INTRODUCTION A clavicle fracture is a bone fracture in the clavicle, or collarbone.

Clavicle fractures involve approximately 5% of all fractures seen in hospital emergency admissions. Clavicles are the most common broken bone in the human body. It is most often fractured in the middle third of its length. Children and infants are particularly prone to it. Newborns often present clavicle fractures following a difficult delivery. After fracture of the clavicle, the sternocleidomastoid muscle elevates the proximal fragment of the bone. The trapezius muscle is unable to hold up the distal fragment owing to the weight of the upper limb, and thus the shoulder droops. A rib fracture is a break or fracture in one or more of the bones making up the rib cage. The middle ribs are the ones most commonly fractured. Fractures usually occur from direct blows or from indirect crushing injuries. The weakest part of a rib is just anterior to its angle, but a fracture can occur anywhere. The most commonly fractured ribs are the 7th and 10th. Rib fractures are usually quite painful because the ribs have to move to allow for breathing. Even a small crack can inflame a tendon and cripple an arm.Rib fractures can occur without direct trauma and have been reported after sustained coughing and in various sports for example, rowing and golf often in elite athletes. They can also occur as a consequence of diseases such as cancer or infections (pathological fracture). Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrous scar tissue as well as regenerative nodules (lumps that occur as a result of a process in which damaged tissue is regenerated), leading to progressive loss of liver function. Cirrhosis is most commonly caused by alcoholism, hepatitis B and C, and fatty liver disease but has many other possible causes. Some cases are idiopathic, i.e., of unknown cause.The word "cirrhosis" derives from Greek, meaning tawny (the orangeyellow colour of the diseased liver). Diabetes mellitus type 2 or type 2 diabetes (formerly called [non-[insulin]]dependent diabetes mellitus (NIDDM), or adult-onset diabetes) is a disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency.While it is often initially managed by increasing exercise and dietary modification, medications are typically needed as the disease progresses. There are an estimated 23.6 million people in the U.S. (7.8% of the population) with diabetes with 17.9 million being diagnosed, 90% of whom are type 2.With prevalence rates doubling between 1990 and 2005, CDC has characterized the increase as an epidemic. Traditionally considered a disease of adults, type 2 diabetes is increasingly diagnosed in children in parallel to rising obesity rates due to alterations in dietary patterns as well as in life styles during childhood.

B. Objectives of the Study The study aims to further analyze a patients condition providing the students of NCM501204 a definite idea on how it is to care for a patient with the same disease condition and how to interconnect all the other laboratory and significant findings of the physician to associate to the patients current state and condition. Proper assessment and nursing interventions are also given priority to emphasize the importance of nursing care to an ill patient. The study also has an objective of assessing and assisting the patient from her present condition towards the patients improvement in a higher level of wellness.

C. Scope and Limitation of the Study The study covers 2 days of assessment and care during our exposure at Cagayan de Oro Medical Center (COMC) and rendered our care to the patient at Station 4 (Private room) these includes thorough assessment, giving of nursing interventions, analyzing of the laboratory results, relating the disease condition to the Anatomy and Physiology of the Human body and the Pathophysiology of the disease. The focus of the study is limited to the time that we had our duty at COMC, the span of time for the assessment of the patient has limited since we had only 2 days to assess and for our nursing interventions. Also the hand writing of the doctors at the doctors order are not legible.

II. PATIENTS PROFILE Name: Age: Sex: Birth date: Birth place: Occupation: Income: Civil status: Nationality: Informant: Religion: Address: Number of children C.B.P 79 years old Female January 12, 1930 Zamboanga De l Sur Housewife 300 pesos/month Widower Filipino Patient and Sons Roman Catholic Balucot, Tambulig, Zamboanga Del Sur 5 children

CLINICAL PROFILE Date of admission: Time of admission: Attending physician: Chief Complaint: Admitting diagnosis: Diet: August 1, 2009 11:35 AM Dr. Chang, Dr. Sison, Dr. Tia, Dr. Pagdilao Body malaise DM, Fracture Left 8th Rib minimally displaced Fracture of Distal Left Clavicle Soft Diabetic Diet

Vital Signs upon Assessment: BP: 140/80mmHg T: 36.60 C RR: 22 cpm

PR: 85 bpm Patients Health History In 2008, patient C.B.P. was admitted at Cebu and was diagnosed to have liver cirrhosis 2004, this is because of her diet since she was young, she was fond of eating street foods. She had been on Godex and Essentiale Natural Meds for several years. History of Present Illness A case of 79 year old, female, widower, Filipino fromBalucot, Tambulig, Zamboanga Del Sur, was admitted at Cagayan de Oro Medical Center on august 1, 2009 at exactly 11:35AM accompanied by her daugther. 2 weeks prior to admission, the patient experienced a fall at there stairs (4 steps), she was admitted at Zamboanga by then. Due to insufficiency of the equipments of their hospital, her children decided to transfer her at COMC here in Cagayan de Oro City and was diagnose DM, Fracture Left 8th Rib minimally displaced Fracture of Distal Left Clavicle.

III. GROWTH AND DEVELOPMENT Developmental Task Theory of Robert Havighurst A developmental task is a task which arises at or about a certain period in the life of an individual. Basing on Havighurst theory our patient C.B.P. belongs in the later maturity 79 years old stage wherein she has adjusted to decreasing physical strength and health and the patient also has settled for a reduced income. Psychosexual Theory of Sigmund Freud The psychosexual stage of Sigmund Freud has five developmental periods during which the individual seeks pleasure from different areas of the body associated with sexual feelings. Basing in this theory, C.B.P. belongs to the genital stage wherein she has already achieved sexual desires. She has five children. Fortunately, She has a good personal relationship with her children. She has fully achieved the implications of this stage because she was able to raise a family, making a living and doing it independently apart from her parents. The value of decision making has already matured in the patient, upon making many decisions for herself and her family. Psychosocial Theory of Erik Erickson Erik Erickson envisioned life has a sequence of levels of achievements. Each stage signals tasks that must achieved. He believed that the greater the task achievement, the healthier the personality of the person. Failure to achieve the tasks influences the persons ability to achieve the next tasks. Basing on this theory, C.B.P. belongs to the maturity Stage wherein she has already achieved sexual desires he has 5 children at present. The patient 5

feels that she has already lived longer to see her children grow up and live a life of their own. She thinks that she already has served her purpose in this life and found uniqueness in the life that she is leading. She accepted that all life forms has their own end and has accepted that sooner she will have to leave his children behind, because she is open in the concept of death but she has also fear from it. Cognitive Theory of Jean Piaget Cognitive development refers to how a person perceives, thinks, and gains understanding of his or her world through the interaction and influence of genetics and learning factors. Basing on this theory C.B.P. belongs to the Formal Operational Phase wherein she has solved previously encountered problems in a logical manner and has used rational thinking. This includes overcoming financial problems and her personal family problems.

IV. MEDICAL MANAGEMENT A. Medical Orders and Rationale Doctors Order August 1, 2009 11:35 AM Pls. admit under the service of Dr. Chang Secure consent of care TPR q4 Soft Diabetic Diet Labs: CBC, U/A, Chest x-ray PA view, Ultrasound of the liver and gallbladder,NA+ K+ Start venoclysis with PNSS I L @ 10gtts/min O2 2-3L/min Med: Celecoxib 200mg BID Intake and output monitor q shift August 2, 2009 8:00 AM Request for FBS, crea, NA+ K+ IVF to follow PNSS 1L at same rate. Rationale For proper management/care. For legal purposes To monitor any changes in TPR Diet for patient to provide proper nutrition To determine deviation and to know any abnormalities . To provide fluid and electrolytes and serves as a channel for any drug that can be administer through it (IVTT). Provide enough oxygen.

For management of moderate to severe pain. To determine fluid balance going in and out from the body.

To re-evaluate the values of the result. To provide fluid and electrolytes and serves as a channel for any drug that can be administer through it (IVTT).

For management of the fracture Meds: Kalimate 2 sachets TID NaHCO3 650mg 1 tab TID Lactulose 30ml OD Continue Celecoxib 200mg BID Refer accordingly For Rehabilitation Informed Dr. Sison for comanagement For co-management For electrolytes balance in the body Antacid; neutralize secreted acid. Laxative: Prevent/treatment for constipation. Management of pain. Refer any abnormalities/ anusualities.

August 3, 2009 8:50 AM Side drip Aminoleban 500 @ 20cc/hr. Repeat for FBS, crea, NA+ K+ Continue Rehabilitation Informed Dra. Tia for comanagement Turn to sides q 2 hours Moderate high back rest Provide footboard Amoxiclav 500 I tab TID Itopride 50 mg TID Pancreatin 50mg BID

For hepatic encelopathy due to chronic liver disease. To monitor blood glucose level and to to check for electrolyte imbalance. For proper management For co-management To prevent bed sore. To facilitate proper breathing To provide comfort. For lower tract infections. To prevent nausea and vomiting. For bloating and flatulence as in pancreatic insufficiency. Refer any abnormalities/ anusualities.

Meds:

Refer accordingly Treatment and prevention of asthma. To provide fluid and electrolytes and serves as a channel for any drug that can be administer through it (IVTT).

August 4, 2009 9:15AM Ventolin 1 neb now IVF to follow PNSS @ 10gtts/min

DRUG STUDY SODIUM BICARBONATE Classification: Acidifiers and Alkalinizers Dosage/route: 650mg TID , po Mechanism of Action: Restores buffering capacity of the body and neutralizer excess acid. Specific Indication: Cardiac Arrest, Metabolic Acidosis, Systemic or Urinary Alkalinization and Antacid Contraindications: Patients who are losing chlorides because of vomiting, continuous GI suction and in those receiving diuretics that produce hypochloremic alkalosis. Oral sodium bicarbonate is contraindicated for patients with acute ingestion of strong mineral acids. Side Effects: Tetany, Edema, Gastric Distention, Belching, and Flatulence. Nursing Precaution: To avoid risk of alkalosis, obtain blood pH, partial pressure of arterial oxygen, partial pressure of partial carbon dioxide, and electrolyte levels. Keep prescriber informed of laboratory results. KALIMATE Classification: Electrolytes Mechanism of Action: After administration of Kalimate via oral, calcium ion of Kalimate is exchanged for potassium ion in the intestinal tract, particularly around the colon, and Kalimate is excreted as unchanged polystyrene sulfonate resin into the feces without digestion and absorption. In consequence, potassium in the intestinal tract is excreted outside the body. Dosage/route: 2 sachets TID, po Specific Indication: Prevention & treatment of hyperkalemia resulting from acute or chronic renal failure. Contraindications: Patients w/ intestinal obstruction & stenosis, constipation.

Side Effects: Constipation, anorexia & nausea. Hypopotassemia. Nursing Precaution: Careful administration in patients with hyperparathyroidism (blood concentration of calcium may be increased by ion exchange) and patients with multiple myeloma (blood concentration of calcium may be increased by ion exchange). Important: Kalimate should be administered while measuring the serum potassium and serum calcium levels regularly to prevent overdose. If any abnormal findings are observed, appropriate measures eg, reduction of dose or withdrawal of the drug should be taken.

FUROSEMIDE Classification: Loop diuretic Dosage/route: 40 mg BID, po Mechanism of Action: Inhibits the reabsorption of sodium and chloride from the ascending limb of the loop of Henle, leading to a sodium-rich diuresis. Specific Indication: Furosemide is a "water pill" (diuretic) that increases the amount of urine you make, which causes your body to get rid of excess water. This drug is used to treat high blood pressure. Lowering high blood pressure helps prevent strokes, heart attacks, and kidney problems. This medication also reduces swelling/fluid retention (edema) which can result from conditions such as congestive heart failure, liver disease, or kidney disease. This can help to improve symptoms such as trouble breathing. Contraindications: Contraindicated with allergy to furosemide, sulfonamides; allergy to tartrazine (in oral solution); anuria, severe renal failure; hepatic coma; pregnancy; lactation. Side Effects: CNS: Dizziness, vertigo, paresthesias, xanthopsia, weakness, headache, drowsiness, fatigue, blurred vision, tinnitus, irreversible hearing loss CV: Orthostatic hypotension, volume depletion, cardiac arrhythmias, thrombophlebitis Dermatologic: Photosensitivity, rash, pruritus, urticaria, purpura, exfoliative dermatitis, erythema multiforme GI: Nausea, anorexia, vomiting, oral and gastric irritation, constipation, diarrhea, acute pancreatitis, jaundice GU: Polyuria, nocturia, glycosuria, urinary bladder spasm Hematologic: Leukopenia, anemia, thrombocytopenia, fluid and electrolyte imbalances, hyperglycemia, hyperuricemia Other: Muscle cramps and muscle spasms Nursing Precaution: Use cautiously with SLE, gout, diabetes mellitus. 10

Give early in the day so that increased urination will not disturb sleep. Administer with food or milk to prevent GI upset. Reduce dosage if given with other antihypertensives; readjust dosage gradually as BP responds. Measure and record weight to monitor fluid changes.

CELECOXIB Classification: Nonsteroidal Antiinflammatory drug Mechanism of Action: This medication is a nonsteroidal anti-inflammatory drug (NSAID), specifically a COX-2 inhibitor, which relieves pain and swelling (inflammation). It is used to treat arthritis, acute pain, and menstrual pain and discomfort. Celecoxib is also used to decrease growths found in the intestines (colon polyps) of persons with a family history of this condition. This drug works by blocking the enzyme in your body that makes prostaglandins. Decreasing prostaglandins helps to reduce pain and swelling. Dosage/route: 200 mg BID, po Specific Indication: Celecoxib is licensed for use in osteoarthritis, rheumatoid arthritis, acute pain, painful menstruation and menstrual symptoms, and to reduce the number of colon and rectal polyps in patients with familial adenomatous polyposis. It was originally intended to relieve pain while minimizing the gastrointestinal adverse effects usually seen with conventional NSAIDs. In practice, its primary indication is in patients who need regular and long term pain relief: there is probably no advantage to using celecoxib for short term or acute pain relief over conventional NSAIDs. In addition, the pain relief offered by celecoxib is similar to that offered by paracetamol.[1] Contraindications: Hypersensitivity including those in whom attacks of angioedema, rhinitis and urticaria have been precipitated by aspirin, NSAIDs or sulfonamides. Severe hepatic impairment; severe heart failure; inflammatory bowel disease; peptic ulcer; renal impairment. Side Effects: The most common adverse effects are headache, abdominal pain, dyspepsia, diarrhea, nausea, flatulence, and insomnia. Other side effects include fainting, kidney failure, heart failure, aggravation of hypertension, chest pain, ringing in the ears, deafness, stomach and intestinal ulcers, bleeding, blurred vision, anxiety, photosensitivity, weight gain, water retention, flu-like symptoms, drowsiness and weakness. Nursing Precaution: History of GI bleeding; renal/hepatic insufficiency; asthma or allergic disorders; hypertension; monitor haemoglobin or haematocrit levels for signs of anaemia. History of cerebrovascular disease or ischaemic heart disease.

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LACTULOSE Classification: Laxatives Mechanism of Action: Lactulose promotes peristalsis by producing an osmotic effect in the colon with resultant distention. In hepatic encephalopathy, it reduces absorption of ammonium ions and toxic nitrogenous compounds, resulting in reduced blood ammonia concentrations. Dosage/route: 30 ml OD Specific Indication: Used to treat constipation. Contraindications: Galactosaemia, intestinal obstruction. Patients on low galactose diet. Side Effects: This medication may cause gas, belching or stomach cramps. If these effects continue or become bothersome, inform your doctor. Notify your doctor if you develop any of these effects while taking this medication: diarrhea, nausea, vomiting. If you notice other effects not listed above, contact your doctor or pharmacist. Nursing Precaution: Monitor electrolyte imbalance. Lactose intolerance; diabetics. Laboratory Exams: Urinalysis Test Color Transparency Pus cells RBC Epithelium Amorphous Complete Blood Count Test WBC Hemoglobin Hematocrit Result 10,800 13.8 38.7 Normal Value 5,00010,000/mm 13.7-16.7 g/dl 40.5-49.7 vols% Result Yellow Clear 10-21hpf 5-12hpf Few Few Date: August 1, 2009, Significance Normal Normal Normal Normal Normal Normal Date: August 1, 2009 Significance Increase infection, dehydration, leukemia, trauma polycythemia vera Hemoglobin is the main transport of oxygen and carbon dioxide in the blood. Increase in erythrocythosis, dehydration and hemoconcentration associated with shock Platelets (also known as thrombocytes) are the 12

Platelet Count

Adequate

150,000-

450,000/mm

smallest formed elements of the blood. They are vital to coagulation of the blood to prevent excessive bleeding. Depressed level may indicate an exhausted immune system. Low levels are indicative of a good state of health. . Basophilic activity is not fully understood but it is known to carry histamine, heparin, and serotonin. Date: August 1, 2009

Lymphocytes Monocyte Basophil

15 3 2.5

Differential Count 17.4-46.2% 4.3-10.3% 2-3%

Blood Chemistry Test Phosphorus Potassium Result 5.43 6.0

Glucose Sodium

422.7 150.6

Normal Value Significance 2.50-50.0mgs/dL Metastatic neoplasm to bone 3.5-5.5mEq/L Increase excess IV administration, Potassiumsparing diuretics, infection, dehydration, acidosis, blood transfusion, burns and trauma 60.00-110.0 Diabetes Mellitus 135-145mEq/L Increase dietary or IV intake DI, Cushings syndrome, increase swating. Date: August 1, 2009 Normal Value 8.1010.40mmol/L 0.6-1.1 mg/dL Significance Acute pancreatitis, nephrosis, Increase renal failure, muscular dystrophy, hyperthyroid, acromegaly, rhabdomyolysis

Blood Chemistry Calcium Creatinine Result 4.03 2.93

Chest X-RAY

Date: August 2, 2009 Impression Cardiomegaly, LV form HEArt enlarged

13

Pulmonary congestion Minimal Pleural effusion, bilateral Atherosclerosis aorta Fracture left clavicle and left 8th posterior rib ULTRASOUND Liver and Gallbladder Impression: Contracted liver Gall stone with sludge Ascites Minimal Date: August 2, 2009

V. ANATOMY AND PHYSIOLOGY The Skeletal System serves many important functions; it provides the shape and form for our bodies in addition to supporting, protecting, allowing bodily movement, producing blood for the body, and storing minerals. Its 206 bones form a rigid framework to which the softer tissues and organs of the body are attached. Vital organs are protected by the skeletal

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system. The brain is protected by the surrounding skull as the heart and lungs are encased by the sternum and rib cage. Bodily movement is carried out by the interaction of the muscular and skeletal systems. For this reason, they are often grouped together as the musculoskeletal system. Muscles are connected to bones by tendons. Bones are connected to each other by ligaments. Where bones meet one another is typically called a joint. Muscles which cause movement of a joint are connected to two different bones and contract to pull them together. An example would be the contraction of the biceps and a relaxation of the triceps. This produces a bend at the elbow. The contraction of the triceps and relaxation of the biceps produces the effect of straightening the arm.

The Ribs The ribs are thin, flat, curved bones that form a protective cage around the organs in the upper body. They are comprised 24 bones arranged in 12 pairs. The first seven bones are called the true ribs. These bones are connected to the spine (the backbone) in back. In the front, the true ribs are connected directly to the breastbone or sternum by a strips of cartilage called the costal cartilage. The next three pairs of bones are called false ribs. These bones are slightly shorter than the true ribs and are connected to the spine in back. However, instead of being attached directly to the sternum in front, the false ribs are attached to the lowest true rib. The last two sets of rib bones are called floating ribs. Floating ribs are smaller than both the true ribs and the false ribs. They are attached to the spine at the back, but are not connected to anything in the front. The ribs form a kind of cage the encloses the upper body. They give the chest its familiar shape.

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The Shoulder Girdle The Shoulder Girdle, also called the Pectoral Girdle, is composed of four bones: two clavicles and two scapulae . The clavicle, commonly called the collarbone, is a slender S-shaped bone that connects the upper arm to the trunk of the body and holds the shoulder joint away from the body to allow for greater freedom of movement.

PATHOPHYSIOLOGY

16

Predisposing Factor

Precipitating

Age (79 y.o) Liver cirrhosis Diabetes Mellitus

Unsafe external environment

Fall (4 steps stairs) Rib fracture, clavicle frature

Body malaise, dyspnea, pain

Pleural infusion

Increase blood glucose level

Impaired tissue perfussion

Liver unable to synthesize protein/amino acid

Renin-angitensinAldosterone-system activation

PAIN Impaired oxygenation

Low fat absorption 17 Low protein absorption

Age (79 y.o) Liver cirrhosis Diabetes Mellitus

Unsafe external environment

Fall (4 steps stairs) Rib fracture, clavicle frature

Body malaise, dyspnea, pain

Pleural infusion

Increase blood glucose level

Impaired tissue perfussion

Liver unable to synthesize protein/amino acid

Renin-angitensinAldosterone-system activation

PAIN Impaired oxygenation

Low fat absorption

Low protein absorption Fluid shifting to secretion Aldosterone secretion

Increase sodium and water retention

Water and sodium retention EDEMA

NURSING ASSSESSMENT (System Review Chart) 2009

Date: August 2,

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Name: C.B.P. BP: 140/80 mmHg inches Weight:

EENT: [ ] Impaired vision [ ] blind [ ] pain redden [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion teeth [ ] assess eyes ears nose [ ] throat for abnormality [x] no problem RESP: [ ] Asymmetric [x ] tachypnea [ ] barrel chest [ ] apnea [ ] rales [ ] cough [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [x ] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic [ ] assess resp. rate, rhythm, depth, pattern, breath sounds, comfort [ ] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ]numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain [ ] Assess heart sounds, rate rhythm, pulse, blood pressure, circ., fluid retention, comfort [ x ] no problem GASTROINTESTINAL TRACT: [ ] obese [ x ] distention [ ] mass [ ] dysphagia [ ] rigidity [ ] pain [ ] assess abdomen, bowel habits, swallowing [ ] bowel sounds, comfort [ ] no problem

T: 36.6C

PR: 85 bpm

RR: 22 cpm

Height: 52

Swelling/edema Pitting Edema (grade 1) Adbominal distention Wound

GENITO URINARY AND GYNE [ ] pain [ ] oliguria [ ] color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia [x ] assess urine frequency, control, color, odor, comfort [ ] gyne bleeding [ ] discharge [ x ] no problem NEURO: [ ] paralysis [ ] stuporus [ x ] unsteady [ ] seizure [ ] lethargic [ ] comatose [ ] vertigo [ ] treamors [ ] confused [ ] vision [ ] grip [ ] assess motor, function, sensation, LOC, strength [ ] grip, gait, coordination, speech [x] no problem MUSCULOSKELETAL and SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechie [ ] hot [ ] drainage [ ] prosthesis [x] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] flushed [ ] atrophy [x] pain [ ] ecchymosis [ ] diaphoretic moist [ ] assess mobility, motion gait, alignment, joint function [ ] skin color, texture, turgor, integrity [ ] no problem

Dry skin

Generalized Weakness

Edema

NURSING ASSESSMENT II
SUBJECTIVE OBJECTIVE

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COMMUNICATION: [ ] hearing difficulty [ ] visual changes [x ] denied Comments:"dili na kyo [ ] glasses [ ] languages siya ka-klaro pero sige [ ] contact lenses [ ] hearing difficulties due to age tanaw og tv as [ ] speech difficulties verbalized by watcher Pupil size:R:3 mm L:3mm Reaction: PERRLA (Pupil Equally Round and Reactive to Light Accommodation) OXYGENATION: [x ] dyspnea [ ] smoking history [ ] cough [ ] sputum [ ] denied CIRCULATION: [ ] chest pain [ ] leg pain [ ] numbness of extremities [x ] denied Comments: wala man ko ing ana nga problema ang akung tiyan lang ang sakit og ayo , as verbalized by patients watcher. Heart Rhythm [x] regular [ ] irregular Ankle Edema: ankle edema is present on both extremities Pulse Car R L + + Rad. 85bpm + DP + + Fem +____ +____ Comments: lisud au iginhawa, as verbalized by the patient. Resp. [x ]regular [] irregular Describe: RR is regular and it is within range. R: unsymmetrical to the left lung L: unsymmetrical to the right lung

Comments: Pulse on all sites are palpabale yet weak on the radial and dorsalis pedis areas due to presence of edema. Comment: Gamay ra lagi iyang gaka-on amo lang luguson ky daghan bya sya tambal,as verbalized by watcher. Ganiwang na gani siya as verbalized by the watcher [ ] dentures Full Upper Lower [ ] [ ] [ x ]none Partial [ ] [ ] With patient [ ] [ ]

NUTRITION: Diet: Soft diabetic Character [x ] recent change in weight [ ] swallowing Difficulty [ ] denied

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ELIMINATION: Usual bowel pattern: Once a day [ ] constipation remedy ______None______ Date of last BM August 1, 2009 [ ] diarrhea ______None_______ _ MGT. OF HEALTH & ILLNESS: [ ] alcohol [x] denied (amount/frequency) [ ] SBE: Not recalled RECAlled LMP: Not recalled Last Pap Smear: NOT [x] urinary frequency In foley catheter [ ] urgency [ ] dysuria [ ] hematuria [ ] incontinence [ ] polyuria [ ] foley in place [ ] denied

Comments:Patients bowel sounds auscultated and she has an audible normoactive.

Bowel sounds Audible normoactive bowel sounds every 10-15 sec. Abdominal Distention Present [x ] yes [] no Urine* (color, consistency, odor) ____amber or strong______ Foley if they are in place: Foley bag catheter in place

Briefly describe the patients ability to follow treatments (diet, meds, etc.) for chronic health problems (if present). Patient is able to follow treatments, such as her medications and soft diabetic diet as prescribe by the physician during this admission but her maintenance for her liver cirrhosis she stop it because of inconvenience during her follow up check up at Cebu.

SUBJECTIVE SKIN INTEGRITY: [x ] dry [ ] other [] denied Comments: dry lagi iyang panit na basin sa pagkatigulang na, as verbalized by the watcher [x ] dry [ ] flushed [ ] moist

OBJECTIVE [ ] cold [ ] warm [ ] cyanotic [x ] pale

*rashes, ulcers, decubitus (describe size, location, drainage: Healing woung at left leg. Comments: Dili kayo lagi niya malihok iyang abaga og likod, as verbalized by the watcher. [ ] LOC and orientation Patient is oriented to time, place, events and person. Gait: [ ] walker [ ] cane [ ] other

ACTIVITY/ SAFETY: [ ] convulsion [ ] dizziness

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[x ] limited motion of Joints Limitation in Ability to [ ] ambulate [ ] bathe self [ ] other COMFORT/SLEEP/ AWAKE: [] pain (location,frequency remedies) [ ] nocturia [x] sleep difficulties [ ] denied COPING: Occupation: Housewife Members of household: 5 members of household Most supportive person: her five children Comments: Dili kayo siya katulog kay galisod siya og ginhawa, as verbalized by the watcher

[ ] steady

[x ] unsteady

[ ] sensory and motor losses in face or extremities No sensory and motor losses on face or extremities [x] ROM limitations: she can move but with limitation and with accompany.

[] facial grimaces [x] guarding [ ] other signs of pain : Patient was able to manage the pain within tolerable limit.

Observed non-verbal behavior: weakness or fatigue Phone number that can be reached anytime: Confidential

SPECIAL PATIENT INFORMATION _Not ordered Daily weight ____N/A___ PT/OT ____N/A___ Irradiation August 1, 2009 Urine test not ordered 24 hour Urine _140/80 mmHg BP q shift ___not ordered__ _ Neuro vs ____N/A_ Collection _ CVP/SG Reading

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VII NURSING MANAGEMENT A. Ideal Nursing Management Diagnoses: Ineffective Breathing Pattern related to respiratory muscle weakness. Intervention Investigate etiology of respiratory failure. Observe over-all breathing pattern. Auscultate chest noting the presence or absence of breath sounds. Count clients respiration 1 full minute and compare with desire set rate. Check tubing of oxygen for obstruction. Rationale To understand the underlying cause. To attempt to correct the deficiency by over breathing. To note the frequent crackles that doesnt clear with coughing. Respirations vary depending on problem requiring ventilatory assistance. Kinks in tubing prevent adequate volume of delivery.

Diagnoses: Acute Pain related to injury to the soft tissue Intervention Rationale Maintain immobilization of Relieves pain and prevent extension affected area. of the injury. Elevate and support injured extremities. Avoid use of plastic sheets. Evaluate reports of pain/discomfort. Identify any diversional activities. Apply cold/ice pack. 23 Promotes venous return. Promotes discomfort Monitor effectiveness of intervention. Prevents boredom, reduces muscle tension. Reduces edema.

Diagnoses: Activity intolerance related to generalized weakness Intervention Adjust activities and reduce intensity level or discontinue activities that cause undesired physiologic changes. Increase exercise and activity level gradually. Plan care with rest periods between activities. Assist with activities and provide client used of assistive devices. Promote comfort measures and provide for relief of pain. Provide positive atmosphere while acknowledging difficulty of the situation for the client. Diagnoses: Risk for ineffective peripheral Tissue Perfusion Intervention Provide air mattress, sheepskin padding, bed/foot cradle. Apply ice and elevate lower extremities. Administer physicians order of medication. Rationale To protect the extremities. To reduce edema. To give comfort and reduce edema. To conserve energy Rationale To prevent over excretion.

To reduce fatigue

To protect the client from injury

To promote comfort measures and provide for relief of client. Helps to minimize frustration, reduce channel energy.

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 To prevent venous stasis Apply ace bandage to lower extremities before arising from bed.

B. Actual Nursing Management

S O A P I E

Lisud au iginhawa as verbalized by the patient. Dyspnea Changes in rate and depth of respirations Increased restlessness

Ineffective Breathing Pattern related to respiratory muscle weakness. At the end of 2-3 minutes, the patient will maintain respiratory pattern. Independent Maintained in moderate to high back rest. Checked tubing for obstruction. Observe over-all breathing pattern Dependent Set Oxygen at 3L/min At the end of 2 minutes, the patient maintains her respiratory pattern.

25

S O A P I

sakit lagi iyang abaga og likod as verbalized by the patient. Restlessness Facial grimace Guarding the affected part.

Acute pain related to injury to the soft tissue

At the end of 15-30 minutes the patient will able to verbalized pain into tolerable level Independent Reinforced position (semi-fowlers) to the patient. Encouraged adequate rest periods Reviewed ways to lessen pain, including techniques. Discuss with significant others ways in which they can assist the client in activities. Dependent Administer medication for pain. Celecoxib 200mg BID

At the end of 30 minutes the patient was able to response to interventions and verbalized relief of pain.

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S O A P I

Dili kayo lagi niya malihok iyang abaga og likod busa dili kayo siya kalihok as verbalized by the watcher Weakness. Inability to begin activity Activity Intolerance related to generalized weakness At the end of 8 hours, the patient will be able to have gradual return to physical movement and mobility Independent Encouraged patient to do bed exercises such as arm exercises abduction and external rotation of shoulder, hand and fingers exercises and foot exercises. Assisted patient in activities that begins by sitting at the side of the bed and in chair. Assisted early ambulation of patient. Assisted patient to performed ADL with involvement of significant others. Provided physical support and maintained patients safety. At the end of 8 hours, the patient was able to demonstrate gradual return to physical movement and mobility within tolerance as evidenced by increasing ambulation and participation in personal care activities.

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VIII. REFERRALS AND FOLLOW-UP

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The patient was instructed to continue medications namely Kalimate 2 sachets TID, Sodium Bicarbonate 650mg TID, Lactulose 30ml OD, Celecoxib 200mg BID, ITOPRIDE 50mg TID, Pancreatin I tab TID

MEDICATIONS

She and her significant others was advised to comply all the medications needed as prescribed by the physician.

Patient and significant others was instructed about the proper administration of medications according to right dose, right time and right route, and be cautious to possible side effects.

EXERCISE

Encourage Range of Motion Exercises Follow medication as prescribed by the physician. Turn to sides every two hours. Provide footboard.

TREATMENT

OUTPATIENT (Check-up)

DIET

Maintained moderate to high back rest. The patient is advised to have her follow-up check-up one week after at Cagayan de Oro Medical Center, Building 1, 2nd Floor at the clinic of Dr. Chang. Encourage patient to eat foods rich in Vit. C like fruits to enhance the immune system. Encourage patient to increase fluid intake to maintain fluid and electrolyte balance in the body.

IX. EVALUATION AND IMPLICATION

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PROGNOSTIC INDICATORS POOR A. Onset of illness B. Duration of illness C. Precipitating factors D. Attitude and willingness to take medication E. Family support

GOOD

After having interacted with the client for 2 days and rendered nursing interventions, we therefore concluded that our objectives were met. Also based on thorough observation and data gathered, we had identified that the client has a poor prognosis since she is too old to recover from her illness and she had experienced many complications. Although the family support system towards the client is good, we still encourages the family to continue on supporting the medical and emotional support of the client in gearing towards hospitalization and consultation. They are encouraged to be sensitive to the needs and care of the patient since she is old. We implied for a continue support system towards the client and be cautious if theres any complains from the client or any signs of another health problems.

B. BIBLIOGRAPHY

Kozier, B. et al. Fundamentals of Nursing, 7th ed. Singapore: Pearson Education South Asia PTE LTD, 2004

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Lippincott. Nursing 2007 Drug Guide, PA: Lippincott Williams & Wilkins, 2007 Phipps, et al. Medical-Surgical Nursing: Concepts and clinical Practice, vol. 1, 5th ed Missouri: Mosby-Year Book, Inc., 1995

MIMS Philippines, 109th ed. CMPMEdica, 2006 Tortora, G.J.& Grabowski S.R.; Principles of Anatomy and Physiology; 10th Edition; John and Wiley and Sons, Inc.; 2003. Karch, Amy M.; Focus on Nursing Pharmacology; 3rd Edition; Lippincot Williams and Wilkins; 2006. Doenges, E.M., Moorhouse, M.F. Geisslerr-Murr, A.C.; Nurses Pocket Guide Diagnoses, Interventions and Rationales; 9th Edition; F.A. Davis Company Philadelphia; 2004.

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