An overview of the disease

2. OBJECTIVES

3. At the end of the case presentation the participants will
be able to practice excellent nursing care in managing
patients with cryptococcal meningitis. Specifically, this
case presentation aims that the participants will be able
to:
Discuss the global statistics of cryptococcal
meningitis and how infrequent the disease is.
Discuss the pathophysiology of the disease.
Identify the signs and symptoms of cryptococcal meningitis.
Enumerate common and emergency medical and nursing
management of patients with cryptococcal meningitis.

4. introduction
What is Cryptococcal Meningitis?

5. efinition of termsd
Cryptococcoal Meningitis
An infectious disease of worldwide distribution caused
by the fungus, Cryptococcus neoformans. The
fungus primarily attacks the lungs, causing torulomas,
but produces few or no symptoms referable to the
lungs.
This may occur as an opportunistic
infection in those suffering from AIDS

6. efinition of termsd
(Cryptococcal Antigen Latex
Agglutination System)
Determinative test for cryptococcus
infections
CALAS
D-Dimer
Confirms that both thrombin generation
and plasmin generation have ocurred

7. very rare among healthy people

8. Worldwide, C. neoformans infections cause an
estimated 1 million cases of cryptococcal
meningitis per year among people with
HIV/AIDS, resulting in nearly 625,000
deaths.
-CDC

9. AIDS
Cryptococcal Meningitis
About 10% of AIDS patients get
CRYPTOCOCCAL MENINGITIS

10. did you
Knowthat?
Cryptococcus
can be inhaled
from pigeon
and other bird
droppings

11. Contents
PHYSICAL
ASSESSMENT
NURSING
HISTORY
LABORATORY
NURSING
CARE PLAN
PATHOPHYSIOLOGY
OBJECTIVES
FINAL
ASSESSMENT
COURSE IN
THE WARD
DRUG STUDY

12. Nursing
HISTORY

13. Name:
Age:
Sex:
Address:
Civil status:
Nationality:
Occupation:
Religion:
R.L.
64 years old
Male
Molo, Iloilo City
Married
Filipino
None
Roman Catholic
Information
Patient

14. Usual Health Status- The client did not
undergo regular check-up. He was
not sickly, he was never hospitalized.
A
Chronological Story/History of Present Illness
>Morning prior to admission, patient complained of
fever and chills associated with headache, patient
sought consult to a private physician and was given
cotrimoxazole.
> 4 hours prior to admission, patient experienced
persistence of above signs and symptoms. This time it
was associated with stiffening of extremities and
upward rolling of eyeballs. The said events
made the family seek medical help and brought Mr. L to
the ER of GSIH-TMCI at 7pm of August 5, 2011.
B

15. Past Medical History
No previous hospitalization or consultation to
a health care provider . Mr. L had chicken pox
and mumps when he was a child, illness were
managed at home. Mr. L has no known allergies.
Fever, flu and cough were also experienced but no
consultation was made as claimed, dates were not
specified.
Family Medical History
On his paternal side, hypertension ran within their
blood and Diabetes mellitus is common on his
maternal side. No incidence of infection noted
within the immediate family such as pneumonia
and tuberculosis as claimed.
Source: M.L. (Mr. L’s son)
C
D

16. Activities of Daily Living
Nutrition: Mr. L ate at least 3 times a day. Mr. L
preferred to eat rice, 1-2 cups per meal, with meat
such as beef, pork and chicken, with variety of
vegetables. He usually drinks at least 6-8 glasses of
water per day. Intake of caffeinated beverages was also
noted, he consumed a cup of coffee per day at
breakfast.
Sleep and Rest: Mr. L usually sleeps around 9pm, with
5-6 hours of sleep per day. Sleeping problems were
reported such as occasional snoring and easily awaken.
Bowel and Elimination: Mr. L usually defecates every
day to a formed to mushy stool. Occasional elimination
problem such as constipation was also noted but was
managed by increasing oral fluid intake and eating
fruits. Mr. L voids frequently with no difficulty as
claimed.
E

17. Activities of Daily Living
Hygiene: Mr. L usually takes a bath daily and does oral
care at least twice a day.
Leisure/Recreation: Mr. L was unemployed and spent
most of his time at their house. Mr. L exercised at least
twice a week for 10-20 minutes by jogging or brisk
walking. Mr. L was also fond of taking care of pigeons.
He owned a flock of pigeons that reside at their
rooftop way back 2 years ago. He usually fed them in
the morning.
E

18. did you
Knowthat
After age 30,
the brain shrinks
a quarter of a percent (0.25%)
in mass each year.
?

19. ASSESSMENT
PHYSICAL

20. General Appearance:
Patient was considered to be obese class 1 as
assessed according to standard body mass index. He
has unkempt appearance. He has no verbal output. Upon
admission Mr. L.R was restless. VS: T- 39.5, PR- 95 bpm, RR- 35
cpm, BP- 200/90 mmHg. Ht: 160 cm, Wt: 87 kgs
Integumentary System:
Has fair complexion noted. Has no presence of edema on skin. Has
no lesions noted. Skin warm to touch. Flushing noted all over
the face and chest. Diaphoretic. Has an intact epidermis
fingernails and toenail beds are pinkish in color, smooth and normal
degree of blanching less than 2 seconds.

21. CNS: GCS-6, pupils are
sluggish, with seizure
episode, with Midazolam drip 20
mg in 100 cc PNSS @ 10
mgtts/min
CVS: HR- 95 bpm, SBP- 160-200 mmHg, consistently
hypertensive, with AC drip of D5W 500cc+2 amps
Apresoline+2 amps Clonidine Hcl @ 10 mgtts/min titrate
increments by 5 mgtts/min to maintain SBP- 130 mmHg.

22. RESPI: With Mechanical
ventilator setting: AC- Mode, Fi02-
100%, TV- 450, PFR- 50, BUR-20, patent
and intact, with O2 saturation of
99%, and respiratory secretions
noted, (+) crackles.
GI: Diet: OTF at 1000 kcal/day 1:1 dilution
divided in 6 equal feedings, abdomen is
soft, (+) bowel movement, 14 bowel
sounds heard on all quadrants of
abdomen.

23. ENDO: with the CBG result of
81 mg/dl-(8/5/11, 7:06 pm)
GU: with adequate urinary output,
with yellowish colored urine, with
foley catheter attached to urobag

24. IDS: WBC- 19.5x10/L, with
Metronidazole 500 mg/tab,
Azithromycin 500 mg/tab and
Ceftriaxone 3 grams.

25. did you
Knowthat
The human brain
has the capacity to
storeeverything that
you experience .
?

26. Course
in thee
Ward

27. Upon admission, the
patient has the following
temperature - 39.7
degrees celsius, CR - 95
bpm, RR – 35 bpm, BP –
190/80 mmHg patient
was managed as a case
of
under the service of Dr.
G.L.

28. He was managed with
Citicoline IV, Mannitol,
Paracetamol IV,
Ceftriaxone, IV, Diazepam
IV, Azithromycin,
Metronidazole IV, Keppra
and in Mechanical
Ventilator Support. He
was then transferred to
ICU for further
management and work
ups. Patient was
monitored closely.

29. Upon admission in
the ICU, there is
Decreased in
sensorium ,
no eye opening, no
verbal response and
decorticate, and focal
seizure noted,
Diazepam 5 mg IVTT
Q6h and Midazolam
drip x 5 mgtts/min as
ordered until the 2nd
day.

30. Increased BP
noted,
, he has
a AC drip started at
10 mgtts/min
titrated increments
by 5 mgtts/min to
maintain SBP 130
mmHg, as ordered

31. The patient was
referred to an
(Dr.I.S)

32. On the 2nd
day, Lumbar
Puncture was
done by Dr. G.L.
CSF specimen
was collected in
4 test tubes and
sent to the
laboratory.

33. TT1- cell
count, differentiated
count, sugar, protein
TT2-
GSCS, KOH, AFB, India
Ink
TT3- For CALAS c/o
Manila Doctors’
Hospital
TT4- Stored at the
freezer for future use

34. On the 4th day,
and
noted until
8th day, it was managed
by Paracetamol 300 mg
IV, Continuous TSB done,
AC Drip and other anti-
hypertensive drugs. ,
.

35. After that, patient
L.R. was referred to
(Dr.
M.G.D.S)due to
hospital acquired
pneumonia with
pleural effusion and
COPD

36. 8/9/11
POSITIVE CALAS
TEST

37. On the 12th day,
patient was
(endotracheal
tube),
done by
Dr. S.

38. did you
Knowthat
The Brain can stay
alive for 4 to 6 minutes
without oxygen.
after that cells begin
to Die
?

39. PHYSIO
PATHO-
LOGY

40. THE PATHOPHYSIOLOGY OF
CRYPTOCOCCAL MENINGITIS

41. Cont..
(+) hyperthermia
(+) ETA coagulase
negative
Staphylococci(8/7)
(+) ETA Candida
spp. (8/10)
(+) ETA
Pseudomonas
aeruginosa (9/1)
increased WBC
count
(Segmenters)
Seizure
sluggish pupillary
reflex
GCS 6 (E - 1 / V - 1
/ M - 4)
(-) motor
response
(+) crackles, tachypnea, excessive
sputum production, desaturation
D-dimer 2.1 mg/L Progressing left
pleural effusion (8/16)
Increased workload of the
heart :increased BP
(+) atherosclerotic aorta
(8/5)(+) lateral wall
ischemia(8/5)
Fluid volume excess
Creatinine 167 mmol/L 98/5)
Sodium 128.8 mmol/L (8/5)
Potassium 2.84 mmol/L (8/18)
Albumin 29 g/L (8/10)

42. did you
Knowthat
10amount of time
to the brain.
until unconsciousness
after the loss of
?
blood supply
seconds is the

44. HEMATOLOGY
Examination Normal Value 8/5/11
Hemoglobin 120-170 g/L 121
Hematocrit 0.40- 0.54 0.39
RBC 4.60-6x10^12/L 3.94
WBC 5-10x10^9/L 7.1
Differential count
Myelocytes 0.00-0.00 0.00
Metamylocytes 0.00-0.1 0.00
Stabs 0.03-0.5 0.04
Segmenters 0.50-0.70 0.74

45. HEMATOLOGY
Examination Normal Value 8/5/11
Eosinophils 0.00-0.05 0.00
Basophils 0.00-0.01 0.00
Lymphocytes 0.20-0.40 0.22
Monocytes 0.00-0.07 0.00
Platelet count 150-450x10^9/L 230
MCV 80-100 cu m 98
MCHC 32-36g/L 30.6
MCH 27-32 pg 31.1

46. HEMATOLOGY REPORT
Examination Normal
Value
8/5/11 08/8/11 8/14/11 9/5/11 9/8/11
WBC 5-
10x10^9/L
7.1 19.5 12.1 7.7 8.9
Lymphocytes 0.20-0.40 0.22 0.07 0.09 0.21 0.20

47. Date Examination Normal Value Result
08/16/11 Bleeding Time 1-3 minutes 3 minutes
Clotting Time 3-6minutes 4minutes and 30
seconds
clotting time
Bleeding time

48. SGPT
SGPT
Examination Normal Value 8/5/11 8/17/11
SGPT Up to 37 56 100

49. Date: 8/5/11 Prothrombin Time
Patient 13.8 seconds
Normal Range 11.1-13.2 seconds
Control 14.9 seconds
% Activity 80.5%
International Snesitivity Index 1.31
International Normalized Ratio 1.10
prothrombin
Time

50. Date: 8/16/11 Prothrombin Time
Patient 13.8 seconds
Normal Range 11.1-13.2 seconds
Control 13.8seconds
% Activity 80.5%
International Snesitivity Index 1.31
International Normalized Ratio 1.10
prothrombin
Time

51. Date: 8/5/11 Activated Partial Thromboplastin Time
Patient 34.0 seconds
Control 34.9 seconds
Normal Range 22.0-35.0 seconds
activated partial
Thromboplastin time

52. serum
Creatinine
CREATININE
Normal Value 8/5/11 8/8/11 8/9/11 8/13/11
53-115 umol/L 167 157 120 112
CREATININE
Normal Value 8/14/11 8/18/11 8/26/11 9/5/11 9/8/11
53-115 umol/L 88 99 118 154 148

53. blood
Urea Nitrogen
BUN
Normal Value 8/5/11 8/6/11 8/18/11 9/8/11
2.80-7.20
mmol/L
6.79 8.03 4.96 4.54

54. serum
Sodium
SODIUM
Normal Value 8/5/11 8/8/11 8/16/11 8/18/11 8/26/11
135-148
mmol/L
128.8 136 146.8 147.7 137.2

55. serum
Potassium
POTASSIUM
Normal
Value
8/5/11 8/8/11 8/9/11 8/14/11 8/16/11 8/18/11
(7AM)
8/18/11
(9PM)
3.5-5.3
mmol/L
3.58 4.28 4.78 3.44 3.53 2.84 2.73
POTASSIUM
Normal
Value
8/19/11 8/21/11 8/26/11
(5AM)
8/26/11(2
PM)
8/30/11 9/5/11 9/8/11
3.5-5.3
mmol/L
3.13 3.59 2.51 3.21 3.02 3.30 3.97

56. Date Examination Normal Value Result
8/6/11 Fasting Blood Sugar 3.9-6.4 mmol/L 8.03
Uric Acid 214-488 umol/L 576
LDL Cholesterol Less than 3.4 mmol/L 2.02
HDL Cholesterol Greater than 0.9
mmol/L
0.68
Triglycerides Up to 2.3 mmol/L 1.42
Cholesterol (total) Up tp 5.2 mmol/L 3.34
FBS, uric acid
Lipid Profile

57. Date Examination Normal Value Result
8/9/11 HBA1C 4.20-6.20 % 6.3
DIABETIC
Good Control: 5.5-6.8%
Fair Control: 6.8-7.6%
Poor Control: above 7.6 %
HBA1C

58. Date Examination Normal Value Result
8/10/11 Total Protein 63-83 g/L 65
Albumin 32-52 g/L 29
Globulin 28-31g/L 36
A/G Ratio 0.00-0.00 0.80:1
Date Examination Normal Value Result
8/15/11 Albumin 32-52 g/L 26
total Protein with
A/G Ratio

59. Urinalysis
URINALYSIS 8/5/11
RBC: 75-100/HPF(++++) CRYSTAL:
PUS CELLS: 25-50/HPF(++) URIC ACID:
EPITHELIAL CELLS: FEW CAL. OXALATE:
RENAL CELLS: AMOR.
URATES:
Occassional
MUCUCS THREADS: AMOR. PHOS.
BACTERIA: FEW TRIPLE PHOS.
OTHERS: OTHERS:
CAST
HYALINE: COARSE
GRAN:
FINE GRAN OTHERS:

60. ABG ANALYSIS RESULT
DATE INTERPRETATION
8/5/11 Partially compensated metabolic acidosis with corrected
hypoxemia
8/6/11 (1 am) Combined respiratory and metabolic acidosis with
corrected hypoxemia
8/6/11 (10 am)
Fi02 80% via VR
Compensated respiratory alkalosis with corrected
hypoxemia
8/8/11
Fi02 80%
Normal acid-base with corrected hypoxemia
8/9/11
Fi02 60% via VR
Normal acid-base with corrected hypoxemia
8/27/11
Fi02 40% via T-piece
Uncompensated respiratory alkalosis
arterial
Blood Gas

61. Total Cell count:
RBC: 1 cell/cumm
WBC: 3 cells/cumm
Differential Count:
Polymorphonuclear cells = 4
Lymphocytes = 6
Remarks: 10 cell counted on smear
Total protein: 257mg/L
Sugar: 7.58 mmol/L
cerebrospinal fluid
Analysis

62. Specimen: CSF
Gram Stain Result 8/6/11
Gram Negative Rods: Occassional
Gram Positive Cocci
In singles: Occassional
In pairs: none
In chains: none
In clusters: none
Pus cells: none
Epithelial cells: none
Others:
cerebrospinal fluid
Analysis

63. Gram Stain Result 8/7/11 8/18/11
Gram Negative Rods: Occasional Few
Gram Positive Cocci
In singles: Moderate Few
In pairs: Few Occasional
In chains: none None
In clusters: Occasional Occasional
Pus cells: 10-12/ HPF (++) 20-30/ HPF (+++)
Epithelial cells: none 0-2/ HPF (Occasional)
Others: Fungal element noted
endotracheal
Aspirate

64. Specimen: CSF8/6/11
Test name Result
KOH : Negative for fungal elements
on direct smear
AFB : Negative – No acid fast bacilli
seen on direct smear
Specimen: ETA 8/7/11
Test name
KOH : No fungal elements seen on
smear
Specimen: Sputum 8/10/11
Test name
KOH :Positive for fungal element
KOH
AFB

65. Specimen: CSF 8/6/11
Organism isolated: Coagulase-negative Staphylococci
Specimen: Endotracheal Aspirate 8/7/11
Organism isolated: Coagulase-negative Staphylococci
Specimen: Endotracheal Aspirate 8/10/11
Organism isolated: Candida spp.
Specimen: Endotracheal Aspirate 9/1/11
Organism isolated: Pseudomonas Aeroginosa
culture and
Sensitivity

66. Specimen: CSF for India Ink Preparation 8/7/11
Result
No encapsulated yeast
cells seen on preparation
CSF
India ink

67. Specimen: Plasma for D-Dimer Detrmination 8/16/11
Result
Reference Value:
D-Dimer 2.1 mg/L <0.3 mg/L
D-dimer
determination

68. cryptococcal antigen latex
agglutination system
(CALAS)
RESULT POSITIVE

69. ECHOCARDIOGRAPHY REPORT
8/19/11
CONCLUSION:
DILATED LEFT VENTRICULAR DIMENSION WITH GOOD
SYSTOLIC BUT IMPAIRED DIASTOLIC FUNCTION.
SLIGHTLY DILATED LEFT ATRIUM.
TRIVIAL MITRAL AND TRICUSPID REGURGITATION.

70. ELECTROCARDIOGRAM
8/5/11
REMARKS:
ATRIAL FIBRILLATION WITH RAPID VENTRICULAR
RESPONSE.
PREMATURE VENTRICULAR CONTRACTION.
LATERAL WALL ISCHEMIA.
8/9/11
REMARKS:
SINUS TACHYCARDIA

71. ELECTROCARDIOGRAM
8/16/11
REMARKS:
OCCASSIONAL PREMATURE ATRIAL CONTRACTIONS.
8/24/11
REMARKS:
SINUS BRADYCARDIA WITH INTERMITTENT EPISODES OF
JUNCTIONAL RHYTHM.

72. CT Scan Report 8/5/11
IMPRESSION:
CEREBRO- CEREBELLAR ATROPHY
ATHEROMATOUS INTERNAL CAROTID ARTERIES, BASILAR ARTERY AND
VERTEBRAL ARTERIES.
SUSPICIOUS HYPODENSITY IN THE LEFT PORTION OF THE MIDBRAIN-
HYPERACUTE OR ACUTE INFARCT NOT RULED OUT; FOLLOW UP IS
RECOMMENDED.
CONSIDER SINUSITIS-LEFT ANTERIOR ETHMOID AND BOTH MAXILIARY
SINUSES.
RIGHTWARD NASAL SEPTAL DEVIATION.
LEFT INFUNDIBULUM BLOCKED BY SOFT TISSUE DENSITIES.
CONSIDER NASAL SECRETIONS LEFT NASAL CAVITY; NASAL CONGESTION,
LEFT NASAL POLYP,LEFT.

73. X-RAY REPORT 8/05/11
IMPRESSION:
PNEUMONIA BILATERAL AND/OR PULMONARY CONGESTION.
RULE OUT PULMONARY EDEMA.
RULE OUT MINMAL PLEURAL EFFUSION, BILATERAL.
ATHEROMATOUS AORTA.
RULE OUT DILATED THORACIC AORTA.
CHEST CT SCAN CORRELATION IS RECOMMMENDED FOR FURTHER.
EVALUATION OF THE PROMINENT SUPERIOR MEDIASTINUM AND LEFT
HILUM IF CLINICALLY WARRANTED.

74. X-RAY REPORT 8/18/11
IMPRESSION
PULMONARY CONGESTION, PROGRESSING
R/O PULMONARY EDEMA.
INTERCURRRENT PNEUMONIA, PROGRESSING.
PLEURAL EFFUSION, BILATERAL, PROGRESSING.
ATHEROMATOUS AORTA.
PLEASE CORRELATE CLINICALLY

75. X-RAY REPORT 9/5/11
IMPRESSION:
PULMONARY CONGESTIVE CHANGES.
PNEUMONIA, BILATERAL WITH PROGRESSION.
ATHEROSCLEROTIC AORTA.
FOLLOW-UP IS SUGGESTED.

76. did you
Knowthat
uses approximately
as much energy
as a 10 watt light bulb.
?
The human brain

77. DRUG
STUDY

78. CNS DRUGS
GENERIC/BRAND NAME/
DOSAGE
CLASSIFICATION INDICATION
Diazepam 5 mg IV PRN for
seizure
Benzodiazepine Adjunct therapy in
convulsive disorders
Levetiracetam KEPPRA 4.5
ml BID
Anti convulsant Mono/Adjunctive therapy
in the treatment of partial
onset of seizures
Special Precautions: Avoid
abrupt withdrawal
Citicoline 1 gram IV Q 12H neurostimulant Cerebral insufficiency in
acute and recovery phase

79. ,
ANTIBIOTICS
DATE ORDERED GENERIC NAME CLASSIFICATION INDICATION
August 5, 2011 Metronidazole Anti-protozoal KOH of sputum reveal
positive for fungal elements.
Endotracheal aspirate reveal
Candida spp.
August 5, 2011 Ceftriaxone 3rd generation
Cephalosporin
Treatment of susceptible
infection.(+) febrile episodes
upon admission
August 6, 2011 Fluconazole Anti-fungal KOH of sputum reveal
positive for fungal elements.
Endotracheal aspirate reveal
Candida spp.
August 17, 2011 Meropenem Beta Lactam Progression of pneumonia

80. ANTIBIOTICS
DATE ORDERED GENERIC NAME CLASSIFICATION INDICATION
August 30, 2011 Cefipime 3rd generation
Cephalosporin
Culture and Sensitivity of
Endotracheal tip reveal
sensitivity to Cefipime
September 5,
2011
Ceftazidime
1 gram IV Q12H
3rd generation
Cephalosporin
9/3/2011
Endotracheal aspirate
Culture and sensitivity
reveal Pseudomonas
aeruginosa. Susceptible to
Ceftazidime
September 5,
2011
Ciprofloxacin Quinolones 9/3/2011
Endotracheal aspirate
Culture and sensitivity
reveal Pseudomonas
aeruginosa. Susceptible to
Ciprofloxacin

81. ANTIBIOTICS
DATE ORDERED GENERIC
NAME
CLASSIFICATION INDICATION
August 12, 2011 Amphotericin B Antibiotic/
Antifungal
(+) Calas test
Systemic, potentially fatal, life
threatening fungal infection
Special Precautions:
• May cause bone marrow
depression- increased incidence
of microbial infection and
delayed healing.
• May cause renal impairment.
Serum creatinine must be
monitored.
• Dose gradually increased daily
to reach desired amount
indicated by the physician.

82. GASTROINTESTINAL DRUGS
GENERIC/BRAND NAME
/DOSAGE
CLASSIFICATION INDICATION
Omeprazole 20 mg/cap BID Proton Pump Inhibitor Used in conditions where
inhibition of gastric acid
secretion may be beneficial
To prevent ulcer and acid
related dyspepsia
Esomeprazole 40 mg IV OD Proton Pump Inhibitor Reduce the occurrence of
gastric ulcers
ESSENTIALE FORTE 1 cap
TID
Hepatic Protector Prevention of toxic
metabolic liver diseases
Lactulose 30 cc OD Laxative Chronic constipation.
Episodes of (-) BM

83. ANTI ASTHMATIC PREPARATIONS
GENERIC/BRAND NAME/DOSAGE INDICATION
Ipratropium Bromide + Salbutamol
COMBIVENT 1 nebule Q 6H
Management of reversible bronchospasm
associated with obstructive airway
diseases in patients who require more
than a single bronchodilator
Salmeterol Xinafoate Fluticasone
Propionate
SERETIDE 2 puffs BID
Prophylaxis and maintenance treatment of
asthma
Budesonide 500mcg/respule Q 12H Prophylaxis and maintenance treatment of
asthma
Doxofylline 400 mg/tab BID Bronchial asthma
Montelukast Na 10 mg/tab OD Management of chronic asthma

84. ANTIHYPERTENSIVES/DIURETICS
GENERIC/BRAND NAME CLASSIFICATION INDICATION
Losartan K 100 mg/tab OD Angiotensin II
Antagonist
Increased BP, Hypokalemia
Special Precaution: Serum
potassium should be monitored
Furosemide + KCL
DIUMIDE K ½ tab OD
Diuretic Congestion, hypokalemia
Special Precaution: Serum
potassium should be monitored
Amlodipine 10 mg/tab OD Calcium Antagonist Hypertension
Mannitol 150cc IV Q 6H Osmotic Diuretic Increased intracranial pressure
and cerebral edema as seen in
the CT scan
Furosemide 20mg IV now Diuretic Dyspnea, desaturation,
wheezing – congestion

85. GENERIC/BRAND NAME
/DOSAGE
CLASSIFICATION INDICATION
Acetylcysteine Mucolytic Acute and Chronic
respiratory tract infection
with abundant mucus
secretions
Paracetamol 300 mg IV Q
4H RTC
antipyretic Client is continuously
febrile
Hydrocortisone 100 mg IV
Q12 H
Corticosteroid For relief of congestion ,
inflammation brought
about by infection
Naproxen Na 275 mg/tab
Q 8H RTC
Non-steroidal Anti
Inflammatory Drugs
Continuously febrile
despite Paracetamol
Intermediate Insulin Insulin Hyperglycemia
Kalium durule 2 durules
TID
Supplement Hypokalemia

86. did you
Knowthat?
The female pigeon
cannot lay eggs if she is alone.
In order for her ovaries to function,
she must be able to see
another pigeon.

88. List of formulated Nursing Dx

89. List of formulated Nursing Dx

90. neffective Airway Clearance
GOAL: Within 5mins-15mins hours, the client will manifest:
• Normal breathing pattern
• A decrease in respiratory secretions
• No episode of desaturation
• A reduction of wheeze and crackles noted upon auscultation
r/t increased production/retained tenacious secretions secondary to infection as
evidenced by ineffective cough, crackles, tachypnea, excessive sputum
I
INDEPENDENT
Monitor respirations and breath sounds, noting rate and sound indicative of
respiratory distress and/or accumulation of secretions.
Suction naso/tracheal/oral prn to clear airway when excess or viscous
secretions are blocking airway.
Elevate head of bed/change position every 2 hours and prn to take advantage of
Gravity decreasing pressure on the diaphragm and enhancing drainage of/ventilation
To different lung segments.
Insert oral airway when needed, to maintain anatomic position of tongue and
natural airway.

91. INDEPENDENT
Keep environment allergen free (e.g., dust)
Monitor vitals signs, noting blood pressure/pulse changes.
Position in semi-fowlers to moderate high back rest to maximize lung expansion.
DEPENDENT
Administer bronchodilators/mucolytics as ordered.
Administer medications, as indicated, to treat underlying cause such as antibiotics.
Chestphysiotherapy to mobilize secretions.
INTERDEPENDENT
Obtain sputum specimen to verify appropriateness of therapy
Ensure most of the time placement of th endotracheal tube.

92. luid Volume Excess
r/t cerebral insufficiency , acute stress, presence of infection, and immobility as
manifested by dyspnea, decreased O2 sat=85%, crackles noted upon auscultation,
diaphoresis, restlessness, increased BP, Jugular vein distention
F
INDEPENDENT
Assess causative/precipitating factors
Monitor progression/alleviation of symptoms
GOAL: Within 8 hours, the client will be able to:
• Stabilize fluid volume as witnessed by balanced intake and output
• Vital signs within normal limits
• Manifest adequate O2 saturation = 95%-100%
• Decreased crackles noted upon auscultation
• Demonstrate calmness
Accurately monitor fluid intake and output from all sources: PO, IV, urine,
insensible fluid loss
Assess presence of jugular vein distention

93. INDEPENDENT
Note and measure parameters that may indicate increasing fluid retention/edema
(e.g. abdominal girth)
Reposition every two hours to prevent stasis and reduce risk of tissue injury
Use safety precautions at all times
DEPENDENT
Administer diuretics and steroids as ordered by the physician.
INTERDEPENDENT
Review diagnostic data (BUN, creatinine, hematocrit, serum albumin and chest
x-ray) correlate and relay accordingly

94. ecreased Cerebral Tissue Perfusion
GOAL: After one month, the client will be able to:
• Demonstrate an improved GCS score of 10-12
• Manifest an enhanced mental status, with increased episodes of wakefulnes
•Manifest a decrease in seizure episodes
r/t interruption of cerebral blood flow secondary to cryptococcal infection as
evidenced by altered mental status, GCS=6 E1V1M4, comatose to stuporous, seizure
episodes, changes in motor response.
D
INDEPENDENT
Determine factors related to individual situation, e.g., presence of fungal infection
Identify changes related to systemic alteration in circulation, such as altered mental
status
Evaluate signs of infection.
Determine duration of problem/ frequency of recurrence
Determine presence of visual sensory motor changes, altered mental status
Elevate head of bed 30 degrees and maintain head/neck in midline or neutral position
To promote circulation/venous drainage
Provide calm and cool environment

95. INDEPENDENT
Decrease noxious stimuli
Provide non-constrictive clothing
Assist with treatment of underlying condition
DEPENDENT
Administer medications as prescribed
Administer fluid replacement/rehydration or blood transfusion to improve
tissue perfusion/organ function
INTERDEPENDENT
Review specific dietary changes/restrictions
Review results of diagnostic studies

96. yperthermia
H
INDEPENDENT
Monitor body temperature .
GOAL: Within 8 Hours, the client will be able to:
• Maintain temperature within normal range
• Manifest relief from symptoms experienced
Monitor and record all sources of fluid loss such as urine
Promote surface cooling by means of undressing (heat loss by radiation/conduction)
Provide cool environment (heat loss by convection)
Tepid sponge baths (heat loss by evaporation and conduction)
Apply local ice pack on groin and axillae
r/t inflammatory process secondary to infection as evidenced by elevated surf
body temperature, skin warm to touch, flushing, diaphoresis, tachypnea,
tachycardia

97. INDEPENDENT
Wrap extremities with bath towel to decrease shivering.
Promote safety by securing both side rails up.
Maintain bed rest to decrease metabolic demands and O2 consumption.
Maintain adequate fluid intake to prevent dehydration.
DEPENDENT
Administer antipyretics, Paracetamol 300mg IV Q4H RTC as ordered.
Administer medications, as indicated, to treat underlying cause such as antibiotics.
INTERDEPENDENT
Monitor laboratory results such as ABGs, electrolytes , coagulation profiles,
Urinalysis, CBC.

98. isk for Aspiration
R
INDEPENDENT
Note the client’s level of consciousness
GOAL: Within one month, the client will :
• Experience no aspiration
• Maintain patent airway
Assess amount and consistency of respiratory secretions
Assess muscle strength, gross and fine motor coordination
Careful administration of enteral feedings, being aware of potential for
regurgitation and/or misplacement of tube
Measure residuals when appropriate to prevent over feeding
Maintain operational suctioning equipment at bedside
r/t altered mental status, GCS score of 6 secondary to cerebral insufficiency
brought about by infection

99. INDEPENDENT
Suction oral cavity, nose and endotracheal tube as needed
Auscultate lung sounds frequently to determine presence of secretions
Elevate client to high fowler’s position during tube feedings
Keep side rails up for safety
DEPENDENT
Administer Diazepam for restlessness and seizure episodes as ordered

100. did you
Knowthat
some of your
brain cells
die.
?
If you sneeze

101. ASSESSMENT
FINAL

102. CLINICAL INSPECTION
Date and Time Taken: September 8, 2011, 4pm
Vital Signs:
T- 36.3
PR- 64 bpm
RR- 22 bpm
BP- 120/80 mmHg

103. CNS: GCS 10 (E-4, V-1, M-5), pupils
equally round and reactive to light and
accommodation 2mm in diameter,
normal power on both upper and lower
extremities.
CVS: Attached to cardiac
monitor, normal sinus rhythm

104. RESPI: attached to
continuous O2 @ 2lpm via
tracheal mask, whitish
secretions upon suction
GI: Diet: Abdomen soft with
bowel sounds upon auscultation.
OTF 2400 kcal in 1800 cc volume
divided by 6 equal feedings.

105. GU: adequate urinary
output, with yellow orange
colored urine

106. Client was transferred per stretcher
per folks request to West Visayas State
University Hospital on September 8, 2011
at around 8:30 in the evening accompanied by
ER staff nurse and on call junior consultant with
O2 @ 2lpm via tracheal mask and venoclysis of
PNSS 1L +20 meq kcl x 20cc/hr.

107. Thank
you