In partial fulfilment of the

In partial fulfilment of
the requirements in RLE 104

CASE STUDY:
LEFT SEPTIC ANKLE

Submitted to:
Flora C. Agajan, R.N., M.A.N.
Submitted by:

GROUP XIII
GAUANG, Jeremy Rose GUZMAN, Pearl Karen
GERONIMO, Kevin Rae HADAP, Florence Paz
GODOY, Renlyn Ruth HERRERA, Joshua Annmielle
GOMEZ, Beatriz Faustine Marie IDLISAN, Shara Jane
GOMEZ, Fatima Nadine IMSON, Francis Miko
GOMEZ, Rogina Elaine

TABLE OF CONTENTS

PAGE
I. Introduction———————————————————————— 3
A. Objectives——————————————————————- 4
B. Theoretical framework————————————————– 5
II. Patient’s data——————————————————————— 6
A. Medical History———————————————————– 7-8
a. History of Present Illness
b. Past Medical History
c. Family Medical History
d. Social History
e. Environmental History
III. Physical Assessment———————————————————- 9-13
IV. Patterns of Functioning——————————————————- 14-17
V. Anatomy and Physiology—————————————————– 18
VI. Pathophysiology ————————————————————— 19
VII. Laboratory Results———————————————————— 20
VIII. Diagnostic Examinations—————————————————21
X. Interventions————————————————————21
IX. Drug study ———————————————————————-22
XI. Discharge Planning ———————————————————–23
XII. Nursing Care Plan ————————————————————24-26

I. Introduction

Sepsis is a condition in which the body is fighting a severe infection that has spread via the bloodstream. If a patient becomes “septic,” they will likely be in a state of low blood pressure termed “shock.” This condition can develop either as a result of the body’s own defense system or from toxic substances made by the infecting agent (such as a bacteria, virus, or fungus).
Many different microbes can cause sepsis. Although bacteria are most commonly the cause, viruses and fungi can also cause sepsis. Infections in the lungs (pneumonia), bladder and kidneys (urinary tract infections), skin (cellulitis), abdomen (such as appendicitis), and other areas (such as meningitis) can spread and lead to sepsis. Infections that develop after surgery can also lead to sepsis.
Signs and Symptoms:
* If a person has sepsis, they often will have fever. Sometimes, though, the body temperature may be normal or even low.
* The individual may also have chills and severe shaking.
* The heart may be beating very fast, and breathing may be rapid low blood pressure is often observed in septic patients.
* Confusion, disorientation, and agitation may be seen as well as dizziness and decreased urination.
* Some patients who have sepsis develop a rash on their skin. The rash may be a reddish discoloration or small dark red dots throughout the body.
* You may also develop pain in the joints at your wrists, elbows, back, hips, knees, and ankles.

A. Objective
GENERAL OBJECTIVE
After nearly two (2) weeks of exposure to the Philippine Orthopedic Center (POC), our group, Group 13 of Batch 2011 from Capitol Medical Center Colleges (CMCC) will be able to acquire knowledge, skills and attitude regarding a musculoskeletal disease which have been left untreated and have complicated to a Left Septic Ankle.
SPECIFIC OBJECTIVES
* We will establish trust and rapport in order to gain cooperation.
* We will encourage to verbally express feelings toward the condition.
* We will encourage active participation while we ask for patterns of functioning.
* We will actively listen to and note behaviours both verbally and non- verbally.
* We will perform physical assessment in order to assess if there are any more problems besides the complaint and final diagnosis.
* We will educate about how the disease/ condition was acquired, its signs and symptoms, and management.
* We will educate on how to deal with the condition without compromising the self esteem and activities of daily living.
* We will instruct on how, when, and what route to take the prescribed drugs and inform what it is for and how it works in the system.
* We will instruct on how to manage the condition through cleaning of the affected part, rehabilitative therapeutic exercises for range of motion and use of assistive devices, such as crutches.
* We will determine through questioning, if the nursing interventions we have discussed has been understood and applied.
* We will monitor the condition through progressive development and maintenance of proper self care.
B. Theoretical frame work
Dorothea Elizabeth Orem
‘Self Care’ Model of Nursing. The Orem model is based upon the philosophy that all “patients wish to care for themselves”.

Orem’s theory specifically focuses on the nurse’s approach towards persons who are limited in their ability to take care of themselves. According to Orem “Individuals take actions to meet others’ health-related needs”. Nurses should ultimately provide a therapeutic human health service.
Since the patient is not able to perform his activities independently even if he wishes due to his condition, the nurse, or a companion must always be at bedside, in order to help him in performing such desired activities cautiously, while not stressing or demanding too much energy so as to conserve it for rehabilitation purposes.
In order to promote total recovery, we must allow the patient to perform their own self care while with assistance to establish independence and at the same time prevention of any more injuries.

II. Personal Data
Name: Patient X
Address: Quezon City
Age: 17 years old
Sex: Male
Civil Status: Single
Religion: Roman Catholic
Birthday: January 26, 1993
Birthplace: Pasig City
Occupation: Student / Dancer
Date of Admission: August 3, 2010
Time of Admission: 14:20
Room and Bed No.: Male A Ward Bed 16
Hospital No.: 123xxx

Attending Physician: Dr. Espinosa
Medical Diagnosis: Left Septic Ankle
Chief Complaint: Left ankle pain to upper thigh

A. Medical history
a. History of Present Illness
Patient was admitted last July 23, 2010 at Philippine Orthopedic Center due to left ankle pain. Patient was apparently well until 4 months prior to admission, as the patient states: he is a dancer, together with his dance troupe they joined a dance contest and then on the later part of the dance he fell out of balance and the left ankle had slipped off. After the incident he didn’t mind it and go on to his daily activities.

3 months prior to admission the patient experience pain in the left ankle and he decided to go to the healers or what they called “mang-hihilot” and the pain was relieved.

2 months prior to admission, the patient experienced again the pain in his left ankle and decided again to go to the ”mang-hihilot”.

1 month prior to admission, the patient’s ankle developed pus with blood accompanied by severe pain radiating to the upper thigh.

1 day prior to admission, patient was febrile and had severe ankle pain with blood and pus, and consulted a physician at Philippine Orthopedic Center and had laboratory exam done and was advised to have surgery.

On the day of admission, the patient was brought to the operating room and had gone through arthrotomy debridement at his left ankle.

b. Past medical History
The patient has no known serious conditions in the past. .
c. Family Medical History
The patient’s family has no known serious conditions such as hypertension, bronchial asthma, diabetes mellitus or cancer.
d. Social History
The patient is able to consume one (1) pack of cigarette per day. He drinks alcoholic beverages with his friends once a week. He spends his time practicing with his dance troupe, where they join various dancing competition in the city. He is also an active member of a brotherhood, a group wherein he is able to interact, meet and be around different people from different places with the same group of brotherhood.
e. Environmental History
The patient lives in V. Luna, Quezon City. His dwelling place is located in a shanty type of area, considered to be called a squatter’s area, which is according to him, full with different types of people. There is something he considers to be an odd description of their place, which is divided in three parts: the first street is the happy part, wherein good vibes are always present; second is the dying part, where there are always an incidence of old people dying; and lastly, the dangerous part, where there are drug addicts, snatchers and gang wars.

III. Physical assessment
– Received patient awake on bed with an ongoing IVF on D5LRx1l, regulated at 21 gtt/min;
– Conscious and coherent;
– Ambulatory with crutches;
– With vital signs of: BP= 110/70; Temp.= 36.0; PR= 63 beats/min ; and RR=18 beats/min
– Weight= 52 kgs. and Height= 5’3” feet
BODY PART
a. Head
METHODS USED
NORMAL FINDINGS
ACTUAL FINDINGS
INTERPRETATION
Skull

Inspection
Palpation
Proportional to the body size, round with prominence in the frontal area anteriorly and the occipital area posteriorly, symmetrical in all planes gently curve
Proportional to the body size, round with prominence in the frontal area anteriorly and the occipital area posteriorly, symmetrical in all planes gently curve
Normal
Scalp
Inspection
Palpation

White, clean, free from masses, lumps, scars, nits, dandruff and lesion
White, free from masses, lumps, scars, nits and lesion. With presence of ample amount of dandruff
Dandruff is due to poor personal hygiene, especially hair care
Hair
Inspection
Palpation
Black evenly distributed and covers the whole scalp, thick, shiny, free from split ends
Hair is thick, shiny and free from split ends. It is long in length, dyed brown, with streaks of highlights.
Normal

Face
Inspection
Palpation
Oblong or oval shape symmetrical facial expressions that is dependent on the mood or true feelings, smooth and free from wrinkles, no involuntary muscle movements
Oval shaped, symmetrical facial expressions that is dependent on the patient’s expression. Skin has scars, but free from wrinkles, no involuntary muscle movements
Scars are caused by chicken pox marks

Eyes
Inspection

Parallel and evenly placed symmetrical. Non-protruding with scant amount of secretion. Both eyes black and clear
Parallel and evenly placed symmetrical. Non-protruding with scant amount of secretion. Both eyes black and clear. With 20/20 vision
Normal
Eyebrows
Inspection
Palpation
Black symmetrical, thick can raise eyebrows symmetrically and without difficulty. Evenly distributed and parallel with each other
Black symmetrical, thick can raise eyebrows symmetrically and without difficulty. Evenly distributed and parallel with each other
Normal
Eyelashes
Inspection

Black, evenly distributed and turned outward
Black, evenly distributed, and turned outward
Normal
Lid margin
Inspection

Upper lids cover a small portion of the iris, cornea and sclera. When eyes are closed the lids close completely. Symmetrical color the same with surrounding eyes
Upper lids cover a small portion of the iris, cornea, and sclera. When eyes are closed lids covers the eye completely. Symmetrical in color the same with surrounding eyes.
Normal
Palpebral fissure
Inspection
Appears equal when eyes are open
Appears equal when eyes are open
Normal
Lower palpebral conjunctiva
Inspection
Palpation
Salmon pink, shiny, moist and transparent
Pale pink, shiny, moist and transparent
Normal
Sclera
Inspection
White, clear and moist
White, clear and moist
Normal
Iris
Inspection

Proportional to the size of the eye, round black/brown and symmetrical
Proportional to the size of the eye, round and brown in color and symmetrical
Normal
Pupil
Inspection

From pinpoint to the size of the iris, round symmetrical. Constrict with increasing light and accommodation when the light comes closely it constricts the size of the pupil
Round and symmetrical, constrict with the increasing light and accommodation when the light comes closely the pupils becomes smaller
Normal
Field of vision
Inspection

Able to see 600 superiorly, 900 temporarily and 700 inferiorly
Able to see 600 superiorly, 900 temporarily, and 700 inferiorly.
Normal
Ears
Inspection
Palpation
Parallel, symmetrically, proportion to the size of the head, bean shaped, helix is in line with the outer canthus of the eye, skin is the same color as the surrounding area and clean
Parallel, symmetrically, proportion to the size of the head, bean shaped, and helix is in line with the outer canthus of the eye, skin is the same color as the surrounding area and clean.
Normal
Ear canal
Inspection

Pinkish, clean with scant amount of cerumen and a few cilia
Pinkish, clean with scant amount of cerumen and a few cilia
Normal
Hearing acuity
Inspection

Able to hear whisper, spoken 2 ft away. Midline, symmetrical and patent
Able to hear whisper, spoken 2 ft away. Midline, symmetrical and patent
Normal
Nose
Inspection
Palpation
Midline, symmetrical and patent
Prominent, midline, symmetrical and patent
Normal
Internal nares
Inspection
Clean, pinkish with few cilia
Clean, pinkish with few cilia
Normal
Septum
Inspection
Palpation
Straight
Straight
Normal
Mouth
Inspection
Palpation
Pinkish, symmetrical. Lips margin well defined, smooth and moist
Brownish pink, symmetrical. Lips’ margin is well defined, smooth and moist
Lip color is due to smoking history

Gums
Inspection
Palpation
Pinkish, smooth, no swelling, no retractions, no discharge
Reddish pink in color, smooth, no swelling, no retractions, no discharge, no bleeding or sores.
Gum color is due to smoking history.
Teeth
Inspection

32 permanent teeth aligned free from carries, no halitosis
22 permanent teeth, yellowish in color, chipped 2 frontal teeth, cavities in both lower molars
Patient’s oral hygiene is poor

Tongue
Inspection
Palpation
Large, medium, red or pink slightly rough on top, smooth along the lateral margins, moist, shiny and freely movable
Large, pinkish in color. Rough on the top, with white strains of food, smooth along the lateral margins, moist, shiny, freely movable
Normal
Frenulum
Inspection
Midline, straight and thin
Midline, straight and thin. Moist and shiny
Normal
Cheeks
Inspection
Pinkish, smooth and moist
Pinkish, smooth and moist. No presence of mouth sore
Normal
Palate
Soft palate

Hard palate
Inspection
Palpation

Pinkish, smooth and moist
Light pink, slightly rough

Pinkish, smooth and moist
Light pink, slightly rough

Normal

Normal

Uvula
Inspection
Located at the center, symmetrical, freely movable, pinkish in color, shiny and moist
Located at the center, symmetrical, freely movable, pinkish in color, shiny and moist
Normal

Tonsil
Inspection
Pinkish, non- Inflammed and no exudate
Pinkish, non- Inflammed and no exudate
Normal

Voice
Inspection
No hoarseness, well modulated
No hoarseness, well modulated
Normal

Neck
Inspection
Palpation
Proportional to the size of the body and head. Symmetrical in position
Proportional to the size of the body and head. Symmetrical in position.
Normal
Range of motion
Inspection
Palpation
Freely movable without difficulty
Freely movable without difficulty on unaffected site, but has pain in left thigh to lower leg
Difficulty due to the pain caused by the ankle sprain and inflammation of the ankle joint that has radiated to the upper thigh.
Muscular strength
Inspection
Palpation
Both muscle are symmetrical and able to resist applied force
Both muscle are symmetrical and able to resist applied force
Normal
Thorax and Lungs
Inspection
Palpation
Auscultation
The chest symmetrical and the chest is twice as wide as deep, the spine is straight posteriorly. The chest wall moves symmetrically during respiration. No lumps, masses or tenderness, side of the thorax expands symmetrically.
Vibrations are prominent over the areas near the bronchi, it increases with the intensity of voice. No difficulty of breathing
No wheezing sound, cracking or gurgling noise while breathing
Respiratory rate ranges from 18-20 breaths per minute
Prominent chest, symmetrical and is twice as wide as deep, the spine is straight posteriorly. The chest wall moves symmetrically during respiration. No lumps, masses or tenderness, side of the thorax expands symmetrically. Slow, deep breathing, sometimes abrupt. No wheezing sound, cracking or gurgling noise while breathing
Respiratory rate is 19 breaths per minute
Normal

Heart
Inspection
Palpation
Auscultation
Pulsation visible and palpable
2 heart sound audible in all areas, but loudest at apical area cardiac rate ranges from 80-100 beats per minute
Pulsation extremely visible and palpable
2 heart sound audible in all areas, but loudest at apical area cardiac rate of 63 beats per minute
Normal

Abdomen
Inspection
Percussion
Palpation
Auscultation
Skin is unblemished, no scar. Color in uniform or scapoid, symmetrical. Movement caused by breathing. The umbilicus is flat or concave, positions midway between the xiphoid process and the symphisis pubis. Color the same as the surrounding skin
Skin is unblemished, Color in uniform or scapoid, symmetrical. Movement caused by breathing. The umbilicus is flat or concave, positions midway between the xiphoid process and the symphisis pubis. Color the same as the surrounding skin. With presence of scars
Scars present are caused by chicken pox marks
UPPER EXTREMITIES
Arms
Inspection
Palpation

Skin color varies from brown, dark brown, fair, pinkish. Symmetrical, presence or absence of visible veins
Warm, dry and elastic no areas of tenderness. Muscle appears equal with good muscle tone

Skin color is brown, symmetrical in size, shape. No presence of tenderness, no visible veins. arms are warm, dry and elastic. Muscle appears equal with good muscle tone

Normal
Palm and dorsal surface
Inspection
Palpation
Palm pinkish brown
Palm slightly pale in color, presence of callus
From excessive friction in the palm due to dancing
Nails
Inspection
Palpation
Transparent, smooth and convex with pinkish nail beds and white translucent
Five fingers in each hand
As pressure applied to the nail bed appears white or balance and pink color returns immediately after releasing the pressure
Transparent, smooth and convex with pinkish nail beds and white translucent
Five fingers in each hand
As pressure applied to the nail bed appears white or balance and pink color returns immediately after releasing the pressure
Normal

Manipulation- Process of moving the part being examined

Shoulder

Arms

Elbows

Hand and wrist

Inspection
Palpation

Inspection
Palpation

Inspection
Palpation

Inspection
Palpation

Perform on ease

Performs on ease

Performs on ease

Perform on ease

Perform on ease

Performs on ease

Performs on ease

Performs limited, on ease; with IVF on right hand with splint

Normal

Normal

Normal

Normal; limited manipulation due to splint

LOWER EXTREMITIES
Legs
Inspection
Palpation

Skin color varies from pinkish, tan, fair, dark brown.
Skin is smooth, fine hair evenly distributed. Absence of varicose veins, muscle symmetrical, length is symmetrical. Muscle appears equal, warm to touch and with good muscle tone

Skin color dark brown.
Skin is dry, few fine hair distributed. Absence of varicose veins, muscle symmetrical, length is symmetrical. Left leg is with short leg posterior mold

Short leg posterior mold was used due to a compound affection in the ankle of the the left foot
Toes
Inspection
Palpation
Five toes in each foot, smooth with pink nail beds and white tips
Five toes in each foot, smooth with pinkish white nail beds and white tips. Takes 3 seconds on left toe after releasing pressure
Poor blood circulation in the left lower extremity due to the limited movement in the affected area

IV. Patterns of Functioning
Patterns of Functioning
Before Hospitalization
During Hospitalization
Nursing Theory
Analysis/Interpretation
1. Health Perception/Health Management
The patient does not give much priority with his health; he self medicates, goes to the “quack doctor” for intervention, and does not prioritize regular check-ups with a physician.
The patient relied and depended on the health care providers regarding his health. He followed the guidelines given to him by his physician for the condition that was diagnosed with.

There is a change in the patient’s health perception. It was improved because of the knowledge he gained from the health care providers in the hospital regarding the importance of health.
2. Nutritional/ Metabolic
The patient eats all kinds of food with rice. He is fond of eating chicken and red meat (beef) and drinking soft drinks (coke). He doesn’t have any pattern of healthy diet and right time in eating. Usually, at breakfast, he eats a cup of rice and egg with tuyo or kamatis. At lunch time, rice with monggo and meat, together with RC soda, 2 glasses. And during dinner, he eats 2 cups of rice and tilapia or beefsteak, whatever viand is available, as long as partnered with rice
The patient is on a DAT diet, or diet as tolerated. He is being served with rice and fish every meal, most of the time, Bangus in various styles of cooking, vegetables as side dish.
Abraham Maslow’s Hierarchy of Needs

(Physiological needs)
The patients’ eating pattern has changed regarding his food choices and time of eating.
3. Elimination
The patient defecates twice a day and voids five (5) to six (6) times a day without difficulty.
The patient defecates semi formed stool twice a day and urinates clear yellow urine about 8x a day

The patient’s elimination pattern changed, due to an increased intake of oral fluids and parenteral intake of 2250ml in the hospital
4. Activity Exercise
The patient is a dancer and he also engages in physical activities and sports, like basketball
Patient always gets out of bed and loiters around the room to chat with his co-patients. He jumps around when out of his bed, due to difficulty in using the crutches

The patient’s activity and exercise pattern has changed. He has limited physical activity due to his current condition.
5. Sleep- Rest Pattern
The patient sleeps eight (8) to ten (10) hours in a day without difficulty.
The patient sleeps four (4) to five (5) hours in a day with difficulty, due to the noise and in and out of visitors in the ward.

The patient’s Sleep-rest pattern has changed due to uncontrolled noise in the area.
6. Cognitive Perceptual
The The patient is conscious and coherent, responsive and is enthusiastic when talking with people. He converses and comprehends well; he actively responds whenever he is being talked to, has good memory and can make decisions independently.
The patient is still responding actively and enthusiastically to whenever he is being talked to.
Jean Piaget’s Cognitive Theory of Development

(Formal Operational Stage)
The patient’s cognitive- perceptual pattern did not change. His condition did not change his ability to understand.
7. Self- Perception/ Self Concept
The patient feels good and comfortable about himself even if he experiences pain he thinks the pain will subside in time
The patient is now aware of the seriousness of his fracture. He feels bad to be seen in crutches when he returns home.

However, his self esteem lowered, in fear that his friends and neighbours will laugh at him, when they see a dancer in crutches.
8. Role Relationship
The patient the 3rd among 4 children. He is the youngest boy in the family. He is not that close with his family. He has little time in spending with his mother and father. he often hangs out in dance practice or just spending time with his friends.
The patient had no companion around, his father and mother left due to an immediate family crisis.
Erik Erikson’s Psychosocial theory of Development
(Identity vs. Role Confusion)
There is no change in his role- relationship pattern. Even though he is not always together with his family, the patient says he loves his family and friends even if they are not with him at his current condition; however he stated that he feels alone that no one is there to be with him.
9. Sexuality Reproductive
The patient is an adolescent who is at the peak of his puberty. He is engaged in a long distance relationship with his girlfriend of 6 months. However, he is not in any intimate contact with her. They text a lot, talk through the phone, despite the distance.
The patient did not inform his girlfriend about his current condition. He is afraid that his girl might get worried and might not be able to concentrate on her studies
Erik Erikson’s Psychosocial theory of Development
(Identity vs. Role Confusion)
There is a change in the patient’s sexuality- reproductive pattern. He used the distance to not be able to inform his girlfriend about his condition to lessen her worries.
10. Coping/ Stress Tolerance
The patient copes with his stress and problems in life through expressing it in dancing and drinking, spending time with his friends
The patient has a positive attitude he keeps himself busy through texting and chatting with his co-patients in the ward.

There is a change in the patient’s coping/ stress tolerance pattern, since he is not able to express his feelings through dancing.
11. Value/ Belief
The patient rarely visits the church to attend mass, but said that he has faith in God.
The patient prays to the Lord for faster recovery.

The patient’s value/ belief pattern changed. He learned to ask for help from God for faster recovery because he thinks it’s God’s way of punishment for not being able to going to church and renewing his faith.

V. Anatomy and Physiology

Medial
Lateral
Anterior
Posterior
The ankle is made up of two joints: The ankle joint and the subtalar joint. The ankle joint includes two bones (the tibia and the fibula) that form a joint that allows the foot to bend up and down. Two bones of the foot (the talus and the calcaneus) connect to make the subtalar joint that allows the foot to move side to side. The tarsal bones connect to the 5 long bones of the foot – the metatarsals
VI. Pathophysiology

Pathophysiology of Septic Ankle

Predisposing Factors Precipitating Factors
-Age (Adolescent, 17) – Lifestyle
-Gender (Male) (smoker, alcoholic drinker)
– Injury/ Trauma
(ankle sprain due to slip)
– Strenuous Activities (Dancing/ dancing practice)
– Consultation to a quack doctor (“Manghihilot”)

TWISTED ANKLE

TRAUMA ON AFFECTED SITE

LIGAMENTS THAT SUPPORT ANKLE IS TORN

SWELLING, INFLAMMATION, BRUISING

BACTERIAL INFECTION PENETRATES IN THE AFFECTED AREA
(Staphylococcus aureus)

POOR HYGIENE

CELLULITIS

JOINT SWELLING, JOINT PAIN, PUS FORMATION, LOW-GRADE FEVER, REDNESS

SEPTIC ANKLE

VII. Laboratory Results
Hematology
Test
Result
Unit
Reference
Hemoglobin
132
g/L
M 127-183
F 120-150
Hematocrit
0.41

F 0.37-0.45
M 0.37-0.54
Leukocytes Count
10.2
q/L
10-48×109
Indices

MCV
85
F1
82-92
MCH
L 27
Pg
28-32
MCHC
32
%
32-38
Differential Count

Segmenters
0.66

0.5-0.7
Lymphocytes
0.25

0.2-0.4
Monocytes
0.05

0.0-0.7
Eosinophils
0.04

0-0.5
Platelet Count
470
/L
150-400×109

*
* Bacteriology Sec. (Aug 2, 2010)
Examination Desired: Gram Stain Right Ankle
Specimen Submitted: Wound
Preliminary Report:
*RBC +
*WBC few
*No Microorganism seen
*No Spore-forming Bacilli seen Final Report: *No growth after 72hrs of incubation.

* Bacteriology Sec. (Aug 2, 2010)
Penicillin Oxacillin (S)
Pen G/ Amoxicillin (R)
Glycopeptide Vancomycin (S)
Cephalosphorin (S)
Gentamycin (S)
Final Organism: Staphyloccoccus Aureus
? moderate to heavy growth

Analysis:
> MEAN CORPUSCULAR HEMOGLOBIN
* It is a calculation of the amount of oxygen-carrying hemoglobin inside the RBCs.
* Decreased MCH occurs in microcytic anemia or hypochromic anemia.

VIII. Diagnostic Examinations
Blood culture
– performed to isolate and aid identification of the pathogens in bacteremia (bacterial invasion of the bloodstream) and septicemia (systemic spread of such infection). It requires inoculating a culture medium with a blood sample and incubating it.

Joint fluid analysis and culture
– Joint fluid analysis is a test to look at joint fluid under a microscope for problems such as infection, gout, pseudogout, inflammation, or bleeding. The test can help find the cause of joint pain or swelling
X-ray of the Left Ankle
– Indirect visualization of the left ankle to determine site of inflammation, and other injury on the affected site.

IX. Interventions
A. Medical
– Diagnostic examinations (Blood culture, C/S, X-ray of Ankle)
– Medications (as said in the Drug Study)
– IVF Therapy (D5LRx1L @21gtt/min)
B. Surgical
– Arthotomy Debridement of left ankle (removal of necrotic tissue in the damaged joint)

X. Discharge Planning
Medications:
1. Oxacillin (oxapen) 500mg IV q6; Ketorolac (trometamol) 30mgIV q6; Ranitidine (hydrochloride) 50mg IV q8; and Nalbuphine 5mg IV q6
Exercise:
Strengthening and range of motion exercises. This will help your patient regain its strength and flexibility; Gentle exercises to prevent stiffness
Treatment:
Hot compresses and splinting the joint to provide it with rest and support can help relieve pain; Septic ankle must be diagnosed quickly and treated with antibiotics.
Health Teachings:
Patient should be aware that they should see gradual improvement in symptoms over time; Patient will often minimize weight bearing and may only be able to perform passive range of motion prior to more active exercises; Patient should finish all their antibiotics as ordered; Maintain general hygiene; Avoid activities that will affect the ankle (walking, running and etc); Elevate and maintain affected area (ankle); and use supportive devices such as crutches when moving (use it on the unaffected side).
Out-patient:
Follow-up appointments made ensure patient is aware of details.
Diet:
Eat a variety of foods. (healthy foods,fruits,vegetables); maintain ideal weight; avoid too much fat and cholesterol; avoid too much sugar; and eat foods with enough starch and fiber.
Spiritual/Social:
Encourage patient to believe in a higher power to lessen anxiety; encourage patient to meet and enjoy support persons to lessen anxiety.
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