Case Study wound Abscess

I. Introduction On January 19, 2015, during our hospital visit to the Surgery ward of Mary Johnston Hospital, there were 7 patients admitted. Of those 7 patients, four were admitted due to diabetic complications. According to the International Diabetes Federation, the Philippines is one of the world’s emerging diabetes hotspots – ranked at 15 – which is home to more than 4 million people diagnosed with this disease. In 2014, there were 571,000 deaths related to non-communicable diseases, including diabetes [WHO 2015]. And of those deaths, 6% of those deaths (between the ages of 30 to 70) were due to diabetes [WHO 2015].
As Filipino citizens, this is significant data, especially when you consider that the Philippines is only a developing country. Worsened by the fact that diabetes is a chronic disease, the Philippine healthcare system will have to shoulder the task of helping the Filipino people prevent and manage the disease. In addition, the Philippine economy will suffer because our working-age citizens, instead of performing their jobs and functions as often and as best they could, may have to divide their time for the workplace to receive diabetic management and treatments.
As student nurses, this is also significant. When we were 2nd years, we were regularly assigned to the Outpatient Department (Dispensary) of the Mary Johnston Hospital. Every Wednesday, the hospital’s Diabetes Club would gather and get their regular check-up, including the taking of their blood pressures, blood sugar and cholesterol. And now as 3rd years, we are regularly assigned to the Medicine and Surgery wards of the same hospital, and unfortunately see a few of the club members there due to complications brought on by diabetes. That is why we – Pearlie, Kaye and Bianca – decided to focus our case study on foot abscess. If this case study can at least make the three of us better teachers to our patients, then this would assist in our goal of helping the Filipino people be more aware of Diabetes, and hopefully, prevent further occurrences of the disease in the Philippines.

II. Demographics
Name: D.I.D.G.
Age: 64 years old
Gender: Male
Marital Status: Married
Religion: Roman Catholic
Address: Tondo, Manila
Occupation: Unemployed/Retired
Educational Attainment: 2nd year of high school
Date of Admission: January 17, 2015 (10:45 AM)

III. Nursing History

Present Health History
Three days prior to admission, the patient felt sharp pain on his right foot. Because he did not want to miss the party at his house, he did not seek any consultation.
A few hours prior to admission, the patient felt the pain on his right foot increase in severity until he could no longer tolerate the pain. He was then rushed to the ER Department and then admitted.

Past Health History
Allergy: (-) Asthma; (-) Food allergies; (-) Drugs and blood transfusion; (-) Allergies of unknown cause; (-) Family history.
Immunizations: Incompletely vaccinated or cannot remember what he received; received Tetanus Toxoid shot in the ER Department (January 17, 2015)
Childhood Illnesses: All before high school = (+) Chickenpox; (+) German Measles; (+) Measles; (+) Mumps
Surgery: Incision & Drainage of right foot (January 18, 2015)
Family History: (+) Hypertension on both sides of family
Current Illnesses: (+) Type-2 diabetes (since 2000 and poorly controlled); (+) Hypertension (since 2000)
Medication: Calcibloc, Metformin; Nalbuphine
Vices: (+) Occasional alcoholic beverages; (-) Smoker; (+) Fatty foods

IV. Gordon 's Functional Health Pattern
Health Perception & Health Management
“Hindi na ako healthy kasi madami na ang sakit ko,” as stated.
“Kung may edad na, hindi na malusog o malakas,” as stated.
Has regular check-ups with Dr. Alex Tan in his clinic in Moriones.
Complies with anti-hypertensive medications.
Manages his Type-2 diabetes poorly.
Nutrition & Metabolism
Before:
Prefers fatty, fried foods.
Usually eats all types of meats.
Can eat 2-3 cups of rice per meal.
Should be on a low-salt, low-fat, diabetic diet.
Drinks 2-3 glasses of water a day.
Has a cup of coffee a day.
Enjoys soft drinks at least twice a day.
Now:
Is on a strict low-salt, low-fat, diabetic diet.
Ate a bread roll with 1 cup of coffee for breakfast.
Ate ¼ piece of a hamburger, rice porridge and a small banana for lunch.
Ate 1 cup of rice and soup for dinner.
Drinks 1 to 1.5 liters of water a day.
Elimination
Before:
Usually urinates 2-3 times a day; urine is usually dark yellow.
Usually defecates every 2 days; stool is usually hard and brown.
Strains when defecating.
No pain.
No abnormal discharges.
Sweats profusely throughout the day.
Now:
Urinates 3-4 times a day; urine is dark yellow.
Defecates every other day; stool is hard and brown.
Strains when defecating.
No pain.
No abnormal discharges.
Sweats moderately due to air conditioning.
Activity & Exercise
Before:
Helps around the house whenever there is nobody to do household chores; otherwise, usually sedentary.
Spends most of his time watching television or talking to family and friends.
Does not actively exercise.
Now:
Is bedridden due to inability to use right foot.
Usually asleep or watching television.
Can perform oral hygiene by himself; otherwise, relies on family to do ADLs for him.
Cognition & Perception
Oriented to person, time and place.
Answers questions accordingly.
Can understand Tagalog fluently and some English phrases.
Is slightly disheveled-looking, but clean.
Has no problems with hearing.
Sleep & Rest
Before:
Sleeps usually between 10 PM to 12 AM and wakes up between 7 AM to 8 AM.
Sleep in interrupted by late night bathroom breaks (1 to 2 times).
Feels refreshed upon waking.
Takes a nap after lunch.
No nightmares, but can sometimes remember dreams.
Snores loudly.
Now:
Sleeps usually between 9 PM to 10 PM and wakes up at 7 AM.
Sleep is interrupted by pain every 5 to 30 minutes.
Wakes up early due to nursing activities.
Sometimes feels refreshed.
Takes naps throughout the day (2 to 3 times).
No nightmares and dreams.
Snores loudly.
Self-Perception & Self-Concept
Before:
Used to be impatient and prone to yelling.
Gets irritated easily.
Does not get violent, but shouts only.
Happiest when family behaves and gets along.
Sad when family leaves him out of outings.
Angry when children are disrespectful or does not take school seriously.
Now:
Tries to be patient and understanding.
Does not yell as much.
Happy when children and grandchildren visits him.
Sad when house is quiet and is by himself.
Angry when he does not agree with family decisions, politics and rude behavior.
Roles & Relationships
Before:
House is noisy, well-lit and well-ventilated.
Used to work regularly to support family; breadwinner.
Held different jobs.
Was the disciplinarian in the family.
Lived with wife and 6 children.
Now:
House is usually peaceful, well-lit and well-ventilated.
Is retired.
Spoils grandchildren by giving them what they want.
Lives with wife usually, but sometimes children and grandchildren spend the weekend with them.
Sexuality & Reproduction
Before:
Has male genitalia and is attracted to women.
Usually intimate with wife 3 times a week.
Has 6 children with wife.
Does not use family planning.
Now:
Usually has no energy or strength to be intimate with wife.
Coping & Stress Tolerance
Before:
Stresses about finances and children.
Felt burdened with supporting family.
Preferred to be alone when stressed.
When overwhelmed, goes to sleep or usually drinks with friends.
Now:
Stresses about his health, finances and grandchildren.
Asks for assistance when overwhelmed.
Prefers company or at least wife’s company.
Can delegate problems to children now that they are grown.
Values & Beliefs
Before:
Is Roman Catholic.
Follows Filipino traditions and customs.
Rarely goes to church.
Worried about children’s education.
Wanted to make it rich.
Now:
Is more spiritual.
Goes to church at least 2-3 times a month.
Prays before meals and sleep

V. Physical Assessment
Vital Signs
Temperature: 38.3˚C
Pulse Rate: 119 bpm
Respiratory Rate: 20 cpm
Blood Pressure: 120/70 mmHg
Skin
Brownish skin color
Warm to touch; febrile
With good skin turgor (< 1 second)
With scars, scabs and bruises all over body
No presence of rashes
No skin allergies
Moist skin; sweaty
Edema (+2) in right foot
Hair
Greasy; short hair
Salt and pepper in color
No infestations
Nails
Pinkish
Round in shape
With good capillary refill (1-2 seconds)
Head
Proportional
Can flex and extend
No bumps or masses
Neck
Supple
Moves from side to side; can rotate freely
No palpable cervical lymph nodes
Face
With small pimples on the forehead
No lesions
With minimal acne at the cheeks
Has a “four o’clock” shadow; unshaven
Eyes
Can rotate
Symmetrical
Anicteric Sclera
Pink palpebral conjunctiva
Pupils equally rounded and reactive to light
Ears
No odor
No auditory discharges
Can hear whispers
Positive for watch-tick test
Nose
Symmetrical
No nasal discharge
No nasal flaring
Lips
Pinkish
Moist lips and buccal mucosa
No lesions
Teeth and Mouth
With dental caries
No toothaches
No mouth ulcers
Appropriate number of dentition for age group
With dentures
Lungs
Symmetrical chest expansion
Equal breath sounds
Clear lung fields
Heart
With regular heart tone
Tachycardia
No palpitations felt
Abdomen
Flabby and distended
No masses or tenderness
Normoactive bowel sounds
Extremities
No cyanosis
Pulses full and equal
Can move freely

VI. Anatomy and Physiology of the Affected System/Organ
INTEGUMENTARY SYSTEM.
Epidermis
The epidermis is the most superficial layer of the skin that covers almost the entire body surface. The epidermis rests upon and protects the deeper and thicker dermis layer of the skin. Structurally, the epidermis is only about a tenth of a millimeter thick but is made of 40 to 50 rows of stacked squamous epithelial cells. The epidermis is an avascular region of the body, meaning that it does not contain any blood or blood vessels. The cells of the epidermis receive all of their nutrients via diffusion of fluids from the dermis.
The epidermis is made of several specialized types of cells. Almost 90% of the epidermis is made of cells known as keratinocytes. Keratinocytes develop from stem cells at the base of the epidermis and begin to produce and store the protein keratin. Keratin makes the keratinocytes very tough, scaly and water-resistant. At about 8% of epidermal cells, melanocytes form the second most numerous cell type in the epidermis. Melanocytes produce the pigment melanin to protect the skin from ultraviolet radiation and sunburn. Langerhans cells are the third most common cells in the epidermis and make up just over 1% of all epidermal cells. Langerhans cells’ role is to detect and fight pathogens that attempt to enter the body through the skin. Finally, Merkel cells make up less than 1% of all epidermal cells but have the important function of sensing touch. Merkel cells form a disk along the deepest edge of the epidermis where they connect to nerve endings in the dermis to sense light touch.
The epidermis in most of the body is arranged into 4 distinct layers. In the palmar surface of the hands and plantar surface of the feet, the skin is thicker than in the rest of the body and there is a fifth layer of epidermis. The deepest region of the epidermis is the stratum basale, which contains the stem cells that reproduce to form all of the other cells of the epidermis. The cells of the stratum basale include cuboidal keratinocytes, melanocytes, and Merkel cells. Superficial to stratum basale is the stratum spinosum layer where Langerhans cells are found along with many rows of spiny keratinocytes. The spines found here are cellular projections called desmosomes that form between keratinocytes to hold them together and resist friction. Just superficial to the stratum spinosum is the stratum granulosum, where keratinocytes begin to produce waxy lamellar granules to waterproof the skin. The keratinocytes in the stratum granulosum are so far removed from the dermis that they begin to die from lack of nutrients. In the thick skin of the hands and feet, there is a layer of skin superficial to the stratum granulosum known as the stratum lucidum. The stratum lucidum is made of several rows of clear, dead keratinocytes that protect the underlying layers. The outermost layer of skin is the stratum corneum. The stratum corneum is made of many rows of flattened, dead keratinocytes that protect the underlying layers. Dead keratinocytes are constantly being shed from the surface of the stratum corneum and being replaced by cells arriving from the deeper layers.
Dermis
The dermis is the deep layer of the skin found under the epidermis. The dermis is mostly made of dense irregular connective tissue along with nervous tissue, blood, and blood vessels. The dermis is much thicker than the epidermis and gives the skin its strength and elasticity. Within the dermis there are two distinct regions: the papillary layer and the reticular layer.
The papillary layer is the superficial layer of the dermis that borders on the epidermis. The papillary layer contains many finger-like extensions called dermal papillae that protrude superficially towards the epidermis. The dermal papillae increase the surface area of the dermis and contain many nerves and blood vessels that are projected toward the surface of the skin. Blood flowing through the dermal papillae provide nutrients and oxygen for the cells of the epidermis. The nerves of the dermal papillae are used to feel touch, pain, and temperature through the cells of the epidermis.
The deeper layer of the dermis, the reticular layer, is the thicker and tougher part of the dermis. The reticular layer is made of dense irregular connective tissue that contains many tough collagen and stretchy elastin fibers running in all directions to provide strength and elasticity to the skin. The reticular layer also contains blood vessels to support the skin cells and nerve tissue to sense pressure and pain in the skin.
Hypodermis
Deep to the dermis is a layer of loose connective tissues known as the hypodermis, subcutis, or subcutaneous tissue. The hypodermis serves as the flexible connection between the skin and the underlying muscles and bones as well as a fat storage area. Areolar connective tissue in the hypodermis contains elastin and collagen fibers loosely arranged to allow the skin to stretch and move independently of its underlying structures. Fatty adipose tissue in the hypodermis stores energy in the form of triglycerides. Adipose also helps to insulate the body by trapping body heat produced by the underlying muscles.

Hair
Hair is an accessory organ of the skin made of columns of tightly packed dead keratinocytes found in most regions of the body. The few hairless parts of the body include the palmar surface of the hands, plantar surface of the feet, lips, labia minora, and glans penis. Hair helps to protect the body from UV radiation by preventing sunlight from striking the skin. Hair also insulates the body by trapping warm air around the skin.
The structure of hair can be broken down into 3 major parts: the follicle, root, and shaft. The hair follicle is a depression of epidermal cells deep into the dermis. Stem cells in the follicle reproduce to form the keratinocytes that eventually form the hair while melanocytes produce pigment that gives the hair its color. Within the follicle is the hair root, the portion of the hair below the skin’s surface. As the follicle produces new hair, the cells in the root push up to the surface until they exit the skin. The hair shaft consists of the part of the hair that is found outside of the skin.
The hair shaft and root are made of 3 distinct layers of cells: the cuticle, cortex, and medulla. The cuticle is the outermost layer made of keratinocytes. The keratinocytes of the cuticle are stacked on top of each other like shingles so that the outer tip of each cell points away from the body. Under the cuticle are the cells of the cortex that form the majority of the hair’s width. The spindle-shaped and tightly packed cortex cells contain pigments that give the hair its color. The innermost layer of the hair, the medulla, is not present in all hairs. When present, the medulla usually contains highly pigmented cells full of keratin. When the medulla is absent, the cortex continues through the middle of the hair.
Nails
Nails are accessory organs of the skin made of sheets of hardened keratinocytes and found on the distal ends of the fingers and toes. Fingernails and toenails reinforce and protect the end of the digits and are used for scraping and manipulating small objects. There are 3 main parts of a nail: the root, body, and free edge. The nail root is the portion of the nail found under the surface of the skin. The nail body is the visible external portion of the nail. The free edge is the distal end portion of the nail that has grown beyond the end of the finger or toe.
Nails grow from a deep layer of epidermal tissue known as the nail matrix, which surrounds the nail root. The stem cells of the nail matrix reproduce to form keratinocytes, which in turn produce keratin protein and pack into tough sheets of hardened cells. The sheets of keratinocytes form the hard nail root that slowly grows out of the skin and forms the nail body as it reaches the skin’s surface. The cells of the nail root and nail body are pushed toward the distal end of the finger or toe by new cells being formed in the nail matrix. Under the nail body is a layer of epidermis and dermis known as the nail bed. The nail bed is pink in color due to the presence of capillaries that support the cells of the nail body. The proximal end of the nail near the root forms a whitish crescent shape known as the lunula where a small amount of nail matrix is visible through the nail body. Around the proximal and lateral edges of the nail is theeponychium, a layer of epithelium that overlaps and covers the edge of the nail body. The eponychium helps to seal the edges of the nail to prevent infection of the underlying tissues.

Sudoriferous Glands
Sudoriferous glands are exocrine glands found in the dermis of the skin and commonly known as sweat glands. There are 2 major types of sudoriferous glands: eccrine sweat glands and apocrine sweat glands. Eccrine sweat glands are found in almost every region of the skin and produce a secretion of water and sodium chloride. Eccrine sweat is delivered via a duct to the surface of the skin and is used to lower the body’s temperature through evaporative cooling.
Apocrine sweat glands are found in mainly in the axillary and pubic regions of the body. The ducts of apocrine sweat glands extend into the follicles of hairs so that the sweat produced by these glands exits the body along the surface of the hair shaft. Apocrine sweat glands are inactive until puberty, at which point they produce a thick, oily liquid that is consumed by bacteria living on the skin. The digestion of apocrine sweat by bacteria produces body odor.
Sebaceous Glands
Sebaceous glands are exocrine glands found in the dermis of the skin that produce an oily secretion known as sebum. Sebaceous glands are found in every part of the skin except for the thick skin of the palms of the hands and soles of the feet. Sebum is produced in the sebaceous glands and carried through ducts to the surface of the skin or to hair follicles. Sebum acts to waterproof and increase the elasticity of the skin. Sebum also lubricates and protects the cuticles of hairs as they pass through the follicles to the exterior of the body.

Ceruminous Glands
Ceruminous glands are special exocrine glands found only in the dermis of the ear canals. Ceruminous glands produce a waxy secretion known as cerumen to protect the ear canals and lubricate the eardrum. Cerumen protects the ears by trapping foreign material such as dust and airborne pathogens that enter the ear canal. Cerumen is made continuously and slowly pushes older cerumen outward toward the exterior of the ear canal where it falls out of the ear or is manually removed.

Physiology of the Integumentary System
Keratinization
Keratinization, also known as cornification, is the process of keratin accumulating within keratinocytes. Keratinocytes begin their life as offspring of the stem cells of the stratum basale. Young keratinocytes have a cuboidal shape and contain almost no keratin protein at all. As the stem cells multiply, they push older keratinocytes towards the surface of the skin and into the superficial layers of the epidermis. By the time keratinocytes reach the stratum spinosum, they have begun to accumulate a significant amount of keratin and have become harder, flatter, and more water resistant. As the keratinocytes reach the stratum granulosum, they have become much flatter and are almost completely filled with keratin. At this point the cells are so far removed from the nutrients that diffuse from the blood vessels in the dermis that the cells go through the process of apoptosis. Apoptosis is programmed cell death where the cell digests its own nucleus and organelles, leaving only a tough, keratin-filled shell behind. Dead keratinocytes moving into the stratum lucidum and stratum corneum are very flat, hard, and tightly packed so as to form a keratin barrier to protect the underlying tissues.

Temperature Homeostasis
Being the body’s outermost organ, the skin is able to regulate the body’s temperature by controlling how the body interacts with its environment. In the case of the body entering a state of hyperthermia, the skin is able to reduce body temperature through sweating and vasodilation. Sweat produced by sudoriferous glands delivers water to the surface of the body where it begins to evaporate. The evaporation of sweat absorbs heat and cools the body’s surface. Vasodilation is the process through which smooth muscle lining the blood vessels in the dermis relax and allow more blood to enter the skin. Blood transports heat through the body, pulling heat away from the body’s core and depositing it in the skin where it can radiate out of the body and into the external environment.
In the case of the body entering a state of hypothermia, the skin is able to raise body temperature through the contraction of arrector pili muscles and through vasoconstriction. The follicles of hairs have small bundles of smooth muscle attached to their base called arrector pili muscles. The arrector pili form goose bumps by contracting to move the hair follicle and lifting the hair shaft upright from the surface of the skin. This movement results in more air being trapped under the hairs to insulate the surface of the body. Vasoconstriction is the process of smooth muscles in the walls of blood vessels in the dermis contracting to reduce the flood of blood to the skin. Vasoconstriction permits the skin to cool while blood stays in the body’s core to maintain heat and circulation in the vital organs.
Vitamin D Synthesis
Vitamin D, an essential vitamin necessary for the absorption of calcium from food, is produced by ultraviolet (UV) light striking the skin. The stratum basale and stratum spinosum layers of the epidermis contain a sterol molecule known as 7-dehydrocholesterol. When UV light present in sunlight or tanning bed lights strikes the skin, it penetrates through the outer layers of the epidermis and strikes some of the molecules of 7-dehydrocholesterol, converting it into vitamin D3. Vitamin D3 is converted in the kidneys into calcitriol, the active form of vitamin D.

Protection
The skin provides protection to its underlying tissues from pathogens, mechanical damage, and UV light. Pathogens, such as viruses and bacteria, are unable to enter the body through unbroken skin due to the outermost layers of epidermis containing an unending supply of tough, dead keratinocytes. This protection explains the necessity of cleaning and covering cuts and scrapes with bandages to prevent infection. Minor mechanical damage from rough or sharp objects is mostly absorbed by the skin before it can damage the underlying tissues. Epidermal cells reproduce constantly to quickly repair any damage to the skin. Melanocytes in the epidermis produce the pigment melanin, which absorbs UV light before it can pass through the skin. UV light can cause cells to become cancerous if not blocked from entering the body.

Skin Color
Human skin color is controlled by the interaction of 3 pigments: melanin, carotene, and hemoglobin. Melanin is a brown or black pigment produced by melanocytes to protect the skin from UV radiation. Melanin gives skin its tan or brown coloration and provides the color of brown or black hair. Melanin production increases as the skin is exposed to higher levels of UV light resulting in tanning of the skin. Carotene is another pigment present in the skin that produces a yellow or orange cast to the skin and is most noticeable in people with low levels of melanin. Hemoglobin is another pigment most noticeable in people with little melanin. Hemoglobin is the red pigment found in red blood cells, but can be seen through the layers of the skin as a light red or pink color. Hemoglobin is most noticeable in skin coloration during times of vasodilation when the capillaries of the dermis are open to carry more blood to the skin’s surface.

Cutaneous Sensation
The skin allows the body to sense its external environment by picking up signals for touch, pressure, vibration, temperature, and pain. Merkel disks in the epidermis connect to nerve cells in the dermis to detect shapes and textures of objects contacting the skin. Corpuscles of touch are structures found in the dermal papillae of the dermis that also detect touch by objects contacting the skin. Lamellar corpuscles found deep in the dermis sense pressure and vibration of the skin. Throughout the dermis there are many free nerve endings that are simply neurons with their dendrites spread throughout the dermis. Free nerve endings may be sensitive to pain, warmth, or cold. The density of these sensory receptors in the skin varies throughout the body, resulting in some regions of the body being more sensitive to touch, temperature, or pain than other regions.

Excretion
In addition to secreting sweat to cool the body, eccrine sudoriferous glands of the skin also excrete waste products out of the body. Sweat produced by eccrine sudoriferous glands normally contains mostly water with many electrolytes and a few other trace chemicals. The most common electrolytes found in sweat are sodium and chloride, but potassium, calcium, and magnesium ions may be excreted as well. When these electrolytes reach high levels in the blood, their presence in sweat also increases, helping to reduce their presence within the body. In addition to electrolytes, sweat contains and helps to excrete small amounts of metabolic waste products such as lactic acid, urea, uric acid, and ammonia. Finally, eccrine sudoriferous glands can help to excrete alcohol from the body of someone who has been drinking alcoholic beverages. Alcohol causes vasodilation in the dermis, leading to increased perspiration as more blood reaches sweat glands. The alcohol in the blood is absorbed by the cells of the sweat glands, causing it to be excreted along with the other components of sweat.

Circulatory System
The cardiovascular system consists of the heart, blood vessels, and the approximately 5 liters of blood that the blood vessels transport. Responsible for transporting oxygen, nutrients, hormones, and cellular waste products throughout the body, the cardiovascular system is powered by the body’s hardest-working organ — the heart, which is only about the size of a closed fist. Even at rest, the average heart easily pumps over 5 liters of blood throughout the body every minute....
Circulatory Loops
There are 2 primary circulatory loops in the human body: the pulmonary circulation loopand the systemic circulation loop.

1. Pulmonary circulation transports deoxygenated blood from the right side of the heart to the lungs, where the blood picks up oxygen and returns to the left side of the heart. The pumping chambers of the heart that support the pulmonary circulation loop are the right atrium and right ventricle.
2. Systemic circulation carries highly oxygenated blood from the left side of the heart to all of the tissues of the body (with the exception of the heart and lungs). Systemic circulation removes wastes from body tissues and returns deoxygenated blood to the right side of the heart. The left atrium and left ventricle of the heart are the pumping chambers for the systemic circulation loop.

Blood Vessels
Blood vessels are the body’s highways that allow blood to flow quickly and efficiently from the heart to every region of the body and back again. The size of blood vessels corresponds with the amount of blood that passes through the vessel. All blood vessels contain a hollow area called the lumen through which blood is able to flow. Around the lumen is the wall of the vessel, which may be thin in the case of capillaries or very thick in the case of arteries.

All blood vessels are lined with a thin layer of simple squamous epithelium known as the endothelium that keeps blood cells inside of the blood vessels and prevents clots from forming. The endothelium lines the entire circulatory system, all the way to the interior of the heart, where it is called the endocardium.
There are three major types of blood vessels: arteries, capillaries and veins. Blood vessels are often named after either the region of the body through which they carry blood or for nearby structures. For example, the brachiocephalic artery carries blood into the brachial (arm) and cephalic (head) regions. One of its branches, the subclavian artery, runs under the clavicle; hence the name subclavian. The subclavian artery runs into the axillary region where it becomes known as the axillary artery.

1. Arteries and Arterioles: Arteries are blood vessels that carry blood away from the heart. Blood carried by arteries is usually highly oxygenated, having just left the lungs on its way to the body’s tissues. The pulmonary trunk and arteries of the pulmonary circulation loop provide an exception to this rule – these arteries carry deoxygenated blood from the heart to the lungs to be oxygenated.

Arteries face high levels of blood pressure as they carry blood being pushed from the heart under great force. To withstand this pressure, the walls of the arteries are thicker, more elastic, and more muscular than those of other vessels. The largest arteries of the body contain a high percentage of elastic tissue that allows them to stretch and accommodate the pressure of the heart.

Smaller arteries are more muscular in the structure of their walls. The smooth muscles of the arterial walls of these smaller arteries contract or expand to regulate the flow of blood through their lumen. In this way, the body controls how much blood flows to different parts of the body under varying circumstances. The regulation of blood flow also affects blood pressure, as smaller arteries give blood less area to flow through and therefore increases the pressure of the blood on arterial walls.

Arterioles are narrower arteries that branch off from the ends of arteries and carry blood to capillaries. They face much lower blood pressures than arteries due to their greater number, decreased blood volume, and distance from the direct pressure of the heart. Thus arteriole walls are much thinner than those of arteries. Arterioles, like arteries, are able to use smooth muscle to control their aperture and regulate blood flow and blood pressure.
2. Capillaries: Capillaries are the smallest and thinnest of the blood vessels in the body and also the most common. They can be found running throughout almost every tissue of the body and border the edges of the body’s avascular tissues. Capillaries connect to arterioles on one end and venules on the other.

Capillaries carry blood very close to the cells of the tissues of the body in order to exchange gases, nutrients, and waste products. The walls of capillaries consist of only a thin layer of endothelium so that there is the minimum amount of structure possible between the blood and the tissues. The endothelium acts as a filter to keep blood cells inside of the vessels while allowing liquids, dissolved gases, and other chemicals to diffuse along their concentration gradients into or out of tissues.

Precapillary sphincters are bands of smooth muscle found at the arteriole ends of capillaries. These sphincters regulate blood flow into the capillaries. Since there is a limited supply of blood, and not all tissues have the same energy and oxygen requirements, the precapillary sphincters reduce blood flow to inactive tissues and allow free flow into active tissues.
3. Veins and Venules: Veins are the large return vessels of the body and act as the blood return counterparts of arteries. Because the arteries, arterioles, and capillaries absorb most of the force of the heart’s contractions, veins and venules are subjected to very low blood pressures. This lack of pressure allows the walls of veins to be much thinner, less elastic, and less muscular than the walls of arteries.

Veins rely on gravity, inertia, and the force of skeletal muscle contractions to help push blood back to the heart. To facilitate the movement of blood, some veins contain many one-way valves that prevent blood from flowing away from the heart. As skeletal muscles in the body contract, they squeeze nearby veins and push blood through valves closer to the heart.

When the muscle relaxes, the valve traps the blood until another contraction pushes the blood closer to the heart. Venules are similar to arterioles as they are small vessels that connect capillaries, but unlike arterioles, venules connect to veins instead of arteries. Venules pick up blood from many capillaries and deposit it into larger veins for transport back to the heart.

Coronary Circulation
The heart has its own set of blood vessels that provide the myocardium with the oxygen and nutrients necessary to pump blood throughout the body. The left and right coronary arteries branch off from the aorta and provide blood to the left and right sides of the heart. The coronary sinus is a vein on the posterior side of the heart that returns deoxygenated blood from the myocardium to the vena cava.

Hepatic Portal Circulation
The veins of the stomach and intestines perform a unique function: instead of carrying blood directly back to the heart, they carry blood to the liver through the hepatic portal vein. Blood leaving the digestive organs is rich in nutrients and other chemicals absorbed from food. The liver removes toxins, stores sugars, and processes the products of digestion before they reach the other body tissues. Blood from the liver then returns to the heart through the inferior vena cava.

Blood
The average human body contains about 4 to 5 liters of blood. As a liquid connective tissue, it transports many substances through the body and helps to maintain homeostasis of nutrients, wastes, and gases. Blood is made up of red blood cells, white blood cells, platelets, and liquid plasma.

Red Blood Cells: Red blood cells, also known as erythrocytes, are by far the most common type of blood cell and make up about 45% of blood volume. Erythrocytes are produced inside of red bone marrow from stem cells at the astonishing rate of about 2 million cells every second. The shape of erythrocytes is biconcave—disks with a concave curve on both sides of the disk so that the center of an erythrocyte is its thinnest part. The unique shape of erythrocytes gives these cells a high surface area to volume ratio and allows them to fold to fit into thin capillaries. Immature erythrocytes have a nucleus that is ejected from the cell when it reaches maturity to provide it with its unique shape and flexibility. The lack of a nucleus means that red blood cells contain no DNA and are not able to repair themselves once damaged.

Erythrocytes transport oxygen in the blood through the red pigment hemoglobin. Hemoglobin contains iron and proteins joined to greatly increase the oxygen carrying capacity of erythrocytes. The high surface area to volume ratio of erythrocytes allows oxygen to be easily transferred into the cell in the lungs and out of the cell in the capillaries of the systemic tissues.
White Blood Cells: White blood cells, also known as leukocytes, make up a very small percentage of the total number of cells in the bloodstream, but have important functions in the body’s immune system. There are two major classes of white blood cells: granular leukocytes and agranular leukocytes.

1. Granular Leukocytes: The three types of granular leukocytes are neutrophils, eosinophils, and basophils. Each type of granular leukocyte is classified by the presence of chemical-filled vesicles in their cytoplasm that give them their function. Neutrophils contain digestive enzymes that neutralize bacteria that invade the body. Eosinophils contain digestive enzymes specialized for digesting viruses that have been bound to by antibodies in the blood. Basophils release histamine to intensify allergic reactions and help protect the body from parasites.
2. Agranular Leukocytes: The two major classes of agranular leukocytes are lymphocytes and monocytes. Lymphocytes include T cells and natural killer cells that fight off viral infections and B cells that produce antibodies against infections by pathogens. Monocytes develop into cells called macrophages that engulf and ingest pathogens and the dead cells from wounds or infections.
Platelets : Also known as thrombocytes, platelets are small cell fragments responsible for the clotting of blood and the formation of scabs. Platelets form in the red bone marrow from large megakaryocyte cells that periodically rupture and release thousands of pieces of membrane that become the platelets. Platelets do not contain a nucleus and only survive in the body for up to a week before macrophages capture and digest them.
Plasma: Plasma is the non-cellular or liquid portion of the blood that makes up about 55% of the blood’s volume. Plasma is a mixture of water, proteins, and dissolved substances. Around 90% of plasma is made of water, although the exact percentage varies depending upon the hydration levels of the individual. Theproteins within plasma include antibodies and albumins. Antibodies are part of the immune system and bind to antigens on the surface of pathogens that infect the body. Albumins help maintain the body’s osmotic balance by providing an isotonic solution for the cells of the body. Many different substances can be found dissolved in the plasma, including glucose, oxygen, carbon dioxide, electrolytes, nutrients, and cellular waste products. The plasma functions as a transportation medium for these substances as they move throughout the body.

VII. Risk Factors
A bacterial infection (often staphylococcus)
A minor wound or injury
Diabetic
Application of oil to the site of infection

VIII. Pathophysiology

IX. Diagnostic and Laboratory Tests

Complete Blood Count Result 01-17-15

Hemoglobin
144
Hematocrit
0.43
RBC
4.62
MCV
92.0
MCH
31.2
MCHC
33.9
Leukocyte
14.1
Segmenters
0.77
Lymphocytes
0.14
Monocytes
0.08
Eosinophils
0.01
Basophiles
0.00
Platelet Count
218

01-17-15 6:38 PM
Result
Normal Values
HBA1C
9.50 %
4.2-6.0
Na
142.10
136-145
K
↓3.10
3.5-5.0
Crea
1.07
0.6-1.3

01-17-15 Urinalysis

COLOR
Yellow
SP. GRAVITY
1.010
REACTION
7.0
CHARACTER
Turbid
PROTEIN
Trace
SUGAR
2+
WBC
0-2
RBC
0-2
SUGAR
2+
BACTERIA
Few
MUCUS THREADS
Moderate
EPITHELIAL CELLS
Few
OTHERS
Amorphous materials-plenty Repeat Potassium
01-20-15
5:52AM
12:07PM
K
3.40 mmol/L
3.90 mmol/L

Right Wound Abscess GSCS Result: Yeast Cells-Few PMN-Few Gram positive cocci in pairs-moderate

X. Drug Study
Kalium Durule 2 tabs TID
Pharmacologic: Potassium supplement
Therapeutic: Potassium salt
Action: Replaces potassium and maintains potassium level
Adverse reactions:
CNS: paresthesia of limbs, listlessness, confusion, wakness or heaviness of limbs, flaccid paralysis
CV: postinfusion phlebitis, arrhythmias, heartblock, cardiac arrest, ECG changes, hypotension
GI: nausea, vomiting, abdominal pain, diarrhea
Metabollic: hyperkalemia
Respiratory: respiratory paralysis
Contraindications and cautions
Contraindicated in patients with severe renal impairment with oliguria, anuria, or azotemia, with untreated Addison disease; or with acute dehydration, heat cramps, hyperkalemia, hyperkalemic form of familial periodic paralysis, or other condition linked to extensive tissue breakdown.
Use cautiously in patients with cardiac disease or renal impairment.
Nursing Considerations:
Patients at an increased risk of GI lesions include those with scleroderma, diabetes, mitral valve replacement, cardiomegaly, or esophageal strictures, and elderly or immobile patients
Drug is commonly used orally with potassium-wasting diuretics to maintain potassium levels
Monitor ECG and electrolyte levels during therapy
Monitor renal function. After surgery, don 't give drug until urine flow is established
Many adverse reactions may reflect hyperkalemia
Patient may be sensitive to tartrazine in some of these products
Patient Teaching:
Teach patient how to prepare powders and how to take drug. Tell patient to take with or after meals with full glass of water or fruit juice to lessen GI distress
Teach patient signs and symptoms of hyperkalemia and tell patient to notify prescriber if they occur
Tell the patient to report discomfort at IV insertion site
Warn patient not to use salt substitutes concurrently, except with prescriber 's prescription
Tell patient not to be concerned if wax matrix appears in stool because the drug has already been absorbed

Omeprazole 40 mg/tab 1 tab OD
Pharmacologic class: proton pump inhibitor
Therapeutic class: anti-ulcer drug
Action: Reduces gastric acid secretion and increases gastric mucus and bicarbonate production, creating protective coating on gastric mucosa and easing discomfort from excess gastric acid
Indications: Gastroesophageal disease, erosive esophagitis, short-term treatment of active dupdenal ulcer, to reduce risk of duodenal ulcers caused by Helicobacter pylori, gastric ulcers, pathologic hypersecretory conditions, frequent heartburn
Contraindicatios: Hypersensitivity to drug or its components
Adverse reactions: dizziness, asthemia, nausea, vomiting, diarrhea, constipation, abdominal pain, back pain, cough, upper respiratory tract infection, rash
Patient monitoring: assess VS, check for abdominal pain, emesis, diarrhea or constipation, evaluate fluid intake and output, watch for elevated liver function test results (rare)
Patient Teaching: Tell patient to take 30-60 minutes before a meal, preferably in morning, Instruct patient to swallow capsules or tablets whole and not to chew or crash them, If he can 't swallow the capsule, tell him he may open in, carefully sprinkle and mix entire contents into 1 tbsp of cool applesauce and swallow immediately with a glass of water, inform patient taking OTC delayed-release tablet for heartburn that full effect may take 1-4 days. Adivise him not to take tablets for more than 14 days without consulting healthcare professional, caution patient to avoid drinking and other hazardous activities until he knows how drug affects concentration and alertness
Metformin 500 mg/ttab 1 tab BID
Classification: anti-diabetic
Therapeutic: Antihyperglycemic
Action: Biguanide oral hypoglycemiv agent thought to both increase the binding of insulin to its receptors and potentiate insulin action. Improves tissue sensitivity to insulin, increases glucose transport into skeletal muscles and fat, and supresses gluconeogenesis and hepatic production of glucose. Effective in lowering serum glucose level and ultimately, the HbA1c value
Uses: Treatment of type 2 diabetes mellitus as adjunct to diet and exercise
Contraindications: Hypersensitivity to metformin, hepatic or cardiopulmonary insufficiency ; alcoholism; concurrent infection; acute MI, cardiogenic shock; diabetic ketoacidosis; hypocemia, lactic acidosis, radiographic contrast administration, renal disease, renal failure, renal impairment, sepsis, surgery young than 10 y/o
Cautions Use: Previous hypersensitivity to phenformin or buformin; anemia, coma; dehydration, diarrhea, ethanol intoxication; fever; gastroparesis, GI obstruction; heart failure; hyperthyroidism; pituitary insufficiency; polycystic ovary syndrome; trauma, emesis, older adults; pregnancy (category B), lactation
Adverse Effects: CNS: Headache, dizziness, agitation, fatigue. Metabollic: Lactic acidosis. GI: Nausea, vomiting, abdominal pain, bitter or metallic taste, diarrhea, bloatedness, anorexia; malabsorption of amino acids, vitamin B12 and folic acid possible.
Nursing implications:
Monitor VS and fasting and postprandial blood glucose values
Report promptly any of the following signs of lactic acidosis: malaise, myalgia, somnolence, respiratory depression, abdominal distress
Lab tests: Monitor baseline and periodic LFTs and kidney functional tests, drug contraindicated in the presence of renal or hepatic insufficiency. Monitor blood glucose and HbA1c, and lipid profile periodically
Monitor known or suspected alcoholics carefully for decreased liver function
Monitor CP status throughout course of therapy; cardiopulmonary insufficiency may predispose to lactic acidosis
Patient and Family education:
Be aware that hypoglycemia is not a risk when drug is taken and recommended therapeutic doses unless combined with other drugs which lower blood glucose
Report to physician immediately S&S of infection, which increase the risk of lactic acidosis
Report promptly severe vomiting, diarrhea, fever or any illness that causes limited fluid intake
Avoid drinking alcohol while taking this drug

Cefuroxime(Eroxmit) 750 mgTIV Q8
Classifications: Antibiotic; second generation cephalosphorin
TherapeuticL Antibiotic
Action: Semisynthetic second generation cephalosphorin beta-lactam antibiotic. Preferentially binds to one or more of the penicillin binding proteins located on cell walls of susceptible organisms. This inhibits third and final stage of bacterial cell wall synthesis, thus killing the bacterium
Uses: Infections caused by susceptible organisms in the lower respiratory tract, urinary tract, skin, and skin structures, also used for treatment of meningitis, gonorrhea, and otitis media and for perioperative prophylaxis, eraly Lyme disease
Contraindications: Hypersensitivity to cephalosphorins and related antibiotics; viral infections
Cautions use: Hx of allergy particular to drugs; penicillin sensitivity; renal insufficiency; hx of colitis or other GI disease; potent diuretics, pregnancy, lactation
Adverse effects: Thrombophlebitis (IV site), pain, burning, cellulitis (IM site); superinfections, positive Coomb 's test. GI: diarrhea, nausea, anibiotic-associated colitis Skin: rash, pruritus, urticaria Urogenital: Increased serum creatinine and BUN, decreased creatinine clearance
Nursing Implications:
Determine hx of hypersensitivity reactions to cephalosphorins, penicillins, and hx of allergy, particularly to drugs, before therapy is initiated
Lab tests: Perform culture and sensitivity tests before initiation of therapy
Report inset of loose stools or diarrhea
Monitor for manifestations of hypersensitivity. Discontinue drug and report their appearance promptly.

Clindamycin(Dynacin) 300 mg TIV Q6
Classification: Lincosamide Antibiotic
Therapeutic: Antibiotic
ActionL Semisynthetic derivative o lincomycin that suppresses protein synthesis by binding to 50 S subunits of bacterial ribosomes, and therefore, inhibits other antibiotics that act as this site
Uses: Serious infections when less toxic alternatives are inappropriate. Topical applications are used in treatment of acne vulgaris. Vaginal applications are used in treatment of bacterial vaginosos in nonpregnant women
Contraindications: hx of hypersensitivity to clindamycin or lincomycin; hx of regional enteritis, ulcerative colitis, or antibiotic-associated colitis, viral infection
Cautious Use: Hx of GI disease, renal or hepatic dieasease; atopic individuals, older patients over 60 y/o; pregnancy, lactation
Adverse effects: fever, serum sickness, sensitization, swelling of face, generalized myalgia, superinfections, procitis, vaginitis, pain, induration, sterile abscess, thrombophlebitis CV: hypotension, cardiac arrest GI: diarrhea, abdominal pain, flatulence, bloating, nausea, vomiting, pseudomembranous colitis; esophageal irritation, loss of taste, medicinal taste, jaundice, abnormal liver function tests.Hematologic: Leukopenia, eosinophilia, agranulocytosis, thrombocytopenia Skin: skin rashes, urticaria, pruiritus, dryness, contact dermatitis, gram negative folliculitis, irritation, oily skin
Nursing implications:
Lab tests: Culture and susceptibility testing should be performed initially.
Monitor BP and pulse in patients receiving drug parenterally. Hypotension has occurred following IM injection. Advise patient to remain in recumbent porition following drug administration until BP has stabilized
Severe diarrhea and colitis, including pseudomembranous colitis have been associated with oral, parenteral and topical clindamycin. Report immediately the onset of watery diarrhea.
Be alert to signs of superinfection and anaphylactoid reactios

Metoprolol(Cardiosel) 100 mg/tab 1 tab OD
Therapeutic: Antihypertensive
Pharmacologic: Selective beta blocker
Action: Unknown. A selective beta blocker that selectively blocks beta1 receptors; decreases cardiac output, peripheral resistance, and cardiac oxygen consumption; and depresses renin secretion
Adverse Reactions:
CNS: fatigue, dizziness, depression
CV: hypotension, bradycardia, heart failure, AV block, edema
GI: nausea, diarrhea, constipation, heart burn
Respiratory: dyspnea, whezzong
Skin: rash
Contraindications and Cautions:
Contraindicated in patients hypersensitive to drug or other beta blockers
Contraindicated in patients with sinus bradycardia, greater than first degree heart block, cardiogenic shock, or overt cardiac failure when used to treat hypertension or angina. When used to treat MI, drug is contraindicated in patients with heart less than 45 beats/minute, greater than first-degree heart block. PR interval of 0.24 second or longer with first degree heart block, systolic blood pressure less than 100 mm Hg, or moderate to severe cardiac failure
Use cautiously in patients with heart failure diabetes, or respiratory or hepatic disease.
Nursing Consideration:
Always check patient 's apical pulse rate before giving drug. If it 's slower than 60 BPM, withhold drug and call prescriber immediately
In diabetic patients, monitor glucose level closely because drug masks common signs and symptoms of hypoglycemia
Monitor blood pressure frequently; drug masks common signs and symptoms of shock
Beta blockers may mask tachycardia caused by hyperthyroidism. In patients with suspected thyrotoxicosis, taper off beta blocker to avoid thyroid storm
Patient Teaching:
Instruct patient to take drug exactly as prescribbed and with meals
Caution patient to avoid driving and other tasks requiring mental alertnes untill response to therapy has been established
Advise patient to inform dentist or prescriber about use of this drug before procedures or surgery
Tell patient to alert prescriber if shortness of breath occurs
Instruct patient not to stop drug suddenly but to notify prescriber about unpleasant adverse reactions, Inform him that drug must be withdrawn gradually over 1 or 2 weeks
Inform patient that use isn 't advisable in breadtfeeding women

Spironolactone 100 mg/tab 1 tab OD
Classification: Electrolyte and water balance; aldosterone antagonist; potassium-sparing diuretic
Therapeutic: Potassium-sparing diuretic; antiihypertensive
Action: Specific pharmacologic antagonist of aldosterone that competes with aldosterone for cellular receptor sites in distal renal tubules. Promotes sodium and chloride excertion without concommitant loss of potassium. Lowers comitant loss of potassium. Lowers systolic and diastolic pressures in hypertive patients. Effective in treatment of primary aldosteronism.
Uses: Essential hypertension, refractory edema due to CHF; hepatic cirrhosis, nephrotic syndrome, hypokalemia and idiopathic edema. May be used to potentiate actions of other diuretics and antihypertensive agents or for its potassium effect. Also used for treatment of primary aldosteronism
Contraindications: Anuria, acute renal insufficiency, renal failure; diabetic nephropathy, progressing impairment of kidney function, hyperkalemia; pregnancy
Cautions use: BUN of 40 mg/dl or greater, mild or moderate renal impairment, liver disease; older adults; pregnancy
Adverse Effects: CNS: Lethargy, mental confusion, fatigue, headache, drowsiness, ataxia Endocrine: gynecomastia (both sexes), inability to achieve or maintain erectuin, androgenic effects, parathyroud changes, decreased glucose tolerance, SLE,GI: Abdominal cramps, nausea, vomiting, anorexia, diarrhea Skin: Maculopapular or erythematous rash, urticaria Metabollic: Fluid and electrolyte imbalance, elevated BUN, mild acidosis, hyperuricemia, gout Hematologic: Agranulocytosis CV: Hypertension
Nursing Implications:
Check blood pressure before initiation of therapy and at regular intervals throughout therapy
Lab tests: Monitor serum electrolytes (sodium and potassium) especially during therapy; monitor digoxin level when used concurrently
Assess for signs of fluid and electrolyte imbalance, and signs og digoxin toxicity
Monitor daily I&O and check for edema. Report lack of diuretic response or development of edema; both may indicate tolerance to drug
Weigh patient under stantart conditions before therapy begins and daily throughout therapy
Observe for and report immediately the onset of mental changes, lethargy, or stupor in patients with liver disease
Adverse reactions are generally reversible with discontinuation of drug.

Furosemide 40 mg/tab 1 tab Q12
Classifications: electrolytic and water balance agent; loop diuretic, hypertensive
Therapeutic: Loop diuretic; anti hypertensive
Action: Rapid acting potent sulfonamide "loop" duiretic and antihypertensive. Inhibits reabsorption of sodium and chloride primarily in loop of Henle and also in proximal and distal renal tubules
Uses: Treatment of edema associated with CHF, cirrhosis of/liver, and kidney disease, including nephrotic syndrome. May be used for management of hypertension, alone or in combination with other hypertensive agents, and for treatment of hypercalcemia. Has been used concomitantly with mannitol for treatment of severe cerebral edema, particularly meningitis
Contraindications: Hx of hypersentivity to furosemide or sulfonamides; increasing oliguria, anuria, fluid and electrolyte depletion states, hepatic coma; preeclampsia, eclampsia
Cautious Use: Infants, older adults, hepatic disease, hepatic cirrhoi=sis; renal disease, nephrotic syndrome; cordiogenic shock associated with acute MI; ventricular arrhthmias, CHF, diarrhea, hx of SLE, hx of gout, DM, pregnancy, lactation.
Adverse Reaction: CV: Postural hypotension, dizzinrss with excessive diuresis, acute hypotensive episodes, circulatory collapse. Metabollic: Hypovolemia, dehydration, hyponatremia, hypokalemia, hypocholremia, metabolic alkalosis, hyperglycemia, glycosuria, elevated BUN, hyperuricemia GI: Nausea, vomiting, oral and gastric burning, anorexia, diarrhea, constipation, abdomnal cramping, acute pancreatitis, jaundice. Urogenital: Allergic instertitia nephritis, irreversible renal failure, urinary frequency. Hematologic: anemia, leukopenia, thrombocytopenia porpura, aplastic anema agranulocytosis Special senses: tinnitus vertigo, feeling of fullness in ears, hearing loss, blurred vision Skin: Pruritus, urticaria, exfoliative dermatitis, purpura, photosesitivity, porphyria cutanea tarda, necrotizing angitis Body as a Whole: Increased perspiration; paresthesias; activation of SLE, muscle spasms, weakness; thrombophlebitis, pain at IM injection site
Nursing Implication:
Observe patients receiving parenteral drug carefully; closely monitor BP and vital signs
Monitor for S&S of hypokalemia
Monitor BP during periods of diuresis and through period of dosage adjustment
Observe older adults closely during period of brisk diuresis
Lab tests: Obtain frequent blood count, serum, and urine electroltes, CO2, BUN, Blood sugar and uric acid values during first few months of therapy and periodically thereafter
Monitor urine and blood glucose and HbA1C closely in diabetics and patiends with decompensated hepatic cerrhosis
Monitor I & O ratio and pattern, Report decrease or unusual increase in output. Excessive diuresis can result in dehydratuin and hypovolemia, circulatory collapse, and hypotension. Weight patient dail under standard conditions

Nifedipine 30 mg (Calcibloc) 1 tab OD
Classification: Calcium channel blocker; antianginal, antihypertensive
Therapeutic: Antihypertensive, anti-angianl
Action: Blocks calcium ion influx across cell membranes of cardiac muscle and vascular smooth muscle. Reduces myocardial oxygen utilization and supply and relaxes and prevents coronary artery spasm. Decreases peripheral vascular resistance and increases cardiac output
Uses: Vasopastic "variant" or Prinzmetal 's angina and chronic stable angina without vasospasm. Mild to moderate hypertension
Contraindications: Known hypersensitivity to nifedipine; unstable angina, acute MI; cardiogenic shock; aortic stenosis; GI obstruction. Safety in children is not established
Adverse effects: Sore throat, weakenss, dever, sweating, chills, febrile reaction CNS: Dizziness, lightheadedness. nervousness, mood changes, weakness, jitterness, sleep disturbances, blurred vision, retinal ischemia, difficulty in balance, headache CV: Hypertension, facial flushing, heat sensation, palpitations, peripheral edema, MI, prolonged systemic hypotension with overdose GI: Nausea, heartburn, diarrhea, constipation, cramps, flatulence, gingival hyperplasia, hepatotoxicity Musculoskeletal: Inflammation, joint stiffness, muscle cramps Respiratory: Nasal congestion, dyspnea, cough, wheezing Skin: dermatitis, pruritis, urticaria Urogenital: Sexual difficulties, possible male infertility
Nursing implications:
Monitor BP carefully titration period.
Monitor blood sugar in diabetic patients
Monitor gingival hyperplasia and report promptly

XI. Course in the Ward
1-17-15
BP=140/90 PR=84 RR=20 T=36.9
Admit to room of choice under the service of Dr. A. Tan
Refer to Dr. Palpal-latoc for co-management
DM diet
IVF PNSS 1L x !6
Diagnostics: CBC, UA
Medications: Tramadol 50 mg TIV q8 PRN pain
Keep leg elevated at all times
Apply warm compress
Give tetagam 0.5 ml TIM and tetavax 250 IV TIM now
TPR qshift
I & O q shift
Inform MROD (Dr. Pasco informed)
Refer
Start cefuroxime (Eroxmit) 1.5 mg TIV(-)ANST now then 750 mg TIV q8
Start clindamycin 300 mg TIV (-) ANST q6
Dr Palpal-latoc aware of this referral
Refer
1-17-15 3PM
For Crea, HbA1C, CBG BID ACBS, Na, K
Please resume pt 's own meds
Nifedipine 300 mg (calcibloc) 1 tab OD
Metropolol 100 mg/tab (Cardiosel) 1 tab OD
Furosemide 40 mg/tab 1 tab q12
1-17-15 4PM T=38.1
Give paracetamol 300 mg TIV now
1-17-15 6:55 PM
PNSS 1L x 16
1-17-15 7:45 PM
Start Paracetamol 500 mg/tab 1 tab q4 PRN (37.8)
TSB
Increase IVF to 12
1-17-15 9:20 PM HbA1c=95% Na=142 K=3.1 Crea=94 CBG=215
Shift furosemide to spironalactone 100 mg/tab OD
KCL tab, 2 tabs TID x 2 days
For repeat serum K+ post correction
Resume metformin 500 mg/tab 1 tab BID
1-17-15 10:10PM
Omeprazole 40 mg/tab 1 tab OD
Add LSLF to the diet
1-18-15 (+) purulent discharge (+)pustular urine
WD done cont. warm compress keep foot elevated refer 1-18-15 4PM
IVF TF: PNSS 1L x 16
1-18-15 6:38 PM
For I&D tom 8AM
Secure consent
Inform OR
NPO p midnight
Anesth: Dr. Florentino
↑IVF to 8 once on NPO
Inform Dr. A. Tan/MROD for medical clearance
Dr. Palpal-latoc updated
1-18-15 6:50 PM
Dra. Florentino updated
Nalpbuphine 10mg IV + promethazine 12.5 mg on call
Inform once cleared done
May give tramaldin 50mg SIVP now
1-18-15 7PM
Cleared as low medical risk for low surgical risk
1-18-15 8:10PM
IVF TF: D5NSS IL x 16
1-19-15 BP=130/80 HR=140 CBG= 183
Referral due to tachycardia
For 12 lead ECG now
For CBG now
Refer
May give Amnioderone 150mg TIV now
Repeat serum K after corrections
1-19-15 8:50AM to PACU; 02 inhalation of 2LPM till fully conscious
S/P wound debridement, application of short leg cast @ R
Keep right lower extremity 2 pillows elevated
Start Tramadol drip: 300mg Tramadin + 200 cc D5W x 24
Nalbuphine 500 mg SIVP for breakthrough pain
May transfer out when full conscious & VS are stable
TF IVF D5NM IL x 12
Resume CBG monitoring, diet, previous medications when fully conscious
Refer
1-19-15 (+) pain @ right foot
IVF TF: D5NM 1L x 12
1-19-15 7:30 PM (+) pain @ right foot
IVF TF: D5NM 1L x 12
1-20-15 8AM
↓IV to KVP
↑oral fluid intake may have LSLF DM diet
1-20-15 8:20 AM
Tramadol drip 200 mg/250 d5w x 24 (Tramadin)
May give Ketorolac 30 mg TIV q8 for severe pain schedule for wound debridement and change of dressing 1/20/15 on call
Inform OR
Anesth: Dra. Florentina
1-20-15 9:50 AM
OR tomorrow @ 8AM
Inform OR
Secure consent
↑IVF rate to 8 once on NPO
NPO @ midnight refer accordingly
Dr. Florentino aware
OR informed
1-20-15 10AM
Inform Dr. A. Tan/MROD of plans of debridement
Refer
6:45 AM
Seen awake in bed in moderate high back rest. With IVF #2 D5 NM 1L times at 400 cc level inserted at left metacarpal vein. With side drip #2 Tramadol 300mg in 250mL D5 Water times 24 hours at 90cc level. With short leg cast at right foot; elevated with pillow; with intact dressing; no signs of swelling, edema and cyanosis. Complaints of stabbing pain on right foot. With pain scale of 6 over 10; with facial grimacing when moved; with guarding behavior; limits movement. For wound debridement at 8:00 AM. With consent; billing office informed.
7:00 AM Vital signs taken with initial V/S of Body Temperature: 36.4˚C, Pulse Rate: 120 bpm, Respiration rate: 20 bpm, Blood Pressure: 130/90 mmHg. Informed for OR at 8:00 AM; instructed to NPO diet. Pre-Op checklist completed. Pre-Op CBG taken with result of 269 mg/dL; Dr. Salvador informed. Removed nail polish and dentures.
7:45 AM
Endorsed to OR nurse on duty; Brought to OR per stretcher. For wound debridement and change of dressing.
9:30 AM
Received from OR nurse per stretcher. Transferred to bed comfortably; raised side rails for safty. Conscious and coherent; oriented to time, place and person. Post wound debridement and change of dressing under General Anesthesia. With IVF #3 D5 NM 1L times 8 hours at 100cc level with side drip #2 Tramadol 300mg in 250mL D5 Water at 120cc level; inserted at right metacarpal vein; no swelling; regulated and infusing well. With posterior leg cast at right foot; with intact dressing; no signs of cyanosis, swelling and edema. Vital signs taken every 15 minutes with initial V/S of Body Temperature: 36.2˚C, Pulse Rate: 102 bpm, Respiration rate: 20 bpm, Blood Pressure: 120/90 mmHg. Instructed to DM, LDLF diet once fully awake.
10:00 AM
Changed IVF to PNSS 1L times 12 hours; regulated and infusing well
11:00 AM
Positioned on moderate high back rest. Started inducing food of three spoon of carbonara and 30cc water. Nifedipine, Metoprolol, Omeprazole, Metformin giver per orem.
12:00 NN
Clindamycin given through IV via solucet; regulated and infusing well
2:00 PM
Cefuroxime given through slow IV push. Still with complaints of stabbing pain at right foot. With pain scale of 6 over 10. Encouraged deep breathing exercise; right foot kept elevated. Endorsed to nurse on duty

XII. Nursing Theories Used
XIII. Conceptual Paradigm
PERSON
Human being is a total person as a client system and the person is a layered multidimensional being.
Each layer consists of five person variable or subsystems:
Physiological - Refers of the physicochemical structure and function of the body.
Psychological - Refers to mental processes and emotions.
Socio-cultural - Refers to relationships and social/cultural expectations and activities.
Spiritual - Refers to the influence of spiritual beliefs.
Developmental - Refers to those processes related to development over the lifespan.
ENVIRONMENT
"the totality of the internal and external forces (intrapersonal, interpersonal and extra-personal stressors) which surround a person and with which they interact at any given time."
The internal environment exists within the client system.
The external environment exists outside the client system.
The created environment is an environment that is created and developed unconsciously by the client and is symbolic of system wholeness.
HEALTH
Health is equated with wellness.
“the condition in which all parts and subparts (variables) are in harmony with the whole of the client (Neuman, 1995)”.
The client system moves toward illness and death when more energy is needed than is available. The client system moved toward wellness when more energy is available than is needed
NURSING
a unique profession that is concerned with all of the variables which influence the response a person might have to a stressor. person is seen as a whole, and it is the task of nursing to address the whole person.
Neuman defines nursing as “action which assist individuals, families and groups to maintain a maximum level of wellness, and the primary aim is stability of the patient/client system, through nursing interventions to reduce stressors.’’
The role of the nurse is seen in terms of degree of reaction to stressors, and the use of primary, secondary and tertiary interventions.

XIV. Nursing Care Plan
Subjective Data:
“Medyo masakit parin siya makirot para bang may tumitibok- tibok” as claimed
With pain scale of 6 over 10 as claimed
Objective Data:
With facial grimacing when moved
With guarding behavior towards affected are
Limits movement
With short leg cast at right foot
With intact dressing
No signs of cyanosis, edema and swelling
V/S of Body Temperature: 36.2˚C, Pulse Rate: 102 bpm, Respiration rate: 20 bpm, Blood Pressure: 120/90 mmHg

Assessment/ Diagnosis Alteration in comfort; Acute pain related to post- surgical incision
Planning:
At the end of 8 hours duty, the patients pain scale will decrease from 6 over 10 to 4-5 over 10 and will manifest no signs of lower extremity edema, swelling and cyanosis
Intervention:
Encouraged deep breathing exercise
Rationale: to reduce tension
Elevated right leg with pillow under it
Rationale: to promote proper circulation and avoid lower extremities cyanosis
Removed nail polish
Rationale: to be able to assess for capillary refill

Evaluation: Goal partially met. At the end of eight hours duty, the patient’s pain scale is still at 6 over 10. But with no signs of lower extremity edema, swelling and cyanosis

XV. Health Teachings
Proper Wound Care
General Objective:
At the end of 1-2 hrs. of health teaching, the client will be able to know proper wound care techniques.
Specific Objectives:
Describe signs and symptoms of wound infections
Identify equipment for wound care
Demonstrate wound cleansing
Describe appropriate action if complications arise

Learning Content:
Infection-is the buildup of extra bacteria in the wound that may slow healing and cause other complications

Signs of infection:
(INFECTED WOUND) thick green or yellow drainage foul odor redness or warmth around wound tenderness of surrounding area swelling (WIDESPREAD INFECTION) fever or chills weakness confusion or difficulty concentrating rapid heart beat swelling Wound Care Equipment:
Cleansing solution and materials as prescribed by physician:
Clear water
Mild soap and water
Antimicrobial solution: alcohol
Cotton balls or cotton applicator
Gauze
Bandaging
Gauze wrap
Adhesive tape
Roller bandage
Cleansing/Irrigation--rinsing of the wound by pouring a solution (usually normal saline) over the wound to remove dead cells and the accumulated drainage.
Taking Care of your Wound
Wash your hands:
Rub hands with soap and water for 15 to 30 seconds
Be sure to wash between fingers and under your nails
Rinse well and dry thoroughly
Get your supplies:
Have everything you need ready before you begin
Remove old dressing
Loosen old dressing
Wear clean gloves
Gently take off the old dressing
Turn the gloves inside out over the old dressing
Dispose it properly
Wash/Irrigate the wound
Always follow doctor 's instruction for your wound care
Pour enough solution to dampen the gauze, then wipe your wound using circular motion from the center of the wound outward.
Make sure you use a new gauze each time you wipe and discard the soiled in a plasticbag
Dry surrounding skin by patting with new gauze
Remember to:
Use dressing only once
Keep dressings in a clean, dry place
Throw out the entire dressing if it gets dirty
Clean up:
Put all your dirty supplies in a double plastic bag
Wash your hands
Tell your doctor if:
The wound gets larger or deeper
More fluids drain from the wound
The wound does not begin to show signs of healing in 2 to 4 weeks
You see signs of infection

XVI. References/Bibliography www.scribd.com “Noncommunicable Diseases (NCD) Country Profiles – Philippines (2014)”. World Health Organization. January 23, 2015. < http://www.who.int/nmh/countries/phl_en.pdf?ua=1>.
“Philippines”. International Diabetes Federation. January 23, 2015. <http://www.idf.org/BRIDGES/map/philippines>.

References: Bibliography www.scribd.com “Noncommunicable Diseases (NCD) Country Profiles – Philippines (2014)”. World Health Organization. January 23, 2015. < http://www.who.int/nmh/countries/phl_en.pdf?ua=1>. “Philippines”. International Diabetes Federation. January 23, 2015. <http://www.idf.org/BRIDGES/map/philippines>.