PYOMYOSITIS

IntroductionBackground

Pyomyositis is an inflammation of muscle tissue, usually of voluntary muscles that results in pus production. Once considered a tropical disease, it is now seen in temperate climates as well. The pathogenesis is unclear, but trauma, infections (S. aureus, S. pneumoniae), and malnutrition have been implicated. Although most cases of pyomyositis occur in healthy individuals, other pathogenetic factors include nutritional deficiency and associated parasitic infection in tropical climates. In the temperate climates, pyomyositis is seen most commonly in patients with diabetes, HIV infection, and malignancy.

Clinical Presentations

Presentation with painful, tender, localized swelling over muscle

Fever

Epidural abscessComplications

Life-threatening complications include sepsis and toxic shock syndrome.

Diagnosis

CT scan or MRI demonstrates muscle abscess.

Aspiration of abscess (by surgery or CT/US guided) yields pus, usually yielding

HYPERLINK "http://hopkins-abxguide.org/pathogens/bacteria/aerobic_gram-positive_cocci/staphylococcus_aureus.html?contentInstanceId=255868" S. aureus. Bacteremia may accompany.

Treatment

Medical Care

Promptly administer systemic antibiotics. This could eliminate the need for surgical drainage in selected cases.

The choice of antibiotic is determined by identification of the causative organism.

Antibiotics initially are given intravenously until clinical improvement is noted, followed by oral antibiotics for a total course of 3 weeks (eg, cefazolin or ceftriaxone IV followed by cephalexin PO).

Surgical Care

During the suppurative phase, abscess aspiration under ultrasonic or CT guidance may be required. Surgical drainage is especially necessary for large abscesses.

Complicated cases may require fasciotomies and debridement.

Prognosis

Prompt administration of antibiotics can result in complete resolution.

Specific Objectives: Define Pyomyositis.

Identify the signs and symptoms manifested by the patient.

Distinguish the precipitating and predisposing factors that trigger this development.

Trace the pathogenesis based on the signs and symptoms manifested by the patient.

Determine appropriate medical and nursing management for the patient.

Use the nursing process as the framework for the care of the patient.

Significance of the Study in Nursing Field: Shall have critical thinking skills necessary for providing safe and effective nursing care.

Shall have a comprehensive assessment and implement care base on our knowledge and skills of the condition.

Shall have familiarized with effective interpersonal skills to emphasize health promotion and illness prevention.

Shall have imparted the learning experience from direct patient care.

PATIENTS PROFILEName: Baby DyeinSex: Female

Birthday: October 2007

Age: 2 - 3 y/o

Religion: Roman Catholic

Civil Status: Single

Nationality: Filipino

Date of Admission: July 27, 2010Time of Admission: 8:40 PM

Admission Diagnosis: Pyomyositis Left Scapular AreaAttending Physician: Dr. De GuzmanA. Family Background

Baby Dyein is the youngest among the four siblings. B. Educational and Socio - Economic Status

She does not go to school yet. The rest of the siblings are funded for their educational expenses by one of their mothers rich customers as a laundry woman, except that the eldest child does not go to school anymore as she decided to stop studying and just help work.C. Lifestyle and Diet

She eats three times a day and drinks 5-6 glasses of water a day though mostly breastfeed on her mother.D. Family Health History

No family history of pyomyositis, diabetes, hypertension, tuberculosis, diabetes, nor any other diseases reported.E. Immunization Record

With complete record of immunization.

F. Past Health History

Had cough, colds and fever but is only hospitalized once now due to pyomyositis.

G. Present Health History

One month prior to consultation, patient together with her older brother had a fall as she was given a piggy backride. Patient fell on her left scapular area and complained of pain. Her mother had her massaged by a so-called manghihilot. Three weeks prior to consultation, patient still complained of pain and endured of fever and localized swelling on the left scapular area. Another hilot session was done and patient was given TSB. But as the swelling and fever still persevered, patient was brought to the nearest clinic. Patient was given Paracetamol and was referred to Philippine Orthopedic Center. Patient was admitted.ANATOMY AND PHYSIOLOGY

The scapula or shoulder blade is the bone that connects the humerus (arm bone) with the clavicle (collar bone). The scapula forms the posterior located part of the shoulder girdle. It is a flat bone, roughly triangular in shape, placed on a posterolateral aspect of the thoracic cage.

LEFT SCAPULA . LATERAL SURFACE

CORACOID PROCESS - bony projection on the shoulder blade

GLENOID CAVITY holds the head of the humerus SUPRAGLENOID TUBERCLE rounded protuberance above the glenoid cavity

INFRAGLENOID TUBERCLE rounded protuberance below the glenoid cavity

SPINE a bony projection from the glenoid to acromion

ACROMION - bony projection from the outer end of the spine of the shoulder blade, to which the collar bone is attached

AXILLARY BORDER near to armpit

INFERIOR ANGLE - gives greater strength to the body of the bone by its arched formOSSIFICATION OF SCAPULA

The larger part of the scapula undergoes membranous ossification. Some of the outer parts of the scapula are cartilagenous at birth, and would therefore undergo endochondral ossification.

The head, processes, and the thickened parts of the bone, contain cancellous tissue; the rest consists of a thin layer of compact tissue.

The central part of the supraspinatous fossa and the upper part of the infraspinatous fossa, but especially the former, are usually so thin as to be semitransparent; occasionally the bone is found wanting in this situation, and the adjacent muscles are separated only by fibrous tissue.

PATHOGENESIS

DIAGNOSTIC EXAMSCOMPLETE BLOOD COUNT

ResultsNormal ValuesInterpretationsNursing Responsibilities

Hemoglobin107110 - 158 g/LBone marrow suppression or iron deficiency anemiaIron deficiency anemia:

> Diet. Foods rich in iron.

Tissue Injury and Trauma:

> Monitoring of VS.

> Wound Care

> Diet. Foods rich in protein and Vit. C.

> Administration of prescribed medications.

> Avoid pressure on the affected area.

Hematocrit0.340.37 - 0.54Iron deficiency anemia

Leukocyte Count22.44.5 - 10 x 109/LTissue injury

Differential Count

Segmenters0.750.50 - 0.70Tissue injury

Lymphocytes0.190.20 - 0.40Tissue injury

Platelet Count513150 - 400 x 109/LTrauma

Indices

MCV69.982 - 92Iron deficiency anemia

MCH21.928 - 32Iron deficiency anemia

MCHC3132 - 38Iron deficiency anemia

ESR1280 - 10mm/hrIron deficiency anemia

MUSCULOSKELETAL SONOGRAPHY

There is a 5.0 x 1.2 cm complex mass in the left scapular area. Remainder is unremarkable.

Impression: PYOMYOSITIS

DRUG STUDYDrugs NameDosageIndicationActionAdverse EffectsNursing Considerations

Generic Name:

IbufropenBrand Name:

Apo Ibufropen

Pharmacologic Class:

NSAID100/s 5ml q8 x 7 days> Mild to moderate pain> FeverMay inhibit prostaglandin synthesis, to produce anti-inflammatory, analgesic, and antipyretic effects.CNS: dizziness, headacheCV: edema

EENT: tinnitus

GI: decreased appetite, peptic ulceration

GU: acute renal failure

Respiratory: bronchospasms

Skin: Stevens Johnson Syndrome> NSAID may mask S/S of infection> It may take 1 or 2 wks before full anti inflammatory effects occur

> Take with meals

> Use with aspirin may increase risk of GI adverse reaction

> Report for S/S of GI bleeding

Generic Name:Acetaminophen

Brand Name:

Paracetamol

Pharmacologic Class:

Para-aminiohenol derivative80 mg q4 IV > Mild pain or feverBlocks pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating center.Hepatic: jaundiceMetabolic: hypoglycemia

Skin: rash, urticaria

> Given for T>38.0C> Monitor V/S

Generic Name:Cefuroxime

Brand Name: Ceftin

Pharmacologic Class:

2nd gen. cephalosphorin250mg IV q8> Skin infectionInhibits cell wall synthesis, promoting osmotic instability.CV: phlebitisGI: diarrhea, N/V, anorexia

Skin: rashes, urticaria

> Perform skin test (ANST)> Give if ANST (-)

> Take with meals

> Monitor for signs of infection

Generic Name:Ceftazidime

Brand Name:

Tazicef

Pharmacologic Class:

3rd gen. cephalosphorin 22 in 50ml IV> Bacteremia and skin infectionInhibits cell wall synthesis, promoting osmotic instability.CNS: seizures, headacheCV: phlebitis

GI: diarrhea, N/V

Skin: rashes, urticaria> Perform skin test (ANST)

> Give if ANST (-)

> Take with meals

> Monitor for signs of infection

NURSING CARE PLAN

AssessmentNursing DiagnosisScientific explanationPlanningInterventionRationaleEvaluation

Subjective Cue:

Objective Cues:

>Flushed skin

> Warm to touch

> With lab results as follows:

- Leukocyte Ct: 22.4 x 109/L

(NV: 4.5 -10 x 109/L)

- Segmenters: 0.75

(NV: 0.50 0.70)

- Lymphocytes: 0.19

(NV: 0.20 0.40)

- Impression of Pyomyositis on Sonography

> with VS taken as ff:

T: 38.2 C

P: 82 bpm

R: 20 cpm

Hyperthermia r/t trauma 2 underlying diseaseTrauma has been implicated to cause Pyomyositis, an inflammation of a muscle tissue. Due to inflammatory process, vasodilatation occurs leading to increase body metabolism and elevated body temperature.

Ref: Brunner and Suddarths Textbook of Medical Surgical NursingAfter 2-3 hours of nursing intervention, patients temperature would be within normal range.Established rapport both with the mother and the patient.Monitored V/S.

Noted clients age.

Monitored I & O.

Reviewed laboratory values.

Provided fans as indicated.

Asked mother to dress the baby with light loose clothing.

TSB done.

Emphasized handwashing.

Promoted maintenance of proper breastfeeding.Administered due medications as prescribed.

To gain cooperation and trust.

To review alterations of V/S as affected by patients condition, and progress as given with interventions.

Age can directly impact ability to regulate temperature.

Hyperthermia may cause dehydration.

To identify potential internal causes of temperature imbalances.

To provide cooling measures.

To promote comfort.

To provide cooling measures.

To prevent cross contamination and transmission of MCOs.

For additional booster of patients immunity.

To protect from identified risk factors and intervene with pyrexia.After 2 hours, patients temperature was within normal range AEB temperature of 37.5C.

NURSING CARE PLAN

AssessmentNursing DiagnosisScientific explanationPlanningInterventionRationaleEvaluation

Subjective Cue:

Medyo masakit po ang likod ko Objective Cues:

- Facial grimace

- Guarding on the left scapular area - Restlessness

- With facial pain scale of 4/10

- V/S taken as follows:

T: 38.2 C

P: 82 bpm

R: 20 cpm

Acute pain related to trauma on the left scapular area As a a vascular anti-inflammatory response, body releases anti-inflammatory mediators causing pain.

Reference:

http://www.who.int/csr/resources/

publications/

pyomyositis/01 223.pdf

Within 4 hours of effective nursing interventions patients pain will be relieved.

Established rapport both with the mother and the patient.Monitored V/S

Performed a comprehensive assessment of pain

Provided nonpharmacologic management like change of position & applying cold or warm compress as indicatedEncouraged diversional activities

Encouraged rest period

Administered medications as ordered by physician.To gain cooperation and trust

Pain may cause alterations in V/S

To improve quality, frequency & location of pain.

To alleviate pain.

To divert his attentions to the pain

To prevent fatigue

To alleviate pain.

After 4 hours of rendering effective nursing interventions patient had reported of less pain AEB less guarding on her left scapular area and had been smiling more frequently.

DISCHARGE SUMMARYMedications. Compliance on the prescribed take home medications with the right generic name, right dosage and preparation, right route and time of administration.

Exercise. Active ROM but prevent massaging nor any other traumatic pressure on the affected area.

Treatment. Compliance on the prescribed treatment. Cover the affected area with a wound gauze as pt has underwent surgery. Instructed proper wound care.

Health teachings. Emphasized proper handwashing and encouraged non pharmacological measures for fracture once re encountered (Rest, Ice or Cold Compress, Compression bandage, Elevate affected part)

Outpatient follow up visit. Attend on the scheduled outpatient follow up visit.

Diet. Consume foods rich in Vitamin C such as fruits for boosting of immunity, protein such as meats for tissue repair, and calcium or phosphorus such as milk and other dairy products for bone growth.

REFERENCES

http://hopkins-abxguide.org/diagnosis/soft_tissue/pyomyositis.html?contentInstanceId=255446Zafar, Mohammed. Infectious Myositis. http:// www.yahoo.com// May 18, 2010Scapula. http:// www. wikipedia.com//

Lippincott. Nursing 2008 Drug Handbook. 28th Edition. 2008

Doenges, M. et al. Nurses Pocket Guide. 11th Edition. 2008

100 mm/h).

Strongly positive Mantoux skin test. Tuberculin skin test (purified protein derivative [PPD]) results are positive.

Spinal X-ray may be normal in early disease as 50% of the bone mass must be lost for changes to be visible on X-ray. Plain X-ray can show vertebral destruction and narrowed disc space.

MRI scanning may demonstrate the extent of spinal compression and can show changes at an early stage. Bone elements visible within the swelling, or abscesses, are strongly suggestive of Pott's disease rather than malignancy.

CT scans reveals early lesions and is more effective for defining the shape and calcification of soft-tissue abscesses.

Needle biopsy of bone or synovial tissue. Numbers of tubercle bacilli present.

Medical Management

Duration of antituberculosis treatment (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol):

If debridement and fusion with bone grafting are performed, treatment can be for six months

If debridement and fusion with bone grafting are NOT performed a minimum of 12 months treatment is required.

Immobilisation of the spine is usually for 2 or 3 months (bed rest, Taylor Brace, head halter, pelvic strap).

Paraplegia resulting from the active disease causing cord compression usually responds well to chemotherapy (6-9 months).

Surgical Management Anterior Decompression Spinal Fusion. Surgery is required if there is spinal deformity or neurological signs of spinal cord compression.Prevention

As for all tuberculosis, BCG vaccination.

Improvement of socio-economic conditions.

References:

http://www.bsac.org.uk/pyxis/Bone%20and%20joint/Potts%20disease/Potts%20disease.htmhttp://www.wisegeek.com/what-is-potts-disease.htm

Fell on her left scapular Area from a Piggy Backride

Inflammatory Response

Vascular Response

Chemical Response

Vasodilatation

Increased Membrane Permeability

Redness

Heat

Swelling

Systemic Response

Pain

Leukocytosis Infiltration

Increased ESR

Fever

PR and RR

Abscess Formation

Trauma: Pressure by hilot

IF NOT TREATED:

Toxic Shock Syndrome Sepsis

PYOMYOSITIS

IF TREATED:

Good Prognosis

Recovery

PYOMYOSITIS

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POTTS DISEASE