CASE PRESENTATION FOR BLOUNT’S DISEASE B PROXIMAL TIBIAPrepared by:BSN students from Universal College of Parañaque Inc.

INTRODUCTION: Blount's disease is a rare growth disorder that affects children, causing the legs to bow

outwards just below the knees.  A small amount of bowing is actually quite normal in young infants, and is referred to as physiologic bowing of the knees.  However, as most children begin to walk, between the ages of 1 and 2 years old, their legs gradually straighten out.  In children with Blount's disease the lower legs remain bowed or bow further outwards, which can lead to future problems with walking.   In addition, the inner surface of the legs just below the knee may bulge outward slightly, the toes may point inwards excessively (a condition known as in-toeing), and one leg may undergo very mild shortening compared to the other leg.  Occasionally, children may experience some discomfort in the legs near the knees and may have some instability when walking.  In general, however, children with Blount's disease have few significant symptoms and do not experience pain from their condition.   Moreover, nearly all children who receive early treatment respond very well and suffer no long-term consequences to their health as a result of the condition.

Blount's disease is a rare growth disorder that affects children, causing the legs to bow outwards just below the knees.  A small amount of bowing is actually quite normal in young infants, and is referred to as physiologic bowing of the knees.  However, as most children begin to walk, between the ages of 1 and 2 years old, their legs gradually straighten out.  In children with Blount's disease the lower legs remain bowed or bow further outwards, which can lead to future problems with walking.   In addition, the inner surface of the legs just below the knee may bulge outward slightly, the toes may point inwards excessively (a condition known as in-toeing), and one leg may undergo very mild shortening compared to the other leg.  Our pediatric orthopedics group sees and manages the treatment of a large number of patients in both infantile and adolescent age groups.

Purpose of the study The purpose of the study is to determine the most appropriate nursing intervention to the pt. with Blount’s Disease

PATIENT’S PROFILE Name: M. A. J Address: 130 Ruby Drive, ST. Francis Village Phase 1,

Bulacan Age: 10y/o Gender: female Religion: Roman Catholic Room & Bed no.: PHSE1

Chief complaints: WHEN PATIENT WAS 4 YEARS OLD HER MOTHER NOTICED SIGHT DURATION ON HER LEGS BUT DIDN’T MADE ANY CONSULT. AS PATIENT PROGRESSED HER STUDIES IN SCHOOL SHE STARTED HAVING DIFFICULTY GOING TO HER CLASSROOM USING THE STAITS, HER MOTHER ASKS THE JANITOR TO ASSIST HER GOING UP THUS PROMTED CONSULT WHEN THE DEVIATION ON BOTH LEGS COMES MORE NOTICEABLE.

Diagnosis: BLOUNT’S DISEASE (B) PROXIMAL TIBIA Attending physician: BALCE CIELO

Present history: At 5years old she was diagnosed with Blount’s Disease at Philippine Orthopedic center. Due to financial constrains the patient will not be able to go in an operation because they cant raised 500,000php.At 7years old they made consult at St. Lukes Hospital and was suggested by the doctor to undergo Acute Anthroscopy but was confirm at the long run possible side effect of cancer morther decline.at 9yrs old patient admit to PGH but due to technical problems of hospital facilities patient was not able to undergo management and treatment. While at PGH she was unexpectedly seen by DRA. Balce and discussion on about management and treatment with her mother and was invited to East Aveñue Medical Center.

Family history: (+) DM (+) HPN (+) COLON CANCER

GORDON’S FUNCTIONAL PATTERN Health Perception- Health Management PatternBefore hospitalization:

Mrs.XYZ describes about the health situation wherein her daughter can do task and activities without hindrance in her physical, mental, emotional, social and spiritual living. He rates the health of her daughter scale, 10 as the highest and 1 as the lowest. Every time she feels about her health, she still increase her activity of her daily living still doing her favorite sports like badminton, she rest and sleep as management. According to MRS.XYZ he seeks medical advice whenever she feels something bad about the health of her daughter.

  During hospitalization:

Mrs.XYZ said that it seems like her daughter is imprisoned with the consequences of being unhealthy that her daughter cannot function well and cannot perform her ADL’s due to her present condition.Mrs. XYZ describes the current health problem as something like down casted from the nor ways of running the life of her daughter which made Mrs. XYZ rate the health status as 5 in the above mentioned health scale. Though in some intonations of her voice, she still wants to insist that everything is ok.

  Nutritional- Metabolic Pattern: Before hospitalization:

The pt. weighs 72 kilograms and she has a height of 5’5. She eats three times a day with sometime snack having a snacks, according to her mom she eats food that are being prepared; she is not choosy in terms of eating but their usual menu is according to her likes. She takes sofdrinks or a juice for a day, included to these is water. In a day she takes large amount of water. According to Mrs. XYZ her daughter takes supplemental vitamins.

  During hospitalization:The pt still has the appetite to eat, but still her drinking habits and behavior don’t change.

She has the appetite to eat. She needs to follow the diet given by the physician which is DAT and he eats foods given by the hospital.

Elimination Pattern:Before hospitalization:Mrs. XYZ did not specified how many times a day her daughter urinates but he made mentioned that her daughter urinates frequently approximately a cup for every urination. Her urine is yellow amber in colour. she defecates 1-2 times a day with brown stool. She doesn’t use suppositories. She feels no discomfort during urination.

  During hospitalization:

She urinates once with a measurement of 1 of a cup in every shift with yellow amber in color, she feels no pain during urination. She defecates once in a day not in a shift in our stay in the hospital with a yellow-brown color.

Activity-Exercise Pattern:Before hospitalization

She considers her playing badminton as her exercise. According to Mrs. XYZ her daughter does her playing everyday. This is her form of living. Though he finds this thing work tiring, but as a child in suit of a lady this thing serves as a satisfaction on her childhood. Taking rest particularly lying on bed in her way to overcome her tiredness and stress. In term of her condition, she, together with his family goes out as he requested. Mrs. XYZ believes that in this way, the bonding of their family ties more strongly.

During hospitalization:Because of her unwanted health problem, according to Mrs. XYZ her daughter activities are so much affected. She is thinking on how her child will continue her living if she is in the hospital suffering the disease. With her daughter present condition she needs some support and assistance.

Sexuality-Reproductive Pattern: Before hospitalization: During hospitalization

Sleep – Rest Pattern:

Before hospitalization:She sleeps early at night and wakes up at around 10pm. She has a nap during the day usually afternoon after her activities. She has a difficulty of falling asleep he wakes up late and cannot fall asleep again.

During hospitalization:According to Mrs. XYZ, her daughter cannot easily fall asleep in the hospital because she is used to sleep in their house and not on other houses or even hospital. She doesn’t have continuous sleeping pattern (she sleeps and after a few hours or minutes, she wakes up) she is okay because she does nothing in the hospital but to sleep, sit and lay down. The client doesn’t take any sleep-including drugs.

Cognitive –Perceptual Pattern: Before hospitalization:

All her senses are all functioning. She is aware of her environment. She has the ability to understand, communicate, write, remember and make decisions.

During hospitalization:There are no changes in the functions of the patient’s senses. She still has the ability to understand, communicate, write, remember and make decisions. She is oriented and aware of her environment.

Role-Relationship Pattern:Before hospitalization:

The patient has good relationship in her family and friends. She is not involved in any organization in their place but she has good relationship with the people around them.

  During hospitalization:The relationship and intimacy of the patient to his role and responsibility is lessened and

decreased due to a great situation which trapped her to continue it.

Self-Perception – Self—Concept Pattern: Before hospitalization:

“According to Mrs. XYZ sya ung tipo ng bata di nagsasawa ipagpatuloy ang pangarap sa pamamagitan ng pag aaral mabuti at patuloy n pagsali sa mga contest, malayo man o malapit” as verbalized by the mother. Mrs. XYZ. She is healthy maybe not in physical aspect but it describes a healthy well rounded child to her family as well as in her society.

During hospitalization:“Gusto ko na nga syang patigilin sa mga activity nya sa skul kasi tingin ko nahihirapan ang bata” as verbalized by the mother… he wants to go home; she can’t let she stay longer in the hospital.

Coping Stress Tolerance Pattern: Before hospitalization:

Whenever the client feels tired, she increases her daily routine she takes rest and sleep. “She always pray” verbalized by the mother.Mrs. XYZ the most stressful thing in her life is when problem comes in one time. She is also stress with her works and being worried about financial problems.

During hospitalization:The child feels tired, she just sleep sometime, rest and relax. Sometimes, she cries in her condition.

Value –Belief Pattern: Before hospitalization:

The client believes in god. She is a roman catholic; she attends masses sometime with her family.

During hospitalization:According to Mrs. XYZ their relationship to God became closer despite of her daughter condition. She believes that God has a great contribution in her daughter’s recovery soon.

PHYSICAL ASSESSMENT Date performed: September 25.2012 11:00 PM  Name: Weight: Age: 10 yrs. old Height:  Vital Signs:

Temperature: 36.5 C PR: 81 bpm RR: 26 bpm BP: 100/60 mmHg

  Regional Examination Skin:

Inspection:-fair in skin-Skin temperature is 36.5 degrees Celsius.-Blood come out from the incision of the fixator @ right leg.

Palpation:-and warm to touch-When press, skin easily return in its previous state.

Head and FaceInspection:

-Symmetric facial features and movements-With equal distribution of short , fine black hair-Head is proportional to the size of her body-No facial involuntary movement-No presence of rashes

Palpation:-Absence of nodules and masses.-Temporal pulse is palpable

  Nails: Inspection:

-No Clubbing of nails-The fingernail shape is convex curvature.-There are no hang nails and it is intact epidermis.

Palpation: -Nails are smooth to touch-Capillary refills about 2 seconds

  Eyes:Inspection:

-Eyebrows symmetrically aligned with equal movement.-Eyelashes equally distributed and curled slightly outward.-Skin of eyelids intact with no discoloration.-Eyes are proportional to the size of her face-Pupils are equal, round and reactive to light-With transparent, pinkish palpebral conjunctiva-Lateral cantus is parallel to the ear-No involuntary movement

 

Ears: Inspection:

-Color same as facial skin-Symmetrical aligned-No lesions or discoloration.-Ear canal is normally curved-Dry cerumen.-Able to hear the ticking of watch in both ears.-Upon weber’s test sound is heard on both ears or is localized at the center of the head.-Upon rinne’s test air conducted hearing is greater that bone conducted hearing which indicates positive rhine.

Palpation:-Ears have no deformities, no tenderness and no masses upon palpation.-Pinna is not tender and immediately recoils after it is folded.

  Nose: Inspection:

-(+) nasal flaring when breathing -In the midline of the face-Nasal bridge is symmetrical to face-Absence of inflammation and lesions-Texture is smooth

Palpation:-Absence of nasal tenderness -No deformities

Mouth and Pharynx: Inspection:

-Outer lips uniform, soft and moist-Tongue is pinkish in color, moist, at central position, and moves freely.-Gums are pink in color-palate surface intact-Oral mucosa, soft and hard palate are also pinkish in color, moist and smooth-Uvula is symmetrical to soft palate and reddish in color-Tonsils are inflamed and reddish in color-Presence of cavity in the upper and lower teeth-There is One Dieseline tooth

Neck: Inspection:

-Proportional to the size of her head-Slightly flexion-Head is centered-No evidence of scars and lesions

Palpation:-No palpable lumps, masses, and areas of tenderness

Spine -Not performed because the patient can’t easily move freely.

Thorax and lungs: Inspection:

-Chest is symmetry-Symmetric chest expansion and excursion.-Respiratory Rate of 26 breaths per minute -Asymmetric breathing pattern

Palpation:-No presence of tenderness or masses

Auscultation:-Rales sound over the right base of the lungs

Breast:

-Not perform because the patient refuses.  Heart and vessels: Inspection:

-BP 100/60 mmHg-Pulse Rate of 81 beats per minute.-No murmurs.

Palpation:-No palpitations.

Auscultation: -67 beat in 1 full minute.-Heart sounds are S1 and S2.

Abdomen: Inspection

-Rounded shape-No signs of inflammation and discharge in umbilicus-With presence of linea negra -No signs of petechiae

  Extremities:Inspection:

-Bone abnormalities @ left and right and legs are bend out ward. -fixator (L) 20 and ® 40

-Muscle equal size on both sides of the body-Presence of blood in right leg.-No Presence of edema

Palpation:-Tenderness 8/10 as verbalized by the patient.

  Genitals:

-Not perform because the patient refuses.  Rectum and anus:

-Not perform because the patient refuses.

Neurological exam:Cerebral Function

-Aware and conscious to time, place, and environment

-Her eye opening is spontaneous,-She responds to verbal commands-She speaks clearly and answers to questions

given-She can point every object that the examiner

tells her topoint.-Can easily differentiate rough and smooth-Alert and cooperative-Oriented to person, place, and time-The patient is lying in bed

FUNCTIONS :

The lower leg is a remarkable structure, where each of its sophisticated components must work in harmony with the adjacent mechanisms to achieve support for the body or movement. No portion of the lower leg anatomy is capable of independent physical action.

The lower leg anatomy is composed of five distinct parts:

a) the knee joint, b) the shin,c) the calf,d) the ankle and the foot.

In terms of the general functions of the lower leg, all movement is initiated by either a flexion or an extension of the knee joint.

The knee joint is the hinge mechanism that initiates the propulsion of the lower leg. A flex of the hinge, powered by the hamstring and quadriceps

Note: When one of the lower leg anatomical parts is not capable of a proper response, the entire structure is compromised.

The tibia and the fibula are commonly treated as a single skeletal structure. While neither bone is capable of independent movement, the chief function of these bones is in the formation of the knee and the various ankle joints, as well as providing support.

ANATOMY AND PHYSIOLOGY OF LEGS

The Lower Leg is comprised of two long bones . The tibia is the larger of the two, and is located toward the middle of the lower leg (medially). The fibula is the smaller bone and it is located on the outside of the lower leg (laterally).

The tibia and the fibula are commonly treated as a single skeletal structure. While neither bone is capable of independent movement, the chief function of these bones is in the formation of the knee and the various ankle joints, as well as providing support

THE BONE STRUCTURE OF THE FOOT IS DIVIDED INTO THREE PARTS:

the forefoot, the forefoot is made up of the bones of the five toes, which are collectively known as the phalanges. The phalanges are connected to the other bones of the foot by a longer connecting bone, called the metatarsal, at joints created at the ball of the foot with each toe. The forefoot is capable of supporting one half of a person's body weight.

The midfoot is the portion of the foot that is designed to absorb the shock created by human movement. The midfoot is constructed of five tarsal bones, and it is supported by the plantar fascia, the ligament that is essential to the function of the arch of the foot. The plantar fascia extends along the entire length of the foot, attached at the calcaneus (the heel bone, the largest bone in the foot) to the forefoot

The hindfoot, including the ankle structure, is connected to the bones of the lower leg by the talus, the ankle bone. The joint created at the heel and the ankle is the subtalar joint, which permits the ankle to be completely rotated in clockwise and counterclockwise directions.

Foot tissues to support the cardiovascular and neurological demands of movement. The sophistication of the skeletal structure of the foot is underscored by the fact that the bones of the two human feet constitute almost 25% of all bones in the human body.

PATHOPHYSIOLOGY OF BLOUNT’S DISEASE

Primary cause-idiopathic(unknown)

RISK FACTORS:-OBESITY-EARLY AGE WALKING-GENDER (FEMALE)-ONSET (COMMON IN CHILDREN

REPEATED STRESS AND INCREASE PRESSURE ON THE UPPER EPIPHYSES OF TIBIA

ABNORMAL COMPRESSION OF THE EPIPHYSEAL PLATE

DECREASE/ REDUCE ABILITY OF THE EPIPHYSEAL TO PRODUCE BONE CELLS AND EXPANDS

ABNORMAL GROWTH OF THE EPIPHYSIS REGION

SIGNS/ SYMPTOMS: (CHANGES IN BONE ALIGNMENT)-ROTATIONAL DEFORMITY 9IN-TOEING)-CURVATURE OF BOWING OF THE BONE

BLOUNT’S DISEASE

LABORATORY EXAMEXAMINATION RESULT NORMAL VALUES INTERPRETATION/SIGNIFICANCE

Hemoglobin 1.457 mmol/L 1.86-2.48 mmol/L BELOW NORMAL-below normal hemoglobin indicate anemia. A low hemoglobin count is a below-average concentration of the oxygen-carrying hemoglobin proteins in your blood.

Leucocyte Count 10.75x10,9/L 5-10x10,9

Neutrophil 0.68 0.45-0.65 ABOVE NORMAL-An increased need for neutrophils, as with an acute bacterial infection, will cause an increase in both the total number of mature neutrophils and the less mature bands or stabs to respond to the infection.

EXAMINATION RESULT NORMAL VALUES INTERPRETATION/SIGNIFICANCE

Hemoglobin 71 120-160 g/L BELOW NORMAL-below normal hemoglobin indicate anemia. A low hemoglobin count is a below-average concentration of the oxygen-carrying hemoglobin proteins in your blood

Hematocrit 0.23 0.36- 0.42 BELOW NORMAL-A low hematocrit is referred to as being anemic. There are many reasons for anemia.

Rbc 2.78 4-6x10,12/L BELOW NORMAL-The term "anemia" is a general term that refers to a decrease in red blood cells. Anemia can occur from either a decrease in the number of red blood cells, a decrease in the hemoglobin content, or both. Red blood cells live for approximately four months in the bloodstream.

Wbc 11.9 5-10x10,9/L ABOVE NORMAL-An elevated number of white blood cells is called leukocytosis. This can result from bacterial infections, and inflammation.

Neutrophil 0.72 0.45-0.65 ABOVE NORMAL-An increased need for neutrophils, as with an acute bacterial infection, will cause an increase in both the total number of mature neutrophils and the less mature bands or stabs to respond to the infection.

Cross Match03-19-12

Patient Blood Type: “B” RH POSITIVE Donor’s Blood Type: “B” RH POSITIVE Blood Component: PRBC Major Cross match: COMPATIBLE Minor Cross match: COMPATIBLE Serial Number: NVBSP20120028273 Date Collected: 3/13/12 Expiration Date: 4/17/12 Blood Bank: PHILIPPINE BLOOD CENTER

X-RAY REPORT

Examination: Chest Pal Radiological findings: no active

parenchymal infiltrates. Heart is normal in size. Both hemidiaphragms, costophrenic sulci visualized bones are intact.

  Impression: CHEST –NEGATIVE

MEDICATIONSBRAND NAME

ACTION INDICATIONS

ADVERSE REACTIONS

NSG. CONSIDERAR

ATIONS

•Paracetamol

•GENERIC NAME•Acetominophen,•Tempra•Forte,Tylenol,•Aminofebrin

•CLASSIFICATION•Analgesics, muscle•Relaxants And uri-•cosurics

• Decreases fever• by inhibiting the effects of pyrogens• on the hypothala-

mic heat regulating centers and by a hypothalamic action leading to sweating and vasodilation.• Relieves pain By inhibiting Prostaglandin synthesis at the CNS but does not have anti-inflammatory action

because of its mini-mal effect on peripheral prostaglandin synthesis.

•Relief of•Mild-to-moderatepain,treatment of fever.DOSAGE:•Take with food•Pedia:3x-4x/day •1-2 y/o-1.2-1.8ml•0-6 mos.-0.3-0.6ml•6-12 mos.-0.6-1.2mlPATIENT DOSAGE:500mg q6hrs X 4 doses

Stimulation, drow-siness, nausea, vo-miting, abdominal pain, renal failure,Convulsions, comaand deathPRECAUTION

Patients withImpaired kidney orliver function.

Patients with Alcohol dependence Pregnancy(Category-B)

Assess patientsFever or pain; type of pain, location,intensity, duration,temperature, diaphoresis. Assess allergicReactions; rash, urti-caria, if these occurDrug may have to be discontinued. Check input andOutput ratio; decrea-Sing out may indicateRenal failure Take appropriate Safety precautions.

BRAND NAME

ACTIONS INDICATIONS

ADVERSE REACTIONS

NSG. CONSIDERATIONS

Toradol

GENERIC NAME

Ketorolac

CLASSIFICATION

Antipyretic NSAID

Inhibits prostaglandin synthesis, producing peripherally mediated analgesiaTherapeutic effect; Decreased pain

•Short term management of pain(not to exceed 5 days total for all routes combined).•Used for treating inflammation and pain in the operation site.DOSAGE;30mg/amp 1amp IM

CNS;drowsiness,ab-normal thinking, dizziness,euphoria,headacheCV;edema,pallor,vasodilationGI; GI bleeding,abnormal taste,diarrhea,dry mouth,dyspepsia,GI pain, nauseaGU;Oliguria,renal toxicity, urinary frequencyRESP;Asthma,dyspneaDERM;Pruritis,purpura,sweating,urticariaLOCAL;Injection siteNEURO;Paresthesia

NURSINGRESPONSIBILITIES

Patients who have asthma. Aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma and urticaria.

Assess pain(note type,location, and intensity)prior to and 1-2 hour following administration.

Ketorolac therapy should always be given initially by he IM or IV route. Oral therapy should be used only as a continuation of parental therapy.

Advise pt. To consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools,persistent headache or influenza-like syndromes(chills,fever muscles aches,pain) occur.

Effectiveness of therapy can be demonstrated by decreases in severity of pain. Patients who do not respond to one NSAIDs mat respond to another.

BRAND NAME

ACTIONS INDICATIONS

ADVERSE REACTIONS

NSG. CONSIDERATI

ONS

Zantac

GENERIC NAMERanitidine

CLASSIFICATIONGastrointestinal agent; Histamine2 (H2) antagonist; Antisecretory

Competitively inhibits the action of histamine at the histamine2 (H2) receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin, and pentagastrin.

•Short-term treatment of

active duodenal ulcer

•Maintenance therapy for

duodenal ulcer at reduced

dosage

• Short-term treatment of

active, benign gastric ulcer

•Short-term treatment

of gastro esophageal reflux

disease

•Pathologic hypersecretory 

conditions (Zollinger-Ellison

syndrome)

•Treatment of erosive

esophagitis

•Treatment of heartburn,

acid indigestion, sour

stomach

•DOSAGE

•50mg IV q 8hrs once on

NPO

CNS: headache, malaise, dizziness, insomniaCV: tachycardia, bradycardiaDEMATOLOGIC: rashGI: constipation, diarrhea, nausea and vomiting, abdominal pain, hepatitisGU: impotence or decreased libidoHEMATOLOGIC: leucopenia, granulocytopenia, thrombocytopenia

Assesment History: allergy to

ranitidine, impared renal or hepatic function, lactation, pregnancy

Physical: skin lesions, liver evaluation, abdominal examination, normal output, renal function tests, CBC

Intervention Administer oral drug with

meals at bedtime Decrease doses in renal

and liver failure Provide concurrent

antacid therapy to relieve pain.

Administer IM dose diluted, deep into large muscle group

Arrange for regular follow-up including blood test, to evaluate effects.

BRAND NAME ACTIONS INDICATIONS ADVERSE REACTIONS

NSG. CONSIDERATI

ONS

Timed-release: Avinza, Kadian, M-Eslon (CAN), MS Contin, Oramorph SROral solution: Roxanol, Roxanol TRectal suppositories: RMSInjection: Astramorph PF, DuramorphPreservative-free concentrate for microinfusion devices for intraspinal use:InfumorphLiposome injection: DepoDur

GENERIC NAME morphine sulfate 

CLASSIFACATIONOpioid agonist analgesicIFICATION

Morphine is a phenanthrene derivative which acts mainly on the CNS and smooth muscles. It binds to opiate receptors in the CNS altering pain perception and response. Analgesia, euphoria and dependence are thought to be due to its action at the mu-1 receptors while respiratory depression and inhibition of intestinal movements are due to action at the mu-2 receptors. Spinal analgesia is mediated by morphine agonist action at the K receptor. Cough is suppressed by direct action on cough centre.

Relief of moderate to severe acute and chronic pain Preoperative medication to sedate and allay apprehension, facilitate induction of anesthesia, and reduce anesthetic dosage Analgesic adjunct during anesthesia Component of most preparations that are referred to as Brompton’s cocktail or mixture, an oral alcoholic solution that is used for chronic severe pain, especially in terminal cancer patients Intraspinal use with microinfusion devices for the relief of intractable pain

BodyWhole:Hypersensitivity (Pruritus, rash, urticaria, edema, hemorrhagic urticaria (rare), anaphylactoid reaction (rare)), sweating, skeletal muscle flaccidity; cold, clammy skin, hypothermia.CNS:Euphoria, insomnia, disorientation, visual disturbances, dysphoria, paradoxic CNS stimulation (restlessness, tremor, delirium, insomnia), convulsions (infants and children); decreased cough reflex, drowsiness, dizziness, deep sleep, coma.

Assessment History: Hypersensitivity to opioids; diarrhea caused by poisoning; labor or delivery of a premature infant; biliary tract surgery or surgical anastomosis; head injury and increased intracranial pressure; acute asthma, COPD, cor pulmonale, preexisting respiratory depression; acute abdominal conditions, CV disease, supraventricular tachycardias, myxedema, seizure disorders, acute alcoholism, delirium tremens, cerebral arteriosclerosis, ulcerative colitis, fever, kyphoscoliosis, Addison disease, prostatic hypertrophy, urethral stricture, recent GI or GU

Treatment of pain following major surgery, ER liposome injection for single-dose administration by epidural route at the lumbar level DOSAGE:Epidural Initial injection of 5 mg in the lumbar region may provide pain relief for up to 24 hr. If adequate pain relief is not achieved within 1 hr, incremental doses of 1–2 mg may be given at intervals sufficient to assess effectiveness, up to 10 mg/24 hr. For continuous infusion, initial dose of 2–4 mg/24 hr is recommended. Further doses of 1–2 mg may be given if pain relief is not achieved initially.

CV: Bradycardia, palpitations, syncope; flushing of face, neck, and upper thorax; orthostatic hypotension, cardiac arrest.GI: Constipation, anorexia, dry mouth, biliary colic, nausea, vomiting, elevated transaminase levels.Urogenital: Urinary retention or urgency, dysuria, oliguria, reduced libido or potency (prolonged use).other: Prolonged labor and respiratory depression of SIDE EFFECTSBodyWhole:Hypersensitivity (Pruritus, rash, urticaria, edema, hemorrhagic urticaria (rare), anaphylactoid reaction (rare)), sweating, skeletal muscle flaccidity; cold, clammy skin, hypothermia.

surgery, toxic psychosis, renal or hepatic impairment pregnancy; lactationPhysical: T; skin color, texture, lesions; orientation, reflexes, bilateral grip strength, affect; P, auscultation, BP, orthostatic BP, perfusion; R, adventitious sounds; bowel sounds, normal output; urinary frequency, voiding pattern, normal output; ECG; EEG; LFTs, renal and thyroid function tests

BRAND NAME ACTIONS INDICATIONS ADVERSE REACTIONS

NSG. CONSIDERATIONS

Nubain

GENERIC NAMENalbuphine hydrochloride

CLASSIFICATIONNarcotic agonist-antagonist analgesic

Unknown. Binds with opiate receptors in the CNS, altering perception of and emotional responseto pain.

 For the relief of moderate to severe pain

Adjunct to balanced anesthesia

DOSAGE Injection: 10 mg/ml, 20 mg/ml, **510 mg IV/IM/SQ every 36 hours

CNS: headache, sedation, dizziness, vertigo, nervousness, depression, restlessness, crying, euphoria, hostility, confusion, unusual dreams, hallucinations, speech disorders, delusionsCV: hypertension, hypotension, tachycardia, bradycardiaEENT: blurred vision, dry mouthGI: cramps, dyspepsia, bitter taste, nausea, vomiting, constipation, biliary tract spasmsGU: urinary urgencyRespiratory: respiratory depression, dyspnea, asthma, pulmonary edemaSkin: pruritus, burning, urticaria, clamminess, diaphoresis

NURSING RESPONSIBILITIES Reassess patient’s level of

pain at least 15 and 30 minutes after parenteral administrati

ALERT! Drug causes respiratory depression, which at 10 mg is equal to respiratory depression produced by 10 mg of morphine.

Monitor circulatory and respiratory status and bladder and bowel function. Withhold dose and notify prescriber if respirations are shallow or rate is below 12 breaths/minute.

• Constipation is often severe with maintenance therapy. Make sure stool softener or other laxative is ordered.• Psychological and physical dependence may occur with prolonged use.•ALERT! Don’t confuse Nubain with Navane.• Caution ambulatory patient about getting out of bed or walking. Warn outpatient to avoid driving and other hazardous activities that require mental alertness until drug’s CNS effects are known.

BRAND NAME

ACTIONS INDICATIONS

ADVERSE REACTIONS

NSG. CONSIDERATION

S

Velosef

GENERIC NAME

Cefradine

CLASSIFICATIONfirst-generation cephalosporin;

Interferes with bacterial cell-wall synthesis, causing cell to rupture and die. Active against many gram-positive bacteria; shows limited activity against gram-negative bacteria.

Infection caused by bsusceptible strains of staphylococci, strepneumonia nd E- coli

CNS: headache, lethargy, paresthesia, syncope, seizuresCV: hypotension, vasodilation, palpitations, chest pain, phlebitis, thrombophlebitisEENT: hearing loss, scleral yellowingGI: nausea, vomiting, constipation, abdominal cramps, oral candidiasis, pseudomembranous colitisGU: vaginal candidiasis, nephrotoxicityHematologic: anemia, lymphocytosis, eosinophilia, bleeding tendency, leukopenia, bone marrow depression, hypoprothrombinemia, neutropenia, thrombocytopenia, agranulocytosisHepatic: hepatomegalyMusculoskeletal: joint painRespiratory: dyspneaSkin: rash, maculopapular and erythematous urticaria, yellow skin discolorationOther: chills, fever, edema, allergic reactions including anaphylaxis, serum sickness

Hypersensitivity to drugs

Monitor for positive response to antibiotic therapy

Monitor for signs of infection

Tell patient to take drug with full glass of water.☞ Instruct patient to immediately report severe diarrhea, abdominal pain, or vomiting.☞ Advise patient to stop taking drug and contact prescriber immediately if rash occurs.

PRIORITY LIST :1. CHRONIC PAIN

2. DISTURB SLEEP PATTERN RELATED TO NOISY SURROUNDING3. RISK FOR INFECTION AS EVIDENCED BY INVASIVE PROCEDURE.

NURSING CARE PLANS

ASSESSMENT NURSING DIAGNOSIS

GOALS and OBJECTIVES INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:“Sumasakit ang dalawang hita ko as verbalized by the patient.

Pain Scale: 8/10

OBJECTIVES:-Restlessness-Facial -Grimace-Irritability

Chronic Pain related to injuring agents

GOAL:After 30 minutes intervention, the client will report or indicate pain is relieved or controlled and manifest decreased restlessness and irritability.

•Perform routine comprehensive pain assessment, including location, characteristics, onset, duration, frequency, quality, and severity using some type of rating scale, such as numbers or visual analog, facial expressions, or color scale.

•Accept child’s description of pain, noting precipitating, exacerbating, and relieving factors.

•Assessment of children involves observational skills and may require enlisting the aid of parent or caregiver to clarify cues and verbalizations. Choice of rating scale is dependent on age and developmental level.

•Pain is subjective and cannot be experienced by others. Note: In presence of chronic pain situation, use of a pain diary may be appropriate for adolescents.

-After 30 minutes intervention, the client will report or indicate pain is relieved or controlled and manifest decreased restlessness and irritability.

Pain Scale: 3/10

ASSESSMENTNURSING

DIAGNOSISGOALS and

OBJECTIVESINTERVENTION RATIONALE EVALUATION

•Observe for guarding, rigidity, crying, and restlessness.

•Identify ways to avoid or minimize pain, such as splinting surgical incisions during coughing, sleeping on a firm mattress, or wearing brace on sprains.

•Administer medications, such as opioid and nonsteroidal analgesics, as indicated. Use multiple routes to deliver analgesia, such as oral, nebulized, transdermal, or patientcontrolled analgesia (PCA), as indicated by current situation

•Nonverbal expressions, body movement, and behavioral state may signal pain or changes in pain severity, especially in infants and younger children.

•Many factors may reduce pain intensity based on specific situation. Child can quickly learn and use such pain management techniques, enhancing sense of control as well as comfort.

•Depending on the cause and type of pain, as well as its chronicity, various means of pain management may be needed to overcome or control pain.

ASSESSMENT

NURSING DIAGNOSIS

GOALS and OBJECTIVES

INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:“Nahihirapan ako matulog” as verbalized by the patient.

OBJECTIVES:-Restlessness-Irritability-

Disturbed sleep pattern related

to noisy surrounding

GOAL:After 2 hours of Nursing intervention the patient will be able to achieve optimal amounts of sleep asevidenced by rested appearance,verbalization of feeling rested, andimprovement in sleep pattern.

Assess past patterns of sleep in normalenvironment: amount, bedtime rituals, depth,length, positions, aids, and interfering agents.

Assess patient’s perception of cause of sleepdifficulty and possible relief measures tofacilitate treatment.

Identify factors that may facilitate or interferewith normal patterns

Provide nursing aids (e.g., back rub, bedtimecare, pain relief, comfortable position, relaxation

Sleep patterns are unique to each

individual.

For short-term problems, patients

may haveinsight into the

etiological factors of the problem

(e.g., fear over results of a

diagnostic test,depression over the loss of a loved one).

Knowingthe specific

etiological factor will guide appropriate

therapy.

Considerable confusion and myths

about sleepexist. Knowledge of

its role in health/wellness andthe wide variation among individuals

may allay.

These aids promotes rest.

After 2 hours of Nursing intervention the patient will be able to achieve optimal amounts of sleep asevidenced by rested appearance,verbalization of feeling rested, andimprovement in sleep pattern.

ASSESSMENTNURSING

DIAGNOSISGOALS and

OBJECTIVESINTERVENTION RATIONALE EVALUATION

OBJECTIVES:-Facial Grimace-Irritability-Guarding Behavior

Risk for Infection as evidenced by invasive procedures, skeletal traction.

GOAL:After 3 days of nursing intervention the nurse will be able to achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile.

•Inspect the skin for preexisting irritation or breaks in continuity.

•Assess pin sites/skin areas, noting reports of increased pain/burning sensation or presence of edema, erythema, foul odor, or drainage.

•Provide sterile pin/wound care according to protocol, and exercise meticulous handwashing.

•Pins or wires should not be inserted through skin infections, rashes, or abrasions (may lead to bone infection).

•May indicate onset of local infection/tissue necrosis, which can lead to osteomyelitis.

•May prevent cross-contamination and possibility of infection.

After 3 days of nursing intervention the nurse was able to achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile.

ASSESSMENTNURSING

DIAGNOSISGOALS and

OBJECTIVESINTERVENTION RATIONALE EVALUATION

•Instruct patient not to touch the insertion sites.

•Observe wounds for formation of bullae, crepitation, bronze discoloration of skin, frothy/fruity-smelling drainage.

•Monitor vital signs. Note presence of chills, fever, malaise, changes in mentation.

•Provide wound/bone irrigations and apply warm/moist soaks as indicated.

•Minimizes opportunity for contamination. •Signs suggestive of gas gangrene infection

 •Hypotension, confusion may be seen with gas gangrene; tachycardia and chills/fever reflect developing sepsis. •Local debridement/cleansing of wounds reduces microorganisms and incidence of systemic infection. Continuous antimicrobial drip into bone may be necessary to treat osteomyelitis, especially if blood supply to bone is compromised. 

DISCHARGE PLANNING

Once you meet the discharge criteria specified for your type of surgery, you will be released to go home or be transferred from the recovery room of a hospital to a room. Hospitals usually require that the patient is transported home by a friend or family member, as coordination and reflexes may be impaired for 24 hours following anesthesia. Your discharge plan may include instructions on how to take care of the wound dressings, what medications to take, what exercises to do, and other home care instructions.