Liceo de Cagayan University College of Nursing RN Pelaez Boulevard

Submitted as partial fulfillment in the subject N103 RLE A case study on Degenerative Osteoarthritis

Submitted by: Franklin Macabada

Submitted to: Mrs. Glenda Demafeliz RN, MN

January 10, 2013

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TABLE OF CONTENTS

I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII.

INTRODUCTION DATABASE AND HISTORY NURSING SYSTEMS REVIEW CHART DEVELOPMENTAL DATA PATHOPHYSIOLOGY ANATOMY AND PHYSIOLOGY DRUG STUDY MEDICAL MANAGEMENT NURSING MANAGEMENT REFERRALS AND FOLLOW UP EVALUATIONS AND IMPLICATIONS BIBLIOGRAPHY

3 8 9 15 19

22 27 29 35 35 36

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I.Introduction A. Overview of the Case Client Migabon, Rey a 52 year old male from Manolo Fortich Bukidnon, was diagnosed with degenerative osteoarthritis last July 25 2012. And was prescribed an analgesic for the pain. He was experiencing epigastric pain without vomiting one month PTA. Which prompted him to seek medical consult last October 08, 2012 And he was admitted due to Acute Gastritis and was promptly treated. But during his admission at CESH other maladies were discovered and were promptly taken care of. The doctors had identified varicoceles on the the left spermatic cord and was surgically corrected. The doctors also identified that client Migabon has Benign Prostatic Hyperplasia. With the occurrence of so many disease conditions, I had to focus on which disease I would prioritize where I would be able to do more independent nursing intervention. And have chosen Degenerative OA because I am familiar with the disease condition for my mother is suffering from the same disease. B. Objective The objective in making this case study is to identify and understand the problem of my client which is Degenerative Osteoarthritis and to determine what are the factors that contribute to the disease so that specific actions should be done and rendered to my client. Having this kind of case study is a privilege for me because it would be a good learning process by adding new knowledge and concept about different kinds of diseases that may be present in some patients. By making this case study I can identify the disease step by step, its nature on how this disease occur, and nursing actions that would be appropriate for the patient.

C. SCOPE and LIMITATIONS of the STUDY The study was conducted at Camp Evangelista Service Hospital, Cagayan de Oro city in which observation, analyzing and understanding the patients condit ion was done. We were
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given two (2) days to conduct the study. The study is also limited to the condition of the patient which is Degenerative Osteoarthritis. The study focuses only on obtaining the patients profile, health history and present health condition; assessing, recording, and gathering of pertinent data about the patient. Estimating the nursing needs and coping capacity of the patient; finding the primary health problems of the patient and the appropriate nursing interventions to solve the condition of the patient. The objectives, nursing care plans, drug study and evaluation for the patient was also done in this study.

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II. Database and History A. Database My client was Migabon, Rey a 52 year old male from Manolo, Fortich Bukidnon. Born on July 05, 1961 in Bugo, Cebu City. A soldier for 35+ years with an average income of 35,000 a month from rendered service. His vitals during my visit were Temperature of 36.2 C, Pulse rate of 82 bpm, Respiratory rate of 19 cpm, and BP of 120/90 mmHg. His height is 55 and weighs 110 lbs. Client Migabon has 3 children all with families of their own. He is currently living with his wife in bukidnon. Health History Family Health History According to client Migabon; Hypertension is a heredofamilial trait. His father had suffered from it. Past Health History Client Migabon has undergone Appendectomy in 1978 and Eye surgery last 2011 at CESH. Present Health History Three months prior to admission client Migabon has been complaining of progressive lower back pain aggravated by movement. One month prior to admission was the onset of epigastric pain which prompted him to seek medical consult. He was admitted with the diagnosis of Acute Gastritis and Degenerative OA . He was promptly treated but remained in the hospital for another condition which was discovered during admission. He was operated on his left spermatic cord because of Varicoceles. During surgery samples were extracted from his prostate and were found to be Benign Prostatic Hyperplasia which was causing his painful dysuria.

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III. NURSING SYSTEM REVIEW CHART

Name of Patient: Migabon, Rey Body Measurements: Weight: 110 lbs Height: 5 feet 5 inches Date of Assessment: December 18, 2012

Vital Signs upon Assessment: Temp: 36.2 C PR: 81 bpm RR: 19 cpm BP: 120/90 mmHg

EENT [ ] Impaired Vision [ ] Impaired Hearing [ ] Blind [ ] Deaf [ ] Pain [ ] Reddened [ ] Burning [ ] Edema [ ] Drainage [ ] Lesions [ ] Gums [ ] Teeth

Assess Eyes, Ears, Nose, and throat for any abnormalities [X] No Problem RESPIRATORY [ ] Asymmetrical [ ] Tachypnea [ ] Apnea [ ] Rales [ ] Cough [ ] Barrel Chest

[ ] Bradypnea [ ] Shallow [ ] Orthopnea [ ] Labored

[ ] Rhonchi [ ] Sputum [ ] Diminished [ ] Dyspnea [ ] Wheezing [X ] Pain [ ] Cyanotic

Assess respiration, rate, rhythm, depth, pattern, breath sounds, comfort. [ ] No Problem CARDIOVASCULAR [ ] Arrhythmia [ ] Edema [ ] Tingling [ ] Tachycardia [ ] Numbness [ ] Diminished Pulse [ ] Fatigue [ ] Irregular [ ] Bradycardia [ ] Mur-mur [ ] Absent Pulse [ ] Pain

Assess heart sounds, rate, rhythm, pulse, blood pressure, circulation, fluid retention, comfort [ X] No Problem GASTROINTESTINAL [ ] Obese [ ] Distension [ ] Mass [ ] Dysphagia [ ] Rigidity [ X] Pain

Assess abdomen, bowel habits, swallowing, bowel sounds, comfort. [ ] No Problem GENITO URINARY and GYNE [X] Pain [ ] Urine Color [ ] Vaginal Bleeding [ ] Hematuria [ ] Discharges [ ] Nocturia Page | 6

Assess Urine frequency, control, color, odor, comfort, Gyne Bleeding, Discharges . [ ] No Problem NEUROLOGIC [ ] Paralysis [ ] Vertigo [ ] Stuporous [ ] Tremors [ ] Unsteady [ ] Seizure [ ] Lethargic [ ] Confused [ ] Vision [ ] Grip [ ] Comatose +Dysuria

Assess motor function, sensation, LOC, Strength, Grip, gait, coordination, Speech [X] No Problem MUSCULOSKELETAL and SKIN [ ] Appliance [ ] Prosthesis [ ] Wound [ ] Echymosis [X] Stiffness [ ] Swelling [ ] Itching [ ] Petechiae [ ] Hot [ ] Lesions [ ] Poor Turgor [ ] Drainage [ ] Cool [ ] Deformity [ ] Pain

[ ] Rash [ ] Skin Color [ ] Flushed [ ] Diaphoretic [ ] Moist

[ ] Atrophy

Assess mobility, motion gait, alignment, joint function, Skin color, texture, turgor, integrity [ ] No Problem +Warm

Place an (X) in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure if appropriate, using (X).

Pain(Sporadic cough) Stiffness and pain (L2-L5) Appendectomy Scar Varicocelectomy Scar

Dysuria

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NURSING ASSESSMENT II

SUBJECTIVE COMMUNICATION: [ ] Hearing Loss Comments:

OBJECTIVE

[X ] Glasses

[ ] Languages [ ] Hearing Aide [ ] Speech Difficulties

[ ] Visual Changes Ok pa man akong panan aw [ ] Contact Lens [X] Denied ug pag-dungog As verbalized by the client.

Pupil Size: R_3mm _ L _3mm__ Bilaterally equal Reaction: _Pupils Equally Round and Reactive to Light Accommodation

OXYGENATION: [ ] Dyspnea Comments: Respiration: [ x ] Regular [ ] Irregular The rise and fall of the chest is symmetric

[X] Smoking History Ga ubo ko karon pero wala Describe: 30 years [ X] Cough [ ] Sputum [ ] Denied CIRCULATION: [X] Chest Pain [ ] Leg Pain [ ] Numbness of extremities [ ] Denied Comments: man plema As verbalized by the client.

R: Symmetric to left; full chest expansion L: Symmetric to right; full chest expansion

Heart Rhythm: [x] Regular [ ] Irregular

Mag sakit akong dughan labi Ankle Edema: No ankle edema_noted_____ na kung mag ubo ko verbalized by the client. As Pulse Right Left Car + + Rad + + DP + + Fem* + +

Comments:

Pulses on both left and right are present and palpable

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NUTRITION: Diet: Diet as tolerated w/ additional calcium [ ]N [ ] V =not noted Comments: Ok

[ ] Dentures

[X ] None Full X Incomplete With Patient

Character [ ] Recent change in weight, appetite [ ] Swallowing difficulty [X ] Denied ELIMINATION: Usual bowel pattern: Twice a day [ ] Constipation

akong Upper pagkaon As verbalized by the client. Lower

ra

man

[ ] Urinary Frequency 4 x day [ ] Urgency

Comments: No tenderness palpation.

Bowel sounds: abdominal_Normoactive 4X_ uponAbdominal Distention: Present: [ ]Yes [X ]No

Remedy= not applicable [X] Dysuria Date of last BM Dec. 18, 2012 [ ] Diarrhea Character applicable = [ ] Hematuria [ ] Incontinence [ ] Polyuria Not [ ] Foly in place [ ] Denied

Urine: Color: Odor: Yellowish Non-foul Clear

Consistency:

MGT. OF HEALTH & ILLNESS: [X] Alcohol [ ] Denied Briefly describe the patients ability to follow

Amount & Frequency

treatments (diet, meds, etc.) for chronic problems (if

Occasionally (once a month at least 500 ml) present). SBE Last Pap Smear: Not applicable Client has been following his medical regimen for his OA religiously

LMP: Not applicable SKIN INTEGRITY: [ ] Dry [ ] Itching [ ] Other Comments:

[ ] Dry

[ ] Cold [X ] Warm [ ] Cyanotic

[ ] Pale

Ok ra man akong panit As [ ] Flushed verbalized by the client. [ ] Moist

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[X] Denied

*Rashes, ulcers, decubitus (describe size, *location, drainage): No rashes, ulcers, or decubitus noted; Poor skin turgor due to loss of elasticity accompanying aging.

ACTIVITY/SAFETY : [ ] Convulsion [ ] Dizziness [X] motion of joints Comments: Magsakit akong buko-buko [ ] Level of Consciousness and Orientation The client is awake and coherent, oriented with time, place and people Cane __ Other

kung dili ko mag inom ug

Limitedtambal As verbalized by the __ Gait: __ Walker client. __ Gait: X Steady __ Gait: __ Unsteady:

[ ] Sensory and motor losses in face or Limitation ability to: [ ] Ambulate [ ] Bathe Self [ ] Other [X ] Denied COMFORT/SLEEP/AWAKE: [X ] Pain Location: Lower back (L2-L5) Frequency: Daily Remedies: Comments: [ ] Facial Grimaces in extremities: No sensory and motor loses on face and extremities noted. [X ] Range of Motion Limitations: Excessive trunk bending and twisting

Magsakit usahay kung [ ] Guarding mangihi ko pero dili [ ] Other Signs of Pain: man pirmi, tagaan pa ko nila ug tambal by as the [ ] Siderail release form signed (60+ years) Not applicable No signs of pain, guarding or facial grimaces observed

verbalized

Warm compress and client._________ massage [ ] Nocturia [ ] Sleep Difficulties [ ] Denied

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COPING: Occupation: Soldier 35+ years Members of household: 2 members (Mr & Mrs Migabon) The person and his phone number that can Most supportive person: Mrs Migabon Carmencita Be reached anytime: 0926456096 Observe non-verbal behavior: Client is very jolly and receptive during the Interview

SPECIAL PATIENT INFORMATION (USE LEAD PENCIL) __NA____Daily Weight 140/90 mmHg_BP q Shift ___ NA ____Neurovs ___ NA ____CVP/SG. Reading Date ordered Diagnostic/ Laboratory Exams 07/03/12 11/27/12 12/03/12 12/06/12 12/06/12 12/09/12 12/09/12 12/19/12 X-ray Ultrasound Ultrasound Blood Chem Hep B Screening ECG Hematology Urinalysis 07/03/12 11/27/12 12/03/12 12/06/12 12/06/12 12/09/12 12/09/12 12/19/12 NA NA NA NA NA NA NA NA Date Done __ NA______PT/OT__________ __ NA _____Irradiation ___ NA _____Urine Test_________ __ NA ____24 hour Urine Collection Date I.V. Fluids/ Date Disc.

Ordered Blood

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Interpretation of Laboratory results ECG: Normal Sinus Rhythm X ray: No fracture or dislocations but presence of spurs on L2 to L5 Ultrasound: Varicoceles, Left Benign Prostate Hyperplasia Hematology: Within normal range Blood Chem: Within normal range Hep B: Non-reactive Urinalysis: Positive for WBC and RBC Indicative of infection

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IV. DEVELOPMENTAL DATA The term growth and development both refers to dynamic process. Often used interchangeably, these terms have different meanings. Growth and development are interdependent, interrelated process. Growth generally takes place during the first 20 years of life; development continues after that. Growth: 1. Physical change and increase in size. 2. It can be measured quantitatively. 3. Indicators of growth include height, weight, bone size, and dentition. 4. Growth rates vary during different stages of growth and development. 5. The growth rate is rapid during the prenatal, neonatal, infancy and adolescent stages and slows during childhood. 6. Physical growth is minimal during adulthood. Development: 1. Is an increase in the complexity of function and skill progression. 2. It is the capacity and skill of a person to adapt to the environment. 3. Development is the behavioral aspect of growth.

Eriksons Stages of Psychosocial Development Theory

Erikson's psychosocial crisis stages (syntonic v dystonic) 1. Trust v Mistrust infant / mother / feeding and being comforted, teething, sleeping toddler / parents / bodily functions, toilet training, muscular control, walking preschool / family / exploration and discovery, adventure and play schoolchild / school, teachers, friends, neighbourhood / achievement and accomplishment Hope and Drive life stage / relationships / issues basic virtue and second named strength (potential positive outcomes from each crisis) maladaptation / malignancy (potential negative outcome - one or the other - from unhelpful experience during each crisis) Sensory Distortion / Withdrawal Impulsivity / Compulsion

2. Autonomy v Shame & Doubt 3. Initiative v Guilt 4. Industry v Inferiority

Willpower and SelfControl Purpose and Direction Competence and Method

Ruthlessness / Inhibition Narrow Virtuosity / Inertia

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5. Identity v Role Confusion 6. Intimacy v Isolation 7. Generativity v Stagnation

adolescent / peers, groups, influences / resolving identity and direction, becoming a grown-up young adult / lovers, friends, work connections / intimate relationships, work and social life mid-adult / children, community / 'giving back', helping, contributing

Fidelity and Devotion Love and Affiliation

Fanaticism / Repudiation

Promiscuity / Exclusivity

Care and Production

Overextension / Rejectivity

Client Migabon is on the 7th stage. Generativity vs Stagnation. He is on the point where he has the need to be productive even with his age. He doesnt want to feel incapable and stagnant even there is just the two of them in the household. He still keeps his duty as a soldier.

Havinghurst Developmental Stages Havighurst identified Six Major Stages in human life covering birth to old age.

Infancy & early childhood (Birth till 6 years old) Middle childhood (613 years old) Adolescence (1318 years old) Early Adulthood (1930 years old) Middle Age (30-60years old) Later maturity (60 years old and over)

From there, Havighurst recognized that each human has three sources for developmental tasks. They are:

Tasks that arise from physical maturation: Learning to walk, talk, control of bowel and urine, behaving in an acceptable manner to opposite sex, adjusting to menopause. Tasks that arise from personal values: Choosing an occupation, figuring out ones philosophical outlook. Tasks that have their source in the pressures of society: Learning to read, learning to be responsible citizen.

The developmental tasks model that Havighurst developed was age dependent and all served pragmatic functions depending on their age. (60 and over)

Adjusting to decreasing physical strength and health. Adjusting to retirement and reduced income. * Adjusting to death of a spouse. * Establishing an explicit affiliation
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with ones age group. * Adopting and adapting social roles in a flexible way. * Establishing satisfactory physical living arrangements. Client Migabon has adapted very well to his current age and status. It was evident during the interview because he was very jolly and didnt really mind being interviewed and sharing parts of his life as well. Piagets Stage Theory of Cognitive Development Swiss biologist and psychologist Jean Piaget (1896-1980) observed his children (and their process of making sense of the world around them) and eventually developed a four-stage model of how the mind processes new information encountered. He posited that children progress through 4 stages and that they all do so in the same order. These four stages are:

Sensorimotor stage (Birth to 2 years old). The infant builds an understanding of himself or herself and reality (and how things work) through interactions with the environment. It is able to differentiate between itself and other objects. Learning takes place via assimilation (the organization of information and absorbing it into existing schema) and accommodation (when an object cannot be assimilated and the schemata have to be modified to include the object. Preoperational stage (ages 2 to 4). The child is not yet able to conceptualize abstractly and needs concrete physical situations. Objects are classified in simple ways, especially by important features. Concrete operations (ages 7 to 11). As physical experience accumulates, accommodation is increased. The child begins to think abstractly and conceptualize, creating logical structures that explain his or her physical experiences. Formal operations (beginning at ages 11 to 15). Cognition reaches its final form. By this stage, the person no longer requires concrete objects to make rational judgments. He or she is capable of deductive and hypothetical reasoning. His or her ability for abstract thinking is very similar to an adult.

Client Migabon has already passed this stage. His ability to make concrete judgment in life has been proven already because he has managed to maintain his job and still has a very good family structure.

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Freudian psychosexual development Stage Age Range Erogenous zone Consequences of psychologic fixation Orally aggressive: chewing gum and the ends of pencils, etc. Orally Passive: smoking, eating, kissing, oral sexual practices. Oral stage fixation might result in a passive, gullible, immature, manipulative personality. Anal retentive: Obsessively organized, or excessively neat Anal expulsive: reckless, careless, defiant, disorganized, coprophiliac Oedipus complex (in boys and girls); according to Sigmund Freud. Electra complex (in girls); according to Carl Jung. Sexual unfulfillment if fixation occurs in this stage. Frigidity, impotence, unsatisfactory relationships

Oral

Birth1 year

Mouth

Anal

13 years

Bowel and bladder elimination

Phallic

36 years

Genitalia Dormant sexual feelings Sexual interests mature

Latency 6puberty Genital Puberty death

Genital stage The fifth stage of psychosexual development is the genital stage that spans puberty and adult life, and thus occupies most of the life of a man and of a woman; its purpose is the psychologic detachment and independence from the parents. The genital stage affords the person the ability to confront and resolve his or her remaining psychosexual childhood conflicts. As in the phallic stage, the genital stage is centered upon the genitalia, but the sexuality is consensual and adult, rather than solitary and infantile. The psychological difference between the phallic and genital stages is that the ego is established in the latter; the person's concern shifts from primary-drive gratification (instinct) to applying secondary process-thinking to gratify desire symbolically and intellectually by means of friendships, a love relationship, family and adult responsibilities. Actually Client Migabon has already passed this stage with grace. He has built a good relationship with his partner, his offsprings together with their grandchildren.

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V. Pathophysiology

Osteoarthritis (OA) also known as degenerative arthritis or degenerative joint disease or osteoarthrosis, is a group of mechanical abnormalities involving degradation of joints

Predisposing Factors: *Age (Adult Male 50+ yrs) *Genetics

Precipitating Factors: *Sedentary lifestyle *Joint trauma or injury

Structural Damage to Cartilage

MMP release w/ degradation of collagen and proteoglycans

Muscle Weakness

Alteration in chondrocyte function

Synovial Inflammation

Cytokine release

Bone remodeling

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VII. Anatomy and Physiology The Skeleton The adult human skeleton has a total of 213 bones, excluding the sesamoid bones. The appendicular skeleton has 126 bones, axial skeleton 74 bones, and auditory ossicles six bones. Each bone constantly undergoes modeling during life to help it adapt to changing biomechanical forces, as well as remodeling to remove old, microdamaged bone and replace it with new, mechanically stronger bone to help preserve bone strength. The four general categories of bones are long bones, short bones, flat bones, and irregular bones. Long bones include the clavicles, humeri, radii, ulnae, metacarpals, femurs, tibiae, fibulae, metatarsals, and phalanges. Short bones include the carpal and tarsal bones, patellae, and sesamoid bones. Flat bones include the skull, mandible, scapulae, sternum, and ribs. Irregular bones include the vertebrae, sacrum, coccyx, and hyoid bone. Flat bones form by membranous bone formation, whereas long bones are formed by a combination of endochondral and membranous bone formation. The skeleton serves a variety of functions. The bones of the skeleton provide structural support for the rest of the body, permit movement and locomotion by providing levers for the muscles, protect vital internal organs and structures, provide maintenance of mineral homeostasis and acid-base balance, serve as a reservoir of growth factors and cytokines, and provide the environment for hematopoiesis within the marrow spaces Osteoarthritis (OA) also known as degenerative arthritis or degenerative joint disease or osteoarthrosis, is a group of mechanical abnormalities involving degradation of joints, including articular cartilage and subchondral bone. Symptoms may include joint pain, tenderness, stiffness, locking, and sometimes an effusion. A variety of causeshereditary, developmental, metabolic, and mechanicalmay initiate processes leading to loss of cartilage. When bone surfaces become less well protected by cartilage, bone may be exposed and damaged. As a result of decreased movement secondary to pain, regional muscles may atrophy, and ligaments may become more lax. Treatment generally involves a combination of exercise, lifestyle modification, and analgesics. If pain becomes debilitating, joint replacement surgery may be used to improve the quality of life. OA is the most common form of arthritis.

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The Prostate The prostate is a walnut sized gland that is only present in men. It is located just below the bladder and top of the penis. This gland surrounds the urethra ( the tube through which urine flows from the bladder and out through the penis ). Prostate gland is partly muscular and partly glandular. Its ducts open into the prostatic portion of the urethra (The portion of urethra surrounded by prostate gland ). It is made up of three lobes. The prostate gland secretes a slightly alkaline fluid which forms the important component of semen. This fluid constitutes the major portion of seminal fluid which carries sperm and sperms move freely in this fluid. The prostate gland is divided into three zones, peripheral, transitional and central. The overgrowth of cells takes place in the central part which leads to BPH. Benign prostatic hyperplasia (BPH), also called benign enlargement of the prostate (BEP), adenofibromyomatous hyperplasia and benign prostatic hypertrophy (technically incorrect usage), is an increase in size of the prostate. BPH involves hyperplasia of prostatic stromal and epithelial cells, resulting in the formation of large, fairly discrete nodules in the periurethral region of the prostate. When sufficiently large, the nodules compress the urethral canal to cause partial, or sometimes virtually complete, obstruction of the urethra, which interferes with the normal flow of urine. It leads to symptoms of urinary hesitancy, frequent urination, dysuria (painful urination), increased risk of urinary tract infections, and urinary retention. Although prostate specific antigen levels may be elevated in these patients because of increased organ volume and inflammation due to urinary tract infections, BPH does not lead to cancer or increase the risk of cancer

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VI. Drug Study

Generic Name of Ordered Drug: Vitamin B Complex

Brand Name:

Date Ordered:

Classification:

Dose/Frequen cy/Route

Mechanism of Action

Specific Indication

Contraindica tion

Neuro plex

Dec. 09, 2012

Vitamin Supplement

1 Cap OD PO

Vitamins are important building blocks of the body and help keep you in good health.

This product is a combination of B vitamins used to treat or prevent vitamin deficiency due to poor diet, certain illnesses, alcoholism, or during pregnancy.

Caution is advised if you have diabetes, alcohol dependence, or liver disease

Side Effects/ Toxic Effects Mild upset stomac h or flushing may occur. These effects are usually tempor ary and may disappe ar as your body adjusts to this product .

Nursing Precaution

Obtain a sensitivity test history before administration. An intradermal test dose is recommended in patients with possible sensitivity. Dont mix parenteral preparations in same syringe with other drugs. Monitor patient for hypokalemia for first 48 hours, as anemia corrects itself. Give potassium supplement, as needed.

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Generic Name of Ordered Drug: Pregabalin

Brand Name:

Date Ordered:

Classificati on:

Dose/Fre quency/ Route 75 mg tab OD PO

Mechanism of Action

Specific Indication

Contraindication

Side Effects/ Toxic Effects

Nursing Precaution

Lyrica

Dec. 09, 2012

Analgesic

Pregabalin binds to calcium channels on nerves and may modify the release of neurotransmit ters (chemicals that nerves use to communicate with each other). Reducing communicatio n between nerves may contribute to pregabalin's effect on pain and seizures.

Pregabalin binds to calcium channels on nerves and may modify the release of neurotransmi tters (chemicals that nerves use to communicate with each other). Reducing communicati on between nerves may contribute to pregabalin's effect on pain and seizures.

Alcohol and drugs that cause sedation may increase the sedative effects of pregabalin

The most common side effects of pregabalin are dizziness, drowsiness, dr y mouth, edema (accumulation of fluid), blurred vision, weight gain, and difficulty concentrating. Other side effects include reduce d blood platelet counts, and increased bloo d creatinine kinase levels

Monitor for changes in mental status

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Generic Name of Ordered Drug: Tramadol

Brand Name : Zydol

Date Ordered: Dec. 10, 2012

Classific ation: Analge sic

Dose/Fre quency/R oute 500 mg cap PRN 8

Mechanis m of Action Binds to opiate receptors in the CNS causing inhibition of ascending pain pathways, altering the perception of and response to pain; also inhibits the reuptake of norepinep hrine and serotonin, which also modifies the ascending pain pathway.

Specific Indication Manageme nt of pain

Contraindication

Side Effects/ Toxic Effects Dizziness Nausea Drowsiness Dry mouth Constipation Headache Sweating Vomiting Itching Rash Visual disturbances Vertigo

Nursing Precaution

Hypersensitivity to tramadol, opioids, or any component of the formulation; opioiddependent patients; acute intoxication with alcohol, hypnotics, centrally-acting analgesics, opioids, or psychotropic drugs

Instruct client to report any adverse reaction to the physician or nurse. Tell patient that tolerance or drug dependence may result from extended use (withdrawal symptoms have been reported); abrupt discontinuation should be avoided.

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Generic Name of Ordered Drug: Ciprofloxaci n

Brand Name:

Date Ordered:

Classifica tion:

Dose/Fre quency/ Route 500 mg 1 cap TID x 7 days (LD 12/19/12 1800H)

Mechanism of Action

Specific Indication

Contraindic ation

Side Effects/ Toxic Effects

Nursing Precaution

Ciprob ay

Dec. 12, 2012

ANTIINFECTIV ESQuinolon es

Inhibits bacterial DNA gyrase thus preventing replication in susceptible bacteria

Infections of the resp. tract, middle ear,paranasal sinuses, eyes, kidneys, urinary tract

Drugs that inhibit peristalsis. Infants and children, growing adolescents . Pregnancy and lactation.

PRECAUTION Severe and persistent diarrhea during and after treatment ADVERSE RXN Common:Nausea, diarrhea, vomiting, rash Uncommon: Anorexia, headache,dizziness, fever, GI and abdominal pain, flatulence, confusion, vertigo

>Assess pt for previous sensitivity reaction >Assess pt for any s/s of infection before & during treatment >Assess for adverse reactions >assess pt. & familys knowledge of drug therapy

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VII. MEDICAL MANAGEMENT Dec 10, 2012 1225 H >IVF to ff: D5LR 1L @20 gtts/min For fluids and medication access >Give last dose IV Tramadol today; for tomorrow shift to PO Tramadol 500 mg 1 cap 8 for pain. For pain management >Continue IV Gentamycin 80 mg IV 8 Antibiotic treatment >Refer Referral for any changes in condition

Dec 11, 2012 0825 H >Terminate Cystoclysis when consumed Removal of bladder irrigation when consumed. >For wound dressing today, then every other day To prevent contamination of surgical wound >IVF to ff: D5LR 1L @20 gtts/min For fluids and medication access >Continue meds Medication purposes >May remove IFC now; refer if unable to void after 6 hours To restart normal voiding pattern >Refer accordingly Referral for any changes in condition >Terminate IVF now Discontinuation of IV fluids >Increase oral fluids To maintain hydration >D/C IV Antibiotics, shift to PO =Ciprofloxacin 500 mg 1 cap TID x 7 dAays Medication purposes >Continue PO Tramadol PRN For pain management >Repeat chest X-ray For diagnostic purposes
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1812 H

Dec 12, 2012

Dec 14, 2012

Dec 17, 2012

>Please follow up result of biopsy and CXR Diagnostic purposes

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VII. NURSING MANAGEMENT NURSING CARE PLAN

Cues Nursing Diagnoses Objectives Interventions Rationale Evaluation

Subjective Date: Kung mangihi ko, ushay naa pa japon mag tulo as verbalized by the client. Objective Data: >Hesitancy to urinate >Inability to empty bladder completely >Urine dribbling

Urinary Retention [acute/chr onic]

At the end of the shift, the client will be able to demonstrate post void residuals of less than 50 ml, w/ absence of dribbling/overflow

Independent: > Encourage patient to void every 24 hr and when urge is noted.

> May minimize urinary retention/overdistension of the bladder. > High urethral pressure inhibits bladder emptying or can inhibit voiding until abdominal pressure increases enough for urine to be involuntarily lost. > Useful in evaluating degree of obstruction and choice of intervention. > A distended bladder can be felt in the suprapubic area. > Promotes muscle relaxation, decreases edema, and may enhance voiding effort.

At the end of the shift, client demonstrated post residuals of less than 50 mL w/ absence of dribbling & overflow.

> Ask patient about stress incontinence when moving, sneezing, coughing, laughing, lifting objects.

> Observe urinary stream, noting size and force.

> Percuss/palpate suprapubic area. > Recommend sitz bath as indicated.

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Cues Subjective Data: Sakit man cya usahay kung mangihi ko as verbalized by the patient. Objective Data: >Mucosal irritation dur to bladder distention >Reports of pain >Restlessness

Nursing Diagnoses Acute pan R/T BPH

Objectives At the end of the shift, client will be able to verbalize relief or control of pain

Interventions Independent: > Assess pain, noting location, intensity (scale of 010), duration.

Rationale > Provides information to aid in determining choice/effectiveness of interventions. > Bedrest may be needed initially during acute retention phase; however, early ambulation can help restore normal voiding patterns and relieve colicky pain. > Promotes relaxation, refocuses attention, and may enhance coping abilities.

Evaluation At the end of the shift client was able to verbalize relief and control of pain

> Recommend indicated.

bedrest

as

> Provide comfort measures, e.g., back rub, helping patient assume position of comfort. Suggest use of relaxation/deep-breathing exercises, diversional activities. > Encourage use of sitz baths, warm soaks to perineum. > Instruct massage. in prostatic

>Promotes muscle relaxation.

> Aids in evacuation of ducts of gland to relieve congestion/inflammation. Contraindicated if infection is present.

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Cues Subjective data: Sakit akong buko buko labi na kung sobrang lihok as verbalized by the client Objective data: >Pain in lower back >Tender to the touch >Limited back motion

Nursing Diagnoses Pain (Acute/Chronic ) R/T osteoarthritis

Objectives At the end of the shift, the client will be able to verbalize reduced or controlled pain.

Interventions Independent: > Encourage clients to frequently change positions. > Help clients to a warm bath at the time of waking. > Help clients to a warm compress >Monitor the temp of the compress >Give a gentle message

Rationale

Evaluation At the end of the shift client was able to verbalize reduced and controlled pain.

>Increases blood flow to the different areas and prevents soreness >Warm baths help in alleviating pain especially in the morning. >Provides extra pain relief on sore areas >To avoid injuring the client

>Provides Comfort

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Actual Nursing Intervention Migabon, Rey 7-3 pm S> Mag lisod ko pangihi ug sakit siya usahay as verbalized by the client O>Received awake sitting on bed >Initial vital signs BP=100/90 mmHg HR=81 bpm RR=20 cpm Temp=36.5 C A>Urinary Retention R/T Bladder outlet obstruction P>At the end of the shift the patient would be able to verbalize relief from discomfort upon voiding I>Vital signs taken and recorded 4 >Positioned on high back rest >Consumed breakfast fair appetite >Health teachings given with emphasis on: =Role of physical exercise and non-strenuous activities =Double voiding =Performing sitz bath =Stress management =Diet modification E>At the end of the shift goals were met, patient was able to verbalize relief from discomfort Dec. 19, 2012

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VIII. REFERRALS AND FOLLOW-UP: Outpatient (check-up): Instructed the patient to abide to his outpatient follow-up check up at the Outpatient department of CESH, where time, date and doctor is still to be set. Encouraged the patient as well to report any unusual findings that he might have observed.

IX: EVALUATION AND IMPLICATIONS: This care study enables us to further our learning association with disease condition of the patient. From it, we have gained knowledge in the progression of the disease and the reaction of the body to maintain homeostasis and how eventually it causes harm. Through this, we actually improved our understanding and skills in the management of the patient through the experiences weve had in implementing our care. It also enhanced our confidence in intervening because of the input gained form our research. Case studies are a way of getting familiar or get acquainted not only with the patient but also on his or her condition. It provides concrete examples of how the theoretical knowledge learned during lectures was applied. How the concepts of the various disease condition were manifested through the client. It allows the opportunity to facilitate the acquisition of knowledge through the experiences gained in management and in caring for the patient. As a result, it is a must that case studies should be made not just for requirement purposes but also for the pursuit of knowledge. In general, the case study promoted learning through the research and actual experiences and made us more knowledgeable in caring for the patient and that can really be used in our chosen field.

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X. Bibliography Books: 120 Diseases (The essential Guide to more than 120 Medical Conditions, syndromes, and diseases) by Prof. Peter Abrahams 2007 pp. 46-47; 74-75; 190-195 Essentials of pathophysiology by Carol Mattson Porth Rn, MSN, PhD pp. 366-399; 705-721; 1034-1037 Manual of Nursing Practice by Lippincott 10thed. pp. 454-462; 910-932; 1087-1088 Portable Rn 3rd edition by Lippincott 2006 pp. 214-216; 226-228; 236-238 Nursing Care Plans, Nursing diagnosis and intervention by Gulanick/Myers 6 th ed pp. 301-305; 777-782; 1050-1062

Internet: WWW.MEDSCAPE.COM WWW.WIKIPEDIA.ORG WWW.DRUGSCAPE.COM

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