[OSTEOMYELITIS]

- 2015

PERPETUAL HELP COLLEGE OF MANILA

1240 V. Concepcion St., Sampaloc, Manila

OSTEOMYELITIS
A Case Study
Presented to the Faculty of College of Nursing

In partial fulfillment of the requirements for the

Degree Bachelor of Science in Nursing

Submitted by:
Alipio, Paul Benedict S.
Gallegos, Jerrickson
Sanchez, Rosemarie
Tiotangco, Charlene V.

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Table of Contents

Contents

Page
3

Consent Form
General and Specific Objectives

Introduction

5-6

Patient Profile:
Clinical Admitting Data
History of Present Illness
Past Medical / Surgical History
Family History
Health History

7-9

Physical Assessment

10 - 19

Review of Systems

20

Pathophysiology

21 - 22

Laboratory Results

23 - 25

Medical / Surgical Management

26

Drug Study

27 - 35

Nursing Management

36 - 37

Nursing Care Plan

38 - 41

Discharge Plan

42

Reference

43

CONSENT FORM
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Objective of the Study

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General Objectives:
The students of the group will be able to gain adequate knowledge, basic nursing skills,
and optimal attitude on the concept on the care of patients with Osteomyelitis.
Specific Objectives:
In order to meet the general objective, the group aims to:

Establish rapport with the patient

Provide privacy in rendering nursing care
Define and identify the probable causative factors of Osteomyelitis
Identify the signs and symptoms of the underlying infection
Identify signs of localized and systemic infections
State past and present health history of the patient
Interpret the laboratory test results of the patient
Discuss the surgical procedures performed to the patient
Formulate the nursing care plan, to achieve the maximum wellness of the patients as

well as awareness on the part of the significant others.

To provide health teaching to the patient and significant others to improve the former

condition and prevent complications

Provide a proper discharge plan for the patient

Introduction
Osteomyelitis is a musculoskeletal infection. It is an infection of the bone that results in
inflammation, necrosis and formation of new bone. The infection can be caused by
direct extension or contamination of an open fracture or wound (contagious invasion);
seeding through the blood stream (hematogenous spread; or skin infections in persons
with vascular insufficiency. Osteomyelitis can occur as an acute, sub-acute or chronic
condition.

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The specific agents isolated in bacterial osteomyelitis are often associated with the age
of the person or the inciting condition such as trauma or surgery. Staphylococcus
aureus is responsible for most cases of acute hematogenous osteomyelitis.
Osteomyelitis can be classified as:

Hematogenous Osteomyelitis (due to bloodborne spread of infection)

Contaguous-focus Osteomyelitis (from contamination from bone surgery, open
fracture, or traumatic injury)
Osteomyelitis with vascular insufficiency, seen most commonly among patients
with diabetes and peripheral vascular disease, most commonly affecting the feet.
(Davis, 2005)

Prognosis
Prognosis varies depending on how quickly an infection is identified. And what other
underlying conditions exist to complicate the infection with quick, appropriate treatment,
only about 5% of all cases of acute osteomyelitis will eventually become chronic
osteomyelitis. Patients with chronic osteomyelitis may require antibiotics periodically for
the rest of their lives.
Etiology
Bacteria are most common cause of osteomyelitis, especially staphylococcus aureus.
However, other bacteria such as Pseudomonas Kiebsiella, Salmonella, and Eschirichia
coli can be causative agents. Viruses, fungi, and parasites can also lead to the
development of osteomyelitis.
Bone has several structural factors that make it difficult to treat osteomyelitis. It results
from organisms that enter bone tissue from either exogenous sources or endogenous
sources. Exogenous sources are from outside the body. Infections from exogenous
sources can come from open fracture, surgery, or puncture wounds. Animal or human
bites can also introduce bacteria to the body that spreads to the bone. People with
chronic health conditions such as drug/alcohol abuse, diabetes, or immunosuppression
are more susceptible to developing osteomyelitis. Those who are poorly nourished are
also more susceptible to osteomyelitis
Endogenous sources of osteomyelitis, also known as hematogenous osteomyelitis,
originate within the boy and are blood-borne. Common sources of infection within the
body are oral, respiratory, ear, sinus, gastrointestinal, and genitourinary. Children and
elderly are more susceptible to this form of osteomyelitis. If osteomyelitis is not treated
promptly in its acute stage, it can progress to chronic osteomyelitis and lead to loss of
function, amputation, and even death.

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Mortality / Morbidity

Mortality from Osteomyelitis was 5 25% In the preantibiotic era.

Currently the mortality rate approaches 0%.
Complications of Osteomyelitis includes:
o Septic Arthritis
o Destruction of the adjacent soft tissues
o Malignant transformation (eg. Marjolin Ulcer, Epidermoid carcinoma
of the sinus tract)
o Secondary Amyloidosis
o Pathologic Fractures

Risk Factors
Recent injury or orthopedic surgery
- A severe bone fracture or a deep puncture wound give infections a route to
enter your bone or nearby tissue. Surgery to repair broken bones or replace
worn joints also can accidentally open a path for germs to enter a bone.
Circulation disorders
- When blood vessels are damaged or blocked your body has trouble
distributing the infection fighting cells needed to keep a small infection from
growing larger. A small cut can progress to a deep ulcer that may expose
deep tissue and bone to infection.

Patients Profile
Personal Data:
Patient Name: Mr. Oso
Age: 19 years old
Gender: Male
Date of Birth: May 25, 1995
Civil Status: Single
Occupation: Student

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City Address: 6 Sitio Tibagan St. Regalado Fairview QC

Nationality: Filipino
Religion: Catholic
Educational Attainment: Second Year College (IT Student)

Clinical/Admitting Data:
Chief Complaint: Masakit at may nana ang kaliwang paa ko as verbalized by
the patient.
Date of Admission: April 08, 2014
Time of Admission: 5:30 pm
Attending Physician: Dr. Sison
Admitting Diagnosis: T/C Peri Implant Infection Left Leg S/P ORIF IM Nailing
Final Diagnosis: Osteomyelitis Left Leg S/P ORIF IM Nailing Tibia Left
Operation Performed: Repeat Debridement and Irrigation Left Leg with
Gastrocnemius Flap with Split-thickness Skin Graft (STSG), Left Leg
Date of Operation:

(March 19, 2014)

History of Present Illness

1 month PTA, the patient had a vehicular accident last February 26, 2014 at
Quezon City. He was rush to the nearest Hospital which was EAMC. Then after a week since
the accident the physician assess the patient and he was diagnosed of Peri Implant Infection.
His date if operation was on March 19, 2014, with a procedure of ORIF IM Nailing in the left
leg. When he was discharge in April 1, 2014. The doctor noticed some signs of infection on the
operated site of the leg. He gave antibiotics and analgesic drugs as his home medications.
Then on April 8, 2014 when he returned for his weekly checkup, the doctor noticed signs of
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accumulation of pus in the operated site of the leg. This makes his second time to be admitted
at EAMC.
Past Medical / Surgical History
The patient only had cough and colds as his disease, he uses paracetamol and neozep
to treat his condition and never been hospitalize until today.
Family History
The patient is the eldest among the children, he has 4 siblings. His mother is 44
years old, who has an eye problem. The patient and the family dont have history of
hypertension, diabetes, and asthma.

Health History
I.

Bowel Habits
The patient has a normal movement and doesnt experience a change in
bowel habits. He defecates twice day.

II.

Sleeping Pattern
The patient stated that he has a normal sleep at home. But when he was
in the hospital, he takes a nap for an hour or two at noon time and usually
has 3 4 hours of sleep at night. Because of scheduled medication and
also he experienced pain on his left leg.
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III.

Lifestyle / Diet
The patients usual menu for lunch and dinner is either meat or fish he
seldom eats vegetable for his breakfast, he eats bread and sometimes
drinks with coffee. He eats four cups of rice per day.
His food preferences are foods that are high in fat such as pork and
chicken. His mother is the one who prepares the food in their house. He
only drinks 4 to 5 glass of water a day. He occasionally drinks liquor since
he was 16.

IV.

Recreational Activities
Patient doesnt exercise regularly but instead he plays computer games
every day as his daily routine. Before his accident, he spends his day
watching television and playing computer games, and seldom does
household chores.

V.

Environmental
Patient lives in Quezon City with his family. They own the house which he
described as an ordinary home, and he added that it was a safe and clean
place to live in. They live in a concrete home together with his mother and
siblings.

Reason for selecting the case

Our group selected the case because it challenges us to further investigate on how the
disease progress and that to give us a deeper knowledge about the disease.

Physical Assessment
Post- op Assessment:
Date assessed: August 13, 2014
Time assessed: 4:15 5:45 pm
General appearance: Patient was in a high fowlers position wearing a t-shirt and shorts. With
the diagnosis of Peri implant Infection Left Leg S/P IM Nailing Tibia Left. He was conscious
and coherent, oriented to date, place, and time. Appears weak and anxious, no shortness of

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breath. Patient was cooperative all throughout the assessment. No signs of acute distress
were present.

Initial Vital Signs:

Actual findings
Temperature

37.0 degree Celsius

Interpretation
Normal

Pulse rate

80

Normal

Respiratory rate

21

Normal

Blood pressure

110 / 70

Height

55

Weight

45kg / 99lbs

PARTS RO BE
ASSESSED
SKIN

Skin color

TECHNIQUE

Inspection

Normal
Normal
Normal

NORMAL FINDINGS

ACTUAL
FINDINGS

Varies from light to

deep brown; from
ruddy pink to light pink;
from yellow overtones
to olive.

Fair complexion
of the skin

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INTERPRETATION/
ANALYSIS

Normal

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Uniformity of
skin color

Inspection

Generally uniform
except in areas
exposed to the sun;
areas of lighter
pigmentation (palms,
lips, nail beds) in darkskinned people

Generally
uniform except in
areas exposed to
the sun

Presence of
edema

Inspection

No edema

With edema on
the left leg

Due to blood clot in

the deep veins of the
lower leg.

Skin lesions

Inspection

Freckles, some
birthmarks, some flat ;
no abrasions or other
lesions

Scars and
lesions are noted
on the lower
extremities

Due to trauma or
infection cause by the
primary lesion.

Skin
Moisture

Inspection

Moisture in skin folds

and axillae

Excessive
moisture or
excessive
dryness

Temperature

Palpation

Uniform; with normal

range

Afebrile

Normal

Skin turgor

Pinching

When pinched, skin

springs back to
previous state

Skin springs
back to previous
state.

Normal

TECHNIQUE

NORMAL FINDINGS

ACTUAL
FINDINGS

INTERPRETATION/
ANALYSIS

Convex curvature;

The shape is

Normal

PARTS TO BE
ASSESSED
NAILS
Shape and

Inspection

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Normal

The skin is dry and

flaky because of
sebaceous and swea
glands are less active
And it could lead to
possible dehydration.

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angle

angle of nail is 160

degrees

Texture
Color

Inspection
Inspection

Tissues
surrounding
nails.
Capillary
refill

Inspection

PARTS TO BE
ASSESSED
SKULL AND
FACE

Skull shape
and
symmetry.
Presence
nodules or
masses and
depressions
Facial
features

- 2015

convex curvature
and angle is 160
degrees.
Smooth in texture
Smooth texture
Color is highly vascular Nails are highly
and pink in light
vascular and
skinned patients; dark
pink in color
skinned patients may
have brown or black
pigmentation in
longitudinal streaks.
Intact epidermis

Normal
Normal

Patient has an
intact epidermis

Normal

Blanch test

Prompt return of pink

or usual
color(generally less
than 4 seconds)

Slow capillary
refill

Slow capillary refill du

to surgical blood loss

TECHNIQUE

NORMAL FINDINGS

ACTUAL
FINDINGS
The patients
head is rounded;
normocephalic
and symmetrical

INTERPRETATION/
ANALYSIS
Normal

There are no
nodules or
masses and
depressions
when palpated
Symmetrical
facial movement,
palpebral
fissures equal in
size.
Symmetrical
nasolabial folds

Normal

Inspection

Rounded
(normocephalic and
symmetric, with frontal,
parietal, and occipital
prominences)

Palpation

Smooth, uniform
consistency; absence
of nodules or masses

Inspection

Symmetric or slightly
asymmetric facial
features; palpebral
fissures equal in size;
symmetric nasolabial
folds

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Normal

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Symmetry of
facial
movements.

HAIR
Evenness of
growth over
the scalp.
Hair
thickness or
thinness.
Hair texture
and oiliness.
Presence of
infections or
infestations
Amount of
body hair

PARTS TO BE
ASSESSED

EYES
Color,
texture, and
the presence
of lesions in
bulbar
conjunctiva.

- 2015

Patient was able

to elevate his
eyebrows, frown,
puff his cheeks,
and smile
symmetrically

Inspection

Symmetric facial
movements

Inspection

Evenly distributed hair

Evenly
distributed hair

Normal

Inspection

Thick hair

The patient has

thick hair.

Normal

Inspection

Silky, resilient

Poor hygiene practice

Inspection

No infection or
infestation

Inspection

Variable

The patient has

dry hair.
No presence of
infection or
infestations.
Adequate

ACTUAL
FINDINGS

INTERPRETATION/
ANALYSIS

TECHNIQUE

Inspection

NORMAL FINDINGS

Transparent;
capillaries sometimes
evident; sclera appears Transparent
white (darker or
White sclera
yellowish and with
small brown macules
in dark-skinned clients)

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Normal

Normal

Normal

Normal

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Palpebral
conjunctiva
appearance

Inspection

Shiny, smooth, and

pink or red

Patients
palpebral
conjunctiva is
pale.

Hemoglobin = 93gm/
Severe decline of
hemoglobin represen
anemia.

Near visual
acuity

Inspection

Able to read newsprint

Normal

Visual Field

Inspection

When looking straight

ahead, client can see
objects in the
periphery.

The patient is
able to read
newsprint in
normal distance
The patient is
able to see
objects when
looking straight
ahead

Normal

EARS

Color,
symmetry of
size and
position of
auricles
Texture,
elasticity,
and areas of
tenderness
of auricles
Hearing
Acuity

Inspection

Color same as facial

skin. Symmetrical.
Auricle aligned with
outer canthus of eye,
about 10 from vertical.

Inspection

Mobile, firm, and not

tender; pinna recoils
after it is folded

Patients ears
are equal in size
bilaterally.
Earlobes are
elongated.
Aligned
Mobile, firm, no
tenderness
present and
pinna recoils
after it is folded.
Patient was able
to hear equally
on both ears

Whisper Test

Able to hear equally on

both ears

Inspection

Symmetric and straight

No discharge or flaring
Uniform color

Symmetrical, no
discharge
,uniform color

Palpation

Not tender; no lesions

No tenderness,
no lesions
present

Normal

Normal

Normal

NOSE and SINUSES

Shape, size,
or color and
flaring or
discharge
from the
nares.
Presence of
tenderness,
masses, and

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Normal

Normal

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displacement
s of bone
and
cartilage.

Patency of
both nasal
cavities

Inspection

Air moves freely as the

client breathes through
the nares

Presence of
tenderness
at maxillary
and frontal
sinuses.

Palpation

No tenderness

PARTS TO BE
ASSESSED
MOUTH
Lips and
Buccal
mucosa

Teeth and
gums

Tongue

TECHNIQUE

Inspection,
Palpation

Inspection

Inspection
Palpation

NORMAL
FINDINGS
Uniform pink color,
Moist, smooth, soft,
glistening, and elastic
32 adult teeth Smooth,
white, shiny tooth
enamel
Pink gums Moist, firm
texture to gums.
Central position Pink
color
moist; slightly rough;
thin whitish coating
Smooth, lateral
margins; no lesions
Raised papillae (taste
buds)

Patient can
breathe freely
and normally
through his
nares.

Normal

No Tenderness

Normal

ACTUAL
FINDINGS

INTERPRETATION/
ANALYSIS

Patients lips
appears pink in
color.

Normal

Without denture,
yellowish and
pink gums.

Normal

Central position
Pink color
moist; slightly
rough; thin
whitish coating
Smooth, lateral
margins; no
lesions
Raised papillae
(taste buds)

Normal

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PARTS TO BE
ASSESSED
NECK
Presence of
swelling/
mass

TECHNIQUE

NORMAL
FINDINGS

Inspection,
Palpation

Muscles equal in
size; head centered
No mass/ swelling.

Inspection

Coordinated,
smooth movements
with no discomfort

Head
movement

Presence of
Palpation
enlarged
lymph nodes

PARTS TO BE
TECHNIQUE
ASSESSED
POSTERIOR THORAX
Shape and
symmetry of the
Inspection
thorax from
posterior and
lateral views.
Spinal
Inspection
alignment
Palpation
Temperature
and integrity of
chest areas

- 2015

ACTUAL
FINDINGS
Patients head is
centered with no
mass swelling.
Coordinated,
smooth
movement with
no discomfort,
head laterally
flexes, head
laterally rotates
and
hyperextends.

INTERPRETATION/
ANALYSIS

Normal

Normal

No lymph nodes
palpated

Normal

ACTUAL
FINDINGS

INTERPRETATION/
ANALYSIS

Antero posterior to
transverse
diameter in ratio of
1:2

Antero posterior
to transverse
diameter in ratio
of 1:2

Normal

Spine vertically
aligned
Skin intact, uniform
temperature.
Chest wall is intact,

Spine vertically
aligned.
Skin intact,
Chest wall is
intact, no

No palpable

NORMAL
FINDINGS

Normal
Normal

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no tenderness; no
masses

Thoracic
expansion

PARTS TO BE
ASSESSED
ANTERIOR THORAX

Breathing
patterns

Palpation

Full and symmetric

chest expansion (35 cm separation)

TECHNIQUE

NORMAL FINDINGS

Auscultation

Temperature
and integrity
of chest areas

Diaphragmatic
excursion

PARTS TO BE
ASSESSED
ABDOMEN

Palpation

Palpation

TECHNIQUE

Skin integrity

Inspection

Sounds

Auscultation

Quiet, rhythmic, and

effortless
respirations
Skin intact, uniform
temperature.
Chest wall is intact,
no tenderness; no
masses
Excursion is 3 to 5
cm (11/2 to 2 in.)
bilaterally in women
and 5 to 6 cm (2 to 3
in.) in men
Diaphragm slightly
higher on the right
side.
NORMAL
FINDINGS
Unblemished skin
Uniform color Silverwhite striae
Audible bowel
sounds Absence of

- 2015

tenderness; no
masses
Full and
symmetric chest
expansion (3-5
cm separation)

ACTUAL
FINDINGS
Effortless and
rhythmic
respirations
Skin intact,
Chest wall is
intact, no
tenderness; no
masses

Normal

INTERPRETATION/
ANALYSIS

Normal

Normal

Slightly higher
on the right side
(diaphragm)

Normal

ACTUAL
FINDINGS

INTERPRETATION/
ANALYSIS

Unblemished
skin

Normal

Absence of
friction rub,

Normal

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Contour and
symmetry

PARTS TO BE
ASSESSED
UPPER EXTREMITIES

Muscle strength
and tone

Joints

Brachial and
radial pulse
Biceps and
tendon reflex

Sensation

Inspection
Palpation

TECHNIQUE

Inspection

Inspection,
Palpation

arterial bruits
Absence of friction
rub
Flat, rounded
(convex), or
scaphoid (concave)
No evidence of
enlargement of liver
or spleen
Symmetric contour

NORMAL
FINDINGS
Equal size on both
sides of body.
No contractures.
Normally firm.
Smooth coordinated
movements.
No swelling
No tenderness,
swelling, crepitation,
or nodules
Joints moves
smoothly.

Palpation

Present and equal

Reflex
hammer

Normal response

Pin and
cotton

Able to
distinguished
"sharp" and "dull"
sensations

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audible bowel
sounds
Rounded, No
evidence of
enlargement of
liver spleen and
symmetrically
contour

Normal

ACTUAL
FINDINGS

INTERPRETATION/
ANALYSIS

No
contractures,
normally firm,
smooth

No tenderness,
crepitation or
nodules. No
swelling
Present and
equal
Normal
response
Able to
distinguished
sharp and dull
sensation

Normal

Normal

Normal
Normal
Normal
Normal

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PARTS TO BE
ASSESSED
LOWER EXTREMITIES

Muscle strength
and tone

Presence of
edema

Joints

Femoral pulse

Patellar, Achilles
reflex

TECHNIQUE

Inspection

Inspection

Inspection,
Palpation

Palpation

Reflex
hammer

NORMAL
FINDINGS

Equal size on both

sides of body.
No contractures.
Normally firm.
Smooth
coordinated
movements.

No edema

No swelling
No tenderness,
swelling,
crepitation, or
nodules
Joints moves
smoothly.

Present and equal

Normal response

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ACTUAL
FINDINGS

INTERPRETATION/
ANALYSIS

Right Leg:
Normally firm,
no contractures

Right Leg: Normal

Left Leg:
With Ilizarov
apparatus

With edema on
the left leg

Right Leg:
No swelling,
nodules. Joints
moves
smoothly.
Left Leg:
With nodules,
mass on
popliteal

Right Leg:
Weak
Left Leg:
Weak
Right Leg:
Normal
Response
Left Leg:
No response

Left Leg:
Used on patients to
treat non-unions of
bones
and for treating a
fractured tibia and
fibula
Due to blood clot in
the deep veins of the
lower leg.

Right Leg: Normal

Left Leg:
With Ilizarov apparatus
Used on patients to
treat non-unions of
bones
and for treating a
fractured tibia and
fibula
Right Leg:
Weak
Left Leg:
With Ilizarov apparatus
Right Leg:
Normal Response
Left Leg:
With Ilizarov apparatus
treating a fractured
tibia and fibula

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Sensation

Pin and
cotton

Able to
discriminate
"sharp" and "dull"
sensations

- 2015

Right Leg:
Able to feel
sharp and dull
sensations
Left Leg:
With Ilizarov
apparatus

Right Leg:
Normal
Left Leg:
With Ilizarov apparatus
treating a fractured
tibia and fibula

Review of Systems

Integumentary System
The patient says he has no known history of skin disease. He has few marks,
healed scars and scratches on his lower extremities from previous accidents. There`s a
excessive dryness of lower extremities. Presence of swelling and cracking of skin with
pitting edema.

Respiratory System
Patient stated that he has no history of lung disease. He stated that he has a normal
breathing pattern.

Cardiovascular System
Patient has no history of any cardiovascular disease.

Gastrointestinal system
Patient has no history of gastrointestinal disease.

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Endocrine System
Patient has no history or diagnose of endocrine disorders.

Urinary System
Patient has no history of any urinary infection.

Hematologic System
Patients latest hematologic result last August 2, 2014 it shows that there is a decrease
hemoglobin and hematocrit. The patient said that in his admission he feels nauseated,
lethargic and pale looking. Then he was advised to take his laboratory tests and found
out that he was anemic.

Musculoskeletal system
Patient has no history or complains of musculoskeletal disorder.

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Pathophysiology

Open wound /
fracture

Predisposing
factors:
Infection
Open wound

Microorganisms
gain entry by way
of blood
Microorganisms lodge
into an area where
circulation slows
Microorganisms
grow
Infection through the bone cortex and
marrow
Increased
Pressure
Vascular compromise of the
periosteum

Fever, night sweats,

chills, restlessness,
nausea and malaise,
constant bone pain,
swelling, tenderness,
warmth at the
infection site,
restricted movement
of the affected part

Chronic
Stage

Ischemia
Cortical
Devascularization
Necrosis
Formation of new
bone

Involucru
m

Systemic
signs may
be
diminished
with
constant
bone pain,
swelling,
tenderness,
warmth at

Separation of devitalized bone from living

bone
Enlarge
Sequestrum

Developmen
t of sinus
tract
Turns to scar
tissue
Site for continued
microorganism
growth
Remission
and
Excessive
vascular
insufficiency

Sequestrum move
out to the soft
tissue
Debrideme
nt
Revascularize
Antibiotics
Removal by the normal immune
Healing

Laboratories
INCREA
SE

Hematology
TEST

NORMAL
VALUES

April
9,
2014

May
17,
2014

June
3,
2014

June
11,
2014

July
13,
2014

July
16,
2014

WBC

5 - 10 x 10
9L

10.3

5.9

8.0

Hemoglobin

140-170gm/l

127

124

112

91

100

90

93

Hematocrit

0.400.50gm/l

0.401

0.371

0.344

0.278

0.307

0.280

0.289

RBC Count

4.5 5.9 x
10^12/L

4.71

4.55

4.34

Neutrophils

0.45-0.65%

0.60

0.62

0.26

DECREAS

August
2, 2014

Interpretation/Analysis

Increased level of WBC may in

response of inflammation due to
direct toxic injury that leads to
damage to the cells tissue. It is
indicative of an infectious
process.
Decreased level may indicate
dietary deficiency Patient has
Iron Deficiency Anemia
Blood Loss
Bone marrow suppression

Decrease Hematocrit
Blood Loss
Dietary Deficiency
Anemia

Decreased RBC Count

Bone Marrow Suppression
Stress
Acute Infection

Lymphocytes

0.25-0.50%

0.30

Monocytes

0.02-0.06%

0.06

Eosinophils

0.02
0.04%
150-450 x
10 9/L

0.04

Platelets

500

0.34

0.04

310

0.36

0.05

Lymphocytes is a typical cellular

elements of lymph, that is
important in cellular mediators of
immunity
Within normal limits

0.03

Within normal limits

454

High platelet count is usually a

result from an existing condition,
like anemia and cancer.

Parameters
Erythrocyte
Sedimentation Rate

Result (June 04, 14)

90 mm / hr

Reference Value
Male: 0 10 mm / hr
Female: 0 20 mm / hr

Test
C Reactive Protein
(CRP)

Result (July 03, 14)

Reference Value

48

Less than
6 mg/dl

Chemistry Test

Interpretation
A very high ESR usually has an obvious
cause, such as a severe infection

Interpretation
A high or increasing amount of CRP in the
blood suggests the presence of inflammation
but will not identify its location or the condition
causing it. In individuals suspected of having a
serious bacterial infection, a high CRP suggests
the presence of one.

Test

Normal

Result

Sodium

135 145 mmol / L

139.5 mmol / L

Potassium

3.6 5.2 mmol / L

3.34 mmol / L

Bacteriological Exam (April 20, 2014)

Gram Staining / Culture
(+) Pus
(+) Gram negative bacilli

Interpretation

As a complication of acetaminophen overdose

MEDICAL/SURGICAL MANAGEMENT
MEDICAL MANAGEMENT

Pharmacologic Therapy
o Post Operative Medications:
Tranexamic Acid, Celecoxib, Cefuroxime, Ferrous Fumarate, Omeprazole, Ferrous
Sulfate, Ascorbic Acid, Paracetamol

Supportive and Nutritional Therapy

o Ambulate as tolerated
o COD daily
o Soft diet
Examples: Banana, Apple, Rice, Oatmeal, Milk, Fruit and or Vegetable juices

SURGICAL MANAGEMENT

Debridement and irrigation, Left leg

Debridement is the medical removal of dead, damaged, or infected tissue to improve
the healing potential of the remaining healthy tissue.
Irrigation is a general term referring to cleaning or rinsing.
Removal of implant and application and application of Ilizarov fixator, left tibia
Ilizarov apparatus is a type of external fixation used in orthopedic surgery to lengthen or
reshape limb bones; to treat complex and/or open bone fractures; and in cases of

infected non-unions of bones that are not amenable with other techniques.
Gastrocnemius flap coverage, Left leg
Flap surgery is a technique in plastic and reconstructive surgery where any type of
tissue is lifted from a donor site and moved to a recipient site with an intact blood
supply.
Gastrocnemius muscle meaning "stomach of leg"

Drug Study
Post-Operative Medications

Drug Name
Tranexamic Acid

Classification
Synthetic Analog

Celecoxib
Cefuroxime
Ferrous Fumarate
Omeprazole
Ferrous Sulfate
Ascorbic Acid
Paracetamol
NAME
OF
DRUG
Brand
name:
Ultram,
Ultram
ER,
Conzip
Generic
name:
Tramadol
Dosage:
50mg
SIVP q6
x 4 doses

CLASSIF
ICATION

ACTION

Analgesi
c
(centrally
acting)

Binds to muopioid
receptors
and inhibits
the reuptake
of
norepinephri
ne
and
serotonin;
causes
many effects
similar to the
opioids
dizziness,
somnolence,
nausea,
constipation
but does not
have
the
respiratory
depressants
effects.

Anti-inflammatory Drug
Antibacterial/Antibiotic
Iron Preparation / To supplement Iron intake
Proton pump inhibitor
Iron Preparation / To supplement Iron Intake
Vitamin C
Analgesics
INDICATION

Relief
of
moderate to
moderately
severe pain.
Relief
of
moderate to
severe
chronic pain
in
adults
who need
around-theclock
treatment
for
extended
periods.
Unlabeled
uses:
Premature
ejaculations
;
restless
leg
syndrome.

CONTRAINDICATION

Contraindicated
with allergy to
tramadol
or
opioids or acute
intoxication with
alcohol, opioids,
or psychoactive
drugs.
Use cautiously
with pregnancy,
lactation;
seizures;
concomitant use
of
GNS
depressants,
MAOIs, SSRIs,
TGAs;
renal
impairment;
hepatic
impairment.

ADVERSE EFFECT

CNS: Sedation, A
dizziness
or
vertigo,
headache,
confusion,
dreaming,
sweating,
anxiety,
seizures.
CV:
Hypotension,
tachycardia,
bradycardia
GI:
Nausea,
vomiting,
dry
mouth,
constipation,
flatulence
Other: Potential
for
abuse,
anaphylactoid
reactions

IN

NAME OF
DRUG
Brand
name:
Celebrex
Generic
name:
Celecoxib
Dosage:
750mg
1 cap BID

CLASSI
FICATI
ON
Analgesi
c
(nonopio
id)

ACTION

INDICATION

CONTRAINDICATIO
N

ADVERSE EFFEC

Analgesic and
antiinflammatory
activities
related
to
inhibition of the
COX-2
enzyme, which
is activated in
inflammation to
cause the signs
and symptoms
associated with
inflammation;
does not affect
the
COX-1
enzyme, which
protects
the
lining of the GI
tract and has
blood clotting
and
renal
functions.

Acute and longterm treatment of

signs
and
symptoms
of
rheumatoid arthritis
and osteoarthritis.

Contraindicated with
allergies
to
sulfonamides,
celecoxib, NSAIDs,
or aspirin; significant
reanl
impairment;
perioperative
pain
Reduction of the post CABG surgery;
number
of pregnancy
(third
colorectal polyps in trimester); lactation.
familial
adenomatous
Use cautiously with
polyposis (FAP)
impaired
hearing,
hepatic
and
CV
Management
of conditions.
acute pain

CNS:
Heada
dizziness, somnole
insomnia,
fat
tiredness,
dizzin
tinnitus, ophthalmo
effects

Treatment
primary
dysmenorrhea

of

Relief of signs and

symptoms
of
ankylosing
spondylitis

Generic
name:

CLASSIF
ACTION
ICATION
Antibiotic Bactericidal:
Inhibits
synthesis of
bacterial cell
wall, causing
cell death.

INDICATION
Pharyngitis,
tonsillitis caused
by streptococcus
pyogenes.

CONTRAINDICATION

UTIs caused by
Escherichia
coli,

GI: Nausea, abdom

pain,
dyspe
flatulence, GI bleed

Hematologic:
Neutropenia,
eosinophilia, leukope
pancytopenia,
thrombocytopenia,
agranulocytosis,
granulocytopenia,
aplastic anemia,
decreased Hgb and
bone marrow
depression, menorrh

Other: Peripheral
edema, anaphylacto
reactions to anaplyla
shock

Relief of signs and

symptoms
of
juvenile rheumatoid
arthritis

NAME OF
DRUG
Brand
name:
Ceftin,
Zinacef

CV: MI, CVA

Contraindicated
with allergy to
cephalosporins
or penicillins.
Use
cautiously
with renal failure
lactation,

ADVERSE EFFECT
CNS: Headache,
dizziness, lethargy,
paresthesias
GI: Nausea, vomiting
diarrhea, anorexia,
abdominal pain,

Cefuroxim
e

Klebsiella
pneumonia
Uncomplicated
gonorrhea

Dosage:
750mg IV
q8

NAME
OF
DRUG
Brand
name:
Ferretts
Iron,
Ferrocite,
Femiron

pregnancy.

CLASSIFI
CATION

ACTION

Iron
Elevates the
preparation serum iron
concentration
, and is then
converted to
Hgb or
trapped in the
Generic
reticuloendot
name:
helial cells for
Ferrous
storage and
Fumarate
eventual
conversion to
Dosage:
a usable form
1 tab TID
of iron.
PO x 2
weeks

flatulence,
pseudomembranous
colitis, hepatotoxicity
GU: Nephrotoxicity

Skin
and
skin
structure
infections,
including impetigo
caused
by
streptococcus
aureas,
S.
pyogens

Hematologic: Bone
marrow depression

Treatment of early
Lyme disease

Local: Pain, abscess

at injection site,
phlebitis, inflammation
at IV site

INDICATION

Prevention and
treatment of iron
deficiency
anemias
Dietary
supplement for
iron
Unlabeled use:
Supplemental
use during
epoetin
theraphy to
ensure proper
hematologic

Hypersensitivity:
Ranging from rash to
fever to anaphylaxis;
serum sickness
reaction

CONTRAINDICATION

Contraindicated with
allergy to any
ingredient; sulfite
allergy;
hemochromatosis,
hemosiderosis,
hemolytic anemias
Use cautiously with
normal iron balance,
peptic ulcer, regional
enteritis, ulcerative
colitis.

ADVERSE
EFFECT

NURS

CNS: CNS
toxicity,
acidosis,
coma and
death with
overdose

ASSESSM
History:
sulfite;
hemoside
normal i
regional e

GI: GI upset,
anorexia,
nausea,
vomiting,
constipation,
diarrhea, dark
stools,
temporary
staining of the

Physical:
teeth (col
Hct, serum

INTERVE
Confirm
deficiency

Give dru

response to
epoetin

teeth

eggs, cof
is severe
tolerance

Administe
or juice to
staining o
solution w

Warm pat
green.

Arrange f
and Hgb l
NAME OF
DRUG

CLASS
ACTION
INDICATION
IFICATI
ON
Brand
AntiGastric
acid- Short-term
name:
secreto pump inhibitor: treatment of
Prilosec,
ry drug Suppresses
active duodenal
Zegerid
gastric
acid ulcer
secretion
by
Generic
specific inhibition Treatment of
name:
of the hydrogen- heartburn or
Omeprazole
potassium
symptoms of
ATPase enzyme GERD
Dosage:
system at the
40mg IV OD
secretory surface Short-term
of the gastric treatment of
parietal
cells; active benign
blocks the final gastric ulcer
step
of
acid
production.
GERD, severe
erosive
esophagitis,
poorly
responsive
symptomatic
GERD
Long-term
therapy:
Treatment of
pathologic

CONTRAINDICATIO
N

ADVERSE EFFECT

Contraindicated with CNS:

Headache,
hypersensitivity
to dizziness, asthenia,
omeprazole or its vertigo,
insomnia,
components
apathy,
anxiety,
paresthesias, dream
Use cautiously with abnormalities
pregnancy, lactation.
GI:
Diarrhea,
abdominal
pain,
nausea,
vomiting,
constipation,
dry
mouth,
tongue
atrophy
Respiratory:
symptoms,
epistaxis

URI
cough,

Other: Cancer in
preclinical
studies,
back pain, fever

hypersecretory
conditions

NAME OF
DRUG
Brand
name:
Feosol, FerIron,
FeroSul
Generic
name:
Ferrous
Sulfate
Dosage:
1 tab OD

CLASS
ACTION
IFICATI
ON
Iron
Elevates the
prepara serum iron
tion
concentration,
and is then
converted to
Hgb or trapped
in the
reticuloendothe
lial cells for
storage and
eventual
conversion to a
usable form of
iron.

INDICATION

Prevention and
treatment of
iron deficiency
anemias
Dietary
supplement for
iron
Unlabeled use:
Supplemental
use during
epoetin
theraphy to

CONTRAINDICATION

ADVERSE EFFECT

Contraindicated with
allergy to any
ingredient; sulfite
allergy;
hemochromatosis,
hemosiderosis,
hemolytic anemias

CNS: CNS toxicity,

acidosis, coma and
death with overdose

Use cautiously with

normal iron balance,
peptic ulcer, regional
enteritis, ulcerative
colitis.

GI: GI upset,
anorexia, nausea,
vomiting,
constipation,
diarrhea, dark stools,
temporary staining of
the teeth

NU

AS
His
ing
he
he
an
pe
ulc

Ph
gu
sou
fer

ensure proper
hematologic
response to
epoetin

NAME OF
DRUG
Brand
Name:
Biogesic
Generic
Name:
Paracetamo
l
Dosage:
600mg IV
q6

CLASS
IFICATI
ON
Non
Opioid
Analgesi
c

INT

ACTION

INDICATION

CONTRAINDICATION

ADVERSE EFFECT

NU

Paracetamol
exhibits
analgesic
action
by
peripheral
blockage
of
pain
impulse
generation. It
produces
antipyresis by
inhibiting
the
hypothalamic
heat-regulating
centre.
Its
weak
antiinflammatory
activity
is
related
to
inhibition
of prostaglandi
n synthesis in
the CNS.

To relieve mild
to moderate
pain due to
things such as
headache,
muscle and
joint pain,
backache and
period pains. It
is also used to
bring down a
high
temperature.
For this reason,
paracetamol
can be given to
children
after vaccinatio
ns to prevent
postimmunization
pyrexia (high
temperature).

Hypersensitivity to
acetaminophen
or phenacetin; use with
alcohol.

Side effects are rare AS

with
paracetamol
when it is taken at
the
recommended
doses. Skin rashes,
blood disorders and
acute inflammation of
the pancreas have
occasionally
occurred in people
taking the drug on a
regular basis for a
long
time.
One
advantage
INT
of paracetamol
over aspirin
and
NSAIDs is that it
doesn't irritate the
stomach or causing it
to bleed, potential
Side effects of aspirin
and NSAIDs

Paracetamol is
often included
in cough, cold
and flu
remedies.

NAME
OF
DRUG
Brand
Name:
Cecon
Generic
Name:
Ascorbic
Acid
Dosage:
500mg/ta
b 1 tab
OD

CLASSIF
ICATION

ACTION

INDICATION

CONTRAINDICATION

ADVERSE EFFECT

Vitamins

Water-soluble
vitamin essential
for synthesis and
maintenance of
collagen
and
intercellular
ground
substance
of
body tissue cells,
blood
vessels,
cartilage, bones,
teeth, skin, and
tendons. Unlike
most mammals,
humans
are
unable
to
synthesize
ascorbic acid in
the
body;
therefore it must
be
consumed
daily.

Prophylaxis and
treatment
of
scurvy and as a
dietary
supplement.
Increases
protection
mechanism of the
immune system,
thus supporting
wound
healing.
Necessary
for
wound
healing
and resistance to
infection.

Use
of
sodium
ascorbate
inpatients
on sodium restriction;
use
of
calcium
ascorbate in patients
receiving
digitalis.
Safety
during
pregnancy (category
C) or lactation is not
established.

GI:
Nausea, vomiting,
heartburn, diarrhea.
Hematologic:
Acute hemolytic
anemia (patients with
deficiency of G6PD);
sickle cell crisis.
CNS:
Headache (high
doses).
Urogenital:
Urethritis, dysuria,
crystal Luria (high
doses).
Other:
Mild soreness at
injection site; dizziness
and temporary
faintness with rapid IV
administration.

Nursing Management
POST OP
NURSING INTERVENTION

RATIONALE

INDEPENDENT:
Review anatomy, physiology and
implications of surgical intervention

Provides knowledge base from which the client can

make informed choices

Focus care on controlling infection,

protecting the bone from injury, and
providing support.

To prevent the risk for extension of infection

Encourage the patient to verbalize his

concerns about his disorder.

To prepare the patient for possible procedures and

complications

Help the patient identify care techniques

and activities that promote rest and
relaxation and encourage him to
perform them.

To lessen management and promote faster

recovery

Use strict aseptic technique when

changing dressings and irrigating
wounds.
Provide a well-balanced diet

To avoid contaminations

To promote healing.

Support the affected limb with firm

pillows.

For good blood circulation

Assess vital signs, observe wound

appearance, and note any new pain
which may indicate secondary infection.

To prevent the risk for extension of infection.

Watch for signs of pressure ulcer

formation.

Prevent further complications

Look for sudden mal positioning of the

affected limb.
Which may the indicate fracture.
Explain all the test and treatment
procedures.

For the affectivity

COLLABORATIVE:
Administer medications as indicated
Relieves pain, enhances comfort and promotes rest

Irrigate and debridement of wound

May be required to treat perioperative

inflammation / infection or intraoperative
contamination

Advance diet to a HIGH PROTEIN,

HIGH CALORIE and LOW RESIDUE
diet

A low residue diet minimizes the production of solid

wastes; still able to meet the nutritional
requirements

Nursing Care Plan

Assessment
Subjective:
Masakit at
namamaga
ang paa ko.
As verbalized
by the patient.
Objective:
> Pain scale of
8/10
> Facial
grimace

Diagnosis
Acute pain
related to
inflammation
and edema

Goals
After 1 2 hours of
nursing
interventions, the
patient will be able
to experience
gradual reduction /
relief of pain.

Intervention
Assess pain
severity on
scale of 1 10
q hour by
asking patient.

Objectives: after
the series of
nursing
interventions of the
patient will be able
to:
1. Verbalize
reduction /
relief of pain
2. Move his
left leg
without
facial
grimace

Provide
medications
per physician
order

Monitor VS

Reposition
and elevate
leg to help
provide
comfort
Give patient a
bath and
provide clean
linens to help
him relax and
provide
comfort.
Observe
nonverbal

Rationale
Initial assessment
provides baseline
and comparison.

Usually altered in
acute pain.
Meds will help
alleviate pain and
provide comfort.
Elevation helps
with swelling and
provides pain
relief.
Bath can help
pain management
and provide
relaxation.

How a patient sits,

holds body or
facial expressions
can reveal a lot
about how a
patient feels.

Evaluation
After rendering nursing
intervention the patient
able to verbalize
reduction / relief of pain
and moves his left leg
without facial grimace.

Assessment
Subjective:
Ang hirap ng
mayganito
(traction).Bawal
kumilos, hindi
man lang ako
makapunta
sa banyo para
maligo. Hinihintay
ko pa na may
bisita ako para
lang makapag
linis ng sarili ko
verbalized by the
client.
Objective:
Client has
ilizarov left leg.
Client is on semifowlers position.
Client had
fracture on the left
tibia

Diagnosis
Impaired
immobility

Goals
Short Term:
After 8 hours
of nursing
interventions, the
patient will be able to
have at least
10steps as signs of
recovery.
Long Term:
After 1-2 weeks of
nursing
intervention, the
patient will be able
to maintain or
increase strength
and function
of affected and
compensatory
body part

cues to
assess.
Intervention
Independent:
1. Assisted/have client
reposition self on a
regular schedule from
side to side.
2. Used side rails
of bed.

3. Encouraged patient
to move the affected
part from time to
time.
4. Encouraged
patientto take few
steps aday..
5. Encouraged
continuation
of exercises.

Rationale

Evaluation

Goal met.
To decrease numbness
After 8 hours
and pain in the affected of nursing
area.
interventions, the
patient was able to
take10 steps even in a
slowed manner.
To prevent the patient from
possible fall or accident
that might happen
To help ease the pain and
numbness of said part

This will help the

patient to mobilize and
recover faster
To maintain/enhance
gains in strength

Assessment
Diagnosis
OBJECTIVE:
Risk for Injury
-Needs assistance
in ambulation
- limited range of
motion

Goals
Short term Goal:
At the end
of Nursing
intervention, the
client will be free
from any signs of
injury.
Long Term Goal:
After nursing
intervention the
risk factors
of client from pain
will be lessen.
After nursing
intervention the
client will
verbalized
understanding of
individual factors
that may
contribute to
possibility
of injury.

Intervention
Assess general
status of the client

Rationale
To determined clients
condition that may
cause injury

Assess mood coping

abilities, personality
style that may result
in carelessness

To determine the level

of cooperation

Assess
To determine causes
environmental
of injury
factors that may lead
to injury
Promoting clients
Safety by:
Monitoring V/S
Providing materials
for injury prevention

To lessen the risk for

injury, safe
environment and
Promote clients
comfort.

Evaluation
The client was free of
any signs of injury.

Assessment
Subjective:
Verbalization
indication lack of
knowledge
includes the
following:
Para saan itong
mga gamot na
ito.
Kailangan ko ba
talagang ubusin
lahat yun.
Objective:
- Doesnt drink
medications on
time.
Irritable
Curious

Diagnosis
Deficient
knowledge
related to the
treatment
regimen

Goals
Client
demonstrates
motivation to
learn as
measured by
verbalization of
desire and asking
questions related
to medicines.
Client
understands the
effects and
importance of the
medications
Client will identify
medications used
for symptom
control for each
medical condition
as measured by
verbalization of
accurate
knowledge.

Intervention
Assess the
clients ability,
readiness to
learn and pr
knowledge
related to
health
preservation,
medication
management,
learning best
occurs when
instruction.
Provide an
atmosphere of
respect,
openness,
trust, and
collaboration.

Explain the
medications
effects, side
effects, and
importance.

Rationale
Learning best
occurs when
learners are
motivated and
when instruction is
tailored to clients
cognitive ability.
(Olinzock, 2004)

Important when
providing
education to
patients with
different values
and beliefs about
health and illness.
For the patient to
understand the
purpose and
benefits of the
medications.

Evaluation
After nursing intervention the
client able to know and
understand the medications
(regimen) as evidenced by:
a. Patient participates in
learning process.
b. Mawala na sana sakit
ng paa ko sa mga
gamot na ito. As
verbalized by the
patient.

Discharge Planning
Medications
Advice patient to continue taking medications needed to maintain a normal functioning of the
body and maintain homeostasis. The treatment regimen ordered by the doctors must be
followed strictly and should not be stopped to prevent the aggravation of the condition. The full
course of antibiotics should be followed.
Advice the patient to observe any reaction towards the given medications and signs that needs
to call the attention of the physician.
Exercise
Encourage patient to have an active and passive ROM because it will promote blood
circulation and to improve muscle strength in order to promote total range of motion.
Treatment:
Instruct patient to consult the physician first if what activities must he/she avoid or put into
limits.
Encourage patient to compliance of medication regimen to promote optimal health.
Health Teachings:
Importance of personal hygiene to prevent infection.
Intake of nutritious foods like vegetables and fruits and intake of foods that is rich in fiber such
as green leafy vegetables and pineapple, also increased fluid intake to prevent constipation.
Strict compliance of medication regimen to promote wellness.
Immediate report to the physician if unusualities occur.
Out-Patient:
Return to the physician for further check-up if whether it is improving or not. Also, for early
diagnosis of any other underlying conditions.
Diet:
Encourage client to eat nutritious or healthy foods such as fruits and vegetables and foods that
are high in fiber such as green leafy vegetables, wheat, cereal and pineapple. Suggest client
also to consult to a dietary physician to know what the correct dietary intake he must maintain
are.
Spiritual:
Advice client to pray and have faith in God always because God is the most powerful of all He
knows what happened and He will never leave us.

References
Medical Surgical Nursing 12th Ed
Fundamentals of Nursing 8th Ed
Medscape.com
http://labtestsonline.org/understanding/analytes/esr/tab/test/