Divine Word College of LaoagSchool of Nursing

Laoag City

A case study presented to the Clinical Instructors of School of Nursing

Thopaceous Gouty Arthritis, septic arthritis

Presented by:

Aaron DondoyanoPaul Galat

Aimen Gallegos Noemi MaruquinIrvin Ross Molina

Ma. Editha Ofely MoralesCamille Pan

Gemaryvive QuiaoitJuvel Rafael

March 2010

PERSONAL DATA

Name of Patient: Mr. Emong Aguilla

Address: Bacarra, Ilocos Norte

Hospital number: 438633

Sex: Male

Age: 40 years old

Date of Birth: December 11, 1969

Civil Status: Married

Educational Attainment: High School Graduate

Occupation: Tricycle Driver

Chief of complaint: Swelling of the right lower extrimities

Admitting Diagnosis: Thopaceous Gouty Arthritis, R/O Septic Arthritis

Final Diagnosis: Thopaceous Gouty Arthritis, Septic Arthritis

Date and time of admission: February 11, 2010

Attending Physician: Dr. Gout

ANATOMY AND PHYSIOLOGY

SKELETAL SYSTEM

Sitting, standing, walking, picking up a pencil and taking a breath all involve the skeletal system. Without the skeletal system to support our bodies, we would have no rigid framework to support the soft tissues of the body and no systems of levers so critical for movement. The skeletal system consists of bones and their associated connective tissues, including cartilage, tendons and ligaments.

FUNCTIONS OF THE SKELETAL SYSTEM

1. Bone is made up of several different tissues working together: bone or osseous tissue, cartilage, dense connective tissue, epithelium, adipose tissue and nervous tissue. It is complex and dynamic living tissue. It continually engage in a process called remodeling-building new bone tissue and breaking down old bone tissue.

Support. Bone provides a rigid framework that supports the soft tissues of the body and maintains the body’s shape.

Protection. Bones protect internal organs that are critical to survival. Assistance in Movement. Because skeletal muscles attach to bones, when

muscles contract, they pull on bones. Together bones and muscles produce movement.

Mineral homeostasis. Bone tissue stores several minerals, especially calcium and phosphorus. On demand, bone releases minerals into the blood to maintain critical mineral balances and to distribute the minerals to other parts of the body.

Blood cell formation. Blood cells are produced in the marrow of many bones.2. Cartilage is somewhat rigid but more flexible than bone.

Model for Bone Growth. Cartilage is abundant in the embryo and the fetus, where it provides a model from which most of the adult bones develop. Cartilage is a major site of skeletal growth in the embryo, fetus and child.

Smooth joint surfaces. In the adult, the surfaces of bones within movable joints are covered with cartilage, which provides a smooth cushion between adjacent bones.

Support. Cartilage also provides a firm, yet flexible support within structures, such as nose, external ears, ribs and trachea.

3. Tendons and ligaments form attachments. Tendons and ligaments are strong bands of fibrous connective tissue.

Tendons. Attach muscle to bones. Ligaments. Attach bones to bones.

TYPES OF BONES

1. Long bone

The long bones are those that are longer than they are wide, and grow primarily by elongation ofthe diaphysis, with an epiphysis at the ends of the growing bone.

The long bones include the, femurs, tibias, and fibulas of the legs, the humeri, radii, and ulnas of the arms, metacarpals and metatarsals of the hands and feet, and the phalanges of the fingers and toes.

2. Short bones

Short bones are somewhat cube-shaped because they are nearly equal in length and in width. They consist of spongy bone tissue except at the surface, where there is a thin layer of compact bone tissue.

Examples of short bones are wrist or carpal bones, and ankle or tarsal bones.

3. Flat bones

Are generally thin and composed of two nearly parallel plates of compact bone tissue enclosing a layer of spongy bone tissue. Flat bones afford considerable protection and provide extensive areas for muscle attachment. Flat bones include the cranial bones, which protect the brain; the breastbone and ribs, which protect organs in the thorax; and the shoulder blades.

4. Irregular bones

The irregular bones are bones, which, from their peculiar form, cannot be grouped as long bone, short bone, flat bone, or sesamoid bone. Irregular bones serve various purposes in the body, such as protection of nervous tissue (such as the vertebrae protect the spinal cord), affording multiple anchor points for skeletal muscle attachment (as with the sacrum), and maintaining pharynx and trachea support, and tongue attachment (such as the hyoid bone). The irregular bones are the vertebræ, sacrum, coccyx, temporal, sphenoid, ethmoid, zygomatic, maxilla, mandible, palatine, inferior nasal concha, and hyoid.

5. Sesamoid Bone

Sesamoid bones are typically found in locations where a tendon passes over a joint, such as the hand, knee, and foot. Functionally, they act to protect the tendon and to increase its mechanical effect. The presence of the sesamoid bone holds the tendon slightly farther away from the center of the joint and thus increases its moment arm. Sesamoid bones also prevent the tendon from flattening into the joint as tension increases and therefore maintain a more consistent moment arm through a variety of possible tendon loads. This differs from menisci, which are made of cartilage and rather act to disperse the weight of the body on joints and reduce friction during movement.

Sesamoid bones can be found on joints throughout the body, including:

In the knee - the patella In the hand - two sesamoid bones are located in distal portions of the first metacarpal bone. There

is also commonly a sesamoid bone in distal portions of the second metacarpal bone. The pisiform of the wrist is a sesamoid bone as well.

In the foot - the first metatarsal bone has two sesamoid bones at its connection to the big toe.

PARTS OF A BONE

1. Diaphysis is the bones shaft or body- the long, cylindrical main portion of the bone.

2. Epiphyses are the distal and proximal ends of a bone.3. Metaphyses are the regions in a mature bone where the diaphysis joins the

epiphysis. In a growing bone, each metaphysis includes an epiphyseal plate, a layer of hyaline cartilage that allows the diaphysis of the bone to grow in length. When bone growth in length stops, the cartilage in the epiphyseal plateis replaced by bone and the resulting bony structure is known as epiphyseal line.

4. Articular cartilage is a thin layer of hyaline cartilage covering the epiphysis where the bone forms an articulation with another bone. Articular cartilage reduces friction and absorbs shock at freely movable joints. Because articular cartilage lacks a perichondrium, repair of damage is limited.

5. Periosteum is a tough sheath of dense irregular connective tissue that surrounds the bone surface wherever it is not covered by articular cartilage. The periosteum contains bone-forming cells that enable bone to grow in diameter or thickness but not in length. It also protects the bone, assists in fracture repair, helps nourish bone tissue and serves as an attachment point for ligaments and tendons.

6. Medullary Cavity or Marrow Cavity is the space within the diaphysis that contains fatty yellow bone marrow in adults.

7. Endosteum is a thin membrane that lines the medullary cavity. It contains a single layer of bone forming cells and a small amount of connective tissue.

TYPES OF BONE CELLS

Osteogenic Cells

These are unspecialized stem cells derived from mesenchyme, the tissue from which all connective tissues are formed. They are the only bone cells to ndergo cell division; the resulting daughter cells develop into osteoblasts. Osteogenic cells are found along the inner portion of the periosteum, in the endosteum, and in the canals within bone that contain blood vessels.

Osteoblasts

These are bone-building cells. They synthesized and secrete collagen fibers and other organic components needed to build the matrix of bone tissue, and they initiate calcification. As osteoblasts surround themselves with matrix, they become trapped in their secretions and become osteocytes.

Osteocytes

These are mature bone cells, the main cells in the bone tissue and maintain its daily metabolism, such as the exchange of nutrients and wastes with the blood. Like osteoblasts, osteocytes do not undergp cell division.

Osteoclasts

These are huge cells derived from the fusion of as many as 50 monocytes and are concentrated in the endosteum. On the side of the cell that faces the bone surface, osteoclats plasma membrane is deeply folded into a ruffled border. Here the cells release powerful lysosomal enzymes and acids that digest the protein and mineral components of the underlying bone matrix. This breakdown of bone matrix, termed resorption, is part of the normal development, growth, maintenance and repair of bone.

Joints

A joint, or articulation, is the place where two bones come together. There are three types of joints classified by the amount of movement they allow: immovable, slightly movable, and freely movable. The joints are the places of union between skeletal elements that are more or less moveable. Joints are commonly defined as being between bones, but joints also occur between bones and cartilages, between cartilages, and between bones and teeth. The articular system joins the skeleton, allows and/or restrains movement, and allows growth of the skeleton until the end of puberty.

Classification of joints by range of movement

Synarthroses - immoveable joints Amphiarthroses - "mixed" joints of limited movement Diarthroses - moveable joints

1. Immovable joints (synarthroses)

In this type of joint, the bones are in very close contact and are separated only by a thin layer of fibrous connective tissue. An example of a synarthrosis is the suture in the skull between skull bones.

Classification of joints by structure

Fibrous joints - joints composed of dense collagenous or elastic connective tissue Cartilaginous joints - joints composed of hyaline cartilage or fibrocartilage Bony unions - fusion between two bones Synovial joints - joints containing a synovial cavity filled with synovial fluid

2. Slightly movable joints (amphiarthroses)

This type of joint is characterized by bones that are connected by hyaline cartilage (fibro cartilage). The ribs that connect to the sternum are an example of an amphiarthrosis joint.

3. Freely movable joints (diarthrosis)

Synovial (diarthrosis): Synovial joints are by far the most common classification of joint within the human body. They are highly moveable and all have a synovial capsule (collagenous structure) surrounding the entire joint, a synovial membrane (the inner layer of the capsule) which secretes synovial fluid (a lubricating liquid) and cartilage known as hyaline cartilage which pads the ends of the articulating bones. There are 6 types of synovial joints which are classified by the shape of the joint and the movement available.

Six types of diarthroses joints

Joint Type Movement at joint Examples Structure

Hinge

A convex projection on one bone fits into a concave depression in another permitting only flexion and extension as in the elbow joints.

Flexion/Extension

Elbow/Knee Hinge joint

Pivot

Rounded or conical surfaces of one bone fit into a ring of one or tendon allowing rotation. An example is the joint between the axis and atlas in the neck.

Rotation of one bone around another

Top of the neck(atlas and axis bones)

Pivot Joint

Ball and Socket

The ball-shaped end of one-bone fits into a cup shaped socket on the other bone allowing the widest range of motion including rotation. Examples include the shoulder and hip.

Flexion/Extension/Adduction/Abduction/Internal & External Rotation Shoulder/Hip Ball and socket

joint

Saddle

This type of joint occurs when the touching surfaces of two bones have both concave and convex regions with the shapes of the two bones complementing one other and allowing a wide range of movement. The only saddle joint in the body is in the thumb.

Flexion/Extension/Adduction/Abduction/Circumduction CMC joint of the

thumbSaddle joint

Condyloid

Oval shaped condyle fits into elliptical cavity of another allowing angular motion but not rotation. This occurs between the metacarpals (bones in the palm of the hand) and phalanges (fingers) and between the metatarsals (foot bones excluding heel) and phalanges (toes).

Flexion/Extension/Adduction/Abduction/Circumduction Wrist/MCP &

MTP jointsCondyloid joint

Gliding

Flat or slightly flat surfaces move against each other allowing sliding or twisting without any circular movement. This happens in the carpals in the wrist and the tarsals in the ankle.

Gliding movements

Intercarpal joints Gliding joint

Big toe

The largest and innermost toe of the human foot.

Ankle

The bones which constitute the ankle are the two long bones of the lower leg (tibia and fibula), which articulate with a short anklebone called the talus. This is a ‘uniaxial’, or hinge, joint, which allows flexion and extension movements. In the case of the ankle these movements are called dorsiflexion (sole of the foot up) and plantarflexion (foot down) respectively. Plantarflexion is achieved by the calf muscles (gastrocnemius and soleus), which form a large strong tendon (Achilles tendon) which inserts into the bone of the heel (calcaneum).

The ankle joint acts like a hinge. But it's much more than a simple hinge joint. The ankle is actually made up of several important structures. The unique design of the ankle makes it a very stable joint. This joint has to be stable in order to withstand 1.5 times your body weight when you walk and up to eight times your body weight when you run.

Knee

The knee joint is functionally a hinge joint, which principally allows movements of the lower leg forwards (extension) and backwards (flexion), although a limited degree of rotation is also possible towards the end of extension. Extension is achieved by a group of four large muscles at the front of the thigh (quadriceps), whilst muscles at the back of the thigh (hamstrings) produce flexion. The lower end of the femur articulates, through two condyles, with the top of the tibia, which is shaped rather like a plateau. In addition to the cartilage covering the surfaces of these bone-ends, there is another piece of cartilage (meniscus) separating them on each side. These can be torn by rotational injuries, particularly in football and rugby players, a condition commonly referred to as torn cartilage.

Hip

The hip joint is an example of a ‘ball and socket’ (multiaxial) type of joint, with the top (head) of the long bone of the leg (femur) being the ‘ball’ and the socket being a depression in the bone of the pelvis known as the acetabulum. This arrangement permits movements in three planes — forwards and backwards (extension/flexion) ; inwards and outwards (adduction/abduction) ; and inward twist and outward twist (internal and external rotation). Combination of these movements also gives rise to ‘circumduction’, a circular movement of the whole leg, which describes a ‘cone’ with the foot at the base and the hip at the apex. The joint is spanned by powerful muscles, which are required not only for postural control and movement but also to confer stability at the hip.

Wrist and Hand

The joint between the end of the forearm and the hand. Movements occur in two planes — flexion/extension and adduction/abduction (inward/outward). This is a relatively complex joint as it is an articulation between the lower end of the long bones of the forearm (radius and ulna) and the eight small bones of the hand (carpal bones). These carpal bones are connected to one another by ligaments so that they form an arch, concave towards the palm, with its ends connected by a fibrous tissue band. Through this ‘tunnel’ run long tendons which control the fingers and, more importantly, the median nerve which carries the nerve supply to some muscles of the hand and to the skin of some of the fingers.

Elbow

The elbow is the region surrounding the elbow-join—the ginglymus or hinge joint in the middle of the arm. Three bones form the elbow joint: the humerus of the upper arm, and the

paired radius and ulna of the forearm. An example of a hinge joint (uniaxial) with movement essentially limited to flexion and extension. The condyles at the lower end of the humerus in the upper arm articulate with the heads of both the radius and the ulna in the lower arm. Twisting movements of the lower arm (pronation and supination) are possible because the top end (the head) of the radius can rotate against the lower end of the humerus. Flexion of the elbow is achieved by action of the biceps muscle, which shortens and bulges, a muscle often shown to advantage in the classic pose of the body builder.

Shoulder

The flexible ball-and-socket joint formed by the junction of the humerus and the scapula. This joint is cushioned by cartilage that covers the face of the glenoid socket and head of the humerus. The joint is stabilized by a ring of fibrous cartilage (the labrum) around the glenoid socket. Ligaments connect the bones of the shoulder, and tendons join these bones to surrounding muscles. The biceps tendon attaches the biceps muscle to the shoulder and helps stabilize the joint. Four short muscles that originate on the scapula pass around the shoulder, where their tendons fuse together to form the rotator cuff.

Common sites of TOPHI formation

READINGS

GOUT

Gout is a complex disease of uncertain origin caused by the faulty metabolism of uric acid produced in the body by breakdown of protein, resulting in elevated levels of uric acid in the blood that crystallizes and deposits in joints, tendons, and surrounding tissues.

It is often characterized as an inflammatory form of arthritis. But unlike the inflammation in RA and lupus, which is related to the immune system, joint inflammation in gout is caused by deposits of sodium urate crystals in the joints. It can cause an attack of sudden burning pain, stiffness, and swelling in a joint, usually a big toe. These attacks can happen over and over unless gout is treated. Over time, they can harm your joints, tendons, and other tissues.

Incidence

Its incidence is not usually affected by climate or season; about 95 percent of sufferers are men. The disease is rare in people under the age of 30; from 10 to 20 percent of cases have a familial history.

Epidemiology

Gout affects 1% of the Western population at some point in their lifetime and is increasing in prevalence. This increases to 2% in men over the age of 30 and women over the age of 50.

Different populations have different propensities to develop gout. In the United States, gout is twice as prevalent in African American males as it is in European-Americans. It is high among the peoples of the Pacific Islands, and the Māori of New Zealand, but rare in Australian aborigines despite the latter's higher mean concentration of serum uric acid.

In the United States and Italy, attacks of gout occur more frequently in the spring.

Types of Gout

Primary gout: The cause is usually unknown. However, it is likely the result of a combination of genetic, hormonal, and dietary factors.

Secondary gout: Secondary gout is caused by medications or medical conditions that cause an increase in the serum (blood) levels of uric acid.

Stages of Gout

1. Asymptomatic hyperuricemia2. Acute gouty arthritis3. Intercritical gout4. Chronic tophaceous gout

Risk Factors of Gout

Age Middle-Aged Adults. Gout usually occurs in middle-aged men, peaking in the mid-40s. It

is most often associated in this age group with obesity, high blood pressure, unhealthy cholesterol levels, and heavy alcohol use.

Elderly. Gout can also develop in older people, when it occurs equally in men and women. In this group, gout is most often associated with kidney problems and the use of diuretics. It is less often associated with alcohol use.

Children. Except for rare inherited genetic disorders that cause hyperuricemia, gout in children is rare.

Gender Men. Men are significantly at higher risk for gout. In males, uric acid levels rise

substantially at puberty. In about 5 - 8% of American men, levels exceed 7 mg/dL (indicating hyperuricemia). However, gout typically strikes after 20 - 40 years of persistent hyperuricemia, so men who develop it usually experience their first attack between the ages of 30 and 50.

Women. Before menopause, women have a significantly lower risk for gout than men, possibly because of the actions of estrogen. This female hormone appears to facilitate uric acid excretion by the kidneys. (Only about 15% of female gout cases occur before menopause.) After menopause the risk increases in women. At age 60 the incidence is equal in men and women, and after 80, gout occurs more often in women.

Family History A family history of gout is present in close to 20% of patients with this condition. Three

genetic locations have been associated with the body's uric acid handling and gout. Some people with a family history of gout have a defective protein (enzyme) that interferes with the way the body breaks down purines.

Obesity Researchers report a clear link between body weight and uric acid levels. In one Japanese

study, overweight people had two to more than three times the rate of hyperuricemia as those who maintained a healthy weight. Children who are obese may have a higher risk for gout in adulthood.

Medications Thiazide diuretics are "water pills" used to control hypertension. The drugs are strongly

linked to the development of gout. A large percentage of patients who develop gout at an older age report the use of diuretics.

Other medications: Aspirin -- low doses of aspirin reduce uric acid excretion and increase the chance for

hyperuricemia. This may be a problem for older people who take baby aspirin (81 mg) to protect against heart disease.

Niacin (used to treat cholesterol problems) Pyrazinamide (used to treat tuberculosis) Alcohol Drinking excessive amounts of alcohol can raise your risk of gout. Beer is the kind of

alcohol most strongly linked with gout, followed by spirits. Moderate wine consumption does not appear to increase the risk of developing gout.

Alcohol use is highly associated with gout in younger adults. Binge drinking particularly increases uric acid levels. Alcohol appears to play less of a role among elderly patients, especially among women with gout.

Alcohol increases uric acid levels in the following three ways: Providing an additional dietary source of purines (the compounds from which uric

acid is formed) Intensifying the body's production of uric acid Interfering with the kidneys' ability to excrete uric acid

Lead Exposure Chronic occupational exposure to lead is associated with build-up of uric acid and a high

incidence of gout. Organ Transplants Kidney transplantation poses a high risk for renal insufficiency and gout. In addition,

other transplantation procedures, such as heart and liver, increase the risk of gout. The procedure itself poses a risk of gout, as does the medication (cyclosporine) used to prevent rejection of the transplanted organ. Cyclosporine also interacts with indomethacin, a common gout treatment.

The kidneys are responsible for removing waste from the body, regulating electrolyte balance and blood pressure, and stimulating red blood cell production.

Other IllnessesTreatment of several other conditions can cause significant elevations of uric acid in the blood, and therefore a gout attack. These conditions include:

Leukemia Lymphoma Psoriasis

Symptoms of Gout

Asymptomatic Hyperuricemia

Asymptomatic means there are no symptoms. Asymptomatic hyperuricemia is considered the first stage of gout. MSU levels slowly increase in the body. This stage lasts for an average of 30 years.Note: Hyperuricemia does not inevitably lead to gout. In fact, less than 20% of cases develop the full-blown arthritic gout disease.

Acute Gouty ArthritisAcute gouty arthritis occurs when the first symptoms of gout appear. Sometimes

the first signs of gout are brief twinges of pain (petit attacks) in an affected joint. These attacks can precede the actual full-blown condition by several years.

MSU crystals form at normal body temperature when the concentration of uric acid in the blood reaches 7 mg/dL. At lower temperatures, MSU crystals form at lower concentrations of uric acid. Since blood temperature falls the further blood gets from the heart, gout usually strikes the toes and fingers first.

Symptoms of acute gouty arthritis include: Severe pain at and around the joint May feel like "crushing" or a dislocated bone Physical activity and even the weight of bed sheets may be unbearable Usually takes 8 - 12 hours to develop Occurs late at night or early in the morning and may wake you up Swelling that may extend beyond the joint Red, shiny, tense skin over the affected area, which may peel after a few days Chills and mild fever, loss of appetite, and feelings of ill

Most often symptoms start in one joint Monoarticular Gout. Gout that occurs in one joint is called monoarticular gout. About

60% of all first-time monoarticular gout attacks in middle-aged adults occur in the big toe. This occurrence is known as podagra. Symptoms can also occur in other locations, such as the ankle or knee.

Polyarticular Gout. If more than one joint is affected, the condition is known as polyarticular gout. Multiple joints are affected in only 10 - 20% of first attacks. Older people are more likely to have polyarticular gout. The most frequently affected joints are the foot, ankle, knee, wrist, elbow, and hand. The pain usually occurs in joints on one side of the body and it is usually, although not always, in the lower legs and the feet. People with polyarticular gout are more likely to have a slower onset of pain and a longer delay between attacks. People with polyarticular gout are also more likely to experience low-grade fever, loss of appetite, and a general feeling of poor health.

o An untreated attack will typically peak 24 - 48 hours after the first appearance of

symptoms, and go away after 5 - 7 days. However, some attacks last only hours, while others persist as long as several weeks.

Intercritical GoutIntercritical gout is the term used to describe the periods between attacks. The

first attack is usually followed by a complete remission of symptoms, but, if left untreated, gout nearly always returns. Over two-thirds of patients will have at least one further attack within 2 years of the first attack. By 10 years, over 90% of the patients are likely to have repeat attacks.

Chronic Tophaceous GoutAfter several years, persistent gout can develop into a condition called chronic

tophaceous gout. This long-term condition often produces tophi, which are solid deposits of MSU crystals that form in the joints, cartilage, bones, and elsewhere in the body. In some cases, tophi break through the skin and appear as white or yellowish-white, chalky nodules that have been described as looking like crab eyes.

Without treatment, tophi develop about 10 years after the initial onset of gout, although the occurrence can range from 3 to 42 years. Tophi are more likely to appear early in the course of the disease in older people. In the elderly population, women appear to be at higher risk for tophi than men. Certain people, such as those who are receiving cyclosporine after a transplant, have a high risk of developing tophi.

A risk for tophaceous gout Had more than two or three acute attacks of gout in the past Unusually severe attacks, or attacks that affect more than one joint Joint damage from gout, as shown on x-rays Hyperuricemia caused by an identifiable inborn metabolic deficiency

Development of Chronic Pain. When gout remains untreated, the intercritical periods typically become shorter and shorter, and the attacks, although sometimes less intense, can last longer. Over the long term (about 10 - 20 years) gout becomes a chronic disorder characterized by constant low-grade pain and mild or acute inflammation. Gout may eventually affect several joints, including those that may have been free of symptoms at the first appearance of the disorder. In rare cases, the shoulders, hips, or spine are affected.

Location of Tophi Curved ridge along the edge of the outer ear Forearms Elbow or knee Hands or feet -- older patients, particularly women, are more likely to have gout in the

small joints of the fingers. Around the heart and spine (rare)

Tophi are generally painless. However, they can cause pain and stiffness in the affected joint. Eventually, they can also erode cartilage and bone, ultimately destroying the joint. Large tophi under the skin of the hands and feet can give rise to extreme deformities.

Hyperuricemia

Hyperuricemia is an excess of uric acid in the blood. Uric acid passes through the liver, and enters your bloodstream. Most of it is excreted (removed from your body) in your urine, or passes through your intestines to regulate "normal" levels. Normal Uric acid levels are 2.4-6.0 mg/dL (female) and 3.4-7.0 mg/dL (male.

Three functional causes of Hyperurecemia:

Increased production of uric acidHyperuricemia of this type is a common complication of solid organ transplant.

Apart from normal variation (with a genetic component), tumor lysis syndrome produces extreme levels of uric acid, mainly leading to renal failure. The Lesch-Nyhan syndrome is also associated with extremely high levels of uric acid.

Decreased excretion of uric acidThe principal drugs that contribute to hyperuricemia by decreased excretion are

the primary antiuricosurics. Other drugs and agents include diuretics, salicylates, pyrazinamide, ethambutol, nicotinic acid, ciclosporin, 2-ethylamino-1,3,4-thiadiazole, and cytotoxic agents.

A ketogenic diet impairs the ability of the kidney to excrete uric acid, due to competition for transport between uric acid and ketones.

Elevated blood lead is significantly correlated with both impaired kidney function and hyperuricemia (although the causal relationship among these correlations is not known).

Mixed typeCauses of hyperuricemia that are of "mixed" ("double whammy") type have a dual

action, both increasing production and decreasing excretion of uric acid.High intake of alcohol (ethanol), a significant cause of hyperuricemia, has a dual

action that is compounded by multiple mechanisms. High dietary intake of fructose contributes significantly to hyperuricemia. Increased

production of uric acid is the result of interference, by a product of fructose metabolism, in purine metabolism.

Starvation causes the body to metabolize its own (purine-rich) tissues for energy. Thus, like a high purine diet, starvation increases the amount of purine converted to uric acid. A very low calorie diet without carbohydrate can induce extreme hyperuricemia;

including some carbohydrate (and reducing the protein) reduces the level of hyperuricemia. Starvation also impairs the ability of the kidney to excrete uric acid, due to competition for transport between uric acid and ketones.

Symptoms of Hyperuricemia

You may not have any symptoms. If your blood uric acid levels are significantly elevated, and you are undergoing

chemotherapy for leukemia or lymphoma, you may have symptoms kidney problems, or gouty arthritis from high uric acid levels in your blood.

You may have fever, chills, fatigue if you have certain forms of cancer, and your uric acid levels are elevated (caused by tumor lysis syndrome)

You may notice an inflammation of a joint (called "gout"), if the uric acid crystals deposit in one of your joints. (*Note- gout may occur with normal uric acid levels, too).

You may have kidney problems (caused by formation of kidney stones), or problems with urination

Drugs or treatments to treat hyperuricemia:

Non-steroidal anti-inflammatory (NSAID) agents and Tylenol®- such as naproxen sodium and ibuprofen may provide relief of gout-related pain.

If you are to avoid NSAID drugs, because of your type of cancer or chemotherapy you are receiving, acetaminophen (Tylenol() up to 4000 mg per day (two extra-strength tablets every 6 hours) may help.

It is important not to exceed the recommended daily dose of Tylenol, as it may cause liver damage.

Uricosuric Drugs: These drugs work by blocking the reabsorption of urate, which can prevent uric acid crystals from being deposited into your tissues. Examples of uricosuric drugs include probenecid, and sulfinpyrazone.

Xanthine oxidase inhibitors - Such as allopurinol, will prevent gout. However, it may cause your symptoms of gout to be worse if it is taken during an episode of painful joint inflammation.

Allopurinol may also be given to you, if you have a certain form of leukemia or lymphoma, to prevent complications from chemotherapy and tumor lysis syndrome - and not necessarily to prevent gout. With high levels of uric acid in your blood, as a result of your disease, the uric acid will collect and form crystals in your kidneys. This may occur during chemotherapy, and may cause your kidneys to fail.

Uric Acid

Uric acid is a normal component of blood serum. It is the end product of purine metabolism. It is catalyzed by the enzyme xanthine oxidase, which is responsible for the production of uric acid and damaging free radicals.

Purines are generated by the body via breakdown of cells in normal cellular turnover, and also are ingested as part of a normal diet. The kidneys are responsible for approximately two-thirds of uric acid excretion, with the liver responsible for the rest.

Human beings have higher levels of uric acid, in part, because of a deficiency of the hepatic enzyme, uricase, and a lower fractional excretion of uric acid. Approximately two thirds of total body urate is produced endogenously, while the remaining one third is accounted for by dietary purines. Approximately 70% of the urate produced daily is excreted by the kidneys, while the rest is eliminated by the intestines. However, during renal failure, the intestinal contribution of urate excretion increases to compensate for the decreased elimination by the kidneys.

The blood levels of uric acid are a function of the balance between the breakdown of purines and the rate of uric acid excretion. Theoretically, alterations in this balance may account for hyperuricemia, although clinically defective elimination accounts for most cases of hyperuricemia.

Causes of high uric acid levels include:

Primary hyperuricemia Elevated serum urate levels or manifestations of urate deposition appear to bbe

consequences of faulty uric acid metabolism. It is maybe due to severe dieting or starvation, evcessive intake of foods that are high n purines, and heredity.

Secondary hyperuricemia Gout is a clinical feature secondary to any of a number of genetic or acquired

processes, including conditions in which there is an increase in cell turnover and an increase in cell breakdown.

Purines

Purines are natural substances found in all of the body's cells, and in virtually all foods. Purines provide part of the chemical structure of our genes and the genes of plants and animals. A relatively small number of foods, however, contain concentrated amounts of purines. For the most part, these high-purine foods are also high-protein foods, and they include organ meats like kidney, fish like mackerel, herring, sardines and mussels, and also yeast.

Foods that are high in purine include: All organ meats (such as liver), meat extracts and gravy Yeasts, and yeast extracts (such as beer, and alcoholic beverages) Asparagus, spinach, beans, peas, lentils, oatmeal, cauliflower and mushrooms

Foods that are low in purine include: Refined cereals - breads, pasta, flour, tapioca, cakes Milk and milk products, eggs Lettuce, tomatoes, green vegetables Cream soups without meat stock Water, fruit juice, carbonated drinks Peanut butter, fruits and nuts

Purines are metabolized into uric acid

When cells die and get recycled, the purines in their genetic material also get broken down. Uric acid is the chemical formed when purines have been broken down completely. It's normal and healthy for uric acid to be formed in the body from breakdown of purines. In our blood, for example, uric acid serves as an antioxidant and helps prevent damage to our blood vessel linings, so a continual supply of uric acid is important for protecting our blood vessels.

Uric acid levels in the blood and other parts of the body can become too high, however, under a variety of circumstances. Since our kidneys are responsible for helping keep blood levels of uric acid balanced, kidney problems can lead to excessive accumulation of uric acid in various parts of the body. Excessive breakdown of cells can also cause uric acid build-up. When uric acid accumulates, uric acid crystals (called monosodium urate crystals) can become deposited in our tendons, joints, kidneys, and other organs. This accumulation of uric acid crystals is called gouty arthritis, or simply "gout”.

SEPTIC ARTHRITIS

Septic arthritis, also called infectious arthritis, is caused by a bacterial infection or more rarely by a fungal or viral infection. The condition is typically acute, causing severe joint pain, inflammation, redness, and in some cases fever and chills but may also become chronic. Septic arthritis may affect any joint but is most frequently found in the knee, hip, shoulder, wrist, elbow, and finger joints. Usually only one joint will be affected but, in some cases, there may be more than one. This condition needs to be diagnosed and treated quickly because it can destroy joints in a short period.

Septic arthritis occurs most often in people who have had a recent traumatic injury to a joint, have had joint surgery or joint replacement, and/or in people who currently have an infection in their blood (bacteremia or septicemia). Microorganisms can spread from an original site of infection into the blood and then can be carried into the joint space. Additional risk factors for septic arthritis include age (older than 80 years), having diabetes, a weakened immune system, and/or another condition that affects the joints, such as gout or rheumatoid arthritis.

The acute form of septic arthritis is usually caused by bacteria, such as Staphylococcus aureus, Streptococcus pneumoniae, group B streptococci, or gonococci (which cause gonorrhea). Sometimes the microorganisms that cause Lyme disease, HIV, hepatitis B, mumps, or rubella can move into and infect a joint. Chronic septic arthritis is rarer and tends to be caused by microorganisms such as Mycobacterium tuberculosis and Candida albicans.

Causes

Septic arthritis develops when bacteria spread through the bloodstream to a joint. It may also occur when the joint is directly infected with bacteria by an injury or during surgery. The most common sites for this type of infection are the knee and hip.

Most cases of acute septic arthritis are caused by organisms such as staphylococcus or streptococcus.

Chronic septic arthritis (which is less common) is caused by organisms such as Mycobacterium tuberculosis and Candida albicans.

The following increase your risk for septic arthritis:

Artificial joint implants Bacterial infection elsewhere in your body Chronic illness or disease (such as diabetes, rheumatoid arthritis, and sickle cell disease) Intravenous (IV) or injection drug use Medications that suppress your immune system Recent joint trauma Recent joint arthroscopy or other surgery

Septic arthritis may be seen at any age. In children, it occurs most often in those younger than 3 years. The hip is a frequent site of infection in infants.

Septic arthritis is uncommon from age 3 to adolescence. Children with septic arthritis are more likely than adults to be infected with group B streptococcus or Haemophilus influenza., if not immunized.

Symptoms

Symptoms usually come on quickly, with joint swelling, intense joint pain, and low-grade fever.

Symptoms in newborns or infants:

Cries when infected joint is moved (example: diaper change causes crying if hip joint is infected)

Irritability Fever Unable to move the limb with the infected joint (pseudoparalysis)

Symptoms in children and adults:

Inability to move the limb with the infected joint (pseudoparalysis) Intense joint pain Joint swelling Joint redness Low-grade fever

Chills may occur, but are uncommon.

Testing The goals with testing for septic arthritis are to identify the microorganism causing the infection, to determine which antimicrobial therapy will be effective, to monitor the effectiveness of treatment, and to evaluate the physical status of the affected joint(s).

Laboratory Tests:

Blood culture - used to determine if a microorganism is present in the blood

Culture of joint fluid or of other body fluids or tissues, such as sputum, urine, cerebrospinal fluid - to detect microorganisms, to determine which antimicrobials they are likely to be susceptible to, and to evaluate the effectiveness of treatment

Synovial fluid analysis - to detect microorganisms and to see if there are any signs, such as crystals in the joint fluid, that may indicate a different or co-existing cause for joint pain (such as gout)

Complete Blood Count (CBC) - this is a group of tests used to evaluate a patient’s red and white blood cells and hemoglobin to help evaluate and monitor the condition

Non-Laboratory Tests:

X-ray of joint(s) - used to help evaluate joint damage; may not show abnormalities until significant damage exists

Treatments The goals with treatment are to eliminate the infection, reduce inflammation and associated fluid pressure on the joint, to minimize joint damage, and to maintain and/or recover joint mobility.

The primary treatment is the appropriate antimicrobial therapy. The exact medication prescribed will depend on which drugs the microorganism is susceptible to and how effective the antimicrobials are at getting into the joint space where the infection is. In most cases, this drug will also be effective in treating the source of the infection when it has originated in the blood or another body organ or tissue. With some organisms, such as a mycobacterium, multiple drugs may need to be taken for extended periods of time. Viral infections will usually resolve on their own.

Patients may also be treated for inflammation and pain. Fluid is usually aspirated from the affected joint(s) to relieve pressure and to obtain material to culture the specific microorganism. Aspiration may need to be done several times to relieve pressure. In some cases, surgery may be needed to drain the fluid.

Outlook (Prognosis)

Recovery is good with prompt antibiotic treatment. If treatment is delayed, permanent joint damage may result.

Possible Complications

Joint degeneration (arthritis)

Prevention

Preventive (prophylactic) antibiotics may be helpful for people at high risk.

FAMILY BACKGROUND

Name Sex Age Educational Attainment

Occupation Religion Residence

Dionisia Female 61 High School Graduate

Housewife Pentecost Bacarra I.N

Emong Male 40 High school Driver Pentecost Bacarra I.N

GraduateEmang Female 36 High school

GraduateCaregiver Pentecost Bacarra I.N

Ago Male 15 Not applicable Not applicable

Pentecost Bacarra I.N

Bendita Female 13 Not applicable Not applicable

Pentecost Bacarra I.N

A) Family Structure

Emong, a 40-year-old male, is the head of the family, happily married with his wife Emang, 36 years old, and is a father of two children, his eldest son is Ago 15 years old, and his youngest daughter is Bendita 13 years old, both are high school students. Living with them is his mother Dionisia, 61 years old.

Their family is considered as an extended type and is permanently residing at Bacarra, Ilocos Norte. Since his wife works abroad, he takes the responsibility for rearing his children with the assistance of Aling Dionisia, his mother. The family is patriarchal because Mang Emong is the leader of the family and is usually the decision maker, but as much as possible he let his children participate.

All the members irrespective of their ages and economic status, where treated equally, which is under egalitarian type. They are devout members of the Pentecost and they attend mass every Sunday. They have a happy home where parental guidance and children’s laughter reigns, both parents and children were harmoniously united by strong ties of affection and understanding.

As a father, he instilled in his children’s mind a love for parents, self-respect and deeply influenced their character to become a better and responsible individual in the future. There are times that problems arise in their family but it does not last in a day because they resolved it immediately as much as they can. Mang Emong’s family is an example of a happy family; they find time to go out together, spend holidays and weekends with their relatives, and participate in various activities of their Barangay.

B) EnvironmentalThe family live in an up and down type of house with a combination of cement

and wood with surrounding fences, behind it were the poultry yard and vegetable garden. They live near a high school and in front of a busy road. Typically, their toilet is water sealed system located inside their house.

C) Socio Economic

As a provider he works hard to sustain their family’s needs, he works as a tricycle driver earning an average monthly income of Php 5,000,his wife who is currently working in Taiwan as caregiver gives an additional Php 5,000 allowance per month.

The total monthly income is approximately Php 10,000 per month. As a decision maker in the family, he makes sure to spend the money wisely. The Php 10,000 monthly income was allotted for food Php3,000 (Php 750 per week), Php 2,000 for education, approximately Php 200 for medicine, Php 500 for electricity, for water Php 5,00 and Php 1,000 for miscellaneous expenses. All in all the total monthly expenses of the family is approximately 7,200. The remaining monthly income of Php 2800 is being kept in the bank for future use of his children and for emergency cases.

30%

20%

2%

5%5%

10%

28%

Sales

FoodEducationMedicineElectricityWaterMiscellaneousSavings

HEALTH HISTORY

Family Health History

The family members had experienced simple ailments such as cough and colds, fever, headache and stomachache. All were managed at home of they can, however, they also consult a physician if they cannot treat themselves alone. For headache, they used to manage by putting a

piece of sliced ginger on to their temporal and taking OTC drug like Biogesic and Cortal. According to him, the ginger can lessen the pain due to its cooling effect. For stomachache, they drink a decoction of “Herba Buena”. For cough and colds, they take Asmasolon and Neozep, drinking plenty of water and taking enough rest. For fever, they stayed at home, rest, and take drug such as Paracetamol. For cases of fractures, the family usually consults a “manghihilot” which is according to him, is also effective.

The family had also experienced childhood diseases such as chickenpox, mumps, and measles. All were managed at home. They used to manage mumps through putting an “akot-akot” (mixed with water) on to their buccal area and below their ears. According to him, the cooling effect of the “akot-akot” can help to reduce the pain. For chickenpox, they stayed at home and take enough rest, and when the vesicles will dry, they burn hay and add with warm water, and they will use this as bath soap believing that this would kill the remaining bacteria in their wounds. For measles, they just stayed at home, wore black clothes and they do not take a bath until the rashes will gone.

The knowledge they had in treating diseases mentioned above were all based from their beliefs and practices, from what they heard from their relatives, friends and neighbors, from the television and also from those who are in the medical field.

However, for his daughters, it were all consulted and treated by a physician.

His father who was already dead due to gunshot way back 1979 had asthma likewise sibling 1 and 2. His daughter 2 had weak lungs at the age of six and was confined and treated at GRBASMH, Laoag City. A physician diagnosed all of these diseases.

He and his siblings had experienced to receive immunizations when they were child, however, he cannot recall what these immunizations anymore. His two daughters were both fully immunized child. They received their immunizations in the hospital and at their Barangay Health Center.

The family is fond of drinking coffee and soft drinks. Their meal is usually comprised of meat and vegetable most of the time. During their free time, they usually watch TV and chat with each other.

Past Health History

During his childhood, he had experienced illnesses such as cough and colds, fever, headache and stomachache. All were managed at home if they can, however, they also consult a physician if they cannot treat themselves alone. For headache, they used to manage by putting a piece of sliced ginger on to their temporal and taking OTC drug like Biogesic and Cortal. According to him, the ginger can lessen the pain due to its cooling effect. For stomachache, they

drink a decoction of “Herba Buena” and taking OTC drug such as Diatabs. For cough and colds, they take Asmasolon and Neozep, drinking plenty of water and taking enough rest. For fever, they stayed at home, rest, and take drug such as Paracetamol. For cases of fractures, the family usually consults a “manghihilot” which is according to him, is also effective.

He had also experienced childhood diseases such as chickenpox, mumps, and measles. All were managed at home. They used to manage mumps through putting an “akot-akot” (mixed with water) on to their buccal area and below their ears. According to him, the cooling effect of the “akot-akot” can help to reduce the pain. For chickenpox, they stayed at home and take enough rest, and when the vesicles will dry, they burn hay and add with warm water, and they will use this as bath soap believing that this would kill the remaining bacteria in their wounds. For measles, they just stayed at home, wore black clothes and they do not take a bath until the rashes will gone.

In 1997, his abdomen particularly his LUQ was stab by a friend while they were drinking. Fortunately, there was no vital organ involved. He was confined and treated at GRBAMH for one week for this incident.

Five years ago, he felt pain from his RUQ, nauseated and feels like vomiting. After one week, he decided to consult a physician here in Laoag City and was diagnosed of having liver cirrhosis. As he can remember, one of his medications was Godecs. After a year of treatment, his liver cirrhosis was treated.

As stated by him, before he had diagnosed to have liver cirrhosis, he used to drink alcoholic beverages such as beer and gin every day. If it is GSM, he can consume one bottle (bilog) and if it is beer, he can consume 1-2 bottles of beer (mL). However, when he was diagnosed to have cirrhosis, he totally stopped drinking alcoholic beverages as advised by his doctor. Nevertheless, after his physician declared that he was already treated, he went back to his vices. He again drinks alcoholic beverages but with a lesser amount and frequency, which is about one to two bottles of beer in each month.

He loves to eat foods such as organ meats except liver, meat, and vegetables. He has allergies to egg, chicken, and shrimps. When ingest these foods, he will manifest rashes and itchiness.

Present Health History

Ten years ago, Mr. Emong felt a severe pain at his right lower leg especially at his right knee during late at night. However, he does not seek medical advice, nor took any drugs to relieve the pain thinking that this was only because he was tired from work. After some weeks (1-2 weeks), the pain subsided even without any consultation and drugs taken.

Five months ago, he observed that there was an attack of pain in his big toe. Again, he does not give attention to this because he thought that he was only tired from work. From his big toe, there was also an attack of pain in his ankle, knee, fingers, and wrists. After four months of attacks of pain, his right knee began to swell that made him difficult to ambulate. His joints particularly his fingers were deformed, nodules were prominent in his elbow, ankle, and fingers and skin eruptions to his right foot. During this period, he just took OTC drugs such as mefenamic acid to alleviate the pain and clean his wounds by just washing with soap and water.

Moreover, on February 4, 2010, he went to GRBAMH, Laoag City for check-up with a complaint of swelling and severe pain on his right knee. From his check-up at the OPD Department, he was confined directly at the said hospital.

After a week, due to absence of progression to his condition, he and his family decided to transfer him at MMMH and MC, Batac City. He was brought to MMMH via ambulance per stretcher with an IVF of PLR 500 cc level. He was admitted on February 11, 2010 at 8:35 pm with an admitting diagnosis of Thopaceous Gouty Arthritis, R/O Septic Arthritis.

DEVELOPMENTAL DATA

A. Havighurst’s Theory of Developmental Task

According to Havighurst, learning is fundamental to life and in order to have a deeper insight on growth and development, one must understand it and recognize the premise that human being continues to learn throughout life. Happiness is being achieved when a particular

task of a certain age is achieved by the person successfully, but if not, failure occurs which is a feeling of unhappiness and disapproval from people surrounding the client

Our patient, 40 years of age, belongs to the MIDDLE AGE, in which the following tasks are very important to accomplish.

ACHIEVING ADULT CIVIC AND SOCIAL RESPONSIBILTY Mang Emong claimed that in this aspect, he was able to carry out his role as an adult and an individual of the society. He usually participates in barangay activities such as clean and green program as well as barangay fiestas. He greatly believes that joining in such activities is vital since one is a part of the community and that, one should abide by it. Whenever asks his help, he never resist helping them as long as he can.

ASSISTING TEENAGE CHILDREN TO BECOME RESPONSIBLE AND HAPPY ADULTS

He verbalized that from the start his children are growing up, he had taught them the proper values and attitudes to live by in order to become better and fulfilled adults in the future. He also considers that the most important thing that he has shared to his children is the virtue of being God-fearing and responsible as well.

RELATING ONESELF TO ONE’S SPOUSE AS A PERSONHis wife works abroad, but according to him, life is not easy to both of them for they

have faced the most difficult trials of their life and with determination and courage to countenance all these things, they were able to surpass it. He also admitted that though there were times of argument, but through proper communication, they easily resolve it. He also added that throughout the years, they have been fulfilled because of the love and harmony they have always shared together.

ACCEPTING AND ADJUSTING TO THE PHYSIOLOGIC CHANGES OF MIDDLE AGE

In this aspect, the client stated that physical and physiologic activity gradually decreases from time to time. Somehow, he accepts that the process of aging and degenerative changes is just but a normal toall creature.

ESTABLISHING AND MAINTAINING AN ECONOMIC STANDARD OF LIVINGAs the head of the family and as a provider he works hard to sustain their family needs,

he works as a tricycle driver and his earnings is placed only an important matter and he makes sure to spend the money wisely.

DEVELOPING ADULT LEISURE TIME ACTIVITIES Mang Emong enjoys performing some leisure activities. He loves chatting with his co-

drivers while waiting for passenger. At home, his past time is reading “bannawag magazines, newspapers and listening to radio. He is also fond of planting vegetables in their backyard.

ANALYSIS:

Mang Emong achieved the expected attitude and behavior at his age. His relationship with his children is good since they maintain good closure and communication although, there are times that conflict arises, but they believes that it’s normal to a family’s life. This implies that he is physically, mentally, emotionally and socially prepared to whatever crisis or unexpected event that may occur.

The client attained the developmental tasks for him, thus, he is now partially ready to go to the next stage of his life.

B. ERIK ERIKSON’S PSYCHOLOGICAL DEVELOPMENT THEORY

Erikson considers life as composed of sequence of levels of achievement and each stage indicates a certain task to be achieved. An achievement would mean a healthier personality while failure would also mean that the person will not be able to go to the next level and probably will lead to regression.

Mang Emong 40 years old, belongs to the stage of adulthood. His developmental task is to achieve GENERATIVITY which includes creativity, productivity and concern for others. Generativity is defined as the concern for establishing and guiding the next generation. STAGNATION, on the contrast, is those people who are unable to expand their interests at the time and who do not assume the responsibilities of a middle age suffer from a sense of boredom and impoverishment, thus, people have difficulty accepting their aging bodies and become withdrawn and isolated. Self-indulgence, self-concern, lack of interests and commitment would mean a negative resolution.

In the case of Mang Emong, we could simply say that he was able to partially achieve the task appropriate for his age. The idea about generativity is reflected with his family of procreation and he does everything in order to keep his family in a stable state not only in the economic aspect but as well as in the social, emotional, and physical aspects. He works hard to provide the things needed by his family. He told that no matter what happens in his life, he strongly believes that everything was planned by the Holy Father. He was able to fully realize his

worth of life when he established his own family and gifted with 2 childrens who made his feel special.

ANALYSIS:

Mang Emong had satisfactorily achieved the initial task required at his age under Erikson. Thereby, this means that he is ready to face any challenges and can easily adjust to any problems that may happen. Overall, He is still struggling generativity in its optimum level.

PATTERNS OF FUNCTIONING

Eating PatternBefore illness During Illness Analysis

Before hospitalization

During hospitalization

Mang Emong eats 4 times a day. In the morning, he takes his breakfast at the “karinderya” at around 5:30 AM. It is usually composed of 1 bowl paksiw or sometimes ½ cup grilled meat. For his lunch at 12 NN, he eats 1½ cup of rice, and 1-cup vegetables. For his dinner, which is 6-6:30 PM, it is composed of 1 cup of rice, 1-cup vegetables & 4-5 matchbox size of meat. His snack was comprised of 2 pcs. of bread and soft drinks.

Mang Emong eats 4 times a day. 5:30 AM for his breakfast, 12 NN for his lunch & 6-6:30 PM for his dinner. His breakfast is usually composed of 1 cup of rice, 1 pc. Egg/noodles, 1 pc. dried fish. His lunch is composed of 2 cup of rice, ½-cup meat, & 1-cup vegetables. For his dinner, it is composed of 1 cup of rice and 1 bowl vegetable. For his snack, it is comprised of 2 pcs. bread and soft drinks.

Mang Emong was on Low Purine Diet. Sometimes, he could able to eat all ration but most of the times he can only consume ½ to ¾ of the hospital ration. Before his operation, the doctor ordered NPO in preparation of his surgery, & goes back to Low Purine Diet when he was brought back to the ward.

There is a change in the eating pattern of the patient as shown in the data given before & during his illness. The change is brought by the discomfort & pain he is feeling. Likewise, he was not used to the manner of serving as well as the food served was not his Food Preference.

Drinking PatternBefore illness During Illness Analysis

Before hospitalization

During hospitalization

Mang Emong usually consumed 8-10 glasses of water a day where in 1 glass is approximately 240 ml, thus, 1920 mL-2400 ml per day. He also drinks soft drinks, 1 bottle a day, which is 360 ml or sometimes juice for

Mang Emong drinks 8-10 glasses of water a day wherein 1 glass is about 240 ml. He also drinks soft drinks, which is about 360 ml. And sometimes liquor for about 360 ml. Total input each day is approximately 2700-

Mang Emong drinks 5-6 glasses of water a day for approximately 1200 ml-1400 ml per day.

There is a change in his drinking pattern since there is a decrease fluid intake. The decrease in fluid intake is brought by the decrease activity of the patient.

about 240 ml. In the afternoon he drinks liquor, usually 3 bottles of BEER at 1500 ml or 1 bottle of GIN (bilog) which is about 360 ml. Total input per day was approximately 2520-3780 ml.

2900 ml.

Bladder EliminationBefore illness During Illness Analysis

Before hospitalization

During hospitalization

Mang Emong voids at least 6-8 times a day for approximately 1400 to 1500 ml/day. His urine is usually clear light yellow without offensive odor.

Mang Emong still voids 6 to 8 times a day approximately 1400 to 1500 ml/day. The color of his urine is yellow.

He voids 2 to 3 times a day. The client is wearing diaper. He changes his diaper two times a day which is partially soaked.

There is a change in his bladder elimination, the decrease in frequency and amount of urine/voiding is attributed to the activity.

Bowel EliminationBefore illness During Illness Analysis

Before hospitalization

During hospitalization

Mang Emong usually defecates once a day early in the morning before taking a bath. His stool was usually soft and semi formed that appears brown in color.

He defecates once a day before taking a bath in the morning. Usually, its consistency is soft and semi formed that appears brown in color.

Mang Emong defecates once every other day. Its consistency is watery that appears yellow in color.

The change in the bowel pattern is brought by the decrease food intake and decrease ambulation activity.

Bathing Patterns

Before illness During Illness AnalysisBefore

hospitalizationDuring

hospitalization He usually takes a bath once a day, every early in the morning. He uses green cross as his soap and sunsilk as his shampoo, his bathing usually lasts 5 to 10 minutes.

He usually takes a bath once a day, every early in the morning. He uses green cross as his soap and sunsilk as his shampoo his bathing usually lasts 5 to 10 minutes.

Mang Emong takes a partial bath every morning with assistance.

There is a change in his bathing pattern. This is brought by the patient’s inability to get up and ambulate.

Sleeping PatternsBefore illness During Illness Analysis

Before hospitalization

During hospitalization

Mang Emong sleeps early at night, at around 7-8:00 PM. He wakes up at around 5-5:30 AM. He sleeps 9½-10 hours of sleep each day.

Mang Emong sleeps at around 9PM because the pain he feels was irritating him. He wakes up at around 3am. He usually takes sleep at daytime, which is 1 to 1 ½ hours. He has 7 ½ hours of sleep each day.

Mang Emong falls asleep at 11pm and awakes at 3am. He usually takes nap during daytime 30 minutes in the am and about 45 minutes in the pm. He has 5 to 5 ½ of sleep each day.

There is an alteration in his sleeping pattern because the pain he feels interrupts him.

LEVELS OF COMPETENCIES

Physical Competency

Before illness During Illness AnalysisBefore

hospitalizationDuring

hospitalization

Our client was able to do his activities of daily living without difficulty and assistance. He can also do his job as a tricycle driver and was able to support the needs of his family as a father and head of the family.

He can perform his usual activities but with limitations and he was not able to do his job as tricycle driver because he has difficulty of walking.

He was not able to perform his usual activities of daily living. He remains lying in bed most of the time. He asks assistance to his “bantay” whenever he needs something.

There is a change in his physical competency due to the client’s inability to get up and walk alone.

Emotional CompetencyBefore illness During Illness Analysis

Before hospitalization

During hospitalization

He is happy person, loving and responsible father. He is an expressive type of person. He is able to verbalize whatever he wants and whatever he feels. When he gets mad, or loses his temper, he is able to express it but not to the extent that he will burst out. He also added that when trials or challenges come, he face it with

Although he feels lonely about his situation, he does not let his self to be emotionally disturbed. He understands that, anyone could experience having a disease and this is just normal to all individuals.

He feels lonely for his situation that he cannot do anything but lie in bed. However, he tries his best to cope up and manage the feeling. The support system he has helps him a lot to overcome to accept his condition.

There is no change in the emotional competency of the client because being lonely is just a normal response when one has illness.

full strength and courage as well as with prayers to be able to surpass that challenge.

Social CompetencyBefore illness During Illness Analysis

Before hospitalization

During hospitalization

Our clients claim that he has a good relationship with their neighbor. He interacts well with other people. He even participates in the activities of their barangay like Oplan Dalus. He also attends occasions and parties in their barangay as well as to their places whenever given the opportunity and time.

He minimizes going outside their house since he has difficulty in walking. However, the way he treats and talk to other people stays the same.

He still able to socialize by merely talking to his inmates and to the health care provider staff. He entertains us very well when we visited him and answer our question thoroughly when we interviewed him.

There was no change in the social competency of the client. His condition is not a hindrance in dealing with other people.

INTELLECTUAL COMPETENCYBefore illness During Illness Analysis

Before During

hospitalization hospitalization

Our client claims that he is the one who made decision in the family.He can recognize, recall place, person and events. He can relate things that happened in the past and things that just happened.

The client can recognize, recall place, person and events. He can relate things that happened in the past and things that just happened. He was still the decision maker in his family.

During interview, he can answer our entire questions thoroughly. He understands our purpose to him. He is still the decision maker in the family and he can relate things that happened in the past and events that recently took place.

There was no change in the client’s intellectual competency.

SPIRITUAL COMPETENCY

Before illness During Illness AnalysisBefore

hospitalizationDuring

hospitalization Our client and his family are religiously affiliated Pentecost faith. He claimed that they attend mass every Sunday and practice their own religious beliefs and practices. He usually prays at night to ask forgiveness, blessings, and gratitude to the Lord and at the same time for the protection and guidance of the entire family.

Our client claimed that his faith in God becomes stronger. He prayed harder and more often believing that what he is experience and suffering right now is just a test to his faith and soon he will be able to recover from that disease.

The client claimed that his faith in God remained strong. He still prayed harder and more often just like before hospitalization.

There was no change in the clients spiritual competency

PHYSICAL ASSESSMENT

The physical assessment was done last February 18, 2010 at 5:00 pm. It was a cephalocaudal physical examination.

I. General AppearanceThe patient was lying in bed awake and conversant with an IVF of PNSS 1 liter at

950 cc level regulated to 27 – 28 gtts/min. He is weak in appearance, in pain, with a pain scale of 7/10 and unable to get up.

Vital Signs taken as follows:

Body temperature – 37.10CBlood pressure – 130/90mmHgPulse rate – 81bpmRespiratory rate – 20 bpm

A. Head Normocephalic In proportion with the size of the neck and body Can move up to 90° (able to move to its desired position but has slightly

difficulty.B. Hair

Equally distributed black hair short, dull and dry

C. Eyes Both eyes are coordinated, moves in unison with parallel alignment Brown colored iris Pupils reaction to light-constrict With eyebags

D. Ears Both auricles are proportional in shape Tip of the ears are aligned to the outer cantus of the eye Able to hear words when whispered 1 – 2 feet away and responds

E. Nose nasal opening are symmetrical with patent airway

F. Mouth Lips - slightly dry, blackish in color Tongue - able to move freely Teeth – yellowish

- 15 teeth’s in the upper jaw, 15 teeth’s in the lower jaw Gums -slightly blackish in color

G. Neck Proportional to head and body Can move side to side at 900 with minimal difficulty

H. Chest Left and right portions are proportional Color of the skin is equal to other body parts With respiratory rate of 20 bpm

I. Abdominal With 15 bowel sounds per minute With scar noted

J. Upper extremities untrimmed and dirty fingernails pale (with poor capillary refill) finger at the right arm are unflexible, with limited mobility of the fingers, enlarge

joints of all fingers white and rough palms with pinkish nodules on both elbow, back of the palm and fingers with scar on the left deltoid (BCG vaccination) with tattoo at left arm

K. Lower

Pale nail bed and thick nails with bandage at right knee right leg and ankle is swelling, shiny with wounds scattered at right leg discharges noted on the wounds with pinkish nodules on both feet poor capillary refill

I. Skin

brown complexion cold skin

ON GOING APPRAISAL

February 19, 2010 @ 11:00 am

First day of appraisal

Mang Emong was lying on bed, awake and conversant with an IVF of PNSS 1L @ 500cc level regulated to 41-42 gtts/min. He is wearing white shirt and black short with bandage at his right knee. He is weak in appearance and unable to get up alone and ambulate. His right lower leg is swelling and he complains of pain on his right leg with a pain scale of 6/10.

Vital signs as follows:

BP – 130/80mmHg

BT – 36.60C

RR – 20 breathe per minute

PR – 78 beats per minute

February 20, 2010 @ 12:30 pm

Second day of appraisal

Mang Emong was lying in bed awake and conversant, with an IVF of D5LRS @ 975 cc level regulated to 41-42gtts/min. He is wearing red shirt and black short with bandages at his right ankle and knees, He is weak in appearance and still unable to get up alone and ambulate. His right lower leg is swelling and with minimal discharges (pus and blood) from his wound noted. He complains of pain on his right leg with a pain scale of 5/10

Vital signs as follows:

BP – 120/80mmHg

BT – 36.70C

RR – 21breathe per minute

PR – 80beats per minute

February 21, 2010 @ 4 pm

Third day of appriasal

Mang Emong had just undergone debridement at his right knee and foot.He was lying in bed, asleep, with an IVF of D5NSS 1L@ 950 cc level regulated to gtts/min., with bandages at his right knee, ankle, and legs. He is weak in appearance and with a pain scale of 8/10

Vital signs as follows:

BP – 140/100mmHg

BT – 36.50C

RR – 20 breathe per minute

PR – 76 beats per minute

February 22, 2010 @ 4 pm

Fourth day of appraisal

Mang Emong was lying in bed, awake and conversant with an IVF of PNSS1L@450cc level regulated to 41-42gtts/min.With bandages at his right knee and leg. About 30-40% of the bandage is soaked with yellowish discharges. He is weak in appearance and still unable to get up alone and ambulate. He complains of post op pain at the operative site with a pain scale of 8/10

Vital signs as follows:

BP – 110/90mmHg

BT – 37.70C

RR – 18 breathe per minute

PR – 75 beats per minute

MEDICAL MANAGEMENT

X-ray/UTZ

Chest AP No definite radiographic abnormality

No definite active parenchymal infiltrates seen Pulmonary vascularity is within normal limits Heart is not enlarged Diaphragm is normal in position and contour Both costrophenic sulci and visualized bones are intact

KNEE APC No definite fracture or dislocation seen Knee joint space appears narrowed, suggest comparison with collateral knee.

X-ray is a radiographic examination of bones. This examination can accurately identify fractures, tumors, bone infection, and bone destruction. Abnormalities identified in x-ray frequently require more extensive diagnostic evaluations through radioisotope scans or biopsy.

Analysis: The Chest AP was done to determine the accumulation of MSU crystals in the heart specifically in the myocardium. The knee APC was done to determine the extent of deformity and base from the result, it shows an abnormal finding in the knee joint space which appears to be narrowed.

Hematology

2-11-10TEST RESULT RANGES INTERPRETATIONCBCHemoglobin 110.00 g/L 140-175 LowHematocrit 0.34 0.41-0.50 LowRBC 4.120 10^12/L 4.5-5.9 LowMCV 82.30 fL 80-100 NormalMCH 26.20 pg 27-32 LowMCHC Concentration 32.40 g/dL 31-35 NormalWBC 25.32 10^9/L 4.50-11.00 HighDIFFERENTIAL COUNTSegmenters 0.77 .50-.70 High Lymphocytes 0.10 .20-.40 LowMonocytes 0.07 .02-.08 NormalEosinophils 0.03 .01-.04 NormalBasophils 0.01 0.00-0.001 NormalPlatelet count 475 10.^9/L 150-450 High

2-13-10TEST RESULT RANGES INTERPRETATION

CBCHemoglobin 116.00 g/L 140-175 LowHematocrit 0.36 0.41-0.50 LowRBC 4.480 10^12/L 4.5-5.9 LowMCV 79.90 fL 80-100 LowMCH 25.9 Pg 27-32 LowMCHC Concentration 32.40 g/dL 31-35 NormalWBC 33.26 10^9/L 4.50-11.00 HighDIFFERENTIAL COUNTSegmenters 0.80 .50-.70 HighLymphocytes 0.11 .20-.40 LowMonocytes 0.06 .02-.08 NormalEosinophils 0.03 .01-.04 NormalBasophils 0.00 0.00-0.001 NormalPlatelet count 495 10.^9/L 150-450 High

2-16-10 @ 06:03 amTEST RESULT RANGES INTERPRETATIONCBCHemoglobin 102.00 g/L 140-175 LowHematocrit 0.32 0.41-0.50 LowRBC 3.880 10^12/L 4.5-5.9 LowMCV 81.70 fL 80-100 NormalMCH 26.30 pg 27-32 LowMCHC Concentration 32.20 g/dL 31-35 NormalWBC 29.75 10^9/L 4.50-11.00 HighDIFFERENTIAL COUNTSegmenters 0.82 .50-.70 HighLymphocytes 0.08 .20-.40 LowMonocytes 0.06 .02-.08 NormalEosinophils 0.04 .01-.04 NormalBasophils 0.00 0.00-0.001 NormalPlatelet count 564 10.^9/L 150-450 High

2-16-10 @ 3:57 pmTEST RESULT RANGES INTERPRETATIONCBCHemoglobin 94.00 g/L 140-175 LowHematocrit 0.20 0.41-0.50 LowRBC 3.630 10^12/L 4.5-5.9 LowMCV 81.80 fL 80-100 NormalMCH 25.90 pg 27-32 LowMCHC Concentration 31.60 g/dL 31-35 NormalWBC 29.48 10^9/L 4.50-11.00 HighDIFFERENTIAL COUNT

Segmenters 0.82 .50-.70 HighLymphocytes 0.08 .20-.40 LowMonocytes 0.05 .02-.08 NormalEosinophils 0.05 .01-.04 HighBasophils 0.00 0.00-0.001 Normal

Platelet count 855 10.^9/L 150-450 High

Analysis:

The result shows that there was a decrease RBC, Hbg, Hct, MCH and lymphocyte while WBC, Eosinophils and platelet count increased.

The decreased level of RBC due to excessive breakdown of cells. increased

WBC increases because of his inflammation likewise eosinophils. An increase in eosinophils may indicate allergic response including asthma, food, and medication, and the increased in platelet count indicates iron deficiency, hemorrhage, infectious and inflammatory D/O.

The decreased in MCU may indicate iron deficiency anemia.

Chemistry and Lipid Profile2-12-10

TEST RESULT RANGES INTERPRETATIONChemistryGlucose, FBS 4.65 mmol/L 4.2-6.4 NormalBUN 4.97 mmol/L 1.7-8.3 NormalAST 65.94 u/L Up to 35 HighALT 49.70 u/L Up to 45 HighLipid ProfileCholesterol 4.43 mmol/L <5.17 NormalTriglycerides 1.46 mmol/L <2.28 NormalHDL 0.22 mmol/L >1.55 LowLDL 1.63 mmol/L <3.36 Normal

Analysis:

Slightly to moderately increased levels of AST was because of his liver damage due to liver cirrhosis.

Slightly to moderately increased levels of ALT may indicate cirrhosis, myocardial infarction, congestive heart failure, or resolving or prodromal hepatitis.

The decreased levels of HDL were because of his lifestyle, which are inadequate exercise and low purine diet.

Urine Analysis2-12-10

TEST RESULT INTERPRETATIONPhysical ExamUrine Color Yellow NormalClarity Slightly turbid NormalSpecific Gravity 1.015 NormalpH 6.5 NormalChemical ExamProtein (-)Glucose (-)Hgb +2Ketone (-)Nitrite (-)Bilirubin +1Urobilinogen +1Leukoesterase (-)Urinary CellsWBC 0-1 HPFRBC 6-8 HPFEpithelial Cells Rare NormalBacteria Few NormalMucus Threads Few NormalRenal Cells (-)Yeast Cells (-)Urinary Casts (-)Hyaline Casts -/LPF 0-1Fine Granular Casts -/LPF 0-1Coarse Granular Casts -/LPF 0-1Waxy Casts -/LPF 0-1Urinary CrystalsAmorphous Urate/phosphate FewCalcium Oxalates (-)Triple Phosphate (-)Uric Acid (-)

ECG2-12-10

Regular Sinus Rhythm

Within normal limits

Electrocardiogram is frequently used to diagnose abnormal heart rhythms, conduction disturbances, hypertrophy of cardiac chambers,and myocardial infarction. It is also used to monitor pacemaker function and the effectiveness if some medications. Likewise, it can also help monitor clients responses to therapy.

Analysis:

The result shows normal findings.

DIET THERAPY

Low Purine Diet- This diet is indicated for the patient to minimize the production of uric acid, which one

of the causes hyperurecemia.Date ordered: February 11, 2010

Nursing Responsibilities Rationale

1. Check doctor’s order. To identify what diet was ordered and to avoid

mistakes.

2. Transcribe the diet ordered to the diet list. To let the dietician know that the client is on low

purine diet.

3. Inform the watcher about the prescribe

diet.

For them to be aware of the diet.

4. Emphasize the purpose of diet therapy. To gain cooperation for the client and family.

5. Remove foods on the bedside table of the

client.

To avoid temptation to eat especially if the foods

are attractive to him.

NPO (Nothing per Orem)

- This was indicated for decreasing the workload of the stomach. It is a preparatory procedure for his operation.Date Ordered: February 20, 2010

Nursing Responsibilities Rationale1. Inform the client and the watcher about

the prescribed diet.For the patient to be aware and gain cooperation. And to get real results.

2. Emphasize the purpose of diet therapy. To gain cooperation from the client and family.

3. Keep all foods or fluids out of patient’s sight.

To lessen patient’s interest and to prevent stimulation of vagal nerves.

4. Instruct the watcher to remind the client about her diet.

For the client not to eat and drink secretly.

5. Regulate IVF properly (as ordered), for nutritional supplementation.

To meet the nutritional supplementation of our client.

INTRAVENOUS THERAPY

Intravenous therapy is an efficient and effective method of giving of liquids directly into a vein. IVF is used to administer fluids that contain water, dextrose, vitamins, electrolytes and drugs. IVF is considered the fastest way of absorption. Intravenous therapy is an important adjunct in the management of the seriously ill or injured patients.

1. Plain Normal Saline Solution 1000 cc x 120

Date ordered: February 11, 2010Date Administered: February 11, 2010

2. D5NSS 1 liter x 120

Date ordered: February 13, 2010

3. PLR 1 liter x 120

Date ordered: February 13, 2010

4.D5LRS 1 liter x 80

Date ordered: February 19, 2010Nursing Responsibilities:

Responsibilities Rationale

1. Review doctor’s order for the type of intravenous fluid to be administered.

-to prevent inserting the wrong IVF

2. Identify the client. - to prevent inserting the IVF to the wrong patient

3. Explain the procedure to the patient. - to gain the cooperation of the client and eliminate doubts of the patient

4. Observe aseptic technique in inserting the IVF.

-to prevent infection

5. Compute and regulate for the infusion rate.

- to prevent fluid overload

6. Check for air bubbles in the tubing. - to prevent the occurrence of air embolism

7. Change or stop the solution before it empties.

-to prevent air embolism

8. Protect the insertion site. - to prevent needle dislodgement

9. Document the procedure done. - to serve as evidence with the quality of care given, it serves as a legal document as a basis for the continuity of care for health care providers.

Blood transfusion

When red and white blood cells, platelets, or blood proteins are lost because of hemorrhage or disease or even because of an operation, it is necessary to replace these components to restore the blood’s ability to transport oxygen and carbon dioxide, to clot, to fight infection, and to keep extra cellular fluid within the intravascular compartment. A blood transfusion is the introduction of whole blood components into the venous circulation.

Mr.Emong was transfused with PRBC, this was given to him to restore his blood volume, to restore the capacity of the blood to carry oxygen and to provide plasma factors or platelet concentrate, which prevent or treat bleeding.

DATE ORDERED DATE TRANSFUSED

SERIAL NO. TYPE OF BLOOD

2-11-2010 2-12-2010 10-0772 2 units of PRBC2-18-2010 2-20-2010(1 unit) 2007- 630611 2 units of PRBC

Nursing Responsibilities

Nursing responsibilities Rationale

1. Check the physicians’ order for the number of units and type of transfusion to be given.

To obtain correct blood component for the client

2. Secure consent. To secure both the patient and the health care provider for legal purposes.

3. Check that the type and cross match has been completed and that the blood is ready in the blood bank.

To check if there is available blood that is to be transfused to the patient.

4. Check and record the vital signs, determine any allergies and previous transfusion. Check also for the expiration date of the blood.

To avoid for any blood transfusion reaction.

5. Confirm client’s identity. To avoid doing the procedure to the wrong patient.

6. Do hand hygiene, observe aseptic technique.

To prevent transfer microorganism that will cause infection

7. Make sure that the only side drip is plain normal saline solution.

To prevent agglutination of blood.

8. Start the infusion slowly and stay with the patient for the first 15 minutes.

To prevent overload and if any abnormalities will occur, only a few amount of blood is being infused. The first 15 minutes is the time that abnormalities will show if there is any.

9. Observe the client for an hour after the transfusion.

To check if there are abnormalities and BT reactions.

10. Document the procedure done. It will serve as a legal document. It is also a basis for the continuity of care.

Debridement

Debridement is the process of removing nonliving tissue from pressure ulcers, burns, and other wounds

Surgical debridementSurgical debridement (also known as sharp debridement) uses a scalpel, scissors, or other

instrument to cut dead tissue from a wound. It is the quickest and most efficient method of debridement. It is the preferred method if there is rapidly developing inflammation of the body's connective tissues (cellulitis) or a more generalized infection (sepsis) that has entered the bloodstream. The procedure can be performed at a patient's bedside. If the target tissue is deep or close to another organ, however, or if the patient is experiencing extreme pain, the procedure may be done in an operating room. Surgical debridement is generally performed by a physician, but in some areas of the country an advance practice nurse or physician assistant may perform the procedure.

Purpose

Debridement speeds the healing of pressure ulcers, burns, and other wounds. Wounds that contain non-living (necrotic) tissue take longer to heal. The necrotic tissue may become colonized with bacteria, producing an unpleasant odor. Though the wound is not necessarily infected, the bacteria can cause inflammation and strain the body's ability to fight infection. Necrotic tissue may also hide pockets of pus called abscesses. Abscesses can develop into a general infection that may lead to amputation or death.

Preparation

The physician or nurse will begin by assessing the need for debridement. The wound will be examined, frequently by inserting a gloved finger into the wound to estimate the depth of dead tissue and evaluate whether it lies close to other organs, bone, or important body features. The assessment addresses the following points:

the nature of the necrotic or ischaemic tissue and the best debridement procedure to follow

the risk of spreading infection and the use of antibiotics the presence of underlying medical conditions causing the wound the extent of ischaemia in the wound tissues the location of the wound in the body the type of pain management to be used during the procedure

Before surgical or mechanical debridement, the area may be flushed with a saline solution, and an antalgic cream or injection may be applied. If the antalgic cream is used, it is usually applied over the exposed area some 90 minutes before the procedure.

Aftercare

After surgical debridement, the wound is usually packed with a dry dressing for a day to control bleeding. Afterward, moist dressings are applied to promote wound healing. Moist

dressings are also used after mechanical, chemical, and autolytic debridement. Many factors contribute to wound healing, which frequently can take considerable time. Debridement may need to be repeated.

DRUG STUDY

1. Generic Name: CiprofloxacinBrand Name: CiproClassification: Antibiotic FluroquinoloneDosage, Route, Frequency: 100 mg IV q 12 hoursMechanism of Action: Interferes with DNA gyrase and topoisomerase IV. DNA gyrase is an

enzyme needed for replication, transcription, and repair of bacterial DNA.

Topoisomerase IV plays a key role in the participation of chromosomal DNA during bacterial cell division. Effective against both gram-positive and gram- negative microorganism Desired Effects: To inhibit growth of bacteria and to treat infection.Side effect: abdominal pain, constipation, drowsiness, dizziness, blurring of vision.Adverse effect:

CNS: headache, restlessness, tremors, dizziness, fatigue, drowsinessCV: Thrombophlebitis, edema, chest painGI: nausea, diarrhea, vomiting, abdominal pain, or discomfort, oral candidiasisHematologic: eosinophilia, leucopenia,neutropenia, thrombocytopeniaMuscuskeletal: arthralgia, joint or back painSkin: rash, photosensitivity, pruritus, erythemaOther: hypersensitivity reaction

Nursing Responsibilities Rationale1.Check doctor's order before giving medication

To avoid mistakes

2. Observed the 10 R's in administering medication.

To prevent administering wrong drug and administering to a wrong person.

3. Administer the drug slowly. To prevent phlebitis.4. Check patency of IV line. To avoid wastage of the drug. 5. Report tendon inflammation and pain to know when to discontinue the drug.

For immediate care.

6.Use caution with hazardous activities until reaction to drug is known.

Drug may cause light-headedness.

2. Generic Name: Clindamycin Brand Name: Cleocin Classification: Antibiotic LincosamideDosage, Route, Frequency: 300-mg IV q 6 hoursMechanism of Action: Suppresses protein synthesis by microorganisms by binding to

ribosomes and preventing peptide bond formation. Desired Effect: To inhibit growth of bacteria and to treat infection.Side effect: nausea and vomiting, super infections in the mouthAdverse Effect:

CV: hypotension, cardiac arrestGI: nausea, vomiting, abdominal pain, diarrheaHematologic: transient leucopenia, eosinophilia, Skin: maculopapular rash, urticaria, dryness, irritation, oily skin

Nursing Responsibilities Rationale1.Check doctor's order before giving medication

To avoid mistakes

2.Observed the 10 R's in administering medication

To prevent administering wrong drug and administering to a wrong person.

3. Monitor BP and pulse in patients receiving drug parenterally.

Because the drug may cause hypotension.

4. Be alert for signs of super infection and anaphylactic reactions.

For immediate attention and intervention.

3. Generic Name: Tramadol HydrochlorideBrand Name: UltramClassification: AnalgesicsDosage, Route, Frequency: 50-mg IV q 5 hoursMechanism of Action: A centrally acting synthetic analgesic compound not chemically related

to opiates. Thought to bind to opoid receptors and inhibit re-uptake of norepinephrine and serotonin.

Desired Effects: To relieve the pain Side effect: dizziness, vertigo, headache, nausea, constipation, vomiting, drowsiness, respiratory

depression, seizuresAdverse Effect:

CNS: drowsiness, dizziness, vertigo, headache, seizureCV: palpitations, vasodilationsGI: nausea, vomiting, constipation, diarrhea, abdominal painBody as a whole: anaphylactic reaction, diarrhea, sweating, nausea, tremorsSkin: rash

Nursing Responsibilities Rationale1.Check doctor's order before giving medication

To avoid mistakes

2.Observed the 10 R's in administering medication

To prevent administering wrong drug and administering to a wrong person.

3. Advice client to increase intake of fluids unless contraindicated.

This is necessary to prevent the constipating effect of the drug.

4. Monitor patient for seizures. Drug may reduce seizure threshold.

4. Generic Name: ParacetamolBrand Name: AcetaminophenClassification: Antipyretics

Dosage, Route, Frequency: 300mg. IV q 5 hoursMechanism of Action: Thought to produce analgesia by blocking pain impulses by inhibiting

synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating center.Desired Effects: To decrease body temperature.Side effect: nuetropenia, luekopenia, pancytopenia, hypoglycemiaAdverse Effect:

CNS: headacheCV: chest pain, dyspneaGI: hepatic toxicity and failureGU: Acute renal failure, renal tubular necrosisHematologic: pancytopenia, hypoglycemiaHypersensitivity: rash, fever

Nursing Responsibilities Rationale1.Check doctor's order before giving medication

To avoid mistakes

2.Observed the 10 R's in administering medication

To prevent administering wrong drug and administering to a wrong person.

3. Administer after meals. To prevent GI upset.4. Discontinue drugs if hypersensitivity reaction occurs.

To prevent further reactions and for immediate care.

5.Do not take other medications containing acetaminophen without medical advice

Overdosing can cause liver damage and other toxic effects.

5. Generic Name: CaptoprilBrand Name: CapotenClassification: AntihypertensiveDosage, Route, Frequency: 25mg 1 tab.SL for Bp >160/180Mechanism of Action: Inhibits ACE preventing conversion of angiotensin I to angiotensin II a

potent vasoconstrictor. Less angiotensin II decreases peripheral arterial resistance, decreasing aldosterone secretion, which reduces sodium

and water retention and lowers blood pressure.Desired Effects: To lower blood pressure Side Effects: Hives, severe stomach pain, difficulty in breathing, and swelling of the face, lips,

tongue, or throat

Adverse Effect:

CV: Slight increase in heart rate, first dose hypotension , dizziness, fainting

GI: altered taste sensation (loss of taste perception, persistent salt or metalic taste); weight loss, intestinal angioedema.Hematologic: Hyperkalemia, neutropenia, agranulocytosis (rare)

Respiratory: coughSkin: Maculopopular rash, urticaria, pruritus, angioedema, photosensitivity.Urogenital: azotemia, impaired renal function, nephrotic, syndrome, membranous glomerulonephritis

Nursing Responsibilities Rationale

1.Check doctor's order before giving medication

To avoid mistakes

2.Observed the 10 R's in administering medication

To prevent administering wrong drug and administering to a wrong person.

3.Raised bedside rails To prevent falling since these drug can cause dizziness

4.Monitor BP closely following the first dose.

A sudden exaggerated hypotensive response may occur within 1-3 hours of first dose, especially in those with high BP or on a diuretic and restricted salt intake.

5.Advise the patient to report any discomfort like cough, dizziness.

for early detection and early prevention

6. Generic Name: ColchicineBrand Name: ColgoutClassification: anti-inflammatoryDosage, Route, Frequency: one tab. TID

Mechanism of Action: As an anti-inflammatory drug,it will decrease WBC motility, phagocytosis and lactic acid production.decreasing urate crystal

deposits and reducing inflammation. As an antiosteolytic drug,may inhibit mitosis of osteoprogenitor cells and decrease osteoclast activity. Desired Effects: to reduce inflammationSide effect: nausea and vomiting, loss of appetite, loss of hairAdverse Effect:

GI: nausea, vomiting, abdominal pain, anorexiaHematologic: bone marrow depressionCNS: Mental confusion, peripheral neuritisSkin: severe irritation and tissue damage

Nursing Responsibilities Rationale1.Check doctor's order before giving medication

To avoid mistakes

2.Observed the 10 R's in administering medication

To prevent administering wrong drug and administering to a wrong person.

3. Monitor I&O ratio and pattern. High fluid intake promotes excretion and reduces danger of crystal formation in kidneys and ureters.

4.Discuss the dosage regimen with patients who have been using colchicines.

So that patients know when to stop the drug before GI aside effects occur.

7. Generic Name: OmeprazoleBrand Name: LosecClassification: Proton Pump InhibitorDosage; Route; Frequency: 40 mg x 1 dose /10 amMechanism of Action: Suppresses gastric secretion by specific inhibition of the hydrogen-

potassium ATPase enzyme system at the secretory surface of the gastric parietal cells thereby it blocks the final step of acid production.Desired Effects: This drug was given to our patient to decrease gastric irritation caused by over

secretion of hydrochloric acid.Side effect: Headache, dizziness, diarrhea, flatulence, nausea, and vomiting

Adverse Effect: CNS: headache, dizziness, vertigo, insomnia, apathy, anxiety,paresthesiaSkin: rash,urticaria, pruritus, dry skinGI: diarrhea, abdominal pain, nausea, vomiting, dry mouth, constipationRespiratory: cough and epistaxis

Nursing Responsibilities Rationale1. Check for the patency of the IV line. To avoid wastage of the drug.2. Advice patient to avoid activities

requiring alertness.Because it may cause dizziness and drowsiness.

3. In cases of rashes, advice patient not to scratch the affected areas.

Because it may lead to bruises and will increase the tendency of infection.

4. Instruct patient to avoid eating sour To prevent further irritation of gastric mucosa.

tasting foods.5. Instruct patient to avoid eating large

meal.To avoid aggravating the condition.

8. Generic Name: Ketorolac tromethamineBrand Name: toradolClassification: Non-steroidal anti-inflammatory drugDosage, Route, Frequency: 30 mg x 6 hours x 4 dosesMechanism of Action: It inhibits synthesis of prostaglandin by inhibiting both COX 1

and COX2 enzymes.Desired Effects: to relieve painSide effect: dizziness, drowsiness, sedation, headache, nausea, vomiting, dyspepsia, constipation Adverse Effect:

CNS: headache, dizziness, insomnia, fatigue, tinnitusSkin: rash, pruritus, sweating, dry mucus membraneGI: nausea, dyspepsia, pain, diarrhea, vomiting, constipation, flatulence

Nursing Responsibilities Rationale

1.Check doctor's order before giving medication

To avoid mistakes

2.Observed the 10 R's in administering medication

To prevent administering wrong drug and administering to a wrong person

4. Caution patient to avoid activities requiring alertness until response to medication is known.

In order to prevent injury since dizziness and drowsiness may occur.

6. Advice client to increase intake of fluids. This is necessary to prevent the constipating effect of the drug.

9. Generic Name: CelecoxibBrand Name: CelebrexClassification: NSAIDS Dosage, Route, Frequency: 40 mg. Cap. ODMechanism of Action: Exhibit anti- inflammatory, analgesic, and anti- pyretic action due to

inhibition of COX- 2 enzyme.Desired Effects: Non-steroidal anti-inflammatory drugSide Effect: dizziness, headache, abdominal pain diarrhea, flatulence, nauseaAdverse Effect:

Body as a whole: back pain, peripheral edemaGI: abdominal pain, diarrhea, dyspepsia, flatulence, nausea

CNS: dizziness, headache, insomnia

Nursing Responsibilities Rationale1.Check doctor's order before giving medication

To avoid mistakes

2.Observed the 10 R's in administering medication

To prevent errors

3 .Instruct patient to take drug with food or milk

For better absorption thus maximum therapeutic effect of the drug will be achieved and to prevent GI upset

4. Tell patient to avoid aspirin or other NSAIDS during therapy.

Because it can cause GI bleeding.

NURSING CARE PLAN

1. NURSING DIAGNOSIS: Pain related to inflammation of joints as evidenced by verbal reports, guarding behavior and a pain scale 6/10.

NURSING INFERENCE: Excessive accumulation of uric acid in the joints causes acute gouty arthriris which if left untreated will lead to repeated attacks and this may cause tophi formation. Tophi can cause pain and stiffness in the affected joint.

NURSING GOAL: After 2-3 days of rendering of nursing intervention, the client will be able to verbalize relief of pain, displayed relaxed manner as well as rest/ sleep appropriately.

NURSING INTERVENTIONS RATIONALE 1. Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency and quality.

1. To provide a base line data and monitors effectiveness of interventions.

2. Maintain immobilization of affected part by means of bed rest.

2. Relieves pain.

3. Perform and supervise active/ passive ROM exercises.

3. Maintains strength/ mobility of unaffected muscles and facilitates resolution of inflammation in injured tissues.

4. Provide alternative comfort measures. 4. Improves general circulation; reduces areas of local pressure and muscle fatigue.

5. Investigate any reports of unusual/ sudden pain or deep, progressive, and poorly localized pain unrelieved by analgesics.

5. May signal developing complications.

6. Provide emotional support and encourage use of stress management techniques.

6. Refocuses attention, promotes sense of control and enhances coping abilities.

7. Administer medication as ordered (toradol) 7. To relieve pain.

NURSING EVALUATION:

After 3 days of rendering of nursing intervention, the client was able to verbalize relief of pain, displayed relaxed manner as well as rest/ sleep appropriately.

2. NURSING DIAGNOSIS: Impaired physical immobility related to joint pain evidenced by reluctance to attempt movement, limited range of motion and therapeutic restriction movement.

NURSING INFERENCE: Acute attacks are characterized by severe pain in the joints, often in the big toe radiating in the ankle, knee, hip, shoulders, wrist, or elbow that leads the client to limit or restricted movement as well as alteration in physical capacity.

NURSING GOAL: After 2-3 hours of rendering of appropriate nursing interventions, the client will be able to maintain position of function and demonstrate techniques that enable resumption of activities, especially ADLs.

NURSING INTERVENTION RATIONALE1. Assess degree of immobility/ treatment and note client’s perception of immobility.

1. Client may be restricted by self- view/ self-perception out of proportion with actual physical limitations, requiring interventions to promote progress toward wellness.

2. Encourage participation in diversional / recreational activities. Maintain stimulating environment.

2. Refocuses attention, enhances client’s sense of control and aids in reducing social isolation.

3. Instruct/ Assist client in active/passive ROM exercises of affected and unaffected extremities.

3. Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility.

4. Encourage use of isometric exercises starting with unaffected limb.

4. Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass.

5. Assist or encourage self- care activities. 5. Improves muscle strength and circulation, enhances client control in situation and promotes self- directed wellness.

6. Monitor BP with resumption of activity. 6. Postural hypertension is a common a problem following prolonged bed rest

7. Encourage increased fluid intake to 2000- 3000 mL/day.

7. Keeps the body well hydrated, decreasing risk of urinary infection, stone formation, ands helps to prevent constipation.

8. initiate bowel program(stool softener, enema, laxative) as indicated.

8. to promote regular bowel evacuation and prevent constipation.

NURSING EVALUATION:

After 3 hours of rendering appropriate nursing interventions, the client was able to maintain position of function and demonstrate techniques that enable resumption of activities, especially ADLs.

3. NURSING DIAGNOSIS: Ineffective peripheral tissue perfusion related to reduction/interruption of blood flow as manifested by poor capillary refill and cold skin.

NURSING INFERENCE: The decrease of RBC in the body leads to decrease oxygen carrying capacity, hence oxygen supply also decreases, and this will cause decrease tissue perfusion.

NURSING GOAL: After 2-3 hours of rendering nursing interventions, the client will be able to demonstrate behaviors/ lifestyle changes to improve circulation and increased perfusion as individually appropriate.

NURSING INTERVENTIONS RATIONALE1. Assess capillary return, skin color and warmth distal to affected area.

1. Return of color should be rapid (3-5 seconds). White, cool skin indicates arterial impairment. Cyanosis suggests venous impairment.

2. Perform neurovascular assessment, noting changes in motor/ Sensory function. Ask patient to localize pain/ discomfort.

2. Impaired feeling, numbness, tingling, increased/diffuse rain occurs when there is inadequate circulation to nerves or nerve damage.

3. Monitor vital signs. Note signs of general pallor/ cyanosis, cool skin, changes in mentation.

3. Inadequate circulating volume compromises systemic tissue perfusion.

4. Encourage client to routinely the exercise digits/ joints distal to affected area.

4. Enhances circulation and reduces pooling of blood, especially in the lower extremities.

5. Demonstrate or encourage use of relaxation techniques.

5. To decrease tension level.

6. Assess entire length of affected extremity for swelling. Measure affected extremity and compare with unaffected extremity.

6. Increasing circumference of affected extremity may suggest general tissue swelling.

7.Monitor Hgb/hct and prothrombin time levels.

7. Assist in calculation of blood loss and effectiveness of replacement therapy.

8. Blood transfusion as prescribed. 8. To maintain circulating volume, enhancing tissue perfusion.

NURSING EVALUATION: After 3 hours of rendering nursing interventions, the client was able to demonstrate behaviors/ lifestyle changes to improve circulation and increased perfusion as individually approach.

4. NURSING DIAGNOSIS: Impaired skin integrity related to tophi break through the skin as evidenced of disruption of skin surface and presence of discharges.

NURSING INFERENCE: In tophaceous gout arthritis, it often produces tophi, which are solid deposits of Mono Sodium Urate crystals that form in the cartilage, joints, bones, and elsewhere in the body. In some cases, tophi break through the skin and appear as white or yellowish –white and this may cause disruption of skin integrity.

NURSING GOAL: After 1-2 weeks of appropriate nursing interventions, the client will verbalize relief of discomfort and achieve timely wound/ lesion healing.

NURSING INTERVENTION RATIONALE1. Examine the skin for open wounds and its discharges.

1. Provides information regarding skin circulation and problems that may require further medical intervention.

2. Keeps the bed linens dry and free wrinkles. Place water pads/ other padding under elbows/ heels as indicated.

2. Reduces pressure on susceptible areas and risk of abrasions / skin breakdown.

3. Keep the area clean/ dry, carefully dress wounds.

3. To assists body’s natural process of repair.

4. Obtain specimen from draining wounds. 4. To determine appropriate therapy.5. Refer to dietitian and adhere to prescribed diet.

5. To enhance healing, reduce risk of recurrence of tophi formation.

NURSING EVALUATION: After 1 week of appropriate nursing interventions, the client will verbalize relief of discomfort and achieve timely wound/ lesion healing.

5. NURSING DIAGNOSIS: Self-care deficit related to pain and discomfort as evidenced by impaired ability to perform ADLs.

NURSING INFERENCE: Our patient wasn’t able to get up and walk alone that leads him to have a deficit in self care activities as well as because of severe pain at and around the affected joint as characterized like “crushing” or a dislocated bone.

NURSING GOAL: After 2-3 days of rendering nursing interventions, the client will be able to perform self care activities within level of own ability.

NUSING INTERVENTIONS RATIONALE1. Determine hygiene needs and provide assistance as needed with in activities, including care of hair/nails/ skin, brushing teeth, etc.

1. As the disease progresses, basic hygienic needs may be forgotten.

2. Inspect skin regularly 2. Presence of such lesions as ecchymoses, lacerations, and rashes may require treatment, as well as signal need for closer monitoring/ protective interventions.

3. Supervise but allow as autonomy as possible.

3. Eases the frustration over lost independence.

4. Be attentive to nonverbal physiologic symptoms.

4. Sensory loss and language dysfunction may cause client to express self are needs in non verbal manner.

5. Provide reminders for elimination needs. Involve in bowel/ bladder program as appropriate.

5. Loss of control/ independence in this self care activity can have a great impact on self esteem and may limit socialization.

6. Assist with and provide reminders for pericare after toileting/ incontinence.

6. Good hygiene promotes cleanliness and reduces risk of skin irritation and infection.

7. Incorporate usual routine into activity schedule as possible.

7. Maintaining routine may prevent worsening of confusion and enhance cooperation.

NURSING EVALUATION: After 2 days of rendering nursing interventions, the client was able to perform self care activities within level of own ability.

6. NURSING DIAGNOSIS: Sleep pattern disturbance related to pain as manifested by verbal complaints of difficulty falling asleep, “Han nak unay makaturog ta sumro iti sakit ti sakak nu rabii ” and presence of eye bag.

NURSING INFERENCE: The abrupt onset of pain of gout arthritis occurs at night, awakening the patient with severe pain, redness, swelling, and warmth of the affected joint.

NURSING GOAL: After 2-3 days of rendering nursing intervention, the client will be able to establish adequate sleep pattern and report rested.

NURSING INTERVENTION RATIONALE1. Assess sleep pattern disturbances that are associated with specific underlying illnesses.

1. To identify the most appropriate interventions to that specific disease.

2. Observe and obtain feedback from patient regarding usual bedtime, routines, number of hour of sleep, time arising of pain and environmental factors.

2. To determine usual sleep pattern and provide comparative baseline data.

3. Determine patient’s/ SO’s expectations of adequate sleep.

3. Provides opportunity to address misconceptions/unrealistic expectations as well as occurrence of pain.

4. Administer pain medication one hour before sleep as ordered.

4. To relieve discomfort and take maximum advantage of sedative effect.

NURSING EVALUATION: After 3 days of rendering nursing intervention, the client will be able to establish adequate sleep pattern and report rested.

GENERAL EVALUATION:

Mr. Emong Aguilla, 40 years old, currently residing at Bacarra, Ilocos Norte was admitted by Dr. Gout at the Mariano Marcos Memorial Hospital and Medical Center, Batac City on February 11, 2010 at 8:35 in the evening with a chief complaint of swelling of right lower extremities and with diffuse tophi. His admitting diagnosis was Thopaceous Gouty Arthritis, R/O Septic Arthritis.

During his stay in the hospital, he had received intravenous therapies, blood transfusion, medications and surgical debridement. His diet was low purine diet, however, he was also placed on NPO in preparation for is operation. He had rendered total nursing care at the hospital.