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West Visayas State UniversityCOLLEGE OF NURSING
La Paz, Iloilo City
Vision: WVSU as one of the TOP TEN universities in Southeast Asia by 2015.Mission: To produce globally competitive individuals who are life-long learners.Core Values: S - Service H – Harmony E – Excellence
PEDIATRIC NURSING PROCESS
I. VITAL INFORMATIONName of Child: K.L.C. Name of Informant: R.C.Sex: Female Relationship with the child: MotherDate of Birth: 08/04/95Age: 13 years oldAddress: Brgy. Malugsod, Dueñas, IloiloDate and Time Admitted: 08/09/08 @ 4:00 pm Chief Complaints: “Gin-convulsion siya nga naglawig mga pulo ka minutos.”Ward: PSW-BReligious Affiliation: Roman CatholicName of Mother: R.C.Educational Attainment: 3rd year high school Age: 48 years oldOccupation: noneName of Father: N.C.Educational Attainment: 3rd year high school Age: 49 years oldOccupation: Farmer,carpentingApproximate Monthly Income of the Family:
a.) Mother – N/A b.) Father – Php 9000-9500 c.) Others – Php 2000 ( Patient’s uncle)
TOTAL Php 11000-11500
Physician: Dr. G.Impression/Diagnosis: Status EpilepticusPre-op Diagnosis: N/APost-op Diagnosis: N/A
I. CLINICAL ASSESSMENT
A. Nursing History
Usual Health status
“Halin sang gamay siya, sang 3 years old pa lang, gina-convulsion na siya nga da-an. Ga turong gid na iya mata pero mga segundo man lang ang kalawigon. Sang nagadako siya, daw gasige-sige na, halos kada adlaw na gani ang atake niya. Kun mabug-atan, makulba-an kag kun grabe iya hulag, amu gid na siya atakihun. Gamay ni siya dayon pakan-on kay medyo pisli-an. Kun masobrahan gani ka gutom, gina atake man siya. Ginapapahuway man lang siya namun tapos ginahilot-hilot ang likod sang iya li-og.” As verbalized by patient’s mother.
Chronologic story
When K.L.C. was 2 years old, a small vase fell in her head (exact location unrecalled). K.L.C. then lost consciousness. She regained her consciousness a few minutes later. No medical check-up made after the incident. 9 years prior to admission, 1998, K.L.C. experienced episodes of seizure attack characterized by crying, upper rolling of eyeballs and involuntary muscle jerking which lasted for about
30-40 seconds. Parents did not seek any medical help. Episodes of seizure attack of same symptoms continued with approximately 5-6 days interval. Still, parents did not seek medical help. Instead, they just massage the lower portion of the neck and let the patient rest.
In year 2000, patient had a seizure attack characterized by change in lost of consciousness, stiffening of the body and upper rolling of eyeballs which lasted for almost 3 minutes. “Daw nag grabe iya atake tapos medyo mas dugay siya komparar sa mga na una ya nga convulsion. Amo ‘to gindali-dali dala sa Western.” As verbalized by the mother. An EEG was done and the mother claimed that the result showed an impinged vessel. Unrecalled anticonvulsant meds were given and monthly check-up was advised. K.L.C. complied with the prescribed meds and medical check-up for 4 months only. There was a noticeable decreased in frequency of seizure attacks with 3-4 weeks interval. The mother stated “ Daw kamahal na gid ya galing sang bulong, amo ‘to gin-untatan na lang namun.” Thus, the seizure attacks recurred with 5-6-day interval.
If the patient would feel hungry or tired, a seizure attack would occur which would last for seconds. The patient would complain of dizziness thereafter. Rest and massage in the neck were again the management of folks after the attack.
1 month prior to admission, July 2008, there was an increase in frequency of seizure attacks (4x weekly).
2 days prior to admission, K.L.C. experienced episodes of seizure attack which lasted for 5 hours within 5-minute interval with no febrile episodes or difficulty of breathing.
A day prior to admission, seizure attacks continued which lasted for 10 minutes with seconds interval and K.L.C. was admitted in Iloilo Provincial Hospital. K.L.C. was then referred to WVSU-MC for further treatment. Thus, last August 9, 2008, K.L.C. was admitted in WVSU-MC, PSW-B.
Past Medical History
Parasitism____________ Tuberculosis____________ Anemia____________ AGE____________ Measles 8 years old Seizure since 3 years oldAGN____________ BPN____________ Emotional Disorder____________ Allergy none Accidents (specify) ______ Others:
No. of Previous Hospitalizations: 1 Date of Last Confinement: August 8, 2008Where: Iloilo Provincial Hospital Reasons for Confinement: seizure attacks
Family History
Birth order of Patient: 5thTotal no. of siblings: 8No. of living siblings: 8Serious diseases/illnesses of siblings: noneCause of death/serious illnesses of siblings: N/A
Heredo-familial diseases: (state relationship with patient)Tuberculosis_________________ Hypertension__________________DM________________________ Cancer________________________Asthma_____________________ Genetic Disorders (specify)________Others (specify)
Maternal and Prenatal History
Maternal age when child was born: 35 years old
Age of Gestation and Birth Weight UnrecalledPretermFull-term /Postterm
TYPE OF DELIVERY Home Attendant/Midwife
Hospital
Spontaneous /Caesarian Section/Forceps (specify reasons)
Complications related to pregnancy:None as claimed by mother
Parental views of pregnancy:“Para sa amon, gapasalamat gid kami kay nadugangan ang kalipay nga ginhatag sang Diyos sa amun.” as verbalized by the mother.
Patient’s problem: (1st month):None as claimed by the mother.
Child’s ability to get along with people as viewed by parents:“Medyo supladahun ni siya. Naspoiled da-an ni lola ya pero ma-ayo man siya makisama sa iban ya nga utod kag mga miga ya.” as verbalized by the mother.
Early behavior patterns as viewed by parents:“ Gamay-gamay lang ni nga akig sa iya, ga sunggod siya dayon. Amo na daw indi gid siya ma-akigan gawa. Sang gamay siya da-an kun ano gusto ya, ginahatag dayon ni lola ya.” As verbalized by the mother.
Parent’s attitude towards rearing:K.L.C. was brought up by her grandmother. Usually the grandmother was in charged in disciplining her. As verbalized by the mother, “Na-spoiled gid ni siya ni lola ya.”
II. PATTERNS OF FUNCTIONING
Nutritional History and eating Patterns
Meal Type and Amount of foods usually taken
Breakfast ½ cup steamed rice, 1 bowl of noodles
Morning snacks 1 pack of Cheese Curls, 1 bottle of
softdrinks
Lunch 1 cup steamed rice, 1 pc. fried fish
Dinner 1 cup steamed rice, 1 bowl of noodles, 1 pc. chorizo
Food likes: Cheeze Curls, fried chicken, “lumpia”Allergies: NoneProblems related to nutrition: none
Elimination Patterns
Frequency Problems/Difficulties Usual RemedyBowel Movement Twice a day none N/A
Urination 4x a day none N/A
Toilet Training
Age in Months Started
Found in Textbook
As seen in the patient and/or verbalized by
significant person
Significance
Bowel:
Bladder:
3 years old
3 years old
Toilet training must start during toddler years or when the child has already the capacity to heed instructions.
As recalled by the mother, “ Indi na na siya magpa-upod sa banyo kun daw mamus-on siya. Siya lang na dayon ga-uba sang iya nga panty.”
This was normal because K.L.C. was in the right age to be toilet-trained.
Sleeping Patterns
Usual Patterns Usual Time Approximate total no. of
sleep/24 hours
Sleeping Arrangement
Special Rituals Problems with Sleeping
Bed time
Waking time
8:30-9:00 pm
6:00-6:30 am
9 hours K.L.C. sleeps at the side of her younger sister
none none
Immunization Status
Type 1st
doseAge 2nd
doseAge 3rd
doseAge
BCG / unrecalledDPT / unrecalled / unrecalled / unrecalledOPV / unrecalled / unrecalled / unrecalled
Hepa BMeasles/MMR
Play
a.) Appropriateness of available toys:K.L.C. is fond of playing chinese garter, jackstones and cell phone games with her playmates. These toys are appropriate for her age since her choice of games is competitive in nature.
b.)Availability and safety of play areas:K.L.C. usually plays within her school campus. Her mother stated, “ Daw tawhan man ang ila eskwelahan kag malapad man ang lugar nga pwede ya hampangan.”
c.)Favorite toys and activities:-chinese garter-jackstones-texting-watching TV
d.)Child initiative and amount of creative play:“Kun wala bi klase, siya gid ni gapanghagad sa mga utod ya kag sa mga taga pihak balay nga maghampang” as verbalized by the mother.
Preferred play: Solitary: ____ Parallel: _____ Cooperative: ____ Competitive:_/__
Peer interaction:“Palahampang ni siya sa mga kilala ya lang galing nga ka-edad ya.Indi man siya pala-away pero amo lang na eh, kun indi ya makwa gusto ya, masinuplada na siya.” As verbalized by the mother.
Current Development Assessment
AREAS AGE OBSERVATIONS FOUND IN TEXTBOOKS
ACTUAL OBSERVATION SIGNIFICANCE
Gross Motor In adolescence stage the development of
locomotion skills is achieved. One is able to
walk and has good coordination and
equilibrium. In this stage, one can walk up and down the stairs, can
jump using both feet, can stand on one foot, walk
on tiptoe, and climb upstairs with alternate
footing.
“Wala man siya problema sa iya, normal man siya maglakat, wala man siya gakadasma. Luwas lang kung akigan ko siya, madalagan na siya kag magkandadasma.” As verbalized by the mother.
Fine Motor12 y.o.
Demonstrated in increasingly skillful manual dexterity.
Improved flexibility and coordination; plays musical instrument.
Sensory12 y.o.
Vision is 20/20.
Psychosocial
(Role identiy vs role confusion)
13 y.o.The development of identity is characterized by rapid and marked physical changes. Previous trust in their bodies is shaken, and children become overly preoccupied with the way they appeared in the eyes of others as compared with their own self-concept. Adolescents struggle to fit the roles they have played and those they hope to play with the current roles and fashions adopted by their peers, to integrate their concepts and values with those of society.
“babae gid siya ya, macrush sa gain nga
classmate man niya. Ang mga upod niya pirme
maghampang mag babae man nga ara sa piyak
balay namon.” As verbalized by the
mother.
PsychosexualGenital Stage 13 y.o.
Genital Stage: The last significant stage begins at puberty with maturation of the reproductive system and production of sex hormones. The sexual organs become the major source of sexual tensions and pleasures, but energies are also invested in forming friends.
Spiritual13 y.o.
Individuating-reflexive: Adolescents become more skeptical and begin to compare the religious standards of their parents with those of others. They attempt to determine which to adopt and incorporate to their own set of values. They also begin to compare religious standards with scientific viewpoint. It is a time of searching than reaching. Adolescents are uncertain about many
religious ideas but will not achieve profound insights until late adolescence or early adulthood.
Cognitive13 y.o.
Formal operations: formal operational thought is characterized by adaptability and flexibility. Adolescents can think in abstract terms, use abstract symbols, and draw logical conclusions from a set of observations. They can consider abstract, theoretic, and philosophic matters. Although they may confuse the ideal with the practical, most contraindications in the world can be dealt with and resolved.
Moral13 y.o.
Younger children merely accept the decisions or part of view of adults, adolescents, to gain autonomy from adults, most substitute their own set of morals and values. Their decision involving moral dilemmas must be based on an internalized set of moral principles that provides them with the resources to evaluate the demands of the situations and to plan actions that are consistent with their ideals.
Language and Speech 12 y.o.
Increase level of comprehension. Vocalizations are intelligible. Uses multi word sentences. Speech is understandable. Has mastery of grammatical rules.
V. PRESENT MEDICAL HISTORY
A. Measurements:
Weight: _40_kg Height: _150 cm.
B. Clinical Inspection
Date and Time Taken: August 27, 2008
Vital Signs:Temperature: _37.2˚C per axilla__________ Pulse Rate: _76 beats per minute______
Respiratory Rate: _21 breaths per minute__ Blood Pressure: _110/70 mmHg_______
VI. PHYSICAL ASSESSMENT
General Appearance:Appears restless, irritable, and disheveled. Easily cries when approached. Has strong
tenseness and rigid movement. Does not follow through with directives. Does not observe eye contact.
Presence of four point restraints on right and left hands and right and left feet, attached to bed frame.
A. Integumentary SystemSkin is brown in color. It is soft and warm to touch. When pinched at the abdomen, it
returned in one second, which indicated good turgor. Reddish, dry, scattered lesions on right forearm, approximately 2 cm. in diameter. Wound with pus draining on right ankle of 2 cm. in diameter and 1 mm. in depth.
Moderate dandruff noted on hair, as well as lice and nit infestations.Nails are not well-trimmed and cleaned. Nail beds are pink and firm. No clubbing or
beau lines.
Neurologic System / EENTConjunctivae are pale. Anicteric sclerae without increased vascularity. Irises uniformly
black in color. Nares patent. Nasal septum is at midline.
CRANIAL NERVE HOW ILICITED NORMAL RESPONSE PATIENT’S RESPONSE
IOLFACTORY
Cologne will be held under one nostril with the other occluded while the client is closing her eyes. Repeat with the other nostril.
Identifies scent correctly with each nostril. Not assessed.
IIOPTIC
Newspaper or nameplate will be held 14 inches away from the eyes.
Reads clearly, without difficulty. Not assessed.
IIIOCULOMOTOR
Ask client to look straight ahead and approach each eye from the client’s side with a penlight.
Pupils equally round and reactive to light and accommodation.
Pupils constrict upon illumination of penlight.
IVTROCHLEAR
Ask client to look straight ahead, covering one eye with a cover card and observe uncovered eye for movement.
Uncovered eye does not move as opposite eye is covered.
Not assessed.
VTRIGEMINAL
With closed eyes, touch forehead, cheeks and chin with the tip of cotton applicator and broken stem of
Identifies light touch, dull, and sharp sensations.
PRESENT
cotton applicator.
VIABDUCENS
Ask client to follow examiner’s finger as it moved in six cardinal fields.
Both eyes move in a smooth, coordinated manner in all directions.
PRESENT
VIIFACIAL
Ask client to smile, frown, purse lips, blow out cheeks, and raise eyebrows.
Let patient taste sugar.
Follows instructions accurately.
Able to discern sweet taste.
No facial anomalies.
Not assessed.
VIIIACOUSTIC
Whisper a word 1 foot behind the client.
Able to repeat the whispered word.
PRESENT
IXGLOSSOPHARYNGEAL
Touch back of tongue with tongue depressor to test for gag reflex.
Brisk response as if to expel tongue depressor from mouth.
Gag reflex present.
XVAGUS
Ask client to open mouth and say “ah”.
Uvula elevates upon phonation.
PRESENT
XISPINAL
ACCESSORY
Ask client to shrug shoulders against examiner’s hands.
Ask client to turn head against examiner’s hand.
Symmetrical, strong contraction of trapezius muscles.Strong contraction of sternocleidomastoid muscle on opposite side that head is turned.
Able to turn head to sides against hand.
XIIHYPOGLOSSAL
Ask client to protrude tongue and move it to each side against tongue depressor.
Symmetrical tongue with smooth outward movement and bilateral strength.
PRESENT
B. Respiratory SystemRespiratory patterns are even and unlabored. No use of accessory muscles upon
respiration. Deep inhalation and shallow expiration. Usual respiratory rate is 20 breaths per minute. Clear breath sounds ascultated on all lung fields.
C. Cardiovascular / Circulatory SystemApical of 76 beats per minute. Palpable right and left radial and posterior tibi al pulses. It
is not thready nor bounding. Regular in rhythm. Clear, brief heart sounds throughout. No murmurs.
D. Genito – urinary SystemPubic hair sparsely distributed. Voids freely to a clear, yellowish urine with an amount of
400 cc per diaper. Consumes 3 diapers per day.
E. Gastrointestinal SystemCanker sore of approximately 2 cm. on lower lip. Buccal mucosa is pink and dry. Pinkish
gums. Papillae present on tongue and midline fissure present. Abdomen is flat. Umbilicus is midline.
F. Reproductive SystemBreasts are bilaterally symmetrical. Areolae are light brown. No discharges on both
nipples.
G. Endocrine SystemNo swelling and tenderness of thyroid gland. No excessive sweating. Equal body hair
distribution.
H. Musculoskeletal SystemFull ROM of the arms and legs. Hand grip is strong. Brief voluntary muscular jerking of
both extremities. Generalized tensed movements.
I. Lymphatic SystemThyroid and cervical lymph nodes are not assessed. No presence of swelling. Neck is
symmetrical and can rotate freely.
J. Hematopoietic SystemCapillary refill of 1 second. No bruising.
VII. LABORATORY AND DIAGNOSTIC PROCEDURES
1. CLINICAL CHEMISTRY
Name of Examination: Serum Electrolytes
Definition:Sodium is the most abundant cation (90% of the electrolyte fluid) and the chief base of the
blood. Its primary functions in the body are to maintain osmotic pressure and acid-base balance chemically and to transmit nerve impulses.
Potassium is the principal electrolyte (cation) of the intercellular fluid and the primary buffer within the cell itself. 90% of potassium is the blood by damaged cells.
Creatinine is a nitrogenous waste product each day, which is related to the muscle mass, seldom changes rapidly. Creatinine is eliminated from the body by the kidneys.
Calcium is an important cation found, predominantly in bones and teeth, combined with phosphate and carbonate. This combination, deposited in bony tissue, provides the mineralization and resulting strength of the skeleton. The remaining 10% of the body calcium is found in the blood serum and is essential for normal functioning of neuromuscular tissue, cardiac activity and the coagulation of blood.
Purposeo It is used to indicate acid-base balance and hydration status.
Preparationo Inform the client about the reason why the specimen was ordered, how is to be
collected, the equipments needed and the stinging sensation that may be felt.o Foods and fluid are usually not restricted before the collection of the specimen.
Specimen o Venous blood collected in a collecting tube or syringe.
ResultsNormal Values Significance of Abnormal Results
8/9 8/14
Serum Sodium146.4
mmol/L139.9
mmol/L135-148 mmol/L Within normal range
Sodium Potassium3.76
mmol/L3.57
mmol/L3.5-5.3 mmol/L Within normal range
Serum Calcium2.62
mmol/L -2.18-2.68 mmol/L Within normal range
Serum Creatinine72.48
µmol/L -20-40 µmol/L Increased. UTI
2. HEMATOLOGY
Name of Examination: Complete Blood Count (CBC)
Definition:Complete blood count a screening test, is one of the most frequently ordered laboratory
procedures. It is a group of tests that includes the hemoglobin, hematocrit, and red blood cell (RBC) count, white blood cell (WBC) count, differential white blood cell count, red cell indices and stained cell examination (peripheral blood smear). A platelet count may also be included in CBC.
Hematocrit is a measurement of the percentage of red cells in the total volume of blood. It is expressed in the percentage of red cells in the total blood volume.
Red blood cells are produced by erthyroid elements in the bone marrow. Under the stimulation of erythropoietin, RBC production is increased. Within each RBC are molecules of hemoglobin that permits the transport and exchange of oxygen to the tissues and carbon dioxide in tissues.
Hemoglobin is the main component of red blood cells. Its main function is to carry oxygen from the lungs to the body tissues and to transport carbon dioxide, the product of cellular metabolism, back to the lungs. Another function of hemoglobin is to act as a buffer to help maintain acid-base balance.
White blood cells (WBC) are produced in red bone marrow and lymphatic tissue. After they are formed they enter the blood, which transport them to the parts of the body where they are needed to defend against invading organisms through phagocytosis and produce or antibodies to help maintain immunity.
Neutrophils which constitute 55%-65% of white of the total number of white blood cells. The protective function of neutrophils includes phagocytosis. Foreign particles are degraded, and pyrogens are released that produce fever by acting on the hypothalamus to set the body’s thermostat at higher level.
Eosinophil constitutes 1% to 3% of the total number of white blood cells. Their protective function is not fully understood. They play a role in allergic reactions, possibly inactivating histamine.
Platelets, also called thrombocytes, are large, non-nucleated cells derived from the megakaryocytes produced in the bone marrow. Two-thirds are found in the blood and one-third in the spleen. One-tenth of the platelets found in the blood maintain endothelial integrity and the rest are available for homeostasis. The adhesive or sticky quality of platelets allows them to clump together or aggregate and adhere to injured surface. Along with fibrin, they form the network for a clot to form.
Purpose
o It determines the number, variety, percentage, concentrations, and quality of blood cells. It provides information about the hematologic and other body systems, prognosis, response to treatments, and recovery.
Preparationo Inform the client about the reason why the specimen was ordered, how is to be
collected, the equipments needed and the stinging sensation that may be felt.o Foods and fluid are usually not restricted before the collection of the specimen.o Instruct the patient to remain still and to hold the arm extended either resting flat on
bed on supported firmly during specimen extraction.
Specimeno 5-10 mL sample of venous blood collected in a tube or syringe.
ResultsNormal Values
Significance Abnormal Results8/9 8/13 8/22
Hemoglobin mass concentration
106 133 110 120-173 g/LDecreased on 8/9. Hemoglobin is the main component of RBC.
Slight decrease of Hgb and erythrocytes (RBC) indicate
nutritional deficiency. Stress.
Erythrocyte volume fraction
0.32 0.41 - 0.35-4.9 L/L
erythrocyte number concentration
3.81 4.82 3.96 3.7-5.3 x 1012/L Within normal range
leukocyte number concentration
12.4 9.0 10.8 6.2-17.0 x 109/L Within normal range
Neutrophil 0.86 0.92 0.10 0.50-0.70 Increased due to infection such as Urinary Tract Infection.
Acute bacterial infection and trauma stimulate neutrophil
production.
Segmenter 0.83 - - 0.50-0.70
Lymphocytes 0.13 0.08 - 0.20-0.40 Decreased.
Eosinophil 0.07 - - .01-.04 Increased.
Platelets 232 220 281200,000-473,000/
cu mmWithin normal range
Protime sec sec - 100%
INR 1.36 0.95 -
APTT 28.7 - -
3. URINALYSIS
Definition: A urinalysis involves multiple routine test of urine specimen. It includes remarks about the
color, appearance, and odor of the urine. The pH is also determined. The urine is tested for the presence of proteins, glucose, ketones, blood and leukocytes esterase.
Urine is a clear, amber-colored fluid that is approximately 95% of water and 5% of dissolved solids. The kidneys normally produce approximately 1.5L of urine each day. Normal urine contains metabolic wastes and few or no plasma proteins, blood cells, or glucose molecules.
The pH of the urine indicated the acid-base balance of the patient.
Specific gravity is a measure of concentration of particles including waste and electrolytes in the urine. Specific gravity refers to the weight of urine compared with that of distilled water. It is used to evaluate the concentrating and excretory power of the kidney. It is also the measurement of hydration status of the patient.
Urine specimens that have been left standing may contain lysed red blood cells, disintegrated casts, and rapidly multiplying bacteria.
Casts are molds of the distal nephron lumen. A gel like substance called tam-horsfall mucoprotein, which is formed in the tubular epithelium, is the major protein constituent of urinary casts. These develops when protein concentration of the urine is high, urine osmolality is high. And urine pH is low.
Purposeo It is used to evaluate the patient’s urine for renal or urinary tract disease. It is also to
help detect metabolic or systemic disease on related to renal disorders and to detect substance use.
Preparationo Instruct the patient about the type of specimen needed and the best time to collect it.
(early morning urine)
o Inform client to collect the midstream urine about 30cc.o The container should be labeled with the patient’s name, date, and the type of the
specimen.
Specimeno 30cc of midstream urine collected in a specimen container.
Component Results Normal Values Significance of Abnormal
Results8/13 8/26
Physical Properties
ColorPale Straw Straw Clear - Straw Within normal range
Transparency Slightly Hazy HazyClear-Slightly
HazyWithin normal range
Reaction (pH) Acidic (6.0) Acidic (6.5) 4.6-8.0 Within normal range
Specific Gravity 1.025 1.025 1.005-1.030 Within normal range
Chemical Tests
Sugarnegative
negative Trace - None Within normal range
Albumin negative negative Trace - None Within normal range
Microscopic Findings
Pus Cells 2-5 0-3 0-1/hpf
Increased. Pus cells in the urine indicates Urinary
Tract Infection.
RBC 2-7 0-2 0-1/hpf
Increased. Any distruption in the blood-urine barrier, whether at the glomerular, tubular
or bladder level, will cause RBC’s to enter the
urine.
ResultsNormal Values
Significance Abnormal Results8/13 8/26
Cast None - Trace - None Within normal range
Crystals
Amorphous Urates-Few - Trace - None Within normal range
Squamous Epithelial Cells Few Occasional Trace - None Within normal range
Round Epithelial Cells Few Few Trace - None Within normal range
Yeast Cells - Occasional Trace - None Within normal range
4. Blood Culture and Sensitivity
Date Taken: 8/17/08
DefinitionA blood culture and sensitivity test is used to identify the microorganisms causing the infection.
The culture is then subjected into antibiotics to identify which one is the most effective treatment and which one is not.
Preparationo Blood culture should ideally be obtained before any antibiotic therapy.o Cleanse skin first before obtaining specimeno NPO status not required.
Specimen : Blood Culture Isolate: Moderate-Heavy Growth of Klebsiella Species
Generic/Brand Name
Potency
ug/discSensitive
Intermediate Sensitive
Resistant
Amikacin 30 *
Ampicillin 10 *
Amoxicillin 25 *
Augmentin 30 *
Cefaclor 30 *
Cefamandole 30 *
Ceftazidime 30 *
Cefotaxime 30 *
Ceftriaxone 30 *
Cefuroxime 30 *
Cephalexin 30 *
Chloramphenicol 30 *
Ciprofloxacin 5 *
Cotrimoxazole 25 *
Erythromycin 15 *
Gentamycin 30 *
Imepenem 10 *
Nalidixic Acid 30 *
Netilmicin 30 *
Nitrofurantoin 300 *
Norfloxacin 10 *
Piperacillin Tazobactam
10/75*
Meropenem
Tetracycline 30 *
Interpretation
Of the drugs the bacteria Klebsiella was subjected to, only chloramphenicol, cotrimoxazole, ceftazedime, and piperacillin tazobactam were considered effective in treating it. Out of these drugs, Chloramphenicol was chosen over the others because it was the cheapest of the group.
5. Name of Examination: ARTERIAL BLOOD GAS ANALYSIS
Date Taken: August 9, 2008
Measurement of ABGs provide valuable information in assessing and managing a patient’s respiratory (ventilation) and metabolic (renal) acid/base and electrolyte homeostasis. It is also used to monitor patients on ventilators, critically ill non-ventilator patients, establish pre-operative baseline parameters and enlighten electrolyte therapy.
Definition:
pH – hydrogen ion concentration, is a measure of alkalinity (>7.4) and acidity (<7.35) of the respiratory and metabolic aspects.
PCO2 – is a measure of the partial pressure of CO2 in the blood. It is a measurement of ventilation capability. The faster and more deeply one breathes, the more CO2 is blown off and PCO2
levels drop. Therefore, PCO2 is referred to as the respiratory component in the acid-base determination because they are primarily controlled by the lungs.
HCO3 – bicarbonate ion or CO2 content. It is a measure of the metabolic (renal/kidney) component of acid-base equilibrium. This ion can be directly measured by the bicarbonate value or indirectly by the CO2 content.
PO2 – this is an indirect measure of the oxygen content of arterial blood. PO2 is a measure of the tension (pressure) of oxygen dissolved in plasma.
O2 saturation – is an indication of the percentage of hemoglobin saturated with O2. When 92% to 100% of the hemoglobin carries O2, the tissues are adequately provided with O2 assuming
normal O2 dissociation.
Base Excess/Deficit – it represent the amount of buffering anions in the blood. Base excess is a way to take all these anions into account when determining acid-base treatment based on the metabolic component. Base deficit indicates a metabolic acidosis and otherwise.
Preparation:
Explain procedure to patient Perform Allen’s test to assess collateral circulation. Cleanse arterial site
Specimen: Arterial blood obtained from any area of the body where strong pulses are palpable. Usually from the radial, brachial, or femoral artery.
Component Result Normal Values SignificancepH 7.409 7.35-7.45 Normal
PCO2 32.4mmHg 35-45 mmHg Decreased due to
HCO3
20.3meq/L 21-28meq/L Decreased due to lactic acidosis, a form of metabolic acidosis experienced by status epilepticus patients
PO2 173mmHg 80-100mmHg Increased due toO2 Sat 99.6% 95-100% Normal
6. Name of Examination: CRANIAL TOMOGRAPHY OF BRAIN
Definition:
CT scan of the brain consists of a computerized analysis of multiple tomographic x-ray films taken of the brain tissue and its successive layers, providing a three-dimensional view of the cranial contents. CT scan is used in differential diagnosis of intracranial neoplasms, cerebral infarctions, ventricular displacement or enlargement, cortical atrophy, cerebral aneurysms, etc.
Preparation:
Explain the procedure to the patient. Cooperation is necessary since the patient is required to lie still during the examination.
Lessen patient anxiety by showing him/her the machine first and encouraging to verbalize concerns.
NPO status for 4 hours before the study if oral contrast medium is used. Remove hairpins, wigs, or any other hair clips and paraphernalia in the head.
Date Taken: August 12, 2008
Result:
Plain and contrast-enhanced axial tomographic sections of the head revealed no evident focal parenchymal mass or abnormally-enhancing lesions.
The ventricles are unenlarged. The cerebral sulci and cisterns are unaffected. No abnormal extra-axial fluid collagen demonstration
The posterior fisa, brainstem and sellar region are unremarkable.
The petromastoids, included orbits, paranasal sinuses and bony calvarium appear unremarkable. Impression : Normal Cranial Study.
7. Name of Examination: CHEST X-RAY
Definition: The chest x-ray film is important in a complete evaluation of the pulmonary and cardiac systems. Much information can be provided by the chest x-ray film such as identification of:
Tumors Inflammation Fluid and air accumulation Fractures of the bones in the thorax Diaphragmatic hernia Heart size Location of centrally placed intravenous access devices.
Preparation:
Explain procedure to the patient No fasting is required Instruct patient to remove clothing to waist and to put on an x-ray gown. Inform patient to remove all metal objects or accessories so as they won’t block the visualization Instruct patient that he or she will have to take a deep breath and hold it while the x-ray films
are being taken. Instruct men to cover their testicles and women to cover their ovaries using lead shield to
prevent radiation-induced abnormalities.
Date Taken: August 9, 2008
Result:
No evident peritubular densities No demonstratable hilar adenopathies Retrosternal and retrocardiac spaces are intact Trachea is at midline Cardiac silhouette is not enlarged Costophrenic sulci are intact Hemidiaphragms are smooth The rest of the findings are unremarkable
Impression: Essential (-) Cardiopulmonary Findings.
VIII. LIST OF PRIORITY NURSING PROBLEMS
1. Ineffective airway clearance r/t NGT
2. Acute pain r/t stomatitis (canker sore)
3. High risk for aspiration
4. Impaired physical mobility r/t neuromuscular impairment secondary to status epilepticus
5. High risk for falls
6. Risk for deficient fluid volume
7. High risk for infection
8. Hyperthermia r/t underlying illness secondary infection
9. Impaired oral mucous membrane r/t mechanical trauma secondary to status epilepticus
10. Impaired swallowing r/t behavioral changes secondary to status epilepticus
11. Imbalanced nutrition: less than body requirements r/t inability to ingest food secondary to
absence of voluntary swallow reflex
12. Impaired tissue integrity r/t mechanical factors as to restraints secondary to status epilepticus
13. Impaired skin integrity r/t mechanical factors as to shearing forces/ increase friction against
skin secondary to status epilepticus
14. Disturbed sleep pattern r/t behavioral changes secondary to status epilepticus
15. Disturbed thought process r/t mental disorders secondary to status epilepticus
16. Self-care deficit: bathing/hygiene/dressing/grooming/feeding/toileting r/t status epilepticus
IX. ON-GOING APPRAISAL (SOAPIE)
8/28/08 @830AM
S –
“Kung kaisa hindi ma-igo sang mga Doctor ang ugat, te hala saylo e. Kag daan grabe siya pa hulagon, budlayan gid guro mga doctor sa iya,” as verbalized by the mother.
“Hala saylo eh, kung kaisa ginahukas niya ukon mag-dinugo na,” referred
IV tubing accidentally being pulled out by patient herself.
“Hulagan siya abi, sadto nga may banig kami di, siguro nag-sag-id hala ka nusnus eh te nagkapilas sya.”
“May bactram cream man kami di ginapahid sa mga pilas niya.”
“Kung wala pa siya guro nahigot, napangkutkot niya pilas nya.”
O –
redness on IV site of about 3 mm in diameter
Guarding behavior
Grimacing upon direct flushing via 10cc syringe through Piggy back port
2mm diameter wound, 1 mm in depth without pus draining on right ankle
Scattered dry abrasions 3 inches in length on forearm
A - Impaired skin integrity r/t mechanical factors as to shearing forces/ increase friction against
skin secondary to status epilepticus
P/I –
1. Application of bactram cream (antibacterial) to wound to prevent infection and promote
wound healing.
2. Providing bed linens which are cotton in nature and no rough edges present on it.
3. Increase fluid intake via NGT tube to promote wound healing.
4. Check temperature for assessing progress of infection if swelling and redness on site and
wound is still evident.
5. Administer anti-bacterial and/or anti-viral medications as prescribed.
6. Provide a clean environment by cleaning and arranging the bedside, and the bed itself which
includes the bed linens, sheets, pillow cases etc.
7. Restraint patient accordingly as prescribed to prevent falls and to prevent further
alimentation of current state
8. Perform ROM exercises on the inflamed site to promote venous return and prevent
hypercoagulation of blood that could lead to thrombophlebitis.
9. Assist patient to reposition in a supported manner with pillows as necessary (side lying for 1
hour, supine for 1 hour, vice versa).
10. Application of cold compress to inflamed IV site to promote vasoconstriction, relieving pain,
redness and swelling.
11. IV pull –out keeping set sterile and reinsertion of the same IVF.
8/28/08 @ 10AM
E –
Application of bactram cream, keeping it dry and clean
IV site inflammation still present on left hand
IV infusion patent and infusing well on right metacarpal vein
Application of cold compress on right ankle wound
Pinkish wound
Pus draining in lesser amount on right ankle wound
TEXTBOOK DISCUSSION AND SCHEMATIC DIAGRAM OF PATHOPHYSIOLOGY
A. Definition
A seizure is a sudden, abnormal electrical discharge from the brain that results in changes sensation, behavior, movements, perception or consciousness.
Seizure disorders have numerous and varied causes. Most are idiopathic. Genetic factors may in some way alter the seizure threshold to influence neuronal discharge. It can also be acquired as a result of brain injury during prenatal, perinatal or postnatal periods.This injury may be caused by trauma, hypoxia, infections. Biochemical events and nutritional deficiencies produce seizure activity
Epilepsy is a chronic of recurrent seizures. An epileptic syndrome is composed of paroxysmal neurologic dysfunction causing recurrent episodes of one or more of the following manifestations: loss of consciousness, convulsive movements or other motor activity, sensory phenomena, and behavioral abnormalities.
Status epilepticus is a tonic clonic or absence seizures that follow one another without restoration of consciousness. Common precipitating factors include abrupt cessation of anticonvulsant medications and alcohol withdrawal. This disorder is life threatening and produces greatly accelerated neuronal metabolic rate, hypoxia, acidosis, hyperthermia, and alterations in cerebral blood flow. Damage occurs to the cerebral cortex, hippocampus, and cerebellum, along with other metabolic derangements.
Tonic-Clonic Seizures are the most common major motor seizure. The tonic phase is followed by the clonic phase, which involves rhythmic bilateral contraction and relaxation of the extremities.
Absence seizures are generalized, nonconvulsive epileptic events and are expressed mainly as disturbances in consciousness. Typical absence seizures have been characterized as a blank stare, motionless, and unresponsiveness, though motion occurs in many cases of absence seizures.
B. Signs and Symptoms
Signs and Symptoms found in the textbook Signs and Symptoms manifested by the patient
Prolonged seizure (lasting longer than 5 min.) (+) Aug. 8,2008
Rolling of eyes upward (+) Aug. 8,2008
Immediate loss of consciousness (+) Aug. 8,2008
Rigidness of the body (+)Aug. 8,2008
Peculiar piercing cry (+)Aug. 8,2008
Respiratory Distress (-)
Cyanosis (-)
Loss of swallowing reflex (-)
Rhythmic muscular contraction and relaxation (+)Aug. 8,2008
Jerking movements (+)Aug. 8,2008
Bladder incontinence (+) Aug. 9, 2008
Bowel incontinence (-)
Hypoxia (-)
Lactic acidosis (+)Aug. 8,2008
C. Schematic Diagram
Predisposing factors Precipitating Factors
Genetic factors Head injury
Head trauma
Cerebrovascular disease
Infection
Physiologic Stimuli
Alteration of the integrity of the neuronal cell membrane
Hyperexcitable cells initiate spontaneous electric discharge
Intensity of discharges reaches a threshold
Neuronal firing spreads to adjacent normal neurons muscle contraction,
loss of consciousness,
jerking movements,
rolling of eyes upward,
rigidness of body
Neuronal excitation spreads to the brainstem
Uncontrolled bursts of electrical activity from the cortex
Seizure
Hypoxia Repeated occurrence of abnormal electrical discharges lactic acidosis
Status Epilepticus
D. Management
a. Nursing Management The management of epilepsy does not usually involve hospitalization. However, a client may initially be hospitalized for assessment, diagnosis, and education immediately after a first seizure. Hospitalization may also be required if seizures become uncontrolled or if status epilepticus develops. Nurses have a role in assessing for altered health maintenance of injury related to knowledge deficit or other barriers, anticipating risk of injury, and providing support for clients and their families who experience life changes related to seizure disorder.
Assessment of clients not actively experiencing seizures includes the following:
History, including prenatal, birth, and developmental history; family history; age at seizure onset; history of all illnesses and trauma; previous brain surgery or stroke; complete description of seizures, including precipitating factors; and presence of an aura
Medication use and postictal symptoms Psychosocial assessment, including mental status examination Complete physical examination, focusing on neurologic signs
The child must be protected from injury during the seizure. It is impossible to halt a seizure once it has begun, and no attempt should be made to do so. The nurse must remain calm, stay with the child, and prevent the child from sustaining any harm during the seizure. If possible, the child should be isolated from the view of others by closing door or pulling screens. A seizure can be very upsetting to the child, other visitors or families. If other persons are present, they should be assured that everything is being done for the child. After the seizure, they can be given a simple explanation about the event as needed.
b. Medical Management The goals of management of clients with seizures and epilepsy are to prevent injury during seizures, to eliminate factors that precipitate seizures, to diagnose and to treat the cause of the seizures, and to control seizures to allow a desired lifestyle.
During a seizure, the major goals are to maintain the airway, to prevent injury, to observe seizure activity and to administer appropriate anticonvulsant medications. Today, “seizure precautions” as identified in a hospital setting refers to the availability of an oral airway, and suction equipment.
For decades, the main antiepileptic drugs (AEDs) were phenytoin, phenobarbital, carbamazepine and valproate sodium. Currently available antiepileptic drugs appear to act
primarily by blocking the initiation or spread of seizures. There are no drugs known to prevent the formation of a seizure focus after a CNS injury in humans.
Medical intervention focuses on prescribing AEDs to arrest or prevent seizures. Developing a program of correctly prescribed anticonvulsants requires weeks of medication adjustment by trial and error. The desired outcome pharmacologic management is monotherapy. Large doses of a single anticonvulsant are often more helpful than smaller doses of several drugs.
Ideally, initial treatment begins with a single drug (primarily anticonvulsant) until either seizure control is attained or unacceptable side effects appear. If side effects become intolerable before seizures are controlled, another drug is added. Combining medications does carry the potential risk of drug-drug interactions, which decrease effectiveness.
c. Surgical Management
The safest and most effective surgical treatment is cortical resection of the anterior temporal lobe for complex partial seizures.Criteria for resection includes:
Failure of the medical approach Localization and identification of a focus of abnormal discharge that is easily
accessible surgically and is located in the “dispensable” areas of the cerebral cortex. Dispensable areas are those for which there is a duplicative area in the cortex.
Cortical resection or Corpus Callosotomy is designed to make the seizures more tolerable. It involves the excision of one section of cortex to reduce the spread of epileptic discharges.
Temporal Lobectomy is performed to remove the area in which the seizures begin without causing neurologic or cognitive deficits.
Hemispherectomy is the removal of most of the cortex of one hemisphere done in children with intractable seizures to control those that are injurious, not to stop all seizures.
Vagal nerve stimulator implantation offers fully understood, the VNS is believed to provide a stimulus that desynchronizes the abnormal uncontrolled electrical discharge of the brain activity during a seizure.
REFERENCES:
Maternal and child health nursing, 4th ed. Pillitteri
Nursing: Understanding Diseases 2008, Lippincott Williams and Wilkins
Focus on Pathophysiology 2008, Lippincott Williams and Wilkins
Medical-Surgical Nursing 7th ed, Black and Hawks
