Introduction Osteomyelitis is from the greek word Osteon means bone and Myelos which means marrow infection.

Osteomyelitis is an infection in the bone. It can occur in infants, children, and adults. Different types of bacteria typically affects the age groups. In children osteomyelitis most commonly occurs at the ends of the long bones of the arms of legs, affecting the hips, knees, shoulders, and wrists. In adults, its more common in the bones of the spine (vertebrae) or the pelvis. Causes of osteomyelits such as Bacterial Blood Stream Infection usually cause by staphylococcus aureus which enter the bone to the blood stream from the source of infection from the part of the body, Traumatic Injury/ Bone Injury because the opening of the bone became more susceptible for the infection to enter the bone itself. Older children, adults and patients with the orthopedic surgery have the highest incidence due to active lifestyle that causes of injury and lastly the extension of soft tissue infection in this case the infection of the wound spread to the adjacent bone tissue. Classification are Acute Osteomyelitis which is the common pathogenic agent is staphylococcus aureus, Sub Acute Osteomyelitis is difficult to diagnose because the characteristics signs and symptoms of the acute form of the disease are absent the disease has an insidious onset and supportive data are inconsistent. and the chronic osteomyelitis results when bone tissue dies as a result of lost blood supply chronic infection can go on for years people who are risk of this illness who have had recent trauma, diabetic patients, hemodialysis patients and IV drug abuse. Chronic osteomyelitis is not very common. It occurs 1 in 5000. Diagnostic procedures would include x-ray, bone aspiration, MRI, blood tests and GS/CS. Antibiotic therapy would be necessary for treatment and surgical procedures done could include: drain the infected area, removed diseased bone and tissue, removed any foreign objects and amputate the limb. According to the available statistics one person among 5,000 people gets affected with Osteomyelitis: 0.033% (4,224) of hospital consultant episodes were for osteomyelitis in 2002-03 (Hospital Episode Statistics, Department of Health, , 2002-03)
80% of hospital consultant episodes for osteomyelitis required hospital admission in 2002-03 (Hospital Episode Statistics, Department of Health, , 2002-03) 64% of hospital consultant episodes for osteomyelitis were for men in 2002-03 (Hospital Episode Statistics, Department of Health, , 2002-03) 36% of hospital consultant episodes for osteomyelitis were for women in 2002-03 (Hospital Episode Statistics, Department of Health, , 2002-03) 54% of hospital consultant episodes for osteomyelitis required emergency hospital admission in England 2002-03 (Hospital Episode Statistics, Department of Health, , 2002-03) 16.2 days was the mean length of stay in hospitals for osteomyelitis in England 2002-03 (Hospital Episode Statistics, Department of Health, , 2002-03) 8 days was the median length of stay in hospitals for osteomyelitis in England 2002-03 (Hospital Episode Statistics, Department of Health, , 2002-03) 45 was the mean age of patients hospitalised for osteomyelitis in 2002-03 (Hospital Episode Statistics, Department of Health, , 2002-03) 48% of hospital consultant episodes for osteomyelitis occurred in 15-59 year olds in England 2002-03 (Hospital Episode Statistics, Department of Health, , 2002-03) 14% of hospital consultant episodes for osteomyelitis occurred in people over 75 in 2002-03 (Hospital Episode Statistics, Department of Health, , 2002-03)

Prognosis: Before the discovery of antibiotics, the mortality of bone and joint infections was quite high. With the introduction of antibiotics, the danger of death has been minimized. Yet the problem of morbidity in terms of joint destruction, bone growth retardation, angular/rotation deformities, contracture, osteoarthritis and even recurrence are still common problems. Even the lifestyle and social relationships of the patients are changed for the rest of his life. Joint involvement has a graver outlook than bone infection. The younger the child, the greater the destruction and complications more severe.The more virulent the organism, the more serious the disease. The delay in diagnosis and treatment worsens the problem. and complicates the management. (Phil J Microbiol Infect Dis 1999; 28(1):S1-S5) Reason for Choosing This Case Study: This case study will allow the nursing student and other health care professionals to have opportunities for fostering health promotion, regarding to its specific management to lessen further complications. This study intention to gather information that can broaden our knowledge, skills and attitude with regards to the condition of the patient and to develop our abilities as future health care providers. Furthermore, this case study will allow us to apply the acquired skills we obtained in the classroom set-up.

General Objective
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To gain knowledge regarding osteomyelitis as well as to ensure quality nursing care to patient by promoting recovery and improving his health status.

Specific Objectives Knowledge Patient Centered

To be able for the patient to know the definition of osteomyelitis. For the patient to know preventive measures on how to avoid infection and further complication. For the patient to identify course of treatment for the patients illness.

Student Centered
To define osteomyelitis. To differentiate the different types of osteomyelitis. To determine possible cause of osteomyelitis.

Skills Patient Centered

For the patient to do proper intervention whenever he experience pain. For the patient to demonstrate preventive measures for further complication and infection. For the patient to practice proper measures in providing hygienic care to himself.

Student Centered
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To be able for the student-nurse to perform proper assessment for patient having osteomyelitis For the student-nurse to carry out appropriate nursing intervention for patient having osteomyelitis For the student-nurse to demonstrate preventive measures for further complications of osteomyelitis

Attitude Patient Centered

Patients family will be eager to comply with the health teaching made by student nurse regarding the prevention of infection and promotion of wound healing. Patient will be able to show acceptance regarding proper hygiene that contributes to his condition. Patient will be able to change perspective in providing much better care in the future.

Student Centered

To establish patient-student nurses interaction for effective communication obtain through assessment and complete data about patients condition. To increase self-efficacy in providing nursing care. To render quality nursing care with confidence and skills.

II. NURSING ASSESSMENT

A. BIOGRAPHIC DATA Name: Patient NG Address: Libis delPilar, City of San Fernando, Pampanga Age: 49 years old Sex: Male Race: Asian Ethnic Origin: Pampanga (Kapampangan) Civil Status: Married Occupation: Machine Operator Religion: Roman Catholic Educational Attainment: Elementary Graduate Health care financing and usual source of medical care: Relatives Closest health care facility if ill or in case of emergency: Brgy. Health Center Date of Admission: January 30, 2012 Date handled: February 22, 2012 Date of discharge: February 28, 2012 Initial Diagnosis: Abscess, left leg distal 3rd tibia with chronic osteomyelitis Principal Diagnosis: Abscess, left leg distal 3rd tibia with chronic osteomyelitis B. CHIEF COMPLAINT Namamaga ang kaliwang binti ko as verbalized by the client.

Time: 3:00pm Time of interview: 10:30am Time: 11:00am

C. HISTORY OF PRESENT ILLNESS

The client has been working on a factory for already 30 years now. He works as a machine/conveyor operator for dressing chickens. Four months prior to admission (November 2011), Patient NG started to feel pain on his left leg. He didnt give much attention thinking that it can be relieved by over-the-counter analgesics such as Mefenamic Acid. The pain became recurrent that he had difficulty walking trying not to bear weight on his left side. The client also reported that he had episodes of fever but was not able to check for his temperature because no thermometer was available. His occupation was affected that he stopped December of last year. Upon noticing that his leg is becoming swollen, he decided to have a check-up to a doctor on a medical mission on their barangay last January 21. He was told that his condition could possibly be arthritis rayuma. He took medications like Diclofenac and Vitamin B complex as prescribed. 6 days passed, no improvement was observed and the swelling was just slowly progressing so the client decided to consult a specialist (orthopedic) even though he has a fever at that time. He was advised for X-ray and was informed that he has a suspected infection. The next day (January 28), the radiologic finding revealed that a calcaneal spur is noted. He went to Jose B. Lingad Memorial Regional Hospital for consultation. He was advised that he needs to be confined because infection is already present. When he asked what possibly caused his illness, the doctor said that his condition commonly results from open wounds. The client denied having wounds on his leg but admitted that he gets minor cuts while working. The doctor then explained to him that it may have contributed to his illness considering the span of years and exposure on his occupation. Upon admission (January 30), he was initially diagnosed of Abscess, left leg distal 3rd tibia with chronic osteomyelitis with physical assessment of warm, moist and (+) erythematoma, swelling on his left leg. Vital signs are as follows: Blood Pressure- 110/80, Heart Rate- 85bpm, Respiratory Rate- 21bpm and Temperature36.6OC. Diagnostic procedures are requested such as CBC with PC, Blood typing, RBS, BUN, Creatinine, wound GS/CS and Blood Chemistry. NPO status was instructed by the admitting physician and ordered PLRS. Medications order includes: Cefuroxime and Clindamycin as antibiotics, Ranitidine as antacid, Tramadol for pain, and Paracetamol for fever. The admitting physician also scheduled Emergency Incision & Drainage, Curettage (January 31) by which informed consent for the procedure was signed and secured. He was told that the purpose of the procedure is to remove and drain the abscess on his left leg. He was informed that there is a possible bone involvement (as revealed by another x-ray exam). He was also told that not all the infection was removed and will be scheduled for another procedure. Post-op orders included: continuation of his antibiotic therapy, and daily wound care. He had a drain tube applied on his left leg. The next procedure, Debridement & Curettage, was performed last February 17. Celecoxib was also ordered (February 20) for pain. Upon handling patient NG (February 22), the client answers well and cooperatively to our questions. He can eat whatever he desires as ordered by the physician. Upon inspection, disruption on the tissue of his left leg is still evident. No itching was reported. Also, he is complaining that pain is still felt on his wound. He gave a pain scale of 7 out of 10. There is (-) output on his drain tube. His IVF was dislodged on February 24 and was ordered MGH the next day. He was discharged on February 28 accompanied by his wife.

D. HISTORY OF PAST ILLNESS

The client stated that he was also confined at JBL when he was 21 years old. Removal of a cyst on his neck was performed. Aside from that, he reported that had only experienced minor illnesses such as fever, cough and colds. He only self-medicated using over-the-counter drugs to treat these conditions. As we enumerated the vaccines BCG, DPT, OPV, MMR and Hepa B, the client stated that he had all of it. He denied any allergies to food, drugs or environmental factors. E. FAMILY HISTORY OF ILLNESS Both the father and mother of the client have passed away. But significant illnesses are noted on both sides. On paternal, His father died of tuberculosis and her aunt has a history of diabetes mellitus. On the other side, her mother and two of her siblings had asthma. Patient NG has not acquired their familial diseases but 4 of his 11 siblings had diabetes mellitus. Three of them already died of the disease, 2 of accidents and the others have no significant findings. (genogram indicated on the next page)

PATERNAL

MATERNAL
7

TM ? ? ?

IM ? (asthma)

JP

GG

LG

PG 90 (DM)

BG 88 (heart attack) (DM) 86

DM

CM

MM 92 - A/W

AM

MM 90 88 (DM)

86 (asthma)

92 91 84 - A/W (PTB) (asthma)

(asthma)

MH

EG

Legends: FG - Male LA Tuberculosis - Female

RG HG - Deceased A/W 54 (DM) DM

NG

RG NG TB - Pulmonary

ES

JR

- Alive and Well 52 51 - A/W 50 49 - osteomyelitis - A/W 48 -

60 46 A/W - DM (DM) 44

58 (poisoned)

56 - (DM) Client

- A/W -(gunshot) Mellitus Diabetes

GORDONS 11 FUNCTIONAL HEALTH PATTERN Functional Health Pattern 1. Health Perception/ Health Management Prior to Hospitalization The client was asked to how he defines the word health. According to him, Kalusugan ito nung para sa akin ay nung wastong pagtulog at syempre pagkain ng mga masusustansyang pagkain. When he was asked if he was smoking and/ or drinking, he stated that, Natigil na akong uminom noong 2004, pero hanggang ngayon nagsisigarilyo pa din ako, mga nakakakalahating kaha ako sa isang araw. Before, the client believes in quack doctors and he purchases over the counter drugs for cough and cold remedies. During Hospitalization Patient NG would rate his general health according to his perception as 5 (1 as the lowest and 10 as the highest). When the client was at the hospital , he said that, Ang dami na palang bago, high tech na ang mga gamit sa ospital. He understands that it is better to consult a licensed and specialized physician rather than consulting quack doctors. Mas mabuti na dito sa hospital, kasi mas natutuunan nilang pansin nung sakit ko at mas naalagaan ng mabuti nung sakit ko. as verbalized by the client. He wasnt able to perform his ADLs that he used to do.

2. Nutritional and Metabolic Pattern

January 27 Breakfast: 5 pcs of pandesal 1 pc of sunny side up fried egg 1 cup of coffee (approx. 180ml) Lunch: 1 saucer of adobongmanok with 2 pcs of chicken wings 1 cup of steamed, white rice 2 glasses of water (approx. 500ml) Dinner: 1 pc of fried tilapia 1 cup of steamed white rice 1 glass of water (approx. 250 ml)

January 28 Breakfast: 1 medium sized bowl of lugaw 1 glass of water (approx. 250 ml) Lunch: 1 saucer ginisang gulay pc of fried bangus 1 cup of steamed, white rice 2 glasses of water (approx. 500ml) Dinner: 1 medium sized bowl of Sinigang na Baboy 1 cup of steamed white rice 1 glass of water (approx. 250 ml)

January 29 Breakfast: 7 pcs of pandesal with a spread of Reno 1 cup of coffee (approx. 180ml) Lunch: 1 pc of tortang talong 1 cup of white steamed rice 2 glasses of water (approx. 500ml)

February 19 Breakfast: 2 slices Tasty bread with one teaspoon spread of star margarine 1 cup of coffee (approx. 180ml) Lunch: 1 saucer of Ginisang Gulay 1 cup of steamed white rice 1 glass of water (approx. 250 ml.) Dinner: 1 pc. of fried tilapia 1 saucer of ginisang petsay and labanos 1 cup of steamed white rice 1 glass of water (approx. 250 ml)

February 20 Breakfast: 2 slices Tasty bread 1 pc of hard-boiled egg 1 cup of coffee (approx.180ml) Lunch: 1 medium-sized bowl of Nilagang Baboy with 1 slice of pork pigue and 2 leaves of pechay 1 cup of steamed white rice 1 glass of water (approx.250ml) Dinner: 1 medium-sized bowl of TinolangManokwith 1 slice of chicken (leg part), 2 slices of sayote and malunggay 1 cup of steamed white rice 1 glass of water (approx.250ml)

February 21 Breakfast: 2 slices tasty bread 1 pc slice of meatloaf 1 cup of coffee (approx. 180ml) Lunch: 1 medium sized saucer of Tortang Corned Beef 1 cup of steamed white rice 2 glass of water (approx. 500ml) Dinner: 1 medium sized bowl of Monggo with 1 slice of bangus(middle) and 5 cubes of tokwa 1 cup of steamed white rice 2 glasses of water (approx.500ml)

Dinner: 1 medium sized bowl of Sinampalokang manok 1 cup of steamed, white rice 2 glasses of water (approx. 500ml)

The client states that his normal intake of fluids a day is 6 glasses a day (approx. 1500ml). He has no difficulty in eating and doesnt take any supplements. The client is fond of eating chicken, fish and vegetable. He also stated that he usually eats cup noodles or pancit canton with biscuits or pandesal to go with it. He didnt have any dental exam. But he stated that he has 3 decayed teeth. he also stated that whenever he will have bruises or wounds, it will heal for about 3-4 days. Feb 19

Intravenous Fluids Feb 20

Feb 21 10

Shift Consumed 7-3 900cc 3-11 800cc 11-7 600cc TOTAL: 2300cc

Shift Consumed 7-3 700cc 3-11 800cc 11-7 400cc TOTAL: 1900cc

Shift Consumed 7-3 1000cc 3-11 700cc 11-7 500cc TOTAL: 2200cc

In his stay in JBL, he stated that he consumes an average of 5-6 glasses (1,250ml-1,500ml) of purified water a day. He stated that he is not experiencing sore throat or nausea and vomiting. His left leg shows signs of improvement and healing. He would consider 74kg as his ideal weight but according to the client his last weight was 57kg ( according to the clients chart) 3. Elimination Pattern Bowel Elimination Urinary Elimination Sweat Frequency Once a day 3-4 times a day moderate Characteristics Brown stool Clear Discomfort No discomfort noted No discomfort noted Consistency and odor Pungent Aromatic Frequency Bowel Once a Elimination day Urinary 3-4 times Elimination a day Sweat moderate
Characteristics Discomfort Consistency and odor

Brown stool Light yellow

No discomfor t noted No discomfor t noted

Pungent Aromatic Foul odor

Before hospitalization, he stated that he normally voids 4-5 times a day (about 800-1000mL) and defecates once. He has no discomfort or problems of defecating and urinating. He had no bowel surgery in the past. He verbalized no problems excess perspiration or odor problems. 4. Activity/ Exercise Pattern

During hospitalization the client was able to maintain his regular bowel and urinary elimination, according to him his stool is brown in color and is formed. While his urine is light yellow in color and he usually urinates 3-4 times a day (approx. 600-800ml).

The client is physically active. He stated that he had that sufficient energy His form of exercise is walking, and biking for at least 30 minutes a day, he also has time for leisure activities such as watching tv and listening to the radio. But when November came, he couldnt do such things because of the pain he has been feeling.

During his hospitalization, he just lies in bed and observes his surroundings. He could go in the comfort room but with his wife. Madaming nawala sa akin simula nung magkasakit ako, lalo na at ngayon eh nasa hospital ako, pati trabaho ko nawala. as verbalized by the client. 11

_0_ feeding _0_ grooming _0_ bathing _0_ general mobility _0_ toileting _0_ cooking _0_ bed mobility _0_ home maintenance _0_ dressing _0_ shopping Level 0- full self-care Level 1- requires equipment or device Level 2- requires assistance or supervision from another person Level 3- requires assistance or supervision from another person or device Level 4- is dependent and does not participate 5. Sleep/ Rest Pattern January 28 12:00am 3am 2am 5:30am 4 hours of sleep January 29 12:30 am 2am 1:45am 4:45am 4 hours of sleep

Time of sleep Time of awakening Nap Number of hours of sleep

_0_ feeding _2_ grooming _2_ bathing _0_ general mobility _1_ toileting _0_ bed mobility _0_ dressing Level 0- full self-care Level 1- requires equipment or device Level 2- requires assistance or supervision from another person Level 3- requires assistance or supervision from another person or device Level 4- is dependent and does not participate February 21 February 22 Time of Sleep 9pm 1am 5am 9pm 1am 5am Time of Awakening 12am 4am 7am 12am 4am 7am Nap Number of hours of 8 hours of sleep 8 hours of sleep sleep In his stay in the hospital, he would rate the quality of his sleep as 5. When he was confined and when he was newly operated, he finds it hard to sleep because of pain, Minsan hirap akong makatulog, lalo na at minsan eh kumikirot nung sugat ko. as verbalized by the client.

According to our client, he had a really hard time sleeping because of the pain in his left leg. He would rate the quality of his sleep as 3 (with 1 being the lowest and 10 as the highest). 6. Cognitive/ Perceptual Pattern The client has a hard time in reading but copes up with it by using his reading glasses. He has an intact memory and has no difficulty in understanding instructions given to him. The easiest way for him to learn thing is through watching or demonstration. He finds decision making in the family difficult but he told that he can manage it.

Despite of his condition, he still finds it easy to comprehend and follow the instructions given to him. Naiintindihan ko naman nung mga binibigay sa akin na direksyon sa akin, pagka hindi ko na naiintindihan, doon lang ako nagtatanong at humihinging tulong. as verbalized by the client. He is willing to participate in his treatment program and understands its purpose. When he was asked of the pain he is experiencing upon interview, he would give a rate of 7 out of 10. When he was asked again to rate his sense of fulfillment after his operation, he rated himself as 8/10. Ngayon kasi alam ko na nung 12

7. Self -Perception/ Self Concept

The client described himself as mabait. When we asked our client to rate himself as to how fulfilled he was a person before he was admitted at the

Pattern

hospital, as 10 being the highest and 0 as the lowest, he rated himself 8/10. For he was able to perform the tasks and responsibilities assigned to him. Masaya ako, kasi na gagawa ko nung mga Gawain ko. Hindi ko nahihirapan. But when he started feeling pain over his legs that started to feel dissatisfaction of his life, for he cannot do his responsibilities anymore. The client belongs to a nuclear family. He is in a cohabiting relationship with his so called 2nd wife together with their 6 children. When it comes to making decisions for the family, he and his wife usually talks about it and then they both decided on what will be the best for them. He is also the provider for his family, and though separated from his first wife he states that, Ok naman nung pamilya ko, magkakasundo sila. Nung mga anak ko sa una at pangalawa. Kaya masaya din naman. He also stated that his 2nd wife is the most important person for him because as he said that his wife has been there for him through thick or thin, and she always supports him on his decisions. According to the client, he and his wife had an intimate moment 10 years ago. The client and his wife arent using any contraceptives and when he was asked to rate his sexual satisfaction; he rated it as 2/10 with 1 being the lowest and 10 the highest. When we asked him if it was ok with his wife, he told us that he and his wife has no problem in discussing this kind of topic. Whenever problems arises in the family, he and his wife usually talks about it especially when it involves their children. He spends 8 hours at his work, and when he arrives at home his grandchildren are his stress relievers, and whenever he has rest days, he plants fruits and vegetables in their backyard and this is his means of relaxation. Work is the word that he immediately said when he was asked of what causes him to be stressed. The client is a Roman Catholic. When we asked our client to define what his religion means to him he only one thing and that was, Para sa akin si God,

tunay na dahilan kung bakit masakit nung binti ko, tapos syempre na alis na nila nung dahilan, kaya Masaya ako kaso syempre may lungkot pa din kasihindikonagagampanangmaayosnungmgaresponsibilidadkosapamil yako. Since he has been hospitalized, and he couldnt work anymore. His eldest child, his brothers and sisters and in-laws are the ones helping him in paying his hospital bills and other needs. Syempre, nalulungkot nung pamilya ko, hindi ako makapagtrabaho. Kaya iyon, lumalapit sila sa mga kamag anak. At buti naman basta may maitutulong ay tumutulong sila. His family is very supportive of him. They always make sure that he is provided with what he needs.

8. Role Relation Pattern

9. Sexuality Reproductive Pattern

Inside the hospital the client and his wife cannot perform any sexual activity. He expressed no interest in the topic.

10. Coping Stress Tolerance

For the past two years and even since birth, he would say that the recent hospitalization is the biggest change that happened in his life. Since his disease has brought a lot of barriers and hindrances in his life, his family was his source of inspiration.

11. Values Belief Pattern

Before his operation, he said that went to the chapel and prayed, he prayed for the success of his operation and that his family would be 13

siya nung sentro ng buhay natin, siya ang lahat lahat sa atin. He also believes that whatever happens to him and his family is in the will of the Lord, that he is ready to face every challenge as long as he have his faith with him.

safe and healthy all the time and have the necessary strength so that they could surpass this challenge in their life.

Growth and Development PSYCHOSOCIAL (Erikson) Integrity vs. Despair 45+ years This phase occurs during old age and is focused on reflecting back on life. Positive PSYCHOSEXUAL (Freud) Genital (12 years to adulthood) COGNITIVE (Piaget) Formal Operations (11 years and above) MORAL (Kohlberg) Post conventional (Adolescence and beyond) Individual understands the morality of having democratically established laws. Positive SPIRITUAL (Fowler) Individual reflective Faith stage Assumes responsibility for own attitudes and beliefs. Positive
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Stage Definition

Emergence of sexual Able to see relationship interests and development and to reason in the of relationship with abstract. potential sexual partners. Positive Positive

Resolution

Analysis

Upon analyzing the client, he is having an intimate relationship with his family. He lives in his 2nd wife with his 6 children. When it comes to decision making they both talk about it and decide. These only show that they do live harmoniously and is concern for the welfare of the family. When it comes to the financial needs they help each other. His family is very supportive to him especially now that he had Osteomyelitis.

The client has eight children (two from his first wife and six from his second wife).

He has problem when it comes to reading. But still, he finds it easy to comprehd and follow the instructions given to him. He can decide on his own. He can face problems. He is contented with the things he and his family have.

As a member of the society, he makes sure that he follows the rules and regulations as much as possible stated by our laws even he is not participating in the community projects.

He believes that whatever happens to him and his family is in the will of the Lord, and he is ready to face new challenges as long as he has his faith with him. He also stated that God is the center of his life. He believes that everything happens for a reason.

ANATOMY AND PHYSIOLOGY OF MUSCULOSKELETAL SYSTEM

A musculoskeletal system (also known as the locomotor system) is an organ system that gives animals (including humans) 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 bones (the skeleton), muscles, cartilage, tendons, ligaments, joints, and other connective 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.
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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. Complex issues and injuries involving the musculoskeletal system are usually handled by a physiatrist (specialist in Physical Medicine and Rehabilitation) or an orthopaedic surgeon.

SUBSYSTEMS SKELETAL

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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 300 to 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 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.

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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.

MUSCULAR

There are three types of musclescardiac, 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
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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.

Contraction Initiation In mammals, when a muscle contracts, a series of reactions occur. Muscle contraction is stimulated by the motor neuron sending a message to the muscles from the somatic nervous system. Depolarization of the motor neuron results in neurotransmitters being released from the nerve terminal. The space between the nerve terminal and the muscle cell is called the neuromuscular junction. These neurotransmitters diffuse across the synapse and bind to specific receptor sites on the cell membrane of the muscle fiber. When enough receptors are stimulated, an action potential is generated and the permeability of the sarcolemma is altered. This process is known as initiation.

Tendons A tendon is a tough, flexible band of fibrous connective tissue that connects muscles to bones. The extra-cellular connective tissue between muscle fibers binds to tendons at the distal & proximal ends, and the tendon binds to the periosteum of individual bones at the muscle's origin & insertion. As muscles contract, tendons transmit the forces to the rigid bones, pulling on them and causing movement. Tendons can stretch substantially, allowing them to function as springs during locomotion, thereby saving energy.

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Joints, Ligaments and Bursa

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 fluid 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.

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Ligaments may also restrict some actions: movements such as hyper extension and hyper flexion 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 joint capsule. It provides a cushion between bones and tendons and/or muscles around a joint; bursa are filled with synovial fluid and are found around almost every major joint of the body.

Schematic Diagram of Chronic Osteomyelitis

Modifiable Factors

Environment

Cuts and wounds

Cigarette Smoking

Hygiene

Exposure to Infective agent (Staphylococcus aureus)

21

Adherence of the bacteria to left leg Presence of the bacteria on the site

Inflammatory process Complement and Kinin System Presence of Pyrogens

Increase Vascularity Blood stasis due to compression (pus formation) Thrombosis on the blood vessels Abscess, distal third leg left with chronic osteomyelitis Distal third tibia left. Ischemia
C C

Braykinin, C3 and C5 release Histamine release A

A

Thermoregulatory set-point in hypothalamus is stimulated

Increased Hydrostatic pressure B B Third space fluid shifting

Vasodilation causing increased blood flow

Heat is produced

Redness and Swelling Disturbance in skin and tissue integrity stimulates mechanical nociceptors

Non-pitting Edema

Exacerbation of the following S/Sx: Fever Pain Left leg immobility

Prolonged infection and inflammation causes more heat

22

Fever Pain

ESR = 37mm/hr elevated) WBC level = 18 x 103 g/L (elevated)

Left Leg Immobility

PHYSICAL ASSESSMENT NAME: Mr. NG AGE: 49 years old VITAL SIGNS: PR: 72 bpm RR: 22 cpm Temperature: 37.4 C BP: 120/90mmHg Date of Performing P.A.: February 22, 2012 (12:30pm)

23

PARTS TO BE ASSESSED GENERAL APPERANCE

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

Body built, height, and Inspection weight in relation to clients age, lifestyle and health

The patient should exhibit body symmetry, no obvious deformity and well appearance. Proportionate varies with lifestyle. The patient stated chronological age should be congruent with the apparent age. BMI Below 18.5 18.5 -24.9 25 - 29.9 30 & Above Weight Status Underweight Normal Overweight Obese

The patients body is symmetric & Not done, it only stated no obvious signs of deformity. on the clients chart. BMI = 20.28 Wt. = 57Kg. Ht.= 56

Clients posture and gait, Inspection standing, sitting and walking

Limbs and trunk should appear The client cant stand erect and can It is a deviation from proportional to body weight; sit properly. normal due to pain posture should be erect. Gait as caused by open wounds well as other body movements on the left leg should be smooth and effortless. All body parts should have controlled purposeful movement. Patients should appear clean and neatly dressed. Clothing choice should be appropriate for the weather. Norms and standard for The client is unkempt. It is a deviation from normal due to poor hygiene.

Clients overall and grooming

hygiene Inspection

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dress and cleanliness may vary among cultures. Body and breath odor Inspection There is no apparent odor from patients. It is normal for some people to have bad breath related to the types of foods ingested or due to individual digestive process and reflux. The patient has slight breath odor It is a deviation from normal due to improper hygiene.

Signs of distress in posture Inspection or facial expression

Breathing should be effortless. The client is awake. Speech should not leave a patient breathless. Face should be relaxed. The patient should not perspire excessively or show signs of emotional distress such as nail biting or avoidance of eye contact. The patient should appear awake and alert. Facial expressions should be appropriate for what is happening in the environment. No obvious sign of illness. There is a sign of illness

Normal.

Obvious signs of health or Inspection illness Clients attitude Inspection

Deviation from normal due to post surgery

The patient should appear awake The patient is awake and responds to Normal and alert. Patient should respond to questions cooperatively (aside from question and commands easily. standing) and commands easily. A patient should be cooperative and The patient is cooperative. pleasant. Normal

Clients affect/mood; Inspection appropriateness of the clients response

25

Quantity of speech, quality Inspection organization

Speech should be clear and The patient speak clearly and in a Normal understandable. Pitch, rate, and calm tone of voice volume should be appropriate to the circumstances. The patient should respond to The patient obeys easily questions and commands easily. responds to questions well. and Normal

SKIN

Relevance and organization Inspection of thoughts

Skin color and uniformity

Inspection

The skin is a uniform whitish pink or brown color, depending on patients race. Exposure to sunlight results to increase in pigmentation of sun-exposed areas. Dark-skinned person may normally have a freckling of the gums, tongue borders, and lining of the checks; the gingival may appear blue or variegated in color. Edema is not normally present.

Skin is varies from light to deep brown. The skin uniformity is generally uniform except in the areas exposed to the sun. There is a presence of skin lesion on the left leg of the client.

It is a deviation from normal due to surgery.

Presence of edema Skin lesions

Inspection/Palpation Inspection / Palpation

No presence of edema noted.

Normal It is a deviation from normal due to surgery.

No skin lesions should be present There is a skin lesion on the left leg except for freckles, birthmarks, or of the client (a Total of 14 stitches moles which may be flat or on the surgical area) with elevated. approximately 18 centimeters and 4 centimeters. The skin is dry with a minimum of perspiration. Moisture on the skin will vary from one body area to Moisture in skin folds and axillae

Skin moisture

Palpation

Normal
26

another. Moisture also varies with No evident of excessive dryness and changes in environment, muscular moisture. activity, body temperature, stress, and activity levels. Body temperature is regulated by the skins production of perspiration, which evaporates to cool the body. Skin temperature Palpation Skin surface temperature should be Her skin temperature of 36.4OC is Normal warm and equal bilaterally. Hands within the normal range. and feet may be slightly cooler than the rest of the body part. When the skin is released, it should When pinched the skin springs back Normal return to its original contour to previous state. rapidly.

Skin turgor

Palpation

NAILS Fingernails plate shape to Inspection determine its curvature and angle The nail surface should be smooth The nails are smooth and slightly Normal and slightly rounded or flat. rounded no brittle edges; the nail Curved nails are a normal variant. plate is about 160angle. There is Nail thickness should be uniform diamond shape. throughout, with no splintering or brittle edges. The angle of the nail base should be approximately 160. Longitudinal ridging is a normal variant. There is a diamond-shaped opening at the base of the nail beds in nails that are normal when assessed.
27

Fingernail and toenail bed Palpation color

The nails have a pink cast in light- Slightly brown, with normal skinned individuals and are brown capillary refill. The color returned to in dark-skinned individuals. normal within 3 seconds Capillary refill is an indicator of peripheral circulation. Normal capillary refill may vary with age, but color should return to normal within 2 to 3 seconds. The tissue surrounding nails should No hang nails have intact epidermis. The nail bed should be firm on Firm nail bed palpation. Normal

Normal

Tissues surrounding nails Fingernail and toenail bed

Inspection Inspection

Normal

Blanch test of capillary Palpation refill

Prompt return of pink or usual Prompt returned in normal color Normal color. within 3 seconds

HAIR & SCALP Evenness of growth over Inspection the scalp Inspection Hair thickness or thinness The hair is evenly distributed. Hair is evenly distributed. Normal Normal

Hair may feel thin, straight, course, The clients hair is thick. thick or curl. Males may experience a certain degree of normal balding and my also develop terminal facial and chest hair. There should be no signs of There are flaking (Dandruff). infestation or lesions. It should be shiny and resilient The hair is shiny and oily.

Presence of infections or Inspection infestations Texture and oiliness Palpation

It is a deviation from normal due to improper hygiene. It is a deviation from

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when traction is applied and should not come out in clumps in your hand. SKULL Size, shape and symmetry. Inspection The skull should be normocephalic Symmetrical and rounded and symmetrical. The normal skull is smooth, Smooth, not tender and no masses. nontender and without masses or depression.

normal due to improper hygiene.

Normal Normal

Nodules or masses and Palpation depression.

FACE Facial features Inspection The facial features should be Symmetrical. Palpebral fissures Normal symmetric or slightly asymmetric. equal in size and symmetric Palpebral fissures equal in size and nasolabial folds symmetric nasolabial folds. The facial features should be Coordinated facial movements , no Normal symmetrical. It is important to asymmetrical movements observed remember that slight variations in symmetry are common. Slanted eyes with inner epincanthal folds.

Symmetry movements

of

facial Inspection

EYEBROWS & EYELASHES Evenness of distribution Inspection and direction of curl. Lashes evenly distributed and sweeping upward from the upper lids and downward from the lower lids. Eyebrows are present bilaterally and are symmetrical and Lashes evenly distributed and Normal slightly curved outward from the upper lids and lower lids. Eye brows evenly distributed no scaling or

29

without lesions or scaling. EYELIDS Surface characteristics and Inspection ability to blink. The eyelids should appear symmetrical with no drooping, infections, or tumors of the lids. When the eyes are focused in a normal frontal gaze, the lids should cover the upper portion of the iris. When eye is closed, no portion of the cornea should be exposed. Normal lid margins are smooth. The patient can raise both eyelids symmetrically.

flakiness of skin.

No redness, swelling, flaking Normal crusting, plaques or any discharge. When the eyes are focused in a normal frontal gaze, the lids should cover the upper portion of the iris. When eye is closed, no portion of the cornea should be exposed. Normal lid margins are smooth. The patient can raise both eyelids symmetrically.

CONJUNCTIVA Bulbar conjunctivas color, Inspection texture and presence of lesions The bulbar conjunctiva is No swelling, exudates, infection, Normal transparent, with small, blood lesions. Bulbar conjunctiva is vessels visible in it. It should appear transparent white except for a few small blood vessels, which are normal. No swelling, infection, exudates, foreign bodies, or lesions noted. The palpebral conjunctiva should Pink and moist without swelling, Normal appear pink and moist. It is without lesions, exudates. swelling, lesions, infection, exudates or foreign bodies.

Palpebral conjunctivas Inspection color texture and presence of lesions.

SCLERA
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Color and clarity

Inspection

In light-skinned individuals, the The sclera may have tuny brown sclera should be white with some small, superficial vessels and without exudates, lesions and foreign bodies. In dark-skinned individuals, the sclera may have tiny brown patches of melanin or grayish-blue or muddy color.

Normal

CORNEA Clarity and color Inspection The corneal surface should be moist Cornea is transparent and shiny, Normal and shiny, with no discharge, moist, no discharge and cloudiness cloudiness, opacities, or or irregularities. irregularities.

IRIS Shape and color Inspection The color is evenly distributed over Dark brown in color not opaque the iris, although there can be a mosaic variant. It is normally smooth and without apparent vascularity. Normal

PUPILS Color, shape, and symmetry Inspection of size. Pupil light reaction and Inspection The pupils should be deep black, Pupils are round and equal in size Normal round and of equal diameter, deep black in color ranging from 2 to 6 mm. Pupils should constrict. It react to the light; constricts; dilates Normal
31

accommodation. Pupil direct and consensual Inspection reaction to light.

and converges Pupils constrict briskly to direct It react to the light; constricts; dilates Normal and consensual light and to and converges accommodation. Small differences in pupil size (anisocoria) may be normal in some people.

VISUAL ACUITY Test near vision Inspection Until the patient is in the late 30s to The patient cannot read without eye Deviation from normal the late 40s, reading is generally glasses. due to poor eyesight / possible at a distance of 14 inches. aging process. The patient who has a visual acuity Not done of 20/20 is considered to have normal visual acuity. Not done, due to unavailability of the snellen chart.

Test distant vision

Inspection

LACRIMAL GLAND, LACRIMAL SAC AND NASOLACRIMAL DUCT Presence of edema Inspection/Palpation There should be no enlargement, No presence of edema, enlargement, Normal swelling, or redness; no large swelling, redness. And other amount of exudates; and minimal discharge tearing.

EXTRAOCULAR MUSCLES Test each eye for alignment Inspection and coordination Both eyes should move smoothly Both eyes moves coordinated with Normal and symmetrically in each of the six parallel alignment fields of gaze and converge on the held object as it moves toward the nose. A few beats of nystagmus with

32

extreme lateral gaze can be normal. VISUAL FIELDS Test for peripheral visual Inspection fields. The patient is able to see the When looking straight ahead the Normal stimulus at about 90 temporally, client can see object in the periphery 60 nasally, 50 superiorly, and 70 inferiorly.

EARS AURICLE Color and symmetry of size Inspection and position The ear should match the flesh Auricles color same as facial skin, Normal color of the rest of the patients skin symmetrical align with the outer and should be position centrally cantus of eye. and in proportion to the head. The top of the ear should cross an imaginary line drawn from the outer canthus of the eye occiput. There is no area of tenderness, No area of tenderness, elastic and Normal elastic and pinna recoils after it is pinna recoils after it is fold. No pain fold. The patient should not or tenderness during palpation. complain of pain or tenderness during palpation.

Texture, elasticity and areas Palpation of tenderness.

EXTERNAL EAR CANAL Cerumen, skin lesions, pus Inspection and blood. Cerumen should be moist and not obscure the tympanic membrane. There should be no foreign bodies, redness, drainage, deformities, nodules, or lesions. Pearly gray in color, distal part has Normal hair follicle, presence of small amount of waxes but no redness, nodules, lesions and discharge.

33

HEARING ACUITY TEST Clients response to normal Inspection voice tones Perform watch tick test Perform the Webers test Perform the Rinne test Inspection Inspection Inspection The patient should be able to repeat Has the ability to hear understand Normal words whispered from a distance of and repeat words that we whispered 2 feet. from the distance of 2feet The patient should be able to hear Can hear the tick of watch in both Normal the tick of the clock. ears, Sound is heard in both ears or is Heard the vibrations in both ears in a Normal localized at the center of the head. span of 10 seconds. Air-conducted hearing is greater Air conduction (Left ear: 13 seconds. Normal than bone-conducted hearing. Right Ear: 12 seconds) Bone conduction (Left: 8 seconds. Right: 7 seconds) Air conducted hearing is greater than bone-conducted hearing.

NOSE Shape, size or color and Inspection flaring or discharge from the nares. The shape of the external nose can Located in the midline of the face Normal vary greatly among individuals. It without discharge, external color is located symmetrically in the same as the skin midline of the face and without discharge. Without swelling, bleeding, lesions, No swelling, bleeding, lesions, Normal masses, growths or discharge. masses, growths or discharge.
34

Presence of redness, Inspection swelling, growths and discharge of nares, using

the flashlight. Position of the nasal septum Inspection

Nasal septum should be intact. The Intact in the midline, intact skin and Normal septum is at the midline and at the middle of two nares without perforation, lesions, or bleeding. A small amount of clear, watery discharge is normal. Each nostril is patent. Patent no signs of difficulty in Normal breathing

Test patency of both nasal septum Tenderness, masses and Palpation displacement of the bone and cartilage

There is no tenderness, masses and Not tender, no masses and the Normal the displacement of bone and displacement of bone and cartilage is cartilage is in the midline. in the midline.

SINUSES Presence of tenderness Palpation There is no evidence of swelling or No signs of swelling or tenderness tenderness around the nose and eyes. Normal

LIPS Symmetry of contour color Inspection and texture The lips and membranes should be Moist, smooth, soft elastic textures Normal pink, and moist with no evidence of and no evidence of lesions and lesions or inflammation. Lip should inflammation. not be flaccid.

BUCCAL MUCOSA Color, moisture, texture and Inspection the presence of lesions The color of the oral mucosa on the Pink in color, moist, smooth and soft Normal inside may vary according to race. and elastic texture, no lesions. Freckle-like macules may appear on the inside of the buccal mucosa.
35

The buccal mucosa should be moist, smooth, and free of infection and lesions. Some patients may have torus mandibularis, which are bony nodules in mandibular region. TEETH Inspect for color, number Inspection and condition and prescience of dentures The adult has normally 32 teeth, Our patients have a total of 28 teeth, which should be white with smooth with yellowish tooth enamel. edges, in proper alignment, without carries. Deviation from normal because the normal adult teeth are 32 it could be due to poor oral hygiene

GUMS Color and condition Inspection In light-skinned individuals, the Pale pink in color, no swelling and Normal gums have a pale red, stippled bleeding. surface. Patchy brown pigmentation may be present in dark skinned patients. The gum margins should be well defined with no pockets existing between the gums and the teeth and no swelling or bleeding.

TONGUE/FLOOR OF THE MOUTH Color and texture of the Inspection/Palpation mouth floor and frenulum. The color is pink in light-skinned Pale color, rough texture due to Normal and some brown pigmentation in presence of taste buds and prominent dark-skinned client. It is moist, veins are observed. No lesions and slightly rough, with thin white
36

coating, smooth lateral margins, no masses. lesions or masses, and with raised papillae. The frenulum has prominent blood vessels. Position, color and texture, Inspection movement and base of the tongue. The tongue is in the midline of the Tongue is in the midline of the Normal mouth and symmetrically and mouth and symmetrically and moves moves freely. The strength of the freely. With slightly rough texture tongue is strong. The texture is slightly rough.

PALATES AND UVULA Color, shape, texture and Inspection/Palpation the presence of bony prominences. The hard and soft palates are concave and pink. The hard palate has many ridges; the soft palate is smooth. No lesions or malformations are noted Hard and soft palates are concave Normal and pink. The hard palate has many ridges; the soft palate is smooth. No lesions or malformations are noted Normal

Position of the uvula and Inspection mobility.

Uvula should rise symmetrically. Uvula is in the midline of soft palate The uvula is in the midline.

OROPHARYNX AND TONSILS Color and texture Inspection The color is pink and with smooth The color is pink and with smooth Normal posterior wall. posterior wall. Normal tonsillar size is evaluated as Pinkish in color 1+ to 2+. The color should be pink discharge and free from discharge. The patients gag reflex should be present but is congenitally absent in and free from Normal

Size of tonsils, color and Inspection discharge. Gag reflex Inspection

Present and elicited by the uvula

Normal

37

some patient. NECK AND LYMPH NODES Symmetry and visible mass Inspection in the thyroid gland. Presences of tenderness or Palpation nodules in the lymph nodes Placement of the trachea Inspection/Palpation The muscles of the neck are No local enlargement and thyroid Normal symmetrically with the head in a gland is not visible. No visible central position. No visible masses. masses No enlargement, masses, or During palpation there is no No Normal tenderness should be noted on enlargement, masses, or tenderness palpation. Trachea should be in the midline of Trachea located in the midline of the Normal the neck and with symmetry. neck. No enlargement and thyroid and lymph nodes. Thyroid gland should be smooth Thyroid gland is smooth while Normal while swallowing without swallowing without enlargement, enlargement, masses or nodules. masses or nodules.

Smoothness and areas of Palpation enlargement, masses or nodules in the thyroid gland

BREAST Size and symmetry Inspection It is not unusual for there to be Round shape, unequal size, right is Normal some difference in the size of the bigger than the left breast breast and areolas areas, with the breast on the dominant arm being larger. Nipples should point upward and laterally nor the may point outward and downward.
38

Skin characteristics

Inspection palpation and Inspection palpation Inspection palpation Palpation

and Skin uniform in color, smooth

No discoloration, hyper Normal pigmentation, lighter than the skin that is exposed to the sun Normal

Nipple condition presence of discharge Areola Lesions and Masses Discharge

and Bilaterally round and dark brown Dark brown in color. No discharge in color, no presence of discharge. and Round in shape dark brown color

Rounded shape, dark brown in Normal color, symmetrical and no masses.

There should be no lesions and There is no lesions and masses, Normal masses. nodules tenderness. In the nonpregnant, nonlactating No discharge female, there should be no discharge. During pregnancy and up through the first week after birth, there may be a yellow discharge known as colostrums. During lactation there is white discharge of breast milk. Normal

Inspection/Palpation

ANTERIOR THORAX Breathing pattern Temperature, masses Inspection Rhythmic; effortless Use of accessory muscles upon breathing; has no effortless Normal

tenderness, Palpation

Temperature is equal to the body The temperature is equal to the body Normal temperature, no tenderness and temperature there is tenderness and masses. masses The measured distance diaphragmatic excursion for The measured distance for Normal is diaphragmatic excursion is normally
39

Respiratory excursion

Palpation

normally 3 to 5 cm. The level of the diaphragm on inspiration is T12 and T10 on expiration. The right side of the diaphragm is usually slightly higher than the left. Vocal fremitus Palpation

3 to 5 cm. The level of the diaphragm on inspiration is T12 and T10 on expiration. The right side of the diaphragm is usually slightly higher than the left.

Normal fremitus is felt as a buzzing Bilateral symmetry of vocal femitus. Normal on the ulnar aspect of the hands. felt a buzzing on the ulnar aspect of The fremitus will be more the hands. pronounced near the major bronchi and the trachea, and will be less in the periphery of the lung Normal lung tissue produces a Normal lung tissue produces a Normal resonant sound. The diaphragm resonant sound and the cardiac silhouette emit dull sounds. Rib sounds are flat. Hyper resonance is normal in thin adults and in patients with decreased musculature. High pitch sound with loud sound with loud intensity intensity and blowing or hollow blowing or hollow quality. quality. and Normal

Percuss the anterior thorax

Percussion

Auscultation of the trachea

Auscultation

Auscultation the anterior Auscultation thorax

Air rushing through the respiratory There is a rushing air through the Normal tract during inspiration and respiratory tract during inspiration expiration generates different and expiration breath sounds in the normal patient.

CAROTID ARTERIES
40

Pulsation of the carotid Palpation arteries Auscultation of the carotid Auscultation arteries

No pulsation can be seen, palpable No pulsation pulsation. pulsation.

seen,

palpable Normal

Pulsation can be heard through the Pulsation heard through the Normal diaphragm. No bruits should be diaphragm. No bruits auscultated. auscultated.

JUGULAR VEINS Visibility of jugular veins Inspection Normally, any pressure should not Normally, any pressure not elicit any Normal elicit any change in jugular vein change in jugular vein and not and not visible. visible.

ABDOMEN Skin integrity Inspection Skin should be intact Skin is itact Normal

Abdominal contour Enlarge liver or spleen Abdominal movements Vascular pattern

Inspection Palpation Inspection Auscultation

In the normal adult, the abdominal Flat contour is flat or rounded.

Normal

No enlarge liver or spleen is No enlargement of liver or spleen Normal palpable. and it is palpable No abdominal movements can be There are no abdominal movements Normal seen. that can be seen. No audible bruits are auscultated. There is no audible bruits are Normal auscultated

Bowel sounds, vascular Auscultation sounds, and peritoneal

Bowel sounds are heard as Bowel movements are heard during Normal intermittent gurgling sounds
41

friction rubs.

throughout the abdominal auscultation quadrants. Vascular sounds no bruit should be heard. No friction rubs should be present. abdominal Percussion Kidney and liver no tenderness No tenderness should be elicited. A urine-filled bladder is dull to percuss. The abdomen should fell smooth Smooth and soft with consistent softness. Normal

Percuss quadrants

Light palpation abdominal quadrants.

of Palpation

Normal

MUSCULOSKELETAL SYSTEM Muscle size, compare the Inspection muscle on one side of the body (arm, thigh, calf) to the same muscle on the other side. Contractures (shortening) Inspection of the muscles and tendons. Muscle fasciculation and Inspection tremors. Presence of tremors of the hand and arms when stretched in front of the body Palpation Muscle tonicity Muscle strength Inspection Muscle contour will be affected by Equal size on both sides of the body. the exercise and activity patterns of the individual. Muscle shape may be accentuated in certain body areas but should be symmetrically. Normal

Muscles and tendons should not There is no muscles and tendons Normal have contractures. contractures There is tremors. no fasciculation and No fasciculation and tremors Normal

Normally it is firm.

Normally firm.

Deviation from normal due to aging

Muscle strength is equal on both The clients leg is weaker than his Deviation from normal sides right leg due to incision and
42

drainage BONES Normal structure Inspection Muscle should structures and noted. be in normal There is a presence of deformities on Deviation from normal no deformities left leg. due to surgery.

JOINTS Swelling Inspection No visible swelling of joints. No swelling of joints Normal

Presence of tenderness, Palpation smoothness of movement, swelling, crepitation, and presence of nodule. RANGE OF MOTION 1. Upper extremities. 2. Lower extremities. Inspection Inspection

No tenderness, swelling, crepitation No tenderness, swelling, crepitating Normal or nodules. Joints move smoothly. or nodules

Perform different range of motion Perform different ROM smoothly smoothly

Normal

Perform different range of motion The client felt discomfort when Deviation from normal smoothly performing Range of Motion because of the incision especially on his left leg because of site post operatively the incision site post operatively

SUMMARY The client cant stand erect and can sit properly due to pain caused by open wounds on left leg. The client is unkempt due to poor hygiene. The client has slight breath odor due to improper hygiene. 43

There is a sign of illness due to sign of post surgery. There is a presence of skin lesion on left leg due to surgery and having a total of 14 stitches on the surgical area (with approximately 18 centimeters and 4 centimeters.) There are flaking (dandruff) due to improper hygiene. The hair is shiny and excessively oily due to improper hygiene. The client cant read without the eye glasses due to poor eye sight (aging process). The client has a total of 28 teeth, with yellowish tooth enamel due to poor oral hygiene. The client left leg is weaker than his right leg due to incision and drainage. With deformities on left leg due to surgical incision. The client felt discomfort when performing Range of Motion especially on his left leg because of the incision site post operatively.

DIAGNOSTIC PROCEDURE/LABORATORY LABORATORY PROCEDURE DATE ORDERED DATE RESULT INDICATION OR PURPOSE RESULT NORMAL VALUES ANALYSIS AND INTERPRETATION OF THE RESULT NURSING RESPONSIBILITIES

44

COMPLETE Ordered: BLOOD COUNT Feb 11, 2012 (CBC) Result: Feb 11, 2012

The CBC test is used as a broad screening test to check for patients blood components and disorders specifically for anemia and bacterial infection as a result of decreased rate of hemoglobin and hematcrit while increased rate of lymphocytes in the blood.

Components Actual Values Hgb 117g/L Hct 0.35 WBC Count 8.3 x 10 g/L Neutrophils 0.55 Lymphocytes 0.45 Plt Count 337x 10/l

125 - 175 g/L 0.40 - 0.52 5 - 10 10g/L 0.45 - 0.65 0.20 - 0.35 150 - 400 x 10/l

All components are normal except for the value of : Hemoglobin which is LOW from the normal value. Indicators: Blood loss Hematocrit which is LOW from the normal value. Indicators: Insuficient body fluids. Body electrolytes imbalance. Sodium retention. Lymphocytes which is HIGH from the normal value. Indicators: Physical stress.

PRIOR: Verify Physicians order. Determine patients understanding for the procedure. Take a complete set of vital signs for base line. DURING: Wait for the result of the examination. AFTER: Document the method of testing and results on the patients record. (If procedure is being performed.) Immediately reached the blood sample on the laboratory. (If needed) Compare the previous and current test results and modifies nursing interventions as needed. Attach the result on the patients chart.

Ordered: Feb 5, 2012

All components are

45

Result: Feb 5, 2012 Components Hgb Hct WBC Count Neutrophils Lymphocytes Plt Count Actual Values 116 g/L 0.35 10.76 x 10 g/L 0.69 0.31 366x 10/l

125 - 175 g/L 0.40 - 0.52 5 - 10 10g/L 0.45 - 0.65 0.20 - 0.35 150 - 400 x 10/l

normal except for the value of : Hematocrit which is LOW from the normal value. Indicators: Insuficient body fluids. Body electrolytes imbalance. Sodium retention. Neutrophils which is HIGH from the normal value. Indicators: Physical stress.

Ordered: Jan 31, 2012 Result:

All components are normal except for the value of :

46

Jan 31, 2012 Components Hgb Hct WBC Count Neutrophils0

x 10 g/L

Actual Values 121g/L 0.36 18 0.59

125 - 175 g/L 0.40 - 0.52 5 - 10 10g/L 0.45 - 0.65 0.20 - 0.35

Hemoglobin which is LOW from the normal value. Indicators: Blood loss Hematocrit which is LOW from the normal value. Indicators: Insuficient body fluids. Body electrolytes imbalance. Sodium retention

Lymphocytes Components Ceticulocytes Count

0.41 Actual Findings Automated

Ordered: Jan 30, 2012 Result:

All components are normal except for the value of :

47

Jan 30, 2012

Hematocrit which is LOW from the normal value. Indicators: Insuficient body fluids. Body electrolytes imbalance. Sodium retention. Lymphocytes which is HIGH from the normal value. Indicators: Physical stress.

LABORATORY PROCEDURE

DATE ORDERED AND DATE RESULT

INDICATION OR PURPOSE

RESULT

NORMAL VALUES

ANALYSIS AND INTERPRETATION OF THE RESULT

NURSING RESPONSIBILITIES

48

BLOOD CHEMISTRY

Ordered: Feb 11, 2012 Result: Feb 11, 2012

Blood Chemistry test performed on a single sample of patients blood to measures the value of different substances like sodium,potas sium, chloride, calcium along with levels of proteins and lipids in the blood. Blood component values provide information on the functions of different organ systems and the risk for certain diseases.

Components RBS BUN Creatinine

Actual Values 5.31 mmol/L 4.3mmol/L 85.2 umol/L

3.85 - 9.0 mmol/L 1.7 - 8.3 mmol/L 60 - 120 umol/L

All components are normal except for the value of: Sodium which is HIGH from the normal value.

PRIOR: Verify Physicians order. Determine patients understanding for the procedure. Take a complete set of vital signs for base line.

ELECTROLYTES Components Actual Values Sodium 146.1 mmol/L Potassium 3.78mmol/L + Ionized Ca 1.23mmol/L

135 - 145 mmol/L 3.5 - 5.5 mmol/L 1.1 - 1.4mmol/L

Indicators: Insuficient body DURING: fluids. Body electrolytes Wait for the result of the imbalance. examination. Sodium retention. AFTER:

Ordered: Feb 5, 2012

Document the method of testing and results on the patients record. (If procedure is being performed.) Immediately reached the blood sample on the laboratory. (If needed) Compare the previous and current test results and modifies nursing interventions as needed. Attach the result on the patients chart. All components are normal.
49

Result: Feb 5, 2012

Components RBS BUN Creatinine

Actual Values 5.75 mmol/L 2.6mmol/L 88.0 umol/L

3.85 - 9.0 mmol/L 1.7 - 8.3 mmol/L 60 - 120 umol/L

(No indicative abnormalities noted.)

ELECTROLYTES Components Actual Values Sodium 146.1 mmol/L Potassium 3.54mmol/L Ionized Ca+ 1.19mmol/L

135 - 145 mmol/L 3.5 - 5.5 mmol/L 1.1 - 1.4mmol/L

Ordered: Feb. 03, 2012 Result: Feb. 03, 2012

Components ESR Reticulocyte Count CRP

Actual Values 37 mm/hr Manual Positive 0 - 10 mm/hr

All components are normal except for the value of: ESR which is HIGH from the normal value. Indicators: Chronic inflammatory disease. Bacterial infection CRP which has POSITIVE finding.
50

Upto 1:4 dilution = 24mg

Indicators: Chronic inflammatory disease Bacterial infection. Ordered: Jan 30, 2012 Result: Jan 30, 2012 Components RBS BUN Creatinine Actual Values 5.37 mmol/L 3.6mmol/L 96.8 umol/L 3.85 - 9.0 mmol/L 1.7 - 8.3 mmol/L 60 - 120 umol/L

All components are normal except for the value of: Sodium which is HIGH from the normal value. Indicators: Insuficient body fluids. Electrolytes imbalance. Soduim Retention

51

52

LABORATORY PROCEDURE X-RAY

DATE ORDERED AND DATE RESULT Ordered: Feb 02, 2012 Result: Feb 02, 2012

INDICATION OR PURPOSE
Use an electromagnetic radiation that differentially penetrates to the body and skin for internal visualization of the structure to monitor and evaluate the condition of the damage part on a fluorescent screen.

ANALYSIS AND INTERPRETATION OF THE RESULT

NURSING RESPONSIBILITIES

PRIOR: Verify Phisicians order. Determine patients understanding for the procedure. Explain the purpose of the procedure. (A clear explanation will facilitate cooperation on the part of the patient). DURING: T/C bone involment. Ensure patients comfort until the procedure is done. Secure result. AFTER:

Abscess, dard leg left with chronic osteomyelitis D3rd fibia left.

Ordered: Jan 30, 2012 Result: Jan 30, 2012

Ordered: Jan 28, 2012 Result: Jan 28, 2012 No evidence of fracture or dislocation calcaneal spur is noted.

Attach the patients chart.

result

on

the

53

LABORATORY PROCEDURE CULTURE AND SENSITIVITY

DATE ORDERED AND DATE RESULT Ordered: Feb 22, 2012 Result: Feb 22, 2012

INDICATION OR PURPOSE

ANALYSIS AND INTERPRETATION OF THE RESULT Result: Ligth Growth of StaphycoccusAucus. S - Sensitive M - Moderately Sensitive R - reactive Cefoxitin Chloramphenicol Clindamycin Cotrimoxazole Erythromycin Gentamicin Oxacillin Penicillin Rifampin Tetracycline Vancomycin Piper/azobactam S S S S S S S R S S S S

NURSING RESPONSIBILITIES

PRIOR: Verify Phisicians order. Determine patients understanding for the procedure. o Explain the purpose of the procedure. (A clear explanation will facilitate cooperation on the part of the patient). DURING: Ensure patients comfort until the procedure is done. Secure result. AFTER: Attach the patients chart. result on the

V. THE PATIENTS AND HIS CARE 54

A. MEDICAL MANAGEMENT a. Intravenous Therapy, Oxygen therapy, Penrose Drain Medical Management Date Ordered, Date General Description Performed, Date Discontinued Intravenous fluid (IVF) PLRs 1L (Plain Lactated Ringer's Solution) (regulated at 3031gtts/min) Date Ordered: January 30, 2010 Time of infusion: 3:45 pm Dislodged: February 9, 2012 Reinserted: February 12, 2012 Date discontinued: February 17, 2012

Indication/purpose

Clients Response

Nursing responsibilities (prior, during, after) Prior >Review the physician's order. >Know the type, amount, and rate of flow of IV therapy. >Prepare all the materials needed >Check the sterility and integrity of the IV solution and IV set. >Observe 10 R's when preparing and administering IVF. >Place IV label on IVF bottle >Identify the patient and explain procedure. >Wash hands. >Remove air bubbles if any and then administer the IVF During >Regulate IV appropriately according to the doctor's order. > Instruct patient and significant others to inform the nurse on duty if bulging of the site is visible, if there is back flow of blood or if IVF is accidentally dislodged. >Monitor the level of the IVF. >Monitor vital signs >Monitor fluid intake and output >Observe for potential complications. After >Evaluate for right solution, right rate and if IV secure >Document the IV insertion on appropriate chart 55

Lactated Ringer's solution is a solution that is isotonic with blood and intended for intravenous administration. Plain Lactated Ringers Solution, a sterile aqueous solution that is similar to Ringer's solution but contains sodium lactate in addition to calcium chloride, sodium chloride, and potassium chloride called also Hartmann's solution lactated Ringer's solution

Indicated for fluid resuscitation after a blood loss due to

The patient was hydrated.

surgery

PNSS 1L (Plain NSS) (regulated at 3031gtts/min)

>Date Performed: February 10, 2012 Discontinued: February 11, 2012 >Performed: February 17, 2012 Date discontinued: February 23, 2012

Normal Saline is a sterile, isotonic and nonpyrogenic solution for fluid and electrolyte replenishment.

Saline is also used in I.V. therapy, intravenously supplying extra water to a dehydrated patient or supplying the daily water

The patient was hydrated.

form. For the removing >Monitor vital signs >Check order >Turn off IV flow >Remove tape and dressing; remove cannula by pulling straight out >Put pressure on site; elevate patient's arm for 1 min >Remove all equipment >Wash hands >Evaluate if bleeding is controlled >Document that IV was discontinued. Prior >Review the physician's order. >Know the type, amount, and rate of flow of IV therapy. >Prepare all the materials needed >Check the sterility and integrity of the IV solution and IV set. >Observe 10 R's when preparing and administering IVF. >Place IV label on IVF bottle >Identify the patient and explain procedure. >Wash hands. >Remove air bubbles if any and then administer the IVF During >Regulate IV appropriately according to the doctor's order. > Instruct patient and significant others to inform the nurse on duty if bulging of the site is visible, if there is back flow of blood or if IVF is accidentally dislodged. >Monitor the level of the IVF. >Monitor vital signs >Monitor fluid intake and output 56

D5LRs 1L (Dextrose 5% in Lactated Ringers Solution) (regulated at 3031gtts/min)

Date Ordered: February 11, 2012 Date discontinued: February 12, 2012

D5LR- Dextrose 5% in Lactated Ringers Solution is a sterile, hypertonic, and nonpyrogenic solution for fluid and electrolyte replenishment and caloric supply in a single dose container for intravenous administration.

Indicated for replenishment of the fluid and for electrolyte imbalance.

Electrolytes imbalance was corrected.

>Observe for potential complications. After >Evaluate for right solution, right rate and if IV secure >Document the IV insertion on appropriate chart form. For the removing >Monitor vital signs >Check order >Turn off IV flow >Remove tape and dressing; remove cannula by pulling straight out >Put pressure on site; elevate patient's arm for 1 min >Remove all equipment >Wash hands >Evaluate if bleeding is controlled >Document that IV was discontinued. Prior >Review the physician's order. >Know the type, amount, and rate of flow of IV therapy. >Prepare all the materials needed >Check the sterility and integrity of the IV solution and IV set. >Observe 10 R's when preparing and administering IVF. >Place IV label on IVF bottle >Identify the patient and explain procedure. >Wash hands. >Remove air bubbles if any and then administer the IVF During >Regulate IV appropriately according to the doctor's order. > Instruct patient and significant others to inform the nurse on duty if bulging of the site is visible, if 57

there is back flow of blood or if IVF is accidentally dislodged. >Monitor the level of the IVF. >Monitor vital signs >Monitor fluid intake and output >Observe for potential complications. After >Evaluate for right solution, right rate and if IV secure >Document the IV insertion on appropriate chart form. For the removing >Monitor vital signs >Check order >Turn off IV flow >Remove tape and dressing; remove cannula by pulling straight out >Put pressure on site; elevate patient's arm for 1 min >Remove all equipment >Wash hands >Evaluate if bleeding is controlled >Document that IV was discontinued.

Oxygen inhalation via face mask

Date Performed: January 31, 2012 Date discontinued: February 1, 2012

Oxygen therapy is the administration of oxygen as a medical intervention, which can be for a variety of purposes in both chronic and acute patient care. Face mask that covers the client's nose and mouth may be

To provide moderate oxygen support and a higher concentration of oxygen and/or humidity than is provided by cannula.

-Patient demonstrates adequate oxygenation

Prior: >Check the doctor's order >Note method of delivery, flow rate and duration of oxygen therapy. >Prepare all the materials needed >Identify the client and explain procedure. >Assist the patient to a semi-Fowler's position if possible for easier chest expansion >Place "oxygen in use" and "no smoking" signs at entrance to client's room and overhead of bed. 58

used for oxygen inhalation. The simple face mask (lowflow system) delivers oxygen concentration from 40% to 60% at liter flows of 5 to 8 liters per minute respectively.

Oxygen inhalation via nasal cannula @ 3 Lpm Oxygen inhalation via nasal cannula @ 2 Lpm

Date Performed: February 17, 2012

Nasal cannula is the most common inexpensive low-flow device used to administer oxygen. It delivers a relatively low concentration of oxygen (2445%) at flow rates of 2 to 6 liters per minute

To deliver a relatively low concentration of oxygen when only minimal oxygen support is required.

The patient's difficulty in breathing was relieved.

Changed: February 17, 2012 ( Date discontinued: February 7, 2012

>Wash hands During: >Set up the oxygen equipment and humidifier. >Turn on the oxygen at the prescribed rate, and ensure proper functioning. >Fit the mask to the contours of the client's face. >Monitor vital signs. >Monitor humidify source every 4 hours. >Observe for pressure necrosis >Checks physician's order for changing oxygen concentration or flow rates After: >Evaluate for the response to administration of oxygen therapy >Evaluate if safety precautions are being followed. >Document for oxygen therapy, respiratory assessment findings, method of oxygen delivery, flow rate, patient's response. Prior: >Check the doctor's order >Note method of delivery, flow rate and duration of oxygen therapy. >Prepare all the materials needed >Identify the patient and explain procedure. >Assist the client to a semi-Fowler's position if possible for easier chest expansion >Place "oxygen in use" and "no smoking" signs at entrance to client's room and overhead of bed. >Wash hands During: >Set up the oxygen equipment and humidifier. >Turn on the oxygen at the prescribed rate, and ensure proper functioning. >Place tips of nasal cannula into patient's nares. >Monitor vital signs. >Monitor cannula every 8 hours. 59

Penrose drain

Date performed: February 17, 2012 Date discontinued: February 24, 2012

Penrose drain have open end that drains onto a dressing. It is a flexible rubber drain.

To facilitate drainage and healing of tissues from the inside to the outside.

The abscess or drainage was eliminated.

>Assess patient's nares and external nose for skin breakdown every 6-8 hours. >Checks physician's order for changing oxygen concentration or flow rates. After: >Evaluate for the response to administration of oxygen therapy >Evaluate if safety precautions are being followed. >Document for oxygen therapy, respiratory assessment findings, method of oxygen delivery, flow rate, patient's response. Prior: >Review the physician's order. >Identify the patient and explain the procedure >Identify presence, location of the drain. >Assess the drain placement accurately > Perform hand hygiene and apply gloves During: >Be sure Penrose drain has a sterile safety pin in place. >Use caution to prevent accidental removal of the drain during dressing changes. After: >Evaluate the appearance of drain insertion site, amount and characteristic of the drainage. >Document the appearance of drain insertion site, amount and characteristic of the drainage.

60

GENERIC NAME

DATE ORDERED/ CHANGED/ DISCONTINUED (ORDERED) January 30, 2012 (DISCONTINUED) February 18, 2012

ROUTE, DOSAGE, FREQUENCY

CLASSIFICATION/ MECHANISM OF ACTION Anti-ulcer agents, Histamine H2 antagonist Healing and prevention of ulcers. Decreased secretion of gastric acid. Antibacterial action against H.Pylori

INDICATION/ PURPOSES

CLIENTS RESPONSE

NURSING RESPONSIBILITY

Ranitidine

50mg / IV q8

Management of GI symptoms.
preoperatively to supress gastric acid secretion

-The patient could not verbalized and distinguish the possible side effect of drug and the manifestations to her condition.

PRIOR: 1. Verify the doctors order. 2. Apply the 10 rights of giving medication. 3. Assess for allergy to the drug. 4. Assess patients pain. 5. Assess for epigastric and abdominal pain and frank or occult blood in the stool, emesis or gastric aspirate. DURING: 1. Apply the 10 rights of giving medication. 2. Check for the IV site. 3. After cleaning the IV port, slowly inject the drug. 4. Administer with meals or
61

immediately afterwards or at bedtime to prolong effect. AFTER: 1. Apply the 10 rights of giving medication. 2. Observe the patient closely for adverse reactions or allergic reaction. 3. Instruct patient to take medication as directed for the full course of therapy, even if feeling better. 4. Notify health care professionals if difficulty swallowing occurs or abdominal pain persists or if vomiting blood or bloody or tarry stools occur. 5. Document the procedure.

GENERIC

DATE

ROUTE,

CLASSIFICATION/

INDICATION/

CLIENTS

NURSING
62

NAME

ORDERED/ CHANGED/ DISCONTINUED (ORDERED) January 30, 2012 (DISCONTINUED) February 24, 2012

DOSAGE, FREQUENCY

MECHANISM OF ACTION Anti-Infectives, Second-generation cephalosporins. Bactericidal action. Antibiotic used to treat a wide variety of bacterial infections. It may also be used before and during certain surgeries to help prevent infections. This medication is known as a cephalosporin antibiotic. It works by stopping the growth of bacteria.

PURPOSES

RESPONSE

RESPONSIBILITY

Cefuroxime

750mg / IV q8

Bone and Joint Infection

Client did not showed signs of adverse effect

PRIOR: 1. Verify the doctors order. 2. Apply the 10 rights of giving medication. 3. Assess for allergy to the drug. 4. Note reasons for therapy. Monitor CBC closely. 5. Warn patient to avoid hazardous activity that requires alertness. DURING: 1. Apply the 10 rights of giving medication. 2. Check for the IV site. 3. After cleaning the IV port, slowly inject the drug. AFTER: 1. Apply the 10 rights of giving medication.
63

2. Observe the patient closely for adverse reactions or allergic reactions. 3. Document the procedure.

GENERIC NAME

DATE ORDERED/ CHANGED/ DISCONTINUED (ORDERED) January 30, 2012 (DISCONTINUED) February 24, 2012 (SHIFTED) February 25, 2012

ROUTE, DOSAGE, FREQUENCY

CLASSIFICATION/ MECHANISM OF ACTION Anti-Infectives

INDICATION/ PURPOSES

CLIENTS RESPONSE

NURSING RESPONSIBILITY

Clindamycin

600mg / IV q8 Inhibits protein synthesis in susceptible bacteria. 300mg / cap q6 x 7 days Bactericidal or bacteriostatic, depending on susceptibility and concentration.

Treatment of skin and skin structure infections. Osteomyelitis

Client did not showed signs of adverse effect

PRIOR: 1. Verify the doctors order. 2. Apply the 10 right of giving medication. 3. Note reasons for therapy. 4. Assess for infection (vital signs, appearance of wound, sputum, urine and stool ; WBC) at beginning of and during therapy. 5. Obtain culture and sensitivity tests.

64

6. Assess patient for signs of hypersensitivity (skin rash, urticaria). DURING: 1. Apply the 10 right of giving medication. 2. Advise patient to take capsule form with a full glass of water to prevent esophageal irritation. AFTER: 1. Apply the 10 rights of giving medication. 2. Observe the patient closely for adverse reactions or allergic reactions and anaphylaxis. 3. Document the procedure.

GENERIC NAME

DATE ORDERED/ CHANGED/ DISCONTINUED

ROUTE, DOSAGE, FREQUENCY

CLASSIFICATION/ MECHANISM OF ACTION

INDICATION/ PURPOSES

CLIENTS RESPONSE

NURSING RESPONSIBILITY

65

Paracetamol

(ORDERED) January 30, 2012

300g / IV q8 if temp is > 37.8

Anti-pyretic, Nonopioid analgesic. Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS. Analgesia. Antipyresis.

Mild pain Fever

The patients temperature went down within normal range.

PRIOR: 1. Verify the doctors order. 2. Apply the 10 right of giving medication. 3. Assess for allergy to the drug. 4. Note reasons for therapy. 5. Assess overall health status and alcohol usage before administering acetaminophen. Patients who are malnourished or chronically abuse alcohol are at higher risk of developing hepatotoxicity with chronic use of usual doses of drug. 6. Pain: assess type, location and intensity prior to and 30-60 min following administration. 7. Fever: assess fever, note presence of associated signs (diaphoresis, tachycardia and malaise).

66

DURING: 1. Apply the 10 right of giving medication. AFTER: 1. Assess patients temperature before and during therapy. 2. Document the procedure. GENERIC NAME DATE ORDERED/ CHANGED/ DISCONTINUED (ORDERED) January 30, 2012 (CHANGED DOSAGE) January 31, 2012 (DISCONTINUED) February 13, 2012 ROUTE, DOSAGE, FREQUENCY CLASSIFICATION/ MECHANISM OF ACTION Analgesic (Centrallyacting) Binds to mu-opioid receptors. Inhibits reuptake of serotonin and norepinephrine in the CNS. Decreased pain. INDICATION/ PURPOSES CLIENTS RESPONSE NURSING RESPONSIBILITY

Tramadol

150mg / IV q8 30mg / IV q8 50mg / SIVP q8

Moderate to moderately severe pain.

Patient showed a relief of pain.

PRIOR: 1. Verify the doctors order. 2. Apply the 10 right of giving medication. 3. Assess for allergy to the drug. 4. Monitor for cardiovascular and respiratory status<with old if respiratory rate is below 12cpm>.

67

5. Assess patients pain before starting therapy, and regularly thereafter to monitor the drugs effectiveness. DURING: 1. Apply the 10 right of giving medication. 2. Check for the IV site. 3. After cleaning the IV port, slowly inject the drug. AFTER: 1. Apply the 10 rights of giving medication. 2. Anticipate for need for laxative (constipation is the primary side effect) 3. Observe the patient closely for adverse reactions or allergic reactions. 4. Document the procedure.

68

GENERIC NAME

DATE ORDERED/ CHANGED/ DISCONTINUED (ORDERED) January 31, 2012 (ORDERED) February 13, 2012

ROUTE, DOSAGE, FREQUENCY

CLASSIFICATION/ MECHANISM OF ACTION Antiemetics, Antihistamines, Phenothiazine. Relief of symptoms of histamine excess usually seen in allergic conditions. Diminished nausea and vomiting.

INDICATION/ PURPOSES

CLIENTS RESPONSE

NURSING RESPONSIBILITY

Promethazine

50mg / IM On call to OR 25mg / IM On call to OR

Treatment and prevention of nausea and vomiting.

The patient could not verbalized and distinguish the possible side effect of drug and the manifestations to his condition.

PRIOR: 1. Verify the doctors order. 2. Apply the 10 right of giving medication. 3. Note reasons for therapy. 4. Monitor blood pressure, pulse and respiratory rate frequently. 5. Assess patient for level of sedation after administration. Risk for sedation and respiratory depression are increased when administered concurrently with other drugs that causes CNS depression. 6. Assess allergy symptoms. 7. Assess patient for nausea and vomiting before and after administration.

69

DURING: 1. Apply the 10 right of giving medication. 2. Increase oral fluid intake. AFTER: 1. Apply the 10 rights of giving medication 2. Observe the patient closely for adverse reactions or allergic reactions and anaphylaxis. 3. Document the procedure.

70

GENERIC NAME

DATE ORDERED/ CHANGED/ DISCONTINUED (ORDERED) February 20,2012

ROUTE, DOSAGE, FREQUENCY

CLASSIFICATION/ MECHANISM OF ACTION Non-Steroidal, Antiinflammatory drug, COX-2 inhibitor. Relieves pain and inflammation of joints and smooth muscle tissue.

INDICATION/ PURPOSES

CLIENTS RESPONSE

NURSING RESPONSIBILITY

Celecoxib

200mg 1 cap BID

Acute pain

Patient showed a relief of pain.

PRIOR: 1. Verify the doctors order. 2. Apply the 10 rights of giving medication. 3. Assess for allergy to the drug or with history of anaphylactic reactions to sulfonamides, aspiring and other NSAIDs maybe allergic to this drug. 4. Assess for liver/ renal dysfunction. Monitor blood pressure. DURING: 1. Apply the 10 right of giving medication. 2. Check for the IV site. 3. After cleaning the IV port, slowly inject the drug. AFTER: 1. Apply the 10 rights of giving medication 2. Observe the patient closely for adverse reactions or allergic 71 reactions. 3. Document the procedure.

GENERIC NAME

DATE ORDERED/ CHANGED/ DISCONTINUED (ORDERED) February 17, 2012

ROUTE, DOSAGE, FREQUENCY

CLASSIFICATION/ MECHANISM OF ACTION

INDICATION/ PURPOSES

CLIENTS RESPONSE

NURSING RESPONSIBILITY

Ketorolac

30mg / IV q6 4 doses

Non-steroidal, Antiinflammatory drug Possess antiinflammatory, analgesic and antipyretic effects Relieves pain and inflammation.

Management of moderately severe acute pain that requires analgesia and the opioid level, usually in a postoperative setting.

Patient showed a relief of pain.

PRIOR: 1. Verify the doctors order. 2. Apply the 10 right of giving medication. 3. Monitor VS especially heart rate and blood pressure. 4. Assess pain (note type, location, and intensity) prior to and 1-2 hour following administration. DURING: 1. Apply the 10 right of giving medication. 2. Check for the IV site. 3. After cleaning the IV port, slowly inject the drug AFTER: 1. Apply the 10 rights of
72

giving medication. 2. Observe the patient closely for adverse reactions or allergic reactions and anaphylaxis. 3. Document the procedure. GENERIC NAME DATE ORDERED/ CHANGED/ DISCONTINUED January 31, 2012 February 17 2012 ROUTE, DOSAGE, FREQUENCY 5mg/ml IM OR CLASSIFICATION/ MECHANISM OF ACTION INDICATION/ PURPOSES CLIENTS RESPONSE NURSING RESPONSIBILITY PRIOR: 1. Verify the doctors order 2. Apply the 10 right of giving medication 3. Monitor VS especially heart rate and blood pressure. DURING: 1. Apply the 10 right of giving medication. AFTER: 1. Apply the 10 rights of giving medication 2. Observe the patient closely for adverse reactions or allergic
73

Diazepam

Antianxiety agents, Anticonvulsants, Sedative, Skeletal Muscle Relaxants Sedation. Skeletal muscle relaxation.

Pre-operative sedation, conscious sedation. Provides light anesthesia.

Client did not showed signs of adverse effect

reactions and anaphylaxis. 3. Document the procedure. GENERIC NAME DATE ORDERED/ CHANGED/ DISCONTINUED January 31, 2012 February 17 2012 ROUTE, DOSAGE, FREQUENCY 2mg/ml IM OR CLASSIFICATION/ MECHANISM OF ACTION Opioid Analgesics. Binds to opiate receptors in the CNS. Alters perception of and response to painful stimuli while producing generalized CNS depression. Decreased pain. INDICATION/ PURPOSES CLIENTS RESPONSE NURSING RESPONSIBILITY PRIOR: 1. Verify the doctors order 2. Apply the 10 right of giving medication. 3. Monitor VS especially heart rate and blood pressure. 4. Assess pain (note type, location, and intensity) prior to and 1-2 hour following administration. 5. Assess previous analgesic history. DURING: 1. Apply the 10 right of giving medication. AFTER: 1. Apply the 10 rights of giving medication 2. Observe the patient closely for diverse reactions or allergic
74

Nubaine

Moderate severe pain. Sedation before surgery, supplement to balanced anesthesia.

Client did not showed signs of adverse effect

reactions and anaphylaxis. 3. Document the procedure.

c. Diet TYPE OF DATE DIET ORDERED,DATE CHANGED,DATE DISCONTINUED Date ordered: NPO January 30, 2012 Time ordered: GENERAL DESCRIPTION INDICATION/ PURPOSES CLIENT RESPONSE NURSING RESPONSIBILITIES

NPO nothing per orem means nothing to eat or drink may be ordered in some cases, such as before surgery to present aspiration related to anesthesia,

A pre- operative patient must be NPO before surgery to prevent risk of aspiration during induction of anesthesia

According to our client PRIOR it is ok for him not to eat. Because he already know what to expect before and after the

Checks for the doctors order Check the patients identity Monitor the client and assess 75

3:00pm

and after surgery until bowel sounds return.

surgery because he already had a 2 surgery from the past.

Date Discontinued: January 31, 2012 ( post midnight) DURING

for signs of weakness. Explain to the patient the purpose of the dietary recommendation to his current condition.

If he wants to eat tell to the patient to avoid watching others. Date ordered: February 16, 2012 Time ordered: (Post midnight) After: Assess the health status of the patient. Compare previous health status from the present. Document all necessary information

Diet as Tolerated

Date ordered: January 31, 2012 Time ordered: (midnight) Date Discontinued: February 16, 2012 (midnight)

Ability to eat and tolerance for certain foods. .

The patient can now eat foods that he can tolerate but he need to control the amount of fat that he consume. Making sure the fats that he consume are not more than 30% of the total calories that he consume. Consuming a low fat diet and avoiding saturated fats, processed oils, refined flours, fried foods, processed foods,

The patient understands Prior: the purpose of this diet. Verify the physicians order According to him he is Explain the type of diet prescribed happy because he can to the patient now eat food. During: After: Assess for patients condition Ensure that the patient strictly follow the diet

76

Date ordered: February 18, 2012 Time ordered: (midnight) Date Discontinued: February 19, 2012 until discharge

etc.

77

INDICATION/PURPOSE TYPE OF EXERCISE DATE ORDERED / DATE STARTED / DATE DISCONTINUED GENEREL DESCRIPTION

CLIENT RESPONSE NURSING RESPONSIBILITIES

Active ROM Exercises

February 15, 2012

Active ROM is measured while you move your joint through the range under your own power. This measurement helps identify weakness or injury within the muscular system. it is more indicative of your functional limitations.

Active ROM exercises help build up or keep your muscles as strong as possible. They help keep your joints flexible (bending and moving in the right way). Doing ROM exercises will help keep good blood flow going to the joint area that is being exercised. They may help prevent blood clots. Increasing blood flow brings more oxygen and other good things to your body tissues and organs. Exercising is natural and needed for the body to stay well.

Client responded Prior: to regimen with positivism and Review and verify physicians affirmation. order. Explain to the patient the purpose of the procedure and No cramping and reassure them by answering any pain noted before, questions they may have. during and after the regimen. During:
Practice

the exercises together with your patient. Make sure your patient is doing the exercises right. Show them the easiest way to do the exercises so your client dont get hurt. Instruct and inform the patient to: Never force, jerk, or overstretch a muscle. This can hurt the muscle or joint instead of helping. o Move the joint only to the point of resistance. This is the point where you cannot bend the joint any further. Put slow, steady pressure on the joint until the muscle relaxes. o The exercises should never 78 cause pain or go beyond the normal movement of that joint. If pain does not go
o

SURGICAL MANAGEMENT January 31, 2012 (5 am- 5:20 am) (E Incision and Drainage, Curettage) Incision and Drainage An abscess incision and drainage is a procedure to cut open the skin and drain pus from the abscess. An abscess is a collection of pus in a warm, red, tender, and swollen lesion (wound). It is most commonly caused by bacteria (germs). An abscess may occur anywhere in or on the body, including the skin. An abscess that needs incision and drainage is usually located deep in soft tissues, such as the thigh. During an abscess incision and drainage, pus that is collected from the abscess may be sent to a lab for tests. A culture or examination of the pus may help your caregiver know what kind of bacteria is causing the infection. A culture will also help your caregiver know what medicines to give you to kill the bacteria. Risks

79

Having an incision and drainage may be very painful and put you at risk of bleeding. Other areas close to the infected area may be affected and problems, such as a bone infection, may occur. You may have problems with blood supply to the area that may lead to tissue death. A scar may form on your skin as it heals. Sometimes, the infection may come back and the abscess may form again after being treated successfully. If left untreated, the infection may get worse and the abscess may grow larger. The infection may also spread to other parts or organs of the body. Talk with your caregiver if you are worried or have questions about your procedure, medicine, or care. Before the procedure:
Informed consent: A consent form is a legal document that explains the tests, treatments, or procedures that you may need. Informed consent

means you understand what will be done and can make decisions about what you want. You give your permission when you sign the consent form. You can have someone sign this form for you if you are not able to sign it. You have the right to understand your medical care in words you know. Before you sign the consent form, understand the risks and benefits of what will be done. Make sure all your questions are answered.
IV: An IV (intravenous) is a small tube placed in your vein that is used to give you medicine or liquids. Pre-op care: You may be given medicine right before your procedure or surgery. This medicine may make you feel relaxed and sleepy. You are taken

on a stretcher to the room where your procedure or surgery will be done, and then you are moved to a table or bed.
Monitoring: Careful monitoring may be needed depending on the anesthesia that will be used. You may have any of the following:

o o

Heart monitor: This is also called an ECG or EKG. Sticky pads placed on your skin record your heart's electrical activity. Pulse oximeter: A pulse oximeter is a device that measures the amount of oxygen in your blood. A cord with a clip or sticky strip is

placed on your finger, ear, or toe. The other end of the cord is hooked to a machine. Never turn the pulse oximeter or alarm off. An alarm will sound if your oxygen level is low or cannot be read. o Vital signs: Caregivers will check your blood pressure, heart rate, breathing rate, and temperature. They will also ask about your pain. These vital signs give caregivers information about your current health. Anesthesia: This is medicine to make you comfortable during the procedure. Your caregivers will decide which type of anesthesia medicine is best for you. You may have any of the following:

80

Local anesthesia: Medicine is used to numb the area of your body where the surgery or procedure will be done. It is usually injected into

the skin. It also may be given as a gel or jelly applied to your gums for dental procedures or as a patch. For such areas as the genitals, medicine may be given as a cream on the skin or mucus membranes.

During the procedure:

You will lie on a table on your side, back, or stomach, depending on where your abscess is. Caregivers will clean the skin around the abscess with

soap and water. This soap may make your skin yellow, but it will be cleaned off later. Sheets are put over you to keep the area clean.
An incision (cut) is made over the abscess. An instrument wrapped in gauze, or a cotton swab, is used to clean the inside of the abscess. Caregivers

then clean the cavity (hole) by washing it with a saline (salt water) solution. The abscess cavity is then packed with plain gauze or gauze with an iodine solution on it. If caregivers think that a foreign object may be present in the cavity, an x-ray may be taken. This is usually taken before the packing is placed in the cavity. Dry gauze is placed over the packing and taped down. The affected part may be placed in a splint.

After surgery: You are taken to a room where your heart and breathing will be monitored. Do not get out of bed until your caregiver says it is okay. A bandage may cover wounds to help prevent infection. You may be able to go home after some time passes. If you had general anesthetic, an adult will need to drive you home. Your driver or someone else should stay with you for 24 hours. If you cannot go home, you will be taken to a hospital room.
Activity: You may need to walk around the same day of surgery, or the day after. Movement will help prevent blood clots. You may also be given

exercises to do in bed. Do not get out of bed on your own until your caregiver says you can. Talk to caregivers before you get up the first time. They may need to help you stand up safely. When you are able to get up on your own, sit or lie down right away if you feel weak or dizzy. Then press the call light button to let caregivers know you need help.

81

 Medicines: You may be given the following medicines:

o o

Antibiotics: This medicine is given to help treat or prevent an infection caused by bacteria. Medicines to treat pain, swelling, or fever: These medicines are safe for most people to use. However, they can cause serious

problems when used by people with certain medical conditions. Tell caregivers if you have liver or kidney disease or a history of bleeding in your stomach. Aftercare Much of the pain around an abscess will be gone after the surgery. Healing is usually very rapid. After the drainage tube is removed, antibiotics may be continued for several days. Applying heat and keeping the affected area elevated may help relieve inflammation.

Wound care:
Do not remove the bandage over your wound unless your caregiver says it is OK. Keep the bandage clean and dry. Clean the wound as often as ordered by your caregiver. If you cannot reach the wound, have someone help you. Make sure all the gauze used to pack the cavity is taken out and changed. Keep track of how many gauze dressings are placed inside the cavity

whenever you do your wound care.

Wash your hands before and after taking care of your wound to prevent spreading an infection.

Curettage is the surgical removal of growths or tissue from the wall of a body cavity or other surface, using a spoon-like instrument with a sharp edge called a curette.

Purpose: The general purpose of curettage is to scrape an area free of undesirable tissue. 82

February 17, 2012 (1:21 pm- 2 pm) (Debridement & Curettage) Debridement is the process of removing dead (necrotic) tissue or foreign material from and around a wound to expose healthy tissue. Purpose: An open wound or ulcer cannot be properly evaluated until the dead tissue or foreign matter is removed. Wounds that contain necrotic and ischemic (low oxygen content) tissue take longer to close and heal. This is because necrotic tissue provides an ideal growth medium for bacteria, especially for Bacteroides spp. and Clostridium perfringens that causes the gas gangrene so feared in military medical practice. Though a wound may not necessarily be infected, the bacteria can cause inflammation and strain the body's ability to fight infection. Debridement is also used to treat pockets of pus called abscesses. Abscesses can develop into a general infection that may invade the bloodstream (sepsis) and lead to amputation and even death. Burned tissue or tissue exposed to corrosive substances tends to form a hard black crust, called an eschar, while deeper tissue remains moist and white, yellow and soft, or flimsy and inflamed. Eschars may also require debridement to promote healing.

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Surgical debridement Surgical debridement (also known as sharp debridement) uses a scalpel, scissors, or other instrument to cut necrotic tissue from a wound. It is the quickest and most efficient method of debridement. It is the preferred method if there is rapidly developing inflammation of the body's connective tissues (cellulitis) or a more generalized infection (sepsis) that has entered the bloodstream. The physician starts by flushing the area with a saline (salt water) solution, and then applies a topical anesthetic or antalgic gel to the edges of the wound to minimize pain. Using forceps to grip the dead tissue, the physician cuts it away bit by bit with a scalpel or scissors. Sometimes it is necessary to leave some dead tissue behind rather than disturb living tissue. The physician may repeat the process again at another session.

Diagnosis/Preparation The physician or nurse will begin by assessing the need for debridement. The wound will be examined, frequently by inserting a gloved finger into the wound to estimate the depth of dead tissue and evaluate whether it lies close to other organs, bone, or important body features. The assessment addresses the following points:

the nature of the necrotic or ischemic tissue and the best debridement procedure to follow the risk of spreading infection and the use of antibiotics the presence of underlying medical conditions causing the wound the extent of ischaemia in the wound tissues the location of the wound in the body the type of pain management to be used during the procedure

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Before surgical debridement, the area may be flushed with a saline solution, and an antalgic cream or injection may be applied. If the antalgic cream is used, it is usually applied over the exposed area some 90 minutes before the procedure.

Aftercare After surgical debridement, the wound is usually packed with a dry dressing for a day to control bleeding. Afterward, moist dressings are applied to promote wound healing. Moist dressings are also used after mechanical, chemical, and autolytic debridement. Many factors contribute to wound healing, which frequently can take considerable time. Debridement may need to be repeated.

Diagnosis/Preparation

Injectable lidocaine is administered before most curetttage. Lidocaine is often used together with epinephrine to further reduce blood loss. Anesthesia may not be necessary when small lesions are being treated. Another alternative is to use a mixture of local anesthetics, containing 2.5% lidocaine and 2.5% prilocaine, in a cream base. The cream is applied to the skin at least one hour before the procedure to achieve topical anesthesia.
Aftercare

After the procedure, the patient is advised to keep the wound clean and dry. The healing process takes at least several weeks or longer, depending on the size of the wound and other factors. These wounds may be cleansed daily and then covered with an antibiotic ointment that provides a moist environment for new tissue growth. The wound may then be covered with common adhesive bandages. Full-thickness wounds require closure with sutures.

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Risks: As with every type of surgical procedure, there is a risk of infection. Antibiotics are not routinely given, but some physicians believe they may minimize the risk. Other potential risks include:

Subcutaneous bleeding. If it occurs, subcutaneous bleeding may create a hematoma and require the wound to be reopened and drained. Temporary or permanent nerve damage. This may result from excision in an area with extensive nerves. Wounds that reopen. If this occurs, the risk of infection and scarring increases. Scarring.

C. NURSING PROBLEM PRIORITIZATION List of problems: DATE IDENTIFIED February 22, 2012 CUES Subjective: ang sakit ng tahi ko, as verbalized by the client. Objective: Facial grimace Obvious guarding of the affected area Pain Scale: 7/10 PROBLEMS/ NURSING DIAGNOSIS JUSTIFICATION Acute pain related to actual tissue damage Pain is an unpleasant sensory and as manifested by Pain scale of 7/10. emotional experiences associated with tissue damage. Pain is intolerable by the client. That makes it to consider with high priority.

T- 36.4 C

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P- 84 bpm R-22 cpm

Subjective: February 22, 2012 Nahihirapan akong maglakad dahilsa sugat ko as verbalized by the client Objective: February 22, 2012 Subjective: May sugat ako sa binti as verbalized by the client Objective:
Presence of 14 sutures at left tibia

Impaired Physical mobility related to pain It was prioritized because it can alter the as manifested by difficulty in ambulating circulation of blood to achieved wound healing

Pain Scale: 7/10 Difficulty in ambulating Presence of 15 sutures at left distal tibia Presence of wound drainage at left distal tibia Inability of performing Range of Motion at left lower extremities Impaired tissue integrity related to surgical It was prioritized because tissue damage incision because it may lead to infection.

Presence of wound drainage at left distal tibia

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February 22, 2012

Incision in the left distal tibia measures 18 cm Objective: Presence of 14 sutures at left tibia Presence of wound drainage at left distal tibia Incision in the left distal tibia measures 18 cm Poor hygiene

Risk for infection related to surgical It was prioritized because the client had incision as manifested by Presence wound drainage that can be a factor in of wound drainage at left distal tibia developing infection

February 22, 2012

Ano ba dapat ko gawin para mabilis humilom tong tahi Readiness for enhanced knowledge related Prioritized last due to wellness diagnosis ko?,as verbalized by the client. to verbalization of interest in learning.

Assessment

Diagnosis

Scientific knowledge

Planning

Intervention

Rationale

Evaluation

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Subjective: ang sakit ng tahi ko, as verbalized by the client.

Acute pain related to actual tissue damage as manifested by Pain scale of 7 over 10.

Short term Goal: Surgical incision of the left distal tibia After 30min of nursing intervention, the clients sensation of pain will subside as evidenced by:
Compliance to pharmacological regimen Demonstration of relaxation skills as indicated for individual situations and diversional activities. Verbalization of methods that provide relief

Independent:
Established rapport Discuss about methods to relieve pain such as diversional activities Provide comfort measures such as touch, applicable compress. Encourage adequate rest periods. Discuss and demonstrate deep breathing exercises

Short term goal: To gain clients trust. To divert attention from pain To promote nonpharmacologi cal pain management . To prevent fatigue. To relieve tension of muscles. After 30min of nursing intervention the client:
Comply to pharmacologic al regimen Demonstrates of relaxation skills as indicated for individual situations and diversional activities. Verbalized of methods that provide relief

Objective: Facial grimace Obvious guarding of the affected area Pain Scale: 7/10

Actual tissue damage

T- 36.4 C P- 84 bpm R-22 cpm

peripheral receptors initiate unpleasant sensations

Long term Goal: Long term Goal: modulation in the dorsal horn of the spinal cord After 8 hours of nursing interventions, the client will be able to report relieve of pain from 7/10 to 4/10-2/10 as Dependent:
Administration of prescribed medications

To relieve pain

After 1hour of nursing interventions the client:

Verbalized of alleviated pain and a pain 89

evidenced by: Verbalization of alleviated oain and a pain scale of 4/10 2/10.

scale of 3/10.

activation in the cerebral cortex

pain sensation ( acute pain)

(MedicalSurgical Nursing 10th edition Brunner &Suddarth)

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Assessment
Subjective:

Diagnosis

Scientific knowledge
Surgical incision of the left distal tibia

Planning
Short term Goal: After 30min of nursing intervention, the clients mobility will improve as evidenced by:
Demonstration of techniques that enable resumption of activities Verbalization of understanding of situation and individual treatment regimen and safety measures.

Intervention
Independent:
Established rapport Encourage adequate rest periods. Discuss and demonstrate deep breathing exercises Support affected part using pillow/ rolls Demonstrate use of standing aids and mobility device Encourage participation in self care activities

Rationale

Evaluation
Short term Goal:

Impaired Physical Nahihirapanakon mobility gmaglakaddahilsa related to sugatko as pain as verbalized by the manifested client by difficulty in ambulating Objective: Pain Scale: 7/10 Difficulty in ambulating Presence of 14 sutures at left distal tibia Presence of wound drainage at left distal tibia Inability of performing Range of Motion at

To gain clients trust. To prevent fatigue. To relieve tension of muscles. To maintain position of function and reduce risk of pressure ulcers To promote independence and enhance safety

Actual tissue damage

After 30min of nursing intervention, the clients mobility will improve as evidenced by:
Demonstration of techniques that enable resumption of activities Verbalization of understanding of situation and individual treatment regimen and safety measures.

Pain sensation

Limited Range of motion (Impaired Physical Mobility)

Long term Goal: After 3 months of nursing interventions, the client will be able to reduce his functional level from 3 to 1-0 as

Long term Goal:

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left lower extremities

evidenced by:
Participation in Range of Motion Exercise

Dependent:
Administration of prescribed medications

To relieve pain

After 3 hours of nursing interventions, the client reduced his functional level to 1/10 as evidenced by:
Participation in Range of Motion Exercise

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ASSESSMENT

DIAGNOSI SCIENTIFIC S KNOWLEDG E

Surgical incision of the Left distal tibia

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: May sugat ako sa binti as verbalized by the client Objective:

Presence of 14

Impaired tissue integrity related to surgical incision

Short term goal:

sutures at left tibia Presence of wound drainage at left distal tibia Incision in the left distal tibia measures 18 cm

Incision in the left distal tibia

-within 4-5 hours of nursing intervention, the client will be able to:
Demonstrates understanding of plan to heal skin Describes measures to protect and heal the skin and to care for any skin lesion

Check the Wound drainage; make sure that it is free flowing.

Application of wound drainage

Incision site drains are used to remove any accumulated abscess. Correct positioning prevents back up of the bile in the operative area.

Goal Met After 4-5 hours of nursing intervention, the client :

Demonstrates understanding of plan to heal skin Describes measures to protect and heal the skin and to care for any skin lesion

Impaired skin integrity

Observe color and character of the drainage.

Initially, may contain blood and pus that is yellowish to greenish in color

Long-term goal:

Within 3 weeks of nursing intervention the client will regains integrity of skin surface.

Place patient in low or semifowlers position. Facilitates drainage of

abscess
Change dressings as often as necessary. Keeps the skin around 93

Discharge Planning

General condition of the patient: After almost a month of stay in the hospital, the patient is better than before. He ambulates with crutches. The patients vital signs are the following: Blood pressure-120/80 mmHg, temperature 37.20C, pulse rate -88 bpm respiratory rate 19 bpm.
METHODS M- Medications Instructed the patient to continue home meds as ordered by the physician. Taught the appropriate dosage, timing, therapeutic effect & possible side effects of the medications

Take home medications : clindamycin 300mg / cap q6 x 7 days and celecoxib 200mg 1 cap BID for pain
E- Exercise Encouraged to continue active exercises within cardiac tolerance Instructed the patient to have an adequate rest periods at home, limit of activities that exhausts him and could enhance complications. Limit stressful activities as much as possible. T- Treatment Instructed to perform regular wound dressing. H- Health Teaching given as follows : Instruct the patient to do proper hand washing before handling the wound. Instructed to keep wound clean and dry. O- Out-Patient Appointment Instructed to have a followed up check up at Jose B. Lingad Memorial General Hospital, March 5, 2012. Instructed to report any signs of fever and reoccurrence of the condition to his physician as much as possible. D- Diet Encouraged to maintain prescribed diet low salt and low sugar diet. Instructed to increased foods high in protein such as meat, fish, and vegetables. Encouraged to increased foods high in vitamin c such as orange and pineapples and other fruits that gives energy

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S- Sex/Spiritual Advice patient to pray according to his religion.

VII. Conclusion Through this case study we were able to gain knowledge regarding the case of the patient as well as to ensure quality nursing care to patient by promoting recovery and improving health status through giving holistic nursing intervention and providing adequate continuous care. We were able to carry out appropriate assessment and nursing intervention for patient having osteomyelitis as well as demonstrating preventive measures for further complications of patients disease. We also gained knowledge with regards in defining and identifying signs and symptoms and determining what causes the disease. Into this end, we were able to establish patient- student interaction for effective communication obtained through assessment and complete data about patients condition. We were able to increase our selfefficacy to render essential quality nursing care, as well as imparting some knowledge in our client through demonstration of preventive measures for complications dealing with osteomyelitis.

Bibliography
htttp://en.Wikipedia.org/wiki/human_musculoskeletal_system http://www.surgeryencyclopedia.com/Ce-Fi/debridement.html http://www.surgeryencyclopedia.com/Ce_Fi/Currettage.html http://www.surgeryencyclopedia.com/A-ce/Abscess-incission-and-Drainage.html Daniels ,Fundamentals In Nursing Vol. 1 Pg 351 Davids drug Guide for nurses 10th Edition Kozier& Erbs Fundamentals of Nursing Vol 1 M.Doenge,M moore house,A. Murr nurses Pocket Guide 12th Edition Suzanne C. Smelthzer,Brenda G Bare, Janice L. Hinkle, Henry H.,Cheever.brunner and Suddarths textbook of medical surgical nursing. Management of patient with musculoskeletal disorders.Lippincott Williams& Wilkiins Philippine Edition. 2010 Priscilla Lemone, Karen Burke , Principle of Medical- Surgical Nursing Care of Client with musculoskeletal disorder,pearson education southeast asiaPTE. LTD Philippine Education Medical-Surgical Nursing Concept and Clinical application, 2nd edition 2009.Josie Quiambao-Udan,Rn,MAN. www.nursingcrib.com

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