea, pain
Fall (4 steps stairs)
Rib fracture,clavicle frature
Impaired tissueperfussion
Increase bloodglucose level
Renin-angitensin-Aldosterone-system
activation
Increase sodium andwater retention
Liver unable to synthesizeprotein/amino acid
Low fat absorption
Low protein absorption
Fluid shifting to secretion
Pleural infusion
PAIN
Impairedoxygenation
Aldosterone secretion
Water and sodiumretention
EDEMA
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EENT:[ ] Impaired vision [ ] blind[ ] pain redden [ ] drainage[ ] gums [ ] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion teeth[ ] assess eyes ears nose[ ] throat for abnormality [x] no problem
RESP:[ ] Asymmetric [x] tachypnea [ ] barrel chest[ ] apnea [ ] rales [ ] cough[ ] bradypnea [ ] shallow [ ] rhonchi[ ] sputum [ ] diminished [x ] dyspnea[ ] orthopnea [ ] labored [ ] wheezing[ ] pain [ ] cyanotic[ ] assess resp. rate, rhythm, depth, pattern,
breath sounds, comfort [ ] no problem
CARDIOVASCULAR:[ ] arrhythmia [ ] tachycardia [ ]numbness[ ] diminished pulses [ ] edema [] fatigue[ ] irregular [ ] bradycardia [ ] murmur[ ] tingling [ ] absent pulses [ ] pain[ ] Assess heart sounds, rate rhythm, pulse, blood
pressure, circ., fluid retention, comfort[ x ] no problem
GASTROINTESTINAL TRACT:[ ] obese [ x ] distention [ ] mass[ ] dysphagia [ ] rigidity [ ] pain[ ] assess abdomen, bowel habits, swallowing[ ] bowel sounds, comfort [ ] no problem
GENITO URINARY AND GYNE[ ] pain [ ] oliguria [ ] color [ ] vaginal bleeding[ ] hematuria [ ] discharge [] nocturia[x ] assess urine frequency, control, color, odor, comfort[ ] gyne bleeding [ ] discharge [ x ] no problem
NEURO:[ ] paralysis [ ] stuporus [ x ] unsteady [ ] seizure[ ] lethargic [ ] comatose [ ] vertigo [ ] treamors[ ] confused [ ] vision [ ] grip[ ] assess motor, function, sensation, LOC, strength[ ] grip, gait, coordination, speech [x] no problem
MUSCULOSKELETAL and SKIN:[ ] appliance [ ] stiffness [ ] itching [ ] petechie[ ] hot [ ] drainage [ ] prosthesis [x] swelling
[ ] lesion [ ] poor turgor [ ] cool [ ] flushed[ ] atrophy [x] pain [ ] ecchymosis [ ] diaphoreticmoist[ ] assess mobility, motion gait, alignment, joint function[ ] skin color, texture, turgor, integrity[ ] no problem
Name: C.B.P.BP: 140/80 mmHg T: 36.6C PR: 85 bpm RR: 22 cpm Height: 52inches Weight:
NURSING ASSESSMENT IISUBJECTIVE OBJECTIVE
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Swelling/edema
Pitting Edema (grade 1)
Adbominal distention
Wound
Dry skin
Generalized Weakness
Edema
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COMMUNICATION:
[ ] hearing difficulty
[] visual changes
[x ] denied
Comments:"dili na kyosiya ka-klaro pero sigetanaw og tv as
verbalized by watcher
[ ] glasses [ ] languages
[ ] contact lenses [ ] hearing difficulties due to age
[ ] speech difficultiesPupil size:R:3 mm L:3mm
Reaction: PERRLA (Pupil Equally Round andReactive to Light Accommodation)
OXYGENATION:
[x ] dyspnea
[ ] smoking history
[] cough
[ ] sputum
[ ] denied
Comments: lisud auiginhawa, asverbalized by thepatient.
Resp. [x ]regular [] irregular
Describe: RR is regular and it is within range.
R: unsymmetrical to the left lung
L: unsymmetrical to the right lung
CIRCULATION:
[ ] chest pain
[ ] leg pain
[] numbness of
extremities
[x ] denied
Comments: wala manko ing ana ngaproblema ang akungtiyan lang ang sakit ogayo , as verbalized bypatients watcher.
Heart Rhythm [x] regular [ ] irregular
Ankle Edema: ankle edema is present on bothextremities
Pulse Car Rad. DP Fem
R + 85bpm + +____
L + + + +____Comments: Pulse on all sites are palpabale yet weakon the radial and dorsalis pedis areas due topresence of edema.
NUTRITION:
Diet: Soft diabetic
Character
[x] recent change in
weight
[] swallowing
Difficulty
[ ] denied
Comment: Gamay ralagi iyang gaka-on amolang luguson kydaghan bya syatambal,as verbalized
by watcher.Ganiwang na ganisiya as verbalized bythe watcher
[ ] dentures [ x ]none
Full Partial With patient
Upper [ ] [ ] [ ]
Lower [ ] [ ] [ ]
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ELIMINATION:
Usual bowel pattern:
Once a day
[ ] constipation
remedy______None______
Date of last BM
August 1, 2009
[ ] diarrhea
-______None________
[x] urinary frequency
In foley catheter
[ ] urgency
[ ] dysuria[ ] hematuria
[ ] incontinence
[ ] polyuria
[ ] foley in place
[ ] denied
Comments:Patientsbowel soundsauscultated and shehas an audiblenormoactive.
Bowel sounds Audiblenormoactive bowel soundsevery 10-15 sec.
Abdominal Distention
Present [x ] yes [] no
Urine* (color, consistency,odor)
____amber or strong______
Foley if they are in place:Foley bag catheter in place
MGT. OF HEALTH & ILLNESS:
[ ] alcohol [x] denied
(amount/frequency)
[ ] SBE: Not recalled Last Pap Smear: NOT
RECAlled
LMP: Not recalled
Briefly describe the patients ability to followtreatments (diet, meds, etc.) for chronic healthproblems (if present).
Patient is able to follow treatments, such as hermedications and soft diabetic diet as prescribe by thephysician during this admission but her maintenancefor her liver cirrhosis she stop it because ofinconvenience during her follow up check up atCebu.
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY:
[x ] dry
[ ] other
[] denied
Comments: dry lagi iyangpanit na basin sapagkatigulang na, asverbalized by the watcher
[x ] dry [ ] cold [x ] pale
[ ] flushed [ ] warm
[ ] moist [ ] cyanotic
*rashes, ulcers, decubitus (describe size,
location, drainage: Healing woung at leftleg.
ACTIVITY/SAFETY:
[ ] convulsion
[ ] dizziness
Comments: Dili kayo laginiya malihok iyang abagaog likod, as verbalized bythe watcher.
[ ] LOC and orientation Patient is orientedto time, place, events and person.
Gait: [ ] walker [ ] cane [ ] other
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[x ] limited motion of
Joints
Limitation in
Ability to
[] ambulate
[ ] bathe self
[ ] other
[ ] steady [x ] unsteady
[ ] sensory and motor losses in face or
extremities No sensory and motor losseson face or extremities
[x] ROM limitations: she can move but withlimitation and with accompany.
COMFORT/SLEEP/
AWAKE:
[] pain
(location,frequencyremedies)
[ ] nocturia
[x] sleep difficulties
[ ] denied
Comments: Dili kayo siyakatulog kay galisod siyaog ginhawa, asverbalized by the watcher
[] facial grimaces
[x] guarding
[ ] other signs of pain :
Patient was able to manage the painwithin tolerable limit.
COPING:
Occupation: Housewife
Members of household: 5 members ofhousehold
Most supportive person: her five children
Observed non-verbal behavior: weaknessor fatigue
Phone number that can be reachedanytime:
Confidential
SPECIAL PATIENT INFORMATION
_Not ordered Daily weight ____N/A___ PT/OT
_140/80 mmHg BP q shift ____N/A___Irradiation
___not ordered__ _Neuro vs August 1, 2009 Urine test
____N/A_ _CVP/SG Reading not ordered 24 hour UrineCollection
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VII NURSING MANAGEMENT
A. Ideal Nursing Management
Diagnoses: Ineffective Breathing Pattern related to respiratory muscleweakness.
Intervention Rationale Investigate etiology of
respiratory failure.
Observe over-all breathingpattern.
Auscultate chest noting thepresence or absence of breathsounds.
Count clients respiration 1 fullminute and compare with desireset rate.
Check tubing of oxygen forobstruction.
To understand the underlying cause.
To attempt to correct the deficiency byover breathing.
To note the frequent crackles thatdoesnt clear with coughing.
Respirations vary depending onproblem requiring ventilatoryassistance.
Kinks in tubing prevent adequatevolume of delivery.
Diagnoses: Acute Pain related to injury to the soft tissueIntervention Rationale
Maintain immobilization ofaffected area.
Elevate and support injuredextremities.
Avoid use of plastic sheets.
Evaluate reports ofpain/discomfort.
Identify any diversionalactivities.
Apply cold/ice pack.
Relieves pain and prevent extensionof the injury.
Promotes venous return.
Promotes discomfort
Monitor effectiveness of intervention.
Prevents boredom, reduces muscletension.
Reduces edema.
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Diagnoses: Activity intolerance related to generalized weakness
Intervention Rationale Adjust activities and reduce
intensity level or discontinue
activities that cause undesired
physiologic changes.
Increase exercise and activity
level gradually.
Plan care with rest periodsbetween activities.
Assist with activities and provide
client used of assistive devices.
Promote comfort measures and
provide for relief of pain.
Provide positive atmosphere
while acknowledging difficulty of
the situation for the client.
To prevent over excretion.
To conserve energy
To reduce fatigue
To protect the client from injury
To promote comfort measures and
provide for relief of client.
Helps to minimize frustration, reduce
channel energy.
Diagnoses: Risk for ineffective peripheral Tissue Perfusion
Intervention Rationale
Provide air mattress, sheepskinpadding, bed/foot cradle.
Apply ice and elevate lowerextremities.
Administer physicians order ofmedication.
To protect the extremities.
To reduce edema.
To give comfort and reduce edema.
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Apply ace bandage to lowerextremities before arising frombed.
To prevent venous stasis
B. Actual Nursing Management
S Lisud au iginhawa as verbalized by the patient.
O Dyspnea Changes in rate and depth of respirations Increased restlessness
A Ineffective Breathing Pattern related to respiratory muscle weakness.
P At the end of 2-3 minutes, the patient will maintain respiratory
pattern.
IIndependent Maintained in moderate to high back rest. Checked tubing for obstruction. Observe over-all breathing pattern
Dependent
Set Oxygen at 3L/min
EAt the end of 2 minutes, the patient maintains her respiratory pattern.
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S sakit lagi iyang abaga og likod as verbalized by the patient.
O
Restlessness Facial grimace Guarding the affected part.
A Acute pain related to injury to the soft tissue
P At the end of 15-30 minutes the patient will able to verbalized pain
into tolerable level
IIndependent
Reinforced position (semi-fowlers) to the patient. Encouraged adequate rest periods
Reviewed ways to lessen pain, including techniques.
Discuss with significant others ways in which they can assist the
client in activities.
Dependent
Administer medication for pain.
Celecoxib 200mg BID
EAt the end of 30 minutes the patient was able to response tointerventions and verbalized relief of pain.
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SDili kayo lagi niya malihok iyang abaga og likod busa dili kayo siya
kalihok as verbalized by the watcher
O Weakness. Inability to begin activity
A Activity Intolerance related to generalized weakness
P At the end of 8 hours, the patient will be able to have gradual
return to physical movement and mobility
IIndependent Encouraged patient to do bed exercises such as arm exercises
abduction and external rotation of shoulder, hand and fingers
exercises and foot exercises. Assisted patient in activities that begins by sitting at the side of
the bed and in chair.
Assisted early ambulation of patient.
Assisted patient to performed ADL with involvement of significant
others.
Provided physical support and maintained patients safety.
EAt the end of 8 hours, the patient was able to demonstrate gradual
return to physical movement and mobility within tolerance as
evidenced by increasing ambulation and participation in personal
care activities.
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VIII. REFERRALS AND FOLLOW-UP
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IX. EVALUATION AND IMPLICATION
MEDICATIONS
The patient was instructed to continue medications
namely Kalimate 2 sachets TID, Sodium
Bicarbonate 650mg TID, Lactulose 30ml OD,
Celecoxib 200mg BID, ITOPRIDE 50mg TID,Pancreatin I tab TID
She and her significant others was advised to
comply all the medications needed as prescribed by
the physician.
Patient and significant others was instructed aboutthe proper administration of medications accordingto right dose, right time and right route, and becautious to possible side effects.
EXERCISEEncourage Range of Motion Exercises
TREATMENT
Follow medication as prescribed by the physician. Turn to sides every two hours. Provide footboard.
Maintained moderate to high back rest.OUTPATIENT
(Check-up)
The patient is advised to have her follow-up check-up oneweek after at Cagayan de Oro Medical Center, Building 1,
2nd
Floor at the clinic of Dr. Chang.
DIET
Encourage patient to eat foods rich in Vit. C like fruits toenhance the immune system.Encourage patient to increase fluid intake to maintain fluidand electrolyte balance in the body.
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PROGNOSTIC INDICATORS POOR GOODA. Onset of illness B. Duration of illness C. Precipitating factors D. Attitude and willingness to take
medication
E. Family support
After having interacted with the client for 2 days and rendered nursing
interventions, we therefore concluded that our objectives were met. Also based
on thorough observation and data gathered, we had identified that the client has
a poor prognosis since she is too old to recover from her illness and she had
experienced many complications. Although the family support system towards
the client is good, we still encourages the family to continue on supporting the
medical and emotional support of the client in gearing towards hospitalization
and consultation. They are encouraged to be sensitive to the needs and care of
the patient since she is old. We implied for a continue support system towards
the client and be cautious if theres any complains from the client or any signs of
another health problems.
B. BIBLIOGRAPHY
Kozier, B. et al. Fundamentals of Nursing, 7 th ed. Singapore: Pearson
Education South Asia PTE LTD, 2004
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Lippincott. Nursing 2007 Drug Guide, PA: Lippincott Williams & Wilkins,
2007 Phipps, et al. Medical-Surgical Nursing: Concepts and clinical
Practice, vol. 1, 5th ed Missouri: Mosby-Year Book, Inc., 1995
MIMS Philippines, 109th ed. CMPMEdica, 2006
Tortora, G.J.& Grabowski S.R.; Principles of Anatomy and Physiology; 10th
Edition; John and Wiley and Sons, Inc.; 2003.
Karch, Amy M.; Focus on Nursing Pharmacology; 3 rd Edition; Lippincot
Williams and Wilkins; 2006.
Doenges, E.M., Moorhouse, M.F. Geisslerr-Murr, A.C.; Nurses Pocket
Guide Diagnoses, Interventions and Rationales; 9th Edition; F.A. Davis
Company Philadelphia; 2004.
Recommended