Biographical Data

Name: PJS

Age: 22 y/o

Address: San Francisco, Minalin Pampanga

Birthday: Jan 23, 1988

Birthplace: San Francisco, Minalin Pampanga

Religion: Roman Catholic

Nationality: Filipino

Civil Status: Single

Occupation: Cook

Educational attainment: College undergraduate

History of Present Illness

Nature of incidence: vehicular accident

Date of incidence: August 16, 2010

Time of incidence: 10pm

Place of incidence: Minalin, Pampanga

 Assessment Diagnosis Planning Intervention Rationale Evaluation

S> “Masakit daw ang paa Acute pain related to head After 1-2 hrs.of nursing  Elevated leg at 1  To provide Goal met. The client was
at mata niya”, as injury secondary to intervention, the client pillow support. able to reduce his pain
verbalized by the mother vehicular accident. will reduced the pain  Encourage  To prevent scale to 5/10 from 7/10.
scale to 5/10 from 7/10. adequate rest fatigue.
O> pain scale of 7/10 periods
> Periorbital hematoma  Provide comfort  To promote
(Racoon’s eye) measures nonpharmacologic
> Intact dressing on al pain
forehead management
> Right leg circular cast  Encourage use of  To distract
> Expressive behavior relaxation attention and
(moaning, crying, techniques reduce tension
irritable)  Encourage
verbalize of
feeling about the
pain.
 Assessment Diagnosis Planning Intervention Rationale Evaluation

S> Ø Impaired skin integrity After 6 hrs.of nursing  Inspect skin on a  To observe any Goal met. The client was
related to mechanical intervention, the client daily basis, changes. able to participate in
O> suture on mandible factors secondary to will participate in describing wound prevention measures and
area vehicular accident. prevention measures and characteristics. treatment program.
>intact dressing on treatment program.  Keep the are
forehead clean/dry,  To assists body’s
carefully dress natural process of
wounds, support repair.
incision, prevent
infection
 Apply appropriate  For wound healing
dressing and to best meet
needs of client.
 Maintain  To avoid
appropriate harboring of
moisture microorganisms.
environment for
particular wound.
 Assessment Diagnosis Planning Intervention Rationale Evaluation

S> Ø Impaired physical After 6 hrs.of nursing  Encourage range  To increase flow Goal met. The client was
mobility related to intervention, the client of motion of blood to the able to demonstrate
O> right leg circular cast musculoskeletal will demonstrate exercises vessels of lower behaviors that enable
>limited range of motion impairment. behaviors that enable extremities resumption of activities &
on right lower extremeties resumption of activities &  Provide for safety  To prevent from techniques and provide
techniques and provide measures fall or injury range of motion exercises.
range of motion exercises.

 Elevate leg at least

 To provide
1 pillow
support to the
affected leg and
reduce risk of
pressure ulcer
 Reposition the  To prevent bed
patient every 2 hrs sores
 Provide client with
ample time to
perform mobility-
related tasks
Non-Modifiable Factors Modifiable Factors
• Age • Alcohol Intake
• Sex • Lifestyle
• Trauma • Environment

Traumatic Injury
(Vehicular Accident)

Fracture to Right Leg

Damage to the blood

supply to an entire bone

Severe Circulatory
Compromise

Avascular (Ischemic)
Necrosis may result

Clinical Manifestations
- Pain - Crepitus - Tenderness
- Loss of function - Swelling and
Discoloration
- Deformity - Paresthesias
 Pathophysiology

Vehicular accident is unintended and unforeseen event, usually resulting in personal injury or property damage. In popular usage, however, the termacci dent
designates an unexpected event, especially if it causes injury or damage without reference to the negligence or fault of an individual. The single greatest cause of
accidents in the United States is the automobile. In 1913 the American industrialist Henry Ford introduced assembly-line techniques in the manufacture of motor
vehicles. The subsequent increase in the number of automobiles in use was huge and led to a great rise in the motor-vehicle accident rate. Accidental deaths reached
a high of 110,000 in 1936, with a death rate of 85.9 per 100,000. In 1991 the total was estimated at 88,000, with a death rate of 34.9 per 100,000; this was the lowest
accidental death toll since 1924 (85,600).

A fracture, a break or crack in a bone, is caused by sudden, violent pressure against the bone. Great pain and swelling characterize both a sprain and a
fracture, but inability to move the affected part, a deformed appearance, and pain or tenderness at a specific point usually indicate a fracture.

Simple, or closed, fractures are not visible on the surface.

Compound, or open, fractures involve a rupturing of the skin, often exposing the bone.
Single and multiple fractures refer to the number of breaks in the same bone.
Fractures are complete if the break is total

Incomplete (greenstick) if the fracture occurs only part of the distance across a bone shaft, with bending or crushing of the bone. Incomplete fractures are found
mostly in young children, whose bones are resilient.

Signs and symptoms include:

Soft tissue edema, Warmth over injured area, Ecchymosis of skin, Loss of sensation or paralysis distal to injury, Signs of shock related to severe tissue injury, blood
loss, and intense pain, Evidence of fracture on x-ray film
 Infection in compound fractures is treated with antiseptics and antibiotics. If the broken segments lie adjacent to each other, stretching or traction to
overcome the pull of powerful muscles may be used to achieve realignment, although external manipulation may sometimes bind the segments. This is called
reduction. If proper alignment cannot be achieved in this way, an operation is usually performed, and the fragments are joined with screws, nuts, nails, wires or
metal plates. This is open reduction. Once aligned, segments are secured externally with a plaster cast or splint to immobilize the fracture and to speed healing.
When ribs are fractured, the chest is often strapped or taped to reduce pain from the motion of breathing. While healing, the body creates new tissue to join the
broken segments. Minerals in the tissue harden to form solid new bone structure.