CASE STUDY

Under supervision
Prof. Dr Nadia Taha
Prof. Dr Fathia Attia
Prof. Dr Ilham Hamad

By
Mohamed Galal
2023-2024

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 CASE STUDY
‫جامعه الزقازيق‬
‫كليه التمريض‬

Patient Name; Ibrahim Yusuf Ali Hospital; Zagazig General Hospital

Date Of Birth 1985 Ward; Orthopedic department
Gender  Male  Female Date of Admission1 / 1 / 2024
Biographic data

Occupation  Working  Not Working

Marital state  Single  married  widowed  divorced
 primary  secondary  university  other Information obtained from;
Education
 illiterate  others…... Nicotine use  Yes  No
Religion; Muslim No. of packs /day; .1pack
Living state  lives alone  lives with family  homeless Drug Abuse  Yes  No
Residence  Rural  Urban

Chief compliant "patient statement of reason for admission" ; Severe joint pain

Patient knowledge about his condition  No knowledge  Partially aware  Fully aware
Present illness

Medical diagnosis; osteoarthritis in knee joint

Allergy  No  Yes Specify;
Bl.p 140 / 90
RR 17 C/M Weight 100 kg Height 165 cm
Vital mmHg
signs Blood glucose; 110 milligrams per
Temp 37 ºc HR 66 B/M
deciliter (mg/dL)

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  Severe Visual  Mild to moderate vision  Severe hearing  Mild to moderate
Vision problems problems Hearing problems hearing problems
 Use vision aids  No problems  Use hearing aids  No problems
Chronic condition Yes No Past Surgical History; no Family history Yes No
Hypertension Hypertension
History and chronic condition

Diabetes Diabetes
COPD Cancer
Asthma Past medical History; The patient suffers from, Others;
high blood pressure and breakdown of cartilage
HCV
in the joint
Heart disease Growth and development; normal
CKD Immunization of COVID-19;  Yes  No
Others- osteoarthritis Others; Childhood diseases; no

Previous hospitalization  No  Yes Reasons….

 No difficulty to fall  difficulty to fall sleep No. of sleep hours during night;
Sleep and rest sleep
Health pattern

The patient has problem in sleep related to pain

BMI= BMI = 100 kg / (1.75
Weight control
m)^2 ≈ 32.62  Underweight  Normal  Overweight  Obese
 Regular
Diet  Special, enumerate no specific diet that can cure osteoarthritis, maintaining a healthy and balanced diet can
contribute to overall joint health and potentially alleviate some symptoms.

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 Amount of fluid/water per day; Approximately 2.2 liters (or about 9 cups) of total water per day
Salt  Low  Usual  High Sugar  Low  Usual  High
Fat  Low  Usual  High Appetite  Good  Poor  Anorexia
Activity and  Active life style  Sedentary life style  Extremely inactive
exercise
Environmental hazards In a hospital setting, patients face increased vulnerability to infections due to the presence of infectious agents. Those recovering
from strokes may encounter challenges like impaired balance and mobility, elevating the risk of falls in a hospital environment.
Additionally, the administration of diverse medications in hospitals raises the potential for errors in prescribing, dispensing, or
administering medications. The hospital atmosphere, characterized by noise and the overall unfamiliar environment, contributes
to a heightened risk of falls. Furthermore, hospitalization induces psychological stress and anxiety in patients, adding to the
complexity of their healthcare experience.
Personal hygiene  Dependent  Partially dependent  Independent
assessment
Functional

Toileting  Dependent  Partially dependent  Independent

Eating  Dependent  Partially dependent  Independent
Ambulatory  Dependent  Partially dependent  Independent
 Yes  No if  Walker  Wheel chair  Cane
Use assistive devices yes

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 Lab investigation

Lab Test Result Normal Range

Complete Blood Count (CBC)
- White Blood Cell Count 8,000/mm³ 4,000 - 11,000/mm³
- Hemoglobin 12 g/dL 12 - 16 g/dL
- Platelet Count 250,000/mm³ 150,000 - 450,000/mm³
Blood Chemistry
- C-Reactive Protein (CRP) 5 mg/L 0 - 3 mg/L
- Erythrocyte Sedimentation Rate 20 mm/h 0 - 20 mm/h
Renal Function Tests
- Blood Urea Nitrogen (BUN) 20 mg/dL 7 - 20 mg/dL
- Serum Creatinine 1.0 mg/dL 0.6 - 1.3 mg/dL
Liver Function Tests
- Alanine Aminotransferase (ALT) 25 U/L 7 - 56 U/L
- Aspartate Aminotransferase (AST) 20 U/L 5 - 40 U/L
Lipid Profile
- Total Cholesterol 180 mg/dL < 200 mg/dL
- Low-Density Lipoprotein (LDL) 100 mg/dL < 100 mg/dL
- High-Density Lipoprotein (HDL) 50 mg/dL > 40 mg/dL (men), > 50 mg/dL)
Thyroid Function Tests
- Thyroid Stimulating Hormone (TSH) 2.5 mIU/L 0.4 - 4.0 mIU/L

Radiology investigation
X-rays (Radiographs):
Magnetic Resonance Imaging (MRI):

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 Physical assessment (mark abnormal/problem findings)
 Fever  Constipation  Diarrhea  Anorexia
 Fatigue
 Mild  Abdominal  Melena
 Sleep problems ( )
Dysphagia pain


GIT
General

Loss of appetite
 Hematemesis  Nausea  Vomiting
 Anxiety
 Fatigue  Oral infection  Jaundice 
 Activity intolerance  Others;
 Weight changes  Loss  Gain Ear Nose Mouth & Throat
 Warm  Cool  Dry  Moist  Infection  Congestion  Teeth problems
Condition Site  Pain  Frequent colds  Tonsilitis
 Bruises  Hearing problems  Bleeding  Hoarseness
 Lacerations  Vertigo  Sinusitis  Sore throat

ENT
 Rashes  Tinnitus  Others; patient  Last dental visit
  ……………………….
Skin

Scars Discharges has no problem

in Nose
 Hematoma  Others; patient  Others;
 Lesions has no problem
 Hair loss in ear
 Color changes
 Others; patient has no obvious problem in skin  Lumps  Masses  Goiter
Neck

 Normal  Pain  Glaucoma  Flattened neck vessels  Distended neck vessels

Eye

 Cataract  Vision problem  Stiffness  Others; patient has no problem in Neck

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  Inflammation  Glasses  Photophobia  Oedema., Describe;

Peripheral
vascular
 Others; patient suffers from  Varicose vein  Pain  Ulceration
 Infection
poor eyesight
 Coldness 
 Cough;  Dry  Wet  Tachycardia  Bradycardia  Murmur
 Color;  Regular  Irregular
 Sputum  Peripheral
 Consistency;  Weak  Thready  Absent
pulse
 Cyanosis  Dyspnea  Orthopnea  Normal 
 Resp. Distress  Hypoxia  Hemoptysis  Capillary refill time  > 2 sec  < 2 sec
Respiratory

  Stridor  Crackles   Heart failure  Heart attack

Heart
Wheezing Chest pain
 Pain  Last CXR or CT-Chest /  Palpitation  Last ECG show normal result
 Covid-19  COPD  Asthma  Percutaneous cardiac intervention  Angiography
 Flail chest  Chest  SOB  Rheumatic fever  Congenital heart diseases
trauma
 Others; patient has no major problem in  Others;
respiratory system put patient

 Urinary  Insertion date;1/1/2024 Neurological system  Headache  Seizure 

 Size; 14 Fr   Paralysis 
& psychological

catheter
Urinary system

Tremors Low back pain

 Urine color ; Straw yellow  Stroke  Fainting  Mood swings
 Dysuria  Nocturia  Retention  Memory problems  Depression  Anxiety
 Hematuria  Urinary  Infection  Hallucination  Aphasia  Facial palsy
Stones
 Incontinence  Burning  Polyurea  Conscious level  Alert  Verbal response
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  Anuria  Urgency  Frequency  Pain responsive  Unconscious
 Postmicturition  Weak  Hesitancy  Glasgow Coma Scale (GCS) score 15
Dribbling stream
 Others; patient has no problem in urinary
system

 Joint pain  Stiffness  Muscle  DM   Goiter

Endocrine
Heat intolerance
Orthopedic

Cramps
 Backache  Swelling  Limited ROM  Excess sweat  Cold intolerance  Polyurea
  Menstrual changes  Others;
 Gravida …...  Para  Menopause  Bleeding; site
……...
Genitalia

 Menstrual  Testicular  Drainage  Anemia; Hb,  Thrombocytopenia  Leukemia

Blood
disorders mass
 Lesions  Others; Patient has no  Thrombocytosis Patient has no problem
obvious problem

Health Education Given To Patient

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1. Understanding Osteoarthritis:
• Explanation of osteoarthritis as a degenerative joint condition involving cartilage breakdown.
• Clarification that osteoarthritis is a chronic condition with varying degrees of symptoms.
2. Risk Factors and Contributing Factors:
• Discussion of common risk factors, such as age, genetics, joint injuries, and obesity.
• Awareness of how joint injuries and overuse contribute to the development and progression of osteoarthritis.
3. Symptom Recognition:
• Education about common symptoms like joint pain, stiffness, and reduced range of motion.
• Understanding that symptoms may fluctuate and can be influenced by various factors.
4. Joint Protection Techniques:
• Guidance on adopting joint-friendly habits to reduce stress on affected joints.
• Tips on proper body mechanics during daily activities to minimize strain.
5. Exercise and Physical Activity:
• Importance of regular, low-impact exercises to maintain joint flexibility and strengthen supporting muscles.
• Specific exercises and activities tailored to the individual's abilities and preferences.
6. Weight Management:
• Emphasis on maintaining a healthy weight to reduce stress on weight-bearing joints.
• Nutritional guidance for a balanced diet to support overall joint health.
7. Pain Management Strategies:
• Overview of various pain management options, including medications, physical therapy, and hot/cold therapy.
• Use of assistive devices and adaptive equipment to enhance daily functioning.

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8. Medication Adherence:
• Explanation of prescribed medications, their purposes, and potential side effects.
• Importance of adhering to the prescribed medication regimen and reporting any concerns to healthcare
providers.
9. Regular Follow-Up and Monitoring:
• Encouragement to attend scheduled follow-up appointments with healthcare providers.
• Monitoring symptoms and promptly reporting any significant changes or concerns.
10.Psychosocial Support:
• Acknowledgment of the emotional impact of osteoarthritis.
• Encouragement to seek psychosocial support, such as counseling or support groups, to cope with the challenges
of chronic pain.
11.Adaptive Techniques:
• Introduction to adaptive tools and techniques to simplify daily tasks and minimize joint stress.

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 Disease Process

Definition:

Osteoarthritis (OA) is a degenerative joint disorder characterized by the breakdown of cartilage in the joints, leading

to pain, stiffness, and impaired joint function. It commonly affects weight-bearing joints such as the knees, hips, and

spine, as well as the hands.

Pathogenesis:

The pathogenesis of osteoarthritis involves a complex interplay of genetic, biochemical, and biomechanical factors. It

primarily results from the gradual breakdown of cartilage, the tissue that cushions the ends of bones in a joint. Over

time, this process may lead to the formation of bone spurs and alterations in joint structure.

Causes:
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The exact cause of osteoarthritis is multifactorial. Common causes include aging, joint injuries or trauma, hereditary

factors, and obesity. Joint overuse and misalignment can contribute to the development and progression of the

condition.

Risk Factors:

1. Age: The risk of osteoarthritis increases with age.

2. Genetics: Family history may predispose individuals to osteoarthritis.

3. Obesity: Excess body weight places added stress on weight-bearing joints.

4. Joint Injuries: Previous joint injuries or surgeries can increase the risk.

5. Gender: Osteoarthritis is more common in women, especially after menopause.

6. Occupation: Jobs involving repetitive joint movements or heavy lifting may contribute.

Signs and Symptoms:

1. Joint Pain: Persistent pain, typically worsened with activity and alleviated with rest.

2. Stiffness: Reduced joint flexibility, especially in the morning or after periods of inactivity.
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 3. Swelling: Joint swelling may occur, particularly after extended use.

4. Crepitus: A grating or grinding sensation during joint movement.

5. Joint Deformities: Formation of bone spurs and changes in joint shape over time.

Complications:

1. Reduced Mobility: Osteoarthritis can limit the range of motion in affected joints.

2. Chronic Pain: Persistent joint pain can significantly impact daily activities.

3. Joint Instability: Weakening of ligaments and joint structures may lead to instability.

4. Loss of Independence: Severe cases may affect the ability to perform routine tasks independently.

Diagnostic Tests:

1. X-rays: To visualize joint structure, assess for cartilage loss, and identify bone spurs.

2. Magnetic Resonance Imaging (MRI): Provides detailed images of soft tissues and cartilage.

3. Blood Tests: To rule out other forms of arthritis and assess inflammation levels.

4. Joint Aspiration: Removing and analyzing fluid from the joint for signs of inflammation or infection.
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Medical Management:

1. Pain Relief Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) and analgesics.

2. Physical Therapy: Exercises to strengthen muscles, improve joint function, and reduce pain.

3. Weight Management: Maintaining a healthy weight to reduce stress on joints.

4. Assistive Devices: Use of braces, canes, or orthopedic footwear to support joints.

5. Corticosteroid Injections: Intra-articular injections to reduce inflammation and pain.

6. Joint Replacement Surgery: In severe cases, joint replacement may be considered.

➢ Nursing Management
Assessment:
1. Comprehensive Health Assessment: Thorough assessment of the patient's medical history, including previous
joint injuries, surgeries, and family history of osteoarthritis.

2. Pain Assessment: Regular evaluation of the nature, location, intensity, and duration of joint pain.

3. Functional Assessment: Assessment of the patient's ability to perform activities of daily living (ADLs) and
mobility status.

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 4. Psychosocial Assessment: Evaluation of the patient's emotional well-being, coping mechanisms, and impact
of osteoarthritis on quality of life.

Education and Patient Empowerment:

1. Disease Education: Providing information about osteoarthritis, including its causes, symptoms, progression,
and management options.

2. Joint Protection Techniques: Educating patients on joint-friendly strategies to minimize stress on affected
joints during daily activities.

3. Exercise and Physical Activity: Recommending appropriate exercises to improve joint flexibility, strength,
and mobility.

4. Weight Management: Counseling on the importance of maintaining a healthy weight to reduce joint strain.

5. Medication Education: Explaining the purpose, dosage, administration, and potential side effects of
prescribed medications.

6. Self-Care Strategies: Teaching patients self-care techniques, such as heat or cold therapy, to manage pain
and inflammation at home.

Pain Management:
1. Medication Administration: Administering prescribed pain medications, including analgesics and anti-
inflammatory drugs, as per the healthcare provider's orders.

2. Non-Pharmacological Pain Relief: Implementing non-drug pain management techniques, such as heat or
cold therapy, massage, and transcutaneous electrical nerve stimulation (TENS).

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 3. Assessment and Monitoring: Regularly assessing pain levels, response to interventions, and potential adverse
effects of pain medications.

Mobility Support and Rehabilitation:

1. Assistive Devices: Recommending and facilitating the use of assistive devices, such as canes, walkers, or
orthopedic shoes, to support mobility and joint stability.

2. Physical Therapy Referral: Collaborating with physical therapists to develop individualized exercise
programs and rehabilitation plans to improve joint function and mobility.

3. Range of Motion Exercises: Guiding patients in performing gentle range of motion exercises to maintain
joint flexibility and prevent stiffness.

Psychosocial Support:
1. Emotional Support: Offering empathetic listening, encouragement, and reassurance to patients experiencing
emotional distress or frustration due to their condition.

2. Counseling and Coping Strategies: Providing counseling and coping strategies to help patients manage stress,
anxiety, and depression associated with chronic pain and disability.

3. Support Groups: Facilitating connections with support groups or community resources where patients can
share experiences, gain support, and access additional information and resources.

Collaboration and Coordination:

1. Interdisciplinary Collaboration: Collaborating with healthcare team members, including physicians, physical
therapists, occupational therapists, and social workers, to develop and implement comprehensive care plans.

2. Referrals: Making appropriate referrals to specialists or community resources for additional evaluation,
treatment, or support services as needed.
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 3. Care Coordination: Ensuring seamless coordination of care transitions, follow-up appointments, and
continuity of care across healthcare settings.

Continuous Monitoring and Evaluation:

1. Regular Follow-Up: Scheduling regular follow-up appointments to monitor the patient's progress, reassess
needs, and adjust the care plan as necessary.

2. Outcome Evaluation: Evaluating the effectiveness of nursing interventions in improving patient outcomes,
such as pain relief, functional ability, and quality of life.

3. Patient Feedback: Soliciting feedback from patients to assess their satisfaction with care, identify areas for
improvement, and address concerns or unmet needs.

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 Actual Nursing Diagnoses Potential Nursing Diagnoses:
1. Chronic Pain related to joint inflammation and 1. Risk for Impaired Skin Integrity related to
cartilage degeneration as evidenced by verbal immobility and pressure points as evidenced by
reports of persistent joint pain and restricted the potential for skin breakdown in areas of
movement. joint deformities.
2. **Impaired Physical Mobility related to joint 2. **Risk for Activity Intolerance related to joint
stiffness and reduced range of motion as pain and reduced stamina as evidenced by
evidenced by difficulty in performing activities of reports of fatigue and limited tolerance for
daily living (ADLs) and limited mobility. physical activity.
3. **Self-Care Deficit: Bathing/Hygiene related to 3. **Risk for Altered Nutrition: Less than Body
joint pain and limited mobility as evidenced by Requirements related to pain-induced anorexia,
the patient's reported difficulty in performing reduced mobility, or dietary restrictions as
self-care activities. evidenced by unintended weight loss or
4. **Disturbed Sleep Pattern related to nocturnal inadequate nutritional intake.
joint pain and discomfort as evidenced by reports 4. **Risk for Impaired Coping related to chronic
of difficulty falling or staying asleep. pain and lifestyle adjustments as evidenced by
expressions of frustration, anxiety, or difficulty
adapting to changes.

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 5. **Risk for Falls related to impaired balance and 5. **Risk for Social Isolation related to decreased
joint instability as evidenced by a history of falls mobility and activity restrictions as evidenced
or near falls and the presence of joint deformities. by reports of limited social interactions and
withdrawal from social activities.
.

nursing interventions
actual done
/Monitor and record vital signs
/Administer prescribed medications
/document intake and output
/ insert Urinary catheter

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 Discharge Plan

Physical Care:
1. Medication Management:
• Provide clear instructions on prescribed medications, including dosage, frequency, and potential side effects.
• Ensure the patient understands the importance of medication adherence.
2. Pain Management:
• Educate the patient on pain management strategies, including the use of prescribed medications and non-
pharmacological interventions.
• Discuss the appropriate use of heat or cold therapy for pain relief.
3. Mobility and Exercise:
• Recommend and demonstrate home exercises to improve joint flexibility and strength.
• Encourage the use of assistive devices like canes or walkers if needed.
4. Nutrition:
• Provide dietary guidance, emphasizing the importance of maintaining a healthy weight.
• Consider a referral to a nutritionist for personalized advice.

Self-Care and Home Safety:

1. Joint Protection Techniques:
• Teach joint protection techniques for daily activities to minimize stress on affected joints.
• Provide demonstrations of adaptive devices and assistive tools.
2. Activities of Daily Living (ADLs):
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 • Work with the patient to develop strategies for managing self-care activities independently.
• Discuss the use of adaptive tools for bathing, dressing, and other ADLs.
3. Home Safety Assessment:
• Conduct a home safety assessment to identify and address potential hazards.
• Recommend modifications such as handrails, raised toilet seats, or non-slip mats.

Education and Follow-Up:

1. Disease Education:
• Reinforce information about osteoarthritis, its progression, and self-management strategies.
• Provide written materials or resources for the patient to refer to at home.
2. Follow-Up Appointments:
• Schedule and explain the importance of follow-up appointments with healthcare providers.
• Discuss signs and symptoms that warrant immediate attention.
3. Physical Therapy:
• Arrange for outpatient physical therapy sessions if deemed necessary.
• Ensure the patient understands the importance of ongoing exercise.

Emotional and Psychosocial Support:

1. Psychosocial Counseling:
• Discuss the emotional impact of osteoarthritis and provide information on available counseling services.
• Encourage open communication about emotional well-being.
2. Support Groups:
• Provide information on local or online support groups for individuals with osteoarthritis.
• Emphasize the importance of connecting with others who share similar experiences.

Contact Information:
1. Emergency Contacts:
• Provide emergency contact information for healthcare providers, including primary care physicians and
specialists.

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 •Ensure the patient has access to emergency services if needed.
2. Home Health Services:
• Discuss the availability of home health services if appropriate, including nursing or physical therapy visits.

Caregiver Support:
1. Caregiver Education:
• Educate family members or caregivers about osteoarthritis, the patient's care plan, and their role in providing
support.
• Provide resources or contacts for caregiver support groups.

Medication Reconciliation:
1. Medication List:
• Provide a comprehensive medication list to the patient and their caregivers.
• Review any changes made during the hospital stay.

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