Putrid visions will turn into reality if from time to time when we pour into our hands the sands from the hourglass of time and dewdrops of windswept fortitude to nourish the seeds of ideas in our minds. And perhaps, we need the warmth of others to watch that seed grow. The author would like to extend her warmest gratitude to the people who helped make the success of this undertaking a reality. First and foremost, to the Almighty Father, for His unceasing love and blessings; for the gift of wisdom and resilience to face all the hardships in the making of this work. To Him be all glory and praise! To the Clinical Instructors, who devoted their time and effort serving as guide in the course of hospital exposures; for being second parents in the field who never stopped imparting their knowledge and skills. To her parents, for their love and support through all the years; for making each day less hard by inspiring her to do more and being always there to look after her. Lastly, to each and every one who helped realize this job into completion, may it be direct or indirect, no matter how minimal, the gratitude and pleasure for the achievement of this task is for the author to share.



Hypoxic Encephalopathy is a condition which results from lack of delivery of oxygen to the brain because of several causes; ranging from hypotension to respiratory failure, the most common causes are MI, cardiac arrest, shock, asphyxiation, paralysis of respiration, and carbon monoxide or cyanide poisoning. In some circumstances, hypoxia may predominate. Effects of this condition may lead to brain death or a persistent vegetative state. Neonatal encephalopathy (NE) is the clinical manifestation of disordered neonatal brain function. Lack of universal agreed definitions of NE and the sub-group with hypoxic-ischaemia (HIE) makes the estimation of incidence and the identification of risk factors problematic. NE incidence is estimated as 3.0 per 1000 live births (95%CI 2.7 to 3.3) and for HIE is 1.5 (95%CI 1.3 to 1.7). The risk factors for NE vary between developed and developing countries with growth restriction the strongest in the former and twin pregnancy in the latter. In the light of this, the proponent of the study encountered a patient at Southern Philippines Medical Center Pediatric Neuro Ward and was chosen to be the subject of this case study principally due to the reason that her condition poses a good avenue to broaden one¶s knowledge regarding pediatric neurological cases, their nature, manifestations and treatment; a case requiring proper nursing understanding and comprehension.


The patient, to be mentioned in this paper as Child Y, was one of the patients admitted to Pediatric Ward due to Hypoxic Encephalopathy secondary to Status Epilepticus secondary to Central Nervous System Infection.



General Objective: The main goal of this undertaking is to be able to present a case study of the chosen client that would provide a comprehensive discussion of the pathological mechanism of the disease, its manifestations, nature, causes, treatment and management to yield significant information for the case study. Specific Objectives: In order to meet the general objective, the following specific objectives are derived: y y y y y Establish rapport to the patient and the patient¶s significant others; Interpret the pertinent data gathered from the patient and her significant others; State past and present health history of the patient; Trace the family genogram; Evaluate the present developmental stage of the patient according to the theories of Erikson, Freud, and Havighurst; y y y Define the complete diagnosis of the patient; Present the cephalocaudal assessment obtained from the patient; Discuss the anatomy and physiology of the organ involved in the patient¶s disease; y y y Present the etiology and symptomatology of the patient¶s disease; Trace the pathophysiology of the patient¶s disease; Obtain and rationalize the doctor¶s order; 4

y y y y

Interpret the laboratory test results of the patient; Discuss the nature of the drugs given to the patient; Discuss the surgical procedure performed to the patient; Relate the patient¶s disease with the different nursing theories specifically those of Nightingale, Orem and Henderson;


Present a specific, measurable, attainable, realistic and time-bounded nursing care plans for the client;

y y

Justify the client¶s prognosis according to different criteria; Provide the patient and family with proper discharge planning (M.E.T.H.O.D); and


outline recommendations based on the case study¶s findings.



Personal data Patients Name: Age: Weight Height Gender: Birth date: Address: Nationality: Religion [Domination]: Child Y 3 years old 10.5 kilograms 3¶2¶¶ Female June 16, 2007 Mateo, Kidapawan City Filipino Christian [Roman Catholic]

Clinical/ Admitting Data Date of admission: January 10, 2011

Time of admission:



Ward [Room & Bed Numbers]:

Pediatric Ward- Neuro, Bed No.2

Admitting Physician: Attending Physician: Chief complaint: Admitting Diagnosis:

Dr. Leo Paolo Lebiano Daisy Mae Mariquit Seizures, vomiting Hypoxic Encephalopathy secondary to Status Epilepticus secondary to Central Nervous System Infection

Source of information:




HEALTH BACKGROUND A. Family Background

Child Y is the youngest child in a brood of three. Only she has been reported to have exhibited signs of seizure of all the three children in the family. The mother reported hypertension to run in her family, while no familial conditions exist in the lineage of her husband. The family¶s source of income is their farm, where the parents of the patient are both self-employed, earning grossly 5,000 to 8,000 a month. Her family¶s diet is composed of meat, fish and vegetables, however, due to her hospitalization she has been administered OT feedings. B. History of Past Illness The patient was born via normal spontaneous vaginal delivery. She did not have any complications nor unusualities when she was delivered. She was breastfed until the age of two and a half and has had the following vaccines: BCG, OPV, DPT, Measles and Hepatitis. She has no known allergies and has not been hospitalized for any other disease before. C. Present Health History Three days prior to admission, the patient had onset of moderate grade fever associated with three episodes of vomiting which are non-projectile in nature and cough. 8

Such symptoms persisted for three days in moderate frequencies which compelled the family to seek medical attention. The patient was brought to a local hospital and was given cefuroxime, with the initial diagnosis of sepsis. On the second hospital day, the patient had several episodes of seizures, with positive rolling of eyeballs and stiffness of extremities approximately 10 minutes in duration with approximately 30 minutes interval, with cyanosis and was not awake after seizure. On the third day, the patient was transferred to another hospital and was given the diagnosis Hypoxic Encephalopathy secondary to Status Epilepticus secondary to Central Nervous System Infection probably Bacterial Meningitis. The following medications were given to address the patient¶s condition: a. Ceftriaxone 100mkd BID for 4-5days b. Gentamycin 8mkd BID for 5 days c. Salbutamol neb q6 d. Phenobarbital 5mkd e. Diazepam 0.2ml stat f. 0xygen Neuro notes of the previous hospital also showed a positive loss of vision and stupor. GCS score was 9/15 with the following breakdown Eye movement= 1, Best verbal response = 2 and Best motor response = 6 with absent deep tendon reflex on both lower extremities.


The patient was referred to Southern Philippines Medical Center for further treatment and evaluation on the 10th of January. D. Effects/ Expectations of Illness to Self/ Family The mother verbalized that after the diagnosis was determined; her family had a hard time accepting the situation. The child used to be very cheerful and playful until the illness took everything away from her. Nevertheless, the mother verbalized that they had already accepted her condition, its treatment and the possible future effects that the condition will eventually bring financially and emotionally. However, everyone in the family has a positive attitude and high hopes towards the patient¶s condition.











LEGEND: - Deceased - Hypertension - Status Epilepticus



Developmental stage theories characterize a person¶s behaviors or tasks into approximate age ranges or in terms that describe the features of an age group. These theories allow nurses to describe typical behaviors of an individual within a certain age group, explain the significance of those behaviors, predict behaviors that may occur in a given situation and provide rationale to control behavioral manifestations. The nurse¶s knowledge of these theories can be used in parental and client education, counseling and anticipatory guidance. Freud's Model of psychosexual development

The concept of psychosexual development was envisioned by Sigmund Freud. It consists of five separate phases: oral, anal, phallic, latency, and genital. In the development of his theory, Freud's main concern was with sexual desire, defined in terms of formative drives, instincts and appetites that result in the formation of an adult personality.

The Freudian theory assets that the individual must meet the needs of each stage in order to move successfully to the next developmental stage. If a person does not achieve a satisfactory progression at one stage, the personality becomes fixated at that stage. Fixation is immobilization or the inability of the personality to proceed to the next stage because of anxiety.







The child has already been toilet trained as claimed by the mother. She reports that the child, before the onset of the illness which generally have put her in a persistence vegetative state, was able to manage to eliminate on her own. The child is said to have been able to go to the CR, flush the toilet and clean herself thereafter on her own.

The child is approached with this conflict with

the parent's demands. A successful completion H of this stage depends on how the parents interact I with the child while toilet training. A child who has not successfully completed this behavior will E become an adult who has an anally expulsive V character. They will be characterized as E disorganized, messy, reckless, careless, and defiant. If the child's tactics are overindulged D then they can form an anally retentive character as an adult. The anal retentive character is the opposite of an anally expulsive character. This child will find pleasure in withholding faeces in the body. However, a child who has successfully completed this stage will be characterized as having used proper toilet training techniques








successfully move on to the next stage. Although the stage seems to be about proper toilet training, it is also about controlling behaviors and urges. A child needs to learn certain boundaries when they are young so that in the future there will not be contention regarding what is over-stepping the boundaries.

Erikson¶s Psychosocial Development Psychosocial development as articulated by Erik Erikson describes eight developmental stages through which a healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future. Although he was influenced by Freud, he believed that the ego exists from birth and that behavior is not totally defensive. Based in part on his study of Sioux Indians on a reservation, Erikson became aware of the massive influence of culture on behavior and placed more emphasis on the external world, such as depression and wars. He felt the course of development is determined by the interaction of the body (genetic biological programming), mind (psychological), and cultural (ethos) influences.


Stage 3: Late Childhood (3-5 years old)



Initiative Versus Guilt A

Verbalizations of the mother asserts that the child has been very active at play. She plays with their neighbors and tends to foster a good sense of leadership and independence. The mother says that she can even leave her child to play at their backyard when she does her household chores. The child manages to pass time on her own, playing with other kids and doing things on her own. She even recalls her daughter giving her flowers from the sidewalk that she picked on her mother¶s birthday.

Initiative adds to autonomy the quality of

undertaking, planning and attacking a task for C the sake of being active and on the move. The H child is learning to master the world around them, learning basic skills and principles of I physics. Things fall down, not up. Round things E roll. They learn how to zip and tie, count and V speak with ease. At this stage, the child wants to begin and complete their own actions for a E purpose. Guilt is a confusing new emotion. They may feel guilty over things that logically should not cause guilt. They may feel guilt when this initiative does not produce desired results. During this stage, the child learns to take initiative and prepare for leadership and goal achievement roles. Activities sought out by a D


child in this stage may include risk-taking behaviors, such as crossing a street alone or riding a bike without a helmet; both these examples involve self-limits. Within instances requiring initiative, the child may also develop negative behaviors. These behaviors are a result of the child developing a sense of frustration for not being able to achieve a goal as planned and may engage in behaviors that seem aggressive, ruthless, and overly assertive to parents.

Aggressive behaviors, such as throwing objects, hitting, or yelling, are examples of observable behaviors during this stage.

Havighurst¶s Developmental Theory Robert Havighurst believed that learning is basic to life and that people continue to learn throughout life. Havighurst's educational research did much to advance education in the United States. Educational theory before Havighurst was underdeveloped. Children learned by rote and little concern was given to how children developed. From 1948 to 1953 he developed his highly influential theory of human development and education. The crown jewel of his research was on developmental task. Havighurst tried to define the developmental stages on many levels. He


describes growth and development as occurring during six stages. Each associated with the six to ten tasks to be learned.


Assess -ment


Infancy to Early Childhood (Birth to 6 years) A C H I

Relative to her age, the child is able to achieve the developmental tasks posed by Havighurst. The child is already able to walk, eat, talk, eliminate, and has formed skills in language and socialization.

y y y y y

Learning to walk. Learning to crawl. Learning to take solid food. Learning to talk. Learning to control the elimination of body wastes.

Although the child is not ready to E V E at the moment since she is still 3 years old. read and properly distinguish sexual differences and modesty, these


Learning sex differences and sexual modesty.

concepts cannot be expected of her

y y

Getting ready to read.

Forming concepts and learning language D to describe social and physical reality.



General Survey Assessed lying on bed, asleep; with IVF of D5 0.3 NaCl 500cc infusing well at 40gtt/min attached to left metacarpal vein with insertion site clean and patent; with NGT attached to right nares with distal end closed, with a height of 3 feet 2inches, weight of 23.1 lbs; a BMI of 11.3 suggestive of being underweight. Patient appears to be in persistent vegetative state, with noted presence of nuchal and decerebrate rigidity; no response can be elicited by applying verbal or tactile stimuli by the nurse. However, response to painful stimuli thru crying was observed. No body odor or breath odor noted, unable to talk and ambulate. Vital Signs Temperature Pulse Rate Respiratory Rate 37.3rC 120 beats per minute 33 cycles per minute

Skin Skin is dark brown in color and uniform in distribution. No edema noted. Skin is warm to touch and is dry. Good skin turgor is noted, with capillary refill time of 2 seconds. No freckles and birthmarks are noted. Head 18

Head is normocephalic and symmetrical with a circumference of 20 inches; smooth skull contour is observed. The patient has thin and short hair which is straight, coming in black strands with smooth and silky texture; no nits, lice and hair flakes upon inspecting the scalp. No nodules, masses, and depressions noted; head is smooth with uniform consistency. There are symmetrical facial feature and symmetric nasal folds. Symmetry of facial movements is normal, upon raising eyebrows, frowning, closing the eyes, and smiling. Eyes Eyes are symmetrical and almond in shape. Eyebrows are evenly distributed with black hair strands; eyebrows symmetrically aligned and equal in movement. Eyelashes are equally distributed and curled slightly outward. Skin of the eyelids is intact; no discharge and discoloration noted; lids close symmetrically while blinking. Ecteric sclera without prominence of capillaries. Conjunctivas are pinkish in color. No edema or tenderness over lacrimal gland; edema or tearing of lacrimal gland not noted. Iris is black in color. No redness and secretions noted. Ptosis not noted. Pupils are 3 mm in diameter upon exposure to light and 4 mm in diameter without light exposure. Pupils equal in size, reactive to light and accommodation but with sluggish reaction. Patient is unable to see anything since the onset of the illness, furthermore, absence of corneal reflex suggesting a damage in CN V is noted. Ears Ears are same in color with the facial skin, symmetrical and aligned to the outer canthus of the eyes. The pinna is semi-firm, non-tenderness noted upon palpation and recoils back after it is folded. No lesions, discoloration and redness noted. Ability of the patient to hear is based on her ability to respond to vocal stimuli of the mother when lulling patient to sleep, however the 19

patient is unable to respond both verbally and nonverbally when being stimulated aurally upon assessment. Nose Nose is symmetric and straight; no lesions and discoloration noted. Nasal septum is positioned in the midline. With evenly distributed ciliary hairs. No discharges noted; no nodules and polyps upon inspection as well. Nasal flaring not noted. No deformity and tenderness noted upon palpation. Air moves freely as the patient breathes through the nares. An NGT tube is placed snuggly in the patient¶s right nares. Mouth Lips are symmetrical, assessed to be pale and dry, symmetry of contour of the lips noted. Teeth are smooth, whitish, and with shiny tooth enamel. Dental plaques and caries were noted. Gingival and mucosal pallor noted. No thrush and mouth sores noted. Tongue is in central position; with pale pink color, moist surface, slightly rough texture, with thin whitish coating, and with spongy white patches on the anterior part of the tongue. Tongue moves freely without tenderness. Tongue is smooth with no palpable nodules. Uvula is positioned in the midline of the soft palate. Oropharynx with pink and smooth posterior wall; tonsils are pink and smooth with no visible inflammation and of normal size. Neck Skin color of the neck is similar with that of the face. No lesions and discoloration noted. Muscles are equal in size and the head is centered. Muscle strength of the left and right sternocleidomastoid muscles is equal; left and right trapezious are equal in strength. Lymph


nodes are not palpable. The trachea is in the midline of the neck. Carotid pulses are palpable. Thyroid glands are not palpable. No masses noted upon palpation. Chest and Lungs No discolorations and lesions noted. Thoracic cavity is symmetrical. The ribs and coastal margins are symmetrical. The sternum is at the midline. Nipples are symmetrical in position. Chest skin is intact and uniform in temperature. Chest wall is intact; no tenderness and masses noted. Normal respiratory rate of 33 breaths per minute with equal spaces in between is noted. Full symmetric excursion of anterior chest noted. Bilateral symmetry of vocal fremitus on the posterior chest noted; vocal fremitus is symmetric in anterior chest but decreased over heart and breast tissue. Adventitious breath sounds are absent upon auscultation. Heart The cardiac rate upon assessment is 120 beats per minute with regular rate and rhythm; with equal intervals between beats. Upon auscultation, no murmurs noted. Not in cardiac

distress. Point of maximal impulse is located at the left midclavicular line, fifth intercoastal space. Abdomen Abdomen is flat and uniform in color; vascular patterns not visible. Skin temperature surrounding the incision is uniform and within normal ranges. No evidence of enlargement of the liver or spleen upon inspection. Abdominal girth is 26 inches. Symmetrical abdominal movements upon respiration noted. Bowel sounds are audible with a rate of 10 bowel sounds per minute, auscultated at the left upper and lower quadrant. Upon percussion, tympany over the left


upper quadrant is noted. Upon light palpation, no tenderness was reported, abdomen is relaxed with smooth, consistent tension. The bladder is not enlarged and not palpable. Genito-Urinary Upon inspection, clear and whitish urine color noted. Discharges were not reported. No odor, lesions and itchiness were reported. No tenderness reported. No swelling and bulges were reported as well; patient voiding freely with urine output in diapers of 800cc in 8 hours. Back and Extremities Spine is vertically aligned; spinal column is straight. Right and left shoulders are of the same height. There is symmetry in the sizes of the extremities. No discolorations and lesions noted. No edema noted. No deformities and contractures noted. Muscles are semi-firm upon palpation. Tremors not noted. Strong radial pulsations noted on upper extremities. Upper and lower extremities have no apparent range of motion due to nuchal rigidity. Patient is unable to walk with absence of deep tendon reflexes on both lower extremities. Bedsores are not noted. Untrimmed fingernails and toenails noted. The capillary refill distribution is 2 seconds; extremities are able to perceive pain sensation upon pinching.



Hypoxic Encephalopathy secondary to Status Epilepticus secondary to Central Nervous System Infection Hypoxic Encephalopathy

Hypoxic-ischemic encephalopathy is characterized by clinical and laboratory evidence of acute or subacute brain injury due to asphyxia (ie, hypoxia, acidosis). Most often, the exact timing and underlying cause remain unknown.
Mosby s Pocket Dictionary of Medicine, Nursing & Health Professions 5th edition

Hypoxic encephalopathy is the amage to cells in the central nervous system (the brain and spinal cord) from inadequate oxygen. Hypoxic-ischemic encephalopathy allegedly may cause in death in the newborn period or result in what is later recognized as developmental delay, mental retardation, or cerebral palsy. This is an area of considerable medical and medicolegal debate.
Hopper P.D., Williams, L.S.; Understanding Medical Surgical Nursing 3rd Edition

Hypoxic encephalopathy is a condition in which the brain does not receive enough oxygen. This particular condition refers to an oxygen deficiency to the brain as a whole, rather than a part of the brain. Although the term most often refers to injury sustained by newborns, hypoxic encephalopathy can be used to describe any injury from low oxygen.

Ray A. Hargrove-Huttel; Medical Surgical Nursing


Status Epilepticus Status epilepticus is a medical emergency familiar to accident and emergency departments, acute medical wards, and intensive care units. It is defined as a continuous seizure lasting for at least 30 minutes, or two or more discrete seizures between which the patient does not recover consciousness. Defined as continuous seizures or repetitive, discrete seizures with impaired consciousness in the interictal period. May occur with all kinds of seizures: grand mal (tonicclonic) status, myoclonic status, petit mal status, and temporal lobe (complex partial) status. Generalized, tonic-clonic seizures are most common and are usually clinically obvious early in the course. After 30-45 min, the signs may become increasingly subtle and include only mild clonic movements of the fingers or fine, rapid movements of the eyes. Raimond, Jeanne, et. Al. Neurological Emergencies and Effective Nursing Care. A seizure that persists for a sufficient length of time or is repeated frequently enough that recovery between attacks does not occur. International League Against Epilepsy, 1981


Central Nervous System Infection

Central nervous system infections are those infections of the central nervous system (CNS). There are four main causes of infections of the nervous system: bacterial, viral, fungal and protozoal.

Maria, Bernard. Current Management in Child Neurology.



The Brain

The brain is the most complex part of the human body. This three-pound organ is the seat of intelligence, interpreter of the senses, initiator of body movement, and controller of behavior. Lying in its bony shell and washed by protective fluid, the brain is the source of all the qualities that define our humanity. The brain is the crown jewel of the human body. The brain serves many important functions. It gives meaning to things that happen in the world surrounding us.

We have five senses: sight, smell, hearing, touch and taste. Through these senses, our brain receives messages, often many at one time. It puts together the messages in a way that has meaning for us, and can store that information in our memory. For example: An oven burner has been left on. By accident we touch the burner. Our brain receives a message from skin sensors on our hand. Instead of leaving our hand on the burner, our brain gives meaning to the signal and tells us to quickly remove our hand from the burner. Heat has been felt. If we were to leave our hand on the burner, pain and injury would result. As adults, we may have had a childhood memory of touching something hot that resulted in pain or watching someone else who has done so. Our brain uses that memory in a time of need and guides our actions and reactions in a harmful situation.

With the use of our senses: sight, smell, touch, taste, and hearing, the brain receives many messages at one time. It can select those which are most important. Our brain controls our thoughts, memory and speech, the movements of our arms and legs and the function of many 26

organs within our body. It also determines how we respond to stressful situations (i.e. writing of an exam, loss of a job, birth of a child, illness, etc.) by regulating our heart and breathing rate. The brain is an organized structure, divided into many parts that serve specific and important functions.

Three cavities, called the primary brain vesicles, form during the early embryonic development of the brain. These are the forebrain (prosencephalon), the midbrain (mesencephalon), and the hindbrain (rhombencephalon).

During subsequent development, the three primary brain vesicles develop into five secondary brain vesicles. The names of these vesicles and the major adult structures that develop from the vesicles follow:


The telencephalon generates the cerebrum (which contains the cerebral cortex, white matter, and basal ganglia).

y y y y

The diencephalon generates the thalamus, hypothalamus, and pineal gland. The mesencephalon generates the midbrain portion of the brain stem. The metencephalon generates the pons portion of the brain stem and the cerebellum. The myelencephalon generates the medulla oblongata portion of the brain stem


TABLE 1 The Vesicles and Their Components Secondary Primary Vesicles prosencephalon (forebrain) Vesicles Important Adult Structure Features Components or

telencephacerebrum cerebral (cerebral cerebral cortex (gray matter): hemispheres) motor areas, sensory areas,

association areas prosencephalon (forebrain) telencephacerebrum cerebral (cerebral cerebral hemispheres) white matter:

association fibers, commisural fibers, projection fibers

prosencephalon (forebrain)

telencephacerebrum cerebral (cerebral basal ganglia (gray matter): hemispheres) caudate nucleus & amygdala, putamen, globus pallidus




thalamus: information



prosencephalon (forebrain) prosencephalon (forebrain) prosencephalon (forebrain)



hypothalamus: maintains body homeostasis






sensations of smells to cerebrum diencephalon Diencephalon optic chiasma: crossover of optic nerves


prosencephalon (forebrain) prosencephalon (forebrain) prosencephalon (forebrain) mesencephalon (midbrain)



infundibulum: stalk of pituitary gland



pituitary hormones






epithalamus: pineal gland


brain stem

midbrain: cerebral peduncles, sup. cerebellar peduncles,

corpora quadrigemina, superior colliculi rhombencephalon (hindbrain) metencephalon brain stem pons: middle cerebellar

peduncles, pneumotaxic area, apneustic area

rhombencephalon (hindbrain)



sup. middle

cerebellar cerebellar

peduncles, peduncles,

inferior cerebellar peduncles rhombencephalon (hindbrain) myelencephalon brain stem medulla oblongata: pyramids, cardiovascular respiratory center center,

A second method for classifying brain regions is by their organization in the adult brain. The following four divisions are recognized (see Figure 1 ) 29

Figure 1The four divisions of the adult brain.


The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve fibers, the corpus callosum. The largest and most visible part of the brain, the cerebrum, appears as folded ridges and grooves, called convolutions. The following terms are used to describe the convolutions:
o o o

A gyrus (plural, gyri) is an elevated ridge among the convolutions. A sulcus (plural, sulci) is a shallow groove among the convolutions. A fissure is a deep groove among the convolutions.


The deeper fissures divide the cerebrum into five lobes (most named after bordering skull bones)²the frontal lobe, the parietal love, the temporal lobe, the occipital lobe, and the insula. All but the insula are visible from the outside surface of the brain.

A cross section of the cerebrum shows three distinct layers of nervous tissue:


The cerebral cortex is a thin outer layer of gray matter. Such activities as speech, evaluation of stimuli, conscious thinking, and control of skeletal muscles occur here. These activities are grouped into motor areas, sensory areas, and association areas.


The cerebral white matter underlies the cerebral cortex. It contains mostly myelinated axons that connect cerebral hemispheres (association fibers), connect gyri within hemispheres (commissural fibers), or connect the cerebrum to the spinal cord (projection fibers). The corpus callosum is a major assemblage of association fibers that forms a nerve tract that connects the two cerebral hemispheres.


Basal ganglia (basal nuclei) are several pockets of gray matter located deep inside the cerebral white matter. The major regions in the basal ganglia²the caudate nuclei, the putamen, and the globus pallidus²are involved in relaying and modifying nerve impulses passing from the cerebral cortex to the spinal cord. Arm swinging while walking, for example, is controlled here.


The diencephalon connects the cerebrum to the brain stem. It consists of the following major regions:



The thalamus is a relay station for sensory nerve impulses traveling from the spinal cord to the cerebrum. Some nerve impulses are sorted and grouped here before being transmitted to the cerebrum. Certain sensations, such as pain, pressure, and temperature, are evaluated here also.


The epithalamus contains the pineal gland. The pineal gland secretes melatonin, a hormone that helps regulate the biological clock (sleep-wake cycles).


The hypothalamus regulates numerous important body activities. It controls the autonomic nervous system and regulates emotion, behavior, hunger, thirst, body temperature, and the biological clock. It also produces two hormones (ADH and oxytocin) and various releasing hormones that control hormone production in the anterior pituitary gland.

The following structures are either included or associated with the hypothalamus.

o o o

The mammillary bodies relay sensations of smell. The infundibulum connects the pituitary gland to the hypothalamus. The optic chiasma passes between the hypothalamus and the pituitary gland. Here, portions of the optic nerve from each eye cross over to the cerebral hemisphere on the opposite side of the brain.


The brain stem connects the diencephalon to the spinal cord. The brain stem resembles the spinal cord in that both consist of white matter fiber tracts surrounding a core of gray matter. The brain stem consists of the following four regions, all of which provide connections between various parts of the brain and between the brain and the spinal cord. (Some prominent structures are illustrated in Figure 2 ).


Figure 2Prominent structures of the brain stem.

o o o

The midbrain is the uppermost part of the brain stem. The pons is the bulging region in the middle of the brain stem. The medulla oblongata (medulla) is the lower portion of the brain stem that merges with the spinal cord at the foramen magnum.


The reticular formation consists of small clusters of gray matter interspersed within the white matter of the brain stem and certain regions of the spinal cord, diencephalon, and cerebellum. The reticular activation system (RAS), one component of the reticular formation, is responsible for maintaining wakefulness and alertness and for filtering out unimportant sensory information. Other components of the reticular formation are responsible for maintaining muscle tone and regulating visceral motor muscles.



The cerebellum consists of a central region, the vermis, and two winglike lobes, the cerebellar hemispheres. Like that of the cerebrum, the surface of the cerebellum is convoluted, but the gyri, called folia, are parallel and give a pleated appearance. The cerebellum evaluates and coordinates motor movements by comparing actual skeletal movements to the movement that was intended.

The limbic system is a network of neurons that extends over a wide range of areas of the brain. The limbic system imposes an emotional aspect to behaviors, experiences, and memories. Emotions such as pleasure, fear, anger, sorrow, and affection are imparted to events and experiences. The limbic system accomplishes this by a system of fiber tracts (white matter) and gray matter that pervades the diencephalon and encircles the inside border of the cerebrum. The following components are included:

y y y

The hippocampus (located in the cerebral hemisphere) The denate gyrus (located in cerebral hemisphere) The amygdala (amygdaloid body) (an almond-shaped body associated with the caudate nucleus of the basal ganglia)

y y y

The mammillary bodies (in the hypothalamus) The anterior thalamic nuclei (in the thalamus) The fornix (a bundle of fiber tracts that links components of the limbic system)

Nervous system
The nervous system has three main functions: sensory input, integration of data and motor output. Sensory input is when the body gathers information or data, by way of neurons, glia and synapses. The nervous system is composed of excitable nerve cells (neurons) and synapses that 34

form between the neurons and connect them to centers throughout the body or to other neurons. These neurons operate on excitation or inhibition, and although nerve cells can vary in size and location, their communication with one another determines their function. These nerves conduct impulses from sensory receptors to the brain and spinal cord. The data is then processed by way of integration of data, which occurs only in the brain. After the brain has processed the information, impulses are then conducted from the brain and spinal cord to muscles and glands, which is called motor output. Glia cells are found within tissues and are not excitable but help with myelination, ionic regulation and extracellular fluid.

The nervous system is comprised of two major parts, or subdivisions, the central nervous system (CNS) and the peripheral nervous system (PNS). The CNS includes the brain and spinal cord. The brain is the body's "control center". The CNS has various centers located within it that carry out the sensory, motor and integration of data. These centers can be subdivided to Lower Centers (including the spinal cord and brain stem) and Higher centers communicating with the brain via effectors. The PNS is a vast network of spinal and cranial nerves that are linked to the brain and the spinal cord. It contains sensory receptors which help in processing changes in the internal and external environment. This information is sent to the CNS via afferent sensory nerves. The PNS is then subdivided into the autonomic nervous system and the somatic nervous system. The autonomic has involuntary control of internal organs, blood vessels, smooth and cardiac muscles. The somatic has voluntary control of skin, bones, joints, and skeletal muscle. The two systems function together, by way of nerves from the PNS entering and becoming part of the CNS, and vice versa.


CNS The "Central Nervous System", comprised of brain, brainstem, and spinal cord.

The central nervous system (CNS) represents the largest part of the nervous system, including the brain and the spinal cord. Together, with the peripheral nervous system (PNS), it has a fundamental role in the control of behavior.

The CNS is conceived as a system devoted to information processing, where an appropriate motor output is computed as a response to a sensory input. Many threads of research suggest that motor activity exists well before the maturation of the sensory systems, and senses only influence behavior without dictating it. This has brought the conception of the CNS as an autonomous system.

Structure and function of neurons

Neurons are highly specialized for the processing and transmission of cellular signals. Given the diversity of functions performed by neurons in different parts of the nervous system, there is, as expected, a wide variety in the shape, size, and electrochemical properties of neurons. For instance, the soma of a neuron can vary in size from 4 to 100 micrometers in diameter.

The soma (cell body) is the central part of the neuron. It contains the nucleus of the cell, and therefore is where most protein synthesis occurs. The nucleus ranges from 3 to 18 micrometers in diameter. The dendrites of a neuron are cellular extensions with many branches, and


metaphorically this overall shape and structure is referred to as a dendritic tree. This is where the majority of input to the neuron occurs. However, information outflow (i.e. from dendrites to other neurons) can also occur (except in chemical synapse in which backflow of impulse is inhibited by the fact that axon do not possess chemoreceptors and dendrites cannot secrete neurotransmitter chemical). This explains one way conduction of nerve impulse. The axon is a finer, cable-like projection which can extend tens, hundreds, or even tens of thousands of times the diameter of the soma in length. The axon carries nerve signals away from the soma (and also carry some types of information back to it). Many neurons have only one axon, but this axon may - and usually will - undergo extensive branching, enabling communication with many target cells. The part of the axon where it emerges from the soma is called the 'axon hillock'. Besides being an anatomical structure, the axon hillock is also the part of the neuron that has the greatest density of voltage-dependent sodium channels. This makes it the most easily-excited part of the neuron and the spike initiation zone for the axon: in neurological terms it has the greatest hyperpolarized action potential threshold. While the axon and axon hillock are generally involved in information outflow, this region can also receive input from other neurons as well. The axon terminal is a specialized structure at the end of the axon that is used to release neurotransmitter chemicals and communicate with target neurons. Although the canonical view of the neuron attributes dedicated functions to its various anatomical components, dendrites and axons often act in ways contrary to their so-called main function.

Axons and dendrites in the central nervous system are typically only about a micrometer thick, while some in the peripheral nervous system are much thicker. The soma is usually about 10±25 micrometers in diameter and often is not much larger than the cell nucleus it contains. The longest axon of a human motor neuron can be over a meter long, reaching from the base of the 37

spine to the toes. Sensory neurons have axons that run from the toes to the dorsal columns, over 1.5 meters in adults. Giraffes have single axons several meters in length running along the entire length of their necks. Much of what is known about axonal function comes from studying the squids giant axon, an ideal experimental preparation because of its relatively immense size (0.5± 1 millimeters thick, several centimeters long).


Sensory afferent neurons convey information from tissues and organs into the central nervous system. Efferent neurons transmit signals from the central nervous system to the effector cells and are sometimes called motor neurons. Interneurons connect neurons within specific regions of the central nervous system. Afferent and efferent can also refer generally to neurons which, respectively, bring information to or send information from brain region.

Excitatory neurons excite their target postsynaptic neurons or target cells causing it to function. Motor neurons and somatic neurons are all excitatory neurons. Excitatory neurons in the brain are often glutamatergic. Spinal motor neurons, which synapse on muscle cells, use acetylcholine as their neurotransmitter. Inhibitory neurons inhibit their target neurons. Inhibitory neurons are also known as short axon neurons, interneurons or microneurons. The output of some brain structures (neostriatum, globus pallidus, cerebellum) are inhibitory. The primary inhibitory neurotransmitters are GABA and glycine. Modulatory neurons evoke more complex effects termed neuromodulation. These neurons use such neurotransmitters as dopamine, acetylcholine, serotonin and others. Each synapses can receive both excitatory and inhibitory signals and the outcome is determined by the adding up of summation.


Excitatory and inhibitory process

The release of a excitatory neurotransmitter (ACHe) at the synapses will cause an inflow of positively charged sodium ions (Na+) making a localized depolarization of the membrane. The current then flows to the resting (polarized) segment of the axon.

Inhibitory synapse causes an inflow of Cl- (chlorine) or outflow of K+ (potassium) making the synaptic membrane hyperpolarized. This increase prevents depolarization, causing a decrease in the possibility of an axon discharge. If they are both equal to their charges, then the operation will cancel itself out. There are two types of summation: spatial and temporal. Spatial summation requires several excitatory synapses (firing several times) to add up,thus causing an axon discharge. It also occurs within inhibitory synapses, where just the opposite will occur. In temporal summation, it causes an increase of the frequency at the same synapses until it is large enough to cause a discharge. Spatial and temporal summation can occur at the same time as well.

The neurons of the brain release inhibitory neurotransmitters far more than excitatory neurotransmitters, which helps explain why we are not aware of all memories and all sensory stimuli simultaneously. The majority of information stored in the brain is inhibited most of the time. 39


A. ETIOLOGY Predisposing Factors Age Present/ Rationale Absent Justification


Extremes of age, being too young and too old,

The patient is aged 3 years old, by this

predisposes an individual age, the immune to infectious diseases since it is in this stages that the immune system of an individual is either already impaired due to age or is still underdeveloped. Bernard Maria. Current Management in Child Neurology. 4th Edition. Immune Deficiency Absent Children who are immune compromised or having inadequate The child is completely immunized as 40 system is not yet well developed as compared to adults and older children, thus predisposing the child to meningitis.

immunization tend to be more susceptible to diseases caused by

reported by the mother and does not have any disease

infective microorganisms condition that would due to the decreased ability of their immune system to ward off invading pathogens than those who are immunologically stable and completely immunized. Bernard Maria. Current Management in Child Neurology. 4th Edition. render her immunologically deficient.

Precipitating Present/ Absent Factors Exposure to Pathogen Present Exposure to causative agents such as H. influenza, S. pneumoniae Presence of infection is suggestive that the child has been exposed Rationale Justification


and N. meningitidis influenced by other factors can cause meningitis in susceptible individuals. Bernard Maria. Current Management in Child Neurology. 4th Edition. Environment Absent Environmental conditions such as those places where houses are too close to each other allow inadequate ventilation and permit easy transmission of bacterial agents of infection. Allan R. Tunkel. Pathogenesis and Pathophysiology of Bacterial Meningitis

to microorganisms.

The mother reports their home to be located near a field, since they were farmers. Houses in their place are said to be far apart.



Malnutrition is a condition caused by a deficiency or excess of one or more

Upon admission, the child¶s weight was 10.5kg, with a height


essential nutrients in the diet. Malnutrition is characterized by a wide array of health problems, including extreme weight loss, stunted growth, weakened resistance to infection, and impairment of intellect. Severe cases of malnutrition can lead to death.

of 3 feet 2 inches summing up to a total BMI of 11.3 suggesting that the child is underweight, which is one of the major indications of malnutrition.

Microsoft ® Encarta ® 2009. © 1993-2008 Microsoft Corporation. All rights reserved.

History of Infection (H. influenza, S. pneumoniae)


H. influenzae and S. pneumoniae, are the two most common causes of bacterial meningitis apart from infection from Neisseria Meningitidis.

The child¶s reontological report shows central pneumonitis.


Commonly causative factors for respiratory infections, H. influenzae and S. pneumoniae may cause CNS infection by infiltrating the CNS through the blood stream. Allan R. Tunkel. Pathogenesis and Pathophysiology of Bacterial Meningitis

B. SYMPTOMATOLOGY Symptoms Projectile vomiting Present/Absent Absent Rationale Vomiting occurs due to increased intracranial pressure. Jeanne Raimond. Neurological Emergencies Effective Nursing Justification The patient has had vomiting but is not projectile in nature.


Care. Lethargy Present Lethargy occurs due to inability of certain parts of the brain to regulate proper body function arising from ischemia depending on areas affected. Jeanne Raimond. Neurological Emergencies Effective Nursing Care. Seizures Present Status epilepticus is a condition wherein seizure persists for a sufficient length of time or is repeated frequently enough that recovery between attacks does not occur. This The patient¶s chief complaint for admission is seizure and vomiting. The patient is arousable only by pain and is unable to wake or perform activities of daily living.


condition is usually precipitated by serious intracranial insults such as head trauma, anoxia, stroke or CNS infections. Bernard Maria. Current Management in Child Neurology. 4th Edition. Hyperreflexia Absent Hyperreflexia occurs as a primary sign of CNS irritation. Jeanne Raimond. Neurological Emergencies Effective Nursing Care. This was not manifested by the patient.


Kernig sign


Kernig sign is the involuntary spasm of the hamstring muscle provoked by knee extension with the patient supine. This is due to the irritation of nerve endings. Bernard Maria. Current Management in Child Neurology. 4th Edition.

This was not manifested by the patient.

Brudzinski sign


Brudzinski sign is present due to the irritation of nerve endings caused by inflammation arising from inflammation. Bernard Maria. Current

This was not manifested by the patient.


Management in Child Neurology. 4th Edition. Fever Present Is a frequent medical symptom that describes an increase in internal body temperature to levels that are above normal. It is stimulated by cytokines (IL-1 & IL-6). These cytokines send signals in the hypothalamus that serves as our thermoregulatory center, thus prostaglandin is released. Once prostaglandin is released, it causes an 48 There were occasions wherein the patient was febrile.

increase in the set point. In response to this, the hypothalamus neurally initiates shivering and vasoconstriction that increases the core body temperature to the new set point, and fever is established. Bernard Maria. Current Management in Child Neurology. 4th Edition. Increased WBC Present White blood cells are The WBC of the patient is responsible for the defense system in the body. White blood cells fight 14.35.


infections and protect our body from foreign particles, which includes harmful germs and bacteria.Thus, elevated WBC counts indicate infection. Jeanne Raimond. Neurological Emergencies Effective Nursing Care. Nuchal rigidity Present Nuchal rigidity occurs as a result of compression and irritation of nerve endings in the brain arising from inflammation. The patient is exhibiting decerebrate rigidity.


Jeanne Raimond. Neurological Emergencies Effective Nursing Care. hyperventilation Absent Hyperventilation is a respiratory compensatory mechanism to increase oxygenation and tissue perfusion. Bernard Maria. Current Management in Child Neurology. 4th Edition. tachycardia Absent Tachycardia takes place in the early stage of status epilepticus as a compensatory mechanism of the This was not manifested by the patient. This was not manifested by the patient.


body to increase perfusion. Bernard Maria. Current Management in Child Neurology. 4th Edition. Decreased response Present Ischemia of certain parts of the brain incur varying effects to an individual¶s neurological, sensory and motor function depending on which areas are affected. These effects may range from simple memory loss to coma. Jeanne Raimond. Neurological Emergencies The patient is unresponsive to any tactile or verbal stimuli made by the nurse upon assessment.


Effective Nursing Care. Diminished reflexes Present Diminished reflexes are indicative of an assault to the peripheral nervous system. Jeanne Raimond. Neurological Emergencies Effective Nursing Care. There was an assessed absence of the patient¶s DTR in both lower extremities.



Predisposing Factor

Precipitating Factors



Entry of pathogen bacteremia Endothelial cell injury

Meningeal invasion Fever Subarachnoid space inflammation Nuchal Rigidity

Increased blood-brain barrier permeability

Increased CSF outflow resistance

Cerebral vasculitis

Interstitial edema Increased Intracranial Pressure  Projectile vomiting

Cerebral infarction 


Impaired dark adaptation Impaired short term learning Loss of judgment Delirium, muscle incoordination Loss of consciousness Neural damage hypoxia

Decreased cerebral blood flow


Stimulation of Compensatory Mechanism

Increased BP

Increased HR


Increased uncontrolled firing of neurons 

Uncontrollable muscle excitement  Stiffness  Rolling of eyeballs

Lactic Acidosis

Failure of Compensatory Mechanisms

Cerebral Autoregulation Failure

Respiratory Depression, Arrythmias

Hypoglycemia Hyponatremia 

Diminished response and lethargy  (-) corneal reflex  (-) DTR



Damage to neurons and brain tissue


If treated: Fair Prognosis

If not treated: Poor Prognosis




Doctor¶s Order Please admit to PICU I Level 4 under P2 service The patient

Rationale upon admission is

Remarks exhibiting DONE

manifestations that require close monitoring and total dependence on the care of health care providers.

Secure Consent

Securing consent enlists the patient's faith and DONE confidence in the efficacy of the treatment and ensures

Jan. 10, 2011 the safety of both the medical team and the patient. 11:10pm TPR q4 and record Vital signs (Temperature, Pulse Rate, and Respiratory DONE Rate) indicate patient¶s state of health. To monitor and note any alterations that may need or elicit prompt referral and immediate intervention Non per orem The patient has diminishing level of GCS, making the DONE

57 risk for aspiration very likely. Labs: CBC PC Complete blood count is the determination of the DONE quantity of each quantity of each type of each blood cell in a given specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white cells. Platelet count is required for the determination of the number of platelets present and/or their ability to function correctly. These tests will help determine underlying diagnosis. Urinalysis Urinalysis is a microscopic examination of the urine DONE that detects red blood cells, white blood cells and bacteria in the urine. This test is done to rule out UTI or kidney or urinary bladder related diseases.This is one of the standard tests done upon admission to completely screen the patient of any underlying disease condition.

58 Sodium/ Potassium Used to detect electrolyte imbalances associated with DONE dehydration, edema, and a variety of diseases. This is one of the standard tests done upon admission to completely screen the patient of any underlying disease condition and help determine the possible management strategies required by the patient. Creatinine Creatinine is mainly filtered by the kidney, though a DONE small amount is actively secreted. Measuring serum creatinine is used to indicate renal function. This is one of the standard tests done upon admission to completely screen the patient of any underlying disease condition and help determine the possible management strategies required by the patient. Chest X-ray APL Chest X-ray provide a good outline of the heart and DONE major blood vessels and usually can reveal a serious disease in the lungs, the adjacent spaces, and the chest

59 wall, including the ribs. This is one of the standard tests done upon admission to completely screen the patient of any underlying disease condition and help determine the possible management strategies required by the patient. Calcium/ Magnesuim Calcium and magnesium belong to a group of DONE "parasympathetic" chromium elements (which includes and

copper), that exhibit anti-inflammatory or degenerative properties at higher amounts, in contrast to elements such as potassium, zinc, manganese, or iron, which are pro-inflammatory when high. This is one of the standard tests done upon admission to completely screen the patient of any underlying disease condition and help determine the possible management strategies required by the patient.

60 Start venoclysis with D5 0.3 NaCl 500cc at 45ggt/min
The 3% NaCl restores blood pressure, pH, and urine output with approximately one half of the cumulative fluid requirement of patients who received isotonic fluids (p less than 0.05).


I and O q shift

Monitoring I & O help assess fluid balance. Accurate DONE measurement of a patient's fluid intake and output will identify those patients at risk of becoming dehydrated or overhydrated. This will assess the functioning of the patient¶s urinary system.


An arterial blood gas (ABG) test measures the acidity DONE (pH) and the levels of oxygen and carbon dioxide in the blood from an artery. This test is used to check how well your lungs are able to move oxygen into the blood and remove carbon dioxide from the blood. An arterial blood gas (ABG) test is done to:


Check for severe breathing problems and lung diseases, such as asthma, cystic fibrosis, or chronic obstructive pulmonary disease (COPD).


See how well treatment for lung diseases is working.


Find out if you need extra oxygen or help with breathing (mechanical ventilation).


Find out if you are receiving the right amount of oxygen when you are using oxygen in the hospital.


Measure the acid-base level in the blood of people who have heart failure, kidney failure, uncontrolled diabetes, sleep disorders, severe infections, or after a drug overdose.

62 Cranial CT Scan A cranial computed tomography (CT) scan uses many x-rays to create pictures of the head, including the skull, brain, eye sockets, and sinuses. This will help visualize and diagnose any abnormalities in the skull and brain which will aid in properly diagnosing patients exhibiting manifestations due to illnesses involving the head and the brain. DONE

Blood GSCS

This is used to screen for presence of microorganisms DONE in the blood which may be suggestive of sepsis.

Medications: a. Ceftriaxone 525mg q12 a. Ceftriaxone is bactericidal, this drug inhibits cell wall synthesis promoting osmotic


63 b. Amikacin 155mg OD b. Amikacin is an aminoglycoside. It binds to ribosomal subunits in bacterial cell causing cell death.

c. Phenobarbital 105 mg as loading dose, then 50mg OD IVTT as maintenance c. Phenobarbital is an anti-seizure drug.

d. Diazepam 2mg IVTT prn for active seizure

d. Diazepam is used to potentiate the effect of GABA, depress the CNS and suppress the spread of seizure activity.

e. Salbutamol nebulization q8 e. Salbutamol is given to treat bronchospasm in order to maintain clear airway and proper gas

64 exchange Hgt now This is done to monitor blood glucose levels. Since the DONE patient is placed on an npo status, the risk for hypoglycemia is thereby elevated. Refer For continuity of care and to give prompt intervention DONE once unusualities occurs to prevent any complication or untoward incidents that may need immediate medical or surgical interventions. Pediatric endotracheal tube sizes are different from DONE Jan. 11, 2011 2am Intubate now with ETT size adult sizes; they range from 2.5mm to 5.0mm. Level 4.0 level 10-11 of ETT is chosen given the formula age divided by two plus 12cm The patient is intubated, thus cannot tolerate oral DONE Npo feedings.

65 This is done to monitor blood glucose levels. Since the DONE Hgt q8 patient is placed on an npo status, the risk for hypoglycemia is thereby elevated. Gram stain and culture sensitivity of Endotracheal NOT DONE For ETA GSCS Aspirate will help in diagnosing any presence of microorganisms that may cause or causal of infection. DONE Start mannitol 52 mg q6 Mannitol allows osmotic dieresis. Lumbar puncture is the primary diagnostic test for the DONE For Lumbar Puncture presence of Bacterial Meningitis The aPTT and PT tests are used as pre-surgical screens DONE For PT APTT for bleeding tendencies. For continuity of care and to give prompt intervention DONE Refer once unusualities occurs to prevent any complication

66 or untoward incidents that may need immediate medical or surgical interventions. January 13, 2011 Replacement & maintenance of fluid & electrolytes. DONE

Continue IVF Continue meds

This ensures the maintenance of drug action and DONE effectivity. Vital signs (Temperature, Pulse Rate, and Respiratory DONE Rate) indicate patient¶s state of health. To monitor and

VSq 4

note any alterations that may need or elicit prompt referral and immediate intervention

January 14, 2011 2am Phenobarbital as a barbiturate, may depress CNS and increase seizure threshold. As a sedative, may interfere with the transmission of impulses from thalamus to


Phenobarbital 53mg IVTT

67 cortex of the brain.

Jan. 15, 2011 11am

Shift Ceftriaxone to Meropenem 525mg IVTT q12

Meropenem inhibits cell wall synthesis in bacteria. DONE Readily penetrates cell wall of most gram positive and gram negative bacteria to reach penicillin-binding protein targets.

Jan. 16, 2011 Start Piperacillin ± Tazobactam







synthesis during bacterial multiplication. 525mg IVTT q6 Meropenem is substituted with piperacillin plus Discontinue Meropenem tazobactam. Gram stain and culture sensitivity of Endotracheal DONE For ETA GSCS Aspirate will help in diagnosing any presence of microorganisms that may cause or causal of infection.

68 Jan. 17, 2011 Start OTF Feeding CHO 630 CHON 315 FAT 105 1050 in 3 divided feedings 01/18/11 Accidental extubation (+) spontaneous breathing 01/23/11 Decrease Mannitol to 26cc q12 IVTT Decreasing mannitol dosage would be necessary to DONE improving signs and symptoms of increased Presence of spontaneous breathing makes it reasonable DONE for the patient to be weaned from ventilator in order to May not reintubate, O2 inhalation establish independent breathing and rehabilitation. via face mask at 4lpm Since the patient is place on NPO it is important to DONE maintain adequate nutrition by implementing OTF feedings at appropriately calculated distributions.

intracranial pressure.

69 Phenobarbital one tab + 5ml water OD at HS Increasing vitality of the patient make it more possible to administer drugs thru the GI tract. This may also help the patient in weaning from IVTT medications to per orem medications. 01/27/11 A cranial computed tomography (CT) scan uses many x-rays to create pictures of the head, including the skull, brain, eye sockets, and sinuses. This will help visualize and diagnose any abnormalities in the skull s/f Cranial CT scan and brain which will aid in properly diagnosing patients exhibiting manifestations due to illnesses involving the head and the brain. DONE




Normal Date Exam Value 01/15/11 The test that Rationale

Result of Remarks Patient

Clinical Nursing Responsibilities Significance 1. Discuss and explain the procedure and purpose of the test.

A measures 115 ± 155 Hemoglobin g/L hemoglobin liter of blood The test measures the percentage of Hematocrit 0.36 ± 0.48 RBC in the total blood volume 0.31 Low referred anemia. to A hemoglobin per anemia. amount of 103 Low referred to the hemoglobin

low is as

2. Inform the patient that no low is as 3. Assess the patient for any fasting is needed.

71 Normal Date Exam Value Rationale Patient Result of Remarks Significance Low RBC may indicate The test measures loss, the RBC count 4.20 ± 6.10 circulating hemorrhage, RBCs in 1 cubic 3.02 millimeter blood. leukemia, malnutrition The test measures High all WBC count 5.0 ± 10.0 leukocytes count present in 1 cubic 14.35 millimeter blood. of infection. High suggestive of is WBC 5. If patient is connected to IVF, make sure that the blood is not taken from the arm connected to the IVF. Hemodilution and elevates the test results. of failure, hydrated. Dehydration Low bone marrow 4. Make sure patient is well anemia, test. blood factor that will probably affect the results of the Clinical Nursing Responsibilities

72 Normal Date Exam Value Neutrophils serve as the body's Normal primary against through Neutrophil 55 ± 75 process phagocytosis. form Usually used to new neutrophils. diagnose specific type of illnesses. Lymphocytes initiate Lymphocyte 20 ± 35 immunologic responses. The 8. Any abnormality noted 16 Low infection, inform the normal treatment from an of body¶s ability to 7. If patient is under defense Some infection may the 73 Normal decrease in the bruising. cause a the site for bleeding or cancers 6. After the puncture, assess Rationale Patient Result of Remarks Significance causes false decrease of the test results. Clinical Nursing Responsibilities

patient that the test will be repeated to monitor progress.

73 Normal Date Exam Value test determines Rationale Patient Result of Remarks Significance will be reported to the physician. Clinical Nursing Responsibilities

lymphocyte blood count. Monocytes have

phagocytic action. It removes dead or injured cells, cell Monocyte 2 ± 10 and microorganism. This test is done to diagnose such an as fragments, 11 High



74 Normal Date Exam Value diseases. Rationale Patient Result of Remarks Significance Clinical Nursing Responsibilities

Eosinophils initiate allergic

responses and act against Eosinophils 1±8 infestation. test is use The to parasitic 0 Low

diagnose infestation.


75 Normal Date Exam Value Basophils initiate Basophil 0±1 type 1 allergic 0 Normal Normal Rationale Patient Result of Remarks Significance Clinical Nursing Responsibilities


The test measures all Platelet count 150 ± 400 platelets High High Platelet

present in 1 cubic 747 millimeter blood. of

76 Normal Date Exam Value Rationale Patient Result of Remarks Significance Clinical Nursing Responsibilities

Activated Partial Thromboplastin Time (APTT) Normal Exam Value The test measures the time in Jan. 15, APTT 2011 specific clotting process to occur. If the test sample takes longer than APTT Control 26.0 ± 31.0 the control sample, it 29.3 Normal Normal 29.4 ± 38.4 seconds for a 29.0 Normal Normal Rationale Patient Result of Remearks Significance Clinical Nursing Responsibilities

77 Normal Date Exam Value indicates decreased clotting function in the intrinsic pathway. Prothrombin Time (PT) Normal Date Exam Value PT Patient 11.8 ± 15.1 PT may be ordered when a patient is to Jan. 15, PT Control 2011 invasive medical procedure, such 12.0 ± 15.0 undergo an 13.8 Normal Normal Rationale Patient 15.0 Normal Result of Remearks Significance Normal Clinical Nursing Responsibilities Rationale Patient Result of Remarks Significance Clinical Nursing Responsibilities

78 Normal Date Exam Value as surgery, to ensure normal clotting ability. Rationale Patient Result of Remarks Significance Clinical Nursing Responsibilities

ABG Analysis



Normal Rationale Value

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance

pH indicates the Jan.19, pH 2011
7.35 7.45

1. Explain the importance of

acid-base level of the blood, or the hydrogen (H+) ion








patient or watcher. Inform the patient or watcher that the test requires blood

79 Normal Date Exam Value concentration Rationale Patient Result of Remarks Significance
sample. 2. Instruct the patient to

Clinical Nursing Responsibilities

breath normally during the test. 3. Warn that a brief cramping or throbbing pain may occur at the puncture site. 4. Take note of the patient s temperature respiratory rate. 5. If patient is receiving O2 therapy, discontinue O2 and

from 15 to 20 minutes before drawing the sample


Normal Date Exam Value Rationale

Result of Remarks Patient

Clinical Nursing Responsibilities Significance
to measure ABG on room air.

Post Test: 1. Apply pressure on the

puncture site. 2. After applying pressure, tape a gauze pad firmly over it. 3. Monitor VS. signs of Observe for circulatory such as

impairment swelling,


pain, numbness or tingling


Normal Date Exam Value Rationale

Result of Remarks Patient

Clinical Nursing Responsibilities Significance
in the bandaged arm. 4. Watch for bleeding from the punctured site.


PaCO2 indicates 35 45 how much oxygen




Normal Date Exam Value
mmHg the lungs are delivering to the blood. It indicates how efficiently the lungs eliminate carbon dioxide.

Result of Rationale Patient Remarks

Clinical Nursing Responsibilities Significance

75 100 PaO2 mmHg

Indicates how much oxygen the lungs are delivering to the blood.




Normal Date Exam Value Rationale

Result of Remarks Patient

Clinical Nursing Responsibilities Significance

Indicates whether a metabolic problem is present (such as 22 26 HCO3 meq/L low HCO3- indicates metabolic acidosis and a high HCO3indicates metabolic alkalosis. ketoacidosis). A





Normal Date Exam Value
The base excess indicates whether the patient is acidotic or alkalotic. A negative base BE (ecf) Base excess acidotic. A high positive base excess indicates that the patient is alkalotic. +/- 2 mmol/L excess indicates that the patient is

Result of Rationale Patient Remarks

Clinical Nursing Responsibilities Significance





Normal Date Exam Value
This indicates impaired respiratory function such as respiratory weakness or 80 100% O2Sat paralysis, airway

Result of Rationale Patient Remarks

Clinical Nursing Responsibilities Significance

obstruction, bronchiole obstruction, asthma, emphysema, and from damaged or filled with fluid




Normal Date Exam Value
because of disease.

Result of Rationale Patient Remarks

Clinical Nursing Responsibilities Significance

This indicates impaired respiratory function such as CO2 23-30 respiratory

weakness or paralysis, airway obstruction, bronchiole obstruction,




Normal Date Exam Value
asthma, emphysema, and from damaged or filled with fluid because of disease.

Result of Rationale Patient Remarks

Clinical Nursing Responsibilities Significance

January 24, 2010

Roentological Report

Subtle hazy infiltrates are seen in both inner lung zone and retrocardiac area. Trachea is at the midline, the heart is not enlarged. Rest of included structures are unremarkable.

Impressions: Consider Central Pneumonitis

Blood GSCS

No organisms found.


No organisms found.


No organisms found.


Urinalysis Urinalysis is performed to screen for urinary tract disorders, kidney disorders, urinary neoplasm and other medical conditions that produce changes in the urine. This test also is used to monitor the effects of treatment of known renal or urinary condition.


Laboratory Test

Normal Value / Results


Clinical Significance

Nursing Interventions

Jan. 19, 2011


Straw yellow to amber

Light yellow



y Inform patient that he should avoid intense athletic training or heavy physical work before the test, as these
Appearance Clear to faintly hazy Clear NORMAL

activities may cause small amounts of blood to appear in the urine. y Provide patient with urine container with lid.





y Instruct the patient to collect a sample of urine, preferably on arising in the morning; must not be contaminated by toilet paper, toilet water, feces or


1.003- 1.030



gravity Albumin Negative Negative NORMAL

y Tell females patients that they should use a clean cotton

ball moistened with lukewarm water (or antiseptic wipes provided with collection kits) to cleanse the external genital Sugar Negative Negative Normal area before collecting a urine sample. To prevent contamination with menstrual blood, vaginal discharge, or Pus cells 4 cells/hpf 1.2 NORMAL germs from the external genitalia, they should release some urine before beginning to collect the sample.

y To minimize sample contamination, women who
Red Blood Cells 2 rbc hpf 1-2 NORMAL

require a urinalysis during menstruation should insert a fresh tampon before providing a urine sample.
y Inform males patients that they should use a piece of clean

cotton moistened with lukewarm water or antiseptic wipes to cleanse the head of the penis and the urethral meatus (opening). Inform uncircumcised males that they should draw back the foreskin. After the area has been thoroughly cleansed, they should use the midstream void method to

collect the sample.
y If urine for culture is to be collected from an indwelling

catheter, it should be aspirated (removed by suction) from the line using a syringe and not removed from the bag in order to avoid contamination.

Post test:

y The lid must be sealed completely and the container must be labeled properly.
Specimen must be delivered to the laboratory.



Generic Name:

Ceftriaxone Brand Name: Classification: Dosage: Rocephin Third Generation Cephalosporin 525mg IVTT q12

Mode of Action: Indication:

Inhibits cell wall synthesis promoting osmotic instability. Bactericidal. This medication is indicated for uncomplicated gonococcal

vulvovaginitis, UTI; LRTI; joint, intraabdominal, skin or skin structure infection, septicemia, meningitis, perioperative prevention, acute bacterial otitis media, neurologic complications, carditis and arthritis from penicillin. Contraindication Contraindicated in patients hypersensitive to drug. This is also to be used cautiously to patients hypersensitive to penicillin because of the possibility of cross sensitivity. This must also be used with caution in breast feeding women and in patients with colitis and renal

94 insufficiency. Drug-Drug Interaction Interactions: 1. Aminoglycosides. May cause synergistic activity against some organisms, may increase nephrotoxicity. 2. Loop diuretics. May increase risk for adverse renal reactions. 3. Probenecid. May inhibit excretion and increase cefuroxime level.

CV: Phlebitis, thrombophlebitis Side/ Effects: Adverse GI: diarrhea, pseudomembraneous colitis, transient neutropenia, thrombocytopenia, eosinophilia Skin: maculopapular and erythemasus rashes, urticaria, pain,

induration, sterile abcesses, temperature elevation, tissue sloughing at IM injection site Other: Anaphylaxis, hypersensitivity reactions, serum sickness Nursing Responsibilities: 1. Check if the patient is hypersensitive to the drug. 2. Obtain specimen for culture and sensitivity tests before administration of the first dose. 3. Monitor for signs of superinfection. 4. Tell watcher to report signs of adverse reactions promptly. 5. Instruct watcher to report discomfort at the IV site. 6. Instruct watcher to report if stools become loose or if diarrhea

95 occurs. 7. Monitor efficacy of the drug by monitoring patient. 8. Ensure that the patient is not manifesting any condition contraindicated with the use of the drug.

Generic Name:

Amikacin Sulfate Amikacin Aminoglycoside 155mg OD

Brand Name: Classification: Dosage:

Mode of Action:

Inhibits protein synthesis by binding directly to the 30S ribosomal subunit. Bactericidal.


This drug is indicated to patients with serious infections caused by sensitive strains of Psuedomonas aureginosa, Eschericha coli, Proteus Klebsiella or Staphylococcus; uncomplicated UTI caused by organisms not susceptible to less toxic drugs; active tuberculosis and

96 Mycobacterium avium complex infection. Contraindication Contraindicated in patients hypersensitive to drug and must be used cautiously in patients with impaired renal function or neuromuscular disorders, in neonates and infants, and in elderly patients. Drug-Drug Interaction Interactions: 1. Acyclovir, Amphotericin B, cidofovir, cisplastatin,

vancomycin and other aminoglycosides. May increase nephrotoxicity. 2. Dimenhydrinate. May mask ototoxicity symptoms. Monitor patient hearing. 3. General blockade. 4. Indomethacin. May increase trough and peak amikacin levels. CNS: Neuromuscular blockade Anesthetics. May increase neuromuscular

Side/ Effects:

Adverse EENT: ototoxicity GU: azotemia, nephrotoxicity, increase in urinary excretion of casts Musculoskeletal: arthralgia Respiratory: apnea

Nursing Responsibilities:

1. Evaluate patient¶s hearing before and during therapy if the patient will be receiving the drug for longer than 2 weeks.

97 Notify prescriber if patient has tinnitus, vertigo or hearing loss. 2. Assess if the patient is hypersensitive to the drug. 3. Weigh patient and review renal function before therapy begins 4. Correct dehydration before therapy because of increased risk for toxicity. 5. Monitor renal function by monitoring intake and output. 6. Watch out for signs and symptoms of superinfection. 7. Instruct patient to promptly report adverse reactions to prescriber. 8. Encourage patient to maintain adequate fluid intake.

Generic Name:

Phenobarbital Brand Name: Classification: Dosage: Solfoton Barbiturate 105 mg as loading dose, then 50mg OD IVTT as maintenance dose

98 Mode of Action: As a barbiturate, may depress CNS and increase seizure threshold. As a sedative, may interfere with the transmission of impulses from thalamus to cortex of the brain. Indication: This drug is indicated as an anticonvulsant inn febrile seizures, status epilepticus, in sedation, short term treatment of insomnia, preoperative sedation. Contraindication Contraindicated in patients hypersensitive to drug and other barbiturates and in those with history of manifest or latent porphyria; in patients with hepatic or renal dysfunction, respiratory disease with dyspnea or obstruction, nephritis. Use cautiously in patients with acute or chronic pain, depression, suicidal tendencies, history of drug abuse, fever, hyperthyroidism, diabetes mellitus, severe anemia, blood pressure alterations, CV diseases, shock or uremia and in elderly debilitated patients. Drug-Drug Interaction Interactions: 5. Acyclovir, Amphotericin B, cidofovir, cisplastatin,

vancomycin and other aminoglycosides. May increase nephrotoxicity. 6. Dimenhydrinate. May mask ototoxicity symptoms. Monitor patient hearing. 7. General blockade. 8. Indomethacin. May increase trough and peak amikacin Anesthetics. May increase neuromuscular

99 levels. CNS: Drowsiness, lethargy, hangover, paradoxical excitement, Side/ Effects: Adverse somnolence, and psychological dependence CV: bradycardia, hypotension, syncope GI: nausea, vomiting Skin: rash, erythema

Nursing Responsibilities:

1. Make sure the patient is not allergic to barbiturates. 2. Watch out for signs of barbiturate toxicity: coma, cyanosis, asthmatic breathing, clammy skin and hypotension. 3. Don¶t stop the drug abruptly because this may worsen seizures. 4. Use for insomnia should not last longer than 14 days. 5. Ensure that the patient is aware that the drug is available in different milligram strengths. 6. Inform patient and significant others that full therapeutic effect aren¶t seen for 2 to 3 weeks, except when loading dose is used. 7. Warn patient not to stop the drug abruptly. 8. Do not let patient do activities that require mental alertness.

100 Generic Name:

diazepam Brand Name: Classification: Dosage: Mode of Action: Valium benzodiazepine 2mg IVTT prn for active seizure Potentiates the effect of GABA, depresses the CNS and suppresses the spread of seizure activity. Indication: This drug is indicated for anxiety, acute alcohol withdrawal, before endoscopic procedures, muscle spasms, preoperative sedation,

cardioversion, adjunct treatment for seizure disorder, status epilepticus, pain on stable regimen of antiepileptic drugs who need diazepam intermittently to control to control bouts of increased seizure activity Contraindication Contraindicated in patients hypersensitive to drug or soy protein; in patients experiencing shock, coma, or acute alcohol intoxication, in pregnant women, especially in first trimester and in children younger than 6months. This should also be used cautiously in patients with renal impairment, depression, or chronic open-angle glaucoma. Drug-Drug 1. Cimetidine, disulfiram, fluoxetine, hormonal contraception,

101 Interaction Interactions: isoniazid, metoprolol, propoxyphene, propanolol, valproic acid. May increase the risk of adverse effects. 2. CNS depressants. May increase CNS depression. 3. Digoxin. May increase digoxin level. 4. Diltiazem. May increase CNS depression and prolong effects of diazepam. 5. Levodopa. May decrease levodopa effectiveness. Monitor patient. 6. Phenobarbital. May increase the effects of both drugs. CNS: Drowsiness, dysarthia, slurred speech, tremor, transient amnesia, Side/ Effects: Adverse fatigue, insomnia, hallucinations CV: bradycardia, hypotension, collapse GI: nausea, vomiting, diarrhea Hematologic: neutropenia Hepatic: Jaundice EENT: nystagmus, blurred vision, diplopia Skin: rash, erythema


1. Warn patient to avoid activities that require alertness and good coordination until effects of drug are known.

102 Responsibilities: 2. Tell patient to avoid alcohol while taking the drug 3. Warn patient not to stop the drug abruptly. 4. Warn woman not to use drug in pregnancy. 5. Tell patient that smoking may decrease the drug¶s effectiveness 6. Make sure the patient is not exhibiting conditions contraindicated to the use of the drug. 7. Monitor elderly patients for dizziness. 8. Inform patient to promptly report signs of adverse reactions.

Generic Name:

Salbutamol Sulfate Brand Name: AccuNeb, Airomir, Asmol CFC-free, Proventil, Proventil HFA, Proventil Repetabs, Ventolin Volmax, VoSpire ER


Adrenergic bronchodilator


1 neb q8

103 Mode of Action: Relaxes bronchial and uterine smooth muscle by acting on beta2adrenergic receptors. Indication: This is indicated to: y y To prevent exercise-induced bronchospasm To prevent or treat bronchospasm in patients with reversible obstructive airway disease. y Solution for inhalation


Contraindicated in patients hypersensitive to drug and its components. Use cautiously in patients with CV disorders (including coronary insufficiency and hypertension),

hyperthyroidism, or diabetes mellitus and too those unusually responsive to adrenergics. Use extended-release tablets cautiously in patients with GI narrowing. With pregnant women, use cautiously. Breastfeeding women shouldn¶t take drug. In children, safety of drug hasn¶t been established in those younger than age 6 for tablets and Repetabs, younger than age 4 for aerosol and capsules for inhalation, and younger than age 2 for inhalation solution and syrup. In elderly patients, use cautiously.


Drug-Drug Interaction Interactions:

Drug ± Drug. CNS stimulants. May increase CNS stimulation. Avoid using together. Levodopa: May increase risk of arrythmias. Mao inhibitors, tricyclic antidepressants: May increase adverse CV effects. Propanolol, other beta blockers:May antagonize each other.

Drug ± herb. Herbs containing caffeine: May have additive adverse effects. Discourage using together.

Drug ± food. Caffeine: May increase CNS stimulation. Discourage using together.

CNS: Side/ Effects: Adverse





headache CV: tachycardia, palpitations, hypertension EENT: drying and irritation of nose and throat GI: heartburn, nausea, vomiting METABOLIC: hypokalemia, weight loss MUSCULOSKELETAL: muscle cramps

Nursing Responsibilities:

o Obtain baseline assessment of patient¶s respiratory status, and assess patient often during therapy. o Be alert for adverse reactions and drug interactions. o Assess patient¶s and family¶s knowledge of drug therapy. o Warn patient to stop drug immediately if paradoxical

105 bronchospasm occurs. o Give these instructions for using metered-dose inhaler: Clear nasal passages and throat. Breathe out, expelling as much air from lungs as possible. Place mouthpiece well into mouth and inhale deeply as dose is released. Hold breath for several seconds, remove mouthpiece and exhale slowly. o Advise patient to wait atleast 2 minutes before repeating procedureif more than one inhalation is ordered. o Warn patient to avoid accidentally spraying inhalant into eyes, which may cause temporary blurred vision. o Take patient to reduce intake of foods and herbs containing caffeine, such as coffee, cola, and chocolate, when using a bronchodilator. o Show patient how to take his pulse. Instruct him to check pulse before and after using bronchodilator and to call prescriber if pulse rate increases more than 20 to 30 beats/minute.

106 Generic Name:

Meropenem Brand Name: Classification: Dosage: Mode of Action: Merrem IV Carbapenem 525mg IVTT q12 Inhibits cell wall synthesis in bacteria. Readily penetrates cell wall of most gram positive and gram negative bacteria to reach penicillinbinding protein targets. Indication: This drug is indicated for: a. Complicated skin and skin structure infections from

Staphylococcus aureus (beta-lactamase or non-beta lactamase producing methicillin susceptible isolates only), Streptococcus pyrogenes, Enterococcus faecalis (excluding vancomycin resistant isolates), Psuedomonas aeruginosa, Eschirichia coli and Peptostreptococcus species. b. Complicated appendicitis and peritonitis from viridians group streptococci, E. coli, Klebseilla pneumonia, Pseuodomonas aeruginosa, B. fragilis and Peptostreptococcus species c. Bacterial meningitis from S. pneumonia, Haemophilus

107 influenza and Neisseria Meningitidis


This is contraindicated in: a. Patients who are hypersensitive to the drug and its components b. Use cautiously in elderly patients and in those with a history of seizure disorders and impaired renal function c. Not to be used in breast-feeding women

Drug-Drug Interaction Interactions:

a. Probenicid. May decrease excretion of meropenem; probenicid competes with meropenem for active tubular secretion.

CNS: seizures, headache, pain Side/ Effects: Adverse CV: phlebitis, thrombophlebitis GI: psuedomembranous colitis, constipation or diarrhea, glossitis, oral condidiasis and vomiting GU: RBCs in the urine

108 Hematologic: anemia Respiratory apnea, dyspnea Skin: injection site inflammation, pruritus, rash Other: anaphylaxis, hypersensitivity reactions, inflammation Nursing Responsibilities: 1. Ensure that the patient is not hypersensitive to the drug and its components. 2. Ensure that the patient is not manifesting any conditions contraindicated with the use of the drug. 3. Watch out for episodes of seizure in patients with meningitis, CNS disorders and compromised renal function. 4. Monitor patient for signs and symptoms of

superinfection. 5. Periodic assessment of organ system functions, incuding renal, hepatic and hemopoietic function is recommended for prolonged therapy. 6. Monitor patient¶s fluid balance. 7. Instruct patient or significant others to promptly report signs of superinfection and adverse reactions. 8. If seizures occur during the therapy, stop the infusion and notify the prescriber promptly.

109 Generic Name:

Piperacillin sodium and Tazobactam sodium Brand Name: Classification: Dosage: Zosyn Extendend-spectru penicillin, beta lactamase inhibitor 525mg IVTT q6

Mode of Action: Indication:

Inhibits cell wall synthesis during bacterial multiplication This drug is indicated for: a. Moderate to severe infections form piperacillin resistant, piperacillin producing and strains tazobactam of susceptible in beta-lactamase appendicitis


complicated by rupture or abscess, skin and skin structure infections, postpartum endometritis or pelvic inflammatory disease and moderate to severe community acquired pneumonia caused by Heaophilus influenza. b. Moderate piperacillin to severe and nosocomial Pneumonia cause by




producing strains of microorganisms.

110 Contraindication Contraindicated in patients who are hypersensitive to the drug and other penecillins. Use cautiously to patients with bleeding tendencies, uremia, hypokalemia, and allergies to other drugs such as cephalosporins because of possible cross sensitivity. Drug-Drug Interaction Interactions: a. Hormonal contraceptive. May decrease contraceptive effectiveness. Advise use of another form of contraceptive. b. Oral anticoagulants. May prolong effects. c. Probenicid. May increase piperacillin level. d. Vecuronium. May prolong neuromuscular blockade. CNS: insomnia, headache, fever, seizures, agitation, dizziness, anxiety Side/ Effects: Adverse CV: hypertension, tachycardia, chest pain, edema GI: diarrhea, nausea, constipation, psuedomembranous colitis,

vomiting, dyspepsia, stool changes and abdominal pain Hematologic: leucopenia. Neutropenia, thrombocypenia, anemia, eosinophilia Respiratory: Dyspnea Skin: rash, pruritus Other: anaphylaxis, pain, inflammation, phlebitis at IV site Nursing 1. Before giving the drug, ensure that the patient is not hypersensitive to it.

111 Responsibilities: 2. Obtain specimen culture and sensitivity tests before giving the first dose. 3. Watch out for signs of superinfection. 4. Inform patient and significant other to promptly report signs of superinfection and adverse reactions. 5. Monitor hematologic and coagulation parameters. 6. Give IVTT in slowly. 7. Assess IV site for irritation and discomfort. 8. Promptly inform the prescriber if signs of superinfection or adverse reactions occur.

Generic Name:

Mannitol Brand Name: Classification: Dosage: Mode of Action: Osmitrol Osmotic diuretic 52 mg q6 Increases osmotic pressure of glomerular filtrate, inhibiting tubular reabsorption of water and electrolytes, drug elevates plasma osmolality,

112 increasing water flow into extracellular fluid. Indication: This drug is given to: a. Test dose for marked oliguria or suspected inadequate renal function b. Oliguria c. To prevent oliguria or acute renal failure d. Diuresis in drug intoxication Contraindication This drug is contraindicated in patients who are hypersensitive to it. Contraindicated in patients with anuria, severe pulmonary congestion, frank pulmonary edema, active intracranial bleeding, metabolic edema, renal dysfunction, azotemia and oliguria, congestive heart failure or pulmonary congestion. Drug-Drug Interaction Interactions: CNS: Seizures, dizziness, headache, fever Side/ Effects: Adverse CV: edema, thrombophlebitis, hupotension, hypertension, heart failure, tachycardia, angina-like pain, vascular overload EENT: blurred vision, rhinitis a. Lithium. May increase urinary excretion of lithium.

113 GI: Thirst, dry mouth, nausaea, vomiting diarrhea GU: urine retention Metabolic: dehydration Skin: local pain, urticaria Nursing Responsibilities: 1. Monitor vital signs prior to, during and after drug administration. 2. Report increasing oliguria if such takes place. 3. Check fluid and electrolyte status of the patient frequently. 4. Increase oral fluid intake. 5. Do not give electrolyte-free IV fluids. 6. Monitor for signs and symptoms of hypokalemia. 7. Ensure adequate nutrition and fluid intake. 8. Instruct patient and significant other to promptly report adverse reactions and discomfort at the IV site.



Environmental theory Florence Nightingale, widely known as the ³Lady with the Lamp´, created the Environmental Theory which is still widely used nowadays. She stated in her nursing notes that nursing "is an act of utilizing the environment of the patient to assist him in his recovery" (Nightingale 1860/1969) and that it involves the nurse's initiative to configure environmental settings appropriate for the gradual restoration of the patient's health, and that external factors associated with the patient's surroundings affect life or biologic and physiologic processes, and his development. Environmental Factors Affecting Health Nightingale defined in her environmental theory the following factors present in the patient's environment: y Pure or fresh air y Pure water y Sufficient food supplies y Efficient drainage y Cleanliness y Light (especially direct sunlight) Any deficiency in one or more of these factors could lead to impaired functioning of life processes or diminished health status. Emphasized in her environmental theory is the provision

115 of a quiet or noise-free and warm attending to patient's dietary needs by assessment, documentation of time of food intake, and evaluating its effects on the patient. In the case of Child Y, the child needs the five elements presented by Nightingle for her present condition and rehabilitation. The parents should have adequate knowledge about sanitation so that they can provide her a comfortable environment. Orem's Model of Nursing The theory Orem is based upon the philosophy that all "patients wish to care for themselves". Orem¶s theory emphasizes on client¶s self-care needs. Client can recover more quickly and holistically if they are allowed to perform their own self cares to the best of their ability. The focus of Orem's model of nursing is to enhance the patient's ability for self-care and extend this ability to care for their dependents (Orem, 2005). A person's self-care deficits is a result of their environment. Three systems exist within the professional nursing model: the compensatory system, in which the nurse provides total care; the partial compensatory system, in which the nurse and the patients share responsibilities for care; and the educative-development system, in which the patient has the primary responsibility for personal health, with the nurse acting as a consultant (Central, 2005; Orem, 2005). The basic premise of Orem's model is that individuals can take responsibility for their health and the health of others, and in a general sense, individuals have the capacity to care for themselves and their dependents. Child Y needs to be completely attended to since she is not in the position to do activities of daily living by herself since she is in a persistent vegetative state. As members of the health care team, it is important to discuss with the significant others the things that Child Y needs putting into priority the survival needs of the child. It the job of health care professionals to

116 provide care for our client, promote their wellness and ensure sustenance of these needs in our absence, hence, there is a need to offer health teachings and support to the family in order to meet her self -care needs. It is important to teach the mother how to help her child bathe, eat and maintain general hygiene and discuss the importance of these measures in the treatment of the child. Virginia Henderson's 14 Basic Needs Virginia Henderson defined Nursing as ³assisting the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that an individual would perform unaided if he had the necessary strength, will or knowledge´. She also identified the 14 basic needs of an individual which includes the following: 1. Breathing normally 2. Eating and drinking adequately 3. Eliminating body wastes 4. Moving and maintaining desirable position 5. Sleeping and resting 6. Selecting suitable clothes 7. Maintaining body temperature within normal range 8. Keeping the body clean and well-groomed 9. Avoiding dangers in the environment 10. Communicating with others 11. Worshiping according to one¶s faith

117 12. Working in such a way that one feels a sense of accomplishment 13. Playing/participating in various forms of recreation 14. Learning, discovering or satisfying the curiosity that leads to normal development and health and using available health facilities. The present condition of the patient makes it utterly impossible for her to meet her 14 basic needs all by herself. She is lethargic and unresponsive, putting care for her own being the responsibility of the people around her. Considering this, it is very important to keep in mind that as health care team members, we should cooperate with the patient¶s significant others in working towards meeting the needs of the child at the present and plan for further rehabilitation once a more stable neurological status and motor function is achieved by the patient.










January 27, 2011



Ineffective peripheral tissue

At the end of the 2 hours nursing intervention, the patient s mother will be able to:

1) Review laboratory findings. ® To assess the extent of the condition of the patient. 2) Assess related physical

June 23, 2009 @ 8:30 P.M. GOAL MET At the end of the 2 hours of nursing care the mother was able to

y Hemoglobin(150- 155) 103

perfusion related T I to low haemoglobin count

y Hematocritsecondary to

a) Verbalize awareness of the

(0.36-0.48) 0.31 y RBC Count-


existence of the condition and
T ® The laboratory

(4.1-6.1) 4.02

measures that

Y RBC, HEMATOCRIT, E X E R failure to nourish C I S E the tissues at the capillary level. and HEMOGLOBIN that signifies decrease in oxygen resulting in the data shows abnormal results in

can improve the present status

examinations including capillary refill time, peripheral pulses and heart rhythm. ® To check the quality of circulation by assessing the cardiovascular system. 3) Instruct the mother to ask the patient to do

verbalize awareness of the existence of her daughter s condition as evidenced by the mother s statement Mao diay mura siya ug luspad tan awon. She also stated that I consulta nalang namo ni sa doctor para mas masolusyonan ug



range of motion

A T T E R N medi

® Range of motion will stimulate peripheral circulation.

4) Refer to the physician.
® To promote proper

5) Discuss with the significant other the necessary dietary changes.
® Proper diet will promote necessary nutrients that would be helpful in maintaining

proper circulation.

6) Check patient¶s intake such as medications, and foods and fluids that can be contraindicated.
® Foods, drugs, fluids that are contraindicated may aggravate patient s condition.

7) Discuss with the mother the condition of the patient, its extent,

122 nature and possible complications in understandable terms. ® To be aware of the action needed to be done. 8) Discuss with the mother measures to improve patient¶s condition like frequent consultation with the physician, diet

123 and exercise. ® It is important for the mother to be involved in the care of the patient since the patient is still a child. 9) Provide a quiet, restful atmosphere ®Conserves energy and lowers tissue oxygen demands. 10) Instruct the significant others

124 to encourage the patient to express any body problems. ® To identify promptly the patient¶s needs

Date January 27, 2011



Nursing Diagnosis

Plan of Care

Nursing Interventions



Hyperthermia related to active Central Nervous System Infection

At the end of 1 hour of nursing care, the patient

1. Monitor

body y


temperature every 30 minutes or more often if indicated.

Temperatur e rechecked: 37.4°C.

y Temperature

® Active infections cause

of 38°C. y Pulse rate of 135bpm. y Flushed skin noted. y Patient s skin is warm to touch. y Diaphoresis noted. L y Restlessness noted & M E T N Gulanick, et. al. Nursing A Care Plans. T I O R I action of pyrogens the body to elevate temperature due to the will:

® Evaluates the a effectiveness of interventions. 2. Employ measures to reduce excessive such as


Pulse rate: 130 bpm



temperature at
stimulated by immune


Left on bed asleep

normal range,
response against

invading microorganisms.

be able to rest fever, removing


applying ice bags to axilla and groins. ® Promotes patient¶s comfort and lowers body temperature. 3. Perform tepid sponge bath. ® Provide patient with comfort and


lowers body temperature. 4. Monitor and record vital signs. ®Increased heart rate, cool skin and decreased blood pressure may indicate hypovolemia, which


leads to decrease tissue perfusion. Increase respiratory rate compensates for tissue hypoxia. 5. Remind the watcher of the client on the


importance of having adequate rest periods. ® Adequate rest periods promote client comfort and avoid exertional activities that might worsen fever. 6. Provide patient with proper ventilation. ® Proper ventilation would provide comfort to the patient thus patient could be able to rest 7. Encourage the watcher

128 to increase oral fluid intake in feeding the baby. ®Encouraging patient may promote adequate hydration. 8. Discuss precipitating

factors with the parent, if known. ® Develops recommendation for keeping cool and avoiding heat-related illnesses. 9. Encourage the watcher about the adherence to

129 other aspects of health care including habits. ® Encouraging adherence to proper care management would help in providing wellness to the patient. 10. Administer antipyretic medication as ordered and effectiveness. ® Antipyretic medications aids in record management, dietary

130 the reduction of fever.

Date January 27, 2011



Nursing Diagnosis Risk for impaired skin integrity related to

Plan of Care At the end of the 8 hours shift the client will maintain tissue integrity as evidenced by:

Nursing Interventions

Evaluation GOAL MET.

OBJECTIVE: Diaphoretic Dry skin noted y with skin turgor y Unable to

N mechanical factors such U T R I T

1. Assess general condition of skin ® Assessment would help check for any abnormalities of the body 2. Assess for

At the end of the 8 hours shift the client was able maintain tissue integrity as evidenced by:

y y

as pressures and friction.

a. absence of redness and

® Skin is the primary

defense of the body; it
b. no skin

a. absence of


I O N A L intact; dryness of the skin M E integrity as compared T A B O NANDA 11th edition (Doenges) with a moist skin. is more prone to friction that may result to impairment of the skin





environmental moisture. ® Moisture may contribute to skin maceration. 3. Encourage the watcher for the implementation and posting of a turning schedule, restricting time in one position to 2 hours or less and customizing the schedule to patient¶s routine and caregiver¶s needs

redness and irritation skin breakdown

against infections
and diseases brought about by the invasion of microbes in the body. A normal skin is moist and


®Building up of pressures on the body could be prevented through turning.


4. Encourage caregiver

to maintain

functional body


®This would

maintain the

alignment of the body. 5. Increase tissue perfusion by massaging around

133 affected area. ®Massaging reddened area may damage skin further. 6. Clean, dry, and moisturize skin, especially over bony prominences, twice daily or as indicated by incontinence or sweating. ® This would thus help in preventing the impairment of the skin 7. Encourage the

134 parent to provide adequate nutrition and hydration ® Hydrated skin is less prone to breakdown. 8. Remind watcher to change the clothing and diapers if soaked ®This would help prevent the irritation of the skin. 9. Instruct the watcher to maintain the hygiene of the

135 patient. ®Hygiene is important for the body to prevent any impairment of the skin. 10. Refer physician for any problems ®Proper referral would give the patient proper management for the problem.






OBJECTIVE OF CARE Within the span 1. of 3 hours, the client·s an significant others will: or a) Verbalize 2.

NURSING INTERVENTIONS Determine the causes of fatigue or activity


Jan. 2011

28, y





Goal met After 3 hours of nursing care, the client·s significant other was able to: a) verbalize techniques to enhance activity tolerance

- (+) decerebrate rigidity -palmar noted - (+) persistent vegetative state -(+) stupor - unable to talk and ambulate pallor

related to persistent vegetative state R: There is

intolerance. R: Assessment guides treatment. Monitor vital signs. R: To watch for changes in blood pressure, pulse and respiratory rate after activities 3. Assist with ADLs as indicated.


insufficient physiological psychological


techniques to enhance activity tolerance; b) Participate willingly in

to endure or complete required daily activity. Nurses· Pocket Guide by Doenges et. al.

b) Participate R: Assisting the patient willingly with ADLs allows for conservation of energy. 4. Encourage sleep. rest and in

necessary/des ired activities.

necessary/des ired activities.

E R: In order to help relax the patient. P A T T E R N 6. 5. Provide a calm

environment. R: To promote a resful atmosphere. Place materials bedside. R: To avoid necessary near the

overexertion 7. Encourage ROM exercises. R: Exercises maintain muscle joint ROM. 8. Teach patient/caregivers to recognize signs of physical overactivity. strength and passive

R: So not to tire the patient. 9. Teach energy

conservation techniques, like: Sitting to do tasks,

Changing often R: In


order not to

exhaust the patient. 10. Administer iron

supplement as ordered. R: To have

supplemental iron which could anemia. help alleviate

Date Cues Needs Nursing Diagnosis Jan. 28, 2011 Objective: N than body y Weight: 10.5 kg y On OT feeding T R knowledge of foods that are y y y Weakness Stupor Low level of hemoglobin, hematocrit and RBC N low level of A nutrition techniques in increasing the perceives food and the act of eating. I T I O ® Patient has a the mother/ nutritionally significant beneficial to the other. patient b.) enumerate ways and information to provide the significant other. 3) Assess how the patient beneficial to the patient ® To determine what nutritionally needs. that are of individual nutritional identify the foods related to inadequate a.) identify the 2) Ascertain SO s understanding was able to will be able to: malnutrition. U requirements care, the significant other level. ® To assess the extent of Imbalanced nutrition: less y BMI = 11.3 At the end of 2 hours of nursing 1) Assess the patient s weight relative to age and activity At the end of 2 hours of nursing care, the significant other GOAL MET Plan of Care Nursing Interventions Evaluation

L knowledge of M E T management of including food preferences A B O L behaviors that need I C P modification. 5) Discuss to the significant other strategies on how to increase the patient s the patient s and intolerance of the patient diet. to different foods. ® To assess the patient s needs and recognize the mother in proper nutritional administration by using the patient s perception. 4) Discuss to the significant other the eating habits, because of the lack of patient s appetite. ®Provides an idea on how to properly manage food

A T attractive manner and T E R 6) Encourage the significant N other to involve the patient in making decisions related to food choice by letting the child choose the foods she wants within the limits of nutritional benefits. ® It is important to consider the child s wants since she will be the one who will eat variation in cooking. ® To motivate the client to eat. appetite like presenting the nutritious foods in an

these foods. 7) Encourage the significant other to promote pleasant and relaxing environment when feeding. ® Pleasant and relaxing environment will positively affect the child s eating disposition. 8) Instruct the significant other to provide oral care to the patient. ® To maintain the integrity of oral mucosa and other structures in the mouth that promotes eating.

9) Limit fluids one hour prior to meals. ® It decreases the possibility of early satiety. Collaborative: 10) Refer to the dietician. ® Helps in the proper management of food and allocation of the needed nutrients of the patient.




Individuals who are discharged from hospitals and rehabilitation facilities are increasingly in need of in-home care. Family caregivers should be aware that they may have to continue some of the medical and personal care regimens at home that had been performed by professionals in the facilities.

Discharge planning begins early during the hospitalization and rehabilitation processes. It involves the patient, family, and other persons taking care of the patient. The purpose of discharge planning is to help the patient continue their improvement outside of a clinical setting and in a more homelike environment. It helps in ensuring that the patient will have a safe place to live after discharge and in deciding what care and assistance is needed for the client¶s recovery. Since the child is not capable of understanding the discharge instruction owing to her developmental stage and present condition, the discharge plan is mainly directed to the parents and significant others. MEDICATION y y Take pain medications as needed. Inform SO to have medications on time, or as directed for the full course of therapy, even if feeling better. y Inform the client¶s significant other about the possible side effects of the medication.

146 y Encourage the significant other to report or inform the physician if any of these side effects occur. Inform and explain to the significant others in simple terms that other drugs, such as over the counter drugs that he or she is taking, will probably have other effects with the medication given. Moreover, emphasize the right timing or taking or the right time intervals of these drugs to maximize its effects and avoid further complications. y Provide information to the mother of the client for better understanding regarding therapeutic regimen.

EXERCISE y y y Encourage walking exercises. Encourage passive ROM exercises. Maintain physical and mental stimulation by ensuring that patient performs normal daily activities to maintain normal body functions.

TREATMENT y y y y Instruct the client¶s significant other to continue drug therapy as ordered. Inform the significant other of the dangers of non compliance to treatment regimen. Discuss to the client¶s significant other the complication of the condition. Instruct the patient¶s significant other to report to the physician promptly about any changes on health condition. y Encourage the patient¶s significant other to strictly comply with the doctor¶s orders given to patient, especially in taking prescribed medications.


HEALTH TEACHINGS y y y y y Instruct significant others to attend to the complains of the patient Encourage patient to express feelings of discomfort involving the condition Encourage rest. Instruct significant others to report any signs of unusuality involving patients condition. Notify the physician on the following:
fever and/or chills recurrent seizures projectile vomiting loss of consciousness

OUTPATIENT y Encourage significant others to have followed up visitations to the physicians after discharge. y Remind client¶s significant other on the arrangements to be made with the physician for follow-up check ups y y y Follow-up check up regularly in order to monitor and properly manage patient¶s illness. Continue medication as ordered. Instruct to have a follow-up check-up or refer to the physician if the patient is uncomfortable y Instruct the client and significant others to contact medical provider for any unusualities.




GOOD Onset of the illness



JUSTIFICATION The onset of illness was sudden. After the first attack, the child s status has progressively deteriorated.

Duration of illness

Although the patient was immediately brought to the hospital upon the early stages of the condition and she was given adequate medical attention and in the course of treatment and is actually showing signs of improvement. The illness has brought great disruptions in her neurologic and motor function which may be irreversible.

Precipitating factors

The precipitating factor present in the patient is exposure to microorganisms. Exposure to microorganisms easily modified by cleaning the cause of the exposure thus decreasing exposure to microorganisms. However, since the effects of the disease has already taken its toll on the body of the patient, it may be reasonable to presume that effects

eliminating precipitating factors at this stage would already prove to be futile.

Willingness to take medications and treatment

The patient complies with the medications strictly. Moreover, the mother is very willing to let her child take the medications prescribed to her by the doctor. The patient was also brought to the hospital be her mother for treatment.


The age of the patient is 3 years old. She is still still too young to recuperate from the disease amd is still very dependent to her family. Her recovey is variable to the presence of people to care for her.

Environmental factors

The client s home as reported is conducive for rest and sleep. The patient lives in a therapeutic environment. There are smaller chances of pollution and noise. It can be said that the environment as well was generally peaceful and calm is very favorable for rest and promotes better health.

Family Support

The family has been very supportive throughout. Her mother was supportive. Her father may not be with her in the hospital but he is working so hard to gain money for her hospitalization.



Poor:  Fair: (3*1)/7 =4/7 (1*2)/7 = 0/7 =6/7 

Good: (3*3)/7 Total: 2.0

General Prognosis: 1-1.6 = POOR 1.7-2.3 = FAIR 2.4-3.0 = GOOD

Rationale for a Fair Prognosis The patient has been brought to the hospital promptly upon experiencing symptoms of seizure and vomiting and was also given medical attention immediately, however, it must be noted that the type of disease that has come to the patient brings irreversible neurologic and motor dysfunction to an individual. Rehabilitation for this type of disease would only prove to be fair.



This case study has provided the proponent with important information about the patient s disease. In order to ensure that optimal health is restored and maintained, the author would like to recommend the following: Since the patient is still a young, suggesting recommendations to her is not ideal. Therefore focus of recommendation is given to her family who are, at present, responsible for meeting her needs.

To the patient s family The patient s family plays an important role in the patient s illness and recovery. Since Child Y is still very much dependent to the people around her, the family should make themselves physically present so that the patient would somehow feel their support and concern. They are encouraged to be the patient s source of strength and inspiration as she undergoes painful, traumatic and harrowing procedures. In addition, it is of prime importance that they are oriented and educated basic facts regarding the patient s condition so that they will understand her even better and assist him in his daily activities.

To the patient s community

The people in the patient s community are encouraged to be sensitive of the patient s condition and not interfere with her recovery. They should help provide an environment conducive for the patient s well-being. It is important that the patient would be provided with time to rest. They are encouraged to show and provide acceptance of the patient s condition and must take efforts to make her feel that she is still the same as the other children in their community. They must provide a happy and child-friendly environment so that the child s anxiety over her condition would be lessen.

To the student nurses: This case study would help them better understand the patient s condition. What is entrusted to student nurses is the life of their patient. Even with the clinical instructor s presence, they can still make mistakes and errors, which can harm the patient. Hence, they are encouraged to equip themselves with necessary knowledge that will enable them to render quality and holistic nursing care and intervention to patients in need. It is known that nurses play a major role in helping the client and family implement healthy behaviors and help them monitor the client s health. Thus, anticipatory guidance and knowledge about health should be supplied to help clients attain, maintain, or regain an optimal level of health. Student nurses should prioritize interaction with family members and significant others to provide support, information, and comfort in addition to caring for the patient. Thus, they should prepare themselves with the reality that they are soon to become health professionals. Genuineness, empathy, and respect are key elements for the nurse to possess. Student nurses must develop patience, love for our work, and empathy to our patients. They must assist in facilitating a remarkable experience as well as share our knowledge regarding the case. They must also continue to

study different cases and be able to impart this to other student nurses, patients and their significant others.

To the Ateneo de Davao University- College of Nursing The AdDU- College of Nursing is the source that provides student nurses with exposures that enable them to apply the knowledge they have gained and practice the skills they honed necessary for their profession. The faculty and staff are encouraged to continue improving the standards of the Ateneo Nursing Curriculum by providing quality education to students. Also they, themselves, must be well-trained to delegate learning to student nurses. It is important that they continue to inspire generations of today to perceive nursing as a gift and act of charity rather than a mere means to success.



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