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Cerebral Palsy

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I. INTRODUCTION Background and rationale of the study: One of the leading cases of musculoskeletal trauma is fracture. Fractures are any break in the continuity of the bone. It usually occurs when the stress placed on a bone is greater than the bone can absorb. Muscles, blood vessels, nerves, tendons, joints and other organs may be injured when fracture occurs (Nettina, Sandra B. 2006). It can be caused by metabolic bone diseases such as osteoporosis, or as a result of direct force when a moving object strikes the body area over the bone, or it could result from accidental falls. Accidental falls is on top of the list when we talk about fracture causes, and it can happen as a result of lack of balance and poor muscle coordination. It can also happen because of underlying neuromuscular disorders like cerebral palsy. Cerebral palsy includes a wide variety of non-progressive brain disorders that occur during intrauterine life, delivery, or early infancy. It is defined as a syndrome of motor disabilities possibly accompanied by mental retardation, seizures, or both. Causes of cerebral palsy are many and include cerebral developmental disorders such as microcephaly, intracranial hemorrhage, cerebral anoxia, and toxins such as excessive bilirubin. Prenatal factors include infection with rubella, nutritional deficiency, and blood factor incompatibility (Bullock and Henze, 2000). One of the most common types of cerebral palsy, that accounts for 50% of all CP cases, is the Spastic cerebral palsy. It has three different subtypes mainly: diplegia, which mostly affects the lower extremities; Quadriplegia, where all four extremities are involved; and lastly Hemiplegia, the most common type of spastic CP and it involves one side of the body. The author of this study chose the above mentioned case because the author would want to make a connection between the two major diseases occurring in one individual, since the occurrence of one would not necessarily mean the presence of the other. Likewise cerebral palsy patient are thought to be somebody that should be given special attention and care because of the affected individuals inability to perform activities of daily living, and to have a CP patient get injured indicates that there must be some negligence on the part of the direct care giver, who is the mother. Moreover cerebral palsy patients have a high seizure tendency and soft brittle bones due to lack of usage of the extremities contributing to the risk of acquiring injuries such as fracture. With the given information above, the researcher would like to know more about the disease condition and to provide important information to the parents of the child to avoid future injuries. Objectives of the study: This study aims to obtain information regarding Cerebral palsy and closed subtrochanteric fracture of the femur. It as well intends to analyze the diagnostic findings of a patient diagnosed with this condition and to identify medical and surgical interventions appropriate for this disease. Lastly this study aims to provide holistic nursing care to patients diagnosed with this disease. SPECIFIC OBJECTIVES: • To know conditions that can possibly lead into cerebral palsy and fracture of the femur. • To be able to connect cerebral palsy to the development of fracture and their relationship to each other. • To be able to gather information on medical interventions and surgical interventions available to possibly cure this disease condition. • As a nurse, to enumerate the responsibilities specific to this kind of disease in order to render compassionate and holistic nursing care. Significance of the study: As we all know Cerebral palsy is not a common condition. This means hat nit too many in society know about the disease, while fracture on the other hand is very common. Like for example, at the Vicente Sotto Memorial Medical Center Orthopedics ward. 70% of the censuses are diagnosed with fracture while cerebral palsy only accounted for 0. 5% of the total census for the whole week of June. This study provides the readers information regarding fracture and cerebral palsy since the presence of the latter predisposes the occurrence of the former. It informs regarding the possible causes, signs and symptoms, and corresponding management to avoid and treat the condition. People with this condition will benefit from this study through their health care providers who will be educated on the proper interventions to promote their fast recovery of their fractured femur and to prevent the injury from occurring by eliminating risk factors. The health care providers will profit from this study through obtaining past and current interventions to promote fast healing and recovery of fractures. They will also benefit in terms of knowing the right seizure precautions, to avoid such injuries from happening again during the course of the disease or in the future, when fracture recovery is already obtained. The study will profit the parent of the patient, since the understudy is a seven year old child and can not read or talk, because it will provide them the right information regarding the child’s condition. It will educate them on the proper precaution that has to be observed in order to avoid injuries if ever seizure episodes of their child occur. Methodology: The study was conducted in Vicente Sotto Memorial Medical Center during a week of exposure at Ward VIII (Ortho Ward). A patient with the name of N. F. S. O. was chosen personally by the student nurse under the guidance of his clinical instructor. She was assisted with her physical, emotional and psychological needs within the next 4 days. Within the allotted time, the patient was rendered with holistic nursing care. The first meeting of the student nurse and patient was devoted to establishing therapeutic relationship in order to gain trust, cooperation and participation from the patient during the course of the treatment. In addition, a physical assessment was also done to obtain baseline data and for the purpose of documentation. This was performed with the aid of the Orthopedic physical assessment form. Following the initial observations, nursing problems were identified. To address the problems recognized, nursing care plans were made to guarantee holistic nursing interventions. The implementation of those plans was reserved to the remaining days of the exposure. Likewise, SOAPIE chartings were done to help test the behavioral outcomes or responses of the patient to interventions done. Then with the support from the clinical instructor who also served as the adviser, the student nurse was guided as to her responsibilities to the patient. Overall, this study is more of evidence on what happened with the activities that have been performed to the patient. And together with the efforts of a multidisciplinary collaboration this study was made possible. II. SITUATIONAL APPRAISAL Patient’s profile: • Name: N. F. S. O. • Age: 7 years old • Sex: Female • Civil Status: Child • Nationality: Filipino • Religion: Roman Catholic • Address: Englis V. Rama, Cebu City • Father: E. O. • Mother: E. T. • Admitting Doctor: Dr. Pia Kareena V. Quinones • Admitting Diagnosis: 1. Fracture Left Subtrochanteric Femur 2. Cerebral Palsy • Admission Date and Time: June 20, 2008: 4:00pm • Hospital Number: 716702 • Diet: Diet as Tolerated • Chief complaint: left leg pain Patient’s History: On June 20, 2008 at around 9-10 AM in the morning patient and his younger brother was playing peek-a-boo, while the mother was washing their cloths, when the brother accidentally sat at the patient’s stroller causing the patient to fall on the floor. And since the patient is a quadriplegic cerebral palsy patient, her left leg was severely bruised. Patient kept on crying and crying even with no movement and manipulation. This prompted the parent’s to admit the child to Vicente Sotto Memorial Medical Center at around 4:00PM. During Assessment mother reported that she had a remarkable prenatal history on the patient, and during her delivery child was intubated @ NICU. And since then child can not walk nor talk. Child has started to exhibit seizure episodes at her 2nd year and 8th month and since then child is being maintained with Phenobarbital 1 Grain. Assessment Findings: Musculoskeletal: There is no muscle coordination. With contractures on the four extremities noted. Pain on the left leg, with some scars on the left foot noted. Patient cannot stand up, nor sit down. She also could not talk, but is able to grasp her feeding bottle. Left and right arm are identical in terms of length and measures 28 cm. While there is a slight deviation in her two legs, as the left is slightly shorter than the right. Left measures 57 cm, while the right is at 58 cm. HEENT: Patient’s head is normocephalic with irregular skull contours. There was no mass or lesions noted. Hair is oily with some dandruff. Pupils are round and reactive to light and accommodation, 2mm in size with arcus seniles evident around brown iris, ecteric sclerae. Pale palpebral conjunctiva was noted, no eye discharges. Upon palpation, no edema or tenderness over lacrimal gland and also there was no tearing noted. Pinna recoils after being folded and are aligned with the outer canthus of the eyes. No lesions or discoloration were noted on outer ear. Intact nose bridge at the midline, with slight nasal flaring noted, pink mucosa with cilia, with clear nasal discharges. Sinuses are not tender or painful upon palpation. Thyroid gland is nonpalpable as well as cervical lymhpnodes. Trachea is at midline. Respiratory: Patient has a labored expiration and was breathing at a rate of 32 cpm. Upon auscultation, rales are audible on all quadrants, crackles noted. Chest indrawing is visible during inspiration and expiration. Cardiovascular: Patient’s heart rate is 72 bpm. Apical pulse is audible, clear and without murmurs, with regular rhythm noted upon auscultation. No visible palpitations were noted. Jugular vein distention was not evident. Peripheral pulses were bounding and easily located at dorsalis pedis and carpal areas. Gastrointestinal: Patient has pinkish dry lips without cracks, and white residues in the tongue were noted. Oral mucosa is pinkish, smooth and moist with saliva. She has a total of 24 permanent teeth with visible dental caries. Tongue is pinkish and can move freely, no palpable mass or nodules on surface. Normal bowel sounds, adequately audible on all quadrants with 17 bowel sounds heard in a minute upon auscultation. Upon palpation there is no tenderness or rigidity of the abdomen. Tympani over stomach and bowels, dull sound noted over liver upon percussion. Urinary: Bladder not distended, without pain, urgency and frequency in urination, no flank pain noted. Patient is on diapers. Reproductive: Immature breast noted with no nipple protrusion. Both breasts are equal. Areola is round and darker in color. Nipples are round, and equal in size, no discharges were noted, no cracks. Skin is intact without lesions, masses, striaes and dimpling in both breasts. Labia majora and minora are intact. No discharges and swelling noted. OB- Gyne history: Patient has not had her menarche yet. Neurologic: CN 1: anosmia noted. Patient can not identify odor. CN 2: Patient can not read. CN 3: pupils equally round and reactive to light and accommodation CN 4: there is some unequal movement in both eyes. More like of a strabismus, but it is not that profound. CN 5: equal face sensation, no facial palsy, able to move upper and lower jaw CN 6: patient is unable to move her eyes from one side to the other. CN 7: able to frown, able to smile, able to raise and lower eyebrows, able to close eyelids, able to taste sweet, sour, salty and bitter. CN 8: Patient can not stand up nor sit down, and can not hear voice, at a normal rate, within 5 feet distance. CN 9: Able to taste sweet, sour, salty an bitter, Gag reflex intact as evidenced by ability to swallow CN 10: When patient said “ah”, upward and downward movement of the palate and oropharynx was noted CN 11: able to flex head but patient was having a hard time shrugging her shoulders due to the present of contractures in both upper extremities. CN 12: Able to stick out tongue to the midline, tongue freely moves inside the oral cavity Patient was unable to perform finger to nose test with difficulty of speech and articulation, with a 0 grade patellar reflexes on lower extremities and 0-grade also for triceps and biceps reflexes on both upper extremities. Psychological: Patient can not talk, stand and sit. Exhibits a blank stare often times, and cries whenever she has problem breathing and when she does not like the food or when she is hungry or feels humid and sleepy. Anatomy and Physiology The femur , the longest and strongest bone in the skeleton, is almost perfectly cylindrical in the greater part of its extent. The femur, like other long bones, is divisible into a body and two extremities [pic] Figure 1-Anterior View of the Femur Upper Extremity (proximal extremity) The upper extremity presents for examination a head, a neck, a greater and a lesser trochanter. The Head (caput femoris) Its surface is smooth, coated with cartilage in the fresh state, except over an ovoid depression, the fovea capitis femoris, which is situated a little below and behind the center of the head, and gives attachment to the ligamentum teres. The cartilage provides smooth articulation. The Neck (collum femoris). The neck is a flattened pyramidal process of bone, connecting the head with the body. The Trochanters. The trochanters are prominent processes which afford leverage to the muscles that rotate the thigh on its axis. They are two in number, the greater and the lesser. The Greater Trochanter (trochanter major; great trochanter) is a large, irregular, quadrilateral eminence, situated at the junction of the neck with the upper part of the body. Tubercle of the femur; it is the point of meeting of five muscles: the Glut? us minimus laterally, the Vastus lateralis below, and the tendon of the Obturator internus and two Gemelli above The Lesser Trochanter (trochanter minor; small trochanter) is a conical eminence; it projects from the lower and back part of the base of the neck. Point of attachment for Psoa’s major. Body or Shaft (corpus femoris). The body, almost cylindrical in form, is a little broader above than in the center, broadest and somewhat flattened from before backward below. [pic] Figure 2- Posterior view of the femur B. The Lower Extremity (distal extremity) The lower extremity, larger than the upper, is somewhat cuboid in form, but its transverse diameter is greater than its antero-posterior; it consists of two oblong eminences known as the condyles. These condyles at the distal end of the femur articulate with the tibia. Epicondyles, located medial and lateral to the condyles are points of ligament attachment. The patella or knee cap, is located within the major tendon of the anterior thigh muscles and enables the tendon to turn the corner over the knee. [pic] Figure 3- Parasympathetic and Sympathetic Nervous System The Brain Three cavities, called the primary brain vesicles, form during the early embryonic development of the brain. These are the forebrain (prosencephalon), the midbrain (mesencephalon), and the hindbrain (rhombencephalon). During subsequent development, the three primary brain vesicles develop into five secondary brain vesicles. • The telencephalon generates the cerebrum (which contains the cerebral cortex, white matter, and basal ganglia). • The diencephalon generates the thalamus, hypothalamus, and pineal gland. • The mesencephalon generates the midbrain portion of the brain stem. • The metencephalon generates the pons portion of the brain stem and the cerebellum. • The myelencephalon generates the medulla oblongata portion of the brain stem A second method for classifying brain regions is by their organization in the adult brain. The following four divisions are recognized. [pic] Figure 4- Lobes of the Cerebrum, Sagittal Section of the Brain, and Ventricles of the Brain The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve fibers, the corpus callosum. The largest and most visible part of the brain, the cerebrum, appears as folded ridges and grooves, called convolutions. The following terms are used to describe the convolutions: • A gyrus (plural, gyri) is an elevated ridge among the convolutions. • A sulcus (plural, sulci) is a shallow groove among the convolutions. A fissure is a deep groove among the convolutions. • The deeper fissures divide the cerebrum into five lobes (most named after bordering skull bones)—the frontal lobe, the parietal love, the temporal lobe, the occipital lobe, and the insula. All but the insula are visible from the outside surface of the brain. • A cross section of the cerebrum shows three distinct layers of nervous tissue: • The cerebral cortex is a thin outer layer of gray matter. Such activities as speech, evaluation of stimuli, conscious thinking, and control of skeletal muscles occur here. These activities are grouped into motor areas, sensory areas, and association areas. [pic] Figure 5-The human central Nervous System • The cerebral white matter underlies the cerebral cortex. It contains mostly myelinated axons that connect cerebral hemispheres (association fibers), connect gyri within hemispheres (commissural fibers), or connect the cerebrum to the spinal cord (projection fibers). The corpus callosum is a major assemblage of association fibers that forms a nerve tract that connects the two cerebral hemispheres. Basal ganglia (basal nuclei) are several pockets of gray matter located deep inside the cerebral white matter. The major regions in the basal ganglia—the caudate nuclei, the putamen, and the globus pallidus—are involved in relaying and modifying nerve impulses passing from the cerebral cortex to the spinal cord. Arm swinging while walking, for example, is controlled here Pathophysiology Etiology: • Trauma • Stress and fatigue • Direct or indirect force • Falls • Cerebral anoxia Risk factors: • Metabolic bone diseases, such as osteoporosis Neoplasm • Osteogensis imperfecta • Osteopenia • Postmenopausal estrogen loss • Protein malnutrition • Seizure tendencies Patient’s etiology: Cerebral Palsy and Trauma Cerebral Anoxia v Spastic cerebral palsy v Quadriplegic type static cerebral palsy v Soft and brittle bones v Trauma v Stress placed on bone exceeds the bone’s ability to absorb it v Break in the continuity of the bone v Muscles attached to the bone are disrupted v Muscles undergo spasm and pull fracture fragments out of position v Distal portion of the femur is displaced v Periosteum and blood vessels in the cortex and marrow of the fractured bone are disrupted v Soft tissue damage v Bleeding occurs from both the soft tissue and from the damage ends of the bone v Signs and symptoms: • pain, • edema, • tenderness of fractured site • abnormal movement and crepitus • loss of function • ecchymoses • visible deformity, • shortening of affected limb • paresthesias • All four extremities are involved. • The individual is non-ambulatory and is not able to acquire speech and no sphincter control. • Contractures on all four limbs III. SUMMARY OF MEDICAL AND SURGICAL MANAGEMENT Diagnostic studies: For fracture and cerebral palsy A. ACTUAL Radiography (X-RAY) - is the most widely used non-invasive musculoskeletal diagnostic procedure. X-ray examinations are used to do the following: • Establish the presence of a musculoskeletal problem • Follow its progress • Evaluate the effectiveness of the treatment A palin film is obtained, usually an anteroposterior or lateral view, possibly both. Patient’s X-ray result: The radiograph study was taken last June 20, 2008 to help diagnose the patient’s skeletal condition. The results showed that there was a fracture on the patient’s left subtrochanteric region of the femur. Complete blood count (CBC) Table 1- Complete Blood Count |HEMATOLOGY | |Blood components |Results |Normal value |Unit |Interpretation | |WBC |12. 7 |4. 8 – 10. 8 |10^9/L |Increased | |RBC |4. 2 |4. 2 – 5. 4 |10^12/L |Within normal limits | |Hemoglobin |12. 4 |F= 12. 6 – 16. 0 |g/L |Slightly decreased | |Hematocrit |0. 373 |F=0. 370 – 0. 470 |l/L |Within normal limits | |MCV |87 |81 – 99 |fl |Within normal limits | |MCH |28 |27. – 31. 0 |pg |Within normal limits | |Platelet |302 |150 – 450 |10^9/L |Within normal limits | |Neutrophils |63. 4 |40. 0 – 74. 0 |% |Within normal limits | |Lymphocytes |20. 6 |19. 0 – 48. 0 |% |Within normal limits | |Monocytes |7. |3. 4 – 9. 0 |% |Within normal limits | |Eosinophils |2. 1 |0. 00 – 7. 0 |% |Within normal limits | |Basophils |0. 8 |0. 0 – 1. 5 |% |Slightly increased | This laboratory results on the blood components were obtained last June 20, 2008 as part of the diagnostic exams that the patient has to undergo. All the components’ results were within normal limits, except for the WBC, Hemoglobin, and Basophils. He increased white blood cell (WBC) component signifies that there is a possible infection. While the slightly decreased Hemoglobin may indicated low oxygen supply in the blood due to hypoxia. And lastly, the slight increase in the basophile content is a result of the inflammatory process that the patient is undergoing due to fracture. B. IDEAL Arthroscopy- used to detect if the injury has any joint involvement. A fiberoptic arthroscope allows endoscopic examination of various joints (hip, knee, shoulder, elbow, and wrist) without making a large incision. Arthroscopy can be used for 1) Obtaining a biopsy specimen, 2) assessing articular cartilage, 3) removing loose bodies, and 4) trimming cartilage. It is usually an out-patient procedure performed with the use of local anesthesia. The client recovers more quickly that after an arthrotomy (opening of the joint). Computed tomography (CT) - assists in determining the extent of bony destruction, and in better delineating bony architecture. CT will also help in better understanding intralesional calcifications. As with plain radiographs, disappearance or change in the nature of calcifications with repeat scanning can be suggestive of malignancy. Magnetic Resonance Imaging (MRI) – Facilitates the early diagnosis of many conditions that affect tendons, ligaments, cartilage and bone marrow. This is also important in assessing the integrity of the bone. MRI is also indicated and used for cerebral palsy patients since can help identify lesions that may be the cause of seizure for CP patients. Electromyogram - is used to assess such problems as muscle weakness, altered gait, and lower motor neuron lesions. It measures and documents electrical currents produced by skeletal muscles, called muscle action potentials. Small-needle electrodes are inserted into muscles. The electrical potentials of each muscle are amplified, transmitted to an oscilloscope, and displayed on a screen. The recording can be made audible and documented on paper. Electroencephalogram (EEG) – is a measurement of the electrical activity of the superficial layers of the cerebral cortex. The electrical potentials from neuron activity within the brain are recorded in the form of wave patterns. It is helpful in lcating epileptic episodes, spread, intensity, and duration; It can also help classify seizure type since one of the major manifestation of cerebral palsy is seizure. Blood tests are generally not helpful in making the diagnosis, although they can be used to make sure that there is no other process going on, such as infection or any bone malignancy. Source: Black and Hawks. 2005. Medical-Surgical Nursing. Clinical Management for Positive Outcome. Volume 1. 7th edition. Singapore Elsevier. Medical Management ACTUAL Table 2- Drug Summary of Tramadol Hydrochloride |Name of |Classifications |Mechanism |Patient’s |Contraindications |Side | |Drug | |of Action |Indication | |Effects | Nursing Responsibilities: Before: ? Baseline vital signs were taken prior to the giving of tramadol. ? Assessed the type, location and intensity of pain ? Assessed patient’s bowel function routinely ? Checked patient’s history of hypersensitivity to tramadol. ? Observed aseptic technique in drug preparation ? Checked doctor’s order before administration of tramadol During: ? Observed the RIGHTS in drug administration ? Maintained aseptic technique in drug administration ? Tramadol was administered every 6 hours as prescribed. ? May be administered without regards to meals ? Tramadol 15mg was given via IVTT every 6 hours to relieve pain After: ? Instructed patient’s S. O. n how and when to ask for pain medication ? Cautioned patient’s S. O to avoid from activities that require attentiveness until response to medication is known ? Advised patient’s S. O. to change patient’s position slowly, to minimize orthostatic hypotension ? Cautioned patient’s S. O. to avoid concurrent use of alcohol and other CNS depressants with this medication ? Encouraged patient’s S. O. to turn, cough and let patient breathe deeply q 2hrs to prevent atelectasis Table 3- Drug summary of Acetaminophen Name of |Classifications |Mechanism |Patient’s |Contraindications |Side | |Drug | |of Action |Indication | |Effects | Nursing responsibilities: Before: ? Assessed vital signs especially temperature ? Assessed fever: note presence of associated signs (diaphoresis, tachycardia, and malaise) ? Monitored patient’s serum bilirubin, LDH, AST, ALT and prothrombin time ? Kept acetylcysteine at bedside ? Explained drug therapy to patient’s S. O. During: ? Administered paracetamol with a full glass of water (for PO use) ? Drug may be taken with food or an empty stomach ? Evaluated patient’s hematologic and hepatic function ? Cautioned patient’s S. O. to avoid patient from taking more on product containing acetaminophen. ? Reassessed vital signs especially temperature After: ? Advised patient’s S. O. to let patient take drug as directed ? Advised patient’s S. O. to avoid patient from intake of alcohol ? Advised patient’s S. O. to consult physician if discomfort or if fever is not relieved ? Instructed patient’s S. O. to inform physician before taking OTC meds Table 4- Drug Summary of Phenobarbital |Name of |Classifications |Mechanism |Patient’s |Contraindications |Side | |Drug | |of Action |Indication | |Effects | Nursing responsibilities: Before: • Assessed patient’s history for hypersensitivity to drugs • Equipment for resuscitation and artificial ventilation are made readily available. Assessed location, and characteristic of seizure activity • Obtained patient’s history before initiating drug therapy • Explained drug therapy to patient’s S. O During: ? Assessed for pain. Drug may increase sensitivity to pain ? Evaluated patent’s hepatic and renal function periodically ? Injections should be given deep into the gluteal muscle ? Tablets were crushed and mixed with food for my patient, since she has difficulty swallowing ? Symptoms of drug toxicity: confusion, drowsiness, dyspnea, slurred speech, and staggering were closely monitored After: Prevented risk for Injury by creating an improvised safety measurements like placing pillow at the side of the bed ? Instituted seizure precaution ? Gradually decreased dose while concurrently increasing dose of replacement drug to maintain anticonvulsant effect ? Advised patient’s S. O. not to discontinue medication without consulting physician ? Advised patient’s S. O. to take medication as prescribed ? Cautioned patient’s S. O. to avoid intake of alcoholic beverages ? Cautioned patient’s S. O. to avoid activities requiring focus. Table 5- Drug Summary of Amoxicillin Trihydrate Name of |Classifications |Mechanism |Patient’s |Contraindications |Side | |Drug | |of Action |Indication | |Effects | Nursing responsibilities: Before: ? Assessed for infection (vital signs, wound appearance, sputum, urine, stool and WBC’s) ? Assessed patient for hypersensitivity to Amoxicillin ? Obtained patient’s medication history, before initiating therapy ? Specimens for culture and sensitivity were obtained. ? Explained drug therapy to patient’s S. O. During: ? Observed for signs and symptoms of anaphylaxis. ? Kept epinephrine, antihistamine, and resuscitation equipment at bedside. ? Monitored hgb, hct, RBC, WBC, neutrophils, and lymphocytes. ? Added mineral water for oral suspension to each 50mg/ml bottle. ? Administered only clear solutions. After: ? Advised patient’s S. O. to report signs of superinfection and allergy. ? Instructed patient’s S. O. to comply with drug regimen. ? Instructed patient’s S. O. o report immediately to physician if diarrhea and fever occurs. ? Instructed patient’s S. O. to notify physician if symptoms do not improve ? Checked and assessed patient’s vital signs after drug administration. IDEAL Therapeutic Interventions 1. Emergency management includes splinting fracture above and below site of injury, applying cold, and elevating limb to reduce edema and pain 2. Control bleeding and provide fluid replacement to prevent shock, if necessary 3. Traction used for long bones 4. Skin traction - force applied to the skin using foam, rubber, tapes, and so forth 5. Skeletal traction – force applied to the bony skeleton directly, using wires, pins, or tongs placed into or through the bone 6. External Fixation to stabilize complex and open fracture with use of a metal frame and pin system. Source: http://www. wheelessonline. com/ortho/femoral_shaft_fracture. Management of Femoral Fractures. Accessed last September 25, 2008. Pharmacological Interventions: 1. Local anesthetics, opioid analgesics, muscle relaxant, or sedative is given to assist the patient during closed reduction procedure 2. Closed reduction may also be done with general anesthesia 3. Analgesics are given as directed to control pain postoperatively Source: http://www. wheelessonline. com/ortho/femoral_shaft_fracture. Management of Fractures. Accessed last September 25, 2008 Surgical Management: IDEAL Open reduction and Internal Fixation (ORIF) – To perform open reduction, the surgeon makes an incision and realigns the fracture fragments under direct visualization. Open reduction is usually performed in combination with internal fixation for femoral and joint fractures. Screws, pins, plates, wires, or nails may be used to maintain alignment of fracture fragments. After wound closure, splints or casts may be used for additional stabilization and support. External Fixation – Depending on the client’s condition and the physician’s judgment, external fixation devices may be used for fracture fragment immobilization. Source: Black and Hawks. 2005. Medical-Surgical Nursing. Clinical Management for Positive Outcome. Volume 1. 7th edition. Singapore Elsevier. ACTUAL No actual surgical interventions done. IV. PROBLEM ANALYSIS 1. Impaired Physical Mobility related to musculoskeletal impairment secondary to left subtrochanteric fracture of the femur. The patient can not stand, walk, and even sit down without assistance. She can not move her left leg because of fracture. • Impaired physical mobility is defined as a limitation in independent, purposeful, physical movement of the body or of one or more extremities (Doenges, et. al. 333). 2. Risk for injury related to uncoordinated large and small muscle contraction secondary to permanent physical disability, cerebral palsy. • The patient has cerebral palsy with seizure tendencies. Patients with seizure tendencies are always at risk for injury. Just like how the patient got her fracture. At risk of injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources ( Doenges, et. al. 312). • A Seizure is a sudden, abnormal electrical discharge from the brain that results in changes in sensation, behavior, movements, perception or consciousness (Black & Hawks. 2077). 3. Risk for impaired skin integrity related to immobility of left leg secondary to left subtrochanteric fracture of the femur. • The patient had been confined to bed rest for almost 2 weeks already, and because oh her inability to move and turn from one side to the other. She is placed on a great risk of developing bed sores or skin ulcers. • Risk for skin integrity is someone at risk for skin being adversely altered ( Doenges, et. al. 417). 4. Health seeking behavior: proper care of a cerebral palsy patient related to lack of experience. • The patient’s S. O. made herself available for help through health teaching regarding the proper care for her daughter with cerebral palsy and fracture. • Health seeking behavior is defined as active seeking of ways to alter personal health habits and/or the environment to move toward a higher level of health (Doenges, et. al. 278). 5. Self-care deficit: bathing and hygiene related to physical immobility secondary to quadriplegic cerebral palsy. • The patients is suffering from quadriplegia or loss of muscle coordination in all four limbs of the body, thus preventing the patient from performing body hygiene activities such as bathing and brushing the teeth. • Self-care deficit, hygiene, is the impaired ability to perform feeding, bathing, dressing, and grooming or, toileting activities for oneself. Self-care may also be expanded o include the practices used by the client to promote health, the individual responsibility for self-care, a way of thinking (Doenges, et. l. 268). V. DECISIONAL ANALYSIS: NCP 1 Nursing Diagnosis: Impaired physical mobility related to musculoskeletal impairment secondary to left subtrochanteric fracture of the femur. Subjective Cues: No verbal cues noted Objective Cues: • Without IVF • With the ff. Vital signs: T= 37. 2 Celsius; P= 118 bpm; R= 24 cpm • Physical immobility noted • With balance traction • Humming noted Laboratory: • Radiograph results show a break in the subtrochanteric region of the left femur. • Ideal: results of arthroscopy and X-ray Theoretical Basis: Impaired physical mobility is defined as a limitation in independent, purposeful, physical movement of the body or of one or more extremities (Doenges, 333). • Manifestations of fracture include pain at site of injury, swelling tenderness, false motion and crepitus (grating sensation), deformity, loss of function, ecchymosis, and paresthesia (Nettina, Sandra M. 2006. p. 1079). • A radiograph may confirm the bone injury, but it does not show evidence of the torn muscle or ligaments, severed nerves, or ruptured blood vessels that can complicate the client’s recovery (Nettina, Sandra M. 006. p. 1079). Expected Outcome: • Short term goal: After 8 hours of nursing intervention patient’s S. O. will be able to verbalize understanding of the situation/ risk factors and individual treatment regimen and safety measures. • Long term goal: After 40 hours of nursing interventions patient’s S. O. will be able to maintain the patient’s position of function and skin integrity as evidenced by absence of decubitus ulcers and foot drops. Intervention and rationale: A. Independent 1. Determine diagnosis that contributes to immobility R: to identify causative factors (Doenges, et. al. 335). 2. Perform physical assessment while doing tepid sponge bath. R: doing sponge bath is the best way to assess your patient (Kozier ,et. al. 706). 3. Assess patient’s physical and mental status. R: To determine patient’s level of consciousness (Kozier, et. al. 528). 4. Note emotional / behavioral responses to problems of immobility. R: Feelings of powerlessness/frustrations may impede attainment of goals (Doenges, et. al. 335). 5. Instruct patient’s S. O. in use of side rails, overhead trapeze, and roller pads. R: For position changes and transfers (Doenges, et. Al. 335). 6. Support affected body part using pillows and foot supports R: To maintain position of function and reduce risk of pressure ulcers (Doenges, 335). 7. Encourage adequate intake of fluids about 8 -10 glasses per day, and eat nutritious foods. R: Promotes well-being and maximizes energy production. Reduce risk for renal calculi formation and constipation (Doenges, 335). 8. Raise side rails up. R: Proper techniques prevent further injury and promote seizure precautions (Doenges, et. al. 335). B. Dependent/Collaborative . Administer pain medications as indicated. R: To relieve pain (Doenges, et. al. 335). 2. Elevate head of bed. R: To promote maximum comfort and resting satisfaction on the child (Black & Hawks. 604). 3. Administer anti seizure and anti-convulsant drugs, as prescribed. R: To prevent and avoid seizures and decreasing the risk for further damage and injury on the child (Black & Hawks. 2018). At the end of the shift, the patient’s was noted for compliance of the medications. She verbalized willingness to participate in activities that will prevent the complications stated above. She was seen placing pillows on the patient’s side and verbalized that she religiously gave Phenobarbital to her daughter before going into bed, of course with the supervision of the nurse on duty. NCP 2 Nursing Diagnosis: Risk for injury related to uncoordinated large and small muscle contractions, secondary to cerebral palsy. Subjective cues: no verbal cues noted. Objective cues: • Without IVF • With balance traction • No side rails noted • Seizure episodes and tendencies reported by the S. O. • Inability to talk observed • Drooling eyes noted. Laboratory: • NO significant laboratory result Ideal: EEG, MRI and Ct scans to confirm the cause of seizure episodes Theoretical basis: • At risk of injury as a result of environmental conditions interacting with the individuals adaptive and defensive resources (Doenges, et. al. 314). • A seizure is a sudden, abnormal electrical discharge from the brain that results in changes in sensation, behavior, movements, perception or consciousness. A seizure may occur in isolation or with some acute problem within the central nervous system, such as low blood glucose level, drug or alcohol withdrawal, or traumatic brain injury (Black and Hawks. 077). • The goals of management of client’s with seizures and epilepsy are to prevent injury during seizures, to eliminate factors that precipitate seizures, to diagnose and treat the cause of the seizures, and to control seizures to allow a desired lifestyle (Black and Hawks. 2077). Expected Outcome Criteria: • Short term goal: After 8 hours of nursing intervention the patient’s S. O will verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct situation. • Long term goal: After 2 days of nursing intervention the patient’s S. O. ill be able to free the patient from any injury. Intervention and Rationale: A. Independent 1. Assess patient’s physical and mental status. R: It shouldn’t only the physical aspects are assess, but also the intellectual and mental state (Doenges, et. al. , 332). 2. Not age and sex. R: Children, young adults, elderly persons and men are at greater risk (Doenges, et. al. 311). 3. Assess mood, coping abilities, personality changes. R: May result in carelessness without consideration of consequences (Doenges, et. al. 311). 4. Provide information regarding disease condition that may result in increased risk of injury. R: Giving information increases knowledge about a topic or let the client know what to expect and to prevent injury (Kozier, et. al. 277). 5. Raise side rails up or put a pillow on the side of the bed. R: To prevent the patient from falling out of her bed (Doenges, et. al. 311). 6. Stay at patient’s bedside. R: To note and observe possible signs of an upcoming seizure episode (Black and Hawks. 499). 7. Teach patient’s S. O. on the possible signs and manifestations that may prelude to a seizure attack. R: To promote awareness when the nurse is not around (Black & Hawks. 1477). 8. Provide bibliotherapy and written resources R: For later review and self-paced learning (Doenges, et. al. 312). B. Dependent/Collaborative: 1. Administer drugs as prescribed, such as Phenobarbital. R: Phenobarbital inhibits and helps prevent convulsion from happening (Black & Hawks. 2077). 2. Place all sharp objects away from patient’s bedside. R: To avoid accidental injuries if ever seizure occurs (Doenges, et. al. 473). 3. Place patient in a supine position with bed lowered down. R: Supine position is the ideal position for patient’s risk for seizure attacks (Black & Hawks. 2079). At the end of the shift patient’s S. O. placed patient in supine position, and stayed at bedside. She also placed a pillow at the side of the bed and freed the bedside table from any sharp objects, including fork and knife. Patient took Phenobarbital before bedtime. And lastly the patient was free fro injury. DISCHARGE PLANNING: Probable date: August 8, 2008 Destination: Englis V. Rama, Cebu City Transportation: Taxi or public utility vehicle/ jeepney Agencies and equipment involved: • Vicente Sotto Memorial Medical Center Ward VIII • All equipments used in the diagnostics Diet: • a low salt low fat diet yet high in carbohydrates, proteins, vitamins and minerals in order to sustain the patient’s metabolic needs. High in calcium to promote fast recovery and bone healing. Medications: 1. Continue medications as prescribed by the physician; 2. Emphasize the importance of strict medication compliance, especially Phenobarbital. Persons responsible for patient: 1. Dr. Pia Kareena V. Quinones – the physician in charge should give the patient final instructions before leaving the hospital, especially regarding the patient’s seizure tendencies and fracture 2. Staff nurses – help in facilitating the patient’s discharge slip and also give some health teachings that are useful when the patient is at home 3. Family members – to receive the patient and take her home. They will also be listening to health teachings to assist in the needs of the client in the absence of the doctors or the nurses Family conference: 1. Encourage family members to assist client in her needs 2. Emphasize that patient will require more rest than before and caution family members to provide added caution in preventing injury, like never leave the patient alone with her siblings. 3. Advise to provide patient lifestyle modifications and avoid excessive environmental stimulation. Also advise family members to provide adequate nutrition and rest to avoid exacerbation. . Inform that their presence and unconditional support will be of great help to the patient especially during the recovery of the patient’s injury. 5. Anticipated problems: 6. Instruct to watch out for signs and symptoms of infection such as increase temperature, weakness, malaise, rapid respiration and pulse rate. If noted inform them to bring patient immediately to the nearest health agency 7. If bone pain occurs or other unusual signs will be observed refer promptly to the hospital. 8. Instruct patient to always practice minimizing environmental stimulation protocol at all times. To decrease the risk of seizure occurrence. . Emphasize regular follow up examination to monitor progress of disease. Home visit: • Check on patient’s health status once every week especially after cast is removed from the fractured leg. (If patient is undergoing one). • Provide ample assistance and support SOAPIE CHARTING: SOAPIE 1 Subjective cue: No verbal cues noted. Objective cues: o Received on bed, awake, conscious and coherent o Without IVF o With balance traction on left leg o Guarded movements noted o Unable to move left leg Assessment: Impaired Physical mobility related to musculoskeletal impairment secondary to fracture on the subtrochanter of the left femur. Plan: After 8 hours of nursing interventions patient’s S. O. will be able to verbalize understanding of situation, risk factors and individual treatment regimen and safety measures. Interventions: o Established rapport o Assessed skin color, integrity and temperature of the affected leg o Provided tepid sponge and bath o Did physical assessment o Provided with adequate rest periods o Supported affected body part using pillows o Instructed patient’s S. O regarding the use of side rails, overhead trapeze, and roller pads o Emphasized strict medication compliance o Encouraged S. O. to increase patient’s fluid intake Provided seizure precautions o Vital signs taken and charted o Environmental care done Evaluation: “Salamat dong, kahibaw nako unsaun pag atiman ako anak”, as verbalized by S. O. SOAPIE 2 Subjective Cue: No verbal cues noted Objective Cues: o Received on bed lying awake, conscious and coherent o Without IVF o With balance traction on left leg o No side-rails noted o Seizure tendencies noted o Blank stare observed o Inability to talk observed o Drooling eyes noted Assessment: Risk for injury related to uncoordinated large and small muscle contractions, secondary to cerebral palsy. Plan: After 8 hours of nursing interventions patient’s S. O. will be able to verbalize understanding of individual factors that contribute to possibility of injury and take steps t correct situations. Interventions: o Assessed physical and emotional status o Instructed Patients S. O. to provide aspiration precaution especially when feeding the patient o Entertained clarifications and questions bout seizure precautions o Encouraged S. O. to religiously give Phenobarbital, an anti-seizure drug o Advised increase in fluid intake o Minimized environmental stimulation o Placed pillow at patient’s side Removed all sharp objects from patient’s bedside table o Stayed at patient’s bedside o Place patient in supine position o Taught S. O. on the possible signs that may prelude to a seizure attack o Provided tepid sponge bath o Vital signs taken and recorded o Bed side care done o Environmental care done Evaluation: “Anaun ra day dong paglikay and digrasya, labi na sa pareha sa akong anak na mukalit lang ug convulsion” as verbalized by S. O. o Pillow at patient’s side o S. O. at patient’s bedside o No sharp objects at bedside table o Patient in supine position SOAPIE 3 Subjective Cue: No verbal cues noted Objective Cues: o Received on bed lying awake, conscious and coherent o Without IVF o With balance traction on left leg o With the following vital signs: T=37. 2 C; R= 24 cpm; P= 118 bpm o Physical immobility noted o Drooping eyes noted o Dirty hands noted o inability to turn from side to side observed Assessment: Risk for impaired skin integrity related to prolonged bed mobility secondary to fracture on the subtrochanter of the left femur Plan: After 8 hours of nursing interventions patient’s S. O. will be verbalize understanding of treatment and regimen therapy. Interventions: Assessed patient’s physical and mental status o Massaged bony prominence gently to avoid friction when moving client o Changed positions bed on a regular schedule o Provided S. O. a turning schedule for the patient o Encouraged S. O. to follow the turning schedule religiously. o Provided pads, pillows, and foam mattresses o Inspected the skin surfaces and pressure points routinely o Administer pain medications o Emphasized to S. O strict medication compliance is very important o Assisted in changing positions o Provided adequate rest periods to prevent fatigue o Vital signs taken and recorded Bed side care done o Environmental care done Evaluation: “Kinahanglan gyud day to nako kay mao man to ang saktong paagi para maayo si inday ug dili masamad ang yang panit” as verbalized by S. O. DISCHARGE SUMMARY A case of N. F. S. O. , 5 years old, female, single, a Roman Catholic from Englis, V. Rama Cebu City was admitted at Vicente Sotto Memorial Medical Center with the chief complaint of left leg pain. Subjective cue: “Maka-uli na gyud intawn mi pero unsaun man nako pag-atiman si inday para dili mugrabe, ug d I na mausab ang nahitabu” as verbalized by S. O. Objective Cues: Received in bed lying awake, conscious, and coherent o seen SO packing their things o beddings are arranged o bedside table cleaned o frequent asking of questions from S. O. noted o attentiveness noted o eye to eye contact with the S. O. observed Assessment: Health-Seeking Behaviors: request for information regarding proper care of fracture with cerebral palsy related to unfamiliarity with the situation and lack of experience. Plan: After 30 minutes of nursing care patient’s S. O. will be able to verbalize the proper way to care for a patient with cerebral palsy and is rehabilitating from a fractured left leg. Interventions: o Emphasized strict compliance to medications as ordered. Phenobarbital before going to bed o Encourage passive range of motions on unaffected extremities during the same time of the day, preferably in the morning o Taught S. O. how aid patient in perform isometric exercises to enhance muscle strength and prevent wasting o Informed of the available treatment for fracture o Taught S. O. to check cast from time to time, and avoid cast from getting wet. o Referred to community resources o Advised S. O. to provide bed bath everyday o Taught S. O. o provide lifestyle modifications for the patient o Instructed S. O. not to leave the patient alone with her younger sister o Instructed to watch out for signs and symptoms of infection such as fever, increase respiratory rate, and heart rate and report immediately to physician if observed o Emphasize the importance of check-ups regularly to monitor health status o Encouraged a well-balanced diet to foster to energy and metabolic requirements o Advised to pray everyday and ask for guidance and good health and to never lose hope. o Emphasized to the S. O. ever ever to forget to thank God for all the graces they have received from him. Evalution: “ Ako gung ampingan mau si inday nurse ug akong ihatag akong best na dili na mausab ang nahitabu para napud maayu ug dali akong anak “ as verbalized by S. O. VI. CONSLUSION AND RECOMMENDATION Conclusion Encountering a patient diagnosed with fracture and cerebral palsy at the same time could be very intriguing, especially if the one diagnosed can not even pronounce the word mama and papa. It is a very sad situation for someone with cerebral palsy, a disease condition that should be given extra care and attention, confined in an Orthopedics ward. This phenomenon could actually make anybody an instant agent, trying to dig dipper to the case, Instead of just focusing on the patient’s diagnosis. The patient is diagnosed with a fractured left subtrochanter femur, and cerebral palsy at the same time. This actually resulted when she fell off her crib, and since she has problems with balance it immediately resulted into fracture. Fracture is very common and very curable, given the right treatment, the patient’s normal functioning can return to its normal state. A lot of bone reconstructing surgeries are available; including Open Reduction with Internal Fixation, and Open Reduction with External Fixation. There are also non-surgical treatments including the closed reduction methods such as leg casts and skeletal and skin tractions. But cerebral palsy is totally the opposite when it comes to curability. Cerebral palsy is a very rare condition. It is a series of non-progressive brain disorders in the intrauterine life, delivery or early infancy that is characterize by motor disabilities accompanied by mental retardation and seizure disorders. In my patient’s case it is the spastic type, more specifically the spastic quadriplegia. Meaning all four limbs is greatly affected. Patient with this disorder is unable to acquire speech, and balance, which means they need special treatment and care. And for a 5 year old cerebral palsy patient admitted in the Orthopedics ward of Vicente Sotto Memorial Medical Center due to fracture, primary health care giver should undergo a lot of counseling regarding proper care of their CP child. Health care providers, such as nurses and doctors, goal is to promote the fast recovery from injury and to avoid further accidents by ensuring proper seizure precautions is observed. Since patients with cerebral palsy have a very high seizure tendency. Proper health education to the parents and family members is very crucial. And the nurse carries the pressure in assuring that the right information regarding the patients treatment is relayed to the family. Therefore prenatal check-ups and right nutrition during pregnancy should be given a high priority. As we can see, the occurrence of one condition was a result of the other. The patient’s disorder could have been prevented if strict prenatal compliance was just observed, and her injury could not have happened if not for her disorder. And lastly she could have been running around, playing with her friends while shouting the name of her mom and dad if not for her condition. Let’s not take cerebral palsy patient for granted. Let’s take care of them and give the treatment they truly deserve. Recommendation To the nursing students: It is already given that nurses are full of energy and optimism; therefore it is only empirical that they hold the responsibility of injecting vigor to the patients. They should always keep in mind that their main goal is to facilitate recovery and promote wellness. Encouraging these patients to stay positive is very important, considering the kind of trauma and emotional meltdown these patients undergo during the course of the disease. Help them to remain optimistic by cheering them up, and acknowledging every progress they make in their condition. Lastly, as much as possible use the time wisely and exhaust every resource that will be of assistance to these patients. And remember always that honesty is still the best policy. Be honest to yourself, to God, and to your job. To family and relatives: It is important for them to show their support and empathy to the patient. It is a reality that some patients react to their disease condition outrageously. Family members should understand that this reaction is only normal and that they should continue to show their love and support to the patient. Moreover the family’s presence alone is already enough to assure the patient that he is not alone in facing the problems that his disease may bring. To the government: Health is wealth and for whatever reasons the health of the Filipino people should not be the least priority. A patient with such disease confined at Vicente Sotto Memorial Medical Center, a public hospital, needs extra attention and care. Just by considering the fact that the hospital lacks the medical equipments and has shortage of manpower, it could not be deny that there is a very big possibility that the patients condition will worsen during the course of treatment. This is a health issue that the government can not afford to ignore. They should address this problem immediately, or else cases of nosocomial infection and other hospital facility related problems will go up. To the patient: It is important for her to follow religiously the instructions of the doctor regarding the patients care. She needs to remember that all the health care professionals’ efforts of helping them will be of no use if they will not cooperate and comply with the treatment. And lastly it is vital for her to always keep in mind that she is still young and that all of these are only trials of life and it is up to her now how she will take it. But of course, rest assured she won’t be alone in facing these hardships. BIBLIOGRAPHY: BOOK SOURCES: • Black and Hawks. 2005. Medical-Surgical Nursing. Clinical Management for Positive Outcome. Volume 1. 7th edition. Singapore Elsevier. • Bullock & Henze. 2000. Focus on Pathophysiology. Philadelphia. Lippincott Williams & Wilkins. • Doenges et. Al. 2002. Nursing Care Plans. Guidelines for Individualizing Patient Care. 6th Edition. Thailand. F. A. Davis Company. • Doenges et. Al. 2004. Nurses Pocket Guide. Diagnoses, Interventions, & Rationales. Thailand. F. A. Davis Company. • Venzon, Lydia M. 2006. Introduction to Nursing Research: Quest for quality Nursing. 1st edition. Quezon City, Philippines. C & E Publishing, Inc. Kozier et. Al. 2004. Fundamentals of Nursing. Concepts, Processes & Beliefs. California. Prentice Hall. • Marieb, E. M. 2003. Essentials of Human Anatomy & Physiology. 7th edition. California. Pearson Education. • Nettina B. Sandra. 2006. Lippincott Manual of Nursing Practice. Volume 1. 8th edition. Philadelphia. Lippincott Williams & Wilkins. • Speer, K. M. 1999. Pediatric Care Planning. Now W/ Clinical Pathways. 3rd edition. Pennsylvania. Springhouse Corporation. INTERNET SOURCES: • http://en. wikipedia. org/wiki/Femur. Femur. Accessed last September 15, 2008 • http://en. ikipedia. org/wiki/Human_brain. Human Brain. Accessed last October 9, 2008 • http://www. wheelessonline. com/ortho/femoral_shaft_fracture. Management of Femoral Fracture. Accessed last September 25, 2008 APPENDICES CURRICULUM VITAE PERSONAL PROFILE Name: Wrygg Blyken Bauer R. Timbal Address: 414 Upper Lipata Minglanilla, Cebu Age: 20 Sex: Male Status: single Nationality: Filipino Birth date: January 5, 1988 Birthplace: Sacred Heart Hospital, Cebu City EDUCATIONAL BACKGROUND: Elementary: Year: Immaculate Heart of Mary Academy - Minglanilla, Cebu1995-1998 Intermedaite: Don Bosco Technology Center - Punta Princesa, Cebu City1998-2001 Secondary: Don Bosco Technology Center - Punta Princesa, Cebu City2001-2005 Tertiary: Cebu Normal University - Osmena Blvd. , Cebu City2005-present ACHIEVEMENTS Elementary: Grade 6 • Graduated as Student with Distinction Honors. Ranked 8 of the whole batch. • Member of the basketball team that won the Jubilee League Championship in 2001. 1st time for Don Bosco since 1994. Secondary: Academics • Graduated as a Student with Distinction Honors in Don Bosco Technology Center for the academic year 2004-2005. Sports: BASKETBALL: 2001-2002: • Member, Midgets Division, 1st Runner-up, 1st Boscolympics held @ Don Bosco Technical Institute, Makati City, Philippines. 2002-2003: • Finals MVP, Champion, Math Week 3 on 3 street ball challenge. 2003-2004: • Member, Champion, 1st ML KWARTA PADALA, Interschool Championship; Cebu City • Mythical team member, 2nd runner-up, 3rd Boscolympics held @ Don Bosco Technical Institute, Makati City, Philippines. 2004-2005: • Member, 1st Runner-up, secondary division in basketball, 4th Cebu Schools and Athletics Foundation Incorporation (CESAFI). Member, Champion, secondary division in basketball, 2004-2005 Cebu City Olympics, Cebu City Sports complex. • Member, Champion, secondary division in basketball, 4th Boscolympics held @ Don Bosco Technology Center, Punta Princesa, Cebu City. • Member of Team Cebu City, Champion, secondary division in basketball, Central Visayas Regional Athletic Association, held @ Dumanjug, Cebu. • Member of Team Region 7, 1st Runner-up, secondary division in basketball, Palarong Pambansa held @ Ilo-ilo Sports Center, Ilo-ilo City, Philippines. [pic]
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