ABSCESS RIGHT UPPER CERVICAL MANDIBULAR

A CASE STUDY PRESENTED

BY

BAMBICO, ROBERT GLENN P.

FERNANDEZ, XIANEL ERIKA O.

NAVIDAD, SHYLA MARIE S.

SAMSON, TRISH KYLA A.

TO

FE M. NISPEROS, RN, MAN

Clinical Instructor

LORMA College of Nursing

November 2022
 CHAPTER I

INTRODUCTION

An abscess is a buildup of pus within the skin that may be caused by a number of different

reasons such as; a sebaceous gland or becoming obstructed, a hair follicle or a group of hair

follicles becoming inflamed, or minor breaks and punctures in the skin allowing bacteria to invade

causing redness, warmth, pain, inflammation, and pus formation. Though the symptoms will only

manifest as acute pain, it can eventually result in the infection spreading to the bloodstream

setting off severe sepsis leading to death.

Risk factors of contracting an abscess include: having a weakened immune system;

having diabetes; or being a carrier of staphylococcal bacteria or catching it through skin-to-skin

contact from a carrier.

When an abscess develops a smooth swelling under your skin can occur; with pain and

tenderness in the affected area; there can also be warmth and redness in the affected area; a

visible build-up of white or yellow pus under the skin in the affected area; and a high temperature

accompanied by chills.

In diagnosing an abscess, the physician will examine: how long the abscess has been

present; if the area is injured; or if there are any other accompanying symptoms. A sample of the

pus can also be taken to specify the strand of bacteria to aid in determining proper treatment. If

there is a presence of more than one skin abscess, an additional urine test for glucose will be

required because diabetics are usually susceptible to having abscess formations.

The treatment available when an abscess fills with infected pus is to surgically drain the

area of all infection or removing the mass and cleaning it with antimicrobial agents to prevent

recurrence; antibiotics are also prescribed for treatment such as Ceftriaxone. Nursing

interventions include: providing health teachings on promoting hygiene to prevent infection; and

also as mentioned before, administering antibiotics as ordered by the physician.

 To prevent an abscess one should, wash hands regularly and encourage housemates to

also wash hands; use separate towels and not share bath towels; and wait until skin abscess is

fully treated and healed before using any communal equipment, such as gym equipment and

swimming pools.

As for statistics, Staphylococcus Aureus is the most common cause of abscess skin,

accounting for up to 75% of cases worldwide. In the United States, dermatology departments

treated over 3.2 million abscess patients, while approximately 13,000 patients were hospitalized

in Australia. It was difficult to assess the incidence and prevalence due to the changing of the

display skin abscess. The annual incidence of skin abscess is 24.6 per 1000 people. Skin and

soft tissue infections, including abscesses, are a major public health concern among children,

with a recurrence rate of around 4%.Three hundred eighteen abscess visits occurred in 308

individual subjects in a retrospective study conducted in a pediatric emergency department; 79%

were due to methicillin-resistant Staphylococcus aureus. Approximately 14% of subjects had

more than one abscess. Buttock abscesses were more common in children aged 2 and under (P

< 0.001). 82 (43%) of the 192 subjects with documented responses had a history of a prior

abscess. Children aged 2 years and under were significantly more likely to be hospitalized or

have surgery: 49% versus 15% (P < 0.001).

In terms of local occurrence at Naguilian District Hospital, in the past 2 years, there has

been a total of 156 cases of abscess (77 during 2021 and 59 as of now in 2022). Whilst there has

been a total of 94 cases of skin infection for the past 2 years (64 during 2021 and 30 as of now in

2022).

Patient Centered Objective

 The patient and their family will realize the significance in the prevention of abscess

through health teachings.

 The patient and family will implement the measures in prevention of abscesses to

decrease the likelihood of recurrences.

 The patient’s family will apprehend the information given to them about abscesses.
Student Centered Objective

 To gain a deeper grasp of the formation of abscesses including its causes, signs and

symptoms, and risk factors.

 To enhance the knowledge, competency, and self-assurance of the nursing student so

they can better care for patients with abscesses.

 To provide the patient's family with meaningful information and awareness about

abscesses.

 To bestow health teachings about abscesses and in the prevention of abscesses.

 CHAPTER II

HEALTH HISTORY

A. BIOGRAPHIC DATA

Patient Z.V.M , is a 1-year old Female. She is the first born of her parents and she has a

younger sibling. Her family resides in Baraoas Norte, Naguilian, La Union.

B. REASONS FOR SEEKING HEALTH CARE

Patient Z.V.M was admitted in the Pediatric Ward due to a swollen neck accompanied with

pain that lasted for 3 weeks already.

C. PRESENT HEALTH HISTORY

In the first week of October, patient Z.V.M’s father reported that a small lump was felt on the

right cervical mandibular of the child. As days went by, it grew bigger and bigger until it became

swollen. He said that his child complains of pain whenever her neck is touched.

D. PAST HEALTH HISTORY

Her parents mentioned that she never had something like this before. On the other hand, she

has a history of asthma.

E. FAMILY HEALTH HISTORY

Patient Z.V.M’s grandfather, her father’s father, has a history of diabetes.

F. LIFESTYLE AND PRACTICES

1. DESCRIPTION OF TYPICAL DAY

Patient Z.V.M’s father said that she is an active kid and goes to their neighbor to

play with other children.

2. NUTRITION

She has no known allergies to foods or medications. She eats his meals three times

a day and drinks milk whenever she feels like it.

3. ACTIVITY LEVEL AND EXERCISE

 Patient Z.V.M’s way of exercise is playing with other children.

4. SELF-CONCEPT

Patient Z.V.M is a petite kid with a fair complexion.

5. RELATIONSHIP

Patient Z.V.M is close to her father and she is a good sister to her sibling.

6. STRESS LEVEL

Patient Z.V.M is a happy child but restless when in pain.

7. ENVIRONMENT

Patient Z.V.M and her family live in a compound.

8. EDUCATION AND WORK

Patient Z.V.M does not go to school yet.

9. VALUES AND BELIEFS

Patient Z.V.M is not yet baptized but her father reported that she’ll be baptized as

a Roman Catholic.

10. SLEEP AND REST

Patient Z.M usually sleeps for 8 hours each night however when she’s in pain, her

sleep gets interrupted.

G. DEVELOPMENTAL STAGE

Patient C.A is a 1 year old Female, she is in the age group of Infancy (Birth to 18 months

old). She’s in Stage 1: Trust vs. Mistrust of Erik Erikson's Stages of Psychosocial

Development. Infants are learning to trust their environment. As for patient Z.M, it is

important that her parents are able to provide what she needs. Most especially when she’s

in pain, this way it will help her develop trust that the environment is safe and that she can

rely on her parents and/or caregivers.

 CHAPTER III

PHYSICAL ASSESSMENT

A. GENERAL ASSESSMENT

Patient Z.V.M was awake, and aware during the assessment. She is restless because of the pain

she is feeling on her neck. She weighs 11.72 kg Her vital signs are Temperature: 36.3 C, PR: 80

beats per minute, RR: 22 breaths per minute, and O2 Sat: 98%.

B. SKIN, HAIR AND NAILS

The patient’s skin is moist, and soft to touch. Patient’s hair is black and evenly distributed. Nail

Beds are pink. Cuticles are smooth; no detachment of nail plates. Capillary refill time goes back

quickly within 2 seconds.

C. HEAD AND NECK

Head is symmetrically round, hard and smooth without lesions or bumps. There is swelling noted

on her right cervical mandibular area. Painful when touched.

D. EYES AND EARS

Her eyes are not sunken. No eye discharge noted. Ears are symmetrical and no lesions,

discharge, and discoloration noted. Mastoid process is non-tender.

E. MOUTH, THROAT, NOSE AND SINUSES

Lips and tongue are pink in color. No lesions present in the buccal mucosa. Throat appears pink

in color and is smooth in texture. Tonsils are pink and symmetric, no lesions and exudates noted.

Nasal mucosa is patent with no discharge.

F. HEART AND NECK VESSELS

Patient’s heart rate is 80 beats per minute. Heart is in a regular rhythm.

G. THORAX AND LUNGS

Patient has normal chest shape, with no visible deformities. Her respiratory rate is 22 breaths per

minute. N difficulty of breathing is noted.

H. ABDOMINAL ASSESSMENT

Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or

scars. No pain is felt by the patient upon palpation.

I. EXTREMITIES

There is no tenderness or deformity noted. No presence of swelling or erythema. Full range of

motion is noted to all joints. Radial-femoral pulses were congruent.

J. GENITALIA

Area not assessed

K. NEUROLOGIC

Patient Z.V.M is restless.

 CHAPTER IV

ANATOMY PHYSIOLOGY

LYMPHATIC SYSTEM

Lymphatic system, a subsystem of the circulatory system in the vertebrate body that

consists of a complex network of vessels, tissues, and organs. The lymphatic system helps

maintain fluid balance in the body by collecting excess fluid and particulate matter from tissues

and depositing them in the bloodstream. It also helps defend the body against infection by

supplying disease-fighting cells called lymphocytes. This article focuses on the human lymphatic

system. The lymphatic system can be thought of as a drainage system needed because,

as blood circulates through the body, blood plasma leaks into tissues through the thin walls of

the capillaries. The portion of blood plasma that escapes is called interstitial or extracellular fluid,

and it contains oxygen, glucose, amino acids, and other nutrients needed by tissue cells. Although

most of this fluid seeps immediately back into the bloodstream, a percentage of it, along with the

particulate matter, is left behind. The lymphatic system removes this fluid and these materials

from tissues, returning them via the lymphatic vessels to the bloodstream, and thus prevents a

fluid imbalance that would result in the organism’s death.

The fluid and proteins within the tissues begin their journey back to the bloodstream by

passing into tiny lymphatic capillaries that infuse almost every tissue of the body. Only a few

regions, including the epidermis of the skin, the mucous membranes, the bone marrow, and

the central nervous system, are free of lymphatic capillaries, whereas regions such as

the lungs, gut, genitourinary system, and dermis of the skin are densely packed with these

vessels. Once within the lymphatic system, the extracellular fluid, which is now called lymph,

drains into larger vessels called the lymphatics. These vessels converge to form one of two large
vessels called lymphatic trunks, which are connected to veins at the base of the neck. One of

these trunks, the right lymphatic duct, drains the upper right portion of the body, returning lymph

to the bloodstream via the right subclavian vein. The other trunk, the thoracic duct, drains the rest

of the body into the left subclavian vein. Lymph is transported along the system of vessels

by muscle contractions, and valves prevent lymph from flowing backward. The lymphatic vessels

are punctuated at intervals by small masses of lymph tissue, called lymph nodes, that remove

foreign materials such as infectious microorganisms from the lymph filtering through them.

In addition to serving as a drainage network, the lymphatic system helps protect the body

against infection by producing white blood cells called lymphocytes, which help rid the body of

disease-causing microorganisms. The organs and tissues of the lymphatic system are the major

sites of production, differentiation, and proliferation of two types of lymphocytes—the T

lymphocytes and B lymphocytes, also called T cells and B cells. Although lymphocytes are

distributed throughout the body, it is within the lymphatic system that they are most likely

to encounter foreign microorganisms.

The lymphatic system is commonly divided into the primary lymphoid organs, which are

the sites of B and T cell maturation, and the secondary lymphoid organs, in which further

differentiation of lymphocytes occurs. Primary lymphoid organs include the thymus, bone marrow,

fetal liver, and, in birds, a structure called the bursa of Fabricius. In humans the thymus and bone

marrow are the key players in immune function. All lymphocytes derive from stem cells in the

bone marrow. Stem cells destined to become B lymphocytes remain in the bone marrow as they

mature, while prospective T cells migrate to the thymus to undergo further growth. Mature B and

T lymphocytes exit the primary lymphoid organs and are transported via the bloodstream to the

secondary lymphoid organs, where they become activated by contact with foreign materials, such

as particulate matter and infectious agents, called antigens.

The lymph nodes, or lymph glands, are small, encapsulated bean-shaped structures

composed of lymphatic tissue. Thousands of lymph nodes are found throughout the body along
the lymphatic routes, and they are especially prevalent in areas around the armpits (axillary

nodes), groin (inguinal nodes), neck (cervical nodes), and knees (popliteal nodes). The nodes

contain lymphocytes, which enter from the bloodstream via specialized vessels called the high

endothelial venules. T cells congregate in the inner cortex (paracortex), and B cells are organized

in germinal centres in the outer cortex. Lymph, along with antigens, drains into the node through

afferent (incoming) lymphatic vessels and percolates through the lymph node, where it comes in

contact with and activates lymphocytes. Activated lymphocytes, carried in the lymph, exit the node

through the efferent (outgoing) vessels and eventually enter the bloodstream, which distributes

them throughout the body.

 CHAPTER V

PATHOPHYSIOLOGY

Non-Modifiable Risk Modifiable Risk Factors

Factors
 Age: 1 year old  Skin-to-skin contact
 Immunocompromised  Hygiene Practices

Resident skin flora

Staphylococcal Bacteria
(The most common pathogen)

Break in skin barrier (may

not be obvious) and entry of
pathogen

Cytokines activate immune

response

Accumulation of
Local inflammatory
pus (bacteria)
response in skin

Impaired Tissue
Integrity Abscess on right
upper cervical
mandibular
Neck pain Swelling
Warmth

Risk for
Imbalance
Nutrition
 CHAPTER VI

DIAGNOSTIC TEST

COMPLETE BLOOD COUNT Date: October 28, 2022

EXAMINATION RESULT NORMAL VALUES INTERPRETATION

Hemoglobin 103 115- 135 g/L Anemia

Hematocrit 0.29 0.33- 0.40 Anemia

WBC 9.74 4-10 x 10 g/L This is a normal finding

Neutrophils 0.69 0.30 - 0.60 Infection

Lymphocytes 0.20 0.25 - 0.50 Lymphocytopenia

Eosinophils 0.7 0.02 - 0.05 Infection

Monocytes 0.4 0.03 - 0.08 This is a normal finding

Platelet Count 295 150 - 450 x 10 g/L This is a normal finding

RADIOLOGY REPORT: October 27, 2022

Chest APL rule out Pulmonary Tuberculosis.

Findings:

No definite active lung densities.

The pulmonary vascular marking is normal.

Heart is not enlarged. aorta and other upper midsternal structures are intact.

Diaphragm is normal in level and contour.

No pleural reactions nor abnormal bony changes of the thoracic cage is noted.

STOOL ANALYSIS: October 31, 2022

Color: Yellow

Consistency: watery

(+) Entamoeba histolytica / dispar cyst

(-) Parasite - no helminthic ova / protozoan parasite seen

 CHAPTER IX

EVALUATION

Patient Z.M, a 1-year-old female client, was a patient assigned in the pediatric ward during

clinical duty at Naguilian District Hospital. She was admitted on October 26th, 2022 at 4:10 PM.

The patient was diagnosed with an abscess at the right upper cervical mandibular, noted with a

grape-sized mass post mandibular 3 days prior to admission. The patient was given

pharmacological treatment, Ceftriaxone, to help with the infection; whilst also placed on a soft-

diet. As of now, November 4th, 2022; Patient Z.M is scheduled to have an ultrasound completed

then to be considered for discharge soon after the procedure.

The patient received competent nursing care which included the monitoring of vital signs,

administration of prescribed medications, and health teachings to her family; in efforts to aid the

prevention of the spreading of the illness. In hand with this, the provided nursing care, helped

work towards attainment of the patient centered objectives. The case study has not only enriched

our nursing practice as students through acquiring new competencies and other skills; but it has

given us the opportunity to provide holistic care, which is essential in the profession.