CASE STUDY

OPD – UFC FP
Abucejo, John Bautista Bongato
Abucejo, Angeli Bernaldez Bumotad
Aton Bolando Bungabong
PATIENT’S PROFILE
Name: Melgar, F. A.
Age: 4 years old
Address: Purok 5, Liloan Sur, Inabanga, Bohol
Sex: Male
Religion: Catholic
Date of Consultation: November 21, 2019
Attending Physician:
Clinic: OPD – UFC
Client’s complaint: Productive cough associated with vomiting and
diarrhea
Diagnosis: Cerebral palsy – spastic quadriplegia
CLIENT’S HISTORY
■ Client was admitted due to cerebral palsy and
hospital acquired pneumonia last October 7-
15, 2019
HISTORY OF PRESENT ILLNESS
■ Client was experiencing fever, cough and
colds, vomiting and diarrhea for 3 days.
LABORATORY RESULTS
■ No lab results.
ORGAN INVOLVED: Brain - Medulla
ANATOMY
■ Brain – main functions: processing sensory information, regulating blood pressure
& breathing, and releasing hormones.
■ Medulla oblongata – the control center for the function of heart and lungs
– Regulates important functions e.g. breathing, sneezing, swallowing
■ Fourth ventricle – to protect brain from trauma & help form central canal
■ Chemoreceptor trigger zone – receives input from blood-borne drugs or hormones
and communicates with other structures in the vomiting center to initiate vomiting
■ Vomitng center – initiatesnand controls the act of emesis, which involves a series
of contractions of the smooth muscles lining the digestive tract
■ CN VIII – mintaining body balance, eye movement and conveying neural impulses
■ CN IX – carries general sensory information (pain, temperature and touch)
■ CN X – conteols motor functions of the larynx, pharynx, and esophagus
 PATHOPHYSIOLOGY: Fluid volume deficiency–excessive fluid loss
Rapid progress from excessive loss of fluid through Risk factors:
vomiting and diarrhea resulting to negative fluid - Age <12 months
Etiology:
balance, secondary to neural impulses of cerebral - Frequent stools >8/day
Dehydration
palsy triggering the medulla. (medications could also - Vomiting >2/day
trigger vomiting reflex) - Severe malnutrition
-pre-existing illnesses
Organ involved: brain- medulla
Benzodiazepine:
Sensory input: CN IX Higher cortical centers Clonazepam

Chemoreceptor trigger zone Sites of action of drugs

Vomiting center: medulla

Vomiting reflex

Excessive fluid loss

Dehydration
SIGNS AND SYMPTOMS
■ Irritable > hyperirritable to lethargic
■ Moderate to intense thirst
■ Skin turgor – decreased to greatly decreased
■ Sunken anterior fontanelle
■ Sunken eyes
■ Abnormal respiratory pattern
COMPLICATIONS
■ Permanent brain damage
■ Seizures
■ Hyponatremia/hypernatremia
■ Hypovolemic shock
■ Kidney failure
■ Coma
■ Death
MEDICAL MANAGEMENT:
■ Prescription of ondansetron
■ IV fluid replacement
NURSING MANAGEMENT
■ Encourage fluid intake
■ Monitor intake and output
■ Notify physician of any side effects
Health Teaching
Topic: Rehydration
Rationale: To restore client’s fluid volume balance, with the knowledge and
information to be imparted on the client’s parents.
Objectives:
General: To hydrate client’s with the parents knowledge and information
imparted from the health teaching.
Specific: Client’s parents will be able to:
1. Demonstrate positive attitude towards the health teaching.
2. Appreciate & realize the importance of a hydrated body.
3. Understand & prevent dehydration from reoccurring.
Health teaching method: Discussion and interaction with client’s parents
Target Audience: Client and client’s parents
Date & time: November 21, 2019
Contents:
1. Importance of hydration.
– To put it simply, dehydration is the window of other diseases and a door for
complications with those who have occurring illness.
2. When to know if a child is dehydrated: signs & symptoms:
– Dryness of: eyes/tears, skin, mouth and tongue
– Sunken eyes and anterior fontanelle
– Rapid heart rate or breathing
– Excessive vomiting and/or diarrhea
3. Home remedy to rehydrate the child and maintain child’s nutrition intake:
– Give sips of clear fluids e.g. oral electrolyte solution, ice chips, clear broth or ice
pops – 1 to 2 tablespoons every 15 to 20 minutes.
– Offer saltine crackers or bland foods to fill stomach.
– Avoid intake of the ff: greasy foods, spicy, high in fat & sugar, and dairy
NURSING CARE PLAN: ASSESSMENT
SUBJECTIVE CUES: OBJECTIVE CUES:
“Sige pa og ubo-suka unya kalibanga ■ Pale skin
pero wala na siya gi hilanat.” as
■ Sunken eyeballs
verbalized by the mother of client.
■ Restlessness
■ Use of accessory muscle
■ Abnormal breath sounds
■ Irritability
■ Vital signs:
T = 35.2C
P = 136bpm
R = 60Bpm
NURSING CARE PLAN: DIAGNOSIS
■ Fluid volume, risk for deficiency related to
excessive losses through vomiting and
diarrhea secondary to cerebral palsy-
spastic quadriplegia.
NURSING CARE PLAN: BACKGROUND
KNOWLEDGE
Cerebral Palsy causes structural abnormalities in both the central and
peripheral nervous system that regulate involuntary body functions,
such as blood flow, heartbeat, digestion and breathing. Those
abnormalities make children with Cerebral Palsy prone to digestive
problems that could interfere with their ability to digest food and
absorb nutrients. In some cases, children are not able to eat at all.
Unfortunately, digestive symptoms such as diarrhea, vomiting,
constipation or bladder infections may be the first sign of a number of
gastrointestinal conditions that require medical attention before they
become unmanageable.
Reference: https://www.cerebralpalsy.org/information/digestive-health
NURSING CARE PLAN: PLANNING
After client’s follow-up check-up, the
parents of the client will be provided with
the adequate information needed to
facilitate and recuperate the client’s health.
NURSING CARE PLAN: INTERVENTION
■ Advised the parents of the client to observe and
record stool and vomiting frequency.
■ Encourage the parents of the client to restart client’s
fluid intake gradually. Offering clear liquids hourly
and avoid cold fluids.
■ Informed the parents of the client regarding the
monitoring of vital signs.
■ Advised parents of the client that client’s
medications are taken on time.
NURSING CARE PLAN: EVALUATION
After client’s follow-up check-up, the
parents of the client has been provided with
the adequate information needed to
facilitate and recuperate the client’s health.
DRUG: SALBUTAMOL
CLASSIFICATION:
Bronchodilator, Adrenergic
DOSAGE/FREQUENCY/ROUTE:
2g/5ml 3/5ml TID po x 5 days
MECHANISM OF ACTION:
It relaxes the smooth muscles of the bronchioles allowing
maximum passage of air. It decreases intracellular calcium
which will relax the smooth muscles of the lungs by
mobilizing kinase through activation of cyclic-3’5’-adenosine
monophosphate (cAMP).
INDICATION:
■To control and prevent reversible airway obstruction caused
by asthma or chronic obstructive pulmonary disorder (COPD)
■Quick relief for bronchospasm
■For the prevention of exercise-induced bronchospasm
■Long-term control agent for patients with chronic or
persistent bronchospasm
CONTRAINDICATION:
■Hypersensitivity to adrenergic amines
■Hypersensitivity to fluorocarbons
ADVERSE EFFECTS:
Nervousness Hypertension
Restlessness Nausea and vomiting
Tremor Hyperglycemia
Headache Hypokalemia
Insomnia
Chest pain
Palpitations
Angina
Arrhythmias
NURSING RESPONSIBILITIES:
■ Assess lung sounds, PR and BP before drug administration and during
peak of medication.
■ Observe fore paradoxical spasm and withhold medication and notify
physician if condition occurs.
■ Administer PO medications with meals to minimize gastric irritation.
■ Extended-release tablet should be swallowed-whole. It should not be
crushed or chewed.
■ If administering medication through inhalation, allow at least 1 minute
between inhalation of aerosol medication.
■ Advise the patient to rinse mouth with water after each inhalation to
minimize dry mouth.
■ Inform the patient that Albuterol may cause an unusual or bad taste.
DRUG: AMOXICILLIN
CLASSIFICATION:
Non-narcotic, analgesic, Antipyretic, Antibiotic
DOSAGE/FREQUENCY/ROUTE:
250g/5ml 5ml TID po x 1 week
MECHANISM OF ACTION:
Prevents bacterial cell wall synthesis during replication.
Bactericidal.
INDICATION:
Treatment of infection of respiratory tract, skin & skin
structures, genitourinary tract, otitis media, meningitis,
septicemia, sinusitis, bacterial endocarditis prophylaxis.
CONTRAINDICATION:
Hypersensitivity to penicillin, cephalosporin, or imipenem. Not
used to treat severe pneumonia, empyema, bacteremia,
pericarditis, meningitis and purulent or septic arthritis during
acute stage.
ADVERSE EFFECTS:
Nausea
Vomiting
Diarrhea
Rash
Pruritus
Urticarial
NURSING RESPONSIBILITIES:
■Advise the patient’s family to take the medication with meals for
better absorption & to reduce GI discomfort.
■Instruct the patient’s family to take medication as prescribed
even after feeling better and not to double dose.
■Teach the patient’s family to report sore throat, bruising,
bleeding and joint pain, this may indicate blood dyscrasias.
■Advise patient’s family to watch out for perineal itching, fever,
malaise, redness, pain, swelling, drainage, rash, diarrhea,
change in cough, sputum or furry tongue, this may indicate
superinfection.
■Advise patient’s family to report bloody, mucoid diarrhea which
may indicate pseudomembranous colitis
DRUG: ZINC SULFATE
CLASSIFICATION:
Mineral, Dietary supplement
DOSAGE/FREQUENCY/ROUTE:
5ml OD PO x 4 months
MECHANISM OF ACTION:
Serves as a cofactor for many enzymatic reactions. Required
for normal growth and tissue repair, wound healing and
sense of taste and smell.
INDICATION:
Replacement and supplementation therapy in patients who
are at risk of zinc deficiency.
CONTRAINDICATION:
■ Hypersensitivity or allergy to any components in the
formulation.
■ Use cautiously in renal failure
ADVERSE EFFECTS:
Gastric irritation
Nausea
Vomiting
NURSING RESPONSIBILITIES:
■ Monitor progression during therapy
■ Encourage diet recommendation
■ Ask client to notify any effects
■ Emphasize importance of follow-ups
DRUG: BACLOFEN
CLASSIFICATION:
Anti-spastic
DOSAGE/FREQUENCY/ROUTE:
½ tab TID PO
MECHANISM OF ACTION:
It inhibits both monosynaptic and polysynaptic reflexes at
spinal level.
INDICATION:
For the relief of flexor spasms and the concomitant pain,
clonus, muscular rigidity; treatment of central spasticity.
Beneficial in reducing spasticity in cerebral palsy in children
(intrathecal use).
CONTRAINDICATION:
■ Hypersensitivity
■ Active peptic ulcer disease
ADVERSE EFFECTS:
Sedation
Drowsiness
Ataxia
Headache
Skin reactions
Confusion
NURSING RESPONSIBILITIES:
■ Give with caution to clients/patients whose spasticity
contributes to upright posture or balance in locomotion
or whenever spasticity is used to increase function.
DRUG:CLONAZEPAM
CLASSIFICATION:
Benzodiazepine, Anti-epileptic, Anticonvulsant
DOSAGE/FREQUENCY/ROUTE:
1/8 tab BID PO
MECHANISM OF ACTION:
It raises the threshold for propagation of seizure activity and
prevents generalization of local activity. Clinically, it improves
local epilepsy and generalized seizures. It is also believed to
enhance activity of GABA, and act as anticlytic.
INDICATION:
Treatment of Lennox-Gastaut syndrome, akinetic and
myoclonic seizures; may be useful in patients with absence
seizure who have not responded to succinimides; up to 30%
show loss of effectiveness of drug, often within 3 months of
therapy; treatment of panic disorder with or without
agoraphobia.
CONTRAINDICATION:
Hypersensitivity to benzodiazepine, acute pulmonary
insufficiency, acute narrow angle glaucoma.
ADVERSE EFFECTS:
Drowsiness
Fatigue
Muscular hypotonia
Coordination disturbances
Dizziness
Vertigo
Anorexia
Visual disturbances
NURSING RESPONSIBILITIES:
■ Remind client’s family to take this long-term therapy religiously
and to not stop taking this medication without consulting
health care provider.
■ Client’s family should monitor and observe frequency of
seizures.
■ Client’s family should notify health care provider if adverse
effects occur,