At the end of the case presentation the participants willbe able to practice excellent nursing care in managingpatients with cryptococcal meningitis. Specifically, thiscase presentation aims that the participants will be ableto:Discuss the global statistics of cryptococcalmeningitis and how infrequent the disease is.Discuss the pathophysiology of the disease.Identify the signs and symptoms of cryptococcal meningitis.Enumerate common and emergency medical and nursingmanagement of patients with cryptococcal meningitis.
efinition of termsdCryptococcoal MeningitisAn infectious disease of worldwide distribution causedby the fungus, Cryptococcus neoformans. Thefungus primarily attacks the lungs, causing torulomas,but produces few or no symptoms referable to thelungs.This may occur as an opportunisticinfection in those suffering from AIDS
efinition of termsd(Cryptococcal Antigen LatexAgglutination System)Determinative test for cryptococcusinfectionsCALASD-DimerConfirms that both thrombin generationand plasmin generation have ocurred
Name:Age:Sex:Address:Civil status:Nationality:Occupation:Religion:R.L.64 years oldMaleMolo, Iloilo CityMarriedFilipinoNoneRoman CatholicInformationPatient
Usual Health Status- The client did notundergo regular check-up. He wasnot sickly, he was never hospitalized.AChronological Story/History of Present Illness>Morning prior to admission, patient complained offever and chills associated with headache, patientsought consult to a private physician and was givencotrimoxazole.> 4 hours prior to admission, patient experiencedpersistence of above signs and symptoms. This time itwas associated with stiffening of extremities andupward rolling of eyeballs. The said eventsmade the family seek medical help and brought Mr. L tothe ER of GSIH-TMCI at 7pm of August 5, 2011.B
Past Medical HistoryNo previous hospitalization or consultation toa health care provider . Mr. L had chicken poxand mumps when he was a child, illness weremanaged at home. Mr. L has no known allergies.Fever, flu and cough were also experienced but noconsultation was made as claimed, dates were notspecified.Family Medical HistoryOn his paternal side, hypertension ran within theirblood and Diabetes mellitus is common on hismaternal side. No incidence of infection notedwithin the immediate family such as pneumoniaand tuberculosis as claimed.Source: M.L. (Mr. L’s son)CD
Activities of Daily LivingNutrition: Mr. L ate at least 3 times a day. Mr. Lpreferred to eat rice, 1-2 cups per meal, with meatsuch as beef, pork and chicken, with variety ofvegetables. He usually drinks at least 6-8 glasses ofwater per day. Intake of caffeinated beverages was alsonoted, he consumed a cup of coffee per day atbreakfast.Sleep and Rest: Mr. L usually sleeps around 9pm, with5-6 hours of sleep per day. Sleeping problems werereported such as occasional snoring and easily awaken.Bowel and Elimination: Mr. L usually defecates everyday to a formed to mushy stool. Occasional eliminationproblem such as constipation was also noted but wasmanaged by increasing oral fluid intake and eatingfruits. Mr. L voids frequently with no difficulty asclaimed.E
Activities of Daily LivingHygiene: Mr. L usually takes a bath daily and does oralcare at least twice a day.Leisure/Recreation: Mr. L was unemployed and spentmost of his time at their house. Mr. L exercised at leasttwice a week for 10-20 minutes by jogging or briskwalking. Mr. L was also fond of taking care of pigeons.He owned a flock of pigeons that reside at theirrooftop way back 2 years ago. He usually fed them inthe morning.E
did youKnowthatAfter age 30,the brain shrinksa quarter of a percent (0.25%)in mass each year.?
General Appearance:Patient was considered to be obese class 1 asassessed according to standard body mass index. Hehas unkempt appearance. He has no verbal output. Uponadmission Mr. L.R was restless. VS: T- 39.5, PR- 95 bpm, RR- 35cpm, BP- 200/90 mmHg. Ht: 160 cm, Wt: 87 kgsIntegumentary System:Has fair complexion noted. Has no presence of edema on skin. Hasno lesions noted. Skin warm to touch. Flushing noted all overthe face and chest. Diaphoretic. Has an intact epidermisfingernails and toenail beds are pinkish in color, smooth and normaldegree of blanching less than 2 seconds.
CNS: GCS-6, pupils aresluggish, with seizureepisode, with Midazolam drip 20mg in 100 cc PNSS @ 10mgtts/minCVS: HR- 95 bpm, SBP- 160-200 mmHg, consistentlyhypertensive, with AC drip of D5W 500cc+2 ampsApresoline+2 amps Clonidine Hcl @ 10 mgtts/min titrateincrements by 5 mgtts/min to maintain SBP- 130 mmHg.
RESPI: With Mechanicalventilator setting: AC- Mode, Fi02-100%, TV- 450, PFR- 50, BUR-20, patentand intact, with O2 saturation of99%, and respiratory secretionsnoted, (+) crackles.GI: Diet: OTF at 1000 kcal/day 1:1 dilutiondivided in 6 equal feedings, abdomen issoft, (+) bowel movement, 14 bowelsounds heard on all quadrants ofabdomen.
ENDO: with the CBG result of81 mg/dl-(8/5/11, 7:06 pm)GU: with adequate urinary output,with yellowish colored urine, withfoley catheter attached to urobag
Upon admission, thepatient has the followingtemperature - 39.7degrees celsius, CR - 95bpm, RR – 35 bpm, BP –190/80 mmHg patientwas managed as a caseofunder the service of Dr.G.L.
He was managed withCiticoline IV, Mannitol,Paracetamol IV,Ceftriaxone, IV, DiazepamIV, Azithromycin,Metronidazole IV, Keppraand in MechanicalVentilator Support. Hewas then transferred toICU for furthermanagement and workups. Patient wasmonitored closely.
Upon admission inthe ICU, there isDecreased insensorium ,no eye opening, noverbal response anddecorticate, and focalseizure noted,Diazepam 5 mg IVTTQ6h and Midazolamdrip x 5 mgtts/min asordered until the 2ndday.
Increased BPnoted,, he hasa AC drip started at10 mgtts/mintitrated incrementsby 5 mgtts/min tomaintain SBP 130mmHg, as ordered
Date Examination Normal Value Result8/6/11 Fasting Blood Sugar 3.9-6.4 mmol/L 8.03Uric Acid 214-488 umol/L 576LDL Cholesterol Less than 3.4 mmol/L 2.02HDL Cholesterol Greater than 0.9mmol/L0.68Triglycerides Up to 2.3 mmol/L 1.42Cholesterol (total) Up tp 5.2 mmol/L 3.34FBS, uric acidLipid Profile
Date Examination Normal Value Result8/9/11 HBA1C 4.20-6.20 % 6.3DIABETICGood Control: 5.5-6.8%Fair Control: 6.8-7.6%Poor Control: above 7.6 %HBA1C
Date Examination Normal Value Result8/10/11 Total Protein 63-83 g/L 65Albumin 32-52 g/L 29Globulin 28-31g/L 36A/G Ratio 0.00-0.00 0.80:1Date Examination Normal Value Result8/15/11 Albumin 32-52 g/L 26total Protein withA/G Ratio
UrinalysisURINALYSIS 8/5/11RBC: 75-100/HPF(++++) CRYSTAL:PUS CELLS: 25-50/HPF(++) URIC ACID:EPITHELIAL CELLS: FEW CAL. OXALATE:RENAL CELLS: AMOR.URATES:OccassionalMUCUCS THREADS: AMOR. PHOS.BACTERIA: FEW TRIPLE PHOS.OTHERS: OTHERS:CASTHYALINE: COARSEGRAN:FINE GRAN OTHERS:
ABG ANALYSIS RESULTDATE INTERPRETATION8/5/11 Partially compensated metabolic acidosis with correctedhypoxemia8/6/11 (1 am) Combined respiratory and metabolic acidosis withcorrected hypoxemia8/6/11 (10 am)Fi02 80% via VRCompensated respiratory alkalosis with correctedhypoxemia8/8/11Fi02 80%Normal acid-base with corrected hypoxemia8/9/11Fi02 60% via VRNormal acid-base with corrected hypoxemia8/27/11Fi02 40% via T-pieceUncompensated respiratory alkalosisarterialBlood Gas
Specimen: CSF8/6/11Test name ResultKOH : Negative for fungal elementson direct smearAFB : Negative – No acid fast bacilliseen on direct smearSpecimen: ETA 8/7/11Test nameKOH : No fungal elements seen onsmearSpecimen: Sputum 8/10/11Test nameKOH :Positive for fungal elementKOHAFB
ECHOCARDIOGRAPHY REPORT8/19/11CONCLUSION:DILATED LEFT VENTRICULAR DIMENSION WITH GOODSYSTOLIC BUT IMPAIRED DIASTOLIC FUNCTION.SLIGHTLY DILATED LEFT ATRIUM.TRIVIAL MITRAL AND TRICUSPID REGURGITATION.
CT Scan Report 8/5/11IMPRESSION:CEREBRO- CEREBELLAR ATROPHYATHEROMATOUS INTERNAL CAROTID ARTERIES, BASILAR ARTERY ANDVERTEBRAL ARTERIES.SUSPICIOUS HYPODENSITY IN THE LEFT PORTION OF THE MIDBRAIN-HYPERACUTE OR ACUTE INFARCT NOT RULED OUT; FOLLOW UP ISRECOMMENDED.CONSIDER SINUSITIS-LEFT ANTERIOR ETHMOID AND BOTH MAXILIARYSINUSES.RIGHTWARD NASAL SEPTAL DEVIATION.LEFT INFUNDIBULUM BLOCKED BY SOFT TISSUE DENSITIES.CONSIDER NASAL SECRETIONS LEFT NASAL CAVITY; NASAL CONGESTION,LEFT NASAL POLYP,LEFT.
X-RAY REPORT 8/05/11IMPRESSION:PNEUMONIA BILATERAL AND/OR PULMONARY CONGESTION.RULE OUT PULMONARY EDEMA.RULE OUT MINMAL PLEURAL EFFUSION, BILATERAL.ATHEROMATOUS AORTA.RULE OUT DILATED THORACIC AORTA.CHEST CT SCAN CORRELATION IS RECOMMMENDED FOR FURTHER.EVALUATION OF THE PROMINENT SUPERIOR MEDIASTINUM AND LEFTHILUM IF CLINICALLY WARRANTED.
CNS DRUGSGENERIC/BRAND NAME/DOSAGECLASSIFICATION INDICATIONDiazepam 5 mg IV PRN forseizureBenzodiazepine Adjunct therapy inconvulsive disordersLevetiracetam KEPPRA 4.5ml BIDAnti convulsant Mono/Adjunctive therapyin the treatment of partialonset of seizuresSpecial Precautions: Avoidabrupt withdrawalCiticoline 1 gram IV Q 12H neurostimulant Cerebral insufficiency inacute and recovery phase
,ANTIBIOTICSDATE ORDERED GENERIC NAME CLASSIFICATION INDICATIONAugust 5, 2011 Metronidazole Anti-protozoal KOH of sputum revealpositive for fungal elements.Endotracheal aspirate revealCandida spp.August 5, 2011 Ceftriaxone 3rd generationCephalosporinTreatment of susceptibleinfection.(+) febrile episodesupon admissionAugust 6, 2011 Fluconazole Anti-fungal KOH of sputum revealpositive for fungal elements.Endotracheal aspirate revealCandida spp.August 17, 2011 Meropenem Beta Lactam Progression of pneumonia
ANTIBIOTICSDATE ORDERED GENERIC NAME CLASSIFICATION INDICATIONAugust 30, 2011 Cefipime 3rd generationCephalosporinCulture and Sensitivity ofEndotracheal tip revealsensitivity to CefipimeSeptember 5,2011Ceftazidime1 gram IV Q12H3rd generationCephalosporin9/3/2011Endotracheal aspirateCulture and sensitivityreveal Pseudomonasaeruginosa. Susceptible toCeftazidimeSeptember 5,2011Ciprofloxacin Quinolones 9/3/2011Endotracheal aspirateCulture and sensitivityreveal Pseudomonasaeruginosa. Susceptible toCiprofloxacin
ANTIBIOTICSDATE ORDERED GENERICNAMECLASSIFICATION INDICATIONAugust 12, 2011 Amphotericin B Antibiotic/Antifungal(+) Calas testSystemic, potentially fatal, lifethreatening fungal infectionSpecial Precautions:• May cause bone marrowdepression- increased incidenceof microbial infection anddelayed healing.• May cause renal impairment.Serum creatinine must bemonitored.• Dose gradually increased dailyto reach desired amountindicated by the physician.
GASTROINTESTINAL DRUGSGENERIC/BRAND NAME/DOSAGECLASSIFICATION INDICATIONOmeprazole 20 mg/cap BID Proton Pump Inhibitor Used in conditions whereinhibition of gastric acidsecretion may be beneficialTo prevent ulcer and acidrelated dyspepsiaEsomeprazole 40 mg IV OD Proton Pump Inhibitor Reduce the occurrence ofgastric ulcersESSENTIALE FORTE 1 capTIDHepatic Protector Prevention of toxicmetabolic liver diseasesLactulose 30 cc OD Laxative Chronic constipation.Episodes of (-) BM
ANTI ASTHMATIC PREPARATIONSGENERIC/BRAND NAME/DOSAGE INDICATIONIpratropium Bromide + SalbutamolCOMBIVENT 1 nebule Q 6HManagement of reversible bronchospasmassociated with obstructive airwaydiseases in patients who require morethan a single bronchodilatorSalmeterol Xinafoate FluticasonePropionateSERETIDE 2 puffs BIDProphylaxis and maintenance treatment ofasthmaBudesonide 500mcg/respule Q 12H Prophylaxis and maintenance treatment ofasthmaDoxofylline 400 mg/tab BID Bronchial asthmaMontelukast Na 10 mg/tab OD Management of chronic asthma
ANTIHYPERTENSIVES/DIURETICSGENERIC/BRAND NAME CLASSIFICATION INDICATIONLosartan K 100 mg/tab OD Angiotensin IIAntagonistIncreased BP, HypokalemiaSpecial Precaution: Serumpotassium should be monitoredFurosemide + KCLDIUMIDE K ½ tab ODDiuretic Congestion, hypokalemiaSpecial Precaution: Serumpotassium should be monitoredAmlodipine 10 mg/tab OD Calcium Antagonist HypertensionMannitol 150cc IV Q 6H Osmotic Diuretic Increased intracranial pressureand cerebral edema as seen inthe CT scanFurosemide 20mg IV now Diuretic Dyspnea, desaturation,wheezing – congestion
GENERIC/BRAND NAME/DOSAGECLASSIFICATION INDICATIONAcetylcysteine Mucolytic Acute and Chronicrespiratory tract infectionwith abundant mucussecretionsParacetamol 300 mg IV Q4H RTCantipyretic Client is continuouslyfebrileHydrocortisone 100 mg IVQ12 HCorticosteroid For relief of congestion ,inflammation broughtabout by infectionNaproxen Na 275 mg/tabQ 8H RTCNon-steroidal AntiInflammatory DrugsContinuously febriledespite ParacetamolIntermediate Insulin Insulin HyperglycemiaKalium durule 2 durulesTIDSupplement Hypokalemia
did youKnowthat?The female pigeoncannot lay eggs if she is alone.In order for her ovaries to function,she must be able to seeanother pigeon.
neffective Airway ClearanceGOAL: Within 5mins-15mins hours, the client will manifest:• Normal breathing pattern• A decrease in respiratory secretions• No episode of desaturation• A reduction of wheeze and crackles noted upon auscultationr/t increased production/retained tenacious secretions secondary to infection asevidenced by ineffective cough, crackles, tachypnea, excessive sputumIINDEPENDENTMonitor respirations and breath sounds, noting rate and sound indicative ofrespiratory distress and/or accumulation of secretions.Suction naso/tracheal/oral prn to clear airway when excess or viscoussecretions are blocking airway.Elevate head of bed/change position every 2 hours and prn to take advantage ofGravity decreasing pressure on the diaphragm and enhancing drainage of/ventilationTo different lung segments.Insert oral airway when needed, to maintain anatomic position of tongue andnatural airway.
INDEPENDENTKeep environment allergen free (e.g., dust)Monitor vitals signs, noting blood pressure/pulse changes.Position in semi-fowlers to moderate high back rest to maximize lung expansion.DEPENDENTAdminister bronchodilators/mucolytics as ordered.Administer medications, as indicated, to treat underlying cause such as antibiotics.Chestphysiotherapy to mobilize secretions.INTERDEPENDENTObtain sputum specimen to verify appropriateness of therapyEnsure most of the time placement of th endotracheal tube.
luid Volume Excessr/t cerebral insufficiency , acute stress, presence of infection, and immobility asmanifested by dyspnea, decreased O2 sat=85%, crackles noted upon auscultation,diaphoresis, restlessness, increased BP, Jugular vein distentionFINDEPENDENTAssess causative/precipitating factorsMonitor progression/alleviation of symptomsGOAL: Within 8 hours, the client will be able to:• Stabilize fluid volume as witnessed by balanced intake and output• Vital signs within normal limits• Manifest adequate O2 saturation = 95%-100%• Decreased crackles noted upon auscultation• Demonstrate calmnessAccurately monitor fluid intake and output from all sources: PO, IV, urine,insensible fluid lossAssess presence of jugular vein distention
INDEPENDENTNote and measure parameters that may indicate increasing fluid retention/edema(e.g. abdominal girth)Reposition every two hours to prevent stasis and reduce risk of tissue injuryUse safety precautions at all timesDEPENDENTAdminister diuretics and steroids as ordered by the physician.INTERDEPENDENTReview diagnostic data (BUN, creatinine, hematocrit, serum albumin and chestx-ray) correlate and relay accordingly
ecreased Cerebral Tissue PerfusionGOAL: After one month, the client will be able to:• Demonstrate an improved GCS score of 10-12• Manifest an enhanced mental status, with increased episodes of wakefulnes•Manifest a decrease in seizure episodesr/t interruption of cerebral blood flow secondary to cryptococcal infection asevidenced by altered mental status, GCS=6 E1V1M4, comatose to stuporous, seizureepisodes, changes in motor response.DINDEPENDENTDetermine factors related to individual situation, e.g., presence of fungal infectionIdentify changes related to systemic alteration in circulation, such as altered mentalstatusEvaluate signs of infection.Determine duration of problem/ frequency of recurrenceDetermine presence of visual sensory motor changes, altered mental statusElevate head of bed 30 degrees and maintain head/neck in midline or neutral positionTo promote circulation/venous drainageProvide calm and cool environment
INDEPENDENTDecrease noxious stimuliProvide non-constrictive clothingAssist with treatment of underlying conditionDEPENDENTAdminister medications as prescribedAdminister fluid replacement/rehydration or blood transfusion to improvetissue perfusion/organ functionINTERDEPENDENTReview specific dietary changes/restrictionsReview results of diagnostic studies
yperthermiaHINDEPENDENTMonitor body temperature .GOAL: Within 8 Hours, the client will be able to:• Maintain temperature within normal range• Manifest relief from symptoms experiencedMonitor and record all sources of fluid loss such as urinePromote surface cooling by means of undressing (heat loss by radiation/conduction)Provide cool environment (heat loss by convection)Tepid sponge baths (heat loss by evaporation and conduction)Apply local ice pack on groin and axillaer/t inflammatory process secondary to infection as evidenced by elevated surfbody temperature, skin warm to touch, flushing, diaphoresis, tachypnea,tachycardia
INDEPENDENTWrap extremities with bath towel to decrease shivering.Promote safety by securing both side rails up.Maintain bed rest to decrease metabolic demands and O2 consumption.Maintain adequate fluid intake to prevent dehydration.DEPENDENTAdminister antipyretics, Paracetamol 300mg IV Q4H RTC as ordered.Administer medications, as indicated, to treat underlying cause such as antibiotics.INTERDEPENDENTMonitor laboratory results such as ABGs, electrolytes , coagulation profiles,Urinalysis, CBC.
isk for AspirationRINDEPENDENTNote the client’s level of consciousnessGOAL: Within one month, the client will :• Experience no aspiration• Maintain patent airwayAssess amount and consistency of respiratory secretionsAssess muscle strength, gross and fine motor coordinationCareful administration of enteral feedings, being aware of potential forregurgitation and/or misplacement of tubeMeasure residuals when appropriate to prevent over feedingMaintain operational suctioning equipment at bedsider/t altered mental status, GCS score of 6 secondary to cerebral insufficiencybrought about by infection
INDEPENDENTSuction oral cavity, nose and endotracheal tube as neededAuscultate lung sounds frequently to determine presence of secretionsElevate client to high fowler’s position during tube feedingsKeep side rails up for safetyDEPENDENTAdminister Diazepam for restlessness and seizure episodes as ordered
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CLINICAL INSPECTIONDate and Time Taken: September 8, 2011, 4pmVital Signs:T- 36.3PR- 64 bpmRR- 22 bpmBP- 120/80 mmHg
CNS: GCS 10 (E-4, V-1, M-5), pupilsequally round and reactive to light andaccommodation 2mm in diameter,normal power on both upper and lowerextremities.CVS: Attached to cardiacmonitor, normal sinus rhythm
RESPI: attached tocontinuous O2 @ 2lpm viatracheal mask, whitishsecretions upon suctionGI: Diet: Abdomen soft withbowel sounds upon auscultation.OTF 2400 kcal in 1800 cc volumedivided by 6 equal feedings.
GU: adequate urinaryoutput, with yellow orangecolored urine
Client was transferred per stretcherper folks request to West Visayas StateUniversity Hospital on September 8, 2011at around 8:30 in the evening accompanied byER staff nurse and on call junior consultant withO2 @ 2lpm via tracheal mask and venoclysis ofPNSS 1L +20 meq kcl x 20cc/hr.