Republic of the Philippines

PALAWAN STATE UNIVERSITY

College of Nursing and Health Sciences
Tiniguiban Heights, Puerto Princesa City

DISCHARGE PLAN
Name of patient: Mr. J

Age: 8y/o

Ward: Surgical

Chief Complaint: Multiple injuries due to landslide Attending Physician: Dr. Jonathan Reblando
NURSING ORDERS

Medications

Exercise

DISCHARGE INSTRUCTIONS
-Instructed patient to take medications as prescribed by
physician to ensure optimum recovery.
-Take analgesics for pain control to ensure patient
comfort and aids physical therapy regimens.
-Take antibiotics medication to kill the bacteria and
prevent infection.
-Instructed the family and the patient that analgesics
have sedating properties that benefit patient who have
sustained fractures.
-Instructed the patient and family to have tetanus toxoid
immunization for the booster against tetanus infection.
-Instructed patient to consult doctor and physical
therapist to coordinate rehabilitation orders (exercise and
ROM) and teaching.
-Instructed patient to actively exercise joints above and
below the immobilized fracture at frequent intervals.
-Explained the reason why to do the exercise and then
teaches the proper gait as necessary.
- Instructed the family to assist the patient on how to use
his crutches.
-Instructed patient to use both crutches 6-8 inches (1520cm) along with the involved leg.
- Instructed to bring the involved leg slowly forward and
bear the bulk of his weight on the crutches.
-Encouraged the patient of importance of taking steps of
equal length and duration with no pause.
-Teach the patient using crutches to get up from chair or
bed. Tell him to hold both crutches in one hand, with the
tips resting firmly on the floor.
-Instructed the patient to push from the chair or bed with
his free hand supporting himself with the crutches.
-When patient to sit down it reverses the process,
instructed him to support himself with crutches in one
hand and lower himself with the other.

Group One - Grand Case Presentation 2015

Fracture Open Complete Tibia Left Displaced Fibula Left, Fracture Open Complete Tibia Right, Fibula Right 2 to Trauma

83 | P a g e

Treatment

Hygiene

OPD

-Instructed the family and patient to applied sterile

dressing to open wounds. Apply gentle traction to reduce
gross deformities.
-Instructed patient to consult for open reduction internal
fixation (ORIF) debridement for development on right
leg and wound care on amputated leg.
- Divert patients thought by immersing him into a light
and pleasant conversation.
-Explain to the patient the loss of his left leg is not his
fault and assist him in coping with the loss.
- Suggest to the patients family that it is better not to
leave patient alone as it is very likely that the patient
might feel a sense of depression as for the loss of his left
leg and in landslide accident.
-Promote adjust of usual lifestyle and responsibilities to
accommodate limitations imposed by fracture.
-Discussed to patient for prevention of recurrent
fracture, review safety consideration, avoidance of
fatigue and proper foot wear.
-Teach patient to recognize and report symptoms
needing attention, such as numbness, decrease function,
increase pain or elevated temperature.
- He cant still go to school until proper instructions
given by the doctor that he can go to school already.
-Instructed patient and family member in bathing, oral
and hygiene techniques. Have one of them demonstrate
it under supervision.
-Instructed the family to use bedpan or urinal at bedside
during night if the patient doesnt want to go up in the
dark to go to the bathroom.
-Teach the family member and patient on how the proper
way of wound dressing and bandaging.
-Instructed to clean the fixation with cotton and alcohol
to prevent growing up of bacteria.
-Encourage follow-up medical supervision to monitor
for bone union problems.
- Follow up visit at OPD after 7 days for evaluation.
- Patient can seek for counselling as for expected
emotional distress accompanying to the landslide
accident and loss of body part.
-Instructed the family on referral on health care delivery
system such as physical therapist near to his location.

Group One - Grand Case Presentation 2015

Fracture Open Complete Tibia Left Displaced Fibula Left, Fracture Open Complete Tibia Right, Fibula Right 2 to Trauma

84 | P a g e

Diet

Spirituality

-Diet as tolerated was ordered by the physician to the

patient.
-Instructed to eat foods in high carbohydrate like
vegetables, legumes, whole grains and fruits and high
protein diet like meats, fish, cheese beans, and yogurt for
adequate healing, and then assist in making food choices
as necessary.
-Foods high in calcium like dark leafy vegetables, low
fat milk, cheese, okra, and spinach.
-Foods in Vit.C like orange, grapes, papaya, melon
-Increase fluid water intake.

-Advise patient to maintain good and safe environment.

-Suggest patient to attend Sunday service/ mass in
church as to boost spirit and to prevent distress.
-Prayer is the best weapon to against all trials.

DOCUMENTATION
Group One - Grand Case Presentation 2015
Fracture Open Complete Tibia Left Displaced Fibula Left, Fracture Open Complete Tibia Right, Fibula Right 2 to Trauma

85 | P a g e

REFERENCES
Group One - Grand Case Presentation 2015
Fracture Open Complete Tibia Left Displaced Fibula Left, Fracture Open Complete Tibia Right, Fibula Right 2 to Trauma

86 | P a g e

 Essentials of Human Anatomy and Physiology 7th Edition

Nurses Pocket Guide 11th Edition
Nursing Spectrum Drug Handbook
Book Med-Surgical Nursing Lipincott Williams and Wilkins
medical-dictionary.thefreedictionary.com/above-knee+amputation
uvahealth.com ... Plastic Surgery Conditions & Treatments
www.webmd.com/a-to-z-guides/definition-amputation
orthoinfo.aaos.org/topic.cfm?topic=A00522
www.physioadvisor.com.au Injuries Lower Leg Tibia Fracture
www.sw.org/misc/health/Wound%20Debridement.html
www.medscape.com/viewarticle/459733_6
www.nursingtimes.net/the-role-of-debridement-in.../5063965.article
https://www.scribd.com/doc/NCP
www.enurse-careplan.com Nursing Care Plan
www.merckmanuals.com
https://www.scribd.com/doc/44135497/Pathophysiology-of-Fracture
allnurses.com Nursing Student Nursing Student Assistance

Group One - Grand Case Presentation 2015

Fracture Open Complete Tibia Left Displaced Fibula Left, Fracture Open Complete Tibia Right, Fibula Right 2 to Trauma

87 | P a g e