113675987 case-study-phd

CASE STUDY: POSTERIORHIP DISLOCATION (RIGHT)
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I. INTRODUCTION
A. Definition
Dislocation of the hip is a common injury to the hip joint. Dislocation occurs when the
ball–shaped head of the femur comes out of the cup–shaped acetabulum set in the pelvis. This
may happen to a varying degree. A dislocated hip is a condition that can either be congenital or
acquired. And the dislocation can be posterior or anterior.
Nine out of ten hip dislocations are posterior. The affected limb will be shortened and
internally rotated in this case. In an anterior dislocation the limb will not be lengthened as
noticeably and will be externally rotated.

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Congenital hip dislocation must be detected early when it can be easily treated by a few
weeks of traction. If it is not detected, the child's hip may develop incorrectly seen when the
child begins to walk. If one hip is affected the child will have a limp and lurch and with
bilateral dislocation there will be a waddling gait. On physical exam, with the baby in the
supine position, the examiner flexes the hips and knees both to 90 degrees, and, holding the
knees, pushes gently downward, which may induce a posterior dislocation or subluxation.
Keeping the baby in this 90 degree flexed position, the examiner then externally rotates the
thighs. A normal infant will demonstrate no evidence of dislocation. It can also be detected
with the Galeazzi test. Congenital hip dislocation is much more common in girls than boys.
Acquired hip dislocations are extremely painful and commonly occur during any kind
of accidents. They may be treated by surgical realignment and traction.
B. Morbidity and Mortality
Hip dislocations are relatively uncommon during athletic events. Injuries to small joints
(e.g., finger, wrist, ankle, and knee) are much more common. However, serious morbidity can be
associated with hip dislocations, making careful and convenient diagnosis and treatment important
for the sports medicine physician.
Large-force traumas (e.g., motor vehicle accidents, pedestrians struck by automobiles,
falling from trees/infrastructures) are the most common causes of hip dislocations. This type of
injury is also associated with high-energy impact athletic events (e.g., football, rugby, water skiing,
alpine skiing/snowboarding, gymnastics, running, basketball, race car driving, equestrian sports).

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Hip dislocations are either anterior or posterior, with posterior hip dislocations comprising the
majority of traumatic dislocations.
C. Incidence and Prevalence
Congenital dislocation of the hip also occurs and is termed developmental dysplasia of the
hip (DDH). The annual incidence of DDH is approximately 2-4 cases per 1000 births;
approximately 80-85% of the affected individuals are girls.
D. Reasons for choosing the disease
We choose posterior hip dislocation (right) particularly acquired dislocation as our case to be
studied because we want each and all of us whether men or women in any ages to be aware of the
possible complications of the disease and the management of patient with such musculoskeletal
disorder.
II. OBJECTIVES
A. General Objectives
Within 1 week of exposure at Philippine Orthopedic Center (POC) children’s ward, we, BSN
IV-A Group 2 student nurses from World Citi Colleges (WCC) Antipolo campus aim to use our
knowledge, skills, and attitude to render holistic care to our client as well as convey information with
regards to the promotion and maintenance of health in order for our client to achieve possible wellness
state and carry out activities of daily living.
B. Specific Objectives

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Knowledge
 To identify the problem of the patient
 To formulate exact and effective nursing care plan to the patient
 To review the normal anatomy and physiology of the musculoskeletal system
Skills
 To improve our ability to handle patient with Balance Skeletal Traction (BST) and to enhance
our skills to the applications of our knowledge
 To provide health teachings and nursing interventions
Attitude
 To establish good nurse-patient relationship with our client and to improve the level of our
communications to our patient and staff nurses
 To build rapport with the patient
III. SIGNIFICANCE OF THE STUDY
To patient with hip dislocation:
 To acquire necessary knowledge related to their health condition
 To be able to manage them when pain and abnormalities related to the disease occurs
 To be able to understand the treatment that the health care providers offer in their recovery
process
 To promote prevention of complications

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To staff nurses:
 To properly indentify the needs of the patient
 To be able to render nursing care and information to the patient through the application of the
nursing skills
 To apply their knowledge and skills when caring to patients with hip dislocation
To nursing students:
 To properly assess the patients who are manifesting the disease
 To be knowledgeable in the treatment they are providing them
 To be able to provide more health teachings in the prevention of the disease
IV. SCOPE AND DELIMITATIONS
We had our duty at Philippine Orthopedic Center (POC) children’s ward, in Banawe street Quezon City
last August 13-17, 2012. We were able to assess the patient’s condition but only for 2 days and 1 hour each day,
it is not really enough to assess due to lack of time but through keen observations we were able to interview for
somehow the father of our patient and with the help of the patient’s chart and records. Another thing, our patient
was not able to talk in neither “tagalog” nor English because he is pure “bisaya.” But fortunately, we are able to
gather certain information needed to formulate this case study. The study lasted about 2 hours of exposure in
total with the patient. Our client R.T. is suffering from acquired posterior hip dislocation (right) which we will
be dealing with this study.

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V. NURSING HISTORY
Name: R.T.
Age: 8 Years Old
Address: Masbate City
Sex: Male
Weight: 33 Lbs/ 15 Kg
Height: 45 Inches

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Birthday: February 4, 2004
Birth Place: Masbate
Religion: Roman Catholic
Date ofAdmission: August 8, 2012 @ 2:30pm
Hospital #: 722273
Hospital Ward: Cw-C3
Referred By: Dr. Aujero
Referred To: Dr. Canete
Reason for Referral: For evaluation and management ofSeizure Episodes (08-12-12)
Diagnosis: Posterior Hip Dislocation (Right)
ChiefComplaint: Inability to walk
A. HISTORY OF PRESENT ILLNESS
Two weeks prior to consult, patient fell from a high tree. Patient was unable to ambulate/ walk
since the incident. Consult was done with a “manghihilot” where massage and other unrecalled
management were done.
B. PAST MEDICAL HISTORY
 Unrecalled
C. PAST ILLNESS
 Unrecalled

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D. FAMILYHISTORY
 (-) HPN
 (-) DM
E. PERSONAL & SOCIAL HISTORY:
• Patient is the 2nd child in a group of 5
• Currently Grade 1 student
• Patient lives with father and grandmother in Masbate where mother resides in Metro Manila
F. PHYSICAL EXAMINATION AND ASSESSMENT
A. General Survey
• Carried by mother
• Not in cardio-respiratory distress
B. Initial Vital Signs
• B/P: 100/60 mmHg
• RR: 25 cpm
• PR: 107 bpm
• Temp: 37.6 °C
C. Other Physical Findings
• (+) LOM of the right hip towards all planes
• (+) tenderness on right hip
• Prominence of right hip
• Leg length discrepancy right shorter than left

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S: Inability to ambulate
O: Right hip fixed in flexion, adduction
(+) LOM of right hip towards all planes
(+) Leg length discrepancy right shorter than left
A: Posterior Hip Dislocation Right
P: for BST (balance skeletal traction) right to aid reduction
VII. THEORETICAL FRAMEWORK
Erik Erikson's Theory of Psychosocial Development Theory
Erik Erikson's theory of psychosocial development is one of the best-known theories of
personality in psychology. Much like Sigmund Freud, Erikson believed that personality develops in a
series of stages. Unlike Freud's theory of psychosexual stages, Erikson's theory describes the impact of
social experience across the whole lifespan.

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One of the main elements of Erikson's psychosocial stage theory is the development of ego
identity. Ego identity is the conscious sense of self that we develop through social interaction.
According to Erikson, our ego identity is constantly changing due to new experiences and information
we acquire in our daily interactions with others. In addition to ego identity, Erikson also believed that
a sense of competence motivates behaviors and actions. Each stage in Erikson's theory is concerned
with becoming competent in an area of life. If the stage is handled well, the person will feel a sense of
mastery, which is sometimes referred to as ego strength or ego quality. If the stage is managed poorly,
the person will emerge with a sense of inadequacy.
In each stage, Erikson believed people experience a conflict that serves as a turning point in
development. In Erikson's view, these conflicts are centered on either developing a psychological
quality or failing to develop that quality. During these times, the potential for personal growth is high,
but so is the potential for failure.
Psychosocial Stage 1 - Trust vs. Mistrust
 The first stage of Erikson's theory of psychosocial development occurs between birth and one
year of age and is the most fundamental stage in life.
 Because an infant is utterly dependent, the development of trust is based on the dependability
and quality of the child's caregivers.
 If a child successfully develops trust, he or she will feel safe and secure in the world.
Caregivers who are inconsistent, emotionally unavailable, or rejecting contribute to feelings of

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mistrust in the children they care for. Failure to develop trust will result in fear and a belief that
the world is inconsistent and unpredictable.
Psychosocial Stage 2 - Autonomy vs. Shame and Doubt
 The second stage of Erikson's theory of psychosocial development takes place during early
childhood and is focused on children developing a greater sense of personal control.
 Like Freud, Erikson believed that toilet training was a vital part of this process. However,
Erikson's reasoning was quite different than that of Freud's. Erikson believe that learning to
control one's bodily functions leads to a feeling of control and a sense of independence.
 Other important events include gaining more control over food choices, toy preferences, and
clothing selection.
 Children who successfully complete this stage feel secure and confident, while those who do
not are left with a sense of inadequacy and self-doubt.
Psychosocial Stage 3 - Initiative vs. Guilt
 During the preschool years, children begin to assert their power and control over the world
through directing play and other social interactions.
 Children who are successful at this stage feel capable and able to lead others. Those who fail to
acquire these skills are left with a sense of guilt, self-doubt, and lack of initiative.
Psychosocial Stage 4 - Industry vs. Inferiority

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 This stage covers the early school years from approximately age 5 to 11.
 Through social interactions, children begin to develop a sense of pride in their
accomplishments and abilities.
 Children who are encouraged and commended by parents and teachers develop a feeling of
competence and belief in their skills. Those who receive little or no encouragement from
parents, teachers, or peers will doubt their abilities to be successful.
Psychosocial Stage 5 - Identity vs. Confusion
 During adolescence, children explore their independence and develop a sense of self.
 Those who receive proper encouragement and reinforcement through personal exploration will
emerge from this stage with a strong sense of self and a feeling of independence and control.
Those who remain unsure of their beliefs and desires will feel insecure and confused about
themselves and the future.
Psychosocial Stage 6 - Intimacy vs. Isolation
 This stage covers the period of early adulthood when people are exploring personal
relationships.
 Erikson believed it was vital that people develop close, committed relationships with other
people. Those who are successful at this step will form relationships that are committed and
secure.

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 Remember that each step builds on skills learned in previous steps. Erikson believed that a
strong sense of personal identity was important for developing intimate relationships. Studies
have demonstrated that those with a poor sense of self tend to have less committed
relationships and are more likely to suffer emotional isolation, loneliness, and depression.
Psychosocial Stage 7 - Generativity vs. Stagnation
 During adulthood, we continue to build our lives, focusing on our career and family.
 Those who are successful during this phase will feel that they are contributing to the world by
being active in their home and community. Those who fail to attain this skill will feel
unproductive and uninvolved in the world.
Psychosocial Stage 8 - Integrity vs. Despair
 This phase occurs during old age and is focused on reflecting back on life.
 Those who are unsuccessful during this stage will feel that their life has been wasted and will
experience many regrets. The individual will be left with feelings of bitterness and despair.
 Those who feel proud of their accomplishments will feel a sense of integrity. Successfully
completing this phase means looking back with few regrets and a general feeling of
satisfaction. These individuals will attain wisdom, even when confronting death.
Based on Erickson’s psychosocial developmental theory, R.T. in early school years classified
under Industry vs. Inferiority which explains that the most important event are through social

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interactions, that children begin to develop a sense of pride in their accomplishments and abilities. And
develop a feeling of competence and belief in their skills. Those who receive little or no
encouragement from parents, teachers, or peers will doubt their abilities to be successful.
In the case of R.T., because of social interactions to his peers his sense of pride to do
accomplishments and to prove his abilities he climb a high alateris tree.
VIII. 13 Areas of Assessment
I. Social Status
Demographic Data
R.T. is an 8-year old male, currently an elementary grade 1 student Born on February
4, 2004. He is the second child of the group of five. The family resides in Masbate City but his

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mother is currently working in metro manila
She has 5 offspring, 2 are working already while the remaining are still studying.
Socio-Economic Factor
R.T. belongs in an extended family, Roman Catholic and currently a grade 1 student,
while his father is a construction worker and his mother is a “kasambahay” residing in Metro
Manila. Their family income is 11,000.00 pesos below per month which according
to his father, it is just enough to meet their basic needs and sometimes it lacks.
Environmental Factor
R.T. resides in a medium size house made up of concrete and some plywood with 1
small room and 2 small windows, 1 in the kitchen and 1 in “sala” which resulted to poor
ventilation. The house is located in a congested area in Masbate. Artesian well is their primary
source of water. Their excreta disposal is with water carriage.
Erick Erickson’s Psychosocial Development Theory
Psychosocial Stage 4 - Industry vs. Inferiority
 This stage covers the early school years from approximately age 5 to 11.
 Through social interactions, children begin to develop a sense of pride in their
accomplishments and abilities.

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 Children who are encouraged and commended by parents and teachers develop
a feeling of competence and belief in their skills. Those who receive little or no
encouragement from parents, teachers, or peers will doubt their abilities to be
successful.
Based on Erickson’s psychosocial developmental theory, R.T. in early school years
classified under Industry vs. Inferiority which explains that the most important event are
through social interactions, that children begin to develop a sense of pride in their
accomplishments and abilities. And develop a feeling of competence and belief in their skills.
Those who receive little or no encouragement from parents, teachers, or peers will doubt their
abilities to be successful.
In the case of R.T., because of social interactions to his peers his sense of pride to do
accomplishments and to prove his abilities he climb a high alateris tree.
II. Mental Status
R.T. is conscious and coherent, oriented to time and date, he is a grade 1 student and is able to
read and write and follow instructions, able to maintain eye to eye contact. He is open is such a way
that he will cry when he is hungry, thirsty and something that is aching, he just nod when we ask him.

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But he is unable to converse thoroughly with the student nurses because of language barrier, but he
understands common “Tagalog”.
During assessment and interview, his father will translate all our questions about what really
happened to him and he will able to tell the story, then his father will again translate. This shows that
his memories are still intact.
III. Emotional Status
Prior to hospitalization, according to the father of R.T., he is very cheerful; he loves to play
with his neighbor children, brothers and sisters.
After the accident, the first 5 days of hospitalization R.T. became very irritable and always
cries due to pain, and can’t able to talk as stated by the father.
IV. Sensory Perception
Vision
In assessing the vision, patient is instructed to look straight to observe the general
appearance of his eyes.
 Eyes are almond in shape, irises are brownish in color, and scleras are whitish in color,
eyebrows and eyelashes are equally distributed. His conjunctiva is pale and moist.
 With the use of a penlight. Pupils are assessed; Pupils are equally round and reactive to
light accommodation. The patient does not use eyeglasses or contact lenses.

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 Visual acuity is assessed by asking the patient to read the “bisaya” word written in a
piece of paper with a approximately font size of 12 about 3 feet away from him, using
the right eye first then left eye and then both eyes. Then test was repeated but this time
it will be only 1 foot away from him using the same procedure. Different words were
use written in different paper in every test. R.T. read all the samples during the test.
Smell
 Client’s nose has no deviation in terms of shape and size; nose is pointed and with
some discharges was seen during assessment due to his cold.
 Before the next procedure, permission was asked to the father of our patient, using a
peel of orange, without the patient’s knowledge, we ask him to identify the sample by
smelling. After smelling he did not identified the fruit.
 Test shows that there are obstructions identified in the sense of smell.
Hearing
 General appearance of R.T.’s ears were parallel, symmetrically proportional to the size
of the head, bean shaped, firm cartilage and with a presence of cerumen and in the
outer part it is not clean.
 In assessing the hearing acuity of the patient, R.T. is instructed by his father to
repeat the words that will be whisper at a distance of two feet away on the left ear first,
then right ear after the test, she was able to repeat the whispered words.

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Taste
 Patient’s lips were dry, symmetrical in shape; tongue is whitish in color, there is
presence of tooth decays up and down, and with teeth loss, with signs of gingivitis due
to presence of teeth decays, buccal areas are moist. We assess using a tongue
depressor.
 To assess her sense of taste, Patient is asked to do some test. She was asked
to taste a pinch of sugar without knowing the sample is. After the test R.T. identified
the sample correctly as he stated “matam-is”.
Touch
 In assessing patient’s sense of touch, he was asked to close his eyes, and a piece of wet
cloth was stroke to his upper extremities, and he stated “matugnaw!” that he felt a
sensation of wet and cold on his skin.
V. Motor Ability
 Before the accident, R.T. was an active child that he could do things that any other
children do. He actually walks meters by meters everyday to go to school.
 In present situation, he is in Balance Skeletal Traction (BST) so when we instructed
him to move his lower extremities and do isometric exercise (e.g. moving the fingers of
the affected toe and relax and contract of the affected leg) but before that, we instructed
first to do it on his unaffected leg.

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VI. Temperature
Date Time Temperature Location
August 14, 2012 2: 00 pm 38.7 ‘C axilla
August 16, 2012 2:00 pm 36.6 ‘C axilla
 R.T. was febrile on August 14, 2012; temperature is at 38.7 ‘C taken at Right axilla. And on
August 16, 2012 R.T. was afebrile with 36.6 ‘C also taken at Right axilla.
VII. Respiratory Status
Date Time RR cpm
August 14, 2012 2: 00 pm 24
August 16, 2012 2:00 pm 17
 On the first day of assessment, his chest expansion was symmetrical. But rhythm pattern is fast
due to his condition, he is febrile and experiencing pain at that moment.
 He has an ineffective airway clearance due to colds that result to an ineffective breathing
pattern.
 Lungs were auscultated for adventitious sounds, after auscultation, no adventitious sounds
were heard.
 Second day of assessment, his chest expansion was symmetrical. Rhythm pattern is regular.

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VIII. Circulatory Status
Date Time PR bpm
August 14, 2012 2: 00 pm 79
August 16, 2012 2:00 pm 68
 Taken at radial pulse, her capillary refill is within 2-3 seconds taken at right forefinger, and as
indicated to his chart he is prescribed with ferrous sulfate and undergoing a nutritional program
to manage malnutrition.
 Pulse is not easily palpable.
Blood Pressure
Date Time BP
August 14, 2012 2: 00 pm 90/60
August 16, 2012 2:00 pm 100/70
 Blood pressure was taken at his left brachial artery, negative for peripheral edema.
IX. Nutritional Status
As we interview the father of R.T. he claimed that sometimes they just eat once a day only and
if lucky, twice a day. Their normal viand is noodles. And as R.T. is in school, he always eats
“chichiria” even when he is at home.
 Weight: 33 Lbs/ 15 Kg

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 Height: 45 Inches
Formula:
BMI = (Weight in Pounds / (Height in inches²) x 703
Computation:
BMI =33lbs/ (45inches²) x 703
BMI = (33lbs/2025 inches) x 703
BMI =0.0162963 x 703
BMI = 11.46
BMI Categories:
 Underweight = <18.5
 Normal weight = 18.5–24.9
 Overweight = 25–29.9
 Obesity = BMI of 30 or greater
Therefore, R.T. with a BMI of 11.46 is under the category of underweight.
X. Elimination Status
 R.T. according to his father he defecates once a day without difficulty. He urinates 4 to 5 times
a day. In his urinalysis urine is yellow in color transparency is hazy.
 During assessment he is diaper due to his condition and he is in balance skeletal traction.
XI. Reproductive System

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According to the father of R.T. he is not yet circumcised.
XII. Physical Rest and Comfort
 Before hospitalization R.T. sleeps before 7 pm because they have no electricity and
wakes up at 5 am to prepare to for school at 6 am.
 During hospitalization, most of the time R.T. is as sleeps due to no other activities to
do.
XIII. State of skin and appendages
Skin
As we assessed R.T. he has poor skin turgor, dry and dark in color.
Hair
Presences of dandruff were seen during assessment, no lice were seen, and
patient has thin short straight hair.
Nails
During the assessment, nails are bluish and pale in color, no signs of clubbing,
no excess nor lacking.
Extremities
The patient was assessed for edema or any inflammation in the affected area.
IX. ANATOMY AND PHYSIOLOGY

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Region
The bones of the hip region are the hip bone (or innominate bone) and the femur (or thigh bone).
 Prominent palpable bony structures of the hip bone include the iliac crest, the anterior superior
(ASIS) and posterior superior iliac spines (PSIS), the posterior inferior iliac spine (PIIS), the

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five or so tubercles and the lower lateral borders of the sacrum, and the ischial tuberosity
("sitting bone").
 Proximally the femur is largely covered by muscles and, as a consequence, the greater
trochanter is often the only palpable bony structure. Distally on the femur some more palpable
bony structures are the condyles.
Articulation
Radiograph of a healthy human hip joint
The hip joint is a synovial joint formed by the articulation of the rounded head of the femur
and the cup-like acetabulum of the pelvis. It forms the primary connection between the bones of the
lower limb and the axial skeleton of the trunk and pelvis. Both joint surfaces are covered with a strong
but lubricated layer called articular hyaline cartilage. The cuplike acetabulum forms at the union of
three pelvic bones — the ilium, pubis, and ischium. The Y-shaped growth plate that separates them,
the triradiate cartilage, is fused definitively at ages 14–16. It is a special type of spheroidal or ball and
socket joint where the roughly spherical femoral head is largely contained within the acetabulum and
has an average radius of curvature of 2.5 cm. The acetabulum grasps almost half the femoral ball, a
grip augmented by a ring-shaped fibrocartilaginous lip, the acetabular labrum, which extends the joint

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beyond the equator. The head of the femur is attached to the shaft by a thin neck region that is often
prone to fracture in the elderly, which is mainly due to the degenerative effects of osteoporosis.
Muscles and movements
The hip muscles act on three mutually perpendicular main axes, all of which pass through the
center of the femoral head, resulting in three degrees of freedom and three pair of principal directions:
Flexion and extension around a transverse axis (left-right); lateral rotation and medial rotation around
a longitudinal axis (along the thigh); and abduction and adduction around a sagittal axis (forward-
backward) ; and a combination of these movements (i.e. circumduction, a compound movement in
which the leg describes the surface of an irregular cone). It should be noted that some of the hip
muscles also act on either the vertebral joints or the knee joint, that with their extensive areas of origin
and/or insertion, different part of individual muscles participate in very different movements, and that
the range of movement varies with the position of the hip joint. Additionally, the inferior and superior
gemelli may be termed triceps coxae together with the obturator internus, and their function simply is
to assist the latter muscle.
The movement of the hip joint is thus performed by a series of muscles which are here
presented in order of importance with the range of motion from the neutral zero-degree position
indicated:
 Lateral or external rotation (30° with the hip extended, 50° with the hip flexed): gluteus
maximus; quadratus femoris; obturator internus; dorsal fibers of gluteus medius and minimus;
iliopsoas (including psoas major from the vertebral column); obturator externus; adductor
magnus, longus, brevis, and minimus; piriformis; and sartorius.

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 Medial or internal rotation (40°): anterior fibers of gluteus medius and minimus; tensor fascia
latae; the part of adductor magnus inserted into the adductor tubercle; and, with the leg
abducted also thepectineus.
 Extension or retroversion (20°): gluteus maximus (if put out of action, active standing from a
sitting position is not possible, but standing and walking on a flat surface is); dorsal fibers of
gluteus medius and minimus; adductor magnus; and piriformis. Additionally, the following
thigh muscles extend the hip: semimembranosus, semitendinosus, and long head of biceps
femoris.
 Flexion or anteversion (140°): iliopsoas (with psoas major from vertebral column); tensor
fascia latae, pectineus, adductor longus, adductor brevis, and gracilis. Thigh muscles acting as
hip flexors: rectus femoris and sartorius.
 Abduction (50° with hip extended, 80° with hip flexed): gluteus medius; tensor fascia latae;
gluteus maximus with its attachment at the fascia lata; gluteus minimus; piriformis; and
obturator internus.
 Adduction (30° with hip extended, 20° with hip flexed): adductor magnus with adductor
minimus; adductor longus, adductor brevis, gluteus maximus with its attachment at the gluteal
tuberosity; gracilis(extends to the tibia); pectineus, quadratus femoris; and obturator externus.
Of the thigh muscles, semitendinosus is especially involved in hip adduction.
Capsule
The capsule attaches to the hip bone outside the acetabular lip which thus projects into the capsular
space. On the femoral side, the distance between the head's cartilaginous rim and the capsular
attachment at the base of the neck is constant, which leaves a wider extracapsular part of the neck at
the back than at the front. The strong but loose fibrous capsule of the hip joint permits the hip joint to

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have the second largest range of movement (second only to the shoulder) and yet support the weight of
the body, arms and head.
The capsule has two sets of fibers: longitudinal and circular.
 The circular fibers form a collar around the femoral neck called the zona orbicularis.
 The longitudinal retinacular fibers travel along the neck and carry blood vessels.
Ligaments
The hip joint is reinforced by five ligaments, of which four are extracapsular and one
intracapsular.
The extracapsular ligaments are the iliofemoral, ischiofemoral, and pubofemoral ligaments
attached to the bones of the pelvis (the ilium, ischium, and pubis respectively). All three strengthen the
capsule and prevent an excessive range of movement in the joint. Of these, the Y-shaped and twisted
iliofemoral ligament is the strongest ligament in the human body. In the upright position, it prevents
the trunk from falling backward without the need for muscular activity. In the sitting position, it
becomes relaxed, thus permitting the pelvis to tilt backward into its sitting position. The ischiofemoral
ligament prevents medial rotation while the pubofemoral ligament restricts abduction in the hip joint.
The zona orbicularis, which lies like a collar around the most narrow part of the femoral neck, is
covered by the other ligaments which partly radiates into it. The zona orbicularis acts like a buttonhole
on the femoral head and assists in maintaining the contact in the joint.
The intracapsular ligament, the ligamentum teres, is attached to a depression in the acetabulum
(the acetabular notch) and a depression on the femoral head (the fovea of the head). It is only stretched
when the hip is dislocated, and may then prevent further displacement. It is not that important as a

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ligament but can often be vitally important as a conduit of a small artery to the head of the femur. This
arterial branch is not present in everyone but can become the only blood supply to the bone in the head
of the femur when the neck of the femur is fractured or disrupted by injury in childhood.
Blood Supply
The hip joint is supplied with blood from the medial circumflex femoral and lateral circumflex
femoral arteries, which are both usually branches of the deep artery of the thigh(profunda femoris), but
there are numerous variations and one or both may also arise directly from the femoral artery. There is
also a small contribution from a small artery in the ligament of the head of the femur which is a branch
of the posterior division of the obturator artery, which becomes important to avoid avascular necrosis
of the head of the femur when the blood supply from the medial and lateral circumflex arteries are
disrupted (e.g. through fracture of the neck of the femur along their course).
The hip has two anatomically important anastomoses, the cruciate and the trochanteric
anastomoses, the latter of which provides most of the blood to the head of the femur. These
anastomoses exist between the femoral artery or profunda femoris and the gluteal vessels.
X. PATHOPHYSIOLOGY
Risk factors:
 Age
 Gender
 Weakness (malnutrition)
 Lack of safety
education/precaution
Etiologic/causative factors
Accident caused by:
 High alateris tree

30

31
XI. NURSING MANAGEMENT
A. Laboratory Test
Name: R.T. Lab no. 61 Date: 08/12/2012
COMPONENT RESULT NORMAL RANGE COMPONENT RESULT NORMAL RANGE
Hemoglobin Mass (MALE) 140 127-183 g/L INDICES
 MVC
 MCH
 MCHC
98
29
30
82-92 fl
28-32 pg
32-38 %
Hematocrit 0.47 0.37-0.54
Leukocyte Count 37.10 4.5-10 x 109/L
Differential Count
Segmenters 0.94 0.50-0.70 RBC Morphology
Lymphocytes 0.05 0.20-0.40 ESR WESTERGREN METHOD
Monocytes 0.01 0.00-0.07 Children 28 0-10 mm/hr
Reticulocytes 0.5-2.0%
Platelet count 525 150-400x10^9/L
Coagulation Studies
Prothrombin Time 11-15 secs Clotting Time
(Lee & White) 5-15 mins
% activity
INR Bleeding Time
(Ivy’s Method) 1-7 mins
Activated PTT 22-45 secs
Blood Type
RH Typing
CRP Reactive
Semi-quantitative CRP 24 < 6mg/L

32
URINALYSIS

33
B. Nursing Care Plan
ASSESSMENT NURSING
DIAGNOSIS
PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective:
R.T. is crying when
we do bed bathing.
“makulog!”
Objective:
-facial grimace
-guarding behaviour
-Pain Scale of 6
-Respiratory Rate: 24
- Acute pain r/t
dislocation of
right posterior hip
with
inflammation
After 4 hours
of nursing
intervention
patient will
decrease pain
from pain scale
of 6 to 4.
- determine and document
presence of possible
cause/s of pain.
** Inflammation in the
affected site.
- Observe signs of
inflammation in the
affected site.
-Monitor client’s vital
signs.
-provide comfort measures
-collaborate in treatment of
underlying condition
causing pain and proactive
management of pain. Give
analgesic (ibuprofen) as
prescribed by the physician
- To rule out worsening
of underlying condition
- Observations may or
may not be congruent
with verbal reports
indicating need for
further evaluation and an
indication of infections.
- Vital signs usually
altered in acute pain.
-repositioning and
providing quiet
environment promotes
nonpharmacoligal pain
management
-for the management of
pain.
After 4 hours of
nursing intervention
patient decreased
pain from pain scale
of 6 to 4.
Goal was met.

34
ASSESSMENT NURSING
DIAGNOSIS
PLANNING INTERVENTIONS RATIONALE
SUBJECTIVE:
“pangalawang araw
nya nang nilalagnat”
as verbalized by the
father of the patient.
OBJECTIVE:
Temp: 38.7 °c
RR: 24 cpm
Warm to touch
Flushed skin
Hyperthermia r/t
inflammation on site
of the dislocation.
After 1 of
nursing
intervention
patient’s
temperature will
decrease from
38.7°c to 36.5°c
-maintain bed rest
-promote surface cooling by
means of tepid sponge bath
-record all sources of fluid loss
such as urine, vomiting and
diarrhea
- Evaluate the affected leg for
inflammation or edema.
-administer antipyretic
(paracetamol) as prescribed by
doctor
-to reduce metabolic demands and
oxygen consumption
-to decrease temperature by means
through evaporation and conduction
-to monitor fluid and electrolyte loses
- Observations may or may not be
congruent with verbal reports indicating
need for further evaluation and an
indication of infections.
-to facilitate fast recovery

35
C. Drug Study
Generic
name
Brand
Name
Classific
ation
Indication Contraindicati
on
Mechanism
Of action
Adverse reaction Nursing
considerations
Co-
amoxiclav
: 312.5
mg/5mL
8mL q12h
x 7days
Amoclav Bacterici
dal
Lower
respiratory
tract
infections,
otitis media,
sinusitis, skin
& soft tissue
infections,
UTI, pre &
post-surgical
procedures,
bone & joint,
O & G
infections,
dental
infections.
History of
penicillin
hypersensitivity
.
Superinfections
involving
Pseudomonas or
candida.
Pregnancy &
lactation
Inhibits enzymes
involved in
formation of
peptidoglycan
layer of bacterial
cell wall
No effect on
human cell walls
Bactericidal; only
works on dividing
bacteria
Well absorbed
enterally
Clavulanic acid
inhibits bacterial
ß-lactamase
Allergic reactions
- itching, rashes,
fever
-
angioneuroticoedema
- anaphylaxis (1 in
50,000 to 100,000)
Cross-allergy with
other penicillins
Partial cross-allergy
with cephalosporins
(10%)
Hepatitis, cholestatic
jaundice
Erythema multiforme
(including Stevens-
Johnson)
Toxic epidermal
necrolysis;
exfoliative dermatitis
Diarrhea, vomiting
Rashes
Neutropenia
Anaemia
- Patients must
ensure they take the
full course of the
medicine.
- Assess respiratory
status.
- Observe for
anaphylaxis.
- Ensure that the
patient has adequate
fluid intake during
any diarrhea attack.
- The medicine must
be taken in equal
doses around the
clock to maintain
level in the blood.

36
Generic
Name
Classification Mechanism
of Action
Specific
Indication
Side Effects Nursing Implications
Acetaminophen
(Paracetamol)
250mg/5ml
8ml q4h PRN
for temperature
≥ 37.8°C
antipyretics,
nonopioid
analgesics
Inhibits the
synthesis of
prostaglandins
that may serve as
mediators of pain
and fever,
primarily in the
CNS
Mild pain
Fever
Hema: hemolytic anemia,
neutropenia, leukopenia,
pancytopenia.
Hepa: jaundice
Metabolic: hypoG
GI: HEPATIC FAILURE,
HEPATOTOXICITY
(overdose)GU: renal failure
(high doses/chronic use).
Derm: rash, urticaria.
BEFORE:
~ Advise parents or caregivers to
check concentrations of liquid
preparations. Errors have resulted
in serious liver damage.
~ Assess fever; note presence of
associated signs (diaphoresis,
tachycardia, and malaise).
DURING:
~ Adults should not take
acetaminophen longer than 10
days and children not longer than
5 days unless directed by health
care professional.
~ Advise mother or caregiver to
take medication exactly as
directed and not to take more than
the recommended amount.
AFTER:
~ Advise patient to consult health
care professional if discomfort or
fever is not relieved by routine
doses of this drug or if fever is
greater than 39.5°C (103°F) or
lasts longer than 3 days.

37
Drug name Action Indication Adverse effects Contraindication
Nursing
Responsibility
Ibuprofen
210mg/5mL
8mL BID
PRN for
pain
Unknown
. May
inhibit
prostagla
ndin
synthesis,
to
produce
anti-
inflamma
tory,
analgesic,
and
antipyreti
c effects.
Ibuprofen
contains the active
ingredient
ibuprofen, which
belongs to a group
of medicines
called non-
steroidal anti-
inflammatory
drugs (NSAIDs).
It works by
blocking the action
of a substance in
the body called
cyclo-oxygenase.
Cyclo-oxygenase
is involved in the
production of
various chemicals
in the body, some
of which are
known as
prostaglandins.
Ibuprofen is
therefore used to
relieve pain and
inflammation.
CNS
 Headache, dizziness,
nervousness, aseptic meningitis.
CV
 Peripheral edema, fluid
retention, edema.
EENT
 Tinnitus
GI
 Epigastric distress, nausea,
occult blood loss, peptic
ulceration, diarrhea, constipation,
abdominal pain, bloating, GI
fullness, dyspepsia, flatulence,
heartburn, decreased appetite.
GU
 Acute renal failure, azotemia,
cystitis, hematuria.
HEMATOLOGIC
 Plonged bleeding time, anemia,
neutropenia, pancytopenia,
thrombocytopenia, aplastic
anemia, leucopenia,
agranulocystocis.
METABOLIC
 Hypoglycemia, hyperkalemia.
RESPIRATORY:
 Bronchospasm
SKIN
 Pruritus, rash, urticaria, stevens
Johnson syndrome.
 Contraindicated in
patients
hypersensitive to
drug and in those
with angioedema,
syndrome of nasal
polyps, or
bronchospastic
reaction to aspirin
or other NSAIDs.
 Contraindicated in
pregnant women.
 Use cautiously in
patients with GI
disorders, history of
peptic ulcer disease,
cardiac
decompensation,
hypertension,
asthma, or intrinsic
coagulation defects.
 Tell patient to take with meals
or milk to reduce adverse GI
reactions.
 Note: Drug is available at
OTC. Instruct patient not to
exceed 1.2 g daily, and not to
take for extended periods (
longer than 3 days for fever or
longer than 10 days for pain)
without consulting presciber.
 Teach patient to watch for and
report to prescriber
immediately signs and
symptoms of GI bleeding,
including blood in vomit,
urine, or stool or coffee
ground vomit, and black, tarry
stool.
 Warn patient to avoid
hazardous activities that
require mental alertness until
effects on CNS are known.
 Advise patient to wear
sunscreen to avoid
hypersensitivity to sunlight.

38
Name of Drug Classification Mechanism of
Action
Adverse Reaction Special Consideration Nursing Responsibilities
Generic Name:
Ceftriaxone
500mg IV q8
ANST (-)
Antimicrobial
and Antiparasitic
-Inhibits bacterial
cell wall synthesis,
rendering cell wall
osmotically unstable,
leading to cell death
Indications:
-Treatment of LRIT
(e.g. bronchitis,
pneumonia,
bronchopneumonia,
emphysema, lung
abscess), skin and
soft tissue infections.
Pre-operative
prophylaxis to reduce
chance of post-
operative surgical
infections.
-Leukopenia, serum
sickness,
anaphylaxis.
Side Effects:
-Phlebitis, rash,
diarrhea, vomiting.
-Use with caution in patients
with history of
gastrointestinal disease.
Nephrotoxicity has been
reported following
concomitant administration
with aminoglycosides.
Contraindications:
-Hypersensitivity to
cephalosporins and
penicillins, lidocaine or any
other local anaesthetic
product of the amide type.
-Instruct patient to take
medication as prescribed
for the length of time
ordered even if he feels
better.
-Teach patient to report
sore throat, bruising,
bleeding and joint pain.
-Advise patient to watch
out for perineal itching,
fever, malaise, redness,
pain, swelling, rash
diarrhea.

39
Drug name Action / classification Indication Contraindication Nursing responsibility
Trade name :
Salbutamol Neb
Generic name:
Albuterol Sulfate
q6
In low doses, acts
relatively selectively at
beta 2 – adrenergic
receptors to cause
bronchodilation and
vasodilation; at higher
doses, beta 2 selectivity
is lost, and the drug acts
at beta 2 receptors to
cause typical
sympathomimetic
cardiac effect.
Anti asthmatic
 Relief and
prevention of
brochospasm in
patients with
reversible
obstructive airway
disease.
 Inhalation:
treatment of acute
attacks of
bronchospasm.
 Prevention of
exercise-induced
bronchospasm.
 Unlabeled use:
adjunct in treating
serious
hyperkalemia in
dialysis patients;
seems to lower
potassium
concentration when
inhaled by patients
on hemodialysis.
 Contraindicated
with
hypersensitivity to
albuterol;
tachyarrhythmias,
tachycardia cause
by digitalis
intoxication.
 Use cautiously
with diabetes
mellitus;
hyperthyroidism,
history of seizure
disorders.
 Observe 10 rights in
giving medications
 Use minimal doses for
minimal periods; drug
tolerance can occur with
prolonged used.
 Prepare solution for
inhalation by diluting 0.5
ml 0.5% solution with 2.5
ml normal saline ; deliver
over 5 – 15 minuts by
nebulization.
 Do not exceed the
recommended dosage;
administer pressurized
inhalation drug forms
during second half of
inspiration, because the
airways are open wider
and the aerosol
distribution is more
extensive.

40
Name of Drug Classification Adverse effect Indication Contraindication Nursing Consideration
Ascorbic acid
syrup
8mL OD daily
Vitamins GI: Nausea,
vomiting,
heartburn, diarrhea.
Hematologic:
Acute hemolytic
anemia (patients
with deficiency of
G6PD); sickle cell
crisis. CNS:
Headache (high
doses). Urogenital:
Urethritis, dysuria,
crystalluria (high
doses). Other:
Mild soreness at
injection site;
dizziness and
temporary faintness
with rapid IV
administration.
Prophylaxis and
treatment of
scurvy and 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
on sodium restriction;
use of calcium
ascorbate in patients
receiving digitalis.
Safety during
pregnancy (category
C) or lactation is not
established.
Assessment & Drug Effects
 Lab tests: Periodic Hct &
Hgb, serum electrolytes.
 Monitor for S&S of
acute hemolytic anemia,
sickle cell crisis.
Patient & Family
Education
Take large doses of vitamin
C in divided amounts
because the body uses only
what is needed at a particular
time and excretes the rest in
urine.
 Megadoses can interfere
with absorption of
vitamin B12.
Note: Vitamin C increases the
absorption of iron when taken at
the same time as iron-rich foods.

41
Drug Name and Dosage Drug Classification and
Action/s
Indication Nursing Consideration/s
Iron
Brandnames:
Ferrous sulfate syrup 8ml
BID x 7 days
*Mineral for antianemia
*Vital for hemoglobin
regeneration, specifically it
enables the RBC development
and oxygen transport via
hemoglobin
*Pharmacokinetics:
Absorption:5-30%intestines
Distribution: PB:UK
Metabolism: t½: Uk
Excretion: Urine, feces, bile
*Pharmacodynamics:
PO Onset: 4 days
Peak: 7-14 days
Duration: 3-4 mos
*To prevent and treat
iron deficiency anemia
*Contraindicated in clients with
hemolytic anemia, Peptic ulcer and
Ulcerative colitis
*Administer vitamins with food to
prevent GI upset.
*Caution on intake of chamomile,
feverfew, peppermint and St. John’s
wort for it interferes with the
absorption of iron and other
minerals.
*Increadead effect of iron with
viatmin C; decreaded effect of
tetracycline, antacids, penicillamine
*Inform clients of side-effects like
nausea and vomiting, diarrhea,
constipation,epigastric pain and
refer to the attending nurse upon
occurrence for management.
*Monitor for adverse reactions like
pallor and drowsiness.

42
XII. DISCHARGE PLANNING/ PROGNOSIS
MEDICATIONS
 Co-amoxiclav 312.5 mg/5mL q12h x 7 days
 Ibufrofen 210 mg/5 mL for pain
 Paracetamol 250mg/5mL q4h PRN
 Ascorbic Acid syrup 8mL OD daily
 Ferrous Sulfate syrup 8mL BID daily
EXERCISE
 Deep breathing exercise ( can use every time in repositioning)
 Isometric exercise in lower extremities
TREATMENT
 antibiotic as prescribed by the doctor
 BST (balance skeletal traction)
HEALTH TEACHINGS
 Isometric exercise everyday for good blood circulation and reduce muscles spasms.
 Provide information about limitations and restrictions of active mobility.

43
 Instruct the patient to maintain good personal hygiene to avoid possible infection in the
infected area also for prevention of other complications.
OUT-PATIENT
 Continuous compliance to medications, treatment and drug regimen given by doctors
 Advised to continue with isometric exercises which are recommended to improve blood
circulation and reduce muscle spasms.
 Remind the client to return to the nearest orthopedic center for a follow-up visit
DIET
 Patient was ordered to take some vitamins.
o Ascorbic acid syrup 8mL OD daily
o Ferrous Sulfate syrup 8mL BID x 7days
 Patient is under nutritional program to manage the malnutrition.
SPIRITUALITY
 Strengthen faith in God.
Homework Help
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