Central Luzon Doctors’ Hospital Educationa Institution

San Pablo, Tarlac City

CASE STUDY
On

Osteoarthritis

Prepared by:
John Lee Dela Cruz
BSN IV-C
Group 12

Ms. Mary Ann Pangan RN MSN

Clinical Instructor
 I. Introduction

For the purpose of privacy and confidentiality, the real name of the patient in this Case
Study is withheld and she will referred to as “Mr. A” throughout the entire document.

Mr. A is a 54 year old female and currently residing in Purok Ilang Ilang, Plastado,
Gerona, Tarlac together with her wife. For further evaluation, hence, he was admitted at Central
Luzon Doctors’ Hospital with the chief complaint of lower back pain.

Osteoarthritis is a chronic, nonsystemic disorder of joints characterized by degeneration of

articular cartilage. Women and men are affected equally, the incidence increases with age. Cause
is still unknown, most important factor in development is aging, other include obesity and joint
trauma. Weight bearing joints in spine, knees and hip and the terminal interphalangeal joints in
fingers are most commonly affected.
II.Assessment

Nursing Health History A

Patient: Mr.A

Age: 53 years old Sex: Male

C/S:married Religion: Roman Catholic

I. CHIEF COMPLAINT

Lower back pain

II. HISTORY OF PRESENT ILLNESS

A day prior to admission patient experienced severe lower back

pain which caused him difficulty doing his job.

III. MEDICAL HISTORY (includes dates, complications, if any)

A. PAST Pediatric and Adult Illness:

Mumps Pertusis HPN

Measles  Rheumatic Heart Disease

Chicken Pox  Pneumonia Hepatitis

Rubella Tuberculosis Others

B. Immunization/Test:
 BCG  Hepa B For Pneumonia

DPT Measles Others

OPV Flu

C. Hospitalizations:

He was hospitalized for 5 times due to fever.

D. Injuries:

He had no injuries.

E. Transfusions:

The patient did not receive any blood transfusions.

F. Medications:

Before admission he usually took alaxan for lower backpain.

G. Allergies:

She had reported not having any allergies to either food groups or
drugs.

IV. FAMILY HISTORY

Age Family Member Cause of death Disease Present in the

Family
L D
* Paternal grandfather old age none
* Paternal Grandmother old age none
 * Maternal Grandfather Accident none
Maternal Grandmother none
78 Mother none
* Father none
49 Wife none

III. SOCIAL AND PERSONAL HISTORY

Date of Birth: june 26, 1957
Educational Attainment:
graduate
Position in the Family: father
Birthplace: Purok Ilang Ilang, Plastado,
Gerona, Tarlac
elementary Ethnic Background: Ilocano
Language : Ilocan, Kapampangan, Tagalog

A. Residence/ Home Environment

Mr. A and his wife currently reside in Purok Ilang Ilang, Plastado, Tarlac.
Their house is constructed with concrete and wood and stands near the rice
fields. They do have ceiling and adequate light source. According to him,
the space is adequate enough for them.

B. Occupation:

Mr. A is currently a jeepney driver at Gerona.

C. Financial Support System:

Mr. A mostly gets their finances from his work as a jeepney

driver which is sufficient to provide their daily expenses.
 D. Habits (tobacco/alcohol use, others)

Mr. A drinks alcohol occasionally and smokes ½ pack of cigarette per

day.

E. Diet (meal distribution, others):

Mr. A eats three times a day. He is fond of eating vegetables, itlog and
usual barrio dishes which they can get from their backyard and sometimes eats
meat occasionally.

F. Physical Activity/Exercise, if any:

His work as a driver is his form of exercise.

G. Brief Description of Average Day:

Mr. A usually wakes up around 4 am. Around six am he then starts his
usual work. He takes his meal at regular time and take a nap in the afternoon.
He usually sleeps around 8 pm.

IV. PHYSICAL EXAMINATION FINDINGS

1. SKIN

Area/ Feature to assess Technique Key Findings

Color Inspection Brown complexion
Lesions Inspection and Absence of lesion
Palpation
Moisture Palpation dry.

Temperature Palpation 36 ⁰C
Texture Palpation Smooth and even.
Mobility and Turgor Palpation Returns immediately to its normal position when
pinched, no tenting noted.

2. HAIR
Area/Feature to assess Technique Key findings
Color and Distribution Inspection Hair is black and well distributed.
Texture and Oiliness Palpation Fine texture and smooth to touch.
Infestation Inspection No infestation.

3. SCALP

Area/Feature to assess Technique Key findings

Scaliness and scars Inspection No scars and scaliness.
Tenderness, Lesions, Palpation Absence of lesion, tenderness and lumps; smooth
lumps, masses and intact.

4. SKULL

Area/Feature to assess Technique Key findings

Shape and symmetry Inspection Symmetrical.
Contour, Masses, Palpation Smooth, non-tender and free from masses and
Depression and depression.
Tenderness

5. FACE

Area/Feature to assess Technique Key findings

Facial Feature Inspection Proportion to the gross body structure.
Edema and Masses Inspection No tender areas, masses, edema or deformities.
Palpation

6. EYES

Area/Feature to assess Technique Key findings

External feature Inspection Sunken eyes, eye bugs noted.
Eyebrows, pupils, iris Eyebrows are symmetrical. The pupils and iris
and sclera. are also symmetrical. There is no obvious
deformity seen in the external eye structures,
with yellowish sclerae (icteric)
 for reaction to Inspection Has a normal pupillary reaction: constrict with
light light and dilate in darkness.
 for Inspection Has a normal pupillary reaction: constrict with a
accommodation near object and dilate with a distant object.
 for convergence Inspection Has a normal convergence.

7. EARS

Area/Feature to assess Technique Key findings

External and internal Inspection Symmetrical with upper attachment at eye corner
ear level, there is absence of cerumen or any
discharge.
Palpation Firm, smooth and free from lesions and pain.

Auditory acuity Inspection The numbers whispered to both ears with one ear
occluded at a time were heard clearly.

8. NOSE AND SINUSES

Area/Feature to assess Technique Key findings

Nose Inspection and Located symmetrically, proportion to the face.
Palpation Presence of nasal flaring. The nasal bridge is
aligned, and is without swelling, bleeding, lesion
or masses.

Nasal cavities Inspection Mucosa is pink without swelling.

Nasal sinuses Palpation There is no pain or discomfort felt upon
palpating the frontal and maxillary sinuses.

9. MOUTH AND PHARYNX

Area/Feature to assess Technique Key findings

Lips Inspection Slightly dark in color, quite dry but no ulcers
present.
Gums Inspection Gums are pink, smooth and moist. There is
absence of swelling, inflammation, or bleeding.
Teeth Inspection Incomplete teeth and presence of cavities
Tongue Inspection Pinkish. Dorsal and ventral surface are both
smooth and mobile.
Palate Inspection Palates are concave and pink. Soft palate is
smooth and hard palate has ridges.
Tonsils Inspection Tonsils are symmetrical and there is no swelling.

10. NECK

Area/Feature to assess Technique Key findings

Symmetry and Inspection and The patient’s neck is mobile and proportion to
Masculature Palpation the gross body structure. The trachea is in its
normal midline position. There is absence of
neck vein engorgement, masses, or scars.
Lymph nodes Palpation The lymph nodes are normal in size and shape.
No pain felt upon palpation.

11. THORAX AND LUNGS

A. POSTERIOR THORAX

Area/Feature to assess Technique Key findings

Lesions Palpation Posterior thorax is free from tenderness and
lesion.
Breath sounds Auscultation Absence of rales.

B. ANTERIOR THORAX

Area/Feature to assess Technique Key findings

Symmetry, Rhythm Inspection Thorax rises and falls in unison with respiratory
cycle.
Sound Auscultation Absence of rales.

12. HEART

Area/Feature to assess Technique Key findings

Heart sound Auscultation No murmur, clear.
Point of maximal Auscultation PMI was located on the 4th to 5th intercostal space
impulse(PMI) left midclavicular line or the apical area.
Heart beat Auscultation 81 cardiac cycle/min.

13. ABDOMEN

Area/Feature to assess Technique Key findings

General appearance of Inspection The 4 quadrants and 9 regions were correctly
the abdomen identified
Sound Auscultation Decreased bowel sounds
Percussion The abdomen has a dull sound while the liver has
a dull sound also.
Tenderness Palpation Tenderness on RUQ, smooth.

14. UPPER and LOWER EXTREMITIES

Area/Feature to assess Technique Key findings

Extremities Inspection and Peripheral pulses were strong and palpable.
palpation Extremities are proportion to the gross body
structure, normal in color and mobile. All body
parts are present. Peripheral IV access at right
arm with no signs of phlebitis and infiltration.
 Radial pulse rate at 81bpm.

15. GENITAL: Unable to perform.

16. NAILS

Area/Feature to assess Technique Key findings

Color, shape and texture Inspection and Transparent, smooth and convex with a 160˚ nail
Palpation bed angle.
Capillary refill Palpation and 1-2 sec.
Inspection
Lesion Inspection No lesion

V. REVIEW OF SYSTEM: Conducted on July 29, 2010

General Description:

Weight Loss: Fatigue: Anorexia:

Night Sweats: Weakness:

Skin

Itch: Bruising:

Rash: Bleeding:

Lesions: Color Change:

Eyes:

Pain: Itch: Vision Loss:

Diplopia: Blurring: Excessive Tearing:

Glasses/Contact Lenses:
Ears:

Earaches Discharge Tinnitus Hearing Loss

Nose:

Obstruction Epistaxis Discharges

Throat and Mouth:

Sore Throats Bleeding Gums Tooth Aches

Neck:

Swelling Dysphagia Hoarseness Others:

Chest:

Cough Sputum: (Amount & character) Hemoptysis

Wheeze Pain on respiration Dyspnea

Breast: Lumps Pain Bleeding Discharged

CVS:

Chest Pain Palpitation Dyspnea on Exertion Edema

PND Orthopnea Others:

GIT:

Food Intolerance Heartburn Nausea Jaundice

Vomiting Epigastric Pain Bloating Excessive Gas

Constipation Chance in BM Melena

GU:
 Dysuria Nocturia Retention Polyuria Dribbling

Hematuria Flank Pain

Male: Penile Discharged Lesion Testicular Pain Others

Extremities:

Joint Pains Varicose veins Claudication

Edema Stiffness Deformities

Neuro:

Headaches Dizziness Memory Loss Fainting

Numbness Tingling Paralysis: (location) Paresis: (location)

Seizures Others:

Mental Health Status:

Anxiety Depression Insomnia

Sexual Problems Fear

VI. CLIENT PROFILE (July 29, 2010)

Nursing Health History B

A. General Description of the Client

Mr. A has a large body built, signs of discomfort were noticed and complaints of mild pain.
He is oriented to time, places and persons. He is attentive and cooperative when asked. His
speech is even and moderately paced with appropriate words in a calm and understandable voice.
B. Health Perception- Health Management Pattern

He believes that health is important because if illness persists a person will not be
able to do daily activities.

C. Nutritional Metabolic Pattern

He does not have any known allergies to any foods or drugs. He is fond of eating vegetables and
fish. He usually eat meat and meat products occasionally

D. Elimination Pattern .

Mr. A voids almost 4-6 times a day, defecates once a day.

E. Activity- Exercise Pattern

He considered his work as his form of exercise.

F. Sleep-Rest Pattern

Mr A usually wakes up around 4 o clock in the morning and sleeps around 8 in the evening.
He usually takes a nap in the afternoon.

G. Cognitive-Perceptual Pattern

He was oriented to time, place and person. He was able to communicate well and accommodate
questions.

H. Sexuality-Reproductive Pattern

He is sexually active and has 5 children.

I. Coping –Stress Tolerance Pattern

Slim copes with stress positively by resolving the problems together with his families. He
told me that if he and his brother had a problem, they solve it calmly and without having any
fights. They talk about the problem without consulting to their parents first. Slim has a positive
attitude in solving their problems.
L. Value- Belief Pattern

Mr. A believes on scientifically based health assistance. Every Sunday he goes

to mass.

VII. LABORATORY July 20,2010

Routine Blood Count (RV) (RV)

WBC 7.82 4.23 - 9.07x10^3/uL RBC 4.72 4.63 - 6.08x10^3/uL

Neutro% 43.4 34.0 - 67.9 HGB 14.1 13.7 - 17.5g/dL

Lympho% 43.2 21.8 - 53.1 HCT 40.6 40.1 - 51.0%

Mono% 9.1 5.3 - 12.2 MCV 86 79.0 - 92.2fL

Eo% 3.7 0.8 - 7.0 MCH 29.9 25.7 - 32.2pg

Baso% 0.6 0.2 - 1.2 MCHC 34.7 32.3 - 36.5g/dL

Neutro# 3.39 1.78 - 5.38x10^3/uL RDW-CV 12.3 11.6 - 14.4 %

Lympho# 3.78 1.32 - 3.57x10^3/uL RDW-SD 37.9 35.1 - 43.09fL%

Mono# 0.71 0.30 - 0.82x^3/uL PLT 324 163 - 337x10^3/uL

Eo# 0.24 0.04 - 0.54x^3/uL

Baso# 0.05 0.01 - 0.08 x^103/uL

Fasting blood sugar

Glucose 6.7 mmol/ L 4.1 – 5.9 mmol/ L

Cholesterol 6.0 mmol/ L >5.2 mmol/ L

Triglycerides 2.26 mmol/ L >1.69 mmol/ L

Urea Nitrogen 3.5 mmol/ L 3.7 – 7.71 mmol/ L

Creatinine 73 mmol/ L 71 – 133 mmol/ L

Urine analysis

Transparency Slightly turbid

Color Yellow
Occult blood Negative
Bilirubin Negative
Urobilirubin 0.2 EU/DL
Ketone Negative
Protein Negative
Nitrate Negative
Glucose Negative
1
Reaction 7.0
SP gravity 1.015
Leukocytes Negative
Pus cells 0 – 2/ HPF
RBC 0- 1/ HPF
Epithelial Cells Few
A phosphates Few

A urates Few

Bacteria Moderate
PATHOLOGY AND PHYSIOLOGY

GENETIC AND
HORMONAL MECHANICAL
FACTORS INJURY

CHONDROLYTE PREVIOUS
OTHER
RELEASE JOINT DAMAGE

RELEASE OF
CYTOKINES

STIMULATION, PRODUCTION,
AND RELEASE OF
PROLEOLYTIC ENZYMES,
METALLOPROTEASES,
COLLAGENASE

RESULTING DAMAGE
PREDISPOSES TO MORE
Cues Nursing Scientific Planning Intervention Rationale Evaluation
Diagnosis Explanation

S> “masakit Impaired bed Tissue After 2 hours Determine pt. To assess After 2 hours of
ang likod ko mobility r/t destruction of nursing level of functional nursing
pag pain and cause inability interventions, mobility ability intervention,
gumagalaw discomfort to move from patient will be patient
ako mula sa one bed able to identify identified
pagkahiga ko” position to techniques to Encourage to This prevent techniques to
another due to enhance bed take deep atelectasis enhance bed
manifestation mobility. breaths, and mobility like
O> of the disease cough, pneumonia practicing the
condition reposition self, range of
 always lying drink motion
flat on bed adequate
 with limited
fluids
movements
 assisted Immobility and
when muscle
moving by Teach proper weakness
the spouse range of from
 with pain in connective
motion and
the lower tissue changes
back; pain self care
activities contribute to
scale: 4/10
contractures

To promote
optimal level
of function
Assist pt. in his
activities
Being in
vertical
position
reduces the
Periodically work of the
position the heart and also
patient on improves lung
upright sitting compliance
position as
tolerated
To prevent
possible
Assist to splint dehiscence or
an incision evisceration
wound, or the
painful
abdominal
area with
pillow as they
change
positions,
cough, or
proper
functional
activities

Involve client’s
To assist in
SO in care learning ways
of managing
problems of
immobility.

To relieve pain

If movement
intensifies
pain,
administer
analgesics as
ordered
 CUES NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EXPECTED
DIAGNOSIS EXPLANATION OUTCOME
S: Constipation Decrease in After 30 1. Identify contributing > Establish baseline After 30 minutes
“Nahihirapa related to normal frequency minutes of factors associated with data. of proper nursing
n akong decreased in of defecation giving constipation. intervention
dumumi.” peristaltic accompanied by appropriate patient was able
movement difficulty or nursing 2. Auscultate >This reflects bowel to identify ways
O: secondary to incomplete intervention characteristics of the activity. to increase
>weak immobility.. passage of stool the patient abdominal sounds. peristaltic
inappearance and passage of will increase movement.
excessively hard, peristaltic 3. Promote adequate fluid >Promotes passage of
>reports of dry stool due to movement. intake including high soft stools
abdominal decreased in fiber fruit juices.
pain or peristalsis.
cramping 4. Encourage exercise >Stimulates
within limit. contractions of the
intestines.
>decreased 5. Provide privacy and
bowel routinely schedule time >So that the client can
sounds for defecation. response to urge.

6. Administer stool
softeners as ordered by >Used to soften stools
the physician. for easy defecation.
 Drug Name Dosage Classification Action Indication Contra- Side Adverse Nursing
Indication Effects Effect Responsibilities
Celecoxib 200 mg 1 Nonsteroidal Inhibitor To relieve Hypersensitivit Nausea, gastric >Administer with
tab OD Anti- and signs and y reaction to vomiting, ulceratio meals, foods or milk to
inflammatory primarily symptoms of drugs dizziness, n,kidney minimize GI adverse
Drugs inhibits osteoarthritis. headache failure,bl effect.
(NSAIDs) this eeding
isoform and
of ulcers in >Instuct the patient to
cyclooxy the avoid sudden change in
genase stomach movement.
and
intestine
>Inform the client that
nausea, vomiting,
dizziness and headache
can be experience and
not to be worried
because these are only
the drug’s side effects

>Prepare a kidney
basin for possible
vomiting
 Drug Name Dosage Classification Action Indication Contra- Side Adverse Nursing
Indication Effects Effect Responsibilities
Lyrica 100 mg 1 Anticonvulsan Binds Management Hypersensitivit Dizziness, Monitor VS
cap OD/ t with high of neuropathic y to any somnolenec
lunch affinity to pain associated component of e, dry mouth Advise to take
the alpha with diabetic the product, peripheral medication with or
delta site peripheral including edema, without food
in CNS neuropathy lactose. asthenia,
tissues. ataxia, Do not stop drug
Binding Lactation confusion, abruptly
may be headache
involved blurred Do not perform
in vision, activities that require
pregabali diplopia, mental alertness
ns constipation
antinocic Advise to report any
eptive unexplained muscle
and anti
pain, weakness or
seizure
effects tenderness
 Drug Name Dosage Classification Action Indication Contra- Side Adverse Nursing
Indication Effects Effect Responsibilities
nutricap 1 cap
OD/ HS
 Drug Name Dosage Classification Action Indication Contra- Side Adverse Nursing
Indication Effects Effect Responsibilities
nutricap 1 cap
OD/ HS
 Drug Name Dosage Classification Action Indication Contra- Side Adverse Nursing
Indication Effects Effect Responsibilities
Cozaar 100 mg/ Antihypertens Complete Antihypertensi Use during URTI,
tab OD ive, ly blocks ve alone or in second and dizziness,
Losartan angiotensin II the combination third trimesters cough ,
potassium receptor angiotens with other of pregnancy diarrhea,
blocker in AT1 antihypertensiv due to possible sinus
receptor e drugs injury and disorder,
located in death to nasal
vascular developing congestion,
smooth fetus. Use in dyspepsia
muscle children less heartburn,
and the than 6 y/o. pain
adrenal
glands,
thus
blocking
the
vosocons
trictor
and
aldostero
ne
secreting
effectd of
angiotens
in II .
thus BP
is
reduced
 Drug Name Dosage Classification Action Indication Contra- Side Adverse Nursing
Indication Effects Effect Responsibilities
Rosuvastatin 20 mg/
tab
 Drug Name Dosage Classification Action Indication Contra- Side Adverse Nursing
Indication Effects Effect Responsibilities
lactulose
 Drug Name Dosage Classification Action Indication Contra- Side Adverse Nursing
Indication Effects Effect Responsibilities
Hydrochlorothiazi
de