MANILA DOCTORS COLLEGE

Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay City

NURSING PROCESS

I. ASSESSMENT

A. General Data

Patients Initials: F.P Gender: Male

Address: Negros Occ. Occupation: Seaman

Age: 44 years old Civil Status: Married

Date of Admission: 11/18/10 Place of Birth: Negros Occ.

Number of Days in the Hospital: 22 Order of Admission: Ambulatory

Informant: Patient (F.P) Date of History Taking: 12/10/10

B. Chief Complaint

Fracture, right acetabulum S/P ORIF right fracture superior and inferior pubic
femur.

C. History of Present Illness

2 months prior to admission

The client while at work on board a ship travelling Europe, while carrying a
long metal baw got stocked between a moving crane and a wall near him which
damaged his pelvic area. He admitted in Netherland. X-ray done at Amstudam
Hospital showed fracture of right acetabulum and left superior vanus the patient
underwent ORIF of right acetabulum last Oct 7, 2010.

3 days prior to admission

 The client decided to transfer in the Manila Doctor Hospital for continuity
of rehabilitation.

D. Past History

1. Childhood Illness: None

2. Adult Illness: None

3. Immunization: Unrecalled

4. Previous Hospitalization: None

5. Previous operation/s: None

6. Injuries: None

7. Medication Taken Prior to Confinement: Neozep

8. Allergies: None

E. System Reviews :GORDON’S ELEVEN FUNCTIONAL AREAS

A. HEALTH PERCEPTION – HEALTH MANAGEMENT PATTERN

Before his admission at MDH, the client verbalized that his health has been well for the past
years. Cough and colds are common every time he’s in cold place and if it is in winter season
which usually falls on November according to the client. Whenever he feels the symptoms of
cough and colds he verbalized that drinking lots of water and taking 1tab of neozep tablet once a
day helps get rid of it. In his kind of work, he verbalized that it is not allowed to absent
eventhough you don’t feel well that why he doesn’t have any absences in his work. The most
important thing for him to keep healthy is eating in balance diet (vegetables, fruits, fish & soup),
drinking lots of water & walking, jogging and playing basketball every morning as his form of
exercise. He doesn’t smoke, take any prohibited drugs or any medications and perform TSE but
drinks alcohol occasionally. He never had any accidents before.
Now during his confinement, his perception of keeping himself healthy and most effective way
to avoid any form of illness is still eating the right kinds of food, drinking lots of water and has
his daily rehab. The client perceives that his condition is still the same as before hospitalization
the only difference is that he can’t walk normally as before. “Okay lang ako ngayon kaso nga
lang hindi ako makatulog masyado kasi sumasakit pa rin itong paa ko”, as verbalized by the
patient.

B. NUTRITIONAL – METABOLIC HEALTH PATTERN

The client verbalized that before confinement, his typical food intake during breakfast, lunch,
and supper are composed of five (5) cups of rice with viand (the viand depends on their cook in
the ship), soup, fruits and beverages. He doesn’t take any food or herbal supplements. He
usually eats biscuits with coffee as his everyday snacks and drinks eight (8) glasses of water a
day. He weighs sixty three (63) kilos and five (5) feet and four (4) inches in height. He doesn’t
have any hair on top of his head because according to him it is in their genes. He has a good
appetite, not picky on foods, no diet restrictions and does not experience any discomfort related
to eating. His wounds healed well for about four to five (4-5) days. He doesn’t have skin lesions
but experienced skin dryness outside the country due to cold weather.

Now during confinement, “Halos wala namang pagbabago malakas pa rin akong kumain yun nga
lang parang gumaan ang timbang ko” as verbalized by the client. He also added that he wears
ten (10) dentures with six (6) remaining teeth in upper and lower set. According to the client, he
doesn’t know his current weight because he said nobody mind to weigh him.

C. ELIMINATION PATTERN

The client’s bowel movement is once a day every morning, the stool is semi-formed and black in
colour due to medication. He doesn’t use any laxatives and doesn’t feel any discomfort while
eliminating. His urinary elimination pattern is four to six (4-6) times a day with no problem in
controlling and with no discomfort. The client stated that he experienced excessive perspiration
every time he made strenuous activities but without foul odor.

During his confinement in MDH, he doesn’t use laxatives because according to him it’s just easy
for him to eliminate his bowels. His urinary elimination pattern is still four to six (4-6) times a
day with no discomfort and problem in controlling.

D. ACTIVITY-EXERCISE PATTERN

Before admission at MDH, the client has sufficient energy for his desired or required activities
especially for his work. Usually have an every morning warm up, jogs, walks, and plays
basketball as his form of exercise. He usually watches TV & DVD movies and take a rest
whenever she has free/spare time. In perceived ability he falls under level 0 which is full self
care in feeding, bathing, toileting, bed mobility, dressing, grooming, general mobility, home
maintenance, cooking and shopping.

During confinement, the client is now in Level II which requires assistance or supervision from
another person in some activities involve with standing. He can do eating on his own but he
can’t stand, he goes to comfort room with guidance or support of his crutches and the walls
because he can’t stand alone. Because of the accident happened, the lower part of his body can’t
function normally unlike his upper body part. He can perform moderate and fast range of motion
exercises and doing his therapy or daily rehab. Her muscles are firm enough and her hand grip is
normal (can hold the hand bars firmly if he wanted to move his body upward).

E. SLEEP-REST PATTERN

The client said that he feels rested and ready for daily activities after sleep. Most of the time, he
has difficulty falling asleep and going back to sleep once he was awaked that’s why he’s taking
sleeping pills to resolve it. He sometimes experiences nightmares and early awakenings. He
usually sleeps four to five (4-5) hours. He allows time for rest-relaxation period.

During hospitalization, the client still has no difficulty in going back to sleep and he doesn’t
experience nightmares or early awakenings. The client verbalized that he likes his rest so he
allows a lot of time for it when given the chance. He relaxes by talking to his wife and sons who
are always there by his side or by reading the newspaper and watching TV.

F. COGNITIVE – PERCEPTION PATTERN

The client stated that he doesn’t have any difficulty in hearing. He doesn’t use hearing aids but
wears eyeglasses because he is farsighted. His last eye check up was last May 2009 without lens
grade changed. He doesn’t know what are the grades of his lenses. He was able to hear
whispered words and has no difficulties in reading newsprints. He has the ability to store and
retain relevant information as soon as he perceived them. Most of the time he does not
experience problem in memory and if ever he had forgotten things he was able to recall it by
effort. Decisions for him are easy to make because he knows his wife is always there by his side
to support him no matter what will happen. For him the easiest way to learn things was to show
or demonstrate it properly.

During confinement, the client still doesn’t have hearing difficulties and with no hearing aids.
According to him, he no longer uses his eyeglasses. The client verbalized that his memory is
still the same before and during his confinement. The client also doesn’t have any learning
difficulties; he said that he still can learn quickly without problems. There’s no discomfort or
pain during the interview. The client verbalized that he can speak Bisaya, Tagalog and English.
 G. SELF PERCEPTION – SELF CONCEPT PATTERN

The client describes himself as someone who is very kind, generous and possesses long patient.
He feels great about himself and said that he doesn’t want to change his looks, personality or
anything about him. According to the client, no one and nothing could make him angry or
annoyed. The client verbalized that he never feels that he was about to lose hope because he
believes that God will never abandon him and his family.

Now in confinement, the client still feels good, relax and assertive about himself despite of his
hospitalization. The client verbalized that nothing worries him anymore because he believes that
all that will happen will be because of God’s will.

H. ROLES – RELATIONSHIP PATTERN

The client verbalized that he currently lives with his family in Negros. They have an extended
type of family. He enjoys his role in the family, giving joys and surprises to his dear wife and
sons. He has a good relationship with his family and feels really loved by them. He doesn’t
belong to any social group but he had lots of close friends. He did well in his work and in his
home. His income as a seaman was sufficient for their needs. The client said that he doesn’t feel
lonely because of his family who is always there by his side.

During confinement, the client verbalized that his family felt really scared, were shocked and sad
about what had happened. He still doesn’t feel lonely during his hospitalization because his wife
and his sons never leave him.

I. SEXUALITY – REPRODUCTIVE PATTERN

The client stated that his sexual relationship with his wife is satisfying and mentioned that only
his wife used contraceptive which has been effective. He also reported that he doesn’t feel
awkward in terms of the way he interacts with both the same and opposite sex.

J. COPING – STRESS TOLERANCE PATTERN

Before confinement, the client is able to cope up with stress and problems as well. The client
said that recently there had been no crisis going on within his family. He possess long patient.
He is relaxed in most of the time. It was mentioned earlier that he doesn’t take any prohibited
drugs or medications and drinks alcohol occasionally. He can able to cope up with stress
because of the supports, love, care and concerns of her family who serves as his inspiration to
 move on and take another challenge in life. The most helpful in talking things over are his wife
and his family who are available all the time whenever there are problems that needed to be
solved. Whenever there are problems, he prays to God for strength. He’s relaxed most of the
time and whenever something is stressing him, he just relaxes by watching TV, taking a nap and
talking with his wife and sons.

During confinement, the client said that his hospitalization caused some changes in his life like
there would be changes in the things he can do.

K. VALUES – BELIEFS PATTERN

The client shared one of his most important plans for the future is to be able to make his sons
graduate with higher education and give them all the things they need in order to be successful in
life. Religion is important for him especially with his condition today.

F. Family Assessment

Initials Relation to patient Age Occupation Educational

Attainment
JP wife 39 yrs old Unemployed College Graduate
CP Son 5 yrs old N/A

G. Heredo – Familial Illness

Maternal: None

Paternal: Hair loss

H. Developmental History
 Theorist Age Task Patient’s Description

Erik Erikson 44 Intimacy and Solidarity The patient seeks more companion and
vs. Isolation love from his family. He’s getting closer
to his family.
Sigmund Freud 44 Genital stage Energy is directed towards full sexually
maturity and function. Development of
skill needed to cope and to build more
relationship in her environment.
Jean Piaget 44 Formal Operational Uses his rational thinking. Able to make
Stage decision with his self but not confident
to pursue. Has his own stand in life and
consider love ones as his motivation.
Lawrence Kohlberg 44 Postconventional Lives autonomously and defines moral
values and principles that are distinct
from personal identification w/ group
values. Lives according to principles
that are universally agreed.
Fowler 44 Individuative-Reflective He takes personal responsibility with his
beliefs and feelings. He really trusts
God whatever happens to his. And she
never forgets to pray every day of her
life.

PHYSICAL EXAMINATION

Date and Time Taken: December 11, 2010-2030H

Height: 5’4 Actual Weight: 61 kg

Actual Height:5’4
Body Mass Index:

Vital Signs
Temp:36.6 °C
PR.: 75 bpm
BP.:120/80 mmHg
RR.:19 cpm

A. SKIN
 I: The skin’s colour is light brown. Generally uniform except in the areas exposed to
the sun. There is presence of scars in some part of the skin and the hair is evenly
distributed.

P: The skin is warm to touch due to high temp in the room.

B. NAILS

I: The fingernails and toenails had smooth texture. The nail beds colour is pink.

P: Prompt return of pink colour return in 2 seconds when performing the capillary refill.

C. HEAD AND FACE

I: The head is symmetrical with the spinal cord. The face has fair color with the skin.

P: There is no tenderness or any swelling present in the face.

D. EYES

I: The client has 20/20 vision. Eyebrows and eyelashes are evenly distributed. The skin is
intact and there is no discoloration. The conjunctive is shiny, smooth and colour pink.
The pupils are black in colour, equal in size and round. The iris is flat.

P: There is no swelling or any tenderness in the lacrimal gland.

E. EARS

I: The colour is the same with the facial skin. Both ears are symmetrical with the other.
The auricle is aligned with the outer canthus of eye.

P: the auricles are firm and not tender. The pinna coils after it is folded.

F. NOSE

I: The external part of the nose is symmetrical. There is no discharge or flaring present. It
is uniform in colour.

P: No tenderness or swelling present in the nose. The air moves freely as the client
breathes through each nares. The gums are pink.

G. MOUTH AND PHARYNX

 I: the patient has only 12 teeth. There is 6 in the upper portion and 6 in the lower portion.
The mucosa is uniformly pink in colour.

P: The mucosa is soft, smooth and moist. When pulling away the lower lip, the gums
didn’t retract.

H. Spine

I: Vertically aligned
Pa: Spinal column is straight, right and left shoulders and hips are at same height

I. Thorax/Lungs

I: Chest symmetric
Pa: Skin intact, no tenderness, no masses, full and symmetric chest expansion
Per: resonate, except over scapula
A: quiet, rhythmic, and effortless respirations

J. Cardiovascular/Heart
I: No lift or heave
A: S1: heard at all sites, louder at apical area
S2: heard at all sites, louder at base of heart
Pa: No pulsations

K. Breast

I: Breast even with the chest wall, skin uniform in color

P: No tenderness, masses or nodules
L. Abdomen
I: Uniform color, symmetric contour
A: Audible bowel sounds
Per: Tympany over the stomach and gas filled bowels; dullness, especially over the liver
and spleen
Pa: No tenderness, relaxed abdomen with smooth, consistent tension

M. Extremities
I: Muscles: Asymmetric
Bones: Bones misaligned, presence of swelling, tenderness
Joints: one swollen joint (right lower), presence of tenderness, swelling,
Limited range of motion.

N. Genitals
Not examined

O. Rectum and Anus

Not examined
 P. Neurologic Exam
The Patient cooperates and listens well. He was well oriented and he answers the
questions well. He has good attention span.

II. PERSONAL HISTORY

III. ENVIRONMENTAL HISTORY
IV. OB/GYNE HISTORY- N/A
V. PEDIATRIC HISTORY- N/A

VI. PATHOPHYSIOLOGY
A. Theoretical based
B. Client Based
 VII. LAB RESULTS

Examination: Pelvic Inlet and Outlet

Examination Date: 11/18/2010

X-RAY RESULTS

Films were barrowed on 18 November 20 and were returned on 03 December 2010 for official.

Two malleable reconstruction plates and screws are seen at the right inferior ilium and
acetabelum maintaining good anatomic alignment of the transverse fracture within.

Fracture at the bilateral superior and inferior pubic femur noted.

The rest of visualized osseous structure and joint spaces are intact.
INTERPRETATION/SIGNIFFICANCE:

VIII. DRUG STUDY

IX. LIST OF PRIORITY PROBLEM

X. NURSING CARE PLAN
ON GOING APPRAISAL

XI. Ongoing Appraisal:

12/9/10

1400H-2200H

Patient was received from rehab. He used wheelchair to serve as replacement of walking. On his
room, he has Balkan Frame that was attached to the bedpost or to a separate stand to produce desired
continuous traction while permitting freedom of motion thus maintaining desired immobilization of the
affected leg until being treated. And an Overhead Trapeze to help the patient to move in bed. The
patient’s diet was Diet as Tolerated. The patient is scheduled for daily rehab.

Patient was encourage to use relaxation techniques such as deep breath exercises or coughing
exercises to promote comfort. Patient was advised to walk using assistive device such as crutches to avoid
bed sores. Patient was monitored for any untoward signs and symptoms occur. Patient’s Vital Signs were
taken every 4 hours, Intake & Output was taken every shift, and medications were given as due.
12/10/10

1400H-2200H

Patient was on the rehab daily. DAT was also maintained for his diet. Patient was walking
inside his room using crutches. The patient needs assistance to perform self-care tasks. He can insist the
pain he felt on his leg. Patient was encourage to increase oral fluid intake for about 6-8 glasses of water
daily. Patient’s Vital Signs were taken every 4 hours, Intake & Output was taken every shift, and
medications were given as due.

12/11/10

1400H-2200H

Patient was on the rehab daily. DAT was also maintained for his diet. The medication of the
patient is still on pending if pain was felt. The patient is also possible for discharge anytime, but for
continues on daily rehab. Patient was monitored for any episodes of pain. Patient supports the affected leg
with one pillow to promote relaxation. Patient’s Vital Signs were taken every 4 hours, Intake & Output
was taken every shift, and medications were given as due.
XII. Discharge Plan:

Medication:

Instruct the patient to take the prescribed home medicines given by the physician, Dolcet 325 mg
if Moderate to Severe Pain persists.

Exercise:

Instruct the patient to use assistive devices such as crutches to walk. Ask for assistance if cannot
walk alone. Wheelchair is another option if the patient is dependent.

Treatment:

• Use of relaxation techniques such as deep breathing exercises and coughing exercises can
help him to promote comfort.
• Provide the patient with therapeutic coping mechanisms about the treatment.
• Advised patient to support affected foot using pillows to reduce risk of pressure ulcer.

Health Education:
• Advised patient to increase fluid intake to 2000-3000 ml/day to keep body well hydrated.
• Advised patient to take pain medication before and after ambulation.
• Advised patient to clean the affected leg with soap and water to avoid risk of infection.
• Always provide relaxing atmosphere and adequate rest for relaxation.

OPD Follow-up:
• Advised patient for weekly checkup to the physician to improve present condition.

Diet:
• Encourage patient to increase intake of water, 8 to 10 glasses daily.
• Encourage patient to eat nutritious foods and take vitamins and supplements.
• Encourage patient to take more on calcium / high fiber foods to increase muscle strength.

Signs and Symptoms:

• Watch out for the signs and symptoms of decreased muscle strength / control of the affected
leg. And watch out for undesirable pain.
XI.
XII. DISCHARGE PLAN