VII.

LABORATORY/DIAGNOSTIC FINDINGS
VIII. ANATOMY AND PHYSIOLOGY
A. MACRO ANATOMY OF THE SKELETAL SYSTEM

(ANTERIOR VIEW)
(POSTERIOR VIEW)
B. MICRO ANATOMY OF RADIUS, ULNA, METATARSAL, PROXIMAL
INTERPHALENGEAL JOINTS, TIBIA, FIBULA, FEMUR AND
METATARSAL

(LEFT RADIUS AND ULNA)

(LEFT METATARSAL AND PROXIMAL INTERPHALANGEAL JOINTS)
(LEFT TIBIA, FIBULA AND FEMUR)
(FEMUR-CROSS SECTION)

(METATARSALS)
 C. MACRO PHYSIOLOGY OF THE SKELETAL SYSTEM

Its 206 bones form a rigid framework to which the softer tissues and organs of
the body are attached.

Vital organs are protected by the skeletal system. The brain is protected by the
surrounding skull as the heart and lungs are encased by the sternum and rib
cage.

Bodily movement is carried out by the interaction of the muscular and skeletal
systems. For this reason, they are often grouped together as the musculo-
skeletal system. Muscles are connected to bones by tendons. Bones are
connected to each other by ligaments. Where bones meet one another is
typically called a joint. Muscles which cause movement of a joint are connected
to two different bones and contract to pull them together. An example would be
the contraction of the biceps and a relaxation of the triceps. This produces a
bend at the elbow. The contraction of the triceps and relaxation of the biceps
produces the effect of straightening the arm.

Blood cells are produced by the marrow located in some bones. An average of

2.6 million red blood cells is produced each second by the bone marrow to
replace those worn out and destroyed by the liver.

Bones serve as a storage area for minerals such as calcium and phosphorus.
When an excess is present in the blood, buildup will occur within the bones.
When the supply of these minerals within the blood is low, it will be withdrawn
from the bones to replenish the supply.

The axial skeleton provides:

(a) Structural support for the body,

(b) Attachment points for ligaments and muscles, and 

(c) Protects the brain, spinal cord and major organs of the chest. The axial
skeleton includes bones of the skull, inner ear, chest and spinal column.

Bones of the Skull: Can be categorized into two groups:

(A) Neurocranium and

(B) Splanchnocranium.
With the exception of the mandible, all the bones of the skull are joined together
by sutures. 

The Neurocranium includes the following bones:

 Frontal bone: makes up the forehead and part of the eye orbits and part
of the nasal cavities.
 Parietal bones: here are 2 parietal bones, which articulate together and
form the roof of the cranium.
 Temporal bones: one on either side of the skull, contain the inner ear.
These bones also provide a foramen  (canal) for the major blood supply to
the brain, the carotid artery and jugular vein.
 Occipital bone: makes up the back and floor of the cranium. The
brainstem passes through this bone and then continues as the spinal cord.
 Ethmoid bone: forms the front part of the cranial floor, part of the eye
orbits, and contains the ethmoid sinuses. 
 Sphenoid bone: contains the sphenoidal sinus cavity. Has a unique
depression called the sella turcica, which houses the pituitary gland.
 Palatine Bone: these bones are at the back of the roof of the mouth. They
form the wall of the nasal cavities and the floor of the eye orbit.

Bones of the Face: The bones of the face (Splanchnocranium) are 14 in total.

They are: 2 nasal, 2 maxilla, 2 zygomatic, 2 lacrimal, mandible, 2 palatine, 2
inferior nasal conchae and vomer.

 Lacrimal Bone: is the smallest bone of the face, from part of the inside
wall of the eye orbit.
Nasal Bone: the two nasal bones meet in the middle and this forms the
bridge of the nose.
Inferior Nasal Conchae: these bones form the lateral wall of the nasal
cavity and cause the inhaled air to swirl and be filtered.
 Vomer Bone: is a triangular shaped bone that forms part of the nasal
septum. 
Zygomatic Bone: it is a paired bone, which makes up the lower eye orbit
and is frequently referred to as the cheekbone.
 Maxilla Bone: the largest bones of the face; they form together to make
the whole upper jaw. These bones hold the upper teeth.
 Mandible Bone: the strongest bone of the face; it forms the lower jaw and
holds the lower teeth. It is the only bone of the skull that moves.
 The hyoid bone is a bone in the neck, which does not articulate with any
other bone. Muscles of the neck support it and it provides support for the
root of the tongue; it is involved in the production of speech.
Bones of the Inner Ear: The bones of the inner ear are called the;

(a) Malleus (hammer),

(b) Incus (anvil) and

(c) Stapes (stirrup).

These bones function together to transmit sound waves from the external
environment to the fluid filled cochlea.

 Malleus (hammer): The malleus, or hammer, is a hammershaped bone

that is attached to the incus. It is attached to the inner surface of the
eardrum and, therefore, it moves as the eardrum vibrates in response to
incoming sound.
 Incus (anvil): is an anvil-shaped bone in between the malleus and the
stapes. It is the bridge that connects the incoming sound waves to the
inner ear.
 Stapes (stirrup): The stapes, or stirrup, transmits the sound vibrations
from the Incus to the oval window. The oval window connects the inner
ear bones with the cochlea.

The Vertebral Column:

 Cervical: The cervical region is the first portion of the spinal column and is
made up of 7 vertebras. The first and second vertebrae are unique, and
they are called the atlas and the axis.
 Thoracic: The thoracic region of the vertebral column is located in the
chest. It contains 12 vertebrae and is connected to the lumbar region of
the spine.
 Lumbar: The lumbar region of the vertebral column is the last main
portion of the vertebral column and is located in the lower back. It contains
5 vertebrae and is connected to the pelvis, through the sacrum and
coccyx.
 Sacrum: The sacrum is a triangular shaped bone that is made up of 5
fused sacral vertebrae. It articulates with and provides a strong foundation
for the pelvis.
 Coccyx: The coccyx is also a triangular shaped bone that is made of 4
fused coccygeal vertebrae, and is also known as the tailbone. It is
attached to the sacrum by cartilage, and this allows some movement
between them and shock absorbance.
Bones of the Chest
Clavicles (or collar bones) are long bones, which support the ribcage and
shoulder joints. The clavicles provide an attachment for the scapula and rotate
when the arm is moved forward.

There are twelve RIBS in the rib cage, 10 pairs that are joined to the sternum
and spine and 2 floating pairs. The ribs protect the underlying organs and assist
in respiration.

 Scapula: also known as the shoulder blade; it is a pair of broad flat bones
that connect the arm bone with the clavicle.
 Sternum: also known as the breastbone; it is a long flat bone in the center
of the chest. It connects to the ribs via cartilage and completes the rib
cage. It has three portions, from the top downward:

(A)Manubrium,

(B) Body and

(C) Xiphoid Process.

Bones of the upper extremity

 Elbow joint: The bones of the elbow include the humerus, radius and
ulna. This joint is a pivot point for the forearm and plays a major role in
hand movement and function.
 Humerus: The humerus has a depression called the olecranon fossa.
This depression receives the     olecranon of the ulna, while the forearm is
extended. The olecranon forms the prominence of the elbow.
 Radius: The radius is the lateral bone of the forearm (located on the
thumb side). The radial head articulates with the humerus and the radia
notch of the ulna.
 Ulna: The ulna is the medial bone of the forearm (located on the little
finger side), which articulates with the humerus in the elbow joint and the
carpals in the wrist.

The wrist: or carpal bones are made up of 8 small bones held together by
ligaments. The carpal bones articulate with the radius and ulna and include the:
The scaphoid, lunate, triquetrium, pisiform, hamate, trapezium, trapezoid and the
capitate.
The hand is made up of the metacarpal bones and phalange bones. There are 5
metacarpal bones, which make up the palm. There are a total of 14 phalanges,
which make up the fingers.

Bones of the pelvis: The pelvis is located at the base of the spine and contains
two sockets for articulation with the lower extremities.

 Ilium: The ilium bone articulates with the sacrum at the sacroiliac joint.
This joint, along with its ligaments, connects the lower extremities with the
torso.
 Ischium: The ischium bone forms the lower and back part of the pelvis.
The ischium bone also makes up part of the acetabulum and contains the
obturator foramen.
 Pubis: The pubis bone is between the ilium and the ishium, and it forms
part of the acetabulum.  

Bones of the lower extremity: the leg bones are the largest bones of the body
and, along with the ankle and feet, provide support for standing and walking.

 Femur: The femur, or thighbone, is the largest and strongest bone of the
human body. It articulates with the hip at the hip joint and the bones of the
lower leg at the knee joint.
 Tibia: The tibia is the larger of the two shinbones. It articulates with the
fibula and femur at the knee joint and the tarsal bones of the ankle.
 Fibula: The fibula is the smaller shinbone; it is more posterior than the
tibia. It forms the lateral portion of the ankle joint.
 The Tarsal bones are a group of bones that make up the ankle, and the
foot is made up of meta-tarsal ones and phalange bones.

 The Patella: The patella or kneecap is a large, triangular sesamoid bone

between the femur and the tibia. It is formed in response to the strain in
the tendon that forms the knee. The patella protects the knee joint and
strengthens the tendon that forms the knee.
 D. MICRO PHYSIOLOGY OF RADIUS, ULNA, METATARSAL, PROXIMAL
INTERPHALENGEAL JOINTS, TIBIA, FIBULA, FEMUR AND
METATARSAL

Radius: The radius is the lateral bone of the forearm (located on the thumb side).
The radial head articulates with the humerus and the radia notch of the ulna. The
radius, contributes more to the movement of the wrist and hand than the ulna.

Ulna: The ulna is the medial bone of the forearm (located on the little finger side),
which articulates with the humerus in the elbow joint and the carpals in the wrist.
The ulna is longer than the radius and connected more firmly to the humerus

The wrist: or carpal bones are made up of 8 small bones held together by
ligaments. The carpal bones articulate with the radius and ulna and include the:
The scaphoid, lunate, triquetrium, pisiform, hamate, trapezium, trapezoid and the
capitate.

Femur: The femur, or thighbone, is the largest and strongest bone of the human
body. It articulates with the hip at the hip joint and the bones of the lower leg at
the knee joint.

Tibia: The tibia is the larger of the two shinbones. It articulates with the fibula and
femur at the knee joint and the tarsal bones of the ankle.

Fibula: The fibula is the smaller shinbone; it is more posterior than the tibia. It
forms the lateral portion of the ankle joint.

The Tarsal bones are a group of bones that make up the ankle, and the foot is
made up of meta-tarsal ones and phalange bones.
IX. PATHOPHYSIOLOGY

Predisposing Factors
Precipitating Factors
Age
Accident Lifestyle
Osteoporosis Diet

Sudden twitching motion

Bone can not tolerate the

increased force in the area

Break in the continuity of bone

Adjacent structure
affected

Joint dislocation Actual shortening of

extremities (in case of long
bone)

Rupture Damage of
blood vessel Muscle spasm

Hemorrhage of
Continuous pain and
muscle and joint
increase in severity

Soft tissue Severed nerve injury

Discoloration
edema of the skin
Loss of function
Pain
X.COURSE IN THE WARD

A. 08-06-10

TIME
14:00 H
Verifying the medicine for the patient

14:30 H
Urinalysis done
Fecalysis done

15:00 H Prepared for chemical analysis

PT, PTT done
CXR PA done
16:00 H
Vital signs taken and recorded
TSB

17:00 H Administered Neurontine 300mg prn for pain

Assessed the patient for pain in the left upper extremities
Assessed the patient for pain in the left lower extremities
19:00 H
ESR and CRP determination done

20:00 H Administered Mecobalamine 500mg/tab TID to the patient

Vital signs taken and recorded
21:00 H
Reassesed for pain
Visited by physician

22:30 H
Needs attended accordingly
XI. NURSING CARE PLAN NCP PRIORITY #1

BACKGROUND
ASSESSMENT DIAGNOSIS STUDY OF PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
INDEPENDENT:
SUBJECTIVE: Acute Pain related Thus, due to STG:  Assess pain  Elevation in  After assessing
to muscle spasms accident. The After 1-2 days characteristics intensity and the pain the
“Masakit tlga yung and tissue trauma patients has of nursing including location, worsening of
frequency may
braso at paa ko lalo secondary to traumatized tissues, interventions, intensity, and condition is
na pag nagagalaw” vehicular accident and bleeding from frequency. indicate
the patient will prevented
as verbalized by as evidenced by damaged bones that worsening
be able to:
the patient. patient’s stimulate condition
 verbalize a
verbalization of inflammatory COLLABORATIVE
relief ofpain
OBJECTIVE: pain, immobility response resulting  Encourage use of  To self manage  The patient
felt on the
and facial pain to the affected non- the pain felt. shows effective
affected leg.
 observed grimaces part. pharmacological non-
evidence of pain methods of pain pharmacological
 multiple fractures LTG: control(heat/ methods to
 open wounds After a week of cold application) control pain.
 immobile nursing
intervention the DEPENDENT
 facial grimaces
patient will be:  Administer and  To maintain  Due meds are
 free of pain. monitor ordered acceptable given
VITAL SIGNS:  appear medications level of pain
relaxed.
BP:120/90  able to rest
T:36.9 HEALTH TEACHING
appropria-
RR:16 BPM  Encourage  To help pt  Patient’s relative
tely is able to
PR: 75 BPM significant others to divert his
continue provision verbalize
attention to understanding of
of diversional
activities and a other matters the importance of
quiet environment. than pain felt. adhering to
 Promote adequate  To allow pt course of
rest periods by continue divert treatment.
temporarily limiting his attention and  The patient is
activity to prevent free of pain and
fatigue. appear relaxed
NCP PRIORITY #2
 NCP PRIORITY #3

BACKGROUND
ASSESSMENT DIAGNOSIS STUDY OF PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
“Risk of infection Thus, due to STG: INDEPENDENT:
SUBJECTIVE: related to accident. The  After 1-2 days  Observe for  To assess  After observing
“NONE” inadequate patients has broken of nursing localized signs of contributing patient, the site
primary defenses skin, traumatized interventions, infection at insertion factors of wounds still
OBJECTIVE: secondary to tissues, tissue any of the site of invasive shows signs of
 multiple fractures vehicular destruction, stasis patient’s family lines, sutures, inflammation.
 open wounds accident” of body fluids and members surgical
 immobile (A risk diagnosis the likes makes him would be able incisions/wounds
is not evidenced more prone on to demonstrate COLLABORATIVE
VITAL SIGNS: by signs and acquiring infections. techniques,  Assist with medical  To reduce  There are no
symptoms, as the Any infectious agent lifestyle procedures as existing risk pending medical
BP:120/90 problem has not might enter the changes to indicated factors procedures.
T:36.9 occurred) patients’ body via promote safe DEPENDENT
RR:16 BPM open wounds environment  Administer and  To determine  Due meds are
PR: 75 BPM because now the for the patient. monitor ordered the given
patient has an medications effectiveness of
increased therapy and
environmental LTG:
presence of
exposure to  after a week of
side effects
pathogens. nursing
HEALTH TEACHING
intervention the
 Emphasize  Premature  Patient’s relative
patient would
necessity of taking discontinuation is able to
be able to
up of medication verbalize
achieve timely
antiviral/antibiotics, may result to understanding of
wound healing
as directed return of the importance
as evidenced
infection and of adhering to
by:
potentiate drug- course of
 negative resistant strains treatment.
erythema on  To promote  Patient’s relative
wound sites wellness
 Teach patients is able to show
and
about ways to techniques to
 absence of
prevent prevent
purulent
postoperative acquiring
drainage
infection. infection.
XII. Drug Study
XIII. DISCHARGE PLANNING

M - Medication

1. Analgesia

- Pain reliever.

2. Aminoglycoside

- To target gram-negative organisms if dirty wound is present.

3. Iron supplement (FERROUS SULFATE)

- One capsule a day, to be taken 1 hour or before or 2 hours after meal.

4. Ascorbic Acid

- Should be taken once a day.

E - Exercise

 Range of Motion Exercises

- Some simple exercises can help maintain ankle motion, and stretch the
injured ligaments in the ankle joint.

 Alphabet writing
- While seated or lying down, write the alphabet in the air with your toes.
Make the letters as big as possible. Get creative by trying all uppercase, then
lower case, then cursive, etc...

 Toe raises
- Stand on a stair or ledge with your heel over the edge. Stand up on your tip
toes, then in a controlled manner, let the heel rest down. Repeat 10-20 times, 4
times a day.

 Activity-Specific Training
- Activity specific exercises may include simply walking or jogging, or may be
more intense for athletes who participate in basketball, soccer, or other sports
  Range of Motion

- The muscles that create motion in the wrists are actually in the forearm and are
called wrists extensors and flexors.

 Wrist Stretching

- Do both wrist extension stretches and wrist flexion stretches.

 Wrist Strengthening

- To strengthen your wrists, add a light weight and use the same motion as in
the wrist extension and flexion stretches.

T - Treatment

 Rehabilitation

- The primary focus of rehabilitation for a dislocation is to relieve pain and to

restore pre-injury functional status.

 Physiotherapy

- Explanation of injury.

 Occupational Therapy

- Any patient with significant chronic stiffness, especially in the PIP joint, can
benefit from occupational therapy. 

 Physical Therapy

- Most patients with dislocations should recover good function.

H - Health Teaching

 Instruct the client to follow the required dietary needs.

  Demonstrate the proper use of mobility devices.

 Instruct the client to follow the required exercise appropriate to him.

 Review safety measures.

O - OPD follow- up

 Client must see/consult a physician at least 1-2 weeks after discharge for
assessment of further complications.

 Client must see a physical therapist to check the client’s body strength
improvement.

D - Diet

 Eat half pineapple every day until it's completely healed. It contains Bromelain,
an enzyme that helps to reduce swelling and inflammation. Do not eat canned or
processed pineapples. If you don't like fresh pineapple, take the supplement
Bromelain. It has the same effect as pineapple.

 Do not eat red meat, and avoid drinking colas and all products containing
caffeine.

 Avoid eating foods with preservatives, they contain Phosphorous which can lead
to bone loss.

 Take Calcium + Magnesium + Potassium.  They are essential to repair bone

damage and to maintain a good muscle and heart condition.

 Increase oral fluid intake.

Spiritual/Sexual

 The religious institution must be accessible and convenient for the patient.

 Client is allowed to have a sexual activity if it will not affect his body healing
process.
XIV. REFERENCES

I. INTRODUCTION. Yamugan, Alfredo R.

Books:

1. Brunner and Suddarth’s Medical Surgical Nursing, 11 th Edition

S.C Smeltzer, B.G. Bare (2007)

e-references:

II. OBJECTIVES. Villafuerte, Ma. Elaiza R.

Books:

1. Brunner and Suddarth’s Medical Surgical Nursing, 11 th Edition

S.C Smeltzer, B.G. Bare (2007)

e-references:

III. PATIENT PROFILE. Sagadraca, Esteven Khen

Books:
 1. Kozier and Erb’s Fundamentals of Nursing, Concepts, Process and Practice 8 th
Edition, Berman, Snyder, Kozier, Erb (2007)

e-references:

IV. PHYSICAL ASSESSMENT. Manio, Merrie Ann Rose

Books:

1. Kozier and Erb’s Fundamentals of Nursing, Concepts, Process and Practice

8th Edition, Berman, Snyder, Kozier, Erb (2007)
2. Our Lady of Fatima University Performance Checklist (2008)

e-references:

V. ACTIVITIES OF DAILY LIVING. Soriano, Al Rajji A.

Books:

1. Kozier and Erb’s Fundamentals of Nursing, Concepts, Process and Practice 8 th

 Edition, Berman, Snyder, Kozier, Erb (2007)

e-references:

http://www.lifenurses.com/nursing-diagnosis-and-11-gordons-functional- health-
patterns/

VI. DEVELOPMENTAL TASK. Sadang, Christine S.

Books:

1. Psychiatric Nursing Contemporary Practice, 4th Edition

Mary Ann Boyd (2008)

e-references:

VII. LABORATORY/DIAGNOSTIC FINDINGS. Samaniego, Maryflor

Books:

1. Brunner and Suddarth’s Medical Surgical Nursing, 11 th Edition

S.C Smeltzer, B.G. Bare (2007)

e-references:
VIII. ANATOMY AND PHYSIOLOGY. Reyes, John Lane E.

Books:

1. Brunner and Suddarth’s Medical Surgical Nursing, 11 th Edition

S.C Smeltzer, B.G. Bare (2007)

2. Our Lady of Fatima Unversity Anatomy and Physiology Book (2008)

e-references:

IX. PATHOPHYSIOLOGY.Rance, Vivienne Valerie C.

Books:

1. Brunner and Suddarth’s Medical Surgical Nursing, 11 th Edition

S.C Smeltzer, B.G. Bare (2007)l

e-references:
XI. NURSING CARE PLAN 1. Villafuerte, Ma. Elaiza R.

NURSING CARE PLAN 2. Zipagan, Randolf A.

NURSING CARE PLAN 3. Reyes, John Lane E.

Books:

1. Nurses Pocket Guide Diagnoses,Prioritized Interventions, and Rationales

(11th Edition). Philadelphia, Pennsylvania. E.A. Davis Company
Doenges, M.E., Moorhouse, M. F., Murr, A.(2008)

e-references:

XII. DRUG STUDY. Zipagan, Randolf A.

Books:

1. 2009 Lippincott’s Nursing DrugGuide

Karch, Amy M. (2009)

e-references:

http://www.pharmaceutical-drug-manufacturers.com/pharmaceutical-
drugs/mecobalamin.html

http://www.drugs.com/neurontin.html

http://www.drugs.com/cefuroxime.html

XIII. DISCHARGE PLANNING. Sanchez, Luis V U.

Books:

e-references:

http://nursingcareplan.blogspot.com/2007/02/ncp-fractures.html