DIZON, DEXIE

BSN 3

RLE – MODULE FOR CASE STUDY

Course Code NCM 104

Course Title CARE OF CLIENTS WITH PROBLEMS IN INFLAMMATORY AND

IMMUNOLOGIC RESPONSE AND PERCEPTION AND COORDINATION

Level Offering 1st Semester AY 2020-2021

Clinical area of assignment Surgical Ward

Date of Exposure Nov 30- Dec 2, 2020

No. of hours 24 hours

CASE STUDY for ORTHOPEDIC WARD

CONGRATULATIONS! For you are a few steps away of pursuing your dream of becoming a “nurse”.

INSTRUCTIONS:
Read the case of a patient whom you are to provide nursing care. Take time to analyze and process the information provided,
before answering the activities following each section of your module.
You may take a break, as necessary. You can ask your friends, classmates, parents, or any person whom you think can help
you understand but remember a greater amount of output should come from you, as you are the LEARNER here.
Of course, you can ask me, your clinical instructor, for clarification on areas you do not seem to understand and do not know
what to do. Would be thankful and gladly help you on your learning needs. You can contact me through my number Messenger/
Mobile number/ Email address at ___________________.

For you to conduct all the requirements for this rotation, we may follow the schedule below:
Online:
Day 1: AM: read on your patient’s case and answer the given activity.
Day 2: AM: processing of 2nd nursing problem (actual/potential), PM – partial or full processing of concept map
Day 3: AM: processing of concept map if not yet done, PM – rotational exam (20 points)
Modular: Remember that you are given 3-5 days to finish this task.

ENDORSEMENT: You are on duty at the Surgery ward on a 7- 3 shift to a female patient Megan.

DAY 1: Endorsing a female client, 65y/o, at orthopedic ward, private room bed 4, with hip fracture.
▪ With an IVF PNSS 1-liter x 16 hrs.
▪ DAT
▪ Oral meds: Tylenol 500 mg q4h
Codeine 30mg q6h
IM meds: Tetanus toxoid: 20,000 IU
▪ Watch out for severe pain
▪ Maintain elevation of the affected area. Do logrolling every 2 hours.
▪ Monitor vital signs q 4hrs.
▪ Initial V/S as follows: T – 37.2°C PR – 100 BPM RR– 20 CPM BP – 130/90mmHg SP02- 90%
▪ Lab/ diagnostic:
A. JOINT FLUID ANALYSIS resulted to a cloudy fluid.
B. X-ray showed an extra capsular subtrochanteric fracture extending from the lateral cortex of the femur
spiraling down the femoral shaft.
Day 2: Continue with current management
IVF to follow: D5W 1-liter x 16.
On NPO.
Secure consent.
Scheduled for gamma nail insertion at 7AM tomorrow.
V/S as follows: T – 37. 9 °C PR – 95 BPM RR– 25 CPM BP – 120/80mmHg SP02- 92%

Day 3: Continue previous prescribed medications.

Procedure: insertion of a right femoral gamma nail
 MEDS: Aspirin 325 mg once a day
Watch out for signs trochanteric pain.
Change dressing accordingly.
Encourage early mobilization.
V/S as follows: T – 37°C PR – 110 BPM RR– 28 CPM BP – 130/90mmHg SP02- 94%

HISTORY:
⮚ Patient Megan, 65-year-old was admitted last November 27, 2020 following a fall with right groin pain and with bruising
and swelling around her hips. Initial X-rays were normal. She represented four weeks later with ongoing pain and by
this, X-rays showed an extracapsular subtrochanteric hip fracture.
Patient’s Profile:
Name: Megan Cho
Age: 65 y/o
Sex: Female
Civil status: Widow
Address: Baguio City
Occupation: Businesswoman
Nationality: Filipino Chinese
Religion: Confucianism
Date and time of Admission: Nov. 27, 2020; 12:00PM
Ward & Bed no: Orthopedic ward, Private room bed 4
Admitting Diagnosis: A case of extracapsular subtrochanteric hip fracture.
Chief complaints: four weeks later with ongoing pain after a fall
Procedure: insertion of a right femoral gamma nail. 

HISTORY OF PRESENT ILLNESS:

⮚ A 65-year-old lady went to emergency room at BGH following a mechanical fall onto her right-hand side. She
complained of pain in the right-hand side of her groin and experienced pain on weight bearing. She also complained of
long standing non-traumatic right knee pain.
⮚ On examination, there was no deformity of the leg and she was non-tender over the greater trochanter. She had a good
range of movement at the hip and knee and was neurovascularly intact.
⮚ X-ray of her pelvis showed no fracture of her femur.

⮚ It did however show a possible un-displaced inferior pubic ramus fracture on the right side. She was given analgesia
and crutches and discharged home from the Emergency Department.
⮚ Four weeks PTA, she complained of ongoing right groin pain. She denied any further trauma to her right leg. Again, it
was non-tender over her greater trochanter and had good range of hip and knee movement. X-rays were repeated and,
on this occasion, showed an extra capsular subtrochanteric fracture extending from the lateral cortex of the femur
spiraling down the femoral shaft.
⮚ Blood works including electrolytes were unremarkable.
PAST MEDICAL AND SURGICAL HISTORY:
⮚ Her past medical history included recurrent falls, osteoarthritis, chronic kidney disease and hyperthyroidism.
FAMILY HISTORY:
⮚ Unremarkable.
SOCIAL, ENVIRONMENTAL AND HEALTH HISTORY:
⮚ The patient and her family lives independently. She works at their business area as a manager and sometimes cashier.
Her husband is lawyer and is an occasional drinker and a smoker.

FEEDBACK: Congratulations! You can now proceed with the activity.

PHYSICAL EXAMINATION & REVIEW OF SYSTEMS

- Focused assessment on the organs/system affected and state pertinent findings appropriately (+/-)
General Survey
Skin
Head, Eyes, Ears, Nose,
Throat
Neck
Breast
Respiratory
Cardiovascular
Gastrointestinal
Urinary
Genital
Peripheral / Vascular
Musculoskeletal
Neurologic
Hematologic
Endocrine
Psychiatric

ACTIVITY 2: Recalling the concepts of health assessment, anatomy and physiology, you have to identify at least FIVE pertinent
PE findings that shows abnormality. Read your books or notes for you to elaborate on the cause of your patient’s clinical signs
and symptoms. In your own words, explain the condition by summarizing what you have read or understood, this is highly
encouraged. You must also supply the textbooks or materials that you have utilized as references.

PERTINENT ABNORMAL PE/ROS EXPLANATION

1.
2.
3.
4.
5.
Reference/s:

FEEDBACK: You might find it easier, if you have your textbooks with you. Congratulations! You can now proceed with the
activity.

DIAGNOSTIC STUDIES:

ACTIVITY 3: Using a reference book (specify), you have to fill in the values that are asked. Indicate the appropriate rationale for
the diagnostic test done, its purpose, the abnormality and/or nursing intervention needed.
Laboratory test & Pertinent Reference/normal Result Interpretation What have caused the
Laboratory Result values abnormality/ Purpose/NI
1. X-ray Showed an extra
capsular
subtrochanteric
fracture extending
from the lateral
cortex of the
femur
2. Joint fluid analysis Cloudy fluid
3. MRI Muscle injury
showed
FEEDBACK: That’s the spirit keep going.
You might want to have a few minutes break before proceeding to the areas of the module.

MEDICAL/SURGICAL DIAGNOSIS:

ACTIVITY 4: Read about your patient’s diagnosis using your textbook (MedSurg/ specify). Focus on the description of the
disease, the etiology or cause, what are the signs and symptoms and why do they occur, what are the recommended
interventions and nursing interventions. Digest the information that you have obtained. Take time to process and analyze them.
Once you are ready, in 500 words or briefly answer the following questions.

Signs & Symptoms Signs & symptoms

(book)
Description of the Disease Etiology (patient)

Reference: Textbooks /Online resources allowed but should not come from blogs, Wikipedia,

FEEDBACK: KEEP UP THE GOOD WORK! What you are doing will keep you focused and enable to understand your patient
the best way possible. It may be hard on you at the start but doing it often, you will soon find it easier. Remember, NO PAIN! NO
GAIN.

PRESCRIBED THERAPEUTIC (MEDICAL/SURGICAL) MANAGEMENT, AND HEALTH PROMOTION PROGRAMS:

Activity 5: After reading your textbook or notes on pharmacology and/or med-surgical books, answer what are asked on the
following table.
Drug/ Dose/Route/ Mechanism of Common Side Nursing responsibilities
Classification Frequency action Effects
1. Tylenol
2. Codeine
3. Aspirin
 4. tetanus toxoid
IVF Amount Infusion rate Purpose Nursing responsibilities
1-liter X 16 hours
1. PNSS
Diagnostic Description Purpose Nursing Responsibilities
Procedure

1. MRI
2. X-RAY
3. joint fluid
analysis
Reference/s: Textbooks /Online resources are allowed but should not come from blogs or Wikipedia

FEEDBACK: I hope you were not intoxicated by these drugs. Remember that these are important in saving your patient’s life
and it should be monitored for its therapeutic and side effects.

ACTIVITY 6: Applying the nursing process, integrate all the significant findings obtained in the analysis of the case and
formulate a nursing care plan for your patient. Use the given table/format presented.

DATA GOALS/ ACTION/ RATIONALE RESPONSE &

Expected outcomes NURSING EVALUATION
INTERVENTIONS
Subjective findings: STG: within ______hour/s Dxtc: After ______hr/s of NI, the
_____________________ of NI the patient will be able patient was able to
______________
_____________________ to _______________ ________________________
______________________ ______________ ________________________
_____________________ _______________
_____________________
______________ as manifested by_________
_____________________ _____________________ _______________
_____________________ ______________ ________________________
_____________________ _______________
_____________________ ______________ _______________________
as manifested/evidenced Txc:
_____________________ ______________ STG: fully/partially/un MET
by: _______________
_____________________ _____________________ ______________
_______________
Objective findings: _____________________ ______________ After ______hr/s of NI, the
_______________
_____________________ _____________________ patient was able to
______________
_ _______________ ________________________
LTG: after ___days of NI ______________ ________________________
_____________________ the patient will be able to: Edx:
_____________________ ______________ as manifested by _________
_____________________ _______________
_____________________ ______________ ________________________
__ _______________
_____________________ STG: fully/partially/un MET
_____________________ ______________
as manifested by: _______________
_____________________ ______________
_____________________ _______________
__ ______________
_____________________ _______________
Focus/ Nursing Dx: (PE/S) ______________
_____________________
_____________________
__

FEEDBACK: CONGRATULATIONS, you have just shown how prepared you are in meeting your patient’s needs. If this
continues, expect that a lot of your patient will be smiling and thanking you for saving their lives.

COLLABORATION
Activity 7: As a future nurse you should be able to work with your co-nurses and other health care professionals and form a
team sharing knowledge and resources to solve or provide patient care.
⮚ After administering the nursing and medical interventions, the patient still complains of pain rated as 5/10. As a nursing
student what are you going to do next? (limit you answers in 3-5 sentences only.)
ETHICO-MORAL-LEGAL CONCERNS
Activity 8: These principles concern the ethics of caring rather than 'curing' by exploring the everyday interaction between you
as a nurse and the person in your care.
⮚ In this situation what are the possible ethico-moral and legal concerns of your patient. Justify you answer in 3-5
sentences only.

FEEDBACK: WELL DONE! Now summarize what you have done by formulating the concept map/table.
ACTIVITY 9:
Incorporating all the data that had been presented to you and your readings, create in a diagram form the pathophysiology of
the patient’s disease/condition. Incorporate the risk factors present in your patient based on his/her history, the signs and
symptoms presented by your patient as shown on his/her PE and ROS, the lab results provided by the various diagnostic
exams. Group all cues together showing how you were able to arrive to a certain nursing diagnosis/es.
Lastly, include the various medications and or procedures. Do not forget to include the arrows to show connections and/or
relationships among the various concepts.

Study the given sample below for you to understand.

BE CREATIVE BUT KEEP IT SIMPLE GOOD LUCK!

⮚ ATTACH COMPLETE CONCEPT MAPPING HERE

COMMUNICATION
Activity 10: Your shift is about to end, using ISBAR (a patient safety communication structure that aids simplified, effective,
structured and anticipated communication between healthcare personnel). Fill in your end of shift report to help guide the
incoming student nurse.
Identify yourself: your name: _________________ role: student nurse ward/area: ________________
Situation: What is your patient’s name, age & gender, current situation/status (stable but in danger of deterioration,
unstable), concern or your observations, what needs to monitor/observe (ex; abnormal VS, labs, active clinical
signs/symptoms)
Background: Give the relevant details such as presenting problems and clinical history that will help the incoming staff
interpret the situation easily; may also include meds / procedures already administered.
Assessment: What is your assessment? (Base it on your observation on your patient during your shift what is his/her
current condition, risks & needs).
Recommendation: What do you recommend being done to correct the situation? Be clear about what you are requesting.
(e.g transfer/review/treatment? When should it happen?

Feedback: CONGRATULATIONS, you have carried out your task. I will be getting back to you after I have read your output.

Prepared by: CHERRY G. KIM

Noted by: DR. GINA L. CASI, DEAN