A Case Study Presented to the Faculty ofThe Ateneo de Davao University College of Nursing A Case Study onAnemia 2 o to Sepsis 2 o Bronchopneumonia Submitted by: Kristi Ann Cabonita Marie Allexis Campaner Francis Thomie Caranay Rico Janrev Castañeda Rashed Eduard Ceniza Joanna Paula Concepcion Submitted to: Loreen S. Marcelo, RN September 25, 2010
3 ACKNOWLEDGMENT In accomplishing great things, we must not only think, but believe in the power of ourcognition; not only aim but make our visions tangible; and at the end of the day, not only smileat the thought of accomplishment, but look back to where the strength to achieve such successcame from. The proponents would like to extend their warmest gratitude to all the people whohelped make the success of this undertaking a reality. First and foremost, to our parents, for giving us support and encouragement every day,for making us feel loved and cared for. To our Clinical Instructor, Mrs.Loreen Marcelo RN, for her invaluable time and effortrendered to us; for her guidance all throughout the our ward exposure. For being a friend andcompanion in the area. And lastly, to the Almighty Father, for His unceasing love and blessings; for giving usenough power and fortitude to face all the hardships in the making of this work. To Him be allglory and praise!
4 INTRODUCTION Anemia is a common problem among acutely ill patients, especially those who developsepsis. There are many factors contributing to the development of anemia in these patients,including blood sampling and other losses, decreased RBC synthesis and possibly increasedRBC destruction. Increased RBC uptake may be due to changes in RBC morphology duringinflammatory processes. Anemia is common in sepsis in part because mediators of sepsis (TNF-α and interleukin-1β) decrease the expression of the erythropoietin gene and protein. Althoughtreatment with recombinant human erythropoietin decreases transfusion requirements, its use inrandomized, controlled trials failed to increase survival. Erythropoietin takes days to weeks toinduce red-cell production and thus may not be effective. Sepsis is a severe illness caused byoverwhelming infection of the bloodstream by toxin-producing bacteria. Microorganismsinvading the body cause infections. Sepsis is also called Systemic inflammatory responsesyndrome (SIRS). Sepsis can also be triggered by events such as pneumonia, With more than 750,000 new cases a year in the United States and a mortality rate of up to50 percent, sepsis is a serious problem. The condition kills more than 1,400 Americans a day,making it the leading cause of mortality in the ICU. There are approximately 1, 000,000 casesof sepsis a year in the Asia,7 and the frequency is increasing, given an aging population withincreasing numbers of patients infected with treatment-resistant organisms, patients withcompromised immune systems, and patients who undergo prolonged, high-risk surgery(University of British Columbia, Critical Care Medicine, St. Pauls Hospital, Vancouver, BC,Canada.)
5 The significance of studying this case is to enhance or broaden our knowledge as well as thepatient’s who are suffering this disease and also to those people who are in high risk of havingthis disease for us to share our knowledge for the primary prevention and simple interventionsof the disease. Thus they are in a pursuit for knowledge to be able to impart it to others. It canbe alarming since many people are confused and unaware of the symptoms presented. With thisstudy, the student nurses hope to apply their learning in taking care not only of their patients butalso of themselves.
6 OBJECTIVES After 3 days of data gathering, research and analysis, the student nurse shall havedevised objectives that will guide them for the proper understanding and fair interpretation ofthe case of their chosen patient.GENERAL OBJECTIVESCognitive The student nurse’s first main goal is to gain knowledge through the completion of thecase study and to impart this learning to the patient, and to those directly and indirectly involvedwith the completion of this case.Specific Objectives under Cognitive aspectWithin the 3 days span of duty, the student nurses will be able to: - Gather significant data from the patient’s chart which includes the doctor’s order, labo- ratory exams and etc. to have complete information about the patient’s current condition. - Research on the anatomy and physiology of the client’s affected system. - Research on the possible causes and also the symptoms the patient experienced that may suggest the current condition of the patient. - Research and understand the disease process of the patient’s illness. - Determine and interpret the medical management employed including laboratory and di- agnostic procedures. - Identify and study the drugs prescribed to the patient which affects the patient’s current situation.
7Psychomotor - In this aspect, the student nurse’s goal is to apply all what they have learned during the process of completing this case study to improve nursing care that will meet the patient’s need for the improvement of her general welfare.Specific Objectives under Psychomotor aspectWithin the 3 days span of duty, the student nurses will be able to: - Conduct a thorough physical assessment and to interpret the assessment in order to give the care the patient need - Formulate nursing care plans and apply them to satisfy the patient’s needs and give ap- propriate nursing interventions. - Make a discharge plan for the patient using M.E.T.H.O.D and validate the patient’s prognosis according to categories.Affective - With the knowledge gained and through the application of this knowledge, another goal is that the student nurses will be able to empathize with the current situation of the pa- tient and to gain some values like the value of patience and calmness which is important for a them to have in order to become better nurses in the future.Specific Objectives under Affective aspectWithin the 3 days span of duty, the student nurses will be able to:
8- Establish rapport and therapeutic communication in order to gain information about the patient which includes the medical and family health history, expectations of her condi- tion, gather significant data from the patient’s chart and to her family and etc.; and for the betterment of nursing care.- Assume the role of being the patient’s advocate.
9 PATIENT’S DATAName: TrudisAge: 4 months oldAddress: Purok 2 Salvacion, Panabo CityCivil status: childNationality: FilipinoReligion: Roman CatholicBirth Place: Panabo CityBirthdate: 5/15/10Name of Father: Michael VisperasName of Mother: Shiela MaeAdmitting Diagnosis: Anemia secondary to sepsis secondary to pneumoniaAdmitting physician: Dr. Evangeline ArnaizDate of Admission:Hospital: Southern Philippines Medical CenterInformant: MotherHistory record:Immunization: I BCG, I DPT(-) HPN (-) CA(-) DM (-) Leukemia(-) PTBChief Complaint: Fever
10History of Past illness: Patient has no other past illness as verbalized by the mother. Trudis was born healthywith a normal delivery. She has already been immunized with I BCG and I DPT.History of present illness: Six days prior to admission patient has intermittent high grade fever, (+) cough- non-productive. She was first admitted at Carmen District hospital and at the same day she wasimmediately referred to SPMC. The mother medicated ,the child with paracetamol and with aherbal medicine called calabong. Three days PTA patient defecated soft stool for four timesapproximately 2 tbsp per episode. Day of admission (+) for vomiting.
11 FAMILY BACKGROUND AND HEALTH HISTORYFamily Background The patients parents; Shiela and Michael has been married for eight years. The couplelives at Panabo city with their 4 children. Michael works as a truck driver for a businessman foralmost 5 years, where he earns 6,000 a month. On the other hand Shiela only stays at home totake care of their children.Shielas youger sister, also lives with them and helps them to lookafter the children. The couple also owns a small sari-sari store at their house where they gain2000-3000 a month. Tessa is the youngest among the four siblings. The oldest child in thefamily is aged 8 years old, who studies at a public school near their place. The second child isaged 5 years old who is still at playschool at a day care center. Their third child is aged 2 yearsold who still doesnt go to school. The family belongs to the lower class. Shiela is a gravida 4para 4. She stated that she has completed the prenatal check-ups needed with all the pregnancyshe had. She also claimed to be fully immunized with tetanus toxoid. Shiela gave birth to all herchildren at the local government hospital in Carmen.Lifestyle and Diet: Shiela wakes up at around 5 a.m to prepare food for the children and her husband. Theirusual meals include fish, meat and vegetables. In the morning their eldest child is sent to school.While Shiela stays at home and takes care of the other 3 children and at the same time watchesover their, with the help of her sister.Effects/ Expectation of illness:
12 Shiela verbalized that it was the first time that a child of hers was admitted to a hospital.Because of this she stated to take better care of her children. She has learned to immediatelyseek help to prevent further complications of her childs condition. She and her husband expectstheir youngest child to recover after the treatment and management done to Trudis.
13 GENOGRAM Grandpapa Grandmama Grandaddy Grandmommy ∆ †∆♥ Francis Marie Tudis Camille Ж Mikko Candice DEVELOPMENTAL DATA Legend:Eriksons Stages of Psychosocial Development Male = Female= † = Deceased Ж = Has Anemia 2o to Sepsis 2o Bronchopneumonia ♥ = Hypertension ∆ = Diabetic
14 Eriksons eight stages reflect both positive and negative aspects of the critical life periods. Erikson envisions life as a sequenceof levels of achievement. Each stage signals a task that must be achieved. The resolution of the task can be complete, partial, orunsuccessful. Erikson believes that the greater the task achievement, the healthier the personality of the person; failure to achieve atask influences the persons ability to achieve the next task. These developmental tasks can be viewed as a series of crises, andsuccessful resolution of these crises is supportive to the persons ego. Failure to resolve the crises is damaging to the ego. Stage Description Result Justification The first stage of Erik EriksonsInfants theory centers around the infants ACHIEVED The parents of the baby always see to it basic needs being met by the that the baby is comfortable. They(0 to 18months) parents. The infant depends on the provide everything that the baby needs. parents, especially the mother, for Trudis is breastfed on demand andTrust vs. food, sustenance, and comfort. The safety of the baby is the top priority ofMistrust childs relative understanding of the parents. The baby has everything world and society come from the that she needs like blankets and parents and their interaction with clothings which is provided by the
15the child. If the parents expose the parents. The parents are warm towardschild to warmth, regularity, and their baby as shown by them carryingdependable affection, the infants the baby. They always think of the needsview of the world will be one of of the baby especially if it comes totrust. Should the parents fail to health. They see to it that the baby getsprovide a secure environment and the proper health care needed.to meet the childs basic need asense of mistrust will result.According to Erik Erikson, themajor developmental task ininfancy is to learn whether or notother people, especially primarycaregivers, regularly satisfy basicneeds. If caregivers are consistentsources of food, comfort, and
16 affection, an infant learns trust- that others are dependable and reliable. If they are neglectful, or perhaps even abusive, the infant instead learns mistrust- that the world is in an undependable, unpredictable, and possibly dangerous place.Piagets Phases of Cognitive Development Piaget concluded that there were four different stages in the cognitive development of children. The first was the SensoryMotor Stage, which occurs in children from birth to approximately two years. The Pre-operational Stage is next, and this occurs inchildren aged around two to seven years old. Children aged around seven to eleven or twelve go through the Concrete Operationalstage, and adolescents go through the Formal Operations Stage, from the age of around eleven to sixteen or more. Stage Description Result Justification
17Sensory Motor Piagets ideas surrounding the The client had achieved thisStage (Birth - ACHIEVED Sensory Motor Stage are stage since the client, as what we2yrs) centred on the basis of a have observed is able to recognize schema. Schemas are mental thing around her. The client was representations or ideas about also able to follow dangling toy, what things are and how we which her parents have, from side to deal with them. Piaget deduced side and tries to get them. She also that the first schemas of an turns her head to the sound around infant are to do with movement. her especially to the voice of her Piaget believed that much of a parents. Her motor development is babys behaviour is triggered by also good as she could held her head certain stimuli, in that they are up in a prone position for a long reflexive. A few weeks after time. birth, the baby begins to Trudis is positive for reflexes like
18 sucking, yawning and many more.understand some of the She begin to learn things asinformation it is receiving from evidenced by her laughing whenits senses, and learns to use ever her mother or father makessome muscles and limbs for faces in front of her. She knows andmovement. These recognize her mother and father.developments are known asaction schemas.Babies are unable to consideranyone elses needs, wants orinterests, and are thereforeconsidered to be ego centric.During the Sensory MotorStage, knowledge about objectsand the ways that they can be
19manipulated is acquired.Through the acquisition ofinformation about self and theworld, and the people in it, thebaby begins to understand howone thing can cause or affectanother, and begins to developsimple ideas about time andspace.Babies have the ability to buildup mental pictures of objectsaround them, from theknowledge that they havedeveloped on what can be donewith the object. Large amounts
20of an infants experience issurrounding objects. What theobjects are is irrelevant, moreimportance is placed on thebaby being able to explore theobject to see what can be donewith it. At around the age ofeight or nine months, infantsare more interested in an objectfor the objects own sake.A discovery by Piagetsurrounding this stage ofdevelopment, was that when anobject is taken from their sight,babies act as though the object
21has ceased to exist. By aroundeight to twelve months, infantsbegin to look for objectshidden, this is what is definedas Object Permanence. Thisview has been challengedhowever, by Tom Bower, whoshowed that babies from one tofour months have an idea ofObject Permanence.
22Freuds Model of psychosexual development According to Freud’s theory of psychosexual development, the personality develops in five overlapping stages from birth toadulthood. The libido changes its location of emphasis within the body from one stage to another. Therefore, a particular area hasspecial significance to a client at a particular stage. If the individual does not achieve a satisfactory progression at each stage, thepersonality becomes fixated at that stage. Stage Description Result Justification Oral (Birth to 1 The oral stage begins at Trudis is a 4 months old baby ACHIEVED ½ year) birth, when the oral who shows pleasure in sucking cavity is the primary and putting things into her mouth. focus of libidal energy. She is breastfed on demand by The child, of course, her mother. Her mother said that preoccupies himself if Trudis cries, she either checks with nursing, with the the diaper or breastfed the baby.
23pleasure of sucking and The mother has no problems inaccepting things into the breastfeeding the baby and she ismouth. The oral equipped with adequatecharacter who is knowledge on the properfrustrated at this stage, breastfeeding technique. She iswhose mother refused to very attached to her baby andnurse him on demand or cares for her a lot. But, she justwho truncated nursing not let the baby put anything onsessions early, is her mouth. She doesn’t disregardcharacterized by the child’s safety which is farpessimism, envy, more important.suspicion and sarcasm.The overindulged oralcharacter, whose nursingurges were always andoften excessively
24satisfied, is optimistic,gullible, and is full ofadmiration for othersaround him. The stageculminates in theprimary conflict ofweaning, which bothdeprives the child of thesensory pleasures ofnursing and of thepsychological pleasureof being cared for,mothered, and held. Thestage lastsapproximately one andone-half years.
14 Physical AssessmentGeneral Survey Physical assessment was taken on September 12, 2010 at 11:45am, approximately 120hours after time of admission. Received lying on bed in supine position, awake, consciousthough visibly tired. Upon entering the room of a four month old female who lying next to parents with aheight of 61 centimeters and a weight of 6.2 kilograms, head circumference of 39 centimeters,chest circumference of 41 centimeters and abdominal circumference of 44 centimeters and iswearing a white colored tank top and a diaper underneath one layer of blue colored underwear.Appears clean. No noted foul body odor. Appeared relaxed though tired. With occasionalsmiling. No noted crying throughout assessment. Noted lesion on right posterior area of thewrist. Skin on noted parted is significantly darker than that of the rest of the body. Initial vitalsigns during time of assessment are: Cardiac Rate: 139 Temperature: 37.5 Respiratory Rate: 39Neurologic Status Is able to smile though with no noted crying throughout the duration of the assessment.Able to suck and swallow especially evident during breastfeeding. Eye movement in unison.Blinks when eyes are exposed to light. Turns head when sound is generated. Sucking reflex ispresent; Palmar reflex is present; Planter reflex is present.No noted signs of neurologic disabilities.
15Skin Skin is generally light brown in color and uniform throughout most of the body; areas oflighter pigmentation include the palms, lips and nail beds. Noted bruising, dark in color, on rightposterior wrist approximately 3 by 4 centimeters in size. Noted redness on left gluteus maximus.No noted foul body odor. Upon palpation, noted skin is dry. Skin felt generally warm on areasunder the cover of clothing but cooler on the arms and extremities. No noted significantbirthmarks, bleeding or lesions aside from the aforementioned. With a Temperature of 36.0°C.Skin has fair skin turgor.Head Inspection, the skull is normocephalic and symmetric has smooth skull contour. With ahead circumference of 39 centimeters. Hair is black in color, unevenly distributed, soft and thin.Has dry hair. No noted change in pigmentation. No noted bruises, lesions, nodules or swelling.Posterior fontanelle is hard indicating it has closed. Anterior fontanelle is soft and flat. No notedbulging or depression. Facial movements are symmetrical and is particularly evident whenshowing emotions such as smiling.. No presence of infection or infestation was noted.Eyes During inspection, eyebrows are evenly distributed, have thin hair that are black in color.Eyebrows were symmetrically aligned with equal movement. The skin of the eyelids were intact,no discharges and no discoloration. Lids close symmetrically however with noted infrequentblinking with a rate of 4 blinks per minute; bilateral blinking. Upon inspection, sclera isgenerally white. No noted visible sclera above cornea. When lids are closed, sclera is not visible.No noted tearing from lacrimal duct and lacrimal sac. No noted discharge. Has brown colored
16iris; pupils are black in color, equal in size of about 2mm. Both pupils constrict when illuminatedand are briskly reactive to light. Both eyes coordinated and move in unison. No noted strabismus,bleeding or purulent discharge.EarAuricles are aligned with the outer canthus of the eye. Upon palpation, found to be firm and nottender; no noted pain. No noted tenderness upon palpation of the mastoid process. Pinnea recoilsafter it is folded. Upon inspection with a penlight, no noted excessive discharge of cerumen orblood. Blinking reflex noted when producing loud noise. No noted difficulty in hearing.Nose Upon inspection, nose is wide, symmetric straight and uniform in color. Upon palpation,no noted tenderness or lesions. With noted minimal amount of mucous discharge from the nose.Upon inspection with a penlight, mucosa is pink; no noted swelling, redness, growth or lesions.Nasal septum is intact and in the midline between the nasal chambers. No noted nasal flaring.Mouth Upon inspection outer lips are dark pink in color; appeared soft, moist and smooth; withsymmetrical contour. No noted dryness and roughness. Inner, lips are pinkish red and uniform incolor; is moist, soft and smooth. Has no teeth. Gums are pink, moist and appear firm. No notedswelling on gums. Tongue is in central position of the mouth, light pink in color; moist; slightlyrough with noted thin whitish coating in some areas. Able to move side to side. Smooth tonguebase with prominent veins. No noted lesions or dryness. Palate is intact. Soft palate is pink andsmooth. Hard palate is light pink and irregular in texture. Uvula is positioned in midline ofpalate.
17Neck Neck is generally uniform in color. Neck is short with not noted head lag when turninghead. Lymph nodes are not swollen and tender. Thyroid gland is not visible. Trachea is in thecenter of the neck.Chest and Lungs Has symmetrical anterior chest expansion with a respiratory rate of 39 breaths perminute. Spine is vertically aligned. Noted productive coughing with green colored sputum. Uponauscultation, faint crackles can be heared. Noted occasional irregular breathing pattern. Rightand left shoulders are of the same height. Anterior chest wall is intact, no noted tenderness ormasses. Posterior chest has full and symmetric respiratory excursion. Upon percussion of theposterior chest, sounds resonate; no noted dullness or flatness over lung tissue. Uponauscultation of the upper chest using a stethoscope, noted faint wheezing. No noted chestindrawing.Back and Extremities Upon inspection upper extremities are grossly proportional to body shape for age, equalin size on both sides of the body. Noted bruise on right posterior wrist. No noted deformities oredema on upper extremities. No noted tremors or palpable nodules. Clavicles are intact, nolumps noted; No noted variation in size of hands; Has five phalanges on each hand; No noteddeformities or unusual length of fingers; Two prominent palmar creases are visible and do notcompletely transverse the palm; No noted single transverse or Simian crease. Nails of upperextremities are trimmed and cleaned. Noted capillary refill of approximately 3 seconds. Lowerextremities are grossly proportional to body shape for age, equal in size and length on both sides
18of the body. Toenails are trimmed and cleaned. No noted deformities or edema. Unable toambulate. Manipulation of the ankles reveals full flexibility in the form of plantar flexion of thefoot. Foot returns to neutral position after manipulation. Joints in upper and lower extremitieshave good range of motion; No noted signs of hip dislocation; No noted signs of abnormalcurvature of the spine; No protrusions or deformities noted. Joints move smoothly with no noteddeformities, swelling, pain, tenderness. Spinal column vertically aligned. Spinal column isstraight with no noted protrusions or deformities.
19 COMPLETE DIAGNOSISAnemia secondary to Sepsis Secondary to BronchopneumoniaANEMIAAnemia is a condition that occurs when the number of red blood cells (RBCs) and/or the amountof hemoglobin found in the red blood cells drops below normal. Red blood cells and thehemoglobin contained within them are necessary for the transport and delivery of oxygen fromthe lungs to the rest of the body. Without a sufficient supply of oxygen, many tissues and organsthroughout the body can be adversely affected. Anemia can be mild, moderate or severedepending on the extent to which the RBC count and/or hemoglobin levels are decreased. It is afairly common condition, affecting both men and women of all ages, races, and ethnic groups.P. 769 Brunner & Sudddarths Textbook of Medical Surgical Nursing 7th edition J.B LippincottCompanyAnemia is a medical condition in which the red blood cell count or hemoglobin is less thannormal. The normal level of hemoglobin is generally different in males and females. For men,anemia is typically defined as hemoglobin level of less than 13.5 gram/100ml and in women ashemoglobin of less than 12.0 gram/100ml. These definitions may vary slightly depending on thesource and the laboratory reference used.P. 336 Rick Randle Contemporary Medical Surgical Nursing 2007
20Anemia is a condition in which your blood has a lower than normal number of red blood cells.Anemia also can occur if your red blood cells dont contain enough hemoglobin Hemoglobin isan iron-rich protein that gives blood its red color. This protein helps red blood cells carry oxygenfrom the lungs to the rest of the body.Hopper P.D., Williams, L.S. ; Understanding Medical Surgical Nursing 3rd editionSEPSISSepsis is any adverse medical conditions due to the presence of any microorgansim in the blood.Usually, the layperson using the term blood poisoning is referring to the medical condition thatarise when bacteria or their products reach the blood.Mosby’s Pocket Dictionary of Medicine, Nursing & Health Professions 5th editionSepsis is a serious infection usually caused by bacteria which can originate in many body parts,such as the lungs, intestines, urinary tract, or skin that make toxins that cause the immunesystem to attack the bodys own organs and tissuesInfection that progress to the blood stream causing systemic infection is called sepsis. It resultsfrom the presence of microorganism in the blood stream.
22Bronchopneumonia is a type of pneumonia that is characterized by an inflammation of the lunggenerally associated with, and following a bout with bronchitis. This is really a specific type ofpneumonia that is localized in the bronchioles and surrounding alveoli. P. 464 Brunner & Sudddarths Textbook of Medical Surgical Nursing 7 thedition J.B Lippincott Company
23 ANATOMY AND PHYSIOLOGYRespiratory System The respiratory system consists of all the organs involved in breathing. These include thenose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two veryimportant things: it brings oxygen into our bodies, which we need for our cells to live andfunction properly; and it helps us get rid of carbon dioxide, which is a waste product of cellularfunction. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes throughwhich the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygenis brought into the bloodstream and carbon dioxide is pushed from the blood out into the air.When something goes wrong with part of the respiratory system, such as an infection likepneumonia, chronic obstructive pulmonary diseases, it makes it harder for us to get the oxygenwe need and to get rid of the waste product carbon dioxide.
24The Upper Airway and Trachea When you breathe in, air enters your body through your nose or mouth. From there, ittravels down your throat through the larynx (or voicebox) and into the trachea (or windpipe)before entering your lungs. All these structures act to funnel fresh air down from the outsideworld into your body. The upper airway is important because it must always stay open for you tobe able to breathe. It also helps to moisten and warm the air before it reaches your lungs.The LungsStructure Air travels to the lungs through a series of air tubes and passages. It enters the bodythrough the nostrils or the mouth, passing down the throat to the larynx, or voice box, and then to
25the trachea, or windpipe. In the chest cavity the trachea divides into two branches, called theright and left bronchi or bronchial tubes, that enter the lungs. In the adult human, each lung is 25 to 30 cm (10 to 12 in) long and roughly conical. Theleft lung is divided into two sections, or lobes: the superior and the inferior. The right lung issomewhat larger than the left lung and is divided into three lobes: the superior, middle, andinferior. The two lungs are separated by a structure called the mediastinum, which contains theheart, trachea, esophagus, and blood vessels. Both right and left lungs are covered by an externalmembrane called the pleura. The outer layer of the pleura forms the lining of the chest cavity. The branches of the bronchi eventually narrow down to tubes of less than 1.02 mm (lessthan 0.04 in) in diameter. These tubes, called bronchioles, divide into even narrower tubes, calledalveolar ducts. Each alveolar duct ends in a grapelike cluster of thin-walled sacs, called alveoli (asingle sac is called an alveolus). From 300 million to 400 million alveoli are contained in eachlung. The air sacs of both lungs have a total surface area of about 93 sq m (about 1000 sq ft),nearly 50 times the total surface area of the skin. In addition to the network of air tubes, the lungs also contain a vast network of bloodvessels. Each alveolus is surrounded by many tiny capillaries, which receive blood from arteriesand empty into veins. The arteries join to form the pulmonary arteries, and the veins join to formthe pulmonary veins. These large blood vessels connect the lungs with the heart. The lungs are paired, cone-shaped organs which take up most of the space in our chests,along with the heart. Their role is to take oxygen into the body, which we need for our cells to
26live and function properly, and to help us get rid of carbon dioxide, which is a waste product. Weeach have two lungs, a left lung and a right lung. These are divided up into ‘lobes’, or bigsections of tissue separated by ‘fissures’ or dividers. The right lung has three lobes but the leftlung has only two, because the heart takes up some of the space in the left side of our chest. Thelungs can also be divided up into even smaller portions, called ‘bronchopulmonary segments’. These are pyramidal-shaped areas which are also separated from each other bymembranes. There are about 10 of them in each lung. Each segment receives its own bloodsupply and air supply.Blood Supply The lungs are very vascular organs, meaning they receive a very large blood supply. Thisis because the pulmonary arteries, which supply the lungs, come directly from the right side ofyour heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungsso that the carbon dioxide can be blown off, and more oxygen can be absorbed into thebloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary veinsinto the left side of your heart. From there, it is pumped all around your body to supply oxygento cells and organs.The Pleurae
27 The lungs are covered by smooth membranes that we call pleurae. The pleurae have twolayers, a ‘visceral’ layer which sticks closely to the outside surface of your lungs, and a ‘parietal’layer which lines the inside of your chest wall (ribcage). The pleurae are important because theyhelp you breathe in and out smoothly, without any friction. They also make sure that when yourribcage expands on breathing in, your lungs expand as well to fill the extra space.The Diaphragm and Intercostal Muscles When you breathe in (inspiration), your muscles need to work to fill your lungs with air.The diaphragm, a large, sheet-like muscle which stretches across your chest under the ribcage,does much of this work. At rest, it is shaped like a dome curving up into your chest. When youbreathe in, the diaphragm contracts and flattens out, expanding the space in your chest anddrawing air into your lungs. Other muscles, including the muscles between your ribs (theintercostal muscles) also help by moving your ribcage in and out. Breathing out (expiration) doesnot normally require your muscles to work. This is because your lungs are very elastic, and whenyour muscles relax at the end of inspiration your lungs simply recoil back into their restingposition, pushing the air out as they go. The Cardiovascular System
28The Blood Blood is denser andmore viscous than water,which is part of the reason it flows more slowly than water. The temperature of blood is about38°C, which is slightly higher than normal body temperature, and it has a slightly alkaline pHranging from 7.35 – 7.45. Blood constitutes about 8% of the total body weight. The bloodvolume is 5 - 6 liters in an average-sized adult male and 4 – 5 liters in an average-sized adultfemale. Several hormonal negative feedback systems ensure that blood volume and osmoticpressure remain relatively constant. Especially important systems are those involvingaldosterone, antidiuretic hormone, and atrial natriuretic peptide, which regulate how much wateris excreted in the urine.Components of Blood
29 Whole blood is composed of two components: blood plasma, a watery liquid thatcontains dissolved substances, and formed elements, which are cells and cell fragment.Blood Plasma When formed elements are removed from blood, a straw-colored liquid calledblood plasma is left. Plasma is about 91.5% water and 8.5% solutes, most of which are proteins.Some of the proteins in plasma are also found elsewhere in the body, but those confined to bloodare called plasma proteins. Among other functions, these proteins play a role in maintainingproper blood osmotic pressure, which is an important factor in the exchange of fluids acrosscapillary walls. Plasma proteins: - Albumins (54% of plasma proteins) - Globulins (38%)
30 - Fibrinogen (7%)Formed Elements:RBC or Red Blood Cell Red blood cells or erythrocytes contain the oxygen-carrying protein hemoglobin, which isa pigment that gives whole blood its red color. A healthy adult male has about 5.4 million redblood cells per microliter of blood, and a healthy adult female has about 4.8 million. To maintainnormal quantities of RBCs, new mature cells must enter the circulation at the astonishing rate ofat least 2 million per second, a pace that balances the equally high rate of RBC destruction. Red blood cells are biconcave discs with a diameter of 7-8 micrometers and are highlyspecialized for their oxygen transport function. Each one contains about 280 millionshemoglobin molecules. A hemoglobin molecule consists of a protein called globin. Red blood cells live only about 120 days because of the wear and tear their plasmamembranes undergo as they squeeze through blood capillaries.WBC or White Blood Cell
31 Unlike red blood cells, white blood cells or leukocytes have a nucleus and do not containhemoglobin. WBCs are classified as either granular or agranular, depending on whether theycontain conspicuous chemical-filled cytoplasmic vescicles that are made visible by staining.Granular leukocytes include neutrophils, eosinophils, and basophils; agranular leukocytesinclude lymphocytes and monocytes. In a healthy body, some WBCs, especially lymphocytes, can live for several months oryears, but most live only a few days. During a period of infection, phagocytic WBCs may liveonly a few hours. WBCs are far less numerous than red blood cells, about 5,000-10,000 cells permicroliter of blood. RBCs therefore outnumber white blood cells by about 700:1. Leukocytosis,an increase in the number of WBCs, is a normal, protective response to stresses and surgery.Platelet
32 Besides the immature cell types that develop into erythrocytes and leukocytes, hemopoietic stem cells also differentiate into cells that produce platelets. Under the influence of the hormone thrombopoietin, myeloid stem cells develop into megakaryocyte-colony-forming cells that, in turn, develop into precursor cells calledmegakaryoblasts. Megakaryoblasts transform into megakaryocytes, huge cells that splinter into2000-3000 fragments. Each fragment, enclosed by a piece of the cell membrane, is a platelet orthrombocyte. Platelets break off from the megakaryocytes in red bone marrow and then enter theblood circulation. Between 150,000 – 400,000 platelets are present in each microliter of blood.They are disc-shaped, 2-4 micrometers in diameter, and exhibit many granules but no nucleus.Platelets help stop blood loss from damaged blood vessels by forming a platelet plug. Theirgranules also contain chemicals that, once released, promote blood clotting. Platelets have a short life span, normally just 5 – 9 days. The Blood Vessels There are 3 types of blood vessels: the arteries, the veins and the capillaries. An
33artery is a vessel that carries blood away from the heart. It carries oxygenated blood. Smallarteries are called arterioles. Veins, on the other hand are vessels that carries blood toward theheart. It contains the deoxygenated blood. Small veins are called venules. Often, very largevenous spaces are called sinuses. Lastly, capillaries are microscopic vessels that carry bloodfrom small arteries to small veins (arterioles to venules) and back to the heart. The walls of the blood vessels, the arteries and veins have three main layers: tunicaadventitia, tunica media and tunica intima. Tunica adventitia which is a fibrous type of vessel is aconnective tissue that helps hold vessels open and prevents tearing of the vessel wall during bodymovement. Tunica media is a smooth muscle, sandwiched together with a layer of elasticconnective tissue. It permits changes of the blood vessel diameter. It allows the constriction anddilation of the vessels. Last but not the least is the tunica intima. Tunica intima, which in Latinmeans inner coat, is made up of endothelium that is continuous with the endothelium that linesthe heart. In arteries, it provides a smoothlining. However in veins itmaintains the one-way flow of the blood.The endothelium, which makes up the thincoat of the capillary, is important becausethe thinness of the capillary wall allowsthe exchange of materials between theblood plasma and the interstitial fluid ofthe surrounding tissues.Circulation of the blood in blood vessels
34 There are two circulatory routes of blood as it flows through the blood vessels: thesystemic and the pulmonary circulation. In systemic circulation, blood flows from the leftventricle of the heart through blood vessels to all parts of the body (except gas exchange tissuesof lungs) and back to the atrium. In pulmonary circulation on the other hand, venous bloodmoves from the right atrium to right ventricle to pulmonary artery to lung arterioles andcapillaries where gases exchanged; oxygenated blood returns to the left atrium via pulmonaryveins; from left atrium, blood enters the left ventricle.Inflammation Cells damaged by microbes, physical agents, or chemical agents initiate a defensiveresponse called inflammation. The four characteristic signs and symptoms of inflammation areredness, pain, heat, and swelling. Inflammation can also cause the loss of function in the injuredarea, depending on the site and extent of injury. Inflammation traps microbes, toxins, and foreign
35material at the site of injury and prepares the site for tissue repair. Thus, it helps restore tissuehomeostasis. Because inflammation is one of the body’s nonspecific defenses, the response of a tissueto, say, a cut is similar to the response to damage caused by burns, radiation, or bacterial or viralinvasion. In each case, inflammation has three basic stages: vasodilation and increasedpermeability of blood vessels, phagocyte emigration, and ultimately, tissue repair. Among the substances that contribute to vasodilation, increased permeability, and otheraspects of the inflammatory response are the following: • Histamine. In response to injury, mast cells in connective tissue and basophils and platelets in blood release histamine. Neutrophils and macrophages attracted to the site of injury also stimulate the release of histamine, which causes vasodilation and increased permeability of blood vessels. • Kinins. These polypeptides, formed in blood from inactive precursors called kininogens, induce vasodilation and increased permeability and serve as chemotactic agents for phagocytes. • Prostaglandins. These lipids are released by damaged cells and intensify the effects of histamine and kinins. It may also stimulate the emigration of phagocytes through capil- lary walls.
Predisposing Present/ Rationale Justification Factors Absent 37Age Present Extremes of age predisposes an individual to pneumonia. The patient is aged 4 Those who are aged 65 and above and those who are very months, by this age, the young are more susceptible to acquiring pneumonia due immune system is not to weakened immune system and under developed yet well developed as immune system respectively. compared to adults and http://emedicine.medscape.com older children, thus predisposing the child to pneumonia.Congenital Absent Congenital Anomalies such as hereditary dyskinesis of There are no diagnosticAnomalies the cilia and squamous metaplasia hinder the body’s findings that would ability to eliminate invading pathogens, thus indicate any congenital predisposing one to acquiring infections in the respiratory abnormalities in the tract. child that would Congenital Abnormalities of the Lung by Karan Madan. predispose her to the http://www.indiachest.org condition. Precipitating Present/ Rationale Justification Factors AbsentImmobility Absent Prolonged immobility causes limited expansion of the The patient did not lungs immobility changes the distribution of ventilation have immobility. and blood flow through the lungs and patients are unable to take a deep breath, also, respiratory muscle weakness occurs due to limited physical activity and metabolic changes. It results in an increase in the work of breathing which causes a decrease in the ability of the patient to cough. With decreased lung expansion and weakened respiratory muscles, secretions stagnate and pool which increases the risk for hypostatic pneumonia.
38B. SYMPTOMATOLOGY Symptoms Present/Absent Rationale Justification Fever Present Is a frequent medical Vital Signs upon admission symptom that reveal a temperature of 38.6. describes an increase in internal body temperature to levels that are above normal. It is stimulated by cytokines (IL-1 & IL-6). These cytokines send signals in the hypothalamus that serves as our thermoregulatory center, thus prostaglandin is released. Once prostaglandin is
39 released, it causes an increase in the set point. In response to this, the hypothalamus neurally initiates shivering and vasoconstriction that increases the core body temperature to the new set point, and fever is established.Pain in the chest Absent Difficulty of This is not manifested by theover the affected breathing may lead patient. lung to chest pain due to a deprivation of oxygen circulating in the lungs and heart. Chemical mediators like bradykinin and prostaglandin also play a role in the
40 pain felt. Dyspnea Present The alveoli are the There are occasions within the main site for oxygen shift that that the patient’s and carbon dioxide respiratory rate rises above exchange in the the normal range with lungs. Once the apparent labored breathing, exudates are poured indicating dyspnea. into the alveoli, it impairs the oxygen- carbon dioxide exchange because the space intended for air is already filled with fluid causing dyspnea or difficulty in breathing.Productive cough Present It is a sudden audible The patient had productive expulsion of air from cough. the lungs with sputum. It is an essential protective
41 response that serves to clear the lungs, bronchi, and trachea or irritants and secretions or to prevent aspiration of foreign material into the lungs. Alterations in Present Hyperthermia or The patient was febril uponbody temperature hypothermia are admission. characteristic signs of sepsis, occurring due to Decreased red Present A decrease in the Laboratory results show a blood cells number of red blood decrease in RBCs, and a cells is called ane- blood transfusion was mia. Anemia is a ordered. common problem in acutely ill patients, especially in those who develop sepsis. There are many fac- tors contributing to
42the developmentof anemia in thesepatients, includingblood sampling andotherlosses, decreased redblood cell (RBC)synthesis, and possi-bly increaseddestruction. In-creased RBC uptakemay be due tochanges in RBCmorphologyand the RBCmembrane duringinflammatoryprocesses.Anemia in sepsis:the importance ofred blood cellmembrane changes
43 Micheal Piagnerelli,, MD, Et al.Tachycardia Absent Tachycardia is This was not manifested by characterized by the patient. rapid beating of the heart. Heart rate considered as tachycardia is above 120 in newborns, above 180bpm in 6 month old infants, more than 160bpm in 1 year old clients and above 130 in two-year olds. RN Notes. 2nd Edition, by Ehren Myers, RN. Since there is an impaired exchange of gases in the lungs, and oxygen transport
44 to tissues is inefficient, the heart compensates by pumping fast.Crackles Present Crackles (or rales) Upon auscultation, crackles are caused by fluid were heard on both lung in the small airways fields. or atelectasis. Crackles are referred to as discontinuous sounds; they are intermittent, nonmusical and brief. Crackles may be heard on inspiration or expiration. The popping sounds produced are created when air is forced through respiratory passages that are
45 narrowed by fluid, mucus, or pus. Crackles are often associated with inflammation or infection of the small bronchi, bronchioles, and alveoli. Crackles that dont clear after a cough may indicate pulmonary edema or fluid in the alveoli. This is common in pneumonia.Tachypnea Present Also known as fast There are occasions within the breathing. For shift that that the patient’s pediatric clients, respiratory rate rises above breathing is the normal range with considered fast when apparent labored breathing. it reaches the rate of above 30cpm in ages 1 to 4 years, above
4635cpm in those aged6-11 months andabove 60cpm innewborns to5months.RN Notes. 2ndEdition, by EhrenMyers, RN.. A decrease inoxygen would causethe body tocompensate toincrease the oxygensupply in the body.This results to theincrease in therespiratory rate.
47 WBC changes Present White blood cells are Laboratory results show responsible for the elevated levels of white blood defense system in cells. the body. White blood cells fight infections and protect our body from foreign particles, which includes harmful germs and bacteria.Thus, elevated WBC counts indicate infection.Decreased blood Absent Due to the cascade This is not manifested by the pressure of interactions patient. between WBCs and
48 component of WBC, neutrophils, release nitric oxide in the process, a potent vasodilator. Thus causing a decrease in blood pressure.Easy Fatigability Absent A decrease in This is not manifested by the circulating red blood patient. cells impairs the transport of oxygen in the different areas in the body. Decreased oxygen delivery to the musculoskeletal tissues cause easy fatiguability. Respiratory Absent Respiratory acidosis No ABG results would Acidosis is acidosis indicate respiratory acidosis. (abnormally
49 decreased ventilation of the pulmonary alveoli, leading to elevated arterial carbon dioxide concentration. In cases of pneumonia, respiratory acidosis occur as a result of the impaired gas exchange in the lungs.Pallor Present Pallor is due to a The baby was reported to be reduced amount of pale. oxyhemoglobin in skin or mucous membrane, a pale color which is caused by anemia. It is more evident on the face and palms.
50 Pathophysiology (Community Acquired Pneumonia)Predisposing Factors: Precipitating Age Factors: Causative agent gains access to Through aspiration or the reparatory inhalation tract Penetrates the LRT Irritation of the site occurs Alveolar macrophages (primary defense) in the site fights off the microorganisms Bacteria adheres to the alveolar macrophages Phagocytosis (cell eating mechanism) occurs Engulfed microorganisms will be removed
51 Weakened immune system due to predisposing factors Microorganism become virulent and is present in large number Overwhelms the alveolar macrophages Activation of the inflammatory response Release of multiple inflammatory mediatorsCause pain Bradykinin Histamine Prostaglandin Cause pain and fever Causes vasodilation Increase capillary permeability Extravasation of fluid into tissues and cavity Plasma enters into the inflammatory site (bronchioles and alveoli)
52 Terminal bronchioles are filled with debris and exudates Cytokines send signal in the hypothalamus Exudates in Exudates in the alveoli the alveoli cause irritation Prostaglandin is released Impairs oxygen- Increase mucus production by carbon dioxide dyspnea goblet cells exchange in the Increase set alveoli point in the hypothalamus Body attempts to expel out Hypothalamus foreign neurally initiates substances shivering and and fluid out of Body vasoconstriction the lungs compensates Increase in the Stimulation of core body the cough Increase in tachypnea temeprature reflex respiratory rateChills and fevers Productive cough
53 Continuous inflammation of the alveoli and bronchioles occur Bacterial Exudation of fluids dissemination into the cavity Conditions exacerbate and bacterial spreadbecomes systemic Fluids accumulate and consolidate Sepsis Fluids consume a lot of space in the lungs Decreased lung expansion Dyspnea
54 Outer membrane component of Continuous inflammation of microorganisms trigger the release of the alveoli and bronchioles chemical mediators occur Bacterial Cytokines, tumor-necrosis factor, platelet-activating factors, Exudation of fluids dissemination interleukin, prostaglandins and leukotrines are released into the cavity Conditions exacerbate and bacterial spread Increased RBC becomes systemic destruction Fluids accumulate and consolidate Production of adhesion Mediators damage endothelial lining molecules and neutrophils Sepsis anemia Fluids consume a lot of space in the lungs Neutrophilic endothelial Decrease in the oxygen carrying Decreased lung reaction leads to further capacity of the blood expansion endothelial injury Neutrophil components release nitric oxide Tissue hypoxia Dyspnea Septic shockmusculoskeletal skin CNS Circulatory pallor Confusion, dizziness High pulse rate, Easy fatigability, increased weakness
55If treated: If not treated: ComplicationsAntibiotics Heart ProblemsIron Supplements Nerve DamageDietary Modifications Impaired Mental Function Bad Prognosis Good Prognosis
09/07/10 Admitting orders Please admit to IMCU For close monitoring of the patient Admitted under Pedia 3 service and proper management of his level 3 condition BF with SAP Mothers are encouraged to give their Mother newborns breastmilk because of the informed benefits of Breastfeeding such as nutritional, immunological, emotional and psychological. A strict aspiration precaution if ordered when patient is at risk for aspiration, because of this, feeding would be strictly watched. Start venoclysis with D5 Intravenous lines provide easy Started 0.3 NaCl 500 cc @ 25 access for drug administration cc/hr intravenously (IVTT). Intravenous solutions containing dextrose and sodium chloride are indicated for parenteral replenishment of fluid, minimal carbohydrate calories, and sodium chloride as required by the clinical condition of the patient. Labs:WT = 6.2 CBC with PC CBC with PC determines the DonekL quantity of each quantity of blood
cell in a given specimen of blood,often including the amount ofhemoglobin, hematocrit, and theproportion of various white bloodcells. This is done to know anycondition of the client that mayaffect his medical management.
BT Blood typing is a method to tell what Done specific type of blood you have. What type you have depends on whether or not there are certain proteins, called antigens, on your red blood cells. Urinalysis Urinalysis is performed to screen for Done urinary tract disorders, kidney disorders, urinary neoplasm and other medical conditions that produce changes in the urine. This test also is used to monitor the effects of treatment of known renal or urinary condition. This test is also used to monitor the effects of certain procedures done to patient and to check if genito-urinary is in normal state or not. Chest X-ray – APL A chest radiograph, commonly Not done called a chest x-ray (CXR), is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs
09/08/10 Dx: S/F PBS please give Examination of the peripheral blood Referral form referral form smear should be considered, along with review of the results of peripheral blood counts and red blood cell indices, an essential component of the initial evaluation of all patients with hematologic disorders. The examination of blood films stained with Wrights stain frequently provides important clues in the diagnosis of anemias and various disorders of leukocytes and platelets. Follow up all labs This is done since the laboratory Followed up result now results are needed in the medical management of the patient’s condition. Rx: IVF @ same rate This may continuously administer Hooked parenteral replenishment of fluid, minimal carbohydrate calories, and sodium chloride as required by the clinical condition of the patient. Meds: Day 1 please give Rx Ampicillin Ampicillin is a beta-lactam antibiotic Given
Still w/ Gentamycin Gentamicin is an aminoglycoside Given antibiotic, used to treat many types of bacterial infections, particularly those caused by Gram-negative bacteria. Gentamycin is given together with ampicillin bcause one of the concern of giving antibacterial is the number of bacteria that become resistant to the drug necessitating combination therapy or use of other antibiotics.febrile VS q 4 hours Vital signs are important for baseline Taken andepisodes assessment and to monitor patients recorded condition which evaluates the whole(+) LBM treatment course, especially the medications he received that could be a contributing factor in the variation results of the vital signs. Refer accordingly This may create a collaborative referred treatment among the client and the health care providers; thus it also makes a good coordination on the treatment of the client. Follow up BT result This is done since the laboratory Followed up
result is needed in the medical management of the patient’s condition which is blood transfusion. To secure PRBC 100cc Packed red blood cells (PRBCs), Not done aliqout and transfuse 70 also called "packed cells," are a cc to run un 4 hours after preparation of red blood cells that proper cross matching are transfused to correct low blood levels in anemic patients. This increases the amount of hemoglobin in the blood that can carry oxygen perfused from alveoli of the lungs to tissues. For PBS prior to Blood This is done to have a baseline data Not done transfusion to determine whether the medical management given was right.09/09/10 Dx: S/F PBS give Examination of the peripheral blood DONE8:20 am request smear should be considered, along with review of the results of peripheral blood counts and red blood cell indices, an essential component of the initial evaluation of all patients with hematologic disorders. The examination of blood films stained with Wrights stain
frequently provides important clues in the diagnosis of anemias and various disorders of leukocytes and platelets.Continue IVF with D5 Intravenous lines provide easy Continued0.3 NaCl 500 cc @ 25 access for drug administrationcc/hr intravenously (IVTT). Intravenous solutions containing dextrose and sodium chloride are continuously given for parenteral replenishment of fluid, minimal carbohydrate calories, and sodium chloride as required by the clinical condition of the patient.Continue medications: Day 2
(-) fever Ampicillin Ampicillin is a beta-lactam antibiotic Given(+) pale Gentamycin that has been used extensively tolooking treat bacterial infections. Strict(+) cough compliance for treatment regimen is(+) rash very important for proper treatment and prevent the growth of drug- resistant bacteria Gentamicin is an aminoglycoside Given antibiotic, used to treat many types of bacterial infections, particularly those caused by Gram-negative bacteria. Gentamycin is given together with ampicillin bcause one of the concern of giving antibacterial is the number of bacteria that become resistant to the drug necessitating combination therapy or use of other antibiotics. Continue VS monitoring Vital signs are important for baseline Taken and q4 hours assessment and to monitor patients recorded condition which evaluates the whole treatment course, especially the medications he received that could be a contributing factor in the
Continue I&O Intake and output helps gauge fluid Monitored monitoring q4 hours balance in the body of the patient. This would also check if patient’s elimination pattern is normal or impaired. Refer accordingly if with This may create a collaborative Referred unusualities treatment among the client and the health care providers; thus it also makes a good coordination on the treatment of the client. Still securing PRBC for Packed red blood cells (PRBCs), Secured BT also called "packed cells," are a preparation of red blood cells that are transfused to correct low blood levels in anemic patients. This increases the amount of hemoglobin in the blood that can carry oxygen perfused from alveoli of the lungs to tissues.09/10/10 Dx: PBS result after 10 This is done to allow enough time7:20 am working days for further testing in case of inclusive or doubtful results Continue IVF with D5 Intravenous lines provide easy Continued 0.3 NaCl 500 cc @ 25 access for drug administration
cc/hr intravenously (IVTT). Intravenous solutions containing dextrose and sodium chloride are continuously given for parenteral replenishment of fluid, minimal carbohydrate calories, and sodium chloride as required by the clinical condition of the patient.
(-) fever Continue medications: Day 3 Ampicillin Ampicillin is a beta-lactam antibiotic Givencomfortable that has been used extensively toAsleep treat bacterial infections. Strict(+) rash compliance for treatment regimen is very important for proper treatment and prevent the growth of drug- resistant bacteria Gentamycin Gentamicin is an aminoglycoside antibiotic, used to treat many types of bacterial infections, particularly those caused by Gram-negative bacteria. Gentamycin is given together with ampicillin bcause one of the concern of giving antibacterial is the number of bacteria that become resistant to the drug necessitating combination therapy or use of other antibiotics. Continue VS monitoring Vital signs are important for baseline Taken and q4 hours assessment and to monitor patients recorded condition which evaluates the whole treatment course, especially the medications he received that could