Group 2 Level III Atienza, Judie Lynn A. Buzar, Tristan Joseph H. Lim, Genicka A. Palma, Mark Anthony A.

GENERAL OBJECTIVE
The purpose of this study is to gain knowledge, to enhance nursing skills by applying principles to develop therapeutic communication, to provide privacy and maintain the confidentiality of the patient and to render care with right attitude towards the patient with fibrous dysplasia. This study will serve as a guideline for student nurses in providing proper nursing care and management to the patient with the said complication.

SPECIFIC To understandOBJECTIVES the condition of fibrous dysplasia and

associate it with the patient having the same/similar manifestations. To know the nursing history, personal data, health history and physical assessment of the patient. To illustrate the Anatomy and Physiology of the affected organ. To discuss the pathophysiology of the complication. To determine and differentiate manifestations of the condition.

SPECIFIC OBJECTIVES To develop an effective nursing skill on how to manage

proper care in patient with fibrous dysplasia. To formulate a drug study regarding the patients condition. To correlate laboratory results to its normal values To provide a set nursing care plan to the patient to assure clients total wellness during his hospitalization. To apply right attitude towards the patient by providing privacy and maintaining clients confidentiality.

Background of the study

and proportion.
Fibrous dysplasia of bone is listed as a "rare disease" by

the Office of Rare Diseases (ORD) of the National Institutes of Health (NIH). This means that Fibrous dysplasia of bone, or a subtype of Fibrous dysplasia of bone, affects less than 200,000 people in the US population. They currently defines a condition rare when if affects 1 person per 2,000. They list Fibrous dysplasia of bone as a "rare disease."

 Race

No specific racial predilection exists. Sex The incidence rates are equal in males and females Age The initial manifestations of fibrous dysplasia is commonly found in persons aged 3-15 y/o 2/3 of patients with polyostotic disease are asymptomatic before they are aged 10 years With monostotic disease, patients as old as 20 or 30 years are asymptomatic

Rationale for choosing

The group decided to choose the case of Fibrous dysplasia to a specific patient because as nursing students, we are to relate our learning acquired in Medical Surgical Nursing subject regarding musculoskeletal impairments especially as we handle our patients from childrens Ward. This case may leave a more interesting study that will bring up knowledge to us.

Significance of the studies The significance of this study is to provide information that
will serve as reference that thorough discusses the patients condition. Through this study, we will be able to actually relate what had been studied in class and the assessments, laboratory results, and interventions done in the clinical setting. We will also be persevered to give the best nursing plan and care to the patient using right attitude and principles we had learned.

Scope of limitation
The study will only focus on the fibrous

dysplasia which is indicative to the clients health condition and its underlying nursing management relevant for the client.

Nursing Theory Dorothea Orem: Self care deficit

Nursing is required when the patient (or in the case of

dependent) is incapable or limited in the provision of continuous self care. Orem identifies 5 methods of helping: Acting for in doing for others Guiding others Supporting another Providing environment promoting personal development in relation to meet future demand Teaching another

 Dorothea Orems theory carries a particular way of

viewing the reality of nursing treatment based on the key concept of self care. Every individual has the capacity for self Care. However, when a health problem arises, it is possible that this capacity is insufficient to confront the situation, making them necessary to received help from other persons to compensate for their deficit. We chose dorothea orems theory regarding self care deficit primarily because the patient is in balanced skeletal traction so he cant able to do and perform his activities of daily living independently and another factor is that he is only 10 years of age, thus he is still dependent on his parents particularly his mother.

GENERAL DATA PROFILE

Name:

Batang X Date of Admission: March 21, 2013 Address: Sampaloc Manila Admitting Diagnosis: Pathologic fracture, Birthday: Nov 28, 2002 femoral neck left probably Age: 10 Years Old secondary to primary Birthplace: Sampaloc fibrous dysplasia probably Manila fibrous dysplasia ruled out Mothers Name: Pokwang infectious disease. Fathers Name: Bentong Admitting Physician: Dr. Nationality: Filipino Callangan Religion: Catholic

 CHIEF COMPLAINT

Pain at the left hip area NURSING HISTORY History of Present Illness Based on his chart he was admitted last march 21, 2013 with a chief complaint of Pain at the left hip area. One month prior to admission patient developed pain at left hip accompanied by limping gait. No consult was done. No medication was taken.

 One week prior to admission patient fell down from a

tricycle and landed with left hip on the floor. Patient developed severe pain and was not able to ambulate. Childhood Illnesses Fever, Cough and Colds Immunization Complete dose of all immunizations.

 Allergies

No known allergies to food and drugs. Accidents Patient fell down from the tricycle and landed on his left hip on the floor on march 14, 2013 Hospitalizations The patient was admitted last march 21, 2013 with a chief complaint of Pain at the left hip area at Philippine orthopedic center, maria clara quezon city.

 Medications used or Currently Taking

Paracetamol, co-amoxiclav, rifampicin, isoniazid, and pyrazinamide. Domestic Travel Within quezon city.

PSYCHOSOCIAL THEORY ACCORDING TO ERIK ERIKSON

TASK

RESOLUTIO NS

NEGATIVE RESOLUTIO NS

School age

6 to 12 years Industry Vs. Beginning to old Inferiority create, develop, and manipulate. Developing sense of competence and perseveranc e.

Loss of hope, sense of being mediocre. Withdrawal from school and peers.

 According to Eriksons theory this is the preadolescent

stage. It is where an individual begins to develop their critical thinking abilities to develop competency. During this time, individual are normally persevered to finish and settle different tasks at their best. Erikson observed that the school age is when we tend to be occupied with creative and meaningful work. Based on our assessment with the patient, we found out that the theory of Erik correlates with the information that weve gathered to the patient.

ACCORDING TO SIGMUND FREUD

STAGE

AGE

CHARACTERISTI IMPLICATIONS CS

Latency

6 to puberty

>Energy is directed to physical and intellectual activities. Sexual impulses tend to be repressed. Develop relationships between peers of the same sex

>Encourage child with physical and intellectual pursuits. Encourage sports nad other activities with same sex peers

 In Freuds psychosexual development, it

is the stage that spans preadolescent life to puberty and thus occupies most of the life of a child/adolescent on peer relationship. The time is most often directed to sports and intellectual activities; its purpose is the psychological independence in decisionmaking. The goal of this stage is to establish a balance between the various life areas.

ENVIRONMENT/LIVING CONDITION
The patient lives in a slum area in Sampaloc Quezon City where the houses are closed together. His father has pulmonary tuberculosis which makes him suscetiple in acquiring PTB.

PHYSICAL ASSESSMENT

Parameters

Normal Findings Actual Findings

Interpretation

General Appearance

-Clean in appearance -With good body built

-Unclean appearance - with weak body built -

Skin

-With good skin turgor

Hair

-Evenly distributed hair -Thick hair

-With good skin turgor - with less than 2-3 seconds -Evenly distributed hair -Thin hair

-The patient has weak body built due to feeling of fatigue and being ill. Normal findings

Normal findings

Nails

-With good capillary refill of 1-3 seconds -with pinkish nail beds -With clean and short nails

-With good Normal capillary refill findings of 1-3 seconds -with white nail beds -With clean and short nails

Skull and Face

-Rounded smooth skull contour -Symmetrical facial movement

-Rounded smooth skull contour -Symmetrical facial movement

Normal findings

Eyes

-No eye discharge -With anicteric sclera -Eyebrows hair evenly distributed; (+)blink reflex -With pinkish conjunctiva -Auricle color same as facial skin -Auricle are mobile firm and not tender -Able to hear on both ears

- No eye discharge Normal -With anicteric sclera findings -Eyebrows hair evenly distributed; (+)blink reflex -With pinkish conjunctiva

Ears

-Auricle color same as facial skin -Auricle are mobile firm and not tender -with partial hearing impairment -No edema and

The patient has congenital partial hearing loss.

Mouth

-Mouth uniform consistency ;absence of nodules and masses -Pinkish lips -Without missing teeth -With pinkish gums -No foul odor -With symmetrical contour

-Mouth uniform Normal findings consistency ; absence of nodules and masses -Without missing teeth -With pinkish lips and gums -With symmetrical contour

Musculoskeletal (Upper and lower extremities)

-Symmetrical -No atrophy -With full range of motion

-Symmetrical -due to presence -No atrophy of balanced -Limited range of skeletal traction. motion

Abdomen

-No abdominal distention -Flat rounded abdomen -Symmetrical contour -No surgical incision

-No abdominal distention -Flat rounded abdomen -Symmetrical contour -No surgical incision

Normal findings

Patterns of Functioning

Functional Health Before Pattern Hospitalization Health Self-medication Management Pattern

During Hospitalization Follows treatment regimen

Interpretation Prior to admission the patient was self medicated due to less severe illness Prior hospitalization The patient was drinking few glasses of water due to being fond of drinking soft drinks.

Nutritional/Meta bolic 3 times a day 3 times a day a. number of Eats one cup of Eats one cup of meals per day rice and viand rice and viand b. appetite appropriately appropriately c. glass of water every meal every meal per day 2-3 glasses of 1050 cc for 24 d. body built water a day hours e. height and Thin Thin weight Approx. 410; 18 Approx. 410; 18

Elimination a. frequency of 3 times per day urination b. amount of urine per day c. frequency of bowel movement Approx. 300 cc/day Twice a day

3 times per day

Approx. 300 cc/day

The patient has a good bowel and bladder functioning.

twice a day

d. consistency of Formed the feces

Formed

Activity and Active Exercise exercise a. exercise (playing)

Decreased ROM exercises of the left lower extremity

Due to the traction being worn.

b. fatigability c.ADL

Easily get tired

Easily get tired

Independent Dependent to significant other

Due to the traction being worn

Cognitive/Perc eptual Oriented to a. Orientation time, place and person b. responsivenes Respond s appropriately to physical stimuli but limited response in verbal stimuli.

Oriented to time, place and person

Respond appropriately to physical stimuli but limited response in verbal stimuli.

-The cognitive and perceptual status of the patient is present. - Due to partial hearing impairment.

Roles/Relations hip a. as a son b. as a brother e. as a patient

With good relationship to his parents With good relationship to his brothers and sisters. With interactive relationship with the healthcare team

With good relationship to his parents With good relationship to his brothers and sisters With interactive relationship with the healthcare team

-Still have good relationship with his family and with mutual cooperation

with the
healthcare team.

Selfperception/Self concept

Have moderate self worth and importance to health

Have moderate self worth and importance to health

-Still possesses moderate self worth and importance to health in spite of his condition

Coping/Stress

Seeks advice to his parents when he has problems

Talks to his Has good coping parents to lessen techniques stress

Values/Beliefs

Has awareness that God really exist

Has awareness that God really exist

Never blames God with his present condition

CBC RESULTS March 21, 2013

Test Name Results Reference Results Interpretation

LDH

318U/L

225-450 U/L

Alkaline phosphatase

258.2 U/L

64- 306 U/L

March 25, 2013

March 25, 2013

Results Reference Value Interpretation

Hemoglobin

21gm/dl

Hematocrit

34

Male : 14Because the 18gm/dl patient Female : 1215gm/dl Male: 40-50 vol% Female: 30-40 vol% 2-4% Within normal range

Eusinophils

Platelets

130,000

150,000450,000/cumm

April 11, 2012 Chest X-ray result Patchy infiltrates are seen in both lung films. Homogenous density seen in left hemithorax of securing the cardiac shadow Through cardiac size cannot be ascertain Right hemi diaphragm postrophrenic sulci are intact Impression: bilateral bronchopneumonia pleural fusion and/or atelectasis left hemithorax

The Skeletal System

The skeletal system includes all of the bones
and joints in the body. Each bone is a complex living organ that is made up of many cells, protein fibers, and minerals.

Function of the skeletal system

Provides framework for the body and allows the body to be

weight bearing
Supports the surrounding tissues Assists in movement through muscle attachment and joint

formation
Protects vital organs
Provide storage for minerals hematopoiesis

Skeleton
Axial portion

cranium, vertebrae, ribs

Appendicular portion

limbs, shoulder, hip

Types of bones

long, short, flat, irregular

Spongy bone located in the ends long bones and the center of flat and irregular bones Dense (compact bone) Covers spongy bone Cylinder around central marrow cavity

 The diaphysis, or shaft, is the long tubular

portion of long bones. It is composed of compact bone

tissue.
The epiphysis (plural, epiphyses) is the expanded

end of a long bone. It is in the epiphyses where red blood cells are formed.
The metaphysis is the area where the diaphysis meets the

epiphysis. It includes the epiphyseal line, a remnant of

cartilage from growing bones.

 The medullary cavity, or marrow cavity, is

the open area within the diaphysis. The adipose tissue inside the cavity stores lipids and forms the yellow marrow.
Articular cartilage covers the epiphysis where joints occur.
The periosteum is the membrane covering the

outside of the diaphysis (and epiphyses where

articular cartilage is absent). It contains osteoblasts (boneforming cells), osteoclasts (bone-destroying cells), nerve

fibers, and blood and lymphatic vessels. Ligaments and

tendons attach to the periosteum.
The endosteum is the membrane that lines the marrow

cavity.

Fibrous Dysplasia Fibrous dysplasia is a bone disorder in which

scar-like (fibrous) tissue develops in place of normal bone. As the bone grows,the softer, fibrous tissue expands, weakening the bone. Fibrous dysplasia can cause the affected bone to deform and become susceptible to fracture. Fibrous dysplasia accounts for approximately 7% of all benign bone tumors. Any bone may be affected. The most common bones involved are the thighbone, shinbone, ribs, skull, upper arm bone, and pelvis.

Most people with fibrous dysplasia are diagnosed during adolescence or early adulthood. Mild cases usually cause no signs or symptoms. More-serious cases of fibrous dysplasia may result in bone pain and deformity.

Causes
Exact cause is unknown
Associated with gene mutation

Occurs in childhood, usually between ages 3 15

Manifestations
Bone pain
Bone sores (lesions)

Difficulty walking
Fractures or bone deformities

Unusual skin color (pigmentation)

Diagnostic examination
Medical history

Physical examination
Blood tests

X-ray examinations
CT scan

Bone biopsy

Treatment
Medications called bisphosphonates, including

pamidronate (Aredia) and alendronate (Fosamax), are used to inhibit bone breakdown, preserve bone mass and even increase bone density in your spine and hip, reducing the

risk of fractures.

 Pain management therapy Physiotherapy to improve joint mobility Surgery to correct bone deformities

Pathophysiology
Predisposing factors
Age Gene mutation

Formation of fibrous tissue

Fibro- osseous tissue replaced the bone marrow

Tissue began to expand

the bone become soft

Fracture

pain

swelling

Assessment

Diagnosis

Planning

Intervention

Rationale

evaluation

Sujective: Nahihirapan ako ng huminga ng maayos as verbalized by the patient Objective: With nasal flaring Use of accesory muscle noted Dyspnea noted Tachypnea noted With RR of 40bpm With deep and rapid breathing

Ineffective breathing pattern related to airway obstruction

After 2 hours of nursing intervention, the patient will be able to establish effective respiratory pattern.

Auscultate chest. Note rate and depth of respirations, type of breathing pattern Elevate head of bed as appropriate Maintain calm attitude while dealing with client and S.O.

To evaluate possible breath sounds To promote physiological ease of maximal inspiration To limit level of anxiety To promote lung expansion and deep breathing

Goal met After 2 hours of nursing intervention, the patient established effective respiratory pattern as evidenced by respiratory rate of 26 bpm

Encourage patient position of comfort. Reposition client frequently if immobility is a factor. Stress importanace of accessory muscle Encourage adequate rest period between activities Perform back tapping

To maximize respiratory effort

To limit fatigue To mobilize pulmonary secretion

Assessment

Diagnosis

Planning

Intervention

Rationale

evaluation

Sujective: hindi ako makagalaw ng ayos as verbalized by the patient Objective: With Limited movement Difficulty of turning side to side With

Impaired bed mobility related to breakage of continuity of bone.

After 4 hours of nursing intervention, the patient will be able to: a. Verbalize understandi ng of situation and risk factors, individual treatment regimen and safety measures.

Assess the muscle strength of the patient Ascertain that dependent client is placed in best bed situation Assist with activities of hygiene toileting, feeding as indicated

To determine the muscle strength of the patient and to identify the type of range of motion that should be use. To promote mobility and enhance environment al safety

Goal met After 4 hours of nursing intervention, the patient will be able to: a. Verbalized understandi ng of situation and risk factors, individual treatment regimen and safety measures.

B. Demonstrate techniques and behaviors that enable safe repositioning.

Encourage continuation of exercises Involve client or S.O. in determining activity schedule

To promote optimal level of functioning To maintain and enhance gains and strength and muscle control Promotes commitment plan, maximizing outcomes

b. Demonstrated techniques and behaviors that enable safe repositioning

generic name Paracetamol

Classification Anti-pyretics

Indication Fever

Mechanism of action Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever primarily in the CNS.

Adverse effect Hepatic failure Hepatotoxicit y Neutropenia Pancytopenia Leucopenia Rash Urticaria Hepatotoxicit y Anorexia Diarrhea Nausea and vomiting Dysuria Anemia Thrombocyto penia Hyperuricemi a Skin rash Artralgia

Pyrazinamide

Anti-tubercular

PTB

Unknown

Nursing responsibility Advise patient ti take medication exactly as directed and not to take more than recommende d amount. Monitor serum uric acid concentration during therapy Advise patient to take medication as directed and not to skip doses or double up on missed doses. Advised patient to use sunscreen

Rifampicin

Anti-tubercular

PTB

Inhibits RNA synthesis by blocking RNA transcription in susceptible organisms.

Ataxia Confusion Drowsines s Fatigue Headache Abdomina l pain Diarrhea Flatulence Heartburn Nausea and vomiting Drug induced hepatitis Anemia Thromboc ytopenia Artralgia

Assess lung sounds and character and amount of sputum periodically during therapy Monitor hepatic functions Evaluate renal functions, CBC and urinalysis Administer medication on an empty stomach atleast one hour before or two hours after meals with a full glass of water

Co-amoxiclav

Anti-biotic

isoniazid

Anti-infective

tuberculosis

Inhibits myobacterial cell wall synthesis and interferes with metabolism

Seizures Drug induced hepatitis Nausea vomiting Rashes Blood dyscrasias Peripheral neuropath y Fever

Advised patient to take medication exactly as directed.

Date

Doctors Order

Nurses Notes

Interpretation

Admission March 21, 2013

The doctor seen and examined the patient and ordered to admit the patient.

Received per stretcher.

Consent for admission for Steinman pin insertion Trans-out to childrens ward per stretcher 90 degrees applied

Ordered the patient on DAT diet.

Monitor vital signs every shift.

to left leg with 5 ponds weight.

Forwarded request for alkaline phosphatase. LDH to laboratory department Posted request for x-ray PA

For monitoring for further complication.

Co- amoxuclav was given as antibiotic because of infection. Pracetaol was given for fever. Alkaline phosphatase, was ordered to know POSSIBLE any bone problems and deformities. ESR was ordered to know any presence of

Medications: Co- amoxiclav 312.5mg/5ml; 7.5ml 2x a day for 7 days. Paracetamol 250mg/5ml; 8ml TID for pain.

Laboratory tests; Alkaline phosphatase, LDH, CBC, ESR, CRP,

chest x-ray

Chest x-ray to visualize the lungs for any deformity and complication 90 -90 degree traction was ordered and applied due to subtrochantheric fracture of the femur.

Application 9090 degree traction at 5lbs.

24 hours post traction x-ray of pelvis PA. Rehabilitation for GBCE.

Pelvic x-ray was ordered to visualize the pelvis alignment.

DATE March 22, 2013

DOCTORS ORDER

NURSES NOTES Co- amoxiclav 312.5ml/5ml; 7-5ml 2x a day for 7days.

INTERPRETATIO N Given as staring dose of the drug.

March 24, 2013

Refer for ORplating of left femur and RFS Afebrile, negative complaint. BST HPI : I month prior to admission positive limping gait, positive episode of left hip pain A week PTA, patient fell from

March 28, 2013

For realigning the distal 3rd of femur HPI was done for additional information of his case

March 30, 2013

Physical examination : + pain on left hip, + tenderness of left hip, + LOM.

To see if there is any improvement

90-90 degree traction

For subtrochanteric fracture of femur. To prevent infection that can cause other complications

Oral anti-biotics

For OR-plating of femur(narrow DCP-arthur), RFS Still logistics

April 1, 2013

Converted BST to 10lbs by 5lbs

Traction and suspension weight of BST was changed due to weight changes of the client

ABG

Chest x-ray offered weekly

To see the condition of the clients lungs

April 2, 2013

For referral pediatric ward with chest x-ray

To visualize the lungs if there is any problem

April 4, 2013

For follow up ultrasound of left hip

To visualize the condition of the bone

Chest xray PA

To visualize further improvement of the lungs To see the condition of

Progress: initial weekly chest x-ray

taken last march 21, 2013 PTB

the clients lungs Due to previous chest x-ray conducted PTB was diagnosed. To prevent bleeding. Due to PTB as its one of manifestation.

Anti coagulant, DOB

decreased bowel sound

Due to BST immobility which causes decreased peristalitic movement.

April 15, 2013

For further consult at PCMC Coordinated with mr. avello.

Pin tract care

April 16, 2013

Fracture in the diagnosis seen by several doctors first before referring The coordinate ambulance transfer Patient was not brought at PCMC because not available To recoordinate with PCMC.

Discharge Plan

 VII. Discharge Plan (M.E.T.H.O.D.) Medication Orient the client about the name of the drugs, their actions,

the exact dosage, the frequency, and the route of administration. Instruct the client to follow the instruction when administering medication. Advice the significant others not to leave the client during medication. Explain to the client the side effects and adverse effects of the drugs he takes by prescribing its manifestations. Advice client not to stop intake of prescribe medications, unless approved by the physician. Environment Provide clean and quiet environment to promote safe and hasten the recovery of the patient.

 Treatment Educate client the importance of drug compliance. Discuss to the client the complication of the condition

because knowledge about the disease supports learning that will decrease knowledge deficit and anxiety. Health teaching Instruct to avoid doing strenuous activities to avoid further deformity. Instruct client to balance activities with adequate rest periods.

Outpatient orders Seek medical assistance if any following occurs: Developed a high grade fever. Experience severe nausea and vomiting Have shortness of breath Have swelling, redness, or pain in face and extremities.

Diet Instruct to eat nutritious foods, especially foods and

beverages rich in Vitamin C to boost immune system. Encourage to increase fluid intake to promote hydration. Instruct client to eat foods that are high in protein to promote wound healing.

Thank you!!!!!!!

=D