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60313733 case-study-format

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60313733 case-study-format

  1. 1. Jose C. Feliciano College Foundation Dau Exit, NLEX, Dau Mabalacat Pampanga Institute of Nursing, Midwifery and Nursing Aide Academic Year 2011 – 2012 Debridement Suture A Case Study In Partial Fulfillment of the Course Requirement In Related Learning Experience Prepared by Tuazon, Christine Jhoy Canlas Mercado, Jennifer BSN III Prepared For Mr. Erwin Pernia, RN Instructor TABLE OF CONTENTS
  2. 2. I. Introduction A. Current trend B. Reason for choosing the case II. Nursing Assessment A. Personal history B. History of the past and present illness C. Family Health illness D. Physical Examination III. Anatomy and Physiology IV. Pathophysiology V. Medication
  3. 3. VI. Diagnostic and Laboratory Procedure VII. Diet VIII. IVF IX. Nursing Care Plan X. SOAPIE XI. Discharge XII. Conclusion and Learning derived XIII. Bibliography
  4. 4. I. Introduction A. Current trend B. Reason for choosing the case The reason why we choose our patient Mr. Damon as our subject for our case presentation is because his medical diagnosis, which is S/P debridement suture, is a common condition. This study will provide us as nursing student with concrete and significant information regarding the fracture condition with the emphasis on the management and nursing care given to patients having the same diagnosis. This also helps in enhancing the skills of the member of the health care team in disseminating information to prevent the occurrence of the fracture, as well as early prevention of further complications when the condition is already present.
  5. 5. Lastly, this study will contribute to the improvement of the standards of nursing practice and the quality of care given to such patients, thereby keeping with latest trends in care management. II. Nursing Assessment A. Personal history Damon Salvatore, a 18 year old Filipino, was born on January 10, 1993, the 2nd to the youngest among the 4 children of Mr. and Mrs. Salvatore both Filipino descent. B. History of the past and present illness According to his mother Mrs. Salvatore, Damon was never been admitted in hospital since he was a child none of her children was admitted in the hospital only for now because of the accident Damon encounter. C. Family Health illness
  6. 6. D. Physical Examination III. Anatomy and Physiology IV. Pathophysiology
  7. 7. V. Medication Medication Dosage/Route Date ordered Date prescribed Date given Indication Client response Cefuroxime Cefuroxime is used to treat certain infections caused by bacteria, such as bronchitis; gonorrhea;
  8. 8. Lyme disease; and infections of the ears, throat, sinuses, urinary tract, and skin. Cefuroxime is in a class of medications called cephalosporin antibiotics. It works by stopping the growth of bacteria. Antibiotics will not work for colds, flu, or other viral infections. Ranitidine Ranitidine is used to treat ulcers; gastro esophageal reflux disease (GERD), a condition in which backward flow of acid from the
  9. 9. stomach causes heartburn and injury of the food pipe (esophagus); and conditions where the stomach produces too much acid, such as Zollinger- Ellison syndrome. Over-the- counter ranitidine is used to prevent and treat symptoms of heartburn associated with acid indigestion and sour stomach. Ranitidine is in a class of medications called H2 blockers. It decreases the amount of acid made in the
  10. 10. stomach. Tramadol Tramadol is used to relieve moderate to moderately severe pain Celecoxib Celecoxib is a nonsteroidal anti- inflammatory drug (NSAID). It works by reducing hormones that cause inflammation and pain in the body. Celecoxib is used to treat pain or inflammation caused by
  11. 11. many conditions such as arthritis, ankylosing spondylitis, and menstrual pain. Celecoxib is also used in the treatment of hereditary polyps in the colon Gentamycin Gentamycin is an antibiotic. It fights bacteria in the body. Gentamycin is used to treat severe or serious bacterial infections.
  12. 12. Ceftriaxone Ceftriaxone injection is given before certain types of surgery to prevent infections that may develop after the operation. Ceftriaxone injection is in a class of medications called cephalosporin antibiotics. It works by killing bacteria. Antibiotics will not work for colds, flu, or other viral infections. Promethazine Promethazine is also used to prevent and control nausea and vomiting that may occur after surgery,
  13. 13. and with other medications to help relieve pain after surgery. Promethazine is also used to prevent and treat motion sickness. Promethazine helps control symptoms, but will not treat the cause of the symptoms or speed recovery. Promethazine is in a class of medications called phenothiazines . It works by blocking the action of a certain natural substance in the body. Famotidine Furosemide
  14. 14. VI. Diagnostic and Laboratory Procedure Diagnostic Lab. procedure Indication Date ordered Date result Result Normal values Analysis/ interpretation Hemoglobin Hemoglobin is a protein inside red blood cells that carries oxygen. A hemoglobin test reveals how much hemoglobin is in a person's blood. This information DO DR- 6/24/11 DO DR- 7/2/11 DO DR- 7/6/11 164 77 92 M- 125-175 g/l F- 115-155 g/l
  15. 15. can be used to help physician's diagnose and monitor anemia (a low hemoglobin level) and polycythemia vera (a high hemoglobin level). DO DR- 7/7/11 DO DR- 7/12/11 104 115 Hematocrit Hematocrit is a blood test that measures the percentage of the volume of whole blood that is made up of red blood cells. This measurement depends on the number of red blood cells and the size of red blood cells. DO DR- 6/24/11 DO DR- 7/2/11 DO DR- 7/6/11 DO DR- 7/7/11 DO DR- 7/12/11 .49 .23 .25 .28 .34 M-0.40- 0.52 F- 0.38- 0.48
  16. 16. The hematocrit is almost always ordered as part of a complete blood count. WBC count The WBC count is used to determine the presence of an infection or leukemia. It is also used to help monitor the body’s response to various treatments and to monitor bone marrow function . DO DR- 6/24/11 DO DR- 7/2/11 DO DR- 7/6/11 DO DR- 7/12/11 19.1 10.6 10.0 7.1 5-10 x 10/ L Neutrophils A neutrophils test helps us detect the levels of neutrophils in our body. These neutrophils are an integral part of our immune DO DR- 6/24/11 DO DR- 7/2/11 DO .88 .80 .80 0.45-0.65
  17. 17. system and through a process called chemotaxis; they reach any place where an infection has occurred. These cells take about an hour to reach the site of infection. In fact, they are one of the main components of pus and are to blame for its whitish color DR- 7/6/11 DO DR- 7/12/11 .68 Lymphocyte s Leukocyte (white blood cell) that normally makes up about 25% of the total white blood cell count but can vary widely. Lymphocytes occur in two forms: B cells, which produce antibodies, and DO DR- 6/24/11 DO DR- 7/2/11 DO DR- 7/6/11 DO DR- 7/12/11 .12 .20 .20 .32 0.20-0.35
  18. 18. T cells, which recognize foreign substances and process them for removal. Platelet count To diagnose a bleeding disorder or a bone marrow disease DO DR- 6/24/11 DO DR- 7/6/11 275 540 150-400 x 10/L VII. Diet Type of diet General description Indication/Purpose Date ordered Date started Date changed Client response NPO (Nothing per >to reduce gastric DO Patient felt
  19. 19. Orem) No food or liquid is allowed to be eaten by the patient secretions related to abdominal pain. >to prevent aspiration during surgery. >to eliminate nausea and vomiting DS DC hungry DAT (Diet as tolerated) introduction of diet that can be tolerated by the patient and the regular foods that are taken by the patient >is only given when client can now tolerate any food she desires that is nutritious >if this will not lead to any complications > if the client needs further monitoring for lab test DO DS DC Patient was able to regain nutrients and strength.
  20. 20. VIII. IVF IX. Nursing Care Plan X. SOAPIE #1 (actual soapie) S > ө O > Received patient on bed in supine position conscious and coherent w/ ongoing IVF of D5LRs 1L @ 700 cc level in the right hand infusing well regulated @ 30 – 31 gtts/min. v/s taken as follows B/P- 120/80 RR- 21 PR- 77 Temperature 36.5 >Right leg w/ dry and intact dressing > (-) pale skin > (+) UO > (-) bowel movement > afebrile
  21. 21. A > Impaired physical mobility r/t musculoskeletal impairment P > after 4 of NPI the patient will verbalize understanding of situation and individual treatment/safety measures I > Established rapport >v/s taken ad recorded >due meds given >determined diagnosis that contributes to immobility >assessed movement >Noted behavioral and emotional response >instructed patient not to eat anything after 12 noon >seen on rounds by Dr. Aldaba @ 7:30 am w/ orders and carried out >NPO past 12 noon >for emergency redebridement >scene consent >inform AROD for procedure >Endorsed
  22. 22. E> After 4 of NPI goal met as evidenced of patient verbalized understanding of situation and individual treatment/safety measures #2 S > ө O > received patient o supine position conscious and coherent w/ IVF of D5LRS 1L @ 500 cc level infusing well on the right hand regulated @ 30-31 gtts/min v/s taken as follow: B/P- 120/70 RR- 20 PR- 76 Temp. 36.8 A > risk for infection r/t inadequate primary defense manifested by broken skin P > after 2° of nursing intervention the patient will gain knowledge in infection control as evidenced by discussing the wound care. I > established rapport > v/s taken and recorded
  23. 23. > due meds. given > wound care done @ 9 am > observed for localized sign of infection > instructed patient S.O to have proper hygiene when cleaning the wound/suture > teached proper hygiene > endorsed E > goal met as evidenced by patient identified intervention to prevent or reduce risk of infection XI. Conclusion and Learning derived XII. Bibliography http://wiki.answers.com/Q/Why_diet_as_tolerated_is_given_to_a_patient http://wiki.answers.com/Q/What_is_NPO http://www.surgeryencyclopedia.com/Fi-La/Hemoglobin-Test.html http://www.nlm.nih.gov/medlineplus/ency/article/003646.htm
  24. 24. http://labtestsonline.org/understanding/analytes/wbc/tab/test http://www.medicalhealthtests.com/blood-tests/neutrophils-blood-test.html http://labtestsonline.org/understanding/analytes/cbc/tab/test http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601206.html http://www.drugs.com/celecoxib.html http://www.drugs.com/mtm/gentamicin.html

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