FIRST ROTATION

CASE PRESENTATION
CONCEPT: INFLAMMATORY AND
IMMUNOLOGIC RESPONSE

BY
KRYSTAL FE NICOLE B. PULMONES
BSN 4A
After 64 hours of related learning experience, I would be able to
apply my knowledge, skills and attitude learned in the classroom
regarding the concept of care of clients with problems with
inflammatory and immunologic response in FM2 ward in Western
Visayas Medical Center.

General OBJECTIVES
I would be able to:
• Identify the problems of a client with inflammatory and immunologic
response by observing the signs and symptoms that she may manifest.
• Recognize the problems of a client’s condition and explain it to her by her
level of understanding.
• Choose appropriate nursing interventions that are applicable to the
client’s condition.
• Ask questions regarding the client’s possible concerns about a procedure
she may undertake or gone through.
• Summarize information gathered in an orderly manner for easier
understanding.

Specific OBJECTIVES
I would be able to:
• Assess client in a cephalocaudal approach to serve as a baseline data.
• Assess the client by taking health history, physical examination, and
laboratory investigation.
• Observe proper aseptic technique such as proper handwashing and
proper gloving when doing sterile procedures.
• Prepare materials needed in advance to save time and effort.
• Enumerate possible and actual nursing management done on the client.

Specific OBJECTIVES
I would be able to:
• Establish good and professional relationship with the client, his or her family
members, hospital staff, clinical instructors, and fellow nursing students.
• Display charity and selfless service as an Augustinian nurse.
• Participate in every procedure that I am assigned to willing with respect.
• Answer the client’s questions regarding his or her health condition
appropriately.
• Comply on the entire task given with love in serving others.

Specific OBJECTIVES
 NURSING HISTORY
DEMOGRAPHIC-BIOGRAPHICAL INFORMATION
Name: HAB Age: 59 years old

Sex: Female Nationality: Filipino

Birthdate: 10/03/1960 Address: Poblacion, Roxas, Capiz

Civil Status: Single Religion: Roman Catholic

Informant: CJB Relation to Client: Daughter

Date/Time of Admission: Date of Discharge:

October 13, 2019/1:20AM --

Chief Complaint: Persistent neck pain

Admission: Diagnosis: To consider Pott’s Disease/ Rule-out metastasis
 NURSING HISTORY
CURRENT HEALTH STATUS
Received in bed, asleep, with main line of IV fluid of PNSS x 60 cc/hr and side drip of
Norepinephrine titrated with D5W x 10 microdrops/min. With endotracheal tube
connected to volume respirator with fraction of inspired O2 (FIO2) of 35. Chief
complaint of persistent neck pain. Has Glasgow coma scale of 11 (E=4, V=1, M=6).
Unable to move lower extremities and obvious foot drop noted. Could follow simple
command such as hand squeezing.
 NURSING HISTORY
HISTORY OF PRESENT ILLNESS
• Two months prior to consult, positive onset of neck pain. Consult done. Pain
medications prescribed and taken.

• One month prior to consult, persistent neck pain. Further consultation advised for
evaluation and management.
 NURSING HISTORY
HISTORY OF PRESENT ILLNESS
• Two months prior to consult, positive onset of neck pain. Consult done. Pain
medications prescribed and taken.

• One month prior to consult, persistent neck pain. Further consultation advised for
evaluation and management.
 NURSING HISTORY
PAST MEDICAL HISTORY
Has history of getting treat for pulmonary tuberculosis in 2017. Was not compliant to
medications for treatment. No reported major hospitalizations before. Other than
previous PTB diagnosis, no major disease encountered. No known food-drug
allergies. No history of diabetes mellitus. No history of bronchial asthma. According
to the informant (daughter), has the occasional cough and cold and mild fevers
and is usually self-medicated.
 NURSING HISTORY
FAMILY MEDICAL HISTORY
No history of diabetes on both maternal and paternal side of the family.
Hypertension is noted with paternal side of the family and maternal side does not
have known history. Has history of breast cancer on one of her siblings. No past
bronchial asthma or any respiratory related illness recorded on both sides of the
family.
 NURSING HISTORY
SOCIO-ECONOMIC STATUS
Before her present illness, HAB works as dried-fish vendor at Teodora Arcena Trade
Center (TATC) in Roxas, Capiz. She only has one daughter, CJB, her companion
during her hospital stay. CJB was studying at her local high school but she had to
stopped going to school because she is needed by her mother. According to her
daughter, they have no one to rely on except themselves. In order to cover her
hospital bills and other expenses during her admission, they had to sell their land.
HAB is the second eldest among her seven siblings. Her siblings still rely on her and
her daughter to give them money for their needs. She has not shared information
about the father of her child because they are not married.
 NURSING HISTORY
NUTRITION
Eats at least two times a day on a regular basis before admission. Likes to eat
vegetables or utan for her side dish with rice. After being admitted, she has a
difficulty of eating by herself due to having an endotracheal tube attached to a
volume respirator, thus, the insertion of the nasogastric tube. She was
recommended to have 2000 kcal/day worth of feedings. She was given six 393 kcal
per feeding.
 PHYSICAL ASSESSMENT
GENERAL SURVEY
HAB, 59 years old, female, single, Roman Catholic devotee was admitted to Western Visayas
Medical Center last October 13, 2019 at around 1:30 AM in the morning. She has a chief complaint
of persistent neck pain. Upon initial assessment, her condition was to be considered as Pott’s
Disease and rule-out metastasis. Received in bed, asleep, with a main line of IV fluid of PNSS x 60
cc/hr and a side drip norepinephrine 16 mg titrated with D5W x 10 microdrops/minute. With a
petite body structure, she could be considered to be underweight for her age with only weighing
around 42 kg. Upon inspection, her over-all body built is skinny or emaciated. Her bone structures
are prominent, from her head to her lower extremities. Obvious signs of craniovertebral dysfunction
are noted as shown by head tilted to her right side. Clavicles are protruding on the area and
somewhat reddish. Currently not wearing any clothing because of difficulty of moving overall
body because of persistent pain on her neck and the inability to feel any sensation on her lower
extremities. Signs of pain noted through facial grimace.
 PHYSICAL ASSESSMENT
NEURO-VITAL SIGNS

Upon assessment, eyes are rated 4, with spontaneous opening when name is
called. Verbal response is noted with 1, with the inability to speak because of the
endotracheal tube attached to her with the volume respirator to help her with her
breathing. As for movement, rated with a 6, with the ability to obey command
when I asked her to squeeze my hands with both of her hands. The total Glasgow
Coma Scale of 11, which could indicate moderately consciouss.
 PHYSICAL ASSESSMENT
SKIN

Skin has an over-all even complexion. Cold and clammy to touch especially on her
hands. She has even skin tone throughout her body. Redness on skin noted on her
clavicle area. No rashes noted. Some insect bites are noted on her left upper
extremity. Swelling noted on the left IV site. The skin on her upper extremities
appears to be wrinkly and dry. Several lesions are noted on the skin of her lower
extremities and appears to be extremely dry. Signs of flakiness and scaling noted.
When pinched, skin takes a while to go back to normal shape. Capillary refill is
delayed upon assessment of blanche test.
 PHYSICAL ASSESSMENT
HAIR

Natural black in color and has a little to no white hairs. Put into an untidy loose
ponytail. Accumulated dirt and oil is noted. Hair is evenly distributed throughout the
head. Dandruffs noted and no signs of folliculitis. No lice noted as well. No empty
patches of hair or early signs of alopecia noted. After palpation, no tenderness,
masses and lesions noted.
 PHYSICAL ASSESSMENT
HEAD, NECK

Head is normocephalic, round and symmetric and appropriate to body size. Tilted
to the right side of the body. Pain is noted whenever the area is moved. Obvious
signs of difficulty on movement. Movement and range of motion on neck is limited.
Redness and signs of swelling noted on clavicle. Facial structures are asymmetric
upon inspection. The mouth is slightly drooping to one side. No tenderness, lesions
and masses on each side of the face upon palpation. No signs of swelling and
edema on the area of the face.
 PHYSICAL ASSESSMENT
EYES

Eyes are dark-brown, and pupils are equally round, react well to light and well
accommodated upon inspection. Lacrimal ducts are clear with no discharges. Few
eye mucus is noted on both eyes. Eyelashes are evenly distributed and turned
outward. Sclera is a bit yellow with some blood vessels visible. No extra ocular
movement noted. With lids close, no tenderness and tension palpated. Conjunctiva
is pale pink in color with no signs of swelling.
 PHYSICAL ASSESSMENT
EARS

Ears are symmetrical and proportional to the head. The color of the outer ears is the
same to the complexion of the skin. No scratches or any visible lesions are noted.
Yellow and sticky cerumen is observed. Eardrums are intact and there are no signs
of inflammation and other discharges upon inspection of the external canal.
 PHYSICAL ASSESSMENT
THORAX AND LUNGS

Attached to a volume respirator via endotracheal tube. Has fraction of inspired

oxygen of 35. Upon inspection, respirator is attached well and has the ability to aid
her with her breathing. No abnormal masses and swelling on thoracic area. Chest
pain noted when area is touched. Upon auscultation, crackles and wheezing could
be heard.
 PHYSICAL ASSESSMENT
HEART

No bulges on chest upon inspection. Normal heart sounds are noted upon
auscultation. Normal pulse rate of 85 beats per minute.

ABDOMEN

Contour of the abdomen is rounded and flat. No distention noted and is bilaterally
symmetric and smooth. No visible masses observed. Umbilicus is inverted and slightly
dirty. No signs of hernia or any inflammation. No lesions are present.
 PHYSICAL ASSESSMENT
UPPER EXTREMITIES

Both upper extremities are equal in size. No voluntary movement are noted. Has
difficulty of moving arms in an upward motion. Obvious signs of muscular atrophy
noted. Range of motion is very limited. Could squeeze hand upon command. Some
lesions are noted from previous IV sites. Swelling and redness is noted on the left-
hand side of the arm on current IV site.
 PHYSICAL ASSESSMENT
LOWER EXTREMITIES

Both lower extremities do not have sensation. Range of motion is not performed.
Flakiness and scales are noted because of dry skin. Toenails are dirty and
untrimmed. Heels are dry and cracked. Foot drop is observed upon inspection. No
other masses or swelling observed.
anatomy & physiology
anatomy & physiology
THE SPINE
• The bone closest to the head is called the
atlas because it carries the weight of the
skull.
• Individuals bones are grouped together
and include – from top to bottom:
• Cervical bones – 7
• Thoracic Bones – 12
• Lumbar – 5
• Sacrum – 4
• Tailbone – 1
 Normal lateral view xray of the neck. Lateral view of neck shows a narrowing at the C3-C4 level with
thickening of the soft tissue in front of the cervical column (pre-
vertebral soft tissue) containing air.

XRAY
Disclaimer: Photos are taken from the internet and not actual from the client’s files.
 Precipitating:
Predisposing:
Modifiable
Non-modifiable
- Poverty
- Older Age (59 years old)
- Malnutrition
- History of Pulmonary
- Overcrowding
Tuberculosis Infection with mycobacterium tuberculosis through exposure - Illiteracy
of the lungs or mucous membranes to infected aerosols.

TB bacilli then access the blood stream and spread through

the body, finding other sites to build cavitation and multiply

Pott’s Disease

Progressive bone destruction leads to vertebral collapse and

kyphosis.

The spinal canal can be narrowed by abscesses, granulation

tissue, or direct dural invasion.

Leading to spinal cord compression and neurologic deficits.

 L A B O R A T O R I E S
HEMATOLOGY
DATE AND TIME PERFORMED: DECEMBER 1, 2019; 3:07 PM

DATE AND TIME RELEASED: DECEMBER 3, 2019; 3:10 PM

REFERENCE
TEST NAME RESULT UNIT SIGNIFICANCE
RANGE
HEMOGLOBIN L 11.4 g/dL 12.3-15.3

HEMATOCRIT L 0.34 Vol% 0.37-0.47

RBC L 4.0 x1012/L 4.5-6.1

WBC H 16.3 x109/L 4.4-11.0

 L A B O R A T O R I E S
HEMATOLOGY
DATE AND TIME PERFORMED: DECEMBER 1, 2019; 3:07 PM

DATE AND TIME RELEASED: DECEMBER 3, 2019; 3:10 PM

REFERENCE
TEST NAME RESULT UNIT SIGNIFICANCE
RANGE
DIFFERENTIAL COUNT
Neutrophils H 0.83 0.54-0.68

Eosinophil 0.01 0.01-0.04

Basophil 0.00 0.00-0.01

Lymphocyte L 0.10 0.25-0.33

Monocyte 0.06 0.03-0.07

 L A B O R A T O R I E S
HEMATOLOGY
DATE AND TIME PERFORMED: DECEMBER 1, 2019; 3:07 PM

DATE AND TIME RELEASED: DECEMBER 1, 2019; 3:10 PM

REFERENCE
TEST NAME RESULT UNIT SIGNIFICANCE
RANGE
TOTAL DIFFERENTIAL
MCV 85.9 fL 76.0-96.0

MCH 28.7 pg 27.0-32.0

MCHC 33.4 g/dL 30.0-35.0

RDW-CV H 14.6 % 1.5-14.5

Platelet Count (APC) 165 X109/L 150-450

 L A B O R A T O R I E S
CLINICAL CHEMISTRY
DATE AND TIME PERFORMED: DECEMBER 3, 2019; 9:53 PM

DATE AND TIME RELEASED: DECEMBER 3, 2019; 10:10 PM

REFERENCE
TEST NAME RESULT UNIT SIGNIFICANCE
RANGE
CLINICAL CHEMISTRY
MAGNESIUM L 0.59 mmol/L 0.63-1.05

PHOSPHOROUS L 0.77 mmol/L 0.81-1.45

 L A B O R A T O R I E S
ARTERIAL BLOOD GAS RESULT
DATE AND TIME PERFORMED: DECEMBER 1, 2019; 10:40 AM

DATE AND TIME RELEASED: DECEMBER 1, 2019; 11:00 AM

REFERENCE
TEST NAME RESULT UNIT SIGNIFICANCE
RANGE
BLOOD GAS VALUES
pH H 7.55 mmHg 7.35-7.45

PaCO2 L 26 mmHg 35-45

PaO2 H 147 mmHg 80-100

HCO3 22.7 mEq/l 22-26

BE 1.4 mEq/l +/- 2

tCO2 23.5 mmol/l 23-27

SaO2 99 %
culture and sensitivity SPECIMEN DATE: NOVEMBER 13, 2019 SPECIMEN TYPE: BLOOD

TIME RECEIVED: 9:25 PM SPECIMEN SITE: LEFT ARM

ORGANISM: ENTEROBACTER AEROGENES

Amikacin R >32 mcg/mL Amoxicillin/Clavulanic Acid R >16 mcg/ml

Cefipime R 32 mcg/ml Cefoxitin R >32 mcg/ml

Ceftazidime S 4 mcg/ml Ceftriaxone R 32 mcg/ml

Cefuroxime R >32 mcg/ml Ciprofloxacin I 2 mcg/ml

Gentamicin R >8 mcg/ml Imipenem R >8 mcg/ml

Meropenem R 8 mcg/ml Piperacillin/Tazobactam R >64 mcg/ml

Trimethoprim/Sulfamethoxazole S ≤2 mcg/ml Cefuroxime axetil R >32 mc/ml

S - SUSCEPTIBLE I – INTERMEDIATE R – RESISTANT NS – NON-SUSCEPTIBLE

culture and sensitivity SPECIMEN DATE: NOVEMBER 14, 2019 SPECIMEN TYPE: BLOOD

TIME RECEIVED: 12:40 AM SPECIMEN SITE: LEFT ARM

ORGANISM: PSEUDOMONAS AERUGINOSA

Amikacin S ≤2 mcg/ml Cefepime S >16 mcg/ml

Ceftazidime S 4 mcg/ml Ciprofloxacin S ≤ .25 mcg/ml

Gentamicin S ≤ 1 mcg/ml Imipenem S 1 mcg/ml

Meropenem S ≤ .25 mcg/ml Piperacillin/Tazobactam S 8 mcg/ml

Colistin S ≤ .5 mcg/ml

S - SUSCEPTIBLE I – INTERMEDIATE R – RESISTANT NS – NON-SUSCEPTIBLE

 D R U G S T U D Y CEFTAZIDIME, 1 gram, Q8H
Brand Name: Ceftime
Classification: Cephalosphorins

SPECIAL SIDE EFFECTS/ADVERSE DOSAGE/

INDICATION ACTION CONTRAINDICATIONS NURSING RESPONSIBILITY
PRECAUTIONS REACTIONS AVAILABILITY

• Assess for infection (vital signs;

1-2 g 8 appearance of wound,
sputum, urine, and stool; WBC)
hourly as at beginning of and throughout
Patient w/ history of deep IM
The bactericidal activity Hypersensitivity to Diarrhea, nausea, therapy.
penicillin allergy, inj, slow IV • Obtain specimens for culture
of ceftazidime results vomiting,
For bone and from the inhibition of cell ceftazidime or seizure disorder. and sensitivity before initiating
abdominal pain, inj over 3-
joint infections wall synthesis via affinity other Renal impairment.
metallic
therapy.
for penicillin-binding Pregnancy and 5 min or • Observe patient for signs and
cephalosporins. taste; hypokalemia symptoms of anaphylaxis.
proteins (PBPs), resulting lactation. IV infusion • Monitor bowel function.
into cell death.
for up to Diarrhea, abdominal cramping,
30 min. fever, and bloody stools.
 D R U G S T U D Y RANITIDINE, 150 mg, IVTT, Q12H
Brand Name: Zantac
Classification: Antacids, Antireflux
Agents & Antiulcerants

SPECIAL SIDE EFFECTS/ADVERSE DOSAGE/

INDICATION ACTION CONTRAINDICATIONS NURSING RESPONSIBILITY
PRECAUTIONS REACTIONS AVAILABILITY

Patient with chronic • Check for allergy to ranitidine,

lung disease, impaired renal or hepatic
function, lactation, pregnancy
diabetes, factors • Administer oral drug with meals
predisposing to Initially, and at bedtime.
cardiac rhythm • Decrease doses in renal and
150 mg
Ranitidine competitively disturbances. liver failure.
and reversibly inhibits Immunocompromis bid or tid, • Provide concurrent antacid
histamine at H2- ed or severely ill Rarely, mental may be therapy to relieve pain.
Pathological receptors of the gastric History of acute patient. Rule out confusion, increased
hypersecretion of parietal cells thereby porphyria. gastric malignancy depression, if
gastric acid inhibiting gastric acid
or possibility of hallucinations.
secretion, gastric necessary
volume and reducing malignancy prior to
, up to
hydrogen ion initiation of therapy.
concentration. Renal and hepatic 6,000 mg
impairment. daily.
Children.
Pregnancy and
lactation.