Case Study 1

Case Study

Care of Infants and Children Practicum NURS 3051P

Submitted by: Daniel Orji Cheche

Submitted to: Mrs. Cynthia Guild

Submitted on: May 21, 2015

Case Study 2

Table of Contents

Page #

Introduction……………………………………………………………………… 4

Preface…………………………………………………………………………… 5

Data collection/Complete Health History………………………………………. 6

- Bio data- Chief complaints- History of present illness- Medical history- Family history- Lifestyle- Socioeconomic history- Environmental history- Psychological- Complete Physical Assessment

Analysis of Data Collected-…………………………………………………… 10

- Gordon’s Typology of 11 Functional Health Patterns*Health perception/Health Management*Nutritional/Metabolic*Elimination*Activity/Exercise*Cognitive/Perceptual*Roles/Relationships*Self-Perception/Self concept*Coping/Stress*Value/Belief*Medication/History*Nursing Physical assessment

- Comparing the data………………………………………………. 14

- Actual and potential problems……………………………………. 18

Implementation/Evaluation…………………………………………………… 17

- Nursing Care Plan- Teaching Plan

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Recommendations……………………………………………………………… 22

Appendix A…………………………………………………………………….. 24

- Bone diagram Fig 1.1- Types of Fractures Fig1.2- Traction Fig 1.3- Traction Fig 1.4- Closed Fracture of femur Fig 1.5- Wong-Baker FACES Pain Rating Scale Fig. 2.1

References……………………………………………………………………….. 26

Case Study 4

Introduction

The skeletal system comprises of all the bones in the body along with the tissues such as

tendons, ligaments and cartilage that connects them. There are four types of bones: long, short

flat, and irregular. The long bones, especially the femur and tibia, are subjected to the most of

the load during activities and are crucial for skeletal mobility.

(http://www.bonefixator.com/long_bone/anatomy_1.html) Bones, joints, cartilages and ligaments

make up the skeletal system. The anatomy of the long bones consists of the diaphysis, epiphysis,

the periosteum metaphysis and epiphyseal growth plate. Fig. 1.1 During childhood, new cartilage

is continuously formed, the older cartilage becomes ossified and bone replaces cartilage. The

process of ossification begins in the embryo and continues until the child is 18 or 21 years old.

Damage to these components of the bone can cause major problems in bone growth and healing

(Hockenberry & Wilson, 2011). A Ffractures is a break in the can be defined as any break in the

continuity of the bon and is defined according to the type and extent. e. Fractures occur when

the bone is subjected to stress greater that it can absorb. Fractures are caused by direct blows,

crushing forces, sudden twisting motions, and even extreme muscle contractions. When the bone

is broken, adjacent structures are also affected, resulting in soft tissue edema, hemorrhage into

the muscles and joints, joint dislocation, ruptured tendons, severed nerves, and damaged blood

vessels. Body organs maybe injured by the force that cause the fracture or by the fracture

fragments.

There are different types of fractures and these include, complete fracture, incomplete

fracture, closed fracture, open fracture and there are also types of fractures that may also be

described according to the anatomic placement of fragments, particularly if they are displaced or

nondisplaced. Such as greenstick fracture, depressed fracture, oblique fracture, avulsion, spinal

fracture, impacted fracture, transverse fracture and compression fracture. Fig 1.2

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Fractures occur when the bone is subjected to stress greater than it can absorb (Smeltzer et al,

2010). Fractures are a common injury at any age, but most likely occur in children and in the

elderly. They can be caused by direct blows, crushing forces, and sudden twisting motions which

can come about from motor vehicle injuries sports or fall from heights. Types of fractures

include: open, closed, incomplete, complete, displaced and comminuted. Fig 1.2 It is manifested

by generalized swelling, pain and tenderness, and limited use to the affected part. X-rays are

used to examine the specific area of the broken bone. Therapeutic management goals are to re-

establish alignment and length of the bony fragment (reduction), to retain alignment and length

(immobilization), to restore function to the injured parts and to prevent further injury

(Hockenberry &Wilson). When bone fragments cannot be reduced with simple traction and

stabilization with a cast, the extended bulling force obtained with continuous traction may be

required. The use of traction is the direct application of such forces to produce equilibrium to the

fracture site. A forward force (traction) is produced by attaching weight to the distal bone

fragment. This force is balanced by the backward force of the muscle pull (countertraction) and

the frictional force between the patient and the bed (Hockenberry & Wilson, 2011). (Fig 1.3 and

1.4)

By choosing this condition as a case study, It is expcted expects to broaden my

knowledge understanding and management of fracture, not just for the fulfillment of the course

requirements in pediactric nursing. It is very important for nurses in general to be adequately

informed regarding the knowledge and skill in managing these condition. Through the

knowledge acquired with this study of this condition, a higher quality of care will be provided to

minors suffering from it.

Case Study 6

Preface

I would like to thank the Ana Jacqueline P.’s parents mother and Ana Jacqueline P.

herself for letting allowing me do a case study based on her injury pf her fractured femur. I

would also like to extend my gratitude to the Pediatric Ward at Karl Heusner Memorial Hospital

(KHMH) at the Pediatric Ward for allowing me to observe and train me to along withhaving

excellentexceptional and capablecompetent nurses who are committed to providing holistic care

to their young patients. It was a great learning experience to be ablve to be working honor

working alongside them and gaining new practical knowledge on Pediatrics and Nnursing care. I

would like to extend my thanks to Mrs. Cynthia Guild for being a motherly and patient instructor

alongside with Ms. Dawn Elliot who guided helped me and mentored me through the practicum

period and assisting me with any and all questions I had in regards to this unit. when I got stuck

in my care plans. I’m coming out of thisfininshg this unit of Pediatric care with new enhanced

knowledge and better capabilities in my nursing skills in order for me to be a good nurse to

children whenever I become certified after my studiesto better myself to become a great nurse.

Case Study 7

I. Data Collection/ Complete Health History

i. Biodata:

Ana Jacqueline P. (Jackie) is a foursix year-old minor female minor residing in Benque Viejo

del Carmen in theBiscayne Village, CayoBelize District. She sought medical help alongside her

motherParents, Mr and Mrs. LP, after being transferred from the San Ignacio Hospital. The

minor is single, with a Catholic upbringing. According to her mother, whenever they are in need

of medical care, they would normally usually go to Benque Ladyville Healthcare Cener

Polyclinic where it is her husband who takes care of the medical bills whenever there is a

medical problem with the family.

ii. Chief complaint

LS’s Jackie’s reason to be at the Karl Heusner Memorial Hospital is because of a closed fracture

to the right femur. Example can be seen in Fig. 1.5

iii. History of Present illness

Mrs. LS P describes that on March Saturday April 182, 20145 her daughter was playing with a

group of children near a tree near their homeanother little girl, who ran behind her daughter and

pushed her in frontthen she suddenly heard a commotion outside along with someone crying.

Case Study 8

When she went outside, she saw her daughter on the ground crying. When she investigated, she

learnt that her daughter had climb a tree and feel,, causing her to feel intense pain on her right

leg. When she went to get her daughter, tThe child was sprawled rolling on the ground, unable

to get up, with her leg in an abnormal position and crying with pain. It all happened so suddenly.

This is the first time that LS Jackie has a sustained a severe injury or broken bones. Two Any

previous visit to the healthcare center would have been due to immunizations shots or severe

influenza symptoms. years ago, LS twisted her hand but it only needed bandaging and rest. The

complete fracture is located in the right femur. The child stated that the fall “hurt a lot” and that

her leg “looked twistedweird” Her mother described that the site of the injury was really highly

inflamed, bruised and and red. Presently, LS Jackie has traction with weight to help the process

of healing and keep the leg straight. LS Jackie complains of pain to the right leg whenever the

weights are lifted. However, and during the night when she has nightmares and begins to cry.

Presently, she is able to sit up in bed with no pain though.

iv. Medical history

Medical history for this patient goes as follows: In the past, as aforementioned, the patient had

twisted her hand but did not require hospital stay to treat the injury to the handThere has been no

instances in which the patient had sustain any serious injury to her person. Her mother says

explained that she her daughter is not a sickly person and only does not get sick very often, but

catches the flu “once in a whileoccasionally”. When she was admitted at Accident and

&Eergency (A&E), she was given Voltaren 20 mg IV stat and Pethidine 20 mg IV stat.

Diclofenac 18 mg IV was later added by the physician. Currently, LS Jackie is being given

Tylenol suspension 180 mg as needed every 8 hours for pain. All these are pain medications. Her

mother says LS Jackie does not suffer from any allergies she is aware of.

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v. Family history

Mrs. LP P stated that no other member of her family has suffered a fracture like this. She can

only recall her grandfather (LS’s great grandfather) who also had a fractured femur and had to

wear a cast as well. Other than him, none of her immediate family has suffered from broken

bones. The only medical ailments the family sufferes from is high blood pressure from Jackies

father side of the family and diabetes from the mother’s side of the family. However no one in

her immediate family is suffering from this currently.

vi. Lifestyle

On a typical day, LS Jackie wakes up and has breakfast of bread and buttereither cereal or

Belizean style breakfasts of fry jacks, beans, egg and cheese. She attends her local primary

school named kinder gardenBiscayne Government School.During For her school break at

schoolbreaks, she usually takes a sandwichhas sandwich or a piece of local fruit in season at the

time. or cheese dip. For lunch at home she has rice and beansvarious Belizean style lunches,

most commonly Rice and beans with juice and. Finally at for dinner she usually eats beans with

flour tortillas and sometimes accompanied with fried eggs with sausage. As the mother, LP Mrs.

P buys the family groceries and cooks for her family. There is no known food allergy to LS

Jackie according to her. There is no difficulty for LS Jackie to perform her basic activities of

self-care prior to her fractured femur.

vii. Socioeconomic history

Ms. LP confides that she used to believe in the “mal de ojo” or “evil eye” in which a child

presents with on and off fever and to cure this, an egg has to be passed over the child’s body to

“cure” it. She states that she no longer believes in that custom though. LSJackie and her family

Case Study 10

live resides in their own home which was inheried from Mrs. P grandparents some years ago.

given to them by her father. Ms. LPThe mother went to reached up to highschool and worked

for a while before meeting her hustabnd starting started an family, she is a stay at home mother.

Mr. P also went to highschool and currently is employed as a stevedore at Port in Belize City

and has to go to work several days at a time to load off ships. Jackie is currently in primary

school and LS with her other siblings and cousins. is still in kinder garden. She noted that the

village is fairly safe and that murders and robberies are not common in the area where the reside.

also states that their neighborhood is safe. Cases of murder or robbery are not heard around

where she lives. It is very safe. When asked questioned about Jackies care and wellbeing when

she returns home with the injured leg, the mother advised that she will care for it s advise by te

hospital. Also if there is any complications, she will be able to seek assistance from the

Ladyville Heathcare Center. what will happen when LS returns home with her injured leg, she

says that she could always seek medical help at Benque Poly Clinic whenever necessary.

viii. Environmental history

In BenqueBiscayne Village, Mrs. LP says states that they do not have they have potable water.

So most villagers, like themselves have created a “Well pump” to divert water in the home. Also,

for drinking purposes, they have two huge vats which collects rain water on the property but they

drink rain water from their tank. Their bathroom is inside the house with sewage. There are no

complaints of any infestation of rats or insects except for the occasional roach and mosquitoes

present. She states that there is a carpentry shop right next to their house that makes furniture but

makes a lot of noise and saw dust. She is concerned about this for her children at home during

the rainy season due which can causes cases of malaria and dengue. She notes that her husband

would occasionally clear the bushes near their property and clear up any places which can harbor

Case Study 11

the mosquitoes.because she has a baby boy at home still breastfeeding and she doesn’t like him

to inhale the dust from the carpentry shop and have to hear the noise from it. They have already

told the owners to move, but they have yet to do so.

ix. Psychological

Mrs. P advises that she has been receiving emotional and financial support from her family

members along with other village members while staying in the hospital. Family members call

her and little LS every day from the hospital to see how she is doing. Mr. LP checks with the

mother every day to talk with Jackie and provide support to her over the phone. ’s husband calls

every day to talk to his little girl.Since he has to work, Mrs. P has to stay with Jackie during her

stay at KHMH and Mr. P comes and checks during the week on them. Mrs P mother has been

taking care of the other two older children at home while she is caring for Jackie. Since they live

in Benque, only she has been staying with her child but her husband and mother provide support

to her over the phone. Jackie is very eager to return home and recover in order to go back to

school. Her classmates have sents cards and treats to encourage her to get better and return to

school. Therefore, it would seem that the physcological state of Jackie is one that is upbeat, with

exception of the occasional onset pain when the skin traction that will return once ina while.

They own a plantain chips business in which they have to fry chips every day to sell plus the

father works, hence the reason LP is the only one staying with her child at Karl Heusner. LS is

very eager to go home. Every day she shows signs of recovery by being able to sit up in bed

despite the skin traction and cries less. She is a happy child.

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x. Physical assessment of the client (Patient’s mother answered the questions

regarding the physical assessment-subjective data)

Generally, patient maintains good weight and eats well. She has not noticed that LS’s clothes are

getting tighter due to weight gain. She is a fairly healthy child that does not get sick as often as in

the past. Presently she has not gotten any high fevers. Her skin is warm and smooth. She sweats

because the room is hot and the fan does not provide enough breeze. There is itching of the skin

under the bandages and it gets worse when the weather is really hot. Her neck is not stiff or

enlarged and does not hurt. She has no difficulty swallowing. Eyes and ears are healthy

according to mother. No eye vision problems or difficulty hearing. She states that she has taught

her children good hygiene; she brushes her teeth before going to school and going to sleep. She

does not have rotten teeth, no problems with gum bleeding. LS’s breathing is normal and has

never had shortness of breath when she plays or does daily activities. She has never gotten

pneumonia. Her breasts have not started developing yet. She states that she does have shyness

when exposing herself and finds it difficult to change with other patients in the room because

there are not curtains to provide privacy. She has never had any chest pain or discomfort relating

to her cardiovascular assessment. She has good appetite and does not have nausea or vomiting

due to her fractured femur. There is no diarrhea that she has noticed and she has normal bowel

movements. She has not had any fainting spells or headaches. No aches of bones except for the

fractured femur which is swollen and causes pain when moved. Her mother states that LS is a

fairly healthy child with no serious illnesses until now.

ANALYSIS OF DATA COLLECTED

Case Study 13

ORGANIZING THE DATA

1. Gordon’s Typology of 11 Functional Health Patterns

I. Health Perception/Health Management

Patient has generally good health prior to injury. From the interview gathered, patient

does not suffer from allergies with food or medications. Their living environment is

stable, free from harm except for the carpentry shop which is a risk factor for

breathing problems due to the saw dust generated from it. Patient practices good self-

care hygiene, has good relationship with parents and siblings and has a positive

outlook in getting better and going home. Parents have good support systems from

family members to assist with stress of mother being away from home and away from

her other children.

II. Nutritional/Metabolic

Patient has good appetite and tolerates food 100% every day when served. Patient

eats sufficient amount of carbohydrates, lipids and nutrients from 24 hour intake

described by mother during a typical day. She does engage in some snacking but it is

not interfere with her 3 meals a day. She usually drinks about two 1 liter bottles of

water a day. Her sleep/wake normal patterns range from getting up around 7 in the

morning and going to sleep around 8 at night (11 hours of sleep).

III. Elimination

Bowel movements are regular everyday consisting of moist, soft stools. There are no

urine incontinence problems with patient. Presently, LS has to wear pampers because

she cannot move from the bed. Mother changes pampers whenever soiled. Patient

drinks sufficient amount of water every day. Mother says LS has never had UTIs.

Case Study 14

IV. Activity/Exercise

Patient is a 4 year old active child who engages in play whether at home or at her

kinder garden. Mother describes her as an active child who rides her bike at times

under supervision. She is not lethargic when at home. Presently, she is able to move

her left leg and arms and sits up in bed. Range of motion exercises are sometimes

done.

V. Cognitive/Perceptual

LS is a bright child. At the ward, she engages in conversation with mother and with

other patients. She reads books and plays with her toys on the bed. Mother states she

is attending kinder garden and will enter a Nazarene school upon completion of

kinder garden. LS is aware of her fractured leg and responds to questions asked by

nurse and mother.

VI. Roles/Relationships

Patient has strong attachment bond to mother but does not shy away from interaction

with medical staff and other patients and visitors. Seems outgoing and will participate

in play activities initiated by nurse and mother.

VII. Self-Perception/Self concept

Patient seems to be at ease at the ward. Mother states that she is potty trained but at

the moment must urinate and stool in pampers due to skin traction to right leg. She is

able to brush her teeth and comb her hair on her own. Appearance seems calm and

relaxed with no signs of anxiety on her features.

VIII. Coping/Stress

Case Study 15

Patient seems to be coping well to situation. Mother discusses that she feels a little

worried that they have to stay at Karl Heusner. She had previously asked for a

transfer back to the San Ignacio Community Hospital since it is much closer to their

home in Benque. She is also still breast feeding her baby but has been unable to do so

for the past 2 weeks due to her being too far away. Doctor Roberts, LS’s doctor,

informed that the patient could not go back and must stay at Belize City. There is

stress to separation of the mother with the rest of her children. Patient has episodes of

nightmares where she suddenly awakes and starts crying. Mother interprets this as she

remembering the accident. Patient also cries and complains when the leg is in pain or

itches. Patient was assessed using Wong-Baker’s FACES Pain rating scale and scored

a 3 using 0-5 coding. See Fig. 2.1

IX. Value/Belief

Other than old beliefs in the “mal de ojo”, patient and mother do not seem to have

other cultural beliefs. Other health beliefs LP practices is putting on sweaters and

covering the head when the weather gets cold, washing hands after using the

bathroom, practicing good oral hygiene and regular baths. They relate their faith to

the Catholic church and have a strong belief in God.

X. Medication/History

Nil allergies to medication referred by mother. Upon admission to Accident and

Emergency, patient was given Pethidine 20 mg IV stat, and Voltaren 20 mg IV stat.

Currently, patient is being given a Tylenol suspension of 7.5 cc for pain whenever it

is needed. All medications prescribed are pain medications to alleviate swelling and

pain to right leg.

Case Study 16

XI. Nursing Physical assessment

In regards to the physical assessment of LS, patient is conscious and alert lying in supine

position in bed with skin traction to the right leg with weights. With regards to skin, hair and

nails, there is no signs of cyanosis or jaundice. Skin is light brown with even pigmentation.

Skin is warm to touch, firm, smooth and even with no tenting. No scars visible. Hair is brown

and straight which is evenly distributed with no alopecia. The scalp is free of lesions or scars.

Nails have a pink undertone with good capillary refill less than 3 seconds. For the Head, neck

and lymph nodes assessment1s, face is symmetrical with ears aligning with canthus of the

eyes. Smile is even, eyebrows rise equally, no rhythmic bobbing or abnormalities with the

head and neck. There is no swelling of the lymph nodes below the jaw and

sternocleidomastoid upon palpation. Patient has good range of motion of the neck. Thyroid

gland is not enlarged, nil bulges. Eyes and ears assessment tests adequate. Patient is able to

follow the direction of the tip of the pen with eyes only, there is no tenderness when

palpating the eyelids and ears. With regards to the abdomen assessment, abdomen is

symmetrical with nil bulges or masses observed. Umbilicus is protruded. Upon percussion,

dullness is heard over solid organs and hollow sounds over the intestines. Upon palpation,

there is no tenderness voiced by client when doing light and deep palpation. The assessment

of the respiratory system shows that respiration is adequate with symmetric chest rise,

posterior chest has even pigmentation as well as anterior chest. Upon auscultation, breath

sounds are normal with no crackles with good chest expansion. When assessing the

cardiovascular system, the head is kept steady, eyes are not bulging. Lips are pink and not

cyanosed. Oral mucosa pink and hydrated. Ear lobes are smooth with no bilateral earlobe

creases. Fingers are pink and even, nil clubbing observed. Respiratory pattern is even and

Case Study 17

regular with no retractions. Legs are even in color and smooth. There is edema to the right

thigh and is painful upon mobilization. Carotid pulses are strong and bounding. Upon

auscultation of the heart, heart sounds are rhythmic with no murmurs. Extremities are well

perfused and hydrated with good capillary refill less than 3 seconds. Overall, client is in good

health except for the closed fracture to the right leg. No abnormalities observed in any of the

other body systems.

COMPARING THE DATA

Table 1: Timeline of events in LS’s injury

Patient has been showing gradual reduced levels of pain from initial admission and assessment

up to the present. Patient scored a 5 on Wong-Baker’s FACES pain assessment tool initially,

scored a 3 last week and is presently scoring a 1. There is definite improvement in the patient’s

ability to sit up in bed and assist in changing clothes and pampers.

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Fig. 2.1 Patient’s current pain rating to the right femur

Vital signs have been consistent and without presence of an infection. Patient is seen and

evaluated by Dr. Roberts and Dr. Parham on a daily basis to assess condition. X-rays have been

taken of the initial injury and how it has been aligning with the help of the skin traction with

weights. Last x-ray taken indicated femur is well aligned but must still be kept of traction to keep

promoting callus formation. Since patient is 4 years old, bone healing is characteristically rapid

because of the thickened periosteum and generous blood supply. In early childhood, healing

times for a femoral fracture can take up to 4 weeks (Hockenberry & Wilson, 2011). LS has been

at the ward for 18 days still and Dr. Roberts has ordered 2 more weeks of being in traction. Bone

healing in any age group is greatly influenced by the patient’s general health. LS does not have

any other illness presently to hinder her healing. Mother should be educated on the importance of

a balanced diet to promote stronger bones and good development of child’s body.

Strengths of LS’s family include having a good support system in terms of taking the time out to

take care of LS and father staying at home to take care of the other children and to keep their

business running. Her grandmother is also helping take care of the other children. Weaknesses

could be that there is only communication through the phone to the rest of the family in Benque.

No other family members have come to relieve LP of taking care of her daughter. In another of

point of view, LS’s injury is an opportunity for the family to grow closer when they help each

other out. LS will become closer to her mother, and vice versa. Father will have the opportunity

Case Study 19

to see what it feels to take care of the rest of the family on his own, and he could be more

understanding to his wife. Financial strain of LS’s injury may decrease the family’s resources,

other siblings could feel neglected since attention is on LS for the moment, and both parents can

be feeling guilt over having failed to protect their child. Other opportunities to educate other

members of the community on fractures and timeframe of bone healing could come to LS’s

family so that they could educate other families to supervise when their children are playing and

try to prevent injuries to their children’s bones.

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Table 2: Nursing interventions related to data gathered

Case Study 21

ACTUAL AND POTENTIAL PROBLEMS

In order of priority

Actual: a. Impaired physical mobility- LS is unable to move the right femur and whole right

leg because of the skin traction with weights to the foot of bed. She is able to move her toes but

has impaired physical mobility to change positions on the bed. She is kept in a supine position,

but she is able to sit up in bed now that she is not experiencing as much pain as before. She needs

assistance in bathing herself and changing clothes. She requires the assistance of her mother. The

nurse helps in changing the bed linens without disturbing the traction.

b. Acute pain- LS is not having as much pain as she had at the beginning of the injury

however there is still pain present whenever she moves the leg suddenly or when she is being

changed and bed linens are being changed. The right leg is still tender to touch and edematous.

Patient is being given 7.5cc of Tylenol for pain management. Patient starts complaining and

crying that it hurts whenever she feels the pain.

Potential: c. Risk for disuse syndrome- Patient is at risk for disuse syndrome since she is not

ambulating and not able to do range of motion exercises to affected leg. Patient is limited to

staying in bed, so muscle strength is at risk to be reduced. Inactive muscle loses strength at a rate

of 3% per day (Hockenberry & Wilson, 2011). Immobility can also affect the circulation to the

skin during inactivity and can cause edema. Friction from the straps and bandages could cause

skin breakdown.

Case Study 22

IMPLEMENTATION/EVALUATION Nursing Care Plan 14/03/2014

Assessment Nursing Diagnosis Goals/Objectives Interventions/Rationale Outcomes

Objective data:-Patient lying in supine position in bed-respiratory effort adequate-skin warm to touch and hydrated-oral mucosa pink and hydrated-Abdomen soft and palpable, non-tender-Extremities well perfused, capillary refill less than 3 seconds. -right leg on skin traction with weights, immobilized with sand bags around leg, edematous and tenderSubjective Data:-patient cries when moved when bed linens are being changed and when she wakes up from a bad dream, and voices pain-Patient cannot bathe on her own, requires help of mother to be sponged in

Actual:Impaired physical mobility related to bone injury to right femur as evidenced by inability to move out of bed to bathe due to skin traction with weights to right leg

Acute pain related to bone injury to right femur as evidenced by client voicing pain felt to right leg and being tender to touch

PotentialRisk for disuse syndrome related to bone injury to right femur

Long term goal:At the end of 3 days, patient will be able to:

1.Pull herself up to assist mother during bathing and when bed linens are being changed according to level of tolerance

Short term goal:At the end of the 8 hour shift, patient will be able to:

2.Voice that she feels little pain or is free of pain to right leg when she moves

3.Move unaffected limbs to do range of motion exercises to reduce risk of disuse syndrome

I. Impaired Physical Mobility1.Assist in changing pampers and bed linens-helps patient since she cannot move much without feeling pain (collaborative-nurse and mother)2.Do range of motion exercises-helps strengthens muscles of legs and arms (independent-nurse)3.Provide books, and toys within reach-keeps patient entertained and not feel bored of staying in bed (collaborative-nurse and mother)4.Keep right leg in traction- promotes correct alignment and healing of bone (collaborative-doctor and nurse)5.Provide skin care by keeping skin clean and dry-helps maintain skin integrity and reduces risk of a break in the skin (independent-nurse)

II. Acute pain1. Assess level of pain using Wong-Baker’s pain assessment tool-helps to see level of pain patient is feeling (independent)

At the end of 3 days, patient was able to:

1.Pull herself up in bed to assist during bed baths and changing of linens according to level of tolerance

At the end of the 8 hour shift, patient was able to:

2.Voice that she felt little or no pain to right leg when she moved

3.move unaffected limbs and do range of motion exercises and therefore reduced the risk of disuse syndrome

Case Study 23

bed-Patient is quiet and calm when she has books to read and TV to watch.

2. Administer Tylenol every 8 hours or when needed-analgesics help control pain (Dependent on doctor’s orders)3.Monitor vital signs for increase in pulse which would indicate pain (independent)4.keep toys and books within reach so patient’s focus will be on the stimuli and not on the pain (independent-mother)5.Provide comfort to child by talking soothingly so she can relax when she is having pain (collaborative-nurse and mother)

III. Risk for disuse syndrome

1.Initiate range of motion exercises to encourage adequate circulation (independent)2.Massage pressure area points to prevent bed sores (collaborative-nurse and mother)3.Encourage patient to wiggle toes, sit up, and stretch as tolerated (collaborative-doctor, nurse and mother)4.Educate mother on disuse syndrome so she can move child’s limbs when nurse is not around (independent-nurse)

Case Study 24

TEACHING PLAN

TOPIC: Fractures and traction VENUE: Patient’s bedside AUDIENCE: Mother and patient DATE: March 14, 2014 DURATION: 30 minutes

THE PURPOSE: To educate the patient and mother on impaired physical mobility, pain management and how to do range of motion exercises

STATEMENT OF OVERALL GOAL: Patient and mother will understand the reasons why traction is placed, and how to manage patient in traction

OBJECTIVES CONTENT OUTLINE

METHODOF

INSTRUCTION

TIMEALLOTEDFOR EACH

OBJECTIVE

RESOURCES/TEACHING

AIDS

METHOD OFEVALUATION

At the end of the discussion, patient and mother will be able to: 1.Describe what is a fracture and the types of fractures and how traction therapy works

2.Identify type of fracture patient suffered by looking at patient’s x-rays

3.Adapt to patient having to stay on traction for 2 more weeks and how to manage pain

4. Describe disuse syndrome and how to do range of motion exercises to prevent it

1.What is a fracture?

2. What are the different types of fractures that can occur?

3. treatment of fractures-cast or traction

4.Medications available: Tylenol, Voltaren, Pethidine-for pain management

5.Disuse syndrome

6.Questions and answers at end of presentation

Discussion-Explain traction care-understand the therapy, maintain traction, maintain alignment (check after patient moves), and prevent skin breakdown

go in depth by demonstrating the correct ways of doing range of motion exercises and have mother perform a return demonstration

5 minutes for each objective and time left will be for demonstration and questions & answers

Visual aids:

Pictures of the types of fractures

Patient’s X-ray

Demonstration

When the nurse finishes

discussion, patient and

mother are able to identify type

of fracture patient

sustained, understand which pain

medications are given and how they work, and how to initiate

range of motion exercises to

prevent disuse syndrome.

Recommendations

Case Study 25

After evaluating the data compiled, some recommendations to patient and family can be

given. Possible ways to improve the situation of the family could be that other family members

should come and help the mother of taking care of the child. Undoubtedly, LP is having

difficulty being the only one who has to stay with the child because she voices that her baby is

still breastfeeding and her breasts are getting tender from not breastfeeding. In the meantime

also, she is also worried about her other children and how things are at home. It would be

recommended to have someone else come to help her at least for 2 or 3 days so she can go back

home. LS is doing very well in the past days. All that is left to do is wait 2 more weeks so the

skin traction can be discontinued. Dr. Roberts could then put on a cast or transfer her to the San

Ignacio Community Hospital so she can be closer to home. LS also needs more books and toys

so that she does not get bored about having to stay immobilized.

Interventions from the nursing care plan were met and the patient’s needs were

prioritized according to the needs that were most outstanding. Range-of motion exercises are still

being done and client is able to sit up in bed and move other limbs to promote circulation.

Patient’s right leg is still in traction and care is done to see that the leg is always aligned and that

the weights are hanging freely. If patient is in pain, Tylenol is given to help alleviate it.

When patient is discharged and taken back home, bed rest and care should be taken so

that leg does not become injured again. The child must not strain the right leg with excessive

running or other physical activities. Follow up care with the doctor should be done as scheduled

for x-rays to see that the bone continues healing. If there is any vomiting or shortness of breath

after being discharged, parents should be advised to seek immediate medical help at the nearest

health center. Patient should keep taking her pain medications as prescribed by the doctor as

well. The mother should be encouraged to freely ask any questions she might have regarding

Case Study 26

future appointments or how to better take care of her child once she is back home. At the same

time the nurse should provide accurate and understandable information on all topics related to

the injury. The teaching plan for this patient should help minimize the lack of knowledge on the

patient’s injury.

Appendix

Case Study 27

Fig. 1.1 Parts of the bone Fig. 1.2 Types of fractures

Fig. 1.4 Traction with weights

Fig 1.3 Application of traction to maintain equilibrium

Case Study 28

Fig. 1.4 example of a fractured femur

Fig 2.1 Wong-Baker’s FACES pain assessment tool

Case Study 29

References

Hockenberry, M., Wilson, D., (2011). Wong’s Nursing Care of Infants and Children. (9th

ed.) St. Louis, MO: Mosby.

Smeltzer, S., Bare, B., Hinkle, J., Cheever, K., (2010). Brunner and Suddarth’s Textbook of Medical Surgical Nursing. (12th ed.). Philadelphia, PA: Lippincott Company

Pinelo, L., Personal Communication. (2014).

Long bone anatomy references1. Perren SM. Physical and biological aspects of fracture healing with special reference to internal fixation. Clinical Orthopaedics & Related Research, 1979(138): p. 175-96.2. Manolagas SC. Editorial: Cell Number Versus Cell Vigor--What Really Matters to a Regenerating Skeleton? Endocrinology, 1999. 140(10): p. 4377-4381.