MANILA DOCTORS COLLEGEMetropolitan Park, President Diosdado Macapagal Blvd.,

Pasay City

A case study on

MOTOR VEHICULAR ACCIDENT

Submitted to:Mr. leonardo

Submitted by:GROUP 50

Gacot, Angelie joy

December 18, 2010

I. ASSESSMENT: 

A.    General DataPatient’s initials: A.R. m            Address:Binondo, Manila Age: 75 yoSex: FemaleDate of Birth:02/08/1935 Place of Birth:ManilaCivil Status: MarriedOccupation: None

Informant: Client,herselfDate of Admission: 11/13/10Order of Admission: via ambulatoryNo. of Days in this hospital: 3 daysDate of History Taking: 12//16/10Religion: Roman Catholic

                       B.     Chief Complaint(s)

 Vehicular crash

C.    History of present illness:

3 days prior to confinement, client was hit by a tricycle after buying foods in Talipapa in the street of Lavaranes, Bonondo. She then lose consciousness. She was brought by the nearest hospital which Saint Andres Hospital. 1 day prior to confinement upon knowing by her relatives that she was not given Tetanus Toxoid, they then decided to transfer her in Manila Doctors College. She was brought to the hospital at 7 pm. She experience contusion at right clavicular bone, contusion on the left cheek below the eyes and lacerated wound pleural left parietal part of her head.

D. Past History:1.) Childhood Illness/es : none2.) Adult Illness/es: none3.) Immunization: complete unrecalled4.) Previous Hospitalization: none5.) Operation/s: thbso (1980’s)6.) Injuries: none7.) Medications taken prior to confinement: none 8.) Allergies: none

E. Systems Reviews:Gordon’s Functional Health Areas

A. Health Perception-Health Management patternBefore admission, client’s health was good. She doesn’t get sick. She eats vegetables and fish

to stay healthy. She refrains from vices too. She had a Thbso on 1980’s.During hospitalization, Client had difficulty moving because her body usually her left side is weak. For

the first 2 days, she just always to lie in the bed. She thinks that complying with her doctor’s advice will help her to get better. She already wants to go home. She doesn’t want to stay in the hospital till Christmas or New Year.

 B. Nutritional-Metabolic pattern  Before admission, client typical food intake were vegetables, chicken, fish and meat. She consumed 6-8 glass of water a day. She starts her day by drinking a glass of coffee.She does have good appetite and has no restriction in food. She doesn’t experience excessive sweating. Her wound heals well and sometimes she experience skin dryness due to aging. She wears dentures.

During confinement, after her operation, she was prescribed NPO then general liquids. On the 3 rd day, her doctor allows her to full diet. She is with IVF D5NSS 1000 l x KVO. B. Elimination Pattern

Before admission client’s elimination pattern was twice a day. It is formed and yellowish. She doesn’t have any discomfort and problem in control in defecating. He micturates 6-8 a day. Her urine is yellowish and doesn’t contain blood. She doesn’t use any laxatives and doesn’t experience any discomfort. He wears dentures.

During confinement, client was not able to eliminate yet. At first, she just urinate sat the bedpan. But on the 3rd day, she manages to urinate in the comfort room with assistance. She micturates 6-8 times a day. C. Activity-Exercise Pattern

Before confinement, patient has sufficient energy for desired activity. But sometimes, sheexperience exhaustion or he easily get tired. She is in full self car. She thinks that she gets enough exercise through walking everyday when marketing in Talipapa. She allows herself to have chitchats with her friends and watch television. She also mans the sari-sari store of her daughter-in-law.

During confinement, client does not have sufficient energy for desired activity. She feels weak. She can’t move her arms the way she wants to because she has clavicular fracture. She needs assistance in getting up the bed and sitting. She tries to ambulate a little for easy recovery. She just watches television in the room.E. Sleep –Rest Pattern

Prior to confinement, client feels well rested and ready for daily activities after sleep. She sleeps for 6-8 hours a day. Sometimes, she wakes up during her sleep. He also experiences nightmares and early awakenings. She allows herself for self-relaxation period.

During confinement, client doesn’t have enough sleep. She complains that she can’t sleep at night because of the pain she feels when her antibiotics was incorporated in her IV line. F. Cognitive-Perception Pattern

Prior to confinement, client doesn’t have any hearing difficulties. She wears eyeglasses. She doesn’t recall her last eye check-up. There are few changes in her memory since she growing older. If there’s any important decision to make, she thinks about it several times, weighs, and think of what is best to resolve the problem. She does this, because she knows her responsibilities and liabilities if she makes a bad decision. She easily learns well and adapt to new things and changes. She is a visual and audio learner.

During confinement, she feels that her body is too weak to do things she wants. She thinks that complying with doctor’s advice will help her get well soon. Her neuro vital signs are good. She can graps ideas both concrete and abstract. She speaks in Filipino.

G. Self Perception - Self Concept PatternPrior to confinement, client feels good about herself. She is satisfied with her life and she is proud that

her two sons became policemen. People that are to makulit and boisterous make her annoyed. During confinement, she described herself as good though weak. She said that everybody dies and she’s

blessed enough to have few more years in this earth. She is relaxed and assertive tha she will get well soon.

H. Roles – Relationship Pattern Prior to confinement, stays with her son’s family. She is already a widow. She has an extended family. They encountered difficult family problems but they are able to resolve. She doesn’t have any job but she’s helping in taking care of her grandkids and in the sari-sari store. She has good social relationship and she doesn’t feel lonely because of her family and friends.

During hospitalization, client was being taken care by family and friends. She depends on them, at all times. Her family worries about her. The suspect was put into jail easily because of her son’s job. She still manages to have good relationship with them and she cannot wait to stay in the hospital for long to celebrate Christmas day.

I. Sexuality – Reproductive Pattern Prior to confinement, client has good relationship with family, relatives and friends. She is already a widow. But she doesn’t feel lonely. Her menstruation period started when she was 13 years old and she had menopause at age 48 years old.

J. Coping – Stress Tolerance Pattern Prior to confinement, there haven’t any changes in the client’s life or crisis within his family and friends. She is relaxed most of the time. Her daughter in law and son helps her most when problems arise. She resolves her stress though eating or walking. She doesn’t have any vices. If there’s big problem, she thinks it very careful and finds solutions to resolve this. Usually these are most of the time successful.

During confinement, client is relaxed. He is in full diet. He responds and follows her doctor’s advice to get well.

K. Values – Beliefs Pattern Prior to confinement, client generally gets things she wants in his life. Religion is important to him. She prays to God when she encounters difficulties.

During confinement, client doesn’t get want she wants. She doesn’t like being confined to bed and she wants to go to home immediately as soon as gets well. Being sick interferes with her religious practices such as going to church.

Regional examination:

F. Family Assessment

Name Relation Age Sex OccupationEducational attainment

ASM Son 50 male Police College graduate

CSLDaughter in

law49 Female

Sari sari store owner

College graduate

KSM grandson 25 male Call center agent College graduate

G. Heredo Family Illness:Maternal: nonePaternal: none

I. Physical Examination:Date of P.E: December 16, 2010 1000H

Height: “5’3” Blood Pressure: 120/70 mmHgActual Weight:56 kgBMI: 19.9 normal Heart rate: 72 bpm

Respiration Rate: 16 cpmTemperature: 37.2°C

GENERAL SURVEY conscious, awake, cooperative, coherent oriented to time, person, and place lying in semi fowlers position has sutures on left parietal, left cheek below the eyes and clavicle has arm sling and clavicular strap.

SKIN tan or brownish skin absence of petechiae moist, cool, pale skin has resilient skin turgor

Hair and Scalp black with white, moist, shiny, curly,

and smooth hair evenly distributed presence of dandruff and dried blood. presence of moist scalp presence of sutures in the left parietal

lobe.

Nails nail edges are smooth and round nail plates are smooth and slightly con-

vex absence of swelling, redness and lesion capillary refill of >3 second

HEAD normocephalic, symmetrical and oval shaped

head still and upright in position proportional with the neck and body has good hair distribution

EYES brown iris white sclera presence of sutures below the left eye

EARS auricle: symmetrical and mobile absence of cerumen, discharges, nodules, le-

sions, negative from areas of tenderness, masses, in-

flammations,

NOSE and SINUSES symmetrical and proportional to the face nasal mucosa: pink; free from redness, swelling

and exudates

nasal bridge: absence of lesion, masses, defor-mities

septum in midline frontal and maxillary sinus: absence of swelling,

tenderness and painMOUTH

lips: moist and light pink buccal mucosa: pink; absence of inflammation,

cold sores, nodules and malocclusions gums: absence of inflammation, lesions, bleed-

ing presence of dentures

NECK negative from enlargement; proportional to gross

body structure symmetrical absence of masses and lesions trachea is in the midline and proportional with

other neck structures negative for vein engorgement absence of thyroid enlargement, symmetrical

CHEST AND LUNGS spine is in the midline Straightened cervical spine With clavicular strap and arm sling

HEART absence of structural deformities, area of tender-

ness and masses negative for visible pulsation (-) crakles

EXTREMITIES With positive left reflexes on both hands

and feetNEUROLOGIC EXAM

alert Can recall Aware of people, time, and place Can move tongue and move around his eyes Impaired physical mobility due to weakness of

body.

H. Developmental History

Theorist Age Task Patient DescriptionSigmund Freud –

Psychosexual Theory 75 Genital StageClient is already a widow. She has good personal

relationship with both sexes.

Erik Erikson – Psychosocial Theory

40 Integrity vs despair

She is satisfied with her life and mature to handle things.

Jean Piaget – Cognitive Theory

40Formal

Operational Stage

In making decisions, she weighs it first and thinks carefully how to solve his problems because she

knows his responsibility and liability.

Lawrence Kohlberg – Moral Development

40 Social contractShe recognizes the higher authorities. She knows

what is right, what is wrong, how to make decisions and his liability and responsibility.

JamesFowler – Spiritual

Development 40Paradoxical- Consolidative

He believes in God, the highest authority in the universe. She prays to him and believe that God will

not do any harm to people

II.PERSONAL/ SOCIAL HISTORY

Habits: talking to friend, watching televisionVices: noneLifestyle: sedentary lifestyleSocial affiliation: noneClient’s usual day like: Client wakes up at 5 am. She then helps in cooking breakfast at 6. Then she eats at 7 or 8 in the morning. She helps in her daughter in law sari-sari store. Then she eats lunch at 12 pm. She then watches television or have chitchats with her friends. She then helps in cooking and eat at 8 pm. The watches again television in the night and fall asleep at around 11 pm. Travel :noneEducational Attainment: Highschool graduate

III. ENVIRONMENTALHISTORYClient is living with his family in Binondo, Manila. They are living in a 2 storey house. Their water is

NAWASA. They use MERALCO for electricity. They have a good drainage. They are near the Talipapa market. She describes their place as a very crowdy place.

I. OB / GYNE HISTORY

Menarche (age): 13 yrs. Old when:amount and characteristics: moderate flow

3-4 pads for dayduration: 3-4 daysassociated symptoms: dysmenorrhea

Deliveries: G2 P2 operations: 1OB Score: T2 P0 A0 L2

VII. LABORATORY RESULTS AND FINDINGS

LABORATORY12/13/2010

NORMAL VALUE

RESULT PURPOSEINTERPRETATION/

SIGNIFICANCE

Hemoglobin140-175

g/l117

Usually done to a patient with renal disease to determine if the kidney’s

ability to release erythorpoietin factor is already affected.

Below normal .Due to the loss of blood during the

accident.

Hematocrit 0. 36-0.46 0.37

Used to measure RBC number and volume. It is an integral part of the

evaluation of anemic parents.Normal

RBC4.5-5.90 x 10ˆ12/L

3.72 To help diagnose anemiaBelow normal. Due to the loss of blood during the

accident.

WBC4.0-10.5 x

10ˆg/L16.02

Determines any inflammation, infection, allergy or immunosuppression

Above Normal. To increase the body defense due to

trauma.

Neutrophils 0.36-0.66 16.02Determines any acute bacterial

infection.Above Normal. To increase

the body defense due to trauma.

Lymphocyte 0.24-0.44 0.07Determines any chronic bacterial

infection or viral infection.Indicates that there’s infection.

Monocytes 0.02-0.12 0.05Determines any acute bacterial

infection. Normal

RDW(red blood cell

distribution width)12-17 % 13.4

calculates the varying sizes of red-blood-cell (RBC) volume in a blood

sampleNormal

MCV(Mean

corpuscularvolume)

80-96 fl 100.5To measure the average red blood cell

sizeAbnormal. Due to the loss of

blood during the accident

MCHMean corpuscular

hemoglobin

27.50-33.2 pg

31.5This is use to measure amount per red

blood cellNormal

MCHCMean corpuscular

hemoglobin concentration

33.40-35.50 g/dL

31.3The amount of hemoglobin relative to

the size of the cell (hemoglobin concentration) per red blood cell

Normal

purpose:X-rays - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. Chest radiographs may depict segmental or lobar infiltrate but they more commonly reveal a diffuse, fine, reticulogranular pattern, much like what is observed in RDS. Pleural effusions may also be observed.Result:No fracture nor listhesis seen. There are osteophytes seen at the margins of the cervical vertebral bodies.The pedicles, posteror elements, and intervertebral disc spaces are intact.The usual cervical lordosis is maintainedThe c7 vertebrae body is not visualized in the lateral view but appears intact in AP projection

Impression:Cervical spondylosis

RadiologyDate: 12/13/2010

A small round calcified density is seen in the right lower hemithorax overlying the Right 8 th posterior rib. The rest of the lungs are clear. The heart is enlarged Aorta is atheromatousThe diaphragm and sulci are intactThoracic spondylosis is evidentImpression:Right lower lobe cacific GranulomaAtheromatous AortaThoracic spondylosis

Zygomatic Arch/Submento VerticalDate: 12/13/2010

No demonstration of fracture is seen in this study. Soft tissue swelling over the left zygomatic arc is evident.

ABO TYPING RESULTSpecimen: Whole Blood Date taken: 12/16/10

ABO : “B”Rh Type : Positive

PATHOPHYSIOLOGY:book based: fractured clavicle communited

.

MODIFIABLE FACTORS-environment-motor vehicular accident-falls

NON- MODIFIABLE FACTORS-extreme age(child and old)

Direct blow to body

lateral fragment is depressed by the weight of the arm

pulled medially and forward by the strong adductor muscles of the shoulder joint, especially the pectoralis major

part of the clavicle near the center of the body is tilted upwards by the sternocleidomastoid muscle

fracture of the clavicle

sternocleidomastoid muscle elevates the proximal fragment of the bone.

trapezius muscle is unable to hold up the distal fragment owing to the weight of the upper limb

shoulder droops

adductor muscles of the arm may pull the distal fragment medially

bone fragments to override

PATHOPHYSIOLOGY:client based: fractured clavicle communited

.

MODIFIABLE FACTORS-motor vehicular accident

NON- MODIFIABLE FACTORS-old age 75 years old

Direct blow to body

lateral fragment is depressed by the weight of the arm

pulled medially and forward by the strong adductor muscles of the shoulder joint, especially the pectoralis major

part of the clavicle near the center of the body is tilted upwards by the sternocleidomastoid muscle

fracture of the clavicle

sternocleidomastoid muscle elevates the proximal fragment of the bone.

trapezius muscle is unable to hold up the distal fragment owing to the weight of the upper limb

shoulder droops

adductor muscles of the arm may pull the distal fragment medially

bone fragments to override

B. Ongoing Appraisal

December 16, 2010Client was with ongoing IVF D5NSS 1 L x KVO at left metacarpal at 950 ml; intact and infusing well. She is on

full diet. Shehas an arm sing on her right arm. She also has a clavicular strap applie dcontinously. She is encouraged to ambulate and to increased oral fluid intake. Warm compress over her clavicle is applied. Her medication are Dilantin 1 tb 100 mg BID, Nexium 1 tab 40 mg OD, Arcoxia 1 tab 60 mg. Then her Cloxacillin was shift to oral medication ( 1 tab 500 mg every 6 waking hours). Dr. Tenorio cleaned and changed her dressing in the head. Her IVF was ordered to stop after consumed. Dr. Domingo ordered with may go home order.

XII. DISCHARGE PLAN:

MEDICATION- Nexium- Arcoxia- Dilantin- Cloxacillin

EXERCISE- ROM- increase ambulation-perform independent activities as tolerated- Provide rest- exercise should increase gradually-

TREATMENT-high back rest

HEALTH EDUCATION- adequate rest-increase oral fluid

OPD FOLLOW-UPDIET

- Low Na and fat diet

SIGNS AND SYMPTOMS- report severe headache-LOC- vital signs fluctuation-nausea

SPIRITUAL

- Be thankful that God is good and save you from death.

NURSING CARE PLAN:

CUES/DATA DIAGNOSIS RATIONALE GOALS AND OBJECTIVES

NURSING INTERVENTION RATIONALE EVALUATION

SUNJECTIVE DATA:“Madali akong mapagod, “ as verbalized by the client

OBJECTIVE DATA:RR=20 cpmBp= 100/70mmHgHeart Rate =96 bpmPalenessWeak body especially on left side

Activity Intolerance r/t fracture in the head and clavicle

Because the brain was hit, several functions are deferred such as coordination and movement. Result is, client may experience weakness of the body.There is also fractured clavicle which makes her arm unmovable because of pain.

After 8 hrs of nursing intervention, client will be able to maintains activity level within capabilities as evidenced by .> will verbalizes and uses energy-conservation techniques

Independent:1. Observe and document response to activities. Report any alteration in normal signs, dyspnea, weakness, dizziness, chest discomfort.2.When appropriate, gradually increase activity, allowing the client to assist with positioning, transferring, and self-care as possible. Progress from sitting in bed to dangling, to standing, to ambulation. 3. Encourage adequate rest periods, especially before meals and ambulation.4.Refrain from performing nonessential procedures

5. Provide the patient with the adaptive equipment needed for completing ADL activities

6. Teach the patient and significant others to recognize signs of physical overactivity.7. Teach energy conservation techniques, such as the following:- sitting to do to the tasks-changing positions often-working at an even pace-placing frequently used items within easy reach-pacing for at least 1 hour after meals before staring a new activity

1. close monitoring serves as a guide for optimal progression of activity.2.This prevents overexerting the heart and promotes attainment of short-range goals3. Rest between activities provides time for energy conservation an recovery. Heart rate recovery following activity is greatest at the beginning of a rest period.4. Patients with limited activity tolerance need to prioritize tasks5.Appropriate aids will enable the patient to achieve optimal independent for self care6.This promote awareness of when to reduce activity

7. These reduce oxygen consumption, allowing more prolonged time-standing requires more work-this distributes work to different muscles to avoid fatigue- this allows enough time so as not all work is completed in a short period

After 8 hours of nursing intervention, goal was met as evidenced by:

.>verbalized and used energy-conservation techniques

Dependent:8.Provide bedside commode as indicated

-this avoids bending and reaching-energy is needed to digest food

This reduces energy expenditure. Using a bed pan or going to rest room requires more energy than using a commode

Nursing Care plan 6th ed by Gulanick and Myers pg 7-10

CUES/DATA DIANOSIS RATIONALE GOALS AND OBJECTIVES

INTERVENTION RATIONALE EVALUATION

SUBJECTIVE DATA:

“Di pa ako makagalaw ng maayos..hirap pa akong tumayo at kailangan ko pang asistehan ng iba”, as verbalized by the client.

OBJECTIVE DATA:- sutured laceration in the left parietal love-injury in the Right clavicle-sutured laceration in the face below the eyes-weakness and unstable gait

Impaired physical mobility related to weakness of body as 2 to multiple physical injury.

The nervous system is made up of nerve cells called neurons that serve as the communication system of the body. They carry messages in the form of electrical impulses. The messages move from one neuron to another to keep the body functioning. Because neurons have, limited ability to repair themselves unlike other body tissues that is why nerve cells cannot be repaired if damaged due to injury or disease.

After 4 hrs. of Nursing Intervention, the pt. will be able to maintain increased strength and function of affected part of his bodyAs manifested by:- more normal movement of the affected extremity-Improved muscle strength- effective use of adaptive devices

>assess client’s degree of muscle strength

> encourage client to exercise while at bed

>Provide adequate rest periods as well as comfort & safety measures> establish a turning schedule and turn pt. slowly from side to side>Assist pt. in his activities>Encourage adequate intake of fluids & Nutritious foods> involve SO in clients activity and instruct him how he

> as a baseline data and for determining and evaluating outcomes> to prepares him for later activities and give him hope and sense of optimism about recovery

> To prevent further stress & fatigue

> To provide proper circulation of blood flow on both sides>To promote optimal level of function>Promotes well-being and maximizes energy

After 4 hrs. of Nursing Intervention, the pt. will be able to maintain increased strength and function of affected part of his bodyAs manifested by:--increase ROMThrough ambulating.

can help in improving clients mobility

production.> to assist in managing immobility

Cues & Data Diagnosis Rationale Planning Intervention Rationale EvaluationSubjective:“Makirot yung sa kamay ko na may swero..hirap ako makatulog” as verbalized by the patient

Objective:- Pain scale of 5/10

- BP of 100/70

- RR of 20 cpm-PR of 96 cpm- weakness of body

- Facial grimace-guarding behaviour-eyebags-looks tired

Acute Pain related to inflammation of the pleura as manifested by pleuritic pain

Cloxacillin was given which was an antibiotic. And antibiotics are painful so it should be given slowly via IM route or IV route.

After 2 hours of nursing intervention, the patient will be able to:

- Report that the pain is controlled as manifested by:

- facial grimace will be gone

-Pain scale will be lessened from 5/10 to 3/10 -guarding behav-iour will be less-ened.

Independent:

- Observe or monitor signs and symptoms associated with pain, such as BP, heart rate, temperature, color and moisture of skin, restlessness, and ability to focus

- Evaluate patient’s response to pain and medications or therapeutics aimed at abolishing or relieving pain

- Accept client’s description of pain. Acknowledge the clients experience and convey acceptance of client’s response to pain.

- Provide comfort measures such as back rubbing, providing quiet environment

- Instruct to use

- Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain

- It is important to help patients express as factually as possible

- Pain is subjective experience and cannot be felt by others

- To promote non pharmacological pain management

-To attention and reduce tension

After 2 hours of nursing intervention the patient was able to:

- Report the pain is relieved or controlled.

Goal was met as manifested by:

-decreased RR from 24 to 20 cpm

-facial grimace is gone

-Pain scale will be less-ened from 5/10 to 3/10

-guarding behaviour was lessened

relaxation techniques like watch television, listen to music or socialized with others

Collaborative:

- Administer analgesics as prescribed such as Arcoxia

- To maintain acceptable level of pain