Ncp And Patients Profile - Pre Clinical Duty2006

PATIENT’S PROFILE

Patient x is a 38 years old male and was born on September 30, 1967 in Las Nieves Agusan del Norte and is currently residing their. He stands about 5 foot 6 inches tall and weighing 80 kg. He is married. He is Roman Catholic. He was able to study on high school but was not able to finish and proceed to college. Presently he is working in the Municipality of Las Nieves as a Collector in the Treasurer Department. He had an elder sister, who were the only one able to finished college and is currently working as a Teacher. He is currently living with his wife and five children’s, three of which are females and was currently studying, the eldest was 14 years old and the youngest was 1 year old. After the incident, he has never been admitted to a Hospital before and with no records of any major Medical and Surgical operations. He has not suffered from any other disorders. He eats his meals regularly (three times a day), he is non-smoker and drinks only occasionally. He sleeps about 6 hours and retires to sleep usually at 10 or 11 pm. and wakes at 4 or 5am for an early jogging. Elimination is regular usually in the morning daily. Sexual life is still active. He has a brownish skin complexion with long wavy hairs and brown eyes. Skin shows observable signs of trauma likely bruises to his right lower left arm on the back portion of his palms, left eye on the eyelids, left lower extremities at the knees also on the back portion at the right scapular region and on his head at the back portion (occipitalis). He has limited range of motion particular to his left knee of were the major injuries can be observed. He was lying on bed at supine position. Skin bruises were covered and draped. Considering the four days of continued medication skin shows observable signs of wound healing.

He is cooperative and responded well during the interview. He is calm and coherent upon answering the questions although a little bit depressed. Prior to admission, he had been into a road motorcycle accident, he was still conscious after that but was not able to help himself and were then immediately admitted to Butuan Doctors’ Hospital that was on May 29, 2005, Saturday at 4:30 pm. but before that, he was first carried to Las Nieves Municipal Hospital for the first aid treatments and at the same hour transferred to Butuan Doctors’. The patient had been experiencing a burning sensations of pain at the scale of about 6:10 particular at the lower extremities on the left leg at the knees and as well as back pains as evidenced by skin bruises related to the accident, muscle pains related to the impact, a little dizziness prior to head contusions and some joint pains of which are probably referred pains. Upon admission he was c/o by Dr. Dacudao as his admitting physician, were he was ordered to taking medication for pain and infection control. On that day he was also ordered to be X-rayed peculiar to the affected body part from were it reveals that the bones of his left knee (patella) were crack or that it shows a slight fracture which needs to be supported “I pa semento” and bruises to be sutured to avoid complications.

NURSING CARE PLAN: Impaired Walking Nursing Diagnosis: controlled knee flexion at the left lower extremities of the leg due a crack patellar bone and intense pain upon movement as evidenced by an open wound. Goals Outcomes Nursing Interventions Implementations Evaluations •

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After a month of continued therapy the patient will be able to walk normal and regain his optimum level of functioning. Be able to coop with his condition physically and psychologically as well. Within 2 months the patient will fully recover.

1. Within an hour or less after admission the patient can express a feeling of relief and satisfaction with no alterations in comfort. 2. The patient will be knowledgeable on his actual and potential health problems prior to his condition. 3. Will be confined for bed rest with continued medications at about a week or more with controlled body

1. The patient will be provided different methods and teachings on pain control measures. So that he will be knowledgeable upon the proper pain management technique. 2. He will be X-rayed STAT or after Hospital admission and be instructed to lie on bed at supine position with limited ROM on the affected body part. To examine for possible minor or major bone fractures or dislocations. 3. Will be assessed for wound care and change of bondages OD and will be medicated as physicians order. To avoid infections and hasten the would healing.

movement particular on the affected part from which will be braced or supported until observable signs of wound healing and no pain upon movement are noted.

4. Vital signs will be monitored every Nursing rotations. To always have a data update for possible complications or infections.

4. Will be provided different teachings and methods of cooping with his impaired functioning and within 2 months the patient will be fully recovered and function normally.

6. Discuss the importance of adequate food intake (eating foods that are rich in proteins, carbohydrates, calories). It would be necessary for him towards faster wound healing and recovery

5. He will be demonstrated on the proper body mechanics regarding on his ROM and will be teached on how to walk with or without support/scratches or assistance. To promote o maintain self-esteem.