Surigao Education Center Km.

2, Surigao City

Of

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PRESENTORS:

• • • • • • • • • •

ALBERCA, Michelle J. BAROTAC, Razil L. COMPRA, Anne rose J. EUSALA, Keene E. LIONG, Kris Madeline E. LLAMERA, Joackimm A. MINARDO, Sheny G. PACHANO. Ana Mae O. PAREDES, Riza Mae M. SINCO, Mark Kevin G.

Table of Contents I. Dedication II. Acknowledgement i ii 2

III. IV. V. VI.

Introduction Review of Related Literature Anatomy and Physiology Patient’s Health History A. Biographic Data B. History of Present Illness C. Past Health History a. Childhood Illness b. Immunization c. History of Hospitalization d. Surgical History e. Accidents and Injuries f. Allergic and Type of Reaction g. Family Health History h. Personal Health History 1. Lifestyle 1.1 Personal habits 1.2 Diet 1.3 Sleep and rest-pattern 1.4 Elimination Pattern 1.5 Activities of Daily Living (ADL) 1.6 Recreation and Hobbies i. Social Data 1. Occupational Data j. Environmental Data k. Psychological Data l. Patterns of Health Care

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VII. Review of System a. Integumentary System b. Head, Eyes, Ears, Nose, Throat( HEENT) c. Neck d. Breast and Axillae e. Thorax and Lungs f. Cardiovascular System g. Gastrointestinal System h. Musculoskeletal System i. Neurologic System j. Urinary System k. Reproductive System l. Hematologic m. Endocrine n. Psychiatric

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VIII. Physical Assessments a. General Survey b. Vital signs c. Integumentary System d. Hair e. Nails f. Head g. Eyes and vision h. Ears and hearing i. Nose and sinusitis j. Oropharynx (mouth and throat) k. Neck l. Thorax and lungs m. Breast and Axillae n. Abdomen o. Musculoskeletal system p. Cardiovascular system q. Urinary system r. Gastrointestinal system s. Neurologic system a. Cranial nerves I- XII b. Glass Coma Scale c. Muscle Strength IX. Doctor’s Order (detailed) X. Laboratory Data t. Urinalysis u. Hematology XI. Drug Study XII. Pathology and Physiology of GBS XIII. Nursing Care Plan (NCP) XIV. Discharge Plan (detailed) XV. Appendix a. IV Record b. Genogram XVI. Definition of Terms XVII. References

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Introduction

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We have nerves that live outside the central nervous system (the brain and spinal cord), and deal with our body's senses and movements. These are called our peripheral nerves. Guillain-Barre syndrome (also known as acute inflammatory or post-infective polyradiculoneuropathy) is a rare but serious disease of the peripheral nervous system. It makes the bodys own immune system attack the nerves, causing widespread inflammation that leads to a tingly, numbing sensation in the arms and legs. This can eventually result in a short-term loss of feeling and movement (temporary paralysis).It is slightly more common in men than women, and can affect people of any age, even children. What exactly causes the condition is unclear and there is no way to pinpoint who may be most at risk. However, in most cases of Guillain-Barre syndrome the person had a virus or bacterial infection in the last four weeks. Most people will make a full recovery within a few weeks or months, with no further trouble. Some cases take longer to recover from and there is a possibility of permanent nerve damage. Patient R is a 16 years old male, single who resides at Esperanza, Loreto, Dinagat Island is an embodiment of rare people who have GBS. He was admitted at Caraga Regional Hospital last September 25, 2009 with the chief complaint of sudden onset of weakness of left lower extremities then after the right extremities for almost 3 weeks under the care of Dr. Asodisen. We chose patient R’s case for our case study because we think it is interesting though it’s rarely seen .It is a culprit condition that can cause temporary paralysis and can affect our activities of daily living since in GBS we can feel weakness and numbness in our body that’s why patient couldn’t walk and have limited range of motion. It’s not so depressing though there is a glint hope with the proper medical attention, the syndrome may be reversed. We are hoping that through this case study we can impart knowledge and better understanding of GBS to the community for them to be aware of the said syndrome.

Review of Related Literature

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What is Guillain Barre’ Syndrome? Guillain-Barre syndrome is a serious disorder that occurs when the body's defense (immune) system mistakenly attacks part of the nervous system. This leads to nerve inflammation that causes muscle weakness. Guillain-Barré syndrome is an acute, usually rapidly progressive inflammatory polyneuropathy characterized by muscular weakness and mild distal sensory loss. Cause is thought to be autoimmune. Guillain-Barré syndrome is the most common acquired inflammatory neuropathy. Although the cause is not fully understood, it is thought to be autoimmune. There are several variants. In some, demyelination predominates; others affect the axon. In about 2⁄3 of patients, the syndrome begins 5 days to 3 wk after a bacterial infectious disorder, surgery, or vaccination. Infection is the trigger in > 50% of patients; common pathogens include Campylobacter jejuni, enteric viruses, herpes viruses (including cytomegalovirus and Epstein-Barr virus), and Mycoplasma sp. A cluster of cases followed the swine flu vaccination program in 1975.

What are the causes? Guillain-Barre syndrome is an autoimmune disorder (the body's immune system attacks itself). Exactly what triggers Guillain-Barre syndrome is unknown. The syndrome may occur at any age, but is most common in people of both sexes between ages 30 and 50. It often follows a minor infection, usually a lung infection or gastrointestinal infection. Usually, signs of the original infection have disappeared before the symptoms of Guillain-Barre begin. Guillain-Barre syndrome causes inflammation that damages parts of nerves. This nerve damage causes tingling, muscle weakness, and paralysis. The inflammation usually affects the nerve's covering (myelin sheath). Such damage is called demyelination. Demyelination slows nerve signaling. Damage to other parts of the nerve can cause the nerve to stop working. Guillain-Barre syndrome may occur along with viral infections such as: • AIDS 6

• •

Herpes simplex Mononucleosis

It may also occur with other medical conditions such as systemic lupus erythematosus or Hodgkin's disease.Some people may get Guillain-Barre syndrome after a bacterial infection or certain vaccinations (such as rabies and swine flu). A similar syndrome may occur after surgery, or when critically ill. What are the risk factors? Guillain-Barre syndrome can affect all age groups, but you're at greater risk if:
• •

You're a young adult You're an older adult

Guillain-Barre may be triggered by:
• • • • • • •

Most commonly, infection with campylobacter, a type of bacteria often found in undercooked food, especially poultry. Surgery Epstein-Barr virus Hodgkin's disease Mononucleosis HIV, the virus that causes AIDS Rarely, rabies or influenza immunizations

What are the symptoms? Symptoms of Guillain-Barre can get worse very quickly. It may take only a few hours to reach the most severe symptoms, but weakness increasing over several days is also common. Muscle weakness or the loss of muscle function (paralysis) affects both sides of the body. In most cases, the muscle weakness starts in the legs and then spreads to the arms. This is called ascending paralysis. Patients may notice tingling, foot or hand pain, and clumsiness. If the inflammation affects the nerves to the diaphragm, and there is weakness in those muscles, the person may need breathing assistance. Typical symptoms include:

Loss of reflexes in the arms and legs

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• • • •

Muscle weakness or loss of muscle function (paralysis) o In mild cases, there may be no weakness or paralysis o May begin in the arms and legs at the same time o May get worse over 24 to 72 hours o May occur in the nerves of the head only o May start in the arms and move downward o May start in the feet and legs and move up to the arms and head Numbness, decreased sensation Sensation changes Tenderness or muscle pain (may be a cramp-like pain) Uncoordinated movement

Additional symptoms may include:
• • • • •

Blurred vision Clumsiness and falling Difficulty moving face muscles Muscle contractions Palpitations (sensation of feeling heartbeat)

Emergency symptoms (seek immediate medical help):
• • • • • • •

Breathing temporarily stops Can't take a deep breath Difficulty breathing Difficulty swallowing Drooling Fainting Feeling light-headed when standing

Flaccid weakness predominates in most patients; it is always more prominent than sensory abnormalities and may be most prominent proximally. Relatively symmetric weakness with paresthesias usually begins in the legs and progresses to the arms, but it occasionally begins in the arms or head. In 90% of patients, weakness is maximal at 3 wk. Deep tendon reflexes are lost. Sphincters are usually spared. Facial and oropharyngeal muscles are weak in > 50% of patients with severe disease. Dehydration and undernutrition may result. Respiratory paralysis severe enough to require endotracheal intubation and mechanical ventilation occurs in 5 to 10%. A few patients (possibly with a variant form) have significant, life-threatening autonomic dysfunction causing BP fluctuations, inappropriate ADH secretion, cardiac arrhythmias, GI stasis, urinary retention, and pupillary changes. An unusual variant (Fisher variant) may cause only ophthalmoparesis, ataxia, and areflexia.

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How to cope with Guillain Barre Syndrome? The emotional impact of Guillain-Barre syndrome can be devastating. In severe cases, Guillain-Barre syndrome can transform you from healthy and independent to critically ill and physically helpless — suddenly, and without warning. Although most people eventually recover fully, a diagnosis of Guillain-Barre syndrome means confronting the possibility of long-term disability or paralysis. And those who do develop these complications must adjust to lasting, limited mobility and a dependence on others to help manage daily activities. Talking with a mental health provider can play a critically important role in helping you cope with the mental and emotional strain of this illness. In some cases, your therapist may recommend family counseling to help you and your loved ones adjust to the changes caused by Guillain-Barre syndrome. You may also benefit from talking with others who have experienced this illness. Ask your doctor or mental health provider to recommend a support group for people and families coping with Guillain-Barre syndrome. When to Contact a Medical Professional? Seek immediate medical help if you have any of the following symptoms:
• •

Can't take a deep breath Decreased feeling (sensation) o Difficulty breathing o Difficulty swallowing o Fainting o Loss of movement Tingling that started in your feet or toes and is now ascending upward through your body Tingling or weakness that's spreading rapidly Tingling that involves both your hands and feet Difficulty catching your breath Choking on saliva

• • • • •

Guillain-Barre syndrome is a serious disease that requires immediate hospitalization because of the rapid rate at which it worsens. The sooner appropriate treatment is started, the better the chance of a good outcome. Alternative Names Landry-Guillain-Barre syndrome; GBS; Acute idiopathic polyneuritis; Infectious polyneuritis; Acute inflammatory polyneuropathy

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What is the prevention? Because so little is known about what causes GBS to develop, there are no known methods of prevention. What is a 'syndrome'? A syndrome is a medical condition, characterized by a collection of symptoms (that the patient feels) and signs (that a doctor can observe or measure), rather than by a specific organism that causes the disease. No one knows what causes GBS. Symptoms and signs can vary a great deal in GBS patients, sometimes making it difficult to diagnose, especially in the early stages.

Diagnosis Guillain-Barre syndrome can be difficult to diagnose in its earliest stages. Its signs and symptoms are similar to those of other neurological disorders and may vary from person to person. The first step in diagnosing Guillain-Barre syndrome is for your doctor to take a careful medical history to fully understand the cluster of signs and symptoms you're experiencing. A spinal tap (lumbar puncture) and nerve function tests are commonly used to help confirm a diagnosis of Guillain-Barre syndrome. Spinal tap (lumbar puncture) This procedure involves withdrawing a small amount of fluid from your spinal canal at your low back (lumbar) level. This cerebrospinal fluid is then tested for a specific type of change that commonly occurs in people who have Guillain-Barre syndrome. Nerve function tests Your doctor may want information from two types of nerve function tests — electromyography and nerve conduction velocity: Electromyography reads electrical activity in your muscle to determine if your weakness is caused by muscle damage or nerve damage.

Nerve conduction studies assess how your nerves and muscles respond to small electrical stimuli.

Diagnosis is primarily clinical. Similar acute weakness can result from myasthenia gravis, botulism, poliomyelitis (mainly outside the US), tick paralysis, West

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Nile virus infection, and metabolic neuropathies, but these disorders can usually be distinguished as follows: • • • • • • Myasthenia gravis is intermittent and worsened by exertion. Botulism may cause fixed dilated pupils (in 50%) and prominent cranial nerve dysfunction with normal sensation. Poliomyelitis usually occurs in epidemics. Tick paralysis causes ascending paralysis but spares sensation. West Nile virus causes headache, fever, and asymmetric flaccid paralysis but spares sensation. Metabolic neuropathies occur with a chronic metabolic disorder.

Tests for infectious disorders and immune dysfunction, including tests for hepatitis and HIV and serum protein electrophoresis, are done. If Guillain-Barré syndrome is suspected, patients should be admitted to a hospital for electrodiagnostic testing, CSF analysis, and monitoring by measuring forced vital capacity every 6 to 8 h. Initial electrodiagnostic testing detects slow nerve conduction velocities and evidence of segmental demyelination in 2/3 of patients; however, normal results do not exclude the diagnosis and should not delay treatment.

CSF analysis may detect albuminocytologic dissociation (increased protein but normal WBC count), but it may not appear for up to 1 wk and does not develop in 10% of patients.

Prognosis Although some people can take months and even years to recover, most cases of Guillain-Barre syndrome follow this general timeline:
• • •

Following the first symptoms, the condition tends to progressively worsen for about two weeks. Symptoms reach a plateau and remain steady for two to four weeks. Recovery begins, usually lasting six to 12 months.

This syndrome is fatal in < 2%. Most patients improve considerably over a period of months, but about 30% of adults and even more children have some residual weakness at 3 yr. Patients with residual defects may require retraining, orthopedic appliances, or surgery. 11

After initial improvement, 3 to 10% of patients develop chronic inflammatory demyelinating polyneuropathy (CIDP—see below). Recovery can take weeks or years. Most people survive and recover completely. According to the National Institute of Neurological Disorders and Stroke, about 30% of patients still have some weakness after 3 years. Mild weakness may persist for some people. A patient's outcome is most likely to be very good when the symptoms go away within 3 weeks after they first started. Complications of Guillan-Barre syndrome can include:

• • • • • • • •

Breathing difficulties. A potentially deadly complication of Guillain-Barre syndrome is that the weakness or paralysis can spread to the muscles that control your breathing. You may need temporary help from a machine to breathe when you're hospitalized for treatment. Residual numbness or other sensations. Most people with Guillain-Barre syndrome recover completely or have only minor, residual weakness or abnormal sensations, such as numbness or tingling. However, full recovery may be slow, often taking a year or longer. Breathing difficulty (respiratory failure) Contractures of joints or other deformity Deep vein thrombosis (blood clots that form when someone is inactive or confined to bed) Increased risk of infections Low or unstable blood pressure Permanent loss of movement of an area Pneumonia Sucking food or fluids into the lungs (aspiration)

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Treatment There's no cure for Guillain-Barre syndrome. But two types of treatments speed recovery and reduce the severity of Guillain-Barre syndrome: When symptoms are severe, the patient will need to go to the hospital for breathing help, treatment, and physical therapy. Plasmapheresis. A method called plasmapheresis is used to remove proteins, called antibodies, from the blood. The process involves taking blood from the body, usually from the arm, pumping it into a machine that removes the antibodies, then sending it back into the body. This treatment — also known as plasma exchange — is a type of "blood cleansing" in which damaging antibodies are removed from your blood. Plasmapheresis consists of removing the liquid portion of your blood (plasma) and separating it from the actual blood cells. The blood cells are then put back into your body, which manufactures more plasma to make up for what was removed. It's not clear why this treatment works, but scientists believe that plasmapheresis rids plasma of certain antibodies that contribute to the immune system attack on the peripheral nerves. Plasmapheresis (see Transfusion Medicine: Plasmapheresis) helps when done early in the syndrome; it is used if γ-globulin is ineffective. Plasmapheresis is relatively safe, shortens the disease course and hospital stay, and reduces mortality risk and incidence of permanent paralysis. Plasmapheresis removes any previously administered γ-globulin, negating its benefits. Intravenous immunoglobulin. Immunoglobulin contains healthy antibodies from blood donors. High doses of immunoglobulin can block the damaging antibodies that may contribute to Guillain-Barre syndrome. High-dose immunoglobulin therapy (IVIg) is another treatment used to reduce the severity and length of Guillain-Barre symptoms. In this case, the immunoglobulins are added to the blood in large quantity, blocking the antibodies that cause inflammation. Other treatments are directed at preventing complications.
• • • •

Blood thinners may be used to prevent blood clots. If the diaphragm is week, breathing support or even a breathing tube and ventilator may be needed. Pain is treated aggressively with anti-inflammatory medicines and narcotics, if needed. Proper body positioning or a feeding tube may be used to prevent choking during feeding if the muscles for swallowing are weak. • Intensive supportive care

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• .

Plasmapheresis or IV immune globulin

Each of these treatments is equally effective. Mixing the treatments or administering one after the other is no more effective than using either method alone.

Often before recovery begins, caregivers may need to manually move your arms and legs to help keep your muscles flexible and strong. After recovery has begun, you'll likely need physical therapy to help regain strength and proper movement so that you'll be able to function on your own. You may need training with adaptive devices, such as a wheelchair or braces, to give you mobility and self-care skills.

Lifestyle Measures How to Live with Guillain Barre Syndrome? Instructions Step 1 Find a good physical therapy program from which isometric, isotonic and resistance exercises to rebuild may do these exercises on an outpatient basis and Remember to pace yourself and get adequate rest, as with Guillain-Barre Syndrome. Step 2 Explore occupational therapy options. Changes in your home environment can aid in your recovery by making it easier for you to bathe, dress and prepare meals while your muscles return to normal levels of strength. Step 3 Manage residual pain in the back, legs and feet with medication as needed. Gabapentin and carbamazepine are often prescribed to relieve Guillain-Barre Syndrome related pain. Both of these medications are anticonvulsants and may cause fatigue and dizziness in some people. you can learn specific weakened muscles. You continue them at home. fatigue is to be expected

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Step 4 Wear comfortable shoes and socks to help soothe pain and burning from neuropathy in the feet. Inspect your feet often to be sure there are no cuts or blisters that you may not have noticed.

Step 5 Follow a healthy eating plan with fresh, seasonal fruits and vegetables , lean meat and fish, whole grains and plenty of colorful salads. Eating well may help you to sustain your energy and can boost your mood.

Step 6 Seek emotional support to cope with feelings of depression and anxiety that are part of living with Guillain-Barre Syndrome. Discuss antidepressant medication with your doctor if you are having trouble with activities necessary for daily living. Step 7 Connect with others who are learning to live with Guillain-Barre Syndrome in forums online. See the Resources section below for links.

How to Recognize the Symptoms of Guillain-Barre Syndrome? Instructions Step 1 Watch for early symptoms like tingling or rubbery sensations in your feet and legs. In many cases, Guillain-Barre Syndrome comes on rapidly, beginning in the lower part of the body and climbing to the arms and upper torso within hours. Tingling around the mouth is common as the symptoms ascend. Step 2 Note any difficulty with facial muscles or movement, such as trouble moving your eyes, slow speech and problems chewing or swallowing.

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Step 3 Assess both sides of your body. Guillain-Barre Syndrome affects both sides, unlike a stroke. Strokes generally paralyze only one side. Step 4 Test your reflexes. Guillain-Barre Syndrome diminishes the reflex response in the legs first. Some people also lose feeling in their extremities.

Step 5 Check your heart rate and blood pressure . Both may drop with Guillain-Barre Syndrome. Step 6 Evaluate and report any changes in bladder or bowel function. Guillain-Barre Syndrome impacts the muscles that control bladder and intestinal function.

Step 7 Monitor your breathing, and get help at once if breathing seems shallow. GuillainBarre Syndrome can worsen very rapidly and spread to the muscles that control your breathing. Many people with the syndrome are temporarily placed on ventilators in order to breathe. Step 8 Review your recent medical history. Although scientists haven’t discovered a single cause for Guillaine-Barre Syndrome, many cases are linked with recent bacterial or viral infections , vaccinations or surgeries. Infection with campylobacter, a bacteria found in undercooked food, especially poultry, may trigger Guillaine-Barre Syndrome. Step 9 Pay attention to unusual or severe lower back pain, which can signal GuillainBarre Syndrome.

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ANATOMY AND PHYSIOLOGY

THE NERVOUS SYSTEM Typical Structure of a Nerve Cell

A nerve cell (neuron) consists of a large cell body and nerve fibers—one elongated extension (axon) for sending impulses and usually many branches (dendrites) for receiving impulses. Each large axon is surrounded by oligodendrocytes in the brain and spinal cord and by Schwann cells in the peripheral nervous system. The membranes of these cells consist of a fat (lipoprotein) called myelin. The membranes are wrapped tightly around the axon, forming a multilayered sheath. This myelin sheath resembles insulation, such as that around an electrical wire. Nerve impulses travel much faster in nerves with a myelin sheath than in those without one. If the myelin sheath of a nerve is damaged , nerve transmission slows or stops

The nervous system is divided into the:
• •

peripheral nervous system (PNS) central nervous system (CNS)

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The PNS consists of
• •

sensory neurons running from stimulus receptors that inform the CNS of the stimuli motor neurons running from the CNS to the muscles and glands - called effectors - that take action.

The CNS consists of the
• •

spinal cord and the brain

THE PERIPHERAL NERVOUS SYSTEM IN FOCUS In the peripheral nervous system, neurons can be functionally divided in three ways: 1. Sensory (afferent) - carry information INTO the central nervous system from sense organs or motor (efferent) - carry information away from the central nervous system (for muscle control). 2. Cranial - connects the brain with the periphery or spinal - connects the spinal cord with the periphery. 3. Somatic - connects the skin or muscle with the central nervous system or visceral - connects the internal organs with the central nervous system

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The peripheral nervous system is subdivided into the
• •

sensory-somatic nervous system and the autonomic nervous system

The Sensory-Somatic Nervous System The sensory-somatic system consists of:
• •

12 pairs of cranial nerves and 31 pairs of spinal nerves. The Cranial Nerves

Nerves I Olfactory II Optic III Oculomotor IV Trochlear V Trigeminal VI Abducens VII Facial VIII Auditory IX Glossopharyngeal X Vagus XI Accessory XII Hypoglossal

Type

Function

sensory olfaction (smell) sensory vision (Contain 38% of all the axons connecting to the brain.)

motor* eyelid and eyeball muscles motor* mixed eyeball muscles Sensory: facial and mouth sensation Motor: chewing

motor* eyeball movement mixed Sensory: taste Motor: facial muscles and salivary glands

sensory hearing and balance mixed mixed motor Sensory: taste Motor: swallowing main nerve of the parasympathetic nervous system (PNS) swallowing; moving head and shoulder

motor* tongue muscles

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*Note: These do contain a few sensory neurons that bring back signals from the muscle spindles in the muscles they control. The Spinal Nerves All of the spinal nerves are "mixed"; that is, they contain both sensory and motor neurons. All our conscious awareness of the external environment and all our motor activity to cope with it operate through the sensory-somatic division of the PNS.

The Autonomic Nervous System The autonomic nervous system consists of sensory neurons and motor neurons that run between the central nervous system (especially the hypothalamus and medulla oblongata) and various internal organs such as the:
• • • •

heart lungs viscera glands (both exocrine and endocrine)

It is responsible for monitoring conditions in the internal environment and bringing about appropriate changes in them. The contraction of both smooth muscle and cardiac muscle is controlled by motor neurons of the autonomic system. The actions of the autonomic nervous system are largely involuntary (in contrast to those of the sensory-somatic system). It also differs from the sensory-somatic system is using two groups of motor neurons to stimulate the effectors instead of one.
• •

The first, the preganglionic neurons, arise in the CNS and run to a ganglion in the body. Here they synapse with postganglionic neurons, which run to the effector organ (cardiac muscle, smooth muscle, or a gland).

The autonomic nervous system has two subdivisions, the
• •

sympathetic nervous system and the parasympathetic nervous system.

The Sympathetic Nervous System The preganglionic motor neurons of the sympathetic system arise in the spinal cord. They pass into sympathetic ganglia which are organized into two chains that run parallel to and on either side of the spinal cord.

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The preganglionic neuron may do one of three things in the sympathetic ganglion:

• •

synapse with postganglionic neurons which then reenter the spinal nerve and ultimately pass out to the sweat glands and the walls of blood vessels near the surface of the body. pass up or down the sympathetic chain and finally synapse with postganglionic neurons in a higher or lower ganglion leave the ganglion by way of a cord leading to special ganglia (e.g. the solar plexus) in the viscera. Here it may synapse with postganglionic sympathetic neurons running to the smooth muscular walls of the viscera. However, some of these preganglionic neurons pass right on through this second ganglion and into the adrenal medulla. Here they synapse with the highlymodified postganglionic cells that make up the secretory portion of the adrenal medulla.

The neurotransmitter of the preganglionic sympathetic neurons is acetylcholine (ACh). It stimulates action potentials in the postganglionic neurons. The neurotransmitter released by the noradrenaline (also called norepinephrine). postganglionic neurons is

The action of noradrenaline on a particular gland or muscle is excitatory is some cases, inhibitory in others. (At excitatory terminals, ATP may be released along with noradrenaline.) The release of noradrenaline
• • • • • • • • •

stimulates heartbeat raises blood pressure dilates the pupils dilates the trachea and bronchi stimulates the conversion of liver glycogen into glucose shunts blood away from the skin and viscera to the skeletal muscles, brain, and heart inhibits peristalsis in the gastrointestinal (GI) tract inhibits contraction of the bladder and rectum and, at least in rats and mice, increases the number of AMPA receptors in the hippocampus and thus increases long-term potentiation (LTP).

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In short, stimulation of the sympathetic branch of the autonomic nervous system prepares the body for emergencies: for "fight or flight" (and, perhaps, enhances the memory of the event that triggered the response). Activation of the sympathetic system is quite general because
• •

a single preganglionic neuron usually synapses with many postganglionic neurons; The release of adrenaline from the adrenal medulla into the blood ensures that all the cells of the body will be exposed to sympathetic stimulation even if no postganglionic neurons reach them directly.

The Parasympathetic Nervous System The main nerves of the parasympathetic system are the tenth cranial nerves, the vagus nerves. They originate in the medulla oblongata. Other preganglionic parasympathetic neurons also extend from the brain as well as from the lower tip of the spinal cord. Each preganglionic parasympathetic neuron synapses with just a few postganglionic neurons, which are located near - or in - the effector organ, a muscle or gland. Acetylcholine (ACh) is the neurotransmitter at all the pre- and many of the postganglionic neurons of the parasympathetic system. However, some of the postganglionic neurons release nitric oxide (NO) as their neurotransmitter. Parasympathetic stimulation causes
• • • • •

slowing down of the heartbeat lowering of blood pressure constriction of the pupils increased blood flow to the skin and viscera peristalsis of the GI tract

In short, the parasympathetic system returns the body functions to normal after they have been altered by sympathetic stimulation. In times of danger, the sympathetic system prepares the body for violent activity. The parasympathetic system reverses these changes when the danger is over. The vagus nerves also help keep inflammation under control. Inflammation stimulates nearby sensory neurons of the vagus. When these nerve impulses reach the medulla oblongata, they are relayed back along motor fibers to the inflamed area. The acetylcholine from the motor neurons suppresses the release of inflammatory cytokines, e.g., tumor necrosis factor (TNF), from macrophages in the inflamed tissue.

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Although the autonomic nervous system is considered to be involuntary, this is not entirely true. A certain amount of conscious control can be exerted over it as has long been demonstrated by practitioners of Yoga and Zen Buddhism. During their periods of meditation, these people are clearly able to alter a number of autonomic functions including heart rate and the rate of oxygen consumption. These changes are not simply a reflection of decreased physical activity because they exceed the amount of change occurring during sleep or hypnosis.

IMMUNE SYSTEM The immune system is composed of many interdependent cell types that collectively protect the body from bacterial, parasitic, fungal, viral infections and from the growth of tumor cells. Many of these cell types have specialized functions. The cells of the immune system can engulf bacteria, kill parasites or tumor cells, or kill viral-infected cells. Often, these cells depend on the T helper subset for activation signals in the form of secretions formally known as cytokines, lymphokines, or more specifically interleukins. The Organs of the Immune System Bone Marrow -- All the cells of the immune system are initially derived from the bone marrow. They form through a process called hematopoiesis. During hematopoiesis, bone marrow-derived stem cells differentiate into either mature cells of the immune system or into precursors of cells that migrate out of the bone marrow to continue their maturation elsewhere. The bone marrow produces B cells, natural killer cells, granulocytes and immature thymocytes, in addition to red blood cells and platelets. Thymus -- The function of the thymus is to produce mature T cells. Immature thymocytes, also known as prothymocytes, leave the bone marrow and migrate into the thymus. Through a remarkable maturation process sometimes referred to as thymic education, T cells that are beneficial to the immune system are spared, while those T cells that might evoke a detrimental autoimmune response are eliminated. The mature T cells are then released into the bloodstream. Spleen -- The spleen is an immunologic filter of the blood. It is made up of B cells, T cells, macrophages, dendritic cells, natural killer cells and red blood cells. In addition to capturing foreign materials (antigens) from the blood that passes through the spleen, migratory macrophages and dendritic cells bring antigens to the spleen via the bloodstream. An immune response is initiated when the macrophage or dendritic cells present the antigen to the appropriate B or T cells. This organ can be thought of as an immunological conference center. In the spleen, B cells become activated and produce large amounts of antibody. Also, old red blood cells are destroyed in the spleen.

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Lymph Nodes -- The lymph nodes function as an immunologic filter for the bodily fluid known as lymph. Lymph nodes are found throughout the body. Composed mostly of T cells, B cells, dendritic cells and macrophages, the nodes drain fluid from most of our tissues. Antigens are filtered out of the lymph in the lymph node before returning the lymph to the circulation. In a similar fashion as the spleen, the macrophages and dendritic cells that capture antigens present these foreign materials to T and B cells, consequently initiating an immune response.

The Cells of the Immune System T-Cells -- T lymphocytes are usually divided into two major subsets that are functionally and phenotypically (identifiably) different. The T helper subset, also called the CD4+ T cell, is a pertinent coordinator of immune regulation. The main function of the T helper cell is to augment or potentiate immune responses by the secretion of specialized factors that activate other white blood cells to fight off infection. Another important type of T cell is called the T killer/suppressor subset or CD8+ T cell. These cells are important in directly killing certain tumor cells, viral-infected cells and sometimes parasites. The CD8+ T cells are also important in down-regulation of immune responses. Both types of T cells can be found throughout the body. They often depend on the secondary lymphoid organs (the lymph nodes and spleen) as sites where activation occurs, but they are also found in other tissues of the body, most conspicuously the liver, lung, blood, and intestinal and reproductive tracts.

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Natural Killer Cells -- Natural killer cells, often referred to as NK cells, are similar to the killer T cell subset (CD8+ T cells). They function as effector cells that directly kill certain tumors such as melanomas, lymphomas and viral-infected cells, most notably herpes and cytomegalovirus-infected cells. NK cells, unlike the CD8+ (killer) T cells, kill their targets without a prior "conference" in the lymphoid organs. However, NK cells that have been activated by secretions from CD4+ T cells will kill their tumor or viral-infected targets more effectively. B Cells -- The major function of B lymphocytes is the production of antibodies in response to foreign proteins of bacteria, viruses, and tumor cells. Antibodies are specialized proteins that specifically recognize and bind to one particular protein that specifically recognize and bind to one particular protein. Antibody production and binding to a foreign substance or antigen, often is critical as a means of signaling other cells to engulf, kill or remove that substance from the body. Granulocytes or Polymorphonuclear (PMN) Leukocytes -- Another group of white blood cells is collectively referred to as granulocytes or polymorphonuclear leukocytes (PMNs). Granulocytes are composed of three cell types identified as neutrophils, eosinophils and basophils, based on their staining characteristics with certain dyes. These cells are predominantly important in the removal of bacteria and parasites from the body. They engulf these foreign bodies and degrade them using their powerful enzymes. Macrophages -- Macrophages are important in the regulation of immune responses. They are often referred to as scavengers or antigen-presenting cells (APC) because they pick up and ingest foreign materials and present these antigens to other cells of the immune system such as T cells and B cells. This is one of the important first steps in the initiation of an immune response. Stimulated macrophages exhibit increased levels of phagocytosis and are also secretory. Dendritic Cells -- Another cell type, addressed only recently, is the dendritic cell. Dendritic cells, which also originate in the bone marrow, function as antigen presenting cells (APC). In fact, the dendritic cells are more efficient apcs than macrophages. These cells are usually found in the structural compartment of the lymphoid organs such as the thymus, lymph nodes and spleen. However, they are also found in the bloodstream and other tissues of the body. It is believed that they capture antigen or bring it to the lymphoid organs where an immune response is initiated. Unfortunately, one reason we know so little about dendritic cells is that they are extremely hard to isolate, which is often a prerequisite for the study of the functional qualities of specific cell types. Of particular issue here is the recent finding that dendritic cells bind high amount of HIV, and may be a reservoir of virus that is transmitted to CD4+ T cells during an activation event.

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An animal’s immune system protects its body from intruders: bacteria, viruses, parasites, cancer cells, etc. An immune system is present in several animal groups, especially within the vertebrates. Animals have both non-specific and specific defense mechanisms to fight invaders. We will be focusing on the human immune system. Non-specific defense mechanisms work against a wide variety of invaders. These defense mechanisms include the barrier formed by our skin; chemicals in perspiration, skin oil, saliva, tears, etc.; the hairs in our nostrils; the ciliary escalator (the cilia and mucus that clean out dust and debris from our lungs and trachea) in our respiratory tracts; the inflammatory response which is the dilation of blood vessels and accumulation of WBCs at the site of an injury (the signs of which are that the area is red, hot, and swollen); and fever, a raised body temperature to inhibit the growth of pathogens. Note that a fever is caused by your body to inhibit the growth of bacteria, etc., not by the “germs” themselves, per se. Specific defense mechanisms are effective against specific pathogens. This involves various WBCs called lymphocytes or leukocytes. There are several kinds of WBCs involved in the immune system, all of which originate in the bone marrow. Leukemia is a cancer of the bone marrow, thus it typically is treated by killing all of the person’s bone marrow. Unfortunately, this leaves the person with no immune system, so (s)he must be extremely careful during that time to avoid all possible pathogens. There are two main types of specific defense mechanisms involved in the immune system.

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The cell-mediated immune system consists of T-cells which originate in the bone marrow, but go to the Thymus to finish their development. T-cells are highly-specialized cells in the blood and lymph to fight bacteria, viruses, fungi, protozoans, cancer, etc. within host cells and react against foreign matter such as organ transplants. There are three kinds of T-cells. Cytotoxic T-cells directly kill invaders. Helper T-cells aid B and other T-cells to do their jobs, and HIV lives in and kills them. Suppressor Tcells suppress the activities of B- and other T-cells so they don’t overreact. Allergy injections are supposed to increase the number of supressor T-cells to make the person less sensitive to allergens. Immunity is the ability to “remember” foreign substance previously encountered and react again, promptly. There are two kinds of immunity: active immunity, when the body is stimulated to produce its own antibodies, and passive immunity, where the antibodies come from outside the person’s body. Active immunity is usually permanent, and can be induced due to actual illness or vaccination. Passive immunity is not permanent because the antibodies are introduced from outside the body, thus the Bcells never “learn” how to make them. Some examples of passive immunity include antibodies passed across the placenta and in milk from a mother to her baby, some travelers’ shots, and the Rhogam shots we we discussed earlier this quarter. Because antibodies are only protein, they don’t last very long and must be replaced if the immunity is to continue.

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Patient Health History Hospital: Caraga Regional Hospital Room Number: Pediatric Ward, Miscellaneous Case number: 15-07-56 Name of the Patient: Patient R Age: 16 years old Date of Birth: October 21, 1993 Civil Status: Single Religion: Iglesia Filipina Independiente Highest Educational Attainment: High School level Occupation: NONE Home Address: Esperanza, Loreto, Dinagat Island, Surigao del Norte Health Care Financing and Usual Source of medical Care: Family income Mode of Admission: carried by his father Date of Admission: September 25, 2009 Time of Admission: 10:25 am Vital Signs upon Admission: Temperature: 36.7'c Pulse Rate: 86bpm Respiratory Rate: 18cpm Blood Pressure: 120/70 mmHg Chief Complain: Present condition noted as sudden onset of weakness of left lower extremities for almost 3 weeks, then after right lower extremities a week after Admitting Diagnosis: Guillain Barre' Syndrome Final Diagnosis: Guillain Barre' Syndrome

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Attending Physician: Dr. Asodisen (from September 25-30) Dr. Moleta ( from October 1-6) Name of Informant: Patient's mother Date of Discharge: October 6, 2009 Condition upon Discharge: Improved Source of Stability of Data gathered: Primary source (patient), Secondary Source (patient's SO and chart)

IBW = 118 -10 129 BMI

118 +10 - 128 lbs patient is only 103.61 lbs, therefore patient is underweight

= weight (in kgs) / height (in m)2 = 47 kg / (1.585 m)2 = 47 / 2.51 = 18.72 patient’s BMI is normal

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A. History of Present Illness On the 2nd week of August 2009, patient stated that he experienced abdominal cramps and diarrhea with watery stool characterized with yellow-green in color which lasted for 2 days after he had eaten kinilaw. After two weeks, patient started to complain a tingling sensation or something like an electric current on his feet and climbed up to the thighs and a little numb. Patient suspected that the cause of this was the usual bathing of legs after having a walk for approximately 4kms everyday going to school and back home. On the 2nd week, patient experienced weakness, especially on his left leg that made him not able to walked and had limited range of motion. On the following days, his condition worsens. He felt weakness accompanied with tingling sensation which often attack early in the morning and late afternoon and a couple of time during hour sleep as claimed by the patient. The day after, numbness on lower extremities with uncontrolled movements/tremors occurs which last about ten minutes. At that time, he couldn’t sit on his own and when he did sit up with assistance as well as in his elimination purposes. He felt like an egg as stated by the patient. Patient’s family sought advice from the local “manghihilot” who massaged the affected area with his own-made mixture of herbs. The latter believed that patient condition is caused by “buyag sa engkanto”. They also asked help from a “mantayhopay” who gave the same impression. His mother followed the instructions of the said persons such as soaking his feet with “nilagang sambong” every morning and at night before sleeping. Hospitalization was not possible during the said span of time because of financial constraints. One day prior to hospitalization, our patient was seen by his mother crying on the floor of their sala. Patient stated that “ gusto na nako magpahospital, nahadlok na ako basin dili na ako makalakaw pagbalik. That incident prompted his mother to bring him to Loreto District Hospital that day but was referred directly to Caraga Regional Hospital for further assessment and management. Patient was admitted to Caraga Regional Hospital last September 25, 2009 at exactly 10:25 am for chief complaints: noted as sudden onset of weakness of left lower extremities for almost 3 weeks, then after right lower extremities a week after Upon confinement, the doctor prescribed the following: • IVF D5IMB100 @ 25 gtts/min • Vitamin B complex 1 cap OD • Hydrocortisone 100mg IVTT q80 Laboratory tests were also ordered by the attending physician such as: • Hematology • Electrolytes 30

Urinalysis

B. Past Health History Childhood Illness Patient’s mother claimed that his son don't have any childhood illnesses like mumps, chickenpox, rubella and pertussis, etc. He experienced diarrhea last January 2009 which lasted for almost 2 and a half days characterized with watery stool yellowish-green in color. After that incidence he suffered diarrhea again last May 2009 with the same duration and feature but he was not able to hospitalized. Patient experienced 1 week fever accompanied with productive cough with thick yellow sputum on the last week of July 2009. Immunization Patient's mother claimed that only BCG had been immunized to her son since health center is far away from their house. History of Hospitalization Patient has no history of hospitalization; in fact this is his first time of being admitted in the hospital. Surgical History Patient claimed that he did not undergo any surgical procedure. Accidents and Injuries A week before he confined at Caraga Regional Hospital, he stated that when he was having an exercise early in the morning nearby shore approximately 7-10 meters away from their house suddenly he felt weakness on his legs and tingling sensation accompanied by tremors that made him fall down to the ground. He was trying to drag himself going to their house that causes abrasion and wounds on his legs, left foot, right and left knees. Until now his wounds are in the healing process, his mother used herbal plants like malungay to treat his wounds. Allergic and Type of Reaction Patient claimed that he don't have any food allergy or drug allergy. Family Health History Patient was the eldest of five. His mother is 43 years old and in good condition. His father is 56 years old currently suffering from cough for almost two weeks and has arthritis. The usual sickness of his siblings experienced, were colds and cough which can be relieved by over the counter drugs such as biogesic, neozep, carbocisteine and paracetamol. The grandmother/father in the mother side are alive with no underlying illness. The grandfather/mother in the father side were already deceased. His grandfather died last 1998 according to them it was just sudden onset of

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swelling on his lower extremities and a week after the upper extremities and developed into entire body. He was not hospitalized and was not diagnosed, in fact according to their belief and rumors his grandfather was "na barang". After one month of suffering from generalized swelling ha was died lying on the bed unnoticely. After 7 years, that is 2005 his grandmother died as claimed by the patient's mother, she died with the same case to her husband because of generalized swelling but patient's mother claimed that she can't recall if what happened to her mother-in-law since they were apart from here when that time happened, all she knows is that after one month also of suffering from swelling she died.

Personal Health History Lifestyle 1. Personal Habit Before Hospitalization Patient is a non-smoker and non-drinker and don't even used harmful drugs. Before he was confined at hospital, he already felt weakness on his legs that made him just stay on their house. He just watched wowowee and listening music and when he got bored he just sit nearby the window and just looked around to his friends outside since he can't walk and join with them. He just study his lesson by himself since he stop going to school for almost 3 weeks because of his condition. During Hospitalization Since patient was weak and can't moved his legs , he just lied on the bed and sometimes sit but still his legs were in straight and flat position. Patient has limited movement that made him uncomfortable. He just sleep and sometimes awake if tingling sensation occur. He also used to have little conversation to his family. He just keep on smiling whenever there were people looked at him. 2. Diet Before Hospitalization Patient typical food is fish since they lived nearby the sea and his father occupation is fishing and also vegetables. Patient eats his meals 3x a day but sometimes he doesn’t want to eat in the breakfast. Patient drinks 8-10 glasses of water a day he don't have any special diet or any food restriction. Patient was fond of eating “kinilaw” with vinegar than cooked. He eats 3 large meals a day and drinks 5-6 glasses of water. Patient is fond of eating raw egg with salt. He eats junk foods as his snacks. He drinks coffee and Milo sometimes if it is available on their kitchen. During Hospitalization Patient eat the food that is being serve in the hospital but sometimes his mother buy food outside like tinolang baka and any food that has soup. He also eats fruits like orange, banana and mango. And early in the morning his mother will make milk/milo for him. Sometimes he refuses to eat because he felt fullness, he drink 3-4

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glasses of water a day. He doesn’t have any order of food restriction or any special diet from the dietician but the doctor ordered 1 banana last September 26, 2009. 3. Sleep and Rest Pattern Before Hospitalization Patient usually sleep at 8pm and wake up 6am, before the present illness he had no difficulties in sleeping, but when he started to felt weakness and tingling sensation he can't sleep appropriately cause he can't moved his legs side by side. During Hospitalization Patient has difficulty of sleeping and wakes up a number of times during hour sleep. He claimed that his not comfortable to sleep in the hospital as well as his position in sleeping, he felt he's like a dead person lying in a straight and flat position. And sometimes he's mother awaken him when uncontrolled movements of muscle occur since patient couldn’t felt any sense. 4. Elimination Pattern Before Hospitalization Patient urinate 3x a day characterized by large amount with yellow in color and defecate once a day characterized by scanty amount with yellowish/brownish in color with no history of difficulty or pain in urinating and defecating. Patient did not experience constipation. Before the present illness , he eliminate with himself but because of his condition he really needs assistance for elimination purposes, usually his father carried him in going to comfort room. During Hospitalization Patient urinate 4-5x a day, when he void he just sit on the bed and his mother will offer plastic container of the IVF since he can't go by himself to the comfort room. Sometimes it takes 3-4 days before he can defecate and his father carried him going to the comfort room. His last void is scanty and yellow in color and his fecal is hard stool, yellowish in color. 5. Activities of Daily Living Before Hospitalization Even though before hospitalization patient has difficulty on his activities of daily living because of his condition he cant take a bath and dress alone, his mother has been always there for him in doing his grooming and hygiene as well as in his elimination and locomotion, he had limited movements. The only thing he can do for himself is just that when he eat or holds any object. He couldn’t help in household chores unlike before. During Hospitalization Patient doesn’t have any activities, he just lies on the bed. He claimed that he was bored; he wants to have some exercise as what he usually did before his

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condition. He just has some conversation with his mother and after that he fined himself sleeping and awakens for a few hours. 6. Recreation and Hobbies Before Hospitalization Patient usual recreation and hobbies were watching television and listen drama in the radio. He used to read pocketbooks when he got bored. Before his condition he exercised everyday early in the morning and swimming in the sea. During Hospitalization Patient just lies in the bed. When the patient is in fine mood, he usually chatty and lights up when he is talking to his visitors/parents. He always war beautiful smiles on his face despite of his condition. 7. Social Data The patient usually turns to his parents for support during time of stress and school problem especially about what he felt on his first trimester of illness. He reported to his parents for every detailed event that happened to his condition. Patient does not believe in superstitious belief or quack doctors even though his parent do so. Patient is currently studying first year high school but eventually stopped because of his condition. 8. Occupational Activity Not applicable. Patient is still studying. 9. Environmental Data Patient lived at Esperanza, Loreto, Dinagat Island, SDN. Their house is located nearby the sea approximately 10-12 meters away from their house. Their house is made of wood and nipa hut. They have one sala, room, and kitchen and comfort room. Their house is surrounded with plants and they have garden wherein they plant vegetables for their food consumption. And also a little chicken poultry for their consumption of eggs. They have a clean environment where in he can breathe fresh air with no pollution. 10. Psychological Data Patient major stressor in life was his condition now, he was worried about his legs if it will be back in normal again but despite of his problem he was trying to be strong and tend to be happy for he believed that he will be cured and nothing is impossible with God. 11. Pattern of Health Care Patient is a non-member of Phil Health, GSIS and SSS. Patient’s mother used herbal plants and sought “quack doctors” and “manghihilot” whenever his son got sick. They used their personal family fund to sustain his need for medical care.

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REVIEW OF SYSTEM Integumentary system Patient has no any allergic reaction to certain foods or medication, he don’t have any history of itchiness. He has lesions, abrasions and scars in his lower extremities. No hair dyes, curling or strengthening preparation. Head, Eyes, Ears, Nose, Throat Patient doesn’t felt any dizziness, lightheadedness and headache. Sometimes he experienced seizures especially when it is cold and tingling sensation attack. He doesn’t use any eyeglasses. No hearing problem patient experienced nasal stuffiness sometimes. Neck Patient claimed that he doesn’t have any neck lumps and was not diagnose with any thyroid problem. Breast and Axillae Patient did not experience any pain on his breast and axillae. Thorax and Lungs Patient experienced productive cough with thick yellow sputum. No history and dyspnea, asthma, pneumonia, and emphysema. He doesn’t felt any chest pain. Cardiovascular System Patient doesn’t have any history of cardiovascular disease. Gastrointestinal System Patient experienced abdominal cramps and hyperactive bowel movement with watery stool characterized with yellow-green in color which lasted for two days. Patient experienced abdominal pain in the lower portion of the abdominal cavity; it just lasted for few minutes and diminished. He used to drink hot water to relieve the pain, he also experienced flatulence for 5x a day, for that day only. He don’t any have difficulty in swallowing. Musculoskeletal System Patient claimed that he experienced like an electric current sensation on his both legs. It is gradual characterized first by the weakness of his legs followed by the tingling sensation and numbness on his legs especially in the left leg. Because of this, he had limited range of motion and he can’t move his both legs. Tingling sensation often attack early in the morning and late afternoon and a couple of time during hour sleep as claimed by the patient. He also had loss of function without pain in her legs.

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Neurologic System Patient experienced tingling sensation, numbness and uncontrolled movements accompanied with tremors on his lower extremities. Patient can’t feel light pressure only deep pressure and pain through pointing point object. Urinary System Patient urinates 2-3x a day, he have difficulty in urination because he need assistance tot go to comfort room. But he doesn’t have any painful urination.

Hematologic Patient claims that he doesn’t have any history of anemia. Endocrine System Patient verbalizes upon assessment that he cannot tolerate warm environment since in their place they have fresh air. He doesn’t have any thyroid problems. Psychiatric Patient can manage the stress that his having now. In fact, he is a happy person. He has a good memory and but he also tend to get nervous easily when strange people like us talk to him and he tend to perspire more.

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PHYSICAL ASSESSMENT Date of Assessment: September 28-29, 2009 Time of assessment: 05:45pm Vital signs upon assessment: September 28, 2009 T = 36.7°C P = 88 bpm R = 20 cpm BP= 110/70 mmHg General Survey: Patient is awake appeared pale and his legs were numb and weak, patient lies on bed in a supine position. He appeared untidy with oily face, hair which is not properly combed and tangled. Patient is coherent and responsive during our interview; he keeps in smiling and felt shy to answer our questions. Ongoing IVF solution of D5IMB with the drop rate of 15gtts/min, patently hooked at the right dorsal metacarpal vein. Integumentary System: Skin: • • • • • Hair: • • • • Nails: • • • • Untrimmed, dirty nails on both fingers and toes Blanch capillary refill test <3 seconds Patients fingernails and toenails are thick Nails are convex with an angle at about 160 degrees Hair is short, thick and reddish/brownish in color, brittle hair Doesn’t use hair dyes No lice infestation noted Dandruff noted Patient has a fair skin Good skin turgor noted Lesion noted in the lower extremities Scar noted at the left knee and left foot Dry skin noted September 29, 2009 T = 36.8°C P = 90 bpm R = 19 cpm BP= 110/70 mmHg

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Head, Eyes, Ears, Nose, Throat (HEENT) Skull and Face: • • • • Normocephalic and symmetrical with frontal, parietal, and occipital prominence Absence of nodules and masses upon palpation Can flex head without support Facial features and movements are symmetrical

Eyes and Vision: • • • • • Eyebrows are thin, but symmetrically aligned Frequent eye blinking No discharges, no discoloration and no masses noted Sunken eyes and eye bags noted Pupil Equally Round Reacted to Light and Accommodation

Ears and Hearing • • • • • • Auricles same color as facial skin, symmetrical and are aligned with outer canthus of eye Able to hear spoken words clearly Able to hear watch ticking in both ears Pinna is mobile, firm and not tender Pinna recoils after it is folded Presence of cerumen noted

Nose and Sinuses • External nose has same color as facial skin except for same parts with small pigments • No discharges noted • No tenderness and masses noted • No sinusitis noted Oropharynx (mouth and throat) • • • • • Lips are pale and dry No swelling of the tongue noted No palpable nodules Bad breath noted No bleeding and swelling of gums noted 38

• • • Neck: • • •

Plaques on teeth noted No tonsillitis noted Gag Reflex noted

Thyroid gland is not visible Patient can turn head left and right, up and down without pain No palpable nodules

Thorax and Lungs • • No difficulty of breathing No abnormalities noted

Posterior Thorax • • • Normal curvature No tenderness upon palpation Symmetric

Anterior Thorax • • • Chest is symmetric Normal breath sounds noted No evidenced of any secretions

Breast and Axillae • • • • No discharges noted Skin uniform in color, areola darken in color No evidence of enlargement of liver and spleen Audible bowel sounds

Musculoskeletal System • • • • • • Limited movements in the lower extremities Weakness of his legs both right and left Tingling sensation, uncontrolled movements Numbness of the legs both right and left Patient didn’t response to light touch Patient response to deep pressure only 39

• • • • •

limited ability to perform gross/fine motor skills, difficulty turning his body slowed movement and uncoordinated movement postural instability, inability to maintain activity.

Cardiovascular System • • • No abnormalities noted Lub-dub sounds noted upon auscultation No edema

Urinary System • • Patient urinate 3x a day Patient’s urine is yellowish in color

Gastrointestinal System • • • • No vomiting No diarrhea No difficulty in swallowing Hard stool noted

Neurologic System Mental Status: Language • Patient does not have any speech problems. He can understand and converse well using Bisaya dialect. He used non-verbal communication such as eye movements, gestures and interaction with the support person. He had a congruence of non-verbal and verbal expression.

Orientation • Patient is oriented to place, time and is able to answer our questions correctly during interview.

Memory • He has good memory and can recall what happened in the past.

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Attention Span • Patient is responsive and coherent.

CRANIAL NERVE ASSESSMENT

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CRANIAL NERVE I II

NAME Olfactory Optic

III

Occulomotor

IV

Trochlear

V

Trigeminal

VI

Abducens

VII

Facial

RESULT Patient is able to smell and he can identify if what he smells. He was able to read our nameplates about 14 inches. He has bright eyes and can see clearly. Patient’s pupil reacted to light. Pupils constrict when looking at near object and dilate when looking far object. It also converges when penlight was moved towards his nose. When penlight was moved at six cardinal fields of gaze using the six ocular movements namely: superior rectus, lateral rectus, inferior rectus, superior oblique, medial rectus and inferior oblique patients both eyes were coordinated and moved in unisonwith parallel alignment. Positive blink reflex with5 blinks/minute and can determine blunt and sharp ends. Using the six ocular movements, he was able to move eyeballs laterally of both eyes with unison and in parallel alignment. Patient flashed his smile when asked of something private and personal. And close his together and able to raise eyebrows. Patient can hear clearly and only seldom questions will be repeated while we were interviewing him. The patient will be able to identify various taste placed on tip and sides of tongue. He was also able to move tongue from side to side and up and down 42 when asked to do. Positive gag reflex.

VIII

Acoustic/Auditory

IX

Glossopharyngeal

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Glasgow Coma Scale Faculty Measured Response Score Eye Opening Spontaneous-open with blinking at baseline__________4pts To verbal stimuli, command, speech________________3pts To pain only(not applied to face)___________________2pts No response___________________________________1pt Oriented______________________________________5pts Confused conversation, but able to answer question____4pts Inappropriate words_____________________________3pts Incomprehensible speech_________________________2ptS No response___________________________________1pt Obeys command for movement____________________6pts Purposeful movement to painful stimulus____________5pts Withdraw in response to pain_____________________4pts Flexion in response to pain(decorticate positioning)___3pts Extension response to pain(deceberate positioning)___2ptS No response__________________________________1pt ****

Verbal Response

*****

Motor Response

****

_________________________________________________________________________________________________ Total Score = 13/15

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MUSCLE STRENGTH SCALE

0 1 2 3 4 5

No detection of muscular contraction A barely detectable flicker on trace of contraction with observation in palpation. Active movement of body part with eliminate of gravity. Active movement against gravity only and not against resistance. Active movement against gravity and some resistance. Active movement against full resistance without evident fatigue (normal muscle strength)

MUSCLE STRENGTH

Left Lower Extremities Plantar flexion Dorsiflexion Knee Flexors Knee Extensors Hip Flexors Hip Extensors Inversion and eversion 0 0 0 0 0 0 0

Right Lower Extremities 0 0 0 0 0 0 0

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Reflex: The patient’s Biceps, Triceps, Brachioradialis, Patellar and Achilles have the following grade of responses: +2, +2, +1, 0, 0, 0 respectively. Scale of grading Reflex: 0-10 reflex response +1= minimal activity (hypoactive) +2= normal response +3= more active than normal +4= maximal activity (hyperactive)

“Patient R”

RIGHT BRACHIORADIALIS +1 BICEPS

LEFT BRACHIORADIALIS +1 BICEPS 46

+2 TRICEPS +2

+2 TRICEPS +2

KNEE REFLEX/ PATELLAR 0

KNEE REFLEX/ PATELLAR 0

ANKLE REFLEX 0

ANKLE REFLEX 0

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DOCTOR’S ORDER 09/25/09 10:25 am  Pls. admit pt. to pedia misc.  TPR every 4 hour  Labs: CBC, Na, Creatinine, u/a Urinalysis AFB AST  Start D5IMB to few at 15  Monitor v/s every 4 hours Dr. Patiño 11:45 am  refer result when in noted  ascending paralysis 09/26/09 T= 37.2˚C  Vit. B complex  Eat 1 banana  Follow up IVF Dr. Patiño 10:50 pm  Hydrocortisone 100mg IVTT every 8˚ 09/27/09 T= 37.1˚C  Continue medication 09/28/09 09:15am  Continue medication 10:24 pm  IVF to follow D5IMB 500ml Dr. Mantilla  warm compression BID  Continue medication  Follow up IVTT with 15 gtts/min. Dr.Mantilla

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09/30/09  continue medication  Bisacodyl pediatric rectal suppository  Hydrocortisone 250mg every 8 hours 10/01/09  afebrile  continue medication  follow IVF with D5LR IL 15gtts/min. 10/02/09  continue medication  Follow IVF with D5LR IL 15gtts/min. 10/03/09  continue medication  Follow IVF with D5LR IL 15gtts/min.  Decrease Hydrocortisone to 250g and IVTT every 12 hours 10/05/09  continue medication  Follow IVF with D5LR IL 15gtts/min. 10/06/09  May go home  Home medication  Follow up check up at OPD after 2 weeks

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LABORATORY TESTS ELECTROLYTE September 26,2009 ELECTROLYTES SODIUM POTASSIUM HEMATOLOGY September 26,2009 Criteria Hematocrit Platelet WBC Neutrophils Lymphocytes Result 35% ADEQUATE 8.4 x 10 9/L 60 40 Normal Values M:40-52% F:36-48% 150 – 400 4.0 – 11 25-75% 15-35% Significance Reduced number of RBC in the blood (anemia) Normal Normal Normal Lymphocytes increased with infectious mononucleosis, viral and some bacterial infection RESULTS 143mmol/L 5.4 mmol/L NORMAL VALUES 135-145mmol/L 3.5-5.5mmol/L SIGNIFICANCE NORMAL NORMAL

Urinalysis October 03, 2009 Result yellow 6.0 negative clear 1.030 negative Normal Result Amber yellow 4.5-8ph negative clear 1.015=1.035 negative Significance Normal Normal Normal Normal Normal Normal

Color Reaction Sugar Transparency Sp. gravity Protein

PONCIANO LIMCANGCO, MD, FPSP

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Pathologist Drug Study Bisacodyl Classifications: Gastrointestinal Agent; Stimulant Laxative Action: Expands intestinal fluid volume by increasing epithelial permeability. Relieves constipation. Stimulant laxative that increases peristalsis, probably by direct effect on smooth muscle of the intestine, by irritating the muscle or stimulating the colonic intramural plexus. Drug also promotes fluid accumulation in colon and small intestine Indication: • temporary relief of acute constipation and • for evacuation of colon before surgery, prostoscopic, sigmoidoscopic, • radiologic examinations. • Also used to cleanse colon before delivery and to relieve constipation in patients with spinal cord damage. • Chronic constipation; preparation for childbirth, surgery, or rectal or bowel examination • Dosage, Route of administration: IVTT every 8 hours , rectal suppository Contraindication: Contraindicated in patients hypersensitive to drug or its components and in those with rectal bleeding, gastroenteritis, intestinal obstruction, abdominal pain, nausea, vomiting, or other symptoms of appendicitis or acute surgical abdomen. Adverse Reaction: • Mild cramping • nausea, • diarrhea • fluid and electrolytes disturbances (especially potassium and calcium). GI: nausea, vomiting. Abdominal cramps, diarrhea, burning sensation in rectum, protein-losing enteropathy, laxative dependence Metabolic: alkalosis, hypokalemia Musculoskeletal: muscle weakness, tetany

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Nursing Implication: • Add high-fiber foods slowly to regular diet to avoid gas and diarrhea. Adequate fluid intake includes at least 6-8glasses/d. • Do not breastfeed while taking this drug without consulting physician. • Give drug at times that don’t interfere with scheduled activities or sleep. Soft, formed stools are usually produced 15 to 60 minutes after rectal use. • Before giving for constipation, determine whether pt. has adequate fluid intake, exercise, intake and diet. • Tablets and suppositories are used together to clean the colon before and after surgery and before and after surgery and before barium enema. • Insert suppositoryas high as possible into the rectum , and try to position suppository against the rectal wall. Avoid embedding within fecal material because doing so may delay onset of action. Bisco-Lax may contain tartrazine

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Generic name:

Ascorbic Acid (Vitamin C)

Brand names: Apo-C, Ascorbicap, Cebid, cecon, cenolate, cemin, c-span, cetane, cesvacin Classification: Vitamin Action: Water-soluble vitamin essential for synthesis and maintenance of collagen and intercellular ground substance of the body tissues cell, blood vessels, cartilages, bones, teeth, skin, and tendons. Indication: Prophylaxis and treatment of scurvy and as a dietary supplement. To prevent vit. C deficiency in pt. w/ poor nutritional habits or increased requirements. • • • RDA Frank and subclinical scurvy Extensive burns, delayed fracture or wound healing, postoperative wound healing, severe febrile or chronic dse. State. Dosage, Route of administration: 1 tab OD, PO Contraindication: Use of sodium ascorbate in patients on sodium restriction; use in calcium ascorbate in patients receiving digitalis. Adverse Reaction: Nausea, vomiting, heartburn, diarrhea, or abdominal cramps, acute hemolytic anemia, sickle cell crisis, headache or insomnia, urethritis, dysuria, crystauria, hyperlaxalunia, hyperuricemia, mildness soreness at injection site, dizziness, temporary faintness with rapid IV administration Nursing implication: • High doses of vitamin C are not recommended during pregnancy. • Take large doses of vitamin C in divided amounts because the body uses only what is needed at a particular time and excretes the rest in urine. • Megadoses can interfere with the absorption of vitamin B12. • Note: vitamin C increases the absorption of iron when taken at the same time as iron rich-foods. • Do not breastfeed while taking this drug without consulting physician. • Stress proper nutritional habits to prevent recurrence of deficiency. • Advise smokers to increase intake of vitamin C. • When giving for urine acidification, check urine pH to ensure efficacy. • For pt. receiving vit. C I.M., explain that M.I, route may promote better utilization.

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Generic name: Hydrocortisone Brand name: Cortef, cortenema, hydrocortone Classification: Skin and Mucous Menbrane Agent; Anti-Inflammatory; synthetic Hormone; adrenal corticosteroids; glucocorticoid; mineralocorticoid Action: Short-acting synthetic steroid with both glucocorticoid and mineralocorticoid properties that affect nearly all system of the body. Hydrocortisone has anti-inflammatory, immunosuppressive, methabolic function in the body. Indication: Replacement therapy in adrenocortical insufficiency; to reduce serum calcium inhypercalcemia, to suppress undesirable inflammatory or immune responses, to produce temporary remission in nonadrenal disease, and to block ACTH production in diagnostic tests. Use as anti-inflammatory or immunosuppressive agent largely replaced by synthetic glucocorticoids that have minimal mineralocortocoid activity. Dosage, Route of administration: 100 grams IVTT every 8 hours Contraindication: Hypersensitivity to glucocorticoids, idiopathic thrombocytopenic purpra, psychoses, acute glomerulonephritis, viral or bacterial diseases of skin. Adverse Reaction: euphoria, insomnia, psychotic behavior, pseudotumor cerebri, seizures, heart failure, hypertension, edema. Arrythmias, thromboembolism, cataracts, glaucoma, peptic ulceration, gastrointestinal irritation, increase appetite, pancreatitis, hypokalemia, hyperglycemia, carbohydrate intolerance, muscle weakness, growth suppression in children, osteoporosis, hirsutism, delayed wound healing, acne, various skin eruption, easy bruising. Nursing Implication: • Teach patient signs of early adrenal insufficiency • Warn patient about easy bruising • Advise him to consider exercise or physical therapy • Warn patient receiving long-term therapy about cushingoid symptom • Determine whether the pt is sensitive to other corticosteroid. • Give oral dose with food when possible.pt. may need another drug to prevent GI irritation. • Most adverse reaction to corticosteroids are dose-duration-dependent. • Monitor pt. weight BP, and electrolyte level • Monitor pt. cushingoid effects including moon face, buffalo hump, central obesity, thinning hair, hypertension and increased susceptibility to infection.

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GENERIC NAME: VITAMIN B COMPLEX - ORAL BRAND NAME(S): Surbex, Theravite, Vicon-C, Z-Bec USES: Vitamins are the building blocks of the body. They are used to prevent or treat a vitamin deficiency due to poor nutrition, certain illnesses or during pregnancy. HOW TO USE: Take as directed. Food may affect the absorption of certain vitamin products. Consult your pharmacist. Chewable tablets must be chewed thoroughly before swallowing followed with a glass of water. Timed-release capsules or tablets must be swallowed whole. SIDE EFFECTS: This medication may cause mild nausea or unpleasant taste. Consult your doctor if any of these effects persist or become severe. If you notice other effects not listed above, contact your doctor or pharmacist. PRECAUTIONS: Before using this medication, tell your doctor or pharmacist your medical history, especially of: diabetes, blood disorders such as vitamin B12 deficiency (pernicious anemia). Tell your doctor if you are pregnant before using this medication. No problems have been reported in pregnant or nursing women when this medication was used in normal doses. DRUG INTERACTIONS: Tell your doctor if you take any other medication, including nonprescription. This medication may affect certain urine lab tests, including some urine glucose tests. Do not start or stop any medicine without doctor or pharmacist approval. OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US national poison hotline at 1800-222-1222. Canadian residents should call their local poison control center directly. Symptoms of overdose may include diarrhea, loss of coordination; numbness of the hands or feet; joint pain, or painful urination.

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Predisposing factor:

PATHOPHYSIOLOGY (Diagram)

Precipitating factor:

Gender: Male (Male to female ratio is 1:5:1) Age: 16 years old (Young adults age 15-35 y-o) (Elderly age 50-75 y-o) Infectious organism: invasion of Campylobacter jejuni via oral route

DIET: 1. eating uncooked food (esp. poultry products) 2. “Kinilaw” 3. Raw eggs DIARRHEA

To cause gastrointestinal infection (diarrhea & abdominal cramping)

C. jejuni undergoes significant physiologic changes w/in the intracellular environment to avoid mixture to lysosomal enzymes w/c could eat & kill them Immune system will response to the intracellular invasion of microorganism

MOLECULAR MIMICRY

DUAL RECOGNITION Cell-mediated immunity Humoral immunity

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Mistaken immune attack may arise

Activates specific T lymphocytes or T-cells Increased level of lymphocytes level T-cells released lymphokines Lymphokines produced macrophages activation

Secrete antibodies Antibodies will fight foreign microorganisms

Penetration of macrophage and antibodies into basement membrane around nerve fibers Inflammation of the nerve cells Inflamed cells secrete cytotoxic substances that affect or damage the Schwann cells Decreased myelin production

DEMYELINATION Sensory and motor loss

Ascending paralysis Impaired transmission of nerve conduction Immobility of the LE Inability to perform ADL Constipation

Tingling sensation Numbness Weakness of the LE

GUILLAIN BARRE SYNDROME
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NURSING CARE PLAN #1 September 28, 2009 Subjective cues: “Pasmo ra man daw ni sa kusog kay manhimasa man ko human baktas” as verbalized by the patient. Objective cues: v/s taken as follow: Temp: 36.5 c RR: 18cpm • • Diagnosis: Knowledge deficit related to cognitive limitation Planning: After 4 hours of rendering nursing intervention patient will be able to verbalize understanding of condition disease process and treatment Intervention: 1. Determined information the client already knows and move to what the client does not know, progressing from simple to complex 2. Explained the cause of the symptoms and disease 3. Explained the goal of treatment 4. Provide an environment that is conducive to learning 5. Identify support persons or SO requiring information Evaluation: Goal met. After 4 hours of rendering of nursing intervention the patient was able to participate in learning process and was able to verbalize understanding of condition of treatment. Rationale To facilitate learning and determine the client and SO’s cognitive limitation

PR: 86bpm

BP:110/70mmHg

Apathy noted Misinterpretation of information

To provide knowledge To provide appropriate information To facilitate learning To let the SO aware of the condition of the client

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NURSING CARE PLAN #2 September 28, 2009 Subjective Cue: “Dili ko kalakaw ma’am kay wala gajud kusog ako tiil”. As verbalized by the patient Objective cues: Limited range of motion, limited ability to perform gross/fine motor skills, difficulty turning, slowed movement uncoordinated movement, movement induced, postural instability, inability to maintain activity. V/S taken as follow: Temp: 36.5 °C RR: 18 cpm PR: 86 bpm BP : 110/70 mmHg

Nursing Diagnosis: Impaired physical mobility related to inability to maintain activity as evidenced by limited range of motion. Planning: Within 8 hours of giving appropriate nursing intervention, patient will be able to participate in Activities of Daily Living and desired activities. Interventions: 1. Monitor vital signs • Baseline data during medication of procedures. 2. Observe movement when client is unaware of observation. • To note any incongruence with reports of abilities. 3. Note emotional/ behavioral responses to problems of immobility. • Feelings of frustration/powerless may impulse attainment of goals. 4. Encourage participation in self care, diversional activities. • Enhances self concept and sense of independence. 5. Identify energy- conserving techniques for ADL’s. • Limits fatigue, maximizing participation. 6. Encourage adequate intake of fluids/ nutritious foods • Promotes well being and maximizes energy production. 7. Encourage clients/SO’s involvement in decision making as much as possible. • Promotes well being and maximizes energy production. Evaluation: Goal was not met. Patient was not able to participate in Activities of Daily livings and desired activities. 51 60

NURSING CARE PLAN #3 September 28, 2009 Subjective cue: “Waya pa ako kaligo pila na kaadlaw” as verbalized by the patient. Objective cues: v/s taken as follow: Temp: 36.5 c RR: 18cpm • • • • • • Dirty nails noted Bad body odor noted Dandruff noted Halitosis noted Patient is not properly groomed Dry skin noted

PR: 86bpm

BP:110/70mmHg

Diagnosis: Self-care deficit related to impaired physical mobility Planning: After 2 hours of rendering nursing intervention patient will be able to perform selfcare activities within physical limitations. Intervention: 1. Determined individual strengths and skills /of the client 2. Provide for communication among those who are involved in caring 3. Provide health teaching to patient about the importance of good hygiene 4. Develop plan of care appropriate to individual situation, scheduling activities to conform to clients normal schedule 5. Plan time for listening to the client and SO 6. Demonstrated to the client and SO the basic ways in self care such as hand washing, combing the hair, trimming nails, tooth brushing and bathing Rationale To know the strengths and weaknesses of the client as basis in giving appropriate interventions To gain trust and cooperation from the client and SO To promote good hygiene to the patient To encourage performance of ADL within physical limitation To discover barriers to participation in regimen To provide awareness that self care activities are still possible even with physical limitations

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7. Encouraged patient and SO to use products to enhance self image such as deodorant

To promote self care

Evaluation: Goal met. After 4 hours of rendering nursing intervention patient was able to perform self-care activities such as combing, tooth brushing and trimming of nails.

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NURSING CARE PLAN #4 September 28, 2009 Subjective cues: “ Nanhina man ako maam, murag nawal an ko ug kusog” , as verbalized by the patient. Objective Cues: v/s taken as follow: Temp: 36.5 c RR: 18cpm PR: 86bpm BP:110/70mmHg • Decreased physical strength • Decreased mobility • Weakness Nursing Diagnosis: Powerlessness related to decreased physical strength. Planning: After 8 hours of rendering nursing care the patient will be able to express sense of control over the present situation and hopefulness about future outcomes. Interventions: 1. • 2. Encourage client to be active in own health care management and to take responsibility for choosing own actions and reactions. Can enhance feelings of power and sense of positive self –esteem. Express hope for client and encourage review of past experiences with successful strategies. • Show concerns to client as a person. Accept expressions of feelings, including anger and reluctance, to try to work things out. • Being able to express feelings freely enables client to sort out what is happening and come to a positive conclusion. Make time to listen to client’s perceptions of the situation. • Shows concern for client as a person. Listen to statements client makes which might indicate feelings of powerlessness. • Suggest concerns regarding on power/ ability to control situation. Monitor vital signs. • To have baseline data.

3.

4. 5.

6.

Evaluation: Goal met. Patient was able to express sense of control and hopefulness about future outcomes. 63

NURSING CARE PLAN #5 September 28, 2009 Subjective cue: “Nabiro ko nga di na ko makalakaw” as verbalized by the patient Objective cue: v/s taken as follow: Temp: 36.5 c RR: 18cpm • • •

PR: 86bpm

BP:110/70mmHg

Poor eye contact Tearfulness during conversation Verbalization of concerns (refer to subjective cue)

Analysis: Anxiety related to threat on role function secondary to physical illness Planning: After 8 hours of duty patient will be able to identify healthy ways to deal with and relieve anxiety Intervention 1. Provided opportunities for question and answer session 2. Compared verbal and non-verbal responses 3. Encouraged verbalization of feelings Rationale Enhance sense of trust and nurse client relationship To note misperception of situations To provide appropriate emotional supportive care To provide information that could help patient understand conditions To provide information and to boost patient’s hope

4. Discussed the disease of GuillainBarre Syndrome 5. Enumerated ways the patient may use to relieve anxiety such as accepting the reality of his condition, optimistic way of seeing things and having faith in God’s love

Evaluation: Goal partially met. After 8 hours of intervening, the patient was able to enumerate ways to relieve anxiety but verbally said, “ Bisan nakasabot na ko..Dili gajud naku malikayan na mag-isip ng ako kahimtang karon.”

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NURSING CARE PLAN #6 September 28, 2009 Subjective cues: ‘ Mahadlok lage ako motindog kay basin matumba ako” as verbalized by the patient. Objective cues: v/s taken as follow: Temp: 36.5 c RR: 18cpm PR: 86bpm BP:110/70mmHg • Diminished productivity • Avoidance behavior • Increased perspiration • Pallor Diagnosis: Fear related to loss of physical support as evidenced by diminished productivity. Planning: After two days of rendering appropriate nursing care patient will display appropriate range of feelings lessened fear. Interventions: 1 .Compare verbal/ non-verbal responses. • To note congruencies as of situation. 2. Stay with the client or make arrangements to have someone else be there. • Sense of abandonment can exacerbate fear. 3. Provide information in verbal and written form. Speak in simple sentences and concrete terms. • Facilitate understanding and retention of information. 4. Provide opportunity for questions and answer honestly. • Enhances sense of trust to nurse-client relationship 5.Present objectives information when available an d allow client to use it freely. Avoid arguing about client perceptions of the situations. • Limits conflicts when fear response may impair rational thinking. 6.Promote client control where possible and health client identify and accept those things over which control is not possible. • strengthen internal locus of control 7.Explain procedures within level of clients ability to understand and handle. • To prevent confusion or overload 8.Encourage assist client to develop exercise program. • Provides a healthy outlet for energy generated by fearful feelings and promotes relaxation. Evaluation:

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Goal is met. After 2 days of rendering appropriate nursing care, patient is able to display appropriate range of feelings and lessened fear. NURSING CARE PLAN #7 September 29, 2009 Subjective cue: “Ma’am dili naman ko kalibang tapos tag dugay” as verbalized by he patient. Objective cue: irritable, restlessness, weakness, unable to move, hard stool. v/s taken as follow: Temp: 36.5 c RR: 18cpm PR: 86bpm BP:110/70mmHg Nursing Diagnosis: Altered Bowel Movement: Constipation related to Insufficient Physical Activity. Planning: After 8 hours of duty, patient will be able to verbalize understanding of the importance of mobility and diet to normal bowel movement Interventions: INTERVENTIONS Independent: 1. Advised patient to drink adequate fluid and include foods that are high in fiber like papaya, oatmeal and pineapple 2. Encouraged activity/exercises within personal limitation. 3.Provided with privacy and routinely scheduled time defecation 4.Educated patient about the importance of mobility and diet to normal bowel movement 5.Note energy. Activity level and exercise pattern. 6. Auscultate abdomen for the characteristics of bowel sounds Dependent: 1.Administered Bisacodyl (pedia) suppository as prescribed Evaluation: RATIONALE -to promote moist and soft stool

-to stimulate abdominal muscle contraction. -to promote defecation -to provide information - sedimentary lifestyle may affect elimination patterns - reflecting bowel activity To increase peristalsis promoting easy defecation

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Goal met. After 8 hours of duty, patient able to defecate and verbalized “ nakalibang na gajud ko maam,importante diay gajud ang exercise ug diet labaw na adtong tambal na tagsuksuk sa ako lubot.” NURSING CARE PLAN #8 September 29, 2009 Subjective: “Dili ko karajaw makatulog” as verbalized by the patient. Objectives: v/s taken as follow: Temp: 36.5 c RR: 18cpm • • • • • • • Eyebags noted Frequent yawning noted Restlessness noted Sunken eyes noted Fatigue Anxiety Decreased ability to function

PR: 86bpm

BP:110/70mmHg

Nursing Diagnosis: Sleep Pattern Disturbance related to environmental factors such as external noise and lack of sleep privacy. Planning: After 8 hours of duty, patient will be able to report improvement in sleep pattern. INTERVENTIONS Independent 1. Provided with quiet and calm environment during bedtime 2. Advised to limit fluid intake in evening 3. Encouraged participation in regular exercise program during day 4. Identified the factors that affect the sleeping pattern 5..Recommended to limit intake of chocolates and caffeinated beverages Dependent 1. Administered sedative / other sleep medication when indicated RATIONALE To promote rest and sleep -to reduce need for nighttime micturation -to aid stress control/release of energy -to reduce sleep disturbance Such beverages are stimulants that inhibits sleep -to enhance clients ability to fall asleep

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Evaluation: Goal met. After 8 hours of duty, patient able to sleep comfortably and report improvement of sleep pattern. NURSING CARE PLAN #9 September 29, 2009 Subjective cue: “Maulaw nako sa ako kahimtang karon,” as verbalized by the patient. Objective cue: v/s taken as follow: Temp: 36.5 c RR: 18cpm

PR: 86bpm

BP:110/70mmHg

• Loss of body function noted • Restlessness noted • Hiding body parts with blanket (lower extremities) • Less eye contact • Weakness and numbness (lower extremities) Analysis: Disturbed body image related to physical illness as evidenced by inability to walk Planning: After 8 hours giving appropriate nursing intervention, patient will acknowledge self as an individual who has responsibility for self. Intervention 1.Encouraged family member to treat client normally and not as invalid. 2.Encouraged expression of feeling regarding his condition. 3.Encouraged client to look and touch affected body parts. 4.Discussed meaning of loss change to client. 5.Visited client frequently and acknowledged the individual as someone who is worthwhile Rationale To avoid feeling of isolation or rejection To provide appropriate emotional support To begin to incorporate changes into body image A change of function such as immobility may be more different for some to deal with than a change in appearance Provides opportunities for listening of patient’s concerns and questions.

Evaluation: Goal met. After 8 hours giving appropriate nursing intervention, patient verbalized feeling of acceptance and responsibility of his affected body parts as evidenced by frequent checking and touching of his lower extremities. 68

NURSING CARE PLAN #10 September 29, 2009 Subjective cue: “Taglaay na man ko diri sa hospital”, as verbalized by the client. Objective cues: v/s taken as follow: Temp: 36.5 c RR: 18cpm • • • •

PR: 86bpm

BP:110/70mmHg

Restlessness noted Frequent yawning noted Verbal expression of boredom Keep on lying in bed

Nursing Diagnosis: Deficient diversional activity related to physical limitations and lack of sources. Planning: After 8 hours of giving appropriate nursing intervention, patient will be able to engage in satisfying activities within personal limitations. Intervention: 1.Acknowledged reality of situation and feelings of the client. 2.Provided with diversional activities such as reading materials and talking to the client. 3.Provided change of scenery . 4.Encouraged expression of feelings 5.Provided requirements for mobility such as wheelchair. 6.Developed plan of care appropriate to individual situation, scheduling activities to conform to clients normal schedule. Evaluation: Rationale To establish therapeutic relationship To refocus the attention of the client . To relieve boredom. To direct attention. To determine concerns that needs intervention. For mobility. To encourage performance of ADL within physical limitation.

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Goal met. After 8 hours of giving appropriate nursing intervention, patient verbalized feelings of satisfaction in activities engaged with in personal limitations. NURSING CARE PLAN #11 September 29, 2009 Subjective Cues: “Kadaghan sad diri tawo, gusto na ako ra isa,” as verbalized by the patient. Objective Cues: v/s taken as follow: Temp: 36.5 c RR: 18cpm • • • • • PR: 86bpm BP:110/70mmHg

Fatigue Observed discomfort Observed use of unsuccessful social in reactions behavior Insecurity in public Dysfunctional interaction with others

Diagnosis: Impaired social interactions related to limited physical mobility. Planning: After 8 hours of giving appropriate nursing intervention patient will express desire/be involved in achieving positive changes in social behaviors and interpersonal relationships. Interventions: 1. Interview family, SO, and friends. • To obtain observation of clients behavior changes. 2. Determine client use of coping skills and defense mechanism. • Affects ability to be involved in social situation 3. Have client list behaviors that cause discomfort. • Once recognized, client can choose to change. 4. Work with the client to alleviate underlying negative self concepts • Because they after impede social interactions 5. Encourage client to verbalized problems and perceptions of reasons for problems • Active listen to note indications of hopelessness, powerlessness, fear, anxiety, grief, anger, feeling unloved or unlovable; problems with sexual identity. Evaluation:

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Goal met. After 8 hours of giving appropriate nursing intervention, patient express desire/be involved in achieving positive changes in social behaviors and interpersonal relationships. NURSING CARE PLAN #12 Potential Nursing Care Plan Subjective cue: Objective cues: • • • • Ascending paralysis noted (from feet to the pelvic part) Limited ROM Slowed body movements noted Weakness

Nursing Diagnosis: High risk for impaired skin integrity related to immobility as evidenced by ascending paralysis Planning: After 8 hours of rendering appropriate nursing interventions, patient will be free from any risk of impaired skin integrity. INTERVENTIONS 1. Changed patient position every 2 hours. 2. Removed wet/wrinkled linens promptly. 3. Developed repositioning schedule for client, involving client in reasons for and decisions about times and positions in conjunction w/ other activities. 4. Provided w/ well ventilated environment. 5. Elevated both legs with a pillow 6. Encouraged patient to touch his lower extremities every now and then RATIONALE -to promote circulation and prevent bed sore and constipation -moisture potentiates skin breakdown -to enhance cooperation. understanding and

-To promote comfort To promote blood venous return -To remind the patient that his lower extremities are present and still needs care 71

7. Increased fluid and high fiber in diet. Evaluation:

-to prevent constipation.

NURSING CARE PLAN #13 Potential Nursing Care Plan Subjective cue: Objective cues: • Physical immobility • Motor dysfunction • Weakness and numbness (lower extremities) Nursing Diagnosis: Risk for Injury related to Physical Immobility. Planning: Patient will be able to understand of individual factors that contribute to possibility of injury. Nursing Intervention: 1. Perform thorough assessment regarding safety issues when planning for client care and/or preparing for discharge from care. • Failure to accurately assess and intervene or refer these issues can place the client at needless risk and creates negligence issues for the health care practitioner. 2. Ascertain knowledge of safety needs/injury prevention and motivation. • To prevent injury in home and community. 3. Note clients’ developmental stage, decision- making ability, level of cognition/competence. • Affects clients ability to protect self and influence choice of intervention. 4. Assess mood, coping abilities, personality styles. • That may result in carelessness/increased risk-taking without consideration of consequences. 5. Assess clients’ muscle strength, gross and fine motor coordination. • To identify risk for falls. 6. Identify interventions/safety devices. • To promote safe physical environment and individual safety. 7. Discuss importance of self monitoring of condition/emotions. 72

• Evaluation:

That can contribute to occurrence of injury.

DISCHARGE PLAN Name: Patient R Final Diagnosis: Guillain Barre’ Syndrome Condition upon Discharge: Improved Date of Discharge: October 06, 2009 Medications: • • • Instructed patient and SO to take the medication on time. Completed duration of those of medications take home. Instructed SO to give patient with Multivitamins.

Environmental Concerns: • • • • Instructed SO to provide clean environment to prevent lodging of infectious microorganisms. Instructed SO to provide proper disposal of wastes. Instructed SO to remove or lessen any environmental hazards. Changes in your home environment can aid in your recovery by making it easier for you to bathe, dress and prepare meals while your muscles return to normal levels of strength.

Treatments: • • • • • Encouraged patient doing light exercise such as walking. Encouraged patient to have an adequate rest periods. Encouraged SO to provide comfort measures to the patients. Instructed SO to change the position of the patient when lying in bed for long periods of time to prevent bed sores. Find a good physical therapy program from which you can learn specific isometric, isotonic and resistance exercises to rebuild weakened muscles. You may do these exercises on an outpatient basis and continue them at home. Remember to pace yourself and get adequate rest, as fatigue is to be expected with Guillain-Barre Syndrome.

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Health Teachings: • Provided patient health teaching about: - Proper hand washing - Proper personal hygiene - Tell patient to frequently change positions when lying in bed for long periods of time to prevent bed sores. Tell patient’s mother about monitoring signs & symptoms or recurring GuillainBarre Syndrome, eg. Tingling sensation, difficulty of swallowing, restlessness, fever. Instructed patient to avoid some heavy works. Instructed SO to well cook the food. Wear comfortable shoes and socks to help soothe pain and burning from neuropathy in the feet. Inspect your feet often to be sure there are no cuts or blisters that you may not have noticed.

• • • •

Out Patient (follow up check-up): • Encouraged patient to have follow up check-up after 3 weeks. • Instructed patient to notify physician if there is any undesired feeling about the disease. Diet • • • • • Encouraged patient to eat nutritious food like vegetables. Encourage patient to eat fruits rich in vitamin C for strong immunity. Advised patient to take low-sodium diet. Instructed patient to avoid junk foods. Follow a healthy eating plan with fresh, seasonal fruits and vegetables, lean meat and fish, whole grains and plenty of colorful salads. Eating well may help you to sustain your energy and can boost your mood.

Spiritual • Encouraged patient to attend mass as frequent as he can, or even once a week together with his family. • Encouraged patient to always pray to God to help him to recover immediately. • Encouraged patient thank God for the gift of life. • Encouraged SO to pray for the health of the patient. Emotional

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Seek emotional support to cope with feelings of depression and anxiety that are part of living with Guillain-Barre Syndrome. Discuss antidepressant medication with your doctor if you are having trouble with activities necessary for daily living.

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SUMMARY OF INTRAVENOUS FLUIDS

Date/Time Started

Intravenous Fluids and Volume

Drop Rate

Number of hours to be Infused

09/25/09 09/26/09 09/27/09

D5IMB 1L D5IMB 1L D5IMB 500ml D5LR 1L

15gtts/min. 15gtts/min. 15gtts/min. 15gtts/min 15gtts/min 15gtts/min 15gtts/min 15gtts/min

16 hours and 30 minutes 16 hours and 30 minutes 8 hours and 15 minutes 16 hours and 30 minutes 16 hours and 30 minutes 16 hours and 30 minutes 16 hours and 30 minutes 16 hours and 30 minutes

10/01/09 10/02/09 10/03/09 10/04/09 10/05/09

D5LR 1L D5LR 1L D5LR 1L D5LR 1L

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B. GENOGRAM Legend: Mother Father Grandfather Grandmother Siblings Patient GBS Cough Arthritis Generalized Swelling Deceased 56 years old 43 years old died at the age of 71 year 1998 69 year old died at the age of 68 year 2005 65 year old

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Definition of Terms Autoimmune: Pertaining to autoimmunity, a misdirected immune response that occurs when the immune system goes awry and attacks the body itself. Autoimmune disease: An illness that occurs when the body tissues are attacked by its own immune system . The immune system is a complex organization within the body that is designed normally to "seek and destroy" invaders of the body, including infectious agents. Patients with autoimmune diseases frequently have unusual antibodies circulating in their blood that target their own body tissues. Axon: A long fiber of a nerve cell (a neuron) that acts somewhat like a fiber-optic cable carrying outgoing (efferent) messages. Bacteria: Single-celled microorganisms which can exist either as independent (freeliving) organisms or as parasites (dependent upon another organism for life). Bacterial: Of or pertaining to bacteria. For example, a bacterial lung infection. Blood pressure: The blood pressure is the pressure of the blood within the arteries. It is produced primarily by the contraction of the heart muscle. It's measurement is recorded by two numbers. The first (systolic pressure) is measured after the heart contracts and is highest. The second (diastolic pressure) is measured before the heart contracts and lowest. A blood pressure cuff is used to measure the pressure. Elevation of blood pressure is called "hypertension". Brain: That part of the central nervous system that is located within the cranium ( skull ). The brain functions as the primary receiver, organizer and distributor of information for the body. It has two (right and left) halves called "hemispheres." Breathing: The process of respiration, during which air is inhaled into the lungs through the mouth or nose due to muscle contraction, and then exhaled due to muscle relaxation. Campylobacter jejuni: a species of curved, rod-shaped, non-spore forming, Gramnegative microaerophilic, bacteria commonly found in animal feces.[1] It is one of the most common causes of human gastroenteritis in the world. Food poisoning caused by Campylobacter species can be severely debilitating but is rarely life-threatening. It has been linked with subsequent development of Guillain-Barré syndrome (GBS), which usually develops two to three weeks after the initial illness. Cerebrospinal fluid: A watery fluid, continuously produced and absorbed, which flows in the ventricles (cavities) within the brain and around the surface of the brain and spinal cord.

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Clinical trials: Trials to evaluate the effectiveness and safety of medications or medical devices by monitoring their effects on large groups of people. Cure: 1. To heal, to make well, to restore to good health. Cures are easy to claim and, all too often, difficult to confirm. 2. A time without recurrence of a disease so that the risk of recurrence is small, as in the 5-year cure rate for malignant melanoma . 3. Particularly in the past, a course of treatment. For example, take a cure at a spa. Diagnosis: 1 The nature of a disease ; the identification of an illness. 2 A conclusion or decision reached by diagnosis. The diagnosis is rabies . 3 The identification of any problem. The diagnosis was a plugged IV. Gastrointestinal: Adjective referring collectively to the stomach and small and large intestines. Heart: The muscle that pumps blood received from veins into arteries throughout the body. It is positioned in the chest behind the sternum (breastbone; in front of the trachea, esophagus, and aorta; and above the diaphragm muscle that separates the chest and abdominal cavities. The normal heart is about the size of a closed fist, and weighs about 10.5 ounces. It is cone-shaped, with the point of the cone pointing down to the left. Two-thirds of the heart lies in the left side of the chest with the balance in the right chest. See the entire definition of Heart Heart rate: The number of heart beats per unit time, usually per minute. The heart rate is based on the number of contractions of the ventricles (the lower chambers of the heart). The heart rate may be too fast ( tachycardia ) or too slow ( bradycardia ). The pulse is bulge of an artery from the wave of blood coursing through the blood vessel as a result of the heart beat. The pulse is often taken at the wrist to estimate the heart rate. See the entire definition of Heart rate Immune: Protected against infection. The Latin immunis means free, exempt. Immune system: A complex system that is responsible for distinguishing us from everything foreign to us, and for protecting us against infections and foreign substances. The immune system works to seek and kill invaders. Infection: The growth of a parasitic organism within the body. (A parasitic organism is one that lives on or in another organism and draws its nourishment therefrom.) A person with an infection has another organism (a "germ") growing within him, drawing its nourishment from the person.

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Knee: The knee is a joint which has three parts. The thigh bone (the femur) meets the large shin bone (the tibia) to form the main knee joint. This joint has an inner (medial) and an outer (lateral) compartment. The kneecap (the patella) joins the femur to form a third joint, called the patellofemoral joint. The patella protects the front of the knee joint. Limb: The arm or leg. Low blood pressure : Any blood pressure that is below the normal expected for an individual in a given environment. Low blood pressure is also referred to as hypotension. Muscle: Muscle is the tissue of the body which primarily functions as a source of power. There are three types of muscle in the body. Muscle which is responsible for moving extremities and external areas of the body is called "skeletal muscle." Heart muscle is called "cardiac muscle." Muscle that is in the walls of arteries and bowel is called "smooth muscle." Myelin: The fatty substance that covers and protects nerves. Myelin is a layered tissue that sheathes the axons (nerve fibers). This sheath around the axon acts like a conduit in an electrical system, ensuring that messages sent by axons are not lost en route. It allows efficient conduction of action potentials down the axon. Myelin consists of 70% lipids (cholesterol and phospholipid) and 30% proteins. It is produced by oligodendrocytes in the central nervous system. Nerve: A bundle of fibers that uses chemical and electrical signals to transmit sensory and motor information from one body part to another.. Neurological: Having to do with the nerves or the nervous system. Onset: In medicine, the first appearance of the signs or symptoms of an illness as, for example, the onset of rheumatoid arthritis . There is always an onset to a disease but never to the return to good health. The default setting is good health. Pain: An unpleasant sensation that can range from mild, localized discomfort to agony. Pain has both physical and emotional components. The physical part of pain results from nerve stimulation. Pain may be contained to a discrete area, as in an injury, or it can be more diffuse, as in disorders like fibromyalgia . Pain is mediated by specific nerve fibers that carry the pain impulses to the brain where their conscious appreciation may be modified by many factors. Paralysis: Loss of voluntary movement (motor function). Paralysis that affects only one muscle or limb is partial paralysis, also known as palsy; paralysis of all muscles is total paralysis, as may occur in cases of botulism.

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Paresthesia: An abnormal sensation of the skin, such as numbness, tingling, pricking, burning, or creeping on the skin that has no objective cause. Paresthesia is the usual American spelling and paraesthesia the preferred English spelling. Peripheral: Situated away from the center, as opposed to centrally located. Peripheral nervous system (PNS): That portion of the nervous system that is outside the brain and spinal cord. Physical therapy: A branch of rehabilitative health that uses specially designed exercises and equipment to help patients regain or improve their physical abilities. Physical therapists work with many types of patients, from infants born with musculoskeletal birth defects, to adults suffering from sciatica or the after- effects of injury, to elderly post-stroke patients. Plasma: The liquid part of the blood and lymphatic fluid, which makes up about half of its volume. Plasma is devoid of cells and, unlike serum, has not clotted. Blood plasma contains antibodies and other proteins. It is taken from donors and made into medications for a variety of blood-related conditions. Some blood plasma is also used in non-medical products. Plasmapheresis: A procedure designed to deplete the body of blood plasma (the liquid part of the blood) without depleting the body of its blood cells. Whole blood is removed from the body, the plasma is separated from the cells, the cells are suspended in saline, a plasma substitute or donor plasma), and the reconstituted solution may be returned to the patient. The procedure is used to remove excess antibodies from the blood in lupus, multiple sclerosis, multiple myeloma, etc. Plasmapheresis carries with it the same risks as any intravenous procedure. The risk of infection increases with the use of donor plasma, which may carry viral particles despite screening procedures. The procedure is done in a clinic or hospital. Protein: A large molecule composed of one or more chains of amino acids in a specific order determined by the base sequence of nucleotides in the DNA coding for the protein. Proteins: Large molecules composed of one or more chains of amino acids in a specific order determined by the base sequence of nucleotides in the DNA coding for the protein. Relapse: The return of signs and symptoms of a disease after a patient has enjoyed a remission . For example, after treatment a patient with cancer of the colon went into remission with no sign or symptom of the tumor, remained in remission for 4 years, but then suffered a relapse and had to be treated once again for colon cancer. Residual: Something left behind. With residual disease, the disease has not been eradicated.

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Respiratory: Having to do with respiration, the exchange of oxygen and carbon dioxide. From the Latin re- (again) + spirare (to breathe) = to breathe again. Sensory: Relating to sensation , to the perception of a stimulus and the voyage made by incoming ( afferent ) nerve impulses from the sense organs to the nerve centers. Spinal cord: The major column of nerve tissue that is connected to the brain and lies within the vertebral canal and from which the spinal nerves emerge. Thirty-one pairs of spinal nerves originate in the spinal cord: 8 cervical , 12 thoracic , 5 lumbar, 5 sacral, and 1 coccygeal. The spinal cord and the brain constitute the central nervous system ( CNS ). The spinal cord consists of nerve fibers that transmit impulses to and from the brain. Like the brain, the spinal cord is covered by three connective-tissue envelopes called the meninges . The space between the outer and middle envelopes is filled with cerebrospinal fluid ( CSF ), a clear colorless fluid that cushions the spinal cord against jarring shock. Also known simply as the cord. Spinal tap: Also known as a lumbar puncture or "LP", a spinal tap is a procedure whereby spinal fluid is removed from the spinal canal for the purpose of diagnostic testing. It is particularly helpful in the diagnosis of inflammatory diseases of the central nervous system, especially infections, such as meningitis. It can also provide clues to the diagnosis of stroke , spinal cord tumor and cancer in the central nervous system. Stage: As regards cancer , the extent of a cancer, especially whether the disease has spread from the original site to other parts of the body.. Steroid: A general class of chemical substances that are structurally related to one another and share the same chemical skeleton (a tetracyclic cyclopenta[a]phenanthrene skeleton). Stroke : The sudden death of some brain cells due to a lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. A stroke is also called a cerebrovascular accident or, for short, a CVA. Surgery: The word "surgery" has multiple meanings. It is the branch of medicine concerned with diseases and conditions which require or are amenable to operative procedures. Surgery is the work done by a surgeon. By analogy, the work of an editor wielding his pen as a scalpel is s form of surgery. A surgery in England (and some other countries) is a physician's or dentist's office. Syndrome: A set of signs and symptoms that tend to occur together and which reflect the presence of a particular disease or an increased chance of developing a particular disease. Trigger: Something that either sets off a disease in people who are genetically predisposed to developing the disease, or that causes a certain symptom to occur in a

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person who has a disease. For example, sunlight can trigger rashes in people with lupus. Viral: Of or pertaining to a virus. For example, "My daughter has a viral rash ." Viral infection: Infection caused by the presence of a virus in the body. Depending on the virus and the person's state of health, various viruses can infect almost any type of body tissue, from the brain to the skin. Viral infections cannot be treated with antibiotics; in fact, in some cases the use of antibiotics makes the infection worse. The vast majority of human viral infections can be effectively fought by the body's own immune system , with a little help in the form of proper diet, hydration, and rest. As for the rest, treatment depends on the type and location of the virus, and may include anti-viral or other drugs. Virus: A microorganism smaller than a bacteria, which cannot grow or reproduce apart from a living cell. A virus invades living cells and uses their chemical machinery to keep itself alive and to replicate itself. It may reproduce with fidelity or with errors (mutations)this ability to mutate is responsible for the ability of some viruses to change slightly in each infected person, making treatment more difficult. Viruses: Small living particles that can infect cells and change how the cells function. Infection with a virus can cause a person to develop symptoms. The disease and symptoms that are caused depend on the type of virus and the type of cells that are infected.

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REFERENCES Brunner and Suddarth’s Medical and Surgical Nursing eleventh edition Pathophysiology 3rd edition by Thomas J. Nowak Assessment by Lippincott Williams and Wilkins http://en.wikipedia.org/wiki/Campylobacter_jejuni http://www.about-guillain-barre.com/ http://www.cehs.siu.edu/fix/medmicro/cmir.htm http://www.about-campylobacter.com/campylobacter_symptoms_risks http://www.medicinenet.com/guillain-barre_syndrome/article.htm http://www.direct-ms.org/pdf/MolecularMimicryOther/GillianBarrMolMimicry.pdf http://www.microbiologybytes.com/blog/2008/01/30/how-campylobacter-jejuni-surviveswithin-cells/ http://www.microbiologybytes.com/blog/2008/01/30/how-campylobacter-jejuni-surviveswithin-cells/ http://en.wikipedia.org/wiki/Myelin_sheath http://www.drkaslow.com/html/blood_cell_counts.html http://www.scribd.com http://www.nursingcrib.com

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