Case Study Part (2) by skitzer

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									                                     Chapter 1


Background and the Rationale of the Study

       Osteomyelitis was one of the oldest recorded diseases, with descriptions

dating back to the time of Hippocrates about 460-370 BC (Lew & Waldyogel,

2004). Terms such as abscessus in medulla, necrosis, and a boil of the bone

marrow were used to describe the infection until Nelaton introduced the term

osteomyelitis in 1844.

       Prior to the introduction of penicillin in 1940, the management of acute

osteomyelitis was purely surgical, with large incisions for removal of all necrotic

bone (Lew & Waldyogel, 2004). Wounds were packed with vaseline gauze and

left to heal by secondary intention after immobilization. Mortality rates remained

high (about 33 percent) due to sepsis until the introduction of penicillin, which

dramatically   changed     the    treatment    and    prognosis    of   osteomyelitis.

Complications such as sequestration, sinus formation, and sepsis became less

common and the goals of therapy changed from disease containment to cure.

       Osteomyelitis was defined as an infection of the bone and its surrounding

soft tissue. It could be acute or chronic condition wherein acute osteomyelitis

(Somners, & Johnson, 2007) refers to an infection less than one month in

duration from the time of the initial infection while chronic osteomyelitis refers to a

longer duration of bone infection that continued more than four weeks or that

represents a persistent problem with periods of remission and exacerbations.
      There were number of health conditions associated to various joints and

bones in the human body. Some conditions were diseases in it whereas many

others are complications produced by certain diseases. Osteomyelitis was

usually a result of complication of some other ailment. In fact, osteomyelitis was

a bone infection that is chronic in nature. Though the bone was the affected site,

normally root cause of such infection was not injuries caused to bone. Most

often the infection was originated from some other body parts and was spread to

bone through blood stream. Any previous trauma to a bone or if the bone had

undergone trauma recently it may predisposed the area to osteomyelitis.

However, any delay in the treatment of a fracture may also contribute to the

development of osteomyelitis (Peoples- Health, 2007).

      Normally long bones such as thigh bone, especially in children, were

affected by infection called osteomyelitis. Unlike children, pelvis and vertebrae

were the most common sites where osteomyelitis affects in adult cases (Peoples-

Health, 2007).

      People with diabetes, hemodialysis, those who have suffered trauma

recently and those who abuse IV drugs were considered on higher risk of

developing chronic osteomyelitis. Fortunately, it was a rare health condition.

According to the available statistics, one person among 5000 people gets

affected with osteomyelitis (Peoples- Health, 2007).

      Osteomyelitis was needed to be studied because this kind of disease may

not only cause some discomfort towards the patient but it may complicate to

even deadly condition and this may lead to further complications later in life. One

of which was bone cancer which is the 24th leading site overall, 18th in males

and 21st among females. In 1998, an estimated 769 new cases will be seen, 479

cases among males and 290 among females. Osteosarcoma was the most

common of all malignant bone tumors and incidence increases at age 60

(Department of Health, 2006).

       Through this study, the researcher can help minimize or even prevent the

development of this disease because he would be able to identify the

predisposing factors that lead to this condition. With this study, people will be

able to gain information and knowledge which they can utilize in the future in

order to be aware of such condition and what to do if in case they will be a victim

of such disease.

Theoretical Background

       In the early part of the 20th century, comfort was the central goal of

nursing and medicine. Comfort was the nurse's first consideration. A good nurse

made patients comfortable. In the early 1900's, textbooks emphasized the role of

a health care provider in assuring emotional and physical comfort and in

adjusting the patient's environment.

       Although the Comfort Theory of Kolcaba originated in nursing, it was now

being applied to all providers in any given institution. This theory was presented

as a pattern for providing holistic care to patients and families in all health care


       Here were some of the definitions of the major concepts in the theory.

Health Care Needs were those identified by the patient/family in a particular

practice setting. Intervening Variables were those factors that are not likely to

change and over which providers have little control such as prognosis, financial

situation, extent of social support, etc. Comfort was a concept that has a strong

association with nursing. Enhanced comfort was an immediate desirable

outcome of nursing care, according to Comfort Theory. Health Seeking

Behaviors could be internal (healing, immune function, number of T cells, etc.),

external (health related activities, functional outcomes, etc.), or a peaceful death.

Institutional Integrity was defined as the values, financial stability, and wholeness

of health care organizations at local, regional, state, and national levels. Best

Policies were protocols and procedures developed by an institution for overall

use after collecting evidence. Best Practices were those protocols and

procedures developed by an institution for specific patient/family applications

after collecting evidence (Kolcaba, 2009).

       The basis of Kolcaba's theory was a taxonomic structure or grid that has

12 cells (Kolcaba, 1991; Kolcaba & Fisher, 1996). Three types of comfort were

listed at the top of the grid and four contexts in which comfort occurs were listed

down the side of the grid. (Ferreira, 2004)

       As mentioned a while ago, comfort was a concept that has a strong

association with nursing. Nurses traditionally provided comfort to patients and

their families through interventions that can be called comfort measures. The

intentional comforting actions of nurses strengthen patients and their families.

When patients and families were strengthened by actions of health care

personnel, they could better engage in health seeking behaviors (Kolcaba, 2009).

      The three types of comfort were relief, ease and transcendence. Relief

was defined as the experience of a patient who had had a specific comfort need

met. Ease was defined as a state of calm or contentment and does not

necessarily specify a prior need that was relieved. Transcendence which is also

known as renewal was defined as the state in which one rises above problems or

pain (Kolcaba, 1991). Transcendence was an important concept for Comfort

Theory because nurses can’t always alleviate pain and suffering completely.

Conveying hope, caring, and commitment to the patient and family are vehicles

for transcendence and were essential components of Comfort Theory.

      The four contexts of comfort were physical, psycho-spiritual, socio-cultural

and environmental. Physical Comfort was described as pertaining to all bodily

sensations. It requires balance in homeostatic mechanisms and immune function

that may or may not be related to specific diagnoses and early stages of

imbalance may or may not be perceived by the patient. Psycho-spiritual Comfort

was a combination of mental, emotional, and spiritual components of self. It was

defined as whatever gives life meaning for an individual and entails self-esteem,

self-concept, sexuality, and one’s relationship to a higher order or being.

Environmental Comfort was defined as pertaining to external surroundings,

conditions, and influences. Entailed in this definition were color, noise, light,

odors, ambience, temperature, views from windows, access to nature, and

natural versus synthetic elements. And lastly, Socio-cultural Comfort was defined

as pertaining to interpersonal, family, and societal relationships including

finances, education, and support. It also included the family traditions, rituals,

and religious practices (Kolcaba, 1991).

      In the comfort theory, Kolcaba asserted that when healthcare needs of a

patient were appropriately assessed and proper nursing interventions carried out

to address those needs, taking into account variables intervening in the situation,

the outcome was enhanced patient comfort over time. Once comfort was

enhanced, the patient will likely to increase health-seeking behaviors. These

behaviors may be internal to the patient such as wound healing or improved

oxygenation, external to the patient such as active participation in rehabilitation

exercises, or a peaceful death. Furthermore, Kolcaba asserted that when a

patient experienced health-seeking behaviors, the integrity of the institution will

subsequently increased because the increase in health-seeking behaviors will

result in improved outcomes. Increased institutional integrity would lend itself to

the development and implementation of best practices and best policies

secondary to the positive outcomes by the patients (Kolcaba, 2009).

      Kolcaba's comfort theory successfully addresses the four concepts

comprising the metaparadigm of nursing.         She defined the metaparadigm

concepts as they correspond to her theory. According to her, Nursing was

described as the process of assessing the patient’s comfort needs, developing

and implementing appropriate nursing interventions, and evaluating patient

comfort following nursing interventions. Assessment may be either objective,

such as in the observation of wound healing, or subjective, such as by asking if

the patient is comfortable. Person was described as the recipient of nursing care

wherein the patient can be considered as individuals, families, institutions, or

communities in need of health care. Environment was considered to be the

external surroundings of the patient and can be manipulated by a nurse, or loved

one to enhance comfort. Finally, Health was viewed as the optimum functioning

of the patient as they defined by the patient, group, family or community. (Dowd,


        The researcher chose this model to see if it was an effective patient care

model for patients in the Orthopedic Ward of the hospital who were having


Conceptual Framework

Figure 1. Schematic Diagram of the Theoretical and Conceptual Framework

for Comfort Theory

      Figure 1 shows that the patient would be able to met Enhanced Comfort

when the healthcare needs of a patient were appropriately assessed and proper

nursing interventions were carried out to address those needs and taking into

account variables intervening in the situation. Once comfort was enhanced, the

patient would likely to increase health-seeking behaviors that could increase the

integrity of the institution that would contribute to the development and

implementation of best practices and best policies.

Statement of the Problem

       The purpose of this case study was to find out whether promotion and

maintenance of health and well-being will be achieved in using Kolcaba’s Theory

of Comfort in the care of patient with Osteomyelitis.

       The following specific problems were formulated to serve as guide for the

conduct of this study:

       1. What were the health care needs of a patient with osteomyelitis that

          may contribute to comfort in terms of its form such as relief, ease and


       2. What were the changes happened in the patient’s comfort context that

          includes its physical, psychospiritual, environmental and sociocultural?

       3. What were the comforting interventions and intervening variables

          applicable to a client with osteomyelitis upon meeting these needs?

       4. What were the client’s health-seeking behaviors after the comfort was


       5. What was the significant effect in caring for a client with osteomyelitis

          guided by the comfort theory?

Significance of the Study

       The results of this study will be of great benefit to the:

Nursing Students. This study will guide them in rendering care to their clients

with osteomyelitis during their related learning exposure most especially at the

Orthopedic Ward.

Nurse Educators. This study can be utilized as bases and one of the sources of

their teaching plans. They can lend inputs to the nursing students regarding the

merits of the case.

Nurse Practitioners. This will serve as a blueprint that will guide nurses in

caring for client with osteomyelitis. This can improve their skills in the

identification of the signs and symptoms, goals of care, management, and

prevention of complications in the care of their patients. This can also provide a

guideline in identifying and utilizing appropriate nursing interventions in the self-

care and management needs of clients with this disorder.

Members of the health care team. This study will serve as a review on what

osteomyelitis is. This study will also improve the promotion of health of patients

with osteomyelitis. Though Kolcaba’s Theory of Comfort is not directly related to

these healthcare fields, the result of the interventions done will actually promote

a better understanding of the applied care management given by doctors and

other members of the healthcare team.

Community. This study will provide them knowledge concerning osteomyelitis.

This will prompt them to seek medical assistance upon observing initial signs of

the infection. Through this awareness, further complications brought by the delay

in seeking health care will be prevented.

Future Researchers. This study will guide them on the data and the information

that is needed to be presented. This will also serve as their reference or basis on

what areas needs elaboration.


Research Study

       This study adopted the qualitative method of the nursing research through

a case study wherein it describes the nature of the phenomenon under

investigation and answers questions and satisfies curiosity about a certain

phenomenon. Case studies were in-depth investigations of an individual, group,

institution, or other social unit (Polit, 2004). As with this case, this study took

place for six consecutive days. Through this design, the researchers attempted to

analyze and understand client’s comfort management needs, design a nursing

system to institute a delivery of care and formulate the comfort management

utilizing Katharine Kolcaba’s Theory of Comfort.

Research Locale

       The study was conducted at the Orthopedic Ward (Ward VIII) of Vicente

Sotto Memorial Medical Center (VSMMC) which is located at B. Rodriguez St.,

Cebu City.

Ward VIII is situated at the left wing of the hospital just below the Ward IX and in

between the Emergency room and Operating Room near the Billing Section. It

accommodate to cases concerning the musculoskeletal system such as

fractures,   amputated   limbs,    osteomyelitis,   and   cancer   of   bones   like

osteosarcoma regardless of age and gender of the patient. However, due to its

limited space, it is overcrowded and extra beds are positioned at the hallway.

The subject’s bed, X-3, is situated at the hallway of the ward which is very narrow

and usually causes traffic in that area.

Research Instrument

       The researcher employs the nursing process as the blue-print in rendering

nursing actions to the patient. The nursing process is a systematic framework for

providing professional, quality nursing care.        It involves the five phases:

assessment, nursing diagnosis, planning, implementation, and evaluation.

       The researcher utilizes Kolcaba’s assessment by using her taxonomic

structure of comfort or the 12-grid cell results which is composed of 3-types of

comfort across the top and 4-context of human experience down the left via

intentional assessment of comfort needs, the design of comfort measures to

address those      needs,   and   the      reassessment   of   comfort levels after

implementation. Assessment may be either objective, such as in the observation

of wound healing, or subjective, such as by asking if the patient is comfortable.

       The tool use to gather the data in this study is the RLE FORM 001 of the

Cebu Normal University – College of Nursing which is a standardized institutional

nursing admission and assessment form which is used to assess patient’s

condition. It is a ready made, three-page paper, back-to-back form to be filled

with information gathered through inspection, palpation, percussion, auscultation

& respondent’s profile and history. Observation was also used since not all

information needed is subjective. Professionalism was also practiced in the

gathering the data through normal conversation to avoid reluctance from the


       Aside from that, Nursing Care Plans (NCP) and Drug Studies were used

as part of the holistic care of the client. A Nursing Care Plan is designed to

outline the nursing care to be provided to the client. It is a set of actions the nurse

will implement to resolve nursing problems identified by assessment. While the

Drug Study outlines the necessary information about a certain medication. It

guides the researcher on proper administration, the right dose, its mechanism of

action, side-effects and the specific interventions to clients taking specific kind of


       And lastly, the chart, which is very useful throughout the data gathering

procedure since the researcher needs information such as the laboratory results

and note what the patient had undergone from the time of admission up to the

researcher’s time of care.

Research Respondent

       Mr. N.L.P. was the respondent of this study. He is a 21 years old male still

single, a pure Cebuano currently residing at Inuburan, Naga, Cebu. He has an

average height of 5’3” and weighs 50 kilograms. He was admitted for the second

time at Vicente Sotto Memorial Medical Center last November 12, 2009 due to

pain on Left lower leg and inability to walk. Patient was diagnosed of

Osteomyelitis Tibia Left; Status Post Application of Illizarove Fixator.

         He is a Roman Catholic and his native language was Cebuano. His

previous hospitalization was due to a motor vehicular accident last October 2007

and was diagnosed of having a Fracture Open, Medial-Distal Third Tibia-Fibula

of Left Leg. An operation, Open reduction Internal Fixation of the Left Leg, was

also done (See Appendix A for the Physical Assessment).

Research Data Gathering Procedure

         On November 16-21, 2009, the researcher was assigned at the Vicente

Sotto memorial Medical Center’s Orthopedic Ward (Ward 8) from 2pm to 10pm


         On the first day, patients’ assignment for the entire week exposure was

given by the Clinical Instructor and assessment and data gathering was

conducted after. On the second day, planning of care was utilized using the first

Nursing Care Plan and the Drug Study was studied. From the third day until the

last day, Nursing Care Plans of each day was performed. Total patient care was

rendered all throughout the exposure. This includes: bedside and environmental

care, vital signs monitoring, administration of oral medications especially pain

reliever and anti-biotic, patient teaching and charting. Review of the related

literature and background of the disease was also studied.

         At the end of the exposure, the case study was approved by the adviser.

Proper analysis, documentation, and knowledge enhancement was then made

about the case.


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