INTRODUCTION

I, from group IV Section D, chose the case of G.S., a 38 year old client who had
undergone surgery to correct his bones in his left arm. Upon seeing my client, he was
sitting on the bed in the hospital. When I asked him if I could perform an assessment on
him, he looked at his wife and said yes. These were the factors that I considered in
choosing my client:

1. Willingness of the client to participate and cooperate in my assessment;

2. The nature of the disease, which I believe will help me develop my skills and
acquire the actual knowledge about the disease.
BACKGROUND OF THE STUDY

FRACTURE

A bone fracture is a break in a bone. Fractures are common. Most people fracture
at least one bone during their lifetime.

The severity of fractures increase with age. Children's bones are more flexible and
less likely to break. Falls or other accidents that do not harm children can cause complete
fractures in older adults. Older adults suffer from fractures more than children because
their bones are more likely to be brittle.

The most common symptoms are:

• swelling around the injured area

• loss of function in the injured area
• bruising around the injured area
• deformity of a limb

Fractures occur when a bone can't withstand the physical force exerted on it.

There are many types of fractures: simple, stress, comminuted, impacted,

compound, complete and incomplete.

1. Simple: Bone breaks into two pieces.

2. Stress: Hairline break that is often invisible on the x-ray for the first six weeks
after the onset of pain.
3. Comminuted: Bone fragments into several pieces
4. Impacted: One fragment of bone is embedded into another fragment of bone.
5. Compound: Bone protrudes through the skin. Also called an open fracture.
6. Complete: Bone snaps completely into two or more pieces.
7. Incomplete: Bone cracks but doesn't separate.
OBJECTIVES

GENERAL OBJECTIVE:

I, a 4th Year Nursing student of Unciano Colleges, Section D Group 4 I am aiming

the proper attitude by interacting with my client. By doing so, I will be able enhance my
knowledge by practicing my nursing skills that I have learned and maximize my
capabilities, vital for aspiring nurses like me.

SPECIFIC OBJECTIVE:

To be able to:

1. Establish rapport with my client as well as his family to help them recognize
and give importance on their health and personal development.
2. Review my knowledge about anatomy and physiology of bone specifically
humerus, radius and ulna as well as the pathophysiology of bone fracture.
3. Review the medications of my client
4. Identify and analyze present health problems of my client that might place
him at risk and be able to use my nursing skills to help him.
5. Formulate appropriate nursing interventions, that will solve, if not, will reduce
or lessen the health problems of my client, by involving him as well as the
members of my group.
6. Impart necessary knowledge regarding health maintenance to my client that
will guide him to achieve a healthy life.
7. Evaluate the effectiveness of my nursing care plan.
PATIENT’S PROFILE

Name: Mr. G.S.

Age: 38 yrs. old
Sex: Male
Date of Birth: September 1, 1972
Status: Married
Religion: Born Again
Ethnic Group: Visaya
Residence: Payatas, Quezon City
Ward: Male Ward
Chief Complaint: Inability to flex the Left elbow
Date and time of admission: February 8, 2011/ 10:00 pm
Admitting Diagnosis: Fracture open 3-C left humerus medial
condyle, transected ulnar nerve
Attending Physician: Dr. Peimon B. Badiee, Orthopedic Surgery
Date and time of Assessment: February 21, 2011 / 3:00 pm
NURSING HISTORY

Chief Complaint:
“Di ko na maigalaw ang braso ko, ” as verbalized by the client.

History of Present Illness:

Mr. G.S. had his accident last February 8, 2011. He was trying to mediate a fight
between his brother and a drunken man, then, he was hit by a bolo in his left arm. He said
that after the accident his arm felt numb and his cousin tried to pull his arm, but because
it hurts they stopped pulling it. He was brought to the FEU hospital to be hospitalized
however, they can not afford the expenses. February 8, 2011, at around 10 pm, he was
rushed to Philippine Orthopedic Center because he was not able to flex his arm and he
felt some pain. His wife accompanied him. In the emergency room he was interviewed
and had his X-ray. He was then admitted to the male ward at 7 am at the next day. On the
following day he was scheduled for an operation. The said operation lasted more than
two hours from 9:25 am-11: 37am. His attending physician was Dr. Peimon B. Badiee,
Orthopedic Surgery

History of Past Illness:

Mr. G.S. was first hospitalized due to his fracture. Aside from that, he had
occasional cough, colds and fever which the client treated with over-the-counter drugs
such as Paracetamol 1 tablet 500mg PRN, Solmux 1 capsule 500 mg every 6 hours for
cough and Neozep 1 tablet 500 mg once a day for colds.

Heredo-Familial History of Disease:

According to Mr. G.S., his grandmother on the father’s side has High blood
pressure.

Socio-Economic History:
Mr. G.S. is a high school student. He will be the one to pay for his hospital bills
and also supported by hi siblings. He is a security Guard in ABS-CBN. Their monthly
income ranges from 19,000 pesos.
13 AREAS OF ASSESSMENT

I. Social Status
Mr. G.S., 38 yrs old, is the 4th child of his parents. He was born in Zamboanga and grew
up in Quezon City. His wife is a housewife. They are currently living in their own house
at Payatas, Quezon City. The people is living with him 2 children and 2 pamangkin. He is
a Born Again in religion and rarely attends mass. His usual activities before his
confinement include playing with his children, washing dishes, washing his clothes and
sweeping the floor. According to Erik Erikson’s Eight Stages of Development, he falls
under the Middle Adulthood: 35 to 55 or 65, Ego Development Outcome: Generativity
vs. Self absorption or Stagnation and the Basic Strengths: Production and Care During
this stage, an individual can either manifest positive resolution that may indicate to
perpetuate culture and transmit values of the culture through the family (taming the kids)
and working to establish a stable environment. Strength comes through care of others and
production of something that contributes to the betterment of society. I was able to
conclude that he manifested positive resolution. It is because he is the bread winner and
he has time to care for his family.

II. Mental Status

During my assessment, Mr. G.S. is conscious and coherent. I was able to talk to
him easily and lightly. I asked him to recite the series of 7 but he wasn’t able to recite it
correctly. I classify him belonging to the average level of mental capacity. He was able to
recall recent events such as the death of Rudy Fernandez and can also recall remote
events like the year when he fist left Zamboanga. He was oriented to time, place and
person. He was able to answer our questions when we asked him what time it was when
we’re assessing him and he was right when he said it’s between 3-4 pm. I also asked him
if he knew where he was and who he was with and he answered us that he was in POC
and he knew that he was with his wife. Our client speaks Tagalog and cebuano words
upon our interview.

III. Emotional Status

Upon my assessment, I noticed that Mr. G.S. was calm and cooperative. He was
very much open with everything that we asked him. He said he was comfortable staying
in the hospital when I asked him what he felt about his confinement since his wife is with
him. He said that he was worried of what will be the appearance of his left arm after the
cast is removed. He also shared to us that he’s afraid that he may not be able move his
arm again.

IV. Sensory and Perception

A. Vision
Upon my observation, Mr. G.S.’s eyebrows are thick, color black and arc shape.
His eyes are almond shaped and symmetrical with long, thick eyelashes. His
sclera’s appear white and have brown-colored irises. His bulbar conjunctivas are
transparent while his palpebral conjunctivas are shiny, smooth and pink in color
and are highly vascular. To test the corneal sensitivity I asked the client to keep
 both eyes open and look straight ahead and tested it with a wisp of cotton, upon
doing so, our client’s eyes blinked. To assess pupil’s reaction to light, I
approached the penlight from the side and shone a light on his pupil. His pupils
constricted when they were illuminated. To assess pupil’s reaction to
accommodation I held the penlight at about 10 cm from the bridge of his nose and
asked him to look at the tip of the penlight. I held the penlight farther from the
bridge of his nose then moved the penlight toward the client’s nose. His pupils
constricted when the penlight was near, dilated when it was held farther and
converged when moved toward the bridge of the nose. His pupils equally round
and react to light and accommodation (PERRLA). His eye muscles are developed
and well coordinated, as we were able to assess the six ocular movements using a
penlight. I asked him to hold his head in a fixed position facing us and follow the
movements of the penlight with his eyes only. We held the penlight 10 inches
away from the bridge of his nose and moved it slowly to the following directions;
from the center of his eyes to the upper right, right, lower right, lower left, left,
upper left, and back to the center of his eyes. Both his eyes can focus on the
penlight at the same time. To assess his visual acuity, I let him cover the eye not
being tested and let him identify the letters written on our flash cards bilaterally.
The sizes of the letters are 5 inches, 3 inches and 1 inch. All were held 10 ft away
and he was able to identify those letters in 5 and 3 inches but failed to identify
letters that are 1 inch in size.

A. Auditory
Mr. G.S.’s auricles are bean shaped and of the same color with the facial skin.
They are symmetrical and aligned with the outer canthus of his eyes. I palpated
his auricles; they were firm and not tender. His pinna recoiled when we folded it.
He exhibited no pain when his auricles were gently pulled upward, downward and
backward. Using a penlight we inspected the external auditory canal and we have
observed that both have dry cerumen. To test his gross hearing acuity we
performed the tuning fork tests. I performed first the Weber’s test using a tuning
fork with his eyes blind folded; we held the tuning fork at its base and activated it
by tapping the fork gently against the back of our hand near the knuckles. I placed
the base of the tuning fork on top of his head and asked him where he heard the
noise. He said that he heard it on both ears. I also conducted the Rinne test by
asking him to cover one of his ears. I held the handle of the activated tuning fork
on the mastoid process of his ears until he stated that the vibration could no longer
be heard. Then I held the still vibrating fork in front of his ear canal. I asked him
if he heard the sound and he answered yes. I also did the same test on his other
ear. He stated that the sound was more audible when the tuning fork was in front
of his ear canal. Mr. G.S. is Weber negative and positive in the Rinne test.

B. Smell
I observed that Mr. G.S.’s nose is symmetric and straight. Its color is the same as
the facial skin. No discharge was observed from the nares. I lightly palpated his
nose. No tender areas and no lesions palpated. To determine the patency of his
nasal cavities, I asked him to close his mouth and exert pressure on one nares and
 breathe through the opposite nares. After doing the procedure on both nares, we
noted that the air moves freely as he breathes. I tested his sense of smell by letting
him identify four sample scents while his eyes were blind folded. I let him smell
safeguard soap (fragrant), vinegar (sour), white flower (menthol) and Spirit of
Ammonia (foul). He was able to identify all the odors correctly.

B. Gustatory
Mr. G.S..’s tongue is pinkish and is in central position. It moves freely and its
frenulum is highly vascular. I assessed his sense of taste by letting him taste sugar
(sweet), salt (salty), vinegar (sour), and coffee (bitter) respectively while his eyes
were covered. I let him taste first the sugar by placing a pinch of it on the tip of
the tongue depressor. Next, I let him taste the salt by doing the same procedure.
Then I let him taste the vinegar by dipping the tip of the tongue depressor into the
vinegar. After which, a pinch of coffee was also placed on the tip of the tongue
depressor allowing him to taste it. I have done the test by letting him sip water in
between tasting each sample. He was able to identify and differentiate each
sample correctly.

C. Tactile
With his eyes still blindfolded, I assessed Mr. G.S.’s sense of touch by letting him
identify a sand paper from an ordinary paper (rough vs. smooth), cotton from a
mug (soft vs. hard), tip of a pen from cover of a pen (sharp vs. dull) and a bowl
with hot soup from a bottle of cold water (warm vs. cold). I applied those on his
right upper extremity, right lower extremity, left upper extremity, and left lower
extremity. He was able to identify it all correctly except for his left arm.
V. Motor Ability
Mr. G.S.. was able to ambulate without assistance and has his bathroom
privileges. He has a functional level of 0 because he is completely independent. I asked
him to follow us as we do the Range of Motion (ROM). After such he was able to rotate,
abduct, adduct, flex and extend his right upper and right lower extremities. I also did the
same procedure with the left upper and left lower extremities. Although he wasn’t able to
do it with his left upper extremity because of his cast he was able to perform it with his
left lower extremity. Aside from his left arm all his other body parts can move freely
against gravity. To assess his gait, we asked him to walk 5 steps forward and backward.
There, we observed that he has a balanced gait. All his muscle strength was graded 5/5
except for his left arm with 2/5.

VI. Body Temperature

During my assessment my client was afebrile with a temperature of 36.4 ºC,
taken at his right axilla.

VII. Respiratory Status

Upon my assessment, I observed the rise and fall of his chest and I obtained a
respiratory rate of 22 cycles per minute. I observed the respirations for depth by the
movement of his chest. I auscultated his anterior chest using the flat disc diaphragm of
the stethoscope beginning from the bronchi between the sternum and the clavicles. I
asked him to take slow, deep breaths through the mouth and normal breath sounds were
heard. He has quiet, rhythmic and effortless respirations.

VIII. Circulatory Status

He has a blood pressure of 140/90 mmHg taken at his right arm. His pulse was
easily palpable as we palpated his pulse at the right radial artery and obtained a pulse rate
of 85 bpm. At the same time I also auscultated his apical pulse and procured a pulse rate
of 85 bpm. I did a capillary refill test (blanch test) on his right thumb and it returned to its
normal color after 1 second. However, in his left arm in his pinky finger it is pale in
color.

IX. Nutritional Status

I inspected Mr. G.S.’s buccal mucosa using a tongue depressor and a penlight. I
observed that his buccal mucosa is pink in color; his lips are moist and also pink in color.
He has no restriction on foods before his hospitalization. He usually eats three times a
day. He is fond of eating meats such as chicken and pork. He also likes to drink
carbonated drinks like coke but was advised not to take carbonated drinks when he was
admitted.
Upon our assessment, he is on DAT and an IVF of D5NM 1L at 750ml level to run for 12
hrs was infused at his right metacarpal vein.

X. Elimination Status
During my assessment, I asked my client how often he voids per day. He said that
before his confinement he defecates twice and urinates four times daily, but since his
confinement, he has only defecated once. However, he was able to urinate thrice that day
with an approximated amount of 240 cc per void. His wife let him urinate in an empty
dextrose bottle. There we observed that it was yellow in color, was pungent and has a
concentration that is similar with water.

XI. Reproductive Status

Mr. G.S. stated that he had his circumcision when he was 13 years old. At his age.

XII. State of Physical Rest and Comfort

Sudden movements like lifting of his left arm made him feel some pain. In order
to alleviate the pain, he would put a pillow underneath his cast. He usually sleeps at 12pm
and wakes up at 5am. He sleeps 5 hrs daily. In the hospital, he said that he was not able
to sleep well because he is uncomfortable with the cast.

XIII. State of Skin and Appendages

I observed that Mr. G.S..’s hair is unkempt. It is resilient, nape level, and black.
His scalp is intact with tinge of dandruff. He has a dark and damp skin. His nails are
pinkish and untrimmed. He has a cast on his left arm. We noticed that he has edema on
his left hand. Upon my assessment, the wound drainage attached to his left arm was
removed.
ANATOMY AND PHYSIOLOGY

Bones of Upper Extremity

Humerus
The humerus is the bone of the upper arm. The smooth, dome-shaped head of the
bone lies at an angle to the shaft and fits into a shallow socket of the scapula (shoulder
blade) to form the shoulder joint. Below the head, the bone narrows to form a cylindrical
shaft. It flattens and widens at the lower end and, at its base, it joins with the bones of the
lower arm (the ulna and radius) to make up the elbow.

Condyles of the Humerus

At the lower end of the humerus (upper arm bone) and the femur, there are two
smooth condyles (rounded processes of the bone): a knob-like "capitulum" on the lateral
side and a pulley-shaped "trochlea" in the middle. The capitulum unites with the radius
(smaller lower arm bone) at the elbow, and the trochlea is a notch, which joins ligaments
to the head of the ulna (larger lower arm bone). Above the condyles on either side are
"epicondyles," which provide attachments for muscles and ligaments of the elbow. The
one toward the center of the arm is the "medial epicondyle," and the one to the side is the
"lateral epicondyle."
Ulna

The ulna is the longer of the two bones of the forearm; the other being the radius. When
the palm faces forward, the ulna is the inner bone (the one nearest the body) running
down the forearm parallel to the radius. The upper end joins with the radius and extends
into a rounded projection that fits around the lower end of the humerus (the upper arm
bone) to form the elbow joint. The lower end of the ulna is rounded and forms a joint
with the wrist bones and lower end of the radius.

Radius

The radius is the shorter of the two long bones of the forearm. The other is the ulna. The
radius is the bone on the thumb side of the arm. The shaft of the radius has a broad base
that joins the lower end of the ulna and the upper bones of the wrist at a large process
called the radial styloid. The disk-shaped head of the radius, which is smaller than the
base, joins the lower end of the humerus (bone in the upper arm) to form the elbow joint.
PATHOPHYSIOLOGY

BONE FRACTURE. When a bone is broken, the periosteum and blood vessels

in the cortex, marrow, and surrounding soft tissues are disrupted. Bleeding occurs from

the damaged ends of the bone and from the neighboring soft tissue. A clot (hematoma)

forms within the medullary canal, between the fractured ends of the bone, and beneath

the periosteum. Bone tissue immediately adjacent to the fracture dies. This necrotic tissue

along with any debris in the fracture area stimulates an intense inflammatory response

characterized by vasodilation, exudation of plasma and leukocytes, and infiltration by

inflammatory leukocytes and mast cells. This results to pain of the fracture site, edema

(will develop shoulder and/or elbow stiffness due to keeping their hand in a protected

position of elbow flexion and shoulder adduction), crepitus (a crackling sound, heard

when pieces move), loss of function of that body part, a deformity of the fracture site and

immobility.
 PREDISPOSING FACTOR PRECIPITATING FACTOR

Age, Gender Accident

Force that is greater than the

bone can hold

FRACTURE

Disruption of Disruption of Death of bone

periosteum blood vessels tissue
Hematoma Bleeding

INFLAMMATORY RESPONSE

Edema Crepitus Loss of function Pain Immobility Deformity

EVALUATION

During my Related Learning Experience at Philippine Orthopedic Center, I was able

to gain the trust and confidence of my client, Mr. G.S. This enabled me to work with him
in completing this case study. I was able to raise Mr. G.S.’s consciousness pertaining to
his health status particularly regarding his fracture. Together with my client, I formulated
a plan of care to help address his present nursing problems. After the proper interventions
and health teachings, I have concluded that I was able to meet the following objectives of
this study:

1. I was able to establish rapport with my client as well as his family and helped
them recognize and gave importance on their health and personal development.

2. I was able to identify and analyze present health problems of our client that might
place him at risk and I was able to use my nursing skills to help him.

3.I was able to formulate appropriate nursing interventions that lessen the health
problems of my client.

4.I was able to impart necessary knowledge regarding health maintenance to my

client that guided him to achieve a healthy life.

5.I was able to evaluate the effectiveness of my nursing care plan.

 HEALTH TEACHINGS

1. Explain the goals of frequent position changes.

Positioning (Goals)
* to prevent contractures
* stimulate circulation and prevent pressure sores
* prevent thrombophlebitis and pulmonary embolism.
* promote lung expansion and prevent pneumonia
* decrease edema of the extremities
* changing position from lying to sitting several times
a day can help prevent changes in the CVS known as deconditioning.
* the recommendation is to change body position at least
every 2 hours, and preferably more frequently in patients who have no
spontaneous movement.

2. Discuss the different therapeutic exercises.

Therapeutic Exercises
1. Positive range of motion exercise
2. active assistive range of motion
3. active range of motion
4. Resistive exercise
5. Isometric or muscle settings exercise.

3. Encourage patient to have adequate nutrition to promote healing of soft

tissue and bone.

4. Encouraged patient to increase oral fluid intake.

5. Teach patient and family to elevate the extremity to minimize edema.

6. Teach patient and family to perform wound care to flap or skin graft after
the wound is closed in 5 to 7 days.