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

A Case Study on
BACTERIAL MENINGITIS
Ms. Loreen S. Marcelo, RN
Clinical Instructor Panelist of the Case Study

Submitted to:

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

Submitted by: [Group 1-A]

25 September 2010

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TABLE OF CONTENTS I. Acknowledgement 3 II. Introduction ..................................................................................................................... 4 III. Objectives (General & Specific) ..................................................................................................................... 6
IV. Patients Data ..................................................................................................................... 8 V. Family Background and Health History ..................................................................................................................... 10

VI. Developmental Data ..................................................................................................................... 14

VII. Definition of Complete Diagnosis ..................................................................................................................... 19

VIII. Physical Assessment ..................................................................................................................... 21 IX. Anatomy and Physiology ..................................................................................................................... 36 X. Etiology and Symptomatology ..................................................................................................................... 36 XI. Pathophysiology ..................................................................................................................... 42
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XII. Doctors Order ..................................................................................................................... 46 XIII. Diagnostic Exams ..................................................................................................................... 55 XIV. Drug Study ..................................................................................................................... 87 XV. Nursing Theories ..................................................................................................................... 102 XVI. Nursing Care Plan ..................................................................................................................... 107
XVII. Discharge Plan (M. E. T. H. O. D.) ..................................................................................................................... 130 XVIII. Prognosis..............132

XIX. Recommendation ..................................................................................................................... 136 XX. References ..................................................................................................................... 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).
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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 patients 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 doctors order obtained from the patients 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 patients disease, Present the etiology and symptomatology of the patients disease, Trace the pathophysiology of the patients 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 clients condition;

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

Justify the clients prognosis according to the different criteria,

Affective: Establish rapport to the patients 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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PATIENTS DATA Personal Data: Patients Name: Age: Gender: Weight: JP 4 months old Male 5.5 kilograms

Birth date: Address: Nationality: Religion: Number of Siblings: Father: Occupation: Educational Attainment: Mother: Occupation: Educational Attainment: Family Income:

May 10, 2010 Purok 7, Barangay 4, Poblacion, San Francisco, Agusan del Sur Filipino Roman Catholic None Bob Utility Man / Janitor High School Undergraduate (Second Year) Marley Sari-Sari Store Vendor High School Undergraduate (Third Year) 9,000 Php (Estimated)

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Clinical/ Admitting Data: Date of admission: Time of admission: Chief Complaint Hospital & Hospital Number: Ward [Room & Bed Numbers]: Attending Physician: Admitting Diagnosis: September 11, 2010 11:40 pm Stomachache and fever Southern Philippines Medical Center [2220291] Pediatric Ward IMCU Dr. Meralyn M. Maduay, M.D. 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 40C 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 8th of September and were asked to return of September 22 since, as explained by the physician, they found a bacteria in the patients 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 JPs 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 didnt 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
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their son. Spiritually, the mother is very submissive to Gods 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 Gods 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 Eriksons Theory of Psychosocial Development Erikson's stages of psychosocial which a development as healthily articulated by Erik pass

Erikson explain eight stages through

developing human should

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 vs. The first stage of Erik Erikson's theory centers Description Achieved or Not Achieved Achieved Justification Our client was just four months old; he is dependent to his parents especially to his mother when it comes to his needs. The client is rich in love from his parents. the They clients the love always needs and

Infants ( 0- 1 on the infant's basic needs year old) being met by the parents. The infant depends on the parents, mother, especially for the food,

provide especially

sustenance, and comfort.

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If the parents expose the child to warmth,

affection. Now that the client is sick, they really do their best to provide the medications the client needed despite the

regularity, and dependable affection, the infant's view of the world will be one of trust. If the parents fail to provide a secure

financial constraints they had. Through needs giving food the and childs most

like

environment and to meet the child's basic need a sense of mistrust will result.

especially love, the child had form sense of security when he was with his parents. He stayed calm and comfy when he was with them.

Freuds Psychosexual Theory of development Stage Oral 1year) stage Description (birth- The oral stage begins at birth, when the oral cavity is the primary Erogenous mouth zone: focus of libidal Achieved or Not Justification The client has

Achieved Achieved

achieved this stage, since observed we that have the

energy. The child, of course, preoccupies

mother bottle fed the child as necessary or when the child

himself with nursing, with the pleasure of

demands it from his

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sucking and accepting things into the mouth. The oral character

mother.

The

erogenous zone is the mouth which means the child feels

who is frustrated at this mother stage, whose to

pleasure as she was being nursed by her mother. The client

refused

nurse him on demand or who truncated

was being bottle fed until hes satisfied and fell asleep as hes sucking the milk from the bottle.

nursing sessions early, is characterized by

pessimism, suspicion sarcasm. overindulged character,

envy, and The oral whose

nursing urges were always and often

excessively satisfied, is optimistic, gullible, and is full of

admiration for others around him. The stage culminates in the

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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 Piagets Theories of Cognitive Development Stage Sensorimotor Stage Secondary Circular Reactions months) Description The first stage of Piagets theory lasts from birth to approximately age two Achieved or Not Achieved Achieved Justification The child has achieved this stage since he has been trying to be more focused in the world. He tries to observe his surrounding and the people around his. Also, he now utilizes his grasping ability in which, as observed, hes been trying to reach out some things and put it on his mouth like when hes being bottle

and is centered on the (4-8 infant trying to make

sense of the world. During the sensorimotor stage, an infants knowledge of the world is limited to their sensory perceptions and motor activities.

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Behaviors are limited to simple motor responses caused by sensory stimuli. Children utilize skills and abilities they were born with, such as looking, sucking, grasping, and

fed he tries to grasp the bottle and put on his mouth.

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. 6th 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 patients height is 62 cm. The patients weight is 5.5 kilograms. Head circumference is 41 centimeters while chest circumference is 38 centimeters. The patients abdominal circumference is 44 centimeters. Skin The patients 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 patients 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 patients 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 ones body parts, the space around ones 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.

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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 vulnerablesuch 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

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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.
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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 bacterial cell membrane are identified by the immune cells of the brain (astrocytes 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.

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ETIOLOGY AND SYMPTOMATOLOGY Etiology

Predisposing Factor Age

Rationale Present/ Absent The anatomical structure of the Present Auditory tube is different in children below 2-3 years of age. Children of this age have a more horizontal auditory tube leading to the pharynx which increases the likelihood of ear infection that may lead to meningeal infection. (Medical-surgical nursing: an

Justification The patient is 4 months old.

integrated approach by Lois White, Underdeveloped immune system Gena Duncan) Infancy is a factor which makes a Present person more susceptible to meningitis and other diseases since infants dont have a fully developed immune sysytem. Removal of your spleen, an important part of the immune system, also may increase the risk. (Handbook of medical-surgical The patient is an infant, 4 months old, so his

immune system is still

underdeveloped.

nursing by Lippincott Williams &

34 | P a g e

Wilkins) Precipitating Factor Rationale Present/ Absent Trauma to the skull Recent trauma to the skull gives Absent or skull fractures bacteria in the nasal cavity the potential to enter the meningeal space. Fractures allow continuity between the external environment and the nervous system which can lead to infection such as meningitis. (Medical-Surgical Nursing Made Prolonged Incredibly Easy! by Springhouse) contact Meningitis is a communicable Absent Prolonged contact may According to the parents, the patient did not have any contact, prolonged nursing: an or not, to a patient with meningitis. The patient had a recent respiratory infection manifested cough. as by Justification The patient has no history of trauma of the skull.

to a patient with disease. meningitis

increase the likelihood of crosscontamination. (Medical-surgical

integrated approach by Lois White, Recent Gena Duncan) respiratory Meningitis follows invasion of the Present

and/or ear infection, bloodstream by organisms that live or sinusitis. upon mucous surfaces such as the nasal cavity and the respiratory tract. Infection in a space adjacent to the meninges such as the ears may also

35 | P a g e

lead to meningitis. (Understanding Nursing Myelomeningocele and meningocele Medical-Surgical

by Linda S. Williams, The patient does not have

Paula D. Hopper) These diseases are neural tube Absent defects that are congenital

anomalies. There is a failure of the posterior spinous processes on the vertebrate to fuse, which may permit meninges and spinal cord to

myelomeningocele and meningocele.

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 3rdEdtion by Barbara E. Gould. 2006)

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Symptomatology

Symptom Nuchal rigidity

Rationale Present/ Absent This is the inability to flex the Present neck forward passively due to increased neck muscle tone and stiffness related to the disease process. (Evaluating signs and symptoms by Lippincott, Williams & sign Absent

Justification It was noted that the patient has stiffness of the neck. It was also written in the

physicians side notes.

Brudzinski's sign

Wilkins. 2009 A positive Brudzinskis signals meningeal

The patient did not manifest symptom. this

irritation.

Passive flexion

of the neck

stretches the nerve roots, causing pain and involuntary flexion of the knees and hips. (Evaluating signs and symptoms by Kernig's sign Lippincott, Williams is & This symptom is not present in the patient.

Wilkins. 2009) Kernigs sign

hamstring Absent

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

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 Seizure Lippincott, Williams result & from Present It was written in the physicians side notes that the patient is

Wilkins. 2009) Seizures may

increased pressure and from areas of inflammation in the brain tissue. (Understanding Medical-Surgical Nursing by Linda S. Williams,

positive for seizure which prompted for his admission to the PICU. Prior hospitalization, to the

Paula D. Hopper) Decreased level A decrease in the patients level Present of consciousness of consciousness usually results from a neurologic disorder or infection. Consciousness is

patient was noted to be lethargic.

affected by the reticular activating system (RAS), an intricate

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

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

makes consciousness possible. (Evaluating signs and symptoms by Fever Lippincott, Williams & The patient had this symptom prior to and during hospitalization. his

Wilkins. 2009) Macrophages, white blood cells, Present and injured cells release chemical substances called pyrogens that act directly on the hypothalamus, causing its thermostat to be set to a higher temperature. Also,

immunological reactions are sped up by temperature. (Medical-surgical integrated Vomiting nursing: by an Lois an Present According to the

approach

White, Gena Duncan) Vomiting results from

increased intracranial pressure as a response to the inflammatory process meningitis. (Pathophysiology for the Health associated with

patients parents, the patient had episodes of vomiting before his hospitalization. Also, it was written in the

39 | P a g e

Professions 3rdEdtion by Barbara E. Gould. 2006) Bulging Fontanel This is due to the inflammatory Present process disease associated and the with the

physicians side notes that the patient is

positive for vomiting. It was observed has a bulging fontanel. anterior

increased

permeability of the blood-brain barrier. This is only present in infants up to 6 months of age. (Clinical Manual of Pediatric nursing 6th Edition by Marilyn j. Poor feeding Hockenberry. 2004) As a response of the immune Absent system to infection, interferon is triggered which initiates a stress response. The stress response can elicit changes in the nervous and endocrine systems and, changes in behavior seen during through an the The patient did not manifest symptom. this

infection

acting

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

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. Irritability McCance& Sue E. According to the

Huether.1994 ) In meningitis, the infection of the Present meninges may also lead to the inflammation of the blood

patients mother, the patient was irritable prior to the

vessels, encountered in acute infection, which means it is harder for blood to enter the brain, and brain cells are deprived of oxygen which may lead to irritability. (Clinical Manual of Pediatric nursing 6th Edition by Marilyn j. Opisthotonos Hockenberry. 2004) Opisthotonus occurs facilitation of the due to Absent

hospitalization.

The patient did not manifest symptom. this

anterior

reticulospinal tract caused by the inactivation of inhibitory

41 | P a g e

corticoreticular

fibers

which

normally act upon the pons reticular formation (Evaluating signs and symptoms by Lippincott, Williams &

Wilkins. 2009)

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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

Fever

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Irritation of nerve endings Inflammation of the Meninges

the

Irritability Muscle rigidity

Nuchal rigidity

Increase in the number of WBC Increased blood flow Leaked fluid and proteins move into inflamed tissue

Vasodilation

Purulent exudates formation

Increased permeability

Edema

Increased ICP Irritates nerve cells of the brain

Bulging fontanel

Seizure

IF TREATED: Fluid and Electrolyte Management Antibiotic Therapy

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

GOOD PROGNOSIS IF NOT TREATED

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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 Kernegs and Brudzinskis 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.

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DOCTORS 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 patient has understood the reason for 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 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 medical CXR PAL tract disorders, that kidney produce Done disorders, urinary neoplasm and other conditions 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, small portions of the Done Done Consent secured

47 | P a g e

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 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) that is is a diagnostic procedure of cerebrospinal and cytological analysis. Its Done

performed in order to collect a sample fluid (CSF) Not Done most for biochemical, microbiological, 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 what type of bacteria the specimen has. In this case, the patients blood is used as the specimen. Venoclysis: IVF to start D5 0.3NaCl is a hypertonic solution with D5 0.3 NaCl 500cc which has free water, salt and calories
48 | P a g e

Done without result Done

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 Given ANST pneumonia and Haemophilus influenza. IVTT q8 hours ANST for meningitis caused by Streptococcus 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 >38C Neuro VS q2 hours of pain. Neuro vital signs is an assessment tool used to evaluate neurological status. It is mostly expressed using Glasgow Vital Signs q4 hours Coma Scale and Reaction Level Score. Vital signs are important for baseline assessment and to monitor patients condition which evaluates the whole I & O q shift treatment course. The measurement and recording of all fluid intake and output during a period provides important data about the patients fluid balance and ability of kidneys to excrete normral volume of Monitor decrease seizure for in urine. further These changes could be indicative of a LOC, worsening condition and increased activity, damaged in the patients central 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

Taken and Recorded

Taken and Recorded

Monitored and Recorded

Monitored

shortness of breath Refer accordingly

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 physicians discretion. This could mean Revise fever a more potent effect for the drug. Paracetamol Decreasing drug dosage is ordered controlled. It could also mean that this dosage is more suitable for the patient Diet for age that the last one ordered. Age-appropriate diet means that the patient 9/13/10 Labs: Follow up CXR PAL Blood GSCS Continue IVF at SR An order made to remind the patient or significant others to obtain result of the specified laboratory tests. IVF continues to rehydrate the patient. This also serves as an access for IVTT 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 patients condition which evaluates the whole I & O q shift treatment course. The measurement and recording of all fluid intake and output during a period provides important data about the Given Continued Done may feed on within the limitations and tolerance of his age. Significant other informed Revised Revised

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

Given

Monitored and Recorded

50 | P a g e

patients 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 coordination on the treatment of the With UTI Start client. cefuroxime Since the patients latest urinalysis 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 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 Puncture Continue IVF at SR for brain. Lumbar Patient has not yet undergone the said conclusive diagnostic test for bacterial 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

Referred

125mg/5ml 4ml TID

Given

Done

Not Done

Done

diseases

have

electrolyte

imbalances s/f LP

due

to

decreased

functioning of the kidneys. Patient has not yet undergone the said conclusive diagnostic test for bacterial Not Done meningitis as of this date. Existing ordered medications

Continue meds

are Continued

continued until their desired effects are Transfer to met. Blue/ This transfer of service is done for the management of the patients urinary

Nephro service (UTI) 09/17/10 (+) upon admission (-) BFC I and O q shift For UA

Done

tract infection. (midstream Midstream catch of urine is preferred since the specimen is most likely not contaminated yet by other external factors. The measurement and recording of all fluid intake and output during a period provides important data about the patients fluid balance and ability of kidneys to excrete normral volume of urine. Vital signs are important for baseline assessment and to monitor patients condition which evaluates the whole treatment course. The family has opted not to have the Lumbar Puncture procedure due to financial constraints. The father was asked to sign three times for formality and legality purposes. serum An order made to remind the patient or Done Continued specified laboratory tests. IVF continues to rehydrate the patient. Done Taken and Recorded Monitored and Recorded Done

seizure catch)

VS q 4

Refused LP (signed by father)

09/18/10 -Normal UA (-) fever GCS 15

52 | P a g e

Follow

up

electrolytes and repeat significant others to obtain result of the UA Continue IVF @ SR

-awaiting blood culture result -if normal, opt parents Refer lesions to derma of evaluation

This also serves as an access for IVTT medications. for Physician observed papular lesions on skin the patients right arm and for further evaluation, she referred it to a Referred dermatologist.

to go home -with papular lesion arm 9/19/10 (+) vomiting (+) tachypnea (+) labored breathing and rash on right

For transfer to PICU Patient is for transfer to Pediatric ICU once with available bed since physician noted worsening of his Done condition that are already alarming. O2 inhalation at 10 L/m This is to relieve hypoxia, headache, via face mask nausea, as well as to restore the ability of the cells of the body to carry on normal metabolic function. This helps Nebulization salbutamol q1 provide oxygenation of the vital organs. with Salbutamol is a bronchodilator that is indicated for acute attacks of bronchospasm. Patient noted to be in Done Done

7:30pm Febrile Awake Irritable Tachypneic (+) intercostal retractions (+) nuchal rigidity
53 | P a g e

respiratory distress. Follow up blood GSCS An order made to remind the patient or and serum electrolytes significant others to obtain result of the Done specified laboratory tests. Shift paracetamol PO to Shifting of paracetamol from PO to paracetamol IVTT 55mg IVTT is most probably ordered either q4 prn for fever for faster effect or giving PO is not already feasible due to some factors For CBC PC such as irritability. CBC with PC determines the quantity of each quantity of blood cell in a given specimen of blood, often including the Done Shifted

UTI resolved

amount of hemoglobin, hematocrit, and the proportion of various white blood cells. This test monitors patients For ABG condition through blood sample. ABG testing is mainly in pulmonology, to used Done

determine gas

exchange levels in the blood related to lung function, but has a variety of applications in other areas. Give Epinephrine 0.1ml Epinephrine facilitates air passage by SQ now Compensate alkalosis 7/20/10 Give 14 meqs dilating bronchioles in patients on respiratory distress. of Patient has a significantly levels thus low

Given

d respiratory NaHCO3 slow IVTT 1:1 bicarbonate dilution now

sodium

bicarbonate is given to correct the

Given

abnormality. Transfuse 1 unit PRBC CBC results showed low levels of 55cc of patients blood hematocrit, hemoglobin and RBC Transfused type after proper cross count. Transfusion was ordered to matching to run in 4 correct these abnormalities. hours May give drops 0.3ml cetirizine Citirizine, an antihistamine is ordered either due to allergies brought about by the blood transfusion or for the popular Continue IVF @ SR lesions and rashes seen on the patient. IVF continues to rehydrate the patient. This also serves as an access for IVTT medications. Start Amikacin 82mg It is a bactericidal indicated for the OD IVTT treatment of infections due to Given susceptible strains of microorganisms, bacterial septicemia and serious and complicated UTIs. Continued Given

54 | P a g e

7/21/10 4am Awake Afebrile (+) rales Post 1 unit PRBC

Repeat CBC

This is done to evaluate if the blood transfusion has been enough to correct the abnormal levels seen in the previous CBCs. The potassium procedure Done

For urine KOH

hydroxide in is

test is used

a to Done

which potassium

hydroxide (KOH)

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. Done

55 | P a g e

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 RBS

Result Result 141.4 L 4.0 0

Normal Normal Range 131.00Range 4.10-6.60 145.00

Clinical Significance Clinical Significance No Clinical Significance Decreased Level: Low blood glucose levels indicate hypoglycemia is termed as the state produced by a lower than normal level of blood glucose.

Rationale Rationale This test is a part of the routine lab This test is done in order to check the evaluation of most patients. It is one of thepatients sugar level. blood electrolytes, which are often ordered as a group. It is also included in the basic metabolic panel, widely used when someone has non-specific health complaints, and in monitoring treatment involving IV fluids or when there is a possibility of developing dehydration. http://www.labtestsonline.org/ understanding/analytes/ uric_acid/test.html Potassium testing is frequently ordered, along with other electrolytes, as part of a routine physical. It is used to detect concentrations that are too high or too low .

Interpretation Interpretation Within normal Below Normal range Range The Client is suffering from Hypoglycemia.

Potassium

4.17

3.6-6.8

No Clinical Significance

Within Normal Range

COMPLETE BLOOD COUNT

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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 Hemoglobin Result 97 Normal Values M:140-180 F:120-140 Clinical Significance Decreased level: May indicate anemia from blood loss, dietary deficiency, malnutrition, from splenomegaly; kidney diseases; systemic lupus erythematosus; thies; or sarcoidosis. A Rationale hemoglobin test is Interpretation A low hemoglobin is referred to as anemia.

performed to determine the amount of hemoglobin in a person's red blood cells

sickle-cell anemia; hemolysis (RBCs). This is important because the amount of oxygen available to tissues depends upon how much oxygen is in of the tissues. Without the

malignancies;hemoglobinopa the RBCs, and local perfusion sufficient hemoglobin,

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 ordered as part of the complete blood count (CBC).
59 | P a g e

Within Normal Values.

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

60 | P a g e

Test Neutrophils

Result 0.75

Normal Values 0.50-0.70

Clinical Significance Increased level: May indicate or bacterial bacterial infection such as otitis media, endocarditis, meningitis.

Rationale Evaluated in relation to total WBC count. If neutrophil count is significantly greater than overall WBC count, immune function may be poor or an overwhelming infection is present.http://www.labtestsonli ne.org/ A WBC count is normally

Interpretation Above normal range. The increase in neutrophil count may be a result of Bacterial Meningitis.

Lymphocytes

0.50

0.25-0.40

Increased level: Elevated result infections, leukemia, WBC from trauma, count

Above Normal Values. The patient has an increase of leukocyte count due to the inflammation brought about by Bacterial Meningitis.

can ordered as part of the complete

bacterial blood count (CBC). In some inflammation, circumstances, a WBC count intense may be ordered to monitor recovery from illness. http://www.labtestsonline.org/ These measures the number of white blood cells called eosinophils. Eosinophilsbecome active when you have certain allergic diseases, infections, and other medical conditions. parasitic

exercise, or stress.

Eosinophils

0.05

0.02-0.04

Increased level: May indicate allergic response such as asthma; infection such as amebiasis; skin disorder such as shingles; neoplastic disorder such as chromic myelocytic anemia and necrosis of solid tumor; pernicious fever; autoimmune anemia; scarlet exercise; a

Above normal range. May be a result of a Bacterial infection.

61 | P a g e

excessive

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

disease; or

September 18, 2010 Test Hemoglobin Result 90.0 Normal Range 115-175 Clinical Significance Decreased level: May indicate anemia from blood loss, dietary deficiency, malnutrition, sickle-cell anemia; hemolysis from splenomegaly; kidney diseases; systemic lupus erythematosus; malignancies;hemoglobinopathies; or sarcoidosis. Rationale A hemoglobin test is performed to determine the amount hemoglobin in a person's red blood cells (RBCs). This is important because the amount of oxygen available to tissues depends upon how much oxygen is in the RBCs, 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 Decreased Level: Low levels of hematocrit are most frequently found in anemias and leukemias. http://www.labtestsonline.org/ This test is given in order to measure the concentration of red blood cells in the blood. Kee, Joyce Lefever. Laboratory and diagnostic tests with nursing implications. 2nd ed.
62 | P a g e

Interpretation Below May indicate anemia.

of normal range.

Below Normal Range And is associated with anemia.

RBC

3.48

4.20-6.10

Decreased level: A decreased number of RBCs results from either acute or chronic blood loss. Acute blood loss is a rapid depletion of blood volume. Chronic blood loss stems from various conditions that often results in some form of an anemia.

Appleton&Lange.1987. An RBC count is ordered as a part of the complete blood count (CBC), often as part of a routine physical, pre-surgical procedure, or for other clinical reasons. The test is also repeated in patients who have hematologic disorders, bleeding problems, chronic anemias, polycythemia, and/or patients undergoing chemotherapy or radiation therapy. A WBC count is normally ordered as part of the complete blood count (CBC). In some circumstances, a WBC count may be ordered to monitor recovery from illness. http://www.labtestsonline.org/

Below Normal Range. May be a result of anemia.

WBC

11.15

5.0-10.0

Increased level: Elevated WBC count can result from bacterial infections, inflammation, leukemia, trauma, intense exercise, or stress.

Above Normal Range. A result of the inflammation brought about by Bacterial Infection. Below

Neutrophils
63 | P a g e

15

55-75

Decrease in Neutrophils indicates viral

Neutrophil count aids in helping in

diseases such as chicken pox, measles, rubella, and Leukemia and anemia.

monitoring the immune response of the patient.

Normal Range 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. infestations with worm and other large parasites and response to treatments. http://www.labtestsonline.org/

Above Normal Range. May be a result of the inflammation Brought about by Bacterial Meningitis. Within Normal Range

Monocyte

2-10

No Clinical Significance

Monocyte levels are checked to know the increase in response to infection of all kinds as well as to inflammatory disorders. http://www.labtestsonline.org/ These measures the number of white blood cells called eosinophils.

Eosinophil

1-8

Decreased Levels: Decreased levels of eosinophils can

Below Normal

64 | P a g e

occur as a result of infection.

Eosinophils become active when you have certain allergic diseases, infections, and other medical conditions. http://www.nlm.nih.gov/ medlineplus/ency/article/ 003649.htm Platelet count is ordered To assist in the diagnosis of bleeding disorders and to monitor patients who are being treated for any disease involving bone marrow failure. This test determines the number of platelets in the patients blood. This test is done to determine the weight of hemoglobin in RBCs, regardless of their size. Kee, Joyce Lefever. Laboratory and diagnostic tests with nursing implications. 2nd ed. Appleton& Lange.1987. This is ordered to measure the

Range. A result of a bacterial infection.

Platelet Count

417

150-400

Increased Level: Increased platelet counts occur in polycythemia, and fractures and after splenectomy.

Above Normal Range

MCH (Mean Corpuscular Hemoglobin)

26.0

26.0-32.20

No Clinical Significance

Within Normal Range

MCHC
65 | P a g e

34.0

32.20-36.50

No Clinical Significance

Within

(Mean Corpuscular Hemoglobin concentration ) MCV (Mean Corpuscular volume) 78.3 79.00-94.80 Decreased levels may indicate Microcytic anemias( iron-deficiency anemia). Malignancy, Rheumatoid Arthritis, Sickle cell Anemia.

hemoglobin concentration per unit volume of RBCs. Kee, Joyce Lefever. Laboratory and diagnostic tests with nursing implications. 2nd ed. Appleton& Lange.1987. This test is done in order to determine the Mean volume of RBCs.

Normal Range

Below normal range. May be indicative of Anemia.

September 19, 2010 Test Hemoglobin Result 96.0 Normal Range 115-175 Clinical Significance Decreased level: May indicate anemia from blood loss, dietary deficiency, malnutrition, sickle-cell anemia; hemolysis from splenomegaly; kidney diseases; systemic lupus erythematosus; malignancies;hemoglobinopathies; or
66 | P a g e

Rationale A hemoglobin test is performed to determine the amount hemoglobin in a person's red blood cells (RBCs). This is important because the amount of oxygen available to tissues depends upon how much oxygen is in the RBCs,

Interpretation Below May indicate anemia.

of normal range.

sarcoidosis.

and local perfusion of the tissues. Without sufficient hemoglobin, the tissues lack oxygen and the heart and lungs must work harder to compensate. http://www.labtestsonline.org/ This test is given in order to measure the concentration of red blood cells in the blood. Kee, Joyce Lefever. Laboratory and diagnostic tests with nursing implications. 2nd ed. Appleton& Lange.1987. An RBC count is ordered as a part of the complete blood count (CBC), often as part of a routine physical, pre-surgical procedure, or for other clinical reasons. The test is also repeated in patients who have hematologic disorders, bleeding problems, chronic anemias, polycythemia, and/or patients undergoing chemotherapy or May be a result of anemia.

Hematocrit

0.30

0.36-0.52

Decreased Level: Low levels of hematocrit are most frequently found in anemias and leukemias.

Below Normal Range And is associated with anemia. Below Normal Range.

RBC

3.73

4.20-6.10

Decreased level: A decreased number of RBCs results from either acute or chronic blood loss. Acute blood loss is a rapid depletion of blood volume. Chronic blood loss stems from various conditions that often results in some form of an anemia.

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WBC

15.68

5.0-10.0

Increased level: Elevated WBC count can result from bacterial infections, inflammation, leukemia, trauma, intense exercise, or stress.

radiation therapy. A WBC count is normally ordered as part of the complete blood count (CBC). In some circumstances, a WBC count may be ordered to monitor recovery from illness. http://www.labtestsonline.org/

Above Normal Range. A result of the inflammation brought about by Bacterial Infection. Within Normal Range Within Normal Range

Neutrophils

57

55-75

No Clinical Significance

Neutrophil count aids in helping in monitoring the immune response of the patient.

Lymphocytes

31

20-35

No Clinical Significance

It is used to diagnose the severity of infestations with worm and other large parasites and response to treatments. http://www.labtestsonline.org/ Monocyte levels are checked to know the increase in response to infection of all kinds as well as to inflammatory disorders.

Monocyte

2-10

No Clinical Significance

Within Normal Range

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Eosinophil

1-8

Decreased Levels: Decreased levels of eosinophils can occur as a result of infection.

http://www.labtestsonline.org/ These measures the number of white blood cells called eosinophils. Eosinophils become active when you have certain allergic diseases, infections, and other medical conditions. http://www.nlm.nih.gov/ medlineplus/ency/article/ 003649.htm Platelet count is ordered To assist in the diagnosis of bleeding disorders and to monitor patients who are being treated for any disease involving bone marrow failure. This test determines the number of platelets in the patients blood. This test is done to determine the weight of hemoglobin in RBCs, regardless of their size. Kee, Joyce Lefever. Laboratory and diagnostic tests with nursing

Below Normal Range. A result of a bacterial infection.

Platelet Count

442

150-400

Increased Level: Increased platelet counts occur in polycythemia, and fractures and after splenectomy.

Above Normal Range

MCH (Mean Corpuscular Hemoglobin)

28.0

26.0-32.20

No Clinical Significance

Within Normal Range

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implications. 2nd ed. Appleton& MCHC (Mean Corpuscular Hemoglobin concentration ) MCV (Mean Corpuscular volume) September 21, 2010 Test Hemoglobin Result 104.0 Normal Range 115-175 Clinical Significance Decreased level: May indicate anemia from blood loss, dietary deficiency, malnutrition, sickle-cell anemia; hemolysis from splenomegaly; kidney diseases; systemic lupus erythematosus; malignancies;hemoglobinopathies; or sarcoidosis.
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32.3

32.20-36.50

No Clinical Significance

Lange.1987. This is ordered to measure the hemoglobin concentration per unit volume of RBCs. Kee, Joyce Lefever. Laboratory and diagnostic tests with nursing implications. 2nd ed. Appleton& Lange.1987. This test is done in order to determine the Mean volume of RBCs.

Within Normal Range

79

79.00-94.80

No Clinical Significance

Within Normal Range.

Rationale A hemoglobin test is performed to determine the amount hemoglobin in a person's red blood cells (RBCs). This is important because the amount of oxygen available to tissues depends upon how much oxygen is in the RBCs, and local perfusion of the tissues.

Interpretation Below May indicate anemia.

of normal range.

Without sufficient hemoglobin, the tissues lack oxygen and the heart and lungs must work harder to compensate. Hematocrit 0.33 0.36-0.52 Decreased Level: Low levels of hematocrit are most frequently found in anemias and leukemias. http://www.labtestsonline.org/ This test is given in order to measure the concentration of red blood cells in the blood. Kee, Joyce Lefever. Laboratory and diagnostic tests with nursing implications. 2nd ed. RBC 4.07 4.20-6.10 Decreased level: A decreased number of RBCs results from either acute or chronic blood loss. Acute blood loss is a rapid depletion of blood volume. Chronic blood loss stems from various conditions that often results in some form of an anemia. Appleton&Lange.1987. An RBC count is ordered as a part of the complete blood count (CBC), often as part of a routine physical, pre-surgical procedure, or for other clinical reasons. The test is also repeated in patients who have hematologic disorders, bleeding problems, chronic anemias, polycythemia, and/or patients undergoing chemotherapy or radiation therapy.
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Below Normal Range And is associated with anemia. Below Normal Range. May be a result of anemia.

WBC

8.43

5.0-10.0

Increased level: Elevated WBC count can result from bacterial infections, inflammation, leukemia, trauma, intense exercise, or stress.

A WBC count is normally ordered as part of the complete blood count (CBC). In some circumstances, a WBC count may be ordered to monitor recovery from illness. http://www.labtestsonline.org/

Above Normal Range. A result of the inflammation brought about by Bacterial Infection. Above Normal Range

Lymphocytes

59

20-35

Increased level: Lymphocyte increase means there is viral infection, leukemia, cancer of the bone marrow, or radiation therapy.

It is used to diagnose the severity of infestations with worm and other large parasites and response to treatments. http://www.labtestsonline.org/ Monocyte levels are checked to know the increase in response to infection of all kinds as well as to inflammatory disorders. http://www.labtestsonline.org/ These measures the number of white blood cells called eosinophils. Eosinophils become active when

Monocyte

10

2-10

No Clinical Significance

Within Normal Range

Eosinophil

1-8

Decreased Levels: Decreased levels of eosinophils can occur as a result of infection.

Below Normal Range.

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you have certain allergic diseases, infections, and other medical conditions. http://www.nlm.nih.gov/ medlineplus/ency/article/ Platelet Count 345 150-400 Increased Level: Increased platelet counts occur in polycythemia, and fractures and after splenectomy. 003649.htm Platelet count is ordered To assist in the diagnosis of bleeding disorders and to monitor patients who are being treated for any disease involving bone marrow failure. This test determines the number of MCH (Mean Corpuscular Hemoglobin) 25.6 26.0-32.20 Decreased level: May indicate microcytic anemia or hypochromic anemia. platelets in the patients blood. This test is done to determine the weight of hemoglobin in RBCs, regardless of their size. Kee, Joyce Lefever. Laboratory and diagnostic tests with nursing implications. 2nd ed. Appleton& MCHC (Mean
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A result of a bacterial infection.

Above Normal Range

Below Normal Range

31.6

32.20-36.50

Decreased level: May indicate iron deficiency anemia

Lange.1987. This is ordered to measure the hemoglobin concentration per unit

Below Normal

Corpuscular Hemoglobin concentration ) MCV (Mean Corpuscular volume) ARTERIAL BLOOD GAS 80.8 79.00-94.80

or thalassemia.

volume of RBCs. Kee, Joyce Lefever. Laboratory and diagnostic tests with nursing implications. 2nd ed. Appleton&Lange.1987. This test is done in order to determine the Mean volume of RBCs.

Range

No Clinical Significance

Within Normal Range.

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 7.39 Normal Range 7.35-7.45 Clinical Significance No Clinical Significance Rationale This test is ordered to determine the acidity and alkalinity of body fluids. Kee, Joyce Lefever. Laboratory and diagnostic tests with nursing implications. 2nd ed. Appleton& PCO2 13.0 35-45 Decreased Level: Lange.1987. pCO2 measures the adequacy of Below Interpretation Within Normal Range

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Low levels of PCO2 may indicate anxiety, hysteria, hypoxia. PO2 150.0 80-100 Increased Level: Elevated pO2 levels are associated with Increased oxygen levels in the inhaled air, Polycythemia.

alveolar ventilation in view of current metabolic demands. This test reflects the amount of oxygen gas dissolved in the blood. It primarily measures the effectiveness of the lungs in pulling oxygen into the blood stream from the atmosphere. http://www.brooksidepress.org/ The HCO3 ion indicates whether a metabolic problem is present (such as ketoacidosis).

Normal Range Above Normal Range

HCO3

6.5

22.0-27.0

Decreased Level: A low HCO3 indicates metabolic acidosis, a high HCO3 indicates metabolic alkalosis. HCO3 levels can also become abnormal when the kidneys are working to compensate for a respiratory issue so as to normalize the blood pH. Negative Values of Base Excess may Indicate: Lactic Acidosis, Ketoacidosis, Ingestion of acids, Cardiopulmonary collapse,

Below Normal Range

BE (ECT)

-19.6

(-2)-(+2)

To indicate whether the patient has metabolic acidosis or metabolic alkalosis.

Negative Result

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Shock. O2 SAT 98.8 80-100 No Clinical Significance This measures the percent of hemoglobin which is fully combined with oxygen. ctC02 6.9 23.0-30.0 Decreased Level: May be due to Addisons disease, Chronic diarrhea, Diabetic ketoacidosis, Metabolic acidosis, Kidney disease, Ethylene glycol or methanol poisoning, Salicylate (aspirin) overdose. The bicarbonate (or total CO2) test is almost never ordered by itself. It is usually ordered along with sodium, potassium, and chloride as part of an electrolyte panel. The electrolyte panel is used to 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
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Within Normal Values Below Normal Range

for known imbalances.

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

CHEMICAL ANALYSIS
Test Glucose Result Negative Normal Values Negative Clinical Significance An excessively high glucose concentration in the blood, such as may be seen with people who 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
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Rationale To help detect if sugar is present in the urine and determine if patient has glucosuria.

Interpretation Within normal result

decrease blood concentrations. Albumin Negative Negative This measures the amount of albumin in the urine. Normally, there will not be detectable quantities. When urine protein is elevated, there is a condition called proteinuria; this can be an early sign of kidney Specific gravity 1.025 1.010 and 1.030 disease. There are no "abnormal" specific gravity values. This test simply indicates how concentrated the urine is. Specific gravity measurements are actually a comparison of the amount of solutes (substances dissolved) in urine as compared to pure
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To help detect traces of protein present in the urine and determine if patient has albuminuria.

Within normal results

Knowing the urine concentration helps health care providers decide if the urine specimen they are evaluating is the best one to detect a particular substance. For example, if they are looking for very small amounts of protein, a concentrated morning urine

Within Normal Range

water.

specimen would be the best sample.

Microscopic Examination

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Test RBC

Result 0.3/hpf

Normal Values 0 3 /hpf

Clinical Significance Normally, a few RBCs are present in urine sediment. Inflammation, injury, or disease in the kidneys or elsewhere in the urinary 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 menstruation. Normally in men and women, a few epithelial cells from the bladder (transitional epithelial cells) or from the external urethra (squamous epithelial cells) can be found in the urine

Rationale This measures Inflammation, injury, or disease in the kidneys or elsewhere in the urinary tract.

Interpretation This means that the patient Is not experiencing any injury In the kidneys or in the urinary tract.

EPITHELIAL CELLS

Positive

Negative

In urinary tract conditions such as infections, inflammation, and malignancies, more epithelial cells are present. Determining the kinds of cells present helps the health care provider pinpoint where the condition is located.

There is a presence of inflammation.

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sediment. Cells from the kidney (kidney cells) are less common

September 18, 2010 Test Glucose Result Negative Normal Values Negative Clinical Significance An excessively high glucose concentration in the blood, such as may be seen with people who 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 of albumin in the urine. Normally, there will not be detectable quantities. When urine protein is elevated, there is a
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Rationale To help detect if sugar is present in the urine and determine if patient has glucosuria.

Interpretation Within normal result

To help detect traces of protein present in the urine and determine if patient has albuminuria.

Within normal results

condition called proteinuria; this can be an early sign of kidney Specific gravity 1.025 1.010 and 1.030 disease. There are no "abnormal" specific gravity values. This test simply indicates how concentrated the urine is. Specific gravity measurements are actually a comparison of the amount of solutes (substances dissolved) in urine as compared to pure water. Knowing the urine concentration helps health care providers decide if the urine specimen they are evaluating is the best one to detect a particular substance. For example, if they are looking for very small amounts of protein, a concentrated morning urine specimen would be the best sample. Microscopic Examination Within Normal Range

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Test Tubex Test RBC

Result 0.3/hpf

Normal Values 0 3 /hpf

Clinical Significance Normally, a few RBCs are present in urine sediment. Inflammation, injury, or disease in the kidneys or elsewhere in the urinary 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 menstruation. Normally in men and women, a few epithelial cells from the bladder (transitional epithelial cells) or from the external urethra (squamous epithelial cells) can be found in the urine

Rationale This measures Inflammation, injury, or disease in the kidneys or elsewhere in the urinary tract.

Interpretation This means that the patient Is not experiencing any injury In the kidneys or in the urinary tract.

EPITHELIAL CELLS

Negative

Negative

In urinary tract conditions such as infections, inflammation, and malignancies, more epithelial cells are present. Determining the kinds of cells present helps the health care provider pinpoint where the condition is located.

There is no presence of inflammation.

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sediment. Cells from the 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 3 Interpretation Guide NEGATIVE- Does not indicate current Typhoid Fever infection BORDERLINE- Inconclusive score, repeat analysis. If still inconclusive repeat sampling 4-5 6 INDETERMINATE at a later date. POSITIVE Indicate of current Typhoid Fever infection. POSITIVE Strong indication of current 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

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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.

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DRUG STUDY Generic Name: Brand Name: Classification: Dosage: Mode of Action: Paracetamol Perfalgan Non-narcotic analgesic, Antipyretic 9/12 180 mg/ml 1.1 ml q4 prn; 0.8 ml q4 prn 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, Drug Interactions: anemia; clients with cardiac or pulmonary disease Activated charcoal, cholestyramine and colestipol: Decreased absorption Barbiturates, carbamezepine, diflunisal, hydantoins, isoniazid,

rifabutim, rifampin, sulfinpyrazone: Increased risk of hepatotoxicity Hormonal contraceptives: Decreased efficacy Oral anticoagulants: Increased anticoagulant effect Phenothiazines: Severe hypothermia
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Zidovudine: Increased risk of granulocytopenia Hematologic: hemolytic anemia, neutropenia, Side/ Effects: Adverse pancytopenia Hepatic: jaundice Metabolic: hypoglycemia Nursing Responsibilities: Skin: rash urticaria 1. Assess vital signs. 2. Document presence of fever.

leukopenia,

3. Instruct the clients mother to give the drug only for complaints indicated. 4. Tell the clients 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: Mode of Action: Indication: Ceftriaxone sodium Rocephin Antibiotic 9/12- 183 mg IVTT q8 ANST 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,
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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 Contraindicated with allergy to cephalosphorins or penicillins. Drug 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/ Effects: Adverse CNS: headache, dizziness, lethargy GI: nausea, vomiting, diarrhea, abdominal pain, flatulence,

hepatotoxicity GU: nephrotoxicity Hematologic: decreased WBC, platelets and Hct Nursing Responsibilities:
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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: Mode of Action:

Albuterol sulfate Salbutamol Bronchodilator 9/19 -1 nebule q1 9/19- 1 nebule q4 Acts relatively selectively at beta2- adrenergic receptors to cause bronchodilation and vasodilation Inhalation: Treatment of acute attacks of bronchospasm Hypersensitivity to albuterol; tachycardia, tachyarrythmisa caused by digitalis intoxication; hypertension, coronary insufficiency, CAD,

Indication: Contraindication

Drug interactions:

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

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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 clients 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.

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

Generic Name Brand Name Classification Suggested Dose Mechanism of Action Indication

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

Contraindication

Impetigo Contraindicated in patients hypersensitive to drug or other cephalosporins. Use cautiously in patients hypersensitive to penicillin because of possibility of cross-sensitivity with other beta-lactam antibiotics.

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

Aminoglycosides: May cause synergistic activity against some organisms; may increase nephrotoxicity. Monitor patients renal function closely.

Loop diuretics: May increase risk of adverse renal reactions. Monitor renal function test results closely.

Probenicid: May inhibit excretion and increasecefuroxime level. Probenicid may be used for this effect.

Side/Adverse Effects

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

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

Nursing Responsibilities

Other: anaphylaxis, hypersensitivity reactions, serum sickness. 1. Before giving the drug, ask the mother if her child is allergic to penicillins or cephalosporins. 2. Absorption of oral drug is enhanced by food. 3. Monitor patient for signs and symptoms of superinfection. 4. Tell patients mother to give the drug as prescribed even after he feels better. 5. Do not double dose the drug.

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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 Action Indication Contraindication Drug Interaction

Sodium Bicarbonate Neut Alkanizer 14 mEqs ofDissociates to provide bicarbonate ion which neutralizes hydrogen ion concentration and raises blood and urinary pH Metabolic acidosis, Systemic or urinary alkalanization, Antacid, Cardiac Arrest Alkalosis, hypernatremia, severe pulmonary edema, hypocalcemia, unknown 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 alkalosis, hypernatremia,

hyperosmolarity with overdose Skin: pain and irritation a injection site

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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 patients 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 ofPotent histamine (H1) receptor antagonist; inhibits histamine release and eosinophil chemotaxis during inflammation, leading to reduced swelling and

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

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GI: nausea, diarrhea, abdominal pain, constipation Respiratory: bronchospasm Nursing Responsibilities Other : fever, rash 1. Ask the mother if the client has any history of allergy with the drug. 2. Instruct to take the drug as prescribed. 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 appears to be disrupted, causing cell death. Indication: 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
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Hypersensitivity to aminoglycosides.

Drug interactions:

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

Side/ Effects:

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

Nursing Responsibilities:

Other: pain at the injection site 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.

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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 - and -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 prolong the duration of effect and to lessen the danger of toxicity.

Indication: Contraindication

INJECTION: relief from respiratory distress of bronchial asthma, chronic 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 involving digits, ears, nose, penis or scrotum.

Drug interactions:

Increased sympathomimetic effects with other TCAs Excessive furazolidone hypertension with beta-blockers, propanolol,

Decreased cardio-stimulating and bronchodilating effects with beta adrenergic blockers

Decreased vasopressor effects with chlorpromazine Decreased guanethidine antihypertensive effects with methyldopa,

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Side/ Effects:

Adverse

CNS: fear, drowsiness, lightheadedness, weakness CV: arrhythmias GI: nausea, vomiting GU: dysuria, urinary retention, decrease urine formation

Other: pallor, respiratory difficulty, sweating Local: necrosis at sites of repeat injection 1. Do not exceed the recommended dosage; loss of effectivess or 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 clients 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 Responsibilities:

NURSING THEORIES
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Florence Nightingaless 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 wards 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 Halls 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.

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KEY CONCEPTS OF 3 INTERLOCKING CIRCLES:

CORE THE PERSON THERAPEUTIC USE OF SELF CURE THE DISEASE SEEING THROUGH THE MEDICAL CARE

CARE THE BODY THE INTIMATE BODILY 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 doctors 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 patients cooperation and as well as the significant others, we health care providers will not be able to

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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 clients situation. In order to achieve our goals in caring for our client its really important to develop a sense of unity and of course communication between colleagues is also very significant all throughout the nursing process. Virginia Hendersons 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 persons basic needs and he enumerated 14 basic needs that a person must possess. The following are the14 basic needs: 1. 2. 3. 4. 5. 6. 7. Breathing normally Eating and drinking adequately Eliminating body wastes Moving and maintaining desirable position Sleeping and resting Selecting suitable clothes Maintaining body temperature within normal range

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8. 9. 10. 11. 12. 13. 14.

Keeping the body clean and well-groomed Avoiding dangers in the environment Communicating with others Worshipping according to ones faith Working in such a way that one feels a sense of accomplishment Playing/participating in various forms of recreation Learning, discovering or satisfying the curiosity that leads to normal development

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 couldnt 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 to her own belief, he doesnt work, and he has not yet learned on his own the available medical facilities that he could utilize for his

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recovery and lastly, he couldnt 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.

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NURSING CARE PLAN

Date 09/22/10 3-11 5:30pm

Cues OBJECTIVE: Respirator y rate of 59 cycles per minute. Tachypnea noted. Rales heard upon auscultatio Restlessne ss and

Needs Nursing Diagnosis Plan of Care A Impaired Gas After 2 hours of nursing C T I V I T Y & E X E R C I Gulanick, et. al. Exchange related to care, the patient will: bronchospasms A state in which an individual to is clear or from

Nursing Interventions 1. Assess respiratory rate, depth and ease. R: Manifestations distress of are

Evaluation GOAL MET 09/22/10 7:30pm After 2 hours of nursing care, the patient was able to:
Demons trate improved ventilation; and Exhibit

Demonstrate improved ventilation; and, Exhibit absence of symptoms of respiratory distress.

respiratory

dependent on the degree of lung involvement general in the health

unable secretions

underlying status.

obstructions

the respiratory tract to maintain airway patency.

2. Monitor heart rate.

R:

Tachycardia

is

usually

present as a result of fever or dehydration but may present as a response to hypoxemia.

3. Monitor body

Nursing Care Plans.

absence of symptoms of

temperature

as

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irritability noted. Labored breathing noted Intercostal retraction noted Nasal flaring noted.

S E

indicated. R: Elevated temperature is a result of increased metabolic

respirator distress RR=33c pm Labored

P A T T E R N

and oxygen demand and alters cellular oxygenation. 4. Observe color of skin and nail beds. R: Cyanosis is a general sign that patient is already

breathing not noted Patient asleep

experiencing an increase in oxygen demand. 5. Administer bronchodilators indicated. R: Bronchodilators facilitate air passage by dilating the airways allowing more oxygen as

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to be inhaled. 6. Administer oxygen

inhalation as ordered. R: O2 reinforcement can

compensate for the increased oxygen demand of the patient. 7. Elevate encourage changes. R: These measures promote maximal inspiration to head and

position

promote ventilation. 8. Promote comfort and decrease stimuli. R: Restlessness and irritability of the the patient could

increase oxygen demand thus

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comfort measures should be observed.

Date September

Cues OBJECTIVE:

Need A

Nursing

Plan of Care

Nursing Interventions 1. Determine factors related

Evaluation GOAL MET

Diagnosis Ineffective At the end of the 2

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14, 2010 @ 11pm

Hemogl

C T I V

tissue perfusion hours related to low intervention, hemoglobin patients

nursing the mother

to individual situation. To assess causative factor of the condition 2. Note customary baseline data. To provide comparison with current findings 3. Review laboratory studies. To serve as a scientific basis for the problem. 4. Encourage for a quiet and restful atmosphere. To conserve energy and lowers tissue oxygen demands 5. Inform significant others

September 2010 @ 1am

15,

obin (115175 g/Dl)=

11-7

90 RBC

concentration in will be able to: blood

Verbalize

At the end of 2 hours of nursing care, the patients mother was able to: Verbalize

I T Y E X E R C I S E

(4.20-6.10)= 3.48 Hemato

awareness and R: A decrease in results failure nourish oxygen in the to the understanding of the existence of the condition and measures that can improve circulation

crit (0.360.52)= 0.27 Weak

awareness and understanding of the existence of the condition and measures that can improve

peripheral pulses ec Pallor CRT=3s

tissues at the capillary level. Nurses Pocket guide by

Doenges et.al.

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P A T T E R N

to reduce stimulation and stress to the patient. This limits oxygen demand and promotes conservation of energy. 6. Place pillow under patients lower legs when the patient is sleeping. 7. This helps in the promotion of good circulation and increases sense of comfort.
8. Discuss with the

circulation, Ahh ok, ana man diay no? sige, himuon nako tong imong giingon., as verbalized by patients mother.

significant other the importance of adherence to diet regimen. Proper diet will promote
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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
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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.

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September 13, 2010 @ 5:00 am Murag init lagi akong anak Sr. 11/7 verbalized by the mother. Subjective: N U T R I T I Objective: O N Vital signs taken as Follows: T 38 PR 132 RR 46 M E T flushed skin warm to touch
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Hyperthermia r/t increase metabolic, presence of Bacteria in the body secondary to Bacterial Menigitis

Within my 4 hours span of care, the patient will maintain core temperature within normal range

1.

Establish rapport

to the client. to gain trust and cooperation 2. Monitor vital signs and recorded. It serves as a baseline

Meningitis

Bacterial is the

data of the patients health condition 3. Administer antipyretic as prescribed. For therapeutic relief and it is given to reduce fever 4. Promote surface cooling by means of cool environment, by letting the Mother use a fan. (heat loss by

inflammation of the protective membranes covering the brain and spinal cord, collectively known as the

A L

meninges caused by bacteria. Hyperthermia is a

A B O L I C

evaporation and conduction) to assist with measures to reduce body temperature 5. Monitor heart rate and rhythm

systemic response to invading viruses

lips are dry

that enter the body, thus the body tries to

Date / Time

Cues

Need N

Nursing Diagnosis Altered nutrition:

Objective of Care

Nursing Intervention

Evaluation GOAL PARTIALLY MET

less At a span of 4 1. Document patients actual weight. Documenting actual weight can determine the weight lost. 2. Weigh patient weekly. Evaluates the patients progress. 3. Monitor or explore attitudes toward eating/food. Many psychological, psychosocial, and cultural factors determine the type, amount, and appropriateness of food consumed. 4. Document appetite.

Septemb er 14, 2010

OBJECTIVE: Low BMI (14.3 kg/m2) Aversion or lack of interest in eating Constant crying Inadequate food intake; bottle fed. Perceived inability to ingest food Low hemoglobin: 96.0 g/L (135175) Low RBC count: 3.73 (4.20-6.10)

U T R I T I O N A L

than body requirements hours of nursing related to inability to intervention: procure inadequate a. The client will tolerate oral feedings, and R: A state in which an individuals intake of b. The client and family members will communicate understanding of special

Patients understand importance

family the of

amounts of food.

117

adequate nutrition to their son, especially on the importance of breast milk. Still,

nutrients is insufficient to meet metabolic needs.

client is still bottle fed.

&

Ref: Nursing Care et. Plans, al., 3rd

dietary needs

M E T A B O L

Gulanick edition.

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Date/Time / shift September 22, 2010

Cues

Need

Nursing Diagnosis With

Objective of Care Within 4 hours span of care the client will be able to:
Be free from injury Enhance his safety through environment modification as indicated

Nursing Interventions With Rationale 1. Ascertain knowledge of safety needs and injury prevention. To prevent injury in the hospital setting. 2. Monitor the

Evaluation

Objective cues: Sometimes infant was left unattended in

H E A L T H

Risk related

for

injury to

Goal met 8:00 pm Within 4 hours span of care, the client was able to be free from injury and the significant others was able to modify

developmental age secondary bacterial meningitis. Infants learn by to

@ 4:00 pm
3 11

an elevated surface. Infant less than 1 year old (4 months old) Restless Irritable

shift

environment for potentially unsafe conditions and

P E R C E P T I O N -

exploring their

with bodies.

modify as needed. Monitoring helps in identifying the hazards that the environment may cause. 3. Instruct the mother to place pillow on babys both side. To prevent falls. 4. Position the client

Young children do not learn simply by being told They

environment that had help enhance clients safety.

something.

discover meaning. It is important that they have as many chances to explore and learn as They do this

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H E

possible. must

comfortably at the center of

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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 personalsocial 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 DOS and the Donts 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 clients 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. 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. Advice Parents to seek for medical advice and inform the physician for any abnormalities

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PROGNOSIS

Onset of the illness

GOOD FAIR POOR 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 factors

Only one precipitating factor is present in the 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 take medications and treatment

the bloodstream. After being admitted and diagnosed with bacterial meningitis, medication orders and treatment plan was ordered. The patients 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 clients 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 sons

Total

condition. Computation: Poor: (1*1)/7 Fair: (1*2)/7 = 1/7 =2/7 =15/7

Good: (5*3)/7 Total: 2.57

General Prognosis: 1-1.6 = POOR

1.7-2.3 = FAIR
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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 patients 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 patients family. They immediately seek for medical attention to find out whats 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 patients 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 patients 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 clients 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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REFERENCES BOOKS Ann Ehrlich, Carol L. Schroeder. Medical Terminology for Health Professions. Copyright 2004. Barbara Janson-Cohen. Medical Terminology: An Illustrated Guide 5th edition. Copyright 2007. Charlene J. Reeves, Gayle M. Roux, Robin Lockhart. Medical-surgical nursing. Copyright 1995. Jane Hokanson Hawks. Medical-surgical Nursing: Clinical Management for Positive Outcomes. Copyright 2008. Kozier and Erbs Fundmentals of Nursing 8th Edition Nursing Pocket Guide to Diagnoses, Prioritized Interventions and Rationale Doenges et. al. Wilma J. Phipps, Judith K. Sands, Jane F. Marek. Medical-Surgical Nursing: Concepts & Clinical Practice, 6th Edition. USA. Copyright 2000. Understanding Medical Surgical Nursing 3rd edition; International Edition; Williams,S.L.; Hopper, P. D.;F.A. Davis Company, 2007 Brunner and Suddarths Textbook of Medical Surgical Nursing, 11th edition; Smeltze, S.C.; Bare, B.G.; Hinkle, J.L.; Cheever, K.H.; Lippincot, Williams and Wilkins; 2008

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