PHARMACOLOGY

CASE STUDY

Submitted by:

Anulao, Michael
Cleofe, Ailyne
Dimagnaong, Zarah
Magadan, Jeanne
Rivera, Esther

Submitted to:
Mr. Peter A. Orlino, RN

Date:
July 26, 2017
2. Groups of person in which osteomyelitis is most difficult to manage.

The group of people in which osteomyelitis is most difficult to manage are those
who are obese. The story behind the obesity in relation to osteomyelitis is not clearly
understood, but it is clear that having apple- shaped obesity or truncal obesity has
insulin resistance which is associated to hypertriglyceridemia and both interferes with
tissue perfusion. If bone injury occurs and blood supply is impaired, over a period of
time, infection of the bone will develop. Diabetes can lead to diabetic foot problems
that may lead to poor wound healing which may be infected by the pyogenic or non-
pyogenic microorganisms like the one in the results of the patient’s blood culture and
gram stain tests which are Staphylococcus aureus and Pseudomonas aeruginosa. If you
have diabetes, there will be less circulation due to its increased blood viscosity, so if
there is less blood circulation, there will be less wound healing which is prone to
infection. Persons who are malnourished, history of alcoholism or liver failure are the
most difficult also because of their immunocompromised status.

3. Discuss the indirect and direct osteomyelitis.

The indirect entry (hematogenous) of microorganism in osteomyelitis most
frequently affects growing bone in boys less than 12 years old, and is associated with
their higher incidence of blunt trauma. Adults with vascular insufficiency disorders (ex.
Diabetes mellitus) and genitourinary and respiratory infections are at a higher risk for
primary infection to spread via the blood to the bone. The pelvis and vertebrae, which
are vascular rich sites of bone, are the most common sites of infection. Direct entry
osteomyelitis can occur at any age where there is an open wound and microorganisms
gain entry into the body.

4. Discuss the organism that is the most common cause of osteomyelitis.

The organism that is the most common cause of osteomyelitis is Staphylococcus
aureus. It is a nonmotile gram-positive bacterium that is normally found on the skin and
in the throat. However, life-threatening staphylococcal infections may arise within
hospitals, and are frequently responsible for osteomyelitis and other infectious diseases.
Staphylococcus aureus infections have become increasingly more difficult to treat due
to the development of resistance to penicillin-related antibiotics. These bacteria are
called methicillin-resistant Staphylococcus aureus (MRSA).
 How this organisms act in causing osteomyelitis is explained by the
pathophysiology map but here’s the explanation, there are many factors that cause this
condition. Just an example: If one person have any acute infection present in his body
maybe limited to the soft tissues regardless where it is located as long as it is not
managed and cared for, microorganisms will invade the site specifically the most
common is staphylococcus aureus, if this person’s immunity is weak then these
microorganism (staphylococcus aureus) escapes the body’s defences and will multiply
which results to increased pus production, then next to that, theses microorganisms will
spread by way of blood and some will go deeper damaging the periosteum (protective
covering of the bone) until it will reach inside the bone, then it will lodge in that bone
and multiply net will be the bone abscess formation and then necrosis that’s when you
can see the five signs of infection.
5. Discuss the psychosocial impact of the client’s amputation on his well-
being and the risk that further surgery may be necessary.

Response to the
amputation of the Explanation
body parts
On being told that his body part will be amputated or cut
the patient first reaction will be shock and it is not easy
DENIAL- for him to accept the situation. The patient may appear
confused at first and may then refuse to the surgery and
deny that there is something wrong with his health.

The patient became frustrated, irritable and angry that he

ANGER- is sick and start asking God why is happens to him, he
may blame God and anger may be displaced onto hospital
staff or doctors who are blamed for his illness.

The patient now may attempt to negotiate with his doctor,

friends, or even God, that in return for his cure, he will
BARGAINING- fulfill one promise, such as giving back his fate.

The patient show clinical sign of depression withdrawal,

psychomotor retardation, sleep disturbance, hopelessness
DEPRESSION- and possible suicidal icliation.it is his reaction to the effect
of amputation of his body parts, it is his anticipation to the
surgery, because it is very hard for him to accept the
situation.

The patient realized that the surgery is the best option to

save the other parts of his body. He will accept the advice
ACCEPTANCE- of his doctor and will be convinced to go on surgery and
go on with life even if one of his body part is missing.

6. Discuss common nursing diagnoses for clients with osteomyelitis.

• Acute pain R/T inflammatory process secondary to infection – The nurse

should prioritize care by focusing on the client’s complaint of pain, assessing location,
and intensity of the pain with the use of a pain scale. Analgesics should be implemented
on time as scheduled, and the client should be instructed to request pain medication
before the pain becomes too severe. Elevation of the extremity will reduce swelling, if
present, and promote comfort.
• Impaired physical mobility R/T loss of integrity of bone structure – The
nurse should assist the client as needed to reduce the client’s frustration with impaired
mobility, and to prevent injury. Assistive devices (e.g., long-handed shoehorn, socks
helpers, pick-up stick) should be used to increase independence in activities of daily
living.
• Ineffective therapeutic regimen management R/T lack of knowledge
regarding long-term management of osteomyelitis – The nurse must provide
information and instruction regarding wound care, aseptic technique, and dressing
disposal to reduce the risk of cross-contamination and encourage wound heal-ing. The
nurse should also review drug regimen including schedule, name, dosage, purpose, and
side effects, because long-term antibiotic therapy is required.

7. What are the purposes for the prescribed orders?

Ticarcillin disodium/clavulanate potassium is an extended spectrum
penicillin and beta-lactamase inhibitor used to treat bone infections. It destroys the
organisms, halting the infectious process by interfering with synthesis of mucopeptides
essential to formation and integrity of bacterial cell wall, resulting in the death of
organisms. Intravenous therapy is to aid with hydration status and as an adjunct to
antibiotic therapy.
Vitamin A is a fat-soluble vitamin supplement that enhances wound healing by
providing collagen synthesis, and improving immune response.
Vitamin C is a water-soluble vitamin supplement that enhances wound healing and
capillary wall integrity by increasing collagen formation and protecting mechanisms of
the immune system, which supports wound healing.
The ESR helps to assess the client’s inflammatory status, and the infectious and
necrotic process in relationship to antibiotic management. This is seen with elevation of
the levels if the infectious process continues in the presence of the antibiotic therapy, or
it decreases and returns to normal when the infectious process responds effectively to
the antibiotic regimen.
The haemoglobin reveals the blood’s oxygen-carrying capacity and helps determine
the significance of oxygen to the involved tissues. An elevated WBC count indicates
infection and helps with the management of wound care. The albumin levels indicate
the nutritional status of the client and the need for modification of treatment.
8.What are the most common adverse reactions, drug-to-drug, drug-to-
food/herbal interactions for the pre-scribed medications?
The most common adverse reactions of ticarcillin disodium/clavulanate
potassium are diarrhea, risk of anaphylaxis, epigastric distress, nausea, vomiting,
hypernatremia, hypokalemia, headache,rashes, and phlebitis at the infusion site,
especially if infused too rapidly through a peripheral site.
Drug-to-drug interactions may occur with the simultaneous use of oral
contraceptives and ticarcillin disodium/clavu-lanate potassium and oral contraceptives,
decreasing the effectiveness of the contraceptive agents. The concurrent use with
probenecid decreases renal excretion and increases serum levels, and there is a syner-
gistic effect when used with amikacin or gentamycin.As with other bacteriocidal
antibiotics, its actions maybe antagonized by bacteriostatic agents such as
erythromycin, tetracyclines, and chloramphenicol. If used with beta-adrenergic blocking
agents, the risk of allergic reactions increases. The risk of bleeding isincreased if used
concurrently with heparin, alteplase, anistreplase, nonsteroidal anti-inflammatory
agents(NSAIDs), aspirin, dextran, dipyridamole, and plicamycin. The concurrent use
with methotrexate decreases methotrexate elimination and increases the risk of serious
toxicity. There are no clinically significant common adverse reactions of vitamin A
established. There are no clinically significant drug-to-drug, drug-to-food/herbal
interactions established. There are no clinically significant adverse reactions of vitamin
C established. Drug-to-drug interactions may occur with the simultaneous use of oral
anticoagulant, which may inhibit ascorbic acid uptake by leukocytes and tissues, and
ascorbic acid may diminish the effects of disulfiram.

9. When is the Onset, peak and duration of action of the prescribed drugs.

Ticarcillin disodium/clavulanate potassium (Timentin)

Onset: unkown
Peak: immediate
Duration: unknown
0.9% NaCL
Onset: immediate
Peak:immediate
Duaration: until renal clearance occurs
 Vitamin A (Aquasol A)
Onset: 1-2hrs
Peak: 4-5 hrs
Duration: unknown
Vitamin C (Ascorbic Acid)
Onset: > 2 days
Peak: unknown
Duration: unknown

10.Discuss discharge instructions for the client with osteomyelitis.

If the client is discharged to home with an unhealed wound that has
approximated at the edges without odor or drainage, the client may be instructed in the
use of a transparent film dressing, which provides a moist environment that promotes
granulation tis-sue. The client should monitor the wound site for swelling or pain and
report these findings to the primary health care provider. The client should complete
antibiotics as prescribed, and keep scheduled appointments. The client should maintain
weight, decrease the amount of salt used in the diet, exercise, and monitor blood
pressure.

11. What are the therapeutic usefulness of the drugs that were prescribed for
Mr. Gon Freecs? Classify them whether the drugs prescribed are agonistic
and antagonist.
The therapeutic usefulness of the drugs prescribed:
Ticarcillin disodium(antagonist): reduce the development of drug-resistant

bacteria and maintain the effectiveness of TIMENTIN (ticarcillin disodium and

clavulanate potassium) and other antibacterial drugs, TIMENTIN should be used only
to treat or prevent infections that are proven or strongly suspected to be caused by
bacteria.
Vitamin A (Agonist): strengthen the immune system
Vitamin C (Agonist): strengthen immune system
0.9% NaCL: helps to maintain the correct balance of fluid in and around the body’s
cells and tissues. Sodium chloride infusions are given to add water to tissues which are
dehydrated and to help to restore the normal salt balance.
ESR -help to detect inflammation associated with conditions such as infections, cancers
and also immune diseases. -Mr.Gon has an elevated ESR that why he is experiencing
inflammation but also with anemia, infection and aging. ESR cause such severe
infection marked by an increase in globulins, polymyalgia rheumatica or temporal
arteritis

HEMOGLOBIN- -Hemoglobin is a protein in the red blood cells that carries oxygen to
the body's organs and tissues and transports carbon dioxide from the organs and
tissues back to the lungs. hemoglobin test reveals that the hemoglobin level is lower
than normal, it means it has a low red blood cell count.

WBC -The normal number of WBC is 4,500-11,000 and the WBC of Mr.Gon is just
13,000/mm3 so Mr.Gon WBC is low that's why he has a viral infection that temporarily
disrupt the work of his bone marrow.

ALBUMIN TEST -It measures the amount of albumin in the blood of Mr.Gon. Having
an open wound raises yhe chances of having a low albumin level.

12. FR= Vol x Df

time
Vol = 100ml x 15gtts/min
1 x 60mins
= 1500 = 25gtts/min
60

GROUP 2

There are many different types of pain medications available to help healthcare
providers treat patients with chronic pain. Depending on the specific medication, they
can be obtained by prescription or are available over-the-counter (OTC). Pain
medications provide an important component of most treatment plans intended to
relieve suffering and enhance the quality of lives for many patients. As with most other
medical treatments, they may also often have significant adverse effects. In some
cases, especially with long-term use, a pain medication may cause more harm than
good. For this reason, the risks of the decision to continue a certain medical therapy
should always be weighed against its benefits, sometimes resulting in possible dose
adjustments to minimize adverse effects, or in other cases discontinuation of the
medicine altogether.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are probably the most popular

OTC pain medications. While some strengths are available by prescription, they are
often easily obtained without a prescription. Some examples of commonly used NSAIDS
are aspirin, ibuprofen, and naproxen. One of the key benefits of NSAIDs is that they are
used to reduce both pain and inflammation. Most types of chronic pain are thought to
have some degree of an inflammatory component.

Possible NSAID-related adverse effects from chronic use include stomach upset,
exacerbation of gastric ulcers, renal function impairment, and increased risk of
bleeding. Chronic use may also increase the likelihood of developing peripheral edema,
likely due to sodium retention and/or renal effects. Some people have reported tinnitus
(ringing in the ears) with long-term and excessive aspirin use. Usually NSAIDS can be
abruptly discontinued without complications but in some cases chronic users may report
a “rebound headache” when they suddenly stop. It is then necessary to gradually
decrease the dose over time in order to completely stop the medication. A special class
of NSAIDs called COX-2 inhibitors was developed with the intention of avoiding many of
these adverse side effects. However, even this subset of NSAIDs has been implicated in
increasing the risk of stroke and heart attack in high-risk patient populations with
chronic use.

Acetaminophen

Acetaminophen is one of the most popular OTC pain medications that are commonly
prescribed for mild to moderate pain. It is frequently used as an analgesic and
antipyretic, and it is considered the first-line pain medication for many conditions,
especially in people for whom NSAIDs are contraindicated. It is also often combined
with other medications in prescription form including opioids like oxycodone or
hydrocodone.

Irreversible hepatotoxicity is the biggest risk of chronically using large doses or

overdose (intentional or unintentional) of acetaminophen. Unfortunately, unintentional
overdose occurs frequently because patients are unaware of combining medications
with each other that both contain acetaminophen. Signs and symptoms of liver damage
can include abdominal pain, yellowing of the skin or eyes, and nausea or vomiting.

Opioids

Opioid analgesics are available only by prescription. Examples of opioids are

morphine, hydrocodone, oxycodone, oxymorphone, and codeine. Three common
adverse effects of opioids are constipation, nausea and respiratory depression. Other
potential adverse effects include cognitive impairment, urinary retention, itching, and
swelling. Physiologic tolerance may result from chronic opioid use, requiring increased
amounts of certain opioids to relieve pain. In some situations, this can ultimately result
in loss of analgesic efficacy, and switching to another opioid molecule may be indicated
(opioid rotation). Some postulate that long-term use of opioids can lead to a
phenomenon known as "opioid induced hyperalgesia". When this occurs, the person
actually experiences increased sensitivity to painful stimuli. Another possible adverse
effect associated with chronic opioid use is its effect on hormonal levels. Hormonal
changes can cause decreased sex drive, tiredness, and changes in a woman’s menstrual
cycle, and galactorrhea (secretion of breast milk in men or in women who are not
breast feeding). Studies have shown that testosterone levels decrease in men and
estrogen levels decrease in women receiving chronic high dose opioid therapy.
Controversy continues to exist regarding the efficacy of long-term opioid analgesic
therapy, with supporting and opposing arguments made on both sides of the debate.
Certainly, most would agree that any good pain treatment plan should include opioid
analgesics when deemed appropriate along with other medical and non-medical
modalities.

Adjuvant Analgesics

Adjuvant analgesics are generally non-opioid medications used for pain relief
which may be primarily used for other health problems, and they are usually prescribed
with other pain medications. Two examples of adjuvant analgesics are anticonvulsants
and antidepressants. They are generally used as part of a treatment plan for
neuropathic pain. Adverse effects of these medications may include sedation and
cognitive impairment and help with sleep. Another type of adjuvant analgesic that may
be used is local anesthetic agents, such as topical lidocaine 5% for the treatment of
post-herpetic neuralgia.

In summary, chronic use of pain medications, like chronic use of any other medications,
can have a variety of adverse effects that can become greater when they are used
regularly or over an extended period of time. It is important to stress to patients to only
take those medications prescribed by a qualified healthcare practitioner, and to take
them as they are directed to be taken. If medications are obtained over-the-counter, it
is very important to read and follow the directions that come with them, no matter how
harmless they may seem. Everything carries some degree of risk.

Of course, using medications inappropriately or in combination with other medications,

including illicit street drugs, or alcohol, can result in particularly serious health
consequences. It is important to review all medications and health problems with your
chronic pain patients. Being informed about the specific adverse effects associated with
pain medications can increase the chances of avoiding severe health problems, and lead
to a better treatment outcome for their pain.

Many different factors come together to determine how quickly and effectively
the body heals from wounds. The wound healing process relies largely on one’s physical
condition – for example, diabetics, smokers and people with immunological conditions
often have a harder time recovering. Many people may not realize it, but psychological
elements can also come into play. Stress is among the most common natural reactions,
and it can have detrimental effects on healing.
Understanding stress
Stress is the body’s natural response to any outside stimulus that agitates you mentally
or physically. It’s a part of the “fight-or-flight” mechanism, in which the body secretes a
boost of hormones such as cortisol and adrenaline during tense situations. In small
amounts, stress can be a life-saving thing. After all, it has worked to prompt our
ancestors to take action in the face of danger.
However, long-term stress can be harmful to one’s health. To make matters
worse, some people’s bodies overreact to everyday, non-threatening life stressors, such
as deadlines and traffic jams, causing continuous and chronic anxiety. According to
the American Psychological Association, it can lead to anxiety, insomnia, muscle
soreness and weakening of the immune system. Additionally, chronic stress can cause
high blood pressure, which may in turn induce cardiovascular issues such as stroke and
heart attack. For instance, people who are experience anxiety may also have trouble
sleeping at night. This can further exacerbate the weakening of the immune system,
which can in turn lead to wound infection when the body can’t fight off harmful
bacteria.

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Broyles, B.E. (2005). Medical-Surgical Nursing Clinical Companion.Durham, NC: Carolina
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Gahart, B.L. and Nazareno, A.R. (2005). 2005 Intravenous Medications. St. Louis:
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Huether, S.E and McCance, K.L. (2004). Understanding Pathophysiology (3rd ed.). St.
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Spratto, G.R. and Woods, A.L. (2005). 2005 Edition: PDR Nurse’s Drug Handbook.
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