DEMOGRAPHIC DATA

Patients Name: Espia, John Raphael Age: 20 years old Case Number: 734658 Civil Status: Single Nationality: Filipino Religion: Roman Catholic Address: 368 Balagtas St. Asuncion, Tondo, Manila Birthday: March 24, 1992 Birthplace: Bian, Laguna Date of Admission: October 3, 2012 Diagnosis: Fracture, closed, complete comminuted, m3, femur R Fracture, open 1, d3, tibia-fibula R Physician: Dr. Reynes

NURSING HISTORY
General Information: J.R.E. is a 20 year old male patient coming in for R lower extremity pain. Chief Complaint: R Thigh and R leg pain. Present Illness: Started 10 days PTA when the patient is riding a motorcycle with a drunk driver. They got involved in a collision with a speeding jeepney throwing him off. He was rushed to a hospital in Laguna and subsequently transferred to Batangas General Hospital and was placed on traction before transferring to POC. Past Medical History: Patient sustained a tibial fracture on the R leg 10 years ago. Family History: (-) Hypertension (-) Diabetes Personal History: He is a canteen service crew. (+) Alcohol drinker (+) Smoker - occasional Physical Exam: (+) Swelling deformity R thigh (+) Swelling deformity R leg (+) Less than 1 cm open wound R leg

Teodoro, Michelle Ann T. Group 3 BSN 3

PHYSICAL ASSESSMENT
BODY PART
HEAD Hair and Scalp

NORMAL FINDINGS
- Hair evenly distributed. - Thick growth of hair. - No presence of infection. - Amount of body hair variable. - Normocephalic. - Absence of nodules or masses. - Symmetrical facial features; palpebral fissures equal in size. - Symmetric facial movements. - Eyebrows and Eyelashes evenly distributed. - Eyelids intact with involuntary blinks per minute, and close symmetrically. - Bulbar conjunctiva is transparent, sclera appears to be white. - Palpebral conjunctiva is shiny, smooth and reddish. - Lacrimal gland/sac has no edema and tenderness -Cornea is transparent. - Color same as facial skin. Symmetrical. - Mobile and firm pinna.

ACTUAL FINDINGS
- Hair evenly distributed. - Thick growth of hair. - No presence of infection. - Amount of body hair variable. - Normocepalic. - No nodules or masses palpated. - Symmetrical features and facial movements.

ANALYSIS/ASSESSMENT

Cranium (Skull)

Face

Eyes and Vision

- Hair evenly distributed; equally distributed. - Eyelids intact.

- Transparent bulbar conjunctiva. Sclera is white. - Shiny, smooth and pale red/pink. - No edema or tenderness - Transparent. - Color same w/ facial skin. Symmetrical. - Presence of ear wax. - Respond to sounds.

Ears and hearing

Nose

- Normal - Symmetric and straight. - No discharges, masses, lesions. - Uniform, pink in color, moist and smooth in texture. - 32 adult teeth. - Tongue pink in color, moves freely. - Uniform, dry in texture - Dry lips indicates fluid volume deficit. - Tongue moves symmetrically w/o difficulty.

Mouth

NECK Muscles

- Muscles equal in size; head centered.

- Normal

Lymph nodes Trachea

- Not palpable - Central placement in midline of neck; spaces are equal on both sides. - Not palpable.

- Normal - Normal

Thyroid Gland

- Normal

Upper extremities Skin, fingers/nails

- Color of skin is the same w/ body color. - Nails have smooth texture, convex curvature in shape. - Nail beds slightly pinkish in appearance, with intact epidermis, capillary refill in two sec.

- Skin is brown. Same w/skin tone. - Normal but longer and dirty. - Normal

- Due to the patients stay in the hospital without regular grooming.

Muscle strength and tone.

-Muscle size equal on both sides of the body. -No contractures and tremors. -Muscle has equal strength.

- Normal

Joints

- No swelling. No tenderness, crepitation or nodules. - Joints move smoothly. - Present upon palpation.

- Normal

Pulses

- Pulse noted as 84 bpm

Chest and Back

- Chest is symmetric, spine is vertically aligned, chest wall intact; no tenderness; no masses. - Uniform in color, Symmetric contour - No evidence of enlargement of liver and spleen. - Audible bowel sounds, bladder not palpable. - Triangular distribution of pubic hair. Pubic hair intact. - No inflammation, swelling or discharges.

- Normal

Abdomen

- Normal

Genitals

- Not examined.

Lower extremities Skin

- Due to fracture. - No abrasions. - Smooth and moisturized. - No swelling or redness. - Uniform in color. - R leg is in cast. - Some visible parts appears to be dry. - (+) swelling on the R leg.

Muscle strength and tone.

-Muscle size equal on both sides of the body. -No contractures and tremors. -Muscle has equal strength.

- Limited ROM. - R leg is in cast. L leg appears to be normal.

- Due to fracture.

Joints - Able to move freely - Limited ROM. Cannot walk or go to another place w/o wheelchair or crutches.

Toenails

- Color of skin is the same w/ body color. - Nails have smooth texture, convex curvature in shape. - Nail beds slightly pinkish in appearance, with intact epidermis, capillary refill in two sec.

- Nail beds on R leg appears to be blanched.

- Due to poor circulation on the casted leg.

PATHOPHYSIOLOGY
The patient got involved in a vehicular accident 10 days PTA Patient had fracture on the femur and tibia-fibula bone. Swelling of the Right leg. Was brought to the hospital and was put into traction. Transferred to POC and had to put Steinmanns Pin and BST. Patient was casted prior to discharge. For closed possible open reduction nailing, tibia and fibula, femur early next year.

ANATOMY AND PHYSIOLOGY OF THE AFFECTED PART

(+) Comminuted Fracture

(+) Fracture with < 1cm open wound

Femur Fracture, closed, complete comminuted, m3, femur R

Tibia and Fibula

The femur, or thigh bone, is the longest, heaviest and strongest bone in the body. Its proximal end articulates the acetabulum of the hip bone. Its distal end articulates with the tibia and patella. The action of the gluteus medius has some tendency to pull the upper fragment outward, and the strong pull of the abductor muscle group tends to cause outward bowing at the point of fracture. In this fracture there is a general tendency to develop inward rotation of the lower fragment and outward bowing. Fracture, open 1, d3, tibia-fibula R The tibia, or shin bone, is the larger, medial, weight-bearing bone of the leg. The tibia articulates at its proximal end with the femur and fibula, and its distal end with the fibula and the talus bone of the ankle.

The fibula is parallel and lateral to the tibia, but it is considerably smaller than the tibia. The proximal end, the head of the fibula, articulates with the inferior surface of the lateral condyle of the tibia below the level of the knee joint to form the proximal tibiofibular joint. In an open fracture, also called a compound fracture, the skin around the fracture site has been punctured. Open fractures often involve much more damage to the surrounding muscles, tendons, and ligaments. They have a higher risk for complications and take a longer time to heal. Only the tibia bears weight, but fracture of the tibia is often associated with fracture of the fibula because force is transmitted via the interosseous membrane that connects the two bones.

DIAGNOSTIC PROCEDURE
CBC CT/BT PT SGOT/SGPT

MEDICAL MANAGEMENT
The patient takes Cefuroxime and Amikacin to prevent bacterial infection The patient also takes Etericoxib to relieve pain. He was also put into long leg circular cast.

SURGICAL MANAGEMENT
Steinmanns pin was inserted to the patient and was put into BST. The patient is scheduled for closed possible open reduction nailing tibia and fibula, femur early next year.

NURSING CARE
Check patient vital sign. Offer bed bath/sponge bath to patient. Provide diversional activities. Assist patient in moving and transferring. Encourage increased fluid intake.

DISCHARGE PLAN
Instruct patient to observe for signs and symptoms of bacterial infection. Instruct patient on how to properly use crutches. Help the patient to plan for changes in self-image and the potential for depression. Drug treatment