West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City Vision: WVSU as one of the TOP TEN

universities in Southeast Asia by 2015. Mission: To produce globally competitive individuals who are life-long learners. Core Values: S - Service H – Harmony E – Excellence PEDIATRIC NURSING PROCESS I. VITAL INFORMATION Name of Child: K.L.C. Name of Informant: R.C. Sex: Female Relationship with the child: Mother Date of Birth: 08/04/95 Age: 13 years old Address: Brgy. Malugsod, Dueñas, Iloilo Date and Time Admitted: 08/09/08 @ 4:00 pm Chief Complaints: “Gin-convulsion siya nga naglawig mga pulo ka minutos.” Ward: PSW-B Religious Affiliation: Roman Catholic Name of Mother: R.C. Educational Attainment: 3rd year high school Age: 48 years old Occupation: none Name of Father: N.C. Educational Attainment: 3rd year high school Age: 49 years old Occupation: Farmer, carpenting Approximate Monthly Income of the Family: a.) Mother – N/A b.) Father – Php 9000-9500 c.) Others – Php 2000 ( Patient’s uncle) TOTAL Php 11000-11500 Physician: Dr. G. Impression/Diagnosis: Status Epilepticus Pre-op Diagnosis: N/A Post-op Diagnosis: N/A I. CLINICAL ASSESSMENT A. Nursing History Usual Health status “Halin sang gamay siya, sang 3 years old pa lang, gina-convulsion na siya nga da-an. Ga turong gid na iya mata pero mga segundo man lang ang kalawigon. Sang nagadako siya, daw gasige-sige na, halos kada adlaw na gani ang atake niya. Kun mabug-atan, makulba-an kag kun grabe iya hulag, amu gid na siya atakihun. Gamay ni siya dayon pakan-on kay medyo pisli-an. Kun masobrahan gani ka gutom, gina atake man siya. Ginapapahuway man lang siya namun tapos ginahilot-hilot ang likod sang iya li-og.” As verbalized by patient’s mother. Chronologic story When K.L.C. was 2 years old, a small vase fell in her head (exact location unrecalled). K.L.C. then lost consciousness. She regained her consciousness a few minutes later. No medical check-up made after the incident. 9 years prior to admission, 1998, K.L.C. experienced episodes of seizure attack characterized by crying, upper rolling of eyeballs and involuntary muscle jerking which lasted for

about 30-40 seconds. Parents did not seek any medical help. Episodes of seizure attack of same symptoms continued with approximately 5-6 days interval. Still, parents did not seek medical help. Instead, they just massage the lower portion of the neck and let the patient rest. In year 2000, patient had a seizure attack characterized by change in lost of consciousness, stiffening of the body and upper rolling of eyeballs which lasted for almost 3 minutes. “Daw nag grabe iya atake tapos medyo mas dugay siya komparar sa mga na una ya nga convulsion. Amo ‘to gindali-dali dala sa Western.” As verbalized by the mother. An EEG was done and the mother claimed that the result showed an impinged vessel. Unrecalled anticonvulsant meds were given and monthly check-up was advised. K.L.C. complied with the prescribed meds and medical check-up for 4 months only. There was a noticeable decreased in frequency of seizure attacks with 3-4 weeks interval. The mother stated “ Daw kamahal na gid ya galing sang bulong, amo ‘to gin-untatan na lang namun.” Thus, the seizure attacks recurred with 5-6-day interval. If the patient would feel hungry or tired, a seizure attack would occur which would last for seconds. The patient would complain of dizziness thereafter. Rest and massage in the neck were again the management of folks after the attack. 1 month prior to admission, July 2008, there was an increase in frequency of seizure attacks (4x weekly). 2 days prior to admission, K.L.C. experienced episodes of seizure attack which lasted for 5 hours within 5-minute interval with no febrile episodes or difficulty of breathing. A day prior to admission, seizure attacks continued which lasted for 10 minutes with seconds interval and K.L.C. was admitted in Iloilo Provincial Hospital. K.L.C. was then referred to WVSU-MC for further treatment. Thus, last August 9, 2008, K.L.C. was admitted in WVSU-MC, PSW-B. Past Medical History Parasitism____________ Tuberculosis____________ Anemia____________ AGE____________ Measles 8 years old Seizure since 3 years old AGN____________ BPN____________ Emotional Disorder____________ Allergy none Accidents (specify) ______ Others: No. of Previous Hospitalizations: 1 Date of Last Confinement: August 8, 2008 Where: Iloilo Provincial Hospital Reasons for Confinement: seizure attacks Family History Birth order of Patient: 5th Total no. of siblings: 8 No. of living siblings: 8 Serious diseases/illnesses of siblings: none Cause of death/serious illnesses of siblings: N/A Heredo-familial diseases: (state relationship with patient) Tuberculosis_________________ Hypertension__________________ DM________________________ Cancer________________________ Asthma_____________________ Genetic Disorders (specify)________ Others (specify)

Maternal and Prenatal History Maternal age when child was born: 35 years old Age of Gestation and Birth Weight Preterm Full-term Postterm TYPE OF DELIVERY Unrecalled / Home Attendant/Mid wife / Hospital

Spontaneous Caesarian Section/Forceps (specify reasons)

Complications related to pregnancy: None as claimed by mother Parental views of pregnancy: “Para sa amon, gapasalamat gid kami kay nadugangan ang kalipay nga ginhatag sang Diyos sa amun.” as verbalized by the mother. Patient’s problem: (1st month): None as claimed by the mother. Child’s ability to get along with people as viewed by parents: “Medyo supladahun ni siya. Naspoiled da-an ni lola ya pero ma-ayo man siya makisama sa iban ya nga utod kag mga miga ya.” as verbalized by the mother. Early behavior patterns as viewed by parents: “ Gamay-gamay lang ni nga akig sa iya, ga sunggod siya dayon. Amo na daw indi gid siya ma-akigan gawa. Sang gamay siya da-an kun ano gusto ya, ginahatag dayon ni lola ya.” As verbalized by the mother. Parent’s attitude towards rearing: K.L.C. was brought up by her grandmother. Usually the grandmother was in charged in disciplining her. As verbalized by the mother, “Na-spoiled gid ni siya ni lola ya.” II. PATTERNS OF FUNCTIONING Nutritional History and eating Patterns Meal Breakfast Morning snacks Lunch Dinner Type and Amount of foods usually taken ½ cup steamed rice, 1 bowl of noodles 1 pack of Cheese Curls, 1 bottle of softdrinks 1 cup steamed rice, 1 pc. fried fish 1 cup steamed rice, 1 bowl of noodles, 1

pc. chorizo Food likes: Cheeze Curls, fried chicken, “lumpia” Allergies: None Problems related to nutrition: none Elimination Patterns Frequency Bowel Movement Urination Twice a day 4x a day Problems/Difficultie s none none Usual Remedy N/A N/A

Toilet Training Age in Month s Starte d 3 years old Found in Textbook As seen in the patient and/or verbalized by significant person As recalled by the mother, “ Indi na na siya magpa-upod sa banyo kun daw mamus-on siya. Siya lang na dayon ga-uba sang iya nga panty.” Significance

Bowel:

Toilet training must start during toddler years or when the child has already the capacity to heed instructions.

This was normal because K.L.C. was in the right age to be toilettrained.

Bladder: 3 years old

Sleeping Patterns Usual Patterns Bed time Waking time Usual Time Approximat e total no. of sleep/24 hours 9 hours Sleeping Arrangemen t K.L.C. sleeps at the side of her younger sister Special Rituals none Problems with Sleeping none

8:30-9:00 pm 6:00-6:30 am

Immunization Status Type BCG DPT OPV Hepa B Measles/MMR 1st dose / / / Age unrecalled unrecalled unrecalled 2nd dose / / Age 3rd dose / / Age

unrecalled unrecalled

unrecalled unrecalled

Play a.) Appropriateness of available toys: K.L.C. is fond of playing chinese garter, jackstones and cell phone games with her playmates. These toys are appropriate for her age since her choice of games is competitive in nature. b.)Availability and safety of play areas: K.L.C. usually plays within her school campus. Her mother stated, “ Daw tawhan man ang ila eskwelahan kag malapad man ang lugar nga pwede ya hampangan.” c.)Favorite toys and activities: -chinese garter -jackstones -texting -watching TV d.)Child initiative and amount of creative play: “Kun wala bi klase, siya gid ni gapanghagad sa mga utod ya kag sa mga taga pihak balay nga maghampang” as verbalized by the mother. Preferred play: Solitary: ____ Competitive:_/__ Parallel: _____ Cooperative: ____

Peer interaction: “Palahampang ni siya sa mga kilala ya lang galing nga ka-edad ya.Indi man siya pala-away pero amo lang na eh, kun indi ya makwa gusto ya, masinuplada na siya.” As verbalized by the mother.

Current Development Assessment AREAS Gross Motor AGE OBSERVATIONS FOUND IN TEXTBOOKS In adolescence stage the development of locomotion skills is achieved. One is able to walk and has good coordination and equilibrium. In this stage, one can walk up and down the stairs, can jump using both feet, can stand on one foot, walk on tiptoe, and climb upstairs with alternate footing. ACTUAL OBSERVATION “Wala man siya problema sa iya, normal man siya maglakat, wala man siya gakadasma. Luwas lang kung akigan ko siya, madalagan na siya kag magkandadasma.” As verbalized by the mother. SIGNIFICANCE

Fine Motor 12 y.o.

Demonstrated in increasingly skillful manual dexterity. Improved flexibility and coordination; plays musical instrument.

Sensory 12 y.o.

Vision is 20/20.

Psychosocial 13 y.o. (Role identiy vs role confusion)

Psychosexu al Genital Stage

13 y.o.

The development of “babae gid siya ya, identity is macrush sa gain nga characterized by classmate man niya. rapid and marked Ang mga upod niya physical changes. pirme maghampang Previous trust in mag babae man nga their bodies is ara sa piyak balay shaken, and children namon.” As become overly verbalized by the preoccupied with mother. the way they appeared in the eyes of others as compared with their own self-concept. Adolescents struggle to fit the roles they have played and those they hope to play with the current roles and fashions adopted by their peers, to integrate their concepts and values with those of society. Genital Stage: The last significant stage begins at puberty with maturation of the reproductive system and production of sex hormones. The sexual organs become the major

source of sexual tensions and pleasures, but energies are also invested in forming friends.

Spiritual 13 y.o.

Cognitive 13 y.o.

Individuatingreflexive: Adolescents become more skeptical and begin to compare the religious standards of their parents with those of others. They attempt to determine which to adopt and incorporate to their own set of values. They also begin to compare religious standards with scientific viewpoint. It is a time of searching than reaching. Adolescents are uncertain about many religious ideas but will not achieve profound insights until late adolescence or early adulthood. Formal operations: formal operational thought is characterized by adaptability and flexibility. Adolescents can think in abstract terms, use abstract symbols, and draw logical conclusions from a set of observations. They can consider abstract, theoretic, and philosophic matters. Although they may confuse the ideal with the practical, most contraindications in the world can be

dealt with and resolved.

Moral 13 y.o.

Language and Speech

12 y.o.

Younger children merely accept the decisions or part of view of adults, adolescents, to gain autonomy from adults, most substitute their own set of morals and values. Their decision involving moral dilemmas must be based on an internalized set of moral principles that provides them with the resources to evaluate the demands of the situations and to plan actions that are consistent with their ideals. Increase level of comprehension. Vocalizations are intelligible. Uses multi word sentences. Speech is understandable. Has mastery of grammatical rules.

V.

PRESENT MEDICAL HISTORY A. Measurements: Weight: _40_kg B. Clinical Inspection Date and Time Taken: August 27, 2008 Vital Signs: Temperature: _37.2˚C per axilla__________ minute______ Respiratory Rate: _21 breaths per minute__ mmHg_______ Pulse Rate: _76 beats per Blood Pressure: _110/70 Height: _150 cm.

VI.

PHYSICAL ASSESSMENT General Appearance: Appears restless, irritable, and disheveled. Easily cries when approached. Has strong tenseness and rigid movement. Does not follow through with directives. Does not observe eye contact. Presence of four point restraints on right and left hands and right and left feet, attached to bed frame.

A. Integumentary System Skin is brown in color. It is soft and warm to touch. When pinched at the abdomen, it returned in one second, which indicated good turgor. Reddish, dry, scattered lesions on right forearm, approximately 2 cm. in diameter. Wound with pus draining on right ankle of 2 cm. in diameter and 1 mm. in depth. Moderate dandruff noted on hair, as well as lice and nit infestations. Nails are not well-trimmed and cleaned. Nail beds are pink and firm. No clubbing or beau lines. Neurologic System / EENT Conjunctivae are pale. Anicteric sclerae without increased vascularity. Irises uniformly black in color. Nares patent. Nasal septum is at midline.

CRANIAL NERVE
I OLFACTORY

HOW ILICITED
Cologne will be held under one nostril with the other occluded while the client is closing her eyes. Repeat with the other nostril. Newspaper or nameplate will be held 14 inches away from the eyes. Ask client to look straight ahead and approach each eye from the client’s side with a penlight. Ask client to look straight ahead, covering one eye with a cover card and observe uncovered eye for movement. With closed eyes, touch forehead, cheeks and chin with the tip of cotton applicator and broken stem of cotton applicator. Ask client to follow examiner’s finger as it moved in six cardinal fields. Ask client to smile, frown, purse lips, blow

NORMAL RESPONSE
Identifies scent correctly with each nostril. Reads clearly, without difficulty. Pupils equally round and reactive to light and accommodation. Uncovered eye does not move as opposite eye is covered.

PATIENT’S RESPONSE

Not assessed.

II OPTIC III OCULOMOTOR

Not assessed. Pupils constrict upon illumination of penlight.

IV TROCHLEAR

Not assessed.

V TRIGEMINAL

Identifies light touch, dull, and sharp sensations. Both eyes move in a smooth, coordinated manner in all directions. Follows instructions accurately.

PRESENT

VI ABDUCENS VII FACIAL

PRESENT No facial anomalies.

out cheeks, and raise eyebrows. VIII ACOUSTIC IX GLOSSOPHARYN GEAL X VAGUS Let patient taste sugar. Whisper a word 1 foot behind the client. Touch back of tongue with tongue depressor to test for gag reflex. Ask client to open mouth and say “ah”. Ask client to shrug shoulders against examiner’s hands. Ask client to turn head against examiner’s hand. Ask client to protrude tongue and move it to each side against tongue depressor.

Able to discern sweet taste. Able to repeat the whispered word. Brisk response as if to expel tongue depressor from mouth. Uvula elevates upon phonation. Symmetrical, strong contraction of trapezius muscles. Strong contraction of sternocleidomastoid muscle on opposite side that head is turned. Symmetrical tongue with smooth outward movement and bilateral strength.

Not assessed. PRESENT Gag reflex present. PRESENT

XI SPINAL ACCESSORY

Able to turn head to sides against hand.

XII HYPOGLOSSAL

PRESENT

B. Respiratory System Respiratory patterns are even and unlabored. No use of accessory muscles upon respiration. Deep inhalation and shallow expiration. Usual respiratory rate is 20 breaths per minute. Clear breath sounds ascultated on all lung fields. C. Cardiovascular / Circulatory System Apical of 76 beats per minute. Palpable right and left radial and posterior tibi al pulses. It is not thready nor bounding. Regular in rhythm. Clear, brief heart sounds throughout. No murmurs. D. Genito – urinary System Pubic hair sparsely distributed. Voids freely to a clear, yellowish urine with an amount of 400 cc per diaper. Consumes 3 diapers per day. E. Gastrointestinal System Canker sore of approximately 2 cm. on lower lip. Buccal mucosa is pink and dry. Pinkish gums. Papillae present on tongue and midline fissure present. Abdomen is flat. Umbilicus is midline. F. Reproductive System Breasts are bilaterally symmetrical. Areolae are light brown. No discharges on both nipples. G. Endocrine System No swelling and tenderness of thyroid gland. No excessive sweating. Equal body hair distribution. H. Musculoskeletal System Full ROM of the arms and legs. Hand grip is strong. Brief voluntary muscular jerking of both extremities. Generalized tensed movements. I. Lymphatic System

Thyroid and cervical lymph nodes are not assessed. No presence of swelling. Neck is symmetrical and can rotate freely. J. Hematopoietic System Capillary refill of 1 second. No bruising.

VII. LABORATORY AND DIAGNOSTIC PROCEDURES 1. CLINICAL CHEMISTRY Name of Examination: Serum Electrolytes • Definition:

Sodium is the most abundant cation (90% of the electrolyte fluid) and the chief base of the blood. Its primary functions in the body are to maintain osmotic pressure and acid-base balance chemically and to transmit nerve impulses. Potassium is the principal electrolyte (cation) of the intercellular fluid and the primary buffer within the cell itself. 90% of potassium is the blood by damaged cells. Creatinine is a nitrogenous waste product each day, which is related to the muscle mass, seldom changes rapidly. Creatinine is eliminated from the body by the kidneys. Calcium is an important cation found, predominantly in bones and teeth, combined with phosphate and carbonate. This combination, deposited in bony tissue, provides the mineralization and resulting strength of the skeleton. The remaining 10% of the body calcium is found in the blood serum and is essential for normal functioning of neuromuscular tissue, cardiac activity and the coagulation of blood.

• o • o o

Purpose It is used to indicate acid-base balance and hydration status. Preparation Inform the client about the reason why the specimen was ordered, how is to be collected, the equipments needed and the stinging sensation that may be felt. Foods and fluid are usually not restricted before the collection of the specimen. Specimen Venous blood collected in a collecting tube or syringe. Results 8/9 8/14 139.9 mmol/L 3.57 mmol/L

• o

Normal Values

Significance of Abnormal Results Within normal range Within normal range

Serum Sodium Sodium Potassium Serum Calcium

146.4 mmol/L 3.76 mmol/L 2.62 mmol/L 72.48 µmol/L

135-148 mmol/L 3.5-5.3 mmol/L

-

2.18-2.68 mmol/L

Within normal range

Serum Creatinine

-

20-40 µmol/L

Increased. UTI

2. HEMATOLOGY Name of Examination: Complete Blood Count (CBC)

Definition: Complete blood count a screening test, is one of the most frequently ordered laboratory procedures. It is a group of tests that includes the hemoglobin, hematocrit, and red blood cell (RBC) count, white blood cell (WBC) count, differential white blood cell count, red cell indices and stained cell examination (peripheral blood smear). A platelet count may also be included in CBC.

Hematocrit is a measurement of the percentage of red cells in the total volume of blood. It is expressed in the percentage of red cells in the total blood volume.

Red blood cells are produced by erthyroid elements in the bone marrow. Under the stimulation of erythropoietin, RBC production is increased. Within each RBC are molecules of hemoglobin that permits the transport and exchange of oxygen to the tissues and carbon dioxide in tissues.

Hemoglobin is the main component of red blood cells. Its main function is to carry oxygen from the lungs to the body tissues and to transport carbon dioxide, the product of cellular metabolism, back to the lungs. Another function of hemoglobin is to act as a buffer to help maintain acid-base balance.

White blood cells (WBC) are produced in red bone marrow and lymphatic tissue. After they are formed they enter the blood, which transport them to the parts of the body where they are needed to defend against invading organisms through phagocytosis and produce or antibodies to help maintain immunity.

Neutrophils which constitute 55%-65% of white of the total number of white blood cells. The protective function of neutrophils includes phagocytosis. Foreign particles are degraded, and pyrogens are released that produce fever by acting on the hypothalamus to set the body’s thermostat at higher level.

Eosinophil constitutes 1% to 3% of the total number of white blood cells. Their protective function is not fully understood. They play a role in allergic reactions, possibly inactivating histamine.

Platelets, also called thrombocytes, are large, non-nucleated cells derived from the megakaryocytes produced in the bone marrow. Two-thirds are found in the blood and one-third in the spleen. One-tenth of the platelets found in the blood maintain endothelial integrity and the rest are available for homeostasis. The adhesive or sticky quality of platelets allows them to clump together or aggregate and adhere to injured surface. Along with fibrin, they form the network for a clot to form.

• o

Purpose It determines the number, variety, percentage, concentrations, and quality of blood cells. It provides information about the hematologic and other body systems, prognosis, response to treatments, and recovery. Preparation Inform the client about the reason why the specimen was ordered, how is to be collected, the equipments needed and the stinging sensation that may be felt. Foods and fluid are usually not restricted before the collection of the specimen. Instruct the patient to remain still and to hold the arm extended either resting flat on bed on supported firmly during specimen extraction. Specimen 5-10 mL sample of venous blood collected in a tube or syringe.

• o o o • o

Results 8/9 Hemoglobin mass concentration Erythrocyte volume fraction erythrocyte number concentration leukocyte number concentration Neutrophil 106 8/13 133 8/22 110

Normal Values

Significance Abnormal Results Decreased on 8/9. Hemoglobin is the main component of RBC. Slight decrease of Hgb and erythrocytes (RBC) indicate nutritional deficiency. Stress. Within normal range

120-173 g/L

0.32

0.41

-

0.35-4.9 L/L

3.81

4.82

3.96

3.7-5.3 x 1012/L

12.4 0.86

9.0 0.92

10.8 0.10

6.2-17.0 x 109/L 0.50-0.70

Within normal range Increased due to infection such as Urinary Tract Infection. Acute bacterial infection and trauma stimulate neutrophil production. Decreased. Increased. Within normal range

Segmenter

0.83

-

-

0.50-0.70

Lymphocytes Eosinophil Platelets Protime

0.13 0.07 232 sec

0.08 220 sec

281 -

0.20-0.40 .01-.04 200,000473,000/cu mm 100%

INR APTT

1.36 28.7

0.95 -

-

3. URINALYSIS • Definition: A urinalysis involves multiple routine test of urine specimen. It includes remarks about the color, appearance, and odor of the urine. The pH is also determined. The urine is tested for the presence of proteins, glucose, ketones, blood and leukocytes esterase.

Urine is a clear, amber-colored fluid that is approximately 95% of water and 5% of dissolved solids. The kidneys normally produce approximately 1.5L of urine each day. Normal urine contains metabolic wastes and few or no plasma proteins, blood cells, or glucose molecules.

The pH of the urine indicated the acid-base balance of the patient.

Specific gravity is a measure of concentration of particles including waste and electrolytes in the urine. Specific gravity refers to the weight of urine compared with that of distilled water. It is used to evaluate the concentrating and excretory power of the kidney. It is also the measurement of hydration status of the patient.

Urine specimens that have been left standing may contain lysed red blood cells, disintegrated casts, and rapidly multiplying bacteria.

Casts are molds of the distal nephron lumen. A gel like substance called tamhorsfall mucoprotein, which is formed in the tubular epithelium, is the major protein constituent of urinary casts. These develops when protein concentration of the urine is high, urine osmolality is high. And urine pH is low.

Purpose It is used to evaluate the patient’s urine for renal or urinary tract disease. It is also to help detect metabolic or systemic disease on related to renal disorders and to detect substance use. o o Preparation Instruct the patient about the type of specimen needed and the best time to collect it. (early morning urine)

o o • o

Inform client to collect the midstream urine about 30cc. The container should be labeled with the patient’s name, date, and the type of the specimen. Specimen 30cc of midstream urine collected in a specimen container.

Component Physical Properties Color Transparency Reaction (pH) Specific Gravity Chemical Tests Sugar Albumin Microscopic Findings Pus Cells

Results 8/13 Pale Straw Slightly Hazy Acidic (6.0) 1.025 negative negative 8/26 Straw

Normal Values Clear - Straw Clear-Slightly Hazy 4.6-8.0 1.005-1.030

Significance of Abnormal Results Within normal range

Hazy Acidic (6.5) 1.025

Within normal range Within normal range Within normal range

negative negative

Trace - None Trace - None

Within normal range Within normal range Increased. Pus cells in the urine indicates Urinary Tract Infection. Increased. Any distruption in the blood-urine barrier, whether at the glomerular, tubular or bladder level, will cause RBC’s to enter the urine. Significance Abnormal Results Within normal range

2-5

0-3

0-1/hpf

RBC

2-7

0-2

0-1/hpf

Results 8/13 Cast Crystals Amorphous Squamous Epithelial Cells Round Epithelial Cells UratesFew Few Few Occasional Few None 8/26 -

Normal Values Trace - None

Trace - None Trace - None Trace - None

Within normal range Within normal range Within normal range

Yeast Cells

-

Occasional

Trace - None

Within normal range

4.

Blood Culture and Sensitivity Date Taken: 8/17/08 Definition A blood culture and sensitivity test is used to identify the microorganisms causing the infection. The culture is then subjected into antibiotics to identify which one is the most effective treatment and which one is not. • o o o • Preparation Blood culture should ideally be obtained before any antibiotic therapy. Cleanse skin first before obtaining specimen NPO status not required. Specimen : Blood Klebsiella Species Potency ug/disc 30 10 25 30 30 30 30 30 30 30 30 30 5 25 15 30 10 30 30 300 10 * * * * * * * * * * * * * * * Culture Isolate: Moderate-Heavy Growth of •

Generic/Brand Name Amikacin Ampicillin Amoxicillin Augmentin Cefaclor Cefamandole Ceftazidime Cefotaxime Ceftriaxone Cefuroxime Cephalexin Chloramphenico l Ciprofloxacin Cotrimoxazole Erythromycin Gentamycin Imepenem Nalidixic Acid Netilmicin Nitrofurantoin Norfloxacin

Sensitive

Intermediate Sensitive

Resistant * * * * * *

Piperacillin Tazobactam Meropenem Tetracycline

10/75

*

30

*

Interpretation Of the drugs the bacteria Klebsiella was subjected to, only chloramphenicol, cotrimoxazole, ceftazedime, and piperacillin tazobactam were considered effective in treating it. Out of these drugs, Chloramphenicol was chosen over the others because it was the cheapest of the group.

5.

Name of Examination: ARTERIAL BLOOD GAS ANALYSIS Date Taken: August 9, 2008 Measurement of ABGs provide valuable information in assessing and managing a patient’s respiratory (ventilation) and metabolic (renal) acid/base and electrolyte homeostasis. It is also used to monitor patients on ventilators, critically ill nonventilator patients, establish pre-operative baseline parameters and enlighten electrolyte therapy. Definition: pH – hydrogen ion concentration, is a measure of alkalinity (>7.4) and acidity (<7.35) of the respiratory and metabolic aspects. PCO2 – is a measure of the partial pressure of CO2 in the blood. It is a measurement of ventilation capability. The faster and more deeply one breathes, the more CO2 is blown off and PCO2 levels drop. Therefore, PCO2 is referred to as the respiratory component in the acid-base determination because they are primarily controlled by the lungs. HCO3 – bicarbonate ion or CO2 content. It is a measure of the metabolic (renal/kidney) component of acid-base equilibrium. This ion can be directly measured by the bicarbonate value or indirectly by the CO2 content. PO2 – this is an indirect measure of the oxygen content of arterial blood. PO2 is a measure of the tension (pressure) of oxygen dissolved in plasma. O2 saturation – is an indication of the percentage of hemoglobin saturated with O2. When 92% to 100% of the hemoglobin carries O2, the tissues are adequately provided with O2 assuming normal O2 dissociation.

Base Excess/Deficit – it represent the amount of buffering anions in the blood. Base excess is a way to take all these anions into account when determining acid-base treatment based on the metabolic component. Base deficit indicates a metabolic acidosis and otherwise. Preparation: • • • Explain procedure to patient Perform Allen’s test to assess collateral circulation. Cleanse arterial site

Specimen: Arterial blood obtained from any area of the body where strong pulses are palpable. Usually from the radial, brachial, or femoral artery. Compon ent pH PCO2 HCO3

Result 7.409 32.4mmHg 20.3meq/L

Normal Values 7.35-7.45 35-45 mmHg 21-28meq/L

Significance Normal Decreased due to Decreased due to lactic acidosis, a form of metabolic acidosis experienced by status epilepticus patients Increased due to Normal

PO2 O2 Sat

173mmHg 99.6%

80-100mmHg 95-100%

6.

Name of Examination: CRANIAL TOMOGRAPHY OF BRAIN Definition: CT scan of the brain consists of a computerized analysis of multiple tomographic xray films taken of the brain tissue and its successive layers, providing a threedimensional view of the cranial contents. CT scan is used in differential diagnosis of intracranial neoplasms, cerebral infarctions, ventricular displacement or enlargement, cortical atrophy, cerebral aneurysms, etc. Preparation: • • • • Explain the procedure to the patient. Cooperation is necessary since the patient is required to lie still during the examination. Lessen patient anxiety by showing him/her the machine first and encouraging to verbalize concerns. NPO status for 4 hours before the study if oral contrast medium is used. Remove hairpins, wigs, or any other hair clips and paraphernalia in the head.

Date Taken: August 12, 2008

Result: • • • • Plain and contrast-enhanced axial tomographic sections of the head revealed no evident focal parenchymal mass or abnormally-enhancing lesions. The ventricles are unenlarged. The cerebral sulci and cisterns are unaffected. No abnormal extra-axial fluid collagen demonstration

The posterior fisa, brainstem and sellar region are unremarkable. • • 7. The petromastoids, included orbits, paranasal sinuses and bony calvarium appear unremarkable. Impression : Normal Cranial Study.

Name of Examination: CHEST X-RAY Definition: The chest x-ray film is important in a complete evaluation of the pulmonary and cardiac systems. Much information can be provided by the chest xray film such as identification of: • • • • • • • Tumors Inflammation Fluid and air accumulation Fractures of the bones in the thorax Diaphragmatic hernia Heart size Location of centrally placed intravenous access devices.

Preparation: • • • • • • Explain procedure to the patient No fasting is required Instruct patient to remove clothing to waist and to put on an x-ray gown. Inform patient to remove all metal objects or accessories so as they won’t block the visualization Instruct patient that he or she will have to take a deep breath and hold it while the x-ray films are being taken. Instruct men to cover their testicles and women to cover their ovaries using lead shield to prevent radiation-induced abnormalities.

Date Taken: August 9, 2008 Result:

• • • • • • • •

No evident peritubular densities No demonstratable hilar adenopathies Retrosternal and retrocardiac spaces are intact Trachea is at midline Cardiac silhouette is not enlarged Costophrenic sulci are intact Hemidiaphragms are smooth The rest of the findings are unremarkable

Impression: Essential (-) Cardiopulmonary Findings.

VIII.

LIST OF PRIORITY NURSING PROBLEMS 1. Ineffective airway clearance r/t NGT 2. Acute pain r/t stomatitis (canker sore) 3. High risk for aspiration 4. Impaired physical mobility r/t neuromuscular impairment secondary to status epilepticus 5. High risk for falls 6. Risk for deficient fluid volume 7. High risk for infection 8. Hyperthermia r/t underlying illness secondary infection 9. Impaired oral mucous membrane r/t mechanical trauma secondary to status epilepticus 10.Impaired swallowing r/t behavioral changes secondary to status epilepticus 11.Imbalanced nutrition: less than body requirements r/t inability to ingest food secondary to absence of voluntary swallow reflex 12.Impaired tissue integrity r/t mechanical factors as to restraints secondary to status epilepticus

13.Impaired skin integrity r/t mechanical factors as to shearing forces/ increase friction against skin secondary to status epilepticus 14.Disturbed sleep pattern r/t behavioral changes secondary to status epilepticus 15.Disturbed thought process r/t mental disorders secondary to status epilepticus 16.Self-care deficit: bathing/hygiene/dressing/grooming/feeding/toileting r/t status epilepticus

IX. ON-GOING APPRAISAL (SOAPIE) 8/28/08 @830AM

S–

“Kung kaisa hindi ma-igo sang mga Doctor ang ugat, te hala saylo e. Kag daan grabe siya pa hulagon, budlayan gid guro mga doctor sa iya,” as verbalized by the mother. “Hala saylo eh, kung kaisa ginahukas niya ukon mag-dinugo na,” referred IV tubing accidentally being pulled out by patient herself.

 

“Hulagan siya abi, sadto nga may banig kami di, siguro nag-sagid hala ka nusnus eh te nagkapilas sya.” “May bactram cream man kami di ginapahid sa mga pilas niya.” “Kung wala pa siya guro nahigot, napangkutkot niya pilas nya.”

O–

redness on IV site of about 3 mm in diameter Guarding behavior Grimacing upon direct flushing via 10cc syringe through Piggy back port 2mm diameter wound, 1 mm in depth without pus draining on right ankle Scattered dry abrasions 3 inches in length on forearm

A - Impaired skin integrity r/t mechanical factors as to shearing forces/ increase friction against skin secondary to status epilepticus

P/I – 1. Application of bactram cream (antibacterial) to wound to prevent infection and promote wound healing. 2. Providing bed linens which are cotton in nature and no rough edges present on it. 3. Increase fluid intake via NGT tube to promote wound healing. 4. Check temperature for assessing progress of infection if swelling and redness on site and wound is still evident. 5. Administer anti-bacterial and/or anti-viral medications as prescribed.

6. Provide a clean environment by cleaning and arranging the bedside, and the bed itself which includes the bed linens, sheets, pillow cases etc. 7. Restraint patient accordingly as prescribed to prevent falls and to prevent further alimentation of current state 8. Perform ROM exercises on the inflamed site to promote venous return and prevent hypercoagulation of blood that could lead to thrombophlebitis. 9. Assist patient to reposition in a supported manner with pillows as necessary (side lying for 1 hour, supine for 1 hour, vice versa). 10.Application of cold compress to inflamed IV site to promote vasoconstriction, relieving pain, redness and swelling. 11.IV pull –out keeping set sterile and reinsertion of the same IVF. 8/28/08 @ 10AM E– • • • • • • Application of bactram cream, keeping it dry and clean IV site inflammation still present on left hand IV infusion patent and infusing well on right metacarpal vein Application of cold compress on right ankle wound Pinkish wound Pus draining in lesser amount on right ankle wound

TEXTBOOK DISCUSSION AND SCHEMATIC DIAGRAM OF PATHOPHYSIOLOGY A. Definition A seizure is a sudden, abnormal electrical discharge from the brain that results in changes sensation, behavior, movements, perception or consciousness. Seizure disorders have numerous and varied causes. Most are idiopathic. Genetic factors may in some way alter the seizure threshold to influence neuronal discharge. It can also be acquired as a result of brain injury during prenatal, perinatal or postnatal periods.This injury may be caused by trauma, hypoxia, infections. Biochemical events and nutritional deficiencies produce seizure activity Epilepsy is a chronic of recurrent seizures. An epileptic syndrome is composed of paroxysmal neurologic dysfunction causing recurrent episodes of one or more of the following manifestations: loss of consciousness, convulsive movements or other motor activity, sensory phenomena, and behavioral abnormalities. Status epilepticus is a tonic clonic or absence seizures that follow one another without restoration of consciousness. Common precipitating factors include abrupt cessation of anticonvulsant medications and alcohol withdrawal. This disorder is life threatening and produces greatly accelerated neuronal metabolic rate, hypoxia, acidosis, hyperthermia, and alterations in cerebral blood flow. Damage occurs to the cerebral cortex, hippocampus, and cerebellum, along with other metabolic derangements. Tonic-Clonic Seizures are the most common major motor seizure. The tonic phase is followed by the clonic phase, which involves rhythmic bilateral contraction and relaxation of the extremities. Absence seizures are generalized, nonconvulsive epileptic events and are expressed mainly as disturbances in consciousness. Typical absence seizures have been characterized as a blank stare, motionless, and unresponsiveness, though motion occurs in many cases of absence seizures. B. Signs and Symptoms

Signs and Symptoms found in the textbook Prolonged seizure (lasting longer than 5 min.) Rolling of eyes upward Immediate loss of consciousness Rigidness of the body Peculiar piercing cry Respiratory Distress Cyanosis Loss of swallowing reflex

Signs and Symptoms manifested by the patient (+) Aug. 8,2008 (+) Aug. 8,2008 (+) Aug. 8,2008 (+)Aug. 8,2008 (+)Aug. 8,2008 (-) (-) (-)

Rhythmic muscular contraction and relaxation Jerking movements Bladder incontinence Bowel incontinence Hypoxia Lactic acidosis C. Schematic Diagram Predisposing factors Genetic factors injury Head trauma Cerebrovascular disease Infection Physiologic Stimuli

(+)Aug. 8,2008 (+)Aug. 8,2008 (+) Aug. 9, 2008 (-) (-) (+)Aug. 8,2008

Precipitating Factors Head

Alteration of the integrity of the neuronal cell membrane Hyperexcitable cells initiate spontaneous electric discharge Intensity of discharges reaches a threshold Neuronal firing spreads to adjacent normal neurons muscle contraction, loss of consciousness, jerking movements, rolling of eyes upward, rigidness of body

Neuronal excitation spreads to the brainstem Uncontrolled bursts of electrical activity from the cortex Seizure Hypoxia Repeated occurrence of abnormal electrical discharges lactic acidosis Status Epilepticus

D. Management

a. Nursing Management

The management of epilepsy does not usually involve hospitalization. However, a client may initially be hospitalized for assessment, diagnosis, and education immediately after a first seizure. Hospitalization may also be required if seizures become uncontrolled or if status epilepticus develops. Nurses have a role in assessing for altered health maintenance of injury related to knowledge deficit or other barriers, anticipating risk of injury, and providing support for clients and their families who experience life changes related to seizure disorder.

Assessment of clients not actively experiencing seizures includes the following:

History, including prenatal, birth, and developmental history; family history; age at seizure onset; history of all illnesses and trauma; previous brain surgery or stroke; complete description of seizures, including precipitating factors; and presence of an aura Medication use and postictal symptoms Psychosocial assessment, including mental status examination Complete physical examination, focusing on neurologic signs

• • •

The child must be protected from injury during the seizure. It is impossible to halt a seizure once it has begun, and no attempt should be made to do so. The nurse must remain calm, stay with the child, and prevent the child from sustaining any harm during the seizure. If possible, the child should be isolated from the view of others by closing door or pulling screens. A seizure can be very upsetting to the child, other visitors or families. If other persons are present, they should be assured that everything is being done for the child. After the seizure, they can be given a simple explanation about the event as needed.

b. Medical Management

The goals of management of clients with seizures and epilepsy are to prevent injury during seizures, to eliminate factors that precipitate seizures, to diagnose and to treat the cause of the seizures, and to control seizures to allow a desired lifestyle.

During a seizure, the major goals are to maintain the airway, to prevent injury, to observe seizure activity and to administer appropriate anticonvulsant medications. Today, “seizure precautions” as identified in a hospital setting refers to the availability of an oral airway, and suction equipment.

For decades, the main antiepileptic drugs (AEDs) were phenytoin, phenobarbital, carbamazepine and valproate sodium. Currently available antiepileptic drugs appear to act primarily by blocking the initiation or spread of seizures. There are no drugs known to prevent the formation of a seizure focus after a CNS injury in humans.

Medical intervention focuses on prescribing AEDs to arrest or prevent seizures. Developing a program of correctly prescribed anticonvulsants requires weeks of medication adjustment by trial and error. The desired outcome pharmacologic management is monotherapy. Large doses of a single anticonvulsant are often more helpful than smaller doses of several drugs.

Ideally, initial treatment begins with a single drug (primarily anticonvulsant) until either seizure control is attained or unacceptable side effects appear. If side effects become intolerable before seizures are controlled, another drug is added. Combining medications does carry the potential risk of drug-drug interactions, which decrease effectiveness.

c. Surgical Management

The safest and most effective surgical treatment is cortical resection of the anterior temporal lobe for complex partial seizures. Criteria for resection includes: • Failure of the medical approach

Localization and identification of a focus of abnormal discharge that is easily accessible surgically and is located in the “dispensable” areas of the cerebral cortex. Dispensable areas are those for which there is a duplicative area in the cortex.

Cortical resection or Corpus Callosotomy is designed to make the seizures more tolerable. It involves the excision of one section of cortex to reduce the spread of epileptic discharges. Temporal Lobectomy is performed to remove the area in which the seizures begin without causing neurologic or cognitive deficits. Hemispherectomy is the removal of most of the cortex of one hemisphere done in children with intractable seizures to control those that are injurious, not to stop all seizures. Vagal nerve stimulator implantation offers fully understood, the VNS is believed to provide a stimulus that desynchronizes the abnormal uncontrolled electrical discharge of the brain activity during a seizure.

REFERENCES: Maternal and child health nursing, 4th ed. Pillitteri Nursing: Understanding Diseases 2008, Lippincott Williams and Wilkins Focus on Pathophysiology 2008, Lippincott Williams and Wilkins Medical-Surgical Nursing 7th ed, Black and Hawks

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