III.

Patient’s Data

Name : Mr. JMR

Age : 43 y/o
Birthday : July 22, 1975
Place of Birth : Balitucan Magalang, Pampanga
Address : San. Nicolas II Magalang, Pampanga
Civil status : Married
Religion : Roman Catholic
Occupation : None
Height :5’ 6”
Weight :160 lbs.

Chief Complaint: Patient J.M.R felt numbness on his left lower extremity

Time and date of Admission: 4AM 01-18-19

Admitting Diagnosis : Mangled Left lower extremity, fracture closed
complete left femur secondary to vehicular accident.

Present Health History

` Few minutes prior to confinement, patient was riding a motorcycle on his
way home when he was hit by a truck. Patient got into a vehicular accident
and he felt numbness on his left lower extremity during the said vehicular
accident and all he could feel that certain time is his wound.

Past Health History

He never experience chickenpox, mumps, measles during his
childhood. There is no known allergy to any food and drugs. As common
illness, he suffers from colds, coughs and fever. In times when he feels any
aforementioned illness: he will just increase her oral fluid intake and he would
usually take over the counter drugs such as paracetamol for fever and
Ambroxol for severe coughs until her condition minimizes.
 (Gordon’s Functional Health Pattern)

Health Perception / Patient perceives health as wealth. He claims that he used to

Health Management walk a kilometer everyday from home going to his friends and
take it as a form of exercise. Since he was amputated, he thinks
that his health is deteriorating each day. Patient states that he
believes in traditional medicines such as the use of herbal
medicines.

Nutritional / He likes to eat vegetables and seldom eats fish and meats.
Metabolic

Elimination He doesn’t have a hard time voiding and defecating. He

defecates once a day. He said that it was normal for him.

Activity / Rest His general appearance is weak. He doesn’t have the energy to
move around the hospital’s room or in the hallway. He complains
of joint pains when asked to raise his arms and legs.

Cognitive / The patient is well oriented to date, time, place and people
Perception around him. He can easily grasps ideas and questions being
asked of him. The patient managed to read newspaper despite
his condition.

Self Perception / Mr. J.M.R felt embarrassed and at the same time, ashamed
Self-concept because of what happened to him. He is also sad and
depressed because he will be having a hard time doing his usual
routine.
Role / Relationship The patient said that he was a good provider to his family.

Coping/Stress Since he is amputated their family is even closer and holds on to

Tolerance each other. They said that they will give their best for him to be
well again. When caught in a stressful situation he normally
prays to God.

Values/Beliefs Patient J.M.R is a Roman Catholic. He states that praying is very

much important to his everyday life .Despite of his condition, he
don’t question God of his current state and doesn’t lose his faith
in Him. ‘
DISCHARGE PLANNING

Upon discharge, the patient maintain normal vital signs and absence of pain
in operative site.

a. METHOD

MEDICATIONS:

The client was prescribed of medications to be continued:

 Paracetamol
 Cefriaxone
 Tramadol

EXERCISE:

Advised to bed rest It is indicated with the client to promote rest, and
decrease metabolic demand to the client with ambulation to the rest room

TREATMENT:

Emphasized to the significant other about the importance of complying

with health teachings and doctor’s orders for optimal recovery.

HEALTH TEACHINGS:
 Instructed client and S.O. to comply about doctor’s orders and health
teachings
 Encourage to clean the wound on operative site
 Encourage to be careful when moving in bed to avoid dislodging the
dressing
 Encourage to wash his hands before and after dressing change
 Encourage to increase oral fluid intake
OUT-PATIENT DEPARTMENT:
 No instruction were given because the client is still confined in the
hospital.
 DIET:

Low salt, low fat diet

(20 to 40 years already professional and some got married
old) and have children too.

At Present Now, it’s his concern to have more

grandchildren and his children would raise
them properly. He is ever glad that his
family has been very supportive in these
times.

Physical Examination History

Patient has posterior bandage of the left femur, has pale pink nail beds on
the left foot, and complained of pain in the operative site, with the pain scale
of 8/10.

General Appearance
Skin. Patient has cool and has good skin turgor. There is absence of rashes
and itchiness and no change in skin color.
Head. Patient is normocephalic, proportion to the body. Sometimes
he experienced headache but was relieved by taking OTC medications.
There is even distribution of hair and has slightly dry hair but has no
presence of flakes.
Eyes. He has pinkish, palpable conjunctiva, does not wear glasses and has
clear vision with absence of eye infection.
Ears. Symmetrical, non-tender and smooth texture.
Nose. The nose is at the midline of the face, palpable, with no presence of
swelling. He also experienced colds due to weather conditions.
Mouth. He does not wear any dentures but experiences toothaches
sometimes due to lack of oral care.
Neck .There was no presence of neck stiffness or pain. It can move regularly
and there is no sign of swelling.
Upper Extremities. Warm and has good skin turgor, smooth texture, and non-
tender.