INTRODUCTION

Bones make up the body's skeletal system. The skeletal system is the framework
of our bodies. Without our bones, we cannot move, stand up, and keep our organs in
place. And when it comes to bone problems, the more common thought would be
fractures from high-velocity impact, misalignment from genetic origins and general
weakening as one gets older. But there is one bone problem that is usually overlooked
and, thus, not known to many people.

“Osteomyelitis represents an acute or chronic infection of the bone. The term

osteo refers to bone and myelo to the marrow cavity, both of which are involved in this
disease. Despite the common use of antibiotics, these infections remain difficult to treat
and eradicate. All types of organisms, including parasites, viruses, bacteria, and fungi can
cause osteomyelitis, but certain pyogenic bacteria and mycobacteria are most common.
“Osteomyelitis after trauma or bone surgery usually is associated with persistent
or recurrent fevers, increased pain at the operative or trauma site, and poor incisional
healing, which often is accompanied by continued wound drainage and wound
separation.
“The hallmark feature of chronic osteomyelitis is the presence of a sequestrum or
pice of dead bone that has separated form the surrounding living bone. A sheath of new
bone, called the involcrum, forms around the dead bone. Radiologic techniques such as x-
ray films, bone scans, and sinograms are used to identify the infected site. Chronic
osteomyelitis or infection around a total joint prosthesis can be difficult to diagnose
because the classic signs of infection are not apparent and the blood leukocite count may
not be elevated. A subclinical infection may exist for years. Bone scans are used in
conjunction with bone biopsy for a definitive diagnosis.”
Porth, C.M. et.al., Essentials of Pathophysiology, 2nd ed. © 2007 Lippincot Williams and Wilkins.

In the United States the overall prevalence is 1 per 5,000 children. Neonatal
prevalence is approximately 1 per 1,000. The annual incidence in sickle cell patients is
approximately 0.36%. The prevalence of osteomyelitis after foot puncture may be as high
as 16% (30-40% in patients with diabetes).

Internationally, the overall incidence is higher in developing countries.

Morbidity can be significant and can include localized spread of infection to

associated soft tissues or joints; evolution to chronic infection, with pain and disability;
amputation of the involved extremity; generalized infection; or sepsis. Up to 10-15% of
patients with vertebral osteomyelitis will develop neurologic findings or frank spinal-cord
compression. Up to 30% of pediatric patients with long-bone osteomyelitis may develop
deep venous thrombosis (DVT). The development of DVT may also be a marker for
disseminated infection.

Mortality rates are low, unless associated sepsis or an underlying serious medical
condition is present.

There are no exceptions for osteomyelitis when it comes to race. However, the
male-to-female ratio is approximately 2:1.
 Age In general, osteomyelitis has a bimodal age distribution; Acute hematogenous
osteomyelitis is primarily a disease in children; Direct trauma and contiguous focus
osteomyelitis are more common among adults and adolescents than in children; Spinal
osteomyelitis is more common in persons older than 45 years.
[http://emedicine.medscape.com/article/785020-overview]

---

During the group’s exposure in the general surgery ward in DMC, a little bit of
curiosity fell upon a certain term that most members of the group had encountered for the
first time: “Osteomyelitis.” Even ‘craniectomy’ stirred some interest.
As the group agreed to consider this as a possible topic for the case study, a
realization was voiced out. “What’s the patient’s name?”
To reserve her right to privacy, we have given our patient the codename: “Mrs.
X.” She is a business woman from Iligan City and during the interviews, was very open
to the group. Mrs. X’s significant others were also very entertaining to the group’s
questions.
Among all of the patients in the General Surgery ward at that day, Mrs. X was the
only one who had the word “osteomyelitis” in her chart.
This case study will present the data that was gathered from Mrs. X and other
different sources regarding her sickness and will show how these data may explain how
she got into these conditions. Thorough study of the topics regarding the disease will also
be presented for osteomyelitis to be understood clearly. After establishing pertinent data,
the different therapeutic managements done for Mrs. X, especially nursing care, will be
presented and evaluated.
OBJECTIVES
General Objectives:
To conduct a thorough and comprehensive study about Mrs. X’s disease according
to data that was gathered by conducting a series of interviews within a total of 6 days of
hospital exposure (3 days a week for 2 weeks), and through the use of data gathered from
extensive research.

Specific Objectives:
 To organize our patient’s data for the establishment of good background
information
 To show the family health history as well as the history of past and present illness
for the knowledge of what could be the predisposing factors that might contribute
to the patient's illness.
 To present the family’s Genogram containing information that will help out in
tracing any hereditary risk factors.
 To trace the psychological development of our patient through analysis of different
developmental theories with comparison to the patient’s data
 To give different definitions of the complete diagnosis of our patient for better
understanding of unfamiliar terms
 To present the data from the physical assessment performed on our patient for a
good overview of her over-all health
 To elaborate on the anatomy and physiology of different systems involved and
affected during osteomyelitis
 To establish whether several factors, signs and symptoms are present or absent in
our patient for the proof that she indeed has osteomyelitis
 To organize a flow chart showing the pathophysiology of osteomyelitis for a clear
visualization of how osteomyelitis affects a person
 To list the different orders of the physicians assigned to our patient together with
their rationale for a general knowledge of what consists of the medical
management for osteomyelitis
 To present the different results of our patient’s diagnostic exams together with
 comparisons with normal values for the understanding of what changes during the
disease
 To list the different drugs together with their specific purposes for the better
understanding of the treatment of osteomyelitis
 To present the surgical procedures done to our patient together with their rationales
so that the purposes of each procedure can be understood
 To analyze different nursing theories applicable to our patient
 To show the nursing care plans used by the group to administer nursing care to the
patient during our exposure
 To present the discharge plan for our patient
 To have our over-all Conclusions and Recommendations about the Case Study
PATIENT’S DATA
Personal Data:
Name: “Mrs. X”
Age: 64 yrs. old
Date of birth: August 5, 1944
Sex: Female
Place of birth: Manila
Address: 18 Military St., GSIS, Matina Proper, Davao City
Nationality: Filipino
Religious affiliation: Roman Catholic
Civil status: Married
Educational Attainment: 3rd year high school
Occupation: Housewife

Clinical Data:
Date admitted: December 10, 2008
Mode of Admission: Ambulatory
Chief complaint: Pus draining from operative site
Case Type: Surgery
Ward: GSI
Case no.: 2008004659
Admitting Doctor: Marjorie L Corpuz
Date of discharge: [still in]
Admitting Diagnosis: T/C osteomyelitis ® ant. parietal bone; S/P craniectomy w/
excision of brain tumor
Date of Operation: December 15, 2008
Operation Performed: Debridment; Removal of necrotic bone fragments, Rotational
flap, STSG, drain
Anesthesia: GETA; O2 Isoflurane
Time started: 2:15pm
Time ended: 7:15pm
Blood Loss: 310cc
Operation Diagnosis: soft tissue defect ® parietal area w/ osteomyelitis, s/p
craniectomy, excision of meningioma
Remarks:
 patient placed supine under CEB
 asepsis
 drapes placed
 debridement of bony fragments + removal of necrotic tissue
 rotational flap done
 STSG done
 end of procedure
FAMILY BACKGROUND AND

HEALTH HISTORY
 Mrs. X has been married for 44 years with Mr. X. Throughout their marriage, they
have had 7 offspring. Their eldest is 43 years old, and their youngest is 29 years old. All
of their children have graduated college and are working independently of each other.
Three of them are living in Davao City, but only two were seen present in the hospital
ward. One of them lives in Manila, while the rest live back in their home town, Iligan.

How Mrs. X ended up staying in a general ward in DMC:

She was recommended by her neurosurgeon in Iligan, Dr. Valdez, to travel to DMC for
the specialization of the operation on her skull. Having this operation being her third, she
cannot afford to get a private room anymore. She then opted to stay in the general ward,
and didn’t think it was too bad compared to how the general wards were in the hospitals
in Iligan.

During our interview, we have established that most of the family members in the
previous generations of Mrs. X’s family are deceased and have a variety of causes of
death. Also, no one else in Mrs. X’s lineage has had osteomyelitis in the last two
generations.

LIFESTYLE
According to Mrs. X herself, she has random schedules everyday. Still, she was
able to formulate a cycle of activities that, for her, would make up the common days in
Iligan. She would wake up just in time for lunch. After freshening up a little, she eats her
lunch. Then she takes a bath. After taking a bath, she goes to the stressful environment in
the ‘mahjongan’ that she runs and owns, which is less than a kilometer away from her
house. She claims that she is hypertensive because of her work environment. There are a
lot of uncivilized clients that give her a bad time, and to top it off, she smokes. She
usually works until the early morning. After work, she goes home to sleep.
There are times that she would have to sleep in a private bedroom she has
provided for herself in the ‘mahjongan’ because her customers would last too long in
playing mahjong that it would come to the point wherein she would be too tired to go
back home to sleep.
When she was young, Mrs. X’s grandfather was a disciplinarian and took care of
his grandchildren, especially Mrs. X, with a hands-on approach. Mrs. X shared that when
she was still a young girl, she wasn’t allowed to go on dates, or go shopping with her
friends or even go out and see a movie. Because of this, she still isn’t much of an out-
going person. She wouldn’t want to shop for clothes, but she’d appreciate gifts from other
people. She also said that her enjoyment comes from her three hobbies: Mahjong,
mahjong and mahjong.
Mr. X does the shopping for the family. Mrs. X verbalized that Mr. X’s daily
routine would always have going to the market as one of the first things to do.
As mentioned earlier, Mrs. X smokes, but doesn’t drink. She shared that if she
stays at home, one pack of cigarettes would last her 3 days. On the other hand, if she
stays in the mahjongan, she would be able to smoke one pack a day. When asked about
how often she stays in the mahjongan, she replied, “Everyday.”
Mr. X is a retired policeman and is supported by pension [P15,000/month]. Mrs.
X earns her money from gambling in the mahjongan. She could earn as much as P60,000
but has the great risk of losing it all to a bad game. Still she estimated an average net
income of P15,000 as well.

DIET
Mrs. X usually eats one meal a day. This is because during breakfast time, she is
asleep. During dinner time, she is at work in the mahjongan. But this one meal does not
have any limit and she said that she is fond of eating a lot of rice. She also eats a lot of
snacks like fruits (mango, chico), palabok, and siopao. She also dislikes bread, cake, and
any pastry foods. However, she claims that she cannot live without pork. She also eats
other meat, but she will always prefer pork over all the rest.
HISTORY OF PATIENT’S PAST ILLNESS
Mrs. X had decided to have herself admitted to the hospital for Dilatation and
Curettage in 1972 because it reached 7 months that she had amenorrhea and she wasn’t
pregnant.
Her asthma started when she was in grade school. Her last asthma attack was
around June of 2008. She had ‘Combivent’ and frequent nebulization to treat her asthma.
She also claims that her asthma is genetic.
She also has a history of cholelithiasis. September 12, 2008 was her last visit to
the doctor. She underwent oral dissolution therapy and had 3 ultrasound sessions
throughout the therapy. During her first ultrasound, it was discovered that she had 3 gall
bladder stones. On her second session, the results revealed a blurry image of the stones.
On the third and final ultrasound, she had no more gall stones. She then stopped
purchasing the recommended medications for her which are Tramadol and Unasyn.

HISTORY OF PATIENT’S PRESENT ILLNESS

In late June 2006, Mrs. X had been having severe migraine and headaches which
alarmed her. She also shared that one day, she wasn’t able to wear her left slipper when
using her left leg. She then had what she calls a ‘pseudo-mild stroke’ and she was
paralyzed on her left side. She went to the hospital and went under Dr. Valdez’s care.
Soon after assessment, she was given the news that there might be something wrong
going on in her skull, and was advised to undergo a Computed Tomography Scan. The
results revealed a brain tumor on Mrs. X’s right hemisphere of the brain. The day after
the CT scan, she had a seizure.
On July 2006, the next month, she underwent the 14-hour craniectomy for the
excision of the brain tumor.
Four months after the successful operation, Mrs. X discovered that the operative
site wasn’t healing. She then had to undergo yet another operation. She claims that the
doctors then were considering osteomyelitis already, yet they didn’t really arrive to the
conclusions that proved so.
Around two years after the surgery that would have supposedly solved her
infection problems, she noticed that there was pus draining from her scalp, and that it was
already numb. She knew that this would mean another costly trip to the hospital, but Dr.
Valdez knew otherwise. He knew that this would mean a more specialized kind of
surgical intervention. He then recommended that Mrs. X seek the services of the surgeons
from DMC.
Mrs. X was able to answer “infection of the bone” when asked what she knows
about osteomyelitis. However, when she was asked about how she acquired the disease,
she gives a shrug, shakes her head a little and keeps silent.

EXPECTATIONS OF THE FAMILY

At first, the sound of ‘tumor’ raised a lot of anxiety within Mrs. X’s family. This
time, however, Mrs. X expresses that she doesn’t feel fear anymore because this is the
third operation and she is used to the pre-operative phase already.
A total of five significant others were observed to have visited and stayed with
Mrs. X. The four significant others consist of 2 nephews, 2 daughters and 1 son-in-law.
She also mentions that there is one more daughter that we keep missing because she visits
on the days when we don’t have our duty in the ward. One of her nephews verbalized that
there were even more people present during her first operation in 2006.
Because of the two seemingly ‘failed attempts’ to cure Mrs. X, her daughter
shares that they hope that “Third time’s the charm” would apply in her mother’s
experience.
Generally, the entire family is matured and treats the illness optimistically. During
our group’s exposure in the ward where Mrs. X was staying, it can be observed that they
are happy together and all of them never fail to smile. Mrs. X’s nephew, the same one
mentioned above, is also very entertaining to the students. Mrs. X’s youngest daughter
admittedly resigned her current job as a call center agent just so that she can stay and
watch over Mrs. X during her stay in the hospital.
GENOGRAM
DEVELOPMENTAL THEORIES
 Theorist Theory Stage Result and
Justification
Erik Erikson’s Erik Erikson Integrity Vs. Despair The patient has

Psychosocial theorized that (45 years old and positively achieved

Theory of development is a above) this stage of

Development lifelong process and A person who can look development. She

does not end with back on good times with views her life as

the cessation of gladness, on hard times meaningful and

adolescence. Just as with self – respect, and fulfilling. She said

physical growth on mistakes an d regrets that she had coped

patterns can be with forgiveness, will well with the

predicted, certain find a new sense of struggles and

psychosocial tasks integrity and a readiness problems that came

must be mastered in for whatever life or her way. She is

each developmental death may bring. thankful because the

stage. The greater A person caught up in struggles made her a

the task old sadness, unable to better person.

achievement, the forgive themselves or

healthier the others for perceived Mrs. X has a very

personality of the wrongs, and dissatisfied supportive and

person however, with the life, they’ve led, caring family.

failure to achieve a will easily drift into According to her she

task influences the depression and despair. is very thankful to

person’s ability to A positive outcome in have children and

achieve the next this stage is achieved if family members

task. The resolution the person gains a self who are always

of the conflicts at fulfillment of about life there to care for her

each and a sense of unity and to support her

within himself and no matter what life

others. That way, he can may give them.

accept death with a

sense of integrity.
Jean Piaget’s Jean Piaget proposed Formal Operations Mrs. X has achieved

Theory of a sequence of This stage is this stage of

Cognitive cognitive characterized by formal development. She

Development development that reasoning. It is in this has knowledge

emphasized the stage that a person’s regarding her

relationship between acquisition of the ability condition. She is

action and thought. to think abstractly, able to exhibit

Each phase in his reason logically and logical thinking that

theory is draw conclusions from aided her in making

characterized by the the information available decisions toward her

ways in which the is measured. over-all health. She

person interprets and considered her

uses the family’s feelings

environment. The upon making the

individual learns by decision whether to

interacting with the have the operation

environment through done or not. She

assimilation, also understands the

accommodation and danger and

adaptation. complications

accompanied by her

condition.
Robert Havighurst theorized Later Maturity Patient X had
Havighurst’s that there are six This stage in a person’s learned to accept the

Developmental developmental life is concerned with changes happening

Milestones stages of life, each the achievement of the to her. She is aware

Theory with essential tasks following tasks: that the surgical

to be achieved. 1. Adjusting to procedures that were

Mastery of a task in physiological performed were for

one developmental changes and her own benefit.

stage is essential for alterations in health

mastery of tasks in status. She owns and runs a

subsequent stages. A 2. Adjusting to “mahjongan” in

successful retirement and altered Iligan. According to

achievement of a income. her, the money that

task leads to 3. Adjusting to death of she gets from her

happiness and to spouse. “mahjongan” is

success with later 4. Developing enough to meet her

tasks. However, affiliation with one’s and her husband’s

failure leads to age group. needs.

unhappiness in the 5. Meeting civic and

individual and social She avails the

difficulty with later responsibilities. services provided

tasks. 6. Establishing for the senior

satisfactory living citizens. She has a

arrangements. medicine booklet

that she uses to get

discounts on the

medications that she

buys. It also serves

as a record of what

medications she was

able to purchase

since she first

obtained the

booklet.

She is able to

establish satisfactory

living arrangements

since she is satisfied

with her

accomplishments in

life.
 DEFINITION OF

COMPLETE DIAGNOSIS
Pre-operative diagnosis: T/c osteomyelitis right anterior parietal bone; s/p

craniectomy with excision of brain tumor.

Operation Diagnosis: Soft tissue defect right parietal area with osteomyelitis, s/p

craniectomy, excision of meningioma.

OSTEOMYELITIS

- represents an acute or chronic infection of the bone. The term osteo refers to

bone and myelo to the marrow cavity, both of which are involved in this disease. Despite

the common use of antibiotics, these infections remain difficult to treat and eradicate. All

types of organism, including parasites, viruses, bacteria, and fungi, can cause

osteomyelitis, but certain pyogenic bacteria and mycobacteria are most common.

Essentials of Concepts of Altered Health Status by Carol Mattson Porth. 2 nd

edition

- is a serious infection of the bone that is often difficult to treat. Osteomyelitis can

be categorized as acute or chronic, which occurs when the symptoms are present for

longer than 3 months.

Contemporary Medical-Surgical Nursing. By Daniels, Nosek & Nicoll

- is an infection of the bone. The bone becomes infected in one of three ways:

first, extension of soft tissue infection (eg, infected pressure or vascular ulcer, incisional

infection). Second, direct bone contamination from bone surgery, open fracture, or

traumatic injury. Third, hematogenous (bloodborne) spread from other sites of infection.
Osteomyelitis resulting from hematogenous spread typically occurs in a bone in an area

of trauma or lowered resistance, possibly from subclinical trauma.

Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Eleventh Edition.

By: Smeltzer, Bare, Hinkle, and Cheever.

- is an infection of bone or bone marrow, usually caused by pyogenic bacteria or

mycobacteria. It can be usefully subclassified on the basis of the causative organism, the

route, duration and anatomic location of the infection.

http://en.wikipedia.org/wiki/Osteomyelitis

-Osteomyelitis is an acute or chronic inflammatory process of the bone and its

structures secondary to infection with pyogenic organisms

http://emedicine.medscape.com/article/785020-overview

- Osteomyelitis is an inflammation or swelling of bone tissue that is usually the

result of an infection. Osteomyelitis, or bone infection, may occur for many different

reasons and can affect children or adults. It can have a sudden onset, a slow and mild

onset, or may be a chronic problem, depending on the source of the infection.

http://www.healthsystem.virginia.edu/uvahealth/adult_bone/osteom.cfm
MENINGIOMA

- develop from the meningothelial cells of the arachnoid and are outside the brain.

They usually have their onset in the middle or later years of life and constitute

approximately 20% of primary brain tumors in this age group. Meningiomas are slow-

growing, well-circumscribed and often highly vascular tumors. They usually are benign,

and complete removal is possible if the tumor does not involved vital structures.

Essentials of Concepts of Altered Health Status by Carol Mattson Porth. 2 nd

edition

- are tumors that arise from the covering of the brain & account for 25% of all

brain tumors and are most common in people over the age of 40 years old. These tumors

are slow-growing and nonmalignant, but they can reoccur.

Contemporary Medical-Surgical Nursing. By Daniels, Nosek & Nicoll

- represents 15% to 20% of all primary brain tumors, are common benign

encapsulated tumors of arachnoid cells on the meninges. They are slow-growing and

occur most often in middle-aged adults (more often in women). Meningiomas most often

occur in areas proximal to the venous sinuses. Manifestations depend on the area

involved and are the result of compression rather than invasion of brain tissue. Standard

treatment is surgery with complete or partial dissection.

Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Eleventh Edition.

By: Smeltzer, Bare, Hinkle, and Cheever.

 - are the most common primary tumor of the central nervous system, arising from

the arachnoid "cap" cells of the arachnoid villi in the meninges. These tumors are usually

benign in nature; however, they can be malignant.

http://en.wikipedia.org/wiki/Meningioma

- Meningioma is a tumor that arises from the meninges — the membranes that

surround your brain and spinal cord. The majority of meningioma cases are noncancerous

(benign), though rarely a meningioma can be cancerous (malignant). Meningioma occurs

most commonly in women. Most people develop meningioma as adults, after age 40. But

meningioma can occur at any age, including childhood.

http://www.mayoclinic.com/health/meningioma/DS00901

- A meningioma is a type of tumor that develops from the meninges, the

membrane that surrounds the brain and spinal cord. There are three layers of meninges,

called the dura mater, arachnoid and pia mater. Most meningiomas (90%) are categorized

as benign tumors, with the remaining 10% being atypical or malignant. However, the

word "benign" can be misleading in this case, as when benign tumors grow and constrict

and affect the brain, they can cause disability and even be life threatening.

http://www.brighamandwomens.org/neurosurgery/Meningioma/Meningiomafacts.aspx
EXCISION

- Surgical removal of tissue

Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Eleventh Edition.

By: Smeltzer, Bare, Hinkle, and Cheever.

- In surgery, an excision (also known as a resection) is the complete removal of an

organ or a tumor from a body, as opposed to a biopsy.

http://en.wikipedia.org/wiki/Excision

-involves the use of a local anesthetic and the removal of a skin lesion by use of a

surgical scalpel. The excised area is then sent to a laboratory for pathologic evaluation.

www.abramsderm.com/patient-education-terms.htm

- To surgically remove; to excise tissue.

http://cancerweb.ncl.ac.uk/cgi-bin/omd?excision
PHYSICAL ASSESSMENT
Patient’s Name: Mrs. X

Age: 64 years old

Sex: Female

Ward: General Surgery

General Survey

Our patient Mrs. X, 64 years old was assessed on December 20, 2008. She was

admitted on December 10, 2008 at 2:00pm. She was received on lying on bed awake,

conscious and coherent. She was responsive and cooperative when asked. In regards to

his emotional state/status, she appeared to be calm. She has a mesomorphic body

structure.

Vital Signs

Temperature (axillary) = 36.8oC

Blood Pressure = 130/80 mmHg

Respiratory Rate = 29 cpm

Pulse Rate = 76 bpm

Skin and Nails

Skin was smooth to touch, generally uniform in color - tan, has a rough texture

and has a good skin turgor. Presence of sutures in the head noted. Bandages were noted in

the right thigh upon observation due to STSG operation. Nails were not trimmed and

traces of dirt noted. Areas around the nails were intact and not inflamed. Nail beds were

pallor with capillary refill of 2 seconds.

Head

The patient is normocephalic. No presence of hair noted in the head due to

craniotomy. Wrinkles were noted on her forehead. Closed surgical inscision is present on

the frontal and midsaggital lines of the head with14 staples on the midsaggital line and

stitches on the frontal line. Presence of JP drain on the mastoid process behind the right

ear was noted.

Eyes

Eyes are symmetrically aligned. Eyelashes are equally distributed and curled

slightly outward. Eyelids are free from discharge and did not show any sign of

inflammation such as redness and swelling. Her palpebral conjunctiva’s color is pink.

Pupils are equally round and reactive to light and accommodation. Pupils, when

constricted, were measured at 3mm.

Ears

Ears are symmetrically aligned to the canthi of the eyes. Also, ears are equal in

size and similar in appearance. No swelling, masses or tenderness were noted.

Nose

Nasolabial folds are symmetrical with no flaring and discharges noted. Nasal

septum is not deviated. Both nostrils are patent. No signs of tenderness and other unusual

signs and symptoms were noted. Patient was able to distinguish the smell of rubbing

alcohol while eyes were closed.

Mouth and pharynx

Outer lips are symmetrical in contour. Upper and lower lips are brown in color.

No lesions or edema were noted. Teeth were not complete. Buccal mucosa appears

pinkish and smooth. Tongue is in midline and pinkish in color. Gums are slightly brown

in color, no bleeding or ulcerations noted. Tonsils were not inflamed and uvula is also in

midline.
Neck

The sides of neck were symmetrical. No masses and swelling noted. Carotid

arteries are palpable. Because of post-operational conditions patient was only able to

rotate, tilt, flex and hyperextend neck minimally, due to her carefulness.

Chest and Lung

Chest muscle expansion during inspiration and relaxation during expiration are

symmetrical and painless. There were no presence of scars and lesions. She was not in

respiratory distress. Respiratory rate is 29 cycles per minute and rhythm was regular.

Breath sounds were clear on both lungs indicating that she is free of cough or colds.

Heart

Upon visual inspection, point of maximum impulse was heard at the left

midclavicular line 5th intercostal space. Heart sounds were regular, no murmurs or

crackling were heard upon auscultation.

Axillae

Axillae are free from rashes. Surface is smooth with no signs of tenderness. No

hair was noted. The color of her axillae is slightly brown.

Abdomen

Abdomen is soft, non-tender and globular in shape. There were no scars and

lesions noted upon inspection. No discharges were noted on her umbilicus. Bowel sounds

are normoactive with 11 sounds counted within one minute.

Extremities

On the upper limb, shoulders and arms were symmetrical. No tenderness noted on

the bones of the wrist and fingers. No deformities and swelling noted. She could freely

move her shoulders. No structural deviations noted.

On the lower limb, she has symmetrical legs. She could freely move her legs in

full range motion. Presence of bandages in right upper leg due to STSG operation noted.

When right leg was assessed for ROM, a sharp pain was felt by Mrs. X. When the pain

scale was introduced for basis of pain intensity, she verbalized a pain scale of “5.”
Neurological Assessment

Pupil

Size (left): 3mm

(right): 3mm

Reaction (right): brisk

(left): brisk

Motor

Handgrip (left): strong

(right): strong

Leg Movement (left): strong

(right): strong

Level of consciousness

Eye opening : 4 (spontaneous)

Best verbal response : 5(oriented)

Best motor response : 6 (obeying)

Reactive Level Scale : 1 (alert, fully conscious)

Glasgow Coma Scale : 15

ANATOMY AND PHYSIOLOGY
A. INTEGUMENTARY SYSTEM

[image from - http://www.dwm.ks.edu.tw/bio/activelearner/37/images/ch37c1.gif]

Also called the integument, which simply means “covering” the skin is much
more than an external body covering. It is absolutely essential because it keeps water and
other precious molecules in the body. It also keeps (and other things) out. Structurally, the
skin is a marvel. It is pliable yet tough, which allows it to take constant punishment from
external agents. Without our skin, we would quickly fall prey to bacteria and perish from
water and heat loss. The skin has many function; most, but not all are protective. It
insulates and cushions the deeper body organs and protects the entire body from
mechanical damage, chemical damage, thermal damage, ultraviolet radiation and
bacteria. The uppermost layer of the skin [stratum corneum] is full of keratin and
cornified, or hardened, in order to prevent water loss from the body surface. [Marieb,
2006]
 [image from - http://www.vitalyouth.com/images/skin_big.jpg]

The skin is composed of two kinds of tissue. The outer epidermis is made up
stratified squamous epithelium that is capable of keratinizing, or becoming hard and
tough. The underlying dermis is mostly made up of dense connective tissue. The
epidermis and dermis are firmly connected. However, a burn or friction may cause them
to separate, allowing interstitial fluid to accumulate in the cavity between the layers,
which results in a blister. [Marieb, 2006]
 The skin of the scalp continues from the front and lateral side of the face into the
occipital region of the skull posteriorly. The makeup of the scalp is important clinically
because trauma to the scalp is frequent and it is up to the clinician to determine by
palpation and observation just how serious the trauma is.
The scalp is made of 5 layers and they spell scalp:

* S -- skin
* C -- dense Connective tissue
* A -- aponeurosis
* L -- loose connective tissue
* P -- periosteum

The blood vessels travel through the dense connective. The connective tissue has
a special relationship with the arteries in this area. When an artery is severed, the
connective tissue fibers around the vessel contract and pull the artery open. This results is
more hemorrhage than in other places. With scalp hemorrhage, compression must be used
to stop the bleeding. Blood vessels and nerves come into the scalp from three different
regions: 1) anterior (supraorbital), 2) lateral (superficial temporal), 3) posterior
(occipital). There are free anastomoses from side to side. With all of this blood supply,
lacerations of the scalp are usually profuse and because of the nerve supply, very
sensitive.
The loose connective layer of the scalp will allow bacteria or fluid to pass freely from the
posterior aspect of the scalp into the eyelids in front. Trauma in the back of the head can
result in blood showing up in the eyelids and should make you suspect something going
on in the back of the head. [http://home.comcast.net/~wnor/lesson1.htm]
 [image from - http://cellbio.utmb.edu/microanatomy/skin/thickskin.jpg; edited]

The outermost layer, the stratum corneum, is 20-30 cell layers thick. It accounts
for about three quarters of the epidermal thickness The snignlelike dead cell remnants,
completely filled with keratin, are referred to as cornified or horny cells (cornu = horn).
The common saying “Beauty is only skin deep” is especially interesting in light of the
fact that nearly everything we see when we look at someone is dead! Keratin is an
exceptionally tough protein. Its abundance in the stratum corneum allows that layer to
provide a durable “overcoat” for the body, which protects deeper cells from the hostile
external environment and from water loss and helps the body resist biological, chemical,
and physical assaults. The stratum corneum rubs and flakes off slowly and steadily and is
replaced by cells produced by the division of the deeper stratum basale cells. Indeed, we
have a totally “new” epidermis every 25 to 45 days. [Marieb, 2006]
 [image from - http://www.koshland-science-museum.org/exhib_infectious/images/s_aureus.jpg]

S. aureus may occur as a commensal on human skin; it also occurs in the nose
frequently (in about a third of the population) and throat less commonly. The occurrence
of S. aureus under these circumstances does not always indicate infection and therefore
does not always require treatment (indeed, treatment may be ineffective and re-
colonisation may occur). It can survive on domesticated animals such as dogs, cats and
horses, and can cause bumblefoot in chickens. It can survive for some hours on dry
environmental surfaces, but the importance of the environment in spread of S. aureus is
currently debated. It can host phages, such as the Panton-Valentine leukocidin, that
increase its virulence.

S. aureus can infect other tissues when normal barriers have been breached (e.g.,
skin or mucosal lining). This leads to furuncles (boils) and carbuncles (a collection of
furuncles). In infants S. aureus infection can cause a severe disease Staphylococcal
scalded skin syndrome (SSSS).

S. aureus infections can be spread through contact with pus from an infected
wound, skin-to-skin contact with an infected person by producing hyaluronidase that
destroy tissues, and contact with objects such as towels, sheets, clothing, or athletic
equipment used by an infected person. Deeply penetrating S. aureus infections can be
severe. Prosthetic joints put a person at particular risk for septic arthritis, and
staphylococcal endocarditis (infection of the heart valves) and pneumonia, which may be
rapidly spread. [http://en.wikipedia.org/wiki/Staphylococcus_aureus]
B. BLOOD

[image from - http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19192.jpg]

Blood is the “river of life” that surges within us. It transports everything that must
be carried from one place to another within the body – nutrients, wastes (headed for
elimination from the body, and body heat – through blood vessels. For centuries, long
before modern medicine, people recognized that blood was vital (some believed
“magical”), and its loss was always considered to be a possible cause of death.

[image from - http://www.scientificpsychic.com/mind/leukocytes0.jpg]

Although leukocytes or white blood cells (WBCs), are far less numerous than red
blood cells, they are crucial to body defense against disease. On average, there are 4,000
to 11,000 WBCs/mm3, and they account for less than 1 percent of total blood volume.
White blood cells are the only complete cells in blood; that is, they contain nuclei and the
usual organelles.
 Leukocytes form a protective, movable army that helps defend the body against
damage by bacteria, viruses, parasites and tumor cells. As such, they have some very
special characteristics. Red blood cells are confined to the blood stream and carry out
their functions in the blood. White blood cells, by contrast, are able to slip into and out of
the blood vessels – a process called diapedesis. The circulatory system is simply their
means of transportation to areas of the body where their services are needed for the
inflammatory or immune responses.
In addition, WBCs can locate areas of tissue damage and infection in the body by
responding to certain chemicals that diffuse from the damaged cells. This capability is
called positive chemotaxis. Once they have “caught the scent,” the WBCs move through
the tissue spaces by ameboid motion (they form flowing cytoplasmic extensions that help
move them along). By following the diffusion gradient, they pinpoint areas of tissue
damage and rally round in large numbers to destroy microorganisms or dead cells.
Whenever WBCs mobilize for action, the body speeds up their production, and as
many as twice the normal number of WBCs may appear in the blood within a few hours.
A total WBC count above 11,000 cells/mm3 is referred to as leukocytosis. Leukocytosis
generally indicates that a bacterial or viral infection is stewing in the body. The opposite
condition, leucopenia, is an abnormally low WBC count. It is commonly caused by
certain drugs, such as corticosteroids and anticancer agents. [Marieb, 2006]
C. CIRCULATORY SYSTEM

[image from - http://www.tvdsb.on.ca/Saunders/courses/Online/SBI3U/Internal_Systems/circulatory%20system-

vessels01.gif]

Most simply stated, the major function of the cardiovascular system is

transportation. Using blood as the transport vehicle, the system carries oxygen, nutrients,
cell wastes, hormones, and many other substances vital for body homeostasis to and from
the cells. The force to move the blood around the body is provided by the beating heart.
The cardiovascular system can be compared to a muscular pump equipped with
one-way valves and a system of large and small plumbing tubes within which the blood
travels.
D. SKELETAL SYSTEM

[image from - http://home.comcast.net/~WNOR/skeletonant.jpg]

Besides contributing to body shape and form, our bones perform several
important body functions:
1. Support. Bones, the “steel-girders” and “reinforced concrete” of the body,
form the internal framework that supports and anchors all soft organs. The
bones of the legs act as pillars to support the body trunk when we stand, and
the rib cage supports the thoracic wall.
2. Protection. Bones protect soft body organs. For example, the fused bones of
the skull provide a snug enclosure for the brain, allowing one to head a soccer
ball without worrying about injuring the brain. The vertebrae surround the
spinal cord, and the rib cage helps protect the vital organs of the thorax.
3. Movement. Skeletal muscles , attached to bones by tendons, use the bones as
levers to move the body and its parts. As a result, we can walk, swim, throw a
ball, and breathe.
4. Storage. Fat is stored in the internal cavities of bones. Bone itself serves as a
storehouse for minerals, the most important being calcium and phosphorus,
although others are also stored. A small amount of calcium in its ion form
must be present in the blood at all times for the nervous system to transmit
messages, for muscles to contract, and for blood to clot. Because most of the
body’s calcium is deposited in the bones as calcium salts, the bones are a
convenient place to get more calcium ions for the blood as they are used up.
Problems occur not only when there is too little calcium in the blood, but also
when there is too much. Hormones control the movement of calcium to and
from the bones and blood according to the needs of the body. Indeed,
“deposits” and “withdrawals” of calcium to and from bones go on almost all
the time.
5. Blood cell formation. Blood cell formation, or hematopoiesis, occurs within
the marrow cavities of certain bones. [Marieb, 2006]
 [image from - http://www.georgehernandez.com/h/xMartialArts/Health/Media/Gray188-Skull-LeftLateral.png]

The skull is formed by two sets of bones. The cranium encloses and protects the
fragile brain tissue. The facial bones hold the eyes in an anterior position and allow the
facial muscles to show our feelings through smiles or frowns. All but one of the bones of
the skull are joined together by sutures, which are interlocking, immovable joints. Only
the mandible is attached to the rest of the skull by a freely movable joint. [Marieb, 2006]

[image from - http://www.ivy-rose.co.uk/Topics/Bones_CranialandFacial.htm]

 [image from - http://en.wikipedia.org/wiki/Parietal_bone]

The parietal bones are bones in the human skull and form, by their union, the
sides and roof of the cranium. Each bone is irregularly quadrilateral in form, and has two
surfaces, four borders, and four angles.
Surfaces
External - The external surface [Fig. 1] is convex, smooth, and marked near the
center by an eminence, the parietal eminence (tuber parietale), which indicates the point
where ossification commenced.
Crossing the middle of the bone in an arched direction are two curved lines, the
superior and inferior temporal lines; the former gives attachment to the temporal fascia,
and the latter indicates the upper limit of the muscular origin of the temporalis.
Above these lines the bone is covered by the galea aponeurotica (epicranial
aponeurosis); below them it forms part of the temporal fossa, and affords attachment to
the temporalis muscle.
At the back part and close to the upper or sagittal border is the parietal foramen,
which transmits a vein to the superior sagittal sinus, and sometimes a small branch of the
occipital artery; it is not constantly present, and its size varies considerably.
Internal - The internal surface [Fig. 2] is concave; it presents depressions
corresponding to the cerebral convolutions, and numerous furrows (grooves) for the
ramifications of the middle meningeal artery; the latter run upward and backward from
the sphenoidal angle, and from the central and posterior part of the squamous border.
 Along the upper margin is a shallow groove, which, together with that on the
opposite parietal, forms a channel, the sagittal sulcus, for the superior sagittal sinus; the
edges of the sulcus afford attachment to the falx cerebri.
Near the groove are several depressions, best marked in the skulls of old persons,
for the arachnoid granulations (Pacchionian bodies).
In the groove is the internal opening of the parietal foramen when that aperture
exists.
Borders
* The sagittal border, the longest and thickest, is dentated (has toothlike projections)
and articulates with its fellow of the opposite side, forming the sagittal suture.
* The squamous border is divided into three parts: of these:
- the anterior is thin and pointed, bevelled at the expense of the outer surface, and
overlapped by the tip of the great wing of the sphenoid;
- the middle portion is arched, bevelled at the expense of the outer surface, and
overlapped by the squama of the temporal;
- the posterior part is thick and serrated for articulation with the mastoid portion of
the temporal.
* The frontal border is deeply serrated, and bevelled at the expense of the outer surface
above and of the inner below; it articulates with the frontal bone, forming half of the
coronal suture. The point where the coronal suture intersects with the sagittal suture
forms a T-shape and is called the bregma.
* The occipital border, deeply denticulated (finely toothed), articulates with the
occipital bone, forming half of the lambdoid suture. That point where the sagittal suture
intersects the lambdoid suture is called the lambda, because of its resemblance to the
Greek letter.
Angles
The frontal angle is practically a right angle, and corresponds with the point of
meeting of the sagittal and coronal sutures; this point is named the bregma; in the fetal
skull and for about a year and a half after birth this region is membranous, and is called
the anterior fontanelle.
 The sphenoidal angle, thin and acute, is received into the interval between the
frontal bone and the great wing of the sphenoid. Its inner surface is marked by a deep
groove, sometimes a canal, for the anterior divisions of the middle meningeal artery.
The occipital angle is rounded and corresponds with the point of meeting of the
sagittal and lambdoidal sutures—a point which is termed the lambda; in the fetus this part
of the skull is membranous, and is called the posterior fontanelle.
The mastoid angle is truncated; it articulates with the occipital bone and with the
mastoid portion of the temporal, and presents on its inner surface a broad, shallow groove
which lodges part of the transverse sinus. The point of meeting of this angle with the
occipital and the mastoid part of the temporal is named the asterion.
Ossification
The parietal bone is ossified in membrane from a single center, which appears at
the parietal eminence about the eighth week of fetal life.
Ossification gradually extends in a radial manner from the center toward the
margins of the bone; the angles are consequently the parts last formed, and it is here that
the fontanelles exist.
Occasionally the parietal bone is divided into two parts, upper and lower, by an
antero-posterior suture. [http://en.wikipedia.org/wiki/Parietal_bone]
 [image form - http://upload.wikimedia.org/wikipedia/commons/3/3a/Bony_sequestrum_in_a_child_femur.jpg]
An X-ray of a child's femur showing a bony sequestrum highlighted by the blue arrow.

A sequestrum is a piece of dead bone that has become separated during the
process of necrosis from normal/sound bone.
It is a complication (sequelae) of osteomyelitis. The pathological process is as follows:
* infection in the bone leads to an increase in intramedullary pressure due to
inflammatory exudates
* the periosteum becomes stripped from the osteum, leading to vascular thrombosis
* bone necrosis follows due to lack of blood supply
* sequestra are formed
The sequestra are surrounded by sclerotic bone which for all intents and purposes
is relatively avascular (without a blood supply). Within the bone itself, the haversian
canals become blocked with scar tissue, and the bone becomes surrounded by thickened
periosteum.
Due to the avascular nature of this bone, antibiotics which travel to sites of infection via
the bloodstream, poorly penetrate these tissues. Hence the difficulty in treating chronic
osteomyelitis.
At the same time as this, new bone is forming (known as involucrum). Opening in this
involucrum allow debris and exudates (including pus) to pass from the sequestrum via
sinus tracts to the skin.
Rarely, a sequestrum may turn out to be an osteoid osteoma, a rare tumor of the

bone.
ETIOLOGY
 PREDISPOSING FACTORS

Factor Rationale Present or Justification

Absent
Mrs. X has had surgery
Surgical wound as a Exposes the bone on her head which
Present
portal of entry to infection exposed her skull
during the operation.
Increases blood
Smoking Present Mrs. X smokes.
pressure
Decreases the
tissue perfusion Mrs. X works in a
High Blood Pressure Present
resulting in poor stressful environment
infection control
Decreases the Although in an
Malnourishment efficiency of the Absent unhealthy diet, Mrs. X
host’s immunity is not malnourished.
Increases the Mrs. X does not have
Immune System
susceptibility to Absent an Immune System
Deficiency
get infected Deficiency
Increases the risk
of having Mrs. X does not have a
Prosthetic Joints Absent
osteomyelitis in prosthetic joint.
the joints
Decreases the
Mrs. X does not have
Sickle-Cell Anemia efficiency of the Absent
Sickle-Cell Anemia
host’s immunity

Increases the
Diabetes susceptibility to Absent Mrs. X is not diabetic
get infected
Increases blood
pressure which
Obesity Absent Mrs. X is not obese
leads to poor
tissue perfusion
 Precipitating factors
Factor Rationale Present or Justification
Absent
There was a break in Mrs. X underwent
sterility, leading to surgery twice which
bacteria introduced Leads to infection could mean that the
Present
during intra- of the bone surgical wound on her
operative or post- scalp might have served
operative care. as a portal of entry.
Mrs. X acquired bone
Bacteria introduced Leads to infection trauma from the
Present
by trauma to bone. of the bone surgeries that she had
undergone.
Bacteria introduced Leads to infection Mrs. X does not have a
Absent
via bone fractures. of the bone bone fracture
Bacteria introduced
Mrs. X does not have
via prosthetic Leads to infection
Absent anything that is
implants (such as an of the bone
prosthetic.
artificial hip joint).
Infections elsewhere Leads to infection Absent Mrs. X does not have
in the body that of the bone any other infection
reach the bones via anywhere else in her
the bloodstream. entire body
A primary infection Leads to infection Absent Mrs. X does not have a
of the blood of the bone primary infection of the
(septicaemia). blood.
SYMPTOMATOLOGY
(as of December 13, 2008)
Symptoms Rationale Present or Justification
Absent
The infection Dressing on her head, ®
triggers parietal area, was noted
Abscess chemotaxis of Present to be absorbing
leukocytes toward purulent pus draining
the infected site from her scalp.
The infection will
There was evidence of
trigger the
Inflammation Present swelling on Mrs. X’s
inflammatory
scalp.
process
The infection will
Mrs. X’s temperature
trigger the
Fever Absent was not higher than
inflammatory
37.5°C
process
The infection will There are not many
Myalgia causes pain to Absent muscles affected by
muscle movement Mrs. X’s osteomyelitis.
The infection Mrs. X verbalized that
affects the tissue her head, especially
Pain and Tenderness Absent
surrounding the around the operative
affected bone site, felt numb
PATHOPHYSIOLOGY
 The host responds to the presence of bacteria in the metaphysis with a local
increase in vascular permeability, resulting in edema, increased vascularity and the influx
of polymorphonuclear leukocytes. Pressure increases as pus collects and is confined
within rigid bone. Exudation through Volkmann's canals and the haversian canal affords
little relief, although the relatively inelastic periosteum may become elevated. The blood
supply to the area of involvement is decreased secondary to the pressure; necrosis of the
infected bone may result in the formation of a sequestrum. A protein-rich liquid
containing inflammatory cells may collect in an adjacent joint but such effusions are
sterile.
After the vascular supply to the involved area has been interrupted and necrosis
has occurred, the chronic phase of osteomyelitis is established. The residual dead bone
acts as a foreign body, making the eradication of bacteria impossible until the sequestrum
is removed.
If the infected area becomes well demarcated and the infection is contained, the
acute inflammatory process may subside, leaving a subperiosteal accumulation of pus
which may be discovered by tenderness on palpation. This relatively quiescent form of
subperiosteal infection is termed a Brodie's abscess. After some time, there is deposition
of new bone, the involucrum, under the elevated periosteum.
[http://www.kcom.edu/faculty/chamberlain/Website/tritzid/skelinfe.htm]
 Acute osteomyelitis is usually caused by bacteria. The infection can be cause by
direct extension or contamination of an open fracture or wound (contiguous invasion); by
seeding through the bloodstream (hematogenous spread); or by spread from skin
infections in persons with vascular insufficiency.
The specific agents isolated in bacterial osteomyelitis are often associated with
the age of the person or the inciting condition (e.g., trauma or surgery). Staphylococcus
aureus is responsible for most cases of acute hematogenous osteomyelitis.
Staphylococcus epidermidis, S. aureus, Pseudomonas aeruginosa, Serratia marcescens,
and Escherichia coli are commonly isolated in persons with chronic osteomyelitis. S.
aureus has several characteristics that favor its ability to produce osteomyelitis: it is able
to produce collagen-binding adhesion molecules that allow it to adhere to the connective
tissue elements of bone; and it has the ability to be internalized and survive in cells such
as the osteoblast, which helps to explain the persisten nature of the infection. S. aureus
and S. epidermidis can also form biofilms, making them more resistant to antimicrobial
therapy.
CHRONIC OSTEOMYELITIS

Chronic osteomyelitis usually occurs in adults. Generally, these infections occur

secondary to an open wound, most often to the bone or surrounding tissue. Chronic
osteomyelitis has long been recognized as a disease. However, the incidence has
decreased in the past century because of improvements in surgical techniques and broad-
spectrum antibiotic therapy. Chronic osteomyelitis may be the result of delayed or
inadequate treatment of acute hematogenous osteomyeltits or osteomyelitis caused by
direct contamination of bone. Acute osteomyelitis is considered to have become chronic
when the infection persists beyond 6 to 8 weeks or when the acute process has been
adequately treated and is expected to resolve, but does not. Chronic osteomyelitis can
persist for years; it may appear spontaneously, after minor trauma, or when resistance is
lowered.
The hallmark feature of chronic osteomyelitis is the presence of a sequestrum or
pice of dead bone that has separated form the surrounding living bone. A sheath of new
bone, called the involcrum, forms around the dead bone. Radiologic techniques such as x-
ray films, bone scans, and sinograms are used to identify the infected site. Chronic
osteomyelitis or infection around a total joint prosthesis can be difficult to diagnose
because the classic signs of infection are not apparent and the blood leukocyte count may
not be elevated. A subclinical infection may exist for years. Bone scans are used in
conjunction with bone biopsy for a definitive diagnosis.
[Porth, C.M. et.al., Essentials of Pathophysiology, 2nd ed. © 2007 Lippincot Williams and Wilkins]
Predisposing Precipitating
Factors: Gram-negative Factors:
Pseudomonas
- Surgical comes in contact - Bacteria
wounds as with bone introduced
portal of to bone
entry during
Gram-negative Pseudomonas
- Smoking surgery
activates osteoclasts
- High blood
pressure
Pathologic bone
breakdown

Bone Injury

Release of histamine
and kinins

Pain Pain receptor

activation

Dilation of blood
Inflammation & vessels and increased
Fever permeability in
capillaries

Leukocytosis

Chemotaxis

Abscess Accumulation
formation of pus
 Diagnostic
Findings
Biopsy
GS/CS
CBC X-ray

Acute Osteomyelitis

Medical Surgical Nursing

Management Management Management

> Antibiotics > Drain > Increase OFI

> Antipyretics > Encourage
> Analgesics nutritious diet
> Promote rest
and sleep

If treated: Prognosis If not treated:

- aseptic technique
- good compliance of -poor compliance of drugs
drug intake -lack of finances for
- support from the medications
family -inefficient surgical
- adequate finance for management
therapeutic regimen

GOOD PROGNOSIS
 Aggravation of infection

Spread of infection
Aggravation
Bone necrosis
of infection Septicemia

Aggravation
Formation ofofsequestra
infection - Advancement
to chronic
osteomyelitis
Sequestra identified Accumulation of
as foreign body bacteria

Influx of polymorpholeukocytes

Phagocytosis

Lysis of necrotic tissue Pus

Formation of medullary abscess

(Brodie’s abscess)

Development of sinus tract to skin Draining Abscess

Non-healing wound

Diagnostic Findings

CBC X-ray
Urinalysis MRI
(Health History) CT Scan

Chronic Osteomyelitis
 Chronic Osteomyelitis

Medical Surgical Nursing

Management Management Management

Antibiotic Debridement Increase OFI

Antipyretic STSG Encourage nutritious
Analgesic Rotational Flap diet
Drain Promote sleep and rest

PROGNOSIS

If treated: If not treated:

Good compliance of Poor compliance of

medications medications
Financially supported Insufficient family
Proper diet Further aggravation of support
Efficient surgical infection Insufficient funds for
procedure surgical intervention

Development of other
infections

Disability and
GOOD PROGNOSIS Deformation

POOR PROGNOSIS

DEATH
DOCTOR’S ORDERS
 DATE DOCTOR'S ORDER
December Please admit under General
10, 2008 Surgery I
@ 3:45
pm
Consent
Please monitor VS q 4 record
LABS: with available lab
result (CBC, UA, CXN, ECG,
NA-, K+, CA++, lipid profile,
PC, blood typing); PLR 1L @
100 cc/hr
Meds:
1. Ciproflaxin 300 mg IVTT q
2 action of the microorganism.
2. Ketorolac 30 mg IVTT q 8
Watch out for unusualities
Daily wound dressing
Still inform Dr. Mapuyo of
this
still inform Dra. Ello Niño of
this
RATIONALE REMARKS
The patient is in need of DONE
medical attention so she is
admitted in Davao Medical
Center in Gen. Surg. I for
preparations for the Pre-
operation.
For legal purposes: to ensure DONE
that the patient knows the
majority of the operation to be
done.
Vital signs are recorded to DONE
obtain patients baseline data
and be useful for further
management. A temperature
higher than normal may
indicate the development of
infection. Pulse & respiration is
taken to watch out for
tachycardia a sign of
hemorrhage & dehydration.
These entire lab tests are DONE
performed to screen for
alteration and to serve as a
baseline data for future
comparison.
Ciproflaxin-prevents infections DONE
by inhibting the growth or
Ketorolac- to reduce pain, fever
& inflammation.
To ensure that immediate DONE
nursing interventions can be
administered to avoid
complications
Dressing is important to prevent DONE
infection and to promote
hygiene and faster healing of
the wound.
Informing the physicians of the DONE
latest news about the patient
will mean better care given to
the patient.
 DATE DOCTOR'S ORDER RATIONALE REMARKS
Refer Accordingly Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition
December Start clindamycin 300 mg QID To reduce fever, pain & DONE
11, 2008 inflammation.
@ 9:00
am
For dressing Dressing is important to prevent DONE
infection and to promote
hygiene and faster healing of
the wound
refer Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition.
11:20 pm Change IV to heplock For convenient administration DONE
of IVTT medications
Continue Referring to the previous order DONE
refer Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition.
December Continue meds All medications previously DONE
12, 2008 ordered by attending physician
should be continued to hasten
patient's recovery.
Change drain To prevent infection. DONE
refer Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition.
December Continue meds All medications previously DONE
13, 2008 ordered by attending physician
should be continued to hasten
patient's recovery.
 DATE DOCTOR'S ORDER RATIONALE REMARKS
Change dressing Dressing is important to prevent DONE
infection and to promote
hygiene and faster healing of
the wound of the patient
For co-management To determine if there are any DONE
unusualities that needs proper
management.
Shave head For preparation in the surgery. DONE
To avoid microorganism from
invading the open incision.
refer Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition.
December NPO post Midnight The patient is maintained on DONE
14, 2008 NPO in order to prevent
(pre-op) aspiration from vomiting which
is one of the side effects of
anesthesia.
General/ oral hygiene PTOR General and Oral Hygiene will DONE
be able to help out in the over
all health and recovery of the
patient by keeping the patient
generally clean. [PTOR –
Periotherapy Oral Rinse]
VS Vital signs are recorded to DONE
obtain patients baseline data
and be useful for further
management.
IVF PLR 1 L @ 120cc/ hr For replacement of fluid DONE
electrolytes balance
maintainance.
Meds: Is an anti-ulcer agent. It is given DONE
Ranitidine 50 mg IVTT q 8 to decrease gastric acid
secretion in which preventing
the stomach from scarring of
the lining.
refer Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
 DATE DOCTOR'S ORDER
Decemebr Neurosurgery:
14, 2008  Patient secure
@11:00 examined
am  health history
recovered
 S/p craniectomy for
meningioma
Osteomyelitis
 retrive CT scan plates
& place at bedside
Retrieve CT scan plates &
place at bedside
For referral
Thanks for this referral
December Schedule for STAT
15, 2008 debridement possible STSG
Secure consent
Inform OR/ AROD
To secure 1 unit whole blood
of patient's blood type and
cross match for OR use
RATIONALE REMARKS
physician of the patient's
condition.
This is for the collaborative DONE
health care of the patient.
Assessment of the patient is
endorsed for the continuity of
care.
For diagnostics purposes. DONE
Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition.
To show appreciation DONE
To inform the nurses that a DONE
surgical operation is being
planned; also, to signal
preparation for pre-operative
care.
For legal purposes: to ensure DONE
that the patient knows the
majority of the operation to be
done.
To schedule the operation. DONE
Fresh whole blood and blood DONE
components are administered to
increase amount of oxygen
being delivered to the tissue and
organs, to prevent/stop bleeding
because of platelet defects or
because of deficiencies or
coagulation and to combat
infection caused by decreased
WBC/ antibodies.
Crossmatching is important to
 DATE DOCTOR'S ORDER
IVF with PLR 1 L @ 120
cc/hr
Cefradine 1 gm IVTT PTOR
Refer accordingly
December To PACU then GS ward once
16, 2008 stable
(post-op)
DAT once fully awake
VS q15 mins. Every 2 hrs.
then q hourly
Neuro VS q hourly x6 hrs then Post operative protocol. Surgery
q shift
IVF: PNS 1 L @ KVO with
ongoing BT @ 25-30 cc/hr
Meds:
 Tramadol 50 mg q6
IVTT
 Ketorolac 15 mg q4
IVTT
 Metroclopromide 10 mg
q6 IVTT x2 doses RTC
then prn for PONV
RATIONALE REMARKS
detect agglutination of donor
RBC's caused by antibodies in
patient's serum.
For replacement of fluid DONE
electrolytes balance
maintainance.
Is given to treat infections with DONE
bacteria
Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition.
For close monitoring of the DONE
patient. To watch out for any
signs of unusualities.
Diet as tolerated is ordered by DONE
the doctor to let patient eat the
regular diet to meet nutritional
needs.
Vital signs is taken to provide DONE
baseline data and to watch for
any unusualities.
DONE
involving any exposure of the
brain will require NVS
monitoring to establish any
neurological unusualites
For replacement of fluid DONE
electrolytes balance
maintenance. Blood transfusion
may treat medical condition
such as massive blood loss.
Tramadol – is administered to DONE
alleviate moderate to severe
pain.
Ketorolac - Ketorolac- to
reduce pain, fever &
inflammation.
Metroclopromide - this action
prevents nausea and vomiting.
 DATE DOCTOR'S ORDER RATIONALE REMARKS
O2 inhalation @ 4LPM via Oxygen therapy is provided to DONE
facemask @ PACU prevent patient from hypoxia.
Keep patient warm and Warmth makes the patient DONE
thermoregulated comfortable and alleviate
anxiety that may be helpful for
her recovery.
INO q hourly x6 hrs then q Intake & output monitoring DONE
shift provides evidence of the client's
fluid volume status. If intake is
greater than 100ml/ hr, fluid
overload may occur, placing the
client at risk for pulmonary
edema.
Elevate head 30 degrees from To allow lung expansion and DONE
improve circulation thus
increased comfort.
Hook to pulse oximeter To measures the oxygen DONE
saturation of a patient's blood
(indirectly) and changes in
blood volume in the skin
Repeat CBC, 6 hours post-BT To evaluate the efficiency of the DONE
Blood Transfusion and to see if
there are any complications
For ABG @ PACU and refer Arterial blood Gas is used to DONE
result test the effectiveness of
respiration. To determine if
there are any changes in the
result.
Refer prn To inform the physician when DONE
services are needed.
December Please re-insert IVF This is for fluid replacement DONE
18, 2008 and to prevent dehydration.
@ 6:00
am
Cloxacillin 50 mg Is an antibiotic drug used to DONE
treat infection caused by
staphylococcus bacteria.
Continue other medications All medications previously DONE
ordered by attending physician
should be continued to hasten
patient's recovery.
DATE DOCTOR'S ORDER RATIONALE REMARKS
refer Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition.
Transfer for surgical rest To signal post-operative care. DONE
DIAGNOSTIC EXAMS
 IPD HEMATOLOGY
CBC+BLT

REF.
TEST RESULT UNIT
RANGES
Hemoglobin
- To identify the amount of O2 carrying
protein contained within the RBC.
L 110.0 g/L 115 - 155
- Decreased Hgb indicates anemia fro
blood loss, dietary deficiency, and
malnutrition and kidney disease.
Hematocrit
- To identify the percentage of the blood
volume occupied by red blood cells.
0.36 0.36 - 0.48
- Decreased Hct indicates blood loss, anemia,
blood replacement therapy, and fluid balance,
and screens red blood cell status
RBC Count
- To know the amount of RBC in the blood.
L 3.88 10^6/uL 4.20 - 6.10
Rule out anemia due to nutritional
deficiencies, blood loss.
WBC Count
- To determine infection or inflammation in
the body and monitor its responses to 7.42
specific therapies. Explain to the patient the 10^3/uL 5.0 - 10.0
necessity of undergoing the test that it helps
detect occurrence of anemia and
polycythemia.
 DIFFERENTIAL COUNT
TEST RESULT UNIT REF. RANGES
Neutrophil L52 55 - 75
- To indicate the presence of bacterial
infection and amount of Leukocyte.
Lymphocytes 35 20 - 35
- To identify if there is an abnormal
amount of lymphocyte that may indicate
viral infection such as HIV. A decreased
number of lymphocytes in the peripheral
circulation, occurring as a primary
hematologic disorder or in association
with nutritional deficiency, malignancy
or infection mononucleosis.
Monocytes 7 2 - 10
- Increase of these may respond to
corticosteroid, with pus conditions,
hemorrhage.
Eosinophil 5 1-8
- High percentage of eosin Phil, may
indicate bacterial infestation or allergies.
Basophil 1 0-1
- Increase of basophil may indicate
parasite, hypersensitiveness and
heartworm causing endocrine disease,
chronic liver disease.
Platelet Count 245 X10^3/uL 150 - 400
- The smallest cells in the blood are the
platelets, which are designed for a single
purpose-to begin the process of
coagulation, or forming a clot, whenever
a blood vessel is broken.

BLOOD TYPE (ABO + Rh)

TEST RESULT UNIT REF. RANGES
 Blood type
Blood type Rh
- In forward typing, if there’s agglutination,
the patient’s RBC’s are mixed with anti-A
B+
and anti-B serum, the A and B antigen is
present, thus blood type is O. This is to
check compatibility of the donor and the
patient before transfusion.

CLINICAL MICROSCOPY
A.) PHYSICAL EXAMINATION

Color Drak Yellow

Apperance Cloudy
Reaction 7.0
Specific Gravity 1.015

B.) CHEMICAL EXAMINATION

Albumin negative
Sugar negative

C.) MICROSCOPIC EXAMINATION

Epithelial Cells Cast

Squamous Few Hyaline /lpf
Ranal --- Fine granular /lpf
Pus cells 0 – 1/hpf Course granular /lpf
 CT SCAN Report
Examination: Cranial
Chief Complaint: c/p craniectomy
Physician: Dr. Mapayo
File no.: 08-0053
Date: 10-11-08
Or no.: 141606
Room no.: OPD

Cranial CT SCAN
- No previous study available for comparison
- Multiple plain and IV-contrast axial tomographic sections of thr head were obtained.
- There is a non-enhancing low attenuation density in the R anterior parietal area.
- Irregular craniectomy defect is noted in the R anterior parietal area. Osseous thickening is
noted in the frontoparietal area on both sides, more in the R parietal area. The thickest
diameter measures 2.8cm. At least 4 metallic densities (craniofixed) are stabilizing the
defect.
- No abnormal enhancing lesions.
- No extra-axial fluid collection noted.
- The ventricles are symmetrical and not dilated.
- The sulci and cisterns are undisplaced.
- The posterior fossa, sella, orbits, paranasal sinuses, petromastoids, and bony calvarium
are unremarkable.

Impression:
s/p craniectomy with ischemic change right parietal bone.

GRAM STAIN: Date : 10/7/08

Findings: specimen: wound discharge
Gram stain (direct)
Predominant organism
 Presence of gram negative rod-shaped organisms.
Culture and Sensitivity
 Moderate growth of pseudomonas
 Diagnostic Imaging Department

Pt. Name: Mrs. X

Exam taken: Chest PA
Age: 64
Sex: F

Radiologic Findings

- Lung fields are clear

- The heart is not enlarged
- Aortic Knob is calcified
- Diaphragm and & Costophrenic sulci are intact
- Visualized osseous structures are porotic
- The rest of the included structures are unremarkable

Impression:
Artherosclerotic Aorta
Senile osteoporosis

ECG Report

Name: Mrs. X
Date: 11/21/08
Rhythm: Sinus
Interval PR 0.15sec
QR 0.9sec
QT 0.38sec

Electocardiographic Diagnosis

Normal ECG
DRUG STUDY
Generic Name Brand Classification Dosage & Mechanism of actions
Name frequency
Tramadol ultram Analgesics, Doses range from The mode of action of tramadol
central acting 50–400 mg daily, has yet to be fully understood,
maximum dose of but it is believed to work
400 mg a day through modulation of the
(webmed), with up to noradrenergic and serotonergic
600 mg daily when systems in addition to its mild
given IV/IM. The agonism of the μ-opioid
formulation receptor. The contribution of
containing APAP non-opioid activity is
contains 37.5 mg of demonstrated by the analgesic
tramadol and 325 mg effects of tramadol not being
of paracetamol, fully antagonised by the μ-
intended for oral opioid receptor antagonist
administration with a naloxone.Tramadol is marketed
common dosing as a racemic mixture with a
recommendation of weak affinity for the μ-opioid
one or two tabs every receptor (approximately
four to six hours. 1/6000th that of morphine;
Gutstein & Akil, 2006). The
(+)-enantiomer is
approximately four times more
potent than the (-)-enantiomer
in terms of μ-opioid receptor
affinity and 5-HT reuptake,
whereas the (-)-enantiomer is
responsible for noradrenaline
reuptake effects (Shipton,
Indications
is used to treat
moderate and severe
pain and most types
of neuralgia, including
trigeminal neuralgia. It
has been suggested
that tramadol could be
effective for alleviating
symptoms of
depression and
anxiety because of its
action on the
noradrenergic and
serotonergic systems,
the involvement of
which appear to play
a part in its ability to
alleviate the
perception of pain.
2000). These actions appear to
produce a synergistic analgesic
effect, with (+)-tramadol
exhibiting 10-fold higher
analgesic activity than (-)-
tramadol (Goeringer et al.,
1997).

The serotonergic modulating

properties of tramadol mean
that it has the potential to
interact with other
serotonergic agents. There
is an increased risk of
serotonin syndrome when
tramadol is taken in
combination with serotonin
reuptake inhibitors (e.g.
SSRIs) or with use of a light
box, since these agents not
only potentiate the effect of
5-HT but also inhibit
tramadol metabolism.
Tramadol is also thought to
have some NMDA-type
antagonist effects which has
given it a potential
application in neuropathic
pain states
Contraindication Side Effects Adverse Reactions Nursing Responsibilities

 Nausea, vomiting,  Document indications for

Hypersensitivity to sweating and The most commonly reported therapy, location, onset, and
tramadol. In acute constipation. adverse drug reactions are characteristics of symptoms.
intoxication with Drowsiness. nausea, vomiting, sweating and Use a pain rating scale.
alcohol, hypnotics,  Stomach upset, constipation. Drowsiness is  Assess for history of drug
centrally acting increased reported, although it is less of addiction, allergy to opiates or
analgesics,opiates, sensitivity to an issue than for other opioids. codeine, or seizures; drug may
or psychotropic stomach acid to Respiratory depression, a increase the risk of convulsions.
drug. Use for the point of common side effect of most  Monitor VS, I & O, liver and
preoperative ulceration of opioids, is not clinically renal function studies; reduce
medication or for esophagus, significant in normal doses. By dose with dysfunction and if over
postdelivery stomach, and itself, it can decrease the 75 yrs. Old.
analgesia in duodenum seizure threshold. When
nursing mothers.  Vasodilation, liver combined with SSRIs, tricyclic CLIENT/FAMILY TEACHING
failure, speech antidepressants, or in patients
disorder.Dermatol with epilepsy, the seizure  Take only as directed. May be
ogic problems. threshold is further decreased. taken without regard to meals.
Seizures have been reported in Do not exceed single or daily
humans receiving excessive doses of tramadol; do not share
single oral doses (700 mg) or meds, store safely out of reach
large intravenous doses (300 of child.
mg). An Australian study found  Do not perform activities that
that of 97 confirmed new-onset require mental alertness; drug
seizures, eight were associated may cause drowsiness and
with Tramadol, and that in the impair mental or physical
authors' First Seizure Clinic, performance. Alcohol may
"Tramadol is the most intensify drug effect.
frequently suspected cause of  Report lack of response. Review
provoked seizure. Seizures
 list side effects (nausea,
caused by tramadol are most dizziness, constipation,
often tonic-clonic seizures. somnolence, and pruritus) that
Constipation can be severe one may experience and report
especially in the elderly if persistent or intolerable.
requiring manual evacuation of
the bowel.
Generic Name Brand Name Classification Dosage & Mechanism of actions Indications
frequency
Ketorolac Toradol and non-steroidal anti- For oral The primary mechanism of Ketorolac is
Acular inflammatory drug dosage form action responsible for indicated for short-
(tablets): ketorolac's anti- term management
inflammatory, antipyretic of pain (up to five
For pain: and analgesic effects is the days maximum).
inhibition of prostaglandin
Adults (patients synthesis by competitive
16 years of age blocking of the the enzyme
and older)— cyclooxygenase (COX).
One 10- Like most NSAIDs,
milligram (mg) ketorolac is a non-selective
tablet four times COX inhibitor.
a day, four to six
hours apart. As with other NSAIDs, the
Some people mechanism of the drug is
may be directed associated with the chiral S
to take two form. Conversion of the R
tablets for the enantiomer into the S
first dose only. enantiomer has been shown
to occur in the metabolism
Children up to of ibuprofen; it is unknown
16 years of age whether it occurs in the
—Use and dose metabolism of ketorolac.
must be
determined by
your doctor.

For injection
dosage
form:

For pain:

Adults (patients
16 years of age
and older)—15
or 30 mg,
injected into a
muscle or a
vein four times
a day, at least 6
hours apart.
This amount of
medicine may
be contained in
1 mL or in one-
half (0.5) mL of
the injection,
depending on
the strength.
 Some people
who do not
need more than
one injection
may receive
one dose of 60
mg, injected
into a muscle.

Children up to
16 years of age
—Use and dose
must be
determined by
your doctor.

Contraindications Side Effects Adverse Reactions Nursing Responsibilities

Rare Ketorolac may cause  Use as a part of a regular

Ketorolac is some people to become analgesic schedule rather than
contraindicated in  Bleeding from the dizzy or drowsy. If on an as needed basis.
patients with a rectum or bloody or either of these side  If given on p.r.n. basis, base
previously black, tarry stools effects occurs, do not the size of a repeat dose on
demonstrated  Bleeding or crusting drive, use machines, or duration of pain relief from
hypersensitivity to sores on lips do anything else that previous dose. If the pain
ketorolac, and in  Blue lips and fingernails could be dangerous if returns within 3-5 hours, the
you are not alert. next dose can be increased by
  Chest pain
patients with the  Convulsions
complete or partial  Fainting
syndrome of nasal  Shortness of breath,
polyps,
fast, irregular, noisy, or
angioedema, troubled breathing,
bronchospastic tightness in chest,
reactivity or other and/or wheezing
allergic  Vomiting of blood or
manifestations to material that looks like occur, including
aspirin or other coffee grounds
non-steroidal anti-
inflammatory drugs More common
(due to possibility
of severe  Swelling of face,
anaphylaxis). As fingers, lower legs,
with all NSAIDs, ankles, and/or feet
ketorolac should be  Weight gain (unusual)
avoided in patients
with renal (kidney) Less common
dysfunction.
 Bruising (not at place of
injection)
 High blood pressure
 Skin rash or itching
 Small, red spots on skin
 Sores, ulcers, or white
spots on lips or in
mouth
up to 50% (as long as the total
Serious side effects can daily dose is not exceeded). If
occur during treatment the pain does not return for 8-
with this medicine. 12 hr, the next dose can be
Sometimes serious side
decreased by as much as 50%
effects can occur or the dosing interval can be
without any warning. increased to q 8-12 hr.
However, possible  Shortening the dosing intervals
warning signs often recommended will lead to an
increased frequency and
swelling of the face, duration of side effects.
fingers, feet, and/or  Correct hypovolemia prior to
lower legs; severe administering.
stomach pain, black,  Protect the injection from light
tarry stools, and/or  Document indications for
vomiting of blood or therapy, onset, location, pain
material that looks like intensity/level, and
coffee grounds; unusual characteristics of the
weight gain; and/or symptoms.
skin rash. Also, signs of  Note any previous experience
serious heart problems with NSAIDs and the results.
could occur such as  Determine any renal or liver
chest pain, tightness in dysfunction; assess hydration.
chest, fast or irregular  Avoid alcohol, ASA, and all
heartbeat, or unusual OTC agents without approval.
flushing or warmth of  Report any unusual
skin. Stop taking this bruising/bleeding, weight gain,
medicine and check swelling of feet and ankle,
with your doctor increased joint pain, change in
immediately if you urine patterns or lack of
notice any of these response.
Rare
warning signs.
 Abdominal or stomach
pain, cramping, or
burning (severe)
 Bloody or cloudy urine
 Blurred vision of other
vision change
 Burning, red, tender,
thick, scaly, or peeling
skin
 Cough or hoarseness
 Dark urine
 Decrease in amount of
urine (sudden)
 Fever with severe
headache, drowsiness,
confusion, and stiff
neck or back
 Fever with or without
chills or sore throat
 General feeling of
illness
 Hallucinations (seeing,
hearing, or feeling
things that are not
there)
 Hearing loss
 Hives
 Increase in amount of
urine or urinating often
 Light-colored stools
 Loss of appetite
 Low blood pressure
 Mood changes or
unusual behavior
 Muscle cramps or pain
 Nausea, heartburn,
and/or indigestion
(severe and continuing)
 Nosebleeds
 Pain in lower back
and/or side
 Pain, tenderness,
and/or swelling in the
upper abdominal area
 Painful or difficult
urination
 Pale skin
 Puffiness or swelling of
the eyelids or around
the eyes
 Ringing or buzzing in
ears
 Runny nose
 Severe restlessness
 Swollen and/or painful
glands
 Swollen tongue
 Thirst (continuing)
 Unusual tiredness or
weakness
  Yellow eyes or skin

Some side effects may occur that

usually do not need medical
attention. These side effects may
go away during treatment as your
body adjusts to the medicine.
Also, your health care
professional may be able to tell
you about ways to prevent or
reduce some of these side effects.
Check with your health care
professional if any of the
following side effects continue or
are bothersome or if you have
any questions about them:

More common

 Abdominal or stomach
pain (mild or moderate)
 Bruising at place of
injection
 Diarrhea
 Dizziness
 Drowsiness
 Headache
 Indigestion
  Nausea

Less common or rare

 Bloating or gas
 Burning or pain at place
of injection
 Constipation
 Feeling of fullness in
abdominal or stomach
area
 Increased sweating
 Vomiting
Generic Name Brand Name Classification Dosage & Mechanism of Indications
frequency actions
Metoclopramide Metoclopramide Gastro Tablets, syrup, It appears to bind to By inhibiting the action
Hydrochloride intestinal concentration dopamine D2 receptors of prolactin-inhibiting
Intensol®. stimulant where it is a receptor hormone (i.e.,
Reglan® Diabetic antagonist, and is also a dopamine),
Reglan® Syrup gastroparesis mixed 5-HT3 receptor metoclopramide has
antagonist/5-HT4 sometimes been used to
Adults: 10 mg 30 receptor agonist. stimulate lactation.
min before meals Metoclopramide
and bedtime for 2- The anti-emetic action of increases peristalsis of
8 weeks(therapy metoclopramide is due to the jejunum and
should be its antagonist activity at duodenum, increases
reinstituted if D2 receptors in the tone and amplitude of
symptoms recur). chemoreceptor trigger gastric contractions, and
zone (CTZ) in the central relaxes the pyloric
IM, IV nervous system (CNS)— sphincter and duodenal
Prophylaxis of this action prevents bulb. These prokinetic
vomiting due to nausea and vomiting effects make
chemotherapy. triggered by most metoclopramide useful
Initial: 1-2 mg/kg stimuli.[2] At higher in the treatment of
IV q 2 hr for two doses, 5-HT3 antagonist gastric stasis (e.g. after
doses, with the activity may also gastric surgery or
first dose 30 mins contribute to the anti- diabetic gastroparesis),
before emetic effect. as an aid in
chemotherapy. gastrointestinal
The prokinetic activity of radiology by increasing
PROPHYLAXIS of metoclopramide is transit in barium
POSTOPERATIVE mediated by muscarinic studies, and as an aid in
N&V. difficult small intestinal
Adults: 10-20 mg activity, D2 receptor intubation. It is also
IM near the end of antagonist activity and 5- used in
surgery. HT4 receptor agonist gastroesophageal reflux
activity.[3][4] The disease
prokinetic effect itself (GERD/GORD).
may also contribute to
the anti-emetic effect.
 Contraindications
Metoclopramide is
contraindicated in
phaeochromocytoma. It
should be used with
caution in Parkinson's
disease since, as a
dopamine antagonist, it If you experience any of the
may worsen symptoms. following symptoms, call
Long-term use should your doctor immediately:
be avoided in patients
with clinical depression
as it may worsen
mental state. Also
contraindicated with a
suspected bowel
obstruction.
Side Effects Adverse Reactions Nursing Responsibilities
 drowsiness Common adverse drug  Document indications for
 restlessness reactions (ADRs) therapy, onset, location, pain
 fatigue associated with intensity/level, and
 constipation metoclopramide therapy characteristics of the
 diarrhea include: restlessness, symptoms.
drowsiness, dizziness,  Determine any renal or liver
lassitude, and/or dystonic dysfunction; assess hydration.
reactions. Infrequent  Avoid alcohol, ASA, and all
ADRs include: headache, OTC agents without approval.
extrapyramidal effects  Report any unusual
 involuntary (EPSE) such as bruising/bleeding, weight gain,
movements of the oculogyric crisis, swelling of feet and ankle,
limbs or eyes hypertension, increased joint pain, change in
 spasm of the neck, hypotension, urine patterns or lack of
face, and jaw muscles hyperprolactinaemia response
 change in mood leading to galactorrhoea,  Metoclopramide is physically
(depression) diarrhoea, constipation, and/or chemically incompatible
and/or depression. Rare with a number of drugs.
but serious ADRs  Report any persistent side
associated with effects so they can be properly
metoclopramide therapy evaluated and counteracted.
include: agranulocytosis,
 After PO use, absorption of
supraventricular
certain drugs from the GI tract
tachycardia,
may be affected.
hyperaldosteronism,
 Inject slowly IV over 1-2 min to
neuroleptic malignant
prevent transient feelings or
syndrome and/or tardive
anxiety and restlessness.
dyskinesia.
  Assess abdomen for bowel
The risk of EPSEs is sounds and distention; note
increased in young adults any N&V.
(<20 years) and children.  Do not operate car hazardous
Such dystonic reactions machinery until drug effects
are usually treated with realized; drug has a sedative
benztropine or effect.
procyclidine. The risk of
tardive dyskinesia and
EPSE is increased with
high-dose therapy and
prolonged use. Tardive
dyskinesias may be
persistent and
irreversible in some
patients.

Generic Brand Name Classification Dosage & Mechanism of Indications

Name frequency actions

Ranitidine Zantac, Histamine H 2 Duodenal Ulcer Completitively Treatment and maintenance

Zantac 150, antagonist (Active) inhibits the action of therapy of duodenal ulcer;
Zantac 300, Adults histamine (H2) at management of
Zantac 75, receptors sites of the gastroesophageal reflux
Zantac parietal cells, disease (GERD; including
EFFERdose PO 150 mg twice decreasing gastric erosive or ulcerative disease);
daily or 300 mg at acid secretion. short-term treatment of benign
bedtime. gastric ulcer; treatment of
Maintenance dose is pathologic hypersecretory
150 mg at bedtime. conditions (Zollinger-Ellison);
IM/IV/Intermittent IV maintenance therapy for
50 mg every 6 to 8 h. gastric ulcer patients at
reduced dosage after healing
Treatment of of acute ulcers; treatment of
Duodenal and endoscopically diagnosed
Gastric Ulcers erosive esophagitis;
Children 1 mo to maintenance of healing of
16 yr of age erosive esophagitis.

PO 2 to 4 mg/kg
twice daily (max, 300
mg/day).

Maintenance of
Healing of
Duodenal and
Gastric Ulcers
Children 1 mo to
16 yr of age

PO 2 to 4 mg/kg daily
(max, 150 mg/day).

Acute Benign
Gastric Ulcer and
GERD
Adults

PO 150 mg twice
daily.
IM/IV/Intermittent IV
50 mg every 6 to 8 h.

Treatment of
GERD and Erosive
Esophagitis
Children 1 mo to
16 yr of age

PO 5 to 10 mg/kg
daily usually given in
2 divided doses.

Pathologic
Hypersecretory
Conditions
Adults

PO 150 mg twice
daily. Individualize.

Erosive
Esophagitis
Adults

PO 150 mg 4 times
 daily.
IM/IV/Intermittent IV
50 mg every 6 to 8 h.
Continuous IV 6.25
mg/h. For patients
with Zollinger-
Ellison, start infusion
at rate of 1 mg/kg/h
and adjust upward in
0.5 mg/kg/h
increments according
to gastric acid output
(max, 2.5 mg/kg/h;
infusion rate 220
mg/h).

Contraindications Side Effects Adverse Reactions Nursing Responsibilities

Standard  chest pain, fever, feeling Cardiovascular  No known

considerations. short of breath, contraindications
coughing up green or AV block; bradycardia; cardiac  Drug is minimally
yellow mucus; arrhythmias; premature ventricular absorbed.
 easy bruising or beats. Incidence of
bleeding, unusual adverse reaction
weakness; CNS is low.
 fast or slow heart rate;  Tell patient for
 problems with your Agitation; confusion; depression; best results to
vision; dizziness; fatigue; hallucinations; take sucralfate on
  fever, sore throat, and an empty stomach
headache with a severe headache; insomnia; malaise; motor (1 hour before
blistering, peeling, and disturbances; somnolence; vertigo. each meal and at
red skin rash; or bed time)
 nausea, stomach pain, Dermatologic  Pain and ulcer
low fever, loss of symptoms may
appetite, dark urine, Alopecia; erythema multiforme; subside within the
clay-colored stools, rash; vasculitis. first few weeks of
jaundice (yellowing of therapy. However,
the skin or eyes). EENT for complete
healing, be sure
Less serious side effects may Blurred vision. patient continues
include: on prescribed
regimen.
 headache (may be  Monitor for
severe); GI severe, persistent
 drowsiness, dizziness; constipation.
 sleep problems Abdominal discomfort;  Studies suggest
(insomnia); constipation; diarrhea; nausea; that drug is as
 decreased sex drive, pancreatitis; vomiting. effective as
impotence, or difficulty cimetidine in
having an orgasm; or Hematologic healing duodenal
 swollen or tender ulcers.
breasts (in men); Acquired immune hemolytic  Drug has been
 nausea, vomiting, anemia; agranulocytosis; used to treat
stomach pain; or autoimmune hemolytic or aplastic gastric ulcers, but
 diarrhea or constipation. anemia; granulocytopenia; effectiveness of
leukopenia; pancytopenia; this use is still
thrombocytopenia. under
investigation.
  Drugs contains
Hepatic aluminum but isn’t
classified as
Cholestatic or hepatocellular antacid.
effects.  Urge patient to
avoid smoking, as
Musculoskeletal this may increase
gastric acid
Arthralgias; myalgias. secretion and
worsen disease.
Miscellaneous

Anaphylaxis; angioneurotic edema;

hypersensitivity reactions.

Precautions

Pregnancy

Category B .

Lactation

Excreted in breast milk.

Children

Safety and efficacy of ranitidine

have been established in children 1
mo to 16 yr of age for the treatment
of duodenal and gastric ulcers,
GERD and erosive esophagitis, and
the maintenance of healed duodenal
and gastric ulcer. Safety and
efficacy have not been established
for the treatment of pathological
hypersecretory conditions or the
maintenance of healing of erosive
esophagitis in children or in
neonates less than 1 mo of age.

Elderly

May have reduced renal function;

therefore, decreased drug Cl may be
more common.

Hypersensitivity

Rare cases of anaphylaxis have

occurred as well as rare episodes of
hypersensitivity.

Renal Function

Decreased Cl may occur; dosage

reduction may be needed.
Hemodialysis reduces level of
ranitidine-dosage; timing must be
adjusted so that scheduled dose
coincides with end of hemodialysis.

Hepatic Function

Use drug with caution; decreased Cl

may occur.

Hepatocellular injury

May occur, manifested as reversible

hepatitis, hepatocellular or
hepatocanalicular or mixed, with or
without jaundice.

Rapid IV administration

May rarely result in bradycardia,

tachycardia, or premature
ventricular beats, usually in patients
predisposed to cardiac rhythm
disturbances.
 Generic Brand Classification Dosage & Mechanism of Indications
Name Name frequency actions
Ceftazidime Cefzim , third Adults,IM, IV: 1 g q inhibits 1. Lower Respiratory Tract
Fortum generation 8-12 hr. mucopeptide Infections, including pneumonia,
cephalosporin UTIs, uncomplicated. synthesis in the caused by Pseudomonas aeruginosa
antibiotics bacterial cell and other Pseudomonas spp.;
Adults, IM, IV: 0.25 wall, making it Haemophilus influenzae, including
g q 12 hr. defective and ampicillin-resistant strains; Klebsiella
UTIs, complicated. osmotically spp.; Enterobacter spp.; Proteus
Adults, IM, IV: 0.5 g unstable. The mirabilis; Escherichia coli; Serratia spp.;
q 8-12 hr. drug is usually Citrobacter spp.; Streptococcus
Uncomplicated bactericidal. It is pneumoniae; and Staphylococcus
pneumonia, mild skin more effective aureus (methicillin-susceptible strains).
and skin structure against rapidly 2.Skin and Skin-Structure Infections
infections. growing caused by Pseudomonas aeruginosa;
Adults, IM, IV: 0.5-1 organisms Klebsiella spp.; Escherichia coli; Proteus
g q 8 hr. forming cell spp., including Proteus mirabilis and
Bone and joint walls. indole-positive Proteus; Enterobacter spp.;
infections. Serratia spp.; Staphylococcus aureus
Adults, IV: 2 g q 12 (methicillin-susceptible strains); and
Generic Brand Classification Dosage & Mechanism of Indications
Name Name frequency actions
hr. Streptococcus pyogenes (group A beta-
Serious gynecologic hemolytic streptococci).
or intra-abdominal 3. Urinary Tract Infections, both
infections, complicated and uncomplicated, caused by
meningitis, severe or Pseudomonas aeruginosa; Enterobacter
life-threatening spp.; Proteus spp., including Proteus
infections (especially mirabilis and indole-positive Proteus;
in Klebsiella spp.; and Escherichia coli.
immunocompromise 4. Bacterial Septicemia caused by
d clients). Pseudomonas aeruginosa, Klebsiella spp.,
Adults, IV: 2 g q 8 Haemophilus influenzae, Escherichia coli,
hr. Serratia spp., Streptococcus pneumoniae,
Pseudomonal lung and Staphylococcus aureus (methicillin-
infections in cystic susceptible strains).
fibrosis clients with 5. Bone and Joint Infections caused by
normal renal Pseudomonas aeruginosa, Klebsiella spp.,
function. Enterobacter spp., and Staphylococcus
aureus (methicillin-susceptible strains).
6. Gynecologic Infections, including
endometritis, pelvic cellulitis, and other
infections of the female genital tract caused
by Escherichia coli.
7. Intra-abdominal Infections, including
peritonitis caused by Escherichia coli,
Klebsiella spp., and Staphylococcus aureus
(methicillin-susceptible strains) and
polymicrobial infections caused by aerobic
and anaerobic organisms and Bacteroides
 Generic Brand Classification Dosage &
Name Name frequency
Contraindications Adverse Reactions
Hypersensitivity to Cardiovascular: Hypotension,
cephalosporins or related palpitations, syncope
antibiotics. CNS: Headache, vertigo, paresthesia,
confucion anxiety, nervousness,
insomnia, hypertonia, seizures, mild
hemiparesis
GI: Nausea, diarrhea, constipation,
anorexia, thirst, oral candidiasis,
flatulence, gastritis, peptic ulcer, gall
bladder sludge, colitis
GU: Transitory elevations in BUN and/or
serum creatinine; dysuria; vaginal
discharge; reversible nephritis,
Mechanism of Indications
actions
spp. (many strains of Bacteroides fragilis
are resistant).
8. Central Nervous System Infections,
including meningitis, caused by
Haemophilus influenzae and Neisseria
meningitidis. Ceftazidime has also been
used successfully in a limited number of
cases of meningitis due to Pseudomonas
aeruginosa and Streptococcus pneumoniae.
Nursing Responsibilities
 Give capsules with meals to decrease GI
discomfort; suspension must be given on an
empty stomach at least 1 hr before or 2 hr after
meals.
 Refrigerate suspension after reconstitution; shake
vigorously before use & discard after 14 days.
 Discontinue drug if hypersensitivity reaction
occurs
 give patient yogurt or buttermilk in case of
diarrhea
 arrange for treatment of superinfection
 reculture infections if patient fails to respond
 advice patient to take capsule with meals or
Contraindications Adverse Reactions
hematuria, casts in urine
Hematologic: Leukocytosis, leucopenia,
agranulocytosis, hemolytic anemia,
pancytopenia, hypoprothrombinemia,
anemia, hemorrhage
Hepatic: Elevated enzymes;
hepatomegaly; hepatitis
Hypersensitivity: Anaphylaxis; Stevens-
Johnson syndrome; erythema
multiforme; macopapular rash
Local: Pain; tenderness; sterile abcess;
thrombophlebitis following IV/IM
injection
Muculoskeletal: Myalgia, arthralgia
Respiratory: Dyspnea; bronchitis
Miscellaneous: Dysgeusia; glucosuria;
malaise; asthenia
Nursing Responsibilities
food; suspension must be taken on an empy
stomach, at leats 2 hours before or 1 hr after
meals
 encourage the patient to complete the full course,
even if you feel better before the course of
treatment is over.
 Tell patient that this drug is prescribed for this
particular infection; do not use it to self-treat any
other infection.
 Report severe diarrhea with blood, pus or mucus;
rash or hives; difficulty breathing; unusual
tiredness, fatigue unusual bleeding or bruising.
Generic Brand Classification Dosage & frequency Mechanism of actions Indications
Name Name
Cloxacillin Cloxapen  Antibiotic Adults: Inhibits bacterial cell wall emisynthetic
 penicillinase synthesis by binding to one penicillin for
resistant  500-1000 mg or more of the penicillin- treatment of
penicillins every 4-6 hours binding proteins (PBPs) infections due to
 Severe which in turn inhibits the susceptible beta-
infections: 2000 final transpeptidation step of lactamase
mg every 4 peptidoglycan synthesis in producing
hours bacterial cell walls, thus staphylococci and
inhibiting cell wall mixed infections of
Children:
biosynthesis. Bacteria penicillin resistant
 50-100 eventually lyse due to organisms
mg/kg/24 hours ongoing activity of cell wall
in equally autolytic enzymes
divided doses (autolysins and murein
every 4-6 hydrolases) while cell wall
hours. assembly is arrested.
 Severe
infections: 150-
200 mg/kg/24
hours
 Contraindications Adverse Reactions Nursing Responsibilities

Hypersensitivity to 1% to 10%: Gastrointestinal: Nausea, 1. Advice patient to Take the medicine 1 hour before
cloxacillin, any component diarrhea, abdominal pain or 2 hours after meals with water.
of the formulation, or 2. Encourage to finish all medication; do not skip
<1%: Fever, seizure with extremely
penicillins doses.
high doses and/or renal failure, rash
3. Immediately report any signs or symptoms of
(maculopapular to exfoliative),
anaphylactic reactions (eg, chills, fever, wheezing,
vomiting, pseudomembranous colitis,
tightness in chest), excessive GI side effects, or
vaginitis, eosinophilia, leukopenia,
signs or symptoms of opportunistic infection (eg,
neutropenia, thrombocytopenia,
white spots or sores in mouth, vaginal discharge or
agranulocytosis, anemia, hemolytic
sores, fever, fatigue, unhealed sores or wounds).
anemia, prolonged PT, hepatotoxicity,
4. Observe for signs and symptoms of anaphylaxis
transient elevated LFTs, hematuria,
during first dose
interstitial nephritis, increased
5. Monitor CBC with differential, urinalysis, BUN,
BUN/creatinine, serum sickness-like
serum creatinine, and liver enzymes
reactions, hypersensitivity
Generic Name Brand Name Classification Dosage & Mechanism of Indications
frequency actions
Cefazedone  Ancef,  Antibiotic  Adults: I.V.Gra Interferes with eradication of
 Kefzol m(+) infections: bacterial cell-wall gram-negative
 cephalosporins
 Zolicef 1-2g daily, in synthesis, causing bacilli from the
two or three cell to rupture and upper and lower
divided die. respiratory tract,
doses.Gram (-) and treatment of
infections: 3-4g urinary tracts, skin,
daily, two or bone, joint, biliary,
three divided genital infections,
doses. endocarditis,
Moderate to surgical
severe prophylaxis, and
infections: The septicemia.
maximal daily
dosage may be
up to 6g.

 Children aged
over 4 weeks:
I.V.50mg/kg
daily, in two or
three divided
doses.
Contraindications Adverse Reactions Nursing Responsibilities

CNS: headache, lethargy, confusion, • if patient is receiving high doses, monitor

hemiparesis, paresthesia, syncope, seizures for extreme confusion, tonic-clonic
CV: hypotension, palpitations, chest pain, seizures, and mild hemiparesis.
• Monitor CBC, prothrombin time, and
vasodilation
kidney and liver function test results.
EENT: hearing loss • Watch for signs and symptoms of
GI: nausea, vomiting, diarrhea, abdominal superinfection and other serious adverse
cramps, oral candidiasis, reactions.
pseudomembranous colitis • Be aware that cross-sensitivity to
penicillins may occur.
GU: vaginal candidiasis, nephrotoxicity
• Tell patient to report reduced urinary
Hematologic: lymphocytosis, eosinophilia, output, persistent diarrhea, bruising, or
bleeding tendency, hemolytic anemia, bleeding.
hypoprothrombinemia, neutropenia, • Instruct patient to take drug exactly as
thrombocytopenia, agranulocytosis, bone prescribed and to complete full course of
marrow depression therapy even when he feels better.
Hepatic: hepatic failure, hepatomegaly • As appropriate, review all other significant
and life-threatening adverse reactions and
Musculoskeletal: arthralgia interactions, especially those related to the
Respiratory: dyspnea drugs, tests, and behaviors mentioned
above.
Skin: urticaria, maculopapular or
erythematous rash
Other: chills, fever, superinfection,
anaphylaxis, serum sickness
Generic Brand Classification Dosage & Mechanism of actions Indications
Name Name frequency
Cefoxitin Mefoxin  Antibiotic 300 mg IVTT Bactericidal: Inhibits  Lower respiratory infections
 Cephalosporin every 2 hrs synthesis of bacterial cell caused by S. pneumoniae, S.
nd
(2 generation) wall, causing cell death. aureus, streptococci, E. coli,
Klebsiella, H. influenzae,
Bacteroides
 Dermatologic infections caused by
S. aureus, S. epidermids,
streptococci, E. coli, P. mirabilis,
Klebsiella, Bacteroides,
Clostridium, Peptococcus,
Peptostreptococcus
 UTIs caused by E. coli, P.
mirabilis, Klebsiella, M. morganii,
P rettgeri, P. vulgaris, Providencia
 uncomplicated gonorrhea caused
by N. gonorrhoeae
 Intra-abdominal infections caused
by E. colo, Klebsiella, Bacteroides,
Clostridium
 Gynecologic infections caused by
E. coli, N. gonorrhoeae,
bacteroides, Clostridium,
Peptococcus, Peptostretococcus,
group B stretococci
 Septicemia caused by S.
pneumoniae, S. aureus, E. coli,
Klebsiella, Bacteroides
Generic Brand Classification Dosage & Mechanism of actions Indications
Name Name frequency
 Bone & joint infections caused by
S. aureus
 Perioperative prophylaxis
 treatment of oral bacterial
Eikenella corodens.
 Contraindications Adverse Reactions
 Contraindicated with  CNS: headache, dizziness, lethargy,
allergy to cephalosporins paresthiasis
or penicillins  GI: Nausea, vomiting, diarrhea,
 use cautiously with renal anorexia, abdominal pain, flatulence,
failure, lactation, pseudomembranous colitis, liver
pregnancy toxicity,
 GU: nephrotoxicity
 HEMATOLOGIC: bone marrow
depression–decreased WBC, decreased
platelets, decreased Hct
 HYPERSENSITIVITY: ranging from
rash to fever to anaphylaxis, serum
sickness reaction
 LOCAL: pain, abscess at injection site,
phlebitis, inflammation at IV site
 OTHER: superinfections, disulfram-like
reaction with alcohol
Nursing Responsibilities
 Culture infection, and arrange for sensitivity
tests before and during therapy if expected
response is not seen
 reconstitute each gram for IM use with 2 mL
sterile water for injection or with 2 mL of
0.5% lidocaine Hcl solution (w/o
epinephrine) to decrease pain at injection site.
Injection deeply into large muscle group.
 Dry powder and reconstituted solutions
darken slightly at room temperature
 have vitamin K in case hypprothrombinemia
occurs
 discontinue if hypersensitivity reaction occurs
 advice patient to avoid alcohol while taking
this drug and for 3 days after because severe
reactions often occur
 tell patient the he may experience side effects
like stomach upset, & diarrhea
 encourage patient to report if there is severe
diarrhea, difficulty in breathing, unusual
tiredness or fatigue, pain at injection site
 Generic Brand Classification Dosage & Mechanism of actions Indications
Name Name frequency
 Ciloxan  Antibacterial 300 mg IVTT It's action depends upon lower respiratory tract infections
 Cipro  Fluroquinolone every 2 hours blocking bacterial DNA (such as pneumonia and acute
 Cipro replication by binding bronchitis), urinary tract infections,
HC Otic itself to an enzyme called several STDs, skin and soft tissue
 Cipro DNA gyrase, thereby infections, septicemia, legionellosis,
I.V. inhibiting the unwinding and anthrax.
 Cipro of bacterial chromosomal
XR DNA during and after the
 Proquin replication.
Ciprofloxacin
XR
 Contraindications Adverse Reactions Nursing Responsibilities

 avoid taking ciprofloxacin with antacids ess common  Arrange for culture and sensitivity tests
which contain aluminium, magnesium or before beginning therapy
 Blistering of skin
calcium. Sucralfate, which has a high  continue therapy for 2 days after signs and
 sensation of skin burning
aluminium content, also reduces the symptoms of infection are gone
 skin itching, rash, redness,
bioavailability of ciprofloxacin to  be aware that Proquin XR is not
or swelling
approximately 4%. interchangeable with other forms
 Ciprofloxacin should not be taken with Rare  ensure that patients swallow ER tablets
dairy products or calcium-fortified juices  skin rash whole; do not cut, crush, or chew
alone, but may be taken with a meal that  itching  ensure that patient is well hydrated
contains these products.  hives  give antacids at least 2 hrs after dosing
 Heavy exercise is discouraged, as  difficulty breathing or  monitor clinical response; if no improvement
achilles tendon rupture has been reported swallowing is seen or a relapse occurs, repeat culture &
in patients taking ciprofloxacin. Achilles  swelling of the face or sensitivity
tendon rupture due to ciprofloxacin use is throat  encourage patient to complete full course of
typically associated with renal failure. therapy
 Fluoroquinolones are increasingly  drink plenty of fluids while you are taking
contraindicated for patients due to the this drug
growing prevalence of antibiotic  report rah, visual changes, severe GI
resistance to the class of antibiotics in problems, weakness, tremors
that region.
 Ciprofloxacin is also contraindicated in
children (except for serious infections
and anthrax post-exposure), pregnancy,
and in patients with epilepsy.
 Generic Brand Name Classification Dosage & frequency Mechanism Indications
Name of actions
Clindamycin  Cleocin Lincosamide  Oral: 150-300 mg q Reversibly Clindamycin is indicated in the
hydrochloride  Dalacin C Antibiotic 6 hr, up to 300 – binds to 50S treatment of serious infections
450 mg q 6 hr in ribosomal caused by susceptible anaerobic
more sevre subunits bacteria.
infections preventing Clindamycin is also indicated in the
 parenteral: 600 – peptide bond treatment of serious infections due
2,700 mg/day in 2 – formation thus to susceptible strains of
4 equal dosages; up inhibiting streptococci, pneumococci, and
to 4.8 g/day IV or bacterial staphylococci. Its use should be
IM may be used for protein reserved for penicillin-allergic
life-threatening synthesis; patients or other patients for whom,
situations bacteriostatic in the judgment of the physician, a
 Vaginal: one or bactericidal penicillin is inappropriate
applicator (100 mg depending on
clindamycin drug
phosphate) concentration,
intravaginally, infection site,
preferably at hs for and organism
7 consecutive days;
or insert vaginal
suppository,
preferably at hs for
3 days for Cleocin
Vaginal Ovules
topical: apply a thin
film to affected area
 Generic Brand Name Classification Dosage & frequency Mechanism
Name
Contraindications
Hypersensitivity to clindamycin or any
component of the formulation; previous
pseudomembranous colitis; regional
enteritis, ulcerative colitis
Cardiovascular: Hypotension
of actions
bid.
Adverse Reactions
 10%: Gastrointestinal: Diarrhea,
abdominal pain
 1% to 10%:
 Dermatologic: Urticaria, rash, Stevens-
Johnson syndrome
 Gastrointestinal: Pseudomembranous
colitis, nausea, vomiting
 Local: Thrombophlebitis, sterile
abscess at I.M. injection site
 Miscellaneous: Fungal overgrowth,
hypersensitivity
 <1% (Limited to important or life-
threatening): Renal dysfunction (rare),
neutropenia, granulocytopenia,
thrombocytopenia, polyarthritis
Indications
Nursing Responsibilities
 Culture infection before therapy
 administer oral drug with a full glass of
water or food to prevent esophageal
irritation
 do not give IM injections of more than
600 mg; inject deep into large muscle
to avoid serious problems
 do not use for minor bacterial or viral
infections
 monitor renal function tests, & blood
counts with prolonged therapy
 keep solution away from eyes, mouth
and abraded skin or mucous
membranes; alcohol base will cause
stinging. Shake well before use
 keep cool tap water available to bathe
eye, mucous membrane, abraded skin
inadvertently contacted by drug
solution
 report sever or watery diarrhea,
abdominal pain, inflamed mouth or
vagina, skin rash or lesions
NURSING THEORIES
DOROTHEA OREM’S Self-Care Deficit Theory

Orem developed the Self- Care Deficit Theory of Nursing, which is composed of

three interrelated theories: (1) the theory of self-care, (2) the self- care deficit theory, and

(3) the theory of nursing systems. She defined self-care as a human need and nursing as a

human service. She also emphasized nursing’s special concern for a person’s need for

self-care actions on a continuous basis to sustain life and health or to recover from

disease or injury.

Application to patient:

We, as nurses require a continuous and practical action to our patient to enable

them to know and meet therapeutic self-care demands for them to be aware of certain

limitations that could help them develop independence towards their needs necessary for

their living.

Mrs. X has an unhealthy diet since she only eats one full meal a day with pork as

her usual viand. She wakes up at noon, eat her one full meal, and then she goes out to

manage her “mahjongan.” She usually goes home in the wee hours of the morning. She is

at times stressed out with managing her “mahjongan. She is also a smoker. According to

her, she usually consumes one pack of cigarettes a day.

As we had our interaction with the patient, we identified some unhealthy practices

that needs to be corrected. We provided her with guided health teachings and imparted to

her our knowledge and the information that she needs since proper care to one’s self is

therapeutic in maintaining one’s health.

FLORENCE NIGHTINGALE’S Environmental Theory

Nightingale’s focus was the control of the environment of individuals, families,

both healthy and ill. She viewed the manipulation of the physical environment as a major

component of nursing care. She indentified ventilation and warmth, light, noise, variety,

bed and bedding, cleanliness of rooms and walls, and nutrition as major areas of the

environment the nurse should control. When one or more aspects of the environment are

out of balance, the client must use increased energy to counter the environmental stress.

These stresses drain the client of energy needed for healing. These aspects of the physical

environment are also influenced by the social and psychological environment of the

individual.

Application to patient:

As student nurses, we know that surgical asepsis is very important in performing

an operation. Concerning Nightingale’s theory, we can say that something wrong might

have happened in practicing this technique or proper surgical asepsis was not followed

which resulted to the environment being contaminated and contributed to the present

condition of the patient that placed her health at risk.

A situation like this tells us of the importance of keeping everything in our

practice clean and free of organisms that might put our patient’s health and life at risk.

We provided our health teachings, which includes daily wound dressing, keeping

the environment clean and proper sanitation and hygiene.

BETTY NEUMAN’S Systems Model

Betty Neuman’s systems model focuses on the wellness of the client system in

relation to the environmental stressors and reactions to stressors. These stressors include

intrapersonal, interpersonal, and extrapersonal stressors. The nursing interventions

involved in this theory focuses on retaining or maintaining system stability on three

preventive levels: (1) Primary prevention, (2) Secondary prevention, and (3) Tertiary

prevention.

Application to patient:

Mrs. X had acquired an infection after she was operated for the removal of her

brain tumor and then two more operations were performed. She is now under tertiary

prevention since she is now on recovery from the last operation performed to her.

She was provided with health teachings and information to hasten the healing

process. The patient was also encouraged to follow the treatment regimen provided by

her doctor, the health teachings rendered to her, and to have a positive outlook regarding

her condition.
NURSING CARE PLANS
 Date Cues Needs Nsg. Diagnosis Objectives Nsg. Interventions Evaluation

Dec. S: C Acute pain r/t Within our span of 1. Evaluate pain level,
13, 08 - “Kung akong O STSG care, patient will and medicate with GOAL MET
@ 2pm ilihok [right G procedure as be able to: analgesics as ordered.
thigh], dira N evidenced by R: Rewarming Patient was able to:
pa siya I surgical - be pain free or process is extremely
magsakit.” T abrasion in the comfortable. painful. Narcotics and - minimize
- PAIN I right upper NSAIDs should be manipulation of
SCALE: 5 V thigh secondary - utilize comfort given to control pain. affected area and
E to soft tissue measures and 2. Elevate injured utilize relaxation
- defect in scalp. techniques extremity on pillows techniques to
P effectively to as warranted. minimize pain.
E R: Unpleasant reduce or alleviate R: Decreases edema
O: R sensory and pain. which can result in - verbalize a pain
C emotional pressure to tissues and scale of 3 after
- Dressing and E experience pain. nursing
bandages P arising from 3. Instruct patient to interventions were
noted on T actual or avoid smoking. applied.
right thigh. U potential tissue R: Nicotine causes
A damage; vasoconstriction,
L sudden or slow which can worsen
onset of any perfusion and increase
P intensity from pain.
A mild to severe 4. Instruct patient to
T with an minimize movement
T anticipated or if pain is present
E predictable end when manipulating
R and a duration the affected area.
N of less than 6 R: Minimizing
months. manipulation of the
affected area can let
Source: Nurse’s the patient avoid pain.
Pocket Guide, 5. Dressings should
Marilynn E. be dry, intact and free
Doenges, Mary of vectors of diseases.
Frances, R: Broken skin
Moorhouse, integrity can serve as
Alice C. Murr a portal of entry for
disease carrying
bacteria.
6. Elaborate to the
patient the importance
of having a variety of
healthy foods
included in her diet.
R: Proper diet can
help in nourishing the
healing wound.
7. Instruct the patient
to increase oral fluid
intake.
R: Increasing the oral
fluid intake can
promote the healing
of her wound.
8. Teach patient
distraction and
relaxation techniques.
R: Distraction and
relaxation can let the
patient transfer her
attention to things
other than the pain.
9. Instruct the patient
to get at least 8 hours
of sleep everyday.
R: Sleep and rest can
reduce stress and thus
help the patient relax
while her wound is
healing.
Date Cues Needs Nsg. Diagnosis Objectives Nsg. Interventions Evaluation
Dec. S: A Impaired Within our span of 1. Evaluate patient’s
13, 08 - “Kung akong C physical care, the client ability and function GOAL MET
@ 2pm ilihok [right T mobility r/t will be able to and injury.
thigh], dira I immobilization R: Identifies Patient was able to:
pa siya V as evidence by - maintain skin impairments and
magsakit.” I pain in lower integrity with no allows for - achieve and
- “Dili na lang T extremities due complications. identification of maintain an optimal
nako lihokon Y to STSG appropriate level of motor
kaayo.” - operation. - increase muscle interventions. function by
E strength and tone 2. Assess patient for compensating for
O: X and achieve a degree of immobility. the immobilization
E R: Limitation functional level of R: Provides a baseline of her right leg with
- Dressing and R in independent, muscle function. on which to base the use of her other
bandages C purposeful interventions. Patient extremeties.
noted on I physical - demonstrate may only require
right thigh. S movement of exercises minimal assistance or
E the body or of imparted. be completely
one or more dependent on
P extremities. - be involved in caregivers for all
A recovery body needs.
T Source: Nurse’s programs. 3. Observe skin in the
T Pocket Guide, area, where STSG
E Marilynn E. operation was done,
R Doenges, Mary for redness, warmth,
N Frances, or tenderness.
Moorhouse,
Alice C. Murr
. R: May indicate
pressure is being
concentrated in one
area and may
predispose patient to
decubitus formation.
4. Provide kinetic bed
or alternating pressure
mattress for patient.
R: Helps promote
circulation and
reduces venous stasis
and tissue
pressure to prevent
formation of pressure
sores.
5. Maintain good
body alignment and
use pillows/rolls to
support body.
R: Prevents further
complications and
contractures.
6. Perform range of
motion exercises
every 4 hours.
. R: Helps to maintain
mobility and function
of joints.
7. Provide skin care
every 8 hours and prn.
Change wet clothing
and linens prn
R: Helps to promote
circulation and
reduces potential for
skin breakdown.
8. Instruct patient/
family in range of
motion exercises and
mobility aids.
R: Helps patient to
regain some control
and allows family
some involvement in
reconditioning
program.
9. Instruct patient/
family in reasons for
impairment and
realistic goals for
changes in patient’s
lifestyle as warranted.
. R: Promotes
understanding and
compliance with
treatment regimen.
10. Consult physical
and/ or occupational
therapy, as warranted.
R: Assists patient with
identifying methods
to compensate for
impairments and
provides for post-
discharge care.
Date Cues Needs Nsg. Diagnosis Objectives Nsg. Interventions Evaluation
Dec. O: H Risk for Within our span of 1. Monitor vital signs
13, 08 - Stiches and E infection r/t care, patient will and patient for GOAL MET
@ 2pm staples noted A open wound as be able to: presence of fever and
on scalp L evidenced by chills. the patient was able
indicating a T dressing on the - maintain optimal R: Fever, tachycardia, to:
surgical H right upper leg amount of tissue and tachyon may
wound underwent revascularization indicate presence of - be free of exposed
- Dressing and P STSG operation. after rewarming infection. wounds and sources
bandages E 2. Stress proper hand of infections..
noted on right R R: At increased - have minimal washing techniques
thigh C risk for being damaging of between
indicating a E invaded by tissues and tissue therapies/clients.
surgical P pathogenic loss. R: A first-line defense
wound T organisms. against nosocomial
I infections/ cross-
O Source: Nurse’s contamination.
N Pocket Guide, 3. When lower
- Marilynn E. extremity has been
H Doenges, Mary rewarmed, apply a
E Frances, bulky sterile dressing
A Moorhouse, to the area as
L Alice C. Murr needed/indicated.
T R: Dressings help
H protect the area to
reduce further injury.
M 4. If blisters are
A present, avoid
N rupturing them.
A R: Reduces the risk of
G infection.
E 5. Use sterile or strict
M aseptic technique for
E all dressing changes.
N R: Skin grafting
T makes the patient
susceptible to
P infection.
A 6. Administer/
T monitor
T medication regimen
E and note client’s
R response.
N R: to determine
effectiveness of
therapy/ presence of
side effects.
7. Instruct patient/
family regarding signs
and symptoms to
observe for, such as
demarcated area
changes, redness,
change or presence of
drainage, and so forth.
R: May indicate
presence of infection
or that tissue necrosis
is extending.
8. Instruct
patient/family
regarding maintaining
proper nutrition, with
increased protein
intake.
R: Adequate nutrition
is required for
maximum wound
healing.
9. Instruct patient on
all medications and
procedures.
R: Promotes
knowledge and helps
to facilitate
compliance with
medical regimen
DISCHARGE PLAN
MEDICATION
 Instruct the patient and family to follow the home medications as prescribed by
the physician.
Ò Treatment regimen is important to have faster recovery.

 Explain the purpose of each medication.

Ò To provide information to the client as to why she needs to take as prescribed
the medications. And to inform patient that each drug has its own action and
indication.

 Educate the patient and family about the side effects of the medication.
Ò To provide information about the drug’s adverse effects which is normally
experienced, therefore reducing anxious behavior especially when side effects
occur during the whole course of the drug therapy.

 Instruct the family or significant others to remind the patient to follow the
prescribed dosage and frequency and be cautious about those things to be
contraindicated while taking the medication.
Ò This is to prevent occurrence of complications.

 Never administer any drug not prescribed by the physician.

Ò Non-prescribed drugs may have an antagonistic effect or synergistic effect in
any drug therapy.

 Let patient complete the whole course of the drug therapy.

Ò This can help the patient alleviate the problem and be able to experience the
full therapeutic effect of the medication.
EXERCISE
 Instruct client to avoid strenuous activities for at least a week or a month until
fully recovered.

Ò Activities that require great muscle strength should be avoided to prevent injury
and muscle strain.

 Encourage early ambulation.

Ò Walking is good exercise and could promote circulation, hence, proper healing.

 Advise patient to have adequate rest and sleep.

Ò To gain back the lost strength and be able to return to its normal state thus
allow ample time for healing.

 Practice deep breathing exercise.

Ò Periodic deep breathing aerate the lungs and help prevent stasis of lung mucus
(Stasis tends to occur because the lungs are relatively quite during surgery and
mucus forms from irritation if general anesthesia is used). Because stasis always
has the potential for causing infection, it must be prevented as much as possible.

 Turn to sides alternately and frequently when lying down.

Ò To prevent both respiratory and circulatory stasis.

TREATMENT
 Explain the purpose of treatment to be at home.

Ò To make the client and family aware that the treatment does not only end at
hospital but needs to be continued at home to make the client responsible towards
medication.

 Inform the client to avoid taking any medication that is not prescribed by the
physician.

Ò To prevent occurrence of on towards effects.

 Explain to the family the condition of the patient and give them factual
information about the illness.

Ò To have better understanding of the patient’s condition and to be able to know

what intervention they should give that could not alter the effect of the therapy.

 Instruct the family and patient to maintain prescribed medication and compliance
of the treatment regimen.

Ò To have a good recovery.

HYGIENE
 Encourage having proper hygiene like taking a bath, meticulous hand washing,
vaginal care, and brushing of teeth every after meal.

Ò Hygiene promotes comfort and cleanliness to the patient. It also increases the
sense of wellness, which is very much needed in the therapeutic process.

 Encourage patient to continue hygienic measures practiced at present such as

changing clothes everyday and changing of underwear as often as necessary,
keeping the nails neatly trimmed, maintaining own supplies/items for personal
necessities.

Ò Keeping all practiced measures is necessary in consistent maintenance of

proper hygiene. Owning personal accessories for hygiene purposes keep client
away from contamination and infectious diseases.

 Provide a calm, clean, and accepting environment.

Ò Calm, clean and non threatening environment may lessen the occurrence of
possible infection and would be a good place for healing.
OUTPATIENT ORDER
 Inform the patient that follow-up check-up is important to have continuous
monitoring and care even after attainment of the course medical therapy.

Ò Through constant visits as out patient, the physician would still monitor the
progress of the therapeutic intervention availed by the patient.

 Encourage client to carry out and follow up diagnostic treatments.

Ò This is to alleviate the condition of the patient.

 Instruct the family to report for any unusual signs and symptoms experienced by
the patient.

Ò This will help detect early signs and symptoms of reoccurrence of the disease.
DIET
 Encourage client to eat a variety nutritious foods like fruits and vegetables.

Ò To maintain and promote healthy body and as well as regain the strength after
the crisis.

 Instruct client to take vitamins or food supplements as ordered.

Ò To boost the body’s defense mechanism.

 Encourage patient to increase oral fluid intake.

Ò This is to replace all the lost fluids.

 Advise client not to skip meals anymore and, instead, have a regular eating
pattern/schedule.

Ò Regular interval of meals is the basic principle of a good dietary plan.

 Tell patient not to eat foods contraindicated by the physician.

Ò To prevent the occurrence of complications.

Prognosis
 Category Poor (1) Fair (2) Good (3) Justification
Although very curable, her
osteomyelitis is of the chronic
type. Recurring infections
1. Duration of
 might occur again if ever
Illness
inefficiency of health
management occurs again as
well.
The onset of her osteomyelitis
2. Onset of Illness  was after the surgery which
should have made her better.
Her disease was caused by
3. Precipitating
ineffective sterility of the
Factors
 surgical environment.
4. Willingness to She complied with treatment
take the regimen and always kept
medications or herself updated with the
compliance to  treatment process and the
treatment regimen therapies for her illness.
She is already 64 years old and
5. Age this belongs to the range of

high risk.
The ratio of male to female
6. Sex  may be 2:1, but osteomyelitis
is not exclusive to males alone.
It is the mismanagement of her
environment that triggered this
disease. But knowing that, she
7. Environment 
and everyone else involved is
more careful now.

8. Family Support Her family and relatives are

 very supportive. She was
carefully watched by her
 daughters and nephews all the
time.
She expressed that she may not
be able to change her lifestyle
9. Lifestyle 
because she has become used
to it.
2 + 10 + 6 = 18
18 / 9 = 2
2 5 2
Calculations *1 *2 *3 Ranges:
2 10 6 1.0 – 1.5 = Poor
1.5 – 2.5 = Fair
2.5 – 3.0 = Good

General Prognosis:

Overall, Mrs. X has a FAIR prognosis. She had good compliance on the treatment
regimen prescribed by her physician. Although the group does not know what day she
was discharged, she was observed to have stayed in the hospital from the preoperative
phase until her postoperative phase. She was closely monitored to prevent further
complications. Her family was with her, supporting her and watching over her all
throughout the duration of her condition.
RECOMMENDATIONS
 To the Student Nurses:

We have evaluated ourselves and have agreed that we have to heed the

recommendations of our clinical instructors. Patient care is our ultimate goal and

continuous monitoring and application of nursing interventions is compulsory for the

patient’s recovery. In cases like Mrs. X, a patient who has an infection, we must be able

to alleviate our patients from any aggravation of their sicknesses, and this is where

Florence Nightingale’s theory comes into play. Data gathering skills should also be honed

for accurate presentation of cases.

To the Patient and her family:

We have elaborated to Mrs. X about the different things that she can do for her to

help herself recover faster. Religious taking of medicine was promoted as well as good

general and oral hygiene. The group did not need to tell her to keep family members

close, because it is clear that their family is closer than most. Good family support can

boost the morale of the patient, thus improving her over-all health. She was also given the

suggestion to add other viands to her meals other than pork.

To the Ateneo de Davao University – College of Nursing

The group is proud to belong to such a prestigious school. Mrs. X’s family,

especially one of her nephews, praised our group for being very well behaved as

compared to other student nurses belonging to other schools. We recommend that the

Ateneo de Davao University’s College of Nursing keep up, or improve their inculcation

of morals and values to their student nurses.

 To OR staff members everywhere:

With all due respect, we recommend that surgical conscience must be observed at

all times during surgical procedures. Lenient judgment of the breakages in sterility should

be avoided. Our case presentation can be a good example of the risks involved within the

Operating Room.

To the readers:

The group recommends that you, the reader, broaden your knowledge and

continue reading other sources and not base anything on this case presentation alone. A

variety of sources make a good over-all understanding of a subject.