Nca - Pop It Like Myelitis PDF

West Visayas State University
COLLEGE OF NURSING
La Paz, Iloilo City
I. Vital Information
Name: E.D.D.
Date of Interview: July 9, 2015 | 6:00 PM
Age: 26 years old
Informant: E.D.D.
Sex: Male
Relationship to patient: Patient himself
Address: Brgy., Libo-on, Dingle, Iloilo

Civil Status: Single
Date and Time Admitted: June 23, 2015 |12:25 P.M.
Chief Complaint: Gasakit akon wala nga batiis kag wala gaayo.
Ward: OSSW
Bed No.: 19
Allergies: Shrimp Paste
Religious Affiliation: Roman Catholic
Physician: Dr. J.
Impression/Diagnosis: Osteomyelitis Left Thigh
Pre-Op Diagnosis: Chronic Osteomyelitis Left Thigh
Post-Op Diagnosis: Chronic Osteomyelitis Left Thigh
Surgical Operation Performed: Debridement Curettage, Application of Gentamycin
Beads
Days Post-Op: 1 day
Nursing Competency Appraisal DREAM TEAM
- Group 2 Section B CLASS 2016
[Chronic Osteomyelitis Left Thigh]
II. CLINICAL ASSESSMENT

II. A.: NURSING HISTORY
A. History of Present Illness

a. Usual Health Status
E.D.D. is a 28-year old farmer who lives with his father. Before being hospitalized, EDD
claimed that he has been consuming almost all of his time farming. He likes to eat vegetables
and does not like shrimp paste. He does not exercise as he devotes mostof time farming.
E.D.D. is an occasional alcoholic beverage drinker and doesnt smoke. He takes Koi herbal
capsule 500mg OD everyday. He believes in quack doctors and hilots.
B. Chronologic History
E.D.D. is a 26 year old farmer who works every day since he was 16 years old.
10 months PTC, August 2014, while plowing the field bear footed, he noticed an
appearance of a boil characterized by a pus-filled red lump about the size of a pea on the left
lateral side of his left leg. He claimed that he just pinched it and continued on working. The next
day he went to the clinic because the area surrounding the boil became reddened and swollen.
The doctor prescribed him with cloxacillin sodium PO b.i.d. which he complied for a week and
fusidate sodium topical ointment t.i.d. which he claimed to use for 1 month. He claimed that he
continued working while taking the prescribed medications. The boil completely healed after a
month.
7 months PTC, on the first week of November 2014, after E.D.D. cut 5 large bamboos he
felt a throbbing pain, 3-4 inches in diameter, with pain scale of 8/10 starting from the left lateral
side of his thigh radiating to the upper and lower part of his thigh for five minutes. He claimed
that the affected area is warm to touch. He verbalized that he just rested and pain was relieved
with pain scale of 5/10. After 3 days, he experienced fever, with temperature unrecalled. He took
paracetamol 1 tab PO PRN and was relieved after 2 hours. The pain at his thigh with a pain scale
of 8/10 continued to recur lasting for 30 minutes to few hours. He just takes a rest until the pain
subsides. Two weeks after, E.D.D used an electric massager to relieve the pain at his thigh but
he verbalized that it became more swollen making it more painful with a pain scale of 9/10.
6 months PTC, December 2014, the pain became more recurrent. He was experiencing
the pain approximately 3-4 times throughout the day and is often precipitated by hearing loud
noises such as loud talking of a group of people. The pain radiates to his whole body with a pain
scale of 8 out of 10. Swelling of the thigh was noted and walking became difficult for him. They
went to an albularyo and he was given a Lana which he applied on his thigh three times a day.
E.D.D. claimed that there was no prompt relief of pain. After a week, they decided to consult a
doctor. He was prescribed with unrecalled antibitiotic PO b.i.d. for one week and pain medication
PRN. He claimed that he only took the antibiotic for 2 days due to increase in pain felt at his thigh
while taking the antibiotic. The pain scale was 9 out of 10. Instead he continued to use lana
three times a day stating that it somehow relieved the pain with pain scale of 7/10.
He continued to apply lana believing that it will collect the pus in the middle area that
will serve as the channel for the pus to be discharged which will lead to healing. With his
application of lana, the pain was alleviated, pain scale 5/10.
4 months PTC, February 2015, E.D.D. noticed a boil about a size of a 10 peso coin filled
with pus on the lower third aspect of his left thigh. He claimed that it was painful with a pain
scale of 7/10 but he just ignored it believing that this is the result of the application of lana to
the boil and just continued with his daily living. After 2 days, a discharge composed of pus and
minimal blood with no odor was noted. He wiped the discharge with cotton ball and claimed that
it was fully soaked. He then cleaned it and the surrounding area with lana thrice a day. Pain in
his thigh still became recurrent with a pain scale of 6 out of 10.
3 months PTC, March 2015, E.D.D. claimed that 2-3 inches proximal to the first protrusion,
a second boil was noted with a size of a one peso coin. He claimed that it is as painful as the first
one which has a pain scale of 6/10. The boil also breaks out with a discharge of pus and minimal
blood with no odor noted. He also cleaned it with lana three times a day. The pain was quite
relieved with pain scale of 5/10 but the discharges still continued.
4 days PTC, June 19, 2015, he decided to consult a doctor because there are still
discharges on both of the boil and the pain is still recurrent with pain scale of 6/10. The doctor
advised him to have an x-ray at WVSU-MC.
On the day of the confinement, June 23, 2015, the result of the x-ray came out. E.D.D
verbalized, Kailangan ko na kuno mag pa admit kay asta na sa akon tul-an ang impeksyon. The
doctor advised him to undergo an operation on his left thigh. Thus, this admission.
C. Review of Systems
A. General Health Survey
Pertinent Findings:
E.D.Ds patterns of ADLs changed because he had difficulty walking due to the pain he
experienced related to his condition.
B. Skin, hair, and nails
Pertinent findings:
Presence of two boils in the left lateral side of the thigh, approximately 2-3 inches away
from each other; tender to touch, presence of redness around the affected area with
presence of pus. E.D.D claimed to have allergies to shrimp paste (known locally as
ginamos). According to him, when he eats the said shrimp paste, he experiences itching
that begins in his abdomen and radiates throughout his body. E.D.D usually takes cetirizine
10 mg PO od to deal with his discomfort.
C. Head and Neck
Pertinent findings:
No relevant findings pertaining to the head and neck areas.
D. Eyes
Pertinent findings:
E.D.D does not use glasses or contacts and has never experienced problems with his
vision.
E. Ears
Pertinent findings:
E.D.D cleans his ears every 2-3 weeks. He has not experienced any problems with his
hearing and balance.
F. Nose and Sinuses

Pertinent findings:
No history of epistaxis or unusual discharges noted. Sinuses nontender.
G. Mouth and Throat

Pertinent findings:
Dental hygiene is done once everyday through brushing of teeth; absent: both first lower
molars, left upper second molar, right upper first molar; no dentures used.
H. Respiratory System
Pertinent findings:
E.D. D has past history of the common cold; breathing patterns are normal.
I. Cardiovascular System
Pertinent findings:
No history of chest pain, coldness of extremities, or palpitations. Usual blood pressure 110120/70-80 mmHg.
J. Breasts
Pertinent findings:
No lumps, pain, or discharges.
K. Gastrointestinal System
Pertinent findings:
E.D.D defecates once per day; no history of gastric ulcers noted.
L. Genitourinary System
Pertinent findings:
No history of UTI; voids 5-6 times per day as claimed.
M. Neurological System
Pertinent findings:
No history of neurologic alterations as claimed.
N. Musculoskeletal System
Pertinent findings:
Has difficulty performing ADLs since pain started on his left lower extremity; limps when
ambulating but can move on his own without assistance; described pain to be throbbing,
radiating from the lower and upper lateral thigh, pain scale of 6-8 in intensity, exacerbated
by noise and movement as claimed by E.D D ROM of both upper extremities and right lower
extremity 5/5. Left lower extremity 3/5.
II.B.: CLINICAL INSPECTION

Date and Time taken: July 9, 2015 | 7:00PM
II.B.1. Vital Signs:
T = 38.2 C/axilla
PR = 76 beats/min.
BP = 120/70 mmHg
RR = 20 breaths/min.
II.B.2. Height: 5 feet and 4 inches

II.B.3. Weight: 62 kilograms
II.B.4. PHYSICAL ASSESSMENT

General Appearance:
Lying in semifowlers position; awake; calm; wearing navy blue jersey top and black shorts,
no foul smelling odor noted; with bandage covering his left leg from thigh to base of the toes
supported by a pillow underneath; oriented to person, place and time; with an IVF of D5LR x
KVO infusing well, attached to right metacarpal vein.
A. INTEGUMENTARY SYSTEM
Skin: Brown and uniform in color except in areas exposed to the sun; warm to touch; with scar
noted on the anterior side of his left elbow, approximately two inches above.
Hair: black in color; thick; evenly distributed; no infestations, lesions or masses noted.
Nails: Fingernails and toenails are neatly trimmed and clean; with translucent nail plate; pink
fingernail beds; pale toenail beds; no clubbing noted; capillary refill: less than 2 seconds.
B. NEURO-SENSORY SYSTEM
Eyes: eyebrows are black in color and symmetrically aligned; eyelashes are black, evenly
distributed and slightly curled outward, bulbar conjunctivae are transparent, palpebral
conjunctivae are pinkish in color, sclera is white, PERRLA.
Ears: Equal in size; auricles are symmetrically aligned; no tenderness or inflammation noted; no
lesions or discharges noted.
Nose: nasal septum midline; no flaring noted; no tenderness noted; sinuses are non-tender and
non-palpable
Cranial Nerve
CN I: Olfactory
CN II: Optic
CN III: Oculomotor
CN IV: Trochlear
CN VI: Abducens
How Elicited
Normal Response
Actual Response
Ask the client to close

eyes, occlude one
nostril, and identify a
scented object that
you are holding such
as soap, coffee, or
vanilla. Repeat
procedure for the
other nostril.
Patient must be able

to identify the
scented object, with
eyes closed, the
student nurse is
holding with each
nostril occluded one
at a time.
Intact; Patient was

able to identify the
aroma of coffee
diluted in water with
both eyes closed.
Ask client to read a

newspaper or
magazine paragraph
to assess near vision.

to read the words in
the newspaper or
magazine at a
distance of 2 feet.
Intact; Able to
identify and read all
the letters of a
Snellens chart at a 2
feet distance; able to
see objects in
periphery.
Perform corneal light

reflex test. Hold a
penlight approximately
12 inches from the
client's face. Shine the
light towards the
bridge of the nose
while the client stares
straight ahead. Note
the light reflected on
the corneas.

to move eyes with
coordination; Eyes
must constrict as the
light moves closer
and dilates as the
light moves farther.
Intact; PERRLA;
Patient was able to
move eyes in unison
with coordinated
movements

to feel the stimulus
of the cotton wisp as
it touches his face;
Intact; Blink reflex

was present when
examiner lightly
touched lateral sclera
To test direct pupil

reaction, shine a light
obliquely into one eye
and observe the
pupillary reaction.
Test accommodation
of pupils. Hold your
finger or a pencil
about 12 to 15 inches
from the client. Ask
the client to focus on
your finger or pencil
and to remain focus
on it as you move it
closer in toward the
eyes.
Test sensory function.
Tell the client: "I am
going to touch your
forehead, cheeks, and
CN V: Trigeminal
chin with the sharp or

dull sensation. Also tell
me where you feel it."
Vary the sharp and
dull stimulus in facial
areas and compare
sides. Repeat test for
light touch with a wisp
of cotton.
feel the difference

and sensation of
sharp and dull
of the eye with wisp

of cotton. Able to
determine light and
deep sensation.
Identified the area
touched with a wisp
of cotton and the
area touched with
the reflex hammer.
Ask client to smile,

frown and wrinkle
forehead, show teeth,
puff out cheeks, purse
lips, raise eyebrows,
close eyes tightly
against resistance

to smile, frown and
wrinkle forehead,
show teeth, puff out
cheeks, purse lips,
raise eyebrows, and
close eyes tightly
against resistance.
Intact; able to keep

mouth open while
the examiner tries to
close it. Able to
smile, frown, wrinkle
forehead, show
teeth, puff out
cheeks, purse lips,
raise eyebrows, close
eyes tightly and
opens mouth.
Rinne Test: Strike a

tuning fork and place
the base of the fork on
the client's mastoid
process. Ask the client
to tell you when the
sound is no longer
heard. Move the
prongs of the tuning
fork to the front of the
external auditory
canal. Ask the client to
tell you if the sound is
audible after the fork
is moved.
Air conduction should

be longer than bone
conduction (positive
Rinne).
Intact; Bone
conduction time is
longer than the air
conduction time
(negative Rinne).
Test corneal reflex.

Ask the client to look
away and up while you
lightly touch the
cornea with a fine
wisp of cotton. Repeat
on the other side.
CN VII: Facial
CN VIII:
Vestibulocochlear
Patient must hear the

two-syllable word
spoken at a distance
of 2 feet on both
ears.
Patient was able to

hear the spoken
word, "Lapis", on
both ears at a
distance of 2 feet
and was able to hear
the vibrations of the
tuning fork.
Whisper a two-syllable
word at a distance of
2 feet unto the client's
ears and let her repeat
the whispered word.
CN X: Vagus
Test gag reflex by

touching the posterior
pharynx by the tongue
depressor. Warn the
client that you are
going to do this and
Gag reflex must be

present.
Intact; (+) gag

reflex.
that the test may feel

a little uncomfortable
Ask client to shrug
shoulders against
resistance.
CN XI: Accessory
CN XII: Hypoglossal
Ask the client to turn

the head against
resistance first to the
right then to the left.
Ask client to protrude
tongue, move it to
each side against the
resistance of a tongue

to shrug shoulders
and turn head to the
right and left against
resistance.
Intact; able to shrug

shoulders and turn
head from side to
side against
pressure, no pain
noted upon doing so.

to protrude tongue,
move it to each side
against the
resistance of the
tongue
Intact; Able to
protrude tongue at
midline, pain felt
while protruding
tongue and move it
side to side.
C. RESPIRATORY SYSTEM
RR= 20 breaths/minute. Nose: midline, non-tender, nares patent; septum: midline; trachea:
midline; Posterior thorax: Anteroposterior to transverse diameter in ratio of 1:2 , thorax
symmetric , skin intact, warm to touch, uniform temperature, chest wall intact, deep inspiration
and shallow expiration, lung sounds clear and audible upon auscultation; tactile fremitus
present; No adventitious breath sounds noted upon auscultation.
D. CARDIOVASCULAR/CIRCULATORY SYSTEM
BP = 120/70 mmHg; peripheral pulses: temporal=95 bpm; carotid=98 bpm; apical/PMI= 76
bpm; brachial=79 bpm; radial= 76 bpm; ulnar=78 bpm; popliteal=80 bpm; and dorsalis
pedis= 93 bpm; all in +2 intensity; with brisk capillary refill of less than 2 seconds; No bruits
heard upon auscultation.
E. GASTROINTESTINAL/HEPATOBILIARY SYSTEM
Lips: pink, moist; teeth: both first lower molars absent, left upper second molar absent, right
upper first molar absent; no dentures used; gums pale-pink, tongue midline; umbilicus at
midline, inverted; abdomen: rounded, uniform color with the skin, no masses noted upon
palpation; bowel sounds: RLQ= 5 cycles/minute, RUQ= 6 cycles/minute, LUQ= 5
cycles/minute; LLQ= 5 cycles/minute.
F. GENITO-URINARY SYSTEM
Bladder not distended upon palpation; Urine: amber in color, 5-6 times a day.
G. REPRODUCTIVE SYSTEM
E.D.D. refused to be assessed.
H. ENDOCRINE SYSTEM
Thyroid gland: non palpable; no evidence of excessive sweating.
I. Musculoskeletal System
Skull: normocephalic, symmetrical with frontal, parietal, temporal and occipital area, smooth
contour and no masses noted; Lower extremities: left leg covered with 32-inch elastic bandage
from thigh to the base of the toes; Muscles: Equal size in both sides of the body; muscle strength
of 5/5 for right lower extremity, 1/5 for left lower extremity; pain felt when moving left leg with
pain scale of 7 out of 10 with 10 being the highest and 1 the lowest; limited ROM in left lower
extremity; Upper extremities: equal size in both sides of the body; muscle strength of 5/5 for
both left and right upper extremities; full ROM on both left and right upper extremities.
J. LYMPHATIC SYSTEM
Pre-auricular, post-auricular, occipital, submental, submandibular, superficial anterior
cervical, posterior cervical, inferior anterior cervical, supraclavicular nodes: non-palpable; no
pain felt upon palpation.
K. HEMATOPOEITIC SYSTEM
No bleeding tendencies; brisk capillary refill less than two seconds; no hematoma, bruises
noted; Blood type = A; Rh positive.
II.B.5. Psychosocial Nursing Assessment

1. Lifestyle information
E.D.D is a 26- year old farmer who lives with his father. He usually earns 1500 pesos
per week. Their house is made of bamboo and wood. He would usually wake up at 5:30am,
after which, he proceeds in doing household chores such as chopping of wood, fetching water
on their deep well approximately 100 km away from the house and washing dishes. He would
take a bath at around 6:00-6:30 am to prepare himself for work. He eats his breakfast at 5:306:00 am and goes to the farm afterwards.
E.D.D claimed that he likes to eat laswa and does not like shrimp paste. The water
they consume for drinking is from a deep well beside their house and what they use for cleaning
is from another artesian well approx. 100km away. Their electricity is being supplied by ILECO.
He is not active in civic-social affairs in their locality. He is a Roman Catholic but is not
a member of any religious organizations and he seldom attends mass. E.D.D denied use of any
prohibited drugs and claims that doesnt smoke and drinks alcohol occasionally with a maximum
of 1 bottle of 1L of Red horse.
He believe in quack doctors and hilots. He would usually consult quack doctors first
before going to a real doctor for medical purposes.
2. Normal Coping Patterns
E.D.D usually keeps any problem to himself, although he doesnt really have problems
that he attends to as claimed. He maintains a good relationship with his family and in his
neighborhood.
3. Understanding of Present Illness
E.D.D is aware of his illness. He understood that he had to undergo surgery in order to
be cured. He knows that his illness is a serious matter that poses threat to his health, he also
understood that he needed to comply with his therapeutic regimen and to follow the doctors
order for him to get better.
4. Personality Style
E.D.D cooperates during the interview. He is willing to answer questions raised by the
student-nurse. He speaks comprehensively. He further claimed that he is a happy-go-lucky
person. He is approachable and is ready to entertain people. He is willing to share information
about his personal life and is open to suggestions regarding his health and well-being.
5. History of Psychiatric Disorder
E.D.D claimed that his grandmother in the paternal side was diagnosed from Postpartum depression due to the death of her new born.
6. Recent Life Changes or Stressors
E.D.D claimed that his current condition brought changes in his life. He claimed that he
had a difficulty in supporting his family financially. He also verbalized decrease in activities such
as doing heavy work like carrying sacks of rice behind his back. However, although he
understood his condition, he is afraid of what might people think of him and see him as someone
who is worthless and someone who has a disease. He said that he is just staying strong and is
keeping his faith, hoping that everything will be well.
7. Major Issues Raised by Current Illness
E.D.D claimed that financial crisis and his inability to work were the major issues that
arose upon his accumulation of this disease. He expressed worry and concern about finances
to aid his hospitalization, medication and maintenance since he cannot work and support his
family financially. He also expressed becoming a burden to his family because of his current
condition.
8. Mental Status Examination
APPEARANCE
Neat
Clean
Dishevelled
Good eye contact
Poor Grooming
Inappropriate makeup
Erect Posture
others: _______________
Description: E.D.D appears neat and clean during the nurse-patient interaction. He also
maintains good eye contact.
BEHAVIOR
Calm
Appropriate
Restless
Unusual actions
Agitated
Compulsions
others: _______________
Description: E.D.D is cooperative and attentive at the onset of interaction. He talks in a calm
and relaxed manner. He readily answers questions and facial expressions are appropriate.
SPEECH
Appropriate
Pressured
Loose Association
Mute
others: _______________
Loud
Soft
Description: E.D.D speaks in a clear voice with moderate intensity, volume and pace. Speech is
coherent and congruent with thoughts.
MOOD/AFFECT
Appropriate
Labile
Flat
Angry
Hopeless
Depressed
Worried
Anxious
others: _______________
Description: E.D.D has a euthymic mood and has appropriate affect. He has good attitude
towards health care staff and other patients in the ward.
THOUGHTS
Appropriate
Low
Self-Esteem
Delusions
Phobias
Suicidal Ideations
Hallucinations
others: _______________
Description: His thoughts were linear and goal directed all throughout the interaction.
ABILITY TO ABSTRACT
Impaired:
YES
NO
Description: After being asked to interpret the proverb: Aanhin pa ang damo kung patay na
ang kabayo, the patient verbalized, Kung indi ka mag pursige, waay ka man may ma dangtan
eh.
MEMORY
Impaired recent memory:
YES
NO
Impaired past memory:
YES
NO
Number of objects able to remember after 5 minutes: 4/4
Description: E.D.D was able to remember 4 objects presented to him namely a cup, ballpen,
cellphone, and electric fan. E.D.D is still able to recite a nursery rhyme (TWINKLE-TWINKLE
LITTLE STAR) and he still remembers when he was admitted.
ESTIMATED INTELLIGENCE
Below Average
Average
Above Average
Description: E.D.D was able to name five presidents of the country namely Aquino,
Macapagal-Arroyo, Ramos, Marcos and Roxas.
CONCENTRATION
Able to focus
Easily distractible
Able to subtract backwards by 3s from 20 correctly until number 12_.
Description: E.D.D was able to maintain focus while subtracting 3s from 20.
ORIENTATION
Person ___
Time ___
Place ___
Situation ___
Description: E.D.D was oriented to person, time, place and situation. When asked who is
talking to him he can tell the name of the student nurse. He also knew that he is currently
admitted at a hospital and can tell the name of the institution and if what time of the day it is.
JUDGMENT
Realistic decision making:
YES
NO
Description: E.D.D was asked what he would do if he found a wallet, he answered Tanawon ko anay ang sulod kung may ara kwarta kag ID, kun may ara ihatag ko sa Bombo Radio.
INSIGHT
Good
Fair
Poor
Description: E.D.D is aware of having an infection on his left leg and that he had to undergo
surgery, he is also aware of his current diagnosis. He anticipates that he will be facing such
burdens when it comes to the symptoms of his disease. He knows and understands that he needs
appropriate medical intervention.
Adapted from Gorman, L. D. Sultan, & M.L. Raines.(2000). Psychosocial nursing for general
patient care. USA: Lexi-Comp Inc.
II.C. OTHER SOURCES OF DATA
1. Name of Examination: Complete Blood Count (CBC)

Definition:
A complete blood count (CBC) is a blood test to evaluate clients overall health and detect a wide
range of disorders, including anemia, infection and leukemia. Abnormal increases or decreases in
cell counts as revealed in a complete blood count may indicate an underlying medical condition
that calls for further evaluation. Furthermore, the result can provide valuable diagnostic
information regarding the overall health of the patient and the patients response to disease and
treatment.
Hemoglobin is the main intracellular protein of the RBC. Its primary function is to transport oxygen
to the cells and to remove carbon dioxide from them for excretion by the lungs.
Hematocrit or packed RBC volume measures the proportion of RBCs in a volume of whole blood
and is expressed as a percentage.
The erythrocyte (RBC) count, a component of the CBC, is the determination of the number of
RBCs per cubic millimeter.
The purpose of white blood cells is to protect the body from the threat of foreign agents, such as
bacteria.
Segmenters. Mature neutrophils are distinguishable by their segmented appearance, thus they
are often called segs.
Lymphocyte. The immune white blood cells, which include the T lymphocytes, or T cells, and the
B lymphocytes, or B cells, mature in lymphoid tissue and migrate between the blood and lymph.
They play an integral part in the antibody response to antigens.
Eosinophils play an important role in the defense against parasitic infections. They also
phagocytize cell debris, but to a lesser degree than neutrophils, and do so in the later stages of
inflammation. They are also active in allergic reactions.
Monocytes, which live months or even years, are not considered phagocytic cells when they are
in the circulating blood. However, after they are present in the tissues for several hours,
monocytes mature into macrophages, which are phagocytic cells.
Basophils release histamine, bradykinin, and serotonin when activated by injury or infection.
These substances are important to the inflammatory process since they increase capillary
permeability and thus increase the blood flow to the affected area. Basophils are also involved in
producing allergic responses.
MCH (Mean Corpuscular Volume) is the weight of the Hgb in each RBC.
MCV (Mean Corpuscular Hemoglobin Concentration) indicates the volume of the Hgb in each RBC.
MCHC (Mean Corpuscular Hemoglobin) is the proportion of Hgb contained in each RBC.
Platelets are non-nucleated, cytoplasmic, round or oval disks formed by budding off of large,
multinucleated cells (megakaryocytes). Platelets have an essential function in coagulation,
hemostasis, and blood thrombus formation.
Purpose:
Complete Blood Count are performed for several reasons:
Detect hematologic disorder, neoplasm, leukemia, or immunologic abnormality
Determine the presence of hereditary hematologic abnormality
Evaluate known or suspected anemia and related treatment
Monitor blood loss and response to blood replacement
Monitor the effects of physical or emotional stress
Monitor fluid imbalances or treatment for fluid imbalances
Monitor progression of nonhematologic disorders, such as chronic obstructive

pulmonary disease, malabsorption syndromes, cancer, and renal disease
Monitor response to chemotherapy and evaluate undesired reactions to drugs that may
cause blood dyscrasias
Provide screening as part of a general physical examination, especially on admission to

a health care facility or before surgery
Preparation:
A purple-topped tube with ethylenediaminetetraacetic acid (EDTA) anticoagulant is used to collect
7 ml of venous blood. As an alternative a purple-tipped capillary tube can be used to collect blood
from a heel stick, earlobe, or finger puncture.
Date and Time of Examination: 06/24/15; 1:209AM, 07/06/15; 9:22PM, 07/08/15; 6:47AM
06/24/15
1:09AM
Results
07/06/15
9:22PM
07/08/15
6:47AM
Complete Blood Count

Hemoglobin
149 g/L
137 g/L
97 g/L
Examination
Hematocrit
0.44 L/L
Red Blood Cell
5.38 1012/L
White Blood
Cell
11.19 109/L
Differential Count
Neutrophil Number Faction
Segmenters
0.47
Monocyte
0.08
0.40 L/L
0.28 L/L
4.89 1012/L 3.37 1012/L
Normal
Values
135-180
g/L
0.40-0.54
L/L
4.6-6.2
1012/L
15.80
109/L
14.79
109/L
4.5-11
109/L
0.66
0.09
0.73
0.09
0.50-0.70
0.04-0.08
Significance
Decreased due to blood loss of

800mL during surgery (07/07/15)
which resulted to decrease in
hemoglobin, hematocrit and red
blood cell component in the body
thereby reducing the transport of
oxygen carrying capacity of blood.
White blood cells protect the body

from the effects of invasion by
organisms. These cells are immune
system cells, increasing its
production is the natural response
of the body to combat the
causative agent of osteomyelitis.
There are three divisions of

immunity (inflammation, antibodymediated immunity and cellmediated immunity). Inflammation
provides immediate protection
against injury or invading
organisms and it is a nonspecific
body defense to invasion or injury
and it can be started quickly by
almost any event, regardless of
where it occurs and what it causes.
Segmenters also known as mature
neutrophils acts by providing
protection to the body against
invaders by destroying them
through the process of
phagocytosis and enzymatic

digestion.
Monocytes
The gradual increase of segmenters

is the bodys primary response
against infection.
Due to the increase in the number

of infection stimulates the
monocytes to respond by
increasing its production and acts
by engulfing these foreign
materials in the body through the
process called phagocytosis.
(Source:
White Blood Cell Differential
Count. Retrieved from
http://www.brooksidepress.org/)
Eosinophils
Basophil
Blood Indices
0.06
0.01
0.04
0.00
0.01
0.00
0.01-0.04
0.00-0.01
Within Normal Range

Within Normal Range
MCH
27.80 fmol
81.10 fL
28.80
fmol
84.00 fL
34.20 g/L
34.00 g/L
34.30 g/L
26.2036.68 fmol
82.75100.5 fL
31.6533.75 g/L
150-450
109/L
0-10
mm/hr
Within Normal Range
MCV
28.00
fmol
82.30 fL
MCHC
Platelets
369 109/L
ESR
52 mm/hr
Within Normal Range

Increased due to agglutination.
Within Normal Range
Increased due to inflammation and
infection that causes blood to
clamp together.
Source: Kranpitz, T.R., Smith, L., Van Leeuwen, A.M. (2006). Daviss Comprehensive Handbook
of Laboratory and Diagnostic Tests with Nursing Implications 2 nd Ed. p.418
Porth, C.M. (2002) .Pathophysiology: Concepts of Altered Health Status Sixth Ed., p.253-254,
p.271
p.308
2. Name of Examination: C-Reactive Protein

Definition:
C-reactive protein (CRP) is a glycoprotein produced by the liver in response to acute
inflammation. The CRP assay is a nonspecific test that determines the presence (not the cause)
of inflammation; it is often ordered in conjunction with erythrocyte sedimentation rate (ESR).
CRP assay is a more sensitive and rapid indicator of the presence of an inflammatory process
than ESR.
Purpose:
Assist in the differential diagnosis of appendicitis and acute pelvic inflammatory disease
Assist in the differential diagnosis of Crohns disease and ulcerative colitis
Assist in the differential diagnosis of rheumatoid arthritis and uncomplicated systemic lupus
erythematosus (SLE)
Assist in the evaluation of coronary artery disease
Detect the presence or exacerbation of inflammatory processes
Monitor response to therapy for autoimmune disorders such as rheumatoid arthritis
Preparation:
There are no special preparations for either a standard CRP test. However, if blood is being
drawn for other tests, fasting may be required but it is best to follow instructions as ordered by
the physician.
Date and Time of Examination: 06/24/15; 1:39AM
Examination
Results
Normal Values
C- Reactive Protein
> 6 mg/L
<6 mg/L
Significance
Increased.
The cellular mediated immunity
regulates the immune system by the
production and activation of
cytokines. Cytokines control
inflammations. Cytokines include the
interleukins, interferons, colonystimulating factors and tumor
necrosis factor. Interleukin-6 (IL-6)
stimulates the liver to produce
fibrinogen and protein C (C-Reactive
Protein), increases rate of bone
marrow production of stem cells,
and increases numbers of sensitized
B-lymphocytes.
Source: Ignatavicius, D.D., & Workman, M.L. (2010). Medical Surgical Nursing: PatientCentered Collaborative Care 6th Ed. p.317-318
3. Name of Examination: Clotting Time Bleeding Time

Definition:
CTBT is a medical test done on someone to assess their platelet function. It is a blood test that
looks at how fast small blood vessels in the skin close to stop you from bleeding. CTBT is used to
measure the duration of bleeding after a measured skin incision. Bleeding time may be measured
by one of three methods: template, Ivy, or Duke.
Purpose:
- To assess overall hemostatic function.
- To detect congenital and acquired platelet function disorders.
Preparation:
No food or fluid restriction before test. ; Blood is taken; It takes 10-20 minutes to perform the
test.
Date and Time of Examination: 06/24/15; 1:00AM

Examination
Results
Normal Values
Significance
Clotting Time
3 min.
3-5 min
Within Normal Range
Bleeding Time
1 min.
1-3 min
Within Normal Range
4. Name of Examination: Protime or Prothrombin Time (PT)

Definition:
Prothrombin time (PT) is a coagulation test performed to measure the time it takes for a firm
fibrin clot to form after tissue thromboplastin (factor III) and calcium are added to the sample.
It is used to evaluate the extrinsic pathway of the coagulation sequence in patients receiving
oral warfarin or coumarin-type anticoagulants. Prothrombin is a vitamin Kdependent protein
produced by the liver; measurement is reported as time in seconds or percentage of normal
activity.
Purpose:
Differentiate between deficiencies of clotting factors II, V, VII, and X, which prolong the PT;
and congenital coagulation disorders, such as hemophilia A (factor VIII) and hemophilia B
(factor IX), which do not alter the PT
Evaluate the response to anticoagulant therapy with coumarin derivatives and determine
dosage required to achieve therapeutic results
Identify individuals who may be prone to bleeding during surgical, obstetric, dental, or
invasive diagnostic procedures
Identify the possible cause of abnormal bleeding, such as epistaxis, hematoma, gingival
bleeding, hematuria, and menorrhagia
Monitor the effects of conditions such as liver disease, protein deficiency, and fat
malabsorption on hemostasis
Screen for prothrombin deficiency
Screen for vitamin K deficiency
Preparation:
Because many drugs may affect the PT result, all medications taken by the client should be
noted. If the individual is receiving anticoagulant therapy, the time and the amount of the last
dose should be noted. A venipuncture is performed and the sample collected in a light-bluetopped tube. Traumatic venipunctures and excessive agitation of the sample should be avoided.
Date and Time of Examination: 06/24/15; 1:39AM, 07/06/15; 9:33PM
Name of Examination
Results
Normal Values
06/24/15
07/06/15
1:39AM
9:33PM
Significance
Protime
Patient
13.5
13.3 sec
11.5-15.5
% Activity
95.0
100.0
INR
1.00
1.00
Normal Control
100.0
92.0 %
75-101
Within Normal Range
Within Normal Range
5. Name of Examination: GRAM STAIN AFB KOH

Definition:
Gram stain
A gram stain is a type of microbiology or laboratory test that determines whether
bacteria are present. It also determines whether bacteria are gram negative or gram positive.
The difference between gram negative and gram positive bacteria can be important when
determining appropriate treatment for an infection
AFB
Acid-fast bacilli (AFB) testing are collected because the health practitioner suspects that
a person has tuberculosis (TB), a lung infection caused by Mycobacterium tuberculosis that can
be present also in bone or in any part of the body. Mycobacteria are called acid-fast bacilli
because they are a group of rod-shaped bacteria (bacilli) that can be seen under the
microscope following a staining procedure where the bacteria retain the color of the stain after
an acid wash (acid-fast).
KOH
Sputum smear (KOH test) is a test for the presence of fungal microorganisms in sputum.
Purpose:
To assist in the differentiation of gram-positive from gram-negative bacteria in the bone.
To test if a mycobacterial infection is suspected.
The test may be performed when there is abnormal an infection of the bone is suspected.
Date released: 7/05/15
Date received: 7/05/15
Specimen: Bone Currettings

EXAMINATION
GRAM STAIN
RESULT
SIGNIFICANCE
Many pus cells

Occasional gram negative
bacilli and gram positive cocci
singly.
AFB
NEGATIVE for Acid fast bacilli
Normal
KOH
NEGATIVE for Fungus
Normal
6. Name of Examination: Culture and Sensitivity

Definition:
A culture is done to find out what kind of organism (usually bacteria) is causing an illness or
infection.
A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to
treat the illness or infectionA culture is done by collecting a sample of body fluid or tissue and
then adding it to a substance that helps promote the growth of bacteria or other diseasecausing organisms. If there are bacteria (or other organisms) in the sample, they will grow in
the culture. Bacteria usually grow quickly in a culture (2 days), while other types of organisms,
such as a fungus, can take longer.
A culture and sensitivity test may be done on many different body fluids, such as urine, mucus,
blood, pus, saliva, breast milk, spinal fluid, or discharge from the vagina or penis.
Purpose:
To determine if bacteria are resistant to certain drugs
Preparation:
Date released: 6/22/15
Date received: 6/18/15
Final Report
Few colonies of staphylococcus aureus
Specimen type= wound
RESULT
Azithromycin
Susceptible
Chloramphenicol
Susceptible
Ofloxacin
Susceptible
Clindamycin
Susceptible
Gentamicin
Susceptible
Linezolid
Susceptible
Oxacillin
Susceptible
Vancomycin
Susceptible
Quinopristin/Dalfopristin
Susceptible
Cefoxitin
Susceptible
Doxycycline
Susceptible
Trimethroprim/sulfamethoxazole S
Susceptible
Erythromycin
Susceptible
Levofloxacin
Susceptible
Moxifloxacin
Susceptible
Tetracycline
Susceptible
ciprofloxacin
Susceptible
OTHER GROWTH:
R=Resistant
I=Intermediate
S=Susceptible
NS=Non-Susceptible
SDD=Susceptible-dose dependent
7. Blood Typing
Definition:
A single unit of whole blood contains 450mL of blood and 50mL of an anticoagulant. A
unit of whole blood can be processed and dispensed for administration. However, it is more
appropriate, economical, and practical to separate that unit of whole blood into its primary
components: RBCs, platelets, and plasma. Each component must be processed and stored
differently to maximize the longevity of the viable cells and factors within it; each individual blood
component has a different storage life. PRBCs are stored at 4C.
It is important also to accurately determine the blood type. More than 200 antigens have
been identified on the surface of RBC membranes. Of these, the most important for safe
transfusion are the ABO and Rh systems. The ABO system identifies which sugars are present on
the membrane of an individual's RBCs: A, B, both A and B, or neither A nor B (type O). To prevent
a significant reaction, the same type of RBCs should be transfused.
The Rh antigen (also called D) is present on the surface of RBCs in 85% of the population
(Rh positive). Those who lack the D antigen are called Rh-negative. RBCs are routinely tested for
the D antigen as well as ABO. Patients should receive PRBCs with a compatible Rh type.
(Source: Brunner & Suddarth's Textbook of Medical-Surgical Nursing; Page 923)
The Rh antigen is present on
the surface of RBCs in 85% of
the population (Rh positive).
Those who lack the D antigen
are called Rh-negative. RBCs
are routinely tested for the D
antigen as well as ABO. Patients
should receive PRBCs with a
compatible Rh type.
Blood type "A" Rh (+)
(Source: Brunner & Suddarth's

Textbook of Medical-Surgical
Nursing; Page 926)
Blood type
Amount| Serial Number
545| T 5700-004546-1
278| T 500-014518-1
528| 004081-2
Remarks:
Compatible
8. Xray
An X-ray is a quick, painless test that produces images of the structures inside your body
particularly your bones.
X-ray beams pass through your body, and they are absorbed in different amounts depending on
the density of the material they pass through. Dense materials, such as bone and metal, show
up as white on X-rays. The air in your lungs shows up as black. Fat and muscle appear as
shades of gray.
For some types of X-ray tests, a contrast medium such as iodine or barium is introduced
into your body to provide greater detail on the images.
Purpose:
Radiologic assessment of chronic osteomyelitis is performed for the following reasons: (1) to
evaluate bone involvement (eg, the extent of active intramedullary infection or abscess
superimposed on areas of necrosis, sequestrum and fibrosis) and (2) to identify soft tissue
involvement (areas of cellulitis, abscess, and sinus tracts).
Date: 6/23/15
Xray requested: Left Thigh APL
Impression:
-
Negative for fracture and/or dislocation.

Sclerosing osteomyelitis, considered.
III. TEXTBOOK DISCUSSION

Definition
Osteomyelitis
Infection in bony tissue can be a severe and difficult-to-treat problem. Bone infection can result
in chronic recurrence of infection, loss of function and mobility, amputation, and even death.
Chronic Osteomyelitis
Inadequate care management results when the treatment period it too short or when the
treatment is delayed or inappropriate. About half of cases of chronic osteomyelitis are caused
by gram-negative bacteria. Although bacteria are the most common causes of osteomyelitis,
viruses and fungal organisms also may cause infection
Signs and Symptoms
Acute Osteomyelitis
Found in Text Book
Fever > 38C
Swelling
Erythema
Tenderness
Bone pain
Chills
Rapid Pulse
General Malaise
(+)
(+)
(-)
(+)
(+)
(-)
(+)
(+)
Manifested by the Patient

Nov. 2014
Nov. 2014
Nov. 2014
Nov. 2014
Nov. 2014
Nov. 2014
Chronic Osteomyelitis
Found in Text Book
Ulceration of the skin
Sinus tract formation
Localized pain
Drainage from the affected area
Manifested by the Patient

(+) Feb. 2014
(+) Feb. 2014
(+) Dec. 2014
(+) Feb. 2014
Management
Bone scan is done to detect osteomyelitis through injection of bone-seeking radioisotope. Bone
scans are used in conjunction with bone biopsy for a definitive diagnosis.
Erythrocyte sedimentation rate (ESR): the erythrocyte sedimentation rate is highly predictive of
osteomyelitis, and that the value of 70 mm/h is the optimal cutoff to predict accurately the
presence or absence of bone infection.
Magnetic resonance imaging (MRI) with gadolinium is the imaging modality of choice,
particularly for detection of early osteomyelitis and associated soft-tissue disease (A-II).
Erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) level may be helpful to
guide response to therapy (B-III) (1). MRI is useful for determining location and extent of
involvement of the bone infection.
IV antibiotic therapy begins as soon as the culture specimens are obtained, based on the
assumption that infection results from a staphylococcal organism that is sensitive to a penicillin
or cephalosporin. IV antibiotic therapy continues for 3 to 6 weeks. After the infection appears to
be controlled, the antibiotic may be administered orally for up to 3 months.
Prophylactic treatment with the bead pouch technique has been suggested in open fractures to
reduce the risk of infection, with systemic antibiotics supplemented with antibiotic beads
compared to using systemic antibiotics alone. Beads have proved to be more effective than
solid antibiotic-loaded cement plugs in the treatment of osteomyelitis.
Oral quinolones are often used in adults for gram-negative organisms. Quinolones have
excellent oral absorption and may be used as soon as patient is able to take them.
Rifampin has an optimal intercellular concentration and a good sensitivity profile for methicillinresistant staphylococci. It is used in combination with cell wall active antibiotics to achieve
synergistic killing and to avoid rapid emergence of resistant strains.
Surgical management
If the infection is chronic and does not respond to antibiotic therapy, surgical dbridement is
indicated. Because surgical dbridement weakens the bone, internal fixation or external
supportive devices may be needed to stabilize or support the bone to prevent pathologic
fracture.
The Ilizarov method involves the use of a tissue-sparing, cortical osteotomy-osteoclasis
technique that preserves the osteogenic elements in the limb. To create a preliminary callus
that can be lengthened, Ilizarov advocated a delay of several days before initiating distraction.
A high-frequency, small-step distraction rhythm permits regeneration of good-quality bone and
less soft-tissue complications such as nerve and vessel injury. An advantage of using this
procedure is that it minimizes the prevalence of nonunion and thus further bone grafting by
producing good-quality bone formation.
A sequestrectomy (removal of enough involucrum to enable the surgeon to remove the
sequestrum) is performed.
In many cases, sufficient bone is removed to convert a deep cavity into a shallow saucer
(saucerization). All dead, infected bone and cartilage must be removed before permanent
healing can occur.
A closed suction irrigation system may be used to remove debris. Wound irrigation using sterile
physiologic saline solution may be performed for 7 to 8 days. The wound is either closed tightly
to obliterate the dead space or packed and closed later by granulation or possibly by grafting.
Nursing Management
- The affected part may be immobilized with a splint to decrease pain and muscle spasm.
The nurse monitors the neurovascular status of the affected extremity. Elevation reduces
swelling and associated discomfort.
- The joints above and below the affected part should be gently moved through their range of
motion. The nurse encourages full participation in ADLs within the physical limitations to
promote general well-being.
- The nurse monitors the patients response to antibiotic therapy and observes the IV access
site for evidence of phlebitis, infection, or infiltration.
- With long-term, intensive antibiotic therapy, the nurse monitors the patient for signs of
superinfection (eg, loose or foul-smelling stools).
- If surgery is necessary, the nurse takes measures to ensure adequate circulation to the
affected area (wound suction to prevent fluid accumulation, elevation of the area to promote
venous drainage, avoidance of pressure on the grafted area), to maintain needed immobility,
and to ensure the patients adherence to weight-bearing restrictions.
- The nurse changes dressings using aseptic technique to promote healing and to prevent
cross-contamination.
- The nurse continues to monitor the general health and nutrition of the patient. A diet high in
protein promotes a positive nitrogen balance and healing. The nurse encourages adequate
hydration as well.
- Encourage the patient to verbalize his concerns about his disorder.
- Encourage the patient to perform as much self-care as his conditions allows.
- Provide thorough skin care and complete cast care.
- Administer prescribed analgesics for pain.
- Watch for signs of pressure ulcer formation.
- Look for sudden malpositioning of the affected limb, which may indicate fracture.
- Explain all the test and treatment procedures.
PROBLEM LIST
1.
2.
3.
4.
5.
6.
7.
Acute pain related to surgical procedure

Impaired physical mobility related to surgical procedure and musculoskeletal impairment
Constipation related to insufficient physical mobility
Risk for impaired peripheral tissue perfusion
Risk for infection related surgical incision
Risk for impaired skin integrity related to surgical procedure
Ineffective Role Performance related to situational crisis

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West Visayas State University

Date of Interview: July 9, 2015 | 6:00 PM

Age: 26 years old

Relationship to patient: Patient himself

Address: Brgy., Libo-on, Dingle, Iloilo

Nursing Competency Appraisal DREAM TEAM

- Group 2 Section B CLASS 2016

[Chronic Osteomyelitis Left Thigh]

II. CLINICAL ASSESSMENT

A. History of Present Illness

Nursing Competency Appraisal DREAM TEAM

- Group 2 Section B CLASS 2016

[Chronic Osteomyelitis Left Thigh]

Nursing Competency Appraisal DREAM TEAM

- Group 2 Section B CLASS 2016

[Chronic Osteomyelitis Left Thigh]

F. Nose and Sinuses

G. Mouth and Throat

Nursing Competency Appraisal DREAM TEAM

- Group 2 Section B CLASS 2016

[Chronic Osteomyelitis Left Thigh]

Nursing Competency Appraisal DREAM TEAM

- Group 2 Section B CLASS 2016

[Chronic Osteomyelitis Left Thigh]

II.B.: CLINICAL INSPECTION

II.B.2. Height: 5 feet and 4 inches

II.B.4. PHYSICAL ASSESSMENT

Nursing Competency Appraisal DREAM TEAM

- Group 2 Section B CLASS 2016

[Chronic Osteomyelitis Left Thigh]

Ask the client to close

Patient must be able

Intact; Patient was

Ask client to read a

Patient must be able

Perform corneal light

Patient must be able

Patient must be able

Intact; Blink reflex

To test direct pupil

Nursing Competency Appraisal DREAM TEAM

- Group 2 Section B CLASS 2016

[Chronic Osteomyelitis Left Thigh]

chin with the sharp or

feel the difference

of the eye with wisp

Ask client to smile,

Patient must be able

Intact; able to keep

Rinne Test: Strike a

Air conduction should

Test corneal reflex.

Patient must hear the

Patient was able to

Test gag reflex by

Nursing Competency Appraisal DREAM TEAM

Gag reflex must be

- Group 2 Section B CLASS 2016

Intact; (+) gag

[Chronic Osteomyelitis Left Thigh]

that the test may feel

Ask the client to turn