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Hypokalemia, Hypoxic Ischemic Encephalopathy, Nosocomial Pneumonia and Urinary Tract Infection
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Hypokalemia, Hypoxic Ischemic Encephalopathy, Nosocomial Pneumonia and Urinary Tract Infection


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Hypokalemia, Hypoxic Ischemic Encephalopathy, Nosocomial Pneumonia and Urinary Tract Infection. This presentation contains real names of persons involve of this particular study. This names should not …

Hypokalemia, Hypoxic Ischemic Encephalopathy, Nosocomial Pneumonia and Urinary Tract Infection. This presentation contains real names of persons involve of this particular study. This names should not be copied or rewritten. Used the data of this study as basis only. All rights reserved 2009.

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  • 1. Velez College – College of Nursing F. Ramos St., Cebu City Presented by: Dave Jay S. Manriquez, RN. A Case Study Presentation on G.M., Diagnosed with Hypokalemia, Hypoxic Ischemic Encephalopathy, Nosocomial Pneumonia and Urinary Tract Infection INTRODUCTION: G.M., 37 y.o., M, was admitted for the first time at CVGH Hospital on November 24, 2006, 7:00 pm via taxi, accompanied by his co-workers under the services of he Department of Family Medicine, co-managed with the Department of Internal Medicine for complaints of lower extremity weakness noted hours PTA. HYPOKALEMIA Definition Hypokalemia is a condition of below normal levels of potassium in the blood serum. Potassium is a necessary electrolyte which facilitates nerve impulse conduction and the contraction of skeletal and smooth muscles, including the heart. It also facilitates cell membrane function and proper enzyme activity. Nearly 98% of the body's potassium is intracellular. Levels must be kept in a proper (homeostatic) balance for the maintenance of health. The kidney determines potassium homeostasis, and excess potassium is excreted in the urine. The normal concentration of potassium in the serum is in the range of 3.5-5.0 mEq/L, thus, hypokalemia means serum or plasma levels of potassium ions that fall below 3.5 mEq/L. Moderate hypokalemia is a serum level of 2.5-3 mEq/L, and severe hypokalemia is defined as a level less than 2.5 mEq/L The patient’s potassium level is 1.5 meq/L, and is classified as severe. Symptoms Mild hypokalemia usually results in no symptoms, while moderate hypokalemia results in: confusion, disorientation, weakness, and discomfort of muscles. It also causes cramps during exercise, and a discomfort in the legs experienced while sitting still. Severe hypokalemia results in: extreme weakness of the body, and occasionally in paralysis, which occurs as quot;flaccid paralysisquot; or limpness. The symptoms manifested by the patient was the weakness of his lower extremities hours prior to admission. Paralysis of the muscles of the lungs results in death. Our patient persistently complained of dyspnea, though pulse oximetry revealed 98-100%. Patient experienced respiratory arrest, on his first day at the ICU, and was intubated with continuous ambubagging at 10 LPM. Another dangerous result is abnormal heart beat (arrhythmia) that can lead to death from cardiac arrest (cessation of heart beat), because of the need for potassium to control muscle action. Mild QRS complexes were documented in ECG. Along the course of intubation, patient went into cardiopulmonary arrest and was resuscitated accordingly.
  • 2. Causes The most common cause is by the use of diuretics, drugs that increase the excretion of water and salts in the urine. These are used to treat medical conditions, including hypertension (high blood pressure), congestive heart failure, liver disease, and kidney disease. However, its side effects produce hypokalemia, the most common cause of hypokalemia in elderly patients. Another common cause is excessive diarrhea and / or vomiting. These can be produced by infections of the gastrointestinal tract. Diarrhea is a major world health problem, responsible for about a quarter of the 10 million deaths that occur each year. in the parts of Asia and Africa. This also results in various abnormalities or complications, such as dehydration (loss in body water), hyponatremia (low sodium level in the blood), and hypokalemia. Diarrhea was the identified cause of the patient’s hypokalemia, who experienced diarrhea, with 10 episodes per day, amounting to 1 cup per episode. No meds were taken nor hydration to correct his condition. His diarrhea was said to be acquired from eating seafood in Cebu. Vomiting provokes an increase in potassium loss in the urine. Vomiting expels acid from the mouth, and this loss of acid results in alkalization of the blood. (pH of the blood increases slightly.) An increased blood pH has a direct effect on the kidneys. Alkaline blood provokes the kidneys to release excessive amounts of potassium in the urine. So, severe and continual vomiting can cause excessive losses of potassium from the body and hypokalemia. Prolonged fasting and starvation also declines the blood serum potassium levels to below 3.0 mEq/L. But eating an unbalanced diet does not cause hypokalemia because most foods, such as fruits (especially bananas, oranges, and melons), vegetables, meat, milk, and cheese, are good sources of potassium. Only foods such as butter, margarine, vegetable oil, soda water, jelly beans, and hard candies are extremely poor in potassium. Diagnosis Hypokalemia can be measured by acquiring a sample of blood, to measure the concentration of potassium ions. Another way is by measuring the potassium content of the urine. In the patient’s case, the serum potassium was measured with the value 1.5 meq/L(3.5-5meq/L). The electrocardiogram is also useful in the diagnosis of hypokalemia, since hypokalemia results in abnormalities in heart behavior. ECG changes may be helpful if present, their absence should not be taken as reassurance of normal cardiac conduction. The ECG of the patient showed mild QRS complexes. Medical Management Asymptomatic or mild hypokalemia may be treated with enteral potassium supplements in the form of pills. This is the safest and most effective treatment for hypokalemia. Symptomatic or severe hypokalemia should be corrected with a solution of intravenous potassium. For people taking diuretics, potassium supplements are not necessary as long as they eat a balanced diet containing foods rich in potassium. But if hypokalemia has already occurred, use of the high potassium diet alone may not reverse hypokalemia. The treatment of the patient’s hypokalemia consisted of kalium durule (C: mineral and electrolyte replacement or supplement; A: replaces potassium and maintains potassium level , 2 durules TID per NGT. Surgical Management Management is nonsurgical. Medical therapy is aimed at potassium supplementation by the enteral (ie, oral or through feeding tubes) or parenteral route. Potassium supplements restore body potassium storage. Electrolytes are used to correct disturbances in fluid and electrolyte homoeostasis or acid-base balance and to reestablish osmotic equilibrium of specific ion..
  • 3. HYPOXIC-ISCHEMIC ENCEPHALOPATHY Definition This is a serious condition causing significant mortality and long-term morbidity. HIE is characterized by clinical and laboratory evidence of acute or subacute brain injury due to asphyxia (ie, hypoxia, acidosis). This damages the cells in the central nervous system (the brain and spinal cord) from inadequate oxygen. Most often, the underlying cause remains unknown. Hypoxic-ischemic encephalopathy allegedly may cause in death or result in what is later recognized as developmental delay, mental retardation, or cerebral palsy. The time of brain injury often remains uncertain, and an abnormal brain (eg, growth failure, impaired development) might be an underlying risk factor. Symptoms May show symptoms of developmental delay, mental retardation, cerebral palsy and growth failure. Causes Brain hypoxia and ischemia due to systemic hypoxemia, reduced cerebral blood flow or both are the primary physiological processes that trigger HIE. A possible cause in the patient’s case is the occurrence of respiratory arrest, secondary to weakness of respiratory muscles while he was in the ICU, leading to the lack of delivery of oxygen to the brain. He complained of dyspnea, and metabolic acidosis was revealed. Diagnosis Diagnosis of HIE is made based on the history and physical and neurological examinations. Many of the tests are performed to assess the severity of brain injury and to monitor the functional status of systemic organs. The results of the tests should be interpreted in conjunction with the clinical history and the findings from physical examination. Cranial ultrasound can also reveal internal hemorrhage; however, visualizations may be difficult in routine ultrasound examination. A CT scan of the head can be useful to confirm cerebral edema (obliteration of cerebral ventricles, blurring of sulci). Echocardiography (ECHO) also helps to define myocardial contractility and the existence of structural heart defects, if any. Medical Management Seizures are generally self-limited, but may significantly compromise other body functions such as maintenance of ventilation, oxygenation, and blood pressure. Seizures should be treated early and be well controlled, since even asymptomatic seizures (ie, seen only on EEG) may continue to injure the brain. Fluid and glucose homeostasis should also be achieved. Avoid hypoglycemia or hyperglycemia, as both are known to cause brain injury. Treatment is supportive and directed at the organ system manifestations. For the brain injury, no established effective treatment is used. Citicoline (Somazine) can be used as a neuroprotectant(C: CNS stimulant; A: it produces CNS stimulation by increasing level of neurotransmitters in the CNS. Produce CNS stimulation and respiratory stimulation dilated pupils, increase motor activity and mental alertness, and a diminished sense of fatigue.); . Surgical Management In cases of posterior cranial fossa hematoma, surgical drainage may be lifesaving if no additional pathologies are present
  • 4. NOSOCOMIAL PNEUMONIA Definition Hospital-acquired pneumonia, also called nosocomial pneumonia, is an infection that patients get while they’re in the hospital. This means the infection is not present at the time a patient is admitted to the hospital. Pathogens thrive in hospitals that could not survive in other environments. These pathogens include resistent aerobic gram-negative rods, such as Pseudomonas, Enterobacter and Serratia; resistent gram positive cocci, such as ORSA. Because of risk factors, underlying morbidity and resistent bacteria, hospital-acquired pneumonia tends to be more deadly than its community counterpart. Hospital acquired pneumonia occurs mostly in patients who are severely debilitated or who are immune suppressed. Nosocomial pneumonia can generally be described as “early nosocomial” (appearing within five days of hospitalization) or “late nosocomial” (more than five days after hospitalization). The nosocomial pneumonia of our patient was identified on the 3 rd day at the ICU which is also the 3rd day of his admission. The organisms leading to community-acquired pneumonia, predominantly Gram-positive cocci, are seen in patients present with pneumonia very shortly after admission to hospital (if no antibiotic therapy has so far been given) and Gram-negative bacilli predominate in patients developing pneumonia after five days of hospitalization. The preliminary result of the tracheal aspirate revealed gram (-) woffi, acinetobacter hypersensitive to Ciprofloxacin and Piperacillin. Symptoms These may include fever, shortness of breath, and a cough that produces yellow, green, or gray sputum from the respiratory tract. Because nosocomial pneumonia is such a serious infection, patients may need to receive more than one type of antibiotic to treat it. Getting pneumonia while in the hospital may prolong the hospital stay, and intravenous (I.V.) antibiotic treatment usually lasts for up to 2 weeks. If patients begin to feel better, they may be switched from I.V. treatment to oral (tablet) treatment. Patient had a productive cough with whitish sputum. Rales were heard on both lung fields. Causes Increased duration of hospital stay (risk increases with >14 days of stay). • Trauma (particularly head trauma). • Chronic underlying diseases (e.g. diabetes and chronic lung disease). • Immunosuppression. • General anaesthetic. • Endotracheal intubations. The patient was intubated for 12 days in the ICU, starting on his first day in the ICU • Hospital admission during the previous month. • Antibiotic history. • Diagnosis • X-ray or CT scan.
  • 5. Purulent sputum. • Fever. • Leucocytosis or leucopenia. • Laboratory Tests • Blood cultures • Sputum Gram stain and culture The patient’s culture of sputum aspirate revealed gram (-) woffi, acinetobacter hypersensitive to Ciprofloxacin (C: Fluroquinolones; A: it inhibits bacterial cell wall synthesis) and Piperacillin (C: Penicillin A: An extended-spectrum penicillin that inhibits cell-wall synthesis during microorganism multiplication.) Treatment Antibiotics used for hospital-acquired pneumonia include aminoglycosides, fluoroquinolones, carbapenems, and vancomycin.. Multiple antibiotics are administered in combination in order to cover all the possible organisms effectively and rapidly, before the infectious agent can be known. The antibiotics administered to the patient are the ff:. Ciprofloxacin 500mg 1 and ½ tab BID (C: Fluroquinolones; A: it inhibits bacterial cell wall synthesis); Clindamycin 300g 1 cup every 6 hrs (C: miscellaneous anti-infective; A: inhibits bacterial protein synthesis by binding to the 50S subunit of the ribosome) and Piperacillin + Tazobactam 4.5 gm IVTT (C: Penicillin A: An extended-spectrum penicillin that inhibits cell-wall synthesis during microorganism multiplication. Tazobactam increases piperacillin’s effectiveness by inactivating beta-lactamases, which destroy penicillins). Management Antibiotic treatment must be started promptly. URINARY TRACT INFECTION Definition The second most common type of infection in the body. Women are especially prone to UTIs. One woman in five develops a UTI during her lifetime. UTIs in men are not as common as in women but can be very serious when they do occur. The urinary system consists of the kidneys, ureters, bladder, and urethra. The key elements in the system are the kidneys, a pair of purplish-brown organs located below the ribs toward the middle of the back. The kidneys: • remove excess liquid and wastes from the blood in the form of urine • keep a stable balance of salts and other substances in the blood, and • produce a hormone that aids the formation of red blood cells.
  • 6. The narrow tubes called ureters, carry urine from the kidneys to the bladder, a sack-like organ in the lower abdomen. Urine is stored in the bladder and emptied through the urethra Urine is normally sterile -- thus, it does not normally contain bacteria. This is a good thing, since the mineral and sugar content of urine makes it a great medium for bacteria to grow in. Several things keep bacteria out of the urine. These include: · The urethral sphincter: when the urethra is squeezed shut, bacteria cannot climb up the urethra from the quot;meatusquot; (the outside opening) into the bladder. · The length of the urethra: it's a long way up to the bladder for a bacterium. (A woman's urethra is shorter than a man's, which is one reason why women are much more likely than men to get UTI's.) · Frequent washing: any bacteria that make it into the urethra are flushed out the next time you urinate, and since most people empty their bladders almost completely when they urinate any bacteria that get to the bladder will be flushed out too. There are also valves where the ureters enter the bladder to prevent urine from quot;refluxingquot; from the bladder to the kidneys, so even if the bladder and its urine is infected the bacteria shouldn't travel up to the kidneys. Symptoms Not everyone with a UTI has symptoms, but most people get at least some symptoms. These may include a frequent urge to urinate and a painful, burning feeling in the area of the bladder or urethra during urination. Often women feel an uncomfortable pressure above the pubic bone, and some men experience a fullness in the rectum. It is common for a person with a urinary infection to complain that, despite the urge to urinate, only a small amount of urine is passed. The urine itself may look milky or cloudy, even reddish if blood is present. A UTI does not normally cause fever if it is in the bladder or urethra. A fever may mean that the infection has reached the kidneys. Other symptoms of a kidney infection include pain in the back or side below the ribs, nausea, or vomiting. Cystitis may show up as burning on urination, often in the quot;middlequot; of urination. However, it may have no symptoms other than fever, lower abdominal (just above the pubic bone) pain, or even just a funny smell or colour or appearance (cloudy, dark, even blood-tinged) to your urine. And since kidneys are located at back, just below the bottom ribs, pyelonephritis may appear as pain at the back or flank(s), or in the abdomen. Fever usually (but not always) comes along with the pain. If the kidneys are severely affected, one may also start seeing some of the complications due to kidney malfunction. Complications The biggest problem with a UTI is if it progresses to pyelonephritis. This can result in scarring and damage to the kidney tissue. If there is enough damage to the filter system, waste products can't be removed properly. This constitutes kidney failure, and if it is bad enough and long-lasting enough, the only solutions are dialysis (filtering blood through an quot;artificial kidneyquot;) or a kidney transplant A different complication occurs if the pressure-regulation tissues in the kidney are scarred. If this is bad enough, your blood pressure may be kept too low (and one may faint frequently at the very least) or too high (leading to strokes, heart disease). Causes
  • 7. Since urine is normally sterile. It is usually free of bacteria, viruses, and fungi but does contain fluids, salts, and waste products. An infection occurs when tiny organisms, usually bacteria from the digestive tract, cling to the opening of the urethra and begin to multiply. The urethra is the tube that carries urine from the bladder to outside the body. Most infections arise from one type of bacteria, Escherichia coli (E. coli), which normally lives in the colon. In many cases, bacteria first travel to the urethra. When bacteria multiply, an infection can occur. • An infection limited to the urethra is called Urethritis. This can be due to other things besides the organisms usually involved in UTI's; in particular, many sexually-transmitted diseases (STD's) appear initially as urethritis. Another is stool-related bacteria (the most common bacteria on the skin near the meatus) will also often cause urethritis. • If bacteria move to the bladder and multiply, a bladder infection, called Cystitis, results. This is the most common form of UTI; it can be aggravated if the bladder does not empty completely when urinating. • An infection of the ureter is called, Ureteritis. This can occur if the bacteria entered the urinary tract from above, or if the ureter-to-bladder valves don't work properly and allow urine to quot;refluxquot; from the bladder into the ureters. • If the infection is not treated promptly, bacteria may then travel further up the ureters to multiply and infect the kidneys. A kidney infection is called Pyelonephritis. Microorganisms called Chlamydia and Mycoplasma may also cause UTIs in both men and women, but these infections tend to remain limited to the urethra and reproductive system. Unlike E. coli, Chlamydia and Mycoplasma may be sexually transmitted, and infections require treatment of both partners. The urinary system is structured in a way that helps ward off infection. The ureters and bladder normally prevent urine from backing up toward the kidneys, and the flow of urine from the bladder helps wash bacteria out of the body. In men, the prostate gland produces secretions that slow bacterial growth. In both sexes, immune defenses also prevent infection. But despite these safeguards, infections still occur. Risk Factors Any abnormality of the urinary tract that obstructs the flow of urine (a kidney stone, for example) sets the stage for an infection. An enlarged prostate gland also can slow the flow of urine, thus raising the risk of infection. A common source of infection is catheters, or tubes, placed in the urethra and bladder. The patient has been catheterized since December 5, 2006 until December 12, 2006 (7 days), was inserted on December 14, 2006. Urinary Tract infection was diagnosed on December 26, 2006. So on December 27, 2006 FBC was removed. A person who cannot void or who is unconscious or critically ill often needs a catheter that stays in place for a long time. Some people, especially the
  • 8. elderly or those with nervous system disorders who lose bladder control, may need a catheter for life. Bacteria on the catheter can infect the bladder, thus, hospital staff take special care to keep the catheter clean and remove it as soon as possible. People with diabetes have a higher risk of a UTI because of changes in the immune system. Any other disorder that suppresses the immune system raises the risk of a urinary infection. Diagnosis A sample of urine is tested for pus and bacteria. A quot;clean catchquot; urine sample is collected by washing the genital area and collecting a quot;midstreamquot; sample of urine in a sterile container. In the urinalysis test, the urine is examined for white and red blood cells and bacteria. Bacteria are then grown in a culture and tested against different antibiotics to see which drug best destroys the bacteria. This last step is called a sensitivity test. Some microbes, like Chlamydia and Mycoplasma, can be detected only with special bacterial cultures. A doctor suspects one of these infections when a person has symptoms of a UTI and pus in the urine, but a standard culture fails to grow any bacteria. The results of the patients urinalysis, revealed cloudy appearance, RBC of 5-10/hpf, epithelial cells of 2-5/hpf, moderate(++) blood, 30(++)protein and heat & acetic acid: (+) An ultrasound exam is also used, which gives pictures from the echo patterns of soundwaves bounced back from internal organs. Another useful test is cystoscopy. A cystoscope is an instrument made of a hollow tube with several lenses and a light source, which allows the doctor to see inside the bladder from the urethra. Treatment UTIs are treated with antibacterial drugs. The choice of drug and length of treatment depend on the patient's history and the urine tests that identify the offending bacteria. The sensitivity test is especially useful in helping the doctor select the most effective drug. A class of drugs called quinolones includes four drugs approved in recent years for treating UTI. These drugs include ofloxacin (Floxin), norfloxacin (Noroxin), ciprofloxacin (Cipro), and trovafloxin (Trovan). A followup urinalysis helps to confirm that the urinary tract is infection-free. It is important to take the full course of treatment because symptoms may disappear before the infection is fully cleared. Various drugs are available to relieve the pain of a UTI. A heating pad may also help. Most doctors suggest that drinking plenty of water helps cleanse the urinary tract of bacteria. During treatment, it is best to avoid coffee, alcohol, and spicy foods. And one of the best things a smoker can do for his or her bladder is to quit smoking. Smoking is the major known cause of bladder cancer.
  • 9. Management • Drink plenty of water every day. • Urinate when you feel the need; don't resist the urge to urinate. • Wipe from front to back to prevent bacteria around the anus from entering the vagina or urethra. • Take showers instead of tub baths. • Cleanse the genital area before sexual intercourse. In women, avoid using feminine hygiene sprays and scented douches, which may irritate the urethra. Anatomy & Physiology Brain Major regions of the brain and their functions
  • 10. The major regions of the brain are the cerebral hemispheres, diencephalon, brain stem and cerebellum. Cerebral hemispheres The cerebral hemispheres, located on the most superior part of the brain, are separated by the longitudinal fissure. They make up approximately 83% of total brain mass, and are collectively referred to as the cerebrum. The cerebral cortex constitutes a 2-4 mm thick grey matter surface layer and, because of its many convolutions, accounts for about 40% of total brain mass. It is responsible for conscious behaviour and contains three different functional areas: the motor areas, sensory areas and association areas. Located internally are the white matter, responsible for communication between cerebral areas and between the cerebral cortex and lower regions of the CNS, as well as the basal nuclei (or basal ganglia), involved in controlling muscular movement. Midbrain Function: Controls Responses to Sight, Eye Movement, Pupil Dilation, Body Movemen,t Hearing. Location: The mesencephalon/midbrain is the most rostral portion of the brainstem. It is located between the forebrain and brainstem. Forebrain Function: Chewing ,Directs Sense Impulses Throughout the Body ,Equilibrium ,Eye Movement, Vision ,Facial Sensation Hearing, Phonation ,Intelligence Memory, Personality Respiration Salivation, Swallowing Smell, Taste Location: The prosencephalon/forbreain is the most anterior portion of the brain. Diencephalon The diencephalon is located centrally within the forebrain. It consists of the thalamus, hypothalamus and epithalamus, which together enclose the third ventricle. The thalamus acts as a grouping and relay station for sensory inputs ascending to the sensory cortex and association areas. It also mediates motor activities, cortical arousal and memories. The hypothalamus, by controlling the autonomic (involuntary) nervous system, is responsible for maintaining the body’s homeostatic balance. Moreover it forms a part of the limbic system, the ‘emotional’ brain. The epithalamus consists of the pineal gland and the CSF producing choroid plexus. Brain stem The brain stem is similarly structured as the spinal cord: it consists of grey matter surrounded by white matter fibre tracts. Its major regions are the midbrain, pons and medulla oblongata. The midbrain, which surrounds the cerebral aqueduct, provides fibre pathways between higher and lower brain centres, contains visual and auditory reflex and subcortical motor centres. The pons is mainly a conduction region, but its nuclei also contribute to the regulation of respiration and cranial nerves. The medulla oblongata takes an important role as an autonomic reflex centre involved in maintaining body homeostasis. In particular, nuclei in the medulla
  • 11. regulate respiratory rhythm, heart rate, blood pressure and several cranial nerves. Moreover, it provides conduction pathways between the inferior spinal cord and higher brain centres. Cerebral Cortex Lobes Frontal Lobe Function: Motor Functions Higher Order Functions Planning Reasoning Judgement Impulse Control Memory Location: The frontal lobes are the anterior portion of the cerebral cortex. Occipital Lobe Function: Controls Vision Color Recognition Location: The occipital lobes are the most caudal portion of the cerebral cortex. Parietal Lobe Function: Cognition Information Processing Pain and Touch Sensation Spatial Orientation Speech Visual Perception Location: The parietal lobes are anterior to the occipital lobes and posterior to the central sulcus (fissure) and frontal lobes. Temporal Lobe Function: Emotional Responses Hearing Memory Speech Location: The temporal lobes are anterior to the occipital lobes and lateral to the Fissure of Sylvius. Insula Function: Associated With Visceral Functions Integrates Autonomic Information Location: The insula is located within the cerebral cortex, beneath the frontal, parietal and temporal opercula. Cerebellum The cerebellum, which is located dorsal to the pons and medulla, accounts for about 11% of total brain mass. Like the cerebrum, it has a thin outer cortex of grey matter, internal white matter, and small, deeply situated, paired masses (nuclei) of grey matter. The cerebellum processes impulses received from the cerebral motor cortex, various brain stem nuclei and sensory receptors in order to appropriately control skeletal muscle contraction, thus giving smooth, coordinated movements. The cerebral circulatory system Blood is transported through the body via a continuous system of blood vessels. Arteries carry oxygenated blood away from the heart into capillaries supplying tissue cells. Veins collect the blood from the capillary bed and carry it back to the heart. The main purpose of blood flow through body tissues is to deliver oxygen and nutrients to and waste from the cells, exchange gas in the lungs, absorb nutrients from the digestive tract, and help forming urine in the kidneys. All the circulation besides the heart and the pulmonary circulation is called the systemic circulation.
  • 12. The internal carotid arteries, branches of the common carotid arteries, run through the neck and enter the skull through the temporal bone. Once inside the cranium, each divides into the anterior and middle cerebral arteries, which supply most of the cerebrum. The paired vertebral arteries pass upward from the subclavian arteries at the base of the neck. Within the skull, the vertebral arteries join to form the single basilar artery, which serves the brain stem and cerebellum as it travels upward. At the base of the cerebrum, the basilar artery divides to form the posterior cerebral arteries, which supply the posterior part of the cerebrum. The anterior and posterior blood supplies of the brain are united by small communicating arterial branches. The result is a complete circle of connecting blood vessels called the circle of Willis, which surrounds the base of the brain. The circle of Willis protects the brain, because it provides more than one route for blood to reach brain tissue in case of a clot or impaired blood flow anywhere in the system. Respiratory System
  • 13. The respiratory system is composed of the nose, the pharynx, the larynx, the trachea, the bronchi & their smaller branches and the lungs. The major function of this system is to supply the body with oxygen and dispose carbon dioxide from the body. During breathing, air enters the body through the nose which is the only externally visible part of the respiratory system. The air passes through the external nares then to the nasal cavity where it is first filtered and warmed. After which passes through pharynx or most commonly known as the “throat” which is the common passageway for both food and air. After passing through the pharynx, the air is now being routed to its proper channel by the larynx also known as the “voice box” which is lies just below the pharynx. The epiglottis protects the superior opening of the larynx which closes as the person swallows so that food will not enter into the trachea, also called the “windpipe”. The trachea extends from the larynx to the primary bronchi. As the air comes down the trachea and enters the right and left primary bronchi, it is again filtered by the ciliated mucosa lining which propels dust particles and other debris away from the lungs. From the subdivision of the trachea results the left and right primary bronchi which are the ones plunged into the hilus of the lungs on its sides. By the time air reaches the bronchi, it is already warm, cleansed and well humidified but because the right primary bronchi is wider, shorter and straighter than the left, inhaled foreign objects are consequently lodged in it. After the primary bronchi enter the lungs, they subdivide into smaller and smaller branches called bronchioles, until it terminates/ends in clusters of alveoli (air sacs) inside the lungs where gas exchange takes place.
  • 14. The paired lungs are fairly large organs. They occupy the entire thoracic cavity except for the most central area, the mediastinum, which houses the heart, the great blood vessels, bronchi, esophagus, and other organs. The narrow superior portion of each lung, the apex, is located just deep to the clavicle. The broad lung area resting on the diaphragm is the base. Each lung is divided into lobes by fissures; the left lung has two lobes, and the right lung has three. The surface of each lung is covered with a visceral serosa called the pulmonary, or visceral, pleura and the walls of the thoracic cavity are lined by the parietal pleura. The pleural membranes produce pleural fluid, a slippery serous secretion which allows the lungs to glide easily over the thorax wall during breathing movements and causes the two pleural layers to cling together. The pleurae can slide easily from side to side across one another, but they strongly resist being pulled apart. Consequently, the lungs are held tightly to the thorax wall, and the pleural space is more of a potential space than an actual one. As described shortly, this condition of tightly adhering pleural membranes is absolutely essential for normal breathing. After the primary bronchi enter the lungs, they subdivide into smaller and smaller branches (secondary and tertiary bronchi, and so on), finally ending in the smallest of the conducting passageways, the bronchioles. Because of this branching and rebranching of the respiratory passageways within the lungs, the network formed is often referred to as the bronchial or respiratory tree. All but the smallest branches have reinforcing cartilage in their walls. The terminal bronchioles lead into respiratory zone structures, even smaller conditions that eventually terminate in alveoli, or air sacs. The respiratory zone, which includes the respiratory bronchioles, alveolar ducts, alveolar sacs, and alveoli, is the only site of gas exchange. All other respiratory passages are conducting zone structures that serve as conduits to and from the respiratory zone. There are millions of the clustered alveoli, which resemble bunches of grapes, and they make up the bulk of the lungs. The balance of the lung tissue, its stroma, is elastic connective tissue. Thus, in spite of their relatively large size, the lungs weigh only about 2 ½ pounds, and they are soft and spongy. The Respiratory Membrane The walls of the alveoli are composed largely of a single, thin layer of squamous epithelial cells. The thinness of their walls is hard to imagine, but a sheet of tissue paper is much thicker. Alveolar pores connect neighboring air sacs and provide alternate routes for air to reach alveoli whose feeder bronchioles have been clogged by mucus or otherwise blocked. The external surfaces of the alveoli are covered with a “cobweb” of pulmonary capillaries. Together, the alveolar and capillary walls and their fused basement membranes construct the respiratory membrane (air-blood barrier), which has gas (air) flowing past on one side and blood flowing past on the other. The gas exchanges occur by simple diffusion through the respiratory membrane – oxygen passing from the alveolar air into the capillary blood and carbon dioxide leaving the blood to enter the gas-filled alveolus. It has been estimated that the total gas exchange surface provided by the alveolar walls of a healthy man is 50 to 70 square meters, or approximately 50 times greater than the surface area of the skin. The final line of defense for the respiratory system is in the alveoli. Macropahges, sometimes called “dust cells,” wander in and out of the alveoli picking up bacteria, carbon particles, and other debris. Also scattered amid the epithelial cells that form most of the alveolar walls are chunky cuboidal cells, which look very different. The cuboidal cells produce a lipid (fat) molecule called surfactant, which coats the gas-exposed alveolar surfaces and is very important in lung function.
  • 15. Urinary System The urinary system consists of the kidneys, ureters, urinary bladder, and urethra. The kidneys form the urine and account for the other functions attributed to the urinary system. The ureters carry the urine away from kidneys to the urinary bladder, which is a temporary reservoir for the urine. The urethra is a tubular structure that carries the urine from the urinary bladder to the outside. Kidneys The kidneys are the primary organs of the urinary system. The kidneys are the organs that filter the blood, remove the wastes, and excrete the wastes in the urine. They are the organs that perform the functions of the urinary system. The other components are accessory structures to eliminate the urine from the body. The paired kidneys are located between the twelfth thoracic and third lumbar vertebrae, one on each side of the vertebral column. The right kidney usually is slightly lower than the left because the liver displaces it downward. The kidneys protected by the lower ribs, lie in shallow depressions against the posterior abdominal wall and behind the parietal peritoneum. This means they are retroperitoneal. Each kidney is held in place by connective tissue, called renal fascia, and is surrounded by a
  • 16. thick layer of adipose tissue, called perirenal fat, which helps to protect it. A tough, fibrous, connective tissue renal capsule closely envelopes each kidney and provides support for the soft tissue that is inside. In the adult, each kidney is approximately 3 cm thick, 6 cm wide, and 12 cm long. It is roughly bean-shaped with an indentation, called the hilum, on the medial side. The hilum leads to a large cavity, called the renal sinus, within the kidney. The ureter and renal vein leave the kidney, and the renal artery enters the kidney at the hilum. The outer, reddish region, next to the capsule, is the renal cortex. This surrounds a darker reddish-brown region called the renal medulla. The renal medulla consists of a series of renal pyramids, which appear striated because they contain straight tubular structures and blood vessels. The wide bases of the pyramids are adjacent to the cortex and the pointed ends, called renal papillae, are directed toward the center of the kidney. Portions of the renal cortex extend into the spaces between adjacent pyramids to form renal columns. The cortex and medulla make up the parenchyma, or functional tissue, of the kidney. The central region of the kidney contains the renal pelvis, which is located in the renal sinus and is continuous with the ureter. The renal pelvis is a large cavity that collects the urine as it is produced. The periphery of the renal pelvis is interrupted by cuplike projections called calyces. A minor calyx surrounds the renal papillae of each pyramid and collects urine from that pyramid. Several minor calyces converge to form a major calyx. From the major calyces the urine flows into the renal pelvis and from there into the ureter. Each kidney contains over a million functional units, called nephrons, in the parenchyma (cortex and medulla). A nephron has two parts: a renal corpuscle and a renal tubule.The renal corpuscle consists of a cluster of capillaries, called the glomerulus, surrounded by a double-layered epithelial cup, called the glomerular capsule. An afferent arteriole leads into the renal corpuscle and an efferent arteriole leaves the renal corpuscle. Urine passes from the nephrons into collecting ducts then into the minor calyces. The juxtaglomerular apparatus, which monitors blood pressure and secretes renin, is formed from modified cells in the afferent arteriole and the ascending limb of the nephron loop. Ureters Each ureter is a small tube, about 25 cm long, that carries urine from the renal pelvis to the urinary bladder. It descends from the renal pelvis, along the posterior abdominal wall, behind the parietal peritoneum, and enters the urinary bladder on the posterior inferior surface. The wall of the ureter consists of three layers. The outer layer, the fibrous coat, is a supporting layer of fibrous connective tissue. The middle layer, the muscular coat, consists of inner circular and outer longitudinal smooth muscle. The main function of this layer is peristalsis to propel the urine. The inner layer, the mucosa, is transitional epithelium that is continuous with the lining of the renal
  • 17. pelvis and the urinary bladder. This layer secretes mucus which coats and protects the surface of the cells. Urinary Bladder The urinary bladder is a temporary storage reservoir for urine. It is located in the pelvic cavity, posterior to the symphysis pubis, and below the parietal peritoneum. The size and shape of the urinary bladder varies with the amount of urine it contains and with pressure it receives from surrounding organs. The inner lining of the urinary bladder is a mucous membrane of transitional epithelium that is continuous with that in the ureters. When the bladder is empty, the mucosa has numerous folds called rugae. The rugae and transitional epithelium allow the bladder to expand as it fills. The second layer in the walls is the submucosa that supports the mucous membrane. It is composed of connective tissue with elastic fibers. The next layer is the muscularis, which is composed of smooth muscle. The smooth muscle fibers are interwoven in all directions and collectively these are called the detrusor muscle. Contraction of this muscle expels urine from the bladder. On the superior surface, the outer layer of the bladder wall is parietal peritoneum. In all other regions, the outer layer is fibrous connective tissue. There is a triangular area, called the trigone, formed by three openings in the floor of the urinary bladder. Two of the openings are from the ureters and form the base of the trigone. Small flaps of mucosa cover these openings and act as valves that allow urine to enter the bladder but prevent it from backing up from the bladder into the ureters. The third opening, at the apex of the trigone, is the opening into the urethra. A band of the detrusor muscle encircles this opening to form the internal urethral sphincter. Urethra The final passageway for the flow of urine is the urethra, a thin-walled tube that conveys urine from the floor of the urinary bladder to the outside. The opening to the outside is the external urethral orifice. The mucosal lining of the urethra is transitional epithelium. The wall also contains smooth muscle fibers and is supported by connective tissue. The internal urethral sphincter surrounds the beginning of the urethra, where it leaves the urinary bladder. This sphincter is smooth (involuntary) muscle. Another sphincter, the external urethral sphincter, is skeletal (voluntary) muscle and encircles the urethra where it goes through the pelvic floor. These two sphincters control the flow of urine through the urethra. In females, the urethra is short, only 3 to 4 cm (about 1.5 inches) long. The external urethral orifice opens to the outside just anterior to the opening for the vagina.
  • 18. In males, the urethra is much longer, about 20 cm (7 to 8 inches) in length, and transports both urine and semen. The first part, next to the urinary bladder, passes through the prostate gland and is called the prostatic urethra. The second part, a short region that penetrates the pelvic floor and enters the penis, is called the membranous urethra. The third part, the spongy urethra, is the longest region. This portion of the urethra extends the entire length of the penis, and the external urethral orifice opens to the outside at the tip of the penis. CLIENT IN CONTEXT PRESENT STATE INTERVENTIONS EVALUATION PHYSICAL EXAMINATION: Informant: father and eldest son, Date: December 13, 2006, 1:45 mostly father pm, Wednesday 65% Reliability G.M., 37 y.o., male, married, General appearance: Roman Catholic, Filipino, Seen lying on bed, awake, currently residing in Tisa conscious, responsive to pain,
  • 19. afebrile, with O2 inhalation @ 2L/ Labangon, Cebu city, was minute via nasal cannula, with admitted for the first time in NGT @ left nostril, with FBC CVGH on November 24, 2006 at draining well to CDU, with the 7:00pm via taxi accompanied by following v/s: BP: 130/90 mmHg, co-worker for complaint of PR: 62 bpm, RR: 15 cpm, T: weakness on the lower extremities 36.5°C/ axilla, height: 5’6” IBW = noted 5 hours PTA, under the service of Dr. Pama of the SKIN: Department of Family Medicine warm, dry, good skin tugor, with and co-managed by Dr. Español of scalings found on both lower the Department of Internal extremities, no rashes, dark Medicine with the case # 84334. complexion, a grade 2 bed sore History of present illness: located approx. 1/2 inch in 5 days , patient had history diameter, circular in form at the of profuse diarrhea approximately inner leg of the left ankle and 10-15 episodes per day amounting approx. 2 inches in diameter, to 1cup per episode. No meds irregular in form 1 inch above the taken nor hydration correction outer right ankle done. Condition tolerated. NAIL: Few hours PTA, patient had pinkish nail bed, smooth and short, weakness of the lower extremities dirty fingernails, CRT <2 seconds, no clubbing of nails associated with numbness which HAIR & HEAD: progressively reached the level evenly distributed short, black below the umbilicus. Patient was hair, no lesions, no lice unable to stand alone, prompting infestations, no dandruff, hair is to seek consult at CVGH-(Cebu smooth, normocephalic Velez General Hospital) and subsequently admitted. Labs taken EYES: outer canthus of eye is inline with were potassium which showed the pinna, eyebrows and eyelashes hypokalemia at 1.5mmOl/L and mild QRS complexes documented evenly distributed, no discharges, on ECG. Pt. was the transferred to pinkish palpebral conjunctivae, iris
  • 20. and pupil are round in shape, ICU for further monitoring. ABG sclera is white, eyes are was likewise taken because he symmetrical in shape, (+) complained of dyspnea which PERRLA,(-) cardinal gaze, (-) revealed acidosis with adequate peripheral gaze, cannot see oxygenation. EARS: On first day at ICU, pt. pinna is in line with the outer complained of persistent dyspnea. canthus of the eye, symmetrical, Pulse oximetry revealed 98-100%. no tenderness, no abnormal or foul Approval of the family was done discharges, can hear spoken words pertaining of possible intubation if at 1 ft. distance respiratory arrest would occur 30 NOSE: mins later. O2 saturated declined With NGT @ left nostril, nasal to less than 90% and was septum at midline, no discharges, subsequently intubated with patent airway, sinuses not tender, continuous ambubagging at (+) frontal and maxillary 10L/min. Along the course of transillumination intubation, pt went into MOUTH: cardiopulmonary arrest and was pinkish and moist lips, pink resuscitated accordingly. mucosa, no lesions, tongue at the floor of the mouth, 30 teeth, On the second day, CBC was NECK: taken which showed WBC of 10.4 supple, located at midline, no k/uL(4.10-10.9 k/uL) and serum tenderness, no lymphadenopathy, potassium of 2.1 mmOl/L(3.5- trachea located at midline, no 5mmOl/L). Pt was comatosed with masses or lesions noted blank stare. Citicoline 1 gm IVTT CHEST and LUNGS: (C: CNS stimulant; A: it produces Presence of tattoo located @ the CNS stimulation by increasing right scapular region, no palpable level of neurotransmitters in the lesions, no bruises, no masses CNS. Produce CNS stimulation palpated, equal chest expansion, and respiratory stimulation dilated rales on both lung fields pupils, increase motor activity and CARDIOVASCULAR: mental alertness, and a diminished
  • 21. no murmurs heard, distinct S1 & sense of fatigue.); Esomeprazole S2, regular rhythm, PR:62 bpm 40mg IVTT OD (C: Anti-ulcer, ABDOMEN: proton pump inhibitor; A: binds an protuberant, umbilicus at midline, enzyme on gastric parietal cells in 5 clicks/min. no masses palpated, the presence of acidic gastric pH, no abdominal distention preventing the final transport of GENITALIA: hydrogen ion into the gastric grossly male, no discharges, no lumen); kalium durule, 2 durules lesions noted QID (C: mineral and electrolyte EXTREMITIES: replacement or supplement; A: upper extremities and lower replaces potassium and maintains extremities are symmetrical in size potassium level); sodium and in decorticate state, palpable bicarbonate gr10 1 tab TID (C: peripheral pulses, a grade 2 bed alkalinizer; A: restores buffering sore located approx. 1/2 inch in capacity of the body and diameter, circular in form at the neutralizes excess acid) were inner leg of the left ankle and likewise given. approx. 2 inches in diameter, On the third day at ICU, irregular in form 1 inch above the preliminary result of the tracheal outer right ankle aspirate revealed acinetobacter woffi sensitive to ciprofloxacin Neurologic assessment: and Piperacillin + Tazobactam. MENTAL STATUS: conscious, Thus was started on Ciprofloxacin incoherent, with GCS of 6 500mg 1 and ½ tab BID (C: SENSORY STATUS: cannot be Fluroquinolones; A: it inhibits assessed bacterial cell wall synthesis); MOTOR STATUS: cannot be Clindamycin 300g 1 cup every 6 assessed hrs (C: miscellaneous anti- infective; A: inhibits bacterial CRANIAL NERVES: protein synthesis by binding to the I: n/a 50S subunit of the ribosome) and II: n/a Piperacillin + Tazobactam 4.5 gm III, IV, VI: (+) PERRLA, (-) IVTT (C: Penicillin A: An
  • 22. cardinal gaze, (-) peripheral gaze extended-spectrum penicillin that V: (+) blink reflex, can open & inhibits cell-wall synthesis during close mouth, microorganism multiplication. VII: n/a Tazobactam increases VIII: can hear spoken words at 1 piperacillin’s effectiveness by ft. distance inactivating beta-lactamases, IX, X: n/a which destroy penicillins). XI: n/a Potassium was taken with a result XII: (+) gag reflex of 3.7 mmol/L. On the 12th day of ICU, pt DEEP TENDON REFLEXES: was extubated but weaning with T- Biceps: (+), triceps (+) piece at 4 LPM was done a day before which he tolerated. Then MUSCLE STRENGTH: nebulization with Salbutamol 1/5 1/5 and Hydrocortisone was done. 1/5 1/5 Finally he was transferred to Ward Date: December 18, 2006, 10:15 though still comatose with blank am Monday stare. He had a working diagnosis of 1 Hypoxic – Ischemic General appearance: Encephalopathy 2 severe Seen lying on bed, awake, hypokalemia - corrected 3 conscious, incoherent, afebrile, Nosocomial pneumonia with NGT @ left nostril, with O2 inhalation @ 2L/minute via nasal Past history illness: cannula, with FBC draining well Patient is known to CDU, with the following v/s: hypertensive with unrecalled bp, BP: 120/80 mmHg, PR: 69 bpm, non-diabetic, non-asthmatic with RR: 22 cpm, T: 36.7°C/ axilla, no known food and drug allergies. He is a non-smoker and an SIGNIFICANT FINDINGS: occasional alcoholic beverage drinker. Heredofamilial disease • includes hypertension on maternal (-) cardinal and side and cancer on the paternal (-)peripheral gaze
  • 23. • still can’t see side. • with O2 inhalation @ Previous hospitalization: 2L/min 1st hospitalization was in the • with NGT @ left nostril 1990s due to appendectomy. • presence of tattoo at right However patient’s father forgot scapular region the details pertaining to it such as • rales in both lung fields the name of the hospital, doctor, • dirty fingernails and take home meds. • with FBC draining well to 2nd hospitalization was in CDU 1993 at unrecalled hospital with • Both upper and lower the diagnosis of urolithiasis. extremities are still in Surgery was done. Number of decorticate state days in the hospital and take home • a grade 2 bed sore located meds were unrecalled. Patient’s approx. 1/2 inch in condition improved upon diameter, circular in form discharged. at the inner leg of the left 1. Health perception - Health ankle and approx. 2 inches management Pattern in diameter, irregular in When he was still residing form 1 inch above the at Manila, he had a regular check outer right ankle up at Genreal hospital, Pasig City • with scalings found both under Dr. Casino. Now that he is on lower extremities residing in Cebu for three years, Date: December 19, 2006, 10: 15 S.O. doesn’t know if the patient am Tuesday still practices regular check-ups. Patient takes OTC drugs. If he has General appearance: fever, he takes Biogesic (C: Seen lying on bed, awake, antipyretic and anti-inflammatory conscious, incoherent, afebrile, A: Inhibits the synthesis of with O2 inhalation @ 2L/minute prostaglandin that serve as via nasal cannula, with NGT @ mediators of pain and fever left nostril, with FBC draining primarily in the CNS) and if he has well to CDU, with the following v/
  • 24. s: BP: 130/90 mmHg, PR: 79 bpm, colds, he takes Neozep and RR: 20 cpm, T: 365°C/ axilla, afforded relief. He does not take herbal medicines and does not SIGNIFICANT FINDINGS: believe in folk healers. S.O. doesn’t know if patient performs • (-) cardinal and TSE. Patient is fully immunized, (-)peripheral gaze and goes to the dentist when need • still can’t see arises. • with O2 inhalation @ 2. Nutritional-metabolic Pattern 2L/min Patient eats 3 to 4 times a • with NGT @ left nostril day with snacks in the morning, • presence of tattoo at right afternoon and evening. He usually scapular region eats breakfast at 7 to 8 am • rales in both lung fields comprising of egg, rice and milo. • with FBC draining well to If rice is unavailable, he replaces CDU them with bread. He takes his • Both upper and lower lunch at 12 to 1 pm and usually extremities are still in eats fried meat, at least 3cups of decorticate state rice and cold water. Dinner is • taken at around 7 – 8 pm a grade 2 bed sore located comprising of meat, at least 3 cups approx. 1/2 inch in of rice and cold water. Patient's diameter, circular in form favorite food is adobong baboy at the inner leg of the left and prefers to drink cold water. He ankle and approx. 2 inches does not have intolerance to any in diameter, irregular in type of food and can chew and form 1 inch above the swallow without difficulty. He outer right ankle does not take any vitamins and • with scalings found both supplements. The last time he took on lower extremities multivitamins is when he was 7 years old brand name unrecalled. Date: December 20, 2006 1:45 pm, Patient drinks at least 8 glasses of Wednesday water/day.
  • 25. General appearance: During hospitalization, Px is Seen lying on bed, awake currently on NGT since he was conscious, inoherent, afebrile, with released at ICU at Dec 5, 2006. O2 inhalation @ 2L/minute via His diet prescription is 1800cal in nasal cannula, with NGT @ left 1000cc volume into 6 equal nostril, with FBC draining well to feedings with 300cc as CDU, with the following v/s: BP: volume/feeding. On December 18, 120/90 mmHg, PR: 66 bpm, RR: 2006 his diet prescription was 24 cpm, T: 36.6 °C/axilla increased to 2500 cal in 2500 cc volume with the same SIGNIFICANT FINDINGS: specification and 100 cc water every 4 hours per NGT. • (-) cardinal and 3. Elimination pattern Pattern (-)peripheral gaze S.O. doesn’t know patient’s • still can’t see elimination pattern before • with O2 inhalation @ admission but claimed that the px 2L/min does not use any laxatives. When • with NGT @ left nostril patient experiences constipation, • presence of tattoo at right he just drinks lots of water and scapular region when experiences diarrhea, patient • rales in both lung fields takes in Lomotil or Diatabs • with FBC draining well to During hospitalization, CDU Patient is currently w/ Foley bag • Both upper and lower catheter draining well to clsed extremities are still in drainage unit (Fbc-cdu) since decorticate state released on December 5, 2006 and • a grade 2 bed sore located urinates more than 1,000ml of approx. 1/2 inch in urine per day with a dark yellow diameter, circular in form colored urine. On December 12, at the inner leg of the left 2006 FBC was removed but ankle and approx. 2 inches patient experienced bladder in diameter, irregular in distention, which was then form 1 inch above the
  • 26. outer right ankle relieved by hot and cold compress • with scalings found both but due to persistent bladder on lower extremities distention FBC, was inserted on December 14, 2006. Urinary Tract Date: January 3, 2007 9:30 am infection was diagnosed on Wednesday December 26, 2006. So on December 27, 2006 FBC was General appearance: removed and was not reinserted Seen lying on bed, asleep, afebrile, again because patient was able to with NGT @ left nostril, with the void thereafter and also due to the following v/s: BP: 120/80 mmHg, UTI. He defecates everyday with a PR: 89 bpm, RR: 20 cpm, T: yellow watery stool. Patient 36.5°C/ axilla, experiences urinary and bowel incontinence and constantly wears SIGNIFICANT FINDINGS: diaper up to present. • (-) cardinal and 4. Activity-exercise pattern (-)peripheral gaze Patient is a supervisor at • still can’t see global insurance for 3 yrs. S.O. • with NGT @ left nostril does not know his daily activities, • presence of tattoo at right and time of patient's work and scapular region patient does not engage in any • rales in both lung fields form of exercise and sports. • Both upper and lower Patient used to play basketball extremities are still in with friends at least once a week decorticate state but stopped after he got married. • with scalings found both Patient’s form of recreation on lower extremities include reading, sleeping, and • A whitish, grade 2 watching tv. bedsore, half inch in During hospitalization, diameter, circular in form patient is always on hospital bed was noted on the left inner and cannot change positions such ankle and a reddish, grade as turning to sides, sitting down 2 bedsore, one inch in
  • 27. diameter, irregular in form and standing up on his own. He was noted 1 inch above the has a schedule positioning every 2 right outer ankle hours. He depends on his S.O. in doing his ADL’s. 5. Sleep-rest pattern Date: January 8, 2007 10:30 am When patient is on a Monday vacation in Manila, S.O. said that the patient usually sleeps at around General appearance: 9pm shortly after eating snacks Seen lying on bed, asleep, with and wakes up at around 9am. And NGT left nostril, with the he does not take any sleeping following v/s: BP 110/80 mmHg, medications. Patient takes nap for PR: 79 bpm, RR: 18 cpm, T: about 1-3 hours in the afternoon. 36.4°C/axilla Patient prefers to sleep in a cold room and uses 2 pillows. S.O. does SIGNIFICANT FINDINGS: not know if the patient experiences nightmares. • (-) cardinal and During hospitalization, (-)peripheral gaze • patient sleeps most of the time. still can’t see • with NGT @ left nostril 6. Cognitive-perceptual pattern • presence of tattoo at right Patient does not wear scapular region eyeglasses and does not have any • rales in both lung fields hearing problems. Patient is a • college graduate with a course of distended bladder banking finance. S.O. couldn’t • Both upper and lower recall the name of the school. extremities are still in decorticate state • A whitish, grade 2 7. Role-relationship pattern bedsore, half inch in The patient, as described diameter, circular in form by his father is a loving person, was noted on the left inner father and a boyfriend. He is also ankle and a reddish, grade the comedian in the family. He is
  • 28. 2 bedsore, one inch in the eldest among 3 siblings and diameter, irregular in form has 4 offsprings; 3 of which are was noted 1 inch above the males. He is the provider together right outer ankle with his wife but because of his • with scalings found both work, he isn’t living together with on lower extremities his family but communicates 2-3x/ week through cellular phone. He is in good terms with his parents, Date: January 9, 2007 2:30 pm siblings, girlfriend and friends. Tuesday GENOGRAM: General appearance: Seen lying on bed, asleep, with NGT @ left nostril, with FBC draining well to CDU, with the following v/s: BP 120/80 mmHg, PR: 71 bpm, RR: 17 cpm, T: 36.7°C/axilla SIGIFICANT FINDINGS: • (-) cardinal and (-)peripheral gaze • still can’t see • with NGT @ left nostril • presence of tattoo at right scapular region • rales in both lung fields • with FBC draining well to CDU • Both upper and lower
  • 29. extremities are still in 9. Sexuality-reproductive decorticate state pattern • A whitish, grade 2 Patient had his bedsore, half inch in circumcision at 10 years old at the diameter, circular in form health center at Novaliches, was noted on the left inner Quezon city. He has no history of ankle and a reddish, grade STD. S.O. does not know if the 2 bedsore, one inch in patient performs TSE and does not diameter, irregular in form know the patient's sexual was noted 1 inch above the activities. right outer ankle 10. Coping-stress pattern • with scalings found both When asked, S.O on lower extremities verbalized that the patient's major stressors are financial problems but is able to afford family's needs Date: January 19, 2007 9:45 am such as tuition fees, food, etc. Wednesday Support comes mainly from family and close relatives and seeks for General appearance: friend's advices. He usually Seen lying on bed, awake, relieves stress by resting. conscious, incoherent, afebrile, 11. Value-belief pattern with NGT @ left nostril, with FBC Patient is a roman draining well to CDU, with the catholic. S.O. does not know if the following v/s: BP: 120/80 mmHg, patient prays everyday and goes to PR: 73 bpm, RR: 18 cpm, T: mass every Sunday. Patient is not 36.8°C/axilla involved in any religious organizations. Patient does not SIGNIFICANT FINDINGS: have cultural practices that causes guilt. • (-) cardinal and (-)peripheral gaze • still can’t see Environmental history: • with NGT @ left nostril Patient is currrently
  • 30. • presence of tattoo at right residing at Happy-happy scapular region compound, Tisa Labangon, Cebu • rales in both lung fields city. According to S.O., this place • with FBC draining well to serves as the patient’s office and CDU home in Cebu however the S.O. • Both upper and lower has not yet been to the patient’s extremities are still in place so he can’t further describe decorticate state the place. • with scalings found both In Pasig, Manila, they on lower extremities have been living there for 37 • A whitish, grade 2 years, the house and lot is owned. bedsore, half inch in They have been living in a two- diameter, circular in form storey house with 4 bedrooms was noted on the left inner occupied by 14 people and a ankle and a reddish, grade separate room for kitchen and 2 bedsore, one inch in dining room. It has 6 windows. It diameter, irregular in form is beside the main road, 1 meter was noted 1 inch above the away from the church, 2 meters right outer ankle away from the brgy. Hall, 3 meters away from the market, and 10 MUSCLE STRENGTH: meters away from the health center. Transportation is 1/5 1/5 accessible. They have 1 pet, dog 1/5 1/5 December 13, 18-20, named Rocky. Water source is 2006 supplied by Nawasa and electricity is supplied by Meralco. 2/5 2/5 2/5 2/5 January 3, 8-10, 2007 Summary of Significant Summary of Significant Findings: Findings: PHYSICAL EXAMINATION: • (-) cardinal and 1. Heredofamilial disease (-)peripheral gaze includes hypertension and
  • 31. • cancer on the paternal side. still can’t see 2. Px is currently on NGT. • with NGT @ left nostril 3. Px has been w/ fbc-cdu • presence of tattoo at right from Dec. 5-12, 2006 and scapular region Dec. 14-26, 2006 and • rales in both lung fields urinates more than 1,000ml • with FBC draining well to of urine per day with a CDU dark yellow colored urine. • Both upper and lower But was removed last Dec. extremities are still in 27, 2006 due to the decorticate state presence of UTI • with scalings found both 4. He defecates everyday with on lower extremities a yellow watery stool. • A whitish, grade 2 5. Px is currently always on bedsore, half inch in hospital bed and cannot diameter, circular in form change positions such as was noted on the left inner turning to sides, sitting ankle and a reddish, grade down and standing up on 2 bedsore, one inch in his own. diameter, irregular in form was noted 1 inch above the right outer ankle LABORATORY: 11/24/06 Urinalysis Color: straw RBC: 0-2/hpf heat & acetic acid: (-) pH: 6.5 WBC: 0-1/hpf
  • 32. Specific Gravity: 1.006 epithelial cells: 0-2/hpf Protein: trace ketone: (-) Glucose: ++ blood: + Reducing Substances: ++ amorphous materials: (-) Purpose: Means of knowing the various properties of urine, a routine procedure for every patient to determine any pathological disorders. Implication: Presence of protein, glucose, Reducing substance, blood in urine and low specific gravity usually indicates Infection 11/24/06 ECG Rate: Atrial = 107/min. Ventricular = 107/ min. Rhythm: sinus Axis: (+) 40 PR interval: 0.16 sec. QRS interval: 0.08 sec. QT interval: 0.40 sec. P Wave: low to flat
  • 33. QRS: bizarre complexes seen in V1, V4 r S R pattern seen in V1, V2 Transitional zone : V4 T wave: upright ST segment: isoelectric Interpretation: Sinus tachycardia with premature ventricular contractions, intraventricular conduction defect. Non specific ST-T wave changes. 11/27/06 Gram Staining: Gram (+) cocci in pairs: few/OIF Pus cells: moderate 11/28/06 Smear Culture: Gram (-) rods Culture: Acinetobacter iwoffi Remarks: Sensitivity test result of culture: A.iwoffi Purpose: Allows for morphologic examination of cells contained in the specimen and differentiate any bacteria present, may be used to differentiate true sputum from saliva and upper respiratory tract infections
  • 34. Implication: Indicates infection of the respiratory tract secondary to pneumonia as manifested by whitish sputum and rales. 12/6/06 Complete Blood Count Normal Values WBC ↑17 K/uL 4.10-10.9 K/uL NEU ↑12.5 73.2%N 2.5-7.5 47-80%N LYM ↑1.60 ↓9.36%L 1-4 13-40%L MONO 1.08 6.34% M 1-1.20 2-11%M EOS. ↑1.78 ↑10.4%E 0-.5 0-5%E BASO ↑.107 .625% B 0-.1 0-2%B RBC ↑5.91M/uL 4-5.2M/uL HGB ↓11.7.0 g/dL 12-16 g/dL HCT 36.1 % 36-46% MCV ↓61.1.0 fL 80-100 fL MCH ↓25.6 pg 26-34 pg MCHC 32.3 g/dL
  • 35. 31-36 g/dL RDW 17 % 11.6-18% PLT 417 K/uL 140-440 K/uL MPV 7.69 fL 0-100 fL Purpose: To determine whether specific blood levels are higher or lower than normal and can be useful I the diagnosis of such diseases such as anemia, leukemia, and infection Implication: An increase in WBC and neutrophils indicate an infection secondary to nosocomial pneumonia and as manifested by rales and whitish sputum A decrease in HBG, MCV and MCHC may indicate red hepatization secondary nosocomial pneumonia An increase in RBC may indicate dehydration 12/6/06 Creatinine = 1.3 mg/dL Normal Value (0.5-13 mg/dL) Purpose:
  • 36. To determine for renal function Implication: Within normal range 12 – 6 – 06 Calcium = 4.32 mg %↓ Normal Value (4.6 – 5.16 mg %) Purpose: To aid diagnosis of neuromuscular, skeletal and endocrine disorder, arrhythmias, blood clotting deficiencies, acid- base imbalance. Implication: Decrease in calcium levels indicates hypocalcemia as manifested by generalized muscle spasms, as seen in the patient having decorticate Potassium = 4.7 mmol/L Normal Value (4.0 – 5.6 mmol/L) Sodium = 131 mmol/ L↓ Normal Value (136 – 142 mmol/L) Purpose: To evaluate fluid electrolyte and acid-base balance and related neuromuscular, renal and adrenal
  • 37. functions Implication: Abnormally low serum sodium levels result from diarrhea Potassium value is within normal 12/11/06 5:58pm WBC 11.7 k/ul ↓ NEU 7.25 61.7% N LYM 2.10 17.9% L MONO .356 3.03%M EOS 1.92 16.4%E↑ BASO .114 .970%B RBC 5.39m/uL HGB 10.5 g/dL↓ HCT 33.5%↓ MCV 62.2 fL↓ MCH 19.4 pg↓ MCHC 31.3 g/dL RDW 17.3% PLT 398 k/uL MPV 7.47 fL Implication: An elevated WBC and Eosinophils usually signal infection as manifested by blood in urine, cloudy appearance A decreased Hgb, HCT, MCV, MCH indicates red hepatization secondary to nosocomial
  • 38. pneumonia 12/26/06 Urinalysis Color: yellow Appearance: cloudy RBC: 5-10/hpf heat & acetic acid: (+) pH: 6.5 WBC: 30-40/hpf Bacteria: moderate Specific Gravity: 1.020 epithelial cells: 2-5/hpf Protein: 30(++ ) ketone: (-) Glucose(-) blood: moderate(++) Reducing Substances:(-) amorphous materials: urates: rare Purpose: Means of knowing the various properties of urine, a routine procedure for every patient to determine any pathological disorders. Implication: Cloudy urine, proteinuria, Increased WBC, presence of epitheilai cells and bacteria indicates infection secondary
  • 39. Urinary Tract Infection Summary of Lab test 11/24 11/25 HGB 12 10.4 HCT 38 31.8 WBC CT 16 18 PH CT 305 268 Summary of Significant findings LABS: 12/6/06 Complete Blood Count WBC ↑17 K/uL 4.10-10.9 K/uL NEU ↑12.5 73.2%N 2.5-7.5 47-80%N LYM ↑1.60 ↓9.36%L 1-4 13-40%L EOS. ↑1.78 ↑10.4%E 0-.5 0-5%E BASO ↑.107 .625% B 0-.1 0-2%B RBC ↑5.91M/uL 4-5.2M/uL HGB ↓11.7.0 g/dL 12-16 g/dL HCT ↑36.1 % 36-46% MCV ↓61.1.0 fL 80-100 fL MCH ↓25.6 pg 26-34 pg
  • 40. 11/24/06 Urinalysis RBC: 0-2/hpf pH: 6.5 WBC: 0-1/hpf epithelial cells: 0-2/hpf Protein: trace Glucose:++ blood: + Reducing Substances:++ amorphous materials: (-) 12/26/06 Urinalysis RBC: 5-10/hpf heat & acetic acid: (+) WBC: 30-40/hpf Bacteria: moderate epithelial cells: 2-5/hpf Protein: 30(++ ) blood: moderate(++) amorphous materials: urates: rare 11/24/06 ECG QRS : bizarre complexes seen in V1, V4 r S R pattern seen in V1, V2 12 – 6 – 06
  • 41. Results Normal Values Calcium = 4.32 mg %↓ 4.6 – 5.16 mg % Sodium = 131 mmol/ L↓ 136 – 142 mmol/L 12/11/06 5:58pm WBC 11.7 k/ul ↓ EOS 1.92 16.4%E↑ HGB 10.5 g/dL↓ HCT 33.5%↓ MCV 62.2 fL↓ MCH 19.4 pg↓ 11/27/06 Gram Staining: Gram (+) cocci in pairs: few/OIF Pus cells: moderate 11/28/06 Smear Culture: Gram (-) rods Culture: Acinetobacter iwoffi Remarks: Sensitivity test result of culture: A.iwoffi KEY ISSUES December 13, 2006 Desired Outcome: Independent Interventions: Within 8 hours of nursing 1. Ineffective airway clearance 1. Auscultated chest, noted presence of intervention, the patient: • will be able to maintain related to excessive secretions and adventitious breath sounds and presence of prolonged immobility 2˚ to secretions patent airway and will be
  • 42. nosocomial pneumonia as R: Provides information regarding inflow through clear from secretions • manifested by presence of the airway and the presence or absence of fluid able to breathe productive cough with whitish mucus obstruction independently without sputum, with rales heard on both 2. Monitored respiratory rate and noted presence Oxygen therapy, lung fields upon auscultation, use of dyspnea, Tachypnea, or reports of air hunger • will manifest clear lung of accessory muscles (subcostal), and use of accessory muscles. sounds restlessness, O2 at 2L/min, noisy R: Tachypnea might further develop to • no longer use of accessory breathing and a culture of gram (-) respiratory distress. muscles in breathing, rods of Acinetobacter iwoffi 3. Observed sputum noting color, odor and • will have a respiratory rate volume within the range of 14- Scientific Basis: R: Normal sputum is clear or gray and minimal; 20cpm Immobilized clients and those on abnormal sputum is green, yellow or bloody, • will no longer manifest bed rest are generally weakened. If malodorous and often copious restlessness and noisy weakness progresses, the cough 4. Maintained a moderate high back rest position, breathing reflex gradually becomes positioned head midline with flexion inefficient. The stasis of secretions R: Lessen pressure on lungs allowing more room Actual Outcome: in the lungs may be life for expansion 12/13/06 threatening for an immobilized 5. Elevated head of bed with the use of pillows. After 8 hours of nursing client since pneumonia can easily R: Stimulates respiratory functioning or lung intervention, the client manifested develop. (Fundamentals of expansion the ff: Nursing, Potter and Perry 6th Ed 6. Provided oral care every four hours • whitish sputum was present pg. 1451) R: Oral care freshens the mouth after respiratory • Strong rales were heard at both secretions have been expectorated lung fields • used accessory muscles for Collaborative Interventions: breathing 1. Suctioned PRN • O2 was on at 2LPM R: Suctioning clears the airway from secretions, • RR was at 16 cpm thus promoting better airway passage. 2. Administered O2 inhalation via nasal cannula 12/18/06 at 2L/min. After 8 hours of nursing R: Maintain adequate O2 supply, and prevent intervention, the client manifested hypoxia. the ff: 3. Administered Salbuterol(Salbutamol) 1/2 neb +
  • 43. • Sputum was present 2cc NSS q 8hrs R: Bronchodilators; relaxes bronchial, uterine and • Strong rales were still heard at vascular smooth muscles by stimulating the beta2 both lung fields receptors • Still used accessory muscles 5. Performed Chest Physiotherapy after for breathing nebulization for 15 minutes • O2 was on at 2LPM R: To encourage loosening and expectoration of • RR was 20 cpm mucus from the respiratory tract through the postural gravity drainage and percussion and 12/19-20/06, 01/03/07 vibrating techniques After 8 hours of nursing intervention, the client manifested the ff: • Minimal rales were heard at both lung fields • Still used accessory muscles for breathing • RR was within normal range • Sputum was present 12/28/06 After 8 hours of nursing intervention, the client manifested the ff: • O2 was out of bedside 01/08-10/07 After 8 hours of nursing intervention, the client manifested the ff: • Strong rales were heard at both lung fields
  • 44. • Still used accessory muscles for breathing • O2 was out of bedside • Sputum was present • RR was within normal range 2. Ineffective breathing pattern Independent Interventions: Desired Outcome: related to neuromuscular 1. Monitored respiratory rate, depth and effort. Within 8 hours of nursing dysfunction and retained R: Dyspnea may be present because of hypoxia interventions, secretions 2˚ nosocomial 2. Auscultated breath sounds, noting crackles on the patient: • will show improved pneumonia as manifested by use both lung fields. of accessory muscles (subcostal), R: Indicates developing complications, increasing respiratory pattern shortness of breath, noisy risk of infection. • will lessen use of breathing pattern and O2 at 2LPM 3. Maintained MHBR position by placing 2 accessory muscles pillows under head when lying down. • have RR within normal SB: The onset of all pneumonias is R: Facilitates breathing by reducing pressure on range 14-20cpm generally marked by any or all of the diaphragm and minimizes risk of aspiration of • Will no longer manifest the following manifestations: secretions shortness of breath and fever, chills, sweats, pleuritic chest 4. Encouraged adequate rest and limit activities noisy breathing pattern pain, cough, sputum production, within client tolerance. hemoptysis, increased in R: Helps limit oxygen needs/consumption. Actual Outcome: respiration, dyspnea, headache, 12/13/06, 12/18-20/06 and fatigue. (Medical-Surgical Collaborative Interventions: After 8 hours of nursing Nursing 6th Edition page 1713 by 1. Suctioned PRN intervention, the client manifested Joyce M. Black) R: Suctioning clears the airway from secretions, the ff: thus promoting better airway passage. • Still used accessory muscles 2. Administered O2 inhalation via nasal cannula for breathing at 2L/min. • O2 was on at 2LPM R: Maintain adequate O2 supply, and prevent • RR was within normal range hypoxia. • Noisy breathing and shortness 3. Administered Salbuterol(Salbutamol) 1/2 neb + of breath 2cc NSS q 8hrs R: Bronchodilators; relaxes bronchial, uterine and
  • 45. vascular smooth muscles by stimulating the beta2 01/03/07, 01/08-10/07 receptors After 8 hours of nursing 4. Performed Chest Physiotherapy after intervention, the client manifested nebulization for 15 minutes the ff: • Still used accessory muscles R: To encourage loosening and expectoration of mucus from the respiratory tract through the for breathing postural gravity drainage and percussion and • O2 was out of bedside vibrating techniques • RR was within normal range • Noisy breathing and shortness of breath was no longer present 3. Risk for Aspiration Independent Interventions: Desired Outcome: Cues: 1. Noted client’s level of consciousness Within 8 hours of nursing • Presence of NGT R: To assess causative/contributing factors intervention, the patient: • will be able to experience 2. Assessed RR • Impaired swallowing R: To assist in correcting factors that can lead to no aspiration as evidenced • Reduced level of aspiration by noiseless respiration, consciousness with the GCS 3. Check gag reflex clear breath sounds of 6 (E-4, M-1, V-1) R: To assist in correcting factors that can lead to • maintain patent airway aspiration The SO: Scientific Basis: 4. Assessed the Glasgow coma scale of the • will follow correct A serious complication associated patient. with enteral feeding is aspiration instructions regarding NGT R: To assist in correcting factors that can lead to of formula into the feeding aspiration tracheobronchial tree. Aspiration 5. Auscultated for gurgling sounds in the stomach of enteral formula into the lungs Actual Outcome: prior to NGT feeding irritates the bronchial mucosa, 12/13, 12/18-20, 01/03, 01/08-10 R: To ensure patency of NGT resulting in decreased blood After 8 hours of nursing 6. Suction client before NGT feeding supply to affected pulmonary intervention, the client manifested R: To prevent aspiration of ingested food tissues. (Fundamentals of Nursing, the ff: 7. Positioned client in a high Fowler’s position • Was positioned at high Potter and Perry 6th Ed pg. 1304) before feeding Fowler’s prior to every NGT R: To prevent aspiration if ingested food feeding and patency of the
  • 46. 8. Instructed SO to maintain the client’s position NGT was checked • No aspiration occurred 30mins-1hour after feeding R: To prevent aspiration if ingested food The SO: 9. Maintained O2 tank and suction machine at • positioned the client at high bedside Fowler’s 30mins-1hour after R: A client with aspiration needs immediate every NGT feeding as suctioning and oxygenation instructed by the student nurse 10. Taught SO the proper way and the nursing considerations on how to perform NGT feeding O2 tank and suction machine R: To equip the SO of the client with knowledge remained at bedside and skills in preparation for the home care of the client 4. Ineffective tissue perfusion Independent Interventions: Desired Outcome: cerebral related to impaired flow 1. Determined the presence of altered mental Within 8 hours of nursing of oxygento the brain manifested status intervention the patient: • will demonstrate increased by changes in motor and sensory R: To assess for any alterations responses, altered mental status, 2. Assessed Glasgow Coma Scale perfusion as manifested by GCS of 6 (E-4, M-1, V-1), R: To assess for any alterations balanced intake or output decorticate, changes in motor 3. Elevated head of bed at 30-45° and alert mental state response R: To promote circulation or venous drainage 4. Monitored input and output Actual Outcome: Scientific Basis: R: Alterations may lead to hypovolemia or 12/13/06, 12/18-20/06, 01/03/07, The relationship between vascular engorgement 01/08-10/07 ventilation and perfusion After 8 hours of nursing determines the efficiency of gas Collaborative Interventions: intervention, the client manifested exchange. Hypoxia, resulting 1. Administered Citicoline (Somazine) the ff: from underventilation of an R: CNS stimulant; it produces CNS stimulation • Balanced intake or output alveolar region, causes by increasing level of neurotransmitters in the vasoconstriction, which redirects CNS. Produce CNS stimulation and respiratory 12/18-/20/06 blood to well-ventilated alveoli. stimulation dilated pupils, increase motor activity After 8 hours of nursing (Medical Surgical Nursing, Black, and mental alertness, and a diminished sense of intervention, the client manifested 6th Edition, p 1621) fatigue. the ff:
  • 47. • GCS of 10 (E-4, M-5, V-1) 01/03/07, 01/08-10/07 After 8 hours of nursing intervention, the client manifested the ff: • GCS of 11 (E-4, M-6, V-1) 5. Total urinary incontinence Independent Interventions: Desired Outcome: related to neuromuscular limitation 1. Palpated bladder Within 8 hours of nursing as manifested by continuous flow R: To assess for bladder distention intervention the SO: • will be able to demonstrate of urine at unpredictable times, 2. Provided alternate warm and cold compress lack of perineal or bladder filling R: To initiate voiding behavior and techniques to awareness and unawareness of 3. Inspected skin for rashes or redness mange condition and to incontinence R: To note alterations in the skin integrity prevent complication 4. Instructed SO to change the patient’s diapers Scientific Basis: regularly every 4 hours or as needed Actual Outcome: Urinary incontinence has been R: To prevent occurrence of infection and rashes 12/13, 12/18-20, 01/03, 01/08-10 defined as a condition in which 5. Instructed SO to wash perineum with mild soap After 8 hours of nursing involuntary loss of urine is a social and to pat dry before changing into a new set of intervention, client manifested the or hygienic problem and is diaper ff : objectively demonstrable R: To avoid irritation • No rashes (Medical Surgical Nursing, Black, • Dry and scaly perineal area 6th Edition, p 833) the SO: • was diligent in changing the diaper of the client every 4 hours and as needed 12/18/06 Independent Interventions: Desired Outcome: 6. Disturbed sleeping pattern 1. Provide a room with adequate ventilation Within 8 hours of nursing related to urinary incontinence as R: To promote comfortable an environment intervention, patient: • will be able to sleep well manifested by waking up between conducive for sleep and rest sleep, irritability, restlessness as 2. Maintained proper positioning and gain adequate rest
  • 48. verbalized by S.O. R: To lessen discomfort and promote sleep periods 3. Provided comfort measures such as pillows and The S.O.: • will be able to identify Scientific Basis: blankets (washing hand/face, cleaning and A number of factors affect the straightening sheets) individually appropriate quantity and quality of sleep. R: These relaxes patient and promotes sleep interventions to promote Often a single factor may not be 4. Instructed S.O. to change the clients diaper sleep. the only cause for a sleep problem. before sleeping. Physiological, psychological and R: To promote a restful and continuous sleep Actual Outcome: environmental factors can alter the 5. Instructed S.O. to occasionally check the 12/18/06 quality and quantity of sleep. client’s diaper. After 8 hours of nursing (Fundamentals of Nursing 5th Ed R: To prevent infection intervention, the client manifested Vol. 2 by Potter and Perry pg. 6. Provided a restful environment the ff: 1260) R: Quiet, restful environment is conducive for • Enough rest was afforded sleep. • Was able to have a peaceful 7. Encouraged enough rest and restful sleep during the R: To prevent fatigue day 7. Impaired physical mobility Independent Interventions: Desired Outcome: related to decreased muscle 1. Provided adequate resting periods Within 8 hours of nursing strength, neuromuscular R: to reduce fatigue intervention, the patient: • Will be assisted by his S.O. impairment as manifested by 2. Instructed use of side rails, roller pads and limited ROM, difficulty in turning, pillows in performing activities of uncoordinated and jerky R: For position changes or transfers that can daily living, especially self movements and muscle strength of provide safety care activities. 1/3 on four extremities. 3. Identified energy conserving techniques like placing essential things at bedside Actual Outcome: Scientific Basis: R: Limits fatigue, maximizing participation. 12/13/06, 12/18-20/06, 01/03/07, People who have impaired 4. Asked S.O to be at patient’s side all the time 01/08-10/07 mobility due to paralysis, muscle R: to aid the patient in doing ADL’s After 8 hours of nursing weakness, and poor balance or 5. Turned to sides every two hours. intervention, the client manifested coordination are obviously prone R: To prevent the occurrence of bed sores the ff: to injury (Fundamentals of 6. Placed pillows in between client’s knees and • was assisted by the SO in his Nursing, Kozier, 7th Edition, bony prominences. activities of daily living
  • 49. p.670) R: To prevent the occurrence of bed sores especially self care activities • Passive exercises were 7. Performed passive exercises. R: To promote blood circulation and venous performed return 01/03/07, 01/08-10/07 8. Instructed S.O. on the proper way in turning After 8 hours of nursing the client to side and to perform passive ROM intervention, the client : R: To prevent injury • Enjoyed wheel chair ride at 9. Encouraged wheelchair rides least once a day. R: To promote blood circulation 10. Assisted the S.O. in transferring the patient to the wheelchair and vise versa. R: To avoid accidents and prevent injury 11. Assisted the S.O. in performing self care activities for the patient. R: To avoid accidents and prevent injury Collaborative Interventions: 1. Administered Sodium Bicarbonate gr X one tab TID/ NGT R: Anti-ulcer agents; acts as an alkanizing agent by releasing bicarbonate ions, capable of neutralizing gastric acid 8. Total self-care deficit: bathing, Independent Interventions: Desired Outcome: dressing, feeding, toileting related 1. Determined the individual strengths and skills Within 8 hours of nursing to neuromuscular impairment as of the patient. intervention, the patient: • will be able to perform manifested by inability to R: to asses the degree of disability chew/swallow food, inability to 2. Established a contractual partnership with SO self-care activities within get in and out of bathroom, wash R: To develop a teamwork between the nurse and level of own ability body parts, put on or take off the SO • maintain proper hygiene clothing, maintain appearance at 3. Promoted SO participation in problem with minimal support and satisfactory level, go to toilet or identification and decision making supervision. commode and carry out proper R: To involve the SO in the self care regimen of toilet hygiene, wearing of diaper at the patient Actual Outcome: all times 4. Performed self care activities to the patient 12/13/06, 12/18-20/06, 01/03/07,
  • 50. such as bed bath, oral care, changing the client’s 01/08-10/07 Scientific Basis: diapers and clothes After 8 hours of nursing Clients with physical or cognitive R: To promote proper hygiene and a sense of well intervention, the SO: • Assisted by the student nurse, impairments need assistancewith being all or some aspects of the personal 5. Taught the SO the importance of providing self performed bed bath, oral care, hygiene. Assessment of the care to the patient perineal care and changing of client’s physical and cognitive R: To motivate the SO to perform self care clothes of the patient status determines specifically what activities to the patient aspects of hygiene care can be 6. Instructed SO to use long circular strokes when performed independently, those performing bed bath to the client that require some assistance, and R: To promote blood circulation those that require total assistance. 7. Instructed SO to turn patient’s head to side (Fundamentals of Nursing by when performing oral care to the patient Perry and Potter 6th ed. Pg. 1014) R: To prevent aspiration 8. Instructed SO to change the patients diaper every 4 hours or as needed R: To prevent the occurrence of infection and rashes 9. Instructed SO to thoroughly clean client’s perineal area with mild soap R: To prevent the occurrence of irritation 10. Instructed SO to pat dry perineal are before changing into a new set of diaper R: Bacteria thrives on places with moisture 11. Instructed SO to inspect perineal area regularly for redness/irritation R: To note alteration in skin integrity 12. Instructed SO to take note of safety measures when performing self care activities such as making sure the floor is dry after giving a bed bath R: To prevent occurrence of injury 13. Taught SO proper body mechanics when
  • 51. changing the client’s clothes R: To prevent occurrence of injury 14. Identified energy-saving behaviors R: To prevent fatigue 15. Acknowledged progress and identified needed changes on how the SO renders self care to the patient R: To motivate the SO in giving care to the patient 16. Provided privacy during personal care activities. R: to maintain patient’s personal dignity and rights. 17. Modified activities or environment. R: to reduce risk of injury. 18. Kept personal belongings within reach. R: to have an easy access. 9. Impaired skin integrity related Independent Interventions: Desired Outcome: to physical immobilization 1. Inspected skin in daily basis Within 8 hours of nursing manifested by bedsores at the R: To assess for occurrence of infections or any intervention, the patient • will display timely wound inner left ankle and the outer right unusualities ankle. 2. Monitored laboratory studies, CBC and healing of bed sores electrolytes. without complication Scientific Basis: R: for changes indicative for wound healing or the S.O. The increased risk for skin infection. • will verbalize breakdown is related to changes in 3. Noted general debilitation, reduced mobility, understanding of the health aging skin and to situations that presence of incontinence/problems with self care. teachings given. arise in the acute care setting such R: To be aware of the risk factors of the patient as immobility, incontinence and 4. Noted changes in skin color, texture and turgor. Actual Outcome: malnutrition. (Fundamentals of R: To assess alterations in the skin integrity 12/13/06, 12/18-20/06, 01/03/07, Nursing, Potter and Perry 6th Ed 5. Turned to side every two hours. 01/08-10/07 pg. 225) R: To prevent bedsores and to enhance blood After 8 hours of nursing circulation intervention, the ff. was
  • 52. 6. Taught S.O. the significance of turning the manifested: • The client was turned to side patient to side and nature of bed sore. R: To supplement the SO with the knowledge every 2 hours regarding the procedure • Pillows were places between 7. Performed passive range of motion exercises bony prominences every 2 hours for 15 minutes • Bed linens were changed every R: To enhance proper blood circulation 3 days 7. Instructed S.O. the proper way to perform • Proper skin care was passive ROM such as supporting the joints and performed doing it every two hours for 15 minutes. R: To prevent injury 12/13/06, 12/18-20/06 8. Kept linens clean and dry at all times After 8 hours of nursing R: Bacteria thrives in places where moisture is intervention, the client manifested present the ff: 9. Change linens regularly. • A reddish, grade 2 bedsore, R: To prevent spread of microorganisms and half inch in diameter, infection circular in form was noted 10. Avoided frequent friction between client skin on the left inner ankle and rough linens. • A reddish, grade 2 bedsore, R: Constant friction increases the risk for bed two inches in diameter, sores circular in form was noted 11. Provided appropriate skin care such as 1 inch above the right outer performing bed bath. ankle R: To promote proper hygiene of the patient 12. Placed pillow in between bony prominences 01/03/07, 01/08-10/07 of the client. After 8 hours of nursing R: To prevent occurrence of bed sores intervention, the client manifested 13. Changed the patient’s diapers every four the ff: hours/as needed. • A whitish, grade 2 bedsore, R: To prevent occurrence of infection and half inch in diameter, irritation circular in form was noted 14. Encouraged foods rich in Vitamin C and on the left inner ankle protein such as fish, meat eggs, oranges. • A reddish, grade 2 bedsore,
  • 53. R: Provides a positive nitrogen balance to aid in one inch in diameter, healing and to maintain general good health. irregular in form was noted 15. Provided a safe and therapeutic environment. 1 inch above the right outer R: Provides comfort ankle 16. Kept skin free from pressure R: Promotes circulation and prevents ischemia 01/08-10/07 After 8 hours of nursing Collaborative Interventions intervention, the client manifested 1. Administered Calmoseptine to bedsores the ff • A reddish, grade bedsore, BID 2. Administered Novalucid to bedsores q8H 2cm in diameter, circular in form was noted on the left outer ankle 10. Risk for injury: Falls Independent Interventions Desired Outcome: Cues: 1. Always made sure that the bed is against the Within 8 hours of nursing • Decreased muscle strength wall. interventions, patient will be free R: To prevent accidental falls from falls and injury, and SO will • Muscle strength of 1/3 on all 2. Secured position of patient on bed, raised side understand the importance of four extremities. rails at all time. safety measures and demonstrate • Reduced level of R: To prevent accidental falls modification in the behavior and in consciousness. 3. Kept pillow at both sides of the patient. the environment to reduce risk • Impaired physical mobility R: To support the patient to prevent from falling factors and to enhance safety. • Absence of side rails 4. Instructed S.O. to always ask for assistance • History of falls when transferring clients from the bed from the Actual Outcome: wheelchair and vise versa. 12/13/06 Scientific Basis: R: To avoid accidents and prevent injury After 8 hours of nursing Prevention of falls in health care 5. Stayed at bedside and observed for any intervention, the ff. was agencies is an ongoing concern. unusualities. manifested: Health care environments are • Side rails were absent R: To detect any signs of injury or deviations. designed with many safety 6. Instructed S.O. to keep floor free from clutter. • The client was free from features to reduce the risk of falls.. R: To avoid accidents falls (Fundamentals of Nursing, Potter • SO constantly stayed at and Perry 6th Ed pg. 680)
  • 54. Collaborative Interventions: clients bedside 1. Calcium Salts (Caltrate) 2 tabs TID/NGT R: Mineral and electrolyte supplement or 12/18-20/06, 01/03/07, 01/08- replacement; Essential for bone formation and 10/07 blood coagulation. Maintain cell membrane and After 8 hours of nursing quality permeability intervention, the ff. was manifested: • The client was free from falls • Side rails were placed and were raised at all times • SO constantly stayed at clients bedside 11. Risk for Suffocation Independent Interventions: Desired Outcome: Cues: 1. Noted presence of external factors in the Within 8 hours of nursing • Decreased muscle strength individual situation intervention the SO: • will verbalize knowledge R: To take note of causative factors • Pillows propped on the bed 2. Note factors that have potential to compromise of hazards of the • Reduced motor abilities airway or affect ability to swallow environment and correct • Restlessness R: To take note of causative factors hazardous situations to • Presence of O2 tank and 3. Position client appropriately prevent/reduce risk of suction machine at bedside R: To maintain airway suffocation 4. Properly fixed bed linens and pillows on the Scientific Basis: client’s bed Actual Outcome: Suffocation or asphyxiation, is R: To reduce risk of accidental 12/13/06, 12/18-20/06; 01/03/07, lack of oxygen due to interrupted suffocation/strangulation 01/08-10/07 breathing. Suffocation occurs 5. Instructed SO to always stay at client’s bedside After 8 hours of nursing when the air source is cut off for R: To reduce risk of accidental suffocation intervention, the client manifested any reason. the ff: (Fundamentals of Nursing, Potter • There was no occurrence of and Perry 6th Ed pg. 685) suffocation. • O2 and suction machine was at bed side.
  • 55. • Pillows and bed linens were properly arranged in bed. The S.O stayed with the client at all times. 12/18/06 After 1hour of nursing intervention, the SO: • verbalized “oo! Talagang binabantayan namin siya buong araw at gabi” 12. Delayed growth and Independent Interventions: Desired Outcome: development related to physical 1. Determined existing conditions contributing to Within 8 hours of nursing disability and neuromuscular growth/developmental deviation such as physical intervention the patient : • will not show any decline dysfunction manifested by disabilities and diminished intellectual capacity inability to perform self R: To know the causative/contributing factors of growth and stagnation care/activities appropriate for age, 2. Identified present developmental age or stage of development loss of previously acquired skills, and noted non-verbal cues of the client • portray improvement in decrease responses, inability to R: To know the appropriate interventions needed his motor, perform motor, social/expressive for the client and to note deviations from growth social/expressive skills skills typical of age group and development norms 3. Performed passive exercise Actual Outcome: Scientific Basis: R: To enhance muscle tone/strength 12/13/06, 12/18-/20/06 Developmental changes tend to be 4. Referred family for physical/occupational After 8 hours of nursing associated with immobility in the therapy intervention, the client manifested very young and in older adults. R: To assist the client in regaining his previous the ff: (Fundamentals of Nursing, Potter motor, sensory and expressive skills • was confined in his bed for the and Perry 6th Ed pg. 1432) 5. Encouraged the S.O to keep on talking to the whole day client about things he used to do. • needed assistance in his R: To constantly provide stimuli to prevent activities of daily living degeneration of the client’s senses
  • 56. 6. Oriented client to time and place 01/03/07, 01/08-10/07 R: To make the client aware of what is happening After 8 hours of nursing around him: intervention, the client 7. Informed the client of the procedures being manifested the ff: • was able to go out on performed R: To reduce the patient’s anxiety wheelchair rides at least once a 8. Encouraged the use of non-verbal day communication such as touch and smells • needed assistance in his R: To enhance effective communication activities of daily living 13. Impaired verbal Independent Interventions: Desired Outcome: communication related to 1. Used short and simple words when speaking to Within 8 hours of nursing alteration of CNS manifested by the client intervention, the patient, SO and inability to speak R: To assist client to establish a means of health care givers will be able to communication to express needs, wants, ideas establish a method of Scientific Basis: and questions communication in which needs can Any disorder that impairs 2. Maintained a calm, unhurried manner be expressed cognitive functioning may affect a R: Allows the patient ample time to express his client’s ability to use and needs Actual Outcome: understand language. These 3. Noted non-verbal cues of the patient 12/13/06, 12/18-20/06, 01/03/07, clients may develop total loss of R: To anticipate what the client needs and to 01/08-10/07 speech, impaired articulation, or promote therapeutic communication After 8 hours of nursing the inability to find or name 4. Oriented the patient to time, place and person intervention, the client: • Was oriented to time, place, words. (Fundamentals of Nursing, R: This makes the client aware of what is Kozier 7th Edition pg. 195) happening around him person and procedure that was 5. Introduced oneself to the client upon entering performed the room R: This makes the client aware of what is The SO’s and the members of the happening around him health care team: 6. Informed the client of the procedures being • used nonverbal cues like performed touch when communicating R: To reduce anxiety of the patient as well as the with the patient SO • have developed an
  • 57. 7. Encouraged SO to use non-verbal understanding of the patient’s communication such as touch when interacting non-verbal cues with the client R: To develop therapeutic communication 8. Maintained eye contact when communicating with the client R: To develop therapeutic communication 9. Anticipated needs until an effective communication is reestablished R: To provide necessary health care to the patient 10. Reduced environmental stimuli R: To reduce anxiety 11. Established therapeutic relationship with the client R: To gain the client’s trust 14. Interrupted family processes Independent Interventions Desired Outcome: related to illness and 1. Identify the family developmental stage Within 8 hours of nursing hospitalization of patient and R: To note baseline data intervention the SO: • Will express feelings situational crisis as manifested by 2. Deal with family members in a warm, caring change in roles, stopping of school and respectful way understanding of illness of the patient’s eldest son R: To make the family comfortable and enhance and appropriately rapport with the family verbalize, treatment Scientific Basis: 3. Recognized family concern and need for regimen and prognosis Illness of a family member is a information and support crisis that affects the entire family R: Sufficient knowledge and awareness provide Actual Outcome: system. The family is disrupted as feeling of competence 12/13/06, 12/18-20/06, 01/03/07, members abandon their usual 4. Developed therapeutic relationship with the 01/08-10/07 activities and focus their energy on family After 8 hours of nursing restoring family equilibrium. R: To gain the trust and confidence of the family intervention, the ff. was Roles and responsibilities 5. Maintained open communication between manifested: previously assumed by the ill family and health care providers • Therapeutic relationship was person are delegated to other R: Open communication ensures accuracy of data developed between the student
  • 58. family members, or those gathered nurses and the family • The patient’s son verbalized functions may remain undone for 6. Encouraged verbalization of feelings the duration of the illness R: To facilitate ongoing problem solving his feelings openly regarding (Fundamentals of Nursing, Kozier 7. Stressed importance of open communication having to missed school to 7th Edition pg. 195) between family members take care of his father “Okay R: To facilitate ongoing problem solving lang kung nandito ako para 8. Encouraged use of stress managing techniques mag alaga sa kanya kasi R: To reduce stress and anxiety babalik din naman ako para sa periodical test nami.” DISCHARGE PLAN Medications Advised SO to let patient take the ff medications on the right route, time and dosage; and to know the adverse reactions, actions, contraindications, and nursing considerations:  Caltrate 2 tabs three times a day/ nasogastric tube  NaHCO3 grain X 1 tab three times a day/ nasogastric tube  Lactulose (Duphalac) 30cc once a day/ nasogastric tube q HS  Salbutamol Nebulization every 8 hours with chest tapping ( ½ neb + 2ml NSS)  Bactidol gargle three times a day  Calmoseptine cream two times a day. Apply to bedsores Environment 1. Instructed SO to keep environment clean at all times 2. Instructed SO to keep sharp objects away from the client. 3. Instructed SO to keep bed linen free from crumbs, irritants and dirt.
  • 59. Treatment 1. Encouraged SO to enroll the client in speech therapy, physical therapy and occupational therapy. 2. Stressed the importance and reminded SO about follow-up check-up. Observable signs and symptoms: Instructed SO to have medical assistance from a medical provider whenever the patient experiences the following signs and symptoms are observed: Fever  Shortness of breath  Cough that produces yellow, green, or gray sputum   Weakness  Discomfort of muscles  Muscle cramps Health Teachings 1. Emphasized to the SO the importance of turning the patient to sides 2. Instructed SO to observe the skin for redness, discoloration and edema. 3. Instructed the SO to place pillows in between bony prominences of the client. 4. Emphasized to the SO the importance of performing passive range of motion exercises. 5. Instructed the SO proper techniques in performing passive range of motion exercises. 6 . Instructed SO to perform bed bath to the client daily. 7 . Instructed SO to thoroughly dry the skin after bathing the client.. 8 Instructed SO to perform oral hygiene to the client three times a day. 9 Instructed SO to turn the client’s head to side when performing oral hygiene, to prevent aspiration. 10.Instructed SO to perform perineal care at least twice a day and as needed. 11.Instructed SO to regularly change the diapers at least every 4 hours or as needed. 12. Instructed SO to stress on proper hand washing before and after feeding, and before and after patient contact, to decrease the spread of organisms causing infection. 13. Instructed and showed SO how to feed patient via nasogastric tube
  • 60. Spirituality Instructed SO to nurture a therapeutic and harmonious relationship with the Lord by going to mass every Sunday and praying every day DRUG STUDY Kalium Durule C : Mineral , Electrolyte Supplements A : maintain acid.base balance, prevents deficiency I : prevention and ttt of K depletion CI: severe tissue trauma, hyperkalemia, renal impairement, diabetes mellitus AR: weakness, confusion, irritation at IV site, nausea, vomiting, dizziness, flatulence PT: a. Caution episodes of falling asleep, and to avoid activities requiring alertness b. Change position slowly to minimize hypotension c. Avoid salt substitution Piperacillin/Tazobactam (tazocin) 2.25gm IVTT q 8H C: anti-infectives A: Binds to bacterial cell wall membrane, causing cell death. Inhibits beta-lactamse, an enzyme that can destroy penicillins I: Treatment of infections of the: Skin and skin structures, respiratory tract, intra-abdominal infections CI: Hypersensitivity to penicillins or tazobactam, AR: confusion, arrythmias, rashes, nausea, hypersensitivy reactions PT: a. Instruct to notify health care professional immediately if fever and diarrhea occur, especially if stool contains blood, pus or mucus. Advised not to treat with diarrhea without consulting health care professionals b. Advise to report signs of superinfection (furry overgrowth on tongue, loose and foul smelling stools) and allergy diphenoxylate/atropine (Lomotil) 1 tab C: Antidiarrheals A: Inhibits excess gastrointestinal motility to subsequently decrease diarrhea I: Adjucntive therapy in the treatment of diarrhea
  • 61. CI: hypersensitivity, dehydrated patients, known alcohol intolerance AR: dizziness, confusion, constipation, dry eyes and mouth, nausea, vomiting, tachycardia PT: a. Caution to avoid activities requiring alertness b. Advise that frequent mouth rinses, good oral hygiene, and sugarless gum or candy may relieve dry mouth c. Caution to avoid alcohol and other CNS Depressants concurrently with medication d. . Instruct to notify health care professional if diarrhea persists or if fever, abdominal pain, or palpitations occur citicoline (Somazine) 500mg i cap BID/ nasogatsric tube C: Central Nervous System Stimulants A: Produce CNS stimulation by increasing levels of neurotransmitters in the CNS. Produce CNS and respiratory stimulation, dilated pupils, increased motor activity and mental alertness, and a diminished sense of fatigue I: CVD in acute & recovery phase, symptoms & signs of cerebral insufficiency (eg dizziness, memory loss, poor concentration, disorientation, recent cranial trauma) CI: hypersensitivity AR: GI disorders PT: a. Advise to avoid intake of large amounts of caffeine b. Caution to avoid activities requiring alertness c. Instruct not to alter dose, since medication have high dependence and abuse potential d. Inform that periodic holidays from the drug may be used to assess progress and decrease dependence fluoroquinolones (Ciprofloxacin) 500mg 1 ½ tab BID/NGT C: Anti-infectives A: Inhibits bacterial DNA synthesis by inhibiting DNA gyrase to cause the death of a susceptible bacteria I: Treatment of Infections of the: Respiratory tract, skin and skin structures, boines and joints, hospital acquired and intra-abdominal infections CI: Hypersensitivity, photosensitivity AR: dizziness, drowsiness, headache, insomnia, abdominal pain, nausea, photosensitivity PT: a. Encourage to maintain a fluid intake of at least 1500-2000ml/day b. Caution to avoid alert requiring activities c. Caution to use sunscreen and protective clothing to prevent phototoxicity reactions d. Instruct to notify health care professional immediately if rash or tendon pain or inflammation occurs. Sodium Bicarbonate (NaHCO3) C: Anti-ulcer agents
  • 62. A: Acts as an alkanizing agent by releasing bicarbonate ions, capable of neutralizing gastric acid I: Antacid, management of metabolic acidosis CI: excessive chloride loss, antidote following ingestion of strong mineral acids AR: flatulence, gastric distention, sodium and water retention PT: a. Advise not to take milk products concurrently with this medication. Renal calculi or hypercalcemia (milk-alkali syndrome) may result b. Emphasized importance of regular follow up examinations to monitor serum electrolyte levels, acid base balance, and to monitor progress. c. Advise patient on sodium-restricted diet to avoid use of baking soda as home remedy for indigestion. lactulose (Duphalac) 30cc OD/NGT C: Laxatives A: Increases water content and softens the stool relieving constipation I: Treatment of chronic constipation CI: Patients on low-galactose diets, diabetes mellitus, excessive or prolonged use AR: belching, cramps, distention, flatulence, diarrhea, hyperglycemia (diabetic patients) PT: a. Encourage to use other forms of bowel regulation:  Increase bulk in diet  Increase fluid intake  Increase mobility b. Caution about prolonged use, may cause electrolyte imbalance Bactidol Gargle TID by H2O C: Oral Antiseptic A: Protective action that kills bacteria, forming decay acid I: To prevent infection and provide relief CI: not indicated AR: not indicated PT: a. Swish and gargle for 30 seconds to ensure affectivity clindamycin 300mg 1cap q 6H/NGT C: Anti-infectives A: Inhibits protein synthesis in susceptible bacteria. I: Treatment of infections of the: Skin and skin structures, respiratory tract, intra-abdominal infections
  • 63. CI: hypersensitivity, known alcohol intolerance AR: dizziness, headache, bitter taste, nausea, vomiting PT: a. Instruct to notify health care professional immediately if diarrhea, abdominal cramping, fever, bloody stools occu. Inform not to treat with antidiarrheal without consulting health care professionals. b. Advise to report signs of superinfection (furry overgrowth on tongue, vaginal or anal itching or discharge) c. Instruct to notify health care professional if no improvement within a few days Albuterol (Salbutamol) ½ neb. + 2cc NSS q 8H C: Bronchodilators A: Relaxes bronchial, uterine and vascular smooth muscles by stimulating the beta2 receptors. I: To control and prevent airway obstruction. CI: hypersensitivity, excess inhaler use may lead to tolerance AR: neravousness, restlessness, tremors, headache, chest pain, palpitation, nausea, vomiting PT: a. Instruct to notify health care professional if shortness of breath is not relieved by medication or is accompanied by diaphoresis, dizziness, palpitations or chest pain. b. Caution not to overdose; it may loss effectiveness of the medication c. Advise to rinse mouth with water after inhalation dose to minimize dry mouth Calcium Salts (Caltrate) 2tabs TID/NGT C: Mineral and electrolyte supplement or replacement A: Essential for bone formation and blood coagulation. Maintain cell membrane and capillary permeability. Act as an activator in the transmission of nerve impulses and contraction of cardiac, skeletal and smooth muscles. I: Treatment and prevention of hypocalcemia CI: hypercalcemia, renal calculi AR: tingling, cardiac arrest, arrythmias, bradycardia, nausea, vomiting, calculi PT: a. Caution not to administer with milk products, may lead to milk-alkali syndrome b. Advise to avoid excessive use of tobacco or beverages containging alcohol or caffeine c. Encourage to maintain a diet adequate in vitamin D such as milk and dairy products, oysters, spinach cream soup, tofu. Esomeprazole 40 mg IVTT OD C: Antiulcer drug A: Binds to an enzyme on gastric paritela cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen I: GERD: including erosive esophagitis
  • 64. CI: hypersensitivity, lactation AR: headache, abdominal pain, constipation, diarrhea, dry mouth, flatulence, nausea PT: a. Instruct patient to take medication as directed for the full course of therapy, even feeling better b. Advise patient to avoid alcohol, products containing aspirin or NSAIDS, and foods that may cause an increase in GI irritation c. Advise patient to report onset of black tarry stools; diarrhea; abdominal pain or persistent headache Diatabs 1 tab C: Antidiarrheal I: Bacterial or protozoal diarrhea and enteritis brought by susceptible organisms CI: Bowel obstruction, AR: Headache, GI upset, acute hemolytic anemia PT: a. Caution to avoid activities requiring alertness b. Advise that frequent mouth rinses, good oral hygiene, and sugarless gum or candy may relieve dry mouth c. Caution to avoid alcohol and other CNS Depressants concurrently with medication d. Instruct to notify health care professional if diarrhea persists or if fever, abdominal pain, or palpitations occur Calmoseptine C: Skin Protectives I: protects, soothes and helps promote healing in those with impaired skin integrity.