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Liceo de Cagayan University
College of Nursing
RN Pelaez Boulevard
Submitted as partial fulfillment in the subject

2. Page | 2
N104 RLE
A case study on
A client with a right knee Fixator
Submitted by:
Franklin Macabada
Submitted to:
Mrs. Glenda DemafelizRN, MN
February 18, 2013
TABLE OF CONTENTS

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I. INTRODUCTION 3
II. DATABASE AND HISTORY 8
III. NURSING SYSTEMS REVIEW CHART 9
IV. DEVELOPMENTAL DATA 15
V. PATHOPHYSIOLOGY 19
VI. DRUG STUDY 22
VII. MEDICAL MANAGEMENT 27
VIII. NURSING MANAGEMENT 29
IX. REFERRALS AND FOLLOW UP 35
X. EVALUATIONS AND IMPLICATIONS 35
XI. BIBLIOGRAPHY 36
I.Introduction
A. Overview of the Case
Client Taw-asan, Bobby is a CAA from the 23IB, 4ID, PA stationed at San Fernando
Bukidnon. On October 24, 2012 there was a grenade explosion at the city hall of San Fernando
where he was stationed. It exploded near his feet where he was sent hurtling. Shrapnel were
imbedded on his stomach which prompted him to be taken to Malabalay Provincial Hospital for
Emergency ExLap. His left side wasn’t badly hurt which for him is surprising because he
sustained most of his damage to his right side particularly on his right knee.

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B. Objective
The objective in making this case study is to identify and understand the problem of my
patient which is a fixator on the right knee and to determine what the specific actions should be
done and rendered to my patient. Having this kind of case study is a privilege for me because it
would be a good learning process by adding new knowledge and concept about different kinds
of diseases that may be present in some patients. By making this case study I can identify the
disease step by step, its nature on how this disease occur, and nursing actions that would be
appropriate for the patient.
C. SCOPE and LIMITATIONS of the STUDY
The study was conducted at Camp Evangelista Service HospitalCagayan de Oro City in
which observation, analyzing and understanding the patient’s condition was done. We were
given two (2) days to conduct the study. The study is also limited to the condition of the patient
which is having a fixator on his right knee. The study focuses only on obtaining the patient’s
profile, health history and present health condition; assessing, recording, and gathering of
pertinent data about the patient. Estimating the nursing needs and coping capacity of the
patient; finding the primary health problems of the patient and the appropriate nursing
interventions to solve the condition of the patient. The objectives, nursing care plans, drug
study and evaluation for the patient was also done in this study.
II. Database and History
A. Database
Client Taw-asan, Bobby a 40 yr old male from San Fernando Bukidnon.A CAA in the
Philippine Army. Was admitted to CESH after being transferred from MPH after undergoing “E”
ExLap due to grenade wounds after an attack on the city hall of san Fernando, bukidnon. He
was admitted for orthopedic recuperation at CESH.
Health History

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Family Health History
According to client Taw-asan; Hypertension is a heredofamilial trait. His father had
suffered from it.
Past Health History
Client Taw-asan underwent emergency exploratory laparotomy at Malabalay Provincial
Hospital on October of 2012
Present Health History
Grenade Blast Injury
NOI: Gunshot Injury
DOI: 24, Ocotber 2012
POI: San Fernando, Bukidnon
TOI: 2100H
Patient Taw-asan sustained injury when a grenade exploded at the city hll. Underwent
‘E’ ExLap at Bukidnon Provincial Hospital and was transferred to CESH for further Orthopedic
Management.
III. NURSING SYSTEM REVIEW CHART
Name of Patient: BobbyA. Taw-asan Date of Assessment: Feb13, 2013
BodyMeasurements:
Weight: 60 lbs Height: 4 feet 9 inches
Vital SignsuponAssessment:
Temp: 36.4 °C PR: 81bpm RR: 19cpm BP: 120/80 mmHg
EENT
[ ] ImpairedVision [ ] Blind [ ] Pain[ ] Reddened [ ] Drainage [ ] Gums
[ ] ImpairedHearing [ ] Deaf[ ] Burning[ ] Edema [ ] Lesions [ ] Teeth

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AssessEyes,Ears,Nose,andthroat forany abnormalities
[X] NoProblem
RESPIRATORY
[ ] Asymmetrical [ ] Tachypnea [ ] Apnea[ ] Rales [ ] Cough[ ] Barrel Chest
[ ] Bradypnea [ ] Shallow [ ] Rhonchi [ ] Sputum[ ] Diminished [ ] Dyspnea
[ ] Orthopnea [ ] Labored [ ] Wheezing [ ] Pain [ ] Cyanotic
Assessrespiration,rate,rhythm,depth,pattern,breathsounds,comfort.
[ x ] No Problem
CARDIOVASCULAR
[ ] Arrhythmia [ ] Tachycardia [ ] Numbness [ ] DiminishedPulse
[ ] Edema [] Fatigue[ ] Irregular [ ] Bradycardia [ ] Mur-mur
[ ] Tingling [ ] AbsentPulse[ ] Pain
Assessheartsounds,rate,rhythm,pulse,bloodpressure,circulation,fluidretention,comfort
[ X] No Problem
GASTROINTESTINAL
[ ] Obese [] Distension [ ] Mass[ ] Dysphagia [ ] Rigidity [ ] Pain
Assessabdomen,bowel habits,swallowing,bowelsounds,comfort.
[X] NoProblem
GENITO – URINARY and GYNE
[ ] Pain[ ] Urine Color [ ] Vaginal Bleeding
[ ] Hematuria [ ] Discharges [] Nocturia
AssessUrine frequency,control,color,odor,comfort,Gyne Bleeding,Discharges .
[X] NoProblem
NEUROLOGIC
[ ] Paralysis [ ] Stuporous [] Unsteady[ ] Seizure [ ] Lethargic [ ] Comatose
[ ] Vertigo [ ] Tremors [ ] Confused [ ] Vision [ ] Grip
Assessmotorfunction,sensation,LOC,Strength,Grip,gait,coordination,Speech
[X] NoProblem
MUSCULOSKELETAL and SKIN
[ ] Appliance [X] Stiffness [ ] Itching [ ] Petechiae [ ] Hot [ X] Drainage
[ ] Prosthesis [ ] Swelling [ ] Lesions [ ] PoorTurgor [ ] Cool [ ] Deformity

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[X] Wound [ ] Rash[ ] SkinColor[ ] Flushed[] Atrophy [X] Pain
[ ] Echymosis [ ] Diaphoretic [ ] Moist
Assessmobility,motion gait,alignment,jointfunction,Skincolor,texture,turgor,integrity
[ ] NoProblem
Place an (X) in the area of abnormality. Comment at the space provided. Indicate the location of the
probleminthe figure if appropriate,using(X).
NURSING ASSESSMENT II
SUBJECTIVE OBJECTIVE
COMMUNICATION:
[] HearingLoss
[] Visual Changes
[X] Denied
Comments:
“Ok pa man akongpanan aw.
Wala pa ganiko mag
antipara” As verbalized by the
[] Glasses
[ ] Contact
Lens
[ ] Languages
[ ] HearingAide
[ ] SpeechDifficulties
Drainage/Pain from fixator on d/3rd
femur
ExLap Scar
Scars
Scars
Scars

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client. Pupil Size:R_3mm_ L _3mm__
Bilaterallyequal
Reaction: _Pupils Equally Round and Reactive to Light
Accomodation
OXYGENATION:
[ ] Dyspnea
[] SmokingHistory
[ ] Cough
[ ] Sputum
[X] Denied
Comments:
“Di man pod
kogapanigarilyo.” As
verbalizedbythe client.
Respiration: [ x ] Regular [ ] Irregular
Describe: The rise and fall of the chest is
symmetric
R: Symmetrictoleft;full chestexpansion
L: Symmetrictoright;full chestexpansion
CIRCULATION:
[ ] ChestPain
[ ] Leg Pain
[] Numbnessof
extremities
[X ] Denied
Comments:
“Wala man
magsakitakongdughan” As
verbalizedbythe client.
Heart Rhythm:[x] Regular [ ] Irregular
Ankle Edema:Noankle edema________________
Pulse Car Rad DP Fem*
Right + + + +
Left + + + +
Comments: Pulses on both left and right are
presentandpalpable
NUTRITION:
Diet: Full (IncreasedProtein)
[] Dentures [X ] None
Full Incomplete WithPatient
X
[ ] N [ ] V
Character
Not applicable
[] Recentchange in
weight,appetite
[ ] Swallowing
Comments:
“Ok ra man pod
hinuonakongpagkaon”
As verbalized by the
client.

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difficulty
[X ] Denied
Upper
Lower
X
ELIMINATION:
Usual bowel pattern:
Once a day
[ ] Constipation
Remedy
Notapplicable
Date of lastBM
Feb,15, 2013
[ ] Diarrhea
Character
[ ] Urinary Frequency
[] Urgency
[ ] Dysuria
[ ] Hematuria
[ ] Incontinence
[ ] Polyuria
[ ] Folyinplace
[X] Denied
Comments:
No abdominal
tenderness upon
palpation.
Bowel sounds:
_Normoactive 5X_
Abdominal Distention:
Present:[ ]Yes [X ]No
Urine:
Color: Yellowish
Odor: Non-foul
Consistency: Clear & non
cloudy
MGT. OF HEALTH & ILLNESS:
[ ] Alcohol [X] Denied
Amount& Frequency
“Dilikogainom. ”asverbalizedbythe client
SBE Last Pap Smear: Notapplicable
LMP: Notapplicable
Briefly describe the patient’s ability to follow
treatments (diet, meds, etc.) for chronic problems (if
present).
Client was keen to ask questions about her disease and
describe it as well. She follows the regimen given to her.
___
SKIN INTEGRITY:
[] Dry
[ ] Itching
[X] Other
[] Denied
Comments:
“Naakoysamadibabawsaakongt
uhod .” As verbalized by the
client.
[X] Dry
[] Flushed
[ ] Moist
[ ] Cold
[X ] Warm
[ ] Cyanotic
[ ] Pale
*Rashes,ulcers,decubitus(describe size,
*location,drainage):
Ulceration noted 5 inches above right knee, outer
aspect.Nearlyhealed2inchesindiameter.

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ACTIVITY/SAFETY
:
[ ] Convulsion
[ ] Dizziness
[X] Limited
motionof
joints
Limitation in
abilityto:
[X] Ambulate
[X ] Bathe Self
[ ] Other
[] Denied
Comments:
“Mag
lisodpakouglihoksaakoongtuho
d, ugtunobsaakongtiil” As
verbalizedbythe client.
[ ] Level of ConsciousnessandOrientation
The clientisawake and coherent andoriented
__ Gait: __ Walker Cane X Other:Crutches
__ Gait: Steady
__ Gait: X Unsteady:
[ ] Sensoryandmotor lossesinface or
extremities:
No sensory and motor loses on face and extremities
noted.
[X] Range of MotionLimitations:
Right knee unable to be bent, right leg can support at
least5 kgs of weight.
COMFORT/SLEEP/AWAKE:
[X] Facial Grimaces
[X] Guarding
[X] OtherSignsof Pain:
Tenderto pressure duringcleaning
[ ] Siderail release formsigned(60+years)
Notapplicable
[X ] Pain
Location:5 inches
above rightknee
Frequency:Daily
Remedies: Warm
Compress and
Elevation
[ ] Nocturia
[ ] SleepDifficulties
[ ] Denied
Comments:
“Mag
ngotngotangakongtuho
d kung I bend
judnakuugayo as
verbalizedbythe client.
COPING:
Occupation: Cafguin the PhilippineArmy
Membersof household:
6 Members
Most supportive person:
Observe non-verbal behavior:
Clientiskeenwithcurrentconditionanseemstohave
Adaptedtothe routines
The personand hisphone numberthatcan

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VilmaTaw-asan Be reachedanytime:
09164680517
SPECIAL PATIENT INFORMATION (USE LEAD PENCIL)
__NA____Daily Weight __ NA______PT/OT__________
02/13/13 BP q Shift __ NA_____Irradiation
___ NA____Neurovs ___ NA_____Urine Test_________
___ NA____CVP/SG. Reading __ NA____24 hour Urine Collection
Date ordered Diagnostic/
Laboratory
Exams
Date Done Date
Ordered
I.V. Fluids/
Blood
Date Disc.
Dec 12, 2012 Blood Chem Dec 13 10/24/13 PNSS 1L 01/13/13
Jan 12, 2013 Ultrasound Jan 13 NA
NA NA
Hematology:
Increased WBC: Indicative of infection
Decreased Hemoglobin: Decreased circulating blood
X-ray:
Normal Chest x-ray finding
Normal Right Leg finding
IV. DEVELOPMENTAL DATA
The term growth and development both refers to dynamic process. Often used interchangeably,
these terms have different meanings. Growth and development are interdependent, interrelated
process.Growthgenerallytakesplace duringthe first20yearsof life;developmentcontinuesafterthat.

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Growth:
1. Physical change andincrease insize.
2. It can be measuredquantitatively.
3. Indicatorsof growthinclude height,weight,bonesize,anddentition.
4. Growth ratesvary duringdifferentstagesof growthanddevelopment.
5. The growth rate is rapid during the prenatal, neonatal, infancy and adolescent stages and slows
duringchildhood.
6. Physical growthisminimal duringadulthood.
Development:
1. Is an increase inthe complexityof functionandskillprogression.
2. It isthe capacityand skill of apersonto adapt to the environment.
3. Developmentisthe behavioral aspectof growth.
Erikson’s Stagesof Psychosocial DevelopmentTheory
Erikson's psychosocial
crisis stages
life stage / relationships / issues basic virtue and
second named
strength (potential
positive outcomesfrom
each crisis)
maladaptation / malignancy (potential
negative outcome - one or the other -
from unhelpful experience during each
crisis)
(syntonic vdystonic)
1. Trust vMistrust infant / mother / feeding and
being comforted, teething,
sleeping
Hope andDrive SensoryDistortion/ Withdrawal
2. AutonomyvShame
& Doubt
toddler / parents / bodily
functions, toilet training,
muscular control, walking
Willpower andSelf-
Control
Impulsivity/ Compulsion
3. Initiative vGuilt preschool / family/ exploration
and discovery, adventure and
play
Purpose andDirection Ruthlessness / Inhibition
4. IndustryvInferiority schoolchild / school, teachers,
friends, neighbourhood/
achievement and
accomplishment
Competence and
Method
Narrow Virtuosity/ Inertia
5. IdentityvRole
Confusion
adolescent / peers, groups,
influences / resolving identity
and direction, becominga grown-
up
Fidelityand Devotion Fanaticism/ Repudiation
6. IntimacyvIsolation young adult / lovers, friends,
work connections / intimate
relationships, work andsociallife
Love and Affiliation Promiscuity/ Exclusivity
7. Generativityv
Stagnation
mid-adult / children, community
/ 'giving back',helping,
contributing
Care andProduction Overextension/ Rejectivity

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Client Taw-asanis on the 7th
stage Generativityvs Stagnation. Even though he is a battle casualty,
he is still trying to provide up to his best for his children. He might as well have retired already since he is
a battle casualtiesbuthe hasdecidedtocare for hisfamilymore avoidingstagnation.
Havinghurst Developmental Stages
HavighurstidentifiedSix MajorStagesinhumanlife coveringbirthtooldage.
 Infancy& earlychildhood(Birthtill 6yearsold)
 Middle childhood(6–13yearsold)
 Adolescence(13–18 yearsold)
 Early Adulthood(19–30 yearsold)
 Middle Age (30-60yearsold)
 Later maturity(60 yearsoldand over)
From there, Havighurst recognized that each human has three sources for developmental tasks. They
are:
 Tasks that arise from physical maturation: Learning to walk, talk, control of bowel and urine,
behavinginanacceptable mannertoopposite sex,adjustingtomenopause.
 Tasks that arise from personal values: Choosing an occupation, figuring out ones philosophical
outlook.
 Tasks that have their source in the pressures of society: Learning to read, learning to be
responsible citizen.
The developmental tasks model that Havighurst developed was age dependent and all served pragmatic
functionsdependingontheirage.
In the middle years, from about thirty to about fifty-five, men and women reach the peak of their
influence upon society, and at the same time the society makes its maximum demands upon them for
social and civic responsibility. It is the period of life to which they have looked forward during their
adolescence and early adulthood. And the time passes so quickly during these full and active middle
years that most people arrive at the end of middle age and the beginning of later maturity with surprise
and a sense of havingfinishedthe journeywhile theywerestillpreparing tocommence it.
The biological changes of ageing, which commence unseen and unfelt during the twenties, make
themselves known during the middle years. Especially for the woman, the latter years of middle age are
full of profoundphysiologically-basedpsychological change.
The developmental tasks of the middle years arise from changes within the organism, from
environmental pressure, and above all from demands or obligations laid upon the individual by his own
valuesandaspirations.

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Client Taw-asan belongs to the middle age group. He has already accepted the biological changes in him
and has sethimself asthe role model forhisteenage childrensince hiswifehaspassedaway.
Piaget’sStage Theory of Cognitive Development
SwissbiologistandpsychologistJeanPiaget(1896-1980) observedhischildren(andtheirprocessof
makingsense of the worldaroundthem) andeventuallydevelopedafour-stage modelof how the mind
processesnewinformationencountered.He positedthatchildrenprogressthrough 4stagesandthat
theyall do so inthe same order.These fourstagesare:
 Sensorimotorstage (Birthto 2 yearsold).The infantbuildsanunderstandingof himselfor
herself andreality(andhowthingswork) throughinteractionswiththe environment.Itisable
to differentiatebetweenitself andotherobjects.Learningtakesplace viaassimilation(the
organizationof informationandabsorbingitintoexistingschema) andaccommodation(when
an objectcannotbe assimilatedandthe schematahave tobe modifiedtoinclude the object.
 Preoperational stage (ages2 to 4). The childisnot yetable to conceptualize abstractlyand
needsconcrete physical situations.Objectsare classifiedinsimple ways,especiallybyimportant
features.
 Concrete operations (ages7 to 11). As physical experience accumulates,accommodationis
increased.The childbeginstothinkabstractlyandconceptualize,creatinglogical structuresthat
explainhisorherphysical experiences.
 Formal operations(beginningatages11 to 15). Cognitionreachesitsfinal form.Bythisstage,
the personno longerrequiresconcrete objectstomake rational judgments.He orshe iscapable
of deductive andhypothetical reasoning.Hisorherabilityforabstract thinkingisverysimilarto
an adult.
ClientTaw-asanhaslongpastthisstage.He has alreadyestablishedhisformaloperationskillsand
has alreadystartedpassingitdowntohis childrenalready.
Freudianpsychosexual development
Stage Age Range Erogenous zone Consequences of psychologic fixation
Oral
Birth–1
year
Mouth
Orallyaggressive:chewinggumandthe endsof
pencils,etc.
OrallyPassive:smoking,eating,kissing,oral sexual
practices.
Oral stage fixation mightresultinapassive,gullible,
immature,manipulative personality.
Anal 1–3 years Bowel andbladder Anal retentive:Obsessivelyorganized,orexcessively

15. Page | 15
elimination neat
Anal expulsive:reckless,careless,defiant,
disorganized,coprophiliac
Phallic 3–6 years Genitalia
Oedipuscomplex(inboysandgirls);accordingto
SigmundFreud.
Electracomplex (ingirls);accordingtoCarl Jung.
Latency 6–puberty
Dormant sexual
feelings Sexual unfulfillmentif fixationoccursinthisstage.
Genital
Puberty–
death
Sexual interests
mature Frigidity,impotence,unsatisfactoryrelationships
Genital stage
The fifth stage of psychosexual development is the genital stage that spans puberty and adult
life, and thus occupies most of the life of a man and of a woman; its purpose is the psychologic
detachment and independence from the parents. The genital stage affords the person the ability to
confront and resolve his or her remaining psychosexual childhood conflicts. As in the phallic stage, the
genital stage is centered upon the genitalia, but the sexuality is consensual and adult, rather than
solitary and infantile. The psychological difference between the phallic and genital stages is that the ego
is established in the latter; the person's concern shifts from primary-drive gratification (instinct) to
applying secondary process-thinking to gratify desire symbolically and intellectually by means of
friendships,alove relationship,familyandadultresponsibilities.
Actually client Taw-asan has also passed this stage with grace as I may say. Even though raising
children on your own can be quite a daunting task but he is still able to manage and provide for his
familyaswell.
V. Pathophysiology
A bone fracture (sometimes abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a
break in the continuity of the bone. A bone fracture can be the result of high force impact or stress, or
trivial injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, bone
cancer, or osteogenesisimperfecta, where the fracture is then properly termed a pathologic fracture.
Grenade Explosion
Injuryto femur/fracture –transverse,oblique,spiral orcomminuted
Restricted/lossof functionof affectedpart
Tissue swelling,bruisingorhematomamassat site of injury

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VI. Drug Study
Mechanism of
Action
Indication Contraindication Adverse Reactions Nursing Implication
Generic Name:
Tramadol
Brand name:
Ultram
Classification:
Analgesic
Dosage:
50mg
Frequency:
Q6°
Route:
PO
Binds to -opiate
receptors in the
CNS causing
inhibition of
ascending pain
pathways, altering
the perceptionof
and response to
pain;also inhibits
the reuptake of
norepinephrine
and serotonin,
which also
modifies the
ascending pain
pathway.
Management
of painin the
operation
site.
Hypersensitivityto tramadol,
opioids, or anycomponent of
the formulation;opioid-
dependent patients;acute
intoxication withalcohol,
hypnotics, centrally-acting
analgesics, opioids, or
psychotropic drugs
 Dizziness
 Nausea
 Drowsiness
 Dry mouth
 Constipation
 Headache
 Sweating
 Vomiting
 Itching
 Rash
 Visual disturbances
 Vertigo
 Tell patient that driving
or operating machinery
should be avoideduntil
the effect of drugwears
off.
 Instruct patient to
report cravings to
physicianimmediately.
 Inform client that
medicationmay cause
CNS depressionand/or
respiratorydepression,
particularlywhen
combined withother
CNS depressants

17. Page | 17
Mechanism of
Action
Indication Contraindication Adverse Reactions Nursing Implication
Generic Name:
CALCIUM
SUPPLEMENT/
VITAMIN D -
ORAL
Brand name:
Citracal + D
Classification:
Vitamin supplemet
Dosage:
1 cap
Frequency:
OD
Route:
PO
Calcium plays a
very important
role inthe body. It
is necessaryfor
normal
functioningof
nerves, cells,
muscle, andbone.
If there is not
enoughcalcium in
the blood, then
the bodywill take
calciumfrom
bones, thereby
weakening bones.
VitaminD helps
your bodyabsorb
calciumand
phosphorus.
This
combination
medicationis
usedto
prevent or
treat low
blood
calcium
levels in
people who
do not get
enough
calciumfrom
their diets.
heart/bloodvessel disease,
kidneystones, kidneydisease,
certainimmune system
disorder (sarcoidosis), liver
disease, certainbowel
diseases (Crohn's disease,
Whipple's disease), little or no
stomach acid(achlorhydria),
low levels of bile, untreated
phosphate imbalance.
serious allergic reaction,
including:rash, itching/swelling
(especiallyof the
face/tongue/throat), severe
dizziness, trouble breathing.
=Monitor for hypercalcemia
=Monitor for
hyperphospathemia

18. Page | 18
Mechanism of
Action
Indication Contraindication Adverse Reactions Nursing Implication
Generic
Name:
Ascorbic Acid
Brand name:
VitaminC
Classification:
Vitamin
Supplement
Dosage:
500 mg 2
tabs
Frequency:
OD
Route:
PO
Essential vitamin
believedto be
important for
synthesis of
cellular
components,
catecholamines,
steroids, and
carnitine.
Prophylaxis
and
treatment of
scurvyand
as a dietary
supplement.
Increases
protection
mechanism
of the
immune
system, thus
supporting
wound
healing.
Necessary
for wound
healing and
resistance to
infection.
Use of sodium ascorbate in
patients onsodium restriction;
use of calcium ascorbate in
patients receiving digitalis.
Safety during pregnancy
(categoryC) or lactation is not
established.
GI:Nausea, vomiting, heartburn,
diarrhea. Hematologic:Acute
hemolytic anemia (patients with
deficiencyof G6PD);sickle cell
crisis. CNS:Headache (high doses).
Urogenital:Urethritis, dysuria,
crystalluria (highdoses). Other:
Mild soreness at injectionsite;
dizziness andtemporaryfaintness
with rapid IV administration.
Assessment & Drug Effects
• Lab tests:
Periodic Hct&Hgb, serum
electrolytes.
• Monitor for S&S
of acute hemolytic anemia,
sickle cell crisis.
Patient & FamilyEducation
Take large doses ofvitamin
C in divided amounts
because the bodyuses only
what is neededat a
particular time and
excretes the rest inurine.
• Megadoses can
interfere withabsorption
of vitaminB12.
Note:VitaminCincreases
the absorptionof iron
when takenat the same
time as iron-rich foods.

19. Page | 19
Mechanism of
Action
Indication Contraindication Adverse Reactions Nursing Implication
Generic Name:
Ferrous sulfate
Brand name:
Classification:
Iron Preparation
Dosage:
1tab
Frequency:
OD
Route:
PO
Elevatesthe serum
iron concentration
which thenhelps
to form High or
trappedin the
reticuloendothelial
cells for storage
and eventual
conversionto a
usable formof
iron.
• Prevention
and
treatment of
iron
deficiency
anemias.
• Dietary
supplement
for iron.
• Hypersensitivity
• Severe hypotension.
• Dizziness
• N & V
• NasalCongestion
• Dyspnea
• Hypotension
• CHF
• MI
• Muscle cramps
• Flushing
Advise patient to take
medicine as prescribed.
• Caution patient to make
position changes slowlyto
minimize orhtostatic
hypotension.
• Instruct patient to avoid
concurrent use of alcohol
or OTC medicine without
consultingthe physician.
• Advise patient to consult
physicianif irregular
heartbeat, dyspnea,
swellingof hands andfeet
and hypotensionoccurs.
• Inform patient that
angina attacks mayoccur
30 min. after
administration due reflex
tachycardia.

20. Page | 20
VII. MEDICAL MANAGEMENT
October 31, 2012 0835H >Please admit to Ortho Ward
=Admission order by doctor
>Monitor VS q 4º
=For baseline vitals
>May have general liquids and soft diet for lunch
=For nourishment and not to stress GI tract too much
>Present IVF D5LR 200cc @ 30 gtts/min
= Present fluid replacement
>IVF to ff: D5LR 1 L @ 20 gtts/min
=Present IVF reduced speed
>Meds: Tramadol 50 mg slow iv q6º
= Management of pain
>Ranitdine 50 g IV q8 within 24 hrs
= To allow the GI tract to rest
>Ciprofloxacin 1 gm IV ANST (-)
= antibiotic for transient skin infection due to ‘E’ ExLap
>Refer accordingly
= Refer for any unusualities
November 02, 2012 0855H >May have DAT
=Diet change to as tolerated
>D/C Ranitidine IV & Tramadol IV
=Meds are slowly switched from IV to PO
>IVF to ff: D5LR 1 L @ 10 gtts/min
=current IVF speed decreased

21. Page | 21
>May give Tramadol 50 mg PO q6 for pain
=For pain management
November 10, 2012 1125h>For ORIF of right Femur tomorrow PM
=For Open Reduction with Internal Fixator on right knee
November 11, 2012 1822H>To recovery room
=Post operative recovery
November 12, 2012 2042H > Morphine 2 mg + Buspirone 10 g in 10 cc PNSS given via EC
=For pain management
>Morphine precaution pls
=For strict monitoring on and during morphine activation levels
November 14, 2012 >For passive ROMexercises
=To help with mobilization of affected knee
November 16, 2012 0845H >Terminate IVF when consumed
= Discontinue IVF once consumed
>D/C IV meds once IVF is terminated, switch to PO
=Continuation of medication via PO
>Daily wound dressing
=Daily cleaning of wound
November 21, 2012 0850H >For removal of skin staples today
=To allow the adhesion and healing of the surgical wound
November 25, 20120940H >Continue assisted Romexercises
=For improvement of muscle tone
November 30, 2012 0949H >FeSO4 1 tab OD
=Increase RBC health
December 10, 2012 1145H >For removal of remaining skin staples and sutures
=To allow the adhesion and healing of the surgical wound

22. Page | 22
December 12, 2012 1002H >May transfer to regular ward
=To facilitate healing and monitoring
January 28, 2013 0935H >May do crutch ambulation, non-weight bearing R leg
=To facilitate ambulation
February 03, 2012 1618h >Daily wound dressing
=Daily cleaning of wound
>Continue assisted Romexercises
=For improvement of muscle tone

23. Page | 23
VII. NURSING MANAGEMENT
NURSING CARE PLAN
Cues Nursing
Diagnoses
Objectives Interventions Rationale Evaluation
Subjective data:
Objective data:
Incision wound with
discharges 5 inches
above Right knee
Impaired skin
integrity
At the end of the
shift client will
verbalize increase of
comfort on affected
knee
- Daily wound dressingdone
- Turned/ Repositioned patient at
leastevery 2 hours.
- Encouraged use of soft, loose
cotton clothing.
- Used preventive skin care devices
such as pillows and padding.
- Kept patient’s skin dry and clean.
- Protected bony prominences with
pillows and padding.
-To maintain optimum
sterility and promote
healing
- Promotes circulation
and prevents undue
pressure on skin and
tissues.
- To promote comfort
and maintain optimum
circulation
- To avoid discomfort
and skin breakdown
- These measures
promote comfort and
reduce risk of irritation
and skin breakdown.
- Prominences have little
subcutaneous fat and
are prone to breakdown;
using padding and
pillows may help
promote skin integrity.
At the end of the
shift client
verbalized increase
of comfort on
affected knee

24. Page | 24
Cues
Nursing
Diagnoses
Objectives Interventions Rationale Evaluation
Subjective data:
“Sakit pa
anggioperahan, labina
kung pugsonnako” as
verbalized by client
Objective data:
- Pain scale9/10
- (+) Facial grimaces
- Elevated BP 130/85
Pain R/T post-
surgical
incision
At the end of 2
hours of NI the
client will manifest a
decrease in pain
scale from 9 to 2/10
or lower
-Asses the clients perception, level
of understandingand needs
-Obtain clients baseline VS
includingpain scale
-Encourage client to verbalize any
discomfort
-Position in comfortableposition
-Administer Tramadol 50 mg PRN
for pain
-To identify and assess
the different nursing
interventions to be done
-To assess the
effectiveness of NI and
obtain baseline VS for
future comparison
-Because pain is highly
subjective
-To providecomfort
-To alleviatepain
-After 2 hours of NI
client was able to
verbalize relief from
pain;2/10 pain scale

25. Page | 25
Cues
Nursing
Diagnoses Objectives Interventions Rationale Evaluation
Subjective data:
“Dilinajudkokomporta
blediri” as verbalized
by client
Objective data:
>Pale & weak looking
>Restless & irritable
>With limited
movements noted.
Impaired
Comfort r/t
Medical
Condition
At the end of 8
hours, client will
verbalize increase in
comfort and
reduction of anxiety
- Allowed patient to
verbalizepain.
- Provided non-
pharmacologic comfort
measures such as
repositioning, back rub and
divertional activities.
- Encouraged use of stress
management skills or
complementary therapies
such as guided imagery
and therapeutic touch.
- Taught to do deep
breathing exercise and
instructed to do it along
with the other
interventions when the
pain starts.
- Instructed relatives to
stay with the patient at
most times.
- Pain is subjective that can only be
felt by the person affected
- Promotes relaxation and helps
refocus attention.
- Enables patient to participate
actively in nondrug treatment of
pain and enhances sense of
control.
- Increases lung expansion,
reduces muscle tension, enhances
circulation and decreases pain
perception.
- To reduce anxiety and enhance
patient’s coping skills which in
turn, decreases pain.
At the end of 8
hours, client
verbalized increase
in comfort and
reduction of anxiety

26. Page | 26
Actual Nursing Intervention
Taw-asan, Bobby February 14, 2013
0700H Post-opWound
D>With post-opwound@R knee withwet& intactdressingwithminimal secretions.
A> Daily wound dressing done aseptically; leg slightly elevated; advised to keep wound covered at all
times & avoid touching with bare hands; Encouraged intake of vitamin c rich foods; ROMexercises done
withintolerable levels.
R> Still withpost-opwound;dressingdryandintact
0700H Post-opPain
D> “Sakitsiyagamaykayakogi exercise”asverbalized;painscale of 5/10
A> Applied warm compress; taught deep breathing & relaxation techniques; advised to ambulate with
crutcheson non-weightbearingleg;encouragedtoverbalize anydiscomfort.
R> Still inpain;withscale of 3/10

27. Page | 27
Taw-asan, Bobby February 14, 2013
0700H Post-opWound
D>With post-opwound@R knee withwet& intactdressingwithminimal secretions.
A> Daily wound dressing done aseptically; leg slightly elevated; advised to keep wound covered at all
times & avoid touching with bare hands; Encouraged intake of vitamin c rich foods; ROMexercises done
withintolerable levels.
R> Still withpost-opwound;dressingdryandintact
0700H Post-opPain
D> “Sakitsiyagamaykayakogi exercisekaganina”asverbalized;painscale of 9/10
A> Applied warm compress; taught deep breathing & relaxation techniques; advised to ambulate with
crutcheson non-weightbearingleg;encouragedtoverbalize anydiscomfort.
R> Still inpain;withscale of 2/10

28. Page | 28
VIII. REFERRALS AND FOLLOW-UP:
Outpatient (check-up): Instructed the patient to abide to her routinecheck-upwith
Dr.Lagapa at CESH once discharged.Encouraged the patient as well to report any unusual
findings that he might have observed.
IX: EVALUATION AND IMPLICATIONS:
This care study enables us to further our learning association with disease condition of
the patient. From it, we have gained knowledge in the progression of the disease and the
reaction of the body to maintain homeostasis and how eventually it causes harm.
Through this, we actually improved our understanding and skills in the management of
the patient through the experiences we’ve had in implementing our care. It also enhanced our
confidence in intervening because of the input gained form our research.
Case studies are a way of getting familiar or get acquainted not only with the patient but
also on his or her condition. It provides concrete examples of how the theoretical knowledge
learned during lectures was applied. How the concepts of the various disease condition were
manifested through the client. It allows the opportunity to facilitate the acquisition of
knowledge through the experiences gained in management and in caring for the patient. As a
result, it is a must that case studies should be made not just for requirement purposes but also
for the pursuit of knowledge.
In general, the case study promoted learning through the research and actual
experiences and made us more knowledgeable in caring for the patient and that can really be
used in our chosen field.

29. Page | 29
X. Bibliography
Books:
120 Diseases (The essential Guide to more than 120 Medical Conditions, syndromes, and
diseases) by Prof. Peter Abrahams 2007
pp. 46-47; 74-75; 190-195
Essentials of pathophysiology by Carol Mattson PorthRn, MSN, PhD
pp. 366-399; 705-721; 1034-1037
Manual of Nursing Practice by Lippincott 10thed.
pp.454-462; 910-932; 1087-1088
Portable Rn 3rd edition by Lippincott 2006
pp. 214-216; 226-228; 236-238
Nursing Care Plans, Nursing diagnosis and intervention by Gulanick/Myers 6thed
pp. 301-305; 777-782; 1050-1062
Internet:
WWW.MEDSCAPE.COM
WWW.WIKIPEDIA.ORG
WWW.DRUGSCAPE.COM