a case study on cns infection

8/3/2019 A Case Study on Cns Infection

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A

CASE STUDY

ON

CNS INFECTION

Submitted to;

Ms. Verlyn Perez RN,MSN

Submitted by;Marie Joy R. Luczon

Student Nurse


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I.INTRODUCTIONA febrile seizure is a convulsion in a child triggered by a fever. Such convulsions occur

without any underlying brain or spinal cord infection or other neurological cause. A

febrile seizure is a convulsion that occurs in some children with a high temperature

(fever). The vast majority of febrile seizures are not serious.A seizure triggered by a fever is usually harmless and typically doesn't indicate a long-

term or ongoing problem.

The first febrile seizure is one of lifes most frightening moments for parents. Most

parents are afraid that their child will die or have brain damage. Thankfully, simple

febrile seizures are harmless.

There is no evidence that simple febrile seizures cause death, brain damage, mental

retardation, a decrease in IQ, or learning difficulties.

However, a very small percentage of children go on to develop other seizure disorders

such as epilepsy later in life.

Although described by the ancient Greeks, it was not until this century that febrile

seizures were recognized as a distinct syndrome separate from epilepsy.In 1980, a consensus conference held by the National Institutes of Health described a

febrile seizure as, "An event in infancy or childhood usually occurring between three

months and five years of age, associated with fever, but without evidence of

intracranial infection or defined cause."It does not exclude children with prior

neurological impairment and neither provides specific temperature criteria nor defines

a "seizure."

Another definition from the International League Against Epilepsy (ILAE) is "a seizure

occurring in childhood after 1 month of age associated with a febrile illness not caused

by an infection of the central nervous system (CNS), without previous neonatal seizures

or a previous unprovoked seizure, and not meeting the criteria for other acute

symptomatic seizures".

Signs and SymptomsA fever, usually higher than 38.9 C

Loss of consciousness

Jerking of the arms & legs

Eyes rolled back in the head

Difficulty breathing

Vomiting & urinating

Crying or moaning

Incidence rateFebrile convulsions are common paediatric patients. According to studies, about 3-5% of

otherwise healthy children between the ages of 9 months and 5 years will have a seizure


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caused by a fever. Toddlers are most commonly affected. Most occur well within the

first 24 hours of an illness, not necessarily when the fever is highest.

Epidemiology

Between 2% and 4% of European children have a febrile convulsion; the peak incidenceis age 18 months.Most are the simple febrile seizure type. Complex febrile seizures

occur in about 20% and febrile status epilepticus in about 5%.

PrognosisGenerally the prognosis is good:

By definition, febrile seizures do not recur beyond the age of 5 years approximately.There is no evidence for an increased risk of death, even for children with status

epilepticus

Intellect is not affected.

Febrile seizures recur in about 30%. Risk factors for recurrence are: family history of

febrile seizures, onset aged


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Complications

Although febrile seizures may cause great fear and concern for parents, most febrile

seizures produce no lasting effects. Simple febrile seizures don't cause brain damage,

mental retardation or learning disabilities, and they don't mean your child has a more

serious underlying disorder.

Febrile seizures also aren't an indication of epilepsy, a tendency to have recurrent

seizures caused by abnormal electrical signals in the brain. The odds that your child will

develop epilepsy after a febrile seizure are small.

Only a small percentage of children who have a febrile seizure go on to develop epilepsy,

but not because of the febrile seizures.

Recurrent febrile seizuresThe most common complication of febrile seizures is the possibility of more febrile

seizures. About a third of children who have a febrile seizure will have another one

with a subsequent fever.

The risk of recurrence is higher if:

Your child had a low fever at the time of the first febrile seizure.

The period between the start of the fever and the seizure was short.

An immediate family member has a history of febrile seizures.

Tests and diagnosisAfter experiencing a febrile seizure, your child will likely have:

A physical exam

Blood tests

Urine tests

These tests can help determine possible causes of the fever and seizure.

If your doctor suspects a central nervous system infection, a lumbar puncture (spinal

tap) may be necessary. In this procedure, a doctor inserts a needle into your child's

lower back to remove a small amount of spinal fluid.


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This test can reveal evidence of infection in the fluid that surrounds the brain andspinal cord.Further tests such as an electroencephalogram (EEG)a test that

measures brain activitymay be necessary if your child had a complex febrile seizure.

II.NURSING HISTORY

Patient Profile

Name; Patient M

Age; 2 y/o

Sex; Female

Address; Purok 4 Bulanao Tabuk,Kalinga

Nationality; Filipino

Religion; Jehovahs Witness

Bithplace; S/A

Admission date ; August 15,2011

Time; 10;00 PM

Attending Physician: Dr. Ramirez/Dr.Pacicolan

PAST HEALTH HISTORY

No previous hospitalization. The patient was confined @ Cagayan Valley Medical

Center because of persistent high grade fever for 20 hours, upward rolling of eyeballs and

stiltering of extremities lasting to about 5 min x 1 episode.

PRESENT ILLNESS HISTORY


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The patient was admitted August 15, 2011 @ 10;00 pm with chief complaint of dizziness,

fever and headache increase in sleeping time.3 days prior to admission, the patient was noted to

have cough and colds. She was given with paracetamol syrup before she was hospitalized. The

patients parent consulted @ emergency room of CVMV hospital and was managed andsubsequently admitted.

FAMILY HEALTH HISTORY

The patients father stated that the family has no history of any disease and illness.

PEARSONS FUNCTIONAL PATTERN

Condition

before

Hospitalization

Condition

During

Hospitalization

PSYCHOLOGICAL She has good stress coping pattern

wherein she dont react to simple

things that is done to her, even if it

is not meant accidentally

Her coping stress pattern is not

quite good after she was

hospitalized. She usually cries

whenever she wants to or even

when you accidentally touch her

body.

ELIMINATION

Patients mother stated the patient

usually voids 5-6 times a day. The

patient usually wears her diaper all

night. She usually defecates twice

in a row.

Patients mother said that the

patient usually voids 2-3 times a

day. When she was hospitalized,

she defecates once. Mother

stated that the patient was

irritable when her diaper was full

of void or even when she made

pu-pu.

ACTIVITY Patients mother stated that she

used to be a jolly child that loves to

play with her cousin and her tita

and tita.She loved to go to the

neighbourhood just to hang

around.

Patient seems irritated all the

time. She doesnt want to play with

anybody even to her father and

mother.


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ROLE

RELATIONSHIP

PATTERN

She has a good relationship with

her family as stated by her mother.

She makes her family happy by

simply giving them simple sing and

dance sample

Her relatives especially her parents

are very concerned with her

present conditions.

SLEEP Patient M usually sleeps about 9 in

the evening until 7 in the morning.

She always took nap during

noontime for about 2-3 hours.

Patients mother stated that her

daughter sleep anytime she want

to. She was easily distracted by

environmental factors such as

noise an even the temperature

inside the room (hotness) .

OXYGEN Before she was admitted, she

inhaled deep and slow due to her

fever.She has difficulty of

breathing according to her.

During her hospitalization, she has

an order of o2 inhalation of 1-2

cpm because there is sign of DOB.

NUTRITION Before she was admitted, her

mother stated that she is fond of

eating any food that is served to

her.

She is NPO during the

hospitalization.

SPIRITUAL She is a christian.She and her

family they usually go to church

together. She was thought to

become a good citizen by her

parents.

Her mother stated that as soon as

they went out to the hospital, they

plan to visit the church.

Laboratory ResultHematology Normal

Values

Result Interpretation

Erythrocyte VolumeFraction

Male 0.40-0.54

Female 0.38-

0.47

0.36 Due to tachypnea

Mean Corpuscular 80-100 fL 78.4 Decrease in the


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Volume (MCV) volume of the

average RBC

Mean Corpuscular

Hemoglobin(MCH)

26-32 pg 25.6 Decrease in the

number of grams

ofhemoglobin/unit

volume

WBC Differential

Count

Neutrophils 0.35-0.65 81.8 Presence of

infections

Lymphocytes 0.20-0.40 12.7 Presence of

chronic infections

Monocytes 0.02-0.08 5.4 Presence of

certain infections

such as glandular

fever

Eosinophil 0.0-0.5 0.0 normal

I. PHYSICAL ASSESSMENT

A

1. GENERAL APPEARANCE/ HEALTH STATUSAppearance

and mental

statusTechnique

used Normalfindings Actual Findings Analysis

Body build Inspection Proportionate Proportionate NormalPosture andgait,

standing,

sitting and

walking

Inspection Erect posturecoordinated

movementProportionate Normal


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MEASUREMENTS:

Level of consciousness; spontaneous

Grooming: satisfactory

2VITAL SIGNS:NORMAL

FINDING

OUTCOME ANALYSIS

BODY

TEMPERATURE

37.0 C 38.4C Presence of on

infectionPULSE RATE 120-160BPM 132 BPM tachycardia

RESPIRATION 20-30CPM 36CPM tachypnea

BLOOD

PRESSURE

100/60MMHG 90/70MMHG NORMAL

Date of assessment: August 15, 2011Time of assessment: 9; 00 am

3 Head to Toe assessment

AREAASSESSED TECHNIQUEUSED NORMALFINDINGS ACTUALFINDINGS ANALYSIS


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Head

Skull

Hair

Scalp

Face

Eyes

Sclera

Pupils

Inspection

Inspection

Inspection

Inspection

Normocephalic

c& smooth

texture

No wounds, no

abrasion

Symmetrical

White

Black

Size of the

proportional

to size of thebody

Black &

smooth

straight

No wounds,

mo abrasion

Symmetrical

Flushed face

Teary eyes

Redness of the

eye

Red, watery

Black in color

and equal insize

Normal

Normal

Normal

Normal

Due to fever

Due to fever

Due to fever


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AREA ASSESSED TECHNIQUE USED NORMALFINDINGS ACTUALFINDINGS ANALYSISEars/ hearing

Pinna

Ear Canal

Inspection Normal voice

Tones audible

Parallel,

Symmetrical,

Proportional to the

size of the head

and bean shape

Ear canal has no

abundant cerumen/ear wax

Hair in the ear

canal are visible

Normal voice

Tones audible

Parallel,

Symmetrical,

Proportional to the

size of the head

and bean shape

Ear canal has no

abundant cerumen/

ear wax

Hair in the ear

canal are visible

Normal

Normal


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Nose and sinuses Inspection Nose is in midline

and symmetrical

(-) secretion ofmucous

Nose is in midline

and symmetrical

(-) secretion ofmucous

Normal

Mouth

Teeth

Tongue

Mucosal lining

Lips

Tonsils

Uvula

Inspection

(-) swelling of gums

and bleeding

Gums is pinkish in

color

In central position,

freely movable,

pinkish and with

prominent veins on

the sublingual area.

Moist

Symmetrical and lipmargin is well

defined

Lips is pinkish

(-) swelling

(-) swelling

Dry lips

(+) swelling of gums

and bleeding

Gums is reddish

In central position,

freely movable,

reddish

(STRAWBERY)

Moist

Symmetrical and lipmargin is well

defined

Lips is dry and

Reddish

(strawberry)

(-) swelling

(-) swelling

Because

of the

diffuse

erythema

and

prominent

papillae.


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2. Neck Inspection (-) rashes and

visible masses

(-) rashes Normal

3.Chest

Breath sound

Breast

Nipple

Areola

Heart

Inspection

Palpation

Auscultatio

n

Inspection

Inspection

Auscultatio

n

No scars

(-) tenderness and

masses

(+) broncho

vesicular breath

sound at 2nd ICS

Breast is even with

the chest wall

Nipple are round,

and equal in size

Areola are round

symmetrical, colorbrown

(-) arrhythmia,

bounding pulse

heart murmurs and

any abnormal

pulsation being

auscultated

No scars

(-) tenderness and

masses

(+) broncho

vesicular breath

sound at 2nd lungs

Breast is even with

the chest wall

Nipple are round,

and equal in size

Areola are round

symmetrical, colorbrown

(-) arrhythmia,

bounding pulse

heart murmurs and

any abnormal

pulsation being

auscultated

Normal

Normal

Normal

Normal

Normal

Normal

2. Posteriorthorax

Inspection

Palpation

No scars

Spine vertically

align; spinal column

is straight right and

left shoulder and

No scars

Spine vertically

align; spinal column

is straight right and

left shoulder and

Normal


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Lungs

Auscultaion

Percussion

hips are at the

same height

Fermitus is heardmost clearly at the

apex of the lungs

No effort when

breathing with

good breathing

pattern

(+) resonance NBS

(normal lung sound)

hips are at the

same height

Fermitus is heardmost clearly at the

apex of the lungs

No effort when

breathing with

good breathing

pattern

(+) resonance NBS

(normal lung sound)

Normal

3. Abdomen Inspection

Auscultation

Percussion

Palpation

Abdominal skin is

unblemished, no

scars, with flat and

rounded

abdomen/symmetric

al contour.

Audible bowelsound

(+) presence of

tympany

No evidence of

enlargement of the

liver

Abdominal skin is

unblemished, no

scars, with flat and

rounded

abdomen/symmetric

al contour

Active bowelsound (10-30 bowel

sound in every 5min)

tympany

No evidence of

enlargement of the

liver

Normal

Due toperistaltic

activity

Normal

Normal


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4. UpperExtremities

SkinArms

Finger

Nail

5. Lowerextremities

Legs

Inspection

Palpation

Inspection

Inspection

(-) scars at thelower forearm

smooth

With fine hair

evenly distributed

and few visible

veins

Symmetrical

With complete five

finger in each hand

smooth, convex

with pinkish nailbed

Smooth, convex

with pinkish nail

bed

(-) negative scars

Fine hair is evenly

distributed

Muscles

symmetrical, length

(-) scars at thelower forearm

With fine hair

evenly distributed

and few visible

veins

Symmetrical

Desquamation of

finger

Peeling and

erythema of the

fingertips.

Transverse grooves

of fingers and

toenails (Beaus

lines).

(-) negative scars

Fine hair is evenly

distributed

Muscles

symmetrical, length

symmetrical

Normal


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Feet

Toe

Nails

Inspection symmetrical

Dorsal surface is

smooth & warm

With convex nails,

pinkish nail bed and

good capillary refill

of 2-3 seconds

(+) short and with

clear and white

translucent tips toe

nails.

Dorsal surface is

smooth & warm

With convex nails,

pinkish nail bed and

good capillary refill

of 2-3 seconds

(-) long and dirty

toe nail

Normal

Normal

ANATOMY AND PHYSIOLOGY


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Anatomy of the Brain: Brain DivisionsThe forebrain is responsible for a variety of functions including receiving and processingsensory information, thinking, perceiving, producing and understanding language, and

controlling motor function. There are two major divisions of forebrain: the diencephalon and

the telencephalon. The diencephalon contains structures such as the thalamus and

hypothalamus which are responsible for such functions as motor control, relaying sensory

information, and controlling autonomic functions. The telencephalon contains the largest part

of the brain, the cerebrum. Most of the actual information processing in the brain takes place

in the cerebral cortex.

The midbrain and the hindbrain together make up the brainstem. The midbrain is the portion ofthe brainstem that connects the hindbrain and the forebrain. This region of the brain is

involved in auditory and visual responses as well as motor function.

The hindbrain extends from the spinal cord and is composed of the metencephalon andmyelencephalon. The metencephalon contains structures such as the pons and cerebellum.

These regions assists in maintaining balance and equilibrium, movement coordination, and the

conduction of sensory information. The myelencephalon is composed of the medulla oblongata

which is responsible for controlling such autonomic functions as breathing, heart rate, and

digestion.

The brain contains various structures that have a multitude of functions. Below is a list of

major structures of the brain and some of their functions.

Basal Ganglia

Involved in cognition and voluntary movement Diseases related to damages of this area are Parkinson's and Huntington's

Brainstem

Relays information between the peripheral nerves and spinal cord to the upper parts ofthe brain

Consists of the midbrain, medulla oblongata, and the ponsBroca's Area

Speech production Understanding language
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Central Sulcus (Fissure of Rolando)

Deep grove that separates the parietal and frontal lobesCerebellum

Controls movement coordination Maintains balance and equilibrium

Cerebral Cortex

Outer portion (1.5mm to 5mm) of the cerebrum Receives and processes sensory information Divided into cerebral cortex lobes

Cerebral Cortex Lobes

Frontal Lobes -involved with decision-making, problem solving, and planning Occipital Lobes-involved with vision and color recognition Parietal Lobes - receives and processes sensory information Temporal Lobes - involved with emotional responses, memory, and speech

Cerebrum

Largest portion of the brain Consists of folded bulges called gyri that create deep furrows

Corpus Callosum

Thick band of fibers that connects the left and right brain hemispheresCranial Nerves

Twelve pairs of nerves that originate in the brain, exit the skull, and lead to the head,neck and torso

Fissure of Sylvius (Lateral Sulcus)

Deep grove that separates the parietal and temporal lobesLimbic System Structures

Amygdala - involved in emotional responses, hormonal secretions, and memory
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Cingulate Gyrus - a fold in the brain involved with sensory input concerning emotionsand the regulation of aggressive behavior

Fornix - an arching, fibrous band of nerve fibers that connect the hippocampus to thehypothalamus

Hippocampus - sends memories out to the appropriate part of the cerebral hemispherefor long-term storage and retrievs them when necessary

Hypothalamus - directs a multitude of important functions such as body temperature,hunger, and homeostasis

Olfactory Cortex - receives sensory information from the olfactory bulb and is involvedin the identification of odors

Thalamus - mass of grey matter cells that relay sensory signals to and from the spinalcord and the cerebrum

Medulla Oblongata

Lower part of the brainstem that helps to control autonomic functionsMeninges

Membranes that cover and protect the brain and spinal cordOlfactory Bulb

Bulb-shaped end of the olfactory lobe

Involved in the sense of smellPineal Gland

Endocrine gland involved in biological rhythms Secretes the hormone melatonin

Pituitary Gland

Endocrine gland involved in homeostasis Regulates other endocrine glands

Pons

Relays sensory information between the cerebrum and cerebellumReticular Formation
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Nerve fibers located inside the brainstem Regulates awareness and sleep

Substantia Nigra

Helps to control voluntary movement and regualtes mood

Tectum

The dorsal region of the mesencephalon (mid brain)Tegmentum

The ventral region of the mesencephalon (mid brain).Ventricular System - connecting system of internal brain cavities filled with cerebrospinal fluid

Aqueduct of Sylvius - canal that is located between the third ventricle and the fourthventricle

Choroid Plexus - produces cerebrospinal fluid Fourth Ventricle - canal that runs between the pons, medulla oblongata, and the

cerebellum

Lateral Ventricle - largest of the ventricles and located in both brain hemispheres Third Ventricle - provides a pathway for cerebrospinal fluid to flow

Wernicke's Area

Region of the brain where spoken language is understood

PATHOGENESIS AND PATHOPHYSIOLOGYThe pathophysiology of febrile seizures is unknown. The role of cytokine network

activation is presently being studied along with an increased susceptibility to febrile

seizures associated with specific interleukin alleles.Circulating toxins, immune reaction products, and viral or bacterial invasion of the

central nervous system have been implicated, together with relative lack of myelination

in the immature brain and increased oxygen consumption during the febrile episode.

Immaturity of thermoregulatory mechanisms and a limited capacity to increase cellular

energy metabolism at elevated temperatures have been suggested as contributory

factors .
http://biology.about.com/library/organs/brain/blsubstantianigra.htmhttp://biology.about.com/library/organs/brain/bltectum.htmhttp://biology.about.com/library/organs/brain/bltegmentum.htmhttp://biology.about.com/library/organs/brain/blventricles.htmhttp://biology.about.com/library/organs/brain/blaqueduct.htmhttp://biology.about.com/library/organs/brain/blchoroidplex.htmhttp://biology.about.com/library/organs/brain/blfourthvent.htmhttp://biology.about.com/library/organs/brain/bllateralvent.htmhttp://biology.about.com/library/organs/brain/blthirdvent.htmhttp://biology.about.com/library/organs/brain/blwernicke.htmhttp://biology.about.com/library/organs/brain/blwernicke.htmhttp://biology.about.com/library/organs/brain/blthirdvent.htmhttp://biology.about.com/library/organs/brain/bllateralvent.htmhttp://biology.about.com/library/organs/brain/blfourthvent.htmhttp://biology.about.com/library/organs/brain/blchoroidplex.htmhttp://biology.about.com/library/organs/brain/blaqueduct.htmhttp://biology.about.com/library/organs/brain/blventricles.htmhttp://biology.about.com/library/organs/brain/bltegmentum.htmhttp://biology.about.com/library/organs/brain/bltectum.htmhttp://biology.about.com/library/organs/brain/blsubstantianigra.htm


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A recently documented pathogen associated with febrile seizures is human Herpes virustype 6. This is the etiologic agent for infant rosella, a common infection of infants and

toddlers usually associated with fever greater than or equal to 103F.

It is postulated that the direct viral invasion of the brain or fever causes the initial

febrile seizure, and that the virus might be reactivated by fever during subsequent

illnesses, causing recurrent febrile seizures.

COURSE IN THE WARDDATE TIME DOCTORS ORDER RATIONALE

8/15/11 10pm Pls. admit to Pedia Ward under theservice of Dr. Ramirez/Dr.Pasicolan

For continuouscare, monitoring

and treatment

Secure consent for admission For legal purposesWt. 10.3 kg

BP-80/50

Temp-39.5CR-124

RR-34

TPR q shift and record Serves as baselinedata

NPO Patient is underobservation

Diagnostics

CBC ; APL

Urinalysis;SG

SE

Hgb nowCranial CT scan

EEG

To providebaseline data on

patients

hematology

CBC:To determinethe extent of the

disease process.To

determine the

blood type and its

composition

Urinalysis;Todetermine

characteristics

and components

of urine which are

not usually presentthat also signal

infection in the

urinary system

Hook for D5 0.3 NaCl 500 ml to run@38-39 uggts/min x 8 hours

To replace fluidloss and for

further

nourishment


22/33

Chloramphenicol 260 mg IV q 6 hours(-)ANST

It has an effectagainst susceptible

bacteria, serve as

antibiotic

Paracetamol 105 mg IV q 4 hoursRTC

To decreasetemperature andfor mild pain

Diazepam 2 mg IV q 4 hours RTC It suppresses thespread of seizure

activity(prevent

seizure)

O2 inhalation 1-2 cpm/nasal cannula Inhalation ofOxygen aimed at

restoring toward

normal to

pathophysiologic

alterations of gas

exchange in the

cardiopulmonary

system.

Monitor IV q and record To serve asbaseline data

Monitor I and O q shift and record To serve asbaseline data

Watch out for seizure Dr. Pasicolan To prevent anyfurther injury

Seizure precaution @ bedside To preventfurther injury

Refer For furtherevaluation and

management

8/16/11 NPO Still the patient isunder observation

afebrile Cont. D5 0.3 NaCl @38-39 ugtts/min To continue inreplacement of

fluid loss and for

further

management

(-) seizure Follow-up CBC with APL and SE CBC:To determinethe extent of thedisease process.To

determine the

blood type and its

composition

(-) DOB Still for cranial CT Scan and EEG To visualize ifthere is affected

part on the cranial


23/33

area

Continue medications andmanagement

For continuoustreatment

Continue vital signs monitoring For baseline dataand to monitor

alteration Seizure precaution @ bedside To prevent

further injury

8/16/11 10am DAT To provideadequate nutrition

in order to regain

strength

IVF of D5 IMB 500 ml to run @ 32-33ugtts/min

To continue inreplacement of

fluid loss and for

further

nourishment

Continue medications andmanagement

For continuoustreatment

Continue vital signs monitoring For baseline dataand to monitor

alteration

Refer HAMA To continuemedications at

home with

physicians consent

PARACETAMOLCLASSIFICATION DOSAGE INDICATION CONTRAINDICATION ADVERSE

REACTION

Antipyretics 105 mg IV q 4

hours RTC

Inhibits

synthesisof

prostaglan

dins that

may serve

as

meditators

of pain and

Products

containingame,saccharinalco

hol,aspartame,sac

charin sugar

tartrazine should

be avoided in

patients who have

hypersensitivity or

GI;hepat

failure,hotoxicity

(overdose)

GU:rena

failure

Derm;ras


24/33

fever,prima

rily in the

CNShas no

significant

anti-

infllammatory

property of

GI toxicity.

intolerance to

these compounds.

CHORAMPHENICOLCLASSIFICATION DOSAGE INDICATION CONTRAINDICATION ADVERSE

REACTION


25/33

Antibiotic 260 mg IV q

6 hours (-)

ANST

May rarely

cause

systemic

hematologic

toxicity ifused

chronically

and in

excessive

causes.It

has bactero-

static

effect,effe

ct against

susceptible

bacteria;pre

vent cell

replication

Contraindicated

in patients

hypersensitive to

drug or its

components andin those with

perforated

eardrum.

EENT;ear

irritation or

itching

Skin;urticar

DIAZEPAM

CLASSIFICATION DOSAGE INDICATION CONTRAINDICATION ADVERSE REACT


26/33

Anxiolytics 2 mg IV q 6

hours

A

benzodi

azepine

that

probablypotentia

tes the

effects

of

GABA,d

epresses

the

CNS,an

d

suppress

es the

spread

of

seizure

activity.

Contraindicated

in patient

hypersensitivity

to drug or soy

protein; inpatients

experiencing

shock, coma or

acute alcohol

intoxication.

CNS;drow

ss,dysarthi

rred speec

CV;hypote

n,bradycarCv collaps

EENT;dipl

blurred vis

Respirator

piratoryde

sion,apnea

AssessmentNursing

DiagnosisPlanning Nursing Interventions Rationale

Objective:

:

Hyperthermia Short term:

Long Term:

After 2 days of

nursinginterventions,

the patient will

be able to befree of

complications

and maintain

coretemperature

within normalrange.

>

>

> > >

>

>

>

.

Assessment Nursing Planning Nursing Interventions Ration


27/33

Diagnosis

Subjective:

Objective:

the patient manifested:

> body weakness

> weight of 7.9kg

> loss of appetite

> poor muscle tone

the patient may manifest:

> abnormal laboratory

studies

> pallor

Imbalance

Nutrition: Less

than the bodyrequirement

related toeconomicalfactors.

Short term:

After 4 hours of

nursing interventions,

the patients willidentify measures to

promote nutrition andfollow the treatment

regimen

Long Term:

After 2 days of nursing

interventions, the will

demonstrate

behaviours or lifestylechanges to regain

appropriate weight.

>Review patients records.

>Assess underlying

condition.

>discuss eating habits and

encourage diet for age.

> Note total daily intake

includes patterns and time

of eating.

>Consult physician for

further assessment and

recommendation regarding

food preferences andnutritional support.

>To ob

data.

>To despecific

interve

>To ac

needs o

with th

diet for

>To re

that sho

in the c

intake.

>For g

understfurther

specific

AssessmentNursing

DiagnosisPlanning Nursing Interventions Rationale

Subjective:

Objective:

The patientmanifested:

>Body temperature

Ineffective

tissue

perfusion

realated todecreased

Hgb

concentration

in blood asevidenced bylow Hgb

count in CBC

Short term:

After 4 hours of nursingintervention, the patient

will demonstrate

behaviour lifestylechanges to improve

circulation.

Long term:

> Establish rapport.

> Monitor VS.

> Determine factors related

to individual situation.

> Evaluate for signs of

infection especially when

immune system is

> To gain patient a

trust and promote

cooperation.

> To monitor patie

> To gain informa

regarding the cond

>To observe for p


28/33

changes.

>Skindiscoloration

The patient maymanifest:

> Anemia

result After 2 days of nursing

intervention, the

patients S.O. willverbalize understanding

of the condition.

compromised.

> Discuss individual riskfactors.

> Elevate head of bed atnight.

> Discuss the importance

of a healthy diet..

risk factors.

> This information

necessary for the cS.O.

> To increase gravblood flow.

>To promote a hea

to help increase RBsynthesis and Hgb

faster recovery.

AssessmentNursing DiagnosisPlanningNursing InterventionsRationaleExpected OutcomeS =

O = the patient manifested:

>body weakness

>fatigue

>poor muscle tone

=The patient may manifest:

>elevated body temperature

>Hgb = 112

>WBC = 22.9

>RBC = 3.97


29/33

>HCT = 0.34

>Platelet count = 234

Risk for (spread) of infection

Short Term:

After 3 hours of nursing interventions, the patient will verbalize understanding of ways on how to prevent

spread of infection.

Long Term:

After 1week of nursing interventions, the patient will be free from infections and further complications

>Establish good working relationship with the client and S.O.

>Monitor and record vital signs

> Determine pts individual strength

>Provide peaceful environment

>Provide adequate rest and sleep.

>Emphasize importance of hand washing

>Provide safety measures

>Monitor I & O

>Check IV and Regulate IVF

>Advice pt to increase oral fluid intake when allowed

>To gain their trust and cooperation

>For comparative baseline data

>To know when to assist client


30/33

>To promote optimum level of functioning

>To prevent fatigue and conserve energy

>.to prevent occurrence of further infections

>To prevent falls and injuries

>To note for imbalances

>To ensure proper hydration

> To replace fluid electrolyte loss

Short Term:

After 3 hours of nursing interventions, the patient shall have verbalized understanding of ways on how to

prevent spread of infection.

Long Term:

After 1week of nursing interventions, the patient shall have been free from infections and further

complications.

AssessmentNursing DiagnosisPlanningNursing InterventionsRationaleExpected

OutcomeSubjective:

Objective:

the patient may manifest the following:

>Fever


31/33

>Convulsion

>Low

>Low Hgb Level = 112

Risk for injury related to possible convulsion.Short term:

After 4 hours of nursing interventions, the SO will modify environment as indicated to enhance safety.

Long term:

After 2 days of nursing interventions, the SO will verbalize understanding of individual factors that

contribute to possibility of injury.

>establish rapport

>monitor and record Vital Signs

> ascertain knwlge of safety needs/ injury prevention

> note clients gender, age, developmnt stage, decision makng ability, level of cognition/competence

>provide health care within a culture of safety

> identify interventions/safety devices

> discuss importance of self monitoring of conditions/ emotions

> To gain patients trust

>To obtain baseline data

> to prevent injuries in home, community, and work setting

>affects clients ability to protect self/others and influence choice of interventions/ teachings

>to prevent errors resulting in client injury, promote client safety and model safety behaviors for

client/SO

>to promote safe physical environment and individual safety


32/33

>it can contribute to occurence of injury

Short term:

The SO shall have modified environment as indicated to enhance safety.

Long term:

The SO shall have verbalized understanding of individual factors that contribute to possibility of injury.

DISCHARGE CARE PLAN

MEDICATION Instructed and explained to the

patient the importance of taking

medication as well as the duration

in taking medicine

Advised SO to continue givingvitamin supplements to patient to

boost her immune system

EXERCISE Advised to avoid strenuous

activities and have moderateexercises lie adduction and

abduction of upper and lower

extremities

TREATMENT Instructed patient to follow strict

compliance with the medicines

ordered and have regular wound

dressing

Advised SO the importance ofadherence to treatment regimen

HYGIENE Encouraged patient to haveproper hand washing regularly,brush teeth 3 times a day and takea bath daily

OPD Advised SO to come back

@CVMC for further follow-up

check-up after discharged

SO is advised to consult doctor if


33/33

any problems or complications

encountered

DIET Advised SO to give nutritious

foods which is high in protein and

essential vitamins

Encouraged SO to increased fluidintake of the patient

SPIRITUAL Encouraged the SO to have strong

faith for fast recovery of the

patient

Advised SO not to be discouragedand lose hope even if there are

many problems theyve encountered

a case study on cns infection

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