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MEMBERS: BSN3C-C2

PARAGAS, Daniel John PEREZ, Kirsten Mae QUIMBA, Moises RAMOS, Emmanuel John RAMOS, Jaimie Anne REGATILLO, Ma. Cristina REINANTE, John Micheal RELOJO, Sheena Mae REYES, Sharmaine Joy ROMBAON, Maritoni ROQUE, Jose Alfonso

I. GOALS AND OBJECTIVES


GOALS: -This case presentation will enable the students to give an appropriate intervention and deliver holistic care for the patient. This will also help the nursing students to know more about the nature and the disease process of pyomyositis.

SPECIFIC OBJECTIVES: Attitude -Establish a nurse-patient interaction through exchanging of thoughts and information. Institute bond between the student nurse and the patient. Skills -To give an appropriate medical and nursing management for the patient with pyomyositis.

Knowledge -Define Pyomyositis. - Discuss the anatomy and physiology of the Musculoskeletal system. - Identify the signs and symptoms manifested by the patient. - Distinguish the precipitating and predisposing factors that trigger this development. - Trace the pathogenesis based on the signs and symptoms manifested by the patient. - Be acquainted with the different drugs, its actions, and perform appropriate nursing responsibilities for each. - Use the nursing process as the framework for the care of the patient. - Plan for suitable nursing care.

II. INTRODUCTION
Background -Pyomyositis is an inflammation of muscle tissue, usually of voluntary muscles (examples are skeletal muscles) that results in pus production.

-Once considered a tropical disease, it is now seen in temperate climates as well. The pathogenesis is unclear, but trauma, infections (S. aureus, S. pneumoniae), and malnutrition have been implicated. Although most cases of pyomyositis occur in healthy individuals, other pathogenetic factors include nutritional deficiency and associated parasitic infection in tropical climates. In the temperate climates, pyomyositis is seen most commonly in patients with diabetes, HIV infection, and malignancy because of decreased immune system they are at greater risk.

Epidemiology - Pyomyositis is most often caused by the bacterium Staphylococcus aureus. The infection can affect any skeletal muscle, but most often infects the large muscle groups such as the quadriceps or gluteal muscles. Most patients are aged 2 to 5 years, but infection may occur in any age group. Infection often follows minor trauma.

Clinical Presentations Presentation with painful, tender, localized swelling over muscle Fever Epidural abscess
Complications Life-threatening complications include sepsis and toxic shock syndrome.

Diagnostic Procedure CT scan or MRI demonstrates muscle abscess. Aspiration of abscess (by surgery or CT/US guided) yields pus, usually yielding S. aureus. Bacteremia may accompany.

Treatment Medical Care Promptly administer systemic antibiotics. This could eliminate the need for surgical drainage in selected cases. The choice of antibiotic is determined by identification of the causative organism(Culture and sensitivity test). Antibiotics initially are given intravenously until clinical improvement is noted, followed by oral antibiotics for a total course of 3 weeks (eg, cefazolinor ceftriaxone IV followed by cephalexin PO).

Surgical Care During the suppurative phase, abscess aspiration under ultrasonic or CT guidance may be required. Surgical drainage is especially necessary for large abscesses. Complicated cases may require fasciotomies (surgical incision of the fascia to relieve pressure) and debridement (removal of dead tissues).
Prognosis Prompt administration of antibiotics can result in complete resolution.

III. PATIENTS PROFILE


Biographic Data Name: Patient R., A.L.R. Address: 10-E Jacinto St. Sta. Lucia Novaliches, Q.C. Birthday: November 10, 2009 Age: 2 years old Religious Affiliation: Roman Catholic Fathers Name: Moises Reyes Mothers Name: Maricris Reyes Gender: Female Marital Status: Single

Hospital Data Hospital NO: 69-38-85 Admission Date and Time: February 19,2012; [2:10 am] Attending Physician: Dr. Chua III

IV. HISTORY
FAMILY HISTORY

- R, A.L.R.s family conditions have a hereditary history of asthma as what her mother stated during the interview. Other than the hereditary issues, families sometimes experienced some minor infirmity such as fever, cough, colds, and among other ailing. With proper knowledge about the remedies of these trifling sicknesses, it can be easily coped by drinking plenty of water daily. It is also advisable for them to consult their doctor whenever cough, colds, or fevers occur.

PAST MEDICAL HISTORY At 2 years of age, the client had not experienced any childhood illnesses or diseases such as chicken pox, mumps or measles. She has also been free of any type of disease or illness over the past six months. However, she has had two stints of colds before that, and has also been previously diagnosed with impetigo. She has no known allergy to any type of food. In terms of her immunization, she is already complete, as stated by the mother. History of immunizations is as follows:

Immunizations BCG (infant) DPT 1, 2, 3 Complete Complete

Polio
Measles BCG (school age)

Complete
Complete Complete

PRESENT ILLNESS Chief Complaint: Pain, Swelling, Tenderness on Right Leg


Provisional Diagnosis: Pyomyositis Right Thigh

V. ACTIVITIES OF DAILY LIVING


ACTIVITIES OF DAILY LIVING 1.NUTRITION BEFORE HOSPITALIZATION The client eats anything, especially biscuits, cereals, green leafy vegetable and her favorite candy is potchi and jelly ace. She has a good appetite. DURING HOSPITALIZATION The client has a poor of appetite she only eats a slice of cake. And drink 2 bottles (30ml) formula milk (lactum) per day. INTERPRETATION AND ANALYSIS I:poor appetite

A: Patients who are hospitalized may have an inadequate dietary intake because of the illness or disorder that necessitated the hospital stay or because of a change in the diet of the patient;

ACTIVITIES OF DAILY LIVING 2. ELIMINATION

BEFORE HOSPITALIZATION According to mother she defecates 1-2 times everyday. She urinates everyday and has no problem in elimination.

DURING HOSPITALIZATION According to the mother, her baby has an absent of bowel elimination 4 days prior to admission.

INTERPRETATION AND ANALYSIS I: O or absent of elimination A: eating can also impair regular defecation. Individuals who eat at the same times everyday usually have a regularly timed, physiologic response to food intake and regular pattern of peristaltic activity in colon; I: decrease in doing her exercise A: Decreases activity because her present conditions that limit her movements.

3. EXERCISE

The client does her exercise by playing and dancing. She also take a walk around in their house

When she was admitted in the hospital, she only moves her upper extremities.

ACTIVITIES OF DAILY LIVING 4. HYGIENE

BEFORE HOSPITALIZATION Takes a bath 2x everyday in morning and at night before going to sleep. She brushes her teeth 3x a day.

DURING HOSPITALIZATION She never takes a full bath, but her mother does sponge bath once a day. She brushes her teeth once a day with the help of her mother.

INTERPRETATION AND ANALYSIS I: decrease in performing in hygiene. A: Decreases activity because of the Intravenous fluid attached to her; limiting her movement prevents the intravenous line to get tangle to her; I. decrease rest pattern. A. Uncomfortable environment and irritabiity results to sleep deprivation.

5. SLEEP AND REST

the patient was able to consume 8 hours sleeping time and had a schedule of nap twice a day .

Patient takes a nap 20-30 mins 3 times a day and at night she only sleeps 3-4 hours.

VI. PATTERNS OF FUNCTIONING


Psychological health Interpretation Coping patterns according to her mother, every time she feels pain in her condition she always hug her toy particularly barney. Coping may be described as dealing with problems and situations, or contending with them successfully. Coping strategies vary among individuals and are often related to the individuals perception of the stressful event. Three approaches to coping stress are to alter the stressor, adapt to the stressor, or avoid the stressor. A persons coping strategies often change with a reappraisal of a situation Reference:Fundamentals of Nursing by Barbara Kozier, GlenoraErb, Audrey Berman &Shirlee Snyder (7th Edition page 1020) Analysis Based on the data we gathered the patient uses an object to alter her feelings every time she feels pain.

Psychological health Emotional patterns according to her mother, the patient is a joyful daughter, but when the incident happened the child become irritable and she has difficulty in sleeping at night.

Interpretation Emotional wellness is the ability to manage stress and to express emotions appropriately. It involves the ability to recognize, accept and express feelings and to accept ones limitation.

Analysis

With the information we gathered, the patient become anxious of being touch and she became irritable about her condition which can lead in slow development on her stage (autonomy vs shame Reference:Fundamentals of and doubt) Nursing by Barbara Kozier, GlenoraErb, Audrey Berman &Shirlee Snyder (7th Edition page 173

Psychological health Interaction patternsAccording to her mother, patient X is a sweet and playful daughter to her parents and siblings. She always interacts with others.

Interpretation Interaction pattern are ways of expressing affection, love, sorrow and anger. It also includes openness of communication with all family members and the most significant persons in his/her life. Reference:Fundamentals of Nursing by Barbara Kozier, GlenoraErb, Audrey Berman &Shirlee Snyder (7th Edition)

Analysis The patient had no difficulty in interacting with others but when the incident suddenly happened it causes trauma to her.

Psychological health Self-concept patterns- According to her mother, patient Xs own perception on herself is strong, and also She has a positive self-concept.

Interpretation Self-concept is ones mental image of oneself. A positive self-concept is essential to a persons mental and physical health. An individual possessing a strong self-concept should be better able to accept or adapt to changes that may occur over the life span.

Analysis

The patient has confidence on discovering and manipulating her surroundings (autonomy, toddler stage) but when the incident happened her Reference:Fundamentals of Nursing by comfort zone became limited. Barbara Kozier, GlenoraErb, Audrey Berman &Shirlee Snyder (7th Edition page 957

Psychological health

Interpretation

Analysis
She is starting to learn to control her bladder and bowels. This is good on her developmental stage.

Sexuality-Patient X is a 2 During toddler stage, they develop years old female. Voluntary control to being able to walk with relatively and speak. They also learn to control their bladder and bowels. Reference:Fundamentals of Nursing by Barbara Kozier, GlenoraErb, Audrey Berman &Shirlee Snyder (8th Edition page 373) Family Coping PatternsAccording to his mother, they gather and have conversations whenever they encounter family problems. Family is a place where you can be yourself. This is where you are completely tension free and everyone is there to help you. Family encourages you when you are surrounded by problems. It helps you survive through tough times and bring joy and happiness into life. Article Source: http://EzineArticles.com/2330415

In terms of family coping patterns, the mother stated that when they are facing problems with the family, they are open and they talk together in order to cope or solve problems.

VII. PHYSICAL ASSESSMENT


Body Part I. Vital signs taken Normal Findings BP=90/60 mmHg Temp= 37- 37.4C CR= 120- 160 beats/ min Actual Findings BP= 90/60 mmHg Temp= 37.3C CR= 160 beats/ min Interpretation and Analysis All vital signs of the patient are within the normal range.

Body Part

Normal Findings

Actual Findings

Interpretation and Analysis

II. Head to Toe Examination


A. Integumentary Color Varies from light to deep brown ; from ruddy pink to light pink ; from yellow overtones to olive; generally uniform except in areas exposed to the sun ; areas of lighter pigmentation in dark skinned people Light to dark brown, olive Normal

Edema

No Edema

No edema seen

Body Part

Normal Findings

Actual Findings

Interpretation and Analysis

lesions

Freckles, some birthmarks, some flat and raises nevi; no abrasions or other lesions

No presence of any lesions

moisture Moisture in skin folds and axillae Temperature Moisture in skin folds and axillae Normal

Uniform within normal range

Warm body temperature

Body Part b. Hair evenness of growth over the scalp hair thickness or thinness hair texture and oiliness

Normal Findings

Actual Findings

Interpretation and Analysis

Evenly distributed hair

Evenly distributed hair

Normal

Thick hair

Thick hair

Normal

Silky, resilient hair

Fine to coarse, pliant

Normal

amount of body hair

Variable, no baldness Variable

Normal

Body Part B. Head a. Skull and Face

Normal Findings

Actual Findings

Interpretation and Analysis

size, shape and symmetry

Round

Has a head size that is proportionate to the body built; normocephalic.

Normal

nodules or masses and depressions

Smooth, uniform consistency; absence of nodules and masses

Has no nodules and masses noted and palpated

Normal

facial feature

Symmetrical, centered head position

Symmetrical, centered head position

Normal

Body Part
b. Eyes
edema eyebrows Hair distribution, alignment, skin quality and movement eyelashes evenness of distribution and direction of curl eyelids surface characteristics, position in relation to corned, ability and frequency of blinking

Normal Findings

Actual Findings

Interpretation and Analysis


Normal

No edema

No edema noted at the time of physical assessment

Hair evenly distributed; skin intact; eyebrows symmetrically aligned ;equal movement

Has well distributed and symmetrically aligned eyebrows; equal in movement and skin surrounding it is intact
Has eyelashes that are equally distributed, curled slightly outward Has intact skin and no discharges

Normal

Equally distributed, curled slightly outward

Normal

Skin intact; no discharge; no discoloration. Approximately 15 20 involuntary blinks per minute; bilateral blinking

Normal

lower conjuctival sac

Clear with tiny vessels visible

Pale

Normal

Body Part c. Ears auricles color, symmetry of size, position, texture, elasticity and areas of tenderness

Normal Findings

Actual Findings

Interpretation and Analysis Normal

Clear with tiny vessels visible

Has color same as facial skin, symmetrical auricle aligned with outer canthus of the eye, mobile, firm, not tender.

Color same as facial skin symmetrical, auricle aligned with outer canthus of eye .Motile, firm and not tender. Pinna recoils after it is folded

Pinna recoils after it is folded

Normal

Body Part d. Nose

Normal Findings

Actual Findings

Interpretation and Analysis

shape, size, color and flaring or discharge from the nares, tenderness, masses, displacement of bone and cartilage nasal septum between nasal chambers
patency of both nasal cavities

Symmetric and straight no discharge or tearing uniform color, not tender no lesions

Symmetrical, no deviations, discharge, tearing and lesions, uniform in color and not tender

Normal

Nasal septum intact and in the midline


Air moves freely as the client breathes through the nares

Has intact nasal septum and it is in the midline Air movement is not restricted on both nares

Normal

This is due to poor nutrition taken by the patient resulting to lack of iron.

Body Part C. Mouth and Oropharynx a. Lip and Buccal Mucosa symmetry of contour of color, texture, moisture, ability to purse lips D. Neck and Lymph Nodes neck muscles swelling , masses, tenderness, placement

Normal Findings

Actual Findings

Interpretation and Analysis

Uniform pink color, soft, moist, smooth, texture, symmetry of contour , can purse lips

Pink in color, smooth, moist, without lesions

Normal

Muscle equal in size, centerplacement , no masses and swelling.

Has muscles equal in size located at the center no masses, swelling.

Normal

Body Part

Normal Findings

Actual Findings

Interpretation and Analysis

E. thorax posterior shape ,symmetry, spinal alignment anterior breathing pattern Chest symmetric, spine vertically aligned Quiet and rhythmic, effortless respirations Has a chest that is symmetrical and vertically aligned Quiet and rhythmic, effortless respirations Normal

Normal

F. Abdomen skin integrity Has a skin that is Unblemished skin, uniform in color and uniform color, silver unblemished white striaeor surgical scars Flat, rounded or scaphoid, symmetric contour Flat , slightly rounded Normal

contour and symmetry

Body Part

Normal Findings

Actual Findings

Interpretation and Analysis

III. MUSCULOSKELETAL SYSTEM


A. Head Facial structure and muscle development Symmetrical structure and development of muscles Symmetrical structure and development of muscles

Normal

Temporomandibular joint (TMJ) function


B. Thorax Posture C. Neck ROM: flexion, extension, rotation, lateral bending

Can open mouth 2 inches

Can open mouth 2 inches

Normal

Erect

Erect

Normal

Full ROM: no pain

Full ROM: no pain

Normal

Body Part

Normal Findings

Actual Findings

Interpretation and Analysis Normal

D.

Spine Curves

Cervical concave; thoracic convex; lumbar concave

Has cervical, thoracic and lumbar concavity

Posture
ROM- flexion, lateral bending, rotation, extension E. Paravertebrals Muscle strength and tone Temperature Temp= 37.3C Sensation

Erect
Full ROM

Erect
Full ROM

Normal
Normal

Equally strong

Equally strong

Normal

Warm

Warm

Normal

Nontender

Nontender

Normal

Body Part F. Shoulder Muscle strength and tone

Normal Findings

Actual Findings

Interpretation and Analysis

Able to shrug shoulders against resistance Nontender

Able to shrug shoulders against resistance Nontender

Normal

Sensation

Normal

G. Upper extremities Shoulder, elbow, wrist hand and fingers Bone structure, bony prominences, muscle mass, joint structure and symmetry ROM

Bilaterally symmetrical

Bilaterally symmetrical

Normal

Full ROM

Full ROM

Normal

Body Part Arm Muscle strength and tone

Normal Findings

Actual Findings

Interpretation and Analysis

Can flex and extend arm against resistance

Can flex and extend arm against resistance

Normal

Hand Muscle strength H. Lower extremities Hip, knee, ankle, foot and toes Bone structure and bony landmarks; muscle mass

Grip is firm and equal

Gripping is firm; has equal muscle strength

Normal

Bilaterally symmetrical and equal

Bilaterally asymmetrical and unequal

Bilaterally asymmetrical of the thighs are due to swelling of the infected site (right thigh).

Full ROM
ROM Full ROM Limited ROM Decreased ROM is due to the pain located at the right thigh of the patient.

VIII. DIAGNOSTIC EXAMS


Hematology
FINDINGS Hemoglobin Mass NORMAL VALUE Male: 127-183 g/L Female: 110-138 g/L 0.37-54 RESULT N SIGNIFICANCE The hemoglobin mass is within the normal range. The hematocrit level of the patient is within the normal range.

Hemotocrit (HCT)

Leukocytes Count

4.5-10 x 109/L

The leukocytes count is within the normal range. The MCV is within the normal range.

Mean Corpuscular Volume (MCV)

Male:82-92 fL Female:78-91 fL

FINDINGS Mean Corpuscular Hemoglobin (MCH)

NORMAL VALUE 28-32 pg/cell

RESULT Decreased

SIGNIFICANCE The patient is anemic because the average mass of hemoglobin per red blood cell in a sample of blood is low. The patient is anemic because the measure of the concentration of hemoglobin in a given volume of packed red blood cells is low. The platelet count is within the normal range.

Mean Corpuscular Hemoglobin Concentration (MCHC)

32-38%

Decreased

Platelet Count (Plt)

150,000-400,000 /L

Differential Counts
FINDINGS NORMAL VALUE RESULT SIGNIFICANCE

Segmenters

0.50-0.70

The segmenters are within normal range.

Monocytes (mono)

0.00-0.07

Decreased

There in an increase number of monocytes that indsicates infection.


There is a decrease number of lymphocytes that protect our body from bacteria and viruses and that, it indicates low immune system.

Lymphocytes

0.20-0.40

Decreased

IX. COURSE IN THE WARD


February 19, 2012 The patient was brought to Philippine Orthopedic Center last February 19, 2012 at 2:10 in the morning because of pain, swelling, tenderness on the right leg. She was admitted in the Emergency Room carried by her mother and was seen by Dr. Chua III. Diagnostic examinations including CBC, ESR, CRP and Blood Typing were made. Therapeutics for the client includes Oxacillin 500mg IV (ANST) now then 250mg IV q6 and Paracetamol 250mg/5ml 4ml q4 for pain and temp above 37.8. At 10 in the morning IVF D5 0.5 NACL 500ml was hooked on her right arm at KVO.

February 20, 2012 At 4 pm, the patients IVF was removed and change with the same D5 0.3 NACL 500ml at KVO.
February 21, 2012 At 9:40 am, the patients IVF was removed and change with the same D5 0.3 NACL 500ml at KVO.

X. ANATOMY AND PATHOPHYSIOLOGY


The lower leg is comprised

of two bones, the tibia and the smaller fibula. The thigh bone, or femur, is the large upper leg bone that connects the lower leg bones (knee joint) to the pelvic bone (hip joint).

The gluteus medius (or glutusmedius), one of the three gluteal muscles, is a broad, thick, radiating muscle, situated on the outer surface of the pelvis.
The gluteus maximus is the

largest and most superficial of the three gluteal muscles. It makes up a large portion of the shape and appearance of the buttocks. of the posterior (the back) thigh. Both heads of the biceps femoris perform knee flexion.

The biceps femoris is a muscle

The gracilis (Latin for "slender") is the most superficial muscle on the medial side of the thigh. It is thin and flattened, broad above, narrow and tapering below. The muscle adducts and flexes the hip as above, and also aids in flexion of the knee.
The Sartorius muscle the longest muscle in the human body is a long thin muscle that runs down the length of the thigh. Assists in flexing, abduction and lateral rotation of hip, and flexion of knee.

Plantaris is a vestigial structure and one of the superficial muscles of the posterior crural compartment of the leg. It flex the knee joint.
Gastrocnemius muscleis a

very powerful superficial pennate muscle that is in the back part of the lower leg. It is involved in standing, walking, running and jumping.

1.

2.

XI. ECOLOGIC MODEL


Pyomyositis is a bacterial infection of the skeletal muscles, which are

attached directly to the bones in the human body. It is usually caused by the bacteria Staphylococcus aureus, the same bacteria that causes pneumonia and toxic shock syndrome.

INTERPRETATION: The Model shows that the patient, which is young had a fall because she slipped to their floor twice in the same day. First, is inside their comfort room and second, is after she went out of the comfort room and the flooring of their house are tiled, which is more prone to slip. And so, it causes a trauma to the patients muscle (at the right thigh) and a damage to the muscle causes the immune system to weaken, allowing the causative agent a place to take root. Most people have at least some Staphylococcus aureus in their bodies at some point in their lives.

RECOMMENDATION: The abscesses within the muscle must be drained surgically (not all patient require surgery if there is no abscess). Antibiotics should be given according to doctors order and watch out for other complications like toxic shock syndrome, and sepsis which is life threatening. If fever persist, apply a Tepid sponge bath and Give an antipyretic medication with doctors order. Consume foods rich in Vitamin C such as fruits for boosting of immunity, protein such as meats for tissue repair, and calcium or phosphorus such as milk and other dairy products for bone growth.

XII. DRUG STUDY

XIII. PROBLEM LIST


Date identify February 22, 2012 Wednesday Nursing diagnosis Impaired Tissue Integrity Imbalanced Nutrition: Less than body requirements Bowel Incontinence Impaired Physical Mobility Sleep Deprivation Acute Pain Fear

XIV. PRIORITOZATION
Nursing Problem
1. ACUTE PAIN related to trauma at right thigh area

Cues
Subjective: -Kapag nakakaramdam siya ng sakit sa hita niya, umiiyak na lang siya, as verbalized by the mother. Objective: -The client cries whenever feels uncomfortable and/or in pain.
Subjective: -Namamaga yung kanang hita niya, as verbalized by the mother. Objective: -The right thigh swells. Subjective: -Mahina na siyang kumain nung nandito kami sa hospital. Puro na lang siya biscuit, as verbalized by the mother. Objective:

Justification
Identified as the first Nursing Diagnosis as it is a present problem related to the medical diagnosis and one of the initial signs of Pyomyositis. It is a sudden onset anticipated pain arising from tissue damage. And prioritized through ABCs of lifeCirculation.
Due to damage of the mucous membrane which results to swelling and formation of abscess.

2. IMPAIRED TISSUE INTEGRITY related to presence of swelling abscess at the right thigh

3. IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS related to lost appetite

Due to insufficient intake of foods that results to lack of nutrients to meet metabolic needs

Nursing Problem
4. ALTERATIONS IN BOWEL ELIMINATION related to present condition/diagnosis

Cues
Subjective: -Nako. Hindi pa nga siya tumatae kahit isang beses mula nung dumating kami dito sa hospital, as verbalized by the mother. Objective: -NONE-

Justification
Due to change of normal bowel movements resulting from medical diagnosis and hospitalization

5.

SLEEP PATTERN DISTURBANCE related to pain

Subjective: -Hindi maayos tulog niya. Madalas gabi na siya natutulog tapos magigising ng madaling araw dahil sumasakit hita niya. Minsan naman irritable siya, as verbalized by the mother. Objective: -The client is easily irritated when move by her mother

Due to prolonged discomfort

Nursing Problem 6. IMPAIRED PHYSICAL MOBILITY related to presence of swelling and abscess at the right thigh

Cues Subjective: -Madalas na lang siyang nakahiga. Minsan umuupo pa naglalaro nito (barney), as verbalized by the mother. Objective: -The client stays at the bed almost the whole time when the interview was held

Justification Due to limited movement of one of the extremities-right thigh

7. ANXIETY related to present condition

Subjective: -Nung minsan ngang niloko ko siya na uuwi na kami, sagot niya sa kin ayaw niya, baka daw madulas siya ulit, as verbalized by the mother. Objective: -NONE-

Due to cognition of possible repetition of the same situation that causes the present condition that is recognized as danger

XV. NURSING CARE PLAN


Client: A.L.R. Age: 2 years old Gender: Female Medical Diagnosis: Pyomyositis Priority #1: Acute Pain related to trauma on the right thigh area

ASSESSMENT

NURSING DIAGNOSIS

OBJECTIVES

NSG. INTERVENTION

RATIONALE

EXPECTED OUTCOME

Subjective: -Kapag nakakaramda m siya ng sakit sa hita niya, umiiyak na lang siya, as verbalized by the mother.
Objective: -The client cries whenever feels uncomfortable and/or in pain.

Acute Pain related to trauma on the right thigh area

Short-Term Goal: Client will manifest a decrease in pain scale from 5/10 to a manageable level of 2/10 within 3-5 hours

-Assess, report, -Reduce and record possible signs and complications. symptoms and reactions to treatment.
-Assess the clients pain scale and perception

-To identify the intensity, onset, duration, and quality of the Long-Term pain Goal: Client -Review factors -Helpful in will exhibit no that aggravate establishing signs or or alleviate diagnosis and symptoms of pain. treatment acute pain with needs. 3-5 days -Encourage -To identify verbal report the during and effectiveness of after the interventions nursing interventions

After a series of nursing intervention, the client will able to: -No evidence of any signs and symptoms of pain and discomfort -Decrease in pain scale measurement (pain is relieved or controlled) -Positive verbal report from clients evaluation

ASSESSMENT

NURSING DIAGNOSIS

OBJECTIVES

NSG. INTERVENTION

RATIONALE

EXPECTED OUTCOME

-Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain. -Reduce or eliminate factors that precipitate or increase pain experience (e.g., fear, fatigue, and lack of knowledge).

-Pain is a subjective experience and must be described by the client in order to plan effective treatment

-Personal factors can influence pain and pain tolerance. Factors that may be precipitating or augmenting pain should be reduced or eliminated to enhance the overall pain management program. -Evaluation affects the ability to rest and relax

-Assist patient to find position for relief

ASSESSMENT

NURSING DIAGNOSIS

OBJECTIVES

NSG. INTERVENTION

RATIONALE

EXPECTED OUTCOME

-Teach the use of nonpharmacologic techniques (e.g., relaxation, music therapy, distraction, and massage) before, after, and if possible during painful activities; before pain occurs or increases; and along with other pain relief measures. -Elicit behaviors that are conditioned to produce relaxation, such as deep breathing, yawning, abdominal breathing, or peaceful imaging. -Provide optimal pain relief with prescribed analgesics

-The use of noninvasive pain relief measures can increase the re- lease of endorphins and enhance the therapeutic effects of pain relief medications

-Relaxation techniques help reduce skeletal muscle tension, which will reduce the intensity of the pain

-To reduce pain

ASSESSME NURSING NT DIAGNOSIS

OBJECTI VES

NSG. INTERVENTION

RATIONALE

EXPECTED OUTCOME

Initiate and maintain extremity mobilization such as ambulation, physical therapy, or continuous passive motion device.

Increases circulation to affected muscles. Minimizes joint stiffness; relieves muscle spasm related to disuse.

Evaluate the effectiveness of the pain control measures used through ongoing assessment of pain experience.

Most common reason for unrelieved pain is failure to routinely assess pain and pain relief. Many clients silently tolerate pain if not specifically asked about it

XVI. DISCHARGE PLAN


Medications. Compliance on the prescribed

take home medications with the right generic name, right dosage and preparation, right route and time of administration. Exercise. Active ROM but prevent massaging nor any other traumatic pressure on the affected area.
Treatment.Compliance on the prescribed treatment.Cover the affected area Health teachings.Emphasized proper handwashing and encouraged non

with a wound gauzeaspt has underwent surgery. Instructed proper wound care. pharmacological measures for fracture once re encountered (Rest, Ice or Cold Compress,Compression bandage,Elevate affected part)

Outpatient follow up visit. Attend on the scheduled outpatient follow up visit.

Diet.Consume foods rich in VitaminC such as fruits for boosting of immunity,

protein such as meats for tissue repair, and calcium or phosphorus such as milk and other dairy products for bone growth.

Spirituality. Encourage the mother to teach the client on how to strengthen her

faith and encourage to attend mass or religious activity.