03 11 18 Revised Osteomyelitis

I.
INTRODUCTION
"Little things amount to big things"
-Robin Sharma
Most cases of osteomyelitis are caused by staphylococcus bacteria, types of

bacteria commonly found on the skin or in the nose of even healthy individuals. Bacteria
can enter a bone in a variety of ways, including bacteria in other parts of the body.
Severe puncture wounds can also carry bacteria deep inside the body. If such an injury
becomes infected, bacteria can spread into a nearby bone. Bacteria can also enter the
body if there is a broken bone so severely that part of it is sticking out through the skin.
Direct contamination can also occur during surgeries to replace joints or repair
fractures. Skin is an important part of the immune system for it acts as a barrier
between bacteria and the body. Skin is tough and generally impermeable to bacteria
and viruses. On the other hand, bacteria can enter our bodies through other areas that
are susceptible to bacteria such as our nose, mouth, eyes, or a break in the skin.
Osteomyelitis is an infection of the bone that results in inflammations, necrosis,

and formation of new bone. Osteomyelitis is classified as hematogenous osteomyelitis
which is due to blood-borne spread of infection, and contiguous-focus osteomyelitis
which from contamination from bone surgery, open fracture or traumatic injury.
Osteomyelitis with vascular insufficiency is seen most commonly among patients with
diabetes and peripheral vascular disease, most commonly affecting the feet (Porth &
Martfin, 2009).
Incidence of osteomyelitis worldwide is approximately 13 per 100,000 in children

and approximately 90 per 100,000 in adults. Hematogenous osteomyelitis occurs
predominantly in children and elderly patients while osteomyelitis due to contiguous
infection is most common in adults. Osteomyelitis is more common in males but equally
affects each race. The disease is more common in developing countries. In the
Philippines, there are 239 per 100,000 cases of chronic osteomyelitis. The most
common bones involved were the femur and tibia with sequestrum as the most common
radiologic finding.
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Current Trend: Recommendations for the treatment of osteomyelitis
The objective of this review article is to indicate some recommendations based

on scientific evidence that will guide the medical approach to different types of
osteomyelitis, aiming to obtain better clinical outcomes and at reducing the social costs
of this disease. The rate and extent of antibiotic penetration in bone tissues are seen as
determining factors for therapeutic success in osteomyelitis. On the other hand,
penetration of an antibiotic into infected bone tissue depends on its pharmacological
characteristics, the degree of vascularization, good conditions of soft tissues, and the
presence of foreign bodies. Integrating information related to tissue concentration in
clinical practice is a stumbling block in the process of antimicrobial selection for the
treatment of bone infections. Antibiotics with a high bone/serum concentration ratio
The decision on the clinical usefulness of an antibiotic in osteomyelitis should combine

studies on bone concentration with the results of clinical studies in patients with
osteomyelitis. The majority of bone penetration studies are performed in patients
undergoing hip replacement surgery, and samples obtained are from uninfected bones.
The success of osteomyelitis treatment, particularly in cases related to implants,
depends on extensive surgical debridement and adequate and effective antibiotic
therapy. Starting empirical antibiotics in anesthetic induction prevents the risks of
bacteremia arising from surgical manipulation of infection without adequate antibiotic
coverage. Yet, it does not interfere with the positivity of cultures taken during the
procedure. Empirical antibiotic can also be started after collecting culture samples in
non-septic patients. Special antimicrobial – rifampin - There is no antimicrobial regimen
that is perfect for every situation. The ability of rifampin in eradicating slow-growing
bacteria in biofilms is well known. Thus, the suggestion to add rifampin to another drug
with activity against S. aureus is recurrent in the literature, but this drug should never be
used as monotherapy. Hyperbaric oxygen therapy (HBO) is a form of adjuvant therapy
that has been used worldwide for more than sixty years. It is used in patients with
infectious, inflammatory, immunological, and ischemic tissue changes. The treatment
involves respiration of 100% oxygen under hyperbaric conditions, i.e. under pressures
artificially elevated above the atmospheric pressure at sea level, with the patient being
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placed inside a pressure-resistant hyperbaric chamber. In this setting, large quantities of
oxygen under pressure penetrate the blood, are dissolved in the plasma, and reach the
tissues. Tissue hyperoxygenation causes specific therapeutic effects, including
stimulation of bacterial lysis by leukocytes, increase in proliferation of fibroblasts and
collagen, and neovascularization of ischemic or irradiated tissues. The effects of HBO,
such as immunomodulation, reduction in pro-inflammatory mediators, and reduction in
effects of ischemia-reperfusion in ischemic tissues, are extremely useful for the
treatment of infections. The use of hyperbaric oxygen (O2HB) is associated with all the
other therapeutic measures, making them more effective. Wound healing time is
accelerated, the esthetic results are better, and the final cost of treatment is also
reduced.
REASON FOR CHOOSING
Considering the prevalence of Osteomyelitis, the student nurses prompted to

pursue study the condition about Osteomyelitis, its predisposing and precipitating
factors and pathophysiology. The student nurses will be able to apply their previous
learnings from their lecture about cardiovascular diseases. By digging deeper with the
disease condition, the student nurses will be able to impart relevant and appropriate
information in the prevention, treatment, and management of Osteomyelitis by helping
them apply the knowledge on how to avert or cope with the disease condition. Also, the
goal of the student nurses is to increase awareness, educate the patients undergoing
with this disease condition and the student nurses themselves, prevent the further
complications from arising and to promote and restore the health of the patient.
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Objectives (Nurse Centered & Patient Centered)
General:
The purpose of this study is to let the student nurses gain more knowledge about the
disease process of Osteomyelitis, to know its causes, how it is acquired and prevented
and to render proper nursing care through a systematic nursing process and
examination.
Nurse-Centered:
Short term Objectives:
After 1-2 days of Nursing Interventions, the student nurses shall have:
 Initiate a trusting therapeutic relationship to obtain important information such as

family history, past and present illness, socio-economic status, etc.
 Review and monitored diagnostic and laboratory results - Formulated and apply
nursing care plans utilizing the nursing process.
 Raise the level of awareness of patient on health problems that he may encounter.
 Learn new skills required in the management of the patient with Osteomyelitis
assisted family members and helped them identify their roles during the treatment
scheme.
Long term Objectives:
After the conduction of case study, the student nurse shall have:
 Execute accurate physical examination to identify signs and symptoms of condition

manifested by the patient.
 Learn the indications of the different diagnostic exam and test done to the patient,
as well as the drugs administered to the patient and will be able to discuss their
corresponding side effects.
 Help patient and SO in motivating her to continue the health care provided by the
health care team
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 Identify the nursing diagnosis from all the data collected and have formulated a
nursing care plan
Patient-Centered:
Short term Objectives:
During the Nurse-Patient interaction and/or his significant other shall have:
 Built trusting relationship with student nurses and understand importance and
reason in conducting interview and to cooperate during physical examination.
 Gain knowledge and be more aware of his condition.
 Learn the basic and appropriate nursing interventions or treatment plan.
 Show interest during the nurse and patient interaction sessions.
Long term Objectives:
 Follow health teachings given by the student nurse for each medical and nursing
management (SO) to prevent complications by applying heath teaching given by
the student nurse.
II. NURSING PROCESS
A. ASSESSMENT
Personal History
a. Demographic Data
This is a case of Patient Bali, 57-year-old male and married. He is a father of three
sons aged 36, 33, and 24. He is a natural born Filipino citizen. He was born on October
5, 1960. Together with his youngest son, they reside in Balanga, Bataan. He was
admitted in a government tertiary hospital in Pampanga last December 20, 2017 with a
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chief complaint of infected wound. He was diagnosed with an admitting diagnosis of
Osteomyelitis Tibia Right.
b. Socio-Economic and Cultural Factors
Patient Bali‘s income is 15,500 PHP per month, 5000 of which comes from the
remittance sent to him by his eldest son. He used to work in Bataan.
Food 5000-6000 PHP

Electricity and Water 2400 PHP
Medicine and Check-ups 1200 PHP
Patient Bali comes from a nuclear family. He and his wife live with their youngest
son. He is a graduate of a two-year technical course and is affiliated with Roman
Catholic religion. They regularly attend the mass every Sunday in their parish and when
there are events in the church such as fiestas and etc. They do not believe in
manghihilot. However, the patient had said that when a member of the family is sick,
they will first consult a doctor base on their preference or they go directly to hospitals,
they do not consult quack doctors. His sons and siblings are responsible for paying their
hospitalizations. According to the patient, he does not smoke or not drink.
c. Environmental Factors
Patient Bali together with his youngest son and wife live in a bungalow type house.
The house is made of concrete materials and is surrounded by commercial buildings.
The house has total floor area of 60 sq m. According to National Building Code of the
Philippines, 3 sq m. is adequate living space for adults, 1.5 sq m. for children and 0 sq
m. for infants. For Patient Bali, his living space must be 3 sq m. For his wife, her living
space must be 3 sq m. For his son, his living space must be 3 sq m. The family’s total
space requirement is 3 (Patient Bali) plus 3 (wife) and plus 3 (son), which equals to 9.
Total floor area is more than the total space requirement. With this, the group have
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identified that the house has an adequate living space. There are two doors in the
house, 1 window each in the living room, kitchen and son’s bedroom, 1 window in the
master’s bedroom, but is closed. They get their water through faucet supplied by the
water district within their community. The family also orders gallons of distilled water
from water refilling station located within their vicinity as their main source of drinking
water. Their daily source of food is from the market and weekly they would do some
groceries.
Since they are living in a city, busy highways are present leading to increased
environmental risks like noise pollution, and air pollution. He stated that they are no that
comfortable with their environment because the houses in their area are in good repair
and are not congested and close enough to each other but the roads are not well-
cemented. For breakfast, they prepare coffee and pandesal bought from a nearby
bakery. For lunch, they usually have rice paired with either fish or vegetables. And for
dinner, they usually have rice paired with fish or vegetables. Sometimes, when they still
have leftovers from lunch, they would have that for dinner. They store their food in a
bowl and they cover it with a plate. They are satisfied with their environment because of
having clean surroundings since their garbage were collected every week by their
barangay that manages their garbage. Their electricity comes from the local electric
company.
Family Health-Illness History
According to Patient Bali’s sister, patient Bali is the third eldest among 5 siblings.
All of them are still alive, but the second eldest sibling has arthritis and hypertension.
According to the patient’s sister, both paternal and maternal grandparents have died but
she could not recall the cause of their deaths. On the paternal side of their family, their
father is the eldest among 6 siblings, and only 4 are still living. Their father and uncle
both died of hypertension at the age of 65 and67, respectively. On the maternal side of
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their family, their mother was the third eldest among 6 siblings. She had also died of
hypertension. The other siblings died of causes the patient’s sister could not recall.
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Genogram
LEGEND
Female
Male
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History of Past Illness
Patient Bali, has completed his immunization status. According to him, he

experienced childhood diseases like chickenpox when he was a child. He experienced
fever, cough and colds rarely. As his management, he usually takes over the counter
drugs and increases his fluid intake to help loosen secretions. Last 2016, he
experienced headache that was two days prior to seeking consultation upon checking
his blood pressure it was 140/100 mmHg and was given medication namely Losartan.
History of Present Illness
On Dec 2016, Patient Bali was admitted to a public hospital located in Bataan
with a chief complaint of wound located on his right lower extremity that doesn’t heal. As
stated by Patient Bali, he was hit by a pick up while riding his motorcycle one week
before admission. He received treatments that include debridement to remove necrotic
tissue to promote bone healing, bone biopsy and sequestration to determine specific
microorganism but he didn’t remembered what specific microorganism for the
implantation of antibiotic beads. According to the result of his x-ray on Dec 2016, he had
his open fracture on his right tibia and given steel rods, screws and plates the following
day, was given antibiotic beads on his right tibia as treatment. He was given a diagnosis
of Osteomyelitis tibia right, has been admitted for fifteen days on a public hospital in
Bataan and had his follow up check-up after two weeks but he didn’t able to come back
because of lack of money.
On February 15, 2017, he was admitted in a tertiary hospital in Pampanga for

check-up and removal of the steel rods, screws and plates. He was given diagnostic
procedures and follow up check-up for his scheduled placement of steel rods, screws
and plates. On March 04, 2017, he undergone insertion of steel rods, screws and plates
and was discharged on March 09, 2017. He was given antibiotic beads but he can’t
remember the type of antibiotic beads and advised to take Amoxiclav and pain reliever.
He was instructed for follow up check after one week.
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On June 09, 2017, he wasn’t able to come back after one week because of lack
of money. The doctor removed his antibiotic beads then asks to go back after one
month. On August 2017, came back for check-up on his steel rods, screws and plates
then was removed and ready for recovery. He took therapy to fasten recovery and be
able to walk. After a month of therapy he stopped because he can already walk. On
November 2017, he went to a tertiary hospital in Pampanga due to complaint of wound
that doesn’t heal. As verbalized by Patient Bali, he was asked to come back after one
month to be able to get ready for money on his treatment. On December 20, 2017 he
came back for his scheduled open reduction internal fixation and complaint of wound
that doesn’t heal. On December 21, 2017 he had undergone open reduction internal
fixation and implantation of gentamicin antibiotic beads. On January 30, 2018 our group
met him and he stated that he’s been admitted since December 20, 2017 for healing
and recovery with a final diagnosis of Osteomyelitis tibia right.
PHYSICAL EXAMINATION (CEPHALOCAUDAL APPROACH)
Admission – December 20, 2017 (Lifted from client’s chart)
General Appearance and Mental Status
Prior to admission the Patient Bali is conscious and coherent, patient come in to
follow up his not healing wound.
Admitting Vital Sign
T-36.5C
PR-72bpm
RR-20bpm
BP-120/80mmHg
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Review of systems:
H-E-E-N-T: no discharge
SKIN- no swellling
MUSCULOSKKELETAL: no gross deformity
RESPIRATORY: no dob
CARDIOVASCULAR no chest pain, normal sinus rate rhythm
GASTROINTESTINAL: no diarrhea
NEUROLOGICAL: no deficit
January 30, 2018
T = 36°C; RR = 20 bpm; PR = 80 bpm; BP = 120/90mmHg
Integumentary
a. Skin
He has a brown complexion, dry skin, absence of pallor and jaundice.
b. Nails
Upon inspection, long finger and toe nails noted. Capillary refill time of less than three
seconds.
Head and Face

c. Head
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Upon inspection, hair is black and evenly distributed with no patches of baldness. No
presence of masses, swelling, nodules and lesions upon palpation. Hair is healthy and
skull is round in shape. He has dandruff all over his hair.
d. Face
Upon inspection, his facial features and movements are symmetrical, absence of
swelling and masses upon palpation and is able to perform different facial expressions.
e. Eyes and Vision

He has black iris, white sclera, Cornea is shiny and smooth and his pupils are equally
round and reactive to light accommodation (PERRLA). His palpebral conjunctiva is pink
in color with absence of discharge, swelling, lesions, and lacrimal glands, Bulbar
conjunctiva is clear and moist, Eyebrows symmetrically aligned, Eyebrow hair is evenly
distributed and equal in movement and eyelashes are evenly distributed and curled
slightly outward.
f. Ears and Hearing

Has same color with his skin complexion, Pinna recoils after it was folded, Auricle is
smooth with no lesions, lumps, or nodules, able to hear watch tick from 1-2 inches,
absence of tenderness, masses, and lesions upon palpation.
g. Nose and sinuses

His nose is normal in shape and symmetrical, same color as facial skin, nasal mucosa
was pink and moist, no difficulty in breathing noted, absence of tenderness and lesions,
absence of secretions and septal deviation.
h. Mouth
Lips were smooth and pinkish color, gums were pink in color with absence of swelling,
color of buccal mucosa is dark pink, smooth and moist without lesions, tongue is in the
central position, pink in color, and moist, tongue able to move freely and absence of
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lesions, uvula is positioned in the midline, no redness of uvula, soft palate and hard
palate are light pink color, hard palate is pale and firm, throat is pink without lesions.
Tonsils are present and without exudates. Dry oral mucous membrane. He has only
6 lower cases teeth.
i. Neck
Neck has the same color as skin with no presence of any difficulty movement when
instructed to move in different directions. Thyroid gland ascends when instructed to
swallow and not visible, trachea is in the midline of the neck upon palpation, absence of
tenderness and masses upon palpation, absence of any difficulty movement when
instructed to move in different directions and no enlargement and tenderness on lymph
nodes.
Thorax and Heart

j. Thorax
Symmetrical from posterior and lateral views, right and left shoulders and hips are
symmetrical, scapula are symmetrical and non-protruding, no adventitious sounds
noted, chest expansion is symmetrical, sternum is position in the midline and
symmetrical with size and shape, absence of wheeze or crackles upon auscultation and
absence of tenderness upon palpation.
k. Heart
Normal pulse rate and regular in rhythm, absence of blowing, swishing and murmurs
upon auscultation.
Abdominal
l. Abdomen
Inspection showed unblemished skin and was uniform in color, symmetric contour and
not distended. There is absence of tenderness, lesions, scars and no palpable masses.
Extremities
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m. Upper Extremities
Symmetrical in shape, firm, smooth, coordinated muscle movement. Absence of
tenderness, lesions, and deformities, capillary refill time was less than three seconds,
pink nail beds noted and even temperature upon palpation.
n. Lower Extremities
Presence of a non-healing wound on his right leg. Wound is sutured and has
small portion of yellowish abscess formation.
Musculoskeletal
o. Muscle tone
Upon inspection, he has normal structures noted in the bones, posture is erect. He is
able to shrug shoulders against resistance and absence of tenderness and deformities
on the joints and moves freely.
Neurological
p. Mental Status and Level of Consciousness
Conscious and coherent with people, time, and day and was able to answers the
questions being asked by the group.
q. Sensory Function
Normal sensory functions, he was able to identify "sharp" and "dull" sensations, able to
identify alcohol through smelling and able to hear ticking off the clock during the watch
tick test.
r. Motor Function
He has a altered gross motor skills. He has difficulty of walking, and balance and
coordination.
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CRANIAL NERVE ASSESSMENT
Cranial Nerve Type and Assessment Expected Actual Result

Function Procedure Result
Cranial Nerve I: A type of Smell is assessed in Patient Bali Patient Bali was
Olfactory sensory nerve each nostril separatel will be able to able to identify
(Sensory) that contributes y by placing the identify the the aroma that
Smell in the sense of aroma to be identify aroma student nurse
smell. under one nostril and presented presented to
occluding the which is smell which is
opposing nostril. The alcohol. alcohol.
stimuli used should be
non-irritating and
identifiable.
Cranial Nerve II: A type of Visual acuity is tested Patient Bali Patient Bali was
Optic sensory nerve in will be able to able to read
(Sensory) that transforms each eye separately. read clearly clearly and
Vision central and information The client is asked to and correctly correctly the
peripheral about vision to read and check for the words words that were
the brain. vision. that are presented
presented through
through the examiner’s
examiner’s visual aid which
visual aid is the module.
which is a
handout and
check for
vision.
Visual fields are Patient Bali
assessed by asking will be able to
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the client to cover one see the
eye while the examiner’s
examiner tests the finger as the
opposite eye. The examiner
examiner wiggles the wiggles
finger in each of the his/her in
four quadrants and each four
asks the client to state quadrants.
when the finger is
seen in the periphery.
The examiner's visual
fields should be
normal, since it is
used as the baseline.
Patient Bali was
Pupillary light reflex, Patient Bali able to stare in
the client stares into will be able to the distance the
the distance as the stare in the examiner shines
examiner shines distance the the penlight
the penlight obliquely examiner obliquely into
into each pupil. shines the each of his
penlight pupil.
obliquely into
each of his
pupil.
Patient Bali’s
Pupillary constriction pupil was able to
is tested for the Patient Bali’s dilate upon
examined eye (direct pupil will be examination by
response) and on the able to dilate shining each
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opposite eye upon eye using a
(consensual examination penlight.
response). by shining
The swinging each eye
flashlight test involves using a
moving the light penlight.
between the two
pupils. Normally both
direct and consensual
responses are elicited
when the light shines
on an eye, and
some dilation will
occur during the
swing between.
Cranial Nerve III: A type of motor The examiner will Patient Bali Patient Bali was
Oculomotor nerve that instruct the client to will be able to able to
(Motor) supplies to superiorly uplift his superiorly superiorly uplift
Eye elevation and different centers eyelid and superiorly uplift his his eyelid and
papillary constriction along midbrain. rotate eyeball. The eyelid and superiorly
Its functions examiner will also superiorly rotated his
include assess for constriction rotate his eyeball without
superiorly of the client’s pupil on eyeball any difficulties.
uplifting eyelid, the exposure to light without any
superiorly and will instruct the difficulties.
rotating eyeball, client to perform eye
constriction of muscle movements in Patient Bali’s
pupil on the various directions. pupil will be Patient Bali’s
exposure to light able to pupil was able to
and operating constrict constrict upon
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several eye upon exposure to light
muscles. exposure to and was able to
light and will executed eye
execute eye muscle
muscle movements in
movements various
in various directions
directions without any
without any difficulties.
difficulties.
Cranial Nerve IV: A form of motor Instruct the client to Patient Bali Patient Bali was
Trochlear nerve that move his eyes will be able to able to move his
(Motor) supplies to the downward and move his eyes
Downward and midbrain and perform lateral eye eyes downwardly
lateral eye performs the muscle movements. downwardly without any
movements function of without any difficulties and
handling the eye difficulties was able to
muscles and and will executed lateral
turning the eye. execute eye muscle
lateral eye movements
muscle without any
movements difficulties.
without any
difficulties.
Cranial Nerve V: The largest Light touch is tested in Patient Bali Patient Bali
Trigeminal cranial nerve and each of the three will be able to responded to
(Sensory/Motor)Mo performs many divisions of the feel the the cotton wisp
tor sensory trigeminal nerve and stimulation of by blinking
functions related on each side of the light touch hiseyes and
Temporal and
to nose, eyes, face using a cotton and will be responded on
Masseter muscles
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contractibility tongue and wisp or tissue paper. able to feel the three
teeth. It is The ophthalmic the three divisions of
Sensory
basically further division is tested by trigeminal trigeminal nerve
All sensations for
divided in three touching the forehead, nerve that were
entire face, scalp,
divisions namely: the maxillary division divisions that performed.
cornea, and nasal
ophthalmic, is tested by touching is perform.
and oral cavities
maxillary and the cheeks, and the
mandibular mandibular division is
nerve. A type of tested by touching the
mixed nerve that chin. Be careful not to
performs sensory test the mandibular
and motor division too laterally,
functions in the as the mandible is
brain. innervated by
the great auricular
nerve (C2 and C3).
Cranial Nerve VI: A type of motor The examiner will Patient Bali Patient Bali was
Abducens nerve that instruct the client to will be able to able to follow
(Motor) supplies to the follow the direction of move his the direction of
Lateral eye pons and the penlight in lateral eyes in the penlight in a
movement performs movement without lateral lateral
function of moving the head. movement movement
turning eye without without moving
laterally. moving his his head.
head.
Cranial Nerve VII: A type of motor Instruct the client to Patient Bali Patient Bali was
Facial nerve that is raise his eyebrows, will be able to able to raise his
responsible for smile, frown, show raise his eyebrows,
(Sensory)
different types of teeth and puff out eyebrows, frown, and
Taste (anterior 2/3
facial hischeeks and to frown, and smile, show
of the tongue)
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expressions. identify taste on the smile, show teeth and puff
(Motor) This also tip of the tongue. teeth and out cheeks and
Facial Expression performs some puff out was able to
functions of cheeks and taste on the tip
sensory nerve by able to taste of his tongue the
supplying on the tip of vinegar that was
information his tongue presented.
about touch on the vinegar
face and senses that was
of tongue in presented.
mouth.
Cranial Nerve VIII: A type of The examiner will Patient Bali Patient Bali was
Vestibulocochlear/ sensory nerve place a second band will be able to able to hear the
Acoustics that is basically watch near the client’s hear the watch tick
(Sensory) functional in ear and ask the client ticking watch sound. He has
Hearing (cochlear) providing if she could hear the and will stand difficulty of
Balance (vestibular) information watch tick. erect and walking and
related to walk in standing.
balance of head For balance, the balance.
and sense of examiner will observe
sound or the client on how to
hearing. It stand and walk.
carries vestibular
as well as
cochlear
information to
the brain and is
placed near
inner ear.
Cranial Nerve IX: A type of The examiner will ask Patient Bali Patient Bali was
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Glossopharyngeal sensory nerve the client to open will be able to able to say “Ah”
(Sensory/Motor) which carries his/her mouth wide say “Ah” and and elicited
Swallow, gag reflex, sensory and say “Ah” while the elicit upward upward
vocalization, information from examiner is using a movement of movement of
posterior pharynx pharynx (initial tongue depressor. soft palate soft palate when
muscles, taste on portion of throat) The examiner will when his his mouth was
posterior third of the and some press the posterior mouth is opened. Gag
tongue portion of tongue tongue with a tongue open. Gag reflex is intact
and palate. The depressor to test for reflex intact and was able to
information sent gag reflex and and will be identify orange
is about introduce stimuli to able to as sour taste.
temperature, check for taste. identify the
pressure and taste of an
other related orange.
facts. It also
covers some
portion of taste
buds and
salivary glands.
The nerve also
carries some
motor functions
such as helping
in swallowing
food.
Cranial Nerve X: A type of mixed The examiner will Patient Bali Patient Bali has
Vagus nerve that instruct the client to will be able to no difficulty in
(Sensory/Motor carries both swallow and ask swallow and swallowing and
Swallow, gag reflex, motor and question. speak thyroid glands
vocalization, cough sensory without moved upward
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functions. This hoarseness. during
basically deals swallowing.
with the area of There was no
pharynx, larynx, hoarseness of
esophagus, voice noted.
trachea, bronchi,
some portion of
heart and palate.
It works by
constricting
muscles of the
above areas. In
sensory part, it
contributes in the
tasting ability of
a person.
Cranial Nerve XI: A type of motor The examiner will Patient Bali Patient Bali was
Accessory nerve supplies instruct the client to will be able to able to move his
(Motor) information to move his head from shrug his head from side
Trapezius and the spinal cord, side to side and ask shoulders to side and was
sternocleidomastoid trapezius and himto elevate his and move his able to elevate
movement: shoulder other shoulders against the head from his shoulders
elevation and lateral surrounding resistance introduce side to side against the
head rotation muscles. It also by the examiner. against resistance of the
provides muscle applied hands of the
movement of the resistance. student nurse.
shoulders and
surrounding
neck.
Cranial Nerve XII: A type of motor The examiner will Patient Bali Patient Bali was
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Hypoglossal nerve that deals instruct the client to will be able to able to move his
(Motor) with the muscles move his tongue from protrude his tongue from side
Tongue movement of tongue. side to side and in tongue and to side and in
and out. move it from and out.
side to side.
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Diagnostic and Laboratory Procedures
ABO and RH Typing
DIAGNOSTIC/ DATE ORDERED INDICATION(S) RESULTS ANALYSIS AND

LABORATORY DATE RESULT(S) IN INTERPRETATION
PROCEDURE
ABO DO:12/20/18 This test is “O” The patient has
DR:12/20/18 indicated for blood Blood type O. This
transfusion typing. indicates that he
can receive blood
transfusion coming
from donors who
has blood type O.
RH or Rheus DO:12/20/18 This test is “Positive The patient is RH
DR:12/20/18 indicated for blood positive. This
transfusion typing. indicates that the
blood transfusion
26
that the patient
must receive is
also rh positive.
NURSING IMPLICATION
 Prior:
1. Verify doctor’s order. Inform the client and explain the purpose of the procedure.
2. Check for cross matching and typing. To ensure compatibility
3. Obtain and record baseline vital signs
4. Practice strict asepsis
5. At least 2 licensed nurse check the label of the blood transfusion. Check the following:
a. Serial number
 Blood component
 Blood type
 Rh factor
 Expiration date
27
 Screening test (VDRL, HBsAg, malarial smear) – this is to ensure that the blood is free from blood-carried
diseases and therefore, safe from transfusion.
6. Warm blood at room temperature before transfusion to prevent chills.
 During:
1. Identify client properly. Two Nurses check the client’s identification.

2. Use needle gauge 18 to 19 to allow easy flow of blood.
3. Use BT set with special micron mesh filter to prevent administration of blood clots and particles.
4. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction usually occurs during
the first 15 to 20 minutes.
5. Monitor vital signs. Altered vital signs indicate adverse reaction (increase in temp, increase in respiratory rate)
6. Do not mix medications with blood transfusion to prevent adverse effects. Do not incorporate medication into the
blood transfusion. Do not use blood transfusion lines for IV push of medication.
7. Administer 0.9% NaCl before; during or after BT. Never administer IV fluids with dextrose. Dextrose based IV fluids
cause hemolysis.
8. Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate, transfuse quickly (20
minutes) clotting factor can easily be destroyed.
28
 After:
1. Observe for potential complications. Notify physician.
Gram Staining Exam
Specimen Source: Tissue Site (Right Leg)
DIAGNOSTIC/ DATE INDICATION(S) RESULTS NORMAL ANALYSIS AND

LABORATORY ORDERED VALUES INTERPRETATION
PROCEDURE DATE
RESULT(S) IN
Gram Stain DO:12/22/18 Gram stain is a method No Microorganism (-) No AFB The results are
DR:12/22/18 of staining used to found found normal. This
distinguish and indicates that
classify bacterial species patient has no
into two large groups bacteria present in
(gram- his wound.
positive and gram-
29
negative).
Pus Cells/OIF DO:12/22/18 Gram stain is a method (++) (++) 5-10 OIF The results are
DR:1/22/18 of staining used to normal. This
distinguish and indicates that
classify bacterial species patient has no
into two large groups bacteria present in
(gram- his wound.
positive and gram-
negative).
NURSING IMPLICATION
 Prior:
1. Explain the procedure to the client in order to gain his cooperation
2. Prepare the materials needed such as gloves, container and etc for the specimen.
 During:
1. Provide privacy.
30
 After:
1. After they have collected the sample, send the sample to a laboratory for testing. Continue taking the
medications that were stopped prior to the procedure.
DIAGNOSTIC/ DATE ORDERED INDICATION(S) RESULT NORMAL ANALYSIS AND

LABORATORY DATE RESULT(S) S VALUES INTERPRETATIO
PROCEDURE IN N
Prothrombin DO:12/20/18 This test is done Patient Normal value: The results are
Time DR:12/20/18 to measure how value: 10.7-13.8secs within normal
long it takes 10.8 range. This
blood to clot. indicates that
Control client is free from
This test can be value: any signs and
used to check 14.1 symptoms of
bleeding bleeding
problems. disorders before
taking his
31
surgery.
Active DO:12/20/18 This test is done Patient Normal value: The results are
Prothrombin DR:12/20/18 to measure how value: 31.0-43.1secs within normal
Time long it takes 33.1 range. This
blood to clot. indicates that
Control client is free from
It is an activator value: any signs and
is added that 36.2 symptoms of
speeds up the bleeding
clotting time and disorders before
results in a taking his
narrower surgery.
reference range.
White Blood DO:1/16/18 White blood cells 22.71 4.00-10.0 The result are
Cells (WBC) DR:1/16/18 (WBC) constitute x10^9/L above the normal
the body’s range. This
primary defense indicates
DO:1/24/18 system against 5.05 possibility of..
DR:1/24/18 foreign infection in the
organisms, wound of the
tissues and other client.
substances. A
32
DO:1/25/18 total WBC count 3.57
DR:1/25/18 indicates the
degree of
response to a
pathological
process, but a
more complete
evaluation for
specific
diagnoses for
any one disorder
is provided by
the differential
count.
To determine
infection or
inflammation.
Neutrophils DO:1/16/18 Neutrophils are 88.3 50-70% The result is
DR:1/16/18 normally found above normal
as the which Indicates
predominant infection in the
DO:1/24/18 WBC type in the 51.9 bone cortex and
33
DR:1/24/18 circulating blood. marrow.
They are the
body’s first line
of defense
DO:1/25/18 through the 45.6
DR:1/25/18 process of
phagocytosis.
They also
contain enzymes
and pyrogenes,
which combat
foreign invaders.
Lymphocytes DO:1/16/18 Lymphocytes are 3.9 20.0-40.0% The result are
DR:1/16/18 agranular below the normal
mononuclear range which
blood cells that indicates the
DO:1/24/18 are smaller than 35.1 affectation of the
DR:1/24/18 granulocytes. bone marrow of
They are found the bone which is
next highest led by the
percentage in infection of the
DO:1/25/18 normal 40.8 wound.
34
DR:1/25/18 circulation.
Lymphocytes are
classified as B
cells and T cells.
Both types are
formed in the
bone marrow but
B cells mature in
the bone marrow
and T cells
mature in the
thymus.
Lymphocytes
play a major role
in the body’s
natural defense
system. B cells
differentiate into
immunoglobulin-
synthesizing
plasma cells. T
cells function as
35
cellular
mediators of
immunity and
comprise helper
(CD4)
lymphocytes,
delayed
hypersensitivity
lymphocytes,
cytotoxic (CD8 or
CD4)
lymphocytes,
and suppressor
(CD8)
lymphocytes.
Monocytes DO:1/16/18 Monocytes are 2.3 3.0-12.0% The results are
DR:1/16/18 mononuclear below the normal
cells similar to range which
lymphocytes, but indicates
DO:1/24/18 they are related 6.8 alteration in
DR:1/24/18 more closely to phagocytosis due
granulocytes in to the infection.
36
terms of their
function. The
DO:1/25/18 major function of 5.6
DR:1/25/18 monocytes is
phagocytosis.
Eosinophils DO:1/16/18 The function of 5.5 0.05-5.0 The results are
DR:1/16/18 eosinophils is above the normal
phagocytosis of range which
antigen-antibody indicates altered
DO:1/24/18 complexes. They 5.6 phagocytosis due
DR:1/24/18 become active in to infection in
the later stages right tibia of the
of inflammation. client.
Eosinophils
DO:1/25/18 respond to 7.8
DR:1/25/18 allergic and
parasitic
diseases. They
have granules
that contain
histamines used
to kill foreign
37
cells in the body
and proteolytic
enzymes that
damage parasitic
worms.
Basophils DO:1/16/18 A white blood 0.00 0.0-1.0% The results are
DR:1/16/18 cell that when within the normal
activated range.
releases
histamine and
DO:1/24/18 other substances 0.6
DR:1/24/18 that are involved
in allergic
reactions.
Basophils are
DO:1/25/18 found chiefly in 0.2
DR:1/25/18 the blood and
sites of
inflammation and
have cytoplasmic
granules that are
stained with
38
basic dyes. adj.
Basophilic.
Erythrocytes DO:1/16/18 This count is 3.64 4.0-5.5 10^9/L The results are
DR:1/16/18 closely related to below the normal
the hemoglobin range which
and hematocrit indicates
levels and alteration of blood
DO:1/24/18 represents 3.55 supply in the
DR:1/24/18 different ways of affected area of
evaluating the the infection at
number of RBCs the right leg
in the peripheral thereby, leading
DO:1/25/18 blood. 3.61 to slow healing of
DR:1/25/18 his wound.
Hemoglobin DO:1/16/18 This test is a 9.4 12.0-16.0g/dL This results are

DR:1/16/18 measure of the below the normal
total amount of range which
Hgb in the blood. indicates
It is used as a alteration in blood
DO:1/24/18 rapid indirect 9.2 supply to the
39
DR:1/24/18 measurement of affected leg sec.
the red blood cell to osteomyelitis or
(RBC) count. It is the infection that
repeated serially led to blood
DO:1/25/18 in patient with 9.6 consumption that
DR:1/25/18 ongoing bleeding is why there is a
or as a routine need of blood
part of the transfusion.
complete blood
cell count (CBC).
Hematocrit DO:1/16/18 The Hct is an 27.8 40-54% This results are
DR:1/16/18 indirect below the normal
measurement of range which
red blood cell indicates
(RBC) number alteration of
DO:1/24/18 and volume. It is 27.4 peripheral blood
DR:1/24/18 used as a rapid circulation due to
measurement of the infection that
RBC count. It is led to low
repeated serially hemoglobin which
DO:1/25/18 in patient with 28.1 also affects the
DR:1/25/18 ongoing bleeding low number of
40
or as a routine hematocrit.
part of the
complete blood
cell count. It is
an integral part
of the evaluation
of anemic
patients.
MCV or Mean DO:1/16/18 Mean 76.2 80-100fl This results are
Corpuscular DR:1/16/18 corpuscular below the normal
Volume volume (MCV) is range which
the average indicates altered
volume of red blood circulation
DO:1/24/18 cells in a 77.2 especially in the
DR:1/24/18 specimen. MCV periphery due to
is elevated or the infection that
decreased in impedes the
accordance with 77.8 circulation at his
DO:1/25/18 average red cell peripheries.
DR:1/25/18 size.
MCH or Mean DO:1/16/18 MCH stands for 25.7 27-34pg The results are
41
Corpuscular DR:1/16/18 Mean below the normal
Hemoglobin Corpuscular range which
Hemoglobin, and indicated
is a calculation of decrease
DO:1/24/18 the average 26.1 hemoglobin that
DR:1/24/18 amount of led to a decrease
hemoglobin number of Mean
contained within Corpuscular Hgb.
each of a
DO:1/25/18 person's red 26.7
DR:1/25/18 blood cells.
MCHC or Mean DO:1/16/18 The mean 33.8 32-36g/dL The results are
Corpuscular DR:1/16/18 corpuscular within normal
Hemoglobin hemoglobin range. This
Concentration concentration indicates client is
(MCHC)test is a free from signs
DO:1/24/18 standard part of 33.8 and symptoms of
DR:1/24/18 the complete anemia from the
blood count bleeding that the
(CBC) that is patient has from
42
done during his wound.
DO:1/25/18 blood analysis, 34.4
DR:1/25/18 and
the MCHC value
is used to
evaluate the
severity and
cause of anemia.
RDW-CV or Red DO:1/16/18 RDW 14.4 11-16% The results are
blood cell DR:1/16/18 test results are within the normal
distribution often used range.
width CD together
DO:1/24/18 with mean 14.2
DR:1/24/18 corpuscular
volume
(MCV) results to
determine the
DO:1/25/18 possible causes 14.1
DR:1/25/18 of the anemia.
RDW-SD or Red DO:1/16/18 RDW 39.2 35-56fl The results are

blood cell DR:1/16/18 test results are within the normal
43
distribution often used range.
width SD together
with mean 39.4
DO:1/24/18 corpuscular
DR:1/24/18 volume
(MCV) results to
determine the
possible causes
DO:1/25/18 of the anemia.
DR:1/25/18
PLT or Platelets DO:1/16/18 Platelets (PLT) 396 150-450 10^9/L The results are
DR:1/16/18 are small within the normal
fragments of range.
cells that are
essential to
DO:1/24/18 normal blood 258
DR:1/24/18 coagulation. A
platelet
examination can
be used to 395
DO:1/25/18 screen for or
44
DR:1/25/18 diagnose various
disorders and
conditions that
can cause blood-
clotting
problems.
MPV or Mean DO:1/16/18 Mean platelet 8.0 6.5-12.0fl The results are
Platelet Volume DR:1/16/18 volume (MPV) is within the normal
a machine- range.
calculated
measurement of
DO:1/24/18 the average size 8.0
DR:1/24/18 of platelets found
in blood and is
typically included
in blood tests as
DO:1/25/18 part of the CBC. 9.4`
DR:1/25/18
Creatinine DO:1/07/18 It measures the 117.4 72-127umol/L The results are

DR:1/07/18 level of within the normal
creatinine in the range which
45
blood to check indicates normal
kidney function. kidney function.
NURSING IMPLICATION
 Prior:
1. Explain the procedure to the patient and the purpose of the procedure.
2. Inform the patient that there is no food/fluid restriction needed, except for FBS, where fasting is required.
3. Inform the patient that the test requires blood sample, tell who will do the test and when.
4. Inform that there will be a discomfort from needle puncture and pressure from the tourniquet.
 During:
1. Instruct the patient not to move the arm and to remain still upon the insertion of the needle.
2. Inform the patient upon the insertion of the needle.
 After:
1. Apply pressure to the punctured site.
2. Observe the venipuncture site for bleeding.
3. Explain that some bruising, discomfort and or swelling may be experienced at the site. Instruct to apply warm,
moist compress.
4. Send the blood sample immediately to the laboratory.
46
URINALYSIS
DATE ANALYSIS AND

DIAGNOSTICS/LABORATOR NORMAL
REQUESTED/DAT INDICATION RESULTS INTERPRETATIO
Y PROCEDURES VALUES
E RESULTS IN N
This Color:
Color:
procedure
Light Yellow
was done to Yellow
The result of the
the patient
Urinalysis showed
as a
DO: 1-17-18 Appearance that patient is
screening for
: manifesting acidic
URINALYSIS presence of
Appearance urine and increase
abnormalitie Slightly hazy
DR: 1-17-18 : number of pus
s within the
cells. This indicates
urinary Clear
the client has
system as Ph: 6.0
Urinary tract
well as for
infection.
systemic
problems Specific
47
that may gravity: Ph: Acidic
manifest 1.030
Specific
throughout
gravity:
the urinary
1.010-1.030
tract. Pus Cells:
3-5/HPF
Pus Cells:
none
Red Cells:
0-2/HPF
Red Cells:
none
Albumin:
Trace Albumin:
negative
Glucose:
Negative Glucose:
negative
48
Bacteria:
Light
Bacteria:
Light
NURSING IMPLICATION
 Prior:
1. Explain the procedure to the client in order to gain his cooperation
2. Inform the client that there is no need for NPO.
3. Educate the patient on the proper way of collecting urine (clean catch midstream specimen).
4. Prepare the container for the urine.
 During:
1. Provide privacy.
2. Assist the patient if unable to get urine sample on his own.
3. Instruct the patient to prevent contamination of the urine and not to add water to the urine specimen, to prevent
alteration of results.
 After:
49
1. Cover all specimens tightly, label properly, and send immediately to the laboratory.
Na, K Cl
DIAGNOSTIC/ DATE INDICATION(S) RESULTS NORMAL ANALYSIS AND

LABORATORY ORDERED VALUES INTERPRETATION
PROCEDURE DATE
RESULT(S) IN
Sodium DO:1/18/18 It is used to detect 133.1 136-145mmOl/L The results are

DR:1/18/18 abnormal within the normal
concentrations of which indicates
sodium, including client is has no
low sodium signs of
DO:1/20/18 (hyponatremia) 136.0 dehydration.
DR:1/20/18 and high sodium
(hypernatremia).
50
Potassium DO:1/18/18 The potassium 4.08 3.5-5.1mmOl/L The results are
DR:1/18/18 test may be used within the normal
to help diagnose range.
and/or monitor
kidney disease,
DO:1/20/18 the most common 3.50
DR:1/20/18 cause of high
blood potassium.
It may also be
used to evaluate
for abnormal
values when
someone has
diarrhea and
vomiting,
excessive
sweating, or with
a variety of
symptoms.
51
Chloride DO:1/18/18 It test if you 98.0 98-107mmOl/L The results
DR:1/18/18 have symptoms of are within the
an acid or fluid normal range.
imbalance,
including:
DO:1/20/18 Vomiting over a
DR:1/20/18 long period of 106.0
time.
NURSING IMPLICATION
 Prior:
 During:
52
 After:
moist compress.
CBC with PC
DIAGNOSTIC/ DATE ORDERED INDICATION(S) RESULTS NORMAL ANALYSIS AND

LABORATORY DATE VALUES INTERPRETATION
PROCEDURE RESULT(S) IN
Hemoglobin This test is a 106 125-175g/L The results are

DO:1/20/18 measure of the below the normal
DR:1/20/18 total amount of Hgb range due to the
in the blood. It is infection to the
used as a rapid bone or
53
indirect osteomyelitis that
measurement of led to blood
the red blood cell consumption.
(RBC) count. It is
repeated serially in
patient with
ongoing bleeding
or as a routine part
of the complete
blood cell count
(CBC).
Hematocrit DO:1/20/18 The Hct is an 0.31 0.40-0.52 The results are
DR:1/20/18 indirect below the normal
measurement of range due to the
red blood cell below number of
(RBC) number and hemoglobin, it also
volume. It is used affects
as a rapid concentration to
measurement of the blood.
RBC count. It is
repeated serially in
patient with
54
ongoing bleeding
or as a routine part
of the complete
blood cell count. It
is an integral part of
the evaluation of
anemic patients.
RBC or Red DO:1/20/18 The RBC count is 3.99 4.5-6.5x109/L The results are
Blood Cell DR:1/20/18 closely related to below the normal
the hemoglobin range which
and hematocrit indicates low
levels and number of RBC in
represents different periphery of the
ways of evaluating client due to
the number of infection to the
RBCs in the bone that led to
peripheral blood. blood consumption.
WBC or White DO:1/20/18 A White blood cell 5.60 4.0-11.0x109/L The results are
Blood Cell DR:1/20/18 count is a two- within the normal
component blood range.
test that first counts
55
the total number of
WBCs in 1 cubic
millimeter of
peripheral venous
blood and then
measures the
percentage of each
type of leukocyte
present in the same
specimen.
Neutrophils DO:1/20/18 Neutrophil is a 45.6 44-55% The results are
DR:1/20/18 polymorphonuclear, within the normal
granular leukocyte range.
that stains easily
with neutral dyes.
Neutrophils are the
circulating white
blood cells
essential for
phagocytosis and
proteolysis by
which bacteria,
56
cellular debris, and
solid particles are
removed and
destroyed. A
neutrophil count
<500 may be life-
threatening.
Lymphocytes DO:1/20/18 Lymphocytes are 39.0 38-45% The results are
DR:1/20/18 agranular within the normal
mononuclear blood range.
cells that are
smaller than
granulocytes. They
are found next
highest percentage
in normal
circulation.
Lymphocytes are
classified as B cells
and T cells. Both
types are formed in
the bone marrow
57
but B cells mature
in the bone marrow
and T cells mature
in the thymus.
Lymphocytes play
a major role in the
body’s natural
defense system. B
cells differentiate
into
immunoglobulin-
synthesizing
plasma cells. T
cells function as
cellular mediators
of immunity and
comprise helper
(CD4) lymphocytes,
delayed
hypersensitivity
lymphocytes,
cytotoxic (CD8 or
58
CD4) lymphocytes,
and suppressor
(CD8) lymphocytes.
Monocytes DO:1/20/18 Monocytes are 7.3 3.0-6.0% The monocytes are
DR:1/20/18 mononuclear cells above the normal
similar to range which
lymphocytes, but indicates that the
they are related need to increase in
more closely to number to defense
granulocytes in mechanism for
terms of their infection of the
function. The major client.
function of
monocytes is
phagocytosis.
Eosinophils DO:1/20/18 The function of 7.7 2.0-6.0% The result is above
DR:1/20/18 eosinophils is the normal range
phagocytosis of which indicated
antigen-antibody chronic
complexes. They inflammation of
become active in clients infection.
the later stages of
59
inflammation.
Eosinophils
respond to allergic
and parasitic
diseases. They
have granules that
contain histamines
used to kill foreign
cells in the body
and proteolytic
enzymes that
damage parasitic
worms.
Basophils DO:1/20/18 A white blood cell 0.4 0-10 The results are
DR:1/20/18 that when activated within the normal
releases histamine range.
and other
substances that are
involved in allergic
reactions.
Basophils are
found chiefly in the
60
blood and sites of
inflammation and
have cytoplasmic
granules that are
stained with basic
dyes. adj.
Basophilic.
Platelets DO:1/20/18 To determine the 269 150-450x109/L The results are
DR:1/20/18 number of platelets within the normal
in a sample of your range.
blood as part of a
health exam; to
screen for,
diagnose, or
monitor conditions
that affect the
number of platelets,
such as a bleeding
disorder, a bone
marrow disease, or
other underlying
condition.
61
NURSING IMPLICATION
 Prior:
 During:
 After:
moist compress.
62
RBS and UREA

RBS or DO:1/21/18 Glucose 5.71 3.85-9.0mmOl/L The results are

Random Blood DR:1/21/18 Random test is within normal
Sugar performed on a range.
sample of blood
to measure level
of Glucose in
blood.It is
performed to
confirm Diabetes
Mellitus
UREA DO:1/21/18 It is also 7.59 2.78-7.20 The results are
DR:1/21/18 measured to mmOl/L above the normal
help diagnose range which
kidney disease if indicated altered
have symptoms kidney function that
63
or are at high will have a problem
risk of in excretion of body
developing wastes.
kidney disease.
NURSING IMPLICATION
 Prior:
1. Explain the test procedures.
2. Explain that slight discomfort may be felt when the skin is punctured.
3. Encourage to avoid stress if possible because altered physiologic status influences and changes normal
hematologic values.
 During:
1. Provide comfort measures.
 After:
1. Apply manual pressure to the dressings over puncture site.
2. Monitor the puncture site for oozing or hematoma formation
3. Instruct the patient to resume normal activities and monitor the patients diet closely.
64
4. Document and record findings and report any abnormalities noted.
CRP and ESR Test

CRP or C- DO:1/24/18 C-reactive <6 <6mg/L The client results

reactive protein DR:1/24/18 protein (CRP) is are within normal
a blood range. This
test marker for indicates Client is
inflammation in free form any signs
DO:1/24/18 the body. <6 and symptoms of
65
DR:1/24/18 inflammation.
ESR or DO:1/24/18 The erythrocyte 67 0-10mm/Hr The results are

Erythrocyte DR:1/24/18 sedimentation above the normal
Sedimentation rate (ESR or sed range. This
Rate rate) is a indicates the client
relatively simple, has signs of
DO:1/27/18 inexpensive, 22 staphylococcal
DR:1/27/18 non- infection.
specific test that
has been used
for many years
to help detect
inflammation
associated with
conditions such
as infections,
cancers, and
autoimmune
diseases.
66
NURSING IMPLICATION
 Prior:
 During:
 After:

moist compress.
67
Anatomy and Physiology
Musculoskeletal System
Musculoskeletal system (also known as the locomotor system) is an organ

system that gives human the ability to move using the muscular and skeletal systems.
The musculoskeletal system provides form, support, stability, and movement to the
body. It is made up of the body’s bone (the skeleton), muscles, cartilage, tendons,
ligaments, joints, and other connective tissue (the tissue that supports and binds tissues
and organs together).
The musculoskeletal system's primary functions include supporting the body,

allowing motion, and protecting vital organs. The skeletal portion of the system serves
as the main storage system for calcium and phosphorus and contains critical
components of the hematopoietic system. This system describes how bones are
connected to other bones and muscle fibers via connective tissue such as tendons and
ligaments. The bones provide the stability to a body in analogy to iron rods in concrete
construction. Muscles keep bones in place and also play a role in movement of the
bones. To allow motion different bones are connected by joints. Cartilage prevents the
bone ends from rubbing directly on to each other. Muscles contract (bunch up) to move
the bone attached at the joint.
There are, however, diseases and disorders that may adversely affect the
function and overall effectiveness of the system. These diseases can be difficult to
diagnose due to the close relation of the musculoskeletal system to other internal
systems. The musculoskeletal system refers to the system having its muscles attached
to an internal skeletal system and is necessary for humans to move to a more favorable
position.
68
Skeletal System
The Skeletal System serves many important

functions; it provides the shape and form for our bodies
in addition to supporting, protecting, allowing bodily
movement, producing blood for the body, and storing
minerals. The number of bones in the human skeletal
system is a controversial topic. Humans are born with
about 350 bones, however, many bones fuse together
between birth and maturity. As a result an average
adult skeleton consists of 206 bones. The number of
bones varies according to the method used to derive
the count. While some consider certain structures to be
a single bone with multiple parts, others may see it as a
single part with multiple bones. There are five general
classifications of bones. These are long bones, short
bones, flat bones, irregular bones, and sesamoid
bones. The human skeleton is composed of both fused
and individual bones supported by ligaments, tendons,
muscles and cartilage. It is a complex structure with two
distinct divisions. These are the axial skeleton and the appendicular skeleton.
Function
The Skeletal System serves as a framework for tissues and organs to attach
themselves to. This system acts as a protective structure for vital organs. Major
examples of this are the brain being protected by the skull and the lungs being
protected by the rib cage.
Located in long bones are two distinctions of bone marrow (yellow and red). The
yellow marrow has fatty connective tissue and is found in the marrow cavity. During
starvation, the body uses the fat in yellow marrow for energy. The red marrow of some
bones is an important site for blood cell production, approximately 2.6 million red blood
69
cells per second in order to replace existing cells that have been destroyed by the liver.
Here all erythrocytes, platelets, and most leukocytes form in adults. From the red
marrow, erythrocytes, platelets, and leukocytes migrate to the blood to do their special
tasks.
Another function of bones is the storage of certain minerals. Calcium and

phosphorus are among the main minerals being stored. The importance of this storage
"device" helps to regulate mineral balance in the bloodstream. When the fluctuation of
minerals is high, these minerals are stored in bone; when it is low it will be withdrawn
from the bone.
Types of Bone Tissue
Bone cells are called osteocytes, and the matrix of bone is made of calcium
salts and collagen. The calcium salts are calcium carbonate (CaCO3) and calcium
phosphate (Ca3(PO4)2), which give bone the strength required to perform its supportive
and protective functions. Bone matrix is non-living, but it changes constantly, with
calcium that is taken from bone into the blood replaced by calcium from the diet. In
normal circumstances, the amount of calcium that is removed is replaced by an equal
amount of calcium deposited. This is the function of osteocytes, to regulate the amount
of calcium that is deposited in, or removed from, the bone matrix.
In bone as an organ, two types of bone tissue are present. Compact bone looks
solid but is very precisely structured. Compact bone is made of osteons or haversian
systems, microscopic cylinders of bone matrix with osteocytes in concentric rings
around central haversian canals. In the haversian canals are blood vessels; the
osteocytes are in contact with these blood vessels and with one another through
microscopic channels (canaliculi) in the matrix.
The second type of bone tissue is spongy bone, which does look rather like a
sponge with its visible holes or cavities. Osteocytes, matrix, and blood vessels are
present but are not arranged in haversian systems. The cavities in spongy bone often
70
contain red bone marrow, which produces red blood cells, platelets, and the five kinds
of white blood cells.
Classification of Bones
1. Long bones—the bones of the arms, legs, hands, and feet (but not the wrists and
ankles). The shaft of a long bone is the diaphysis, and the ends are called epiphyses.
The diaphysis is made of compact bone and is hollow, forming a canal within the shaft.
This marrow canal (or medullary cavity) contains yellow bone marrow, which is
mostly adipose tissue. The epiphyses are made of spongy bone covered with a thin
layer of compact bone. Although red bone marrow is present in the epiphyses of
children’s bones, it is largely replaced by yellow bone marrow in adult bones.
2. Short bones—the bones of the wrists and ankles.
3. Flat bones—the ribs, shoulder blades, hip bones, and cranial bones.
4. Irregular bones—the vertebrae and facial bones.
Bone Tissue
Short, flat, and irregular bones are all made of spongy bone covered with a thin
layer of compact bone. Red bone marrow is found within the spongy bone.
The joint surfaces of bones are covered with articular cartilage, which provides
a smooth surface. Covering the rest of the bone is the periosteum, a fibrous connective
tissue membrane whose collagen fibers merge with those of the tendons and ligaments
that are attached to the bone. The periosteum anchors these structures and contains
71
both the blood vessels that enter the bone itself and osteoblasts that will become active
if the bone is damaged.
The Skeleton
The human skeleton has two divisions: the axial skeleton, which forms the axis of
the body, and the appendicular skeleton, which supports the appendages or limbs. The
axial skeleton consists of the skull, vertebral column, and rib cage. The bones of the
arms and legs and the shoulder and pelvic girdles make up the appendicular skeleton.
Many bones are connected to other bones across joints by ligaments, which are strong
cords or sheets of fibrous connective tissue. The importance of ligaments becomes
readily apparent when a joint is sprained. A sprain is the stretching or even tearing of
the ligaments of a joint, and though the bones are not broken, the joint is weak and
unsteady. We do not often think of our ligaments, but they are necessary to keep our
bones in the proper positions to keep us upright or to bear weight. There are 206 bones
in total.
72
Types of muscle and their appearance
There are three types of muscles— cardiac,

skeletal, and smooth. Smooth muscles are used to
control the flow of substances within the lumens of
hollow organs, and are not consciously controlled.
Skeletal and cardiac muscles have striations that
are visible under a microscope due to the
components within their cells. Only skeletal and
smooth muscles are part of the musculoskeletal
system and only the skeletal muscles can move the
body.
Cardiac
muscles are found in the heart and are used
only to circulate blood; like the smooth
muscles, these muscles are not under
conscious control. Skeletal muscles are
attached to bones and arranged in opposing
groups around joints. Muscles are
innervated, to communicate nervous energy
to, by nerves, which conduct electrical
currents from the central nervous system
and cause the muscles to contract.
Tendons
A tendon is a tough, flexible band of fibrous connective tissue that connects

muscles to bones. Muscles gradually become tendon as the cells become closer to the
73
origins and insertions on bones, eventually becoming solid bands of tendon that merge
into the periosteum of individual bones. As muscles contract, tendons transmit the
forces to the rigid bones, pulling on them and causing movement.
Joints, ligaments, and bursae
Human synovial joint composition
Joints
Joints are structures that connect

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

connect the ends of bones together in order to form a joint. Most ligaments limit
dislocation, or prevent certain movements that may cause breaks. Since they are only
elastic they increasingly lengthen when under pressure. When this occurs the ligament
may be susceptible to break resulting in an unstable joint. Ligaments may also restrict
74
some actions: movements such as hyperextension and hyperflexion are restricted by
ligaments to an extent. Also ligaments prevent certain directional movement.
Bursa
A bursa is a small fluid-filled sac made of white fibrous tissue and lined with
synovial membrane. Bursa may also be formed by a synovial membrane that extends
outside of the join capsule. It provides a cushion between bones and tendons and/or
muscles around a joint; bursas are filled with synovial fluid and are found around almost
every major joint of the body.
75
76
PATHOPHYSIOLOGY (BOOK BASED)
NON MODIFIABLE FACTORS MODIFIABLE FACTORS
 Age  Recent fracture or orthopedic

 Gender surgery
 Diabetes Mellitus  Use of invasive procedures
 Long term corticosteroid therapy
Open wounds/fracture
Microorganism gain entry

by way of blood
Microorganism lodge into an

area where circulation slows
77
Microorganism
grow
Increase
pressure
Vascular compromise
of the periosteum
Inflammation
Infection through the Fever

bone cortex and marrow
Pain
Cortical
Swelling
Devascularization
Redness
Ischemia
Warmth
Necrosis Exudates
formation
Debridement
78
Formation of new bone Separation of devitalized
bone from a living bone
Involucrum
Sequestra
Doesn’t easily
liquefy and drain
Continues to be infected
Enlarged sequestrum
Development of sinus Sequestrum move out

tract
Revascularized
Turns to scar
tissue
Removal of
sequestrum
Site for continued
microorganism growth
79
Healing
Remission and
exacerbation
Excessive vascular
insufficiency
Loss of function
Amputation
80
SYNTHESIS OF THE DISEASE (BOOK BASED)
Osteomyelitis is a bone infection most often cause by bacteria; however, fungi,

parasites and viruses also can cause bone infection. It is further categorized according
to the pathogen’s mode of entry into bone tissue. Contiguous-focus osteomyelitis is an
infection that enters from outside the body, for example through open fractures,
penetrating wounds, or surgical procedures. In contiguous-focus osteomyelitis, the
infection spreads from soft tissue into adjacent bone. Hematogenous osteomyelitis is
caused by pathogens carried in the blood from sites of infection elsewhere in the body.
In hematogenous osteomyelitis, the infection spreads from bone to adjacent soft
tissues. Staphylococcus aureus is the usual cause of hematogenous osteomyelitis.
Other microogranisms include group B streptococcus, Haemophilus influenza,
Salmonella and gram negative infections which is common in older adults and
immunocompromised individuals with impaired immunity.
Bone is normally resistant to infection. However, when microorganisms are

introduced into bone hematogenously from surrounding structures or from direct
inoculation related to surgery or trauma, osteomyelitis can occur. Bone infection may
result from the treatment of trauma, which allows pathogens to enter bone and
proliferate in the traumatized tissue. When bone infection persists for months, the
resulting infection is referred to as chronic osteomyelitis. Although all bones are subject
to infection, the lower extremity is most commonly involved. (Huether & McCane, 2008)
81
Non-Modifiable factors
 Age – occurs frequently in person ages 50 years old and older. (Brunner &
Suddarth, 2014)
 Gender – males are affected twice as often as females. (Brunner & Suddarth,
2014)
 Diabetes Mellitus – more susceptible to osteomyelitis because of decreased

resistance to infection and vascular insufficiency. (Brunner & Suddarth, 2014)
Modifiable factors
 Recent fracture or orthopedic surgery – bacterial infection enters the bone

tissue from the bloodstream due to injury or surgery. (Brunner & Suddarth, 2014)
 Use of invasive procedures – people with compromised immune system that

receives invasive procedures are more likely to get an infection. (Brunner &
Suddarth, 2014)
 Long term corticosteroid therapy – increased susceptibility to infections due to

compromised immune system. (Brunner & Suddarth, 2014)
Signs and Symptoms
 Inflammation - a local response to cellular injury

(https://www.mayoclinic.org/diseases-conditions/osteomyelitis/symptoms-
causes/syc-20375913)
82
 Fever – way our immune system attempts to combat an infection.
(https://www.mayoclinic.org/diseases-conditions/osteomyelitis/symptoms-
 Pain – as the infection extends through the cortex of the bone, it involves the
periosteum and soft tissues the infected are become painful. It may describe as
constant, pulsating pain that intensifies with movement. (Brunner & Suddarth,
2014)
 Swelling – increased in vascular permeability, plasma fluids leak into the

inflamed tissues thus producing swelling. (https://www.mayoclinic.org/diseases-
conditions/osteomyelitis/symptoms-causes/syc-20375913)
 Redness – as a result of increase rate of blood flow in capillaries.

(https://www.mayoclinic.org/diseasesconditions/osteomyelitis/symptoms-
 Warmth - as a result of increase rate of blood flow in capillaries.

 Exudates formation – due to inflammation a fluid rich protein and cellular

elements oozes out of blood vessels and is deposited in nearby tissues.
83
PATHOPHYSIOLOGY (CLIENT- CENTERED)
NON MODIFIABLE FACTORS MODIFIABLE FACTORS
 Age (57 years old)  Recent fracture (December

 Gender (Male) 2016)
Open wounds/fracture
(December 2016
right tibia; open
fracture)
Microorganism gain entry

by way of blood
Microorganism lodge into an

area where circulation slows
84
Microorganism
grow
Increase
pressure
Inflammation
WBC
ESR
Vascular compromise
1/16/18: 22.71 x10^9/L
of the periosteum 1/24/18: 67 mm/Hr
1/24/18: 5.05 x10^9/L
1/27/18: 22 mm/Hr
N: 4.00-10.0 x10^9/L N: 0-10mm/Hr

Infection through the
bone cortex and marrow
Neutrophilia
1/16/18: 88.3%
Cortical
N: 50-70%
Devascularization
Swelling
Lymphocytes ESR
1/16/18: 3.9% Ischemia 1/24/18: 67 mm/Hr
N: 20.0-40.0% 1/27/18: 22 mm/Hr
N: 0-10mm/Hr
Necrosis
January 20, 2018
Presence of non-healing
wound on his right leg.
Wound is sutured and Debridement
has small portion of
(Dec 2016)
yellowish abscess
formation.
85
Separation of devitalized
bone from a living bone
Sequestra
Osteoblastic
response
New bone growth
Involucrum
Healing
86
Synthesis of the disease
Osteomyelitis is inflammation of the bone caused by an infecting organism.

Although bone is normally resistant to bacterial colonization, events such as trauma,
surgery, the presence of foreign bodies, or the placement of prostheses may disrupt
bony integrity and lead to the onset of bone infection. Osteomyelitis can also result from
hematogenous spread after bacteremia. When prosthetic joints are associated with
infection, microorganisms typically grow in biofilm, which protects bacteria from
antimicrobial treatment and the host immune response.
Bone is normally resistant to infection. However, when microorganisms are

introduced into bone hematogenously from surrounding structures or from direct
inoculation related to surgery or trauma, osteomyelitis can occur. Bone infection may
result from the treatment of trauma, which allows pathogens to enter bone and
proliferate in the traumatized tissue. When bone infection persists for months, the
resulting infection is referred to as chronic osteomyelitis and may be polymicrobial.
Although all bones are subject to infection, the lower extremity is most commonly
involved. (https://emedicine.medscape.com/article/1348767-overview)
The patient had an open fracture and the disease process starts with the
invasion of microorganisms in the said lesion. The microorganism spreads to the bone
by blood stream. The microorganism lodge into an area where circulation slows, it
initiates an inflammatory response that increases the pressure in the area. Due to the
vascular engorgement, the vessels in the area thrombose and the blood flow to the site
are compromised. As the site of infection expands, pressure develops at the site
causing inflammation and swelling leading to ischemia of the bone and eventually
necrosis.
The necrotic bone that develops forms an area referred to as sequestrum. The
sequestrum is separated from the surrounding bone that is still living; it provides an area
for bacteria to continue to live. In response to bone destruction and disruption of the
periosteum, the body initiates an intense osteoblastic activity. The osteoblasts stimulate
87
the growth of new bone, which surrounds and encloses the area of dead bone. The new
bone which surrounds the sequestrum is referred to as involucrum.
Non-Modifiable factors
 Age – Patient Bali’s age is 57 years old which makes him prone to have
osteomyelitis.
 Gender – Patient Bali is male which makes him affected twice as often as
females.
Modifiable factors
 Recent fracture– Patient Bali had his open fracture last December 2016
Signs and Symptoms
 Inflammation – as the infection expands, pressure develops at the site causing

inflammation as evidenced by ESR of 67 mm/Hr on 1/24/18; 22 mm/Hr on
1/27/18
 Swelling – due to increase in vascular permeability, plasma fluids leak into

inflamed tissue, producing swelling as evidenced by ESR of 67 mm/Hr on
1/24/18; 22 mm/Hr on 1/27/18
88
Problem #1: ACUTE PAIN
Assessment Nursing Scientific Objectives Interventions Rationale Evaluation

Diagnosis Explanation
S: The patient will Acute Pain Osteomyelitis is Short term: Assessed for To help Short term: The
verbalize: an infection of the After 1 hour of referred pain, determine patient shall have
-pain bone that results nursing as appropriate. possibility of demonstrated use
-changes in in inflammations, interventions, underlying of relaxation skills
appetite necrosis, and the patient will condition or and diversional
formation of new demonstrate organ activities, as
O: The patient bone. Presence use of dysfunction indicated for
may manifest: of pain in relaxation skills requiring individual situation.
-Guarding osteomyelitis is and diversional treatment.
behavior due to infection activities, as Long term: The
-Expressive and inflammation indicated for Acknowledge To alleviate or patient shall have
behavior of the bone. individual the pain control the pain. reported pain is
-Narrowed Focus situation. experience relieved or
and convert controlled.
Patient Long term: acceptance of
manifested: After 1 day of client’s
-A pain scale of nursing response to
7/10. interventions, pain.
89
-Expressive the patient will
behavior. report pain is
relieved or Encourage To distract
controlled. diversional attention and
activities such reduce tension.
as radio or
socialization
with others.
Instruct in
encourage use To evaluate
of relaxation coping abilities
techniques, and to identify
such as areas of
focused additional
breathing. concern.
Encourage Reduces
verbalization of defensive
feelings about responses,
the pain such promotes trust,
as concern and enhances
90
about cooperation
tolerating pain, with regimen.
anxiety.
Acknowledge To prevent
the pain fatigue that can
experience impair ability to
and convey manage or
acceptance of cope with pain.
client’s
response to To alleviate or
pain. control the pain.
Encourage
adequate rest
periods.
Administer
analgesics as
indicated.
91
Problem #2: IMPAIRED PHYSICAL MOBILITY RELATED TO MUSCULOSKELETAL IMPAIRMENT
ASSESSMENT DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

EXPLANATION
Subjective: Ø Impaired Open wounds Short Term Goal:  Support  To Short term:
physical serve as an entry affected maintain The patient will
After 1 hour of
Objective: mobility r/t site for body parts position shall have
nursing
The patient musculoskeleta microorganisms to or joints of verbalized
interventions, the
manifested the l impairment enter the using function understanding of
patient will
following: bloodstream, after pillows, and situation and
verbalize
which rolls, foot reduce individual
understanding of
 Limited microorganisms support or risk of treatment
situation and
range of lodge into an area shoes, gel pressure regimen and
individual
motion where circulation is pads, foam, ulcers safety measures
treatment
 Limited slow. It would lead etc.
regimen and
ability to to an increase in Long term:
safety measures
perform pressure, as well  Encourage The patient will
gross or as vascular adequate  Promotes shall have
Long Term Goal:
fine compromise of the intake of well- demonstrated
motor periosteum, which fluids and being techniques that
After 1 day of
skills would lead to nutritious and enable
nursing
The patient inflammation and food maximize resumption of
interventions, the
92
may swelling. patient will be s energy activities
manifest: able to productio
 Difficulty demonstrate  Identify n
in techniques that energy
turning enable conserving  Limits
 Slowed resumption of techniques fatigue,
moveme activities for ADLS maximizi
nt, ng
Engages participati
in  Encourage on
substituti participatio
ons for n in self-  Enhance
moveme care s self-
nt concept
and
sense of
 Schedule independ
activities ence
with  To
adequate reduce
rest periods fatigue
during the
93
day
 Instruct in
use of side
rails
 For
position
changes,
transfers,
and
 Provide or ambulatio
recommen n
d pressure-
reducing  Reduces
mattress, tissue
such as pressure
egg crate, and aids
or in
pressure- maximizi
relieving ng
mattress, cellular
such as perfusion
94
alternating to
air prevent
pressure or dermal
water injury.
95
Problem #3: IMPAIRED SKIN INTEGRITY RELATED TO MECHANICAL INJURY
Assessment Nursing Scientific Objectives Nursing Rationale Evaluation

Diagnosis Explanation Interventions
S:ᴓ Impaired Osteomyelitis Short term: - Assess skin, - Establish Short term:
skin is an infection After 2-3 wound, color, comparative The patient
O: integrity in a bone. hours of turgor and baseline for shall have
Patient manifested: related to Infections can nursing sensation care participated
- Disruption of skin mechanical reach a bone interventions, in treatment
surface at the right factor; by traveling the patient - Demonstrate - Maintaining program
lower extremity injury through the will be able good skin clean, dry skin
- Yellow fluid bloodstream or to participate hygiene provides a
draining from the spreading from in treatment barrier to Long term:
site nearby tissue. program infection The patient
- Dry skin Infections can - Emphasize - Adequate shall have
- Presence of a non- also begin in Long term: importance of nutrition and displayed
healing wound on the bone itself After 2-3 adequate hydration will timely
his right tibia. if an injury days of nutrition and improve skin healing of
Wound is sutured exposes the Nursing fluid intake condition wounds
and has small bone to Interventions, without
portion of yellowish microorganism. the patient - Instruct family - Long nails complications
abscess formation Skin is the will be able to cut increases risk
96
primary to display fingernails and of skin
Patient may defense of the timely toe nails damage
manifest: body; it healing of regularly
protects the wounds
- Itching in the body against without
affected or infections and complications - Provide and - Wound
surrounding diseases applied wound dressings
area brought about dressings protect the
by the invasion carefully wound and the
- Numbness of of surrounding
affected or microorganism tissues
surrounding in the body. - Determine - To clarify the
area However, the client’s level of intervention
skin can be discomfort needs and
- Pain in the damaged by priorities
affected area several - Keep the area - To assist
circumstances. clean and dry body’s natural
Factors that process of
can cause skin repair
damage
include
- To provide
mechanical
97
factors such as - Assess blood comparative
injury. supply and baseline and
sensation of opportunity for
skin surfaces timely
and affected intervention
area on a when
regular basis problems are
noted
- To describe
- Perform routine observed
skin inspection changes
noting skin
color, texture
and turgor.
Assess areas of
least
pigmentation for
color changes
- To assess for
- Note odors signs of
98
emitted from infection
the skin, lesion
or wound - To remove
nonviable,
- Assist with contaminated
debridement or or infected
enzymatic tissue
therapy, as
indicated
99
Problem #4: RISK FOR INJURY RELATED TO ALTERED MOBILITY SEC. TO OSTEOMYELITIS
Assessment Nursing Scientific Objectives Nursing Rationale Evaluation

Diagnosis Explanation Interventions
s> RISK FOR Osteomyelitis ST> After 3 hrs. > Assess general >to gain baseline ST> the client
INJURY RT TO is an infection of nursing status of the parameters identified
o> The ALTERED in a bone. interventions, the client. >to enhance understanding
patient MOBILITY SEC. Infections can client will identify >Consider the mobility of the of individual
manifested: OSTEOMYELITIS reach a bone understanding of client’s need for client factor that
>Inability to by individual factor assistive devices. >to prevent contribute to
stand bloodstream or that contribute to >Instruct the further injury possible
autonomously spreading from possible injury. client’s SO assist injury.
>pallor on the nearby tissue. client standing or >to promote
right leg It can also walking. muscle strength
>decrease begin in the >Encourage
LT> After 5 days LT>the client
muscle bone itself, if passive exercises,
of nursing practiced
strength in an injury as indicated. >to identify risk
interventions, the selected
the right leg exposes the >Assess client’s for falls
client relates prevention
>decrease bone to germs muscle strength,
intent to practice measures.
range of such as in gross and fine
selected
motion open fracture. motor skills. >to display caring
prevention
Signs and and concern but
100
The patient symptoms are measures. >Instruct the does not hinder
may manifest: fever, family and with client’s
>restlessness irritability, significant others efforts to attain
>paresthesia tenderness, to promote autonomy.
warmth, and autonomy and to
redness on the intervene if the
effected side. client becomes
Then chronic tired, not capable >to identify what
affectation of of carrying out assistive device is
the bone can task, or become appropriate for
lead to Limited extremely the client.
ROM and if left aggravated.
untreated, can >Refer client in
lead to physical therapist,
amputation of as needed.
the affected
leg.
101
Problem #5: DEFICIENT KNOWLEDGE RELATED TO LACK OF INFORMATION OF MEDICAL CONDITION
ASSESSMENT DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE

EXPLANATION
S: patient may Deficient Absence or Short term: After 1. Reinforce 1. Using multiple
verbalize request knowledge deficiency of 1 hour of nursing explanations of learning
for information. related to lack of cognitive information interventions, the risk factors, methods
O: information of related to specific patient will be able dietary and/or enhances
Patient medical condition topic. to exhibit activity retention of
manifested: increased interest restrictions, material.
 inaccurate A lack of cognitive and assume medications,
information or responsibility for and
follow-
through of psychomotor ability own learning by symptoms.
needed for health beginning to look
instruction
restoration,
 lack of recall for information and 2. Stress
preservation, or
 Lack of ask questions. importance of
health promotion is follow-up care.
exposure
identified Long term: After 2. Reinforces that
as Knowledge 1 day of nursing this is an
Patient may
Deficit or Deficient interventions, the ongoing and
manifest:
Knowledge. patient will be able continuing
● Failure to
102
improve on Knowledge plays an to initiate health problem
previous influential and necessary lifestyle for which
regimen significant part of a changes and support and
● Developme patient’s life and participate in assistance is
nt of recovery. It may treatment available after
preventable include any of the regimen. 3. Provide discharge.
complicatio three domains: positive
ns. cognitive domain reinforcement. 3. Can encourage
(intellectual continuation of
activities, problem- 4. Establish efforts.
solving, and others); realistic activity
affective domain goal with client 4. Enhances
(feelings, attitudes, and encourage commitment to
belief); and forward promoting
psychomotor movement. optimal
domain (physical outcomes.
skills or procedures). 5. Assess the
It is the duty of the patient’s
nurse to determine current level of
with the patient what knowledge.
to teach, when to 5. To properly
103
teach, and how to construct plans
teach certain for care within
matters and client’s
concerns on 6. Reinforce the capacity.
health. Adult importance of
learning principles adhering to
guide the teaching- treatment
learning process. regimen and
keeping follow
up 6. Lack of
appointments. cooperation is
common reason
7. Present for the
material that is development of
most osteomyelitis.
significant to
client first,
such as how to
give injections
or change
dressings; 7. Information
104
present building begins
additional with explaining
material once simple concepts
client's most and moves on
pressing to explanations
educational of
needs have complex applica
been met. tionsituations.
105
106
Implementation
MEDICAL MANAGEMENT
a.IVFs, BT, IFC
MEDICAL DATE ORDERED GENERAL INDICATIONS CLIENT’S

MANAGEMENT DESCRIPTION OR PURPOSES RESPONSE TO
DATE PERFORMED
TREATMENT THE
DATE TREATMENT
CHANGED/D/C
This intravenous
D5LRS 1L Date Ordered: Hypertonic The patient
fluid was
solutions are responded well to
12/20/2017 indicated for
those that have the intravenous
Patient Bali in
Date Performed: an effective fluid as evidenced
order to replace
osmolarity by a stable
fluid loss and
12/20/2017 greater than the hydration status,
electrolytes in
body fluids. This and normal
Date Changed: the body
pulls the fluid into electrolyte levels.
12/21/2018 the vascular by
osmosis resulting
in an increase
vascular volume.
It raises
intravascular
osmotic pressure
and provides
fluid, electrolytes
and calories for
107
energy.
NURSING RESPONSIBILITIES
Before
 Check the doctor’s order for the type of solution to be infused

 Prepare equipment needed.
 Obtain intravenous solution needed.
 Check also the expiration date
 Check fluid for discoloration, foreign particles, cloudiness
 Check IV tubing for discoloration or defects, if noted, secure new equipment
During
 Explain the importance and purpose of IVF

 Prepare patient and explain the procedures
108
 Maintain Aseptic technique
 Follow the proper procedures in infusing IV solutions
 Watch out for fluid overload
 Secure the needle properly after insertion
After
 Check for swelling around the site for IV infiltration

 Regulate IVF as ordered
 Observe the reaction of the patient to the solution
109
DATE ORDERED
MEDICAL DATE PERFORMED GENERAL INDICATIONS CLIENT’S

MANAGEMENT DESCRIPTION OR PURPOSES RESPONSE TO
DATE
TREATMENT THE
CHANGED/D/C
TREATMENT
Plain Normal Date Ordered: Plain Normal This intravenous The patient
Saline Solution Saline Solution fluid was responded well to
12/21/2017
(PNSS) 1L also known as 0.9 indicated for the intravenous
Date Performed: NaCl, is an Patient Bali in fluid as evidenced

isotonic order to maintain by maintenance of
12/21/2018 intravenous hydration, and is hydration status
solution. It is used for Blood as evidenced by
Date Changed:
sterile, non- Transfusion line good skin turgor,
Ongoing pyrogenic and it is also moist membranes,
solution for fluid used to dilute absence of dry.
and electrolyte other IVs and
replacement. It medications.
has no
antimicrobial
agents and has a
pH of 5.0. It
contains 9 g/L
Sodium Chloride
with an osmolarity
of 308
mOsmoml/L and
154 mEq/L of
sodium.
110
Before
 Check the doctor’s order for the type of solution to be infused

 Prepare equipment needed.
 Obtain intravenous solution needed.
 Check also the expiration date
 Check fluid for discoloration, foreign particles, cloudiness
 Check IV tubing for discoloration or defects, if noted, secure new equipment
During
 Explain the importance and purpose of IVF

 Prepare patient and explain the procedures
 Maintain Aseptic technique
 Follow the proper procedures in infusing IV solutions
 Watch out for fluid overload
 Secure the needle properly after insertion
After
 Check for swelling around the site for IV infiltration

 Regulate IVF as ordered
 Observe the reaction of the patient to the solution
111
DATE ORDERED
MEDICAL DATE GENERAL INDICATIONS CLIENT’S

MANAGEMENT PERFORMED DESCRIPTION OR PURPOSES RESPONSE TO THE
TREATMENT TREATMENT
DATE
CHANGED/D/C
Date Ordered:
Packed Red Packed red The blood The patient
1/21/18
Blood Cells cells are used transfusion was responded well to the
(PRBC) 1unit primarily in given to Patient blood transfusion as
patients with Bali because of evidenced by an
Date Performed:
low hematocrits a decreased increased in RBC of
1/22/18
before surgery RBC count of 4.18% and a hgb
or in patients 3.61% and a hgb count of 11.2g/dL
that are likely to count 9.6g/dL. which are in normal
have low ranges.
tolerance for a
decreased
hematocrit that
develops during
surgery.
112
Before
 Verify the physician’s written order and make a treatment card according to
hospital policy
 Explain the procedure/rationale for giving blood transfusion
 Get the baseline vital signs- BP, RR, and Temperature before transfusion. Refer
to MD accordingly.
 Give pre-meds 30 minutes before transfusion as prescribed.
 Do hand hygiene
 Prepare equipment needed for BT
During
 Open compatible blood set aseptically and close the roller clamp. Spike blood
bag carefully; fill the drip chamber at least half full; prime tubing and remove air
bubbles
 Disinfect the Y-injection port of IV tubing and insert the needle, from BT
administration and secure with adhesive tape.
 Close the roller clamp of IV fluid of Plain NSS and regulate to KVO while
transfusion is going on.
 Transfuse the blood via the injection port and regulate at 10-15gtts/min
After
 Observe/Assess patient on an on-going basis for any untoward signs and

symptoms such as flushed skin, chills, elevated temperature, itchiness, urticaria,
and dyspnea. If any of these symptoms occur, stop the transfusion, open the IV
line with Plain NSS and regulate accordingly, and report to the doctor
immediately.
 When blood is consumed, close the roller clamp, of BT, and disconnect from IV
lines then regulate the IVF of plain NSS as prescribed.
 Continue to observe and monitor patient post transfusion, for delayed reaction
could still occur.
113
 Re-check hgb and hct, bleeding time, serial platelet count within specified hours
as prescribed and/or per institution’s policy.
 Discard blood bag and BT set and sharps according to Health Care Waste
Management (DOH/DENR)
b. DRUGS
Medical Date Ordered/Date General Indication/Purp Client’s

MGT/TX Performed/Date Description ose Response
Changed/D/C/admini to the TX
stered
Cefazolin Date Ordered: Inhibits cell-wall This antibiotic The patient
2g/IV, Q8˚ 12/20/17 synthesis, was indicated responded
Date Performed: promoting for Patient Bali well to the
12/20/17 osmotic in order to treat medication
instability; infection. as evidenced
usually by no further
bactericidal. complication
of infection.
Ranitidine Date Competitively This medication The patient
50mg/IV Q8˚ Ordered:12/20/17 inhibits action of was indicated responded
Date Performed: histamine at H2- for Patient Bali well to the
12/20/17 receptors sites in order medication
12/21/17 of parietal cells, because the as evidenced
decreasing patient was on by an
gastric acid NPO to absence of
secretion. decrease the aspiration.
gastric contents
and prevent
aspiration.
Tramadol Date Inhibits Calcium This medication The patient’s
114
50mg/IV Q8˚ Ordered:12/22/17 ion influx across was indicated response
PRN Date Performed: cardiac and for Patient Bali differently as
12/22/17 smooth-muscle for relieving the evidenced by
cells, dilates pain. relieved in
coronary pain.
arteries and
arterioles, and
decrease BP
and myocardial
and oxygen
demand.
Losartan Date Ordered: Inhibits This medication The patient
50mg/tab OB 12/20/207 vasoconstrictive was indicated responded
Date Performed: and for Patient Bali well to the
1/30/18 aldosterone- in order to treat medication
secreting action hypertension. as evidenced
of angiotensin II by a blood
by blocking pressure of
angiotensin II 120/90
receptor on the
surface of
vascular smooth
muscle and
other tissue
cells.
Metocloprami Date Stimulates This GI The patient
de 10mg/IV Ordered:12/22/17 motility of upper stimulant was was not
Date Performed: GI tract, indicated to handled by
12/22/17 increases lower Patient Bali to the student
esophageal prevent post- nurses
115
sphincter tone, operative during the
and blocks nausea and time of post-
dopamine vomiting. operative,
receptors at the and was not
chemoreceptor able to ask.
trigger zone.
General Nursing Responsibilities:
PRIOR:
❖ Prepare the medication/s correctly.
❖ Ensure the 8 Rights:

o right PATIENT
o right MEDICATION to be given
o right REASON
o right DOSE - what is the patient's weight
o right ROUTE
o right FREQUENCY
o right TIME/ DAY of order
o right SITE
DURING:
❖ Monitor the patient while administering the medication.
❖ Appropriately intervene as necessary.
AFTER:
❖ Evaluate the outcome of the medication on the patient’s health status.
❖ Document the process.
116
NURSING RESPONSIBILITIES (CEFAZOLIN)
 Assess for infection (vital signs; appearance of wound, sputum, urine, and stool;
(WBC) at beginning of and throughout therapy.
 Before initiating therapy, obtain a history to determine previous use of and
reactions
 To Penicillin or Cephalosporin. Persons with a negative history of penicillin
sensitivity may still have an allergic response.
 Obtain specimens for culture and sensitivity before initiating therapy. First dose
may be given before receiving results.
 Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal
edema, wheezing). Discontinue drug and notify health care professional
immediately if these problems occur. Keep epinephrine, an antihistamine, and
resuscitation equipment close by in case of an anaphylactic reaction.
 Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools
should be reported to health care professional promptly as a sign of
pseudomembranous colitis. May begin up to several weeks following cessation of
therapy.
 Assess patient for skin rash frequently during therapy. Discontinue at first sign of
rash; may be life-threatening. Stevens-Johnson syndrome may develop. Treat
symptomatically; may recur once treatment is stopped.
NURSING RESPONSIBILITIES (RANITIDINE)

 Use caution in presence of renal or hepatic impairment
 Assess potential for interactions with other pharmacological agents patient may
be taking (e.g. increased or decreased levels/effects and toxicity)
 Monitor AST, ALT, serum creatinine; when used to prevent stress-related GI
bleeding, measure the intragastric pH and try to maintain pH > 4; signs and
symptoms of peptic ulcer disease, occult blood with GI bleeding, monitor renal
function to correct dose; monitor for side effects
117
 Evaluate results of laboratory tests, therapeutic effectiveness, and adverse
reactions (e.g., bradycardia, PVCs, tachycardia, CNS changes [depression,
hallucinations, confusion, malaise], rash, gynecomastia, GI disturbances, hepatic
failure)
 Assess knowledge/teach patient appropriate use, possible side
effects/appropriate interventions, and adverse symptoms to report.
NURSING RESPONSIBILITIES (TRAMADOL)

 Assess patient’s pain before therapy and regularly thereafter to monitor drug
effectiveness (give before pain become extreme)
 Assess for hypersensitivity reactions
 Monitor for possible drug induced adverse reactions
 Monitor for CNS changes
 Monitor input-output ratio and check for decreasing output which may indicate
retention
 Assess changes in bowel pattern. Increase diet bulk and oral fluids and to
prevent constipation
 Assess patient’s and family’s knowledge on drug therapy
NURSING RESPONSIBILITIES (LOSARTAN)
 Evaluate the outcome of the medication on the patient’s health status.

 Document the process.
 Reassess patient’s level of pain at least 30 minutes after administration.
 Monitor CV and respiratory status. Withhold dose and notify prescriber if
respirations are shallow or rate is below 12 breaths/min.
 Monitor bowel and bladder function. Anticipate need for stimulant laxative.
 In the case of an overdose, naloxone may also increase risk of seizures.
 Monitor for patient’s drug dependence. Drug can produce dependence thus has
potential for abuse.
118
 Withdrawal symptoms may occur if drug is stopped abruptly. Reduce dosage
gradually.
NURSING RESPONSIBILITIES (METOCLOPRAMIDE)
 Report immediately the onset of restlessness, involuntary movements, facial

grimacing, rigidity, or tremors. Extrapyramidal symptoms are most likely to occur
in children, young adults, and the older adult and with high-dose treatment of
vomiting associated with cancer chemotherapy. Symptoms can take months to
regress.
 Be aware that during early treatment period, serum aldosterone may be elevated;
after prolonged administration periods, it returns to pretreatment level.
 Check for periodic serum electrolyte.
 Monitor for possible hypernatremia and hypokalemia, especially if patient has
CHF or cirrhosis.
 Adverse reactions associated with increased serum prolactin concentration
(galactorrhea, menstrual disorders, gynecomastia) usually disappear within a few
weeks or months after drug treatment is stopped.
119
120
121
c.Diet
Medical MGT/TX Date Ordered/Date General Indication/Purpose Client’s Response

Performed/Date Description to the TX
Changed/D/C/administered
DAT Date ordered: 12/20/17 Diet as Tolerated, Diet as tolerated is The patient was
Date started: 12/20/17 this particular diet is usually advised in eating his food
Date changed: 12/21/17 only given when relation to surgery. normally and without
client can now Once a surgical any complications
tolerate any food he procedure is
desires that is complete, individuals
nutritious, if this will are given only liquids,
not lead to any such as water. The
complications and if diet progresses to
the client needs solid foods in the form
further monitoring for of purees, chunks and
lab test. finally a regular diet.
Diet as tolerated is a
term that indicates
that the
gastrointestinal tracts
is tolerating food and
122
is ready for
advancement to the
next stage.
NPO Date Ordered: 12/20/17 NPO or nothing per This diet was The patient was
Date Performed: 12/21/17 orem means no food indicated for Patient adhered to the order
or drinks can be Bali prior to surgery because he will
taken. procedure. undergo surgery.
Date of surgery:
January 21, 2018
Type of surgery:
Debridement
General Nursing Responsibilitie:
PRIOR:
 Check for the doctor’s order.
 Before prepare the appropriate diet, be sure that proper hand washing is maintained.
DURING:
 Feed patient in an upright position.
 Give feedings with strict aspiration precaution.
123
AFTER:
 Monitor if the feeding is well-tolerated.
 Note and document any reaction.
124
Surgical Management (Client-centered)
Debridement is the removal of

unhealthy or necrotic tissues
from a wound to promote faster
healing. It can be done
surgically, chemically,
mechanically, or autolytic (using
your body’s own processes)
removal of the tissue.
For patient’s Bali, the doctor
ordered for Debridement on
January 20, 2018 and was done
the following day January 21,
2018.
Debridement was done with spinal anesthesia and supine position.
● Surgical debridement is done using scalpels, forceps, scissors, and other

instruments.
● The skin surrounding the part will be cleaned and disinfected.
● The doctor will cut away dead tissue.
● The part will be washed out to remove any free tissue
PREOPERATIVE
● Secure written informed consent. Make sure to let the patient sign the consent
before sedative medication is given
● Prepare all the needed forms (depending on the hospital protocol)
● Routine vital signs must be obtained before the procedure
125
● NPO post-midnight or hours prior to procedure, usually 6-8 hours (depends upon
the physician’s order or the protocol of the hospital)
● Start IV fluid as ordered.
INTRAOPERATIVE
● Place the patient in a position appropriate for the procedure to allow optimum
exposure of the operative site, access for the anesthetist, access for the nurse to
take vital signs and monitor IV infusions, safety of the patient by preventing
injuries and maintaining circulation, and maintenance of the patient’s dignity and
modesty.
● Prepare the skin with an antiseptic in the incision site and drape the patient
immediately after the area is prepared to avoid contamination.
● Monitor vital signs, level of consciousness, and blood loss
● Document findings and the surgical counts on the patient’s records.
POSTOPERATIVE
● Follow your doctor's directions for wound care. If you are unsure about any
aspect or unable to manage your care, discuss your concerns with your doctor.
● Keep the wound and dressings clean and dry.
● Avoid moving the affected part
126
Surgical Management (Book-centered)
Debridement- is the process of removing non-living tissue from pressure ulcers, burns,
and other wounds. Debridement speeds the healing of pressure ulcers, burns, and other
wounds. Wounds that contain nonliving (necrotic) tissue take longer to heal. The
necrotic tissue may become colonized with bacteria, producing an unpleasant odor.
Though the wound is not necessarily infected, the bacteria can cause inflammation and
strain the body's ability to fight infection. Necrotic tissue may also hide pockets of pus
called abscesses. Abscesses can develop into a general infection that may lead to
amputation or death. Not all wounds need debridement. Sometimes it is better to leave
a hardened crust of dead tissue, called an eschar, than to remove it and create an open
wound, particularly if the crust is stable and the wound is not inflamed. Before
performing debridement, the physician will take a medical history with attention to
factors that might complicate healing, such as medications being taken and smoking.
The physician will also note the cause of the wound and the ways it has been treated.
Some ulcers and other wounds occur in places where blood flow is impaired, for
example, the foot ulcers that can accompany diabetes mellitus. In such cases, the
physician or nurse may decide not to debride the wound because blood flow may be
insufficient for proper healing. In debridement, dead tissue is removed so that the
127
remaining living tissue can adequately heal. Dead tissue exposed to the air will form a
hard black crust, called an eschar. Deeper tissue will remain moist and may appear
white, or yellow and soft, or flimsy. The four major debridement techniques are surgical,
mechanical, chemical, and autolytic.
Nursing responsibilities:
 Secure written informed consent. Make sure to let the patient sign the consent
before sedative medication is given
 Prepare all the needed forms (depending on the hospital protocol)
 NPO post-midnight or hours prior to procedure, usually 6-8 hours (depends upon
the physician’s order or the protocol of the hospital)
 Start IV fluid as ordered.
 Place the patient in a position appropriate for the procedure to allow optimum
exposure of the operative site, access for the anesthetist, access for the nurse to
take vital signs and monitor IV infusions, safety of the patient by preventing
injuries and maintaining circulation, and maintenance of the patient’s dignity and
modesty.
 Prepare the skin with an antiseptic in the incision site and drape the patient
immediately after the area is prepared to avoid contamination.
 Monitor vital signs, level of consciousness, and blood loss
 Document findings and the surgical counts on the patient’s records.
 Follow your doctor's directions for wound care. If you are unsure about any
aspect or unable to manage your care, discuss your concerns with your doctor.
 Tell the patient that he/she may experience increased pain and/or exudate, which
may appear bloody but is harmless;
128
Nursing Management (Actual SOAPIERs)
January 30, 2018
S- Ø
O- Received patient lying on bed, coherent, with an ongoing IVF of #94 D5LRS 1L x 30gtts/min received at the level of
800 cc, infusing well on the left hand, , with VS taken as follows: T = 36°C; RR = 20 bpm; PR = 80 bpm; BP =
120/90mmHg. Use of accessory muscles while breathing upon rest
 Needs assistance or supervision of another person with ADLs (Level II functional classification)
 Limited range of motion
 Slowed movement
A- Impaired physical mobility r/t musculoskeletal impairment
P- After 4 hours of nursing interventions, the patient will be able to demonstrate techniques that enable resumption of
activities
I-
 Encourage adequate intake of fluids and nutritious food

 Assessed neurologic status and vital signs
 Provided rest in between periods of activities
 Instructed the patient and SO to increase activity ability levels gradually
129
 Identified energy conserving techniques for ADLS
E- Goal met as evidenced by patient was able to participate willingly in necessary or desired activities to increase
functional level of activities.
130
EVALUATION
Client’s Daily Progress Chart
DAYS ADMISSION 1st SNPI
(12/20/17) (01/30/18)
 ACUTE PAIN  
 IMPAIRED MOBILITY RT
 IMPAIRED SKIN INTEGRITY RT

FLUID IMBALANCES SEC. TO
CUSHINGS SYNDROME  

 RISK FOR INFECTION R/T 
INCREASE SERUM CORTISOL
LEVELS SEC. CUSHINGS
SYNDROME
131
 DISTURBED BODY IMAGE RT
ABNORMAL FAT

DISTRIBUTION SEC TO.
CUSHING’S SYNDROME 

Vital Signs:
 Temperature  36C  36C

 Heart Rate  84bpm  68bpm
 Respiratory Rate  19bpm  20bpm
 Blood Pressure  140/100mmHg  140/100mmHg
IVFs
 PNSS 1L  
 D5W  
132
Drugs
 Cefazolin 2g/IV Q8
 Ranitidine 50mg/IV Q8
 Tramadol 50mg/IV PRN 

 Losartan 50mg/tab
 Metoclopramide 10mg/IV
Diet
 DAT  
 NPO 
133
Summary of findings
Medicines such as Cefazolin, Ranitidine, Tramadol, Losartan, and Metoclopramide were

given to the patient. Several diagnostic tests such as CPR, ESR, RBS, Urea, and blood
tests were performed. The patient had undergone Debridement, which is the removal of
unhealthy or necrotic tissues from a wound to promote faster healing. The patient was
also given PNSS 1L and D5LRS.
The patient had an open fracture and the disease process starts with the invasion of
microorganisms in the said lesion. The microorganism spreads to the bone by blood
stream. As the site of infection expands, pressure develops at the site causing
inflammation and swelling leading to ischemia of the bone and eventually necrosis
Conclusion
In conclusion, Osteomyelitis is a disease that could have damaging results if left

untreated. Population-based studies estimate that the prevalence of Osteomyelitis was
higher in men than in women, although it can happen at any age. It can be fatal if not
treated right because it results in results in inflammations, necrosis, and formation of
new bone. It is important that people who are at risk of developing this disease to be
careful and get checked. Early detection can significantly help prevent serious damage.
The student nurses have learned in this case study the characteristics of this condition,
the risk factors that predisposed the client to such condition, and the management for
such condition. They were able to understand different mechanisms, physiology, as well
as the pathophysiology of the disease.
The student-nurse patient interaction plays a very crucial role because it serves as
a way to know more about the disease condition & its manifestation through thorough
assessment of the patient’s history.
134
Standardization of related terminology, a systematic approach to diagnosis and
investigation, and a step-wise approach to intervention is necessary. Treatment
commencing with medical therapeutic modalities followed by the least invasive surgical
modalities achieving results satisfactory to the patient is the ultimate goal of all
therapeutic interventions.
Recommendations
NURSING PROFESSION
May this study be an instrument to elevate the quality of nursing care, especially
upon the service and treatments that are rendered to cure or treat people with
Osteomyelitis
NURSES
May this study help nurses of today to improve their skills upon interacting with their
clients, and implementing nursing interventions to people with Osteomyelitis. This also
aims to increase the knowledge of nurses in order for them to become more aware and
knowledgeable of that certain disorder
DOCTORS
We recommend this study to doctors in order to be encouraged to find new

treatments for this kind of case especially now that technology has been a great aspect
to our society.
FELLOW BATCHMATES
To my fellow batch mates, may this study serve as a tool for us to enrich our
knowledge and enhance our skills to become productive nurses in the near future. May
135
this prepare our minds and be ready to plan nursing interventions properly in order to
alleviate the illness condition of our clients.
FURTHER RESEARCH
For further research, may the gathered data in this study serve as a guide to
increase their knowledge and be additional information when it is already their turn in
doing the same study. May this also serve as a guide in order for them to know the
process and steps towards the achievement of their research.
Learning derived
I am quite thrilled in choosing our patient for our case study because it is our
first time to have our duty in the surgical ward. There are so many cases in the surgery
ward that you can explored on that is why I am thankful to have that kind of opportunity.
Osteomyelitis is an infection from the bone and it is our chosen case study because it
was already discussed in the lecture. It is commonly happening in open type of fracture,
because the bacteria has chance to invade the exposed affected area and that causes
infection. It is very important to take care our body and to have follow up check-up
because our health is our wealth. A malfunction in our system can affect other good
parts of the body, so we must maintain our good health.
- Cabusao, Mikee Pauline G.
“Case studies are a great way to improve learning and training. They provide
learners like us with an opportunity to solve a problem by applying what we know. There
are no unpleasant consequences for getting it “wrong”, and cases give learners a much
better understanding of what they really know and what they need to practice. This
taught me to become time-wise person and also to become willing to learn and be
progressive. It may be hard, but at least we experienced and discovered new
information that might be really helpful for our future years in the College.”
136
- Cepe, Shyla Bree
In this case study, I’ve learned how osteomyelitis can be acquired. It can frequently
acquire on people who had open fracture that may gain entrance for the microorganism.
The most common type of microorganism for Osteomyelitis is Staphylococcus aureus.
To determine specific microorganism is through bone biopsy and sequestration. I have
not seen yet antibiotic beads that the doctor put to kill the microorganism. I also want to
thank my group mates for cooperating in finishing this case study, and thank you Ma’am
Tec for giving us the opportunity to see and care for orthopedic patients with cast,
braces and traction.
- Lacson, Zandra Dia
In this case study, I learned much more about Osteomyelitis. Its

pathophyisiology, management, medications, and what causing the disease. During
the case study, I realized that adrenal glands are very important in order for our body
to function normally. Like in this case, the client has an a benign tumor which
produces an increase adrenal hormones that causes his hypertension and increase
in glucose levels as well. It is important to take care of our body and start at a young
age.
- Lazatin, Charlene Ann
I have learned with this study the importance of caring for our bones and eating
foods that will help us to strengthen our bones. And with the making of this case
study I hope to learn more about the complications of this disease so that I can
better express my knowledge if a client asks.
- Magallanes, Joshua
BIBLIOGRAPHY
137
(https://www.mayoclinic.org/diseases-conditions/osteomyelitis/symptoms-causes/syc-
20375913)
(https://www.mayoclinic.org/diseases-conditions/osteomyelitis/symptoms-causes/syc-
20375913)
(https://www.mayoclinic.org/diseasesconditions/osteomyelitis/symptoms-causes/syc-
20375913)
(https://www.mayoclinic.org/diseasesconditions/osteomyelitis/symptoms-causes/syc-
20375913)
Brunner & Suddarth.(2010) Diagnostic and Laboratory Tests. Philadelphia: Lippincott

Williams & Wilkins
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I.

"Little things amount to big things"

Most cases of osteomyelitis are caused by staphylococcus bacteria, types of

Osteomyelitis is an infection of the bone that results in inflammations, necrosis,

Incidence of osteomyelitis worldwide is approximately 13 per 100,000 in children

The objective of this review article is to indicate some recommendations based

The decision on the clinical usefulness of an antibiotic in osteomyelitis should combine

REASON FOR CHOOSING

Considering the prevalence of Osteomyelitis, the student nurses prompted to

Short term Objectives:

 Initiate a trusting therapeutic relationship to obtain important information such as

Long term Objectives:

 Execute accurate physical examination to identify signs and symptoms of condition

Short term Objectives:

Long term Objectives:

II. NURSING PROCESS

b. Socio-Economic and Cultural Factors

Food 5000-6000 PHP

Family Health-Illness History

Patient Bali, has completed his immunization status. According to him, he

History of Present Illness

On February 15, 2017, he was admitted in a tertiary hospital in Pampanga for

PHYSICAL EXAMINATION (CEPHALOCAUDAL APPROACH)

Admission – December 20, 2017 (Lifted from client’s chart)

General Appearance and Mental Status

Admitting Vital Sign

MUSCULOSKKELETAL: no gross deformity

CARDIOVASCULAR no chest pain, normal sinus rate rhythm

January 30, 2018

T = 36°C; RR = 20 bpm; PR = 80 bpm; BP = 120/90mmHg

Head and Face

e. Eyes and Vision

f. Ears and Hearing

g. Nose and sinuses

Thorax and Heart

Cranial Nerve Type and Assessment Expected Actual Result

ABO and RH Typing

DIAGNOSTIC/ DATE ORDERED INDICATION(S) RESULTS ANALYSIS AND

6. Warm blood at room temperature before transfusion to prevent chills.

1. Identify client properly. Two Nurses check the client’s identification.

1. Observe for potential complications. Notify physician.

Gram Staining Exam

Specimen Source: Tissue Site (Right Leg)

DIAGNOSTIC/ DATE INDICATION(S) RESULTS NORMAL ANALYSIS AND

DIAGNOSTIC/ DATE ORDERED INDICATION(S) RESULT NORMAL ANALYSIS AND

Hemoglobin DO:1/16/18 This test is a 9.4 12.0-16.0g/dL This results are

RDW-SD or Red DO:1/16/18 RDW 39.2 35-56fl The results are

Creatinine DO:1/07/18 It measures the 117.4 72-127umol/L The results are

DATE ANALYSIS AND

DIAGNOSTIC/ DATE INDICATION(S) RESULTS NORMAL ANALYSIS AND

Sodium DO:1/18/18 It is used to detect 133.1 136-145mmOl/L The results are

DIAGNOSTIC/ DATE ORDERED INDICATION(S) RESULTS NORMAL ANALYSIS AND

Hemoglobin This test is a 106 125-175g/L The results are

DIAGNOSTIC/ DATE ORDERED INDICATION(S) RESULTS NORMAL ANALYSIS AND

RBS or DO:1/21/18 Glucose 5.71 3.85-9.0mmOl/L The results are

CRP and ESR Test

DIAGNOSTIC/ DATE ORDERED INDICATION(S) RESULTS NORMAL ANALYSIS AND

CRP or C- DO:1/24/18 C-reactive <6 <6mg/L The client results

ESR or DO:1/24/18 The erythrocyte 67 0-10mm/Hr The results are

2. Observe the venipuncture site for bleeding.

Musculoskeletal system (also known as the locomotor system) is an organ

The musculoskeletal system's primary functions include supporting the body,

The Skeletal System serves many important

Another function of bones is the storage of certain minerals. Calcium and