A case study conducted during the clinical rotation at Jose R. Reyes Memorial Medical Center.

1. CASE PRESENTATION: FRACTURE
OPEN III A, COMPLETE
COMMINUTED DISPLACED FEMUR
LEFT
Marjie Hilotina
Christelle Mallari
Gianina Marcelo
Katherine Nuevas
Francis Oglesby

2. INTRODUCTION

3. • Increasing number of crime rates in the
Philippines has been a major social problem.
Despite the government’s effort for the
improvement of law and order, crime still remains
as a menace to the society.
• Last 3rd day of August in 2015, Philippine National
Police (PNP) claimed a 60 percent decrease in
crimes in Metro Manila due to the systematic
implementation of Oplan Lambat-Sibat, an anti-
crime drive supervised by Interior and Local
Government Secretary Manuel Roxas II.

4. • However, the report also indicated that the
number of crimes committed nationwide,
increased by about 46 percent during the first
six months of the year as compared to the
same period last year. Records from the PNP
showed that theft, car theft, physical injuries
and rape were among the crimes that had a
huge increase. Cases of physical injury
increased to 182,886 from 122,084 last year.

5. • Possession of firearms is one of the factors of
the increasing crime rate in the country.
According to Esmeralda, A. (2011), the
Philippines is the only country in Asia and the
Pacific that allows widespread civilian gun
ownership although there is no constitutional
right to bear arms. A number of people
thought that this fact is both beneficial and
dangerous.

6. • In 2013, PROGUN, a firearms advocacy
group based in the Philippines recorded a
number of 1210 violent crime incidents involving
gun violence in which there were 610 injuries and
967 fatalities from the beginning of the COMELEC
gun ban from January 2013 up to the close of
March 31, 2013. It is clear that inspite of the
enforcement of the COMELEC gun ban, violent
crime rates did not change which has in fact gone
upwards to astronomical proportions.

7. • Inappropriate use of firearms will greatly endanger the
safety of the public. It will cause injuries or worse can
lead to immediate death of a person. Injuries caused
by a bullet strike also called gunshot wound is a
common chief complaint of gun violence victims. In
2014, Heller, J. stated that a gunshot wound is caused
when a bullet or other projectile is shot into or through
the body. Gunshot wounds can cause serious injury,
including severe bleeding, damage to tissues and
organs, broken bones, wound infections and also
paralysis. The amount of damage depends on the
location of the injury and the speed and type of bullet.

8. GENERAL OBJECTIVES
This case study aims to identify and determine
the general health problems and basic needs of
the patient with a diagnosis of Fracture Open III
A, Complete Comminuted Displaced Femur Left,
as well as the proper management and
treatment for such condition.

9. SPECIFIC OBJECTIVES
• Tracing how the specific condition affects the
body of the patient.
• Performing physical examination and the right
assessment to the patient in order to have a basis
for effective nursing interventions.
• Studying the drugs being administered to
patients with this condition as well as the action
of the medications of the patient’s body.
• Applying the theoretical skills we have learned as
student nurses in performing the appropriate
management of the patient’s case.

10. DEMOGRAPHIC DATA
Patient: Mr. I
Sex: Male
Address: Tondo, Manila
Age: 38 years old
Birth date: November 7, 1976
Birth place: Manila
Occupation: None
Marital Status: Single
No. Of children: 1
Nationality: Filipino
Religion: Roman Catholic
Date of Admission:
July 5, 2015 7:27 AM
Date of Operation:
July 6, 2015 - 90ᴏ to 90ᴏ Distal
Femoral Pin Skeletal Traction
System
August 12, 2015 - S/P ORIF (Open
Reduction Internal Fixation), Plate
and Screw Fixation with ICBG (Iliac
Crest Bone Grafting)

11. CHIEF COMPLAINT:
Gunshot Wound
ADMITTING DIAGNOSIS:
Open Fracture Femur Left
FINAL DIAGNOSIS:
Fracture Open III A, Complete Comminuted
Displaced Femur Left

12. HISTORY OF PRESENT ILLNESS
 10 hours prior to admission (July 4, 2015 9:00 pm) - patient was walking around
their community because he is bored watching television at their house.
 9 hours and 30 minutes prior to admission (July 4, 2015 10:00 pm) – patient was
buying food from a local eatery when suddenly a riot came by, seconds after that,
he felt so much pain and then later on it developed into a numbing sensation at
his left leg for him to notice that he got hit by a stray bullet which deeply
penetrates the femur site.
 9 hours prior to admission (July 4, 2015 9:00 pm) – patient was brought by a
tricycle for an emergency care at Gat Andres Bonifacio Memorial Medical Center
which is the nearest hospital from their community. Patient undergone bullet
extraction at the hospital’s operating room. After that, patient was referred to Jose
Reyes Memorial Medical Center for further management of his condition.
 July 5, 2015 7:27 am – patient was brought at Jose Reyes Memorial Medical
Center since the hospital has the facility to accommodate orthopedic patients.
Orthopedic specialists decided to put 90ᴏ to 90ᴏ Distal Femoral Pin Skeletal
Traction System
 August 12, 2015- patient was due to operation [ORIF (Open Reduction Internal
Fixation), Plate and Screw Fixation with ICBG (Iliac Crest Bone Grafting)]

13. PAST MEDICAL HEALTH HISTORY
 In 1977, the patient who is 1 year old from that time was diagnosed
to have polio. The mother took 3 years for her to take medical
advice from the Philippine General Hospital where her son had a
brace at his left lower extremity. The patient used the brace for a
duration of 1 year ranging from 4 to his 5 years of age.
 In his grade school days, the patient reported that he was bitten by
a dog before. His mother did not know about this incident and no
medical advice was taken. The patient just washed the wound with
soap and water and did not mind it seriously after that.
 In December of 2014, the patient was grazed by a stray bullet at the
bottom part of his axilla (right side). He was taken immediately to
Gat Andres Bonifacio Memorial Medical Center and was ordered to
undergo X-ray. Fortunately results were fine and he was sent home
by the physician.

14. PAST MEDICAL HEALTH HISTORY
 Three months prior to hospitalization, the patient was
diagnosed to have pneumonia according to a health center
at their community. He was advised to take an unrecalled
medication by which he consumes 3 times in a row per day.
He was also encouraged to stop cigarette smoking of half a
pack per day which started since he was 13 years old up
until that month. Since that day, he stopped smoking
cigarettes. However, he did not take the advice to take the
medication for a duration of 6 months, instead he only took
it for only one month. He did not attend to follow up check-
ups at the health center until then.
 The patient reported no signs of allergies with any food or
medications.

15. PSYCHOSOCIAL HISTORY
 The patient, now 38 years old is the eldest child of the family,
he was followed by his half-sister who is only 14 years old as
of now and currently studying her 9th grade in a public school.
 The patient’s mother, now 59 years old, was widowed in her
early 20s. Her first husband left her with their child which is
still an infant before. According to the mother, she does not
know the exact cause of her husband’s death. She recalled
that her husband just left the house that day without saying
anything. Upon noticing his absence, she tried to find and
reach him everywhere only to find him lying at a morgue,
lifeless. At her 40s she met her second husband and they had
a daughter. The second husband became the primary source
of income which is shared by the whole family up until this
time.

16. PSYCHOSOCIAL HISTORY
 The patient has attained his 2nd year of high school in
Tondo, Manila. Before hospitalization, he often stays at
their house, watching television or just outside, playing
basketball with his friends. He does not engage in
alcohol drinking whenever he has a problem.
 In the year of 2004 until 2012, the patient was
imprisoned due to an undisclosed reason. During the
imprisonment, the patient met his partner and they
had a child in the year of 2010. His partner together
with their child frequently visited him at Manila City
Jail. After his imprisonment, he never got to see them
anymore up until now. According to him, his partner
before is currently living with another man. The patient
leaves his son who is now 5 years of age under the
custody of his partner before.

17. FAMILY HEALTH HISTORY
The patient’s mother has hypertension. She reports poor
eyesight by which she thinks it as a sign of aging but manages
the problem with wearing of eyeglasses. The patient’s father
cause of death was unknown; also the mother could not recall
any health problems related to her first husband. The patient’s
sister was also reported to have poor eyesight. The mother
stated that her daughter is a computer addict which affects her
academic status at school. She thinks that the long usage of
computer made her daughter to have poor eyesight. Her
daughter also wears eyeglasses.

18. GENOGRAM

20. GORDON’S FUNCTIONAL
HEALTH PATTERN

32. REVIEW OF SYSTEMS

33. System Subjective (as verbalized by the patient)
CONSTITUTIONAL
“Okay naman na ako. Makakauwi na raw ako sabi ni doc
kapag nakuyakoy ko na ‘to (his legs). Kaso sumasakit pa
yung banda dito (his knee). Pinipigilan nung ganito ko
(pointing at his lateral muscles – vastus lateralis)”
EYES “Hindi naman ako gumagamit ng salamin. Pero ‘yung
kapatid ko may grado na ang mata. Hindi rin sumasakit
‘yung ulo ko. Hindi lang ako nakakatulog ng maayos lalo
na sa gabi.”
ENT “Wala namang masakit sa tenga at lalamunan ko.
Nakakahinga rin ako ng maayos.”
CARDIOVASCULAR “Hindi naman sumisikip ‘yung dibdib ko. Hindi rin ako
high blood. Si mama ko ‘yung high blood sa pamilya pero
ako hindi.”
RESPIRATORY “Nagkaroon ako ng ano dati, ‘yung sa pawis (Pneumonia).
Last july o august ata. Tapos may iniinom ako na gamot
galing sa health center. Ininom ko ‘yun ng 6 months.
Ngayon wala na.”
GASTROINTESTINAL “Okay naman ‘yung pagdumi ko. Hindi naman ako
nahihirapan dumumi. Hindi siya araw-araw. Minsan
dalawang araw bago ako dumumi ulit. Wala rin akong
iniinom na gamot pampalambot ng dumi.”

34. GENITOURINARY “Hindi naman ako nahihirapan umihi. Nung naka-catheter
lang ako nung inoperahan ako. Pero ngayon hindi na. Wala
naming sumasakit kapag umiihi ako.”
MUSCULOSKELETAL “Nagbabasketball ako dati. Ngayon hinihintay na lang
naming na makuyakoy ko ‘yung legs ko para makauwi na
kami. Hindi ko pa kaya kasi sumasakit pa yung banda dito
(knee and lateral muscles)”
NEUROLOGICAL “Okay naman na ako ngayon. Wala namang nagbago sa
pang-amoy ko. Hindi rin sumasakit yung ulo ko. Hindi rin
naman ako nanghihina.”
PSYCHIATRIC “Hindi ako gano nakakatulog lalo na sa gabi. Hindi rin ako
nakakatulog ng hapon sa sobrang init. Siguro mataas na
‘yung 3 oras na tulog ko.”
ENDOCRINE “Mahilig ako sa softdrinks dati. Sa isang araw nakaka-
anim ako na inom. Pero ngayon puro tubig na lang iniinom
ko. Buti nga wala akong diabetes. Mahirap gumaling yung
mga sugat ko kung ganon. Punta ka dun sa C kapag
naimpeksyon pa.”
HEMATOLOGIC “Hindi naman ako anemic. Pero lalagyan daw ako ng dugo
ngayon. Pangatlo ko na ‘yun kapag nalagyan ako.”
ALLERGY/IMMUNE “Wala akong allergy sa pagkain at gamot.”

35. PHYSICAL ASSESSMENT

36. • Patient: I
• Age: 38 years old / Male
• Date of assessment: August 17, 2015 @ 3:30
pm. 6 days post-operative
• Diagnosis: Fracture Open III A, Complete
Comminuted Displaced Femur Left

37. General Survey:
• Patient X is seen in sitting position on his bed without
his relative beside. Glasgowcoma scale is 15/15,
E4V5M6. Patient has good posture and in positive
mood as always, greeted us (student nurses) as we
approach him.
• Body structure is big, size of upper body symmetrical
with torso and lower extremities except for his right leg
due to his polio. Weight loss is not evaluated due to
patient is not weighed recently. Initial vital signs are:
BP: 120/80 mmHg, T: 37.1 ºC, PR: 70 bpm, RR: 20 cpm,
taken August 17, 2015 @ 3:20 pm prior to interview.

38. Body Part Normal
Findings
Actual
Findings
Techniques
Used
Interpretation
Head
- Hair
Even distribution,
thick hair
Silky, resilient hair
No infection or
infestation
Thick, brown with
white hair.
Evenly distributed
but not well
combed hair.
Hair is dry and
coarse
No lesions,
infection and
infestation noted
Inspection Patient can’t fully
wash his body
because of his
current status. So
he was assisted by
his mom while
cleaning his body
on bed. Hair
becomes dry
because the scalp
doesn’t make
enough oil to
moisturize the hair.
- Skull Normocephalic and
symmetrical
Smooth, uniform
consistency,
absence of nodules
or masses
Normocephalic and
symmetrical
Smooth, with
uniform
consistency, no
presence of
nodules or masses
Inspection-
Palpation
Essentially normal

39. - Face
Symmetric or
slightly
asymmetric facial
features
Absence of edema
or hollowness
Skin color light to
deep brown
Symmetrical facial
features.
With moustache
and beard
No noted edema or
hollowness
Inspection Essentially normal
Eyes
- External Eye
Structure
Eyebrows-
even distribution of
hair, intact skin
symmetrical
alignment, equal
movement
Eyelashes-
Even distribution
of hair, curled
slightly outward
Eyelids-
Skin intact, no
discharge, no
discoloration
Lids close
symmetrically
Hair evenly
distributed with
skin intact
Symmetrically
aligned with equal
movement
Evenly distributed
hair
Skin intact
Lids close
symmetrically
Inspection Essentially Normal

40. - Internal Eye
Structure
Sclera appears white
Shiny, smooth, and
pink or red in color
palpebral conjunctiva
Lacrimal sac and
nasolacrimal duct-
Absence of edema or
tearing
Cornea-
Transparent, shiny,
smooth;
Details of iris are
visible
Blinks when touched
Pupils-
Black in color; equal
in size; normally 3-7
mm in diameter;
round smooth border;
iris flat and round
Six ocular
movements-
Both eyes coordinate,
move in unison, with
parallel alignment
Visual acuity-
Able to read
newsprint
White in color
Shiny and smooth but
pale upon observation
No edema noted
Transparent, shiny
and smooth. Details of
iris are visible.
Blinks when touched
Constricts and dilates
equally with the
presence of light.
Constricts with light
and dilates without
the light
Eyes can move co-
ordinately and
symmetrically with
both eyes.
Patient no difficulty in
reading. No reading
glasses needed.
Inspection Essentially Normal

41. Ears- Auricles-
Color same as
facial skin
Symmetrical and
aligned with outer
canthus in eye
Mobile, firm and
not tender; pinna
recoils after it is
folded
External ear canal-
Can hear ticking
off the clock when
placed on both
ears. Should be
symmetrical.
Color same as
facial skin
Symmetrical and
aligned with outer
canthus in eye
No difficulty in
hearing. Can hear
whispered voices
Inspection Essentially Normal
Nose and Sinuses External nose-
Symmetric and
straight
Absence of
discharge or flaring
Uniform color
Sinuses-
Absence of
tenderness
Symmetric and
straight
No discharge or
flaring
Uniform in color
No tenderness,
masses palpated
Inspection
Palpation
Essentially Normal

42. Teeth and Gums 28-32 whitish teeth
with smooth
surfaces and edges.
No decayed areas,
no missing teeth
Tissue is smooth
and moist without
lesion
Tongue should be
pink, moist, and
moderate size with
papillae present
Tongue can
determine between
different tastes
Gums should be
pink and no lesions
Incomplete teeth.
No upper frontal
teeth and lower
front teeth overlap
each other.
Yellowish teeth
noted.
Tissue, gums, and
tongue are pink and
no lesion noted
Patient determined
different tastes and
no changes in taste
noted.
Inspection Poor dental
hygiene is
considered as the
main cause of tooth
discoloration.
Inadequate
brushing and
flossing to remove
plaque and stain-
producing
substances like
coffee and tobacco
can cause tooth
discoloration.
Foods like coffee,
tea can cause also
discoloration.
Cigarette usage can
cause also
discoloration
(Patient smokes
from 13 years old
to 36 years old
consuming half
pack per day)

43. Neck Muscles equal in
size; head centered
Not palpable
lymph nodes
Trachea in central
of neck
Neck muscle equal
in size and head
centred
No palpable lymph
nodes
Trachea in central
of neck
Inspection
Palpation
Essentially Normal
Thorax and Lungs Symmetric chest,
Chest wall intact,
Absence of
tenderness and
masses, Spine
vertically aligned,
Full and symmetric
chest expansion
Vesicular,
Broncho-vesicular,
and bronchial
breath sounds
Symmetric, Chest
wall intact.
With tattoos at the
back.
With noted small
scar at right thorax.
Vesicular breath
sound when
auscultated
With 20 cpm
Inspection
Palpation
Scar is due to past
history of gunshot.
But not a major
injury. A near-
missed gunshot.
Tattoos were done
when he’s inside of
the jail last 2004-
2012

44. Heart No lift or heave at
apical area
S1 usually heard at
all sites; S2 usually
heard at all sites
Auscultated at
apical area with S1
usually heard at all
sites; S2 usually
heard at all sites
No heart murmurs
noted
Auscultation Essentially Normal
Abdomen Uniform in color
Audible bowel
sounds
Skin uniform in
color.
Inspection Essentially normal
Genitourinary Tract No pain in
urinating,
yellowish urine, no
blood in urine.
No pain in
urination, yellow
and no blood noted
in urine
Inspection Essentially normal

45. Extremities Upper extremities-
Skin generally uniform
Skin turgor – 1 sec
Lower extremities
Skin complexion is,
uniform with all body
parts, skin is intact.
Tattoos in left arm and
right wrist
Skin turgor – 1sec
Uniform color both left
and right legs
Dry foot noted
Not equal size of legs
due to polio
Presence of the post-
incision site at Left Leg
Presence of scars in
both legs due to dog
bite, fell on bike, and
scratches from dragging
him in motorcycle as
mode of transportation
in his recent health
injury
Inspection Patient shows signs and
symptoms of polio
when he’s only 1 year
old. Polio (also known
as poliomyelitis) is a
highly contagious
disease caused by a
virus that attacks the
nervous system.
Children younger than 5
years old are more
likely to contract the
virus than any other
group.
Weather and heat can
affect the normal oil
that emits by our skin.
Reduce in humidity can
cause dryness to our
skin. Sun dries your
skin, and its ultraviolet
(UV) radiation
penetrates far beyond
the top layer of skin.
The most significant
damage occurs deeper,
leading to deep
wrinkles and loose,
sagging skin

46. Fingernails -
Convex curvature,
angle about 180
degrees; smooth
texture
180 degrees angle;
smooth in texture
Inspection,
Palpation
Essentially Normal
Highly vascular
and pink in color
Capillary refill – 1-
2 sec
Nails appear to be
pink and highly
vascular
Cut fingernails in
hands but uncut
fingernails in toes
Capillary refill of 1
second.
Inspection Essentially Normal

47. Cranial Nerves
I. Olfactory –
able to identify
familiar scent
Can identify scent
of bed side food.
Inspection Essentially normal
II. Optic- able to
read newspaper
with one eye at
a time
No difficulty upon
reading. No
reading glasses
used.
Making the patient
read the written
word by student
nurses, also some
text messages from
cellular phone.
Essentially normal
III. Oculomotor-
constriction of
both pupils
when a bright
light was
shined on one
of it.
Constriction of
both pupils when a
bright light was
shined on one of it.
Using penlight Movement of eyes
are also normal
which shows that
cranial nerves III,
IV, VI are
functioning well.
IV. Trochlear-
Client should be
able to move
eyeballs
obliquely
The client was able
to move eyeballs
obliquely
Inspection Essentially normal

48. V. Trigeminal-
Client blinks
whenever sclera
is lightly
touched; able to
feel the wisp
of cotton over the
area touched;
able to
discriminate
blunt and sharp
stimuli
VI. Abducens-
Client should be
able to move
eyeballs
laterally
The client blinked
when the sclera is
touched by a sterile
pad gauze
The client was able
to move eyeballs
laterally
By using sterile
gauze
Inspection
Essentially normal
Movement of eyes
are also normal
which shows that
cranial nerves III,
IV, VI are
functioning well.

49. VII. Facial- Client
should be able to
do different
facial
expressions such
as smiling,
frowning and
raising
of eyebrows;
able to Identify
different tastes
such as sweet,
salty and
bitter taste
The client was able
to do different
facial expressions
such as frowning
and smiling. No
signs of
hemiplegia.
Inspection Essentially normal
VIII. Acoustic- Client
should be able to
hear loud and
soft spoken
words; able to
hear ticking of
watch on both
ears
Patient has no
trouble hearing or
understanding
verbal commands
Interview Essentially normal

50. IX. Glosso-
pharyngeal-
Client should be
able to identify
different tastes
such as sweet,
salty and
bitter taste; able
to move tongue
from side to side
and up and
down; able to
swallow without
difficulty,
with(+) gag
reflex
Patient can identify
food he is eating.
No difficulty in
swallowing.
Inspection Essentially normal
X. Vagus- Client
should be able to
swallow without
difficulty; has
absence
of hoarseness in
speech
Patient can
swallow food. No
hoarseness in
speech heard.
Inspection Essentially normal

51. XI. Spinal
accessory-
Client should be
able to shrug
shoulders and
turn head from
side to side
against resistance
from
nurse’s hands
The client was able
to shrug shoulders
and turn head from
side to side against
resistance from
nurse’s hands
Inspection Essentially normal
XII. Hypoglossal-
Client should be
able to protrude
tongue at midline
and move it
side to side
The client was able
to protrude tongue
at midline and
move it side to
side.
Inspection Essentially normal

52. Neurological
System
Language-
No defects in
the power to
express
oneself
through
speech
Responds to
simple verbal
commands
Patient can express
his thoughts
clearly, sometimes
crack some jokes.
Responds to simple
verbal commands
such as rising of
right and left arms.
Interview
Essentially normal
Essentially normal
Orientation-
Oriented to
time, place
and person
Patient oriented to
time and to the part
of day, where he is
and whom he is
with.
Interview Essentially normal

53. Memory-
Immediate
Recent
Remote
memory
Oriented in time,
place and person.
Could recall name
of student nurses
Could recall the
date of his
operation and
admission.
Can remember past
events years ago
like, where he
attended high
school, his
birthday, and the
recent president.
Interview Essentially normal

54. Muscle Strength  0/5: no
contraction
 1/5: muscle
flicker, but no
movement
 2/5: movement
possible, but not
against gravity
(test the joint in
its horizontal
plane)
 3/5: movement
possible against
gravity, but not
against resistance
by the examiner
 4/5: movement
possible against
some resistance
by the examiner
 5/5: normal
strength
Upper extremities:
5/5 or normal
strength
Lower extremities:
Right leg is 5/5 or
normal strength
Left leg is 3/5 or
movement possible
against gravity, but
not against
resistance by the
examiner due to
post-operation
Inspection and
examining the
strength by giving
force opposite to
gravity.
Essentially normal
Left leg is 3/5 or
movement possible
against gravity, but
not against
resistance by the
examiner due to
post-operation

55. ANATOMY AND PHYSIOLOGY

57. FEMUR
• The femur, or thigh bone, is the longest,
heaviest, and strongest bone in the entire
human body. All of the body’s weight is
supported by the femurs during many
activities, such as running, jumping, walking,
and standing.

58. A. STRUCTURE
1.Upper Extremity
2.Body of Femur
3.Lower Extremity

59. B. FUNCTION
• It serves as an attachment point for all the
muscles that exert their force over the hip and
knee joints. Some biarticular muscles – which
cross two joints, like the gastrocnemius and
plantaris muscles – also originate from the femur.
In all, 22 individual muscles either originate from
or insert onto the femur.

60. In cross-section, the thigh is divided up into three
separate fascial compartments divided by fascia,
each containing muscles. These compartments use
the femur as an axis, and are separated by tough
connective tissue membranes (or septa). Each of
these compartments has its own blood and nerve
supply, and contains a different group of muscles.
These compartments are named the anterior,
medial and posterior fascial compartments.

61. PATHOPHYSIOLOGY

64. LABORATORY TESTS RESULTS

65. LABORATORY TESTS RESULTS
• Anemia is a result from
blood loss in the case of
Patient I, he sustained after
he went to two operations
which happened on Jul 5 at
Gat Andres Bonifacio
Memorial Medical Center
and last August 12 which he
received two blood
transfusions during the
operation.
Low levels Hgb, Hct
and RBC indicates
anemia.

66. • In the case of Patient I, the
increase in WBC is caused of the
injury he sustained from the
fracture of his left femur that
results to inflammation which
manifested before his operation.
Also, the increase of neutrophils
indicates that the body is
fighthing infections and heal
injuries.
• the latest lab results indicated
low number of WBC is use to the
patients intake of two antibiotics;
Cefuroxime and Clindamycin
The function of white blood cells in our
system is to fight infections, if there is a
high number or value of WBC in the blood
circulation, it helps to identify if there is
an infection. It also shows if the numbers
of differential cells are in proper
proportion with each other. Irregularities
in this test could signal an infection,
inflammation, autoimmune disorders,
anemia, or other health concerns.

67. • Patient I’s first laboratory result showed increased in the
level of creatinine, this is due muscle injury that he
sustained from the stray bullet that resulted to left femur
fracture and this lead to the release of muscle
components in the bloodstream in which the kidneys are
not able to remove this waste product.

68. • Increased level in ESR is common blood test that is used
to detect and monitor inflammation in the body
(Sedimentation Rate;
http://www.emedicinehealth.com/). In the case of Patient
I, the inflammation that is detected by the ESR test is due
to the presence of fracture in infection of staphylococcus
in the wound. CRP test is also done, high levels in CRP also
indicates inflammation (Definition of C-Reactive Protein
Test; http://www.medicinenet.com/)

69. Medical-Surgical Management

70. A. Medical
• Pharmacologic Management
– Cefuroxime
– Clindamycin
– Paracetamol
– Diclofenac
• The patient was given medications, strictly
following the time element. The medications
administered to the patient were mostly
antibiotics, anti-inflammatory drugs, and pain
relievers.

71. • Blood Transfusion
Blood transfusion was ordered by the physician
in charge due to the low results of red blood
cell count found in the patient’s hematology
lab results. The physician would order 1 unit
of packed RBC (PRBC)

72. • IVF
The patient was administered D5LRS IVF during
his stay. D5LRS is needed fordaily maintenance
of body fluids and nutrition, and for
rehydration of the patient.

73. B. Surgical

74. • Patient has undergone Open Reduction Internal
Fixation (ORIF) plate and screw fixation with Iliac
Crest Bone Graft (ICBG), this refers to a surgical
procedure to fix a severe bone fracture, or break.
“Open reduction” means surgery is needed to
realign the bone fracture into the normal
position. “Internal fixation” refers to the steel
rods, screws, or plates used to keep the bone
fracture stable in order to heal the right way and
to help prevent infection. Bone grafting is used to
repair bone fractures that are extremely complex,
pose a significant risk to the patient, or fail to
heal properly.

75. Drug study

76. Drug Drug Class Dosage Route and
Frequency
Action Indication Contraindic
ation
Adverse
Effect
Nursing
Responsibilit
ies
Cefuroxime
Antibiotic
750 mg IVF Q8 Second-
generation
cephalospori
n that inhibits
cell-wall
synthesis,
promoting
osmotic
instability;
usually
bactericidal.
Infections of
skin-structure
infections
caused by
Streptococcu
s pneumonia
and S.
pyogenes,
Haemophillu
s influenzae,
Staphylococc
us aureus,
Escherichia
coli.
Contraindicat
ed in patients
hypersensitiv
e to drug.
Use
cautiously in
patients
hypersensitiv
e to penicillin
because of
possibility of
cross-
sensitivity
with other
beta-lactam
antibiotics.
Body as a
Whole:
Thrombophle
bitis (IV
site); pain,
burning,
cellulitis(
IMsite)
GI:
Diarrhea,
nausea,
antibiotic-
associated
colitis.
Skin:
Rash,
pruritus,
urticaria.
Urogenital:
Increased
serum
cretonne
BUN,
decreased
creatinine
clearance
Determine
history of
hypersensitiv
ity reactions
to
cephalosphor
ins,
penicillins
and history of
allergies
particularly
to drugs
before
therapy is
initiated.
Report onset
of loose
stools
Absorption
of
cefuroxime is
enhanced by
food.
Notify
prescriber
about rashes
or super
infections

77. Drug Drug Class Dosage Route and
Frequency
Action Indication Contraindicat
ion
Adverse
Effect
Nursing
Responsibiliti
es
Paracetamol Antipyretic 600mg Q6 IV Decreases
fever by a
hypothalamic
effect leading
to sweating
and
vasodilation
Decreases
fever by a
hypothalamic
effect leading
to sweating
and
vasodilation
Inhibits CNS
prostaglandin
synthesis with
minimal
effects on
peripheral
prostaglandin
synthesis
Control of pain
due to
headache,
earache,
dysmenorrhea,
arthralgia,
myalgia,
musculoskelet
al pain,
arthritis,
immunizations
, teething,
tonsillectomy
reduce fever in
viral and
bacterial
infections
Renal
Insufficiency
Anemia
Hypersensitivit
y
Contraindicate
d with allergy
to
acetaminophen
Stimulation,
drowsiness,
nausea,
vomiting,
abdominal
pain,
hepatotoxicity,
hepatic
seizure(overdos
e, Renal
failure(high,
prolonged
doses),
leucopenia,
neutropenia,
hemolytic
anemia (long
term use)
thrombocytope
nia,
pancytopenia,
rash, urticaria,
hypersensitivity
, cyanosis,
anemia,
jaundice, CNS,
stimulation,
delirium
followed by
vascular
collaps,
convulsions,
coma, death.
Assess
patient’s fever
or pain: typeof
pain, location,
intensity,
duration,
temperature,
and
diaphoresis.
Assess allergic
reactions: rash,
urticaria; if
these occur,
drug may have
to be
discontinued.
Teach patient
to recognize
signs of chronic
overdose:
bleeding,
bruising,
malaise, fever,
sore throat.
Tell patient to
notify
prescriber for
pain/ fever
lasting for more
than 3 days.

78. Drug Drug Class Route, dosage
and Frequency
Action Indication Contraindicatio
n
Adverse Effect Nursing
Responsibilities
Clindamycin Antibiotic 300 mg IV Q6 Clindamycin
(Cleocin) is an
antibiotic used
for serious
infections
caused by
susceptible
strains of
anaerobes,
streptococci,
staphylococci,
pneumococci;
reserve use for
penicillin-
allergic patients
or when
penicillin is
inappropriate;
less toxic
antibiotics
(erythromycin)
should be
considered.
Serious
infections
caused by
susceptible
strains of
staphylococci
Contraindicated
with allergy to
clindamycin,
history of
asthma or other
allergies,
tartrazine (in 75-
and 150-mg
capsules);
hepatic or renal
dysfunction;
lactation.
Use cautiously
in newborns and
infants due to
benzyl alcohol
content;
associated with
gasping
syndrome.
Hypotension,
Severe colitis,
including
pseudomembran
ous colitis,
nausea,
vomiting,
diarrhea,
abdominal pain,
esophagitis,
anorexia,
jaundice, liver
function
changes, Rashes
Culture infection
before therapy.
Do not give IM
injections of
more than 600
mg; inject deep
into large
muscle to avoid
serious
problems.
Do not use for
minor bacterial
or viral
infections.
Monitor renal
and liver
function tests,
and blood
counts with
prolonged
therapy.

79. Drug Drug Class Route , dosage
and Frequency
Action Indication Contraindicati
on
Adverse Effect Nursing
Responsibilitie
s
Diclofenac NSAID 750 mg IV Produces anti
inflammatory,
analgesic, and
antipyretic
effects, possibly
by inhibiting
prostaglandin
synthesis
Relieve pain,
swelling, or
inflammation
caused by
injuries and
conditions such
as osteoarthritis
and rheumatoid
arthritis
Hypersensitivity
Hepatic
porphyria
History of
asthma,
urticaria, or
other allergic
reactions
Upset stomach,
nausea,
heartburn,
diarrhea,
constipation,
gas, headache,
drowsiness, and
dizziness may
occur
Evaluate
therapeutic
response by
assessing pain,
joint stiffness,
joint swelling
and mobility.
- Assess any
worsening of
asthma in
appropriate
patients.
- Regular full
dosage has both
lasting
analgesic and
anti-
inflammatory
effects, making
it useful for
continuous pain
associated with
inflammation.

80. NURSING CARE PLAN

81. ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
“Kumikirot lagi
tong sugat ng
bagong opera
sa’kin. ‘Yun lang
naman, wala ng
ibang sumasakit.”
As verbalized by
the patient
Objective:
 Guarding
behavior
 Facial
grimace
from time
to time
 Pain scale of
8/10
 Immobile
Acute pain related
to post surgical
incision
Post surgery
Wearing off of
anesthesia on
surgical site
Sensation and
function regains
Pain on surgical
incision
After 2 hours of
nursing
intervention the
patient will:
 Reports
pain is
controlled
 Verbalize
methods
that provide
relief
Independent:
Perform
comprehensive
assessment of
patient’s pain and
further
verbalization
Provide comfort
measure( e.g.,
change of
position, back rub,
use of heat or
cold compress)
Help patient focus
on activities
rather than on
pain
Promote
adequate rest and
sleep
Collaborative:
Administering
pharmacologic
agents as
prescribed by the
physician
To obtain
necessary
information about
the case of the
patient
To provide
nonpharmacologi
c pain
management
To divert patient’s
attention on pain
To facilitate pain
relief and reduce
pain
Pharmacologic
agents lessens
pain and controls
sever pain
After 2 hours of
nursing
intervention the
patient shows:
 Reports
pain is
controlled
 Verbalizes
methods
that provide
relief
Goal was met

82. ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
“Simula nung
maadmit ako
dito, hindi na ko
nakatulog ng
maayos.
Palaging mga
tatlong oras lang
ako nakakatulog
sa gabi tas
nagigising na
ko.” As verbalized
by the patient
Objective:
 Presence
of yawning
 Changes
in posture
Disturbed sleep
pattern related to
unfamiliar sleep
environment
Familiar setting at
home
Hospitalization
Unfamiliar
environment
Disturbed sleep
pattern
After 2 days of
nursing
intervention, the
patient will
identify
individually
appropriate
interventions to
promote sleep.
Assess client's
sleep patterns
and usual
bedtime rituals
and incorporate
these into the
plan of care.
Observe and
obtain feed backs
regarding on the
usual sleeping
pattern, bed time
routine and the
usual number of
hours of sleep
and rest
Provide
environment that
enhance the
relaxation of the
patient
Provide comfort
measures and
uninterrupted
care
Usual sleep
patterns are
individual; data
collected through
a comprehensive
and holistic
assessment are
needed to
determine the
etiology of the
disturbance
To determine
usual sleeping
pattern and to
compare if there
are any
improvements on
the sleeping
pattern of the
patient
This provides a
conducive
environment for
the client to relax
To Avoid
disturbance
during sleep and
also to maximize
the sleep and rest
of the client
After 2 days of
nursing
intervention, the
patient Identifies
individually
appropriate
interventions to
promote sleep.
Goal was met

83. ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
“Okay pa din
naman. Halos
ganun pa din pero
mas bihira yung
pagdumi ko dito.”
As verbalized by
the patient
Object:
 Immobile
 Altered
bowel
sounds
Risk for
constipation
related to
dormant lifestyle
Decrease physical
activity
Decrease
intestinal activity
Pooling of feces
Risk for
constipation
After 8 hours of
nursing
intervention, the
patient will
demonstrate
behaviors and
lifestyle changes
to prevent
developing
problem
Ausculate bowel
sounds
Encourage to
increase fluid
intake
Encourage patient
to eat foods rich
in high fiber
Encourage activity
within limits of
individuals ability
Bowel sounds are
generally
decreased in
constipation
Fluids improve
stool consistency
To enhance easy
defecation
Physical activities
may stimulate
contraction of the
intestines
After 8 hours of
nursing
intervention, the
patient
demonstrates
behaviors and
lifestyle changes
to prevent
developing
problem. Goal
was met