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Bones make up the body's skeletal system. The skeletal system is the framework
of our bodies. Without our bones, we cannot move, stand up, and keep our organs in
place. And when it comes to bone problems, the more common thought would be
fractures from high-velocity impact, misalignment from genetic origins and general
weakening as one gets older. But there is one bone problem that is usually overlooked
and, thus, not known to many people.
In the United States the overall prevalence is 1 per 5,000 children. Neonatal
prevalence is approximately 1 per 1,000. The annual incidence in sickle cell patients is
approximately 0.36%. The prevalence of osteomyelitis after foot puncture may be as high
as 16% (30-40% in patients with diabetes).
Mortality rates are low, unless associated sepsis or an underlying serious medical
condition is present.
There are no exceptions for osteomyelitis when it comes to race. However, the
male-to-female ratio is approximately 2:1.
Age In general, osteomyelitis has a bimodal age distribution; Acute
hematogenous osteomyelitis is primarily a disease in children; Direct trauma and
contiguous focus osteomyelitis are more common among adults and adolescents than in
children; Spinal osteomyelitis is more common in persons older than 45 years.
[http://emedicine.medscape.com/article/785020-overview]
---
During the group’s exposure in the general surgery ward in DMC, a little bit of
curiosity fell upon a certain term that most members of the group had encountered for the
first time: “Osteomyelitis.” Even ‘craniectomy’ stirred some interest.
As the group agreed to consider this as a possible topic for the case study, a
realization was voiced out. “What’s the patient’s name?”
To reserve her right to privacy, we have given our patient the codename: “Mrs.
X.” She is a business woman from Iligan City and during the interviews, was very open
to the group. Mrs. X’s significant others were also very entertaining to the group’s
questions.
Among all of the patients in the General Surgery ward at that day, Mrs. X was the
only one who had the word “osteomyelitis” in her chart.
This case study will present the data that was gathered from Mrs. X and other
different sources regarding her sickness and will show how these data may explain how
she got into these conditions. Thorough study of the topics regarding the disease will also
be presented for osteomyelitis to be understood clearly. After establishing pertinent data,
the different therapeutic managements done for Mrs. X, especially nursing care, will be
presented and evaluated.
OBJECTIVES
General Objectives:
To conduct a thorough and comprehensive study about Mrs. X’s disease according
to data that was gathered by conducting a series of interviews within a total of 6 days of
hospital exposure (3 days a week for 2 weeks), and through the use of data gathered from
extensive research.
Specific Objectives:
• To organize our patient’s data for the establishment of good background
information
• To show the family health history as well as the history of past and present illness
for the knowledge of what could be the predisposing factors that might contribute
to the patient's illness.
• To present the family’s Genogram containing information that will help out in
tracing any hereditary risk factors.
• To trace the psychological development of our patient through analysis of different
developmental theories with comparison to the patient’s data
• To give different definitions of the complete diagnosis of our patient for better
understanding of unfamiliar terms
• To present the data from the physical assessment performed on our patient for a
good overview of her over-all health
• To elaborate on the anatomy and physiology of different systems involved and
affected during osteomyelitis
• To establish whether several factors, signs and symptoms are present or absent in
our patient for the proof that she indeed has osteomyelitis
• To organize a flow chart showing the pathophysiology of osteomyelitis for a clear
visualization of how osteomyelitis affects a person
• To list the different orders of the physicians assigned to our patient together with
their rationale for a general knowledge of what consists of the medical
management for osteomyelitis
• To present the different results of our patient’s diagnostic exams together with
comparisons with normal values for the understanding of what changes during the
disease
• To list the different drugs together with their specific purposes for the better
understanding of the treatment of osteomyelitis
• To present the surgical procedures done to our patient together with their rationales
so that the purposes of each procedure can be understood
• To analyze different nursing theories applicable to our patient
• To show the nursing care plans used by the group to administer nursing care to the
patient during our exposure
• To present the discharge plan for our patient
• To have our over-all Conclusions and Recommendations about the Case Study
PATIENT’S DATA
Personal Data:
Name: “Mrs. X”
Age: 64 yrs. old
Date of birth: August 5, 1944
Sex: Female
Place of birth: Manila
Address: 18 Military St., GSIS, Matina Proper, Davao City
Nationality: Filipino
Religious affiliation: Roman Catholic
Civil status: Married
Educational Attainment: 3rd year high school
Occupation: Housewife
Clinical Data:
Date admitted: December 10, 2008
Mode of Admission: Ambulatory
Chief complaint: Pus draining from operative site
Case Type: Surgery
Ward: GSI
Case no.: 2008004659
Admitting Doctor: Marjorie L Corpuz
Date of discharge: [still in]
Admitting Diagnosis: T/C osteomyelitis ® ant. parietal bone; S/P craniectomy w/
excision of brain tumor
Date of Operation: December 15, 2008
Operation Performed: Debridment; Removal of necrotic bone fragments, Rotational
flap, STSG, drain
Anesthesia: GETA; O2 Isoflurane
Time started: 2:15pm
Time ended: 7:15pm
Blood Loss: 310cc
Operation Diagnosis: soft tissue defect ® parietal area w/ osteomyelitis, s/p
craniectomy, excision of meningioma
Remarks:
patient placed supine under CEB
asepsis
drapes placed
debridement of bony fragments + removal of necrotic tissue
rotational flap done
STSG done
end of procedure
FAMILY BACKGROUND AND
HEALTH HISTORY
Mrs. X has been married for 44 years with Mr. X. Throughout their marriage, they
have had 7 offspring. Their eldest is 43 years old, and their youngest is 29 years old. All
of their children have graduated college and are working independently of each other.
Three of them are living in Davao City, but only two were seen present in the hospital
ward. One of them lives in Manila, while the rest live back in their home town, Iligan.
She was recommended by her neurosurgeon in Iligan, Dr. Valdez, to travel to DMC for
the specialization of the operation on her skull. Having this operation being her third, she
cannot afford to get a private room anymore. She then opted to stay in the general ward,
and didn’t think it was too bad compared to how the general wards were in the hospitals
in Iligan.
During our interview, we have established that most of the family members in the
previous generations of Mrs. X’s family are deceased and have a variety of causes of
death. Also, no one else in Mrs. X’s lineage has had osteomyelitis in the last two
generations.
LIFESTYLE
According to Mrs. X herself, she has random schedules everyday. Still, she was
able to formulate a cycle of activities that, for her, would make up the common days in
Iligan. She would wake up just in time for lunch. After freshening up a little, she eats her
lunch. Then she takes a bath. After taking a bath, she goes to the stressful environment in
the ‘mahjongan’ that she runs and owns, which is less than a kilometer away from her
house. She claims that she is hypertensive because of her work environment. There are a
lot of uncivilized clients that give her a bad time, and to top it off, she smokes. She
usually works until the early morning. After work, she goes home to sleep.
There are times that she would have to sleep in a private bedroom she has
provided for herself in the ‘mahjongan’ because her customers would last too long in
playing mahjong that it would come to the point wherein she would be too tired to go
back home to sleep.
When she was young, Mrs. X’s grandfather was a disciplinarian and took care of
his grandchildren, especially Mrs. X, with a hands-on approach. Mrs. X shared that when
she was still a young girl, she wasn’t allowed to go on dates, or go shopping with her
friends or even go out and see a movie. Because of this, she still isn’t much of an out-
going person. She wouldn’t want to shop for clothes, but she’d appreciate gifts from other
people. She also said that her enjoyment comes from her three hobbies: Mahjong,
mahjong and mahjong.
Mr. X does the shopping for the family. Mrs. X verbalized that Mr. X’s daily
routine would always have going to the market as one of the first things to do.
As mentioned earlier, Mrs. X smokes, but doesn’t drink. She shared that if she
stays at home, one pack of cigarettes would last her 3 days. On the other hand, if she
stays in the mahjongan, she would be able to smoke one pack a day. When asked about
how often she stays in the mahjongan, she replied, “Everyday.”
Mr. X is a retired policeman and is supported by pension [P15,000/month]. Mrs.
X earns her money from gambling in the mahjongan. She could earn as much as P60,000
but has the great risk of losing it all to a bad game. Still she estimated an average net
income of P15,000 as well.
DIET
Mrs. X usually eats one meal a day. This is because during breakfast time, she is
asleep. During dinner time, she is at work in the mahjongan. But this one meal does not
have any limit and she said that she is fond of eating a lot of rice. She also eats a lot of
snacks like fruits (mango, chico), palabok, and siopao. She also dislikes bread, cake, and
any pastry foods. However, she claims that she cannot live without pork. She also eats
other meat, but she will always prefer pork over all the rest.
HISTORY OF PATIENT’S PAST ILLNESS
Mrs. X had decided to have herself admitted to the hospital for Dilatation and
Curettage in 1972 because it reached 7 months that she had amenorrhea and she wasn’t
pregnant.
Her asthma started when she was in grade school. Her last asthma attack was
around June of 2008. She had ‘Combivent’ and frequent nebulization to treat her asthma.
She also claims that her asthma is genetic.
She also has a history of cholelithiasis. September 12, 2008 was her last visit to
the doctor. She underwent oral dissolution therapy and had 3 ultrasound sessions
throughout the therapy. During her first ultrasound, it was discovered that she had 3 gall
bladder stones. On her second session, the results revealed a blurry image of the stones.
On the third and final ultrasound, she had no more gall stones. She then stopped
purchasing the recommended medications for her which are Tramadol and Unasyn.
Development lifelong process and A person who can look development. She
does not end with back on good times with views her life as
task. The resolution the person gains a self who are always
sense of integrity.
Jean Piaget’s Jean Piaget proposed Formal Operations Mrs. X has achieved
adaptation. complications
accompanied by her
condition.
Robert Havighurst theorized Later Maturity Patient X had
Havighurst’s that there are six This stage in a person’s learned to accept the
Milestones stages of life, each the achievement of the to her. She is aware
discounts on the
as a record of what
able to purchase
obtained the
booklet.
She is able to
establish satisfactory
living arrangements
with her
accomplishments in
life.
DEFINITION OF
COMPLETE DIAGNOSIS
Pre-operative diagnosis: T/c osteomyelitis right anterior parietal bone; s/p
Operation Diagnosis: Soft tissue defect right parietal area with osteomyelitis, s/p
OSTEOMYELITIS
- represents an acute or chronic infection of the bone. The term osteo refers to
bone and myelo to the marrow cavity, both of which are involved in this disease. Despite
the common use of antibiotics, these infections remain difficult to treat and eradicate. All
types of organism, including parasites, viruses, bacteria, and fungi, can cause
osteomyelitis, but certain pyogenic bacteria and mycobacteria are most common.
edition
- is a serious infection of the bone that is often difficult to treat. Osteomyelitis can
be categorized as acute or chronic, which occurs when the symptoms are present for
- is an infection of the bone. The bone becomes infected in one of three ways:
first, extension of soft tissue infection (eg, infected pressure or vascular ulcer, incisional
infection). Second, direct bone contamination from bone surgery, open fracture, or
traumatic injury. Third, hematogenous (bloodborne) spread from other sites of infection.
Osteomyelitis resulting from hematogenous spread typically occurs in a bone in an area
mycobacteria. It can be usefully subclassified on the basis of the causative organism, the
http://en.wikipedia.org/wiki/Osteomyelitis
http://emedicine.medscape.com/article/785020-overview
result of an infection. Osteomyelitis, or bone infection, may occur for many different
reasons and can affect children or adults. It can have a sudden onset, a slow and mild
http://www.healthsystem.virginia.edu/uvahealth/adult_bone/osteom.cfm
MENINGIOMA
- develop from the meningothelial cells of the arachnoid and are outside the brain.
They usually have their onset in the middle or later years of life and constitute
approximately 20% of primary brain tumors in this age group. Meningiomas are slow-
growing, well-circumscribed and often highly vascular tumors. They usually are benign,
and complete removal is possible if the tumor does not involved vital structures.
edition
- are tumors that arise from the covering of the brain & account for 25% of all
brain tumors and are most common in people over the age of 40 years old. These tumors
- represents 15% to 20% of all primary brain tumors, are common benign
encapsulated tumors of arachnoid cells on the meninges. They are slow-growing and
occur most often in middle-aged adults (more often in women). Meningiomas most often
occur in areas proximal to the venous sinuses. Manifestations depend on the area
involved and are the result of compression rather than invasion of brain tissue. Standard
the arachnoid "cap" cells of the arachnoid villi in the meninges. These tumors are usually
http://en.wikipedia.org/wiki/Meningioma
- Meningioma is a tumor that arises from the meninges — the membranes that
surround your brain and spinal cord. The majority of meningioma cases are noncancerous
most commonly in women. Most people develop meningioma as adults, after age 40. But
http://www.mayoclinic.com/health/meningioma/DS00901
membrane that surrounds the brain and spinal cord. There are three layers of meninges,
called the dura mater, arachnoid and pia mater. Most meningiomas (90%) are categorized
as benign tumors, with the remaining 10% being atypical or malignant. However, the
word "benign" can be misleading in this case, as when benign tumors grow and constrict
and affect the brain, they can cause disability and even be life threatening.
http://www.brighamandwomens.org/neurosurgery/Meningioma/Meningiomafacts.aspx
EXCISION
http://en.wikipedia.org/wiki/Excision
-involves the use of a local anesthetic and the removal of a skin lesion by use of a
surgical scalpel. The excised area is then sent to a laboratory for pathologic evaluation.
www.abramsderm.com/patient-education-terms.htm
http://cancerweb.ncl.ac.uk/cgi-bin/omd?excision
PHYSICAL ASSESSMENT
Patient’s Name: Mrs. X
Sex: Female
General Survey
Our patient Mrs. X, 64 years old was assessed on December 20, 2008. She was
admitted on December 10, 2008 at 2:00pm. She was received on lying on bed awake,
conscious and coherent. She was responsive and cooperative when asked. In regards to
his emotional state/status, she appeared to be calm. She has a mesomorphic body
structure.
Vital Signs
Skin was smooth to touch, generally uniform in color - tan, has a rough texture
and has a good skin turgor. Presence of sutures in the head noted. Bandages were noted in
the right thigh upon observation due to STSG operation. Nails were not trimmed and
traces of dirt noted. Areas around the nails were intact and not inflamed. Nail beds were
Head
craniotomy. Wrinkles were noted on her forehead. Closed surgical inscision is present on
the frontal and midsaggital lines of the head with14 staples on the midsaggital line and
stitches on the frontal line. Presence of JP drain on the mastoid process behind the right
Eyes
Eyes are symmetrically aligned. Eyelashes are equally distributed and curled
slightly outward. Eyelids are free from discharge and did not show any sign of
inflammation such as redness and swelling. Her palpebral conjunctiva’s color is pink.
Pupils are equally round and reactive to light and accommodation. Pupils, when
Ears are symmetrically aligned to the canthi of the eyes. Also, ears are equal in
Nose
Nasolabial folds are symmetrical with no flaring and discharges noted. Nasal
septum is not deviated. Both nostrils are patent. No signs of tenderness and other unusual
signs and symptoms were noted. Patient was able to distinguish the smell of rubbing
Outer lips are symmetrical in contour. Upper and lower lips are brown in color.
No lesions or edema were noted. Teeth were not complete. Buccal mucosa appears
pinkish and smooth. Tongue is in midline and pinkish in color. Gums are slightly brown
in color, no bleeding or ulcerations noted. Tonsils were not inflamed and uvula is also in
midline.
Neck
The sides of neck were symmetrical. No masses and swelling noted. Carotid
arteries are palpable. Because of post-operational conditions patient was only able to
rotate, tilt, flex and hyperextend neck minimally, due to her carefulness.
Chest muscle expansion during inspiration and relaxation during expiration are
symmetrical and painless. There were no presence of scars and lesions. She was not in
respiratory distress. Respiratory rate is 29 cycles per minute and rhythm was regular.
Breath sounds were clear on both lungs indicating that she is free of cough or colds.
Heart
Upon visual inspection, point of maximum impulse was heard at the left
midclavicular line 5th intercostal space. Heart sounds were regular, no murmurs or
Axillae
Axillae are free from rashes. Surface is smooth with no signs of tenderness. No
Abdomen is soft, non-tender and globular in shape. There were no scars and
lesions noted upon inspection. No discharges were noted on her umbilicus. Bowel sounds
Extremities
On the upper limb, shoulders and arms were symmetrical. No tenderness noted on
the bones of the wrist and fingers. No deformities and swelling noted. She could freely
On the lower limb, she has symmetrical legs. She could freely move her legs in
full range motion. Presence of bandages in right upper leg due to STSG operation noted.
When right leg was assessed for ROM, a sharp pain was felt by Mrs. X. When the pain
scale was introduced for basis of pain intensity, she verbalized a pain scale of “5.”
Neurological Assessment
Pupil
(right): 3mm
(left): brisk
Motor
(right): strong
(right): strong
Level of consciousness
Also called the integument, which simply means “covering” the skin is much
more than an external body covering. It is absolutely essential because it keeps water and
other precious molecules in the body. It also keeps (and other things) out. Structurally,
the skin is a marvel. It is pliable yet tough, which allows it to take constant punishment
from external agents. Without our skin, we would quickly fall prey to bacteria and perish
from water and heat loss. The skin has many function; most, but not all are protective. It
insulates and cushions the deeper body organs and protects the entire body from
mechanical damage, chemical damage, thermal damage, ultraviolet radiation and
bacteria. The uppermost layer of the skin [stratum corneum] is full of keratin and
cornified, or hardened, in order to prevent water loss from the body surface. [Marieb,
2006]
[image from - http://www.vitalyouth.com/images/skin_big.jpg]
The skin is composed of two kinds of tissue. The outer epidermis is made up
stratified squamous epithelium that is capable of keratinizing, or becoming hard and
tough. The underlying dermis is mostly made up of dense connective tissue. The
epidermis and dermis are firmly connected. However, a burn or friction may cause them
to separate, allowing interstitial fluid to accumulate in the cavity between the layers,
which results in a blister. [Marieb, 2006]
The skin of the scalp continues from the front and lateral side of the face into the
occipital region of the skull posteriorly. The makeup of the scalp is important clinically
because trauma to the scalp is frequent and it is up to the clinician to determine by
palpation and observation just how serious the trauma is.
The scalp is made of 5 layers and they spell scalp:
* S -- skin
* C -- dense Connective tissue
* A -- aponeurosis
* L -- loose connective tissue
* P -- periosteum
The blood vessels travel through the dense connective. The connective tissue has
a special relationship with the arteries in this area. When an artery is severed, the
connective tissue fibers around the vessel contract and pull the artery open. This results is
more hemorrhage than in other places. With scalp hemorrhage, compression must be used
to stop the bleeding. Blood vessels and nerves come into the scalp from three different
regions: 1) anterior (supraorbital), 2) lateral (superficial temporal), 3) posterior
(occipital). There are free anastomoses from side to side. With all of this blood supply,
lacerations of the scalp are usually profuse and because of the nerve supply, very
sensitive.
The loose connective layer of the scalp will allow bacteria or fluid to pass freely from the
posterior aspect of the scalp into the eyelids in front. Trauma in the back of the head can
result in blood showing up in the eyelids and should make you suspect something going
on in the back of the head. [http://home.comcast.net/~wnor/lesson1.htm]
[image from - http://cellbio.utmb.edu/microanatomy/skin/thickskin.jpg; edited]
The outermost layer, the stratum corneum, is 20-30 cell layers thick. It accounts
for about three quarters of the epidermal thickness The snignlelike dead cell remnants,
completely filled with keratin, are referred to as cornified or horny cells (cornu = horn).
The common saying “Beauty is only skin deep” is especially interesting in light of the
fact that nearly everything we see when we look at someone is dead! Keratin is an
exceptionally tough protein. Its abundance in the stratum corneum allows that layer to
provide a durable “overcoat” for the body, which protects deeper cells from the hostile
external environment and from water loss and helps the body resist biological, chemical,
and physical assaults. The stratum corneum rubs and flakes off slowly and steadily and is
replaced by cells produced by the division of the deeper stratum basale cells. Indeed, we
have a totally “new” epidermis every 25 to 45 days. [Marieb, 2006]
[image from - http://www.koshland-science-museum.org/exhib_infectious/images/s_aureus.jpg]
S. aureus may occur as a commensal on human skin; it also occurs in the nose
frequently (in about a third of the population) and throat less commonly. The occurrence
of S. aureus under these circumstances does not always indicate infection and therefore
does not always require treatment (indeed, treatment may be ineffective and re-
colonisation may occur). It can survive on domesticated animals such as dogs, cats and
horses, and can cause bumblefoot in chickens. It can survive for some hours on dry
environmental surfaces, but the importance of the environment in spread of S. aureus is
currently debated. It can host phages, such as the Panton-Valentine leukocidin, that
increase its virulence.
S. aureus can infect other tissues when normal barriers have been breached (e.g.,
skin or mucosal lining). This leads to furuncles (boils) and carbuncles (a collection of
furuncles). In infants S. aureus infection can cause a severe disease Staphylococcal
scalded skin syndrome (SSSS).
S. aureus infections can be spread through contact with pus from an infected
wound, skin-to-skin contact with an infected person by producing hyaluronidase that
destroy tissues, and contact with objects such as towels, sheets, clothing, or athletic
equipment used by an infected person. Deeply penetrating S. aureus infections can be
severe. Prosthetic joints put a person at particular risk for septic arthritis, and
staphylococcal endocarditis (infection of the heart valves) and pneumonia, which may be
rapidly spread. [http://en.wikipedia.org/wiki/Staphylococcus_aureus]
B. BLOOD
Blood is the “river of life” that surges within us. It transports everything that must
be carried from one place to another within the body – nutrients, wastes (headed for
elimination from the body, and body heat – through blood vessels. For centuries, long
before modern medicine, people recognized that blood was vital (some believed
“magical”), and its loss was always considered to be a possible cause of death.
Although leukocytes or white blood cells (WBCs), are far less numerous than red
blood cells, they are crucial to body defense against disease. On average, there are 4,000
to 11,000 WBCs/mm3, and they account for less than 1 percent of total blood volume.
White blood cells are the only complete cells in blood; that is, they contain nuclei and the
usual organelles.
Leukocytes form a protective, movable army that helps defend the body against
damage by bacteria, viruses, parasites and tumor cells. As such, they have some very
special characteristics. Red blood cells are confined to the blood stream and carry out
their functions in the blood. White blood cells, by contrast, are able to slip into and out of
the blood vessels – a process called diapedesis. The circulatory system is simply their
means of transportation to areas of the body where their services are needed for the
inflammatory or immune responses.
In addition, WBCs can locate areas of tissue damage and infection in the body by
responding to certain chemicals that diffuse from the damaged cells. This capability is
called positive chemotaxis. Once they have “caught the scent,” the WBCs move through
the tissue spaces by ameboid motion (they form flowing cytoplasmic extensions that help
move them along). By following the diffusion gradient, they pinpoint areas of tissue
damage and rally round in large numbers to destroy microorganisms or dead cells.
Whenever WBCs mobilize for action, the body speeds up their production, and as
many as twice the normal number of WBCs may appear in the blood within a few hours.
A total WBC count above 11,000 cells/mm3 is referred to as leukocytosis. Leukocytosis
generally indicates that a bacterial or viral infection is stewing in the body. The opposite
condition, leucopenia, is an abnormally low WBC count. It is commonly caused by
certain drugs, such as corticosteroids and anticancer agents. [Marieb, 2006]
C. CIRCULATORY SYSTEM
Besides contributing to body shape and form, our bones perform several
important body functions:
1. Support. Bones, the “steel-girders” and “reinforced concrete” of the body,
form the internal framework that supports and anchors all soft organs. The
bones of the legs act as pillars to support the body trunk when we stand, and
the rib cage supports the thoracic wall.
2. Protection. Bones protect soft body organs. For example, the fused bones of
the skull provide a snug enclosure for the brain, allowing one to head a soccer
ball without worrying about injuring the brain. The vertebrae surround the
spinal cord, and the rib cage helps protect the vital organs of the thorax.
3. Movement. Skeletal muscles , attached to bones by tendons, use the bones as
levers to move the body and its parts. As a result, we can walk, swim, throw a
ball, and breathe.
4. Storage. Fat is stored in the internal cavities of bones. Bone itself serves as a
storehouse for minerals, the most important being calcium and phosphorus,
although others are also stored. A small amount of calcium in its ion form
must be present in the blood at all times for the nervous system to transmit
messages, for muscles to contract, and for blood to clot. Because most of the
body’s calcium is deposited in the bones as calcium salts, the bones are a
convenient place to get more calcium ions for the blood as they are used up.
Problems occur not only when there is too little calcium in the blood, but also
when there is too much. Hormones control the movement of calcium to and
from the bones and blood according to the needs of the body. Indeed,
“deposits” and “withdrawals” of calcium to and from bones go on almost all
the time.
5. Blood cell formation. Blood cell formation, or hematopoiesis, occurs within
the marrow cavities of certain bones. [Marieb, 2006]
[image from - http://www.georgehernandez.com/h/xMartialArts/Health/Media/Gray188-Skull-LeftLateral.png]
The skull is formed by two sets of bones. The cranium encloses and protects the
fragile brain tissue. The facial bones hold the eyes in an anterior position and allow the
facial muscles to show our feelings through smiles or frowns. All but one of the bones of
the skull are joined together by sutures, which are interlocking, immovable joints. Only
the mandible is attached to the rest of the skull by a freely movable joint. [Marieb, 2006]
The parietal bones are bones in the human skull and form, by their union, the
sides and roof of the cranium. Each bone is irregularly quadrilateral in form, and has two
surfaces, four borders, and four angles.
Surfaces
External - The external surface [Fig. 1] is convex, smooth, and marked near the
center by an eminence, the parietal eminence (tuber parietale), which indicates the point
where ossification commenced.
Crossing the middle of the bone in an arched direction are two curved lines, the
superior and inferior temporal lines; the former gives attachment to the temporal fascia,
and the latter indicates the upper limit of the muscular origin of the temporalis.
Above these lines the bone is covered by the galea aponeurotica (epicranial
aponeurosis); below them it forms part of the temporal fossa, and affords attachment to
the temporalis muscle.
At the back part and close to the upper or sagittal border is the parietal foramen,
which transmits a vein to the superior sagittal sinus, and sometimes a small branch of the
occipital artery; it is not constantly present, and its size varies considerably.
Internal - The internal surface [Fig. 2] is concave; it presents depressions
corresponding to the cerebral convolutions, and numerous furrows (grooves) for the
ramifications of the middle meningeal artery; the latter run upward and backward from
the sphenoidal angle, and from the central and posterior part of the squamous border.
Along the upper margin is a shallow groove, which, together with that on the
opposite parietal, forms a channel, the sagittal sulcus, for the superior sagittal sinus; the
edges of the sulcus afford attachment to the falx cerebri.
Near the groove are several depressions, best marked in the skulls of old persons,
for the arachnoid granulations (Pacchionian bodies).
In the groove is the internal opening of the parietal foramen when that aperture
exists.
Borders
* The sagittal border, the longest and thickest, is dentated (has toothlike projections)
and articulates with its fellow of the opposite side, forming the sagittal suture.
* The squamous border is divided into three parts: of these:
- the anterior is thin and pointed, bevelled at the expense of the outer surface, and
overlapped by the tip of the great wing of the sphenoid;
- the middle portion is arched, bevelled at the expense of the outer surface, and
overlapped by the squama of the temporal;
- the posterior part is thick and serrated for articulation with the mastoid portion of
the temporal.
* The frontal border is deeply serrated, and bevelled at the expense of the outer surface
above and of the inner below; it articulates with the frontal bone, forming half of the
coronal suture. The point where the coronal suture intersects with the sagittal suture
forms a T-shape and is called the bregma.
* The occipital border, deeply denticulated (finely toothed), articulates with the
occipital bone, forming half of the lambdoid suture. That point where the sagittal suture
intersects the lambdoid suture is called the lambda, because of its resemblance to the
Greek letter.
Angles
The frontal angle is practically a right angle, and corresponds with the point of
meeting of the sagittal and coronal sutures; this point is named the bregma; in the fetal
skull and for about a year and a half after birth this region is membranous, and is called
the anterior fontanelle.
The sphenoidal angle, thin and acute, is received into the interval between the
frontal bone and the great wing of the sphenoid. Its inner surface is marked by a deep
groove, sometimes a canal, for the anterior divisions of the middle meningeal artery.
The occipital angle is rounded and corresponds with the point of meeting of the
sagittal and lambdoidal sutures—a point which is termed the lambda; in the fetus this part
of the skull is membranous, and is called the posterior fontanelle.
The mastoid angle is truncated; it articulates with the occipital bone and with the
mastoid portion of the temporal, and presents on its inner surface a broad, shallow groove
which lodges part of the transverse sinus. The point of meeting of this angle with the
occipital and the mastoid part of the temporal is named the asterion.
Ossification
The parietal bone is ossified in membrane from a single center, which appears at
the parietal eminence about the eighth week of fetal life.
Ossification gradually extends in a radial manner from the center toward the
margins of the bone; the angles are consequently the parts last formed, and it is here that
the fontanelles exist.
Occasionally the parietal bone is divided into two parts, upper and lower, by an
antero-posterior suture. [http://en.wikipedia.org/wiki/Parietal_bone]
[image form - http://upload.wikimedia.org/wikipedia/commons/3/3a/Bony_sequestrum_in_a_child_femur.jpg]
An X-ray of a child's femur showing a bony sequestrum highlighted by the blue arrow.
A sequestrum is a piece of dead bone that has become separated during the
process of necrosis from normal/sound bone.
It is a complication (sequelae) of osteomyelitis. The pathological process is as follows:
* infection in the bone leads to an increase in intramedullary pressure due to
inflammatory exudates
* the periosteum becomes stripped from the osteum, leading to vascular thrombosis
* bone necrosis follows due to lack of blood supply
* sequestra are formed
The sequestra are surrounded by sclerotic bone which for all intents and purposes
is relatively avascular (without a blood supply). Within the bone itself, the haversian
canals become blocked with scar tissue, and the bone becomes surrounded by thickened
periosteum.
Due to the avascular nature of this bone, antibiotics which travel to sites of infection via
the bloodstream, poorly penetrate these tissues. Hence the difficulty in treating chronic
osteomyelitis.
At the same time as this, new bone is forming (known as involucrum). Opening in this
involucrum allow debris and exudates (including pus) to pass from the sequestrum via
sinus tracts to the skin.
Rarely, a sequestrum may turn out to be an osteoid osteoma, a rare tumor of the
bone.
ETIOLOGY
PREDISPOSING FACTORS
Increases the
Diabetes susceptibility to Absent Mrs. X is not diabetic
get infected
Increases blood
pressure which
Obesity Absent Mrs. X is not obese
leads to poor
tissue perfusion
PRECIPITATING FACTORS
Factor Rationale Present or Justification
Absent
There was a break in Mrs. X underwent
sterility, leading to surgery twice which
bacteria introduced Leads to infection could mean that the
Present
during intra- of the bone surgical wound on her
operative or post- scalp might have served
operative care. as a portal of entry.
Mrs. X acquired bone
Bacteria introduced Leads to infection trauma from the
Present
by trauma to bone. of the bone surgeries that she had
undergone.
Bacteria introduced Leads to infection Mrs. X does not have a
Absent
via bone fractures. of the bone bone fracture
Bacteria introduced
Mrs. X does not have
via prosthetic Leads to infection
Absent anything that is
implants (such as an of the bone
prosthetic.
artificial hip joint).
Infections elsewhere Leads to infection Absent Mrs. X does not have
in the body that of the bone any other infection
reach the bones via anywhere else in her
the bloodstream. entire body
A primary infection Leads to infection Absent Mrs. X does not have a
of the blood of the bone primary infection of the
(septicaemia). blood.
SYMPTOMATOLOGY
(as of December 13, 2008)
Symptoms Rationale Present or Justification
Absent
The infection Dressing on her head, ®
triggers parietal area, was noted
Abscess chemotaxis of Present to be absorbing
leukocytes toward purulent pus draining
the infected site from her scalp.
The infection will
There was evidence of
trigger the
Inflammation Present swelling on Mrs. X’s
inflammatory
scalp.
process
The infection will
Mrs. X’s temperature
trigger the
Fever Absent was not higher than
inflammatory
37.5°C
process
The infection will There are not many
Myalgia causes pain to Absent muscles affected by
muscle movement Mrs. X’s osteomyelitis.
The infection Mrs. X verbalized that
affects the tissue her head, especially
Pain and Tenderness Absent
surrounding the around the operative
affected bone site, felt numb
PATHOPHYSIOLOGY
The host responds to the presence of bacteria in the metaphysis with a local
increase in vascular permeability, resulting in edema, increased vascularity and the influx
of polymorphonuclear leukocytes. Pressure increases as pus collects and is confined
within rigid bone. Exudation through Volkmann's canals and the haversian canal affords
little relief, although the relatively inelastic periosteum may become elevated. The blood
supply to the area of involvement is decreased secondary to the pressure; necrosis of the
infected bone may result in the formation of a sequestrum. A protein-rich liquid
containing inflammatory cells may collect in an adjacent joint but such effusions are
sterile.
After the vascular supply to the involved area has been interrupted and necrosis
has occurred, the chronic phase of osteomyelitis is established. The residual dead bone
acts as a foreign body, making the eradication of bacteria impossible until the sequestrum
is removed.
If the infected area becomes well demarcated and the infection is contained, the
acute inflammatory process may subside, leaving a subperiosteal accumulation of pus
which may be discovered by tenderness on palpation. This relatively quiescent form of
subperiosteal infection is termed a Brodie's abscess. After some time, there is deposition
of new bone, the involucrum, under the elevated periosteum.
[http://www.kcom.edu/faculty/chamberlain/Website/tritzid/skelinfe.htm]
Acute osteomyelitis is usually caused by bacteria. The infection can be cause by
direct extension or contamination of an open fracture or wound (contiguous invasion); by
seeding through the bloodstream (hematogenous spread); or by spread from skin
infections in persons with vascular insufficiency.
The specific agents isolated in bacterial osteomyelitis are often associated with
the age of the person or the inciting condition (e.g., trauma or surgery). Staphylococcus
aureus is responsible for most cases of acute hematogenous osteomyelitis.
Staphylococcus epidermidis, S. aureus, Pseudomonas aeruginosa, Serratia marcescens,
and Escherichia coli are commonly isolated in persons with chronic osteomyelitis. S.
aureus has several characteristics that favor its ability to produce osteomyelitis: it is able
to produce collagen-binding adhesion molecules that allow it to adhere to the connective
tissue elements of bone; and it has the ability to be internalized and survive in cells such
as the osteoblast, which helps to explain the persisten nature of the infection. S. aureus
and S. epidermidis can also form biofilms, making them more resistant to antimicrobial
therapy.
CHRONIC OSTEOMYELITIS
Bone Injury
Release of histamine
and kinins
Dilation of blood
Inflammation & vessels and increased
Fever permeability in
capillaries
Leukocytosis
Chemotaxis
Abscess Accumulation
formation of pus
Diagnostic
Findings
Biopsy
GS/CS
CBC X-ray
Acute Osteomyelitis
Nursing
Management
Medical
Management Surgical
> Increase OFI
Management
> Encourage
> Antibiotics
nutritious diet
> Antipyretics > Drain
> Promote rest
> Analgesics
and sleep
GOOD PROGNOSIS
Aggravation of infection
Spread of infection
Septicemia
Aggravation
Bone necrosis
of infection
- Advancement
Aggravation
Formation ofofsequestra
infection to chronic
osteomyelitis
Influx of polymorpholeukocytes
Phagocytosis
Non-healing wound
Diagnostic Findings
CBC X-ray
Urinalysis MRI
(Health History) CT Scan
Chronic Osteomyelitis
Chronic Osteomyelitis
Surgical Nursing
Medical
Management Management
Management
Debridement Increase OFI
Antibiotic
STSG Encourage nutritious
Antipyretic
Rotational Flap diet
Analgesic
Drain Promote sleep and rest
PROGNOSIS
Disability and
Deformation
GOOD PROGNOSIS
POOR PROGNOSIS
DEATH
DOCTOR’S ORDERS
DATE DOCTOR'S ORDER RATIONALE REMARKS
December Please admit under General The patient is in need of DONE
10, 2008 Surgery I medical attention so she is
@ 3:45 admitted in Davao Medical
pm Center in Gen. Surg. I for
preparations for the Pre-
operation.
Consent For legal purposes: to ensure DONE
that the patient knows the
majority of the operation to be
done.
Please monitor VS q 4 record Vital signs are recorded to DONE
obtain patients baseline data
and be useful for further
management. A temperature
higher than normal may
indicate the development of
infection. Pulse & respiration is
taken to watch out for
tachycardia a sign of
hemorrhage & dehydration.
LABS: with available lab These entire lab tests are DONE
result (CBC, UA, CXN, ECG, performed to screen for
NA-, K+, CA++, lipid profile, alteration and to serve as a
PC, blood typing); PLR 1L @ baseline data for future
100 cc/hr comparison.
Meds: Ciproflaxin-prevents infections DONE
1. Ciproflaxin 300 mg IVTT q by inhibting the growth or
2 action of the microorganism.
2. Ketorolac 30 mg IVTT q 8 Ketorolac- to reduce pain, fever
& inflammation.
Watch out for unusualities To ensure that immediate DONE
nursing interventions can be
administered to avoid
complications
Daily wound dressing Dressing is important to prevent DONE
infection and to promote
hygiene and faster healing of
the wound.
Still inform Dr. Mapuyo of Informing the physicians of the DONE
this latest news about the patient
still inform Dra. Ello Niño of will mean better care given to
this the patient.
DATE DOCTOR'S ORDER RATIONALE REMARKS
Refer Accordingly Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition
December Start clindamycin 300 mg QID To reduce fever, pain & DONE
11, 2008 inflammation.
@ 9:00
am
For dressing Dressing is important to prevent DONE
infection and to promote
hygiene and faster healing of
the wound
refer Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition.
11:20 pm Change IV to heplock For convenient administration DONE
of IVTT medications
Continue Referring to the previous order DONE
refer Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition.
December Continue meds All medications previously DONE
12, 2008 ordered by attending physician
should be continued to hasten
patient's recovery.
Change drain To prevent infection. DONE
refer Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition.
December Continue meds All medications previously DONE
13, 2008 ordered by attending physician
should be continued to hasten
patient's recovery.
DATE DOCTOR'S ORDER RATIONALE REMARKS
Change dressing Dressing is important to prevent DONE
infection and to promote
hygiene and faster healing of
the wound of the patient
For co-management To determine if there are any DONE
unusualities that needs proper
management.
Shave head For preparation in the surgery. DONE
To avoid microorganism from
invading the open incision.
refer Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition.
December NPO post Midnight The patient is maintained on DONE
14, 2008 NPO in order to prevent
(pre-op) aspiration from vomiting which
is one of the side effects of
anesthesia.
General/ oral hygiene PTOR General and Oral Hygiene will DONE
be able to help out in the over
all health and recovery of the
patient by keeping the patient
generally clean. [PTOR –
Periotherapy Oral Rinse]
VS Vital signs are recorded to DONE
obtain patients baseline data
and be useful for further
management.
IVF PLR 1 L @ 120cc/ hr For replacement of fluid DONE
electrolytes balance
maintainance.
Meds: Is an anti-ulcer agent. It is given DONE
Ranitidine 50 mg IVTT q 8 to decrease gastric acid
secretion in which preventing
the stomach from scarring of
the lining.
refer Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
DATE DOCTOR'S ORDER RATIONALE REMARKS
physician of the patient's
condition.
Decemebr Neurosurgery: This is for the collaborative DONE
14, 2008 • Patient secure health care of the patient.
@11:00 examined Assessment of the patient is
am • health history endorsed for the continuity of
recovered care.
• S/p craniectomy for
meningioma
Osteomyelitis
• retrive CT scan plates
& place at bedside
Retrieve CT scan plates & For diagnostics purposes. DONE
place at bedside
For referral Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition.
Thanks for this referral To show appreciation DONE
December Schedule for STAT To inform the nurses that a DONE
15, 2008 debridement possible STSG surgical operation is being
planned; also, to signal
preparation for pre-operative
care.
Secure consent For legal purposes: to ensure DONE
that the patient knows the
majority of the operation to be
done.
Inform OR/ AROD To schedule the operation. DONE
To secure 1 unit whole blood Fresh whole blood and blood DONE
of patient's blood type and components are administered to
cross match for OR use increase amount of oxygen
being delivered to the tissue and
organs, to prevent/stop bleeding
because of platelet defects or
because of deficiencies or
coagulation and to combat
infection caused by decreased
WBC/ antibodies.
Crossmatching is important to
DATE DOCTOR'S ORDER RATIONALE REMARKS
detect agglutination of donor
RBC's caused by antibodies in
patient's serum.
IVF with PLR 1 L @ 120 For replacement of fluid DONE
cc/hr electrolytes balance
maintainance.
Cefradine 1 gm IVTT PTOR Is given to treat infections with DONE
bacteria
Refer accordingly Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition.
December To PACU then GS ward once For close monitoring of the DONE
16, 2008 stable patient. To watch out for any
(post-op) signs of unusualities.
DAT once fully awake Diet as tolerated is ordered by DONE
the doctor to let patient eat the
regular diet to meet nutritional
needs.
VS q15 mins. Every 2 hrs. Vital signs is taken to provide DONE
then q hourly baseline data and to watch for
any unusualities.
Neuro VS q hourly x6 hrs then Post operative protocol. Surgery DONE
q shift involving any exposure of the
brain will require NVS
monitoring to establish any
neurological unusualites
IVF: PNS 1 L @ KVO with For replacement of fluid DONE
ongoing BT @ 25-30 cc/hr electrolytes balance
maintenance. Blood transfusion
may treat medical condition
such as massive blood loss.
Meds: Tramadol – is administered to DONE
•Tramadol 50 mg q6 alleviate moderate to severe
IVTT pain.
•Ketorolac 15 mg q4 Ketorolac - Ketorolac- to
IVTT reduce pain, fever &
•Metroclopromide 10 mg inflammation.
q6 IVTT x2 doses RTC Metroclopromide - this action
then prn for PONV prevents nausea and vomiting.
DATE DOCTOR'S ORDER RATIONALE REMARKS
O2 inhalation @ 4LPM via Oxygen therapy is provided to DONE
facemask @ PACU prevent patient from hypoxia.
Keep patient warm and Warmth makes the patient DONE
thermoregulated comfortable and alleviate
anxiety that may be helpful for
her recovery.
INO q hourly x6 hrs then q Intake & output monitoring DONE
shift provides evidence of the client's
fluid volume status. If intake is
greater than 100ml/ hr, fluid
overload may occur, placing the
client at risk for pulmonary
edema.
Elevate head 30 degrees from To allow lung expansion and DONE
improve circulation thus
increased comfort.
Hook to pulse oximeter To measures the oxygen DONE
saturation of a patient's blood
(indirectly) and changes in
blood volume in the skin
Repeat CBC, 6 hours post-BT To evaluate the efficiency of DONE
the Blood Transfusion and to
see if there are any
complications
For ABG @ PACU and refer Arterial blood Gas is used to DONE
result test the effectiveness of
respiration. To determine if
there are any changes in the
result.
Refer prn To inform the physician when DONE
services are needed.
December Please re-insert IVF This is for fluid replacement DONE
18, 2008 and to prevent dehydration.
@ 6:00
am
Cloxacillin 50 mg Is an antibiotic drug used to DONE
treat infection caused by
staphylococcus bacteria.
Continue other medications All medications previously DONE
ordered by attending physician
should be continued to hasten
DATE DOCTOR'S ORDER RATIONALE REMARKS
patient's recovery.
refer Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition.
Transfer for surgical rest To signal post-operative care. DONE
DIAGNOSTIC EXAMS
IPD HEMATOLOGY
CBC+BLT
REF.
TEST RESULT UNIT
RANGES
Hemoglobin
- To identify the amount of O2 carrying
protein contained within the RBC.
L 110.0 g/L 115 - 155
- Decreased Hgb indicates anemia fro
blood loss, dietary deficiency, and
malnutrition and kidney disease.
Hematocrit
- To identify the percentage of the blood
volume occupied by red blood cells.
0.36 0.36 - 0.48
- Decreased Hct indicates blood loss, anemia,
blood replacement therapy, and fluid balance,
and screens red blood cell status
RBC Count
- To know the amount of RBC in the blood.
L 3.88 10^6/uL 4.20 - 6.10
Rule out anemia due to nutritional
deficiencies, blood loss.
WBC Count
- To determine infection or inflammation in
the body and monitor its responses to 7.42
specific therapies. Explain to the patient the 10^3/uL 5.0 - 10.0
necessity of undergoing the test that it helps
detect occurrence of anemia and
polycythemia.
DIFFERENTIAL COUNT
TEST RESULT UNIT REF. RANGES
Neutrophil L52 55 - 75
- To indicate the presence of bacterial
infection and amount of Leukocyte.
Lymphocytes 35 20 - 35
- To identify if there is an abnormal
amount of lymphocyte that may indicate
viral infection such as HIV. A decreased
number of lymphocytes in the peripheral
circulation, occurring as a primary
hematologic disorder or in association
with nutritional deficiency, malignancy
or infection mononucleosis.
Monocytes 7 2 - 10
- Increase of these may respond to
corticosteroid, with pus conditions,
hemorrhage.
Eosinophil 5 1-8
- High percentage of eosin Phil, may
indicate bacterial infestation or allergies.
Basophil 1 0-1
- Increase of basophil may indicate
parasite, hypersensitiveness and
heartworm causing endocrine disease,
chronic liver disease.
Platelet Count 245 X10^3/uL 150 - 400
- The smallest cells in the blood are the
platelets, which are designed for a single
purpose-to begin the process of
coagulation, or forming a clot, whenever
a blood vessel is broken.
CLINICAL MICROSCOPY
A.) PHYSICAL EXAMINATION
Albumin negative
Sugar negative
Cranial CT SCAN
- No previous study available for comparison
- Multiple plain and IV-contrast axial tomographic sections of thr head were obtained.
- There is a non-enhancing low attenuation density in the R anterior parietal area.
- Irregular craniectomy defect is noted in the R anterior parietal area. Osseous thickening is
noted in the frontoparietal area on both sides, more in the R parietal area. The thickest
diameter measures 2.8cm. At least 4 metallic densities (craniofixed) are stabilizing the
defect.
- No abnormal enhancing lesions.
- No extra-axial fluid collection noted.
- The ventricles are symmetrical and not dilated.
- The sulci and cisterns are undisplaced.
- The posterior fossa, sella, orbits, paranasal sinuses, petromastoids, and bony calvarium
are unremarkable.
Impression:
s/p craniectomy with ischemic change right parietal bone.
Radiologic Findings
Impression:
Artherosclerotic Aorta
Senile osteoporosis
ECG Report
Name: Mrs. X
Date: 11/21/08
Rhythm: Sinus
Interval PR 0.15sec
QR 0.9sec
QT 0.38sec
Electocardiographic Diagnosis
Normal ECG
DRUG STUDY
Generic Name Brand Classification Dosage & Mechanism of actions Indications
Name frequency
Tramadol ultram Analgesics, Doses range from The mode of action of tramadol is used to treat
central acting 50–400 mg daily, has yet to be fully understood, moderate and severe
maximum dose of but it is believed to work pain and most types
400 mg a day through modulation of the of neuralgia, including
(webmed), with up to noradrenergic and serotonergic trigeminal neuralgia. It
600 mg daily when systems in addition to its mild has been suggested
given IV/IM. The agonism of the μ-opioid that tramadol could be
formulation receptor. The contribution of effective for alleviating
containing APAP non-opioid activity is symptoms of
contains 37.5 mg of demonstrated by the analgesic depression and
tramadol and 325 mg effects of tramadol not being anxiety because of its
of paracetamol, fully antagonised by the μ- action on the
intended for oral opioid receptor antagonist noradrenergic and
administration with a naloxone.Tramadol is marketed serotonergic systems,
common dosing as a racemic mixture with a the involvement of
recommendation of weak affinity for the μ-opioid which appear to play
one or two tabs every receptor (approximately a part in its ability to
four to six hours. 1/6000th that of morphine; alleviate the
Gutstein & Akil, 2006). The perception of pain.
(+)-enantiomer is
approximately four times more
potent than the (-)-enantiomer
in terms of μ-opioid receptor
affinity and 5-HT reuptake,
whereas the (-)-enantiomer is
responsible for noradrenaline
reuptake effects (Shipton,
2000). These actions appear to
produce a synergistic analgesic
effect, with (+)-tramadol
exhibiting 10-fold higher
analgesic activity than (-)-
tramadol (Goeringer et al.,
1997).
Hypersensitivity to • Nausea, The most commonly reported • Document indications for therapy,
tramadol. In acute vomiting, adverse drug reactions are nausea, location, onset, and
intoxication with sweating and vomiting, sweating and characteristics of symptoms. Use
alcohol, hypnotics, constipation. constipation. Drowsiness is a pain rating scale.
centrally acting Drowsiness. reported, although it is less of an • Assess for history of drug
analgesics,opiates, • Stomach issue than for other opioids. addiction, allergy to opiates or
or psychotropic upset, Respiratory depression, a codeine, or seizures; drug may
drug. Use for increased common side effect of most increase the risk of convulsions.
preoperative sensitivity to opioids, is not clinically • Monitor VS, I & O, liver and renal
medication or for stomach acid significant in normal doses. By function studies; reduce dose
postdelivery to the point of itself, it can decrease the seizure with dysfunction and if over 75
analgesia in ulceration of threshold. When combined with yrs. Old.
nursing mothers. esophagus, SSRIs, tricyclic antidepressants,
stomach, and or in patients with epilepsy, the CLIENT/FAMILY TEACHING
duodenum seizure threshold is further
• Vasodilation, decreased. Seizures have been • Take only as directed. May be
liver failure, reported in humans receiving taken without regard to meals. Do
speech excessive single oral doses (700 not exceed single or daily doses
disorder.Derm mg) or large intravenous doses of tramadol; do not share meds,
atologic (300 mg). An Australian study store safely out of reach of child.
problems. found that of 97 confirmed new- • Do not perform activities that
onset seizures, eight were require mental alertness; drug
associated with Tramadol, and may cause drowsiness and
that in the authors' First Seizure impair mental or physical
Clinic, "Tramadol is the most performance. Alcohol may
frequently suspected cause of intensify drug effect.
provoked seizure. Seizures caused
• Report lack of response. Review
by tramadol are most often tonic-
list side effects (nausea,
clonic seizures. Constipation can
be severe especially in the elderly dizziness, constipation,
requiring manual evacuation of somnolence, and pruritus) that
the bowel. one may experience and report if
persistent or intolerable.
Generic Name Brand Name Classification Dosage & Mechanism of actions Indications
frequency
Ketorolac Toradol and non-steroidal For oral The primary mechanism of Ketorolac is
Acular anti- dosage form action responsible for indicated for short-
inflammatory (tablets): ketorolac's anti- term management of
drug inflammatory, antipyretic pain (up to five days
For pain: and analgesic effects is the maximum).
inhibition of prostaglandin
Adults (patients synthesis by competitive
16 years of age blocking of the the enzyme
and older)—One cyclooxygenase (COX).
10-milligram (mg) Like most NSAIDs,
tablet four times a ketorolac is a non-selective
day, four to six COX inhibitor.
hours apart.
Some people may As with other NSAIDs, the
be directed to mechanism of the drug is
take two tablets associated with the chiral S
for the first dose form. Conversion of the R
only. enantiomer into the S
enantiomer has been shown
Children up to 16 to occur in the metabolism
years of age— of ibuprofen; it is unknown
Use and dose whether it occurs in the
must be metabolism of ketorolac.
determined by
your doctor.
For injection
dosage form:
For pain:
Adults (patients
16 years of age
and older)—15 or
30 mg, injected
into a muscle or a
vein four times a
day, at least 6
hours apart. This
amount of
medicine may be
contained in 1 mL
or in one-half
(0.5) mL of the
injection,
depending on the
strength. Some
people who do
not need more
than one injection
may receive one
dose of 60 mg,
injected into a
muscle.
Children up to 16
years of age—
Use and dose
must be
determined by
your doctor.
More common
• Abdominal or stomach
pain (mild or moderate)
• Bruising at place of
injection
• Diarrhea
• Dizziness
• Drowsiness
• Headache
• Indigestion
• Nausea
• Bloating or gas
• Burning or pain at place
of injection
• Constipation
• Feeling of fullness in
abdominal or stomach
area
• Increased sweating
• Vomiting
Generic Name Brand Name Classification Dosage & Mechanism of Indications
frequency actions
Metoclopramide Metoclopramide Gastro Tablets, syrup, It appears to bind to By inhibiting the action
Hydrochloride intestinal concentration dopamine D2 receptors of prolactin-inhibiting
Intensol®. stimulant where it is a receptor hormone (i.e.,
Reglan® Diabetic antagonist, and is also a
dopamine),
Reglan® Syrup gastroparesis mixed 5-HT3 receptor metoclopramide has
antagonist/5-HT4 sometimes been used to
Adults: 10 mg 30 receptor agonist. stimulate lactation.
min before meals Metoclopramide
and bedtime for 2- The anti-emetic action of increases peristalsis of
8 weeks(therapy metoclopramide is due to the jejunum and
should be its antagonist activity at duodenum, increases
reinstituted if D2 receptors in the tone and amplitude of
symptoms recur). chemoreceptor trigger gastric contractions, and
zone (CTZ) in the central relaxes the pyloric
IM, IV nervous system (CNS)— sphincter and duodenal
Prophylaxis of this action prevents bulb. These prokinetic
vomiting due to nausea and vomiting effects make
chemotherapy. triggered by most metoclopramide useful
Initial: 1-2 mg/kg stimuli.[2] At higher in the treatment of
IV q 2 hr for two doses, 5-HT3 antagonist gastric stasis (e.g. after
doses, with the activity may also gastric surgery or
first dose 30 mins contribute to the anti- diabetic gastroparesis),
before emetic effect. as an aid in
chemotherapy. gastrointestinal
The prokinetic activity of radiology by increasing
PROPHYLAXIS of metoclopramide is transit in barium
POSTOPERATIVE mediated by muscarinic studies, and as an aid in
N&V. difficult small intestinal
Adults: 10-20 mg activity, D2 receptor intubation. It is also
IM near the end of antagonist activity and 5- used in
surgery. HT4 receptor agonist gastroesophageal reflux
activity.[3][4] The disease
prokinetic effect itself (GERD/GORD).
may also contribute to
the anti-emetic effect.
Contraindications Side Effects Adverse Reactions Nursing Responsibilities
PO 2 to 4 mg/kg
twice daily (max, 300
mg/day).
Maintenance of
Healing of
Duodenal and
Gastric Ulcers
Children 1 mo to
16 yr of age
PO 2 to 4 mg/kg daily
(max, 150 mg/day).
Acute Benign
Gastric Ulcer and
GERD
Adults
PO 150 mg twice
daily.
IM/IV/Intermittent IV
50 mg every 6 to 8 h.
Treatment of
GERD and Erosive
Esophagitis
Children 1 mo to
16 yr of age
PO 5 to 10 mg/kg
daily usually given in
2 divided doses.
Pathologic
Hypersecretory
Conditions
Adults
PO 150 mg twice
daily. Individualize.
Erosive
Esophagitis
Adults
PO 150 mg 4 times
daily.
IM/IV/Intermittent IV
50 mg every 6 to 8 h.
Continuous IV 6.25
mg/h. For patients
with Zollinger-
Ellison, start infusion
at rate of 1 mg/kg/h
and adjust upward in
0.5 mg/kg/h
increments according
to gastric acid output
(max, 2.5 mg/kg/h;
infusion rate 220
mg/h).
Precautions
Pregnancy
Category B .
Lactation
Children
Elderly
Hypersensitivity
Renal Function
Hepatic Function
Hepatocellular injury
Rapid IV administration
Hypersensitivity to 1% to 10%: Gastrointestinal: Nausea, 1. Advice patient to Take the medicine 1 hour before
cloxacillin, any component diarrhea, abdominal pain or 2 hours after meals with water.
of the formulation, or 2. Encourage to finish all medication; do not skip
<1%: Fever, seizure with extremely
penicillins doses.
high doses and/or renal failure, rash
3. Immediately report any signs or symptoms of
(maculopapular to exfoliative),
vomiting, pseudomembranous colitis, anaphylactic reactions (eg, chills, fever, wheezing,
tightness in chest), excessive GI side effects, or
vaginitis, eosinophilia, leukopenia,
signs or symptoms of opportunistic infection (eg,
neutropenia, thrombocytopenia,
white spots or sores in mouth, vaginal discharge or
agranulocytosis, anemia, hemolytic
anemia, prolonged PT, hepatotoxicity, sores, fever, fatigue, unhealed sores or wounds).
4. Observe for signs and symptoms of anaphylaxis
transient elevated LFTs, hematuria,
during first dose
interstitial nephritis, increased
5. Monitor CBC with differential, urinalysis, BUN,
BUN/creatinine, serum sickness-like
serum creatinine, and liver enzymes
reactions, hypersensitivity
Generic Name Brand Name Classification Dosage & Mechanism of Indications
frequency actions
Cefazedone • Ancef, •Antibiotic • Adults: I.V. Interferes with eradication of
• Kefzol Gram(+) bacterial cell-wall gram-negative
•cephalosporins
• Zolicef infections: 1-2g synthesis, causing bacilli from the
daily, in two or cell to rupture and upper and lower
three divided die. respiratory tract,
doses.Gram (-) and treatment of
infections: 3-4g urinary tracts, skin,
daily, two or bone, joint, biliary,
three divided genital infections,
doses. Moderate endocarditis,
to severe surgical
infections: The prophylaxis, and
maximal daily septicemia.
dosage may be
up to 6g.
• Children
aged over 4
weeks:
I.V.50mg/kg
daily, in two or
three divided
doses.
Contraindications Adverse Reactions Nursing Responsibilities
• Contraindicated with • CNS: headache, dizziness, lethargy, • Culture infection, and arrange for sensitivity
allergy to cephalosporins paresthiasis tests before and during therapy if expected
or penicillins • GI: Nausea, vomiting, diarrhea, response is not seen
• use cautiously with renal anorexia, abdominal pain, flatulence, • reconstitute each gram for IM use with 2 mL
failure, lactation, pseudomembranous colitis, liver sterile water for injection or with 2 mL of
pregnancy toxicity, 0.5% lidocaine Hcl solution (w/o
• GU: nephrotoxicity epinephrine) to decrease pain at injection site.
• HEMATOLOGIC: bone marrow Injection deeply into large muscle group.
depression–decreased WBC, decreased • Dry powder and reconstituted solutions
platelets, decreased Hct darken slightly at room temperature
• HYPERSENSITIVITY: ranging from • have vitamin K in case hypprothrombinemia
rash to fever to anaphylaxis, serum occurs
sickness reaction • discontinue if hypersensitivity reaction occurs
• LOCAL: pain, abscess at injection site, • advice patient to avoid alcohol while taking
phlebitis, inflammation at IV site this drug and for 3 days after because severe
• OTHER: superinfections, disulfram-like reactions often occur
reaction with alcohol • tell patient the he may experience side effects
like stomach upset, & diarrhea
• encourage patient to report if there is severe
diarrhea, difficulty in breathing, unusual
tiredness or fatigue, pain at injection site
Generic Brand Classification Dosage & Mechanism of actions Indications
Name Name frequency
• Ciloxan • Antibacterial 300 mg IVTT It's action depends upon lower respiratory tract infections
• Cipro • Fluroquinolone every 2 hours blocking bacterial DNA (such as pneumonia and acute
• Cipro replication by binding bronchitis), urinary tract infections,
HC Otic itself to an enzyme called several STDs, skin and soft tissue
• Cipro DNA gyrase, thereby infections, septicemia, legionellosis,
I.V. inhibiting the unwinding of and anthrax.
• Cipro bacterial chromosomal
XR DNA during and after the
• Proquin replication.
Ciprofloxacin
XR
Contraindications Adverse Reactions Nursing Responsibilities
• avoid taking ciprofloxacin with antacids ess common • Arrange for culture and sensitivity tests
which contain aluminium, magnesium or before beginning therapy
• Blistering of skin
calcium. Sucralfate, which has a high • continue therapy for 2 days after signs and
• sensation of skin burning
aluminium content, also reduces the symptoms of infection are gone
• skin itching, rash, redness,
bioavailability of ciprofloxacin to • be aware that Proquin XR is not
or swelling
approximately 4%. interchangeable with other forms
• Ciprofloxacin should not be taken with Rare • ensure that patients swallow ER tablets
dairy products or calcium-fortified juices • skin rash whole; do not cut, crush, or chew
alone, but may be taken with a meal that • itching • ensure that patient is well hydrated
contains these products. • hives • give antacids at least 2 hrs after dosing
• Heavy exercise is discouraged, as • difficulty breathing or • monitor clinical response; if no improvement
achilles tendon rupture has been reported swallowing is seen or a relapse occurs, repeat culture &
in patients taking ciprofloxacin. Achilles • swelling of the face or sensitivity
tendon rupture due to ciprofloxacin use is throat • encourage patient to complete full course of
typically associated with renal failure. therapy
• Fluoroquinolones are increasingly • drink plenty of fluids while you are taking
contraindicated for patients due to the this drug
growing prevalence of antibiotic • report rah, visual changes, severe GI
resistance to the class of antibiotics in problems, weakness, tremors
that region.
• Ciprofloxacin is also contraindicated in
children (except for serious infections
and anthrax post-exposure), pregnancy,
and in patients with epilepsy.
Generic Brand Name Classification Dosage & frequency Mechanism of Indications
Name actions
Clindamycin • Cleoci Lincosamide • Oral: 150-300 mg q Reversibly binds Clindamycin is indicated in the
hydrochloride n Antibiotic 6 hr, up to 300 – to 50S treatment of serious infections caused
450 mg q 6 hr in ribosomal by susceptible anaerobic bacteria.
• Dalacin
more sevre subunits
C Clindamycin is also indicated in the
infections preventing treatment of serious infections due to
• parenteral: 600 – peptide bond susceptible strains of streptococci,
2,700 mg/day in 2 – formation thus pneumococci, and staphylococci. Its
4 equal dosages; up inhibiting use should be reserved for penicillin-
to 4.8 g/day IV or bacterial protein allergic patients or other patients for
IM may be used for synthesis; whom, in the judgment of the
life-threatening bacteriostatic or physician, a penicillin is
situations bactericidal inappropriate
• Vaginal: one depending on
applicator (100 mg drug
clindamycin concentration,
phosphate) infection site,
intravaginally, and organism
preferably at hs for
7 consecutive days;
or insert vaginal
suppository,
preferably at hs for
3 days for Cleocin
Vaginal Ovules
topical: apply a thin film
to affected area bid.
Contraindications Adverse Reactions Nursing Responsibilities
Hypersensitivity to clindamycin or any • 10%: Gastrointestinal: Diarrhea, • Culture infection before therapy
component of the formulation; previous abdominal pain • administer oral drug with a full glass of
pseudomembranous colitis; regional water or food to prevent esophageal
• 1% to 10%:
enteritis, ulcerative colitis irritation
Cardiovascular: Hypotension • do not give IM injections of more than
• Dermatologic: Urticaria, rash, Stevens- 600 mg; inject deep into large muscle
Johnson syndrome to avoid serious problems
• do not use for minor bacterial or viral
• Gastrointestinal: Pseudomembranous infections
colitis, nausea, vomiting • monitor renal function tests, & blood
• Local: Thrombophlebitis, sterile counts with prolonged therapy
abscess at I.M. injection site • keep solution away from eyes, mouth
and abraded skin or mucous
• Miscellaneous: Fungal overgrowth, membranes; alcohol base will cause
hypersensitivity stinging. Shake well before use
• <1% (Limited to important or life- • keep cool tap water available to bathe
threatening): Renal dysfunction (rare), eye, mucous membrane, abraded skin
neutropenia, granulocytopenia, inadvertently contacted by drug
thrombocytopenia, polyarthritis solution
• report sever or watery diarrhea,
abdominal pain, inflamed mouth or
vagina, skin rash or lesions
NURSING THEORIES
DOROTHEA OREM’S Self-Care Deficit Theory
Orem developed the Self- Care Deficit Theory of Nursing, which is composed of
three interrelated theories: (1) the theory of self-care, (2) the self- care deficit theory, and
(3) the theory of nursing systems. She defined self-care as a human need and nursing as a
human service. She also emphasized nursing’s special concern for a person’s need for
self-care actions on a continuous basis to sustain life and health or to recover from
disease or injury.
Application to patient:
We, as nurses require a continuous and practical action to our patient to enable
them to know and meet therapeutic self-care demands for them to be aware of certain
limitations that could help them develop independence towards their needs necessary for
their living.
Mrs. X has an unhealthy diet since she only eats one full meal a day with pork as
her usual viand. She wakes up at noon, eat her one full meal, and then she goes out to
manage her “mahjongan.” She usually goes home in the wee hours of the morning. She is
at times stressed out with managing her “mahjongan. She is also a smoker. According to
As we had our interaction with the patient, we identified some unhealthy practices
that needs to be corrected. We provided her with guided health teachings and imparted to
her our knowledge and the information that she needs since proper care to one’s self is
both healthy and ill. She viewed the manipulation of the physical environment as a major
component of nursing care. She indentified ventilation and warmth, light, noise, variety,
bed and bedding, cleanliness of rooms and walls, and nutrition as major areas of the
environment the nurse should control. When one or more aspects of the environment are
out of balance, the client must use increased energy to counter the environmental stress.
These stresses drain the client of energy needed for healing. These aspects of the physical
environment are also influenced by the social and psychological environment of the
individual.
Application to patient:
an operation. Concerning Nightingale’s theory, we can say that something wrong might
have happened in practicing this technique or proper surgical asepsis was not followed
which resulted to the environment being contaminated and contributed to the present
practice clean and free of organisms that might put our patient’s health and life at risk.
We provided our health teachings, which includes daily wound dressing, keeping
Betty Neuman’s systems model focuses on the wellness of the client system in
relation to the environmental stressors and reactions to stressors. These stressors include
preventive levels: (1) Primary prevention, (2) Secondary prevention, and (3) Tertiary
prevention.
Application to patient:
Mrs. X had acquired an infection after she was operated for the removal of her
brain tumor and then two more operations were performed. She is now under tertiary
prevention since she is now on recovery from the last operation performed to her.
She was provided with health teachings and information to hasten the healing
process. The patient was also encouraged to follow the treatment regimen provided by
her doctor, the health teachings rendered to her, and to have a positive outlook regarding
her condition.
NURSING CARE PLANS
Dec. S: C Acute pain r/t Within our span 1. Evaluate pain level,
13, 08 - “Kung akong O STSG of care, patient and medicate with GOAL MET
@ 2pm ilihok [right G procedure as will be able to: analgesics as ordered.
thigh], dira N evidenced by R: Rewarming Patient was able to:
pa siya I surgical - be pain free or process is extremely
magsakit.” T abrasion in the comfortable. painful. Narcotics and - minimize
- PAIN I right upper NSAIDs should be manipulation of
SCALE: 5 V thigh secondary - utilize comfort given to control pain. affected area and
Date Cues Needs
E toNsg.
softDiagnosis
tissue Objectives
measures and 2. Nsg. Interventions
Elevate injured Evaluation
utilize relaxation
- defect in scalp. techniques extremity on pillows techniques to
P effectively to as warranted. minimize pain.
E R: Unpleasant reduce or alleviate R: Decreases edema
O: R sensory and pain. which can result in - verbalize a pain
C emotional pressure to tissues and scale of 3 after
- Dressing and E experience pain. nursing
bandages P arising from 3. Instruct patient to interventions were
noted on T actual or avoid smoking. applied.
right thigh. U potential tissue R: Nicotine causes
A damage; vasoconstriction,
L sudden or slow which can worsen
onset of any perfusion and increase
P intensity from pain.
A mild to severe 4. Instruct patient to
T with an minimize movement
T anticipated or if pain is present
E predictable end when manipulating
R and a duration the affected area.
N of less than 6 R: Minimizing
months. manipulation of the
affected area can let
Source: Nurse’s the patient avoid pain.
Pocket Guide, 5. Dressings should
Marilynn E. be dry, intact and free
Doenges, Mary of vectors of diseases.
Frances, R: Broken skin
Moorhouse, integrity can serve as
Alice C. Murr a portal of entry for
disease carrying
bacteria.
6. Elaborate to the
patient the importance
of having a variety of
healthy foods
included in her diet.
Date Cues Needs Nsg. Diagnosis Objectives Nsg. Interventions Evaluation
Dec. S: A Impaired Within our span 1. Evaluate patient’s
13, 08 - “Kung akong C physical of care, the client ability and function GOAL MET
@ 2pm ilihok [right T mobility r/t will be able to and injury.
thigh], dira I immobilization R: Identifies Patient was able to:
pa siya V as evidence by - maintain skin impairments and
magsakit.” I pain in lower integrity with no allows for - achieve and
- “Dili na lang T extremities due complications. identification of maintain an optimal
nako lihokon Y to STSG appropriate level of motor
kaayo.” - operation. - increase muscle interventions. function by
E strength and tone 2. Assess patient for compensating for
O: X and achieve a degree of immobility. the immobilization
E R: Limitation functional level of R: Provides a baseline of her right leg with
- Dressing and R in independent, muscle function. on which to base the use of her other
bandages C purposeful interventions. Patient extremeties.
noted on I physical - demonstrate may only require
right thigh. S movement of exercises minimal assistance or
E the body or of imparted. be completely
one or more dependent on
P extremities. - be involved in caregivers for all
A recovery body needs.
T Source: Nurse’s programs. 3. Observe skin in the
T Pocket Guide, area, where STSG
E Marilynn E. operation was done,
R Doenges, Mary for redness, warmth,
N Frances, or tenderness.
Moorhouse,
Alice C. Murr
. R: May indicate
pressure is being
concentrated in one
area and may
predispose patient to
decubitus formation.
4. Provide kinetic bed
or alternating pressure
mattress for patient.
R: Helps promote
circulation and
reduces venous stasis
and tissue
pressure to prevent
formation of pressure
sores.
5. Maintain good
body alignment and
use pillows/rolls to
support body.
R: Prevents further
complications and
contractures.
6. Perform range of
motion exercises
every 4 hours.
. R: Helps to maintain
mobility and function
of joints.
7. Provide skin care
every 8 hours and prn.
Change wet clothing
and linens prn
R: Helps to promote
circulation and
reduces potential for
skin breakdown.
8. Instruct patient/
family in range of
motion exercises and
mobility aids.
R: Helps patient to
regain some control
and allows family
some involvement in
reconditioning
program.
9. Instruct patient/
family in reasons for
impairment and
realistic goals for
changes in patient’s
lifestyle as warranted.
. R: Promotes
understanding and
compliance with
treatment regimen.
10. Consult physical
and/ or occupational
therapy, as warranted.
R: Assists patient with
identifying methods
to compensate for
impairments and
provides for post-
discharge care.
Date Cues Needs Nsg. Diagnosis Objectives Nsg. Interventions Evaluation
Dec. O: H Risk for Within our span of 1. Monitor vital signs
13, 08 - Stiches and E infection r/t care, patient will and patient for GOAL MET
@ 2pm staples noted A open wound as be able to: presence of fever and
on scalp L evidenced by chills. the patient was able
indicating a T dressing on the - maintain optimal R: Fever, tachycardia, to:
surgical H right upper leg amount of tissue and tachyon may
wound underwent revascularization indicate presence of - be free of exposed
- Dressing and P STSG operation. after rewarming infection. wounds and sources
bandages E 2. Stress proper hand of infections..
noted on right R R: At increased - have minimal washing techniques
thigh C risk for being damaging of between
indicating a E invaded by tissues and tissue therapies/clients.
surgical P pathogenic loss. R: A first-line defense
wound T organisms. against nosocomial
I infections/ cross-
O Source: Nurse’s contamination.
N Pocket Guide, 3. When lower
- Marilynn E. extremity has been
H Doenges, Mary rewarmed, apply a
E Frances, bulky sterile dressing
A Moorhouse, to the area as
L Alice C. Murr needed/indicated.
T R: Dressings help
H protect the area to
reduce further injury.
M 4. If blisters are
A present, avoid
N rupturing them.
A R: Reduces the risk of
G infection.
E 5. Use sterile or strict
M aseptic technique for
E all dressing changes.
N R: Skin grafting
T makes the patient
susceptible to
P infection.
A 6. Administer/
T monitor
T medication regimen
E and note client’s
R response.
N R: to determine
DISCHARGE PLAN
MEDICATION
Instruct the patient and family to follow the home medications as prescribed by
the physician.
Treatment regimen is important to have faster recovery.
Educate the patient and family about the side effects of the medication.
To provide information about the drug’s adverse effects which is normally
experienced, therefore reducing anxious behavior especially when side effects
occur during the whole course of the drug therapy.
Instruct the family or significant others to remind the patient to follow the
prescribed dosage and frequency and be cautious about those things to be
contraindicated while taking the medication.
This is to prevent occurrence of complications.
This can help the patient alleviate the problem and be able to experience the full
therapeutic effect of the medication.
EXERCISE
Instruct client to avoid strenuous activities for at least a week or a month until
fully recovered.
Activities that require great muscle strength should be avoided to prevent injury
and muscle strain.
Walking is good exercise and could promote circulation, hence, proper healing.
To gain back the lost strength and be able to return to its normal state thus allow
ample time for healing.
Periodic deep breathing aerate the lungs and help prevent stasis of lung mucus
(Stasis tends to occur because the lungs are relatively quite during surgery and
mucus forms from irritation if general anesthesia is used). Because stasis always
has the potential for causing infection, it must be prevented as much as possible.
To make the client and family aware that the treatment does not only end at
hospital but needs to be continued at home to make the client responsible towards
medication.
Inform the client to avoid taking any medication that is not prescribed by the
physician.
Explain to the family the condition of the patient and give them factual
information about the illness.
To have better understanding of the patient’s condition and to be able to know
what intervention they should give that could not alter the effect of the therapy.
Instruct the family and patient to maintain prescribed medication and compliance
of the treatment regimen.
Hygiene promotes comfort and cleanliness to the patient. It also increases the
sense of wellness, which is very much needed in the therapeutic process.
Calm, clean and non threatening environment may lessen the occurrence of
possible infection and would be a good place for healing.
OUTPATIENT ORDER
Inform the patient that follow-up check-up is important to have continuous
monitoring and care even after attainment of the course medical therapy.
Through constant visits as out patient, the physician would still monitor the
progress of the therapeutic intervention availed by the patient.
Instruct the family to report for any unusual signs and symptoms experienced by
the patient.
This will help detect early signs and symptoms of reoccurrence of the disease.
DIET
Encourage client to eat a variety nutritious foods like fruits and vegetables.
To maintain and promote healthy body and as well as regain the strength after
the crisis.
Advise client not to skip meals anymore and, instead, have a regular eating
pattern/schedule.
General Prognosis:
Overall, Mrs. X has a FAIR prognosis. She had good compliance on the treatment
regimen prescribed by her physician. Although the group does not know what day she
was discharged, she was observed to have stayed in the hospital from the preoperative
phase until her postoperative phase. She was closely monitored to prevent further
complications. Her family was with her, supporting her and watching over her all
throughout the duration of her condition.
RECOMMENDATIONS
To the Student Nurses:
We have evaluated ourselves and have agreed that we have to heed the
recommendations of our clinical instructors. Patient care is our ultimate goal and
patient’s recovery. In cases like Mrs. X, a patient who has an infection, we must be able
to alleviate our patients from any aggravation of their sicknesses, and this is where
Florence Nightingale’s theory comes into play. Data gathering skills should also be
We have elaborated to Mrs. X about the different things that she can do for her to
help herself recover faster. Religious taking of medicine was promoted as well as good
general and oral hygiene. The group did not need to tell her to keep family members
close, because it is clear that their family is closer than most. Good family support can
boost the morale of the patient, thus improving her over-all health. She was also given the
The group is proud to belong to such a prestigious school. Mrs. X’s family,
especially one of her nephews, praised our group for being very well behaved as
compared to other student nurses belonging to other schools. We recommend that the
Ateneo de Davao University’s College of Nursing keep up, or improve their inculcation
With all due respect, we recommend that surgical conscience must be observed at
all times during surgical procedures. Lenient judgment of the breakages in sterility should
be avoided. Our case presentation can be a good example of the risks involved within the
Operating Room.
To the readers:
The group recommends that you, the reader, broaden your knowledge and
continue reading other sources and not base anything on this case presentation alone. A