INTRODUCTION Bacterial meningitis is a serious infection of the fluid in the spinal cord and the fluid that surrounds

the brain. It is most commonly caused by one of three types of bacteria: Haemophilus influenzae type B, Neisseria meningitides (Meningococcal Meningitis), and Streptococcus pneumoniae (Pneumococcal Meningitis) bacteria.

The bacteria are spread by direct close contact with the discharges from the nose or throat of an infected person. In persons over age 2, common symptoms are high fever, headache, and stiff neck. These symptoms can develop over several hours, or they may take 1 to 2 days. Other symptoms can include nausea, vomiting, sensitivity to light, confusion, and sleepiness. In advanced disease, bruises develop under the skin and spread quickly.

In newborns and infants, the typical symptoms of the disease are fever, headache, and neck stiffness. Other signs in babies are irritability, vomiting, and poor feeding.

As the disease progresses, patients of any age who suffer the disease can have seizures thereby causing more complications. Seizures are episodes of abnormal motor, sensory, autonomic or psychic activity (or a combination of these resulting) from sudden excessive fro cerebra neurons. Symptoms may vary depending on the part of the brain that is involved, but seizures often cause unusual sensations, uncontrollable muscle spasms, and loss of consciousness.

Anyone can get bacterial meningitis, but it is most common in infants and children. People who have had close or prolonged contact with patients with meningitis caused by Neisseria meningitidis or Haemophilus influenzae can also be at increased risk.

The diagnosis is usually made by growing bacteria from a sample of spinal fluid. The spinal fluid is obtained by a spinal tap. Identification of the type of bacteria responsible for the meningitis is important for the selection of correct antibiotic treatment.

Advanced bacterial meningitis can lead to brain damage, coma, and death. Survivors can suffer long-term complications, including hearing loss, mental retardation, paralysis, and seizures. The subject of the proponents case presentation is Patient X, 2-month old. She was admitted in JRB Memorial Hospital on the 3rd day of October 2009, 7:42 in the evening with a chief complain of fever. Patient X was then diagnosed by the attending physician to have bacterial meningitis and was considered to have bronchitis. As health care providers we ought to endow the client with health care managements to our optimum best. Moreover, facilitate the client to revive from his current condition. Nevertheless, despite the interventions rendered, patient X was declared dead last October 8, 2009 at 12:15 pm.

General Objectives At the end of an hour of case presentation, the BSN-II students of block NF will be able to present the over-all concept of the case study conducted which includes the pathophysiology of the disease and the managements done to alleviate the clients condition. The students will also be able to suffice the panellists expectations and be able to give satisfying answers to their questions and defend promptly. Lastly, the students will be able to understand and integrate their learning to their future clinical experiences. Specific Objectives At the end of 1 hour of case presentation the students will be able to: Present the case total framework of the case study Answer the panellists questions correctly Accept the constructive criticism of the panel lists or clinical instructors. Formulate viable nursing diagnoses in connection with the clients over-all health status State and specify the interrelationship of the identified disease condition and their complications which further led to the clients death

D. Scope and Limitation This study revolves around the case of Patient F, 2 months old, diagnosed with baterial meningitis. This study includes the patients study. Considering the age and the stuporous condition of the client, the proponents have failed to gather more information regarding the patients data and overall health status subjectively. The data gathered are based only to the statements of the clients significant other/ informant and from the patients chart. Furthermore, this study is limited only to the current condition of the client as assessed during the 16-hours of duty at JRB Memorial Hospital on October 7-8, 2009, 3-11pm shift. However, documented data beyond the duty hours were used for a broader range of support on the study conducted. general profile health history of the patient history of present illness anatomy and physiology of the involved structures pathophysiology of the condition patients diagnosis diagnostic exams nursing management medical management recommendation of the case study Patients prognosis as evaluated by the student nurse conducting this

II. Assessment Tool: I. GENERAL INFORMATION NAME: Patient F old BIRTHDAY: August 1, 2009 Bulua, CDOC SEX: Female Catholic ADDRESS: Zone 9 Bulua, Cagayan de Oro City CURRENT EDUCATIONAL LEVEL: N/A 8, 2009 INFORMANT: Mother F ADMISSION: Date: October 3, 2009 2009 TIME: 7:48 PM CHIEF COMPLAINT UPON ADMISSION: Fever ATTENDING PHYSICIAN: Dr. Arbeen Laurito DIAGNOSIS/IMPRESSION: Bacterial Meningitis HISTORY OF PRESENT ILLNESS: Three days PTA had acute onset of fever, moderate grade, unassociated with cough, colds, cyanosis. Eight brought to the hospital. hours PTA had acute onset of dyspnea, then TIME: 12:15 PM TIME: 2:00 PM DEATH: Date: October 8, DISCHARGE: DATE: October RELIGION: Roman BIRTHPLACE: AGE: 2 months

II. PAST ILLNESS/MEDICAL/SURGICAL HISTORY: ILLNESS FEVER October 1, 2009 DATE

VITAL SIGNS: HEART RATE: 126 bpm RESPIRATORY RATE: N/A BLOOD PRESSURE: 60/45 mmHg SATURATION: 89% TEMPERATURE: 33.6C WEIGHT: N/A

OXYGEN HEIGHT: N/A 4

*Vital signs reflected here were taken at 10:00 PM on Wednesday, October 7, 2009

III. CURRENT MEDICATIONS: DRUG Calcium Gluconate DOSE/FREQUENCY/R INDICATION OUTE 92.5 cl/17 Emergency treatment mgtts/min/IV of hyperkalemia and hypermagnesemia and adjunct in cardiac arrest or calcium channel blocking agent toxicity.

Dopamine

500cc/4 gtts/min/IV

Adjunct to standard measures to improve: blood pressure, cardiac output, urine output in treatment of shock unresponsive to fluid replacement.

Drug Allergies: no known allergies

IV. ASSESSMENT OF SYSTEMS: Objective General Appearance: patient is unresponsive, lies on bed the whole time, pale skin, soft bulging anterior fontanel, cracked lips with coffee ground secretions. Personal Hygiene/Habits Grooming/Hair: hair is well combed, scalp is clean, no parasites found Clothing/Manner of Dress: dressed lightly Immunizations Received: Immunization BCG HEP B-1 DPT 1 OPV 1 HEP B-2 Date Received August 1, 2009 August 1, 2009 September 25, 2009 September 25, 2009 September 25, 2009 Place Received Bulua Health Center Bulua Health Center Bulua Health Center Bulua Health Center Bulua Health Center

V. NUTRITIONAL/METABOLIC PATTERN: Skin Color: Pale Lesions: lips are chapping (cheilosis) Hair Color: Black Lesions: none Nail Color : bluish (cyanotic) nails, capillary refill (2 seconds) Oral Mucosa: Teeth: None Texture: smooth Texture: shiny and smooth Condition: firm, elastic, long Condition: dried chapped lips; 6

reddish gums with retained coffee-ground secretions Daily Food Intake Breakfast: mixed bottle feed (Nestogen) and breastfeed Lunch: mixed bottle feed (Nestogen) and breastfeed Dinner: mixed bottle feed (Nestogen) and breastfeed Note: Breastfed every time the child feels hungry evident through crying. Food Supplements: none Vitamins taken: Tiki-tiki Food Allergies: none Comment: The patient has an inconsistent type of feeding but adequate amount of nutrient components can be found in the breast milk (bottle feeding and breastfeeding)

VI. ELIMINATION: Bowel Habits: Frequency: approximately 1 to 2 times every 8 hours Consistency: sakto lang, dili kaayo gahi, dili pud kayo basa, as verbalized by the informant. Color: yellowish stool Amount: depende na siya sa kadaghan nga gatas iyang gina-inom, gang, as verbalized by the informant. Comment: the patient was able to defecate formed yellowish cylindrical stool prior to admission. Bladder Habits: Frequency: approximately 3 to 4 times every 8 hours Amount: 15 cc for 8 hours Color: yellowish urine VII. ACTIVITY-EXERCISE: Daily Activities usually wakes up at 6 am; breastfed; plays with SOs; sleeps again; wakes up at 11am-12noon for breastfeed; plays with SOs; siesta; breastfed; sleeps at 6pm and wakes up again at 6am. Leisure Activities plays with her own hands; enjoys watching colourful things; plays with her SOs; enjoys listening to mellow music genre. Exercise Routine raises her head and maintains the position; holds any light objects momentarily before dropping it. VIII. SLEEP-REST Time of sleep: 6pm-6am (12 hours of sleep) 7

Sleep Aids: mosquite net, duyan, pillows, blanket, with her mother on her sight before finally get into sleep. Quality: deep sound sleep IX. SLEEP-REST Vision unable to clearly visualize objects but can identify source of light Hearing already developed however client is stuporous and was therefore not assessed Smell already developed however client is stuporous and was therefore not assessed Aids for Vision none Aids for Hearing none X. COGNITIVE Ability to express N/A XI. ROLE-RELATIONSHIP PATTERN Ordinal position of the client in the family 3rd (2nd to the youngest) out of 4 siblings Primary Caregiver of the client Mother X Other Support System of Client Father, siblings, grandmother, aunts, and other kins Developmental Milestones (Infants to Adolescents) Age Infancy Psychosexual Oral Stage (Freuds theory), Child explores the world by using mouth, especially the tongue. Psychosocial Trust VS Mistrust (Eriksons Theory), Child is learning confidence and learning to love. Cognitive Primary Circular Reaction (Jean Piaget), The Child spends much time looking at objects and separating self from them. 8

Toddler Preschool School-Age Adolescent

N/A N/A N/A N/A

N/A N/A N/A N/A

Brings thumb to mouth for a purpose: to suck it. N/A N/A N/A N/A

BODY MAP: (Illustrate in the body map how your patient looks like, e.g. tubes inserted bruises, surgical incisions, and physical abnormality affected areas. Mark with a small X where it is located or draw it on the body map and then label.) Describe Affected Areas: dried chapped lips; reddish gums with retained coffee-ground secretions, soft bulging anterior fontanel, IV line inserted at left and right hand with IV fluid regulated well.
Chapped lips, with OGT (visible secretions noted), oxygen inhalation via ambubag

Soft bulging anterior fontanel

The entire skin of the baby is pallor Accentuation of bronchovascular markings

Decerebrate and cyanosis PNSS 1L solu set Decerebrate and cyanosis Dopamine Premix 50 cc solu set

Laboratory/Diagnostic Results (Include date and interpret results.): a. 10/03/09 Complete Blood Count RESULTS WBC Count RBC Count Hemoglobin 4,100 10.2 EXPECTED VALUES 5,000-10,000 4.20-5.40 (M) 12.0-16.0 gm/dl INTERPRETATI ONS WBCs are below normal range HMG are below normal range. 10

Hematocrit Platelet Count

30.8 307,000

37.0-47.0 vol % 150,000400,000/nm

HCT are below normal range. Platelet is within normal range.

b.10/05/09 Complete Blood Count RESULTS WBC Count RBC Count Hemoglobin Hematocrit Platelet Count ABO typing O Rh+ Differential Count RESULTS Granulocytes Lymphocytes Monocytes Eosonophils Basophils Stabs c.10/06/09 Complete Blood Count RESULTS WBC Count RBC Count Hemoglobin Hematocrit Platelet Count 14.9 44.8 EXPECTED VALUES 5,000-10,000 4.20-5.40 (M) 12.0-16.0 gm/dl 37.0-47.0 vol % 150,000400,000/nm INTERPRETATI ONS HMG within normal range. HCT within normal range. EXPECTED VALUES 43.4-76.2% 17.4-40.2% 4.5-10.5% 0-7.0% 0-2.0% 1.0-2.0% INTERPRETATI ONS EXPECTED VALUES 5,000-10,000 4.20-5.40 (M) 12.0-16.0 gm/dl 37.0-47.0 vol % 150,000400,000/nm INTERPRETATI ONS -

Differential Count RESULTS Granulocytes Lymphocytes Monocytes EXPECTED VALUES 43.4-76.2% 17.4-40.2% 4.5-10.5% INTERPRETATI ONS 11

Eosonophils Basophils Stabs d. 10/07/09 Urinalysis

0-7.0% 0-2.0% 1.0-2.0%

Color: straw pH: 5.5 Transparency: clear SpGr: 1.020 Pus: 0-2 hpf Albumin: +1 RBC: 0-2 hpf Epithelial cells: Few Mucous Thread Mucous Thread Bacteria: Few Crystals: Amorphoric wastes- few Ca oxalate- occasional Casts: yeast cells- plenty

III.

Anatomy and Physiology A. Narrative:

The nervous system is essentially a biological information highway, and is responsible for 12

controlling all the biological processes and movement in the body, and can also receive information and interpret it via electrical signals which are used in this nervous system.

It consists of the Central Nervous System (CNS), essentially the processing area and the Peripheral Nervous System which detects and sends electrical impulses that are used in the nervous system.

The Central Nervous System is effectively the centre of the nervous system, the part of it that processes the information received from the peripheral nervous system. The CNS consists of the brain and spinal cord. It is responsible for receiving and interpreting signals from the peripheral nervous system and also sends out signals to it, either consciously or unconsciously.

The Central Nervous System is arguably the most important part of the body because of the way it controls the biological processes of our body and all conscious thought. Due to their importance, they are safely encased within bones, namely the cranium protecting the brain and the spine protecting the spinal cord.

The brain weighs approximately 1.3 kg and is surrounded by warm shock-absorbing fluid called the cerebrospinal fluid. It is contained in cranium, which consists of three layers of membranes, also referred to as meninges, to protect the brain. First, it is covered by the most thickest later called the dura mater, the second layer is called archnoid membrane and the finally the thinnest and the most delicate layer is called the pia mater.

The brain is composed of three distinct parts: Cerebrum, Cerebellum and Brainstem. Cerebrum is a network of neurons that consists of billions of various neurons cells as well as glial cells. Cerebellum is also composed of network of neurons, but is different in function-wise. Brainstem contains fibre tracts that connect the cerebrum and cerebellum to the rest of the body.

Spinal Cord The spinal cord is a long bundle of neural tissue continuous with the brain that occupies the interior canal of the spinal column and functions as the primary communication link 13

between the brain and the rest of the body. The spinal cord receives signals from the peripheral senses and relays them to the brain.

Brain Stem The brain stem is the part of the brain that connects the cerebrum and diencephalons with the spinal cord.

Medulla Oblongata The medulla oblongata is located just above the spinal cord. This part of the brain is responsible for several vital autonomic centers including:

the respiratory center, which regulates breathing. the cardiac center that regulates the rate and force of the heartbeat. the vasomotor center, which regulates the contraction of smooth muscle in the blood vessel, thus controlling blood pressure.

The medulla also controls other reflex actions including vomiting, sneezing, coughing and swallowing.

Pons Continuing up the brain stem, one reaches the Pons. The pons lie just above the medulla and acts as a link between various parts of the brain. The pons connect the two halves of the cerebellum with the brainstem, as well as the cerebrum with the spinal cord. The pons, like the medulla oblongata, contain certain reflex actions, such as some of the respiratory responses.

Midbrain The midbrain extends from the pons to the diecephalon. The midbrain acts as a relay center for certain head and eye reflexes in response to visual stimuli. The midbrain is also a major relay center for auditory information.

Diencephalon The diencephalons is located between the cerebrum and the mid brain. The 14

diencephalons houses important structures including the thalamus, the hypothalamus and the pineal gland.

Thalamus The thalamus is responsible for "sorting out" sensory impulses and directing them to a particular area of the brain. Nearly all sensory impulses travel through the thalamus.

Hypothalamus The hypothalamus is the great controller of body regulation and plays an important role in the connection between mind and body, where it serves as the primary link between the nervous and endocrine systems. The hypothalamus produces hormones that regulate the secretion of specific hormones from the pituitary. The hypothalamus also maintains water balance, appetite, sexual behavior, and some emotions, including fear, pleasure and pain.

Cerebellum The functions of the cerebellum include the coordination of voluntary muscles, the maintenance of balance when standing, walking and sitting, and the maintenance of muscle tone ensuring that the body can adapt to changes in position quickly.

Cerebrum

The largest and most prominent part of the brain, the cerebrum governs higher mental processes including intellect, reason, memory and language skills. The cerebrum can be divided into 3 major functions:

Sensory Functions - the cerebrum receives information from a sense organ; i.e., eyes, ears, taste, smell, feelings, and translates this information into a form that can be understood.

Motor Functions - all voluntary movement and some involuntary movement. Intellectual Functions - responsible for learning, memory and recall.

Meninges 15

The meninges are made up of three layers of connective tissue that surround and protect both the brain and spinal cord. The layers include the dura mater, the arachnoid and the pia matter.

Cerebrospinal Fluid The cerebrospinal fluid is a clear liquid that circulates in and around the brain and spinal cord. Its function is to cushion the brain and spinal cord, carry nutrients to the cells and remove waste products from these tissues.

16

PATHOPHYSIOLOGY OF BACTERIAL MENINGITIS Narrative

17

Illustration

18

Medical Management General Management Ideal Management Initial Spinal Tap/ Lumbar Puncture 1. procedure that is often performed in the emergency department to obtain information about the CSF to rule out potential life threatening conditions 2. should be performed only after a neurologic examination and should never delay potentially life-saving intervention such as administration of antibiotics Indications for repeat lumbar puncture To determine if the illness is progressing as the CSF may become pus-filled from clear fluid Isolation is used until the patient has received at least 24 hours of antibiotic therapy Establish an intravenous line Serves as vehicle for the administration of antibiotics, which need to be quickly assimilated, and also aids in the restoration of fluids and electrolytes Fluid and electrolyte management Closely monitor patients by checking vital signs and neurologic status and by ensuring an accurate record of intake and output. By prescribing the correct type and volume of fluid, the risk of development of brain edema can be minimized. The child should receive fluids sufficient to maintain systolic blood pressure at around 80 mm Hg, urinary output of 500 mL/m2/d, and adequate Actual management Vital Signs Monitoring - to monitor the clients condition. Intake and Output - to determine any abnormalities of the function of the urinary and digestive systems. Hgt determination - to determine glucose level in the body. Intravenous Therapy 0.3 NaCl - for rehydration and supplying fluids and medications directly into the intravascular compartment. Oxygen Therapy - to treat harmful and possibly lethal effects of hypoxemia resulting from respiratory or cardiac emergency, an increase in metabolic function and shock. Sodium and Potassium determination - to determine sodium and potassium level in the body. Cranial UltrasoundX-ray - to check the abnormalities and complication inside the body. Blood transfusion(PRBC) 19

tissue perfusion. While care to avoid SIADH is important, underhydrating the patient and risk of decreased cerebral perfusion are equally concerning as well. Dopamine and other inotropic agents may be necessary to maintain blood pressure and adequate circulation. Antibiotic therapy Antibiotics are given in combination and are adjusted on the basis of culture and sensitivity reporting of the patient Antibiotics are given according to the patients progress but are usually administered for a minimum of 10 days. Laboratory Examinations: 1. Hematology Complete Blood Count Include hemoglobin and hematocrit measurements, erythrocyte (RBC) count, Red Blood Cell (RBC) indices and a differential white cell count. Basic screening test and one of the most frequently ordered blood test. Blood Transfusion process of transferring blood or blood-based products from one person into the circulatory system of another. Urinalysis Examination of urine for certain physical properties,

- ordered to restore the loss of Red Blood Cells and fresh whole blood. Pharmacotherapy 1. Diazepam 2. Phenobartibal 3. Paracetamol 4. Ceftadizine 5. Diphenyldramin 6. Ampicillin 7. Furosemide 8. Phytonadione 9. Ciprofloxacin 10.Mannitol 11. Dopamine 12.Ceftriazone 13.Penicillin G 14.Gentamycin 15.Paracetamol 16.Ranitidine 20

solutes, cells, casts, crystals, organisms, or particulate matter. Ultrasound examination to diagnose a variety of conditions and to assess organ damage following illness. Oxygen administration o Monitor blood gas levels closely to ensure adequate oxygenation and metabolic stability. Computed tomographic (CT) scan may be helpful in pointing secondary sites of infection

Laboratory Examinations Urinalysis - to assess for any abnormalities in the kidney and in the endocrine system. ABO Blood Typing - to check compatibility of blood for blood transfusion. Complete Blood Count basic screening test for determining the specific blood cell values which includes Include hemoglobin and hematocrit measurements, erythrocyte (RBC) count, Red Blood Cell (RBC) indices and a differential white cell count. Hemoglobin

measure the severity of anemia or polycythemia, monitor the response to treatment of anemia or polycythemia, and help make decisions about blood transfusions if the anemia is severe.

Hematocrit the diagnosis of anemia and polycythemia, the monitoring of treatment for anemia, recovery from dehydration, and monitoring of ongoing bleeding to check its severity.
o o o o

21

Platelet Count DRUG STUDY

Generic Name Penicillin G Brand name Wycillin Drug Classification Anti-infectives Indication Moderate to severe systemic infection. Children older than 1 month: 25,000 to 50,000 units/kg I.M. daily in a single dose Drug Action Inhibits cell-wall synthesis during bacterial multiplication. Route: IM Availability or Stock Injection: 600,000 units/ml; 1,200,000 units/ml Special Consideration CNS: seizures, * Before giving , ask lethargy, patient/SO about hallucinations, allergic reactions to anxiety, confusion, penicillin agitation, * Give deep IM in depression, midlateral thigh in dizziness, fatigue small children. GI: Nausea, Dont massage vomiting, injection sites. enterocolitis, Avoid injection near pseudomembranous major nerves or colitis blood vessels to GU: Interstitial prevent permanent nephritis , neurovascular nephropathy damage. Hematologic: *Monitor renal and thrombocytopenia, hematopoietic hemolytic anemia, functions leukopenia, anemia, periodically eosinopihilia, *Treatment duration agranulocytosis depends on site Musculoskeletal: and cause of arthralgia infection. Other: hypersentivity reactions, anaphylaxis, overgrowth of nonsusceptible organisms Adverse Reaction Date Ordered Oct. 3, 2009

22

Gentamicin

Garamycin

Anti-infectives

Serious infections caused by sensitive strains of Pseudomonas aeruginosa, Escherichia coli, Proteus, Klebsiella or Staphyococcus Infants: 2.5 mg/kg q8h I.M. or by I.V. infusion

Inhibits protein synthesis by binding directly to the 30S ribosomal subunit; bactericidal Route: IV or IM

Injection: 10 mg/ml I.V. infusion: 40 mg, 60 mg, 70 mg, 80 mg, 90 mg, 100 mg, 120 mg, in normal saline solution

CNS: fever, headache, lethargy, encephalopathy, confusion, dizziness, seizures, numbness, peripheral neuropathy, vertigo, ataxia, tingling CV: hypotension EENT: ototoxicity, lured vision, tinnitus GI: vomiting, nausea GU: nephrotoxicity, possible increase in urinary excretion of casts Hematologic: anemia, eosinophilia, Leukopenia, thrombocytopenia, agranulocytosis Musculoskeletal: muscle twitching, myasthenia gravislike syndrome Respiratory: apnea Skin: rash, urticaria, pruritus, injection site pain Other: anaphylaxis

*Evaluate patients hearing before and during therapy. Notify prescriber, if patient complaints of tinnitus, vertigo or hearing loss. * Weigh patient and review renal function studies before therapy begins * Watch for signs and symptoms of superinfection especially at upper respiratory tract such as continues fever, chills and increased pulse rate * Encourage patient to drink plenty of fluids

Oct. 3, 2009

23

Paracetamol

Acetaminophen

Nonopioid analgesic and antipyretics

Mild pain and fever Children up to 3 months: 40 mg P.O. q4 to 6h dont exceed five doses in 24 hour

Unknown. Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandins in the CNS or of other substances that sensitize pain receptors for stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating center Route: PO Competitively inhibits action of histamine on the H2 at receptor sites of parietal cells, decreasing gastric acid secretion Route: P.O or I.V

Caplets: 160 mg, 500 mg Capsules: 325 mg, 500 mg Elixir: 80 mg/2.5 ml, 80 mg/5ml Gelcaps: 500 mg Oral liquid: 160 mg/5ml, 500 mg/15ml Oral solution: 48 mg/ml Oral suspension: 80 mg/ 0.8ml Oral Syrup: 16 mg/ml Sprinkles: 80 mg/capsule Suppositories: 80 mg, 120 mg, 125 mg, 300 mg, 325 mg, 650 mg Tablets: 160 mg Granules: 150 mg Infusion: 1 mg/ml in 50-ml container Injection: 25 mg/ml Syrup: 15 mg/ml Tablets: 75 mg, 150 mg, 300 mg

Hematologic: hemolytic anemia, neutropenia, leukopenia, pancytopenia Hepatic: jaundice Metabolic: hypoglycemia Skin: rash, urticaria

* use liquid form for children and patients who have difficulty in swallowing * in children, dont exceed in five doses in 24 hours

Oct. 3, 2009

Ranitidine

Zantac

Therapeutic: Anti-ulcer agents

Pharmacologic: Histamine H2 antagonists

Treatment and prevention of heartburn, acid indigestion, and sour stomach.

CNS: vertigo, malaise, headache EENT: blurred vision Hepatic: jaundice Other: burning and itching at injection site, anaphylaxis, angioedema

*Assess patient for abdominal pain. Note presence of blood in emesis, stool or gastric aspirate * Drug may be added to total parenteral nutrition solutions

Oct. 3, 2009

24

Phenobarbital

Solfoton

Anticonvulsants

Anticonvulsants, febriles seizures

As a barbiturate, may depress CNS and increase seizure threshold. As a sedative, may interfere with transmission of impulses from thalamus to cortex of brain Route: PO, IM, IV

Elixir: 20 mg/5 ml Injection: 30 mg/ ml, 130 mg/ml Tablets: 15 mg, 30 mg, 60 mg, 100 mg

CNS: drowsiness, lethargy, hangover, somnolence, changes in EEG patterns, physical and psychological dependence CV: bradycardia, hypotension, syncope, GI: nausea, vomiting Hematologic: exacerbation of porphyria Respiratory: Respiratory depression, apnea Skin: rash, erythema multiforme, urticaria, pain, swelling thrombophlebitis, necrosis, nerve injury at injection site.

*Give IM injection deeply into large muscles. Superficial injection may cause pain, sterile abscess and tissue sloughing * Watch for signs of barbiturate toxicity: coma, cyanosis, asthmatic breathing, clammy skin, and hypotension. Overdose can be fatal * Dont stop drug abruptly because it may worsen seizures. Call prescriber immediately if adverse reactions develop * Drug may decreae bilirubin level in neonates, patients with epilepsy and those with congenital nonhemolytic, unconjugated hyperbilirubinemia

Oct. 4, 2009

25

Hydrocortisone

Aquacort,

Corticosteroids Hormonal Drug

Severe inflammation, adrenal insufficiency, shock, adjunct treatment for ulcerative colitis and proctitis

Decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses ummune response; stimulates bone marrow; and influences protein, fat and carbohydrate metabolism Route: IV, PO, IM

Enema: 100 mg/60 ml Tablets: 5 mg, 10 mg, 20 mg

CNS: vertigo, headache, seizures CV: Heart failure, hypertension, edema, thrombophlebitis, thromboembolism EENT: cataract, glaucoma GI: Peptic ulceration, increased appetite, nausea, vomiting GU: increased urine calcium levels Hematologic: easy bruising Musculoskeletal: Growth suppression in children, muscle weakness Skin: delayed wound healing, acne, skin eruption

* For better results and les toxicity, give a once-daily dose in morning * Inject IM deeplyin glutealmuscle. Rotate injection site to avoid muscle atrophy. Avoid subcutaneous injection because atrophy and sterile abscesses may occur. * Always adjust to lowest effective dose * Monitor patients weight, blood pressure and electrolyte level

Oct. 4, 2009

26

Mannitol

Osmitrol,

Diuretics

Test dose for marked oliguria, or suspected inadequate renal function; diuresis in drug intoxification; to reduce intraocular and intracranial pressure

Increases osmotic pressure of glomerular filtrate, inhibiting tubular reabsorption of water and electrolytes; drug elevates plasma osmolality, increasing water flow into extracellular fluid Route: IV

Injection: 5%, 10%, 15%, 20%, 25%

CNS: seizures, dizziness, headache, fever CV: edema, thrombophlebitis, hypotension, heart failure, tachycardia, chest pain, vascular overload EENT: blurred vision, rhinitis GI: thirst, dry mouth, nausea, vomiting, diarrhea GU: urine retention Metabolic: dehydration Skin: local pain, urticaria, Other: chills

*monitor vital signs * Check weight, renal failure, fluid balance, serum and urine sodium and potassium levels daily * to relieve thirst, give frequent mouth care or fluids Drug can be use to measure glomerular filtration rate

Oct. 4, 2009

27

Diazepam

Diastat

Anxiolytics

Status epilepticus, severe recurrent seizures; preoperative sedation; before endoscopic procedure

A benzodiazepine that probably potentiates the effects of GABA, depresses the CNS and suppresses the spread of seizure activity Route: IV, PO, IM, PR

Capsules: 15 mg Injection: 5 mg/ml Oral solution: 5 mg/ml Rectal Gel Twin Packs: 2.5 mg, 5 mg Tablets: 2 mg, 5 mg, 10 mg

CNS: drowsiness, headache, hallucinations, minor changes in EEG patterns, slurred speech CV: hypotension, CV collapse, bradycardia GI: nausea, constipation, diarrhea GU: incontinence, urine retention Hematologic: neutropenia Hepatic: jaundice Respiratory: respiratory depression, apnea Skin: rash Others: pain, phlebitis in the injection site

* When using oral concentrate solution, dilute dose just before giving * Monitor periodic hepatic, renal and hematopoietic function studies in patient receiving repeated or prolonged therapy

Oct. 4, 2009

28

Ceftazidime

Ceptaz

Anti-infectives

Serious UTI and lower respiratory tract infection; skin, gynecologic, intra-abdominal and CNS infection; bacteremia and septicemia caused by susceptible microorganisms, such as streptococci

Third generation Cephalosporin that inhibit cellwall synthesis, promoting osmotic instability; usually bactericidal Route: IV, IM

Infusion: 1g, 2g in 50-ml and 100-ml vials Injection: 1g, 2g

CNS: headache, dizziness, paresthesia, seizures CV: phlebitis, thrombophlebitis GI: nausea, vomiting, diarrhea, abdominal cramps Hematologic: eosinophilia, hemolytic anemia, leukopenia, Skin: rashes, urticaria, pain, induration, tissue sloughing on the injection site

*For IM Oct. 5, 2009 administration, inject deep into a large muscle, such as the gluteus maximusor the side of the thigh *Advise SO to notify prescriber about loose of stools and diarrhea * Before administrations, ask SO if there are ay allergies of penicillin and cephalosporins

29

Ampicillin

Novo Ampicillin

Aniti-infectives

Bacterial meningitis or septicemia

Inhibits cell-wall synthesis during bacterial multiplication Route: PO,IV,IM

Capsules: 250 mg, 500 mg, 1 g, 2g Oral suspensions: 125 mg/5ml, 250mg/5m

CNS: lethargy, seizure, dizziness, fatigue, agitation CV: thrombophlebitis GI: nausea, vomiting, diarrhea Hematologic: Anemia, eosinophilia, hemolytic anemia Skin: pain at injection site

* Before giing the drug, ask S.O if patient about allergic reactions to penicillin. A negative history to penicillin allergy is no guarantee against a future allergic reaction * Give drug I.M or I.V only if prescribed and the infections is severe or if patient cant take oral dose *Give drug 1 hour r 2 hours before or 2 to 3 hours after meals. When given orally, drug may cause GI disturbances. Food may interfere with absorption In pediatric meningitis, ampicillin may be given with parenteral chloramphenicol for 24 hours, pending cultures

Oct. 5, 2009

30

Ceftriaxone

Rocephin

Cephalosphorin

UTI, lower respiratory tract, gynecologic, bone or joint, intra abdominal, skin, or skin structure infection, septicemia

Third-generation cephalosphorin that inhibits cellwall synthesis, promoting osmotic instability; usually bactericidal

Infusions: 1g, 2g piggyback; 1g, 2g/50ml premixed Injection: 250 mg, 500 mg, 1g, 2g

CNS: fever headache, dizziness CV: phlebitis GI: diarrhea Hematologic: eosinophilia, thrombocytosis Skin: pain induration, tenderness at injection site, rash pruritis

*Before giving drug, ask SO if patient is allergic to penicillins or cephalosphorins *For IM use, inject deep into a large muscle, such as the gluteus maximus or the lateral aspect of the thigh *If large doses are given, therapy is prolonged, or patient is at high risk, monitor patient for signs and symptoms of super infection * Check label for administration injection route restriction * If severe bleeding occurs, give fresh frozen plasma or whole blood immediately * Watch for flushing, weakness, tachycardia and hypotension; condition may progress to shock

Oct. 5, 2009

Vitamin K

Mephyton

Vitamins and minerals

Hypoprothrombo Penia caused by vitamin K malabsorption, drug therapy, or excessive vitamin A dosages

An antihemorrhagic factor that promotes hepatic formation of active coagulation factors

Injection: 2mg/ml Tablets: 5mg

CNS: dizziness CV: flushing, transient hypotension after IV administration, rapid and weak pulse Skin: Diaphoresis, erythema Others: pain, swelling and hematoma at the injection site

Oct 6, 2009

31

Ciprofloxacin

Ciproxin

Anti-infectives Mild to moderate UTI

Inhibits bacterial DNA synthesis, mainly by blocking DNA gyrase; bactericidal

Infusion: 200 mg in 100 ml D5W, 400 mg in 200ml D5W Injection: 200 mg, 400 mg Suspension: 5g/100ml, 10g/100ml Tablets: 500 mg

CNS: headache, restlessness, tremor, dizziness, hallucinations, seizures CV: thrombophlebitis, chest pain, edema GI: nausea, diarrhea, vomiting, abdominal pain, dyspepsia, flatulence, constipation Hematologic: eosinophilia, leukopenia, neutropenia, thrombocytopenia Skin: rash, photosensitivity, burning, erythema Other: hypersensitivity reaction

* Some drugs require waiting up to 6 hours after giving this drug to avoid decreasing its effects. Food doesnf affect absorption but delay peak levels * Long termtherapy may result in overgrowth of organisms resistant to the drugs

Oct 6, 2009

32

Dopamine

Intropin

Andrenergics To treat shock and correct hemodynamic imbalances, improve perfusion to vital organs, increase cardiac output or correct hypotension

Stimulates dopaminergic and alpha and beta receptors of the sympathetic nervous system. Action is doserelated; large doses cause mainly alpha stimulation Route: IV

Injection: 40 mg/ml, 80mg/ml, 160mg/ml parenteral Concentrate for injection for IV infusion

CNS: headache CV: ectopic beats, tachycardia, angina, palpitations, hypotension GI: nausea, vomiting Metabolic: azotemia, hyperglycemia Respiratory: dyspnea, asthmatic episodes Skin: necrosis and tissue sloughing with extravasation Other: anaphylactic reactions

*During infusion, frequently monitor ECG, blood pressure, cardiac output, central venous pressure, pulse rate, urine output, and color and temperature of limbs * If diastolic pressure rises, disproportionately decrease infusion rate and watch carefully for further evidence of predominant vasoconstrictor activety.

Oct 7, 2009

33

Calcium Gluconate

Calcium Gluconate

Electrolytes and replacement solutions

During exchange transfusions

Replaces calcium and maintains calcium levels Route: PO, IV,IM

Injection: 10% solution in 10-ml ampules and vials Powder for oral suspension: 3,756 mg/15ml Tablets: 500 mg, 650 mg, 1g

CNS: tingling sensations, sense of oppression or heat wavesin IV use CV: mild drop in blood pressure, vasodilation, bradycardia, cardiac arrest with rapid IV injection GI: irritation, constipation, chalky taste, hemorrhage, nausea, vomiting, thirst and abdominal pain GU: polyuria, renal calculi Metabolic: hypercalcemia Skin: soft tissue calcification with IM use, pain, irritation at subcutaneous injection site.

*Give IM injection in gluteals in adults and in side of the thigh in infants. Use IM only in emergencies when no IV route is available because of irritation of tissues by calcium salts * Double check that you are giving the correct form of calcium; resuscitation cart may contain both calcium gluconate and calcium chloride * Monitor calcium levels frequently * Report abnormalities

Oct 7, 2009

34

Epinephrine

Primatene

Bronchodilators Bronchospasm, hypersensitivity reactions, anaphylaxis; To restore cardiac rhythm in cardiac arrest

Relaxes bronchial muscles by stimulating beta2 receptors and alpha and beta receptors in sympathetic nervous system

Aerosol inhaler: 160 mcg, 200 mcg, 220 mcg Injections: 0.01 mg/ml Nebulizer Inhaler: 1%

CNS: nervousness, tremor, vertigo, pain, headache, disorientation, drowsiness, fear, dizziness, weakness CV: palpitations, hypertension, tachycardia, altered ECG GI: nausea, vomiting Respiratory: dyspnea Skin: urticaria, hemorrhage at injection site, pallor Other: tissue necrosis

*Massage site after IM injection to counteract vasoconstriction *Observe patient closely for adverse reaction * If blood pressure increases sharply, give rapid-acting vasodilators

Oct. 7, 2009

35

Furosemide

Lasix

Diuretics Acute pulmonary edema, edema and hypertension

A potent loop diuretic that inhibits sodium and chloride reabsorption at the proximal and distal tubules and the ascending loop of Henle

Injection: 10mg/ml Oral solution: 10mg/ml, 40 mg/5ml Tablets: 20 mg, 40 mg, 80 mg, 500 mg

CNS: vertigo, headache, dizziness, weakness, restlessness, fever CV: orthostatic hypotension, thrombophlebitis with IV administration EENT: blurred vision, transient deafness GI: diarrhea, nausea, vomiting, anorexia, constipation GU: frequent urination Skin: dermatitis, transient pain at the injection site

* Monitor uric acid evel * Monitor glucose level, especially in diabetic patients * To prevent nocturia, give medication in the morning *Watch for signs and symptoms of hypokalemia, such as muscle weakness and cramps

Oct. 4, 2009

36

Ideal Nursing Managements

Name of Patient: Patient F Diagnosis: Bacterial Meningitis Cues Objective: cyanosis noticed on nail beds adventitious breath sound(crackles) noted in both lung fields coffee ground secretions ambubagdependent Nursing Diagnosis Ineffective airway clearance r/t retained bronchial secretions Age: 2 months old Attending Physician: Dr. A. Laurito NURSING CARE PLAN Objectives Dependent: Room No.: Room 104 Ward 1 Hospital No.: 628 363 Interventions Rationale - to maintain oxygen saturation level within specified range of 90100% - to clear airway - to allow significant others to achieve proper rate of ambubagging - various modalities may be required to acquire/maintain adequate airways and improve respiratory exchange - to keep track with the status of the client - put on high back rest - to promote maximum chest expansion

Long Term: will be able to:

After 16 hours of nursing intervention, client Maintain oxygen saturation level within the range of through ambubaging Short Term: Following 8-hours of nursing intervention, significant others will be able to: Fully verbalize understanding of the importance of ambubaging and O2 inhalation Properly perform pumping of the ambubag for the patient 90-100%

- O2 inhalation rate and concentration to be carried out as ordered by physician Independent: - assist with suctioning procedure - teach significant others on how to properly use the ambubag - assist with use of respiratory devices - perform suctioning procedure to decrease accumulation of secretions in the ET area - monitor water level in the chamber of the oxygen apparatus, and regulate O2 gauge to desired rate monitor vital signs qd

37

Name of Patient: Patient F Diagnosis: Bacterial Meningitis

Age: 2 months old Attending Physician: Dr. A. Laurito NURSING CARE PLAN

Room No.: Room 104 Ward 1 Hospital No.: 628 363

Cues Subjective: Objective: somnolence cyanosis noted on nail beds

Nursing Diagnosis Impaired gas exchange r/t acute respiratory distress

Objectives Following 16-hours of duty, client will be able to: display improved O2 sat with the use of the pulse oximeter After 8-hours of nursing intervention, SO will be able to: properly handle the ambubag to the proper respiration rate of the client patient will demonstrate adequate oxygenation of tissues by arterial blood gas within patients normal range and be free of symptoms of respiratory distress

Interventions Independent: assess skin and mucosa color

Rationale

- to determine abnormalities/ changes of the skin and mucosa color

monitor O2 sat through the pulse oximeter monitor vital signs

-to closely monitor the O2 sat of the patient to keep track on the client's condition

Collaborative: assist significant others in ambubaging - to facilitate proper usage of the ambubag

38

Name of Patient: Patient F Diagnosis: Bacterial Meningitis

Age: 2 months old Attending Physician: Dr. A. Laurito NURSING CARE PLAN

Room No.: Room 104 Ward 1 Hospital No.: 628 363

Cues Subjective: Objective:

Nursing Diagnosis Anticipatory Grieving related to perceived potential loss of loved one

Objectives After nursing intervention, family will be able to: - Verbalize feelings, and establishes and maintains functional support systems

Interventions
Independent: o Establish rapport with patient and significant others; try to maintain continuity in care providers. Listen and encourage patient or significant others to verbalize feelings o Minimize environmental stresses or stimuli o Recognize the patient or familys need to maintain hope for the future -to open

Rationale

lines of communication and facilitate eventual resolution of grief -to reduce anxiety
- They

may continue to deny the inevitability of the loss as a means of maintaining some degree of hope. Until the whole is actually grasped.
-to prepare SOs with the possible outcomes of clients condition - to still meet the self-care demands of Sos despite the crisis

o Provide realistic information about health status without false reassurances or taking away hope o Encourage significant others to maintain their own self-care needs for rest, sleep, nutrition, leisure activities, and time away from patient Collaborative: - Refer to other resources (e.g., counseling, pastoral support, or group therapy

39

Name of Patient: Patient F Diagnosis: Bacterial Meningitis

Age: 2 months old Attending Physician: Dr. A. Laurito NURSING CARE PLAN

Room No.: Room 104 Ward 1 Hospital No.: 628 363

Cues Subjective Subjective: naa pa kaya nay pagasa akong anak? as verbalized by the mother Objective: Crying Pacing Feelings of helplessness and discomfort

Nursing Diagnosis Ineffective coping related to situational crisis

Objectives Following nursing intervention, clients SO will be able to: demonstrate positive coping mechanisms describe a reduction in the level of anxiety experienced

Interventions Independent:
o

Rationale - validates the feelings and communicates acceptance of those feelings. -presence of a trusted person may be helpfu. -to promote proper understanding on the procedure to be done, thus, decreasing SOs level of anxiety -anxiety may escalate with excessive conversation, noise, and equipment around the patient -reduce anxiousness and develop relief

Acknowledge awareness of patients anxiety Stay with patient if this appears necessary. Use simple language and brief statements when instructing patient about self-care measures or about diagnostic and surgical procedures.

Reduce sensory stimuli by maintaining a quiet environment; keep "threatening" equipment out of sight.

Encourage patient to talk about anxious feelings and examine anxietyprovoking situations if able to identify them.

Assist significant others in assessing the situation realistically and recognizing factors leading to the anxious feelings. Avoid false reassurances. - to facilitate acceptance of possible outcomes on clients health condition

40

Name of Patient: Patient F Diagnosis: Bacterial Meningitis

Age: 2 months old Attending Physician: Dr. A. Laurito NURSING CARE PLAN

Room No.: Room 104 Ward 1 Hospital No.: 628 363

Cues Subjective: 1. Karon nga adlaw nagsugud siya ug kabugnaw hikapun Objective: 1. CCore temperature: 33.5 C 2. Cold clammy skin 3. PPallor 4. CCyanosis

Nursing Diagnosis Short term: Hypothermia related to illness evidenced by decreased in core temp. below normal range 36.8C

Objectives

Interventions Independent: 1. MMonitor Vital signs accordingly 2. SShine perilamp on the patients body 3. PPlace thermoregulator on his body 4. AAdd bed linens as indicated

Rationale 1. TTo assess contributing factor 2. TTo provide additional warmth 3. To provide additional warmth 4. TTo provide additional warmth

At the end of 2 hours, with proper nursing intervention, the patients temp. will increase from 33.5 C to 36.8 C Long term: At the end of 8 hours, with proper nursing intervention, The patient will maintain her temp. within the normal range (36.8 C )

41

Actual Nursing Managements D: Received patient on bed unconscious in supine position with 1000 ml PNSS ( 0.9% sodium chloride) at 800 ml on the R arm infusing well in 17 gtts/min and 250 ml Dopamine at 10 ml on the L arm infusing well in 6 gtts/min, with 02 inhalation via ambubag at 10 L/min. Patient is pale having dry mucosa with chopping lips with an initial vital signs of: T= 33.5oC and HR= 126bpm. A: vital signs taken and recorded, regulate IVF and Dopamine medication to the desired rate needed, help in setting drop light for thermoregulation, applied thermobag to help regain infants body temperature, applied wet cotton to the patients lips to promote moisture and to prevent from further cracking, monitor 02 sat and results are taken and recorded, pumping of ambubag done, bed side care done, monitored frequency and characteristic of urine, needs attended and kept watched for any changes in vital signs. R: Patient is endorsed.

42

VII.

Discharge Planning - Follow strict compliance to the medications as prescribed by the attending physician following the right medication, dosage, time and route. - Provide a well organized plan for administering and taking in of Medication.

M (medications)

E (Exercise)

Expose the child to the sun because sunlight provide natural

source of vitamin D, for only short periods, beginning with 3-5 minutes the first day, a little more the next day, and so on up to 1520 minutes at a time. Allow the child to move freely, play and other physical activities in an enclosed play space of course with the supervision of the parents. T (Treatment) Allow the mother to assist the patient in providing ROM. If seizure attacks may occur, inform caregivers to remove sharp - Provide medication for illnesses like Paracetamol for fever. H (Hygiene) Change diapers frequently to reduce discomfort and irritation.

objects away from the childs vicinity.

Bathe the child and check for the temperature of the bath water to promote comfort and to prevent chilling. O (Outpatient) - Plan a follow-up visit one week after being discharged or if there are any frequent recurrences. - If fever recurs, refer back to the hospital. D (Diet) - Diet as tolerated, encourage the mother to breastfeed if possible. - Encourage increase of fluid intake to replace the fluid lost due to fever. S (Spirituality) - Help the significant others to accept any possible outcome. - Strengthen spirituality by allowing the significant others to spend time in prayer.

43

Prognosis The prognosis for patients with bacterial meningitis varies, depending on its severity. With early diagnosis and prompt treatment, most patients recover from meningitis. However, in some cases, the disease progresses so rapidly that death occurs during the first 48 hours, despite early treatment. Due to some financial constraints, the most ideal medical managements to the client were not given, thereby aggravating the condition of the client. Furthermore, as indicated by the Apache II Scoring done, the client has 60-80% risk of dying, which was even proved by the death of the client. Conclusion Meningitis refers to the inflammation of the meninges, commonly the pia mater and arachnoid mater and more rarely on the dura mater. It is usually caused by an infection with a virus or a bacterium. Knowing whether meningitis is caused by a virus or a bacterium is important because of differences in the seriousness of the illness and the treatment needed. Among the two, bacterial meningitis is much more serious. It can cause severe disease that can result in brain damage and even death.

Certain medical managements are ought to be done to really confirm the diagnosis of the client however, due to some financial restraints these were not done. Furthermore, medications such as Diazepam, Phenobartibal, Paracetamol, Ceftadizine, Mannitol, Diphenyldramin, Ampicillin, Furosemide, Phytonadione, Ciprofloxacin,

Dopamine, Ceftriazone, Penicillin G, Gentamycin, Paracetamol and Ranitidine.

Therefore, it is very necessary to be fully knowledgeable about meningitis because as student nurses, we may encounter cases like these and we have to know what to do. It is indeed advisable to seek the doctors advice promptly when seizures occur rather than prolonging the time to seek for medical assistance because this aggrevate the disease process.

44

Recommendation The proponents of this study would like to recommend more thorough diagnostic examinations to really identify the causative agent of the disease. Also, more specific medical managements must have also been done to improve the clients condition. medical managements Thus, providing a broader range of support on the study conducted. Moreover, more time must have been allotted in observing the condition of the client to further increase the level of understanding of the student nurses on the exact health condition of the client. XII. Bibliography

Anello, Michaelangelo E. et al. Nursing Drug Handbook. 23rd ed. Lippincot Williams & Wilkins. Springhouse. 2003. pp. 70-72, 341-343, 463-465. Black, Joyce E. et al. Medical-Surgical Nursing: Clinical Management for Continuityt of Care. 5th ed. Merriam Webster Bookstore, Inc. Philippines. 1997. pp. 771-783. Doenges, Marilynn E. et al. Nursing Care Plans: Guidelines for Individualizing Patient Care. 6th ed. F.A. Davis Company. Bangkok, Thailand. 2002. pp. 118-122. Doyle, Rita E. et al. Nursing Drug Handbook. 28th ed. Lippincot Williams & Wilkins. Colombia. 2008. pp. 84-86, 493-465. Stephenson, Brenda E. et al. Nurses Drug Handbook. Little Brown Publication. Boston. 1990. pp. 64, 95-96, 264, 299, 465. Smeltzer, Suzanne E. et al. Textbook of Medical Surgical Nursing. 10th ed. Lippincot Williams & Wilkins. Springhouse. 2004. pp. 1850-1863, 1878-1876. <http://www.soulhealer.com/anatomy-ner.html> https://www.bcbsri.com/BCBSRIWeb/images/image_popup/r7_meningitis.jpg http://www.health-res.com/EX/07-28-08/CentralNervousSystemS.jpg

45

APPENDICES DOCTOR'S ORDER 10/03/09 7:42 pm > Admit patient to ward > Secure consent to care > TPR q4h + fever 38.8 C <24 hrs T= 38.8 C P= 180 bpm R= tachypneic > O2 inhalation at 0.5 LDM nasal prung > start venoclysis c D5 0.3% NaCl 500 ml at 19 cc/hr > NPO > meds 1. Pen G 205,000 U q6h NST 2. GentaMYCIN 20 mg IV OD NST 3. Paracetamol 61.5 mg IV q4h 4. Raniticide 4 mg IV q8h > TSB Lab: - lumbar puncture secure consent consent to care - CBC - Urinalysis, S/E - Chest X-Ray ( Antero Posterior ) Monitor I and O q shift Monitor V/S q hourly X 4HR or until stable supine precaution at bedside refer accordingly 10/04/2009 3:15 am > Diazepam 0.8 mg IVTT for active seizure > Phenobarbital 41 mg IV-LD, then 20 mg IV as maintenance dose 12 H after LD febrile > still on NPO > may wet lips c wet-cotton > Na+, K+ determination

46

> Hgt determination IVF to follow c D5 0.3% NACl 500 ml at SR 10/04/2009 4:07 pm 7:32 pm asleep, distended hypogastrium greenish oral secretions 8:15 pm > cranial ultrasound in AM > run 30ml of PNSS as side drip, then KSS > vol/vol replacement c PNSS 10:55 pm ICP O2 sat 99% 180 190's febrile + urine output 10/05/2009 6:00pm patient IVF 6= GCS E,V,M4 patient ET HR = 150 RR= CAI O2Sat= 99% soft bulging ant. Fontanelle >Hydrocortisone 20mg IV q 6H >continue ambubagging >pls supply/ reserve extra full tank at bed side for ABG >replace OGT output c D5 0.45% NSS > to secure 82cc of whole fresh blood, patient blood type, properly screened, > for blood typing today attach urine cellestol > Ceftazidine 200 mg IV q12h ANST > IVF to ff. C D5 0.3% NaCl + run at > hold LP > hyperventilate patient > insert ET S.3.7 = level 9 secure properly >give Mannitol 20% 20ml IVTT = 1 draw, then 10ml q6h (check BP before giving Mannitol, hold if BP < 90/60 mmHg) monitor v/s q 3 min > suction oral secretion PRN > Paracetamol to 80 mg q4h > IVF to follow c D5 0.3% NaCl 500 ml at 8R > apply ice pack on hypogastrium > I and O monitoring q2h > insert OGT FS- open to drain and secure pro,

47

17 cc/min > c plain NSS > replace OGT output O2Sat= 93.2 > preset the blood to packed RBL before transfusion > transfuse available PRBC at 45 cc after proper +-matching and screening and run for 4H > monitor V/S q min while on BT and up to IV post BT > refer for BT reaction ( rashes, fever, hypotension, dyspnea) > refer to PROD after transfusion > report Hct, Hgb 6H post BT > aspirate OGT q2h and replace aspirated c plain NSS 4:50 pm > Ranitidine for 5.5 g IVTT q8h > Ampicillin 205 g IVTT q6h ANST > Ceftriaxone 410 mg IVTT OD ANST > D/C Pen G Na and Gentamycin once ampicillin started > hold Ceftriaxone > continue Ceftazidine + Ampicillin 10/05/2009 8:00 pm > hold blood transfusion temporarily if c seizure > revise BT to FWB and transfuse 82 cc after proper x-matching-4-6 hrs. of packed BT > Furosemide 4 mg IVTT post BT 10/06/2009 > continue meds > still for ultrasound > continue ambubagging > Phytonadione 4 mg IVTT >Serum Na+, K+ determination > HGT q8h refer if < 60 mg/dl > suction ET secretions PRN > IVF to follow c D5 0.3% NaCl and put to run at 18cc/hr.

48

> Ciprofloxacin 20 mg slow IVTT q 12 NST (no skin test) > D/C Pen G and quit once Ciprofloxacin started > Mannitol at 20 cc > Dopamine drip at 4 mgtts/min > Vitamin K 4 mg IVT now, then OD to complete total of 3 doses 10/07/2009 1:30 am 7:30 am > plain NSS 41 cc/hour > increase Dopamine to 6 gtts/min > provide goose neck lamp for thermoregulation > continue all meds > revise IVF to D10 0.3% NaCl 100cc every 6 hours at 16 gtts D50W D5 0.3% NaCl Ca Gluconate 6% Aminosterile 11cc 79.5cc 1cc 8.5cc 100cc > refer IVF to following > follow up with the following: Plain NSS Ca Gluconate 6% Aminosterile 92.5cc - 1cc (100mg/kg/day) - 8.5cc (0.5g/kg/day) 102cc to run at 17cc/hr for 6H > O2 sat monitoring q2h and record > serum Na+ ,K+ 10-08-09 > continue med > still for Na+ ,K+ , determination > repeat Hct and Hgb determination today 11:50 am > do CPR > epinephrine (1:10,000 dilution) 0.4 cc q2min x 3 doses 12: 15 pm > pronounce dead

49

 do post mortem care NURSES NOTES October 3, 2009 7:15 pm - Admitted a 2 month old child from zone 9 Bulua, CDO due to fever - Vital Signs taken and recorded - Seen and examined by Dr. Laurito with orders carried out - Venoclysis started and recorded - Labs: CBC, CT scan, AP view requested - for V/A, S/E - for lumbar puncture score consent to care - brought to ward/mothers arm with IVF on - Endorsed with latest temp. 37.5C October 3, 2009 7:55 pm - Received for ER with potent IV line, afebrile with T=37.5C, weak, tachypmic - IVF regulated as ordered - IVF regulated as ordered - O2 inhalation started at at 0.5 L DM via nasal cannula - an NPO watcher instructed - for lumbar puncture to secure consent undecided - for CBC request , result in at 9pm referred to Dr. Laurito - for urinalysis , fecalysis specified containers provided - for chest x-ray - in intake and output regimen - on seizure precautions

50

- kept watched - endorsed October 3, 2009 11 pm 7 am shift D - HR = 140bpm RR=40cpm - Febrile , T=13C - with continuous 02 inhalation going on via nasal cannula - weak in appearance

A - vital signs monitored - IVF regulated - still for SIE and watcher reminder - still for VIA - still follow up CXR result - still for lumbar puncture undecided - on intake and output regimen - on seizure precaution - kept watched for any unusualities - (+) seizure referred to Dr.Laurito with new orders carried out 6:50am A - needs attended - (+) seizure, stat needs given - kept watched - plan of care followed R 51

- endorsed

October 4 , 2009 7am-3pm Shift D - with continued O2 inhalation via nasal cannula at 2 LPM - (-) seizure - HR=154bpm A - IVF regulated - Vital signs taken and recorded - on NPO maintained - still for lumbar puncture undecided RR=42cpm

8:10am - visited by DR. Laurito with new order carried out - instructed to wet lips via cotton ball - for NA+ and K+ determination requested - Hgt determination attached to chart - still for U/4 and stool exam - to follow up chest x-ray PA - on Intake and Output regimen - on seizure precaution - kept watched - plan of care followed 52

R - Endorsed 3pm-11pm shift D 8pm - HR= 130bpm - Febrile - (-) seizure - with continuous O2 inhalation via nasal cannula 2.5LPM A - IVF regulated - vital signs taken and recorded - on NPO maintained - still for lumbar puncture undecided - still for U/A and stool exam - to follow up chest x-ray AP - on intake and output regimen - for Hgt determination requested - on seizure precaution 7:25pm D - patient vomited greenish secretions RR=40cpm

A - notified Dr. Laurito with new orders carried out - ice pack applied on hypogastrium - Intake and Output regimen monitored every 2 hours

53

- OGT inserted by Dr. Laurito open to drain secured properly - suction oral secretions PRN - for cranial ultrasound in AM requested - on V/V replacement with PNSS - needs attended - kept watched R - endorsed

10:45pm D - (+) hiccups A - O2Sat taken 99% - reffered to Dr. Laurito with new orders carried out - Hyperventilate patient done - ET inserted S.3.7 level 9 and properly secured by ROD - ET attached to O2 at 10LPM - stats need given - on continuous bagging R - endorsed October 4, 2009 11pm-7am shift D - with ET attached to manual inhalation: i u oc inh at 10 L/M - i c ear open u chain with discharged

54

A - IVF regulated - V/S checked and monitored - Medicated - to follow up CXR result - on intake and output regimen - suctioned secretion IE - still for cranial test requested - kept watched - CO October 5, 2009 7am to 3pm Shift D - HR= 161 bpm RR=40cpm

- with ET attached to ambubag at 10 L/min - V/S taken and monitored 7am - seen and visited by Dr. Laurito with new orders carried out - with OGT open to drain - still on NPO - still for urinalysis and stool exam - for Chest X ray follow up visit - on intake and output regimen monitoring - on NA+ and K+ - on vol/vol with PNSS IL

55

- plan of care provided

October 5, 2009 3pm-11pm shift D 3pm - with ET attached to ambubag to O2 on 10L/min on - with OGT open to drain draining to coffee ground output - HR=165bpm - on critical list

A - vital signs monitored - IVF regulated - kept on NPO - kept monitored - continuous ambubagging done - seen and examined by Dr. Oliveros with order - to replace OGT output with PNSS v/v - still for cranial ultrasound 4:50pm - seen and examined by Dr.Dy with orders 8pm - to hold blood transfusion temporarily if with seizure - (+) bleeding from NGT; referred to Dr. Dy with order 9pm - Diphenhydramine IV given 30 mins before blood transfusion as ordered - FWD to transfused 82 cc revised order by Dr.Dy 9:35pm 56

- 82cc FWB transfused after proper x matching with S# 2009-039802 blood type O (+) to run for 4-6 hours on - for repeat Hgb Hct 6 hours post Blood Transfusion - to give Furosemide IV post BT-prescribed - kept watched for Blood Transfusion reaction - still on critical list - plan of care followed R - endorsed still on critical list; with continuous ambubagging 11pm-7am shift D - HR=165 bpm; with going blood transfusion - Afebrile, with OGT bloody discharge - with ET attached to manual resuscitation at 10LPM - weak in appearance

A - vital signs taken and recorded - intravenous fluid regulated - still for ABG - on replacement OGT output with PNSSiL (4cc)

- on NPO instructed watcher 4:30 am - available medication given - for repeat Hemoglobin requested - for Hematocrit determination 8-6hours post Blood Transfusion - for OGT aspirations every 2 hours - to follow up chest x-ray result 57

- on intake and output regimen - on seizure precaution - suctioned secretions - for sodium, potassium determination - kept watched for any unusualities - plan of care followed - endorsed with 5am condition - last O2sat 99%

October 6, 2009 7am-3pm Shift D - HR=164 - with ET to ambubag at 10L/min - with OGT open to drain A 9am - vital signs taken and recorded - seen and visited by Dr. Dy with new orders carried out - on NPO - still for cranial ultrasound - still for fecalysis and urinalysis - for Chest X-ray to follow up result - for sodium, potassium - on Input and output regimen - suction ET secretion PRN - mHgt monitoring q8h

58

- plan of care followed R - endorsed 3pm-11pm shift D - with ET attached to ambubag to O2 at 10 LPM - with OGT open to drain draining to coffee ground output - on critical list; HR=140 A - Kept on moderate high back rest - IVF regulated - V/S monitored - on NPO maintained - still for ABC requested - still for cranial Ultrasound no sched. - still for Sodium and Potassium requested - still for U/A and S/E - to follow-up CXR result - on HGT monitoring q8h hgt strip prescribed - on Intake and Ouput regimen - on seizure precaution - visited by Dr. Dublado with new orders carried out - kept watched for any unusualities - plan of care followed R - endorsed 11pm-7am Shift

59

D - with ET attached to Antibody to O2 Inhalation 10 LPM - with OGT pen to drain draining to coffee ground output - HR=140bpm, on critical list - with Dopamine drip A - continue ambubagging done - V/S monitored - IVF regulated - kept monitored - NPO maintained - on Hgt q8h monitoring 1:30 - still for cranial ultrasound and Sodium and Potassium diet requested

October 6, 2009 D
-

With ET attached to antibody to O2 inhalation 10 cpm With OGT open to drain, draining to coffee ground output HR: 140 bpm, on critical list With Dopamine drip

A
-

Continuous ambubagging done Vital signs monitored IVF regulated Kept monitored NPO maintained On HGT every monitoring

60

Still for cranial UTZ and Na K direct- requested HGT result in and referred to Dr. Dublado with order Dopamine drip increased rate to 6 gtts/min as ordered HR: 132 bpm, cold clumsy skin, Dr. Dublado, formed Still to follow up chest Xray result On Intake and output required Reminded on urinalysis and fecalysis Plan of care followed

R
-

Endorsed, still with ambubagging to 02 inhalatio on 10 L/min, still with OGT, still HR: 126, still on critical list.

October 7, 2009 7-3pm shift D

-

HR=126 With ET to ambobag at 10 L/min With OGT open to drain With dopamine drip

A
-

Vital signs taken and recorded IVF regulated

8am
-

Seen and visited by Dr. Dublado with new orders- carried out On NPO Still for cranial ultrasound and Na K determination requested With HGT every 8 ours monitoring- refer if <60 Still for fecalysis and to follow up chest

61

Visited and seen by Dr. Oliveros with new orders- carried out With 02 saturation monitoring every 2 hours recorded Plan of care followed

R
-

Endorsed

3-11pm shift D
-

With ET to ambubag to 02 tank at 10 L/min With OGT open to drain coffee brown output With dopamine drip HR= 115 bpm Bp= 70/50

A
-

Vital signs monitored Still for cranial UTZ- c/o outside On HGT monitoring Chest x-ray to follow up result On 02 saturation monitoring Sunction secretion PRN Goose lamp provided for thermoregulation

R
-

Endorsed

11-7am shift D
-

OGT open to drain with coffee brown output With ET for ambubag HR= 126 on critical list

62

With dopamine drugs

A
-

Vital signs monitored On 02 sat monitoring every 2 hours On HGT monitoring Still for cranial UTZ N+ K+ - requested as endorsed Kept visited for any unusualities Goose neck lamp provided for thermoregulation Ambubagging continuously done by watcher Plan of care followed HR= 124, O2 sat= 92%, BP= palpatory

R
-

On actual condition

October 8, 2009 7-3pm shift D

-

HR= 124 RR= 92 With ET to ambubag attached to 02 at 10 L/min With OGT open to drain Vital signs taken and recorded

8 am
-

Seen and visited by Dr. Dy with new orders- carried out IVF regulated

63

Medicated Replaced OGT output with PNSS vol/vol On 02 sat monitoring every 2 hours and record On HGT every 8 hours monitoring For Na K- requested Still for cranial ultrasound On seizure precaution For repeat hematocrit and hemoglobin determination- requested On intake and output monitoring endorsed

Addendum: 11:40 A
-

(-) HR, BP= 0, (+) cyanosis is noted Referred out once to Dr. Oliveros Seen patient by Dr. Oliveros with orders carried out Continuous CPR done Start medication given

12:10pm
-

Vital signs reached HR=0, dilated pupils ECG long lead II taken- flat line result

12:15pm
-

Pronounced dead by Dr. Oliveros Post mortem care done Cadaver released Chart signed

64

Glasgow Coma Scale

Best eye response (E)

10-7
No eye opening Eye Opening in response to pain Eye opening to speech Eyes opening spontaneously 1 2 3 4

10-8

Best verbal response (V)

No verbal response Incomprehensible sounds Inappropriate words Confused Oriented 1 2 3 4 5

Best motor response (M)

No motor response Extension to pain Abnormal flexion to pain Flexion/ Withdrawal to pain Localizes to pain Obeys commands 1 2 3 4 5 6 * *

TOTAL GCS:

13

Interpretation of GCS results: Severe, with GCS 8 Moderate, GCS 9 - 12 Minor, GCS 13.

65