LICEO DE CAGAYAN UNIVERSITY

COLLEGE OF NURSING 1st Semester 2009 2010

In Partial Fulfillment of NCM 50124 Related Learning Experience

Care Study
Submitted to: Mrs. Joei Oliveros Clinical Instructor

Submitted by: Tiu, John T. Aquino, Joey Sazon, Gian Azuela, Ariel Student

TABLE OF CONTENTS
I. INTRODUCTION

A. Overview B. Objective and Purpose of the Study C. Scope and Limitation II. HEALTH HISTORY A. Profile of patient B. Family and personal health history C. History of present illness D. Chief complaint III. DEVELOPMENTAL DATA IV. MEDICAL MANAGEMENT A. Medical orders and rationale B. Drug study V. VI. PATHOPHYSIOLOGY WITH ANATOMY & PHYSIOLOGY NURSING ASSESSMENT (SYSTEM REVIEW & NSG. ASSESSMENT II) VII. NURSING MANAGEMENT A. Ideal Nursing Management (NCP) B. Actual Nursing Management (SOAPIE) VIII. REFERRALS & FOLLOW-UP IX. X. EVALUATION & IMPLICATIONS BIBLIOGRAPHY

I. INTRODUCTION Osteomyelitis is an infection of bone or bone marrow with a propensity for progression, usually caused by pyogenic bacteria or mycobacteria. It can be usefully sub classified on the basis of the causative organism, the route, duration and anatomic location of the infection. By definition osteomyelitis is inflammation of the bone and marrow, but, since it is always caused by an infection, it implies an infection. Osteomyelitis is inflammation and destruction of bone caused by bacteria, mycobacteria, or fungi. Common symptoms are localized bone pain and tenderness with constitutional symptoms (in acute osteomyelitis) or without constitutional symptoms (in chronic osteomyelitis). Diagnosis is by imaging studies and cultures. Treatment is with antibiotics and sometimes surgery. The bone become becomes infected in three ways: Extension of soft tissue infection - infected pressure or vascular ulcer - incisional infection Direct bone contamination from bone surgery, open fracture, or traumatic injury gunshot wound

Hematogenous (blood borne) spread from the other sites of infection

Infected tonsils, boils, infected teeth, upper respiratory infection

Osteomyelitis resulting from hematogenous spread typically occurs in a bone in an area of trauma or lowered resistance, possibly from subclinical (nonapparent) trauma.

A. OBJECTIVE This study aims to aid students on problems related to the patients condition and understand what the disease process is all about. It is also conducted to promote health care delivery and identify the clients immediate needs. B. SCOPE & LIMITATION OF THE STUDY This study was conducted within a 16-hours duty at Northern Mindanao Medical Center which focuses on the information about the patient and her condition as well as the immediate interventions required. C. SIGNIFICANCE OF THE STUDY The study focuses on the disease condition of the patient and its underlying causes. We aimed to have a much deeper understanding about the disease process for us to know proper interventions and conduct health teachings to the patient. The study also aims to promote health wellness not only for the benefit of the patient but also for the significant others.

II.HEALTH HISTORY A. Profile of patient Name: Villegas, Mark Zandro Age: 18 years old Sex: Male Birth Place: Makati City Birthday: August 21 1991 Civil Status: Single Nationality: Filipino Informant: Himself Religion: Born Again Address: Purok 3 La Verdad Talisayan Mis. Or Weight: 40 kg Height: 54 Temperature: 38 C Pulse rate: 84 bpm Respiratory rate: 24 cpm Blood pressure: 120/80 mmHg

Clinical Profile
Date of Admission: Time of Admission: Attending Physician: Chief of complaint: Admitting Diagnosis: Diet: Allergy: August 11, 2009 3: 00 PM Dr. Roem F. Castillano MD. Fever Chronic Osteomyelitis
DAT

none

B. HEALTH HISTORY Villegas, Mark Zandro 18 years old, was born on August 21, 1991 at Makati City in a Normal Spontaneous Vaginal Delivery (NSVD). The patient had an operation last December 2008 due to fracture at right femur. The patient also experienced having headaches, cough and colds, as well as fever for a couple of times in a year. Her mother usually gave him OTC medication for the relief of the aforementioned illnesses. C. HISTORY OF PRESENT ILLNESS The patient was admitted at Northern Mindanao Medical Center on August 11, 2009 at 3 PM due to fever. Two days prior to admission, the patient had an on and off fever. Fever was relieved by Paracetamol 500mg, 1 tablet every four hours. No other medications were given and no consult was made. The patients condition went on and off. Morning prior to admission, condition persisted patient has sudden undocumented fever and the day after fever. Assessment was done during admission vital signs were checked for baseline data: temperature, 38 oC; pulse rate, 84bpm; respiratory rate, 24cpm; and blood pressure, 120/80 mmHg and weight, 40 kg. D.The patient was diagnosed Chronic Osteomyelitis Right Femur

III.DEVELOPMENTAL HISTORY A. Erik Eriksons Stages of Psychosocial Development Theory Erikson describes eight developmental stages through which a healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future. Each of Erikson's stages of psychosocial development are marked by a conflict, for which successful resolution will result in a favorable outcome and by an important event that this conflict resolves itself around The subject is a 17 year old, high school student which is under the 5th stage of Ericksons psychosocial stage. This begins with puberty and ending around 18 or 20 years old. The task during adolescence is to achieve ego identity and avoid role confusion. Ego identity means knowing who you are and how you fit in to the rest of society. It requires that you take all you've learned about life and yourself and mold it into a unified self-image, one that your community finds meaningful. B. Sigmund Freuds Psychosexual Development Theory Freud advanced a theory of personality development focusing on the effects of the sexual pleasure drive on a person's emerging personality. According to his theory, parts of the personality develop as we move through a series of psychosexual stages. Each stage is characterized by different demands for sexual gratification and different ways of achieving that gratification.

The drives that have been responsible for gratification in the previous stages appear relatively inactive. The patients repressed drives were redirected into other activities, such as the formation of friendships, or hobbies.

Robert J. Havighursts Developmental Task Theory The tasks involved which need to be accomplished by the patient are: Achieving new and more mature relations with age-mates of both sexes Achieving a masculine or feminine social role Accepting one's physique and using the body effectively Achieving emotional independence of parents and other adults Preparing for marriage and family life Preparing for an economic career Acquiring a set of values and an ethical system as a guide to behavior; developing an ideology Desiring and achieving socially responsible behavior C. Jean Piagets Theory of Development According to Piaget, development is driven by the process of equilibration. Equilibration encompasses assimilation and accommodation The patient is classified under the last stage in Piaget's theory which is the formal operations stage. This stage exists between the ages of about twelve to adulthood. Children in this stage are capable of thinking logically and abstractly and reason theoretically. Piaget considered this stage the ultimate stage of development.

IV. Medical Management

a. Medical Orders and Rationale

DOCTORS ORDER 09-14-09 > TPR q 4h > DAT

RATIONALE > During this period of time, potentially fatal complications may develop > Re-establish normal eating pattern

> Paracetamol 500mg PO for > To reduce fever by direct action on the Fever Hypothalamus >Tramadol 500 mg IVTT PRN >to relieve pain for pain >CBC-, although a high WBC counts may > CBC present in viral infection. >Urinalysis > D5LR @ 20gtts/min > To know the presence of bacteria in the urine > Fluids are required to replace losses, to prevent patient dehydration. For hydration purposes

09-15-09 > TPR q 4h > DAT > To monitor patients V/S > Re-establish normal eating pattern

>Nafcillin sodium 1 gm IVTT Acute to chronic osteomyelitis caused by every 8 hours susceptible organism > IVF follow up D5LR @ 20 > Fluids are required to replace losses, to gtts/min prevent patient dehydration. For hydration purposes.

DIAGNOSTIC EXAMINATIONS

N/O

B.DRUG STUDY Name of drug, dosage, route Paracetam Indication Nursing Precaution Do not give to patient more than 5 times in 24 hours not unless prescribed by the physician.

Antipyretic lowers down fever with its direct action on ol 500mg PO the hypothalamus for temperature > 38 oC Tramadol Moderate to moderately severe pain

50 mg IVTT PRN for Pain Nafcillin Acute or chronic osteomyelitis caused by susceptible organism

Patient increased intracranial pressure or head trauma. Dosage adjustment may be required for pt. with cirrhosis or renal impairment.

sodium 1 gm IVTT every 8 hours

VI.NURSING SYSTEM REVIEW CHART

Name: Villegas, Mark Zandro Date: August 14, 2009 Vital Signs: Pulse: 84 bpm BP: _120/80 mmHg Temp: _38C Height:54 Weight:40kg EENT: Impaired vision blind pain reddened drainage gums hard of hearing deaf burning edema lesion [x] teeth Asses eyes, ears, nose Throat for abnormality [ ] no problem RESPIRATION asymmetric tachypnea apnea rales [ ] cough barrel chest bradypnea shallow rhonchi sputum diminished dyspnea orthopnea labored wheezing pain cyanotic Asses resp. rate, rhythm, depth, pattern breath sounds, comfort [x] no problem CARDIO VASCULAR arrhythmia tachycardia numbness diminished pulses edema fatigue irregular bradycardia murmur tingling absent pulses pain Assess heart sounds, rate, rhythm, pulse, blood pressure, etc., fluid retention, comfort [x] no problem GASTRO INTESTINAL TRACT obese distention mass dysphagia rigidity pain Asses abdomen, bowel habits, swallowing, bowel sounds, comfort [x] no problem GENITO-URINARY and GYNE pain urine color vaginal bleeding hematuria discharge nocturia Assess urine freq., control, color, odor, comfort/ Gyn-bleeding, discharge [x] no problem NEURO paralysis stuporous unsteady seizures lethargic comatose [ ] vertigo tremors confused vision grip Assess motor function, sensation, LOC, strength, grip, galt, coordination, orientation, speech. [x] no problem MUSCULOSKELETAL and SKIN appliance stiffness [x] itching [] petechiae hot drainage prosthesis swelling lesion poor turgor cool [x] deformity wound rash skin color flushed atrophy [x] pain ecchymosis diaphoretic moist Asses mobility, motion, galt, alignment, joint function /skin color, texture, turgor, integrity no problem Place an (X) in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure if appropriate, using (x)

Tooth Decay P

Dry and flushed skin Febrile T: 38C Pain4/10 , itchyness Present of wound Pus, ulcer on the right femur Dirty Toenails

Headache

Skin is warm to touch

SUBJECTIVE COMMUNICATION: [ ] hearing difficulty [ ] visual changes [x]denied Comments: okay raman akomg paglantaw ug ang akong pandungog as verbalized by the patient [ ] glasses [ ] contact lenses

OBJECTIVE

[ ] languages [ ] hearing difficulties

Pupil size:R:3 mm L:3mm [ ] speech difficulties Reaction: PERRLA (Pupil Equally Round Reactive to Light and Accommodation)

OXYGENATION: [ ] dyspnea [ ] smoking history Non-smoker [ ] cough [ ] sputum [x]denied CIRCULATION: [ ] chest pain [x] leg pain [ ] numbness of extremities [ ]denied NUTRITION: Diet: DAT Character [ ] recent change in weight [ ] swallowing Difficulty [x]denied Comments: okay raman akong pagkaon dili man ko galisod pud as verbalized by he patient Comments: hhm. Usahay mosakit akong tiil pero ma wala wala rman pud ang kasakit as verbalized by the patient Comments: Dili man ko gapanigarilyo as verbalized by the patient

Resp. [x] regular

[ ] irregular

Describe: There was no difficulty of breathing or shortness of breath that was noted R: full and symmetrical to the left lung L: full and symmetrical to the right lung

Heart Rhythm

[x ] regular

[ ] irregular

Ankle Edema: No ankle edema is present on both extremities Pulse R L Car + + Rad. 84 bpm 84 bpm DP + + Fem* + +

Comments: All pulses were palpable on both upper and lower extremity [ ]dentures Full Upper Lower [] [] [x]none Partial [ ] [ ] with patient [] []

ELIMINATION: Usual bowel pattern Once a day [ ] constipation Remedy [ ] urinary frequency Twice a day [ ] urgency [ ] dysuria [ ] hematuria [ ] incontinence [ ] diarrhea character [ ] polyuria [ ] foley in place [x]denied

Comments: bowel sounds (Normoactive).

Bowel sounds Audible normoactive bowel sounds Abdominal Distention Present [ ] yes [x] no Urine* (color, consistency, odor) Urine color is yellowish, moderate amount and aromatic in odor.

Not Applicable.

*if they are in place

MGT. OF HEALTH & ILLNESS: [ ] alcohol [x] denied (amount & frequency) N|A [ ] SBE: N/A Last Pap Smear: N/A SUBJECTIVE SKIN INTEGRITY: [x] dry [ ] other [ ] denied LMP: N/A

Briefly describe the patients ability to follow treatments (diet, meds, etc.) for chronic health problems (if present). Prescribed by physician and proper nutrition in diet was enforced OBJECTIVE [x] dry [ ] flushed [ ] moist [ ] cold [x ] warm [ ] cyanotic [ ] pale

Comments: ga dry akong samad sa tiil as verbalized by the patient

*rashes, ulcers, decubitus (describe size, location, drainage: (-) rashes; (+) ulcers ; (-) decubitus (1 peso coin size, right femur mod.amount) Comments: Maka lihok lihok man ko pero usahay mosakit akong tiil as verbalized by the patient [ ] LOC and orientation: patients knows where she is and knows what day today. Gait: [ ] walker [ ] cane [ ] other

ACTIVITY/ SAFETY: [ ] convulsion [ ] dizziness [ ] limited motion of Joints Limitation in Ability to [ ] ambulate [ ] bathe self [ ] other

[ x] steady

[ ] unsteady:

[ ] sensory and motor losses in face or Extremities: There was no motor and sensory losses in face and extremities noted from the patient [ ] ROM limitations: The patient is able to flex, extend, rotate the head

[ x ] denied COMFORT/SLEEP/ AWAKE: [x] pain (location) femur right Frequency Remedies [ ] nocturia [ ] sleep difficulties [ ] denied COPING: Occupation: None Members of household: 5 members Most supportive person: her father Observed non-verbal behavior: None Phone number that can be reached anytime: Not given Comments: Sakit sakit usahay akong tiil, pero ma tolerate raman pud as verbalized by the patient [x] facial grimaces [x] guarding [ ] other signs of pain : [ ] side rail release form signed (60 + years) N/A

VII NURSING MANAGEMENT A.IDEAL NURSING MANAGEMENT A. Hyperthermia related to present of pathogens in the body as evidenced by increase in body temperature higher than normal range. Desired outcomes/evaluation criteria- patient will: Demonstrate temperature within normal range, be free of chills. INTERVENTION Independent monitor patient temperature(degree and pattern); note shaking chills/profuse diaphoresis. RATIONALE Temperature of 38 degree C suggests acute infectious disease process. Fever pattern may aid in diagnosisr; remittent fever (varying only a few degrees in either direction) reflects pulmonary infections; intermittent curves or fever that returns to normal once in 24-hour period suggests septic episode, septic endocarditis, or tuberculosis (TB). Chills often precede temperature spikes. Note: Use of antipyretics alters fever patterns and may be restricted until diagnosis is made or if fever remains higher that 102F (38.9C). Room temperature/number of blankets should be altered to maintain near-normal body temperature.

Monitor environmental temperature; limit/add bed linens as indicated. Provide tepid sponge baths; avoid use of alcohol.

Dependent Administer antipyretics, paracetamol 500mg PO May help reduce fever. Note: use of ice water/alcohol may cause chills, actually elevating temperature. In addition, alcohol is very drying to skin. Used to reduce fever by its central action on the hypothalamus; However, fever may be benefial in

Provide cooling blanket.

limiting growth of organisms and enhancing autodestruction of infected cells. Used to reduce fever, usually higher than 104F-105F (39.5C-40C), when brain damage/seizures can occur.

B. Acute pain related to inflammation and tissue necrosis DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL: Will b relieved of experiencing pain and shows relief and relax physical and emotional outlook. ACTIONS/INTERVENTIONS Independent Perform a comprehensive assessment of pain to include location, characteristic, onset/duration, frequency severity(0-10 scale) Instruct use of relation exercise such as focused breathing, commercial or musics. Encourage adequate rest period (ex. TV and radio). Encourage diversional activities. RATIONALE To know how intense is the pain and to asses in relieving the pain. To provide diversional activities.

To prevent fatigue and promote wellness To divert the attention of the patient to diminish pain.

Dependent Administer medications as indicated, . To lessen the pain

C.Knowledge deficient regarding condition, related to unfamiliarity with disease. Desire outcomes/evaluation criteria- the significant others will: Verbalize understanding of disease processes, possible complications. INTERVENTION INDEPENDENT Determine the mothers perception of disease process. Review disease process, cause/effect relationship of factors that precipitate symptoms, and identify ways to reduce contributing factors. Encourage questions. RATIONALE Establishes knowledge base and provides some insight into individual learning needs. Precipitating/aggravating factors are individual; therefore, the mother needs to be aware of what foods, fluids, and lifestyle factors can precipitate symptoms. Accurate knowledge base provides opportunity for the mother to make informed decisions/choices about future and control of chronic disease. Although most others know about their own disease process, they may have outdated information or misconceptions. Promotes understanding and may enhance cooperation with regimen.

Review medications, purpose, frequency, dosage, and possible side effects. Stress importance of good skin care, e.g., proper handwashing techniques. Emphasize need for long-term follow-up and periodic reevaluation.

Reduces spread of bacteria and risk of skin irritation/breakdown, infection. Provides opportunity for evaluation of effectiveness of regimen.

32e2323

B. Actual Nursing Management (SOAPIE)

S O

gilantan ko, init akong panit as verbalized by the patient

T- 38 degree C Skin is warm to touch

A P

Hyperthermia related to present of pathogens in the body.

At the end of 2 hours the patient will be able to lower down body the body temperature from 38 degree C to normal range 1. Provided tepid sponge bath 2.Encouraged the patient to drink water at least 10-12 glasses a day

I
3. Provided adequate rest period 4. Administered paracetamol 500 mg PO as prescribed by the physician

At the end of 2 hours the patient was able to lower down the temperature from 38 degree C to normal range

S O

Sakit akong tiil kong i-lihok-lihok as verbalized by the patient

guarding facial grimace pain-pain scale of 4/10

A P

Acute pain related to inflammation and tissue necrosis

At the end of 2 hours the patient will be able to ease the pain and the pain scale will lower down from 4/10 to 1/10 1. Performed a comprehensive assessment of pain 2.Encouraged verbalization of feelings about the pain

3. Provided comfort measure (change of position) 4. Encouraged use of relaxation exercises such as deep breathing 5 Administered pain reliever as prescribed by the physician (50mg Tramadol IVTT for pain)

At the end of 2 hours the patient was able to ease the pain and the pain scale was lower down from 4/10-to-1/10

IX. EVALUATION AND IMPLICATIONS At the end of my hospital duty, we as a student nurse were able to render care to our patient to help him resolve his problem regarding health. Through observing the patients status, we were able to identify some problems during our assessment. Patient was willing to pursue his medical therapy just to promote health and wellness for the betterment of his condition. During the treatment, the patient was able to develop or enhance health awareness on his disease and with this knowledge instilled to his mind, he was then aware on how the disease was transmitted and what are the proper ways or interventions done just to minimize or prevent this disease from getting worst. We have also made the patient realize the importance of completing the course of therapy by taking the medicines prescribed or ordered to him by his physician. In addition, eating healthy or nutritious foods that were prescribed to him by the health providers was further been explained to him especially the benefits he will gain in eating these nutritious foods. In general, the patient was very cooperative to what health measures administered to him by the health providers. Moreover, these several interventions given to the patient made his body functions different than as before.

X. BIBLIOGRAPHY Lippincott Williams and Wilkins, Nursing 2006 Drug Handbook, 26th Edition, Barbara Kozier et al, Fundamentals of Nursing, 7th Edition, Lippincott Williams and Wilkins, Nursing 2004 Drug Handbook, 24rd Edition, Mosbys Pocket Dictionary of Medicine, Nursing Allied Health, 4th Edition, Published in Elsevier Science (Singapore) PTE LTD Microsoft Encarta Premium Suite 2005. 1993-2004 Microsoft Corporation. All rights reserved. Mosbys Comprehensive Review of Nursing, 13th Edition by: Saxton,Nugent,Pelikan http://www.cnn.com/HEALTH/library/DS/00583.html Smeltzer & Bare, medical Surgical Nursing, 10th ed. Vol. 1, Lippincott Williams & Wilkins, Philadelphia, USA Mosbys MEDICAL ENCYCLOPEDIA, the definitive health reference http://www.wrongdiagnosis.com/p/leptospirosis/symptoms.htm http://en.wikipedia.org/wiki/diabetic http://www.emedicine.com/med/topic1776.htm http://www.gicare.com/pated/ecdgs09.htm