case study final. pott's disease
TRANSCRIPT
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
I. INTRODUCTION
This is a case of an 8 year-old male patient who is diagnosed of Aspiration
Pneumonia, Sepsis, Cerebral Palsy, and Pott’s disease and was admitted to Capitol
University Medical City (CUMC) ICU last November 23, 2010. During the assessment,
findings revealed that there was a normal blood pressure of 100/70, pulse rate was
98bpm, respiration rate of 25cpm and temperature of 37.3 degree Celsius and had chief
complaints of difficulty in breathing with coffee-ground vomitus. His weight revealed 42
lbs (20.1 kg).
Aspiration pneumonia is an inflammation of the lungs and bronchial tubes caused
by inhaling foreign material, usually food, drink, vomit, or secretions from the mouth into
the lungs. This may progress to form a collection of pus in the lungs (lung abscess).
Aspiration pneumonia is a form of pneumonia that can develop when foreign material,
such as food, liquid, vomit, or mucus, is accidentally inhaled into the lungs. This can
happen when a person is unconscious or has a seizure or when a stroke has affected
the person's ability to swallow. Childhood pneumonia is the leading single cause of
mortality in children aged less than 5 years. The incidence in this age group is
estimated to be 0.29 episodes per child-year in developing and 0.05 episodes per child-
year in developed countries. This translates into about 156 million new episodes each
year worldwide, of which 151 million episodes are in the developing world. Most cases
occur in India (43 million), China (21 million) and Pakistan (10 million), with additional
high numbers in Bangladesh, Indonesia and Nigeria (6 million each). Of all community
cases, 7–13% are severe enough to be life-threatening and require hospitalization.
Substantial evidence revealed that the leading risk factors contributing to pneumonia
incidence are lack of exclusive breastfeeding, undernutrition, indoor air pollution, low
birth weight, crowding and lack of measles immunization. Pneumonia is responsible for
about 19% of all deaths in children aged less than 5 years, of which more than 70%
take place in sub-Saharan Africa and south-east Asia. Although based on limited
available evidence, recent studies have identified Streptococcus pneumoniae,
Haemophilus influenzae and respiratory syncytial virus as the main pathogens
associated with childhood pneumonia. (Bulletin of the World Health Organization
2008;86:408–416.)
On the other hand, sepsis is a serious infection usually caused by bacteria —
which can originate in many body parts, such as the lungs, intestines, urinary tract, or
skin — that make toxins that cause the immune system to attack the body's own organs
and tissues. Sepsis can be frightening because it can lead to serious complications that
affect the kidneys, lungs, brain, and hearing, and can even cause death. As mentioned,
42
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
conditions originating in the perinatal period is among the leading cause of mortality; the
top cause of death being pneumonia, followed by bacterial sepsis.
Meanwhile, Cerebral Palsy (CP) is a disorder that affects muscle tone,
movement, and motor skills (the ability to move in a coordinated and purposeful way).
Cerebral palsy can also lead to other health issues, including vision, hearing, and
speech problems, and learning disabilities. CP is usually caused by brain damage that
occurs before or during a child's birth, or during the first 3 to 5 years of a child's life.
There is no cure for CP, but treatment, therapy, special equipment, and, in some cases,
surgery can help a child who is living with the condition. Statistics that were calculated
extrapolations of various prevalence or incidence rates against the populations of a
particular country or region which shows the prevalence/incidence of Cerebral Palsy are
typically based on US, UK, Canadian or Australian statistics. This extrapolation
calculation is automated and does not take into account any genetic, cultural,
environmental, social, and racial or other differences across the various countries and
regions for which the extrapolated Cerebral Palsy statistics below refer to. As such,
these extrapolations may be highly inaccurate (especially for developing or third-world
countries) and only give a general indication (or even a meaningless indication) as to
the actual prevalence or incidence of Cerebral Palsy in that region. Specifically, in the
aforementioned statistics, Philippines has 172,483 cases for the population of
86,241,6972
Finally, Pott’s disease is a presentation of extrapulmonary tuberculosis that
affects the spine, a kind of tuberculous arthritis of the intervertebral joints. Scientifically,
it is called tuberculous spondylitis. Pott’s disease is the most common site of bone
infection in TB; hips and knees are also often affected. The lower thoracic and upper
lumbar vertebrae are the areas of the spine most often affected. Pott's disease, which is
also known as Pott’s caries, David's disease, and Pott's curvature, is a medical
condition of the spine. Individuals suffering from Pott's disease typically experience back
pain, night sweats, fever, weight loss, and anorexia. They may also develop a spinal
mass, which results in tingling, numbness, or a general feeling of weakness in the leg
muscles. Often, the pain associated with Pott's disease causes the sufferer to walk in an
upright and stiff position. Pott’s disease is caused when the vertebrae become soft and
collapse as the result of caries or osteitis. Typically, this is caused by Mycobacterium
tuberculosis. As a result, a person with Pott's disease often develops kyphosis, which
results in a hunchback. This is often referred to as Pott’s curvature. In some cases, a
person with Pott's disease may also develop paralysis, referred to as Pott’s paraplegia,
when the spinal nerves become affected by the curvature. The incidence and
prevalence of pediatric tuberculosis (TB) worldwide varies significantly according to the
burden of the disease in different countries. It has been estimated that 3.1 million
42
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
children under 15 years of age are infected with TB worldwide. According to the World
Health Organization (WHO), children with TB represent 10 % to 20 % of all TB cases.
The majority of these cases occur in low-income countries where the prevalence of
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) is
high. TB occurs frequently among disadvantaged populations, such as malnourished
individuals, and those living in crowded areas. According to WHO reports, India, China,
Pakistan, the Philippines, Thailand, Indonesia, Bangladesh, and the Democratic
Republic of the Congo account for nearly 75 % of all cases of pediatric TB (World
Health Organization 2006, Dye 1990). Furthermore, it has also been reported that TB is
responsible in Sub-Saharan countries for between 7 % and 16 % of all episodes of
acute pneumonia in HIV-infected children, and for approximately one fifth of all deaths
in children presenting with acute pneumonia (Chintu 2002, Jeena 2002).
This kind of case, requires continuous care and necessitates proper health
education to the patient and to significant others to provide safety, proper nourishment.
It is but a collaborative effort of health care providers and the patient in line to
preventing reoccurrence, and further complication. In light to this, through this case
presentation the group will be able to come up with versatile ideas relevant to the care
of patient not only for the betterment of his condition but also to address the needs of
patient holistically. This paper contains all the relevant care rendered to the patient
through our duties and all other forms of intervention given by the health team in
response to the patient’s condition including the medications, laboratory results and
other doctors’ orders which are related to the patient’s condition.
42
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
II. GOALS AND OBJECTIVES
General Objectives:
This case presentation seeks to enhance the students’ knowledge with regards
to the patient’s general health and disease condition, its pathophysiology, possible
complications, treatment plan and medical regimen. It also seeks to assimilate the
student’s skills through application of several nursing interventions and medical
management. Furthermore, this case presentation intends to improve the students’
attitude by conveying open-mindedness and utilizing therapeutic communication all
throughout the activity.
Specific Objectives:
Within one week of thorough study of this specific case, the student nurses aim
to achieve the following objectives in this case presentation:
Accurately present a thorough general health assessment of the client which
includes physical assessment and family history taking.
Effectively discuss and elaborate actual signs and symptoms of the specific
diagnoses exhibited by the client.
Thoroughly discuss, explain, and elaborate the nature of the disease process.
Efficiently provide appropriate and proper nursing diagnosis in line with the
client’s medical condition.
Skillfully formulate nursing care plans for the different problems identified.
Appropriately provide nursing interventions according to the standards of nursing
practice.
Effectively apply the learned concepts and theories of the disease and the
management.
Efficiently Appraise the effectiveness and efficacy of nursing interventions
rendered to the client.
Impart the outcome of the rendered nursing interventions.
Convey the significance of client’s response to the rendered nursing interventions
Accurately provide concise and concrete information to the audience with
regards to Aspiration Pneumonia, Sepsis, Cerebral Palsy, and Pott’s disease.
Appropriately provide an environment for learning for the audience.
42
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
III. CLIENT’S PROFILE
A. Socio-demographic Date
Patient X is an eight year old male who lives with his family at Damilag,
Manolo Fortich, Bukidnon. He is the second and youngest son of his Roman
Catholic parents.
B. Vital Signs
The patient vital signs are one of the most important data that should be
given a direct attention because it will serve as basis in determining any risk
factors towards the patient. The increase and decreased of the vital sign of the
patient must be monitored in order to determined whether the patient is at risk or
not.
Upon assessment, the patient’s vital signs were: BP: 100/70 mmHg,
Temperature: 37.3 degree Celsius (but during the shift he reached the
temperature of 37.7C) , PR: 98 beats per minute, and RR: 25 cycles per minute.
The patient weighs 20.1n kilograms and is 4 feet and 2 inches tall.
C. Health Pattern Assessment
Past Medical History
According to the mother, about 10 days after the patient has given
birth, he experienced having high intermittent fever, the mother ignored it
at once but when the patient exhibits seizure activities, the mother then
immediately brought him to the hospital specifically Northern Mindanao
Medical Center (NMMC) and was advised for ICU admission. The doctor’s
diagnosis then was meningitis. In addition to that, as a complication, the
patient develops hydrocephalus and was managed through brain
shunting. The patient went on being comatose for about a week, and was
later diagnosed with Pott’s disease. He was given high doses of antibiotic
then. From then, the patient is no longer able to move by himself, and
went on entirely dependent all his life.
Patient X was 6 years old then when he was readmitted to the ICU
but now in Capitol University Medical City (CUMC) with the same
manifestations. After about 5 days of admission, he was later diagnosed
with Cerebral Palsy.
42
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
History of Present Illness
Three days prior to admission, the patient had cough and colds, the
phlegm is very copious but the mother opted to nebulizer him, considering
the he has always been coughing and had persistent respiratory infection
until last November 23, 2010 he began vomiting blood-like, coffee ground
vomitus. This alarmed the mom and immediately sought medical attention.
Physical Assessment
Patient X has nasogastric tube in place. He also has a mouth guard
secured in place and has an endotracheal tube, at the same time,
connected to a mechanical ventilator with set-up as follows: TV=20, FiO2=
40%, BUR= 25, PEEP 3. He is hooked with D5NM 1L@15 drops per
minute infusing at his left foot. He has heplock on his right arm. He is
hooked to a cardiac monitor and a pulse oximeter. He has a condom
cathether attached to urobag.
HEENT:
Head, hair and scalp Head appears bigger with fine hair and clean
scalp.
Eyes: sclera, pupils Sclerae are anicteric and pupils are covered with
cataracts and are equal in size. The mother also
reported the patient has been blind since birth.
Ears and tympanic membrane The right ear is bigger than the left with no
discharges and has equal auditory function.
Nose No nasal flaring noted. Septum is medial.
Mouth, lips, tongue, teeth and
oral mucosa
Lips and oral mucosa are pale. No lesions noted
in the mouth. Tongue is midline. Teeth are
complete with plaques noted.
Throat and neck Neck has limited range of motion. Thyroids are
non palpable.
Facial movements Symmetrical but decreased or limited mobility.
Cognitive/ Neurological Assessment
Level of consciousness Conscious, often drowsy and less responsive (by
means of motor)
Orientation N/A
42
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
Emotional state Calm at times and gets restless when coughing
Primary language Communicates thru moaning and crying. The
mother also reported, the patient has been mute
from birth.
Educational attainment Haven’t gone to school.
Nutritional and Metabolic Pattern
At home, Patient X is fed with blenderized food ever since, which
includes rice, milk and a little of soft viands. He is fed about once or twice
a day per demand or if he can tolerate. According to the mom, he often
gets choked when fed. He has no vitamins or mineral supplement. Upon
hospital stay, Patient X is fed thru NGT with 2500 kcal a day equally
divided in four feedings. He seems poorly nourished with a BMI below
normal range.
Elimination Pattern
Patient X usually does not follow a pattern in defecating. He used to
defecate once in three days or more, but when he does, his stool appears
soft in consistency, yellow to brown in color and in minimal amount.
He urinates at about 4 times a day with amber to yellow colored
urine. He is not used to wearing diaper even at home because he seems
to have allergic reactions when he wears it.
Abdominal configuration Symmetrical, no superficial veins, with no lesions
and scars
Bowel sounds Hypoactive (3clicks) upon auscultation
Percussion Tympanic and dullness noted on right upper
quadrant
Activity-Exercise Pattern
At home, the patient has no exercise at all. He lies flat on bed most
of the time and gets to sit when fed. He doesn’t have any leisure activities.
He is fully dependent with all the activities of daily living (ADL) as well as
with his mobility. Most of his joints have decreased mobility, in its range of
motion exercises. In terms of his muscular tone and strength, his muscles,
in both limbs, are very weak; tend to become spastic and immobile at
some time. The patient’s gait might not be uncoordinated nor shuffling
neither staggering but definitely not coordinated because he has never
42
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
learned to walk at all. Patient has kyphosis brought about the complication
of Pott’s disease.
CARDIOVASCULAR STATUS
Chest pain, radiation No pain noted and assessed
Point of maximal impulse,
Precordial area
3rd intercostals space, midclavicular line
bulging
Heart sounds Distinct and regular, no murmurs noted
Peripheral pulses Regular, symmetrical and faint
Capillary refill time 2 seconds, no clubbing noted
RESPIRATORY STATUS
Breathing pattern regular, use of accessory muscles noted
Lung expansion Decreased at left side
Vocal/tactile fremitus Not assessed
Percussion Tympany
Breath sounds Crackles noted
Cough nonproductive sputum
Sleep and Rest Pattern
Patient X used to sleep most of the time, if not, lies on bed and
listens to stories being shared by his mother in a resting position. His
sleep accounts almost 18 hours each day.
Role and Relationship Pattern
Patient X is a son to a 39-year-old mother and overseas worker
father. He used to be the youngest and gets almost all attention from his
mom. His dad works overseas and seldom talks with him via phone call.
His dad, according to his mom, cannot come home and take care of their
son because he signed a contract and he needs to strive harder to sustain
Patient X’s needs. However, the mother provides ample time and devotes
most of her attention for her “special” son. On the other hand, the mother
reported their family doesn’t have any history of diabetes, hypertension
nor cancer.
Value and Belief Pattern
42
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
The family is affiliated to the Roman Catholic Church and believes
that God can heal their patient. The mother silently prays and moans all
her desires and wishes of healing to God.
D. Physical Assessment
1. Neurologic Assessment
Level of consciousness Conscious but drowsy and less responsive
Orientation N/A
Emotional state Restless when coughing
2. Head
Head Slightly bigger ( heading to macrocephalic)
Facial movement Symmetrical but limited
Fontanels Closed
Hair Fine
Scalp Clean
3. Eyes
Lids Symmetrical
Periorbital region Non edematous
Conjunctiva pink
Cornea & lens cataracts
42
1
2
3
4
5
6
7
8
9
10
11
12
13
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
Sclera Anicteric
Pupils Equal in size
Visual acuity Loss of sight
Peripheral vision absent
4. Ears
External pinnae Right ear is slightly bigger
External canal No discharge
Tympanic membrane Intact
Gross hearing normal
5. Nose
Mucosa Pinkish
Patency Both patent
Gross smell N/A
Sinuses No tenderness presence
6. Mouth
Lips Pallor
Mucosa Pallor
Tongue Midline
42
1
2
3
4
5
6
7
8
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
Teeth Missing Teeth
Gums pinkish
7. Pharynx
Uvula Midline
Tonsils Not inflamed
Posterior pharynx No inflammation is present
8. Neck
Trachea Midline
Thyroids non-palpable
9. Skin
General color Pallor
Texture Rough
Turgor Firm
Tempareture warm
42
1
2
3
4
5
6
7
8
9
10
11
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
10.Abdomen
General Normal
Configuration Symmetrical
Bowel sound Hypoactive (3 clicks)
Percussion Tympanitic
11.Cardiovascular Status
Precordial area bulging
Point of maximal impulse(PMI) 3rd intercostal space
Apical & rhythm Regular
Heart sound Regular
Peripheral pulse Symmetrical & regular
Capillary refill 2 seconds
12.Respiratory Status
Breathing pattern Regular
Shape of chest AP1:L2
Lung expansion Decreased at the left side
Percussion Resonant
Breath sound Crackles noted
42
1
2
3
4
5
6
7
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
IV. ANATOMY AND PHYSIOLOGY
Brain Structure FunctionAssociated Signs and
Symptoms
1. Cerebral Cortex
Ventral View ( From bottom)
The outermost layer of the
cerebral hemisphere which
is composed of gray matter.
Cortices are asymmetrical.
Both hemispheres are able
to analyze sensory data,
perform memory functions,
learn new information, form
thoughts and make
decisions.
2. Left Hemisphere Sequential Analysis:
systematic, logical
interpretation of information.
Interpretation and
production of symbolic
information:language,
mathematics, abstraction
and reasoning. Memory
stored in a language format.
3. Right Hemisphere Holistic Functioning:
processing multi-sensory
input simultaneously to
provide "holistic" picture of
one's environment. Visual
spatial skills. Holistic
functions such as dancing
and gymnastics are
coordinated by the right
hemisphere. Memory is
stored in auditory, visual
and spatial modalities.
4. Corpus Callosum Connects right and left Damage to the Corpus
42
1
2
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
hemisphere to allow for
communication between the
hemispheres. Forms roof of
the lateral and third
ventricles.
Callosum may result in "Split
Brain" syndrome.
5. Frontal Lobe
Ventral View (From Bottom)
Side View
Cognition and memory.
Prefrontal area: The ability
to concentrate and attend,
elaboration of thought. The
"Gatekeeper"; (judgment,
inhibition). Personality and
emotional traits.
Movement:
Motor Cortex (Brodman's):
voluntary motor activity.
Premotor Cortex: storage
of motor patterns and
voluntary activities.
Language: motor speech.
Premotor – selects
movements, selection and
direction of motor
sequences, choose
behavior in response to
clues, frontal eye fields.
Prefrontal (PFC) – controls
the cognitive processes so
that appropriate movements
are selected at the correct
time and place
Impairment of recent
memory, inattentiveness,
inability to concentrate,
behavior disorders, difficulty
in learning new information.
Lack of inhibition
(inappropriate social and/or
sexual behavior). Emotional
lability. "Flat" affect.
Contralateral plegia, paresis.
Expressive/motor aphasia.
6. Parietal Lobe Processing of sensory input,
sensory discrimination.
Inability to discriminate
between sensory stimuli.
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
Body orientation.
Primary/ secondary somatic
area.
Inability to locate and
recognize parts of the body
(Neglect).
Severe Injury: Inability to
recognize self.
Disorientation of environment
space.
Inability to write.
7. Occipital LobePrimary visual reception
area.
Primary visual association
area: Allows for visual
interpretation.
Primary Visual Cortex: loss
of vision opposite field.
Visual Association Cortex:
loss of ability to recognize
object seen in opposite field
of vision, "flash of light",
"stars".
8. Temporal LobeAuditory receptive area and
association areas.
Expressed behavior.
Language: Receptive
speech.
Memory: Information
retrieval.
Hearing deficits.
Agitation, irritability, childish
behavior.
Receptive/ sensory aphasia.
9. Limbic System
Olfactory pathways:
Amygdala and their different
pathways.
Hippocampi and their
different pathways.
Limbic lobes: Sex, rage,
fear; emotions. Integration
of recent memory, biological
rhythms.
Hypothalamus.
Agitation, loss of control of
emotion. Loss of recent
memory.
Loss of sense of smell.
10.Basal Ganglia Subcortical gray matter
nuclei. Processing link
between thalamus and
Movement disorders: chorea,
tremors at rest and with
initiation of movement,
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
motor cortex. Initiation and
direction of voluntary
movement. Balance
(inhibitory), Postural
reflexes.
Part of extrapyramidal
system: regulation of
automatic movement.
abnormal increase in muscle
tone, difficulty initiating
movement.
Parkinson's.
11.Thalamus Processing center of the
cerebral cortex. Coordinates
and regulates all functional
activity of the cortex via the
integration of the afferent
input to the cortex (except
olfaction).
Contributes to affectual
expression.
Altered level of
consciousness.
Loss of perception.
Thalamic syndrome -
spontaneous pain opposite
side of body.
12.Hypothalamus Integration center of
Autonomic Nervous
System (ANS): Regulation
of body temperature and
endocrine function.
Anterior Hypothalamus:
parasympathetic activity
(maintenance function).
Posterior Hypothalamus:
sympathetic activity ("Fight"
or "Flight", stress response.
Behavioral patterns:
Physical expression of
behavior.
Appestat: Feeding center.
Pleasure center.
Hormonal imbalances.
Malignant hypothermia.
Inability to control
temperature.
Diabetes Insipidus (DI).
Inappropriate ADH (SIADH).
Diencephalic dysfunction:
"neurogenic storms".
13. Internal Capsule Motor tracts. Contralateral plegia
(Paralysis of the opposite
side of the body).
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
14.Reticular Activating
System (RAS)
Responsible for arousal
from sleep, wakefulness,
attention.
Altered level of
consciousness.
Spinal cord
The spinal cord is about 18 inches long and is
the thickness of your thumb. It runs within the
protective spinal canal from the brainstem to the 1st
lumbar vertebra. At the end of the spinal cord, the
cord fibers separate into the cauda equina and
continue down through the spinal canal to your
tailbone before branching off to your legs and feet.
The spinal cord serves as an information super-
highway, relaying messages between the brain and
the body. The brain sends motor messages to the
limbs and body through the spinal cord allowing for
movement. The limbs and body send sensory
messages to the brain through the spinal cord about
what we feel and touch. Sometimes the spinal cord
can react without sending information to the brain.
These special pathways, called spinal reflexes, are
designed to immediately protect our body from harm.
The nerve cells that make up your spinal cord itself are called upper motor
neurons. The nerves that branch off your spinal cord down your back and neck are
called lower motor neurons. These nerves exit between each of your vertebrae and go
to all parts of your body.
Any damage to the spinal cord can result in a loss of sensory and motor function below
the level of injury. For example, an injury to the
thoracic or lumbar area may cause motor and
sensory loss of the legs and trunk (called
paraplegia). An injury to the cervical (neck) area
42
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
may cause sensory and motor loss of the arms and legs (called tetraplegia, formerly
known as quadriplegia).
Vertebral arch & spinal canal
On the back of each vertebra body are bony projections that form the vertebral
arch. The arch is made of two supporting pedicles and two arched laminae (Fig. 5). The
hollow spinal canal contains the spinal cord, fat, connective tissue, and blood supply of
the cord. Under each pedicle, a pair of spinal nerves exits the spinal cord and passes
through the intervertebral foramen to branch out to your body.
Surgeons often remove the lamina of the vertebral arch (laminectomy) to access
and decompress the spinal cord and nerves to treat spinal stenosis, tumors, or
herniated discs.
Seven processes arise from the vertebral arch: the central spinous process, two
transverse processes, two superior facets, and two inferior facets.
The Anatomy of the Lung
Each lung is divided into
lobes. The right lung, which
has three lobes, is slightly
larger than the left, which has
two. The lungs are housed in
the chest cavity, or thoracic
cavity, and covered by a
protective membrane called
the pleura. The diaphragm,
the primary muscle involved
in respiration, separates the
lungs from the abdominal
cavity. The pulmonary
arteries carry de-oxygenated
blood from the right ventricle of the heart to the lungs. The pulmonary veins, on the
other hand, carry oxygenated blood from the lungs to the heart, so it can be pumped to
the rest of the body.
42
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
LEGEND:
Predisposing Factors
Precipitating Factors
Disease Process
Management
Diagnostic Examination
Signs and symptoms
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
V. PATHOPHYSIOLOGY
42
Predisposing Factors:
Gender (male) Age ( 10 days old) Environmental factors (living
near the mountains)
Precipitating Factors:
No full immunity against infection
Exposure to the specific microorganism via droplet
Ingestion of bacteria via nasal cavity
Proliferates to the meninges through the bloodstream reaching the subarachnoid space Infection spreads within the CSF
Activation of astrocyte and microlgiaDescending proliferation of infection occurs
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
42
Infectious Agent spread from the anterior aspect of vertebral body adjacent to the
subchondral plate
Progressive bone destruction
Infection spread to the adjacent intervertebral disk
Interstitial edema
Increase ICP
Inflammation of the meninges
Vasculity of cerebral vessels
Reached to the centrecephalic system
Collapse in the anterior spine
Neuronal excitation from the epileptic focus spreads
to the brainstem
Brain shunting
Stimulates the release of cytokines
Increase WBC in CSF
Increases blood- brain barrier permeability
Spinal cord compression and neurologic deficits
Spinal canal can be narrowed by abscesses,
granulation tissue of direct dural invasion
Fluid leakages from vessels and extends
to the ventriclesIntermittent feverDecrease blood flow
going to the CNS
Head intends to get bigger
Uncoordinated movements were
observed
Comatose (about a week)
Blindness and development of
cataracts in both eyes
Extended infections which causes Cranial compressionkyphosis
Decrease mobility of facial movements
X-ray revealed severe skeletal deformities are noted
preextending proper chest structures
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
42
Alters the functioning of the
brainstem
2. Fever of 37.7 C
Decrease functioning of the epiglottis to close in
the entry of food.
Entry of food/fluid within the respiratory premises
Inflammatory response of the body
Continuous proliferation of infection
Lodge in the lungs
Release of damaging toxins
1. Crackles heard
upon auscultation
2. Nonproductive
cough
1. ET suctioning
2. Given Combivent I nebule via inhalation at HSBlood-like
coffe-ground vomitus
1. amikacin 100 mg IVTT very 8 hours
2. clindamycin 1mg IVTT every 6 hours
3. cefepime I mg IVTT every 6 hours
NGT insertion
Ascending infection occurs
Alters the neuromuscular activity
Language deficit, Uncoordinated gait,
Jerky movements present, and Abnormal
posture
1. Abnormal increase
of WBC of 31, 000
Affects GI activity
Decrease peristaltic movement
1. hypoactive bowel
movement (3 clicks)
2. constipation
Excessive production of
HCl
1. famotidine 10mg IVTT BID
2. sucralfate 250mg IVTT at HS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
VI. LABORATORY RESULTS
The laboratory test and diagnostic procedures indicates a very significant finding necessary for the care and prevention of particular disease
which may occur in the clinical settings, here are the data as followed with interpretation.
Hematology Report
(24/11/10)
TEST RESULTS REFERENCE VALUES INTERPRETATION
Hgb 12.0 13.7-16.7 g/dL Decrease number of hemoglobin may indicate the
existence of anemia.
Hct 36.0 40.5-49.7 gm% Within the normal range.
WBC 22, 800 5,000-10,000 cell/mm3 It is beyond normal range. Increase in the WBC count
may indicate the presence of infection.
DIFFERENTIAL
42
Production of copious secretion
Impairs the ciliary functioning
1
2
3
4
5
6
7
8
9
10
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
COUNT:
Segmenters 83.0 45-70% High number of segmenters would indicate existence
of infection.
Lymphocytes 14.0 18-45% Low lymphocytes means that the patient is susceptible
to infection.
Monocytes 3.0 4-8% Decrease in the number of monocytes would indicate
the susceptibility of the client in acquiring any form of
infection.
Platelet count 329, 000 144,000-372,000 cell/mm3 Within the normal range which connotes the clotting
factor is good.
RBC 4.05 4.7-6.1 10^6/uL Within the normal range.
MCV 77.8 80.0-96.0 fL Low MCV may indicate microcytic anemia.
MCH 25.3 27.0-31.0 pg Indicate microcytic anemia
MCHC 32.6 32.0-36.0% Within the normal range.
42
1
2
3
4
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
Hematology Report
(23/11/10)
TEST RESULTS REFERENCE VALUES INTERPRETATION
Hgb 13.3 13.7-16.7 g/dL Decrease number of hemoglobin may indicate the
existence of anemia.
Hct 40.0 40.5-49.7 gm% Slightly decrease which suggest anemia.
WBC 31, 000 5,000-10,000 cell/mm3 It is beyond normal range. Increase in the WBC count
may indicate infection.
DIFFERENTIAL
COUNT:
Segmenters 81.0 45-70% High number of segmenters would indicate existence
of infection.
Lymphocytes 14.0 18-45% Low lymphocytes means that the patient is susceptible
to infection.
42
1
2
3
4
5
6
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
Monocytes 5.0 4-8% Within the normal range.
Platelet count 376, 000 144,000-372,000 cell/mm3 Within the normal range thus, the clotting factors is
good.
RBC 4.85 4.7-6.1 10^6/uL normal
MCV 78.0 80.0-96.0 fL Low MCV may indicate microcytic anemia.
MCH 25.5 27.0-31.0 pg Indicate microcytic anemia
MCHC 36.0 32.0-36.0% normal
PHILLIPS MEMORIAL HOSPITAL
Hematology Report
(23/11/10)
TEST RESULTS REFERENCE VALUES INTERPRETATION
Hgb 15.6 13.7-16.7 g/dL Within the normal range
Hct 47.0 40.5-49.7 gm% Within the normal range
WBC 26, 800 5,000-10,000 cell/mm3 It is beyond normal range. Increase in the WBC count
42
1
2
3
4
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
may indicate infection.
DIFFERENTIAL
COUNT:
Segmenters 86.0 45-70% Indicates viral infection
Lymphocytes 14.0 18-45% Low lymphocytes means that the patient is susceptible
to infection.
Platelet count 260, 000 144,000-372,000 cell/mm3 normal
Culture Report (11/23/10)
Specimen: Tracheal aspirate
Preliminary Report:
Date: 11/27/10
Findings: organisms isolated, Yeast cells Germ
Tube negative
Specimen: blood
Date: 11/25/10
Findings: no growth after 2 days of incubation
AFB Stain Report
Date: 11/23/10
Result: negative
Grade: O
Specimen: tracheal aspiration
Reference:
RESULT GRADING NO. OF FIELDS
EXAMINE
42
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
More than 10 AFB
per oil immersion
field
Positive 3+ 20
1-10 AFB per oil
immersion fields
Positive 2+ 50
10-99 AFB in 100
oil immersion
fields
Positive 1+
11/23/10
Specimen: tracheal aspirate
Result: Gram (-) bacilli: few
Polymorphonuclear cells: moderate
Yeast cells: moderate
Hyphal elements seen.
X-ray report: 11/23/10
Severe skeletal deformities are noted preextending proper
evaluation of chest structures.
42
1
2
3
4
5
6
7
8
9
10
11
12
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
VII. DRUG STUDY
DRUG ORDER
(Generic name, brand
name, classification,
dosage, route,
frequency)
MECHANISM OF
ACTIONINDICATIONS
CONTRAINDICATIONS ADVERSE EFFECTS
OF THE DRUG
NURSING
RESPONSIBILITIES/
PRECAUTIONS
Generic Name:
amikacin
Brand Name:
Amikin
Classification:
Anti-infectives
Dosage: 100 mg
Route: IVTT
Frequency: every 8
hours
Timing: 8am-1pm-6pm
Inhibits production of
bacterial protein,
causing bacterial cell
death.
Treatment of
serious gram-
negative bacillary
infections and
infections caused
by staphylococci
when penicillins or
other less toxic
drugs are
contrsindicated.
Hypersensitivity to
aminoglycosides.
> CNS: ataxia, vertigo
> EENT: ototoxicity
> GU: nephrotoxicity
> MS: muscle paralysis
> Neuro: inc.
Neuromuscular blockade
> Resp: apnea
> Misc: hypersensitivity
reactions.
1. Advise patient’s SO
about the importance of
drinking plenty of fluids.
Maintain adequate
hydration.
2. Patient’s SO should be
counseled that antibacterial
drugs including Amikacin
should only be used to treat
bacterial infections.
3. Patient’s SO should be
told that the medication
should be taken exactly as
directed.
42
1
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
DRUG ORDER
(Generic name, brand
name, classification,
dosage, route,
frequency)
MECHANISM OF
ACTIONINDICATIONS
CONTRAINDICATIONS ADVERSE EFFECTS
OF THE DRUG
NURSING
RESPONSIBILITIES/
PRECAUTIONS
Generic Name:
clindamycin
Brand Name:
Cleocin
Classification:
Anti-infectives
Dosage: 2 mg
Route: IVTT
Frequency: every 6
hours
Timing: 12mn-6am-
12nn-6pm
Inhibits protein
synthesis in susceptible
bacteria at the level of
the 50S ribosome.
Treatment of: Skin
and skin structure
infections,
Respiratory tract
infections,
Septicemia, Intra-
abdominal
infections,
Osteomyelitis,
Gynecologic
infections,
Endocarditis
prophylaxis.
Hypersensitivity;
Prevoius
pseudomembraneous
colitis; Severe liver
impairment; Diarrhea;
Known alcohol
intolerance.
> CNS: dizziness,
headache, vertigo
> CV: arrythmias,
hypotension
> GI:
pseudomembraneous
colitis, diarrhea, bitter
taste, nausea, vomiting
> Derm: rashes
> Local: phlebitis at IV
site.
1. Instruct patient to notify
health care professional
immediately if diarrhea,
abdominal cramping, fever,
or bloody stools occur and
not to treat with
antidiarrheals without
consulting health care
professionals.
2. Inform patient that bitter
taste occuring with IV
administration is not
clinically significant.
3. Notify health professional
if no improvement within
few days.
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
DRUG ORDER
(Generic name, brand
name, classification,
dosage, route,
frequency)
MECHANISM OF
ACTIONINDICATIONS
CONTRAINDICATIONS ADVERSE EFFECTS
OF THE DRUG
NURSING
RESPONSIBILITIES/
PRECAUTIONS
Generic Name:
cefepime
Brand Name:
Maxipime
Classification:
Anti-infectives
Dosage: 1 mg
Route: IVTT
Frequency:every 6
hours
Timing: 12mn-6am-
12nn-6pm
Binds to the bacterial
cell wall membrane,
causing cell death.
Treatment of bone
and joint infections.
Patient w/ hypersensitive
to drugs, cephalosporin,
beta-lactam antibiotics,
or penicillin
> CNS: fever, headaches
> CV: phlebitis
> GI: colitis, diarrhea,
nausea, vomiting, ural
candidiasis
> SKIN: rash, pruritus
uticaria
> OTHER: pain
inflammation, hypersensitivity
reactions anaphylaxis
1. Before giving drug ask
patients if he/she is allergic
to penicillin or
cephalosporin.
2. Obtain culture and
sensitivity test.
3. Adjust dosage in pt. w/
renal function.
4. Monitor patients for super
infection.
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
DRUG ORDER
(Generic name, brand
name, classification,
dosage, route,
frequency)
MECHANISM OF
ACTIONINDICATIONS
CONTRAINDICATIONS ADVERSE EFFECTS
OF THE DRUG
NURSING
RESPONSIBILITIES/
PRECAUTIONS
Generic Name:
famotidine
Brand Name:
Pepcid
Classification:
H2 receptor antagonist
Dosage: 10 mg
Route: IVTT
Frequency: BID
Timing:
Competitively inhibits
action of histamine on
the H2 at receptor sites
of parietal cells,
decreasing gastric acid
secretion.
Short-term
treatment for
duodenal ulcer.
Contraindicated in
patients hypertensive to
drug.
> CNS: headache,
dizziness, fever,
malaise, paresthesia,
vertigo.
> CV: flushing,
palpitations.
> EENT: orbital edema,
tinnitus.
> G.I.: anorexia,
constipation, diarrhea,
dry mouth, taste
perversion.
> Musculoskeletal:
bone & muscle pain.
> Skin: acne, dry skin.
1. Assess patient for
abdominal pain. Look for
blood in emesis, stool or
gastric aspirate.
2. Oral suspension
must be reconstituted and
shaken before use.
3. Store reconstituted
oral suspension
below 86°F
(30°C). Discard after
30 days
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
DRUG ORDER
(Generic name, brand
name, classification,
dosage, route,
frequency)
MECHANISM OF
ACTIONINDICATIONS
CONTRAINDICATIONS ADVERSE EFFECTS
OF THE DRUG
NURSING
RESPONSIBILITIES/
PRECAUTIONS
Generic Name:
sucralfate
Brand Name:
Carafate
Classification:
Antiulcer agents
Dosage: 250 mg
Route: IVTT
Frequency: at HS
Timing: 8pm
Binds to the bacterial
cell wall membrane,
causing cell death.
> Short-
term
treatment
(up to 8
weeks) of
active
duodenal
ulcer. While
healing with
sucralfate
may occur
during the
first week or
two,
treatment
should be
There are no known
contraindications to the
use of sucralfate.
> CNS: dizziness,
drowsiness
> GI: constipation,
diarrhea, dry mouth,
gastic discomfort,
indigestion, nausea
> Derm: pruritus,
rashes
1. Advise patient
that increase fluid
intake, dietary
bulk, and exercise
may prevent drug-
induced
constipation.
2. Emphasize the
routine
examinations to
monitor progress.
3. If antacids are
also required for
pain, administer 30
min before or after
sucralfate dosage.
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
continued
for 4 to 8
weeks
unless
healing has
been
demonstrat
ed by x-ray
or
endoscopic
examination
.
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
DRUG ORDER
(Generic name, brand
name, classification,
dosage, route,
frequency)
MECHANISM OF
ACTIONINDICATIONS
CONTRAINDICATIONS ADVERSE EFFECTS
OF THE DRUG
NURSING
RESPONSIBILITIES/
PRECAUTIONS
Generic Name:
ipratropium bromide
and albuterol sulfate
Brand Name:
Combivent
Classification:
bronchodilators
Dosage: 1 nebule
Route: inhalation
Frequency: at HS
Timing: 8pm
Combivent
Inhalation
Solution is a
combination of
the
anticholinergic
bronchodilator,
ipratropium
bromide, and
the beta2-
adrenergic
bronchodilator,
salbutamol
sulfate.
Ipratropium
bromide is a
Indicated for use in
patients
with chronic
obstructive
pulmonary
disease (COPD) on
a regular aerosol
bronchodilator who
continue to have
evidence of
bronchospasm and
who require a
second
bronchodilator.
Patients with cardiac
tachyarrhythmias,
hypertrophic obstructive
cardiomyopathy and
patients with a history of
hypersensitivity to any of
its components or to
atropine or its
derivatives.
> CNS: nervousness,
restlessness, tremor,
headache, insomnia
> CV: chest pain,
palpitations,
hypertension
> GI: nausea, vomiting
> Endo: hyperglycemia
> F and E: hypokalemia
> Neuro: tremor
1. Monitor
respiratory status;
auscultate lungs
before and after
inhalation
2. Consult a doctor
immediately in the
event of acute,
rapidly worsening
dyspnea. In
addition, the
patient should be
warned to seek
medical advice
should a reduced
response become
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
quaternary
ammonium
derivative of
atropine and is
an
anticholinergic
drug which has
bronchodilator
properties.
Salbutamol
produces
bronchodilation
through
stimulation of
beta2-
adrenergic
receptors in
bronchial
smooth
muscle, thereby
causing
relaxation of
apparent.
3. Rinse mouth
after medication
puffs to reduce
bitter taste.
4. Do not allow the
solution/ mist to
enter the eyes.
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
muscle fibres.
This action is
manifested by
an increase in
pulmonary
function as
demonstrated
by spirometric
measurements.
VIII. NURSING CARE PLAN
ASESSMENT DATA
(Subjective and Objective)
NURSING DIAGNOSIS
(Problem and Etiology)
GOAL AND OBJECTIVES NURSING INTERVENTIONS AND
RATIONALE
EVALUATION
Subjective:
Intubated
Ineffective Airway
clearance related to
retained secretions in
the upper airway
Short-Term Goals:
Within 3-5 minutes of
thorough nursing
intervention the patient will
INDEPENDENT:
1. Monitor respiration rate and
breath sounds.
R – To come up with a baseline
Short- Term Goals:
Goals met. After 5 minutes of
nursing intervention the patient
was able to improve airway
42
1
2
3
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
Objective:
Crackles heard upon
auscultation
Inability to cough-out
secretions
With Endotracheal
tube attached to
Mechanical ventilator
with the following set-
up:
- TV= 200
- FiO2= 40%
- BUR= 25
- PEEP= 3 cmH20
restless
secondary to upper
respiratory tract
infection and food
aspiration
be able to:
improve airway
clearance as
evidenced by the
absence and/or
diminished
adventitious sounds
Long-Term Goals:
After 8 hours of the course
of duty, the client will be
able to:
Maintain the patency
of the airways as
manifested by
normal respirations
and effective
excretion of copious
secretions.
data.
2. Assist client in positioning the
head appropriate for age/condition
R - To open or maintain open
airway.
3. Elevate head of bed/ change
position every two hours and as
needed.
R - To take advantage of gravity
decreasing pressure on
diaphragm and enhancing
mobilization of secretions for
easy expectoration in order to
promote ventilation to different
lung segments.
4. Suction tracheal and oral
secretions.
R - To provide patent airway.
clearance as evidenced by the
absence and/or diminished
adventitious sounds.
Long-Term Goals:
Goals met. After 8 hours of
thorough nursing interventions
the client was able to maintain
the patency of the airways as
manifested by normal
respirations and effective
excretion of copious
secretions.
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
5. Increase fluid intake of the client
appropriate to his age and disease
condition.
R – It aids in the mobilization of
secretion for easy expectoration.
DEPENDENT:
1. Administer combivent 1 neb at
HS, as ordered.
R - To loosen viscous secretions.
ASESSMENT DATA
(Subjective and Objective)
NURSING DIAGNOSIS
(Problem and Etiology)
GOAL AND OBJECTIVES NURSING INTERVENTIONS AND
RATIONALE
EVALUATION
Subjective:
“Luoy kayo akong
anak kay dili jud siya
kadagan-dagan
parehas sa uban
bata” as verbalized
Delayed Growth and
Development related to
effects of
physical/mental
disability as evidenced
by altered physical
Short- Term Goals:
At the end of 2 hours duty,
my patient’s mother will be
able to:
a. Verbalize
INDEPENDENT:
1. Determine existing condition(s)
contributing to growth
developmental deviation, such as
limited intellectual capacity, physical
disabilities, chronic illness, genetic
Short- Term Goals:
Goals Met. At the end of 2
hours duty, my patient’s
mother was able to verbalize
understanding of
growth/developmental delay
42
1
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
by the mother
Objective:
Altered physical growth
Flat affect
Listlessness
Decreased Responses
growth appropriate for
age
understanding of
growth/developmenta
l delay or deviation
her son
b. Demonstrate
modification of
various activities
appropriate for age
(i.e instead of
running, patient can
be assisted with
passive ROM)
Long- Term Goals:
At the end of 8 hours duty,
my patient’s mother will be
able to:
a. Initiate
interventions/lifestyle
changes promoting
appropriate
development
anomalies or substance abuse.
R – Basis for implementing plans.
2. Determine nature of
parenting/caretaking activities (e.g.,
inadequate, inconsistent,
unrealistic/insufficient expectations;
lack of stimulation, limit setting,
responsiveness)
R – To anticipate a more
promotive intervention to client in
accordance to his age.
3. Assist/ demonstrate modified
activities suited for the client’s age
and disease condition.
R – To encourage and enhance
development of the client.
4. Assist client’s SO to accept and
adjust to irreversible developmental
deviatios.
or deviation her son and
demonstrated modification of
various activities appropriate
for age.
Long- Term Goals:
Goals Met. At the end of 8
hours duty, my patient’s
mother was be able to initiate
interventions/lifestyle changes
promoting appropriate
development and maintained
modified activities which help
in promoting gradual growth
and development appropriate
for the client.
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
b. Maintain modified
activities which help
in promoting gradual
growth and
development
appropriate for the
client.
R – To avoid giving of false
assurance to family and most
especially to the client.
COLLABORATIVE:
1. Refer for consultation of
appropriate professional resources
specific to the client.
R – To address specific individual
needs.
ASESSMENT DATA
(Subjective and Objective)
NURSING DIAGNOSIS
(Problem and Etiology)
GOAL AND OBJECTIVES NURSING INTERVENTIONS AND
RATIONALE
EVALUATION
Subjective:
Intubated
Objective:
skin warm to touch
temperature of 37.7C
Hyperthermia related to
altered body
thermoregulation
secondary to disease
condition
Short-Term Goals:
After 4 hours of nursing
interventions, the client will
be able to:
a. have a decreased
axillary temperature
from 37.7°C to
INDEPENDENT:
1. Provide tepid sponge
bath(if not
contraindicated)
R – It provides coolness to body’s
surface.
Short-Term Goals:
Goals. Met. After 4 hours of
nursing interventions, the
client was able to have a
decreased axillary
temperature from 37.7°C to
37.5°C and improved the
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
flushed skin 37.5°C
b. Improve the skin’s
condition from warm
to cool.
Long-Term Goals:
After 8 hours of nursing
interventions, the client will
be able to:
a. maintain body
temperature at a
normal range.
b. Free from
complications
2. Promote ventilation of
skin by means of undressing
R - Heat loss by radiation and
conduction
3. Promote client safety.
R – To avoid interference in
improving of the nursing care to
the client and it prevents further
complication.
DEPENDENT:
1. Administer antipyretics
w/ correct pediatric
dose (as ordered).
R – Inhibits the inflammatory
response which causes the
abnormal increase in body’s
temperature.
2. administer antibiotics
w/ correct pediatric dose
R - to treat underlying
skin’s condition from warm to
cool.
Long-Term Goals:
Goals Mt. After 8 hours of
nursing interventions, the
client was able to maintain
body temperature at a normal
range and free from
complications.
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
cause(as ordered)
COLLABORATIVE:
1. Instruct the mother to
increase adequate fluid
intake (if not
contraindicated).
R – To prevent dehydration
causing further complications
unto the client.
ASESSMENT DATA
(Subjective and Objective)
NURSING DIAGNOSIS
(Problem and Etiology)
GOAL AND OBJECTIVES NURSING INTERVENTIONS AND
RATIONALE
EVALUATION
Subjective:
Intubated
Objective:
Crackles heard upon
auscultation
Inability to cough-out
Impaired Gas
exchange related to
obstruction of mucous
secretions secondary
to respiratory tract
infection and
aspiration
Short- Term Goals:
Within 1-2 minutes of
nursing intervention the
patient will be able to:
a. Improve the
patency of airways
b. Gradual excretion of
INDEPENDENT:
1. Monitor respiration rate and breath
sounds.
R - For baseline data.
2. Position head appropriate for
age/condition
Short- Term Goals:
Goals Met. Within 1-2 minutes
of nursing intervention the
patients was able to improve
the patency of airways,
gradually excreted of
secretions and displayed and
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
secretions
O2 sat= 72-75%
restlessness
With Endotracheal tube
attached to Mechanical
ventilator with the
following set-up:
- TV= 200
- FiO2= 40%
- BUR= 25
- PEEP= 3 cmH20
Restless
secretions
c. Display and
maintain normal O2
saturation from 95-
100%
Long-Term Goals:
After 8 hours of thorough
nursing intervention the
client will be able:
a. Maintain the
patency of airways
as manifested by
respirations within
the normal range as
well as the oxygen
saturation and the
absence of retained
secretions.
R - To open or maintain open
airway.
3. Suction tracheal and oral
secretions to provide patent airway,
R - To promote proper gas
exchange, and to normalize the
O2sat.
4. Keep suction materials like suction
catheters, gloves, and other
equipment patent and accessible.
R - For emergency situation or
during desaturation.
DEPENDENT:
1. Administer combivent 1 neb at HS
R - to loosen viscous secretions.
maintained normal O2
saturation from 95-100%.
Long-Term Goals:
Goals Met. After 8 hours of
thorough nursing intervention
the client was able to maintain
the patency of airways as
manifested by respirations
within the normal range as
well as the oxygen saturation
and the absence of retained
secretions.
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
ASESSMENT DATA
(Subjective and Objective)
NURSING DIAGNOSIS
(Problem and Etiology)
GOAL AND OBJECTIVES NURSING INTERVENTIONS AND
RATIONALE
EVALUATION
Subjective:
Intubated
Objective:
Limited Range of
Motion
Slowed movement
Postural instability; gait
Impaired physical
mobility related to
neuromuscular
impairment secondary
to cerebral palsy.
At the end of 8 hours of
thorough nursing
intervention, the client will
be able to:
a. Demonstrate
techniques that
enable gradual
INDEPENDENT:
1. Assist client reposition self on a
regular schedule as directed by
individual situation.
R – To promote blood circulation.
2. Support affected body parts and
keep the bed mattress free from
wrinkles.
Goals Met. At the end of 8
hours of thorough nursing
intervention, the client was
able to demonstrate
techniques that enable gradual
resumption of activities and
increased strength gradually
and function of affected or
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
changes resumption of
activities
b. Increase strength
gradually and
function of affected
or compensatory
body part.
R – To reduce risk of premature
ulcers.
3. Provide skin care to include
pressure care management.
R – To prevent further
complication brought about the
immobility.
4. Schedule activities with adequate
rest periods during the day.
R – To reduce fatigue.
5. Encourage adequate intake of
fluids (as indicated) and nutritious
foods (OF).
R- To maximized energy
production.
COLLABORATIVE:
1. Refer with physical therapist, as
indicated.
R – To develop mobility program.
compensatory body part.
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
ASESSMENT DATA
(Subjective and Objective)
NURSING DIAGNOSIS
(Problem and Etiology)
GOAL AND OBJECTIVES NURSING INTERVENTIONS AND
RATIONALE
EVALUATION
Subjective:
“Gikan pa sa Martes
hangtud karon sa Sabado
wala pa jud sya kalibang”
as verbalized by the mother.
Objcetive:
Distended abdomen
Constipation related to
insufficient physical
activity
At the end of 8 hours of
thorough nursing
intervention, the client will
be able to:
a. Regain normal
pattern of bowel
movement from 3
clicks to 5 clicks.
INDEPENDENT:
1. Determine fluid intake.
R – To evaluate client’s hydration
status.
2. Encourage gradual activity within
limits of individual.
R – to stimulate contraction of
Goals Partially Met. At the end
of 8 hours of thorough nursing
intervention, the client was
able to regain normal pattern
of bowel movement from 3
clicks to 5 clicks and
demonstrated behaviors or
lifestyle changes to prevent
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
Hypoactive bowel
movement (3 clicks)
Restless
b. Demonstrate
behaviors or lifestyle
changes to prevent
recurrence of
problem.
c. Identify and maintain
bowel habit within
the client’s
preference.
intestines (peristalsis)
3. Provide privacy and routinely
scheduled time for defecation.
R - For the client response to
urge.
DEPENDENT:
1. Administer laxatives, if indicated.
R – To soften stool for easy
defecation.
recurrence of problem but
failed to identify and maintain
bowel habit within his
preference.
ASESSMENT DATA
(Subjective and Objective)
NURSING DIAGNOSIS
(Problem and Etiology)
GOAL AND OBJECTIVES NURSING INTERVENTIONS AND
RATIONALE
EVALUATION
Risk Factors:
Visual problems (blind)
Uncoordinated
movement
Gait problems
Risk for falls At the end of 45 minutes of
thorough nursing
intervention, the client’s
mother will be able to:
a. Demonstrate
measures to reduce
risk factors and
protect client from
INDEPENDENT:
1. Provide health teaching to the
Client’s SO about the risk opf the
client in falls and developing injury.
R – To provide essential
information about the client’s
situation.
Goals met. At the end of 45
minutes of thorough nursing
intervention, the client’s
mother was able to
demonstrate measures to
reduce risk factors and protect
client from injury, modify
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
injury
b. Modify environment
as indicated to
enhance safety
c. Promote an injury-
free environment.
2. Raising side rails.
R – To ensure safety
3. Placing pillows on both sides of
the patient
R – To prevent from falls
4. Instruct client’s SO never leave
the child alone without companion.
R – Because of the uncoordinated
movements of the child, it may
precipitate incidents of falls.
COLLABORATIVE:
1. Assist In treatment and provide
necessary information regarding
client’s disease/ conditions
R – That may result in increased
risk in falls.
environment as indicated to
enhance safety and promote
an injury-free environment.
42
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
IX. DISCHARGE PLANNING
MEDICATION:
Encourage significant others to continue medications as prescribe by the physician.
With a strict emphasis on explaining the mechanisms of action of the drugs, the
prescribed dosage, side effects, proper timing of intake of drugs and importance of
continuing the medications.
EXERCISE:
Encourage significant others to have an gradual passive ROM to the patient
because it will promote blood circulation and to improve muscle strength in order to
promote total range of motion.
TREATMENT:
Instruct the significant others to consult first the physician in anything that will help
the patient in his conditions like physical activities that she must follow & most
especially his diet.
Encourage the significant others to compliance on further treatment for the proper
maintenance and gain of optimal health.
HEALTH TEACHINGS:
Importance to maintain proper personal hygiene.
Strict adherence to medications to promote wellness.
Increase fluid intake to help liquefy secretions
Importance of proper nutritious food to maintain healthy body.
Immediate report to the physician for any abnormalities to note any complications.
OUT-PATIENT:
Compliance to medical check-up and therapeutic regimen to reduce or prevent risk
of recurrence of the disease condition. Instruct patient to continue medications as
prescribed.
42
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
DIET:
Suggest the the significant others to let the patient eat healthy foods because it
helps the patient feel better and have more energy. Tell the significant others the
importance of following diet and food restrictions. The patient may also consult to a
dietary physician to know what are the correct dietary intake he must maintain.
SPIRITUAL:
Advise patient to never forget to always pray to god. Always have faith and never
lose hope because God is always with us no matter what.
42
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
X. RELATED LEARNING EXPERIENCE
In our duty experiences in Capitol University Medical City we’ve
encountered so many things, though it was not out first time to affiliate in the institution,
it was still a nerve-wracking experience for each and every one of us. It was really
unexpected and was full of lessons that must be inculcated in our hearts and minds.
First day of duty, it’s a mixture of feelings. We were both excited and normal as we are;
we were a little bit anxious. Though we have an idea what it feels like to be on duty at
the ICU, it is still different in the actual setting. We learned so many things like
procedures that we haven’t done in the previous rotations.
We were glad that finally had a chance to perform procedures like
suctioning, tracheostomy care, ECG tracing and a lot of special procedures that we
don’t usually performed. In addition to that, we also got the basic knowledge on how to
operate high technology devices commonly found and used in an ICU setting in
preparation for the brighter future. We also have learning from our patients and their
significant others. The Nurse-Client relationship had helped us a lot.
Predominantly, we experienced so much fun with the fact that the
environment is so conducive for both learning the much-a-nurse responsibilities of a
nurse----- specifically ICU nurse. Our PCI’s had helped us so much by guiding us and
assisting us whatever procedures we are doing. Our CI is calm and cool! He somehow
trusted us on our performance though we think on ourselves we can’t do all of those
things as perfectly as it is. And we would like to thank them for doing so.
Mistakes are inevitable in life which is also true during the ICU rotation. Yes, we
made different kinds of errors and we are all guilty for that but for those errors we’ve
learned a lot and gradually we are learning to improve our work in order to follow the
mission of the nursing profession, which is to give care to the patient. We’ve learn that
not at all the times we will be perfect on what we will be doing, we’ve learn that the
patients admitted in the ICU are mostly confined due to vehicular accident and therefore
strict monitoring is observed, thus, they need more attention and we need to be more
careful in the provision of the care they needed.
Being there was an easier rotation because you don’t worry much of the I&O
thing because they’re using infusion pumps and usually doesn’t require us to get the
vital signs manually because of the cardiac monitor attached to most of the patients.
In making this case study, it strengthens us and really proves that in everything
that we do, learning is always there for us, waiting to be grasped and to be well-
digested. I know for the fact that this study requires a lot of sacrifices and fortunately we
did survive all the things we have done. My greatest felicitation and commemoration to
our beloved Clinical Instructor, Mr. Camilo Rey “Kit” Pabito, RN, MN who gave us the
42
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
motivation to be serious in the clinical area in order to promote the proper and
appropriate care towards our patient. It was truly enjoyable because we have a clinical
instructor who is very much approachable and mindful. Though we have “life
threatening patient”, he’s still there to make some inspiring words and cheers for us (he
usually does it *LOL*). He makes us calm when we get nervous and treated us like his
children (I think much more of colleague ‘coz he doesn’t want to be the oldest in the
group >oops<).
We would like to extend our thanks to our PCI, Ms. Georgia Dawn Gacus and Mr.
Dan Michael Canios who taught and gave us the inspiration to do things well. They did
not just do things to comply with the requirements but have done it with passion and
whole heartedly. We also appreciate the nursing staffs for attending to our inquiries
properly whenever we have some clarifications.
And last, we have learned the real value of being a student nurse that we should
control our temper, our emotions while we are on our patient’s side, we have to adjust to
the environment where we belong. It is because we didn’t know the feelings of the
watchers and more importantly our patient. Patient must not be only a patient but
he/she should be “my/our” patient. Thank you…………
42
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott’s Disease
XI. REFERENCE
BOOKS:
Doenges, M.E., Moorhouse, M.F., & Geissler, A.C, (2002). Nursing Care
Plans Guidelines for Individualizing Patient Care, (6th ed.). Thailand
Doenges, M.E., Moorhouse, M.F., & Geissler, A.C (2006). Nurse’s pocket
Guide; Diagnoses, Prioritized Interventions, and Rationales. (10thed.).
Philadelphia, Pennsylvania
Smeltzer, Suzanne C., RN, Edd, FAAN, & Bare, Brenda G., RN, MSN,(2004).
Textbook of Medical-Surgical Nursing, (10th ed.), Philadelphia
Karch, Amy M. ; 2006 Lippicott’s Nursing Drug Guide, 8th edition. Lippincott
Williams & Wilkins.
Nurses’ Pocket Guide, 10th edition F.A. Davis.
Nursing Care Plans, 7th edition F.A. Davis Doeuger, Moorhouse, Murr.
Patient’s Chart
Black, Joyce M. et. al, Medical-Surgican Nursing: Clinical Management for
Positive outcome. 7th edition. Philadelphia, W.B. Saunders. 2005
Malseed, Roger T. ; Springhouse Nurses’ Drug Guide 2004, 5th edition.
Davis drug handbook, 10th edition
Drug handbook by Saunders
Medical-Surgical Nursing (Clinical Management for Positive Outcomes) 8th
edition By: Joyce Black and Jane Hokanson Hawks
Nursing Care of Infants and Children by Wong
INTERNET:
http://cpmcnet.columbia.edu/dept/gi/.html
http://digestive.niddk.nih.gov/ddiseases/pubs/_ez/
http://www.angelfire.com/scifi2/lnuphysiology/Blood_Physiology_1.pdf
http://www.drstandley.com/labvalues
http://www.google.com.ph/search
http://www.google.com.ph/search?anatomy&meta=
http://www.merck.com/ l
rehyd rate .org/diarrhoea/pdf/diarrhoea-abstracts.pdf
http://www.wpro.who.int/countries/2009/phl/health_situation.htm
www.cureresearch.com/c/cerebral_palsy/stats-country.htm?ktrack=kcplink
http://www.tuberculosistextbook.com/tb/tbchild.htm
42
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35