A Case Study on

Pyomyositis Pyomyositis Left Leg

(In Partial Fulfillment of the Requirements in NCM – 104)

S.Y. 2010-2011 1st Semester

I.INTRODUCTION

Pyomyositis is a bacterial infection of the striated muscles, not arising from contagious infection, presumably hematogenous in origin, and often, but not invariably, associated with abscess formation . It is primarily caused by Staphylococcus aureus. It occurs in tropical areas and people with weak immune systems .

Pyomyositis is endemic in tropical areas. In tropical areas, PM is more frequent among men, with a female/male ratio of 3/5. It affects mostly young people and children. By contrast in non tropical areas, PM is uncommon and affects mainly adults and elderly patients. It is worth noting that 25% of the cases were reported to have travelled recently to the tropics .Trauma is found in 25-40% of the cases. PM is a feature mostly associated with various causes of immunodeficiency. PM is also frequently associated with malnutrition.

Symptoms of Pyomyositis includes (early stage) fever, localized inflammation, muscle pain, sepsis or infection, tender induration of the effected muscle, (late stages) abscess formation, bacterimia and metastatic abscesses.

The clinical course of PM is divided into three stages; (1) firt stage or invasive phase, (2) second stage or suppurative stage and (3) third stage. In the first stage, for the first two weeks, the disease is subacute and symptoms are often neglected. General symptoms are variable including fever and anorexia. Local symptoms are swelling, erythema, mild pain and minimal tenderness. On second stage of PM, diagnosis is often made at this stage. General signs are more prominent with high fever, chills and septic syndrome. Local abnormalities include tenderness, swelling, fluctuance (presence of pus), myalgia and inflammatory skin. And in the third stage systemic manifestations are severe with sepsis and fever. Local examination shows erythema, exquisite tenderness and obvious fluctuance. Further complications can occur: metastatic abscesses, arthritis, septic shock and renal failure.

Predisposing factors for pyomyositis include immunodeficiency, trauma, injection drug use, concurrent infection, and malnutrition

Diagnostic method used for PM includes ultrasound, CT scan and MRI. Ultrasound can be helpful in showing muscular heterogeneity or a purulent collection but it is not useful during the first stage of the disease. CT scan can confirm the diagnosis before abscesses occur with enlargement of the involved muscles and hypodensity when abscess is present, terogenous attenuation and fluid collection with rim enhancement can be found. MRI is useful to assess PM and determine its localization and extension.

Pyomyositis is treated with surgical procedure and antibiotic theraphy. The surgical management used in treating PM is radio-guided drainage of the abscesses. And the antibiotic therapy is based on the result of gram-staining and culture sensitivity done.

This case of AD was taken at the Children’s Ward of Philippine Orthopedic Center, Quezon City

under the supervision of Professor Milagros Rea. Her diagnosis was Pyomyositis on left leg with the chief

of pain and swelling on the left knee and leg.

A. OBJECTIVES

This study chosen by the researcher aims the following in the improvement of the following

interests:

KNOWLEDGE

To gather vital information regarding the present case and health status of the patient

To have a comprehensive understanding of the disease process and the implications of

laboratory and diagnostic examinations

To enhance the knowledge and ideas of the group with regards to Pyomyositis.

SKILLS

To determine appropriate nursing care management or interventions to be rendered to the

patient

To be aware of the effectiveness of the medical and surgical procedures the client may

undergo

ATTITUDE

To determine constructive and appropriate nurse actions for the patient

To impart knowledge through health teachings pertaining to the illness and its preventive

and promotive measures to observe

B. SCOPES AND DELIMITATIONS

This study involved the case of patient A.D. who is currently admitted at

Philippine Orthopedic Center with a diagnosis of Pyomyositis Left Leg. The study will

cover all information regarding the patient’s history and current condition, laboratory

work-ups, medications and some intervention that she had undergone that were

documented and available on the patient’s chart during the conduction of the study and

the information gathered during the nurse-patient interaction. This study will also

include the physical assessment and nursing intervention done with the client.

II.NURSING HEALTH HISTORY

A. BIOGRAPHIC DATA1. Name: AD2. Address: J. Pascual St. Navotas City 3. Age: 114. Date of Birth: May 1, 19995. Sex: female 6. Race: Filipino7. Marital status: Single 8. Occupation: (Currently Studying) Grade 5 student9. Religious orientation: Roman Catholic10. Health care financing and usual source of medical care: Her mother financing her

hospitalization11. Date of admission: September 9, 201012. Attending Physician: Dr. Bernabe13. Admitting diagnosis: Pyomyositis Left Leg

B. NURSING HISTORYChief Compliant or Reason for VisitThe patient is brought to hospital because of pain and swelling of left knee and leg.

History of Present IllnessThree weeks prior to admission, patient is walking going to the church when suddenly patient slipped and injured her left knee. After that it develops persistent pain. Then after a week she was brought to a “hilot” and manipulation is done with oil. That night the patient develops low grade fever and swelling of the left knee and leg with persistent pain. Currently, the patient is admitted to Philippine Orthopedic Center and the said condition is being managed by antibiotic therapy and wound drainage. Past HistoryAccording to her mother, she had immunization but not completed. She had chickenpox and sore eyes when she was younger. She has no allergy to drugs and foods. She had no history of hospitalization; her current confinement to the POC is her first hospitalization.

Family History of IllnessOn her mother’s side there is a history of hypertension and Diabetes mellitus. On the family of her father was not recalled by her mother.

III. PHYSICAL ASSESSMENT

A. GENERAL SURVEY

Patient AD, female 11 years old, stands about 4 feet tall and weighs approximately 40 kilograms. Patient is conscious and coherent. Patient has an IV line on right arm.

CUES Actual Findings Normal Findings Interpretation Analysis

General Appearance

Facial grimacing is observed.

Healthy appearance, no distress in facial expression or posture

With Deviation

For clients who are young facial expression is often the first indication of pain and it may be the only one.

(Kozier et al. Fundamentals of Nursing 7th edition 2004 p. 1145)

Behavior Cooperative Cooperative Normal

Age 11 years old, age appropriate to appearance

Age appropriate to appearance

Normal

Sex Female Male or female Normal

Race Filipino Varies w/ individuals Normal

Body Type Proportionate, varies with lifestyle

Proportionate, varies with lifestyle

Normal

Hygiene Clean and neat Clean and neat Normal

Posture

Able to sit but unable to stand because of pain and swelling on the left foot.

Relaxed, erect posture; coordinated movement With Deviation

Immobilization of the body part or a part of the body may indicate pain.

(Kozier et al. Fundamentals of Nursing 7th edition 2004 p. 426)

Gait Not Assessed

Relaxed, erect posture; coordinated movement Not Assessed

Dressing Clean, neat and appropriate

Clean, neat and appropriate

Normal

Odor

No body odor, no breath odor

No body odor or minor body odor relative to work or exercise; no breath odor

Normal

Mood Irritable Appropriate to situation

With deviation

Pain causes discomfort to the patient causing patient to be irritable.

Kozier et al. Fundamentals of Nursing 7th edition 2004 p. 425)

Speech Understandable, moderate pace; exhibits thought association

Understandable, moderate pace; exhibits thought association

Normal

II. HEAD TO TOE ASSESSMENT (PART I)

A. HEAD

Parts Actual Findings Normal Findings Interpretation Analysis

Skull

Normocephalic, proportional to the size of the body, round, symmetrical in all planes, gently curved and with prominences in the frontal and occipital area anteriorly and posteriorly respectively.

Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); smooth skull contour, uniform consistency, absence of nodules or masses

Normal

Scalp

Free from dandruff, lesions, lumps, and scars, nits, clean and whitish. No masses of tenderness

White, clean, free from masses, lumps, scars, nits, dandruff and lesions

Normal

Hair

Black, evenly distributed and covers the whole scalp, thick and free from split ends.

Black, evenly distributed & covers the whole scalp, thick, shiny, free from split ends

Normal

oval-shaped, symmetrical, with facial

Oblong, oval, square or heart-shaped, symmetrical, facial

For clients who are young facial expression is often the first indication of pain

Face

grimacing , smooth and free from wrinkles, no involuntary muscle movements

expression that is dependent on the moods and feelings, smooth and free from wrinkles, no involuntary muscle movements

With Deviation

and it may be the only one.

(Kozier et al. Fundamentals of Nursing 7th edition 2004 p. 1145)

Eyes

Eyes are brown, parallel and evenly placed, symmetrical, non-protruding, with scant amount of secretions.

Parallel and evenly placed, symmetrical, non-protruding, with scant amount of secretions, both eyes are black and clear

Normal

Eyebrows

Black, symmetrical, thick, can raise & lower eyebrows symmetrically and without difficulty, thin & evenly distributed & parallel with each other

Black, symmetrical, thick, can raise & lower eyebrows symmetrically and without difficulty, evenly distributed & parallel.

Normal

Eyelashes

Turned outward, black evenly distributed

Black, evenly distributed and turned outward Normal

Eyelids

When eyes are open, upper lids cover small portion of the iris, cornea and sclera. When eyes are closed, the lids meet completely. The same color as the surrounding skin.

Upper lids cover a small portion of the iris, cornea & the sclera when the eyes are open. When the eyes are closed, the lids meet completely. Symmetrical and color is the same as the surrounding skin

Normal

Lid Margins

Puncta are evident at nasal ends, clear, without scaling or secretions.

Clear, without scaling or secretions, lacrimal duct openings (puncta) are evident at nasal

Normal

ends

Palpebral fissures

Appear equal when the eyes are open

Appear equal when the eyes are open

Normal

Lower Palpebral

Conjunctiva

Salmon pink, shiny, moist and transparent

Salmon Pink, shiny, moist and transparent Normal

Sclera White and clear White and clear Normal

Iris

Iris are brown in color, symmetrical, proportional to the size of the eyes, round

Proportional to the size of the eye, round, black/brown and symmetrical Normal

Pupils

Pupils are equally round and reactive to light and accommodation

Pupils are equally round and reactive to light and accommodation

Normal

Eye movement

Able to move eyes in full range of motion or able to move in all direction

Able to move eyes in full range of motion or able to move in all direction

Normal

Visual Acuity Patient can see clearly Eyes can see clearly Normal

Field of Vision Able to see 60 degrees superiorly, 90 degrees temporally and 70 degrees inferiorly

Able to see 60 degrees superiorly, 90 degrees temporally and 70 degrees inferiorly

Normal

Ears

Parallel, symmetrical, proportional to the size of the head, bean-shaped. Helix is in line with the outer canthus of the eye, skin is the

Parallel, symmetrical, proportional to the size of the head, bean-shaped. Helix is in line with the outer canthus of the eye,

Normal

same color as the surrounding skin, clean

skin is the same color as the surrounding skin, clean

Ear Canal

Slightly Pinkish, clean with scant amount of cerumen and a few cilia

Pinkish, clean with scant amount of cerumen and a few cilia

Normal

Hearing Acuity

Able to hear and verbalize or repeat whispered spoken word two feet away

Able to hear and verbalize or repeat whispered spoken word two feet away

Normal

Nose

Midline, symmetrical and patent

Midline, symmetrical and patent

Normal

Internal Nares Not Assessed

Clean, pinkish, with few cilia

Not Assessed

Septum Straight, midline Straight, midline Normal

Lips

Dark, symmetrical, lip margin well defined, smooth and moist

Pinkish, symmetrical, lip-margin well defined. Smooth and moist Normal

Gums

Slightly pinkish, smooth, moist, no swelling, no retraction, no discharge

Pinkish, smooth, moist, no swelling, no retraction, no discharge

Normal

Teeth 32 permanent teeth, , no halitosis

32 permanent teeth, well-aligned, free from caries or filling, no halitosis

Normal

Tongue

Slight pinkish in color and medium in size, margins are moist, shiny

Large, medium, red or pink, the lateral margins moist, shiny, freely movable

Normal

Frenulum Midline, straight, and thin

Midline, straight, and thin

Normal

Buccal Mucosa

Pinkish, moist and smooth

Pinkish, moist and smooth

Normal

Soft Palate Pinkish, moist and smooth

Pinkish, moist, and smooth

Normal

Hard Palate Pinkish in color Slightly pinkish Normal

Uvula

At the center, symmetrical and freely movable

At the center, symmetrical, and freely movable Normal

Tonsils

non-inflamed, no exudates

Pinkish, non-inflamed, no exudates Normal

Voice

No hoarseness and well modulated

No hoarseness and well modulated

Normal

Neck

Proportional to the size of the body and head, symmetrical and straight, no palpable lumps, masses, or areas of tenderness.

Proportional to the size of the body and head, symmetrical and straight, no palpable lumps, masses, or areas of tenderness, Adam’s apple palpable

Normal

Range of motion

Freely movable without difficulty

Freely movable without difficulty

Normal

Muscular strength

Able to resist applied force, symmetrical in structure of size and muscular strength

Able to resist applied force, symmetrical in structure of size and muscular strength

Normal

Part 2

CHEST & ABDOMEN EXAMINATION

Parts Actual Findings Normal Findings Interpretation Analysis

Inspection of Anterior and

Posterior Thorax

The chest contour is symmetrical and the chest is twice as wide as deep (antero-posterior diameter in a 1:2 ratio) the spine is straight, the ribs tend to slope across and down. The ribs are prominent in a thin person. There is no bulging or retraction of the ICS while breathing. The chest wall moves symmetrically during respiration

The chest contour is symmetrical and the chest is twice as wide as deep (antero-posterior diameter in a 1:2 ratio) the spine is straight, the ribs tend to slope across and down. The ribs are prominent in a thin person. There is no bulging or retraction of the ICS while breathing. The chest wall moves symmetrically during respiration

Normal

Palpation of Anterior and

Posterior Thorax

No lumps, masses, areas of tenderness. Sides of the thorax expand symmetrically. The examiner’s thumb separate approximately 3 cm during expansion.

No lumps, masses, areas of tenderness. Sides of the thorax expand symmetrically. The examiner’s thumb separate approximately 3-5 cm during expansion.

Not Done

Tactile fremitus of

Anterior and

Variations are prominent over the areas near the bronchi. It increases with intensity of the voice. Vibrations are strongest

Posterior Thorax

Not Done between the scapulae posteriorly.

Not Done

Percussion of Anterior

and Posterior Thorax

Not Done

Percussion note varies with the thickness of the chest wall. Resonance – sound created by air filled lungs. It is clear, long, low pitch. Dull – short, high pitch, soft and thudding, heard over the heart. Flat – absolute dullness; absence of air in the underlying tissue. Tympany – moderately loud with quality with specific pitch, noted in the upper left quadrant of the abdomen.

Not Done

Auscultation of Anterior

and Posterior Thorax

Normal breath sounds were heard upon ascultation.

Normal breath sounds differ in their character depending on the area being auscultated. Bronchovesicular sounds-medium pitched sound heard posteriorly between the scapulae. The sound has a blowing quality with the inspiratory phase equal to the expiratory phase. Vesicular sounds-heard over the lung periphery. The sounds are created by air moving through the smaller airways. They are soft, breezy and low pitched. The inspiratory phase is about 3 times longer than the expiratory phase. Bronchial sounds-hollow high pitched whistling sounds, which are normal id heard over large airways like the trachea.

Normal

No pulsations on the No pulsations on the aortic,

Heart

aortic, pulmonic and tricuspid valves while pulsations are visible and palpable in the apical area. Abdominal aortic pulsations are visible and palpable in thin people. 2 heart sounds are audible in one area but loudest in the apical area.

No enlargement of the heart. Cardiac rate: 80 beats/min.

pulmonic and tricuspid valves while pulsations are visible and palpable in the apical area. Abdominal aortic pulsations are visible and palpable in thin people. 2 heart sounds are audible in one area but loudest in the apical area. Cardiac rate ranges from 60-100 beats/min.

Normal

Breast Not Assessed

Females: rounded, symmetrical. If obese, maybe slightly rounded. Color of the skin same as the surrounding skin, no retraction, no dimpling.

Not Assessed

Areola Not Assessed

Round or oval, color darker than surrounding skin, symmetrical. For dark-skinned client, color is darker than other skin surfaces. No masses and areas of tenderness.

Not Assessed

Nipples Not Assessed

Round or inverted, equal in size, similar in color, nipples point in one direction, no discharge, no lesion, no dimpling, and no crusting. No masses, no tenderness

Not Assessed

Skin unblemished, no scars, color is uniform, flat, rounded or scaphoid, symmetrical

Skin unblemished, no scars, color is uniform, flat, rounded or scaphoid, symmetrical movements

Abdomen (Inspection)

movements cause by respiration, umbilicus is concave, color is the same as the surrounding skin

cause by respiration, aortic pulsation at the epigastric area visible in thin persons, umbilicus is flat or concave, color is the the same as the surrounding skin

Normal

Auscultation of the

Abdomen

There are clicks and gurgles, the frequency of which has been 26 per minute.

There are clicks and gurgles, the frequency of which has been estimated from 5-34 per minute. Occasionally, borborygmi (loud prolonged gurgles of hyperpersitalsis) – the unfamiliar stomach can be heard.

Normal

Percussion in the Abdomen

Not Assessed

Tympany predominates because of the presence of air in the stomach and intestines. Percussion is dull at the liver’s lower border.

Not Assessed

Palpation of the Abdomen

Not Assessed

Liver’s edge feels firm and non-tender.

Not Assessed

Part 3

UPPER EXTREMITIES

Parts Actual Findings Normal Findings Interpretation Analysis

Arms

Skin color is brown, symmetrical, fine hair evenly distributed no presence of visible veins, warm but dry.There are no areas of

Skin color varies (pinkish, tan, dark brown), symmetrical, fine hair evenly distributed, presence/absence of visible veins. Warm, dry and elastic, no areas of tenderness, muscle

Normal

tenderness, muscle appear equal.

appear equal with good muscle tone, performs motion with relative ease.

Elbows

Performs motion with relative ease

Performs motion with relative ease

Normal

Hands and wrist Performs motion with relative ease

Performs motion with relative ease

Normal

Nails

Nails are transparent, smooth & convex with pale nail beds & white translucent tips, 5 fingers in each hand. As pressure is applied to the nail bed, it appears blanched, & pink color returns in 2 seconds.

Nails are transparent, smooth & convex with pink nail beds & white translucent tips, 5 fingers in each hand. As pressure is applied to the nail bed, it appears blanched, & pink color returns immediately as pressure is released.

Normal

Palms and dorsal surfaces

Palms are pale, thick and warm.

Palms pinkish (dorsal surface), warm, thick

Normal

Shoulders Performs motion with relative ease

Performs motion with relative ease

Normal

Lower Extremities

Parts Actual Findings Normal Findings Interpretation Analysis

Skin varies (pinkish, tan, dark brown) skin is smooth, fine hair evenly distributed, absence of varicose veins, muscles symmetrical, length

The release of chemical mediators during an injury increases capillary permeability resulting to leakage

Legs Swelling on the left leg with tenderness. The area is warm to touch.

symmetrical. Muscles appear equal, warm & with good muscle tone, performs motion with relative ease

With Deviation

of fluids in the surrounding tissue. The pain that occurs is attributed to the pressure of fluids on nerve endings and to the irritation of nerve endings by chemical mediators like Bradykinin.

(Smeltzer et al. Brunner & Suddarth’s Medical-Surgical Nursing 10th ed. 2004 p. 103)

Knees Patient cannot move the left knee or the affected area

Performs motion with relative ease

With Deviation

Loss of function is most likely related to pain and swelling, but the exact mechanism is not completely known.

(Smeltzer et al. Brunner & Suddarth’s Medical-Surgical Nursing 10th ed. 2004 p. 103)

Ankles Patient cannot move the left ankle.

Performs motion with relative ease

With Deviation

Immobilization of the body part or a part of the body may indicate pain.

(Kozier et al. Fundamentals of Nursing 7th edition 2004 p. 426)

. Five toes in each foot, sole and dorsal surface is smooth: With pale nail beds & translucent tips. As

Five toes in each foot, sole and dorsal surface is smooth: With pink nail beds & translucent tips.

Toes pressure is applied, the nail bed appears white or blanched; pink color returns in 2 secs when pressure is released.

As pressure is applied, the nail bed appears white or blanched; pink color returns when pressure is released. Performs motion with relative ease.

Normal

CEREBELLAR FUNCTION

Activity Actual Findings Normal Findings Interpretation Analysis

Pats hands against the thigh as fast as possible

Asymmetrical and slow movement

Symmetrical and fast movement

Normal

Finger to nose test

Repeatedly and rhythmically touches the nose

Repeatedly and rhythmically touches the nose Normal

MOTOR FUNCTION

Activity Actual findings Normal findings Interpretation Analysis

Describe Muscle mass

Proportionate to the body type

Proportionate to the body type

Normal

Passively flexing of elbow

Can passively flex the elbow

Can passively flex the elbow

Normal

Squeezing of fingers

Can squeeze the fingers with both

Can squeeze the fingers with both

Normal

with both hands

hands hands

Muscle tone

Good muscle tone Good muscle tone Normal

IV. ANATOMY AND PHYSIOLOGY

MUSCULOSKELETAL SYSTEM

Every one of the body's 430 skeletal muscles consists of muscle tissue, connective tissue, nerves and blood vessels. A fibrous fascia called the epimysium covers each muscle and tendon. Tendons connect the muscle belly to bone and they attach to the bone periosteum - more connective tissue that covers

all bones. Contraction of the muscle belly pulls on the tendon and in turn, the bone it is attached to.

Limb muscles (such as the biceps brachii in the upper arm) have two attachments to bone. The proximal or origin is the attachment closest to the trunk. The distal or insertion is the attachment furthest from the trunk. Trunk muscles (such as the rectus abdominus in the stomach) also have two attachments - superior (closer to the head) and inferior (further from the head).

A closer look at muscle anatomy shows that each muscle belly is made up of muscle cells or fibres. Muscle fibres are grouped into bundles (of up to 150 fibres) called fasciculi. Each fasiculus or bundle is surrounded by connective tissue called perimysium. Fibres within each bundle are surrounded by more connective tissue called endomysium.

Each individual fibre consists of a membrane (sarcolemma) and can be further broken down into hundreds or even thousands of myofibrils. Myofibrils are surrounded by sarcoplasm and together they make up the contractile components of a muscle.

Sarcoplasm contains glycogen, fat particles, enzymes and the mitochondria. The myofibrils it encases consist of two types of protien filaments or myofilaments. They are actin and myosin.

Myosin and actin filaments run in parallel to each other along the length of the muscle fibre. Myosin has tiny globular heads protruding from it at regular intervals. These are called cross bridges and play a pivotal role in muscle action.

Each myofibril is organized into sections along its length. Each section is called a sarcomere and they are repeated right along the length of a muscle fibre. It's similar to how a meter ruler is split into centimeters and millimeters. Just as the millimeter is the smallest function of a ruler, the sarcomere is the smallest contractile portion of a muscle fibre.

IMMUNE SYSTEM

The immune system protects the body from potentially harmful substances by recognizing and responding to antigens. Antigens are molecules (usually proteins) on the surface of cells, viruses, fungi, or bacteria. Nonliving substances such as toxins, chemicals, drugs, and foreign particles (such as a splinter) can also be antigens. The immune system recognizes and destroys substances that contain these antigens.

Even your own body's cells have proteins that are antigens. These include a group of antigens called HLA antigens. Your immune system learns to see these antigens as normal and usually does not react against them.

INNATE IMMUNITY

Innate, or nonspecific, immunity is the defense system with which you were born. It protects you against all antigens. Innate immunity involves barriers that keep harmful materials from entering your body. These barriers form the first line of defense in the immune response. Examples of innate immunity include:

Cough reflex Enzymes in tears and skin oils

Mucus, which traps bacteria and small particles

Skin

Stomach acid

Innate immunity also comes in a protein chemical form, called innate humoral immunity. Examples include the body's complement system and substances called interferon and interleukin-1 which is a type of is one type of cytokines produced by macrophages that initiate inflammation and stimulates the hypothalamus to increase body temperature (which causes fever).

If an antigen gets past these barriers, it is attacked and destroyed by other parts of the immune system.

BLOOD COMPONENTS

The immune system includes certain types of white blood cells. It also includes chemicals and proteins in the blood, such as antibodies, complement proteins, and interferon. Some of these directly attack foreign substances in the body, and others work together to help the immune system cells.

Lymphocytes are a type of white blood cell. There are B and T type lymphocytes.

B cells produce antibodies. Antibodies attach to a specific antigen and make it easier for the immune cells to destroy the antigen.

T cells attack antigens directly and help control the immune response. They also release chemicals, known as cytokines, which control the entire immune response.

As lymphocytes develop, they normally learn to tell the difference between your own body tissues and substances that are not normally found in your body. Once B cells and T cells are formed, a few of those cells will multiply and provide "memory" for your immune system.

This allows your immune system to respond faster and more efficiently the next time you are exposed to the same antigen, and in many cases will prevent you from getting sick. For example, a person who has had chickenpox or has been immunized against chickenpox is immune from getting chickenpox again.

INFLAMMATION

The inflammatory response (inflammation) occurs when tissues are injured by bacteria, trauma, toxins, heat, or any other cause. The damaged cells release chemicals including histamine, bradykinin, and prostaglandins. These chemicals cause blood vessels to leak fluid into the tissues, causing swelling. This helps isolate the foreign substance from further contact with body tissues.

The primary physical effect of the inflammatory response is for blood circulation to increase around the affected area. In particular, the blood vessels around the site of inflammation dilate, allowing increased

blood flow to the area. Gaps appear in the cell walls surrounding the area, allowing the larger cells of the blood, i.e. the immune cells, to pass through. As a result of the increased blood flow, the immune presence is strengthened. All of the different types of cells that constitute the immune system congregate at the site of inflammation, along with a large supply of proteins, which fuel the immune response. There is an increase in body heat, which can itself have an anti-biotic effect, swinging the balance of chemical reactions in favour of the host. The main symptoms of the inflammatory response are as follows.

The tissues in the area are red and warm, as a result of the large amount of blood reaching the site.

The tissues in the area are swollen, again due to the increased amount of blood and proteins that are present.

The area is painful, due the expansion of tissues, causing mechanical pressure on nerve cells, and also due to the presence of pain mediators.

Once the inflammatory process has begun, it continues until the infection that caused it has been eradicated. Phagocytes continue to consume and destroy bacteria, the acquired immune system binds and disposes of harmful toxins. Pus is produced, pus being the debris that is left over from the battle between the invader and the immune system. The colour of the pus depends on the organism causing the infection.

The immune cells involved in the inflammatory response, once they become activated, are primed to commit Apoptosis. Helper T cells emit the stay-alive signal, and keep emitting the signal for as long as they recognise foreign antigens in the body, thus prolonging the inflammatory response. It is only when the infection has been eradicated, and there is no more foreign antigen that the helper T cells stop emitting the stay-alive signal, thus allowing the cells involved in the inflammatory response to die off.

If foreign antigen is not eradicated from the body or the helper T cells do not recognise that fact, or if the immune cells receive the stay-alive signal from another source, then chronic inflammation may develop.

V. LABORATORY

Name of Test or Procedure

Date Done Indication for Test

Normal Value Actual Results/ Findings

Significance of the Result & Findings

Hematology

September 12, 2010

Hemoglobin 110 -150 g/L 103 With deviation-Decreased

Low hemoglobin may indicate anemia

(Clinical Laboratory Tests: Values And

Implications p.336)Hematocrit 0.37 – 0.54 0.32 With deviation-

Decreased

Low hematocrit may indicate anemia

(Clinical Laboratory Tests: Values And

Implications p.327)Segmenters 0.50 - 0.70 89 With deviation-

Increased

Increase Segmenters indicates the

presence of an acute bacterial infection or some inflammation going on inside the body to provide the

body a greater ability to fight infection

(Clinical Laboratory

Tests: Values And Implications p.249)

Lymphocytes 0.20 - 0.40 .07 With deviation-Decreased

Decrease in lymphocytes indicates a sign of infection or

sepsis.(Kozier et al.

Fundamentals of Nursing 7th edition 2004

p. 759)ESR 0 - 10 mm/hr 107 With deviation-

Increased

ESR rises in acute or chronic inflammation.

(Clinical Laboratory Tests: Values And

Implications p.249)

Hematology September 28, 2010

Hemoglobin 110 -150 g/L 136NORMAL

Hematocrit 0.37 – 0.54 0.42NORMAL

Segmenter 0.50 - 0.70 0.61NORMAL

Lymphocytes 0.20 - 0.40 0.32NORMAL

Platelet 150-400 x 109L

874 With deviation-Increased

Increase platelet count can result from

infectious disorder(Clinical Laboratory Tests: Values And

Implications p.499)

ESR 0 - 10 mm/hr 79 With deviation-Increased

ESR rises in acute or

chronic inflammation.(Clinical Laboratory Tests: Values And

Implications p.249)

VI. DRUG STUDY

Drug Action Indication Contraindications Adverse Effect Nursing Responsibilities

Generic Name:Ceftriaxone sodium

Brand Name:

Classification:Anti-infective/ Antibiotic

Dosage: 500mg IV q12° (-) ANST

Interferes with bacterial cell-wall synthesis and division by binding to cell wall, causing cell to die. Active against gram-negative and gram-positive bacteria, with expanded activity against gram-negative bacteria. Exhibits minimal immunosuppressant activity.

Infections of respiratory system, bones, joints, and skin; septicemia

Hypersensitivity to cephalosporins or penicillins

Use cautiously in • renal impairment, hepatic disease, gallbladder disease, phenylketonuria • history of GI disease, diarrhea following antibiotic therapy

CNS: headache, confusion, hemiparesis, lethargy, paresthesia, syncope, seizures CV: hypotension, palpitations, chest pain, vasodilation EENT: hearing loss GI: nausea, vomiting, diarrhea, abdominal cramps, oral candidiasis, pseudomembranous colitis, pancreatitis, Clostridium difficile-associated diarrhea GU: vaginal candidiasis Hematologic: lymphocytosis, eosinophilia, bleeding tendency,hemolytic anemia, hypoprothrombinemia, neutropenia, thrombocytopenia, agranulocytosis, bone marrow depression Hepatic: jaundice, hepatomegaly Musculoskeletal: arthralgia Respiratory: dyspnea Skin: urticaria,

Monitor for extreme confusion, tonic-clonic seizures, and mild hemiparesis when giving high doses.

Monitor coagulation studies.

Instruct patient to report persistent diarrhea, bruising, or bleeding.

Monitor for signs and symptoms of superinfection and other serious adverse reactions.

maculopapular or erythematous rash Other: chills, fever, superinfection, pain at I.M. injection site, anaphylaxis, serum sickness

Generic Name:Mefenamic acid

Brand Name:

Classification:Analgesic

Dosage:250mg/5ml5ml q4° PRN for pain

Mefenamic acid binds the prostaglandin synthetase receptors COX-1 and COX-2, inhibiting the action of prostaglandin synthetase. As these receptors have a role as a major mediator of inflammation and/or a role for prostanoid signaling in activity-dependent plasticity, the symptoms of pain are temporarily reduced.

Relief of painincludingmuscular,rheumatic,traumatic,dental, post-op andpostpartumpain,headache,migraine,fever,

hypersensitivity,active ulcerationor chronicinflammation ofeither upper orlower GIT, blooddisorders, poorplatelet function,kidney or liverimpairment,children < 14 yrs

GI:GI disturbances, GI hemorrhageHEMA: blood dyscrasiasCNS:drowsiness dizziness, headacheEENT: visual disturbancesDERMA: skin reactionsKIDNEY: nephropathy

Assess pt.’spain beforetherapy

Advice pt. not to take drug for more than 7 days

Advice pt. to report immediately persistence or failure to relieve pain

Monitor for possible drug induced adverse reactions

Generic Name:Paracetamol

Brand Name:

Classification:Antipyretic/ Analgesic

Unclear. Pain relief may result from inhibition of prostaglandin synthesis in CNS, with subsequent blockage of pain impulses. Fever

Relief of fever, minor aches and pains

Anemia, cardiac and pulmonary disease. Hepatic and severe renal disease.

Use cautiously to patients with pain of >10 days and fever

Allergic skin reactions and GI disturbances.

Assess for urinary output, change in blood chemistry, abdominal examination and respiratory auscultation.

Dosage:250mg/5ml 5ml q4° for Temp of 37.8 and above

reduction may result from vasodilation and increased peripheral blood flow in hypothalamus, which dissipates heat and lowers body temperature.

of > 3 days.

Generic Name:Oxacillin

Brand Name:

Classification:Anti-infective/ Antibiotic

Dosage:500mg IV q6° (-) ANST

By binding to specific penicillin-binding proteins (PBPs) located inside the bacterial cell wall, Oxacillin inhibits the third and last stage of bacterial cell wall synthesis. Cell lysis is then mediated by bacterial cell wall autolytic enzymes such as autolysins; it is possible that Oxacillin interferes with an autolysin inhibitor.

Treatment of infections due to Staph resistant to benzylpenicillin including bone and tissue infections.

Hypersensitivity to penicillin and its derivatives.

Allergy and psuedomembraneous colitis.

Assess client’s sensitivity to drug.

Instruct client to report any sign to anaphylactic reaction such as rush, itchiness and difficulty of breathing.

Nursing Care PlanCues Nursing

DiagnosisBackground Knowledge

Planning Intervention &Rationale

Evaluation

Objective Cues: - Skin is warm

to touch- Flushing of

skin

Parameters:T: 37.9°CP: 82 bpmR: 20 cpm

Hyperthermia r/t trauma

During an infection, there will be a release of interleukin-1 by macrophages. This interleukin-1 initiates inflammatory response and stimulates the hypothalamus to increase body temperature.

Ref: Brunner and Suddarth’s Textbook of Medical Surgical Nursing

After 4 hours of nursing intervention, the patient will demonstrate decrease in body temperature would be within normal range.

Explain to the client the need for immediate intervention for lowering down her temperature to gain patient’s cooperation.

Provide surface cooling by means of providing loose clothing for the client to promote heat loss by radiation and convection.

Cool the environment by opening the fan and providing adequate ventilation to promote heat loss by means of convection.

Perform tepid sponge bath (to promote heat loss through evaporation and conduction) concentrating on groin and axillae (areas of high blood flow)

Expected outcome:

After 4 hours of nursing intervention, the patient will achieve normal body temperature.

Promote bed rest to reduce metabolic demands/oxygen consumption.

Encourage high-calorie diet and increase fluid intake to meet increased metabolic demand and because hyperthermia causes dehydration.

Administer due antipyretic medication (paracetamol 250mg/5ml; 5ml q4° for Temp of 37.8 and above as) prescribed to aid in relieving pain.

Reassess V/S especially body temperature to review alterations of V/S as affected by patient’s condition, and progress as given with interventions.

(Reference: Nurse’s Pocket Guide, 11th edition, pp. 384-

386)

Nursing Care PlanCues Nursing

DiagnosisBackground Knowledge

Planning InterventionRationale

Evaluation

Subjective Cue:“Wag ninyo ate hawakan dyan, masakit po dyan sa parteng yan ”

Objective Cues:- Facial grimace- Guarding on the left leg - Inability to move-Irritability-Positioning of the knee to avoid pain

Acute pain related to trauma on the knee and legs.

The entry of pathogens in circulation leads to release of chemical mediators, increasing the capillary permeability allowing escape of fluid into the vessels, causing mechanical pressure on nerve cells, and also due to the presence of pain mediators.

Ref: Brunner and Suddarth’s Textbook of Medical Surgical Nursing

Within 4 hours of nursing intervention the patient will verbalize reduced pain from a pain scale of 5/10 to at least 3/10.

Explain to the client why she is suffering from pain and let her know that you acknowledge the pain experience and convey acceptance to client response to pain to gain cooperation and trust and because pain is subjective and cannot be felt by others.

Promote comfort measures like touch, repositioning, providing quiet environment and calm activities to promote non-pharmacological pain management.

Instruct patient to use relaxation techniques such as deep breathing and imaging to distract attention and reduce tension.

Expected outcome:After 4 hours of rendering effective nursing interventions, the will patient report of less pain AEB decreased irritability and had been smiling more frequently.

Parameters:With facial pain scale of 5/10

Encouraged diversional activities like letting the patient watch a movie or TV show, listen to radio or to chat with others to divert his attention to the pain.

Administered medication (Mefenamic acid 250mg/5ml5ml q4° PRN for pain) as ordered by physician to aid in relieving pain.

(Reference: Nurse’s Pocket Guide, 11th edition, pp. 498-503)

VIII. DISCHARGE SUMMARY

M edications. Compliance on the prescribed take home medications with the right generic name, right dosage and preparation, right route and time of administration.

E xercise. Patient is instructed to do active ROM at home and avoid massaging or prevent applying any other traumatic pressure on the affected area.

T reatment. Instruct client to comply on the prescribed treatment. Cover the affected area with a wound gauze as pt has underwent surgery. Patient is instructed to do proper wound care.

H ealth teachings. Emphasized proper handwashing and encouraged non pharmacological measures for pain once experienced (use of relaxation techniques like deep breathing,

imaging and use of diversion activities like watching movies, playing with toys, socializing with others)

O utpatient follow up visit. Attend on the scheduled outpatient follow up visit.

D iet. Instruct client to consume foods rich in Vitamin C such as fruits for boosting of immunity, protein such as meats, beans, egg and milk for tissue repair and high in fiber such as fruits, fruit juices, vegetables and oats to aid in elimination.