University of Southern Philippines Foundation

Salinas Drive, Lahug Cebu City

COLLEGE OF NURSING
 I. Introduction
II. General Information and Patient’s Profile
III. Developmental task
IV. Genogram
V. Gordon’s Functional Health Problems
VI. Physical Assessment
VII. Diagnostic and Laboratories
VIII. Anatomy and Physiology
IX. Pathophysiology
X. Nursing Care Management: Nursing Care Plan
XI. Drug Studies
XII. Health Teaching Plan
XIII. Discharge Plan
INTRODUCTION
General Information and Patient’s Profile

Name: W. D

Age: 17 y/o

Sex: Male

Civil Status: Single

Address: San Juan, Patao, Bantayan Island

Religion: Roman Catholic

Nationalism: Filipino

Occupation: Student

Case no: 2016332685

Date & Time of Admission: October 27, 2019 @ 4:14 am

Ward & Bed No.:B24 Orthopedic Ward

Institution: Vicente Sotto Memorial Medical Center

Physician: Dr. Alejandro Montejo, Md

Chief of Complaint: Abdominal pain, Abnormal Uterine Bleeding

Medical Diagnosis: Fracture ,Comminuted Left Femur

Operation Performed: Reduction and Fixation , skeletal Traction

Erik Erikson’s Development Task:

Identity Vs Role Confusion

(12-18 years old)

It occurs during adolescence, from about 12-18 years. During this stage,
adolescents search for a sense of self and personal identity, through an intense
exploration of personal values, beliefs and goals. Development depends on what is
done to a person. At this point, development now depends primarily upon what a
person does. An adolescent must struggle to discover and find his or her own
identity, while negotiating and struggling with social interactions and “fitting in” and
developing a sense of morality and right from wrong. Some attempt to delay
entrance to adulthood and withdraw from responsibilities. Those unsuccessful with
this stage tend to experience role confusion and upheaval. Adolescents begin to
develop a strong affiliation and devotion to ideal, causes, and friends.

In lined with my patient ,he patient wanted to explore and enjoy life. He is
fun going out late with friends. Drinking sessions and partying with his friends. He
disobeys his mother and father most of the time, this is one of the main reason why
he got vehicular accident. He regret for not following his parents advises. He
underappreciated and misunderstood the role of his parents. He is a Grade 12
student, all he think is what makes him happy and he forgot the people around him
who cared and loved him. Based on the struggle he experienced while he is
currently hospitalized he realized that it wasn’t easy and has no plans for doing it
again. The experience he had taught him so much that he will keep for the rest of
his life.
Genogram
Gordon’s Functional Health Problems

Gordon’s Before Hospitalization During

functional health Hospitalization
pattern
Health As verbalized by the
perception & patient he completed
maintenance his immunization,he
experienced minor
illnesses such fever and
diarrhea 1 year ago and
used to take OTC
drugs, the patient
consider himself as
healthy despite of his
present condition, he
added also that he has
pain score of 5 out of
10 scale but doesn’t
perceive as health
problem, he is positive
person.
Nutrition& Patient used to eats 3-
metabolism 4x a day, before
heading to school
patient ates a cup of
rice with egg,corned
beef, and hotdogs
during breakfast, during
lunch time patient used
to eat a cup rice, fish,
vegetables and pork,
and during break time
in school he used to eat
banana cue, junkfoods,
with ice candy.He
consumed atleast 8
glasses of water a
day,during weekends
patient says he used to
drink liquor and
consumed 2 bottles.
Elimination Patient voids 8 times a
day,with regular urine
color of light yellow, no
burning sensation felt
upon urination, usually
moves his bowels every
other day and with
firmed in consistency
and brown in color
stools.

Activity& Patient states that he

Exercise has sufficient energy for
completing his daily
needs , patient used to
play outside with his
friends, he used to
walked sometimes in
going to school, they
have morning exercise.

Cognitive & Patient is a passive and

perception easy going person, he
also added that he
hasn’t hearing
difficulities or uses of
aids,has no vision
problems and has
20/20 vision, no
problems with his
senses, no changes in
his memory,he does
well scholastically,
patient stated also that
he is
aware of his condition,
he does not fail to
answer questions
coherently.
Sleep and Rest Patient sleeps around
8-9 pm and wakes up
at 5am for
school,school starts at
7am , he is generally
rested and ready for
daily activities after
sleeping,he verbalizes
that his sleeping
pattern is effective and
still have condition
feeling in going to
school,he doesn’t take
a nap most of the time.
Self-perception Patient is the youngest
& self-concept child among 3 siblings,
he is independent on
many things such as
preparing his uniform
and foods before
heading to school,he is
very close to his
mother, he added also
that he is satisfied with
his physical
appearance, he
expresses his desire to
maintain his weight for
the preparation of his
upcoming surgery.
Role- Patients states that he
Relationship lives with his family
including grandmother
and grandfather, and
they’re 3 siblings, he
says that his father
does not always stay
with him since his
father used to left early
morning, since his
father is a fish
vendor,as verbalized by
patient he has no
family problems or
 conflicts ,he has good
family relations, he
added that theyre
income is at times,
lacking but it is enough
to provide for their
needs, he says that he
does well in school
academically and
socially,family cares for
him, has friends in his
school and
neighborhood.
Sexuality Patient cicrcumsized at
the age of 9, has no
children and sexually
inactive since he doenst
have partner, he use to
watch both girly and
boyish shows on tv.

Stress Tolerance As verbalized by the

patient his main source
of stress is the money
that they are going to
use for his upcoming
surgery,he verbalized
also that he manages
this by praying and he
said it slightly helps him
to calm down but stress
still present.
Values & Patient is Roman
Beliefs Catholic and he
consider himself a
devout he added that
he had devoution with
“Senyor Santo
Nino”,but he stated
that he is rarely visit
church.
Physical Assessment

General Survey:

SKIN, HAIR, AND NAILS

The skin is intack with no redness, skin

brown complexion.
INSPECTION The hair is black, clean, with even
distribution and kept short, with out
presence of dandruff.
The nails are both clean without any signs
of clubbing, well trimmed.
Skin is smooth, warm, even,thin , dry with
PALPATION no presence of lesions.
His skin turgor returns to its original shape
immediately in under a second.
The hair is smooth and dry
The nails are hard and immobile,
The capillary refills in one second.
 HEAD, NECK AND CERVICAL LYMPHNODES

Head size is symmetric, round, and in the

midline with no involuntary movement.

INSPECTION Skull is intact without palpable lesions or

masses, scars and bruises.

The neck is symmetric,with the head

centered and without bulging masses.

The head is hard and smooth, there is no

PALPATION presence of lesions in both neck and head
area, the temporomandibullar joint has not
swelling.

Neck are not palpable

THORACIC AND LUNGS

Thorax has the same color as the rest of the

INSPECTION bod,with no presence of lesions

Patient has straight thorax symmetric and

not protruding.

Patient has a respiratory rate of 20cpm and

AUSCULTATION has regular breathing pattern.
 No adventitious sounds are hear

CARDIOVASCULAR

INSPECTION No redness of chest, and no protruding of

thorax.

AUSCULTATION The heart rate pumping well with the pulse

rate 77bpm from the normal rate of 60-
100bpm, and has regular rhythm, presence
of S1 and S2 sounds

No adventitious sounds heard

Point or maximal mpulse is heard between

4th and 5th intercoastal space.

BREAST

INSPECTION Breast are symmetrical with out lesions and

discharges.

Nipples and areolas are dark

 PALPATION Both breast are firmed to touch and no
lumps/masses upon palpation

Tenderness noted upon palpation

ABDOMEN

Abdominal distention noted

Patient abdomen free from lesions and

rashes.

INSPECTION Umbilical is recessed –midline and the skin

color is even.

His abdomen is globular

Vugular veins are not visible

Intact surgical dressing, JP drain noted, no

unusualities.

PALPATION Epigastric tenderness noted

AUSCULTATION Bowel sounds are hypoactive

Positive Murphy sign on ther right upper

PERCUSSION quadrant noted upon percussion.
 MUSCULOSKELETAL

INSPECTION Patients movements coordinated and

rhythmic, arms swings in opposition stride
length appropriate.
Pt. had good posture and gait

Client has full ROM in flexion, entension and

suppination with hils elbows.

Head has full ROM when bending and

rotating bilaterally

No tingling, numbness, or pain

Carpals and phalanges are intact no sign of

fractured bone.

NEUROLOGIC

Patient was awake, responsive, and

INSPECTION coherent. She was oriented to time, place

and person.
GCS:
E: 4
V: 5
M: 6
Diagnostic and Laboratories
HEMATOLOGY

Test Date Normal Patient’s Significant

type & Values Profile Findings
Time
Complet
e Blood
Count
WBC 11/25 (4.0-13.0) 5.70
X10^9/L
/19

11:45

AM

RBC 11/25 M: (4.7- 4.91

6.10)
/19 F: (4.2-
5.4)
@
X10^12/L
11:45

AM

HEMOGLO 11/25 125-161 L 115.00 Measures the

amount of
BIN g/L
/19 hemoglobin in
your blood.
@ Hemoglobin level
is lower than
11:45 normal, it means
you have a low
 AM red blood cell
count (anemia)
HEMATOC 11/25 M: (41- L 42-52 To determine the
53) proportion of your
RIT
/19 F: (36-47) blood that is
made up of red
%
@ blood cells (RBCs)
in order to screen
11:45 for, help
diagnose, or
AM monitor
conditions that
affect RBCs; as
part of a routine
health
examination or if
your healthcare
provider suspects
that you
have anemia or p
olycythemia
MCV 11/25 78-95 fl L 72.90 Measures the size
red blood cells, if
/19 blood cells are too
small or too large,
@ it may incdicate
blood disorder
11:45 such as anemia,
vitamin A
AM deficiency.
 MCH 26-32 L 23.40
The most common
pg/cell cause of low MCHC is
anemia.
Hypochromic
microcytic anemia
commonly results in
MCHC 32-36% 32.10 low MCHC. This
condition means
your red blood cells
are smaller than
usual and have a
decreased level of
hemoglobin. ...
hemolysis, or the
premature
destruction of red
blood cells over time.
RDW-CV 11/25 11.50- 13.70
14.50%
/19

11:5A

AM

PLATELET 11/25 (150,000- 318.00

450,000)
/19 X10^9/L

11:45

AM
Differential Count

Neutrophil 11/25/1 54- L 49.00 Are a type of white

blood cell (WBC or
9 62%
granulocyte) that
@ protect us from
infections, among
11:45
other functions.
AM
Lymphocyt 011/25/ 25- H 37.20 One of the subtypes
of WBC in
e 19 33%
a vertebrate's
@ immune system.
Lymphocytes
11:45
include natural killer
AM cells
(T cells and B cells)

Monocyte 11/25/1 3-11% 6.50

9
@
11:45
AM
Eosinophils 11/25/1 1-3% H 6.80 Body's response to
 9 allergic reactions,
asthma, and infection
@
with parasites.
11:45
AM
Basophils 11/25/1 0-1% 0.50
9
@
11:45
AM

CLINICAL MICROSCOPY

URINALYSIS

Test type Date & Normal Patient’ Significant

Time Values s Findings
Profile
Physical
Char.
Color 10/27/ Pale yellow Dark An unusual urine
yellow color can be a sign
19
of disease.
@
4:14AM
Transparen 10/27/ Hazy/clear Clear The result of a
cy pigment called
19
urochrome and how
@ diluted or
concentrated the
4:14AM
urine is.
Chemical parameter
Specific 10/27/ 1.01-1.03 1.020 A measure of the
Gravity concentration of
19
solutes in the urine.
@
4:14
AM
Ph 10/27/ 5.5-6 6.0 The higher the
number, the more
19
basic (alkaline) it is.
@ The lower the
number, the more
4:14
acidic your urine is.
AM
Glucose 10/27/ NEGATIVE NEGATIVE A quick and simple
way to check for
19
abnormally high
@ levels of glucose in
your urine. having
4:145
too much glucose in
AM your body can be a
sign of a health
problem.
Protein 10/27/ NEGATIVE NEGATIVE Measures the
amount of protein
19
present in urine.
@ Healthy people don’t
have a significant
4:14
amount of protein in
AM their urine.
Ketone 10/27/ NEGATIVE NEGATIVE The presence of
ketones in the urine
19
indicates that body
@ using fats rather
than carbohydrates
4:14
for energy, high
AM levels of ketones
may be present in
the urine of
individuals with
uncontrolled
diabetes to
metabolizes
carbohydrates is
defective.
Nitrites 10/27/ NEGATIVE NEGATIVE It appears in the
urine when a person
19
has bacterial
@ infection in their
bladder, ureters or
4:14
kidney.
AM

Leukocyt 10/27/ NEGATIVE NEGATIVE To screen for or

es diagnose a variety
19
of conditions that
@ can affect white
blood cells (WBC)
4:14
such as
AM an infection, inflam
mation or a disease
that affects the
production or
survival of WBCs
Blood 10/27/ NEGATIVE NEGATIVE Blood is a
combination of
19
plasma and cells
 @ that circulates
through the entire
4:14
body, it is a
AM specialized bodily
fluid that supplies
essential substances
around the body,
such as sugars,
oxygen, and
hormones.

CHEMISTRY SECTION

Test type Date & Normal Patient’s

Time Values Profile Significant
Findings
Creatinine 11/18/ 0.8-1.3 0.96mg/d Elevated creatinine
levels signifies
19
impaired kidney
@ function or kindney
disease.As the
10:35
kidneys become
am impaired creatinine
level in the blood
will rise due to
poor clearance of
creatinine by the
kidneys.
Sodium 11/18/ 135.oo- 138.90mmol Sodium plays an
important role in
19 145.00 /L
thr gut,maintaining
@ mmol/d cognitive function,
nerve impulse
10:35a
transmission and in
m muscle contraction.
Potassium 11/18/ 3.50- 3.84mmol/L Is an important
5.50mm mineral that
19
ol/L functions as an
@ electrolyte, it helps
regulate fluids
10:35a
balance, nerve
m
signals and mucles
contraction.
Chloride 11/18/ 98.00- 107.20 Chloride such as
sodium chloride
19 108.00
are often very
@ mmol/L soluble in water, its
is essential
10:35a
electrolyte located
m in all body fluids
responsible for
maintaining
acid/base balance,
transmitting
impulses and
regulating fluid in
and out of cells.
Ionized 11/18/ 1.10- 1.18 Indicates
hypoparathyroidis
Calcium 19 1.40
m, inherited
@ resistance to
parathyroid
10:35a
hormone a
m malabsorption of
calcium. A vitamin
D deficiency It may
important to know
if any
abnormalities in
level of protein,
immunoglobins in
the blood.
IMMUNOSEROLOGY SE CTION

TEST NAME RESULT METHOD

HBsAg Non-reactive ICT

HEMATOLOGY SECTION

Blood typing Result

ABO type “O”
Rh Positive

TEST NAME DATE & TIME REFERENCE RESULT

CLOTTING 10/27/19 3-6mins 5’23”mins
TIME @
4:14AM
BLEEDING 10/27/19 1-3mins 2’34mins
TIME @4:14AM
FBS 10/27/19 70.00- 90.82mgcll
@ 115.00
4:14AM

TEST NAME RESULTS UNITS REFERENCE

Prothrombine
Time
Patient H 14.70 SEC 10.2-13.5
% Activity L 66.30 % 80.5-10.4
INR 1.25 0.90.1.0
Control 11.70 SEC
Control % 98.60
Activity

Control INR 0.98

X-RAY Report

DATE: 11/18/2019

PROCEDURE: LEFT THIGH APL

Findings:
There is a comminuted fracture at the middle third of the left femur call as
formation.

IMPRESSION:
= REJECTION COMMINUTED FRACTURE, MIDDLE 3RD , LEFT FEMUR

DATE: 10/27/2019

PROCEDURE: CHEST PA

Both Lungs are clear.Heart is normal in size and shape. The trachea is at the
midline.Both hemidial and distinct. The osseous thoracic cage showed no signal
bony abnormality.

IMPRESSION:
=NORMAL

Anatomy and Physiology

Pathophysiology
Nursing Care Management: Nursing Care Plan
Drug Studies
Health Teaching Plan
Discharge Plan