UNIVERSITY OF SOUTHERN PHILIPPINES FOUNDATION Salinas Drive, Lahug, Cebu City COLLEGE OF NURSING CASE STUDY PATIENT PROFILE
Name : V.N.C. Age : 11 years old Sex : Male Status : Single Address : Buena Hills, Sambag II Guadalupe Cebu City Name of Hospital : Vicente Sotto Memorial Medical Center Date of Admission : November 9, 2008 Ward and Bed no. : Ward VIII, bed no. 27 Case no. : 813890 Chief Complaint : Left Hip Pain Medical Diagnosis : Chronic Osteomyelitis Left Proximal Femur HEALTH ASSESSMENT 1. History of Present Illness: V.N.C., 11 years old, Male, Single, Filipino, Roman Catholic and a resident of Buena Hills, Sambag II Guadalupe Cebu who was admitted for the first time at Vicente Sotto Memorial Medical Center on November 9, 2008. Months prior to admission, patients left thigh was accidentally hit by a foot during at a game, since that time patient was noted to limp. Regular manipulation by a hilot was done, 3 months prior to admission patient started having left hip pain thus ruptured with a yellow green fluid oozing from an opening. Patient was unable to walk since this time due to pain, consult were sought and advised X-ray at left hip in anterior posterior view, and they were referred to hospital but due to financial problems they declined.. One day prior to admission, they went to a local Health center and was seen by a nurse who referred them to VSMMC thru this admission. 2. Gordon’s Functional Health Patterns:
Health Perception and Health Maintenance
Past: Patient sees himself as a very “kiat” person. He said that “sauna sige ra mn ko ug duwa oi, unya mag skwela sad katong wa pud ko masakit”. Present: Now patient sees himself as “luoy” because he is at the hospital and is doing nothing and he is so restless.
Nutrition and Metabolism
Past: Patient ate more than 6 times daily per day including snacks. He loves to eat pork especially “humba” and also chicken. His mother claims that he has no allergy to foods nor drugs, he also drinks about 4-5 glass of water per day. Present: Patient doesn’t want to eat a lot in the hospital, he only eats a bit if his mom forces him, but he takes all his medicines while at the hospital. 2.3 Elimination
Past: Patient usually defecates everyday early in the morning and urinates approximately 4-6 times per day. He doesn’t have any difficulties in defecation and urination. The color of his stool is brown and his urine is yellow as claimed by the patient. Present: Patient usually defecates at bedpan and urinates at the urinal because he has difficulty standing up and going to the comfort room because of his present condition. But other than that he has no other problems. 2.4 Activity and Exercise
Past: Patient played a lot at school before with his classmates, he doesn’t have any exercise routines. Present: Patient has been very sad these days because he cant do want is usual to him. He can’t even stand up on his own.
Cognition and Perception
Past: Patient was able to communicate with her parents and he understands very well if he is taught something. He is also responsive, attentive, and answered the questions with enthusiasm. Present: Patient still understands, and communicates well but after his hospitalization and operation his mood changes a bit. As claimed but his mother. 2.6 Sleep and Rest
Past: Patient sleep early at night usually at around 8:00-9:00 pm and wakes up at 6:00 am. He doesn’t take a nap during afternoon because his class is until 4:30 pm Present: Patient always sleeps at the hospital because he has nothing to do. 2.7 Sexuality and Reproduction
Self-perception and Self-concept
Past: Patient worked hard for his studies because he want to become a doctor someday and help his mother. Present: Patient is still working hard. But now it’s not in his studies but in retrieving his health and do his daily activities. 2.9 Roles and Relationships
Past: Patient had a good relationship with his family, he often plays with his siblings at home and help his mother in household chores. Present: Patient still has a good relationship towards his family especially his mother who is taking care of him in the hospital and he is also doing everything to help himself.
Stress Tolerance and Coping
Past: Patient lies down when he is too tired or just watch television. Present: Patient usually talk with his mother to cope up, he will just tell his mother his aches or pain if there’s any. He gets his inspiration from his family. 2.11 Values and Belief Past: Patient goes to Church with his family every Sunday. But if there are times that they cannot make it to Church they would just still say their prayers at home. Present: Due to patients hospitalization he cant make it to Church but then again he is not that sad not to go to Church because even if he is at the hospital he still can say his prayers. 3. Physical Examination 3.1 General Survey
Patient is lying on bed with IVTT PNSS 1L at 30gtts/min. He is wearing blue short pants and white t-shirt. He looks lively and smiles a lot. Vital Signs: T- 36.7°C P- 85 bpm R- 22 cpm BP- 80/60 mmHg
INSPECTION Skin is brown in pigment. Free from lesions.
PALPATION Skin is smooth and warm to touch. Soft and with good skin turgor. No mass palpated.
Evenly distributed, thick, silky, resilient hair, no infection
or infestation Convex curvature, smooth texture, highly vascular and pink, intact
Capillary refill time less than 2 seconds.
epidermis. Normocephalic, symmetrical facial features, symmetric facial movement, no flaking of scalp, no lesion.
Smooth uniform consistency; absence of nodule and masses.
Muscles equal in size, coordinated movements with no discomfort upon rotation of head. Visible
Non-palpable lymph nodes, trachea is at midline of neck
CERVICAL LYMPH NODE 3.4 MOUTH
thyroid gland. No visible lymph nodes. Teeth are smooth, white and shiny. Pink gums. Tongue is at the center, pink in color, smooth lateral margins, no lesions, moves freely. No foul odor and no
Moist mucous membranes and firm texture of gums
discharges. Symmetrical and straight Uniform in color. No
SINUS 3.5 EYES
lesions. Sinuses are transilluminate. Eyebrows
Non-tender, no mass. Non tender
symmetrically aligned; equal movement. Skin is intact; no discharge, no discoloration of eyelids. Sclera appears white and shiny. Pink EAR conjunctiva. Color same as facial skin tone, symmetrical, auricle aligned with outer canthus of eye. No discharges with minimal 3.6 THORACIC & LUNG cerumen. Uniform in color with intact skin. Symmetrical lung expansion. No structural deformity. Warm, nontender, no mass felt. Bilateral symmetry of vocal fremitus. Resonance heard in areas of the lung field. Dullness over scapula. Bronchial or tubular breaths sounds heard in the upper area of the thoracic cavity or over the trachea, Mobile, firm, non tender pinna, pinna recoils after it is folded.
Fremitus is heard most clearly at the apex of the lungs. 3.7 CARDIOVASCULAR No bulging, and non-observable apical pulse Thrills, heaves, or abnormal pulsations are not present. Apical impulse is felt at the fifth 3.8 BREAST Skin is smooth and uniform in color. Nipple is symmetrical with equal size. No 3.9 ABDOMEN discharges. Flat and uniform in color to other areas of body. Symmetrical movements caused by ICS. No tenderness, masses and nodules palpated. No tenderness. Dullness heard over the liver and tympany heard on the left upper quadrant.
bronchovesicula r over the lung fields and vesicular at the bases of the lungs. S1 and S2 are heard in expected locations with expected intensities; no extra sounds or murmur are present.
Gurgling sounds heard with no hyperactive sounds.
3.10 GENITOURINARYREPRODUCTIVE 3.11 NEUROLOGIC
respiration. No discharges
I. Olfactory II. Optic III. Oculomotor
>Patient was able to identify mild aromas. >Emmetropic and with clear vision. >follows the 6 cardinal gaze >pupil is equally round reactive to light accommodation
IV. Trochlear V. Trigeminal
>follows the six cardinal gaze >corneal reflex test positive >positive light sensation >can feel pain on both sides of the face >patient was able to clench teeth
VI. Abducens VII. Facial
>follows the six cardinal gaze >can frown, smile at the same time >can identify the taste placed on the tip and sides of tongue
VIII. Acoustic IX. Glossopharyngeal
>able to hear whispered words on both ears > can identify taste on posterior tongue > can move tongue from side to side & from up and down
>no hoarseness of speech >palate and uvula elevates simultaneously
XI. Accessory XII. Hypoglossal
>elevates shoulder with force >able to stick tongue out >can move tongue from side to side
4. Diagnostic and Laboratory Tests Date: January 6, 2009 Test: Hematology (complete blood count) Components Erythrocytes Number 4.39/µL Normal Values Male: 4.6-6.2 x 10 /µL Female: 4.2-5.9 x 10 /µL Decreased Significance polycethymia Anemia, leukemia and hypothyroidism
Acute leukemia, infections and surgery Anemia Leukemia and hemorrhage Anemia Anemia Anemia Hemolytic anemia
140-180 Male: 45-52% Female: 37-48% 80-94fL 27-31pg 330-370g/dL 11-16%
MCV MCH MCHC RDW
76.5fL 24.9pg 325g/dL 17.9%
Decreased Decreased Decreased Increased
disorder and thromboembolism
Urine Analysis Component s Color Result Normal Values Yellow to Amber Significance
Pale yellow Clear
Specific Gravity Reaction Sugar
Uric Acid RBC
Negative <2 Presence Identify the presence of the infection Identify the presence of the infection Identify the presence of the infection
Squamous Epithelial Cells Bacteria
Bacteriology (culture) Date: November 11,2008 Specimen: Wound discharge Result: Moderate growth of pseudomonas aeruginosa.
Anatomy and Pathophysiology: 1. Anatomy The Femur
FIG. a.j. – Upper extremity of right femur viewed from behind and above. The femur, the longest and strongest bone in the skeleton, is almost perfectly cylindrical in the greater part of its extent. In the erect posture it is not vertical, being separated above from its fellow by a considerable interval, which corresponds to the breadth of the pelvis, but inclining gradually downward and medialward, so as to approach its fellow toward its lower part, for the purpose of bringing the knee-joint near the line of gravity of the body. The degree of this inclination varies in different persons, and is greater in the female than in the male,on account of the greater breadth of the pelvis. The femur, like other long bones, is divisible into a body and two extremities.
The Upper Extremity (proximal extremity, Fig. a.j.).— The upper extremity presents for examination a head, a neck, a greater and a lesser trochanter. The Head (caput femoris).—The head which is globular and forms rather more than a hemisphere, is directed upward, medialward, and a little forward, the greater part of its convexity being above and in front. Its surface is smooth, coated with cartilage in the fresh state, except over an ovoid depression, the fovea capitis femoris, which is situated a little below and behind the center of the head, and gives attachment to the ligamentum teres. The Neck (collum femoris).—The neck is a flattened pyramidal process of bone, connecting the head with the body, and forming with the latter a wide angle opening medialward. The angle is widest in infancy, and becomes lessened during growth, so that at puberty it forms a gentle curve from the axis of the body of the bone. In the adult, the neck forms an angle of about 125° with the body, but this varies in inverse proportion to the development of the pelvis and the stature. In the female, in consequence of the increased width of the pelvis, the neck of the femur forms more nearly a right angle with the body than it does in the male. The angle decreases during the period of growth, but after full growth has been attained it does not usually undergo any change, even in old age; it varies considerably in different persons of the same age. It is smaller in short than in long bones, and when the pelvis is wide. In addition to projecting upward and medialward from the body of the femur, the neck also projects somewhat forward; the amount of this forward projection is extremely variable, but on an average is from 12° to 14°. The neck is flattened from before backward, contracted in the middle, and broader laterally than medially. The vertical diameter of the lateral half is increased by the obliquity of the lower edge, which slopes downward to join the body at the level of the lesser trochanter, so that it measures one-third more than the antero-posterior diameter. The medial half is smaller and of a more circular shape. The anterior surface of the neck is perforated by numerous vascular foramina. Along the upper part of the line of junction of the anterior surface with the head is a shallow groove, best marked in elderly subjects; thisgroove lodges the orbicular fibers of the capsule of the hip-joint. The posterior surface is smooth, and is broader and more concave than the anterior: the posterior part of the capsule of the hip-joint is attached to it about 1 cm. above the intertrochanteric crest. The superior border is short and thick, and ends laterally at the greater trochanter; its surface is perforated by large foramina. The inferior border, long and narrow, curves a little backward, to end at the lesser trochanter. The Trochanters.—The trochanters are prominent processes which afford leverage to the muscles that rotate the thigh on its axis. They are two in number, the greater and the lesser.
The Greater Trochanter (trochanter major; great trochanter) is a large, irregular, quadrilateral eminence, situated at the junction of the neck with the upper part of the body. It is directed a little lateralward and backward, and, in the adult, is about 1 cm. lower than the head. It has two surfaces and four borders. The lateral surface, quadrilateral in form, is broad, rough, convex, and marked by a diagonal impression, which extends from the posterosuperior to the antero-inferior angle, and serves for the insertion of the tendon of the Glutæus medius. Above the impression is a triangular surface, sometimes rough for part of the tendon of the same muscle, sometimes smooth for the interposition of a bursa between the tendon and the bone. Below and behind the diagonal impression is a smooth, triangular surface, over which the tendon of the Glutæus maximus plays, a bursa being interposed. The medial surface, of much less extent than the lateral, presents at its base a deep depression, the trochanteric fossa (digital fossa), for the insertion of the tendon of the Obturator externus, and above and in front of this an impression for the insertion of the Obsturatorinternus and Gemelli. The superior border is free; it is thick and irregular, and marked near the center by an impression for the insertion of the Piriformis. The inferior border corresponds to the line of junction of the base of the trochanter with the lateral surface of the body; it is marked by a rough, prominent, slightly curved ridge, which gives origin to the upper part of the Vastus lateralis. The anterior border is prominent and somewhat irregular; it affords insertion at its lateral part to the Glutæus minimus. The posterior border is very prominent and appears as a free, rounded edge, which bounds the back part of the trochanteric fossa. The Lesser Trochanter (trochanter minor; small trochanter) is a conical eminence, which varies in size in different subjects; it projects from the lower and back part of the base of the neck. From its apex three well-marked borders extend; two of these are above—a medial continuous with the lower border of the neck, a lateral with the intertrochanteric crest; the inferior border is continuous with the middle division of the linea aspera. The summit of the trochanter is rough, and gives insertion to the tendon of the Psoas major. A prominence, of variable size, occurs at the junction of the upper part of the neck with the greater trochanter, and is called the tubercle of the femur; it is the point of meeting of five muscles: the Glutæus minimus laterally, the Vastus lateralis below, and the tendon of the Obturator internus and two Gemelli above. Running obliquely downward and medialward from the tubercle is the intertrochanteric line (spiral line of the femur); it winds around the medial side of the body of the bone, below the lesser trochanter, and ends about 5 cm. below this eminence in the linea aspera. Its upper half is rough, and affords attachment to the iliofemoral ligament of the hip-joint; its lower half is less prominent, and gives origin to the upper part of the Vastus medialis. Running obliquely downward and medialward from the summit of the greater trochanter on the posterior surface of the neck is a prominent ridge, the intertrochanteric crest. Its upper half forms the posterior border of the greater trochanter, and its lower half runs downward and medialward to the lesser trochanter. A slight ridge is sometimes seen commencing about the middle of the intertrochanteric’ crest, and reaching vertically downward for about 5 cm. along the back part of the body: it is
called the linea quadrata, and gives attachment to the Quadratus femoris and a few fibers of the Adductor magnus. Generally there is merely a slight thickening about the middle of the intertrochanteric crest, marking the attachment of the upper part of the Quadratus femoris.
2. Pathophysiolog y ETIOLOGY pseudomonas aeruginosa
formation of subcutaneous abscesses (that may drain spontaneously through the skin)
Affected individual may experience
weight loss, fatigue, fever, and localized warmth, Sweeling,erythema and tenderness
Osteomyelitis occurs more often in men than in women. People of any age can develop osteomyelitis,, Certain situations allow germs more opportunities to access your body Examples include people who illegally inject drugs, people on dialysis, people who use urinary catheters,, Poor circulation,, A recent injury,, Orthopedic surgery.
Penetrates to the body Occlude blood vessels Bone necrosis and local spread of infections Infection may expand through the bone cortex and spread under the periosteum
3. Signs and Symptoms Textbook- based 1. Warmth, swelling and redness over the area of the infection 2. Pain or tenderness in the affected area. 3. Chronic fatigue 4. Drainage from an open wound near the area of the infection 5. Fever, sometimes Patient’s Manifestation Swelling of patients hip. Pain was felt in his hip. none Has yellowish discharge from wound. Had fever before hospitalization. Interpretation Due to the bacteria that invaded Due to the bacteria that invaded Due to bacteria in the wound Due to infection caused by the bacteria.
Medical Management: Medication and Treatment ordered: 1. 2. Rifampicin 250/5ml OD 5ml Isoniazid 250/5ml OD 2.5ml
3. Pyrazinamide 250/5ml OD 5ml 4. Pyrazinamide 250/5ml OD 5ml
The primary goal in medical management is to kill the bacteria through specific antibiotics. And it is also important to maintain fluid and electrolyte balance and to control symptoms.
3. Health Teaching Plan
Teach patient good hand washing technique. Most especially after defecation and before handling food Encourage cleanliness and sanitation as well as proper food handling, preparation and storage techniques and not to allow food to sit at room temperature for very long periods. Encourage patient to avoid scratching the affected area. Encourage patient to do simple range of motion exercise. Encourage patient to follow doctor’s orders to promote fast recovery. Encouraged patient to eat foods that are recommended for him, and avoid fatty and too salty foods. Encouraged patient to say a Prayer, and thank GOD for everyday’s blessings.
4. Discharge plan M- Advised patient to take medications at the right time and amount as prescribed by the physician. 1. Rifampicin 250/5ml OD 5ml 2. Isoniazid 250/5ml OD 2.5ml 3. Pyrazinamide 250/5ml OD 5ml 4. Pyrazinamide 250/5ml OD 5ml E- Instructed the S.O. of the patient to do environmental sanitation such as cleaning the house and backyard. T- Advised the S.O.to have the patient a regular check-up and visit the doctor after a week of discharge. H- Advised the patient to have a proper hygiene and if possible clean the affected area more often and keep it dry always. (Please refer to health teachings at the top)
O- Advised S.O. to consult a Doctor if symptoms occur such as severe pain on affected area. D- Encouraged S.O. to give clean foods to patients to prevent ingesting bacteria and viruses that may harm her child. S- Encouraged S.O. to bring her child to Church if possible to say a little prayer.
BIBLIOGRAPHY: Black, Joyce M. et. al. Medical-Surgical Nursing: Clinical Management for Positive Outcomes, 6th Edition, Vol. 1. Philadelphia : WB Saunders Company, 2001. Daniels, Rick. Nursing Fundamentals: Caring & Clinical Decision Making. Thomson Learning Asia , 2004. Deglin, Judith Hopfer & April Hazard Vallerand. Davis's Drug Guide for Nurses, 9th Edition. Philadelphia : F.A. Davis Company, 2005. Doenges, Marilynn E. et. al. Nursing Care Plans: Guidelines for Individualizing Patient Care, 6th Edition. Philadelphia : F.A. Davis Company, 2002. Marieb, Elaine N. Essentials of Human Anatomy & Physiology, 7th Edition. California : Pearson Education Inc., 2004. Nettina, Sandra M. The Lippincott Manual of Nursing Practice, 7th Edition, Vol. 1. Philadelphia : Lippincott Williams & Wilkins, 2001.
Prepared By: _________________ Yap, Aileen Jane T. Roldan (Student)
Checked By: _____________________ Mr. Elbert Jann (Clinical Instructor)