A CASE STUDY ON

SEPTIC ARTHRITIS
Prepared by: AGATHA ALISON D. PALAFOX MARY ROSE D. PANTUA SARAH REFUGIA LEA MARIE SILAVA MICKY A. SOLA RHEA L. SOLA MENIZA AMY A. TOTANES EMMANUEL VALENCIA BSN 4-A / GROUP 3

INTRODUCTION

A. Background of the Study

July 18, 2011 was the first day of our duty in the orthopedic ward at Bicol Medical Center. Most of the cases were associated with fracture. The case that caught our attention was the case of a twelve years old child who has a Septic Arthritis. The said case was chosen for this case study.

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

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

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

B. Objectives of the Study

General Objective
This case study is designed for the student nurses to become practiced, well-informed and mannered in delivering holistic care for patients diagnosed with Septic Arthritis.

B. Objectives of the Study

 Specific Objectives Skills Knowledge Attitude

SKILLS y To demonstrate the vision/mission of the school (specifically the Nursing and Health Sciences Department NHSD). y Imply appropriate medical nursing management for Septic Arthritis.

KNOWLEDGE y Define Septic Arthritis. Learn about major etiologic its causes, identify its clinical manifestations and risk factors. y Discuss the anatomy and physiology of the Musculoskeletal System. y Be familiar with the pathophysiology of Septic Arthritis. y Be familiar with the different drugs, its actions, and perform obligatory nursing responses for each. y Plan for a suitable nursing care.

ATTITUDE y Establish a nurse-patient interaction through exchanging of thoughts and information y Institute bond between the student nurse and the patient.

NURSING HEALTH HISTORY

A. Biographic Data
Name: Address: Age: Religion: Civil Status: Nationality: Date of Birth: Date of Admission: Ward and Room: Admitting Diagnosis: Attending Physician: Sources of Information: Mr. S.A. Centro, Fundado, Siruma, Camarines Sur 12 years old Roman Catholic Single Filipino March 28, 1999 July 12, 2011 Orthopedic Ward, Room 2 Sepsis, Septic Arthritis Knee Joint L Dr. Joseph S. Sanchez, M.D. Patient, Significant Others, Patient s chart, Attending Physician.

B. Chief Complaint
y Fever (37.9) y Swelling on the left thigh and knee y Pain

C. History of Present Illness

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

D. Past Medical History

Patient had a history of cough and colds, no history of hospitalization or operation. Patient s immunization status was complete.

E. Family History of Illness

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

F. Lifestyle (Gordon s Functional Health Pattern)

G. Social Data
y Mr. SA is a 12 year old boy and a grade six student of Siruma, Elementary School. y He s non-smoker and non- alcoholic y His past time is playing basketball

H. Psychosocial Data
y (-) hallucinations and delusions y During admission he is aware that he was on the hospital y Obtunded LOC y Able to recall past and recent events

I. Patterns of Health Care

The patient seeks medical attention at the rural health center in their municipality especially when they are experiencing minor health problems such as cough and colds, fever, e.t.c. it s the first time that the patient was hospitalized.

REVIEW OF SYSTEMS AND PHYSICAL ASSESSMENT

A. General Appearance
Weight: 25 kg Height: 5 feet Level of Consciousness: Obtunded Body Build: Endomorphic Posture and Gait: Unable to stand and walk Overall Hygiene: Fair

B. Vital Signs

C. Head/Scalp/Hair
y Head is normocephalic (symmetrical and round) y No palpable nodules or masses noted. y Lesions are not noted. y Has a short black hair. y No presence of flakes, lice or lesions noted.

D. Eye/Vision
Anicteric sclerae with pupils round and black in color. Brisk reaction to light Blinking symmetrical Cornea is transparent , smooth and moist Both eyes move in a smooth, coordinated manner in all directions

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

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

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

H. Throat and Neck

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

I. Respiratory System
Breathes normally and easily No crackles or abnormal lung sounds noted

J. Circulatory/Cardiovascular System
Swelling is noted on the left knee Edema on the IV sites (left hand and right foot) There is fatigue upon arising from bed to sitting position

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

L. Genitourinary System
No difficulty in urination Urine is yellowish in color Fluid intake is approximately 800mL/day

M. Musculoskeletal System
Muscle weakness is noted Movements are weak. Unable to walk and cannot tolerate standing. Slightly weak handgrip and weak lower extremities

N. Integumentary System
Skin is brown in complexion, warm, and slightly dry with fair skin turgor. Pallor/cyanosis is noted Swelling is noted on the left knee Edema at the IV site (left hand and right foot)

LABORATORY TESTS

Date: July 12, 2011 8:39:58 AM EXAM NAME RESULT WBC 17.06 RBC 3.29 Hemoglobin 76.1 Hematocrit 0.2363 MCV 71.76 MCH 23.12 MCHC 32.22 Platelet count 639 Neutrophil 79.7 Lymphocyte 10.8 Eosinophil 1.8 Monocyte 7.2 Basophils 0.5 UNIT 10^9/L 10^12/L g/L % fl Pg g/L 10^9/L % % % % 0% NORMAL VALUES 4.8-10.8 4.7-6.1 120-180 0.37-0.54 82-98 28-33 33-36 150-400 40-70 19-48 2-8 3-9 0-5

Date: July 14, 2011 1:52:35 PM EXAM NAME WBC RBC Hemoglobin Hematocrit MCV MCH MCHC Platelet count Neutrophil Lymphocyte Eosinophil Monocyte Basophils RESULT 14.03 3.31 74.1 0.2422 73.17 22.34 30.6 496 76 12.4 2.2 8.8 0.6 UNIT 10^9/L 10^12/L g/L % fl Pg g/L 10^9/L % % % % 0% NORMAL VALUES 4.8-10.8 4.7-6.1 120-180 0.37-0.54 82-98 28-33 33-36 150-400 40-70 19-48 2-8 3-9 0-5

Date: July 15, 2011 1:38:18 PM EXAM NAME WB C RBC Hemoglobin Hematocrit MCV MCH MCHC Platelet count Neutrophil Lymphocyte Eosinophil Monocyte Basophils RESULT 22.58 3.4 78.5 0.2511 73.92 23.09 31.24 520 85.1 7.3 1.8 5.2 0.6 UNIT 10^9/L 10^12/L g/L % fl Pg g/L 10^9/L % % % % 0% NORMAL VALUES 4.8-10.8 4.7-6.1 120-180 0.37-0.54 82-98 28-33 33-36 150-400 40-70 19-48 2-8 3-9 0-5

Date: July 16, 2011 1:42:34 AM EXAM NAME RESULT WBC 7.93 RBC 3.63 Hemoglobin 86.6 Hematocrit 0.2752 MCV 75.81 MCH 25.87 MCHC 31.48 Platelet count 374 Neutrophil 80.4 Lymphocyte 12.8 Eosinophil 2 Monocyte 4 Basophils 0.8 UNIT 10^9/L 10^12/L g/L % fl Pg g/L 10^9/L % % % % 0% NORMAL VALUES 4.8-10.8 4.7-6.1 120-180 0.37-0.54 82-98 28-33 33-36 150-400 40-70 19-48 2-8 3-9 0-5

Date: July 17, 2011 1:56 AM EXAM NAME White blood cell Red blood cell Hemoglobin Hematocrit MCV MCH MCHC Platelet count Neutrophil Lymphocyte Eosinophil Monocyte Basophils RESULT 8.12 3.99 101.1 0.3061 76.67 25.33 33.04 471 89.73 4.95 1.24 4.03 0 UNIT 10^9/L 10^12/L g/L % fl Pg g/L 10^9/L % % % % 0% NORMAL VALUES 4.8-10.8 4.7-6.1 120-180 0.37-0.54 82-98 28-33 33-36 150-400 40-70 19-48 2-8 3-9 0-5

Date: July 18, 2011 02:36 AM EXAM NAME White blood cell Red blood cell Hemoglobin Hematocrit MCV MCH MCHC Platelet count Neutrophil Lymphocyte Eosinophil Monocyte Basophils RESULT 14.99 3.13 75.5 0.2369 75.7 24.14 31.89 267 83.7 6.3 1 8.5 0 UNIT 10^9/L 10^12/L g/L % fl Pg g/L 10^9/L % % % % % NORMAL VALUE 4.8-10.8 4.7-6.1 120-180 0.37-0.54 82-98 28-33 33-36 150-400 40-70 19-48 2-8 3-9 0-5

COURSE IN THE WARD

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

On July 13, 2011, the patient was examined by the Pediatrician. History was taken. He has no history of previous hospitalization, his immunization status was complete. On assessment, he has no cough and colds, anicteric sclera, (-) murmurs. Diagnosis was T/C sepsis, cellulitis, L thigh. The physician ordered that the patient may proceed with I and D procedure. July, 14, 2011, repeat CBC was done. IVF was D5LR 1L at 20 gtts/min. The physician scheduled patient for elective I&D and debridement on the left thigh and knee.

July 15, 2011, the doctor ordered to transfuse 1 unit of blood as PRBC type O after cross-matching. Consent for blood transfusion was secured. The patient was in febrile state with the temperature of 38.7 and intravenous antipyretic was administered. July 16, 2011, the patient was placed in NPO and rescheduled for elective I&D and debridement. Then, via telephone, the doctor ordered to transfuse another 1 unit PRBC. At 11:00 PM per verbal order, the doctor placed the patient on DAT then NPO post midnight. The patient was possible for elective OR in the morning. July 17, 2011, at 8pm, the patient is for I & D. He was on NPO since 9am in the same day. His vital signs were stable.

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

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

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

July 21, 2011, the previous IV and oral medications of the patient was discontinued and the doctor orderd cloxacillin 500 mg 1 capsule TID, metronidazole 500 mg 1/5 tablet TOD p.o. and ordered wound care. The patient had fever, with the temperature of 37.9 Paracetamol was given. July 22, 2011, IVF of the patient was discontinued. July 23, 2011, via telephone, the doctor ordered to transfuse PRBC, and start IVF of PNSS 1L at KVO.

July 25, 2011, the patient was received lying on bed with PNSS 1L regulated at KVO. Due medications was administered. The patient had a pustule in his right ankle. Wound care was done aseptically. July 26, 2011, the patient undergone blood transfusion of 2 packs of RBC.

THEORY OF NURSING AS FRAMEWORK OF THE CASE STUDY

HENDERSON S 14 ACTIVITIES OF CLIENT ASSISTANCE:

BREATH NORMALLY
Respiratory rate (24-26-28-30-34): experienced cough and colds before admission: with shortness of breath.

EAT AND DRINK ADEQUATELY

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

ELIMINATE BODY WASTE

reported constipation as related to problem in elimination.

MOVE AND MAINTAIN DESIRABLE POSTURE

Reported pain in left knee joint every time he moves.

 SLEEP AND REST

Report no problem related to sleep and rest.

SELECT SUITABLE CLOTHES-DRESS AND UNDRESS

Wear shirt and short

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

KEEP THE BODY CLEAN AND WELL GROOMED AND PROTECT THE INTEGUMENTARY.
Can t perform his proper personal hygiene due to his condition

 AVOID DANGER IN THE ENVIRONMENT AND AVOID INJURING OTHERS.

Wears clothes that match the weather condition

COMMUNICATES WITH OTHERS IN EXPRESSING EMOTIONS, NEEDS, FEAR, OR OPINIONS.

Able to speak and understand, verbalized his fear about his present condition and the pain being felt.

WORSHIP ACCORDING TO ONE S FAITH

Attends church with family often during Sundays.

 WORK IN SUCH A WAY THAT THERE IS A SENSE OF ACCOMPLISHMENT

Reports unhappiness because he didn t attend his class for two months. And that he cannot perform the simple activities of his daily living

PLAY OR PARTICIPATE ON VARIOUS FORMS OF RECREATIONS

Only his father spends time with him

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

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

ERIKSON S STAGES OF PSYCHOSOCIAL DEVELOPMENT

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

ERIKSON S STAGES OF PSYCHOSOCIAL DEVELOPMENT

BEFORE HOSPITALIZATION
Patient was able to perform activities of daily living and goes to school. Active in doing household chores. Is able to decide on his own activities Presence of self-esteem

ERIKSON S STAGES OF PSYCHOSOCIAL DEVELOPMENT

DURING HOSPITALIZATION
Patient unable to perform activities of daily living, was absent in his class for almost 1 month. Always on the bed Unable to help in the household chores. Decrease self-esteem due to his condition

ERIKSON S STAGES OF PSYCHOSOCIAL DEVELOPMENT

AFTER HOSPITALIZATION
Able to perform activities of daily living and goes to school but with precautions. Able to ambulate and do self-care activities. Is able to do light household activities. Self-esteem is not totally regained but progressing.

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

RISK FACTORS
Past joint disease Injury or trauma Infection within the body Taking medications that suppress the immune system Intravenous drug abuse Surgery Immunocompromised

CLINICAL MANIFESTATIONS
Fever Severe pain in the affected joint, especially when you move that joint Swelling of the affected joint Warmth in the area of the affected joint redness in the affected area limited use of the affected extremity guarding or protecting the affected area to prevent it from being touched or seen redness in the affected area

MEDICAL MANAGEMENT

DISCHARGE PLAN

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

Cloxacillin
500 mg capsule three times a day (8am-1pm-6pm) Take medication around the clock, do not miss a dose, and continue taking the medication until it is finished. Report to physician the onset of hypersensitivity reaction Check with physician if GI adverse effects (nausea, vomiting, diarrhea) appear

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

Esomeprazole
40 mg tablet once a day for 3 days (8am) Report any changes in urinary elimination such as pain or discomfort associated with urination to physician. Report severe diarrhea. Drug may need to be discontinued. Headache, abdominal pain, diarrhea, flatulence, nausea, vomiting, constipation (side effect of the drug.)

Oral Tramadol
37.5mg 1 tablet per day (8am)

Heat / cold application

Heat or cold application can provide temporary pain relief. Heat application (by taking a hot shower, for example) helps reduce pain and stiffness by relaxing the muscles and increasing blood circulation. There is some concern, however, that heat may worsen symptoms in an already inflamed joint. Cold application (placing ice or cold packs on the affected area) has a numbing effect by constricting the blood vessels and blocking nerve impulses in the joint. Cold appears to decrease inflammation and therefore is usually the method of choice when joints are inflamed.

HEALTH TEACHING
Instruct the patient to do: Splinting
the affected joint may need to be splinted, as movement can be very painful at first.

Relaxation
Relaxing the muscles around an inflamed joint often helps reduce pain.

EXERCISE
Once the infection has cleared up, your doctor will frequently recommend exercises to build up muscle strength and increase the joint's range of motion. A physical therapist can instruct you in how to do suitable exercises. ROME Emphasize the importance of complying to the therapeutic regimen. Instruct the patient regarding his next follow-up care Instruct the patient and his family regarding the side effects of the medication.

HYGIENE
Encourage the patient and his family to do proper personal hygiene. For skin rash: calamine lotion For pruritus: TSB

 DIET:
Instruct the patient to increase fluid intake and increase consumption of foods rich in carbohydrates and protein. Include intake of iron and calcium Small frequent feeding For diarrhea: low fiber, BRAT diet For constipation: high fiber

SPIRITUAL VALUES:
Emphasize the importance of the spiritual beliefs

END. Success!!!
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