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    Assessment Findings For Segmental Femural Fracture

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    Jansen Arquilita Rivera
    Patient R.D., a 43-year-old married woman, was admitted to the hospital due to severe pain in her left arm and lower extremities after being hit by a falling tree branch during Typhoon Yolanda. She was diagnosed with a closed segmental fracture of the left femur. Skeletal traction and a cast were applied to her left arm and leg in the emergency room. The pain became unbearable after the accident, prompting immediate hospitalization. She has a family history of diabetes, hypertension, and bronchial asthma on her father's side. On examination, she has tenderness and limited range of motion in her left arm and lower extremities due to the injuries sustained.

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    Assessment Findings For Segmental Femural Fracture

    Uploaded by

    Jansen Arquilita Rivera
    44 views3 pages
    Patient R.D., a 43-year-old married woman, was admitted to the hospital due to severe pain in her left arm and lower extremities after being hit by a falling tree branch during Typhoon Yolanda. She was diagnosed with a closed segmental fracture of the left femur. Skeletal traction and a cast were applied to her left arm and leg in the emergency room. The pain became unbearable after the accident, prompting immediate hospitalization. She has a family history of diabetes, hypertension, and bronchial asthma on her father's side. On examination, she has tenderness and limited range of motion in her left arm and lower extremities due to the injuries sustained.

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    Assessment Findings for closed segmental femural fracture and Nursing History

    Original Title

    Assessment Findings for segmental femural fracture

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    Patient R.D., a 43-year-old married woman, was admitted to the hospital due to severe pain in her left arm and lower extremities after being hit by a falling tree branch during Typhoon Yolanda. She was diagnosed with a closed segmental fracture of the left femur. Skeletal traction and a cast were applied to her left arm and leg in the emergency room. The pain became unbearable after the accident, prompting immediate hospitalization. She has a family history of diabetes, hypertension, and bronchial asthma on her father's side. On examination, she has tenderness and limited range of motion in her left arm and lower extremities due to the injuries sustained.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as ODT, PDF, TXT or read online from Scribd
    Download as odt, pdf, or txt
    44 views3 pages

    Assessment Findings For Segmental Femural Fracture

    Uploaded by

    Jansen Arquilita Rivera
    Patient R.D., a 43-year-old married woman, was admitted to the hospital due to severe pain in her left arm and lower extremities after being hit by a falling tree branch during Typhoon Yolanda. She was diagnosed with a closed segmental fracture of the left femur. Skeletal traction and a cast were applied to her left arm and leg in the emergency room. The pain became unbearable after the accident, prompting immediate hospitalization. She has a family history of diabetes, hypertension, and bronchial asthma on her father's side. On examination, she has tenderness and limited range of motion in her left arm and lower extremities due to the injuries sustained.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as ODT, PDF, TXT or read online from Scribd
    Download as odt, pdf, or txt
    of 3

    PRESENT HEALTH HISTORY

    A case of Patient R.D., Female, 43 y.o., Married, from Catmon, Cebu, was admitted to Vicente Sotto Memorial Medical Center last o!ember ", #$%3, due to com&lains of se!ere &ain s&ecifically, on t'e left arm and bot' t'e lower e(tremities. Patient was dia)nosed wit' 'a!in) *Fracture +Closed, se)mental, on t'e -eft Femur. and 'as under)one a&&lication of s/eletal traction and cast in t'e left arm in VSMMC0s 1mer)ency Room last o!ember ", #$%3.

    HISTORY OF PATIENTS ILLNESS


    2ours, &rior to admission, &atient was 'it by a branc' of a tree durin) t'e ty&'oon 3olanda. Patient used left arm to co!er 'erself u& from bein) 'it but unfortunately, 'er lower e(tremities were 'it. Pain in t'e areas 'it became unbearable, t'us, &rom&ted immediate 'os&itali4ation.

    FAMILY, PSYCHOSOCIAL, AND PERSONAL HISTORY


    Patient is a female, was born on o!em %4, %565 in Carmen, Cebu. S'e is a Fili&ino citi4en, currently li!in) in Catmon, Cebu. S'e is t'e second c'ild amon) 3 c'ildren. 2er ot'er siblin)s are boys, w'o are also married li/e 'er. S'e was married at t'e a)e of #%, wit' 7 /ids. 3 of w'om are boys, w'ile t'e rest are )irls. Patient is 8 feet 6 inc'es, wei)'s 64 /ilo)rams. Patient Patient is unem&loyed but ma/es a li!in) by sellin) ice candy and c'arcoal9ma/in) wit' 'er 'usband, w'o is unem&loyed li/e 'er. Patient re&orts no si)ns of boredom at 'ome. Patient usually slee&s 697 'ours e!ery ni)'t. Patient family 'ealt' 'istory: Paternal side +;, Diabetes Mellitus, 2y&ertension, and <ronc'ial ast'ma.

    DEVELOPMENTAL HISTORY
    Erik Ericsons Psychosocial S a!"# Pt. R.D. w'o is now 43 years old, is under t'e Generativity vs. Stagnation of 1ri/ 1ric/son0s Psyc'osocial Sta)e. Adults need to create or nurture things that will outlast them, often by having
    children or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world. 'ose w'o are successful

    durin) t'is &'ase will feel t'at t'ey are contributin) to t'e world by bein) acti!e in t'eir 'ome and community. ='ose w'o fail to attain t'is s/ill will feel un&roducti!e and unin!ol!ed in t'e world. <ein) &roud of your accom&lis'ments, watc'in) your c'ildren )row into adults,

    and de!elo&in) a sense of unity wit' your life &artner are im&ortant accom&lis'ments of t'is sta)e.

    Si!$%n& Fr"%&s Psychos"'%al S a!"# Genital Durin) t'e final sta)e of &syc'ose(ual de!elo&ment, t'e indi!idual de!elo&s a stron) se(ual interest in t'e o&&osite se(. ='is sta)e be)ins durin) &uberty but last t'rou)'out t'e rest of a &erson>s life.

    ASSESSMENT
    EYES. Patient does not 'a!e any redness or swellin) in t'e eyes. o e(cessi!ewaterin) or tearin) of t'e eye. Minimal disc'ar)es noted, )reenis' w'ite in color. ='e u&&er lid mar)in is between t'e u&&er mar)in of t'e iris and t'e u&&er mar)in of t'e &u&il. ='e u&&er and lower lids close easily and meet com&letely w'en closed. 1yelas'es are e!enly distributed alon) t'e lid mar)ins. S/in on bot' eyelids is wit'out redness, swellin) or lesions. ='e eyeballs are symmetrically ali)ned in t'e soc/ets wit'out &rotrudin) or sin/in). ='e iris is round, flat and e!enly colored +dar/ brown,. ='e &u&il is centered in t'e iris and are e?ual in si4e. EARS. ='e auricle ali)ns wit' t'e corner of eac' eye. 1arlobes are free. ='e s/in is smoot' wit' no lesions, lum&s are lesions@ sli)'tly oily. Color is consistent wit' facial color. ='e auricles are not tender u&on &al&ation. NOSE.Patient0s nose is consistent wit' facial color@ nasal structure is smoot' and symmetrical@ no &ain and tenderness noted on &al&ation@ wit' no disc'ar)es noted. LIPS. ='e &atient0s li&s are dry@ 'as a com&lete set of teet'. TONGUE. =on)ue is &in/, moist and moderate in si4e. Patient does not smo/e nor drin/ alco'ol.Patient brus'es 'is teet' 3( a day, usually after e!ery meal. GAIT. Client cannot stand on 'eels or toe. Patient 'as been on bed since s'e was admitted. TEMPOROMANDIBULAR JOINT. Aaw mo!ed laterally. Sna&&in) and clic/in) is felt and 'eard. Mout' o&ened and closed smoot'ly. Aaw 'a full RBM wit' no &ain. STERNOCLAVIC(LAR JOINT. ='ere is no !isible bony o!er)rowt', no swellin) or redness@ Coint is nontender. CERVICAL, THORACIC, and LUMBAR SPINE. Cer!ical and lumbar s&ines are conca!e@ t'oracic s&ine is con!e( +w'en obser!ed from be'ind,. ='ere is &ain in t'e lower bac/ of t'e &atient. SHOULDERS, ARMS, and ELBOWS. S'oulders are symmetrically round, no redness, swellin) or deformity noted. Muscles are fully de!elo&ed. Cla!icles and sca&ulae are e!en and symmetric. Pain is &resent in t'e left arm. Painful and limited abduction accom&anied by muscle wea/ness and atro&'y is noted on t'e left arm. WRISTS. Drists are symmetric@ redness and sli)'t swellin) and limited RBM on t'e left wrist noted, increased &ain wit' e(tension of t'e wrist a)ainst resistance noted. HANDS and FINGERS. 2ands and fin)ers are symmetric@ tenderness and sli)'t swellin) noted on left 'and. ='e client 'as full RBM a)ainst resistance e(ce&t on left &art. HIPS. Patient is unable to stand. =enderness and decreased RBM noted.

    KNEES. Ri)'t /nee 'as no swellin) or deformities noted@ nontender and muscles are firm, no &ain or clic/in) sound noted. -eft /nee is wit' cast. AN)LES an& FEET* =oes on bot' feet &ointed u&ward and lie flat. =oes and feet are in ali)nment wit' t'e lower le). S/in is smoot', lesions on ri)'t foot noted.

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