UNCIANO COLLEGES, INC.

Antipolo City
COLLEGE OF NURSING

In Partial Fulfillment of the Requirements

For the Actual Clinical Hospital: Related Learning Experience
Affiliating Institution: Unciano Medical Center

ABSCESS
SUBMITTED BY:
ASAARI, MARWA J.
GESTIADA, ACEAR L.
ADAY PRINCESS S.
GAMBOL, LEAH P.
DAGOY, ALYZZA MAE L.
LEYBLE, LAMBERT JOHN O.
PANER, MA. VERONICA M.

SUBMITTED TO:
MILAGROS JAVIER - NUEZ, RN, MAN
Clinical Instructor

TABLE OF CONTENTS
I.

BACKGROUND OF THE STUDY

II.

OBJECTIVES
1. Cognitive
2. Affective
3. Psychomotor

III.

PATIENTS PROFILE

IV.

NURSING HISTORY

V.

GORDONS FUNCTIONAL HEALTH PATTERN

VI.

PHYSICAL EXAMINATION

VII.

ANATOMY AND PHYSIOLOGY

VIII.

PATHOPHYSIOLOGY

IX.

COLLABORATIVE MANAGEMENT
1. LABORATORY AND DIAGNOSTIC TESTS
2. FDAR STUDENT NURSES NOTES

X.

ACKNOWLEDGEMENT
XI.

XII.

First and foremost praise is to God, the Almighty, and the Greatest of all, on

whom ultimately we depend for sustenance and guidance. Thank thee to God for showering all
His kindness that weve used in taking care of other people, for blessing us with patience and
giving us knowledge, strength and determination to prioritize our work and do our entire task in
time.
XIII.
XIV.

Secondly, we would like to show our sincere gratitude to our beloved Dean of the

College of Nursing, Ms. Maria Haydi P. Medina RN, MAN for sharing her pearls of wisdom with
us during the course of this study and for her professed insights. We deeply show appreciation
for her assistance and commentary observations that greatly improved our work.
XV.
XVI.

Third, we would like to express our gratitude to Ms. Milagros Javier-Nuez, RN,

MAN, our clinical instructor for guiding us in every step weve done. For giving a lot of patience,
for throwing a big smile even if theres a mistake weve done and for the knowledge that she
have shared to us. We attribute all our accomplishments to her encouragement and effort and
without her this thesis, too, would not have been completed or written.
XVII.
XVIII.

We would also like to thank the staff nurses at Unciano Medical Center for letting
us see all important charts and documents related to our case study. Thank you for
accommodating us.

XIX.
XX.

And finally, we wish to extend our sincerest thanks and gratitude to our parents

for the support, encouragement and contribution in the accomplishment of this study.
XXI.

XXII.
XXIII.
XXIV.

BACKGROUND OF THE STUDY

An abscessis a collection of pus that has built up within the tissue of the

body. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The
swelling may feel fluid filled when pressed. [1] The area of redness often extends beyond the
swelling. Carbuncles and boils are types of abscess that often involve hair follicles with
carbuncles being larger.
XXV.

Abscesses may occur in any kind of solid tissue but most frequently on skin

surface (where they may be superficial pustules (boils) or deep skin abscesses), in the
lungs, brain, teeth, kidneys and tonsils. Major complications are spreading of the abscess
material to adjacent or remote tissues and extensive regional tissue death (gangrene).
XXVI.

The main symptoms and signs of a skin abscess are redness, heat, swelling,

pain and loss of function. There may also be high temperature (fever) and chills. Risk factors for
abscess formation include intravenous drug use. Another possible risk factor is a prior history of
disc herniation or other spinal abnormality, though this has not been proven.
XXVII.

Abscesses are caused by bacterial infection, parasites, or foreign substances.

Bacterial infection is the most common cause. Often many different types of bacteria are
involved in a single infection. In the United States and many other areas of the world the most
common bacteria present is methicillin-resistant Staphylococcus aureus. Among spinal subdural
abscesses, methicillin-sensitive Staphylococcus aureus is the most common organism involved.
XXVIII.

An abscess is a defensive reaction of the tissue to prevent the spread of

infectious materials to other parts of the body.The organisms or foreign materials kill the
local cells, resulting in the release of cytokines. The cytokines trigger an inflammatory response,

which draws large numbers of white blood cells to the area and increases the regional blood
flow.
XXIX.

The final structure of the abscess is an abscess wall, or capsule, that is formed

by the adjacent healthy cells in an attempt to keep the pus from infecting neighboring structures.
However, such encapsulation tends to prevent immune cells from attacking bacteria in the pus,
or from reaching the causative organism or foreign object.
XXX.

Abscesses may be classified as either skin abscesses or internal abscesses.

Skin abscesses are common; internal abscesses tend to be harder to diagnose, and more
serious. Skin abscesses are also called cutaneous or subcutaneous abscesses. Abscesses
should be differentiated from empyemas, which are accumulations of pus in a preexisting rather
than a newly formed anatomical cavity.Other conditions that can cause similar symptoms
include: cellulitis, a sebaceous cyst and necrotising fasciitis. Cellulitis typically also has an
erythematous reaction, but does not confer any purulent drainage.
XXXI.

The standard treatment for an uncomplicated skin or soft tissue abscess is

opening and draining. There does not appear to be any benefit from also using antibiotics in
most cases A small amount of evidence did not find benefit from packing the abscess with
gauze.The abscess should be inspected to identify if foreign objects are a cause, which may
require their removal. If foreign objects are not the cause, incision and drain of the abscess is
standard treatment.In critical areas where surgery presents a high risk, it may be delayed or
used as a last resort. Warm compresses and elevation of the limb may be beneficial for a skin
abscess.
XXXII.

Most people who have an uncomplicated skin abscess should not use

antibiotics. Antibiotics in addition to standard incision and drainage is recommended in persons

with severe abscesses, many sites of infection, rapid disease progression, the presence
of cellulitis, symptoms indicating bacterial illness throughout the body, or a health condition

causing immunosuppression. People who are very young or very old may also need antibiotics.
If the abscess does not heal only with incision and drainage, or if the abscess is in a place that
is difficult to drain such as the face, hands, or genitals, then antibiotics may be indicated.
XXXIII.

In those cases of abscess which do require antibiotic treatment, Staphylococcus

aureus bacteria

is

common

cause

and

an

anti-staphylococcus

antibiotic

such

as flucloxacillin or dicloxacillin is used. The Infectious Diseases Society of America advises that
the draining of an abscess is not enough to address Staphylococcus aureus (MRSA), and in
those cases, traditional antibiotics may be ineffective. Alternative antibiotics effective against
often include clindamycin,doxycycline, minocycline, and trimethoprim-sulfamethoxazole.. If the
condition is thought to be cellulitis rather than abscess, consideration should be given to
possibility of strep species as cause that are still sensitive to traditional anti-staphylococcus
agents such as dicloxacillin or cephalexin in patients able to tolerate penicillin. Antibiotic therapy
alone without surgical drainage of the abscess is seldom effective due to antibiotics often being
unable to get into the abscess and their ineffectiveness at low pH levels.
XXXIV.

Culturing the wound is not needed if standard follow-up care can be provided

after the incision and drainage. Performing a wound culture is unnecessary because it rarely
gives information which can be used to guide treatment.
XXXV.

Skin abscesses are common and have become more common in recent

years. Even without treatment they rarely result in death as they will naturally break through the
skin. Risk factors include intravenous drug use with rates reported as high as 65% in this
population. In 2005 in the United States 3.2 million people went to the emergency department
for an abscess. In Philippines, around 13,000 people were hospitalized in 2008 for the disease.
XXXVI.

About one in four healthy people are colonized by staphylococcus bacteria.

Those who are colonized have the bacteria present in their skin and nasal passages, but the
presence of the bacteria doesnt make them ill. Historically, most staph was sensitive to beta-

lactam antibiotics, such as penicillin, methicillin, and ampicillin. Some strains of staph developed
resistance to beta-lactam antibiotics.
XXXVII.
XXXVIII.

OBJECTIVES

A. General Objectives
XXXIX.

After 8 hours of exposure in the General Ward at Unciano Medical

Centrer, we, as nursing students of Unciano Colleges Inc are here to present a case
study of a 18 year old, male patient diagnosed of having a Right Tissue Swelling at the
right thigh. This is to identify and determine the patients health, problems and needs,
and to develop the skills needed to render proper nursing care to the patient.
XL.
B. Specific Objectives
XLI.
1. Knowledge/Cognitive
To establish therapeutic communication to gather pertinent data
To analyze the diagnostic and laboratory exams done to the patient and
understand its significance to the disease condition.
To formulate an effective and efficient nursing care plan
XLII.
2. Skills/Psychomotor
To perform physical examinations and necessary nursing procedures.
XLIII.
3. Attitude/Affective
To establish good rapport with the client, clients relatives and to the

staff nurses assigned at the emergency room.

To cooperate with each member of the group for the success of our
case study.
XLIV. PATIENTS PROFILE

XLV.

A. Patients Data

XLVI.

Name:

RSG

XLVII.

Age:

18 years old

XLVIII.

Sex:

Male

Birthdate:

September 13, 1997

L.

Birth Place:

Danao, Bohol

LI.

Address:

Antipolo City

LII.

Religion:

Roman Catholic

LIII.

Nationality:

Filipino

XLIX.

LIV.

B. Admission Data
LV.

Date of Admission:

January 29, 2016 (03:46PM)

LVI.

Hospital:

Unciano Medical Center

LVII.

Chief Complain:

Swelling Right Thigh

LVIII.

Admitting Diagnosis:

Soft Tissue Swelling Right Thigh

LIX.

Admitting Physician:

Dr. Tipon

C. Medical History
LX.

Source and reliability of information: The patient himself and his sister who
brought him to the hospital who seems to be reliable.
LXI.

LXII.

NURSING HISTORY

LXIII.

History of Present Illness:

LXIV.

It all started, as confirmed by the client, year 2006, that was 9 years ago. Client

was first known to have a boil or furuncle at the anterior right thigh. Due to cost and
economic constraints, and also because of age-old myths and folklore, initial
consultation is often with the albularyo who offered a variety of treatments from his bag
of folkloric remedies. The albularyo suggested treatment of concoction of leaves used to
clean wounds and to hasten wound healing, fresh Bayabas leaf poultice may be applied
to the wound. It had been said that the client recovered from the skin disease.
LXV.
Three months ago, which is last November 2015, patient noted pinching pain and
noted swelling of the right anterior leg. The client along with his mother consulted at the
health center in Bohol and was given Co-amoxiclav to be taken for 2 months and
Tramadol in times of pain. Client heed doctors's advice and takes the antibiotic
prescribed. However, in the process of taking the medications for one month, the client
observes that there is no effect of drugs taken. To no avail, he cease on taking the
antibiotics prescribed. After one week, client consulted at the health center again and
was advised for x-ray and biopsy. Hence, he consulted done xray of leg, CBC and fineneedle aspiration biopsy done. Fortunately, the result of the biopsy is negative.
LXVI.
Last December 20, 2015, it was noted that the client arrived at Antipolo City to
spend Christmas with his sister residing there. He consulted albularyo again but swelling
of the right thigh persisted.
LXVII.
One week prior to admission, client along wit his sister consulted at Dr. Reynaldo
Tipon Clinic at and was advised to be admitted at Unciano Medical Center for further
management. The client, as confirmed, was fearful of his underlying condition and
treatment process. Afterwhich, their family decided that he is to be admitted last January
29, 2016.
LXVIII.
At the emergency room, client was accompanied by his sister via wheelchair and
was assessed and prescibed therapeutics: Gentamicin 120 mg q 12hrs ANST(-),

Cloxacillin 500 mg I cap TID and Reparil-N Gel to be applied to affected area. His vital
signs were taken and recorded by the nurse as BP- 120/70, CR- 131 bpm, RR-28 cpm,
T- 36.3C and Oxygen Saturation of 98%. . He was seen and examined by Dr. Abalde
and was advised admission for a few days for further evaluation. At 03:46PM, he was
started on venoclysis of PNSS 1 L to run for 8 hours on left metacarpal vein using
introcan g.20 and regulated at 41-42gtts/min. He rested for a few more hours then he
was transferred at room of choice which is 2nd Floor room 222 at around 6:10 PM.
LXIX.

Past Medical History:

LXX.

The client has no previous hospitalization. He has no allergies to foods and

medications. He hasnt undergone surgery yet. However, client had past illnesses of fever,
cough and common colds and took over the counter drugs like Paracetamol for a remedy.He
has no history of allergies.
LXXI.

Family Health History:

LXXII.

Client has only familial history of Hypertension in his mothers side. No

heredofamilial diseases known on fathers side

LXXIII.
LXXIV.
LXXV.
LXXVI.
LXXVII.

I.G

LXXVIII.

L.G

LXXIX.
LXXX.
I.G

Z.G
R.G

L.G
R.G

R.

LXXXI.

E.G
R.G

LXXXII.
LEGEND:

LXXXIII.
LXXXIV.

Patient

Deceased

Socio-economic History:

LXXXV.

Client is living in a rural area in Bohol. Here in Antipolo, he resides with his sister

in a somewhat crowded neighborhood though client is not into mingling with their neighbors
since he just arrived at Antipolo last December 20, 2015. In Bohol, their house is well ventilated
and made up of mixed materials which is concrete and wood. Their source of drinking water is
via poso water pump. There are trash cans nearby and an open garbage trash and they also
used burning as a form of waste disposal. They have their private comfort room for excreta
disposal.
LXXXVI.

. He live with his mother and one sibling because his other siblings have their

own families living in different areas. According to the clients sister, the client is already a Ist
year college student. But due to financial matters, he stopped schooling for the second semeter
(SY:15-16). The client claimed he never tasted alcohols or cigarette; moreover he hasnt tried
addictive drugs.
LXXXVII.

In his hospitalization, Philhealth and other government subsidies would pay his

bills. Or if that would not be the case, his sister would pay for his hospital billls.
LXXXVIII.

GORDONS FUNCTIONAL HEALTH PATTERN

LXXXIX.
XC.

XCI.

Before

XCIII.

During

XCV.

Analysis

XCII.

hospitalizati XCIV.

hospitalizati

on:
XCVI.

HEALTH
PERCEPTIO

C.
XCVIII.

N-HEALTH
MANAGEME
NT PATTERN
XCVII.

on:

According to XCIX.

He is not able

the patient,

to do his daily

being healthy

hygiene

is important. A

routines

person is

because of

healthy when

his inability to

he is strong;

move and

he can do

walk.

what he
wants and
does not
experience
any pain. A
person has a
disease when
he feels
intolerable
pain and can
do limited
activites.
Patient said
he has had
immunization

Illness and
hospitalization
s generally
require
modifications
in hygiene
practice.
Conventional
way of
keeping the
body is
altered
because of
lack of
facilities and
privacy to do
personal
hygiene
practices. His
inability to
move freely is
also a
hindrance

s but not sure

if it was
complete. No
known
allergies to
any food and
drugs. When
he feelssick
or ill, she
takes over the
counter drugs
like bio-flu or
biogesic.
CI.

NUTRITIONA
LMETABOLIC
PATTERN

CIV.
CIII.

The patient
eats 3 times a
day and with
afternoon

CII.

snacks after

The patient

CV.

The change in

has loss his

her metabolic

appetite and

pattern is due

hasnt eaten a

to his

lot. He is on a

underlying

DAT (Diet as

condition.

coming from
school.

CVI.

Tolerated). He

According to

likes to eat

the patient, he

fast food like

eats meat,

Jollibees fried

fish and also

chicken and
burgers rather

than the food

vegetables.

prepared by

He doesnt

the hospital.

have any

His fluid

allergies on

intake has

foods and

decreased to

drugs. His

5 glass of

appetite is

water daily.

moderate and
usually
depends on
the food being
served. He
drinks 7 glass
of water daily.
CVII.

ELIMINATION
PATTERN

CX.
CIX.

The patient
does not have

CVIII.

any problem
on his
elimination
pattern. He
usually
urinates 5-6
times a day
without any

The patient

CXII.

The change in

voids 2-3

his elimination

times a day.

pattern is due

He was

to lack of

always been

activity and

assisted by

inadequate

his sister

fluid intake

when voiding
in bed
pan.The color
of his urine is

yellow. The
difficulty. He

patient

added that

defecates

the color of

once every

his urine is

two days.

light yellow.
He didnt feel
any pain in
urination. The
patient
defecates
once a day
usually early
in the morning
before going
to school with
yellow to
brown color.
He verbalized
that
sometimes
however, it is
hard in
consistency
with dark
color, which

CXI.

generally
depends on
what he eats.
CXIII.

CXIV.

ACTIVITY-

CXV.

He could

CXVI.

His activity

CXVII.

Patient lacks

EXERCISE

perform his

was limited

activity and

PATTERN

activities daily

lying on bed.

exercise

living.

because he is

According to

immobile due

him, he often

to his wound.

plays
basketball
and this
serves as his
form of
exercise. He
likes to
converse with
his friends
and neighbors
when he is
done with his
chores. He
does not
involve
himself in

any vigorous
activities.
However, he
is aware that
his activity is
not enough
and he
recognizes
the
importance of
having regular
exercise.
CXVIII.

SLEEP-REST CXX.
PATTERN

He has the
normal 6-8

CXXIV.
CXXIII.

hours sleep.

CXIX.

He also has
his nap time
for 1-2 hours
a day.

He doesnt
have the
adequate time
of sleep since
he is
disturbed with
the nurses

CXXI.

Sleeping and

that enters

watching the

the room

television are

every now

his form of

and then, and

rest.

because of
the

The change in
his sleeping
pattern is due
to adherence
in time of
medication
and vital signs
monitoring.

CXXII.
environmental
changes of
his
surroundings.
He also has
inadequate
time to rest
since he
doesnt have
enough time
to sleep.
CXXV.

COGNITIVECXXVII.
PERCEPTUA
L PATTERN

CXXVI.

CXXIX.
He is normalCXXVIII.

He was

in terms of his

normal as

cognitive

before in his

abilities. He

cognitive and

has good

perceptual

memory and

pattern. He

reasoning

responds

skills. He can

clearly and

easily

well

comprehend

understood.

on things. In

He has no

terms of his

sensory

perceptual

deficit; He

pattern, he

responds

has no

appropriately

problems with

to verbal and

his senses.

physical
stimuli and
obeys simple
commands.

CXXX.

SELFCXXXII.
PERCEPTIO
N SELFCONCEPT
PATTERN

CXXXIII.
He sees
himself as a
person with a
good
personality.

CXXXI.

He has been
a good friend,
brother and a
son. He said
he has to be a
good person
in order not to
hurt others.
He also
describes
himself as a
typical type of

Patient is

CXXXIV.

The change in

concerned if

his self-

he will still be

perception is

able to move

due to his

and walk

wound. He

normally.

worries that

Patient is not

he might not

satisfied with

be able to

his health

function like

status.

before. His
body image
changed
because he
worries that
he will
become
dependent to
other people.

student and
person.
CXXXV.

ROLECXXXVII.
RELATIONSH
IP PATTERN

CXXXVI.

He has a CXXXVIII.

CXXXIX.
He had more

close

time to bond

relationship

with his

with his

family. He

family. They

said that it

were eight

was a nice

siblings in

feeling to

their family.

know that

He was at the

your family is

7th. I was

so concerned

also able to

to him. He

ask his sister

learned to

about his

appreciate the

brother being

beauty of

a son and she

having a

confessed

family that

that he is a

gives you

good son but

strength and

at times he

support no

doesnt obey

matter what.

her. He is also
a responsible

Patient feels
that he is
inadequate to
fulfill and
share himself
to the people
around him
because he is
incapacitated
and cant do
things like
before.

student and
knows all his
duties as a
friend.
CXL.

SEXUALITY- CXLII.

According to
CXLIII.

REPRODUCT

him, he

IVE

doesnt think

PATTERN

of the things

CXLIV.

like having a

CXLI.

girlfriend and
getting
married yet.
He is still
young for
such matters.
CXLV.

COPING-

CXLVII.

He does not CXLIX.

He shares his

STRESS

fully identify

problems to

TOLERANCE

his situations

his family. He

PATTERN

having stress

verbalizes his

but he always

feelings.

CXLVI.

CL.

tell his
CXLVIII.

parents when
something is
wrong.

CLI.

VALUE-

CLIII.

He is a

CLIV.

He

prays CLV.

The change in

CLII.

BELIEF

Roman

more often to ask

his value

PATTERN

Catholic. He

for guidance.

belief is due

goes to

to his

church with

condition. He

his family

feels that he

occasionally.

needs more

He was

spiritual

taught by his

guidance to

family to

give him

believe and

strength in

have fear to

dealing with

GOD.

his current
situation.

CLVI.
CLVII.
CLVIII.
CLIX.
CLX.
CLXI.
CLXII.
CLXIII.

PHYSICAL EXAMINATION

CLXIV.

Date assessed: February 03, 2016

General assessment: The patient is awake, conscious, and responsive. The client has
an IVF of PNSS to run for 8 hours with a drop factor of 41-42gtts/min @ Left metacarpal
vein, infusing and regulated well.
Initial vital signs: T=____ C, PR=____bpm, RR=15 cpm, BP=100/80 mmHg.

CLXV.

PhysicalCLXVI.
assessm

I.

ent
Head CLXX.

Metho CLXVII.
ds

Normal
finding

CLXXIV.

Actual CLXIX.

Analysi

finding

use
PalpatCLXXI.

Head

ion

symmetric,

shape, round

round,

and

CLXXII.
is

erect

A. Hair

CLXVIII.

and

Symmetric CLXXIII.
in

in

the

midline.

No

in midline.

Visible

no lesions

lesions.

Inspec
CLXXV.

are visible.
Black CLXXVI.

Black

tion,

evenly

color. evenly
CLXXIX.

palpati

distributed

distributed CLXXX.

on

and covers

that

covers
CLXXXI.

the

the

whole
CLXXXII.

whole

CLXXVIII.
in

Normal

Normal

Due to

scalp, thick

scalp.

no

and

Slightly thick,

proper

moist

and

hygiene

dry

with

free

shiny
CLXXVII.
from

split ends.

presence
dandruff.

of

B. Face CLXXXIII.

Inspec
CLXXXIV.

Oval,

CLXXXV.

tion

square

or

Round

CLXXXIX.
in

shape.

CXC.

heart

Absence

shape.

involuntary CXCII.

Decrea

Symmetry

muscle.

se

and

Face

no

involuntary

ofCXCI.

is

slightly pale.

muscle.CLXXXVI.

CLXXXVIII.

D. Ears

CXCIV.

CXCVIII.

CXCIII.

shows

stress

anxiety

and

irritable
Eyes

are
CXCVII.

and evenly

black

placed,

color,

symmetrica

Parallel

l.

position and

with scant

and

amount of

Scleras

secretions,

anicteric.

and

clear.
Position of CC.

Align

Normal

in

equal in size

black

as

in

protruding

eyes

can

expression

tion

both

It

manifes

Parallel

none

obin

Facial

InspecCXCV.

Inspec
CXCIX.

CXCVI.

hemogl

count.

CLXXXVII.

C. Eyes

Normal

shape.
are

with CCI.

Presen

tion

the ears is

the

line up with

color

is

cerume

the

similar to the

n is due

the color is

face,

to

similar with

is proportion

taking

the

with

bath

eyes.

facial

color.

eyes,

ce

shape

the

head.

Shape

is

presence

of

unable

proportion

cerumen

in

to

to the face;

the inner part

groom

no

of ear.

properly
.

nodules or
CCIII.

not

and

drainage,

E. Nose

of

CCII.

Inspec CCIV.

lesions.
Midline andCCVI.

Nose

tion/

symmetric.

the

Palpat

Equal

Equal

ion

nasal

opening and

opening.

there is no

Presence

nasal

of

discharges.

nasal

is

inCCVII.

Normal

midline.
nasal

folds
F. Mouth

CCVIII.

CCV.
Inspec CCIX.

Lips

tion

pinks,

cracked and

se

smooth

pale in color.

hemogl

and moist.

Dry, rough in

obin

are CCX.

Lips

areCCXI.

Decrea

G. Teeth

CCXIV.

Gums

are

texture.

moist

and

Gums

CCXII.
are
CCXIII.

Inadeq

pinkish

pale in color

uate

without any

with no foul

fluid

InspecCCXV.

discharges
3 molar, CCXVI.
2

odor.
Complete CCXVII.

intake.
Comple

tion

premolar, 1

teeth without

te teeth

canine and

dentures

are due

use.

to

central

incisor.
Align

Align

well.
well

calcium
level

and no foul

that has

odor

been
maintai
ned
upon
childho
od

up

to

the

present
H. Inspectio
CCXVIII.
n

Inspec
CCXIX.

Proportion CCXX.

Proportion to
CCXXI.

tion/

to the size

the size of

palpati

of

the body. No

on

body,

tenderness

symmetrica

present.

the

l in shape,

.
Normal

palpable
II.

Thora
CCXXII.

Inspec
CCXXIII.

masses.
Scapula CCXXIV.

Scapula are
CCXXVI.

x and

tion,

are

symmetric

lungs:

palpati

symmetric

and

on,

and

protrusion.

percus

protruding.

No

sion,

Does

accessory

auscul

use

muscle

tation

accessory

during

muscle

breathing. no

A. Posterior
thorax

no

not

in

no

use

breathing.

tenderness,

No

pain. Has a

tenderness

normal

, pain. has

breath sound

and pattern

normal

breath

Normal

CCXXV.

sound and
B. Anterior
CCXXVII.
thorax

Inspec
CCXXVIII.

pattern.
Sternum CCXXX.
is

Sternum CCXXXI.

tion,

positioned

located

palpati

at

the

on,

midline and

and straight.

percus

straight.

Relaxed,

sion,

respiration

effortless

auscul

is relaxed,

and

tation

effortless

during

the

at

midline

quite

Normal

and

quite.

Use

of

respiration.
No

use

accessory

accessory

muscle

muscle.

not

is

seen

Lung

of

is

with normal

resonance in

respiratory

sound

effort.

No

tenderness
or

pain

palpated.
C. Breathing
CCXXXII.

CCXXIX.
Inspec
CCXXXIII.

Respiratory
CCXXXIV.

Respiratory
CCXXXV.

tion,

rate of 12

rate

Auscul

to

per minute

tation

counts per

20

Normal

of CCXXXVI.
15

minute.
Lung
sounds are
clear

to

auscultatio
n
D. HeartCCXXXVII.
Rate

Palpat
CCXXXVIII.

bilaterally.
Heart CCXXXIX.
rate

Heart rate ofCCXL.

ion

of

to

60 beats per

beats

minute. And

100

60

per minute.

blood

Normal

Blood

pressure

pressure is

100/80

within

of

90-

120/ 60-90
E. Breast CCXLI.

F. Abdomen
CCXLV.

Inspec
CCXLII.

mmhg
Texture CCXLIII.
is

Breast

tion,

smooth

equally

palpati

with

on

edema.

smooth

Areolas

texture.

vary

from

Areolas

pink

to

no

are
CCXLIV.
in

size

dark

Normal.

and
in

are

brown

dark

in

color.

brown.

there is no

nipples are

tenderness

equally

upon

bilateral in

palpation.

Inspec
CCXLVI.

size
Abdomen
CCXLVII.

Abdomen CCXLIX.

tion,

is free from

has

palpati

lesions,

color with the

on,

tenderness

face.

auscul

or pain and

sound

tation,

palpable

slightly heard

percus

masses.

on

sion

Umbilicus

auscultation

is free from

and

same

Bowel
are

there

Normal

swelling

are

bulge

protrusion

and

masses.

no

and pain felt

upon
palpation
and
percussion.

G. Lower

CCL.

Inspec CCLI.

Skin

extremitie

tion,

varies

s:

palpati

within

on

A. Legs

CCXLVIII.
colorCCLII.

He

hasCCLIV.

Due to

brown

and

complexion,

lack of

normal

slightly rough

hygiene

range, skin

in texture,

and

is

Has

abcess

febrile.

no lesions,

in the rightCCLV.

Presen

absence of

thigh

ce

the

smoothCCLIII.

of

varicose

infectio

veins. And

there

is

presence
of

good

muscle
H. Mental CCLVI.
Status

Listeni
CCLVII.

tone.
The patient
CCLVIII.

Patient

ng,

should

aware

Obser

conscious

dizzy. He is

to

vation

and aware

depressed

conditio

be

is
CCLIX.
but

Depres
sed due
his

in

her

surroundin

and

not

n.

cooperative.

gs.
CCLX.
CCLXI.
CCLXII.
CCLXIII.
CCLXIV.
CCLXV.
CCLXVI.
CCLXVII.
CCLXVIII.
CCLXIX.

ANATOMY AND PHYSIOLOGY

A. Integumentary System
CCLXX.
The integumentary system is the organsystem that protects the body from
various kinds of damage, such as loss of water or abrasion from outside.
The system comprises the skin and its appendages (including hair, scales, feathers,
hooves, and nails).
CCLXXI.

Functions of the integumentary system include:

1.
2.
3.
4.
5.

Protects the body's internal living tissues and organs

Protects against invasion by infectious organisms
Protects the body from dehydration
Protects the body against abrupt changes in temperature
Helps dispose of waste materials

6. Acts as a receptor for touch, pressure, pain, heat, and cold

7. Stores water and fat
CCLXXII.

The three layers of the skin:

a) Epidermis
CCLXXIII.
-the outermost layer of skin, provides a waterproof barrier and creates our
skin tone.
b) Dermis
CCLXXIV.
-beneath the epidermis, contains
tough connective tissue, hair follicles, and
sweat glands.
c) Hypodermis
CCLXXV.
-is made of fat and connective
tissue.
B. Lymphatic System
CCLXXVI.

The lymphatic system is a network of tissues and organs that help rid the

body of toxins, waste and other unwanted materials. The primary function of the
lymphatic system is to transport lymph, a fluid containing infection-fighting white blood
cells, throughout the body.
CCLXXVII.

Functions of the lymphatic system include:

1. Transport of excess tissue fluid to the blood vascular system.
2. Transport of red blood cells to the blood vascular system.
3. Maintenance of blood pressure in the venous circulation.
4. Excretion of excess dietary fat

CCLXXVIII.

Lymph is a clear-to-white fluid made of white blood cells, especially lymphocytes,

the cells that attack bacteria in the blood and fluid from the intestines called chyle, which
contains proteins and fat s.

CCLXXIX.

Lymph nodes are soft, small, round- or bean-shaped structures. They usually

cannot be seen or easily felt. They are located in clusters in various parts of the body, such as
the neck, armpit, groin, and inside the center of the chest and abdomen
CCLXXX.

Lymph nodes make immune cells that help the body fight infection. They also

filter the lymph fluid and remove foreign material such as bacteria and cancer cells. When
bacteria are recognized in the lymph fluid, the lymph nodes make more infection-fighting white
blood cells, which cause the nodes to swell. The swollen nodes are sometimes felt in the neck,
under the arms, and groin.
CCLXXXI.
CCLXXXII. Phagocytosis:

CCLXXXIII.
CCLXXXIV. A phagocyte is a cell able to engulf and digest bacteria, protozoa, cells, cell debris, and
other small particles. Phagocytes include many leucocytes (white blood cells) and
macrophages - which play a major role in the body's defence system.
CCLXXXV.
CCLXXXVI. Phagocytosis is the engulfment and digestion of bacteria and other antigens by
phagocytes.

CCLXXXVII.
CCLXXXVIII. Lymphocytes:

CCXC.

CCLXXXIX.

CCXCI. The term "antigen" refers to something that is not naturally present and 'should
CCXCII.not
be in the body'.

CCXCIII. CCXCIV. T Cells (lymphocytes) are activated by the thymus gland.

CCXCV.

CCXCVI. CCXCVII. B Cells (lymphocytes) are activated by other lymphoid tissue. The 'B' indicates
CCXCVIII.
'bone marrow' cells.

CCXCIX.

CCC. Both T-cells and B-cells:

(1) destroy antigens, and

CCCI.

(2) produce 'memory cells' and anti-bodies.

CCCII.
CCCIII.
CCCIV.
CCCV.
CCCVI. Basophils:
CCCVIII.

CCCIX. An increased (higher than usual) percentage of basophils in the blood may
CCCX.
indicate an inflammatory condition somewhere in the body.

CCCXI.
CCCXII. Neutrophils & Monocytes:

CCCXIV.

CCCXV. Neutrophils are the first leucocytes to respond to bacterial invasion of the
body. They act by carrying out the process of phagocytosis, and also be
releasing enzymes - such as lysozyme, that destroy certain bacteria.
Monocytes take longer to reach the site of infection than neutrophils CCCXVI.
- but
they eventually arrive in much larger numbers. Monocytes that migrate into
infected tissues develop into cells called wandering macrophages that can
phagocytize

many

more

microbes

than

neutrophils

are

able

to.

Monocytes also clear up cellular debris after an infection.

CCCXVII. Eosinophils:

CCCXIX. CCCXX. An increased (higher than usual) percentage of eosinophils in the blood
may indicate parasitic infection somewhere in the body.
CCCXXI.
CCCXXVI.

CCCXXII.
CCCXXIII.
CCCXXIV.
CCCXXV.
CCCXXVII.
CCCXXVIII.

INFLAMMATORY PROCESS
CCCXXIX.
Bacterial infection is
CCCXXX.
established

CCCXXXI.
vv
Release of chemical
mediators

CCCXXXII.
Vascular
Response

CCCXXXIII.

Cellular
Response

CCCXXXIV.
Rapid
vasodilation
of the
arterioles

Increase
blood flow to
the area

Plasma leaks
CCCXXXV.Increase
v
pressure
out of
in the site
CCCXXXVI.
interstitial
space

Mast Cells
releases
inflammatory
mediators

Irritation
Increase
CCCXXXVIII. of the
capillary
nerve
permiability
CCCXXXIX.
endings

Bradykinin and
Prostaglandin

CCCXXXVII.

REDNESS

WARMTH

SWELLIN

CCCXL.

PAIN

WBC are
stimulated
and
neutrophils
adheres to
the
Neutrophil
moves
outside the
blood vesel

CCCXLI.
Chemostaxis

CCCXLII.
Macrophages
remove
damage
tissues

Phagocytes vv
continue
CCCXLIII.
to consume and
destroy the bacteria

CCCXLIV.
CCCXLV.
CCCXLVI.
CCCXLVII.

Formation of
cellular exudates

Secrete
cytokines

Pus Production

FEVER

CCCXLVIII.

Chemicals signals the body to

destroy cell

Cells of the body die irreparably

damage due to deprivation of
nutrients

CCCXLIX.
CCCL.

Necrotic
Death

Apoptosis

CCCLI.

CCCLII.

LEGEND:

PATHOPHYSIOLOGY

Precipitating Factors:

-inflammatory response to an

CCCLIII. infectious process

(invasion of bacteria or parasite)

CCCLIV. -Minor wound/Skin disease

(boils/folliculitis)

CCCLV. -problems with immune system

CCCLVI.

-poor nutrition
-poor hygiene

Neutrophil
adheres to
the bacteria
and begin
phagocytising
pathogens

Predisposing
Factors:
-18 years old
-Male

CCCLVII.
CCCLVIII.

Entry of foreign material or microorganisms(Staphylococcus aereus)

CCCLIX.

CCCLX.

Microorganism kills/attacks the local cells

CCCLXI.
CCCLXII.

Feve

Release of toxins

CCCLXIII.
CCCLXIV.

Triggering of an inflammatory response

CCCLXV.

Localize
d
swelling

CCCLXVI.

Drawing of huge amount of white blood cells to the infected site

CCCLXVII.
CCCLXVIII.

Increase blood flow to affected area

CCCLXIX.

CCCLXX.

Tenderness
and warmth
in the

Formation of pus

CCCLXXI.
CCCLXXII.

Adjacent healthy cells forms a barrier around the pus

CCCLXXIII.
CCCLXXIV.

ABSCESS FORMATION
CCCLXXV.

CCCLXXVI.
CCCLXXVII.
PUS FORMATION
CCCLXXVIII.
CCCLXXIX.
CCCLXXX.
CCCLXXXI.
CCCLXXXII.
Blood vessels permit the migration of the wbc,
CCCLXXXIII.

mainly neutrophils, outside of the blood vessels

CCCLXXXIV.

(extravasation) into the tissue

CCCLXXXV.

CCCLXXXVI.
CCCLXXXVII.

The neutrophils migrate along a chemotactic

CCCLXXXVIII.

gradient created by the local cells

CCCLXXXIX.

to reach the site of injury

CCCXC.
CCCXCI.

CCCXCII.

along with the destruction of the pathogens

CCCXCIII.

is the death of the leukocytes

CCCXCIV.
CCCXCV.

CCCXCVI.

Dead tissues, dead leukocytes and

CCCXCVII.

the pathogens are produced

CCCXCVIII.
CCCXCIX.

CD.

Accumulation of cellular debris

CDI.
CDII.

CDIII.
CDIV.

COLLABORATIVE MANAGEMENT

1. LABORATORY/ DIAGNOSTIC STUDIES

HEMATOLOGY

CDV.

CDVI.

1/2CDVIII.

2/2/ CDX.

9/1

26

6
CDVII.

CDIX.

REFER

CDXI.

CLINICAL

ENCE

SIGNIFICANCE

5 10CDXIX.

Increase. There

RE

RE

SU

SU

LT

LT
CDXII.

WBC

CDXIV.

13.
0* CDXV.

CDXIII.

11.CDXVII.

X109/L

40*

is a presence of
infection.

CDXVIII.

CDXVI.

The

body is adapting
to the pathogen
present

to

produce
antibodies.
CDXX.

HematocritCDXXII.

CDXXI.

0.3
CDXXIV.
3*

0.2
CDXXVI.
2*

0.40CDXXVII.

0.54

CDXXIII.

Hemoglobin
CDXXIX.

percentage

of

red blood cells in

CDXXV.

CDXXVIII.

Decrease

110
CDXXX.
*

the whole blood

73*
CDXXXI.

140CDXXXII.

175 g/L

Insufficient
supply of oxygen
to the body

CDXXXIII.

Segmenter
CDXXXIV.

0.5
CDXXXV.
5

CDXXXVIII.

Eosinophils
CDXXXIX.

0.0 CDXL.
1

CDXLIII.

Lymphocyte
CDXLIV.

0.5
CDXXXVI.
4
0.5CDXLI.

0.40CDXXXVII.

Normal

0.60
0.1-0.06
CDXLII.

Normal

0.1CDXLV.

0.4CDXLVI.

0.20CDXLVII.

Increase.

4*

3*

0.40

combat
pathogens
phagocytosis

To
by

and

immune

response
CDXLVIII.

Monocyte CDXLIX.

CDL.

0.0

CDLI.

0.02- CDLII.

Normal

0.08

CDLIII.
CDLIV.
CLINICAL CHEMISTRY

CDLVIII.
CDLV.

01/29/

CDLVI.

RESULT

CDLVII.

REFERENCE

CLINICAL
SIGNIFICANCE

16
CDLIX.

BUN
CDLX.

5.36

CDLXI.

CDLXII.

Normal

62-115

CDLXVI.

Normal

135 -145

CDLXX.

Normal

CDLXXIV.

Normal

2.9-8.20
mmol/L

CDLXIII.

CDLXVII.

CREA
CDLXIV.

85.27

CDLXVIII.

135.5

CDLXV.

Sodiu
m

CDLXIX.

mmol/L
CDLXXI.

Potas
sium

CDLXXII.

3.85

CDLXXIII.

3.5 5.5
mmol/L

CDLXXV.

01/30/
16 CDLXXVI.

CDLXXIX.
RESULTCDLXXVII.

REFERENCE

CLINICAL
SIGNIFICANCE

CDLXXVIII.
CDLXXX.

Gluco
se CDLXXXI.

5.62

CDLXXXII.

4.2
mmol/L

6.4CDLXXXIII.

Normal

CDLXXXIV.
ULTRASOUND REPORT

CDLXXXV.

CDXC.

BOD
CDLXXXVI.

1/31/16
CDLXXXVIII.

Y
CDLXXXVII.
PART

IMPRE

Right
CDXCIII.
Thig
h

CDXCI.

NCE

Large
CDXCV.
absces

formati

CDXCVI.
Upper half
22.5

13.96

17.17 cm

on

CDXCII.

CLINICAL SIGNIFICANCE

SSION

s
CDXCIV.

REFERE
CDLXXXIX.

Evaluation
including

of

infections,

abscess,

and

necrotizing fasciitis and to locate

foreign bodies. Thus monitoring
the accumulation of pus extent.

CDXCVII.
X-RAY REPORT

CDXCVIII.

CDXCIX.

BODY
PART

DIII.

Chest

D.

1/31/16

DI.

IMPRESSION

DIV.

Essentially
normal chest

DII.

CLINICAL SIGNIFICANCE

DV.

Help come to a diagnosis. The soft

tissues are also often misleading and it is
important to be aware of the pitfalls.

DVI.

Right

DX.

Thigh

Negative

for DXI.

fracture

Help find the cause of symptoms such as

pain,

limp,

tenderness,

swelling,

or

deformity of the upper leg. It can detect a

DVII.

broken bone, and after a broken bone has

DVIII.

been set, it can help determine whether

the bone is in satisfactory alignment.

DIX.
DXII.
DXIII.
DXIV.
DXV.
DXVI.
DXVII.
2. FDAR STUDENT NURSES NOTES
DXVIII.
DXXI.

DATE/

DXIX.

HOUR
DXXII.

FOCUS

DXX.

Impaired skinDXXIII.
integrity
related to

PROGESS NOTES

D:

DXXIV.

slow wound DXXV.

Vital Sign
Presence of large abscess (57 cm)at right thigh
A:

healing at the
right thigh.

Inspected the following areas signs and

symptoms of infection

Implemented measures to prevent tissue

breakdown associated with decreased mobility:

positioned client properly

lifted and move client carefully using a

turn sheet and adequate assistance

turned client at least every 2 hours

kept bed linens dry and wrinkle-free

increased activity as allowed and

tolerated.

Kept affected leg elevated

Provided calm and safe environment

Health teaching done on proper hygiene

DXXVI.
DXXVII.

R:

DXXVIII.

The patients process of wound healing

had significantly progressed as displayed by a

DXXIX.
DXXXII.

DATE/

DXXX.

HOUR
DXXXIII.

timely wound healing.

DXXXI.
PROGRESS NOTES

FOCUS
Acute pain DXXXIV.
related to
increased
permeability
and

D:
Pain scale of 6 out of 10
(+) facial grimace
Less movement on the (R) leg as compared to
the (L) leg

stimulation ofDXXXV.
pain receptors
DXXXVI.
secondary to

A:

Monitored Vital Signs, noting tachycardia,

hypertension and increased respiration

Performed pain scale assessment
Provided comfort measures
Placing pillow under the right buttock
Placing warm compress over affected area of

release of
inflammatory
mediators

pain
Encouraged diversion activities
- Talking with family and friends
Administered pain medications as ordered.
Informed patient when some procedure can

cause pain
Informed S.O a way to assist patient in
activities of daily living.

DXXXVII.

R:

DXXXVIII.

Patient will have a decreased level of pain as

evidenced by the patient verbalizing pain of 2

DXXXIX.
DXLII.

DATE/

DXL.

HOUR
DXLIII.

or less on a 0-10 scale

DXLI.
PROGRESS NOTES

FOCUS
Ineffective

DXLV.

tissue
perfusion
related to
decrease in
blood flow to
the area of

DXLVI.

D:
(R) thigh circumference larger than (L) thigh
Abscess on right thigh(57cm)
Sign of inflammation on the (R) thigh
- Pain
- Swelling
- redness
- heat
A:

Instructed the patient to mobilize to improve

blood circulation.
Elevated the patient's leg is slightly lower

abscess due

to obstruction
of blood
vessels

than the heart (elevation position at rest)

Observed nonverbal cues
Measured affected area
Provided comfort measures
Performed assistive range of motion

exercise
Administered pain medications as ordered

DXLIV.

DXLVII.

R:

DXLVIII.

DATE/ DXLIX.

Patient maintained peripheral circulation and

remained normal.
DL.
PROGRESS NOTES

FOCUS

HOUR
DLI.

DLII.

Impaired
physical
mobility
related to

DLIII.

D:

decreased
muscle
strength

secondary to DLIV.
abscess
formation

Limited movement on the (R) leg

Slowed movement as compared to the (L) leg
(R) thigh circumference larger than (L) thigh
Abscess on right thigh
Sign of inflammation on the (R) thigh
- Pain
- Swelling
- redness
- heat
Flaccid right leg
A:

Assessed degree of pain or affected area

Determined degree of immobility
Noted emotional and behavioral response on

the problem
Repositioned patient on regular schedule
Monitor and record client's ability to tolerate

activity and use all four extremities

Performed passive range of motion (ROM)
exercises at least twice a day unless

contraindicated
Helped client achieve mobility and start walking

as soon as possible if not contraindicated.

Increased independence in ADLs and
discourage helplessness as client gets

stronger.
Administered pain medication as ordered
Performed assistive range of motion exercise
Informed S.O a way to assist patient in
activities of daily living.

DLV.

R:
Patient Verbalizes feeling of increased strength

and ability to move

DLVI.
DLVII.