I.

Clients Profile

Name: E.D Address: Antipolo City Age: 47y/o Gender: Female Birthday: November 5, 1963 Religion: Roman Catholic Educational Attainment: High school Graduate Occupation: Housewife Civil Status: Married Nationality: Filipino Cc: Diagnosis:

Health History

History of Present Illness

5 days PTA, the patient accidentally slipped on the floor while preparing for lunch and then urgently brings to the hospital for immediate care

2 days PTA, the patient was bring to the Philippine Orthopedic Center for better intervention. Surgery was scheduled right after consultation.

Past Health History

It was the patient 1st confinement. The patient is hypertensive and was taking amlodipine as a maintenance.

Genogram

II.

Gordons Functional Health Pattern

A. Health Perception Health Management Pattern Subjective Cue: hindi ako ok, pero kinakaya ko naman lahat, simple lang naman ang gusto ko e syempre ang gumaling ako, at alam ko gagaling ako. Sa high bloo ko naman, may iniinum naman ako. as verbalized by the patient Objective Cue: The patient is oriented to time, place and person, no hearing aid seen; the patient can distinguish sweet and sour taste. The patient is able to sense warm and cold sensation. Patient has fair complexion and skin is warm to touch. Clothes are appropriate to occasion. The patient is just taking over the counter drugs whenever his sick . No allergies reported Vital signs are as follows: T: 34.7 oC HR: 57bpm RR: 19 breaths/min

BP: 140/90bpm Analysis: readiness for enhanced therapeutic management B. Nutrition Metabolic Pattern Subjective Cue: mahilig ako sa gulay at saka isda, mahilig ako sa gulay lalo na sa maaasim as verbalized by the SO. Objective Cue. Mouth is moist, no lesions were noted, gag reflex is present. Capillary refill of <2seconds. Muscle tone normal. Clients weight is 64kg with a height of 51 ft. Analysis: readiness for enhanced therapeutic management C. Elimination Pattern Subjective Cue: normal naman ang pagdumi ko mga 2-3 days yung interval as verbalized by the patient. Objective Cue: the patient have normal bowel sounds. Analysis: readiness for enhanced therapeutic management D. Activity Exercise Pattern Subjective Cue: ako na lang naiiwan sa bahay minsan pumupunta un yung kapatid ko, ako ung naglilinis, naglalaba ng mga damit at saka nagluluto., as verbalized by the patient Objective Cue: Patient on a balance skeletal traction. Pulses are easily palpable. Normal capillary refill. Respiratory rate is w/in normal rate. Analysis: Risk for injury related to immobility secondary to balance skeletal traction `F. Sleep Rest Pattern Subjective Cue: sapat naman ang tulog ko sa gabi may afternoon nap pa nga ako, mga 9 ng gabi ako nakakatulog tapos 6 nmn ng umaga ako nagigising kasi aasikasuhin ko na yung umagahan naming ng asawa ko, pero dito di msyadong ayus ang pahinga ko namamahay siguro aq as verbalized by the patient Objective Cue: Patient is not pale but lethargic, puffy dark circle eyes and yawning. Patient is also slightly irritable. Analysis: Disturbed Sleep pattern r/t changed of environment E. Sensory Cognitive Perceptual Pattern Subjective Cue: high schoollang ang natapos ko, ok naman kahit ganun kasi nkapagtrabaho naman ako nun dalaga pa ako, nung nagkaasawa ako tumigil na ako sa pagttratrabaho as verbalized by the SO.

Objective Cue: No pain noted. Light sensation and immobilize left leg. Right leg with an active ROM of 5/5 while the left leg with an passive ROM of 0/5. Analysis: impaired physical mobility of the lower extremity related to balance skeletal traction as manifested of passive ROM F. Role Relationship Pattern Subjective Cue: ako yung nadedecide saming pamilya, at ako rin yung takbuhan ng anak ko pag may problema sila as verbalized by the SO. Objective Cue: Communication with family members is good. The patient speaks in Tagalog. His with his wife all the time and can see good relationship between them Analysis: readiness for enhanced therapeutic management G. Self Perception Self Concept Pattern Subjective Cue: bata pa ako paramamatay, gusto ko magsaya pa sa buhay ko. Kaya pinipilit kong gumaling agad ok ako sa lahat ng gagawin sa akin basta gagaling ako as verbalized by the patient. Objective Cue: Client is calm with soft voice. Analysis: readiness for enhanced therapeutic management

ASSESSMENT OBJECTIVE: Balance skeletal traction noted Vital signs are as follows: T: 34.7 oC HR: 57bpm RR: 19 breaths/min BP: 140/90bpm Side rails are down

DIAGNOSIS Risk for injury related to immobility secondary to balance skeletal traction

RATIONALE Any restrictions of mobility occurring as a result of injury or psychological trauma (such as fear of falling), in turn, can lead to periods of immobility and the risk of complications, such as pressure sores, contractions, muscle weakness, bone loss, depression, etc. Mobility restrictions can precipitate further functional decline, which may contribute to increased risk of falls.

PLANNING After the 1 hour nursing intervention the patient will be free of injury

INTERVENTION Assess clients muscle strength gross and fine motor coordination Always keep the side rails up Orient client to environment. Assess ability to use side rails Make changes in clients environment that may cause or contribute to injury Routinely assist the client when she wants to urinate on her own schedule

EVALUATION After the 1 hour of nursing intervention the patient was able to be free of injury

ASSESSMENT Subjective: medyo hindi ako makakilos ng maayos as verbalizeby the patient Objective: With balance skeletal traction Need assistance

DIAGNOSIS Impaired physical mobility of the lower extremity related to balance skeletal traction as manifested by passive ROM

PLANNING After 1 hour of intervention the patient will be able to demonstrate proper exercise of the lower extremities

INTERVENTION Assisted with the normal range of motion exercises and function of lower extremities Encourage exercise of the lower extremities Encourage family/SO support and assistance with ROM exercises. Note emotional/behavi oral responses to problems of immobility Encourage use of proper body mechanics Support affected body parts/joints using pillows/rolls, foot supports/shoes, gel pads, etc.,

EVALUATION After 1 hour of intervention the patient was able to demonstrate proper exercise of the lower extremities

ASSESSMENT Subjective: ok naman ang pagtulog ko noong ok ako pero dito hindi talaga ako makapagpahinga ng maayus as verbalized by the patient Objective: Patient is not pale but lethargic, puffy dark circle eyes and yawning. Patient is also slightly irritable.

DIAGNOSIS Disturbed Sleep pattern r/t changed of environment

PLANNING After 8 hours of nursing intervention the patient will be able to report improvement in sleeping pattern

INTERVENTION

EVALUATION After 8 hours of nursing intervention the patient was able to report improvement in sleeping pattern

Assess client's sleep patterns and usual bedtime rituals and incorporate these into the plan of care. Keep environment quiet. Encourage social activities. Suggest light reading or TV viewing that does not excite as an evening activity. Increase daytime physical activity. Reduce

daytime napping in the late afternoon; limit naps to short intervals as early in the day as possible.