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MANILA DOCTORS COLLEGE

Metropolitan Park, President Diosdado Macapagal Blvd.,


Pasay City

A case study on

MOTOR VEHICULAR ACCIDENT

Submitted to:
Mr. leonardo

Submitted by:
GROUP 50

Gacot, Angelie joy

December 18, 2010


I. ASSESSMENT:

A. General Data
Patient’s initials: A.R. m
Address:Binondo, Manila Informant: Client,herself
Age: 75 yo Date of Admission: 11/13/10
Sex: Female Order of Admission: via ambulatory
Date of Birth:02/08/1935 No. of Days in this hospital: 3 days
Place of Birth:Manila Date of History Taking: 12//16/10
Civil Status: Married Religion: Roman Catholic
Occupation: None

B. Chief Complaint(s)
Vehicular crash

C. History of present illness:

3 days prior to confinement, client was hit by a tricycle after buying foods in Talipapa in the street of
Lavaranes, Bonondo. She then lose consciousness. She was brought by the nearest hospital which Saint Andres
Hospital. 1 day prior to confinement upon knowing by her relatives that she was not given Tetanus Toxoid, they
then decided to transfer her in Manila Doctors College. She was brought to the hospital at 7 pm.
She experience contusion at right clavicular bone, contusion on the left cheek below the eyes and lacerated
wound pleural left parietal part of her head.

D. Past History:
1.) Childhood Illness/es : none
2.) Adult Illness/es: none
3.) Immunization: complete unrecalled
4.) Previous Hospitalization: none
5.) Operation/s: thbso (1980’s)
6.) Injuries: none
7.) Medications taken prior to confinement: none
8.) Allergies: none

E. Systems Reviews:
Gordon’s Functional Health Areas

A. Health Perception-Health Management pattern


Before admission, client’s health was good. She doesn’t get sick. She eats vegetables and fish
to stay healthy. She refrains from vices too. She had a Thbso on 1980’s.
During hospitalization, Client had difficulty moving because her body usually her left side is weak. For
the first 2 days, she just always to lie in the bed. She thinks that complying with her doctor’s advice will help
her to get better. She already wants to go home. She doesn’t want to stay in the hospital till Christmas or New
Year.

B. Nutritional-Metabolic pattern
Before admission, client typical food intake were vegetables, chicken, fish and meat. She consumed 6-8
glass of water a day. She starts her day by drinking a glass of coffee.She does have good appetite and has no
restriction in food. She doesn’t experience excessive sweating. Her wound heals well and sometimes she
experience skin dryness due to aging. She wears dentures.
During confinement, after her operation, she was prescribed NPO then general liquids. On the 3 rd day,
her doctor allows her to full diet. She is with IVF D5NSS 1000 l x KVO.

B. Elimination Pattern
Before admission client’s elimination pattern was twice a day. It is formed and yellowish. She doesn’t
have any discomfort and problem in control in defecating. He micturates 6-8 a day. Her urine is yellowish and
doesn’t contain blood. She doesn’t use any laxatives and doesn’t experience any discomfort. He wears dentures.
During confinement, client was not able to eliminate yet. At first, she just urinate sat the bedpan. But on
rd
the 3 day, she manages to urinate in the comfort room with assistance. She micturates 6-8 times a day.
C. Activity-Exercise Pattern
Before confinement, patient has sufficient energy for desired activity. But sometimes, she
experience exhaustion or he easily get tired. She is in full self car. She thinks that she gets enough exercise
through walking everyday when marketing in Talipapa. She allows herself to have chitchats with her friends and
watch television. She also mans the sari-sari store of her daughter-in-law.
During confinement, client does not have sufficient energy for desired activity. She feels weak. She can’t
move her arms the way she wants to because she has clavicular fracture. She needs assistance in getting up the
bed and sitting. She tries to ambulate a little for easy recovery. She just watches television in the room.
E. Sleep –Rest Pattern
Prior to confinement, client feels well rested and ready for daily activities after sleep. She sleeps for 6-8
hours a day. Sometimes, she wakes up during her sleep. He also experiences nightmares and early awakenings.
She allows herself for self-relaxation period.
During confinement, client
doesn’t have enough sleep. She complains that she can’t sleep at night because of the pain she feels when her
antibiotics was incorporated in her IV line.
F. Cognitive-Perception Pattern

Prior to confinement, client doesn’t have any hearing difficulties. She wears eyeglasses. She doesn’t
recall her last eye check-up. There are few changes in her memory since she growing older. If there’s any
important decision to make, she thinks about it several times, weighs, and think of what is best to resolve the
problem. She does this, because she knows her responsibilities and liabilities if she makes a bad decision. She
easily learns well and adapt to new things and changes. She is a visual and audio learner.
During confinement, she feels that her body is too weak to do things she wants. She thinks that
complying with doctor’s advice will help her get well soon. Her neuro vital signs are good. She can graps ideas
both concrete and abstract. She speaks in Filipino.

G. Self Perception - Self Concept Pattern


Prior to confinement, client feels good about herself. She is satisfied with her life and she is proud that
her two sons became policemen. People that are to makulit and boisterous make her annoyed.
During confinement, she described herself as good though weak. She said that everybody dies and she’s
blessed enough to have few more years in this earth. She is relaxed and assertive tha she will get well soon.

H. Roles – Relationship Pattern


Prior to confinement, stays with her son’s family. She is already a widow. She has an extended family.
They encountered difficult family problems but they are able to resolve. She doesn’t have any job but she’s
helping in taking care of her grandkids and in the sari-sari store. She has good social relationship and she
doesn’t feel lonely because of her family and friends.

During hospitalization, client was being taken care by family and friends. She depends on them, at all
times. Her family worries about her. The suspect was put into jail easily because of her son’s job. She still
manages to have good relationship with them and she cannot wait to stay in the hospital for long to celebrate
Christmas day.
I. Sexuality – Reproductive Pattern
Prior to confinement, client has good relationship with family, relatives and friends. She is already a
widow. But she doesn’t feel lonely. Her menstruation period started when she was 13 years old and she had
menopause at age 48 years old.

J. Coping – Stress Tolerance Pattern


Prior to confinement, there haven’t any changes in the client’s life or crisis within his family and friends.
She is relaxed most of the time. Her daughter in law and son helps her most when problems arise. She resolves
her stress though eating or walking. She doesn’t have any vices. If there’s big problem, she thinks it very careful
and finds solutions to resolve this. Usually these are most of the time successful.
During confinement, client is relaxed. He is in full diet. He responds and follows her doctor’s advice to
get well.

K. Values – Beliefs Pattern


Prior to confinement, client generally gets things she wants in his life. Religion is important to him. She
prays to God when she encounters difficulties.
During confinement, client doesn’t get want she wants. She doesn’t like being confined to bed and she
wants to go to home immediately as soon as gets well. Being sick interferes with her religious practices such as
going to church.

Regional examination:

F. Family Assessment
Educational
Name Relation Age Sex Occupation
attainment
ASM Son 50 male Police College graduate
Daughter in Sari sari store
CSL 49 Female College graduate
law owner
KSM grandson 25 male Call center agent College graduate

G. Heredo Family Illness:


Maternal: none
Paternal: none

I. Physical Examination:
Date of P.E: December 16, 2010 1000H

Height: “5’3” Blood Pressure: 120/70 mmHg


Actual Weight:56 kg
BMI: 19.9 normal Heart rate: 72 bpm
Respiration Rate: 16 cpm
Temperature: 37.2°C
GENERAL SURVEY
• conscious, awake, cooperative, coherent
• oriented to time, person, and place
• lying in semi fowlers position
• has sutures on left parietal, left cheek below the eyes and clavicle
• has arm sling and clavicular strap.
SKIN • nasal mucosa: pink; free from redness, swelling
• tan or brownish skin and exudates
• absence of petechiae • nasal bridge: absence of lesion, masses,
• moist, cool, pale skin deformities
• has resilient skin turgor • septum in midline
• • frontal and maxillary sinus: absence of swelling,
Hair and Scalp tenderness and pain
• black with white, moist, shiny, curly, MOUTH
and smooth hair • lips: moist and light pink
• evenly distributed • buccal mucosa: pink; absence of inflammation,
• presence of dandruff and dried blood. cold sores, nodules and malocclusions
• presence of moist scalp • gums: absence of inflammation, lesions,
• presence of sutures in the left parietal bleeding
lobe. • presence of dentures
• NECK
Nails • negative from enlargement; proportional to gross
• nail edges are smooth and round body structure
• nail plates are smooth and slightly • symmetrical
convex • absence of masses and lesions
• absence of swelling, redness and lesion • trachea is in the midline and proportional with
• capillary refill of >3 second other neck structures
HEAD • negative for vein engorgement
• normocephalic, symmetrical and oval shaped • absence of thyroid enlargement, symmetrical
head CHEST AND LUNGS
• still and upright in position • spine is in the midline
• proportional with the neck and body • Straightened cervical spine
• has good hair distribution • With clavicular strap and arm sling
EYES HEART
• brown iris • absence of structural deformities, area of
• white sclera tenderness and masses
• presence of sutures below the left eye • negative for visible pulsation
EARS • (-) crakles
• auricle: symmetrical and mobile EXTREMITIES
• absence of cerumen, discharges, nodules, • With positive left reflexes on both hands
lesions, and feet
• negative from areas of tenderness, masses, NEUROLOGIC EXAM
inflammations,
alert
NOSE and SINUSES Can recall
• symmetrical and proportional to the face Aware of people, time, and place
Can move tongue and move around his eyes
Impaired physical mobility due to weakness of body.

H. Developmental History

Theorist Age Task Patient Description


Sigmund Freud –
Psychosexual Theory Client is already a widow. She has good personal
75 Genital Stage
relationship with both sexes.
Erik Erikson –
Psychosocial Theory
She is satisfied with her life and mature to handle
40 Integrity vs
things.
despair

Jean Piaget –
Cognitive Theory
In making decisions, she weighs it first and thinks
Formal
40 carefully how to solve his problems because she
Operational Stage
knows his responsibility and liability.

Lawrence Kohlberg –
Moral Development She recognizes the higher authorities. She knows
40 Social contract what is right, what is wrong, how to make decisions
and his liability and responsibility.
James
Fowler – Spiritual He believes in God, the highest authority in the
Paradoxical-
Development 40 universe. She prays to him and believe that God will
Consolidative
not do any harm to people

II.PERSONAL/ SOCIAL HISTORY

Habits: talking to friend, watching television


Vices: none
Lifestyle: sedentary lifestyle
Social affiliation: none
Client’s usual day like:
Client wakes up at 5 am. She then helps in cooking breakfast at 6. Then she eats at 7 or 8 in the morning.
She helps in her daughter in law sari-sari store. Then she eats lunch at 12 pm. She then watches television or
have chitchats with her friends. She then helps in cooking and eat at 8 pm. The watches again television in the
night and fall asleep at around 11 pm.
Travel :none
Educational Attainment: Highschool graduate

III. ENVIRONMENTALHISTORY
Client is living with his family in Binondo, Manila. They are living in a 2 storey house. Their water is
NAWASA. They use MERALCO for electricity. They have a good drainage. They are near the Talipapa market.
She describes their place as a very crowdy place.

I. OB / GYNE HISTORY

Menarche (age): 13 yrs. Old when:


amount and characteristics: moderate flow
3-4 pads for day
duration: 3-4 days
associated symptoms: dysmenorrhea

Deliveries: G2 P2 operations: 1
OB Score: T2 P0 A0 L2
VII. LABORATORY RESULTS AND FINDINGS

LABORATORY NORMAL INTERPRETATION/


RESULT PURPOSE
12/13/2010 VALUE SIGNIFICANCE
Usually done to a patient with renal
disease to determine if the kidney’s Below normal .Due to the
140-175
Hemoglobin 117 ability to release erythorpoietin factor loss of blood during the
g/l
is already affected. accident.

Used to measure RBC number and


volume. It is an integral part of the
Hematocrit 0. 36-0.46 0.37 Normal
evaluation of anemic parents.

Below normal. Due to the


4.5-5.90 x
RBC 3.72 To help diagnose anemia loss of blood during the
10ˆ12/L
accident.
Determines any inflammation,
Above Normal. To increase
4.0-10.5 x infection, allergy or
WBC 16.02 the body defense due to
10ˆg/L immunosuppression
trauma.
Determines any acute bacterial Above Normal. To increase
Neutrophils 0.36-0.66 16.02 infection. the body defense due to
trauma.
Determines any chronic bacterial
Indicates that there’s
Lymphocyte 0.24-0.44 0.07 infection or viral infection.
infection.
Determines any acute bacterial
Monocytes 0.02-0.12 0.05 infection. Normal

RDW calculates the varying sizes of red-


(red blood cell 12-17 % 13.4 blood-cell (RBC) volume in a blood Normal
distribution width) sample
MCV
(Mean
To measure the average red blood cell Abnormal. Due to the loss of
corpuscular 80-96 fl 100.5
size blood during the accident
volume)

MCH
27.50-33.2 This is use to measure amount per red
Mean corpuscular 31.5 Normal
pg blood cell
hemoglobin
MCHC
The amount of hemoglobin relative to
Mean corpuscular 33.40-35.50
31.3 the size of the cell (hemoglobin Normal
hemoglobin g/dL
concentration) per red blood cell
concentration

purpose:
X-rays - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal
tissues, bones, and organs onto film. Chest radiographs may depict segmental or lobar infiltrate but they more
commonly reveal a diffuse, fine, reticulogranular pattern, much like what is observed in RDS. Pleural effusions
may also be observed.
Result:
No fracture nor listhesis seen. There are osteophytes seen at the margins of the cervical vertebral bodies.
The pedicles, posteror elements, and intervertebral disc spaces are intact.
The usual cervical lordosis is maintained
The c7 vertebrae body is not visualized in the lateral view but appears intact in AP projection
Impression:
Cervical spondylosis

Radiology
Date: 12/13/2010

A small round calcified density is seen in the right lower hemithorax overlying the Right 8 th posterior rib. The
rest of the lungs are clear. The heart is enlarged
Aorta is atheromatous
The diaphragm and sulci are intact
Thoracic spondylosis is evident
Impression:
Right lower lobe cacific Granuloma
Atheromatous Aorta
Thoracic spondylosis

Zygomatic Arch/Submento Vertical


Date: 12/13/2010

No demonstration of fracture is seen in this study. Soft tissue swelling over the left zygomatic arc is evident.

ABO TYPING RESULT


Specimen: Whole Blood Date taken: 12/16/10

ABO : “B”
Rh Type : Positive
PATHOPHYSIOLOGY:book based: fractured clavicle communited

MODIFIABLE FACTORS NON- MODIFIABLE


-environment FACTORS
-motor vehicular accident -extreme age(child and old)
-falls

Direct blow to body

lateral fragment is depressed by


the weight of the arm
shoulder droops

pulled medially and forward by


the strong adductor muscles of
the shoulder joint, especially the adductor muscles of the arm may pull
pectoralis major the distal fragment medially

part of the clavicle near the


center of the body is tilted
upwards by the bone fragments to
sternocleidomastoid muscle override

fracture of the clavicle


.

sternocleidomastoid muscle
elevates the proximal fragment
of the bone.

trapezius muscle is unable to


hold up the distal fragment
owing to the weight of the upper
limb
PATHOPHYSIOLOGY:client based: fractured clavicle communited

MODIFIABLE FACTORS NON- MODIFIABLE


-motor vehicular accident FACTORS
-old age 75 years old

Direct blow to body

lateral fragment is depressed by


the weight of the arm
shoulder droops

pulled medially and forward by


the strong adductor muscles of
the shoulder joint, especially the adductor muscles of the arm may pull
pectoralis major the distal fragment medially

part of the clavicle near the


center of the body is tilted
upwards by the bone fragments to
sternocleidomastoid muscle override

fracture of the clavicle


.

sternocleidomastoid muscle
elevates the proximal fragment
of the bone.

trapezius muscle is unable to


hold up the distal fragment
owing to the weight of the upper
limb
B. Ongoing Appraisal

December 16, 2010


Client was with ongoing IVF D5NSS 1 L x KVO at left metacarpal at 950 ml; intact and infusing well. She is on
full diet. Shehas an arm sing on her right arm. She also has a clavicular strap applie dcontinously. She is encouraged to
ambulate and to increased oral fluid intake. Warm compress over her clavicle is applied. Her medication are Dilantin 1 tb
100 mg BID, Nexium 1 tab 40 mg OD, Arcoxia 1 tab 60 mg. Then her Cloxacillin was shift to oral medication ( 1 tab 500
mg every 6 waking hours). Dr. Tenorio cleaned and changed her dressing in the head. Her IVF was ordered to stop after
consumed. Dr. Domingo ordered with may go home order.

XII. DISCHARGE PLAN:

MEDICATION
- Nexium
- Arcoxia
- Dilantin
- Cloxacillin

EXERCISE
- ROM
- increase ambulation
-perform independent activities as tolerated
- Provide rest
- exercise should increase gradually
-
TREATMENT
-high back rest

HEALTH EDUCATION
- adequate rest
-increase oral fluid
OPD FOLLOW-UP
DIET
- Low Na and fat diet

SIGNS AND SYMPTOMS


- report severe headache
-LOC
- vital signs fluctuation
-nausea

SPIRITUAL

- Be thankful that God is good and save you from death.


NURSING CARE PLAN:

CUES/DATA DIAGNOSIS RATIONALE GOALS AND NURSING INTERVENTION RATIONALE EVALUATION


OBJECTIVES
SUNJECTIVE Activity Because the brain After 8 hrs of Independent: 1. close monitoring After 8 hours of
DATA: Intolerance r/t was hit, several nursing intervention, 1. Observe and document response serves as a guide for nursing
“Madali akong fracture in the functions are client will be able to to activities. Report any alteration optimal progression of intervention,
mapagod, “ as head and deferred such as maintains activity in normal signs, dyspnea, activity. goal was met as
verbalized by clavicle coordination and level within weakness, dizziness, chest 2.This prevents evidenced by:
the client movement. Result capabilities as discomfort. overexerting the heart
is, client may evidenced by 2.When appropriate, gradually and promotes attainment .>verbalized
OBJECTIVE experience .> will verbalizes increase activity, allowing the of short-range goals and used
DATA: weakness of the and uses energy- client to assist with positioning, 3. Rest between activities energy-
RR=20 cpm body. conservation transferring, and self-care as provides time for energy conservation
Bp= There is also techniques possible. Progress from sitting in conservation an recovery. techniques
100/70mmHg fractured clavicle bed to dangling, to standing, to Heart rate recovery
Heart Rate =96 which makes her ambulation. following activity is
bpm arm unmovable 3. Encourage adequate rest periods, greatest at the beginning
Paleness because of pain. especially before meals and of a rest period.
Weak body ambulation. 4. Patients with limited
especially on 4.Refrain from performing activity tolerance need to
left side nonessential procedures prioritize tasks
5.Appropriate aids will
5. Provide the patient with the enable the patient to
adaptive equipment needed for achieve optimal
completing ADL activities independent for self care
6.This promote
6. Teach the patient and significant awareness of when to
others to recognize signs of reduce activity
physical overactivity.
7. Teach energy conservation 7. These reduce oxygen
techniques, such as the following: consumption, allowing
- sitting to do to the tasks more prolonged time
-changing positions often -standing requires more
-working at an even pace work
-placing frequently used items -this distributes work to
within easy reach different muscles to
-pacing for at least 1 hour after avoid fatigue
meals before staring a new activity - this allows enough time
so as not all work is
completed in a short
period
-this avoids bending and
reaching
Dependent: -energy is needed to
8.Provide bedside commode as digest food
indicated
This reduces energy
expenditure. Using a bed
pan or going to rest room
requires more energy
than using a commode

Nursing Care plan 6th ed


by Gulanick and Myers
pg 7-10

CUES/DATA DIANOSIS RATIONALE GOALS AND INTERVENTION RATIONALE EVALUATION


OBJECTIVES
SUBJECTIVE Impaired physical The nervous system After 4 hrs. of >assess client’s degree > as a baseline data After 4 hrs. of
DATA: mobility related to is made up of nerve Nursing of muscle strength and for determining Nursing Intervention,
weakness of body cells called neurons Intervention, the pt. and evaluating the pt. will be able to
“Di pa ako as 2 to multiple that serve as the will be able to > encourage client to outcomes maintain increased
makagalaw ng physical injury. communication maintain increased exercise while at bed > to prepares him strength and function
maayos..hirap pa system of the body. strength and for later activities of affected part of his
akong tumayo at They carry messages function of affected and give him hope body
kailangan ko pang in the form of part of his body and sense of As manifested by:
asistehan ng iba”, as electrical impulses. As manifested by: >Provide adequate optimism about -
verbalized by the The messages move - more normal rest periods as well as recovery -increase ROM
client. from one neuron to movement of the comfort & safety Through ambulating.
another to keep the affected extremity measures > To prevent further
OBJECTIVE DATA: body functioning. -Improved muscle > establish a turning stress & fatigue
- sutured laceration Because neurons strength schedule and turn pt.
in the left parietal have, limited ability - effective use of slowly from side to
love to repair themselves adaptive devices side > To provide proper
-injury in the Right unlike other body >Assist pt. in his circulation of blood
clavicle tissues that is why activities flow on both sides
-sutured laceration nerve cells cannot be >Encourage adequate >To promote
in the face below the repaired if damaged intake of fluids & optimal level of
eyes due to injury or Nutritious foods function
-weakness and disease. > involve SO in >Promotes well-
unstable gait clients activity and being and
instruct him how he maximizes energy
can help in improving production.
clients mobility > to assist in
managing
immobility
Cues & Data Diagnosis Rationale Planning Intervention Rationale Evaluation
Subjective: Acute Pain Cloxacillin After 2 hours of Independent: After 2 hours of nursing
“Makirot yung related to was given nursing intervention the patient
sa kamay ko na inflammation of which was an intervention, the - Observe or monitor - Some people deny was able to:
may the pleura as antibiotic. And patient will be signs and symptoms the experience of pain
swero..hirap ako manifested by antibiotics are able to: associated with pain, when it is present. - Report the pain is
makatulog” as pleuritic pain painful so it such as BP, heart rate, Attention to associated relieved or controlled.
verbalized by should be - Report that the temperature, color signs may help the
the patient given slowly pain is and moisture of skin, nurse in evaluating Goal was met as
via IM route controlled as restlessness, and pain manifested by:
Objective: or IV route. manifested by: ability to focus
- Pain scale of -decreased RR from 24
5/10 - Evaluate patient’s to 20 cpm
- facial grimace response to pain and - It is important to
- BP of 100/70 will be gone medications or help patients express as -facial grimace is gone
therapeutics aimed at factually as possible
- RR of 20 cpm -Pain scale will abolishing or -Pain scale will be
-PR of 96 cpm be lessened from relieving pain lessened from 5/10 to
- weakness of 5/10 to 3/10 3/10
body -guarding - Accept client’s - Pain is subjective
behaviour will description of pain. experience and cannot -guarding behaviour
- Facial grimace be lessened. Acknowledge the be felt by others was lessened
-guarding clients experience and
behaviour convey acceptance of
-eyebags client’s response to
-looks tired pain.
- To promote non
- Provide comfort pharmacological pain
measures such as management
back rubbing,
providing quiet
environment -To attention and
reduce tension
- Instruct to use
relaxation techniques
like watch television,
listen to music or
socialized with others
- To maintain
Collaborative: acceptable level of pain

- Administer
analgesics as
prescribed such as

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