Submitted by: Rostum Harold B. Serrano Joshua Meolyn O. Ibarrola Eva Merlyn V. Tagle Camille Kaye R. Ortiz Group 11 BSN III-SLSU

A. General Objectivey After further assessment, providing care to

the client and conducting a careful and thorough study of the client s condition, the student will be able to gain knowledge, develop skills and enhance attitude in rendering quality nursing care in actual situation to the client with diagnosis of pyogenic discitis.

B. Specific ObjectiveyState the definition of discitis. yEnumerate the clinical

manifestations shown by the client. yReview of the anatomy & physiology of the involved system.

yTrace the pathophysiology of the

disease. yDetermine and state latest issues regarding the disease. yEstablish a therapeutic nursepatient relationship.

y Determine the client s status throughy General and Demographic data y Present History of the Illness y Family Health History y Physical Assessment

y Analyze laboratory results; correlate it with the client s present condition and manifestations; and apply appropriate nursing interventions.

y Familiarize self with the diagnostic

procedures done to the patient in determining the present illness and possible interpretation in accordance to its normal values. y Identify and understand the importance of pharmacological interventions to the patient s present condition. y Render quality nursing care through implementation of nursing care plan. y Evaluate the effectiveness of the nursing care plan and medical management.

II. INTRODUCTION OF THE DISEASEy Diskitis is swelling (inflammation) and

irritation of the space between the bones of the spine (intervertebral disk space). III. ANATOMY AND PHYSIOLOGY A musculoskeletal system (also known as the locomotor system) is an organ system that gives animals (including humans) the ability to move using the muscular and skeletal systems. The musculoskeletal system provides form, support, stability, and movement to the body.

y It is made up of the body's bones (the

skeleton), muscles, cartilage, tendons, ligaments, joints, and other connective tissue (the tissue that supports and binds tissues and organs together). The musculoskeletal system's primary functions include supporting the body, allowing motion, and protecting vital organs. The skeletal portion of the system serves as the main storage system for calcium and phosphorus and contains critical components of the hematopoietic system.

y This system describes how bones are

connected to other bones and muscle fibers via connective tissue such as tendons and ligaments. The bones provide the stability to a body in analogy to iron rods in concrete construction. Muscles keep bones in place and also play a role in movement of the bones. To allow motion, different bones are connected by joints. Cartilage prevents the bone ends from rubbing directly on to each other. Muscles contract (bunch up) to move the bone attached at the joint.

y There are, however, diseases and disorders

that may adversely affect the function and overall effectiveness of the system. These diseases can be difficult to diagnose due to the close relation of the musculoskeletal system to other internal systems. The musculoskeletal system refers to the system having its muscles attached to an internal skeletal system and is necessary for humans to move to a more favorable position. Complex issues and injuries involving the musculoskeletal system are usually handled by an orthopedic surgeon.

SubsystemsSkeletal y The Skeletal System serves many important functions; it provides the shape and form for our bodies in addition to supporting, protecting, allowing bodily movement, producing blood for the body, and storing minerals. The number of bones in the human skeletal system is a controversial topic. Humans are born with about 300 to 350 bones, however, many bones fuse together between birth and maturity. As a result an average adult skeleton consists of 206 bones. The number of bones varies according to the method used to derive the count. While some consider certain structures to be a single bone with multiple parts, others may see it as a single part with multiple bones.

y . There are five general classifications of

bones. These are Long bones, Short bones, Flat bones, Irregular bones, and Sesamoid bones. The human skeleton is composed of both fused and individual bones supported by ligaments, tendons, muscles and cartilage. It is a complex structure with two distinct divisions. These are the axial skeleton and the appendicular skeleton.

y The Skeletal System serves as a framework for tissues

Function

and organs to attach themselves to. This system acts as a protective structure for vital organs. Major examples of this are the brain being protected by the skull and the lungs being protected by the rib cage. y Located in long bones are two distinctions of bone marrow (yellow and red). The yellow marrow has fatty connective tissue and is found in the marrow cavity. During starvation, the body uses the fat in yellow marrow for energy. The red marrow of some bones is an important site for blood cell production, approximately 2.6 million red blood cells per second in order to replace existing cells that have been destroyed by the liver. Here all erythrocytes, platelets, and most leukocytes form in adults. From the red marrow, erythrocytes, platelets, and leukocytes migrate to the blood to do their special tasks.

Musculary There are three types of muscles

cardiac, skeletal, and smooth. Smooth muscles are used to control the flow of substances within the lumens of hollow organs, and are not consciously controlled. Skeletal and cardiac muscles have striations that are visible under a microscope due to the components within their cells. Only skeletal and smooth muscles are part of the musculoskeletal system and only the skeletal muscles can move the body. Cardiac muscles are found in the heart and are used only to circulate blood; like the smooth muscles, these muscles are not under conscious control.

Contraction initiationy In mammals, when a muscle contracts, a series of

reactions occur. Muscle contraction is stimulated by the motor neuron sending a message to the muscles from the somatic nervous system. Depolarization of the motor neuron results in neurotransmitters being released from the nerve terminal. The space between the nerve terminal and the muscle cell is called the neuromuscular junction. These neurotransmitters diffuse across the synapse and bind to specific receptor sites on the cell membrane of the muscle fiber. When enough receptors are stimulated, an action potential is generated and the permeability of the sarcolemma is altered. This process is known as initiation.

y Tendons

A tendon is a tough, flexible band of fibrous connective tissue that connects muscles to bones. Muscles gradually become tendon as the cells become closer to the origins and insertions on bones, eventually becoming solid bands of tendon that merge into the periosteum of individual bones. As muscles contract, tendons transmit the forces to the rigid bones, pulling on them and causing movement.

Joints, ligaments, and bursaey Joints Joints are structures that connect individual bones and may allow bones to move against each other to cause movement. There are two divisions of joints, diarthroses which allow extensive mobility between two or more articular heads, and false joints or synarthroses, joints that are immovable, that allow little or no movement and are predominantly fibrous. Synovial joints, joints that are not directly joined, are lubricated by a solution called synovia that is produced by the synovial membranes. This fluid lowers the friction between the articular surfaces and is kept within an articular capsule, binding the joint with its taut tissue.

Ligaments

y A ligament is a small band of dense, white, fibrous

elastic tissue.[6] Ligaments connect the ends of bones together in order to form a joint. Most ligaments limit dislocation, or prevent certain movements that may cause breaks. Since they are only elastic they increasingly lengthen when under pressure. When this occurs the ligament may be susceptible to break resulting in an unstable joint. y Ligaments may also restrict some actions: movements such as hyperextension and hyperflexion are restricted by ligaments to an extent. Also ligaments prevent certain directional movement.

Bursa y A bursa is a small fluid-filled sac made of white fibrous tissue and lined with synovial membrane. Bursa may also be formed by a synovial membrane that extends outside of the join capsule. It provides a cushion between bones and tendons and/or muscles around a joint; bursa are filled with synovial fluid and are found around almost every major joint of the body.

Spinal Anatomy y The spinal column is one of the most vital parts of the human body, supporting our trunks and making all of our movements possible. Its anatomy is extremely well designed, and serves many functions, including: Movement y Balance y Upright posture y Spinal cord protection y Shock absorption

y All of the elements of the spinal column and

vertebrae serve the purpose of protecting the spinal cord, which provides communication to the brain and mobility and sensation in the body through the complex interaction of bones, ligaments and muscle structures of the back and the nerves that surround it. y The normal adult spine is balanced over the pelvis, requiring minimal workload on the muscles to maintain an upright posture. y Loss of spinal balance can result in strain to the spinal muscles and spinal deformity. When the spine is injured and its function impaired, the consequences may be painful and even disabling.

Regions of the Spine y Humans are born with 33 separate vertebrae. By adulthood, we typically have 24 due to the fusion of the vertebrae in the sacrum. y The top 7 vertebrae that form the neck are called the cervical spine and are labeled C1-C7. The seven vertebrae of the cervical spine are responsible for the normal function and mobility of the neck. They also protect the spinal cord, nerves and arteries that extend from the brain to the rest of the body.

y The upper back, or thoracic spine, has 12

vertebrae, labeled T1-T12. y The lower back, or lumbar spine, has 5 vertebrae, labeled L1-L5. The lumbar spine bears the most weight relative to other regions of the spine, which makes it a common source of back pain. The sacrum (S1) and coccyx (tailbone) are made up of 9 vertebrae that are fused together to form a solid, bony unit.

Spinal Curvature y When viewed from the front or back, the normal spine is in a straight line, with each vertebra sitting directly on top of the other. Curvature to one side or the other indicates a condition called scoliosis. y When viewed from the side, the normal spine has three gradual curves: y The neck has a lordotic curve, meaning that it curves inward.

y The thoracic spine has a kyphotic curve,

meaning it curves outward. y The lumbar spine also has a lordotic curve. y These curves help the spine to support the load of the head and upper body, and maintain balance in the upright position. Excessive curvature, however, may result in spinal imbalance.

Elements of the Spiney The elements of the spine are designed to

protect the spinal cord, support the body and facilitate movement.

A.Vertebrae y The vertebrae support the majority of the weight imposed on the spine. The body of each vertebra is attached to a bony ring consisting of several parts. A bony projection on either side of the vertebral body called the pedicle supports the arch that protects the spinal canal. The laminae are the parts of the vertebrae that form the back of the bony arch that surrounds and covers the spinal canal. There is a transverse process on either side of the arch where some of the muscles of the spinal column attach to the vertebrae. The spinous process is the bony portion of the vertebral body that can be felt as a series of bumps in the center of a person's neck and back.

y B. Intervertebral Disc y Between the spinal vertebrae are discs, which function as

shock absorbers and joints. They are designed to absorb the stresses carried by the spine while allowing the vertebral bodies to move with respect to each other. Each disc consists of a strong outer ring of fibers called the annulus fibrosis, and a soft center called the nucleus pulposus. The outer layer (annulus) helps keep the disc's inner core (nucleus) intact. The annulus is made up of very strong fibers that connect each vertebra together. The nucleus of the disc has a very high water content, which helps maintain its flexibility and shock-absorbing properties.

C. Facet Jointy The facet joints connect the bony arches of each of the

vertebral bodies. There are two facet joints between each pair of vertebrae, one on each side. Facet joints connect each vertebra with those directly above and below it, and are designed to allow the vertebral bodies to rotate with respect to each other. D. Neural Forameny The neural foramen is the opening through which the

nerve roots exit the spine and travel to the rest of the body. There are two neural foramen located between each pair of vertebrae, one on each side. The foramen creates a protective passageway for the nerves that carry signals between the spinal cord and the rest of the body.

y E. Spinal Cord and Nerves y The spinal cord extends from the base of the

brain to the area between the bottom of the first lumbar vertebra and the top of the second lumbar vertebra. The spinal cord ends by diverging into individual nerves that travel out to the lower body and the legs. Because of its appearance, this group of nerves is called the cauda equina - the Latin name for "horse's tail." The nerve groups travel through the spinal canal for a short distance before they exit the neural foramen.

y The spinal cord is covered by a protective

membrane called the dura mater, which forms a watertight sac around the spinal cord and nerves. Inside this sac is spinal fluid, which surrounds the spinal cord.

y The nerves in each area of the spinal cord

are connected to specific parts of the body. Those in the cervical spine, for example, extend to the upper chest and arms; those in the lumbar spine the hips, buttocks and legs. The nerves also carry electrical signals back to the brain, creating sensations. Damage to the nerves, nerve roots or spinal cord may result in symptoms such as pain, tingling, numbness and weakness, both in and around the damaged area and in the extremities.

Spinal Muscles y Many muscle groups that move the trunk and the limbs also attach to the spinal column. The muscles that closely surround the bones of the spine are important for maintaining posture and helping the spine to carry the loads created during normal activity, work and play. Strengthening these muscles can be an important part of physical therapy and rehabilitation.

Nervous System y All of the elements of the spinal column and vertebrae serve the purpose of protecting the spinal cord, which provides communication to the brain, mobility and sensation in the body through the complex interaction of bones, ligaments and muscle structures of the back and the nerves that surround it.

y The true spinal cord ends at approximately

the L1 level, where it divides into the many different nerve roots that travel to the lower body and legs. This collection of nerve roots is called the cauda equina, which means "horse's tail," and describes the continuation of the nerve roots at the end of the spinal cord.

IV. OVERVIEW OF THE DISEASEy Diskitis is an inflammation of the vertebral disk space

often related to infection. Infection of the disk space must be considered with vertebral osteomyelitis, as these conditions are almost always present together and share much of the same pathophysiology, symptoms, and treatment. Although diskitis and associated vertebral osteomyelitis are uncommon conditions, they are often the causes of debilitating neurologic injury. Unfortunately, morbidity can be exacerbated by a delay in diagnosis and treatment of this condition. The lumbar region is most commonly affected, followed by the cervical spine and, lastly, the thoracic spine.

y Axial CT scan in a patient with diskitis

demonstrates extensive destruction of the vertebral endplate. Note the preservation of the posterior elements, including facet joints, lamina, and spinous process. This is characteristic for pyogenic diskitis and less common in tuberculosis (Pott disease).

y Sagittal T1-weighted MRI of the lumbar

spine in a 74-year-old man, revealing diskitis of the L4-L5 disk space. Note extensive destruction of the endplates of the adjacent vertebral bodies. No compression of the thecal sac is present, which is an important consideration when contemplating surgical intervention.

y Contrast-enhanced sagittal T1-weighted

MRI image in a 55-year-old woman shows thoracic diskitis with an associated epidural abscess and spinal cord compression. Because of the significant cord compression, this patient underwent surgical decompression.

y Trajectory of a needle in a biopsy of the

infected disk space guided by CT scan. Care is taken to avoid the thecal sac and nerve roots.

Physicaly Localized tenderness over the involved area

with concomitant paraspinal muscle spasm is the most common physical sign. If the cervical or lumbar segments are involved, restricted mobility secondary to pain occurs. Reported rates of neurologic deficit (eg, radiculopathy, myelopathy) vary widely from 2% to 70%. Cervical disease is associated with a much higher rate of neurologic deficit.

Causesy Diskitis is thought to spread to the involved

intervertebral disk via hematogenous spread of a systemic infection (eg, urinary tract infection [UTI]). Many sites of origin have been implicated, but UTI, pneumonia, and soft-tissue infection seem to be the most common. Direct trauma has not been conclusively shown to be related to diskitis. Intravenous drug use with contaminated syringes offers direct access to the bloodstream for a variety of organisms. Often, no other site of infection is discovered.

y Staphylococcus aureus is the organism most

commonly found; however, Escherichia coli and Proteus species are more common in patients with UTIs. Pseudomonas aeruginosa and Klebsiella species are other gram-negative organisms observed in intravenous drug abusers, although they are not seen as commonly as S aureus. Not surprisingly, medical conditions that predispose patients to infections elsewhere in the body are associated with diskitis. Diabetes, AIDS, steroid use, cancer, and chronic renal insufficiency are common comorbidities.

y Although rare, infection of the disk space

can also occur following surgical intervention at the site. The rate of infection following anterior cervical diskectomy has been quoted at 0.5% of cases. The rate of infection for lumbar diskectomy is half of that. In such cases, infection is transmitted through direct inoculation of the operative site. As in spontaneous diskitis, the most common organism is S aureus, but Staphylococcus epidermidis and Streptococcus species also should be considered.

y Childhood diskitis has not been consistently

associated with an initial causative infection elsewhere in the body. S aureus is the most common organism found.

Laboratory Studiesy Hematologyy Elevated erythrocyte sedimentation rate

(ESR) and C-reactive protein (CRP) are the most consistent laboratory abnormalities seen in cases of diskitis. y The mean ESR for patients with diskitis is 85-95 mm per hour. ESR utility can be extended by serial measurements during treatment.

y A 50% decline in ESR can usually be

expected with successful treatment, and ESR often continues to decline after treatment. y Frequently, ESR may not return to normal levels despite adequate therapy.

y Leukocytosis is often present in systemic

disease but is frequently absent in diskitis cases. Diskitis is generally accompanied by a normal peripheral white blood cell (WBC) count if the primary site of infection has been treated.

y Microbiologyy Blood cultures must be obtained on a

frequent basis for any patient suspected of harboring an infected disk. y Appropriate therapy may be instituted for positive blood cultures without the need for invasive tests. y Unfortunately, blood cultures are positive in only one third to one half of diskitis cases.

y Sputum and urine cultures are necessary to

locate any other sources of infection, including respiratory and genitourinary sites.

Imaging Studiesy Plain radiographyy Although radiographic films of the spine can be very

useful in diagnosing diskitis, abnormalities are visible only after several weeks following the onset of disease. y The most common early finding on plain films is disk-space narrowing, followed by irregularities and erosion of the adjacent endplates and calcification of the anulus around the affected disk. y As osteomyelitis progresses, bone density decreases, with loss of the normal trabeculation of the vertebra. If bone destruction continues, subluxation (with possible instability of the spine) becomes evident.

y Nuclear mediciney Gallium-67 and technetium-99m have

been utilized in the detection of diskitis with similar results. Radionuclide scanning has demonstrated a high degree of sensitivity shortly after the onset of symptoms. Diffuse initial uptake is followed by more focal uptake on delayed scans. Technetium-99m has been recommended more often because of its lower cost and smaller radiation dose.

y Because of the availability and sensitivity

of other tests, radionuclide scans may be most useful in the workup of patients with fever of unknown origin. y Indium-111 WBC scintigraphy has been shown to have a low sensitivity for diskitis and is not the test of choice.

y CT scany CT scanning has the ability to detect

diskitis earlier than plain radiographs. y Findings include hypodensity of the intervertebral disk and destruction of the adjacent endplate and bone, as seen in the image below, with edematous surrounding tissues. Organisms at the affected site can also produce a gas that is easily detected on CT scans.

y The advantage of CT scans over

radiographs is that associated paraspinal disease can also be detected, especially when combined with intravenous contrast or myelography. y Use of CT scanning can supplement magnetic resonance imaging (MRI), as it is better at distinguishing between bone and soft tissue than MRI. y CT can help monitor successful treatment, which is accompanied by increased bone density and sclerosis.

y MRIy The most sensitive and specific test for

diskitis is MRI. T1-weighted images, as seen in the image below, show narrowing of the disk space and low signals consistent with edema in the marrow of adjacent vertebral bodies. MRI is very useful in helping distinguish between infectious diskitis, neoplasia, and tuberculosis. Diffusionweighted imaging is useful in distinguishing between degenerative and infectious endplate abnormalities. Compared with positron emission tomography, diffusionweighted MRI costs less, has faster imaging times, and lacks ionizing radiation.

y Disk space involvement directs attention

to infection, as it only is involved late in tuberculosis and very rarely in neoplasia. y With the use of intravenous contrast, as seen in the image below, MRI, like CT, can detect paraspinal disease (eg, paraspinal phlegmon, epidural abscess. y A large amount of paraspinal soft-tissue swelling and a psoas abscess are often associated with spinal tuberculosis.

y Bone scans are not specific for infection over

inflammation; therefore, they are ineffective in postoperative patients.

Other Testsy Echocardiography can detect bacterial

endocarditis, which is a common source of diskitis and embolic infection throughout the body.

Proceduresy Needle biopsyy Needle or trocar placement into the

infected area is a minimally invasive test used to obtain histologic confirmation of the disease and tissue samples for culture. y Yield and safety of the procedure are maximized by the use of CT scanning for guidance.

y As in blood cultures, positive tissue

cultures occur in only half of biopsies, especially if antibiotic therapy has already been initiated. In such cases, needle biopsy can be repeated or the patient can be referred for open surgical biopsy.

y Surgical biopsyy Open biopsy has been found in some

studies to have the highest yield in terms of positive cultures and diagnosis confirmation. y Open biopsy is the most invasive test. y While some surgeons prefer to combine open biopsy with surgical debridement, no difference has been found between antibiotics and debridement when compared with antibiotics alone in cases of early diskitis.

Histologic Findingsy The histologic findings of diskitis are similar

to those of any bacterial pyogenic infection. Local destruction of the disk and endplates occurs with infiltration of neutrophils in the early stages. Later, a lymphocytic infiltrate predominates.

Medical Carey Antibiotic treatment must be tailored to the

isolated organism and any other sites of infection. y Broad-spectrum antibiotics must be used if no organism is isolated; however, this is very rare, and other disease processes (eg, spinal tuberculosis) must be considered in the face of persistently negative cultures.

y Parenteral treatment is usually administered for 6-8

weeks. Before parenteral therapy is discontinued, the ESR should have dropped by one half to one third, the patient should have no pain on ambulation, and there should be no neurologic deficits.[1, 3] y The use of oral antibiotics following intravenous treatment has not been shown to be of added benefit. y Any laboratory or clinical sign of persistent infection should prompt another biopsy and continued antibiotic therapy.

y Immobilization is necessary, especially in

the initial stages of the disease. y Two weeks of bed rest should be followed by external immobilization with a brace when the patient gets out of bed. y Any pain on ambulation is an indication for continued bed rest.

y The goal of immobilization is to provide

the opportunity for the affected vertebrae to fuse in an anatomically aligned position. y Generally, bracing is used for 3-6 months following initiation of treatment; however, even with the use of appropriate antibiotics and bracing, collapse of the vertebral segments and kyphos formation may occur.

y Pain control is an important adjunct to

antibiotics and immobilization.

Surgical Carey Indications for surgery beyond open biopsy include neurologic deficit, spinal deformity, disease progression, noncompliance, and antibiotic toxicity. The goal of surgery is to remove diseased tissue, decompress neural structures, and ensure spinal stability. Although in most cases the vertebrae fuse spontaneously following diskitis and osteomyelitis, operative fusion can be a useful adjunct by allowing earlier mobilization of the patient. Despite early concerns, use of a fusion plug and metallic instrumentation in an infected field has not been shown to impede successful treatment.

Consultationsy Infectious disease y Neurosurgery y Orthopedic spine surgery

Diety No particular diet has been shown to have a

clinical benefit in patients with diskitis.

Activityy Many authors believe that 2 weeks of bed

rest with initial treatment helps prevent the development of a kyphotic deformity. Use of an orthotic brace to help stabilize the spine while spontaneous fusion takes place is recommended for 3-6 months. Ambulation is recommended only if the patient has neither pain nor radiographic signs of instability.

V. CASE STUDY PROPERy Name: y Age: y Nationality: y Religion: y Birthdate: y Admission Date: y Admission Time:

Patient X 41 yrs. Old Filipino Roman Catholic 1969, July March 9, 2011 5:00pm

VI. PATIENT S HISTORYy Past Medical History

Last December 2010, the patient was playing badminton, while playing, she fell back on the ground. The buttocks of the patient fell first before the entire body. She felt severe pain immediately. She was unable to ambulate but there was no paralysis noted. Three days after the incident, she consulted at Philippine General Hospital and X-ray of the affected part was done but there was no abnormality seen last February, lumbar pain radiating to subchondral was felt and decided to consult at Perpetual Las Pias. Again, no radiographic abnormality was observed. This last month, symptoms persist again and consulted at Philippine Orthopedic Center and confined on March 9, 2011.

y Family History

According to the patient, her parents have no history of diabetes and hypertension. But, they have history of Cancer. Cough and colds, fever, diarrhea, etc. were also experienced by the patient s relatives and manage at house only.

y Social History

Before experiencing the symptoms of the disease, the patient was actively participating in outdoor games such as badminton, biking, etc. Also, the patient was always hanging out with her friends. They sometimes drink alcohol during occasions.

VII. PHYSICAL ASSESSMENTy General Condition y conscious and coherent y not in respiratory distress y unable to sit upright, stand, and flex spine y with complaints of severe back pain when

stretching spine

y Vital Signs: yT y PR y RR y BP

1st day 37.6 C 82 bpm 22 bpm 110/70 mmHg

2nd day 3rd day 37.4 C 37.4 C 79 bpm 84 bpm 24 bpm 23 bpm 110/80 mmHg 110/80 mmHg

y SKINy with fair complexion y slightly dry in texture y with fair skin turgor y no lesions noted

y HAIRy with black hair extending to the back y evenly distributed to the scalp y with good hair texture y no head lice and dandruff noted

y HEAD y Normocephalic y proportionate to body size y with symmetrical features y EYES y with whitish sclera y with pale conjunctiva y with conjugate eye movements y with pupil equally round and reactive to light and accommodation y no discharges noted

y EARSy auricles aligned to outer cantus of the eye y no discharges noted

y NOSEy nasal septum aligned and intact y no nasal discharges noted y no nasal flaring noted

y MOUTH AND TEETHy with pale and dry lips y able to purse lips y with good dentition y with retainer on teeth y without stains on teeth noted

y NECKy Symmetrical y no distended vein noted upon palpation y with palpable carotid pulse

y THORAX and LUNGS y with clear breath sounds heard on both Lung fields upon auscultation y with symmetrical chest expansion upon respiration y chest wall intact y with regular breathing pattern y ABDOMEN y with soft and non-tender abdomen upon palpation y with normoactive bowel sounds of 18 BS/min

y GENITOURINARY y voiding freely into yellowish urine;

moderate in amounty UPPER and LOWER EXTREMITIESy symmetrical y without contraptions noted y no deformities noted

y NAILSy with pale nailbeds y with capillary refill tine of 2secs.

VIII. COURSE IN THE WARDy March 9, 2011, the patient was admitted at

female ward, room 309, at Philippine Orthopedic Center. The diagnostic procedures ordered by the Dr. Pasion were CBC, ESR, CRP, blood typing, PT, PTT, FBS, BUN, CREA, SGOT, SGPT, lipid profile, Na, K, Cl, and blood culture on 2 weeks. Blood transfusion of 2 u of PRBC was ordered after properly typed and crossmatched. CT scan of L1 was also ordered. Medication prescribed was etoricoxib 70mg 1 tab once a day PRN for pain.

y On March 13, 2011, IVF of PNSS 1L was

inserted and regulated for 12 hours. On the next day at 2:15 in the afternoon, repeat PTT, PT, CBC with platelet count was done. y On March 15, 2011, CT scan followed up guided biopsy. Intravenous line was discontinued on March 17, 2011. Also, still waiting for biopsy results.

y On March 21, 2011, ciprofloxacin 500mg 1

cap BID for 7 days was started. As ordered, urinalysis should be repeated after 7 days. On the next day, they followed up histopathologic results. y On March 27, 2011, Acid Fast Bacilli for 3 days was ordered. Etoricoxib 90mg 1 tab OD PRN for pain was given and started.

y On March 28, 2011, diagnostic procedures were ordered such as thyroid function test, ionized calcium, CBC, ESR, ALP and LDH. On the next day, results were referred to Endo for further evaluation and management. y

On March 31, 2011, the patient underwent thyroid ultrasound. Skeletal summary was ordered on April 1, and was scheduled for Serum Protein Electrophoresis on April 4. Also, levofloxacin 500 mg 1 cap BID for 7 days was started.

y On April 2, 2011, awaits results of SPE and

send to Endo for suggestions. On April 11, 2011, result was submitted to endocrinologist. y On April 13, 2011, referral to Tumor service was ordered and for bone marrow aspiration under local anesthesia.

X. LABORATORY ANALYSIS

TEST NAME Hemoglobin

RESULTS NORMAL X. LABORATORY ANALYSIS INTERPRETATION VALUES 80 110-158 Slightly Decreased; risk for anemia

Hematocrit Leukocytes Segmenters Lymphocytes Monocytes Eosinophils latelet count

0.24 4400 0.60 0.33 0.07 0.00 385,000/cumm

0.37-0.54

Decreased; hemodilution

4500-10000/cumm Within normal limits 0.5-0.7 0.2-0.4 0.00-0.07 0.00-0.05 150000450000/cumm Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits

Nursing Responsibilities:y Transfused blood, 1st u of PRBC properly crossmatched and typed. y Provide adequate rest and sleep periods. y Demonstrate and encourage on doing deep breathing exercises to improve oxygenation. y Encourage to eat foods rich in iron such as green leafy vegetables for iron supplement. y Encourage to eat vitamin C rich foods such as citrus fruits to improve iron absorption. y Increase oral fluid intake. y Strict adherence to treatment regimen.

COMPLETE BLOOD COUNT (MARCH 11, 2011) 6 hours post BT

TEST NAMEl

RESULTS

NORMAL VALUES11 -158

INTERPRE TATIONDecrease ; a e ia Decrease ; he o iluti o

87

i at cri t .27 .37- .54

Nursing Responsibilitiesy Transfused 2nd u of PRBC properly typed

and crossmatched. y Provide adequate rest and sleep periods. y Encourage to eat foods rich in iron such as green leafy vegetables for iron supplement. y Encourage to eat vitamin C rich foods such as citrus fruits to improve iron absorption.

COMPLETE BLOOD COUNT (MARCH 13, 2011) 6 hours post BT

TEST NAME

RESULTS

NORMAL VALUES 110-158

INTERPRE TATION Slightly Decreased; risk for anemia Decreased; hemodiluti on

Hemoglob 106 in

Hematocri 0.34 t

0.37-0.54

Nursing Responsibilities:y Provide adequate rest and sleep periods. y Encourage to eat foods rich in iron such as

green leafy vegetables for iron supplement. y Encourage to eat vitamin C rich foods such as citrus fruits to improve iron absorption.

COMPLETE BLOOD COUNT (MARCH 15, 2011)TEST NAME Hemoglobin Hematocrit Leukocytes Segmenters Lymphocytes Monocytes Eosinophils Platelet count RESULTS 101 0.31 3600 0.56 0.34 0.10 0.00 220,000/cumm NORMAL VALUES 110-158 0.37-0.54 INTERPRETATIO N Slightly Decreased; risk for anemia Decreased; hemodilution

4500-10000/cumm Within normal limits 0.5-0.7 0.2-0.4 0.00-0.07 0.00-0.05 150000450000/cumm Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits

Nursing Responsibilities:y Provide adequate rest and sleep periods. y Demonstrate and encourage on doing deep

breathing exercises to improve oxygenation. y Encourage to eat foods rich in iron such as green leafy vegetables for iron supplement. y Encourage to eat vitamin C rich foods such as citrus fruits to improve iron absorption. y Increase oral fluid intake. y Strict adherence to treatment regimen.

COMPLETE BLOOD COUNT (MARCH 29, 2011)TEST NAME Hemoglobin Hematocrit Leukocytes Segmenters Lymphocytes Monocytes Eosinophils Platelet count RESULTS 99 0.30 4100 0.40 0.43 0.08 0.02 154,000/cumm NORMAL VALUES 110-158 0.37-0.54 INTERPRETATIO N Decreased; anemia Decreased; hemodilution

4500-10000/cumm Within normal limits 0.5-0.7 0.2-0.4 0.00-0.07 0.00-0.05 150000450000/cumm Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits

Nursing Responsibilities:y Provide adequate rest and sleep periods. y Demonstrate and encourage on doing deep breathing exercises to improve oxygenation. y Encourage to eat foods rich in iron such as green leafy vegetables for iron supplement. y Encourage to eat vitamin C rich foods such as citrus fruits to improve iron absorption. y Observe proper personal hygiene to prevent infection. y Increase oral fluid intake. y Keep back dry at all times to prevent pulmonary complications. y Strict adherence to treatment regimen.

URINALYSIS (MARCH 11, 2011)

TEST NAME Color Reaction Transparency RBC Pus cells Bacteria

RESULTS Light yellow 6.0 Turbid 8-10 TNTC ++++

NORMAL VALUES Light yellow 4.5-8.0 Slightly turbid 1.015-1.030 0-2/hpf 0-2/hpf None

INTERPRETATI ON Normal Normal Infection Normal Increased; infection Increased; infection Increased; infection Increased; infection

Specific Gravity 1.030

Epithelial Cells ++

None

Nursing responsibilities:y Increase oral fluid intake. y Instruct on proper perineal care and proper

personal hygiene. y Encourage to urinate when there s an urge to void. y Give vitamin C rich foods such as citrus fruits. y Give levofloxacin 500mg 1 cap BID for 7 days

URINALYSIS (APRIL 1, 2011)

TEST NAME Color Reaction Transparency

RESULTS Yellow 5.0 Slightly Turbid

NORMAL VALUES Light yellow 4.5-8.0 Slightly turbid 1.015-1.030 0-2/hpf 0-2/hpf None None

INTERPRETATI ON Infection Normal Normal Normal Normal Increased; infection Increased; infection Increased; infection

Specific Gravity 1.030 RBC Pus cells Bacteria 0-2 14-16 Few

Epithelial Cells Few

Nursing Responsibilities:y Continue taking levofloxacin for antibiotic

therapy. y Increase oral fluid intake. y Encourage on regular urination.

URINALYSIS (APRIL 11, 2011)TEST NAME Color Reaction Transparency RESULTS Light Yellow 5.0 Slightly Turbid NORMAL VALUES Light Yellow 4.5-8.0 Slightly Turbid 1.015-1.030 0-2/hpf 0-2/hpf None None INTERPRETATI ON Normal Normal Normal Normal Normal Increased; infection Increased; infection Increased; infection

Specific Gravity 1.030 RBC Pus cells Bacteria 0-3 3-6 Few

Epithelial Cells +

Nursing Responsibilitiesy Increase oral fluid intake. y Encourage on regular urination.

LIPID PROFILE (MARCH 14, 2011)TEST NAME Glucose Urea Creatinine Cholesterol Triglycerides RESULTS 5.0 mmol/L 6.42 mmol/L 54.03 umol/L 6.40 mmol/L 2.25 mmol/L 0.60 mmol/L 2.34 mmol/L V 1.02 mmol/L NORMAL VALUES 4.2-6.40 1.7-8.3 44-115