PYOMYOSITIS

MEMBERS: BSN3C-C2
PARAGAS, Daniel John
PEREZ, Kirsten Mae
QUIMBA, Moises
RAMOS, Emmanuel John
RAMOS, Jaimie Anne
REGATILLO, Ma. Cristina
REINANTE, John Micheal
RELOJO, Sheena Mae
REYES, Sharmaine Joy
ROMBAON, Maritoni
ROQUE, Jose Alfonso
I. GOALS AND OBJECTIVES
GOALS:
-This case presentation will enable the students to give
an appropriate intervention and deliver holistic care
for the patient. This will also help the nursing students
to know more about the nature and the disease
process of pyomyositis.
SPECIFIC OBJECTIVES:
Attitude
-Establish a nurse-patient interaction through
exchanging of thoughts and information.
Institute bond between the student nurse and the
patient.
Skills
-To give an appropriate medical and nursing
management for the patient with pyomyositis.
Knowledge
-Define Pyomyositis.
- Discuss the anatomy and physiology of the Musculo-
skeletal system.
- Identify the signs and symptoms manifested by the
patient.
- Distinguish the precipitating and predisposing factors
that trigger this development.
- Trace the pathogenesis based on the signs and symptoms
manifested by the patient.
- Be acquainted with the different drugs, its actions, and
perform appropriate nursing responsibilities for each.
- Use the nursing process as the framework for the care
of the patient.
- Plan for suitable nursing care.
II. INTRODUCTION
Background
-Pyomyositis is an inflammation of muscle tissue,
usually of voluntary muscles (examples are skeletal
muscles) that results in pus production. 
-Once considered a tropical disease, it is now
seen in temperate climates as well. The
pathogenesis is unclear, but trauma, infections (S.
aureus, S. pneumoniae), and malnutrition have
been implicated. Although most cases of
pyomyositis occur in healthy individuals, other
pathogenetic factors include nutritional deficiency
and associated parasitic infection in tropical
climates. In the temperate climates, pyomyositis is
seen most commonly in patients with diabetes,
HIV infection, and malignancy because of
decreased immune system they are at greater risk.
Epidemiology
- Pyomyositis is most often caused by the
bacterium Staphylococcus aureus. The infection can
affect any skeletal muscle, but most often infects the
large muscle groups such as the quadriceps or gluteal
muscles. Most patients are aged 2 to 5 years, but
infection may occur in any age group. Infection often
follows minor trauma.
Clinical Presentations
•Presentation with painful, tender, localized swelling
over muscle
•Fever 
•Epidural abscess

Complications
•Life-threatening complications include sepsis and
toxic shock syndrome.
Diagnostic Procedure
•CT scan or MRI demonstrates muscle abscess.
•Aspiration of abscess (by surgery or CT/US guided)
yields pus, usually yielding S. aureus.
•Bacteremia may accompany.
Treatment
Medical Care
•Promptly administer systemic antibiotics. This could
eliminate the need for surgical drainage in selected
cases.

•The choice of antibiotic is determined by identification 
of the causative organism(Culture and sensitivity test).
•Antibiotics initially are given intravenously until clinical
improvement is noted, followed by oral antibiotics for a
total course of 3 weeks (eg, cefazolinor ceftriaxone IV
followed by cephalexin PO).
Surgical Care
•During the suppurative phase, abscess aspiration
under ultrasonic or CT guidance may be required.
Surgical drainage is especially necessary for large
abscesses.
•Complicated cases may require fasciotomies (surgical
incision of the fascia to relieve pressure) and
debridement (removal of dead tissues).

Prognosis
•Prompt administration of antibiotics can result
in complete resolution.
III. PATIENT’S PROFILE
Biographic Data
Name: Patient R., A.L.R.
Address: 10-E Jacinto St. Sta. Lucia Novaliches, Q.C.
Birthday: November 10, 2009
Age: 2 years old
Religious Affiliation: Roman Catholic
Father’s Name: Moises Reyes
Mother’s Name: Maricris Reyes
Gender: Female
Marital Status: Single
Hospital Data
Hospital NO: 69-38-85
Admission Date and Time: February 19,2012; [2:10 am]
Attending Physician: Dr. Chua III
IV. HISTORY
FAMILY HISTORY
- R, A.L.R.’s family conditions have a hereditary
history of asthma as what her mother stated
during the interview. Other than the hereditary
issues, families sometimes experienced some
minor infirmity such as fever, cough, colds, and
among other ailing. With proper knowledge about
the remedies of these trifling sicknesses, it can be
easily coped by drinking plenty of water daily. It is
also advisable for them to consult their doctor
whenever cough, colds, or fevers occur.
PAST MEDICAL HISTORY
At 2 years of age, the client had not experienced any
childhood illnesses or diseases such as chicken pox,
mumps or measles. She has also been free of any type
of disease or illness over the past six months. However,
she has had two stints of colds before that, and has
also been previously diagnosed with impetigo. She has
no known allergy to any type of food. In terms of her
immunization, she is already complete, as stated by
the mother. History of immunizations is as follows:
 Immunizations

BCG (infant) Complete

DPT 1, 2, 3 Complete

Polio Complete

Measles Complete

BCG (school age) Complete

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

Provisional Diagnosis: Pyomyositis Right Thigh

 V. ACTIVITIES OF DAILY LIVING
ACTIVITIES OF DAILY BEFORE DURING INTERPRETATION AND
LIVING HOSPITALIZATION HOSPITALIZATION ANALYSIS

1.NUTRITION The client eats The client has a I:poor appetite

anything, especially poor of appetite
A: Patients who are
biscuits, cereals, green she only eats a
hospitalized may have an
leafy vegetable and slice of cake. And
inadequate dietary intake
her favorite candy is drink 2 bottles
because of the illness or
potchi and jelly ace. (30ml) formula
disorder that necessitated
She has a good milk (lactum) per
the hospital stay or because
appetite. day.
of a change in the diet of
the patient;
 ACTIVITIES OF DAILY BEFORE DURING INTERPRETATION AND
LIVING HOSPITALIZATION HOSPITALIZATION ANALYSIS

2. ELIMINATION According to mother According to the I: O or absent of elimination

she defecates 1-2 mother, her baby
A: eating can also impair
times everyday. She has an absent of
regular defecation.
urinates everyday and bowel elimination
Individuals who eat at the
has no problem in 4 days prior to
same times everyday
elimination. admission.
usually have a regularly
timed, physiologic response
to food intake and regular
pattern of peristaltic
activity in colon;

3. EXERCISE The client does her When she was I: decrease in doing her
exercise by playing and admitted in the exercise A: Decreases
dancing. She also take hospital, she only activity because her
a walk around in their moves her upper present conditions that
house extremities. limit her movements.
 ACTIVITIES OF DAILY BEFORE DURING INTERPRETATION AND
LIVING HOSPITALIZATION HOSPITALIZATION ANALYSIS

4. HYGIENE Takes a bath 2x She never takes a full I: decrease in

everyday in morning bath, but her mother performing in hygiene.
and at night before does sponge bath
A: Decreases activity
going to sleep. once a day. She
because of the
brushes her teeth
She brushes her teeth Intravenous fluid
once a day with the
3x a day. attached to her; limiting
help of her mother.
her movement prevents
the intravenous line to
get tangle to her;

5. SLEEP AND REST the patient was able to Patient takes a nap I. decrease rest pattern.
consume 8 hours 20-30 mins 3 times a
A. Uncomfortable
sleeping time and had day and at night she
environment and
a schedule of nap only sleeps 3-4
irritabiity results to
twice a day . hours.
sleep deprivation.
 VI. PATTERNS OF FUNCTIONING
Psychological health Interpretation Analysis

Coping patterns – Coping may be described as dealing with Based on the

according to her problems and situations, or contending with data we
mother, every time them successfully. Coping strategies vary gathered the
she feels pain in her among individuals and are often related to the patient uses an
condition she always individual’s perception of the stressful event. object to alter
hug her toy Three approaches to coping stress are to alter her feelings
particularly “barney”. the stressor, adapt to the stressor, or avoid the every time she
stressor. A person’s coping strategies often feels pain.
change with a reappraisal of a situation
Reference:Fundamentals of Nursing by Barbara
Kozier, GlenoraErb, Audrey Berman &Shirlee
Snyder (7th Edition page 1020)
Psychological health
Emotional patterns – Emotional wellness is the
according to her mother,
the patient is a joyful
daughter, but when the
incident happened the child
become irritable and she
has difficulty in sleeping at
night.
Interpretation Analysis
With the information we
ability to manage stress and gathered, the patient
to express emotions become anxious of being
appropriately. It involves touch and she became
the ability to recognize, irritable about her
accept and express feelings condition which can lead in
and to accept one’s slow development on her
limitation. stage (autonomy vs shame
Reference:Fundamentals of and doubt)
Nursing by Barbara Kozier,
GlenoraErb, Audrey Berman
&Shirlee Snyder (7th Edition
page 173
Psychological health Interpretation Analysis

Interaction patterns- Interaction pattern are ways The patient had no difficulty
According to her mother, of expressing affection, in interacting with others
patient X is a sweet and love, sorrow and anger. It but when the incident
playful daughter to her also includes openness of suddenly happened it
parents and siblings. She communication with all causes trauma to her.
always interacts with family members and the
others. most significant persons in
his/her life.
Reference:Fundamentals of
Nursing by Barbara Kozier,
GlenoraErb, Audrey Berman
&Shirlee Snyder (7th Edition)
Psychological health Interpretation Analysis

Self-concept patterns- Self-concept is one’s mental image ofThe patient has

According to her oneself. A positive self-concept is confidence on
mother, patient X’s essential to a person’s mental and discovering and
own perception on physical health. An individual
manipulating her
herself is strong, and possessing a strong self-concept surroundings
also She has a should be better able to accept or (autonomy, toddler
positive self-concept. adapt to changes that may occur over stage) but when the
the life span. incident happened her
Reference:Fundamentals of Nursing by comfort zone became
limited.
Barbara Kozier, GlenoraErb, Audrey
Berman &Shirlee Snyder (7th Edition
page 957
Psychological health Interpretation
Sexuality-Patient X is a 2 During toddler stage, they develop
years old female. Voluntary control to being able to walk
with relatively and speak. They also learn
to control their bladder and bowels.
Reference:Fundamentals of Nursing by
Barbara Kozier, GlenoraErb, Audrey
Berman &Shirlee Snyder (8th Edition page
373)
Family Coping Patterns- Family is a place where you can be
According to his mother, yourself. This is where you are completely
they gather and have tension free and everyone is there to help
conversations whenever you. Family encourages you when you are
they encounter family surrounded by problems. It helps you
problems. survive through tough times and bring joy
and happiness into life.
Article Source:
http://EzineArticles.com/2330415
Analysis
She is starting to learn to
control her bladder and
bowels. This is good on
her developmental stage.
In terms of family coping
patterns, the mother
stated that when they
are facing problems with
the family, they are open
and they talk together in
order to cope or solve
problems.
 VII. PHYSICAL ASSESSMENT
Body Part Normal Findings Actual Findings Interpretation and
Analysis
I. Vital signs taken BP=90/60 mmHg BP= 90/60 mmHg All vital signs of the
patient are within the
Temp= 37- 37.4˚C Temp= 37.3˚C
normal range.
CR= 120- 160 beats/ CR= 160 beats/ min
min
 Body Part Normal Findings Actual Findings Interpretation and
Analysis

II. Head to Toe

Examination
A. Integumentary

Color Varies from light to Light to dark brown, Normal

deep brown ; from olive
ruddy pink to light
pink ; from yellow
overtones to olive;
generally uniform
except in areas
exposed to the sun ;
areas of lighter
pigmentation in dark
skinned people

Edema No Edema No edema seen

 Body Part Normal Findings Actual Findings Interpretation and
Analysis

lesions Freckles, some No presence of any

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

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

Temperature
Uniform within Warm body
temperature
normal range
 Body Part Normal Findings Actual Findings Interpretation and
Analysis

b. Hair
evenness of Evenly distributed Evenly distributed Normal
growth over the hair hair
scalp

hair thickness or Thick hair Thick hair Normal

thinness

hair texture and Silky, resilient hair Fine to coarse, pliant Normal
oiliness

amount of body Variable, no baldness

hair Variable Normal
 Body Part Normal Findings Actual Findings Interpretation and
Analysis
B. Head
a. Skull and Face
size, shape and Round Has a head size that is Normal
proportionate to the
symmetry body built;
normocephalic.

nodules or Smooth, uniform Normal

Has no nodules and
masses and consistency; absence masses noted and
depressions of nodules and palpated
masses

Normal
facial feature Symmetrical, Symmetrical, centered
head position
centered head
position
 Body Part Normal Findings Actual Findings Interpretation
and Analysis
b. Eyes
edema No edema No edema noted at the time of Normal
physical assessment
 eyebrows
Hair distribution, Hair evenly distributed;
skin intact; eyebrows Has well distributed and
alignment, skin Normal
symmetrically aligned symmetrically aligned
quality and eyebrows; equal in movement
;equal movement
movement and skin surrounding it is intact
 eyelashes
evenness of Equally distributed, Has eyelashes that are equally
Normal
distribution and curled slightly outward distributed, curled slightly
direction of curl outward
 eyelids
surface Skin intact; no discharge;
no discoloration. Has intact skin and no
characteristics, Approximately 15 – 20 discharges Normal
position in relation involuntary blinks per
to corned, ability minute; bilateral blinking
and frequency of
blinking
Clear with tiny vessels
 lower conjuctival sac visible Pale Normal
 Body Part Normal Findings Actual Findings Interpretation and
Analysis
c. Ears
 auricles Clear with tiny vessels Has color same as facial Normal
color, symmetry visible skin, symmetrical auricle
of size, position, aligned with outer
texture, elasticity canthus of the eye,
and areas of mobile, firm, not tender.
tenderness

Color same as facial Pinna recoils after it is

skin symmetrical, Normal
folded
auricle aligned with
outer canthus of
eye .Motile, firm and
not tender.
Pinna recoils after it is
folded
 Body Part Normal Findings Actual Findings Interpretation and
Analysis
d. Nose
Symmetrical, no
 shape, size, color Symmetric and Normal
deviations, discharge,
and flaring or straight no discharge tearing and lesions,
discharge from or tearing uniform uniform in color and
the nares, color, not tender no not tender
tenderness, lesions
masses,
displacement of
bone and
cartilage
 nasal septum
Nasal septum intact
Has intact nasal
Normal
between nasal septum and it is in the
and in the midline midline
chambers
Air moves freely as Air movement is not
 patency of both This is due to poor
nasal cavities the client breathes restricted on both
nares nutrition taken by the
through the nares
patient resulting to
lack of iron.
 Body Part Normal Findings Actual Findings Interpretation and
Analysis
C. Mouth and
Oropharynx
a. Lip and Buccal Uniform pink color, Pink in color, smooth, Normal
Mucosa soft, moist, smooth, moist, without lesions
 symmetry of texture, symmetry of
contour of color, contour , can purse
texture, moisture, lips
ability to purse
lips
D. Neck and Lymph
Nodes
Has muscles equal in Normal
 neck muscles Muscle equal in size, size located at the
 swelling , masses, centerplacement , no center no masses,
tenderness, masses and swelling. swelling.
placement
 Body Part Normal Findings Actual Findings Interpretation and
Analysis

E. thorax
 posterior Chest symmetric, Has a chest that is Normal
 shape ,symmetry, spine vertically symmetrical and
spinal alignment aligned vertically aligned

 anterior Quiet and rhythmic, Quiet and rhythmic, Normal

 breathing pattern effortless respirations effortless respirations

F. Abdomen
Has a skin that is Normal
 skin integrity Unblemished skin,
uniform color, silver uniform in color and
unblemished
white striaeor surgical
scars
Flat, rounded or Flat , slightly rounded
 contour and
symmetry scaphoid, symmetric
contour
 Body Part Normal Findings Actual Findings Interpretation and
Analysis
III. MUSCULO-
SKELETAL SYSTEM
A. Head
Facial structure Symmetrical structure Symmetrical structure
and muscle and development of and development of Normal
development muscles muscles

Temporo- Can open mouth 2 Can open mouth 2 Normal

mandibular joint inches inches
(TMJ) function

B. Thorax
Posture Erect Erect
Normal
C. Neck
ROM: flexion,
extension, Full ROM: no pain Full ROM: no pain
Normal
rotation, lateral
bending
 Body Part Normal Findings Actual Findings Interpretation and
Analysis
D. Spine
Curves Cervical concave; Has cervical, thoracic
Normal
thoracic convex; and lumbar concavity
lumbar concave
Posture Erect Erect Normal

ROM- flexion, Full ROM Full ROM Normal

lateral bending,
rotation,
extension
E. Paravertebrals
Muscle strength Equally strong Equally strong Normal
and tone

Temperature Warm Warm Normal

Temp= 37.3˚C

Sensation Normal
Nontender Nontender
 Body Part Normal Findings Actual Findings Interpretation and
Analysis
F. Shoulder
 Muscle strength Able to shrug Able to shrug Normal
and tone shoulders against shoulders against
resistance resistance

 Sensation
Nontender Nontender Normal
G. Upper extremities
 Shoulder, elbow,
wrist hand and
fingers
 Bone structure, Bilaterally Bilaterally
bony Normal
symmetrical symmetrical
prominences,
muscle mass, joint
structure and
symmetry
 ROM
Full ROM Full ROM Normal
 Body Part Normal Findings Actual Findings Interpretation and Analysis

 Arm
 Muscle strength Can flex and Can flex and extend Normal
and tone extend arm arm against
against resistance resistance

 Hand
 Muscle strength Grip is firm and Gripping is firm; has
Normal
equal equal muscle
H. Lower extremities strength
 Hip, knee, ankle,
foot and toes
 Bone structure Bilaterally asymmetrical of
and bony Bilaterally Bilaterally the thighs are due to
landmarks; symmetrical and asymmetrical and swelling of the infected
muscle mass equal unequal site (right thigh).
Full ROM
ROM Decreased ROM is due to
the pain located at the
Full ROM Limited ROM right thigh of the patient.
 VIII. DIAGNOSTIC EXAMS
Hematology

FINDINGS NORMAL VALUE RESULT SIGNIFICANCE

Hemoglobin Mass Male: 127-183 g/L N The hemoglobin mass

Female: 110-138 g/L is within the normal
range.

Hemotocrit (HCT) 0.37-54 N The hematocrit level of

the patient is within
the normal range.

Leukocytes Count 4.5-10 x 109/L N The leukocytes count

is within the normal
range.

Mean Corpuscular Male:82-92 fL N The MCV is within the

Volume (MCV) Female:78-91 fL normal range.
 FINDINGS NORMAL VALUE RESULT SIGNIFICANCE

Mean Corpuscular 28-32 pg/cell Decreased The patient is anemic because

Hemoglobin (MCH) the average mass
of hemoglobin per red blood
cell in a sample of blood is
low.

Mean Corpuscular 32-38% Decreased The patient is anemic because

Hemoglobin the measure of the
Concentration (MCHC) concentration
of hemoglobin in a given
volume of packed red blood
cells is low.

Platelet Count (Plt) 150,000-400,000 /µL N The platelet count is within

the normal range.
 Differential Counts

FINDINGS NORMAL VALUE RESULT SIGNIFICANCE

Segmenters 0.50-0.70 N The segmenters are

within normal range.

Monocytes (mono) 0.00-0.07 Decreased There in an increase

number of monocytes
that indsicates
infection.

Lymphocytes 0.20-0.40 Decreased There is a decrease

number of
lymphocytes that
protect our body from
bacteria and viruses
and that, it indicates
low immune system.
IX. COURSE IN THE WARD
February 19, 2012
The patient was brought to Philippine Orthopedic
Center last February 19, 2012 at 2:10 in the morning
because of pain, swelling, tenderness on the right leg.
She was admitted in the Emergency Room carried by
her mother and was seen by Dr. Chua III. Diagnostic
examinations including CBC, ESR, CRP and Blood
Typing were made. Therapeutics for the client includes
Oxacillin 500mg IV (ANST) now then 250mg IV q6
and Paracetamol 250mg/5ml 4ml q4 for pain and temp
above 37.8. At 10 in the morning IVF D5 0.5 NACL
500ml was hooked on her right arm at KVO.
 February 20, 2012
At 4 pm, the patient’s IVF was removed and change
with the same D5 0.3 NACL 500ml at KVO.
 
February 21, 2012
At 9:40 am, the patient’s IVF was removed and
change with the same D5 0.3 NACL 500ml at KVO.
X. ANATOMY AND PATHOPHYSIOLOGY
The lower leg is comprised
of two bones, the tibia and
the smaller fibula. The thigh
bone, or femur, is the large
upper leg bone that
connects the lower leg
bones (knee joint) to the
pelvic bone (hip joint).
 The gluteus medius (or
glutæusmedius), one of the three
gluteal muscles, is a broad, thick,
radiating muscle, situated on the
outer surface of the pelvis.

The gluteus maximus is the

largest and most superficial of the
three gluteal muscles. It makes up a
large portion of the shape and
appearance of the buttocks.

The biceps femoris is a muscle of

the posterior (the back) thigh. Both
heads of the biceps femoris perform
knee flexion.
The gracilis (Latin for "slender")
is the most superficial muscle on
the medial side of the thigh. It is
thin and flattened, broad above,
narrow and tapering below. The
muscle adducts and flexes the
hip as above, and also aids in
flexion of the knee.

The Sartorius muscle – the

longest muscle in the human
body – is a long thin muscle that
runs down the length of the
thigh. Assists in flexing,
abduction and lateral rotation of
hip, and flexion of knee.
 Plantaris is a vestigial
structure and one of the
superficial muscles of the
posterior crural compartment
of the leg. It flex the knee
joint.

Gastrocnemius muscleis a
very powerful superficial
pennate muscle that is in the
back part of the lower leg. It is
involved in standing, walking,
running and jumping.
1.
2.
XI. ECOLOGIC MODEL
 Pyomyositis is a bacterial infection of the skeletal muscles, which are
attached directly to the bones in the human body.
 It is usually caused by the bacteria Staphylococcus aureus, the same
bacteria that causes pneumonia and toxic shock syndrome.
 INTERPRETATION:
The Model shows that the patient, which is young had a fall because she
slipped to their floor twice in the same day. First, is inside their comfort
room and second, is after she went out of the comfort room and the
flooring of their house are tiled, which is more prone to slip. And so, it
causes a trauma to the patient’s muscle (at the right thigh) and a damage
to the muscle causes the immune system to weaken, allowing the
causative agent a place to take root. Most people have at least some
Staphylococcus aureus in their bodies at some point in their lives.
 
RECOMMENDATION:
The abscesses within the muscle must be drained surgically (not all
patient require surgery if there is no abscess). Antibiotics should be given
according to doctor’s order and watch out for other complications like
toxic shock syndrome, and sepsis which is life threatening. If fever persist,
apply a Tepid sponge bath and Give an antipyretic medication with
doctor’s order. Consume foods rich in Vitamin C such as fruits for
boosting of immunity, protein such as meats for tissue repair, and calcium
or phosphorus such as milk and other dairy products for bone growth.
XII. DRUG STUDY
XIII. PROBLEM LIST
Date identify Nursing diagnosis

February 22, 2012  Impaired Tissue Integrity

Wednesday  Imbalanced Nutrition: Less than body
requirements
 Bowel Incontinence
 Impaired Physical Mobility
 Sleep Deprivation
 Acute Pain
 Fear
 XIV. PRIORITOZATION
Nursing Problem
1. ACUTE PAIN related to
trauma at right thigh area
2. IMPAIRED TISSUE
INTEGRITY related to
presence of swelling abscess
at the right thigh
3. IMBALANCED
NUTRITION: LESS THAN
BODY REQUIREMENTS
related to lost appetite
Cues
Subjective:
-“Kapag nakakaramdam siya ng
sakit sa hita niya, umiiyak na
lang siya”, as verbalized by the
mother.
Objective:
-The client cries whenever feels
uncomfortable and/or in pain.
Subjective:
-“Namamaga yung kanang hita
niya”, as verbalized by the
mother.
Objective:
-The right thigh swells.
Subjective:
-“Mahina na siyang kumain
nung nandito kami sa hospital.
Puro na lang siya biscuit”, as
verbalized by the mother.
Objective:
Justification
Identified as the first Nursing
Diagnosis as it is a present
problem related to the medical
diagnosis and one of the initial
signs of Pyomyositis. It is a
sudden onset anticipated pain
arising from tissue damage. And
prioritized through ABC’s of life-
Circulation.
Due to damage of the mucous
membrane which results to
swelling and formation of
abscess.
Due to insufficient intake of
foods that results to lack of
nutrients to meet metabolic
needs
 Nursing Problem
4. ALTERATIONS IN BOWEL
ELIMINATION related to
present condition/diagnosis
5. SLEEP PATTERN
DISTURBANCE related to
pain
Cues Justification
Subjective: Due to change of normal bowel
-“Nako. Hindi pa nga siya movements resulting from
tumatae kahit isang beses mula medical diagnosis and
nung dumating kami dito sa hospitalization
hospital”, as verbalized by the
mother.
Objective: -NONE-
Subjective:
-“Hindi maayos tulog niya. Due to prolonged discomfort
Madalas gabi na siya natutulog
tapos magigising ng madaling
araw dahil sumasakit hita niya.
Minsan naman irritable siya”, as
verbalized by the mother.
Objective:
-The client is easily irritated
when move by her mother
 Nursing Problem Cues Justification

6. IMPAIRED PHYSICAL Subjective:

MOBILITY related to -“Madalas na lang siyang Due to limited movement of
presence of swelling and nakahiga. Minsan umuupo one of the extremities-right
abscess at the right thigh pa naglalaro nito (barney)”, thigh
as verbalized by the mother.
Objective:
-The client stays at the bed
almost the whole time when
the interview was held  

Subjective:
7. ANXIETY related to -“Nung minsan ngang niloko
present condition ko siya na uuwi na kami,
sagot niya sa kin ayaw niya,
baka daw madulas siya ulit”,
as verbalized by the mother.
Objective: -NONE-
 
Due to cognition of possible
repetition of the same
situation that causes the
present condition that is
recognized as danger
XV. NURSING CARE PLAN
Client: A.L.R.
Age: 2 years old
Gender: Female
Medical Diagnosis: Pyomyositis
Priority #1: Acute Pain related to trauma on the right
thigh area
 ASSESSMENT NURSING OBJECTIVES NSG. RATIONALE EXPECTED
DIAGNOSIS INTERVENTION OUTCOME

Subjective: Acute Pain Short-Term -Assess, report, -Reduce After a series of

-“Kapag related to Goal: and record possible nursing
nakakaramda trauma on Client will signs and complications.intervention,
m siya ng sakit the right manifest a symptoms and   the client will
sa hita niya, thigh area decrease in reactions to   able to:
umiiyak na pain scale from treatment. -No evidence
lang siya”, as 5/10 to a   of any signs
verbalized by manageable -Assess the -To identify the and symptoms
the mother. level of 2/10 client’s pain intensity, of pain and
  within 3-5 scale and onset, discomfort
Objective: hours perception duration, and -Decrease in
-The client     quality of the pain scale
cries whenever Long-Term pain measurement
feels Goal: Client -Review factors -Helpful in (pain is
uncomfortable will exhibit no that aggravate establishing relieved or
and/or in pain. signs or or alleviate diagnosis and controlled)
symptoms of pain. treatment -Positive verbal
acute pain with   needs. report from
3-5 days -Encourage -To identify the client’s
verbal report effectiveness of evaluation
during and interventions
after the
nursing
interventions
ASSESSMENT NURSING OBJECTIVES NSG. INTERVENTION
DIAGNOSIS
-Perform a
comprehensive
assessment of pain to
include location,
characteristics, onset,
duration, frequency,
quality, intensity or
severity, and precipitating
factors of pain.
-Reduce or eliminate
factors that precipitate or
increase pain experience
(e.g., fear, fatigue, and
lack of knowledge).
 
 
 
 
 
-Assist patient to find
position for relief
RATIONALE EXPECTED
OUTCOME
-Pain is a subjective
experience and must be
described by the client in
order to plan effective
treatment
 
 
 
 
 
-Personal factors can
influence pain and pain
tolerance. Factors that
may be precipitating or
augmenting pain should
be reduced or eliminated
to enhance the overall
pain management
program.
 
-Evaluation affects the
ability to rest and relax
ASSESSMENT NURSING OBJECTIVES NSG. INTERVENTION RATIONALE EXPECTED
DIAGNOSIS OUTCOME

-Teach the use of -The use of noninvasive

nonpharmacologic pain relief measures can
techniques (e.g., increase the re- lease of
relaxation, music therapy, endorphins and enhance
distraction, and massage) the therapeutic effects of
before, after, and if pain relief medications
possible during painful  
activities; before pain  
occurs or increases; and  
along with other pain
relief measures.
   
-Elicit behaviors that are -Relaxation techniques
conditioned to produce help reduce skeletal
relaxation, such as deep muscle tension, which
breathing, yawning, will reduce the intensity
abdominal breathing, or of the pain
peaceful imaging.  
   
-Provide optimal pain -To reduce pain
relief with prescribed  
analgesics
ASSESSME NURSING OBJECTI NSG. INTERVENTION RATIONALE EXPECTED
NT DIAGNOSIS VES OUTCOME

Initiate and maintain Increases circulation

extremity to affected muscles.
mobilization such as Minimizes joint
ambulation, physical stiffness; relieves
therapy, or continuous muscle spasm related
passive motion device. to disuse.
   
 
Evaluate the Most common reason
effectiveness of the for unrelieved pain is
pain control measures failure to routinely
used through ongoing assess pain and pain
assessment of pain relief. Many clients
experience. silently tolerate pain if
not specifically asked
about it
 XVI. DISCHARGE PLAN
Medications. Compliance on the prescribed
take home medications with the right generic name, right dosage and
preparation, right route and time of administration.
Exercise. Active ROM but  prevent massaging nor any other  traumatic 
pressure  on  the affected area.
 
Treatment.Compliance on the prescribed treatment.Cover the affected area
with a wound gauzeaspt has underwent surgery. Instructed proper wound care.
 
Health teachings.Emphasized proper handwashing and encouraged non
pharmacological measures for fracture once re encountered (Rest, Ice or Cold
Compress,Compression bandage,Elevate affected part)
 
Outpatient follow up visit. Attend on the scheduled outpatient follow up visit.
 
Diet.Consume foods rich in VitaminC such as fruits for boosting of immunity,
protein such as meats for tissue repair, and calcium or phosphorus such as milk
and other dairy products for bone growth.

Spirituality. Encourage the mother to teach the client on how to strengthen her
faith and encourage to attend mass or religious activity.