CASE PRESENTATION

GLOBAL CITY INNOVATIVE COLLEGE College of Nursing and International Health Studies Fort Bonifacio, Taguig City, Metro Manila A Study of Synovitis Las Pias Medical Center In Partial Fulfillment of the Requirements In Related Learning Experience NCM 102 Presented to: Maam Ausin, R.N January 27, 2010 Presented by: Group # 1 Cluster B N211

General Objectives:
To gain knowledge and to further understand the nature and extent of the disease so as to prepare and arm ourselves with knowledge whenever we encounter the same case in the future. And also to have a clear and better understanding about synovitis particularly on its diseases process, treatment, diagnostic exam, preventive measures and nursing management.

Specific Objectives:
To know the latest facts and keep our self updated with the newest information about the disease. To be familiar with the disease and medical used that may help us in doing health teaching with our client. To let the public be aware with the manifestation and complications brought by the diseases.

Cellulitis
Cellulitis is a diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin. Cellulitis can be caused by normal skin flora or by exogenous bacteria, and often occurs where the skin has previously been broken: cracks in the skin, cuts, blisters, burns, insect bites, surgical wounds, or sites of intravenous catheter insertion. Skin on the face or lower legs is most commonly affected by this infection, though cellulitis can occur on any part of the body. The mainstay of therapy remains treatment with appropriate antibiotics. Erysipelas is the term used for a more superficial infection of the dermis and upper subcutaneous layer that presents clinically with a well defined edge. Erysipelas and cellulitis often coexist, so it is often difficult to make a distinction between the two. Cellulitis is unrelated (except etymologically) to cellulite, a cosmetic condition featuring dimpling of the skin.

Causes
Cellulitis is caused by a type of bacteria entering the skin, usually by way of a cut, abrasion, or break in the skin. This break does not need to be visible. Group A Streptococcus and Staphylococcus are the most common of these bacteria, which are part of the normal flora of the skin but cause no actual infection while on the skin's outer surface. Predisposing conditions for cellulitis include insect bite, blistering, animal bite, tattoos, pruritic skin rash, recent surgery, athlete's foot, dry skin, eczema, injecting drugs (especially subcutaneous or intramuscular injection or where an attempted IV injection "misses" or blows the vein), pregnancy, diabetes and obesity, which can affect circulation, as well as burns and boils, though there is debate as to whether minor foot lesions contribute.

Risk Factors
The elderly and those with immunodeficiency (a weakened immune system) are especially vulnerable to contracting cellulitis. Diabetics are more susceptible to cellulitis than the general population because of impairment of the immune system; they are especially prone to cellulitis in the feet because the disease causes impairment of blood circulation in the legs leading to diabetic foot/foot ulcers. Poor control of blood glucose levels allows bacteria to grow more rapidly in the affected tissue and facilitates rapid progression if the infection enters the bloodstream. Neural degeneration in diabetes means these ulcers may not be painful and thus often become infected. Immunosuppressive drugs, and other illnesses or infections that weaken the immune system are also factors that make infection more likely. Chickenpox and shingles often result in blisters that break open, providing a gap in the skin through which bacteria can enter. Lymphedema, which causes swelling on the arms and/or legs, can also put an individual at risk. Diseases that affect blood circulation in the legs and feet, such as chronic venous insufficiency and varicose veins, are also risk factors for cellulitis. Cellulitis is also extremely prevalent among dense populations sharing hygiene facilities and common living quarters, such as military installations, college dormitories, and homeless shelters.

Diagnosis
Cellulitis is most often a clinical diagnosis, and local cultures do not always identify the causative organism. Blood cultures usually are positive only if the patient develops generalized sepsis. Conditions that may resemble cellulitis include deep vein thrombosis, which can be diagnosed with a compression leg ultrasound, and stasis dermatitis, which is inflammation of the skin from poor blood flow. There have been many cases where Lyme disease has been misdiagnosed as staph- or strep-induced cellulitis. Because the characteristic bullseye rash does not always appear in patients infected with Lyme disease, the similar set of symptoms may be misdiagnosed as cellulitis. Standard treatments for cellulitis are not sufficient for curing Lyme disease. The only way to rule out Lyme disease is with a blood test, which is recommended during warm months in areas where the disease is endemic.

Incubation
Cellulitis can develop in as little as 24 hours or can take days to develop.

Duration
In many cases, cellulitis takes less than a week to disappear with antibiotic therapy. However, it can take months to resolve completely in more serious cases and can result in severe debility or even death if untreated. If it is not properly treated, it may appear to improve but can resurface months or even years later.

Treatment
Treatment consists of resting the affected limb or area, cleaning the wound site if present (with debridement of dead tissue if necessary) and treatment with oral antibiotics, except in severe cases, which may require admission and intravenous (IV) therapy. Flucloxacillin monotherapy (to cover staphylococcal infection) is often sufficient in mild cellulitis, but in more moderate cases or where streptococcal infection is suspected then usually combined with oral phenoxymethylpenicillin or intravenous benzylpenicillin, or ampicillin/amoxicillin (e.g. co-amoxiclav in the UK). Pain relief is also often prescribed, but excessive pain should always be considered relevant, as it is a symptom of necrotising fasciitis, which requires emergency surgical attention. As in other maladies characterized by wounds or tissue destruction, hyperbaric oxygen treatment can be a valuable adjunctive therapy, but is not widely available.

Prevention
Any wound should be cleaned and dressed appropriately. Changing bandages daily or when they become wet or dirty will reduce the risk of contracting cellulitis. Medical advice should be sought for any wounds that are deep or dirty and when there is concern about retained foreign bodies.

Signs and Symptoms

Cellulitis usually begins as a small area of pain and redness on the skin. This area spreads to surrounding tissues, resulting in the typical signs of inflammation - redness, swelling, warmth, and pain. A person with cellulitis can also develop fever and/or swollen lymph nodes in the area of the infection.

Synovitis
Synovitis is the medical term for inflammation of the synovial membrane. This membrane lines joints which possess cavities, known as synovial joints. The condition is usually painful, particularly when the joint is moved. The joint usually swells due to synovial fluid collection. Synovitis may occur in association with arthritis as well as lupus, gout, and other conditions. Synovitis is more commonly found in rheumatoid arthritis than in other forms of arthritis, and can thus serve as a distinguishing factor, although it can present to a lesser degree in osteoarthritis. Long term occurrence of synovitis can result in degeneration of the joint.

Signs and Symptoms Synovitis causes joint tenderness or pain, swelling and hard lumps, called nodules. When associated with rheumatoid arthritis, swelling is a better indicator than tenderness
Treatment Synovitis symptoms can be treated by with anti-inflammatory drugs such as NSAIDs. Specific treatment depends on the underlying cause of the synovitis.

Nursing Health History

Personal Data Name: Patient X Age: 28 years old Sex: Male Nationality: Filipino Civil Status: Single Job: Call Center Agent Religion: Catholic Sources of Health Care Finance: Maxi care and Phil health Date of admission: January 12, 2010 Time of admission: 1:24 p.m.

Chief Complaint and Clinical Impression

Chief complaint: Swelling R knee Clinical impression: Acute Bacterial

History of Present Illness

According to my interview with our patient the pain on his right knee started last week to be exact he felt it last January 12, 2010 and according to him it was the first time ever that he felt that in his whole entire life up to the present. He was just having the usual everyday stretching of the knee and all of a sudden felt the pain with the pain scale of 10, so he decided to be brought to the hospital for check up. He actually decided to have a check up regarding his sore eyes and sore throat as well during that time but because of the pain he decided to consult what was the pain all about so he was referred to an ortho doctor there it was diagnosed that probably secondary to septic arthritis and or uric acid arthritis. He was really bothered about the pain that he was feeling during that time. A minor operation was done called Arthrocentitis (aspirate) then medications were given after the surgery and there with our assessment the pain scale went down to three. He was able to get those bacteria from his sore throat that triggered the pain on his right knee.

Past Medical History

Allergies: No allergy Vaccine: Complete immunization Accident/s: No previous accident Medicine: No previous medicines Previous hospitalization: Acute bronchitis 2 or 3 years ago.

Family History of Illness

The family history illness is hypertension both sides.

Activity Exercise Pattern

Prior to admission patient X had sore eyes and ore throat he thought that it was just because of being tired on work, he occasionally feel dizzy, light headed and headaches it happened mostly at night and in the morning when he wakes up.

Sleep-rest Pattern
Prior to illness patient X admitted that he just had 5-6 hours of sleep a day because he sometimes work overtime on being a work. However, he makes a point to exercise and use the gym of establishment hes been working for. He doesnt even have time to take a nap in a day. But during hospitalization he believed that he already have time to have enough sleep, he also finds time to take a nap in a day, in spite of the illness patient X has time to rest by reading, or talking with family and friends. Patient X usually sleep and have rest on their house only after his work.

Cognitive Perceptual Pattern

Patient X is well oriented and mentally fit evidenced by his cooperative attitude during the interview. He was able to comprehend the questions and answer them logically. Patient X has an intact short term memory, he also admitted that now, knowing his situation made him feel anxious.

Self perception and Self Concept Pattern

Patient X sees himself as ever determined thats why hes really working hard for his family, he has a positive outlook about life and he always believes that he can still do things that he normally do before having the illness. He believes that he can still do hes plans for him and family after his medications. Mr. X hopes that his present condition will not affect his lifestyle before that he can still continue to be a provider for his family.

Role Relationship Pattern

Patient X admitted that his family is not that ideal, being the only one working for the family he consider himself as the breadwinner. Patient X lives with his parents he considers his place as safe home environment. He doesnt have health insurance but believes that his finances is just enough for the needs of his family. Now that patient X is having an illness his family serves as his inspiration, he is also glad that his partner has always been supportive in spite the fact that he is not on work already for the preparation of his treatment. His family always made him feel that he is still their provider, which is really helping him and inspiring him to be better, he once told that being in the hospital doesnt stop him from being a great son.

Functional Health Patterns

Patient X is a hardworking person thats why he was able to give what his family needs. In their community hazard, patient X was living near the main road, air and noise pollution affects them but the patient interpreted that their place is safe.

Health Perception and Health Management Pattern

Patient X is aware that his present condition is something that needs an immediate medication, he is also aware that the symptoms that he is experiencing, is not normal. He admitted that he is afraid about it, thats why he decided to seek help and medication by hospitalization and he is always willing to undergo treatment and rehabilitations to have a healthy and normal life again.

The patient doesnt primary health care providers. His last check up was when he is still young he already forgot when it was.
Before having a work in manila he smokes, he is still an occasional alcohol drinker he drinks 4 bottles of beer in a week he said that he just drinks if there is an occasion.

Nutritional and Metabolic Pattern

Feeding daily Dressing - daily Grooming - daily Toileting daily 3x a day

Elimination Pattern
He believes that his pattern of urination and bowel elimination is normal.

Sexuality Reproductive Pattern

Mr. X admitted that he and his partner rarely have sexual activity anymore because his job takes most of his time.

Coping Stress Tolerance Pattern

Mr. X views problems as something normal that should be faced; this has been his perception on problems even before when he knew that he has a heart problem. Now having an illness, he said that the support of his family is the main reason that he is coping with his hospitalization, he believes that having an illness will not end his being the family provider but instead, made him feel that he is well love and appreciated by his family. Mr. X admitted that having an illness is considered to be his main stressor now.

Value Belief Pattern

Being a Catholic Mr. X has a strong faith in God. He believes that he will not give you problems that you cannot solve. His present condition made his faith stronger and made him closer to God. He believes that God has a purpose behind everything and he is willing to accept Gods will.

Discharge Plan
Medications: Oxacillin Kalium Durule Natravox Nexium Arcoxia Ciprofloxacin Colchicine

Physical assessment
Part of the Body
Head (Skull, scalp, hair) Observe the size, shape and contour of the skull Inspection Palpation Generally round, Normocephalic , with prominences no massess , no in the frontal and tenderness. occipital area. (Normocephalic). No tenderness noted upon palpation. Lighter in color, - Lighter in color oily, no scars, no than the lice complexion - Can be moist or oily - No scars noted - Free from lice, nits and dandruff

TECHNIQUE

Normal findings

Actual findings

Observe scalp in Inspection Palpation several areas by separating the hair at various locations; inquire about any injuries. Note presence of lice, nits, dandruff or lesions.

Palpate the head by running the pads of the fingers over the entire surface of skull; inquire about tenderness upon doing so.

Inspection Palpation

- No lesions should No lesions and be noted. tenderness - No tenderness no masses on palpation

Observe and feel the hair condition.

Inspection Palpation

Can be black, brown or burgundy depending on the race Evenly distributed covers the whole scalp Maybe thick or thin, coarse or smooth Neither brittle nor dry
Capillary refill, color, texture

black hair, no lesions no lice, evenly distributed

Nails

Inspection , palpation

Pinkish nail beds Convex, Smooth texture, Capillary refill is 1-2 seconds

Face Facial features

Inspection, palpation Symmetrical or slightly asymmetrical facial features

Symmetrica

Eyebrows, Eyes, Eyelashes Hair distribution, alignment, skin quality and movement Equal, and inline

Inspection

Symmetrical and in Symmetrical line with each other Maybe black, brown or blond depending on race Evenly distributed Evenly placed and linline with each other Non protruding Equal palpebral fissureaced and Inline and non protruding

Inspection

Evenness of distribution and direction of curl

Inspection

Brown, evenly distributed

Eye lids and Lacrimal gland Inspect the eyelids for position and symmetry

Inspection Palpation

Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open. Meets completely when eyes are closed. Symmetrical Pinkish or red in color

Able to close the eyes and has the ability to blink.

Color, texture, and the presence of lesions in the conjunctiva Iris Shape and color

Inspection Palpation

Pinkish, smooth in texture

Inspection

Anterior chamber is transparent; no noted visible materials Equally round

Dark brown in color; transparent amterior chamber

Pupils Color, shape and symmetry

Inspection

Equal in size

Light reaction and accomodation

Inspection

Constrict briskly/ sluggishly when light is directed to the eye When looking straight ahead, client can see objects in the periphery

Dilates when looking at far objects and constricts when looking at near objects Can see objects periphery

Visual Acuity Peripheral visual fields

Inspection

Ears Auricles Color, symmetry of size and position

Inspection

Color same as facial Same color as the skin; symmetrical facial skin; tip of auricle aligned at the outer canthus of the eye, Symmetric and proportion to the head Smooth, even in color, and consistent with the rest of the skin (-) pain, edema, lesions

. Texture elasticity and areas of tenderness

Palpation

Firm and not tender pinna recoils after it is folded

No tenderness, smooth in texture

Hearing acuity Clients response to normal voice tones

Nose and Sinuses

Inspection

Normal voice tones audible

Can hear normal volume tones or words

Color is consistent with the rest of the skin (-) swelling (-) pain and edema (-) discharges

Inspection, palpation Shape, size, color, redness, swelling, discharges

Throat Color, moisture, texture and the presence of lesions

Inspection

Color, texture, Temperature, moisture, skin turgor, hair distribution

No lesions, No discharge, No Masses, Color is consistent with the rest of the skin (-) lesions, masses (+) pain, tenderness

Mouth

Inspection, palpation smooth, moist, and grayish pink

Lips are pink, moist and smooth. The tongue and mucus membranes are pink, moist and free of swelling or lesions. Patient has complete set of teeth. No cavity and dental restoration has been noted. Gums are pink. Tonsils are pink and symmetric in size

Thorax and Lungs

Inspection, palpation Symmetry, Color, shape, presence of barrel, funnel, or pigeon test

Chest is symmetrical, Color is consistent with the rest of the skin.

Head and Neck

Inspection, Palpation

Normocephalic, with prominences in the frontal and occipital area. No tenderness noted upon palpation. Short black fine hair are evenly distributed, no dandruff, knits and lice. Negative for wounds, scars and lesions, Neck is straight, no visible mass or lumps and is symmetric and with full range of motion and no neck vein distention Extremities are symmetrical. Reflex, muscle contraction and joint range of motion are present. Patient able to raise her hands, put side to side, flex and able to

Back and Extremities

Inspection, palpation

Anatomy and Physiology

Knee
The knee joint joins the thigh with the leg and consists of two articulations: one between the femur and tibia, and one between the femur and patella.It is the largest and most complicated joint in the human body.The knee is a mobile trochoginglymus (i.e. a pivotal hinge joint),which permits flexion and extension as well as a slight medial and lateral rotation. Since in humans the knee supports nearly the whole weight of the body, it is the joint most vulnerable both to acute injury and the development of osteoarthritis.

Human Anatomy
The knee is a complex, compound, condyloid variety of a synovial joint. It actually comprises three functional compartments: the femoropatellar articulation consists of the patella, or "kneecap", and the patellar groove on the front of the femur through which it slides; and the medial and lateral femorotibial articulations linking the femur, or thigh bone, with the tibia, the main bone of the lower leg.The joint is bathed in synovial fluid which is contained inside the synovial membrane called the joint capsule. Upon birth, a baby will not have a conventional knee cap, but a growth formed of cartilage. In human females this turns to a normal bone knee cap by the age of 3, in males the age of 5.

Articular bodies
The articular bodies of the femur are its lateral and medial condyles. These diverge slightly distally and posteriorly, with the lateral condyle being wider in front than at the back while the medial condyle is of more constant width.The radius of the condyles' curvature in the sagittal plane becomes smaller toward the back. This diminishing radius produces a series of involute midpoints (i.e. located on a spiral). The resulting series of transverse axes permit the sliding and rolling motion in the flexing knee while ensuring the collateral ligaments are sufficiently lax to permit the rotation associated with the curvature of the medial condyle about a vertical axis.The pair of tibial condyles are separated by the intercondylar eminence composed of a lateral and a medial tubercle The patella is inserted into the thin anterior wall of the joint capsule.On its posterior surface is a lateral and a medial articular surface, both of which communicate with the patellar surface which unites the two femoral condyles on the anterior side of the bone's distal end. A common disease found in the knee is "Tartas".

Articular capsule
Lateral and posterior aspects of right knee Main article: Articular capsule of the knee joint The articular capsule has a synovial and a fibrous membrane separated by fatty deposits. Anteriorly, the synovial membrane is attached on the margin of the cartilage both on the femur and the tibia, but on the femur, the suprapatellar bursa or recess extends the joint space proximally. Behind, the synovial membrane is attached to the margins of the two femoral condyles which produces two extensions similar to the anterior recess. Between these two extensions, the synovial membrane passes in front of the two cruciate ligaments at the center of the joint, thus forming a pocket direct inward.

Bursae
Main article: Bursae of the knee joint Numerous bursae surround the knee joint. The largest communicative bursa is the suprapatellar bursa described above. Four considerably smaller bursae are located on the back of the knee. Two non-communicative bursae are located in front of the patella and below the patellar tendon, and others are sometimes present.

Cartilage
Cartilage is a thin, elastic tissue that protects the bone and makes certain that the joint surfaces can slide easily over each other. Cartilage ensures supple knee movement. There are two types of joint cartilage in the knees: fibrous cartilage( the meniscus) and hyaline cartilage. Fibrous cartilage has tensile strength and can resist pressure. Hyaline cartilage covers the surface along which the joints move. Cartilage will wear over the years. Cartilage has a very limited capacity for self-restoration. The newly formed tissue will generally consist for a large part of fibrous cartilage of lesser quality than the original hyaline cartilage. As a result, new cracks and tears will form in the cartilage over time.

Menisci
The articular disks of the knee-joint are called menisci because they only partly divide the joint space.These two disks, the medial meniscus and the lateral meniscus, consist of connective tissue with extensive collagen fibers containing cartilage-like cells. Strong fibers run along the menisci from one attachment to the other, while weaker radial fibers are interlaced with the former. The menisci are flattened at the center of the knee joint, fused with the synovial membrane laterally, and can move over the tibial surface. The menisci serve to protect the ends of the bones from rubbing on each other and to effectively deepen the tibial sockets into which the femur attaches. They also play a role in shock absorption, and may be cracked, or torn, when the knee is forcefully rotated and/or bent.

Ligaments
The ligaments surrounding the knee joint offer stability by limiting movements and, together with several menisci and bursae, protects the articular capsule.

Intracapsular
The knee is stabilized by a pair of cruciate ligaments. The anterior cruciate ligament (ACL) stretches from the lateral condyle of femur to the anterior intercondylar area The ACL is critically important because it prevents the tibia from being pushed too far anterior relative to the femur. It is often torn during twisting or bending of the knee. The posterior cruciate ligament (PCL) stretches from medial condyle of femur to the posterior intercondylar area. Injury to this ligament is uncommon but can occur as a direct result of forced trauma to the ligament. This ligament prevents posterior displacement of the tibia relative to the femur. The transverse ligament stretches from the lateral meniscus to the medial meniscus. It passes in front of the menisci. Is divided into several strips in 10% of cases.The two menisci are attached to each others anteriorly by the ligament.The posterior and anterior meniscofemoral ligaments stretch from posterior horn of lateral meniscus to the medial femoral condyle. They pass posteriorly behind the posterior cruciate ligament. The posterior meniscofemoral ligament is more commonly present (30%); both ligaments are present less often. The meniscotibial ligaments (or "coronary") stretches from inferior edges of the mensici to the periphery of the tibial plateaus.

Extracapsular
The patellar ligament connects the patella to the tuberosity of the tibia. It is also occasionally called the patellar tendon because there is no definite separation between the quadriceps tendon (which surrounds the patella) and the area connecting the patella to the tibia. This very strong ligament helps give the patella its mechanical leverage and also functions as a cap for the condyles of the femur. Laterally and medially to the patellar ligament the lateral and medial patellar retinacula connect fibers from the vasti lateralis and medialis muscles to the tibia. Some fibers from the iliotibial tract radiates into the lateral retinaculum and the medial retinaculum receives some transverse fibers arising on the medial femoral epicondyle. The medial collateral ligament (MCL a.k.a. "tibial") stretches from the medial epicondyle of the femur to the medial tibial condyle. It is composed of three groups of fibers, one stretching between the two bones, and two fused with the medial meniscus. The MCL is partly covered by the pes anserinus and the tendon of the semimembranosus passes under it. It protects the medial side of the knee from being bent open by a stress applied to the lateral side of the knee (a valgus force). The lateral collateral ligament (LCL a.k.a. "fibular") stretches from the lateral epicondyle of the femur to the head of fibula. It is separated from both the joint capsule or the lateral meniscus.. It protects the lateral side from an inside bending force (a varus force). Lastly, there are two ligaments on the dorsal side of the knee. The oblique popliteal ligament is a radiation of the tendon of the semimembranosus on the medial side, from where it is direct laterally and proximally. The arcuate popliteal ligament originates on the apex of the head of the fibula to stretch proximally, crosses the tendon of the popliteus muscle, and passes into the capsule.

Movements
The knee permits flexion and extension about a virtually transversal axis, as well as a slight medial and lateral rotation about the axis of the lower leg in the flexed position. The knee joint is called "mobile" because the femur and menisci move over the tibia during rotation, while the femur rolls and glides over the menisci during extensionflexion.The center of the transverse axis of the extension/flexion movements is located where both collateral ligaments and both cruciate ligaments intersect. This center moves upward and backward during flexion, while the distance between the center and the articular surfaces of the femur changes dynamically with the decreasing curvature of the femoral condyles. The total range of motion is dependent of several parameters such as soft-tissue restraints, active insufficiency, and hamstring tightness.

Extended position
With the knee extended both the lateral and medial collateral ligaments, as well as the anterior part of the anterior cruciate ligament, are taut. During extension, the femoral condyles glide into a position which causes the complete unfolding of the tibial collateral ligament. During the last 10 of extension, an obligatory terminal rotation is triggered in which the knee is rotated medially 5. The final rotation is produced by a lateral rotation of the tibia in the non-weight-bearing leg, and by a medial rotation of the femur in the weight-bearing leg. This terminal rotation is made possible by the shape of the medial femoral condyle, assisted by the iliotibial tract and is caused by the stretching of the anterior cruciate ligament. Both cruciate ligaments are slightly unwinded and both lateral ligaments become taut

Flexed position
In the flexed position, the collateral ligaments are relaxed while the cruciate ligaments are taut. Rotation is controlled by the twisted cruciate ligaments; the two ligaments get twisted around each other during medial rotation of the tibia which reduces the amount of rotation possible while they become unwounded during lateral rotation of the tibia. Because of the oblique position of the cruciate ligaments at least a part of one of them is always tense and these ligaments control the joint as the collateral ligaments are relaxed. Furthermore, the dorsal fibers of the tibial collateral ligament become tensed during extreme medial rotation and the ligament also reduces the lateral rotation to 45-60.

 Is a minor surgical procedure also called joint aspiration A procedure used to obtain joint fluid for analysis of cause of joint swelling or arthritis Helpful in relieving joint swelling and pain Removal of joint fluid that is inflamed can also remove WBC within that are sources of enzymes that are destructive t the joint.

 To find out reasons why a joint is painful, swollen, or fluid-filled To drain fluid out f a swollen joint to reduce pain and increase ability to move the joint To diagnose the specific type of arthritis occurring within a joint To confirm a diagnosis of infection in the joint To check for crystals in the joint fluid (sign

 Diagnostic indications
Unexplained arthritis with synovial effusion Suggestion of an infected joint Suspicion of crystal-induced arthritis Evaluation of therapeutic response in septic arthritis

Therapeutic indications
Drainage of septic joint Relief of elevated intra-articular pressure Injection of medications

 Severe coagulopathy Severe thrombocytopenia Overlying cellulitis

 Alcohol sponges Iodinated solution and surgical soap Gauze Hemostat Ethyl chloride Sterile gloves and drapes

18-gauge needle Sterile 20-mL syringes Blood collection tubes Anaerobic transport media Trypticase soy broth for most bacteria 1% Lidocaine

 Patients may be asked to shave the joint and the area around prior to have an arthrocentesis. The area of the joint being aspirated will be cleaned by a nurse prior to the procedure. Patients taking blood thinners should consult their physician because they may need to adjust their dosage or refrain from these medications for a few days before

 The patient is supine on the table with the knee extended (some physicians prefer that the knee be bent to 90 degrees). The knee is examined to determine the amount of joint fluid present and to check for overlying cellulitis or coexisting pathology in the joint or surrounding tissues.

 The superior lateral aspect of the patella is palpated. The skin is marked with a pen, one fingerbreadth above and one fingerbreadth lateral to this site. This location provides the most direct access to the synovium. The skin is washed with povidone-iodine solution. A 21-gauge, 1-inch needle is attached to a 5- to 20-mL syringe, depending on the anticipated amount of

 The needle is inserted through stretched skin. The needle is directed at a 45degree angle distally and 45 degrees into the knee, tilted below the patella. Once the needle has been inserted 1 to inches, aspiration is performed, and the syringe should fill with fluid. Using the nondominant hand to compress the opposite side of the joint or the patella may aid in arthrocentesis.

 Once the syringe has filled, a hemostat can be placed on the hub of the needle. With the needle stabilized with the hemostat, the syringe can be disconnected and the fluid sent for studies. A syringe filled with corticosteroid medication can then be attached to the needle.

 For injection, use betamethasone (Celestone, 6 mg per mL), 1 mL, mixed with 3 to 5 mL of 1 percent lidocaine. Alternately, methylprednisolone (DepoMedrol, 40 mg per mL), 1 mL, mixed with 3 to 5 mL of 1 percent lidocaine can be used. After injection of the medication, the needle and syringe are withdrawn.

 The skin is cleansed, and a bandage is applied over the needle-puncture site. The patient is warned to avoid forceful activity on the joint while it is anesthetized. After diagnostic arthrocentesis, appropriate intervention usually will be dictated by the results of the fluid analysis. Joint infections are usually treated aggressively with intravenous antibiotics.

 Inflammatory arthritis, such as rheumatoid arthritis, can be treated with diseasemodifying medications such as methotrexate or penicillamine. Large effusions can recur and may require repeat aspiration. Repeat injections can be considered after six weeks. Large, weight-bearing joints should not be injected more than three times a year.

 Infection of the joint Bleeding into the joint Increased pain Allergic reaction

Laboratory Results

E
Electrolytes Actual Results Normal Finding Interpretation and Analysis

Sodium Potassium

140.90 412

135-148 3.5-5.3

Normal Normal

CBC
Component Actual Results Normal Finding Interpretation and Analysis Normal

Hemoglobin

12.8

12-17

Hematocrite

38.0

40-54

Low

WBC

7900

5000-10000

Normal

RBC

4.16

4.6-6.0

Normal

CBC
Component Actual Results Normal Finding Interpretation and Analysis High

Segmenters

71

50-70

Eosinophils

0-5

Normal

Lymphocytes

22

20-40

Normal

Monocyte

0-7

Normal

BUA

288.00

200-420

Normal

X-ray results
Knee joint
No demonstrate evidence of fracture or dislocation in the section taken. Patellar spur is present.

Culture and Sensitivity test

Synovial Fluid
Sensitive: tobramycin, gentamycin, ciprofloxacine, cefapine, ceflraxone, cefotoxine Resistant: piperacillin/ tazobactan Cell count: App: 15cc , yellowish, fade RBC: 1000 WBC: 1230 Platelet: 150,400 Final report: positive to flaxobacterium

Other Tests
Acid fast test
No acid FB seen No microorganism stain

Gram stain
No microorganism stain Moderate pus cells

Course in The Ward

Date/ time 1-12-10 2AM Doctors Order Nursing management Interpretation Admit to Room under of Dr. Gerry tan Law salt low fat diet IVF: PNSS 1L X 12 Diagnostics Regulate IV fluids. Oxacillin 1g/ IV q8 (- Check IV lines ) ANST Monitor v/s q4 Attending physician update / informed Refer to Dr. tan Kalium durule and tab TID Dr. Gerry tan Should be taken with food. Do not break, chew or crush. Do not administer to a

to treat or prevent infections that are caused by strong bacteria.

1-12-10 8:14 AM

For use as an electrolyte replenisher and in the treatment of hypokalemia

1-12-10 10:15 AM

IVF : PNSS 1L X 12

1-13-10 4:30 PM
9PM

Continue medications
IVF : PNSS 1L X 12

IVF to consume
Shift to heplock 6:40 Natravox In patients with renal impairment, dosage should be adjusted according to the degree of impairment Should be taken with food. Do not break, chew or crush. Do not administer to a patient in a supine postion, For use as an electrolyte replenisher and in the treatment of hypokalemia

1-14-10 12:15 nn

Kalium durule

5:00 PM 1-15-10 1-16-10 2:03PM

Referred done to Dr. Pineda No new orders Reinsert heplock for coamoxiclav Check if the patient had an allergy on the medicine Coamoxiclav used to treat bacterial infections, such as infections of the chest and throat, by killing or stopping the growth of bacteria. It can also be used in high-risk patients to prevent infections occurring. Upper respiratory tract infections, sinusitis, otitis media, recurrent tonsillitis. These infections are often caused by Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pyogenes.

1-18-10 9:57PM

May go home anytime tom Check up with orthopedic Consume antibiotics coamoxiclav 6.5 tab TID Ok for discharge IVF: PNSS 1L X 2 Continue IV Shift coamoxiclav to ciprofloxacin 500mg IV BID Ciprofloxacin is used for Mild to moderate bone or joint infection

1-19-10 8:30 AM

1-19-10 4:55 PM

6:00PM

7:03 PM

Ok carry out order of Dr. Pineda

IVF: PNSS 1L X 12

Date / Time

Nursing Problem

Nursing Evaluation Intervention

1-12-10

Knee pain

>Assessment done >Encouraged on most comfortable pos Advised to do DBE >WOF any untoward S/sx >Promoted comfort with safety

Positive pain

1-12-10/ 3- Knee pain 6 am (R) Swelling 3:15 am

>Received patient from ER

>Assessment done >Encouraged verbalization of thought & feelings >DBE advised >Skin done >Provided safety &comfort >Done meds given as advised >WOF any untoward s/sx >Health need attended

(positive) swelling, with tolerable pain

>endorsed

1-12-10 / 6am -2pm

Alteration of comfort (R) knee pain

>Assessment done >Advise to elevate affected knee >Encourage verbalization of feeling >Due meds given >Advised DBE >Health attended >endorsed >Assessment done >Encouraged verbalization of feeling >Advised DBE >Health needs attended >endorsed

Positive pain (R) Knee tolerable Positive (R) knee pain tolerable Positive pain @ Right knee tolerable

1-12 -10/ 2 pm 10 pm 1-12-10/ 10pm- 6am

Alteration in comfort (R) knee pain r/t present condition Alteration in comfort pain R swelling of R knee

>Assessment done >Encouraged verbalization of feeling >endorsed

1-13-10 / 6am- 2pm

Altered comfort M acute pain on R knee pain scale 7/10

>Assessment done >Encouraged verbalization of feeling >Advised DBE >Health needs attended >Endorsed

Tolerable pain

1-13-10 / 2pm- 10 pm 1-14- 10/ 10pm-6am

Alteration in comfort pain r/t swelling of (R) Knee

>Assessment done >Advise to elevate affected knee >Encourage verbalization of feeling >Due meds given >Advised DBE >Health needs attended >Endorsed >Assessment done >Encourage verbalization of feeling >Due meds given >Advised DBE >Kept rested >Health needs attended >Endorsed

Tolerable pain

Alteration in comfort r/t acute pain (R) knee

Tolerable pain

1-14-10/ 6am -2pm

Knee pain

>Assessment done >Encourage verbalization of feeling >Advised DBE >Due meds given >V/S taken

Pleasurabl e pain

1-14-10/ 7 For :25 pm arthrocente 7:35 pm sis

>Received pt from ward NOD with heplock >Px transferred to MR >Px in supine >knee prepping done >Arthrocentesis done >Aspirated estimated 45cc at signovial fluid >Procedure ended >Endorsed to ward NOD

S/P arthrocente sis px tolerated the procedure

7:35 pm

7:45 pm

1-14-10 / 2pm 10pm

Knee pain

>Assessment is done >Encourage verbalization of feeling >Advised DBE >v/s taken recorded >health needs >endorsed

Tolerable pain

1-14-10/ Knee pain 10pm- 6am

>Assessment is done >Encourage verbalization of feeling >Advised DBE >v/s taken recorded >health needs >endorsed

Tolerable pain

1-15-10/ 6am -2pm

1-15-10/ 2pm 10pm 1-15- 10/ 10pm 6am

Alteration of comfort r/t swelling on( R) Knee Pain r/t op pain

>Assessment done >Encourage verbalization of feeling >Due meds given >Advised DBE >Kept rested >Health needs attended >Endorsed

Positive pain on( R) knee tolerable With tolerable pain Tolerable pain

>Assessment done >Encourage verbalization of feeling >Due meds given >Advised DBE >Kept rested >Health needs attended >Endorsed >Assessment done >Encourage verbalization of feeling >Due meds given >Advised DBE >Kept rested >Health needs attended >Endorsed

Post op pain

1-16-10/ 6am-2pm

Knee pain

>Assessment done >Encourage verbalization of feeling >Due meds given >Endorsed

With tolerable pain With tolerable pain With tolerable pain

1-16-10/ Right knee 2pm- 10pm pain

>Assessment done >Encourage verbalization of feeling >Due meds given >Health needs attended >Endorsed

1-16-10/ Alteration 10pm- 6am in comfort R knee pain

>Assessment done >Encourage verbalization of feeling >Due meds given >Health needs attended >Endorsed

1-17-10/ 6am -2pm

Pain R knee

>Assessment done >Encourage verbalization of feeling >Due meds given >Health needs attended >Endorsed

Negative pain

1-17-10/ 2pm-10pm

Right knee pain

>Assessment done >Encourage verbalization of feeling >Due meds given >Advised DBE >Health needs attended >Endorsed

Tolerable pain

1-17-10/ 10pm-6am

Right knee pain

>Assessment done >Encourage verbalization of feeling >Advised to elevate right ankle >Monitor to any untoward >Sign and symptoms >endorsed

Still with swelling on R ankle With tolerable pain

1-18-10/ 6am -2pm

Knee pain

>Assessment done >Encourage verbalization of feeling >Advised to elevate right ankle >Monitor to any untoward >Sign and symptoms >endorsed >Assessment done >Encourage verbalization of feeling >Due meds given >Advised DBE >Kept rested >Health needs attended >Endorsed >Assessment done >Encourage verbalization of feeling >Due meds given >Advised DBE >Kept rested >Health needs attended >Endorsed

With tolerable pain With tolerable pain

Positive swelling R knee pain With minimal tolerable

1-1810/2pm10pm

Knee pain

1-18-10/ Positive 10pm -6am right pain

pain

1-19-10/ 6am- 2pm

Alteration in comfort R knee Knee pain

>Assessment done >Encourage verbalization of feeling >Due meds given >Advised DBE >Kept rested >Health needs attended >Endorsed >Assessment done >Encourage verbalization of feeling >Due meds given >Advised DBE >Kept rested >Health needs attended >Endorsed

With tolerable pain With tolerable pain

1-19-10/ 2pm -10

Exercise:
Encourage non competitive aerobic exercises. Heavy weight lifting is not recommended. Prefer a light daily exercise such as walking. * Lifestyle change (smoking, drinking, alcohol should stop) is an important part of treatment too.

Important Health Teaching Includes:

Pay attention on medications, dietary and fluid restriction. Self care activities such as exercise and how to perform them. Patient and family should report symptoms immediately. Monitor blood glucose, blood pressure and weight regularly. Have a regular medical check ups. Drinking alcoholic beverages can worsen.

Out Patient Care Includes:

Support and cooperation of family members. Incorporate therapeutic activities to balance lifestyle and work. Have a regular check ups as preferred by the doctor. Monitor blood glucose level, blood pressure and weight regularly.

Diet
Maintain low salt, low fat diet. Remove salt from preparing foods. Avoid fatty foods or foods high in cholesterol. Promote proper hydration. Limit drinking alcoholic beverages.

Statistics - Cellulitis
Ascending cellulitis of the leg is a common emergency. An audit was conducted in two district general hospitals to determine how it is managed and the long-term morbidity, and to formulate a treatment strategy. Case notes were reviewed for 92 patients admitted to hospital under adult specialties. Mean duration of inpatient therapy was 10 days. A likely portal of entry was identified in 51/92 cases, of which the commonest were minor injuries and tinea pedis. Pathogens were rarely identified, group G streptococci being the single most frequent organism. Benzylpenicillin was administered in only 43 cases. Long-term morbidity, identified in 8 of 70 patients with over six months' follow-up, included persistent oedema (6) and leg ulceration (2); an additional 19 patients had either suffered previous episodes or experienced a further episode subsequently. Ascending cellulitis of the leg has substantial short-term and long-term morbidity. Important but often neglected therapeutic suggestions are the inclusion of benzylpenicillin in all cases without a contraindication, assessment and treatment of tinea pedis, use of support hosiery, and serological testing for streptococci to confirm the diagnosis in retrospect. The high frequency of recurrent episodes suggests that longer courses of penicillin, or penicillin prophylaxis, might be useful.

Statistics - Synovitis
Although satisfactory results have been obtained with conventional synovectomy of the knee, there are frequent complications, and a long period of rehabilitation is necessary after this surgery. We performed arthroscopic synovectomy of the knees of 30 patients (33 knees), 22 of whom had rheumatoid arthritis. These patients underwent the procedure after failure to respond to an intraarticular injection of either osmic acid or yttrium 90. The operated knee was moved 3-5 hours after the arthroscopy, and the patients walked the next day. No rehabilitation was needed. The followup period ranged from 6 months to 36 months, with an average of 17.7 months. Except for 1 patient with severe arthritis, all patients experienced improvement. Results were rated as good or very good in 27 knees. Six months after synovectomy, the patients were asked to rate their improvement; the mean SEM degree of improvement was 79.1 22.9%. All patients had significant improvement in the range of motion of the knee. One patient required manipulation of the knee (while under anesthesia) soon after the arthroscopy. There were no other complications. There was no detectable radiographic evidence of disease progression in 24 patients who were seen 1 year after the procedure or in 9 patients who were seen 2 years after the arthroscopy. Thus, arthroscopic synovectomy appears to be an effective and simple treatment for chronic knee synovitis, and has a low morbidity rate.

Evaluation
Patient x was admitted to Las Pinas Cedical Center since January 12, 2010 with a chief complaint of swelling R knee. It has been suspected that patient x has synovitis. All the results of the laboratory is in the normal range as shown in are report. Patient was cooperative enough to follow the doctors order that made the pain scale decreased and was advise that he can be go home.