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Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES


Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

In Partial Fulfillment
Of the Requirement in
________________________
Related Learning Experience (RLE)

A CASE STUDY ON

“Avascular Necrosis of the Hip”

Presented by:

Eva U. Corpuz
Andres L. Bernabe
BSN III-A

Presented to:

Jerrick B. Tabudlo, RN, MAN

Date:
July 18, 2020
Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

PARAMETER PERCENTAGE ACTUAL GRADE


(%)
Introduction and Objectives
Personal Data 5

Nursing History of Past and Present Health Illness 5

PEARSON Assessment 15

Diagnostic Procedures
a. Ideal 5
b. Actual

Anatomy and Physiology 5

Pathophysiology
a. Algorithm 15
b. Explanation

Management
a. Medical and Surgical (Ideal and Actual) 5
b. Nursing Care Plan (NCP) 25
c. Promotive and Preventive Management 5
Drug Study 5

Discharge Plan 5

Updates 5

Organization/Documentation 2.5

Bibliography 2.5

TOTAL: 100

REMARKS:
______________________________________________________________________________
______________________________________

SIGNATURE OF THE CLINICAL INSTRUCTOR: ________________________________________


TABLE OF CONTENTS

I. Introduction
II. Personal Information
III. Objectives
IV. Medical History
a. History of Past Illness
b. History of Present Illness
V. Anatomy and Physiology
VI. Diagnostic Procedures
A. Laboratory Test
B. Radiologic Findings
VII. Management
A. Medical
B. Actual
C. Nursing Care Plan
VIII. PEARSON Assessment
IX. Discharge Planning
X. Promotion and Prevention
XI. Drug Studies
XII. Bibliography
I. INTRODUCTION

Bones in our body are living tissues that requires blood supply to get nourish and

keep them healthy.

Avascular necrosis is the death of bone tissue due to a lack of blood supply. Also

called osteonecrosis, aseptic necrosis or ischaemic necrosis. it can lead to tiny breaks

in the bone and the bone's eventual collapse.

Avascular necrosis of femoral head means that blood supply to the ball of hip joint is

interrupted. It can be Traumatic which is fracture neck of femur or fracture

dislocation of hip injuries/ surgeries around hip or can be Non-traumatic which is

steroid use; excessive alcohol intake; sickle cell disease or other blood cell disorders;

deep sea divers and miners.

In the case of Patient Midyear who is 49 years of age has been using steroids due to

her severe allergy. For about 5 years she is using steroids. Since most of the patient

with avascular necrosis have no symptoms in early stages, she did not realize that

long term use of steroids causes blockage to the blood supply in the hip. The reason

are unknown but hypothesis is that increased fat globules in the blood which get

lodged in the vessels. When avascular necrosis worsens with time, eventually the

bone collapse and that is what happened to Patient Midyear. Seven months ago she

started to feel pain on her right hip and worsen when walking. This time she came

to the hospital complaining of hip pain on the right with associated unsteady gait,

and when she was examine by a doctor and results from her imaging test came, she

was advised to go under Total Hip Arthroplasty.


II. PERSONAL INFORMATION

Name: Patient Midyear


Address: Tamag, Vigan, Ilocos Sur
Sex: Female
Age: 49 years old
Date of Birth: March 5, 1971
Nationality: Filipino
Religion: Roman Catholic
Admitting diagnosis: Avascular Necrosis Hip
Chief Complaints: Pain on the right hip
Admitting Physician: Dr. Kevin Ubaldo Quilala
Attending Physician: Dr. Guzman
Date Admitted: July 14, 2020 3.14pm

Patient Midyear was admitted at Northside Doctors Hospital on July 14, 2020 at 3:14

due to hip pain in her right side.

She was diagnosed of Avascular Necrosis Hip. And undergone Total Hip Arthroplasty.

Upon receiving the patient on July 18, 2020, patient is still un-conversant and lying on

bed.

The patient is diabetic and with a family history of hypertension.


III. Objectives

This case study aims to identify and determine the general health problems and
needs of the patient with an admitting diagnosis of Avascular Necrosis Hip. This also
intends to help patient promote health and medical understanding of such condition
through the application of the nursing skills.

o To raise the level of awareness of patient on health problems that she may
encounter.
o To facilitate patient in taking necessary actions to solve and prevent the
identified problems on her own.
o To help patient in motivating her to continue the health care provided by the
health workers.
o To render nursing care and information to patient through the application of
the nursing skills.

IV. MEDICAL HISTORY

A. History of past illness


The patient stated that while she was working at The University of Northern
Philippines, she would get injected corticosteroids at the UNP hospital due to her
allergies.

The patient is diabetic and taking metformin and have had steroids for her severe
allergic reactions to seafood.

B. History of present illness


After a few years of getting injected with this medication, her hip started to
deteriorate.
Seven months ago the patient complains of pain on her right side hip. On July 14,
2020 came to the hospital complaining of pain over the hip associated with unsteady
walking. She was then admitted by Doctor Quilala and was referred to Doctor
Guzman for a possible Total Hip Arthroplasty.
Later that day Dr. Guzman saw her and advised for Total Hip Arthroplasty and
ordered series of test before the surgery. After the test results and CP clearance are
ready they push through with the surgery.
V. ANATOMY AND PHYSIOLOGY

Hip joint is a large weight bearing ball and socket joint. The ball is formed by the upper part of
the thigh bone or femur which fits into a socket formed by the acetabulum which is part of the
large pelvic bone. The ball and socket are covered by a smooth glistening white tissue known
as cartilage. It helps in the smooth gliding of the ball in various movements about the joint such
as walking, running, squatting, sitting cross legged.

Interruption of blood flow to the bone. AVN often affects bones with a single terminal blood
supply, such as the femoral head, carpals, talus, and humerus. The earliest pathologic
characteristics of avascular necrosis are death of hematopoietic cells and adipocytes followed
by interstitial marrow edema.
Osteocyte necrosis occurs after approximately 3 hours of anoxia, but histological signs of
osteocyte death do not appear until approximately 24 to 72 hours after oxygen deprivation.
Interruption of the vascular supply and resultant necrosis of marrow, medullary bone, and
cortex are theorized to be caused by the mechanisms.


Vascular occlusion: This is characterized by the interruption of the extraosseous blood
supply via factors such as direct trauma (fracture, dislocation), non-traumatic stress, and
stress fracture.

Altered lipid metabolism: Animal studies have led to the hypothesis that increased levels
of serum lipids leads to lipid deposition in the femoral head, causing femoral hypertension
and ischemia.  Lipid level lowering drugs in animals reverse this process. Corticosteroid
administration was associated with fat emboli in the femoral heads of rabbits.  

Intravascular coagulation: Disorders of the coagulation system have been implicated in
the pathogenesis of AVN. Typically, it is a secondary event triggered by a familial
thrombophilia, hypercholesterolemia, allograft organ rejection, other disorders (infection,
malignancy), or pregnancy.

Healing process: Necrotic bone triggers a process of repair that includes osteoclasts,
osteoblasts, histiocytes, and vascular elements. Osteoblasts build new bone on top of the
dead bone, leading to a thick scar that prevents revascularization of the necrotic bone,
with resultant abnormal joint remodeling and joint dysfunction.

Primary cell death: Osteocyte death without other features of AVN has been seen in
renal transplant patients, as well as in patients receiving steroids and those who consume
significant amounts of alcohol.
VI. DIAGNOSTIC PROCEDURES

A. Laboratory Test Result

Test Result Normal Value

PROTIME 12.6 11.000 – 15.000

Percentage Activity 90.8

INR 1.09

APTT 30.5 22.600 – 35.000

Angela Chrissie F. Macalanda, RMT Brenda Rosuman, MD, FPSP,

Meedical Technologist Pathologist

Laboratory test

Test Result Flag Normal Range

Urea 16.9 mg/dl L 17.0 – 43.0 mg/dl

Creatinine PAP 0.71mg/dl 0.67 – 1.17 mg/dl

Na 135.6 mmol/L 135 – 148 mmol/L

K 4.05 mmol/L 3.5 – 5.3 mmol/L

Cl 104.5 mmol/L 98 – 107 mmol/L

Ca 1.10 mmol/L 1.13 – 1.32mmol/L


Clinical Chemistry Report

Test Result Reference Range /Unit

Sodium 142.8 135.00 – 145.00 mmol/L

Potassium 4.10 3.50 – 5.50 mmol/L

Pauline Carbon Valdez, RMT Procesa Rebullo GamildeMD, FPSP

Medical Technologies Pathologist

Clinical Chemistry Report

Test Result Unit Reference Range (NCEP- ATP III Guidelines)

Total Cholesterol 251.38 mg/dL Desirable: <200

Borderline:200-239

High: >240

_____________________________________________________________________________________

Triglycerides 223 71 mg/dL Normal: <150 mg/dL

Borderline high:,150 – 199

High: 200 – 499

Very high: > 500

_____________________________________________________________________________________

HDL-C 47.96 mg/dL Low: < 40

High: > 60

_____________________________________________________________________________________

LDL 158.68 mg/dL Optional: <100

Near Optimal: 100 – 129

Borderline High: 130 -159

Very high: >190

Cherryl Quaresma Utrera, RMT Procesa Rebullo GamildeMD, FPSP

Medical Technologist Pathologist


Clinical Chemistry Report

Test Result Reference Range / Unit

Fasting blood sugar 13. 82 (H) 3.90 – 5.80 mmol/L

Uric Acid 337.4 153 – 354 mmol/L

SGPT(ALT) 31.31 10.00 – 40.00 U/L

Cherryl Quaresma Utrera, RMT Procesa Rebullo GamildeMD, FPSP

Medical Technologist Pathologist

B. Radiologic Findings

Type of Examination: Chest PA

Lungs are devoid of active parenchymal densities and are opposed to the chest wall on
all sides

Cardiac shadow is normal in size

Diaphragm is intact.

Costophrenic recesses are clear.

IMPRESSION:

No definite radiographic abnormality.

Nester F. Plete – Feliciano, RPh, MD, DFBR, FPCR, FUSP, MHcA

Radiologist - Sonologist

IMPRESSION:

NO SIGNIFICANT CHEST FINDINGS ON THE PROJECTION TAKEN. CLINICAL CORRELATION


IS SUGGESTED

Radiologist:

Marlon Batulan, MD, DPBR


VII. MANAGEMENT

Medical

In the early stages of avascular necrosis, symptoms might be eased with medications and
therapy. The doctor might recommend:

Nonsteroidal anti-inflammatory drugs to relieve the pain associated with avascular
necrosis.

Lipid lowering drugs which are useful in people with high blood lipids/cholesterol

Anti-osteoporotic drugs which helps to decrease bone loss and pain.

Blood thinners used to prevent clots blocking the blood vessels

Physical therapy and precautions that is avoiding weight bearing on the affected limb
means slows down the collapse and physical therapy helps maintain active range of
motion.

Surgical

Surgical interventions depend on the patients age, the segment of bone affected and the
stage of the disease. Some of the various interventions are.

Core decompression
Multiple drills are done in the hip to reduce to reduce the pressure inside and
potentially allowing the bine forming cells to lay down new bone replacing dead
bone. The reduced pressure allows for increased blood supply to the bone. The
procedure is helpful when performed before the collapse of the bone and
cartilage.

Vascularised and Non-vascularized grafts
An attempt is made to reestablish the blood supply of the hip bone by inserting a
bone graft taken from another part of the body. Usually a part of fibula bone
along with its blood vessel is used as a graft. The grafted bone incorporates into
the hip bone and with its blood supply helps in revascularization.
The grafts can also be non-vascularized. Grafted bone not only provides
structural support but also supplies potential bone forming cells which creep in
substituting the dead bone, Muscle pedicle grafts can also be used. Again the
procedure is helpful only if performed in early stages of the disease.

Osteotomies
These are surgeries which change the segments of the ball of the hip which bear
weight. The diseased segment is surgically rotated so that the healthy segment
comes to lie under the weight bearing portion and relieves the pain and stiffness.
The diseased unloaded segment potentially starts to get healthy. The surgery is
useful in smaller lessions.

Total hip replacement/ Hip resurfacing
Majority of patient reports to the physicians when in pain and the disease
process is already in advanced stages. Total hip replacement is the best surgical
option, which not only relieves pain and stiffness but offers a faster rehabilitation
usually 8 weeks.
It involves replacing the hip joint with a prosthetic or artificial joint which
recreates the movements and biomechanics of the normal joint. It offers a
normal lifestyle even in advanced stages.

Actual

The patient had her Total hip replacement surgery.

Nursing Care Plan

NURSING NURSING
DATA PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION

“Haan pay Constipation Client will Encourage Fluid intake The patient
nagbawas” as related to maintain patient to helps make the were able to
verbalized by immobility as bowel increase stool soft and defacate
the carer evidenced by elimination in adequate fluid moist for
change in his normal intake unless easier
bowel habits pattern contraindicated elimination
DATA NURSING GOAL/OBJECTIV NURSING INTERVENTION RATIONALE EVALUATI
DIAGNOSIS E ON
Subjective P- Pain After 30 – 60 Independent Nursing Fears and
cues: “on a E- Related to minutes of Intervention: concerns can
scale of one their hip nursing Encourage verbalization of increase muscle Within 1
through ten, surgery interventions feelings about the pain. tension and lower hour the
how would you S- as and threshold of pain patient
rate your pain, evidenced administrating perception. was asleep
ma’am?” by their pain and
facial medication, the Collaborative Nursing comfortab
grimace. patient’s pain Intervention: Maintain a le.
should decrease Assist with patient- constant drug
Objective Cues: substantially. controlled analgesia or level avoids cyclic -Goal met.
“a nine, it really analgesia through epidural periods of pain,
hurts.” catheter. Administer aids in muscle
intermittent analgesics healing, and
routinely, as indicated, improves
especially 45 to 60 minutes respiratory
before respiratory function and
treatments and deep- emotional
breathing, and coughing comfort and
exercises. coping.
VIII. PEARSON ASSESSMENT

ASSESSMENT Hospital Date: Hospital Date: Hospital Date: Home


07-16-2020 07-18-20 07-19-20 Visit
Date
Patient X, 49 yrs old, Patient X is resting Patient X is sleepy but
widowed, had surgery and trying to cope at unrest due to pain.
due to avascular with pain.
Physiological necrosis at the hips.

Urine- 500mL Urine- 800mL Urine- 700mL


Bowel Movement- 0 Bowel Movement- 0 Bowel Movement-2

Elimination

Well positioned at Well positioned at her Well positioned at


hospital bed, irritated, hospital bed, irritated, hospital bed, and
and sleepy. and sleepy. sleepy.
Activity and Rest

Initial vital signs taken Initial vital signs taken Initial vital signs taken
as follows: as follows: as follows:
BP: BP:120/80 BP:120/80
Safety and Security PR: PR:90 PR:76
Temp: Temp:37.2 Temp:36.7
IV site intact and patent IV site intact and IV site intact and
well positioned with her patent well positioned patent well
bantay. with her bantay. positioned with her
bantay.

No o2 supplement No o2 supplement No o2 supplement


RR= RR=20 RR=20
o2 saturation= 96% o2 Saturation=97%
Oxygenation

Normal Diet, avoid Normal Diet, avoid Normal Diet, avoid


sugary foods. sugary foods. sugary foods.
With good appetite With good appetite With good appetite
Nutrition With D5NSS 1L at With PLRS 1L for 15- With PLRS 1L for 15-
300ml for 30- 30gtts/min 30gtts/min
31gtts/min
IX. DISCHARGE PLANNING

Discharge Summary
Date Admitted: July 14, 2020
Admiting Physician: Dr. Quilala
Admitting Diagnosis: Avascular necrosis of hip
Chief Complaint: Pain on the hip
Hospital Course: Patient was admitted and undergone Total Hip Arthroplasty
Attending Physician: Dr. Guzman
Education:
Follow up: Follow up check up for the removal of suture and to check if the
wound is healing properly
Diet: diebetic diet
Medication: Instruct patient how, when to take home medications.

X. PROMOTIVE AND PREVENTIVE

Instruct patient to do deep breathing and coughing exercise to limit the chance of
pneumonia
Continue medication as per physician’s order.
Encourage exercise to strengthen muscles.
Encourage a healthy diet.
Be sure to keep the incision or wound clean and dry.
XI. DRUG STUDY

DRUG STUDY (Andres)

NAME AND DOSE, MECHANIS INDICATIO CONTRAINDICA ADVERSE NURSING


CLASSIFICA FREQUENCY, M OF NS TIONS EFFECT RESPONSIBILIT
TION OF ROUTE, ACTION Y/TIES
DRUG DURATION
OF
ADMINISTRA
TION
The Short-term Ketorolac is Headach Give as
primary treatment contraindicated e, ordered.
mechanis of mild to in those with Drowsine
Ketrolac 30 mg, every m of action moderate hypersensitivity ss,
8 hours, responsibl pain in the , allergies to the Indigesti
Intravenousl e for postoperati medication, on,
y ketorolac's ve period cross-sensitivity Stomach
anti- and in to other or
inflammat musculosk NSAIDs, prior to abdomin
ory, eletal surgery, history al pain,
antipyretic trauma; of peptic ulcer Nausea,
and pain disease, Diarrhea,
analgesic caused by gastrointestinal Dizziness,
effects is renal colic. bleeding, Itching,
the alcohol Swelling,
inhibition intolerance, Increase
of renal d blood
prostaglan impairment, urea
din cerebrovascular nitrogen,
synthesis bleeding, nasal Constipa
by polyps, tion,
competitiv angioedema, Purpura,
e blocking and asthma. Increase
of the d serum
enzyme creatinin
cyclooxyge e,
nase Drowsine
(COX). ss,
Ketorolac High
is a non- blood
selective pressure
COX
inhibitor. It
is
considered
a first-
generation
NSAID.
Tramadol This Tramadol Dizziness, Give as
Tramadol 50 mg, every binds to μ- medication hydrochloride is Headach ordered.
6 hours, opioid is used to contraindicated e,
Intravenousl receptors. help in any situation Drowsine
y The parent relieve where opioids ss,
compound moderate are nausea
has weak to contraindicated and
binding moderately , including vomiting,
affinity. severe acute constipa
The pain. intoxication tion
metabolite Tramadol is with any of the lack of
s have 200 similar to following: energy
times the opioid alcohol, sweating
binding analgesics. hypnotics, dry
affinity for It works in narcotics, mouth
the μ- the brain centrally acting
receptor. to change analgesics,
Tramadol how your opioids or
inhibits body feels psychotropic
reuptake and drugs.
of responds
norepinep to pain
hrine and
serotonin,
thus acting
like an α2-
agonist.
a Cephalexin is diarrhea, Give as
Cephalexin 1 g, every 8 bactericida contraindicated dizziness, ordered.
hours, l agent for use in tiredness
Intravenousl that acts patients with ,
y by the cephalosporin headach
inhibition hypersensitivity e,
of bacterial . stomach
cell-wall Cephalosporins upset,
synthesis. cause abdomin
hypersensitivity al pain,
reactions in <= joint
5% of patients pain,
receiving them. vaginal
A variety of itching or
hypersensitivity discharge
reactions ,
ranging from
mild rash to
fatal
anaphylaxis
may occur.
XII. BIBLIOGRAPHY

Book:
Medical –Surgical Nursing
Brunner and Suddarth’s
Vol 1&2, 10th edition
Medical –Surgical Nursing
Brunner and Suddarth’s
Vol 1&2, 14th edition
Nursing Care Plan
Guidelines for Individualizing Client Care Across Life Span
8th edition.
Internet:
https://www.google.com/search?
q=pathophysiology+of+intracerebral+hemorrhage&sxsrf=ACYBGNQVIxQbXze8n3VegdGtoG5XBGAwIA:1
575180782615&source=lnms&tbm=isch&sa=X&ved=2ahUKEwiSzITY5ZPmAhWrGqYKHe2pAasQ_AUoAX
oECA0QAw&biw=1024&bih=499#imgrc=88Hkizef9djUDM:

https://www.yumpu.com/en/document/view/45752570/nursing-care-plan-fever-nursing-crib

https://emedicine.medscape.com/article/

https://www.google.com/search?
q=tranexamic+acid&oq=tranexamic+acid&aqs=chrome..69i57j0l7.6438j0j4&sourceid=chrome&ie=UTF-8

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