SURGICAL CASE PRESENTATION ON

Presented By :

Mrs.Anisha Mane
PATIENT DATA :

Name :

Age : 6 months 23 days

Gender : Male

Address : A/P –, Mumbai.

Date of Admission : 0//2019

Diagnosis :
PRESENT HISTORY :

Baby admitted in Kem Hospital

on 0//2019 with complaints of :
High grade fever i.e. 1010F since 5-6 days
Cough since 5-6 days
Pain in right leg since 6-7 days
BIRTH HISTORY:
Master Rehman was a full term normal child
delivered by normal delivery. There was no
complication before and after pregnancy.
Child cried immediately after birth. Weight of
the child at birth was 2.7 kg.

IMMUNIZATION :
Received all the immunization till date.
FAMILY TREE DIAGRAM :
DIETARY PATTERN:
Master Rehman takes breast feeding and complementary
feed. He takes 3-4 times breast feeding 2 times
complimentary feed like rice kanji at home. After
hospitalization his appetite has reduced because of pain. He
takes only 2-3 times breast feed per day in hospital.
SOCIO- ECONOMIC STATUS:
Master Rehman belongs from a middle class socio-
economic status where the earning member of the family is
only his father. His father is a shopkeeper. Monthly income
of the family is between Rs.20,000-25,000.
DEFINITION OF SEPTIC ARTHRITIS :

• Septic arthritis is acute bacterial inflammation of the joints

usually occur in malnourished children or in association with
acute infections diseases such as septicemia, enteric fever,
pneumonia or influenza.
• The common infecting organisms are Staphylococcus
aureus, Streptococcus, Pneumococcus, Gonococcus,
Meningococcus, E. coli, tubercle bacilli and H. enfluenzae.

• Infection usually occur by hematogenous route, but may

spread from adjacent soft tissue inflammation.

• Commonly affected joints are hip, knee, elbow and shoulder,

but any joints may be affected by the septic arthritis.
INCIDENCE RATE :
BOOK PICTURE PATIENT PICTURE

1. It is more common in boys, and Master Rehman is male child.

it most often affects the large joints
of the lower limb.

2. Usually occur in malnourished Master Rehman’s present weight is

children low i.e 4.2 Kg.

3. associated with acute infections Master Rehman have history of

diseases such as septicemia, typhoid fever when he was 5
enteric fever, pneumonia or months old.
influenza.
CAUSES OF SEPTIC ARTHRITIS :

Different types of bacteria, viruses, and fungi can

infect a joint. The types that can cause septic arthritis
include:

• Staphylococci. These are common bacteria that often

cause skin infections.

• Haemophilus influenzae. These are bacteria that can

infect the larynx, trachea, and bronchi.
• Gram-negative bacilli. This is a group of bacteria
that includes Escherichia coli (E. coli).

• Streptococci. This is a group of strep bacteria that

can lead to many different diseases.
• The most common type of bacteria that cause septic arthritis is
called Staphylococcus aureus. These bacteria can enter the
body in many ways, such as:

 An infected wound

 A broken bone that goes through the skin (open fracture)

 Foreign object that goes through the skin

 Injury that breaks the skin

PATHOPHYSIOLOGY :

Synovial membrane is highly vascularized

Bacteria can easily enter synovial joint via blood

stream

There will be inflammatory reaction with seropurulent

exudate and increase in synovial fluid
As pus appear in the joint, the articular cartilage is
eroded and destroyed partly by the bacterial
enzyme, and partly by the enzyme released from
synovium, inflammatory cell and pus

Infant Children
Destroy the epiphysis, Vascular occlusion lead
which is still largely to necrosis of epiphyseal
cartilaginous bone
a) In the early stage, there is an acute synovitis with a purulent joint
effusion.
b) Soon the articular cartilage is attacked by bacterial and cellular
enzymes
c) If infection is not arrested, the cartilage may be completely destroyed
d) Sequlae include necrosis, sublaxation, dislocation and ankylosis.
SIGNS AND SYMPTOMS :
BOOK PICTURE
1. Inflamed joint with severe pain,
swelling, tenderness, warmth and
marked restriction of movement of
the limb, which is kept in flexed
position.
2. Usually there is joint effusion
which rapidly becomes purulent.
PATIENT PICTURE
Child have severe pain in right leg.
Restriction of movement of affected
area.
Moderate effusion noted in the right
hip joint with synovial thickening
and resultant erosion of the
metaphysis of right femur.

3. Fever, malaise and vomiting High grade fever i.e. 1010F, Cough
4. As the disease progress,
destruction of cartilage, septic
necrosis of the heads of ling bones
and pathological dislocation may
occur.
DIAGNOSTIC TESTS :
BOOK PICTURE
1. X-ray or CT scan
2. Biochemical Investigations
3. C – Reactive protein
(Immunoturbidometry)
4. Complete Blood Count
PATIENT PICTURE
CT scan of both hip joint has done for
child.
Moderate effusion noted in the right
hip joint with synovial thickening and
resultant erosion of the metaphysis of
right femur.
S.G.O.T – 47.37 (8.0 – 40.0 U/L)
CRP – 55.5 (Upto 6,0 mg/dl)
Hb – 7.3 (11-13 gms%)
RBC – 3.52 (4-5.2 mili/Cu.mm
WBC – 10,000 (4500-15000)
cells/cmm
Platelet count – 5.60 (1.5-4.5
Lakhs/cmm)
MEDICAL MANAGEMENT : BOOK
PICTURE

 Management of septic arthritis is performed with

appropriate broad-spectrum antibiotics for 2 to 4 weeks
parenterally.

 Other measures are joint aspiration or arthrotomy for

drainage of affected joint and immobalization of the limb by
POP cast or traction.
• Analgesics and other symptomatic treatment are
provided.

• Supportive care is given including rest, support of

the affected limb with comfortable position,
nutritiuos diet, extra fluid intake, hygienic care,
emotional support and necessary health teaching.
MEDICAL MANAGEMENT : PATIENT
PICTURE :

• Inj. Cefuroxime 200 mg IV BD

• Tab. PCM 250 mg BD

• Syp. Ibugesic 2.5 ml P/O BD

• Syp. Gelusil 2 ml P/O OD

• Syp. A to Z 3 ml P/O OD
SURGICAL MANAGEMENT : BOOK
PICTURE

• Surgical :
 Percutaneous arthrocentesis
 Arthroscopy of open surgical drainage

• Rehabilitation :
 Physiotherapy : Rapid mobalization
SURGICAL MANAGEMENT : PATIENT
PICTURE

• Right hip arthrotomy and hip spica surgery is done on

07/12/2018.

Findings and Procedure :

• Supine position on OT table.
• 18 G needle inserted in right hip joint medially below
adductor longus tendon. Frank pus aspirated.
• 18 G needle inserted in right hip below right greater
trochanter. Frank pus aspirated.

• Incision taken in groin crease lateral to right femoral artery.

• Subcutaneous tissue dissected, interval between TFL and

sartorius made. Rectus femoris retracted and capsule of right
hip exposed.

• Incision taken in capsule

• Right hip joint exposed.

• Synovial tissue sample collected.

• Joint wash given.

• Closure done over drain.

• Dressing done.

• 1 and half hip spica applied

NURSING MANAGEMENT :

Nursing Diagnosis :
1. Acute pain related to incisional wound secondary to
inflammation of joint as evidenced by continous cry of the
child.
2. Elevated body temperature more than normal related to
infection.
3. Impaired physical mobility related to restricted joint
movement.
4. Impaired skin integrity related to invasive procedure.
5. Risk for infection related to invasive procedure
1. To relieve pain

 Assess child’s pain level by using pain scaling

grade.
 Assess the location of pain.
 Provide comfort measures.
 Establish quite environment.
 Elevate head of the bed.
 Administer analgesics as prescribed.
2. To maintain body temperature

 Check and record child’s temperature whenever

required.
 Check and record vital signs.
 Remove unnecessary cloths that could only
aggravate heat.
 Promote a well ventilated area to the child.
 Promote adequate rest and sleep.
 Provide tepid sponge bath.
 Administer antipyretics as prescribed.
3. To improve mobility

 Check for functional level of mobility.

 Assess for impediments to mobility
 Assess input and output record and nutritional
pattern.
 Monitor nutritional needs as they relate to
immobility.
 Assess the safety of the environment.
4. To maintain skin integrity :

 Monitor site of impaired tissue integrity at least

once daily for color changes, redness, swelling,
warmth, pain, or other signs of infection.
 Monitor status of skin around wound.
 Keep a sterile dressing technique during wound
care.
 Administer antibiotics as ordered.
5. To decrease risk of Infection

 Assess for the presence, existence of, and history

of risk factors
 Monitor white blood cell (WBC) count
 Assess and monitor nutritional status, weight,
 history of weight loss, and serum albumin.
 Assess immunization status and history.
 Monitor the following signs of actual
 Infection, redness, swelling, increased pain,
 purulent discharge from incisions, injury, and exit
 sites of tubes (IV tubings), drains, or catheters.
• DISCHARGE EDUCATION :
 Discharge education was given on following topics :

 Medicines : Antibiotics are given to prevent infections and

analgesics to relieve pain. Give your child medicine as
prescribed by the doctor. Do not stop giving antibiotics
abruptly.

 Nutrition : Breast feed the baby adequately along with

complementary feed as per the demand of baby.

 Hygiene : Maintain proper care of child to maintain skin

integrity. Proper cleanliness of wound to prevent infection.

 Follow – up.
RESEARCH ARTICLES :

1. Anoplasty for low anorectal malformation

( hristine Whytelow asterisk) In oct 2016.
• Background

• The presence of a slightly anterior, stenotic anus is a low anorectal

malformation. It is a type of rectoperineal fistula. The cardinal symptoms
are constipation and straining at stool. Hendren described a technically
simple anoplasty for this condition in 1978. Controversy about terminology
has led to a lack of clarity about this condition.
• Methods

• Clinical data were reviewed about the authors' patients, who had Hendren
anoplasty, from 2009 to 2015. Followup data were obtained from office
visits and telephone interviews with families and primary care doctors.
• Results

• Seven patients (4 boys) presented with intractable

constipation. All had a stenotic anal orifice, located anterior to
the center of the anal wink, within the pigmented perianal skin.
In 4 of 7 cases, the lesion was not recognized at birth.
Anoplasty was performed at a median age of 8 months (range
6–28). Late followup information was obtained on six of the
seven patients at a median of 32 months (range 28–61). Four
reported no or minimal laxative requirement and two reported
daily laxative use but good symptom control.
• Conclusions

• Low anorectal malformation/rectoperineal fistula may be

overlooked in the newborn. When symptomatic, it may be
corrected by a simple anoplasty with excellent results.
BIBLIOGRAPHY :

1. Gupta P., Essential Pediatric Nursing, (4th

edition), CBS Publishers and distributors.

2. Ghai O. P. , Essential Pediatrics, (3rd edition),

Interprint publishers.

3. Wong’s,Clinical Manual of Pediatric Nursing (7th

edition). Mosby : Elsevier Publications.