A Case Study

Presented to the Faculty of

The Ateneo de Davao University

College of Nursing

A Case Study on

HYPOXIC ENCEPHALOPATHY SECONDARY TO STATUS EPILEPTICUS

SECONDARY TO CENTRAL NERVOUS SYSTEM INFECTION

Submitted by:

Marie Allexis Campaner

Submitted to:

February 2011

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TABLE OF CONTENTS

i. Acknowledgement.……………………………………………………………………………. 1

I. Introduction……………………………………………………………………………………. 2

II. Objectives (General & Specific)………………………………………………………………. 4

III. Patient’s Data………………………………………………………………………………….. 6

IV. Family Background & Health History………………………………………………………… 8

V. Genogram …………………………………………………………………………………. 11

VI. Developmental Data…………………………………………………………………………… 12

VII. Physical Assessment…………………………………………………………………………... 18

VIII. Complete Diagnosis…………………………………………………………………………… 23

IX. Anatomy and Physiology……………………………………………………………………… 26

X. Etiology……………………………………………………………………………………….. 40

XI. Symptomatology……………………………………………………………………………… 44

XII. Pathophysiology……………………………………………………………………………… 54

XIII. Doctor’s Order……………………………………………………………………………….. 56

XIV. Diagnostic Examination………………………………………………………………………. 70

XV. Drug Study……………………………………………………………………………………. 93

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XVI. Nursing Theories……………………………………………………………………………… 114

XVII. Nursing Care Plans……………………………………………………………………………. 118

XVIII. Prognosis ……………………..………………………………………………………………. 149

XIX. Discharge Planning ……………………..……………………………………………………. 145

XX. Recommendation …………………………………………………………………………….. 152

XXI. Bibliography …..……………………………………………………………………………… 155

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Acknowledgment

Putrid visions will turn into reality if from time to time when we pour into our

hands the sands from the hourglass of time and dewdrops of windswept fortitude to

nourish the seeds of ideas in our minds. And perhaps, we need the warmth of others to

watch that seed grow.

The author would like to extend her warmest gratitude to the people who helped

make the success of this undertaking a reality.

First and foremost, to the Almighty Father, for His unceasing love and blessings;

for the gift of wisdom and resilience to face all the hardships in the making of this work.

To Him be all glory and praise!

To the Clinical Instructors, who devoted their time and effort serving as guide in

the course of hospital exposures; for being second parents in the field who never stopped

imparting their knowledge and skills.

To her parents, for their love and support through all the years; for making each

day less hard by inspiring her to do more and being always there to look after her.

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 for the author to share.

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INTRODUCTION

Hypoxic Encephalopathy is a condition which results from lack of delivery of

oxygen to the brain because of several causes; ranging from hypotension to respiratory

failure, the most common causes are MI, cardiac arrest, shock, asphyxiation, paralysis of

respiration, and carbon monoxide or cyanide poisoning. In some circumstances, hypoxia

may predominate. Effects of this condition may lead to brain death or a persistent

vegetative state.

Neonatal encephalopathy (NE) is the clinical manifestation of disordered neonatal

brain function. Lack of universal agreed definitions of NE and the sub-group with

hypoxic-ischaemia (HIE) makes the estimation of incidence and the identification of risk

factors problematic. NE incidence is estimated as 3.0 per 1000 live births (95%CI 2.7 to

3.3) and for HIE is 1.5 (95%CI 1.3 to 1.7). The risk factors for NE vary between

developed and developing countries with growth restriction the strongest in the former

and twin pregnancy in the latter.

In the light of this, the proponent of the study encountered a patient at Southern

Philippines Medical Center Pediatric Neuro Ward and was chosen to be the subject of

this case study principally due to the reason that her condition poses a good avenue to

broaden one’s knowledge regarding pediatric neurological cases, their nature,

manifestations and treatment; a case requiring proper nursing understanding and

comprehension.

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The patient, to be mentioned in this paper as Child Y, was one of the patients

admitted to Pediatric Ward due to Hypoxic Encephalopathy secondary to Status

Epilepticus secondary to Central Nervous System Infection.

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OBJECTIVES

General Objective:

The main goal of this undertaking is to be able to present a case study of the

chosen client that would provide a comprehensive discussion of the pathological

mechanism of the disease, its manifestations, nature, causes, treatment and

management to yield significant information for the case study.

Specific Objectives:

In order to meet the general objective, the following specific objectives are derived:

Establish rapport to the patient and the patient’s significant others;

Interpret the pertinent data gathered from the patient and her significant others;

State past and present health history of the patient;

Trace the family genogram;

Evaluate the present developmental stage of the patient according to the theories

of Erikson, Freud, and Havighurst;

Define the complete diagnosis of the patient;

Present the cephalocaudal assessment obtained from the patient;

Discuss the anatomy and physiology of the organ involved in the patient’s

disease;

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

Trace the pathophysiology of the patient’s disease;

Obtain and rationalize the doctor’s order;

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Interpret the laboratory test results of the patient;

Discuss the nature of the drugs given to the patient;

Discuss the surgical procedure performed to the patient;

Relate the patient’s disease with the different nursing theories specifically those

of Nightingale, Orem and Henderson;

Present a specific, measurable, attainable, realistic and time-bounded nursing care

plans for the client;

Justify the client’s prognosis according to different criteria;

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

and

outline recommendations based on the case study’s findings.

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PATIENT’S DATA

Personal data

Patients Name: Child Y

Age: 3 years old

Weight 10.5 kilograms

Height 3’2’’

Gender: Female

Birth date: June 16, 2007

Address: Mateo, Kidapawan City

Nationality: Filipino

Religion [Domination]: Christian [Roman Catholic]

Clinical/ Admitting Data

Date of admission: January 10, 2011

Time of admission: 11:10pm

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Ward [Room & Bed Numbers]: Pediatric Ward- Neuro, Bed No.2

Admitting Physician: Dr. Leo Paolo Lebiano

Attending Physician: Daisy Mae Mariquit

Chief complaint: Seizures, vomiting

Admitting Diagnosis: Hypoxic Encephalopathy secondary to Status Epilepticus

secondary to Central Nervous System Infection

Source of information: Mother

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FAMILY BACKGROUND AND HEALTH HISTORY

HEALTH BACKGROUND

A. Family Background

Child Y is the youngest child in a brood of three. Only she has been reported to

have exhibited signs of seizure of all the three children in the family. The mother reported

hypertension to run in her family, while no familial conditions exist in the lineage of her

husband.

The family’s source of income is their farm, where the parents of the patient are

both self-employed, earning grossly 5,000 to 8,000 a month. Her family’s diet is

composed of meat, fish and vegetables, however, due to her hospitalization she has been

administered OT feedings.

B. History of Past Illness

The patient was born via normal spontaneous vaginal delivery. She did not have

any complications nor unusualities when she was delivered. She was breastfed until the

age of two and a half and has had the following vaccines: BCG, OPV, DPT, Measles and

Hepatitis. She has no known allergies and has not been hospitalized for any other disease

before.

C. Present Health History

Three days prior to admission, the patient had onset of moderate grade fever

associated with three episodes of vomiting which are non-projectile in nature and cough.

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Such symptoms persisted for three days in moderate frequencies which compelled the

family to seek medical attention. The patient was brought to a local hospital and was

given cefuroxime, with the initial diagnosis of sepsis.

On the second hospital day, the patient had several episodes of seizures, with

positive rolling of eyeballs and stiffness of extremities approximately 10 minutes in

duration with approximately 30 minutes interval, with cyanosis and was not awake after

seizure.

On the third day, the patient was transferred to another hospital and was given the

diagnosis Hypoxic Encephalopathy secondary to Status Epilepticus secondary to Central

Nervous System Infection probably Bacterial Meningitis. The following medications

were given to address the patient’s condition:

a. Ceftriaxone 100mkd BID for 4-5days

b. Gentamycin 8mkd BID for 5 days

c. Salbutamol neb q6

d. Phenobarbital 5mkd

e. Diazepam 0.2ml stat

f. 0xygen

Neuro notes of the previous hospital also showed a positive loss of vision and

stupor. GCS score was 9/15 with the following breakdown Eye movement= 1, Best

verbal response = 2 and Best motor response = 6 with absent deep tendon reflex on both

lower extremities.

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The patient was referred to Southern Philippines Medical Center for further

treatment and evaluation on the 10th of January.

D. Effects/ Expectations of Illness to Self/ Family

The mother verbalized that after the diagnosis was determined; her family had a hard

time accepting the situation. The child used to be very cheerful and playful until the

illness took everything away from her. Nevertheless, the mother verbalized that they had

already accepted her condition, its treatment and the possible future effects that the

condition will eventually bring financially and emotionally. However, everyone in the

family has a positive attitude and high hopes towards the patient’s condition.

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GRANDFATHER A Ω

GRANDMOTHER A GRANDFATHER B GRANDMOTHER B

UNCLE B1 UNCLE B2 UNCLE B3 FATHERUNCLE A

MOTHER

CHILD Y

∑

LEGEND:

Ω - Deceased

- Hypertension

∑ - Status Epilepticus

DEVELOPMENTAL DATA

Developmental stage theories characterize a person’s behaviors or tasks into approximate

age ranges or in terms that describe the features of an age group. These theories allow nurses to

describe typical behaviors of an individual within a certain age group, explain the significance of

those behaviors, predict behaviors that may occur in a given situation and provide rationale to

control behavioral manifestations. The nurse’s knowledge of these theories can be used in

parental and client education, counseling and anticipatory guidance.

Freud's Model of psychosexual development

The concept of psychosexual development was envisioned by Sigmund Freud. It consists

of five separate phases: oral, anal, phallic, latency, and genital. In the development of his theory,

Freud's main concern was with sexual desire, defined in terms of formative drives, instincts and

appetites that result in the formation of an adult personality.

The Freudian theory assets that the individual must meet the needs of each stage in order

to move successfully to the next developmental stage. If a person does not achieve a satisfactory

progression at one stage, the personality becomes fixated at that stage. Fixation is immobilization

or the inability of the personality to proceed to the next stage because of anxiety.

Assess

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Stages -ment Justification

ANAL STAGE

The child is approached with this conflict with

the parent's demands. A successful completion

of this stage depends on how the parents interact

with the child while toilet training. A child who

has not successfully completed this behavior will

become an adult who has an anally expulsive

character. They will be characterized as

disorganized, messy, reckless, careless, and

defiant. If the child's tactics are overindulged

then they can form an anally retentive character

as an adult. The anal retentive character is the

opposite of an anally expulsive character. This

child will find pleasure in withholding faeces in

the body. However, a child who has successfully

completed this stage will be characterized as

having used proper toilet training techniques

throughout toilet training years and will

successfully move on to the next stage. Although

the stage seems to be about proper toilet training,

A

C

H

I

E

V

E

D

The child has already been toilet

trained as claimed by the mother.

She reports that the child, before the

onset of the illness which generally

have put her in a persistence

vegetative state, was able to manage

to eliminate on her own. The child is

said to have been able to go to the

CR, flush the toilet and clean herself

thereafter on her own.

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it is also about controlling behaviors and urges.

A child needs to learn certain boundaries when

they are young so that in the future there will not

be contention regarding what is over-stepping

the boundaries.

Erikson’s Psychosocial Development

Psychosocial development as articulated by Erik Erikson describes eight developmental

stages through which a healthily developing human should pass from infancy to late adulthood.

In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on

the successful completion of earlier stages. The challenges of stages not successfully completed

may be expected to reappear as problems in the future. Although he was influenced by Freud, he

believed that the ego exists from birth and that behavior is not totally defensive. Based in part on

his study of Sioux Indians on a reservation, Erikson became aware of the massive influence of

culture on behavior and placed more emphasis on the external world, such as depression and

wars. He felt the course of development is determined by the interaction of the body (genetic

biological programming), mind (psychological), and cultural (ethos) influences.

Stages Assess Justification

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-ment

Stage 3: Late Childhood (3-5 years old)

Initiative Versus Guilt

Initiative adds to autonomy the quality of

undertaking, planning and attacking a task for

the sake of being active and on the move. The

child is learning to master the world around

them, learning basic skills and principles of

physics. Things fall down, not up. Round things

roll. They learn how to zip and tie, count and

speak with ease. At this stage, the child wants to

begin and complete their own actions for a

purpose. Guilt is a confusing new emotion. They

may feel guilty over things that logically should

not cause guilt. They may feel guilt when this

initiative does not produce desired results.

During this stage, the child learns to take

initiative and prepare for leadership and goal

achievement roles. Activities sought out by a

child in this stage may include risk-taking

behaviors, such as crossing a street alone or

riding a bike without a helmet; both these

A

C

H

I

E

V

E

D

Verbalizations of the mother asserts

that the child has been very active at

play. She plays with their neighbors

and tends to foster a good sense of

leadership and independence. The

mother says that she can even leave

her child to play at their backyard

when she does her household chores.

The child manages to pass time on

her own, playing with other kids and

doing things on her own. She even

recalls her daughter giving her

flowers from the sidewalk that she

picked on her mother’s birthday.

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examples involve self-limits. Within instances

requiring initiative, the child may also develop

negative behaviors. These behaviors are a result

of the child developing a sense of frustration for

not being able to achieve a goal as planned and

may engage in behaviors that seem aggressive,

ruthless, and overly assertive to parents.

Aggressive behaviors, such as throwing objects,

hitting, or yelling, are examples of observable

behaviors during this stage.

Havighurst’s Developmental Theory

Robert Havighurst believed that learning is basic to life and that people continue to learn

throughout life. Havighurst's educational research did much to advance education in the United

States. Educational theory before Havighurst was underdeveloped. Children learned by rote and

little concern was given to how children developed. From 1948 to 1953 he developed his highly

influential theory of human development and education. The crown jewel of his research was on

developmental task. Havighurst tried to define the developmental stages on many levels. He

describes growth and development as occurring during six stages. Each associated with the six to

ten tasks to be learned.

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StagesAssess

-mentJustification

Infancy to Early Childhood (Birth to 6 years)

Learning to walk.

Learning to crawl.

Learning to take solid food.

Learning to talk.

Learning to control the elimination of

body wastes.

Learning sex differences and sexual

modesty.

Getting ready to read.

Forming concepts and learning language

to describe social and physical reality.

A

C

H

I

E

V

E

D

Relative to her age, the child is able

to achieve the developmental tasks

posed by Havighurst. The child is

already able to walk, eat, talk,

eliminate, and has formed skills in

language and socialization.

Although the child is not ready to

read and properly distinguish sexual

differences and modesty, these

concepts cannot be expected of her

at the moment since she is still 3

years old.

PHYSICAL ASSESSMENT

General Survey

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Assessed lying on bed, asleep; with IVF of D5 0.3 NaCl 500cc infusing well at 40gtt/min

attached to left metacarpal vein with insertion site clean and patent; with NGT attached to right

nares with distal end closed, with a height of 3 feet 2inches, weight of 23.1 lbs; a BMI of 11.3

suggestive of being underweight. Patient appears to be in persistent vegetative state, with noted

presence of nuchal and decerebrate rigidity; no response can be elicited by applying verbal or

tactile stimuli by the nurse. However, response to painful stimuli thru crying was observed. No

body odor or breath odor noted, unable to talk and ambulate.

Vital Signs

Temperature 37.3C

Pulse Rate 120 beats per minute

Respiratory Rate 33 cycles per minute

Skin

Skin is dark brown in color and uniform in distribution. No edema noted. Skin is warm to

touch and is dry. Good skin turgor is noted, with capillary refill time of 2 seconds. No freckles

and birthmarks are noted.

Head

Head is normocephalic and symmetrical with a circumference of 20 inches; smooth skull

contour is observed. The patient has thin and short hair which is straight, coming in black strands

with smooth and silky texture; no nits, lice and hair flakes upon inspecting the scalp. No nodules,

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masses, and depressions noted; head is smooth with uniform consistency. There are symmetrical

facial feature and symmetric nasal folds. Symmetry of facial movements is normal, upon raising

eyebrows, frowning, closing the eyes, and smiling.

Eyes

Eyes are symmetrical and almond in shape. Eyebrows are evenly distributed with black

hair strands; eyebrows symmetrically aligned and equal in movement. Eyelashes are equally

distributed and curled slightly outward. Skin of the eyelids is intact; no discharge and

discoloration noted; lids close symmetrically while blinking. Ecteric sclera without prominence

of capillaries. Conjunctivas are pinkish in color. No edema or tenderness over lacrimal gland;

edema or tearing of lacrimal gland not noted. Iris is black in color. No redness and secretions

noted. Ptosis not noted. Pupils are 3 mm in diameter upon exposure to light and 4 mm in

diameter without light exposure. Pupils equal in size, reactive to light and accommodation but

with sluggish reaction. Patient is unable to see anything since the onset of the illness,

furthermore, absence of corneal reflex suggesting a damage in CN V is noted.

Ears

Ears are same in color with the facial skin, symmetrical and aligned to the outer canthus

of the eyes. The pinna is semi-firm, non-tenderness noted upon palpation and recoils back after it

is folded. No lesions, discoloration and redness noted. Ability of the patient to hear is based on

her ability to respond to vocal stimuli of the mother when lulling patient to sleep, however the

patient is unable to respond both verbally and nonverbally when being stimulated aurally upon

assessment.

Nose

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Nose is symmetric and straight; no lesions and discoloration noted. Nasal septum is

positioned in the midline. With evenly distributed ciliary hairs. No discharges noted; no nodules

and polyps upon inspection as well. Nasal flaring not noted. No deformity and tenderness noted

upon palpation. Air moves freely as the patient breathes through the nares. An NGT tube is

placed snuggly in the patient’s right nares.

Mouth

Lips are symmetrical, assessed to be pale and dry, symmetry of contour of the lips noted.

Teeth are smooth, whitish, and with shiny tooth enamel. Dental plaques and caries were noted.

Gingival and mucosal pallor noted. No thrush and mouth sores noted. Tongue is in central

position; with pale pink color, moist surface, slightly rough texture, with thin whitish coating,

and with spongy white patches on the anterior part of the tongue. Tongue moves freely without

tenderness. Tongue is smooth with no palpable nodules. Uvula is positioned in the midline of the

soft palate. Oropharynx with pink and smooth posterior wall; tonsils are pink and smooth with no

visible inflammation and of normal size.

Neck

Skin color of the neck is similar with that of the face. No lesions and discoloration noted.

Muscles are equal in size and the head is centered. Muscle strength of the left and right

sternocleidomastoid muscles is equal; left and right trapezious are equal in strength. Lymph

nodes are not palpable. The trachea is in the midline of the neck. Carotid pulses are palpable.

Thyroid glands are not palpable. No masses noted upon palpation.

Chest and Lungs

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No discolorations and lesions noted. Thoracic cavity is symmetrical. The ribs and coastal

margins are symmetrical. The sternum is at the midline. Nipples are symmetrical in position.

Chest skin is intact and uniform in temperature. Chest wall is intact; no tenderness and masses

noted. Normal respiratory rate of 33 breaths per minute with equal spaces in between is noted.

Full symmetric excursion of anterior chest noted. Bilateral symmetry of vocal fremitus on the

posterior chest noted; vocal fremitus is symmetric in anterior chest but decreased over heart and

breast tissue. Adventitious breath sounds are absent upon auscultation.

Heart

The cardiac rate upon assessment is 120 beats per minute with regular rate and rhythm;

with equal intervals between beats. Upon auscultation, no murmurs noted. Not in cardiac

distress. Point of maximal impulse is located at the left midclavicular line, fifth intercoastal

space.

Abdomen

Abdomen is flat and uniform in color; vascular patterns not visible. Skin temperature

surrounding the incision is uniform and within normal ranges. No evidence of enlargement of the

liver or spleen upon inspection. Abdominal girth is 26 inches. Symmetrical abdominal

movements upon respiration noted. Bowel sounds are audible with a rate of 10 bowel sounds per

minute, auscultated at the left upper and lower quadrant. Upon percussion, tympany over the left

upper quadrant is noted. Upon light palpation, no tenderness was reported, abdomen is relaxed

with smooth, consistent tension. The bladder is not enlarged and not palpable.

Genito-Urinary

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Upon inspection, clear and whitish urine color noted. Discharges were not reported. No

odor, lesions and itchiness were reported. No tenderness reported. No swelling and bulges were

reported as well; patient voiding freely with urine output in diapers of 800cc in 8 hours.

Back and Extremities

Spine is vertically aligned; spinal column is straight. Right and left shoulders are of the

same height. There is symmetry in the sizes of the extremities. No discolorations and lesions

noted. No edema noted. No deformities and contractures noted. Muscles are semi-firm upon

palpation. Tremors not noted. Strong radial pulsations noted on upper extremities. Upper and

lower extremities have no apparent range of motion due to nuchal rigidity. Patient is unable to

walk with absence of deep tendon reflexes on both lower extremities. Bedsores are not noted.

Untrimmed fingernails and toenails noted. The capillary refill distribution is 2 seconds;

extremities are able to perceive pain sensation upon pinching.

DEFINITION OF COMPLETE DIAGNOSIS

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Hypoxic Encephalopathy secondary to Status Epilepticus secondary to Central Nervous

System Infection

Hypoxic Encephalopathy

Hypoxic-ischemic encephalopathy is characterized by clinical and laboratory evidence of

acute or subacute brain injury due to asphyxia (ie, hypoxia, acidosis). Most often, the exact

timing and underlying cause remain unknown.

Mosby’s Pocket Dictionary of Medicine, Nursing & Health Professions 5th edition

Hypoxic encephalopathy is the amage to cells in the central nervous system (the brain and spinal

cord) from inadequate oxygen. Hypoxic-ischemic encephalopathy allegedly may cause in death

in the newborn period or result in what is later recognized as developmental delay, mental

retardation, or cerebral palsy. This is an area of considerable medical and medicolegal debate.

Hopper P.D., Williams, L.S.; Understanding Medical Surgical Nursing 3rd Edition

Hypoxic encephalopathy is a condition in which the brain does not receive enough

oxygen. This particular condition refers to an oxygen deficiency to the brain as a whole, rather

than a part of the brain. Although the term most often refers to injury sustained by newborns,

hypoxic encephalopathy can be used to describe any injury from low oxygen.

Ray A. Hargrove-Huttel; Medical Surgical Nursing

Status Epilepticus

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Status epilepticus is a medical emergency familiar to accident and emergency

departments, acute medical wards, and intensive care units. It is defined as a continuous seizure

lasting for at least 30 minutes, or two or more discrete seizures between which the patient does

not recover consciousness.

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

Defined as continuous seizures or repetitive, discrete seizures with impaired

consciousness in the interictal period. May occur with all kinds of seizures: grand mal (tonic-

clonic) status, myoclonic status, petit mal status, and temporal lobe (complex partial) status.

Generalized, tonic-clonic seizures are most common and are usually clinically obvious early in

the course. After 30-45 min, the signs may become increasingly subtle and include only mild

clonic movements of the fingers or fine, rapid movements of the eyes.

Raimond, Jeanne, et. Al. Neurological Emergencies

and Effective Nursing Care.

A seizure that persists for a sufficient length of time or is repeated frequently enough that

recovery between attacks does not occur. International

League Against Epilepsy, 1981

Central Nervous System Infection

27

Central nervous system infections are those infections of the central nervous system

(CNS). There are four main causes of infections of the nervous system: bacterial, viral, fungal

and protozoal.

Maria, Bernard. Current Management in Child Neurology.

ANATOMY AND PHYSIOLOGY

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The Brain

The brain is the most complex part of the human body. This three-pound organ is the seat

of intelligence, interpreter of the senses, initiator of body movement, and controller of behavior.

Lying in its bony shell and washed by protective fluid, the brain is the source of all the qualities

that define our humanity. The brain is the crown jewel of the human body. The brain serves

many important functions. It gives meaning to things that happen in the world surrounding us.

We have five senses: sight, smell, hearing, touch and taste. Through these senses, our

brain receives messages, often many at one time. It puts together the messages in a way that has

meaning for us, and can store that information in our memory. For example: An oven burner has

been left on. By accident we touch the burner. Our brain receives a message from skin sensors on

our hand. Instead of leaving our hand on the burner, our brain gives meaning to the signal and

tells us to quickly remove our hand from the burner. Heat has been felt. If we were to leave our

hand on the burner, pain and injury would result. As adults, we may have had a childhood

memory of touching something hot that resulted in pain or watching someone else who has done

so. Our brain uses that memory in a time of need and guides our actions and reactions in a

harmful situation.

With the use of our senses: sight, smell, touch, taste, and hearing, the brain receives many

messages at one time. It can select those which are most important. Our brain controls our

thoughts, memory and speech, the movements of our arms and legs and the function of many

organs within our body. It also determines how we respond to stressful situations (i.e. writing of

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an exam, loss of a job, birth of a child, illness, etc.) by regulating our heart and breathing rate.

The brain is an organized structure, divided into many parts that serve specific and important

functions.

Three cavities, called the primary brain vesicles, form during the early embryonic

development of the brain. These are the forebrain (prosencephalon), the midbrain

(mesencephalon), and the hindbrain (rhombencephalon).

During subsequent development, the three primary brain vesicles develop into five secondary

brain vesicles. The names of these vesicles and the major adult structures that develop from the

vesicles follow:

The telencephalon generates the cerebrum (which contains the cerebral cortex, white

matter, and basal ganglia).

The diencephalon generates the thalamus, hypothalamus, and pineal gland.

The mesencephalon generates the midbrain portion of the brain stem.

The metencephalon generates the pons portion of the brain stem and the cerebellum.

The myelencephalon generates the medulla oblongata portion of the brain stem

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TABLE 1 The Vesicles and Their Components

Primary Vesicles Secondary Vesicles Adult Structure

Important Components or

Features

prosencephalon

(forebrain)

telencephacerebrum cerebral (cerebral

hemispheres)

cerebral cortex (gray matter):

motor areas, sensory areas,

association areas

prosencephalon

(forebrain)

telencephacerebrum cerebral (cerebral

hemispheres)

cerebral white matter:

association fibers, commisural

fibers, projection fibers

prosencephalon

(forebrain)

telencephacerebrum cerebral (cerebral

hemispheres)

basal ganglia (gray matter):

caudate nucleus & amygdala,

putamen, globus pallidus

prosencephalon diencephalon diencephalon thalamus: relays sensory

information

prosencephalon

(forebrain)

diencephalon diencephalon hypothalamus: maintains body

homeostasis

prosencephalon

(forebrain)

diencephalon diencephalon mammillary bodies: relays

sensations of smells to cerebrum

prosencephalon

(forebrain)

diencephalon Diencephalon optic chiasma: crossover of

optic nerves

prosencephalon diencephalon Diencephalon infundibulum: stalk of pituitary

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Primary Vesicles Secondary Vesicles Adult Structure

Important Components or

Features

(forebrain) gland

prosencephalon

(forebrain)

diencephalon Diencephalon pituitary gland: source of

hormones

prosencephalon

(forebrain)

diencephalon Diencephalon epithalamus: pineal gland

mesencephalon

(midbrain)

mesencephalon brain stem midbrain: cerebral peduncles,

sup. cerebellar peduncles,

corpora quadrigemina, superior

colliculi

rhombencephalon

(hindbrain)

metencephalon brain stem pons: middle cerebellar

peduncles, pneumotaxic area,

apneustic area

rhombencephalon

(hindbrain)

metencephalon Cerebellum sup. cerebellar peduncles,

middle cerebellar peduncles,

inferior cerebellar peduncles

rhombencephalon

(hindbrain)

myelencephalon brain stem medulla oblongata: pyramids,

cardiovascular center,

respiratory center

32

A second method for classifying brain regions is by their organization in the adult brain. The

following four divisions are recognized (see Figure 1 )

Figure 1 The four divisions of the adult brain.

The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve

fibers, the corpus callosum. The largest and most visible part of the brain, the cerebrum,

appears as folded ridges and grooves, called convolutions. The following terms are used

to describe the convolutions:

o A gyrus (plural, gyri) is an elevated ridge among the convolutions.

33

o A sulcus (plural, sulci) is a shallow groove among the convolutions.

o A fissure is a deep groove among the convolutions.

The deeper fissures divide the cerebrum into five lobes (most named after bordering skull

bones)—the frontal lobe, the parietal love, the temporal lobe, the occipital lobe, and the

insula. All but the insula are visible from the outside surface of the brain.

A cross section of the cerebrum shows three distinct layers of nervous tissue:

o The cerebral cortex is a thin outer layer of gray matter. Such activities as speech,

evaluation of stimuli, conscious thinking, and control of skeletal muscles occur

here. These activities are grouped into motor areas, sensory areas, and association

areas.

o The cerebral white matter underlies the cerebral cortex. It contains mostly

myelinated axons that connect cerebral hemispheres (association fibers), connect

gyri within hemispheres (commissural fibers), or connect the cerebrum to the

spinal cord (projection fibers). The corpus callosum is a major assemblage of

association fibers that forms a nerve tract that connects the two cerebral

hemispheres.

o Basal ganglia (basal nuclei) are several pockets of gray matter located deep inside

the cerebral white matter. The major regions in the basal ganglia—the caudate

nuclei, the putamen, and the globus pallidus—are involved in relaying and

modifying nerve impulses passing from the cerebral cortex to the spinal cord.

Arm swinging while walking, for example, is controlled here.

34

The diencephalon connects the cerebrum to the brain stem. It consists of the following

major regions:

o The thalamus is a relay station for sensory nerve impulses traveling from the

spinal cord to the cerebrum. Some nerve impulses are sorted and grouped here

before being transmitted to the cerebrum. Certain sensations, such as pain,

pressure, and temperature, are evaluated here also.

o The epithalamus contains the pineal gland. The pineal gland secretes melatonin,

a hormone that helps regulate the biological clock (sleep-wake cycles).

o The hypothalamus regulates numerous important body activities. It controls the

autonomic nervous system and regulates emotion, behavior, hunger, thirst, body

temperature, and the biological clock. It also produces two hormones (ADH and

oxytocin) and various releasing hormones that control hormone production in the

anterior pituitary gland.

The following structures are either included or associated with the hypothalamus.

o The mammillary bodies relay sensations of smell.

o The infundibulum connects the pituitary gland to the hypothalamus.

o The optic chiasma passes between the hypothalamus and the pituitary gland.

Here, portions of the optic nerve from each eye cross over to the cerebral

hemisphere on the opposite side of the brain.

The brain stem connects the diencephalon to the spinal cord. The brain stem resembles

the spinal cord in that both consist of white matter fiber tracts surrounding a core of gray

matter. The brain stem consists of the following four regions, all of which provide

35

connections between various parts of the brain and between the brain and the spinal cord.

(Some prominent structures are illustrated in Figure 2 ).

Figure

2

Prominent structures of the brain stem.

o The midbrain is the uppermost part of the brain stem.

o The pons is the bulging region in the middle of the brain stem.

o The medulla oblongata (medulla) is the lower portion of the brain stem that

merges with the spinal cord at the foramen magnum.

o The reticular formation consists of small clusters of gray matter interspersed

within the white matter of the brain stem and certain regions of the spinal cord,

diencephalon, and cerebellum. The reticular activation system (RAS), one

36

component of the reticular formation, is responsible for maintaining wakefulness

and alertness and for filtering out unimportant sensory information. Other

components of the reticular formation are responsible for maintaining muscle tone

and regulating visceral motor muscles.

The cerebellum consists of a central region, the vermis, and two winglike lobes, the

cerebellar hemispheres. Like that of the cerebrum, the surface of the cerebellum is

convoluted, but the gyri, called folia, are parallel and give a pleated appearance. The

cerebellum evaluates and coordinates motor movements by comparing actual skeletal

movements to the movement that was intended.

The limbic system is a network of neurons that extends over a wide range of areas of the brain.

The limbic system imposes an emotional aspect to behaviors, experiences, and memories.

Emotions such as pleasure, fear, anger, sorrow, and affection are imparted to events and

experiences. The limbic system accomplishes this by a system of fiber tracts (white matter) and

gray matter that pervades the diencephalon and encircles the inside border of the cerebrum. The

following components are included:

The hippocampus (located in the cerebral hemisphere)

The denate gyrus (located in cerebral hemisphere)

The amygdala (amygdaloid body) (an almond-shaped body associated with the caudate

nucleus of the basal ganglia)

The mammillary bodies (in the hypothalamus)

The anterior thalamic nuclei (in the thalamus)

The fornix (a bundle of fiber tracts that links components of the limbic system)

37

Nervous system

The nervous system has three main functions: sensory input, integration of data and motor

output. Sensory input is when the body gathers information or data, by way of neurons, glia and

synapses. The nervous system is composed of excitable nerve cells (neurons) and synapses that

form between the neurons and connect them to centers throughout the body or to other neurons.

These neurons operate on excitation or inhibition, and although nerve cells can vary in size and

location, their communication with one another determines their function. These nerves conduct

impulses from sensory receptors to the brain and spinal cord. The data is then processed by way

of integration of data, which occurs only in the brain. After the brain has processed the

information, impulses are then conducted from the brain and spinal cord to muscles and glands,

which is called motor output. Glia cells are found within tissues and are not excitable but help

with myelination, ionic regulation and extracellular fluid.

The nervous system is comprised of two major parts, or subdivisions, the central nervous

system (CNS) and the peripheral nervous system (PNS). The CNS includes the brain and spinal

cord. The brain is the body's "control center". The CNS has various centers located within it that

carry out the sensory, motor and integration of data. These centers can be subdivided to Lower

Centers (including the spinal cord and brain stem) and Higher centers communicating with the

brain via effectors. The PNS is a vast network of spinal and cranial nerves that are linked to the

brain and the spinal cord. It contains sensory receptors which help in processing changes in the

internal and external environment. This information is sent to the CNS via afferent sensory

nerves. The PNS is then subdivided into the autonomic nervous system and the somatic nervous

system. The autonomic has involuntary control of internal organs, blood vessels, smooth and

cardiac muscles. The somatic has voluntary control of skin, bones, joints, and skeletal muscle.

38

The two systems function together, by way of nerves from the PNS entering and becoming part

of the CNS, and vice versa.

CNS

The "Central Nervous System", comprised of brain, brainstem, and spinal cord.

The central nervous system (CNS) represents the largest part of the nervous system, including

the brain and the spinal cord. Together, with the peripheral nervous system (PNS), it has a

fundamental role in the control of behavior.

The CNS is conceived as a system devoted to information processing, where an appropriate

motor output is computed as a response to a sensory input. Many threads of research suggest that

motor activity exists well before the maturation of the sensory systems, and senses only

influence behavior without dictating it. This has brought the conception of the CNS as an

autonomous system.

Structure and function of neurons

Neurons are highly specialized for the processing and transmission of cellular signals. Given the

diversity of functions performed by neurons in different parts of the nervous system, there is, as

expected, a wide variety in the shape, size, and electrochemical properties of neurons. For

instance, the soma of a neuron can vary in size from 4 to 100 micrometers in diameter.

39

The soma (cell body) is the central part of the neuron. It contains the nucleus of the cell, and

therefore is where most protein synthesis occurs. The nucleus ranges from 3 to 18 micrometers in

diameter. The dendrites of a neuron are cellular extensions with many branches, and

metaphorically this overall shape and structure is referred to as a dendritic tree. This is where the

majority of input to the neuron occurs. However, information outflow (i.e. from dendrites to

other neurons) can also occur (except in chemical synapse in which backflow of impulse is

inhibited by the fact that axon do not possess chemoreceptors and dendrites cannot secrete

neurotransmitter chemical). This explains one way conduction of nerve impulse. The axon is a

finer, cable-like projection which can extend tens, hundreds, or even tens of thousands of times

the diameter of the soma in length. The axon carries nerve signals away from the soma (and also

carry some types of information back to it). Many neurons have only one axon, but this axon

may - and usually will - undergo extensive branching, enabling communication with many target

cells. The part of the axon where it emerges from the soma is called the 'axon hillock'. Besides

being an anatomical structure, the axon hillock is also the part of the neuron that has the greatest

density of voltage-dependent sodium channels. This makes it the most easily-excited part of the

neuron and the spike initiation zone for the axon: in neurological terms it has the greatest

hyperpolarized action potential threshold. While the axon and axon hillock are generally

involved in information outflow, this region can also receive input from other neurons as well.

The axon terminal is a specialized structure at the end of the axon that is used to release

neurotransmitter chemicals and communicate with target neurons. Although the canonical view

of the neuron attributes dedicated functions to its various anatomical components, dendrites and

axons often act in ways contrary to their so-called main function.

40

Axons and dendrites in the central nervous system are typically only about a micrometer thick,

while some in the peripheral nervous system are much thicker. The soma is usually about 10–25

micrometers in diameter and often is not much larger than the cell nucleus it contains. The

longest axon of a human motor neuron can be over a meter long, reaching from the base of the

spine to the toes. Sensory neurons have axons that run from the toes to the dorsal columns, over

1.5 meters in adults. Giraffes have single axons several meters in length running along the entire

length of their necks. Much of what is known about axonal function comes from studying the

squids giant axon, an ideal experimental preparation because of its relatively immense size (0.5–

1 millimeters thick, several centimeters long).

Function

Sensory afferent neurons convey information from tissues and organs into the central nervous

system. Efferent neurons transmit signals from the central nervous system to the effector cells

and are sometimes called motor neurons. Interneurons connect neurons within specific regions of

the central nervous system. Afferent and efferent can also refer generally to neurons which,

respectively, bring information to or send information from brain region.

Excitatory neurons excite their target postsynaptic neurons or target cells causing it to function.

Motor neurons and somatic neurons are all excitatory neurons. Excitatory neurons in the brain

are often glutamatergic. Spinal motor neurons, which synapse on muscle cells, use acetylcholine

as their neurotransmitter. Inhibitory neurons inhibit their target neurons. Inhibitory neurons are

also known as short axon neurons, interneurons or microneurons. The output of some brain

structures (neostriatum, globus pallidus, cerebellum) are inhibitory. The primary inhibitory

neurotransmitters are GABA and glycine. Modulatory neurons evoke more complex effects

41

termed neuromodulation. These neurons use such neurotransmitters as dopamine, acetylcholine,

serotonin and others. Each synapses can receive both excitatory and inhibitory signals and the

outcome is determined by the adding up of summation.

Excitatory and inhibitory process

The release of a excitatory neurotransmitter (ACHe) at the synapses will cause an inflow of

positively charged sodium ions (Na+) making a localized depolarization of the membrane. The

current then flows to the resting (polarized) segment of the axon.

Inhibitory synapse causes an inflow of Cl- (chlorine) or outflow of K+ (potassium) making the

synaptic membrane hyperpolarized. This increase prevents depolarization, causing a decrease in

the possibility of an axon discharge. If they are both equal to their charges, then the operation

will cancel itself out. There are two types of summation: spatial and temporal. Spatial summation

requires several excitatory synapses (firing several times) to add up,thus causing an axon

discharge. It also occurs within inhibitory synapses, where just the opposite will occur. In

temporal summation, it causes an increase of the frequency at the same synapses until it is large

enough to cause a discharge. Spatial and temporal summation can occur at the same time as well.

42

The neurons of the brain release inhibitory neurotransmitters far more than excitatory

neurotransmitters, which helps explain why we are not aware of all memories and all sensory

stimuli simultaneously. The majority of information stored in the brain is inhibited most of the

time.

ETIOLOGY AND SYMPTOMATOLOGY

A. ETIOLOGY

Predisposing

Factors

Present/

AbsentRationale Justification

Age Present Extremes of age, being

too young and too old,

predisposes an individual

to infectious diseases

since it is in this stages

that the immune system

of an individual is either

already impaired due to

age or is still

underdeveloped.

Bernard Maria. Current

Management in Child

The patient is aged 3

years old, by this

age, the immune

system is not yet

well developed as

compared to adults

and older children,

thus predisposing

the child to

meningitis.

43

Neurology. 4th Edition.

Immune Deficiency Absent Children who are

immune compromised or

having inadequate

immunization tend to be

more susceptible to

diseases caused by

infective microorganisms

due to the decreased

ability of their immune

system to ward off

invading pathogens than

those who are

immunologically stable

and completely

immunized.

Bernard Maria. Current

Management in Child

Neurology. 4th Edition.

The child is

completely

immunized as

reported by the

mother and does not

have any disease

condition that would

render her

immunologically

deficient.

Precipitating Present/ Absent Rationale Justification

44

Factors

Exposure to Pathogen Present Exposure to causative

agents such as H.

influenza, S. pneumoniae

and N. meningitidis

influenced by other factors

can cause meningitis in

susceptible individuals.

Bernard Maria. Current

Management in Child

Neurology. 4th Edition.

Presence of infection is

suggestive that the

child has been exposed

to microorganisms.

Environment Absent Environmental conditions

such as those places where

houses are too close to

each other allow

inadequate ventilation and

permit easy transmission

of bacterial agents of

infection.

Allan R. Tunkel. Pathogenesis and Pathophysiology of Bacterial Meningitis

The mother reports

their home to be

located near a field,

since they were

farmers. Houses in

their place are said to

be far apart.

45

Malnutrition Present Malnutrition is a condition

caused by a deficiency or

excess of one or more

essential nutrients in the

diet. Malnutrition is

characterized by a wide

array of health problems,

including extreme weight

loss, stunted growth,

weakened resistance to

infection, and impairment

of intellect. Severe cases

of malnutrition can lead to

death.

Microsoft ® Encarta ®

2009. © 1993-2008

Microsoft Corporation.

All rights reserved.

Upon admission, the

child’s weight was

10.5kg, with a height

of 3 feet 2 inches

summing up to a total

BMI of 11.3

suggesting that the

child is underweight,

which is one of the

major indications of

malnutrition.

History of Infection

(H. influenza, S.

Present H. influenzae and S.

pneumoniae, are the two

The child’s

reontological report

46

pneumoniae) most common causes of

bacterial meningitis apart

from infection from

Neisseria Meningitidis.

Commonly causative

factors for respiratory

infections, H. influenzae

and S. pneumoniae may

cause CNS infection by

infiltrating the CNS

through the blood stream.

Allan R. Tunkel. Pathogenesis and Pathophysiology of Bacterial Meningitis

shows central

pneumonitis.

B. SYMPTOMATOLOGY

Symptoms Present/Absent Rationale Justification

Projectile

vomiting

Absent Vomiting occurs due

to increased

intracranial pressure.

The patient has had vomiting

but is not projectile in nature.

47

Jeanne Raimond.

Neurological

Emergencies

Effective Nursing

Care.

Lethargy Present Lethargy occurs due

to inability of certain

parts of the brain to

regulate proper body

function arising from

ischemia depending

on areas affected.

Jeanne Raimond.

Neurological

Emergencies

Effective Nursing

Care.

The patient is arousable only

by pain and is unable to wake

or perform activities of daily

living.

Seizures Present Status epilepticus is

a condition wherein

seizure persists for a

sufficient length of

time or is repeated

The patient’s chief complaint

for admission is seizure and

vomiting.

48

frequently enough

that recovery

between attacks does

not occur. This

condition is usually

precipitated by

serious intracranial

insults such as head

trauma, anoxia,

stroke or CNS

infections.

Bernard Maria.

Current

Management in

Child Neurology. 4th

Edition.

Hyperreflexia Absent Hyperreflexia occurs

as a primary sign of

CNS irritation.

Jeanne Raimond.

Neurological

Emergencies

This was not manifested by

the patient.

49

Effective Nursing

Care.

Kernig sign Absent Kernig sign is the

involuntary spasm of

the hamstring muscle

provoked by knee

extension with the

patient supine. This

is due to the

irritation of nerve

endings.

Bernard Maria.

Current

Management in

Child Neurology. 4th

Edition.

This was not manifested by

the patient.

Brudzinski sign Absent Brudzinski sign is

present due to the

irritation of nerve

endings caused by

inflammation arising

from inflammation.

This was not manifested by

the patient.

50

Bernard Maria.

Current

Management in

Child Neurology. 4th

Edition.

Fever Present Is a frequent medical

symptom that

describes an increase

in internal body

temperature to levels

that are above

normal. It is

stimulated by

cytokines (IL-1 &

IL-6). These

cytokines send

signals in the

hypothalamus that

serves as our

thermoregulatory

center, thus

prostaglandin is

released. Once

There were occasions wherein

the patient was febrile.

51

prostaglandin is

released, it causes an

increase in the set

point. In response to

this, the

hypothalamus

neurally initiates

shivering and

vasoconstriction that

increases the core

body temperature to

the new set point,

and fever is

established.

Bernard Maria.

Current

Management in

Child Neurology. 4th

Edition.

Increased WBC Present White blood cells are

responsible for the

defense system in

the body. White

The WBC of the patient is

14.35.

52

blood cells fight

infections and

protect our body

from foreign

particles, which

includes harmful

germs and

bacteria.Thus,

elevated WBC

counts indicate

infection.

Jeanne Raimond.

Neurological

Emergencies

Effective Nursing

Care.

Nuchal rigidity Present Nuchal rigidity

occurs as a result of

compression and

irritation of nerve

endings in the brain

arising from

inflammation.

The patient is exhibiting

decerebrate rigidity.

53

Jeanne Raimond.

Neurological

Emergencies

Effective Nursing

Care.

hyperventilation Absent Hyperventilation is a

respiratory

compensatory

mechanism to

increase oxygenation

and tissue perfusion.

Bernard Maria.

Current

Management in

Child Neurology. 4th

Edition.

This was not manifested by

the patient.

tachycardia Absent Tachycardia takes

place in the early

stage of status

epilepticus as a

compensatory

mechanism of the

This was not manifested by

the patient.

54

body to increase

perfusion.

Bernard Maria.

Current

Management in

Child Neurology. 4th

Edition.

Decreased

response

Present Ischemia of certain

parts of the brain

incur varying effects

to an individual’s

neurological, sensory

and motor function

depending on which

areas are affected.

These effects may

range from simple

memory loss to

coma.

Jeanne Raimond.

Neurological

Emergencies

The patient is unresponsive to

any tactile or verbal stimuli

made by the nurse upon

assessment.

55

Effective Nursing

Care.

Diminished

reflexes

Present Diminished reflexes

are indicative of an

assault to the

peripheral nervous

system.

Jeanne Raimond.

Neurological

Emergencies

Effective Nursing

Care.

There was an assessed

absence of the patient’s DTR

in both lower extremities.

56

PATHOPHYSIOLOGY

57

Precipitating Factors

Malnutrition

Predisposing Factor

Age

Decreased cerebral blood flow

Increased Intracranial Pressure

Projectile vomiting

Cerebral infarctionInterstitial edema

Cerebral vasculitisIncreased CSF outflow resistance

Increased blood-brain barrier permeability

Fever

Nuchal Rigidity

Subarachnoid space inflammation

Meningeal invasion

Endothelial cell injury

bacteremia

Entry of pathogen

Impaired dark adaptation Impaired short term learning Loss of judgment Delirium, muscle incoordination Loss of consciousness Neural damage hypoxia

58

Stimulation of Compensatory Mechanism

Increased uncontrolled firing of neurons

Uncontrollable muscle excitement

Stiffness Rolling of

eyeballs

Increased BP Increased HR Hyperpyrexia

Lactic Acidosis

Failure of Compensatory Mechanisms

Cerebral Autoregulation Failure

Respiratory Depression, Arrythmias

Hypoglycemia Hyponatremia

Diminished response and lethargy

(-) corneal reflex (-) DTR

55

Damage to neurons and brain tissue

Encephalopathy

If treated:

Fair Prognosis

If not treated:

Poor Prognosis

56

DOCTOR’S ORDERS

Date Doctor’s Order Rationale Remarks

Jan. 10, 2011

11:10pm

Please admit to

PICU I Level 4 under P2 service

The patient upon admission is exhibiting

manifestations that require close monitoring and total

dependence on the care of health care providers.

DONE

Secure Consent Securing consent enlists the patient's faith and

confidence in the efficacy of the treatment and

ensures the safety of both the medical team and the

patient.

DONE

TPR q4 and record Vital signs (Temperature, Pulse Rate, and Respiratory

Rate) indicate patient’s state of health. To monitor

and note any alterations that may need or elicit

prompt referral and immediate intervention

DONE

Non per orem The patient has diminishing level of GCS, making the DONE

57

risk for aspiration very likely.

Labs: CBC PC Complete blood count is the determination of the

quantity of each quantity of each type of each blood

cell in a given specimen of blood, often including the

amount of hemoglobin, hematocrit, and the

proportion of various white cells. Platelet count is

required for the determination of the number of

platelets present and/or their ability to function

correctly. These tests will help determine underlying

diagnosis.

DONE

Urinalysis Urinalysis is a microscopic examination of the urine

that detects red blood cells, white blood cells and

bacteria in the urine. This test is done to rule out UTI

or kidney or urinary bladder related diseases.This is

one of the standard tests done upon admission to

completely screen the patient of any underlying

DONE

58

disease condition.

Sodium/ Potassium Used to detect electrolyte imbalances associated with

dehydration, edema, and a variety of diseases. This is

one of the standard tests done upon admission to

completely screen the patient of any underlying

disease condition and help determine the possible

management strategies required by the patient.

DONE

Creatinine Creatinine is mainly filtered by the kidney, though a

small amount is actively secreted. Measuring serum

creatinine is used to indicate renal function. This is

one of the standard tests done upon admission to

completely screen the patient of any underlying

disease condition and help determine the possible

management strategies required by the patient.

DONE

Chest X-ray APL Chest X-ray provide a good outline of the heart and

major blood vessels and usually can reveal a serious

DONE

59

disease in the lungs, the adjacent spaces, and the chest

wall, including the ribs. This is one of the standard

tests done upon admission to completely screen the

patient of any underlying disease condition and help

determine the possible management strategies

required by the patient.

Calcium/ Magnesuim Calcium and magnesium belong to a group of

"parasympathetic" elements (which includes

chromium and

copper), that exhibit anti-inflammatory or

degenerative properties at higher amounts, in contrast

to elements

such as potassium, zinc, manganese, or iron, which

are pro-inflammatory when high. This is one of the

standard tests done upon admission to completely

screen the patient of any underlying disease condition

and help determine the possible management

DONE

60

strategies required by the patient.

Start venoclysis with D5 0.3 NaCl

500cc at 45ggt/min

The 3% NaCl restores blood pressure, pH, and urine

output with approximately one half of the cumulative

fluid requirement of patients who received isotonic fluids

(p less than 0.05).

DONE

I and O q shift Monitoring I & O help assess fluid balance. Accurate

measurement of a patient's fluid intake and output

will identify those patients at risk of becoming

dehydrated or overhydrated. This will assess the

functioning of the patient’s urinary system.

DONE

ABG An arterial blood gas (ABG) test measures the acidity

(pH) and the levels of oxygen and carbon dioxide in

the blood from an artery. This test is used to check

how well your lungs are able to move oxygen into the

blood and remove carbon dioxide from the blood. An

DONE

61

arterial blood gas (ABG) test is done to:

Check for severe breathing problems and lung

diseases, such as asthma, cystic fibrosis, or

chronic obstructive pulmonary disease

(COPD).

See how well treatment for lung diseases is

working.

Find out if you need extra oxygen or help with

breathing (mechanical ventilation).

Find out if you are receiving the right amount

of oxygen when you are using oxygen in the

hospital.

Measure the acid-base level in the blood of

people who have heart failure, kidney failure,

uncontrolled diabetes, sleep disorders, severe

62

infections, or after a drug overdose.

Cranial CT Scan A cranial computed tomography (CT) scan uses many

x-rays to create pictures of the head, including the

skull, brain, eye sockets, and sinuses. This will help

visualize and diagnose any abnormalities in the skull

and brain which will aid in properly diagnosing

patients exhibiting manifestations due to illnesses

involving the head and the brain.

DONE

Blood GSCS This is used to screen for presence of microorganisms

in the blood which may be suggestive of sepsis.

DONE

Medications:

a. Ceftriaxone 525mg q12 a. Ceftriaxone is bactericidal, this drug inhibits

63

b. Amikacin 155mg OD

c. Phenobarbital 105 mg as

loading dose, then 50mg

OD IVTT as maintenance

d. Diazepam 2mg IVTT prn

for active seizure

e. Salbutamol nebulization

cell wall synthesis promoting osmotic

instability.

b. Amikacin is an aminoglycoside. It binds to

ribosomal subunits in bacterial cell causing

cell death.

c. Phenobarbital is an anti-seizure drug.

d. Diazepam is used to potentiate the effect of

GABA, depress the CNS and suppress the

spread of seizure activity.

64

q8 e. Salbutamol is given to treat bronchospasm in

order to maintain clear airway and proper gas

exchange

Hgt now This is done to monitor blood glucose levels. Since

the patient is placed on an npo status, the risk for

hypoglycemia is thereby elevated.

DONE

Refer For continuity of care and to give prompt intervention

once unusualities occurs to prevent any complication

or untoward incidents that may need immediate

medical or surgical interventions.

DONE

Jan. 11, 2011

2am

Intubate now with ETT

size 4.0 level 10-11

Pediatric endotracheal tube sizes are different from

adult sizes; they range from 2.5mm to 5.0mm. Level

of ETT is chosen given the formula age divided by

two plus 12cm

DONE

65

Npo

The patient is intubated, thus cannot tolerate oral

feedings.

DONE

Hgt q8

This is done to monitor blood glucose levels. Since

the patient is placed on an npo status, the risk for

hypoglycemia is thereby elevated.

DONE

For ETA GSCS

Gram stain and culture sensitivity of Endotracheal

Aspirate will help in diagnosing any presence of

microorganisms that may cause or causal of infection.

NOT DONE

Start mannitol 52 mg q6 Mannitol allows osmotic dieresis.

DONE

For Lumbar Puncture

Lumbar puncture is the primary diagnostic test for the

presence of Bacterial Meningitis

DONE

For PT APTT

The aPTT and PT tests are used as pre-surgical

screens for bleeding tendencies.

DONE

Refer For continuity of care and to give prompt intervention DONE

66

once unusualities occurs to prevent any complication

or untoward incidents that may need immediate

medical or surgical interventions.

January 13, 2011 Continue IVF Replacement & maintenance of fluid & electrolytes. DONE

Continue meds This ensures the maintenance of drug action and

effectivity.

DONE

VSq 4

Vital signs (Temperature, Pulse Rate, and Respiratory

Rate) indicate patient’s state of health. To monitor

and note any alterations that may need or elicit

prompt referral and immediate intervention

DONE

January 14, 2011

2am Phenobarbital 53mg IVTT Phenobarbital as a barbiturate, may depress CNS and

increase seizure threshold. As a sedative, may

interfere with the transmission of impulses from

DONE

67

thalamus to cortex of the brain.

Jan. 15, 2011

11am

Shift Ceftriaxone to Meropenem

525mg IVTT q12

Meropenem inhibits cell wall synthesis in bacteria.

Readily penetrates cell wall of most gram positive

and gram negative bacteria to reach penicillin-binding

protein targets.

DONE

Jan. 16, 2011Start Piperacillin – Tazobactam

525mg IVTT q6

Discontinue Meropenem

Piperacillin plus tazobactam inhibits cell wall

synthesis during bacterial multiplication.

Meropenem is substituted with piperacillin plus

tazobactam.

For ETA GSCS

Gram stain and culture sensitivity of Endotracheal

Aspirate will help in diagnosing any presence of

microorganisms that may cause or causal of infection.

DONE

Jan. 17, 2011 Start OTF Feeding

CHO 630

Since the patient is place on NPO it is important to

maintain adequate nutrition by implementing OTF

DONE

68

CHON 315

FAT 105

1050 in 3 divided feedings

feedings at appropriately calculated distributions.

01/18/11

Accidental

extubation

(+) spontaneous

breathing

May not reintubate, O2 inhalation

via face mask at 4lpm

Presence of spontaneous breathing makes it

reasonable for the patient to be weaned from

ventilator in order to establish independent breathing

and rehabilitation.

DONE

01/23/11 Decrease Mannitol to 26cc q12

IVTT

Phenobarbital one tab + 5ml water

OD at HS

Decreasing mannitol dosage would be necessary to

improving signs and symptoms of increased

intracranial pressure.

Increasing vitality of the patient make it more

possible to administer drugs thru the GI tract. This

may also help the patient in weaning from IVTT

DONE

69

medications to per orem medications.

01/27/11

s/f Cranial CT scan

A cranial computed tomography (CT) scan uses many

x-rays to create pictures of the head, including the

skull, brain, eye sockets, and sinuses. This will help

visualize and diagnose any abnormalities in the skull

and brain which will aid in properly diagnosing

patients exhibiting manifestations due to illnesses

involving the head and the brain.

DONE

70

DIAGNOSTIC EXAM

COMPLETE BLOOD COUNT WITH PLATELET COUNT

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

01/15/11

Hemoglobin115 – 155

g/L

The test that

measures the

amount of

hemoglobin per

liter of blood

103 Low

A low

hemoglobin is

referred to as

anemia.

1. Discuss and explain the

procedure and purpose of

the test.

2. Inform the patient that no

fasting is needed.

3. Assess the patient for any

Hematocrit 0.36 – 0.48 The test measures

the percentage of

RBC in the total

blood volume

0.31 Low A low

hemoglobin is

referred to as

anemia.

71

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

factor that will probably

affect the results of the

test.

4. Make sure patient is well

hydrated. Dehydration

elevates the test results.

5. If patient is connected to

IVF, make sure that the

blood is not taken from

the arm connected to the

IVF. Hemodilution

causes false decrease of

RBC count 4.20 – 6.10

The test measures

the circulating

RBCs in 1 cubic

millimeter of

blood.

3.02 Low

Low RBC may

indicate blood

loss, anemia,

hemorrhage,

bone marrow

failure,

leukemia, and

malnutrition

WBC count 5.0 – 10.0

The test measures

all leukocytes

present in 1 cubic

millimeter of

blood.

14.35 High

High WBC

count is

suggestive of

infection.

Neutrophil 55 – 75 Neutrophils serve 73 Normal Normal

72

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

as the body's

primary defense

against infection

through the

process of

phagocytosis.

Usually used to

diagnose specific

type of illnesses.

Some cancers

may cause a

decrease in the

body’s ability to

form normal

new neutrophils.

the test results.

6. After the puncture, assess

the site for bleeding or

bruising.

7. If patient is under

treatment from an

infection, inform the

patient that the test will

be repeated to monitor

progress.

8. Any abnormality noted

will be reported to the

Lymphocyte 20 – 35 Lymphocytes

initiate

immunologic

responses. The

test determines

16 Low

73

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

lymphocyte blood

count.

physician.

Monocyte 2 – 10 Monocytes have

phagocytic action.

It removes dead

or injured cells,

cell fragments,

and

microorganism.

This test is done

to diagnose an

illness such as

inflammatory

diseases.

11 High

74

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

Eosinophils 1 – 8

Eosinophils

initiate allergic

responses and act

against parasitic

infestation. The

test is use to

diagnose worm

infestation.

0 Low

Basophil 0 – 1

Basophils initiate

type 1 allergic

responses

0 Normal Normal

Platelet count 150 – 400 The test measures

all platelets

present in 1 cubic

747 High High Platelet

75

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

millimeter of

blood.

Activated Partial Thromboplastin Time (APTT)

76

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

ExamNormal

ValueRationale

Result of

PatientRemearks

Clinical

SignificanceNursing Responsibilities

Jan. 15,

2011APTT 29.4 – 38.4

The test measures

the time in

seconds for a

specific clotting

process to occur.

29.0 Normal Normal

APTT Control 26.0 – 31.0 If the test sample

takes longer than

the control

sample, it

indicates

decreased clotting

function in the

29.3 Normal Normal

77

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

intrinsic pathway.

Prothrombin Time (PT)

Date ExamNormal

ValueRationale

Result of

PatientRemearks

Clinical

SignificanceNursing Responsibilities

PT Patient 11.8 – 15.1 PT may be

ordered when a

patient is to

undergo an

invasive medical

procedure, such

as surgery, to

ensure normal

clotting ability.

15.0 Normal Normal

Jan. 15,

2011PT Control 12.0 – 15.0 13.8 Normal Normal

78

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

ABG Analysis

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

Jan.19,

2011

pH

7.35 – 7.45 pH indicates the

acid-base level of

the blood, or the

hydrogen ion (H+)

concentration

7.50 high Alkalosis Pretest:

1. Explain the importance of

the procedure to the

patient or watcher. Inform

the patient or watcher that

the test requires blood

sample.

2. Instruct the patient to

breath normally during the

test.

79

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

3. Warn that a brief cramping

or throbbing pain may

occur at the puncture site.

4. Take note of the patient’s

temperature and

respiratory rate.

5. If patient is receiving O2

therapy, discontinue O2

from 15 to 20 minutes

before drawing the sample

to measure ABG on room

air.

Post Test:

80

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

1. Apply pressure on the

puncture site.

2. After applying pressure,

tape a gauze pad firmly

over it.

3. Monitor VS. Observe for

signs of circulatory

impairment such as

swelling, discoloration,

pain, numbness or tingling

in the bandaged arm.

4. Watch for bleeding from

the punctured site.

81

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

PaCO2 35 – 45

mmHg

PaCO2 indicates

how much oxygen

the lungs are

delivering to the

blood. It indicates

how efficiently the

lungs eliminate

31.9 Low

82

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

carbon dioxide.

PaO2

75 – 100

mmHg

Indicates how

much oxygen the

lungs are delivering

to the blood.

155.4 High

HCO3 22 – 26

meq/L

Indicates whether

a metabolic

problem is present

(such as

24.4 normal Normal

83

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

ketoacidosis). A

low HCO3- indicates

metabolic acidosis

and a high HCO3-

indicates metabolic

alkalosis.

BE (ecf)

Base excess

+/- 2 mmol/L The base excess

indicates whether

the patient is

acidotic or

alkalotic. A

negative base

excess indicates

1.4 normal normal

84

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

that the patient is

acidotic. A high

positive base

excess indicates

that the patient is

alkalotic.

O2Sat 80 – 100% This indicates

impaired

respiratory

function such as

respiratory

weakness or

paralysis, airway

99.2% normal normal

85

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

obstruction,

bronchiole

obstruction,

asthma,

emphysema, and

from damaged or

filled with fluid

because of disease.

CO2 23-30 This indicates

impaired

respiratory

25.5 normal normal

86

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

function such as

respiratory

weakness or

paralysis, airway

obstruction,

bronchiole

obstruction,

asthma,

emphysema, and

from damaged or

filled with fluid

because of disease.

87

Date ExamNormal

ValueRationale

Result of

PatientRemarks

Clinical

SignificanceNursing Responsibilities

88

January 24, 2010

Roentological Report

Subtle hazy infiltrates are seen in both inner lung zone and retrocardiac area. Trachea is at the midline, the heart is not enlarged. Rest of included structures are unremarkable.

Impressions: Consider Central Pneumonitis

Blood GSCS

No organisms found.

ETA

No organisms found.

CSF

No organisms found.

89

90

Urinalysis

Urinalysis is performed to screen for urinary tract disorders, kidney disorders, urinary neoplasm and other medical conditions that produce

changes in the urine. This test also is used to monitor the effects of treatment of known renal or urinary condition.

Date Laboratory

Test

Normal Value /

Results

Result Clinical Significance Nursing Interventions

Jan.

19,

2011

Color Straw yellow to

amber

Light

yellow

NORMAL Pretest:

Inform patient that he should avoid intense athletic

training or heavy physical work before the test, as these

activities may cause small amounts of blood to appear

in the urine.

Provide patient with urine container with lid.

Instruct the patient to collect a sample of urine,

preferably on arising in the morning; must not be

contaminated by toilet paper, toilet water, feces or

Appearance Clear to faintly

hazy

Clear NORMAL

Reaction 4.0-8.0 7.0 NORMAL

Specific 1.003- 1.030 1.005 NORMAL

91

gravity secretions.

Tell females patients that they should use a clean cotton

ball moistened with lukewarm water (or antiseptic wipes

provided with collection kits) to cleanse the external genital

area before collecting a urine sample. To prevent

contamination with menstrual blood, vaginal discharge, or

germs from the external genitalia, they should release some

urine before beginning to collect the sample.

To minimize sample contamination, women who

require a urinalysis during menstruation should insert a

fresh tampon before providing a urine sample.

Inform males patients that they should use a piece of clean

cotton moistened with lukewarm water or antiseptic wipes

to cleanse the head of the penis and the urethral meatus

(opening). Inform uncircumcised males that they should

draw back the foreskin. After the area has been thoroughly

cleansed, they should use the midstream void method to

Albumin Negative Negative NORMAL

Sugar Negative Negative Normal

Pus cells ≤ 4 cells/hpf 1.2 NORMAL

Red Blood

Cells

≤ 2 rbc hpf 1-2 NORMAL

92

collect the sample.

If urine for culture is to be collected from an indwelling

catheter, it should be aspirated (removed by suction) from

the line using a syringe and not removed from the bag in

order to avoid contamination.

Post test:

The lid must be sealed completely and the container must

be labeled properly.

Specimen must be delivered to the laboratory.

93

94

DRUG STUDY

Generic Name:

Ceftriaxone

Brand Name: Rocephin

Classification: Third Generation Cephalosporin

Dosage: 525mg IVTT q12

Mode of Action: Inhibits cell wall synthesis promoting osmotic instability. Bactericidal.

Indication: This medication is indicated for uncomplicated gonococcal

vulvovaginitis, UTI; LRTI; joint, intraabdominal, skin or skin structure

infection, septicemia, meningitis, perioperative prevention, acute

bacterial otitis media, neurologic complications, carditis and arthritis

from penicillin.

Contraindication Contraindicated in patients hypersensitive to drug. This is also to be

used cautiously to patients hypersensitive to penicillin because of the

possibility of cross sensitivity. This must also be used with caution in

breast feeding women and in patients with colitis and renal

insufficiency.

95

Drug-Drug

Interaction

Interactions:

1. Aminoglycosides. May cause synergistic activity against some

organisms, may increase nephrotoxicity.

2. Loop diuretics. May increase risk for adverse renal reactions.

3. Probenecid. May inhibit excretion and increase cefuroxime

level.

Side/ Adverse

Effects:

CV: Phlebitis, thrombophlebitis

GI: diarrhea, pseudomembraneous colitis, transient neutropenia,

thrombocytopenia, eosinophilia

Skin: maculopapular and erythemasus rashes, urticaria, pain,

induration, sterile abcesses, temperature elevation, tissue sloughing at

IM injection site

Other: Anaphylaxis, hypersensitivity reactions, serum sickness

Nursing

Responsibilities:

1. Check if the patient is hypersensitive to the drug.

2. Obtain specimen for culture and sensitivity tests before

administration of the first dose.

3. Monitor for signs of superinfection.

4. Tell watcher to report signs of adverse reactions promptly.

5. Instruct watcher to report discomfort at the IV site.

6. Instruct watcher to report if stools become loose or if diarrhea

occurs.

96

7. Monitor efficacy of the drug by monitoring patient.

8. Ensure that the patient is not manifesting any condition

contraindicated with the use of the drug.

Generic Name:Amikacin Sulfate

Brand Name: Amikacin

Classification: Aminoglycoside

Dosage: 155mg OD

Mode of Action: Inhibits protein synthesis by binding directly to the 30S ribosomal

subunit. Bactericidal.

Indication: This drug is indicated to patients with serious infections caused by

sensitive strains of Psuedomonas aureginosa, Eschericha coli, Proteus

Klebsiella or Staphylococcus; uncomplicated UTI caused by organisms

not susceptible to less toxic drugs; active tuberculosis and

Mycobacterium avium complex infection.

Contraindication Contraindicated in patients hypersensitive to drug and must be used

97

cautiously in patients with impaired renal function or neuromuscular

disorders, in neonates and infants, and in elderly patients.

Drug-Drug

Interaction

Interactions:

1. Acyclovir, Amphotericin B, cidofovir, cisplastatin,

vancomycin and other aminoglycosides. May increase

nephrotoxicity.

2. Dimenhydrinate. May mask ototoxicity symptoms. Monitor

patient hearing.

3. General Anesthetics. May increase neuromuscular

blockade.

4. Indomethacin. May increase trough and peak amikacin

levels.

Side/ Adverse

Effects:

CNS: Neuromuscular blockade

EENT: ototoxicity

GU: azotemia, nephrotoxicity, increase in urinary excretion of casts

Musculoskeletal: arthralgia

Respiratory: apnea

Nursing

Responsibilities:

1. Evaluate patient’s hearing before and during therapy if the

patient will be receiving the drug for longer than 2 weeks.

Notify prescriber if patient has tinnitus, vertigo or hearing

loss.

2. Assess if the patient is hypersensitive to the drug.

98

3. Weigh patient and review renal function before therapy

begins

4. Correct dehydration before therapy because of increased

risk for toxicity.

5. Monitor renal function by monitoring intake and output.

6. Watch out for signs and symptoms of superinfection.

7. Instruct patient to promptly report adverse reactions to

prescriber.

8. Encourage patient to maintain adequate fluid intake.

Generic Name:

Phenobarbital

Brand Name: Solfoton

Classification: Barbiturate

Dosage: 105 mg as loading dose, then 50mg OD IVTT as maintenance dose

Mode of Action: As a barbiturate, may depress CNS and increase seizure threshold. As a

sedative, may interfere with the transmission of impulses from

thalamus to cortex of the brain.

99

Indication: This drug is indicated as an anticonvulsant inn febrile seizures, status

epilepticus, in sedation, short term treatment of insomnia, preoperative

sedation.

Contraindication Contraindicated in patients hypersensitive to drug and other

barbiturates and in those with history of manifest or latent porphyria; in

patients with hepatic or renal dysfunction, respiratory disease with

dyspnea or obstruction, nephritis. Use cautiously in patients with acute

or chronic pain, depression, suicidal tendencies, history of drug abuse,

fever, hyperthyroidism, diabetes mellitus, severe anemia, blood

pressure alterations, CV diseases, shock or uremia and in elderly

debilitated patients.

Drug-Drug

Interaction

Interactions:

5. Acyclovir, Amphotericin B, cidofovir, cisplastatin,

vancomycin and other aminoglycosides. May increase

nephrotoxicity.

6. Dimenhydrinate. May mask ototoxicity symptoms. Monitor

patient hearing.

7. General Anesthetics. May increase neuromuscular

blockade.

8. Indomethacin. May increase trough and peak amikacin

levels.

CNS: Drowsiness, lethargy, hangover, paradoxical excitement,

somnolence, and psychological dependence

100

Side/ Adverse

Effects:

CV: bradycardia, hypotension, syncope

GI: nausea, vomiting

Skin: rash, erythema

Nursing

Responsibilities:

1. Make sure the patient is not allergic to barbiturates.

2. Watch out for signs of barbiturate toxicity: coma, cyanosis,

asthmatic breathing, clammy skin and hypotension.

3. Don’t stop the drug abruptly because this may worsen seizures.

4. Use for insomnia should not last longer than 14 days.

5. Ensure that the patient is aware that the drug is available in

different milligram strengths.

6. Inform patient and significant others that full therapeutic effect

aren’t seen for 2 to 3 weeks, except when loading dose is used.

7. Warn patient not to stop the drug abruptly.

8. Do not let patient do activities that require mental alertness.

101

Generic Name:

diazepam

Brand Name: Valium

Classification: benzodiazepine

Dosage: 2mg IVTT prn for active seizure

Mode of Action: Potentiates the effect of GABA, depresses the CNS and suppresses the

spread of seizure activity.

Indication: This drug is indicated for anxiety, acute alcohol withdrawal, before

endoscopic procedures, muscle spasms, preoperative sedation,

cardioversion, adjunct treatment for seizure disorder, status epilepticus,

pain on stable regimen of antiepileptic drugs who need diazepam

intermittently to control to control bouts of increased seizure activity

Contraindication Contraindicated in patients hypersensitive to drug or soy protein; in

patients experiencing shock, coma, or acute alcohol intoxication, in

pregnant women, especially in first trimester and in children younger

than 6months. This should also be used cautiously in patients with

renal impairment, depression, or chronic open-angle glaucoma.

Drug-Drug 1. Cimetidine, disulfiram, fluoxetine, hormonal contraception,

isoniazid, metoprolol, propoxyphene, propanolol, valproic acid.

102

Interaction

Interactions:

May increase the risk of adverse effects.

2. CNS depressants. May increase CNS depression.

3. Digoxin. May increase digoxin level.

4. Diltiazem. May increase CNS depression and prolong effects of

diazepam.

5. Levodopa. May decrease levodopa effectiveness. Monitor

patient.

6. Phenobarbital. May increase the effects of both drugs.

Side/ Adverse

Effects:

CNS: Drowsiness, dysarthia, slurred speech, tremor, transient amnesia,

fatigue, insomnia, hallucinations

CV: bradycardia, hypotension, collapse

GI: nausea, vomiting, diarrhea

Hematologic: neutropenia

Hepatic: Jaundice

EENT: nystagmus, blurred vision, diplopia

Skin: rash, erythema

Nursing

Responsibilities:

1. Warn patient to avoid activities that require alertness and

good coordination until effects of drug are known.

2. Tell patient to avoid alcohol while taking the drug

103

3. Warn patient not to stop the drug abruptly.

4. Warn woman not to use drug in pregnancy.

5. Tell patient that smoking may decrease the drug’s

effectiveness

6. Make sure the patient is not exhibiting conditions

contraindicated to the use of the drug.

7. Monitor elderly patients for dizziness.

8. Inform patient to promptly report signs of adverse reactions.

Generic Name:

Salbutamol Sulfate

Brand Name: AccuNeb, Airomir, Asmol CFC-free, Proventil, Proventil HFA,

Proventil Repetabs, Ventolin Volmax, VoSpire ER

Classification: Adrenergic bronchodilator

Dosage: 1 neb q8

Mode of Action: Relaxes bronchial and uterine smooth muscle by acting on beta2-

104

adrenergic receptors.

Indication: This is indicated to:

To prevent exercise-induced bronchospasm

To prevent or treat bronchospasm in patients with reversible

obstructive airway disease.

Solution for inhalation

Contraindication Contraindicated in patients hypersensitive to drug and

its components.

Use cautiously in patients with CV disorders (including

coronary insufficiency and hypertension),

hyperthyroidism, or diabetes mellitus and too those

unusually responsive to adrenergics.

Use extended-release tablets cautiously in patients with

GI narrowing.

With pregnant women, use cautiously. Breastfeeding

women shouldn’t take drug. In children, safety of drug

hasn’t been established in those younger than age 6 for

tablets and Repetabs, younger than age 4 for aerosol and

capsules for inhalation, and younger than age 2 for

inhalation solution and syrup. In elderly patients, use

cautiously.

105

Drug-Drug

Interaction

Interactions:

Drug – Drug. CNS stimulants. May increase CNS stimulation. Avoid using together.Levodopa: May increase risk of arrythmias.

Mao inhibitors, tricyclic antidepressants: May increase adverse CV effects.

Propanolol, other beta blockers:May antagonize each other.

Drug – herb. Herbs containing caffeine: May have additive adverse effects. Discourage using together.

Drug – food. Caffeine: May increase CNS stimulation. Discourage using together.

Side/ Adverse

Effects:

CNS: tremors, nervousness, dizziness, insomnia,

headache

CV: tachycardia, palpitations, hypertension

EENT: drying and irritation of nose and throat

GI: heartburn, nausea, vomiting

METABOLIC: hypokalemia, weight loss

MUSCULOSKELETAL: muscle cramps

Nursing

Responsibilities:

o Obtain baseline assessment of patient’s respiratory

status, and assess patient often during therapy.

o Be alert for adverse reactions and drug interactions.

o Assess patient’s and family’s knowledge of drug

therapy.

o Warn patient to stop drug immediately if paradoxical

bronchospasm occurs.

o Give these instructions for using metered-dose inhaler:

106

Clear nasal passages and throat. Breathe out, expelling

as much air from lungs as possible. Place mouthpiece

well into mouth and inhale deeply as dose is released.

Hold breath for several seconds, remove mouthpiece

and exhale slowly.

o Advise patient to wait atleast 2 minutes before repeating

procedureif more than one inhalation is ordered.

o Warn patient to avoid accidentally spraying inhalant

into eyes, which may cause temporary blurred vision.

o Take patient to reduce intake of foods and herbs

containing caffeine, such as coffee, cola, and chocolate,

when using a bronchodilator.

o Show patient how to take his pulse. Instruct him to

check pulse before and after using bronchodilator and to

call prescriber if pulse rate increases more than 20 to 30

beats/minute.

Generic Name:

Meropenem

107

Brand Name: Merrem IV

Classification: Carbapenem

Dosage: 525mg IVTT q12

Mode of Action: Inhibits cell wall synthesis in bacteria. Readily penetrates cell wall of

most gram positive and gram negative bacteria to reach penicillin-

binding protein targets.

Indication: This drug is indicated for:

a. Complicated skin and skin structure infections from

Staphylococcus aureus (beta-lactamase or non-beta lactamase

producing methicillin susceptible isolates only), Streptococcus

pyrogenes, Enterococcus faecalis (excluding vancomycin

resistant isolates), Psuedomonas aeruginosa, Eschirichia coli

and Peptostreptococcus species.

b. Complicated appendicitis and peritonitis from viridians group

streptococci, E. coli, Klebseilla pneumonia, Pseuodomonas

aeruginosa, B. fragilis and Peptostreptococcus species

c. Bacterial meningitis from S. pneumonia, Haemophilus

influenza and Neisseria Meningitidis

Contraindication This is contraindicated in:

108

a. Patients who are hypersensitive to the drug and its components

b. Use cautiously in elderly patients and in those with a history of

seizure disorders and impaired renal function

c. Not to be used in breast-feeding women

Drug-Drug

Interaction

Interactions:

a. Probenicid. May decrease excretion of meropenem; probenicid

competes with meropenem for active tubular secretion.

Side/ Adverse

Effects:

CNS: seizures, headache, pain

CV: phlebitis, thrombophlebitis

GI: psuedomembranous colitis, constipation or diarrhea, glossitis, oral

condidiasis and vomiting

GU: RBCs in the urine

Hematologic: anemia

Respiratory apnea, dyspnea

Skin: injection site inflammation, pruritus, rash

Other: anaphylaxis, hypersensitivity reactions, inflammation

Nursing

Responsibilities:

1. Ensure that the patient is not hypersensitive to the drug

and its components.

2. Ensure that the patient is not manifesting any conditions

109

contraindicated with the use of the drug.

3. Watch out for episodes of seizure in patients with

meningitis, CNS disorders and compromised renal

function.

4. Monitor patient for signs and symptoms of

superinfection.

5. Periodic assessment of organ system functions, incuding

renal, hepatic and hemopoietic function is recommended

for prolonged therapy.

6. Monitor patient’s fluid balance.

7. Instruct patient or significant others to promptly report

signs of superinfection and adverse reactions.

8. If seizures occur during the therapy, stop the infusion

and notify the prescriber promptly.

Generic Name:

Piperacillin sodium and Tazobactam sodium

Brand Name: Zosyn

Classification: Extendend-spectru penicillin, beta lactamase inhibitor

Dosage: 525mg IVTT q6

110

Mode of Action: Inhibits cell wall synthesis during bacterial multiplication

Indication: This drug is indicated for:

a. Moderate to severe infections form piperacillin resistant,

piperacillin and tazobactam susceptible beta-lactamase

producing strains of microorganisms in appendicitis

complicated by rupture or abscess, skin and skin structure

infections, postpartum endometritis or pelvic inflammatory

disease and moderate to severe community acquired pneumonia

caused by Heaophilus influenza.

b. Moderate to severe nosocomial Pneumonia cause by

piperacillin and tazobactam susceptible beta-lactamase

producing strains of microorganisms.

Contraindication Contraindicated in patients who are hypersensitive to the drug

and other penecillins. Use cautiously to patients with bleeding

tendencies, uremia, hypokalemia, and allergies to other drugs

such as cephalosporins because of possible cross sensitivity.

Drug-Drug

Interaction

Interactions:

a. Hormonal contraceptive. May decrease contraceptive

effectiveness. Advise use of another form of contraceptive.

b. Oral anticoagulants. May prolong effects.

c. Probenicid. May increase piperacillin level.

111

d. Vecuronium. May prolong neuromuscular blockade.

Side/ Adverse

Effects:

CNS: insomnia, headache, fever, seizures, agitation, dizziness, anxiety

CV: hypertension, tachycardia, chest pain, edema

GI: diarrhea, nausea, constipation, psuedomembranous colitis,

vomiting, dyspepsia, stool changes and abdominal pain

Hematologic: leucopenia. Neutropenia, thrombocypenia, anemia,

eosinophilia

Respiratory: Dyspnea

Skin: rash, pruritus

Other: anaphylaxis, pain, inflammation, phlebitis at IV site

Nursing

Responsibilities:

1. Before giving the drug, ensure that the patient is not

hypersensitive to it.

2. Obtain specimen culture and sensitivity tests before giving the

first dose.

3. Watch out for signs of superinfection.

4. Inform patient and significant other to promptly report signs of

superinfection and adverse reactions.

5. Monitor hematologic and coagulation parameters.

6. Give IVTT in slowly.

7. Assess IV site for irritation and discomfort.

112

8. Promptly inform the prescriber if signs of superinfection or

adverse reactions occur.

Generic Name:

Mannitol

Brand Name: Osmitrol

Classification: Osmotic diuretic

Dosage: 52 mg q6

Mode of Action: Increases osmotic pressure of glomerular filtrate, inhibiting tubular

reabsorption of water and electrolytes, drug elevates plasma osmolality,

increasing water flow into extracellular fluid.

Indication: This drug is given to:

a. Test dose for marked oliguria or suspected inadequate renal

function

b. Oliguria

c. To prevent oliguria or acute renal failure

d. Diuresis in drug intoxication

Contraindication This drug is contraindicated in patients who are hypersensitive

113

to it. Contraindicated in patients with anuria, severe pulmonary

congestion, frank pulmonary edema, active intracranial

bleeding, metabolic edema, renal dysfunction, azotemia and

oliguria, congestive heart failure or pulmonary congestion.

Drug-Drug

Interaction

Interactions:

a. Lithium. May increase urinary excretion of lithium.

Side/ Adverse

Effects:

CNS: Seizures, dizziness, headache, fever

CV: edema, thrombophlebitis, hupotension, hypertension, heart failure,

tachycardia, angina-like pain, vascular overload

EENT: blurred vision, rhinitis

GI: Thirst, dry mouth, nausaea, vomiting diarrhea

GU: urine retention

Metabolic: dehydration

Skin: local pain, urticaria

Nursing

Responsibilities:

1. Monitor vital signs prior to, during and after drug

administration.

2. Report increasing oliguria if such takes place.

3. Check fluid and electrolyte status of the patient frequently.

114

4. Increase oral fluid intake.

5. Do not give electrolyte-free IV fluids.

6. Monitor for signs and symptoms of hypokalemia.

7. Ensure adequate nutrition and fluid intake.

8. Instruct patient and significant other to promptly report

adverse reactions and discomfort at the IV site.

NURSING THEORIES

Environmental theory

Florence Nightingale, widely known as the “Lady with the Lamp”, created the

Environmental Theory which is still widely used nowadays. She stated in her nursing notes that

nursing "is an act of utilizing the environment of the patient to assist him in his recovery"

(Nightingale 1860/1969) and that it involves the nurse's initiative to configure environmental

settings appropriate for the gradual restoration of the patient's health, and that external factors

115

associated with the patient's surroundings affect life or biologic and physiologic processes, and

his development.

Environmental Factors Affecting Health

Nightingale defined in her environmental theory the following factors present in the patient's

environment:

Pure or fresh air

Pure water

Sufficient food supplies

Efficient drainage

Cleanliness

Light (especially direct sunlight)

Any deficiency in one or more of these factors could lead to impaired functioning of life

processes or diminished health status. Emphasized in her environmental theory is the provision

of a quiet or noise-free and warm attending to patient's dietary needs by assessment,

documentation of time of food intake, and evaluating its effects on the patient.

In the case of Child Y, the child needs the five elements presented by Nightingle for her

present condition and rehabilitation. The parents should have adequate knowledge about

sanitation so that they can provide her a comfortable environment.

Orem's Model of Nursing

The theory Orem is based upon the philosophy that all "patients wish to care for

themselves". Orem’s theory emphasizes on client’s self-care needs. Client can recover more

quickly and holistically if they are allowed to perform their own self cares to the best of their

116

ability. The focus of Orem's model of nursing is to enhance the patient's ability for self-care and

extend this ability to care for their dependents (Orem, 2005). A person's self-care deficits is a

result of their environment. Three systems exist within the professional nursing model: the

compensatory system, in which the nurse provides total care; the partial compensatory system, in

which the nurse and the patients share responsibilities for care; and the educative-development

system, in which the patient has the primary responsibility for personal health, with the nurse

acting as a consultant (Central, 2005; Orem, 2005). The basic premise of Orem's model is that

individuals can take responsibility for their health and the health of others, and in a general

sense, individuals have the capacity to care for themselves and their dependents.

Child Y needs to be completely attended to since she is not in the position to do activities

of daily living by herself since she is in a persistent vegetative state. As members of the health

care team, it is important to discuss with the significant others the things that Child Y needs

putting into priority the survival needs of the child. It the job of health care professionals to

provide care for our client, promote their wellness and ensure sustenance of these needs in our

absence, hence, there is a need to offer health teachings and support to the family in order to

meet her self -care needs. It is important to teach the mother how to help her child bathe, eat and

maintain general hygiene and discuss the importance of these measures in the treatment of the

child.

Virginia Henderson's 14 Basic Needs

Virginia 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

117

knowledge”. She also identified the 14 basic needs of an individual which includes the

following:

1. Breathing normally

2. Eating and drinking adequately

3. Eliminating body wastes

4. Moving and maintaining desirable position

5. Sleeping and resting

6. Selecting suitable clothes

7. Maintaining body temperature within normal range

8. Keeping the body clean and well-groomed

9. Avoiding dangers in the environment

10. Communicating with others

11. Worshiping according to one’s faith

12. Working in such a way that one feels a sense of accomplishment

13. Playing/participating in various forms of recreation

14. Learning, discovering or satisfying the curiosity that leads to normal development and

health and using available health facilities.

The present condition of the patient makes it utterly impossible for her to meet her 14 basic

needs all by herself. She is lethargic and unresponsive, putting care for her own being the

responsibility of the people around her. Considering this, it is very important to keep in mind that

as health care team members, we should cooperate with the patient’s significant others in

working towards meeting the needs of the child at the present and plan for further rehabilitation

once a more stable neurological status and motor function is achieved by the patient.

118

119

NURSING CARE PLAN

DATE CUES NEEDS NURSING

DIAGNOSIS

GOAL OF CARE NURSING

INTERVENTIONS

EVALUATION

January

27, 2011

Objective:

Hemoglobin-

(150- 155)

103

Hematocrit-

(0.36-0.48)

0.31

RBC Count-

(4.1-6.1) 4.02

A

C

T

I

V

I

T

Ineffective

peripheral tissue

perfusion related

to low

haemoglobin count

secondary to

anemia

® The laboratory

data shows

At the end of the 2 hours

nursing intervention, the

patient’s mother will be

able to:

a) Verbalize

awareness of the

existence of the

condition and

measures that

can improve the

1) Review

laboratory

findings.

® To assess the

extent of the

condition of the

patient.

2) Assess related

physical

examinations

June 23, 2009

@

8:30 P.M.

GOAL MET

At the end of the

2 hours of nursing

care the mother

was able to

verbalize

120

Y

-

E

X

E

R

C

I

S

E

P

abnormal results in

RBC, HEMATOCRIT,

and HEMOGLOBIN

that signifies

decrease in oxygen

resulting in the

failure to nourish

the tissues at the

capillary level.

present status including

capillary refill

time, peripheral

pulses and heart

rhythm.

® To check the

quality of

circulation by

assessing the

cardiovascular

system.

3) Instruct the

mother to ask the

patient to do

range of motion

activities.

® Range of motion will

awareness of the

existence of her

daughter’s

condition as

evidenced by the

mother’s

statement “ Mao

diay mura siya ug

luspad tan awon.”

She also stated

that “ I consulta

nalang namo ni sa

doctor para mas

masolusyonan ug

tarung”

121

A

T

T

E

R

N

stimulate peripheral

circulation.

4) Refer to the

physician.

® To promote proper

medi

5) Discuss with the

significant other

the necessary

dietary changes.

® Proper diet will

promote necessary

nutrients that would be

helpful in maintaining

proper circulation.

6) Check patient’s

122

intake such as

medications, and

foods and fluids

that can be

contraindicated.

® Foods, drugs, fluids

that are

contraindicated may

aggravate patient’s

condition.

7) Discuss with the

mother the

condition of the

patient, its extent,

nature and

possible

complications in

123

understandable

terms.

® To be aware of

the action needed

to be done.

8) Discuss with the

mother measures

to improve

patient’s

condition like

frequent

consultation with

the physician, diet

and exercise.

® It is important

for the mother to

be involved in the

124

care of the patient

since the patient

is still a child.

9) Provide a quiet,

restful

atmosphere

®Conserves

energy and lowers

tissue oxygen

demands.

10) Instruct the

significant others

to encourage the

patient to express

any body

problems.

® To identify

125

promptly the

patient’s needs

Date Cues Needs Nursing Diagnosis Plan of Care Nursing Interventions Evaluation

January 27,

2011

6pmOBJECTIVE:

Temperature

of 38°C.

Pulse rate of

135bpm.

Flushed skin

noted.

Patient’s skin

N

U

T

R

I

T

I

Hyperthermia related to

active Central Nervous

System Infection

® Active infections cause

the body to elevate

temperature due to the

action of pyrogens

stimulated by immune

response against

At the end of

1 hour of nursing

care, the patient

will:

have a

temperature at

normal range,

be able to rest

1. Monitor body

temperature every 30

minutes or more often

if indicated.

® Evaluates the

effectiveness of

interventions.

2. Employ measures to

reduce excessive

fever, such as

GOAL MET

Temperatur

e rechecked:

37.4°C.

Pulse rate:

130 bpm

Left on bed

asleep

126

is warm to

touch.

Diaphoresis

noted.

Restlessness

noted

O

N

A

L

&

M

E

T

A

B

O

L

invading microorganisms.

Gulanick, et. al. Nursing

Care Plans.

removing blankets,

applying ice bags to

axilla and groins.

® Promotes patient’s

comfort and lowers

body temperature.

3. Perform tepid sponge

bath.

® Provide patient

with comfort and

lowers body

temperature.

4. Monitor and record

vital signs.

®Increased heart rate,

cool skin and

decreased blood

127

I

C

P

A

T

T

E

R

N

pressure may indicate

hypovolemia, which

leads to decrease

tissue perfusion.

Increase respiratory

rate compensates for

tissue hypoxia.

5. Remind the watcher of

the client on the

importance of having

adequate rest periods.

® Adequate rest

periods promote

client comfort and

avoid exertional

activities that might

128

worsen fever.

6. Provide patient with

proper ventilation.

® Proper ventilation

would provide

comfort to the patient

thus patient could be

able to rest

7. Encourage the watcher

to increase oral fluid

intake in feeding the

baby.

®Encouraging patient

may promote

adequate hydration.

8. Discuss precipitating

factors with the parent,

129

if known.

® Develops

recommendation for

keeping cool and

avoiding heat-related

illnesses.

9. Encourage the watcher

about the adherence to

other aspects of health

care management,

including dietary

habits.

® Encouraging

adherence to proper

care management

would help in

providing wellness to

130

the patient.

10. Administer antipyretic

medication as ordered

and record

effectiveness.

® Antipyretic

medications aids in

the reduction of

fever.

Date Cues Needs Nursing Diagnosis Plan of Care Nursing Interventions Evaluation

January 27,

2011OBJECTIVE:

Diaphoretic

Dry skin

N

U

Risk for impaired skin

integrity related to

mechanical factors such

as pressures and friction.

At the end of the 8

hours shift the

client will maintain

tissue integrity as

1. Assess general

condition of skin

® Assessment

GOAL MET.

At the end of the

8 hours shift the

client was able

131

noted

with skin

turgor

Unable to

ambulate

T

R

I

T

I

O

N

A

L

-

M

E

® Skin is the primary

defense of the body; it

protects the body

against infections

and diseases brought

about by the invasion of

microbes in the body. A

normal skin is moist and

intact; dryness of the skin

is more prone to friction

that may result to

impairment of the skin

integrity as compared

with a moist skin.

evidenced by:

a. absence of

redness and

irritation

b. no skin

breakdown.

would help check

for any

abnormalities of

the body

2. Assess for

environmental

moisture.

® Moisture may

contribute to skin

maceration.

3. Encourage the

watcher for the

implementation and

posting of a turning

schedule, restricting

time in one position

to 2 hours or less

maintain tissue

integrity as

evidenced by:

a. absence of

redness

and

irritation

skin

breakdown

132

T

A

B

O

L

I

C

P

A

T

T

E

R

N

NANDA 11th edition

(Doenges)

and customizing the

schedule to patient’s

routine and

caregiver’s needs

®Building up of

pressures on the

body could be

prevented through

turning.

4. Encourage caregiver

to maintain

functional body

alignment.

®This would

maintain the

alignment of the

body.

133

5. Increase tissue

perfusion by

massaging around

affected area.

®Massaging

reddened area may

damage skin further.

6. Clean, dry, and

moisturize skin,

especially over bony

prominences, twice

daily or as indicated

by incontinence or

sweating.

® This would thus

help in preventing

the impairment of

134

the skin

7. Encourage the

parent to provide

adequate nutrition

and hydration

® Hydrated skin is

less prone to

breakdown.

8. Remind watcher to

change the clothing

and diapers if

soaked

®This would help

prevent the irritation

of the skin.

9. Instruct the watcher

to maintain the

135

hygiene of the

patient.

®Hygiene is

important for the

body to prevent any

impairment of the

skin.

10. Refer physician for

any problems

®Proper referral

would give the

patient proper

management for the

problem.

136

DATE CUES NEED NURSING

DIAGNOSIS

OBJECTIVE OF

CARE

NURSING

INTERVENTIONS

EVALUATION

Jan. 28,

2011

Objective:

- (+)

decerebrate

rigidity

-palmar pallor

noted

- (+) persistent

vegetative

state

-(+) stupor

- unable to talk

and ambulate

A

C

T

I

V

I

T

Y

-

E

X

E

R

C

I

S

Activity Intolerance

related to persistent

vegetative state

R: There is an

insufficient

physiological or

psychological

energy to endure or

complete required

daily activity.

Nurses’ Pocket

Guide by Doenges

et. al.

Within the

span of 3

hours, the

client’s

significant

others will:

a) Verbalize

techniques

to enhance

activity

tolerance;

b) Participate

willingly in

necessary/d

esired

1. Determine the causes of

fatigue or activity

intolerance.

R: Assessment guides

treatment.

2. Monitor vital signs.

R: To watch for changes

in blood pressure, pulse

and respiratory rate after

activities

3. Assist with ADLs as

indicated.

R: Assisting the patient

with ADLs allows for

conservation of energy.

4. Encourage rest and

Goal met

After 3 hours of

nursing care,

the client’s

significant other

was able to:

a) verbalize

techniques

to enhance

activity

tolerance

b) Participate

willingly in

necessary/d

esired

137

E

P

A

T

T

E

R

N

activities. sleep.

R: In order to help relax

the patient.

5. Provide a calm

environment.

R: To promote a resful

atmosphere.

6. Place necessary

materials near the

bedside.

R: To avoid

overexertion

7. Encourage passive

ROM exercises.

R: Exercises maintain

muscle strength and

joint

ROM.

8. Teach patient/caregivers

to recognize signs of

activities.

138

physical overactivity.

R: So not to tire the

patient.

9. Teach energy

conservation techniques,

like:

Sitting to do tasks,

Changing positions

often

R: In order not to

exhaust the patient.

10. Administer iron

supplement as ordered.

R: To have

supplemental iron which

could help alleviate

anemia.

139

Date Cues Needs Nursing

Diagnosis

Plan of Care Nursing Interventions Evaluation

Jan. 28, 2011 Objective:

BMI = 11.3

Weight: 10.5

kg

On OT

feeding

Weakness

Stupor

Low level of

hemoglobin,

hematocrit

and RBC

N

U

T

R

I

T

I

O

N

Imbalanced

nutrition: less

than body

requirements

related to

inadequate

knowledge of

the mother/

significant

other.

® Patient has a

low level of

nutrition

At the end of 2

hours of nursing

care, the

significant other

will be able to:

a.) identify the

foods that are

nutritionally

beneficial to the

patient

b.) enumerate

ways and

techniques in

increasing the

1) Assess the patient’s weight

relative to age and activity

level.

® To assess the extent of

malnutrition.

2) Ascertain SO’s understanding

of individual nutritional

needs.

® To determine what

information to provide the

significant other.

3) Assess how the patient

perceives food and the act of

eating.

GOAL MET

At the end of 2

hours of nursing

care, the

significant other

was able to

identify the foods

that are

nutritionally

beneficial to the

patient

140

A

L

-

M

E

T

A

B

O

L

I

C

because of the

lack of

knowledge of

the mother in

proper

nutritional

management of

the patient’s

diet.

patient’s appetite. ®Provides an idea on how to

properly manage food

administration by using the

patient’s perception.

4) Discuss to the significant

other the eating habits,

including food preferences

and intolerance of the patient

to different foods.

® To assess the patient’s

needs and recognize

behaviors that need

modification.

5) Discuss to the significant

other strategies on how to

increase the patient’s

appetite like presenting the

141

P

A

T

T

E

R

N

nutritious foods in an

attractive manner and

variation in cooking.

® To motivate the client to

eat.

6) Encourage the significant

other to involve the patient in

making decisions related to

food choice by letting the

child choose the foods she

wants within the limits of

nutritional benefits.

® It is important to consider

the child’s wants since she

will be the one who will eat

these foods.

7) Encourage the significant

142

other to promote pleasant

and relaxing environment

when feeding.

® Pleasant and relaxing

environment will positively

affect the child’s eating

disposition.

8) Instruct the significant other

to provide oral care to the

patient.

® To maintain the integrity of

oral mucosa and other

structures in the mouth that

promotes eating.

9) Limit fluids one hour prior to

meals.

® It decreases the possibility

143

of early satiety.

Collaborative:

10) Refer to the dietician.

® Helps in the proper

management of food and

allocation of the needed

nutrients of the patient.

144

145

DISCHARGE PLAN (M.E.T.H.O.D.)

Individuals who are discharged from hospitals and rehabilitation facilities are

increasingly in need of in-home care. Family caregivers should be aware that they may have to

continue some of the medical and personal care regimens at home that had been performed by

professionals in the facilities.

Discharge planning begins early during the hospitalization and rehabilitation processes. It

involves the patient, family, and other persons taking care of the patient. The purpose of

discharge planning is to help the patient continue their improvement outside of a clinical setting

and in a more homelike environment. It helps in ensuring that the patient will have a safe place

to live after discharge and in deciding what care and assistance is needed for the client’s

recovery. Since the child is not capable of understanding the discharge instruction owing to her

developmental stage and present condition, the discharge plan is mainly directed to the parents

and significant others.

MEDICATION

Take pain medications as needed.

Inform SO to have medications on time, or as directed for the full course of therapy,

even if feeling better.

Inform the client’s significant other about the possible side effects of the medication.

Encourage the significant other to report or inform the physician if any of these side

effects occur. Inform and explain to the significant others in simple terms that other

146

drugs, such as over the counter drugs that he or she is taking, will probably have other

effects with the medication given. Moreover, emphasize the right timing or taking or

the right time intervals of these drugs to maximize its effects and avoid further

complications.

Provide information to the mother of the client for better understanding regarding

therapeutic regimen.

EXERCISE

Encourage walking exercises.

Encourage passive ROM exercises.

Maintain physical and mental stimulation by ensuring that patient performs normal daily

activities to maintain normal body functions.

TREATMENT

Instruct the client’s significant other to continue drug therapy as ordered.

Inform the significant other of the dangers of non compliance to treatment regimen.

Discuss to the client’s significant other the complication of the condition.

Instruct the patient’s significant other to report to the physician promptly about any

changes on health condition.

Encourage the patient’s significant other to strictly comply with the doctor’s orders

given to patient, especially in taking prescribed medications.

HEALTH TEACHINGS

147

Instruct significant others to attend to the complains of the patient

Encourage patient to express feelings of discomfort involving the condition

Encourage rest.

Instruct significant others to report any signs of unusuality involving patients condition.

Notify the physician on the following:

- fever and/or chills

- recurrent seizures

- projectile vomiting

- loss of consciousness

OUTPATIENT

Encourage significant others to have followed up visitations to the physicians after

discharge.

Remind client’s significant other on the arrangements to be made with the physician for

follow-up check ups

Follow-up check up regularly in order to monitor and properly manage patient’s illness.

Continue medication as ordered.

Instruct to have a follow-up check-up or refer to the physician if the patient is

uncomfortable

Instruct the client and significant others to contact medical provider for any

unusualities.

148

PROGNOSIS

GOOD FAIR POOR JUSTIFICATION

Onset of the illness √ The onset of illness was sudden. After the first attack,

the child’s status has progressively deteriorated.

Duration of illness √ Although the patient was immediately brought to the

hospital upon the early stages of the condition and she

was given adequate medical attention and in the

course of treatment and is actually showing signs of

improvement. The illness has brought great disruptions

in her neurologic and motor function which may be

irreversible.

Precipitating factors √ The precipitating factor present in the patient is

exposure to microorganisms. Exposure to

microorganisms easily modified by cleaning the cause

of the exposure thus decreasing exposure to

microorganisms. However, since the effects of the

disease has already taken its toll on the body of the

patient, it may be reasonable to presume that effects

149

eliminating precipitating factors at this stage would

already prove to be futile.

Willingness to take

medications and

treatment

√ The patient complies with the medications strictly.

Moreover, the mother is very willing to let her child

take the medications prescribed to her by the doctor.

The patient was also brought to the hospital be her

mother for treatment.

Age √ The age of the patient is 3 years old. She is still still too

young to recuperate from the disease amd is still very

dependent to her family. Her recovey is variable to the

presence of people to care for her.

Environmental

factors

√ The client’s home as reported is conducive for rest and

sleep. The patient lives in a therapeutic environment.

There are smaller chances of pollution and noise. It can

be said that the environment as well was generally

peaceful and calm is very favorable for rest and

promotes better health.

Family Support √ The family has been very supportive throughout. Her

mother was supportive. Her father may not be with her

in the hospital but he is working so hard to gain money

for her hospitalization.

150

Total

Computation:

Poor: (3*1)/7 =4/7

Fair: (1*2)/7 = 0/7

Good: (3*3)/7 =6/7

Total: 2.0

General Prognosis:

1-1.6 = POOR

1.7-2.3 = FAIR

2.4-3.0 = GOOD

Rationale for a Fair Prognosis

The patient has been brought to the hospital promptly upon experiencing symptoms of seizure

and vomiting and was also given medical attention immediately, however, it must be noted that the

type of disease that has come to the patient brings irreversible neurologic and motor dysfunction to an

individual. Rehabilitation for this type of disease would only prove to be fair.

151

RECOMMENDATIONS

This case study has provided the proponent with important information about the patient’s

disease. In order to ensure that optimal health is restored and maintained, the author would like to

recommend the following:

Since the patient is still a young, suggesting recommendations to her is not ideal. Therefore

focus of recommendation is given to her family who are, at present, responsible for meeting her needs.

To the patient’s family

The patient’s family plays an important role in the patient’s illness and recovery. Since Child Y is

still very much dependent to the people around her, the family should make themselves physically

present so that the patient would somehow feel their support and concern. They are encouraged to be

the patient’s source of strength and inspiration as she undergoes painful, traumatic and harrowing

procedures. In addition, it is of prime importance that they are oriented and educated basic facts

regarding the patient’s condition so that they will understand her even better and assist him in his daily

activities.

To the patient’s community

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The people in the patient’s community are encouraged to be sensitive of the patient’s condition

and not interfere with her recovery. They should help provide an environment conducive for the

patient’s well-being. It is important that the patient would be provided with time to rest. They are

encouraged to show and provide acceptance of the patient’s condition and must take efforts to make

her feel that she is still the same as the other children in their community. They must provide a happy

and child-friendly environment so that the child’s anxiety over her condition would be lessen.

To the student nurses:

This case study would help them better understand the patient’s condition. What is entrusted to

student nurses is the life of their patient. Even with the clinical instructor’s presence, they can still make

mistakes and errors, which can harm the patient. Hence, they are encouraged to equip themselves with

necessary knowledge that will enable them to render quality and holistic nursing care and intervention

to patients in need.

It is known that nurses play a major role in helping the client and family implement healthy

behaviors and help them monitor the client’s health. Thus, anticipatory guidance and knowledge about

health should be supplied to help clients attain, maintain, or regain an optimal level of health. Student

nurses should prioritize interaction with family members and significant others to provide support,

information, and comfort in addition to caring for the patient. Thus, they should prepare themselves

with the reality that they are soon to become health professionals.

Genuineness, empathy, and respect are key elements for the nurse to possess. Student nurses

must develop patience, love for our work, and empathy to our patients. They must assist in facilitating a

remarkable experience as well as share our knowledge regarding the case. They must also continue to

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study different cases and be able to impart this to other student nurses, patients and their significant

others.

To the Ateneo de Davao University- College of Nursing

The AdDU- College of Nursing is the source that provides student nurses with exposures that

enable them to apply the knowledge they have gained and practice the skills they honed necessary for

their profession. The faculty and staff are encouraged to continue improving the standards of the

Ateneo Nursing Curriculum by providing quality education to students. Also they, themselves, must be

well-trained to delegate learning to student nurses. It is important that they continue to inspire

generations of today to perceive nursing as a gift and act of charity rather than a mere means to success.

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Bernard L. Maria. Current Management in Child Neurology. 4th Edition.

Raimond, Jeanne, et. Al. Neurological Emergencies.

Nursing Pocket Guide to Diagnoses, Prioritized Interventions and Rationale

Doenges et. al.

Textbook of Medical Surgical Nursing 11th Edition

Lippincot and Willers

David Mullins (2007) 501 Human Diseases

Thomsom Asian Edition (p.306), Singapore

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Delamar Learning

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.

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.

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Understanding Medical Surgical Nursing 3rd edition; International Edition; Williams,S.L.; Hopper, P.

D.;F.A. Davis Company, 2007

Brunner and Suddarth’s Textbook of Medical Surgical Nursing, 11th edition; Smeltze, S.C.; Bare, B.G.;

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