OBJECTIVES:

- To be able to know about the patient’s profile

- To be able to identify the anatomy and physiology

- To be able to know the discharge planning of the patient

- To be able to know the pathophysiology

PATIENTS PROFILE:

Name : AIZA ELEZON

Address : Alipangpang, Pozorrobio, Pangasinan

Age : 19 years old

Sex : Female

Status : Single

Religion : Roman Catholic

Date of Admission : August 19, 2007 at 6:20 PM

A.P. : Dr. Mayreen Fernandez

Diagnosis : Cerebral Concussion

PATIENT’S HISTORY

General Data:

Aiza Elezon, 19 years old, female, single, Roman Catholic from Alipangpang

Pozorrobio Pangasinan was admitted on 8-19-07 for the first time at this institution

Patient History: Unremarkable

Family History: Unremarkable

LABORATORY RESULT

HEMATOLOGY RESULT

LNC : 25. 4 X 109 /L DIFFERENT COUNT

HGB: 117 g/L SEGMENTERS: 0.80

HCT: 0.34 LYMPOCYTES: 0.14

MEHC: 345 g/L MIXED CELLS: 0.06

BLOOD TYPE: “0+” PLATELET COUNT: 274 X109/L

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.

Functions

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 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 musculo-skeletal 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.

Blood cells are produced by the marrow located in some bones. An average of 2.6

million red blood cells are produced each second by the bone marrow to replace those

worn out and destroyed by the liver.

Bones serve as a storage area for minerals such as calcium and phosphorus. When

an excess is present in the blood, buildup will occur within the bones. When the supply of

these minerals within the blood is low, it will be withdrawn from the bones to replenish

the supply.

Types of Bone

The bones of the body fall into four general categories: long bones, short bones,

flat bones, and irregular bones. Long bones are longer than they are wide and work as

levers. The bones of the upper and lower extremities (ex. humerus, tibia, femur, ulna,

metacarpals, etc.) are of this type. Short bones are short, cube-shaped, and found in the

wrists and ankles. Flat bones have broad surfaces for protection of organs and attachment

of muscles (ex. ribs, cranial bones, bones of shoulder girdle). Irregular bones are all

others that do not fall into the previous categories. They have varied shapes, sizes, and

surfaces features and include the bones of the vertebrae and a few in the skull.

Bone Composition

Bones are composed of tissue that may take one of two forms. Compact, or dense

bone, and spongy, or cancellous, bone. Most bones contain both types. Compact bone is

dense, hard, and forms the protective exterior portion of all bones. Spongy bone is inside

the compact bone and is very porous (full of tiny holes). Spongy bone occurs in most

bones. The bone tissue is composed of several types of bone cells embedded in a web of

inorganic salts (mostly calcium and phosphorus) to give the bone strength, and

collagenous fibers and ground substance to give the bone flexibility

PATHOPHYSIOLOGY

DISCHARGE PLANNING

MEDICATION :

- Clindamycin, Erythomycin Chlorampenicol

Environment

a. Advice patient to wash hands frequently, especially after going to

bathroom to avoid further infection

b. Advice patient to clean and disinfect all kitchen surfaces.

c. Proper hygiene

d. Provide cleanliness and sanitation.

Patients should be instructed to complete the full course of antibiotic

therapy.

Patients should be instructed to follow up when indicated or if symptoms

worsen.

MEDICAL TREATMENT AND MANAGEMENT

Medical Treatment

- Instruct the patient’s caregiver to take the medication prescribe by

the physician

- instruct the patient’s caregiver regarding the medication, dosage,

time of administration and side effects

Teach the client to:

a. Show patient or caregivers how to give drug to avoid reinfection

b. Warn patient not to touch ear with dropper-

c. Boil water before drinking, boil for at least 30 mins onwards

d. Warn client not to eat food containing raw eggs and refrain from buying

cans, boxes or jars that are damaged.

e. Advised clients to avoid the use of antibiotics over a long time.

f. Avoid drinking tap water, ice cube, milk products, raw meat and foods

that cannot be cooked or peeled.

UNIVERSITY OF LUZONCollege of Nursing

Dagupan City

Name of Patient: Aiza Eleson Age: 19 Sex: Female Ward / Area: Hospital: R1MC Chief Complaint/s: ______ Diagnosis / Impression: Cerebral Concussion___ Date of Admission: August 19, 2007___

NURSING CARE PLAN

ASSESSMENTCues/ Clues

(Subjective/ Objective Data)

NURSING DIAGNOSIS

(Nursing Problem)

PLANNING(Nursing Objective/

Goal/ Outcome Criteria)

NURSINGINTERVENTION

RATIONALE PATIENT TEACHING

Subjective Data: “Masakit yung sa may panga ko.” As verbalized by the patient.

Objective Data: -grimacing -irritability -weak looking

Pain r/t injury AEB by weak looking and

grimacing Patient will carry out

appropriate interventions for pain

relief.

1) Monitor vital signs

2) Provide comfort measures (e.g. back rub, change of position and use of heat and cold)

3) Encourage adequate rest periods

4) Instructed patients to practice personal hygiene

5) Encourage diversional activities like reading newspapers or listening to radio

6) Administer pain relievers as ordered

- usually altered in pain

- To provide nonpharmacologic pain management

- To prevent fatigue

- To prevent infection

- To divert attention

- to minimize pain felt by the patient

Show patient or caregiver how to give drug, to avoid reinfection, warm patient not to touch ear with dropper.

UNIVERSITY OF LUZONCollege of Nursing

Dagupan City

DRUG STUDY

Name of Patient: Aiza Eleson Age: 19 Sex: Female Ward / Area: Hospital: R1MC Chief Complaint/s: ______ Diagnosis / Impression: Cerebral Concussion___ Date of Admission: August 19, 2007___

DRUG STUDY

DRUG NAME ACTION DOSAGE INDICATION CONTRA-INDICATION

SIDE/ADVERSE EFFECTS

DRUG INTERACTION

NURSING CONSIDERATION

Clindamycin Hydrochloride

Inhibits bacterial

protein synthesis

by binding 15

the 50s subunit

of the ribosome.

30 mg + tab BID

Infections caused by sensitive staphylococci, streptococci, pneumococci, bacteroides, fusobacterium, clostridium, perfringens, and other sensitive aerobic and anaerobic organisms.

Contraindicated in patients hypersensitive to drugsUse cautiously in patients with renal or hepatic disease, asthma history of GI disease or significant allergies

CV: ThrombophlebitiaGI nausea, vomiting, abdominal pain, diarrhea, pseudomembranous colitisHematoligic :transient leucopenia, eosinophilia, thrombocytopeniaHepatic jaundiceSkin: maculopapolar rash, urticariaOther anaphylaxis

Drug-Drug! Erythomycin, may block access of clindamycin to its site of action. Avoid using together. Koalin: May decrease absorption of oral clindamycin separate dosage times.

Obtain specimen for culture and sensitivity tests before giving first dose. Therapy may begin pending results.

For IM administration, inject deep into muscle. Rotate sites IM injection may raise CK level in response to muscle irritation

Don’t refrigerate reconstituted oral solution because it will thicken. Drug is stable for 2 weeks at room temperature monitor renal, hepatic and hematopoietic functions during prolonged therapy.

Observe patients for signs and symptoms of superinfection

UNIVERSITY OF LUZONCollege of Nursing

Dagupan City

DRUG STUDY

Name of Patient: Aiza Eleson Age: 19 Sex: Female Ward / Area: Hospital: R1MC Chief Complaint/s: ______ Diagnosis / Impression: Cerebral Concussion___ Date of Admission: August 19, 2007___

DRUG STUDY

DRUG NAME ACTION DOSAGE INDICATION CONTRA-INDICATION

SIDE/ADVERSE EFFECTS

DRUG INTERACTION

NURSING IMPLICATION

PATIENT TEACHING

Erythromycin Inhibits bacterial

protein synthesis

usually

bacteriostatic but

maybe

bactericidal in

high

concentrations or

against highly

susceptible

organisms

TID on the affected eye

Acute and Chronic conjunctivitis other eye infections

Contraindicated in patients hypersensitive to drugs use cautiously in breastfeeding women

EENT slowed comeal wound healing, blurred vision, itching and burning eyes

None significant To patient opthalmia neonaturum, apply ointment no later than 1 hour after birth. Drug is used in neonates born either vaginally or by cesarean section. Gently massage eyelids for 1 minute 5 spread ointment.

Tell patient to clean eye area of excessive discharge before application.

Teach patient how to apply drug. Advise him to wash hands before and after applying ointment and warm him not to touch tip of applicator to eye or surrounding tissue.

Tell patient that vision may be blured for a few minutes after applying ointment.

UNIVERSITY OF LUZONCollege of Nursing

Dagupan City

DRUG STUDY

Name of Patient: Aiza Eleson Age: 19 Sex: Female Ward / Area: Hospital: R1MC Chief Complaint/s: ______ Diagnosis / Impression: Cerebral Concussion___ Date of Admission: August 19, 2007___

DRUG STUDY

DRUG NAME ACTION DOSAGE INDICATION CONTRA-INDICATION

SIDE/ADVERSE EFFECTS

DRUG INTERACTION

NURSING IMPLICATION

PATIENT TEACHING

Chloramphenicol Inhibits or

destroys bacteria

in the ear canal

500 mg IV q 80

External ear canal infection

Contraindicated in patients hypersensitive to drugs or its components and in those with perforated eardrum

EENT ear itching or burningGV: hemogloniburiaHematolic: bone marrow depression, bone marroe hypoplasia aplastic anemia Metabolic: lactic acidosis Skin pruritus, urticartiaOther: overgrowth of nonsusceptible organisms

Non significant

Obtain history of drug use and reaction

Monitor patients for signs and symptoms of superinfection

Avoid prolonged use

Monitor patients for sore throat

Alert Don’t confuse chloromycetin with chorambucil

Advise patient to take capsule form with full glass of water to prevent esophageal irritation

Warm patient that IM inection may be painful

Tell patient to report discomfort at I. V insertion site.

Instruct patient to notify prescriber of adverse reactions (esp. diarrhea) warm him not to treat such diarrhea himself because clindamycin therapy may cause severe even life threatening colitis