Jose C. Feliciano College Foundation

Dau Exit, NLEX, Dau Mabalacat Pampanga

Institute of Nursing, Midwifery and Nursing Aide

Academic Year 2011 – 2012

Debridement Suture

A Case Study

In Partial Fulfillment of the Course Requirement

In Related Learning Experience

Prepared by

Tuazon, Christine Jhoy Canlas

Mercado, Jennifer

BSN III

Prepared For

Mr. Erwin Pernia, RN

Instructor

TABLE OF CONTENTS

I. Introduction

A. Current trend

B. Reason for choosing the case

II. Nursing Assessment

A. Personal history

B. History of the past and present illness

C. Family Health illness

D. Physical Examination

III. Anatomy and Physiology

IV. Pathophysiology

V. Medication

VI. Diagnostic and Laboratory Procedure

VII. Diet

VIII. IVF

IX. Nursing Care Plan

X. SOAPIE

XI. Discharge

XII. Conclusion and Learning derived

XIII. Bibliography

I. Introduction

A. Current trend

B. Reason for choosing the case

The reason why we choose our patient Mr. Damon as our subject for our case presentation is because his medical diagnosis, which is S/P debridement suture, is a common condition. This study will provide us as nursing student with concrete and significant information regarding the fracture condition with the emphasis on the management and nursing care given to patients having the same diagnosis.

This also helps in enhancing the skills of the member of the health care team in disseminating information to prevent the occurrence of the fracture, as well as early prevention of further complications when the condition is already present.

Lastly, this study will contribute to the improvement of the standards of nursing practice and the quality of care given to such patients, thereby keeping with latest trends in care management.

II. Nursing Assessment

A. Personal history

Damon Salvatore, a 18 year old Filipino, was born on January 10, 1993, the 2nd to the

youngest among the 4 children of Mr. and Mrs. Salvatore both Filipino descent.

B. History of the past and present illness

According to his mother Mrs. Salvatore, Damon was never been admitted in hospital

since he was a child none of her children was admitted in the hospital only for now

because of the accident Damon encounter.

C. Family Health illness

D. Physical Examination

III. Anatomy and Physiology

IV. Pathophysiology

V. Medication

Medication Dosage/Route

Date ordered Date prescribed Date given

Indication Client response

Cefuroxime Cefuroxime is used to treat certain infections caused by bacteria, such as bronchitis; gonorrhea; Lyme disease; and infections of

the ears, throat, sinuses, urinary tract, and skin. Cefuroxime is in a class of medications called cephalosporin antibiotics. It works by stopping the growth of bacteria. Antibiotics will not work for colds, flu, or other viral infections.

Ranitidine Ranitidine is used to treat ulcers; gastro esophageal reflux disease (GERD), a

condition in which backward flow of acid from the stomach causes heartburn and injury of the food pipe (esophagus); and conditions where the stomach produces too much acid, such as Zollinger-Ellison syndrome. Over-the-counter ranitidine is used to prevent and treat symptoms of heartburn associated with acid indigestion

and sour stomach. Ranitidine is in a class of medications called H2 blockers. It decreases the amount of acid made in the stomach.

Tramadol Tramadol is used to relieve moderate to moderately severe pain

Celecoxib Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID). It works by reducing

hormones that cause inflammation and pain in the body.

Celecoxib is used to treat pain or inflammation caused by many conditions such as arthritis, ankylosing spondylitis, and menstrual pain. Celecoxib is also used in the treatment of hereditary

polyps in the colon

Gentamycin Gentamycin is an antibiotic. It fights bacteria in the body. Gentamycin is used to treat severe or serious bacterial infections.

Ceftriaxone  Ceftriaxone injection is given before certain types of surgery to prevent infections that may develop after the operation.

Ceftriaxone injection is in a class of medications called cephalosporin antibiotics. It works by killing bacteria. Antibiotics will not work for colds, flu, or other viral infections.

Promethazine

Promethazine is also used to prevent and control nausea and vomiting that may occur after surgery, and with other medications to help relieve pain after

surgery. Promethazine is also used to prevent and treat motion sickness. Promethazine helps control symptoms, but will not treat the cause of the symptoms or speed recovery. Promethazine is in a class of medications called phenothiazines. It works by blocking the action of a certain natural substance in the body.

Famotidine

Furosemide

VI. Diagnostic and Laboratory Procedure

Diagnostic Lab. procedure

Indication Date ordered Date result

Result Normal values

Analysis/ interpretation

Hemoglobin

Hemoglobin is a protein inside red blood cells that carries oxygen. A hemoglobin test reveals how much hemoglobin is in a person's blood. This information can be used to help

DODR- 6/24/11DODR- 7/2/11DODR- 7/6/11DODR- 7/7/11DODR- 7/12/11

164

77

92

104

115

M- 125-175 g/lF- 115-155 g/l

physician's diagnose and monitor anemia (a low hemoglobin level) and polycythemia vera (a high hemoglobin level).

Hematocrit

Hematocrit is a blood test that measures the percentage of the volume of whole blood that is made up of red blood cells. This measurement depends on the number of

DODR- 6/24/11DODR- 7/2/11DODR- 7/6/11DODR- 7/7/11DODR- 7/12/11

.49

.23

.25

.28

.34

M-0.40- 0.52F- 0.38- 0.48

red blood cells and the size of red blood cells.

The hematocrit is almost always ordered as part of a complete blood count.

WBC count

The WBC count is used to determine the presence of an infection or leukemia. It is also used to help monitor the body’s response to various treatments and to

DODR- 6/24/11DODR- 7/2/11DODR- 7/6/11DODR- 7/12/11

19.1

10.6

10.0

7.1

5-10 x 10/ L

monitor bone marrow function.

Neutrophils

A neutrophils test helps us detect the levels of neutrophils in our body. These neutrophils are an integral part of our immune system and through a process called chemotaxis; they reach any place where an infection has occurred. These cells take about an hour to reach the site of infection. In fact, they are one of the

DODR- 6/24/11DODR- 7/2/11DODR- 7/6/11DODR- 7/12/11

.88

.80

.80

.68

0.45-0.65

main components of pus and are to blame for its whitish color

Lymphocytes

Leukocyte (white blood cell) that normally makes up about 25% of the total white blood cell count but can vary widely. Lymphocytes occur in two forms: B cells, which produce antibodies, and T cells, which recognize foreign substances and process them for removal.

DODR- 6/24/11DODR- 7/2/11DODR- 7/6/11DODR- 7/12/11

.12

.20

.20

.32

0.20-0.35

Platelet count

To diagnose a bleeding disorder or a bone marrow disease

DODR- 6/24/11DODR- 7/6/11

275

540

150-400 x 10/L

VII. Diet

Type of diet General description

Indication/Purpose

Date ordered Date started Date changed

Client response

NPO (Nothing per Orem) No food or liquid is allowed to be eaten by the patient

>to reduce gastric secretions related to abdominal pain. >to prevent aspiration during surgery.

DODSDC

Patient felt hungry

>to eliminate nausea and vomiting

DAT (Diet as tolerated) introduction of diet that can be tolerated by the patient and the regular foods that are taken by the patient

>is only given when client can now tolerate any food she desires that is nutritious >if this will not lead to any complications >if the client needs further monitoring for lab test

DODSDC

Patient was able to regain nutrients and strength.

VIII. IVF

IX. Nursing Care Plan

X. SOAPIE

#1 (actual soapie)

S > ө

O > Received patient on bed in supine position conscious and coherent w/ ongoing IVF of D5LRs 1L @ 700 cc level in the right hand infusing well regulated @ 30 – 31 gtts/min. v/s taken as follows B/P- 120/80 RR- 21 PR- 77 Temperature 36.5 >Right leg w/ dry and intact dressing > (-) pale skin > (+) UO > (-) bowel movement > afebrile A > Impaired physical mobility r/t musculoskeletal impairment

P > after 4 of NPI the patient will verbalize understanding of situation and individual treatment/safety measures

I > Established rapport

>v/s taken ad recorded

>due meds given

>determined diagnosis that contributes to immobility

>assessed movement

>Noted behavioral and emotional response

>instructed patient not to eat anything after 12 noon

>seen on rounds by Dr. Aldaba @ 7:30 am w/ orders and carried out

>NPO past 12 noon

>for emergency redebridement

>scene consent

>inform AROD for procedure

>Endorsed

E> After 4 of NPI goal met as evidenced of patient verbalized understanding of situation and individual treatment/safety measures

#2

S > ө

O > received patient o supine position conscious and coherent w/ IVF of D5LRS 1L @ 500 cc

level infusing well on the right hand regulated @ 30-31 gtts/min v/s taken as follow:

B/P- 120/70 RR- 20 PR- 76 Temp. 36.8

A > risk for infection r/t inadequate primary defense manifested by broken skin

P > after 2° of nursing intervention the patient will gain knowledge in infection control as evidenced by discussing the wound care.

I > established rapport

> v/s taken and recorded

> due meds. given

> wound care done @ 9 am

> observed for localized sign of infection

> instructed patient S.O to have proper hygiene when cleaning the wound/suture

> teached proper hygiene

> endorsed

E > goal met as evidenced by patient identified intervention to prevent or reduce risk of

infection

XI. Conclusion and Learning derived

XII. Bibliography

http://wiki.answers.com/Q/Why_diet_as_tolerated_is_given_to_a_patient

http://wiki.answers.com/Q/What_is_NPO

http://www.surgeryencyclopedia.com/Fi-La/Hemoglobin-Test.html

http://www.nlm.nih.gov/medlineplus/ency/article/003646.htm

http://labtestsonline.org/understanding/analytes/wbc/tab/test

http://www.medicalhealthtests.com/blood-tests/neutrophils-blood-test.html

http://labtestsonline.org/understanding/analytes/cbc/tab/test

http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601206.html

http://www.drugs.com/celecoxib.html

http://www.drugs.com/mtm/gentamicin.html