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General Goal: To know the major cause/causes of this condition, how it is acquired, and the major manifestations of this disease. Specific Objectives: The student should be able to: 1. To know the common cause(s) of this disease. 2. To identify the means by means this disease can be acquired 3. To know the major manifestations of this disease. 4. To know ways on how to prevent the transmission of this disease.
A. Background of the Study Abscesses occur when an area of tissue becomes infected and the body's immune system tries to fight it. White blood cells move through the walls of the blood vessels into the area of the infection and collect within the damaged tissue. During this process, pus forms. Pus is the build up of fluid, living and dead white blood cells, dead tissue, and bacteria or other foreign substances. Abscesses can form in almost every part of the body and may be caused by infectious organisms, parasites, and foreign substances. Abscesses in the skin can be easily seen, and are red, raised, and painful. Abscesses in other areas of the body may not be obvious, but if they may cause significant organ damage. This case study will help the student nurse in understanding the disease process of the patient. This will also help the student nurse in identifying the primary needs of the patient with an abscess by identifying the needs and health problems of the patient and formulating an individualized nursing care plan. Effective management of the problem identified will help the patient recover faster and maintain a holistic sense of wellness even while in the hospital. B. Definition of the Case An abscess is a common infection characterized by a localized accumulation of polymorphonuclear leukocytes with tissue necrosis involving the dermis and subcutaneous tissue. It is also a collection of pus (dead neutrophils) that has accumulated in the cavity formed by the tissue on the basis of an infectious process (usually caused by bacteria and parasites) or other foreign materials (e.g. splinters, bullet wounds, or injecting needles). It is a defense reaction of the tissue to prevent the spread of infectious materials to other parts of the body. An abscess is typically painful and it appears as a swollen area that is warm to touch. The skin surrounding an abscess typically appears pink or red.
C. General Signs and Symptoms General signs and symptoms of an abscess includes:
• • • • •
Redness (rubor) Heat (callor) Swelling (tumor) Pain (callor) Loss of function
D. Etiology The primary causes of abscess includes: • Inflammatory response to an infectious process; invasion of bacteria or parasite such as streptococci or staphylococci • Foreign substance within the body (a needle or a splinter) • Obstructed oil or sweat glands • Inflammation of hair follicles • Minor breaks or punctures in the skin E. Incidence Skin abscesses are fairly common. They occur when an infection causes pus and infected material to collect in the skin. During the last decade, the incidence of the skin and soft tissue infections has risen dramatically in the Philippines and skin abscesses caused by methicillin-resistant staphylococcus aureus are largely accountable for this increase.
III. PATIENT’S PROFILE
A. Biographic Data Name: Age: Gender: Nationality: Marital Status: Occupation: Religious Orientation: Educational Attainment: Date of Admission: Attending Physician: Diagnosis: xxx 6 ½ months male Filipino single N/A Roman Catholic N/A August 5, 2009 Dra. Abana Abscess, thigh Left
B. Chief Complaint: Abscess, fever C. History of Present Illness 1 week PTA, the patient has erythematous swelling on his left thigh associated with fever, hence, they consulted a family doctor and was given meds. 3 days PTA, the patient have the above condition associated with cough, again sought the help of the family doctor and meds were given. Persistence of swelling associated with pustular discharge hence consulted again the family doctor then advised for admission. D. Past Health History According to the SO, the patient has never been hospitalized before. He also has no known allergies and negative for asthma. The patient hasn’t yet completed his immunization vaccines (measles and oral polio vaccine) E. Family History of Illness
F. Physical Assessment • • • • Flaring nares upon respiration With supple neck Eyes slightly swollen With warm skin
• • • • • •
With good skin turgor (-) cyanosis Afebrile: T= 36.5°C With adventitious breath sounds (whezzes) heard on both upper lobes upon auscultation (+) non-productive cough Erythematous swelling with pustular drainage, ulcer, on left thigh
G. Vital Signs: From Admission Up to Discharge August 5, 2009 Temperature Pulse rate Respiratory rate August 6, 2009 Temperature Pulse rate Respiratory rate August 6, 2009 Temperature Pulse rate Respiratory rate 8pm 37.7 139 60 12 -. 4am 8pm 38 116 62 12 37.3 137 56 4am 37.5 129 60 8pm 37.4 130 46 12 38.8 132 44 4am 37.2 140 50
H. Course in the Ward (Doctor’s Progress Notes) August 5, 2009 admitted to ROC under the servce of Dra. Abana having the chief complaint of fever and abscess inserted with IVF of D50.3NaCl 1L x 40 µgtts/min labs ordered and done: CBC, U/A medications given: Paracetamol oral drops 0.9mL q4 PRN for fever Fucidin cream over skin lesion 3x a day Sulbactam-ampicillin 750mg/vial 160mg IV q6 IVF to follow: D5IMB 1L x 27 µgtts/min August 6, 2009
continue meds as ordered by the physician
IV. ANATOMY AND PHYSIOLOGY
A. Integumentary System The integumenatry system is the organ system that protects the body from damge, comprising the skin and its appendages. It is the largest organ system. Functions of the integumentary system: 1. 2. 3. 4. 5. 6. 7. Protects the body against invasion by infectious organisms. Protects the body from dehydration. Protects the body against abrupt changes in temperature. Helps excrete waste materials through perspiration. Acts as receptor for touch, pressure, pain, heat and cold. Generate vitamin D through the exposure to UV rays. Stores, fat, glucose and Vitamin D. The 3 layers of the skin includes: a. Epidermis - top layer of the skin made up of epithelial cells. Main job is protection, absorption of nutrients and homeostasis. b. Dermis - dense connective tissue that makes up the dermis contains fibroblasts, fat cells and macrophages. c. Hypodermis - layer of tissue directly underneath the dermis. Functions include insulation, storage of energy and aiding in the anchoring of the skin. It also cushions the underlying body for extra protection against trauma. B. Lymphatic System The lymphatic system is composed of the tissues and the organs that produce, store and carry WBC that fight infections and other disease. This system includes the bone marrow, spleen, thymus, lymph nodes and lymphatic vessels that branch into all tissues of the body. Functions of the lymphatic system includes: 1. Filtering out organisms that cause disease. 2. Produces certain WBC’s and generate antibodies
3. Distribution of fluids and nutrients in the body 4. Fat absorption in the digestive tract Lymph is a milky body fluid a type of WBC, called “lymphocytes”, along with proteins and fats. Lymph seeps outside the blood vessels in spaces of the body tissue and is stored in the lymphatic system to flow back into the bloodstream. Through the flow of blood in and out of the arteries, and into the veins, and through the lymph nodes and into the lymph, the body is able to eliminate the products of cellular breakdown and bacterial invasion. Two very large areas are of significance to this system: 1. Right lymphatic duct – drains lymph fluid from the upper right quarter of the body above the diaphragm and down the midline. 2. Thoracic duct – a structure, roughly 16 inches long located in the mediastenum of the pleural cavity which drains the rest of the body. It is through the action of this system, including the spleen and the thymus, the lymph nodes and the lymph ducts that our body is able to fight infection and ward off infection from foreign invaders. The lymphatic vessels are present wherever there are blood vessels and transport excess fluid to the end of vessels without the assistance of any “pumping” action. There are 100 tiny, oval structures (called lymph nodes) in the body. These are mainly in the neck, groin and armpits, but are scattered along the lymph vessels. They act as barriers to infection by filtering out and destroying toxins and germs. The largest body of lymphoid tissue in the human body is the spleen.
Break in the skin
Invasion of bacteria in the site (staphylococci and streptococci)
Body releases toxins
Histamine, plasmins, kinins, serotonin, and prostaglandins are released and activated
Redness and Heat
Histamine, kinins, and prostaglandins causes increase in cellular permeability.
Swelling and loss of function
WBC collects to the site
Formation of a thick, yellowish pus from broken down tissues, dead bacteria and leukocytes, and extracellular fluid.
Leukocyte breakdown the dead tissue and absorb the bacteria by means of a phagocytosis.
ABSCESS FORMATION Nearby healthy cells form a capsule of tissue around the pus and develop a cell wall that delimits the abscess from nearby healthy tissues. Fibroblasts produce collagen fibers and tissue regeneration.
Resolution of inflammation and formation of scar tissue
VI. LABORATORY AND DIAGNOSIS EXAMINATION
Urinalysis: • Pus cells • RBC
Presence of infection Slight hematuria; a sign of bleeding in the genitourinary tract as a result of systemic bleeding disorders, various kidney diseases, bacterial infections, parasitic infections, obstructions in the urinary tract, scurvy, subacute bacterial endocarditis, traumatic injuries, and tumors. Anemia Presence of infection Presence of bacteria Low body immunity
Hematology: a. hematocrit b. WBC c. segmenters d. lymphocytes
0.37-0.45 5-10x10^/L 0.55-0.65 0.25-0.35
0.35 12.9 0.78 0.20
VII. DISCHARGE PLANNING METHOD
M E Continue medication regimen as ordered by the physician strictly following the right medicine, right dose, and time as prescribed. Provide environment that is conducive to health and wellness. Minimize clutter around the house to prevent accidents and injuries and maintain cleanliness to minimize the potentials of harboring microorganisms. Allow the child to play but with strict supervision since playing a form of play to the child. Regimen of antibiotics should be followed as scheduled even after the signs and symptoms of the condition are gone to ensure the potency and effectivity of the drug. Stress the importance of a good personal hygiene and its contribution to health and wellbeing. Teach the client the proper hand washing technique. Teach the clients that pressing an abscess in an attempt to drain it is not good. This can push the infected material into the deeper tissues. Teach the client not to stick needle or any other sharp instruments into the abscess because it may injure an underlying blood vessel or cause the infection to spread. Carefully follow any instructions that the doctor provides. Be sure to keep all follow-up appointments. Report any fever or increased pain or redness to the doctor immediately. Emphasize the importance of offering baby breastmilk instead of formula milk May also add solid foods little by little like mashed potatoes.
REVIEW OF THEORETICAL FRAMEWORKS THEORY Environmental Theory (Florence Nightingale) External life conditions affect life and the individual’s development.
Interpersonal Relations in Nursing (Hildegard Peplau) 14 Basic Needs (Virginia Henderson)
To develop an interpersonal interaction between patient and the nurse. 14 basic needs are provided by assisting the client with his needs that the client would perform unaided if they have necessary strength, will or knowledge.
Four Conservation Principles (Myra Levine)
To use conversation activities aimed at optimal use of patient’s resources.
Maintained a safe environment. Maintained a wellventilated environment. Maintained a clean and noise-free environment. Provided diet appropriate for the condition of the patient. Established rapport with the patient. Performed a good NPI. Encouraged mother to breastfeed the patient. Encouraged mobilization to facilitate bowel movement. Suggested SO to provide patient to have adequate rest and sleep for faster recovery. Encouraged SO to breastfeed infant to strengthen the child’s immunity.
DRUG NAME GN: Biogesic BN: Paracetamol drops GN: Fucidic Acid BN: Fucidin cream
CLASSIFICATION Analgesic and antipyretics
INDICATION Relief of fever, minor aches and pain Primary and secondary bacterial skin infections caused by staph., strep., methicillinresistant strains and other organisms sensitive to fucidic acid Treatment of succesptible bacterial infections involved in the skin and skin structure, intraabdominal infections, gynecological infections.
ACTUAL DOSAGE 0.9mL q4h
CONTRAINDICATION Anemia, cardiac pulmonary disease. Hepatic or sever renal disease. ---
ADVERSE REACTION Allergic reactions ang GI disturbances Hypersensitivity (rare)
NURSING INTERVENTION Observe the 10 R’s of drug administration. Observe the 10 R’s of drug administration.
Apply 3x a day
GN: Sulbactam BN: Unasyn
400mg IVP (TID)
Hypersensitivity to ampicillin, sulbactam, penicillins, or any component of the medication.
Pain, rash, diarrhea, allergic reaction
Observe the 10 R’s of drug administration.
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