UNIVERSITY OF SOUTHERN PHILIPPINES FOUNDATION COLLEGE OF NURSING

Salinas Drive, Lahug, Cebu City

FRACTUE,OPEN, TYPE I THIRD OF TIBIA Vicente Sotto Memorial Medical Center Ward VIII

Submitted by: Novo, Shogen faith Fallan BSN IV-A

PATIENT PROFILE: Name Age Sex Status Address Name of Hospital Date of Admission Ward & Bed No. Case No. Chief Complaint Medical Diagnosis : : DRD : 43 years old : Male : Married :Bato,Toledo City, Cebu : Vicente Sotto Memorial Medical Center : July 27, 2011 : Ward 8 Bed X14 : 266383 : Injury secondary to MVA Fracture, Open, Type I, Proximal Third of Tibia

Developmental Task :

1.1 Erik Erikson Stage: Adulthood Central Task : Generativity vs. Stagnation

Significant Characteristics: creates a family, considers future welfare of others  Patient is already married and has a family. He is a responsible employee and is the breadwinner of their family and would want his child to finish his studies. 1.2 Robert Havighurst Middle Age  Patient achieves social and civic responsibility.  Establishing and maintaining an economic standard of living  Developing adult leisure-time activities  Patient accepts and adjusts to the physiologic changes of middle age

HEALTH ASSESSMENT 1. History of Present Illness: On July 25,2011, patient was riding at the back of a truck bus when suddenly the driver lost control of the vehicle and fell onto the sea. He was also thrown off . A multicab was following not too far behind them and transported them to District Hospital where his left arms and leg s were cleaned and care, but because of his leg injury, he was rushed to Vicente Sotto Memorial Medical Center for further management. History of Past Illness: On 1987, patient is hospitalized at Cortes Hospital due to industrial accident. Patient had been amputated at the 2nddigit, left hand on 1987 also.There is a family of hypertention, but no family history of diabetes, mellitus, asthma, tuberculosis.

2. Gordon s Functional Health Patterns: 2.1 Health Perception and Health Maintenance Before admission, patient considers self-healthy and has never had any experience of having a major health problem except the hospitalization on 1987 due to an accident. The only things patienthas experienced are bouts of cough, colds and fever when exposed to the extremes of temperature. Patient never went to the doctor for a check-up; instead seeks help from wife, to tell him the medication he would take for the illness. Some of patient s usual over-the-counter medications include Biogesic, Alaxan and Multivitamins with Iron. Patient smokes at least 10 sticks per day and he started smoking when he was still 14 years old. During hospitalization, patient considers himself weak, restless, stressed out, sleep deprived and rates health 6 out of 10 with ten being the highest. Has difficulty in rising from bedand cannot move around by own. 2.2 Nutrition and Metabolism Before admission, patient has a very good appetite and eats three times a day. His usual diet includes rice, corn, linat-angbaboy , inun-unan and dried fish. Drinks water always and includes other beverages such as juice and softdrinks. During hospitalization, the patient has loss of appetite especially when patient is experiencing pain. Patients hospital diet is diet as tolerated or DAT. 2.3 Elimination Before admission, he defecates 1x a day and his stool is brown in color and soft in consistency. His urine output depends on the amount of fluid he takes and the weather because during cold days patient voids more. During hospitalization, he does not feel the urge to defecate and according to him, due to the pain felt, patient don t want to defecate and want to focus on pain felt. Patient voids with the use of commode

2.4 Activity and Exercise Before admission, patient walks from house to the office. He considers it as a form of exercise and a very good work out. During hospitalization, he has been confined in bed because of the injury. Can only move his upper extremities and right leg and can only turn to sides with assistance from his significant others. 2.5 Cognition and Perception Before admission, patientmakes decision together with his wife. His five senses were intact and pain is felt only if there is a pain stimulus. At the hospital, he is still oriented to date, time and place. Still makes decisions together with his wife. Complains that his hearing isn t as good as it was and complaints of acute pain. He said that pain occurs when he suddenly tries to move his back and arms and it last for 5 seconds, 7 to 8 times a day. He takeCelecoxib for the pain and drinks water to help relieve the pain. Rates pain felt as 7 out of 10 with 10 as the highest. 2.6 Sleep and Rest Before admission, he sleeps at 8 pm and wakes up at 5 am. Patient rates the quality of sleep as good. Patient does not use sleeping pills or any sleeping aid to go to sleep at night and he sleeps with the lights off. Patient has experiences of having nightmares and he snores loudly. During hospitalization, patient spends most of his time resting. He said that he sleeps for about 5 hours from 9 pm to 6 am. However, he complains of sleep disturbance because of the noisy environment and still feels tired upon waking. 2.7 Sexuality and Reproduction Patient is aware of his gender and sexual orientation; he is also sexually active and blessed with three children.Was circumcised when his7 years old. Patient and his wife practice the withdrawal method. During hospitalization, patient is still aware of his gender and sexual orientation, but the illness has affected his sexual function and sexual relationship with his wife.

2.8 Self- Perception and Self- Concept Before admission, patient lived a happy life and would go about with the usual activities. Considerself as a useful person and a good provider.Consider the ability to think positively despite of problems as his strength. During hospitalization, patientfeels sad and confused about the current state. Patient felt disappointed because he still wants to provide for his family and provide a better future for the children.

2.9 Roles and Relationship Patient is the head of the family and has a good relationship with his wife and children. Patient wants his wife to be with his children always, but the wife wants to work since his salary is not enough to sustain them. They usually quarrel but immediately fix them. During hospitalization, money is not a problem since his finances are covered by the sibling that works abroad. His mother and his brother are taking care of his children. 2.10 Stress Tolerance and Coping Before admission, patient used to work every day and is a hardworking person. Whenever patient is stressed out, patient said that the wife supports him, and also his During the hospitalization, the illness makes him weak and considers it as a major stressor. The patient is still optimistic to get well soon and the family has the same thing on their mind. 2.11 Values and Beliefs Before the admission, he doesn t go to church with his family. During the hospitalization, patient s faith in God grew strong and believes to be cured soon.

PHYSICAL EXAMINATION 3. 1 General Survey Date examined: August 1, 2011

Examined patient lying on bed, awake, conscious, coherent, and responsive with #5 Plain Lactated Ringer 1L at 20gtts/min infusing well at left arm, with intact bandage at Left leg. Temp: 37.2oC PR: 78bpm RR: 21cpm BP: 130/100 mmHg Inspection Skin Uniform skin color, with pressure sores at ankle and heel area of both feet, scars noted at posterior region with dry and intact elastic bandage at left leg Hair Hair is evenly distributed with

Palpation Uniform skin temperature, edematous feet with an edema scale of +1 on the left foot, with good skin turgor and elasticity N/A

Percussion N/A

Auscultation N/A

N/A

N/A

Nails

thick hair and no evidence of infestation Rough texture, intact epidermis, pale nail beds Rounded with smooth skull contour, symmetric facial structures and facial movements Muscles are equal in size, head centered

Head

Capillary refill time of less than 2 seconds Uniform in consistency, absence of nodules and masses No masses or lesions noted

N/A

N/A

N/A

N/A

Neck

N/A

N/A

Cervical Lymph Nodes Mouth

N/A

Nose

Sinus Eyes

Lips have symmetry of contour, paleness noted, chapped and cracked lips noted, can purse lips, 32 adult teeth with dental carries present Symmetric with no discharge or flaring, uniform in color, closed nasogastric tube attached at the left nostril N/A Skin intact and hair evenly distributed, eyebrows symmetrically aligned and with equal movement, no discharge or discoloration, pale conjunctiva, pupils equally round and reactive to light

Lymph nodes are not palpable N/A

N/A

N/A

N/A

N/A

No tenderness or lesions

N/A

N/A

Not tender N/A

N/A N/A

N/A N/A

accommodation Ears Color same as facial skin, symmetrical and with stitches at the left ear s uppermost pinna Uniform skin color, with bony prominences N/A Pallor noted in nail beds No tenderness and no discharges N/A N/A

Thoracic

No pain felt

Lungs Cardiovascular

N/A Pulse strength of right and left arm is normal while that of the lower extremities are weak No tenderness, no masses or nodules noted Auscultation Bowel sounds of ten per minute

Normal percussion sounds N/A N/A

N/A

Clear breath sounds Audible Heart sounds

Breast

Uniform skin color

N/A

N/A

Abdomen

Inspection Uniform skin color and flat abdominal contour noted

Percussion Tympanitic sounds over the small and large intestine

GenitourinaryReproductive

Musculoskeleta l

Grossly male, Presence of Foley Bag Catheter attached to Urobag, no discharges, negative cremasteric reflex Paraplegic, foot drop noted, muscles are not equal in size and graded muscle strength is 1 in the lower extremities. Able to lift upper extremities with

No tenderness

N/A

Palpation No tenderness upon palpation and no evidence of enlargement of abdominal organs N/A

N/A

N/A

N/A

Neurologic

slower movement, however, he cannot move his lower extremities Conscious, coherent. Glasgow coma scale is 15.

Can't feel any sensation in both lower extremities

Deep tendon reflex in lower extremities is 0.

N/A

DIAGNOSTIC TESTS DATE TEST NORMAL VALUES PATIENT S RESULT INTERPRETATIO N

July 27,2011

1. Complete Blood Count

WBC 4.3- 10.8 x10^9/L

17.7

An elevated leukocyte count indicates an inflammatory response.

RBC 4.6-6.2 x 10^12/L

3.58

A decreased RBC count indicates

tissue injury Hgb 140-180 Hct 0.45-0.52 Platelet 150-400 x10^9/L 109 Associated blood loss 0.340 Associated blood loss 177 NORMAL with with

July 27,2011

2. Urinalysis

COLOR Pale yellow to amber TRANSPARENCY Clear to slightly hazy

Light Yellow Clear

NORMAL

May indicates urinary tract infection

pH

5.0-8.0

7.5 1.010

NORMAL NORMAL

SPECIFIC GRAVITY 1.005-1.030

SUGAR (-) negative PROTEIN (+) positive

(-)

NORMAL

(-)

indicate kidney damage Mayindicates proteinuria.

July 27,2011

3. Clinical Chemistry test

CREATININE 0.60- 1.10 mg/dl

1.35 mg/dl

May indicate decrease kidney filtration

ALBUMIN 3.50-5.00 mg/dl

3.50 mg/dl

NORMAL

July 27,2011

4. Clotting time

COAGULATION TIME 3- 6 minutes

2 minutes, 55 seconds 1 minute and 15 seconds

The blood is slightly slow for clotting process.

BLEEDING TIME 1-3 minutes

NORMAL

NOTE: X-ray and CT scan examinations were done but the results were not found at the patient s chart. OTHER PROCEDURE:Chest PA moderate cardiac enlargement -atherosclerosis at thoracic aorta

SUMMARY OF SIGNIFICANT FINDINGS A. GORDON S FUNCTIONAL HEALTH PATTERN  A smoker. He smokes 10 sticks per day since he was 14 years old. 11 pack years.  confined in bed always during this hospitalization  does not feel rested and keeps waking up due to noisy environment  With intact bandage at Left leg  Don t want to defecate due to pain felt  On a DAT diet  Complaints of pain upon movement  disturbed sexual function and sexual relationship with wife B. PHYSICAL EXAMINATION  With intact bandage at Left Leg  Chapped and cracked lips  Scars on the right leg and arms.  Pallor noted on nail beds  Pulse strength of the lower extremities is weak  Difficulty to move the lower extremities  Pale conjunctiva  Muscles are not equal in size  Graded muscle strength is 5 at the lower extremities

C. DIAGNOSTIC EXAMINATIONS Results as of April & May 2010:  White blood cell count 17.7 & 13.2 x10^9/L  Red blood cell count 3.58 & 3.02 x 10^12/L  Hemoglobin 109 & 90 mg/dl  Hematocrit 0.340 & 0.274 meq/L  Transparency of the urine is clear  negative protein in the urine  Creatinine of 1.35 mg/dl

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Anatomy and Physiology of Tibia and Fibula

TIBIA The inner and thicker of the two lower leg bones. It is the supporting bone of the lower leg and runs parallel to the narrower lower leg bone, thefibulato which it is attached byligaments.Thetibia, or shinbone, articulates with thecondylesof the femur, or upper leg bone, and the head of the fibula above, and with the talus and the distal end of the fibula below. It has an expandedupper end, a smaller lower end, and a shaft.At the upper end are the lateral and medial condyles (sometimes called medial and lateral tibia plateaus), which articulate with the lateral and medial condyles of the femur, the lateral and medial semilunar cartilages intervening. Separating the upper articular surfaces of the tibia condyles are anterior and posterior intercondylar areas; lying between these areas is theintercondylar eminence. The lateral condyle possesses on its lateral aspect a circular articular facet for the head of the fibula. The medial condyle shows a groove on its posterior aspect for the insertion of the semimembranosusmuscle. The shaft of the tibia is triangular in cross section, presenting three borders and three surfaces. Its anterior and medial borders, with the medial surface between them, are subcutaneous. Theanterior border is prominent and forms the shin. At the junction of the anterior body with the upper end of the tibia is the tuberosity, which receives the attachment of the ligamentum patellae. Theanterior border becomes rounded below, where it becomes continuous with the medial malleolus. The lateral and interosseous border gives attachment to the interosseous membrane. The posterior surface of the shaft shows an oblique line, the soleal line. Below the soleal line a vertical ridge passes downward, dividing the posterior surface into medial and lateral areas. The lower end of the tibia is slightly expanded and on its inferior aspect show aa saddleshapedarticular surface for the talus. The lower end of the tibia shows a wide, rough depression on itslateral surface for articulation with the fibula. Fracture of the tibia The tibia is one of the most commonlyfracturedbones. It may break across the shaft as a resultof a direct blow to the front of the leg, or at the upper end from a blow to the outside of the legbelow the knee. Fracture of the lower edge of the tibia may accompany dislocation of the ankleand fracture of the fibula in a Pott's fracture, caused by violent twisting of the ankle. Prolongedrunning or walking on hard ground may cause a stress fracture of the tibia.Some fractures of the shaft heal satisfactorily if the leg is immobilized in a plaster cast, usually for about six to eight weeks. If the bone ends are displaced or unstable, an operation may be neededto fasten them together with a nail or screw. FIBULA The long thin outer bone of the lower leg of four- and two-leggedvertebrates, including humans.The fibula takes no part in the articulation at thekneejoint but, below, it forms the Lateralmalleolus of theanklejoint. It takes no part in the transmission of body weight, a task which fallsto the other, and much sturdier, lower leg bone, thetibia. The fibula has an expanded upper end, a shaft, and a lower end. The upper end, or head, is surmounted by a styloid process . It possesses an articular surfacefor articulation with the lateralcondyleof the tibia. The shaft of the fibula is long and slender, and its shape is subject to considerable variation. Typically, its has four borders and four surfaces. Theanterior surface is very narrow in its upper part, where the anterior and medial borders run close together or may become confluent. Themedial or interosseous border gives attachment to the interosseous membrane. The lower end of the fibula forms the triangular lateral malleolus, which is subcutaneous. On themedial surface of the lateral malleolus is a triangular articular facet for articulation with the lateralaspect of the talus. Below and behind the articular facet is a depression called the malleolar fossa

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.The main function of the fibula is to provide an attachment for muscles. It provides little supportive strength to the lower leg, which is why pieces of bone can safely be taken from it for grafting elsewhere in the body. Fractures of the fibula The fibula is one of the most commonly broken bones. Fracture of the fibula just above the ankle may occur with a severe ankle sprain as a result of a violent twisting movement. Pott'sfracture is fracture of the fibula just above the ankle combined with dislocation of the ankle andsometimes with fracture of the tibia. A suspected fracture of the fibula isX-rayedto confirm the diagnosis. In some cases the lower legis immobilized in a plaster cast to allow the bone to heal. If the fracture occurs in the middleportion of the fibula, immobilization may not be needed. If the fracture is severe (especially if it isaccompanied by dislocation of the ankle), surgery may be necessary to fasten the broken pieces of bone with metal pins. A fractured fibula may take up to six weeks to heal, Depending on its severity and the age of thepatient

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PATHOPHYSIOLOGY

AGENTHOST DRD, 43 years old, male

ENVIRONMENT Motor Vehicular Accident

Sudden impact to the lower extremities (Left Leg)

Flexion, Extension, Rotation, Compression or a combination of these mechanisms may cause fracture

Inability of the structure to absorb too much pressure

Damage to the 3rd Tibia Left

Disruption of surrounding blood tissues, blood vessels and nerve supply occurs

SIGNS AND SYMPTOMS Infection Pallor Fatigue Weakness Tachycardia Weight loss Headache Loss of muscle control Edema Muscle Spasm

COMPLICATIONS: -compartment syndrome -amputation of the affected limb

A.MEDICAL/SURGICAL MANAGEMENT

-non-union -greenstick fracture

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UNIVERSITY OF SOUTHERN PHILIPPINES FOUNDATION College of Nursing Salinas Drive, Lahug Cebu City NURSING CARE PLAN Client s name: DRD Age: 43y.o Gender: Male Date of Admission: July 27, 2011 Civil Status: Married Religion: Roman CatholicEducation: College levelWard and Bed No.:Ward 8, Bed X14 Agency:Vicente Sotto Memorial Medical Center Medical Diagnosis:Fracture, Open, Type I ,Proximal Third of Tibia NURSING DIAGNOSIS: Impaired Physical Mobility related to injury to the spinal cord at the level of thoracic 11 DEFINING CHARACTERISTICS S: Dilikomakalihoklihok as verbalized by the patient. SCIENTIFIC BASIS EXPECTED OUTCOME Short term goal: After 6 hours of holistic nursing intervention, the patient together with the significant others will be able to: 1. Verbalize willingness to/and participate in repositioning program. 2. Demonstrate techniques/b ehaviors that enable safe repositioning. 3. Cooperate NURSING INTERVENTION RATIONALE Diet: DAT

O: Received patient lying flat on bed, noted inability to move or even get up, loss of sensation in lower extremities, foot drop noted, with a functional level of 3 which requires help from another person and equipment devices.

Impaired bed mobility- limitation of independent movements from one position to another. Paralysis may occur as a result of the destruction of the nerves following cord hemorrhage and Swelling.

INDEPENDENT: -Note individual risk factor and current situation, such as trauma, injury, fracture, etc. -Assessed patient s functional level. -Note presence of complication related to immobility such as constipation, pressure ulcers, etc. -Observe for changes in strength to do more or less self-care. -Provide extremity protection such as pillows or rolled towels. -Involve client/SO in determining schedule of turning the patient from side to side.

-to know what causes the immobility of the patient.

- To determine up to what level the patient is capable to function. -to prevent or treat any complications that the patient (may) experience. - To adjust care as indicated.

Source: Kozier and Erb s Fundamentals of Nursing. 7th edition.

- to prevent pressure ulcers

- Promotes commitment to plan, maximizing outcomes.

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with the interventions being carried. Long term goal: After 2 weeks of holistic nursing interventions, the patient as well as the significant others will be able to:

-Assist patient in his activities such as turning side to side, eating, drinking, etc. DEPENDENT: -Administer pain reliever Celecoxib 200 mg 1 tab PRN as indicated.

-to meet patient s needs.

- To permit maximal effort or involvement in activity.

1. Be free from complications of immobility 2. Move with assistance from the SO.

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UNIVERSITY OF SOUTHERN PHILIPPINES FOUNDATION College of Nursing Salinas Drive, Lahug Cebu City

NURSING CARE PLAN

Client s name: DRD Age: 43y.o Gender: Male Date of Admission: April 15, 2010 Diet: DAT Religion: Roman Catholic Education: College LevelWard and Bed No.:Ward 8, Bed X14 Agency:Vicente Civil Status: Married Memorial Medical Center Medical Diagnosis:Fracture, Open, Type I ,Proximal Third of Tibia NURSING DIAGNOSIS: Acute Pain related to physical injury as evidenced by reports of pain DEFINING CHARACTERISTICS S: Sakitakongwalangatiil day , as verbalized by the patient with a pain score of 7/10, 0 as no pain and 10 as very painful. SCIENTIFIC BASIS EXPECTED OUTCOME NURSING INTERVENTION INDEPENDENT: -Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, quality and severity. -perform pain assessment each time pain occur. Sotto

O: Grimaced face noted and slightly irritable, complaints of sharp pain at his back and his arms for 5 sec, aggravated by sudden movements and relieved by drinking water or not moving, with the treatment of Celecoxib 200 mg 1 tab.

Acute pain- unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Study of Pain); sudden slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months. Pain occurs frequently in spinal cord-injured clients with intact sensation. Dysenthetic pain, which is distal to the site of injury, is extremely disabling.the usual treatment is with nonopioid analgesics.

After 6 hours of holistic nursing intervention, patient will be able to: 1. Verbalize method that provide pain relief. 2. Demonstrate use of relaxation skills and diversional activities as indicated for individual situation. 3. Report alleviation of pain

-To know the degree of pain through OLDCART.

-To rule out worsening of underlying condition or development of complications. -To determine possibility of underlying condition or organ

-assess for referred pain as appropriate.

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Source: HuetherMcCance. Understanding Pathophysiology. 3rd edition.

-accept client s description of pain.

-observe nonverbal cues.

-provide quiet environment, calm activities. -provide rest and comfort measures such as placing a soft pillow when repositioning the patient. -encourage diversional activities such as socialization or talking to others.

dysfunction requiring treatment. -Pain is subjective experience and cannot felt by others. -observation may or may not be congruent with verbal reports -. To reduce stimulation. -To provide nonpharmacolog ic pain management.

-To avoid boredom and to divert things on the process of controlling or relieving pain. -. In order to prevent fatigue. -To relieve pain and inflammation

-encourage patient to take adequate rest periods. DEPENDENT: -administer Celecoxib 200 mg 1 tab PRN as indicated.

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UNIVERSITY OF SOUTHERN PHILIPPINES FOUNDATION College of Nursing Salinas Drive, Lahug Cebu City NURSING CARE PLAN Client s name: DRD Age: 43 y.oGender: Male Date of Admission: July 27, 2011 Civil Status: Married Religion: Roman CatholicEducation: College Level Ward and Bed No.:Ward 8, Bed X14 Agency:Vicente Sotto Memorial Medical Center Medical Diagnosis:Fracture, Open, Type I ,Proximal Third of Tibia Diet: DAT

NURSING DIAGNOSIS: Risk for impaired Skin Integrity related to prolonged physical immobility of the lower extremities DEFINING CHARACTERISTICS S: Maghigdaramankodnhi day, kaysakit man ibangun as verbalized by the patient SCIENTIFIC BASIS EXPECTED OUTCOME After 6 hours of holistic nursing intervention, the patient and the significant others will be able to: 1. Explain ways to prevent pressure sores and promote wound healing 2. Participate in prevention measures and treatment program. 3. Improve wound and pressure sores healing without complication. NURSING INTERVENTION INDEPENDENT: - Assess reduced mobility, changes in muscle mass, and presence of problems with self-care. to identify contributing factors. - Inspect surrounding skin where the pressure sores are located to assess extent of injury. - Note presence of compromised vision, hearing, or speech to determine impact of condition. - Inspect skin on a daily basis, describing lesions and changes observed to EVALUATION

O: received patient lying flat on bed, noted redness but intact pressure sores in the heel and ankle area of both feet

Injury to the spinal cord can range in severity from mild flexion-extension whiplash injuries to complete transaction of the cord with permanent quadriplegia and paraplegia. This could lead to permanent immobility. With the loss of motor function, a pressure sore could develop due to decreased movement of extremities, a damage to the integumentary system. Source: Workman and Ignatavicius. MedicalSurgical Nursing. 5th edition.

MAY 12, 2010 After 6 hours of nursing interventions, the patient was able to manage his condition positively and performed preventive measures such as putting support to pressure areas.

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monitor progress of wound healing. - Keep the area clean and dry, carefully dress wounds, prevent infection, and stimulate circulation to surrounding areas to assist body s natural process of repair.

- Stretch bed linens promptly for a wrinkle-free bed to prevent further skin damage. - Remove wet bed linens to avoid skin breakdown.

- Assist to learn stress reduction and alternate therapy techniques to control feelings of helplessness and deal with situation. DEPENDENT: e - Encourage intake of high protein and vitamin C rich food to promote wound healing.

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NAME OF DRUG Generic Name: Celecoxib

CLASSIFIC ATION General Classificatio n: Antirheumatics, Nonsteroid al antiinflammato ry Agents Functional Classificatio n: COX-2 inhibitors

Trade Name: Celeberex Pts. Dose: 200mg 1tab PRN

MECHANISM OF ACTION Inhibits the enzyme Cycloxigenase 2 inhibitors. this enzyme is required for the symthesis of prostaglandins . Has an analgesic, antiinflammatory and antipyretic properties. Therapeutic Effects: -decrease pain and inflammation caused by arthritis -decrease number of colorectal polyps

INDICATION y Relief of sighns and symptoms of osteoarthritis Relief of signs and symptoms of rheumatoid arthritis in adults Reduction of the number of adenomatous colorectal polyps in familial adenomatous polyposis (FAP)

CONTRAINDICATION

y Hypersensitivit y, crosssensitivity may exist with other NSAIDs, including aspirin, y History of allergic-type reactions to sulfonamides, aspirin or any NSAIDs y History of asthma, urticaria y Advanced renal disease y Should not be used in late pregnancy (may cause premature closure of the ductusarteriosu s)

ADVERSE REACTION CNS: dizziness, headache, insomnia GI: GI bleeding, abdominal pain, diarrhea, dyspepsia, flatulence, nausea SKIN: rash

NURSING RESPONSIBILITY BEFORE -Assess patients range of motion, degree of swelling, and pain in affected joints before and periodically through out therapy -Assess patients for allergy to sulfonamides, aspirin, or NSAIDS. Patient with this allergy should not receive celecoxib. DURING -Instruct patient tpo take celecoxib exactly as directed. Do not take more than prescribe dose. Increasing doses does not appear to increase effectiveness. -Advise patient to notify health care professional promptly if signs or symptoms of GI toxicity, skin rash, unexplained weight gain, or edema occurs. -Advised patient to notify health care professional if pregnancy is planned or suspected. -Advised patient with Familial Adenomatous Polyposis(FAP). To continue routine surveillance procedures.

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USE CAUTIOUSLY y Concurrent therapy with corticosteroids or anticoagulants, long duration NSAID therapy

AFTER - Advise patient to notify physician if signs and symptoms occurs.

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NAME OF DRUG Generic Name:

CLASSIFICATIO N General Classification: Fluoroquinolones

Ciprofloxacin Functional Classification: Anti-infective

MECHANISM OF ACTION Inhibits bacterial DNA synthesis, mainly by blocking DNA ghyrase; bactericidal

INDICATION y complicated intraabdominal infection y severe complicated bone or joint infection, severe respiratory tract infection, severe skin or skin structure infection y severe or complicated UTI; infectious diarrhea, typhoid fever y nosocomial pneumonia y acute uncomplicat ed cystitis

CONTRAINDICATION y sensitive to fluoroquinolo nes

ADVERSE REACTION CNS: Seizures, confusion, depression, dizziness, drowsiness, fatigue, hallucinations, head ache, insomia, lightheadedness, paresthesia, restlessness, tremor CV: Chest pain, edema, thrombophlebitis GI: Pseudomembranous colitis, diarrhea, nausea, abdominal pain or discomfort, constipation, dyspepsia, flatulence, oral candidiasis, vomiting GU: Crystalluria, intestinal nephritis HEMATOLOGIC: Leucopenia, Neutropenia, thrombocytopenia, eosinophilia

USE CATIOUSLY: y CNS disorder such as severe cerebral arteriosclerosi s or seizure disorder and in those at risk for seizures, drug may cause CNS stimulation

Trade Name: Ciproxin Pts. Dose: 500mg 1tab BID

NURSING RESPONSIBILITY BEFORE: - obtain specimen for culture and sensitivity test before giving first dose - monitor patients input and output DURING: - observe patient for signs and symptoms of crystalluria - tendon rupture may occur in patient receiving quinolones. If pain or inflammation occurs or if patient rupture a tendon. Stop drug - Steroids may be used as adjunctive therapy for anthrad patients with severe edema and for

22

meningitis AFTER: - Long term therapy may result in overgrowing of organisms resistant to drug - Advise patient to notify physician if signs and symptoms occurs

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TEACHING PLAN Topic General objectives : Prevention of complications of immobility : After 30 minutes of nurse-patient interaction, the patient as well as the significant others or family will be able to acquire the knowledge, skills and right attitude that will prevent the occurrence of complications of immobility. Learning Content Teaching Learning Activities Time Allotment Resources Evaluation

Specific Objectives

Within 30 minutes of lecturedemonstration, the patient as well as the significant other or family will be able to: 1. Explain the contributing factors to immobility I. Contributing Factors of Immobility Any diseases or disability that requires complete bed rest or extremely limits activity is considered immobility. Patients who have these illnesses are at risk for immobility. a. stroke resulting in partial or complete hemiparalysis b. spinal cord injuy resulting in paraplegia or quadriplegia Let them state what they know of certain factors that contribute to one s immobility and discuss to them afterwards. 5 minutes Visual Aids (Cartolina) Question and Answer

c.

fracture

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d. prolonged bed rest after surgery e. electrolyte abnormality f. depression g. myopathy

2. Discuss the different signs and symptoms of the complications associated with immobility

II. Signs and Symptoms of the Complications of Immobility A. Disuse Atrophy -muscle wasting caused by inactivity or disuse of the "good" muscles, those that are unaffected by motor neuron degeneration. Signs and Symptoms: > muscle weakness > loss of muscle mass B. Joint Stiffness and Pain -can occur if weak limbs are not stretched and if joints are not given adequate full range of motion. The stiffness is due to tightness of the muscles and tissues surrounding the joints.

Ask for their ideas on the different signs and symptoms and ask if they could identify these symptoms as they manifest.

10 minutes

Visual Aids (Cartolina with pictures)

Question and Answer

Signs and Symptoms:

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> difficulty moving > pain

C. Contractures -are shortenings of muscle or connective tissue around the joints that prevent the normal range of movement of joints. Signs and Symptoms: > muscle shortening > presence of nodules D. Pressure sores or Ulcers -can result from pressure to an area of the body from a bed or chair. Any surface that presses against the skin and underlying tissues decrease circulation to the area. Signs and Symptoms: > fever >draining from the sore > foul odor E. Poor Circulation -can result from lying or sitting in one position for too long. Improper positioning can also hamper blood flow to any body part.

Signs and Symptoms:

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> poor healing in some areas > color changes

F. Urinary Tract Infection -This can promote urinary stasis or stagnation in the flow of urine from the kidneys to the bladder, and thus, lead to infection. Prolonged immobility also causes an increase of minerals and salts to circulate in the blood that can promote the formation of kidney stones. Signs and Symptoms: > strong urge to urinate that cannot be delayed > back pain > chills G. Constipation -is a common problem that may result from decreased physical activity. Signs and Symptoms: > abdominal cramps > decreased appetite > lethargy

H.

Aggravations

of

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Respiratory Problems -Being confined to a chair or bed for long periods in one position may suppress lung expansion and the ability to take a good breath that is needed for an effective cough force to clear the airways. Consequently, secretions in the lungs may accumulate and thicken, causing mucus plugs that may aggravate breathing. Secretions in the lungs also harbor bacteria that may multiply and possibly result in pneumonia. Signs and Symptoms: > chills > fever > productive cough > malaise > pleural pain > hemoptysis > dyspnea

3. Perform measures that will prevent the occurrence of complications of immobility

III. Measures to prevent occurrence of complications A. Disuse Atrophy > frequent passive ROM exercises B. Joint Stiffness/ Pain > frequent turning to sides > massage stiff and painful

Get their ideas regarding how to prevent the occurrence of the complications according to what they have known.

15 minutes

Visual Aids (Cartolina with Pictures) Question and Answer

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areas to give relaxation > have a good diet such as fish, seafood and olive oil

C. Contractures > perform passive ROM exercises > use splints to hold limbs in the correct position D. Pressure sores or Ulcers > proper skin care > carefully look for skin damage or redness especially in bony prominences > turn to sides at least every 2 hours > protect skin from injury E. Poor Circulation > frequent tuning to sides F. Urinary Tract Infection >increase oral fluid intake as tolerated >urinate when one feels the urge to void G. Constipation >increase oral fluid intake as tolerated >eat foods which are high in fiber H. Aggravations in

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Respiratory Problems > frequent turning to sides > wipe sweat off the back

4. Adjust lifestyle as demanded by the current situation

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DISCHARGE PLAN

MEDICATION: Instruct patient to take the medications as prescribed by the doctor

ENVIRONMENT: Instruct significant others to clean the environment and provide the patient with clean and wrinkle free linens. Place the patient s necessary things within reach.

TREATMENT: Instruct patient to follow the treatment regimen set out by his doctor.

HEALTH TEACHING: Advise significant others to assist patient with regular exercise daily Instruct significant others to help client with proper hygiene everyday.

OBSERVABLE SIGNS AND SYMPTOMS: Instruct patient and significant others to see the doctor immediately if the following signs and symptoms will occur, such as back pain and swelling of the lower extremities, fatigue,severe pain.

DIET: Instruct patient to eat nutritious food such as green leafy vegetables for fiber and foods that is rich in Vitamin C and calcium.

SPIRITUAL: Encourage patient to pray everyday and to have a strong faith in God. Encourage to go to church every Sunday with the family.

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