PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)

COLLEGE OF NURSING
GRADUATE PROGRAM
Intramuros, Manila

A Case Study on
Spinal Cord Compression vs Guillain-Barre Syndrome
secondary to Urosepsis from complicated Cystitis,
Acute Kidney Injury, Hypertension,
Multiple Electrolyte Imbalance,
Neutropenia secondary to Sepsis
Gouty Arthritis not in Flare

In Partial Fulfillment of the Requirements in

Intensive Clinical Practicum

OSPITAL NG MAYNILA MEDICAL CENTER

Intensive Care Unit

Submitted by:
Hassan Magdy Mohammed Ibrahim, Suha C.

Submitted To:
Prof. Ma. Teresa A. Monderin
I. DATA BASE

A. Client’s Profile

Name: PATIENT VG
Address: Rd 10 Tondo, Manila
Age: 80 years old
Date of Birth: April 15, 1939
Place of Birth: Malolos Bulacan
Occupation: N/A
Marital Status: Widow
Number of Children: 6
Gender: Female
Religion: Roman Catholic
Weight: 145 lbs.
Height: 5 feet and 3 inches
BMI: 25.68
Date of Admission: October 14, 2019
Chief Complaint: Body Weakness
Diagnosis: Spinal Cord Compression vs Guillain-Barre Syndrome secondary to Urosepsis from
complicated Cystitis, Acute Kidney Injury, Hypertension, Multiple Electrolyte Imbalance,
Neutropenia secondary to Sepsis, Gouty Arthritis not in Flare
Source of Information: Patient X, Daughter and Chart
Introduction:

Guillain-Barre Syndrome according to Mayo Clinic (Oct 2019), is a rare disorder in

which one’s immune system attack one’s own nerves. Weakness and tingling in the lower
extremities are usually the first symptoms. As Guillain-Barre Syndrome progresses, muscle
weakness can evolve into paralysis. This case was chosen by the student for on the time of
clinical area practicum most of the patients admitted are diagnosed only with cerebrovascular
disease and are not multi-organ failure.

B. History of Present Illness

This is a case of an 80-year old female from Tondo, Manila who came in due to
generalized body weakness. 2 weeks prior to confinement patient was complaining of
hypogastric pain and sought consult at a private institution. She undergone EGD then and
was diagnosed with gastritis. The patient was then sent home without any medications
prescribed. 1 week prior to confinement patient had onset of hypogastric pain characterized
as dull pain with severity of 3-4 out of 10. This was associated with frequent urination about
10 times per day with loss of appetite and generalized body weakness. There was no noted
fever or nausea and vomiting or chest pain or changes in sensorium. Hence no consult was
done, and no medication taken.

Three days prior to confinement there was a persistence of symptoms and increase in
severity of hypogastric pain, urinary frequency and generalized body weakness. Patient was
observed to be increasingly weak with loss of appetite. There was still persistence of increase
in frequency of urination. No noted fever change in sensorium, chest pain or nausea and
vomiting. Persistence of symptoms prompted consult.

C. Functional Health Pattern

1. Health Perception and Health Management Patterns

Before Admission During Admission Analysis

Prior to admission Patient VG
perceives herself as healthy.
However, 10 years ago when her
husband died patient VG
develops hypertension. Since
then patient VG is very
compliant with her
antihypertensives according to
her daughter and always makes
time for her follow up check-up.
Aside from being hypertensive,
she was also diagnosed to have
gouty arthritis and is compliant
with her medications as well.
Patient VG describes herself as
very healthy by mouthing words
“Malakas pa kaya ako”.
2. Nutritional and Metabolic Pattern
Before Admission
VG’s daughter prepared her
mother’s meal. They eat three
times a day and makes sure her
mother eats a well-balanced
meal with less salt. When VG
was diagnosed with
hypertension which follows
their father death, patient VG’s
daughter makes sure her
Patient VG is not as positive
about her health status as she
used to be for this is the first
time she was admitted in an
ICU. She feels that she is very
weak in the moment and very
sick.
During Admission
Patient VG is being fed via
NGT every four hours as
computed by the hospital’s
dietician.
Due to the constant
monitoring in the
intensive care unit and
the presence of various
medical equipment.
Patient VG becomes
anxious that her diagnosis
may be very serious and
scares her for she used to
be strong just one week
ago.
Analysis
Patient VG’s nutritional
status was taken care of
even before admission to
prevent progression of her
illness.
mother eats a healthy diet.
Patient VG daughter also aims
to help her mother lose weight
but there is not much change in
patient VG’s weight. However,
patient VG is very fond of
eating sweets. Saying that what
her daughter cooks is not very
tasty.

3. Elimination Pattern

Before Admission During Admission Analysis

Patient VG daughter said that Patient VG is currently voiding Patient VG’s changes in
her mother’s bowel activity is via urinary catheter. Her stools stool pattern may be due
at regular pattern. She defecates are loose and greyish in color. to her gastritis or may be
daily. However, 2 weeks prior due to the presence of an
to confinement Patient VG infection.
didn’t tell her daughters that
she had 6 loose bowel
movements and some with
blood on it.

4. Activity and Exercise

Before Admission During Admission Analysis

Patient VG’s daughters’ Patient VG is mostly lying on Patient VG is scared to do

problem is that their mother is bed all day due to her exercises at home due to
very sedentary. She tends to sit generalized body weakness. her age. She said that
all day watching television.
She never exercises at home.
5. Sleep and Rest Pattern
Before Admission
Patient VG has no problems
sleeping at home and just tends
to wake up early. She said that
it may be due to her age.
However, when her arthritis
attacks sometimes she can’t
sleep at night.
6. Cognitive and Perceptual Pattern
Before Admission
Has no problem with auditory,
olfactory, tactile, gustatory
senses. Just a bit blurring on
vision and just wears reading
glasses. Had never experienced
any pain and discomfort with
her senses. She also has keen
memory with things.
But is helped by healthcare
providers by providing bedside
passive range of motion
exercises.
During Admission
Patient VG tends to sleep most
of the time saying that she has
nothing to do rather than
sleeping.
During Admission
She has difficulty of expressing
herself due to placement of
endotracheal tube and difficulty
of using her hand due to
weakness. However, she makes
sure to answer to questions by
mouthing words. Other than
that, she has no other problems.
exercising might do more
harm to her than good.
Analysis
Being well rested helps to
relax patient VG which
helps her to be able to
control her hypertension.
Analysis
Although with difficulty
of using her extremities
and with the presence of
generalized body
weakness patient VG’s
cognitive and perceptual
pattern is still intact.
 7. Self-perception and Self-concept Pattern
Before Admission
Patient VG is very happy with
her life. She was able to let all
her children except one whom
had a medical condition
graduate school and for her that
is a sense of fulfillment.
8. Role and Relationship Pattern
Before Admission
Patient VG is very close with
her family she lives with her
daughters and sometimes still
plays the role as the decision
maker of the family.
9. Sexuality and Reproductive Pattern
During Admission
She’s unsure of what to feel.
She’s mostly scared of what
will happen to her, with her
illness.
During Admission
Despite the short visiting hours
daily, 5 minutes at most.
Patient VG makes sure she
smiles when her daughter visits and have someone to rely
her and looks for them when
the visiting hours are over. Her
daughters also always ask their
mother about her condition and
updates her on what is
happening at home.
Analysis
Due to the sudden change
in health status, patient
VG sense of self-
perception had change.
She is more worried now
that her condition might
deteriorate. She is more
focused now of her illness
that she can’t express what
she feels.
Analysis
Having a good relationship
with one’s family help
patient VG to be strong
to on times of difficulty.
Before Admission
Patient VG is a widow. Other
data on sexuality were not
assessed.
10. Coping and Stress-Tolerance Pattern
Before Admission
When Patient VG faces
problems at home the first
thing she do is to pray. For her
prayers helps her go through
difficulties and tough times.
Patient VG also consults her
family whenever she faces
problems.
11. Values and Belief Pattern
Before Admission
Patient VG is a Catholic, she
practices her faith by going to
church weekly with her family.
D. Behavioral Wheel
HEALTHFUL AFFECTED
During Admission
Patient VG is a widow. Other
data on sexuality were not
assessed.
During Admission
Patient VG still prays
regardless of her situation and
still hold on to her faith to cope
up with her situation.
During Admission
Patient VG still prays and hold
on to her faith that she would
be able to get through he
condition
HOLLISTIC
Analysis
This area was not explored
by the student.
Analysis
Having faith and will to
live helps patient VG to be
compliant with medical
treatments which can help
her to heal faster.
Analysis
Having faith helps patient
VG relieve her anxiety and
worries about her
condition.
SOURCE
 BEHAVIOR AREAS OF EFFECTS
BEHAVIORAL
WHEEL

Eats a well-balanced 1. Disease and A well-balanced meal According to the

with less salt meal Disorder helps a person to be World Health
three times a day healthy and avoid or Organization in 2018,
prepared by her lessen the chances of eating a healthy diet
daughter. a person to acquire protects you against
any type of disease or many chronic
disorder. noncommunicable
diseases, such as
heart disease,
diabetes and cancer.
Eating a variety of
foods and consuming
less salt, sugars and
saturated and
industrially produced
trans-fats, are
essential for healthy
diet.

2. Growth and As one ages, the Older persons are

Development nutritional needs of particularly
an individual vulnerable to
malnutrition. The
changes, both their
process of ageing
lean body mass and also affects other
basal metabolic rate nutrient needs. For
declines with age example, while
therefore a well requirements for
balances meal is some nutrients
needed to supply the may be reduced,
some data suggest
nutrients that often
that requirements
gets insufficient as for other essential
one ages. nutrients may in
fact rise in later
life. Therefore a
healthy diet
should be ensured.
 (WHO, 2018)

3. Drugs Eating a well- Food can help

balanced meal helps control some
to maintain a positive chronic health
conditions, and in
health status thus
some cases
reduces the need for eliminates the
medications. need for drugs.

(Adams, 2019)

HEALTHFUL AFFECTED HOLLISTIC SOURCE

BEHAVIOR AREAS OF EFFECTS
BEHAVIORAL
WHEEL

Patient VG is 1. Disease and Being compliant with Medication

compliant with her Disorders her anti- adherence means
hypertensive hypertensives and taking medications as
medications and strictly committing prescribed – the right
always makes time with her check-up dose, at the right
for her follow-up schedules decreases time, in the right way
check-up the chances for and frequency. It is
patient VG to important to take
develop medicine as
complications from prescribed by a
hypertension for she doctor or instructed
always monitors her by a pharmacist to
condition. avoid the disease
getting worse,
hospitalization, even
death. (FDA, 2016)

2. Safety and First One of the The excessive

Aid complications of pressure on your
hypertension is stroke artery walls caused
which may cause by high blood
paralysis to the pressure can damage
patient and possible your blood vessels, as
 injury. Therefore, well as organs in your
being compliant to body. The higher
medication avoids your blood pressure
such complications. and the longer it goes
uncontrolled, the
greater the damage.
Uncontrolled high
blood pressure can
lead to complications
including: Heart
Attack, Stroke,
Aneurysm, and Heart
Failure. (Mayo Clinic
2018)

RISK AFFECTED HOLLISTIC SOURCE

AREAS OF EFFECTS
BEHAVIORS BEHAVIORAL
WHEEL

Patient VG just 1. Safety and First Sitting or lying for Inactive lifestyle
watches TV all day Aid too long causes affects your body by
and does not exercise. decrease in muscle losing muscle
mass which may strength and
increase risk for endurance and your
injury. bones may get
weaker and lose some
mineral content.
Which makes you at
risk for injury.
(Medline Plus, 2016)

2. Disease and Sedentary lifestyle Sedentary lifestyles

Disorder especially on older increase all causes of
adult may contribute mortality, double the
to worsening of non- risk of cardiovascular
communicable diseases, diabetes,
diseases. Just laying and obesity, and
 down all day increase the risks of
increases the chance colon cancer, high
Patient VG’s blood pressure,
hypertension can osteoporosis, lipid
cause complication. disorders, depression
and anxiety. (Pope,
2019)

3. Nutrition Sedentary lifestyle Being inactive affects

makes metabolism one’s metabolism by
slow down which burning fewer
could increase calories. Which
chances of being makes one likely to
overweight. gain weight and have
trouble in breaking
down fats and sugars.
(Medline Plus, 2019)

RISK AFFECTED HOLLISTIC SOURCE

AREAS OF EFFECTS
BEHAVIORS BEHAVIORAL
WHEEL

Patient VG prefers to 1. Exercise and
eat sweet foods.
Eating foods high in Rates of obesity are
Fitness sugar content rising worldwide and
increases the risk of added sugar is
gaining weight. thought to be one of
the main culprits.
Also, drinking a lot
of sugar-sweetened
beverages is linked to
an increased amount
of visceral fat, a kind
of deep belly fat
associated with
conditions like
diabetes and heart
 disease. (Healthline,
2018)

2. Disease and High sugar diet may High sugar diets have
Disorder increase patient VG’s been associated with
blood pressure and an increased risk of
cause complication many diseases,
for high sugar diets including heart
increases blood disease. Evidence
viscosity. suggest that high-
sugar diets can lead
to obesity,
inflammation and
high triglyceride,
blood sugar and
blood pressure levels
which are all risk
factor for heart
diseases. (Healthline,
2018)

3. Mental Health Eating a lot of foods While a healthy diet

high in sugar content can help improve
affects one’s mood. your mood, a diet
high in added sugar
and processed foods
may increase chances
of developing
depression. In
another study in over
69,000 women
demonstrated that
those with the highest
intakes of added
sugar had a
significantly greater
risk of depression
compared to those
with the lowest
intakes. (Healthline,
 2018)

E. Past Health History

Patient VG was a known hypertensive for 10 years maintained on Amlodipine 10mg/tablet
one tab once a day and Irbesartan 300mg/tab one tab once a day and takes Febuxostat
40mg/tab one tab once a day for her gouty arthritis. Regularly consults a private Physician.
Not known diabetic. Non-smoker, non-alcoholic and denies use of illicit drugs. No known
allergies as well. Admitted once due to gastritis however no maintenance medications were
prescribed for it.

F. Course in the Ward:

October 14, 2019. Patient was admitted due to generalized body weakness. Upon admission
patient’s consent for admission and management was secured. She was positioned into
moderate high back rest. She was on a DASH diet or dietary approaches to stop hypertension
with strict aspiration precaution. She was hydrated with Plain Normal Saline Solution with
the rate of 100ml per hour. The following diagnostic procedures were ordered: CBC,
urinalysis, urine culture, BUN, CREA, AST, ALT, NA, K, BUA, 12-lead ECG, FBS, lipid
profile, CBG, Blood culture 2 sites and KUB ultrasound. The following medications were
prescribed: Ceftriaxone 2 grams TIV OD, HNBB 10mg TIV every 8 hours for abdominal
pain, Omeprazole 40 mg TIV twice daily, Paracetamol 300mg TIV for fever, Amlodipine
10mg/tab one tab once a day at night and Febuxostat 40mg/tab one tab once a day. Her vital
signs were monitored every 4 hours and her intake and output was monitored accurately. She
was then referred to IDS and Nephrology as comanaging services.

October 15, 2019. On second day of admission patient is seen awake not in distress, no
pertinent change in physical examination. With the following latest vital signs BP 120/80 HR
79 RR 21 Temp 36.7, O2 Sat at 94 % on room air. Still on DASH Diet. However, lab results
showed hypokalemia, patient’s potassium result is 2.7. Therefore, her fluid was shifted to
PNSS one liter plus 40 meqs of potassium chloride for 8 hours for 3 cycles and is prescribed
with Potassium Chloride tab, 2 tablets three times a day. Then a post correction potassium
was ordered as well. Her omeprazole was shifted to once a day prebreakfast. Then her
Amlodipine was ordered to be given during morning not in nighttime and her Febuxostat was
placed on hold. Still awaiting comanaging services. Frequency of monitoring vital signs was
increased to every hour from every four hours while ongoing potassium correction.

October 16, 2019. On the third day of admission patient seen awake, conscious and coherent
and not in distress. Patient is still weak presenting with bilateral lower extremities weakness
with no other pertinent deviations on physical exam. Latest vitals as follows: BP 110/70 HR
80 RR 21 Temp 36.6 O2 sat 98% on room air. Still on DASH diet and with ongoing
Potassium correction fluids. Patient was ordered to have a repeat CBC.

October 17, 2019. On the fourth day of admission patient is still presenting with generalized
body weakness. On DASH diet and still on potassium correction. Latest Vital Signs: BP
120/80 HR 80 RR 21 Temp 36.6 O2 sat 98% on room air. Ordered to facilitate pending labs
and was ordered Lumbosacral X-ray AP-L.

October 18, 2019. On the fifth day of admission patient was awake, conscious and coherent
with no apparent distress. Still presenting with bilateral lower extremities weakness. Patient
had completed potassium correction thus fluid was shifted to PNSS 1L at 80cc/hr and post
correction potassium was done. Still with the following presenting problems: urosepsis,
hypokalemia in which etiology is to be determined and HCVD, LVH. Patient is closely
monitored for increasing extremities weakness, DOB and hypotension.

October 19, 2019. On the sixth day of admission patient was still seen with bilateral lower
extremities weakness. Latest Vital as follows: BP 140/90 HR 81 RR 20 Temp 36.7 O2 sat
96%. Her post correction potassium came in and shows hyperkalemia with a result of 5.8.
She was then ordered to have a stat 12-lead ECG and stat repeat potassium. She was then
prescribed with Salbutamol nebulization every hour for 6 cycles, GI solution with 1 vial
D50/50 + 10 units regular insulin as fast drip for 6 cycles and Furosemide 40mg IV as now
dose only. Rest of her medications are continued and her oral KCL tabs were put on hold.

October 20, 2019. On the seventh day of admission patient was seen awake conscious and
coherent. On DASH diet with SAP and with hydration of PNSS 1L x 80cc/hr. She was noted
to have febrile episode with latest vital signs as follows: BP 130/70 HR 110 RR 24 Temp 39
O2 sat of 95% on room air. She was also noted to have episodes of loose stools. Her
antibiotics was then shifted from Ceftriaxone 2 grams IV OD to Piperacillin + Tazobactam
2.25 grams in PNSS 100ml for 2 hours infusion every 6 hours. Due to her constant lower
extremities’ weakness following labs were ordered as well: ESR, EMG, Plain Cranial CT.
CBG monitoring pre-meals and at hours of sleep was ordered as well.

October 21, 2019. On the Eighth day of admission persistence of weakness of lower
extremities was noted despite of potassium correction. Hence spinal cord compression versus
demyelinating spinal cord disease was considered. On the same day patient was noted to
have episodes of tachypnea with shallow breathing. It was also noted that the patient had an
episode of desaturation to 87% in room air which has improved with oxygen
supplementation via nasal cannula at 3 lpm. The apparent respiratory distress of patient and
the probability of demyelinating spinal cord disease prompt transfer of patient to ICU for
close monitoring. Patient was then admitted to ICU. On ICU an NGT was inserted and
patient was started on blenderized feeing at 1600 kcal/day with the following breakdown
Carbohydrates 220g Protein 120g Fats 37g. Her hydration was then shifted to D5W 1l x 80
cc/hr for 2 cycles then D5W 1l x 40 cc/hr from PNSS 1l x 80 cc/hr. The following laboratory
and diagnostic procedures are ordered as well: CBC, urinalysis, Na, K, Cl, Na every 6 hours,
AST, ALT, BUN, CREA, Procalcitonin, CXR-AP, Plain Cranial CT Scan, Plain
Thoracolumbar CT scan, 12-lead ECG, EMG-NCV, Lumbar puncture with CSF analysis,
Blood CS for 2 sites, DTVS and IE c/o OB GYN. Patient’s current meds are the following:
(1) Piperacillin + Tazobactam 2.25 g in PNSS 100ml for 2 hours every 6 hours, (2)
Paracetamol 300 mg IV every 4 hours RTC, (3) Omeprazole 40 mg IV in AM, (4)
Amlodipine 10mg/tab one tab in PM, (5) Losartan 50mg/tab in AM, (6) Lactulose 30ml once
a day at HS for constipation, (7) D50/50 vial for CBG less than or equal to 80mg/dl, (8)
Regular Insulin 5 units SC for CBG greater than or equal to 180 mg/dl, (9) Febuxostat
40mg/tab one tab once a day. Vitals are monitored hourly. CBGs are monitored TID and at
HS. Patient was placed on standby intubation.

October 22, 2019. Patient was awake not in apparent distress but still with lower extremities
weakness. Still on blenderized feeding with 1,600 kcal. The rate of her fluid was increased to
90 cc/hr. Her losartan tablet was put on hold and her paracetamol was shifted back as PRN
dose. Levofloxacin 750 mg/tab one tab once a day per NGT and clonidine 75mg/tab one-tab
SL for BP greater than or equal to 160/90 were added to her medications. Repeat Chest X-ray
PA, sputum gs/cs, ABG, MRI are added to her diagnostic procedures. Serial monitoring of
Na was decreased to 12 hours. She was also referred to the following services IDS,
Neurology, Cardiology, Pulmonology, Nephrology, Rheumatology and Hematology as
comanaging services. On the same day patient was seen by the Pulmonology service and
noted impending respiratory failure and suggests intubation. Hence patient was intubated and
was connected to mechanical ventilator with the following settings: AC mode, BUR 16, IFR
50, TV 320, PEEP 5, Sensitivity 0, FiO2 40%. Post intubation patient was ordered to have
CXR AP again, ETA GS/CS and ABG 1-hour post intubation. On the same day at 10 pm
patient electrolytes were noted K 5.17 and Na 150. Distilled water 200 ml every 8 hours per
NGT and Salbutamol 1 neb every hour for 6 doses was started. Post correction K was then
ordered.

October 23, 2019. Patient was awake, not in apparent distress and intubated. Patient still
conscious and coherent mouths words and follows command. Able to feel touch on both
lower extremities but is having difficulty moving them. With latest vital signs BP 100/60, HR
72, RR 20, Temp 36.1 O2 sat while on Mech Vent 100%. Noted onset of grade 3 bipedal
edema hence IVF was shifted to heparin lock. Maintained on Mechanical Ventilator with the
same settings. Continued with the same medications. VS monitored hourly and intake and
output accurately. Monitoring of sodium was decreased to every 24 hours from 24 hours.
ABG was ordered and repeat CBC on third day of Piperacillin + Tazobactam.

October 24, 2019. On the ninth day of admission, patient was noted to be in not apparent
distress. Follows command and with no changes in sensorium noted. Patient still on heparin
lock. Pre and post feeding flushing with distilled water was decreased to 50ml. Still for
EMG-NCV. Still hooked to mechanical ventilator with the same settings. Patient was ordered
to start Sodium Bicarbonate tablet three times daily and Furosemide 80mg IV every 12
hours.

October 25, 2019. On the tenth day of admission, patient was still on NGT feeding she was
referred to clinical nutritionist for nutritional build-up. Feeding was revised then from 1,600
kcal per day to 1,500 kcal into 6 divided feedings. Patient antibiotic was shifted to
Meropenem 1 gram IV every 12 hours.
II. CLINICAL NURSING

A. Assessing Client

The student handled the patient from October 23-25, 2019 during the three days of
interaction Maslow’s Hierarchy of needs was used as guide in assessing the patient holistically.
However, due to the limitations of the patient in verbal communication for she is intubated and
was able to only answer by mouthing words, for she has difficulty in lifting her arms due to her
condition therefore communicating via writing was not possible as well. Also visiting hours is
only limited to 5 minutes per day. Therefore, data gathered is very limited.

The first level of Malow’s hierarchy of needs is the patient’s Physiological needs. Here
the students assessed the patient’s physical status on October 23, 2019. Upon assessment the
patient is awake and not in apparent distress. Patient is cooperative and is coherent. Skin appears
normal in color however patient’s upper and lower extremities are both edematous with a scale
of 4+ and is pitting. Patient has good turgor. However, presence of pressure sores is observed on
the sacrum area (grade 2) and on both heels (grade2). Upon inspection of both eyes, patient’s
palpebral conjunctiva is pinkish in color. Cornea is not cloudy. Pupils are equally round and
reactive to light and accommodation. No edema or excessive tearing. No tenderness upon
palpation. While inspecting patient’s ears no lesion, nodules or masses noted. Both ears are
symmetrical in shape. Pinna recoils during palpation with no tenderness. Patient’s nose is
symmetric and straight in shape; no paleness of the inner mucosa. No discharge or inflammation
present. During palpation, no tenderness or lesion was noted, and the nasal pathway is patent.
Patient’s oral cavity is moist and pink in color, no bleeding noted. Patient’s neck muscles are
equal in size, neck veins are not distended. Upon inspection, chest movement is symmetrical in
shape. During auscultation, crackles are heard on both lung fields. No abnormal breathing pattern
observed even when the patient is intubated. Upon inspection, abdomen is round and
symmetrical in shape. There are audible bowel sounds during auscultation. There is slight
tenderness on the hypogastric area upon palpation. Patient’s heart rate and rhythm is regular,
Touch, pain, and temperature sensations are normal. GCS level is 15. CN I (Olfactory) is normal
patient was able to differentiate and identify different scents. CN II (Optic), III (Oculomotor), IV
(Trochlear), and VI (Abducens) are good as patient was able to perform the six ocular
movements, was able to read reading materials, and was able to move eyeballs laterally. CN V
(Trigeminal) and VII (Facial) are both normal as patient’s, for there is a symmetrical facial
movement and mandible and maxillae are able to freely open. CN VIII (Auditory) is normal
since patient was able to hear the watch tick sound. CN XI (Accessory) is limited since patient
can do a little of head movements and shrugging of shoulders. CN IX (Glossopharyngeal), and X
(Vagus) are normal, gag reflex is patient. CN XII (Hypoglossal) is normal patient moves tongue
freely. However, there is a significant observation in patient’s musculoskeletal system. Patient
has difficulty in lifting both lower extremities but is able to feel touch while patient is able to lift
both upper extremities but wasn’t able to resist when force is applied. Cervical Nerves 1-6 are
intact however Cervical Nerves 7-8 sensations are decreased, Thoracic Nerves 1-4 are decreased
as well, while Thoracic Nerves 5-12 and Lumbar Nerves 1-5 are not intact. The 5 Sacral Nerve
and the Coccygeal Nerve are intact. No Babinski reflex noted.

The other components of the physiological stage of Maslow’s hierarchy of needs are
sleep, food, shelter and activity. After assessing the physical status, the student assessed the
patient’s sleep pattern. According to the patient’s daughter which is the secondary source of
information her mother sleeps regularly at home and usually wakes up early however days prior
to admission it was noted that the patient had difficulty of sleeping due to abdominal pain it was
also noted that one night the patient wasn’t able to sleep because her stools has fresh blood but
she kept it from her daughter. Which her daughter just learned recently. The patient started living
with her third daughter when her daughter’s husband died 10 years ago. Before moving in with
her third daughter she used to live in Bulacan with her fourth daughter who was a PWD as well.
Living together helps them provide care for each other. Both of her daughters accompany her
whenever she has a follow-up check-up. Another aspect assessed is the daily activity of the
patient. She usually is sedentary she tends to just watch television all day long and avoids
exercising for it may cause her injury.

The second level of Maslow’s Hierarchy of needs is the safety needs. The aspects
assessed under the safety needs is the patient’s view of safety, resources and health. Patient
viewed her lifestyle as secured, her first daughter which lives and work at Dubai supplies her
needs. While her third daughter whom she lives with, have children who helps at the financial
aspects of their family. Patient VG is very happy for she is still considered as the main decision
maker of their family. The other aspect assessed in this level is the patient’s view of her health.
Patient VG said that for her she was healthy prior to hospitalization. She is very compliant with
her hypertensive medications and her check-up schedules. Patient VG was saddened by the fact
that she was admitted at the ICU.

The third level of Maslow’s Hierarchy of needs is love and belongingness. The aspects
assessed under this level are the patient’s relationship with her family, friends and neighbors.
Patient VG and her daughter said that they are very close with each other. They always rely on
each other. That’s why when her mother didn’t tell her immediately that her bowel movements
contain blood, she was very saddened. Patient VG said that she is very close with her neighbors
and friends. Sometimes she and her friends play cards at each other’s home.

The fourth level of Maslow’ Hierarchy of needs if Self-Esteem assessed here is the
patient’s strengths and status. Patient VG said that her strength always comes from God.
Whenever faced with problems she always makes sure that she prays for guidance. She and her
family always attend Sunday mass together to ask for guidance and strength. Patient VG is very
positive that God will be able to help her with what she is going through right now.
 The last level of Maslow’s Hierarchy of need is self-actualization. Here patient’s view of
her life was assessed. Patient VG was very thankful for the life she had lived. She was able to
bring her five children into college and be able to care for her child with special needs. Patient
VG said that she is very happy with her family.

Significant Findings:

Some of the significant findings observed during gathering data are the following:

 Physical Aspect

The deviations noted in the physical assessment are the following: The patient is unable
to move lower extremities and limitations of movement of the upper extremities. These may be
due to the demyelination process of her illness or probably due to nerve compression. It can also
be observed that the patient is developing edema on both upper and lower extremities, this may
be due to the patient is unable to move extremities therefore there is a poor circulation and fluid
tends to be on stasis. Other significant assessment noted are beginning signs of respiratory
distress, patient VG prior to intubation has rapid shallow breathing this may be also due to the
demyelination of the patient’s disease process.

 Mental and Spiritual Aspect

The significant findings noted in this aspect that the patient has strong values and faith.
The patient was able to cope up and accept her diagnosis and believes that she can be cured from
it. She always prays to God that she will be able to get through her disease.

 Social Aspect
The significant findings in this aspect is that the patient is very close to her family,
whenever her daughter visits she always smiles. She said that her daughter tends to worry easily
that’s she smiles to lessen her daughter’s worry. She also smiles whenever approach by any of
the healthcare team. Patient VG is very approachable and friendly.
Laboratory and Diagnostic Studies:

A. Cultures

Test Result

 Urine GS/CS (October 15, 2019) No Microorganism seen after two days of
incubation.

Patient VG’s urine GS/CS may have yielded a negative result may be due to patient was
loaded with antibiotics already prior to collection of specimen.

Test Result

 ETA GS/CS (October 22, 2019) A. Microscopy:

PUS CELLS: +++
GRAM NEGTIVE BACILLI: ++

EPITHELIAL CELLS: +++

B. Culture: Heavy Growth of Enterobacter

aerogenes

The presence of bacterial growth on patient’s endotracheal aspirate may be due to the
neutropenic state of the patient and improper practice of VAP bundle of care. Such as failing to
turn the patient every two hours.
 B. Blood Chemistry

Test Reference Oct 13 Oct 15 Oct 16 Oct 18 Oct 19 Oct 19 Oct 20 Oct 20 Oct 21 Oct 22 Oct Oct
5:14 8:26 11:52 9:50 11:05 11:43 12:28 11:12 9:23 11:49 23 24
PM AM AM AM AM PM AM AM AM AM 12:12 8:12
AM AM

Glucose 3.90-6.40 3.91 10.75

mmol/L

BUN 1.70-8.30 11.4 18.63 22.92 15.83 16.73 15.60

mmol/L

Creatinine 44.0-80.0 156.8 174.2 196.6 137.9 159.5 158.6

mol/L

AST <=32.0 162.2

U/L

ALT <=35.0 98.6

U/L

Total 3.80-5.10 3.08 2.71

Cholesterol mmol/L

Triglycerides 0.40-2.25 2.14 2.20

mmol/L

HDL 0.87-1.94 0.41 0.30

mmol/L
VLDL <=1.04 0.97 1.00
mmol/L

LDL 1.32-2.52 1.70 1.41

mmol/L

Uric Acid 142.6- 372.8

339.2
mol/L

Sodium 135.0- 133.0 134.7 138.7 142.6 145.6 145.6 147.9 150.7 137.6 140
145.0
mmol/L

Potassium 3.4-5.0 2.7 2.7 3.0 5.8 5.87 5.06 5.1 5.4 5.13 4.18 4.18
mmol/L

Chloride 93.0-109.0 96.4 103.7 107.3 123.0 123.0 127.7 131.1

mmol/L

The patient’s potassium can be seen as extremely low within the first few days of admission, due to this the patient’s initial
complain of generalized body weakness was correlated with the said results. However, upon correcting patient’s potassium levels,
patient’s VG was still presenting with generalized body weakness and is worsening therefore GBS was considered. The etiology of
patient’s hypokalemia is still unknown, but episodes of loose bowel movement prior to confinement may be a contributing factor. It
can also be observed that serial monitoring of sodium was done to patient VG. According to the study conducted by Wankar, Pauranik
and Dinesh in 2014 occurrence of hyponatremia in patients diagnosed with GBS is well described. In a prospective study of 50
patients diagnosed with GBS, hyponatremia was noted in 48% of cases and motor dysfunction preceded the onset of hyponatremia.
This presentation raises the possibility that early changes in the autonomic nervous system triggered by GBS might lead to alterations
in water and sodium balance that can precede symptomatic changes in the peripheral nervous system. The increasing trends in patient
VG’s BUN and Crea result may be an indication of an acute kidney injury. Acute kidney injury according to Sinert (2019) is
commonly defined as an abrupt decline in renal function, clinically manifesting as a reversible acute increase in nitrogen waste
products measured by blood urea nitrogen and serum creatinine levels over the course of hours to weeks.
 C. Complete Blood Count
Parameter Reference Oct 13 Oct 14 Oct 15 Oct 16 Oct 17 Oct 18
Range 2019 1:35 AM 8:41 AM 8:05 PM 5:04 PM 9:05 AM

WBC 5.20-12.40 3.5 2.5 2.69 2.37 2.70 2.69

10^3/uL

Neutrophils 40.0-74.0 50 48.8 63.0 64.6 55.2 45.9

%

Lymphocytes 19.0-48.0 44 27.4 27.1 20.7 19.0 23.6

%

Monocytes 3.0-6.0 % 3.0 7.4 13.7 22.8 28.7

Eosinophils 2.0-4.0 % 0.0 1.9 0.6 2.2 1.3

Basophils 0.0-1.0 % 3.0 0.6 0.4 0.8 0.5

MID % 3.4-9.0 % 23.8

RBC 4.20-6.10 3.79 3.81 3.59 3.58 3.37 3.53

10^6/uL

HGB 12.0-18.0 11.1 11.5 11.2 11.3 10.5 11.0

g/dL

HCT 37.0- 32.1 32.3 31.8 31.8 30.2 31.7

52.0%

MCV 80.0-99.0 84.8 84.6 88.7 88.7 89.7 89.7

fL

MCH 27.0-31.0 29.4 30.3 31.2 31.4 31.2 31.2

pg

MCHC 33.0-37.0 34.6 35.8 35.1 35.3 34.8 34.8

g/dL

RDW-CV 11.5-14.5 13.5 13.8 13.9 14.1 14.6 14.7

%

PLT 150-450 87 82 80 69 107 156

10^9/L
 The CBC trends show that patient VG has decreased WBC count according to
Aminzadeh and Parsa in 2011, elderly population tends to have a decreased level of wbc counts.
However, it can be observed that patient VG’s monocyte count is increasing. High levels of
monocytes may indicate the presence of chronic infection, an autoimmune or blood disorder,
cancer, or other medical conditions (Smith, 2018).
 D. Erythrocyte Sedimentation Rate

Test Normal Result

ESR 0-20 mm/hr 50 mm/hr

According to the National Institute of Health (Oct 1 2019), an erythrocyte sedimentation

rate (ESR) is a type of blood test that measures how quickly erythrocytes (red blood cells) settle
at the bottom of a test tube that contains a blood sample. Normally, red blood cells settle
relatively slowly. A faster-than-normal rate may indicate inflammation in the body.
Inflammation is part of your immune response system. It can be a reaction to an infection or
injury. Inflammation may also be a sign of a chronic disease, an immune disorder, or other
medical condition. The test was indicated to patient VG to be able to identify if the causative
factor of her generalized body weakness may be due a demyelinating syndrome.

E. Chest X-ray

Result (October 13 2019)

Cardiomegaly

Tortouos atheromatouos aorta to exclude aneurysmal dilatation

Disc atelectasis or scarrings, left

The result of the patient x-ray may be due to patient’s history of hypertension.

F. Urinalysis

Result Oct 13, 2019

Physical
Color: Yellow
 Transparency: Turbid

Chemical
Blood: Negative
Bilirubin: Negative
Urobilinogen: Negative
Ketone: Negative
Protein: +1
Nitrite: Negative
Glucose: Negative
pH: 6.0
Specific Gravity: 1.030
Leukocytes: +2

Microscopic

Epithelial Cells: Few/lpf

Mucus Thread: Few/lpf

Amorphous Urates: Few/lpf

WBC: Abundant/hpf

RBC: 2-4/ hpf

Bacteria: Moderate/hpf

According to Bates (2013), there are several factors to consider when evaluating
urinalysis for indicators of infection. The most obvious indicator of bacterial infection in the
urine is the presence of bacteria; this is often quantified in terms of the number of bacteria per
high-power field (HPF). Any amount of bacteria in the urine may suggest UTI in a symptomatic
patient, but the threshold for the classic definition of bacteriuria is 5+, which is roughly
equivalent to 100,000 colony-forming units (CFUs)/mL. An alternative definition for bacteriuria
is 2+ present on urinalysis (representing 100 CFU/mL); this may be considered positive in
selected populations, such as catheterized or strongly symptomatic patients. Thus patient VG is
diagnosed to have a urosepsis due to presence of bacteria in her urine.
Other Insights:

While gathering data with Patient VG, the student observed that the patient is very
accommodating and approachable. It was nice to get to know patient VG for she is very positive
with her life. Although at some point patient VG is saddened because she didn’t know what
caused her illness she still hopes for the best. The student is also saddened due to the limitations
encountered while collecting the data. Such as, patient VG can only mouth words and tries easily
during assessment and the time the relatives can visit is only limited to 5 minutes thus
interactions are very limited.

B. Problem Identification

(see next page)

CUES WELLNESS ANALYSIS GOALS IDENTIFIED RATIONALE NURSES’ ROLE EVALUATION
STRATEGIES
NURSING ROLE EXPLANATION

DIAGNOSI
S
Subjective Gaining Gaining After an Ask patient This will help the nurse Teacher As a teacher, the nurse Patient was able t
Cues: knowledge information hour of what she knows gather baseline helps clients learn understand her
on current about their explanatio about her information the patient about their health and current treatment
“Para saan ito?” treatment the health care
treatment. n and treatment. has. plan.
(patient mouth plan helps procedures they need to
the patient to lecture on perform to restore or
words and her current
be maintain their health.
points towards empowered treatment The nurse assesses the
mechanical Allow patient to Allowing the patient to
and inspire plan, client’s learning needs
ventilator” them to take ask questions ask about her treatment and readiness to learn,
patient VG
ownership of about her plans helps the nurse sets specific learning
acquire
“Hanggang their care. treatment. identify what goals in conjunction
knowledge
kalian ako may (Heath, information the patient with the client, enacts
2016) . teaching strategies, and
ganito?” needs to learn.
(Mouths words measures learning.
and point to
mechanical Provide This will help the
ventilator) education about patient to understand
patient’s what is happening to
Objective
treatment plan. her and what are the
Cues:
treatment modalities
Patient looks at that are being
her environment prescribed to her.
very often and
tends to listen Ask the patient This will help the nurse
well and asks what her assess if the patient had
questions when treatment plan is learned and if there are
a healthcare for. more additional
provider information needed to
approaches her. be taught.

CUES WELLNESS ANALYSIS GOALS IDENTIFIED RATIONALE NURSES’ ROLE EVALUATION

STRATEGIES
NURSING ROLE EXPLANATION
 DIAGNOSI
S

Subjective Initiating Compliance After Ask client when Asking the client will Facilitator As a facilitator the The patient was a
Cues: ability to with therapy providing is the best time help the nurse the nurse coordinates the to participate on h
comply with is an passive for her to identify when the planning of care for a exercise schedule
“Ano ang dapat indication of patient with the
passive range of participate in patient is most willing
kong gawin para a positive patient, family and
range of behavior. motion doing exercises. to do her exercises to physicians. The
makagalaw ulit” motion exercises in be able to expect a
This can be facilitator ensures the
exercises observed an 8-hour good compliance of the patient and family
Objective
when the shift patient patient. have access to the
Cues: patient is care plan and
VG while
motivated maintain understand the goals
Patient tries sufficiently of the treatment or
very hard to compliance.
to adhere to Increasing the patient’s recovery plan.
move the Allow the
involvement helps her
extremities and prescribed patient to
to be more compliant.
participate on treatment choose exercises
exercise because of a that she is able
perceived to do with the
sessions done
self-benefit nurse.
by nurses. and positive
outcome.
(Panesar
2012) Allow patient to Prolonging exercise
set time limit on sessions might tire
exercise patient and may make
sessions her less compliant to
each session.
 CUES WELLNESS ANALYSIS GOALS IDENTIFIED RATIONALE NURSES’ ROLE EVALUATION
STRATEGIES
NURSING ROLE EXPLANATION

DIAGNOSI
S

Objective Initiating Good After 30 Encourage and Positive feedback Communicator In the role of Patient was able t
Cues: effective communicati minutes of praise the patient’s encourages the communicator, nurses communicate and
communicati on between ongoing attempt to patient to quality of answers questions
Mouth words nurses and communication is an
on conversati communicate. communicate. congruently despi
when being patients is important factor in
essential for patient VG nursing care. The nurse being intubated.
talked to despite will sustain Provide alternative Providing
the must be able to
being intubated. successful effective means of alternative means communicate clearly
outcome of communic communication. such as providing and accurately in order
Answers individualize writing materials or for a client’s health
ation
questions, d nursing providing a simple care needs to be met.
coherently and care of each board with common
cohesively patient. (Kou questions where the
rkota &
patient can point
Tries to lift Papathanasio
u 2014) out what she wants
arms as a sign
to say may increase
of gestures
understanding
when mouthing
between the nurse
words.
and the patient.

Clarifying the
Clarify
message with the
understanding of
patient allows
messages delivered
effective
by the patient with
communication by
the patient
verifying that the
message received
was the message
sent.
 Decision Tree

Adequate
Ventilation
Anticipatory
Mechanical
Ventilation
Patient’s
Comfort
Impending
Respiratory Failure

Adequate
Ventilation

Assistive Oxygen
Supplementation
Patient’s
Comfort

Legend:

Decision node: Blue box

Chance node: Yellow Circle

End node: Green Hexagon

 1 2 3

Invasiveness Minimal Moderate Very

Cost Minimal Moderate Very

Complications Minimal Moderate Very

Effectiveness Minimal Moderate Very

INVASIVENES COST COMPLICATIONS EFFECTIVENES TOTAL

S S SCORE

3 3 3 3 9

Anticipatory Mechanical Ventilator

(9 x 0.50 = 4.5)

INVASIVENES COST COMPLICATIONS EFFECTIVENES TOTAL

S S SCORE

1 2 2 2 7

Assistive Oxygen Supplementation

(7 x 0.50 = 3.5)

 After weighing options to help patient VG is assisting with her respirations to be able to be
oxygenated properly. It is noted that anticipatory mechanical ventilation can help avoid
possible complication patient VG’s condition. Therefore, anticipatory mechanical ventilation
is done to the patient.
Evaluation of Care:

After the provision of holistic care patient will be able to be trans-out from the intensive care
unit and will be discharged with no complications.