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Case study: case 1 Group 4.2 - Coggle Diagram
Case study: case 1
Group 4.2
Medical Diagnosis
: Open fracture at right femur.
The procedure:
debridement with ORIF with plate and screw right femur with off external fixation femur on 21/3/2022
Spinal block with morphine
Treatment
Date: 20/3/2022
Order for one day
At 3:00 a.m.
-Collected blood for CBC (Complete Blood Count)
-Admitted at ward 8 (IPD)
At 4:00 a.m.
-Provide Tramadol 50 mg/ml inj. every 6 hrs.
-Provide NaCl 0.9% 1000 ml rate 100 ml/hrs
At 6:15 a.m.
-Collected blood for CBC (Complete Blood Count)
At 1:00 p.m.
-Provide Metoclopramide 10mg/2 ml inj. every 6 hrs prn.
-Provide Tramadol 50 mg/ml inj. every 6 hrs prn.
-Provide NaCl 0.9% 1000 ml rate 83.33 ml/hrs
At 2:00 p.m.
-Blood sugar (DTX)
-Collected blood for group match.
At 4:25 p.m.
-Provide Leukocyte Poor Packed Red Cell (LPRC)
At 11:00 p.m.
-Collected blood for Hematocrit
Order for continuous
At 4:00 a.m.
-Provide Paracetamol 500 mg tab every 6 hr prn.
-Provide ceFAzolin 1 g inj 1000 mg every 6 hrs rate 100 ml/hrs.
-Provide NaCl 0.9% 100 ml every 6 hrs rate 100 ml/hrs.
At 1:00 p.m.
-Provide Diclofenac EC 25mg (tab) 1x3 pc
-Provide Paracetamol 500 mg (tab) 1 tab every 6 hrs prn.
-Provide Orphenadrine+Para 35+500 mg (tab) 1x3 meals pc.
-Provide Ciprofloxacin 200mg/100 ml inj. every 12 hrs. At 10:00 a.m., 10:00 p.m.
Date: 21/3/2022
Order for one day
At 0:00 a.m.
-Provide soft diet
At 5:00 a.m.
-Collected blood for assess Hematocrit.
At 8:25 a.m.
-Provide Leukocyte Poor Packed Red Cell (LPRC)
At 2:00 p.m.
-Transfer to operation room for do the procedure.
At 7:00 p.m.
-Admitted at ward
-Provide NaCl 0.9% 1000 ml rate 100 ml/ hrs.
-Provide Metoclopramide 10 mg/2 ml inj. every 6 hours prn.
-Provide Morphine 10 mg/ml inj. every 3 hours prn.
-Provide Marcain isobaric spinal 0.5% 4 ml inj. 3.4 ml in one time.
Order for continuous
At 7:00 p.m.
-Dietary Order
Date: 22/3/2022
Order for one day
At 6:00 a.m.
-Collected blood for assess Hematocrit.
At 8:25 a.m.
-Provide NaCl 0.9% 1000 ml rate 100 ml/hrs.
-Provide Morphine 10 mg/ml inj. every 3 hours prn.
-Dressing wound
Date: 23/3/2022
Order for one day
At 6:00 a.m.
-Collected blood for assess Hematocrit.
At 7:50 a.m.
-Provide Metoclopramide 10 mg/2 ml inj. every 6 hours prn.
-Provide Tramadol 50 mg/ml inj. every 6 hrs prn.
At 8:30 a.m.
-Consult to physicians therapist.
-Dressing wound
At 9:30 a.m.
-Ambulation gait Training+ Education
At 10:30 a.m.
-Provide Leukocyte Poor Packed Red Cell (LPRC)
Date: 24/3/2022
Order for one day
At 6:00 a.m.
-Collected blood for assess Hematocrit.
At 9:40 a.m.
-Dressing wound.
At 9:55 a.m.
-Discharge with homemed
-Follow up
At 10:15 a.m.
-Ambulation gait Training+ Education
At 2:00 p.m.
-Discharge
Order for continuous
At 9:55 a.m.
-Provide Orphenadrine+Para 35+500 mg (tab) 1x3 pc. per oral.
-Provide Diclofenac EC 25 mg (tab) 1x3 pc per oral.
-Provide CaCO3 1 gm (tab) Calcium carbonate 1x2 pc per oral.
-Provide Ciprofloxacin 500 mg (tab) 1x2 pc per oral.
-Provide Co-amoxiclav 1 gm (tab) 1x2 pc. per oral.
Patient sign and symptoms
Date 20 March 2022
The patient had lacerate wound on his right femur with the bone come out
Date 21 March 2022
The patient had pain score 3
Date 23 March 2022
Post-operation day 2
The patient had pain score 2
The patient had nausea and vomiting
Date 24 March 2022
The patient had nausea and vomiting
Post-operation day 3
Date 22 March 2022
Post-operation day 1
The patient had pain score 5 and fever 38.2 C
**Nursing problems and Nursing intervention
Patient had pain related to lacerate wound on his right femur with the bone come out
Subjective : The patient said “I feel pain”
Objective : The patient pain score 3
Nursing goal : Patient are able to management with pain
Evaluation criteria
Vital signs normal
BP 140-90 mmHg
T 36.5-37.4 C
RR 16-24 bpm
P 60-100 bpm
The patient pain score did not increase
The patient can answer 2 of 3 pain management questions
His face expressions has better
Nursing intervention
Assess pain score of patient
Check vital sign every 4 hours
Promote patient to do activities in bed to relieve patient movement
Provide pain management to patient include take a deep breath, find an activity that enjoy doing to distract yourself from the pain
Provide a comfortable position for the patient to relieve the pain
Provide peaceful environment for the patient to rest to relieve pain
Evaluation
Date 21 March 2022
Patient are able to management with pain
Vital signs
BP 134/76 mmHg
T 37 C
RR 20 bpm
P 50 bpm
Patient had pain related to surgical wound
Subjective : The patient said “I feel pain”
Objective : The patient pain score 5
Nursing goal : To reduce the pain of the patient
Evaluation criteria
Vital signs normal
BP 140-90 mmHg
T 36.5-37.4 C
RR 16-24 bpm
P 60-100 bpm
The patient pain score did not increase
His face expressions has better
Nursing intervention
Provide pain management to patient include take a deep breath, find an activity that enjoy doing to distract yourself from the pain
Provide a comfortable position for the patient to relieve the pain
Check vital sign every 4 hours
Provide peaceful environment for the patient to rest to relieve pain
Assess pain score of patient
Provide Tramadol 50 mg to reduce pain
Evaluation
22 March 2022 (Post operation day 1)
Vital signs
T 38.2 C
RR 20 bpm
BP 116/53 mmHg
P 59 bpm
The patient has reduce of pain score 3
His face expressions has better
Risk for fall
Subjective : -
Objective : The patient had surgery at right femur
Nursing goal : To prevent fall of patient
Evaluation criteria
Patient are able to perform daily activities
Nursing intervention
Assess the risk of falls and the ability to perform activities
Inform the patient for the buzzer, if there is a problem, press it
Inform the patient for the buzzer, if there is a problem, press it periodic visits to the patient to assist with daily activities and chang position
Arrange for bed that is not high to prevent fall
Arrange the bedside caninet to be close to the patient hand for convenient to pick up items
Raise the bed guards after provide nursing intervention every time
Evaluation
Date 22-24 March 2022
Patient are able to perform daily activities
Anxiety before operation
Subjective data
: patient said “I feel anxiety about the operation.”
Objective data:
His facial expression has worried because he has never operation before.
Nursing goal:
To reduce anxiety and understand about treatment plan.
Evaluation Criteria:
-His facial expression has better which reduces anxiety.
-Patient has already for doing the procedure.
Nursing intervention:
1.) Give information and express patient to understand the procedure.
2.) Allow the patient to express his feeling.
3.) Suggest his family to encouragement.
4.) When the patient has already, a nurse will suggest self-management before and after the operation.
Evaluation:
On 21/3/2020
1.) His facial expression has better
2.) Patient has already for doing the procedure.
Promote patient to early postoperative ambulation.
Objective data:
patient had surgery on the right femur.
Nursing goal:
To improve the body can recover to do the duties and can reduce time when recovering at the hospital.
Evaluation criteria:
Patient can movement very well.
Patient can recover the body well.
Patient didn’t have complications after operation.
Nursing intervention:
1.) Assess patient about movement that the patient can do.
2.) Assess the limitation of the patient after an operation. If the patient has a limited to move, the nurse will suggest patient to moving his feet.
3.) Assess Pain scores.
4.) Explain to the patient about benefits of early postoperative ambulation.
Evaluation:
On 21/3/2022 24/3/2022
1.) Patient can movement very well.
2.) Patient can recover the body well.
3.) Patient didn’t have complications after the operation.
Patient has nausea and vomiting
Subjective data:
patient said “I feel nausea and vomiting around 3 times.
Objective data:
His facial expression has worried and tried because he has nausea and more vomit.
Nursing goal:
To reduce symptoms of nausea and vomiting.
Evaluation criteria:
patient didn’t have symptoms of nausea and vomit.
His facial expression has better.
Nursing intervention:
1.) Observe signs and symptoms of nausea and vomiting.
2.) Provide food and beverage that can be easy to digest.
3.) Do not force to eat the food.
4.) If the patient has nausea, the nurse will suggest eating a small meal.
Evaluation
:
On 23/3/2022- 24/3/2022
1.) His symptoms of nausea and vomit has better.
2.) His facial expression has better and patient reduce tired.
The patient has anemia related to blood loss in operation room.
Objective data : Hct 32.2% (before OR), Estimate blood loss 400 ml.
Vital signs are normal.
The patient has no signs and symptoms of anemia such as fatigue, dizziness, pale conjunctiva skin or nails, anorexia, heart palpitations, cold hand and feet.
Keep Hct >= 30% as ordered (23 March 2022)
Evaluation criteria :
Goal : The patient has no signs and symptoms of anemia.
Nursing intervention
Monitoring vital signs
Observe signs and symptoms of anemia such as fatigue, dizziness, pale conjunctiva skin or nails, anorexia, heart palpitations, cold hand and feet.
Observe wound have discharge and Radivac drain.
Encourage the patient eat more foods.
Encourage the patient get enough sleep.
Provide LPRC 1 unit and observe signs of allergic blood.
Repeat Hct again on tomorrow by keep Hct >= 30% as ordered. (Order started on 23 March 2022)
Evaluation
21 March 2022
Vital signs are normal : BT 36 C, P 66 bpm, RR 20 bpm, O2 97%, BP 125/80 mmHg (6 PM).
Surgical wound no discharge.
The patient got LPRC 1 Unit 8 AM 1 unit (before OR) and LPRC 1 unit in OR (total 2 unit) no signs of allergic blood. Hct 39.8%
The patient has fatigue but no dizziness, pale conjunctiva skin or nails, anorexia, heart palpitations, cold hand and feet.
22 March 2022 (Post op day 1)
Vital signs are normal : BT 37 C, P 48 bpm, RR 20 bpm, O2 96%, BP 128/66 mmHg (6 PM)
Hct 32.3%
Radivac drain 200 ml
The patient has fatigue but no dizziness, pale conjunctiva skin or nails, anorexia, heart palpitations, cold hand and feet.
23 March 2022 (Post op day 2)
Vital signs are normal : BT 37.1 C, P 64 bpm, RR 20 bpm, O2 99%, BP 123/76 mmHg (6 PM)
Hct 30.4% got LPRC 1 unit repeat Hct tomorrow (24 March 22)
Radivac drain 270 ml
The patient has fatigue but no dizziness, pale conjunctiva skin or nails, anorexia, heart palpitations, cold hand and feet.
24 March 2022 (Post op day 3)
Vital signs are normal : BT 37.9 C, P 60 bpm, RR 20 bpm, O2 97%, BP 115/75 mmHg (6 AM)
Hct 31.6%
Off Radivac drain.
The patient can eat foods more and got enough rest.
The patient has fatigue but no dizziness, pale conjunctiva skin or nails, anorexia, heart palpitations, cold hand and feet.
D/C
Risk for infection.
Objective data : Body temperature 38.2 C, Pain score 5/10
Goal : No signs and symptoms of infection.
Evaluation criteria : vital signs are normal, wound no d/c, swelling, or redness
Nursing intervention
Monitoring vital signs
Observe surgical wound have swelling, pain, redness, discharge, smell or not.
Keep sterile technique when nurse provide procedures.
Provide antibiotic drug as ordered Ciprofloxacin 200 mg + NSS 100 ml q 12 hr. and Cefazolin 1 gm q 6 hr.
Evaluation
22 March 2022 (6 PM)
The patient hasn’t fever related to vital signs body temperature 36 C, P 66 bpm, RR 20 bpm, O2 97, BP 125/80 mmHg
Pain score 3/10 and wound don’t have any discharge.
Continue provide antibiotics drug as ordered. (Ciprofloxacin and Cefazolin)
Discharge plan by D-METHOD
Goal : To the patient can receive continuous care and reduce the risk of complications that may develop during treatment.
Evaluation criteria :
The patient can answer ways to take care himself when he back home by appropriate.
M-Medication : Home medication
Co-amoxiclav 1 gm (tablet) 1 x 2 pc for 10 days : Co-amoxiclav is a combination antibiotic used for bacterial infections.
Ciprofloxacin 500 mg (tablet) 1 x 2 pc 10 days : This medication is used to treat a variety of bacterial infections.
Calcium Carbonate 1 gram (tablet) 1 x 2 pc 14 days : Calcium Carbonate is a medication used to prevent or treat low blood calcium levels in people who do not get enough calcium from their diets. It may be used to treat conditions caused by low calcium levels such as bone loss.
Diclofenac EC 25 mg (tablet) 1 x 3 pc 7 days : is a nonsteroidal anti-inflammatory drug used to treat pain and inflammatory.
Orphenadrine + para 35 + 500 mg (tablet) 1 x 3 pc 7 days : Orphenadrine is used with rest, physical therapy, and other measures to relieve pain and discomfort caused by strains, sprains, and other muscle injuries.
D-Diagnosis : Fracture are Injury to one part of the musculoskeletal system results in the malfunction of adjacent muscles, joints, and tendons. Open fracture. An open fracture is one in which the skin or mucous membrane wound extends to the fractured bone.
E-Environment :
A safe home environment that’s clutter-free, well-lit, and has stairwell railings and balance bars in baths and showers, can reduce the risk to falls.
Appropriate use of assistive devices such as canes or walkers can improve your stability when walking.
A safety alert button is a good idea for the elderly; if you do fall, you will be able to summon help quickly.
T-Treatment : Open reduction and internal fixation (ORIF) is surgery used to stabilize and heal a broken bone. You might need this procedure to treat your broken thighbone (femur). If you fracture your femur, you usually need ORIF to bring your bones back into place and help them heal.
H-Health :
You might have some fluid draining from your incision. This is normal. Let your healthcare provider know right away if you see an increase in redness, swelling, or draining from your incision, a high fever, chills, or severe pain. Also, let him or her know about any loss of feeling in your leg.
You may need to clean your wound 1 time per day and protect your leg from water. Follow all your healthcare provider’s instructions carefully.
Doing your exercises as prescribed can improve your chances for a full recovery. Most femoral fractures take about 4 to 6 months to heal completely, but you should be able to resume many activities before this time.
O-Out patient : Make sure to keep all of your follow-up appointments. You may need to have your stitches or staples removed a week or so after your surgery.
D-Diet :
Protein and calcium : When you have a fracture, your body needs it to build new bone for the repair. It also helps your body take in and use calcium, another key nutrient for healthy bones. Good sources: Meat, fish, milk, cheese, cottage cheese, yogurt, nuts, seeds, beans, soy products, and fortified cereals.
Vitamin D : This vitamin should be a part of your diet to help your fracture heal.
Vitamin C : Collagen is a protein that's an important building block for bone. Vitamin C helps your body make collagen, which helps your bone fracture heal. Good sources: Citrus fruits like oranges, kiwi fruit, berries, tomatoes, peppers, potatoes, and green vegetables.
Iron : If you have iron-deficiency anemia when you don't have enough healthy red blood cells. You may heal more slowly after a fracture. Iron helps your body make collagen to rebuild bone. Good sources: Red meat, dark-meat chicken or turkey, oily fish, eggs, dried fruits, leafy green veggies, whole-grain breads, and fortified cereals.
What Not to Eat : Alcohol, Salt : too much of this in your diet can make you lose more calcium in your urine. Coffee: Lots of caffeine -- more than four cups of strong coffee a day -- can slow down bone healing a little.
Chief complain :
The patient has refer from Prince hospital with motorcycle accident and due to received treatment following social security.
History of present illness and past illness :
2 days PTA the patient has motorcycle accident with drinks alcohol. The patient has unconscious but can remember the situation and he has a laceration wound with an open fracture. First, the patient received treatment at Prince hospital do U/S fast result is negative, CT brain : no hemorrhage, CXR : normal, Film : Right femur Cominuted fracture at middle thrial of right femur Set OR for debridement with external fixation. Provide Cefazolin 2gm state before go to OR then Cefazolin 1 gm IV q 6 hr and then go to Sikarin Hospital for received treatment following social security.
The patient denied history of underlying disease and denied history of any operation.
Date of nursing student who received to take care
: March 21,2022- March 24,2022.