83474403 case-study-ortho

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New Era University
College of Nursing
In Partial Fulfillment for the Requirements in
Philippine Orthopedic Center
A Case Study on
Septic ankle left
Submitted by:
Santiago, Joshua M

BSN Group. 3
A.Y. 2011-2012
Introduction
Swelling of the feet and ankles can occur as a result ofconditions involving the local extremities as
well as systemic conditions (diseases and conditions thataffect the entire body). Localized processes such
as injuries and infections may lead to a swollen footand/or ankle only on the involved side. Swelling of the
ankle on one side is often a result of sprains or strains. Sometimes diseases that affect the entire body,
such as heart disease and kidney or liver failure, can result in excess fluid buildup (edema) that is often
concentrated in the legs and feet, leading to swelling not only of the ankles but also of the feet and lower
legs. This can also occur with obstruction of the venous system, as may occur with pregnancy and obesity.
Diseases ofthe joints, such as arthritis, can also affect the joints ofthe ankle and foot, leading to swelling of
the involved areas. Treatments for swollen ankles and feet depend on the particular cause, but anti-
inflammatory medications are often used to manage the pain associated with strains and sprains
Infection is an unusual cause of ankle swelling. Infections can either occur in the soft tissues around the
ankle joint (cellulitis) or in the joint itself (septic joint). Infections can often be treated with medications
alone, butmay also require surgery.

II. BIOGRAPHIC DATA
Name: J.B.I
Address: Bulacan
Age: 2 years old
Gender: male
Race: Filipino
Marital Status: Single
Religious Orientation: Roman Catholic
Date of Admission: October 1, 2011 at 10:00pm
III. CHIEF COMPLAINT OR REASON FOR VISIT
Left ankle swelling
IV. NURSING HISTORY
History of Present Illness
14 days prior to admission, Patient had chicken pox infection associated with progression of left
ankle swelling. It was noted to be warm and tender to touch. Patient was also noted to have
difficulty in bearing weight on left lower extremities. Fever was also noted
10 days prior to admission. Patient prompted consult with local hospital wherein oral antibiotics
were given and provided relief of fever only
1 day prior to admission, there is still persistent symptoms where they consulted with another
hospital where in doctor diagnosed this as to consider septic bone left. Patient was advised
arthrotomy ankle but not done due to financial problem
History of past illness
Patient has chicken pox. No known allergies to food and medications
Family history
There are known hypertension in their family according to the grandmother of the patient
Anatomy and physiology

The ankle and foot are incredibly complex, with a variety of
connecting bones, ligaments, tendons and muscles.
The ankle is made up of two joints: The ankle joint and the
subtalar joint. The ankle joint includes two bones (the tibia and
the fibula) that form a jointthat allows the foot to bend up and
down. Two bones ofthe foot (the talus and the calcaneus)
connectto make the subtalar joint that allows the footto move
side to side. The tarsal bones connectto the 5 long bones of
the foot - the metatarsals.
Ligaments and Tendons
The large Achilles tendon is the mostimportant tendon for walking, running and jumping. It
attaches the calf muscles to the heel bone to allow us to puch off and up on the toes. There are
another 12 tendons that cross the ankle. They are responsible for movements ofthe ankle, foot,
and toes; some ofthese tendons also help supportthe arches ofthe foot.
Muscles
The muscles ofthe footare classified as intrinsic and extrinsic. The intrinsic muscles are located
within the foot and cause movementofthe toes and are flexors (plantar flexors), extensors
(dorsiflexors), abductors,and adductors ofthe toes. Several intrinsic muscles also help support the
arches of the foot.
The extrinsic muscles are located outside the foot, in the lower leg. The gastrocnemius muscle
(calf) is the largest. They have long tendons that cross the ankle, to attach on the bones ofthe foot
and assistmovement.

Pathophysiology
Modifiable Factors
Trauma
Trauma or open
wound
Microorganism gain
entry
Immunity response
Redness, localized
pain and swelling
White blood cells
attack
microorganisms
through
phagocytosis
Inflammatory
response
Increased WBC
Non-Modifiable Factors
Physical active persons

Laboratory
Name of test Date done Indication Result Normal Significance
HEMATOLOGY
hemoglobin
October 5 ,2011
October 11,2011
The Hb determination is part
of a CBC. It is used to screen
for disease associated with
anemia, to determine the
severity ofanemia, to monitor
the response to treatment for
anemia, and to evaluate
polycythemia.
(A manual of laboratory and
diagnostic test p74)
80 gms/L
93 gms/L
127-
183gms/L
Decreased Hb levels
are found in anemia
states (a condition in
which there is a
reduction ofHb, Hct,
and/or RBC values)
Iron deficiency,
thalassemia,
pernicious anemia,
hemoglobinopathies
(A manual of
Formation of
localized dead cells
White blood cells
still recognized this
as foreign object

laboratory and
diagnostic test p74-
75)
HCT October 5 ,2011
October 11,2011
The Hct testis part ofthe
CBC. This test indirectly
measures the RBC mass. It is
an important measurementin
the determination of anemia
or polycythemia.
.25gms/L
.28 gms/L
.
0.37-0.54
gms/L
Decreased Hctvalues
are an indicator of
anemia, a condition in
which there is a
reduction in the PVC.
An Hct <30% (<0.30)
means that the
patient is moderately
to severely anemic.
Decreased values
also occur in the
following conditions:
Acute and chronic
blood loss
Hemolytic reaction
(A manual of
laboratory and
Leukocyte count October 5 ,2011
October 11,2011
The WBC serves as a useful
guide to the severity ofthe
disease process. Specific
patterns of leukocyte
response can be expected in
various types ofdiseases as
9.10x109L
7.20x109L
4.5-
10x109L
The findings are
normal

determined by the differential
count (percentages ofthe
different types ofleukocytes).
Segmenters October 5 ,2011
October 11,2011
0.60
0.32
0.50-0.70
LYMPHOCYTES October 5 ,2011
October 11,2011
This test measures the
number of lymphocytes in the
peripheral blood
0.30
0.55
0.20-0.40 Lymphopenia
Aplastic anemia
(A manual of
laboratory and
Monocytes October 5 ,2011
October 11,2011
This test counts monocytes,
which circulate in certain
specific conditions such as
tuberculosis, subacute
bacterial endocarditis, and the
recovery phase ofacute
infections.
0.08
0.07
0.00-0.07 The findings are
normal
Eosinophils October 5 ,2011
October 11,2011
This test is used to diagnose
allergic infections, assess
severity ofinfestations with
worms and other large
parasites, and monitor
response to treatment.
0.02
0.06
0.00-0.05 Increased
eosinophils:allergic
states, drug sensitivity
reaction, skin
disorders, tissue
invasion by parasites,
periarteritis nodosa,

hypersensitivity
response to
malignancy (e.g.
Hodgkin's disease),
pulmonary infiltrative
disease,
disseminated
eosinophilic
hypersensitivity
disease.
Platelet October 5 ,2011
October 11,2011
A plateletcount is a test to
measure how many platelets
you have in your blood.
Platelets help the blood clot.
They are smaller than red or
white blood cells.
363
353
150-
400X109/L
The findings are
normal
MCV October 5 ,2011
October 11,2011
Average volume ofthe red cell
is measured by automated
instrument, by electrical
impedance or by lightscatter.
77
78
82-92 fl Decreased in: Iron
deficiency,
thalassemia;
decreased or normal
in anemia ofchronic
disease.
MCH October 5 ,2011
October 11,2011
MCH calculated from
measured values ofHb and
RBC; ie, MCH = Hb/RBC. A
low MCH can mean
hypochromia or microcytosis
or both. A high MCH is
evidence ofmacrocytosis
25
26
28-32 pg Lymphopenia
Aplastic anemia
(A manual of
laboratory and
diagnostic testp61)

MCHC October 5 ,2011
October 11,2011
MCHC describes how fully the
erythrocyte volume is filled
with hemoglobin and is
calculated from measurement
of hemoglobin (Hb), mean
corpuscular corpuscular
volume (MCV) and red cell
count (RBC); ie, MCHC =
Hb/MCV x RBC.
32
33
32-38% The findings are
normal
WOUND GRAM STAINING AND CULTURE SENSITIVITY TEST
GS: RBC-- ++, NO MICROORGANISM SEEN
AFB: NO ACID FAST BACILLI SEEN

DRUG ORDER
(Generic name,
dosage, route,
frequency, etc.)
TRADE /
BRAND
NAME
PHARMACOLOGIC
ACTION OF DRUG
INDICATIONS AND
CONTRAINDICATION
S
ADVERSE EFFECTS OF
THE DRUG
DESIRED
ACTION ON
YOUR CLIENT
NURSING
RESPONSIBILITIES/
PRECAUTIONS
PARACETAMOL
NSAIDS
200mg/ml IV q4
TID
paracetamol
Decreases fever by
ahypothalamic effect
leading to sweating
and vasodilation and
inhibits the effect of
pyrogens on the
hypothalamic heat-
regulating centers.
May cause analgesia
by inhibiting CNS
prostaglandin
synthesis; however,
due to minimal effects
on peripheral
prostaglandin
synthesis,
acetaminophen has
no anti-inflammatory
or uricosuric effects.
Does notcause any
anticoagulant effect or
ulceration ofthe GI
tract. antipyretic and
analgesic effects are
comparable to those
of aspirin.
INDICATIONS
Control of pain due to
headache, earache,
To reduce fever in
bacterial or viral
infections
CONTRAINDICATION
S
Renal insufficiency,
anemia. Clients with
cardiac or pulmonary
disease are more
susceptible to
acetominophen toxicity
Chronic and even acute
toxicity can develop after
long symptom-free usage.
Hematologic:
methemoglobinemia,
hemolytic anemia,
neutropenia,
thrombocytopenia,
pancytopenia, leucopenia
Allergic: urticarial and
erythematous skin reactions,
skin eruptions, fever.
Miscellaneous: CNS
stimulation, hypoglycemic
coma, jaundice, drowsiness,
glossitis. Possible liver
damage in those who
consume three or more
alcoholic drinks daily
The patient’s
fever will return
to the normal
range of
temperature
Note prescribed dosage
and expected outcomes
Monitor CBC, liver and
renal function studies
Documentpresence of
fever, onsetand the
duration
Check for urine for occult
blood

DRUG ORDER
(Generic name,
dosage, route,
frequency, etc.)
TRADE /
BRAND
NAME
PHARMACOLOGIC
ACTION OF DRUG
INDICATIONS AND
CONTRAINDICATION
S
ADVERSE EFFECTS OF
THE DRUG
DESIRED
ACTION ON
YOUR CLIENT
NURSING
RESPONSIBILITIES/
PRECAUTIONS
Clindamycin
antibiotic
100g IV q8H ANST
- inhibits bacterial
protein synthesis by
binding to 50S
subunit of ribosome.
- hinders or kills
susceptible bacteria.
indication
infections caused by
sensitive
staphylococci,
streptococci,
pneumococci,
bacteroides, and other
sensitive aerobic and
anaerobic organisms.
Contraindication
-contraindicated in
patients hypersensitive
to drug or lincomycin
-use cautiously in
patients with renal or
hepatic disease,
asthma, history of GI
disease, or significant
allergies
CNS: headache
CV: Thrombophlebitis
EENT: pharyngitis
GI: abdominal pain,
Anorexia, bloody or tarry
stools, constipation, diarrhea,
dysphagia, esophagitis,
flatulence, nausea,
psuedomembranus colitis,
unpleasant or bitter taste,
vomiting.
GU: UTI
HEMATOLOGIC:
Eosinophilia,
thrombocytopenia, transient
leukopenia
SKIN: maculopapular rash,
urticaria
OTHER: anaphylaxis,
erythema, pain (I.V. use),
induration, pain; sterile
abcess (I.M. use)
The patient will
have a
decrease signs
of infections
-assess patients
infection before and
regularly throughout
therapy
-before giving firstdose,
obtain specimen for
culture and sensitivity
test, begin therapy
pending results.
-monitor renal, hepatic,
and hematopoetic
functions during
prolonged therapy.
-be alert for adverse
reactions
-tell patient to take entire
amount prescribed even
after he feels better.
-tell patient receiving
drug to reportdiscomfort

DRUG ORDER
(Generic name,
dosage, route,
frequency, etc.)
TRADE /
BRAND
NAME
PHARMACOLOGIC
ACTION OF DRUG
INDICATIONS AND
CONTRAINDICATION
S
ADVERSE EFFECTS OF
THE DRUG
DESIRED
ACTION ON
YOUR CLIENT
NURSING
RESPONSIBILITIES/
PRECAUTIONS
salbutamol
bronchodilator
1 neb + 1cc PNSS
q6
reduce chemical
mediator release from
pulmonary
mast cells and
improve ability ofcilia
to clear mucus
direct-acting agent
that relaxes smooth
muscle walls
of the bronchi, uterus,
and skeletal muscle
vascular bed
Indication
To relieve
bronchospasm
associated with acute
or chronic
asthma,bronchitis, or
other reversible
obstructive
airway diseases. Also
used toprevent
exercise-
induced bronchospas
m.
Contraindication
Contraindicated in
patients hypersensitive
to drug or its
ingredients.
CNS: tremor, nervousness,
dizziness, insomnia,
headache,
hyperactivity, weakness,
CNS stimulation, malaise.
CV: tachycardia, palpitations,
hypertension.
EENT: dry and irritated nose
and throat with inhaled form,
nasal
congestion, epistaxis,
hoarseness.
GI: heartburn, nausea,
vomiting, anorexia,
altered taste, increased
appetite.
Metabolic: hypokalemia.
Musculoskeletal: muscle
cramps.
Respiratory: bronchospasm,
cough, wheezing, dyspnea,
bronchitis,
increased sputum.
Other: hypersensitivity
reactions
The patient will
be able to
loosen his/her
secretions
Drug may decrease
sensitivity ofspirometry
used for diagnosis of
asthma.
When switching patient
from regular to extended-
release
tablets,remember thata
regular 2-mg tablet every
6 hours is equivalent
toan extended-release 4-
mg tablet every 12
hours.
Syrup contains no
alcohol or sugar and may
be taken by children as
young as age 2.
In children, syrup may
rarely cause erythema
multiforme or
Stevens-Johnson
syndrome

DRUG ORDER
(Generic name,
dosage, route,
frequency, etc.)
TRADE /
BRAND
NAME
PHARMACOLOGIC
ACTION OF DRUG
INDICATIONS AND
CONTRAINDICATION
S
ADVERSE EFFECTS OF
THE DRUG
DESIRED
ACTION ON
YOUR CLIENT
NURSING
RESPONSIBILITIES/
PRECAUTIONS
Ferrous sulfate
- Elevates the serum
iron concentration
which then helps to
form High or trapped
in the
reticuloendothelial
cells for storage and
eventual conversion
to a usable form of
iron.
Indication
Prevention and
treatment of iron
deficiency anemias.
Dietary supplement
for iron.
Contraindication
Hypersensitivity
Severe hypotension.
Dizziness
Nasuea and vomiting
Nasal Congestion
Dyspnea
Hypotension
Muscle cramps
Flushing
The patient will
have an
increase of
HGB and HCT
Advise patientto take
medicine as prescribed.
• Caution patient to make
position changes slowly
to minimize orhtostatic
hypotension.
• Instruct patient to avoid
concurrent use ofalcohol
or OTC medicine without
consulting the physician.
• Advise patientto
consultphysician if
irregular heartbeat,
dyspnea, swelling of
hands and feet and
hypotension occurs.
• Encourage patientto
comply with additional
intervention for
hypertension like proper
diet, regular exercise,
lifestyle changes and
stress management.

CUES NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS EVALUATION
Objective:
 Sitting in
the wheel
chair
 Limited
leg
movemen
t
Impaired physical
mobility ofthe
lower extremity r/t
surgical incision at the left
leg
Goal
After 1-2 days ofnursing
interventions, clientwill be able
to demonstrates and
verbalizes proper
exercises ofthe lower
extremities & can
perform activities of
daily living with
Minimal assistance.
Objectives:
1.participate willingly in the
necessary activities
2. demonstrate a increase in
physical mobility
3. Use identified techniques to
enhance mobility
Evaluate current limitations/degree of
deficitin light ofusual
status.
Ascertain ability to stand and move
about and degree ofassistance
necessary/use ofequipment
Adjustactivities to prevent
overexertion. Reduce intensity
level or discontinue activities that cause
undesired physiological
changes.
Plan care with rest periods between
activities to reduce
fatigue.
Involve client/SO(s) in planning of
activities as much as
possible.
Assistwith activities and provide/monitor
client’s use ofassistive
GOAL MET
interventions, clientwas able to
demonstrates and
verbalizes proper
exercises ofthe lower
extremities & can
perform activities of
daily living with
Minimal assistance as evidenced by:
Using of wheel chair by himself
Was able to perform simple activities
such as eating and combing hair by
himself

devices (crutches, walker, wheelchair,
oxygen tank, etc.) to
protect client from injury.
Increase exercise/activity levels
gradually; teach methods to
conserve energy, such as stopping to
rest for 3 minutes during
a 10-minute walk, sitting down instead of
standing to brush
hair.

CUES NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS EVALUATION
Objective:
Age: 2 yrs
old
Risk for injury Goal
intervention the client will be
free from injury.
Objectives:
After 2 hours ofnursing
intervention the client will be
given instruction carefully to be
able to reduce the risk for injury
through attaining safe
environment:
- padded side rails
- watch door edges
curbs and landing steps
INDEPENDENT
1. Assess clients muscle strength gross
and fine motor coordination
2. Assess mood, coping abilities,
personality styles ( e.g. temperament
aggressions impulsive behavior, levelof
self- esteem )
3. Provide safe environment:
- pad side rails
- remove obstacles in the room
4. Discuss important of self – monitoring
of conditions / emotions
GOAL MET
After 1-2 days ofnursing intervention
the client was free from any injury as
evidenced by:
Always with supportofthe significant
others
Always insight ofthe significant
others

Discharge Plan
The patient is instructed to take the following plan for discharge.
M-EDICATION, instruct patient to continuously drink medication as prescribe by Doctor
E-XERCISES, instruct patient to conduct 15-20 minutes exercises morning and active ROM in
extremities for about 5-10minutes every afternoon
T-REATMENT, instruct patient to continuously stick to the regimen of drinking medication on time and
reporting to physician for any signs of deviations
H-EALTH TEACHING, instruct patient to exercise daily, increase fluid intake
O-UT-PATIENT FOLLOW UP, Instruct patient to attend follow-up check-ups as recommended by the
physician.
D-IET, the patient will be place on diet as tolerated
S-PIRITUAL, Encourage client to attend religious practices like attending the worship service

Treatment and management
ARTHROTOMY
The medical term “arthrotomy” means “cutting into a joint.” Also known as a synosteotomy,
an arthrotomy can be performed for a variety of reasons, usually as part of a larger surgery which is
intended to address a problem inside the joint or an issue with one or more of the bones which articulates
at the joint. Procedures of this nature are usually performed by anorthopedic surgeon, a surgeon who
specializes in surgeries involving the bones and joints.
One reason to perform an arthrotomy is to gain access to the joint for the purpose of a joint repair or
replacement surgery. Cutting into the joint may be necessary to access the surgical field and to make the
interior of the joint visible to the physician. However, it also increases healing time. Historically, surgeons
had to weigh the damage caused by an arthrotomy with the need for the surgery when making treatment
recommendations to patients.
Today, cutting into the joints is less necessary because surgeons can perform arthroscopicsurgery. In this
type of surgery, cameras are inserted into the joint along with tools which can be used to perform
manipulations inside the joint. This allows the surgeon to work within the surgical field without having to cut
the joint open to do so. Minimally invasive surgery is safer for the patient, decreases the risk of
complications, and shortens healing time considerably, making it an appealing choice when it is an
available option.
Cutting into a joint may also be necessary during an amputation or during exploratory surgery in
which arthroscopic surgery is not an option. Arthroscopy may not be possible in some emergency
situations, for example, or when a joint is badly crushed and thus the surgeon has difficulty understanding
what is going on inside the surgical field without looking at it directly.
When arthrotomy is required as part of a medical procedure,the surgeon uses specialized tools which have
been designed for cutting quickly and efficiently into the joints while minimizing damage. The surgeon plans
out the cuts ahead of time so that when the patient is on the table, the surgeon already has a plan in mind
for performing the surgery. Patients should be aware that even “routine” surgeries can be accompanied

with complications, and a good surgeon will discuss the potential risks of a procedure before it begins so
that the patient will be prepared ahead of time.
BLOOD TRANSFUSION
A blood transfusion is the transfer of blood or blood products from one person (donor) into another person's
bloodstream (recipient). This is usually done as a life saving maneuver to replace blood cells or blood
products lostthrough severe bleeding, during surgery when blood loss occurs or to increase the blood
count in an anemic patient. The following material is provided to all patients and/or their family members
regarding blood transfusions and the use ofblood products. Although in mostsituations the likelihood ofa
blood transfusion associated with surgery is uncommon, attimes patients may require blood products. You
are encouraged to discuss your particular need for transfusion as well as the risks of transfusion with your
doctor.
Your options may be limited by time and health factors, so it is important to begin carrying outyour decision
as soon as possible. For example,iffriends or family members are donating blood for a patient(directed
donors), their blood should be drawn several days prior to the anticipated need to allow adequate time for
testing and labeling. The exactprotocols are hospital and donor site specific.
The safest blood productis your own, so ifa transfusion is likely, this is your lowestrisk choice.
Unfortunately this option is usually only practical when preparing for elective surgery. In mostother
instances the patient cannot donate their own blood due to the acute nature of the need for blood.Although
you have the right to refuse a blood transfusion, this decision may hold life-threatening consequences. If
you are a parent deciding for your child, you as the parentor guardian must understand that in a life-
threatening situation your doctors will act in your child's bestinterestto insure your child's health and well
being in accordance with standards of medical care regardless ofreligious beliefs. Please carefully review
this material and decide with your doctor which option(s) you prefer.

To assure a safe transfusion make sure your healthcare provider who starts the transfusion verifies your
name and matches it to the blood thatis going to be transfused. Besides your name, a second personal
identifier usually is used as your birthday. This assures the blood is given to the correctpatient.
If during the transfusion you have symptoms of shortness ofbreath, itching, fever or chills or just not feeling
well, alert the person transfusing the blood immediately.
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