New Era University College of Nursing

In Partial Fulfillment for the Requirements in Philippine Orthopedic Center

A Case Study on Septic ankle left

Submitted by: Santiago, Joshua M

BSN Group. 3 A.Y. 2011-2012

Introduction Swelling of the feet and ankles can occur as a result of conditions involving the local extremities as well as systemic conditions (diseases and conditions that affect the entire body). Localized processes such as injuries and infections may lead to a swollen foot and/or ankle only on the involved side. Swelling of the ankle on one side is often a result of sprains or strains. Sometimes diseases that affect the entire body, such as heart disease and kidney or liver failure, can result in excess fluid buildup (edema) that is often concentrated in the legs and feet, leading to swelling not only of the ankles but also of the feet and lower legs. This can also occur with obstruction of the venous system, as may occur with pregnancy and obesity. Diseases of the joints, such as arthritis, can also affect the joints of the ankle and foot, leading to swelling of the involved areas. Treatments for swollen ankles and feet depend on the particular cause, but antiinflammatory medications are often used to manage the pain associated with strains and sprains Infection is an unusual cause of ankle swelling. Infections can either occur in the soft tissues around the ankle joint (cellulitis) or in the joint itself (septic joint). Infections can often be treated with medications alone, but may also require surgery.

II.

BIOGRAPHIC DATA Name: J.B.I Address: Bulacan Age: 2 years old Gender: male Race: Filipino Marital Status: Single Religious Orientation: Roman Catholic Date of Admission: October 1, 2011 at 10:00pm

III.

CHIEF COMPLAINT OR REASON FOR VISIT Left ankle swelling

IV.

NURSING HISTORY History of Present Illness 14 days prior to admission, Patient had chicken pox infection associated with progression of left ankle swelling. It was noted to be warm and tender to touch. Patient was also noted to have difficulty in bearing weight on left lower extremities. Fever was also noted 10 days prior to admission. Patient prompted consult with local hospital wherein oral antibiotics were given and provided relief of fever only 1 day prior to admission, there is still persistent symptoms where they consulted with another hospital where in doctor diagnosed this as to consider septic bone left. Patient was advised arthrotomy ankle but not done due to financial problem History of past illness Patient has chicken pox. No known allergies to food and medications Family history There are known hypertension in their family according to the grandmother of the patient

Anatomy and physiology The ankle and foot are incredibly complex, with a variety of connecting bones, ligaments, tendons and muscles. The ankle is made up of two joints: The ankle joint and the subtalar joint. The ankle joint includes two bones (the tibia and the fibula) that form a joint that allows the foot to bend up and down. Two bones of the foot (the talus and the calcaneus) connect to make the subtalar joint that allows the foot to move side to side. The tarsal bones connect to the 5 long bones of the foot - the metatarsals. Ligaments and Tendons The large Achilles tendon is the most important tendon for walking, running and jumping. It attaches the calf muscles to the heel bone to allow us to puch off and up on the toes. There are

another 12 tendons that cross the ankle. They are responsible for movements of the ankle, foot, and toes; some of these tendons also help support the arches of the foot. Muscles The muscles of the foot are classified as intrinsic and extrinsic. The intrinsic muscles are located within the foot and cause movement of the toes and are flexors (plantar flexors), extensors (dorsiflexors), abductors, and adductors of the toes. Several intrinsic muscles also help support the arches of the foot. The extrinsic muscles are located outside the foot, in the lower leg. The gastrocnemius muscle (calf) is the largest. They have long tendons that cross the ankle, to attach on the bones of the foot and assist movement.

Pathophysiology

Modifiable Factors Trauma

Non-Modifiable Factors Physical active persons

Trauma or open wound

Microorganism gain entry

Immunity response

Increased WBC

White blood cells attack microorganisms through phagocytosis

Inflammatory response

Redness, localized pain and swelling

Formation of localized dead cells

White blood cells still recognized this as foreign object

Laboratory Name of test HEMATOLOGY hemoglobin October 11,2011 Date done October 5 ,2011 Indication The Hb determination is part of a CBC. It is used to screen for disease associated with anemia, to determine the severity of anemia, to monitor the response to treatment for anemia, and to evaluate polycythemia. (A manual of laboratory and diagnostic test p74) Iron deficiency, thalassemia, pernicious anemia, hemoglobinopathies (A manual of laboratory and diagnostic test p7475) 93 gms/L Result 80 gms/L Normal 127183gms/L Significance Decreased Hb levels are found in anemia states (a condition in which there is a reduction of Hb, Hct, and/or RBC values)

HCT

October 5 ,2011

The Hct test is part of the CBC. This test indirectly measures the RBC mass. It is

.25gms/L

0.37-0.54 gms/L

Decreased Hct values are an indicator of anemia, a condition in which there is a reduction in the PVC. An Hct <30% (<0.30) means that the patient is moderately to severely anemic. Decreased values

October 11,2011

an important measurement in the determination of anemia or polycythemia. (A manual of laboratory and diagnostic test p69)

.28 gms/L .

also occur in the following conditions: Acute and chronic blood loss Hemolytic reaction (A manual of laboratory and diagnostic test p72) Leukocyte count October 5 ,2011 The WBC serves as a useful guide to the severity of the disease process. Specific October 11,2011 patterns of leukocyte response can be expected in various types of diseases as determined by the differential count (percentages of the different types of leukocytes). (A manual of laboratory and diagnostic test p48) Segmenters October 5 ,2011 0.60 0.50-0.70 7.20x109L 9.10x109L 4.510x109L The findings are normal

October 11,2011 LYMPHOCYTES October 5 ,2011 This test measures the number of lymphocytes in the peripheral blood October 11,2011 (A manual of laboratory and

0.32 0.30 0.20-0.40 Lymphopenia Aplastic anemia 0.55 (A manual of

diagnostic test p60)

laboratory and diagnostic test p61)

Monocytes

October 5 ,2011

October 11,2011

This test counts monocytes, which circulate in certain specific conditions such as tuberculosis, subacute bacterial endocarditis, and the recovery phase of acute infections.

0.08

0.00-0.07

The findings are normal

0.07

Eosinophils

October 5 ,2011

October 11,2011

This test is used to diagnose allergic infections, assess severity of infestations with worms and other large parasites, and monitor response to treatment.

0.02

0.00-0.05

Increased eosinophils: allergic states, drug sensitivity

0.06

reaction, skin disorders, tissue invasion by parasites, periarteritis nodosa, hypersensitivity response to malignancy (e.g. Hodgkin's disease), pulmonary infiltrative disease, disseminated eosinophilic hypersensitivity disease.

Platelet

October 5 ,2011

A platelet count is a test to measure how many platelets you have in your blood.

363

150400X109/L

The findings are normal

October 11,2011

Platelets help the blood clot. They are smaller than red or

353

white blood cells. MCV October 5 ,2011 Average volume of the red cell is measured by automated instrument, by electrical October 11,2011 impedance or by light scatter. 78 77 82-92 fl Decreased in: Iron deficiency, thalassemia; decreased or normal in anemia of chronic disease. MCH October 5 ,2011 MCH calculated from measured values of Hb and RBC; ie, MCH = Hb/RBC. A October 11,2011 low MCH can mean hypochromia or microcytosis or both. A high MCH is evidence of macrocytosis MCHC October 5 ,2011 MCHC describes how fully the erythrocyte volume is filled with hemoglobin and is October 11,2011 calculated from measurement of hemoglobin (Hb), mean corpuscular corpuscular volume (MCV) and red cell count (RBC); ie, MCHC = Hb/MCV x RBC. 33 32 32-38% 26 Aplastic anemia (A manual of laboratory and diagnostic test p61) 25 28-32 pg Lymphopenia

The findings are normal

WOUND GRAM STAINING AND CULTURE SENSITIVITY TEST GS: RBC-- ++, NO MICROORGANISM SEEN AFB: NO ACID FAST BACILLI SEEN

DRUG ORDER (Generic name, dosage, route, frequency, etc.) PARACETAMOL NSAIDS 200mg/ml IV q4 TID

TRADE / BRAND NAME

PHARMACOLOGIC ACTION OF DRUG

INDICATIONS AND CONTRAINDICATION S

ADVERSE EFFECTS OF THE DRUG

DESIRED ACTION ON YOUR CLIENT The patients fever will return to the normal range of temperature

NURSING RESPONSIBILITIES/ PRECAUTIONS Note prescribed dosage and expected outcomes Monitor CBC, liver and renal function studies Document presence of fever, onset and the duration Check for urine for occult blood

paracetamol

Decreases fever by INDICATIONS ahypothalamic effect Control of pain due to leading to sweating headache, earache, and vasodilation and To reduce fever in inhibits the effect of bacterial or viral pyrogens on the infections hypothalamic heatCONTRAINDICATION regulating centers. S May cause analgesia Renal insufficiency, by inhibiting CNS anemia. Clients with prostaglandin cardiac or pulmonary synthesis; however, disease are more due to minimal effects susceptible to on peripheral acetominophen toxicity prostaglandin synthesis, acetaminophen has no anti-inflammatory or uricosuric effects. Does not cause any anticoagulant effect or ulceration of the GI tract. antipyretic and analgesic effects are comparable to those of aspirin.

Chronic and even acute toxicity can develop after long symptom-free usage. Hematologic: methemoglobinemia, hemolytic anemia, neutropenia, thrombocytopenia, pancytopenia, leucopenia Allergic: urticarial and erythematous skin reactions, skin eruptions, fever. Miscellaneous: CNS stimulation, hypoglycemic coma, jaundice, drowsiness, glossitis. Possible liver damage in those who consume three or more alcoholic drinks daily

DRUG ORDER (Generic name, dosage, route, frequency, etc.)

TRADE / BRAND NAME

PHARMACOLOGIC ACTION OF DRUG

INDICATIONS AND CONTRAINDICATION S indication infections caused by sensitive staphylococci, streptococci, pneumococci, bacteroides, and other sensitive aerobic and anaerobic organisms. Contraindication -contraindicated in patients hypersensitive to drug or lincomycin -use cautiously in patients with renal or hepatic disease, asthma, history of GI disease, or significant allergies

ADVERSE EFFECTS OF THE DRUG

DESIRED ACTION ON YOUR CLIENT The patient will have a decrease signs of infections

NURSING RESPONSIBILITIES/ PRECAUTIONS -assess patients infection before and regularly throughout therapy -before giving first dose, obtain specimen for culture and sensitivity test, begin therapy pending results. -monitor renal, hepatic, and hematopoetic functions during prolonged therapy. -be alert for adverse reactions -tell patient to take entire amount prescribed even after he feels better. -tell patient receiving drug to report discomfort

Clindamycin antibiotic 100g IV q8H ANST

- inhibits bacterial protein synthesis by binding to 50S subunit of ribosome.

- hinders or kills susceptible bacteria.

CNS: headache CV: Thrombophlebitis EENT: pharyngitis GI: abdominal pain, Anorexia, bloody or tarry stools, constipation, diarrhea, dysphagia, esophagitis, flatulence, nausea, psuedomembranus colitis, unpleasant or bitter taste, vomiting. GU: UTI HEMATOLOGIC: Eosinophilia, thrombocytopenia, transient leukopenia SKIN: maculopapular rash, urticaria OTHER: anaphylaxis, erythema, pain (I.V. use), induration, pain; sterile abcess (I.M. use)

DRUG ORDER (Generic name, dosage, route, frequency, etc.)

TRADE / BRAND NAME

PHARMACOLOGIC ACTION OF DRUG

INDICATIONS AND CONTRAINDICATION S Indication To relieve bronchospasm associated with acute or chronic asthma,bronchitis, or other reversible obstructive airway diseases. Also used toprevent exerciseinduced bronchospas m. Contraindication Contraindicated in patients hypersensitive to drug or its ingredients.

ADVERSE EFFECTS OF THE DRUG

DESIRED ACTION ON YOUR CLIENT The patient will be able to loosen his/her secretions

NURSING RESPONSIBILITIES/ PRECAUTIONS Drug may decrease sensitivity of spirometry used for diagnosis of asthma. When switching patient from regular to extendedrelease tablets,remember that a regular 2-mg tablet every 6 hours is equivalent toan extended-release 4mg tablet every 12 hours. Syrup contains no alcohol or sugar and may be taken by children as young as age 2. In children, syrup may rarely cause erythema multiforme or Stevens-Johnson syndrome

salbutamol bronchodilator 1 neb + 1cc PNSS q6

reduce chemical mediator release from pulmonary mast cells and improve ability of cilia to clear mucus direct-acting agent that relaxes smooth muscle walls of the bronchi, uterus, and skeletal muscle vascular bed

CNS: tremor, nervousness, dizziness, insomnia, headache, hyperactivity, weakness, CNS stimulation, malaise. CV: tachycardia, palpitations, hypertension. EENT: dry and irritated nose and throat with inhaled form, nasal congestion, epistaxis, hoarseness. GI: heartburn, nausea, vomiting, anorexia, altered taste, increased appetite. Metabolic: hypokalemia. Musculoskeletal: muscle cramps. Respiratory: bronchospasm, cough, wheezing, dyspnea, bronchitis, increased sputum. Other: hypersensitivity reactions

DRUG ORDER (Generic name, dosage, route, frequency, etc.)

TRADE / BRAND NAME

PHARMACOLOGIC ACTION OF DRUG

INDICATIONS AND CONTRAINDICATION S Indication Prevention and treatment of iron deficiency anemias. Dietary supplement for iron. Contraindication Hypersensitivity Severe hypotension.

ADVERSE EFFECTS OF THE DRUG

DESIRED ACTION ON YOUR CLIENT The patient will have an increase of HGB and HCT

NURSING RESPONSIBILITIES/ PRECAUTIONS Advise patient to take medicine as prescribed. Caution patient to make position changes slowly to minimize orhtostatic hypotension. Instruct patient to avoid concurrent use of alcohol or OTC medicine without consulting the physician. Advise patient to consult physician if irregular heartbeat, dyspnea, swelling of hands and feet and hypotension occurs. Encourage patient to comply with additional intervention for hypertension like proper diet, regular exercise, lifestyle changes and stress management.

Ferrous sulfate

- Elevates the serum iron concentration which then helps to form High or trapped in the reticuloendothelial cells for storage and eventual conversion to a usable form of iron.

Dizziness Nasuea and vomiting Nasal Congestion Dyspnea Hypotension Muscle cramps Flushing

CUES

NURSING DIAGNOSIS

GOALS AND OBJECTIVES

NURSING INTERVENTIONS Evaluate current limitations/degree of deficit in light of usual status. Ascertain ability to stand and move about and degree of assistance necessary/use of equipment Adjust activities to prevent overexertion. Reduce intensity level or discontinue activities that cause undesired physiological changes. Plan care with rest periods between activities to reduce fatigue. Involve client/SO(s) in planning of activities as much as possible. Assist with activities and provide/monitor clients use of assistive

EVALUATION

Objective: Sitting in the wheel chair Limited leg movemen t

Impaired physical mobility of the lower extremity r/t surgical incision at the left leg

Goal After 1-2 days of nursing interventions, client will be able to demonstrates and verbalizes proper exercises of the lower extremities & can perform activities of daily living with Minimal assistance. Objectives: 1.participate willingly in the necessary activities 2. demonstrate a increase in physical mobility 3. Use identified techniques to enhance mobility

GOAL MET

After 1-2 days of nursing interventions, client was able to demonstrates and verbalizes proper exercises of the lower extremities & can perform activities of daily living with Minimal assistance as evidenced by: Using of wheel chair by himself Was able to perform simple activities such as eating and combing hair by himself

devices (crutches, walker, wheelchair, oxygen tank, etc.) to protect client from injury. Increase exercise/activity levels gradually; teach methods to conserve energy, such as stopping to rest for 3 minutes during a 10-minute walk, sitting down instead of standing to brush hair.

CUES

NURSING DIAGNOSIS

GOALS AND OBJECTIVES

NURSING INTERVENTIONS INDEPENDENT 1. Assess clients muscle strength gross and fine motor coordination

EVALUATION

Risk for injury Objective: Age: 2 yrs old

Goal After 1-2 days of nursing intervention the client will be free from injury. Objectives: After 2 hours of nursing intervention the client will be given instruction carefully to be able to reduce the risk for injury through attaining safe environment:

GOAL MET

2. Assess mood, coping abilities, personality styles ( e.g. temperament aggressions impulsive behavior, level of self- esteem )

After 1-2 days of nursing intervention the client was free from any injury as evidenced by: Always with support of the significant others Always insight of the significant others

3. Provide safe environment:

- padded side rails - watch door edges curbs and landing steps

pad side rails remove obstacles in the room

4. Discuss important of self monitoring of conditions / emotions

Discharge Plan The patient is instructed to take the following plan for discharge.

M-EDICATION, instruct patient to continuously drink medication as prescribe by Doctor E-XERCISES, instruct patient to conduct 15-20 minutes exercises morning and active ROM in extremities for about 5-10minutes every afternoon T-REATMENT, instruct patient to continuously stick to the regimen of drinking medication on time and reporting to physician for any signs of deviations H-EALTH TEACHING, instruct patient to exercise daily, increase fluid intake O-UT-PATIENT FOLLOW UP, Instruct patient to attend follow-up check-ups as recommended by the physician. D-IET, the patient will be place on diet as tolerated S-PIRITUAL, Encourage client to attend religious practices like attending the worship service

Treatment and management ARTHROTOMY The medical term arthrotomy means cutting into a joint. Also known as a synosteotomy, an arthrotomy can be performed for a variety of reasons, usually as part of a larger surgery which is intended to address a problem inside the joint or an issue with one or more of the bones which articulates at the joint. Procedures of this nature are usually performed by anorthopedic surgeon, a surgeon who specializes in surgeries involving the bones and joints. One reason to perform an arthrotomy is to gain access to the joint for the purpose of a joint repair or replacement surgery. Cutting into the joint may be necessary to access the surgical field and to make the interior of the joint visible to the physician. However, it also increases healing time. Historically, surgeons had to weigh the damage caused by an arthrotomy with the need for the surgery when making treatment recommendations to patients. Today, cutting into the joints is less necessary because surgeons can perform arthroscopicsurgery. In this type of surgery, cameras are inserted into the joint along with tools which can be used to perform manipulations inside the joint. This allows the surgeon to work within the surgical field without having to cut the joint open to do so. Minimally invasive surgery is safer for the patient, decreases the risk of complications, and shortens healing time considerably, making it an appealing choice when it is an available option. Cutting into a joint may also be necessary during an amputation or during exploratory surgery in which arthroscopic surgery is not an option. Arthroscopy may not be possible in some emergency situations, for example, or when a joint is badly crushed and thus the surgeon has difficulty understanding what is going on inside the surgical field without looking at it directly. When arthrotomy is required as part of a medical procedure, the surgeon uses specialized tools which have been designed for cutting quickly and efficiently into the joints while minimizing damage. The surgeon plans out the cuts ahead of time so that when the patient is on the table, the surgeon already has a plan in mind for performing the surgery. Patients should be aware that even routine surgeries can be accompanied

with complications, and a good surgeon will discuss the potential risks of a procedure before it begins so that the patient will be prepared ahead of time.

BLOOD TRANSFUSION A blood transfusion is the transfer of blood or blood products from one person (donor) into another person's bloodstream (recipient). This is usually done as a life saving maneuver to replace blood cells or blood products lost through severe bleeding, during surgery when blood loss occurs or to increase the blood count in an anemic patient. The following material is provided to all patients and/or their family members regarding blood transfusions and the use of blood products. Although in most situations the likelihood of a blood transfusion associated with surgery is uncommon, at times patients may require blood products. You are encouraged to discuss your particular need for transfusion as well as the risks of transfusion with your doctor. Your options may be limited by time and health factors, so it is important to begin carrying out your decision as soon as possible. For example, if friends or family members are donating blood for a patient (directed donors), their blood should be drawn several days prior to the anticipated need to allow adequate time for testing and labeling. The exact protocols are hospital and donor site specific. The safest blood product is your own, so if a transfusion is likely, this is your lowest risk choice. Unfortunately this option is usually only practical when preparing for elective surgery. In most other instances the patient cannot donate their own blood due to the acute nature of the need for blood. Although you have the right to refuse a blood transfusion, this decision may hold life-threatening consequences. If you are a parent deciding for your child, you as the parent or guardian must understand that in a lifethreatening situation your doctors will act in your child's best interest to insure your child's health and well being in accordance with standards of medical care regardless of religious beliefs. Please carefully review this material and decide with your doctor which option(s) you prefer.

To assure a safe transfusion make sure your healthcare provider who starts the transfusion verifies your name and matches it to the blood that is going to be transfused. Besides your name, a second personal identifier usually is used as your birthday. This assures the blood is given to the correct patient. If during the transfusion you have symptoms of shortness of breath, itching, fever or chills or just not feeling well, alert the person transfusing the blood immediately.