Tagum Doctors College Inc.

Tagum City College of Nursing

___________________

A CASE STUDY On OSTEOARTHRITIS ___________________

In Partial fulfillment of the Requirements In Related Learning Experience

By Abuda, Shelou Germata, Geza Dee Liquit, Charmaine Lynne Ria, Dyan Bebs Segovia, Cherry Ann Serra, Marlunee Suico, Mary Joy Tanzo, Glezel Ann Verin,Krystel Ybaez, Vanessa Joy YecYec, Ara Annie Del BSN 3

ii

January 23, 2010

TABLE OF CONTENTS

I.

INTRODUCTION Objectives
A. General Objective B. Specific Objective

iv

vii vii 1 1 2 2 3 3 3 4 5 18 18 18 22

II.

ASSESSMENT A. Biographical Data B. Chief Complaint

C. History of Present Illness

D. Past Medical History E. Personal and Family History F. Socio-economic Status G. Nutritional Status H. Family Genogram I. Developmental Task J. Physical Assessment a. b. c. General Survey Vital Signs Physical Examination

III. IV.

REVIEW OF ANATOMY AND PHYSIOLOGY SYMPTOMATOLOGY AND ETIOLOGY

41 44

iv

V. a. b.

PATHOPHYSIOLOGY 51 52

51

Narrative Diagram VI. PLANNING A. Nursing Care Plan 1 B. Nursing Care Plan C. Nursing Care Plan VII. VIII. IX. PHARMACOLOGICAL MANAGEMENT DISCHARGE PLAN SYNTHESIS OF CLIENTS CONDITION A. Synthesis of Clients Condition B. Patients Prognosis C. Recommendation X. XI.

54 54 57 61 66 75 79 79 80 82 83 84

EVALUATION OF OBJECTIVES OF THE STUDY BIBLIOGRAPHY

I. INTRODUCTION Osteoarthritis is a type of arthritis that is caused by the breakdown and eventual loss of the cartilage of one or more joints. Cartilage is a protein substance that serves as a "cushion" between the bones of the joints (William C. Shiel Jr., 2010). Healthy cartilage allows bones to glide over one another. It also absorbs energy from the shock of physical movement. In osteoarthritis, the surface layer of cartilage breaks and wears away. This allows bones under the cartilage to rub together, causing pain, swelling, and loss of motion of the joint. Over time, the joint may lose its normal shape. Also, small deposits of bone called osteophytes or bone spursmay grow on the edges of the joint. Bits of bone or cartilage can break off and float inside the joint space. This causes more pain and damage. People with osteoarthritis usually have joint pain and stiffness. Unlike some other forms of arthritis, such as rheumatoid arthritis, osteoarthritis affects only joint function. It does not affect skin tissue, the lungs, the eyes, or the blood vessels. Osteoarthritis is the most common type of arthritis and is seen especially among older people. Sometimes it is called degenerative joint disease or osteoarthrosis (Gayle Lester, Kenneth D. Brandt, & Victor M. Goldberg, 2010). Osteoarthritis commonly affects the hands, feet, spine, and large weight-bearing joints, such as the hips and knees. Most cases of osteoarthritis have no known cause and are referred to as primary osteoarthritis. When the cause of the osteoarthritis is known, the condition is referred to as secondary

osteoarthritis. Osteoarthritis does not affect other organs of the body. Primary

vi

osteoarthritis in which our patient belongs is mostly related to aging. With aging, the water content of the cartilage increases, and the protein makeup of cartilage degenerates. Eventually, cartilage begins to degenerate by flaking or forming tiny crevasses. The most common symptom of osteoarthritis is pain in the affected joint(s) after repetitive use. Joint pain is usually worse later in the day. There can be swelling, warmth, and creaking of the affected joints. Pain and stiffness of the joints can also occur after long periods of inactivity. In severe osteoarthritis, complete loss of the cartilage cushion causes friction between bones, causing pain at rest or pain with limited motion. Symptoms of osteoarthritis vary greatly from patient to patient. Some patients can be debilitated by their symptoms. On the other hand, others may have remarkably few symptoms in spite of dramatic degeneration of the joints apparent on X-rays. Symptoms also can be intermittent. It is not unusual for patients with osteoarthritis of the finger joints of the hands and knees to have years of pain-free intervals between symptoms. Osteoarthritis of the knees which occurred in our patient is often associated with excess upper body weight, with obesity, or a history of repeated injury and/or joint surgery. Before age 45, osteoarthritis occurs more frequently in males. After 45 years of age, it occurs more frequently in females. A higher incidence of osteoarthritis exists in the Japanese population, while South-African blacks, East Indians, and Southern Chinese have lower rates (William C. Shiel Jr., 2010). Lifestyle effects include depression, anxiety, feelings of helplessness, limitations on daily activities, job limitations and difficulty participating in everyday personal and family joys and responsibilities. Financial effects include the cost of treatment and wages lost because of disability. In our patient, only few of this

vii

effects happened which were anxiety, limitations on daily activities and the cost of treatment (Gayle Lester, Kenneth D. Brandt, & Victor M. Goldberg, 2010). These statistics are calculated extrapolations of various prevalence or incidence rates against the populations of a particular country or region. The following are number of cases with osteoarthritis. In African region 765, 020, 157 cases ; Region of the Americas 752, 015, 074 cases ; Asia Region 3,570, 771, 642 cases ; European Region 787, 880, 037 cases with a total of 5, 875, 686, 910 cases globally in the year 2004. In the Philippines a number of 6, 341, 301 cases were noted in the year 2004 (Statistics by Country for Ostearthritis, 2004)

Locally, in Davao Regional Hospital a total number of 1229 cases of osteoarthritis were reported in the year 2009 (Medical Records Section, 2009). Osteoarthritis affects various people differently. It may progress quickly, but for most people joint damage developed gradually over years. In some people, osteoarthritis is relatively mild and interferes little with day-to-day life; in others, it causes significant pain and disability. Although osteoarthritis is a disease of the joints, its effects are not just physical. In many people with osteoarthritis, lifestyle and finances also decline. For this reason, we come to choose this case to determine if the above-mentioned effects occurred in our patient and to know the reason how joint pain in the knee was experienced wherein fact the patient did not have any past injuries or accidents?

viii

OBJECTIVES a. GENERAL OBJECTIVES: This study aims to deepen our knowledge about acute osteoarthritis its cause and underlying factors which may contribute to its development.

b. SPECIFIC OBJECTIVES: This study was undertaken to:

Present the overview of the patients case; identify the objectives; show the biographical data of the patient; study the patients history of past and present illness; trace the family genogram of the patient;

review the developmental stages in accordance with our patient;

assess the vital signs and overall condition of the patient;

review the anatomy and physiology of the affected organs and systems related to the case chosen;

identify the underlying symptoms of the chosen case; determine the etiology of osteoarthritis; trace the pathophysiology of osteoarthritis; formulate nursing care plans applicable for patient with osteoarthritis;

ix

create a discharge plan that are appropriate for patient with osteoarthritis;

classify the drugs for osteoarthritis and explain its action and effects to the patient;

identify prognosis of the patient patients condition in relation to its etiology and its existing signs and symptoms; and

list down recommendations for the improvement of health of the patients condition.

II.

ASSESSMENT A. BIOGRAPHICAL DATA

Name: Lantican, Elizabeth De Jesus Address: #73 Catleya St. Merville Subd. Tagum City Sex: Female Date of birth: July 12, 1947 Place of birth: Tondo, Manila, Philippines Age: 63 yrs. & 5 mos. Nationality: Filipino Weight: 55 kg. Height: 55ft. BMI: 20.45 normal Fathers name: Mr. Carlos De Jesus Mothers name: Mrs. Severa De Jesus Brother: Reymundo- 67 years old

Sisters: Carmensita- 59 years old Carmelita- 59 years old

Husband: Ernesto De Jesus Children: Erik- 40 years old

11

Gary 39 years old Erwin deceased Eleonor 36 years old Emerson 35 years old

Admission date: November 13, 2010 Admission time: 11:05 am Attending Physician: Dr. Glenn Renegado Admitting Physician: Dr. Pealver Admission Diagnosis: Osteoarthritis, r/o Gouty Arthritis

B. CHIEF COMPLAINT

The patient is 63 years and 5 months old with complaints of right knee pain affecting her walking ability.

C. HISTORY OF PRESENT ILLNESS Last November 10, 2010 the patient had experienced right knee pain and difficulty of walking. For that reason, she had self medication and took Skelan as to relieve the pain temporarily. On November 13, 2010 at 8:00 AM, the patient was unable to stand or walk due to severe right knee pain that's why she decided to go to the hospital for a check up. At 11: 05 am the same day, she was accompanied by her husband and son; that was her first time to be admitted in a hospital. She was seen and examined by the admitting physician, Dr.Penalver with admitting diagnosis of

12

Osteoarthritis, r/o Gouty Arthritis. Subsequently, she was admitted right away at Tagum Doctors Hospital ward. . D. PAST MEDICAL HISTORY

Like a normal person, she experienced common health problems such as fever, common colds, flu, cough and chicken pox during her childhood years. She had no history of allergies or skin disorders. She received complete immunization such as BCG, DPT, TT, Hepa-B and OPV as reported by the patient. She has no past hospital admission or any surgery experience.

E. PERSONAL AND FAMILY HISTORY

The patient is a Filipino citizen born in Tondo, Manila .She was raised up by her parents, Mr. and Mrs. De Jesus bestowed upon Christian belief. She had her elementary years at Lopez Elementary School in Manila but her family moved to Laguna the preceding year meant for financial reasons. She had her high school years at Los Baos School of Fisheries and took commerce for three years at Far Eastern University, however she did not finished her college studies. Fortunately, when she met her husband she had experienced stable life. She is now a 63 year old active mother, married and blessed with five children. She works as a flower vendor and rents out a business stall at Trade Center, Tagum City. Her husband assisted her in their flower shop selling. During spare time, she enjoys gardening and cleaning the yard. When she

13

was only two years old, her parents died because of hypertension. Presently, her three siblings have hypertension as well. Her way of doing exercise is walking. At home, her way of relaxation is reading magazines, watching television and play with her grandsons and granddaughters whenever they visit.

F. SOCIO-ECONOMIC STATUS

The patient lives together with her husband at #73 Catleya Street Merville Subdivision, Tagum City. Her children has their own family and own houses separately. They live in a two storey concrete house with six bedrooms, has a small kitchen, living room equipped with home appliances such as television, radio, electric fan, cooking stove, and refrigerator and three comfort rooms with a flushed type toilet as described by the patient. Their source of water is from water district and dumoy as potable water. Their estimated annual income is 90, 000.00 pesos which comes from their flower shop business.

G. NUTRITIONAL STATUS

The patients weight is 55 kg. and a height of 55ft. Her body mass index (BMI) is 20.45 which is considered normal. Food intake is three times a day with an estimation of three to four cups of rice, vegetables and citrus fruits daily for every meal, meat once a week and sea foods for two times a week. Sometimes, she doesnt want to eat breakfast and only drinks coffee as her meal. The patient seldom eats processed foods

14

such as corned beef, sardines, and hotdog. Fluid intake is 8-10 glasses per day as reported. She doesnt drink alcohol yet loves to drink sodas about 2-3 times a week.

H. FAMILY GENOGRAM

MS Grandmoth er

MS Grandfathe r

PS Grandfath er

PS Grandmother

Legend: Hypertension Arthritis Alive and well Brain Tumor Deceased Paternal side - PS Maternal side - MS Male Female Vehicular accident Paternal side - PS Maternal side - MS Male Female
Erik 40y/o
Gary 39y/o PATIENT 63y/o

Severa

Carlos

Reymundo 67 y/o

Carmensita 59 y/o

Carmelita 59 y/o

Ernesto 63 y/o

15
Erwin 35 y/o Eleonor 36y/o
Eeo mrs n

I. Developmental Task

Theorist

Theory

Developmental Task

Rating

Result Justification

and

Robert Havighurst

Activity aging

during Middle Adulthood (35 t0 55or 65

Patient was able to achieve this entire task, she was a She

years old)

currently Robert Havighurst believed that This stage in a Housewife.

was able to earn enough money in order to sustain

learning is basic to persons life life and that is concerned with

peoplecontinue to theachievement of learn throughout the followingtask:

their children and daily need. She

life. He defines a developmental task as Fulfill a social civic and

also teaches their children become responsible by to

taskwhich arises at responsibilities or about a certain period in the life of Maintain an an

way of discipline. As a mother shes responsible managing their

individual. economicstandard of living

Successfulachieve

17

Assistadolescent ment of these children tasks leads to his responsible happiness and to happy adults. successand later Learning leads to withpartner unhappiness in the individual,disappro val by society and difficulty tasks. in later Robert Havighurst (1971) J. to live tasks, while failure and become

home, and happily married.

18

Lawrence Kohlberg

Moral Theory The theory holds that reasoning, basis for moral

Her age correlates to post-conventional level. post-

Patient

knows

and understands the basic social rules that and should laws be

the The

ethical conventional level

behavior, has six OfLawrence identifiable developmental Kohlbergs Development, Moral is

followed. She is also what and according societys aware is of

wrong right to laws.

stages, each more also known as the adequate responding moral than predecessor. at principled level. In to Stage five (social driven),

dilemmas contract

She is coming up with with a decision the

its the world is viewed as holding different rights

Kohlberg followed opinions, the

consensus of her significant others. She laws knows must that be

development and values. Such

of moral judgment perspectives far ages beyond the should be mutually as to each or Laws as

studied respected

abided because it is her

earlier by Piaget unique who also claimed person that logic

responsibility as a citizen of the state. She is an active

and community.

morality

develop areregarded

19

through constructive

social rather

contracts than rigid Those do not the welfare

voter

and

pays

taxes on the right time. And agrees on basic states

stages. Expanding dictums. on Piaget's work, which Kohlberg determined the moral process promote that general

rules. She she knows can that

of should be changed when necessary to

violate

some laws if it is untoward and

development was meet "the greatest principally concerned good for the

unjust. As a moral person she is herself, capable

with greatest number of This is

justice, and that it people". continued throughout individual's achieved the majority and

through decision, inevitable

enough to reflect on her own

conscience.

lifetime, a notion compromise. that dialogue spawned on the (Lickona,1976)

philosophical implications such of

research.

(http.wikipedia.org) Erik Erikson Psychosocial Theory Middle Adulthood: The Patient has positively

35 to 55 or 65

20

Ego

Development

achieved this Stageof

All of the stages in Outcome: Erikson's epigenetic are Generativity theory Self-absorption implicitly Stagnation Strengths: vs. or

development. She views her life asmeaningful because already and she married has 5 and their to

present at birth (at Basic least in

latent Production and Care

form), but unfold according to both an innate scheme and one's upDuring this stage, work become priority. observed seems a to high

children helping children become

bringing in a family that expresses the values of a culture. Each stage builds on the preceding stages, and paves the way for

Erikson that

responsible. She was also thankful to have children and family

middle-age is the time people their more when like days most filling with

member who are always there to

meaningful

subsequent stages. stage Each is

and creative work and family issues. Also, middle

care for her and to support.

characterized by a psychosocial

adulthood is when we can expect to She reaffirms the

21

crisis, based

which

is "be in charge," the on role we've longer envied. The main but goal of this stage is

values of life that have real meaning philosophical, and

physiological development,

religious, social.

also on demands to take the values put on the of your own family by such as raising and

individual parents society.

and/or children

Ideally, passing them onto

the crisis in each the next generation stage should be to help guide them resolved by the

ego in that stage, in order for to Source: *Fundamentals Nursing 8thedition.page 353 of

development

proceed correctly. The outcome of

one stage is not permanent, but

can be altered by later experiences. Everyone mixture has of a the

22

traits attained at each stage, but

personality development considered successful if the individual has is

more of the "good" traits than the

"bad" traits.

J. PHYSICAL ASSESSMENT

A. General Survey The patient was alert, awake and responsive. She was also oriented to time, place and to the people around her. She experienced right knee pain with the pain scale of 5/10. Shes not able to walk and stand without assistance and for long period of time.

B. VITAL SIGNS DATE TIME VITAL SIGNS NORMAL ACTUAL INTERPRETATION

23

11/13/10 (Upon Admission)

11:05 am

Temperature

36.5-37.5 C0

36.8 C0 Temperature normal Temperature maintained the bodys is within range. is between heat-

producing (metabolism, shivering, contraction,

functions

muscle exercise,

and thyroid activity). Temperature can vary with such other as factors, exercise,

drinking hot or cold fluids, sitting in a cold room, fighting an

infection, and by the accuracy and type of thermometer Blood Pressure Systolic: 90130mmHg used.

(McKesson. 2005) 120/80 Blood Pressure is within mmHg normal range. Normal BP varies with age and others factors such as stress,

24

Diastolic : 60-90 mmHg

genetics, medications, heavy meals. Diurnal variations,

exercise and weight. It can be often taken in several positions- supine, sitting and

Pulse Rate

60-100 beats/min.

86 bpm

standing. (Dillon 2007) Normal. The heart

rate

changes based upon the body's most need for oxygen, during

notably,

Respiratory Rate

18-25

22

exercise. (Pillitteri,A. 2007) Respiratory Rate is within normal range. The normal respiratory rate varies with age. Respiratory Rate tends to increase with age. It also tends to be fit lower in

cycles/min cpm

physically

people,

because exercise makes the heart stronger so it can pump more blood through the body with each

contraction. Control

(Respiration Mechanisms

25

from World of Anatomy and Physiology. 2005-2006.) 11/15/10 (Upon Assessment) 8:00 am Temperature 36.5-37.5 C0 37.2 C0 Temperature normal Temperature maintained the bodys is within range. is between heat-

producing (metabolism, shivering, contraction,

functions

muscle exercise,

and thyroid activity). Temperature can vary with such other as factors, exercise,

drinking hot or cold fluids, sitting in a cold room, fighting an

infection, and by the accuracy and type of thermometer Blood Systolic: 120/80 used.

(McKesson. 2005) Blood pressure is within

26

Pressure

90130mmHg

mmHg

normal

range.

Various

factors influence a person's average BP and variations.

Diastolic : 60-90 mmHg

Factors such as age and gender values. influence As average age,

adults

systolic pressure tends to rise and diastolic tends to fall. Pulse Rate 60-100 beats/min. 90 bpm (Pillitteri,A. 2007). Normal. The heart rate

changes based upon the body's most need for oxygen, during

notably,

Respiratory Rate

18-25

20

exercise. (Pillitteri,A. 2007) Respiratory Rate is within normal range. The normal respiratory rate varies with age. Respiratory Rate tends to increase with age. It also tends to be fit lower in

cycles/min cpm .

physically

people,

because exercise makes the heart stronger so it can

27

pump more blood through the body with each

contraction. Control

(Respiration Mechanisms

from World of Anatomy and Physiology. 2005-2006.) C. Physical Assessment ASSESSMENT NORMAL FINDINGS Neurologic Fully Status alert and Oriented to ACTUAL FINDINGS INTERPRETATION time, Patients level of people consciousness is

conscious. Oriented place

and

to time, place and around her. Able to good and he is a people. No speech respond to questions responsive defects and uses and maintains to eye correspondent. the Memory is intact

appropriate Thought

words. contact

is interviewer. Thought and is based in is reality reality. Good

comprehensible and content based Positive tendon reflex. Reference: (2007). in reality. based

without Language skills.

deep speech defects. Uses Reference: appropriate words in Dillon Dillon answering questions. Assessing Sensory(2007). the

Assessing Memory is intact.

28

the

Sensory-

Neurologic System, Nursing Health Assessment A

Neurologic System, Nursing Assessment critical Case Approach. Davis 1915 Health A

Thinking, Studies F.A. Company Arch Street PA

critical Thinking, Case Studies F.A.

Approach. Davis

Company

1915 Arch Street Philadelphia, PA 19103

Philadelphia, 19103

Integumentary System Methods Assessment Used: Inspection Palpation Skin Skin is uniform in Skin is fair, soft warm Good skin turgor color, warm to touch to touch and uniform indicates patient with good skin in color with slightly is not of

29

turgor. No cyanosis.

darker areas. No

exposed dehydrated. scars Exposed areas usually because to

noted or any lesions are on the upper and darker lower extremities. of

exposure

Decreased turgor noted.

skin the heat of the sun.

Mucous membranes Mucous membranes Pink

mucous

pink in color, moist pink and moist with membranes with no lesions or no inflammations. and noted inspection. sores, any redness indicate lesions hematologic upon disease like no

anemia. No sign of redness in the mucosal area

shows that there is inflammatory infectious disorder present. no or

Hair

and Hair

is

evenly Hair

is

evenly Fair

distribution

30

Scalp

distributed. Scalp is distributed, intact and free of strand, lesions pediculosis. silky

thick of hair. Free from and pediculosis. Hair and are

and black in color. White color hair noted upon distribution

inspection. Fine body genetically hair noted over the linked. body. No scalp

lesions, dandruff, lice and nits noted. No masses tenderness upon palpation. and noted

Nails

Nails vary from light Fingernails skinned brown in to light toenails darker and well in are

and Nails may grow clean longer, soften or

trimmed, thin. shape, Clubbing is not which no

skinned individuals. convex

Nails are convex in smooth texture with present shape and firm no inflammations signifies

without clubbing. Reference: (2007). the

noted. Nail beds pink diseases that

Dillon in color. No clubbing associated

Assessing and

bluish affect the level of noted. oxygenation such

Integumentary discoloration

31

System,

Nursing Capillary refill of less as heart and

congenital disorders chronic

Health Assessment than 2 seconds. A critical Thinking, Case Approach. Davis 1915 Studies F.A. Company Arch Street PA

pulmonary diseases. bluish discoloration nails and of no No

Philadelphia, 19103 .

clubbing indicate no peripheral or

disease hypoxia. Reference: Dillon Assessing Integumentary

(2007). the

System, Nursing Health Assessment A

critical Thinking, Case Studies F.A.

Approach. Davis

Company

32

1915 Arch Street Philadelphia, PA 19103 HEENT Methods Assessment Used: Inspection Palpation Head Round symmetrical. palpable and Normocephalic with Symmetry of of

No no palpable masses, facial

features movements no

masses, lesions or tenderness and

swelling and lesions. and swelling noted indicate

Facial features and upon inspection and previous trauma, movements symmetrical. palpation. Symmetrical features movements congenital facial deformity, and paralysis noted edema. or

upon inspection.

Eyes

In parallel alignment Sclera is white with Clear with white Positive smooth

eyes

and no lesions. Both eyes indicate that the

sclera. are clear and bright patient is not in pupillary in parallel alignment. febrile state.

33

reaction to light and Parallel blinking Smooth, reflex. in all

movements Parallel directions movement of the Positive eye in all no and

conjugate noted.

movement of eyes blinking reflex noted. directions, in all directions Cornea is shiny and nystagmus eyelid lag smooth. Pupil

without

is eyelid lag show damage, or on

and nystagmus.

round, equal in size no and reactive to light. irritation Both pupils constricts pressure

in response to light. correspond-ding Iris is brown in color extraocular upon inspection. No muscle or cranial corrective lenses or nerves eyeglasses noted. innervates that the

muscle. Eyelids, Fair Eyebrows eyelashes evenly and eyebrows are eyelashes distributed presence with no lesions or discharges, swelling any swelling. intact. Eyelashes outward curves will indicate without carcinoma. Eyelids or inflammations. occurs since it swelling of and no edema or without fair in distribution and eyelashes are distribution of eyebrows and

34

crusting infestations.

or Conjunctiva Eyelids smooth

is and

intact without lesions. Pinkish color peach

pinkish in color. Red conjunctiva

conjunctiva Conjunctiva is pinkish indicates in color or with no conjunctivitis

with no lesions.

lesions noted.

swelling while in anemia, it is pale pink. Positive reflexes in the eyes no

signify neurological problems. Consistent with skin Ears color with and the aligned Aligned with the Normally,

ears

external external canthus of are aligned with external of Color the is with No

canthus of the eyes. the eyes. Consistent the No tenderness swelling. lesions, with skin color. No canthus and lesions, nodules and eyes. No swelling

noted. consistent color.

palpable nodules or Cerumen noted upon skin exudates. inspection and

in lesions abnormal

found,

small amount.

35

findings of having lesions in the

ears will indicate skin cancer from Skin is intact. No Neck palpable masses or Is in the midline and bulges, lymph nodes movable 180 degrees and swelling. without feeling of sun exposure.

Thyroid glands not discomfort enlarge. Left and

reported. right cervical

superficial

nodes not palpable. No bulges or

masses, lesions and swelling Thyroid lower anterior is half noted. in of mid the No

neck.

Enlargement, tenderness nodularity noted. Mucosa Throat/mouth redness pink, no or Pink, moist, smooth, Pink, moist and and

36

inflammations lesions.

and glistening and intact intact mucosa. Tongue is indicates

mucosa good

pink in color, mobile condition of oral with no lesions or mucosa. swelling and any Reddened, inflamed oral

discolorations. Lateral

margins mucosa

present. Tonsils are sometimes pink and indicate no accompanied by signs inflammation. Lips pink, moist and intact. of ulcerations. Lips that moist Moist, pink lips noted cracks are intact, no

with

signify

without any lesions that the patient is and swelling. No not experiencing dehydration, cheilosis, lip and or

cracks noted. Gums pink with no lesions, redness bleeding. discharges exudates.

swelling, Gums are consistent licking and in color with other infectious No mucosa with no inflammatory

or bleeding. No lesions, disorders. swelling exudates noted.

No

and signs of tonsillitis. Reference:

37

Hard and soft palate pink and

Dillon

(2007). the

intact, Teeth are white in Assessing

teeth are white in color. Hard and soft Head, Face and color, not loose with palate is pink and Neck, Assessing good occlusion and intact. in good Dentures the Eye and Ear. Health A

repair. noted on the upper Nursing

Swallowing is easily portion of the buccal Assessment done

without mucosa. Reports no critical Thinking, in Case Studies F.A.

difficulty or feeling of difficulty pain. Reference: (2007). Dillon swallowing.

Approach. Davis

Company

Assessing

1915 Arch Street Philadelphia, PA 19103

the Head, Face and Neck, Assessing the Eye Nursing Assessment critical Case Approach. Davis 1915 and Ear. Health A

Thinking, Studies F.A. Company Arch Street PA

Philadelphia,

38

Pulmonary System Methods Assessment Used: Inspection Palpation Auscultation

19103 Respiratory

rate Respiration recorded cycles per

rate as

is Normal.

Not

in

ranges from 18 -25 of cycles per minute.

20 respiratory

minute. distress. If there this of

Nose is symmetrical is an increase in and nasal flaring. indicates

Equal rise and fall of with no discharges fremitus the chest when Septum intact and in accumulation breathing, full and even. Chest midline. is in the midline. There in is equal rise and fall Even of color. Trachea is in the chest rate regular and difficulty the

Trachea is fluid or exudates lungs. breathing no in

consistent with skin

with indicates

the midline. Tactile rhythm of respiration respiration. fremitus equal without any masses Reference: noted upon palpation. bilaterally. Nose is No pain the no reported chest. dyspnea Assessing the symmetrical with no over discharges. Septum intact and in midline. Reference: (2007). the System. even, Dillon (2007).

Breathing pattern is Respiratory System. Nursing Health A noted. Vocal fremitus bilaterally No on the Assessment and Case Studies F.A. Approach. Davis

Dillon is symmetric, equal upper anterior chest.

Assessing Respiratory

critical Thinking,

secretions

Nursing presence of cough not noted.

Health Assessment A critical Thinking, Case Approach. Studies F.A.

Company

1915 Arch Street Philadelphia, PA

39

Davis 1915

Company Arch Street PA

19103

Philadelphia, 19103 Cardiovascular System Methods Assessment Used: Inspection Palpation Auscultation

Heart rate of 60-100 Pulse beats of regular. per

rate

was Pulse rate and 90 blood pressure is normal

minute, recorded as

Capillary beats per minute and within

refill of less than 2 is in regular rhythm. range. The heart seconds pressure 90/60mmHg140/90mmHg Reference: (2007). the .Blood Blood pressure was rate changes

of recorded as 120/80 based upon the mmHg. No murmurs body's need for noted. No chest pain oxygen, Dillon reported. refill Good notably, most during

Assessing capillary

less exercise. Various factors influence a person's

Cardiovascular than 2 seconds. Nursing

System.

Health Assessment A critical Thinking, Case Approach. Davis 1915 Studies F.A. Company Arch Street PA

average BP and variations. Factors such as age and gender influence average As values. age,

Philadelphia,

adults

40

19103

systolic pressure tends to rise and diastolic tends to fall.

Reference: Dillon Assessing (2007). the

Cardiovascular System. Nursing Health Assessment A

critical Thinking, Case Studies F.A.

Approach. Davis

Company

1915 Arch Street Philadelphia, PA 19103 Gastrointestinal System Methods Assessment Abdomen is intact No lesions, masses Bowel sound is with no lesions, and scars noted over within and the abdomen. range of normal 5-30

of masses

consistent with skin Umbilicus

noted, clicks per minute

41

Used: Inspection Palpation Auscultation

color. inverted midline. bowel

Umbilicus inverted and

and

in which

suggest

in midline. Bowel sound that the patient is at four not constipated.

Audible audible

sounds abdominal quadrants No scars in the may no

present 5-30 clicks with 13 clicks per abdomen per minute. minute auscultation. Reference: (2007). the Nursing Assessment critical Case Approach. Davis 1915 Dillon bowel upon indicate Last previous

movement: abdominal

Assessing November 15, 2010, surgery done. Abdomen. 6:00 in the morning Reference: Health with no difficulty in Dillon A defecation and with Assessing (2007). the

Thinking, soft yellowish stool Abdomen. Studies as reported. F.A. Company Arch Street PA Nursing Health A

Assessment

critical Thinking, Case Studies F.A.

Philadelphia, 19103

Approach. Davis

Company

1915 Arch Street Philadelphia, PA

Genitourinary System

No sensation

19103 burning No burning sensation No difficulty during and difficulty

in

in urination signifies

42

Methods Assessment Used: Inspection

of urination. Reference: (2007). the

urination Dillon Last

reported. no urinary tract voided: problems.

Assessing November 15, 2010, Reference: Female in the afternoon with Dillon yellowish colored Assessing (2007). the

Genitourinary System.

Nursing urine with total output Female

Health Assessment of 400cc throughout Genitourinary A critical Thinking, the shift. Case Approach. Davis 1915 Studies F.A. Company Arch Street PA System. Nursing Health Assessment A

critical Thinking, Case Studies F.A.

Philadelphia, 19103

Approach. Davis

Company

1915 Arch Street Philadelphia, PA Musculoskeletal System Methods Assessment Used: Inspection Palpation Posture erect, head Posture midline and weight head of evenly Both in is 19103 erect, Coordinated midline. movements range noted, of indicate Not cerebellar good

distributed. Reduced feet point motion

straight ahead. All able to fully bend, function. movements coordinated flex and extend her Reference: and knees. Muscle Dillon (2007).

43

arms

swings

in weakness

noted. Assessing

the

opposition. Balance Patient cannot stand Motorintact. Reference: (2007). the or walk for a long Musculoskeletal Dillon period of time without System. Nursing

Assessing assistance. Able to Health Motor- walk for only 4-5 Assessment A

Musculoskeletal System.

steps with assistance critical Thinking, Studies F.A.

Nursing Pain reported on the Case

Health Assessment right knee with the Approach. A critical Thinking, pain scale of 5/10. Davis Case Approach. Davis 1915

Company

Studies Stiffness on the right 1915 Arch Street F.A. knee area reported. Philadelphia, PA Company Complete upper and 19103 Arch Street lower PA noted. extremities

Philadelphia,

19103 III. LABORATORY AND DIAGNOSTIC EXAMINATION HEMATOLOGY RESULT NORMAL 11/13/10 A.)HEMOGLOBIN VALUE 131 g/L 120-150 g/L

INTERPRETATION

The result was within normal range. If increase it indicates polycythemia, chronic obstructive pulmonary disease, failure of oxygenation because of congestive heart failure and normally in people living at high altitudes. If decrease it

44

implicates

various

enemas,

pregnancy, severe or prolonged hemorrhage and with excessive fluid intake. B.) LEUKOCYTE 6.1 x 12 g/ 5-10 x12 g/L L The result was within normal range. A low WBC count will make the individual susceptible and vulnerable to diseases and foreign invasive organism. D.) LYMPHOCYTES 0.34 0.25-0.40 The result was within normal range. Lymphocytosis is seen in infectious viral mononucleosis, , cytomegalovirus infection, other infections, pertussis, toxoplasmosis, brucellosis, TB, syphilis, lymphocytic leukemias, and lead, carbon disulfide, tetrachloroethane, and arsenical poisonings. A mature lymphocyte count >7,000/L is an individual over 50 years of age is highly suggestive of chronic lymphocytic leukemia (CLL). Drugs increasing the lymphocyte count include aminosalicyclic acid, griseofulvin, haloperidol, niacinamide, mephenytoin. E.) MONOCYTES 0.09 0.02-0.06 The result was above normal range. An increase a viral in result indicates infection, levodopa, phenytoin, and

45

parasitic disease, collagen and hemolytic disorder. Monocytosis is seen in the recovery phase of many acute infections. It is also seen in diseases characterized by chronic inflammation sarcoidosis), systemic many granulomatous (TB, ulcerative lupus, syphilis, colitis,

brucellosis, Crohn's disease, and rheumatoid neoplasms. and as well as of griseofulvin,

arthritis, polyarteritisnodosa, and hematologic Poisoning by carbon disulfide, phosphorus, tetrachloroethane, administration

haloperidol, and methsuximide, may cause monocytosis. F.) EOSINOPHILS 0.01 0.01-0.05 The result was within normal range. If increase it specifies allergy, infection. G. BASOPHILS 0.01 0.00 0.01 The result was within normal range. If increase with acute leukemia and following surgery and trauma. If decrease with allergic reactions, stress, allergy, parasitic disease and use of corticosteroids. H. 187 x 10 9/L 130 400 x The result was within normal parasitic disease, collagen disease and subacute

46

THROMBOCYTE S (PLATELETS)

10 9/L

range. If increase, thrombocytosis is seen in many inflammatory disorders and myeloproliferative states, as well as in acute or chronic blood loss, hemolytic anemias, carcinomatosis, status post-splenectomy, post- exercise, etc. If decrease, hrombocytopenia is into divided pathophysiologically defects and production

consumption defects based on examination of the bone marrow aspirate presence or of biopsy for the megakaryocytes.

Production defects are seen in Wiskott-Aldritch syndrome, MayHegglin anomaly, Bernard-Soulier syndrome, anomaly, above), Chediak-Higashi Fanconi's marrow syndrome,

aplastic anemia (see list of drugs, replacement, megaloblastic and severe iron deficiency anemias, uremia, etc. Consumption defects are seen in autoimmune (including lupus), DIC, thrombocytopenias ITP and TTP, systemic congenital

hemangiomas,

hypersplenism,

following massive hemorrhage, G.) HEMATOCRIT 0. 40 0.36-0.44 and in many severe infections. The result was within normal

47

range. in

If

increase dehydration

it

shows or

erythrocytosis of any cause and hemoconcentration severe anemias, associated anemia of

with shock. If decrease it shows pregnancy and acute massive blood loss. HEMATOLOGY 11/13/10 A.)HEMOGLOBIN RESULT NORMAL VALUE 131 g/L 120-150 g/L The result was within normal range. If increase it indicates polycythemia, chronic obstructive pulmonary disease, failure of oxygenation because of congestive heart failure and normally in people living at high altitudes. implicates If decrease it various enemas, INTERPRETATION

pregnancy, severe or prolonged hemorrhage and with excessive fluid intake. B.) LEUKOCYTE 6.1 x 12 g/ 5-10 x12 g/L L The result was within normal range. A low WBC count will make the individual susceptible and vulnerable to diseases and foreign invasive organism. D.) LYMPHOCYTES 0.34 0.25-0.40 The result was within normal range. Lymphocytosis is seen in infectious mononucleosis, ,

48

cytomegalovirus infection, other viral infections, pertussis, toxoplasmosis, brucellosis, TB, syphilis, lymphocytic leukemias, and lead, carbon disulfide, tetrachloroethane, and arsenical poisonings. A mature lymphocyte count >7,000/L is an individual over 50 years of age is highly suggestive of chronic lymphocytic leukemia (CLL). Drugs increasing the lymphocyte count include aminosalicyclic acid, griseofulvin, haloperidol, niacinamide, mephenytoin. E.) MONOCYTES 0.09 0.02-0.06 The result was above normal range. An increase a viral in result indicates infection, levodopa, phenytoin, and

parasitic disease, collagen and hemolytic disorder. Monocytosis is seen in the recovery phase of many acute infections. It is also seen in diseases characterized by chronic inflammation sarcoidosis), systemic many granulomatous (TB, ulcerative lupus, syphilis, colitis,

brucellosis, Crohn's disease, and rheumatoid neoplasms.

arthritis, polyarteritisnodosa, and hematologic

49

Poisoning by carbon disulfide, phosphorus, tetrachloroethane, administration of as well and as griseofulvin,

haloperidol, and methsuximide, may cause monocytosis. F.) EOSINOPHILS 0.01 0.01-0.05 The result was within normal range. If increase it specifies allergy, infection. G. BASOPHILS 0.01 0.00 0.01 The result was within normal range. If increase with acute leukemia and following surgery and trauma. If decrease with allergic reactions, stress, allergy, parasitic disease and use of corticosteroids. H. THROMBOCYTE S (PLATELETS) 187 x 10 9/L 130 400 x The result was within normal 10 9/L range. If increase, thrombocytosis is seen in many inflammatory disorders and myeloproliferative states, as well as in acute or chronic blood loss, hemolytic anemias, carcinomatosis, status post-splenectomy, post- exercise, etc. If decrease, hrombocytopenia is into divided pathophysiologically defects and production parasitic disease, collagen disease and subacute

consumption defects based on examination of the bone marrow

50

aspirate presence

or of

biopsy

for

the

megakaryocytes.

Production defects are seen in Wiskott-Aldritch syndrome, MayHegglin anomaly, Bernard-Soulier syndrome, anomaly, above), Chediak-Higashi Fanconi's marrow syndrome,

aplastic anemia (see list of drugs, replacement, megaloblastic and severe iron deficiency anemias, uremia, etc. Consumption defects are seen in autoimmune (including lupus), DIC, thrombocytopenias ITP and TTP, systemic congenital

hemangiomas,

hypersplenism,

following massive hemorrhage, G.) HEMATOCRIT 0. 40 0.36-0.44 and in many severe infections. The result was within normal range. in If increase dehydration it shows or associated anemia of erythrocytosis of any cause and hemoconcentration severe anemias,

with shock. If decrease it shows pregnancy and acute massive blood loss.

51

RADIOLOGIC FINDING (11/15/10) RADIOLOGIC FINDING 11/15/10 Procedure: Knee APL-DLX

INTERPRETATION INTERPRETATION No significant bony nor joint

abnormality is noted save for a patellar base degenerative bony spur.

IV.

REVIEW OF ANATOMY AND PHYSIOLOGY

The Skeletal System

Functions of the Skeleton

52 1. ) Provide a framework that supports the body; the muscles that are attached to bones move the skeleton. 2. ) Protects some internal organs from mechanical injury; the rib cage protects the heart and lungs, for example. 3. ) Contains and protects the red bone marrow, the primary hemopoietic (blood forming) tissue. 4. ) Provides a storage site for excess calcium. Calcium may be removed from bone to maintain a normal blood calcium level, which is essential for blood clotting and proper functioning of muscles and nerves. Classification of Bones 1. ) Long bones- bones of the arms, legs, hands, and feet (but not the wrists and ankles). 2. Short bones- the bones of the wrists and ankles. 3. ) Flat bones- the ribs, shoulder blades, hip bones and cranial bones. 4. ) Irregular bones- the vertebrae and facial bones. Divisions of the Skeleton The human skeleton is divided into two distinct parts: The axial skeleton consists of bones that form the axis of the body and support and protect the organs of the head, neck, and trunk.

The Skull

53 The Sternum The Ribs The Vertebral Column

The appendicular skeleton is composed of bones that anchor the appendages to the axial skeleton.

The Upper Extremities The Lower Extremities The Shoulder Girdle The Pelvic Girdle--(the sacrum and coccyx are considered part of the vertebral column)

Joints Is where two bones meet, or articulate.

The classification of Joints The classification of joints is based on the amount of movement possible. A synarthrosis is an immovable joint, such as suture between two cranial bones. An amphiarthrosis is a slightly movable joint, such as the symphysis joint between adjacent vertebrae. A diarthrosis is a freely movable joint. This is the largest category of joints and includes the ball-and-socket joint, the pivot, hinge and others. Synovial joints

54

All diarthroses, or freely movable joints, are synovial joints because they share similarities of structure. On the joint surface of each joint is the articular cartilage, which provides a smooth surface. The joint capsule, made of fibrous connective tissue, encloses the joint in a strong sheath, like sleeve. Lining the joint capsule is the synovial membrane, which secretes synovial fluid into the joint cavity. This fluid is thick and slippery and prevents friction as the bones move. Cartilaginous Joint Made up of cartilage. Joint where cartilage fixes two bones together so that they cannot move. Primary cartilaginous bone- temporary joint where the intervening cartilage is converted into adult bone. Secondary cartilaginous bonejoint where the surfaces of the two bones are connected by a piece of cartilage so that they cannot move. Ball and socket joint

55

Joint where the rounded edge of along bone fits into a socket or another bone. Fibrous joint Joint where two bones are fixed together by fibrous tissue, so that they can move only slightly. Hinge Joint Joint which allows the two bones to move in one plane only. Pivot joint Joint where bone can rotate easily. Saddle joint Synovial joint where one element is concave and the other convex, like the joint between the thumb and wrist.

IV.

SYMPTOMATOLOGY AND ETIOLOGY

56

A. SYMTOMATOLOGY Symptoms Pain: Your Actual Symptoms joints may Moderate pain in the right knee. Interpretation Osteoarthritis causes the cartilage in a joint to become stiff and lose its elasticity, making it more susceptible to damage. Over time, the cartilage may wear away in some areas, greatly decreasing its ability to act as a shock absorber. As the cartilage tendons wears away,

ache, or the pain may feel burning or sharp. For

some people, the pain may come pain and or go. pain

Constant

while you sleep may be a sign that your arthritis is getting worse.

and ligaments

stretch, causing pain. If the the condition bones worsens, could rub other,

against

each

causing even more pain

Stiffness:

When

Stiffness in the right knee.

and loss of movement. Stiffness will also occur when the joints are used more than normal. Most sufferers find that the

you have arthritis, getting up in the morning can be

57

hard.

Your

joints

stiffness is the worst in the morning, and severe stiffness will last less than 30 minutes. Moving the joint repeatedly in

may feel stiff and creaky for a short time, until you get moving. You may also get stiff from sitting.

moderate way can often help Muscle weakness in the right leg. to alleviate the

Muscle weakness: The around may get muscles the joint

stiffness. Muscle has an integral role in the structure and function Evidence weakness of for joints. muscle in

weaker.

This happens a lot with arthritis in the knee.

osteoarthritis of the knee exists and is not fully explained by the effects of aging. Weakness is associated with pain and disability. The temporal relationship further study, requires but

preliminary evidence for a causative emerging. role is

Muscle

58

weakness assessed ways.

can in

be various

Voluntary

measures of strength are affected by degree of effort. In osteoarthritic as in other

patients,

patient groups, effort may be influenced by pain and Swelling/ Arthritis Tenderness: can cause Swelling in the right knee. psychologic outlook. Once the synovial membrane (smooth

swelling in joints, making them feel tender and sore.

tissue that surrounds the joint) becomes irritated by the erosion of cartilage, it may produce an

excessive amount of fluid that can collect within the joint and lead to continual Deformed joints: Joints can start to look like they are the wrong shape, or occasional swelling. Progressive breakdown of cartilage may lead to the formation of enlarged bony growths or "spurs

especially as arthritis gets

59

worse.

"on the bone ends. Such growths increase the

appearance of swelling and knobbiness as they continue

the

cycle

of

Reduced range of motion: As your

Difficulty in changing

irritation and swelling. The range of motion of a given joint depends

arthritis gets worse, you may not be able to fully bend, flex, or extend your joints. Or you may not be able to use them at all.

position while lying on bed,

primarily on the structure and function of bone,

muscle and connective tissue. OA affects the structure of these tissues, such that range of motion and reduced. flexibility are

B. ETIOLOGY

Predisposing Factors

Actual findings

Implications

Since the patients Grandfather was diagnosed having

60

Hereditary

Osteoarthritis, based on researches a patient is more likely to develop osteoarthritis if one or both of your parents had the condition. It also suggests that

defective genes, which cause deterioration of the joint, Gender can be passed down from parent to child. Since the patient is a female, her body is designed to give birth, and that means the tendons in her lower body are more elastic than men. Also, osteoarthritis is more common in women after age 45 compared to men who experienced osteoarthritis before age 45.

Age

The patient was considered old as evidenced by her age. Osteoarthritis usually occurs in older people (although it can afflict young adults who experience joint injuries). Almost all people over 65 show some signs of developing osteoarthritis, and by age 70, nearly every person will have this condition. <http://www.home-remedies-foryou.com/blog/osteoarthritis-hereditary-disease.html>

61

V.

PATHOPHYSIOLOGY a. Narrative The main cause of Osteoarthritis is an imbalance in the natural breakdown and

repair process that occurs with cartilage. In Osteoarthritis, damaged cartilage cannot repair itself in the normal way. It occurs when the cartilage that covers and cushions the ends of bones in your joints deteriorates over time. Cartilage is composed of water, collagen, and specific proteins. In healthy cartilage, there is a continual process of natural breaking down and repair of the cartilage in joints. This process becomes disrupted in Osteoarthritis, leading to cartilage deterioration and an abnormal repair response. The reason this normal repair process is disrupted is not known but it is likely caused by several factors. With aging, the water content of the cartilage increases, and the protein makeup of cartilage breaks down. Eventually, the smooth surface of the cartilage begins to deteriorate and become worn causing friction between the bones. If the cartilage wears down completely, the result will be bone to bone contact. Repetitive use of worn joints over the years can irritate the cartilage, causing joint pain and inflammation of surrounding tissues. As pieces of cartilage break off, the bones thicken and broaden, causing inflammation. This inflammation may stimulate new bone outgrowths called spurs (also called osteophytes) to form around the joints. As the bones thicken and broaden, joints become stiff, painful, and may be difficult to move. Fluid may also build up in your joints.

b. Diagram
Predisposing Factors Precipitating Factors

Age 63 years old Hereditary - + Grandfather Gender - Female

Loss of HMGB2 that can cause loss of chondrocytes in the cartilage Degeneration of cartilage

Diet Excessive Activity level

Pinch/crowd nerve Pai n

Formation of osteophytes

Narrowing of joint spaces Formation of subchondral cysts

Increase in synovial fluid Pressure between joint Pain

Difficulty of moveme nt Continuous use of joint

Disappearing of full thickness of articular cartilage Release of chemical mediators Inflammatory response Immobilization

If treated:

Repair and remodelling

Acts on pain receptors Pai n

Increase blood flow

Increase vascular permeablity edem a

Osteoarthriti s

If not remodeled Surgery, GH & stem cell injection

Redness, increase WBC

63

VI.
A.

PLANNING

Nursing Care Plan 1 DATE /SHIFT CUES NSG. DIAGNOSIS OBJECTIVE OF CARE Independent: November 15,2010 7-3 Subjective: Sakit pa akong tuhod day as verbalized by the patient Pain Scale: 7 0 10 Numeric Rating Scale Acute Pain related to joint degeneration secondary to Osteoarthritis Scientific basis: After 2 hours of nursing interventions the patient will manifest reduction of Assessed the patients description of pain. The patient may manifest any or part of the defining characteristics, so focused assessment is important. Goal met as evidence by Dili na kaayo xa sakit makaya kaya na kung irate Changed positions frequently while maintaining functional alignment. Muscle spasm may result from poor alignment, resulting in increased discomfort. Supported joints in slightly
64

INTERVENTION

Evaluation

0-None 1-3 Mild 4-6 Moderate

In patients older than pain from a 55 years of age, women pain scale of 7 are more frequently affected. Osteoarthritis is to 4 or lesser distinguished by a as evidence progressive degeneration of the cartilage in a joint by: usually weight-bearing joint, but any joint can be Absence of affected. True to the facial progressive nature of the disease, the cartilage grimacing and continues to degenerate, Absence of and bone spurs called

nako from 1-10, 2 nalang xa as verbalize by the patient. No

7- 10 Severe

osteophytes develop at the joint margins and at the attachment sites of the tendons and ligaments. In the joint margin, there can be thickening of the joint capsule and the formation of osteophytes that may cause pain. . Reference:

restlessness.

flexed position through the use of pillows, rolls, and towels. Flexion of the joint may reduce muscle spasms and other discomforts. Applied hot pack. Some patients prefer hot therapy over cold therapy to provide comfort. Provided for adequate rest periods Fatigue impairs ability to cope with discomfort. Provided assistance and utilized adaptive equipment (e.g., cane, walker) when needed. These aids assist in ambulation and reduce joint stress

facial grimacing and signs of restlessnes s noted.

Objective: 63 years old Female Facial grimace Limited ROM

Gulanick/Myers Restlessness Vital signs: Temp-37.2C Eustice, RR- 20cpm PR-90bpm BP- 120/80 mmHg Causes Pain Carol. in Edition, Mosby

2007 Inc.

Nursing Care Plans 6th pp.777-780. What a

Osteoarthritis

Joint?About.com Guide.13, June 2008

McCaffery, M., & Beebe, A. (1993). Pain: Clinical Manual for Nursing

65

Practice. Baltimore: V.V. Mosby Company.

Dependent: Administered a muscle relaxant drug (Myonal 50 mg tid) as ordered. This drug may relax painful muscle spasm. Provided instruction in important side effect of muscle relaxant. This drug may cause drowsiness and may exaggerate the CNS depressive effects of alcohol and other drugs.

66

B. Nursing Care Plan 2 DATE /SHIFT CUES NSG. DIAGNOSIS OBJECTIVE OF CARE INTERVENTION EXPECTED OUTCOMES

November 15,2010 7-3

Subjective cues: Dili na kayo naku malihok lihok akong tiil kay magsakit man gud, as verbalize by the patient. Objective: Limited Range of Motion (Able to walk for

Impaired physical Mobility r/t joint degeneration as evidenced by verbalization of limited range of motion.

After 6-hours of rendering nursing interventions and health teachings, the patient will demonstrate

Assisted patient to do active/passive ROM exercise to affected and unaffected extremities To increase the blood flow to muscles and bone to improve muscle tone Observed movement of the client

Goal met as evidenced by demonstrating flexion/extension of extremities and able to care one self by bathing herself and combing herself

SB: OA was associated with significant impairment, and had an important impact on, healthrelated quality of life in

behaviors that enable resumption of activities such as active and passive ROM

only 4-5 steps) Stiffness of the right knee Unable to flex/bend her right knee Difficulty in changing position while lying on bed Walks and stands with assistance (Able to walk for only 4-5 steps) 63 years old Female Diagnosed with osteoarthritis

the areas of ambulation, body care and movement, emotional behavior, sleep and rest, home management, and work, especially in patients ages 4160. The older patients differed less from the controls than did the younger ones. Items that contributed to the differences between OA patients and controls were mainly related to physical limitations.

exercise.

To note any incongruence with report of abilities Assisted client or encourage client to do self care activities like bathing To improve muscle strength circulation and promote self directed wellness

Monitored Vital signs It serves as a baseline data

Reference: http://journals.cambrid

Removed excess clothing especially

68

ge.org/action/displayA bstract? fromPage=online&aid =565320

the rough ones This would lead to further damage of the skin

Responded immediately to complaint of the patient prompt responses to complaints may result in decreased anxiety in patient

Provided rest periods to facilitate comfort, sleep and relaxation

69

 Fatigue on the patient may exaggerate on the pain he experienced

Dependent Administration of analgesics as prescribed To relieve pain Application of heat or cold compress as ordered Hot moist compress have penetrating effect. Cold compress promote some
70

numbing thereby promoting comfort

C. Nursing Care Plan 3

71

DATE /SHIFT November 15,2010 7-3

CUES

NSG. DIAGNOSIS

OBJECTIVE OF CARE That within our 6-hour span of care, our patient will be safe and remain free from injury as evidenced by:

INTERVENTION

EXPECTED OUTCOMES GOAL MET! After 6 hour span of care our patient was free from injury as evidenced by:

Objective: Limited Range of motion Stiffness of right knee Walks and stands with assistance (Able to walk for only 4-5 steps) 63 years old Female Diagnosed with osteoarthritis

Risk for injury r/t limited range of motion secondary to joint degeneration

1.) Noted age and sex. Children, young adults, elderly persons and men are at greater risk. 2.) Evaluated developmental level, decisionmaking ability, level of competence. Serves as a baseline data in avoiding injury. 3.) Assessed muscle strength, gross and fine motor coordination. To serve as a baseline date for the tolerance of exercise and other activities. 4.) Observed for signs of injury (e.g. old/new bruises, history of fractures, frequent absences from work). To evaluate degree/source of risk inherent in the

Scientific basis: A huge assortment of things can influence range of motion, including disease, injury, trauma, physical activity, and other events. People with a limited range of motion may experience frustration because they cannot engage in many common tasks, and they can be at increased risk of injury and other medical problems as a result of their stiffer joints and muscle groups. For example, a woman who cannot fully bend her knee joint may be prone to falls or injuries to muscle groups in the leg.

a.) no falls or accidents b.) absence of possible complicat ions from fall,

a.) no falls or accident s, b.) absence of possible complic ations from fall, c.) provide a safe environ ment for the patient such as; c.1) raising 72 of side rails

-Vital signs: Temp-36C RR- 20cpm PR-74bpm BP- 120/80 mmHg

73

VII.

PHARMACOLOGICAL MANAGEMENT Indication Mechanism ofSide Effects Action Short term Inhibits the-drowsiness -abnormal thinking - euphoria - headache - asthma - dyspnea - edema - pallor Nursing Responsibilities Pt. who has

Date/ Shift Name of Drug/Classification Dosage/ Drawing . November 13, 2010 Ketorolac Time/ Route Nonsteroidal 30mg/q antiinflammatory agents, nonopioids analgesics. Write the frequency 8/IVTT

management prostaglandin of pain (not tosynthesis, also exceed 5 daysproducing total routes combined). for allperipherally mediated analgesics. Also have antipyretic and antiinflammatory

asthma, aspirin induced are at allergy, risk for and nasal polyns developing hypersensitivity reactions. Assess for rhinitis, asthma and urticaria. -Assess pain (note type, location, and intensity) prior to and 1-2 hrs

properties.

- vasodilation following

- GI bleeding - diarrhea - dry mouth - GI pain - nausea -urinary frequency - oliguria

administration. Advice pt. to if

consult health care professionals disturbances, tinnitus, stools, weight persistent or (drills, muscle pain) gain, edema, black headache, influenza-like syndrome aches, - sweating - paresthesia occurs. rash, itching, visual

-renal toxicity fever,

75

Date/ Name of Drug/Classificati Dosage/ Shift Drawing Nov. 13, 2010 / (NSAIDs) 73 Diclofenac on nonsteroidal antiinflammator y drug 6-6 25 mg BID Time/ Route 1Tab

Indication

Mechanism Action

ofSide Effects

Nursing Responsibilities - Advise patient to take this by medication

Treatment mild moderate pain, fever, and

of Inhibits the Lipo--Ulcerations toxygenase pathways, thus reducing formation so -abdominal Burning pain of

mouth with a full glass of water (8 ounces directed phycisian. or 240 by milliliters)as

inflammation. the leukotrienes(al -cramping pro-nausea inflammatory auta coids. also speculation that diclofenac inhibit phospholipase A2 as part of its mechanism action. of may There is -gastritis

-Advise

the

patient not to lie down for at least 30 minutes after taking this drug. To prevent upset, this 76 with

stomach take medication antacid.

ask the patient to

food, milk, or an

77

Date Name of Drug/Classification / Drawing Antirheumatics, 13 2010 nonsteroidal antiinflammatory agents / Shift Nov. Celebrex

Dosage/ Time/ Route 400mg/ 1cap/ OD/PO

Indication

Mechanism Action

ofSide Effects

Nursing Responsibilities

Management acute primary rhea.

Inhibits ofenzyme

the-dizziness

COX-2. -headache painThis enzyme is required for the-insomnia synthesis of -edema

including

dysmenor- prostaglandins. Have analgesics,-GI bleeding antiinflammatory, and -Diarrhea antipyretic -Dyspepsia -Flatulence -Nausea -Rash -Abdominal pain

- Assess range of motion, degree of swelling, and pain in affected joints before and periodically throughout therapy. - Assess pt for allergy to sulfonamides, aspirin, or NSAIDs. Pt. with these allergies should not receive celecoxib.

properties.

78

Date/ Name Shift Drawing Nov. Myonal 15, 2010 / 73

of

Drug/Classification

Dosage/

Indication

Mechanism

ofSide Effects Nursing Responsibilities -Patients should be in cautioned potentially against engaging hazardous activities requiring alertness, such as operating machinery driving a car. -Since the elderly theoften have a or

Muscle relaxant

Time/ Route Action 1 Tab Improvemen Inhibition of-Sleepit of Experimen-tallymyotonic Induced Muscleness 50mg TID symptoms in Rigidity: the following Eperisone HCl-Insomia P.O diseases: suppresses Cervical intercollicu-lar 6-12-6 -Head syndrome section-induced Periarthritis decerebrate of the rigidity (-rigidity)Ache shoulder, lu and ischemic -numbmbargo decerebrate rigidity (-rigidity) in rats dose-ness dependently.
Discharge Plan

in

extremi-ties physiological hypofunction, it is -weakness advisable to take -lightheadedness measures, as dosage careful such in under reduction

79

supervision. - Since shock and anaphylactoid reactions occur, should carefully observed. In the event redness, of itching, symptoms such as urticaria, edema of the face or other parts and dyspnea etc., should discontinued appropriate measures taken. treatment be and may patients be

80

81

VIII.

DISCHARGE PLAN

DISCHARGE GOALS: 1. Dealing with current situation realistically. 2. Pain relieved/controlled. 3. Complications prevented/minimized. 4. Mobility/function regained or compensated for. 5. Prognosis, and therapeutic regimen understood.

Medications

Instruct the patient the importance of compliance to medicines. achieve appropriate therapeutic effects.

Rationale: to

Instruct the patient to report adverse reaction promptly.

Rationale: to prevent further complications.

Explain the medications how they work, the side effects, and precautions.

Rationale: to know how to react on unexpected problem during the course of taking the medication.

Give

adequate

instructions

to

the significant

others

about the

importance of the following medications and dietary regimens.

83

Rationale: so that the patients condition can remain stable as soon as possible. Exercise/Environment

Encourage walking.

Rationale: to endure musculoskeletal functioning.

Abduction of pillows, sitting recommendations, a little bed rest and frequent positioning of the patient as much as possible.

Rationale: to support the back and prevent further complications.

Instruct patient to stay in calm, quiet environment.

Rationale: for the patient not to be uneasy all the time. Home environment must be free from slipping or accident hazards. Rationale: this may contribute to different kinds of injury. Reinforce the need to continue exercises at home. Active ROM exercises

increase muscle mass, tone, & strength pressure joint mobility & improve cardiac & respiratory function. Rationale: to prevent further complications.

Encourage/advise patient to use/wear a clean cotton T-shirt to prevent perspiration.

contact between the skin & shoulder harness & to promote absorption of Rationale: to prevent pulmonary problems. Treatment:

Promote monotherapy (treatment with a single agent) if appropriate

84

Rationale: to simplify the medication regimen and make it less expensive.

Encourage the client to relax and have adequate rest stress and promote healing.

Rationale: to prevent

Encourage the client to compliance on further treatment proper maintenance and gain of optimal health. self-

Rationale: for the

Encourage active participation of patient in the program, including monitoring of blood pressure and diet.

Rationale: for increased compliance.

Remind clients relative on close monitoring of clients activities. some may interfere with ongoing treatment and procedures

Rationale: as

Health Teachings:

Practice good hygiene.

Rationale: to prevent acquiring bacteria and germs that may lead to inflammation and fever.

Practice good preventive measures by eating proper diet.

Rationale: to maintain weight and prevent being overweight or underweight.

Getting regular exercise and plenty of sleep.

Rationale: to regain energy.

Instruct patient to avoid strenuous activity.

Rationale: this may lead to muscle pain.

85

Out-patient Referral: Remind the patient with an immediate family member or her son for a follow-up appointment in the hospital 1-2 weeks after discharge or when complications of the disease appear. Rationale: to have a close monitoring on her condition.

Diet:

Encourage the patient to drink Milk.

Rationale: for the bones and to prevent osteoporosis Discourage the client to eat sardines.

Rationale: this may contribute to acute attacks of arthritis.

Encourage patient to increase fluid intake

Rationale: to prevent dehydration.

Recommend cessation of smoking. vasoconstriction, impairing circulation and

Rationale: Smoking potentates peripheral tissue oxygenation.

Inform patient that there are no restrictions in the diet except for foods that could interact & delay absorption of some medications, & those that are included in her food-allergy list.

86

Instruct the patient to eat at the right time.

Rationale: to prevent skipping of meals and further complications X. SYNTHESIS OFCLIENTS CONDITION A. CONCLUSION In line with the information being gathered, our patient was diagnosed of

Osteoarthritis, r/o Gouty Arthritis. Osteoarthritis was given emphasis during the
course of case study. With these, there is a need to monitor clients condition in terms of signs and symptoms of this disease as well as the degree and severity of its occurrence so as to collaboratively intervene to stabilize the patient. Moreover, taken the consideration of implementing prescriptive orders of medicine are given importance. However the progress and fast recuperation of the client depends on the cause and severity of the condition, therefore modifications in activities, exercise and diet particularly in taking foods which are rich in purines are prohibited. There is also a need for the patient as well as the family members to watch more closely in monitoring and assessing her condition well to avoid further complications. B. PATIENTS PROGNOSIS CRITERIA Onset Illness of GOOD FAIR POOR JUSTIFICATION The patient resorted into seeking medical attention upon the onset of the disease episode. Duration of Illness Duration of illness is rated as good since her condition was being monitored and followed the advices by her physician.

87

Willingness to take treatment regimen Age

Patient is very cooperative in achieving fast recuperation by religiously taking her prescribed medications. Ages 45 and above are the highest age risk of acquiring osteoarthritis. Since this accompanies with aging, patient is rated as poor. The environment of the client is not hazardous to her condition. Both males and females are prone of having osteoarthritis.

Environment Gender

Family Support

The family had supported the client during her condition has been identified, during her hospital stay and verbalized that they would try their best to help the patient recover easily.

Legend: Good - 3pts. Rating: Good: 2.4 3.0 Fair: 1.7 2.3 Poor: 1 1.6 Fair - 2pts. Poor -1pt.

Computation:

88

Good: 3 x 5 = 15 Fair: 2 x 0 = 0 Poor: 1 x 2 = 2 *15/7 = 2.1 (Fair Prognosis)

GENERAL PROGNOSIS: Based on the aforementioned result, the overall prognosis of the client is fair. The client is on the process of achieving a state of good care providence given by the health care team as well as the support rendered by her family members. The family assured that they will support the client financially and emotionally and will see to it that the patient will religiously take the medications prescribed on time. Moreover, the client is willing to subject herself into treatment that will therefore facilitate her fast recuperation.

C. RECOMMENDATION Home Treatment If the doctor has prescribed medications, give the medicine on schedule for as long as directed. This will help the patient recover faster and will decrease the chance that the condition will worsen. Encourage the patient to avoid foods which contains purine such as sardines since this will contribute to the severity and worsening of the disease. Advice to drink milk or to eat milk containing foods which is good for the bones and thus prevents the formation of osteoarthritis. Apply alternate warm and cold compress to alleviate the pain felt by the patient. Provide comfort measures such as rubbing three inches away of the area of pain or

89

provide diversional activities. Promote good hygiene for the patients comfort measures since the patient is immobilized momentarily.

XI.

EVALUATION OF THE OBJECTIVES OF STUDY Our target objectives were met after we have done our study for our patient. We

have performed physical assessment and identified the chief complaints of the patient, distinguished the family history to trace the possibilities of the occurrence of the disease, reviewed the procedures that have been done on the patient during her admission, enumerated and classified the drugs that was given to the patient and associated its action or effects to the patient, enumerated the normal values and interpretations of the diagnostic examinations that was being performed to the patient, reviewed the anatomy and physiology of the affected organs and system, comprehended and traced the pathophysiology pertaining to osteoarthritis recognized the course in the ward and appropriate nursing interventions to be done, rated the overall prognosis of the patient, provided recommendations regarding with patients case, formulated and enumerated discharge plans for the patient, and evaluated the objectives of the study in the end.

XI.

BIBLIOGRAPHY A. BOOKS

Applegate, Edith J. The Anatomy and Physiology Learning System: Textbook. W.B. Saunders Company. Philadelphia. 1995.

Boyer, M.J. (2010). The Study Guide for Brunner & Suddarths Textbook of Medical - Surgical Nursing. 12th ed. Philadelphia : Lippincott Williams & Wilkins

Deglin, V.H. Pharma D, & Vallerand, April.H. , PhD, RN, FAAn, 2009, DAVISs DRUG GUIDE for NURSES, 11th Edition. F.A. Davis Company

Dillon (2007). Assessing the Sensory-Neurologic System, Nursing Health Assessment A critical Thinking, Case Studies Approach. F.A. Davis Company 1915 Arch Street Philadelphia, PA 19103

Dillon (2007). Assessing the Integumentary System, Nursing Health Assessment A critical Thinking, Case Studies Approach. F.A. Davis Company 1915 Arch Street Philadelphia, PA 19103

Dillon (2007). Assessing the Head, Face and Neck, Assessing the Eye and Ear. Nursing Health Assessment A critical Thinking, Case Studies Approach. F.A. Davis Company 1915 Arch Street Philadelphia, PA 19103

91

Dillon (2007). Assessing the Respiratory System. Nursing Health Assessment A critical Thinking, Case Studies Approach. F.A. Davis Company 1915 Arch Street Philadelphia, PA 19103

Dillon (2007). Assessing the Cardiovascular System. Nursing Health Assessment A critical Thinking, Case Studies Approach. F.A. Davis Company 1915 Arch Street Philadelphia, PA 19103

Dillon (2007). Assessing the Abdomen. Nursing Health Assessment A critical Thinking, Case Studies Approach. F.A. Davis Company 1915 Arch Street Philadelphia, PA 19103

Dillon (2007). Assessing the Female Genitourinary System. Nursing Health Assessment A critical Thinking, Case Studies Approach. F.A. Davis Company 1915 Arch Street Philadelphia, PA 19103

Dillon (2007). Assessing the Motor- Musculoskeletal System. Nursing Health Assessment A critical Thinking, Case Studies Approach. F.A. Davis Company 1915 Arch Street Philadelphia, PA 19103

Fundamentals of Nursing 8thedition.page 353 Gulanick/Myers 2007 Nursing Care Plans 6th Edition, Mosby Inc. pp.777-780. Pillitteri,A.(2007).Maternal & Child Health Nursing:Care of the Childbearing Family. New York: Lippincott Williams & Wilkins

Robert J. Havighurst (1971) Developmental Tasks and Education, Third Edition. New York. Longman.

Van De Graaff, Kent M. Human Anatomy 5th Edition. WEB McGraw-Hill. Boston, MA. 1998.

92

Valerie C. Scanlon, Tina Sanders. Essentials of Anatomy and Physiology, 5th Ed. Smeltzer, Suzanne C.et al.2010.Medical-Surgical Nursing.Volume1.12th

edition.530 Walnut St. Philadelphia PA 19106:Wolters Kluwer Health/Lippincott Willams & Wilkins.

B. WEB

Chidambaranathan, S. Chennaionline Archives. All About Urine Urinalysis. n.d. Retrieved July 25, 2010 from

http://archives.chennaionline.com/health/homoeopathy/2005/04homoeopathy40. asp

Crowley, I. Medical Technology. Clinical Laboratory Science: Urinalysis. n.d. Retrieved July 25, 2010 from http://www.irvingcrowley.com/cls/urin.htm

DeMoranville, V.E., Best, M.A. Encyclopedia of Surgery. Urinalysis. n.d. Retrieved July 25, 2010 from http://www.surgeryencyclopedia.com/St-

Wr/Urinalysis.html Ed Uthman, MD., (2009). Interpretation of Lab Test Profiles. file:///C:/Documents %20and%20Settings/angelo%20gaebriel/My%20Documents/LAbtst.htm

Gayle Lester, P. J.-S., Kenneth D. Brandt, M. I., & Victor M. Goldberg, M. U. (2010, july). Handout on Health: Osteoarthritis. Retrieved 2010, from National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS): http://www.niams.nih.gov/Health_Info/Osteoarthritis/default.asp

93

http://www.ehealthmd.com/library/osteoarthritis/OSA_causes.html http://en.wikipedia.org/wik http://www.ehealthmd.com/library/osteoarthritis/OSA_symptoms.htmlCopyrig http.haverford.com http://www.home-remedies-for-you.com/blog/osteoarthritis-hereditarydisease.html

http://www.ihaveosteoarthritis.com/what-causes-it.php http://www.jarretmorrow.com/osteoarthritis-and-knee-pain-increase-risk-of-fallsin-elderly/

http://journals.cambridge.org/action/displayAbstract? fromPage=online&aid=565320

http://www.microbiologytext.com/index.php http://www.osteoarthritisremedy.com/herbal remedies/osteoarthritisremedy/osteoarthritis-stiffness

http://www.webmd.com/osteoarthritis/tc/osteoarthritis-symptoms http://www.webmd.com/osteoarthritis/tc/osteoarthritis-symptoms Integrative medicine by David Rake, http://books.google.com.ph/books?

id=G7uXK9Z2TSoC&pg=PA668&lpg=PA668&dq.com

94

Kennedy, R. The Doctors Medical Library. Urinalysis Report Interpretation. n.d. Retrieved July 25, 2010 from http://www.medical-

library.net/urinalysis_interpretation.html

Muscle

weakness

in Unit,

osteoarthritis.

O'Reilly

S, Jones City

A, Doherty

M. UK.

Rheumatology

Nottingham

Hospital,

http://www.ncbi.nlm.nih.gov/pubmed/9204263

Statistics by Country for Ostearthritis. (2004). Retrieved 2004, from Wrong Diagnosis: http://www.wrongdiagnosis.com/o/osteoarthritis/stats-country.htm

William C. Shiel Jr., M. F. (2010). Osteoarthritis. Retrieved 2010, from Medicinenet.com: http://www.medicinenet.com/osteoarthritis/article.htm

What causes osteoarthritis, eHealthMD 2010, http://www.ehealthmd.com/library/osteoarthritis/OSA_causes.html

Zaykoski, L.A. (2010, May 4). Bright hub, The hub for bright minds. Urinalysis Interpretation: Information on Urinalysis Values. Retrieved July 25, 2010 from http://www.brighthub.com/science/medical/articles/30891.aspx)

C.OTHERS

Medical Records Section, Davao Regional Hospital (2009). Cases of Osteoarthritis. Tagum City.

95