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New Era University

College of Nursing

In Partial Fulfillment for the Requirements in

Philippine Orthopedic Center

A Case Study on

Septic ankle left

Submitted by:

Santiago, Joshua M



http://www.homeworkping.com/





BSN Group. 3

A.Y. 2011-2012

Introduction

Swelling of the feet and ankles can occur as a result of conditions involving the local extremities as

well as systemic conditions (diseases and conditions that affect the entire body). Localized processes such

as injuries and infections may lead to a swollen foot and/or ankle only on the involved side. Swelling of the

ankle on one side is often a result of sprains or strains. Sometimes diseases that affect the entire body,

such as heart disease and kidney or liver failure, can result in excess fluid buildup (edema) that is often

concentrated in the legs and feet, leading to swelling not only of the ankles but also of the feet and lower

legs. This can also occur with obstruction of the venous system, as may occur with pregnancy and obesity.

Diseases of the joints, such as arthritis, can also affect the joints of the ankle and foot, leading to swelling of

the involved areas. Treatments for swollen ankles and feet depend on the particular cause, but anti-

inflammatory medications are often used to manage the pain associated with strains and sprains

Infection is an unusual cause of ankle swelling. Infections can either occur in the soft tissues around the

ankle joint (cellulitis) or in the joint itself (septic joint). Infections can often be treated with medications

alone, but may also require surgery.

II. BIOGRAPHIC DATA

http://www.medicinenet.com/script/main/art.asp?articlekey=7776





Name: J.B.I

Address: Bulacan

Age: 2 years old

Gender: male

Race: Filipino

Marital Status: Single

Religious Orientation: Roman Catholic

Date of Admission: October 1, 2011 at 10:00pm

III. CHIEF COMPLAINT OR REASON FOR VISITLeft ankle swelling

IV. NURSING HISTORYHistory of Present Illness14 days prior to admission, Patient had chicken pox infection associated with progression of left

ankle swelling. It was noted to be warm and tender to touch. Patient was also noted to have

difficulty in bearing weight on left lower extremities. Fever was also noted

10 days prior to admission. Patient prompted consult with local hospital wherein oral antibiotics

were given and provided relief of fever only

1 day prior to admission, there is still persistent symptoms where they consulted with another

hospital where in doctor diagnosed this as to consider septic bone left. Patient was advised

arthrotomy ankle but not done due to financial problem

History of past illnessPatient has chicken pox. No known allergies to food and medications

Family historyThere are known hypertension in their family according to the grandmother of the patient

Anatomy and physiologyThe ankle and foot are incredibly complex, with a variety of

connecting bones, ligaments, tendons and muscles.

The ankle is made up of two joints: The ankle joint and the subtalar joint. The ankle joint includes

two bones (the tibia and the fibula) that form a joint that allows the foot to bend up and down. Two

bones of the foot (the talus and the calcaneus) connect to make the subtalar joint that allows the

foot to move side to side. The tarsal bones connect to the 5 long bones of the foot - the

metatarsals.

Ligaments and TendonsThe large Achilles tendon is the most important tendon for walking, running and jumping. It

attaches the calf muscles to the heel bone to allow us to puch off and up on the toes. There are

another 12 tendons that cross the ankle. They are responsible for movements of the ankle, foot,

and toes; some of these tendons also help support the arches of the foot.

MusclesThe muscles of the foot are classified as intrinsic and extrinsic. The intrinsic muscles are located

within the foot and cause movement of the toes and are flexors (plantar flexors), extensors

(dorsiflexors), abductors, and adductors of the toes. Several intrinsic muscles also help support the

arches of the foot.

The extrinsic muscles are located outside the foot, in the lower leg. The gastrocnemius muscle

(calf) is the largest. They have long tendons that cross the ankle, to attach on the bones of the foot

and assist movement.

Pathophysiology

Modifiable Factors

Trauma

Trauma or open wound

Microorganism gain entry

Immunity response

Redness, localized pain and swelling

White blood cells attack microorganisms

through phagocytosisInflammatory responseIncreased WBC

Formation of localized dead cells

White blood cells still recognized this as

foreign object

Non-Modifiable Factors

Physical active persons

LaboratoryName of test Date done Indication Result Normal Significance

HEMATOLOGY

hemoglobin

October 5 ,2011

October 11,2011

The Hb determination is part

of a CBC. It is used to screen

for disease associated with

anemia, to determine the

severity of anemia, to monitor

the response to treatment for

anemia, and to evaluate

polycythemia.

(A manual of laboratory and diagnostic test p74)

80 gms/L

93 gms/L

127-

183gms/L

Decreased Hb levels

are found in anemia

states (a condition in

which there is a

reduction of Hb, Hct,

and/or RBC values)

Iron deficiency,

thalassemia,

pernicious anemia,

hemoglobinopathies

(A manual of laboratory and diagnostic test p74-75)

HCT October 5 ,2011

October 11,2011

The Hct test is part of the

CBC. This test indirectly

measures the RBC mass. It is

an important measurement in

the determination of anemia

.25gms/L

.28 gms/L

.

0.37-0.54

gms/L

Decreased Hct values

are an indicator of

anemia, a condition in

which there is a

reduction in the PVC.

An Hct <30% (<0.30)

or polycythemia.


means that the

patient is moderately

to severely anemic.

Decreased values

also occur in the

following conditions:

Acute and chronic

blood loss

Hemolytic reaction


Leukocyte count October 5 ,2011

October 11,2011

The WBC serves as a useful

guide to the severity of the

disease process. Specific

patterns of leukocyte

response can be expected in

various types of diseases as

determined by the differential

count (percentages of the

different types of leukocytes). (A manual of laboratory and diagnostic test p48)

9.10x109L

7.20x109L

4.5-

10x109L

The findings are

normal

Segmenters October 5 ,2011

October 11,2011

0.60

0.32

0.50-0.70

LYMPHOCYTES October 5 ,2011 This test measures the

number of lymphocytes in the

peripheral blood

0.30 0.20-0.40 Lymphopenia

October 11,2011


0.55Aplastic anemia


Monocytes October 5 ,2011

October 11,2011

This test counts monocytes, which circulate in certain specific conditions such as tuberculosis, subacute bacterial endocarditis, and the recovery phase of acute infections.

0.08

0.07

0.00-0.07 The findings are

normal

Eosinophils October 5 ,2011

October 11,2011

This test is used to diagnose allergic infections, assess severity of infestations with worms and other large parasites, and monitor response to treatment.

0.02

0.06

0.00-0.05 Increased

eosinophils: allergic

states, drug sensitivity

reaction, skin

disorders, tissue

invasion by parasites,

periarteritis nodosa,

hypersensitivity

response to

malignancy (e.g.

Hodgkin's disease),

pulmonary infiltrative

disease,

disseminated

eosinophilic

hypersensitivity

disease.

Platelet October 5 ,2011

October 11,2011

A platelet count is a test to

measure how many platelets

you have in your blood.

Platelets help the blood clot.

They are smaller than red or

363

353

150-

400X109/L

The findings are

normal

white blood cells.

MCV October 5 ,2011

October 11,2011

Average volume of the red cell

is measured by automated

instrument, by electrical

impedance or by light scatter.

77

78

82-92 fl Decreased in: Iron

deficiency,

thalassemia;

decreased or normal

in anemia of chronic

disease.

MCH October 5 ,2011

October 11,2011

MCH calculated from

measured values of Hb and

RBC; ie, MCH = Hb/RBC. A

low MCH can mean

hypochromia or microcytosis

or both. A high MCH is

evidence of macrocytosis

25

26

28-32 pg Lymphopenia

Aplastic anemia

(A manual of

laboratory and

diagnostic test p61)

MCHC October 5 ,2011

October 11,2011

MCHC describes how fully the

erythrocyte volume is filled

with hemoglobin and is

calculated from measurement

of hemoglobin (Hb), mean

corpuscular corpuscular

volume (MCV) and red cell

count (RBC); ie, MCHC =

Hb/MCV x RBC.

32

33

32-38% The findings are

normal

WOUND GRAM STAINING AND CULTURE SENSITIVITY TEST

GS: RBC-- ++, NO MICROORGANISM SEEN

AFB: NO ACID FAST BACILLI SEEN

DRUG ORDER

(Generic name, dosage, route,

frequency, etc.)

TRADE / BRAND NAME

PHARMACOLOGIC ACTION OF DRUG

INDICATIONS AND CONTRAINDICATION

S

ADVERSE EFFECTS OF THE DRUG

DESIRED ACTION ON

YOUR CLIENT

NURSING RESPONSIBILITIES/

PRECAUTIONS

PARACETAMOL

NSAIDS

200mg/ml IV q4 TID

paracetamol

Decreases fever by ahypothalamic effect leading to sweating and vasodilation and inhibits the effect of pyrogens on the hypothalamic heat-regulating centers. May cause analgesia by inhibiting CNS prostaglandin synthesis; however, due to minimal effects on peripheral prostaglandin synthesis, acetaminophen has no anti-inflammatory or uricosuric effects. Does not cause any anticoagulant effect or ulceration of the GI tract. antipyretic and analgesic effects are comparable to those of aspirin.

INDICATIONSControl of pain due to headache, earache,To reduce fever in bacterial or viral

infectionsCONTRAINDICATION

SRenal insufficiency, anemia. Clients with cardiac or pulmonary

disease are more susceptible to

acetominophen toxicity

Chronic and even acute toxicity can develop after long symptom-free usage.

Hematologic: methemoglobinemia, hemolytic anemia, neutropenia, thrombocytopenia, pancytopenia, leucopenia

Allergic: urticarial and erythematous skin reactions, skin eruptions, fever.

Miscellaneous: CNS stimulation, hypoglycemic coma, jaundice, drowsiness, glossitis. Possible liver damage in those who consume three or more alcoholic drinks daily

The patient’s fever will return to the normal range of temperature

Note prescribed dosage and expected outcomes

Monitor CBC, liver and renal function studies

Document presence of fever, onset and the duration

Check for urine for occult blood

DRUG ORDER TRADE / PHARMACOLOGIC INDICATIONS AND ADVERSE EFFECTS OF DESIRED NURSING


frequency, etc.)

BRAND NAME ACTION OF DRUG CONTRAINDICATION

S THE DRUG ACTION ON YOUR CLIENT

RESPONSIBILITIES/ PRECAUTIONS

Clindamycin

antibiotic

100g IV q8H ANST

- inhibits bacterial protein synthesis by binding to 50S subunit of ribosome.

- hinders or kills susceptible bacteria.

indication

infections caused by sensitive staphylococci, streptococci, pneumococci, bacteroides, and other sensitive aerobic and anaerobic organisms.

Contraindication

-contraindicated in patients hypersensitive to drug or lincomycin

-use cautiously in patients with renal or

hepatic disease, asthma, history of GI disease, or significant

allergies

CNS: headacheCV: ThrombophlebitisEENT: pharyngitisGI: abdominal pain, Anorexia, bloody or tarry stools, constipation, diarrhea, dysphagia, esophagitis, flatulence, nausea, psuedomembranus colitis, unpleasant or bitter taste, vomiting.GU: UTIHEMATOLOGIC:Eosinophilia, thrombocytopenia, transient leukopeniaSKIN: maculopapular rash, urticariaOTHER: anaphylaxis, erythema, pain (I.V. use), induration, pain; sterile abcess (I.M. use)

The patient will have a decrease signs of infections

-assess patients infection before and regularly throughout therapy

-before giving first dose, obtain specimen for culture and sensitivity test, begin therapy pending results.

-monitor renal, hepatic, and hematopoetic functions during prolonged therapy.

-be alert for adverse reactions

-tell patient to take entire amount prescribed even after he feels better.

-tell patient receiving drug to report discomfort

DRUG ORDER


frequency, etc.)

TRADE / BRAND NAME



S


DESIRED ACTION ON

YOUR CLIENT


PRECAUTIONS

salbutamol

bronchodilator

1 neb + 1cc PNSS q6

reduce chemical mediator release from pulmonarymast cells and improve ability of cilia to clear mucus

direct-acting agent that relaxes smooth muscle wallsof the bronchi, uterus, and skeletal muscle vascular bed

IndicationTo relieve bronchospasm associated with acute or chronic asthma,bronchitis, or other reversible obstructive airway diseases. Also used toprevent exercise-induced bronchospasm.

Contraindication

Contraindicated in patients hypersensitive to drug or its ingredients.

CNS: tremor, nervousness, dizziness, insomnia, headache,hyperactivity, weakness, CNS stimulation, malaise.CV: tachycardia, palpitations, hypertension.EENT: dry and irritated nose and throat with inhaled form, nasalcongestion, epistaxis, hoarseness.GI: heartburn, nausea, vomiting, anorexia, altered taste, increasedappetite.Metabolic: hypokalemia.Musculoskeletal: muscle cramps.Respiratory: bronchospasm, cough, wheezing, dyspnea, bronchitis,increased sputum.Other: hypersensitivity reactions

The patient will be able to loosen his/her secretions

Drug may decrease sensitivity of spirometry used for diagnosis ofasthma.

When switching patient from regular to extended-release tablets,remember that a regular 2-mg tablet every 6 hours is equivalent toan extended-release 4-mg tablet every 12 hours.

Syrup contains no alcohol or sugar and may be taken by children asyoung as age 2.

In children, syrup may rarely cause erythema multiforme orStevens-Johnson syndrome

DRUG ORDER TRADE / BRAND




DESIRED ACTION ON



frequency, etc.)NAME S YOUR CLIENT PRECAUTIONS

Ferrous sulfate

- Elevates the serum iron concentration which then helps to form High or trapped in the reticuloendothelial cells for storage and eventual conversion to a usable form of iron.

Indication

Prevention and treatment of iron

deficiency anemias. Dietary supplement for

iron.

Contraindication

Hypersensitivity Severe hypotension.

Dizziness Nasuea and vomiting

Nasal CongestionDyspnea

Hypotension Muscle cramps

Flushing

The patient will have an increase of HGB and HCT

Advise patient to take medicine as prescribed.• Caution patient to make position changes slowly to minimize orhtostatic hypotension.• Instruct patient to avoid concurrent use of alcohol or OTC medicine without consulting the physician.• Advise patient to consult physician if irregular heartbeat, dyspnea, swelling of hands and feet and hypotension occurs.• Encourage patient to comply with additional intervention for hypertension like proper diet, regular exercise, lifestyle changes and stress management.

CUES NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS EVALUATION

Objective:

Sitting in the wheel chair

Limited leg movement

Impaired physicalmobility of thelower extremity r/tsurgical incision at the left leg

Goal

After 1-2 days of nursing interventions, client will be able to demonstrates andverbalizes properexercises of the lowerextremities & canperform activities ofdaily living withMinimal assistance.

Objectives:

1.participate willingly in the necessary activities

2. demonstrate a increase in physical mobility

3. Use identified techniques to enhance mobility

Evaluate current limitations/degree of deficit in light of usualstatus.

Ascertain ability to stand and move about and degree of assistancenecessary/use of equipment

Adjust activities to prevent overexertion. Reduce intensitylevel or discontinue activities that cause undesired physiologicalchanges.

Plan care with rest periods between activities to reducefatigue.

Involve client/SO(s) in planning of activities as much aspossible.

Assist with activities and provide/monitor client’s use of assistivedevices (crutches, walker, wheelchair, oxygen tank, etc.) toprotect client from injury.

Increase exercise/activity levels gradually; teach methods to

GOAL MET

After 1-2 days of nursing interventions, client was able to demonstrates andverbalizes properexercises of the lowerextremities & canperform activities ofdaily living withMinimal assistance as evidenced by:

Using of wheel chair by himself

Was able to perform simple activities such as eating and combing hair by himself

conserve energy, such as stopping to rest for 3 minutes duringa 10-minute walk, sitting down instead of standing to brushhair.

CUES NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS EVALUATION

Objective:

Age: 2 yrs old

Risk for injury Goal

After 1-2 days of nursing intervention the client will be free from injury.

Objectives:

After 2 hours of nursing intervention the client will be given instruction carefully to be able to reduce the risk for injury through attaining safe environment:

- padded side rails- watch door edges

curbs and landing steps

INDEPENDENT

1. Assess clients muscle strength gross and fine motor coordination

2. Assess mood, coping abilities, personality styles ( e.g. temperament aggressions impulsive behavior, level of self- esteem )

3. Provide safe environment:

- pad side rails- remove obstacles in the room

4. Discuss important of self – monitoring of conditions / emotions

GOAL MET

After 1-2 days of nursing intervention the client was free from any injury as evidenced by:

Always with support of the significant others

Always insight of the significant others

Discharge Plan

The patient is instructed to take the following plan for discharge.

M-EDICATION, instruct patient to continuously drink medication as prescribe by Doctor

E-XERCISES, instruct patient to conduct 15-20 minutes exercises morning and active ROM in

extremities for about 5-10minutes every afternoon

T-REATMENT, instruct patient to continuously stick to the regimen of drinking medication on time and

reporting to physician for any signs of deviations

H-EALTH TEACHING, instruct patient to exercise daily, increase fluid intake

O-UT-PATIENT FOLLOW UP, Instruct patient to attend follow-up check-ups as recommended by the

physician.

D-IET, the patient will be place on diet as tolerated

S-PIRITUAL, Encourage client to attend religious practices like attending the worship service

Treatment and management

ARTHROTOMY

The medical term “arthrotomy” means “cutting into a joint.” Also known as a synosteotomy,

an arthrotomy can be performed for a variety of reasons, usually as part of a larger surgery which is

intended to address a problem inside the joint or an issue with one or more of the bones which articulates

at the joint. Procedures of this nature are usually performed by anorthopedic surgeon, a surgeon who

specializes in surgeries involving the bones and joints.

One reason to perform an arthrotomy is to gain access to the joint for the purpose of a joint repair or

replacement surgery. Cutting into the joint may be necessary to access the surgical field and to make the

interior of the joint visible to the physician. However, it also increases healing time. Historically, surgeons

had to weigh the damage caused by an arthrotomy with the need for the surgery when making treatment

recommendations to patients.

Today, cutting into the joints is less necessary because surgeons can perform arthroscopicsurgery. In this

type of surgery, cameras are inserted into the joint along with tools which can be used to perform

manipulations inside the joint. This allows the surgeon to work within the surgical field without having to cut

the joint open to do so. Minimally invasive surgery is safer for the patient, decreases the risk of

complications, and shortens healing time considerably, making it an appealing choice when it is an

available option.

Cutting into a joint may also be necessary during an amputation or during exploratory surgery in

which arthroscopic surgery is not an option. Arthroscopy may not be possible in some emergency

situations, for example, or when a joint is badly crushed and thus the surgeon has difficulty understanding

what is going on inside the surgical field without looking at it directly.

When arthrotomy is required as part of a medical procedure, the surgeon uses specialized tools which have

been designed for cutting quickly and efficiently into the joints while minimizing damage. The surgeon plans

out the cuts ahead of time so that when the patient is on the table, the surgeon already has a plan in mind

for performing the surgery. Patients should be aware that even “routine” surgeries can be accompanied

with complications, and a good surgeon will discuss the potential risks of a procedure before it begins so

that the patient will be prepared ahead of time.

BLOOD TRANSFUSION

A blood transfusion is the transfer of blood or blood products from one person (donor) into another person's

bloodstream (recipient). This is usually done as a life saving maneuver to replace blood cells or blood

products lost through severe bleeding, during surgery when blood loss occurs or to increase the blood

count in an anemic patient. The following material is provided to all patients and/or their family members

regarding blood transfusions and the use of blood products. Although in most situations the likelihood of a

blood transfusion associated with surgery is uncommon, at times patients may require blood products. You

are encouraged to discuss your particular need for transfusion as well as the risks of transfusion with your

doctor.

Your options may be limited by time and health factors, so it is important to begin carrying out your decision

as soon as possible. For example, if friends or family members are donating blood for a patient (directed

donors), their blood should be drawn several days prior to the anticipated need to allow adequate time for

testing and labeling. The exact protocols are hospital and donor site specific.

The safest blood product is your own, so if a transfusion is likely, this is your lowest risk choice.

Unfortunately this option is usually only practical when preparing for elective surgery. In most other

instances the patient cannot donate their own blood due to the acute nature of the need for blood. Although

you have the right to refuse a blood transfusion, this decision may hold life-threatening consequences. If

you are a parent deciding for your child, you as the parent or guardian must understand that in a life-

threatening situation your doctors will act in your child's best interest to insure your child's health and well

being in accordance with standards of medical care regardless of religious beliefs. Please carefully review

this material and decide with your doctor which option(s) you prefer.

To assure a safe transfusion make sure your healthcare provider who starts the transfusion verifies your

name and matches it to the blood that is going to be transfused. Besides your name, a second personal

identifier usually is used as your birthday. This assures the blood is given to the correct patient.

If during the transfusion you have symptoms of shortness of breath, itching, fever or chills or just not feeling

well, alert the person transfusing the blood immediately.

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