potts ds- chorvah

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,

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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

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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.

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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.

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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,

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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).

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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

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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.

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LEGEND:

Predisposing Factors

Precipitating Factors

Disease Process

Management

Diagnostic Examination

Signs and symptoms


V. PATHOPHYSIOLOGY

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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

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8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29


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


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


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


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


Hematology Report

(23/11/10)


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.


may indicate infection.

DIFFERENTIAL

COUNT:

Segmenters 81.0 45-70% High number of segmenters would indicate existence

of infection.


to infection.

42

1

2

3

4

5

6


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)


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


42

1

2

3

4


may indicate infection.

DIFFERENTIAL

COUNT:

Segmenters 86.0 45-70% Indicates viral infection


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


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


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


DRUG ORDER



dosage, route,

frequency)

MECHANISM OF

ACTIONINDICATIONS


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


DRUG ORDER



dosage, route,

frequency)

MECHANISM OF

ACTIONINDICATIONS


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


DRUG ORDER



dosage, route,

frequency)

MECHANISM OF

ACTIONINDICATIONS


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


DRUG ORDER



dosage, route,

frequency)

MECHANISM OF

ACTIONINDICATIONS


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


continued

for 4 to 8

weeks

unless

healing has

been

demonstrat

ed by x-ray

or

endoscopic

examination

.

42


DRUG ORDER



dosage, route,

frequency)

MECHANISM OF

ACTIONINDICATIONS


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

http://www.rxlist.com/script/main/art.asp?articlekey=7784




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


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


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


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


NURSING DIAGNOSIS



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


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:


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


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


NURSING DIAGNOSIS



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


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


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


NURSING DIAGNOSIS



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


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


ASESSMENT DATA


NURSING DIAGNOSIS



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.


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


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


ASESSMENT DATA


NURSING DIAGNOSIS



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

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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


NURSING DIAGNOSIS



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

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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.

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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.

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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.

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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

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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…………

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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

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http://www.tuberculosistextbook.com/tb/tbchild.htm

http://www.cureresearch.com/c/cerebral_palsy/stats-country.htm?ktrack=kcplink

http://www.wpro.who.int/countries/2009/phl/health_situation.htm

http://www.merck.com/mmhe/sec10/ch135/ch135e.html

http://www.drstandley.com/labvalues

http://www.angelfire.com/scifi2/lnuphysiology/Blood_Physiology_1.pdf

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