INTRODUCTION

A. BACKGROUND AND RATIONALE OF THE STUDY

Since the discovery and usage of antituberculous drugs, tuberculosis has now
become rare in industrialized countries where their public health measures have
improved. However, in developing countries, tuberculosis is still a significant cause of
disease (www.emedicine.com).
Skeletal tuberculosis makes up about 10-15% of extra-pulmonary tuberculosis
and 2% of all tuberculosis cases (www.worldortho.com). It has 3 types: the TB
spondylitis (or Pott’s disease), TB osteomyelitis, and TB arthritis. Among the three,
tuberculous arthritis is perceived as the most dangerous because disease progression
is so slow that it can be easily missed in the earlt stages (www.worldortho.com). Thus,
by the time proper treatment will be given, complications may already have begun.
Immobility of the patient is always present in the tuberculous arthritis. In its
symptoms, there is joint swelling with warm, tender joints, thus resulting to decreased
joint mobility (www.nlm.nih.gov). Likewise, in its management, immobilization is one of
the key interventions on order to lessen the trauma and injury the patient is going
through and may be at risk for (www.worldortho.com).
The Orem self-care model of nursing id based upon the philosophy that “all
patients wish to care for themselves”. However, when the individual s unable to meet
his/her self care requisites. a deficit in self-care arises. Self-care deficit, then, can be
seen in the patient with tuberculous arthritis due to the immobility that he/she
undergoes.

B. OBJECTIVES OF THE STUDY

This study aims to determine how the Orem self-care model of nursing can be
applied to and be most useful to a patient with tuberculous arthtritis.

C. SIGNIFICANCE OF THE STUDY

This study, upon completion, would give support to the validity of the Orem self-
care model of nursing. It would also generate ideas on how to render self-care to
patients who are immobilized, particularly those who are affected with tuberculous
arthritis.

D. METHODOLOGY

1. STUDY ENVIRONMENT

This study was conducted at the Ward 8 (Orthopedic Ward) of Vicente

Sotto Memorial Medical Center.

2. DESIGN OF THE STUDY

This study utilizes the case study type of qualitative research design,

3. INSTRUMENT

Observation and interview were used as instruments in conducting this

study.

4. PROCEDURE OF THE STUDY

The patient was assigned to the student nurse’s patient load during the
period of duty in Ward 8 of VSMMC. During the course of care, the student nurse
observed and assessed the patient’s physical and psychological condition and
conducted interviews with the patient and some of her family members. SOAPIEs,
nursing care plans, and drug studies were created centering around the individualized
care for the patient.
 SITUATIONAL APPRAISAL

A. PATIENT’S PROFILE

A case of M.P., 21 years old, female, single, a Roman Catholic, a college student,
and a resident of Babag I Lapulapu City, Ceby, admitted for the first time at Vicente
Sotto Memorial Medical Center in April 10, 2008, with the chief complaint of abscess at
the inner left thigh.

B. HISTORY

On November 2006, one of the patient’s teachers commented that she was
losing weight. Pain in her lower back started to be felt on December of that year.
On January 2007, the patient started to take pain relievers as the pain intensified.
The patient sought consultations in various clinics from March to April, but to no
avail. Her weight steadily decreased, from more then 50 kg to 47 kg.
In May of that year, the patient slipped and the pain she felt increased. That
August, she decided to stop schooling because she could not anymore handle the
pain to go to school. In September, she noticed that her right knee bowed, and so on
the next month she sought consultation at Chong Hua Hospital where she stayed for
8 days and was diagnosed with hernia. An operation was proposed but, since the
patient and her family could not afford the operation, they decided to go home.
On January 2008, the patient again sought consultation at Chong Hua Hospital
where she was confined for 15 days. A lower abdomen/pelvic CT scan was ordered
where extensive bone damage was seen and tuberculous arthirtis was diagnosed. The
patient was thereby released and went back to Chong Hua Hospital on intervals from
February to March for draining of the abscess. On April, she was referred by Dr. Akol to
VSMMC for admission and thus was admitted.

C. ASSESSMENT FINDINGS

Admission Interview

1. Patient’s perception of reason for admission:

- patient perceives admission as due to TB of the bone and its symptoms
and complications
2. Patient’s symptoms as he/she sees them:
- body malaise, local pain. fever, weight loss, abscess at inner left thigh
3. Problems in daily living created by symptoms (as patient views them):
- patient cannot perform household chores and she has stopped schooling
due to the symptoms

4. Past medical history:

a. Medical: patient was hospitalized when she was 10 years old due to
fever
b. Surgical: none
c. Allergies: none
d. Medication: patient has taken pain relievers about 1 year ago due to low
back pain
e. Traumatic Injuries: patient had slipped more than 1 year ago
f. Orthopedic: none
g. Other (psychiatric, etc.): none

5. Habits:
a. Smoking: none Alcohol: none Drugs: none
b. Eating: meat. fish, eggs, rice, canned goods, noodles; fruits and
vegetables occasionally
c. Social Activity: going out with friends
Physical exercise: household chores
d. Rest/Sleeping: patient sleeps at around 10 pm and wakes up at around
6am-7am. patient often does not take a nap in the afternoon
e. sexual: patient has not had sex
f. elimination: patient defecates approximately twice a week, urinates 3
times a day

6. Social Economic History:

a. Native Language: Cebuano
b. Education: 3rd year college
c. Occupation: student (previously)
d. Financial Status (what is the impact of the current hospitalization):
patient’s parents borrow money from relatives since their own finances are
not enough to support patient’s treatment
e. Civil Status: single
f. Living Situation: Living with family (father. mother. siblings)

7. Family History:
diabetes and heart disease in both paternal and maternal sides

8. Primary physician’s admitting diagnosis: TB Arthritis with Psoas Abscess

 Nursing Review of Systems

1. EENT: no symptoms
2. CARDIO-RESPIRATORY: no symptoms
3. GATRO-INTESTINAL: no symptoms
4. GENITO-URINARY: no symptoms
a. Female Genital Tract – Menstrual History:
Age of Onset: 11 years old
Frequency: monthly
Regularity: regular
Duration: 3-4 days
Date Last Period: May 2008 (as of August 2008)

5. MUSCULOSKELETAL: muscle pain, joint pain, deformity, limited motion

6. NERVOUS: none
7. ENDOCRINE: none
8. EMOTIONAL: depression (patient is somehow disappointed in the turn of
events, in how her illness affecting her life and future)

Nursing Observations

1. HEENT
A. Symmetry: head is normocephalic and symmetrical in both sides
B. Eyes and Pupils: eyebrows are evenly distributed in both sides, pupils
constrict when light is shone on them, eyelashes are curled outward
C. Ears: no pain upon palpation is noted, dry cerumen observed
D. Mouth and Throat: lips are pinkish and slightly dry, teeth are yellowish
in color, tongue and uvula are in midline
E. Lymph nodes: not palpable

2. RESPIRATORY
A. Depth and Rate: respiration is at 21 cpm, normal depth
B. Breath Sounds: no adventitous breath sounds noted
C. Chest expansion: regular chest expansion on both sides

3. CARDIOVASCULAR
A. Blood Pressure:
Right: 110/60 Left: 110/60
B. Apical Pulse Rate and Regularity: 125 bpm, regular
C. Pedal Pulses Rate per minute:
Right: 120 bpm Left: 121 bpm
D. Neck Vein Distention: present
4. CHEST
A. Anterior Chest: no lesions present, equal expansion upon respiration
B. Posterior Chest: no lesions present, equal expansion upon respiration
C. Breasts
Breast and Axillae: no pain noted upon palpation, no lumps
palpated

5. GASTROINTESTINAL
A. Bowel sounds: 8 bowel sounds per minute
B. Tenderness or rigidity: none present

6. URINARY
A. Bladder: not palpated

7. SKELETAL
A. Joints/Range of Motion: no limited motion in the upper extremities,
limited painful motion the lower extremities

8. NEURO
A. Motor Function
1. Facial: patient is able to move facial muscles at will and without
difficulty
2. Extremities: patient is able to move upper extremities without
difficulty, lower extremities with difficulty and pain
B. Sensory Function: equal
C. Equilibrium
1. Balance: patient is not able to stand up, balance was not tested
2. Finger to nose: patient is able to perform the finger to nose test
properly
D. Reflexes
1. Knees: not equal Arms: equal

9. CRANIAL NREVE FUNCTION

A. Olfactory Nerve
Anosmia: not present
Hyperosmia: not present
B. Optic Nerve
Myopia: not present
Hyperopia: not present
C. Oculomotor Nerve
Right Eye: pupil is able to react to light and accomodation
Left Eye: pupil is able to react to light and accomodation
D. Trochlear Nerve
Eyeballs are able to follow upward and downward movement of
finger shown to patient
 E. Trigeminal Nerve
1. Right Eye: corneal reflexes present
Left Eye: corneal reflexes present
2. Patient is able to clench teeth
F. Abducens Nerve
Right Eye: eyeball is able to follow side to side movement of finger
shown to patient
Left Eye: eyeball is able to follow side to side movement of finger
shown to patient
G. Facial Nerve
1. Patient is able to taste salty foods
Patient is able to taste sweet foods
2. Patient is able to smile
Patient is able to frown
Patient is able to puff out cheeks
Patient was able to raise and lower eyebrows
H. Auditory Nerve
Patient is able to hear at right ear
Patient is able to hear at left ear
I. Glossopharyngeal Nerve
1. Patient is able to taste sour foods
Patient is able to taste sweet foods
2. Patient exhibits gag reflex when tongue blade touches the
posterior part of tongue
J. Vagus Nerve
1. No hoarseness of voice present
2. Palate and pharynx moves when patient speaks
K. Spinal Accessory Nerve
Patient is able to move head upward, downward, and side to side
Patient is able to rotate shoulder
L. Hypoglossal Nerve
Patient is able to stick tongue to midline

10. EMOTIONAL
A. Communication: Patient is able to communicate her thoughts and
feelings
B. Mood/Affect: Patient is sometimes irritable; proper affect is exhibited
C. Behavior: Patient does not exhibit any abnormal behavior

Knowledge of Illness

1. Learning Limitations: Patient is knowledgeable about her disease and

its medical and surgical management
2. Learning Needs: Patient wonders about the risk factors and hiw she
may have contacted the disease
 D. ANATOMY AND PHYSIOLOGY

The pelvic girdle consists of the coxae and is the place where the
lower limbs attach to the body. The pelvis is a ring of bones formed by the
sacrum, coccyx, and two coxae. The sacrum and coccyx form part of the
pelvis but are also part of the axial skeleton. Each coxa is formed by three
bones fused to one another to form a single bone. The ilium is the most
superior, the ischium is inferior and posterior, and the pubis is inferior and
anterior. An iliac crest can be seen along the superior margin of each
ilium, and an anterior superior iliac spine, an important hip landmark, is
located at the anterior end of the iliac crest. The coxae join each other
anteriorly at the pubic symphysis and join the sacrum posteriorly at the
sacroiliac joints. The acetabulum is the socket of the hip joint. The
obturator foramen is the large hole in each coxa that is closed off by
muscles and other structures.
The male pelvis can be distinguished from the female pelvis
because it is usually larger and more massive, but the female pelvis tends
to be broader. Both the inlet and the outlet of the female pelvis are larger
than those of the male pelvis, and the subpubic angle is greater in the
female. The increased size of these openings helps accommodate the
fetus during childbirth. The pelvic inlet is formed by the pelvic brim and the
sacral promontory. The pelvic outlet is bounded by the ischial spines, the
pubic symphysis, and the coccyx.

E. PATHOPHYSIOLOGY

Risk Factors: HIV infection, alcoholism poverty/homelessness, certain

immigrant populations, gross immunosuppresion from arthritis therapy,
children and adolescents especially below 10 years old

Hematogenous spread of tuberculous bacilli

Bone and joint react to infection by forming granulomas

Joint synovium becomes inflamed

Formation of a pannus of granulation tissue which erodes into cartilage and bone

Fever, chills/rigors, anorexia, weight loss, local swelling, gradual narrowing

of joint space, subchondral osteoporosis, peripherally-located osseous
erosions
 SUMMARY OF MEDICAL AND SURGICAL MANAGEMENT

A. DIAGNOSTIC STUDIES

May 22, 2008

 Magnetic Resonance Imaging
MRI examination of the inguinal region was performed with axial T1, T2W, and STRI
as well as T2 coronal sequences. Post contrast T1 axial, sagittal and coronal images
were also obtained.
There is a large multilobulated mass lesion involving the left hip measuring about
10.4 x 13.5 x 20.3 cm (greatest Ap x Tx CC dimensions).
The superior margins of the lesion are seen just below the pelvic rim and extend
inferior to the proximal left thigh the epicenter at the level of the femoral head.
In fact, lytic erosion of the superior and inferior ramus of the pelvic bone, ischium
including the acetabulum, left femoral head and neck as well as the inferior aspect of
the left iliac one.
The lesion exrtends intraabdominal. Infiltrating the left iliacus muscles as well as the
left piriformis and obturator muscles.
The lesion likewise is seen extending to the left presacral and left pararectal space.
Both the internal and external iliac are subsequently compressed and partially
encased although remain patent.
Posteriorly infiltration of the left gemellus as well as the left gluteus medius and
minimus is noted.
The sciatic nerve appears completely encased and edematous.
As the mass extends inferiorly, infiltration of the adductor muscles as well as the
vastus intermedius, vastus lateralis, sartorius, rectus femoris, and left tensor fasciae
lata at the proximal femoral level.
The mass per se is characterized by highly heterogenous signals with prominent
components of necrosis.
The urinary bladder is only partially distended without evidence of mucosal or
intraluminal abnormalities.
The visualized rectosigmoid and uterus are unremarkable.
May 28, 2008
 Bacteriology
 Specimen: discharges of left hip
 Examination done: catase
 Culture results: no growth after 72 hours of incubation

May 29, 2008

 Gram Stain Result
*No microorganisms seen
*No acid fast bacilli seen
June 11, 2008
 Surgical Pathology Report
*Source of specimen: soft tissue, left hip (acetabulum)
*Diagnosis: Chronic Osteomyelitis
*Gross Description:
The specimen labeled as “soft tissue, left hip” consists of dark tan soft
tissue with white surface on one side, measuring 4 x 2.5 x 1.5 cm. On section,
cut surface is light to dark tan, firm and smooth. Representative sections are
processed.
 Urinalysis
*color: light yellow
*transparency: slightly cloudy
*reaction: 6.5
*specific gravity: 1.95
*sugar: negative
*protein: negative
*RBC: 2-6/hpf
*pus cells: 0-3/hpf
*urates: few
*squamous epithelial cells: few
*bacteria: few

COMPONENT RESULT REFERENCE UNIT INTERPRETATION

4/10/2008
Creatine 0.6 0.50-0.90 mg/dl normal
4/23/2008
sodium 134.9 135-148 mmol/ L slightly decreased
potassium 3.08 3.5-5.3 mmol/ L decreased
chloride 107.6 98-107 mmol/ L slightly increased
4/24/2008
prothrombin time 12.06 10.4-12.6 secs normal
Creatine 0.58 0.60-1.10 mg/dl slightly decreased
BUN 3.23 4.70-23.40 mg/dl decreased
Albumin 3.51 3.50-5.00 g/dl normal
5/14/2008
total protein 8.53 6.0-8.3 g/dl elevated
5/19/2008
Albumin 3.29 3.50-5.00 g/dl slightly decreased
5/26/2008
c-reactive protein negative <6 mg/l normal
 MECHANISM OF
NAME OF DRUG CLASSIFICATION ACTION INDICATIONS CONTRAINDICATIONS SIDE EFFECTS NURSING RESPONSIBILITIES
inhibit bacterial synthesis
Generic Name anti-infectives by *urinary tract and *hypersensitivity CNS: seizures, dizziness, Before:
*pregnancy or children drowsiness, headache,
Ciprofloxacin inhibiting DNA gyrase gynecologic infections below insomnia, >Assess patient for infection prior to
*gonorrhea 18 years old acute psychoses, agitation, and during therapy
Trade Name *prostatitis confusions. hallucinations, >Obtain specimens for culture and
increased ICP, light-
Cipro *respiratory tract headedness, sensitivity before initiating therapy.
infections tremors First dose may be given before
Maximum Dose *skin and skin structure GI: pseudomembranous colitis, receving results
abdominal pain, diarrhea,
750 mg infections nausea, During:
*bone and joint
infections altered taste >if gastric irritation occurs, medication
may be administered with meals.
Minimum Dose *infectious diarrhea GU: interstitial cystitis, vaginitis Food
*intra-abdominal
250 mg infections Derm: photosensitivity, rash slows and may slightly decrease
*febrila neutropenia Endo: hyperglycemia, absorption
>Milk and yogurt decrease
Patient's Dose *post-exposure hypoglycemia absorption.
500 1 tab OD PO treatment of inhalational Local: phlebitis at IV site Do not administer concurrently
anthrax MS: tendinitis, tendon rupture >Extended-release tablets should be
Misc: hypersensitivity
Content reactions, swallowed whole; do not crush, break
fluoroquinolones including anaphylaxis, Stevens- or chew
Johnson syndrome, After:
Availability lymphadenopathy >Instruct patient to take medication as
directed at evenly spaced times and
tablets, extended to
release tablets,
oral finish drug completely even if feeling
suspension,
injection better
>Encourage patient to maintain a fluid
intake of at least 1500-200 ml/day to
prevent crystalluria
>Advise patients that antacids or
medications containing iron or zinc
will
decrease absorption and should not
be
taken within 6 hours before taking this
medication
>May cause drowsiness.Caution
patient
to avoid activities requiring alertness
until response to drug is known
NAME OF DRUG CLASSIFICATION MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS SIDE EFFECTS NURSING RESPONSIBILITIES
>bind to mu-opioid *moderately to severe
Generic Name analgesic receptors pain *hypersensitivity CNS: seizures, dizziness, Before:
Tramadol Hcl >inhibits reuptake of *pregnancy & lactation somnolence, anxiety, CNS >Assess type, location, & intensity of
serotonin and
norepinephrine *patients who are acutely stimulation, confusion, pain before and 2-3 hous after
Trade Name in the CNS intoxicated with alcohol, coordination disturbance, administration
euphoria, malaise,
Ultram sedative/hypnotics, nervousness, >Assess blood pressure and respiratory
centrally-acting analgesics, sleep disorder, weakness role before and periodically during
Maximum Dose opioid analgesics GI: constipation, diarrhea, administration
abdominal pain, anorexia,
50 mg nausea >Assess previous analgesic history
dry mouth, flatulence, vomiting During:
>Ensure that the right drug is given at
Minimum Dose GU: menopausal symptoms, the
50 mg urinary retention/frequency right dose to the right person through
Derm: pruritus, sweating the right route at the right time
>Explain therapeutic value of
Patient's Dose Neuro: hypertonia medication
50 mg IVTT q 6 Misc: physical dependence, before administration to enhance
psychological dependence, analgesic efffect
Content tolerance After:
analgesics >Instruct patient on how and when to
ask for pain medication
Availability >Advise patient to change position
tablets slowly to minimize orthostatic
hypotension
>Caution patient to avoid concurrent
use of alcohol and other CNS
depressants with this medication
>Encourage patient to turn, cough, and
breathe deeply every 2 hours to
prevent atelectasis
>Monitor for side effects of
medication
>May cause drowsiness.Caution patient
 to avoid activities requiring alertness
until response to drug is known
B. PHARMACOLOGIC THERAPY
 D. SURGICAL PROCEDURE PERFORMED

 Incision and Drainage

Incision and drainage are minor surgical procedures to release pus or pressure
built up under the skin, such as from an abscess or boil. It is performed by treating the
area with an antiseptic, such as iodine based solution, and then making a small incision
to puncture the skin using a sterile instrument such as a sharp needle, a pointed scalpel
or a lancet. This allows the pus fluid to escape by draining out through the incision.

 Debridement

Debridement is a medical term referring to the removal of dead, damaged, or

infected tissue to improve the healing potential of the remaining healthy tissue. Removal
may be surgical, mechanical, chemical, autolytic (self-digestion), and by maggot
therapy, where certain species of live maggots selectively eat only necrotic tissue.

In oral hygiene and dentistry, debridement refers to the removal of plaque and
calculus that have accumulated on the teeth. Debridement in this case may be
performed using ultrasonic instruments, which fracture the calculus, thereby facilitating
its removal, as well as hand tools, including periodontal scaler and curettes, or through
the use of chemicals such as hydrogen peroxide.

Debridement is an important part of the healing process for burns and other
serious wounds.
 PROBLEM ANALYSIS

 Acute Pain related to stimulation of nerve endings secondary to disease process

 Impaired Tissue Integrity related to tissue trauma secondary to disease process

and surgical procedures

 Activity Intolerance related to immobility secondary to disease process

 Impaired Mobility related to activity intolerance secondary to immobility

 Self-Care Deficit related to activity intolerance secondary to general weakness

 DECISION ANALYSIS

A. NURSING CARE PLANS

I.
Defining Characteristics
Nursing Diagnosis: Acute Pain related to stimulation of nerve endings secondary to
disease process
Subjective Cues: “Sakit ilihuk akung tiil”
Objective Cues:
*received patient lying on bed, awake, conscious, and coherent
with dressing at inner left thigh, clean and intact
*grimaced face noted
*guarded movements observed
*limited movement noted
*with pain score of 6
*slight irritability noted

Expected Outcome Criteria

Short Term: After 8 hours of nursing intervention, patient will verbalize understanding of
techniques that could be employed in alleviating pain
Long Term: After 3 days of nursing interventions, patient will be able to verbalize
alleviation of pain, from a pain score of 6/10 to 3/10 or less\

Intervention And Rationale

 Assess the pain characteristics of the patient
Rationale: The pain characteristics of the patient can help in determining the
dosage of pain reliever to be used
 Observe/monitor other associated signs and symptoms such as BP, heart rate,
temperature, color and moisture of skin, restlessness, and ability to focus
Rationale: These signs and symptoms can help in determining the extent of pain
and how it affects patient’s vital signs
 Anticipate need for analgesics or additional methods of pain relief
Rationale: One can most effectively deal with pain by preventing it. Early
interventions may decrease the total amount of analgesics required
 Respond immediately to complaint of pain
Rationale: Prompt responses to complaints may result in decreased anxiety in
patient. Demonstrated concern for patient’s welfare and comfort fosters the
development of a trusting relationship
 Instruct patient in nonpharmacological ways in dealing with pain, such as deep
breathing and guided imagery.
 Rationale: promotes pain relief without being dependent on drugs
 Allowed patient to verbalize feelings when in pain
Rationale: decreases tension and anxiety that arises when patient is in pain
 Notify physician if interventions are unsuccessful or if current complaint is a
significant change from patient’s past experience of pain
Rationale: Patients who request pain medications at intervals more frequent than
prescribed may actually require higher doses of analgesic or more potent analgesia

Dependent/Collaborative:
 Give analgesics as ordered, evaluating effectiveness and observing for any signs
and symptoms of untoward effects
R: Pain medications are absorbed and metabolized differently by patients, so
their effectiveness must be evaluated from patient to patient. Analgesics may cause
side effects that range from mild to life-threatening

II.

Defining Characteristics
Nursing Diagnosis: Impaired Tissue Integrity related to tissue trauma secondary to
disease process and surgical procedures
Subjective Cues: no verbal cues
Objective Cues:
*received patient on bed, awake, conscious, and coherent
*with dressing at inner left thigh, clean and intact
*with abscess at inner left thigh, with thick purulent yellowish foul-odored
drainage
*limited movements noted
*with pain score of 6/10

Expected Outcome Criteria

Short Term: After 8 hours on nursing intervention, patient and SO will demonstrate
behaviors/techniques to promote healing and to prevent complications
Long Term: After 3 days of nursing intervention, patient's skin remains intact and
condition of impaired skin improved as evidenced by decreased redness, swelling and
pain

Interventions and Rationale

 Limit chair sitting to 2 hours at any one time.

Rationale: Pressure over sacrum may exceed 100 mm Hg pressure during sitting
 Discourage rubbing and scratching of incision site
Rationale: To decrease risk for infection of the site and promote healing of the
incision
  Instruct patient in proper care of the area (i.e., cleansing, dressing and
application of topical medications)
Rationale: To promote patient independence and to assure that care of the
incision area is continued even when the patient is discharged
 Use lift sheets to move patient in bed and discourage patient from elevating head
in bed
Rationale: These measures reduce shearing forces on the skin
 Discourage rubbing and scratching. Provide gloves or clip nails if necessary
Rationale: To prevent further injury and delayed wound healing
 Teach patient signs and symptoms of infection and when to notify
physician/nurse
Rationale: To assure that infection will be detected and treated as soon as
possible
 Instruct and assist patient with general hygiene, including handwashing and toilet
practices
Rationale: Proper handwashing sis the most effective method of disease
prevention. Bacteria from hands can easily contaminate other areas.

Dependent/ Collaborative:
 Encourage adequate nutrition and hydration
Rationale: Hydrated skin is less prone to breakdown. Adequate nutrition is
essential in effective healing and recovery

B. DISCHARGE PLANNING
1. Probable Date:
No probable date yet
2. Destination:
Babag I, Lapulapu City, Cebu
3. Tranportation
Taxi or private car borrowed from patient’s relatives
4. Agencies and Equipment Involved:
Local health care center; wheelchair (if patient is strong enough to sit) or
stretcher
5. Diet:
High protein, high carbohydrate diet with adequate amount of vitamins and
minerals
6. Medications
Analgesics, antibiotics, vitamin and mineral supplements
7. Person Responsible for Patient
Mother and Father
8. Family Conference
Encourage family to assist patient in preparing and eating nutritious foods
and in complying the drug therapy. Also encourage them to provide emotional and
psychosocial support to patient
 9. Anticipated Problems:
Financial means to continue purchase of medications and healthy foods
11. Home Visit
To be planned
C. SOAPIE CHARTING

S: “Maglisod man ko ug lihoklihok. Ganahan unta ko mubangon.”

O: >received patient on bed, awake, conscious, and coherent
>with abscessat inner left thigh, with dressing dry and intact
>difficulty moving noted
>pain upon movement observed
A: Activity intolerance related to general weakness secondary to disease process
P: After 8 hours of nursing intervention, patient will be able to use identified
techniques to enhance activity tolerance
I: >noted presence of factors contributing to fatigue
>provided positive atmosphere while acknowledging difficulty of situation for
client
>encouraged expression of feelings contributing to or resulting from condition
>promoted comfort measures and provided for relief of pain
>encouraged participation in recreation activities and hobbies appropriate for
situation
>assisted patient with ambulation such as turning side to side
E: “Arang-arang na lang jud, makalisoliso ko bisan gamay lang”
 CONCLUSION AND RECOMMENDATION

A. CONCLUSION
Each individual is hardwired with the desire to take care of his or her self. This
still holds true for sick people – hospital patients or the home-bound ill – even when
they are immobilized to a certain degree. Losing physical or even psychological
health does not deprive a person of his right to self-determination, self-preservation,
and self-care.
Assistance should be provided in the event that the sick person cannot anymore
do an activity for his/her self. The safety and security of the patient should be every
health care provider’s top priority.
The proper balance of providing independence and assistance enhances rapport
and interaction. When the nurse demonstrates concern for the patient’s welfare,
while at the same time acknowledges his/her autonomy, the patient is encouraged to
build a trusting relationship with the nurse.

B. RECOMMENDATIONS
In conducting a case study the researcher/nurse should find the line between a
professional and emotionally attached relationship. This allows for a more objective
view of the situation, subjecting the researcher to a lesser inner turbulence and a
better outcome in the study.
 BIBLIOGRAPHY

BOOKS:
 Doenges, et al. 2006. Nurse’s Pocket Guide: Diagnoses Prioritized Interventions,
Rationales. 10th edition. USA: F.A. Davis Company
 Doenges, et al. 2006. Nursing Care Plans: Guidelines for Individualizing Client
Care Across the Life Span. 7th edition. USA: F.A. Davis Company
 Gulanick et al. 1994. Nursing Care Plans: Nursing Diagnosis and Intervention. 3 rd
edition. USA: Mosby Yearbook Company
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INTERNET:
 http://www.emedicine.com/med/topic1902.htm
 http://www.ourjeet.com/general1/about_moreinfo.asp#bones
 http://www.worldortho.com/index.php?
option=com_content&task=view&id=490&Itemid=269
 http://www.nlm.nih.gov/medlineplus/ency/article/000417.htm
 http://www.ispub.com/ostia/index.php?
xmlFilePath=journals/ijs/vol11n1/psoas.xmlt be related to late and incorrect
diagnosis
 http://en.wikipedia.org.wiki/Orem_model_of_nursing
 http://www.nurses.info/nursing_theory_person_orem_dorothea.htm
 http://www.associatedcontent.com/article/494735/selfcare_deficit_theor y.html
Orem’s Self Care Model of Nursing in the Care of
Patient with Tuberculous Arthritis

A Case Study presented

to the Faculty of the College of Nursing
Cebu Normal University

in partial fulfillment
of the Requirements of the Degree
Bachelor of Science in Nursing

JULIE VICTORIA MARIE L. ERASGA

2009
 ACKNOWLEDGMENT

This study would not have been completed without the guidance of the Cebu

Normal University College of Nursing faculty, for the effort and support of my parents,

Mr. Vicente E. Erasga and Mrs. Ofelia L. Erasga, and for the presence of the Almighty

God in my life.

I would also like to acknowledge the cooperation and participation of the subject

in this study and her significant others and family members. Without her, there would

have been no study.

NURSING DIAGNOSIS: IMBALANCED NUTRITION: LESS THAN BODY

REQUIREMENTS RELATED TO ALTERED TASTE SENSATION

S: “Wala ko’y gana mukaon; wala ko’y panlasa”

O: > received sitting on bed, conscious, coherent

Weight 10%–20% below ideal for frame and height

Reported lack of interest in food, altered taste sensation

Poor muscle tone

DESIRED OUTCOMES

Short-Term Goal: Initiate behaviors/lifestyle changes to regain and/or to maintain

appropriate weight.

Long-Term Goal: Demonstrate progressive weight gain toward goal with normalization

of laboratory values and be free of signs of malnutrition.