ABSCESS I. OBJECTIVES General Objectives: To know condition, how it is manifestations of this disease. the major cause/causes of this acquired, and the major

Specific Objectives: The student should be able to: 1. To know the common cause(s) of this disease. 2. To identify the means by means this disease can be acquired 3. To know the major manifestations of this disease. 4. To know ways on how to prevent the transmission of this disease. II. BACKGROUND OF THE STUDY Abscess occurs when an area of tissue becomes infected and the body's immune system tries to fight it. White blood cells move through the walls of the blood vessels into the area of the infection and collect within the damaged tissue. During this process, pus forms. Pus is the build up of fluid, living and dead white blood cells, dead tissue, and bacteria or other foreign substances. Abscesses can form in almost every part of the body and may be caused by infectious organisms, parasites, and foreign substances. Abscesses in the skin can be easily seen, and are red, raised, and painful. Abscesses in other areas of the body may not be obvious, but if they may cause significant organ damage. This case study will help the student nurse in understanding the disease process of the patient. This will also help the student nurse in identifying the primary needs of the patient with an abscess by identifying the needs and health problems of the patient and 1

formulating an individualized nursing care plan. Effective management of the problem identified will help the patient recover faster and maintain a holistic sense of wellness even while in the hospital. Definition of the Case An abscess is a common infection characterized by a localized accumulation of polymorphonuclear leukocytes with tissue necrosis involving the dermis and subcutaneous tissue. It is also a collection of pus (dead neutrophils) that has accumulated in the cavity formed by the tissue on the basis of an infectious process (usually caused by bacteria and parasites) or other foreign materials (e.g. splinters, bullet wounds, or injecting needles). It is a defense reaction of the tissue to prevent the spread of infectious materials to other parts of the body. An abscess is typically painful and it appears as a swollen area that is warm to touch. The skin surrounding an abscess typically appears pink or red. Signs and Symptoms General signs and symptoms of an abscess includes: Erythema Loss of function Oozing or drainage of a fluid from the skin Pain on or around a lump Peeling or ulcerating skin Redness, warmth or swelling Other symptoms that may occur along with an abscess: Enlarged lymph nodes Fatigue or malaise Fever, chills or sweating Headache Joint pain Loss of appetite or rapid weight loss Nausea, vomiting or diarrhea Sore throat

Common Causes

2

The primary causes of abscess includes: Inflammatory response to an infectious process; invasion of bacteria or parasite such as streptococci or staphylococci Foreign substance within the body (a needle or a splinter) Minor breaks or punctures in the skin Immunosuppressed patients Skin Diseases Poor Hygiene

Incidence Skin abscesses are fairly common. They occur when an infection causes pus and infected material to collect in the skin. During the last decade, the incidence of the skin and soft tissue infections has risen dramatically in the Philippines and skin abscesses caused by methicillin-resistant staphylococcus aureus are largely accountable for this increase. Complications The complications of an abscess vary widely depending on the cause and location. A small skin abscess treated promptly usually does not result in any permanent complications other than a small scar. However, a large abscess or an abscess in an organ can affect underlying tissue or organ function and may possibly cause serious and permanent damage. Because an abscess can be due to serious diseases, failure to seek treatment can result in serious complications and permanent damage. Once the underlying cause is diagnosed, it is important for you to follow the treatment plan that you and your health care professional design specifically for you to reduce the risk of potential complications including: Brain or spinal cord injury Liver damage Nerve damage resulting in weakness or tingling Paralysis Sepsis (widespread infection) or localized spread of infection

3

Treatment Wound abscesses cannot be treated with antibiotics. They require surgical intervention, debridement, and curettage. a. Incision and drainage The abscess should be inspected to identify if foreign objects are a cause, which may require their removal. If foreign objects are not the cause, a doctor will incise and drain the abscess and prescribe painkillers and possibly antibiotics. Surgical drainage of the abscess (e.g., lancing) is usually indicated once the abscess has developed from a harder serous inflammation to a softer pus stage. In critical areas where surgery presents a high risk, it may be delayed or used as a last resort. The drainage of a lung abscess may be performed by positioning the patient in a way that enables the contents to be discharged via the respiratory tract. Warm compresses and elevation of the limb may be beneficial for a skin abscess. b. Packing After drainage, an abscess cavity is often packed. However, there is no evidence to support this practice and it may in fact delay healing. To try to answer this question more definitely, a randomized double-blind study was started in September 2008 and was completed in March 2010. Interim analysis of data from this study suggests that "wound packing may significantly increase the failure rates." A small pilot study has found no benefit from packing of simple cutaneous abscesses. c. Antibiotics As Staphylococcus aureus bacteria is a common cause, an antistaphylococcus antibiotic such as flucloxacillin or dicloxacillin is used. With the emergence of community-acquired methicillin-resistant staphylococcus aureus MRSA, these traditional antibiotics may be ineffective; alternative antibiotics effective against communityacquired MRSA often includeclindamycin, trimethoprimsulfamethoxazole, and doxycycline. These antibiotics may also be prescribed to patients with a documented allergy to penicillin. (If the condition is thought to be cellulitis rather than abscess, consideration should be given to possibility of strep species as cause that is still sensitive to traditional anti-staphylococcus agents such as dicloxacillin or cephalexin in patients able to tolerate penicillin). It is important to 4

note that antibiotic therapy alone without surgical drainage of the abscess is seldom effective due to antibiotics often being unable to get into the abscess and their ineffectiveness at low pH levels. Whilst most medical texts advocate surgical incision some medical doctors will treat small abscesses conservatively with antibiotics.

III. NURSING HISTORY A. Demographic Data Name: Mr. Abs Address: P-4, Calaocan, Santiago City Age: 62 years old Gender: Male Date of Birth: January 17, 1950 Place of Birth: Nueva Ecija Nationality: Filipino Religion: Roman Catholic Civil Status: Separated Educational Attainment: High School Graduate Occupation: Bread delivery and water delivery boy Date of Admission: February 21, 2012 Time of Admission: 3:45 PM Chief Complaint: Swelling of the right buttocks Admitting Diagnosis: Abscess vs. Mass Admitting Physician: Dr. Yambot Attending Physician: Dr. Mabbayad B. Present Health History One week prior to admission, the patient slipped and fell on his buttocks. He then felt an inflammation on his right buttock. His daughter gave him pain relievers and antibiotic specifically Mefenamic Acid, Paracetamol and Amoxicillin. When the pain was relieved, he 5

goes back to work but later, the pain goes back. He then ignores the pain until he couldnt bear it any longer. On February 21, 2012 at exactly 3:45 PM, Mr. Abs was admitted to Southern Isabela General Hospital, his chief complaint was swelling of the right buttock. He was assessed by Dr. Yambot with an admitting diagnosis of Abscess vs. Mass. C. Past Health History Mr. Abs states that he was not fully immunized and he cant remember the vaccines he had received. His first hospitalization was in 1986 at Cagayan Valley Adventist Hospital due to Vehicular Accident at Ariweng, Nueva Viscaya. His stomach was hit by a flat bar and his abdomen was dissected. His left eye protrudes due to the accident, it was re-attached. His left leg was fractured and his orthopedic surgeon Dr. Richard Longid put an external fixator to stabilize and repairs the fractured bone. He stayed in the hospital for six months. In 2010, Mr. Abs was admitted at Southern Isabela General Hospital due to penetrating and puncture wounds on the pelvic and thoracic region. He stated that he was drunk that day, had a fight and was stab by his relatives. He also experienced common illnesses like cough, colds, headaches and fever and he managed them through over-the-counter drugs. D. Family Health History Mr. Abs had no family history of Diabetes Mellitus, Cancer, Hypertension, Asthma, and Allergies. E. Social History Mr. Abs claims that he had vices; smoking and drinking alcohol. He started smoking when he was 15 years old, consuming 4 sticks of cigarette (Philip) per day. At the same age, he starts drinking alcohol (Ginebra San Miguel) three times a week (approximately 400ml). In 2000, he increases his frequency in smoking and drinking alcohol. From 4 sticks turned to 20 sticks per day. The approximate 400ml per week turned to 350ml per day. These incidences are all related to family problem such as his separation with his wife as he stated. In addition, Mr. Abs no longer stays with his family but he lives with his cousin. He doesnt attend to barangay meetings because he travels a lot in his job as dealer. 6

F. Gordons 11 Functional Health Pattern Health Perception and Health Management Pattern Mr. Abs claimed that before hospitalization, he viewed health as a complete wellness and managed it by eating nutritious foods. He said that he suffered common illness such as fever, cough, headache, and colds. He managed those by taking OTC drugs such as Paracetamol, Salbutamol, and Neozep and stops whenever he feels good. When he experienced pain, he takes Paracetamol, Amoxicillin, and Mefenamic Acid when he cant tolerate it. During hospitalization, he claimed that he is not healthy. He manages his condition by obeying the doctors and nurses order and advice.

Nutritional Metabolic Pattern Before hospitalization, Mr. Abs never skips meals and has good appetite. He drinks coffee twice a day (AM and PM) approximately 250 ml and eat trice a day. Usually, he consumes three cups of rice, he eat fruits, vegetables and all the kinds of meat. He loves to eat beefsteak. He can consume approximately 1800ml of water a day and 350 ml of alcohol (GSM and Emperador Lights) per day, it starts in year 2000. During hospitalization, Mr. Abs was on DAT diet for 10 days, he ate what they serve and consumed 1000ml of oral and parenteral fluid for 24 hours, with an on-going IVF of PNSS regulated at 10 gtts/min. On March 3, 2012 he was on NPO diet in preparation for I and D (Incision and Drainage). Elimination Pattern Before hospitalization, the patient usually urinates approximately seven times a day for 24 hours about 900 ml, crystal in color with no associated pain felt upon urination. He usually defecate twice a day (AM and PM), solid and formed, brown in color with no associated pain upon defecation. During hospitalization, Mr. Abs usually urinates five times and approximately 700ml for 24 hours, yellow orange in color with pain upon urination. He usually defecates once a day, formed and light brown in color with pain upon defecation. 7

Activity Exercise Pattern Before hospitalization, Mr. Abs can perform his activities of daily living (ADL), such as fetching water for the neighbors, he considers this as his form of exercise, delivery of bread to places like Quirino and Aurora Province, dish washing and cooking. During hospitalization, he cannot perform activities of daily living. Mr. Abs spends all his time lying on bed from side to side and makes conversation with his daughter. He uses assisted walking device such as cane when going to the bathroom to defecate and urinate. Mr. Abs cant tolerate standing for a long period of time because of pain. Sexuality and Reproductive Pattern Mr. Abs is 62 year old male and married in January 17, 1971. They had seven children and did not use any contraceptive methods. In the year 2000, Mr. Abs and his wife end their relationship in separation. He was circumcised when he was 9 years old in traditional method called pukpok.

Sleep Rest Pattern Before hospitalization, Mr. Abs usually sleeps at around 8:00 in the evening and felt rested when waking up at 6:00 in the morning. His total number of sleep is approximately 12 hours. This was interrupted when he urinates. He claimed that he had no problems in sleeping. During hospitalization, his sleep rest pattern was disturbed because of pain. He usually sleeps at 7:00 in the evening and feel unrested when he wakes up at 4:00 in the morning. His total number of sleep is 9 hours. He prefers sleeping in the left side and uses a pillow on the affected buttock to promote comfort. He usually naps for two hours in the afternoon. Cognitive Perception Pattern Mr. Abs is conscious and coherent, oriented to time place, person and events. He can understand and able to speak English and Tagalog. He can feel pain and manage them with OTC drugs. He can smell and respond to normal voice and responds to stimulus. He finished his elementary education at Nueva Ecija and high school at Tondo, Manila. His highest educational attainment is high school. 8

During hospitalization, he was uncomfortable because of pain. He uses eye glasses with a grade of 500 due to blurring of vision especially on his left eye. He can easily learn and perceived all the question asked and had no signs of memory impairment. Self-Perception Self Concept Pattern Before hospitalization, he views himself as a functional individual because he can able to do all his task and attend to his work. He is confident and felt good most of the time. He is hot-tempered and whenever he gets irritated, he shouts to relieve what he felts. He handles problems through his vises. During hospitalization, Mr. Abs views himself not as functional as before because he is unable to attend his work. He is irritated of the pain, bored and wants to go home. He believed and hoped that he get well soon. Role Relationship Pattern Mr. Abs was a father of 7 children, three boys and four girls. He is separated to his wife and lived with his cousin. Before the separation, he and his wife talk and fixed their problem. When he was a bus driver before, he cant get along with his co-drivers or sometimes to the passengers. During hospitalization, he obeys doctors and nurses advise for fast recovery. He claimed that he was a good patient. Coping Stress Pattern Before hospitalization, whenever he had a problem or when he was under stress, he diverts them by resting, drinking alcohol, and smokes. When he feels exhausted, he usually sleeps. During hospitalization, he cant get enough sleep because of pain and discomforts on elimination. He claimed that he didnt usually pray. Value Belief Pattern Mr. Abs claimed that he only attends mass during birthdays and prays occasionally whenever there is a big problem. He doesnt believed quack doctors and herbal medicine.

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G. Physical Assessment Date: March 3, 2012 Time: 12:00 PM Vital Signs: T: 36.5 C CR: 68 bpm RR: 19 cpm BP: 130/80 mm Hg General Appearance: Received patient lying on bed, conscious and coherent, alert and oriented to person, time and place with an ongoing IVF of PNSS regulated at 10 gtts/min, inserted at the left arm, intact and infusing well. The patient is well groomed. Body Parts Head Hair Inspection Evenly distributed Presence of white Normal. Related to

Method

Normal

Findings

Interpretatio n

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hair Scalp Inspection No lesions No infection and infestation Round Firm; absence of nodules and masses PERRLA Pinkish in color; teary;

aging process Normal

Skull

Inspection Palpation

Round Firm; absence of nodules and masses

Normal Normal

Eyes Pupils Conjuncti va and sclera Inspection Inspection PERRLA No color alterations and inflammati ons Clear vision

Normal Normal Abnormal. Related to history of proptosis Abnormal. Related to history of proptosis

Vision Eye glass: Grade 500

Visual Acuity

Blurred vision on left eye

Ears Inspection The same color with the body and free of any lesions Dry cerumen Smooth; no evidence of lumps and masses; the pinna recoils The same color with the body and no lesions Dry cerumen Smooth; no lumps and masses; the pinna recoils Normal

Palpation

Abnormal related lack of self-care Normal

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Nose Patency

Inspection

Inspection

when folded Midline; equal color to the face Nares are equal in size; no discharge Symmetric al No evidence of sores and inflammati on Movable; have the ability to swallow and speak 32 permanent teeth; no cavities and tartars The same color with the body; free of lesion Absence of nodule and masses The same coloration with the body; free of lesion Presence of vibrations Full and symmetric

In midline; equal color Nares are symmetric al with no discharge Symmetric al No sores and lesions Movable. The patient can swallow and speak 2 teeth on the upper part and 11 on the lower part Same color with the skin; no lesions No palpable nodules and masses Same color to the body; no lesions

Normal

Normal

Mouth Lips Gums Tongue

Inspection Inspection

Normal Normal

Inspection

Normal

Teeth

Inspection

Normal. Related to aging

Neck

Inspection

Normal

Palpation

Normal

Chest

Inspection

Normal

Tactile fremitus Chest excursion

Inspection Inspection

Presence of vibration Full and

Normal Normal

12

Auscultati on

chest expansion Heart and breath sounds are heard

Abdomen

Inspection

Auscultati on

The same color with the body; free of lesion Presence of burburygm ic sounds

symmetric chest expansion No adventitio us breath sounds RR = 19 CR = 68 The same color to the body; no lesion Presence of burburygm ic sounds in 3 seconds

Normal

Normal

Abnormal related to increase motility because patient is in NPO Normal

Palpation Inspection

Absence of tenderness The same color with the body Symmetric al; the same muscle strength The same color with the body No tenderness Same color to the body; no lesions Symmetric al; the same muscle strength Redness and swelling on the right buttock Not symmetric

Upper extremities

Normal Normal

Lower extremities

Inspection

Abnormal. Related to release of inflammatio n mediators secondary to fracture. Abnormal. Right buttock is bigger than the left related to

Symmetric al

13

Absence of tenderness

Palpation

al Left thigh=48c m Right thigh=38c m No palpable masses

Skin

Inspection

Good complexio n; no lesions No evidence of any alteration Prompt return pink or usual color (0-3 seconds)

Nails

Inspection

Tendernes s on the right buttock. Warmth With hematoma at the right brachial area No evidence of any alteration Prompt return pink or usual color (2 seconds)

swelling. Right thigh is smaller related to atrophy because of decrease perfusion secondary to abscess formation Abnormal related to lactic acid formation and released of inflammator y mediators

Abnormal related to blood extraction for FBS Normal

Blanch test for capillary refill

Inspection

Normal

Pain Assessment P Pain when the patient moves, mobilizing the affected part Q Stabbing pain R Radiation to the right lower leg S Pain scale 9 T Intermittent, usually in the afternoon

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IV. COURSE IN THE WARD Date: February 21, 2012 Doctors Order 3:45 PM BP: 150/90 Please admit to ward Secure consent TRP every shift

DAT CBC, Creatinine

PNSS 1L X KVO

Ketorolac 1 amp IV q 8

Cefuroxime 750 mg IV q 8 ANST

Ranitidine 1 amp IV q 8

Nursing Responsibility To provide comfort Inform patient about it and privacy to the for them to choose patient during his stay what room they want in the hospital To have all the Assist and be a intervention legal and witness during signing to have proof of consent To serve as a baseline Monitor and record data patients vital signs. To determine any Report any changes in patients abnormalities. vital signs To achieve nutritional Inform patient about demands the foods that he can eat Laboratory exams Inform the patient and serve as further SO about the test. assessment to Accompany patient to patients condition. the Laboratory Department. To keep venous open, Check doctors order. serves as an access Regulate at 10 for routes of gtts/min medicine. For fluids Check if intact and and electrolytes infusing well. maintenance For short-term Check doctors order. management of pain Observe 11Rs of safe drug administration. Check for any side effects. To stop infection Check doctors order. caused by bacteria Observe 11Rs of safe drug administration. Check for any side effects. To prevent ulcers Check doctors order. Observe 11Rs of safe drug administration. 15

Rationale

Check for any side effects. Date: February 21, 2012 10:35 PM BP: 160/100 Warm compress over To relax the muscle, right buttocks three increase blood flow, times a day for 15 and relieve pain minutes Catapres 75 mcg 1 To decrease blood tab SL now pressure.

Measure the temperature of the water to prevent scalding. Assist the patient during warm compress. Check doctors order. Observe 11Rs of safe drug administration. Check for any side effects. Check BP and PR

Date: February 22, 2012 2:55 PM To inhibit ACE. BP: 160/100 To decrease blood Captopril 25 mg 1 tab pressure. SL now

Check doctors order. Observe 11Rs of safe drug administration. Check for any side effects. Check BP 10:20 PM To inhibit Check doctors order. BP: 150/90 vasoconstriction to Observe 11Rs of safe Losartan 50 mg 1 tab decrease blood drug administration. OD pressure. Check for any side effects. Check BP Date: February 23, 2012 8:25 AM For operation of the To allow drainage of Inform the patient right buttock the abscess SO about procedure 1:40 PM For I and D To allow drainage of Inform the patient the abscess SO about procedure Request ultrasound on To detect and Inform the patient right buttock diagnose whether SO about the test masses are solid or

and the and the and

16

fluid Date: February 24, 2012 8:00 AM BP: 150/90 Because of the Increase blood Defer I and D until patients increased pressure may alter with ultrasound result blood pressure the procedure Date: February 26, 2012 4:00 PM Blood Typing stat To identify the type of blood in case blood transfusion is to be done Stand by PRBC 2 units For possible blood for possible OR use transfusion For I and D Notify anesthesiologist Notify OR team BP: 210/100 Defer OR DAT To allow drainage of the abscess To be prepared on the procedure To prepare the operating room Because of the patients increased blood pressure To achieve nutritional demands

Inform the patient and SO about the test and accompany the patient in the laboratory department Inform the patient and SO to look for compatible blood donors Inform the patient and SO about the procedure Allow the NOD to notify the anesthesiologist Allow the NOD to notify the OR team Increase blood pressure may alter the procedure Inform patient about the foods that he can eat Inform the patient and SO about the test

Date: February 28, 2012 1 PM To obtain electrical For ECG currents of the heart. To diagnose dysrhythmias, conduction abnormality, myocardial ischemia, injury and infarction. Check, K, Na, FBS in To serve as a baseline AM data

Inform the patient and SO about the test and 17

To determine imbalance electrolytes, blood glucose

any accompany the in patient in the and laboratory department

Date: February 29, 2012 3 PM To inhibit calcium ions BP: 160/100 on cardiac and Amlodipine 5mg OD smooth muscle cells. PM To decrease blood pressure. Check protein albumin or To determine imbalance and a determinant if there is an edema For further assessment and diagnosis of the patients condition

X-ray pelvic area rule out osteosarcoma vs osteomyelitis Suggest Cefuroxime to Ceftriaxone 1g q 12 IV ANST Clindamycin 150 mg QID PO

Check doctors order. Observe 11Rs of safe drug administration. Check for any side effects. Check BP Inform the patient and SO about the test and accompany the patient in the laboratory department Inform the patient and SO

Do wound drainage

To stop infection Check doctors order. caused by bacteria Observe 11Rs of safe drug administration. Check for any side effects. To stop infection Check doctors order. caused by bacteria Observe 11Rs of safe drug administration. Check for any side effects. To allow drainage of Inform the patient and the abscess SO about the procedure. Assist in the procedure Check doctors order. Observe 11Rs of safe drug administration. Check for any side effects. Check BP inhibit Check doctors order. 18

Date: March 1, 2012 10:32 AM To inhibit calcium ions BP: 130/80 on cardiac and Amlodipine 5 mg 1 smooth muscle cells. tab 6 AM To decrease blood pressure. Losartan 50 mg 1 tab To

6 AM

TPR every 2 hours

vasoconstriction to Observe 11Rs of safe decrease blood drug administration. pressure. Check for any side effects. Check BP To serve as a baseline Monitor and record data patients vital signs. To determine any Report any changes in patients abnormalities. vital signs Pre-operative management. Advised not to ingest food and fluids until told To allow drainage of Inform the patient and the abscess SO about the procedure To be prepared on the Allow the NOD to procedure notify the anesthesiologist To prepare the Allow the NOD to operating room notify the OR team

Date: March 2, 2012 5:53 PM NPO post-midnight Schedule for I and D tomorrow AM Notify anesthesiologist Notify OR team

V. DIAGNOSTIC PROCEDURES HEMATOLOGY 2012 Parameters Hgb FEBRUARY Normal Value 13.0 18.0 Result 12.1 22,

Interpretation Abnormal related to inflammation and abscess formation. 19

Hct

40.0 54.0

35.2

Decrease tissue perfusion Normal FEBRUARY Interpretation Normal

CLINICAL CCHEMISTRY REPORT 22, 2012 KIDNEY Normal Value Result FUNCTION Creatinine 73 133 umol/L 76

URINALYSIS 22, 2012 Parameters Pus cells RBC

FEBRUARY Normal Value 0-2/HPO 0-2/HPO Result 5-8HPO 0-3/HPO Interpretation Presence of infection Bacterial infections, parasitic infections, traumatic injuries, and tumors.

ULTRASOUND OF THE RIGHT BUTTOCKS FEBRUARY 25, 2012 There is a thick walled fluid collection within the right buttock almost measuring 300 cc consider Abscess Sonologist: Rose Angelie Joy C .Lim, MD

HEMATOLOGIC REPORT 26, 2O12 BLOOD TYPING

FEBRUARY O+ 20

CLINICAL CHEMISTRY REPORT 29, 2012 Electrolyte Normal Value K 3.5 5.0 mmol/L Na 135 145 mmol/L Liver Function Albumin 35 50 g/L

FEBRUARY Result 4.03 139.46 Interpretation Normal Normal

20.9

Abnormal related to decrease plasma protein Normal

Glucose FBS

70 145 mg/dL

108

VI. ANATOMY AND PHYSIOLOGY 21

A. Integumentary System The integumenatry system is the organ system that protects the body from damge, comprising the skin and its appendages. It is the largest organ system. Functions of the integumentary system: 1. Protects the body against invasion by infectious organisms. 2. Protects the body from dehydration. 3. Protects the body against abrupt changes in temperature. 4. Helps excrete waste materials through perspiration. 5. Acts as receptor for touch, pressure, pain, heat and cold. 6. Generate vitamin D through the exposure to UV rays. 7. Stores, fat, glucose and Vitamin D. The 3 layers of the skin includes: a. Epidermis - Top layer of the skin made up of epithelial cells. Main job is protection, absorption of nutrients and homeostasis. b. Dermis - Dense connective tissue that makes up the dermis contains fibroblasts, fat cells and macrophages. c. Hypodermis - Layer of tissue directly underneath the dermis. Functions include insulation, storage of energy and aiding in the anchoring of the skin. It also cushions the underlying body for extra protection against trauma. B. Lymphatic System The lymphatic system is composed of the tissues and the organs that produce, store and carry WBC that fight infections and other disease. This system includes the bone marrow, spleen, thymus, lymph nodes and lymphatic vessels that branch into all tissues of the body. Functions of the lymphatic system includes: 22

1. 2. 3. 4.

Filtering out organisms that cause disease. Produces certain WBCs and generate antibodies Distribution of fluids and nutrients in the body Fat absorption in the digestive tract

Lymph is a milky body fluid a type of WBC, called lymphocytes, along with proteins and fats. Lymph seeps outside the blood vessels in spaces of the body tissue and is stored in the lymphatic system to flow back into the bloodstream. Through the flow of blood in and out of the arteries, and into the veins, and through the lymph nodes and into the lymph, the body is able to eliminate the products of cellular breakdown and bacterial invasion. Two very large areas are of significance to this system: 1. Right lymphatic duct drains lymph fluid from the upper right quarter of the body above the diaphragm and down the midline. 2. Thoracic duct a structure, roughly 16 inches long located in the mediastinum of the pleural cavity which drains the rest of the body. It is through the action of this system, including the spleen and the thymus, the lymph nodes and the lymph ducts that our body is able to fight infection and ward off infection from foreign invaders. The lymphatic vessels are present wherever there are blood vessels and transport excess fluid to the end of vessels without the assistance of any pumping action. There are 100 tiny, oval structures (called lymph nodes) in the body. These are mainly in the neck, groin and armpits, but are scattered along the lymph vessels. They act as barriers to infection by filtering out and destroying toxins and germs. The largest body of lymphoid tissue in the human body is the spleen.

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VII. PATHOPHYSIOLOGY OF ABSCESSPredisposing Factors Age Gender Family History (Diabetes Mellitus) Etiologic Agent Staphylococcu s aureus Precipitating Factors

Inflammatory response to an infectious process(invasion of bacteria or parasite) Foreign substance within the body (a needle or a splinter) Minor breaks or punctures in the skin Immunosuppressed patients Skin Diseases Poor Hygiene

Trauma/Injury

Invasion of Bacteria in the site (Staphylococcus aureus) Inflammatory response

Vascular Response

Cellular Response

24

Arteriols and Venules dilates

Mast cell releases inflammatory mediators

WBC, neutrophils, and other molecules adheres to the endothelial cell Pavementing of neutrophils

Congestion Increase capillary permeability

Histamin e

Serotoni n

Bradyki nin

Prostaglan din

Leakage of fluid out of the vessel

Localized edema Swelling

Plasma moves outward Viscous blood and flows more slowly

Dilation of blood vessels and Increase permeabilit y Erythem a

Increase permeability and stimulates pain receptors

Increase vascular permeability

Neutrophils moves outside the blood vessel

Chemotaxi s Neutrophils adhere to the bacteria (increase opsonin) Engulfment of the bacteria Formation of cellular exudates Swelling Neutrophil dies

Increase blood flow and RBC concentration on the site Warmth Erythema

25 Pus Formation

Decreas e renal perfusio n

ABSCESS FORMATION Erythema Swelling Tenderness Pain Stiffness Loss of function Warmth

Increa se BP

Activation of RAAS

Obstruction of blood flow Decrease tissue perfusion Anaerobic metabolism

Stimulation of the Sympathetic Nervous

Increas e C02

Lactic acid formation

Pain

Necrosi s

VIII. DRUG STUDY 26

Drug Name Cefuroxime 750 mg IV q 8 Brand Name: Zinacef

Classificati on Pharmacolog ic Class: secondgeneration cephalospori n Therapeutic Class: antibiotic

Action Secondgeneration cephalospori n that inhibits cellwall synthesis, promoting osmotic instability; usually bactericidal.

IndicationSerious lower respiratory tract infection, UTI, skin or skinstructure infections, bone or joint infection, septicemia, meningitis, and gonorrhea Acute bacterial maxillary sinusitis Pharyngitis and tonsillitis Otitis media Uncomplica ted skin and skin structure infection

Contraindic ation Contraindicat ed in patients hypersensitiv e to drug or other cephalospori ns.

Adverse Effect CV: phlebitis, thrombophlebit is. Hematologic: transient neutropenia, eosinophilia, hemolytic anemia, thrombocytope nia. Skin: maculopapular and erythematous rashes, urticaria, pain, induration, sterile abscesses, temperature elevation, tissue sloughing at I.M. injection site.

Nursing Responsibil ity Before giving drug, ask patient if he is allergic to penicillins or cephalospo rins. Absorption of oral drug is enhanced by food. Monitor patient for signs and symptoms of super infection.

27

Drug Name Ranitidine 1 amp IV q 8 Brand Name: Zantac

Classificati on Pharmacolog ic Class: H2 receptor antagonist Therapeutic Class: antiulcerative

Action Competitivel y inhibits action of histamine on the H2 at receptor sites of parietal cells, decreasing gastric acid secretion.

IndicationActive duodenal and gastric ulcer Maintenance therapy for duodenal or gastric ulcer Gastroesopha geal reflux disease Heart burn

Contraindic ation Contraindicat ed in patients hypersensitiv e to drug and those with acute porphyria. Use cautiously in patients with hepatic dysfunction. Adjust dosage in patients with impaired renal function.

Adverse Effect CNS: vertigo, malaise, headache. EENT: blurred vision. Hepatic: jaundice. Other: burning and itching at injection site, anaphylaxis, angioedema.

Nursing Responsibil ity Assess patient for abdominal pain. Note presence of blood in emesis, stool, or gastric aspirate. Instruct patient to take without regard to meals because absorption isn't affected by food. Advise patient to report abdominal pain and

28

blood in stool or emesis.

Drug Name Ceftriaxone 1g IV q 12 Brand Name: Rocephin

Classificatio n Antiinfective, Antibiotic

Action Semisyntheti c third generation cephalospori n antibiotic. Preferentially binds to one or more of the penicillinbinding proteins located on the cell walls of susceptible organisms. This inhibits third and final stage of bacterial cell wall

Indication Effectively treats bone and joint infections, otitis media, pelvic inflammatory disease, proteuse infections, septicemia, skin and soft tissue infections, UTI and is used for surgical prophylaxis, reducing or eliminating infection

Contraindic ation Contraindicat ed in patients hypersensitiv e to cephalospori ns and related antibiotics

Adverse Effect Body as whole: Pruritis, fever, chills, pain GI: Diarrhea, abdominal cramps Urogenital: Genital Pruritis

Nursing Responsibili ty Determine history of hypersensit ivity reactions Inspect injection sites for induration and inflammati on. Monitor for manifestati ons of hypersensit ivity and report appearance Check for fever if 29

synthesis, thus killing the bacterium.

diarrhea occurs

Drug Name Amlodipine 5 mg OD PRN Brand Name: Norvasc

Classificatio n Pharmacologi c Class: calcium channel blocker Therapeutic Class: antianginal, antihyperten sive

Action Inhibits calcium ion influx across cardiac and smoothmuscle cells, dilates coronary arteries and arterioles, and decreases blood pressure and myocardial oxygen demand.

Indication Chronic stable angina, Hypertension

Contraindic ation Contraindicat ed in patients hypersensitiv e to drug. Use cautiously in patients receiving other peripheral vasodilators, especially those with severe aortic stenosis, and in those with heart failure.

Adverse Effect CNS: headache, somnolence, fatigue, dizziness, lightheadedness, paresthesia. CV: edema, flushing, palpitations. GI: nausea, abdominal pain. Skin: rash,

Nursing Responsibili ty Monitor blood pressure frequently during initiation of therapy.

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pruritus. Drug Name Clindamycin 150 mg QID Brand Name: Cleocin Classificati on Therapeutic Class: antiinvectives Action Inhibits bacterial protein synthesis by binding to the 50s subunit of ribosome. Indication Infection caused by bacteria, pelvic inflammatory disease, pneumonia Contraindic ation Contraindicat ed in patients hypersensitiv e to drug. Adverse Effect CV: thrombophlebit is, thrombocytope nia, eosinophilia Gi: nausea, vomiting, diarrhea, abdominal pain Hepatic: Jaundice Skin: rash, ulticaria Drug Name Ketorolac 30 mg IV q 8 PRN Brand Name: Toradol Classificatio n Non-steroidal antiinflammatory drugs (NSAIDs) Action Inhibition of prostaglandin synthesis by competitive blocking of the enzyme cyclooxygena Indication Indicated for short-term management of pain (up to five days maximum). Contraindic ation Adverse Effect

Nursing Responsibili ty Monitor for systemic complicatio ns Advise patient to take drug with a full glass of water to prevent esophageal irritation Instruct the patient to report adverse reactions

Nursing Responsibili ty Contraindicat Gastrointesti Instruct the ed in patients nal ulceration patient that it hypersensitiv and bleeding should be e to drug. Renal taken every toxicity, 4-6 hours on sodium and a schedule or fluid as needed for 31

se

retention, decreased renal perfusion, and decreased renal function. Heart attack or stroke

pain. May take with food to reduce GI upset In pregnant women this drug should not be used in the 2nd or 3rd trimester of pregnancy

Drug Name

Classificatio n

Action Unknown. Thought to stimulate alpha2 receptors and inhibit the central vasomotor centers, decreasing

Indication Severe cancer pain that is unresponsive to epidural or spinal opiate analgesia or other more conventional methods of analgesia,

Contraindic ation Contraindicat ed in patients hypersensitiv e to drug.

Adverse Effect CNS: drowsiness, dizziness, fatigue, sedation, weakness, malaise, agitation, depression.

Nursing Responsibil ity Monitor blood pressure and pulse rate frequently. Advise patient that stopping drug

Clonidine 75 Pharmacologi mcg 1 tab c Class: SL now centrally acting alpha Brand agonist name: Therapeutic catapres Class: antihyperten sive

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sympathetic Pheochromocyto outflow to ma, Migraine the heart, prophylaxis kidneys, and peripheral vasculature, and lowering peripheral vascular resistance, blood pressure, and heart rate.

CV: orthostatic hypotension, bradycardia, severe rebound hypertension . Skin: pruritus, dermatitis with transdermal patch, rash.

abruptly may cause severe rebound high blood pressure. Tell patient to take the last dose immediatel y before bedtime. Inform patient that dizziness upon standing can be minimized by rising slowly

Drug Name Losartan 50 mg 1 tab OD Brand Name: Coozar

Classificatio n Pharmacologi c Class: angiotensin II receptor antagonist

Action Inhibits vasoconstrict ive and aldosteronesecreting

Indication Hypertension , Nephropathy in type 2 diabetic

Contraindic ation Contraindicat ed in patients hypersensitiv e to drug. Breast-

Adverse Effect CNS: dizziness, asthenia, fatigue, headache,

Nursing Responsibili ty Monitor patient's BP closely to evaluate effectivene ss of

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Therapeutic Class: antihyperten sive

action of angiotensin II by blocking angiotensin II receptor on the surface of vascular smooth muscle and other tissue cells.

patients , To reduce risk of stroke in patients with hypertension and left ventricular hypertrophy

feeding isn't recommende d during losartan therapy.

insomnia. CV: edema, chest pain. Other: infection, flulike syndrome, trauma, diabetic neuropathy, diabetic vascular disease, angioedema.

therapy. Monitor patients who are also taking diuretics for symptomati c hypotensio n.

IX. NURSING CARE PLAN Date Performed: March 02, 2012 Assessment Nursing Diagnosis Subjective: Acute pain related Masakit ang puwet to increased

Planning After 30 minutes of nursing intervention

Interventions Monitored patients vital

Rationale For baseline data and check

Evaluation After 30 minutes of nursing intervention 34

ko as verbalized by permeability and patient stimulation of pain receptors secondary pain scale rated to release of inflammatory at 9/10 mediators Objective: (+) facial grimace (+) guarding behavior Less movement noted on right leg as compared to the left leg Pain assessment: P movement Q stabbing R radiating to the right leg S pain scale of 9/10 T intermittent. Usually starts in the afternoon

the pt. pain scale will be reduced from 9 to 2

signs performed pain assessment

for changes to know pertinent data regarding pain experienced by the pt to implement appropriate interventions to reduce pressure on right buttocks and reducing pain relieves pain by promoting muscle relaxation, increasing circulation, and promoting psychologic relaxation to temporarily divert the patients attention from the pain

the goal is met as evidenced by pain scale reduced from 9 to 2.

provide comfort measures such as placing pillow under the right buttocks and placing warm compress over affected area of pain

encouraged diversional activities such as talking with family and

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friends administer ketorolac 30mg I.V. as ordered informed patient when some procedures may cause pain to relieve pain

to gain patients cooperation and understanding

informed S.O. to help prevent on ways to assist aggravation of pt. in activities the pain of daily living

Date Performed: March 02, 2012 Assessment Nursing Diagnosis Subjective: Ineffective tissue Nahihirapan akong perfusion related to maglakad as obstruction

Planning After 2 days of nursing intervention the patient will have

Interventions Monitored vital signs

Rationale > For baseline data and check for changes

Evaluation After 2 days of nursing intervention the goal is met as 36

verbalized by patient patient verbalizes pain on right buttocks when placing pressure on right foot when walking Objective: (+) limp when walking (+) use of cane when walking Right thigh circumference smaller than left thigh ( R: 38inches, L: 48inches) Abscess on right buttocks Signs of inflammation on right buttocks: pain, swelling, redness, and heat Rigid right buttocks Clotting time?

secondary to abscess formation

increased tissue perfusion on the right buttocks

determine duration of problem ascertained characteristics of pain: such as pain is aggravated by movement observed nonverbal cues measured right thigh circumference assessed affected area provide comfort measure such as placing pillow under the right buttocks performed assistive raonge of motion exercise administered

to note degree of evidenced by removal of impairment obstruction and increased tissue > to note degree perfusion of impairment

to further assess the affected area to assess for tissue perfusion for assessment to reduce pain

to promote circulation

to relieve pain 37

ketorolac 30 mg I.V. as ordered Patient has undergone I&D in O.R. encouraged ambulation when possible discouraged sitting or standing for a long period of time encouraged patient to quit smoking to drain abscess

to promote circulation to avoid thrombosis

to avoid vasoconstriction

Date Performed: March 02, 2012 Assessment Nursing Diagnosis Subjective: Altered physical

Planning After 2 days of

Interventions determine

Rationale to formulate plan for

Evaluation After 2 days of 38

Hindi ko masyadong maigalaw ang kanang paa ko as verbalized by patient. Objective: limited movement on right leg slowed movement as compared to left leg (+) limp when walking (+) use of cane when walking Right thigh circumference smaller than left thigh ( R: 38inches, L: 48inches) Abscess on right buttocks Signs of inflammation on right buttocks: pain, swelling, redness, and

mobility related to decreased muscle strength secondary to abscess formation

nursing diagnosis that intervention the contributes to patient will be able immobility to increase movement in assess degree of affected area pain on affected area observed for nonverbal cues

assessment

to identify contributing factors to note any incongruencies on report of abilities

nursing intervention the goal is met as evidenced by removal of obstruction and increased physical mobility.

determine degree to assess functional of immobility ability

note feelings of emotional/behavi frustration/powerless oral responses to ness may impede problems of attainment of goals immobility assist or have enhances selfpatient reposition concept and sense of self on a regular independence schedule as dictated by the situation placed pillow under the right to reduce risk of pressure ulcers 39

heat Flaccid right leg

buttocks administer ketorolac 30mg i.v. as ordered Patient has undergone I&D in O.R. to relieve pain

to drain abscess

encouraged to promote participation in independence and a activities of daily form of exercise to living promote circulation performed to promote to assistive range of promote circulation motion exercises and avoid risk for complications of immobility encouraged enhances S.O.s commitment to plan, involvement in optimizing outcomes the interventions review individual dietary needs X. DISCHARGE CARE PLAN Medication 40 to identify food to be eaten to obtain optimum recovery

Informed patient of medications that will be taken at home including dosage and frequency. Educated patient on benefits of compliance to drug regimen. Exercise Instructed patient to continue his work when he is able and to perform exercises to optimize health. Treatment Instructed the patient to comply with the treatment regimen with regard to the medications ordered by the doctor. Hygiene Educated patient on the importance of proper hygiene especially on the site of surgery. OPD Instructed the patient to have a follow up checkup after 1 week Diet Educated the patient on food that he can eat to optimize healing and promote wellness. Spirituality Informed patient to continue attending holy mass and encouraged praying because it helps to have faith in God.

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