nca - pop it like myelitis (1).pdf

Nursing Competency Appraisal – DREAM TEAM - Group 2 Section B – CLASS 2016 [Chronic Osteomyelitis Left Thigh]

West Visayas State University COLLEGE OF NURSING

La Paz, Iloilo City

I. Vital Information

Name: E.D.D. Date of Interview: July 9, 2015 | 6:00 PM

Age: 26 years old Informant: E.D.D.

Sex: Male Relationship to patient: Patient himself

Address: Brgy., Libo-on, Dingle, Iloilo

Civil Status: Single

Date and Time Admitted: June 23, 2015 |12:25 P.M.

Chief Complaint: “Gasakit akon wala nga batiis kag wala gaayo.”

Ward: OSSW

Bed No.: 19

Allergies: Shrimp Paste

Religious Affiliation: Roman Catholic

Physician: Dr. J.

Impression/Diagnosis: Osteomyelitis Left Thigh

Pre-Op Diagnosis: Chronic Osteomyelitis Left Thigh

Post-Op Diagnosis: Chronic Osteomyelitis Left Thigh

Surgical Operation Performed: Debridement Curettage, Application of Gentamycin

Beads

Days Post-Op: 1 day


II. CLINICAL ASSESSMENT

II. A.: NURSING HISTORY

A. History of Present Illness

a. Usual Health Status

E.D.D. is a 28-year old farmer who lives with his father. Before being hospitalized, EDD

claimed that he has been consuming almost all of his time farming. He likes to eat vegetables

and does not like shrimp paste. He does not exercise as he devotes mostof time farming.

E.D.D. is an occasional alcoholic beverage drinker and doesn’t smoke. He takes Koi herbal

capsule 500mg OD everyday. He believes in quack doctors and “hilots”.

B. Chronologic History

E.D.D. is a 26 year old farmer who works every day since he was 16 years old.

10 months PTC, August 2014, while plowing the field bear footed, he noticed an

appearance of a boil characterized by a pus-filled red lump about the size of a pea on the left

lateral side of his left leg. He claimed that he just pinched it and continued on working. The next

day he went to the clinic because the area surrounding the boil became reddened and swollen.

The doctor prescribed him with cloxacillin sodium PO b.i.d. which he complied for a week and

fusidate sodium topical ointment t.i.d. which he claimed to use for 1 month. He claimed that he

continued working while taking the prescribed medications. The boil completely healed after a

month.

7 months PTC, on the first week of November 2014, after E.D.D. cut 5 large bamboos he

felt a throbbing pain, 3-4 inches in diameter, with pain scale of 8/10 starting from the left lateral

side of his thigh radiating to the upper and lower part of his thigh for five minutes. He claimed

that the affected area is warm to touch. He verbalized that he just rested and pain was relieved

with pain scale of 5/10. After 3 days, he experienced fever, with temperature unrecalled. He took

paracetamol 1 tab PO PRN and was relieved after 2 hours. The pain at his thigh with a pain scale

of 8/10 continued to recur lasting for 30 minutes to few hours. He just takes a rest until the pain

subsides. Two weeks after, E.D.D used an electric massager to relieve the pain at his thigh but

he verbalized that it became more swollen making it more painful with a pain scale of 9/10.

6 months PTC, December 2014, the pain became more recurrent. He was experiencing

the pain approximately 3-4 times throughout the day and is often precipitated by hearing loud


noises such as loud talking of a group of people. The pain radiates to his whole body with a pain

scale of 8 out of 10. Swelling of the thigh was noted and walking became difficult for him. They

went to an albularyo and he was given a “Lana” which he applied on his thigh three times a day.

E.D.D. claimed that there was no prompt relief of pain. After a week, they decided to consult a

doctor. He was prescribed with unrecalled antibitiotic PO b.i.d. for one week and pain medication

PRN. He claimed that he only took the antibiotic for 2 days due to increase in pain felt at his thigh

while taking the antibiotic. The pain scale was 9 out of 10. Instead he continued to use “lana”

three times a day stating that it somehow relieved the pain with pain scale of 7/10.

He continued to apply “lana” believing that it will collect the pus in the middle area that

will serve as the channel for the pus to be discharged which will lead to healing. With his

application of “lana”, the pain was alleviated, pain scale 5/10.

4 months PTC, February 2015, E.D.D. noticed a boil about a size of a 10 peso coin filled

with pus on the lower third aspect of his left thigh. He claimed that it was painful with a pain

scale of 7/10 but he just ignored it believing that this is the result of the application of “lana” to

the boil and just continued with his daily living. After 2 days, a discharge composed of pus and

minimal blood with no odor was noted. He wiped the discharge with cotton ball and claimed that

it was fully soaked. He then cleaned it and the surrounding area with “lana” thrice a day. Pain in

his thigh still became recurrent with a pain scale of 6 out of 10.

3 months PTC, March 2015, E.D.D. claimed that 2-3 inches proximal to the first protrusion,

a second boil was noted with a size of a one peso coin. He claimed that it is as painful as the first

one which has a pain scale of 6/10. The boil also breaks out with a discharge of pus and minimal

blood with no odor noted. He also cleaned it with “lana” three times a day. The pain was quite

relieved with pain scale of 5/10 but the discharges still continued.

4 days PTC, June 19, 2015, he decided to consult a doctor because there are still

discharges on both of the boil and the pain is still recurrent with pain scale of 6/10. The doctor

advised him to have an x-ray at WVSU-MC.

On the day of the confinement, June 23, 2015, the result of the x-ray came out. E.D.D

verbalized, “Kailangan ko na kuno mag pa admit kay asta na sa akon tul-an ang impeksyon”. The

doctor advised him to undergo an operation on his left thigh. Thus, this admission.

C. Review of Systems

A. General Health Survey

Pertinent Findings:

E.D.D’s patterns of ADLs changed because he had difficulty walking due to the pain he

experienced related to his condition.

B. Skin, hair, and nails

Pertinent findings:


Presence of two boils in the left lateral side of the thigh, approximately 2-3 inches away

from each other; tender to touch, presence of redness around the affected area with

presence of pus. E.D.D claimed to have allergies to “shrimp paste” (known locally as

“ginamos”). According to him, when he eats the said shrimp paste, he experiences itching

that begins in his abdomen and radiates throughout his body. E.D.D usually takes cetirizine

10 mg PO od to deal with his discomfort.

C. Head and Neck

Pertinent findings:

No relevant findings pertaining to the head and neck areas.

D. Eyes

Pertinent findings:

E.D.D does not use glasses or contacts and has never experienced problems with his

vision.

E. Ears

Pertinent findings:

E.D.D cleans his ears every 2-3 weeks. He has not experienced any problems with his

hearing and balance.

F. Nose and Sinuses

Pertinent findings:

No history of epistaxis or unusual discharges noted. Sinuses nontender.

G. Mouth and Throat

Pertinent findings:

Dental hygiene is done once everyday through brushing of teeth; absent: both first lower

molars, left upper second molar, right upper first molar; no dentures used.

H. Respiratory System

Pertinent findings:

E.D. D has past history of the common cold; breathing patterns are normal.


I. Cardiovascular System

Pertinent findings:

No history of chest pain, coldness of extremities, or palpitations. Usual blood pressure 110-

120/70-80 mmHg.

J. Breasts

Pertinent findings:

No lumps, pain, or discharges.

K. Gastrointestinal System

Pertinent findings:

E.D.D defecates once per day; no history of gastric ulcers noted.

L. Genitourinary System

Pertinent findings:

No history of UTI; voids 5-6 times per day as claimed.

M. Neurological System

Pertinent findings:

No history of neurologic alterations as claimed.

N. Musculoskeletal System

Pertinent findings:

Has difficulty performing ADLs since pain started on his left lower extremity; limps when

ambulating but can move on his own without assistance; described pain to be throbbing,

radiating from the lower and upper lateral thigh, pain scale of 6-8 in intensity, exacerbated


by noise and movement as claimed by E.D D ROM of both upper extremities and right lower

extremity 5/5. Left lower extremity 3/5.

II.B.: CLINICAL INSPECTION

Date and Time taken: July 9, 2015 | 7:00PM

II.B.1. Vital Signs:

T = 38.2 C/axilla PR = 76 beats/min.

BP = 120/70 mmHg RR = 20 breaths/min.

II.B.2. Height: 5 feet and 4 inches

II.B.3. Weight: 62 kilograms

II.B.4. PHYSICAL ASSESSMENT

General Appearance:

Lying in semifowler’s position; awake; calm; wearing navy blue jersey top and black shorts,

no foul smelling odor noted; with bandage covering his left leg from thigh to base of the toes

supported by a pillow underneath; oriented to person, place and time; with an IVF of D5LR x

KVO infusing well, attached to right metacarpal vein.

A. INTEGUMENTARY SYSTEM

Skin: Brown and uniform in color except in areas exposed to the sun; warm to touch; with scar

noted on the anterior side of his left elbow, approximately two inches above.

Hair: black in color; thick; evenly distributed; no infestations, lesions or masses noted.

Nails: Fingernails and toenails are neatly trimmed and clean; with translucent nail plate; pink

fingernail beds; pale toenail beds; no clubbing noted; capillary refill: less than 2 seconds.

B. NEURO-SENSORY SYSTEM

Eyes: eyebrows are black in color and symmetrically aligned; eyelashes are black, evenly

distributed and slightly curled outward, bulbar conjunctivae are transparent, palpebral

conjunctivae are pinkish in color, sclera is white, PERRLA.

Ears: Equal in size; auricles are symmetrically aligned; no tenderness or inflammation noted; no

lesions or discharges noted.


Nose: nasal septum midline; no flaring noted; no tenderness noted; sinuses are non-tender and

non-palpable

Cranial Nerve How Elicited Normal Response Actual Response

CN I: Olfactory

Ask the client to close eyes, occlude one nostril, and identify a

scented object that you are holding such as soap, coffee, or

vanilla. Repeat procedure for the other nostril.

Patient must be able to identify the scented object, with

eyes closed, the student nurse is holding with each

nostril occluded one at a time.

Intact; Patient was able to identify the aroma of coffee

diluted in water with both eyes closed.

CN II: Optic

Ask client to read a newspaper or

magazine paragraph to assess near vision.

Patient must be able to read the words in

the newspaper or magazine at a distance of 2 feet.

Intact; Able to identify and read all

the letters of a Snellen’s chart at a 2 feet distance; able to

see objects in periphery.

CN III: Oculomotor

CN IV: Trochlear

CN VI: Abducens

Perform corneal light reflex test. Hold a penlight approximately

12 inches from the client's face. Shine the light towards the

bridge of the nose while the client stares straight ahead. Note

the light reflected on the corneas.

To test direct pupil reaction, shine a light obliquely into one eye

and observe the pupillary reaction.

Test accommodation of pupils. Hold your finger or a pencil

about 12 to 15 inches from the client. Ask the client to focus on

your finger or pencil and to remain focus on it as you move it closer in toward the

eyes.

Patient must be able to move eyes with coordination; Eyes

must constrict as the light moves closer and dilates as the

light moves farther.

Intact; PERRLA; Patient was able to move eyes in unison

with coordinated movements

Test sensory function. Tell the client: "I am going to touch your

forehead, cheeks, and

Patient must be able to feel the stimulus of the cotton wisp as

it touches his face;

Intact; Blink reflex was present when examiner lightly

touched lateral sclera


CN V: Trigeminal chin with the sharp or dull sensation. Also tell

me where you feel it." Vary the sharp and dull stimulus in facial

areas and compare sides. Repeat test for light touch with a wisp

of cotton.

Test corneal reflex.

Ask the client to look away and up while you lightly touch the

cornea with a fine wisp of cotton. Repeat on the other side.

feel the difference and sensation of

sharp and dull

of the eye with wisp of cotton. Able to

determine light and deep sensation. Identified the area

touched with a wisp of cotton and the area touched with

the reflex hammer.

CN VII: Facial

Ask client to smile, frown and wrinkle

forehead, show teeth, puff out cheeks, purse lips, raise eyebrows,

close eyes tightly against resistance

Patient must be able to smile, frown and

wrinkle forehead, show teeth, puff out cheeks, purse lips,

raise eyebrows, and close eyes tightly against resistance.

Intact; able to keep mouth open while

the examiner tries to close it. Able to smile, frown, wrinkle

forehead, show teeth, puff out cheeks, purse lips,

raise eyebrows, close eyes tightly and opens mouth.

CN VIII: Vestibulocochlear

Rinne Test: Strike a tuning fork and place

the base of the fork on the client's mastoid process. Ask the client

to tell you when the sound is no longer heard. Move the

prongs of the tuning fork to the front of the external auditory canal. Ask the client to

tell you if the sound is audible after the fork is moved.

Whisper a two-syllable word at a distance of

2 feet unto the client's ears and let her repeat the whispered word.

Air conduction should be longer than bone

conduction (positive Rinne).

Patient must hear the two-syllable word spoken at a distance

of 2 feet on both ears.

Intact; Bone conduction time is

longer than the air conduction time (negative Rinne).

Patient was able to hear the spoken

word, "Lapis", on both ears at a distance of 2 feet

and was able to hear the vibrations of the tuning fork.

CN X: Vagus

Test gag reflex by touching the posterior

pharynx by the tongue depressor. Warn the client that you are

going to do this and

Gag reflex must be present.

Intact; (+) gag reflex.


that the test may feel a little uncomfortable

CN XI: Accessory

Ask client to shrug shoulders against

resistance.

Ask the client to turn

the head against resistance first to the right then to the left.

Patient must be able to shrug shoulders

and turn head to the right and left against resistance.

Intact; able to shrug shoulders and turn

head from side to side against pressure, no pain

noted upon doing so.

CN XII: Hypoglossal

Ask client to protrude tongue, move it to

each side against the resistance of a tongue

Patient must be able to protrude tongue,

move it to each side against the resistance of the

tongue

Intact; Able to protrude tongue at

midline, pain felt while protruding tongue and move it

side to side.

C. RESPIRATORY SYSTEM

RR= 20 breaths/minute. Nose: midline, non-tender, nares patent; septum: midline; trachea:

midline; Posterior thorax: Anteroposterior to transverse diameter in ratio of 1:2 , thorax

symmetric , skin intact, warm to touch, uniform temperature, chest wall intact, deep inspiration

and shallow expiration, lung sounds clear and audible upon auscultation; tactile fremitus

present; No adventitious breath sounds noted upon auscultation.

D. CARDIOVASCULAR/CIRCULATORY SYSTEM

BP = 120/70 mmHg; peripheral pulses: temporal=95 bpm; carotid=98 bpm; apical/PMI= 76

bpm; brachial=79 bpm; radial= 76 bpm; ulnar=78 bpm; popliteal=80 bpm; and dorsalis

pedis= 93 bpm; all in +2 intensity; with brisk capillary refill of less than 2 seconds; No bruits

heard upon auscultation.

E. GASTROINTESTINAL/HEPATOBILIARY SYSTEM

Lips: pink, moist; teeth: both first lower molars absent, left upper second molar absent, right

upper first molar absent; no dentures used; gums pale-pink, tongue midline; umbilicus at

midline, inverted; abdomen: rounded, uniform color with the skin, no masses noted upon

palpation; bowel sounds: RLQ= 5 cycles/minute, RUQ= 6 cycles/minute, LUQ= 5

cycles/minute; LLQ= 5 cycles/minute.

F. GENITO-URINARY SYSTEM

Bladder not distended upon palpation; Urine: amber in color, 5-6 times a day.


G. REPRODUCTIVE SYSTEM

E.D.D. refused to be assessed.

H. ENDOCRINE SYSTEM

Thyroid gland: non palpable; no evidence of excessive sweating.

I. Musculoskeletal System

Skull: normocephalic, symmetrical with frontal, parietal, temporal and occipital area, smooth

contour and no masses noted; Lower extremities: left leg covered with 32-inch elastic bandage

from thigh to the base of the toes; Muscles: Equal size in both sides of the body; muscle strength

of 5/5 for right lower extremity, 1/5 for left lower extremity; pain felt when moving left leg with

pain scale of 7 out of 10 with 10 being the highest and 1 the lowest; limited ROM in left lower

extremity; Upper extremities: equal size in both sides of the body; muscle strength of 5/5 for

both left and right upper extremities; full ROM on both left and right upper extremities.

J. LYMPHATIC SYSTEM

Pre-auricular, post-auricular, occipital, submental, submandibular, superficial anterior

cervical, posterior cervical, inferior anterior cervical, supraclavicular nodes: non-palpable; no

pain felt upon palpation.

K. HEMATOPOEITIC SYSTEM

No bleeding tendencies; brisk capillary refill less than two seconds; no hematoma, bruises

noted; Blood type = A; Rh positive.

II.B.5. Psychosocial Nursing Assessment

1. Lifestyle information

E.D.D is a 26- year old farmer who lives with his father. He usually earns 1500 pesos

per week. Their house is made of bamboo and wood. He would usually wake up at 5:30am,

after which, he proceeds in doing household chores such as chopping of wood, fetching water

on their deep well approximately 100 km away from the house and washing dishes. He would

take a bath at around 6:00-6:30 am to prepare himself for work. He eats his breakfast at 5:30-

6:00 am and goes to the farm afterwards.

E.D.D claimed that he likes to eat “laswa” and does not like shrimp paste. The water

they consume for drinking is from a deep well beside their house and what they use for cleaning

is from another artesian well approx. 100km away. Their electricity is being supplied by ILECO.


He is not active in civic-social affairs in their locality. He is a Roman Catholic but is not

a member of any religious organizations and he seldom attends mass. E.D.D denied use of any

prohibited drugs and claims that doesn’t smoke and drinks alcohol occasionally with a maximum

of 1 bottle of 1L of Red horse.

He believe in quack doctors and “hilots”. He would usually consult quack doctors first

before going to a real doctor for medical purposes.

2. Normal Coping Patterns

E.D.D usually keeps any problem to himself, although he doesn’t really have problems

that he attends to as claimed. He maintains a good relationship with his family and in his

neighborhood.

3. Understanding of Present Illness

E.D.D is aware of his illness. He understood that he had to undergo surgery in order to

be cured. He knows that his illness is a serious matter that poses threat to his health, he also

understood that he needed to comply with his therapeutic regimen and to follow the doctor’s

order for him to get better.

4. Personality Style

E.D.D cooperates during the interview. He is willing to answer questions raised by the

student-nurse. He speaks comprehensively. He further claimed that he is a happy-go-lucky

person. He is approachable and is ready to entertain people. He is willing to share information

about his personal life and is open to suggestions regarding his health and well-being.

5. History of Psychiatric Disorder

E.D.D claimed that his grandmother in the paternal side was diagnosed from Post-

partum depression due to the death of her new born.

6. Recent Life Changes or Stressors

E.D.D claimed that his current condition brought changes in his life. He claimed that he

had a difficulty in supporting his family financially. He also verbalized decrease in activities such

as doing heavy work like carrying sacks of rice behind his back. However, although he

understood his condition, he is afraid of what might people think of him and see him as someone

who is worthless and someone who has a disease. He said that he is just staying strong and is

keeping his faith, hoping that everything will be well.

7. Major Issues Raised by Current Illness

E.D.D claimed that financial crisis and his inability to work were the major issues that

arose upon his accumulation of this disease. He expressed worry and concern about finances

to aid his hospitalization, medication and maintenance since he cannot work and support his

family financially. He also expressed becoming a burden to his family because of his current

condition.


8. Mental Status Examination

APPEARANCE

Neat Clean Dishevelled Poor Grooming Erect Posture

Good eye contact Inappropriate makeup others: _______________

Description: E.D.D appears neat and clean during the nurse-patient interaction. He also

maintains good eye contact.

BEHAVIOR

Calm Appropriate Restless Agitated Compulsions

Unusual actions others: _______________

Description: E.D.D is cooperative and attentive at the onset of interaction. He talks in a calm

and relaxed manner. He readily answers questions and facial expressions are appropriate.

SPEECH

Appropriate Pressured Loose Association Loud Soft

Mute others: _______________

Description: E.D.D speaks in a clear voice with moderate intensity, volume and pace. Speech is

coherent and congruent with thoughts.

MOOD/AFFECT

Appropriate Labile Flat Depressed Worried Anxious

Angry Hopeless others: _______________

Description: E.D.D has a euthymic mood and has appropriate affect. He has good attitude

towards health care staff and other patients in the ward.

THOUGHTS

Appropriate Low Self-Esteem Suicidal Ideations Hallucinations

Delusions Phobias others: _______________


Description: His thoughts were linear and goal directed all throughout the interaction.

ABILITY TO ABSTRACT

Impaired: YES NO

Description: After being asked to interpret the proverb: “Aanhin pa ang damo kung patay na

ang kabayo”, the patient verbalized, “Kung indi ka mag pursige, waay ka man may ma dangtan

eh.”

MEMORY

Impaired recent memory: YES NO

Impaired past memory: YES NO

Number of objects able to remember after 5 minutes: 4/4

Description: E.D.D was able to remember 4 objects presented to him namely a cup, ballpen,

cellphone, and electric fan. E.D.D is still able to recite a nursery rhyme (TWINKLE-TWINKLE

LITTLE STAR) and he still remembers when he was admitted.

ESTIMATED INTELLIGENCE

Below Average Average Above Average

Description: E.D.D was able to name five presidents of the country namely Aquino,

Macapagal-Arroyo, Ramos, Marcos and Roxas.

CONCENTRATION

Able to focus Easily distractible

Able to subtract backwards by 3s from 20 correctly until number 12_.

Description: E.D.D was able to maintain focus while subtracting 3s from 20.

ORIENTATION

Person ___ Time ___ Place ___ Situation ___


Description: E.D.D was oriented to person, time, place and situation. When asked who is

talking to him he can tell the name of the student nurse. He also knew that he is currently

admitted at a hospital and can tell the name of the institution and if what time of the day it is.

JUDGMENT

Realistic decision making: YES NO

Description: E.D.D was asked what he would do if he found a wallet, he answered “Tan-

awon ko anay ang sulod kung may ara kwarta kag ID, kun may ara ihatag ko sa Bombo Radio.”

INSIGHT

Good Fair Poor

Description: E.D.D is aware of having an infection on his left leg and that he had to undergo

surgery, he is also aware of his current diagnosis. He anticipates that he will be facing such

burdens when it comes to the symptoms of his disease. He knows and understands that he needs

appropriate medical intervention.

Adapted from Gorman, L. D. Sultan, & M.L. Raines.(2000). Psychosocial nursing for general

patient care. USA: Lexi-Comp Inc.

II.C. OTHER SOURCES OF DATA

1. Name of Examination: Complete Blood Count (CBC)

Definition:

A complete blood count (CBC) is a blood test to evaluate client’s overall health and detect a wide

range of disorders, including anemia, infection and leukemia. Abnormal increases or decreases in

cell counts as revealed in a complete blood count may indicate an underlying medical condition

that calls for further evaluation. Furthermore, the result can provide valuable diagnostic

information regarding the overall health of the patient and the patient’s response to disease and

treatment.

Hemoglobin is the main intracellular protein of the RBC. Its primary function is to transport oxygen

to the cells and to remove carbon dioxide from them for excretion by the lungs.

Hematocrit or packed RBC volume measures the proportion of RBCs in a volume of whole blood

and is expressed as a percentage.

The erythrocyte (RBC) count, a component of the CBC, is the determination of the number of

RBCs per cubic millimeter.

The purpose of white blood cells is to protect the body from the threat of foreign agents, such as

bacteria.


Segmenters. Mature neutrophils are distinguishable by their segmented appearance, thus they

are often called “segs.”

Lymphocyte. The immune white blood cells, which include the T lymphocytes, or T cells, and the

B lymphocytes, or B cells, mature in lymphoid tissue and migrate between the blood and lymph.

They play an integral part in the antibody response to antigens.

Eosinophils play an important role in the defense against parasitic infections. They also

phagocytize cell debris, but to a lesser degree than neutrophils, and do so in the later stages of

inflammation. They are also active in allergic reactions.

Monocytes, which live months or even years, are not considered phagocytic cells when they are

in the circulating blood. However, after they are present in the tissues for several hours,

monocytes mature into macrophages, which are phagocytic cells.

Basophils release histamine, bradykinin, and serotonin when activated by injury or infection.

These substances are important to the inflammatory process since they increase capillary

permeability and thus increase the blood flow to the affected area. Basophils are also involved in

producing allergic responses.

MCH (Mean Corpuscular Volume) is the weight of the Hgb in each RBC.

MCV (Mean Corpuscular Hemoglobin Concentration) indicates the volume of the Hgb in each RBC.

MCHC (Mean Corpuscular Hemoglobin) is the proportion of Hgb contained in each RBC.

Platelets are non-nucleated, cytoplasmic, round or oval disks formed by budding off of large,

multinucleated cells (megakaryocytes). Platelets have an essential function in coagulation,

hemostasis, and blood thrombus formation.

Purpose:

Complete Blood Count are performed for several reasons:

Detect hematologic disorder, neoplasm, leukemia, or immunologic abnormality

Determine the presence of hereditary hematologic abnormality

Evaluate known or suspected anemia and related treatment

Monitor blood loss and response to blood replacement

Monitor the effects of physical or emotional stress

Monitor fluid imbalances or treatment for fluid imbalances

Monitor progression of nonhematologic disorders, such as chronic obstructive

pulmonary disease, malabsorption syndromes, cancer, and renal disease

Monitor response to chemotherapy and evaluate undesired reactions to drugs that may

cause blood dyscrasias

Provide screening as part of a general physical examination, especially on admission to

a health care facility or before surgery


Preparation:

A purple-topped tube with ethylenediaminetetraacetic acid (EDTA) anticoagulant is used to collect

7 ml of venous blood. As an alternative a purple-tipped capillary tube can be used to collect blood

from a heel stick, earlobe, or finger puncture.

Date and Time of Examination: 06/24/15; 1:209AM, 07/06/15; 9:22PM, 07/08/15; 6:47AM

Examination

Results Normal

Values Significance

06/24/15

1:09AM

07/06/15

9:22PM

07/08/15

6:47AM

Complete Blood Count

Hemoglobin 149 g/L 137 g/L 97 g/L 135-180

g/L

Decreased due to blood loss of

800mL during surgery (07/07/15)

which resulted to decrease in

hemoglobin, hematocrit and red

blood cell component in the body

thereby reducing the transport of

oxygen carrying capacity of blood.

Hematocrit 0.44 L/L 0.40 L/L 0.28 L/L 0.40-0.54

L/L

Red Blood Cell 5.38 1012/L 4.89 1012/L 3.37 1012/L 4.6-6.2

1012/L

White Blood

Cell

11.19 109/L 15.80

109/L

14.79

109/L

4.5-11

109/L

White blood cells protect the body

from the effects of invasion by

organisms. These cells are immune

system cells, increasing its

production is the natural response

of the body to combat the

causative agent of osteomyelitis.

Differential Count

Neutrophil Number Faction

Segmenters 0.47 0.66 0.73 0.50-0.70

There are three divisions of

immunity (inflammation, antibody-

mediated immunity and cell-

mediated immunity). Inflammation

provides immediate protection

against injury or invading

organisms and it is a nonspecific

body defense to invasion or injury

and it can be started quickly by

almost any event, regardless of

where it occurs and what it causes.

Segmenters also known as mature

neutrophils acts by providing

protection to the body against

invaders by destroying them

through the process of

Monocyte 0.08 0.09 0.09 0.04-0.08


Source: Kranpitz, T.R., Smith, L., Van Leeuwen, A.M. (2006). Davis’s Comprehensive Handbook

of Laboratory and Diagnostic Tests with Nursing Implications 2nd Ed. p.418

Porth, C.M. (2002) .Pathophysiology: Concepts of Altered Health Status Sixth Ed., p.253-254,

p.271

p.308

phagocytosis and enzymatic

digestion.

Monocytes

The gradual increase of segmenters

is the body’s primary response

against infection.

Due to the increase in the number

of infection stimulates the

monocytes to respond by

increasing its production and acts

by engulfing these foreign

materials in the body through the

process called phagocytosis.

(Source:

“White Blood Cell Differential Count”. Retrieved from

http://www.brooksidepress.org/)

Eosinophils 0.06 0.04 0.01 0.01-0.04 Within Normal Range

Basophil 0.01 0.00 0.00 0.00-0.01 Within Normal Range

Blood Indices

MCH 27.80 fmol 28.00

fmol

28.80

fmol

26.20-

36.68 fmol

Within Normal Range

MCV 81.10 fL 82.30 fL 84.00 fL 82.75-

100.5 fL

Within Normal Range

MCHC 34.20 g/L 34.00 g/L 34.30 g/L 31.65-

33.75 g/L

Increased due to agglutination.

Platelets 369 109/L 150-450

109/L

Within Normal Range

ESR 52 mm/hr 0-10

mm/hr

Increased due to inflammation and

infection that causes blood to

clamp together.

http://www.brooksidepress.org/


2. Name of Examination: C-Reactive Protein

Definition:

C-reactive protein (CRP) is a glycoprotein produced by the liver in response to acute

inflammation. The CRP assay is a nonspecific test that determines the presence (not the cause)

of inflammation; it is often ordered in conjunction with erythrocyte sedimentation rate (ESR).

CRP assay is a more sensitive and rapid indicator of the presence of an inflammatory process

than ESR.

Purpose:

• Assist in the differential diagnosis of appendicitis and acute pelvic inflammatory disease

• Assist in the differential diagnosis of Crohn’s disease and ulcerative colitis

• Assist in the differential diagnosis of rheumatoid arthritis and uncomplicated systemic lupus

erythematosus (SLE)

• Assist in the evaluation of coronary artery disease

• Detect the presence or exacerbation of inflammatory processes

• Monitor response to therapy for autoimmune disorders such as rheumatoid arthritis

Preparation:

There are no special preparations for either a standard CRP test. However, if blood is being

drawn for other tests, fasting may be required but it is best to follow instructions as ordered by

the physician.

Date and Time of Examination: 06/24/15; 1:39AM

Source: Ignatavicius, D.D., & Workman, M.L. (2010). Medical Surgical Nursing: Patient-

Centered Collaborative Care 6th Ed. p.317-318

Examination Results

Normal Values Significance

C- Reactive Protein > 6 mg/L <6 mg/L Increased.

The cellular mediated immunity

regulates the immune system by the

production and activation of

cytokines. Cytokines control

inflammations. Cytokines include the

interleukins, interferons, colony-

stimulating factors and tumor

necrosis factor. Interleukin-6 (IL-6)

stimulates the liver to produce

fibrinogen and protein C (C-Reactive

Protein), increases rate of bone

marrow production of stem cells,

and increases numbers of sensitized

B-lymphocytes.


3. Name of Examination: Clotting Time Bleeding Time

Definition:

CTBT is a medical test done on someone to assess their platelet function. It is a blood test that

looks at how fast small blood vessels in the skin close to stop you from bleeding. CTBT is used to

measure the duration of bleeding after a measured skin incision. Bleeding time may be measured

by one of three methods: template, Ivy, or Duke.

Purpose:

- To assess overall hemostatic function.

- To detect congenital and acquired platelet function disorders.

Preparation:

No food or fluid restriction before test. ; Blood is taken; It takes 10-20 minutes to perform the

test.

Date and Time of Examination: 06/24/15; 1:00AM

Examination Results Normal Values Significance

Clotting Time 3 min. 3-5 min Within Normal Range

Bleeding Time 1 min. 1-3 min Within Normal Range

4. Name of Examination: Protime or Prothrombin Time (PT)

Definition:

Prothrombin time (PT) is a coagulation test performed to measure the time it takes for a firm

fibrin clot to form after tissue thromboplastin (factor III) and calcium are added to the sample.

It is used to evaluate the extrinsic pathway of the coagulation sequence in patients receiving

oral warfarin or coumarin-type anticoagulants. Prothrombin is a vitamin K–dependent protein

produced by the liver; measurement is reported as time in seconds or percentage of normal

activity.

Purpose:

• Differentiate between deficiencies of clotting factors II, V, VII, and X, which prolong the PT;

and congenital coagulation disorders, such as hemophilia A (factor VIII) and hemophilia B

(factor IX), which do not alter the PT

• Evaluate the response to anticoagulant therapy with coumarin derivatives and determine

dosage required to achieve therapeutic results

• Identify individuals who may be prone to bleeding during surgical, obstetric, dental, or

invasive diagnostic procedures

• Identify the possible cause of abnormal bleeding, such as epistaxis, hematoma, gingival

bleeding, hematuria, and menorrhagia

• Monitor the effects of conditions such as liver disease, protein deficiency, and fat

malabsorption on hemostasis

• Screen for prothrombin deficiency

• Screen for vitamin K deficiency


Preparation:

Because many drugs may affect the PT result, all medications taken by the client should be

noted. If the individual is receiving anticoagulant therapy, the time and the amount of the last

dose should be noted. A venipuncture is performed and the sample collected in a light-blue-

topped tube. Traumatic venipunctures and excessive agitation of the sample should be avoided.

Date and Time of Examination: 06/24/15; 1:39AM, 07/06/15; 9:33PM

Name of Examination Results Normal Values Significance

06/24/15

1:39AM

07/06/15

9:33PM

Protime

Patient 13.5 13.3 sec 11.5-15.5 Within Normal Range

% Activity 95.0 100.0 -

INR 1.00 1.00 -

Normal Control 100.0 92.0 % 75-101 Within Normal Range

5. Name of Examination: GRAM STAIN AFB KOH

Definition:

Gram stain

A gram stain is a type of microbiology or laboratory test that determines whether

bacteria are present. It also determines whether bacteria are gram negative or gram positive.

The difference between gram negative and gram positive bacteria can be important when

determining appropriate treatment for an infection

AFB

Acid-fast bacilli (AFB) testing are collected because the health practitioner suspects that

a person has tuberculosis (TB), a lung infection caused by Mycobacterium tuberculosis that can

be present also in bone or in any part of the body. Mycobacteria are called acid-fast bacilli

because they are a group of rod-shaped bacteria (bacilli) that can be seen under the

microscope following a staining procedure where the bacteria retain the color of the stain after

an acid wash (acid-fast).

KOH

Sputum smear (KOH test) is a test for the presence of fungal microorganisms in sputum.

Purpose:

To assist in the differentiation of gram-positive from gram-negative bacteria in the bone.

To test if a mycobacterial infection is suspected.

The test may be performed when there is abnormal an infection of the bone is suspected.

Date released: 7/05/15 Date received: 7/05/15

https://labtestsonline.org/understanding/conditions/tuberculosis

https://labtestsonline.org/glossary/mycobacteria/

https://labtestsonline.org/glossary/bacterium


Specimen: Bone Currettings

EXAMINATION RESULT SIGNIFICANCE

GRAM STAIN Many pus cells

Occasional gram negative

bacilli and gram positive cocci

singly.

AFB NEGATIVE for Acid fast bacilli Normal

KOH NEGATIVE for Fungus Normal

6. Name of Examination: Culture and Sensitivity

Definition:

A culture is done to find out what kind of organism (usually bacteria) is causing an illness or

infection.

A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to

treat the illness or infectionA culture is done by collecting a sample of body fluid or tissue and

then adding it to a substance that helps promote the growth of bacteria or other disease-

causing organisms. If there are bacteria (or other organisms) in the sample, they will grow in

the culture. Bacteria usually grow quickly in a culture (2 days), while other types of organisms,

such as a fungus, can take longer.

A culture and sensitivity test may be done on many different body fluids, such as urine, mucus,

blood, pus, saliva, breast milk, spinal fluid, or discharge from the vagina or penis.

Purpose:

To determine if bacteria are resistant to certain drugs

Preparation:

Date released: 6/22/15

Date received: 6/18/15 Specimen type= wound Final Report Few colonies of staphylococcus aureus

RESULT

Azithromycin

Chloramphenicol

Ofloxacin

Clindamycin

Gentamicin

Linezolid

Oxacillin

Vancomycin

S

S

S

S

S

S

S

S

Susceptible

Susceptible

Susceptible

Susceptible

Susceptible

Susceptible

Susceptible

Susceptible


Quinopristin/Dalfopristin

Cefoxitin

Doxycycline

Trimethroprim/sulfamethoxazole

Erythromycin

Levofloxacin

Moxifloxacin

Tetracycline

ciprofloxacin

S

S

S

S

S

S

S

S

S

Susceptible

Susceptible

Susceptible

Susceptible

Susceptible

Susceptible

Susceptible

Susceptible

Susceptible

OTHER GROWTH:

R=Resistant I=Intermediate S=Susceptible NS=Non-Susceptible

SDD=Susceptible-dose dependent

7. Blood Typing

Definition:

A single unit of whole blood contains 450mL of blood and 50mL of an anticoagulant. A

unit of whole blood can be processed and dispensed for administration. However, it is more

appropriate, economical, and practical to separate that unit of whole blood into its primary

components: RBCs, platelets, and plasma. Each component must be processed and stored

differently to maximize the longevity of the viable cells and factors within it; each individual blood

component has a different storage life. PRBCs are stored at 4˚C.

It is important also to accurately determine the blood type. More than 200 antigens have

been identified on the surface of RBC membranes. Of these, the most important for safe

transfusion are the ABO and Rh systems. The ABO system identifies which sugars are present on

the membrane of an individual's RBCs: A, B, both A and B, or neither A nor B (type O). To prevent

a significant reaction, the same type of RBCs should be transfused.

The Rh antigen (also called D) is present on the surface of RBCs in 85% of the population

(Rh positive). Those who lack the D antigen are called Rh-negative. RBCs are routinely tested for

the D antigen as well as ABO. Patients should receive PRBCs with a compatible Rh type.

(Source: Brunner & Suddarth's Textbook of Medical-Surgical Nursing; Page 923)

Blood type "A" Rh (+)

The Rh antigen is present on

the surface of RBCs in 85% of

the population (Rh positive).

Those who lack the D antigen

are called Rh-negative. RBCs

are routinely tested for the D

antigen as well as ABO. Patients

should receive PRBCs with a

compatible Rh type.

(Source: Brunner & Suddarth's

Textbook of Medical-Surgical

Nursing; Page 926)


Blood type Amount| Serial Number

A 545| T 5700-004546-1

A 278| T 500-014518-1

A 528| 004081-2

Remarks: Compatible

8. Xray

An X-ray is a quick, painless test that produces images of the structures inside your body —

particularly your bones.

X-ray beams pass through your body, and they are absorbed in different amounts depending on

the density of the material they pass through. Dense materials, such as bone and metal, show

up as white on X-rays. The air in your lungs shows up as black. Fat and muscle appear as

shades of gray.

For some types of X-ray tests, a contrast medium — such as iodine or barium — is introduced

into your body to provide greater detail on the images.

Purpose:

Radiologic assessment of chronic osteomyelitis is performed for the following reasons: (1) to

evaluate bone involvement (eg, the extent of active intramedullary infection or abscess

superimposed on areas of necrosis, sequestrum and fibrosis) and (2) to identify soft tissue

involvement (areas of cellulitis, abscess, and sinus tracts).

Date: 6/23/15

Xray requested: Left Thigh APL

Impression:

- Negative for fracture and/or dislocation.

- Sclerosing osteomyelitis, considered.


III. TEXTBOOK DISCUSSION

Definition

Osteomyelitis

Infection in bony tissue can be a severe and difficult-to-treat problem. Bone infection can result

in chronic recurrence of infection, loss of function and mobility, amputation, and even death.

Chronic Osteomyelitis

Inadequate care management results when the treatment period it too short or when the

treatment is delayed or inappropriate. About half of cases of chronic osteomyelitis are caused

by gram-negative bacteria. Although bacteria are the most common causes of osteomyelitis,

viruses and fungal organisms also may cause infection

Signs and Symptoms

Acute Osteomyelitis

Found in Text Book Manifested by the Patient

Fever > 38ºC (+) Nov. 2014

Swelling (+) Nov. 2014

Erythema (-)

Tenderness (+) Nov. 2014

Bone pain (+) Nov. 2014

Chills (-)

Rapid Pulse (+) Nov. 2014

General Malaise (+) Nov. 2014

Chronic Osteomyelitis

Found in Text Book Manifested by the Patient

Ulceration of the skin (+) Feb. 2014

Sinus tract formation (+) Feb. 2014

Localized pain (+) Dec. 2014

Drainage from the affected area (+) Feb. 2014


Management

Bone scan is done to detect osteomyelitis through injection of bone-seeking radioisotope. Bone scans are used in conjunction with bone biopsy for a definitive diagnosis.

Erythrocyte sedimentation rate (ESR): the erythrocyte sedimentation rate is highly predictive of osteomyelitis, and that the value of 70 mm/h is the optimal cutoff to predict accurately the

presence or absence of bone infection. Magnetic resonance imaging (MRI) with gadolinium is the imaging modality of choice,

particularly for detection of early osteomyelitis and associated soft-tissue disease (A-II). Erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) level may be helpful to guide response to therapy (B-III) (1). MRI is useful for determining location and extent of

involvement of the bone infection. IV antibiotic therapy begins as soon as the culture specimens are obtained, based on the

assumption that infection results from a staphylococcal organism that is sensitive to a penicillin or cephalosporin. IV antibiotic therapy continues for 3 to 6 weeks. After the infection appears to be controlled, the antibiotic may be administered orally for up to 3 months.

Prophylactic treatment with the bead pouch technique has been suggested in open fractures to reduce the risk of infection, with systemic antibiotics supplemented with antibiotic beads compared to using systemic antibiotics alone. Beads have proved to be more effective than

solid antibiotic-loaded cement plugs in the treatment of osteomyelitis. Oral quinolones are often used in adults for gram-negative organisms. Quinolones have

excellent oral absorption and may be used as soon as patient is able to take them. Rifampin has an optimal intercellular concentration and a good sensitivity profile for methicillin-

resistant staphylococci. It is used in combination with cell wall active antibiotics to achieve synergistic killing and to avoid rapid emergence of resistant strains.

Surgical management If the infection is chronic and does not respond to antibiotic therapy, surgical débridement is

indicated. Because surgical débridement weakens the bone, internal fixation or external supportive devices may be needed to stabilize or support the bone to prevent pathologic fracture.

The Ilizarov method involves the use of a tissue-sparing, cortical osteotomy-osteoclasis technique that preserves the osteogenic elements in the limb. To create a preliminary callus

that can be lengthened, Ilizarov advocated a delay of several days before initiating distraction. A high-frequency, small-step distraction rhythm permits regeneration of good-quality bone and less soft-tissue complications such as nerve and vessel injury. An advantage of using this

procedure is that it minimizes the prevalence of nonunion and thus further bone grafting by producing good-quality bone formation.

A sequestrectomy (removal of enough involucrum to enable the surgeon to remove the sequestrum) is performed. In many cases, sufficient bone is removed to convert a deep cavity into a shallow saucer

(saucerization). All dead, infected bone and cartilage must be removed before permanent healing can occur. A closed suction irrigation system may be used to remove debris. Wound irrigation using sterile

physiologic saline solution may be performed for 7 to 8 days. The wound is either closed tightly to obliterate the dead space or packed and closed later by granulation or possibly by grafting.


Nursing Management - The affected part may be immobilized with a splint to decrease pain and muscle spasm. The nurse monitors the neurovascular status of the affected extremity. Elevation reduces swelling and associated discomfort.

- The joints above and below the affected part should be gently moved through their range of motion. The nurse encourages full participation in ADLs within the physical limitations to

promote general well-being. - The nurse monitors the patient’s response to antibiotic therapy and observes the IV access

site for evidence of phlebitis, infection, or infiltration. - With long-term, intensive antibiotic therapy, the nurse monitors the patient for signs of

superinfection (eg, loose or foul-smelling stools). - If surgery is necessary, the nurse takes measures to ensure adequate circulation to the affected area (wound suction to prevent fluid accumulation, elevation of the area to promote

venous drainage, avoidance of pressure on the grafted area), to maintain needed immobility, and to ensure the patient’s adherence to weight-bearing restrictions.

- The nurse changes dressings using aseptic technique to promote healing and to prevent cross-contamination.

- The nurse continues to monitor the general health and nutrition of the patient. A diet high in protein promotes a positive nitrogen balance and healing. The nurse encourages adequate hydration as well.

- Encourage the patient to verbalize his concerns about his disorder.

- Encourage the patient to perform as much self-care as his conditions allows.

- Provide thorough skin care and complete cast care.

- Administer prescribed analgesics for pain.

- Watch for signs of pressure ulcer formation.

- Look for sudden malpositioning of the affected limb, which may indicate fracture.

- Explain all the test and treatment procedures.


PROBLEM LIST

1. Acute pain related to surgical procedure

2. Impaired physical mobility related to surgical procedure and musculoskeletal impairment

3. Constipation related to insufficient physical mobility

4. Risk for impaired peripheral tissue perfusion

5. Risk for infection related surgical incision

6. Risk for impaired skin integrity related to surgical procedure

7. Ineffective Role Performance related to situational crisis

nca - pop it like myelitis (1).pdf

Documents

pain scale

throbbing pain

chronic osteomyelitis

left leg

thigh postop diagnosis

thigh preop diagnosis

thigh surgical operation

nursing history