pyomyositis case study
TRANSCRIPT
PYOMYOSITIS
Introduction
Background
Pyomyositis is an inflammation of muscle tissue, usually of voluntary muscles that results in pus production. Once considered a tropical disease, it is now seen in temperate climates as well. The pathogenesis is unclear, but trauma, infections (S. aureus, S. pneumoniae), and malnutrition have been implicated. Although most cases of pyomyositis occur in healthy individuals, other pathogenetic factors include nutritional deficiency and associated parasitic infection in tropical climates. In the temperate climates, pyomyositis is seen most commonly in patients with diabetes, HIV infection, and malignancy.
Clinical Presentations
Presentation with painful, tender, localized swelling over muscle Fever Epidural abscess
Complications
Life-threatening complications include sepsis and toxic shock syndrome.
Diagnosis
CT scan or MRI demonstrates muscle abscess. Aspiration of abscess (by surgery or CT/US guided) yields pus, usually yielding S. aureus. Bacteremia may accompany.
Treatment
Medical Care
Promptly administer systemic antibiotics. This could eliminate the need for surgical drainage in selected cases.
The choice of antibiotic is determined by identification of the causative organism. Antibiotics initially are given intravenously until clinical improvement is noted, followed
by oral antibiotics for a total course of 3 weeks (eg, cefazolin or ceftriaxone IV followed by cephalexin PO).
Surgical Care
During the suppurative phase, abscess aspiration under ultrasonic or CT guidance may be required. Surgical drainage is especially necessary for large abscesses.
Complicated cases may require fasciotomies and debridement.
Prognosis
Prompt administration of antibiotics can result in complete resolution.
Specific Objectives:
Define Pyomyositis. Identify the signs and symptoms manifested by the patient. Distinguish the precipitating and predisposing factors that trigger this development. Trace the pathogenesis based on the signs and symptoms manifested by the patient. Determine appropriate medical and nursing management for the patient. Use the nursing process as the framework for the care of the patient.
Significance of the Study in Nursing Field:
Shall have critical thinking skills necessary for providing safe and effective nursing care. Shall have a comprehensive assessment and implement care base on our knowledge and skills of
the condition. Shall have familiarized with effective interpersonal skills to emphasize health promotion and
illness prevention. Shall have imparted the learning experience from direct patient care.
PATIENT’S PROFILEName: Baby DyeinSex: Female Birthday: October 2007Age: 2 - 3 y/oReligion: Roman CatholicCivil Status: SingleNationality: FilipinoDate of Admission: July 27, 2010Time of Admission: 8:40 PMAdmission Diagnosis: Pyomyositis Left Scapular AreaAttending Physician: Dr. De Guzman
A. Family BackgroundBaby Dyein is the youngest among the four siblings.
B. Educational and Socio - Economic Status
She does not go to school yet. The rest of the siblings are funded for their educational expenses by one of their mother’s rich customers as a laundry woman, except that the eldest child does not go to school anymore as she decided to stop studying and just help work.
C. Lifestyle and DietShe eats three times a day and drinks 5-6 glasses of water a day though mostly breastfeed
on her mother.
D. Family Health HistoryNo family history of pyomyositis, diabetes, hypertension, tuberculosis, diabetes, nor any
other diseases reported.
E. Immunization RecordWith complete record of immunization.
F. Past Health History Had cough, colds and fever but is only hospitalized once – now due to pyomyositis.
G. Present Health HistoryOne month prior to consultation, patient together with her older brother had a fall as she
was given a piggy backride. Patient fell on her left scapular area and complained of pain. Her mother had her massaged by a so-called manghihilot. Three weeks prior to consultation, patient still complained of pain and endured of fever and localized swelling on the left scapular area. Another hilot session was done and patient was given TSB. But as the swelling and fever still persevered, patient was brought to the nearest clinic. Patient was given Paracetamol and was referred to Philippine Orthopedic Center. Patient was admitted.
ANATOMY AND PHYSIOLOGY
The scapula or shoulder blade is the bone that connects the humerus (arm bone) with the clavicle (collar bone). The scapula forms the posterior located part of the shoulder girdle. It is a flat bone, roughly triangular in shape, placed on a posterolateral aspect of the thoracic cage.
LEFT SCAPULA . LATERAL SURFACE
CORACOID PROCESS - bony projection on the shoulder blade
GLENOID CAVITY– holds the head of the humerus SUPRAGLENOID TUBERCLE – rounded protuberance
above the glenoid cavity INFRAGLENOID TUBERCLE – rounded protuberance below
the glenoid cavity SPINE – a bony projection from the glenoid to acromion ACROMION - bony projection from the outer end of the spine of
the shoulder blade, to which the collar bone is attached AXILLARY BORDER – near to armpit INFERIOR ANGLE - gives greater strength to the body of the bone
by its arched form
OSSIFICATION OF SCAPULA
The larger part of the scapula undergoes membranous ossification. Some of the outer parts of the scapula are cartilagenous at birth, and would therefore undergo endochondral ossification.
The head, processes, and the thickened parts of the bone, contain cancellous tissue; the rest consists of a thin layer of compact tissue.
The central part of the supraspinatous fossa and the upper part of the infraspinatous fossa, but especially the former, are usually so thin as to be semitransparent; occasionally the bone is found wanting in this situation, and the adjacent muscles are separated only by fibrous tissue.
PATHOGENESIS
Fell on her left scapular Area from a Piggy Backride
Inflammatory Response
Vascular Response Chemical Response
Vasodilatation
Increased Membrane
Permeability
Redness
Heat
Swelling
Systemic Response
Pain Leukocytosis Infiltration
Increased ESR
Fever
PR and RR
Trauma: Pressure by hilot
Abscess Formation
PYOMYOSITIS
IF NOT TREATED:Toxic Shock Syndrome
Sepsis
IF TREATED:Good Prognosis
Recovery
DIAGNOSTIC EXAMS
COMPLETE BLOOD COUNT
Results Normal Values Interpretations Nursing Responsibilities
Hemoglobin 107 110 - 158 g/L Bone marrow suppression or iron deficiency
anemiaIron deficiency
anemia:> Diet. Foods rich in
iron.
Tissue Injury and Trauma:
> Monitoring of VS.> Wound Care
> Diet. Foods rich in protein and Vit. C.> Administration of
prescribed medications.
> Avoid pressure on the affected area.
Hematocrit 0.34 0.37 - 0.54 Iron deficiency anemia
Leukocyte Count 22.4 4.5 - 10 x 109/L Tissue injuryDifferential Count
Segmenters 0.75 0.50 - 0.70 Tissue injuryLymphocytes 0.19 0.20 - 0.40 Tissue injuryPlatelet Count 513 150 - 400 x 109/L Trauma
IndicesMCV 69.9 82 - 92 Iron deficiency
anemiaMCH 21.9 28 - 32 Iron deficiency
anemiaMCHC 31 32 - 38 Iron deficiency
anemiaESR 128 0 - 10mm/hr Iron deficiency
anemia
MUSCULOSKELETAL SONOGRAPHY
There is a 5.0 x 1.2 cm complex mass in the left scapular area. Remainder is unremarkable.
Impression: PYOMYOSITIS
DRUG STUDY
Drugs Name Dosage Indication Action Adverse Effects Nursing ConsiderationsGeneric Name: Ibufropen
Brand Name: Apo – Ibufropen
Pharmacologic Class:NSAID
100/s 5ml q8 x 7 days
> Mild to moderate pain> Fever
May inhibit prostaglandin synthesis, to produce anti-inflammatory, analgesic, and antipyretic effects.
CNS: dizziness, headacheCV: edemaEENT: tinnitusGI: decreased appetite, peptic ulcerationGU: acute renal failureRespiratory: bronchospasmsSkin: Stevens – Johnson Syndrome
> NSAID may mask S/S of infection> It may take 1 or 2 wks before full anti inflammatory effects occur> Take with meals> Use with aspirin may increase risk of GI adverse reaction> Report for S/S of GI bleeding
Generic Name:Acetaminophen
Brand Name:Paracetamol
Pharmacologic Class:Para-aminiohenol derivative
80 mg q4 IV > Mild pain or fever
Blocks pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating center.
Hepatic: jaundiceMetabolic: hypoglycemiaSkin: rash, urticaria
> Given for T>38.0°C> Monitor V/S
Generic Name:Cefuroxime
Brand Name: Ceftin
250mg IV q8 > Skin infection Inhibits cell wall synthesis, promoting osmotic instability.
CV: phlebitisGI: diarrhea, N/V, anorexiaSkin: rashes, urticaria
> Perform skin test (ANST)> Give if ANST (-)> Take with meals> Monitor for signs of infection
Pharmacologic Class:2nd gen. cephalosphorinGeneric Name:Ceftazidime
Brand Name:Tazicef
Pharmacologic Class:3rd gen. cephalosphorin
22 in 50ml IV > Bacteremia and skin infection
Inhibits cell wall synthesis, promoting osmotic instability.
CNS: seizures, headacheCV: phlebitisGI: diarrhea, N/VSkin: rashes, urticaria
> Perform skin test (ANST)> Give if ANST (-)> Take with meals> Monitor for signs of infection
NURSING CARE PLAN
Assessment Nursing Diagnosis Scientific explanation Planning Intervention Rationale EvaluationSubjective Cue: ø
Objective Cues: >Flushed skin> Warm to touch> With lab results as follows:- Leukocyte Ct: 22.4 x 109/L (NV: 4.5 -10 x 109/L)- Segmenters: 0.75(NV: 0.50 – 0.70)- Lymphocytes: 0.19(NV: 0.20 – 0.40)- Impression of Pyomyositis on Sonography> with VS taken as ff:T: 38.2 °CP: 82 bpmR: 20 cpm
Hyperthermia r/t trauma 2° underlying disease
Trauma has been implicated to cause Pyomyositis, an inflammation of a muscle tissue. Due to inflammatory process, vasodilatation occurs leading to increase body metabolism and elevated body temperature.
Ref: Brunner and Suddarths Textbook of Medical Surgical Nursing
After 2-3 hours of nursing intervention, patient’s temperature would be within normal range.
Established rapport both with the mother and the patient.
Monitored V/S.
Noted client’s age.
Monitored I & O.
Reviewed laboratory values.
Provided fans as
To gain cooperation and trust.
To review alterations of V/S as affected by patient’s condition, and progress as given with interventions.
Age can directly impact ability to regulate temperature.
Hyperthermia may cause dehydration.
To identify potential internal causes of temperature imbalances.
To provide cooling
After 2 hours, patient’s temperature was within normal range AEB temperature of 37.5°C.
indicated.
Asked mother to dress the baby with light loose clothing.
TSB done.
Emphasized handwashing.
Promoted maintenance of proper breastfeeding.
Administered due medications as prescribed.
measures.
To promote comfort.
To provide cooling measures.
To prevent cross contamination and transmission of MCOs.
For additional booster of patient’s immunity.
To protect from identified risk factors and intervene with pyrexia.
NURSING CARE PLAN
Assessment Nursing Diagnosis Scientific explanation
Planning Intervention Rationale Evaluation
Subjective Cue:“Medyo masakit po ang likod ko”
Objective Cues:- Facial grimace- Guarding on the left scapular area - Restlessness- With facial pain scale of 4/10- V/S taken as follows:T: 38.2 °CP: 82 bpmR: 20 cpm
Acute pain related to trauma on the left scapular area
As a a vascular anti-inflammatory response, body releases anti-inflammatory mediators causing pain.
Reference: http://www.who.int/csr/resources/publications/pyomyositis/01 2-23.pdf
Within 4 hours of effective nursing interventions patient’s pain will be relieved.
Established rapport both with the mother and the patient.
Monitored V/S
Performed a comprehensive assessment of pain
Provided nonpharmacologic management like change of position & applying cold or warm compress as indicated
Encouraged diversional activities
Encouraged rest period
Administered medications
To gain cooperation and trust
Pain may cause alterations in V/S
To improve quality, frequency & location of pain. To alleviate pain.
To divert his attentions to the pain
To prevent fatigue
To alleviate pain.
After 4 hours of rendering effective nursing interventions patient had reported of less pain AEB less guarding on her left scapular area and had been smiling more frequently.
as ordered by physician.
DISCHARGE SUMMARY
M edications. Compliance on the prescribed take home medications with the right generic
name, right dosage and preparation, right route and time of administration.
E xercise. Active ROM but prevent massaging nor any other traumatic pressure on the
affected area.
T reatment. Compliance on the prescribed treatment. Cover the affected area with a wound
gauze as pt has underwent surgery. Instructed proper wound care.
H ealth teachings. Emphasized proper handwashing and encouraged non pharmacological
measures for fracture once re encountered (Rest, Ice or Cold Compress, Compression bandage, Elevate affected part)
O utpatient follow up visit. Attend on the scheduled outpatient follow up visit.
D iet. Consume foods rich in Vitamin C such as fruits for boosting of immunity, protein
such as meats for tissue repair, and calcium or phosphorus such as milk and other dairy products for bone growth.
REFERENCES
http://hopkins-abxguide.org/diagnosis/soft_tissue/pyomyositis.html?contentInstanceId=255446
Zafar, Mohammed. Infectious Myositis. http:// www.yahoo.com// May 18, 2010
Scapula. http:// www. wikipedia.com//
Lippincott. Nursing 2008 Drug Handbook. 28th Edition. 2008
Doenges, M. et al. Nurse’s Pocket Guide. 11th Edition. 2008
PYOMYOSITIS
Saint Michael’s College of Laguna School of Nursing and Midwifery
Old National Highway, Platero, City of Binan, Laguna AY 2010-2011
In Partial Fulfillment for the requirements in NCM 104 – RLE
Case Study
Submitted to:
MRS. ELLA R. ASTETE, RN MANBuilt In Clinical Instructor
Supervisor, Philippine Orthopedic Center
Submitted by:
COSICO, Marineth April A.BSN4A, SMCL
[Year]
[Year]
POTT’S DISEASE
Saint Michael’s College of Laguna School of Nursing and Midwifery
Old National Highway, Platero, City of Binan, Laguna AY 2010-2011
In Partial Fulfillment for the requirements in NCM 104 – RLE
Submitted to:
MRS. ELLA R. ASTETE, RN MANBuilt In Clinical Instructor
Supervisor, Philippine Orthopedic Center
Submitted by:
COSICO, Marineth April A.BSN4A, SMCL
[Year]
[Year]
POTT’S DISEASESynonyms: Pott's syndrome, Pott's caries, Pott's curvature, angular kyphosis, kyphosis secondary to tuberculosis, tuberculosis of the spine, tuberculous spondylitis and David's disease
Pott's disease is named after Percival Pott (1714-1788), an eighteenth century surgeon who was considered an authority in issues related to the back and spine in London. Pott’s disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints. Scientifically, it is called tuberculous spondylitis. Pott’s disease is the most common site of bone infection in TB; hips and knees are also often affected. The lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected. . The commonest area affected is T10 to L1.
Epidemiology Pott's disease in developing countries it represents about 2% of cases of tuberculosis and
40 to 50% of musculoskeletal tuberculosis. Tuberculosis worldwide accounts for 1.7 billion infections, and 2 million deaths per year. Over 90% of tuberculosis occurs in poorer countries, but a global resurgence is affecting
richer ones. The disease affects males more than females in a ratio of between 1.5 and 2:1.
Risk factors Endemic tuberculosis. Poor socio-economic conditions. Historical exposure on infections
Mortality/Morbidity Pott disease is the most dangerous form of musculoskeletal tuberculosis because it can
cause bone destruction, deformity, and paraplegia. Lower thoracic vertebrae is the most common area of involvement (40-50%), followed
closely by the lumbar spine (35-45%). In other series, proportions are similar but favor lumbar spine involvement
Approximately 10% of Pott disease cases involve the cervical spine.
PathophysiologyPott disease is usually secondary to an extraspinal source of infection. The source of
infection is usually outside the spine. It is most often spread from the lungs via the blood. The basic lesion involved in Pott disease is a combination of osteomyelitis and arthritis that
usually involves more than one vertebra. The anterior aspect of the vertebral body adjacent to the subchondral plate is area usually affected. Tuberculosis may spread from that area to adjacent intervertebral disks. In adults, disk disease is secondary to the spread of infection from the vertebral body. In children, because the disk is vascularized, it can be a primary site.
If only one vertebra is affected, the disc is normal, but if two are involved the disc between them collapses as it is avascular and cannot receive nutrients. Progressive bone destruction leads to vertebral collapse and kyphosis or Pott’s curvature. The spinal canal can be narrowed by abscesses, granulation tissue, or direct dural invasion, leading to spinal cord compression and neurologic deficits. The kyphotic deformity is caused by collapse in the anterior spine. Lesions in the thoracic spine are more likely to lead to kyphosis than those in the lumbar
spine. A cold abscess can occur if the infection extends to adjacent ligaments and soft tissues. Abscesses in the lumbar region may descend down the sheath of the psoas to the femoral trigone region and eventually erode into the skin.
Clinical Manifestations The onset is gradual. Localised back pain Paravertebral swelling may be seen Systemic signs and symptoms of tuberculosis may be present (fever, night sweats,
anorexia, weight loss) Neurological signs may occur, leading to paraplegia.
o Cervical spine tuberculosis causes severe neurologic complications characterized
by pain and stiffness, dysphagia or stridor, retropharyngeal abscess, torticollis, hoarseness, and neurologic deficits.
o Lumbar spine tuberculosis is characterized with hip flexion.
o Lower thoracic tuberculosis causes chest pain, and patient tends to have stiff
spine, erected gait and dislikes sitting. Back pain is localised. May include kyphosis, gibbus or Pott’s curvature (pathognomonic sign) A psoas abscess may present as a lump in the groin and resemble a hernia:
o There is a tender swelling below the inguinal ligament and they are usually
apyrexial.
Nursing Assessments The examination should include the following:
o Careful assessment of spinal alignment o Inspection of skin, with attention to detection of sinuses o Abdominal evaluation for subcutaneous flank mass o Meticulous neurologic examination
Alert for abscess. Monitor patient’s body weight and appetite record. May provide some diversional therapies.
Diagnostic Exams The erythrocyte sedimentation rate (ESR) may be markedly elevated (>100 mm/h). Strongly positive Mantoux skin test. Tuberculin skin test (purified protein derivative
[PPD]) results are positive. Spinal X-ray may be normal in early disease as 50% of the bone mass must be lost for
changes to be visible on X-ray. Plain X-ray can show vertebral destruction and narrowed disc space.
MRI scanning may demonstrate the extent of spinal compression and can show changes at an early stage. Bone elements visible within the swelling, or abscesses, are strongly suggestive of Pott's disease rather than malignancy.
CT scans reveals early lesions and is more effective for defining the shape and calcification of soft-tissue abscesses.
Needle biopsy of bone or synovial tissue. Numbers of tubercle bacilli present.
Medical Management Duration of antituberculosis treatment (Rifampicin, Isoniazid, Pyrazinamide,
Ethambutol):o If debridement and fusion with bone grafting are performed, treatment can be for six
months o If debridement and fusion with bone grafting are NOT performed a minimum of 12
months’ treatment is required. Immobilisation of the spine is usually for 2 or 3 months (bed rest, Taylor Brace, head
halter, pelvic strap). Paraplegia resulting from the active disease causing cord compression usually responds
well to chemotherapy (6-9 months).
Surgical Management Anterior Decompression Spinal Fusion. Surgery is required if there is spinal deformity or
neurological signs of spinal cord compression.
Prevention As for all tuberculosis, BCG vaccination. Improvement of socio-economic conditions.
References:http://www.bsac.org.uk/pyxis/Bone%20and%20joint/Potts%20disease/Potts%20disease.htmhttp://www.wisegeek.com/what-is-potts-disease.htm