Case Pres Block 2

8/4/2019 Case Pres Block 2

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I. OVERVIEW OF THE DISEASE

Infection of a knee joint is a very serious medical condition. A septic (infected) knee is mostoften caused by bacteria (such as staph or strep), but in rare instances can be caused by other

microorganisms. Prompt diagnosis and treatment is essential in the native knee to avoid rapid

destruction of the cartilage and bone in the knee.

When diagnosed early, treatment is usually arthroscopic irrigation and debridement.

However, an open debridement may be required. Despite early diagnosis and treatment, joint

destruction may still occur. Late effects of joint infection (septic arthritis) may require treatment with

joint replacement as long as there is no persistent infection remaining within the knee.

Predisposing Factors

Diabetic patient

Trauma such as injury or wound

Bacteria/microorganism

Drug use Alcoholism

Kidney dialysis

Malnutrition

Advanced age

Orthopaedic surgery

Signs and Symptoms

Bone pain Swelling and redness of the skin Fatigue


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Fatigue

III. PATIENT HISTORY

History of Present Illness/InjuryPatient X is a 8 year old boy who was admitted last May 31, 2011, 3 weeks prior to

consultation, patient X hit his right big toe while playing football with (+) manipulation done 3times and (+) swelling persisted with involvement/swelling of right ankle noted and (+) fevernoted.

Past Medical History

Vomited and treated

Family Medical History

Uncle (father side): (+) Explore Laparotomy due to Acute Appendicitis with GeneralizedPeritonitis

Grandmother (mother side): (+) Hypertension with maintenance antihypertensive drugs

Grandmother (father side): (+) Diabetes Mellitus

Both parents: Deceased due to vehicular accident

Socioenomic History

Patient X was on his 4th grade. Both parents are deceased due to vehicular accident, therewere six in the family and he was the youngest, their auntie is the one who support their needs, workas a Brgy. Health Worker with the monthly income of P3,000.

IV. ANATOMY AND PHYSIOLOGY


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The metatarsus or metatarsal bones are a group of

five long bones in the foot located between the tarsal

bones of the hind- and mid-foot and the phalanges of thetoes. Lacking individual names, the metatarsal bones are

numbered from the medial side (side of big toe):

the first, second, third, fourth, and fifth metatarsal. The

metatarsals are analogous to themetacarpal bones of

the hand.

Normal Abnormal
http://en.wikipedia.org/wiki/Long_bonehttp://en.wikipedia.org/wiki/Foothttp://en.wikipedia.org/wiki/Tarsus_(skeleton)http://en.wikipedia.org/wiki/Tarsus_(skeleton)http://en.wikipedia.org/wiki/Phalanges_of_the_foothttp://en.wikipedia.org/wiki/Anatomical_terms_of_locationhttp://en.wikipedia.org/wiki/First_metatarsal_bonehttp://en.wikipedia.org/wiki/Second_metatarsal_bonehttp://en.wikipedia.org/wiki/Third_metatarsal_bonehttp://en.wikipedia.org/wiki/Fourth_metatarsal_bonehttp://en.wikipedia.org/wiki/Fifth_metatarsal_bonehttp://en.wikipedia.org/wiki/Metacarpushttp://en.wikipedia.org/wiki/Handhttp://en.wikipedia.org/wiki/Handhttp://en.wikipedia.org/wiki/Handhttp://en.wikipedia.org/wiki/Metacarpushttp://en.wikipedia.org/wiki/Fifth_metatarsal_bonehttp://en.wikipedia.org/wiki/Fourth_metatarsal_bonehttp://en.wikipedia.org/wiki/Third_metatarsal_bonehttp://en.wikipedia.org/wiki/Second_metatarsal_bonehttp://en.wikipedia.org/wiki/First_metatarsal_bonehttp://en.wikipedia.org/wiki/Anatomical_terms_of_locationhttp://en.wikipedia.org/wiki/Phalanges_of_the_foothttp://en.wikipedia.org/wiki/Tarsus_(skeleton)http://en.wikipedia.org/wiki/Tarsus_(skeleton)http://en.wikipedia.org/wiki/Foothttp://en.wikipedia.org/wiki/Long_bone


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V. PATHOPHYSIOLOGY

ove

Predisposing factors:

Modifiable:Compromised Immune systemInvasive procedures (catheterinsertion, etc.)Unsafe sexIV drug abuse

Bacterial infections alreadypresent in the bodyTrauma

Non Modifiable:Age extremes

Trauma

Tissue damageManipulation

Exposure of joints

Entrance ofmicroorganism to

synovial membrane

Growth ofmicroorganism

Infection of

metatarsal (R) foot

H t d


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Risk Factor : Poor Environmental Sanitation, Living in a congested area,Trauma: Fall

MYCOBACTERIUM TUBERCLE BACILLI

Lungs

Circulation

Potts Disease


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VI. PHYSICAL EXAMINATION

Procedure Technique Normal Findings Actual Findings Interpretation Analysis1. MonitorTemperature

Using thermometer 35.6-37.7 C Normal Normal

2. Monitor PulseRate

Palpation 70-100 BPM Normal Normal

3. MonitorRespiration Rate

Observation 20-28 BPM Normal Normal

4. Monitor ApicalPulse Rate

Auscultation 60-100 BPM Normal Normal

5. Skin Inspection Pink, smooth, turgor present Normal Normal6. Hair Inspection Lustrous and shiny Normal Normal7. Eyes Inspection Clear, moist surfaces,

transparent corneaNormal Normal

8. External Ear Inspection Non-tender auricle, tragus Normal Normal

9. Internal Ear Inspection Free from any discharge Normal Normal10. External Nose Inspection Color same as face, smooth and

symmetrical appearanceNormal Normal

11. Sinuses Palpation Non-tender upon palpation Normal Normal12. Lips Inspection Pink, smooth, moist Normal Normal13. Tongue Inspection Deep red with papillae Normal Normal14. Gums Inspection Smooth, firm, pink Normal Normal15. Teeth Inspection Straight with no cavities With missing

upper central andlateral incisor

Abnormal Not related to the case,the patient was at his

deciduous teethextraction

16. Neck Inspection Smooth, controlled movements,

ROM flexion 45, extension 55,

lateral abduction 40, rotation70

Normal Normal

17. Thyroid Inspection/Palpation Midline, smooth, firm, non- Normal Normal


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tender18. Trachea Inspection Midline position, symmetrical,

landmarks identifiableNormal Normal

19. Abdomen Inspection Rounded or flat Normal Normal20. Umbilicus Inspection Sunken, centrally located Protrude Abnormal Poor nutritional status

21. Bowel Sounds Auscultation 2 or 3 times/minute Normal Normal22. Extremities Inspection Fair color over the body, warm

to touchNormal Normal

23. Nails Inspection Pinkish nail beds. Nail firm Normal Normal24. PeripheralPulses

Palpation Bilateral pulses strong and equal Normal Normal

25. CarotidArteries

Palpation Palpable, equal and strong Normal Normal

26. TemporalArteries

Palpation Palpable, equal and strong Normal Normal

27. ROM

-Cervical Spine Inspection/Observation Flexion/extension 45 Normal

Normal

Lateral Bending 40 Normal Normal

-Elbow Inspection/Observation Flexion 160Extension 180 Normal Normal

Pronation/Supination 90 Normal Normal

-Wrist Inspection/Observation Flexion/Hypertension 90 Normal Normal

Ulnar deviation 55 Normal Normal

Radial deviation 20 Normal Normal

-Fingers Inspection/Observation Flexion 90 Normal Normal

Hyperextension 20 Normal Normal

-Ankles Inspection/Observation Dorsiflexion 20 Limited ROM Abnormal Due to accumulation ofmicroorganism in thearea, swelling occurs

thus causing pain whenmoving

Plantar flexion 45 Limited ROM Abnormal Due to accumulation of


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microorganism in thearea, swelling occurs


Eversion 20 Limited ROM Abnormal Due to accumulation of

microorganism in thearea, swelling occurs


Inversion 30 Limited ROM Abnormal Due to accumulation ofmicroorganism in thearea, swelling occurs


Abduction 10 Limited ROM Abnormal Due to accumulation ofmicroorganism in the

area, swelling occursthus causing pain when

moving

Adduction 20 Limited ROM Abnormal Due to accumulation ofmicroorganism in thearea, swelling occurs



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VII. DIAGNOSTIC TEST

Test Name Actual Findings Normal Findings Interpretation Clinical significanceof this test

HematologyMay 31, 2011 August 31,

2011May 31 August 31 To provide valuable

information about theblood and to some

extent the bonemarrow, which is the

blood-forming tissue. To

monitor the plateletand WBC count for

patient with infection.

Hemoglobin Mass 71 92 127-183 g/L Low LowHematocrit 0.23 0.28 0.37-0.54 Low Low

Leukocyte 11.50 8.80 4.5 - 10 x 10 9/L High NormalDifferential Count

Lymphocytes 0.38 0.21 0.20-0.40 Normal NormalSegmenters 0.51 0.64 0.50-0.70 Normal NormalMonocytes 0.06 0.08 0.00-0.07 Normal HighEosinophils 0.05 0.07 0.00-0.05 Normal High

Platelet Count 688 511 150-400 x 10 g/L High HighIndices

MCV 70 82 82-92 fl Low Normal

MCH 22 27 28-32 pg Low Low

MCHC 31 33 32-38 % Low

Chemistry To determine drugseffect taken by thepatient thus causingcholestasis and other

hepato toxicity.

SGOT 40.58 U/L


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June 3, 2011CS: No growth after 72 hoursof incubationGS:

a.) RBC: few; nomicroorganism seen; Nospore-forming bacilli seenb.) RBC: few; WBC: rare; Nomicroorganism seen; Nospore-forming bacilli seen; Noacid fast bacilli seen.

Chest X-ray -lung marking are prominent-some enlarged hilar andtransbronchial lymphodes arenoted-heart is not enlarged-diaphragm and sulci are intactImpression:Findings may relate to primaryKochs infection.

A normal chest x ray willshow normal structuresfor the age and medicalhistory of the patient.

Abnormal(some enlarged hilarand transbronchial

lymphodes are noted)

To evaluate organsand structures within

the chest forsymptoms of disease.

To determine theextent of

microorganism to thispart.

VIII. MEDICAL MANAGEMENT

Management Focus Clinical significance of this management

Medication Antibiotic Therapy To eradicate and prevent the multiplicationof infectious microorganisms

Anti-tuberculosis drugs To eradicate theMycobacterium tubercle bacilli

NSAIDS To relieve the painNutrition High calorie, High protein, High calcium diet To regain the energy lost, to achieve normal

body weight, to promote adequatecalcification of the bone and bone

remodelling and healingExercise Isometric exercise in the unaffected part To prevent paresthesia


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Blood transfusion PRBC, FWB PRBC: For OR (Arthrostomy) usedTo compensate the decreaseresult of CBC

IX. SURGICAL MANAGEMENT

Procedures Name Actual Finding Clinical significance of this procedureArthrotomy and Debridement The specimen consists of several, irregular, pale

red to tan-brown, soft tissue fragments with anaggregate measurement of 5x4x1.5 m and

labeled as intracapsular.

To remove the patient's dead, damaged,or infected tissue to improve the healingpotential of the remaininghealthytissue.

Aspiration of right knee, ankle, and bigtoe

Received specimen in a vial containing yellow,blood tinged fluid with clots, approximately 8.0

ml in volume

To examine bone marrow, the spongy liquidpart of the bone where blood cells are made.

X. DRUG STUDY

GenericName

BrandName

Action Indication Side Effects/ AdverseReactions

Nursing Considerations

Ibuprofen Advil Unknown. Mayinhibitprostaglandinsynthesis, to

produce anti-inflammatory,analgesic, andantipyreticeffects.

Ibuprofencontains the activeingredient ibuprofen, whichbelongs to a group ofmedicines called non-steroidal

anti-inflammatory drugs(NSAIDs).It works by blocking theaction of a substance in thebody called cyclo-oxygenase.Cyclo-oxygenaseis involved inthe production of variouschemicals in the body, someof which are known as

CNSHeadache, dizziness,nervousness, asepticmeningitis.

CVPeripheral edema, fluidretention, edema.EENTTinnitusGIEpigastric distress, nausea,occult blood loss, pepticulceration, diarrhea,

-Tell patient to take withmeals or milk to reduceadverse GI reactions.-Note: Drug is available at

OTC. Instruct patient notto exceed 1.2 g daily, not togive to chidren youngerthan age 12, and not totake for extended periods (longer than 3 days for feveror longer than 10 days forpain) without consultingpresciber.
http://en.wikipedia.org/wiki/Deadhttp://en.wikipedia.org/wiki/Infecthttp://en.wikipedia.org/wiki/Tissue_(biology)http://en.wikipedia.org/wiki/Healthhttp://en.wikipedia.org/wiki/Healthhttp://en.wikipedia.org/wiki/Tissue_(biology)http://en.wikipedia.org/wiki/Infecthttp://en.wikipedia.org/wiki/Dead


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prostaglandins. Prostaglandinsare produced in response toinjuryor certain diseases andwould otherwise go on tocausepain, swelling andinflammation. Ibuprofenistherefore used to relievepainand inflammation.All the medicines in thisgroup (NSAIDs) reduceinflammationcaused by thebody's own immune system,and are effective painkillers. Ibuprofencan be usedto relieve painsuch as muscular

achesandpains,period pains,headache, backache, rheumaticpain, dental painand neuralgia.It can also reducefeverishnessand the symptoms ofcoldsandflu.

constipation, abdominalpain, bloating, GI fullness,dyspepsia, flatulence,heartburn, decreasedappetite.GUAcute renal failure,azotemia, cystitis,hematuria.HEMATOLOGICPlonged bleeding time,anemia, neutropenia,pancytopenia,thrombocytopenia, aplasticanemia, leucopenia,

agranulocystocis.METABOLICHypoglycemia,hyperkalemia.RESPIRATORYBronchospasmSKINPruritus, rash, urticaria,stevens Johnson syndrome.

-Tell patient that fulltherapeutic effect forarthritis may be delayed for2 to 4 weeks. Althoughpain relief occurs at lowdosage levels, inflammationdoesnt improve at dosagesless than 400 mg q.i.d.-Teach patient to watch forand report to prescriberimmediately signs andsymptoms of GI bleeding,including blood in vomit,urine, or stool or coffeeground vomit, and black,

tarry stool.-Warn patient to avoidhazardous activities thatrequire mental alertnessuntil effects on CNS areknown.-Advise patient to wearsunscreen to avoidhypersensitivity to sunlight.

Isoniazid Niazid The mechanism

of action ofINH is notknown, but it isthought towork throughits effects onlipids (fats) andDNA withinthe tuberculosis

INH is used to prevent

active tuberculosis inpersons who have anabnormal skin test fortuberculosis or incombination with otherdrugs for the treatment ofactive tuberculosis.Prophylaxis in specificpatients who are tuberculin

-allergic reaction (difficulty

breathing; closing of thethroat; swelling of the lips,tongue, or face; or hives);

-unusual weakness orfatigue;

-nausea, vomiting, or loss ofappetite;

Health teachings:

-Take this drug in singledaily dose.-Take drug on an emptystomach, 1 hour before or2 hours after meals. If GIdistress occurs, may betaken with food.-Take this drug regularly,avoid missing doses, do


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bacterium. It isvery selectivefor thetuberculosisbacteria, that is,it has few if anyeffects on otherbacteria.

reactors (positive Mantouxtest)) or who are consideredto be high risk for TB.

-abdominal pain;

-yellow skin or eyes;

-dark urine;

-numbness or tingling inyour hands or feet;

-seizures;

-blurred vision; or

-confusion or abnormal

behavior.

not discontinue withoutfirst consulting your healthcare provider.-Do not drink alcohol ordrink as little as possible.There is an inc. risk ofheap if these two drugs arecombined.-Avoid foods containingtyramine, consult a dietitianto obtain a list of foodscontaining tyramine orhistamine.-Have periodic medicalcheck-ups, including an eye

examination and bloodtest, to evaluate the drugeffects.-Report for weakness,fatigue, loss of appetite,n/v, yellowing of skin oreyes, darkening of theurine, numbness or tinglingin hands or feet,


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RifampinRifadin Inhibits DNA-

dependentRNApolymeraseactivity insusceptiblebacterial cells.

Treatment of PulmonaryTB in conjunction with atleast one other effectiveantituberculotic.Neisseria meningitidiscarriers, for asymptomaticcarriers to eliminatemeningococci fromnasopharynx; not fortreatment of meningitis.Unlabeled uses: Infectionscaused by Staphylococcusaureus and Staphylococcusepidermis, usually incombination therapy; gram-

negative bacteremia in infancy;Legionella pneumophilia, notresponsive to erythromycin;leprosy (in combination withdapsone); prophylaxis ofmeningitis caused byHaemophilis influenzae.

CNS: headache,drowsiness, fatigue,dizziness, inability toconcentrate, mentalconfusion, generalizednumbness, muscleweakness, visualdisturbances.Dermatologic: Rash,pruritus, urticaria, flushing,reddish discoloration ofbody fluidstears, saliva,urine, sweat, sputum.GI: heartburn, distress,anorexia, vomiting gas,

cramps, diaarhea, hepatitis,pancreatitis.GU: hemoglobinuria,hematuria, renalinsufficiency, acute renalfailure, menstrualdisturbances.Hematologic: eosinophilia,thrombocytopenia, transientleucopenia, hemolytic

anemia, decreased Hgb,hemolysis.Other: pain in extremities,osteomalacia, myopathy,fever, flulike symptoms.

-Teach client to take drugin a single daily dose. Takeon an empty stomach, 1 hrbefore or 2 hrs after meals.-Inform client to take thisdrug regularly; avoidmissing any doses; do notdiscontinue this drugwithout consulting thehealth care provider.-Tell client to have periodicmedical checkups,including eye examinationsand blood test, to evaluatethe drug effects.

-Inform client that he mayexperience the drugs sideeffects (especially the redcolored secretion)-Instruct client to see hisphysician if he experiencefever, chills, muscle andbone pain, excessivetiredness or weakness, lossof appetite, N/V, yellowing

of eyes/skin, unusualbleeding or bruising, skinrash or itching.-Instruct client to removecontact lenses as they maydiscolor


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Pyrazinamide Pyrazinamide Pyrazinamidemay bebacteriostatic orbactericidalagainstMycobacteriumtuberculosisdepending ontheconcentrationof the drugattained at thesite of infection.The mechanismof action is

unknown. Invitro and invivo the drug isactive only at aslightly acidicpH.

Pyrazinamide is indicatedfor the initial treatment ofactive tubercuIosis in adultsand children whencombined with otherantituberculous agents. (Thecurrent recommendation ofthe CDC for drug-susceptible disease is to usea six-month regimen forinitial treatment ofactivetuberculosis, consisting ofisoniazid, rifampin andpyrazinamide given for 2months, followed by

isoniazid and rifampin for 4months.*4)(Patients with drug-resistantdisease should be treatedwith regimensindividualized to theirsituation. Pyrazinamidefrequently will be animportant component ofsuch therapy.)

(In patients withconcomitant HIV infection,the physician should beaware of currentrecommendation of CDC.It is possible these patientsmay require a longer courseof treatment.)

General: Fever, porphyriaand dysuria have rarely beenreported.Gastrointestinal: Theprincipal adverse effect is ahepatic reaction (seeWARNINGS).Hepatotoxicity appears tobe dose related, and mayappear at any time duringtherapy. Gl disturbancesincludingnausea, vomitingand anorexia have also beenreported.Hematologic and

Lymphatic:Thrombocytopenia andsideroblastic anemiawitherythroid hyperplasia,vacuolation of erythrocytesand increased serum ironconcentration haveoccurred rarely with thisdrug. Adverse effects onblood clotting mechanisms

have also been rarelyreported.Other: Mild arthralgia andmyalgia have been reportedfrequently. Hypersensitivityreactions including rashes,urticaria, and pruritis havebeen reported. Fever, acne,photosensitivity, porphyria,

-Take this drug in singledaily dose.-Take drug on an emptystomach, 1 hour before or2 hours after meals. If GIdistress occurs, may betaken with food.-Take this drug regularly,avoid missing doses, donot discontinue withoutfirst consulting your healthcare provider.-Do not drink alcohol ordrink as little as possible.There is an inc. risk of

heap if these two drugs arecombined.
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dysuria and interstitialnephritis have beenreported rarely.

Vitamin Bcomplex

Surbex,Vicon-C, Z-

Bec

A coenzymethatstimulatemetabolicfunction and isneeded for cellreplication,hematopoiesis,andnucleoproteinand myelin

synthesis

This product is acombination of B vitaminsused to treat or preventvitamin deficiency due topoor diet, certain illnesses,alcoholism, or duringpregnancy. Vitamins areimportant building blocksof the body and help keepyou in good health. Bvitamins include thiamine,

riboflavin,niacin/niacinamide, vitaminB6, vitamin B12, folic acid,and pantothenic acid

CV:Peripheral vascularthrombosis,heart failure.GI:transientdiarrhea.Respi:pulmonaryedema.Skin:

it ching,transitoryexanthema,urticaria.Other:anaphylaxis,anaphylactoidreactions withparenteraladministration

, pain orburning atinjection site

BEFORE:~ Determine reticulocytecount, hct, Vit.B12, iron,folate levels beforebeginning therapy.~ Obtain a sensitivity testhistory beforeadministration~ Avoid I.V.administrationbec. faster systemic

elimination will reduceeffectiveness of vitamin.DURING:~ Dont give large doses ofvitaminB12 routinely; drugis lost through excretion.~ Dont mix parenteralpreparation in samesyringe with other drugs.AFTER:

~ Protect Vit.B12 fromlight. Dont refrigerate orfreeze.~ Monitor patient forhypokalemia for first 48hours, as anemia correctitself. Give potassiumsupplements, as needed
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XI. NURSING CARE PLAN

Case Pres Block 2

Documents

Transcript of Case Pres Block 2