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Case Study 1
Case Study
Care of Infants and Children Practicum NURS 3051P
Submitted by: Daniel Orji Cheche
Submitted to: Mrs. Cynthia Guild
Submitted on: May 21, 2015
Case Study 2
Table of Contents
Page #
Introduction……………………………………………………………………… 4
Preface…………………………………………………………………………… 5
Data collection/Complete Health History………………………………………. 6
- Bio data- Chief complaints- History of present illness- Medical history- Family history- Lifestyle- Socioeconomic history- Environmental history- Psychological- Complete Physical Assessment
Analysis of Data Collected-…………………………………………………… 10
- Gordon’s Typology of 11 Functional Health Patterns*Health perception/Health Management*Nutritional/Metabolic*Elimination*Activity/Exercise*Cognitive/Perceptual*Roles/Relationships*Self-Perception/Self concept*Coping/Stress*Value/Belief*Medication/History*Nursing Physical assessment
- Comparing the data………………………………………………. 14
- Actual and potential problems……………………………………. 18
Implementation/Evaluation…………………………………………………… 17
- Nursing Care Plan- Teaching Plan
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Recommendations……………………………………………………………… 22
Appendix A…………………………………………………………………….. 24
- Bone diagram Fig 1.1- Types of Fractures Fig1.2- Traction Fig 1.3- Traction Fig 1.4- Closed Fracture of femur Fig 1.5- Wong-Baker FACES Pain Rating Scale Fig. 2.1
References……………………………………………………………………….. 26
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Introduction
The skeletal system comprises of all the bones in the body along with the tissues such as
tendons, ligaments and cartilage that connects them. There are four types of bones: long, short
flat, and irregular. The long bones, especially the femur and tibia, are subjected to the most of
the load during activities and are crucial for skeletal mobility.
(http://www.bonefixator.com/long_bone/anatomy_1.html) Bones, joints, cartilages and ligaments
make up the skeletal system. The anatomy of the long bones consists of the diaphysis, epiphysis,
the periosteum metaphysis and epiphyseal growth plate. Fig. 1.1 During childhood, new cartilage
is continuously formed, the older cartilage becomes ossified and bone replaces cartilage. The
process of ossification begins in the embryo and continues until the child is 18 or 21 years old.
Damage to these components of the bone can cause major problems in bone growth and healing
(Hockenberry & Wilson, 2011). A Ffractures is a break in the can be defined as any break in the
continuity of the bon and is defined according to the type and extent. e. Fractures occur when
the bone is subjected to stress greater that it can absorb. Fractures are caused by direct blows,
crushing forces, sudden twisting motions, and even extreme muscle contractions. When the bone
is broken, adjacent structures are also affected, resulting in soft tissue edema, hemorrhage into
the muscles and joints, joint dislocation, ruptured tendons, severed nerves, and damaged blood
vessels. Body organs maybe injured by the force that cause the fracture or by the fracture
fragments.
There are different types of fractures and these include, complete fracture, incomplete
fracture, closed fracture, open fracture and there are also types of fractures that may also be
described according to the anatomic placement of fragments, particularly if they are displaced or
nondisplaced. Such as greenstick fracture, depressed fracture, oblique fracture, avulsion, spinal
fracture, impacted fracture, transverse fracture and compression fracture. Fig 1.2
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Fractures occur when the bone is subjected to stress greater than it can absorb (Smeltzer et al,
2010). Fractures are a common injury at any age, but most likely occur in children and in the
elderly. They can be caused by direct blows, crushing forces, and sudden twisting motions which
can come about from motor vehicle injuries sports or fall from heights. Types of fractures
include: open, closed, incomplete, complete, displaced and comminuted. Fig 1.2 It is manifested
by generalized swelling, pain and tenderness, and limited use to the affected part. X-rays are
used to examine the specific area of the broken bone. Therapeutic management goals are to re-
establish alignment and length of the bony fragment (reduction), to retain alignment and length
(immobilization), to restore function to the injured parts and to prevent further injury
(Hockenberry &Wilson). When bone fragments cannot be reduced with simple traction and
stabilization with a cast, the extended bulling force obtained with continuous traction may be
required. The use of traction is the direct application of such forces to produce equilibrium to the
fracture site. A forward force (traction) is produced by attaching weight to the distal bone
fragment. This force is balanced by the backward force of the muscle pull (countertraction) and
the frictional force between the patient and the bed (Hockenberry & Wilson, 2011). (Fig 1.3 and
1.4)
By choosing this condition as a case study, It is expcted expects to broaden my
knowledge understanding and management of fracture, not just for the fulfillment of the course
requirements in pediactric nursing. It is very important for nurses in general to be adequately
informed regarding the knowledge and skill in managing these condition. Through the
knowledge acquired with this study of this condition, a higher quality of care will be provided to
minors suffering from it.
Case Study 6
Preface
I would like to thank the Ana Jacqueline P.’s parents mother and Ana Jacqueline P.
herself for letting allowing me do a case study based on her injury pf her fractured femur. I
would also like to extend my gratitude to the Pediatric Ward at Karl Heusner Memorial Hospital
(KHMH) at the Pediatric Ward for allowing me to observe and train me to along withhaving
excellentexceptional and capablecompetent nurses who are committed to providing holistic care
to their young patients. It was a great learning experience to be ablve to be working honor
working alongside them and gaining new practical knowledge on Pediatrics and Nnursing care. I
would like to extend my thanks to Mrs. Cynthia Guild for being a motherly and patient instructor
alongside with Ms. Dawn Elliot who guided helped me and mentored me through the practicum
period and assisting me with any and all questions I had in regards to this unit. when I got stuck
in my care plans. I’m coming out of thisfininshg this unit of Pediatric care with new enhanced
knowledge and better capabilities in my nursing skills in order for me to be a good nurse to
children whenever I become certified after my studiesto better myself to become a great nurse.
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I. Data Collection/ Complete Health History
i. Biodata:
Ana Jacqueline P. (Jackie) is a foursix year-old minor female minor residing in Benque Viejo
del Carmen in theBiscayne Village, CayoBelize District. She sought medical help alongside her
motherParents, Mr and Mrs. LP, after being transferred from the San Ignacio Hospital. The
minor is single, with a Catholic upbringing. According to her mother, whenever they are in need
of medical care, they would normally usually go to Benque Ladyville Healthcare Cener
Polyclinic where it is her husband who takes care of the medical bills whenever there is a
medical problem with the family.
ii. Chief complaint
LS’s Jackie’s reason to be at the Karl Heusner Memorial Hospital is because of a closed fracture
to the right femur. Example can be seen in Fig. 1.5
iii. History of Present illness
Mrs. LS P describes that on March Saturday April 182, 20145 her daughter was playing with a
group of children near a tree near their homeanother little girl, who ran behind her daughter and
pushed her in frontthen she suddenly heard a commotion outside along with someone crying.
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When she went outside, she saw her daughter on the ground crying. When she investigated, she
learnt that her daughter had climb a tree and feel,, causing her to feel intense pain on her right
leg. When she went to get her daughter, tThe child was sprawled rolling on the ground, unable
to get up, with her leg in an abnormal position and crying with pain. It all happened so suddenly.
This is the first time that LS Jackie has a sustained a severe injury or broken bones. Two Any
previous visit to the healthcare center would have been due to immunizations shots or severe
influenza symptoms. years ago, LS twisted her hand but it only needed bandaging and rest. The
complete fracture is located in the right femur. The child stated that the fall “hurt a lot” and that
her leg “looked twistedweird” Her mother described that the site of the injury was really highly
inflamed, bruised and and red. Presently, LS Jackie has traction with weight to help the process
of healing and keep the leg straight. LS Jackie complains of pain to the right leg whenever the
weights are lifted. However, and during the night when she has nightmares and begins to cry.
Presently, she is able to sit up in bed with no pain though.
iv. Medical history
Medical history for this patient goes as follows: In the past, as aforementioned, the patient had
twisted her hand but did not require hospital stay to treat the injury to the handThere has been no
instances in which the patient had sustain any serious injury to her person. Her mother says
explained that she her daughter is not a sickly person and only does not get sick very often, but
catches the flu “once in a whileoccasionally”. When she was admitted at Accident and
&Eergency (A&E), she was given Voltaren 20 mg IV stat and Pethidine 20 mg IV stat.
Diclofenac 18 mg IV was later added by the physician. Currently, LS Jackie is being given
Tylenol suspension 180 mg as needed every 8 hours for pain. All these are pain medications. Her
mother says LS Jackie does not suffer from any allergies she is aware of.
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v. Family history
Mrs. LP P stated that no other member of her family has suffered a fracture like this. She can
only recall her grandfather (LS’s great grandfather) who also had a fractured femur and had to
wear a cast as well. Other than him, none of her immediate family has suffered from broken
bones. The only medical ailments the family sufferes from is high blood pressure from Jackies
father side of the family and diabetes from the mother’s side of the family. However no one in
her immediate family is suffering from this currently.
vi. Lifestyle
On a typical day, LS Jackie wakes up and has breakfast of bread and buttereither cereal or
Belizean style breakfasts of fry jacks, beans, egg and cheese. She attends her local primary
school named kinder gardenBiscayne Government School.During For her school break at
schoolbreaks, she usually takes a sandwichhas sandwich or a piece of local fruit in season at the
time. or cheese dip. For lunch at home she has rice and beansvarious Belizean style lunches,
most commonly Rice and beans with juice and. Finally at for dinner she usually eats beans with
flour tortillas and sometimes accompanied with fried eggs with sausage. As the mother, LP Mrs.
P buys the family groceries and cooks for her family. There is no known food allergy to LS
Jackie according to her. There is no difficulty for LS Jackie to perform her basic activities of
self-care prior to her fractured femur.
vii. Socioeconomic history
Ms. LP confides that she used to believe in the “mal de ojo” or “evil eye” in which a child
presents with on and off fever and to cure this, an egg has to be passed over the child’s body to
“cure” it. She states that she no longer believes in that custom though. LSJackie and her family
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live resides in their own home which was inheried from Mrs. P grandparents some years ago.
given to them by her father. Ms. LPThe mother went to reached up to highschool and worked
for a while before meeting her hustabnd starting started an family, she is a stay at home mother.
Mr. P also went to highschool and currently is employed as a stevedore at Port in Belize City
and has to go to work several days at a time to load off ships. Jackie is currently in primary
school and LS with her other siblings and cousins. is still in kinder garden. She noted that the
village is fairly safe and that murders and robberies are not common in the area where the reside.
also states that their neighborhood is safe. Cases of murder or robbery are not heard around
where she lives. It is very safe. When asked questioned about Jackies care and wellbeing when
she returns home with the injured leg, the mother advised that she will care for it s advise by te
hospital. Also if there is any complications, she will be able to seek assistance from the
Ladyville Heathcare Center. what will happen when LS returns home with her injured leg, she
says that she could always seek medical help at Benque Poly Clinic whenever necessary.
viii. Environmental history
In BenqueBiscayne Village, Mrs. LP says states that they do not have they have potable water.
So most villagers, like themselves have created a “Well pump” to divert water in the home. Also,
for drinking purposes, they have two huge vats which collects rain water on the property but they
drink rain water from their tank. Their bathroom is inside the house with sewage. There are no
complaints of any infestation of rats or insects except for the occasional roach and mosquitoes
present. She states that there is a carpentry shop right next to their house that makes furniture but
makes a lot of noise and saw dust. She is concerned about this for her children at home during
the rainy season due which can causes cases of malaria and dengue. She notes that her husband
would occasionally clear the bushes near their property and clear up any places which can harbor
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the mosquitoes.because she has a baby boy at home still breastfeeding and she doesn’t like him
to inhale the dust from the carpentry shop and have to hear the noise from it. They have already
told the owners to move, but they have yet to do so.
ix. Psychological
Mrs. P advises that she has been receiving emotional and financial support from her family
members along with other village members while staying in the hospital. Family members call
her and little LS every day from the hospital to see how she is doing. Mr. LP checks with the
mother every day to talk with Jackie and provide support to her over the phone. ’s husband calls
every day to talk to his little girl.Since he has to work, Mrs. P has to stay with Jackie during her
stay at KHMH and Mr. P comes and checks during the week on them. Mrs P mother has been
taking care of the other two older children at home while she is caring for Jackie. Since they live
in Benque, only she has been staying with her child but her husband and mother provide support
to her over the phone. Jackie is very eager to return home and recover in order to go back to
school. Her classmates have sents cards and treats to encourage her to get better and return to
school. Therefore, it would seem that the physcological state of Jackie is one that is upbeat, with
exception of the occasional onset pain when the skin traction that will return once ina while.
They own a plantain chips business in which they have to fry chips every day to sell plus the
father works, hence the reason LP is the only one staying with her child at Karl Heusner. LS is
very eager to go home. Every day she shows signs of recovery by being able to sit up in bed
despite the skin traction and cries less. She is a happy child.
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x. Physical assessment of the client (Patient’s mother answered the questions
regarding the physical assessment-subjective data)
Generally, patient maintains good weight and eats well. She has not noticed that LS’s clothes are
getting tighter due to weight gain. She is a fairly healthy child that does not get sick as often as in
the past. Presently she has not gotten any high fevers. Her skin is warm and smooth. She sweats
because the room is hot and the fan does not provide enough breeze. There is itching of the skin
under the bandages and it gets worse when the weather is really hot. Her neck is not stiff or
enlarged and does not hurt. She has no difficulty swallowing. Eyes and ears are healthy
according to mother. No eye vision problems or difficulty hearing. She states that she has taught
her children good hygiene; she brushes her teeth before going to school and going to sleep. She
does not have rotten teeth, no problems with gum bleeding. LS’s breathing is normal and has
never had shortness of breath when she plays or does daily activities. She has never gotten
pneumonia. Her breasts have not started developing yet. She states that she does have shyness
when exposing herself and finds it difficult to change with other patients in the room because
there are not curtains to provide privacy. She has never had any chest pain or discomfort relating
to her cardiovascular assessment. She has good appetite and does not have nausea or vomiting
due to her fractured femur. There is no diarrhea that she has noticed and she has normal bowel
movements. She has not had any fainting spells or headaches. No aches of bones except for the
fractured femur which is swollen and causes pain when moved. Her mother states that LS is a
fairly healthy child with no serious illnesses until now.
ANALYSIS OF DATA COLLECTED
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ORGANIZING THE DATA
1. Gordon’s Typology of 11 Functional Health Patterns
I. Health Perception/Health Management
Patient has generally good health prior to injury. From the interview gathered, patient
does not suffer from allergies with food or medications. Their living environment is
stable, free from harm except for the carpentry shop which is a risk factor for
breathing problems due to the saw dust generated from it. Patient practices good self-
care hygiene, has good relationship with parents and siblings and has a positive
outlook in getting better and going home. Parents have good support systems from
family members to assist with stress of mother being away from home and away from
her other children.
II. Nutritional/Metabolic
Patient has good appetite and tolerates food 100% every day when served. Patient
eats sufficient amount of carbohydrates, lipids and nutrients from 24 hour intake
described by mother during a typical day. She does engage in some snacking but it is
not interfere with her 3 meals a day. She usually drinks about two 1 liter bottles of
water a day. Her sleep/wake normal patterns range from getting up around 7 in the
morning and going to sleep around 8 at night (11 hours of sleep).
III. Elimination
Bowel movements are regular everyday consisting of moist, soft stools. There are no
urine incontinence problems with patient. Presently, LS has to wear pampers because
she cannot move from the bed. Mother changes pampers whenever soiled. Patient
drinks sufficient amount of water every day. Mother says LS has never had UTIs.
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IV. Activity/Exercise
Patient is a 4 year old active child who engages in play whether at home or at her
kinder garden. Mother describes her as an active child who rides her bike at times
under supervision. She is not lethargic when at home. Presently, she is able to move
her left leg and arms and sits up in bed. Range of motion exercises are sometimes
done.
V. Cognitive/Perceptual
LS is a bright child. At the ward, she engages in conversation with mother and with
other patients. She reads books and plays with her toys on the bed. Mother states she
is attending kinder garden and will enter a Nazarene school upon completion of
kinder garden. LS is aware of her fractured leg and responds to questions asked by
nurse and mother.
VI. Roles/Relationships
Patient has strong attachment bond to mother but does not shy away from interaction
with medical staff and other patients and visitors. Seems outgoing and will participate
in play activities initiated by nurse and mother.
VII. Self-Perception/Self concept
Patient seems to be at ease at the ward. Mother states that she is potty trained but at
the moment must urinate and stool in pampers due to skin traction to right leg. She is
able to brush her teeth and comb her hair on her own. Appearance seems calm and
relaxed with no signs of anxiety on her features.
VIII. Coping/Stress
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Patient seems to be coping well to situation. Mother discusses that she feels a little
worried that they have to stay at Karl Heusner. She had previously asked for a
transfer back to the San Ignacio Community Hospital since it is much closer to their
home in Benque. She is also still breast feeding her baby but has been unable to do so
for the past 2 weeks due to her being too far away. Doctor Roberts, LS’s doctor,
informed that the patient could not go back and must stay at Belize City. There is
stress to separation of the mother with the rest of her children. Patient has episodes of
nightmares where she suddenly awakes and starts crying. Mother interprets this as she
remembering the accident. Patient also cries and complains when the leg is in pain or
itches. Patient was assessed using Wong-Baker’s FACES Pain rating scale and scored
a 3 using 0-5 coding. See Fig. 2.1
IX. Value/Belief
Other than old beliefs in the “mal de ojo”, patient and mother do not seem to have
other cultural beliefs. Other health beliefs LP practices is putting on sweaters and
covering the head when the weather gets cold, washing hands after using the
bathroom, practicing good oral hygiene and regular baths. They relate their faith to
the Catholic church and have a strong belief in God.
X. Medication/History
Nil allergies to medication referred by mother. Upon admission to Accident and
Emergency, patient was given Pethidine 20 mg IV stat, and Voltaren 20 mg IV stat.
Currently, patient is being given a Tylenol suspension of 7.5 cc for pain whenever it
is needed. All medications prescribed are pain medications to alleviate swelling and
pain to right leg.
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XI. Nursing Physical assessment
In regards to the physical assessment of LS, patient is conscious and alert lying in supine
position in bed with skin traction to the right leg with weights. With regards to skin, hair and
nails, there is no signs of cyanosis or jaundice. Skin is light brown with even pigmentation.
Skin is warm to touch, firm, smooth and even with no tenting. No scars visible. Hair is brown
and straight which is evenly distributed with no alopecia. The scalp is free of lesions or scars.
Nails have a pink undertone with good capillary refill less than 3 seconds. For the Head, neck
and lymph nodes assessment1s, face is symmetrical with ears aligning with canthus of the
eyes. Smile is even, eyebrows rise equally, no rhythmic bobbing or abnormalities with the
head and neck. There is no swelling of the lymph nodes below the jaw and
sternocleidomastoid upon palpation. Patient has good range of motion of the neck. Thyroid
gland is not enlarged, nil bulges. Eyes and ears assessment tests adequate. Patient is able to
follow the direction of the tip of the pen with eyes only, there is no tenderness when
palpating the eyelids and ears. With regards to the abdomen assessment, abdomen is
symmetrical with nil bulges or masses observed. Umbilicus is protruded. Upon percussion,
dullness is heard over solid organs and hollow sounds over the intestines. Upon palpation,
there is no tenderness voiced by client when doing light and deep palpation. The assessment
of the respiratory system shows that respiration is adequate with symmetric chest rise,
posterior chest has even pigmentation as well as anterior chest. Upon auscultation, breath
sounds are normal with no crackles with good chest expansion. When assessing the
cardiovascular system, the head is kept steady, eyes are not bulging. Lips are pink and not
cyanosed. Oral mucosa pink and hydrated. Ear lobes are smooth with no bilateral earlobe
creases. Fingers are pink and even, nil clubbing observed. Respiratory pattern is even and
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regular with no retractions. Legs are even in color and smooth. There is edema to the right
thigh and is painful upon mobilization. Carotid pulses are strong and bounding. Upon
auscultation of the heart, heart sounds are rhythmic with no murmurs. Extremities are well
perfused and hydrated with good capillary refill less than 3 seconds. Overall, client is in good
health except for the closed fracture to the right leg. No abnormalities observed in any of the
other body systems.
COMPARING THE DATA
Table 1: Timeline of events in LS’s injury
Patient has been showing gradual reduced levels of pain from initial admission and assessment
up to the present. Patient scored a 5 on Wong-Baker’s FACES pain assessment tool initially,
scored a 3 last week and is presently scoring a 1. There is definite improvement in the patient’s
ability to sit up in bed and assist in changing clothes and pampers.
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Fig. 2.1 Patient’s current pain rating to the right femur
Vital signs have been consistent and without presence of an infection. Patient is seen and
evaluated by Dr. Roberts and Dr. Parham on a daily basis to assess condition. X-rays have been
taken of the initial injury and how it has been aligning with the help of the skin traction with
weights. Last x-ray taken indicated femur is well aligned but must still be kept of traction to keep
promoting callus formation. Since patient is 4 years old, bone healing is characteristically rapid
because of the thickened periosteum and generous blood supply. In early childhood, healing
times for a femoral fracture can take up to 4 weeks (Hockenberry & Wilson, 2011). LS has been
at the ward for 18 days still and Dr. Roberts has ordered 2 more weeks of being in traction. Bone
healing in any age group is greatly influenced by the patient’s general health. LS does not have
any other illness presently to hinder her healing. Mother should be educated on the importance of
a balanced diet to promote stronger bones and good development of child’s body.
Strengths of LS’s family include having a good support system in terms of taking the time out to
take care of LS and father staying at home to take care of the other children and to keep their
business running. Her grandmother is also helping take care of the other children. Weaknesses
could be that there is only communication through the phone to the rest of the family in Benque.
No other family members have come to relieve LP of taking care of her daughter. In another of
point of view, LS’s injury is an opportunity for the family to grow closer when they help each
other out. LS will become closer to her mother, and vice versa. Father will have the opportunity
Case Study 19
to see what it feels to take care of the rest of the family on his own, and he could be more
understanding to his wife. Financial strain of LS’s injury may decrease the family’s resources,
other siblings could feel neglected since attention is on LS for the moment, and both parents can
be feeling guilt over having failed to protect their child. Other opportunities to educate other
members of the community on fractures and timeframe of bone healing could come to LS’s
family so that they could educate other families to supervise when their children are playing and
try to prevent injuries to their children’s bones.
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Table 2: Nursing interventions related to data gathered
Case Study 21
ACTUAL AND POTENTIAL PROBLEMS
In order of priority
Actual: a. Impaired physical mobility- LS is unable to move the right femur and whole right
leg because of the skin traction with weights to the foot of bed. She is able to move her toes but
has impaired physical mobility to change positions on the bed. She is kept in a supine position,
but she is able to sit up in bed now that she is not experiencing as much pain as before. She needs
assistance in bathing herself and changing clothes. She requires the assistance of her mother. The
nurse helps in changing the bed linens without disturbing the traction.
b. Acute pain- LS is not having as much pain as she had at the beginning of the injury
however there is still pain present whenever she moves the leg suddenly or when she is being
changed and bed linens are being changed. The right leg is still tender to touch and edematous.
Patient is being given 7.5cc of Tylenol for pain management. Patient starts complaining and
crying that it hurts whenever she feels the pain.
Potential: c. Risk for disuse syndrome- Patient is at risk for disuse syndrome since she is not
ambulating and not able to do range of motion exercises to affected leg. Patient is limited to
staying in bed, so muscle strength is at risk to be reduced. Inactive muscle loses strength at a rate
of 3% per day (Hockenberry & Wilson, 2011). Immobility can also affect the circulation to the
skin during inactivity and can cause edema. Friction from the straps and bandages could cause
skin breakdown.
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IMPLEMENTATION/EVALUATION Nursing Care Plan 14/03/2014
Assessment Nursing Diagnosis Goals/Objectives Interventions/Rationale Outcomes
Objective data:-Patient lying in supine position in bed-respiratory effort adequate-skin warm to touch and hydrated-oral mucosa pink and hydrated-Abdomen soft and palpable, non-tender-Extremities well perfused, capillary refill less than 3 seconds. -right leg on skin traction with weights, immobilized with sand bags around leg, edematous and tenderSubjective Data:-patient cries when moved when bed linens are being changed and when she wakes up from a bad dream, and voices pain-Patient cannot bathe on her own, requires help of mother to be sponged in
Actual:Impaired physical mobility related to bone injury to right femur as evidenced by inability to move out of bed to bathe due to skin traction with weights to right leg
Acute pain related to bone injury to right femur as evidenced by client voicing pain felt to right leg and being tender to touch
PotentialRisk for disuse syndrome related to bone injury to right femur
Long term goal:At the end of 3 days, patient will be able to:
1.Pull herself up to assist mother during bathing and when bed linens are being changed according to level of tolerance
Short term goal:At the end of the 8 hour shift, patient will be able to:
2.Voice that she feels little pain or is free of pain to right leg when she moves
3.Move unaffected limbs to do range of motion exercises to reduce risk of disuse syndrome
I. Impaired Physical Mobility1.Assist in changing pampers and bed linens-helps patient since she cannot move much without feeling pain (collaborative-nurse and mother)2.Do range of motion exercises-helps strengthens muscles of legs and arms (independent-nurse)3.Provide books, and toys within reach-keeps patient entertained and not feel bored of staying in bed (collaborative-nurse and mother)4.Keep right leg in traction- promotes correct alignment and healing of bone (collaborative-doctor and nurse)5.Provide skin care by keeping skin clean and dry-helps maintain skin integrity and reduces risk of a break in the skin (independent-nurse)
II. Acute pain1. Assess level of pain using Wong-Baker’s pain assessment tool-helps to see level of pain patient is feeling (independent)
At the end of 3 days, patient was able to:
1.Pull herself up in bed to assist during bed baths and changing of linens according to level of tolerance
At the end of the 8 hour shift, patient was able to:
2.Voice that she felt little or no pain to right leg when she moved
3.move unaffected limbs and do range of motion exercises and therefore reduced the risk of disuse syndrome
Case Study 23
bed-Patient is quiet and calm when she has books to read and TV to watch.
2. Administer Tylenol every 8 hours or when needed-analgesics help control pain (Dependent on doctor’s orders)3.Monitor vital signs for increase in pulse which would indicate pain (independent)4.keep toys and books within reach so patient’s focus will be on the stimuli and not on the pain (independent-mother)5.Provide comfort to child by talking soothingly so she can relax when she is having pain (collaborative-nurse and mother)
III. Risk for disuse syndrome
1.Initiate range of motion exercises to encourage adequate circulation (independent)2.Massage pressure area points to prevent bed sores (collaborative-nurse and mother)3.Encourage patient to wiggle toes, sit up, and stretch as tolerated (collaborative-doctor, nurse and mother)4.Educate mother on disuse syndrome so she can move child’s limbs when nurse is not around (independent-nurse)
Case Study 24
TEACHING PLAN
TOPIC: Fractures and traction VENUE: Patient’s bedside AUDIENCE: Mother and patient DATE: March 14, 2014 DURATION: 30 minutes
THE PURPOSE: To educate the patient and mother on impaired physical mobility, pain management and how to do range of motion exercises
STATEMENT OF OVERALL GOAL: Patient and mother will understand the reasons why traction is placed, and how to manage patient in traction
OBJECTIVES CONTENT OUTLINE
METHODOF
INSTRUCTION
TIMEALLOTEDFOR EACH
OBJECTIVE
RESOURCES/TEACHING
AIDS
METHOD OFEVALUATION
At the end of the discussion, patient and mother will be able to: 1.Describe what is a fracture and the types of fractures and how traction therapy works
2.Identify type of fracture patient suffered by looking at patient’s x-rays
3.Adapt to patient having to stay on traction for 2 more weeks and how to manage pain
4. Describe disuse syndrome and how to do range of motion exercises to prevent it
1.What is a fracture?
2. What are the different types of fractures that can occur?
3. treatment of fractures-cast or traction
4.Medications available: Tylenol, Voltaren, Pethidine-for pain management
5.Disuse syndrome
6.Questions and answers at end of presentation
Discussion-Explain traction care-understand the therapy, maintain traction, maintain alignment (check after patient moves), and prevent skin breakdown
go in depth by demonstrating the correct ways of doing range of motion exercises and have mother perform a return demonstration
5 minutes for each objective and time left will be for demonstration and questions & answers
Visual aids:
Pictures of the types of fractures
Patient’s X-ray
Demonstration
When the nurse finishes
discussion, patient and
mother are able to identify type
of fracture patient
sustained, understand which pain
medications are given and how they work, and how to initiate
range of motion exercises to
prevent disuse syndrome.
Recommendations
Case Study 25
After evaluating the data compiled, some recommendations to patient and family can be
given. Possible ways to improve the situation of the family could be that other family members
should come and help the mother of taking care of the child. Undoubtedly, LP is having
difficulty being the only one who has to stay with the child because she voices that her baby is
still breastfeeding and her breasts are getting tender from not breastfeeding. In the meantime
also, she is also worried about her other children and how things are at home. It would be
recommended to have someone else come to help her at least for 2 or 3 days so she can go back
home. LS is doing very well in the past days. All that is left to do is wait 2 more weeks so the
skin traction can be discontinued. Dr. Roberts could then put on a cast or transfer her to the San
Ignacio Community Hospital so she can be closer to home. LS also needs more books and toys
so that she does not get bored about having to stay immobilized.
Interventions from the nursing care plan were met and the patient’s needs were
prioritized according to the needs that were most outstanding. Range-of motion exercises are still
being done and client is able to sit up in bed and move other limbs to promote circulation.
Patient’s right leg is still in traction and care is done to see that the leg is always aligned and that
the weights are hanging freely. If patient is in pain, Tylenol is given to help alleviate it.
When patient is discharged and taken back home, bed rest and care should be taken so
that leg does not become injured again. The child must not strain the right leg with excessive
running or other physical activities. Follow up care with the doctor should be done as scheduled
for x-rays to see that the bone continues healing. If there is any vomiting or shortness of breath
after being discharged, parents should be advised to seek immediate medical help at the nearest
health center. Patient should keep taking her pain medications as prescribed by the doctor as
well. The mother should be encouraged to freely ask any questions she might have regarding
Case Study 26
future appointments or how to better take care of her child once she is back home. At the same
time the nurse should provide accurate and understandable information on all topics related to
the injury. The teaching plan for this patient should help minimize the lack of knowledge on the
patient’s injury.
Appendix
Case Study 27
Fig. 1.1 Parts of the bone Fig. 1.2 Types of fractures
Fig. 1.4 Traction with weights
Fig 1.3 Application of traction to maintain equilibrium
Case Study 28
Fig. 1.4 example of a fractured femur
Fig 2.1 Wong-Baker’s FACES pain assessment tool
Case Study 29
References
Hockenberry, M., Wilson, D., (2011). Wong’s Nursing Care of Infants and Children. (9th
ed.) St. Louis, MO: Mosby.
Smeltzer, S., Bare, B., Hinkle, J., Cheever, K., (2010). Brunner and Suddarth’s Textbook of Medical Surgical Nursing. (12th ed.). Philadelphia, PA: Lippincott Company
Pinelo, L., Personal Communication. (2014).
Long bone anatomy references1. Perren SM. Physical and biological aspects of fracture healing with special reference to internal fixation. Clinical Orthopaedics & Related Research, 1979(138): p. 175-96.2. Manolagas SC. Editorial: Cell Number Versus Cell Vigor--What Really Matters to a Regenerating Skeleton? Endocrinology, 1999. 140(10): p. 4377-4381.