Beruflich Dokumente
Kultur Dokumente
Group Leader:
Rubio, Reshiel
Members:
Afante, Booz
Andres, Jessica
Arcena. Katrine Ann
Atienza, Angielique
Barron, Edgar Allan
Cabutihan, Precious Diane
Delos Santos, Rosella
De Luna, Leny
Macabasco, Queenie
Chapter I
INTRODUCTION
Chapter II
CLINICAL SUMMARY
A. Biological Data
B. Physical Assessment
Cephalocaudal Assessment
C. System Assessment
Vital Signs
• Height: 5’8’’
• Weight: 70 kg
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Maam, ung course in the community po n kay miss delos santos po..
Chapter III
Clinical Discussion
Joints
• Also called articulations
- joined by cartilage
• The joint cavity is filled with a fluid called synovial fluid that is
enclosed by a joint capsule that helps hold the bone together
and allows movement. Portion of the joint capsule maybe
thickened to form ligaments and tendons outside the joint
capsule that helps in strengthening of the joint.
• Saddle joint
• Hinge joints
• Ball-and-socket joints
o It consists of the ball or the head at the end of 1 bone and
a socket in an adjacent bone into which portion of the ball
fits.
Bone Repair
Stages of Healing
normal bone ---------- ----- --------- ----- ---------- -----------healed fracture
Clot formation Callus formation Callus ossification Bone
remodeling
Pai
------------------------------ Decrease in synovial Pressure between Obliteration of joint
n fluid joint space
! !
Degeneration of Pai
! -------------
n !
cartilage
! ! !
Continuous use of Difficulty
! ! !
joint of
! ---------movement Formation of subchondral
Disappearing of full cysts
! thickness of articular ! ! !
WBC !
Pai
Redness, increase
edema ! If not remodeled
Osteoarthritis
n Surgery, GH & stem
cell injection
!-------------------------------!-------------------------------!------------------------ --------------------- !-------------------------------------------
-------- !
C. Drug Study
Drug Name Classification Mechan
of Actio
• To minimize
• Teach the the use of
importance body energy.
and
appropriate
use of
devices such
as walker,
canes and
crutches.
• Advised
client to rest
between
each
activities.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Acute pain After series of • Assessed for • To help After series of
“Masakit ang related to loss nursing referred determine nursing
tuhod ko,” as of integrity of intervention the pain. possibility of intervention the
verbalized by bone structure client’s pain underlying client’s pain was
the client. as evidenced by scale of 6/10 conditions lessened from
client’s verbal will decrease to requiring 6/10 to 3/10
Objective: reports, facial 2/10. treatment. and
• Pain scale of grimace, • To determine demonstrated
6/10 immobility & • Note client’s the ways on how to
• With swollen joints. attitude effectiveness provide relief as
guarded towards pain of relieving evidenced by;
behavior medication. pain. • The client
• With facial • Determine • To determine follow
grimace factors of the effect pharmacologi
• Immobility client’s response to cal regimen
• Swollen lifestyle. analgesic or as
joints choice of prescribed.
intervention • Took glasses
P= cold for pain of milk
weather/ management everyday.
analgesic • Monitor vital . • Walk for 15-
Q=pressing signs and • This usually 30minutes as
R=thigh & lower skin color. alters when a means of
leg • Provide pain occurs. exercise.
S= 6/10 comfort • To promote
T= measure non-
such as use pharmacolog
of hot ical pain
compress management
and and avoid
encourage being
the use of dependant to
diversional pain
activities like relievers.
watching tv,
listening to
music and
socialization
with others. To prevent
• Encourage fatigue and
adequate conserve
rest periods. energy.
• Instruct the
client to • To help
follow reduce the
medication pain
regimen as sensation.
prescribed
by the
physician.
• Instructed • To
the client to strengthen
eat nutritious the bone
foods density and
especially reduce
food that are inflammatory
rich in response.
calcium,
protein and
carbohydrate
.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Deficient After 8 hours of • Determine • Individual After 8 hours of
“Bakit po kaya knowledge nursing the client’s may not be nursing
lagi paring related to lack intervention the ability or physically, intervention the
sumasakit ang of information client will readiness emotionally client was able
tuhod ko tuwing and verbalized and barriers or mentally to verbalized
umaga at kapag unfamiliarity understanding to learning. capable at and
malamig ang with information of situation and • Be alert in this time. demonstrated
panahon.” As resource. treatment the signs of • Client may understanding
verbalized by regimen and avoidance. need to of situation and
the client safety suffer individual
measures. consequence treatment
Objective: of lack of regimen and
• Does not knowledge safety measures
know how to • Assess the before he is AEB client
manage the level of ready to followed safety
present client’s accept measures &
condition capabilities information. treatment
particularly and the • May need regimen such
as to what possibilities the help of as: does simple
type of of the SO or exercise every
action to be situation. caregivers to morning for 15-
done and • Provide learn. 30min., drinks
diet to be information milk every
followed. relevant only Can improve morning, takes
• Always to the understandin analgesic as
asking situation g about the prescribed.
questions as such as disease
related to definition of condition
the osteoarthritis thereby
condition. , causes, acquiring
signs and clients
symptoms, cooperation
treatment on disease
and management
management .
.
• Provide feed
back. • Can
encourage
• Begin the continuation
information of efforts.
the client • Can arouse
already interest or
knows and limit sense of
more to being
what the overwhelmed
client does .
not know,
progressing
from simple
to complex.
• Advised the
client the • To monitor
importance the
of having a progression
regular of the
check up to disease and
the physician effectiveness
or RHU. of therapy.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Goal met
Subjective: Impaired After series of Support To maintain
“ Kadalasan Physical nursing affected position of
hindi agad ako Mobility related intervention the body parts / function and
makakilos o to loss of patient will be joints using reduce risk of
makagalaw lalo integrity of maintain or pillows / pressure ulcers.
na tuwing bone structure. increase rolls, foot
umaga” as strength & support /
verbalized by function of shoes.
the patient. affected and or
compensatory Encourage To promotes
Objective: body part. adequate well being and
Limited intake of maximizes
range of fluids as well energy
motion as nutritious production.
Slow ed foods.
movement
Gait Encourage To keep joints
Stiffness the patient mobile and not
(early to increase taxing the joint
morning activity as too much
until about indicated.
an half hour
after rising Encourage To reduces the
Muscle the patient load on the
spasms to ambulate joint and
Joint with promotes
swelling assistive safety.
devices.
Chapter V
Discharge Planning