Tibial Fracture

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NURSING ASSESSMENT

Present Health History

The patient, Francis Lumasac, is a victim of nature-insinuated accident. The incident happened in the morning of July 6, 2006 wherein Francis and 3 of his friends are having their lunch at a mountain slope in their place. A large branch of tree hit him at the back and at the same time another struck him at his left leg. Immediately he was brought to Paulino J. Garcia Memorial General Hospital at Cabanatuan. Treatments were done such as Closed Tube Thoracotomy due to the impact of the branch on his posterior chest; wound cleaning and wound dressing for the injury he obtained from the impact at his left leg. He noticed that the healthcare providers in the said hospital did nothing but to clean his wounds and replace the dressing, so he decided to transfer to another hospital. On July 29, 2006 he was admitted by Dr. Geronilla at the East Avenue Medical Center wherein his admitting diagnosis is Open Complete Comminuted Fracture at the left tibia, fibula. The following day, July 30 at exactly 3:50pm he had undergone an operation conducted by Dr. Tagaba and was given a spinal anesthesia by Dr. Sangcate. The operation performed was Debridement Impaction and Application of External Fixator at the left tibia.

Past Health History

Prior to his hospitalization at Cabanatuan and Quezon City, he had no records or medical history of being admitted with any disease to any other hospital.

Family Health History

No hereditary disease can be attributed from his mother side, but his father died of asthma. Other than the latter, no other hereditary disease from both of his parents are within the patient’s knowledge.

Demographic Data | Physical Assessment and General Appearance | Head to Toe Assessment

Gordon’s Functional Health Pattern

? Health-Perception/ Health Management Pattern

The patient is almost generally the same as how every Filipino seeks health assistance. Without any problem regarding his health, he would not approach health workers not unless it is life-threatening.
Although he was not hospitalized prior to his current illness, the patient has the proper perception whether he is being treated correctly as with the management done to him at the hospital in Cabanatuan.

? Nutritional/ Metabolic Pattern

The patient eats three times a day. He says that he eats a balanced diet. Although he is not fond of eating fish, he loves to eat vegetables such as okra and is fond of munching fruits like bananas and catmon. He usually drinks coffee every morning. He prefers to drink water than carbonated beverages. During his hospital stay, he is instructed with diet as tolerated.

? Elimination Pattern

According to the patient, when he is at home or even at work he usually defecates for at least once a day, same as with his stay in the hospital. He urinates more frequently (average of 4 times daily) during his stay at the hospital than the time prior to his admission.

? Activity/ Exercise Pattern

For his leisure time, the patient likes to have drink with friends. He often does this almost once a week, drinking a glass or two of gin or brandy. Aside from drinking, he is also fond of smoking cigarette, consuming almost 10 sticks a day. He started drinking and smoking almost 5 years ago. He is not fond of playing physical games. He implied that he would rather watch television and court a girl.

? Sleep-rest Pattern

The patient sleeps for an average of 8 hours per day before his confinement. During his hospital stay, he usually sleeps for 4 hours and takes nap in the afternoon. He had a difficulty of moving around the bed due to the external fixator attached to his leg.

? Cognitive/ Perceptual Pattern

From his point of view, he has a good memory. He says that he can still remember things of great importance especially with regards to his family and loved ones. His hearing ability is also in normal condition and so does his sense of sight.

? Self Perception/ Self-Concept Pattern

The patient says that he is very much comfortable with his body image prior to his injury. Even if his left leg is injured, he still feels optimistic about regaining his old functionality and image.

? Role/ Relationship Pattern

He still lives with his mother and performs his obligations as a son. The patient did not confirm that he is into an intimate relationship right now.

? Sexuality & Reproductive Pattern

Being 5th among children of six wherein 5 of them are female and him, the only male among them, he managed to have a stable gender identity during his growing years.

? Coping/ Stress-tolerance Pattern

As part of his stress-tolerance activity, the patient likes to listen to soothing music to relieve him from anxiety. He also smokes for that matter and often he relaxes his body by taking a time off his work and spending time with his friends.

? Value/ Belief Pattern

The patient is a Roman Catholic, but not really the type of follower who goes to the church every Sunday to hear mass. He makes his decision in accordance to his principles in life and how he perceives it.

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