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Tagum Doctors College Inc.Tagum City
College of Nursing
___________________
A CASE STUDY
On
OSTEOARTHRITIS
___________________
In Partial fulfillment of the RequirementsIn Related Learning Experience
ByAbuda, Shelou
Germata, Geza DeeLiquit, Charmaine Lynne
Riña, Dyan BebsSegovia, Cherry Ann
Serra, MarluneeSuico, Mary Joy
Tanzo, Glezel AnnVerin,Krystel
Ybañez, Vanessa JoyYecYec, Ara Annie Del
BSN 3
January 23, 2010
TABLE OF CONTENTS
I. INTRODUCTION iv
Objectives
A. General Objective vii
B. Specific Objective vii
II. ASSESSMENT 1
A. Biographical Data 1
B. Chief Complaint 2
C. History of Present Illness 2
D. Past Medical History 3
E. Personal and Family History 3
F. Socio-economic Status 3
G. Nutritional Status 4
H. Family Genogram 5
I. Developmental Task
J. Physical Assessment 18
a. General Survey 18
b. Vital Signs 18
c. Physical Examination 22
III. REVIEW OF ANATOMY AND PHYSIOLOGY 41
IV. SYMPTOMATOLOGY AND ETIOLOGY 44
iii
V. PATHOPHYSIOLOGY 51
a. Narrative
51
b. Diagram
52
VI. PLANNING 54
A. Nursing Care Plan 1 54
B. Nursing Care Plan 57
C. Nursing Care Plan 61
VII. PHARMACOLOGICAL MANAGEMENT 66
VIII. DISCHARGE PLAN 75
IX. SYNTHESIS OF CLIENT’S CONDITION 79
A. Synthesis of Client’s Condition 79
B. Patient’s Prognosis 80
C. Recommendation 82
X. EVALUATION OF OBJECTIVES OF THE STUDY 83
XI. BIBLIOGRAPHY 84
iv
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 spurs—may 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
vi
osteoarthritis. Osteoarthritis does not affect other organs of the body. Primary
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
vii
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
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 patient’s case;
identify the objectives;
show the biographical data of the patient;
study the patient’s 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;
ix
determine the etiology of osteoarthritis;
trace the pathophysiology of osteoarthritis;
formulate nursing care plans applicable for patient with
osteoarthritis;
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 patient’s condition in
relation
to its etiology and its existing signs and symptoms; and
list down recommendations for the improvement of health of
the patient’s condition.
x
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: 5”5’ft.
BMI: 20.45 – normal
Father’s name: Mr. Carlos De Jesus
Mother’s 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
Gary– 39 years old
12
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. Peñalver
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
13
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 Baños 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
14
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 patient’s weight is 55 kg. and a height of 5’5”ft. 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 doesn’t want to eat
breakfast and only drinks coffee as her meal. The patient seldom eats processed foods
15
such as corned beef, sardines, and hotdog. Fluid intake is 8-10 glasses per day as
reported. She doesn’t drink alcohol yet loves to drink sodas about 2-3 times a week.
H. FAMILY GENOGRAM
16
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
Vehicular accident
MSGrandmother
MSGrandfather PS
Grandfather
PSGrandmother
Severa Carlos
PATIENT 63y/o
Carmensita 59 y/oCarmelita 59 y/o
Ernesto 63 y/o
Erik 40y/o Gary 39y/o Erwin 35 y/o Eleonor
36y/o
Emerson
Reymundo67 y/o
I. Developmental Task
Theorist Theory Developmental
Task
Rating Result and
Justification
Robert
Havighurst
Activity during
aging
Robert Havighurst
believed that
learning is basic to
life and that
peoplecontinue to
learn throughout
life. He defines a
developmental
task as a
taskwhich arises at
or about a certain
period in the life of
Middle Adulthood
(35 t0 55or 65
years old)
This stage in a
person’s life
is concerned with
theachievement of
the followingtask:
Fulfill civic and
social
responsibilities
Maintain an
economicstandard
of living
√
√
Patient was able
to achieve this
entire task, she
was currently a
Housewife. She
was able to earn
enough money in
order to sustain
their children and
daily need. She
also teaches their
children to
become
responsible by
way of discipline.
As a mother she’s
responsible
managing their
18
an individual.
Successfulachieve
ment of these
tasks leads to his
happiness and to
successand later
tasks, while failure
leads to
unhappiness in the
individual,disappro
val by society and
difficulty in later
tasks.
Assistadolescent
children become
responsible and
happy adults.
Learning to live
withpartner
Robert J.
Havighurst
(1971)
√
√
home, and happily
married.
Lawrence
Kohlberg
Moral Theory Her age correlates
to post-conventional
√ Patient knows
and understands
19
The theory holds
that moral
reasoning, the
basis for ethical
behavior, has six
identifiable
developmental
stages, each more
adequate at
responding to
moral dilemmas
than its
predecessor.
Kohlberg followed
the development
of moral judgment
far beyond the
ages studied
earlier by Piaget
who also claimed
that logic and
morality develop
through
level.
The post-
conventional level
OfLawrence
Kohlberg’s Moral
Development, is
also known as the
principled level. In
Stage five (social
contract driven),
the world is viewed
as holding different
opinions, rights
and values. Such
perspectives
should be mutually
respected as
unique to each
person or
community. Laws
areregarded as
social contracts
rather than rigid
the basic social
rules and laws
that should be
followed. She is
also aware of
what is wrong
and right
according to
society’s laws.
She is coming up
with a decision
with the
consensus of her
significant others.
She knows that
laws must be
abided because it
is her
responsibility as a
citizen of the state.
She is an active
voter and pays
taxes on the right
20
constructive
stages. Expanding
on Piaget's work,
Kohlberg
determined that
the process of
moral
development was
principally
concerned with
justice, and that it
continued
throughout the
individual's
lifetime, a notion
that spawned
dialogue on the
philosophical
implications of
such research.
(http.wikipedia.org)
dictums. Those
which do not
promote the
general welfare
should be changed
when necessary to
meet "the greatest
good for the
greatest number of
people". This is
achieved through
majority decision,
and inevitable
compromise.
(Lickona,1976)
time. And agrees
on basic state’s
rules.
She knows that
she can violate
some laws if it is
untoward and
unjust. As a moral
person herself,
she is capable
enough to reflect
on her own
conscience.
Erik
Erikson
Psychosocial
Theory
Middle Adulthood:
35 to 55 or 65
The Patient has
positively
21
All of the stages in
Erikson's
epigenetic theory
are implicitly
present at birth (at
least in latent
form), but unfold
according to both
an innate scheme
and one's up-
bringing in a family
that expresses the
values of a culture.
Each stage builds
on the preceding
stages, and paves
the way for
subsequent
stages. Each
stage is
characterized by a
psychosocial
Ego Development
Outcome:
Generativity vs.
Self-absorption or
Stagnation
Basic Strengths:
Production and Care
During this stage,
work seems to
become a high
priority. Erikson
observed that
middle-age is the
time when most
people like filling
their days with
more meaningful
and creative work
and family issues.
Also, middle
adulthood is when
we can expect to
√ achieved this
Stageof
development.
She views her life
asmeaningful
because she
already married
and has 5
children and
helping their
children to
become
responsible. She
was also thankful
to have children
and family
member who are
always there to
care for her and
to support.
She reaffirms the
22
crisis, which is
based on
physiological
development, but
also on demands
put on the
individual by
parents and/or
society. Ideally,
the crisis in each
stage should be
resolved by the
ego in that stage,
in order for
development to
proceed correctly.
The outcome of
one stage is not
permanent, but
can be altered by
later experiences.
Everyone has a
mixture of the
"be in charge," the
role we've longer
envied. The main
goal of this stage is
to take the values
of your own family
such as raising
children and
passing them onto
the next generation
to help guide them
Source:
*Fundamentals of
Nursing
8thedition.page
353
values of life that
have real meaning
– philosophical,
religious, and
social.
23
traits attained at
each stage, but
personality
development is
considered
successful if the
individual has
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. She’s not able to walk and stand without assistance and
for long period of time.
B. VITAL SIGNS
DATE TIME VITAL NORMAL AC- INTERPRETATION
24
SIGNS TUAL
11/13/10
(Upon
Admission)
11:05
am
Tem-
perature
36.5-37.5
C0
36.8
C0 Temperature is within
normal range.
Temperature is maintained
between the body’s heat-
producing functions
(metabolism, shivering,
muscle contraction,
exercise, and thyroid
activity). Temperature can
vary with other factors,
such as exercise, drinking
hot or cold fluids, sitting in
a cold room, fighting an
infection, and by the
accuracy and type of
thermometer used.
(McKesson. 2005)
Blood
Pressure
Systolic:
90-
130mmHg
Diastolic :
120/80
mmHg
Blood Pressure is within
normal range. Normal BP
varies with age and others
factors such as stress,
genetics, medications, heavy
25
60-90
mmHg
meals. Diurnal variations,
exercise and weight. It can
be often taken in several
positions- supine, sitting and
standing. (Dillon 2007)
Pulse
Rate
60-100
beats/min.
86
bpm
Normal. The heart rate
changes based upon the
body's need for oxygen,
most notably, during
exercise. (Pillitteri,A. 2007)
Respi-
ratory
Rate
18-25
cycles/min
22
cpm
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 lower in
physically fit people,
because exercise makes the
heart stronger so it can
pump more blood through
the body with each
contraction. (Respiration
Control Mechanisms
26
from World of Anatomy and
Physiology. 2005-2006.)
11/15/10
(Upon
Assess-
ment)
8:00
am
Tempe-
rature
36.5-37.5
C0
37.2
C0 Temperature is within
normal range.
Temperature is maintained
between the body’s heat-
producing functions
(metabolism, shivering,
muscle contraction,
exercise, and thyroid
activity). Temperature can
vary with other factors,
such as exercise, drinking
hot or cold fluids, sitting in
a cold room, fighting an
infection, and by the
accuracy and type of
thermometer used.
(McKesson. 2005)
Blood
Pressure
Systolic:
90-
130mmHg
120/80
mmHg
Blood pressure is within
normal range. Various
factors influence a person's
27
Diastolic :
60-90
mmHg
average BP and variations.
Factors such as age and
gender influence average
values. As adults age,
systolic pressure tends to
rise and diastolic tends to
fall.
(Pillitteri,A. 2007).
Pulse
Rate
60-100
beats/min.
90
bpm
Normal. The heart rate
changes based upon the
body's need for oxygen,
most notably, during
exercise. (Pillitteri,A. 2007)
Respi-
ratory
Rate
18-25
cycles/min
.
20
cpm
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 lower in
physically fit people,
because exercise makes the
heart stronger so it can
pump more blood through
28
the body with each
contraction. (Respiration
Control Mechanisms
from World of Anatomy and
Physiology. 2005-2006.)
C. Physical Assessment
ASSESSMENT NORMAL
FINDINGS
ACTUAL FINDINGS INTERPRETA-
TION
Neurologic
Status
Fully alert and
conscious. Oriented
to time, place and
people. No speech
defects and uses
appropriate words.
Thought is
comprehensible and
based in reality.
Positive deep
tendon reflex.
Reference: Dillon
(2007). Assessing
Oriented to time,
place and people
around her. Able to
respond to questions
and maintains eye
contact to the
interviewer. Thought
content is reality
based without
speech defects. Uses
appropriate words in
answering questions.
Memory is intact.
Patient’s level of
consciousness is
good and he is a
responsive
correspondent.
Memory is intact
and is based in
reality. Good
Language skills.
Reference:
Dillon (2007).
Assessing the
Sensory-
29
Integumentary
System
Methods of
Assessment
Used:
Inspection
Palpation
Skin
the Sensory-
Neurologic System,
Nursing Health
Assessment A
critical Thinking,
Case Studies
Approach. F.A.
Davis Company
1915 Arch Street
Philadelphia, PA
19103
Skin is uniform in
color, warm to touch
with good skin
Skin is fair, soft warm
to touch and uniform
in color with slightly
Neurologic
System, Nursing
Health
Assessment A
critical Thinking,
Case Studies
Approach. F.A.
Davis Company
1915 Arch Street
Philadelphia, PA
19103
Good skin turgor
indicates patient
is not
30
Hair and
turgor. No cyanosis.
Mucous membranes
pink in color, moist
with no lesions or
inflammations.
Hair is evenly
darker exposed
areas. No scars
noted or any lesions
on the upper and
lower extremities.
Decreased skin
turgor noted.
Mucous membranes
pink and moist with
no sores, redness
and any lesions
noted upon
inspection.
Hair is evenly
dehydrated.
Exposed areas
are usually
darker because
of exposure to
the heat of the
sun.
Pink mucous
membranes
indicate no
hematologic
disease like
anemia. No sign
of redness in the
mucosal area
shows that there
is no
inflammatory or
infectious
disorder present.
Fair distribution
31
Scalp
Nails
distributed. Scalp is
intact and free of
lesions and
pediculosis.
Nails vary from light
skinned to light
brown in darker
skinned individuals.
Nails are convex in
shape and firm
without clubbing.
Reference: Dillon
(2007). Assessing
the Integumentary
distributed, thick
strand, silky and
black in color. White
hair noted upon
inspection. Fine body
hair noted over the
body. No scalp
lesions, dandruff, lice
and nits noted. No
masses and
tenderness noted
upon palpation.
Fingernails and
toenails are clean
and well trimmed,
convex in shape,
smooth texture with
no inflammations
noted. Nail beds pink
in color. No clubbing
and bluish
discoloration noted.
of hair. Free from
pediculosis. Hair
color and
distribution are
genetically
linked.
Nails may grow
longer, soften or
thin.
Clubbing is not
present which
signifies no
diseases
associated that
affect the level of
oxygenation such
32
System, Nursing
Health Assessment
A critical Thinking,
Case Studies
Approach. F.A.
Davis Company
1915 Arch Street
Philadelphia, PA
19103
.
Capillary refill of less
than 2 seconds.
as congenital
heart disorders
and chronic
pulmonary
diseases. No
bluish
discoloration of
nails and no
clubbing indicate
no peripheral
disease or
hypoxia.
Reference:
Dillon (2007).
Assessing the
Integumentary
System, Nursing
Health
Assessment A
critical Thinking,
Case Studies
Approach. F.A.
Davis Company
33
1915 Arch Street
Philadelphia, PA
19103
HEENT
Methods of
Assessment
Used:
Inspection
Palpation
Head
Eyes
Round and
symmetrical. No
palpable masses,
swelling and lesions.
Facial features and
movements
symmetrical.
In parallel alignment
with smooth and
white sclera.
Normocephalic with
no palpable masses,
lesions or tenderness
and swelling noted
upon inspection and
palpation.
Symmetrical facial
features and
movements noted
upon inspection.
Sclera is white with
no lesions. Both eyes
are clear and bright
Symmetry of
facial features
and movements
indicate no
previous trauma,
congenital
deformity,
paralysis or
edema.
Clear eyes
indicate that the
patient is not in
34
Positive pupillary
reaction to light and
blinking reflex.
Smooth, conjugate
movement of eyes
in all directions
without eyelid lag
and nystagmus.
Eyebrows and
eyelashes are
evenly distributed
with no lesions or
swelling. Eyelids
intact.
in parallel alignment.
Parallel movements
in all directions
noted. Positive
blinking reflex noted.
Cornea is shiny and
smooth. Pupil is
round, equal in size
and reactive to light.
Both pupils constricts
in response to light.
Iris is brown in color
upon inspection. No
corrective lenses or
eyeglasses noted.
Fair distribution of
eyebrows and
eyelashes without
presence of
discharges, swelling
or inflammations.
Eyelashes curves
febrile state.
Parallel
movement of the
eye in all
directions, no
nystagmus and
eyelid lag show
no damage,
irritation or
pressure on
correspond-ding
extraocular
muscle or cranial
nerves that
innervates the
muscle. Eyelids,
eyebrows and
eyelashes are
fair in distribution
and no edema or
any swelling
occurs since it
will indicate
35
Ears
Pinkish – peach
color conjunctiva
with no lesions.
Consistent with skin
color and aligned
with the external
canthus of the eyes.
No lesions,
tenderness and
swelling. No
palpable nodules or
outward without
crusting or
infestations. Eyelids
intact without lesions.
Conjunctiva is pinkish
in color with no
lesions or swelling
noted.
Aligned with the
external canthus of
the eyes. Consistent
with skin color. No
lesions, nodules and
swelling noted.
Cerumen noted upon
inspection and in
carcinoma.
Conjunctiva is
smooth and
pinkish in color.
Red conjunctiva
indicates
conjunctivitis
while in anemia,
it is pale pink.
Positive reflexes
in the eyes
signify no
neurological
problems.
Normally, ears
are aligned with
the external
canthus of the
eyes. Color is
consistent with
skin color. No
lesions found,
36
Neck
exudates.
Skin is intact. No
palpable masses or
bulges, lymph nodes
and swelling.
Thyroid glands not
enlarge.
small amount.
Is in the midline and
movable 180 degrees
without feeling of
discomfort reported.
Left and right
superficial cervical
nodes not palpable.
No bulges or
masses, lesions and
swelling noted.
Thyroid is in mid
lower half of the
anterior neck. No
Enlargement,
tenderness and
nodularity noted.
abnormal
findings of having
lesions in the
ears will indicate
skin cancer from
sun exposure.
37
Throat/mouth Mucosa pink, no
redness or
inflammations and
lesions.
Lips pink, moist and
intact.
Gums pink with no
lesions, swelling,
redness and
bleeding. No
discharges or
Pink, moist, smooth,
glistening and intact
mucosa. Tongue is
pink in color, mobile
with no lesions or
swelling and any
discolorations.
Lateral margins
present. Tonsils are
pink and indicate no
signs of
inflammation.
Moist, pink lips noted
without any lesions
and swelling. No
cracks noted.
Gums are consistent
in color with other
mucosa with no
bleeding. No lesions,
swelling and
Pink, moist and
intact mucosa
indicates good
condition of oral
mucosa.
Reddened,
inflamed oral
mucosa
sometimes
accompanied by
ulcerations. Lips
that are intact,
moist with no
cracks signify
that the patient is
not experiencing
dehydration,
cheilosis, lip
licking and
infectious or
inflammatory
disorders. No
signs of tonsillitis.
38
exudates.
Hard and soft palate
pink and intact,
teeth are white in
color, not loose with
good occlusion and
in good repair.
Swallowing is easily
done without
difficulty or feeling of
pain.
Reference: 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
exudates noted.
Teeth are white in
color. Hard and soft
palate is pink and
intact. Dentures
noted on the upper
portion of the buccal
mucosa. Reports no
difficulty in
swallowing.
Reference:
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
39
1915 Arch Street
Philadelphia, PA
19103
Pulmonary
System
Methods of
Assessment
Used:
Inspection
Palpation
Auscultation
Respiratory rate
ranges from 18 -25
cycles per minute.
Equal rise and fall of
the chest when
breathing, full and
even. Chest is
consistent with skin
color. Trachea is in
the midline. Tactile
fremitus equal
bilaterally. Nose is
symmetrical with no
discharges. Septum
intact and in midline.
Reference: Dillon
(2007). Assessing
the Respiratory
System. Nursing
Health Assessment
Respiration rate is
recorded as 20
cycles per minute.
Nose is symmetrical
with no discharges
and nasal flaring.
Septum intact and in
midline. Trachea is
in the midline. There
is equal rise and fall
of the chest with
regular rate and
rhythm of respiration
without any masses
noted upon palpation.
No pain reported
over the chest.
Breathing pattern is
even, no dyspnea
noted. Vocal fremitus
is symmetric, equal
bilaterally on the
upper anterior chest.
No secretions and
presence of cough
not noted.
Normal. Not in
respiratory
distress. If there
is an increase in
fremitus this
indicates
accumulation of
fluid or exudates
in the lungs.
Even breathing
indicates no
difficulty in
respiration.
Reference:
Dillon (2007).
Assessing the
Respiratory
System. Nursing
Health
Assessment A
critical Thinking,
Case Studies
Approach. F.A.
Davis Company
40
A critical Thinking,
Case Studies
Approach. F.A.
Davis Company
1915 Arch Street
Philadelphia, PA
19103
1915 Arch Street
Philadelphia, PA
19103
Cardiovascular
System
Methods of
Assessment
Used:
Inspection
Palpation
Auscultation
Heart rate of 60-100
beats per minute,
regular. Capillary
refill of less than 2
seconds .Blood
pressure of
90/60mmHg-
140/90mmHg
Reference: Dillon
(2007). Assessing
the Cardiovascular
System. Nursing
Health Assessment
A critical Thinking,
Case Studies
Pulse rate was
recorded as 90
beats per minute and
is in regular rhythm.
Blood pressure was
recorded as 120/80
mmHg. No murmurs
noted. No chest pain
reported. Good
capillary refill less
than 2 seconds.
Pulse rate and
blood pressure is
within normal
range. The heart
rate changes
based upon the
body's need for
oxygen, most
notably, during
exercise. Various
factors influence
a person's
average BP and
variations.
Factors such as
41
Approach. F.A.
Davis Company
1915 Arch Street
Philadelphia, PA
19103
age and gender
influence
average values.
As adults age,
systolic pressure
tends to rise and
diastolic tends to
fall.
Reference:
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
42
Gastrointestinal
System
Methods of
Assessment
Used:
Inspection
Palpation
Auscultation
Abdomen is intact
with no lesions,
masses and
consistent with skin
color. Umbilicus
inverted and in
midline. Audible
bowel sounds
present 5-30 clicks
per minute.
Reference: Dillon
(2007). Assessing
the Abdomen.
Nursing Health
Assessment A
critical Thinking,
Case Studies
Approach. F.A.
Davis Company
1915 Arch Street
Philadelphia, PA
No lesions, masses
and scars noted over
the abdomen.
Umbilicus noted,
inverted and in
midline. Bowel sound
audible at four
abdominal quadrants
with 13 clicks per
minute upon
auscultation. Last
bowel movement:
November 15, 2010,
6:00 in the morning
with no difficulty in
defecation and with
soft yellowish stool
as reported.
Bowel sound is
within normal
range of 5-30
clicks per minute
which suggest
that the patient is
not constipated.
No scars in the
abdomen may
indicate no
previous
abdominal
surgery done.
Reference:
Dillon (2007).
Assessing the
Abdomen.
Nursing Health
Assessment A
critical Thinking,
Case Studies
Approach. F.A.
43
19103 Davis Company
1915 Arch Street
Philadelphia, PA
19103
Genitourinary
System
Methods of
Assessment
Used:
Inspection
No burning
sensation during
urination.
Reference: 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
No burning sensation
and difficulty in
urination reported.
Last voided:
November 15, 2010,
in the afternoon with
yellowish colored
urine with total output
of 400cc throughout
the shift.
No difficulty in
urination signifies
no urinary tract
problems.
Reference:
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
44
Musculoskeletal
System
Methods of
Assessment
Used:
Inspection
Palpation
Posture erect, head
midline and weight
evenly distributed.
Both feet point
straight ahead. All
movements
coordinated and
arms swings in
opposition. Balance
intact.
Reference: 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
Posture is erect,
head in midline.
Reduced range of
motion noted, Not
able to fully bend,
flex and extend her
knees. Muscle
weakness noted.
Patient cannot stand
or walk for a long
period of time without
assistance. Able to
walk for only 4-5
steps with assistance
Pain reported on the
right knee with the
pain scale of 5/10.
Stiffness on the right
knee area reported.
Complete upper and
lower extremities
noted.
Coordinated
movements
indicate good
cerebellar
function.
Reference:
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
45
III. LABORATORY AND DIAGNOSTIC EXAMINATIONHEMATOLOGY
11/13/10
RESULT NORMAL
VALUE
INTERPRETATION
A.)HEMOGLOBI
N
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. If
decrease it implicates various
enemas, pregnancy, severe or
prolonged hemorrhage and
with excessive fluid intake.
B.) LEUKOCYTE 6.1 x 12 g/
L
5-10 x12 g/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, ,
cytomegalovirus infection, other
viral infections, pertussis,
toxoplasmosis, brucellosis, TB,
syphilis, lymphocytic leukemias,
and lead, carbon disulfide,
tetrachloroethane, and arsenical
poisonings. A mature
46
lymphocyte count >7,000/µL 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,
levodopa, niacinamide,
phenytoin, and mephenytoin.
E.) MONOCYTES 0.09 0.02-0.06 The result was above normal
range. An increase in result
indicates a viral infection,
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 granulomatous
inflammation (TB, syphilis,
brucellosis, Crohn's disease,
and sarcoidosis), ulcerative
colitis, systemic lupus,
rheumatoid arthritis,
polyarteritisnodosa, and many
hematologic neoplasms.
Poisoning by carbon disulfide,
phosphorus, and
tetrachloroethane, as well as
administration of griseofulvin,
haloperidol, and methsuximide,
47
may cause monocytosis.
F.)
EOSINOPHILS
0.01 0.01-0.05 The result was within normal
range. If increase it specifies
allergy, parasitic disease,
collagen disease and subacute
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
10 9/LThe result was within normal
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
divided pathophysiologically into
production defects and
consumption defects based on
examination of the bone marrow
aspirate or biopsy for the
presence of megakaryocytes.
48
Production defects are seen in
Wiskott-Aldritch syndrome, May-
Hegglin anomaly, Bernard-
Soulier syndrome, Chediak-
Higashi anomaly, Fanconi's
syndrome, aplastic anemia (see
list of drugs, above), marrow
replacement, megaloblastic and
severe iron deficiency anemias,
uremia, etc. Consumption
defects are seen in autoimmune
thrombocytopenias (including
ITP and systemic lupus), DIC,
TTP, congenital hemangiomas,
hypersplenism, following
massive hemorrhage, and in
many severe infections.
G.)
HEMATOCRIT
0. 40 0.36-0.44 The result was within normal
range. If increase it shows
erythrocytosis of any cause and
in dehydration or
hemoconcentration associated
with shock. If decrease it shows
severe anemias, anemia of
pregnancy and acute massive
blood loss.
HEMATOLOGY
11/13/10
RESULT NORMAL
VALUE
INTERPRETATION
A.)HEMOGLOBI 131 g/L 120-150 g/L The result was within normal
49
N 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 implicates various
enemas, pregnancy, severe or
prolonged hemorrhage and
with excessive fluid intake.
B.) LEUKOCYTE 6.1 x 12 g/
L
5-10 x12 g/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, ,
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/µL is
an individual over 50 years of
age is highly suggestive of
chronic lymphocytic leukemia
50
(CLL). Drugs increasing the
lymphocyte count include
aminosalicyclic acid,
griseofulvin, haloperidol,
levodopa, niacinamide,
phenytoin, and mephenytoin.
E.) MONOCYTES 0.09 0.02-0.06 The result was above normal
range. An increase in result
indicates a viral infection,
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 granulomatous
inflammation (TB, syphilis,
brucellosis, Crohn's disease,
and sarcoidosis), ulcerative
colitis, systemic lupus,
rheumatoid arthritis,
polyarteritisnodosa, and many
hematologic neoplasms.
Poisoning by carbon disulfide,
phosphorus, and
tetrachloroethane, as well as
administration of 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
51
allergy, parasitic disease,
collagen disease and subacute
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
10 9/LThe result was within normal
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
divided pathophysiologically into
production defects and
consumption defects based on
examination of the bone marrow
aspirate or biopsy for the
presence of megakaryocytes.
Production defects are seen in
Wiskott-Aldritch syndrome, May-
Hegglin anomaly, Bernard-
52
Soulier syndrome, Chediak-
Higashi anomaly, Fanconi's
syndrome, aplastic anemia (see
list of drugs, above), marrow
replacement, megaloblastic and
severe iron deficiency anemias,
uremia, etc. Consumption
defects are seen in autoimmune
thrombocytopenias (including
ITP and systemic lupus), DIC,
TTP, congenital hemangiomas,
hypersplenism, following
massive hemorrhage, and in
many severe infections.
G.)
HEMATOCRIT
0. 40 0.36-0.44 The result was within normal
range. If increase it shows
erythrocytosis of any cause and
in dehydration or
hemoconcentration associated
with shock. If decrease it shows
severe anemias, anemia of
pregnancy and acute massive
blood loss.
53
RADIOLOGIC FINDING (11/15/10) INTERPRETATION
RADIOLOGIC FINDING 11/15/10 INTERPRETATION
Procedure: Knee APL-DLX 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
1. ) Provide a framework that supports the body; the muscles that are attached to bones move the
skeleton.
54
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
The Sternum
The Ribs
The Vertebral Column
The appendicular skeleton is composed of bones that anchor the appendages to the axial skeleton.
55
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
56
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 bone- joint where the surfaces of the two bones are connected by a
piece of cartilage so that they cannot move.
Ball and socket joint
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.
57
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
A. SYMTOMATOLOGY
Symptoms Actual Symptoms Interpretation
Pain: Your joints may
ache, or the pain may feel
burning or sharp. For
some people, the pain
may come and go.
Constant pain or pain
while you sleep may be a
sign that your arthritis is
getting worse.
Moderate pain in
the right knee.
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
58
cartilage wears away,
tendons and ligaments
stretch, causing pain. If
the condition worsens,
the bones could rub
against each other,
causing even more pain
and loss of movement.
Stiffness: When
you have arthritis, getting
up in the morning can be
hard. Your joints may feel
stiff and creaky for a short
time, until you get moving.
You may also get stiff from
sitting.
Stiffness in the right
knee.
Stiffness will also occur
when the joints are used
more than normal. Most
sufferers find that the
stiffness is the worst in
the morning, and severe
stiffness will last less than
30 minutes. Moving the
joint repeatedly in
moderate way can often
help to alleviate the
stiffness.
Muscle weakness:
The muscles around the
joint may get weaker. This
Muscle weakness in
the right leg.
Muscle has an integral
role in the structure and
function of joints.
59
happens a lot with arthritis
in the knee.
Evidence for muscle
weakness in
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 requires
further study, but
preliminary evidence for
a causative role is
emerging. Muscle
weakness can be
assessed in various
ways. Voluntary
measures of strength are
affected by degree of
effort. In osteoarthritic
patients, as in other
patient groups, effort may
be influenced by pain and
psychologic outlook.
60
Swelling/ Tenderness:
Arthritis can cause
swelling in joints, making
them feel tender and sore.
Swelling in the right
knee.
Once the synovial
membrane (smooth
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 or occasional
swelling.
Deformed joints: Joints
can start to look like they
are the wrong shape,
especially as arthritis gets
worse.
Progressive breakdown
of cartilage may lead to
the formation of enlarged
bony growths or "spurs
"on the bone ends. Such
growths increase the
appearance of swelling
and knobbiness as they
continue the cycle of
irritation and swelling.
Reduced range of
motion: As your arthritis Difficulty in
The range of motion of a
given joint depends
61
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.
changing 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 flexibility are
reduced.
B. ETIOLOGY
Predis-
posing
Factors
Actual
findings
Implications
Hereditary
Since the patient’s Grandfather was diagnosed having
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,
can be passed down from parent to child.
62
Gender
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-for-you.com/blog/
osteoarthritis-hereditary-disease.html>
V. PATHOPHYSIOLOGY
a. Narrative
63
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
Diet Excessive Activity
level
Formation of osteophytes
Increase in synovial fluid
Pinch/crowd nerve
Pain
Narrowing of joint spaces
Pressure between joint
Formation of subchondral cysts
Pain
Difficulty of movement
Degeneration of cartilage
Continuous use of joint
Disappearing of full thickness of articular cartilage
Loss of HMGB2 that can cause loss of chondrocytes in the cartilage
65
Repair and remodelling
If not remodeled Surgery, GH & stem cell injection
If treated:
Inflammatory responseRelease of chemical mediators
Acts on pain receptors
Increase vascular permeablity
Increase blood flow
Pain edemaRedness, increase WBC
Immobilization
Osteoarthritis
VI. PLANNING
A. Nursing Care Plan 1
DATE
/SHIFT
CUES NSG.
DIAGNOSIS
OBJECTIVE
OF CARE
INTERVENTION Evaluation
Novem-
ber
15,2010
7-3
Subjective:
“Sakit pa akong
tuhod day” as
verbalized by the
patient
Pain Scale: 7
0 – 10 Numeric
Rating Scale
0-None
1-3 Mild
Acute Pain related to
joint degeneration
secondary to
Osteoarthritis
Scientific basis:
In patients older than 55 years of age, women are more frequently affected. Osteoarthritis is distinguished by a progressive degeneration of the cartilage in a joint—usually weight-bearing joint, but any joint can be affected. True to the progressive nature of the disease, the cartilage continues to degenerate,
After 2 hours
of nursing
interventions
the patient will
manifest
reduction of
pain from a
pain scale of 7
to 4 or lesser
as evidence
by:
Absence of
facial
grimacing and
Independent:
Assessed the patient’s
description of pain.
® The patient may manifest any
or part of the defining
characteristics, so focused
assessment is important.
Changed positions frequently
while maintaining functional
alignment.
®Muscle spasm may result from
poor alignment, resulting in
increased discomfort.
Goal met as
evidence
by “Dili na
kaayo xa
sakit
makaya
kaya na
kung irate
nako from
1-10, 2
nalang xa”
as
verbalize
by the
patient. No 66
4-6 Moderate
7- 10 Severe
Objective:
63 years old
Female
Facial grimace
Limited ROM
Restlessness
Vital signs:
Temp-37.2°C
RR- 20cpm
PR-90bpm
BP- 120/80 mmHg
and bone spurs called 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:
Gulanick/Myers 2007
Nursing Care Plans 6th
Edition, Mosby Inc.
pp.777-780.
Eustice, Carol. “What
Causes Osteoarthritis
Pain in a
Joint?”About.com
Guide.13, June 2008
McCaffery, M., & Beebe,
Absence of
restlessness. Supported joints in slightly
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
facial
grimacing
and signs
of
restlessnes
s noted.
67
A. (1993). Pain: Clinical Manual for Nursing Practice. Baltimore: V.V.Mosby Company.
ambulation and reduce joint
stress
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.
68
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
only 4-5 steps)
Impaired physical
Mobility r/t joint
degeneration as
evidenced by
verbalization of limited
range of motion.
SB: OA was
associated with
significant impairment,
and had an important
impact on, health-
related quality of life in
the areas of
After 6-hours of
rendering
nursing
interventions
and health
teachings, the
patient will
demonstrate
behaviors that
enable
resumption of
activities such
as active and
passive ROM
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
® To note any
Goal met as
evidenced by
demonstrating
flexion/extension
of extremities
and able to care
one self by
bathing herself
and combing
herself
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
ambulation, body care
and movement,
emotional behavior,
sleep and rest, home
management, and
work, especially in
patients ages 41–60.
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.
Reference:
http://journals.cambrid
ge.org/action/displayA
exercise. 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
Removed excess
clothing especially
70
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,
71
sleep and relaxation
® 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.
72
Cold compress
promote some
numbing thereby
promoting comfort
73
C. Nursing Care Plan 3
DATE /SHIFT
CUES NSG.
DIAGNOSIS
OBJECTIVE OF CARE
INTERVENTION EXPECTED OUTCOMES
November 15,2010
7-3
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
-Vital signs:
Risk for injury r/t limited range of
motion secondary to joint degeneration
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
That within our 6-hour span of care, our patient will be safe and remain free from injury as evidenced by:
a.) no falls or accidents
b.) absence of possible complications from fall,
1.) Noted age and sex.
® Children, young adults, elderly
persons and men are at greater risk.
2.) Evaluated developmental level, decision-making 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
GOAL MET!
After 6 hour span of care our patient was free from injury as evidenced by:
a.) no falls or accidents,
b.) absence of possible complications from fall,
74
Temp-36°C
RR- 20cpm
PR-74bpm
BP- 120/80 mmHg
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.
Reference: http://www.wisegeek.com/what-is-range-of-
motion.htm
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 individual situation.
5.) Identified interventions/sa
fety devices.® To promote safe
physical environment and individual safety.
6.) Anticipated movement of extraneous
lines and tubes during the
transfer and secure or guide
them into
c.) provide a safe environment for the patient such as;
c.1) raising of side rails
c.2) removing of any sharp objects away from patient’s bed
75
position.® Prevents undue
tension and dislocation of IV lines, NG tubes, catheters, and chest tubes;
maintains gravity drainage when
appropriate.
7.) Provided safety environment
such as removal of breakable objects.
® Required when equilibrium
problem exists.
8.) Never leaved the patient
alone.®Patient may be
forced to move up in bed when they need something
and there’s no one
76
to help him.
9.) Provided cool and quiet
environment.®Environment conducive for
sleeping would help patient fall
asleep and achieve bed rest.
10.)Secure patient as last resort. Raise the side
rails.® Limiting patient
action of the environment would
greatly limit or lessen the risk of
injury. Raising side rails prevents him
from falling.
11.)Reviewed expectations
caregivers have of children, cognitively
impaired and/or
77
elderly family members.
® To assist client/caregiver to reduce or correct
individual risk factors.
78
VII. PHARMACOLOGICAL MANAGEMENT
Date/ Shift Name of
Drug/
Drawing
Classification Dosage/
Time/
Route
Indication Mechanism
of Action
Side Effects Nursing
Responsibilities
.November
13,
2010
/
7³
Ketorolac
Nonsteroidal
anti-
inflammatory
agents,
nonopioids
analgesics.
30mg/q
8°/IVTT
Write
also the
frequenc
y
Short term
management
of pain (not
to exceed 5
days total for
all routes
combined).
Inhibits the
prostaglandin
synthesis,
producing
peripherally
mediated
analgesics.
Also have
antipyretic
and anti-
inflammatory
properties.
-drowsiness
-abnormal
thinking
- euphoria
- headache
- asthma
- dyspnea
- edema
- pallor
-
vasodilation
- Pt. who has
asthma, aspirin
– induced
allergy, and
nasal polyns are
at risk for
developing
hypersensitivity
reactions.
Assess for
rhinitis, asthma
and urticaria.
-Assess pain
(note type,
location, and
intensity) prior to
- GI bleeding
- diarrhea
- dry mouth
- GI pain
- nausea
-urinary
frequency
- oliguria
-renal
toxicity
- sweating
- paresthesia
and 1-2 hrs
following
administration.
- Advice pt. to
consult health
care
professionals if
rash, itching,
visual
disturbances,
tinnitus, weight
gain, edema,
black stools,
persistent
headache, or
influenza-like
syndrome (drills,
fever, muscle
aches, pain)
occurs.
80
Date/
Shift
Name of Drug/
Drawing
Classifica
tion
Dosage/
Time/
Route
Indication Mechanism of
Action
Side Effects Nursing
Responsibilities
Nov.
13,
2010
/
73
Diclofenac
non-
steroidal
anti-
inflammat
ory drug
(NSAIDs)
1Tab
25 mg
BID
6-6
Treatment of
mild to
moderate
pain, fever,
and
inflammation
.
Inhibits
the Lipo-
xygenase
pathways, thus
reducing
formation of
the leukotrienes
(also pro-
inflammatory au
tacoids. There is
also
speculation that
diclofenac may
inhibit
phospholipase
A2 as part of its
mechanism of
action.
-Ulcerations
-abdominal
Burning pain
-cramping
-nausea
-gastritis
- Advise patient
to take this
medication by
mouth with a full
glass of water
(8 ounces or
240 milliliters)as
directed by
phycisian.
-Advise the
patient not to lie
down for at
least 30
minutes after
81
taking this drug.
- To prevent
stomach upset,
ask the patient
to take this
medication with
food, milk, or an
antacid.
82
Date
/
Shift
Name of Drug/
Drawing
Classification Dosage/
Time/ Route
Indication Mechanism of
Action
Side Effects Nursing
Responsibilities
Nov.
13
2010
/
7³
Celebrex
Antirheuma-
tics,
nonsteroidal
anti-
inflammatory
agents
400mg/
1cap/
OD/PO
Manage-
ment of
acute pain
including
primary
dysmenor-
rhea.
Inhibits the
enzyme COX-
2. This enzyme
is required for
the synthesis of
prostaglandins.
Have
analgesics,
anti-
inflammatory,
and antipyretic
properties.
-dizziness
-headache
-insomnia
-edema
-GI bleeding
-Abdominal pain
-Diarrhea
-Dyspepsia
-Flatulence
-Nausea
-Rash
- 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.
83
Date/
Shift
Name of Drug/
Drawing
Classification Dosage/
Time/ Route
Indication Mechanism of
Action
Side
Effects
Nursing
Responsibilities
Nov.
15,
2010
/
73
Myonal
Muscle
relaxant
1 Tab
50mg TID
P.O
6-12-6
Improvement of myotonic symptoms in the following diseases: Cervical syndrome Periarthritis of the shoulder, lumbargo
Inhibition of Experimen-tally-Induced Muscle Rigidity: Eperisone HCl suppresses intercollicu-lar section-induced decerebrate rigidity (γ-rigidity) and ischemic decerebrate rigidity (α-rigidity) in rats dose-dependently.
Discharge Plan
-Sleepi-
ness
-Insomia
-Head
Ache
-numb-
ness
in the
extremi-
ties
-Patients
should be
cautioned
against
engaging in
potentially
hazardous
activities
requiring
alertness, such
as operating
machinery or
driving a car.
-Since the
elderly often
84
-
weakness
-light-
headed-
ness
have a
physiological
hypofunction, it
is advisable to
take measures,
such as
reduction in
dosage under
careful
supervision.
- Since shock
and
anaphylactoid
reactions may
occur, patients
should be
carefully
observed. In the
event of
symptoms such
85
as redness,
itching, urticaria,
edema of the
face or other
parts and
dyspnea etc.,
treatment
should be
discontinued
and appropriate
measures
taken.
86
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.
Rationale: to achieve appropriate therapeutic effects.
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.
88
Rationale: so that the patient’s 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
contact between the skin & shoulder harness & to promote absorption of perspiration.
Rationale: to prevent pulmonary problems.
Treatment:
Promote monotherapy (treatment with a single agent) if appropriate
89
Rationale: to simplify the medication regimen and make it less expensive.
Encourage the client to relax and have adequate rest
Rationale: to prevent stress and promote healing.
Encourage the client to compliance on further treatment
Rationale: for the proper maintenance and gain of optimal health.
Encourage active participation of patient in the program, including self-
monitoring of blood pressure and diet.
Rationale: for increased compliance.
Remind client’s relative on close monitoring of client’s activities.
Rationale: as some may interfere with ongoing treatment and procedures
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.
90
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.
Rationale: Smoking potentate’s peripheral vasoconstriction, impairing circulation and
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.
91
Instruct the patient to eat at the right time.
Rationale: to prevent skipping of meals and further complications
X. SYNTHESIS OFCLIENT’S 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 client’s 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. PATIENT’S PROGNOSIS
CRITERIA
GOOD FAIR POOR JUSTIFICATION
Onset of
Illness
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
92
physician.
Willingness
to take
treatment
regimen
Patient is very cooperative in achieving
fast recuperation by religiously taking
her prescribed medications.
Age Ages 45 and above are the highest age
risk of acquiring osteoarthritis. Since this
accompanies with aging, patient is rated
as poor.
Environ-
ment
The environment of the client is not
hazardous to her condition.
Gender Both males and females are prone of
having osteoarthritis.
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. Fair - 2pts. Poor -1pt.
Rating:
Good: 2.4 – 3.0 Fair: 1.7 – 2.3 Poor: 1 – 1.6
93
Computation:
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.
94
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
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 patient’s
case, formulated and enumerated discharge plans for the patient, and evaluated the
objectives of the study in the end.
95
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 & Suddarth’s Textbook of
Medical - Surgical Nursing. 12th ed. Philadelphia : Lippincott Williams & Wilkins
Deglin, V.H. Pharma D, & Vallerand, April.H. , PhD, RN, FAAn, 2009, DAVIS’s
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
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
97
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.
Valerie C. Scanlon, Tina Sanders. Essentials of Anatomy and Physiology, 5th Ed.
98
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
http://www.ehealthmd.com/library/osteoarthritis/OSA_causes.html
99
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-hereditary-
disease.html
http://www.ihaveosteoarthritis.com/what-causes-it.php
http://www.jarretmorrow.com/osteoarthritis-and-knee-pain-increase-risk-of-falls-
in-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
Kennedy, R. The Doctor’s Medical Library. Urinalysis Report Interpretation. n.d.
Retrieved July 25, 2010 from
http://www.medical-library.net/urinalysis_interpretation.html
100
Muscle weakness in osteoarthritis. O'Reilly S, Jones A, Doherty M.
Rheumatology Unit, Nottingham City Hospital, UK.
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.
