Divine Word College of Laoag School of Nursing Laoag City

A case study presented to the Clinical Instructors of School of Nursing

THOPACEOUS GOUTY ARTHRITIS, SEPTIC ARTHRITIS

Presented by: Aaron Dondoyano Paul Galat Aimen Gallegos Noemi Maruquin Irvin Ross Molina Ma. Editha Ofely Morales Camille Pan Gemaryvive Quiaoit Juvel Rafael

March 2010

PERSONAL DATA Name of Patient: Mr. Emong Aguilla Address: Bacarra, Ilocos Norte Hospital number: 438633 Sex: Male Age: 40 years old Date of Birth: December 11, 1969 Civil Status: Married Educational Attainment: High School Graduate Occupation: Tricycle Driver Chief of complaint: Swelling of the right lower extrimities Admitting Diagnosis: Thopaceous Gouty Arthritis, R/O Septic Arthritis Final Diagnosis: Thopaceous Gouty Arthritis, Septic Arthritis Date and time of admission: February 11, 2010 Attending Physician: Dr. Gout

ANATOMY AND PHYSIOLOGY SKELETAL SYSTEM Sitting, standing, walking, picking up a pencil and taking a breath all involve the skeletal system. Without the skeletal system to support our bodies, we would have no rigid framework to support the soft tissues of the body and no systems of levers so critical for movement. The skeletal system consists of bones and their associated connective tissues, including cartilage, tendons and ligaments.

bone releases minerals into the blood to maintain critical mineral balances and to distribute the minerals to other parts of the body. femurs. and fibulas of the legs.  Support. especially calcium and phosphorus.  Smooth joint surfaces. The long bones include the. Attach muscle to bones. the humeri. the surfaces of bones within movable joints are covered with cartilage. Cartilage is a major site of skeletal growth in the embryo.  Ligaments. Because skeletal muscles attach to bones. fetus and child. Tendons and ligaments form attachments.  Tendons. and grow primarily by elongation ofthe diaphysis. with an epiphysis at the ends of the growing bone. Bone provides a rigid framework that supports the soft tissues of the body and maintains the body¶s shape. Together bones and muscles produce movement. Bones protect internal organs that are critical to survival.  Assistance in Movement. It is complex and dynamic living tissue. Blood cells are produced in the marrow of many bones. It continually engage in a process called remodelingbuilding new bone tissue and breaking down old bone tissue. dense connective tissue. Long bone The long bones are those that are longer than they are wide.  Protection. tibias. ribs and trachea.  Support. which provides a smooth cushion between adjacent bones. . radii. they pull on bones. yet flexible support within structures. Bone is made up of several different tissues working together: bone or osseous tissue.  Mineral homeostasis. metacarpals and metatarsals of the hands and feet. epithelium. such as nose. adipose tissue and nervous tissue. Bone tissue stores several minerals. 2. In the adult. and ulnas of the arms. Cartilage is abundant in the embryo and the fetus. and the phalanges of the fingers and toes. TYPES OF BONES 1. external ears. 3. where it provides a model from which most of the adult bones develop. Tendons and ligaments are strong bands of fibrous connective tissue.FUNCTIONS OF THE SKELETAL SYSTEM 1. On demand.  Model for Bone Growth. Cartilage also provides a firm.  Blood cell formation. Cartilage is somewhat rigid but more flexible than bone. Attach bones to bones. when muscles contract. cartilage.

knee. affording multiple anchor points for skeletal muscle attachment (as with the sacrum). which protect the brain.the patella In the hand . which protect organs in the thorax. and the shoulder blades. 3. such as the hand. where there is a thin layer of compact bone tissue. Sesamoid bones also prevent the tendon from flattening into the joint as tension increases and therefore maintain a more consistent moment arm through a variety of possible tendon loads. including: y y y In the knee . maxilla. and ankle or tarsal bones. palatine. Flat bones afford considerable protection and provide extensive areas for muscle attachment. cannot be grouped as long bone. temporal. Irregular bones serve various purposes in the body. Examples of short bones are wrist or carpal bones. In the foot . coccyx.two sesamoid bones are located in distal portions of the first metacarpal bone.2. they act to protect the tendon and to increase its mechanical effect. Functionally. Short bones Short bones are somewhat cube-shaped because they are nearly equal in length and in width. such as protection of nervous tissue (such as the vertebrae protect the spinal cord). and hyoid. This differs from menisci. which. The irregular bones are the vertebræ. Flat bones Are generally thin and composed of two nearly parallel plates of compact bone tissue enclosing a layer of spongy bone tissue. and maintaining pharynx and trachea support. zygomatic. which are made of cartilage and rather act to disperse the weight of the body on joints and reduce friction during movement. Sesamoid Bone Sesamoid bones are typically found in locations where a tendon passes over a joint. . There is also commonly a sesamoid bone in distal portions of the second metacarpal bone. or sesamoid bone. and foot. flat bone. They consist of spongy bone tissue except at the surface. 4. Sesamoid bones can be found on joints throughout the body. Flat bones include the cranial bones. inferior nasal concha. short bone. 5. The presence of the sesamoid bone holds the tendon slightly farther away from the center of the joint and thus increases its moment arm. and tongue attachment (such as the hyoid bone).the first metatarsal bone has two sesamoid bones at its connection to the big toe. sacrum. mandible. The pisiform of the wrist is a sesamoid bone as well. ethmoid. sphenoid. from their peculiar form. Irregular bones The irregular bones are bones. the breastbone and ribs.

Periosteum is a tough sheath of dense irregular connective tissue that surrounds the bone surface wherever it is not covered by articular cartilage. 5. They are the only bone cells to ndergo cell division. and in the canals within bone that contain blood vessels. helps nourish bone tissue and serves as an attachment point for ligaments and tendons. They synthesized and secrete collagen fibers and other organic components needed to build the matrix of bone tissue. Diaphysis is the bones shaft or body. The periosteum contains bone-forming cells that enable bone to grow in diameter or thickness but not in length. Osteogenic cells are found along the inner portion of the periosteum. 3. 6. 4. and they initiate calcification. repair of damage is limited. Epiphyses are the distal and proximal ends of a bone. Articular cartilage is a thin layer of hyaline cartilage covering the epiphysis where the bone forms an articulation with another bone. assists in fracture repair. As osteoblasts surround themselves with matrix. 7. TYPES OF BONE CELLS Osteogenic Cells These are unspecialized stem cells derived from mesenchyme. a layer of hyaline cartilage that allows the diaphysis of the bone to grow in length.the long.PARTS OF A BONE 1. Metaphyses are the regions in a mature bone where the diaphysis joins the epiphysis. When bone growth in length stops. the tissue from which all connective tissues are formed. in the endosteum. cylindrical main portion of the bone. Because articular cartilage lacks a perichondrium. Endosteum is a thin membrane that lines the medullary cavity. It contains a single layer of bone forming cells and a small amount of connective tissue. the cartilage in the epiphyseal plateis replaced by bone and the resulting bony structure is known as epiphyseal line. the resulting daughter cells develop into osteoblasts. In a growing bone. . Medullary Cavity or Marrow Cavity is the space within the diaphysis that contains fatty yellow bone marrow in adults. Osteoblasts These are bone-building cells. they become trapped in their secretions and become osteocytes. each metaphysis includes an epiphyseal plate. 2. It also protects the bone. Articular cartilage reduces friction and absorbs shock at freely movable joints.

Immovable joints (synarthroses) In this type of joint. There are three types of joints classified by the amount of movement they allow: immovable.immoveable joints Amphiarthroses . such as the exchange of nutrients and wastes with the blood. is part of the normal development. termed resorption. but joints also occur between bones and cartilages. allows and/or restrains movement. growth. Classification of joints by structure y y y y Fibrous joints .moveable joints 1. The joints are the places of union between skeletal elements that are more or less moveable. or articulation. slightly movable. the main cells in the bone tissue and maintain its daily metabolism. Osteoclasts These are huge cells derived from the fusion of as many as 50 monocytes and are concentrated in the endosteum. and freely movable. between cartilages. An example of a synarthrosis is the suture in the skull between skull bones. The articular system joins the skeleton. On the side of the cell that faces the bone surface. Here the cells release powerful lysosomal enzymes and acids that digest the protein and mineral components of the underlying bone matrix.Osteocytes These are mature bone cells. Joints A joint. Joints are commonly defined as being between bones. the bones are in very close contact and are separated only by a thin layer of fibrous connective tissue. and allows growth of the skeleton until the end of puberty. This breakdown of bone matrix. maintenance and repair of bone.joints composed of dense collagenous or elastic connective tissue Cartilaginous joints ."mixed" joints of limited movement Diarthroses .fusion between two bones Synovial joints . Classification of joints by range of movement y y y Synarthroses . Like osteoblasts.joints containing a synovial cavity filled with synovial fluid . osteocytes do not undergp cell division. is the place where two bones come together. osteoclats plasma membrane is deeply folded into a ruffled border. and between bones and teeth.joints composed of hyaline cartilage or fibrocartilage Bony unions .

2. The ribs that connect to the sternum are an example of an amphiarthrosis joint. . Slightly movable joints (amphiarthroses) This type of joint is characterized by bones that are connected by hyaline cartilage (fibro cartilage). They are highly moveable and all have a synovial capsule (collagenous structure) surrounding the entire joint. There are 6 types of synovial joints which are classified by the shape of the joint and the movement available. a synovial membrane (the inner layer of the capsule) which secretes synovial fluid (a lubricating liquid) and cartilage known as hyaline cartilage which pads the ends of the articulating bones. Freely movable joints (diarthrosis) Synovial (diarthrosis): Synovial joints are by far the most common classification of joint within the human body. 3.

Examples include the Socket shoulder and hip. Rotation of one bone around another Top of the neck (atlas and axis Pivot Joint bones) The ball-shaped end of one-bone fits into a cup shaped socket on the other bone allowing the widest range of motion Ball and including rotation. An example is the joint between the axis and atlas in the neck. Flexion/Extension Elbow/Knee Hinge joint Pivot Rounded or conical surfaces of one bone fit into a ring of one or tendon allowing rotation. Flexion/Extension/Adduction/Abduction/ Internal & External Rotation Shoulder/Hip Ball and socket joint .Six types of diarthroses joints Joint Type Movement at joint Examples Structure Hinge A convex projection on one bone fits into a concave depression in another permitting only flexion and extension as in the elbow joints.

Flexion/Extension/Adduction/Abduction/ Wrist/MCP Circumduction MTP joints Flat or slightly flat surfaces move against each other allowing sliding or twisting without any circular movement. The only saddle joint in the body is in the thumb.Saddle This type of joint occurs when the touching surfaces of two bones have both concave and convex regions with the shapes of the two bones complementing one other and allowing a wide range of movement. Gliding movements Intercarpal joints Gliding joint & Condyloid Condyloid joint Gliding . Flexion/Extension/Adduction/Abduction/ CMC joint of the Circumduction Saddle joint thumb Oval shaped condyle fits into elliptical cavity of another allowing angular motion but not rotation. This happens in the carpals in the wrist and the tarsals in the ankle. This occurs between the metacarpals (bones in the palm of the hand) and phalanges (fingers) and between the metatarsals (foot bones excluding heel) and phalanges (toes).

Big toe The largest and innermost toe of the human foot. Ankle The bones which constitute the ankle are the two long bones of the lower leg (tibia and fibula). The unique design of the ankle makes it a very stable joint. joint. The ankle is actually made up of several important structures. The ankle joint acts like a hinge. which articulate with a short anklebone called the talus. This joint has to be stable in order to withstand 1. But it's much more than a simple hinge joint.5 times your body weight when you walk and up to eight times your body weight when you run. This is a µuniaxial¶. which form a large strong tendon (Achilles tendon) which inserts into the bone of the heel (calcaneum). y . Plantarflexion is achieved by the calf muscles (gastrocnemius and soleus). or hinge. In the case of the ankle these movements are called dorsiflexion (sole of the foot up) and plantarflexion (foot down) respectively. which allows flexion and extension movements.

Extension is achieved by a group of four large muscles at the front of the thigh (quadriceps). with the top of the tibia. Combination of these movements also gives rise to µcircumduction¶. through two condyles. a condition commonly referred to as torn cartilage. there is another piece of cartilage (meniscus) separating them on each side. particularly in football and rugby players. with the top (head) of the long bone of the leg (femur) being the µball¶ and the socket being a depression in the bone of the pelvis known as the acetabulum. This arrangement permits movements in three planes ² forwards and backwards (extension/flexion) . inwards and outwards (adduction/abduction) . although a limited degree of rotation is also possible towards the end of extension. In addition to the cartilage covering the surfaces of these bone-ends. which describes a µcone¶ with the foot at the base and the hip at the apex. which are required not only for postural control and movement but also to confer stability at the hip. which is shaped rather like a plateau. whilst muscles at the back of the thigh (hamstrings) produce flexion. and inward twist and outward twist (internal and external rotation). These can be torn by rotational injuries. The lower end of the femur articulates. which principally allows movements of the lower leg forwards (extension) and backwards (flexion). . The joint is spanned by powerful muscles.Knee The knee joint is functionally a hinge joint. a circular movement of the whole leg. Hip The hip joint is an example of a µball and socket¶ (multiaxial) type of joint.

Three bones form the elbow joint: the humerus of the upper arm. more importantly. concave towards the palm. The condyles at the lower end of the humerus in the upper arm articulate with the heads of both the radius and the ulna in the lower arm. with its ends connected by a fibrous tissue band.Wrist and Hand The joint between the end of the forearm and the hand. This is a relatively complex joint as it is an articulation between the lower end of the long bones of the forearm (radius and ulna) and the eight small bones of the hand (carpal bones). and the paired radius and ulna of the forearm. These carpal bones are connected to one another by ligaments so that they form an arch. Elbow The elbow is the region surrounding the elbow-join²the ginglymus or hinge joint in the middle of the arm. An example of a hinge joint (uniaxial) with movement essentially limited to flexion and extension. a muscle often shown to advantage in the classic pose of the body builder. Through this µtunnel¶ run long tendons which control the fingers and. the median nerve which carries the nerve supply to some muscles of the hand and to the skin of some of the fingers. Movements occur in two planes ² flexion/extension and adduction/abduction (inward/outward). which shortens and bulges. . Flexion of the elbow is achieved by action of the biceps muscle. Twisting movements of the lower arm (pronation and supination) are possible because the top end (the head) of the radius can rotate against the lower end of the humerus.

Four short muscles that originate on the scapula pass around the shoulder. . Ligaments connect the bones of the shoulder. where their tendons fuse together to form the rotator cuff. The biceps tendon attaches the biceps muscle to the shoulder and helps stabilize the joint. and tendons join these bones to surrounding muscles.Shoulder The flexible ball-and-socket joint formed by the junction of the humerus and the scapula. The joint is stabilized by a ring of fibrous cartilage (the labrum) around the glenoid socket. This joint is cushioned by cartilage that covers the face of the glenoid socket and head of the humerus.

Common sites of TOPHI formation .

about 95 percent of sufferers are men. These attacks can happen over and over unless gout is treated. and swelling in a joint. and the M ori of New Zealand.READINGS GOUT Gout is a complex disease of uncertain origin caused by the faulty metabolism of uric acid produced in the body by breakdown of protein. In the United States. It is high among the peoples of the Pacific Islands. hormonal. and other tissues. It can cause an attack of sudden burning pain. it is likely the result of a combination of genetic. usually a big toe. In the United States and Italy. and surrounding tissues. Types of Gout  Primary gout: The cause is usually unknown. stiffness. resulting in elevated levels of uric acid in the blood that crystallizes and deposits in joints. Incidence Its incidence is not usually affected by climate or season. Epidemiology Gout affects 1% of the Western population at some point in their lifetime and is increasing in prevalence. Asymptomatic hyperuricemia 2. But unlike the inflammation in RA and lupus. tendons. from 10 to 20 percent of cases have a familial history. It is often characterized as an inflammatory form of arthritis. which is related to the immune system. gout is twice as prevalent in African American males as it is in European-Americans. However. Acute gouty arthritis . but rare in Australian aborigines despite the latter's higher mean concentration of serum uric acid. The disease is rare in people under the age of 30. tendons. they can harm your joints. Stages of Gout 1. Over time.  Secondary gout: Secondary gout is caused by medications or medical conditions that cause an increase in the serum (blood) levels of uric acid. joint inflammation in gout is caused by deposits of sodium urate crystals in the joints. and dietary factors. Different populations have different propensities to develop gout. attacks of gout occur more frequently in the spring. This increases to 2% in men over the age of 30 and women over the age of 50.

40 years of persistent hyperuricemia. women have a significantly lower risk for gout than men. Before menopause. . gout occurs more often in women. In one Japanese study. peaking in the mid-40s. gout typically strikes after 20 . (Only about 15% of female gout cases occur before menopause. when it occurs equally in men and women. uric acid levels rise substantially at puberty.) After menopause the risk increases in women.  Obesity  Researchers report a clear link between body weight and uric acid levels. The drugs are strongly linked to the development of gout. so men who develop it usually experience their first attack between the ages of 30 and 50. In about 5 . overweight people had two to more than three times the rate of hyperuricemia as those who maintained a healthy weight.  Women. At age 60 the incidence is equal in men and women. In this group.8% of American men.  Children. gout is most often associated with kidney problems and the use of diuretics. This female hormone appears to facilitate uric acid excretion by the kidneys. Except for rare inherited genetic disorders that cause hyperuricemia. In males. Chronic tophaceous gout Risk Factors of Gout  Age  Middle-Aged Adults. gout in children is rare. Gout can also develop in older people. Children who are obese may have a higher risk for gout in adulthood.  Elderly. and heavy alcohol use. Gout usually occurs in middle-aged men.3. It is most often associated in this age group with obesity. A large percentage of patients who develop gout at an older age report the use of diuretics.  Medications  Thiazide diuretics are "water pills" used to control hypertension. levels exceed 7 mg/dL (indicating hyperuricemia). and after 80. Three genetic locations have been associated with the body's uric acid handling and gout. possibly because of the actions of estrogen. It is less often associated with alcohol use. Men are significantly at higher risk for gout. However. Some people with a family history of gout have a defective protein (enzyme) that interferes with the way the body breaks down purines. Intercritical gout 4.  Family History  A family history of gout is present in close to 20% of patients with this condition.  Gender  Men. unhealthy cholesterol levels. high blood pressure.

followed by spirits.low doses of aspirin reduce uric acid excretion and increase the chance for hyperuricemia. In addition.  Alcohol use is highly associated with gout in younger adults. Beer is the kind of alcohol most strongly linked with gout. as does the medication (cyclosporine) used to prevent rejection of the transplanted organ. Other Illnesses Treatment of several other conditions can cause significant elevations of uric acid in the blood. other transplantation procedures.  Niacin (used to treat cholesterol problems)  Pyrazinamide (used to treat tuberculosis)  Alcohol  Drinking excessive amounts of alcohol can raise your risk of gout. Binge drinking particularly increases uric acid levels. Alcohol appears to play less of a role among elderly patients. The kidneys are responsible for removing waste from the body. Alcohol increases uric acid levels in the following three ways:  Providing an additional dietary source of purines (the compounds from which uric acid is formed)  Intensifying the body's production of uric acid  Interfering with the kidneys' ability to excrete uric acid Lead Exposure Chronic occupational exposure to lead is associated with build-up of uric acid and a high incidence of gout. Cyclosporine also interacts with indomethacin. Moderate wine consumption does not appear to increase the risk of developing gout. especially among women with gout. a common gout treatment. These conditions include: Leukemia Lymphoma Psoriasis          . The procedure itself poses a risk of gout. and stimulating red blood cell production. and therefore a gout attack. This may be a problem for older people who take baby aspirin (81 mg) to protect against heart disease. such as heart and liver. increase the risk of gout. Organ Transplants Kidney transplantation poses a high risk for renal insufficiency and gout. regulating electrolyte balance and blood pressure. Other medications:  Aspirin -.

and hand. the condition is known as polyarticular gout. which may peel after a few days Chills and mild fever. loss of appetite. Symptoms can also occur in other locations. At lower temperatures. Note: Hyperuricemia does not inevitably lead to gout. The most frequently affected joints are the foot. Polyarticular Gout. MSU levels slowly increase in the body. elbow. and feelings of ill Most often symptoms start in one joint Monoarticular Gout. In fact. Asymptomatic hyperuricemia is considered the first stage of gout. If more than one joint is affected. The pain usually occurs in joints on one side of the body and it is usually. People with polyarticular gout are also more likely to experience low-grade fever. Sometimes the first signs of gout are brief twinges of pain (petit attacks) in an affected joint. MSU crystals form at normal body temperature when the concentration of uric acid in the blood reaches 7 mg/dL. About 60% of all first-time monoarticular gout attacks in middle-aged adults occur in the big toe. less than 20% of cases develop the full-blown arthritic gout disease. gout usually strikes the toes and fingers first.12 hours to develop Occurs late at night or early in the morning and may wake you up Swelling that may extend beyond the joint Red. Since blood temperature falls the further blood gets from the heart. although not always. People with polyarticular gout are more likely to have a slower onset of pain and a longer delay between attacks. shiny. Symptoms of acute gouty arthritis include: Severe pain at and around the joint May feel like "crushing" or a dislocated bone Physical activity and even the weight of bed sheets may be unbearable Usually takes 8 . Multiple joints are affected in only 10 . and a general feeling of poor health. knee. These attacks can precede the actual full-blown condition by several years. ankle.           . MSU crystals form at lower concentrations of uric acid. loss of appetite.  Acute Gouty Arthritis Acute gouty arthritis occurs when the first symptoms of gout appear. wrist.20% of first attacks.Symptoms of Gout  Asymptomatic Hyperuricemia Asymptomatic means there are no symptoms. Older people are more likely to have polyarticular gout. in the lower legs and the feet. This occurrence is known as podagra. tense skin over the affected area. This stage lasts for an average of 30 years. Gout that occurs in one joint is called monoarticular gout. such as the ankle or knee.

while others persist as long as several weeks. the shoulders. A risk for tophaceous gout y Had more than two or three acute attacks of gout in the past y Unusually severe attacks. The first attack is usually followed by a complete remission of symptoms. In some cases. tophi break through the skin and appear as white or yellowish-white. such as those who are receiving cyclosporine after a transplant. some attacks last only hours. the intercritical periods typically become shorter and shorter.7 days.  Intercritical Gout Intercritical gout is the term used to describe the periods between attacks. if left untreated. can last longer. including those that may have been free of symptoms at the first appearance of the disorder.48 hours after the first appearance of symptoms. In the elderly population.  Chronic Tophaceous Gout After several years. cartilage. This long-term condition often produces tophi. but. women appear to be at higher risk for tophi than men. hips. over 90% of the patients are likely to have repeat attacks. When gout remains untreated. which are solid deposits of MSU crystals that form in the joints. as shown on x-rays y Hyperuricemia caused by an identifiable inborn metabolic deficiency Development of Chronic Pain. Gout may eventually affect several joints. In rare cases. and elsewhere in the body. Tophi are more likely to appear early in the course of the disease in older people. or attacks that affect more than one joint y Joint damage from gout. and the attacks. Without treatment. gout nearly always returns. and go away after 5 . Over two-thirds of patients will have at least one further attack within 2 years of the first attack. chalky nodules that have been described as looking like crab eyes. However. Over the long term (about 10 .20 years) gout becomes a chronic disorder characterized by constant low-grade pain and mild or acute inflammation. although sometimes less intense. persistent gout can develop into a condition called chronic tophaceous gout. have a high risk of developing tophi.o An untreated attack will typically peak 24 . bones. Location of Tophi y Curved ridge along the edge of the outer ear y Forearms y Elbow or knee . By 10 years. although the occurrence can range from 3 to 42 years. Certain people. or spine are affected. tophi develop about 10 years after the initial onset of gout.

tumor lysis syndrome produces extreme levels of uric acid. due to competition for transport between uric acid and ketones. are more likely to have gout in the small joints of the fingers. However. ciclosporin.  Decreased excretion of uric acid The principal drugs that contribute to hyperuricemia by decreased excretion are the primary antiuricosurics. . and enters your bloodstream. Other drugs and agents include diuretics. A ketogenic diet impairs the ability of the kidney to excrete uric acid. has a dual action that is compounded by multiple mechanisms. pyrazinamide. Elevated blood lead is significantly correlated with both impaired kidney function and hyperuricemia (although the causal relationship among these correlations is not known). particularly women. Around the heart and spine (rare) Tophi are generally painless. ultimately destroying the joint.4-thiadiazole. mainly leading to renal failure. Three functional causes of Hyperurecemia:  Increased production of uric acid Hyperuricemia of this type is a common complication of solid organ transplant. Uric acid passes through the liver. or passes through your intestines to regulate "normal" levels. they can also erode cartilage and bone. nicotinic acid. The Lesch-Nyhan syndrome is also associated with extremely high levels of uric acid.4-6. Eventually.older patients. Hyperuricemia Hyperuricemia is an excess of uric acid in the blood.3.0 mg/dL (female) and 3. and cytotoxic agents. Normal Uric acid levels are 2. ethambutol. salicylates. they can cause pain and stiffness in the affected joint.y y Hands or feet -.0 mg/dL (male.4-7.  Mixed type Causes of hyperuricemia that are of "mixed" ("double whammy") type have a dual action. Large tophi under the skin of the hands and feet can give rise to extreme deformities. 2-ethylamino-1. Most of it is excreted (removed from your body) in your urine. a significant cause of hyperuricemia. High intake of alcohol (ethanol). both increasing production and decreasing excretion of uric acid. Apart from normal variation (with a genetic component).

fatigue if you have certain forms of cancer. to prevent complications from chemotherapy and tumor lysis syndrome . Starvation causes the body to metabolize its own (purine-rich) tissues for energy. (*Note. you may have symptoms kidney problems.such as naproxen sodium and ibuprofen may provide relief of gout-related pain.  You may have fever.gout may occur with normal uric acid levels. due to competition for transport between uric acid and ketones. which can prevent uric acid crystals from being deposited into your tissues.Such as allopurinol. chills.  Allopurinol may also be given to you.and .  Uricosuric Drugs: These drugs work by blocking the reabsorption of urate.  Xanthine oxidase inhibitors . and sulfinpyrazone. Thus. acetaminophen (Tylenol() up to 4000 mg per day (two extra-strength tablets every 6 hours) may help. if you have a certain form of leukemia or lymphoma. However. and you are undergoing chemotherapy for leukemia or lymphoma.  If you are to avoid NSAID drugs. like a high purine diet. in purine metabolism. and your uric acid levels are elevated (caused by tumor lysis syndrome)  You may notice an inflammation of a joint (called "gout"). Increased production of uric acid is the result of interference.  You may have kidney problems (caused by formation of kidney stones). because of your type of cancer or chemotherapy you are receiving. by a product of fructose metabolism. or gouty arthritis from high uric acid levels in your blood. if the uric acid crystals deposit in one of your joints. Starvation also impairs the ability of the kidney to excrete uric acid. including some carbohydrate (and reducing the protein) reduces the level of hyperuricemia. Symptoms of Hyperuricemia  You may not have any symptoms. or problems with urination Drugs or treatments to treat hyperuricemia:  Non-steroidal anti-inflammatory (NSAID) agents and Tylenol®. as it may cause liver damage.  It is important not to exceed the recommended daily dose of Tylenol. it may cause your symptoms of gout to be worse if it is taken during an episode of painful joint inflammation. starvation increases the amount of purine converted to uric acid.High dietary intake of fructose contributes significantly to hyperuricemia. A very low calorie diet without carbohydrate can induce extreme hyperuricemia. too). Examples of uricosuric drugs include probenecid.  If your blood uric acid levels are significantly elevated. will prevent gout.

Uric Acid Uric acid is a normal component of blood serum. and a lower fractional excretion of uric acid. However. with the liver responsible for the rest.  Secondary hyperuricemia  Gout is a clinical feature secondary to any of a number of genetic or acquired processes. although clinically defective elimination accounts for most cases of hyperuricemia. Approximately 70% of the urate produced daily is excreted by the kidneys. Purines provide part of the chemical structure of our genes and the genes of plants and animals. uricase. Theoretically.not necessarily to prevent gout. including conditions in which there is an increase in cell turnover and an increase in cell breakdown. while the rest is eliminated by the intestines. alterations in this balance may account for hyperuricemia. and may cause your kidneys to fail. the uric acid will collect and form crystals in your kidneys. as a result of your disease. and heredity. the intestinal contribution of urate excretion increases to compensate for the decreased elimination by the kidneys. because of a deficiency of the hepatic enzyme. The blood levels of uric acid are a function of the balance between the breakdown of purines and the rate of uric acid excretion. Purines are generated by the body via breakdown of cells in normal cellular turnover. It is maybe due to severe dieting or starvation. and in virtually all foods. in part. It is catalyzed by the enzyme xanthine oxidase. Purines Purines are natural substances found in all of the body's cells. The kidneys are responsible for approximately twothirds of uric acid excretion. Approximately two thirds of total body urate is produced endogenously. and also are ingested as part of a normal diet. during renal failure. With high levels of uric acid in your blood. Human beings have higher levels of uric acid. evcessive intake of foods that are high n purines. . It is the end product of purine metabolism. Causes of high uric acid levels include:  Primary hyperuricemia  Elevated serum urate levels or manifestations of urate deposition appear to bbe consequences of faulty uric acid metabolism. This may occur during chemotherapy. while the remaining one third is accounted for by dietary purines. which is responsible for the production of uric acid and damaging free radicals.

and alcoholic beverages)  Asparagus. beans. fish like mackerel. these high-purine foods are also high-protein foods. or simply "gout´. This accumulation of uric acid crystals is called gouty arthritis. tomatoes. Septic arthritis may affect any joint but is most frequently found in the knee. hip. lentils. peas. redness. eggs  Lettuce. kidney problems can lead to excessive accumulation of uric acid in various parts of the body. the purines in their genetic material also get broken down. It's normal and healthy for uric acid to be formed in the body from breakdown of purines. causing severe joint pain. tapioca. there may be . Uric acid is the chemical formed when purines have been broken down completely. and other organs. For the most part. meat extracts and gravy  Yeasts. contain concentrated amounts of purines. in some cases. When uric acid accumulates. shoulder.A relatively small number of foods. is caused by a bacterial infection or more rarely by a fungal or viral infection. however. and yeast extracts (such as beer. oatmeal. cauliflower and mushrooms Foods that are low in purine include:  Refined cereals . Uric acid levels in the blood and other parts of the body can become too high. however. Excessive breakdown of cells can also cause uric acid build-up. sardines and mussels. green vegetables  Cream soups without meat stock  Water. wrist. and also yeast. also called infectious arthritis. flour. and finger joints. inflammation. and in some cases fever and chills but may also become chronic. pasta. and they include organ meats like kidney. uric acid crystals (called monosodium urate crystals) can become deposited in our tendons. herring. The condition is typically acute. fruit juice. carbonated drinks  Peanut butter.breads. uric acid serves as an antioxidant and helps prevent damage to our blood vessel linings. SEPTIC ARTHRITIS Septic arthritis. Usually only one joint will be affected but. joints. under a variety of circumstances. Foods that are high in purine include:  All organ meats (such as liver). kidneys. cakes  Milk and milk products. elbow. In our blood. for example. Since our kidneys are responsible for helping keep blood levels of uric acid balanced. fruits and nuts Purines are metabolized into uric acid When cells die and get recycled. spinach. so a continual supply of uric acid is important for protecting our blood vessels.

Streptococcus pneumoniae. mumps. and/or in people who currently have an infection in their blood (bacteremia or septicemia).more than one. HIV. having diabetes. The following increase your risk for septic arthritis: y y y y y y y Artificial joint implants Bacterial infection elsewhere in your body Chronic illness or disease (such as diabetes. group B streptococci. Additional risk factors for septic arthritis include age (older than 80 years). The acute form of septic arthritis is usually caused by bacteria. Causes Septic arthritis develops when bacteria spread through the bloodstream to a joint. In children. such as Staphylococcus aureus. It may also occur when the joint is directly infected with bacteria by an injury or during surgery. rheumatoid arthritis. Chronic septic arthritis (which is less common) is caused by organisms such as Mycobacterium tuberculosis and Candida albicans. Most cases of acute septic arthritis are caused by organisms such as staphylococcus or streptococcus. Sometimes the microorganisms that cause Lyme disease. The most common sites for this type of infection are the knee and hip. such as gout or rheumatoid arthritis. have had joint surgery or joint replacement. Microorganisms can spread from an original site of infection into the blood and then can be carried into the joint space. or rubella can move into and infect a joint. The hip is a frequent site of infection in infants. . or gonococci (which cause gonorrhea). This condition needs to be diagnosed and treated quickly because it can destroy joints in a short period. and sickle cell disease) Intravenous (IV) or injection drug use Medications that suppress your immune system Recent joint trauma Recent joint arthroscopy or other surgery Septic arthritis may be seen at any age. Chronic septic arthritis is rarer and tends to be caused by microorganisms such as Mycobacterium tuberculosis and Candida albicans. a weakened immune system. and/or another condition that affects the joints. Septic arthritis occurs most often in people who have had a recent traumatic injury to a joint. it occurs most often in those younger than 3 years. hepatitis B.

Septic arthritis is uncommon from age 3 to adolescence. to determine which antimicrobial therapy will be effective.used to determine if a microorganism is present in the blood Culture of joint fluid or of other body fluids or tissues.. Laboratory Tests: y y Blood culture . such as sputum.to detect microorganisms and to see if there are any signs.to detect microorganisms. urine. that may indicate a different or co-existing cause for joint pain (such as gout) y . Children with septic arthritis are more likely than adults to be infected with group B streptococcus or Haemophilus influenza. such as crystals in the joint fluid. to monitor the effectiveness of treatment. and low-grade fever. and to evaluate the physical status of the affected joint(s). Testing The goals with testing for septic arthritis are to identify the microorganism causing the infection. if not immunized. but are uncommon.  Symptoms in newborns or infants: y y y y Cries when infected joint is moved (example: diaper change causes crying if hip joint is infected) Irritability Fever Unable to move the limb with the infected joint (pseudoparalysis)  Symptoms in children and adults: y y y y y Inability to move the limb with the infected joint (pseudoparalysis) Intense joint pain Joint swelling Joint redness Low-grade fever  Chills may occur. and to evaluate the effectiveness of treatment Synovial fluid analysis . with joint swelling. to determine which antimicrobials they are likely to be susceptible to. Symptoms  Symptoms usually come on quickly. intense joint pain. cerebrospinal fluid .

this is a group of tests used to evaluate a patient¶s red and white blood cells and hemoglobin to help evaluate and monitor the condition Non-Laboratory Tests: y X-ray of joint(s) . y y The primary treatment is the appropriate antimicrobial therapy. . to minimize joint damage. reduce inflammation and associated fluid pressure on the joint. Fluid is usually aspirated from the affected joint(s) to relieve pressure and to obtain material to culture the specific microorganism. Patients may also be treated for inflammation and pain. Aspiration may need to be done several times to relieve pressure. Outlook (Prognosis) Recovery is good with prompt antibiotic treatment. In most cases. If treatment is delayed. multiple drugs may need to be taken for extended periods of time. surgery may be needed to drain the fluid. In some cases.y Complete Blood Count (CBC) . such as a mycobacterium. may not show abnormalities until significant damage exists Treatments The goals with treatment are to eliminate the infection. Viral infections will usually resolve on their own. and to maintain and/or recover joint mobility. Possible Complications Joint degeneration (arthritis) Prevention Preventive (prophylactic) antibiotics may be helpful for people at high risk. With some organisms. this drug will also be effective in treating the source of the infection when it has originated in the blood or another body organ or tissue.used to help evaluate joint damage. permanent joint damage may result. The exact medication prescribed will depend on which drugs the microorganism is susceptible to and how effective the antimicrobials are at getting into the joint space where the infection is.

N Bacarra I. he takes the responsibility for rearing his children with the assistance of Aling Dionisia. and participate in various activities of their Barangay. spend holidays and weekends with their relatives.N Bacarra I.FAMILY BACKGROUND Name Dionisia Emong Emang Ago Bendita Sex Female Male Female Male Female Age Educational Attainment 61 High School Graduate 40 High school Graduate 36 High school Graduate 15 Not applicable 13 Not applicable Occupation Housewife Driver Caregiver Not applicable Not applicable Religion Pentecost Pentecost Pentecost Pentecost Pentecost Residence Bacarra I. Mang Emong¶s family is an example of a happy family. 61 years old. Living with them is his mother Dionisia. . happily married with his wife Emang. both are high school students. and is a father of two children. They have a happy home where parental guidance and children¶s laughter reigns. Ilocos Norte.N A) Family Structure Emong. Since his wife works abroad.N Bacarra I. They are devout members of the Pentecost and they attend mass every Sunday. Their family is considered as an extended type and is permanently residing at Bacarra. where treated equally. 36 years old. his eldest son is Ago 15 years old. but as much as possible he let his children participate. The family is patriarchal because Mang Emong is the leader of the family and is usually the decision maker. and his youngest daughter is Bendita 13 years old. As a father. self-respect and deeply influenced their character to become a better and responsible individual in the future. a 40-year-old male.N Bacarra I. which is under egalitarian type. All the members irrespective of their ages and economic status. he instilled in his children¶s mind a love for parents. both parents and children were harmoniously united by strong ties of affection and understanding. his mother. they find time to go out together. is the head of the family. There are times that problems arise in their family but it does not last in a day because they resolved it immediately as much as they can.

000 (Php 750 per week).000 per month. All in all the total monthly expenses of the family is approximately 7. C) Socio Economic As a provider he works hard to sustain their family¶s needs. Php 2.000 for education. Sales Food 28% 30% Education Medicine Electricity Water 10% 5% 5% 2% 20% Miscellaneous Savings .000 allowance per month. The Php 10. their toilet is water sealed system located inside their house.000 monthly income was allotted for food Php3. behind it were the poultry yard and vegetable garden. he works as a tricycle driver earning an average monthly income of Php 5.000 for miscellaneous expenses. approximately Php 200 for medicine. Php 500 for electricity.his wife who is currently working in Taiwan as caregiver gives an additional Php 5. he makes sure to spend the money wisely.B) Environmental The family live in an up and down type of house with a combination of cement and wood with surrounding fences. The total monthly income is approximately Php 10.000. As a decision maker in the family. Typically.00 and Php 1. for water Php 5.200. They live near a high school and in front of a busy road. The remaining monthly income of Php 2800 is being kept in the bank for future use of his children and for emergency cases.

they just stayed at home. His two daughters were both fully immunized child. He and his siblings had experienced to receive immunizations when they were child. All were managed at home of they can. wore black clothes and they do not take a bath until the rashes will gone. the cooling effect of the ³akot-akot´ can help to reduce the pain. His daughter 2 had weak lungs at the age of six and was confined and treated at GRBASMH. is also effective. For cases of fractures. they drink a decoction of ³Herba Buena´. According to him. mumps. fever. they take Asmasolon and Neozep. The family had also experienced childhood diseases such as chickenpox. they stayed at home. they used to manage by putting a piece of sliced ginger on to their temporal and taking OTC drug like Biogesic and Cortal. . however. His father who was already dead due to gunshot way back 1979 had asthma likewise sibling 1 and 2. They received their immunizations in the hospital and at their Barangay Health Center. However. he cannot recall what these immunizations anymore. and when the vesicles will dry. headache and stomachache. All were managed at home. Their meal is usually comprised of meat and vegetable most of the time. they usually watch TV and chat with each other. for his daughters. from the television and also from those who are in the medical field. For chickenpox. it were all consulted and treated by a physician. drinking plenty of water and taking enough rest. They used to manage mumps through putting an ³akotakot´ (mixed with water) on to their buccal area and below their ears. however. they also consult a physician if they cannot treat themselves alone. During their free time. and they will use this as bath soap believing that this would kill the remaining bacteria in their wounds. For cough and colds. they stayed at home and take enough rest. from what they heard from their relatives. For fever. friends and neighbors. the ginger can lessen the pain due to its cooling effect. and take drug such as Paracetamol. Laoag City. the family usually consults a ³manghihilot´ which is according to him. The knowledge they had in treating diseases mentioned above were all based from their beliefs and practices. For stomachache. A physician diagnosed all of these diseases. rest. According to him. and measles.HEALTH HISTORY Family Health History The family members had experienced simple ailments such as cough and colds. For headache. The family is fond of drinking coffee and soft drinks. For measles. they burn hay and add with warm water.

When ingest these foods. he had experienced illnesses such as cough and colds. As stated by him. and shrimps. Nevertheless. his liver cirrhosis was treated. they stayed at home and take enough rest. He was confined and treated at GRBAMH for one week for this incident. he can consume one bottle (bilog) and if it is beer. mumps. he totally stopped drinking alcoholic beverages as advised by his doctor. He has allergies to egg. which is about one to two bottles of beer in each month. his abdomen particularly his LUQ was stab by a friend while they were drinking.Past Health History During his childhood. however. For headache. For stomachache. there was no vital organ involved. wore black clothes and they do not take a bath until the rashes will gone. he felt pain from his RUQ. they just stayed at home. and they will use this as bath soap believing that this would kill the remaining bacteria in their wounds. he can consume 1-2 bottles of beer (mL). and when the vesicles will dry. For fever. . For measles. he went back to his vices. He again drinks alcoholic beverages but with a lesser amount and frequency. All were managed at home. when he was diagnosed to have cirrhosis. they stayed at home. They used to manage mumps through putting an ³akot-akot´ (mixed with water) on to their buccal area and below their ears. chicken. the ginger can lessen the pain due to its cooling effect. after his physician declared that he was already treated. they drink a decoction of ³Herba Buena´ and taking OTC drug such as Diatabs. they used to manage by putting a piece of sliced ginger on to their temporal and taking OTC drug like Biogesic and Cortal. All were managed at home if they can. before he had diagnosed to have liver cirrhosis. Fortunately. is also effective. headache and stomachache. the family usually consults a ³manghihilot´ which is according to him. the cooling effect of the ³akot-akot´ can help to reduce the pain. He loves to eat foods such as organ meats except liver. one of his medications was Godecs. After a year of treatment. For chickenpox. For cases of fractures. If it is GSM. fever. they burn hay and add with warm water. As he can remember. and measles. For cough and colds. According to him. and take drug such as Paracetamol. they also consult a physician if they cannot treat themselves alone. After one week. According to him. meat. drinking plenty of water and taking enough rest. In 1997. Five years ago. However. he decided to consult a physician here in Laoag City and was diagnosed of having liver cirrhosis. he will manifest rashes and itchiness. they take Asmasolon and Neozep. rest. nauseated and feels like vomiting. and vegetables. He had also experienced childhood diseases such as chickenpox. he used to drink alcoholic beverages such as beer and gin every day.

He was admitted on February 11. he was confined directly at the said hospital. 2010. knee. Laoag City for check-up with a complaint of swelling and severe pain on his right knee. ankle. the pain subsided even without any consultation and drugs taken. However. he went to GRBAMH. nodules were prominent in his elbow. he and his family decided to transfer him at MMMH and MC. After four months of attacks of pain. From his big toe. Mr. After a week. Emong felt a severe pain at his right lower leg especially at his right knee during late at night. After some weeks (1-2 weeks). on February 4. 2010 at 8:35 pm with an admitting diagnosis of Thopaceous Gouty Arthritis. nor took any drugs to relieve the pain thinking that this was only because he was tired from work. Again. From his check-up at the OPD Department. and fingers and skin eruptions to his right foot. he observed that there was an attack of pain in his big toe. he just took OTC drugs such as mefenamic acid to alleviate the pain and clean his wounds by just washing with soap and water. Five months ago. he does not give attention to this because he thought that he was only tired from work.Present Health History Ten years ago. His joints particularly his fingers were deformed. Batac City. Moreover. there was also an attack of pain in his ankle. R/O Septic Arthritis. and wrists. due to absence of progression to his condition. his right knee began to swell that made him difficult to ambulate. . He was brought to MMMH via ambulance per stretcher with an IVF of PLR 500 cc level. fingers. During this period. he does not seek medical advice.

life is not easy to both of them for they have faced the most difficult trials of their life and with determination and courage to countenance all these things. y . but according to him. one should abide by it. RELATING ONESELF TO ONE¶S SPOUSE AS A PERSON His wife works abroad. Havighurst¶s Theory of Developmental Task According to Havighurst. Whenever asks his help. but through proper communication. they easily resolve it. he accepts that the process of aging and degenerative changes is just but a normal toall creature. but if not. He also added that throughout the years. he had taught them the proper values and attitudes to live by in order to become better and fulfilled adults in the future. He also admitted that though there were times of argument. y ACCEPTING AND ADJUSTING TO THE PHYSIOLOGIC CHANGES OF MIDDLE AGE In this aspect. they were able to surpass it. they have been fulfilled because of the love and harmony they have always shared together. belongs to the MIDDLE AGE. ACHIEVING ADULT CIVIC AND SOCIAL RESPONSIBILTY Mang Emong claimed that in this aspect. 40 years of age. y y ASSISTING TEENAGE CHILDREN TO BECOME RESPONSIBLE AND HAPPY ADULTS He verbalized that from the start his children are growing up. He usually participates in barangay activities such as clean and green program as well as barangay fiestas. He also considers that the most important thing that he has shared to his children is the virtue of being God-fearing and responsible as well. He greatly believes that joining in such activities is vital since one is a part of the community and that. Somehow. he was able to carry out his role as an adult and an individual of the society. one must understand it and recognize the premise that human being continues to learn throughout life. Happiness is being achieved when a particular task of a certain age is achieved by the person successfully. the client stated that physical and physiologic activity gradually decreases from time to time.DEVELOPMENTAL DATA A. he never resist helping them as long as he can. in which the following tasks are very important to accomplish. failure occurs which is a feeling of unhappiness and disapproval from people surrounding the client Our patient. learning is fundamental to life and in order to have a deeper insight on growth and development.

thus. y DEVELOPING ADULT LEISURE TIME ACTIVITIES Mang Emong enjoys performing some leisure activities. Generativity is defined as the concern for establishing and guiding the next generation. ERIK ERIKSON¶S PSYCHOLOGICAL DEVELOPMENT THEORY Erikson considers life as composed of sequence of levels of achievement and each stage indicates a certain task to be achieved. he is now partially ready to go to the next stage of his life. B. productivity and concern for others. thus. his past time is reading ³bannawag magazines. . ANALYSIS: Mang Emong achieved the expected attitude and behavior at his age. Mang Emong 40 years old. Self-indulgence. The client attained the developmental tasks for him. He loves chatting with his codrivers while waiting for passenger. mentally. newspapers and listening to radio. belongs to the stage of adulthood. He is also fond of planting vegetables in their backyard. there are times that conflict arises. An achievement would mean a healthier personality while failure would also mean that the person will not be able to go to the next level and probably will lead to regression. This implies that he is physically. emotionally and socially prepared to whatever crisis or unexpected event that may occur. is those people who are unable to expand their interests at the time and who do not assume the responsibilities of a middle age suffer from a sense of boredom and impoverishment. he works as a tricycle driver and his earnings is placed only an important matter and he makes sure to spend the money wisely. but they believes that it¶s normal to a family¶s life. His relationship with his children is good since they maintain good closure and communication although. people have difficulty accepting their aging bodies and become withdrawn and isolated. self-concern. At home. His developmental task is to achieve GENERATIVITY which includes creativity. STAGNATION. lack of interests and commitment would mean a negative resolution.y ESTABLISHING AND MAINTAINING AN ECONOMIC STANDARD OF LIVING As the head of the family and as a provider he works hard to sustain their family needs. on the contrast.

Overall. He is still struggling generativity in its optimum level. he strongly believes that everything was planned by the Holy Father. He told that no matter what happens in his life. and physical aspects. The idea about generativity is reflected with his family of procreation and he does everything in order to keep his family in a stable state not only in the economic aspect but as well as in the social. emotional. He was able to fully realize his worth of life when he established his own family and gifted with 2 childrens who made his feel special.In the case of Mang Emong. Thereby. we could simply say that he was able to partially achieve the task appropriate for his age. He works hard to provide the things needed by his family. this means that he is ready to face any challenges and can easily adjust to any problems that may happen. . ANALYSIS: Mang Emong had satisfactorily achieved the initial task required at his age under Erikson.

He also drinks soft drinks.PATTERNS OF FUNCTIONING Eating Pattern Before illness During Illness Before hospitalization Mang Emong eats 4 times a day. thus. it is comprised of 2 pcs. it is composed of 1 cup of rice and 1 bowl vegetable. In the morning. For his snack. and 1-cup vegetables. And During hospitalization Mang Emong drinks 5-6 glasses of water a day for approximately 1200 ml-1400 ml per day. The decrease in fluid intake is brought by the decrease activity . the doctor ordered NPO in preparation of his surgery. For his lunch at 12 NN. During Illness Before hospitalization Mang Emong drinks 8-10 glasses of water a day wherein 1 glass is about 240 ml. 1 pc. His snack was comprised of 2 pcs. The change is brought by the discomfort & pain he is feeling. Analysis Mang Emong usually consumed 810 glasses of water a day where in 1 glass is approximately 240 ml. His breakfast is usually composed of 1 cup of rice. Drinking Pattern Before illness There is a change in the eating pattern of the patient as shown in the data given before & during his illness. 1-cup vegetables & 4-5 matchbox size of meat. he eats 1½ cup of rice. he takes his breakfast at the ³karinderya´ at around 5:30 AM. dried fish. Likewise. he was not used to the manner of serving as well as the food served was not his Food Preference. which is 6-6:30 PM. For his dinner. 1920 mL2400 ml per day. Before his operation. which is about 360 ml. & goes back to Low Purine Diet when he was brought back to the ward. 12 NN for his lunch & 6-6:30 PM for his dinner. it is composed of 1 cup of rice. of bread and soft drinks. His lunch is composed of 2 cup of rice. Egg/noodles. Analysis Mang Emong eats 4 times a day. 1 pc. It is usually composed of 1 bowl paksiw or sometimes ½ cup grilled meat. Sometimes. 5:30 AM for his breakfast. ½-cup meat. he could able to eat all ration but most of the times he can only consume ½ to ¾ of the hospital ration. For his dinner. He There is a change in his drinking pattern since there is a decrease fluid intake. During hospitalization Mang Emong was on Low Purine Diet. bread and soft drinks. & 1-cup vegetables.

1 bottle a day. During hospitalization He voids 2 to 3 times a day. In the afternoon he drinks liquor. His urine is usually clear light yellow without offensive odor. Analysis Mang Emong voids at least 6-8 times a day for approximately 1400 to 1500 ml/day. which is 360 ml or sometimes juice for about 240 ml. There is a change in his bladder elimination. The color of his urine is yellow. Usually. The client is wearing diaper. its consistency is soft and semi formed that During hospitalization Mang Emong defecates once every other day. usually 3 bottles of BEER at 1500 ml or 1 bottle of GIN (bilog) which is about 360 ml. of the patient. He changes his diaper two times a day which is partially soaked. Bladder Elimination Before illness During Illness Before hospitalization Mang Emong still voids 6 to 8 times a day approximately 1400 to 1500 ml/day. Total input each day is approximately 27002900 ml. . sometimes liquor for about 360 ml.also drinks soft drinks. Its consistency is watery that appears yellow in color. the decrease in frequency and amount of urine/voiding is attributed to the activity. His stool was usually soft and semi The change in the bowel pattern is brought by the decrease food intake and decrease ambulation activity. Bowel Elimination Before illness During Illness Before hospitalization He defecates once a day before taking a bath in the morning. Analysis Mang Emong usually defecates once a day early in the morning before taking a bath. Total input per day was approximately 25203780 ml.

Analysis Mang Emong sleeps early at night. He usually takes sleep at daytime. He usually takes nap during daytime 30 minutes in the am and about 45 minutes in the pm. his soap and sunsilk as his shampoo his bathing usually lasts 5 to 10 minutes. This is brought by the patient¶s inability to get up and ambulate. He wakes up at around 5-5:30 AM. He has 7 ½ hours of sleep each day. Bathing Patterns Before illness brown in During Illness Before During hospitalization hospitalization He usually takes a Mang Emong takes bath once a day. He has 5 to 5 ½ of sleep each day. There is an alteration in his sleeping pattern because the pain he feels interrupts him. color. every early in the morning. at around 7-8:00 PM. During hospitalization Mang Emong falls asleep at 11pm and awakes at 3am. He sleeps 9½-10 hours of sleep each day. morning with He uses green cross as assistance. He wakes up at around 3am. Analysis He usually takes a bath once a day. his bathing usually lasts 5 to 10 minutes. There is a change in his bathing pattern. He uses green cross as his soap and sunsilk as his shampoo. every a partial bath every early in the morning. which is 1 to 1 ½ hours. Sleeping Patterns Before illness During Illness Before hospitalization Mang Emong sleeps at around 9PM because the pain he feels was irritating him. .formed that appears appears brown in color.

There is no change in the emotional competency of the client because being lonely is just a normal response when one has illness. He understands that. or loses his temper. The support system he has helps him a lot to overcome to accept his condition. There is a change in his physical competency due to the client¶s inability to get up and walk alone. Analysis Emotional Competency Before illness During Illness Before hospitalization During hospitalization He feels lonely for his situation that he cannot do anything but lie in bed. During hospitalization He was not able to perform his usual activities of daily living. he does not let his self to be emotionally disturbed. He is able to verbalize whatever he wants and whatever he feels.LEVELS OF COMPETENCIES Physical Competency Before illness During Illness Before hospitalization Our client was able to do his activities of daily living without difficulty and assistance. he is able to express it but not to the extent that Although he feels lonely about his situation. . loving and responsible father. He is an expressive type of person. anyone could experience having a disease and this is just normal to all individuals. He can perform his usual activities but with limitations and he was not able to do his job as tricycle driver because he has difficulty of walking. He remains lying in bed most of the time. Analysis He is happy person. he tries his best to cope up and manage the feeling. He can also do his job as a tricycle driver and was able to support the needs of his family as a father and head of the family. When he gets mad. However. He asks assistance to his ³bantay´ whenever he needs something.

he face it with full strength and courage as well as with prayers to be able to surpass that challenge. However. He interacts well with other people. He also attends occasions and parties in their barangay as well as to their places whenever given the opportunity and time. He also added that when trials or challenges come. His condition is not a hindrance in dealing with other people.he will burst out. There was no change in the social competency of the client. He even participates in the activities of their barangay like Oplan Dalus. the way he treats and talk to other people stays the same. He entertains us very well when we visited him and answer our question thoroughly when we interviewed him. Analysis Our clients claim that he has a good relationship with their neighbor. . He minimizes going outside their house since he has difficulty in walking. Social Competency Before illness During Illness Before hospitalization During hospitalization He still able to socialize by merely talking to his inmates and to the health care provider staff.

and gratitude to the Lord and at the same time for the protection and guidance of the entire family. He is still the decision maker in the family and he can relate things that happened in the past and events that recently took place. He usually prays at night to ask forgiveness. He can recognize. understands our purpose to him. blessings. He competency. The client can recognize. person and events. person and events. recall place. He prayed harder and more often believing that what he is experience and suffering right now is just a test to his faith and soon he will be able to recover from that disease. Our client claimed that his faith in God becomes stronger. SPIRITUAL COMPETENCY Before illness During Illness Before hospitalization Our client and his family are religiously affiliated Pentecost faith. . He can relate things that happened in the past and things that just happened.INTELLECTUAL COMPETENCY Before illness During Illness Before During hospitalization hospitalization Our client claims that he is the one who made decision in the family. He claimed that they attend mass every Sunday and practice their own religious beliefs and practices. He still spiritual competency prayed harder and more often just like before hospitalization. There was no he can answer our change in the client¶s entire questions intellectual thoroughly. Analysis During hospitalization The client claimed There was no that his faith in God change in the clients remained strong. He can relate things that happened in the past and things that just happened. recall place. He was still the decision maker in his family. Analysis During interview.

Vital Signs taken as follows: Body temperature ± 37. Nose  nasal opening are symmetrical  with patent airway F.PHYSICAL ASSESSMENT The physical assessment was done last February 18. dull and dry C.15 teeth¶s in the upper jaw. Eyes  Both eyes are coordinated. General Appearance The patient was lying in bed awake and conversant with an IVF of PNSS 1 liter at 950 cc level regulated to 27 ± 28 gtts/min. with a pain scale of 7/10 and unable to get up. in pain.slightly dry.10C Blood pressure ± 130/90mmHg Pulse rate ± 81 bpm Respiratory rate ± 20 bpm A. 15 teeth¶s in the lower jaw .able to move freely  Teeth ± yellowish . 2010 at 5:00 pm. I. Head  Normocephalic  In proportion with the size of the neck and body  Can move up to 90° (able to move to its desired position but has slightly difficulty. Ears  Both auricles are proportional in shape  Tip of the ears are aligned to the outer cantus of the eye  Able to hear words when whispered 1 ± 2 feet away and responds E. B. It was a cephalocaudal physical examination. Mouth  Lips . blackish in color  Tongue . He is weak in appearance. Hair  Equally distributed black hair  short. moves in unison with parallel alignment  Brown colored iris  Pupils reaction to light-constrict  With eyebags D.

Abdominal  With 15 bowel sounds per minute  With scar noted J. Skin  brown complexion  cold skin Pale nail bed and thick nails with bandage at right knee right leg and ankle is swelling. shiny with wounds scattered at right leg discharges noted on the wounds with pinkish nodules on both feet poor capillary refill . enlarge joints of all fingers  white and rough palms  with pinkish nodules on both elbow. Gums -slightly blackish in color G. back of the palm and fingers  with scar on the left deltoid (BCG vaccination)  with tattoo at left arm K. Neck  Proportional to head and body  Can move side to side at 900 with minimal difficulty H. with limited mobility of the fingers. Upper extremities  untrimmed and dirty fingernails  pale (with poor capillary refill)  finger at the right arm are unflexible. Lower        I. Chest  Left and right portions are proportional  Color of the skin is equal to other body parts  With respiratory rate of 20 bpm I.

He complains of pain on his right leg with a pain scale of 5/10 Vital signs as follows: BP ± 120/80mmHg BT ± 36. He is weak in appearance and still unable to get up alone and ambulate. His right lower leg is swelling and with minimal discharges (pus and blood) from his wound noted. He is weak in appearance and unable to get up alone and ambulate.60C RR ± 20 breathe per minute PR ± 78 beats per minute February 20. His right lower leg is swelling and he complains of pain on his right leg with a pain scale of 6/10. He is wearing red shirt and black short with bandages at his right ankle and knees. He is wearing white shirt and black short with bandage at his right knee. 2010 @ 12:30 pm Second day of appraisal Mang Emong was lying in bed awake and conversant. awake and conversant with an IVF of PNSS 1L @ 500cc level regulated to 41-42 gtts/min.70C RR ± 21breathe per minute PR ± 80beats per minute . with an IVF of D5LRS @ 975 cc level regulated to 41-42gtts/min. 2010 @ 11:00 am First day of appraisal Mang Emong was lying on bed.ON GOING APPRAISAL February 19. Vital signs as follows: BP ± 130/80mmHg BT ± 36.

asleep. He is weak in appearance and with a pain scale of 8/10 Vital signs as follows: BP ± 140/100mmHg BT ± 36.70C RR ± 18 breathe per minute PR ± 75 beats per minute . 2010 @ 4 pm Fourth day of appraisal Mang Emong was lying in bed..50C RR ± 20 breathe per minute PR ± 76 beats per minute February 22. with an IVF of D5NSS 1L@ 950 cc level regulated to gtts/min. He complains of post op pain at the operative site with a pain scale of 8/10 Vital signs as follows: BP ± 110/90mmHg BT ± 37. and legs. 2010 @ 4 pm Third day of appriasal Mang Emong had just undergone debridement at his right knee and foot. About 30-40% of the bandage is soaked with yellowish discharges. with bandages at his right knee. awake and conversant with an IVF of PNSS1L@450cc level regulated to 41-42gtts/min.February 21. ankle.He was lying in bed.With bandages at his right knee and leg. He is weak in appearance and still unable to get up alone and ambulate.

suggest comparison with collateral knee.20-.10 Monocytes 0.08 . bone infection.07 RANGES 140-175 0.00 .00 g/L Hematocrit 0.MEDICAL MANAGEMENT X-ray/UTZ Chest AP  No definite radiographic abnormality  No definite active parenchymal infiltrates seen  Pulmonary vascularity is within normal limits  Heart is not enlarged  Diaphragm is normal in position and contour  Both costrophenic sulci and visualized bones are intact KNEE APC  No definite fracture or dislocation seen  Knee joint space appears narrowed.30 fL MCH 26.02-.32 10^9/L DIFFERENTIAL COUNT Segmenters 0. Analysis: The Chest AP was done to determine the accumulation of MSU crystals in the heart specifically in the myocardium. This examination can accurately identify fractures.50-. Abnormalities identified in x-ray frequently require more extensive diagnostic evaluations through radioisotope scans or biopsy.40 . X-ray is a radiographic examination of bones. and bone destruction. tumors.70 .120 10^12/L MCV 82. Hematology 2-11-10 INTERPRETATION Low Low Low Normal Low Normal High High Low Normal TEST RESULT CBC Hemoglobin 110. it shows an abnormal finding in the knee joint space which appears to be narrowed.5-5.9 80-100 27-32 31-35 4.20 pg MCHC Concentration 32.41-0.50 4. The knee APC was done to determine the extent of deformity and base from the result.34 RBC 4.40 g/dL WBC 25.50-11.77 Lymphocytes 0.

40 .04 0.70 fL MCH 26.08 .9 Pg MCHC Concentration 32.20-.03 Basophils 0.00 .41-0.20-.04 0.40 .00 Platelet count 495 10.001 150-450 TEST CBC Hemoglobin Hematocrit RESULT 94.11 Monocytes 0.08 .00 Platelet count 564 10.41-0.5-5.00 g/L Hematocrit 0.50-.41-0.50 .04 0.^9/L RANGES 140-175 0.70 .01 475 10.75 10^9/L DIFFERENTIAL COUNT Segmenters 0.02-.^9/L RANGES 140-175 0.20 g/L RANGES 140-175 0.26 10^9/L DIFFERENTIAL COUNT Segmenters 0.880 10^12/L MCV 81.32 RBC 3.36 RBC 4.00-0.00 g/L Hematocrit 0.50 4.00-0.50-11.5-5.04 Basophils 0.82 Lymphocytes 0.50-.20 g/dL WBC 29.001 150-450 Normal Normal High 2-13-10 INTERPRETATION Low Low Low Low Low Normal High High Low Normal Normal Normal High 2-16-10 @ 06:03 am INTERPRETATION Low Low Low Normal Low Normal High High Low Normal Normal Normal High 2-16-10 @ 3:57 pm INTERPRETATION Low Low TEST RESULT CBC Hemoglobin 116.01-.50 4.00-0.00 0.9 80-100 27-32 31-35 4.08 Monocytes 0.90 fL MCH 25.06 Eosinophils 0.00 .70 .480 10^12/L MCV 79.9 80-100 27-32 31-35 4.50-11.Eosinophils Basophils Platelet count 0.01-.40 g/dL WBC 33.06 Eosinophils 0.02-.01-.80 Lymphocytes 0.03 0.^9/L .001 150-450 TEST RESULT CBC Hemoglobin 102.30 pg MCHC Concentration 32.

60 g/dL WBC 29. and medication.01-.70 .70 4.20-.9 80-100 27-32 31-35 4.43 1.7-8. and the increased in platelet count indicates iron deficiency.22 1. Chemistry and Lipid Profile TEST Chemistry Glucose.50-. hemorrhage.00-0.90 pg MCHC Concentration 31.05 Eosinophils 0. increased WBC increases because of his inflammation likewise eosinophils.05 Basophils 0.80 fL MCH 25.2-6.82 Lymphocytes 0. Hbg.00 .3 Up to 35 Up to 45 <5.00 Platelet count 855 10.08 Monocytes 0.630 10^12/L MCV 81. Hct.55 <3.65 4. An increase in eosinophils may indicate allergic response including asthma.48 10^9/L DIFFERENTIAL COUNT Segmenters 0.RBC 3.08 . infectious and inflammatory D/O.4 1.36 2-12-10 INTERPRETATION Normal Normal High High Normal Normal Low Normal Analysis: . food.40 .46 0.94 49. MCH and lymphocyte while WBC.50-11.02-.17 <2.^9/L 4.5-5. FBS BUN AST ALT Lipid Profile Cholesterol Triglycerides HDL LDL RESULT 4.63 mmol/L mmol/L u/L u/L mmol/L mmol/L mmol/L mmol/L RANGES 4.28 >1.97 65. The decreased level of RBC due to excessive breakdown of cells. Eosinophils and platelet count increased.04 0. The decreased in MCU may indicate iron deficiency anemia.001 150-450 Low Normal Low Normal High High Low Normal High Normal High Analysis: The result shows that there was a decrease RBC.

Urine Analysis 2-12-10 TEST Physical Exam Urine Color Clarity Specific Gravity pH Chemical Exam Protein Glucose Hgb Ketone Nitrite Bilirubin Urobilinogen Leukoesterase Urinary Cells WBC RBC Epithelial Cells Bacteria Mucus Threads Renal Cells Yeast Cells Urinary Casts Hyaline Casts Fine Granular Casts Coarse Granular Casts Waxy Casts Urinary Crystals Amorphous Urate/phosphate Calcium Oxalates RESULT Yellow Slightly turbid 1. congestive heart failure. or resolving or prodromal hepatitis.5 (-) (-) +2 (-) (-) +1 +1 (-) 0-1 6-8 Rare Few Few (-) (-) (-) -/LPF -/LPF -/LPF -/LPF Few (-) HPF HPF Normal Normal Normal INTERPRETATION Normal Normal Normal Normal 0-1 0-1 0-1 0-1 . which are inadequate exercise and low purine diet. The decreased levels of HDL were because of his lifestyle. Slightly to moderately increased levels of ALT may indicate cirrhosis.Slightly to moderately increased levels of AST was because of his liver damage due to liver cirrhosis. myocardial infarction.015 6.

Date ordered: February 11. Analysis: The result shows normal findings. 2010 Nursing Responsibilities 1. conduction disturbances. To let the dietician know that the client is on low purine diet. 3. DIET THERAPY y Low Purine Diet . To gain cooperation for the client and family. Transcribe the diet ordered to the diet list. 4. hypertrophy of cardiac chambers. . Inform the watcher about the prescribe For them to be aware of the diet. which one of the causes hyperurecemia. Emphasize the purpose of diet therapy. It is also used to monitor pacemaker function and the effectiveness if some medications.Triple Phosphate Uric Acid (-) (-) ECG 2-12-10  Regular Sinus Rhythm  Within normal limits Electrocardiogram is frequently used to diagnose abnormal heart rhythms.This diet is indicated for the patient to minimize the production of uric acid. 2. Likewise. Check doctor¶s order. diet. it can also help monitor clients responses to therapy.and myocardial infarction. Rationale To identify what diet was ordered and to avoid mistakes.

5. Remove foods on the bedside table of the To avoid temptation to eat especially if the foods client. 4.This was indicated for decreasing the workload of the stomach. Regulate IVF properly (as ordered). are attractive to him. 2010 3. IVF is used to administer fluids that contain water. Inform the client and the watcher about the prescribed diet. 2010 Nursing Responsibilities 1. electrolytes and drugs. 2010 4. D5NSS 1 liter x 120 Date ordered: February 13. INTRAVENOUS THERAPY Intravenous therapy is an efficient and effective method of giving of liquids directly into a vein. for To meet the nutritional supplementation of nutritional supplementation. To gain cooperation from the client and family. Intravenous therapy is an important adjunct in the management of the seriously ill or injured patients.D5LRS 1 liter x 80 Date ordered: February 19. vitamins. IVF is considered the fastest way of absorption. dextrose. Date Ordered: February 20. about her diet. Keep all foods or fluids out of patient¶s To lessen patient¶s interest and to prevent sight. 2. Emphasize the purpose of diet therapy. Rationale For the patient to be aware and gain cooperation. 2010 . PLR 1 liter x 120 Date ordered: February 13. 2010 Date Administered: February 11. 1. our client. And to get real results. y NPO (Nothing per Orem) . Instruct the watcher to remind the client For the client not to eat and drink secretly. Plain Normal Saline Solution 1000 cc x 120 Date ordered: February 11. 2010 2. 3.5. stimulation of vagal nerves. It is a preparatory procedure for his operation.

2.to serve as evidence with the quality of care given. to clot. Observe aseptic technique in inserting -to prevent infection the IVF. 8.to prevent the occurrence of air embolism 7. or blood proteins are lost because of hemorrhage or disease or even because of an operation. to restore the capacity of the blood to carry oxygen and to provide plasma factors or platelet concentrate. it serves as a legal document as a basis for the continuity of care for health care providers. 6. . and to keep extra cellular fluid within the intravascular compartment. Blood transfusion When red and white blood cells. Compute and regulate for the infusion . to fight infection. Check for air bubbles in the tubing. Identify the client. 4.to prevent needle dislodgement . Explain the procedure to the patient. A blood transfusion is the introduction of whole blood components into the venous circulation. which prevent or treat bleeding. Change or stop the solution before it -to prevent air embolism empties. .Nursing Responsibilities: Responsibilities Rationale 1. 5. 9. Protect the insertion site. Document the procedure done. Mr. it is necessary to replace these components to restore the blood¶s ability to transport oxygen and carbon dioxide.to gain the cooperation of the client and eliminate doubts of the patient 3.to prevent fluid overload rate. . . Review doctor¶s order for the type of -to prevent inserting the wrong IVF intravenous fluid to be administered. this was given to him to restore his blood volume.to prevent inserting the IVF to the wrong patient . platelets.Emong was transfused with PRBC.

DATE ORDERED 2-11-2010 2-18-2010 DATE TRANSFUSED 2-12-2010 2-20-2010(1 unit) SERIAL NO. 8. normal saline solution. 2. Check also for the expiration date of the blood. The first 15 minutes is the time that abnormalities will show if there is any. Make sure that the only side drip is plain To prevent agglutination of blood. 3. 10. To avoid for any blood transfusion reaction. Secure consent. occur. observe aseptic To prevent transfer microorganism that will cause technique. Check the physicians¶ order for the To obtain correct blood component for the client number of units and type of transfusion to be given. only a few amount of blood is being infused. Check and record the vital signs. Start the infusion slowly and stay with To prevent overload and if any abnormalities will the patient for the first 15 minutes. Confirm client¶s identity. infection 7. Do hand hygiene. To avoid doing the procedure to the wrong patient. 6. in the blood bank. reactions. It is also a basis for the continuity of care. Document the procedure done. 4. It will serve as a legal document. Observe the client for an hour after the To check if there are abnormalities and BT transfusion. To secure both the patient and the health care provider for legal purposes.630611 TYPE OF BLOOD 2 units of PRBC 2 units of PRBC Nursing Responsibilities Nursing responsibilities Rationale 1. . 5. determine any allergies and previous transfusion. Check that the type and cross match has To check if there is available blood that is to be been completed and that the blood is ready transfused to the patient. 10-0772 2007. 9.

The assessment addresses the following points: y y y y y y the nature of the necrotic or ischaemic tissue and the best debridement procedure to follow the risk of spreading infection and the use of antibiotics the presence of underlying medical conditions causing the wound the extent of ischaemia in the wound tissues the location of the wound in the body the type of pain management to be used during the procedure . the procedure may be done in an operating room. The procedure can be performed at a patient's bedside. or important body features. the bacteria can cause inflammation and strain the body's ability to fight infection. however. burns. It is the quickest and most efficient method of debridement. frequently by inserting a gloved finger into the wound to estimate the depth of dead tissue and evaluate whether it lies close to other organs. Wounds that contain non-living (necrotic) tissue take longer to heal. or other instrument to cut dead tissue from a wound. scissors. bone. or if the patient is experiencing extreme pain. Though the wound is not necessarily infected. Necrotic tissue may also hide pockets of pus called abscesses.Debridement  Debridement is the process of removing nonliving tissue from pressure ulcers. but in some areas of the country an advance practice nurse or physician assistant may perform the procedure. Preparation The physician or nurse will begin by assessing the need for debridement. burns. It is the preferred method if there is rapidly developing inflammation of the body's connective tissues (cellulitis) or a more generalized infection (sepsis) that has entered the bloodstream. Surgical debridement is generally performed by a physician. The necrotic tissue may become colonized with bacteria. and other wounds. producing an unpleasant odor. Abscesses can develop into a general infection that may lead to amputation or death. If the target tissue is deep or close to another organ. The wound will be examined. Purpose Debridement speeds the healing of pressure ulcers. and other wounds Surgical debridement Surgical debridement (also known as sharp debridement) uses a scalpel.

. moist dressings are applied to promote wound healing. and an antalgic cream or injection may be applied. the wound is usually packed with a dry dressing for a day to control bleeding. the area may be flushed with a saline solution. Afterward. chemical. Aftercare After surgical debridement. If the antalgic cream is used. which frequently can take considerable time. Debridement may need to be repeated.Before surgical or mechanical debridement. Moist dressings are also used after mechanical. Many factors contribute to wound healing. it is usually applied over the exposed area some 90 minutes before the procedure. and autolytic debridement.

6. chest pain GI: nausea. dizziness. Drug may cause light-headedness. . Observed the 10 R's in administering medication. Frequency: 300-mg IV q 6 hours Mechanism of Action: Suppresses protein synthesis by microorganisms by binding to ribosomes and preventing peptide bond formation. abdominal pain. transcription. Administer the drug slowly. Frequency: 100 mg IV q 12 hours Mechanism of Action: Interferes with DNA gyrase and topoisomerase IV. Report tendon inflammation and pain to know when to discontinue the drug. fatigue. Topoisomerase IV plays a key role in the participation of chromosomal DNA during bacterial cell division. joint or back pain Skin: rash. leucopenia. Effective against both gram-positive and gramnegative microorganism Desired Effects: To inhibit growth of bacteria and to treat infection.Use caution with hazardous activities until reaction to drug is known. DNA gyrase is an enzyme needed for replication. To avoid wastage of the drug.Check doctor's order before giving medication 2. tremors. pruritus. Route. 5. Check patency of IV line. 3. and repair of bacterial DNA. thrombocytopenia Muscuskeletal: arthralgia. 4. drowsiness CV: Thrombophlebitis. 2. constipation. To prevent phlebitis. diarrhea. Generic Name: Clindamycin Brand Name: Cleocin Classification: Antibiotic Lincosamide Dosage. Route. dizziness. edema. blurring of vision. Side effect: abdominal pain. Generic Name: Ciprofloxacin Brand Name: Cipro Classification: Antibiotic Fluroquinolone Dosage.neutropenia. photosensitivity. or discomfort. drowsiness. Rationale To avoid mistakes To prevent administering wrong drug and administering to a wrong person. For immediate care.DRUG STUDY 1. Adverse effect: CNS: headache. erythema Other: hypersensitivity reaction Nursing Responsibilities 1. oral candidiasis Hematologic: eosinophilia. vomiting. restlessness.

dizziness. constipation. seizures Adverse Effect: CNS: drowsiness. Generic Name: Tramadol Hydrochloride Brand Name: Ultram Classification: Analgesics Dosage. vertigo. Because the drug may cause hypotension. Monitor BP and pulse in patients receiving drug parenterally. seizure CV: palpitations. oily skin Nursing Responsibilities 1. super infections in the mouth Adverse Effect: CV: hypotension. Side effect: nausea and vomiting. dryness. sweating. nausea.Desired Effect: To inhibit growth of bacteria and to treat infection. vomiting. urticaria. respiratory depression. irritation. drowsiness. Be alert for signs of super infection and anaphylactic reactions. tremors Skin: rash Nursing Responsibilities Rationale 1. vasodilations GI: nausea. nausea. abdominal pain Body as a whole: anaphylactic reaction. Frequency: 50-mg IV q 5 hours Mechanism of Action: A centrally acting synthetic analgesic compound not chemically related to opiates. Route.Check doctor's order before giving To avoid mistakes medication 2. cardiac arrest GI: nausea. diarrhea.Check doctor's order before giving medication 2. For immediate attention and intervention. constipation. eosinophilia. abdominal pain. Thought to bind to opoid receptors and inhibit re-uptake of norepinephrine and serotonin. Skin: maculopapular rash. 3. headache. Rationale To avoid mistakes To prevent administering wrong drug and administering to a wrong person. diarrhea. headache. Desired Effects: To relieve the pain Side effect: dizziness. diarrhea Hematologic: transient leucopenia. vomiting.Observed the 10 R's in administering To prevent administering wrong drug and . 4. vomiting. vertigo.Observed the 10 R's in administering medication 3.

medication 3. Advice client to increase intake of fluids unless contraindicated. 4. Monitor patient for seizures.

administering to a wrong person.

This is necessary to prevent the constipating effect of the drug. Drug may reduce seizure threshold.

4. Generic Name: Paracetamol Brand Name: Acetaminophen Classification: Antipyretics Dosage, Route, Frequency: 300mg. IV q 5 hours Mechanism of Action: Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating center. Desired Effects: To decrease body temperature. Side effect: nuetropenia, luekopenia, pancytopenia, hypoglycemia Adverse Effect: CNS: headache CV: chest pain, dyspnea GI: hepatic toxicity and failure GU: Acute renal failure, renal tubular necrosis Hematologic: pancytopenia, hypoglycemia Hypersensitivity: rash, fever Nursing Responsibilities 1.Check doctor's order before giving medication 2.Observed the 10 R's in administering medication 3. Administer after meals. 4. Discontinue drugs if hypersensitivity reaction occurs. Rationale To avoid mistakes

To prevent administering wrong drug and administering to a wrong person. To prevent GI upset. To prevent further reactions and for immediate care. 5.Do not take other medications containing Overdosing can cause liver damage and other acetaminophen without medical advice toxic effects. 5. Generic Name: Captopril Brand Name: Capoten Classification: Antihypertensive Dosage, Route, Frequency: 25mg 1 tab.SL for Bp >160/180 Mechanism of Action: Inhibits ACE preventing conversion of angiotensin I to angiotensin II a potent vasoconstrictor. Less angiotensin II decreases peripheral arterial

resistance, decreasing aldosterone secretion, which reduces sodium and water retention and lowers blood pressure. Desired Effects: To lower blood pressure Side Effects: Hives, severe stomach pain, difficulty in breathing, and swelling of the face, lips, tongue, or throat Adverse Effect: CV: Slight increase in heart rate, first dose hypotension , dizziness, fainting GI: altered taste sensation (loss of taste perception, persistent salt or metalic taste); weight loss, intestinal angioedema. Hematologic: Hyperkalemia, neutropenia, agranulocytosis (rare) Respiratory: cough Skin: Maculopopular rash, urticaria, pruritus, angioedema, photosensitivity. Urogenital: azotemia, impaired renal function, nephrotic, syndrome, membranous glomerulonephritis

Nursing Responsibilities 1.Check doctor's medication order before

Rationale giving To avoid mistakes

2.Observed the 10 R's in administering To prevent administering wrong drug and medication administering to a wrong person. 3.Raised bedside rails To prevent falling since these drug can cause dizziness

4.Monitor BP closely following the first A sudden exaggerated hypotensive response dose. may occur within 1-3 hours of first dose, especially in those with high BP or on a diuretic and restricted salt intake. 5.Advise the patient to report discomfort like cough, dizziness. any for early detection and early prevention

6. Generic Name: Colchicine Brand Name: Colgout Classification: anti-inflammatory Dosage, Route, Frequency: one tab. TID

Mechanism of Action: As an anti-inflammatory drug,it will decrease WBC motility, phagocytosis and lactic acid production.decreasing urate crystal deposits and reducing inflammation. As an antiosteolytic drug,may inhibit mitosis of osteoprogenitor cells and decrease osteoclast activity. Desired Effects: to reduce inflammation Side effect: nausea and vomiting, loss of appetite, loss of hair Adverse Effect: GI: nausea, vomiting, abdominal pain, anorexia Hematologic: bone marrow depression CNS: Mental confusion, peripheral neuritis Skin: severe irritation and tissue damage Nursing Responsibilities 1.Check doctor's order before giving medication 2.Observed the 10 R's in administering medication 3. Monitor I&O ratio and pattern. Rationale To avoid mistakes

To prevent administering wrong drug and administering to a wrong person. High fluid intake promotes excretion and reduces danger of crystal formation in kidneys and ureters. 4.Discuss the dosage regimen with patients So that patients know when to stop the drug who have been using colchicines. before GI aside effects occur. 7. Generic Name: Omeprazole Brand Name: Losec Classification: Proton Pump Inhibitor Dosage; Route; Frequency: 40 mg x 1 dose /10 am Mechanism of Action: Suppresses gastric secretion by specific inhibition of the hydrogenpotassium ATPase enzyme system at the secretory surface of the gastric parietal cells thereby it blocks the final step of acid production. Desired Effects: This drug was given to our patient to decrease gastric irritation caused by over secretion of hydrochloric acid. Side effect: Headache, dizziness, diarrhea, flatulence, nausea, and vomiting Adverse Effect: CNS: headache, dizziness, vertigo, insomnia, apathy, anxiety,paresthesia Skin: rash,urticaria, pruritus, dry skin GI: diarrhea, abdominal pain, nausea, vomiting, dry mouth, constipation Respiratory: cough and epistaxis

drowsiness.Nursing Responsibilities 1. To avoid aggravating the condition. In cases of rashes. insomnia. Because it may cause dizziness and drowsiness. Check for the patency of the IV line. pain. advice patient not to scratch the affected areas. Generic Name: Celecoxib Brand Name: Celebrex Classification: NSAIDS . Instruct patient to avoid eating sour tasting foods. Instruct patient to avoid eating large meal. Advice patient to avoid activities requiring alertness. dry mucus membrane GI: nausea. diarrhea. fatigue. sweating. tinnitus Skin: rash. constipation. the 9. dyspepsia. vomiting. Desired Effects: to relieve pain Side effect: dizziness. 2. 4. Advice client to increase intake of fluids. nausea. constipation Adverse Effect: CNS: headache. pruritus. Route. dyspepsia. sedation. vomiting. 6.Check doctor's medication 2. 5. Frequency: 30 mg x 6 hours x 4 doses Mechanism of Action: It inhibits synthesis of prostaglandin by inhibiting both COX 1 and COX2 enzymes. 3. headache. Caution patient to avoid activities requiring In order to prevent injury since dizziness alertness until response to medication is known. Rationale To avoid wastage of the drug. dizziness.Observed medication the 10 order R's before Rationale giving To avoid mistakes in administering To prevent administering wrong drug and administering to a wrong person 4. Because it may lead to bruises and will increase the tendency of infection. flatulence Nursing Responsibilities 1. 8. To prevent further irritation of gastric mucosa. and drowsiness may occur. Generic Name: Ketorolac tromethamine Brand Name: toradol Classification: Non-steroidal anti-inflammatory drug Dosage. This is necessary to prevent constipating effect of the drug.

Observed the 10 R's in administering medication 3 . . headache. NSAIDS during therapy. peripheral edema GI: abdominal pain. analgesic. dyspepsia.inflammatory. insomnia Nursing Responsibilities 1. abdominal pain diarrhea.Dosage. flatulence. nausea Adverse Effect: Body as a whole: back pain.Instruct patient to take drug with food or milk Rationale To avoid mistakes To prevent errors For better absorption thus maximum therapeutic effect of the drug will be achieved and to prevent GI upset 4. OD Mechanism of Action: Exhibit anti. diarrhea. Route. flatulence. Desired Effects: Non-steroidal anti-inflammatory drug Side Effect: dizziness.pyretic action due to inhibition of COX. headache. and anti. Cap. Tell patient to avoid aspirin or other Because it can cause GI bleeding. nausea CNS: dizziness. Frequency: 40 mg.Check doctor's order before giving medication 2.2 enzyme.

Investigate any reports of unusual/ sudden pain or deep. promotes sense of control and enhances coping abilities.NURSING CARE PLAN 1. Administer medication as ordered (toradol) RATIONALE 1. Improves general circulation. 4. the client was able to verbalize relief of pain. 3. 5. 2. 7. reduces areas of local pressure and muscle fatigue. Perform a comprehensive assessment of pain to include location. To relieve pain. Tophi can cause pain and stiffness in the affected joint. displayed relaxed manner as well as rest/ sleep appropriately. Perform and supervise active/ passive ROM exercises. 5. NURSING DIAGNOSIS: Pain related to inflammation of joints as evidenced by verbal reports. Maintains strength/ mobility of unaffected muscles and facilitates resolution of inflammation in injured tissues. Refocuses attention. guarding behavior and a pain scale 6/10. NURSING EVALUATION: After 3 days of rendering of nursing intervention. Relieves pain. displayed relaxed manner as well as rest/ sleep appropriately. To provide a base line data and monitors effectiveness of interventions. characteristics. frequency and quality. 4. 6. Provide alternative comfort measures. May signal developing complications. the client will be able to verbalize relief of pain. 7. NURSING INFERENCE: Excessive accumulation of uric acid in the joints causes acute gouty arthriris which if left untreated will lead to repeated attacks and this may cause tophi formation. . NURSING GOAL: After 2-3 days of rendering of nursing intervention. NURSING INTERVENTIONS 1. Maintain immobilization of affected part by means of bed rest. 2. progressive. 6. onset/duration. 3. Provide emotional support and encourage use of stress management techniques. and poorly localized pain unrelieved by analgesics.

5. NURSING INFERENCE: Acute attacks are characterized by severe pain in the joints. decreasing risk of urinary infection. the client will be able to maintain position of function and demonstrate techniques that enable resumption of activities. 8. Maintain stimulating environment. initiate bowel program(stool softener. RATIONALE 1. NURSING DIAGNOSIS: Impaired physical immobility related to joint pain evidenced by reluctance to attempt movement. Keeps the body well hydrated. Client may be restricted by self. requiring interventions to promote progress toward wellness. Monitor BP with resumption of activity. Encourage use of isometric exercises starting with unaffected limb. Improves muscle strength and circulation. Encourage participation in diversional / recreational activities.view/ selfperception out of proportion with actual physical limitations. 4. enema. enhances client control in situation and promotes self. 5. 7. especially ADLs. often in the big toe radiating in the ankle. 4. Instruct/ Assist client in active/passive ROM exercises of affected and unaffected extremities. Postural hypertension is a common a problem following prolonged bed rest 7. .directed wellness. Assess degree of immobility/ treatment and note client¶s perception of immobility. enhances client¶s sense of control and aids in reducing social isolation. Increases blood flow to muscles and bone to improve muscle tone. wrist. ands helps to prevent constipation. 2. Assist or encourage self. 3. Encourage increased fluid intake to 20003000 mL/day. 6. laxative) as indicated. hip. knee. maintain joint mobility. 8.2. NURSING INTERVENTION 1. 6. Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass.care activities. 3. stone formation. Refocuses attention. or elbow that leads the client to limit or restricted movement as well as alteration in physical capacity. shoulders. NURSING GOAL: After 2-3 hours of rendering of appropriate nursing interventions. 2. limited range of motion and therapeutic restriction movement. to promote regular bowel evacuation and prevent constipation.

7. 7. skin color and warmth distal to affected area. increased/diffuse rain occurs when there is inadequate circulation to nerves or nerve damage. and this will cause decrease tissue perfusion. cool skin indicates arterial impairment.Monitor Hgb/hct and prothrombin time levels. White. Measure affected extremity and compare with unaffected extremity. the client was able to maintain position of function and demonstrate techniques that enable resumption of activities. noting changes in motor/ Sensory function. 3. especially ADLs. Note signs of general pallor/ cyanosis. 3. 2. 5. numbness. cool skin. 3. NURSING GOAL: After 2-3 hours of rendering nursing interventions. Ask patient to localize pain/ discomfort. Assess capillary return. NURSING INFERENCE: The decrease of RBC in the body leads to decrease oxygen carrying capacity. 8. Cyanosis suggests venous impairment.NURSING EVALUATION: After 3 hours of rendering appropriate nursing interventions. 4. Blood transfusion as prescribed. Increasing circumference of affected extremity may suggest general tissue swelling. 5. 8. Inadequate circulating volume compromises systemic tissue perfusion. especially in the lower extremities. NURSING INTERVENTIONS 1. Perform neurovascular assessment. 6. the client will be able to demonstrate behaviors/ lifestyle changes to improve circulation and increased perfusion as individually appropriate. To decrease tension level. 6. Encourage client to routinely the exercise digits/ joints distal to affected area. 4. To maintain circulating volume. hence oxygen supply also decreases. tingling. enhancing . Enhances circulation and reduces pooling of blood. NURSING DIAGNOSIS: Ineffective peripheral tissue perfusion related to reduction/interruption of blood flow as manifested by poor capillary refill and cold skin. Return of color should be rapid (3-5 seconds). Monitor vital signs. Impaired feeling. 2. changes in mentation. Assess entire length of affected extremity for swelling. Assist in calculation of blood loss and effectiveness of replacement therapy. Demonstrate or encourage use of relaxation techniques. RATIONALE 1.

Refer to dietitian and adhere to prescribed diet. the client will verbalize relief of discomfort and achieve timely wound/ lesion healing. To assists body¶s natural process of repair. Place water pads/ other padding under elbows/ heels as indicated. carefully dress wounds. tophi break through the skin and appear as white or yellowish ±white and this may cause disruption of skin integrity. To enhance healing. 3. and elsewhere in the body. In some cases. joints. NURSING DIAGNOSIS: Impaired skin integrity related to tophi break through the skin as evidenced of disruption of skin surface and presence of discharges. Provides information regarding skin circulation and problems that may require further medical intervention. 2. Obtain specimen from draining wounds. 2. 4. NURSING EVALUATION: After 3 hours of rendering nursing interventions. NURSING INFERENCE: In tophaceous gout arthritis. bones. . Examine the skin for open wounds and its discharges. To determine appropriate therapy. RATIONALE 1.tissue perfusion. the client was able to demonstrate behaviors/ lifestyle changes to improve circulation and increased perfusion as individually approach. NURSING GOAL: After 1-2 weeks of appropriate nursing interventions. NURSING INTERVENTION 1. Reduces pressure on susceptible areas and risk of abrasions / skin breakdown. 4. 3. which are solid deposits of Mono Sodium Urate crystals that form in the cartilage. Keep the area clean/ dry. reduce risk of recurrence of tophi formation. the client will verbalize relief of discomfort and achieve timely wound/ lesion healing. NURSING EVALUATION: After 1 week of appropriate nursing interventions. 4. Keeps the bed linens dry and free wrinkles. 5. 5. it often produces tophi.

NURSING EVALUATION: After 2 days of rendering nursing interventions. and rashes may require treatment. basic hygienic needs may be forgotten. including care of hair/nails/ skin. NURSING INFERENCE: Our patient wasn¶t able to get up and walk alone that leads him to have a deficit in self care activities as well as because of severe pain at and around the affected joint as characterized like ³crushing´ or a dislocated bone. etc. NURSING GOAL: After 2-3 days of rendering nursing interventions. ³Han nak unay makaturog ta sumro iti sakit ti sakak nu rabii ´ and presence of eye bag. Eases the frustration over lost independence. 3. Presence of such lesions as ecchymoses. 3. as well as signal need for closer monitoring/ protective interventions. Involve in bowel/ bladder program as appropriate. Provide reminders for elimination needs. Supervise but allow as autonomy as possible. 6. 6. 7. . 4. NURSING DIAGNOSIS: Self-care deficit related to pain and discomfort as evidenced by impaired ability to perform ADLs. Be attentive to nonverbal physiologic symptoms. 4. As the disease progresses. 7. NUSING INTERVENTIONS 1. the client will be able to perform self care activities within level of own ability. Maintaining routine may prevent worsening of confusion and enhance cooperation. Inspect skin regularly RATIONALE 1. Determine hygiene needs and provide assistance as needed with in activities. 2. 5. the client was able to perform self care activities within level of own ability. lacerations. Good hygiene promotes cleanliness and reduces risk of skin irritation and infection. Sensory loss and language dysfunction may cause client to express self are needs in non verbal manner. 5. NURSING DIAGNOSIS: Sleep pattern disturbance related to pain as manifested by verbal complaints of difficulty falling asleep. brushing teeth. 2.5. Incorporate usual routine into activity schedule as possible. Loss of control/ independence in this self care activity can have a great impact on self esteem and may limit socialization. Assist with and provide reminders for pericare after toileting/ incontinence. 6.

To identify the most appropriate interventions to that specific disease. redness. RATIONALE 1. Provides opportunity to address misconceptions/unrealistic expectations as well as occurrence of pain. and warmth of the affected joint. time arising of pain and environmental factors.NURSING INFERENCE: The abrupt onset of pain of gout arthritis occurs at night. To determine usual sleep pattern and provide comparative baseline data. number of hour of sleep. Observe and obtain feedback from patient regarding usual bedtime. 4. NURSING INTERVENTION 1. 2. 3. Administer pain medication one hour before sleep as ordered. swelling. the client will be able to establish adequate sleep pattern and report rested. NURSING GOAL: After 2-3 days of rendering nursing intervention. Assess sleep pattern disturbances that are associated with specific underlying illnesses. Determine patient¶s/ SO¶s expectations of adequate sleep. routines. 2. awakening the patient with severe pain. 4. To relieve discomfort and take maximum advantage of sedative effect. the client will be able to establish adequate sleep pattern and report rested. NURSING EVALUATION: After 3 days of rendering nursing intervention. 3. .

. he was also placed on NPO in preparation for is operation. During his stay in the hospital. He had rendered total nursing care at the hospital. R/O Septic Arthritis. Gout at the Mariano Marcos Memorial Hospital and Medical Center. currently residing at Bacarra. Emong Aguilla.GENERAL EVALUATION: Mr. His admitting diagnosis was Thopaceous Gouty Arthritis. His diet was low purine diet. however. he had received intravenous therapies. medications and surgical debridement. Batac City on February 11. Ilocos Norte was admitted by Dr. 40 years old. blood transfusion. 2010 at 8:35 in the evening with a chief complaint of swelling of right lower extremities and with diffuse tophi.

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