BUERGER’S DISEASE A nursing case study Presented by: Group 26 Charlotte faith Valeroso Barbie Joy Tumaliuan Chramaigne Tumaru Rovierose Sotelo Leslie Agngarayngay Grace Tabanda Rohmar jones Tingonong Caroline D. UY Submitted to: Ms. Divina L. Malana, RN, MSN INTRODUCTION Buerger’s disease is thrombotic and inflammatory occlusion of small arteries and veins among smokers. It is also known as ThromboangiitisObliterans. It involves inflammation and fibrosis of nerves. It results in thrombus formation and segmental occlusion of the vessels.
It is differentiated from other vessel diseases by its microscopic appearance. In contrast to atherosclerosis, Buerger’sdisease is believed to be an autoimmune vasculitis that results in occlusion of distal vessels. Buerger’s disease occurs most often in men between 20 and 35 of age, and it has been reported in all races and in many areas of the world. There is considerable evidence that heavy smoking or chewing tobacco is a causative or an aggravating factor. The clinical manifestations are pain, foot cramps, especially of the arch (instep claudication), after exercise and cold sensitivity.
Physical signs include intense rubor (reddish- blue discoloration) of the foot and absence of pedal pulse, but with normal femoral and popliteal pulses. If the upper extremities are involved, the radial and ulnar artery pulses are absent or diminished. As the disease progresses, definite redness or cyanosis of the part appears when the extremity is in a dependent position. Color changes may progress to ulceration, and ulceration with gangrene eventually occurs. Segmental limb blood pressures are taken to demonstrate the distal location of the lesions or occlusions.
Duplex ultrasonography is to document patency of the proximal vessels and to visualize the extent of distal disease. Contrast angiography is used to identify the diseased portion of the anatomy. Treatment focuses on improving circulation to the extremities, prevent the progression of the disease, and to protect the extremities from trauma and infection. Treatment of ulceration and gangrene is directed toward minimizing infection and conservative debridement of necrotic tissue.
If gangrene of a toe as a result of arterial occlusive disease in the leg, it is unlikely that toe amputation or even transmetatarsal amputation will be sufficient; often, a below- knee amputation or occasionally an above- knee amputation is necessary. The indications for amputation include gangrene, especially if the infected area is moist; severe rest pain; severe sepsis. The disease is found worldwide, but the highest incidence of thromboangiitisobliterans occurs in the Middle and Far East. Figure 1 shows the worldwide prevalence of this disease. SOURCE: emedicine. medscape. com
Figure 1 shows the prevalence of the disease ranges from values as low as 3. 05% in Western Europe to values as high as 54% in India, 41% in Korea and Japan, and 80% among Jews of Ashkenazi ancestry living in Israel. In the country, a growing number of young Filipinos are picking up smoking despite new restrictions on tobacco advertising, according to a nationwide study. Based on health report in 2005, there are 20 million of Filipinos who are smoking. Four million youth, aged between 11 and 19, are smokers, said the 2007 survey commissioned by the World Health Organization and the health department.
The youth group made up 23 percent of all Filipino smokers, compared to about 18 percent in 2005. This 23 percent could further increase in a matter of three years. SOURCE: CVMC Medical records Fig 2 shows the number of cases admitted with Buerger’s Disease for the 4 years in CVMC. There were a total of 5 patients. In 2008, there is 1 patient admitted (male). By the year 2009, there have been 2 patients (a male and a female). In the year 2011, there were 2 males admitted. This figure indicates that males are more at risk than females. This year, from January-November, there were 2 male patients admitted with this disease aged 20-44.
SIGNIFICANCE OF THE STUDY A case study on Buerger’s disease is significant to have an in-depth understanding of the disease. It is important to know and understand its clinical manifestation in order to help the patient manage such. For the Presenters: This will study will provide an opportunity for the presenters to really know the disease that significantly affects anybody. It will also give them an avenue to show how much they have understood about the disease and how much are they able to share effectively to their fellow student nurses – the simplest and the best way that they could.
For the Audience: This study will significantly give essential insights and raise awareness among the members of the audience. Their wrong notions about the disease will be rectified via the case presentation For the Clinical Instructors: This study will provide a venue for the clinical instructors to gauge learning competence of the level three students on medical-surgical nursing concepts taught during the previous semester. It will also provide them the opportunity to give supplements and/or updates not known to the case presenters. OBJECTIVES General:
The very objective of this case study is for the students to have an in-depth understanding of Buerger’s Disease – its manifestations and management – and its prevention. Specific: Towards the end of the case presentation, the following shall have been achieved: 1. Increased knowledge and understanding of the disease among the student nurses 2. Predisposing and precipitating factors shall have been identified including risk factors 3. Full understanding of the disease process 4. Full understanding of the signs and symptoms 5. Enhanced nursing management of signs and symptoms 6.
Enhanced therapeutic communication in dealing with patients 7. Increased skill in educating patients 8. Full mastery of appropriate clinical procedures in diagnosing the disease 9. Enhanced student nurse – patient relationship 10. Enhanced collaboration with other members of the health care team. 11. Increased appreciation among all student nurses on the value of case study & presentation 12. Increased appreciation on the significant roles of nurses in health promotion PATIENT’S PROFILE Name: Patient C. P Age: 58y/o Sex: Male Birth date: January 1, 1958 Birthplace: Lingaling, Sta.
Maria Isabela Address: Lingaling, Sta. Maria Isabela Civil status: Married Nationality: Filipino Religion: Roman Catholic Educational Attainment: Grade Three Occupation: None Chief complaint: Pain on Right Foot Date of admission: November 14, 2011 Time of admission: 3: 42PM Mode of arrival: Ambulatory with assistance Admitting/Initial Diagnosis: Buerger’s Disease Principal diagnosis: Buerger’s disease Attending physician: Dr. Abogado Final Diagnosis: Buerger’s disease Principal Operation Procedure: Syme’s amputation R Sources of Information: Patient, Patient’s chart and SO
Date of discharge: November 18, 2011 Time of discharge: 5: 55 PM NURSING HEALTH HISTORY A. HISTORY OF PRESENT ILLNESS Two months prior to admission, while sleeping at night, the patient experienced painful and tingling sensation on his middle toe of his right foot. He believes that it started with a bite of a rat. He ignored it until the pain disappeared and neither took medicines nor seek for medical advice. One month prior to confinement, he experienced same but more painful that he cannot tolerate it and is aggravated by walking or by prolonged standing and cold environment.
He also noticed that his middle toe appeared red to bluish in color. That’s the time he decided to seek for medical advice at their nearest hospital, Elvin Masigan National Hospital. He was diagnosed with Buerger’s disease. He underwent a procedure which his middle toe was amputated. He was discharged right after the procedure and was advised to return after 1 week for follow up check-up. A week after, he returned to the hospital for his follow up check-up. According to the patient, the doctor noticed that the wound got worse and it started to affect the surrounding area of the amputated toe.
The doctor referred him to CVMC for better evaluation. Last October 26, he was confined at CVMC. He was scheduled for amputation but then the doctor wasn’t available. He was then discharged October 31 and was advised to return on November 14. Last November 14, he returned to CVMC and was readmitted. The operation was successfully done after 2 days of admission. B. HISTORY OF PAST ILLNESS Accordingly, the patient couldn’t recall any childhood illnesses. He only remembers having immunization when he was grade 1. He has no allergies to food and drugs. The patient has no history of any accidents.
If the patient would experience minor pains like headache and muscle pains, fever, cough and colds, he would never take medicines instead he takes his rest until he’ll feel well. According to him, it’s only his second time to be hospitalized. C. FAMILY HISTORY OF ILLNESS The patient’s family has no known history of any hereditary disease like hypertension, diabetes, or heart problems in both paternal and maternal sides. D. PSYCHOSOCIAL HEALTH HISTORY The patient acts as a father of his 4 children. He is married with his 50 years old wife and they live together.
He sometimes depends on his children for financial needs because of unstable job. He is an occasional liquor drinker and a chain smoker consuming one pack or 20 sticks per day. GORDON’S 11 FUNCTIONAL PATTERN HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN Before hospitalization, the patient viewed health as a state in which can perform his work daily and with the absence of illness and diseases. He considers himself healthy as long as he can do all his duties and responsibilities. Whenever he experiences minor pains like fever, cough and colds, he neither takes any OTC drugs nor consults to health care provider.
He doesn’t use any herbal medications. He believes in albularyo . During hospitalization, the patient views his health as poor because of his present condition. He is not able to adjust immediately with the changing environment from his usual lifestyle in the community because of his hospitalization. But, he has a positive outlook and believes he will be able to achieve his normal health again. He tries to comply with all his medications and orders from the healthcare team. NUTRITIONAL- METABOLIC PATTERN Before hospitalization, the patient has no allergies to foods and drugs.
For breakfast, he would drink 2 cups of coffee which he sometimes takes with 2-3 cups of rice. For lunch and supper, he takes 2-3 cups of rice and much prefers to eat fish and vegetables rather than meat. He had good appetite and no problems in chewing and swallowing. According to him, he drinks 5-6 glasses of coffee (1200-1440ml) per day and 8-10 glasses of water (1920-2400ml) daily. He doesn’t take any food supplement. During hospitalization, the patient is under DAT (diet as tolerated). He eats the food served in the hospital consisting of 1 cup of rice, a piece of fish or meat and vegetables.
He drinks 1 glass of milk in the morning. He consumes 3-4 bottles (1 bottle = 500 ml) of water (1500-2000ml). He’s also receiving D5LRS 1L x 8 hours regulated at 31 drops per minute. His weight is 52 kgs. ELIMINATION PATTERN Before hospitalization, the patient usually voids 4-5 times a day, with yellow color of urine. He had no difficulties or discomforts upon voiding. He voided whenever he felt the urge. He defecated twice a day, in the morning upon waking up and in the afternoon. He verbalized that his stool usually appears brown in color and formed. He never used any chemical laxatives and stool softeners.
During hospitalization, the patient voids 2-3 times a day. He stated that sometimes he refrains from voiding because he tries to avoid feeling pain on his right foot. He stated that he needs assistance in going to the bathroom because of his amputated right foot. He verbalized that he haven’t defecated yet for two days from the day of his operation. ACTIVITY-EXERCISE PATTERN Before hospitalization, he states that he does some household chores like cleaning their backyard and chopping firewood. The patient considered walking for 20-30 minutes and performing household chores as his form of exercise.
He verbalized that he was satisfied with the amount of exercise he gets. He considered chatting with his friends as his leisure activity. During hospitalization, the patient’s activities were limited to going to the comfort room with assistance, talking to his visitors, sitting, lying down and stretching his arms. SLEEP-REST PATTERN Before hospitalization, the patient usually sleeps 8 hours from around 10PM and wakes up at 6 AM without any interruptions and has no problem in falling asleep. He is not taking any medications to aid him in sleeping. He takes a nap for 30 minutes in the afternoon and is fully comfortable and well rested.
During hospitalization, he cannot sleep well because of the pain felt on his right foot. When asked to rate the degree of his pain in a scale of 1-10, 1 being the lowest and 10 being the highest, he answered 6 and described his feeling of pain as mild. His sleep is also interrupted by the routine hospital procedures. He stays in bed most of the time and talks to his significant other/s. COGNITIVE-PERCEPTUAL PATTERN Before hospitalization, the patient’s developmental stage does not affect his sense of touch, smell, hearing, taste and sight. In terms of ways to learn new things, the client was able to easily understand new instruction.
He can speak and understand Ybanag and a little bit ofIlocano. He has difficulty in understanding Tagalog. His educational attainment is grade 3 and he’s able to read and write. During hospitalization, the patient is oriented to time, place and person. His senses are still normal. He is able to communicate well and can understand instructions. SELF-PERCEPTION-SELF CONCEPT PATTERN Before hospitalization, he perceived himself as an individual who contributes to the happiness of his family. He is contented seeing his family, their support, love and care. He is very expressive of his thoughts and feelings.
He is a happy person. During hospitalization, the patient’s self concept was affected due to his present condition. He feels bad that he needs to stay in the hospital for a couple of days because he is unable to do his usual activities but according to him, he needs to do it to get better and to be healthy again. ROLE-RELATIONSHIP PATTERN Before hospitalization, the patient plays the role of a father to his 4 children and husband to his wife. He lives with his wife alone. His family serves as his source of strength and inspiration. He is contented by merely seeing his family’s care and love.
There are no conflicts among them and shares his ideas when it comes to decision making. During hospitalization, the patient receives positive reinforcement from his children. They take turns in attending to his needs and in providing him comfort and reassurance. Their relationship became stronger. SEXUALITY-REPRODUCTIVE Before hospitalization, the patient was circumcised when he was 17 years old, got married and had his coitarche at 19th year of age. He stated that he’s still sexually active. He showed affections and love by hugging and kissing his wife and family. He stated the he never engaged in sexual affair outside marriage.
He never tried to use family planning methods. During hospitalization, the patient still shows affection through hugging his wife and family. COPING-STRESS TOLERANCE PATTERN Before hospitalization, according to the client, when under stress or problems occur, his way of coping stress was to keep silent and made a positive way to solve problems instead of drinking alcohol which is not helpful in solving problems. His children, friends are the people who give pieces of advice when he cannot handle certain problems. During hospitalization, the patient uses the same coping mechanism. VALUE-BELIEF PATTERN
Before hospitalization, the patient’s religious affiliation is Roman Catholic. He stated that though he doesn’t attend mass, he has a strong faith in God. The most important thing for the patient is to thank and praise God. He believes that there is always hope. He believes in “ albularyo” During hospitalization, the patient’s relationship with God remained unchanged and incessantly prays to God for her recovery. PHYSICAL ASSESSMENT Date of Assessment: November 17, 2011 Time: 5: 30PM Mental Status * Level of Consciousness: The patient is fully awake, alert, conscious, and coherent and responds to question spontaneously. Orientation: The patient is oriented to person, time and place as he recognized other persons and himself and is aware of when and where he presently is. * Appearance and Behavior: The patient is appropriately dressed and properly groomed. He is cooperative and can follow instruction appropriately. * Speech: The patient can speak and express himself clearly. * Upon assessment: Received lying on bed with ongoing IVF of D5LRS 1 Liter regulated at 31gtts/minute at the level of 650cc, hooked at left arm, patent and infusing well. * Ht: 5 feet and 2 inches Wt: 52 kgs. * BMI: 21. 14 kg/ m2 * Vital Signs: Temp: 37. 1 °C RR: 19cpm PR : 85bpm * BP: 120/70mmHg AREA ASSESSED| TECHNIQUES USED| NORMAL FINDINGS| ACTUAL FINDINGS| ANALYSIS| General Survey| Posture and gait, standing| Inspection | Relaxed, erect posture, coordinated movement| Unstable gait, slight uncoordinated movements | Due to amputation| Overall hygiene and grooming| Inspection | Clean, neat| Clean, neat| Normal | Body and breath odor| Inspection| No body or breath odor| No body or breath odor| Normal | Integumentary (Skin)|
Color and uniformity of color| Inspection| Varies from light to deep brown, generally uniform in color except in areas exposed to the sun| Deep brown, uniform in color generally uniform in color except in areas exposed to the sun| Normal| Edema| Inspection| Absent| Swelling in areas of stump| Sign of inflammatory response| Skin turgor| Palpation| Skin springs back immediately when pinched| Skin springs back immediately when pinched| Normal| Wounds | Inspection| No wounds| Post- operative wound on stump soak in blood| Due to amputaton| Head |
Size, shape and symmetry| inspection| Rounded (normocephalic) | Rounded (normocephalic) | Normal| Presence of mass or nodules| Palpation| No nodules and mass| No nodules or mass| Normal| Scalp| Color and appearance| Inspection| White, pinkish in color, no scales or lice | White in color, no scales or lice | Normal| Areas of tenderness| Palpation| No tenderness| No tenderness| Normal| Hair |
Color| Inspection| brown or black and some white| black| Normal| Thickness| Inspection| Thick| Thin (geriatric consideration)| Normal | Distribution| Inspection| Evenly distributed| Evenly distributed | Normal| Texture | Palpation| Smooth and silky| Smooth and silky| Normal| Eyes| Eyebrows: hair distribution and alignment| Inspection| Hair evenly distributed, skin intact, eyebrows symmetrically aligned| Hair evenly distributed, skin intact, eyebrows symmetrically aligned| Normal| Eyelashes: evenness of distribution and direction of curl| Inspection | Equally distributed, curled slightly outward. Equally distributed, curled slightly outward. | Normal| Eyelids: surface characteristics| Inspection | Skin intact, no discharge, no discoloration| Skin intact, no discharge, no discoloration| Normal| Conjuctiva | Inspection| Conjunctivae are pinkish with visible tiny capillaries and no discharges| Conjunctivae are pinkish with visible tiny capillaries and no discharges| Normal | Sclera| Inspection| White and shiny| White and shiny| Normal | Pupils: color, shape and equality| Inspection| Round, black, equal in size, 3-7 mm| Round, black, equal in size, 3 mm| Normal | Response to light|
Inspection| Illuminated pupils constrict| Illuminated pupils constrict| Normal | Cornea: clarity| Inspection| Transparent, shiny and smooth| Opaque | Due to aging process| Visual acuity | Inspection| Able to read | Able to read| Normal| Lacrimal gland| Inspection and palpation | No edema or tenderness| No edema or tenderness| Normal| EARS:|
Auricles: Color, symmetry of size and position| Inspection| Color is same as the color of the face, symmetrical auricles align in the outer canthus of the eyes| Color is same as the color of the face, symmetrical auricles align in the outer canthus of the eyes| Normal| Texture, elasticity and areas of tenderness| Palpation| Mobile, firm, no tenderness, pinna recoils after it is folded| Mobile, firm, no tenderness, pinna recoils after it is folded| Normal| Auditory function| Inspection| Able to hear clearly| Able to hear clearly| Normal| NOSE:|
Symmetry, shape, color and discharges| Inspection| Symmetrical, straight, no discharges, and uniform in color| Symmetrical, straight, no discharges and uniform in color| Normal| Ability to smell| Inspection| Able to smell and distinguish odor| Able to smell and distinguish odor| Normal| Patency| Inspection| Air moves freely| Air moves freely| Normal | Sinuses| Palpation | Not tender | Not tender| Normal | MOUTH:|
Lips: | Inspection and palpation| Uniform, pink color, soft, moist, smooth texture| Uniform, brown in color, soft, moist, smooth texture| Due to smoking| Tongue: Mobility| Inspection| Moves freely | Moves freely| Normal| Teeth: Color, number, condition and presence of dentures | Inspection| Smooth, white, shiny tooth Enamel, 32 teeth| Tooth decay are present, yellowish and some are black, 30 teeth left, no dentures| Due to smoking| Gums : Signs of Bleeding, swelling| Inspection| No signs of bleeding, no swelling | No signs of bleeding, no swelling| Normal| Tonsils: Swelling, difficulty of swallowing| Inspection| No swelling and no difficulty of swallowing | No swelling and no difficulty of swallowing| Normal | Neck| Presence of lesions or mass| Inspection | No lesions, tremors or mass| No lesions, tremors or mass| Normal | Lymph nodes swelling| Inspection | No lymph nodes swelling| No lymph nodes swelling| Normal | Jugular vein engorgement| Inspection| No engorgement| No engorgement| Normal | Chest |
Symmetry| Inspection | Symmetrical | Symmetrical | Normal | Nipples | Inspection | No itchiness, no inflammation, no cracks | No itchiness, no inflammation, no cracks| Normal | Presence of nipple discharges| Inspection, palpation | No discharges | No discharges| Normal| Lungs | Lung sounds| Auscultation | Lungs clear to auscultation on inspiration and expiration| Lungs clear to auscultation on inspiration and expiration| Normal | Breathing pattern| Inspection | No difficulty of breathing| No difficulty of breathing, | Normal | Rate | Inspection| 12-20 cpm| 19 cpm| Normal | Rhythm | Inspection| Regular| Regular| Normal | Shape and Symmetry| Inspection| Round and Chest symmetric| Round and chest symmetric| Normal| Breath sound| Auscultation| Clear breath sounds| Clear breath sounds| Normal| HEART:| |
Cardiac rate and rhythm | Auscultation | 60-100 bpm| 85 bpm| Normal| Pulse rate deficit| Auscultation | Apical and radial pulse are identical| Apical and radial pulse are identical | Normal | Presence of chest pain| Interview, inspection| No chest pain| No chest pain| Normal | ABDOMEN:| | Skin Integrity| Inspection| follows general body color, or paler than general body color, unblemished skin| Fair , paler than general body | Normal | Abdominal contour| Inspection | Flat round| Flat round| Normal | Bowel sounds| Auscultation| Audible bowel sounds (5 – 35/min)| Audible bowel sounds RUQ-6RLQ-8LUQ-16LLQ-10| Normal| Sounds| Percussion | Tympany| Tympany| Normal | Presence of tenderness| Palpation| No tenderness, relaxed abdomen with smooth, consistent tension | No tenderness, relaxed abdomen with smooth, consistent tension| Normal| Extremities| Nails| | | | |
Shape| Inspection| Convex in curvature| Convex in curvature| Normal| Texture | Palpation | Smooth| Smooth| Normal | Color| Inspection| Pinkish| Pinkish| Normal | Capillary refill| Blanched test| Prompt return to usual color (1-2 seconds)| Prompt return to usual color (1-2 seconds)| Normal | Varicosities| Inspection| No varicosities| No varicosities| Normal | Range of motion | Inspection| Full range of motion without pain| Limited range of motion on right foot| Due to presence of stump| Ability to ambulate| Inspection| Able to ambulate without any assistance| Ambulation with the use of assistive devices (crutches)| Use of assistive devices (crutches)| NEUROLOGIC|
Behavior and appearance| Interview| Makes eye contact with the examiner| Makes eye contact with the examiner| Normal| Speech| Interview| Clear speech| Clear speech| Normal| Recall recent and remote memory| Interview| Able to recall recent and remote information| Able to recall recent and remote information| Normal | LABORATORY RESULT November 14, 2011 Hematology PARAMETER| NORMAL FINDINGS| ACTUAL FINDINGS| Analysis| Rationale| Hemoglobin mass concentration| 135 – 180 g/ dl| 147 g/ dl| Within normal range| Normal| Erythrocyte volume fraction| 0. 40 – 0. 54| 0. 44| Within normal range| Normal| Erythrocyte number concentration| 4. 5 – 6. 0x109/L| 4. 53 x109/L| Within normal range| Normal| Thrombocyte number concentration| 150 – 400×109/L| 355 x109/L| Within normal range| Normal| Mean corpuscular volume| 80 – 100 fL| 96. fL| Within normal range| Normal| Mean corpuscular hemoglobin| 26 – 32pg| 32pg| Within normal range| Normal| Mean hemoglobin content| 320 – 360g/ L| 335 g/ L| Within normal range| Normal| Leukocyte number concentration| 4. 5 – 11×109/L| 13. 9 x109/L| Increased| Due to presence of infection related to gangrene formation related to inflammation due to disease process| WBC Differential count| NORMAL FINDINGS| ACTUAL FINDINGS| Analysis| Rationale| Neutrophils| 35-65| 74. 0| Increased| | Lymphocytes| 20-40| 19. 9| Within normal range| Normal| Monocytes| 2-8| 6. 1| Within normal range| Normal| CLINICAL CHEMISTRY | NORMAL FINDINGS| ACTUAL FINDINGS| Analysis| Rationale| Sodium| 135-145 mmol/ L| 138. mmol/ L| Within normal range| Normal| Potassium| 3. 5-5. 4 mmol/ L| 4. 58 mmol/ L| Within normal range| Normal| Chloride| 96-110 mmol/ L| 108. 1 mmol/ L| Within normal range| Normal| Creatinine| 53. 0-115. 0 µmol/L| 84. 5 µmol/L| Within normal range| Normal| BLOOD CHEMISTRY | NORMAL FINDINGS| ACTUAL FINDINGS| Analysis| Rationale| Glucose| 4. 44 – 6. 01 mmol/ L| 5. 35 mmol/ L| Within normal range| Normal| Triglycerides| 0. 46 – 1. 71 mmol/ L| 0. 92 mmol/ L| Increased| | Cholesterol| 3. 90 – 5. 20 mmol/ L| 3. 59 mmol/ L| Decreased| | HDL| 0. 91 – 1. 68 mmol/ L| 0. 92 mmol/ L| Within normal range| Normal| LDL| 0. 0 3. 8 mmol/ L| 2. 3 mmol/ L| Within normal range| Normal| VLDL| 0. 18 – 0. 772 mmol/ L| 0. 418 mmol/ L| Within normal range| Normal| COAGULATION ASSAY RESULT PT(Prothrombin time) | Actual findings | Reference range | Analysis | Patient’s time| 13. 6 sec. | 12-16 sec| Normal| Control time | 13. 2 sec. | 12-16 sec| Normal| % Activity| 94. 4%| | | Activated Partial Thromboplastin Time (aPTT) | Actual findings | Reference range | Analysis | Patient’s time| 31. 17 sec. | 26-38 sec. | Normal| ANATOMY AND PHYSIOLOGY Arteries are blood vessels that carry blood away from the heart. Blood is pumped from the ventricles of the heart into large elastic arteries, which branched repeatedly to form progressively smaller arteries.
As they become smaller, the arteries undergo a gradual transition from having walls containing more elastic tissue than smooth muscle to having walls with more smooth muscle than elastic tissue. The arteries are normally classified as elastic arteries, muscular arteries or arterioles, although they form a continuum from the largest to the smallest branches. Blood flows from the arterioles into capillaries, where exchange occurs between the blood and tissue fluid. Capillaries have thinner walls. Blood flows through them more slowly and there are far more than any other blood vessel type. PATHOPHYSIOLOGY Predisposing factor: > 20 and above > male > Asians and Jews > Autoimmune disorder Precipitating factor: > Occupation > Diet (excessive intake of coffee) > smoking Inflammation of small and medium sized blood vessels
Inflammatory factors migrate to affected inflamed area Platelet deposition Thickening of vessels Micro abscess formation Fibroid occlusion Luminal thrombotic occlusion Impaired blood supply hypoperfusion Decreased O2 supply Ischemia Cellular aerobic respiration Lactic acid production 2 molecules of O2 formation Decrease integrity of pulse Intermittent claudication Further ischemia Cold to touch Weak pedal pulse Necrosis (if unmanaged) COURSE IN THE WARD November 11, 2011 DOCTOR’S ORDER| RATIONALE| NURSING RESPONSIBILITIES| Pls. admit under my service| For further monitoring, management, and evaluation of patient’s condition| * Prepared and filled out necessary documents. Obtained initial vital signs and recorded. | DAT| To meet nutritional-metabolic needs| * Informed and explained to the patient and significant others about the ordered diet. | v/s q shift| To monitor deviation from normal values| * Monitored v/s q shift and reported immediately any deviation and recorded. | Diagnostics> CBC> 12 LED ECG> CXR AP> Na, K, Cl> FBS, Crea| To determine alteration in blood components, electrolyte imbalances, and involvement of the major organs affected. | * Verified doctor’s order. * Informed the patient about the diagnostic exams. * Filled out necessary request forms. * Informed the laboratory department about the exams. Followed up results and attached to the patients chart. | 2: 45PMFollow up all lab results and refer for final evaluation| All lab results are followed up preoperatively to determine whether the patient can proceed to the scheduled operation. | * Followed up all lab results and attached to the patient’s chart * Referred for final evaluation| For PT, PTT| PT and PTT are bleeding parameters in order to determine the patient’s blood coagulation activity and for preparation to OR. | * Verified doctor’s order * Informed the patient about the diagnostic exams. * Filled out necessary request forms. * Informed the laboratory department about the exams. Followed up results and attached to the patients chart. | Facilitate FBS| To determine the level of blood sugar; elevated blood sugar may cause poor wound healing since the patient will undergo an invasive procedure and to rule out that the reason of TAO caused by DM. | * Verified doctor’s order * Informed the patient about the diagnostic exams. * Filled out necessary request forms. * Informed the laboratory department about the exams. * Followed up results and attached to the patients chart. | Start antibiotic, Ciprofloxacin 500mg/ tab 1 ? tab BID| To prevent further infection and promote wound healing. | * Verified doctor’s order * Observed 10 Rs of drug administration. gt; right drug> client> route> dose> education> assessment> time> refuse> evaluation> document * Check for renal impairment * Assess for allergy to ciprofloxacin| Will follow up patient| For further assessmentand treatment| * Referred and endorsed accordingly| Refer| For further assessmentand treatment| * Referred and endorsed accordingly| November 15, 2011 9: 00AMFor “ E” debridement, Syme” s| Clean out dead tissue; Prevent infection and promote healing and to determine the extent of the distal disease for amputation. | * Witnessed the signing of consent. * Informed the surgery department| Secure consent| For medico-legal and ethico-moral purposes| * Verified if the patient understood the rules and regulations according to the hospital policy. * Reinforced information explained by the attending physician regarding admission. Witnessed the signing of the informed consent| Send OR request| To inform OR team| * Facilitated sending OR request| Inform AROD (Anesthesiologist Resident on Duty)| Anesthesiologist to have own assessment regarding to what kind of anesthesia will be use| * Informed the AROD| Refer| For further assessmentand treatment| * Referred and endorsed accordingly| Start Oxacillin 1g/ IVq 6hrs. ANST 1 hr prior to OR| For prophiylaxis| * Verified doctor’s order * Observed 10 Rs of drug administration. * Assess for allergy to penicillin| IVF of D5LRS 1L x 8hrs once on NPO| The patient needs sugar containing fluid while he is under NPO and serve also as an access for IV medication| * Regulated IVF at 31gtts/ min and put on IV tag| | | | 9: 15AM| | | Suggest adequate oxygenationMay nebulizer with Ipratropium neb. PRN for dyspnea| Ipratropium is a bronchodilator which prevents bronchospasm thereby maintains airway patency| * Verified doctor’s order * Observed 10 Rs of drug administration. Encourage deep breathing exercise| To promote maximum lung expansion to prevent congestion| * Instructed patient the proper way of deep breathing exercise| Encourage early ambulation post operatively| To prevent stagnation of blood in the area of stump for better blood circulation| * Instructed the patient to perform early ambulation post operatively. * Instructed significant other/s to assist patient. | We will follow up patient c/o yellow team| To monitor patient for further assessment and evaluation. | * Followed up patient with collaboration to yellow team. | Refer| For further assessmentand treatment| * Referred and endorsed accordingly| 5: 45PMPre anesthetic ordersFor OR tomorrow under regional anesthesia| To prepare the patient preoperatively| * Informed the patient the scheduled operation| Anesthetic plan and risks explained to pt. nd daughters understood accepted| To inform the patient and significant other/s about the procedure to be done and its risk| * Act as a witness| NPO post midnight| To prevent aspiration during actual operation| * Enforced the patient to not eat anything by mouth| Check for patency of IV line prior to OR| Serve as an access for IV medication. | * Ensured that the IV line is well regulated| Refer| For further assessmentand treatment| * Referred and endorsed accordingly| 12: 20PMPost Op Ordersv/s q 15 mins. Until stable and record pls. | To monitor deviation from normal values. | * Monitored and recorded v/s every 15 mins. and reported immediately any deviation from normal. O2 regulate at 2 Liters/min via face mask| To provide adequate oxygenation| * Provided O2 and regulated as ordered. | DAT once fully awake| To provide nutritional metabolic needs. | * Informed and explained to the patient and significant others about the ordered diet. | IVF order D5LRS 1L x 12 hrs. | For hydration and serve as an access for IV medication | * Verified doctor’s order * Regulated at 21 gtts/ min. and put on IV tag. | Meds:> Nalbuphine 10mg IV q 4 PRN> Ketorolac 30mg IV q6 ANST x 4 doses then shift to mefenamic acid 500mg / cap TID> Continue IV antibiotic | * For pain relief * To prevent infection and for pain relief * For better outcome and continuation of treatment. * Verified doctor’s order * Observed 10 R’s of drug administration| Keep thermoregulated| * To prevent chilling and provide patient’s comfort. * To keep patient’s body temperature normal. | * Kept the room warm and instructed patient on proper clothing. * Monitored patient’s body temperature and recorded. | Moderate high back rset| To promote maximum lung expansion and to prevent congestion. | * Assisted patient on proper positioning. | Encourage DBE| To promote lung expansion and maintain airway patency| * Instructed the patient the proper way of deep breathing exercise| Refer accordingly| For further assessment and treatment. | * Referred accordingly. | 2: 00PMMay transfer to ward| For further assessment and onitoring| * Assisted the patient| Refer| For further assessmentand treatment| * Referred and endorsed accordingly| November 18, 2011 12: 24PMMGH today| Signs and symptoms are manageable; not causing so much trouble to the patient| * Explained to the pt the need for follow up consultations/check up * Instructed pt regarding home meds * Took VS * Assisted pt in preparing her things and other personal belongings. | Daily wound dressing done| To promote wound healing thereby preventing infection. | * Evaluated wounds for infections. * Performed proper wound dressing. * Educated patient and significant other/s on proper wound care. * Demonstrated wound care procedures to significant others. Post op care and complications explained| To educate patient regarding proper wound care thereby promote wound healing and prevent further complications| * Educated patient and significant other/s on proper wound care. * Demonstrated wound care procedures to significant others. * Explained patient the possible complications if left untreated. | Home meds:> Clindamycin 300mg/ cap BID> Ciprofloxacin500mg/ cap TID| To prevent further infection and promote wound healing. | * Verified doctor’s orderObserved 10R’s of drug administration. | For follow up checkup on November 29, 2011| The patient must do a follow up care to continue post care. | * Advise the patient to strictly follow the scheduled follow up check up. | NURSING CARE PLAN
ASSESSMENT | DIAGNOSIS | PLANNING | IMPLEMENTATION | RATIONALE | EVALUATION | Subjective: “ mataki yaw gurig na nagappo tu takki ”(“ the wound on my amputated foot is painful”), as verbalized by the patientObjective:> presence of post-op wound> guarding behavior> facial grimace> irritability> pain scale 6/10 | Pain related to traumatized nerve endings secondary to surgical procedure | After 30 minutes of nursing intervention the patient will be able to report pain relief/control and pain scale from 6/10 to 2/10 | * Assessed quality of pain as appropriate * Positioned comfortably on bed * Promoted quite environment and calm activity * encouraged used of relaxation technique such as focused breathing| * To help patient determined possibility of underlying condition * to promote comfort * to promote non-pharmacological pain management * to distract attention and to reduce tension| Goal partially met as evidence the patient verbalization of decreased pain from 6 to 4. | | | | * encouraged adequate rest period * administered medication as ordered| * To prevent fatigue * To relieve pain | |
Assessment | Diagnosis | Planning | Implementation | Rationale | Evaluation | Subjective * ” makatal anna mataki y gurig ku” ( My wound is itchy and painful ) Objective * disruption of skin surface | Impaired skin integrity r/t surgery | At the end of the shift the patient will participate in prevention measures and treatment regimen | * Encouraged patient to provide optimum nutrition, including vitamins and increase protein * Encouraged early ambulation mobilization * Instructed the patient to avoid mechanical trauma. | * To provide nitrogen balance to aid in skin tissue healing and to maintain general good health * Promote circulation and reduces risks associated with mobility * To prevent further trauma | Goal met. The patient was able to participate and cooperate in preventing and treatment regimen | ASSESSMENT | DIAGNOSIS | PLANNING | IMPLEMENTATION | RATIONALE | EVALUATION | Subjective:“ Amme makalakag magitadday nu awan tu mangalalay niakang”(‘ I can’t walk alone without assistance. )Objective: Limited ROMSlowed movementGait changes | Impaired physical mobility related to loss of limb | After two days, the will demonstrate techniques or behavior that enable resumption of activities | * Supported affected body parts/ joints using pillows or soft mattresses * scheduled activities with adequate rest periods during the day * Identified energy-conserving techniques for ADL’s| To maintain position of function and reduce risk of pressure ulcerto reduce fatigueLimits fatigue, maximizing participation| Goal met; After two days, the patient to demonstrate techniques or behavior that enable resumption of activities. | | | | * Encouraged participation in self-care, divertional/ recreational activities * Encouraged adequate intake of fluids/ nutritious food * Administered edication prior to activities as needed for pain relief | Enhances self concept and sense of independencePromotes well being and maximizes energy productionTo permit maximal effort/ involvement in activities | | Assessment | Diagnosis | Planning | Implementation | Rationale | Evaluation | Subjective * Kunnasi ngana tamma ngana , awang ngana y tadday tu takki. (what will happen now, I lost my 1 foot already) | Disturbed body image r/t surgery (amputation) | At the end of the shift, the patient will be able to manifest acceptance of presence condition by looking or touching body part and verbalizing acceptance of presence condition | * Evaluated level of client’s knowledge of and anxiety related to situation. Notes sign of grieving/indicators of severe and prolonged depression | * Observed emotional changes which may indicate acceptance/not acceptance of situation * To evaluate need for counselling and/ or medications | Goal not met the patient was not able to manifest acceptance of present condition. | Objective * missing right metatarsals * not looking or touching body part | | | * Assessed client’s current level of adaptation and progress * Encouraged family members to treat client normally and not as an invalid | * To determine to coping abilities and skills * To assist S. O to deal with or accept issues of self-concept related to body image. | | ASSESSMENT | DIAGNOSIS | PLANNING | IMPLEMENTATION | RATIONALE | EVALUATION | Subjective:“ namegafu yaw nguri ta nakaga na akag y takki. ”(it started when my foot bitten by a rat), as verbalized by the patient . Knowledge Deficit r/t statement of misinterpretation | After 1 hour, the patient will verbalize understanding of his condition/ disease process b restating the given information | * Assessed patient’s, willingness in learning * ascertained level of knowledge and preferred dialect * involved significant other in health education * provided adequate information > causes > simple tracing of the disease process> prevention * encouraged to ask question | * to achieve implementation of plan * to facilitate learning * significant other is also implementor of care regimen * to increase awareness and understanding of his disease * for clarification purposes| Goal met after 1 hour of nursing intervention , the patient verbalized “ ammu ngana ta ngatta nakunaw nga y passigarilyu akkantu ta kagana akag (now I know that smoking is the cause of my present condition, not the bite of the rat ) | DRUG STUDY
DRUG | CLASSIFICATION | ACTION | INDICATON | CONTRAINDICATION | ADVERSE EFFECT | NURSING RESPONSIBILITIES | Ranitidine 50mg IV| H2 receptor antagonist| Inhibits the action of histamine at the H2-receptor site located in gastric parietal cells, resulting in inhibition of gastric acid secretion| Short term treatment of active duodenal ulcers and benign gastric ulcers. Management of GERD. Treatment of heartburn, acid indigestion and sour stomach. | Contraindicated in hypersensitivity lactation and pregnancy. | CNS, confusion, dizziness, drowsiness, headache, hallucination. CV: arrhythmiasGI: diarrhea, constipation, nausea, drug induced hepatitisEndo: gynecomastia Hemat: aplastic anemia, neutropenia, thrombocytopenia| 1. Assess for epigastric or abdominal pain and frank or occult blood in the stool, emesis or gastric aspirate. 2. Assess geriatric and debilitated patients routinely for confusion. Report promptly. 3.
Inform patient that increased fluid and fiber intake may minimize constipation. 4. Caution patient that the drug may cause dizziness or drowsiness. 5. Inform patient that medication may temporarily cause stools and tongue to appear gray black. 6. Advise patient to report onset of black, tarry stools; fever; sore throat; diarrhea; dizziness; rash or hallucinations to healthcare professional promptly| DRUG | CLASSIFICATION | ACTION | INDICATON | CONTRAINDICATION | ADVERSE EFFECT | NURSING RESPONSIBILITIES | CIPROFLOXACIN 500mg/ tab 1 ? tab BID| Therapeutic: Anti-infectivesPharmacologic: Fluoroquinolenes| Inhibit bacterial DNA synthesis by inhibiting DNA gyrase.
Therapeutic effects: Death of susceptible bacteria| Treatment of the following bacterial infections: UTI, Respiratory Tract Infections, skin and skin structure infections, bone and joint infections and intra-abdominal infections. | Contraindicated in hypersensitivity to ciproflaxin or other fluoroquinolones and pregnancy| CNS: seizures, dizziness, headache, insomnia, agitation, confusion and drowsiness. CV: arrhythmias and vasodilationGI: diarrhea, nausea, abdominal pain, and increased liver function tests. GV: vaginitisDerm: photosensitivity and rashEndo: hyperglycemia, hypoglycemia| 1. Assess for infection (vital signs, appearance of wound, sputum, urine and stool; WBC; urinalysis; frequency and urgency of urination; cloudy or foul smelling urine) prior to and during therapy. 2.
Observe for signs and symptoms of anaphylaxis(rash, pruritus, laryngeal edema, wheezing) 3. Instruct patient to take medication as directed at spaced times and to finish drug completely even if feeling better. 4. Encourage patient to maintain a fluid intake of at least 1500-2000 ml a day to prevent crystalluria. 5. Advise patient that the drug may cause dizziness and drowsiness. | DRUG | CLASSIFICATION | ACTION | INDICATON | CONTRAINDICATION | ADVERSE EFFECT | NURSING RESPONSIBILITIES | CLINDAMYCIN 300mg/ cap BID| Anti-infectives | Inhibits protein synthesis in susceptible bacteria , causing cell death| Treatment of skin and skin structure infections| Contraindicated with allergy to clindamycin, lactation. CV; Hypotension, cardiac arrest(with rapid IV infusion)Hypersensitivity; RashesLocal: Pain following injectionCNS; Fatigue, Headache| 1. Assess for infection (vital signs; appearance of wound) at beginning of and during therapy. 2. Assess patient for sensitivity(skin rash) 3. Be aware that serious facial colitis can occur; reserve use, and monitor patient closely| DRUG | CLASSIFICATION | ACTION | INDICATON | CONTRAINDICATION | ADVERSE EFFECT | NURSING RESPONSIBILITIES | MIDAZOLAM 2mg IV| Benzodiazepine (short-acting)CNS depressant| Acts mainly at the limbic system and reticular formation; potentiates the effects of GABA, an inhibitory neurotransmitter; anxiolytic and amnesia effects occur at doses below those needed to cause sedation. Sedation, anxiolytics, and amnesia prior to diagnostic, therapeutic, or endoscopic procedures or surgery. | Contraindicated with hypersensitivity to benzodiazepines, shock, coma, acute alcoholic intoxication, pregnancy. | CNS: transient and mild drowsiness, sedation, sedation, depression, lethargy, apathy, fatigue, light- headedness, disorientation, restlessness, confusion, delirium, slurred speech, stupor, tremor, vertigo, and difficulty in concentration. CV: bradycardia, tachycardia, hypotension, palpitations and edemaGI: constipation, dry mouth, salivation, nausea, anorexia, vomiting, GU: incontinence, urine retention| 1. Monitor IV injection site for extravasation 2.
Arrange to reduce dosage if patient is also being given opioid analgesic 3. Monitor patient’s v/s closely 4. Monitor level of consciousness before, during, and for at least 2-6 hr after administratio | NAME | CLASSIFICATION | ACTION | INDICATION | CONTRAINDICATION | ADVERSE EFFECT | NURSING RESPONSIBILITY | Nalbuphine 10mg IV q 4 prn | Analgesic | Binds with opiate receptors in the CNS altering both perception of emotional response to pain | Moderate to severe pain adjunct to balance anesthesia | Contraindicated with patients with hypersensitive to drug | CNS: headache, sedation, diziness vertigo GU: urinary urgency | 1. Observe 10 R’s in administering medication. 2. each patient how to manage troublesome adverse effect such constipationm | NAME | CLASSIFICATION | ACTION | INDICATION | CONTRAINDICATION | ADVERSE EFFECT | NURSING RESPONSIBILITY | Ketorolac 30 mg IV q6 ANST x4 doses | Non-steroidal anti inflammatory | Inhibits prostaglandins and leukotriene synthesis | Short term pain management | Contraindicated with significant renal impairment during concurrent used of NSAIDS, PUD, recent GI bleeding perforation, hypersensitivity to ketorolac, treatment for perioperative care for CABG, suspected or confirmed cerebro vascular bleeding, hemorrhagic diathesis, incomplete homeostasis | CNS: headache, dizziness, insomnia, fatigue, tinnitus, ophthalmologic effects.
Dermatologic: Rash, Pruritus, sweating, dry mucus membranes, GI: pain, diarrhea, vomiting, constipation, flatulence, gastric or duodenal ulcerGU: dysuria, renal impairment | 1. Observe 10 R’s in administering medication. 2. Monitor patient regularly because patient is at risk for cardiovascular events, GI bleeding, renal toxicity3. Keep emergency equipment readily available at time of initial dose in case hypersensitivity reaction | NAME | CLASSIFICATION | ACTION | INDICATION | CONTRAINDICATION | ADVERSE EFFECT | NURSING RESPONSIBILITY | ipratropiu, m neb | Anticholinergic, bronchodilator | Anticholinergic, chemically r/t atropine, w/c blocks vagally mediated reflexes by antagonizing tye action of acetylcholine.
Cause broncho dilation and inhibits secretion from serous and seromucous glands lining the nasal mucosa | Broncho dilator for maintenance treatment of bronchospasm associated w/ COPD, Chronic Bronchitis and Emphysema | Contraindicated w/ hypersensitivity to atropine or its derivatives, soybean or peanut allergies (aerosol) | CNS: nervousness, dizziness, headache, fatigue, insomia, blurred vission, GI: nausea, gastrointestinl, dry mouth, Respiratory: Dyspnea, bronchitis, bronchospasm, cough, hoarseness, pharyngitis Others;> Back or chest pain> Palpitations| 1. Observe 10 R’s in administering medication2. Instruct to use of nebulizer , mouth piece instead face-mask to avoid blurred vission 3. Ensure adequate hydration4. Intruct patient to void before taking medication to avoid urinary retention5. Teach patient proper use of inhaler 6. Instruct patient to use this drug as inhalation product|
NAME | CLASSIFICATION | ACTION | INDICATION | CONTRAINDICATION | ADVERSE EFFECT | NURSING RESPONSIBILITY | Mefenamic 500 mg/ cap TID | NSAIDS | Anti-inflammatory, analgesic, anti- pyreticActivities r/t inhibition of prostaglandin synthesis, exact mechanism of action are not known | Relief of moderate pain when therapy will not exceed in one week | > Contraindicated w/ hypersentivity to mefenamic acid, aspirin, allergy and as treatment of perioperative pain w/ CABG. > Use cautiously w/ asthma, hepatic impairment, PUD, gastro intestinal bleeding, heart failure | CNS: headache, dizziness, somnolence, insomnia, fatigue, tirednessDermatologic: Rash, sweating, dry mucus membraneGI: Nausea, dyspepsia, gastrointestinal pain, diarrhea, vomiting and constipation | 1. Observe 10 R’s in administering medication2. instruct patient to take the drug w/ food3. Give milk/food to decrease GI upset4.
Discontinue drug and consult health care provider if rash, diarrhea, or digestive problem, dizziness drowsiness can occur| DISCHARGE CARE PLAN MEDICATION: Emphasized to the patient the importance of strict compliance in taking his medication prescribed by the doctor, proper way of administering at the right time, right route and right dosage such as: * Clindamycin 300mg/cap BID > Instructed the patient to take the drug with a full glass of water and with food. > Instructed the patient to take full prescribed course of the drug. > Do not stop taking it without notifying his doctor. * Ciprofloxacin 500mg/cap TID > Instructed the patient to take the drug with a full glass of water and with food. > Instructed the patient to swallow the drug. gt; Instructed the patient to complete full course of the drug. EXERCISE: * Encouraged the patient to practice the use of assistive device (crutches) to promote independent mobility. * Encouraged the patient to perform movement such as walking within the limit of therapeutic immobility. * Instructed patient to perform active range-of-motion exercises and isometric exercises like flexion, extension and rotation can be done to maintain the muscle needed for ambulation. TREATMENTS: * Instructed patient and the significant others to follow religiously the treatment regimen especially the medications prescribed. * Instructed the patient to perform daily wound dressing. Advised the patient to stop smoking. HYGIENE: Educated the patient and the significant others on basic hygiene practices. Encouraged patient to properly observe and promote proper hygiene and other sanitary measures like taking a bath every day, brushing teeth, washing hands before and after meals and explained its importance in building and promoting a sound and healthy body. Emphasized also the importance of proper foot care guidelines especially the stump on his right foot: * Instructed patient to avoid touching operative wound with dirty hand for this may cause infection. * Always inspect stump daily for signs of irritation * Wash with warm water and bacteriostatic soap. Rinse and dry thoroughly. Never apply lotion, powder or alcohol on the stump for this may cause irritation. OUT PATIENT DEPARTMENT: * Instructed patient to strictly follow the scheduled follow-up check up on November 29, 2011 at CVMC. * Emphasized for the importance of the following check-up schedule to continue post- op care. DIET: * Advised patient to eat balanced nutritious foods especially protein and vitamin C rich foods such as meat, fish, green leafy veggies, and citrus fruits to promote wound healing. * Instructed patient to increase oral fluid intake to promote good circulation. SPIRITUALITY: * Advised to continue praying and thanking God for the blessings.