PATIENT’S PROFILE

Patient x is a 38 years old male and was born on September 30,

1967 in Las Nieves Agusan del Norte and is currently residing their. He
stands about 5 foot 6 inches tall and weighing 80 kg. He is married. He
is Roman Catholic. He was able to study on high school but was not
able to finish and proceed to college. Presently he is working in the
Municipality of Las Nieves as a Collector in the Treasurer Department.

He had an elder sister, who were the only one able to finished
college and is currently working as a Teacher. He is currently living with
his wife and five children’s, three of which are females and was
currently studying, the eldest was 14 years old and the youngest was 1
year old.

After the incident, he has never been admitted to a Hospital

before and with no records of any major Medical and Surgical
operations. He has not suffered from any other disorders. He eats his
meals regularly (three times a day), he is non-smoker and drinks only
occasionally. He sleeps about 6 hours and retires to sleep usually at 10
or 11 pm. and wakes at 4 or 5am for an early jogging. Elimination is
regular usually in the morning daily. Sexual life is still active.

He has a brownish skin complexion with long wavy hairs and

brown eyes. Skin shows observable signs of trauma likely bruises to his
right lower left arm on the back portion of his palms, left eye on the
eyelids, left lower extremities at the knees also on the back portion at
the right scapular region and on his head at the back portion
(occipitalis).

He has limited range of motion particular to his left knee of were

the major injuries can be observed. He was lying on bed at supine
position. Skin bruises were covered and draped. Considering the four
days of continued medication skin shows observable signs of wound
healing.
 He is cooperative and responded well during the interview. He is
calm and coherent upon answering the questions although a little bit
depressed.

Prior to admission, he had been into a road motorcycle accident,

he was still conscious after that but was not able to help himself and
were then immediately admitted to Butuan Doctors’ Hospital that was
on May 29, 2005, Saturday at 4:30 pm. but before that, he was first
carried to Las Nieves Municipal Hospital for the first aid treatments and
at the same hour transferred to Butuan Doctors’.

The patient had been experiencing a burning sensations of pain

at the scale of about 6:10 particular at the lower extremities on the left
leg at the knees and as well as back pains as evidenced by skin bruises
related to the accident, muscle pains related to the impact, a little
dizziness prior to head contusions and some joint pains of which are
probably referred pains.

Upon admission he was c/o by Dr. Dacudao as his admitting

physician, were he was ordered to taking medication for pain and
infection control. On that day he was also ordered to be X-rayed
peculiar to the affected body part from were it reveals that the bones
of his left knee (patella) were crack or that it shows a slight fracture
which needs to be supported “I pa semento” and bruises to be sutured
to avoid complications.
NURSING CARE PLAN: Impaired Walking
Nursing Diagnosis: controlled knee flexion at the left lower extremities of the leg due a crack patellar bone and
intense pain upon movement as evidenced by an open wound.
Goals Outcomes Nursing Interventions Implementations Evaluations

• After a month 1. Within an hour 1. The patient will be provided

of continued or less after different methods and teachings on
therapy the admission the pain control measures. So that he will
patient will be patient can express be knowledgeable upon the proper
able to walk a feeling of relief pain management technique.
normal and and satisfaction
regain his with no alterations 2. He will be X-rayed STAT or after
optimum level in comfort. Hospital admission and be instructed
of functioning. to lie on bed at supine position with
2. The patient will limited ROM on the affected body
• Be able to be knowledgeable part. To examine for possible minor or
coop with his on his actual and major bone fractures or dislocations.
condition potential health
physically and problems prior to 3. Will be assessed for wound care
psychologically his condition. and change of bondages OD and will
as well. be medicated as physicians order. To
3. Will be confined avoid infections and hasten the would
• Within 2 for bed rest with healing.
months the continued
patient will medications at
fully recover. about a week or
more with
controlled body
movement 4. Vital signs will be monitored every
particular on the Nursing rotations. To always have a
affected part from data update for possible
which will be complications or infections.
braced or
supported until 5. He will be demonstrated on the
observable signs of proper body mechanics regarding on
wound healing and his ROM and will be teached on how
no pain upon to walk with or without
movement are support/scratches or assistance. To
noted. promote o maintain self-esteem.

4. Will be provided 6. Discuss the importance of

different teachings adequate food intake (eating foods
and methods of that are rich in proteins,
cooping with his carbohydrates, calories). It would be
impaired necessary for him towards faster
functioning and wound healing and recovery
within 2 months
the patient will be
fully recovered and
function normally.