A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease I.

INTRODUCTION

This is a case of an 8 year-old male patient who is diagnosed of Aspiration Pneumonia, Sepsis, Cerebral Palsy, and Pott¶s disease and was admitted to Capitol University Medical City (CUMC) ICU last November 23, 2010. During the assessment, findings revealed that there was a normal blood pressure of 100/70, pulse rate was 98bpm, respiration rate of 25cpm and temperature of 37.3 degree Celsius and had chief complaints of difficulty in breathing with coffee-ground vomitus. His weight revealed 42 lbs (20.1 kg). Aspiration pneumonia is an inflammation of the lungs and bronchial tubes caused by inhaling foreign material, usually food, drink, vomit, or secretions from the mouth into the lungs. This may progress to form a collection of pus in the lungs (lung abscess). Aspiration pneumonia is a form of pneumonia that can develop when foreign material, such as food, liquid, vomit, or mucus, is accidentally inhaled into the lungs. This can happen when a person is unconscious or has a seizure or when a stroke has affected the person's ability to swallow. Childhood pneumonia is the leading single cause of mortality in children aged less than 5 years. The incidence in this age group is estimated to be 0.29 episodes per child-year in developing and 0.05 episodes per childyear in developed countries. This translates into about 156 million new episodes each year worldwide, of which 151 million episodes are in the developing world. Most cases occur in India (43 million), China (21 million) and Pakistan (10 million), with additional high numbers in Bangladesh, Indonesia and Nigeria (6 million each). Of all community cases, 7±13% are severe enough to be life-threatening and require hospitalization. Substantial evidence revealed that the leading risk factors contributing to pneumonia incidence are lack of exclusive breastfeeding, undernutrition, indoor air pollution, low birth weight, crowding and lack of measles immunization. Pneumonia is responsible for about 19% of all deaths in children aged less than 5 years, of which more than 70% take place in sub-Saharan Africa and south-east Asia. Although based on limited available evidence, recent studies have identified Streptococcus pneumoniae, Haemophilus influenzae and respiratory syncytial virus as the main pathogens associated with childhood pneumonia. (Bulletin of the World Health Organization 2008;86:408±416.) On the other hand, sepsis is a serious infection usually caused by bacteria ² which can originate in many body parts, such as the lungs, intestines, urinary tract, or skin ² that make toxins that cause the immune system to attack the body's own organs and tissues. Sepsis can be frightening because it can lead to serious complications that affect the kidneys, lungs, brain, and hearing, and can even cause death. As mentioned,

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease conditions originating in the perinatal period is among the leading cause of mortality; the top cause of death being pneumonia, followed by bacterial sepsis. Meanwhile, Cerebral Palsy (CP) is a disorder that affects muscle tone, movement, and motor skills (the ability to move in a coordinated and purposeful way). Cerebral palsy can also lead to other health issues, including vision, hearing, and speech problems, and learning disabilities. CP is usually caused by brain damage that occurs before or during a child's birth, or during the first 3 to 5 years of a child's life. There is no cure for CP, but treatment, therapy, special equipment, and, in some cases, surgery can help a child who is living with the condition. Statistics that were calculated extrapolations of various prevalence or incidence rates against the populations of a particular country or region which shows the prevalence/incidence of Cerebral Palsy are typically based on US, UK, Canadian or Australian statistics. This extrapolation calculation is automated and does not take into account any genetic, cultural, environmental, social, and racial or other differences across the various countries and regions for which the extrapolated Cerebral Palsy statistics below refer to. As such, these extrapolations may be highly inaccurate (especially for developing or third-world countries) and only give a general indication (or even a meaningless indication) as to the actual prevalence or incidence of Cerebral Palsy in that region. Specifically, in the aforementioned statistics, Philippines has 172,483 cases for the population of 86,241,6972 Finally, Pott¶s disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints. Scientifically, it is called tuberculous spondylitis. Pott¶s disease is the most common site of bone infection in TB; hips and knees are also often affected. The lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected. Pott's disease, which is also known as Pott¶s caries, David's disease, and Pott's curvature, is a medical condition of the spine. Individuals suffering from Pott's disease typically experience back pain, night sweats, fever, weight loss, and anorexia. They may also develop a spinal mass, which results in tingling, numbness, or a general feeling of weakness in the leg muscles. Often, the pain associated with Pott's disease causes the sufferer to walk in an upright and stiff position. Pott¶s disease is caused when the vertebrae become soft and collapse as the result of caries or osteitis. Typically, this is caused by Mycobacterium tuberculosis. As a result, a person with Pott's disease often develops kyphosis, which results in a hunchback. This is often referred to as Pott¶s curvature. In some cases, a person with Pott's disease may also develop paralysis, referred to as Pott¶s paraplegia, when the spinal nerves become affected by the curvature. The incidence and prevalence of pediatric tuberculosis (TB) worldwide varies significantly according to the burden of the disease in different countries. It has been estimated that 3.1 million

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease children under 15 years of age are infected with TB worldwide. According to the World Health Organization (WHO), children with TB represent 10 % to 20 % of all TB cases. The majority of these cases occur in low-income countries where the prevalence of Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) is high. TB occurs frequently among disadvantaged populations, such as malnourished individuals, and those living in crowded areas. According to WHO reports, India, China, Pakistan, the Philippines, Thailand, Indonesia, Bangladesh, and the Democratic Republic of the Congo account for nearly 75 % of all cases of pediatric TB (World Health Organization 2006, Dye 1990). Furthermore, it has also been reported that TB is responsible in Sub-Saharan countries for between 7 % and 16 % of all episodes of acute pneumonia in HIV-infected children, and for approximately one fifth of all deaths in children presenting with acute pneumonia (Chintu 2002, Jeena 2002). This kind of case, requires continuous care and necessitates proper health education to the patient and to significant others to provide safety, proper nourishment. It is but a collaborative effort of health care providers and the patient in line to preventing reoccurrence, and further complication. In light to this, through this case presentation the group will be able to come up with versatile ideas relevant to the care of patient not only for the betterment of his condition but also to address the needs of patient holistically. This paper contains all the relevant care rendered to the patient through our duties and all other forms of intervention given by the health team in response to the patient¶s condition including the medications, laboratory results and other doctors¶ orders which are related to the patient¶s condition.

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease II. GOALS AND OBJECTIVES

General Objectives: This case presentation seeks to enhance the students¶ knowledge with regards to the patient¶s general health and disease condition, its pathophysiology, possible complications, treatment plan and medical regimen. It also seeks to assimilate the student¶s skills through application of several nursing interventions and medical management. Furthermore, this case presentation intends to improve the students¶ attitude by conveying open-mindedness and utilizing therapeutic communication all throughout the activity.

Specific Objectives: Within one week of thorough study of this specific case, the student nurses aim to achieve the following objectives in this case presentation: 

Accurately present a thorough general health assessment of the client which includes physical assessment and family history taking.  Effectively discuss and elaborate actual signs and symptoms of the specific diagnoses exhibited by the client.  Thoroughly discuss, explain, and elaborate the nature of the disease process.  Efficiently provide appropriate and proper nursing diagnosis in line with the client¶s medical condition.  Skillfully formulate nursing care plans for the different problems identified.  Appropriately provide nursing interventions according to the standards of nursing practice.  Effectively apply the learned concepts and theories of the disease and the management.  Efficiently Appraise the effectiveness and efficacy of nursing interventions rendered to the client.  Impart the outcome of the rendered nursing interventions.  Convey the significance of client¶s response to the rendered nursing interventions  Accurately provide concise and concrete information to the audience with regards to Aspiration Pneumonia, Sepsis, Cerebral Palsy, and Pott¶s disease.  Appropriately provide an environment for learning for the audience.

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease III. CLIENT¶S PROFILE A. Socio-demographic Date Patient X is an eight year old male who lives with his family at Damilag, Manolo Fortich, Bukidnon. He is the second and youngest son of his Roman Catholic parents.

B. Vital Signs The patient vital signs are one of the most important data that should be given a direct attention because it will serve as basis in determining any risk factors towards the patient. The increase and decreased of the vital sign of the patient must be monitored in order to determined whether the patient is at risk or not. Upon assessment, the patient¶s vital signs were: BP: 100/70 mmHg, Temperature: 37.3 degree Celsius (but during the shift he reached the temperature of 37.7C) , PR: 98 beats per minute, and RR: 25 cycles per minute. The patient weighs 20.1n kilograms and is 4 feet and 2 inches tall. C. Health Pattern Assessment Past Medical History According to the mother, about 10 days after the patient has given birth, he experienced having high intermittent fever, the mother ignored it at once but when the patient exhibits seizure activities, the mother then immediately brought him to the hospital specifically Northern Mindanao Medical Center (NMMC) and was advised for ICU admission. The doctor¶s diagnosis then was meningitis. In addition to that, as a complication, the patient develops hydrocephalus and was managed through brain shunting. The patient went on being comatose for about a week, and was later diagnosed with Pott¶s disease. He was given high doses of antibiotic then. From then, the patient is no longer able to move by himself, and went on entirely dependent all his life. Patient X was 6 years old then when he was readmitted to the ICU but now in Capitol University Medical City (CUMC) with the same manifestations. After about 5 days of admission, he was later diagnosed with Cerebral Palsy.

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease History of Present Illness Three days prior to admission, the patient had cough and colds, the phlegm is very copious but the mother opted to nebulizer him, considering the he has always been coughing and had persistent respiratory infection until last November 23, 2010 he began vomiting blood-like, coffee ground vomitus. This alarmed the mom and immediately sought medical attention.

Physical Assessment Patient X has nasogastric tube in place. He also has a mouth guard secured in place and has an endotracheal tube, at the same time, connected to a mechanical ventilator with set-up as follows: TV=20, FiO2= 40%, BUR= 25, PEEP 3. He is hooked with D5NM 1L@15 drops per minute infusing at his left foot. He has heplock on his right arm. He is hooked to a cardiac monitor and a pulse oximeter. He has a condom cathether attached to urobag.

HEENT: Head, hair and scalp Head appears bigger with fine hair and clean scalp. Eyes: sclera, pupils Sclerae are anicteric and pupils are covered with cataracts and are equal in size. The mother also reported the patient has been blind since birth. Ears and tympanic membrane The right ear is bigger than the left with no discharges and has equal auditory function. Nose No nasal flaring noted. Septum is medial.

Mouth, lips, tongue, teeth and Lips and oral mucosa are pale. No lesions noted oral mucosa in the mouth. Tongue is midline. Teeth are complete with plaques noted. Throat and neck Neck has limited range of motion. Thyroids are non palpable. Facial movements Symmetrical but decreased or limited mobility.

Cognitive/ Neurological Assessment Level of consciousness Conscious, often drowsy and less responsive (by means of motor) Orientation N/A

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease Emotional state Primary language Calm at times and gets restless when coughing Communicates thru moaning and crying. The mother also reported, the patient has been mute from birth. Educational attainment Haven¶t gone to school.

Nutritional and Metabolic Pattern At home, Patient X is fed with blenderized food ever since, which includes rice, milk and a little of soft viands. He is fed about once or twice a day per demand or if he can tolerate. According to the mom, he often gets choked when fed. He has no vitamins or mineral supplement. Upon hospital stay, Patient X is fed thru NGT with 2500 kcal a day equally divided in four feedings. He seems poorly nourished with a BMI below normal range.

Elimination Pattern Patient X usually does not follow a pattern in defecating. He used to defecate once in three days or more, but when he does, his stool appears soft in consistency, yellow to brown in color and in minimal amount. He urinates at about 4 times a day with amber to yellow colored urine. He is not used to wearing diaper even at home because he seems to have allergic reactions when he wears it. Abdominal configuration Symmetrical, no superficial veins, with no lesions and scars Bowel sounds Hypoactive (3clicks) upon auscultation

Percussion

Tympanic and dullness noted on right upper quadrant

Activity-Exercise Pattern At home, the patient has no exercise at all. He lies flat on bed most of the time and gets to sit when fed. He doesn¶t have any leisure activities. He is fully dependent with all the activities of daily living (ADL) as well as with his mobility. Most of his joints have decreased mobility, in its range of motion exercises. In terms of his muscular tone and strength, his muscles, in both limbs, are very weak; tend to become spastic and immobile at some time. The patient¶s gait might not be uncoordinated nor shuffling

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease neither staggering but definitely not coordinated because he has never learned to walk at all. Patient has kyphosis brought about the complication of Pott¶s disease.

CARDIOVASCULAR STATUS Chest pain, radiation No pain noted and assessed Point of maximal impulse, 3rd intercostals space, midclavicular line Precordial area Heart sounds Peripheral pulses Capillary refill time bulging Distinct and regular, no murmurs noted Regular, symmetrical and faint 2 seconds, no clubbing noted

RESPIRATORY STATUS Breathing pattern Lung expansion Vocal/tactile fremitus Percussion Breath sounds Cough regular, use of accessory muscles noted Decreased at left side Not assessed Tympany Crackles noted nonproductive sputum

Sleep and Rest Pattern Patient X used to sleep most of the time, if not, lies on bed and listens to stories being shared by his mother in a resting position. His sleep accounts almost 18 hours each day. Role and Relationship Pattern Patient X is a son to a 39-year-old mother and overseas worker father. He used to be the youngest and gets almost all attention from his mom. His dad works overseas and seldom talks with him via phone call. His dad, according to his mom, cannot come home and take care of their son because he signed a contract and he needs to strive harder to sustain Patient X¶s needs. However, the mother provides ample time and devotes most of her attention for her ³special´ son. On the other hand, the mother reported their family doesn¶t have any history of diabetes, hypertension nor cancer.

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease Value and Belief Pattern The family is affiliated to the Roman Catholic Church and believes that God can heal their patient. The mother silently prays and moans all her desires and wishes of healing to God.

D. Physical Assessment 1. Neurologic Assessment Level of consciousness Orientation Emotional state Conscious but drowsy and less responsive N/A Restless when coughing

2. Head Head Facial movement Fontanels Hair Scalp Slightly bigger ( heading to macrocephalic) Symmetrical but limited Closed Fine Clean

3. Eyes Lids Periorbital region Conjunctiva Symmetrical Non edematous pink

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease Cornea & lens Sclera Pupils Visual acuity Peripheral vision cataracts Anicteric Equal in size Loss of sight absent

4. Ears External pinnae External canal Tympanic membrane Gross hearing Right ear is slightly bigger No discharge Intact normal

5. Nose Mucosa Patency Gross smell Sinuses Pinkish Both patent N/A No tenderness presence

6. Mouth Lips Pallor

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease Mucosa Tongue Teeth Gums Pallor Midline Missing Teeth pinkish

7. Pharynx Uvula Tonsils Posterior pharynx Midline Not inflamed No inflammation is present

8. Neck Trachea Thyroids Midline non-palpable

9. Skin General color Texture Turgor Tempareture Pallor Rough Firm warm

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease

10. Abdomen General Configuration Bowel sound Percussion Normal Symmetrical Hypoactive (3 clicks) Tympanitic

11. Cardiovascular Status Precordial area Point of maximal impulse(PMI) Apical & rhythm Heart sound Peripheral pulse Capillary refill bulging 3rd intercostal space Regular Regular Symmetrical & regular 2 seconds

12. Respiratory Status Breathing pattern Shape of chest Lung expansion Percussion Breath sound Regular AP1:L2 Decreased at the left side Resonant Crackles noted

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease IV. ANATOMY AND PHYSIOLOGY

Brain Structure

Function The outermost layer of the

Associated Signs and Symptoms

1. Cerebral Cortex

cerebral hemisphere which is composed of gray matter. Cortices are asymmetrical. Both hemispheres are able to analyze sensory data, perform memory functions, learn new information, form

Ventral View ( From bottom) thoughts decisions. 2. Left Hemisphere Sequential systematic,

and

make

Analysis: logical

interpretation of information. Interpretation production of and symbolic

information:language, mathematics, and reasoning. abstraction Memory

stored in a language format. 3. Right Hemisphere Holistic processing input Functioning: multi-sensory to

simultaneously

provide "holistic" picture of one's environment. Visual spatial skills. Holistic

functions such as dancing and gymnastics by the are right is

coordinated hemisphere.

Memory

stored in auditory, visual and spatial modalities. 4. Corpus Callosum Connects right and left Damage to the Corpus

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease hemisphere to allow for Callosum may result in "Split

communication between the Brain" syndrome. hemispheres. Forms roof of the lateral and third

ventricles. Cognition and memory. Impairment of recent

Prefrontal area: The ability memory, to concentrate and attend, inability to

inattentiveness, concentrate,

elaboration of thought. The behavior disorders, difficulty "Gatekeeper"; (judgment, in learning new information. of inhibition

inhibition). Personality and Lack emotional traits. Movement:

(inappropriate social and/or sexual behavior). Emotional

5. Frontal Lobe

lability. "Flat" affect.

Motor Cortex (Brodman's): Contralateral plegia, paresis. voluntary motor activity. Premotor Cortex: storage of motor patterns and Expressive/motor aphasia.

voluntary activities. Ventral View (From Bottom) Language: motor speech. Premotor ± selects

movements, selection and direction Side View sequences, behavior in of motor choose response to

clues, frontal eye fields.

Prefrontal (PFC) ± controls the cognitive processes so that appropriate movements are selected at the correct time and place

6. Parietal Lobe

Processing of sensory input, Inability

to

discriminate

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease sensory discrimination. between sensory stimuli. Inability Body orientation. to locate and

recognize parts of the body (Neglect).

Primary/ secondary somatic Severe Injury: Inability to area. recognize self. Disorientation of environment space. Inability to write. 7. Occipital Lobe Primary area. visual reception Primary Visual Cortex: loss of vision opposite field. Visual Association Cortex:

Primary visual association loss of ability to recognize area: Allows for visual object seen in opposite field of vision, "flash of light", "stars". 8. Temporal Lobe Auditory receptive area and Hearing deficits. association areas. Expressed behavior. Language: speech. Memory: retrieval. Information Agitation, irritability, childish behavior.

interpretation.

Receptive Receptive/ sensory aphasia.

Olfactory pathways: Amygdala and their different Agitation, loss of control of pathways. 9. Limbic System Hippocampi and emotion. their memory. Loss of sense of smell. Loss of recent

different pathways. Limbic lobes: Sex, rage, fear; emotions. Integration of recent memory, biological rhythms. Hypothalamus. 10. Basal Ganglia Subcortical nuclei. gray

matter Movement disorders: chorea, link tremors at rest and with

Processing

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease between thalamus and initiation of movement,

motor cortex. Initiation and abnormal increase in muscle direction movement. (inhibitory), reflexes. Part system: of extrapyramidal regulation of of voluntary tone, difficulty initiating

Balance movement. Postural Parkinson's.

automatic movement. 11. Thalamus Processing center of the Altered level of

cerebral cortex. Coordinates consciousness. and regulates all functional Loss of perception. activity of the cortex via the Thalamic syndrome -

integration of the afferent spontaneous pain opposite input to the cortex (except side of body. olfaction). Contributes expression. 12. Hypothalamus Integration Autonomic center of Hormonal imbalances. to affectual

Nervous Malignant hypothermia. to control

System (ANS): Regulation Inability of body temperature and temperature. endocrine function. Anterior

Diabetes Insipidus (DI).

Hypothalamus: Inappropriate ADH (SIADH). activity Diencephalic dysfunction:

parasympathetic

(maintenance function). Posterior Hypothalamus:

"neurogenic storms".

sympathetic activity ("Fight" or "Flight", stress response. Behavioral Physical behavior. Appestat: Feeding center. Pleasure center. 13. Internal Capsule Motor tracts. Contralateral plegia patterns: expression of

(Paralysis of the opposite side of the body).

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease

14. Reticular Activating Responsible System (RAS) from sleep,

for

arousal Altered

level

of

wakefulness, consciousness.

attention.

Spinal cord The spinal cord is about 18 inches long and is the thickness of your thumb. It runs within the protective spinal canal from the brainstem to the 1st lumbar vertebra. At the end of the spinal cord, the cord fibers separate into the cauda equina and continue down through the spinal canal to your tailbone before branching off to your legs and feet. The spinal cord serves as an information superhighway, relaying messages between the brain and the body. The brain sends motor messages to the limbs and body through the spinal cord allowing for movement. The limbs and body send sensory messages to the brain through the spinal cord about what we feel and touch. Sometimes the spinal cord to can the react brain. without These sending special

information

pathways, called spinal reflexes, are designed to immediately protect our body from harm. The nerve cells that make up your spinal cord itself are called upper motor neurons. The nerves that branch off your spinal cord down your back and neck are called lower motor neurons. These nerves exit between each of your vertebrae and go to all parts of your body. Any damage to the spinal cord can result in a loss of sensory and motor function below the level of injury. For example, an injury to the

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease thoracic or lumbar area may cause motor and sensory loss of the legs and trunk (called paraplegia). An injury to the cervical (neck) area may cause sensory and motor loss of the arms and legs (called tetraplegia, formerly known as quadriplegia).

Vertebral arch & spinal canal On the back of each vertebra body are bony projections that form the vertebral arch. The arch is made of two supporting pedicles and two arched laminae (Fig. 5). The hollow spinal canal contains the spinal cord, fat, connective tissue, and blood supply of the cord. Under each pedicle, a pair of spinal nerves exits the spinal cord and passes through the intervertebral foramen to branch out to your body. Surgeons often remove the lamina of the vertebral arch (laminectomy) to access and decompress the spinal cord and nerves to treat spinal stenosis, tumors, or herniated discs. Seven processes arise from the vertebral arch: the central spinous process, two transverse processes, two superior facets, and two inferior facets.

The Anatomy of the Lung Each lung is divided into lobes. The right lung, which has three lobes, is slightly larger than the left, which has two. The lungs are housed in the chest cavity, or thoracic by cavity, a and

covered

protective the

membrane

called

pleura. The diaphragm, the primary muscle involved in respiration, separates the lungs from the abdominal cavity. The pulmonary arteries carry de-oxygenated blood from the right ventricle of the heart to the lungs. The pulmonary veins, on the other hand, carry oxygenated blood from the lungs to the heart, so it can be pumped to the rest of the body.

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease V. PATHOPHYSIOLOGY

Predisposing Factors: Precipitating Factors: y y y Gender (male) Age ( 10 days old) Environmental factors (living near the mountains) LEGEND: y No full immunity against infection Predisposing Factors Precipitating Factors Disease Process Management Diagnostic Examination Exposure to the specific microorganism via droplet Signs and symptoms

Ingestion of bacteria via nasal cavity

Proliferates to the meninges through the bloodstream reaching the subarachnoid space

Infection spreads within the CSF

Activation of astrocyte and microlgia Descending proliferation of infection occurs

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease

Stimulates the release of cytokines Infectious Agent spread from the anterior aspect of vertebral body adjacent to the subchondral plate

Increase WBC in CSF

Increases blood- brain barrier permeability

Vasculity of cerebral vessels

Infection spread to the adjacent intervertebral disk X-ray revealed severe skeletal deformities are noted preextending proper chest structures

Inflammation of the meninges Fluid leakages from vessels and extends to the ventricles Decrease blood flow going to the CNS

Progressive bone destruction

Intermittent fever

Interstitial edema

Spinal canal can be narrowed by abscesses, granulation tissue of direct dural invasion kyphosis Collapse in the anterior spine

Head intends to get bigger

Increase ICP

Reached to the centrecephalic system Comatose (about a week)

Extended infections which causes Cranial compression

Brain shunting

Neuronal excitation from the epileptic focus spreads to the brainstem Uncoordinated movements were observed

Spinal cord compression and neurologic deficits

Decrease mobility of facial movements

Blindness and development of cataracts in both eyes

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease

Affects GI activity

Ascending infection occurs

Alters the functioning of the brainstem

1. amikacin 100 mg IVTT very 8 hours 2. clindamycin 1mg IVTT every 6 hours

Excessive production of HCl

Decrease peristaltic movement

3. cefepime I mg IVTT every 6 hours Alters the neuromuscu lar activity Decrease functioning of the epiglottis to close in the entry of food.

1. ET suctioning 2. Given Combivent I nebule via inhalation at HS

Blood-like coffe-ground vomitus

1. hypoactive bowel movement (3 clicks) 2. constipation

Entry of food/fluid within the respiratory premises

NGT insertion

Lodge in the lungs 1. famotidine 10mg IVTT BID 2. sucralfate 250mg IVTT at HS Inflammatory response of the body

1. Abnormal increase of WBC of 31, 000 1. Crackles heard upon auscultation 2. Fever of 37.7 C 2. Nonproductive cough

Language deficit, Uncoordinated gait, Jerky movements present, and Abnormal posture

Continuous proliferation of infection

Release of damaging toxins

Impairs the ciliary functioning

Production of copious secretion

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease VI. LABORATORY RESULTS

The laboratory test and diagnostic procedures indicates a very significant finding necessary for the care and prevention of particular disease which may occur in the clinical settings, here are the data as followed with interpretation.

Hematology Report (24/11/10) TEST Hgb 12.0 RESULTS REFERENCE VALUES 13.7-16.7 g/dL INTERPRETATION Decrease number of hemoglobin may indicate the existence of anemia. Hct WBC 36.0 22, 800 40.5-49.7 gm% 5,000-10,000 cell/mm3 Within the normal range. It is beyond normal range. Increase in the WBC count may indicate the presence of infection. DIFFERENTIAL COUNT: Segmenters 83.0 45-70% High number of segmenters would indicate existence of infection.

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease Lymphocytes 14.0 18-45% Low lymphocytes means that the patient is susceptible to infection. Monocytes 3.0 4-8% Decrease in the number of monocytes would indicate the susceptibility of the client in acquiring any form of infection. Platelet count 329, 000 144,000-372,000 cell/mm3 Within the normal range which connotes the clotting factor is good. RBC MCV MCH MCHC 4.05 77.8 25.3 32.6 4.7-6.1 10^6/uL 80.0-96.0 fL 27.0-31.0 pg 32.0-36.0% Within the normal range. Low MCV may indicate microcytic anemia. Indicate microcytic anemia Within the normal range.

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease Hematology Report (23/11/10) TEST Hgb 13.3 RESULTS REFERENCE VALUES 13.7-16.7 g/dL INTERPRETATION Decrease number of hemoglobin may indicate the existence of anemia. Hct WBC 40.0 31, 000 40.5-49.7 gm% 5,000-10,000 cell/mm3 Slightly decrease which suggest anemia. It is beyond normal range. Increase in the WBC count may indicate infection. DIFFERENTIAL COUNT: Segmenters 81.0 45-70% High number of segmenters would indicate existence of infection. Lymphocytes 14.0 18-45% Low lymphocytes means that the patient is susceptible to infection. Monocytes Platelet count 5.0 376, 000 4-8% 144,000-372,000 cell/mm3 Within the normal range. Within the normal range thus, the clotting factors is good.

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease RBC MCV MCH MCHC 4.85 78.0 25.5 36.0 4.7-6.1 10^6/uL 80.0-96.0 fL 27.0-31.0 pg 32.0-36.0% normal Low MCV may indicate microcytic anemia. Indicate microcytic anemia normal

PHILLIPS MEMORIAL HOSPITAL Hematology Report (23/11/10) TEST Hgb Hct WBC 15.6 47.0 26, 800 RESULTS REFERENCE VALUES 13.7-16.7 g/dL 40.5-49.7 gm% 5,000-10,000 cell/mm3 INTERPRETATION Within the normal range Within the normal range It is beyond normal range. Increase in the WBC count may indicate infection. DIFFERENTIAL COUNT:

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease Segmenters Lymphocytes 86.0 14.0 45-70% 18-45% Indicates viral infection Low lymphocytes means that the patient is susceptible to infection. Platelet count 260, 000 144,000-372,000 cell/mm3 normal

Culture Report (11/23/10) Specimen: Tracheal aspirate Preliminary Report:   Date: 11/27/10 Findings: organisms isolated, Yeast cells Germ Tube negative Specimen: blood Date: 11/25/10 Findings: no growth after 2 days of incubation

Grade: O Specimen: tracheal aspiration

Reference: RESULT GRADING NO. OF FIELDS EXAMINE More than 10 AFB Positive per oil immersion field 3+ 20

AFB Stain Report Date: 11/23/10 Result: negative

1-10 AFB per oil immersion fields

Positive

2+

50

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease 10-99 AFB in 100 oil immersion fields Positive 1+ y y y Polymorphonuclear cells: moderate Yeast cells: moderate Hyphal elements seen.

11/23/10 y y Specimen: tracheal aspirate Result: Gram (-) bacilli: few

X-ray report: 11/23/10 y Severe skeletal deformities are noted preextending proper evaluation of chest structures.

42

A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease
1

VII. DRUG STUDY DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG NURSING RESPONSIBILITIES/ PRECAUTIONS

INDICATIONS

Generic amikacin Brand Name: Amikin Classification: Anti-infectives Dosage: 100 mg Route: IVTT Frequency: hours

Name: Inhibits bacterial causing death.

production

of Treatment

of Hypersensitivity gram- aminoglycosides. bacillary and caused

to > CNS: ataxia, vertigo > EENT: ototoxicity > GU: nephrotoxicity > MS: muscle paralysis > Neuro: inc.

1.

Advise

patient¶s

SO

protein, serious bacterial cell negative infections infections by

about the importance of drinking plenty of fluids. Maintain hydration. 2. Patient¶s SO should be counseled that antibacterial drugs including Amikacin should only be used to treat > Resp: apnea > Misc: hypersensitivity reactions. bacterial infections. 3. Patient¶s SO should be told that the medication should be taken exactly as directed. adequate

staphylococci

when penicillins or other drugs contrsindicated. every 8 less toxic are

Neuromuscular blockade

Timing: 8am-1pm-6pm

42

A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG NURSING RESPONSIBILITIES/ PRECAUTIONS

INDICATIONS

Generic clindamycin Brand Name: Cleocin Classification: Anti-infectives Dosage: 2 mg Route: IVTT Frequency: hours Timing: 12nn-6pm

Name: Inhibits

protein Treatment of: Skin Hypersensitivity;

>

CNS:

dizziness, 1. Instruct patient to notify health care professional if diarrhea,

synthesis in susceptible and skin structure Prevoius bacteria at the level of infections, the 50S ribosome. Respiratory infections, Septicemia, abdominal infections, Osteomyelitis, Gynecologic every 6 infections, Endocarditis prophylaxis. 12mn-6ampseudomembraneous tract colitis; Intra- Known intolerance. Severe liver

headache, vertigo > CV: arrythmias,

immediately

hypotension

abdominal cramping, fever, or bloody stools occur and

impairment;

Diarrhea;

GI: not to treat with alcohol > pseudomembraneous antidiarrheals without colitis, diarrhea, bitter consulting taste, nausea, vomiting > Derm: rashes professionals. 2. Inform patient that bitter taste occuring with is IV not health care

> Local: phlebitis at IV administration site.

clinically significant. 3. Notify health professional if no improvement within few days.

42

A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG NURSING RESPONSIBILITIES/ PRECAUTIONS

INDICATIONS

Generic cefepime Brand Maxipime Classification: Anti-infectives Dosage: 1 mg Route: IVTT

Name: Binds to the bacterial Treatment of bone Patient w/ hypersensitive > CNS: fever, headaches cell Name: wall membrane, and joint infections. to drugs, cephalosporin, beta-lactam or penicillin antibiotics, > CV: phlebitis > GI: colitis,

1. Before giving drug ask patients if he/she is allergic to penicillin Obtain culture or and

causing cell death.

diarrhea, cephalosporin. ural 2. sensitivity test. 3. Adjust dosage in pt. w/

nausea, candidiasis > SKIN: uticaria > 6

vomiting,

rash, pruritus

renal function. 4. Monitor patients for super

OTHER:

pain infection.

inflammation, hypersensitivity Frequency:every hours Timing: 12nn-6pm 12mn-6amreactions anaphylaxis

42

A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG NURSING RESPONSIBILITIES/ PRECAUTIONS

INDICATIONS

Generic famotidine Brand Name: Pepcid Classification:

Name: Competitively

inhibits Short-term

Contraindicated

in >

CNS:

headache, 1.

Assess

patient

for

action of histamine on treatment the H2 at receptor sites duodenal ulcer. of parietal cells,

for patients hypertensive to dizziness, drug. malaise, vertigo. > CV:

fever, abdominal pain. Look for paresthesia, blood in emesis, stool or gastric aspirate. flushing, 2. Oral suspension

decreasing gastric acid secretion.

palpitations.

must be reconstituted and

H2 receptor antagonist Dosage: 10 mg Route: IVTT Frequency: BID Timing:

> EENT: orbital edema, shaken before use. tinnitus. > G.I.: 3. anorexia, oral diarrhea, below taste (30°C). 30 days Discard Store reconstituted suspension 86°F after

constipation, dry mouth,

perversion. > Musculoskeletal:

bone & muscle pain. > Skin: acne, dry skin.

42

A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) 1. Generic sucralfate Brand Name: Carafate Classification: Antiulcer agents Dosage: 250 mg Route: IVTT Frequency: at HS Timing: 8pm Name: Binds to the bacterial > cell wall Short-term There are no known > CNS: dizziness, membrane, treatment (up to 8 weeks) of active duodenal ulcer. contraindications to the drowsiness use of sucralfate. > GI: MECHANISM OF ACTION CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG NURSING RESPONSIBILITIES/ PRECAUTIONS

INDICATIONS

Advise patient that fluid intake,

increase

dietary bulk, and exercise constipation, may dry prevent drug-

causing cell death.

While healing with sucralfate may

diarrhea, gastic

mouth, induced constipation. examinations to monitor progress. 3. If antacids are also required for pain,

discomfort, 2. Emphasize the routine

occur during the first week or two, treatment should

indigestion, nausea > Derm: pruritus,

rashes

be continued for 4 to 8 weeks unless healing has been demonstrated x-ray endoscopic examination. by or

administer 30 min before or after sucralfate

dosage.

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG NURSING RESPONSIBILITIES/ PRECAUTIONS

INDICATIONS

Generic ipratropium

Name: Combivent bromide Solution combination

Inhalation is of a the

Indicated for use in Patients patients with chronic obstructive pulmonary

with

cardiac > CNS: nervousness, 1. restlessness,

Monitor

respiratory

tachyarrhythmias,

tremor, status; auscultate lungs before inhalation 2. Consult a doctor and after

and albuterol sulfate Brand Combivent Classification: bronchodilators Dosage: 1 nebule Route: inhalation Frequency: at HS Timing: 8pm Name:

hypertrophic obstructive headache, insomnia cardiomyopathy and > CV: chest pain,

anticholinergic bronchodilator, ipratropium and the bromide, beta2-

patients with a history of

disease (COPD) on hypersensitivity to any of a regular aerosol its components or to bronchodilator who atropine continue to have derivatives. of or

palpitations, hypertension

immediately in the event of acute, rapidly In

adrenergic bronchodilator, salbutamol sulfate.

its > GI: nausea, vomiting > Endo: hyperglycemia

worsening addition,

dyspnea. the

patient

evidence

should be warned to seek > F and E: hypokalemia medical advice should a > Neuro: tremor reduced 3. Rinse response mouth puffs after to

Ipratropium bromide is a ammonium quaternary derivative

bronchospasm and who second bronchodilator. require a

become apparent.

of atropine and is an anticholinergic drug

medication

reduce bitter taste.

42

A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease which bronchodilator properties. Salbutamol produces has 4. Do not allow the

solution/ mist to enter the eyes.

bronchodilation through stimulation of beta2-adrenergic receptors in bronchial smooth muscle, thereby

causing relaxation of muscle fibres. This

action is manifested by an increase in

pulmonary function demonstrated spirometric measurements.
1 2

as by

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease
1

VIII. NURSING CARE PLAN

ASESSMENT DATA (Subjective and Objective)

NURSING DIAGNOSIS (Problem and Etiology)

GOAL AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective: Intubated Objective: y

Ineffective clearance

Airway Short-Term Goals: related to Within 3-5 minutes

INDEPENDENT: of 1. Monitor respiration rate

Short- Term Goals: and Goals met. After 5 minutes of nursing intervention the patient

retained secretions in thorough the upper to Crackles heard upon secondary auscultation y respiratory and Inability to cough-out infection secretions y With tube Endotracheal attached to aspiration upper be able to: tract food y improve clearance evidenced absence diminished

nursing breath sounds.

airway intervention the patient will R ± To come up with a baseline was able to improve airway data. airway the head appropriate for age/condition airway. Goals met. After 8 hours of thorough nursing interventions 3. Elevate head of bed/ change the client was able to maintain Long-Term Goals: position every two hours and as the patency of the airways as manifested by and of normal effective copious clearance as evidenced by the absence and/or diminished

as 2. Assist client in positioning the adventitious sounds. by and/or R - To open or maintain open Long-Term Goals:

Mechanical

ventilator

adventitious sounds

with the following setup: TV= 200 FiO2= 40% BUR= 25

After 8 hours of the course needed. decreasing pressure

of duty, the client will be R - To take advantage of gravity respirations able to: on excretion

42

A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease PEEP= 3 cmH20 y Maintain patency airways manifested normal and of the diaphragm the mobilization and of enhancing secretions. for

y

restless

secretions

as easy expectoration in order to by promote ventilation to different respirations lung segments. effective Suction tracheal and oral secretions. R - To provide patent airway. 5. Increase fluid intake of the client appropriate to his age and disease condition. R ± It aids in the mobilization of secretion for easy expectoration.

excretion of copious 4. secretions.

DEPENDENT: 1. Administer combivent 1 neb at HS, as ordered. R - To loosen viscous secretions.
1

42

A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease

ASESSMENT DATA (Subjective and Objective)

NURSING DIAGNOSIS (Problem and Etiology)

GOAL AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Short- Term Goals: Subjective: y ³Luoy kayo akong anak kay dili jud siya kadagan-dagan parehas sa uban Delayed Growth and Short- Term Goals: INDEPENDENT: Goals Met. At the end of 2 At the end of 2 hours duty, 1. Determine existing condition(s) my patient¶s mother will be contributing able to: a. Verbalize understanding of to growth hours duty, my patient¶s Development related to effects physical/mental disability as evidenced by age altered physical of

mother was able to verbalize understanding growth/developmental of delay

developmental deviation, such as limited intellectual capacity, physical disabilities, chronic illness, genetic anomalies or substance abuse. R ± Basis for implementing plans.

bata´ as verbalized by the mother

growth appropriate for

or deviation her son and demonstrated modification of various activities appropriate for age.

growth/developmenta l delay or deviation

Objective: y y y y Altered physical growth Flat affect Listlessness Decreased Responses

her son b. Demonstrate modification various of activities

2.

Determine

nature

of

parenting/caretaking activities (e.g., Long- Term Goals: inadequate, inconsistent, Goals Met. At the end of 8 duty, my patient¶s unrealistic/insufficient expectations; hours

appropriate for age (i.e instead of

lack of stimulation, limit setting, mother was be able to initiate responsiveness) R ± To anticipate a interventions/lifestyle changes more promoting appropriate

running, patient can be assisted with

promotive intervention to client in development and maintained

42

A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease passive ROM) accordance to his age. modified activities which help in promoting gradual growth Long- Term Goals: 3. Assist/ demonstrate modified and development appropriate

At the end of 8 hours duty, activities suited for the client¶s age for the client. my patient¶s mother will be and disease condition. able to: a. Initiate interventions/lifestyle changes appropriate development b. Maintain modified promoting R ± To encourage and enhance development of the client. 4. Assist client¶s SO to accept and adjust to irreversible developmental deviatios. R ± To avoid giving of false assurance to family and most especially to the client.

activities which help in promoting gradual growth development appropriate for the client. and

COLLABORATIVE: 1. Refer for consultation of

appropriate professional resources specific to the client. R ± To address specific individual needs.

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease

ASESSMENT DATA (Subjective and Objective)

NURSING DIAGNOSIS (Problem and Etiology)

GOAL AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective:

Hyperthermia related to Short-Term Goals: altered

INDEPENDENT: Provide tepid

Short-Term Goals: sponge Goals. Met. After 4 hours of not nursing interventions, the

body After 4 hours of nursing 1. interventions, the client will bath(if

Intubated Objective: y y y skin warm to touch temperature of 37.7C flushed skin

thermoregulation

secondary to disease be able to: condition a. have axillary from 37.5°C b. Improve the a

contraindicated)

client was able to have a axillary 37.7°C to the

decreased R ± It provides coolness to body¶s decreased temperature surface. 37.7°C to 2. skin¶s skin Promote by means ventilation of temperature from 37.5°C and

improved

of skin¶s condition from warm to

undressing cool.

condition from warm R - Heat loss by radiation and to cool. Long-Term Goals: conduction 3. Promote client safety. Long-Term Goals: Goals Mt. After 8 hours of nursing interventions, the

After 8 hours of nursing R ± To avoid interference in client was able to maintain interventions, the client will improving of the nursing care to body temperature at a normal be able to: the client and it prevents further range complication. and free from

complications.

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease a. maintain temperature normal range. b. Free complications body DEPENDENT: at a 1. w/ Administer correct antipyretics pediatric

from dose (as ordered). R ± Inhibits the inflammatory response abnormal which increase causes in the

body¶s

temperature.

2. w/ R -

administer correct to

antibiotics dose

pediatric treat

underlying

cause(as ordered) COLLABORATIVE: 1. Instruct the mother to fluid not

increase intake

adequate (if

contraindicated). R ± To prevent further dehydration complications

causing

unto the client.

42

A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease

ASESSMENT DATA (Subjective and Objective)

NURSING DIAGNOSIS (Problem and Etiology)

GOAL AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective: Intubated

Impaired exchange related

Gas Short- Term Goals: to Within 1-2 minutes

INDEPENDENT:

Short- Term Goals:

of 1. Monitor respiration rate and breath Goals Met. Within 1-2 minutes the sounds. R - For baseline data. the of nursing intervention the

obstruction of mucous nursing Objective: y secretions Crackles heard upon to auscultation y respiratory tract and

intervention

secondary patient will be able to: a. Improve

patients was able to improve the patency of airways, of

infection

patency of airways

2. Position head appropriate for gradually

excreted

Inability to cough-out aspiration secretions

b. Gradual excretion of age/condition secretions c. Display

secretions and displayed and normal O2

R - To open or maintain open maintained and airway.

y y y

O2 sat= 72-75% restlessness With Endotracheal tube attached to Mechanical ventilator with the

saturation from 95-100%.

maintain normal O2 saturation from 95- 3. 100% Long-Term Goals: Suction tracheal and oral Long-Term Goals:

secretions to provide patent airway, Goals Met. After 8 hours of R To promote proper gas thorough nursing intervention

following set-up: TV= 200 FiO2= 40% BUR= 25

exchange, and to normalize the the client was able to maintain the patency of airways as manifested by respirations

After 8 hours of thorough O2sat. nursing intervention the

client will be able:

4. Keep suction materials like suction within the normal range as

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease PEEP= 3 cmH20 a. Maintain the catheters, gloves, and other well as the oxygen saturation and the absence of retained

y

Restless

patency of airways equipment patent and accessible. as manifested

by R - For emergency situation or secretions.

respirations

within during desaturation.

the normal range as well as the oxygen DEPENDENT: saturation and the 1. Administer combivent 1 neb at HS absence of retained R - to loosen viscous secretions. secretions.

42

A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease

ASESSMENT DATA (Subjective and Objective)

NURSING DIAGNOSIS (Problem and Etiology)

GOAL AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective: Intubated Objective: y Limited Motion y y Slowed movement Postural instability; gait changes Range of

Impaired mobility

physical At the end of 8 hours of INDEPENDENT: related to thorough nursing 1. Assist client reposition self on a regular schedule as directed by individual situation. a. Demonstrate techniques enable resumption activities b. Increase gradually that gradual of R ± To promote blood circulation.

Goals Met. At the end of 8 hours of thorough nursing

neuromuscular impairment

intervention, the client will

intervention, the client was able to demonstrate

secondary be able to:

to cerebral palsy.

techniques that enable gradual resumption of activities and

2. Support affected body parts and increased strength gradually keep the bed mattress free from and function of affected or wrinkles. R ± To reduce risk of premature compensatory body part.

strength ulcers. and 3. Provide skin care to include pressure care management. R ± To prevent further

function of affected or compensatory

body part.

complication brought about the immobility.

42

A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease

4. Schedule activities with adequate rest periods during the day. R ± To reduce fatigue. 5. Encourage adequate intake of fluids (as indicated) and nutritious foods (OF). RTo maximized energy

production.

COLLABORATIVE: 1. Refer with physical therapist, as indicated. R ± To develop mobility program.

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease

ASESSMENT DATA (Subjective and Objective)

NURSING DIAGNOSIS (Problem and Etiology)

GOAL AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Goals Partially Met. At the end Subjective: ³Gikan pa sa Martes hangtud karon sa Sabado wala pa jud sya kalibang´ as verbalized by the mother. Objcetive: y y Distended abdomen Hypoactive bowel movement (3 clicks) y Restless Constipation related to At the end of 8 hours of INDEPENDENT: insufficient activity physical thorough nursing 1. Determine fluid intake. R ± To evaluate client¶s hydration normal of bowel from 3 status. 2. Encourage gradual activity within limits of individual. R ± to stimulate contraction of intestines (peristalsis) 3. Provide privacy and routinely scheduled time for defecation. R - For the client response to urge. and DEPENDENT: 1. Administer laxatives, if indicated. R ± To soften stool for easy defecation. of 8 hours of thorough nursing intervention, the client was able to regain normal pattern of bowel movement from 3 clicks to 5 clicks behaviors and or

intervention, the client will be able to: a. Regain pattern

demonstrated

movement

lifestyle changes to prevent recurrence of problem but

clicks to 5 clicks. b. Demonstrate behaviors or lifestyle changes to prevent recurrence problem. c. Identify of

failed to identify and maintain bowel habit within his

preference.

maintain bowel habit within the client¶s

preference.

42

A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease

ASESSMENT DATA (Subjective and Objective)

NURSING DIAGNOSIS (Problem and Etiology)

GOAL AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Risk Factors: y y Visual problems (blind) Uncoordinated movement y Gait problems

Risk for falls

At the end of 45 minutes of thorough nursing intervention, the client¶s mother will be able to: a. Demonstrate measures to reduce risk factors and protect client from injury b. Modify environment as indicated to enhance safety c. Promote an injuryfree environment.

INDEPENDENT: 1. Provide health teaching to the Goals met. At the end of 45 Client¶s SO about the risk opf the minutes of thorough nursing client in falls and developing injury. R ± To provide about the intervention, the client¶s

essential mother was able to client¶s demonstrate measures to reduce risk factors and protect client from injury, modify

information situation.

2. Raising side rails. R ± To ensure safety 3. Placing pillows on both sides of the patient R ± To prevent from falls 4. Instruct client¶s SO never leave the child alone without companion.

environment as indicated to enhance safety and promote an injury-free environment.

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease R ± Because of the uncoordinated movements of the child, it may precipitate incidents of falls. COLLABORATIVE: 1. Assist In treatment and provide necessary information regarding

client¶s disease/ conditions R ± That may result in increased risk in falls.

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease IX. DISCHARGE PLANNING

MEDICATION: Encourage significant others to continue medications as prescribe by the physician. With a strict emphasis on explaining the mechanisms of action of the drugs, the prescribed dosage, side effects, proper timing of intake of drugs and importance of continuing the medications.

EXERCISE: Encourage significant others to have an gradual passive ROM to the patient because it will promote blood circulation and to improve muscle strength in order to promote total range of motion.

TREATMENT: Instruct the significant others to consult first the physician in anything that will help the patient in his conditions like physical activities that she must follow & most especially his diet. Encourage the significant others to compliance on further treatment for the proper maintenance and gain of optimal health.

HEALTH TEACHINGS: Importance to maintain proper personal hygiene.

Strict adherence to medications to promote wellness. Increase Importance of fluid proper intake nutritious to food help to liquefy maintain secretions healthy body.

Immediate report to the physician for any abnormalities to note any complications.

OUT-PATIENT: Compliance to medical check-up and therapeutic regimen to reduce or prevent risk of recurrence of the disease condition. Instruct patient to continue medications as prescribed.

42

A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease DIET: Suggest the the significant others to let the patient eat healthy foods because it helps the patient feel better and have more energy. Tell the significant others the importance of following diet and food restrictions. The patient may also consult to a dietary physician to know what are the correct dietary intake he must maintain.

SPIRITUAL: Advise patient to never forget to always pray to god. Always have faith and never lose hope because God is always with us no matter what.

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A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease X. RELATED LEARNING EXPERIENCE In our duty experiences in Capitol University Medical City we¶ve encountered so many things, though it was not out first time to affiliate in the institution, it was still a nerve-wracking experience for each and every one of us. It was really unexpected and was full of lessons that must be inculcated in our hearts and minds. First day of duty, it¶s a mixture of feelings. We were both excited and normal as we are; we were a little bit anxious. Though we have an idea what it feels like to be on duty at the ICU, it is still different in the actual setting. We learned so many things like procedures that we haven¶t done in the previous rotations. We were glad that finally had a chance to perform procedures like suctioning, tracheostomy care, ECG tracing and a lot of special procedures that we don¶t usually performed. In addition to that, we also got the basic knowledge on how to operate high technology devices commonly found and used in an ICU setting in preparation for the brighter future. We also have learning from our patients and their significant others. The Nurse-Client relationship had helped us a lot. Predominantly, we experienced so much fun with the fact that the environment is so conducive for both learning the much-a-nurse responsibilities of a nurse----- specifically ICU nurse. Our PCI¶s had helped us so much by guiding us and assisting us whatever procedures we are doing. Our CI is calm and cool! He somehow trusted us on our performance though we think on ourselves we can¶t do all of those things as perfectly as it is. And we would like to thank them for doing so. Mistakes are inevitable in life which is also true during the ICU rotation. Yes, we made different kinds of errors and we are all guilty for that but for those errors we¶ve learned a lot and gradually we are learning to improve our work in order to follow the mission of the nursing profession, which is to give care to the patient. We¶ve learn that not at all the times we will be perfect on what we will be doing, we¶ve learn that the patients admitted in the ICU are mostly confined due to vehicular accident and therefore strict monitoring is observed, thus, they need more attention and we need to be more careful in the provision of the care they needed. Being there was an easier rotation because you don¶t worry much of the I&O thing because they¶re using infusion pumps and usually doesn¶t require us to get the vital signs manually because of the cardiac monitor attached to most of the patients. In making this case study, it strengthens us and really proves that in everything that we do, learning is always there for us, waiting to be grasped and to be welldigested. I know for the fact that this study requires a lot of sacrifices and fortunately we did survive all the things we have done. My greatest felicitation and commemoration to our beloved Clinical Instructor, Mr. Camilo Rey ³Kit´ Pabito, RN, MN who gave us the

42

A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease motivation to be serious in the clinical area in order to promote the proper and appropriate care towards our patient. It was truly enjoyable because we have a clinical instructor who is very much approachable and mindful. Though we have ³life threatening patient´, he¶s still there to make some inspiring words and cheers for us (he usually does it *LOL*). He makes us calm when we get nervous and treated us like his children (I think much more of colleague µcoz he doesn¶t want to be the oldest in the group >oops<). We would like to extend our thanks to our PCI, Ms. Georgia Dawn Gacus and Mr. Dan Michael Canios who taught and gave us the inspiration to do things well. They did not just do things to comply with the requirements but have done it with passion and whole heartedly. We also appreciate the nursing staffs for attending to our inquiries properly whenever we have some clarifications. And last, we have learned the real value of being a student nurse that we should control our temper, our emotions while we are on our patient¶s side, we have to adjust to the environment where we belong. It is because we didn¶t know the feelings of the watchers and more importantly our patient. Patient must not be only a patient but he/she should be ³my/our´ patient. Thank you««««

42

A Case Study on Aspiration Pneumonia, Sepsis, Cerebral Palsy, Pott¶s Disease XI. REFERENCE BOOKS: y Doenges, M.E., Moorhouse, M.F., & Geissler, A.C, (2002). Nursing Care Plans Guidelines for Individualizing Patient Care, (6th ed.). Thailand y Doenges, M.E., Moorhouse, M.F., & Geissler, A.C (2006). Nurse¶s pocket Guide; Diagnoses, Prioritized Interventions, and Rationales. (10thed.). Philadelphia, Pennsylvania y Smeltzer, Suzanne C., RN, Edd, FAAN, & Bare, Brenda G., RN, MSN,(2004). Textbook of Medical-Surgical Nursing, (10th ed.), Philadelphia y Karch, Amy M. ; 2006 Lippicott¶s Nursing Drug Guide, 8th edition. Lippincott Williams & Wilkins. y Nurses¶ Pocket Guide, 10th edition F.A. Davis. y Nursing Care Plans, 7th edition F.A. Davis Doeuger, Moorhouse, Murr. y Patient¶s Chart y Black, Joyce M. et. al, Medical-Surgican Nursing: Clinical Management for Positive outcome. 7th edition. Philadelphia, W.B. Saunders. 2005 y Malseed, Roger T. ; Springhouse Nurses¶ Drug Guide 2004, 5th edition. y Davis drug handbook, 10th edition y Drug handbook by Saunders y Medical-Surgical Nursing (Clinical Management for Positive Outcomes) 8th edition By: Joyce Black and Jane Hokanson Hawks y Nursing Care of Infants and Children by Wong

INTERNET: y http://cpmcnet.columbia.edu/dept/gi/.html y http://digestive.niddk.nih.gov/ddiseases/pubs/_ez/ y http://www.angelfire.com/scifi2/lnuphysiology/Blood_Physiology_1.pdf y http://www.drstandley.com/labvalues y http://www.google.com.ph/search y http://www.google.com.ph/search?anatomy&meta= y http://www.merck.com/ l y rehydrate.org/diarrhoea/pdf/diarrhoea-abstracts.pdf y http://www.wpro.who.int/countries/2009/phl/health_situation.htm y www.cureresearch.com/c/cerebral_palsy/stats-country.htm?ktrack=kcplink y http://www.tuberculosistextbook.com/tb/tbchild.htm

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