A Case Study on Septic Arthritis

A CASE STUDY ON

SEPTIC ARTHRITISPrepared by:

AGATHA ALISON D. PALAFOXMARY ROSE D. PANTUA

SARAH REFUGIALEA MARIE SILAVA

MICKY A. SOLARHEA L. SOLA

MENIZA AMY A. TOTANESEMMANUEL VALENCIA

BSN 4-A / GROUP 3

INTRODUCTION

A. Background of the Study

July 18, 2011 was the first day of our duty in

the orthopedic ward at Bicol Medical Center. Most of the cases were associated with fracture. The case that caught our attention was the case of a twelve years old child who has a Septic Arthritis. The said case was chosen for this case study.

Septic, or infectious, arthritis is infection of one or more joints by microorganisms. Normally, the joint is lubricated with a small amount of fluid that is referred to as synovial fluid or joint fluid. The normal joint fluid is sterile and, if removed and cultured in the laboratory, no microbes will be found. With septic arthritis, microbes are identifiable in an affected joint fluid.

SEPTIC ARTHRITIS

Most commonly, septic arthritis affects a single joint, but occasionally more joints are involved. The joints affected vary somewhat depending on the microbe causing the infection and the predisposing risk factors of the person affected. Septic arthritis is also called infectious arthritis.

Septic arthritis refers to the joints that become infected through the spread of infection from other parts of the body (hematogenous spread) or directly through trauma or surgical instrumentation. Previous trauma to joints, joint replacement, coexisting arthritis, and diminished host resistance contribute to the development of infected joints. Staphylococus aureus causes at least 50% of all joint infections and 80% of cases of septic arthritis in patients with rheumatoid arthritis and diabetes. The knee is the joint that is commonly infected (50% of cases), followed by the hip and the shoulder. Prompt recognition and treatment of an infected joint are important because accumulating purulent material results in chondrolysis (destruction of hyaline cartilage).

B. Objectives of the Study

General Objective– This case study is designed for the student nurses

to become practiced, well-informed and mannered in delivering holistic care for patients diagnosed with Septic Arthritis.

Specific Objectives

•Skills

•Knowledge

•Attitude

B. Objectives of the Study

SKILLS

To demonstrate the vision/mission of the school

(specifically the Nursing and Health Sciences

Department – NHSD).

Imply appropriate medical nursing management for

Septic Arthritis.

KNOWLEDGE

Define Septic Arthritis. Learn about major etiologic its causes, identify its clinical manifestations and risk factors.

Discuss the anatomy and physiology of the Musculoskeletal System.

Be familiar with the pathophysiology of Septic Arthritis.

Be familiar with the different drugs, its actions, and perform obligatory nursing responses for each.

Plan for a suitable nursing care.

ATTITUDE

Establish a nurse-patient interaction through

exchanging of thoughts and information

Institute bond between the student nurse and the

patient.

NURSING HEALTH HISTORY

A. Biographic Data

Name: Mr. S.A.Address: Centro, Fundado, Siruma, Camarines SurAge: 12 years oldReligion: Roman CatholicCivil Status: SingleNationality: FilipinoDate of Birth: March 28, 1999Date of Admission: July 12, 2011Ward and Room: Orthopedic Ward, Room 2Admitting Diagnosis: Sepsis, Septic Arthritis Knee Joint LAttending Physician: Dr. Joseph S. Sanchez, M.D.Sources of Information: Patient, Significant Others, Patient’s chart,

Attending Physician.

B. Chief Complaint

Fever (37.9)

Swelling on the left thigh and knee

Pain

C. History of Present IllnessPresent condition started two months prior to

admission while walking when he accidentally fell off on the ground and landed on a prone position. Pain was manifested after two weeks then the patient seek to “hilot” and it was aggravated. The said manipulation caused further swelling on the affected area. The father also stated that they only consulted the “hilot” once and no medications was taken. He suffered pain, swelling and stiffness on the left thigh and left knee, which prompted S.BMC assessed by the ROD and admitted at BMC Orthopedic ward under the care of Dr. Joseph Sanchez for further evaluation and management.

D. Past Medical History

Patient had a history of cough and colds, no

history of hospitalization or operation.

Patient’s immunization status was complete.

E. Family History of Illness

In their family there is no history of diseases or illness. But his father stated that the child’s grandfather had an asthma.

F. Lifestyle (Gordon’s Functional Health Pattern)

G. Social Data

Mr. SA is a 12 year old boy and a grade six student of Siruma, Elementary School.

He’s non-smoker and non- alcoholic His past time is playing basketball

H. Psychosocial Data

(-) hallucinations and delusions During admission he is aware that he was on

the hospital Obtunded LOC Able to recall past and recent events

I. Patterns of Health Care

The patient seeks medical attention at the rural health center in their municipality especially when they are experiencing minor health problems such as cough and colds, fever, e.t.c. it’s the first time that the patient was hospitalized.

REVIEW OF SYSTEMS AND PHYSICAL ASSESSMENT

A. General Appearance

Weight: 25 kgHeight: 5 feetLevel of Consciousness: ObtundedBody Build: EndomorphicPosture and Gait: Unable to stand and walkOverall Hygiene: Fair

B. Vital Signs

C. Head/Scalp/Hair

Head is normocephalic (symmetrical and round)

No palpable nodules or masses noted. Lesions are not noted. Has a short black hair. No presence of flakes, lice or lesions

noted.

D. Eye/Vision

• Anicteric sclerae with pupils round and black in color.

• Brisk reaction to light• Blinking symmetrical• Cornea is transparent , smooth and moist• Both eyes move in a smooth, coordinated

manner in all directions

E. Ears/Hearing

• Size is normal and equal• similar in color to face• (-) discharges and swelling. • Cerumen not noted.• Skins smooth and without nodules• No tenderness or pain when palpated

F. Nose

• No discharges. • Color is same as face, with smooth consistency• Symmetrical appearance• No changes in nares with respiration• No nodules, masses, or pain reported on

palpation

G. Mouth/Speech

• Lips are slightly dry and slightly pale. • No bleeding of gums noted.• Lips and surrounding tissue is symmetrical• No lesions, swelling, drooping

H. Throat and Neck

• No distention of jugular vein noted. • No inflammation of lymph nodes• No stiffness

I. Respiratory System

• Breathes normally and easily• No crackles or abnormal lung sounds

noted

J. Circulatory/Cardiovascular System

• Swelling is noted on the left knee• Edema on the IV sites (left hand and right

foot)• There is fatigue upon arising from bed to

sitting position

K. Gastrointestinal System

• No abdominal pain noted.• Vomited once (07-20-11)• Unable to defecate since admission• There are incidence of constipation

L. Genitourinary System

• No difficulty in urination• Urine is yellowish in color• Fluid intake is approximately 800mL/day

M. Musculoskeletal System

• Muscle weakness is noted• Movements are weak. Unable to walk

and cannot tolerate standing. • Slightly weak handgrip and weak lower

extremities

N. Integumentary System

• Skin is brown in complexion, warm, and slightly dry with fair skin turgor.

• Pallor/cyanosis is noted• Swelling is noted on the left knee• Edema at the IV site (left hand and right

foot)

LABORATORY TESTS

Date: July 12, 2011 8:39:58 AM

EXAM NAME RESULT UNIT NORMAL VALUES

WBC 17.06 10^9/L 4.8-10.8RBC 3.29 10^12/L 4.7-6.1Hemoglobin 76.1 g/L 120-180Hematocrit 0.2363 % 0.37-0.54MCV 71.76 fl 82-98MCH 23.12 Pg 28-33MCHC 32.22 g/L 33-36Platelet count 639 10^9/L 150-400Neutrophil 79.7 % 40-70Lymphocyte 10.8 % 19-48Eosinophil 1.8 % 2-8Monocyte 7.2 % 3-9Basophils 0.5 0% 0-5

Date: July 14, 2011 1:52:35 PM


WBC 14.03 10^9/L 4.8-10.8RBC 3.31 10^12/L 4.7-6.1Hemoglobin 74.1 g/L 120-180Hematocrit 0.2422 % 0.37-0.54MCV 73.17 fl 82-98MCH 22.34 Pg 28-33MCHC 30.6 g/L 33-36Platelet count 496 10^9/L 150-400Neutrophil 76 % 40-70Lymphocyte 12.4 % 19-48Eosinophil 2.2 % 2-8Monocyte 8.8 % 3-9Basophils 0.6 0% 0-5

Date: July 15, 2011 1:38:18 PM


WB C 22.58 10^9/L 4.8-10.8RBC 3.4 10^12/L 4.7-6.1Hemoglobin 78.5 g/L 120-180Hematocrit 0.2511 % 0.37-0.54MCV 73.92 fl 82-98MCH 23.09 Pg 28-33MCHC 31.24 g/L 33-36Platelet count 520 10^9/L 150-400Neutrophil 85.1 % 40-70Lymphocyte7.3 % 19-48Eosinophil 1.8 % 2-8Monocyte 5.2 % 3-9Basophils 0.6 0% 0-5

Date: July 16, 2011 1:42:34 AM


WBC 7.93 10^9/L 4.8-10.8RBC 3.63 10^12/L 4.7-6.1Hemoglobin 86.6 g/L 120-180Hematocrit 0.2752 % 0.37-0.54MCV 75.81 fl 82-98MCH 25.87 Pg 28-33MCHC 31.48 g/L 33-36Platelet count 374 10^9/L 150-400Neutrophil 80.4 % 40-70Lymphocyte 12.8 % 19-48Eosinophil 2 % 2-8Monocyte 4 % 3-9Basophils 0.8 0% 0-5

Date: July 17, 2011 1:56 AM


White blood cell 8.12 10^9/L 4.8-10.8Red blood cell 3.99 10^12/L 4.7-6.1Hemoglobin 101.1 g/L 120-180Hematocrit 0.3061 % 0.37-0.54MCV 76.67 fl 82-98MCH 25.33 Pg 28-33MCHC 33.04 g/L 33-36Platelet count 471 10^9/L 150-400Neutrophil 89.73 % 40-70Lymphocyte 4.95 % 19-48Eosinophil 1.24 % 2-8Monocyte 4.03 % 3-9Basophils 0 0% 0-5

Date: July 18, 2011 02:36 AM

EXAM NAME RESULT UNIT NORMAL VALUEWhite blood cell 14.99 10^9/L 4.8-10.8Red blood cell 3.13 10^12/L 4.7-6.1Hemoglobin 75.5 g/L 120-180Hematocrit 0.2369 % 0.37-0.54MCV 75.7 fl 82-98MCH 24.14 Pg 28-33MCHC 31.89 g/L 33-36Platelet count 267 10^9/L 150-400Neutrophil 83.7 % 40-70Lymphocyte 6.3 % 19-48Eosinophil 1 % 2-8Monocyte 8.5 % 3-9Basophils 0 % 0-5

COURSE IN THE WARD

On July 12, 2011, he was admitted in the orthopedic ward from the emergency room accompanied by his father. He was given D5LR 1L regulated at 20 gtts/min. The doctor ordered to record TPR every shift and the patient was placed on DAT. Laboratory tests was done such as CBC typing, urinalysis, fecalysis, blood culture, chest PA, pelvis AP, and AP/L left thigh x-rays. He was given Oxacillin 500mg every 6 hours, Metronidazole 500mg every 6 hours, Tramadol 50mg every 8 hours, and Paracetamol 300mg every 4 hours. The doctor also ordered patient for elective I&D / debridement on the left thigh/knee.

On July 13, 2011, the patient was examined by the Pediatrician. History was taken. He has no history of previous hospitalization, his immunization status was complete. On assessment, he has no cough and colds, anicteric sclera, (-) murmurs. Diagnosis was T/C sepsis, cellulitis, L thigh. The physician ordered that the patient may proceed with I and D procedure.

July, 14, 2011, repeat CBC was done. IVF was D5LR 1L at 20 gtts/min. The physician scheduled patient for elective I&D and debridement on the left thigh and knee.

July 15, 2011, the doctor ordered to transfuse 1 unit of blood as PRBC type “O” after cross-matching. Consent for blood transfusion was secured. The patient was in febrile state with the temperature of 38.7 and intravenous antipyretic was administered.

July 16, 2011, the patient was placed in NPO and rescheduled for elective I&D and debridement. Then, via telephone, the doctor ordered to transfuse another 1 unit PRBC. At 11:00 PM per verbal order, the doctor placed the patient on DAT then NPO post midnight. The patient was possible for elective OR in the morning.

July 17, 2011, at 8pm, the patient is for I & D. He was on NPO since 9am in the same day. His vital signs were stable.

July 18, 2011, the patient was received lying on bed with D5LR 1L for 8 hours. He was on diet as tolerated (DAT), on intravenous and oral medications. In the afternoon at 2pm the patient was febrile with a temperature of 39.2. Intravenous Paracetamol 300mg was administered as ordered.

July 19, 2011, the patient was received sitting on bed with an IVF of D5LR 1L regulated at 20 gtts/min. The patient complained nausea and later on he vomited. Oral Esomeprazole, oral tramadol was given as ordered. Intravenous medication such as oxacillin, metronidazole and tramadol was also administered. Doctor’s order for this day was to continued Oxacillin and Metronidazole at same dose and frequency. Paracetamol IV was shifted to paracetamol 250 mg PRN for fever. Then the doctor ordered to transfuse 1 unit (500 cc) of PRBC( type O).

July 20, 2011, the patient was received lying on bed with an IVF of D5LR 1L regulated at 20gtts/min. Due oral and intravenous medications was given. The patient complaint pain on the right knee. He was also febrile in the afternoon with the temperature of 38.2.

July 21, 2011, the previous IV and oral medications of the patient was discontinued and the doctor orderd cloxacillin 500 mg 1 capsule TID, metronidazole 500 mg 1/5 tablet TOD p.o. and ordered wound care. The patient had fever, with the temperature of 37.9 Paracetamol was given.

July 22, 2011, IVF of the patient was discontinued.

July 23, 2011, via telephone, the doctor ordered to transfuse PRBC, and start IVF of PNSS 1L at KVO.

July 25, 2011, the patient was received lying on bed with PNSS 1L regulated at KVO. Due medications was administered. The patient had a pustule in his right ankle. Wound care was done aseptically.

July 26, 2011, the patient undergone blood transfusion of 2 packs of RBC.

THEORY OF NURSING AS FRAMEWORK OF THE CASE STUDY

HENDERSON’S 14 ACTIVITIES OF CLIENT ASSISTANCE:

• BREATH NORMALLY– Respiratory rate –(24-26-28-30-34): experienced cough and

colds before admission: with shortness of breath.• EAT AND DRINK ADEQUATELY

– Height 5’ ; weight 25 kg ; dry skin ; drinks 8 glasses of water per day ; preferred to eat vegetables than meat ; with good appetite.

• ELIMINATE BODY WASTE– reported constipation as related to problem in elimination.

• MOVE AND MAINTAIN DESIRABLE POSTURE– Reported pain in left knee joint every time he moves.

• SLEEP AND REST– Report no problem related to sleep and rest.

• SELECT SUITABLE CLOTHES-DRESS AND UNDRESS– Wear shirt and short

• MAINTAIN BODY TEMPERATURE WITHIN NORMAL RANGE BY ADJUSTING CLOTHING AND MODIFYING ENVIRONMENT.– Temperature of 38.2-39.2 only during the afternoon.

• KEEP THE BODY CLEAN AND WELL GROOMED AND PROTECT THE INTEGUMENTARY.– Can’t perform his proper personal hygiene due to his condition

• AVOID DANGER IN THE ENVIRONMENT AND AVOID INJURING OTHERS.– Wears clothes that match the weather condition

• COMMUNICATES WITH OTHERS IN EXPRESSING EMOTIONS, NEEDS, FEAR, OR OPINIONS.– Able to speak and understand, verbalized his fear

about his present condition and the pain being felt.• WORSHIP ACCORDING TO ONE’S FAITH– Attends church with family often during Sundays.

• WORK IN SUCH A WAY THAT THERE IS A SENSE OF ACCOMPLISHMENT– Reports unhappiness because he didn’t attend his class for

two months. And that he cannot perform the simple activities of his daily living

• PLAY OR PARTICIPATE ON VARIOUS FORMS OF RECREATIONS– Only his father spends time with him

• LEARN, DISCOVER OR SATISFY THE CURIOSITY THAT LEADS TO NORMAL DEVELOPMENT OF HEALTH AND USED THE AVAILABLE HEALTH FACILITIES– Reports interest in finishing his studies, and plans to pursue

his secondary and college education.

EFFECTS OF PRESENT ILLNESS ON THE GROWTH AND DEVELOPMENT OF THE PATIENT AS A TOTAL PERSON

ERIKSON’S STAGES OF PSYCHOSOCIAL DEVELOPMENT

Our patient falls on the stage of INDUSTRY VERSUS INFERIORITY. In this stage, the task to be achieved is to develop necessary social skills .


BEFORE HOSPITALIZATION– Patient was able to perform activities of daily

living and goes to school.– Active in doing household chores.– Is able to decide on his own activities– Presence of self-esteem


DURING HOSPITALIZATION– Patient unable to perform activities of daily living,

was absent in his class for almost 1 month.– Always on the bed– Unable to help in the household chores.– Decrease self-esteem due to his condition


AFTER HOSPITALIZATION– Able to perform activities of daily living and goes

to school but with precautions.– Able to ambulate and do self-care activities.– Is able to do light household activities.– Self-esteem is not totally regained but progressing.

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

RISK FACTORS– Past joint disease – Injury or trauma– Infection within the body– Taking medications that suppress the immune

system– Intravenous drug abuse– Surgery – Immunocompromised

CLINICAL MANIFESTATIONS – Fever– Severe pain in the affected joint, especially when

you move that joint– Swelling of the affected joint– Warmth in the area of the affected joint– redness in the affected area– limited use of the affected extremity– guarding or protecting the affected area to

prevent it from being touched or seen– redness in the affected area

MEDICAL MANAGEMENT

DISCHARGE PLAN

Medications

Paracetamol (Biogesic)– 250 mg PRN– Instruct the client about the side effect of this medication

Cloxacillin– 500 mg capsule three times a day (8am-1pm-6pm)– Take medication around the clock, do not miss a dose, and

continue taking the medication until it is finished.– Report to physician the onset of hypersensitivity reaction– Check with physician if GI adverse effects (nausea, vomiting,

diarrhea) appear

Metronidazole– 500 mg ½ tablet two time a day (8am-6pm)– Urine may appear dark or reddish brown (especially with

higher than recommended doses

Esomeprazole– 40 mg tablet – once a day for 3 days (8am)– Report any changes in urinary elimination such as pain or

discomfort associated with urination to physician.– Report severe diarrhea. Drug may need to be discontinued.– Headache, abdominal pain, diarrhea, flatulence, nausea,

vomiting, constipation (side effect of the drug.)

Oral Tramadol

– 37.5mg 1 tablet per day (8am)

Heat / cold application– Heat or cold application can provide temporary pain

relief. – Heat application (by taking a hot shower, for example)

helps reduce pain and stiffness by relaxing the muscles and increasing blood circulation. There is some concern, however, that heat may worsen symptoms in an already inflamed joint.

– Cold application (placing ice or cold packs on the affected area) has a numbing effect by constricting the blood vessels and blocking nerve impulses in the joint. Cold appears to decrease inflammation and therefore is usually the method of choice when joints are inflamed.

HEALTH TEACHING

Instruct the patient to do:

Splinting – the affected joint may need to be splinted,

as movement can be very painful at first.

Relaxation– Relaxing the muscles around an inflamed joint

often helps reduce pain.

EXERCISE

– Once the infection has cleared up, your doctor will frequently recommend exercises to build up muscle strength and increase the joint's range of motion. A physical therapist can instruct you in how to do suitable exercises.

– ROME– Emphasize the importance of complying to the

therapeutic regimen.– Instruct the patient regarding his next follow-up care– Instruct the patient and his family regarding the side

effects of the medication.

HYGIENE

– Encourage the patient and his family to do proper personal hygiene.

– For skin rash: calamine lotion– For pruritus: TSB

• DIET:– Instruct the patient to increase fluid intake and

increase consumption of foods rich in carbohydrates and protein.

– Include intake of iron and calcium– Small frequent feeding– For diarrhea: low fiber, BRAT diet– For constipation: high fiber

• SPIRITUAL VALUES:– Emphasize the importance of the spiritual beliefs

END.Success!!!

thank you

Documents

A Case Study on Septic Arthritis