Care Study Osteomyelitis

LICEO DE CAGAYAN UNIVERSITY

1st _{Semester 2009 – 2010}

In Partial Fulfillment of NCM 50124 Related Learning Experience

Care Study

Care Study

TABLE OF CONTENTS

I. INTRODUCTION

A. Overview

B. Objective and Purpose of the Study C. Scope and Limitation

II. HEALTH HISTORY A. Profile of patient

B. Family and personal health history C. History of present illness

D. Chief complaint

III. DEVELOPMENTAL DATA IV. MEDICAL MANAGEMENT

A. Medical orders and rationale B. Drug study

V. PATHOPHYSIOLOGY WITH ANATOMY & PHYSIOLOGY VI. NURSING ASSESSMENT (SYSTEM REVIEW & NSG.

ASSESSMENT II)

VII. NURSING MANAGEMENT

A. Ideal Nursing Management (NCP) B. Actual Nursing Management (SOAPIE) VIII. REFERRALS & FOLLOW-UP

IX. EVALUATION & IMPLICATIONS X. BIBLIOGRAPHY

I. INTRODUCTION

Osteomyelitis is an infection of bone or bone marrow with a propensity for progression, usually caused by pyogenic bacteria or mycobacteria. It can be usefully sub classified on the basis of the causative organism, the route, duration and anatomic location of the infection. By definition osteomyelitis is inflammation of the bone and marrow, but, since it is always caused by an infection, it implies an infection.

Osteomyelitis is inflammation and destruction of bone caused by bacteria, mycobacteria, or fungi. Common symptoms are localized bone pain and tenderness with constitutional symptoms (in acute osteomyelitis) or without constitutional symptoms (in chronic osteomyelitis). Diagnosis is by imaging studies and cultures. Treatment is with antibiotics and sometimes surgery. The bone become becomes infected in three ways:

• Extension of soft tissue infection - infected pressure or vascular ulcer - incisional infection

• Direct bone contamination from bone surgery, open fracture, or traumatic injury

• gunshot wound

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

• Infected tonsils, boils, infected teeth, upper respiratory infection Osteomyelitis resulting from hematogenous spread typically occurs in a bone in an area of trauma or lowered resistance, possibly from subclinical (nonapparent) trauma.

A. OBJECTIVE

This study aims to aid students on problems related to the patient’s condition and understand what the disease process is all about. It is also conducted to promote health care delivery and identify the client’s immediate needs.

B. SCOPE & LIMITATION OF THE STUDY

This study was conducted within a 16-hours duty at Northern Mindanao Medical Center which focuses on the information about the patient and her condition as well as the immediate interventions required.

C. SIGNIFICANCE OF THE STUDY

The study focuses on the disease condition of the patient and its underlying causes. We aimed to have a much deeper understanding about the disease process for us to know proper interventions and conduct health teachings to the patient. The study also aims to promote health wellness not only for the benefit of the patient but also for the significant others.

II.HEALTH HISTORY A. Profile of patient

Name: Villegas, Mark Zandro

Age: 18 years old

Sex: Male

Birth Place: Makati City Birthday: August 21 1991 Civil Status: Single

Nationality: Filipino Informant: Himself Religion: Born Again

Address: Purok 3 La Verdad Talisayan Mis. Or

Weight: 40 kg Height: 5’4 Temperature: 38 ° C Pulse rate: 84 bpm Respiratory rate: 24 cpm Blood pressure: 120/80 mmHg

Clinical Profile

Date of Admission: August 11, 2009 Time of Admission: 3: 00 PM

Attending Physician: Dr. Roem F. Castillano MD. Chief of complaint: Fever

Admitting Diagnosis: Chronic Osteomyelitis

Diet: DAT

B. HEALTH HISTORY

Villegas, Mark Zandro 18 years old, was born on August 21, 1991 at Makati City in a Normal Spontaneous Vaginal Delivery (NSVD). The patient had an operation last December 2008 due to fracture at right femur. The patient also experienced having headaches, cough and colds, as well as fever for a couple of times in a year. Her mother usually gave him OTC medication for the relief of the aforementioned illnesses.

C. HISTORY OF PRESENT ILLNESS

The patient was admitted at Northern Mindanao Medical Center on August 11, 2009 at 3 PM due to fever.

Two days prior to admission, the patient had an on and off fever. Fever was relieved by Paracetamol 500mg, 1 tablet every four hours. No other medications were given and no consult was made. The patient’s condition went on and off.

Morning prior to admission, condition persisted patient has sudden undocumented fever and the day after fever.

Assessment was done during admission vital signs were checked for baseline data: temperature, 38 o_{C; pulse rate, 84bpm; respiratory rate,}

24cpm; and blood pressure, 120/80 mmHg and weight, 40 kg. D.The patient was diagnosed Chronic Osteomyelitis Right Femur

III.DEVELOPMENTAL HISTORY

A. Erik Erikson’s Stages of Psychosocial Development Theory Erikson describes eight developmental stages through which a healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future. Each of Erikson's stages of psychosocial development are marked by a conflict, for which successful resolution will result in a favorable outcome and by an important event that this conflict resolves itself around

The subject is a 17 year old, high school student which is under the 5th _{stage of Erickson’s psychosocial stage. This begins with puberty and}

ending around 18 or 20 years old. The task during adolescence is to achieve ego identity and avoid role confusion. Ego identity means knowing who you are and how you fit in to the rest of society. It requires that you take all you've learned about life and yourself and mold it into a unified self-image, one that your community finds meaningful.

B. Sigmund Freud’s Psychosexual Development Theory

Freud advanced a theory of personality development focusing on the effects of the sexual pleasure drive on a person's emerging personality. According to his theory, parts of the personality develop as we move through a series of psychosexual stages. Each stage is characterized by different demands for sexual gratification and different ways of achieving that gratification.

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

Robert J. Havighurst’s Developmental Task Theory

The tasks involved which need to be accomplished by the patient are:

♠ Achieving new and more mature relations with age-mates of both sexes

♠ Achieving a masculine or feminine social role

♠ Accepting one's physique and using the body effectively

♠ Achieving emotional independence of parents and other adults

♠ Preparing for marriage and family life Preparing for an economic career

♠ Acquiring a set of values and an ethical system as a guide to behavior; developing an ideology

♠ Desiring and achieving socially responsible behavior C. Jean Piaget’s Theory of Development

According to Piaget, development is driven by the process of equilibration. Equilibration encompasses assimilation and accommodation

The patient is classified under the last stage in Piaget's theory which is the formal operations stage. This stage exists between the ages of about twelve to adulthood. Children in this stage are capable of thinking logically and abstractly and reason theoretically. Piaget considered this stage the ultimate stage of development.

IV. Medical Management

DIAGNOSTIC EXAMINATIONS

DOCTORS ORDER RATIONALE

09-14-09 > TPR q 4h > DAT > Paracetamol 500mg PO for Fever >Tramadol 500 mg IVTT PRN for pain > CBC >Urinalysis > D5LR @ 20gtts/min 09-15-09 > TPR q 4h > DAT

>Nafcillin sodium 1 gm IVTT every 8 hours

> IVF follow up D5LR @ 20 gtts/min

> During this period of time, potentially fatal complications may develop

> Re-establish normal eating pattern

> To reduce fever by direct action on the Hypothalamus

>to relieve pain

>CBC-, although a high WBC counts may present in viral infection.

> To know the presence of bacteria in the urine > Fluids are required to replace losses, to prevent patient dehydration. For hydration purposes

> To monitor patient’s V/S

> Re-establish normal eating pattern

Acute to chronic osteomyelitis caused by susceptible organism

> Fluids are required to replace losses, to prevent patient dehydration. For hydration purposes.

N/O

B.DRUG STUDY

Name of drug, dosage, route

Indication Nursing Precaution

• Paracetam ol 500mg PO for temperature > 38 o_C • Tramadol 50 mg IVTT PRN for Pain • Nafcillin sodium 1 gm IVTT every 8 hours

Antipyretic – lowers down fever with its direct action on the hypothalamus Moderate to moderately severe pain Acute or chronic osteomyelitis caused by susceptible organism

Do not give to patient more than 5 times in 24 hours not unless prescribed by the physician.

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

VI.NURSING SYSTEM REVIEW CHART

EENT:

� Impaired vision � blind � pain � reddened � drainage � gums � hard of hearing � deaf � burning � edema � lesion [x] teeth Asses eyes, ears, nose

Throat for abnormality [ ] no problem

RESPIRATION

�asymmetric � tachypnea

� apnea � rales [ ] cough � barrel chest � bradypnea � shallow � rhonchi

� sputum � diminished � dyspnea � orthopnea � labored � wheezing � pain � cyanotic

Asses resp. rate, rhythm, depth, pattern breath sounds, comfort [x] no problem

CARDIO VASCULAR

� arrhythmia � tachycardia � numbness � diminished pulses � edema � fatigue � irregular � bradycardia � murmur � tingling � absent pulses � pain

Assess heart sounds, rate, rhythm, pulse, blood pressure, etc., fluid retention, comfort

[x] no problem

GASTRO INTESTINAL TRACT

� obese � distention � mass � dysphagia � rigidity � pain

Asses abdomen, bowel habits, swallowing, bowel sounds, comfort [x] no problem

GENITO-URINARY and GYNE

� pain � urine color � vaginal bleeding � hematuria � discharge � nocturia

Assess urine freq., control, color, odor, comfort/ Gyn-bleeding, discharge [x] no problem

NEURO

� paralysis � stuporous � unsteady � seizures � lethargic � comatose [ ] vertigo � tremors � confused � vision � grip

Assess motor function, sensation, LOC, strength, grip, galt, coordination, orientation, speech. [x] no problem

MUSCULOSKELETAL and SKIN

� appliance � stiffness [x] itching [] petechiae � hot � drainage � prosthesis � swelling � lesion � poor turgor � cool [x] deformity � wound � rash � skin color � flushed � atrophy [x] pain � ecchymosis � diaphoretic � moist

Asses mobility, motion, galt, alignment, joint function /skin color, texture, turgor, integrity � no problem Place an (X) in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure if appropriate, using (x)

Tooth Decay

P

Dry and flushed skin Febrile T: 38˚C Pain4/10 , itchyness Present of wound Pus, ulcer on the right femur Dirty Toenails Headache Skin is warm to touch

Name: Villegas, Mark Zandro Date: August 14, 2009 Vital Signs:

SUBJECTIVE OBJECTIVE COMMUNICATION:

[ ] hearing difficulty [ ] visual changes [x]denied

Comments: okay raman akomg paglantaw ug ang akong pandungog ‘as verbalized by the patient

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

OXYGENATION: [ ] dyspnea [ ] smoking history Non-smoker [ ] cough [ ] sputum [x]denied

Comments: Dili man ko gapanigarilyo ‘ as verbalized by the patient’

Resp. [x] regular [ ] irregular

Describe: There was no difficulty of breathing or shortness of breath that was noted

R: full and symmetrical to the left lung L: full and symmetrical to the right lung

CIRCULATION: [ ] chest pain [x] leg pain [ ] numbness of extremities [ ]denied Comments: hhm. Usahay mosakit akong tiil pero ma wala wala rman pud ang kasakit’ as

verbalized by the patient’

Heart Rhythm [x ] regular [ ] irregular Ankle Edema: No ankle edema is present on both extremities

Pulse Car Rad. DP Fem* R + 84 bpm + + L + 84 bpm + +

Comments: All pulses were palpable on both upper and lower extremity

NUTRITION: Diet: DAT Character [ ] recent change in weight [ ] swallowing Difficulty [x]denied

Comments: okay raman akong pagkaon dili man ko galisod pud ‘as verbalized by he patient’

[ ]dentures [x]none

Full Partial with patient Upper [ ] [ ] [ ] Lower [ ] [ ] [ ]

ELIMINATION:

Usual bowel pattern Once a day [ ] constipation Remedy [ ] diarrhea character [ ] urinary frequency Twice a day [ ] urgency [ ] dysuria [ ] hematuria [ ] incontinence [ ] polyuria [ ] foley in place [x]denied Comments: bowel sounds (Normoactive). Not Applicable.

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

MGT. OF HEALTH & ILLNESS:

[ ] alcohol [x] denied (amount & frequency) N|A

[ ] SBE: N/A Last Pap Smear: N/A LMP: N/A

Briefly describe the patient’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present).

Prescribed by physician and proper nutrition in diet was enforced SUBJECTIVE OBJECTIVE SKIN INTEGRITY: [x] dry [ ] other [ ] denied

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

[x] dry [ ] cold [ ] pale [ ] flushed [x ] warm [ ] moist [ ] cyanotic

*rashes, ulcers, decubitus (describe size, location, drainage: (-) rashes; (+) ulcers ; (-) decubitus (1 peso coin size, right femur mod.amount) ACTIVITY/ SAFETY: [ ] convulsion [ ] dizziness [ ] limited motion of Joints Limitation in Ability to [ ] ambulate [ ] bathe self [ ] other

Comments: Maka lihok lihok man ko pero usahay mosakit akong tiil’ as verbalized by the patient’

[ ] LOC and orientation: patients knows where she is and knows what day today.

Gait: [ ] walker [ ] cane [ ] other [ x] steady [ ] unsteady: [ ] sensory and motor losses in face or Extremities: There was no motor and sensory losses in face and extremities noted from the patient

[ ] ROM limitations: The patient is able to flex, extend, rotate the head

[ x ] denied COMFORT/SLEEP/ AWAKE: [x] pain (location) femur right Frequency Remedies [ ] nocturia [ ] sleep difficulties [ ] denied

Comments: Sakit sakit usahay akong tiil, pero ma tolerate raman pud ‘ as verbalized by the patient’

[x] facial grimaces [x] guarding

[ ] other signs of pain :

[ ] side rail release form signed (60 + years) N/A

COPING:

Occupation: None

Members of household: 5 members Most supportive person: her father

Observed non-verbal behavior: None

Phone number that can be reached anytime: Not given

VII NURSING MANAGEMENT A.IDEAL NURSING MANAGEMENT

A. Hyperthermia related to present of pathogens in the body as evidenced by increase in body temperature higher than normal range.

Desired outcomes/evaluation criteria- patient will:

Demonstrate temperature within normal range, be free of chills.

INTERVENTION RATIONALE

Independent

• monitor patient

temperature(degree and pattern); note shaking chills/profuse diaphoresis.

• Monitor environmental temperature; limit/add bed linens as indicated.

• Provide tepid sponge baths; avoid use of alcohol.

Dependent

• Administer antipyretics, paracetamol 500mg PO

• Provide cooling blanket.

• Temperature of 38 degree C suggests acute infectious disease process. Fever pattern may aid in diagnosisr; remittent fever (varying only a few degrees in either

direction) reflects pulmonary infections; intermittent curves or fever that returns to normal once in 24-hour period suggests septic episode, septic endocarditis, or tuberculosis (TB). Chills often precede temperature spikes. Note: Use of antipyretics alters fever patterns and may be restricted until diagnosis is made or if fever remains higher that 102F (38.9C).

• Room temperature/number of blankets should be altered to maintain near-normal body temperature.

• May help reduce fever. Note: use of ice water/alcohol may cause chills, actually elevating temperature. In addition, alcohol is very drying to skin.

• Used to reduce fever by its central action on the hypothalamus; However, fever may be benefial in

limiting growth of organisms and enhancing autodestruction of infected cells.

• Used to reduce fever, usually higher than 104F-105F (39.5C-40C), when brain damage/seizures can occur.

B. Acute pain related to inflammation and tissue necrosis

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Will b relieved of experiencing pain and shows relief and relax physical and emotional outlook.

ACTIONS/INTERVENTIONS RATIONALE

Independent

• Perform a comprehensive assessment of pain to include location, characteristic,

onset/duration, frequency severity(0-10 scale)

• Instruct use of relation exercise such as focused breathing, commercial or music’s.

• Encourage adequate rest period (ex. TV and radio). • Encourage diversional

activities. Dependent

• Administer medications as indicated,

• To know how intense is the pain and

to asses in relieving the pain. • To provide diversional

activities.

• To prevent fatigue and promote wellness

• To divert the attention of the patient to diminish pain.

• To lessen the pain

C.Knowledge deficient regarding condition, related to unfamiliarity with disease.

Desire outcomes/evaluation criteria- the significant others will: Verbalize understanding of disease processes, possible complications.

INTERVENTION RATIONALE

INDEPENDENT

• Determine the mother’s perception of disease process.

• Review disease process,

cause/effect relationship of factors that precipitate symptoms, and identify ways to reduce

contributing factors. Encourage questions.

• Review medications, purpose, frequency, dosage, and possible side effects.

• Stress importance of good skin care, e.g., proper handwashing techniques.

• Emphasize need for long-term follow-up and periodic

reevaluation.

• Establishes knowledge base and provides some insight into individual learning needs.

• Precipitating/aggravating factors are individual; therefore, the mother needs to be aware of what foods, fluids, and lifestyle factors can precipitate symptoms. Accurate knowledge base provides

opportunity for the mother to make informed decisions/choices about future and control of chronic

disease. Although most others know about their own disease process, they may have outdated information or misconceptions.

• Promotes understanding and may enhance cooperation with regimen.

• Reduces spread of bacteria and risk of skin irritation/breakdown,

infection.

• Provides opportunity for evaluation of effectiveness of regimen.

B. Actual Nursing Management (SOAPIE)

S

O

A

P

I

1. Provided tepid sponge bath

2.Encouraged the patient to drink water at least 10-12 glasses a day

3. Provided adequate rest period

4. Administered paracetamol 500 mg PO as prescribed by the physician

E

S

O

 pain-pain scale of 4/10

A

P

I

1. Performed a comprehensive assessment of pain

2.Encouraged verbalization of feelings about the pain 3. Provided comfort measure (change of position)

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

E

IX. EVALUATION AND IMPLICATIONS

At the end of my hospital duty, we as a student nurse were able to render care to our patient to help him resolve his problem regarding health. Through observing the patient’s status, we were able to identify some problems during our assessment.

Patient was willing to pursue his medical therapy just to promote health and wellness for the betterment of his condition. During the treatment, the patient was able to develop or enhance health awareness on his disease and with this knowledge instilled to his mind, he was then aware on how the disease was transmitted and what are the proper ways or interventions done just to minimize or prevent this disease from getting worst.

We have also made the patient realize the importance of completing the course of therapy by taking the medicines prescribed or ordered to him by his physician. In addition, eating healthy or nutritious foods that were prescribed to him by the health providers was further been explained to him especially the benefits he will gain in eating these nutritious foods.

In general, the patient was very cooperative to what health measures administered to him by the health providers.

Moreover, these several interventions given to the patient made his body functions different than as before.

X. BIBLIOGRAPHY

• Lippincott Williams and Wilkins, Nursing 2006 Drug Handbook, 26th

Edition,

• Barbara Kozier et al, Fundamentals of Nursing, 7th _Edition,

• Lippincott Williams and Wilkins, Nursing 2004 Drug Handbook, 24rd Edition,

• Mosby’s Pocket Dictionary of Medicine, Nursing Allied Health, 4th

Edition, Published in Elsevier Science (Singapore) PTE LTD

• Microsoft ® Encarta ® Premium Suite 2005. © 1993-2004 Microsoft Corporation. All rights reserved.

• Mosby’s Comprehensive Review of Nursing, 13th _{Edition by:}

Saxton,Nugent,Pelikan

• http://www.cnn.com/HEALTH/library/DS/00583.html

• Smeltzer & Bare, medical Surgical Nursing, 10th ed. Vol. 1, Lippincott Williams & Wilkins, Philadelphia, USA

• Mosby’s MEDICAL ENCYCLOPEDIA, the definitive health reference

• http://www.wrongdiagnosis.com/p/leptospirosis/symptoms.htm

• http://en.wikipedia.org/wiki/diabetic

• http://www.emedicine.com/med/topic1776.htm