I.

Health History Date of Admission: January 3, 2012 Date of Interview: January 5, 2012 Time of Admission: 9:02 am Time of Interview: 11:00 am

A. Demographic Data Name: Gender: Age: Birth Date: Marital Status: Race: Religion: Address: J.D. Male 8 y/o May 31, 2002 Single Filipino Catholic Area H, Gatego, Parola, Tondo, Manila

Educational Background: Grade 1 Undergraduate

B. Source and Reliability of Information J.D., his mother, Mrs. J.D. and his father, R.D. served as the provider of information relevant for data gathering. Most of the relevant information were gathered from J.D.s parents since he was a bit aloof to the student nurses and selectively answered only some of the questions in brevity during the interview. Other data sources were gathered through the clients records from San Lazaro Hospital and Philippine Orthopedic Center.

C. Reasons for Seeking Care or Chief Complaint J.D. was referred to Philippine Orthopedic Center from San Lazaro Hopsital for better management of his current condition that was related to skeletal disorder.

D. History of present Illness On November 22, 2011 prior to admission, J.D. went home telling his mother that his playmate, Omar had dropped him and had pulled him. He had abrasion and moderate pain on his right knee. No consultation was done immediately after. On November 29, 2011 prior to admission, he experienced swelling of his right knee then progressed to his right leg, still with pain. The parents intermittently applied ice to the swollen area. No consultation done. On December 6, 2011, he started to have intermittent fever, ranging from 38C to 39C. His parents gave him paracetamol, Neo Kidilet, for his fever. He was brought to a herbolario, who told them that J.D. was nabati. He still has swelling on his right lower extremity and pain became more painful. On December 13, 2011, he experienced a fever of 40C, still with swelling and pain on his right lower extremity, which made his parents decide to bring him to San Lazaro Hospital, thinking that their son is having tetanus or dengue hemorrhagic fever. He was admitted there for 3 weeks. Oxacillin IV was given and incision & drainage was done. Then on January 3, 2012, he was referred to Philippine Orthopedic Center for better management of his current condition and for further evaluation.

8 Critical Characteristics of Pain Assessment  Timing - On November 22, 2011 prior to admission, J.D. went home with abrasion and pain on his right knee. From then on, the pain continuously increased.  Location - J.D. felt continuous right leg pain starting from his right knee radiating to his thigh and he has swelling on his right lower extremity.  Severity - Utilizing the facial expression scale, the patient described the pain felt as 6/10 or severe pain, in a pain scale of 0 10, where 10 is the worst possible pain (highest) and 0 means there is no pain.  Quality - The patient described the pain he felt as sharp on his right lower extremity. While his mother described the swelling as color red to black which increases in size.
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 Quantity - The pain he felt and the swelling he have are constant as it never ceased nor alleviated by the pain medication.  Associated Phenomena - The continuous severe pain led to his irritability and disturbed sleeping pattern.  Aggravating and Alleviating Factors - The pain was aggravated when he is trying to move his right leg or if it is touched. It was somehow alleviated when applying ice or by resting the affected leg.

E. Past Medical history 1. Childhood Illnesses J.D.s mother, Mrs. J.D., said that her son had already experienced having chickenpox and measles. 2. Injuries / Accidents R.D. said that he had not experienced any accident nor acquired injury before other than what he suffered recently. 3. Hospitalization Mrs. J.D. said that J.D. was never hospitalized before until recently. He has been admitted to San Lazaro Hospital last December 13, 2011 and was referred to Philippine Orthopedic Center. 4. Operation- The client had undergone incision and drainage in San Lazaro Hospital due to swelling of his right leg, but other than that, he has not undergone any other operation. 5. Allergies According to G.D., clients father, J.D. does not have any known allergy to food, dust nor medications. 6. Medications Over the Counter (OTC) Neo Kidilet syrup for fever 7. Immunization His father said that the client is a fully immunized child, with MMR. J.D. also said that he received a shot of vaccine while he was in Grade I on his right deltoid. 8. Last Examination J.D. had his last examination last December 13, 2011 on San Lazaro Hospital.

F. Family History Father Side

R.D. 80 y/o HPN
G.D. 75y/o HPN

Mother Side M.A. 72 y/o HPN

E.A. 68y/o HPN

V.A. 44y/o TB

G.A. 47y/o A&W

A.A. 37y/o TB

M.A. 34y/o A&W

R.D. 52y/o A&W

J.D. 40y/o A&W

Legend:
Male

R.D. 10y/o A&W

R.D. 5y/o A&W

J.D. 4y/o A&W

J.D. 10mos. A&W

Female Client A&W HPN TB Family of orientation Alive and Well Hypertension Tuberculosis

J.D. 8y/o
Osteomyelitis

Interpretation: Based on the genogram above, J.D. is in a family of orientation since he lives with his mother, Mrs. J.D., father, R.D. and his 4 siblings, namely: R.D., R.D., J.D., and J.D., respectively, where he is the second son. He has a family history of hypertension, where his grandparents from both side of thee family have hypertension. His two aunts from mother side also suffered from tuberculosis. The rest of the members were alive and well. Thus, J.D. is highly susceptible of acquiring hypertension since it is hereditary.

G. Socio-Economic

According to R.D., their everyday expenditure only came from driving his taxi every other day in Manila.

Familys Monthly Income Family Members Mr. R.D. Mrs. J.D. R.D. J.D. R.D. J.D. J.D. Position Occupation Average Monthly Income Share in the Family Php15,000.00 Not Available N/A N/A N/A N/A N/A Php 15,000.00 Php15,000.00 Not Available N/A N/A N/A N/A N/A Php15,000.00

Father Taxi Driver Mother None Oldest son N/A Second son N/A (client) Third son N/A Fourth son N/A Fifth daughter N/A TOTAL

Average Monthly Expenses ALLOTMENT Food Utilities (Electric and water bills) Allowance (Education) Medication/ Health Maintenance Other needs TOTAL Overall Savings PRICE (Php) 6,000.00 2,000.00 3,000.00 2,000.00 500.00 13,500.00 1,500.00

Based on the table above regarding the average monthly expenses of J.D.s family, their expenses do not exceed their monthly income, which means that their money is sufficient for their family expenditures. They could also save money for future and/or emergency use.

H.

Developmental History Eriksons Psychosocial Theory of Development Stage Central Task Trust vs. Mistrust Actual Finding and Interpretation When asked if J.D. was breastfed, the parents negated it explaining how Mrs. J.D. was unable to accommodate breastfeeding due to her need to work. The patients primary caregiver were his father, aunt and eldest half- sister as Mrs. J.D. left Mindanao for Manila to earn a living. The father, Mr. R.D. narrated how his son never gave him a problem during his infancy period as he rarely cries and had not exhibited fear of stranger despite having been cared by a lot of his relatives. Further, the father narrated how his son easily changed from bottled milk to cup claiming it the reasons behind J.D.s healthy set of teeth. Interpretation During the interview the patient was observed to act irritably refusing to answer most of the questions. He would furrow his brows and looked away even after the student nurses introduced themselves and had attempted to establish rapport. Although the father claimed that his son had not exhibited fear of stranger, J.D. evoked signs of mistrust to strangers. While fear or nurses wearing white uniform could be a factor, when Erikson stated in his theory regarding mistrust when needs during infancy was not met could not be overlooked. The absence of the mother and the replacement of her eldest daughter in her first wedding could contribute to this lack of trust to strangers. Actual Finding
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Infancy Birth to 18 months

Learning to trust others when needs are met while becoming mistrustful and exhibiting sense of withdrawal and estrangement if otherwise An important role lies in the primary caretaker who can be assumed by the parents, siblings, grandparents or caretaker who will feed the need of infants such as bonding. (Pillitteri, 2003)

Early

Autonomy vs. Shame and Doubt

Childhood 1 years to 3 years

J.D.s father narrated how his son had stopped wearing diaper even before reaching two years. He said that among his children, J.D. was one of the earliest who had mastered toilet training at a younger age. He said that the patients half-sister was bent and strict in implementing early toilet training claiming that caring for 3 toddlers was messy enough that they need to be responsible soon enough. Before age 2 R.D. learned how to defecate in the toilet. When asked if the eldest half-sister reinforced punishment when their children failed to comply, J.D.s parents did not deny this and even verbalized their support to this type of discipline claiming that this contributed to fast learning. Autonomy which means selfgovernment or independence builds on childrens new motor and mental abilities. Children take pride in new accomplishments and want to do everything independently Crucial positive development of sense of control is triggered when parents recognize the toddlers need to do what they are capable of doing at their own pace and in their own time. On the other hand, impatient caregivers lead the children to develop a sense of doubt and shame Interpretation Erikson emphasized how early and strict toilet training could trigger an inner conflict to the child that could be manifested when he grew up. At this stage, the toddler realizes that he is a separate person with his own desires and abilities. He wants to do things for himself without help or hindrance from other people. This push for autonomy is enhanced by muscular maturation as toddlers try to use their developing muscles to explore their environment. Potentially, toddlers can get into dangerous situations. Therefore, parents have to balance the opposing virtues of encouragement and restraint. If a toddler's efforts to do things on his own were frustrated by over-protective parents then he may not have many opportunities to develop autonomy. On the other hand, if a toddler was harshly
8

Late Childhood Initiative vs. Guilt 3 to 5 years

criticized then he may develop doubt about his own abilities to tackle new challenges. This reflected to the childs withdrawal from school during the succeeding stage. Actual Finding When asked if J.D. had spent his late childhood playing outside, his father admitted that their eldest half-sister did not allow them to play outside as she was trying to protect them. The younger J.D. would prefer to play with his brothers so as not to aggravate his older sister. Upon reaching 5, they enrolled J.D. to barangay day care center. His father admitted how his son excelled academically even finishing the term with honors. He stated how enthusiastic his son was at school. At home, his aunt and older sister would teach and help them in their homework. Interpretation The sense of overprotection was observed in prohibiting the patient to play outside. While ensuring a safe playing environment is healthy to the childrens development, being overly strict could hamper the childs sense of assertiveness. While it did not become apparent during this stage as compensated by the childs achievement at school, patient would eventually withdraw from school when the parents least expected it. Actual Finding When the child was transferred from Mindanao to GMA, Cavite, his eldest half-sister was also left in Mindanao having had a family of her own. J.D. was then observed to have an increased appetite to play unceasingly, playing after he had his breakfast and would only
9

Positive indicator of development is marked by the degree of learning to which assertiveness and purpose influence the environment Negative indicator is marked by lack of self-confidence, pessimism, fear of wrongdoing, over control and over restriction of own activity (Kozier, et al, 2004)

School Age 6 to 12 years

Industry vs. Inferiority

return home before dinner. During his first grade, the teachers child reported the childs explicit disinterest to listen. J.D. would cover his ears during class discussion and eventually decided to leave school for a year. When asked why his parents heed to their sons request, the father said that they could not really force him to do something he does not want to do. When asked if he had problem academically, the father negated it claiming that his son was actually smart. He also had no problem adjustment at his new school since they had always used Tagalog as they vernacular even when they were in Mindanao. Interpretation Conflict was manifested by the childs withdrawal from school. The compounding problem during his preceding developmental stage had triggered a sense of being mediocre at school that he chose not to listen anymore to his lessons contrary to most of the children his age. The freedom from strict and firm mode of disciplining could also trigger this change of behavior or could have created an opportunity to do what he really wanted to play with his friends.

Positive indicator is marked by beginning to create, develop, and manipulate and a development a sense of competence and perseverance According to Erikson, in contrast to what was mentioned above, manifestations than conflict arises include loss of hope, sense of being mediocre and withdrawal from school and peers

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I. Review of System and Physical Examination

Weight: 18 kg
Physical Examination

Height: 1.15 m

BMI: 14.37 Normal Range - (18.5 24.9) Normal Finding Clinical Significance

Body Part Examined

GENERAL APPEARANCE 1. Body build and heightweight proportionality

ROS
Bumaba nga ang timbang niya mula ng maospital siya. Dati 25 kg yan, ngayon nasa 18 kg nalang, as verbalized by the patients father.

Actual Finding

 Ectomorph (thin upper limbs, with noticeable bony prominences, thin left lower extremity with slightly edematous right lower limb)

 Proportionate, varies with lifestyle

Ectomorph - An individual whose body builds tends to be lean and fragile, with thin muscles and slightly underdeveloped digestive organs. Reference: Blackwells Nursing Dictionary 2nd Ed, 2004. The infected area in ostemyelitis becomes painful, swollen, and extremely tender. The patient may describe a constant, pulsating pain the intensifies with movement as a result of collecting pus. This prevents the patient to stand. Reference: Brunner and Suddarths Medical Surgical Nursing, 12th Ed, 2010. Normal Normal

2. Posture and Gait

Hindi pa rin siya nakakalakad hanggang ngayon kasi masakit parin ang binti niya as verbalized by the patients mother.

 Inability to perform gross motor activities such as walking.

 Relaxed, erect posture; coordinated movement

3. Over-all hygiene and grooming 4. Body and breath odor

Kapapaligo ko palang sa kaniya kaninang umaga. Shinanpumhan at pinunasan ko siya kanina as verbalized by the patients mother.

 Clean and neat  Smell of the body is like a soap; menthol toothpaste-like breath odor  Coherent, oriented to time, person and place, not fully alert

 Clean, neat  No body odor; no breath odor

5. Mental status

 Coherent, oriented to time, person and place, alert,  Calm and cooperative

Normal

6. Attitude

Akala kasi niyan kapag lalapit ang nakaputi magi injection na naman as verbalized by the mothers patient.

 Tensed and uncooperative

Some children may exhibit temper tantrums . reasons for this may include fear or separation anxiety and manipulative. A more common reason that children may resist physical exam is fear. Reference: Advanced Pediatric Assessment by Ellen Chiocca Lack of eye contact indicates

7. Affect/mood;

 lack of eye contact

 Responses are

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with student nurses

appropriate, understandable, moderate pace, clear tone; thoughts are associated

shyness, insecurity and lack of interest in the interview. Reference: The perception of Nonverbalbehavior The phonologic disorder results in errors in whole words because of incorrect pronounciation of consonants, substitution of one sound for another, omission of entire phonemes and in some cases, dysarthria. Reference: Kaplan and Sadock's concise textbook of child and adolescent psychiatry

8. Quantity and quality of speech, relevance and organization of thoughts

 Responses are  Understandable, limited and moderate pace, clear appropriate, slurred tone; thoughts are speech, unclear tone, associated, Logical; moderate pace, make sense; has sense thoughts are of reality associated, Gives relevant insufficient answers

INTEGUMENT Skin I: color, uniformity, edema, lesions

Iyang sugat niya sa paa pinutok yan noong nasa San Lazaro pa kami, as verbalized by the patients mother.

 Light brown skin on  Varies from light to all extremities; deep brown; from ruddy darkened skin pink to light pink; from around the affected, yellow overtones to edematous area on olive; freckles, some the right thigh and birthmarks, some flat leg, skin abrasion on and raised nevi; no the right knee, abrasions or other incision site on the lesions. right middle leg(for status post incise and drain)

Presence of skin abrasion indicates loss of superficial structure. Swelling of tissue indicates fluid (pus) collection under the interstitial space. Reference Medical Surgical Nursing By Basavanthappa In cases of abscess formation, debridement of necrotic bone and tissue is done. It creates an opening necessary to drain the abscess. Reference: Principles of Surgical Patient by C.J. Meny Elevation of temperature is the bodys reaction to an acute bacterial infection. It is a sign that the body is defending itself against the infectious invader. Reference: Smart medicine for a healthier child, 1994 Tight skin May result from edema Reference: Nurses Handbook of health Assessment by: Janet R. Weber, 2009

P: moisture, temp.

Naiinitan po ako ng kaunti when ask about how he is feeling. Panaka-naka nga ay nilalagnat siya as verbalized by the patients mot. her

 Warm to touch, 38.1 o C

 Moisture in skin folds and the axillae (varies with environmental temperature and humidity; body temperature and activity); uniform within normal range, when pinched  Skin springs back to previous state.

Skin Turgor

 Skin in right thigh and leg could not be grasped when pulled(tight) while

HAIR I: evenness of growth thickness, texture

Patient's hair is thinner on the right lower extremities, (area of

Evenly distributed hair, thick hair, silky resilient hair, no infection or

Patient's hair is thinner on the lower extremities - this may indicate diminished

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edematous leg)

infestation, variable.

arterial blood flow to these extremities Reference: Assessment: A 2-inReference for Nurses, 2005 Smooth and shiny skin is normal.

Smooth, shiny. P: smoothness, shininess

Smooth, shiny.

NAILS I: plate shape, texture, bed color,

Convex curvature, smooth, rounded and clean and pinkish nail.

Convex curvature; angle of nail plate about 160 degrees, smooth texture, highly vascular and pink in light- skinned clients; dark skinned clients may have brown or black pigmentation in longitudinal streaks, intact epidermis. Prompt return of pink or usual color (generally 2-3 seconds).

Normal

P: Blanch test

4-5 seconds at right foot. Both nails at hand had 2 seconds. 2 seconds at left foot.

Deviation from Normal Pale nail bed and delayed capillary refill indicates poor circulation at right leg because of wound infection and pus drainage. Reference: Assessment: A 2-inReference for Nurses, 2005

HEAD Skull and Face I: size, shape , symmetry : facial features

Normocephalic, symmetric facial features. Skin is intact. Clean scalp Flat and Smooth

Rounded (normocephallic and symmetrical, with frontal, parietal, and occipital prominences); smooth skull contour. Flat and Smooth

Normal

P: nodules, masses, Depressions EYES AND VISION I: eyebrows for distribution & alignment, quality & movement : eyelashes for evenness of distribution & direction of curl : bulbar & palpebral conjunctiva for color, texture, and lesion, sclera

Normal

Symmetrically aligned and equally distributed eyebrows Evenly distributed hair and curling upward and symmetrically aligned.

Smooth uniform consistency; absence of nodules or masses. Hair evenly distributed; hair intact, eyebrows symmetrically aligned; equal movement.

Normal

Normal

Whitish sclera

Evenly distributed, curled slightly upward. Transparent; capillaries sometimes evident; sclera appears white (yellowish in dark skinned clients), shiny, smooth, pink or red palpebral conjunctiva

Normal

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I/P: lacrimal gland sac, nasolacrimal duct for tenderness / tearing I: cornea for clarity, texture & sensitivity

Non tender No excessive tearing

No tearing or tenderness.

Normal

Clear, smooth and shiny.

Transparent No shadows of light on iris Depth of about 3mm Black in color; equal in size; normally 3-7 mm in diameter; round smooth border, iris flat and round Illuminated pupil constricts (direct response). Nonilluminated pupil constricts (consensual response) Pupils constrict when looking at a near object; pupils dilate when looking at far objects; pupils converge when near object is moved toward nose. When looking straight ahead, client can see objects in the periphery Both eyes are coordinated; movements are parallel

Normal

I: pupils for color, shape, symmetry of size, direct and consensual reaction to light, & accommodation

Pupils are round and reactive to light with light accommodation, 2-3 mm pupil gauge during constriction

Normal

* Visual Field Test

Can see objects at periphery

Normal

* EOM Test

Parallel movement of both eyes.

Normal

EARS AND HEARING I: auricles for color, symmetry and position : external canal for cerumen, lesions, pus or blood

Pinkish, symmetrical and bilateral, skin is intact and both have minimal cerumen.

Color same as facial skin, symmetrical, auricle aligned with outer canthus of eye, about 10 degrees from vertical. Dry cerumen, grayish- tan color; or sticky wet cerumen in various shades of brown Smooth, and absent from tenderness Normal voice tones audible Tick of the clock audible

Normal

P: auricles for texture and areas of tenderness * Gross Hearing Acuity Tests: normal voice tone and whispered voice *Watch- Tick test

Smooth, non tender Can respond to both normal and whispered voice Can hear the ticking sound from the wrist watch

Normal Normal Normal

NOSE AND SINUSES I: nose deviation in shape size, color, flaring, discharge;

Nose is in the middle, negative nasal flaring, uniform color of nose to face

Symmetric and straight, no discharge or flaring, uniform color pink mucosa, clear watery discharge, no lesions

Normal

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Pa: tenderness, masses, displacements; : nasal patency : maxillary and frontal sinuses for tenderness MOUTH / OROPHARYNX I: lips for symmetry of contour, color, texture, moisture, lesion

Non tender and smooth, nasal septum is in middle Nose is patent

Not tender, no lesions air moves freely as the client breathes through the nares not tender

Normal

Pinkish lips, smooth and moist,

Uniform pink color Soft, moist, smooth texture, symmetry of contour, ability to purse lips, inner lips are uniform pink color 32 adult teeth, smooth, white, shiny tooth enamel

Normal

: teeth for alignment, loss, dental filings and caries;

Mahilig din siyang kumain ng kornik. Palagi yan kaya tignan mo yang ngipin nya, as verbalized by the patients mother.

Yellowish teeth, with dental caries

Dental caries are major problem in children. Food containing carbohydrates that stick to the surface of of teeth can interact with the bacteria Streptococcus mutans. Reference: Community nutrition: planning health promotion and disease prevention, 2009 Normal Normal

: gums for bleeding, color, retraction, lesions, swelling

Intact gum integrity, pinkish, smooth

Pink gums, moist, firm texture of gums, no retraction of gums(pulling away from teeth) Central position, pink color Positioned in midline of the soft palate Pink and smooth no discharge of normal size or not visible Presence of gag reflex

: tongue for position, color & texture; : uvula for position

Positioned in the center, slightly white in color, rough Positioned in midline

Normal

Normal

: tonsils for color, discharge, and size Test for Gag Reflex

Pink, smooth and intact

Normal

Presence of gag reflex was observed when client was eating his dinner Smooth with non palpable nodules

Normal

P: nodules, lump and excoriated areas NECK Neck Muscles I: abnormal swelling or masses, head movement, and muscle strength

Smooth with no palpable nodules

Normal

Smooth and intact Able to turn head against force exerted by the hand of the student nurse Non tender Non palpable lymph nodes Central placement of

Muscles equal in size; head centered, coordinated, smooth movements with no discomfort Non tender Not palpable

Normal

Lymph Nodes Pa: tenderness

Normal

Trachea P: lateral deviation

Central placement in

Normal

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trachea Thyroid Gland I: symmetry and visible masses, rise during swallowing P: smoothness Parallel movement while swallowing

midline of neck Not visible upon inspection, gland ascends during swallowing but is not visible Lobes may not be palpated, if palpated, lobes are small, smooth, centrally located, painless, and rise freely with swallowing Normal

Non palpable mass

Normal

THORAX & LUNGS Anterior Thorax I: breathing pattern, coastal and costovertebral angle

Thorax is symmetric, spine is vertically aligned

Anteroposterior to transverse diameter in ratio of 1:2, chest symmetric, spine vertically aligned, spinal column is straight, right and left shoulders and hips are at the same height Normal respiratory rate of 12 to 20 cpm. Quiet, rhythmic, and effortless respirations, costal angle is less than 90 degrees, Bronchial and tubular breath sounds (trachea) Bronchovesicular and vesicular breath sounds (anterior chest)

Normal

Pa: respiratory excursion, tactile fremitus

Respiratory rate of 18 cpm Effortless respiration, quiet and rhythmic respiration Without adventitious breath sounds over anterior and posterior chest. Clear breath sounds heard.

Normal Normal

Normal

A: breath sounds

HEART and Peripheral Vascular assessment Pulse Rate Rate of 98 bpm at regular rhythm. bilateral pulse Normal pulse rate of 60 to 100 bpm Bilateral pulses strong and equal Not distended Normal

Jugular Veins I: distention

When client was placed in a semi fowlers position with head turned slightly away from the side being examined, the jugular veins does not appear distended

Normal

GASTROINTESTINAL I: skin integrity, contour & symmetry, hernia, distention (girth), movements associated w/ respiration, peristalsis & aortic pulsations

Intact skin, with smooth contour and symmetrical. uniform skin color with other body parts.

Unblemished skin, uniform color, silver white striae, or surgical scars, flat rounded(convex), or scaphoid (concave), symmetric movements

Normal

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caused by respirations, visible peristalsis in very lean people, aortic pulsations in thin persons at epigastric area, no visible vascular pattern A: bowel, peritoneal friction rub sounds 15 times per minutes Four times per minute Hyperactive bowel sounds can be characterized as a loud, gurgling sound; they are high pitched and occur more frequently than normal sounds. It reflect increased intestinal motility (peristalsis). Reference: Nursing know-how: Evaluating signs & symptoms Normal

Pe: all quadrants / regions for tympany and deviations

Tympany in the umbilical area while Dullness on Left lower quadrant, Right lower quadrant Ayan nagsuka na naman, palagi iyan pagkatapos ibigay ang gamot. Medyo nagtae ang anak ko, as verbalized by the patients mother. No tenderness

Tympany on all quadrants

Pa: light to deep palpations ALL quadrants

No tenderness; relaxed abdomen with smooth, consistent tension, tenderness may be present near xiphoid process, over cecum, and over sigmoid colon Have good appetite and not experiencing excessive hunger and taste Not feeling nauseated and will not vomit

Normal

Appetite

Decrease appetite

Nausea and vomiting

Kulay brown ang dumi nyan, as verbalized by the patients mother.

Due to treatment regimen and pain radiating from right leg, these factors add up to decrease appetite of patient. Vomiting due to side effects of Penicillin G. Reference: Pharmacology for Nurses: A Pathophysiological Approach Diarrhea is one of the side effects of Penicillin G. Reference: Pharmacology for Nurses: A Pathophysiological Approach Normal

Vomits an estimated amount of 50 ml during the interview.

Usual bowel habits Defecated two to three times a day One defecation per day

Stool color and consistency MUSCULOSKELETAL Muscles I: size, contractures, tremors

Not assessed

Formed greenish to brown color of stool

Mas malaki talaga ang kanan niyang hita kaysa sa kanan, mas maga, as verbalized by the patients mother.

Right thigh has greater circumference (11 inches) than left thigh (10 inches) while right leg has a greater circumference (8

Equal size on both sides of the body, no contractures, no fasciculations and tremors

In ostemyelitis, the infected area becomes painful, swollen, and extremely tender. (The patient may describe a constant, pulsating pain that intensifies with

17

P: tonicity, flaccidity, spasticity, smoothness of movement, strength

Simula ng maospital siya, hindi pa siya nakakaalis ng kama mag isa, kasi hindi niya magalaw yung paa niya as verbalized by the patients mother. When asks if the patient can move the affected area, he responded Hindi, then pointed the affected area.

inches) than left leg (7 inches) Pain with movement on the right leg. Lack of strength on the right leg. Unable to straighten and move the right leg well. Normally firm, smooth coordinated movements, equal strength on each body side No deformities

movement as a result of the pressure of the collecting pus. This creates to the symptoms manifested. Reference: Brunner and Suddarths Medical Surgical Nursing, 12th Ed, 2010.

Bones P: tenderness NEUROLOGIC Mental Status - Language - Orientation - Memory - Attention Span Consciousness Level Glasgow Coma Scale

Tenderness on right leg

No deformities or contractures

Able to express emotion Aware of time and place Able to recall memory Short attention span

Able to express emotion Aware of time and place Able to recall memory Long attention span

Normal Normal Normal Normal Normal

Score of 15 E-4 V-5 M-6

Score of 15

URINARY Color, odor Frequency/amount Urination Dysuria

Amber color of urine 3 diaper fully soaked Urinates well Absence of pain during urination

Amber in color, aromatic >= 30cc/ hr Urinates well Not experiencing pain during urination

Normal Normal Normal Normal

P. HEMATOLOGICAL Bleeding and Bruising

Noong nilinis kanina, mayroon pang dugo at nana pero konti na lang, as verbalized by the patients mother.

When changing dressing, Free of bleeding and there is residual of blood bruising and pus at a minimal amount.

Prothrombin Time

16.5 sec

11-15 sec

Prolonged prothrombin time can be a result on deficiency in vitamin K, malabsorption, or lack of intestinal colonization by bacteria caused by antibiotic therapy.
Reference: Brunner and Suddarths Medical Surgical Nursing, 12th Ed, 2010.

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J. Laboratory Studies/ Diagnostics

Procedure/ Date Complete Blood Count 01/03/2012 Indications Test Nursing Responsibilities Actual 74 g/L 0.22 16.60 Nursing Implications Bone marrow suppression caused by antibiotic therapy reduces total RBC count and therefore lower total hemoglobin content. Decreased hematocrit indicates anemia, such as that caused by iron deficiency or other deficiencies like in vitamins and minerals. Leukocyte count increases in response to certain disease states such as infections or intoxication. In clients case, due to his current condition, osteomyelitis. Segmenters would be elevated if the overall white count is up, usually due to some kind of

The complete blood cell count (CBC) identifies the total number of white and red blood cells, the platelet count, and the hemoglobin and hematocrit. The CBC is carefully monitored in patients with CVD. White blood cell counts are monitored in immunocomprom ised patients and in situations where there is concern for infection (eg, after invasive procedures or surgery). The red blood cells carry haemoglobin, which transports oxygen to the cells. The hematocrit is a measure of the relative proportion of red

Test Hgb mass Hct

Normal 127-183 g/L 0.37-0.54

Leukocyte 4.5 10 count x10 g/L Differential count segmenters 0.50-0.70 lymphocytes 0.20-.0.40 monocytes 0.00-0.07 eosinophils 0.00-0.05 Platelet count 150-400 x 10^g/L Coagulation studies Prothrombin time % activity Act PTT Blood type CRP Semiquantitative CRP MCV MCH MCHc indices 82-92FL 28-32 pg 32-38 % 11-15 sec

0.80 0.09 0.10 0.01 955

16.5 sec 79.4 33.3 sec B Nonreactive <6

22-45 sec

88 29 33

01/05/2012

Hgb mass Hct MCV MCH MCHc

127-183 g/L 0.37-0.54 indices 82-92FL 28-32 pg 32-38 %

91 0.28 88 28 32

Preprocedure 1. Explain test procedure. Explain that slight discomfort may be felt when skin is punctured. Refer to venipuncture procedure for additional information. 2. Avoid stress if possible because altered physiologic status influences and changes normal hemogram values. 3. Select hemogram components ordered at regular intervals (eg, daily, every other day). These should be drawn consistently at the same

19

blood cells and plasma. Low haemoglobin and hematocrit levels have serious consequences for patients with CAD, such as more frequent angina episodes. Platelets are the first line of protection against bleeding. Once activated by blood vessel wall injury or rupture of atherosclerotic plaque, platelets undergo chemical changes that form a thrombus.

time of day for reasons of accurate comparison; natural body rhythms cause fluctuations in laboratory values at certain times of the day. 4. Dehydration or over hydration can dramatically alter values; for example, large volumes of IV fluids can dilute the blood, and values will appear as lower counts. The presence of either of these states should be communicat ed to the laboratory. 5. Fasting is not necessary. However, fat-laden meals may alter some test results as a result of lipidemia.

infection. The primary reason for decreased lymphocytes is viral infections. Decreased lymphocytes in children are a cause of concern as these are the major cells of the body that fight against infections in children unlike adults, where the neutrophils also play an equally important role. An increased number of monocytes in the blood (monocytosis) occur in response to chronic infections, in autoimmune disorders. Elevated monocytes may suggest presence of inflammation which is the bodys response to injury. Prolonged prothrombin time can be a result on deficiency in vitamin K, malabsorption, or 20

1.

2.

3.

4.

Postproced ure Apply manual pressure and dressings to the puncture site on removal of the needle. Monitor the puncture site for oozing or hematoma formation. Maintain pressure dressings on the site if necessary. Notify physician of unusual problems with bleeding. Resume normal activities and diet. Bruising at the puncture site is not uncommon. Signs of inflammatio n are unusual and should be reported if the inflamed area appears larger, if red streaks develop, or if drainage

lack of intestinal colonization by bacteria caused by antibiotic therapy.

Reference: A Manual of laboratory and Diagnoostic Tests 7th edition by Frances Fischbach

21

occurs. NEVER apply a total circumferential dressing and wrap because this may compromise circulation and nerve function if constriction, from whatever cause, occurs

22

K.

Gordons Functional Health Assessment a. Health Perception/Health Management Pattern When asked to describe the clients current health status, the client rate it as 4/10 where 10 is the highest. Prior to hospitalization, the client and her mother admitted that they first consulted albolaryo in an attempt to alleviate the pain and the condition of his son. Regarding the patients hospitalization, he rated it as 6/10, fearing that nurses in white uniform would continue to inject him medication or extract blood from him. According to the clients mother, the client did not have any past major illnesses and chronic diseases aside from the usual fever, cough and colds. He was a fully immunized child according to his mother. J.D. does not have any known allergies in terms foods, medications and in environment. b. Nutritional Metabolic Prior to hospitalization, the J.D.s mother recalled that her sons weight was 25 kg. During his last weight examination, the patients weight dropped to 18 kg despite the minimal change in his appetite. In reference to patients diet preference, he eats variety of foods such as fish, eggs, vegetables, soups, pork, chicken, processed foods. When asked what the usual diet at

home was, rice and along with the food mentioned above became their staple menu. When asked what are the foods the client least preferred, client stated that he had no particular preference because he has a good appetite among variety of foods served by his mother.

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c.

Elimination The client has a diaper and he regularly consumes 3 diapers during daytime and 3 diapers during night. He stated that he does not experience any difficulty and discomfort while urinating. Prior to hospitalization, J.D. defecates once a day. However, change was observed during upon admission as bowel movement increased to 2 3 times a day. Similar to the situation mentioned above, he wears diaper because of difficulty in ambulation. His stool was described as brownish to yellowish. No report of constipation or diarrhea. In reference to his perspiration, J.D. perspires slightly that he attributed to warm moist weather and crowded ward.

d. Activity Exercise Prior to the incident, J.D.s self-care rating (using NANDA scale) was 0 being completely independent as he was able to feed himself, bathe and dress without the assistance of his mother. According to the patients mother, this reflected to the early and strict training and discipline by his eldest sister who served as the patients guardian when they were still in Mindanao. During his stay at the hospital, changes was observed as J.D. experienced difficulty in ambulation. Continuous pain and unceasing administration of parenteral medication were also factors that made the patient felt uneasy and was unable to rest properly. His wound at the right knee and leg also aggravated the situation making him unable to resume his activities of daily living.

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e. Sleep Rest Prior to hospitalization, the client stated that his normal sleeping pattern starts at 9 pm to 8 am only. Sometimes he drinks a glass of milk before going to sleep. He shared that he does not have any difficulty in having sleep.

f. Self Perceptual Self concept The client appears weak and fatigued. During the actual interview for data gathering he was irritable. The clients view of himself coincides with his appearance. He drifts to sleep when not stimulated or bothered. Client declares anxiety over his condition. He was looking forward for his discharge. His thoughts are associated and associated to the questions asked. He has a positive view of his condition. Though he was hospitalized, he believed that this had help strengthen the bond of their family. He greatly believes that wellness is on his way especially when the medical regimen advised was religiously followed. f. Self Perceptual Self concept The client appears weak and fatigue. Client declares anxiety over his condition. He was looking forward for his discharge. He was irritable when talking to us. According to his mother he is afraid of nurses because he thinks that nurses will just hurt him by injecting something to him. g. Role Relationship According to patients mother, her son, J.D. is a good son. She admitted that her son was closer to his father than to her because their father always gave him what he wants. Another factor that could have contributed to the childs preference was her failure to stay with

25

the family when they were younger as she needed to leave Mindanao for Manila to work. For his siblings he is closer to his 3rd brother because his brother knows how to take good care of their toys unlike his 4th brother whom they consider as destroyer because he always tears down their toys. According to R.D.s mother, he prefers to be with his friends whenever he is not doing anything at home he just goes with his friends. J.D.s mother narrated how her son enjoyed being with his playmates all the time that leaving school allowed him to spend more time with his friends. h. Sexuality and Reproductive Pattern The client and the clients family refused to answer questions regarding sexuality and reproductive pattern. i. Coping Stress Tolerance As observed, patient R.D. cries whenever he is under stressful circumstances like when he was given medication by the nurse. According to R.D.s mother, R.D.s way of dealing with his problem is through crying whenever his toys was destroyed by his brother he will just cry because R.D. really give importance to his belongings but when he wanted something and their parents could not afford to give what he want R.D. can understand their parents. When at home, he usually watches television and plays with his siblings. He often goes out to play with his friends. j. Value Belief R.D. goes to church when their father is with them. He is not saying bad words because his mother taught him that saying bad words is not good so he better not do the same thing some of his friends say.

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According to R.D.s mother, RD has fear of the Lord because when she says to RD that if they dont behave God will get mad to him and whenever she says this to RD he will behave. The family also believed to faith healers because according to R.D.s mother before they consulted a doctor they first went to a faith healer to know the possible cause of R.D.s condition.

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II. Problem List a. Actual Problem

Problem No. 1 2 3 4 5 Problems Pain at the right lower extremity Fever with temperature of 38.1C BMI = 14.37 Incision and Drainage site Limited ROM and Functional Classification of 3 Nursing Diagnoses Acute Pain in Right Lower Extremity Hyperthermia Imbalance Nutrition; Less than Body Requirements Impaired Skin Integrity Impaired Physical Mobility Date Identified January 5, 2012 January 5, 2012 January 5, 2012 January 5, 2012 January 5, 2012

b. High Risk or Potential

Problem Problem No. 6 Increased WBC and Osteomyelitis 7 Inability to move right lower extremity well Nursing Diagnosis Risk for Extension of Infection Risk for Falls Date Identified January 5, 2012 January 5, 2012

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I.

Nursing Care Plan a. Actual Problems Acute Pain at the right lower extremity

DIAGNOSIS BACKGROUND KNOWLEDGE Subjective: Acute Pain Unpleasant Di ko maigalaw in the right sensory and ang binti ko kasi legarea emotional masakit. related to experience felt as verbalized by the compression by the patient patient of pain arising from receptors explicit tissue Objective: (nociceptors) damage resulting secondary to from injury of y With facial grimace especially osteomyelitis right lower extremity when right lower extremities is touched y Pain Assessment Provokes-felt pain suddenly when he move his leg too much. Quality He experienced

ASSESSMENT

PLANNING

IMPLEMENTATION

RATIONALE Rationale 1. To evaluate clients current health status and to determine factors that could contribute to pain.

EVALUATION GOAL MET At the end of the shift, the patient:

At the end of the Independent: shift, the patient 1.Assessed clients condition will: and perceptions, along with behavioral and physiologic 1. Report pain is responses. Noted clients attitude toward pain and controlled if use of specific pain not relieved medication. (alleviation of pain from 6/10 2.Monitored vital signs. to at least 2/10) 2. Follow prescribed pharmacologic 3.Performed and documented al and noncomprehensive assessment pharmacologic al methods that of pain. Determined clients acceptable level of pain on provide relief. facial expression scale 3. Demonstrate use of relaxation skills and diversional

y Reported pain relief of 2/10 from 7/10 2. For baseline data of y Followed patients condition and prescribed determine any abnormality pharmacologic due to pain. al and nonpharmacologic 3. It provides information al methods about condition (splinting) that progression or resolution, provide relief. development of y Used complications and diversional effectiveness of activities such interventions, thus as playing his appropriate interventions toys. can be done.
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sharp, excruciating pain on his right leg Radiates - the pain is start at the knee area extending to the thigh and right lower leg Severity - Pain scale of 6/10 (with 10 being the highest and 1 being the lowest). Time pain started on November 22, 2011 when J.D. went home with abrasion and pain on his right knee. From then on, the pain continuously increased.

activities

4.Accepted clients description of pain.

4. Pain is a subjective explanation and must be described by the client.

5.Observed nonverbal cues or 5. Observations may not be congruent with verbal pain behaviors and other reports or may be only objective defining indicator present when characteristics client is unable to verbalize. 6.Provided comfort measures 6. To promote non pharmacological pain and calm activities. management. 7. Encouraged diversional activities such as playing 7. To distract focus on the pain. with toys.

Collaborative: 1. T o promote continuity 1. Coordinate with and collaboration patient other health team members in reducing care. the patient pain. 2. Referred to physical therapy. 2. For prescription of passive ROM exercises that will not aggravate the patients pain. Reference: Nurses Pocket Guide 11th edition

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Hyperthermia ASSESSMENT Subjective cues: DIAGNOSIS BACKGROUND KNOWLEDGE Diagnosis Body temperature elevated above Hypertherm normal range ia r/t presence of imflammato ry process as evidence by increase body temperature, flushed skin warm to touch PLANNING IMPLEMENTATION Independent: 1. Assessed patients vital signs RATIONALE EVALUATION Goal met as evidence by the patient temperature from 38.1c36.9c

Naiinitan po ako nang kaunti as verbalized by the client when asked about how is he feeling . Panaka-naka ay nilalagnat siya as verbalized by the mothers patient

After 30 minutes of nursing intervention of the patients temperature will decrease from 38.1c to 37.0c

2. Identified underlying cause of hyperthermia

1. This serve as a baseline for nursing intervention to intervene accordingly 2. To determine the intervention needs for specific cause of fever 3. Evaporation is decreased by environmental factors of high humidity and high ambient temperature, as well as body factors producing loss of ability to sweat or sweat glands dysfunction. 4. Room temperature or number of blankets should be altered to maintain near normal temperature

3. Noted for absence of sweating as a body attempts to increase heat loss by evaporative, conduction, and diffusion

Objective:  Warm to touch noted  Flush skin noted  Headache noted  Facial grimace noted

4. Monitored environmental temperature; limit or add bed linens as indicated

31

 Body weakness noted  Irritability noted  With temperature of 38.1c

5. Provided tepid sponge baths; avoid use of alcohol

5. May help reduce fever

Dependent: 1. Refer the temperature to the clinical instructor to be reffered to the nurse on duty for the administration of paracetamol

1. Paracetamol is reduces fever by direct action on hypothalamus heat regulating center with consequent peripheral vasodilation, sweating and dissipation of heat

2. Administered continuous PNSS and 0.3 NaCl as ordered by the doctor

2. PNSS is a isotonic solution. 0.3 NaCl is a hypotonic solution which increases and support circulating volume tissue perfusion.

Collaborative: 1. Instructed the patient to increase fluid intake 1. To support circulating volume and tissue perfussion

Reference: Nurses Pocket Guide 11th edition

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Imbalanced Nutrition: Less Than Body Requirements ASSESSMENT Subjective: Bumaba nga ang timbang niya mula ng maospital siya. Dati 25 kg iyan, ngayon nasa 18 kg an lang, as verbalized by the patients father. Ayan nagsuka na naman, palagi iyan pagkatapos ibigay ang gamot. Medyo nagtae ang anak ko, as verbalized by the patients mother. DIAGNOSIS Imbalanced Nutrition: less than body requirements related to decreased appetite as manifested by weight loss BACKGROUND PLANNING KNOWLEDGE Intake of nutrients Short Term Goal insufficient to meet After 8 hours of metabolic needs nursing intervention, the patient will be able to have: y Increased appetite every meal Long Term Goal After 2 weeks of nursing intervention, the patient will be able to: y Gain 2 pounds per week for the next 3 weeks y Exhibit no signs and symptoms of malnutrition by time of discharge from treatment y Maintain IMPLEMENTATION Independent: 1.Assessed clients weight; BMI and note age, body build, strength, activity Rationale 1. To establish baseline parameters for interventions and these will help determine the clients nutritional needs. EVALUATION Goal met Client has shown a slow, progressive weight gain during hospitalization

2.Evaluate total 2. To reveal possible cause of malnutrition daily food or changes that could intake. Obtain be made in clients diary of calorie intake. intake , and patterns and times of eating 3. It is necessary to 3.Keep strict make an accurate documentation nutritional assessment of intake, and maintain client output and safety. calorie count. 4.Weigh client daily. 4. Weight loss or gain is important assessment information.
33

Objective: Weight = 18 kg Height = 1.15 m BMI = 14.37 Weight Loss (from 25kg to 18kg)

Decreased appetite Vomits an estimated amount of 50 ml during the interview. Diarrhea (Defecated two to three times a day) Ectomorph

electrolytes and blood 5.Ensure that 5. counts within client receives normal limits small, frequent feedings, Demonstrate including a a steady bedtime snack, weight gain rather than Exhibit three larger increased meals energy in participation 6. in activities. 6.Explain the importance of adequate nutrition and fluid intake.

Large amounts of food may be objectionable, or even intolerable, to the client.To establish a baseline data and to determine the effectiveness of care given. Client may have inadequate or inaccurate knowledge regarding the contribution of good nutrition to overall wellness.

(Reference: Nurses Pocket Guide 11th edition pp 478483)

7.Encourage 7. To stimulate appetite. client to choose foods or have family member bring foods that seem appealing

34

8.Observe for 8. These indicate absence of protein-energy subcutaneous malnutrition to give immediate and fat/ muscle appropriate to the wasting, loss client for these signs of hair, and symptoms. fissuring of nails, delayed healing, gum bleeding, swollen abdomen. etc., Dependent 9.To provide a positive 9. Administer nitrogen balance to aid multi in skin or tissue healing vitamin and to maintain general and good health mineral 10. Laboratory values provide objective data regarding nutritional status and for the nurse to intervene immediately if there is significant change.

10. Monitor laboratory values, and report significant changes to physician.

35

Collaborative 11. Consult dietician or nutritional team, as indicated and determine number of calories required. 11. To provide adequate nutrition and realistic ( according to body structure and height) weight gain

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Impaired Skin Integrity

Assessment

Diagnosis Impaired skin integrity related to incision and drainage (I&D) site at the right proximal tibia

Subjective Data: Yang sugat nya sa paa pinutok yan noong nasa San Lazaro pa kami, as verbalized by the patients mother.

Objective Data: y Light brown skin on all extremities and darkened skin around the affected y edematous area on the right thigh and

Background Knowledge Altered epidermis and/or dermis caused by the incision site from status post incise and drain (I&D) to remove the accumulation of pus in the injured area of the bone specifically on the right tibia

Planning At the end of the shift, the patient will be able to:

Implementation

Rationale

Evaluation

Independent: 1. Assessed skin integrity for possible complications. Noted skin color, texture and - Display timely turgor near the incision healing of incision site. site without 2. Assessed blood supply complication and sensation of the affected area (proximal -Maintain optimal tibia) nutrition and physical wellbeing

1. To check areas that At the end of the might indicate infection shift, the client and to intervene was able to: accordingly. - Display timely healing of 2. Decreased blood incision site supply and sensation of without the affected area may complication lessen the healing time of the incision and can2. -Maintain optimal contribute to infection nutrition and of the I&D site physical wellbeing 3. Obtain a history of 3. To determine factors condition, including that could increase the age of onset, date of risk of patient in further first episode, original skin breakage and to site/ characteristics of intervene accordingly. (Reference: lesions, duration of Nurses Pocket problem and changes Guide 11th edition that have occurred over pp 619-623) time.
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leg y skin abrasion on the right knee y incision site on the right middle leg (for status post incise and drain) 1.

4. Determined nutritional status and potential for delayed or tissue injury exacerbated by malnutrition.

4. Poor nutrition alters timely incision site healing.

5. To assist bodys natural 5. Kept the wound area process repair. clean/ dry, carefully Increasing blood dressed wounds and supply in the affected stimulated circulation to area increases the surrounding areas. healing time of the incision site. 6. Emphasized importance 6. To maintain general good health and skin of adequate nutritional/ turgor fluid intake to the client and significant others Dependent: 7. Provided optimum nutrition by giving vitamins as ordered by the physician.

7. To provide a positive nitrogen balance to aid in skin/tissue healing and to maintain general good health. 8. To enhance healing by Collaborative: provision of proper 8. Referred to dietitian as nutritional intake. appropriate for proper diet of the patient.

38

Impaired Physical Mobility Assessment Subjective: Simula ng maospital siya, hindi pa siya nakakaalis ng kama mag-isa, kasi hindi niya magalaw yung paa niya as verbalized by the patients mother. When asked if the patient can move the affected area, he responded Hindi, then pointed the affected area. Objective: y Pain with movement and tenderness of the right leg y Limited Diagnosis Impaired Physical Mobility related to pain at the right proximal tibia secondary to (acute infection in the bone/ incision and drainage site) Background Knowledge Limitation in independent, purposeful physical movement of the body or of one or more extremities due to physical dysfunction caused by underlying disease of the patient, osteomyelitis, which is infection of the bone. Incise and drain was done to remove the accumulation of pus in the bones. Immobility can be classified into: 0-Completely independent Planning At the end of the shift, the patient will: y Cooperate with the student nurse in treatment regimen and safety measures y Participate in ADLs and desired activities such as eating, maintenance of proper hygiene Implementation Independent: 1. Assessed patients condition. Rationale Evaluation At the end of the shift, the patient was able to: y Cooperate with the student nurse in treatment regimen and safety measures y Partially participate in ADLs and desired activities such as eating, maintenance of proper hygiene.

1. To obtain baseline information about the patients condition. 2. To determine abnormalities thus provide immediate intervention.

2. Identified underlying condition that cause/exacerbate problems associated with inactivity or immobility. 3. Performed and documented comprehensive assessment of pain.

3. To know what condition (osteomyelitis) and surgery (I&D) affect the client and consequently address patients needs. 4. The patient was classified in the 3rd functional level of immobility noting that he requires help from another person and equipment upon movement. 5. To determine feelings of frustration/ powerlessness that may impede attainment of goals.

4. Determined the degree of immobility in relation to previously suggested scale.

5. Noted emotional or behavioral responses to problems of immobility.

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ROM: -inability to perform gross motor activities such as walking - Lack of strength on the right leg -Unable to straighten and move the right leg well. -unable to perform ADL without assistance y Functional Level Classification of 3 - Requires help from another person and equipment

1-Requires use of equipment/device 2- Requires help from another person for assistance, supervision or teaching 3- Requires help from another person and equipment 4- Dependent, does not participate in activity

6. Determined presence of 6. To address possible complications related to complication such as immobility. pressure ulcer, infection, contractures or anxiety which will impede recovery of the patient 7. Assisted patient in a comfortable position. 8. Supported the lower limb with pillows. 7. To reduce anxiety felt by the client. 8. To maintain position and reduce risk for pressure ulcers. 9. To avoid stress.

9. Encouraged frequent rest periods. 10. Encouraged adequate intake of fluids and nutritious foods

10. It promotes wound healing, well-being and maximizes energy production. 11. To enhance understanding of the patients condition and will promote correct management of the condition Collaborative: 1. To avoid falls or further injury. (Reference: Nurses Pocket Guide 11th edition pp 457-461)
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11. Discussed the cause of the condition and management for immobility to the patient and relatives Collaborative: 1. Coordinated with the nurses on duty in providing safety measures to the patient.

B. High Risk Problem Risk for extension of infection: bone abscess formation Assessment Risk factors:  Inadequate primary defences (incision and drainage site)  Decreased hemoglobin  Malnutrition  Pharmaceutical agent (antibiotic therapy) Diagnosis Risk for extension of infection: bone abscess formation related to inadequate secondary defences Background Knowledge At increase risk of being invaded by pathogenic organisms. Planning Intervention Implementation Rationale Independent 1. To assess 1. Observed for patients localized signs present of infection at condition the site of incision and drainage 2. To limit exposure, thus reduce crosscontamination Expected Outcome 1. Patient will verbalize understandi ng of individual risk factors 2. Patient performed intervention s to prevent infection 3. Patient is afebrile and free of purulent drainage

At the end of the shift the patient will be able to : 1. Verbalize understandin g of individual risk factors 2. Monitored 2. Identify clients interventions visitors/ to reduce risk caregivers for of infection respiratory 3. Achieve illnesses timely wound healing ; be 3. Performed free of daily mouth purulent care. drainage or erythema ; be afebrile

3. To maintain good oral hygiene and prevent source of infection

4. Recommended 4. To reduce bacterial routine or colonization preoperative body scrub as indicated

41

5. Instructed client in techniques to protect the integrity of skin

5. To prevent further skin breakdown and increase risk of infection

6. To prevent 6. Included post information in operative preoperative infection teaching about ways to reduce potential for post operative infection. Dependent: 7. Administered antibiotics such as amikacin, cefazolin, and penicillin G. Collaborative: 8. Stress proper hand hygiene by all caregivers between therapies and clients 7. Antibiotics slows down and kills the growth of bacteria

8. A first line defenses against healthcare associated infections (HAI).

(Reference: Nurses Pocket Guide 11th Edition pp 409413)

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Risk For Falls ASSESSMENT DIAGNOSIS

BACKGROUND KNOWLEDGE

PLANNING

IMPLEMENTATION

RATIONALE 1. To determine presence of risk factors that might increase the risk of the patient for falls.

EVALUATION Goal Met At the end of the shift, the client was able to: 1.Verbalize risk factors that contribute to his possibility of fall such as the side effects of the drug he is taking and due to weakness of his lower extremities 2.Demonstrate behaviours to reduce risk factors and protect self from injury by allowing others to assist him and by sitting and standing slowly 3.Be free of injury/fall
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Risk for falls Increased Risk Factors: related to susceptibility to decreased falling that may y Decree cause harm. strength on right mobility lower extremity. y Impaired physical mobility

Short Term Goal: Independent: After 8 hours of 1. Observed individuals nursing intervention general health status, the patient will be noticing factors that able to: might affect safety, such y Identify factors as use of multiple recent that increase medications, potential for fall by trauma. the end of the day muscle y Remain free of 2. Assessed strength, gross and fine falls per shift motor coordination, review history of past or Long-Term Goal current physical injuries. y Client will not experience any falls 3. Reviewed history of during stay prior falls associated with y Client will make immobility, weakness, necessary physical and prolonged bed rest. changes in environment to 4. Ascertained clients ensure increased and significant others safety within first level of knowledge about week of returning attendance to safety home needs. y Verbalize willingness of 5. Oriented client to patient and environment. Assess significant others to ability to use side rails, demonstrate and bed controls. behavior lifestyle to

2. To determine factors that alter the patients coordination gait and balance that could increase that patient for falls. 3. To predict risk for falls current

4. These measures will help the client to cope with an unfamiliar environment

5. To increase clients awareness on his environment and to promote cooperation on maintaining his safety

reduce risk factors 6. Made changes in and protect self clients environment that from injury. may cause or contribute to injury 7. Identified factors that may cause or contribute to injury from a fall

6. To lessen the risk for fall of the client.

7. This will serve as the basis for the intervention needed to maintain and promote the safety of the patient. 8. To determine how the medications affect the client, its side and adverse effects

Dependent: 8. Reviewed medication regimen prescribed by the physician

Collaborative 9. Encouraged and demonstrated ROM exercises of lower extremities to client and significant others. 10. Stressed the importance of monitoring conditions/risks that may contribute to occurrence of falls to the significant others and the client and the need to practice client safety.

9. To improve muscle tone of the legs and prevent falls

10. To improve participation of the significant others to the clients care and safety.

(Reference: Nurses th Pocket Guide 11 edition pp 291-295)

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IV. Anatomy and Physiology

Anatomy and Physiology The human skeleton consists of both fused and individual bones supported and

supplemented by ligaments, tendons, muscles and cartilage. It serves as a scaffold which supports organs, anchors muscles, and protects organs such as the brain, lungs and heart. The biggest bone in the body is the femur in the thigh and the smallest is the stapes bone in the middle ear. In an adult, the skeleton comprises around 3040% of the total body weight, and half of this weight is water. Fused bones include those of the pelvis and the cranium. Not all bones are interconnected directly: there are three bones in each middle ear called the ossicles that articulate only with each other. The hyoid bone, which is located in the neck and serves as the point of attachment for the tongue, does not articulate with any other bones in the body, being supported by muscles and ligaments.

Development Early in gestation, a fetus has a cartilaginous skeleton from which the long bones and most other bones gradually form throughout the remaining gestation period and for years after birth in a process called endochondral ossification. The flat bones of the skull and the clavicles are formed from connective tissue in a process known as intramembranous ossification, andossification of the mandible occurs in the fibrous membrane covering the outer surfaces of Meckel's cartilages. At birth, a newborn baby has over 300 bones, whereas on average an adult human has 206 bones[2] (these numbers can vary slightly from individual to individual). The difference comes from a number of small bones that fuse together during growth, such as thesacrum and coccyx of the vertebral column.

Organization There are over 206 bones in the adult human skeleton, a number which varies between individuals and with age newborn babies have over 270 bones some of which fuse together into a longitudinal axis, the axial skeleton, to which the appendicular skeleton is attached.

45

Axial skeleton The axial skeleton (80 bones) is formed by the vertebral column (26), the rib cage (12 pairs of ribs and the sternum), and the skull (22 bones and 7 associated bones). The axial skeleton transmits the weight from the head, the trunk, and the upper extremities down to the lower extremities at the hip joints, and is therefore responsible for the upright position of the human body. Most of the body weight is located in back of the spinal column which therefore have the erectors spinae muscles and a large amount of ligaments attached to it resulting in the curved shape of the spine. The 366 skeletal muscles acting on the axial skeleton position the spine, allowing for big movements in the thoracic cage for breathing, and the head. Conclusive research cited by the American Society for Bone Mineral Research (ASBMR) demonstrates that weightbearing exercise stimulates bone growth. Only the parts of the skeleton that are directly affected by the exercise will benefit. Non weight-bearing activity, including swimming and cycling, has no effect on bone growth.

Appendicular skeleton The appendicular skeleton (126 bones) is formed by the pectoral girdles (4), the upper limbs (60), the pelvic girdle (2), and the lower limbs (60). Their functions are to make locomotion possible and to protect the major organs of locomotion, digestion, excretion, and reproduction.

Function The skeleton serves six major functions. Support The skeleton provides the framework which supports the body and maintains its shape. The pelvis and associated ligaments and muscles provide a floor for the pelvic structures. Without the ribs, costal cartilages, the intercostal muscles and the heart would collapse. Movement The joints between bones permit movement, some allowing a wider range of movement than others, e.g. the ball and socket joint allows a greater range of movement than the pivot joint at the neck. Movement is powered by skeletal muscles, which are attached to the skeleton at various sites

46

on bones. Muscles, bones, and joints provide the principal mechanics for movement, all coordinated by the nervous system. Protection The skeleton protects many vital organs:
      

The skull protects the brain, the eyes, and the middle and inner ears. The vertebrae protects the spinal cord. The rib cage, spine, and sternum protect the lungs, heart and major blood vessels. The clavicle and scapula protect the shoulder. The ilium and spine protect the digestive and urogenital systems and the hip. The patella and the ulna protect the knee and the elbow respectively. The carpals and tarsals protect the wrist and ankle respectively.

Blood cell production The skeleton is the site of haematopoiesis, which takes place in red bone marrow. Storage Bone matrix can store calcium and is involved in calcium metabolism, and bone marrow can store iron in ferritin and is involved in iron metabolism. However, bones are not entirely made of calcium,but a mixture of chondroitin sulfate and hydroxyapatite, the latter making up 70% of a bone. Endocrine regulation Bone cells release a hormone called osteocalcin, which contributes to the regulation of blood sugar (glucose) and fat deposition. Osteocalcin increases both the insulin secretion and sensitivity, in addition to boosting the number of insulin-producing cells and reducing stores of fat.

Sex-based differences There are many differences between the male and female human skeletons. Most prominent is the difference in the pelvis, owing to characteristics required for the processes of childbirth. The shape of a female pelvis is flatter, more rounded and proportionally larger to allow the head of a fetus to pass. A male's pelvis is about 90 degrees or less of angle, whereas a woman's is 100 degrees or more. Also, the coccyx of a female's pelvis is oriented more inferiorly whereas the man's coccyx is
47

usually oriented more anteriorly. This difference allows more room for a developing fetus. Men tend to have slightly thicker and longer limbs and digit bones (phalanges), while women tend to have narrower rib cages, smaller teeth, less angular mandibles, less pronounced cranial features such as the brow ridges and external occipital protuberance (the small bump at the back of the skull), and the carrying angle of the forearm is more pronounced in females. Females also tend to have more rounded shoulder blades.

48

49

V. Pathophysiology Modifiable Factors: y y y Traumatic injury (fall) Malnourished Impaired immune system Non-modifiable Factors: y y Age: 8 years old Gender: Male

Extension of soft tissue

Infecting agent

Metaphysis (growing bone)

Feed upon the surrounding tissue

Inflammatory cell activation and bone destruction

Leukocytosis

Phagocytic cells Toxic oxygen radicals Proteolytic enzymes

PAIN

Vascularity

Edema Swelling

Purulent Drainage

Intraosseous pressure

Blood flow impairment

Ischemic bone necrosis

OSTEOMYELITIS

Abscess Formation Venous sinus clots Sequestrum

Incision and Drainage

50

Involocrum

VI. Medical Management Pharmacotherapeutics (Medications)

AMIKACIN SULFATE
DRUG MECHANISM OF ACTION INDICATION CONTRAINDICATION  For serious Inhibits  Contraindicated infections protein in patients caused by synthesis by hypersensitive to sensitive strains drugs or other binding of directly to the aminoglycosides 30S ribosomal Pseudomonas  Use cautiously aeruginosa, subunit; in patients with Escherichia bactericidal impaired renal coli, Proteus, function or Klebsiella or neuromuscular Staphylococcus ADVERSE EFFECT DRUG INTERACTION NURSING RESPONSIBILITY

Generic Name: amikacin sulfate Brand Name: Amikin Dosage: 500 mg Classification: Aminoglycosides Form: Injection Route: Intravenous

 Uncomplicate d UTI caused by organisms not susceptible to less toxic drugs

disorders, in neonates and infants, and in elderly patients

CNS: neuromuscular blockade EENT: ototoxicity GU:azotemia, nephrotoxicity, increase in urinary excreation of casts MUSCULO: arthralgia RESPI: apnea

1. Assess patient for infection (vital signs; Inactivated by appearance of wound, urine and stool; penicillins and WBC) at the beginning and during therapy. cephalosporins 2. Obtain specimen for culture and sensitivity when test before giving first dose coadministered 3. Follow the 10 rights of medication to patients with administration renal 4. Correct dehydration before therapy because insufficiency dehydration increases risk of toxicity. 5. Keep patient well hydrated (15002000ml/day) during therapy. 6. Monitor intake and output and daily weight to assess hydration status and renal function. 7. Monitor renal function: urine output, specific gravity, Urinalysis, BUN, creatinine levels &creatinine clearance. Report to prescriber evidence of declining renal function. 8. Watch out for signs and symptoms of superinfection (especially of upper respiratory tract) such as continued fever, chills and increase pulse rate 9. Instruct patient to promptly report adverse reactions to prescriber 10. Encourage patient to maintain adequate fluid intake.

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ANCEF
DRUG MECHANISM INDICATION CONTRAINDICA -TION OF ACTION ADVERSE EFFECT
DRUG INTERACTION

NURSING RESPONSIBILITY

First  Perioperative  Contraindicate CNS: headache, generation prevention in d in patients confusion, seizures cephalospori contaminated hypersensitive CV: phlebitis, n that surgery to drugs or thrombophlebitis inhibits cell-  Infections of other with IV injection Brand Name: wall bone and joint cephalosporins GI: nausea, Ancef synthesis, infections;  Use cautiously anorexia, diarrhea, promoting respiratory, in patients glossitis, dyspepsia, Dosage: osmotic biliary, and hypersensitive abdominal cramps, 500mg instability, genitourinary to penicillin pseudomembranou usually tracts; skin, because of the s colitis, oral Classification: bactericidal soft tissue, possibility of candidiasis First septicemia crossHEMAT: generation sensitivity neutropenia, cephalosporin with other leucopenia, betalactam eosinophilia, Form: antibiotics thrombocytopenia Injection  Use cautiously SKIN: in patients maculopapular and Route: with a history erythematous Intravenous of colitis or rashes, pruritus, renal pain, induration, insufficiency sterile abscesses, Others: hypersensitivity reactions, serum sickness, anaphylaxis, drug fever Generic Name cepazolin sodium

Inactivated 1. Assess patient for infection (vital signs; by penicillins appearance of wound, urine and stool; and WBC) at the beginning and during therapy. aminoglyco- 2. Before initiating the therapy, obtain a sides when history to determine previous use of and coreaction to penicillins/ cephalosporins. administered Persons with a negative history of penicillin to patients sensitivity may still have an allergic with renal response. insufficiency 3. Obtain specimen for culture and sensitivity tests before giving first dose 4. Follow the 10 rights of medication administration 5. Tell patient to report discomfort at IV injection site. 6. Monitor IV site frequently for thrombophlebitis (pain, redness, swelling). Change site every every 48-72 hr to prevent phlebitis. 7. If aminoglycosides are administered concurrently, administer in separate sites, if possible, at least 1 hour apart. If second site is unavailable, flush line between medications. 8. Advise patient to report adverse reactions promptly and notify prescriber if a rash develops or if signs and symptoms of superinfection appears such as recurring fever, chills and malaise

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PARACETAMOL
DRUG MECHANISM INDICATION CONTRAINDICA OF ACTION -TIONS ADVERSE EFFECT DRUG INTERACTIONS NURSING RESPONSIBILITIES

Reduces fever by direct action on hypothalamus Brand Name: heat regulating Abenal center with consequent Classification: peripheral vasodilatation, Antipyretic, sweating, and analgesia dissipation of heat Dosage: 30 mg Generic Name: Paracetamol Route: IV Frequency: PRN

Fever reduction. Temporary relief of mild to moderate pain

Hypersensitivity to paracetamol

Body as a whole: Rashes, anorexia, nausea Use cautiously in and vomiting, patients with dizziness, hepatic disease/ lethargy, chills, renal disease diaphoresis and abdominal pain GU: renal failure (high doses/ chronic use GI: hepatotoxicity (overdose)

1. Assess overall health status before administering paracetamol. Cholestyramine Malnourished patient are at higher risk may decrease of developing hepatotoxicity with acetaminophen chronic use of usual doses of this drug. absorption. 2. Assess fever; note presence of associated Chronic signs (diaphoresis, tachycardia and ingestion of malaise). 3. Observe 10 rights of drug alcohol may administration. cause 4. Educate about side effects of drug. heptotoxicity 5. Do not exceed the recommended dosage 6. Consult physician if needed for children <3 yr; if needed for longer than 10 days; if continued fever, severe or recurrent pain occurs (possible serious illness). 7. Avoid using multiple preparations containing acetaminophen. Carefully check all OTC products. 8. Give drug with food if GI upset occurs. 9. Discontinue drug if hypersensitivity reactions occur. 10. Treatment of overdose: Monitor serum levels regularly, 11. N acetylcysteine should be available asa specific antidote; basic life support measures may be necessary

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PENICILLIN G BENZATHINE
DRUG MECHANISM INDICATION CONTRAINDICATIONS OF ACTION ADVERSE EFFECT DRUG INTERACTIONS NURSING RESPONSIBILITIES

Interferes with bacterial cell wall synthesis during active multiplication, Brand Name: causing cell Megacillin wall death and resultant Classification: bactericidal Anti infective activity against Dosage: susceptible 5 ml & 10 ml bacteria u Generic Name: Penicillin G Benzathine Route: IV Frequency: q12

CNS: Lethargy, hallucinations, Treatment of Allergies to seizures a wide penicillins, GI: Glossitis, variety of cephalosporins, gastritis,sore mouth, infections or other blackhairy tongue, caused by allergens nausea, vomiting, sensitive abdominal pain, bloody diarrhea, organisms enterocolitis, (streptococci) pseudomembranous - URTI colitis, nonspecific caused by hepatitis sensitive GU: Nephritis streptococci Hematologic: Anemia, thrombocytopenia, leukopenia, neutropenia Hypersensitivity: Rash, fever, wheezing, anaphylaxis Local: Pain, phlebitis, thrombosis at injection site Other: Superinfections, Na overload leading to heart failure

1. Assess patient for infection (vital signs; appearance of wound, urine and stool; Drug to drugWBC) at the beginning and during therapy. Decreased 2. Before initiating the therapy, obtain a effectiveness history to determine previous use of and with reaction to penicillins/ cephalosporins. tetracyclinesPersons with a negative history of penicillin Inactivation sensitivity may still have an allergic of parenteral aminoglycosides response. (amikacin, 3. Observe 10 rights of drug administration. gentamicin,kana 4. Reduce dosage with hepatic or renal failure mycin, 5. Assess for hypersensitivity to drug.- Assess neomycin, for any contraindications to the drug tobramycin 6. Change IV site every 48 hrs to prevent phlebitis 7. Educate about side effects of drug. 8. Monitor client for at least 30minutes. 9. Arrange for regular follow-up, including blood tests, to evaluate effects. 10. Instruct to report difficulty breathing, rashes, severe pain at injection site, mouth sores, unusual bleeding or bruising. 11. Instruct to take medication as directed for the full course of therapy, even if feeling better 12. Do proper documentation
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VI. Doctors Order Date / Time Day 1 1/3/2012 Progress Notes  Please admit pt to WOC under Co  DIC M. Velasco  Monitor VS q shift  Labs CBC with Plt, ESR. CRP(quantitative) Ct, BT, PTT, Blood typing  Round GS&Cs  Meds please load Cefazolin 1 gm/IV ( )ANST q8 Amithacin 500mg/IV ( )ANST q12 Pen G 10 m u/ IV after 5 ml u q12 Paracetamol 30mg/ IV q4 prn for fever Multivitamins once a day  IVF: D5 0.3 NaCl 500 cc @ KVO  Please give Pen G loading dose 5 ml u Day 2 1/4/2012 1:15 pm Day 4 1/6/2012 11:12 am  Kindly transfuse 250cc PRBC properly typed and cross matched  Refer  (-) Subjective complaints  (+) swelling, tenderness @ R leg  Osteomyelitis  For debridement  For repeat H&H Post BT  IVF D5 0.3 NaCl 500 cc @ KVO  Prepare 2 u FWB for OR  Please transfuse 250 ml of PRBC properly typed and matched  For repeat H&H after  PNSS 1LxKVO

12:14 pm

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VII. Discharge Health Teaching Plans TEACHINGS Diet y y y y y CONTENT High in vitamins and protein to promote positive nitrogen balance and healing DAT Encourage adequate hydration ROM exercises of unaffected extremities The affected area with osteomyelitis is immobilized to decrease discomfort and to present pathologic fracture of the weakened bone Encourage patient to have a good sleeping habit Discuss the importance of having an adequate rest period Demonstrate and encourage patient to perform regular wound dressing Antibiotic therapy RTC (Penicillin G/ Cephazolin orally for 3 months) Medication should not be administered with food to enhance absorption. Teach warm compress techniques and aseptic dressing Instruct patient and family to observe for and report elevated temperature, odor, signs of increased inflammation, adverse reactions and signs of super infection.

Exercise

Activity, Lifestyle changes

y y y

Drugs

y y

Health Teaching

y y

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VIII. Summary of Client Status as of Last Day of Contact January 6, 2011, 10am-2pm shift at Philippine Orthopedic Center

Patient J.D. still is febrile with temperature of 37.8C. He is on diet as tolerated, as prescribed by physician. He still has swelling on his right lower extremity so he remains on bedrest. He performs his activities of the daily living with assistance from his mother and the nurse on duty.

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