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RLE at Philippine

Orthopedic

Center


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1st

Day

The first day in our duty at POC is cancelled due to bad weather

2nd

Day

The 2ndday is the day our duty in POC officially started; the first activity is orientation which is attended

not only my group but others from other schools too. The speaker discuss about the rules and all about

to know in the hospital. Afterwards they demonstrated step by step procedure on how to do BST. After

the orientation we then eat and decided to go home.


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3rd

Day

The 3

rd

day, our activity this day is touring specifically on the Childrens ward. Afterwards we go to thelibrary located at the second floor of the nurse training office, which has a lot of interesting things

specially reports of other nursing student coming from latter batches. This is also the day we got our

individual report during our post conference In the service.


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4th

day

The 4

th

day, our activity this day is continuation of our exposure in the childrens ward where, we arenow able to read the chart, interview our patients. Afterwards we continue our day by means of actual

introduction of hardwares use in POC. Then we continue by reporting and take quizzes then go home.


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5th

day

The 5

th

day, there is no duty because of bad weather.

6th

day

The 6thday, our activity this day is performing step by step procedure of BST. But this comes later before

we tour the male ward. on the occasion of visiting the ward I notice that almost all of the patient is there

because of the fact that they use motorcycles or along the lines of it. Then afterwards we go to the

classroom to perform the said BST which we are group by 3s. After all of this, we packed up then go

home.


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7th

day

The 7

th

day, our activity for this day is touring on OPD. During my exposure at this area of POC Ipersonally see kinds of cast in which I only see on papers or dolls for the reason that weve only been

expose to such area which specializes on bones or along the lines of it. Afterwards we do our reporting

as scheduled and take a quiz, then go home afterwards.


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8th

day

The 8

th

day, there is no duty because of the fact that Calamba is celebrating a holiday.

9th

day

The 9thday, our activity for this day is touring first to spinal ward, male ward B and lastly the traction

ward. Many of the people located there have bone problem obviously and majority of them got it from

vehicular accident. Then afterwards we then go and see the gadget in miniature size all of which are

used in POC, then proceeded to reporting. We go home after finishing all the said activities.


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10th

day

The 10

th

day is our evaluation day, our activity for this day is evaluating our knowledge gainedthroughout our exposure in POC. To do this we take extensive exam covering about bone, casting etc.

after this we go to mental to do some stuff and go home.


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Carpal tunnel syndrome(CTS) is a median entrapment neuropathy that causesparesthesia, pain,

numbness, and other symptoms in the distribution of themedian nerve due to its compression at the

wrist in the carpal tunnel. The mechanism is not completely understood but can be consideredcompression of the median nerve traveling through the carpal tunnel. It appears to be caused by a

combination of genetic and environmental factors.[2]Some of the predisposing factors

include: diabetes, obesity, pregnancy, hypothyroidism, and heavy manual work or work with vibrating

tools. There is, however, little clinical data to prove that lighter, repetitive tasks can cause carpal tunnel

syndrome. Other disorders such as bursitis and tendinitis have been associated with repeated motions

performed in the course of normal work or other activities.

The main symptom of CTS is intermittent numbness of the thumb, index, long and radial half of the ring

finger.[4]The numbness often occurs at night, with the hypothesis that the wrists are held flexed during

sleep. Recent literature suggests that sleep positioning, such as sleeping on one's side, might be an

associated factor.[5]

It can be relieved by wearing a wrist splint that prevents flexion. Long-standing CTS

leads to permanent nerve damage with constant numbness, atrophy of some of the muscles of

the thenar eminence, and weakness of palmar abduction.

Pain in carpal tunnel syndrome is primarily numbness that is so intense that it wakes one from sleep.

Pain in electrophysiologically verified CTS is associated with misinterpretation

of nociception anddepression.

Conservative treatments include use of night splints and corticosteroid injection. The only scientifically

established disease modifying treatment is surgery to cut the transverse carpal ligament.

There is no consensus reference standard for the diagnosis of carpal tunnel syndrome. A combination ofdescribed symptoms, clinical findings, and electrophysiological testing is used by a majority of hand

surgeons. Numbness in the distribution of the median nerve, nocturnal symptoms, thenar muscle

weakness/atrophy positive Tinel's sign at the carpal tunnel and abnormal sensory testing such as two


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Prevention

Suggested healthy habits such as avoiding repetitive stress, work modification through useof ergonomic equipment (wrist rest,mouse pad), taking proper breaks, using keyboard alternatives

(digital pen, voice recognition, and dictation), and employing early treatments such as taking turmeric

(anti-inflammatory), omega-3 fatty acids, and B vitamins have been proposed as methods to help

prevent carpal tunnel syndrome. The potential role of B-vitamins in preventing or treating carpal tunnel

syndrome has not been proven. There is little or no data to support the concept that activity adjustment

prevents carpal tunnel syndrome.

Stretches and isometric exercises will aid in prevention for persons at

risk. Stretching before the activity and during breaks will aid in

alleviating tension at the wrist. Place the hand firmly on a flat surface

and gently pressing for a few seconds to stretch the wrist and

fingers. An example for an isometric exercise of the wrist is done by

clinching the fist tightly, releasing and fanning out fingers. None of

these stretches or exercises should cause pain or discomfort.

Carpal tunnel prevention stretch

Biological factors such as genetic predisposition and anthropometrics

had significantly stronger causal association with carpal tunnel

syndrome than occupational/environmental factors such as

repetitive hand use and stressful manual work.[56]This suggests that

carpal tunnel syndrome might not be preventable simply by avoiding certain activities or types of

work/activities.
http://en.wikipedia.org/wiki/File:Carpal_tunnel_prevention_stretch.JPG


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A rigid splint can keep the wrist straight

The importance of wrist braces and splints in the carpal tunnelsyndrome therapy is known, but many people are unwilling to

use braces. In 1993, The American Academy of Neurology

recommend a non-invasive treatment for the CTS at the

beginning (except for sensitive or motor deficit or grave report at

EMG/ENG): a therapy using splints was indicated for light and

moderate pathology. Current recommendations generally don't

suggest immobilizing braces, but instead activity modification and non-steroidal anti-inflammatorydrugs as initial therapy, followed by more aggressive options or specialist referral if symptoms do not

improve.

Many health professionals suggest that, for the best results, one should wear braces at night and, if

possible, during the activity primarily causing stress on the wrists.

Corticosteroids

Corticosteroid injections can be effective for temporary relief from symptoms while a person develops a

long-term strategy that fits their lifestyle. This treatment is not appropriate for extended periods,

however. In general, local steroid injections are only used until other treatment options can be

identified. For most surgery is the only option that will provide permanent relief.
http://en.wikipedia.org/wiki/File:Carpal_tunnel_splint.jpghttp://en.wikipedia.org/wiki/File:Carpal_tunnel_splint.jpg


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Introduction

Osteomyelitis is a local or generalized pyogenic disease of the bone, bone marrow and surroundingtissue. In children, the disease usually results from untreated acute hematogenous osteomyelitis.

Chronic osteomyelitis may also be seen after traumatic injuries, especially in times of civil unrest or war,

or as a complication of surgical procedures such as open reduction and internal fixation of fractures. The

long bones are affected most commonly, and the femur and tibia account for approximately half of the

cases. Predisposing factors include poor hygiene, anemia, malnutrition, and a coexisting infectious

disease burden (parasites, mycobacteria, acquired autoimmune deficiency syndrome), or any other

factors that decrease immune function. Chronic osteomyelitis is defined by the presence of residual fociof infection (avascular bone and soft tissue debris), which give rise to recurrent episodes of clinical

infection.

Eradication of the infection is difficult, and complications associated with both the infection and their

treatments are frequent. Our goals are to review the pathophysiology, natural history, and management

for children with chronic osteomyelitis within the context of a developing world setting.

Definition

Osteomyelitis (osteo- derived from the Greek word

osteon, meaning bone, myelo- meaning marrow, and -itis


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An open injury to the bone, such as anopen fracture with the bone ends

piercing the skin.

An infection from elsewhere in the

body, such as pneumonia or a urinary

tract infection that has spread to the

bone through the blood (bacteremia,

sepsis).

A minor trauma, which can lead to a

blood clot around the bone and then a secondary infection from seeding of bacteria.

Bacteria in the bloodstream bacteremia (poor dentition), which is deposited in a focal (localized)

area of the bone. This bacterial site in the bone then grows, resulting in destruction of the bone.

However, new bone often forms around the site.

A chronic open wound or soft tissue infection can eventually extend down to the bone surface,

leading to a secondary bone infection. (Black and Hawks, 2005)

Risk Factors

Males are affected more often than females, often as a result of trauma. Susceptibility to infection


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Complications of osteomyelitis include (1) septic arthritis, (2) destruction of the adjacent

soft tissues, (3) malignant transformation (eg, Marjolin ulcer [squamous cell carcinoma],

epidermoid carcinoma of the sinus tract), (4) secondary amyloidoses, and (5) pathologicfractures.

Signs and Symptoms

Clinical manifestations may slightly vary according to the site of involvement. Infection in the long bones

is accompanied by acute localized pain and redness or drainage often with a history of recent trauma or

newly acquired prostheses. Fever and malaise may be present. Infection in the vertebrae usually brings

pain and mobility difficulties. The client with vertebral osteomyelitis often reports a history of

genitourinary infection or drug abuse. Osteomyelitis in the foot is most commonly associated with

vascular insufficiency. (Black and Hawks, 2005)

Acute osteomyelitis refers to the initial infection or an infection of less than 1 month duration. The

clinical manifestations of acute myelitis are both systemic and local. Systemic manifestations include

fever, night sweat, chills restlessness, nausea and malaise. Local manifestations include constant bone

pain that is unrelieved by rest and worsens with activity; swelling, tenderness and warmth at the

infection site; and restricted movement of the affected part. Later signs include drainage from sinus

tracts to the skin and/or the fracture site. (Lewis, 2004)


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increases in level when there is inflammation) usually occur. Along with clinical manifestations, usually

allow initial diagnosis and early treatment while the physician waits for further evidence from blood

cultures or needle aspirate analysis. To diagnose a bone infection and identify the organisms causing it,doctors may take samples of blood, pus, joint fluid, or the bone itself to test. Usually, for vertebral

osteomyelitis, samples of bone tissue are removed with a needle or during surgery.

Radiographic changes related to osteomyelitis are generally evident within 7 to 10 days, but in some

cases the diagnosis is not confirmed on X-rays until 3 to 4 weeks after infection develops. Early acute

osteomyelitis is more efficiently identified by radionuclide bone scans, which can detect lesions within

24 to 72 hours after the onset of infection. Because of its ability to distinguish between soft tissue and

bone marrow, magnetic resonance imaging It is also being used increasingly for definitive diagnosis of

osteomyelitis.

To diagnose osteomyelitis, the doctor will first perform a history, review of systems, and a completephysical examination. In doing so, the physician will look for signs or symptoms of soft tissue and bone

tenderness and possibly swelling and redness. The doctor will also ask you to describe your symptoms

and will evaluate your personal and family medical history. The doctor can then order any of the

following tests to assist in confirming the diagnosis:

Blood tests:When testing the blood, measurements are taken to confirm an infection: a CBC(complete blood count), which will show if there is an increased white blood cell count; an ESR

(erythrocyte sedimentation rate); and/or CRP (C-reactive protein) in the bloodstream, which


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and show an increased concentration of the radioactive material, which can be seen with a

special camera that produces the images on a computer screen. The scan can help your doctor

detect these abnormalities in their early stages, when X-ray findings may only show normalfindings.

Treatment and Management

Elimination of the infecting organisms, both locally from the bone and systemically from the body, is the

major treatment goal for osteomyelitis. Prompt treatment also prevents further bone deformity and

injury, increases client comfort, and avoids complications of impaired mobility. Surgery is initially

performed on the adult client with osteomyelitis to ensure effective debridement and drainage,

elimination if dead space, and adequate soft tissue coverage. Antibiotics alone rarely resolve infection in

adults, but they do work more efficiently after surgical preparation of the treatment area. High doses of

parenteral antibiotics are frequently administered for 4 to 8 weeks to achieve a bactericidal level in the

bone tissue. Oral antibiotics are continued for another 4 to 8 weeks, with serial bone scans and ESR

measurements performed to evaluate the effectiveness of drug therapy. Open drainage wounds are

packed with gauze to promote drainage. If initial treatment is delayed or inadequate, the necrotic bone

separates from the living bone to form sequestra, which serves as a medium for additional

microorganism growth. Chronic osteomyelitis can result.(Black and Hawks, 2005)

The objective of treating osteomyelitis is to eliminate the infection and prevent the development of


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important to first identify the offending organism through blood cultures, aspiration, and biopsy so that

the organism is not masked by an initial inappropriate dose of antibiotics. The preference is to first make

attempts to do procedures (aspiration or bone biopsy) to identify the organisms prior to startingantibiotics.

Splinting or cast immobilization:This may be necessary to immobilize the affected bone and nearby

joints in order to avoid further trauma and to help the area heal adequately and as quickly as possible.

Splinting and cast immobilization are frequently done in children, although motion of joints after initial

control is important to prevent stiffness and atrophy.

Surgery:Most well-established bone infections are managed through open surgical procedures during

which the destroyed bone is scraped out. In the case of spinal abscesses, surgery is not performed

unless there is compression of the spinal cord or nerve roots. Instead, patients with spinal

osteomyelitis are given intravenous antibiotics. After surgery, antibiotics against the specific bacteriainvolved in the infection are then intensively administered during the hospital stay and for many weeks

afterward.

With proper treatment, the outcome is usually good for osteomyelitis, although results tend to be worse

for chronic osteomyelitis, even with surgery. Some cases of chronic osteomyelitis can be so resistant to

treatment that amputation may be required; however, this is rare. Also, over many years, chronicinfectious draining sites can evolve into a squamous-cell type of skin cancer; this, too, is rare. Any

change in the nature of the chronic drainage, or change of the nature of the chronic drainage site,


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Demographic Data

NAME : R.M.

ADDRESS : Caloocan City

AGE : 10 years old

SEX : Male

WEIGHT : 15.9 kg

NATIONALITY : Filipino

RELIGION : Roman Catholic

BIRTHDAY : April 03, 2004

STATUS : Child

ADMISSION DATE : August 8, 2014; 4:30 pm

WARD : Childrens ward

DIAGNOSIS : Chronic osteomyelitis: 3rd

digit, right foot


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PAST MEDICAL HISTORY

Patient has not been hospitalized PTA and is complete in immunization.

FAMILY HEALTH HISTORY

There is a history of high blood pressure on her fathers side. There is no other condition his father said

they have in the family.

PATHOPHYSIOLOGY

Direct entry osteomyelitis can occur at any age when there is an open wound (e.g. penetrating wounds,

fractures) and microorganisms gain entry to the body. Osteomyelitis may also occur in the presence of a

foreign body such as an implant or an orthopedic prosthetic device (e.g. plate, total joint prosthesis).

After gaining entrance to the bone by way of the blood, the microorganisms then lodge in an area of the

bone in which circulation slows, usually the metaphysis. The microorganisms grow, resulting in an

increase in pressure because of the nonexpanding nature of most bones. This increasing pressure

eventually leads to ischemia and vascular compromise of the periosteum. Eventually the infection

passes through the bone cortex and marrow cavity, ultimately resulting in cortical devascularization and

necrosis. Once ischemia occurs, the bone dies. The area of devitalized bone eventually separates from

the surrounding living bone forming sequestra. The part of the periosteum that continues to have blood

supply forms new bone called involucrum. (Lewis, 2004)


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Bacterial invasion

Neutrophil invasion/Inflammatory response

Pus formation Fever Leukocytosis Heat,Leukocyte: 22.2 x 10^ g/L Redness

Swelling

TendernessPus spread into vascular channels

Periosteumlifts form the bone

Non-modifiable:

- 10 yearsold

Modifiable:

- penetrating wound


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Osteoblastic response

Involucrum

Osteomyelitis

Composition Result Normal Values Interpretation Nursing Responsibility

August 11,2014

Urinalysis:

Color

Transparency

RBC

Pus cells

Blood

Light yellow

Hazy

18-20

20-22

Amber to

yellowish

Clear

0-4 hpf

0-5 hpf

Assess for presence of,existence of, & history ofrisk factors for infection.

Monitor laboratorystudies.

Monitor the ff. for signs ofinfection. Elevated temp. Color of respiratory

secretions Appearance of urine

Administer or teachuse of antimicrobial

drugs. Teach patient or

caregiver to wash


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NURSING CARE PLAN

Assessment Nursing Diagnosis Nursing Plan Nursing Intervention Rationale Evaluation

Subjective:

Namamaga

yung paa ko. as

verbalized

Objective:

slow healing of

lesion

swelling of the

right foot

presence of

abscess on the

right foot

weak pulse onthe right foot

Risk for peripheral

neurovascular

dysfunction related

tointerruption of

blood flow

secondsary to

disease condition

At the end of the

nursing

interventions, the

patient will be able

to maintain tissue

perfusion as

evidenced by

palpable pulses,

skin warm, normal

sensation and

stable vital signs.

Assess general

condition of and

contributing

factors to patient.

Evaluatepresence/quality of

peripheral pulse

distal to injury via

palpation.

Assess capillaryreturn, skin color,

and warmth distal

to inflammation.

Provide basis for

understanding

general, current

situation of client.

Decreased/absent

pulse may reflectvascular injury and

necessitates

immediate medical

evaluation of

circulatory status.

Return of color

should be rapid (3-5

secs.). White, cool

skin indicates arterial

impairment. Cyanosis

suggests venous

impairment.

Promotes venous


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Maintain elevation

of inflamed

extremity unless

contraindicated byconfirmed

presence of

compartmental

syndrome.

Investigate sudden

signs of limb

ischemia, e.g.,

decreased skin

temperature,pallor, and

increased pain.

Encourage patient

to routinely

exercise

digits/joints distal

to inflammation.

drainage/decreases

edema.

Osteomyelitis may

cause damage to

adjacent arteries,

with resulting loss of

distal blood flow.

Enhances circulation

and reduces pooling

of blood, especially in

the lower

extremities.


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Subjective:

Ang sakit ng

paa ko. as

verbalized.

Objective:

pain scale-

8/10

with guarding

behaviorwith

reluctance to

attempt

movement;

limited ROM

with reports

of pain

with

Altered comfort:

pain related to

inflammatory

process secondaryto disease condition

At the end of the

nursing

interventions, the

patient will be ableto incorporate

relaxation skills and

diversional activities

to reduce pain.

Investigate

reports of pain,

noting location

and intensity

(scale of 0-10),

note

precipitating

factors and

nonverbal cues.

Maintain bed

rest or chair rest

when indicated.

Place pillows onaffected area.

Encourage

frequent

changes of

position to move

Helpful in

determining

pain

management

and

effectiveness of

interventions.

Bed rest may be

necessary to

limit pain/injury

to joints.

Rests painful

and maintains

neutral position.

Prevents

general fatigue


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distracted

behavior

in bed,

supporting

affected joints

above and

below, avoidingjerky

movements.

Involve in

diversional

activities

appropriate for

individual

situation, e.g.,

coloring of

books, playing

with toys.

and joint

stiffness,

stabilizes joint,

decreasing joint

movements andassociated pain.

Refocuses

attention,

provides

stimulation, and

enhances self-

esteem and

feelings of

general well-

being.


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Objective:

leukocyte: 22.2

x 10^ g/L

with purulent

discharges on

right foot

pus cells in

urine: 20-22hpf

presence of

lesion on rightfoot

Actual infection

related to increasedWBC count and

presence of

pyogenic

microorganisms in

the local infection

At the end of the

nursinginterventions, the

patient will achieve

timely wound

healing; free of

signs of infection.

Assess skin

lesions, notingreports of

increased pain

or presence of

edema,

erythema, foul

odor, or

drainage.

Provide sterile

wound care,

and exercise

meticulous

handwashing.

Instruct

patient not to

Indicates local

infection/tissue

necrosis which is

a major sign of

osteomyelitis.

May prevent

cross-

contamination

and any further

complications.

Minimizes

opportunity for

contamination.

Tachycardia and


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touch wound

with bare

hands.

Monitor vital

signs. Note

presence of

chills, fever

and malaise.

chills/fever

reflect

developing

sepsis.


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DRUG STUDY

DRUG ORDER

(Generic

name,

Dosage,

Route,

Frequency,

etc.)

SPECIFIC ACTIONPHARMACOLOGIC

ACTION OF DRUG

INDICATIONS AND

CONTRAINDICATIONS

ADVERSE EFFECTS OF

THE DRUG

NURSING RESPONSIBILITIES

/PRECAUTIONS

Generic

Name:

Cefuroxime

400mg IV q8

Brand Name:

Kefurox

ANTIINFECTIVE;

ANTIBIOTIC; SECOND-

GENERATION

CEPHALOSPORIN

Preferentially binds to one

or more of the penicillin-

binding proteins (PBP)

located on cell walls of

susceptible organisms.

This inhibits 3rd

and final

stage of bacterial cell wall

synthesis, thus killing the

bacteria.

Indications:

It is effective for the

treatment of penicillinase-

producing Neisseria

gonorrhoea(PPNG).

Effectively treats bone and

joint infections, bronchitis,

meningitis, gonorrhea,

otitis media,pharyngitis/tonsillitis,

sinusitis, lower respiratory

tract infections, skin and

soft tissue infections,

urinary tract infections, and

is used for surgical

prophylaxis, reducing or

Body as a Whole:

Thrombophlebitis (IV

site); pain, burning,

cellulitis (IM site);

superinfections, positive

Coombs' test.

GI:Diarrhea,nausea,

antibiotic-associated

colitis.

Skin:Rash, pruritus,

urticaria.

Determine history of

hypersensitivity

reactions to

cephalosporins,

penicillins, and

history of allergies,

particularly to drugs,

before therapy is

initiated.

Inspect IM and IV

injection sites

frequently for signs of

phlebitis.

Report onset of loose

stools or diarrhea.


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Generic

Name:

Paracetamol

550mg/5mL

q4; for

T>=38.0oC

Brand Name:Gandol

NON-OPIOID

ANALGESIC

Paracetamol exhibits

analgesic action byperipheral blockage of

pain impulse generation.

It produces antipyresis by

inhibiting the

hypothalamic heat-

regulating centre. Its weak

anti-inflammatory activity

is related to inhibition of

prostaglandin synthesis inthe CNS.

Indications:

To relieve mild to

moderate pain due tothings such as headache,

muscle and joint pain,

backache and period pains.

It is also used to bring

down a high temperature.

For this reason,

paracetamol can be given

to children after

vaccinations to preventpost-immunisation pyrexia

(high temperature).

Paracetamol is often

included in cough, cold and

flu remedies.

Contraindications:

Hypersensitivity to

acetaminophen or

phenacetin; use with

alcohol.

Side effects are rare with

paracetamol when it istaken at the

recommended doses.

Skin rashes, blood

disorders and acute

inflammation of the

pancreas have

occasionally occurred in

people taking the drug

on a regular basis for along time. One advantage

of paracetamol over

aspirin and NSAIDs is that

it doesn't irritate the

stomach or causing it to

bleed, potential Side

effects of aspirin and

NSAIDs.

Assessment & Drug Effects

Monitor for S&S of:

hepatotoxicity, even

with moderate

acetaminophen

doses, especially in

individuals with poor

nutrition.

Patient & Family Education

Do not take other

medications (e.g.,

cold preparations)

containing

acetaminophen

without medical

advice; overdosingand chronic use can

cause liver damage

and other toxic

effects.

Do not self-medicate

children for pain


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more than 5 d

without consulting a

physician.

Do not use for fever

persisting longer than

3 d, fever over 39.5 C

(103 F), or recurrent

fever.

Do not give children

more than 5 doses in

24 h unless

prescribed by

physician.

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