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Pyomyositis
Pyomyositis Left Leg
(In Partial Fulfillment of the Requirements in NCM – 104)
S.Y. 2010-2011 1st Semester
I.INTRODUCTION
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.
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
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.
A. BIOGRAPHIC DATA
1. Name: AD
3. Age: 11
5. Sex: female
6. Race: Filipino
B. NURSING HISTORY
The patient is brought to hospital because of pain and swelling of left knee
and leg.
History of Present Illness
Three 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 History
According 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.
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
(Kozier et al.
Fundamentals
of Nursing 7th
edition 2004 p.
426)
Relaxed, erect
posture; coordinated
Gait Not Assessed movement Not Assessed
Dressing Clean, neat and Clean, neat and Normal
appropriate appropriate
Pain causes
discomfort to
Mood Irritable Appropriate to With deviation the patient
situation causing patient
to be irritable.
Kozier et al.
Fundamentals
of Nursing 7th
edition 2004 p.
425)
A. HEAD
Normocephalic, Rounded
proportional to the size (normocephalic and
of the body, round, symmetrical, with
symmetrical in all frontal, parietal, and
planes, gently curved occipital
and with prominences in prominences); Normal
the frontal and occipital smooth skull contour,
Skull area anteriorly and uniform consistency,
posteriorly respectively. absence of nodules
or masses
Visual Acuity Patient can see clearly Eyes can see clearly Normal
Part 2
No enlargement of the
heart. Cardiac rate: 80
beats/min.
Females: rounded,
symmetrical. If obese,
maybe slightly rounded.
Color of the skin same as
Breast Not Assessed Not Assessed
the surrounding skin, no
retraction, no dimpling.
Tympany predominates
because of the presence of
Percussion in Not Assessed air in the stomach and Not Assessed
the Abdomen intestines. Percussion is dull
at the liver’s lower border.
UPPER EXTREMITIES
Lower Extremities
(Smeltzer et al.
Brunner &
Suddarth’s
Medical-Surgical
Nursing 10th ed.
2004 p. 103)
Loss of function is
most likely related to
pain and swelling,
but the exact
Knees Patient cannot move the left Performs motion with With Deviation
mechanism is not
knee or the affected area relative ease
completely known.
(Smeltzer et al.
Brunner &
Suddarth’s
Medical-Surgical
Nursing 10th ed.
2004 p. 103)
Immobilization of
the body part or a
Ankles Patient cannot move the left Performs motion with With Deviation part of the body may
ankle. relative ease indicate pain.
(Kozier et al.
Fundamentals of
Nursing 7th edition
2004 p. 426)
CEREBELLAR FUNCTION
MOTOR FUNCTION
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).
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.
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
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
VI. DRUG STUDY
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.
(Reference: Nurse’s
Pocket Guide, 11th
edition, pp. 384-386)
Nursing Care Plan
Cues Nursing Background Planning Intervention Evaluation
Diagnosis Knowledge Rationale
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.
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.