I.

INTRODUCTION

A. Background of the Study

In recent wars, most penetrating musculoskeletal injuries were not
caused by bullets but by exploding ordinance such as bombs, artillery shells,
mortar rounds, grenades, or landmines (Kimmerle & Baraybar, 2008).

Every day, people die or lose limbs from stepping on a landmine.

Mostly in countries at peace - and the majority of victims are civilians
(“Landmines – United Nations Office for Disarmament Affairs”,2016). Since
mines are not aimed at a specific target they can indiscriminately kill or injure
civilians, including children, soldiers, peacekeepers, and aid workers. As of
October 2014, 56 states and four other areas were confirmed to be mine-
affected. There is no credible estimate of the total number of mines in the
ground worldwide, however the impact of mines can be measure in several
ways, including totaling the amount of land that is unusable due to
contamination or gathering data about the number of people killed or injured
by mines (“Landmines | The Issues | Monitor”, 2016).

The Philippines denies the existence of any mined areas, but has
reported and continues to face use of landmines and improvised explosive
devices (IEDs) in continuing low-level insurgencies by at least three (3) rebel
groups: New People’s Army (NPA), Moro Islamic Liberation Front (MILF), and
Abu Sayyaf Group (“Landmine and Cluster Munition Monitor”, 2016).

According to Convey, cited by Kimmerle & Baraybar, 2008, blast

injuries are the most prevalent wounds in modern warfare and that secondary
blast injuries resulting from shrapnel compromise the majority of the cases.
Injuries of musculoskeletal system are the most common type of wounds seen
in modern warfare accounting 60 to 70% of all wounds.

In the Armed Forces of the Philippines Medical Center, from 2011 to

2013 there were 22 soldiers wounded with blast injuries admitted in Heroes

1
Ward while in September 2014 up to the present, there were 16 soldiers
included in the admission list with the same nature of injuries.
The New People”s Army (NPA) denies using landmine, but
acknowledge that it continues to use command-detonated IEDs in attacks on
government security forces, asserting that the these are the legitimate
weapon of war (Landmine and Cluster Munition Monitor”,2016). Most
explosive devices are used to target the military and are planted in regions
where there is on-going armed conflict. For this reason, the author, as a
military nurse, believes that he should equip with the outmost knowledge and
skills in caring of clients, both comrades and enemies, incurred with this so
called blast injuries hence this study was made.

B. Objectives of the Study

2
General Objective:
This case study aims to present a comprehensive study about Fracture
Open III comminuted Distal third Femur Left, Fracture Open III Comminuted
Middle Third Tibia Left, Avulsed Wound Anterior Forearm Left to enhance
knowledge, apply skills, and practice the right attitude in rendering quality
nursing care for patient acquiring fracture due to blast injury.

Specific Objectives:
This study specifically aims to achieve the following:
a. Obtain a comprehensive nursing history, past medical history, and
physical assessment presented at the time of hospitalization.

b. To discuss the anatomy and physiology of skeletal system, the

mechanism of blast injury and its schematic diagram.

c. Discuss the course in the ward and importance of medical, surgical

and nursing management including the laboratories, diagnostic
procedures, and pharmacologic interventions.

d. Prioritize the list of nursing problems identified and formulate a

comprehensive nursing care plan.

e. Formulate discharge plan to facilitate continuity of care at home,

enhance client cooperation with the involvement of significant others
to achieve optimum level of wellness.

C. Significance of the Study

This study is significant to the following:

3
Patient - this study will enhance further understanding thus facilitate
cooperation and compliance to treatment regimen.

Family – this study will provide information regarding the effects of blast and
the management of injuries for them to become more cooperative with
treatment and participate in the provision of care.

Nurses – this study will enhance the knowledge of nurses handling patients
injured by blast incident.

Nursing Research – this study will serve as a reference for future studies
about the management of blast-injured patient.

D. Scope and Limitation

4
 The study was conducted from the time of admission 17 March 2016
up to 05 May 2016 at 3 Alpha (Heroes Ward) of Armed Forces of the
Philippines Medical Center, Victoriano Luna General Hospital. Pertinent data
were obtained during his 40th day of confinement in actual nurse patient
interaction, chart reviews and interviews from the relatives and from all
medical personnel who were actively involved in the care and management of
the patient. The study does not cover on his transfer to Post Anesthesia Care
Unit for his pre and post-operative management.Procedures and laboratories
done outside AFPMC are not included. Furthermore, facts and information
regarding the case were taken from books and articles from the internet to
strengthen the study. The author was able to identify five (5) nursing problems
during the length of the study in which nursing care was formulated to the 3
prioritized problems (2 actual and 1 potential).

NURSING HISTORY

5
 A. Patient Profile:
Name: MH
Age: 26 years old
Gender: Male
Rank: PFC (Private First Class)
Civil Status: Single
Religion: Roman Catholic
Home Address: Tairan, Lantawan, Basilan
Date/Time Admitted: 17 2145H March 16
Chief Complaint: Pain, Leg and Thigh Left
Admitting Diagnosis: Fracture open III comminuted Distal
Third Femur Left, Fracture Open III Comminuted Middle Third
Tibia Left, Avulsed wound Anterior Forearm Left Secondary to
Blast Injury; Status Post Debridement Thigh and Leg Left and
Forearm Left with Application of Knee spanning External Fixator
Left.

B. Socio-demographic Characteristics
HM was born in Brgy.Tairan,Lantawan,Basilan.HM finished his
Elementary Education in Lantawan Elementary School and Secondary
Education in Latawan Annex High School in Basilan. He belongs in a
nuclear family. He is the eldest among the six (6) siblings, and fluent in
Bisaya, Chavacano,Tausog,Tagalog and can comprehend English words.
He lives with his parents together with his siblings on their own
bungalow-type house in rural area. He considered their family’s social
class under working class. Mainly, their source of income were coming
from HM’s salary. As a breadwinner of their family, his Php 16,000
estimated monthly income was divided into his family’s daily expenses.
HM decided to enter the Armed Forces of the Philippines, Marine
Corps in the year 2012 and already in three (3) years and eight (8) months
of total length in service.

C. History of Present Illness

Six (6) days prior to admission HM and his troops was involved in battle
encounter with Bangsamoro Islamic Freedom Fighter (BIFF) when he stepped

6
on a landmine. He incurred blast injury on his left forearm, thigh, leg and foot
left. He noted pain and bleeding on affected area. Patient wounds were also
said to be submerged in mud.He was immediately brought to Camp Siongco
Station Hospital where he received unrecalled medicines and underwent
removal of Retained Metallic Foreign Body (RMFB), cleaning and dressing of
wound, and application of long leg posterior mold cast on his left lower
extremity.
Three (3) days prior to admission HM was operated for debridement with
application of knee spanning external fixator thigh and leg left was done in
Camp Siongco Station Hospital. He was subsequently evacuated to V.Luna
General Hospital for further evaluation and management.

D. Past Medical History

HM verbalized that he is being fully immunized when he was one (1) year
of age. He mentioned that he suffered chickenpox in the year 1998 and
mumps in the year 1999. No medical history of disease such as Tuberculosis,
Cancer, Diabetes Mellitus, Asthma, Hypertension. HM is known to be allergic
to chicken. He did not undergo any surgical operation. The client had only
minor cough, colds and fever before and have never been brought to a
hospital due to any serious cases. He used to self-medicate by taking
Paracetamol, Mefenamic Acid and BioFlu whenever he’s sick.

7
 E. Genogram

PATERNAL MATERNAL

Legend: Male Female Patient Deceased

Hypertension Motor-Vehicular Accident

Source: Retrieved from https://en.wikipedia.org/wiki/Genogram

http://www.smartdraw.com/genogram

8
F. Nursing History (Gordon’s Eleven Functional Health Pattern)

HEALTH PERCEPTION/ HEALTH MANAGEMENT PATTERN

HM said that he understands health as physically fit and that is capable
of doing all assigned task both mentally and physically. He said that being
healthy is when a person has not been to a hospital and was not diagnosed to
have any diseases. Illness in his own understanding means an unhealthy
condition of mind and body. Whereas being sick is a result of lack of control to
the body’s wants and needs. Hospitalized person is the one seeking for
medical/ surgical treatment and management.

HM knows that being physically fit and healthy is important as military

personnel to function excellently on his duty. He practiced to maintain his
wellness through exercises every day. But now, since he was admitted, his
level of wellness decreases as he cannot perform all his activities of daily
living freely as compared to how he does them before his injury. HM still
positively thinking that after his hospitalization he can regain his strength and
make his condition back to normal.

NUTRITIONAL METABOLIC PATTERN

HM told that he is not known to be picky when it comes to food. Their
usual meal consists of one (1) viand of vegetable or fish, rice and fruits this is
for him to maintain healthy. He seldom eats junk food and rarely drinks coffee
and soda. He is allergic to chicken. He then drinks a lot of water, an estimated
eight (8) to ten (10) or (2) Liters to three (3) Liters a day to maintain well
hydrated as he done lots of physical activities. Client does not take any
vitamin supplements. As he hospitalized the client was noted to have less
intake of food than usual.

9
ELIMINATION PATTERN
HM verbalized that he defecates without any restrain, once or twice a
day and it is regularly every morning. He describes his feces as formed,
yellowish to brownish in color, not too smelly depending on what food he eats.
He voids without difficulty of estimated six (6) to eight (8) times per day and
he described his urine as yellowish in color. Presently he observed that his
bowel elimination changed from daily to every other day. There are no
changes in his urination

ACTIVITY/ EXERCISE PATTERN

HM said that he has an active life style. Every day if he is not on duty
he was able to perform sit ups and push-ups with ease and he run for
approximately 5 kilometers with a time of 25 minutes. He also plays basketball
in his spare time. As he acquired his injury, the client cannot perform the
above mentioned exercises. He now used to watch television and play games
in his cellphone.

SLEEP/ REST PATTERN

HM stated that he usually sleeps for about five (5) – six (6) hours when
he was staying in the barracks. But when he is at home, he rested and sleep
for about eight (8) hours. As he stays in the hospital, he sleeps at 2200H and
woke up at 0500H and take a nap at 1400H to 1600H, it is almost nine (9)
hours per day.

COGNITIVE-PERCEPTUAL PATTERN
HM is alert, conscious, and oriented to time and place. He stated that
he seldom read books especially if they are about military combat tactics. He
speaks Chavacano and Bisaya fluently. He can comprehend instructions
given to him and can communicate properly.

SELF PERCEPTION/ SELF CONCEPT PATTERN

HM perceives himself as an approachable person, kind, God centered,
strong willed and dedicated. He sees himself to be in the service for twenty

10
(20) years and more, and after retiring, he will engage in business together
with his family.

ROLE RELATIONSHIP PATTERN

HM verbalized that he maintains a good relationship and relates well to
his family and friends. He lives in a simple life with his family. According to the
client, he and his family maintain a constant communication with each other
no matter the distance is.

SEXUALITY- REPRODUCTIVE PATTERN

HM stated that he is comfortable with his sexuality and has no problem
with his gender preference. He verbalized that he is sexually active and
satisfied with his girlfriend until the time he was admitted.
COPING STRESS TOLERANCE PATTERN
According to HM he has a high tolerance in stress. He sees stress as a
factor to keep him going in life. Stress and problems make him stronger. He
always prays for strength especially when a problem arises. Before telling
other people about his problems, he would first keep it to himself and try to fix
it alone.

VALUE- BELIEF PATTERN

HM told that he is a Roman Catholic and believes that God is always
there for him especially when he is in an operation or battle. He accepts that
whatever happens to him, it’s all in God’s plan. He went to church every
Sunday as per situation permits, but now that he hospitalized he seldom went
to church.

11
A. Physical Assessment
17 March 2016
Vital signs were as follows:

Temperature: 36.5⁰ C

Respiratory: 19 cpm

Pulse Rate: 75 bpm

Blood Pressure:110/70mmHg

Height: 5’5” ft. 5’1

Weight: 59 kgs 53

General Survey:

 Awake, calm, cooperative and coherent

 Oriented to date, place and time

 Not in cardio-pulmonary distress

 Medium build

 With proper dressing and grooming

Head:

 Normocephalic

 Symmetrical facial contour

 Palpable temporal pulse

 No evidence of abnormal mass

 No protrusions, (-) edema

Hair:

 Short, thick, silky, black in color and evenly distributed

 No presence of dandruff and infestations.

12
 Eyes and Vision:

 Eyebrows hair is evenly distributed.

 Symmetrical

 Pupils Equal Round Reactive to Light and Accommodation

 Cornea is transparent, smooth and shiny

 Anicteric sclera and pink palpebral conjunctiva.

 Able to see from the periphery

 Able to read the newsprint held at a distance of 14 inches.

Nose:

 Nasal septum midline

 symmetrical and patent

 No discharge, lesion and bleeding

 No tenderness.

 Able to breathe thru his nose.

Ears:

 Auricle is parallel and symmetrical, has the same color with his facial
skin.

 Aligned with the outer canthus of the eye and no aural drainage.

 When palpating for the texture, the auricles are mobile, firm and no
tenderness.

Mouth:

 Lips are uniform in color, moist, symmetric and smooth texture.

 No lesions, well defined margin, open and close symmetrically.

13
  Pink, moist buccal mucosa

 No mouth sore noted.

 Tongue is centrally positioned, pink in color, moist and slightly rough.

 Uvula positioned in the midline of the soft palate.

Neck:

 No wounds, mass, or nodules

 Palpable jugular pulse

 Can perform range of motion with ease

Throat:

 No dysphagia

 No signs of inflammation of tonsils and pharynx

Skin:

 Good skin turgor, uniform in color

 Unblemished and no presence of any foul odor

Left forearm

 With 2 x 1cm avulsed wound on anteromedial aspect middle third

- distal third of forearm

 With 11 x 2cm avulsed wound on posterior aspect of middle third

of forearm

 (+) Purulent discharge

 (+) Swelling

Left thigh

 With 6cm avulsed wound on the lateral aspect of left upper thigh

14
  With 12cm avulsed wound on lateral aspect of left distal thigh

 With intact external fixator on lateral aspect of thigh

Left leg

 With 3 x 4cm avulsed wound on the anterolateral aspect of middle

third leg with approximately 1-2cm

 With intact external fixator, anterior aspect of leg

Chest and Lungs:

 Symmetrical chest expansion, no retractions.

 Breath sounds are clear, no rales, crackles and wheezes

Heart:

 No visible pulsations

 Normal rate

 Regular rhythm and no murmur

Abdomen:

 Flat, soft, non-tender and normoactive bowel sounds

 No masses and enlargement of organ noted

 With good peristaltic movement heard and no pulsation

Extremities:

 Full equal pulses on both upper and lower extremity.

 Muscle weakness noted on left leg.

 Muscle strength assessment of 5/5 at both upper extremities and right

leg, 1/5 at left leg.

15
III.CLINICAL DISCUSSION

A. Anatomy and Physiology

THE LOWER LIMB

Each lower limb has 30 bones in four locations: the femur in the thigh;

the patella or knee cap; the tibia and fibula in the leg; the tarsus and

metatarsus; and the phalanges in the foot. The basic function of lower limb is

to support the body weight and is used for locomotion.

Source: www.lookfordiagnosis.com

16
FEMUR
The femur (thigh bone) is the largest bone of the body. It is a long bone

between the hip and the knee. The head of the femur articulates with the

acetabulum of the hip bone. The neck- shaft angle averages approximately

127 degrees, although it begins 141 degrees in the fetus. The greater and the

lesser trochanters are protuberances on which the gluteus and psoas major

muscles respectively are inserted. The lateral and medial condyles articulate

with the tibia and the concave grooved patellar surface accommodates the

kneecap (patella).

PATELLA

Patella is the lens-shaped bone that forms the kneecap. It is situated in

front of the knee joint in the tendon of quadriceps muscle of the thigh.It

connects the femur of the upper leg and tibia-fibula of lower leg.

TIBIA

The tibia (shin bone) is the larger, stronger and more medially and

superficially located of two leg bones. The proximal end of tibia consists of

two fairly flat-topped prominences (Condyles) that articulate with the condles

of femur to form the knee joint. The shaft of the tibia is approximately

triangular in cross section and tapers to its thinnest point at the junction of

middle and distal thirds before widening again to form the tibial plafond. At the

lower end of tibia there is a medial extension (the medial malleolus), which

forms part of the ankle joint and articulates with the talus below; there is also

a fibular notch, which meets the lower end of the shaft of the fibula.

17
FIBULA

Fibula is the long thin outer bone of the lower leg. The head of the

fibula articulates with the tibia just below the knee; the lower ends projects

laterally as the lateral malleolus, which articulates with one side of the talus.

TARSUS

Tarsus is the seven bones of the ankle and the proximal part of the

foot. The tarsus articulates with the metatarsals distally and with the tibia and

fibula proximally.

METATARSUS AND PHALANGES

Metatarsus is the five bones of the foot that connect the ankle to the

phalanges. Phalanges are the bones of the toes.

BONE OSSIFICATION

Bone ossification, also called formation, is a process by which new

bone is produced. Ossification is the formation of bone by osteoblasts. After
an osteoblast becomes completely surrounded by bone matrix, it becomes a
mature bone cell, or osteocyte. Bones develop in the fetus by two processes,
each involving the formation of bone matrix on preexisting connective tissue.

Bone formation that occurs within connective tissue membranes is

intramembranous ossification, and bone formation that occurs inside
cartilage is endochondral ossification. Both types of bone formation result in
compact and cancellous bone

TYPES OF BONE CELLS

Bone tissue is formed by osteoblasts, maintained by osteocytes and

broken down by osteoclasts. Osteoblasts are bone forming cells, they secrete
the organic component of the bone matrix. They are found on all bone

18
surfaces and are enlarged and active at all sites of bone growth and repair. As
osteoblasts secrete bone matrix they surround and isolate themselves,
eventually developing into osteocytes. Osteocytes are found within the bone
matrix and they function to maintain the surrounding bone tissue, dealing with
the metabolic requirements, waste products, mineral homeostasis etc.

They are mature, quiescent (resting) bone cells trapped within the bone
matrix. They sit in a compartment called a 'lacuna' and communicate with
neighboring osteocytes through fine processes (links) which run through tubes
known as 'cannuliculi'. Compared with osteoblasts from which they are
derived, osteoclasts are smaller, have a reduced cytoplasm and a less well
developed RER (rough endoplasmic reticulum). Osteoclasts are derived from
a type of bone marrow cell. They are multi nucleate cells which vary greatly in
size. They are involved in the mobilization of calcium and the destruction of
the bone matrix. Osteoclasts are found on bone surfaces and are important in
the normal growth, maintenance and repair of bone.

19
B.MECHANISM OF INJURY

Source: www.ahcmedia.com

Landmine is a munition designed to be placed under, or near the

ground or other surface area and to be exploded by the presence, proximity or
contact of a person or a vehicle (IMAS 2003). Landmines are easy to make,
cheap and effective weapon that can be deployed easily over large areas to
prevent enemy movements. Mines are typically placed in the ground by hand,
but there are also mechanical minelayers that can plow the earth and drop
and bury mines at specific intervals.

Mines can be either design as “anti-personnel” or “anti-tank”. Anti-

personnel (AP) mines are designed to be activated by people, they are small,
flat and cylindrical, typically 60-140 mm in diameter. They rely on the effect of
explosive blast to damage the victim, and are designed to detonate when the
victim steps on them. They are often buried in order to camouflage their
presence blast mines are deliberately designed to be small: this makes them
cheaper and easier to store, carry and deploy. Anti- tanks (AT)mines are much
larger and filled with more explosive, hence making it able to defeat tanks.
Usually AT mines are also designed to have a minimum operating pressure so
that people do not set them off. The usual aim of AT mines is to achieve a
“mobility kill” by blowing the track off a tank, immobilizing it thus making it

20
easier target, though there are some AT mines that are also designed to
detonate under the belly of the tank.

Most anti-tank and many anti-personnel mines deploy this method of

activation. It can also be activated by tripwire in which mine has a wire or
filament attached to a pull switch on the mine that causes the mine to
detonate when a predetermined load is placed on the tripwire. The other end
of the tripwire extends to fixed object, often on metal stake driven the ground
or, in some cases, another mine. Another rare type of activation where the
mine is detonated when a preapplied source of pressure is removed from the
mine. Most commonly used as an anti-lift device when placed under an anti-
tank mine or as a boobytrap. Proximity is also use to equipped with the fuse
which detonates the mine when a victim or target passes within a
predetermined distance of mine. And remote firing, designed to dispense
fragmentation over a set field of effect-known as directional or ambush mines,
can be activated by a pull wire or a similar device or may employ radio signal
or other remote firing method. The mine is fired from the observation point.

During the explosion, gases heat up and expand rapidly outward under
pressure. Blast wave or shock wave was created by this explosion. The
waves travel outward at about 1,600 feet per second over hundreds of yards
or more upon the amount of explosive. The explosion fragments the container
that propels shrapnel at high speed outward. The explosion produces heat
that causes fire. The blast wave leaves a partial vacuum, which causes air to
rush back under high pressure.

21
Blast Injury

Blast injury is a complex type of physical trauma resulting from direct or

indirect exposure to an explosion. There are four categories of blast injury:
Primary; Secondary; Tertiary and Quarternary or Miscellaneous Injuries. The
direct effect of blast or shock waves on tissue will result to primary blast injury.

Air filled structure such as lungs and ears are almost always affected by
this kind of injury. As the pressure or duration increases, the severity of injury
will also increase. The absence of external injuries characterizes the primary
injury.

The secondary injuries are caused by shrapnel and other objects expelled
by explosion. It resulted in penetrating trauma with visible bleeding on any
part of the body.

A blast with that throws victims against solid object is categorized under
tertiary injury. It is a feature of high explosions and causes some kind of blunt
and penetrating trauma including bone fracture.

Quartenary or miscellaneous injuries encompassed all other injuries cause

by explosion such as burns, crush injuries and toxic inhalations.

Blast injury either one or a combination of its types result in the destruction
of soft tissue and blood vessel as well as fracture, especially on long bones
that are usually open and comminuted due to its capacity to absorb shock
wave. Any break in the continuity of bone is considered a fracture. Fracture
happen when bone cannot withstand the force applied to it. Depending on the
type and amount of explosive used, some explosives can produce a lethal
blast-induced overpressure of 100 (pounds per square inch) travels a velocity
approximately 1500 mph comparing to the hurricane-force wind
(approximately 200 km/h) exerts only 0.25 PSI overpressure.

In an Open fracture, which is characterized by bleeding, swelling, pain and

inability to bear weight, death may occur as a result of hypovolemic shock if
bleeding is uncontrolled. Complications from fracture include Early

22
Complications which are usually life threatening and the Late Complications.
Although bone has ability to heal itself with or without intervention,
unmanaged fracture increases the risk of having complications that need an
immediate medical attention such as in case of tetanus, gas gangrene, soft
tissue complication, compartment syndrome, and sepsis as these will lead to
amputation or worst-death. In addition, mal-union, non-union and delayed
union are examples of late complications of fracture.

BONE HEALING

Stages of bone healing

1. Hematoma formation: Blood vessels in the broken bone tear hematoma,

resulting in the formation of clotted blood, hemorrhage at the site of the
break. The severed blood vessels at the broken ends of the bone are
sealed by the clotting process. Bone cells deprived of nutrients and begin
to die
2. Fibrocartilaginous formation: Within days of the fracture, capillaries grow
into the hematoma, while phagocytic cells begin to clear away the dead
cells. Though fragments of the blood clot may remain, fibroblasts and
osteoblasts enter the area and begin to reform bone. Fibroblasts produce
collagen fibers that connect the broken bone ends, while osteoblasts start
to form spongy bone. The repair tissue between the broken bone ends, the
fibrocartilaginous callus, is composed of both hyaline and fibrocartilage.
Note that the fibrocartilaginous callus serves to splint the fracture.
3. Bony callous formation: The fibrocartilaginous callus is converted into a
bony callus of spongy bone. It takes about two months for the broken bone
ends to be firmly joined together after the fracture.
4. Bone remodeling: The bony callus is then remodeled by osteoclasts and
osteoblasts, with excess material on the exterior of the bone. Compact
bone is added to create bone tissue that is similar to the original, unbroken
bone. This remodeling can take many months; the bone may remain
uneven for years. Remodeling is the final stage.

23
 Source: www.freelearingchannel.com
To attain good prognosis, medical, surgical, collaborative and nursing
management must be considered to prevent complications.

A. Schematic Diagram

24
 Landmine
(Anti-Personnel AP mine)

BLAST EXPLOSION

Destruction of soft tissue and blood vessels

Confirmatory Diagnostic
FRACTURE on the Long Bone
X-ray of LLE
S/S:
 Bleeding
 Swelling
 Pain
 Unable to bear weight
 Loss of function
Management

With Management

Complicati Medical Surgical Collabor

ons: Mgmt: Mgmt: ative
 Tetan  Admi  Loc Mgmt:
us/Se nistr al  Ref
ation
psis of
Wo erra
 Gas anti- und l to:
Gangr tetan dre >
ene us ssin Infe
 Soft vacci g ctio
ne
tissue and
 Deb us
compli tetan ride ser
cation us me vice
 Throm toxio nt for
boem d  App anti
 Anti
bolitic licat bioti
bioti
compli cs ion c
cation thera of cov
 Mal- py exte era
union  Hydr rnal ge
of ation fixat >
(Intr

25
 bone avenous or and Psychiatric
 Non-union of Fluid) immobilizati dept. for
 Diagnostics
bone monitoring:
on counseling
 Compartment -Hematology/ESR  Wound care > PMRS and
Syndrome -Radiologic Exam OT Service
-Wound GS/CS/KOH

Prognosis

GOOD
Tissue and Bone
healing

26
Course in the Ward

17 March 2016 (Admission)

HM was admitted at Heroes Ward per stretcher accompanied by ER ward

man, with chief complaint of moderate acute pain at thigh and left leg and with
diagnosis of Fracture Open III Comminuted Distal Third Femur Left, Fracture
Open III Comminuted Middle Third Tibia Left, Avulsed wound, Middle Aspect
Leg Left, Avulsed Wound Anterior Forearm Left secondary to Blast Injury; S/P
Debridement, Thigh and Leg Left and Forearm Left with Application of Knee
Spanning External Fixator. He was calm, coherent and noted with heplock on
his right hand, wound dressing on left forearm, left thigh and leg and external
fixator on his left lower extremity.HM’s vital signs were taken and initial
assessment were done including the degree of mobility as well as the onset,
location and severity of pain. Ordered routine diagnostics such as CXR-PA, X-
ray of Forearm APL Left, Hand APO Left, Pelvis AP, Thigh APL Left, Knee APL
Left, Leg APL Left, Wound GS/CS Thigh Left were taken at Emergency Room
as endorsed by ER NOD while CBC w/ QPC, CT, BT, PT, PTT, Blood Typing,
Serum Sodium, Potassium, Creatinine, HbsAg, ESR, CRP,12 lead ECG and
Urinalysis were taken at ward and these serve as his baseline data.

Medications such as Clindamycin 300mg TIV every 6 hours, Cefuroxime

750mg TIV every 8 hours was ordered and given after with negative skin test
result also Metronidazole 500mg/vial every 6 hours was continued as

27
previously started antibiotic from Camp Siongco station hospital. Naproxen
550mg/tablet 1 tablet twice a day, as needed for pain taken with meals was
also ordered. HM requested a no pork no chicken diet thus he was instructed
to eat foods high in protein such as fish and beans as substitute to pork and
chicken. Safety measures were also ensured by raising side rails.

18 March 16 (1st day of hospitalization)

HM was instructed that his Clindamycin IV antibiotic was shifted to

Gentamycin 80mg /amp through intravenous every 12hours as ordered. HM
was for Emergency Debridement Thigh, Leg Left with revision of external
fixator, Femur, left under Sub-Arachnoid Anesthesia thus he was instructed on
nothing per orem and operative site was shave. Three Units Fresh Whole
Blood properly typed and cross matched was requested. Signed consent for
the said procedure including materials for OR use were secured. Pre-
operative teaching such as deep breathing exercises was done and pre-
operative checklist was completed before he was accompanied by staff and
transferred to PACU at 0950H with proper endorsement.

19 March 16 (2nd day of hospitalization)

HM is received on bed awake, coherent and not in distress with ongoing

IVF of D5LR 1L infusing well and regulated at 30gtts/min. With epidural
catheter in placed. HM is maintained on indwelling Foley catheter. HM was
assessed and monitored vital signs, intake and output, post-operative pain,
degree of mobility, as well as his wound dressing. He is on diet as tolerated,
no pork and chicken diet. Left leg is elevated and maintained on immobilizer.
Results of post blood transfusion hemoglobin and hematocrit is received and
referred to resident on duty.

20 March 16 (3rd day of hospitalization)

HM received on bed with on-going intravenous fluid of D5LRS 1L at 30

gtts/min. With epidural catheter in placed and patent indwelling Foley catheter
draining into amber colored urine. Anesthesia resident on duty came in, made

28
orders and carried out. Ketorolac 30mg TIV every 6 hours for 48hrs then shift
to celecoxib 200mg/cap two times a day for 2 doses as needed for pain was
ordered. HM was referred to Psychology Department for Psychiatric
Evaluation as ordered.

21 March 16 (4th day of hospitalization)

HM was noted with fever accompanied with chills. He was placed on

bed with droplight and temperature was measured and read as of 38.5 degree
Celsius.After the chills, he was provided with tepid sponge bath. He was also
referred to ROD and Paracetamol 300mg/amp 1 amp TIV was given. He was
encouraged to increase oral fluid intake.Temperature was monitored until it
dropped to 37.2 degree Celsius. HM was advised not to touch the pin site to
avoid contaminating it. Importance of good hygiene was emphasized to
prevent infection.

22 March 16 (5th day of hospitalization)

Anesthesia resident on duty came in, made orders and carried out.
Tramadol 200mg in 236 cc PNSS regulated at 10 mgtts /min was started as
ordered. Tramadol 200mg/ cap two times a day for 24 hours was given.
Epidural catheter was removed by anesthesiologist.Indwelling Foley catheter
was pulled out after bladder training.

25 March 16 (8th day of hospitalization)

Regular wound dressing was done with aseptic technique strictly

observed. Wound GS/CS and KOH was taken. Advised HM to eat foods rich
in protein and vitamin C to promote wound healing process. Antibiotic
medications was continued.

28 March 16 (11th day of hospitalization)

Wound GS/CS KOH in, with no growth after 48 hours of incubation.

Result relayed to ROD. The doctor ordered repeat x-ray Thigh Left APL; Knee
Left APL; Leg Left APL, and x-ray Left Ankle AP lateral with mortise view left

29
foot. Assisted patient per stretcher to X-ray department for x-ray of knee, leg
and ankle.

Due to large amount of mucopurulent discharge as assessed in the

affected area, HM was scheduled for Emergency Debridement of Leg, left
under subarachnoid anesthesia. 2 Units Fresh Whole Blood for OR use and 2
Units FWB as standby properly typed and cross matched was requested. HM
was instructed nothing per Orem then hooked to D5LRS 1L regulated to
41gtts/min.Omeprazole 40mg IV was given. Signed consent was secured by
resident on duty for the procedure. Completed pre-operative check list and
prepared pre-operative site. Prepared materials needed.

29 March 16 (12th day of hospitalization)

Emergency Debridement was deferred by the ROD. Said deferment

was explained to the patient. Cefuroxime 750 mg TIV every 8 hours and
Gentamycin 80 mg TIV every 12 hours was continued as ordered.HM was
instructed to resume diet.

01 April 16 (15th day of hospitalization)

HM was seen by ROD. He was scheduled for Emergency Debridement

of thigh and leg left under Sub-Arachnoid anesthesia. Consent for the
contemplated procedure was secured by resident on duty.2 units of Fresh
Whole Blood Properly typed & cross matched for OR with 2 units Fresh Whole
Blood on standby was requested.He was instructed on nothing per Orem and
hooked to D5LRS 1 L at 35 – 40 drops per hour via blood set. Omeprazole
40mg TIV was given. Materials needed was prepared.

02 April 16 (16th day of hospitalization)

HM was trans-in to ward from PACU accompanied by ward man via

stretcher with S/P Debridement, Thigh and Leg left. He is awake, coherent
and not in distress. Transfered from stretcher to bed safely with ongoing IVF
of D5LR 1L regulated at 30gtts/min. With side drip of Tramadol 200mg in
236ml of PNSS regulated at 10 mggts/min. Cefuroxime 750 mg TIV every 8

30
hours and Gentamycin 80 mg TIV every 12 hours was given as antibiotic. HM
was instructed to resume diet. Maintained patency of indwelling Foley
catheter. He is positioned comfortably on bed, assessed wound dressing.

03 April 16 (17th day of hospitalization)

Anesthesia ROD came in, made orders and carried out. Tramadol
200mg in 236ml of PNSS regulated at 10 mgtts/min to consumed,then
Tramadol 50mg slow intravenous push every 6hours for 24 hours (diluted in
10 cc PNSS) started. Tramadol 25mg SIV as rescue dose for break through
pain or VAS 4/10 and Ketorolac 30mg TIV every 6 hours for 24 hours then
shift to celecoxib 200mg/tab twice a day for 48hours then PRN for pain was
also ordered.

04 April 16 (18th day of hospitalization)

Regular wound care was done. Wound GS/CS/KOH result came in.
Result as follows: microscopy Negative for fungal element, no found
microorganisms. Culture: NO growth after 48hours of incubation (02 March -
03 April 2016). Relayed to ROD.

05 April 16 (19th day of hospitalization)

With negative result of wound GS/CS/KOH, Gentamycin IV antibiotics

was discontinued as ordered. Requested for repeat CBC, ESR, CRP
(Quantitative). Other medications was continued.

06 April 16 (20th day of hospitalization)

Encouraged patient to do isomeric, active and passive range of motion

exercises. Seen by ROD, made orders and carried out. Heplock pulled out
and Cefuroxime 750 mg TIV shifted to Cefuroxime 500mg tab 1 tab two times
a day.

07 April 16 (21st day of hospitalization)

Pin site dressing was done with aseptic technique strictly observed.
Cefuroxime 500mg tab discontinued. Heplock inserted and started

31
Ciprofloxacin 200mg IV every 12hours for 5 days then shift to Ciprofloxacin
500mg/cap 1 cap two times a day for 10days was ordered.

09 April 16 (23rd day of hospitalization)

Seen by ROD, scheduled for Emergency Debridement thigh and leg left
under Sub-Arachnoid anesthesia. Consent for the contemplate procedure was
secured. Requested 2 units Fresh Whole Blood Properly typed & cross
matched for OR with 2 units Fresh Whole Blood on standby.Instructed HM on
Nothing per Orem and hooked to D5LRS 1 L at 35 – 40 drops per hour via
blood set. Omeprazole 40mg TIV was given. Pre-operative checklist
completed and operative site prepared.

On the same day Emergency debridement was deferred by the ROD.

Said deferment explained to HM.

19 April 16 (33rd day of hospitalization)

HM was seen and examined by Residents on duty, made orders and

carried out. Requested repeat CBC with QPC, results referred to ROD.

29 April 16 (43rd day of hospitalization)

Regular wound care was done with strict aseptic technique.HM was
referred to Dental Service for Dental Prophylaxis.

30 April 16 (44th day of hospitalization)

Prepared and assisted ROD in wound care and wound dressing. For
OR scheduling: “E” Debridement, Leg, Left. Cefuroxime 750 mg every 8 hours
TIV after negative skin test was given.

03 May 16 (47th day of hospitalization)

HM was seen and examined by Residents on duty, made orders and

carried out. Requested repeat X- ray of Thigh APL and Leg APL left was done.
Encouraged to perform range of motion exercises.

32
F. Laboratory and Diagnostic Procedure:

RESULTS
TEST 18 Mar 16 01 April 19 April Normal Values
16
ESR 99 88 25 0 – 15 MM/HR
CRP Positive Positive Negative Negative

 Increased ESR: may indicate an acute or chronic inflammation,

rheumatoid arthritis, or anemia.

 C-reactive protein (CRP) is a protein found in the blood, the levels of

which rise in response to inflammation.

WOUND GS/CS

Test Date Results

Wound GS/CS 25 – 27 Mar 16 Microscopy: Positive cocci in
cluster - few

Culture: No growth after 48

hours of incubation.
Wound GS/CS/KOH 31 – 02 April 16 Microscopy: Negative for fungal
Elements
Culture: No growth after 48
hours of incubation.

33
Wound GS/CS/KOH 04 – 06 April 16 Microscopy: Positive Bacilli
moderate
Negative for fungal Elements

Culture: Moderate growth of

pseudomonas aeruginosa

CULTURE AND SENSITIVITY

04 April 16
Drug Drug Resistant
Sensitivity
Amikacin Ampicilin
Cefepime Ampicilin sulbactam
Ceftazidime Chloramphenicol
Ciprofloxacin Sulfamethoxazole
trimethoprim
Gentamycin Tetracycline
Imipenem
Levofloxacin
Piperacillin
Tazobactam
Ticarcillin
ciavulanic acid
Aztreonam

Significance:

Wound Gram Staining (GS) is a useful diagnostic procedure in

determining the presence of specific microorganism present in the wound

while wound culture and sensitivity (CS) will help determine the specific drug

34
to be given to the patient based on what drug that the microorganism is

sensitive.

35
Complete Blood Count with Quantitative Platelet Count

Hgb Hct RBC WBC Seg Lymph Eosin Mono Baso QPC
0.25- 0.02- 0.03- 0.00-
Normal 130-180 0.40-0.50 4.5-6.2 4.0-10.0 0.55-0.65 130-400
0.35 0.04 0.06 0.01
17 Mar 16 115↓ 0.34↓ 3.85↓ 10.50↑ 0.71↑ 0.16↓ 0.05↑ 0.08↑ 0.00 291
18 Mar 16 117↓ 0.35↓ 3.94↓ 8.64 0.63 0.23↓ 0.07↑ 0.07↑ 0.00 358
28 Mar 16 150 0.46 5.12 9.39 0.58 0.22↓ 0.08↑ 0.11↑ 0.01 355
01 Apr 16 142 0.43 4.86 7.98 0.63 0.16↓ 0.12↑ 0.09↑ 0.00 395
14 Apr 16 108↓ 0.32↓ 3.66↓ 9.12 0.53 0.21↓ 0.19↑ 0.07↑ 0.00 311
19 Apr 16 112↓ 0.34↓ 3.77↓ 8.08 0.49↓ 0.26 0.18↑ 0.07↑ 0.00 317

36
Hemoglobin and Hematocrit post Blood Transfusion

Hgb Hct
Normal 130-180 gms/L 0.40-0.50 gms/L

19 Mar 2016 ↓121.0 gms/L ↓0.36 gms/L

 Low hemoglobin count is due to prolonged blood loss because of

bleeding or hemorrhage as well as due to inability of the body to
acquire more oxygen.
 A low hematocrit means the percentage of red blood cells is below the
lower limits of normal referred to as being anemic of the patient
 An increased level of white blood cells indicates compensatory
mechanism of the body to fight an infection
 High levels of segmenters usually represent an ongoing infection and
inflammation.
 An increased eosinophil means that the body is sending more and
more WBC to fight off infections.
 An increased in monocyte count signify a chronic infection or a chronic
inflammatory condition.
 An increased monocyte indicates that it helps other WBC to remove
dead or damage tissues and regulate immunity against foreign
substances.

ECG FINDINGS

Date Diagnostic Examination Results

18 Mar 16 Electrocardiograph Normal

37
X – RAY

X – ray of Left Thigh dated 17 March 2016

38
X – ray of Left Leg dated 17 March 2016

39
40
Omeprazole 40 mg IV OD once
on NPO
Classification:
Proton pump inhibitor
Converted to active metabolites
that irreversibly bind to inhibit
hydrogen-potassium adenosine,
triphosphase, an enzyme on the
surface of gastric parietal cells.
Inhibits hydrogen ion transport
into gastric lumen.
41
 Diarrhea, abdominal  Observe for 12 rights of
pain, nausea,vomiting, giving medications.
flatulence.  Assessed GI system:
bowel sounds, abdominal
 Headache, dizziness. pain and swelling,
anorexia.
 Checked patency of IV
tubing.
 Administered drug as
ordered.
 Tell patient to report
severe headache,
worsening of symptoms,
fever, chills.
 Watched out for any signs
and symptoms of phlebitis
and infiltration.
 Provided safety (raised
side rails)
 NAME OF DRUG AND ACTION ADVERSE REACTION NURSING RESPONSIBILITIES
CLASSIFICATION

Cefuroxime 750 mg IV every 8 Interferes with bacterial cell wall
hours. synthesis by inhibiting the final
step in the cross linking
peptidoglycan makes the cell
Classification: membrane rigid and protective.
Without it, bacteria cells rupture
Bacteriocidal and die.
 GI disturbances,diarrhea,
nausea, vomiting
 Weakness,
dizziness,ataxia, headache.
 Observe for 12 rights of
giving medications.
 Skin tested to check
sensitivity to the drug.
 Observed for signs of
anaphylaxis after giving the
drug.
 Inspected the IV sites for
patency and inflammation
 Educated patient about the
drug and its side effects.
 Administered drug through
slow IV push.

42
43
 NAME OF DRUG AND
CLASSIFICATION
Gentamycin 80mg IV every
12hrs
Classification:
Bacteriostatic/Bactericidal
ACTION ADVERSE REACTION
Inhibits protein synthesis by  Dizziness, vertigo
binding directly to 30s ribosomal
subunit  Ringing in the ears, hearing
loss
 Numbness, tingling or
muscles twitching.
44
NURSING RESPONSIBILITIES
 Observe for 12 rights of
giving medications.
 Avoid long term therapies
because of increased risk of
toxicity. Reduction in dose
maybe clinically indicated.
 Evaluate client hearing
before and during therapy
begins.
 Monitor renal function.
 Instruct client to promptly
report adverse reaction such
as dizziness, vertigo, ringing
in the ears, hearing loss,
numbness, tingling or
muscle twitching.
 Encourage client to drink
plenty of fluids.
45
 NAME OF DRUG AND
CLASSIFICATION
Celecoxib 200mg/cap 1 cap
twice a day PRN for pain PO
Classification:
Non-steroidal anti inflammatory
ACTION
Thought to inhibits prostaglandin
synthesis produces anti
-inflammatory, analgesic and
antipyretic effects.
46
ADVERSE REACTION NURSING RESPONSIBILITIES
 Dizziness, drowsiness,  Observe for 12 rights of
headache, insomnia, giving medications.
fatigue
 Nausea, diarrhea,  Assessed client’s history of
abdominal pain, dry mouth allergic reaction to drug.
 Instruct the client to take
drug with food to avoid GI
upset.
 Advised client to immediately
report bloody stool and blood
in vomit.
 Watch out for any signs and
symptom of liver damage
(nausea, pruritus, yellowish
of eyes or skin and
tenderness on upper right
side of abdomen
47
 NAME OF DRUG AND
CLASSIFICATION
Paracetamol
300mg/amp 1 amp every 4hrs
for temp more than to 38.0 ⁰C
Classification:
Analgesic/Antipyretic
ACTION
Inhibits analgesic action by
peripheral blockage of pain
impulse generation. It produces
antipyresis by inhibiting the
hypothalamic heat- regulating
center. Its weak anti-
inflammatory activity is related to
inhibition of prostaglandin
synthesis in CNS.
48
ADVERSE REACTION NURSING RESPONSIBILITIES
 Dizziness, headache  Observe for 12 rights of
 Tachycardia, giving medications.
hypotension
 Nausea, vomiting,  Assessed client’s fever or
constipation pain; location, intensity,
 Pruritus, sweating duration and temperature.
 Respiratory depression
 Assessed allergic
reactions: rash, urticaria;
if these occur, drug may
have to be discontinued.
 Inspected the IV sites for
patency and
inflammation.
 Watch out promptly, may
cause liver damage.
49
 NAME OF DRUG AND ACTION ADVERSE REACTION NURSING RESPONSIBILITIES
CLASSIFICATION

Metronizazole 500mg/vial every
6 hours
Classification: Antibiotic
Metronidazole inhibits bacterial
nucleic acid synthesis and
causes cell death.
 Diarrhea, nausea and  Observe 12 rights in drug
vomiting, administration.
 Pruritus, rash,
 Dizziness, ataxia,  Determined history of
vertigo, insomnia hypersensitivity reaction to
Metronidazole.

 Educate the patient about

the drug and its side effect.

 Checked the patency of IV

line.
 Observed patient for signs of
allergic after giving the drug.

50
51
 NAME OF DRUG AND ACTION
CLASSIFICATION
Clindamycin 300mg TIV every 6 Suppresses protein synthesis by
hours microorganism by binding to
ribosomes (50s subunit) and
Classification: Both bacteriostatic preventing peptide bond
and bactericidal. formation.
52
SIDE EFFECTS AND NURSING RESPONSIBILITIES
ADVERSE REACTION
 Nausea, vomiting, or
diarrhea.  Observe for 12 rights of
 severe skin reaction giving medications.
 headache
 Assessed patient’s infection
 anorexia before and regularly throughout
therapy.
 Be alert for adverse reactions
and drug interactions.
 Assessed allergic reactions:
rash, urticaria; if these occur,
drug may have to be
discontinued.
 Inspected the IV sites for
patency and inflammation.
53
 NAME OF DRUG AND
CLASSIFICATION
Tramadol Hcl 50mg TIV every 8  Binds to opioid receptors and
hours for severe pain
Classification: Analgesic
ACTION SIDE EFFECTS AND NURSING RESPONSIBILITIES
ADVERSE REACTION
 Dizziness, headache  Observe for 12 rights of
inhibits the reuptake of drowsiness giving medications.
norepinephrine and  Assessed type, location, and
serotonin; causes any effects  Dry mouth, vomiting, intensity of pain before and
similar to opioids such as nausea, constipation 2-3 hours (peak) after
dizziness, somnolence, administration
nausea, constipation but  Itching, sweating
does not have the respiratory  Assess BP & RR before and
depressant effects. periodically during
administration.
 Assess bowel function
routinely. Prevention of
constipation should be
instituted with increased
intake of fluids
 Monitor patient for seizures.
May occur within
recommended dose range.
54
55
 NAME OF DRUG AND
CLASSIFICATION
Tramadol Hcl 50mg TIV every 8  Binds to opioid receptors and
hours for severe pain
Classification: Analgesic
ACTION SIDE EFFECTS AND NURSING RESPONSIBILITIES
ADVERSE REACTION
 Dizziness, headache  Observe for 12 rights of
inhibits the reuptake of drowsiness giving medications.
norepinephrine and  Assessed type, location, and
serotonin; causes any effects  Dry mouth, vomiting, intensity of pain before and
similar to opioids such as nausea, constipation 2-3 hours (peak) after
dizziness, somnolence, administration
nausea, constipation but  Itching, sweating
does not have the respiratory  Assess BP & RR before and
depressant effects. periodically during
administration.
 Assess bowel function
routinely. Prevention of
constipation should be
instituted with increased
intake of fluids
 Monitor patient for seizures.
May occur within
recommended dose range.
56
57
IV. NURSING MANAGEMENT

A. Problem List

Problem Date Identified Date Resolved

Impaired Skin Integrity 19 1000H March 2016

Impaired Physical Mobility 25 1100H March 2016

Acute pain 04 1000H April 2016 04 1030H April 2016

Anxiety 07 0930H April 2016 07 1230 April 2016

Risk for infection 10 0800H May 2016 10 1500H May 2016

B. Long Term Objective

Upon discharge with the help of significant others, HM will be able to

regain optimal level of wellness, maintain or restore health and perform self-
care activities, will adhere to the discharge plan instructed and will apply the
best way possible to take care of him to prevent development of further
complications.

58
59
25 1100H March 2016
Impaired physical mobility r/t
presence of immobilization
device
Subjective:
“Hindi ako masyado makagalaw
dahil sa bakal na nakakabit”
Objective:
Left leg:
w/ External fixator
Motor function 1/5
Difficulty in turning @ right side
After 4 hours of nursing
interventions the patient will be
able to maintain position of
function as evidenced by
absence of contractures.
60
Assessed degree of mobility After 4 hours of nursing
interventions the goal is fully
Assessed muscle strength met. The patient is able to
maintain position of function as
Monitored for presence of evidenced by absence of
complications related to contractures.
immobility
Positioned comfortably on bed.
Instructed to use overhead
trapeze for position changes
and transfers.
Supported affected body parts
using pillows.
Applied foot board.
Rendered passive-assistive
ROM exercises to maintain
venous stasis, joint mobility
and prevent contractures.
 NURSING DIAGNOSIS NURSING OBJECTIVES NURSING INTERVENTION EVALUATION

04 1000H April 2016 After 30mins HM will be able to  Assessed location, After 30 minutes of nursing
verbalize relief of pain as characteristics, duration intervention goals partially met
Acute pain related to tissue and
bone trauma secondary to evidenced by: and frequency of pain as evidenced by:
Surgical procedure  Monitored and recorded
Pain scale from decreased from “Nabawasan na ang sakit ng
vital signs.
8/10 to 3/10 paa ko”
 Encouraged use of
Subjective:
(-) Guarding behavior Pain scale of 4/10 from 8/10
relaxation techniques
“ang sakit ng sugat sa paa ko” (-) Diaphoresis
(-) Guarding behavior
(-) Facial grimace such as deep breathing
Pain scale: 8/10 (-) Diaphoresis
Vital signs:
exercises. (-) Facial grimace
BP: 120/80 mmHg  Provided quiet and calm Vital signs:
RR:18cpm environment such as BP: 130/80 mmHg
Objective:
limiting visitors RR:20cpm
with Guarding behavior  Maintained affected part
Diaphoresis (right leg) elevated and
with facial grimace immobilize the affected
Vital signs: part to prevent
BP: 140/90 mmHg aggravation of injury and
RR:23cpm pain.
 Pain medication given as
ordered.

61
NURSING DIAGNOSIS NURSING OBJECTIVES NURSING INTERVENTION EVALUATION

62
07 0930H April 2016
Anxiety related to present health
condition secondary to possible
dysfunction of right lower
extremity
Subjective:
“natatakot ako na di ko na
mailalakad ang paa ko.”
Objective:
With poor eye contact
With voice quivering upon talking
With cold, clammy skin
Irritable
Vital signs:
BP: 130/80 mmHg
RR:22cpm
After 4hrs of nursing
interventions HM anxiety level
will be reduced as evidenced by:
With good eye contact
Calm and relax
(-) quivering of voice upon
talking
(-) cold, clammy skin
(-) Irritable
Vital signs:
BP: 130/80 mmHg
RR:22cpm
 Assessed level of anxiety After 4hrs of nursing
interventions, the goal was met
(mild, moderate, severe
HM will verbalized:
and panic)
 Monitored vital signs to Magpapagaling ako agad at
determine physical makakalakad”
response to anxiety
With good eye contact
 Established therapeutic
Calm and relax
relationship.
(-) quivering of voiceupon talking
 Acknowledge feeling of
(-) cold, clammy skin
anxiety.
(-) Irritable
 Maintained quiet
Vital signs:
environment
BP: 130/80 mmHg
 Provided comfort
RR:22cpm
measures such as
listening music, reading
books and watching
favorite TV shows.
 Encouraged verbalization
of feelings.

63
D. DISCHARGE PLAN

Upon discharge, the client with the help of immediate family members
will adhere to the following instructions:

MEDICATIONS
 Take prescribed home medication Celecoxib 200mg/tablet 1 tablet
Twice a day (0800H – 1800H) for pain as needed, properly at right time
and right dosage and frequency.

EXERCISE
 Instructed and educate client how to perform range of motion exercises
and the importance of doing strengthening activities.
 Instructed significant others to provide safe and hazard – free
environment and assist the client in doing activities of daily living that
he cannot fully perform.

TREATMENT
 Instructed client about the importance of strict compliance in following
the physician’s advice on continuing medications as prescribed, dietary
supplements as indicated and continuing physiotherapy as
recommended by PMRS.

HEALTH TEACHINGS
 Educate the client and significant others the importance of personal
hygiene
and proper wound care with aseptic technique.
 Advised safety measures, home modification as needed that will focus
on
safety environment that will prevent further injuries such as fall.

OUT-PATIENT
 Emphasized the importance of follow up checkup after discharge at
the fracture clinic to assure proper wound and bone healing.

64
  Location of fracture clinic: Third Floor 3Bravo VLGH.
 Schedule: Monday to Thursday 0900H – 1700H, Friday 0800H –
1200H

DIET

 Instructed to eat foods that are rich in protein such as fish and milk,
dietary fibers, carbohydrates, Vitamin A (green leafy vegetables)
and Vitamin C rich foods such as fruits to promote faster wound and
bone healing.
 Encouraged to avoid coffee as it decreases calcium absorption

SPIRITUAL
 Encouraged to strengthen his faith to the Divine Creator.
 Encouraged to attend socials with friends and family members

65
V. CONCLUSION

The nature of injury created by explosion affects the physical and

psychological health of its victim. The author learned that the bone has a
capability to heal itself with or without intervention however unmanaged
fracture will put the life of a victim in danger due to a possible complication
that will arise. For the victims of explosion especially for the survivors of battle
field, they deserved the rightful care from their health providers. This rightful
care will only be achieved if their providers are equipped with proper
knowledge, skills and attitude essential for the management of blast related
injuries. Understanding the mechanism of blast injury as well as the process
of which the victim is going through creates an opportunity for nurses to
provide a holistic care and help the injured to lessen his worries and fears.

66
 VI. BIBLIOGRAPHY

(2015). Daily Multivitamins/Iron Oral : Uses, Side Effects, Interactions,

Pictures, Warning and Dosing. Retrieved 02 May 2016.
http:/www.webmd.com/drugs/2/drug-167633/aily-vitamin-formula-iron-
oral/details

(2015) Femur Anatomy, Diagram and Definition /Body Maps. Retrieved

04 May 16, from http:www.healthline.com/human-body-maps/femur

Espjo, E. (2013). Mindanao bombs: over 300 killed in 12 years. Rappler.

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VII.APPENDIX
Assessing for signs of motor dysfunction

+5 - full ROM, full strength

+4 - full ROM, less than normal strength

+3 - can raise extremity but not against resistance

+2 - can move extremity but not lift it

+1 - slight movement

0 - no movement

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