Ms. Reena Devi, a 38-year-old female, was admitted to the hospital with complaints of dizziness, difficulty breathing, pale skin, loss of appetite, weakness, and fatigue for the past 15 days. She has a history of pulmonary tuberculosis 2 years ago. On examination, she had impaired nourishment and activity. Investigations revealed low hemoglobin and lymphocytes. She was diagnosed with tubercular osteomyelitis of the right leg based on x-ray, CT scan, MRI, and bone biopsy findings. She was started on anti-tubercular treatment including isoniazid, rifampicin, pyrazinamide, and ethambutol along with pyridoxine and

1. 1
Case Study
On
Thalassemia
Submitted To: Submitted by:
Ms. Mahima Ms.Astha Mahant
Nursing Tutor M.Sc Nursing 2nd year
BS18MHNS002
Submitted On:15 1119

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IDENTIFICATION DATA OF THE PATIENT
Name Of The Patient: mrs. Reena devi
Age: 38yrs
Sex : Female
Marital Status: married
Ward: female medical ward
Bed No/Room No: 45
Date Of Admission: 4/7/22
Discharge Date: 5/7/22
Address: Vill. Chauri Po. Ghangnu The. Sunder Nagar Distt. Mandi
Religion: Hindu
Education: +2 pass
Occupation: Private Job
Diagnosis: Thalassemia
Surgery: Not Done
Dr. Incharge: Dr. Sirat
CHIEF COMPLAINTS WITH DURATION:
Ms. Reena admitted to the hospital with chief complaints of-
 dizziness

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 Difficulty in breathing X 15 days
 Pale skin
 Loss of appetite x 15 days
 Weakness x few days
 Fatigue x few days
HISTORY OF PRESENT ILLNESS:
Present Medical History:
Patient was admitted with the chief complaints of pain in the right leg from last 15 days. Pain was moderate in intensity, increased during
walking and relieved with rest. There was history of fever from last 3 days due to abcess in Right lower leg fever was high grade in nature and
during the time of admission she was unable to breathe properly and patient intubated on 28/11/2019 in emergency department and extubated on
04/11/2019. She also noticed a small painful swelling in the leg. She is also having loss of appetite from last 15 days and due to this she is
having fatigue and weakness. She had under gone radiology tests and came to know that she is suffering from tubercular osteomyelitis for which
she is taking Anti tuberculosis drugs and some of her symptoms is relieved. She is also old case of pulmonary koch’s and 2 years back she had
taken treatment for that from PHC, Wazirabad, but now pulmonary Koch’s symptoms are almost relieved but patient is feeling difficulty in
breathing and cough since last 15 days. When patient got admitted to the hospital her GCS was E2M3V3
PRESENT SURGICAL HISTORY: There was no present significant history of surgical intervention .

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PAST HEALTH HISTORY:
Past Medical History: She was taking treatment from a private clinic located near by Wazirabad for osteomyelitis and for pulmonary Koch’s
she was seeking treatment from PHC Wazirabad .She was taking pain killer and antibiotic from there but there was no relieve from pain and
infection and then she take LAMA from there and admitted to Sir Ganga Ram Hospital.. When she was 20 years old she had typhoid fever for
which she has taken treatment from local hospital .according to her verbal report she is having minor problems like cold, headache, cough this
indicate that she has low immunity .
 Childhood illnesses: There was history of typhoid fever for which she has taken treatment from local hospital.
 Other illnesses: No history of any non-communicable or hereditary illnesses e.g. Diabetes mellitus, COPD, heart problems etc.
PAST SURGICAL HISTORY: There is no significant past surgical history.
Childhood immunization
There was no significant evidence of pateints immunization status as she did not remember .
DIETARY HABITS/FEEDING HABITS
TYPE OF FEEDING : Not able to eat by herself

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CURRENT DIET : She is on ryles tube feeding she used to feed 200 ml every 2nd hourly.
EATING HABITS : She is non vegetarian.
FAMILY HEALTH HISTORY:
 Type of family: joint
 No. of family members: 6
 Any Illness:No history of any hereditary or communicable diseases in the family e.g. Cancer, T.B. etc.
Family tree:
(Father )Age-45 yrs Age – 43 yrs (Mother)
Male
(Sister)
( Sister )
( Brother )
( Patient )
Family Composition:
Keys-
Male
Female
Patient

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Family Members Age Sex Relationship with
the patient
Occupation Education Health status
Mr. Ram Chandra
Singh
45yrs Male Father Farmer 5th Healthy
Mrs. Savitri Devi 43yrs Female Mother Housewife 8th Healthy
Ms. Monika 18yrs Female Sister Student 12th Healthy
Ms. Ranjana 25yrs Female Patient Student Graduation Osteomyelitis
Master Vikas 13yrs Male Brother Student 7th healthy
Ms. Kajal 10yrs Male Sister Student 5th Healthy
PERSONAL HISTORY
 Personal Hygiene:
Oral Hygiene: Maintained (0nce a day)
Bath: Once a day
Diet: Non Vegetarian
No. Of meals / day: Ryles tube feeding every 2nd hourly
Food preferences: Non Vegetarian
Sleep&Rest: Patient is having restlessness, sleep inadequate (4 hours/ day) due to pain in leg .

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Elimination: Patient used to have normal bowel movement
Urine frequency: 1500-2000 ml/day
Exercise / Activity: patient is not able to walk.
Joints : pain present
Substance use: No history of smoking and alcohol abuse
SOCIO-ECONOMIC STATUS
-EDUCATION : Graduate
-OCCUPATION : Student
-TOTAL INCOME/ MONTH : Rs.80000 only.
-HOUSING : Pucca house with 3 rooms , common kitchen and
1 washroom with govt. supply of water
-SANITATIION : Closed sanitation.
-DISPOSAL OF REFUSE : Closed disposal system.
HISTORY OF ANY HEREDITARY DISEASE No history of Hypertension /Asthma /Diabetes mellitus or any other hereditary disease in the
family.
ENVIRONMENT HISTORY

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Ventilation :Appropirate
Drainage : open drainage
Water supply: govt water supply
Electricity : present
Sanitation : well mainatined
PHYSICAL EXAMINATION
 GENERAL EXAMINATION
Weight:38kg
Height:150 cm
BMI : 16.8kg /m2
Foul Body Odour: present
Foul Breath: Absent
Sensorium: Conscious
Orientation:Oriented to time place and person
Nourishment :Impaired (weak)
Body built: Weak
Activity: Dull
Look: lethargic

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Hygiene: Maintained
Speech: Impaired due to Et Tube
VITAL SIGNS
Date TIME TEMP. HEART
RATE
RESP. RATE B.P SPO2
04/11/19 10:00am 100.3°F 82/min 22/min 110/66mmHg 98%(on oxygen
therapy @5-
6l/min
05/11/19 10:00am 98.6°F 76/min 20/min 100/60mmHg 99%(on oxygen
therapy @ 3l/min
SYSTEMIC EXAMINATION
• HEAD AND NECK EXAMINATION-
HEAD
• Hair : texture is normal
• Any abrasion/wound : no abrasions or wound present
• Size,shape and configuration : normocephalic
• Any involuntary movements : not significant

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• Uniformity : there is no lump or lesion present
FACE
• Shape : round in shape
• Palpation of tempomandibular joint: No moments done by patient while palpation
NECK
• Movement of neck: present
• Cervical vertebrae: normal
• Range of motion: present
• Trachea : midline
• Thyroid gland: not enlarged
EYES
• Eyebrows :normal distribution of hairs
• Eyelashes : normal and no infection
• Eye lids:normal
• Conjunctiva : pinkish
• Eyeball : normal movement
• Pupils : equally reacted to light(PERLA present)
EARS
• External years : normal and cerumen present

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• Tympanic membrane :no perforation ,lesions or infection
• Use of hearing aids :not significant
• Auricle and mastoid process :normal
• Hearing :normal
NOSE
• Shape :No deviated nasal septum and no discharge
• Nesogastric Tube : Present
• Nasal polyps : absent
MOUTH AND PHARYNX
 Mouth : No infection or ulcer formation in the mouth
• Lips : Pink, no chillosis
• Oral mucosa : Intact
• Teeth and Tongue :Teeth are present and tongue is coated
• Throat and pharynx : Normal
CHEST
• Thorax : Symmetrical

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• Breath sound : Normal breath sounds
• Heart rate : 86/min.
ABDOMEN
• Observation : no distension
• Auscultation : normal bowel sounds present
• Palpation : Soft, Not distended and no organomegaly
• Percussion : No fluid and Gas accumulated
EXTREMETIES
• Joint movement : Moveable( pain present )
• Tremors :not significant
• Clubbing of finger : Absent
• Edema : present in right leg
• Cyanosis : absent
• Range of motion : present but limited due to disease condition
• Deformity : osteomyelitis in Rt leg and abcess
• Clubbing of foot not significant
BACK

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• Kyphosis , scoliosis and lordosis : Absent ( lower back present )
GENITAL AND RECTUM
• Inguinal hernia : Absent
• Urethral discharge : Absent
• Urine output : Adequate(50ml/ hour)
SYSTEMIC EXAMINATION
 NERVOUS SYSTEM
• Conscious
• Speech appropriate
• Oriented to time, place and person.
• Glasgow Coma Scale (E2V3M3 at admission) but now it is E4V4M5
 MUSCULOSKELETAL SYSTEM

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• Range of motion :Present (limited)
• Muscle tone : Abnormal
• Muscle strength : Poor
• Fracture : Absent
 RESPIRATORY SYSTEM
• Respiratory rate : 22/min.
• B/L air entry equal
• Breath sound : Bronchial breath present
• Dyspnea : Absent
 CIRCULATORY SYSTEM
• Heart rate : 82 beats/min
• BP : 110/70 mm/Hg
• Capillary refill :> 3 seconds
• S1 & S2 present

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• Jugular vein : Not distended
 ENDOCRINE SYSTEM
• Thyroid disorder :Not signified
• Diabetes : Not signified
 INTEGUMENTARY SYSTEM
• Skin turgor :normal
• No skin lesions or disease signified
• Temperature : Warm
 GASTROINTESTINAL SYSTEM
• Intake : Ryles tube feeding
• Diarrhea : Absent
• Constipation : Absent
• Bowel sounds : Present
 GENITOURINARY SYSTEM
• Urine output : Adequate 50 ml/hr

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• Catheterization : Foleys catheter present
• Genitourinary disorder : Not signified
• Dark yellow color urine . : Present
INVESTIGATION:
Sr. No. Investigation 04/11/2019 Normal value Remarks
1 TLC 6.40 4-11 Normal
2 Na+ 137 mmol/L 136-145 mmol/L Normal
3 K 4.40 mmol/L 2.1-2.8 m mol/L Normal
4 Glucose 114 mg/dL 70-120 md/dL Normal
5 Cl 100 mmol/L 95-110 m mol/L Normal
6 Hemoglobin 11.5gm% 12-18gm % Low
7 WBC 6.40 4-11 Normal
8 Urea 18 mg/dl 10-45 mg/dl Normal

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9 LYM 18% 20-40% Low
10 Direct billirubin 0.14 mg/dl 0.0-0.30 mg/dl Normal
11 Total billirubin 0.54 mg/dl 0.2-1.2 Normal
12 SGOT 54 U/L 9-40 Normal
13 SGPT 37 U/L 8-37 Normal
14 Platelet 243 150-450 Normal
15. PT/INR 2.0 2.0-3.0 Normal
16. S.creat 0.71 0.5-1.5 Normal
17. Eosino 06 1-6 Normal
18. Monos 0.5% 2-10 Low
19. Baso 00% 1-2% Low
20. RBC 4.57 3.8-4.8 Normal
21. S.amylase 26 23-85 U/L Normal
22. Cholesterol 84 <100 mg/dl Normal
23. S.lipase 7 0-160 U/L Normal
24 HCT 34.4 36-46 Low
25 ESR 0 0.02-0.10 Low
OTHER TESTS

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 X-rays. X-rays reveal damage to the bone and shows osteolytic lesion 1 cm in diameter at junction of of upper two third and lower one
third of tibia
 Computerized tomography (CT) scan right knee .Tibiotalar and talo-calcaneal joint spaces are markedly reduced with sclerosis of
adjacent subarticular regions. Multiple subchondral cysts in distal tibia, medial and lateral malleolus and talus.
 Magnetic resonance imaging (MRI) knee joint .peripherally enhancing small epiphyseal collections with intra articular extension at
lower end of tibia and fibula as described with enhancing altered SI changes at articular surface of tibia and talus with enhancing soft
tissue around the ankle joint (infective tubercular)
 Mantoux test : positive
Bone biopsy
It suggested there is infection in the bone which is caused by mycobacterium tuberculosis
TREATMENT CHART
Sr. no. Name of the Drug Dose Route Frequency Action
1. Tab isoniazid 360mg Oral OD Isoniazid is a prodrug and must be activated by a
bacterial catalase-peroxidase enzyme in
Mycobacterium tuberculosis called KatG.KatG
catalyzes the formation of the isonicotinic acyl
radical, which spontaneously couples with NADH to

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form the nicotinoyl-NAD adduct. This complex
binds tightly to the enoyl-acyl carrier protein
reductase InhA, thereby blocking the natural enoyl-
AcpM substrate and the action of fatty acid synthase.
This process inhibits the synthesis of mycolic acids,
which are required components of the mycobacterial
cell wall.
2. Tab rifampicin 540mg OD Rifampicin inhibits bacterial DNA-dependent RNA
synthesis by inhibiting bacterial DNA-dependent
RNA polymerase.
Crystal structure data and biochemical data suggest
that rifampicin binds to the pocket of the RNA
polymerase β subunit within the DNA/RNA channel,
but away from the active site.The inhibitor prevents
RNA synthesis by physically blocking elongation,
and thus preventing synthesis of host bacterial
proteins.
3. Tab pyrazinamide 900mg OD

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Pyrazinamide is a prodrug that stops the growth of
M. tuberculosis. Pyrazinamide diffuses into the
granuloma of M. tuberculosis, where the tuberculosis
enzyme pyrazinamide converts pyrazinamide to the
active form pyrazinoic acid.Under acidic conditions
of pH 5 to 6, the pyrazinoic acid that slowly leaks
out converts to the protonated conjugate acid, which
is thought to diffuse easily back into the bacilli and
accumulate. The net effect is that more pyrazinoic
acid accumulates inside the bacillus at acid pH than
at neutral pH
4. Tab ethambutol 540mg OD Ethambutol is bacteriostatic against actively growing
TB bacilli. It works by obstructing the formation of
cell wall. Mycolic acids attach to the 5'-hydroxyl
groups of D-arabinose residues of arabinogalactan
and form mycolyl-arabinogalactan-peptidoglycan

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complex in the cell wall. It disrupts arabinogalactan
synthesis by inhibiting the enzyme arabinosyl
transferase. Disruption of the arabinogalactan
synthesis inhibits the formation of this complex and
leads to increased permeability of the cell wall
5. Tab pyridoxine 10 OD Pyridoxine is in the vitamin B family of vitamins .it
is required by the body to make amino acids ,
carbohydrates , and lipid . sources in the diet include
fruit, vegetables,and grain
6. Tab pantop 40 mg OD Proton pump inhibitor that decreases the amount of
acid produced in the stomach
7. Inj streptomycin 750 mg Intramuscul
ar
OD Streptomycin is a protein synthesis inhibitor. It binds
to the small 16S rRNA of the 30S subunit of the
bacterial ribosome, interfering with the binding of
formyl-methionyl-tRNAto the 30S subunit. This
leads to codon misreading, eventual inhibition of
protein synthesis and ultimately death of microbial
cells through mechanisms that are still not
understood.

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DISEASE CONDITION
INTRODUCTION:
Osteomylelitis is the infection of the bone caused by staphylococcus aures. Patient who are at high risk for Osteomelitis include those are poorly
nourished, Elderly or obese. In children, Osteomylelitis most commonly affects the long bones of the legs and upper arms. Adults are more
likely to develop Osteomylelitis in the bones that make up the spine (vertebrae). People who have diabetes may develop Osteomylelitis in their
feet if they have foot ulcers.
Once considered an incurable condition, Osteomylelitis can be successfully treated today. Most people require surgery to remo ve parts of the
bone that have died — followed by strong antibiotics, often delivered intravenously, typically for at least four to six weeks.
Tuberculous Osteomyelitis
Skeletal lesions occur in approximately 1% of children with tuberculosis.130,164 Bones and joints are infected through hematogenous or
lymphatic dissemination of Mycobacterium tuberculosis. Infection can smolder for years before clinical signs are apparent. The most commonly
involved bones are the vertebrae (tuberculous spondylitis), femur, long bones around knees and ankles, and small bones of the hands and
feet.165 Other sites less frequently infected are the ribs, mandible, sternum, clavicle, and other long bones. Multifocal osteomyelitis is reported
in 10% to 15% of cases.166,167

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Clinical signs and symptoms of skeletal tuberculosis include low-grade fever, weight loss, pain, and soft-tissue swelling at the site of infection.
Vertebral involvement begins in the anterior vertebral body, eventually causing disk space collapse and anterior wedging of vertebral bodies, and
sometimes gibbus deformity. The lower thoracic spine is the usual site of involvement (Pott disease), followed by the lumbar spine.
The Mantoux tuberculin skin reaction is usually positive. The role of interferon-γ release assays in the diagnosis of Pott disease is currently
being evaluated. Plain radiographic findings include periarticular osteopenia, lytic lesions in the body of the vertebra, joint space narrowing, and
soft-tissue swelling.168 The chest radiograph often is normal. CT is useful for the evaluation of bone destruction, adjacent soft-tissue abscess
formation, and calcification, and in guiding percutaneous biopsy.169,170 MRI is helpful in determining extent of bone and soft-tissue
disease.171 Biopsy specimens should be obtained in an attempt to demonstrate the organism with stains and culture. Antituberculous therapy
includes 2 months of therapy with four drugs, followed by 7 to 10 months of isoniazid and rifampin (for susceptible organisms) daily or twice
weekly .172 Surgical intervention is indicated in cases of spinal instability and neurologic impairment secondary to paravertebral abscess
formation and for drainage of soft-tissue abscesses. Nontuberculous Mycobacteriumspp. infrequently cause osteomyelitis in
immunocompromised individual
ANATOMY AND PHSYIOLOGY

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Bone Classifications
Bone
classification
Features Function(s) Examples
Long Cylinder-like shape, longer than it is wide Leverage
Femur, tibia, fibula, metatarsals, humerus,
ulna, radius, metacarpals, phalanges
Short Cube-like shape, approximately equal in Provide stability, support, while Carpals, tarsals

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Bone Classifications
Bone
classification
Features Function(s) Examples
length, width, and thickness allowing for some motion
Flat Thin and curved
Points of attachment for muscles;
protectors of internal organs
Sternum, ribs, scapulae, cranial bones
Irregular Complex shape Protect internal organs Vertebrae, facial bones
Sesamoid Small and round; embedded in tendons Protect tendons from compressive Patellae
Like the upper limb, the lower limb is divided into three regions. The thigh is that portion of the lower limb located between the hip joint and
knee joint. The leg is specifically the region between the knee joint and the ankle joint. Distal to the ankle is the foot. The lower limb contains 30
bones. These are the femur, patella, tibia, fibula, tarsal bones, metatarsal bones, and phalanges The femur is the single bone of the thigh. The
patella is the kneecap and articulates with the distal femur. The tibia is the larger, weight-bearing bone located on the medial side of the leg, and
the fibula is the thin bone of the lateral leg. The bones of the foot are divided into three groups. The posterior portion of the foot is formed by a
group of seven bones, each of which is known as a tarsal bone, whereas the mid-foot contains five elongated bones, each of which is a
metatarsal bone. The toes contain 14 small bones, each of which is a phalanx bone of the foot.
Femur
The femur, or thigh bone, is the single bone of the thigh region. It is the longest and strongest bone of the body, and accounts for approximately
one-quarter of a person’s total height. The rounded, proximal end is the head of the femur, which articulates with the acetabulum of the hip

26. 26
bone to form the hip joint. The fovea capitis is a minor indentation on the medial side of the femoral head that serves as the site of attachment
for the ligament of the head of the femur. This ligament spans the femur and acetabulum, but is weak and provides little support for the hip
joint. It does, however, carry an important artery that supplies the head of the femur.
Figure 1:Femur and Patella.
The narrowed region below the head is the neck of the femur. This is a common area for fractures of the femur. The greater trochanter is the
large, upward, bony projection located above the base of the neck. Multiple muscles that act across the hip joint attach to the greater trochanter,
which, because of its projection from the femur, gives additional leverage to these muscles. The greater trochanter can be felt just under the skin
on the lateral side of your upper thigh. The lesser trochanter is a small, bony prominence that lies on the medial aspect of the femur, just below
the neck. A single, powerful muscle attaches to the lesser trochanter. Running between the greater and lesser trochanters on the anterior side of

27. 27
the femur is the roughened intertrochanteric line. The trochanters are also connected on the posterior side of the femur by the larger
intertrochanteric crest.
The elongated shaft of the femur has a slight anterior bowing or curvature. At its proximal end, the posterior shaft has the gluteal tuberosity, a
roughened area extending inferiorly from the greater trochanter. More inferiorly, the gluteal tuberosity becomes continuous with the linea
aspera (“rough line”). This is the roughened ridge that passes distally along the posterior side of the mid-femur. Multiple muscles of the hip and
thigh regions make long, thin attachments to the femur along the linea aspera.
The distal end of the femur has medial and lateral bony expansions. On the lateral side, the smooth portion that covers the distal and posterior
aspects of the lateral expansion is the lateral condyle of the femur. The roughened area on the outer, lateral side of the condyle is the lateral
epicondyle of the femur. Similarly, the smooth region of the distal and posterior medial femur is the medial condyle of the femur, and the
irregular outer, medial side of this is the medial epicondyle of the femur. The lateral and medial condyles articulate with the tibia to form the
knee joint. The epicondyles provide attachment for muscles and supporting ligaments of the knee. The adductor tubercle is a small bump
located at the superior margin of the medial epicondyle. Posteriorly, the medial and lateral condyles are separated by a deep depression called the
intercondylar fossa. Anteriorly, the smooth surfaces of the condyles join together to form a wide groove called the patellar surface, which
provides for articulation with the patella bone. The combination of the medial and lateral condyles with the patellar surface gives the distal end
of the femur a horseshoe (U) shape.

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Patella
The patella (kneecap) is largest sesamoid bone of the body. A sesamoid bone is a bone that is incorporated into the tendon of a muscle where
that tendon crosses a joint. The sesamoid bone articulates with the underlying bones to prevent damage to the muscle tendon due to rubbing
against the bones during movements of the joint. The patella is found in the tendon of the quadriceps femoris muscle, the large muscle of the
anterior thigh that passes across the anterior knee to attach to the tibia. The patella articulates with the patellar surface of the femur and thus
prevents rubbing of the muscle tendon against the distal femur. The patella also lifts the tendon away from the knee joint, which increases the
leverage power of the quadriceps femoris muscle as it acts across the knee. The patella does not articulate with the tibia.
Tibia
The tibia (shin bone) is the medial bone of the leg and is larger than the fibula, with which it is paired. The tibia is the main weight-bearing bone
of the lower leg and the second longest bone of the body, after the femur. The medial side of the tibia is located immediately under the skin,
allowing it to be easily palpated down the entire length of the medial leg.

29. 29
.
Tibia and Fibula.
The proximal end of the tibia is greatly expanded. The two sides of this expansion form the medial condyle of the tibia and the lateral condyle
of the tibia. The tibia does not have epicondyles. The top surface of each condyle is smooth and flattened. These areas articulate with the medial
and lateral condyles of the femur to form the knee joint. Between the articulating surfaces of the tibial condyles is the intercondylar eminence,
an irregular, elevated area that serves as the inferior attachment point for two supporting ligaments of the knee.

30. 30
The tibial tuberosity is an elevated area on the anterior side of the tibia, near its proximal end. It is the final site of attachment for the muscle
tendon associated with the patella. More inferiorly, the shaft of the tibia becomes triangular in shape. The anterior apex of
MH this triangle forms the anterior border of the tibia, which begins at the tibial tuberosity and runs inferiorly along the length of the tibia.
Both the anterior border and the medial side of the triangular shaft are located immediately under the skin and can be easily palpated along the
entire length of the tibia. A small ridge running down the lateral side of the tibial shaft is the interosseous border of the tibia. This is for the
attachment of the interosseous membrane of the leg, the sheet of dense connective tissue that unites the tibia and fibula bones. Located on the
posterior side of the tibia is the soleal line, a diagonally running, roughened ridge that begins below the base of the lateral condyle, and runs
down and medially across the proximal third of the posterior tibia. Muscles of the posterior leg attach to this line.
The large expansion found on the medial side of the distal tibia is the medial malleolus (“little hammer”). This forms the large bony bump
found on the medial side of the ankle region. Both the smooth surface on the inside of the medial malleolus and the smooth area at the distal end
of the tibia articulate with the talus bone of the foot as part of the ankle joint. On the lateral side of the distal tibia is a wide groove called the
fibular notch. This area articulates with the distal end of the fibula, forming the distal tibiofibular joint.
Fibula
The fibula is the slender bone located on the lateral side of the leg. The fibula does not bear weight. It serves primarily for muscle attachments
and thus is largely surrounded by muscles. Only the proximal and distal ends of the fibula can be palpated.

31. 31
The head of the fibula is the small, knob-like, proximal end of the fibula. It articulates with the inferior aspect of the lateral tibial condyle,
forming the proximal tibiofibular joint. The thin shaft of the fibula has the interosseous border of the fibula, a narrow ridge running down
its medial side for the attachment of the interosseous membrane that spans the fibula and tibia. The distal end of the fibula forms the lateral
malleolus, which forms the easily palpated bony bump on the lateral side of the ankle. The deep (medial) side of the lateral malleolus articulates
with the talus bone of the foot as part of the ankle joint. The distal fibula also articulates with the fibular notch of the tibia.
Figure 4. Bones of the Foot.

32. 32
The bones of the foot are :
Metatarsal Bones
The anterior half of the foot is formed by the five metatarsal bones, which are located between the tarsal bones of the posterior foot and the
phalanges of the toes These elongated bones are numbered 1–5, starting with the medial side of the foot. The first metatarsal bone is shorter and
thicker than the others. The second metatarsal is the longest. The base of the metatarsal bone is the proximal end of each metatarsal bone.
These articulate with the cuboid or cuneiform bones. The base of the fifth metatarsal has a large, lateral expansion that provides for muscle
attachments. This expanded base of the fifth metatarsal can be felt as a bony bump at the midpoint along the lateral border o f the foot. The
expanded distal end of each metatarsal is the head of the metatarsal bone. Each metatarsal bone articulates with the proximal phalanx of a toe
to form a metatarsophalangeal joint. The heads of the metatarsal bones also rest on the ground and form the ball (anterior end) of the foot.
Phalanges
The toes contain a total of 14 phalanx bones (phalanges), arranged in a similar manner as the phalanges of the fingers. The toes are numbered 1–
5, starting with the big toe (hallux). The big toe has two phalanx bones, the proximal and distal phalanges. The remaining toes all have proximal,
middle, and distal phalanges. A joint between adjacent phalanx bones is called an interphalangeal joint.

33. 33
Arches of the Foot
When the foot comes into contact with the ground during walking, running, or jumping activities, the impact of the body weight puts a
tremendous amount of pressure and force on the foot. During running, the force applied to each foot as it contacts the ground can be up to 2.5
times your body weight. The bones, joints, ligaments, and muscles of the foot absorb this force, thus greatly reducing the amount of shock that is
passed superiorly into the lower limb and body. The arches of the foot play an important role in this shock-absorbing ability. When weight is
applied to the foot, these arches will flatten somewhat, thus absorbing energy. When the weight is removed, the arch rebounds, giving “spring”
to the step. The arches also serve to distribute body weight side to side and to either end of the foot.
The foot has a transverse arch, a medial longitudinal arch, and a lateral longitudinal arch. The transverse arch forms the medial-lateral curvature
of the mid-foot. It is formed by the wedge shapes of the cuneiform bones and bases (proximal ends) of the first to fourth metatarsal bones. This
arch helps to distribute body weight from side to side within the foot, thus allowing the foot to accommodate uneven terrain.
The longitudinal arches run down the length of the foot. The lateral longitudinal arch is relatively flat, whereas the medial longitudinal arch is
larger (taller). The longitudinal arches are formed by the tarsal bones posteriorly and the metatarsal bones anteriorly. These arches are supported
at either end, where they contact the ground. Posteriorly, this support is provided by the calcaneus bone and anteriorly by the heads (distal ends)
of the metatarsal bones. The talus bone, which receives the weight of the body, is located at the top of the longitudinal arches. Body weight is
then conveyed from the talus to the ground by the anterior and posterior ends of these arches. Strong ligaments unite the adjacent foot bones to
prevent disruption of the arches during weight bearing. On the bottom of the foot, additional ligaments tie together the anterior and posterior
ends of the arches. These ligaments have elasticity, which allows them to stretch somewhat during weight bearing, thus allowing the longitudinal
arches to spread. The stretching of these ligaments stores energy within the foot, rather than passing these forces into the leg. Contraction of the

34. 34
foot muscles also plays an important role in this energy absorption. When the weight is removed, the elastic ligaments recoil and pull the ends of
the arches closer together. This recovery of the arches releases the stored energy and improves the energy efficiency of walking.
Stretching of the ligaments that support the longitudinal arches can lead to pain. This can occur in overweight individuals, with people who have
jobs that involve standing for long periods of time (such as a waitress), or walking or running long distances. If stretching of the ligaments is
prolonged, excessive, or repeated, it can result in a gradual lengthening of the supporting ligaments, with subsequent depression or collapse of
the longitudinal arches, particularly on the medial side of the foot. This condition is called pes planus (“flat foot” or “fallen arches”).
The Functions of the Skeletal System
Bone, or osseous tissue, is a hard, dense connective tissue that forms most of the adult skeleton, the support structure of the body. In the areas of
the skeleton where bones move (for example, the ribcage and joints), cartilage, a semi-rigid form of connective tissue, provides flexibility and
smooth surfaces for movement. The skeletal system is the body system composed of bones and cartilage and performs the following critical
functions for the human body:
 supports the body
 facilitates movement
 protects internal organs
 produces blood cells
 stores and releases minerals and fat

35. 35
Support, Movement, and Protection
The most apparent functions of the skeletal system are the gross functions—those visible by observation. Simply by looking at a person, you can
see how the bones support, facilitate movement, and protect the human body.
Just as the steel beams of a building provide a scaffold to support its weight, the bones and cartilage of your skeletal system compose the
scaffold that supports the rest of your body. Without the skeletal system, you would be a limp mass of organs, muscle, and skin.
Bones also facilitate movement by serving as points of attachment for your muscles. While some bones only serve as a support for the muscles,
others also transmit the forces produced when your muscles contract. From a mechanical point of view, bones act as levers and joints serve as
fulcrums. Unless a muscle spans a joint and contracts, a bone is not going to move. For information on the interaction of the skeletal and
muscular systems, that is, the musculoskeletal system, seek additional content.
Bones Support Movement
Bones also protect internal organs from injury by covering or surrounding them. For example, your ribs protect your lungs and heart, the bones
of your vertebral column (spine) protect your spinal cord, and the bones of your cranium (skull) protect your brain
Mineral Storage, Energy Storage, and Hematopoiesis
On a metabolic level, bone tissue performs several critical functions. For one, the bone matrix acts as a reservoir for a number of minerals
important to the functioning of the body, especially calcium, and phosphorus. These minerals, incorporated into bone tissue, can be released

36. 36
back into the bloodstream to maintain levels needed to support physiological processes. Calcium ions, for example, are essential for muscle
contractions and controlling the flow of other ions involved in the transmission of nerve impulses.
Bone also serves as a site for fat storage and blood cell production. The softer connective tissue that fills the interior of most bone is referred to
as bone marrow There are two types of bone marrow: yellow marrow and red marrow. Yellow marrow contains adipose tissue; the triglycerides
stored in the adipocytes of the tissue can serve as a source of energy. Red marrow is where hematopoiesis—the production of blood cells—
takes place. Red blood cells, white blood cells, and platelets are all produced in the red marrow.

37. 37
DEFINITION
Osteomylelitis is an infection in a bone. Infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue.
Infections can also begin in the bone itself if an injury exposes the bone to germs.
CLASSIFICATION OF OSTEOMYLELITIS
Osteomylelitis is classified:
 Acute Osteomyelitis ( within 2 weeks )
 Sub acuteOsteomyelitis (within month to several months)
 Chronic Osteomyelitis ( after several months )
Cierny classification Osteomylelitis ( describes anatomical involvement, host, treatment, prognosis
Anatomic position
Stage 1 Medullar
Stage2 Superficial
Stage3 Localized
Stage 4 Diffuse

38. 38
TUBERCULOSIS
Tuberculosis (TB) is a disease caused by germs that are spread from person to person through the air. TB usually affects the lungs, but it can also
affect other parts of the body, such as the brain, the kidneys, or the spine. A person with TB can die if they do not get treatment.

39. 39
Symptoms of TB
The general symptoms of TB disease include feelings of sickness or weakness, weight loss, fever, and night sweats. The symptoms of TB
disease of the lungs also include coughing, chest pain, and the coughing up of blood. Symptoms of TB disease in other parts of the body depend
on the area affected.
Difference Between Latent TB Infection and TB Disease
People with latent TB infection have TB germs in their bodies, but they are not sick because the germs are not active. These people do not have
symptoms of TB disease, and they cannot spread the germs to others. However, they may develop TB disease in the future. They are often
prescribed treatment to prevent them from developing TB disease. People with TB disease are sick from TB germs that are active, meaning that
they are multiplying and destroying tissue in their body.
Treatment of Latent TB Infection
If the person have latent TB infection but not TB disease, your doctor may want you to take a drug to kill the TB germs and prevent you from
developing TB disease. The decision about taking treatment for latent infection will be based on your chances of developing TB disease. Some
people are more likely than others to develop TB disease once they have TB infection. This includes people with HIV infection, people who
were recently exposed to someone with TB disease, and people with certain medical conditions
RISK FACTORS
1. Recent injury or orthopedic surgery
A severe bone fracture or a deep puncture wound gives infections a route to enter your bone or nearby tissue. Surgery to repair broken bones or
replace worn joints also can accidentally open a path for germs to enter a bone.
Implanted orthopedic hardware is a risk factor for infection. Deep animal bites also can provide a pathway for infection.

40. 40
2. Circulation disorders
When blood vessels are damaged or blocked, your body has trouble distributing the infection-fighting cells needed to keep a small infection from
growing larger. What begins as a small cut can progress to a deep ulcer that may expose deep tissue and bone to infection.
Diseases that impair blood circulation include:
 Poorly controlled diabetes
 Peripheral arterial disease, often related to smoking
 Sickle cell disease
3. Problems requiring intravenous lines or catheters
There are a number of conditions that require the use of medical tubing to connect the outside world with your internal organs. However, this
tubing can also serve as a way for germs to get into your body, increasing your risk of an infection in general, which can lead to osteomyelitis.
Examples of when this type of tubing might be used include:
 Dialysis machine tubing
 Urinary catheters
 Long-term intravenous tubing, sometimes called central lines

41. 41
4. Conditions that impair the immune system
If your immune system is affected by a medical condition or medication, you have a greater risk of Osteomylelitis. Factors that may suppress
your immune system include:
 Chemotherapy
 Poorly controlled diabetes
 Needing to take corticosteroids or drugs called tumor necrosis factor (TNF) inhibitors
5. Illicit drugs
People who inject illicit drugs are more likely to develop Osteomylelitis because they typically use non sterile needles and don't sterilize their
skin before injections.
CAUSES
Most cases of Osteomylelitis are caused by staphylococcus bacteria, types of germs commonly found on the skin or in the nose of even healthy
individuals.
Germs can enter a bone in a variety of ways, including:

42. 42
 The bloodstream. Germs in other parts of your body — for example, in the lungs from pneumonia or in the bladder from a urinary tract
infection — can travel through your bloodstream to a weakened spot in a bone. In children, osteomyelitis most commonly occurs in the
softer areas, called growth plates, at either end of the long bones of the arms and legs.
 Infected tissue or an infected prosthetic joint. Severe puncture wounds can carry germs deep inside your body. If such an injury
becomes infected, the germs can spread into a nearby bone.
 Open wounds. Germs can enter the body if you have broken a bone so severely that part of it is sticking out through your skin. Direct
contamination can also occur during surgeries to replace joints or repair fractures.
 Infected Prosthesis.An infected prosthesis or other implanted orthopedic hardware is an extreme risk factor for infection. So if you’ve
had either, it is important to take the necessary precautions to protect yourself from germs. Take antibiotics as directed by your doctor
following surgery. Be sure to change dressings frequently or as directed by your physician, and avoid animal bites or other incidents that
could provide a greater pathway to infection.
 Urinary Tract Infection.A urinary tract infection can give way to osteomyelitis in a similar way as pneumonia. This type of infection is
caused by germs that collect in the urinary system, though the same germs can spread to the bloodstream and settle into a weak spot in
the bone, resulting in osteomyelitis. Individuals who have a suppressed immune system are at an increased risk of this.
COMPARISON
S.NO Book picture Patient picture
1. Blood stream infection Present
2. Infected tissue Present

43. 43
3. Open wounds Present
4. Infected prosthesis Absent
5. Urinary tract infection Absent

44. 44
PATHOPHYSIOLOGY

45. 45
SYMPTOMS
Nausea Feeling nauseous is one of the main indicators of osteomyelitis. Any infection can lead to these feelings, as the body tries to fight back
against invaders. Many antibiotics also list nausea as a main possible side effect, meaning your treatment options may not alleviate this symptom
once you are diagnosed.
Swelling Swelling is also a tell-tale sign of infection, and this is no different when the bones are concerned. Patients with osteomyelitis may feel
swelling in the long bones of the legs, in the arms, across the back, and in the ankles, feet, and hands. This occurs as the body attempts to fight
off the infection
Reduced Range Of Motion Osteomyelitis can also cause a patient to have a reduced range of motion, especially in the area of infection. Bones
can feel ‘tight’ or ‘locked,’ limiting movement. Everyday tasks and normal activities can become challenging, requiring more energy and
exertion and potentially causing pain in the process. It is not uncommon for patients with osteomyelitis to develop a limp or otherwise altered
gait in response to the bone infection
Tender And Red Infected AreaPatients who suspect osteomyelitis may also notice their skin becoming tender and red around the infection.
The bones can feel weak, fragile, and flimsy, but the tissues, muscle, and skin can also show signs of infection. Tenderness can range from mild
discomfort to impairing one’s movement, while redness can be bright and obvious as well as light and pink. It is typically the legs, arms, ankles,
feet, and hands that undergo a color change as a result of osteomyelitis, but other parts of the body can also show this symptom.
Fever
Having a fever can also be indicative of osteomyelitis, though this is a common symptom of many diseases. Fever is typically mild, though it can
rise to dangerous levels if the disorder progresses. A high temperature can also lead the patient to experience noticeable chills, excessive

46. 46
sweating, and paleness. The hands, feet, and forehead may become clammy, and the skin can wash out to appear grey or green. Furthermore,
having a high temperature can cause mild to severe delirium. Regardless, it is always a dangerous sign, no matter what the underlying cause is,
and it needs to be treated quickly before rising to a dangerous level.
Back Pain
Like other infections, osteomyelitis can present with significant pain. Specifically, with osteomyelitis in the vertebrae, patients often experience
severe, persistent back pain that worsens at night or with movement. Osteomyelitis-associated back pain can affect numerous areas of the spine,
including the neck (cervical), the mid-back (thoracic), the lower back (lumbar), as well as the sacrum (sacral). Depending on the area affected
and the patient, back pain in osteomyelitis can radiate or travel to other areas of the body. Of course, severe back pain can be the result of a
number of other issues, including an improper mattress and insufficient support, so it is important to be on the lookout for other signs of
osteomyelitis.
S.no Book picture Patient picture
1. Nausea Absent
2. Swelling Present
3. Reduced range of Present

47. 47
DIAGNOSTIC EVALUATION
Combination of tests and procedures to diagnose Osteomylelitis and to determine which germ is causing the infection, such as:
Blood tests
Blood tests may reveal elevated levels of white blood cells and other factors that may indicate that your body is fighting an infection. If your
osteomyelitis was caused by an infection in the blood, tests may reveal what germs are to blame.
No blood test exists that tells your doctor whether you do or do not have osteomyelitis. However, blood tests do give clues that your doctor uses
to decide what further tests and procedures you may need.
motion
4. Fever Present
5. Back pain Present
6. Tender and red infected
area
Present

48. 48
Imaging tests
 X-rays. X-rays can reveal damage to your bone. However, damage may not be visible until osteomyelitis has been present for several
weeks. More-detailed imaging tests may be necessary if your osteomyelitis has developed more recently.
 Computerized tomography (CT) scan. A CT scan combines X-ray images taken from many different angles, creating detailed cross-
sectional views of a person's internal structures.
 Magnetic resonance imaging (MRI). Using radio waves and a strong magnetic field, MRI scans can produce exceptionally detailed
images of bones and the soft tissues that surround them.
Bone biopsy
A bone biopsy is the gold standard for diagnosing osteomyelitis, because it can also reveal what particular type of germ has infected your bone.
Knowing the type of germ allows your doctor to choose an antibiotic that works particularly well for that type of infection.An open biopsy
requires anesthesia and surgery to access the bone. In some situations, a surgeon inserts a long needle through your skin and into your bone to
take a biopsy. This procedure requires local anesthetics to numb the area where the needle is inserted. X-ray or other imaging scans may be used
for guidance
S.NO Book picture Patient picture
1. Blood tests Done
2. Xray Done
3. CT scan Done

49. 49
4. MRI Done
5. Bone biopsy Done
COMPLICATIONS
Osteomylelitis complications may include:
 Bone death (osteonecrosis). An infection in your bone can impede blood circulation within the bone, leading to bone death. Your bone
can heal after surgery to remove small sections of dead bone. If a large section of your bone has died, however, you may need to have
that limb surgically removed (amputated) to prevent spread of the infection.
 Septic arthritis. In some cases, infection within bones can spread into a nearby joint.
 Impaired growth. In children, the most common location for Osteomylelitis is in the softer areas, called growth plates, at either end of
the long bones of the arms and legs. Normal growth may be interrupted in infected bones.
 Skin cancer. If your Osteomylelitis has resulted in an open sore that is draining pus, the surrounding skin is at higher risk of developing
squamous cell cancer.
Book picture Patient picyure
Osteonecrosis Absent

50. 50
Septic Arthritis Present
Impaired growth Absent
Skin cancer Absent
MANAGEMENT
Pharmacological management:
The initial goal of the therapy is to control and half the infective process .antibiotic depends on the results of blood and wound culture. As soon
as the culture specimen is obtained, IV antibiotic therapy begins based on the assumptions that infection results from a streptococcal organism
that is sensitive to a semisynrhetic penicillin or cephalosporin.
 Amoxicillin –clavulanate 875 mg/125 mg PO 12h
 Ciprofloxacin 750mg POq 12h + clindamycin 300-450 mg POq 6 h
 Levofloxcin 750mg POq daily.
 Analgesics
 IV antibiotic therapy continues for 3-6 weeks. After the infection appears to be control, the antibiotic may be administered orally for up
to 3 months.

51. 51
 Hyperbaric oxygen therapy:-some researches proved that this type of non surgical management useful in treating Osteomelitis that are
not responding to conventional treatment. During hyperbaric oxygen therapy patient is placed in a specially designed chamber. This
chamber is filled with oxygen, administered at a much high pressure (hyperbaric) then normal level of oxygen in the atmosphere. Thigh
level of oxygen speed up the healing process and slow the spared of infection.
 Anti TB drugs: the anti tubercular drugs are used in different combinations in different circumstances. Anti TB drugs , the first line
drugs , are used for the treatment of new pateints who are very unlikely to have resistence to any of the TB drugs. 2nd line drugs , that are
only used for the treatment of drug resistant TB.
SURGICAL MANAGEMENT
Depending on the severity of the infection, osteomyelitis surgery may include one or more of the following procedures:
 Drain the infected area. Opening up the area around your infected bone allows your surgeon to drain any pus or fluid that has
accumulated in response to the infection.
 Remove diseased bone and tissue. In a procedure called debridement, the surgeon removes as much of the diseased bone as possible,
and takes a small margin of healthy bone to ensure that all the infected areas have been removed. Surrounding tissue that shows signs of
infection also may be removed.
 Restore blood flow to the bone. Your surgeon may fill any empty space left by the debridement procedure with a piece of bone or other
tissue, such as skin or muscle, from another part of your body.

52. 52
Sometimes temporary fillers are placed in the pocket until you're healthy enough to undergo a bone graft or tissue graft. The graft helps
your body repair damaged blood vessels and form new bone.
 Remove any foreign objects. In some cases, foreign objects, such as surgical plates or screws placed during a previous surgery, may
have to be removed.
 Amputate the limb. As a last resort, surgeons may amputate the affected limb to stop the infection from spreading further.
COMPARISON OF MANAGEMENT
S.NO Book picture Patient picture
1. Antibiotic therapy Given
2. Hyperbaric therapy Not done
3. Anti TB drugs Given
4. Drain the infected area Done
5. Remove diseased tissue and bone Not done
6. Restore blood flow to the bone Not done
7. Remove any foreign objects Not done
8. Amputate the limb Not done

53. 53
Nursing assessment
 Physical examination
 History collection
 Onset of acute symptoms
 Recurrent drainage of an infected sinus
 Assess risk factors
 Purulent discharge
 History of previous illness
 Ask for any family history of Tuberculosis .
 Ask for history of smoking, alcoholism and occupation.
 Assess for chief complaints.
 Assess for dietery pattern .
 Inspect the affected area and charcterstics of wound .
 Auscultate the bowel and lungs sounds.
 Any previous use of antibiotics or other drugs.
 Asses the moisture of the skin over wound site
 Assess for the knowledge regarding disease condition ,treatment ,surgery, dietry pattern etc.

54. 54
THEORY APPLICATION:- Orem’s theory self care deficit.
UNIVERSAL SELF – CARE REQUISITE :-
S.NO. COMPONEN’S PATIENT COMPONENT
1. Maintenance of sufficient intake of air , water , food. Patient having a loss of appetite not
eating sufficient food , and not drinking
adequate amount of water and breathing
pattern is also not normal. Patient is on
BiPAP support.
2. Provision of care associatedwith elimination and excrements processes Elimination is on bed. Patient herself is
not able to maintain hygiene after
elimination.
3. Balance between activity and rest;between solitude and social
interaction
Patient having tiredness, patient not able
to perform activity of daily living because
of surgery
4. Prevention of hazards to human life, functioning and well being Not able to prevent hazards of her life
and also not able to perform the function
of daily living
5. Promotion of human functioning and development. Patient is not promoting her functioning
and development

55. 55
 DEVELOPMENTAL SELF CARE REQUISITIES:-
S.NO COMPONENT’S PATIENT COMPONENT
1. Maintenance of developmental environment Not able to feed self , difficult to perform
the dressing
2. Prevention/ management of the conditions threatening the normal
development
Feel that the problem are due to her own
behavior .
 HEALTH DEVIATION SELF- CARE REQUISITE:

S.NO COMPONENT’S PATIENT COMPONENT
1. Seeking and securing appropriate medical assistance Patient need medical assistance
2. Being aware of and attending to the effects and results of pathologic
conditions.
Patient was aware about her diseases
condition
3 Effectively caring out medically prescribed measures. Patient effectively carrying medically
prescribed measures.
4 Modify self concepts is accepting oneself as being in a particular state
of health and in specific forms of health care.
Patient accepting her diseases condition
and herself
5 Learning to live with effects of pathological conditions Patient living with her pathological
conditions.

56. 56
Nursing diagnosis:
1) Acute pain related to inflammation and swelling as evidenced by patient verbal report and pain scale
2) Ineffective thermoregulation (hyperthermia) related to inflammatory process as evidenced by vital signs
3) Impaired physical mobility r/t pain, and decrease mobility as evidenced by patient is not able to do his daily activities of living she
need assistance.
4) Risk for infection r/t abscess formation as evidenced by purulent discharge from the wound.
5) Impaired skin integrity r/t inflammatory changes as evidenced by pus formation at infected site.
6) Imbalanced nutrition less than body requirements related to loss of appetite as evidence by pateints verbal report and intake
output chart.
7) Risk for fall related to impaired physical mobility and disease condition as evidence by observation
8) Disturbed sleeping pattern related to acute pain as evidence by patient verbal report and facial expressions.
9) Knowledge deficit related to disease condition , treatment prognosis and healing process of disease condition
10) Fear and anxiety related to changes in health and situational crises as evidence by observation
Short term goals:
 Pain will be relieved
 To enhance physical mobility
 To maintain body temperature
 Nutritional status will be improved
 Activity tolerance will be improved.

57. 57
 Anxiety will be reduced.
 Risk for infection will be reduce
 Long term goals:
 Nutritional status will be maintained at acceptable level
 Knowledge will be improved regarding causes, management and prevention of disease.
 Patient will be encouraged for follow up visit
 Patient will be able to sleep properly
NURSING CARE PLAN
Assessment Nursing
Diagnosis
Goal Nursing interventions Implementation Scientific Rationale Evaluation
Subjective data:
Patient says “ Iam
having leg pain.
Objective data:
Patient is having
pain in Right leg
and back pain
Pain is moderate
in intensity8/10
Acute pain
related to
inflammati
on and
swelling as
evidenced
by patient
verbal
report
Pain will
be
reduced
Assess the level and
characteristics of pain.
Provide comfortable
position to the patient.
Provide comfort devices
to the patient
Encourage and assist the
patient in relaxation
Assessment is done. Pain
is moderate with score of
8 on pain rating scale.
Supine position was
provided to the patient.
Comfort devices was
provided to the patient
(extra pillows)
Patient was assisted in
Provide baseline data.
Provide comfort to the
patient .
Provide relief from
physical and mental
suffering.
To promote the comfort
and to reduce the level of
Pain is reduced
as evidenced
by pain rating
scale.5/10

58. 58
pain scale
8/10
techniques
Administer analgesics
as prescribed.
Provide diversional
therapy to the patient.
Elevate the leg of
patient
deep breathing exercises.
Analgesics voveron SOS
was given.
Music therapy provided
to the patient.
To reduce the level of
pain
pain
Relieves pain.
Provides psychological
relief from pain.
Leg is elevated with the
help of pillow
Assessment Nursing
Diagnosis
Goal Nursing
interventions
Rational Implementation Evaluation
Subjective data:
Patient said that I
am feeling hot
Objective data:
Fever 100.2 F
Hot flushes
Hot in
Ineffective
thermoregulation
hyperthermia
related to
inflammatory
process as
evidenced by
vital sign
monitoring
To improve
thermoregulation
Assess the vital sign
Provide cool and
calm environment
Encourage fluid
intake
Know baseline data
Reduce body
temperature
Maintain hydration
Assessed vital sign
T= 100.8F,PR= 92
b/min
Provided cool and
calm environment
Encouraged by
giving I V fluids
through IV line
(NS,RL)
Temperature
was reduced
to some
extent as
evidenced
by vital
signs i.e. 99̊
F

59. 59
Apply cool sponges
for elevated body
temperature
Avoid exposure to
infection
Administer medicine
as prescribed by
Maintain body
temperature
Reduce body
temperature
Reduce the fever
Applied cool sponge
for elevated body
temperature
Avoidedby following
aseptic technique
Administered Inj
Paracip TDS to client

60. 60
ASSESSMENT DIAGNOSIS GOAL Interventions Rationale Implementation Evaluation
Subjective data:
Patient says “ I
can’t do my daily
activities
independently”
Objective data:
Patient is having
pain and
numbness in
lower limbs
Impaired
physical
mobility r/t
pain, and
decrease
mobility as
evidenced by
patient is not
able to do his
daily activities
of living she
need assistance
To improve
physical
mobility
Assess the general
condition of the
patient
Encourage patient to
perform an activity
more slowly than
usual and with
assistance initially
Assist the patient in
performance of
energy consuming
activity
Provide active and
passive exercises to
patient.
Encourage patient to
avoid strenuous
To get the baseline
data for planning
To improve the
activity level
To increase the
activity and to reduce
the workload on
patient
To maintain
circulation and
improve activity level.
To conserve energy
and improve activity
Assessment was
done
Encouraged to
perform the activity
more slowly than
usual
Assisted to perform
the energy
consuming activity
Active and passive
exercises provided
to patient.
Instructed to avoid
strenuous activity
Physical
mobility of
client has been
improved up to
some extent by
doing different
interventions.

61. 61
activity and
competitive sports
Instruct the patient to
provide support to
the suture
.
tolerance
To improve the patient
safety
.
Instructed the
patient to provide
support to the
patient

62. 62
ASSESSMENT DIAGNOSIS GOAL INTERVENTION RATIONAL IMLEMENTATIO
N
EVALUATION
Subjective data-
Patient says that I
am having fever.
Objective data
Fever
Increase ESR
level
Risk for infection
r/t abscess
formation as
evidenced by
purulent
discharge from
the wound.
To
reduce
the
chances
of
infection
Assess the general
condition of the patient
Use aseptic technique
during performing any
procedure.
Maintain general head to
foot care.
Assess the surgical site for
any infection signs
Follow all principles
during performing any
procedure.
Administer antibiotics as
provide baseline
data for planning
prevent infection.
.
maintain hygiene.
reduce chances of
infections.
identify risk of
infection
To treat
Assessment was done
by physical
examination.
Aseptic technique
used during
performing
procedure.
General head to foot
care maintained.
.Periodic assessment
of surgical site
Strict aseptic
techniques was
maintained
Antibiotics
By providing all care
risk of infection
reduced .

63. 63
ordered. infections. administered as
ordered e.g. cefexim
1gm IV.
HEALTH EDUCATION
Diet- patient is taught regarding balanced diet, rich in fibres and fluids as patient has history of constipation.
 Patient is advised to take green vegetables, fruits, juices & salad in diet.
 Advised patient to take protein rich diet.
 Leafy, dark-colored greens like kale and spinach, for their high iron and B-vitamin content.
 Plenty of whole grains, like whole wheat pastas, breads, and cereals.
 Antioxidant-rich, brightly-colored vegetables, such as carrots, peppers, and squash, and fruits.
 Unsaturated fats like vegetable or olive oil, instead of butter.
Types of food

64. 64
Major Nutrients Foods
Energy rich foods Carbohydrates & fats
Whole grain cereals, millets.
Vegetable oils, ghee, butter.
Nuts and oil seeds. Sugars
Body building foods Proteinsss
Pulses, nuts and some oilseeds.
Milks & milk products
Meat, fish, poultry
Protective foods Vitamins & minerals
Green leafy vegetables.
Other vegetables & fruits.
Eggs, milk & milk products and flesh foods.

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Exercise – patient is taught some active & passive exercise.
 Patient is advised to do deep breathing exercise.
 Advised patient to sit in a semi-fowler’s position
Hygiene – patient is advised to keep his surroundings clear & perform hand hygiene properly.
Advised patient to change clothes daily
Fluids – patient is advised to take more fluids & beverages.
Advised patient to take 8-10 glasses of water daily
Administer iv fluids as prescribed.
Pain management & Medications - Analgesic medication timing is clearly explained to patient & with that feedback for medications intake is
also taken .
Follow Up- follow up dates are given to patient & clearly explained regarding it.

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Progress note
Day 1:
On day 1 I collected the history of Ms.Ranjana she is having acute pain then I provided her inj tramadol and checked the vital sign of the patient
. I collected the history of patient. Pateint was having 100.3f fever
s.no Procedure Remarks
1. Vital sign checked and recorded and monitoring recorded BP:/110/66,Pulse 72/min,R.R:28/min,Temp :100.3F
2. Positioning was done Right leg was elevated
3. Medication was given and tapid sponging was done Regular medication given
4. Provided comfortable position to the patient and devices Supine position was provided and pillows was provided
DAY 2:
On 2nd day physical examination was done and range of motion excersise was provided to the patient patient said that I am not able to eat the
meals I am not feeling hungry
s.no Procedure Remarks
1. Physical examination was done Abnormal findings are mentioned in the physical
examination
2. Medication was given to patient Regular medication was given
3. Nutritional assessment was done Ryles tube feeding was given to the patient

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4. Assisted in passive and active excersises Extension and flexion
RECORDING AND REPORTING
s.no Date Procedure Remarks
1. 04/11/19  Vital sign checked and recorded
 History collection was done
 Personal history collection done
 Medication done
 Comfortable postion was given with devices
Patient is stable
Vital sign are recorded and monitored
Patient was having fever 100.3f F
2. 05/11/19  Physical examination was done
 Oral hygiene was done
 Dressing done
 Nutritional assessment was done
Patient’s hygiene is maintained
Recording and reporting done
CONCLUSION
Patient was admitted with the chief complaints of pain in the right leg from last 15 days. Pain was moderate in intensity, increased during
walking and relieved with rest. There was history of fever from last 3 days due to abscess in Right lower leg . She also noticed a small painful
swelling in the leg. She is also having loss of appetite from last 15 days and due to this she is having fatigue and weakness. She had under gone

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radiology tests and came to know that she is suffering from tubercular osteomyelitis for which she is taking Anti tuberculosis drugs and some of
her symptoms is relieved History collection and physical examination was done and proper treatment is provided to the patient .active and
passive ROM was provided to the patient .now the patient is stable and pain level is reduced and her nutritional pattern is improved and patient
is satisfied with the care provided in the hospital.
SUMMARY
I was posted in general ICU at Sir Ganga Ram Hospital, where I took a case of tuberculosis osteomyelitis who was suffering from severe Pain in
back ,leg and fever . she have loss of appetite . I provided her proper care according to priority wise . medication is provided to the patient
.proper nursing care is provided to the patient that is nutritional assessment.ROM is provided to the patient .health education is provided to the
patient regarding diet ,hygiene ,exercise etc .Patient is satisfied by nursing care and in future if I got these type of case I will be able to provide
proper care to the patient .

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BIBLIOGRAPHY
 Brunner & suddhart’s, “textbook of medical-surgical nursing”, 11th edition published by Elsevier, page no. 670-676.
 Smeltzer CS, Bare B. Brunner &Suddarth’s Textbook of Medical Surgical Nursing. 10th ed. Philadelphia(PA): Lippincott Publishers;
2006.
 Chintamani. Lewis’s Medical Surgical Nursing. 7thed. New Delhi: Elsevier limited; 2010, page no.810-821.
NET REFRENCES
 J Bone Joint Surg Br. 1997 Jul;79(4):562-6. Mohan Dai Oswal Cancer Treatment and Research Foundation, Ludhiana, India.
Available from-http://m.authorstream.com/presentation/tuberculous-osteomylitis