INTRODUCTION

I, from group IV Section D, chose the case of G.S., a 38 year old client who had

undergone surgery to correct his bones in his left arm. Upon seeing my client, he was

sitting on the bed in the hospital. When I asked him if I could perform an assessment on

him, he looked at his wife and said yes. These were the factors that I considered in

choosing my client:

1. Willingness of the client to participate and cooperate in my assessment;

2. The nature of the disease, which I believe will help me develop my skills and

acquire the actual knowledge about the disease.

BACKGROUND OF THE STUDY

FRACTURE

A bone fracture is a break in a bone. Fractures are common. Most people fracture

at least one bone during their lifetime.

The severity of fractures increase with age. Children's bones are more flexible and

less likely to break. Falls or other accidents that do not harm children can cause complete

fractures in older adults. Older adults suffer from fractures more than children because

their bones are more likely to be brittle.

The most common symptoms are:

swelling around the injured area

loss of function in the injured area

bruising around the injured area

deformity of a limb

Fractures occur when a bone can't withstand the physical force exerted on it.

There are many types of fractures: simple, stress, comminuted, impacted,

compound, complete and incomplete.

1. Simple: Bone breaks into two pieces.

2. Stress: Hairline break that is often invisible on the x-ray for the first six weeks

after the onset of pain.

3. Comminuted: Bone fragments into several pieces

4. Impacted: One fragment of bone is embedded into another fragment of bone.

5. Compound: Bone protrudes through the skin. Also called an open fracture.

6. Complete: Bone snaps completely into two or more pieces.

7. Incomplete: Bone cracks but doesn't separate.

OBJECTIVES

GENERAL OBJECTIVE:

I, a 4th Year Nursing student of Unciano Colleges, Section D Group 4 I am aiming

the proper attitude by interacting with my client. By doing so, I will be able enhance my

knowledge by practicing my nursing skills that I have learned and maximize my

capabilities, vital for aspiring nurses like me.

SPECIFIC OBJECTIVE:

To be able to:

1. Establish rapport with my client as well as his family to help them recognize

and give importance on their health and personal development.

2. Review my knowledge about anatomy and physiology of bone specifically

humerus, radius and ulna as well as the pathophysiology of bone fracture.

3. Review the medications of my client

4. Identify and analyze present health problems of my client that might place

him at risk and be able to use my nursing skills to help him.

5. Formulate appropriate nursing interventions, that will solve, if not, will reduce

or lessen the health problems of my client, by involving him as well as the

members of my group.

6. Impart necessary knowledge regarding health maintenance to my client that

will guide him to achieve a healthy life.

7. Evaluate the effectiveness of my nursing care plan.

PATIENT’S PROFILE

Name: Mr. G.S.

Age: 38 yrs. old

Sex: Male

Date of Birth: September 1, 1972

Status: Married

Religion: Born Again

Ethnic Group: Visaya

Residence: Payatas, Quezon City

Ward: Male Ward

Chief Complaint: Inability to flex the Left elbow

Date and time of admission: February 8, 2011/ 10:00 pm

Admitting Diagnosis: Fracture open 3-C left humerus medial

condyle, transected ulnar nerve

Attending Physician: Dr. Peimon B. Badiee, Orthopedic Surgery

Date and time of Assessment: February 21, 2011 / 3:00 pm

NURSING HISTORY

Chief Complaint:“Di ko na maigalaw ang braso ko, ” as verbalized by the client.

History of Present Illness:Mr. G.S. had his accident last February 8, 2011. He was trying to mediate a fight

between his brother and a drunken man, then, he was hit by a bolo in his left arm. He said that after the accident his arm felt numb and his cousin tried to pull his arm, but because it hurts they stopped pulling it. He was brought to the FEU hospital to be hospitalized however, they can not afford the expenses. February 8, 2011, at around 10 pm, he was rushed to Philippine Orthopedic Center because he was not able to flex his arm and he felt some pain. His wife accompanied him. In the emergency room he was interviewed and had his X-ray. He was then admitted to the male ward at 7 am at the next day. On the following day he was scheduled for an operation. The said operation lasted more than two hours from 9:25 am-11: 37am. His attending physician was Dr. Peimon B. Badiee, Orthopedic Surgery

History of Past Illness:Mr. G.S. was first hospitalized due to his fracture. Aside from that, he had

occasional cough, colds and fever which the client treated with over-the-counter drugs such as Paracetamol 1 tablet 500mg PRN, Solmux 1 capsule 500 mg every 6 hours for cough and Neozep 1 tablet 500 mg once a day for colds.

Heredo-Familial History of Disease: According to Mr. G.S., his grandmother on the father’s side has High blood

pressure.

Socio-Economic History:Mr. G.S. is a high school student. He will be the one to pay for his hospital bills

and also supported by hi siblings. He is a security Guard in ABS-CBN. Their monthly income ranges from 19,000 pesos.

13 AREAS OF ASSESSMENT

I. Social StatusMr. G.S., 38 yrs old, is the 4th child of his parents. He was born in Zamboanga and grew up in Quezon City. His wife is a housewife. They are currently living in their own house at Payatas, Quezon City. The people is living with him 2 children and 2 pamangkin. He is a Born Again in religion and rarely attends mass. His usual activities before his confinement include playing with his children, washing dishes, washing his clothes and sweeping the floor. According to Erik Erikson’s Eight Stages of Development, he falls under the Middle Adulthood: 35 to 55 or 65, Ego Development Outcome: Generativity vs. Self absorption or Stagnation and the Basic Strengths: Production and Care During this stage, an individual can either manifest positive resolution that may indicate to perpetuate culture and transmit values of the culture through the family (taming the kids) and working to establish a stable environment. Strength comes through care of others and production of something that contributes to the betterment of society. I was able to conclude that he manifested positive resolution. It is because he is the bread winner and he has time to care for his family.

II. Mental Status

During my assessment, Mr. G.S. is conscious and coherent. I was able to talk to him easily and lightly. I asked him to recite the series of 7 but he wasn’t able to recite it correctly. I classify him belonging to the average level of mental capacity. He was able to recall recent events such as the death of Rudy Fernandez and can also recall remote events like the year when he fist left Zamboanga. He was oriented to time, place and person. He was able to answer our questions when we asked him what time it was when we’re assessing him and he was right when he said it’s between 3-4 pm. I also asked him if he knew where he was and who he was with and he answered us that he was in POC and he knew that he was with his wife. Our client speaks Tagalog and cebuano words upon our interview.

III. Emotional StatusUpon my assessment, I noticed that Mr. G.S. was calm and cooperative. He was

very much open with everything that we asked him. He said he was comfortable staying in the hospital when I asked him what he felt about his confinement since his wife is with him. He said that he was worried of what will be the appearance of his left arm after the cast is removed. He also shared to us that he’s afraid that he may not be able move his arm again.

IV. Sensory and PerceptionA. Vision

Upon my observation, Mr. G.S.’s eyebrows are thick, color black and arc shape. His eyes are almond shaped and symmetrical with long, thick eyelashes. His sclera’s appear white and have brown-colored irises. His bulbar conjunctivas are transparent while his palpebral conjunctivas are shiny, smooth and pink in color and are highly vascular. To test the corneal sensitivity I asked the client to keep

both eyes open and look straight ahead and tested it with a wisp of cotton, upon doing so, our client’s eyes blinked. To assess pupil’s reaction to light, I approached the penlight from the side and shone a light on his pupil. His pupils constricted when they were illuminated. To assess pupil’s reaction to accommodation I held the penlight at about 10 cm from the bridge of his nose and asked him to look at the tip of the penlight. I held the penlight farther from the bridge of his nose then moved the penlight toward the client’s nose. His pupils constricted when the penlight was near, dilated when it was held farther and converged when moved toward the bridge of the nose. His pupils equally round and react to light and accommodation (PERRLA). His eye muscles are developed and well coordinated, as we were able to assess the six ocular movements using a penlight. I asked him to hold his head in a fixed position facing us and follow the movements of the penlight with his eyes only. We held the penlight 10 inches away from the bridge of his nose and moved it slowly to the following directions; from the center of his eyes to the upper right, right, lower right, lower left, left, upper left, and back to the center of his eyes. Both his eyes can focus on the penlight at the same time. To assess his visual acuity, I let him cover the eye not being tested and let him identify the letters written on our flash cards bilaterally. The sizes of the letters are 5 inches, 3 inches and 1 inch. All were held 10 ft away and he was able to identify those letters in 5 and 3 inches but failed to identify letters that are 1 inch in size.

B. AuditoryMr. G.S.’s auricles are bean shaped and of the same color with the facial skin. They are symmetrical and aligned with the outer canthus of his eyes. I palpated his auricles; they were firm and not tender. His pinna recoiled when we folded it. He exhibited no pain when his auricles were gently pulled upward, downward and backward. Using a penlight we inspected the external auditory canal and we have observed that both have dry cerumen. To test his gross hearing acuity we performed the tuning fork tests. I performed first the Weber’s test using a tuning fork with his eyes blind folded; we held the tuning fork at its base and activated it by tapping the fork gently against the back of our hand near the knuckles. I placed the base of the tuning fork on top of his head and asked him where he heard the noise. He said that he heard it on both ears. I also conducted the Rinne test by asking him to cover one of his ears. I held the handle of the activated tuning fork on the mastoid process of his ears until he stated that the vibration could no longer be heard. Then I held the still vibrating fork in front of his ear canal. I asked him if he heard the sound and he answered yes. I also did the same test on his other ear. He stated that the sound was more audible when the tuning fork was in front of his ear canal. Mr. G.S. is Weber negative and positive in the Rinne test.

C. SmellI observed that Mr. G.S.’s nose is symmetric and straight. Its color is the same as the facial skin. No discharge was observed from the nares. I lightly palpated his nose. No tender areas and no lesions palpated. To determine the patency of his nasal cavities, I asked him to close his mouth and exert pressure on one nares and

breathe through the opposite nares. After doing the procedure on both nares, we noted that the air moves freely as he breathes. I tested his sense of smell by letting him identify four sample scents while his eyes were blind folded. I let him smell safeguard soap (fragrant), vinegar (sour), white flower (menthol) and Spirit of Ammonia (foul). He was able to identify all the odors correctly.

D. Gustatory

Mr. G.S..’s tongue is pinkish and is in central position. It moves freely and its frenulum is highly vascular. I assessed his sense of taste by letting him taste sugar (sweet), salt (salty), vinegar (sour), and coffee (bitter) respectively while his eyes were covered. I let him taste first the sugar by placing a pinch of it on the tip of the tongue depressor. Next, I let him taste the salt by doing the same procedure. Then I let him taste the vinegar by dipping the tip of the tongue depressor into the vinegar. After which, a pinch of coffee was also placed on the tip of the tongue depressor allowing him to taste it. I have done the test by letting him sip water in between tasting each sample. He was able to identify and differentiate each sample correctly.

E. TactileWith his eyes still blindfolded, I assessed Mr. G.S.’s sense of touch by letting him identify a sand paper from an ordinary paper (rough vs. smooth), cotton from a mug (soft vs. hard), tip of a pen from cover of a pen (sharp vs. dull) and a bowl with hot soup from a bottle of cold water (warm vs. cold). I applied those on his right upper extremity, right lower extremity, left upper extremity, and left lower extremity. He was able to identify it all correctly except for his left arm.

V. Motor AbilityMr. G.S.. was able to ambulate without assistance and has his bathroom

privileges. He has a functional level of 0 because he is completely independent. I asked him to follow us as we do the Range of Motion (ROM). After such he was able to rotate, abduct, adduct, flex and extend his right upper and right lower extremities. I also did the same procedure with the left upper and left lower extremities. Although he wasn’t able to do it with his left upper extremity because of his cast he was able to perform it with his left lower extremity. Aside from his left arm all his other body parts can move freely against gravity. To assess his gait, we asked him to walk 5 steps forward and backward. There, we observed that he has a balanced gait. All his muscle strength was graded 5/5 except for his left arm with 2/5.

VI. Body TemperatureDuring my assessment my client was afebrile with a temperature of 36.4 ºC,

taken at his right axilla.

VII. Respiratory Status Upon my assessment, I observed the rise and fall of his chest and I obtained a

respiratory rate of 22 cycles per minute. I observed the respirations for depth by the movement of his chest. I auscultated his anterior chest using the flat disc diaphragm of

the stethoscope beginning from the bronchi between the sternum and the clavicles. I asked him to take slow, deep breaths through the mouth and normal breath sounds were heard. He has quiet, rhythmic and effortless respirations.

VIII. Circulatory StatusHe has a blood pressure of 140/90 mmHg taken at his right arm. His pulse was

easily palpable as we palpated his pulse at the right radial artery and obtained a pulse rate of 85 bpm. At the same time I also auscultated his apical pulse and procured a pulse rate of 85 bpm. I did a capillary refill test (blanch test) on his right thumb and it returned to its normal color after 1 second. However, in his left arm in his pinky finger it is pale in color.

IX. Nutritional StatusI inspected Mr. G.S.’s buccal mucosa using a tongue depressor and a penlight. I

observed that his buccal mucosa is pink in color; his lips are moist and also pink in color. He has no restriction on foods before his hospitalization. He usually eats three times a day. He is fond of eating meats such as chicken and pork. He also likes to drink carbonated drinks like coke but was advised not to take carbonated drinks when he was admitted. Upon our assessment, he is on DAT and an IVF of D5NM 1L at 750ml level to run for 12 hrs was infused at his right metacarpal vein.

X. Elimination StatusDuring my assessment, I asked my client how often he voids per day. He said that

before his confinement he defecates twice and urinates four times daily, but since his confinement, he has only defecated once. However, he was able to urinate thrice that day with an approximated amount of 240 cc per void. His wife let him urinate in an empty dextrose bottle. There we observed that it was yellow in color, was pungent and has a concentration that is similar with water.

XI. Reproductive StatusMr. G.S. stated that he had his circumcision when he was 13 years old. At his age.

XII. State of Physical Rest and ComfortSudden movements like lifting of his left arm made him feel some pain. In order

to alleviate the pain, he would put a pillow underneath his cast. He usually sleeps at 12pm and wakes up at 5am. He sleeps 5 hrs daily. In the hospital, he said that he was not able to sleep well because he is uncomfortable with the cast.

XIII. State of Skin and AppendagesI observed that Mr. G.S..’s hair is unkempt. It is resilient, nape level, and black.

His scalp is intact with tinge of dandruff. He has a dark and damp skin. His nails are pinkish and untrimmed. He has a cast on his left arm. We noticed that he has edema on his left hand. Upon my assessment, the wound drainage attached to his left arm was removed.

ANATOMY AND PHYSIOLOGY

Bones of Upper ExtremityHumerus The humerus is the bone of the upper arm. The smooth, dome-shaped head of the bone lies at an angle to the shaft and fits into a shallow socket of the scapula (shoulder blade) to form the shoulder joint. Below the head, the bone narrows to form a cylindrical shaft. It flattens and widens at the lower end and, at its base, it joins with the bones of the lower arm (the ulna and radius) to make up the elbow.

Condyles of the Humerus

At the lower end of the humerus (upper arm bone) and the femur, there are two smooth condyles (rounded processes of the bone): a knob-like "capitulum" on the lateral side and a pulley-shaped "trochlea" in the middle. The capitulum unites with the radius (smaller lower arm bone) at the elbow, and the trochlea is a notch, which joins ligaments to the head of the ulna (larger lower arm bone). Above the condyles on either side are "epicondyles," which provide attachments for muscles and ligaments of the elbow. The one toward the center of the arm is the "medial epicondyle," and the one to the side is the "lateral epicondyle."

Ulna

The ulna is the longer of the two bones of the forearm; the other being the radius. When the palm faces forward, the ulna is the inner bone (the one nearest the body) running down the forearm parallel to the radius. The upper end joins with the radius and extends into a rounded projection that fits around the lower end of the humerus (the upper arm bone) to form the elbow joint. The lower end of the ulna is rounded and forms a joint with the wrist bones and lower end of the radius.

Radius

The radius is the shorter of the two long bones of the forearm. The other is the ulna. The radius is the bone on the thumb side of the arm. The shaft of the radius has a broad base that joins the lower end of the ulna and the upper bones of the wrist at a large process called the radial styloid. The disk-shaped head of the radius, which is smaller than the base, joins the lower end of the humerus (bone in the upper arm) to form the elbow joint.

PATHOPHYSIOLOGY

BONE FRACTURE. When a bone is broken, the periosteum and blood vessels

in the cortex, marrow, and surrounding soft tissues are disrupted. Bleeding occurs from

the damaged ends of the bone and from the neighboring soft tissue. A clot (hematoma)

forms within the medullary canal, between the fractured ends of the bone, and beneath

the periosteum. Bone tissue immediately adjacent to the fracture dies. This necrotic tissue

along with any debris in the fracture area stimulates an intense inflammatory response

characterized by vasodilation, exudation of plasma and leukocytes, and infiltration by

inflammatory leukocytes and mast cells. This results to pain of the fracture site, edema

(will develop shoulder and/or elbow stiffness due to keeping their hand in a protected

position of elbow flexion and shoulder adduction), crepitus (a crackling sound, heard

when pieces move), loss of function of that body part, a deformity of the fracture site and

immobility.

PREDISPOSING FACTOR

Age, Gender

Force that is greater than the bone can hold

PRECIPITATING FACTOR

Accident

FRACTURE

Disruption of periosteum

Disruption of blood vessels

BleedingHematomaDeath of bone tissue

INFLAMMATORY RESPONSE

EdemaPainCrepitus Loss of function Immobility Deformity

EVALUATION

During my Related Learning Experience at Philippine Orthopedic Center, I was able

to gain the trust and confidence of my client, Mr. G.S. This enabled me to work with him

in completing this case study. I was able to raise Mr. G.S.’s consciousness pertaining to

his health status particularly regarding his fracture. Together with my client, I formulated

a plan of care to help address his present nursing problems. After the proper interventions

and health teachings, I have concluded that I was able to meet the following objectives of

this study:

1. I was able to establish rapport with my client as well as his family and helped

them recognize and gave importance on their health and personal development.

2. I was able to identify and analyze present health problems of our client that might

place him at risk and I was able to use my nursing skills to help him.

3.I was able to formulate appropriate nursing interventions that lessen the health

problems of my client.

4.I was able to impart necessary knowledge regarding health maintenance to my

client that guided him to achieve a healthy life.

5.I was able to evaluate the effectiveness of my nursing care plan.

HEALTH TEACHINGS

1. Explain the goals of frequent position changes.

Positioning (Goals)

* to prevent contractures

* stimulate circulation and prevent pressure sores

* prevent thrombophlebitis and pulmonary embolism.

* promote lung expansion and prevent pneumonia

* decrease edema of the extremities

* changing position from lying to sitting several times

a day can help prevent changes in the CVS known as deconditioning.

* the recommendation is to change body position at least

every 2 hours, and preferably more frequently in patients who have no

spontaneous movement.

2. Discuss the different therapeutic exercises.

Therapeutic Exercises1. Positive range of motion exercise2. active assistive range of motion3. active range of motion4. Resistive exercise5. Isometric or muscle settings exercise.

3. Encourage patient to have adequate nutrition to promote healing of soft tissue and bone.

4. Encouraged patient to increase oral fluid intake.

5. Teach patient and family to elevate the extremity to minimize edema.

6. Teach patient and family to perform wound care to flap or skin graft after the wound is closed in 5 to 7 days.