LICEO DE CAGAYAN UNIVERSITY COLLEGE OF NURSING NCM104

In Partial Requirements of the course NCM104 SURGICAL WARD Related Learning Experience

A CASE STUDY ON Multiple physical injuries secondary to vehicular accident

Submitted To:
Maam Glenda Demafeliz RN, MN
Clinical Instructor

Submitted by:
Xyrex D. Nicolas
BSN-NCM104 FEB 26, 2013

TABLE OF CONTENTS PAGES I. INTRODUCTION a. b. c.

OVERVIEW OF THE STUDY SCOPE AND LIMITATIONS OF THE STUDY OBJECTIVE OF THE STUDY

2 3 4

II. PROFILE OF THE PATIENT

5 6

III.DEVELOPMENTAL THEORY IV. HEALTH HISTORY

a.Personal Health History

b.History of Present Illness V. MEDICAL MANAGEMENT a. Medical Orders with Rationale b. Laboratory Results c. Drug Study VI. ANATOMY AND PHYSIOLOGY VII. PATHOPHYSIOLOGY VIII. NURSING ASSESSMENT a. Nursing System Review Chart IX. NURSING MANAGEMENT b. Ideal Nursing Management c. Actual Nursing Management X. EVALUATION AND IMPLICATION XI. REFERRALS AND RECOMMENDATION(HEALTH TEACHINGS) XII. PROGNOSIS XIII.BIBLIOGRAPHY

9 14 16 22 27

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29 34 37 38 40 41

I. INTRODUCTION a. Overview of the Study

Motorcycles are becoming more popular as a means of transportation. However, per vehicle-mile traveled, a motorcyclist is 37 times more likely to die in a crash and 9 times more likely to be injured (NHTSA, 2008f). As the motorcycle itselfoffers almost no protection, the occupant is subject to severe forces similar to those experienced by an ejected automobile or truck occupant. Head injury is common, especially in the absence of a helmet. There may be multiple fractures and large, painful abrasions with imbedded debris (road rash).Before looking at injury patterns, it is helpful to review some of the physics involved. Newtons First Law of Motion states that an object in motion will remain in motion until acted on by another force. Thus, a vehicle in motion will keep moving until somethinga tree, another vehicle, the brakes, or some other forcecauses it to slow down, stop, or change direction. When such a force is applied, people in the vehicle will continue to move at the original speed and direction until a force such as the seat belt, the steering wheel, or the windshield causes them to slow down, stop, or change direction. Even then, the organs of the body will continue in motion until slowed or stopped by the bones and other supporting structures within the body. The forces on the vehicle, the body, and the organs are applied in sequence. This sequence is rapid if the vehicle strikes a fixed object and much less so during a controlled stop. If this sequence were to be observed in slow motion, the body and the organs would seem to move toward the point of impact. This is important because it provides clues as to where to look for injury. Remember that it is not only the change in speed that causes the damage but how fast the change occurs. Going from 60 mph to a full stop may do no damage if it happens over a few seconds. But if the change occurs over a few milliseconds, a much greater force is involved, and it can be deadly. Anything that increases the stopping time will decrease the forces involved. This is the reason for such safety features as crush zones in the vehicles front end, a collapsible steering column, and the stretch in seat belts.

b. Scope and Limitation of the Study This study includes the collection of information specifically to the patient s health condition primarily to multiple physical injuries secondary to vehicular accident. The study also includes the assessment of the physiological-emotional status, adequacy of support systems, and care given by the family as well as other health care providers.

The scope of this study includes: Data collected via assessment, interviews with the patient and the Wife. Actual and Ideal problems and its appropriate nursing interventions that would be applied throughout his stay in the hospital. Developing a plan of care that will reduce identified predicaments and complications Coordinating and delegating interventions within the plan of care to assist patient Mr. RED to reach maximum functional health. Further evaluating the effectiveness of nursing interventions that have been applied to patient Mr. RED entire course of therapy.

The study is limited by the following factors: The nursing interventions done to patient Mr. RED are only limited to our assessment for 2 consecutive dates: January 30, 2013 @4:00p.m (assessment 1st visit) and February 6,2013 (2nd visit). Information gathered was limited only to the client himself, and to his wife. The X ray result is also not available on the chart. There were also limitations on the interventions we were only permitted to perform, the time and distance allotted for our visit only. No interviews were made with the previous physicians attending to our patient.

c. Objective of the study At the end of 4 day-care to the patient, I will be able to do the following: 1. Assess and monitor the health status and vital signs of my patients. 2. Identify actual and potential health problems of the patient. 3. Plan for the patients care 4. Perform nursing interventions (medications included) effectively and efficiently 5. Evaluate patients response and reaction and 6. Impart health teachings to our patient

II. PATIENTS PROFILE Name: Gender: Age: Birthdate: Place of Birth: Address: Status: Religion: Nationality: Height: Weight (present): Educational Attainment: Occupation: Income: RED Male 37 years old January 6, 1976 BUKIDNON Manolo fortich,bukidnin, Married Roman Catholic Filipino 5Ft. & 5inches Tall 65 kg High School Graduate CAA 3000/month

Chief Complaints: Admitting Diagnosis: Admission Date: Admission Time: Attending Physician: Hospital:

tenderness of face Multiple injuries secondary to vehicular accident. January 29, 2013 07:30p.m. DRA. Cynthia M. Woo CAMP EVANGELISTA STATION HOSPITAL

III.DEVELOPMENTAL THEORY Erik Erikson Psychosocial Theory Later Adulthood: 20-45 years old Ego Development Outcome: intimacy vs. isolation Basic Strengths: LOVE This stage takes place during young adulthood between the ages of approximately 19 and 40. During this period of time, the major conflict centers on forming intimate, loving relationships with other people.

While psychosocial theory is often presented as a series of neatly defined, sequential steps, it is important to remember that each stage contributes to the next. For example, Erikson believed that having a fully formed sense of self (established during the identity versus confusion stage) is essential to being able to form intimate relationships. Studies have demonstrated that those with a poor sense of self tend to have less committed relationships and are more likely to suffer emotional isolation, loneliness, and depression.

Erikson believed it was vital that people develop close, committed relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation Robert Havighurst Theory of Developmental Task Middle Adult (Ages 30-60) Assisting teenage children to become responsible and happy adults. * Achieving adult social and civic responsibility. * Reaching and maintaining satisfactory performance in ones occupational career. * Developing adult leisure time activities. * Relating oneself to ones spouse as a person. * To accept and adjust to the physiological changes of middle age. * Adjusting to aging parent
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IV. HEALTH HISTORY a. History of Present Illness Sustained injury secondary to Vehicular Accident(motorcycle passenger) last January 13, 2013, brought to Adela Ty Memorial Hospital, where skull x-ray was done. Brought to CESH for further evaluation and management.

b. Past Medical History Client has no known medical history and this is the first time that he was being hospitalized. He has previous illnesses such as fever, cough and colds but only managed at home and no consultation was done and no medication were taken.

V. MEDICAL MANAGEMENT

a. Medical Orders with Rationale Date/time 01-29-2013 @ 7:30 a.m Please secure consent to care To provide understanding in the part of the client including significant others for any medical, surgical, and nursing intervention and also for legal documentation purposes. To secure the patients status while he is under observation for any unusualities and any untoward complications To check or evaluate any deviation from normal in blood count, blood typing to check for what type of blood the patient has for possible blood transfusion and urine analysis to check for infection., cxray shows if there are any problems related to the bones and inner organs on the chest It could also be seen through this lab tests if there is a possible internal bleeding. An antibacterial used to treat for bacterial infection/ prophylaxis treatment post operatively. Doctors Order Please admit to surgical ward Rationale of Order To provide surgical management of the pt.

NPO temporarily

LABS: CBC with Platelet Count, Blood Typing, Urinalysis, Chest Xray PAV

Meds: 1.Cephalexin 500mg POevery 8 hrs.,

3.Mefinamic acid 500mg PO every 8 hrs, with BP Precaution, hold if BP is 90/60mmHg.

A non-opiod analgesic for acute to severe pain

Refer accordingly

02-01-13

Continue Meds Ambulate Refer accordingly

To Inform the attending physicians for any complications and untoward reactions For continuity of treatment regimen This is to promote blood circulation, to prevent the risk of pressure ulcer To Inform the attending physicians for any complications and untoward reactions

b. Laboratory Results

COMPLETE BLOOD COUNT

Jan 30, 2013

Test
WBC

Results
22.9

Reference
(5,000-10,000)mm3

Rationale
Indicates infection; acute stress/trauma Within normal values May indicate bleeding; acute stress/trauma May indicate bleeding; acute stress/trauma

RBC

4.30

(4.2-5.0)mm3

Hemoglobin

11.6

(13.7-16.7)g/dL

Hematocrit

34.6

(40.5 -49.7)%

Lymphocyte

3.0

(17.4 -46.2 )%

Indicates bacterial infections; acute stress/trauma Within normal limit Blood Type B its signifies a need for a donor with a blood type B+

Platelet count Blood Typing

adequate B(+)

(150,000-450,000)

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URINALYSIS February 3, 2013

Color: Yellow Clarity : Slightly hazy pH: 6.0 specific gravity: 1.026 Epithelial Cells: Few Pus Cells(WBC): 2.3 RBC : 0 2 Bacteria: Few

Proteins: Negative Glucose: Trace Blood: ++

Casts: Finely Granular: 0 1 hyaline: 0 1 Mucus threads: Plenty

Indicates Bacterial Infection in the body and a possible internal bleeding due to the blunt trauma of the chest as evidenced by the presence of blood in the urine.

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c. Drug Study

Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action:

Cephalexin January 29, 2013 Antibiotic 500mg PO every 8hrs This drug binds to one or more of the penicillinbinding proteins (PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell death

Specific Indication:

Treatment of infections of lower respiratory tract, urinary tract, skin and skin structures.

Contraindication: Side Effects:

Hypersensitivity to cephalosporins.

Nausea, vomiting, diarrhea, stomach pain Headache, dizziness Sleep problems (insomnia) Vaginal itching or discharge.
If tablet must be crushed, mix with food or beverage.

Nursing Precaution:

a. Advise patient to take with meals to enhance absorption.

b. Advise patient to maintain normal fluid intake while using this medication. c. Instruct patient to report these symptoms to health care provider: bruising, bleeding, muscle or joint pain.

d. Instruct patient to seek emergency care immediately if

wheezing or difficulty breathing occurs.

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Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action:

Mefinamic acid January 29, 2013 Non-Opioid Analgesic 100mg IVTT every 8hrs RTC X24hrs then PRN Binds to opioids receptors and inhibits the reuptake of norepinephrine and serotonin.

Specific Indication: Contraindication:

Moderate to severe pain Acute intoxication withopioids or psychoactive drugs

Side Effects:

CNS: Sedation, Dizziness, Headache, and Confusion CV: Hypotension, Tachycardia, Bradycardia Dermatologic: Sweating

Nursing Precaution:

Administer with food if GI upset occurs; Monitor patient response, Give the drug before the pain becomes intense

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VI. ANATOMY AND PHYSIOLOGY

THE SKELETAL SYSTEM

Humans are born with over 270 bones, some of which fuse together into a longitudinal axis, the axial skeleton, to which the appendicular skeleton is attached. The axial skeleton (80 bones) is formed by the vertebral column (26), the rib cage (12 pairs of ribs and the sternum), and the skull (22 bones and 7 associated bones). The upright posture of humans is maintained by the axial skeleton, which transmits the weight from the head, the trunk, and the upper extremities down to the lower extremities at the hip joints. The bones of the spine are supported by many ligaments. The erectors spinae muscles are also supporting and are useful for balance. The appendicular skeleton (126 bones) is formed by the pectoral girdles (4), the upper limbs (60), the pelvic girdle (2), and the lower limbs (60). Their functions are to make locomotion possible and to protect the major organs of locomotion, digestion, excretion, and reproduction.

Function
The skeleton serves six major functions.
Support

The skeleton provides the framework which supports the body and maintains its shape. The pelvis, associated ligaments and muscles provide a floor for the pelvic structures. Without the rib cages, costal cartilages, and intercostal muscles, the heart would collapse.
Movement

The joints between bones permit movement, some allowing a wider range of movement than others, e.g. the ball and socket joint allows a greater range of movement than the pivot joint at the neck. Movement is powered by skeletal muscles, which are attached to the skeleton at
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various sites on bones. Muscles, bones, and joints provide the principal mechanics for movement, all coordinated by the nervous system.
Protection

The skeleton protects many vital organs:

The skull protects the brain, the eyes, and the middle and inner ears. The vertebrae protect the spinal cord. The rib cage, spine, and sternum protect the human lungs, human heart and major blood vessels. The clavicle and scapula protect the shoulder. The ilium and spine protect the digestive and urogenital systems and the hip. The patella and the ulna protect the knee and the elbow respectively. The carpals and tarsals protect the wrist and ankle respectively.

Blood cell production

The skeleton is the site of haematopoiesis, the development of blood cells that takes place in the bone marrow.
Storage

Bone matrix can store calcium and is involved in calcium metabolism, and bone marrow can store iron in ferrotin and is involved in iron metabolism. However, bones are not entirely made of calcium, but a mixture of chondroitin sulfate and hydroxyapatite, the latter making up 70% of a bone.

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VII. PATHOPHYSIOLOGY
DIAGNOSIS: Multiple injuries secondary to vehicular accidentl. DEFINITION: In medical terminology, blunt trauma, blunt injury, non-penetrating trauma or blunt force
trauma refers to type of physical trauma caused to a body part, either injury or physical attack; latter usually being referred as a blunt force trauma. Abdominal blunt trauma is the most common type of trauma attributed from car to- car collisions, concussion, abrasion, laceration or bone fracturing characterized by severe abdominal pain, tenderness, rigidity, and bruising of the external abdomen. Abdominal trauma presents a risk of severe blood loss and

PATHOPHYSIOLOGY:
Gender (male) Substance abuse Driving under influence of drugs and alcohol. Alcohol Drinking

Physical trauma due to vehicular accident Breakage in skin tissue damage bone cannot withstand the outside body caused breakage of bone nerve endings that surrounds bone contain pain fibers these fibers become irritated when bone is broken or bruise series of bleeding internally or externally blood is associated to swelling (edema) swelling causes pain muscles that surrounds the injured area may go into spasm when they try to hold the broken bone and these spasm causes further pain resulting in immobilization of the injured lower extremity
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NURSING SYSTEM REVIEW CHART Name: RED Vital Signs: Temp:36.6C Pulse:82bpm BP: 110/80mmHg Respiration:17cpm Date:January 30, 2013

Tenderness on face

Low salt low fat diet

Generalized weakness; restless Complaints of pain on site scale of 8/10

Skin dry, warm to touch

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IX. IDEAL NURSING MANAGEMENT NURSING DIAGNOSIS: Infection, risk for Risk factors may include Inadequate primary defenses; perforation; peritonitis; abscess formation Invasive procedures, Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL: Wound Healing: Primary Intention (NOC) Achieve timely wound healing; free of signs of infection/inflammation, purulent drainage, erythema, and fever.

ACTIONS/INTERVENTIONS Infection Control (NIC) Independent Practice/instruct in good handwashing and aseptic wound care. Encourage/provide perineal care.

RATIONALE

Reduces risk of spread of bacteria.

Inspect incision and dressings. Note characteristics of drainage from wound/drains (if inserted), presence of erythema.

Provides for early detection of developing infectious process, and/or monitors resolution of preexisting peritonitis.

ACTIONS/INTERVENTIONS Infection Control (NIC) Independent Monitor vital signs. Note onset of fever, chills, diaphoresis, changes in mentation, reports of increasing abdominal pain.

RATIONALE

Suggestive of presence of infection/developing sepsis, abscess, peritonitis.

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Obtain drainage specimens if indicated. Grams stain, culture, and sensitivity testing isuseful in identifying causative organism and choice of therapy.

Collaborative

Administer antibiotics as appropriate. Antibiotics given before appendectomy are primarily for prophylaxis of wound infection and are not continued postoperatively. Therapeutic antibiotics are administered if the appendix is ruptured/abscessed or peritonitis has developed.

Prepare for/assist with incision and drainage (I&D) if indicated.

May be necessary to drain contents of localized abscess.

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NURSING DIAGNOSIS: Pain, acute May be related to Presence of wound on the injured part and Presence of surgical incision Possibly evidenced by Reports of pain Restlessness Autonomic responses DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL: Pain Level (NOC) Report pain is relieved/controlled. Appear relaxed, able to sleep/rest appropriately.

ACTIONS/INTERVENTIONS
Pain Management (NIC)

RATIONALE

Independent Assess pain, noting location, characteristics, severity (010 scale). Investigate and report changes in pain as appropriate.

Useful in monitoring effectiveness of medication, progression of healing. Changes in characteristics of pain may indicate developing abscess/peritonitis, requiring prompt medical evaluation and intervention.

ACTIONS/INTERVENTIONS Pain Management (NIC) Independent Provide accurate, honest information to patient/SO.

RATIONALE

Being informed about progress of situation provides emotional support, helping to decrease anxiety

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Keep at rest in semi-Fowlers position.

Gravity localizes inflammatory exudate into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position.

Encourage early ambulation.

Promotes normalization of organ function, e.g., stimulates peristalsis and passing of flatus, reducing abdominal discomfort.

Provide diversional activities.

Refocuses attention, promotes relaxation, and may enhance coping abilities. Decreases discomfort of early intestinal peristalsis and gastric irritation/vomiting.

Collaborative .

Administer analgesics as indicated.

Soothes and relieves pain through desensitization of nerve endings. Note: Do not use heat, because it may cause tissue congestion.

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Anxiety related to threat of Health Status

INTERVENTIONS Independent:

RATIONALE

Explain procedures to be done, equipment and rationale for therapy to patient and family.

Increasing knowledge assist in alleviating fear and anxiety.

Encourage patient to verbalize fears concerning diagnosis and prognosis.

Accurate information about the situation reduces fear, strengthens nurse-patient relationship and assist patient to deal realistically with the situation.

Provide privacy for patient and significant others.

Allows needed time for personal expression of feelings; may enhance mutual support and promote more adaptive behaviors.

Explain sensations patient will experience before procedures and routine care measures.

Predictability and information decrease anxiety for patient.

can

Provide for periods of uninterrupted rest and sleep.

Conserves energy and enhances coping abilities.

Dependent: Administer antianxiety medications as indicated: alprazolam, diazepam, lorazepam, flurazepam. Promotes relaxation/rest feelings of anxiety. and reduces

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Actual Nursing Management 1.

S O A

sakit ang akung samad as verbalized by the patient.

facial grimace, guarding, restlessness, , pain scale

rated at 8/10 Acute pain .

Short term:

At the end of 4hours the patients pain will be reduced

into a tolerable level from 8/10 to 6/10. Provided with comfort measures such as fanning or removed clothings near at bedside.

Provided with diversional activity e.g talking with the patient. Encouraged patient to verbalized concerns Instructed not to move/touched the affected part.
Administered Tramadol 100mg IVTT every 8hrs

Round the clock

At the end of 4hrs, the patient was able to verbalized tolerable level of pain rated 6/10

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2.

S O A

Risk for infection related to surgical incision

At the end of 30 minutes the patient will verbalize

understanding on the importance of wound cleaning and preventing infection. Provided universal precaution e.g. handwashing. Provided daily wound dressing

Encouraged to dry wound and change dressing aseptically

Taught proper wound dressing Encouraged proper hygiene Instructed to take medication cephalexin 500mg I

cap TID religiously

After 30 minutes of nursing intervention, patient was able to verbalize understanding on the importance of a clean and proper wound dressing.

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3.

S O A

kanus-a kaha ni matangtang ning tahi sir?

Anxious/restlessness Expression of fear Preoccupied

Anxiety related to change in health status. At the end of 1 hour, the client will be able to minimize anxious behavior.

1. Spent times with the client. - Non- care related time spent with anxious patient builds trust and reduces tension 2. Allowed client to express feelings verbally - This may allow patient to identify anxious behaviors and discover source of anxiety 3. Provided a comfortable stress free environment. - To relieve anxiety 4. Taught client relaxation technique - These measures can restore psychological and physical equilibrium 5. Provide privacy for patient and significant others. Allows needed time for personal expression of feelings; may enhance mutual support and promote more adaptive behaviors.

6. Provided treatment information on an ongoing basis.

Goal met. At the end of 1 hour, the client has been able to minimize anxious behavior.
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X. EVALUATION AND IMPLICATION

During the initial assessment, patient Mr. RED was in a dire condition, sustaining serious injuries. The incident will surely be a traumatic experience to him considering that he feels Iikes his family no longer needs him to sustain their needs although he was anxious, restless at first but the support of his family really gave him the courage that they can. In response to his condition, care was given to him. His vital signs were monitored every 4 hours, I & 0 every hour to closely monitored his kidney functioning. Medications due for him were given and wound dressing was done everyday. Advocacy in nursing was definitely applied in his care, accepting his minute requests so as to alleviate his suffering as much as possible. His temperature was also monitored because of some changes due to his status post condition. In caring for patient Mr. RED, I have not only contributed to the betterment of his health, but also to the improvement of myself as student nurses. Any circumstance during the time of caring for patient Mr. RED added to the skills, knowledge and attitude which will surely be beneficial in the future.

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XI. REFERRALS and RECOMMENDATION HEALTH TEACHINGS Name of patient:RED Medications Instructed client as well as the significant others about the indications and mechanisms of actions of each drug that the doctor ordered so that without hesitation they will really comply all the medications given with them. Adherence to the medication promotes improvement of condition. Exercise Encouraged frequent changes of position according to his comfort like sitting on bed if his body can tolerate and by turning to sides to prevent bedsores. Avoid over strenuous activities Encouraged passive range of motion to promote proper circulation and prevent muscle atrophy/complication brought by immobility. Instructed also the client at home to balance his daily activities especially when discharged. Encouraged patient to do deep breathing exercises/ Relaxation Technique Treatment Advised/Emphasized the importance to adhere to treatment regimen. That is to facilitate faster improvement of present condition and prevent complication. Bed rest is important to prevent over fatigability then ambulate with in tolerable limits Encouraged to apply lotion such as Johnson lotion and petroleum jelly to his dry and cracked skin to prevent further skin injury. Advised to have a regular check up at the nearest health center/health care provider for check up monitoring. Increased fluid intake up to 6-8 glasses a day
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Outpatient (CHECK-UP) Instructed the clients family to come back one week after discharged for further follow-up and evaluation of the clients health condition. This is very important so that the health condition of the client will be evaluated if there is better improvement. The physician should see and examine the physical appearance of the client. Diet Taught the importance of eating green leafy vegetables such as alugbati, malunggay, saluyot because this will prevent constipation especially at this time because his peristalsis decreases due to limited movement Encouraged low salt intake. The use of salt as a flavoring agent needs to be controlled because this is usually the cause of fluid retention. Encouraged intake of vitamin C, such as home made lemonade and oranges because the patient has post surgical incision that will aid in healing. Increased intake of protein because this is important for skin integrity. Increased intake of fruits and vegetables because this can provide vitamins and minerals for nutrition.

The family or the significant others is advised to comeback on the scheduled date of visit with the physician together with the referral form given during time of discharged on the exact time/date and place specified for monitoring/rechecking of his condition. The family is also encouraged to monitor the patient and to not allow the patient to do strenuous activities that would be a cause of further exacerbation of the injured area. We encouraged the patients family to let the patient eat more fruits and vegetables as well to have rich in fiber to prevent constipation. And lastly encouraged the family or the significant others to have regular visit to the health center or clinic and avoid self-medication or taking medications out of what is being prescribed.

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XII. PROGNOSIS
The attending physician, as well as those who gave care and studied the case of Mr. RED came up with good prognosis basing from the aforementioned indicators, and justified as follows: A. Knowledge of the disease condition The diagnosis for this criterion is good because he showed understanding in the importance of compliance/adhering to treatment regimen, although he has a positive attitude but lacks financial aspect was really an impact on him considering as well that he is the only person who works in the family B. Extent of the disease

The extent of the disease was good . C. Availability of medications and compliance

Not good, because sometimes he can take those medication needed but as much as they wanted to still there would be a times that they dont have sufficient funds for treatment regimen compliance. D. Attitude and willingness to take the medications and follow treatment regimen Good prognosis because he was able to take his medications on time and followed the treatment regimen for management of his condition with a positive attitude for compliance and cooperation although there would be a time that he cant deny that he missed some dosage due to financial aspect E. Family support Mr. REDs wife was always there for him supports and helps the patient cope with stress and anxiety.

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XIV.Bibliography

Douges, M.E. et.al., (2002).. Nurses pocket guide: diagnosis, interventions & rationales. (8th Edition).Philadelphia: F.A. Davis Company.

Douges, M.E. et.al., (2002).. Nursing care plan: guidelines for individualizing patient care (6th Edition) Philadelphia: F..A. Davis Company.Gulandick, M. et.al., Nursing care plan. (3rd Edition)

Ignatavicius, D.D. & Workman, M.L. (2006). Medical-surgical nursing: critical thinking for collaborative care. (5th Edition). St. Louis, Missouri: Elsevier Saunders.

Kozier, B. et.al., (2004). Fundamentals of nursing: concepts, process & practice. (7th Edition). Philippines: Pearson Education South Asia PTE Ltd.

Smeltzer, S.C.& Bare, B.G. (2004).Textbook of medical-surgical nursing(10th Edition, Volume 2). Philadelphia: Lippincott Williams and Wilkins. pp 553-538.

Spratto, G.R. & Woods, A.L. (1994). Nurses drug reference. USA: Delmar Publishers Incorporated. Ulrich & Canale. (2005). Nursing care planning guides. (6th Edition).

Webliography: www.mayoclinic.com/INJURIEs www.yahoo.com/fall www.google.com/images/lungs

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