IDENTIFICATION DATA

IDENTIFICATION DATA OF PATIENT

Name: Mrs Nirmala devi
Age: 34 years
I.P No.: - 256366
Address: v.p.o samloti teh nagrota bagwan district kangra.
D.O. A:-o4-02-2019
Marital status: married
Occupation: - private job
Education: - graduate
Religion: - Hindu
Ward: -ortho female ward
Bed No.: - 15
Diagnosis: - Right arm radial fracture

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CHIEF COMPLAINTS:
Mrs Nirmala devi was admitted in male medicine ward center at Dr. RPMC Tanda on 03/02/2019 with the chief complaint of:

 Pain X 1day
 Swelling X 1 day
 Brushing at injury site X1day
 No pulsation at injury site X 1 day

PRESENT MEDICAL HISTORY: The patient was suffering from pain at right arm,swelling ,irritability and brushing at injured
site.there is no movement of injured arm
PAST MEDICAL HISTORY
 History of any past illness & treatment:
no history of any severe illness, DM, hypertension.
 H/o allergy/medications/ infection: Not significant
 Allergies: No history of any other allergy.
 Immunization: done
 Hospitalization: not significant.
 Habits: non-vegetarian.
 Sleeping pattern: disturbed due to hospital environment and disease.

PRESENT SURGICAL HISTORY: not significant.

PAST SURGICAL HISTORY: not significant
FAMILY HISTORY
Type of family: joint

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 a) Composition of family members- 5

S.No Name of family Age Sex Education Occupation Marital Health Condition
members Status
1. Mr. Govind 56 Male Graduate Private job Married Healthy
years
2. Mrs Nirmala 54 year FA Graduate House wife Married healthy
devi
3. Mr Rahul 24 MA Graduate private unmarried patient
employee
Year

b) Family tree:
KEY POINTS:
Male=

Mr. Govind mrs nirmala

Female =

Mr.rahul
Patient=

c) Family Medical History: not significant.

PERSONAL HISTORY
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  Diet- soft diet
 Number of meals per day: 3 times a day
 Food allergies, food preferences: soft diet. No food allergies.
 Bowel & Bladder habit- regular
 Frequency of Micturition: 5-6 time per day
 Frequency of defecation: normal
 Sleep pattern: disturbed due to hospitalization and disease.
 Smoking: non-smoker
 Alcohol Consumption: non-alcoholic
 Tobacco chewing: not significant

Psychosocial history:
 Languages spoken: Hindi
 Social support systems present.
 Any psychological stressors present: anxiety related to associated disease.

PHYSICAL EXAMINATION
GENERAL APPEARANCE AND BEHAVIOUR
 Body build- normal
 Hygiene & grooming – well groomed
 Mobility status- mobile
 Activity level- dull
 Pallor: yes
 Jaundice: absent
 Consciousness-oriented to person, place, time

ANTROPOMENTRIC MEASUREMENT
 Height: 157 cm
 Weight:53kg

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  BMI= WEIGHT IN KG/ (height in meters)2= 20kg/m2

VITAL SIGNS

Date temperature Pulse Respiration Bp

28/01/2019 97.5 F 85 bpm 20bpm 140/90 mmHg

SKIN: -
Inspection
 Colour – Fair.
 Lesion – no Primary, Skin lesions, secondary skin lesions
 Vascularity: - no Ecchymosis, Petechiae

Palpation
 Moisture: dry
 Texture: - rough
 Turgor: - normal
 Temperature: - warm

HAIR AND SCALP: -

Hair
 Colour: - black
 Texture: - rough
 Distribution: - normal

SCALP
Dryness present. No Lumps, Lesions, Pediculosis and dandruff is present.
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HEAD
No head injuries
NAILS
 Nail bed color: - pale
 Shape of nail plate: - flat
 Tissues surrounding nails: - intact
 Blanch test of capillary refill: - intact
 Blanch test of capillary refill: - 4 sec

SKULL: normocephalic
FACE
 Color: fair
 Symmetry: symmetrical
 Edema: - not present
 Involuntary movements: -not present
 Examination of Trigeminal nerve: sensory: he was not able to distinguish between sharp and soft touch.
Motor: bilateral equal tension.
 Examination of facial nerve: sensory: corneal reflex present.
Motor: symmetrical facial expressions.
EYES & VISION: -
External structures

 Eye brows: present

 Hair distribution: equal
 Scaling & Flakiness of skin: not present
 Alignment & movement of eyebrows: symmetrical
 Iris/ pupil: normal

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  Eye lashes: - no sty and other infection
 Eye lids: - no ptosis/ectropion/entropion.
 Conjunctiva: - pink
 Sclera: - White
 Cornea: soft
Pupils: -

 Reaction to light: pupils constriction to light

 Coronal reflex: - present
 Enophthalmos: not present
 Ptosis: absent
 Examination of optic nerve: Bilateral pupillary constriction to light
 Visual acuity: - 6/6 (both right and left eye).

EARS:
Auricles
 Colour: - normal
 Alignment: - symmetrical
 Elasticity: -pinna recoils after it is folded
 Tenderness: - non-tender

External ears
No redness and discharge. Dry cerumen present
Hearing acuity:

 Weber test: - sound is heard in both ears. Equal laterization of sound.

 Rinne’s test: - AC>BC

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NOSE AND SINUS:

 Nasal septum: - deviated

 Facial sinuses (maxillary, frontal): - no tenderness
 Smell (examination of olfactory nerve): - Normal
 Any other problem: no discharge, no tender, no lesions

MOUTH AND OROPHARYNX

1. LIPS

 Color: - darkening
 Texture: - dry
 Angular stomatitis: not present

2. BUCCAL MUCOSA

 Color- reddish dark

 Texture-Moist
 Presence of lesions: not present

3. GUM
 Colour- dark complex
 Texture- Moist firm
 Gums bleeding/Gingivitis: not present

4. TEETH: dental carries

5. TONGUE
 Position-Central
 Colour and texture-Pink Colour, moist, smooth lateral margins, no lesions.
 Tongue base- smooth tongue base with prominent veins

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  Mobility- Moves freely

6. FLOOR OF MOUTH: Smooth with no nodule

7. TONSIL: not enlarged

8. PALATE
 Light Pink & smooth soft palate
 Light pink hard palate,

9. UVULA: Midline in position

10. OROPHARYNX

 Taste: normal
 Odor of mouth: no foul odor
 Gag reflex: present
 Swallowing reflex: present
NECK: -
Muscle
 Size: Equal and Head centered
 Head movement: - Coordinated smooth movements with no discomfort
 ROM: rotation, extension, flexion is possible.
 Lymph node: not enlarged
 Trachea: midline
 Thyroid gland: not enlarged
 Jugular veins: not distended

CHEST
Thorax and lungs

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Posterior thorax

 Shape and symmetry: - normal shape

 Movement of chest: equal
 Percussion: -resonant sound
 Auscultation: -– bilateral normal breath sound present

Anterior Thorax
Inspection
 Shape &symmetry: - normal
 Movement of chest: Equal
 Any deformity- absent
 Dyspnea on rest- absent
 Dyspnea on expansion- absent
Palpation:
 Symmetrical chest expansion- symmetrical
 Any tenderness- no
 Lump or mass- No
 Skin Temp – warm
 Moisture- dry
Percussion: - resonant sound
Auscultation: - bronchial sound
BREATHING PATTERN-
 Regular
 Respiration rate- 24 breath/min
 Breathing via oxygen mask- no
 Breathing via ET tube- No
 Breathing via F piece- No

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  On ventilator- No

CIRCULATORY SYSTEM:

 Pain: not present

 Numbness: not present
 Syncope: absent
 Dizziness: absent

HEART:

 Heart sounds: - S1& S2

 Chest pain- not present
 Any other heart disease or any problem- no history of hypertension.
CHEST AND AXILLAE
 Symmetry: symmetrical
 Lymph nodes: not enlarged
 No gynecomastia.

ABDOMEN:

 Position of umbilicus: central

Inspection

 Contour of the abdomen: mild distension.

 Shape of abdomen: flat and symmetrical.
 Umbilical hernia: not present.
 Umbilicus: clean
Percussion: - mass
 Bowel sounds: present,
 Inguinal hernia: not present

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  Appetite: decreased
Palpation:
 No Hepatosplenomegaly
BACK
 presence of decubitus ulcer: not present.
NUTRITIONAL:

 Appetite: decreased
 Nausea: absent
 Vomiting: absent
 Pain related to eating: absent
 Dysphagia: absent
NEUROLOGICAL:
 Confusion: absent
 Convulsions: absent
 Loss of strength: yes
 Weakness: present
 Pain: present
 In-coordination: absent
 Changes in sensation: no
 Tingling /pricking: absent
 Level of consciousness: conscious, orientated

REFLEXES
Superficial reflexes
 Superficial abdominal reflex: physiological absent.
Deep reflexes
 Biceps reflex: reactive

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  Triceps reflex: reactive
 Patellar reflex: reactive
 Achilles reflex: reactive
INTEGUMENTARY SYSTEM:
 Skin color: Fair complex
 Texture: dry
 Skin turgor: decreased
 Hydration: hydrated
 Discoloration: not present
 Pigmentation: not present
 Lesions /masses: absent
ENDOCRINE SYSTEM- no goiter, no thyroid tenderness, no tremors and weakness.
hormone therapy: no.
HEMATOLOGIC SYSTEM – Any known abnormalities of blood cells: no
MUSCULOSKELETAL SYSTEM:

 Postural curve: kyphosis

 Muscle tone: normal
 Muscle strength: week
Upper extremities:
 Inspection: - symmetrical, right arm deformity, and swelling.
 Palpation: - no edema, tenderness present
 ROM: adduction, abduction, extension, flexion not possible of right arm.
 Finger nails: capillary refille of right hand take times
 Peripheral pulses: Radial: - 78 beats per minute
 Triceps: reactive
 Edema/swelling: swelling present
 Cyanosis: present in right arm

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  Joint: absent

Lower extremities:
Muscle
 Symmetry: symmetrical
 Contractures/tremors/atrophy/hypertrophy/asymmetry: No
 Muscle tone: normal
 Toe nails: capillary refill 3 seconds
 Range of motion: possible
 Reflexes: patellar – reactive
 Edema/swelling: not present
 Cyanosis: absent
 Joint: no pain
 Deformity: absent
 Other signs /symptoms: loss of sensation in lower limb.
GENITOURINARY SYSTEM –

 no history of STD
 incontinence
 Catheterized.

RECTUM&ANUS:

 Perineal skin integrity: intact

 Bowel elimination pattern: diarrhea
 Subjective symptoms: no other subjective complaints

INVESTIGATIONS DONE:

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 Investigation Patient value Normal value Remarks

Heamoglobin 12.7 mg/dl 13- 17mg/dl Normal

TLC 18.8 7+/ 3.0 Increased
Neutrophil 82 40-80% Increased
LYMPHOCYTES 33 20-40% Normal
Esonophil 1.3 01-06% Normal
Blood urea nitrogen 7 6.0-23.0 mg/dl Normal
Serum urea 11 10-45 mg/dl Normal
Serum creatinine 0.9 0.2-1.2 mg/dl Normal
Serum uric acid 6.6 2.4-7.0 mg/dl Normal
Bilirubin total 0.2 0.2-1.0 mg/dl Normal
Bilirubin direct 0.02 0-0.3 mg/dl Normal
SGOT 83 5.0-40 IU/L Normal
SGPT 84 5.0-40 IU/L Normal
Alkaline phosphate 72 40-129 U/L Increased

ESR 12 0-15 Normal

TREATMENT CHART
Sr. Name of the Drug Dose Route Frequency Action
no.
1) Inj doxicyclin 1 gm IV BD Board spectrum antibiotic
2) Inj Pantocid 40 mg IV BD PPI
3) Inj Emset 4 mg IV SOS Antiemetic
4) Inj Voveron 75 mg IM SOS Analgesics
5) Tab calcium 500mg orally BD
6) Capsule B-complex 400 mg Oral OD Vitamin E supplements

NURSING MANAGEMENT

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NURSING ASSESSMENT
 History : Ask for past history of cardiac disorder, liver disorders, Hypertension, Diabetes etc.
 Ask for any family history.
 Ask for history of smoking, alcoholism and occupation.
 Assess for chief complaints.
 Assess the client for the multiple effects of gall bladder on all body systems
 Cardiac monitoring
 Strict intake output monitoring
 Regularly assess the biochemistry profile of the patient

NURSING DIAGNOSIS:

 Pain related to pressure on nerve ending as evidence by patient verbalisation

 Impaired physical mobility related to decreased strength as evidence by X-ray reports .
 Risk for infection related to break in continuity
 Self care deficit related to immobility as evidenced by inability to carry out self –care activities to carry out.
 Ineffective therapeutic regimen related to knowledge deficit as evidence by frequent question.

Goals:
Short term goal Long term goal
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 To reduce the pain.  To maintain optimal health care.
 To improve the physical mobility upto some level .  To provide head to foot care.
 To maintain the skin integrity  To rehabilitate the patient.
 To prevent from infection  To maintain aseptic technique.

Nursing Nursing Goal Nursing intervention Nursing

Assessment diagnosis evaluation
Subjective data- Pain related To reduce the  Assess the general condition of the patient By providing
to pressure on pain. all measures
Patient says “ Iam now patients
nerve ending  Monitor vital signs of the patient.
having pain at the pain is reduced
as evidence upto some
site of injury.
by patient level.
 Provide comfortable environment to patient.
verbalization

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 .  Administer medication (analgesics) as prescribed by

Objective data-
doctor
 I observed the
physical
expression of
the patient.

Assessment Nursing Expected Implementation Evaluation

diagnosis outcome

Sub data- Impaired To improve Physical

physical the physical • Assess the general condition of the patient mobility is
The patient says mobility mobility improved upto
• Monitor vital signs of the patient.
that “iam not able related some level .
decresed • check the ROM of the patient
to move my arm “ .
strength as • Advice the patient for movement of the hands and
evidence by fingers

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Objectiv data X-ray reports

I observed that
patient having
fracture by
checking X-ray
reports

Assessment Diagnosis Goal Planning Evaluation

Subjective data Risk for To prevent Assess the general condition of the patient Risk of
Patient says “ I infection related from infection is
have irritation on to break in skin infection reduced
the site of injury ’’ . continuity . upto some
Advice to use antiseptic at site of fracture level.
Objective data
I observed the mild
redness and
swelling at the site Take the healthy diet
of injury

Administer antibiotics to patient .

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 Assessement Diagnose Goal Intervention Evaluation
Subjective data: self care deficit to improve the  Assess the general Activity level is improved upto
Patient says related to activity level of the condition of the patient . some level
that:iam not able to immobility patient
perform my daily evidence by
activities. inability to carry out
self care activities  Assist the patient in her
successfully daily work

 Provide the support to the

patient

OBJECTIVE
DATA :I observed
that patient is not
able to perform her

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daily work alone

HEALTH EDUCATION:
 Diet- Patient is taught regarding balanced diet, rich in fibers and fluids. Patient is advised to take green vegetables, fruits, juices &
salad in diet and to avoid fat rich diet
 Exercise – Patient is taught some active & passive exercise. Patient is advised to do deep breathing exercise.
 Hygiene – Patient is advised to keep her surroundings clear & perform hand hygiene properly.
 Fluids – Patient is advised to take more fluids & beverages.
 Pain management & Medications - Analgesic medication timing is clearly explained to patient & with that feedback for
medications intake is also taken.
 Follow Up- Follow up dates are given to patient & them should be clearly explained regarding it. The patient was referring to
oncology ward and all its treatment was explained to her.

Conclusion:
I was posted in female ortho ward at Dr. RPGHC Tanda, where I took a case of right arm fracture . I took detailed history of
patient & performed physical examination on patient. I provided all the need-based care to my patient. with that I maintained good

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IPR with patient & listened her difficulties & problems. I provided health education to my patient. In future, if I will get the similar
case, I will be able to provide holistic care to my patient.

References:

 Brunner and Suddarth’s ‘ Textbook of Medical Surgical Nursing’ 9th edition 2001 page: 1234-1248

 Smeltzer CS, Bare B. Brunner & Suddarth’s Textbook of Medical Surgical Nursing. 10th ed. Philadelphia(PA): Lippincott
Publishers; 2006.

 Chintamani. Lewis’s Medical Surgical Nursing. 7thed. New Delhi: Elsevier limited; 2010.

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