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OBJECTIVES
At the end of the case presentation the participants willbe able to practice excellent nursing care in managingpatients wi...
introductionWhat is Cryptococcal Meningitis?
efinition of termsdCryptococcoal MeningitisAn infectious disease of worldwide distribution causedby the fungus, Cryptococc...
efinition of termsd(Cryptococcal Antigen LatexAgglutination System)Determinative test for cryptococcusinfectionsCALASD-Dim...
very rare among healthy people
Worldwide, C. neoformans infections cause anestimated 1 million cases of cryptococcalmeningitis per year among people with...
AIDSCryptococcal MeningitisAbout 10% of AIDS patients getCRYPTOCOCCAL MENINGITIS
did youKnowthat?Cryptococcuscan be inhaledfrom pigeonand other birddroppings
ContentsPHYSICALASSESSMENTNURSINGHISTORYLABORATORYNURSINGCARE PLANPATHOPHYSIOLOGYOBJECTIVESFINALASSESSMENTCOURSE INTHE WAR...
NursingHISTORY
Name:Age:Sex:Address:Civil status:Nationality:Occupation:Religion:R.L.64 years oldMaleMolo, Iloilo CityMarriedFilipinoNone...
Usual Health Status- The client did notundergo regular check-up. He wasnot sickly, he was never hospitalized.AChronologica...
Past Medical HistoryNo previous hospitalization or consultation toa health care provider . Mr. L had chicken poxand mumps ...
Activities of Daily LivingNutrition: Mr. L ate at least 3 times a day. Mr. Lpreferred to eat rice, 1-2 cups per meal, with...
Activities of Daily LivingHygiene: Mr. L usually takes a bath daily and does oralcare at least twice a day.Leisure/Recreat...
did youKnowthatAfter age 30,the brain shrinksa quarter of a percent (0.25%)in mass each year.?
ASSESSMENTPHYSICAL
General Appearance:Patient was considered to be obese class 1 asassessed according to standard body mass index. Hehas unke...
CNS: GCS-6, pupils aresluggish, with seizureepisode, with Midazolam drip 20mg in 100 cc PNSS @ 10mgtts/minCVS: HR- 95 bpm,...
RESPI: With Mechanicalventilator setting: AC- Mode, Fi02-100%, TV- 450, PFR- 50, BUR-20, patentand intact, with O2 saturat...
ENDO: with the CBG result of81 mg/dl-(8/5/11, 7:06 pm)GU: with adequate urinary output,with yellowish colored urine, withf...
IDS: WBC- 19.5x10/L, withMetronidazole 500 mg/tab,Azithromycin 500 mg/tab andCeftriaxone 3 grams.
did youKnowthatThe human brainhas the capacity tostoreeverything thatyou experience .?
Coursein theeWard
Upon admission, thepatient has the followingtemperature - 39.7degrees celsius, CR - 95bpm, RR – 35 bpm, BP –190/80 mmHg pa...
He was managed withCiticoline IV, Mannitol,Paracetamol IV,Ceftriaxone, IV, DiazepamIV, Azithromycin,Metronidazole IV, Kepp...
Upon admission inthe ICU, there isDecreased insensorium ,no eye opening, noverbal response anddecorticate, and focalseizur...
Increased BPnoted,, he hasa AC drip started at10 mgtts/mintitrated incrementsby 5 mgtts/min tomaintain SBP 130mmHg, as ord...
The patient wasreferred to an(Dr.I.S)
On the 2ndday, LumbarPuncture wasdone by Dr. G.L.CSF specimenwas collected in4 test tubes andsent to thelaboratory.
TT1- cellcount, differentiatedcount, sugar, proteinTT2-GSCS, KOH, AFB, IndiaInkTT3- For CALAS c/oManila Doctors’HospitalTT...
On the 4th day,andnoted until8th day, it was managedby Paracetamol 300 mgIV, Continuous TSB done,AC Drip and other anti-hy...
After that, patientL.R. was referred to(Dr.M.G.D.S)due tohospital acquiredpneumonia withpleural effusion andCOPD
8/9/11POSITIVE CALASTEST
On the 12th day,patient was(endotrachealtube),done byDr. S.
did youKnowthatThe Brain can stayalive for 4 to 6 minuteswithout oxygen.after that cells beginto Die?
PHYSIOPATHO-LOGY
THE PATHOPHYSIOLOGY OFCRYPTOCOCCAL MENINGITIS
Cont..(+) hyperthermia(+) ETA coagulasenegativeStaphylococci(8/7)(+) ETA Candidaspp. (8/10)(+) ETAPseudomonasaeruginosa (9...
did youKnowthat10amount of timeto the brain.until unconsciousnessafter the loss of?blood supplyseconds is the
HEMATOLOGYExamination Normal Value 8/5/11Hemoglobin 120-170 g/L 121Hematocrit 0.40- 0.54 0.39RBC 4.60-6x10^12/L 3.94WBC 5-...
HEMATOLOGYExamination Normal Value 8/5/11Eosinophils 0.00-0.05 0.00Basophils 0.00-0.01 0.00Lymphocytes 0.20-0.40 0.22Monoc...
HEMATOLOGY REPORTExamination NormalValue8/5/11 08/8/11 8/14/11 9/5/11 9/8/11WBC 5-10x10^9/L7.1 19.5 12.1 7.7 8.9Lymphocyte...
Date Examination Normal Value Result08/16/11 Bleeding Time 1-3 minutes 3 minutesClotting Time 3-6minutes 4minutes and 30se...
SGPTSGPTExamination Normal Value 8/5/11 8/17/11SGPT Up to 37 56 100
Date: 8/5/11 Prothrombin TimePatient 13.8 secondsNormal Range 11.1-13.2 secondsControl 14.9 seconds% Activity 80.5%Interna...
Date: 8/16/11 Prothrombin TimePatient 13.8 secondsNormal Range 11.1-13.2 secondsControl 13.8seconds% Activity 80.5%Interna...
Date: 8/5/11 Activated Partial Thromboplastin TimePatient 34.0 secondsControl 34.9 secondsNormal Range 22.0-35.0 secondsac...
serumCreatinineCREATININENormal Value 8/5/11 8/8/11 8/9/11 8/13/1153-115 umol/L 167 157 120 112CREATININENormal Value 8/14...
bloodUrea NitrogenBUNNormal Value 8/5/11 8/6/11 8/18/11 9/8/112.80-7.20mmol/L6.79 8.03 4.96 4.54
serumSodiumSODIUMNormal Value 8/5/11 8/8/11 8/16/11 8/18/11 8/26/11135-148mmol/L128.8 136 146.8 147.7 137.2
serumPotassiumPOTASSIUMNormalValue8/5/11 8/8/11 8/9/11 8/14/11 8/16/11 8/18/11(7AM)8/18/11(9PM)3.5-5.3mmol/L3.58 4.28 4.78...
Date Examination Normal Value Result8/6/11 Fasting Blood Sugar 3.9-6.4 mmol/L 8.03Uric Acid 214-488 umol/L 576LDL Choleste...
Date Examination Normal Value Result8/9/11 HBA1C 4.20-6.20 % 6.3DIABETICGood Control: 5.5-6.8%Fair Control: 6.8-7.6%Poor C...
Date Examination Normal Value Result8/10/11 Total Protein 63-83 g/L 65Albumin 32-52 g/L 29Globulin 28-31g/L 36A/G Ratio 0....
UrinalysisURINALYSIS 8/5/11RBC: 75-100/HPF(++++) CRYSTAL:PUS CELLS: 25-50/HPF(++) URIC ACID:EPITHELIAL CELLS: FEW CAL. OXA...
ABG ANALYSIS RESULTDATE INTERPRETATION8/5/11 Partially compensated metabolic acidosis with correctedhypoxemia8/6/11 (1 am)...
Total Cell count:RBC: 1 cell/cummWBC: 3 cells/cummDifferential Count:Polymorphonuclear cells = 4Lymphocytes = 6Remarks: 10...
Specimen: CSFGram Stain Result 8/6/11Gram Negative Rods: OccassionalGram Positive CocciIn singles: OccassionalIn pairs: no...
Gram Stain Result 8/7/11 8/18/11Gram Negative Rods: Occasional FewGram Positive CocciIn singles: Moderate FewIn pairs: Few...
Specimen: CSF8/6/11Test name ResultKOH : Negative for fungal elementson direct smearAFB : Negative – No acid fast bacillis...
Specimen: CSF 8/6/11Organism isolated: Coagulase-negative StaphylococciSpecimen: Endotracheal Aspirate 8/7/11Organism isol...
Specimen: CSF for India Ink Preparation 8/7/11ResultNo encapsulated yeastcells seen on preparationCSFIndia ink
Specimen: Plasma for D-Dimer Detrmination 8/16/11ResultReference Value:D-Dimer 2.1 mg/L <0.3 mg/LD-dimerdetermination
cryptococcal antigen latexagglutination system(CALAS)RESULT POSITIVE
ECHOCARDIOGRAPHY REPORT8/19/11CONCLUSION:DILATED LEFT VENTRICULAR DIMENSION WITH GOODSYSTOLIC BUT IMPAIRED DIASTOLIC FUNCT...
ELECTROCARDIOGRAM8/5/11REMARKS:ATRIAL FIBRILLATION WITH RAPID VENTRICULARRESPONSE.PREMATURE VENTRICULAR CONTRACTION.LATERA...
ELECTROCARDIOGRAM8/16/11REMARKS:OCCASSIONAL PREMATURE ATRIAL CONTRACTIONS.8/24/11REMARKS:SINUS BRADYCARDIA WITH INTERMITTE...
CT Scan Report 8/5/11IMPRESSION:CEREBRO- CEREBELLAR ATROPHYATHEROMATOUS INTERNAL CAROTID ARTERIES, BASILAR ARTERY ANDVERTE...
X-RAY REPORT 8/05/11IMPRESSION:PNEUMONIA BILATERAL AND/OR PULMONARY CONGESTION.RULE OUT PULMONARY EDEMA.RULE OUT MINMAL PL...
X-RAY REPORT 8/18/11IMPRESSIONPULMONARY CONGESTION, PROGRESSINGR/O PULMONARY EDEMA.INTERCURRRENT PNEUMONIA, PROGRESSING.PL...
X-RAY REPORT 9/5/11IMPRESSION:PULMONARY CONGESTIVE CHANGES.PNEUMONIA, BILATERAL WITH PROGRESSION.ATHEROSCLEROTIC AORTA.FOL...
did youKnowthatuses approximatelyas much energyas a 10 watt light bulb.?The human brain
DRUGSTUDY
CNS DRUGSGENERIC/BRAND NAME/DOSAGECLASSIFICATION INDICATIONDiazepam 5 mg IV PRN forseizureBenzodiazepine Adjunct therapy i...
,ANTIBIOTICSDATE ORDERED GENERIC NAME CLASSIFICATION INDICATIONAugust 5, 2011 Metronidazole Anti-protozoal KOH of sputum r...
ANTIBIOTICSDATE ORDERED GENERIC NAME CLASSIFICATION INDICATIONAugust 30, 2011 Cefipime 3rd generationCephalosporinCulture ...
ANTIBIOTICSDATE ORDERED GENERICNAMECLASSIFICATION INDICATIONAugust 12, 2011 Amphotericin B Antibiotic/Antifungal(+) Calas ...
GASTROINTESTINAL DRUGSGENERIC/BRAND NAME/DOSAGECLASSIFICATION INDICATIONOmeprazole 20 mg/cap BID Proton Pump Inhibitor Use...
ANTI ASTHMATIC PREPARATIONSGENERIC/BRAND NAME/DOSAGE INDICATIONIpratropium Bromide + SalbutamolCOMBIVENT 1 nebule Q 6HMana...
ANTIHYPERTENSIVES/DIURETICSGENERIC/BRAND NAME CLASSIFICATION INDICATIONLosartan K 100 mg/tab OD Angiotensin IIAntagonistIn...
GENERIC/BRAND NAME/DOSAGECLASSIFICATION INDICATIONAcetylcysteine Mucolytic Acute and Chronicrespiratory tract infectionwit...
did youKnowthat?The female pigeoncannot lay eggs if she is alone.In order for her ovaries to function,she must be able to ...
List of formulated Nursing Dx
List of formulated Nursing Dx
neffective Airway ClearanceGOAL: Within 5mins-15mins hours, the client will manifest:• Normal breathing pattern• A decreas...
INDEPENDENTKeep environment allergen free (e.g., dust)Monitor vitals signs, noting blood pressure/pulse changes.Position i...
luid Volume Excessr/t cerebral insufficiency , acute stress, presence of infection, and immobility asmanifested by dyspnea...
INDEPENDENTNote and measure parameters that may indicate increasing fluid retention/edema(e.g. abdominal girth)Reposition ...
ecreased Cerebral Tissue PerfusionGOAL: After one month, the client will be able to:• Demonstrate an improved GCS score of...
INDEPENDENTDecrease noxious stimuliProvide non-constrictive clothingAssist with treatment of underlying conditionDEPENDENT...
yperthermiaHINDEPENDENTMonitor body temperature .GOAL: Within 8 Hours, the client will be able to:• Maintain temperature w...
INDEPENDENTWrap extremities with bath towel to decrease shivering.Promote safety by securing both side rails up.Maintain b...
isk for AspirationRINDEPENDENTNote the client’s level of consciousnessGOAL: Within one month, the client will :• Experienc...
INDEPENDENTSuction oral cavity, nose and endotracheal tube as neededAuscultate lung sounds frequently to determine presenc...
did youKnowthatsome of yourbrain cellsdie.?If you sneeze
ASSESSMENTFINAL
CLINICAL INSPECTIONDate and Time Taken: September 8, 2011, 4pmVital Signs:T- 36.3PR- 64 bpmRR- 22 bpmBP- 120/80 mmHg
CNS: GCS 10 (E-4, V-1, M-5), pupilsequally round and reactive to light andaccommodation 2mm in diameter,normal power on bo...
RESPI: attached tocontinuous O2 @ 2lpm viatracheal mask, whitishsecretions upon suctionGI: Diet: Abdomen soft withbowel so...
GU: adequate urinaryoutput, with yellow orangecolored urine
Client was transferred per stretcherper folks request to West Visayas StateUniversity Hospital on September 8, 2011at arou...
Thankyou
A Case of Cryptococcal Meningitis
A Case of Cryptococcal Meningitis
A Case of Cryptococcal Meningitis
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A Case of Cryptococcal Meningitis

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Transcript of "A Case of Cryptococcal Meningitis"

  1. 1. OBJECTIVES
  2. 2. At the end of the case presentation the participants willbe able to practice excellent nursing care in managingpatients with cryptococcal meningitis. Specifically, thiscase presentation aims that the participants will be ableto:Discuss the global statistics of cryptococcalmeningitis 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 nursingmanagement of patients with cryptococcal meningitis.
  3. 3. introductionWhat is Cryptococcal Meningitis?
  4. 4. efinition of termsdCryptococcoal MeningitisAn infectious disease of worldwide distribution causedby the fungus, Cryptococcus neoformans. Thefungus primarily attacks the lungs, causing torulomas,but produces few or no symptoms referable to thelungs.This may occur as an opportunisticinfection in those suffering from AIDS
  5. 5. efinition of termsd(Cryptococcal Antigen LatexAgglutination System)Determinative test for cryptococcusinfectionsCALASD-DimerConfirms that both thrombin generationand plasmin generation have ocurred
  6. 6. very rare among healthy people
  7. 7. Worldwide, C. neoformans infections cause anestimated 1 million cases of cryptococcalmeningitis per year among people withHIV/AIDS, resulting in nearly 625,000deaths.-CDC
  8. 8. AIDSCryptococcal MeningitisAbout 10% of AIDS patients getCRYPTOCOCCAL MENINGITIS
  9. 9. did youKnowthat?Cryptococcuscan be inhaledfrom pigeonand other birddroppings
  10. 10. ContentsPHYSICALASSESSMENTNURSINGHISTORYLABORATORYNURSINGCARE PLANPATHOPHYSIOLOGYOBJECTIVESFINALASSESSMENTCOURSE INTHE WARDDRUG STUDY
  11. 11. NursingHISTORY
  12. 12. Name:Age:Sex:Address:Civil status:Nationality:Occupation:Religion:R.L.64 years oldMaleMolo, Iloilo CityMarriedFilipinoNoneRoman CatholicInformationPatient
  13. 13. Usual Health Status- The client did notundergo regular check-up. He wasnot sickly, he was never hospitalized.AChronological Story/History of Present Illness>Morning prior to admission, patient complained offever and chills associated with headache, patientsought consult to a private physician and was givencotrimoxazole.> 4 hours prior to admission, patient experiencedpersistence of above signs and symptoms. This time itwas associated with stiffening of extremities andupward rolling of eyeballs. The said eventsmade the family seek medical help and brought Mr. L tothe ER of GSIH-TMCI at 7pm of August 5, 2011.B
  14. 14. Past Medical HistoryNo previous hospitalization or consultation toa health care provider . Mr. L had chicken poxand mumps when he was a child, illness weremanaged at home. Mr. L has no known allergies.Fever, flu and cough were also experienced but noconsultation was made as claimed, dates were notspecified.Family Medical HistoryOn his paternal side, hypertension ran within theirblood and Diabetes mellitus is common on hismaternal side. No incidence of infection notedwithin the immediate family such as pneumoniaand tuberculosis as claimed.Source: M.L. (Mr. L’s son)CD
  15. 15. Activities of Daily LivingNutrition: Mr. L ate at least 3 times a day. Mr. Lpreferred to eat rice, 1-2 cups per meal, with meatsuch as beef, pork and chicken, with variety ofvegetables. He usually drinks at least 6-8 glasses ofwater per day. Intake of caffeinated beverages was alsonoted, he consumed a cup of coffee per day atbreakfast.Sleep and Rest: Mr. L usually sleeps around 9pm, with5-6 hours of sleep per day. Sleeping problems werereported such as occasional snoring and easily awaken.Bowel and Elimination: Mr. L usually defecates everyday to a formed to mushy stool. Occasional eliminationproblem such as constipation was also noted but wasmanaged by increasing oral fluid intake and eatingfruits. Mr. L voids frequently with no difficulty asclaimed.E
  16. 16. Activities of Daily LivingHygiene: Mr. L usually takes a bath daily and does oralcare at least twice a day.Leisure/Recreation: Mr. L was unemployed and spentmost of his time at their house. Mr. L exercised at leasttwice a week for 10-20 minutes by jogging or briskwalking. Mr. L was also fond of taking care of pigeons.He owned a flock of pigeons that reside at theirrooftop way back 2 years ago. He usually fed them inthe morning.E
  17. 17. did youKnowthatAfter age 30,the brain shrinksa quarter of a percent (0.25%)in mass each year.?
  18. 18. ASSESSMENTPHYSICAL
  19. 19. General Appearance:Patient was considered to be obese class 1 asassessed according to standard body mass index. Hehas unkempt appearance. He has no verbal output. Uponadmission Mr. L.R was restless. VS: T- 39.5, PR- 95 bpm, RR- 35cpm, BP- 200/90 mmHg. Ht: 160 cm, Wt: 87 kgsIntegumentary System:Has fair complexion noted. Has no presence of edema on skin. Hasno lesions noted. Skin warm to touch. Flushing noted all overthe face and chest. Diaphoretic. Has an intact epidermisfingernails and toenail beds are pinkish in color, smooth and normaldegree of blanching less than 2 seconds.
  20. 20. CNS: GCS-6, pupils aresluggish, with seizureepisode, with Midazolam drip 20mg in 100 cc PNSS @ 10mgtts/minCVS: HR- 95 bpm, SBP- 160-200 mmHg, consistentlyhypertensive, with AC drip of D5W 500cc+2 ampsApresoline+2 amps Clonidine Hcl @ 10 mgtts/min titrateincrements by 5 mgtts/min to maintain SBP- 130 mmHg.
  21. 21. RESPI: With Mechanicalventilator setting: AC- Mode, Fi02-100%, TV- 450, PFR- 50, BUR-20, patentand intact, with O2 saturation of99%, and respiratory secretionsnoted, (+) crackles.GI: Diet: OTF at 1000 kcal/day 1:1 dilutiondivided in 6 equal feedings, abdomen issoft, (+) bowel movement, 14 bowelsounds heard on all quadrants ofabdomen.
  22. 22. ENDO: with the CBG result of81 mg/dl-(8/5/11, 7:06 pm)GU: with adequate urinary output,with yellowish colored urine, withfoley catheter attached to urobag
  23. 23. IDS: WBC- 19.5x10/L, withMetronidazole 500 mg/tab,Azithromycin 500 mg/tab andCeftriaxone 3 grams.
  24. 24. did youKnowthatThe human brainhas the capacity tostoreeverything thatyou experience .?
  25. 25. Coursein theeWard
  26. 26. Upon admission, thepatient has the followingtemperature - 39.7degrees celsius, CR - 95bpm, RR – 35 bpm, BP –190/80 mmHg patientwas managed as a caseofunder the service of Dr.G.L.
  27. 27. He was managed withCiticoline IV, Mannitol,Paracetamol IV,Ceftriaxone, IV, DiazepamIV, Azithromycin,Metronidazole IV, Keppraand in MechanicalVentilator Support. Hewas then transferred toICU for furthermanagement and workups. Patient wasmonitored closely.
  28. 28. Upon admission inthe ICU, there isDecreased insensorium ,no eye opening, noverbal response anddecorticate, and focalseizure noted,Diazepam 5 mg IVTTQ6h and Midazolamdrip x 5 mgtts/min asordered until the 2ndday.
  29. 29. Increased BPnoted,, he hasa AC drip started at10 mgtts/mintitrated incrementsby 5 mgtts/min tomaintain SBP 130mmHg, as ordered
  30. 30. The patient wasreferred to an(Dr.I.S)
  31. 31. On the 2ndday, LumbarPuncture wasdone by Dr. G.L.CSF specimenwas collected in4 test tubes andsent to thelaboratory.
  32. 32. TT1- cellcount, differentiatedcount, sugar, proteinTT2-GSCS, KOH, AFB, IndiaInkTT3- For CALAS c/oManila Doctors’HospitalTT4- Stored at thefreezer for future use
  33. 33. On the 4th day,andnoted until8th day, it was managedby Paracetamol 300 mgIV, Continuous TSB done,AC Drip and other anti-hypertensive drugs. ,.
  34. 34. After that, patientL.R. was referred to(Dr.M.G.D.S)due tohospital acquiredpneumonia withpleural effusion andCOPD
  35. 35. 8/9/11POSITIVE CALASTEST
  36. 36. On the 12th day,patient was(endotrachealtube),done byDr. S.
  37. 37. did youKnowthatThe Brain can stayalive for 4 to 6 minuteswithout oxygen.after that cells beginto Die?
  38. 38. PHYSIOPATHO-LOGY
  39. 39. THE PATHOPHYSIOLOGY OFCRYPTOCOCCAL MENINGITIS
  40. 40. Cont..(+) hyperthermia(+) ETA coagulasenegativeStaphylococci(8/7)(+) ETA Candidaspp. (8/10)(+) ETAPseudomonasaeruginosa (9/1)increased WBCcount(Segmenters)Seizuresluggish pupillaryreflexGCS 6 (E - 1 / V - 1/ M - 4)(-) motorresponse(+) crackles, tachypnea, excessivesputum production, desaturationD-dimer 2.1 mg/L Progressing leftpleural effusion (8/16)Increased workload of theheart :increased BP(+) atherosclerotic aorta(8/5)(+) lateral wallischemia(8/5)Fluid volume excessCreatinine 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)
  41. 41. did youKnowthat10amount of timeto the brain.until unconsciousnessafter the loss of?blood supplyseconds is the
  42. 42. HEMATOLOGYExamination Normal Value 8/5/11Hemoglobin 120-170 g/L 121Hematocrit 0.40- 0.54 0.39RBC 4.60-6x10^12/L 3.94WBC 5-10x10^9/L 7.1Differential countMyelocytes 0.00-0.00 0.00Metamylocytes 0.00-0.1 0.00Stabs 0.03-0.5 0.04Segmenters 0.50-0.70 0.74
  43. 43. HEMATOLOGYExamination Normal Value 8/5/11Eosinophils 0.00-0.05 0.00Basophils 0.00-0.01 0.00Lymphocytes 0.20-0.40 0.22Monocytes 0.00-0.07 0.00Platelet count 150-450x10^9/L 230MCV 80-100 cu m 98MCHC 32-36g/L 30.6MCH 27-32 pg 31.1
  44. 44. HEMATOLOGY REPORTExamination NormalValue8/5/11 08/8/11 8/14/11 9/5/11 9/8/11WBC 5-10x10^9/L7.1 19.5 12.1 7.7 8.9Lymphocytes 0.20-0.40 0.22 0.07 0.09 0.21 0.20
  45. 45. Date Examination Normal Value Result08/16/11 Bleeding Time 1-3 minutes 3 minutesClotting Time 3-6minutes 4minutes and 30secondsclotting timeBleeding time
  46. 46. SGPTSGPTExamination Normal Value 8/5/11 8/17/11SGPT Up to 37 56 100
  47. 47. Date: 8/5/11 Prothrombin TimePatient 13.8 secondsNormal Range 11.1-13.2 secondsControl 14.9 seconds% Activity 80.5%International Snesitivity Index 1.31International Normalized Ratio 1.10prothrombinTime
  48. 48. Date: 8/16/11 Prothrombin TimePatient 13.8 secondsNormal Range 11.1-13.2 secondsControl 13.8seconds% Activity 80.5%International Snesitivity Index 1.31International Normalized Ratio 1.10prothrombinTime
  49. 49. Date: 8/5/11 Activated Partial Thromboplastin TimePatient 34.0 secondsControl 34.9 secondsNormal Range 22.0-35.0 secondsactivated partialThromboplastin time
  50. 50. serumCreatinineCREATININENormal Value 8/5/11 8/8/11 8/9/11 8/13/1153-115 umol/L 167 157 120 112CREATININENormal Value 8/14/11 8/18/11 8/26/11 9/5/11 9/8/1153-115 umol/L 88 99 118 154 148
  51. 51. bloodUrea NitrogenBUNNormal Value 8/5/11 8/6/11 8/18/11 9/8/112.80-7.20mmol/L6.79 8.03 4.96 4.54
  52. 52. serumSodiumSODIUMNormal Value 8/5/11 8/8/11 8/16/11 8/18/11 8/26/11135-148mmol/L128.8 136 146.8 147.7 137.2
  53. 53. serumPotassiumPOTASSIUMNormalValue8/5/11 8/8/11 8/9/11 8/14/11 8/16/11 8/18/11(7AM)8/18/11(9PM)3.5-5.3mmol/L3.58 4.28 4.78 3.44 3.53 2.84 2.73POTASSIUMNormalValue8/19/11 8/21/11 8/26/11(5AM)8/26/11(2PM)8/30/11 9/5/11 9/8/113.5-5.3mmol/L3.13 3.59 2.51 3.21 3.02 3.30 3.97
  54. 54. Date Examination Normal Value Result8/6/11 Fasting Blood Sugar 3.9-6.4 mmol/L 8.03Uric Acid 214-488 umol/L 576LDL Cholesterol Less than 3.4 mmol/L 2.02HDL Cholesterol Greater than 0.9mmol/L0.68Triglycerides Up to 2.3 mmol/L 1.42Cholesterol (total) Up tp 5.2 mmol/L 3.34FBS, uric acidLipid Profile
  55. 55. Date Examination Normal Value Result8/9/11 HBA1C 4.20-6.20 % 6.3DIABETICGood Control: 5.5-6.8%Fair Control: 6.8-7.6%Poor Control: above 7.6 %HBA1C
  56. 56. Date Examination Normal Value Result8/10/11 Total Protein 63-83 g/L 65Albumin 32-52 g/L 29Globulin 28-31g/L 36A/G Ratio 0.00-0.00 0.80:1Date Examination Normal Value Result8/15/11 Albumin 32-52 g/L 26total Protein withA/G Ratio
  57. 57. UrinalysisURINALYSIS 8/5/11RBC: 75-100/HPF(++++) CRYSTAL:PUS CELLS: 25-50/HPF(++) URIC ACID:EPITHELIAL CELLS: FEW CAL. OXALATE:RENAL CELLS: AMOR.URATES:OccassionalMUCUCS THREADS: AMOR. PHOS.BACTERIA: FEW TRIPLE PHOS.OTHERS: OTHERS:CASTHYALINE: COARSEGRAN:FINE GRAN OTHERS:
  58. 58. ABG ANALYSIS RESULTDATE INTERPRETATION8/5/11 Partially compensated metabolic acidosis with correctedhypoxemia8/6/11 (1 am) Combined respiratory and metabolic acidosis withcorrected hypoxemia8/6/11 (10 am)Fi02 80% via VRCompensated respiratory alkalosis with correctedhypoxemia8/8/11Fi02 80%Normal acid-base with corrected hypoxemia8/9/11Fi02 60% via VRNormal acid-base with corrected hypoxemia8/27/11Fi02 40% via T-pieceUncompensated respiratory alkalosisarterialBlood Gas
  59. 59. Total Cell count:RBC: 1 cell/cummWBC: 3 cells/cummDifferential Count:Polymorphonuclear cells = 4Lymphocytes = 6Remarks: 10 cell counted on smearTotal protein: 257mg/LSugar: 7.58 mmol/Lcerebrospinal fluidAnalysis
  60. 60. Specimen: CSFGram Stain Result 8/6/11Gram Negative Rods: OccassionalGram Positive CocciIn singles: OccassionalIn pairs: noneIn chains: noneIn clusters: nonePus cells: noneEpithelial cells: noneOthers:cerebrospinal fluidAnalysis
  61. 61. Gram Stain Result 8/7/11 8/18/11Gram Negative Rods: Occasional FewGram Positive CocciIn singles: Moderate FewIn pairs: Few OccasionalIn chains: none NoneIn clusters: Occasional OccasionalPus cells: 10-12/ HPF (++) 20-30/ HPF (+++)Epithelial cells: none 0-2/ HPF (Occasional)Others: Fungal element notedendotrachealAspirate
  62. 62. Specimen: CSF8/6/11Test name ResultKOH : Negative for fungal elementson direct smearAFB : Negative – No acid fast bacilliseen on direct smearSpecimen: ETA 8/7/11Test nameKOH : No fungal elements seen onsmearSpecimen: Sputum 8/10/11Test nameKOH :Positive for fungal elementKOHAFB
  63. 63. Specimen: CSF 8/6/11Organism isolated: Coagulase-negative StaphylococciSpecimen: Endotracheal Aspirate 8/7/11Organism isolated: Coagulase-negative StaphylococciSpecimen: Endotracheal Aspirate 8/10/11Organism isolated: Candida spp.Specimen: Endotracheal Aspirate 9/1/11Organism isolated: Pseudomonas Aeroginosaculture andSensitivity
  64. 64. Specimen: CSF for India Ink Preparation 8/7/11ResultNo encapsulated yeastcells seen on preparationCSFIndia ink
  65. 65. Specimen: Plasma for D-Dimer Detrmination 8/16/11ResultReference Value:D-Dimer 2.1 mg/L <0.3 mg/LD-dimerdetermination
  66. 66. cryptococcal antigen latexagglutination system(CALAS)RESULT POSITIVE
  67. 67. ECHOCARDIOGRAPHY REPORT8/19/11CONCLUSION:DILATED LEFT VENTRICULAR DIMENSION WITH GOODSYSTOLIC BUT IMPAIRED DIASTOLIC FUNCTION.SLIGHTLY DILATED LEFT ATRIUM.TRIVIAL MITRAL AND TRICUSPID REGURGITATION.
  68. 68. ELECTROCARDIOGRAM8/5/11REMARKS:ATRIAL FIBRILLATION WITH RAPID VENTRICULARRESPONSE.PREMATURE VENTRICULAR CONTRACTION.LATERAL WALL ISCHEMIA.8/9/11REMARKS:SINUS TACHYCARDIA
  69. 69. ELECTROCARDIOGRAM8/16/11REMARKS:OCCASSIONAL PREMATURE ATRIAL CONTRACTIONS.8/24/11REMARKS:SINUS BRADYCARDIA WITH INTERMITTENT EPISODES OFJUNCTIONAL RHYTHM.
  70. 70. CT Scan Report 8/5/11IMPRESSION:CEREBRO- CEREBELLAR ATROPHYATHEROMATOUS INTERNAL CAROTID ARTERIES, BASILAR ARTERY ANDVERTEBRAL ARTERIES.SUSPICIOUS HYPODENSITY IN THE LEFT PORTION OF THE MIDBRAIN-HYPERACUTE OR ACUTE INFARCT NOT RULED OUT; FOLLOW UP ISRECOMMENDED.CONSIDER SINUSITIS-LEFT ANTERIOR ETHMOID AND BOTH MAXILIARYSINUSES.RIGHTWARD NASAL SEPTAL DEVIATION.LEFT INFUNDIBULUM BLOCKED BY SOFT TISSUE DENSITIES.CONSIDER NASAL SECRETIONS LEFT NASAL CAVITY; NASAL CONGESTION,LEFT NASAL POLYP,LEFT.
  71. 71. X-RAY REPORT 8/05/11IMPRESSION: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 LEFTHILUM IF CLINICALLY WARRANTED.
  72. 72. X-RAY REPORT 8/18/11IMPRESSIONPULMONARY CONGESTION, PROGRESSINGR/O PULMONARY EDEMA.INTERCURRRENT PNEUMONIA, PROGRESSING.PLEURAL EFFUSION, BILATERAL, PROGRESSING.ATHEROMATOUS AORTA.PLEASE CORRELATE CLINICALLY
  73. 73. X-RAY REPORT 9/5/11IMPRESSION:PULMONARY CONGESTIVE CHANGES.PNEUMONIA, BILATERAL WITH PROGRESSION.ATHEROSCLEROTIC AORTA.FOLLOW-UP IS SUGGESTED.
  74. 74. did youKnowthatuses approximatelyas much energyas a 10 watt light bulb.?The human brain
  75. 75. DRUGSTUDY
  76. 76. CNS DRUGSGENERIC/BRAND NAME/DOSAGECLASSIFICATION INDICATIONDiazepam 5 mg IV PRN forseizureBenzodiazepine Adjunct therapy inconvulsive disordersLevetiracetam KEPPRA 4.5ml BIDAnti convulsant Mono/Adjunctive therapyin the treatment of partialonset of seizuresSpecial Precautions: Avoidabrupt withdrawalCiticoline 1 gram IV Q 12H neurostimulant Cerebral insufficiency inacute and recovery phase
  77. 77. ,ANTIBIOTICSDATE ORDERED GENERIC NAME CLASSIFICATION INDICATIONAugust 5, 2011 Metronidazole Anti-protozoal KOH of sputum revealpositive for fungal elements.Endotracheal aspirate revealCandida spp.August 5, 2011 Ceftriaxone 3rd generationCephalosporinTreatment of susceptibleinfection.(+) febrile episodesupon admissionAugust 6, 2011 Fluconazole Anti-fungal KOH of sputum revealpositive for fungal elements.Endotracheal aspirate revealCandida spp.August 17, 2011 Meropenem Beta Lactam Progression of pneumonia
  78. 78. ANTIBIOTICSDATE ORDERED GENERIC NAME CLASSIFICATION INDICATIONAugust 30, 2011 Cefipime 3rd generationCephalosporinCulture and Sensitivity ofEndotracheal tip revealsensitivity to CefipimeSeptember 5,2011Ceftazidime1 gram IV Q12H3rd generationCephalosporin9/3/2011Endotracheal aspirateCulture and sensitivityreveal Pseudomonasaeruginosa. Susceptible toCeftazidimeSeptember 5,2011Ciprofloxacin Quinolones 9/3/2011Endotracheal aspirateCulture and sensitivityreveal Pseudomonasaeruginosa. Susceptible toCiprofloxacin
  79. 79. ANTIBIOTICSDATE ORDERED GENERICNAMECLASSIFICATION INDICATIONAugust 12, 2011 Amphotericin B Antibiotic/Antifungal(+) Calas testSystemic, potentially fatal, lifethreatening fungal infectionSpecial Precautions:• May cause bone marrowdepression- increased incidenceof microbial infection anddelayed healing.• May cause renal impairment.Serum creatinine must bemonitored.• Dose gradually increased dailyto reach desired amountindicated by the physician.
  80. 80. GASTROINTESTINAL DRUGSGENERIC/BRAND NAME/DOSAGECLASSIFICATION INDICATIONOmeprazole 20 mg/cap BID Proton Pump Inhibitor Used in conditions whereinhibition of gastric acidsecretion may be beneficialTo prevent ulcer and acidrelated dyspepsiaEsomeprazole 40 mg IV OD Proton Pump Inhibitor Reduce the occurrence ofgastric ulcersESSENTIALE FORTE 1 capTIDHepatic Protector Prevention of toxicmetabolic liver diseasesLactulose 30 cc OD Laxative Chronic constipation.Episodes of (-) BM
  81. 81. ANTI ASTHMATIC PREPARATIONSGENERIC/BRAND NAME/DOSAGE INDICATIONIpratropium Bromide + SalbutamolCOMBIVENT 1 nebule Q 6HManagement of reversible bronchospasmassociated with obstructive airwaydiseases in patients who require morethan a single bronchodilatorSalmeterol Xinafoate FluticasonePropionateSERETIDE 2 puffs BIDProphylaxis and maintenance treatment ofasthmaBudesonide 500mcg/respule Q 12H Prophylaxis and maintenance treatment ofasthmaDoxofylline 400 mg/tab BID Bronchial asthmaMontelukast Na 10 mg/tab OD Management of chronic asthma
  82. 82. ANTIHYPERTENSIVES/DIURETICSGENERIC/BRAND NAME CLASSIFICATION INDICATIONLosartan K 100 mg/tab OD Angiotensin IIAntagonistIncreased BP, HypokalemiaSpecial Precaution: Serumpotassium should be monitoredFurosemide + KCLDIUMIDE K ½ tab ODDiuretic Congestion, hypokalemiaSpecial Precaution: Serumpotassium should be monitoredAmlodipine 10 mg/tab OD Calcium Antagonist HypertensionMannitol 150cc IV Q 6H Osmotic Diuretic Increased intracranial pressureand cerebral edema as seen inthe CT scanFurosemide 20mg IV now Diuretic Dyspnea, desaturation,wheezing – congestion
  83. 83. GENERIC/BRAND NAME/DOSAGECLASSIFICATION INDICATIONAcetylcysteine Mucolytic Acute and Chronicrespiratory tract infectionwith abundant mucussecretionsParacetamol 300 mg IV Q4H RTCantipyretic Client is continuouslyfebrileHydrocortisone 100 mg IVQ12 HCorticosteroid For relief of congestion ,inflammation broughtabout by infectionNaproxen Na 275 mg/tabQ 8H RTCNon-steroidal AntiInflammatory DrugsContinuously febriledespite ParacetamolIntermediate Insulin Insulin HyperglycemiaKalium durule 2 durulesTIDSupplement Hypokalemia
  84. 84. did youKnowthat?The female pigeoncannot lay eggs if she is alone.In order for her ovaries to function,she must be able to seeanother pigeon.
  85. 85. List of formulated Nursing Dx
  86. 86. List of formulated Nursing Dx
  87. 87. neffective Airway ClearanceGOAL: 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 auscultationr/t increased production/retained tenacious secretions secondary to infection asevidenced by ineffective cough, crackles, tachypnea, excessive sputumIINDEPENDENTMonitor respirations and breath sounds, noting rate and sound indicative ofrespiratory distress and/or accumulation of secretions.Suction naso/tracheal/oral prn to clear airway when excess or viscoussecretions are blocking airway.Elevate head of bed/change position every 2 hours and prn to take advantage ofGravity decreasing pressure on the diaphragm and enhancing drainage of/ventilationTo different lung segments.Insert oral airway when needed, to maintain anatomic position of tongue andnatural airway.
  88. 88. INDEPENDENTKeep 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.DEPENDENTAdminister bronchodilators/mucolytics as ordered.Administer medications, as indicated, to treat underlying cause such as antibiotics.Chestphysiotherapy to mobilize secretions.INTERDEPENDENTObtain sputum specimen to verify appropriateness of therapyEnsure most of the time placement of th endotracheal tube.
  89. 89. luid Volume Excessr/t cerebral insufficiency , acute stress, presence of infection, and immobility asmanifested by dyspnea, decreased O2 sat=85%, crackles noted upon auscultation,diaphoresis, restlessness, increased BP, Jugular vein distentionFINDEPENDENTAssess causative/precipitating factorsMonitor progression/alleviation of symptomsGOAL: 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 calmnessAccurately monitor fluid intake and output from all sources: PO, IV, urine,insensible fluid lossAssess presence of jugular vein distention
  90. 90. INDEPENDENTNote 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 injuryUse safety precautions at all timesDEPENDENTAdminister diuretics and steroids as ordered by the physician.INTERDEPENDENTReview diagnostic data (BUN, creatinine, hematocrit, serum albumin and chestx-ray) correlate and relay accordingly
  91. 91. ecreased Cerebral Tissue PerfusionGOAL: 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 episodesr/t interruption of cerebral blood flow secondary to cryptococcal infection asevidenced by altered mental status, GCS=6 E1V1M4, comatose to stuporous, seizureepisodes, changes in motor response.DINDEPENDENTDetermine factors related to individual situation, e.g., presence of fungal infectionIdentify changes related to systemic alteration in circulation, such as altered mentalstatusEvaluate signs of infection.Determine duration of problem/ frequency of recurrenceDetermine presence of visual sensory motor changes, altered mental statusElevate head of bed 30 degrees and maintain head/neck in midline or neutral positionTo promote circulation/venous drainageProvide calm and cool environment
  92. 92. INDEPENDENTDecrease noxious stimuliProvide non-constrictive clothingAssist with treatment of underlying conditionDEPENDENTAdminister medications as prescribedAdminister fluid replacement/rehydration or blood transfusion to improvetissue perfusion/organ functionINTERDEPENDENTReview specific dietary changes/restrictionsReview results of diagnostic studies
  93. 93. yperthermiaHINDEPENDENTMonitor body temperature .GOAL: Within 8 Hours, the client will be able to:• Maintain temperature within normal range• Manifest relief from symptoms experiencedMonitor and record all sources of fluid loss such as urinePromote 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 axillaer/t inflammatory process secondary to infection as evidenced by elevated surfbody temperature, skin warm to touch, flushing, diaphoresis, tachypnea,tachycardia
  94. 94. INDEPENDENTWrap 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.DEPENDENTAdminister antipyretics, Paracetamol 300mg IV Q4H RTC as ordered.Administer medications, as indicated, to treat underlying cause such as antibiotics.INTERDEPENDENTMonitor laboratory results such as ABGs, electrolytes , coagulation profiles,Urinalysis, CBC.
  95. 95. isk for AspirationRINDEPENDENTNote the client’s level of consciousnessGOAL: Within one month, the client will :• Experience no aspiration• Maintain patent airwayAssess amount and consistency of respiratory secretionsAssess muscle strength, gross and fine motor coordinationCareful administration of enteral feedings, being aware of potential forregurgitation and/or misplacement of tubeMeasure residuals when appropriate to prevent over feedingMaintain operational suctioning equipment at bedsider/t altered mental status, GCS score of 6 secondary to cerebral insufficiencybrought about by infection
  96. 96. INDEPENDENTSuction oral cavity, nose and endotracheal tube as neededAuscultate lung sounds frequently to determine presence of secretionsElevate client to high fowler’s position during tube feedingsKeep side rails up for safetyDEPENDENTAdminister Diazepam for restlessness and seizure episodes as ordered
  97. 97. did youKnowthatsome of yourbrain cellsdie.?If you sneeze
  98. 98. ASSESSMENTFINAL
  99. 99. CLINICAL INSPECTIONDate and Time Taken: September 8, 2011, 4pmVital Signs:T- 36.3PR- 64 bpmRR- 22 bpmBP- 120/80 mmHg
  100. 100. CNS: GCS 10 (E-4, V-1, M-5), pupilsequally round and reactive to light andaccommodation 2mm in diameter,normal power on both upper and lowerextremities.CVS: Attached to cardiacmonitor, normal sinus rhythm
  101. 101. RESPI: attached tocontinuous O2 @ 2lpm viatracheal mask, whitishsecretions upon suctionGI: Diet: Abdomen soft withbowel sounds upon auscultation.OTF 2400 kcal in 1800 cc volumedivided by 6 equal feedings.
  102. 102. GU: adequate urinaryoutput, with yellow orangecolored urine
  103. 103. Client was transferred per stretcherper folks request to West Visayas StateUniversity Hospital on September 8, 2011at around 8:30 in the evening accompanied byER staff nurse and on call junior consultant withO2 @ 2lpm via tracheal mask and venoclysis ofPNSS 1L +20 meq kcl x 20cc/hr.
  104. 104. Thankyou

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