FINAL CASE-GOUT...print

Divine Word College of Laoag School of Nursing Laoag City

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

THOPACEOUS GOUTY ARTHRITIS, SEPTIC ARTHRITIS

Presented by:

Aaron Dondoyano Paul Galat Aimen Gallegos Gallegos Noemi Maruquin Irvin Ross Molina Ma. Editha Ofely Morales Camille Pan Gemaryvive Quiaoit  Juvel 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 r ight lower extrimities extrimities Admitting Diagnosis: Thopaceous Go uty Arthritis, Arthritis, R/O Septic Arthritis Final Diagnosis: Thopaceous Gouty Arthritis, Septic Arthritis Date and time of admission: February 11, 2010 Attending Physician: Dr. Gout

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 r ight lower extrimities extrimities Admitting Diagnosis: Thopaceous Go uty Arthritis, 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 soft tissues of the body body and no systems of levers so critical for movement. 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 e mbryo, 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 ep iphysis at the ends of the gro wing 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: y y

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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 o f 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 att achment 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 y

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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 y

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Fibrous joints - joints composed of dense co llagenous 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 ca vity 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 a mphiarthrosis  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

Hinge

Examples

Structure

Elbow/Knee

Hinge joint

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

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 Pivot Joint  bones)

The ball-shaped end of one-bone fits into a cup shaped socket on the other bone allowing the widest range of motion Ball and including rotation. Examples include the Socket 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/ CMC joint of the Circumduction Saddle joint thumb

Oval shaped condyle fits into elliptical cavity of another allowing angular  motion but not rotation. This occurs   between the metacarpals (bones in the Condyloid  palm of the hand) and phalanges (fingers) and between the metatarsals (foot bones excluding heel) and phalanges (toes). Flexion/Extension/Adduction/Abduction/ Wrist/MCP Circumduction MTP joints

Gliding

&

Condyloid joint

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 µuniaxial¶, 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 bo ne 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.

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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 µball and socket¶ (multiaxial) type of joint, with the top (head) of the long bone of the leg (femur) being the µball¶ and the socket being a depression in the bone of the pelvis known as the acetabulum. This arrangement permits movements in three   planes ² 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 µcircumduction¶, a circular movement of the whole leg, which describes a µcone¶ 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   ² 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 µtunnel¶ 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-join²the 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, t endons, 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 t issues. 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 Mori of New Zealand, but rare in Australian aborigines despite the latter's higher mean co ncentration 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 hyperuricemia 2. Acute gouty arthritis

3. Intercritical gout 4. Chronic tophaceous gout Risk Factors of Gout  Age  Middle-Aged Adults. Gout usually occurs in middle-aged men, peaking in the mid-40s. It

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is most often associated in this age group with obesity, high blood pressure, unhealthy cholesterol levels, and heavy alcoho l 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 

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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 ac id  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 K idney 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 Illnesses Treatment 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 Arthritis

Acute 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.  ymptoms  S 

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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  M ost 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.

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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 Gout

Intercritical 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 Gout

After 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 to phi. A risk for tophaceous gout Had more than two or three acute attacks of gout in the past y y

Unusually severe attacks, or attacks that affect more than one joint

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Joint damage from gout, as shown on x-rays

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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  y

Curved ridge along the edge of the outer ear 

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Forearms

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Elbow or knee

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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 "nor mal" 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 acid

Hyperuricemia 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 o f uric acid.  Decreased excretion of uric acid

The 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 type

Causes 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 a nd 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 

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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 twothirds 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 extract s 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 ur ic 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 infect ion 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 a nd chills but may also beco me 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, t here 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 a lbicans. 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: y

y

y

y

y

y

y

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: y

y

y

y

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: y

y

y

y

y

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 e ffective, to monitor the effectiveness of treatment, and to evaluate the physical status of the affected joint(s).

Laboratory Tests: y

y

y

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)

y

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: y

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 da mage, and to maintain and/or recover joint mobility. y

y

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 helpfu l for people at high risk.

FAMILY

 

Name

Sex

BACKGRO UND

Age Educational Attainment High School Graduate

Occupation

Religion

Residence

Housewife

Pentecost

Bacarra I.N

Driver

Pentecost

Bacarra I.N

Caregiver

Pentecost

Bacarra I.N

Not applicable Not applicable

Pentecost

Bacarra I.N

Pentecost

Bacarra I.N

Dionisia

Female

61

Emong

Male

40

Emang

Female

36

Ago

Male

15

High school Graduate High school Graduate Not applicable

Bendita

Female

13

Not applicable

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) Environmental The 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.

Sales

Food 28%

30%

Education Medicine Electricity Water

10%

Miscellaneous 20%

5% 5% 2%

Savings

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 ³Herba 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 ³manghihilot´ 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 ³akotakot´ (mixed with water) on to their buccal area and below their ears. According to him, the cooling effect of the ³akot-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 ³Herba 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 ³manghihilot´ 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 ³akot-akot´ (mixed with water) on to their buccal area and below their ears. According to him, the cooling effect of  the ³akot-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 acco mplish.

ACHIEVING AD ULT 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. y

y

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 ONESEL F TO ONE¶S SPO USE AS A PERSON His 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. y

ACCEPTING AND ADJ USTING TO THE PHYSIOLOGIC CHANGES O F 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. y

ESTABLISHING AND MAINTAINING AN ECONOMIC STANDARD O F LIVING As 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. y

DEVELOPING ADULT LEISURE TIME ACTIVITIES Mang Emong enjoys performing some leisure activities. He loves chatting with his codrivers while waiting for passenger. At home, his past time is reading ³bannawag magazines, newspapers and listening to radio. He is also fond of planting vegetables in their   backyard. y

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 Pattern Before illness

During Illness

Before hospitalization Mang Emong eats Mang Emong eats 4 times a day. In the 4 times a day. 5:30 morning, he takes his AM for his breakfast,   breakfast at the 12 NN for his lunch & ³karinderya´ at 6-6:30 PM for his around 5:30 AM. It is dinner. His breakfast usually composed of 1 is usually composed   bowl paksiw or  of 1 cup of rice, 1 pc. sometimes ½ cup Egg/noodles, 1 pc. grilled meat. For his dried fish. His lunch lunch at 12 NN, he is composed of 2 cup eats 1½ cup of rice, of rice, ½-cup meat, and 1-cup vegetables. & 1-cup vegetables. For his dinner, which For his dinner, it is is 6-6:30 PM, it is composed of 1 cup of  composed of 1 cup of  rice and 1 bowl rice, 1-cup vegetables vegetable. For his & 4-5 matchbox size snack, it is comprised of meat. His snack  of 2 pcs. bread and was comprised of 2 soft drinks.   pcs. of bread and soft drinks. Drinking Pattern Before illness

Mang Emong usually consumed 810 glasses of water a day where in 1 glass is approximately 240 ml, thus, 1920 mL2400 ml per day. He

Analysis

During hospitalization Mang Emong was There is a change on Low Purine Diet. in the eating pattern of  Sometimes, he could the patient as shown able to eat all ration in the data given   but most of the times   before & during his he can only consume illness. The change is ½ to ¾ of the hospital   brought by the ration. Before his discomfort & pain he operation, the doctor  is feeling. Likewise, ordered NPO in he was not used to the   preparation of hismanner of serving as surgery, & goes back  well as the food to Low Purine Diet served was not his when he was brought Food Preference.  back to the ward.

During Illness Before hospitalization

During hospitalization

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

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

Analysis

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

also drinks soft drinks, 1 bottle a day, which is 360 ml or  sometimes juice for  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 25203780 ml.

Bladder Elimination Before illness

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.

Bowel Elimination Before illness

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

sometimes liquor for  about 360 ml. Total input each day is approximately 27002900 ml.

of the patient.

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

During hospitalization 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.

During Illness Before hospitalization He defecates once a day before taking a   bath in the morning. Usually, its consistency is soft and semi formed that

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

Analysis

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

Analysis

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

formed that appears appears  brown in color. color.

brown

in

Bathing Patterns Before illness

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.

During Illness Before During hospitalization hospitalization He usually takes a Mang Emong takes  bath once a day, every a partial bath every early in the morning. morning with He uses green cross as assistance. his soap and sunsilk  as his shampoo his  bathing usually lasts 5 to 10 minutes.

Analysis

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

Sleeping Patterns Before illness

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.

During Illness Before hospitalization 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.

During hospitalization 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.

Analysis

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

LEVELS OF COMPETENCIES Physical Competency Before illness

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.

During Illness Before hospitalization

During hospitalization

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 ³bantay´ whenever he needs something.

Analysis

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

Emotional Competency Before illness

During Illness Before hospitalization

He is happy Although he feels   person, loving and lonely about his responsible father. He situation, he does not is an expressive type let his self to be of person. He is able emotionally disturbed. to verbalize whatever  He understands that, he wants and anyone could whatever he feels. experience having a When he gets mad, or  disease and this is just loses his temper, he is normal to all able to express it but individuals. not to the extent that

Analysis

During hospitalization

He feels lonely for  There is no change his situation that he in the emotional cannot do anything competency of the   but lie in bed.client because being However, he tries his lonely is just a normal   best to cope up and response when one manage the feeling. has illness. The support system he has helps him a lot to overcome to accept his condition.

he will burst out. He also added that when trials or challenges come, he face it with full strength and courage as well as with prayers to be able to surpass that challenge.

Social Competency Before illness

During Illness Before hospitalization

Our clients claim He minimizes that he has a good going outside their  relationship with their  house since he has neighbor. He interacts difficulty in walking. well with other  However, the way he   people. He eventreats and talk to other    participates in the people stays the same. 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.

Analysis

During hospitalization

He still able to There was no socialize by merely change in the social talking to his inmates competency of the and to the health care client. His condition is   provider staff. Henot a hindrance in entertains us very well dealing with other  when we visited him  people. and answer our  question thoroughly when we interviewed him.

INTELLECTUAL COMPETENCY Before illness

During Illness Before 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.

Analysis

During hospitalization

The client can During interview, There was no recognize, recall he can answer our  change in the client¶s   place, person andentire questions intellectual events. He can relate thoroughly. He competency. things that happened understands our  in the past and things   purpose to him. He is that just happened. He still the decision was still the decision maker in the family maker in his family. and he can relate things that happened in the past and events that recently took   place.

SPIRITUAL COMPETENCY Before illness

During Illness Before 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.

Analysis

During hospitalization

Our client claimed The client claimed There was no that his faith in God that his faith in God change in the clients   becomes stronger. He remained strong. He still spiritual competency   prayed harder and more   prayed harder and more often believing that often just like before what he is experience hospitalization. and suffering right now is just a test to his faith and soon he will be able to recover from that disease.

PHYSICAL ASSESSMENT

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

General Appearance The 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: 0

Body temperature ± 37.1 C Blood pressure ± 130/90mmHg Pulse rate ± 81 bpm Respiratory 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 e ye  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 0

 Can move side to side at 90 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 co mplains of pain on his right leg with a pain scale of 6/10. Vital signs as follows: BP ± 130/80mmHg 0

BT ± 36.6 C 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 o n his right leg with a pain scale of 5/10 Vital signs as follows: BP ± 120/80mmHg 0

BT ± 36.7 C 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 o f 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 0

BT ± 36.5 C RR ± 20 breathe per minute PR ± 76 beats per minute

February

22, 2010 @

Fourth

4

pm

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 0

BT ± 37.7 C 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  K nee 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 k nee joint space which appears to be narrowed.

Hematology

TEST RESULT CBC Hemoglobin 110.00 g/L Hematocrit 0.34 RBC 4.120 10^12/L MCV 82.30 fL MCH 26.20 pg MCHC Concentration 32.40 g/dL WBC 25.32 10^9/L DIFFERENTIAL CO UNT Segmenters 0.77 Lymphocytes 0.10 Monocytes 0.07

RANGES

2-11-10 INTERPRETATION

140-175 0.41-0.50 4.5-5.9 80-100 27-32 31-35 4.50-11.00

Low Low Low Normal Low Normal High

.50-.70 .20-.40 .02-.08

High Low Normal

Eosinophils Basophils Platelet count

0.03 0.01 475 10.^9/L

.01-.04 0.00-0.001 150-450

Normal Normal High

RANGES

2-13-10 INTERPRETATION

140-175 0.41-0.50 4.5-5.9 80-100 27-32 31-35 4.50-11.00

Low Low Low Low Low Normal High

.50-.70 .20-.40 .02-.08 .01-.04 0.00-0.001 150-450

High Low Normal Normal Normal High

RANGES

2-16-10 @ 06:03 am INTERPRETATION

140-175 0.41-0.50 4.5-5.9 80-100 27-32 31-35 4.50-11.00

Low Low Low Normal Low Normal High

.50-.70 .20-.40 .02-.08 .01-.04 0.00-0.001 150-450

High Low Normal Normal Normal High

RESULT

RANGES

2-16-10 @ 3:57 pm INTERPRETATION

94.00 0.20

140-175 0.41-0.50

Low Low

TEST RESULT CBC Hemoglobin 116.00 g/L Hematocrit 0.36 RBC 4.480 10^12/L MCV 79.90 fL MCH 25.9 Pg MCHC Concentration 32.40 g/dL WBC 33.26 10^9/L DIFFERENTIAL CO UNT Segmenters 0.80 Lymphocytes 0.11 Monocytes 0.06 Eosinophils 0.03 Basophils 0.00 Platelet count 495 10.^9/L

TEST RESULT CBC Hemoglobin 102.00 g/L Hematocrit 0.32 RBC 3.880 10^12/L MCV 81.70 fL MCH 26.30 pg MCHC Concentration 32.20 g/dL WBC 29.75 10^9/L DIFFERENTIAL CO UNT Segmenters 0.82 Lymphocytes 0.08 Monocytes 0.06 Eosinophils 0.04 Basophils 0.00 Platelet count 564 10.^9/L

TEST CBC Hemoglobin Hematocrit

g/L

RBC 3.630 10^12/L MCV 81.80 fL MCH 25.90 pg MCHC Concentration 31.60 g/dL WBC 29.48 10^9/L DIFFERENTIAL CO UNT Segmenters 0.82 Lymphocytes 0.08 Monocytes 0.05 Eosinophils 0.05 Basophils 0.00

4.5-5.9 80-100 27-32 31-35 4.50-11.00

Low Normal Low Normal High

.50-.70 .20-.40 .02-.08 .01-.04 0.00-0.001

High Low Normal High Normal

Platelet count

150-450

High

855

10.^9/L

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 Profile TEST Chemistry Glucose, FBS BUN AST ALT Lipid Profile Cholesterol Triglycerides HDL LDL

Analysis:

RESULT

RANGES

2-12-10 INTERPRETATION

4.65 4.97 65.94 49.70

mmol/L mmol/L u/L u/L

4.2-6.4 1.7-8.3 Up to 35 Up to 45

Normal Normal High High

4.43 1.46 0.22 1.63

mmol/L mmol/L mmol/L mmol/L

<5.17 <2.28 >1.55 <3.36

Normal Normal Low Normal

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

Urine

Analysis 2-12-10

TEST Physical Exam Urine Color  Clarity Specific Gravity   Chemical Exam Protein Glucose Hgb K etone   Bilirubin Urobilinogen Leukoesterase Urinary Cells WBC RBC Epithelial Cells Bacteria Mucus Threads Renal Cells Yeast Cells Urinary Casts Hyaline Casts Fine Granular Casts Coarse Granular Casts Waxy Casts Urinary Crystals Amorphous Urate/phosphate Calcium Oxalates

RESULT Yellow

Slightly turbid 1.015 pH

INTERPRETATION

Normal Normal Normal 6.5

(-) (-) +2 (-) Nitrite

(-) +1 +1 (-)

0-1 6-8 Rare Few Few (-) (-) (-) -/LPF -/LPF -/LPF -/LPF Few (-)

HPF HPF Normal Normal Normal

0-1 0-1 0-1 0-1

Triple Phosphate Uric Acid

(-) (-)

ECG 2-12-10  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 y

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

1. Check doctor¶s order.

Rationale

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

For them to be aware of the diet.

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 To avoid temptation to eat especially if the foods client.

y

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 Rationale 1. Inform the client and the watcher about For the patient to be aware and gain the prescribed diet. cooperation. And to get real results.

2. Emphasize the purpose of diet therapy. 3.

K eep

To gain cooperation from the client and family.

all foods or fluids out of patient¶s

To lessen patient¶s interest and to prevent sight. stimulation of vagal nerves. 4. Instruct the watcher to remind the client For the client not to eat and drink secretly. about her diet. 5. Regulate IVF properly (as ordered), for  To meet the nutritional supplementation of  nutritional supplementation. 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 o f the seriously ill or injured patients.

0

1. Plain Normal Saline Solution 1000 cc x 12 Date ordered: February 11, 2010 Date Administered: February 11, 2010 0 2. D5NSS 1 liter x 12 Date ordered: February 13, 2010 3.

0

PLR 1 liter x 12 Date ordered: February 13, 2010

4.D5LRS

0

1 liter x 8 Date ordered: February 19, 2010

Nursing Responsibilities: Responsibilities

Rationale

1. Review doctor¶s order for the type of  -to prevent inserting the wrong IVF intravenous fluid to be administered. 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 - to prevent fluid overload rate. 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 2-11-2010 2-18-2010

DATE TRANSFUSED 2-12-2010 2-20-2010(1 unit)

SERIAL NO.

TYPE OF BLOOD

10-0772 2007- 630611

2 units of PRBC 2 units of PRBC

Nursing Responsibilities Nursing responsibilities

Rationale

1. Check the physicians¶ order for the To obtain correct blood component for the client number of units and type of transfusion to  be given. 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 To check if there is available blood that is to be  been completed and that the blood is ready transfused to the patient. in the blood bank. 4. Check and record the vital signs, To avoid for any blood t ransfusion reaction. determine any allergies and previous transfusion. Check also for the expiration date of the blood. 5. Confirm client¶s identity.

To avoid doing the procedure to the wrong patient.

6. Do hand hygiene, observe aseptic To prevent transfer microorganism that will cause technique. 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 To prevent overload and if any abnormalities will the patient for the first 15 minutes. 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 To check if there are abnormalities and BT transfusion. 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 debridement Surgical 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: y

y

y

y

y

y

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 wo und 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.

DR UG STUDY 1. Generic Name: Ciprofloxacin Brand Name: Cipro Classification: Antibiotic Fluroquinolone Dosage, Route, Frequency: 100 mg IV q 12 hours Mechanism 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 gra mnegative 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, drowsiness CV: Thrombophlebitis, edema, chest pain GI: nausea, diarrhea, vomiting, abdominal pain, or discomfort, oral candidiasis Hematologic: eosinophilia, leucopenia,neutropenia, thrombocytopenia Muscuskeletal: arthralgia, joint or back pain Skin: rash, photosensitivity, pruritus, erythema Other: hypersensitivity reaction Nursing Responsibilities 1.Check doctor's order before medication

Rationale giving To avoid mistakes

2. Observed the 10 R's in administering To prevent administering wrong drug and medication. 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 For immediate care. know when to discontinue the drug. 6.Use caution with hazardous activities until Drug may cause light-headedness. reaction to drug is known.

2. Generic Name: Clindamycin Brand Name: Cleocin Classification: Antibiotic Lincosamide Dosage, Route, Frequency: 300-mg IV q 6 hours Mechanism 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 mouth Adverse Effect: CV: hypotension, cardiac arrest GI: nausea, vomiting, abdominal pain, diarrhea Hematologic: transient leucopenia, eo sinophilia, Skin: maculopapular rash, urticaria, dryness, irritation, oily skin

Nursing Responsibilities 1.Check doctor's order before medication

Rationale giving To avoid mistakes

2.Observed the 10 R's in administering medication 3. Monitor BP and pulse in patients receiving drug parenterally. 4. Be alert for signs of super infection and anaphylactic reactions.

To prevent administering wrong drug and administering to a wrong person. Because the drug may cause hypotension. For immediate attention and intervention.

Generic Name: Tramadol Hydrochloride Brand Name: Ultram Classification: Analgesics Dosage, Route, Frequency: 50-mg IV q 5 hours Mechanism 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, seizures 3.

Adverse Effect: CNS: drowsiness, dizziness, vertigo, headache, seizure CV: palpitations, vasodilations GI: nausea, vomiting, constipation, diarrhea, abdominal pa in Body as a whole: anaphylactic reaction, diarrhea, sweating, nausea, tremors Skin: rash Nursing Responsibilities 1.Check doctor's order medication

Rationale

before

giving

2.Observed the 10 R's in administering

To avoid mistakes To

prevent

administering

wrong

drug

and

administering to a wrong person. medication 3. Advice client to increase intake of fluids This is necessary to prevent the constipating unless contraindicated. effect of the drug.

4. Monitor patient for seizures.

Drug may reduce seizure threshold.

Generic Name: Paracetamol Brand Name: Acetaminophen Classification: Antipyretics Dosage, Route, Frequency: 300mg. IV q 5 hours Mechanism of Action: Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of o f 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, hypoglycemia Adverse Effect: CNS: headache CV: chest pain, dyspnea GI: hepatic toxicity and failure GU: Acute renal failure, renal tubular necrosis Hematologic: pancytopenia, hypoglycemia Hypersensitivity: rash, fever  4.

Nursing Responsibilities 1.Check doctor's order before medication

Rationale giving To avoid mistakes

2.Observed the 10 R's in administering medication 3. Administer after meals. 4. Discontinue drugs if hypersensitivity reaction occurs.

To prevent administering wrong drug and administering to a wrong person. To prevent GI upset. To prevent further reactions and for immediate care. 5.Do not take other medications containing Overdosing can cause liver damage and other  acetaminophen without medical advice toxic effects.

5. Generic Name: Captopril Brand Name: Capoten Classification: Antihypertensive Dosage, Route, Frequency: 25mg 1 tab.SL for Bp >160/180 Mechanism 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 sod ium and water  retention and lowers blood pressure. Desired Effects: To lower blood pressure d ifficulty culty in breathing, and swelling of the face, lips, Side Effects: Hives, severe stomach pain, diffi tongue, or throat Adverse Effect:

CV: Slight increase in heart rate, first first dose do se hypotension hypotension , dizziness, fainting GI: altered taste sensation (loss of taste perception, persistent salt or metalic taste); weight loss, intestinal angioedema. Hematologic: Hyperkalemia, neutropenia, agranulo cytosis (rare) Respiratory: cough Skin: Maculopopular rash, urt icaria, pruritus, angioedema, photosensitivity. Urogenital: azotemia, impaired renal function, nephrotic, syndrome, membranous glomerulonephritis

Nursing Responsibilities

1.Check doctor's medication

order

before

Rationale

giving To avoid mistakes

2.Observed the 10 R's in administering To prevent administering wrong drug and medication 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 A sudden exaggerated hypotensive response dose. 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 discomfort like cough, dizziness.

6.

Generic Name: Colchicine Brand Name: Colgout Classification: anti-inflammatory Dosage, Route, Frequency: one tab. TID

any for early detection and early prevention

Mechanism of Action: As an anti-inflammatory drug,it will decrease WBC motility,  phagocytosis and lactic acid production.decreasing pro duction.decreasing urate crystal deposits and reducing inflammation. As an antiosteolytic antiosteolytic drug,may inhibit mitosis of osteoprogenitor cells and decrease osteoclast activity. Desired Effects: to reduce inflammation Side effect: nausea and vomi vo miting, ting, loss of o f appetite, loss of hair  Adverse Effect: GI: nausea, vomiting, abdominal pain, anorexia Hematologic: bone marrow depression CNS: Mental confusion, peripheral neuritis Skin: severe irritation and tissue damage Nursing Responsibilities 1.Check doctor's order before medication

Rationale giving To avoid mistakes

2.Observed the 10 R's in administering To prevent administering wrong drug and medication 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 So that patients know when to stop the drug who have been using colchicines.  before GI aside effects occur. Generic Name: Omeprazole Brand Name: Losec Classification: Proton Pump Inhibitor  Dosage; Route; Frequency: 40 mg x 1 dose /10 am Mechanism of Action: Suppresses gastric secretion by specific inhibition of the hydrogen potassium ATPase enzyme system at the secretor y surface of the gastric parietal cells thereby it blocks the final 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 7.

Adverse Effect: CNS: headache, dizziness, vertigo, insomnia, apathy, anxiety,paresthesia Skin: rash,urticaria, pruritus, dry skin GI: diarrhea, abdominal pain, nausea, vomiting, dry mouth, constipation Respiratory: cough and epistaxis

Nursing Responsibilities 1. Check for the patency of the IV line.

Rationale To avoid wastage of the drug.

2. Advice patient to avoid activities requiring alertness. 3. In cases of rashes, advice patient not to scratch the affected areas. 4. Instruct patient to avoid eating sour  tasting foods. 5. Instruct patient to avoid eating large meal.

Because it may cause dizziness and drowsiness. Because it may lead to bruises and will increase the tendency of infection. To prevent further irritation of gastric mucosa. To avoid aggravating the condition.

8. Generic Name: K etorolac tromethamine Brand Name: toradol Classification:  Non-steroidal anti-inflammatory drug Dosage, Route, Frequency: 30 mg x 6 hours x 4 doses Mechanism of Action: It inhibits synthesis of prostaglandin by inhibiting bot h COX 1 and COX2 enzymes. Desired Effects: to relieve pain Side effect: dizziness, drowsiness, sedation, headache, nausea, vo miting, dyspepsia, constipation Adverse Effect: CNS: headache, dizziness, insomnia, fatigue, tinnitus Skin: rash, pruritus, sweating, dry mucus membrane GI: nausea, dyspepsia, pain, diarrhea, vo miting, constipation, flatulence Nursing Responsibilities

1.Check doctor's medication 2.Observed medication

the

10

order R's

before in

Rationale

giving To avoid mistakes

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

4. Caution patient to avoid activities requiring In order to prevent injury since dizziness alertness until response to medication is known. and drowsiness may occur. 6. Advice client to increase intake of fluids.

9. Generic Name: Celecoxib Brand Name: Celebrex Classification: NSAIDS

This is necessary to prevent constipating effect of the drug.

the

Dosage, Route, Frequency: 40 mg. Cap. OD Mechanism of Action: Exhibit anti- inflammatory, analgesic, and anti- pyretic action due to inhibition of COX- 2 enzyme. Desired Effects: Non-steroidal anti-inflammatory drug Side Effect: dizziness, headache, abdominal pain diarrhea, flatulence, nausea Adverse Effect: Body as a whole: back pain, peripheral edema GI: abdominal pain, diarrhea, dyspepsia, flatulence, nausea CNS: dizziness, headache, insomnia Nursing Responsibilities 1.Check doctor's order medication

before

Rationale giving To avoid mistakes

2.Observed the 10 R's in administering To prevent errors medication 3 .Instruct patient to take drug with food or  For better absorption thus maximum therapeutic milk  effect of the drug will be achieved and to  prevent GI upset 4. Tell patient to avoid aspirin or other  Because it can cause GI bleeding.  NSAIDS during therapy.

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 o f nursing intervention, the client will be able to verbalize relief of pain, displayed relaxed manner as well as rest/ sleep appropriately. NURSING INTERVENTIONS 1. Perform a comprehensive assessment of   pain to include location, characteristics, onset/duration, frequency and quality.

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

2. Maintain immobilization of affected part by means of bed rest. 3. Perform and supervise active/ passive ROM exercises.

2. Relieves pain.

4. Provide alternative comfort measures. 5. Investigate any reports of unusual/ sudden  pain or deep, progressive, and poorly localized  pain unrelieved by analgesics. 6. Provide emotional support and encourage use of stress management techniques. 7. Administer medication as ordered (toradol)

3. Maintains strength/ mobility of unaffected muscles and facilitates resolution of  inflammation in injured tissues. 4. Improves general circulation; reduces areas of local pressure and muscle fatigue. 5. May signal developing co mplications.

6. Refocuses attention, promotes sense of  control and enhances coping abilities. 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 we ll 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 therapeut ic restriction movement. NURSING INFERENCE: Acute attacks are characterized by severe pa in 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 p hysical 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 1. Assess degree of immobility/ treatment and note client¶s perception of immobility.

RATIONALE 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 / 2. Refocuses attention, enhances client¶s sense recreational activities. Maintain stimulating of control and aids in reducing social isolation. environment. 3. Instruct/ Assist client in active/passive ROM 3. Increases blood flow to muscles and bone to exercises of affected and unaffected improve muscle tone, maintain joint mobility. extremities. 4. Encourage use of isometric exercises 4. Isometrics contract muscles without bending starting with unaffected limb.  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. 7. Encourage increased fluid intake to 20003000 mL/day. 8. initiate bowel program(stool softener, enema, laxative) as indicated.

6. Postural hypertension is a common a  problem following prolonged bed rest 7. K eeps the body well hydrated, decreasing risk of urinary infection, stone formation, ands helps to prevent constipation. 8. to promote regular bowe l evacuation and  prevent constipation.

NURSING EVALUATION:

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

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

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 c irculation and increased perfusion as individually appropriate.

NURSING INTERVENTIONS

1. Assess capillary return, skin color and warmth distal to affected area.

2. Perform neurovascular assessment, noting changes in motor/ Sensory function. Ask   patient to localize pain/ discomfort. 3. Monitor vital signs. Note signs of general  pallor/ cyanosis, cool skin, changes in mentation. 4. Encourage client to routinely the exercise digits/ joints distal to affected area.

RATIONALE

1. Return of color should be rapid (3-5 seconds). White, cool skin indicates arterial impairment. Cyanosis suggests venous impairment. 2. Impaired feeling, numbness, tingling, increased/diffuse rain occurs when there is inadequate circulation to nerves or nerve damage. 3. Inadequate circulating volume compromises systemic tissue perfusion. 4. Enhances circulation and reduces pooling of   blood, especially in the lower extremities.

5. Demonstrate or encourage use of relaxation 5. To decrease tension level. techniques. 6. Assess entire length of affected extremity for  6. Increasing circumference of affected swelling. Measure affected extremity and extremity may suggest general tissue swelling. compare with unaffected extremity. 7.Monitor Hgb/hct and prothrombin time levels. 8. Blood transfusion as prescribed.

7. Assist in calculation of blood loss and effectiveness of replacement therapy. 8. To maintain circulating volume, enhancing

tissue perfusion.

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

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

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 c lient will verbalize relief of discomfort and achieve timely wo und/ lesion healing. NURSING INTERVENTION 1. Examine the skin for open wounds and its discharges.

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

2. K eeps the bed linens dry and free wrinkles. Place water pads/ other padd ing under elbows/ heels as indicated. 3. K eep the area clean/ dry, carefully dress wounds. 4. Obtain specimen from draining wounds. 5. Refer to dietitian and adhere to prescribed diet.

2. Reduces pressure on susceptible areas and risk of abrasions / skin breakdown. 3. To assists body¶s natural process of repair. 4. To determine appropriate therapy. 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 wo und/ 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 ³crushing´ o r 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 o f own ability.

NUSING INTERVENTIONS 1. Determine hygiene needs and provide assistance as needed with in act ivities, including care of hair/nails/ skin, brushing teeth, etc.

RATIONALE 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. Eases the frustration over lost independence.

3. Supervise but allow as autonomy as  possible. 4. Be attentive to nonverbal physiologic symptoms. 5. Provide reminders for elimination needs. Involve in bowel/ bladder program as appropriate. 6. Assist with and provide reminders for   pericare after toileting/ incontinence.

4. Sensory loss and language dysfunction may cause client to express self are needs in non verbal manner. 5. Loss of control/ independence in this self  care activity can have a great impact on self  esteem and may limit socialization. 6. Good hygiene promotes cleanliness and reduces risk of skin irritation and infection.

7. Incorporate usual routine into act ivity 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 o f own ability.

NURSING DIAGNOSIS : Sleep pattern disturbance related to pain as manifested by verbal complaints of difficulty falling asleep, ³Han nak unay makaturog ta sumro iti sakit ti sakak nu rabii ´ and presence of eye bag. 6.

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 1. Assess sleep pattern disturbances that are associated with specific underlying illnesses.

RATIONALE 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. 3. Determine patient¶s/ SO¶s expectations of  adequate sleep.

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

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

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