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60313733 case-study-format
1. 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
2. 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
3. VI. Diagnostic and Laboratory Procedure
VII. Diet
VIII. IVF
IX. Nursing Care Plan
X. SOAPIE
XI. Discharge
XII. Conclusion and Learning derived
XIII. Bibliography
4. 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.
5. 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
7. 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;
8. 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
9. 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
10. 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
11. 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.
12. 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,
13. 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
14. 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
DO
DR- 6/24/11
DO
DR- 7/2/11
DO
DR- 7/6/11
164
77
92
M- 125-175
g/l
F- 115-155
g/l
15. can be used to
help physician's
diagnose and
monitor anemia
(a low
hemoglobin
level) and
polycythemia
vera (a high
hemoglobin
level).
DO
DR- 7/7/11
DO
DR- 7/12/11
104
115
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 red
blood cells and
the size of red
blood cells.
DO
DR- 6/24/11
DO
DR- 7/2/11
DO
DR- 7/6/11
DO
DR- 7/7/11
DO
DR- 7/12/11
.49
.23
.25
.28
.34
M-0.40- 0.52
F- 0.38- 0.48
16. 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
monitor bone
marrow function
.
DO
DR- 6/24/11
DO
DR- 7/2/11
DO
DR- 7/6/11
DO
DR- 7/12/11
19.1
10.6
10.0
7.1
5-10 x 10/
L
Neutrophils A neutrophils
test helps us
detect the levels
of neutrophils in
our body. These
neutrophils are
an integral part
of our immune
DO
DR- 6/24/11
DO
DR- 7/2/11
DO
.88
.80
.80
0.45-0.65
17. 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 main
components of
pus and are to
blame for its
whitish color
DR- 7/6/11
DO
DR- 7/12/11
.68
Lymphocyte
s
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
DO
DR- 6/24/11
DO
DR- 7/2/11
DO
DR- 7/6/11
DO
DR- 7/12/11
.12
.20
.20
.32
0.20-0.35
18. T cells, which
recognize
foreign
substances and
process them for
removal.
Platelet
count
To diagnose
a bleeding
disorder or
a bone marrow
disease
DO
DR- 6/24/11
DO
DR- 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 >to reduce gastric DO Patient felt
19. Orem) No food
or liquid is
allowed to be
eaten by the
patient
secretions related
to abdominal pain.
>to prevent
aspiration during
surgery.
>to eliminate
nausea and
vomiting
DS
DC
hungry
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
DO
DS
DC
Patient was
able to regain
nutrients and
strength.
20. 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
21. 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
22. 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
23. > 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
