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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 DATA

1. Name: AD

2. Address: J. Pascual St. Navotas City

3. Age: 11

4. Date of Birth: May 1, 1999

5. Sex: female

6. Race: Filipino

7. Marital status: Single

8. Occupation: (Currently Studying) Grade 5 student

9. Religious orientation: Roman Catholic

10.Health care financing and usual source of medical care: Her


mother financing her hospitalization

11.Date of admission: September 9, 2010

12.Attending Physician: Dr. Bernabe

13.Admitting diagnosis: Pyomyositis Left Leg

B. NURSING HISTORY

Chief Compliant or Reason for Visit

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.

Family History of Illness

On 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

For clients who


are young facial
expression is
often the first
General Facial grimacing is Healthy appearance,
indication of
Appearance observed. no distress in facial
pain and it may
expression or
be the only one.
posture
(Kozier et al.
With Deviation Fundamentals
of Nursing 7th
edition 2004 p.
1145)

Behavior Cooperative Cooperative Normal

Age 11 years old, age Age appropriate to Normal


appropriate to appearance
appearance

Sex Female Male or female Normal

Race Filipino Varies w/ individuals Normal

Body Type Proportionate, Proportionate, varies Normal


varies with lifestyle with lifestyle

Hygiene Clean and neat Clean and neat Normal

Able to sit but Relaxed, erect Immobilization


unable to stand posture; coordinated of the body part
Posture because of pain movement With Deviation or a part of the
and swelling on the body may
left foot. indicate pain.

(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

No body odor, no No body odor or


breath odor minor body odor
Odor relative to work or Normal
exercise; no breath
odor

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)

Speech Understandable, Understandable,


moderate pace; moderate pace;
exhibits thought exhibits thought Normal
association association

II. HEAD TO TOE ASSESSMENT (PART I)

A. HEAD

Parts Actual Findings Normal Findings Interpretation Analysis

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

Free from dandruff, White, clean, free


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

Black, evenly distributed Black, evenly


and covers the whole distributed & covers
Hair scalp, thick and free the whole scalp, Normal
from split ends. thick, shiny, free from
split ends

For clients who


are young facial
Oblong, oval, square expression is
or heart-shaped, often the first
oval-shaped, symmetrical, facial indication of pain
symmetrical, with facial expression that is and it may be the
grimacing , smooth and dependent on the only one.
free from wrinkles, no moods and feelings,
Face With Deviation
involuntary muscle smooth and free from (Kozier et al.
movements wrinkles, no Fundamentals
involuntary muscle of Nursing 7th
movements edition 2004 p.
1145)

Eyes are brown, parallel Parallel and evenly


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

Black, symmetrical, Black, symmetrical,


thick, can raise & lower thick, can raise &
eyebrows symmetrically lower eyebrows
and without difficulty, symmetrically and
thin & evenly distributed without difficulty,
Eyebrows & parallel with each evenly distributed & Normal
other parallel.

Turned outward, black Black, evenly


evenly distributed distributed and
Eyelashes turned outward Normal

When eyes are open, Upper lids cover a


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

Puncta are evident at Clear, without scaling


nasal ends, clear, or secretions,
without scaling or lacrimal duct
secretions. openings (puncta)
Lid Margins Normal
are evident at nasal
ends

Palpebral Appear equal when the Appear equal when


fissures eyes are open the eyes are open
Normal

Lower Salmon pink, shiny, Salmon Pink, shiny,


Palpebral moist and transparent moist and
Conjunctiva transparent Normal

Sclera White and clear White and clear Normal

Iris are brown in color, Proportional to the


symmetrical, size of the eye,
proportional to the size round, black/brown
of the eyes, round and symmetrical
Iris Normal

Pupils are equally round Pupils are equally


and reactive to light and round and reactive to
Pupils accommodation light and Normal
accommodation

Able to move eyes in full Able to move eyes in


range of motion or able full range of motion
Eye to move in all direction or able to move in all Normal
movement direction

Visual Acuity Patient can see clearly Eyes can see clearly Normal

Field of Vision Able to see 60 degrees Able to see 60


superiorly, 90 degrees degrees superiorly,
temporally and 70 90 degrees Normal
degrees inferiorly temporally and 70
degrees inferiorly

Parallel, symmetrical, Parallel, symmetrical,


proportional to the size proportional to the
of the head, bean- size of the head,
shaped. Helix is in line bean-shaped. Helix is
Ears Normal
with the outer canthus of in line with the outer
the eye, skin is the canthus of the eye,
same color as the skin is the same color
surrounding skin, clean as the surrounding
skin, clean

Slightly Pinkish, clean Pinkish, clean with


with scant amount of scant amount of
Ear Canal cerumen and a few cilia cerumen and a few Normal
cilia

Able to hear and Able to hear and


verbalize or repeat verbalize or repeat
Hearing whispered spoken word whispered spoken Normal
Acuity two feet away word two feet away

Midline, symmetrical Midline, symmetrical


and patent and patent
Nose Normal

Clean, pinkish, with


few cilia
Internal Nares Not Assessed Not Assessed

Septum Straight, midline Straight, midline Normal

Dark, symmetrical, lip Pinkish, symmetrical,


margin well defined, lip-margin well
smooth and moist defined. Smooth and
moist
Lips Normal

Slightly pinkish, smooth, Pinkish, smooth,


moist, no swelling, no moist, no swelling, no
Gums retraction, no discharge retraction, no Normal
discharge

Teeth 32 permanent teeth, , no 32 permanent teeth,


halitosis well-aligned, free
from caries or filling, Normal
no halitosis

Slight pinkish in color Large, medium, red


and medium in size, or pink, the lateral
Tongue margins are moist, shiny margins moist, shiny,
freely movable Normal

Frenulum Midline, straight, and Midline, straight, and Normal


thin thin

Buccal Pinkish, moist and Pinkish, moist and Normal


Mucosa smooth smooth

Soft Palate Pinkish, moist and Pinkish, moist, and Normal


smooth smooth

Hard Palate Pinkish in color Slightly pinkish Normal

At the center, At the center,


symmetrical and freely symmetrical, and
Uvula movable freely movable Normal

non-inflamed, no Pinkish, non-


exudates inflamed, no
Tonsils exudates Normal

No hoarseness and well No hoarseness and


modulated well modulated
Voice Normal

Proportional to the size Proportional to the


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

Range of Freely movable without Freely movable Normal


motion difficulty without difficulty

Able to resist applied Able to resist applied


force, symmetrical in force, symmetrical in
Muscular structure of size and structure of size and Normal
strength muscular strength muscular strength

Part 2

CHEST & ABDOMEN EXAMINATION

Parts Actual Findings Normal Findings Interpretation Analysis

The chest contour is The chest contour is


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

No lumps, masses, No lumps, masses, areas of


areas of tenderness. tenderness. Sides of the
Palpation of Sides of the thorax thorax expand
Anterior and expand symmetrically. symmetrically. The
Posterior Not Done
The examiner’s thumb examiner’s thumb separate
Thorax separate approximately approximately 3-5 cm during
3 cm during expansion. expansion.

Variations are prominent


over the areas near the
Tactile bronchi. It increases with
fremitus of intensity of the voice.
Anterior and Not Done
Vibrations are strongest
Posterior between the scapulae Not Done
Thorax posteriorly.

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
Percussion Not Done Not Done
the underlying tissue.
of Anterior
Tympany – moderately loud
and Posterior
with quality with specific
Thorax
pitch, noted in the upper left
quadrant of the abdomen.

Normal breath sounds differ


in their character depending
on the area being
auscultated.
Bronchovesicular sounds-
Auscultation Normal breath sounds medium pitched sound Normal
of Anterior were heard upon heard posteriorly between
and Posterior ascultation. the scapulae. The sound
Thorax 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.

No pulsations on the No pulsations on the aortic,


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

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.

Round or oval, color darker


than surrounding skin,
Areola Not Assessed symmetrical. For dark- Not Assessed
skinned client, color is
darker than other skin
surfaces. No masses and
areas of tenderness.

Round or inverted, equal in


size, similar in color, nipples
Nipples Not Assessed point in one direction, no Not Assessed
discharge, no lesion, no
dimpling, and no crusting.
No masses, no tenderness

Skin unblemished, no Skin unblemished, no scars,


scars, color is uniform, color is uniform, flat,
flat, rounded or rounded or scaphoid,
scaphoid, symmetrical symmetrical movements
Abdomen
movements cause by cause by respiration, aortic
(Inspection)
respiration, umbilicus is pulsation at the epigastric Normal
concave, color is the area visible in thin persons,
same as the umbilicus is flat or concave,
surrounding skin color is the the same as the
surrounding skin

There are clicks and


gurgles, the frequency of
There are clicks and which has been estimated
gurgles, the frequency from 5-34 per minute.
Auscultation of which has been 26 Normal
Occasionally, borborygmi
of the per minute. (loud prolonged gurgles of
Abdomen
hyperpersitalsis) – the
unfamiliar stomach can be
heard.

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.

Palpation of Liver’s edge feels firm and


the Abdomen non-tender.
Not Assessed Not Assessed
Part 3

UPPER EXTREMITIES

Parts Actual Findings Normal Findings Interpretatio Analysis


n

Skin color is brown, Skin color varies (pinkish,


symmetrical, fine tan, dark brown),
hair evenly symmetrical, fine hair
distributed no evenly distributed,
presence of visible presence/absence of
Arms veins, warm but visible veins. Warm, dry Normal
dry.There are no and elastic, no areas of
areas of tenderness, muscle
tenderness, muscle appear equal with good
appear equal. muscle tone, performs
motion with relative ease.

Performs motion Performs motion with


with relative ease relative ease
Elbows Normal

Hands and wrist Performs motion Performs motion with Normal


with relative ease relative ease

Nails are Nails are transparent,


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

Palms and Palms are pale, Palms pinkish (dorsal Normal


dorsal surfaces thick and warm. surface), warm, thick
Shoulders Performs motion Performs motion with Normal
with relative ease relative ease

Lower Extremities

Parts Actual Findings Normal Findings Interpretation Analysis

Skin varies (pinkish, tan, The release of


dark brown) skin is chemical mediators
smooth, fine hair evenly during an injury
distributed, absence of increases capillary
varicose veins, muscles permeability
Legs Swelling on the left leg with symmetrical, length resulting to leakage
tenderness. The area is symmetrical. Muscles of fluids in the
warm to touch. appear equal, warm & With Deviation surrounding tissue.
with good muscle tone, The pain that occurs
performs motion with is attributed to the
relative ease 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)

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)

. Five toes in each foot, sole Five toes in each foot,


and dorsal surface is sole and dorsal surface
smooth: With pale nail beds is smooth: With pink nail
& translucent tips. As beds & translucent tips.
Toes
pressure is applied, the nail As pressure is applied,
bed appears white or the nail bed appears Normal
blanched; pink color returns white or blanched; pink
in 2 secs when pressure is color returns when
released. pressure is released.
Performs motion with
relative ease.

CEREBELLAR FUNCTION

Activity Actual Findings Normal Findings Interpretation Analysis

Pats hands Asymmetrical and Symmetrical and Normal


against the slow movement fast movement
thigh as fast
as possible

Finger to Repeatedly and Repeatedly and


nose test rhythmically rhythmically touches
touches the nose the nose Normal

MOTOR FUNCTION

Activity Actual findings Normal findings Interpretation Analysis


Describe Proportionate to the Proportionate to the Normal
Muscle body type body type
mass

Passively Can passively flex Can passively flex Normal


flexing of the elbow the elbow
elbow

Squeezing Can squeeze the Can squeeze the Normal


of fingers fingers with both fingers with both
with both hands hands
hands

Muscle Good muscle tone Good muscle tone Normal


tone

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 Date Indication Normal Actual Significance of


Test or Done for Test Value Results the Result &
Procedure / Findings
Finding
s
Septemb Hemoglobin 110 -150 103 With deviation-
er 12, g/L Decreased
Hematolo 2010
gy 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
VI. DRUG STUDY

Drug Action Indication Contraindicati Adverse Effect Nursing


ons Responsibilities
Generic Interferes with Infections of Hypersensitivity CNS: headache, Monitor for extreme
Name: bacterial cell- respiratory to confusion, confusion, tonic-clonic
Ceftriaxone wall synthesis system, cephalosporins hemiparesis, seizures, and mild
sodium and division by bones, joints, or penicillins lethargy, hemiparesis when
binding to cell and skin; paresthesia, giving high doses.
Brand Name: wall, causing cell septicemia Use cautiously in syncope, seizures
to die. Active • renal CV: hypotension, Monitor coagulation
Classification: against gram- impairment, palpitations, chest studies.
Anti-infective/ negative and hepatic disease, pain, vasodilation
Antibiotic gram-positive gallbladder EENT: hearing loss Instruct patient to
bacteria, with disease, GI: nausea, vomiting, report persistent
Dosage: expanded phenylketonuria diarrhea, abdominal diarrhea, bruising, or
500mg IV activity against • history of GI cramps, oral bleeding.
q12° (-) ANST gram-negative disease, candidiasis,
bacteria. Exhibits diarrhea pseudomembranous Monitor for signs and
minimal following colitis, pancreatitis, symptoms of
immunosuppress antibiotic Clostridium difficile- superinfection and
ant activity. therapy associated diarrhea other serious adverse
GU: vaginal reactions.
candidiasis
Hematologic:
lymphocytosis,
eosinophilia,
bleeding
tendency,hemolytic
anemia,
hypoprothrombinemi
a, neutropenia,
thrombocytopenia,
agranulocytosis,
bone marrow
depression Hepatic:
jaundice,
hepatomegaly
Musculoskeletal:
arthralgia
Respiratory: dyspnea
Skin: urticaria,
maculopapular or
erythematous rash
Other: chills, fever,
superinfection, pain
at I.M. injection site,
anaphylaxis, serum
Nursing Care Plan
Cues Nursing Background Planning Intervention & Evaluation
Diagnosis Knowledge Rationale
Objective Hyperthermi During an After 4 hours of Explain to the client the Expected
Cues: a r/t trauma infection, there nursing need for immediate outcome:
- Skin is will be a intervention, the intervention for lowering
warm to release of patient will down her temperature After 4 hours of
touch interleukin-1 by demonstrate to gain patient’s
nursing
- Flushing macrophages. decrease in body cooperation.
intervention,
of skin This temperature would
interleukin-1 be within normal Provide surface cooling the patient will
Parameters: initiates range. by means of providing achieve normal
T: 37.9°C inflammatory loose clothing for the body
P: 82 bpm response and client to promote heat temperature.
R: 20 cpm stimulates the loss by radiation and
hypothalamus convection.
to increase
body Cool the environment by
temperature. opening the fan and
providing adequate
Ref: Brunner ventilation to promote
and Suddarth’s heat loss by means of
Textbook of convection.
Medical
Surgical Perform tepid sponge
Nursing bath (to promote heat
loss through
evaporation and
conduction)
concentrating on groin
and axillae (areas of
high blood flow)

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 Plan
Cues Nursing Background Planning Intervention Evaluation
Diagnosis Knowledge Rationale

Subjective Acute pain The entry of Within 4 hours Expected


Cue: related to pathogens in of nursing Explain to the client why outcome:
circulation leads
“Wag ninyo trauma on to release of intervention she is suffering from pain After 4 hours of
ate the knee chemical the patient will and let her know that you rendering
hawakan and legs. mediators, verbalize acknowledge the pain effective
dyan, increasing the reduced pain experience and convey nursing
capillary
masakit po permeability from a pain acceptance to client interventions,
dyan sa allowing escape scale of 5/10 response to pain to gain the will patient
parteng yan of fluid into the to at least cooperation and trust report of less
” vessels, causing 3/10. and because pain is pain AEB
mechanical
pressure on subjective and cannot decreased
Objective nerve cells, and be felt by others. irritability and
Cues: also due to the had been
presence of pain
- Facial Promote comfort measures smiling more
mediators.
grimace like touch, repositioning, frequently.
- Guarding providing quiet
on the left Ref: Brunner and environment and calm
leg Suddarth’s activities to promote
- Inability to Textbook of non-pharmacological
move Medical Surgical pain management.
-Irritability Nursing
-Positioning Instruct patient to use
of the knee relaxation techniques such
to avoid as deep breathing and
pain imaging to distract
attention and reduce
tension.

Parameter Encouraged diversional


s: activities like letting the
With facial patient watch a movie or
pain scale TV show, listen to radio or
of 5/10 to chat with others to
divert his attention to
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.

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