Bacterial Meningitis

A Case Study Presented to the Faculty of The Ateneo de Davao University College of Nursing

A Case Study on BACTERIAL MENINGITIS Submitted to:

Ms. Loreen S. Marcelo, RN Clinical Instructor – Panelist of the Case Study

Submitted by: [Group 1-A]

Ampilanon, Rae Maikko M. Ausa, Ryan S. Balboa, Tessa Marie R. Barbarose, Pamela Erika J. Beltran, Maribel S. Bulosan, Von Rainier S. BSN-4H

25 September 2010

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TABLE OF CONTENTS

I.

Acknowledgement 3 II. II. Intr Introd oduc ucttion ..................................................................................................................... 4 III. Object Objective ivess (Gene (General ral & Speci Specific fic)) ..................................................................................................................... 6 Patient’s Data ..................................................................................................................... 8 IV.

Family Background and Health History ..................................................................................................................... 10 V.

VI. VI. Deve Develo lopm pmen enta tall Data Data ..................................................................................................................... 14 Definition of Complete Diagnosis ..................................................................................................................... 19 VII.

VIII. VIII. Physi Physica call Asses Assessm sment ent ..................................................................................................................... 21 IX. IX. Anat Anatom omyy and and Physi Physiol olog ogyy ..................................................................................................................... 36 X. Eti Etiolo ology gy and Sympto Symptomat matolog ologyy ..................................................................................................................... 36 XI. XI. Path Pathop ophy hysi siol olog ogyy ..................................................................................................................... 42 2 | Page

XII. XII. Doct Doctor or’s ’s Orde Order r ..................................................................................................................... 46 XIII XIII.. Diag Diagno nost stic ic Exam Examss ..................................................................................................................... 55 XIV. Drug rug St Study ..................................................................................................................... 87 XV. XV. Nurs Nursin ingg The Theor orie iess ..................................................................................................................... 102 XVI. XVI. Nurs Nursin ingg Care Care Plan Plan ..................................................................................................................... 107 Discharge Plan (M. E. T. H. O. D.) ..................................................................................................................... 130 XVII.

XVIII.

Prognosis………………………………………..............…………………………132 XIX. XIX. Reco Recomm mmen enda dati tion on ..................................................................................................................... 136 XX. Referen rences ..................................................................................................................... 138

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ACKNOWLEDGEMENT

First and foremost, to the Almighty Father, for His unceasing love and blessings; for giving us enough strength and fortitude to face all the adversity in the making of this work. Also, the proponents of this case study would like to extend their earnest appreciation to all the people who made the success of this study a reality: To our Clinical Instructor, Mrs. Loreen S. Marcelo, R.N. for her helpful time, knowledge and effort extended to us. To the staff of Southern Philippines Medical Center, especially in the Pediatrics Ward, for giving us the opportunity to complete our exposure and our case study. To our dearest family and friends, for their never ending support and understanding; for always being there to guide us and care for us after the long days of duties. To the patients who marked a part of our hearts, for challenging us to do more and for pushing us beyond our limits to maintain and improve their quality of health, to appease their restlessness and sometimes to endure their unexplainable combative behaviors; it was an experience to care for them. Lastly, to each and every one who helped realize this job into completion, may it be direct or indirect, no matter how minimal, the gratitude and pleasure for the achievement of this task is ours to share.

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INTRODUCTION

Meningitis is an inflammation of the membranes that cover the brain and spinal cord. People sometimes refer to it as spinal meningitis. Meningitis is usually caused by a viral or bacterial infection. Knowing whether meningitis is caused by a virus or bacterium is important because the severity of illness and the treatment differ depending on the cause. For bacterial meningitis, it is also important to know which type of bacteria is causing the meningitis because antibiotics can prevent some types from spreading and infecting other people. Today, Streptococcus pneumoniae and Neisseria meningitidis are the leading causes of bacterial meningitis. Bacterial meningitis continues to be among the top ten killers of children less than four years old in the Philippines. Pathogens isolated from patients with this disease as well as their susceptibility patterns are different from those isolated in western countries. A delay in treatment leads to higher morbidity and mortality, thus early recognition of the disease is necessary. Signs and symptoms of bacterial meningitis are variable and depend on the age of the patient and the duration of illness before treatment. Neonates and young infants may only have subtle manifestations. These are difficult to distinguish from a coexisting septicemia. Worldwide, as of January 2004, about 5,600 people were infected each year with an estimated 4,719 deaths, average weight of 84.3%, among those infected will die (www.nmaus.org/meningitis). Nationwide, an estimate of 926 incidences out of 86,241,697 of the

whole

population

were

cited

leading

to

20%

of

deaths

(www.nationmaster.com/graph/mor_bac_men_not_els_cla). Locally, only an estimate of 10-15% incidence was found, specifically to those children less than four years old (www.inmed.co.uk/lectures/lecture8.ppt). 5 | Page

The group of BSN 4H 1-A, was given opportunity to have their hospital exposure last September 13 to 15, 2010 at Southern Philippines Medical Center. JP, not his real name, was one of the patients admitted to the Pediatrics Ward due to Bacterial Meningitis. The group has chosen JP as their subject mainly for the reason that his case posed as a very complex study that requires thorough understanding and knowledge. Our chosen client presented most noted clinical manifestations from the disease which provided us with significant notes for the study.

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OBJECTIVES General Objective: The objective of the group is to present a holistic and comprehensive case presentation of our chosen client and provide a complete discussion of the study, deliver optimal care for our client from the knowledge obtained from this study. Specific Objectives: In order to meet the general objective, the group aims to: Cognitive: •

Interpret the relevant data gathered from the patient’s significant others,

•

Evaluate the present developmental stage of the patient according to the theories of Erikson, Freud, and Piaget.

•

Define the complete diagnosis of the patient, Bacterial Meningitis,

•

Rationalize the doctor’s order obtained from the patient’s chart,

•

Interpret the laboratory test results of the patient,

•

Apply the nursing theories of Nightingale, Hall, and Hendersion in the nursing care

Psychomotor: •

State the past and present health history of the client,

•

Trace the family genogram,

•

Present the cephalocaudal assessment obtained from the patient,

•

Discuss the anatomy and physiology of the central nervous system that is involved in the patient’s disease,

•

Present the etiology and symptomatology of the patient’s disease,

•

Trace the pathophysiology of the patient’s disease,

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•

Present the medications given to the client, including their respective modes of action, indications, contraindications, side effects, adverse reactions, nursing responsibilities, and importance to the client’s condition;

•

Present specific, measurable, attainable, realistic and time-bound nursing care plans for the client,

•

Justify the client’s prognosis according to the different criteria,

Affective: •

Establish rapport to the patient’s significant others,

•

Provide the patient and family with proper discharge planning (M.E.T.H.O.D),

•

Inform suitable recommendations to the client, his significant others and community, and the medical world, etc.

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PATIENT’S DATA Personal Data: Patients Name: Age: Gender:

“JP” 4 months old Male

Weight:

5.5 kilograms

Birth date: Address:

May 10, 2010 Purok 7, Barangay 4, Poblacion, San Francisco, Agusan del Sur

Nationality:

Filipino

Religion:

Roman Catholic

Number of Siblings:

None

Father:

“Bob”

Occupation:

Utility Man / Janitor

Educational Attainment:

High School Undergraduate (Second Year)

Mother:

“Marley”

Occupation:

Sari-Sari Store Vendor

Educational Attainment:

High School Undergraduate (Third Year)

Family Income:

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9,000 Php (Estimated)

Clinical/ Admitting Data: Date of admission:

September 11, 2010

Time of admission:

11:40 pm

Chief Complaint

Stomachache and fever

Hospital & Hospital Number:

Southern Philippines Medical Center [2220291]

Ward [Room & Bed Numbers]: Attending Physician:

Pediatric Ward – IMCU Dr. Meralyn M. Maduay, M.D.

Admitting Diagnosis:

Bacterial Meningitis

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FAMILY BACKGROUND AND HEALTH HISTORY Family Background JP, a 4-month old baby, is the first and only child of Bob and Marley. The family lives in San Francisco, Agusan del Sur and only came here in Davao City to seek medical aid. Bob, 25, works as a utility man in a hotel in Agusan while Marley, 24, stays at home and manages their own sari-sari store. The couple got married last February 2009 in the “Kasalang Bayan” in San Francisco. The family lives in their own house which, according to Marley, was given to her by her parents as a wedding gift to them. The first year of their marriage was filled with joy and excitement as they were able to plan and prepare for their first child. Both of them worked hard to save money for JP. Their parents advised them to secure PhilHealth insurance; however, they just neglected this and took things for granted. Bob and Marley came from small families since both of them were the only child of their parents respectively. They originally decided to have 2-3 children. They considered proper spacing of years between them. They also learned from seminars they attended about family planning and the different options they could take. However, when JP got ill, these plans were set aside since they wanted to focus on him first and with all the hardwork and expenses, they cannot afford to have another child yet. JP was breastfed until 1 week old. He was then hospitalized since he had “cord infection” according to her mother. “Nahospital mana siya atong 4 days pa human pagkaanak kay naimpeksyon iyang pusod. Mga usa pud kasemana to.”, as verbalized by Marley. After which, breastfeeding was stopped and he was bottle-fed from then on. He took 3 multivitamins: PedZinc, Clusivol and Tiki-Tiki. The mother failed to remember how long JP was taking each of

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these vitamins. What she knew was, she stopped giving Tiki-Tiki to JP when his second hospitalization began. There were no known familial illnesses such as Diabetes Mellitus, Asthma, and Hypertension in the family. Bob claimed his father has hypertension however, this is not diagnosed. His father is not also taking maintenance medications for the said illness. As far as Marley can recall, this is the first case of Bacterial Meningitis in the family and close relatives.

Past Health History JP was delivered through normal spontaneous vaginal delivery in a maternity clinic at San Francisco, Agusandel Sur. In his age, he has received a dose of BCG, 3 doses of OPV, 3 doses of DPT and 2 doses of Hepatitis B vaccine. Measles vaccine is not yet given to him since he is not yet of age. He has not received Haemophilus Influenza Type B (Hib) vaccine too. His first hospitalization was when he was still 4 days old. According to her mother, he had high-grade fever with convulsions and his skin turned yellowish. It was found out there in the hospital that he had infection of the umbilical cord. This prompted his admission and stayed in the hospital for a week. Marley decided to stop breastfeeding since JP cries every time she attempts to breastfeed. From then on, she feeds her baby with formula milk and never came back to breastfeeding. She failed to remember the exact medications given to JP however she was “sure” that some of those were antibiotics.

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History of Present Illness Three days prior to his admission at DO Plaza Memorial Hospital on September 3, 2010, Marley noticed his son to be irritable and crying most of the day. He also had intermittent fever reaching up to 40°C relieved by paracetamol. Marley also noticed generalized body stiffness. “Manuskig usahay iyang lawas unya magsulirap iyang mata.”, as she described. She also observed generalized pallor. Persistence of the said symptoms led them to consultation. During the course of his admission, several tests were run including urinalysis, fecalysis, and some blood tests. After the results were secured, they were discharged on the 8 th of September and were asked to return of September 22 since, as explained by the physician, they found a bacteria in the patient’s blood. JP was given dicycloverine, metronidazole, and ranitidine as home medications. Two days after admission, on September 10, 2010, JP began to cry loudly again as if he was in pain. He also had fever that day and so they rushed him again to the same hospital. The hospital again made some routine tests however they were not able to get the results since the physician decided to refer them at Southern Philippines Medical Center (SPMC). They arrived at SPMC on September 12, 2010 and JP was admitted at the Pediatric Ward.

Effects and Expectations of Illness to Family Everyone in the family, including the grandparents, was greatly alarmed by JP’s illness. It is their first time to experience this health crisis and they are clueless on what further actions to take. His parents regretted that they didn’t get a PhilHealth insurance. Only now that they realized how helpful it is in paying the bills. The grandparents were very supportive and promised to help in the expenses. Bob and Marley also promised to do everything they can for 13 | P a g e

their son. Spiritually, the mother is very submissive to God’s plans. “Gina ampo na lang jud nako na mahimong okay tanan. Gipasa-Diyos na lang man nako. Kabalo ko dili ko niya pasagdan.”.They have also been asking for God’s guidance and help. As of now, they just leave

it all to the hands of the health team taking care of JP. They hope that they will do their best too in treating his illness.

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DEVELOPMENTAL DATA

These are just a few of the fascinating aspects of the field of “human development”: the science that studies how we learn and develop psychologically, from birth to the end of life. This very young science not only enables us to understand how each individual develops, it also gives us profound insights into who we are as adults. Each theory has its own perspective on the development of man. Erik Erikson’s Theory of Psychosocial Development Erikson's

stages

of

psychosocial

Erikson explain eight stages through

which

a

development as healthily

articulated

by Erik

developing human should

pass

from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future. Developmental stage Trust Mistrust

Description

Achieved or

Justification

Not Achieved vs. The first stage of Erik Achieved Our client was just four months Erikson's theory centers

old; he is dependent to his

Infants ( 0- 1 on the infant's basic needs

parents especially to his mother

year old)

being met by the parents.

when it comes to his needs.

The infant depends on the

The client is rich in love from

parents,

his

mother,

especially the for

food,

sustenance, and comfort.

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parents.

provide the especially

the

They client’s love

always needs and

If the parents expose the

affection. Now that the client is

child

warmth,

sick, they really do their best to

regularity, and dependable

provide the medications the

affection, the infant's view

client

of the world will be one

financial constraints they had.

of trust. If the parents fail

Through giving the child’s

to

secure

needs like food and most

environment and to meet

especially love, the child had

the child's basic need a

form sense of security when he

sense of mistrust will

was with his parents. He stayed

result.

calm and comfy when he was

to

provide

a

needed

despite

the

with them. Freud’s Psychosexual Theory of development Stage Oral

Description stage

1year)

Erogenous mouth

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Achieved

or

Achieved (birth- The oral stage begins Achieved

Not Justification The

client

has

at birth, when the oral

achieved this stage,

cavity is the primary

since

zone: focus

of

libidal

observed

we that

have the

energy. The child, of

mother bottle fed the

course,

child as necessary or

preoccupies

himself with nursing,

when

the

child

with the pleasure of

demands it from his

sucking and accepting

mother.

things into the mouth.

erogenous zone is the

The oral

mouth which means

character

who is frustrated at

the

this

pleasure as she was

stage,

mother

whose

refused

to

child

feels

being nursed by her

nurse him on demand

mother. The

or

truncated

was being bottle fed

nursing sessions early,

until he’s satisfied and

is characterized by

fell asleep as he’s

who

pessimism,

client

envy,

sucking the milk from

suspicion

and

the bottle.

sarcasm.

The

overindulged

oral

character,

whose

nursing urges were always

and

often

excessively satisfied, is optimistic, gullible, and

is

full

of

admiration for others around him. The stage culminates

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The

in

the

primary conflict of weaning, which both deprives the child of the sensory pleasures of nursing and of the psychological pleasure

of

being

cared for, mothered, and held. Jean Piaget’s Theories of Cognitive Development Stage

Description

Achieved or

Justification

Sensorimotor

Not Achieved The first stage of Piaget’s Achieved

The child has achieved this

Stage

theory lasts from birth to

stage since he has been trying

Secondary

approximately age two

to be more focused in the

Circular

and is centered on the

world. He tries to observe his

infant trying to make

surrounding and the people

sense of the world. During

around his. Also, he now

the sensorimotor stage, an

utilizes his grasping ability in

infant’s knowledge of the

which, as observed, he’s been

world is limited to their

trying to reach out some

sensory perceptions and

things and put it on his mouth

motor

like when he’s being bottle

Reactions months)

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(4-8

activities.

Behaviors are limited to

fed he tries to grasp the bottle

simple motor responses

and put on his mouth.

caused by sensory stimuli. Children utilize skills and abilities they were born with, such as looking, sucking, grasping, and listening, to learn more about the environment.

DEFINITION OF COMPLETE DIAGNOSIS BACTERIAL MENINGITIS

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Infection of the layers of tissue covering the brain and spinal cord (meninges). Meningitis is similar in older children, adolescents, and adults but different in newborns and infants. Meningitis in newborns is typically caused by bacteria acquired from the birth canal. The most common such bacteria are group B streptococci, Escherichia coli, and Listeria monocytogenes. Mark H. Beers, MD, et al. Merck Manual.2nd Edition. Merck and Co, Inc. Copyright 2003.Page 1411.

An inflammation of the brain and spinal cord that may be caused by either bacterial or viral infection. Any microorganism that enters the body can result in meningitis. Bacterial meningitis is a serious infection that is spread by direct contact with discharge from the respiratory tract of an infected person. Linda S. Williams, et.al. Understanding Medical Surgical Nursing. 3rd Edition. F.A. Davis Company. Copyright 2007.Page 1054.

It is an inflammation of the meninges. It can be caused by either a viral or bacterial infection. Symptoms usually include stiffness in the neck, headache, and fever. In severe cases, meningitis can also cause paralysis, coma or death. Seeley, Stephens and Tate.Essentials of Anatomy and Physiology. 6 th Edition.Mc-Graw Hill.Copyright 2007.Page 232.

Meningitis is an infection of the fluid in the spinal cord and the fluid that surrounds the brain. Meningitis is usually caused by an infection with a virus or a bacterium. Knowing whether meningitis is caused by a virus or a bacterium is important because of differences in the

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seriousness of the illness and the treatment needed. Bacterial meningitis is much more serious. It can cause severe disease that can result in brain damage and even death. Kluwer.Medical Terminology Handbook.2nd Edition. Lippincott Williams and Wilkins.Copyright 2002.Page 114.

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PHYSICAL ASSESSMENT

Date and Time of Assessment: September 13, 2010 @ 6:00 A.M.

General Survey The patient is lying supine on bed, awake, with IVF of D5.3Nacl @ 300 cc level infusing well at left metacarpal vein. He is not in respiratory distress. He has a newly changed diaper. He is calm and is not crying during the assessment process.

Vital Signs The patient has temperature of 37.1 degrees Celsius, afebrile. He has a respiratory rate of 41 cycles per minute which is normal for his age. He has a pulse rate of 136 beats per minute, with no skip beats noted, taken via his apical pulse.

Anthropometric Measurement The patient’s height is 62 cm. The patient’s weight is 5.5 kilograms. Head circumference is 41 centimeters while chest circumference is 38 centimeters. The patient’s abdominal circumference is 44 centimeters. Skin The patient’s skin color is light brown and uniform in all areas. No birthmark is noted upon inspection. No odor is noted. It has a good skin turgor. The skin is soft, warm and slightly moist and free from lesions and edema. Diaper dermatitis is not noted. Hair

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Hairs are unevenly distributed over the scalp. It is black in color. It is thin and dry. No infestation or dandruff is noted.

Nail The patient’s nails are clean. It has a concave shape. It is thin and has pale nail beds with no infection noted. It is soft to touch with a capillary refill time of 3 seconds.

Head The patient’s head is normocephalic and rounded. It is proportional to body size. It has symmetrical facial features with symmetrical facial movements. Head circumference is 41 centimeters. It has a uniform consistency with no nodules or masses noted. It is non tender. Bulging anterior fontanel is noted while posterior fontanel is already closed.

Eyes Eyes are symmetrical. Hairs are evenly distributed with intact skin. Eyebrows are symmetrically aligned. Visual following is noted with equal eye movement. No discharges and discoloration of the eyelids. When the eyelids are closed, no sclera is visible. Anicteric sclera is noted. Pale palbebral conjunctiva is noted. No edema or tenderness is noted over the lacrimal glands.

Ears Ears are symmetrical with color that is same as the facial skin. Auricles are aligned with the outer canthus of the eyes. No lesions noted. It is firm and non tender. When a sound was

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made on his ears, the patient blinks but did not turn his head on the side where the sound was produced.

Nose The nose is symmetrical with uniform skin color that is the same as facial skin. No discharges and nasal flaring noted. Nose is non-tender. Nasal septum is intact and in the midline. Nares are patent. Maxillary and ethmoid sinuses are non-tender upon palpation.

Mouth and Oropharynx Tooth is not present. Lips are soft, moist and have a smooth texture. There is a uniform pink color of gums, tongue and tonsils. Tongue is located at the midline with moist texture. Tongue is able to move. Deviations and abnormalities are not noted upon inspection of soft and hard palate. Uvula is positioned in the midline. Rooting and sucking reflexes are noted.

Neck Neck is located at the midline. It is short and with intact skin. The skin color is the same as facial skin. Nuchal rigidity is noted as manifested by difficulty of the head to turn to sides.

Thorax and Lungs The thorax is rounded with chest circumference of 38 centimeters. The skin is intact with no tenderness noted. Skin color is consistent with facial skin. Respiratory rate is 41 cycle per minute with regular pattern of breathing. Patient has regular depths of respiration. Upon auscultation, crackles are noted on both lung fields. No stridor is noted upon inspiration.

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Heart and Peripheral Pulses The patient has a cardiac rate of 136 beats per minute. No abnormal heart sound is noted upon auscultation. Peripheral pulses have regular and full pulsations. It is symmetric on both sides. The skin is warm upon palpation with no discolored extremities. Capillary refill time is 3 seconds.

Abdomen The patient has an enlarged, globular and distended abdomen with an abdominal circumference of 44 centimeters. It has a uniform color. No lesions or tenderness noted. It is nontender. Abdominal movements are symmetric that are caused by respiration. Umbilicus is located at the center with no signs of infection and protrusions.

Genito-Urinary The patient is uncircumcised with tight foreskin. External meatus is located at the tip of the glans penis. Testes are descended. No swelling or tenderness in the inguinal area. Pateint is able to void freely.

Musculo-Skeletal Upper Extremities Upon inspection, no lesions and scars is noted on arms and shoulders. No tenderness, inflammations, or masses is evident on elbows. 5 fingers are present on each hand, with no deformed fingers. No contractures, bone enlargements, nodules or redness is noted. Tenderness

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and nodules are not noted on the left wrist, hands and fingers upon palpation. It is free from inflammation and with normal angle curvature. No hand tremors noted. He is able to exhibit hand grip when an object touches his hand. Lower Extremities No lesions and scar is noted. No tenderness, inflammation or mass is seen. 5 toes are present on each foot with no deformed toes. He is able to move his legs without difficulty. No fractures and dislocation is noted. No tremor noted. No edema noted on both extremities.

Neurolomuscular Reflexes Upon assessment, the patient startles and abducts and adducts arms in response to stimuli indicating that Moro Reflex is still present. Plantar Reflex is present. Palmar Grasp Reflex is also present as the patient exhibits hand grip when an object touches his hand.

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ANATOMY AND PHYSIOLOGY

The nervous system is an intricate, highly organized network of billions of neurons and neuroglia. The structures that make up the nervous system include the brain, cranial nerves, spinal nerves, ganglia, enteric plexuses and sensory receptors. The two main subdivisions of the nervous system are the central nervous system and the peripheral nervous system. The central nervous system consists of the brain and spinal cord. The brain is the center for registering sensations, correlating them with one another and with stored information, making decisions and taking actions. It also is the center for the intellect, emotions, behavior, and memory. The major parts of the brain include: the brain stem, cerebellum, diencephalon, and cerebrum. The spinal cord is connected to a section of the brain called the brainstem and runs through the spinal canal. Cranial nerves exit the brainstem. Nerve roots exit the spinal cord to both sides of the body. The spinal cord carries signals (messages) back and forth between the brain and the peripheral nerves. The brain stem is continuous with the spinal cord and consists of the medulla oblongata, pons, and midbrain. The medulla oblongata forms the inferior part of the brain stem. The medulla contains the cardiac, respiratory, vomiting and vasomotor centers and deals with breathing, heart rate and blood pressure. The pons is a bridge that connects parts of the brain with one another. The midbrain extends from the pons to the diencephalon. The midbrain is a short section of the brain stem between the diencephalon and the pons. Posterior to the brain stem is the cerebellum. Traditionally, the cerebellum has been known to control equilibrium and coordination and contributes to the generation of muscle tone. It has more recently become evident, however, that the cerebellum plays more diverse roles such

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as participating in some types of memory and exerting a complex influence on musical and mathematical skills. Superior to the brain stem is the diencephalon, which consists of the thalamus, hypothalamus, and epithalamus. The thalamus acts a relay center for all sensory impulses, except smell, to the cerebral cortex. The hypothalamus is involved in the acceleration or deceleration of the heart. Impulses from the posterior hypothalamus produce a rise in arterial blood pressure and an increase of the heart rate. Impulses from the anterior portion have the opposite effect. The hypothalamus is also involved in body-temperature regulation. If the arterial blood flowing through the anterior portion of the hypothalamus is above normal level, the hypothalamus initiates impulses that cause heat loss through sweating and vasodilation of cutaneous vessels of the skin. A below-normal blood temperature causes the hypothalamus to relay impulses that result in heat production and retention through the initiation of shivering, the contraction of cutaneous blood vessels. The hypothalamus is also involved in the regulation of hunger and control of gastrointestinal activity. Low levels of blood glucose, fatty acids and amino acids are partially responsible for the sensation of hunger elicited from the hypothalamus. When sufficient amounts of food have been ingested, the hypothalamus inhibits the feeding center. It also regulates sleeping and wakefulness. A specialized sexual center in the hypothalamus responds to sexual stimulation of the tactile receptors within the genital organs. Also, the hypothalamus is associated with specific emotional responses, such as anger, fear, pain and pleasure. The hypothalamus produces neurosecretory chemicals that stimulate the anterior pituitary gland to release various hormones. The epithalamus is the posterior portion of the diencephalon. Supported on the diencephalon and brain stem is the cerebrum, which is the largest part of the brain. The cerebrum is the largest part of the brain and controls voluntary actions, speech,

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senses, thought, and memory. The surface of the cerebral cortex has grooves or infoldings (called sulci), the largest of which are termed fissures. Some fissures separate lobes. The frontal lobes are located in the front of the brain and are responsible for voluntary movement and, via their connections with other lobes, participate in the execution of sequential tasks; speech output; organizational skills; and certain aspects of behavior, mood, and memory. The parietal lobes are located behind the frontal lobes and in front of the occipital lobes. They process sensory information such as temperature, pain, taste, and touch. In addition, the processing includes information about numbers, attentiveness to the position of one’s body parts, the space around one’s body, and one's relationship to this space. The temporal lobes are located on each side of the brain. They process memory and auditory (hearing) information and speech and language functions. The occipital lobes are located at the back of the brain. They receive and process visual information. Nervous tissue consists of groupings of nerve cells or neurons that transmit information called nerve impulses in the form of electrochemical changes. A nerve is a bundle of nerve cells or fibers. Nervous tissue is also composed of cells that perform support and protection. These cells are called neuroglia or glial cell. Over 60% of all brain cells are neuroglia cells. There are different kinds of neuroglial cells, and, unlike neurons, they do not conduct impulses. Astrocytes are star-shaped cells that wrap around nerve cells to form a supporting network in the brain and spinal cord. They attach neurons to their blood vessels, thus helping regulate nutrients and ions that are needed by the nerve cells. Oligodendroglia look like small astrocytes. They also provide support by forming semi rigid connective-like tissue rows between neurons in the brain and the spinal cord of the CNS. Microglial cells are small cells that protect the CNS and whose role is to

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engulf microorganisms like bacteria and cellular debris. They are responsible for the phagocytosis of unwanted substances in the CNS. Ependymal cells line the fluid-filled ventricles of the brain. Some produce cerebrospinal fluid and others with cilia move the fluid through the CNS. Schwann cells form myelin sheaths around nerve fibers in the PNS. The meninges comprise three membranes that, together with the cerebrospinal fluid, enclose and protect the brain and spinal cord (the central nervous system). The pia mater is a very delicate impermeable membrane that firmly adheres to the surface of the brain and the spinal cord, following all the minor contours. The arachnoid mater (so named because of its spider-web-like appearance) is a loosely fitting sac on top of the pia mater. The subarachnoid space separates the arachnoid and pia mater membranes, and is filled with cerebrospinal fluid. The outermost membrane, the dura mater, is a thick durable membrane, which is attached to both the arachnoid membrane and the skull.

30 | P a g e

Each of the four ventricles of the brain contains a choroid plexus, a capillary network that forms cerebrospinal fluid from blood plasma. As the tissue fluid of the CNS, cerebrospinal fluid permits the exchange of nutrients and wastes between the blood and CNS neurons. It also acts as a cushion or shock absorber for the CNS. The pressure and constituents of the cerebrospinal fluid may be determined by means of a lumbar puncture and may be helpful in the diagnosis of diseases such as meningitis.

In bacterial meningitis, bacteria reach the meninges by one of two main routes: through the bloodstream or through direct contact between the meninges and either the nasal cavity or the skin. In most cases, meningitis follows invasion of the bloodstream by organisms that live upon mucous surfaces such as the nasal cavity. This is often in turn preceded by viral infections, which break down the normal barrier provided by the mucous surfaces. Once bacteria have entered the bloodstream, they enter the subarachnoid space in places where the blood-brain barrier is vulnerable—such as the choroid plexus. Direct contamination of the cerebrospinal fluid may arise from indwelling devices, skull fractures, or infections of the nasopharynx or the nasal 31 | P a g e

sinuses that have formed a tract with the subarachnoid space; occasionally, congenital defects of the dura mater can be identified. The blood-brain barrier (BBB) is a separation of circulating blood and cerebrospinal fluid (CSF) in the central nervous system (CNS). It occurs along all capillaries and consists of tight junctions around the capillaries that do not exist in normal circulation. Endothelial cells restrict the diffusion of microscopic objects (e.g. bacteria) and large or hydrophilic molecules into the CSF, while allowing the diffusion of small hydrophobic molecules (O2, hormones, CO2). Cells of the barrier actively transport metabolic products such as glucose across the barrier with specific proteins.

The blood-brain barrier acts very effectively to protect the brain from many common bacterial infections. Thus, infections of the brain are very rare. However, since antibodies and antibiotics are too large to cross the blood-brain barrier, infections of the brain that do occur are often very serious and difficult to treat. However, the blood-brain barrier becomes more permeable during inflammation, meaning that some antibiotics can get across. Viruses easily bypass the blood-brain barrier by attaching themselves to circulating immune cells. 32 | P a g e

The inflammation that occurs in the subarachnoid space during meningitis is not a direct result of bacterial infection but can rather largely be attributed to the response of the immune system to the entrance of bacteria into the central nervous system. When components of the bac bacte teri rial al cell cell memb membran ranee are iden identi tifi fied ed by the the immu immune ne cells cells of the the brai brainn (astr (astrocy ocyte tess and microglia), they respond by releasing large amounts of cytokines, hormone-like mediators that recruit other immune cells and stimulate other tissues to participate in an immune response. Large numbers of white blood cells enter the CSF, causing inflammation of the meninges, and leading to "interstitial" edema.

33 | P a g e

ETIOLOGY AND SYMPTOMATOLOGY Etiology

Predisposing Factor Rationale Present/ Absent Justification Age The an a natomical st s tructure of o f th t he Present The patient is 4 Auditory tube is different in children

months old.

below 2-3 years of age. Children of this his age age have have a more ore hori horizo zont ntal al auditory tube leading to the pharynx which increases the likelihood of ear infection that may lead to meningeal infection. (Med (M edic ical al-s -sur urgi gica call

nurs nursin ing: g:

an

integrated integrated approach by Lois White, Gena Duncan)

Underdeveloped

Infancy is a factor which makes a Present

The patient is an

immune system

person more susceptible to meningitis

infant, 4 months

and other diseases since infants don’t

old,

have have a ful fully deve develloped oped immun mmunee

immune immune system system

sysytem. Removal of your spleen, an

is

important part of the immune system,

underdeveloped.

also may increase the risk. (Han (H andb dboo ookk

of

medi me dica call-su surg rgiical cal

nursi nursing ng by Lipp Lippin inco cott tt Will Willia iams ms &

34 | P a g e

so

his

still

Wilkins)

Precipitating Factor Rationale Present/ Absent Justification Trauma to the skull Rece Recent nt trau trauma ma to the the skull skull give givess Absent The patient has no or skull fractures

bac bacte teri riaa in the the nasa nasall cavi cavity ty the the

hist histor oryy of trau trauma ma

pot poten enti tial al to ente enterr the the meni meninge ngeal al

of the skull.

space. space. Fractur Fractures es allow allow contin continuit uityy betwe between en the extern external al environm environment ent and the nervous system which can lead to infection such as meningitis. (Medic (Medicalal-Surg Surgica icall

Nursin Nursing g

Made Made

Incredibly Easy! by Springhouse)

Prolo Prolong nged ed

conta contact ct Meni Mening ngiitis is a

com communi munica cabl blee Absent

According to to th the

to a pat patient with dise diseas ase. e. Prol Prolon onge gedd cont contac actt may may

parents, parents, the patient patient

meningitis

incre increase ase the the likel likelih ihood ood of cross cross--

did not have any

contamination.

contact, contact, prolonged prolonged

(Med (M edic ical al-s -sur urgi gica call

nurs nursiing: ng:

an

integrated approach by Lois White,

or not, to a patient with meningitis.

Gena Duncan)

Recent Recent respira respirator toryy Meningitis follows invasion of the Present

The patient had a

and/or ear infection, bloodstream by organisms that live

recent recent respira respirator toryy

or sinusitis.

upon mucous surfaces such as the

infection

as

nasal cavity and the respiratory tract.

manifested

by

Infection in a space adjacent to the

cough.

meninges such as the ears may also

35 | P a g e

lead to meningitis. (Understanding Nursing

Medical-Surgical

by Linda S. Williams,

Paula D. Hopper)

Myelomeningocele

These diseases are neural tube Absent

The patient does

and meningocele

defects

not

that

are

congenital

anomalies. There is a failure of the

myelomeningocele

posterior spinous processes on the

and meningocele.

vertebrate to fuse, which may permit meninges

and

spinal

cord

to

herniate, resulting in neurologic impairment. Meningitis may occur in infants with these diseases if direct

communication

occurs

between the skin and the meninges. (Pathophysiology for the Health Professions 3rd Edtion by Barbara E. Gould. 2006)

36 | P a g e

have

Symptomatology

Symptom Nuchal rigidity

Rationale Present/ Absent Justification This is the inability to flex the Present It was noted that the neck forward passively due to

patient has stiffness of

increased neck muscle tone and

the neck. It was also

stiffness related to the disease

written

process.

physician’s side notes.

in

the

(Evaluating signs and symptoms by

Lippincott,

Williams

&

Wilkins. 2009

Brudzinski's sign A positive Brudzinski’s sign Absent signals

meningeal

irritation.

Passive flexion of the neck

The patient did not manifest

this

symptom.

stretches the nerve roots, causing pain and involuntary flexion of the knees and hips. (Evaluating signs and symptoms by

Lippincott,

Williams

&

Wilkins. 2009)

Kernig's sign

Kernig’s

sign

is

hamstring Absent

stiffness and muscle pain when the examiner attempts to extend the knee while the hip and knee 37 | P a g e

This symptom is not present in the patient.

are flexed 90 degrees. Hamstring muscle resistance results from stretching the blood or exudateirritated meninges surrounding the spinal nerve roots. (Evaluating signs and symptoms by

Lippincott,

Williams

&

Wilkins. 2009)

Seizure

Seizures

may

result

from Present

It was written in the

increased pressure and from areas

physician’s side notes

of inflammation in the brain

that the patient is

tissue.

positive for seizure

(Understanding Medical-Surgical

which prompted for

Nursing

his admission to the

by Linda S. Williams,

Decreased level A decrease in the patient’s level Present

PICU. Prior

of consciousness

of consciousness usually results

hospitalization,

from a neurologic disorder or

patient was noted to

infection.

be lethargic.

Paula D. Hopper)

Consciousness

is

affected by the reticular activating system

(RAS),

an

intricate

network of neurons with axons extending from the brain stem, thalamus, and hypothalamus to

38 | P a g e

to the

the cerebral cortex. A disturbance in any part of this system prevents the

intercommunication

that

makes consciousness possible. (Evaluating signs and symptoms by

Lippincott,

Williams

&

Wilkins. 2009)

Fever

Macrophages, white blood cells, Present

The patient had this

and injured cells release chemical

symptom prior to and

substances called pyrogens that

during

act directly on the hypothalamus,

hospitalization.

his

causing its thermostat to be set to a

higher

temperature.

Also,

immunological reactions are sped up by temperature. (Medical-surgical integrated

nursing:

approach

by

an Lois

White, Gena Duncan)

Vomiting

Vomiting

from

an Present

According

to

the

increased intracranial pressure as

patient’s parents, the

a response to the inflammatory

patient had episodes

process

39 | P a g e

results

associated

with

of vomiting before his

meningitis.

hospitalization. Also,

(Pathophysiology for the Health

it was written in the

Professions 3rd Edtion by Barbara

physician’s side notes

E. Gould. 2006)

that the patient is

Bulging Fontanel This is due to the inflammatory Present process

associated

with

disease

and

increased

the

the

positive for vomiting. It was observed has a bulging

anterior

fontanel.

permeability of the blood-brain barrier. This is only present in infants up to 6 months of age. (Clinical Manual of Pediatric nursing 6 th Edition by Marilyn j. Hockenberry. 2004)

Poor feeding

As a response of the immune Absent

The patient did not

system to infection, interferon is

manifest

triggered which initiates a stress

symptom.

response. The stress response can elicit changes in the nervous and endocrine systems and, changes in behavior seen during an infection acting through the mediation of neuropeptides. An effect

of

this

is

anorexia.

Anorexia may be beneficial in the early phase of infection because

40 | P a g e

this

of the reduction of nutrients available which is essential for microbial growth. (Pathophysiology: The Biologic Basis for Disease in Adults and Children 2nd Edition by Kathryn L.

McCance&

Sue

E.

Huether.1994 )

Irritability

In meningitis, the infection of the Present

According

meninges may also lead to the

patient’s mother, the

inflammation

patient was irritable

of

the

blood

vessels, encountered in acute infection, which means it is

prior

to

to

the

the

hospitalization.

harder for blood to enter the brain, and brain cells are deprived of oxygen which may lead to irritability. (Clinical Manual of Pediatric nursing 6 th Edition by Marilyn j. Hockenberry. 2004)

Opisthotonos

Opisthotonus facilitation

occurs of

the

due

to Absent

anterior

reticulospinal tract caused by the inactivation

41 | P a g e

of

inhibitory

The patient did not manifest symptom.

this

corticoreticular

fibers

which

normally act upon the pons reticular formation (Evaluating signs and symptoms by

Lippincott,

Wilkins. 2009)

42 | P a g e

Williams

&

PATHOPHYSIOLOGY Predisposing Factors Age Underdeveloped immune system

Precipitating Factors

•

•

•

Infection

Bacteria enters into the blood stream

Crosses the blood-brain barrier

Bacteria proliferates in the CSF Irritates and induces inflammatory reaction to the CSF and meninges

Immune response of astrocytes, microglia and cytokins is released

43 | P a g e

Fever

Irritation of nerve endings

Irritability

the

Muscle rigidity

Inflammation of the Meninges Increase in the number of WBC

Vasodilation

Increased blood flow

Increased permeability

Edema

Nuchal rigidity

Leaked fluid and proteins move into inflamed tissue

Purulent exudates formation

Increased ICP

Bulging fontanel

Irritates nerve cells of the brain IF TREATED: Fluid and Electrolyte Management •

•

Infected CSF and purulent exudates travel throughout the CNS and proliferates in the brain, sheath of cranial and spinal nerves and to

Antibiotic Therapy Encephalitis

GOOD PROGNOSIS

44 | P a g e

IF NOT TREATED

Seizure

NARRATIVE PATHOPHYSIOLOGY Meningitis is an inflammation of the pia mater, the arachnoid space and the cerebrospinal fluid-filled subarachnoid space. Meningitis is classified as septic or aseptic. In this case, the patient experience septic meningitis as the condition is cause by bacteria. There are different bacteria that cause bacterial meningitis and that includes Streptoccocus pneumoniae and Nesseria meningitides. Other factors that placed an individual at risk for bacterial meningitis are otitis media, skull fracture and respiratory tract infection as these serves as the gateway for the infecting bacteria to enter the blood stream. Usually, children from 1-23 months are highly susceptible to this condition as their immune system is not yet fully developed, enabling them to fight off infection. As the bacteria enter into the body, it passes through the blood stream. It the crosses the blood-brain barrier, a protective barrier that enables many substances to enter the CNS. Due to the accompanying infection of the bacteria, the blood-brain barrier becomes permeable, thus allowing the infected blood to pass through. The bacteria then penetrates the cerebrospinal fluid and reaches the subarachnoid space. Once pathogens enter the subarachnoid space, an intense host inflammatory response is triggered by lipoteichoic acid and other bacterial cell wall products produced as a result of bacterial lysis. This response is mediated by the stimulation of macrophage-equivalent brain cells that produce cytokines and other inflammatory mediators. Temperature spikes up thus casuing fever. As the microglia and astrocytes are release, the inflammation of the meninges occurs. The whole process of inflammation takes place. There will be irritation of the nerve cells thus causing irritability. Muscle rigidity also takes place. This results into signs such as nuchal rigidity, positive Kerneg’s and Brudzinski’s sign. Blood examination shows an increase in white

45 | P a g e

blood cells as a result of infection. Vasodilation and increased permeability also take place where leaked fluids and other protein accumulate in the inflamed tissue to produce pus. This will also lead to edema causing increased intracranial pressure. As the CNS is continuously affected, brain cells are also triggered to produce seizure. Lumbar puncture is the best way to diagnose the condition and to detect what microorganism has infected. Medical management includes prevention of fever and febrile symptoms, fluid and electrolyte management, antibiotic therapy and corticosteroids. Dehydration and shock are treated with fluid volume expanders. Seizures are controlled with phenytoin. Once diagnosed and properly managed, bacterial meningitis is not fatal and leads to a good prognosis. However, if no treatment is done, there is a continuous circulation of the infected cerebrospinal fluid accompanied by the purulent exudates formed. It will then reach the brain as well as the cranial sheaths. Another infection will occur. As soon as infection takes place, it can lead to brain damage, decreased cerebral blood flow and encephalitis among others. Death will soon take place if no treatment is done.

46 | P a g e

DOCTOR’S ORDER DATE 9/12/10

ORDER JUSTIFICATION REMARKS Admit to IMCU under For close monitoring of the patient and Admitted P1 service, Level 3 proper management of his condition. Please secure consent Informed consent is the permission for care

obtained from a patient/guardian to allow health care providers to do their tasks. This also evaluates whether the

Consent

patient has understood the reason for

secured

his admission and his or her condition. To secure the consent of the client is important for legal purposes. Labs: CBC with PC

CBC is a standard routine laboratory test which determines the quantity of each quantity of blood cell in a given specimen of blood. This is done to

Done

know any underlying condition that produces UA

changes

in

the

blood

components. Urinalysis is a routine and standard laboratory test performed to screen for urinary

tract

disorders,

kidney

disorders, urinary neoplasm and other medical CXR PAL

conditions

that

produce

changes in the urine. A chest x ray is a procedure used to evaluate organs and structures within the chest for symptoms of disease. Chest x rays include views of the lungs, heart,

47 | P a g e

small

portions

Done

of

the

Done

gastrointestinal tract, thyroid gland, and Cranial Ultrasound

the bones of the chest area. Cranial ultrasound is a procedure where reflected sound waves are used to produce the images of the brain and inner

fluid

chambers.

Cranial

ultrasound test is useful for diagnosing the problems in babies (up to 18 months old). The test should be done before the

Done

bones of the brain grow together because ultrasound waves cannot pass through the bones. This is done to find out infection and abnormal growths in or around the brain. For Lumbar Puncture if Lumbar puncture (colloquially known with consent

as

a spinal

tap)

a diagnostic procedure

that

is is

performed in order to collect a sample of cerebrospinal

fluid (CSF)

for biochemical, microbiological, and cytological analysis. Its

Not Done most

common purpose is to collect CSF in a case of suspected meningitis, since there is no other reliable tool with Blood GSCS

which meningitis can be excluded. Gram staining and culture and sensitivity tests are used to determine

Done

what type of bacteria the specimen has.

without

In this case, the patient’s blood is used

result

as the specimen. Venoclysis: IVF to start D5 0.3NaCl is a hypertonic solution

Done

with D5 0.3 NaCl 500cc which has free water, salt and calories 48 | P a g e

to run at 34cc/hour

that is commonly used for rehydration. Intravenous lines also provide easy access

for

drug

administration

intravenously (IVTT). Meds: Ceftriaxone

183mg Ceftriaxone is an antibacterial indicated

IVTT q8 hours ANST for meningitis caused by Streptococcus

Given

(-)

ANST

pneumonia and Haemophilus influenza.

This also used as prophylaxis. Paracetamol 100ml, give It is an antipyretic and analgesic drug 1.1 mL q4 hours, prn for used to decrease fever and for control fever >38°C Neuro VS q2 hours

of pain. Neuro vital signs is an assessment tool

Vital Signs q4 hours

used to evaluate neurological status. It

Taken and

is mostly expressed using Glasgow

Recorded

Coma Scale and Reaction Level Score. Vital signs are important for baseline assessment and to monitor patient’s

Taken and

condition which evaluates the whole

Recorded

treatment course. The measurement and recording of all

I & O q shift

fluid intake and output during a period provides important data about the patient’s fluid balance and ability of kidneys to excrete normral volume of Monitor

for

urine. further These changes could be indicative of a

decrease

in

LOC, worsening condition and increased

seizure

activity, damaged in the patient’s central

shortness of breath Refer accordingly

nervous system. This creates a collaborative treatment among the client and the health care providers; thus it also makes a good

49 | P a g e

Given

Monitored and Recorded

Monitored Referred

coordination on the treatment of the client. Revise Ceftriaxone to Revision of the frequency of drug 550mg IVTT OD

administration may be upon the physician’s discretion. This could mean

Revise

Revised

a more potent effect for the drug. Paracetamol Decreasing drug dosage is ordered

drops to 0.8ml q4 for since the fever of the patient is already fever

controlled. It could also mean that this

Revised

dosage is more suitable for the patient that the last one ordered. Age-appropriate diet means that the Significant

Diet for age

patient may feed on within the limitations and tolerance of his age. 9/13/10

other informed

Labs: Follow up CXR PAL

An order made to remind the patient or

Blood GSCS

significant others to obtain result of the

Continue IVF at SR

specified laboratory tests. IVF continues to rehydrate the patient. This also serves as an access for IVTT

Done

Continued

medications. Meds: Continue

Ceftriaxone These medications are continued until

550mg IVTT q8 their desired effects are met. PRN Paracetamol 0.8ml q4 medications are only given as the need prn for fever arises. VS q6

Vital signs are important for baseline assessment and to monitor patient’s condition which evaluates the whole

I & O q shift

Given

Given

treatment course. The measurement and recording of all

Monitored

fluid intake and output during a period

and

provides important data about the Recorded 50 | P a g e

patient’s fluid balance and ability of kidneys to excrete normral volume of Refer accordingly

urine. This creates a collaborative treatment among the client and the health care providers; thus it also makes a good

Referred

coordination on the treatment of the With UTI

client. cefuroxime Since the patient’s latest urinalysis

Start

125mg/5ml 4ml TID

showed that he has UTI, cefuroxime, an antibacterial primarily indicated for the

9/14/10

said condition, is ordered. For cranial ultrasound This is done to find out infection and tomorrow

09/15/10

Given

abnormal growths in or around the

Done

brain. For cranial ultrasound Patient is scheduled for the said test today at 1:30pm

today. This is done to find out infection and abnormal growths in or around the

Still

for

Done

brain. Lumbar Patient has not yet undergone the said

Puncture

conclusive diagnostic test for bacterial Not Done

Continue IVF at SR

meningitis on this date. IVF continues to rehydrate the patient. This also serves as an access for IVTT

09/16/10

medications. For serum Na, K, Ca, This test is being ordered in order to Mg

create a baseline data and to know the specific values of electrolytes in the blood. It also suggests if there is progress in the treatment if the unusual levels of the serum will be back to the desired normal values. Patients with kidney

51 | P a g e

diseases

have

electrolyte

Done

imbalances

due

to

decreased

functioning of the kidneys. Patient has not yet undergone the said

s/f LP

conclusive diagnostic test for bacterial Not Done meningitis as of this date. Existing ordered medications

Continue meds

are

continued until their desired effects are Transfer

to

met. Blue/ This transfer of service is done for the

Nephro service (UTI) 09/17/10 (+)

For

management of the patient’s urinary

Done

tract infection. (midstream Midstream catch of urine is preferred

UA

seizure catch)

since the specimen is most likely not

upon

contaminated yet by other external

admission

factors. The measurement and recording of all

(-) BFC

Continued

I and O q shift

fluid intake and output during a period provides important data about the patient’s fluid balance and ability of kidneys to excrete normral volume of

Done

Monitored and Recorded

urine. Vital signs are important for baseline

VS q 4

assessment and to monitor patient’s

Taken and

condition which evaluates the whole

Recorded

Refused LP

treatment course. The family has opted not to have the

(signed by father)

Lumbar Puncture procedure due to financial constraints. The father was

Done

asked to sign three times for formality 09/18/10

Follow

-Normal UA

electrolytes and repeat significant others to obtain result of the

(-) fever

UA Continue IVF @ SR

GCS 15 52 | P a g e

up

and legality purposes. serum An order made to remind the patient or specified laboratory tests. IVF continues to rehydrate the patient.

Done Continued

-awaiting

This also serves as an access for IVTT

blood culture result

medications. Refer to derma for Physician observed papular lesions on

normal, evaluation parents opt lesions -if

of

skin the patient’s right arm and for further evaluation, she referred it to a dermatologist.

to go home

Referred

-with papular lesion

and

rash on right arm 9/19/10

For transfer to PICU Patient is for transfer to Pediatric ICU

(+) vomiting

once with available bed

(+) tachypnea

condition that are already alarming. O2 inhalation at 10 L/m This is to relieve hypoxia, headache,

(+) labored

via face mask

since physician noted worsening of his

nausea, as well as to restore the ability of the cells of the body to carry on

breathing

Done

Done

normal metabolic function. This helps Nebulization salbutamol q1

provide oxygenation of the vital organs. withSalbutamol is a bronchodilator that is indicated

for

acute

attacks

of

bronchospasm. Patient noted to be in 7:30pm

respiratory distress. Follow up blood GSCS An order made to remind the patient or

Febrile

and serum electrolytes

Awake Irritable

specified laboratory tests. Shift paracetamol PO to Shifting of paracetamol from PO to

Tachypneic

paracetamol IVTT 55mg IVTT is most probably ordered either

(+)

q4 prn for fever

significant others to obtain result of the

for faster effect or giving PO is not

intercostal

already feasible due to some factors

retractions

such as irritability. CBC with PC determines the quantity

(+)

nuchal

rigidity 53 | P a g e

For CBC PC

of each quantity of blood cell in a given specimen of blood, often including the

Done

Done

Shifted

Done

UTI resolved

amount of hemoglobin, hematocrit, and the proportion of various white blood cells. This test monitors patient’s condition through blood sample. ABG testing is mainly

For ABG

in pulmonology,

to

used

determine gas

exchange levels in the blood related

Done

to lung function, but has a variety of applications in other areas. Give Epinephrine 0.1ml Epinephrine facilitates air passage by SQ now Compensate

Give

dilating bronchioles in patients on 14

meqs

respiratory distress. of Patient has a significantly

d respiratory NaHCO3 slow IVTT 1:1

bicarbonate

levels

thus

Given

low sodium

alkalosis

dilution now

bicarbonate is given to correct the

7/20/10

abnormality. Transfuse 1 unit PRBC CBC results showed low levels of

Given

55cc of patient’s blood hematocrit, hemoglobin and RBC type after proper cross count. Transfusion was ordered to Transfused matching to run in 4 correct these abnormalities. hours May give

cetirizine Citirizine, an antihistamine is ordered

drops 0.3ml

either due to allergies brought about by the blood transfusion or for the popular

Continue IVF @ SR

Given

lesions and rashes seen on the patient. IVF continues to rehydrate the patient. This also serves as an access for IVTT

Continued

medications. Start Amikacin 82mg It is a bactericidal indicated for the OD IVTT

treatment

of

infections

due

to

susceptible strains of microorganisms, bacterial septicemia and serious and complicated UTIs. 54 | P a g e

Given

7/21/10

Repeat CBC

This is done to evaluate if the blood

4am

transfusion has been enough to correct

Awake

the abnormal levels seen in the previous

Afebrile

CBCs. The potassium

(+) rales

For urine KOH

procedure

Post 1 unit

hydroxide in

hydroxide (KOH)

PRBC

test is

Done

a

which potassium is

used

to

Done

detect fungi by dissolving human cells in a given specimen. Continue IVF at same IVF continues to rehydrate the patient. rate

This also serves as an access for IVTT medications.

55 | P a g e

Done

DIAGNOSTIC EXAMS September 12, 2010 Chest X-RAY The chest x-ray is the most commonly performed diagnostic x-ray examination. A chest x-ray makes images of the heart, lungs, airways, blood vessels and the bones of the spine and chest. An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging. Findings: Minimal hazy sensities are seen in both inner lung zones. The rest of the lungs are clear and well expanded. The heart is within normal size limit. There are no other additional significant remarkable findings. Impression: Bronchopneumonia

56 | P a g e

September 19, 2010 Blood Chemistry Test A procedure in which a sample of blood is examined to measure the amounts of certain substances made in the body. An abnormal amount of a substance can be a sign of disease in the organ or tissue that produces it.

57 | P a g e

Test Test Sodium Glucose

Result Result 141.4 L – 4.0 0

Normal Normal Range 131.00Range 4.10-6.60 145.00

RBS

Clinical Significance Clinical Significance No Clinical Significance Decreased Level:

Rationale Rationale This test is a part of the routine lab This test is done in order to check evaluation of most patients. It is the one

Interpretation Interpretation Within normal Belowrange Normal

Low blood glucose levels indicate

sugar level.which are of the patient’s blood electrolytes,

Range

hypoglycemia is termed as the state produced by a lower than normal level

often ordered as a group. It is also included in the basic metabolic

The Client is

of blood glucose.

panel, widely used when someone

suffering from

has non-specific health complaints,

Hypoglycemia.

and in monitoring treatment involving IV fluids or when there is a possibility of developing dehydration. http://www.labtestsonline.org/ understanding/analytes/ Potassium

4.17

3.6-6.8

No Clinical Significance

uric_acid/test.html Potassium testing is frequently

Within Normal

ordered, along with other

Range

electrolytes, as part of a routine physical. It is used to detect concentrations that are too high or too low . COMPLETE BLOOD COUNT 58 | P a g e

Complete blood count (CBC) gives important information about the kinds and numbers of cells in the blood, especially red blood cells, white blood cells, and platelets. A CBC helps your health professional check any symptoms, such as weakness, fatigue, or bruising, you may have. A CBC also helps him or her diagnose conditions, such as anemia, infection, and many other disorders. DATE: September 11, 2010 Test

Result

Normal Values

Hemoglobin

97

M:140-180 F:120-140

Clinical Significance Decreased level:

Rationale A

hemoglobin

Interpretation test

is

A low hemoglobin is

May indicate anemia from

performed to determine the

referred to as

blood loss, dietary

amount of hemoglobin in a

anemia.

deficiency, malnutrition, person's red blood cells sickle-cell anemia; hemolysis (RBCs). This is important from splenomegaly; kidney

because the amount of oxygen

diseases; systemic lupus

available to tissues depends

erythematosus;

upon how much oxygen is in

malignancies;hemoglobinopa

the RBCs, and local perfusion

thies; or sarcoidosis.

of

the

tissues.

Without

sufficient hemoglobin, the tissues lack oxygen and the heart and lungs must work harder to compensate. Leukocytes

9.1

4-11

No significance

http://www.labtestsonline.org/ A WBC count is normally Within Normal Values. ordered

as

part

of

the

complete blood count (CBC). 59 | P a g e

In some circumstances, a WBC count may be ordered to monitor recovery from illness. http://www.labtestsonline.org/

60 | P a g e

Test

Result

Normal

Neutrophils

0.75

Values 0.50-0.70

Clinical Significance Increased level: May

indicate

bacterial

infection such as otitis media, endocarditis,

or

bacterial

meningitis.

Rationale

Interpretation

Evaluated in relation to total

Above normal range.

WBC count. If neutrophil

The increase in

count is significantly greater

neutrophil count may be

than overall WBC count,

a result of Bacterial

immune function may be poor

Meningitis.

or an overwhelming infection is present.http://www.labtestsonli Lymphocytes

0.50

0.25-0.40

ne.org/ A WBC count is normally

Increased level:

Elevated WBC count can ordered as part of the complete result

from

infections, leukemia,

bacterial blood count (CBC). In some inflammation, circumstances, a WBC count

trauma,

Above Normal Values. The patient has an increase of leukocyte count due to the

intense may be ordered to monitor

inflammation brought

recovery from illness.

about by Bacterial

exercise, or stress.

Meningitis. Eosinophils

0.05

0.02-0.04

http://www.labtestsonline.org/ These measures the number of

Above normal range.

May indicate allergic response

white blood cells called

May be a result of a

such as asthma; parasitic

eosinophils.

Bacterial infection.

infection such as amebiasis;

Eosinophilsbecome active

skin disorder such as shingles;

when you have certain allergic

neoplastic disorder such as

diseases, infections, and other

chromic myelocytic anemia

medical conditions.

Increased level:

and necrosis of solid tumor; 61 | P a g e

pernicious fever;

anemia;

excessive

scarlet

exercise;

http://www.nlm.nih.gov/

autoimmune disease; or a

medlineplus/ency/article/

September 18, 2010 Test Hemoglobin

Result

Normal

90.0

Range 115-175

Clinical Significance

Rationale

Interpretation

Decreased level:

A hemoglobin test is performed to

Below

May indicate anemia from blood loss,

determine

the

amount

of normal range.

dietary deficiency, malnutrition,

hemoglobin in a person's red blood

May indicate

sickle-cell anemia; hemolysis from

cells (RBCs). This is important

anemia.

splenomegaly; kidney diseases;


systemic lupus erythematosus;

available to tissues depends upon

malignancies;hemoglobinopathies; or how much oxygen is in the RBCs, sarcoidosis.

and local perfusion of the tissues. Without sufficient hemoglobin, the tissues lack oxygen and the heart and lungs must work harder to compensate.

Hematocrit

0.27

0.36-0.52

http://www.labtestsonline.org/ This test is given in order to

Below

Low levels of hematocrit are most

measure the concentration of red

Normal

frequently found in anemias and

blood cells in the blood.

Range

leukemias.

Kee, Joyce Lefever. Laboratory and

And is

diagnostic tests with nursing

associated

Decreased Level:

nd

implications. 2 ed. 62 | P a g e

with anemia.

RBC

3.48

4.20-6.10

Appleton&Lange.1987. An RBC count is ordered as a part

Below

A decreased number of RBCs results

of the complete blood count (CBC),

Normal

from either acute or chronic blood

often as part of a routine physical,

Range.

loss. Acute blood loss is a rapid

pre-surgical procedure, or for other

depletion of blood volume. Chronic

clinical reasons. The test is also

May be a

blood loss stems from various

repeated in patients who have

result of

conditions that often results in some

hematologic disorders, bleeding

anemia.

form of an anemia.

problems, chronic anemias,

Decreased level:

polycythemia, and/or patients undergoing chemotherapy or WBC

11.15

5.0-10.0

Increased level:

radiation therapy. A WBC count is normally ordered

Above

Elevated WBC count can result from

as part of the complete blood count

Normal

bacterial infections, inflammation,

(CBC). In some circumstances, a

Range.

leukemia, trauma, intense exercise, or

WBC count may be ordered to

A result of

stress.

monitor recovery from illness.

the inflammation

http://www.labtestsonline.org/

brought about by Bacterial

Neutrophils 63 | P a g e

15

55-75

Decrease in Neutrophils indicates viral

Neutrophil count aids in helping in

Infection. Below

diseases such as chicken pox,

monitoring the immune response

Normal

measles, rubella, and Leukemia and

of the patient.

Range

anemia. May indicate anemia. Lymphocytes

78

20-35

Lymphocytes can increase in cases of It is used to diagnose the severity of viral infection, leukemia, cancer of the bone marrow, or radiation therapy.

Above

infestations with worm and other

Normal

large parasites and response to

Range.

treatments.

May be a


result of the inflammation Brought about by Bacterial

Monocyte

9

2-10


Monocyte levels are checked to

Meningitis. Within

know the increase in response to

Normal

infection of all kinds as well as to

Range

inflammatory disorders. Eosinophil

0

1-8

Decreased Levels: Decreased levels of eosinophils can

64 | P a g e


Below

white blood cells called eosinophils.

Normal

occu occurr as as a resu result lt of infe infect ctio ion. n.

Eosi Eosino noph phil ilss beco become me acti active ve when when

Range.

you have certain allergic diseases, infections, and other medical

A result of a

conditions.

bacterial infection.

http://www.nlm.nih.gov/ medlineplus/ency/article/ Platelet Count

417

150-400

003649.htm Platelet count is ordered To assist in

Above

Increased platelet counts occur in

the diagnosis of bleeding disorders

Normal

polycythemia, and fractures and after

and to monitor patients who are

Range

splenectomy.

being treated for any disease

Increased Level:

involving bone marrow failure. This test determines the number of platelets in the patient’s blood. This test is done to determine the

Within

(Mean

weight of hemoglobin in RBCs,

Normal

Corpuscular

regardless of their size.

Range

Hemoglobin)


MCH

26.0

26.0-32.20


diagnostic tests with nursing implications. implications. 2nd ed. Appleton& MCHC 65 | P a g e

34.0

32.20-36.50


Lange.1987. This is ordered to measure the

Within

(Mean

hemoglobin concentration per unit

Normal

Corpuscular

volume of RBCs.

Range

Hemoglobin


concentration


)

implications. implications. 2nd ed. Appleton&

MCV

Decreased levels may indicate

Lange.1987. This test is done in order to

Below

(Mean

Microcytic anemias( iron-deficiency iron-deficiency

determine the Mean volume of

normal range.

Corpuscular

anemia). Malignancy, Rheumatoid

RBCs.

May be

volume)

Arthritis, Sickle cell Anemia.

78.3

79.00-94.80

indicative of Anemia.

September 19, 2010 Test Hemoglobin

Result

Normal

96.0

Range 115-175


Rationale

Interpretation

Decreased level:


Below


determine

the

amount

of normal range.

dietary deficiency, malnutrition, malnutrition,

hemoglobin in a person's red blood

May indicate

sickle-cell anemia; hemolysis from

cells cells (RBCs) (RBCs).. This This is impor importan tantt

anemia.


bec becau ause se the the amou amount nt of oxyg oxygen en

systemic lupus erythematosus; availabl availablee to tissues tissues depends depends upon upon malignancies;hemoglobinopathies; or how much oxygen is in the RBCs, 66 | P a g e

sarcoidosis.

and lo local pe perfusion of of th the titissues. Without sufficient hemoglobin, the tissues lack oxygen and the heart and and lung lungss must must work work hard harder er to compensate.

Hematocrit

RBC

0.30

3.73

0.36-0.52

4.20-6.10


Below



Normal



Range

leukemias.


And is


associated

implications. implications. 2nd ed. Appleton&

with anemia.

Lange.1987. An RBC count is ordered as a part

Below



Normal



Range.


pre-surgical pre-surgical procedure, or for other



May be a



result of



anemia.

form of an anemia.


Decreased Level:

Decreased le level:

polycythemia, and/or patients undergoing chemotherapy or 67 | P a g e

WBC

15.68

5.0-10.0

Increased level:

radiation therapy. A WBC count is normally ordered

Above



Normal



Range.



A result of

stress.


the inflammation



Neutrophils

Lymphocytes

57

31

55-75

20-35



Neutrophil count aids in helping in

Infection. Within

monitoring the immune response

Normal

of the patient.

Range

It is used to diagnose the severity of

Within


Normal


Range

treatments. Monocyte

2

2-10


http://www.labtestsonline.org/ Monocyte levels are checked to

Within


Normal


Range

inflammatory disorders. 68 | P a g e

Eosinophil

0

1-8


Below

Decreased levels of eosinophils can


Normal

occur as a result of infection.

Eosinophils become active when

Range.

Decreased Levels:


A result of a

conditions.



442

150-400


Above



Normal



Range

splenectomy.


Increased Level:

involving bone marrow failure. This test determines the number of platelets in the patient’s blood. This test is done to determine the

Within

(Mean


Normal

Corpuscular


Range

Hemoglobin)


MCH

28.0

26.0-32.20


diagnostic tests with nursing 69 | P a g e

implications. 2nd ed. Appleton& Lange.1987. This is ordered to measure the

Within

(Mean


Normal

Corpuscular

volume of RBCs.

Range

Hemoglobin


concentration


)

implications. 2nd ed. Appleton&

MCV

Lange.1987. This test is done in order to

Within

(Mean


Normal

Corpuscular

RBCs.

Range.

Rationale

Interpretation

Decreased level:


Below


determine

MCHC

32.3

79

32.20-36.50

79.00-94.80



volume) September 21, 2010 Test Hemoglobin

Result

Normal

104.0

Range 115-175


dietary deficiency, malnutrition, sickle-cell anemia; hemolysis from

the

amount

of normal range.

hemoglobin in a person's red blood May indicate cells (RBCs). This is important anemia.



systemic lupus erythematosus;

available to tissues depends upon

malignancies;hemoglobinopathies; or how much oxygen is in the RBCs, sarcoidosis. 70 | P a g e

and local perfusion of the tissues.

Without sufficient hemoglobin, the tissues lack oxygen and the heart and lungs must work harder to compensate. Hematocrit

RBC

0.33

4.07

0.36-0.52

4.20-6.10


Below



Normal



Range

leukemias.


And is


associated

implications. 2nd ed.

with anemia.

Appleton&Lange.1987. An RBC count is ordered as a part

Below



Normal



Range.


pre-surgical procedure, or for other



May be a



result of



anemia.

form of an anemia.


Decreased Level:

Decreased level:

polycythemia, and/or patients undergoing chemotherapy or radiation therapy. 71 | P a g e

WBC

8.43

5.0-10.0

Increased level:

A WBC count is normally ordered

Above



Normal



Range.



A result of

stress.


the inflammation



Lymphocytes

Monocyte

59

10

20-35

2-10

Increased level:

It is used to diagnose the severity of

Infection. Above

Lymphocyte increase means there is


Normal

viral infection, leukemia, cancer of the


Range

bone marrow, or radiation therapy.

treatments.


http://www.labtestsonline.org/ Monocyte levels are checked to

Within


Normal


Range

inflammatory disorders. Eosinophil

72 | P a g e

0

1-8


Below

Decreased levels of eosinophils can


Normal

occur as a result of infection.

Eosinophils become active when

Range.

Decreased Levels:


A result of a

conditions.



345

150-400


Above



Normal



Range

splenectomy.


Increased Level:

involving bone marrow failure. This test determines the number of MCH

25.6

26.0-32.20

Decreased level:

platelets in the patient’s blood. This test is done to determine the

Below

(Mean

May indicate microcytic anemia or


Normal

Corpuscular

hypochromic anemia.


Range

Hemoglobin)

Kee, Joyce Lefever. Laboratory and diagnostic tests with nursing implications. 2nd ed. Appleton&

MCHC (Mean 73 | P a g e

31.6

32.20-36.50

Decreased level: May indicate iron deficiency anemia

Lange.1987. This is ordered to measure the

Below


Normal

Corpuscular

or thalassemia.

volume of RBCs.

Range

Hemoglobin


concentration


)

implications. 2nd ed.

MCV

Appleton&Lange.1987. This test is done in order to

Within

(Mean


Normal

Corpuscular

RBCs.

Range.

80.8

79.00-94.80


volume) ARTERIAL BLOOD GAS Determination of ABGs is usually ordered to assess disturbances of acid-base balance caused by a respiratory disorder, cardiac failure, drug overdose, renal failure, uncontrolled diabetes mellitus, and other metabolic disorders. September 19, 2010 Test PH

Result

Normal


Rationale

Interpretation

7.39

Range 7.35-7.45


This test is ordered to determine the

Within

acidity and alkalinity of body fluids.

Normal


Range

diagnostic tests with nursing implications. 2nd ed. Appleton& PCO2 74 | P a g e

13.0

35-45

Decreased Level:

Lange.1987. pCO2 measures the adequacy of

Below

PO2

150.0

80-100

Low levels of PCO2 may indicate

alveolar ventilation in view of current

Normal

anxiety, hysteria, hypoxia.

metabolic demands.

Range

Increased Level:

This test reflects the amount of

Above

Elevated pO2 levels are associated

oxygen gas dissolved in the

Normal

with Increased oxygen levels in the

blood. It primarily measures

Range

inhaled air, Polycythemia.

the effectiveness of the lungs in pulling oxygen into the blood stream from the atmosphere.

HCO3

6.5

22.0-27.0

Decreased Level:

http://www.brooksidepress.org/ The HCO3− ion indicates

Below

A low HCO3− indicates metabolic

whether a metabolic problem

Normal

acidosis, a high HCO3− indicates

is present (such as

Range

metabolic alkalosis. HCO3− levels

ketoacidosis).

can also become abnormal when the kidneys are working to compensate for a respiratory issue BE (ECT)

-19.6

(-2)-(+2)

so as to normalize the blood pH. Negative Values of Base Excess

To indicate whether the patient

Negative

may Indicate: Lactic Acidosis,

has metabolic acidosis or

Result

Ketoacidosis, Ingestion of acids,

metabolic alkalosis.

Cardiopulmonary collapse, 75 | P a g e

Shock. O2 SAT

ctC02

98.8

6.9

80-100

23.0-30.0


This measures the percent of

Within

hemoglobin which is fully

Normal

combined with oxygen.

Values

The bicarbonate (or total CO2)

Below

May be due to Addison’s disease,

test is almost never ordered by

Normal

Chronic diarrhea, Diabetic

itself. It is usually ordered

Range

ketoacidosis, Metabolic acidosis,

along with sodium, potassium,

Kidney disease, Ethylene glycol or

and chloride as part of an

methanol poisoning, Salicylate

electrolyte panel. The

(aspirin) overdose.

electrolyte panel is used to

Decreased Level:

detect, evaluate, and monitor electrolyte imbalances. It may be ordered as part of a routine exam or to help evaluate a chronic or acute illness. It may be ordered at intervals to help monitor conditions, such as kidney disease and hypertension, and to monitor the effectiveness of treatment 76 | P a g e

for known imbalances.

Urinalysis The examination of the chemical and physical components of urine is useful in measuring many kidney functions such as acid base balance, electrolyte regulation, and elimination of the products of metabolism. Date: September 11, 2010

CHEMICAL ANALYSIS Test

Result

Normal


Rationale

Interpretation

Glucose

Negative

Values Negative

An excessively high

To help detect if sugar is

Within normal result

glucose concentration in

present in the urine and

the blood, such as may be

determine if patient has

seen with people who

glucosuria.

have uncontrolled diabetes mellitus. A reduction in the “renal threshold.” When blood glucose levels reach a certain concentration, the kidneys begin to excrete glucose into the urine to 77 | P a g e

decrease blood concentrations. Albumin

Negative

Negative

This measures the amount

To help detect traces of

of albumin in the urine.

protein present in the urine

Normally, there will not

and determine if patient has

be detectable quantities.

albuminuria.

Within normal results

When urine protein is elevated, there is a condition called proteinuria; this can be an early sign of kidney Specific gravity

78 | P a g e

1.025

1.010 and

disease. There are no "abnormal"

Knowing the urine

1.030

specific gravity values.

concentration helps health

This test simply indicates

care providers decide if the

how concentrated the

urine specimen they are

urine is. Specific gravity

evaluating is the best one to

measurements are actually

detect a particular substance.

a comparison of the

For example, if they are

amount of solutes

looking for very small

(substances dissolved) in

amounts of protein, a

urine as compared to pure

concentrated morning urine

Within Normal Range

water.

specimen would be the best sample.

Microscopic Examination

79 | P a g e

Test

Result

Normal


Rationale

Interpretation

RBC

0.3/hpf

Values 0 – 3 /hpf

Normally, a few RBCs are

This measures Inflammation,

This means that the patient

present in urine sediment.

injury, or disease in the

Is not experiencing any

Inflammation, injury, or

kidneys or elsewhere in the

injury

disease in the kidneys or

urinary tract.

In the kidneys or in the

elsewhere in the urinary

urinary tract.

tract, for example, in the bladder or urethra, can cause RBCs to leak out of the blood vessels into the urine. RBCs can also be a contaminant due to an improper sample collection and blood from hemorrhoids or EPITHELIAL CELLS

80 | P a g e

Positive

Negative

menstruation. Normally in men and

In urinary tract conditions

There is a presence of

women, a few epithelial

such as infections,

inflammation.

cells from the bladder

inflammation, and

(transitional epithelial

malignancies, more epithelial

cells) or from the external

cells are present. Determining

urethra (squamous

the kinds of cells present

epithelial cells) can be

helps the health care provider

found in the urine

pinpoint where the condition

sediment. Cells from the

is located.

kidney (kidney cells) are less common

September 18, 2010 Test

Result

Normal


Rationale

Interpretation

Glucose

Negative

Values Negative

An excessively high

To help detect if sugar is

Within normal result

glucose concentration in

present in the urine and

the blood, such as may be

determine if patient has

seen with people who

glucosuria.

have uncontrolled diabetes mellitus. A reduction in the “renal threshold.” When blood glucose levels reach a certain concentration, the kidneys begin to excrete glucose into the urine to decrease blood Albumin

Negative

Negative

concentrations. This measures the amount

To help detect traces of

of albumin in the urine.

protein present in the urine

Normally, there will not

and determine if patient has

be detectable quantities.

albuminuria.

When urine protein is elevated, there is a 81 | P a g e

Within normal results

condition called proteinuria; this can be an early sign of kidney Specific

1.025

gravity

1.010 and

disease. There are no "abnormal"

Knowing the urine

1.030

specific gravity values.

concentration helps health

This test simply indicates

care providers decide if the

how concentrated the

urine specimen they are

urine is. Specific gravity

evaluating is the best one to

measurements are actually

detect a particular substance.

a comparison of the

For example, if they are

amount of solutes

looking for very small

(substances dissolved) in

amounts of protein, a

urine as compared to pure

concentrated morning urine

water.

specimen would be the best sample.

Microscopic Examination

82 | P a g e

Within Normal Range

Test Tubex Test RBC

Result

Normal


Rationale

Interpretation

0.3/hpf

Values 0 – 3 /hpf

Normally, a few RBCs are

This measures Inflammation,

This means that the patient

present in urine sediment.

injury, or disease in the

Is not experiencing any

Inflammation, injury, or

kidneys or elsewhere in the

injury

disease in the kidneys or

urinary tract.

In the kidneys or in the

elsewhere in the urinary

urinary tract.

tract, for example, in the bladder or urethra, can cause RBCs to leak out of the blood vessels into the urine. RBCs can also be a contaminant due to an improper sample collection and blood from hemorrhoids or EPITHELIAL CELLS

83 | P a g e

Negative

Negative

menstruation. Normally in men and

In urinary tract conditions

There is no presence of

women, a few epithelial

such as infections,

inflammation.

cells from the bladder

inflammation, and

(transitional epithelial

malignancies, more epithelial

cells) or from the external

cells are present. Determining

urethra (squamous

the kinds of cells present

epithelial cells) can be

helps the health care provider

found in the urine

pinpoint where the condition

sediment. Cells from the

is located.

kidney (kidney cells) are less common

TUBEX (IDL Biotech) is a 5 min semiquantitative colorimetric test for typhoid fever, a widely endemic disease. TUBEX detects anti-Salmonella O9 antibodies from a patient's serum by the ability of these antibodies to inhibit the binding between an indicator antibody-bound particle and a magnetic antigen-bound particle. Result

Score ≤2

Interpretation Guide NEGATIVE- Does not indicate current

3

Typhoid Fever infection BORDERLINE- Inconclusive score, repeat analysis. If still inconclusive repeat sampling

4-5

at a later date. POSITIVE – Indicate of current Typhoid Fever

≥6

infection. POSITIVE – Strong indication of current

INDETERMINATE

Typhoid Fever infection. No Clear score obtained due to: 3.) Poor adherence to assay protocol analysis. 4.) Poor specimen quality. Repeat sampling and analysis.

Cranial Ultrasound Cranial ultrasound uses reflected sound waves to produce pictures of the brain and the inner fluid chambers (ventricles) through which cerebrospinal fluid (CSF) flows. This test is most commonly done on babies to evaluate complications of birth. In adults, cranial ultrasound may be done to visualize brain masses during brain surgery. Date requested : 9/13/10

84 | P a g e

REAL TIME SCANS OVER THE ANTERIOR FONTANEL SHOW A HOMOGENOUS BRAIN PARENCHYMA WITH NO ABNORMAL FOCAL MASS LESIONS. THE GYRI AND SULCI PATTERNS ARE REMARKABLE. THE LATERAL 3 RD AND 4TH VENTRICLES ARE NOT DILATED. NO EXTRA-AXIAL FLUID COLLECTION NOTED.

85 | P a g e

DRUG STUDY Generic Name: Brand Name: Classification: Dosage:

Paracetamol Perfalgan Non-narcotic analgesic, Antipyretic 9/12 180 mg/ml 1.1 ml q4 prn; 0.8 ml q4 prn

Mode of Action:

55 mg IVTT for prn fever Decreases fever by hypothalamic effect leading to sweating and vasodilation. Also inhibits the effect of pyrogens on the hypothalamic heat-regulating centers. May cause analgesia by inhibiting CNS prostaglandin synthesis; however, due to minimal effects on peripheral prostaglandin synthesis, it has no anti-inflammatory or uricosuric effects. Antipyretic and analgesic effects are comparable to those of

Indication:

aspirin Control of pain due to headache, earache, dysmenorrheal, arthralgia, myalgia, musculoskeletal pain, arthritis, immunizations, teething, tonsillectomy; to reduce fever in bacterial or viral infections; as a substitute for aspirin in upper GI disease, aspirin allergy, bleeding

disorders, clients on anticoagulant therapy, and gouty arthritis. Contraindication Contraindicated in patients hypersensitive to drug; renal insufficiency, anemia; clients with cardiac or pulmonary disease Drug

Activated

Interactions:

absorption

charcoal,

Barbiturates,

cholestyramine

carbamezepine,

and

diflunisal,

colestipol:

hydantoins,

Decreased

isoniazid,

rifabutim, rifampin, sulfinpyrazone: Increased risk of hepatotoxicity Hormonal contraceptives: Decreased efficacy Oral anticoagulants: Increased anticoagulant effect Phenothiazines: Severe hypothermia 86 | P a g e

Zidovudine:

Increased risk of granulocytopenia Hematologic: hemolytic anemia, neutropenia,

Side/

Adverse

Effects:

leukopenia,

pancytopenia Hepatic: jaundice Metabolic: hypoglycemia

Nursing

Skin: rash urticaria 1. Assess vital signs. 2. Document presence of fever.

Responsibilities:

3. Instruct the client’s mother to give the drug only for complaints indicated. 4. Tell the client’s mother not to exceed the recommended dose; do not take longer for 10 days. 5. Encourage the client to avoid using other over-the-counter drug preparations; if the client needs an OTC preparation, instruct the client to consult the health care provider. 6. Discuss with the client the possible side effects of the drug. 7. Reassess the vital signs to evaluate the efficacy of the drug. 8. If any of the side effects occur, report it immediately to the physician. Generic Name: Brand Name: Classification: Dosage:

Ceftriaxone sodium Rocephin Antibiotic 9/12- 183 mg IVTT q8 ANST

Mode of Action: Indication:

9/12 550 MG OD Bactericidal: Inhibits bacterial cell wall synthesis, causing cell death. Lower Respiratory tract infections caused by Streptococcus •

pneumoniae, Staphylococcus aureus, Haemophilus influenza, 87 | P a g e

Escherichia coli, and Proteus mirabilis. •

UTI caused by E.coli, Klebsiella, Proteus vulgaris, P. mirabilis.

•

Meningitis caused Streptococcus pneumoniae, Haemophilus influenza.

•

Dermatologic infections caused by Klebsiella, S. aureus, P. mirabilis.

•

Bone and joint infection caused by by Streptococcus pneumoniae, Staphylococcus aureus, Escherichia coli, Klebsiella pneumonia, Proteus mirabilis and Enterobacter.

Contraindication Drug

Contraindicated with allergy to cephalosphorins or penicillins. Increased nephrotoxicity with aminoglycosides. •

interactions: •

Increased bleeding effects with oral anticoagulants.

•

Disulfiram-like reaction may occur if taken within 72 hr after ceftriaxone administration.

Side/

Adverse

Effects:

CNS: headache, dizziness, lethargy GI: nausea, vomiting, diarrhea, abdominal pain, flatulence, hepatotoxicity GU: nephrotoxicity Hematologic: decreased WBC, platelets and Hct

Nursing Responsibilities:

88 | P a g e

Hypersensitivity: ranging from rash to fever to anaphylaxis 1. Ask the mother if the client has any history of allergy with the drug.

2. Tell the client to receive the full course of therapy as prescribed. 3. Have vitamin K available in case of hypoprothrombinemia occurs. 4. Do not mix it with other antimicrobial drugs. 5. Discontinue if hypersensitivity reaction occurs. 6. Discuss the possible side effects to the client like stomach upset or diarrhea. 7. Do not double dose the drug. 8. Report any unusualities to the physician immediately.

Generic Name: Brand Name: Classification: Dosage:

Albuterol sulfate Salbutamol Bronchodilator 9/19 -1 nebule q1

Mode of Action:

9/19- 1 nebule q4 Acts relatively selectively at beta2- adrenergic receptors to cause

Indication: Contraindication

bronchodilation and vasodilation Inhalation: Treatment of acute attacks of bronchospasm Hypersensitivity to albuterol; tachycardia, tachyarrythmisa caused by digitalis intoxication; hypertension, coronary insufficiency, CAD,

Drug interactions:

89 | P a g e

COPD patients with degenerative heart disease. Decreased bronchodilating effects with beta-adrenergic blockers •

•

Decreased effectiveness of insulin, oral hypoglycaemic drugs

•

Decreased serum levels and therapeutic effects of digoxin

•

Increased risk of toxicity when used with theopylline and aminophylline

•

Increased symphatomimetic effects with other symphatomimetic drugs

Side/ Adverse Effects:

•

CNS: restlessness, anxiety, fear, tremor, drowsiness, weakness, vertigo, headache

Nursing Responsibilities:

•

CV: cardiac arrhythmias, tachycardia, palpitations, angina pain

•

GI: nausea, vomiting, heartburn

•

Respiratory: coughing, bronchospasm

1. Ask the client’s mother if the client has any history of allergy with the drug. 2. Instruct the mother not to exceed recommended dosage of the drug because it may loss its effectiveness or may cause adverse effects. 3. Explain the possible side effects of the drug like dizziness, drowsiness, fatigue, rapid heart rate, nausea and vomiting. 4. Encourage mother to feed her child to avoid vomiting. 5. Assist the client in performing his daily activities because it may cause drowsiness and dizziness. 6. Instruct the mother to perform oral care for the child to avoid changes in taste.

90 | P a g e

7. Perform gentle back tapping after the administration of the drug through inhalation.

Generic Name

Cefuroxime

Brand Name Classification Suggested Dose Mechanism of

Aeruginox Second Generation 125/5 ml tid Second-generation cephalosporin that inhibits cell-wall synthesis, promoting

Action Indication

osmotic instability; usually bactericidal. Serious lower respiratory tract infection UTI, skin or skin-structure •

infections, bone or joint infection, septicemia, meningitis, and gonorrhea •

Perioperative prevention

•

Bacterial exacerbations of chronic bronchitis or secondary bacterial

infection of acute bronchitis •

Acute bacterial maxillary sinusitis

•

Pharyngitis and tonsillitis

•

Otitis media

•

Uncomplicated UTI

•

Early Lyme disease

•

Impetigo Contraindicated in patients hypersensitive to drug or other cephalosporins.

•

Use cautiously in patients hypersensitive to penicillin because of possibility

•

Contraindication

of cross-sensitivity with other beta-lactam antibiotics. •

Use cautiously in breast-feeding women and in patients with history of colitis or renal insufficiency.

Drug Interaction 91 | P a g e

•

Drug-drug.

o

May cause synergistic activity against some

Aminoglycosides:

organisms; may increase nephrotoxicity. Monitor patient’s renal function closely. o

Loop diuretics:

May increase risk of adverse renal reactions.

Monitor renal function test results closely. o

Probenicid:

May inhibit excretion and increasecefuroxime level.

Probenicid may be used for this effect. •

Drug-food.

•

Any food: may increase absorption. Give drug with food. CV: phlebitis, thrombophlebitis

•

GI: diarrhea, pseudomembrabous colitis, nausea, anorexia, vomiting.

•

Hematologic:

o

Side/Adverse Effects

hemolytic

anemia,

thrombocytopenia,

transient

neutropenia, eosinophilia •

Skin: maculopopular and erythematous rashes, urticaria, pain,

induration, sterile abscesses, temperature elevation, tissue slaughting at I.M. injection site. •

Other: anaphylaxis, hypersensitivity reactions, serum sickness.

Nursing

1. Before giving the drug, ask the mother if her child is allergic to

Responsibilities

penicillins or cephalosporins. 2. Absorption of oral drug is enhanced by food. 3. Monitor patient for signs and symptoms of superinfection. 4. Tell patient’s mother to give the drug as prescribed even after he feels better. 5. Do not double dose the drug.

92 | P a g e

6. Explain the possible side effects of the drug like nausea and vomiting. 7. Report any unusualities immediately if it occur.

Generic Name Brand Name Classification Suggested Dose Mechanism

Sodium Bicarbonate Neut Alkanizer 14 mEqs to provide bicarbonate ion which neutralizes hydrogen ion ofDissociates

Action Indication

concentration and raises blood and urinary pH Metabolic acidosis, Systemic or urinary alkalanization, Antacid, Cardiac

Contraindication

Arrest Alkalosis, hypernatremia, severe pulmonary edema, hypocalcemia, unknown

Drug Interaction

abdominal pain Decreased effect/levels of lithium, chlorpropamide, methotrexate, •

tetracyclines, and salicylates due to urinary alkalinization •

Increased toxicity/levels of amphetamines, anorexiants,

mecamylamine, ephedrine, pseudoephedrine, flecainide, quinidine, quinine due to urinary alkalinization Side/Adverse Effects CNS: tetany CV: edema Metabolic:

hypokalemia,

metabolic

hyperosmolarity with overdose Skin: pain and irritation a injection site 93 | P a g e

alkalosis ,

hypernatremia,

Nursing Responsibilities

1. To avoid risk of alkalosis, obtain blood pH, partial pressure of arterial oxygen, partial pressure of arterial carbon dioxide, and electrolyte levels. Tell prescriber laboratory results. 2. Monitor the cardiac rhythm carefully during I.V. administration. 3. Tell patient’s mother not to let the child take drug with milk because doing so may cause high levels of calcium in the blood, abnormally high alkalinity in tissues and fluids, or kidney stones. 4. Inform about milk-alkali syndrome (characterized by hypercalcemia caused by repeated ingestion of calcium and absorbable alkali) if use is long-term. 5. Observe for extravasations when giving I.V. 6. Explain the possible side effects of the drug, like pain and irritation in the injection site. 7. Report to the physician immediately if unusualities occur.

Generic Name Brand Name Classification Suggested Dose Mechanism Action

Cetirizine Hydrochloride Histrine Antihistamine 0.3 drops prn histamine (H1) receptor antagonist; inhibits histamine release and ofPotent eosinophil chemotaxis during inflammation, leading to reduced swelling and

decreased inflammatory response. Management of allergic rhinitis, treatment of idiopathic or chroni urticaria Indication Contraindication Contraindicated with allergy to any antihistamines, hydroxyzine Side/Adverse Effects CNS: somnolence, sedation CV: edema

94 | P a g e

GI: nausea, diarrhea, abdominal pain, constipation Respiratory: bronchospasm

Nursing

fever, rash 1. Ask the mother if the client has any history of allergy with the drug.

Responsibilities

2. Instruct to take the drug as prescribed.

Other :

3. Tell the mother not to double dose the drug. 4. Give without regards to meal. 5. Encourage adequate intake of fluids. 6. Explain the possible side effects of the drug such as sedation, fever and rash. 7. Provide skin care if urticaria had occur. 8. Report any unsualities if it occur. Generic Name: Brand Name: Classification: Dosage: Mode of Action:

Amikacin sulfate Amikacil Aminoglycoside 82 IVTT OD Bactericidal; inhibits protein synthesis in susceptible strains of gramnegative bacteria and the functional integrity of bacterial cell membrane

Indication:

appears to be disrupted, causing cell death. Treatment of the following infections due to susceptible strains of microorganisms: Bacterial septicemia including neonatal sepsis; serious infections of the respiratory tract; infections of the bones and joints; intra-abdominal

infections

including peritonitis; burns and

postoperative infections; serious and complicated urinary tract infections due to susceptible organisms. Contraindication 95 | P a g e

Hypersensitivity to aminoglycosides.

Drug interactions:

•

Increased ototoxic and nephrotoxic effects with potent diuretics and similarly toxic drugs.

Risk for inactivation if mixed with parenteral penicillins. Adverse CNS: ototoxicity, visual disturbances, lethargy, muscle twitching, tremor, •

Side/ Effects:

apnea CV: palpitation GI: nausea, vomiting, diarrhea, stomatitis GU: nephrotoxicity Hematologic:

electrolyte disturbances, haemolytic anemia, anemia,

thrombocytopenia, leukopenia, Hepatic:

hepatic toxicity

Hypersensitivity:

rash, urticaria, itching

Other: pain at the injection site Nursing Responsibilities:

1. Ask the mother if the client has any history of allergy with the drug. 2. Ensure that the patient is well hydrated before and during the therapy; encourage increase oral fluid intake. 3. Instruct the mother to give frequent oral care to the child. 4. Explain the possible side effects of the drug like nausea, vomiting and dizziness. 5. Report any unusalities immediately to the physician.

96 | P a g e

Generic Name: Brand Name: Classification:

Epinephrine hydrochloride Uni-amp Sympathomimetic, alpha adrenergic agonist, beta adrenergic agonist, cardiac stimulant,

Dosage: Mode of Action:

vasopressor, bronchodilator, anti-astmatic 0.1 ml SQ now Epinephrine, an active principle of the adrenal medulla, is a directacting sympathomimetic. It stimulates α- and β-adrenergic receptors resulting in relaxation of smooth muscle of the bronchial tree, cardiac stimulation and dilation of skeletal muscle vasculature. It is frequently added to local anaesthetics to retard diffusion and limit absorption, to

Indication:

prolong the duration of effect and to lessen the danger of toxicity. INJECTION: relief from respiratory distress of bronchial asthma, chronic

Contraindication

bronchitis, emphysema and other COPDs Preexisting hypertension; occlusive vascular disease; angle-closure glaucoma (eye drops); hypersensitivity; cardiac arrhythmias or tachycardia. When used in addition to local anaesthetics: Procedures

Drug interactions:

involving digits, ears, nose, penis or scrotum. Increased sympathomimetic effects with other TCAs •

•

Excessive

hypertension

with

beta-blockers,

propanolol,

furazolidone •

Decreased cardio-stimulating and bronchodilating effects with beta adrenergic blockers

•

Decreased vasopressor effects with chlorpromazine

•

Decreased guanethidine

97 | P a g e

antihypertensive

effects

with

methyldopa,

Side/

Adverse

Effects:

CNS: fear, drowsiness, lightheadedness, weakness CV: arrhythmias GI: nausea, vomiting GU:

dysuria,

urinary

retention,

decrease

Other:

pallor, respiratory difficulty, sweating

urine

formation

necrosis at sites of repeat injection 1. Do not exceed the recommended dosage; loss of effectivess or

Local: Nursing Responsibilities:

adverse effects may result. 2. Ensure that the drug solution should be clear and colorless, do not use pink or brown solution. 3. Protect the drug solution from extreme light, extreme heat and freezing. 4. Rotate subcutaneous injection sites to prevent necrosis. Monitor it frequently. 5. Monitor client’s cardiac rate. 6. Have an alpha-adrenergic blocker readily available if pulmonary edema occurs or a beta- adrenergic blocker in case of cardiac arrhythmias. 7. Explain the possible side effects of the drug like drowsiness, nausea, vomiting and fast heart rate. 8. Observe for unusualities and if it occurs, notify the physician immediately.

NURSING THEORIES 98 | P a g e

Florence Nightingales’s Environmental Theory Florence Nightingale, the lady with the lamp defined nursing as, “the act of utilizing the environment of the patient to assist him in his recovery.”

This theory focuses on changing and

manipulating the environment in order to put the patient in the best possible conditions for nature to act. She identified 5 environmental factors: fresh air, pure water, efficient drainage, cleanliness/sanitation and light/direct sunlight. Any deficiencies in these 5 factors produce illness or lack of health, but with a nurturing environment, the body could repair itself. In the case of our client, he has an infection, so he really needed a clean and sound environment conducive for his healing. He was admitted at SPMC Pediatric ward-IMCU, as observed the ward’s cleanliness was well maintained by the utility men but there are a lot of patients who occupied the ward so, sometimes the cleanliness of the place is compromised. Also, sometimes there are rats that can be seen around the ward that made it not so conducive for the healing process. The client was able to drink fresh water and was able to breathe fresh air since her bed is located near the window. The hospital has an efficient drainage system, as well. The client was not able to get direct sunlight since he was not allowed to go out the hospital premises. Lydia Hall’s Care, Core, Cure Theory Hall defined nursing , “participation in care, core cure aspects of patient care where care is the sole function of the nurses, whereas the core and cure are shared with other members of the health team.”

The major purpose of care is to achieve an interpersonal relationship with the

individual to facilitate the development of core.

99 | P a g e

KEY CONCEPTS OF 3 INTERLOCKING CIRCLES:

CORE

THE PERSON THERAPEUTIC USE OF SELF

CARE

THE BODY THE INTIMATE BODILY CARE

CURE

THE DISEASE SEEING THROUGH THE MEDICAL CARE

We student nurses did our best to render the quality nursing care we could offer to our client. We offered ourselves to his and are always there to lend a hand whenever he and his mother needed help. Our client is our concern and we must aid him in his recovery. In the case of our client, we had given his mother health teachings especially regarding the breastfeeding and its benefits, since his mother stopped breastfeeding the child. Also, since the client is dependent to his parents, they must be there all the time to help the child in doing his activities of daily living. Together with the other members of the health team, as student nurses, we had cooperated with them in giving the quality care our client needed. We help out in carrying out the doctor’s orders giving to follow intravenous fluid for the client. A collaborative work between the physicians and nurses is very significant in the disease process, and is very important for faster recovery of the patient but without the patient’s cooperation and as well as the significant others, we health care providers will not be able to

100 | P a g e

render the best care we could possibly give to the client so relationship between the client and health team is also essential. Since the major purpose of the care is to achieve an interpersonal relationship with the individual that will facilitate the development of the core, our client; in our case, we had developed a good working relationship with our colleagues in the hospital, especially with the staff nurses and together we had implemented our different plans of care for the alleviation of the client’s situation. In order to achieve our goals in caring for our client it‘s really important to develop a sense of unity and of course communication between colleagues is also very significant all throughout the nursing process. Virginia Henderson’s Definition 14 Basic Needs Henderson defined nursing as: “assisting the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that an individual would perform unaided if he had the necessary strength, will or knowledge”. She

formulated a

nursing theory which focuses on person’s basic needs and he enumerated 14 basic needs that a person must possess. The following are the14 basic needs: 1.

Breathing normally

2.

Eating and drinking adequately

3.

Eliminating body wastes

4.

Moving and maintaining desirable position

5.

Sleeping and resting

6.

Selecting suitable clothes

7.

Maintaining body temperature within normal range

101 | P a g e

8.

Kee Keeping th the bod bodyy cl clean an and we well-gro groome omed

9.

Avo Avoiding dange ngers in the envir vironm onment

10.

Comm ommunicat cating with others

11. 11.

Wors Worshi hipp ppiing acc accor ordi ding ng to one’ one’ss fai faitth

12.

Worki Working ng in in such such a way way that that one one feels feels a sense sense of of acco accomp mpli lishm shment ent

13.

Play Playin ing/ g/par parti tici cipat patin ingg in in vari various ous form formss of of rec recrea reati tion on

14.

Learni Learning, ng, disc discover overing ing or satis satisfyi fying ng the the curi curiosi osity ty that that leads leads to norm normal al devel developm opment ent

and health and using available health facilities. The first 9 components are physiological. The tenth and fourteenth are psychological aspects of communicating and learning. The eleventh component is spiritual and moral. The twelfth and thirteenth components are sociologically oriented to occupation and recreation. Henderson believed nursing as primarily complementing the patient by supplying what he needs in knowledge, will or strength to perform his daily activities and to carry out the treatment prescribed for him by the physician. In the case of our client he is only four months old and we would understand why he couldn’t meet all of these needs discussed by Henderson. The client was able eliminate her body wastes. The client also had an adequate rest and sleep. Her mother chose suitable clothes for him and kept him well- groomed all the time. Furthermore, he was also able to participate in play suitable for her age. The client was also fed as necessary and the client can also communicate with her parents through her gesture and actions. But since the client was too young to understand everything, he was not able to meet the 14 basic needs, he was not able to worship according according to her own belief, he doesn’t work, and he has not yet learned on his own the available medical facilities that he could utilize for his

102 | P a g e

recovery and lastly, he couldn’t avoid the dangers that the environment may bring by himself. The client was also tachypnic most of the time and he was not able to maintain his desirable position or move freely since he had nuchal rigidity.. Lastly, he was not able to maintain his normal body temperature when we have handled him.

103 | P a g e

NURSING CARE PLAN

Date 09/22/10 3-11

Cues OBJECTIVE: •

5:30pm

•

•

•

Needs Nursing Diagnosis Plan of Care A Impaired Gas After 2 hours of nursing

Respirator

C

Exchange related to care, the patient will:

y rate of

T

bronchospasms

59 cycl cycles es

I

per

Evaluation GOAL MET

depth and ease.

09/22/10

Demonstrate

R:

® A state in which

improved

resp respiirato ratory ry

V

an

ventilation; ventilation; and,

depen depende dent nt on the degre degreee of nursing care, the

minute.

I

unable

Exhibit absence

lun lung

Tachypnea

T

secretions

of symptoms of

unde underl rlyi ying ng

noted.

Y

obst obstru ruct ctio ions ns

respiratory

status.

Rales

&

the respirat respiratory ory tract tract

heard

E

to maint maintain ain airway airway

R: Tach Tachyc ycar ardi diaa is usua usuall llyy

improved

upon

X

patency.

present as a result of fever or

ventilation;

auscultatio

E

dehydration dehydration but may present as

and

Restlessne

R

Gulan ulaniick, ck,

ss

C

Nursing Care Plans.

and

I 104 | P a g e

Nursing Interventions 1. Assess Assess resp respira irato tory ry rate, rate,

individual to

•

is clear or from from

et.

al. al.

•

distress.

Manifestations

of

distr istreess

inv involvem lvemeent

are

in

gene genera rall

7:30pm After 2 hours of

the the patient was able

heal health th

to: Demons

•

trate

2. Monitor heart rate.

•

a response to hypoxemia. 3. Mon Monitor itor

temperature

body body

as

Exhibit

absence of symptoms of

•

•

•

irritability

S

noted.

E

indicated.

respirator

result of increased metabolic

Labored breathing

P

and oxygen demand and alters

noted

A

cellular oxygenation.

Intercostal

T

retraction

T

noted

E

R: Cyanosis is a general sign

Nasal

R

that

flaring

N

experiencing an increase in

noted.

distress

R: Elevated temperature is a •

pm •

noted

and nail beds.

is

•

oxygen demand.

bronchodilators indicated. R: Bronchodilators facilitate air passage by dilating the airways allowing more oxygen

Patient asleep

already

5. Administer

105 | P a g e

Labored

breathing not

4. Observe color of skin

patient

RR=33c

as

to be inhaled. 6. Administer

oxygen

inhalation as ordered. R: O2 reinforcement

can

compensate for the increased oxygen demand of the patient. 7. Elevate

head

encourage

and

position

changes. R: These measures promote maximal

inspiration

to

promote ventilation. 8. Promote comfort and decrease stimuli. R: Restlessness and irritability of the the patient could increase oxygen demand thus 106 | P a g e

comfort measures should be observed.

Date

Cues

September OBJECTIVE: 107 | P a g e

Need A

Nursing

Plan of Care

Diagnosis Ineffective At the end of the 2

Nursing Interventions 1. Determine factors related

Evaluation GOAL MET

14, 2010

•

@ 11pm

11-7

C

tissue perfusion hours

obin (115-

T

related to low intervention,

175 g/Dl)=

I

hemoglobin

90

V

concentration in will be able to:

2. Note customary baseline

At the end of 2

RBC

I

blood

data.

hours of nursing

(4.20-6.10)=

T

awareness and

® To provide comparison

care, the patient’s

3.48

Y

R: A decrease

understanding

with current findings

mother was able

-

in

of the

3. Review laboratory

to:

crit (0.36-

E

results in the

existence of

studies.

•

0.52)= 0.27

X

failure

to

the condition

® To serve as a scientific

awareness and

Weak

E

nourish

the

and measures

basis for the problem.

understanding

peripheral

R

tissues at the

that can

4. Encourage for a quiet

of the

pulses

C

capillary level.

improve

and restful atmosphere.

existence of

I

Nurses’ Pocket

circulation

® To conserve energy and

the condition

lowers tissue oxygen

and measures

demands

that can

5. Inform significant others

improve

•

•

•

Hemato

•

Pallor

•

CRT=3s

ec

108 | P a g e

Hemogl

nursing

to individual situation.

September

the

® To assess causative

2010 @ 1am

mother

factor of the condition

patient’s

•

oxygen

S

guide

E

Doenges et.al.

by

Verbalize

15,

Verbalize

P

to reduce stimulation and

circulation,

A

stress to the patient.

“Ahh ok, ana

T

® This limits oxygen

man diay no?

T

demand and promotes

sige, himuon

E

conservation of energy.

nako tong

R

6. Place pillow under

imong gi-

N

patient’s lower legs when

ingon.”, as

the patient is sleeping.

verbalized by

7. ® This helps in the

patient’s

promotion of good

mother.

circulation and increases sense of comfort. 8.

Discuss with the

significant other the importance of adherence to diet regimen. ® Proper diet will promote 109 | P a g e

necessary nutrients that would be helpful in maintaining proper circulation.

9. Promote position changes and discourage staying at the same position for a long period of time. ® Helps in maximization of tissue perfusion.

10.

Discuss ways to

improve circulation such as intake of iron rich vitamin syrups and nutritious milk. ® It is effective in increasing hemoglobin 110 | P a g e

levels, which relieves the clinical manifestations of the disease.

11.

Administer

medications with precautions. ® Drug response, half-life and toxicity levels may be affected by altered tissue perfusion.

111 | P a g e

September

Hyperthermia r/t

Within my 4 hours

N

increase metabolic,

span of care, the

U

presence of Bacteria

patient will maintain

“ Murag init lagi

T

in the body

core temperature

akong anak Sr.”

R

secondary to

within normal range

verbalized by the

I

Bacterial Menigitis

mother.

T

13, 2010 @

Subjective:

5:00 am

11/7

Objective:

®

O

Meningitis

to the client. ® to gain trust and cooperation

2. Monitor vital signs and recorded.

Bacterial is

the

inflammation of the

data of the patient’s health condition

3. Administer antipyretic as

Vital signs taken as

A

protective

prescribed.

Follows:

L

membranes covering

® For therapeutic relief and

the brain and spinal

it is given to reduce fever

T 38 PR 132

M

cord,

known

4. Promote surface cooling by

RR 46

E

collectively as the

means of cool environment,

T

meninges caused by

by letting the Mother use a

•

flushed skin

A

bacteria.

fan. (heat loss by

•

warm to

B

Hyperthermia is a

evaporation and conduction)

touch

O

systemic response to

® to assist with measures to

lips are dry

L

invading

reduce body temperature

I

that enter the body,

C

thus the body tries to

•

112 | P a g e

Establish rapport

® It serves as a baseline

I

N

1.

viruses

5. Monitor heart rate and rhythm

Date /

Cues

Need

Nursing Diagnosis

Objective of Care

Nursing Intervention

Evaluation

Time Septemb er 14,

N

Altered nutrition: less At a span of 4 1. Document patient’s

U

than body requirements hours of nursing

actual weight.

Low BMI

T

related to inability to intervention:

Documenting

(14.3 kg/m2)

R

actual weight can

Patient’s

Aversion or lack

I

amounts of food.

tolerate oral

determine the

understand

of interest in

T

feedings, and

weight lost.

importance

eating

I

•

Constant crying

O

A state in which an

•

Inadequate food

N

OBJECTIVE: •

2010 •

117

intake; bottle fed. •

Perceived

procure

inadequatea. The client will

R:

b. The client and

•

175) •

Low RBC count: 3.73 (4.20-6.10)

113 | P a g e

family the of

adequate nutrition to

weekly. Evaluates

their son, especially

individual’s intake of

members will

the patient’s

on the importance of

A

nutrients is insufficient to

communicate

progress.

breast milk. Still,

L

meet metabolic needs.

understanding

&

Ref: Nursing

Low hemoglobin: 96.0 g/L (135-

PARTIALLY MET

family

inability to ingest food

2. Weigh patient

GOAL

M

Gulanick

E

edition.

Care et.

al.,

Plans, 3rd

3. Monitor or explore

of special

attitudes toward

dietary needs

eating/food. Many psychological, psychosocial, and cultural factors

T

determine the type,

A

amount, and

B

appropriateness of

O

food consumed.

L

4. Document appetite.

client is still bottle fed.

Date/Time

Cues

Need

Nursing Diagnosis

Objective of

Nursing Interventions

With ®

Care

With Rationale

for

injury

Within 4 hours

1. Ascertain knowledge of

Goal met

to

span of care the

safety needs and injury

8:00 pm

/ shift September

H

Risk

Sometimes

E

related

infant was left

A

developmental age

unattended in

L

secondary

@

an elevated

T

bacterial

4:00 pm

surface.

H

meningitis.

22,

Objective cues: •

2010

3

11

shift

114 | P a g e

to

Be free from injury

than 1 year

P

exploring

old (4 months

E

their

old)

R

Young children do

•

Restless

C

not learn simply

•

Irritable

E

by

able to: •

® Infants learn by

Infant less

•

client will be

with bodies.

being

told

P

something.

T

discover meaning.

I

It is important that

O

they have as many

N

chances to explore learn

They

Enhance his safety through environment modification as indicated

prevention.

Within 4 hours

® To prevent injury in the

span of care, the

hospital setting.

client was able

2. Monitor

the

environment for potentially unsafe

conditions

and

to be free from injury and the significant others was able

modify as needed. ® Monitoring helps in identifying the hazards that

to

modify

environment that had help

the environment may

enhance client’s

cause.

safety. 3. Instruct the mother to place pillow on baby’s both side. ® To prevent falls.

-

and

H

possible.

They

4. Position

E

must

this

comfortably at the center of

do

as

•

Evaluation

the

client

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DISCHARGE PLAN Medication

1.

Encourage Parents of the client to take the full course of the prescribed medications.

Abide with all ordered medications ® Medications are being prescribed in order to promote healing and recovery from the current condition of the patient, as well as to prevent any further complications. 2.

Stress that over the counter drugs or self medication should not be practiced especially if

it is somehow unfamiliar, it is better to consult the physician first. ® Unprescribed medications may interact with the ones prescribed by the physician which may decrease or increase the effect. Some drugs are not compatible with the prescribed drug. Notify physician if an over the counter drug is to be taken. 3.

Warn about the possible side effects and adverse effects of the medications given.

® Side effects are those expected of the drugs aside from its main effect or affection; Adverse effects are those that are life threatening. Explanation will make the patient aware of the possible unusual developments brought about by the drugs being prescribed. 4.

Tell the client and significant others to report immediately any adverse reactions towards

the drugs. ® Relieves apprehensions about the drugs and prevents worsening of the clients physical and mental condition. 5.

Instruct client that it is important to check the expiration date of the drugs.

® Ensures that the drug still aiding in the recovery of the client. Drugs that are expired are no longer helpful and it may result to many untoward effects and complications.

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Exercise

1.

Encourage significant others to perform play activities or therapy to the child. R: To develop the fine motor adaptive behavior, gross motor behavior and personal-

social behavior of the child and to promote circulation in the body. Treatment

1.

Give the client and significant other information about the disease and the possible

treatment applicable after hospitalization ® Giving the client and significant others an overview of the disease process and treatment available for her particular condition so that client as well as significant others may be able to know the DO’S and the Don’ts for caring the patient. 3.

Explain to the significant others why and how the current treatment procedures should be

done and the purpose of treatment to be continued at home. ® Reduces the level of anxiety of the Parents and significant others and promotes cooperation and makes the client and significant others aware that the treatment may be continued at home to achieve optimal recovery. HealthTeaching

1.

Provide knowledge about current illness of the child to his significant others

® Bacterial meningitis is a life-threatening illness that results from bacterial infection of the meninges. The more the significant others can understand it, the more they can participate in the treatment of their child and in order for them to prevent the possibility for it to reoccur. 2.

Encourage significant others to promote proper hygiene to the child.

® This will aid to prevent in acquiring certain diseases and to prevent the recurrence of Bacterial Meningitis.

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4.

Encourage significant others to help the child get plenty of rest.

® Adequate rest is important to maintain progress toward full recovery and to avoid relapse. 3.

Encourage significant others to maintain a comfortable and clean environment.

® A comfortable and clean environment is conducive for recovery and promotes relaxation. Out patient

1.

Instruct patient to have regular check-ups

® Allows the physician to continually monitor and evaluate the client’s overall condition. 2.

Keep all of follow-up appointments.

R: Vision and auditory testing should be done in order to provide early interventions to prevent developmental delays. 3.

Advice Parents to seek for medical advice and inform the physician for any abnormalities

noted. R: To prevent further complications in the long run. Diet

1. Encourage mother to always breastfeed the baby if possible ® Breast milk provides the natural nutrients that the child needs for growth and development.

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PROGNOSIS GOOD FAIR POOR

Onset of the

√

illness

JUSTIFICATION

There is an acute manifestation of illness. Signs and symptoms of the illness were seen 3 days prior to admission in a local hospital in Prosperidad, Agusan del Sur.. These symptoms include productive cough, intermittent fever, nausea and vomiting, abdominal distention and irritability lead to admission. The patient was then referred to Southern Philippine

Medical

Center where

additional manifestations of illness such as nuchal rigidity and seizure were observed. These additional manifestations relate that the infection Duration of illness √

has already affected the CNS. The illness of the patient started only this month. Acute symptoms appearden the. Abrupt and sudden manifestations such as fever, irritability and nausea and vomiting appeared during the 1st week of September. Upon referral to SPMC last September 11, 2010, more symptoms related to the illness appeared including nuchal rigidity and the onset of seizure. The seizure experience by the patient lead to his admission to the Pediatric Intensive Care Unit. Upon follow-up, the patient is back at the

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Pediatric Ward.

Precipitating

√

Only one precipitating factor is present in the

factors

patient. However, this precipitating factor is one of the major causes of the development of his illness. The respiratory infection he had, as evidenced by productive cough and crackles upon auscultation served as the gateway for the bacteria to enter into

Willingness to

the bloodstream. After being admitted and diagnosed with bacterial

√

take medications

meningitis, medication orders and treatment plan

and treatment

was ordered. The patient’s family was able to follow the treatment regimen knowing that this is the best thing for him. This was shown by following the transfer orders from their local hospital to SPMC for further treatment and comanagement. However, the family refused to have a lumbar puncture, the best confirmatory test for

Age

√

bacterial meningitis. The patient is still 4 months old. With his body still on the process of development, he is predisposed to this kind of illness. His immune system is still weak and has a lesser capability to fight off infection.

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Environmental

√

factors

Now that the patient has been transferred to Pediatric ICU, the environment is conducive for achieving optimum health. It is not crowded. It is clean and well-ventilated. On the other hand, The client’s environment is conducive for achieving optimum health. As claimed by the parents, their community is clean and favors for rest and recovery. It is peaceful and calm. Their place is surrounded with trees and is not exposed to the

Family Support

√

pollution of the crowded city. The support given by the family is remarkable. Since the start of the illness, the parents have been very prompt in providing the needs of their only child. They travelled from Agusan del Sur to Davao in order to find treatment to their son’s

Total

condition. Computation: 

Poor: (1*1)/7

= 1/7



Fair: (1*2)/7

=2/7



Good: (5*3)/7

=15/7

Total:

2.57

General Prognosis: 1-1.6 = POOR 1.7-2.3 = FAIR 121 | P a g e

2.4-3.0 = GOOD

Rationale for a Good Prognosis At 4 months old, the patient is at risk for several infections and diseases since his immune system is not yet fully developed. Along with this, his body is not yet fully capable of adapting to the different physiological disturbances in his body. However, this downside of the patient’s situation did not hinder the group from perceiving a good prognosis to his condition. First, during the early signs of the illness, prompt attention was already made by the patient’s family. They immediately seek for medical attention to find out what’s wrong in their child. They even went to Davao for a more concrete and aggressive medical management. In addition, the antibiotic therapy as well as the intensive care rendered greatly helped in managing the patient’s illness. Moreover, the support given by the family is admirable and greatly helps in the whole process. With his improving condition out of the intensive care unit, his chances of recuperating from this illness and improving his health is increase..

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RECOMMENDATION

To the patient. Compliance with the treatment regimen should be recommended, to achieve a good recovery. More importantly, having a healthy lifestyle is recommended for the patient to provide him a proper growth and development. Following treatments and medications is also recommended for an easy restoration of health. The client should be provided with a nourishing environment filled with love and care. The client needs to feel that he is in a safe place surrounded by the people who care for him. The client is encouraged to be given the right nutrition, rest, and activities to aid him during his growth and development. To the patient’s family. The support of each family member is vital for the recovery of the patient. By simply being present during the hospital stays of the patient is enough to feel that he is being cared for. Also, the client’s family should keep update with follow-up check-ups and laboratory tests even after discharge. The family should also be responsible in terms of complying to the medications and other therapeutic regimens in order to facilitate an improving health status of the patient. To the Ateneo de Davao University- College of Nursing. For years the faculty of the College of Nursing has been offering excellent quality education, they are recommended to continue improving and aim for becoming one of the best nursing schools. We appreciate them for assigning us in a remarkable institution for having to expand our experiences in wards. May the Academe continue to serve excellence and yield top professionals in future generations.

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To the Southern Philippines Medical Center. The group would like to recommend the hospital to continue giving better service to their clients. Another recommendation goes to the staff, that they continue being patient and understanding to the clients regardless of their diagnosis and social class. Kinds of treatment and care should be emphasized and considered to different wards and areas. Specifically the Pediatrics ward with patients ranging from neonates to school aged children; they should be treated differently and given care according to their developmental stage. To the student nurses. May we continue to strive hard in attaining success and the best in our exposures. May we continue to provide better care for our patients and enhance our nurse-patient interaction. May we student nurses continue to provide a more concise and comprehensive case presentation and provide optimum care to our patients from the knowledge and learning derived from our lectures in school. Learning to accept and be motivated to improve in our endeavors is an important characteristic a student nurse should possess. We, as student nurses, should still be open to more changes in order to become the best nurses that we can be someday. A lot of practice is expected to student nurses to increase our experience in the work assigned to us. Lastly, may we continue to uphold our legacy and strive for excellence as we continue to integrate both our character and competence.

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Bacterial Meningitis

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