A Case Study On: Bacterial Meningitis

A Case Study
Presented to the Faculty of

The Ateneo de Davao University
College of Nursing
A Case Study on
BACTERIAL MENINGITIS
Submitted to:
Ms. Loreen S. Marcelo, RN
Clinical Instructor – Panelist of the Case Study
Submitted by:
[Group 1-A]
Ampilanon, Rae Maikko M.
Ausa, Ryan S.
Balboa, Tessa Marie R.
Barbarose, Pamela Erika J.
Beltran, Maribel S.
Bulosan, Von Rainier S.
BSN-4H
25 September 2010
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TABLE OF CONTENTS
I. Acknowledgement
........................................................................................................................
3
II. Introduction
.....................................................................................................................
4
III. Objectives (General & Specific)

.....................................................................................................................
6
IV. Patient’s Data

.....................................................................................................................
8
V. Family Background and Health History

.....................................................................................................................
10
VI. Developmental Data

.....................................................................................................................
14
VII. Definition of Complete Diagnosis

.....................................................................................................................
19
VIII. Physical Assessment

.....................................................................................................................
21
IX. Anatomy and Physiology

.....................................................................................................................
36
X. Etiology and Symptomatology

.....................................................................................................................
36
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XI. Pathophysiology
.....................................................................................................................
42
XII. Doctor’s Order

.....................................................................................................................
46
XIII. Diagnostic Exams

.....................................................................................................................
55
XIV. Drug Study

.....................................................................................................................
87
XV. Nursing Theories

.....................................................................................................................
102
XVI. Nursing Care Plan

.....................................................................................................................
107
XVII. Discharge Plan (M. E. T. H. O. D.)

.....................................................................................................................
130
XVIII. Prognosis………………………………………..............…………………………132
XIX. Recommendation
.....................................................................................................................
136
XX. References
.....................................................................................................................
138
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ACKNOWLEDGEMENT
First and foremost, to the Almighty Father, for His unceasing love and blessings; for
giving us enough strength and fortitude to face all the adversity in the making of this work.
Also, the proponents of this case study would like to extend their earnest appreciation to
all the people who made the success of this study a reality:
To our Clinical Instructor, Mrs. Loreen S. Marcelo, R.N. for her helpful time, knowledge
and effort extended to us.
To the staff of Southern Philippines Medical Center, especially in the Pediatrics Ward, for
giving us the opportunity to complete our exposure and our case study.
To our dearest family and friends, for their never ending support and understanding; for
always being there to guide us and care for us after the long days of duties.
To the patients who marked a part of our hearts, for challenging us to do more and for
pushing us beyond our limits to maintain and improve their quality of health, to appease their
restlessness and sometimes to endure their unexplainable combative behaviors; it was an
experience to care for them.
Lastly, to each and every one who helped realize this job into completion, may it be direct
or indirect, no matter how minimal, the gratitude and pleasure for the achievement of this task is
ours to share.
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INTRODUCTION
Meningitis is an inflammation of the membranes that cover the brain and spinal cord.
People sometimes refer to it as spinal meningitis. Meningitis is usually caused by a viral or
bacterial infection. Knowing whether meningitis is caused by a virus or bacterium is important
because the severity of illness and the treatment differ depending on the cause. For bacterial
meningitis, it is also important to know which type of bacteria is causing the meningitis because
antibiotics can prevent some types from spreading and infecting other people.
Today, Streptococcus pneumoniae and Neisseria meningitidis are the leading causes of bacterial
meningitis.
Bacterial meningitis continues to be among the top ten killers of children less than four
years old in the Philippines. Pathogens isolated from patients with this disease as well as their
susceptibility patterns are different from those isolated in western countries. A delay in treatment
leads to higher morbidity and mortality, thus early recognition of the disease is necessary. Signs
and symptoms of bacterial meningitis are variable and depend on the age of the patient and the
duration of illness before treatment. Neonates and young infants may only have subtle
manifestations. These are difficult to distinguish from a coexisting septicemia.
Worldwide, as of January 2004, about 5,600 people were infected each year with an
estimated 4,719 deaths, average weight of 84.3%, among those infected will die
(www.nmaus.org/meningitis). Nationwide, an estimate of 926 incidences out of 86,241,697 of
the whole population were cited leading to 20% of deaths
(www.nationmaster.com/graph/mor_bac_men_not_els_cla). Locally, only an estimate of 10-15%
incidence was found, specifically to those children less than four years old
(www.inmed.co.uk/lectures/lecture8.ppt).
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The group of BSN 4H 1-A, was given opportunity to have their hospital exposure last
September 13 to 15, 2010 at Southern Philippines Medical Center. JP, not his real name, was one
of the patients admitted to the Pediatrics Ward due to Bacterial Meningitis. The group has chosen
JP as their subject mainly for the reason that his case posed as a very complex study that requires
thorough understanding and knowledge. Our chosen client presented most noted clinical
manifestations from the disease which provided us with significant notes for the study.
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OBJECTIVES
General Objective:
The objective of the group is to present a holistic and comprehensive case
presentation of our chosen client and provide a complete discussion of the study, deliver
optimal care for our client from the knowledge obtained from this study.
Specific Objectives:
In order to meet the general objective, the group aims to:
Cognitive:
 Interpret the relevant data gathered from the patient’s significant others,
 Evaluate the present developmental stage of the patient according to the theories of
Erikson, Freud, and Piaget.
 Define the complete diagnosis of the patient, Bacterial Meningitis,
 Rationalize the doctor’s order obtained from the patient’s chart,
 Interpret the laboratory test results of the patient,
 Apply the nursing theories of Nightingale, Hall, and Hendersion in the nursing care
Psychomotor:
 State the past and present health history of the client,
 Trace the family genogram,
 Present the cephalocaudal assessment obtained from the patient,
 Discuss the anatomy and physiology of the central nervous system that is involved in the
patient’s disease,
 Present the etiology and symptomatology of the patient’s disease,
 Trace the pathophysiology of the patient’s disease,
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 Present the medications given to the client, including their respective modes of action,
indications, contraindications, side effects, adverse reactions, nursing responsibilities, and
importance to the client’s condition;
 Present specific, measurable, attainable, realistic and time-bound nursing care plans for
the client,
 Justify the client’s prognosis according to the different criteria,
Affective:
 Establish rapport to the patient’s significant others,
 Provide the patient and family with proper discharge planning (M.E.T.H.O.D),
 Inform suitable recommendations to the client, his significant others and community, and
the medical world, etc.
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PATIENT’S DATA
Personal Data:
Patients Name: “JP”

Age: 4 months old
Gender: Male
Weight: 5.5 kilograms
Birth date: May 10, 2010

Address: Purok 7, Barangay 4, Poblacion, San Francisco,
Agusan del Sur
Nationality: Filipino
Religion: Roman Catholic
Number of Siblings: None
Father: “Bob”
Occupation: Utility Man / Janitor
Educational Attainment: High School Undergraduate (Second Year)
Mother: “Marley”
Occupation: Sari-Sari Store Vendor
Educational Attainment: High School Undergraduate (Third Year)
Family Income: 9,000 Php (Estimated)
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Clinical/ Admitting Data:
Date of admission: September 11, 2010
Time of admission: 11:40 pm
Chief Complaint Stomachache and fever
Hospital & Hospital Number: Southern Philippines Medical Center [2220291]
Ward [Room & Bed Numbers]: Pediatric Ward – IMCU

Attending Physician: Dr. Meralyn M. Maduay, M.D.
Admitting Diagnosis: Bacterial Meningitis
Vital signs on admission:
Temperature: 37.6 Degrees Celsius
Pulse Rate: 120 Beats per Minute
Respiratory Rate: 40 Cycles per Minute
Source of Information: Patient’s mother and the patient’s chart
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FAMILY BACKGROUND AND HEALTH HISTORY
Family Background
JP, a 4-month old baby, is the first and only child of Bob and Marley. The family lives in
San Francisco, Agusan del Sur and only came here in Davao City to seek medical aid. Bob, 25,
works as a utility man in a hotel in Agusan while Marley, 24, stays at home and manages their
own sari-sari store. The couple got married last February 2009 in the “Kasalang Bayan” in San
Francisco. The family lives in their own house which, according to Marley, was given to her by
her parents as a wedding gift to them.
The first year of their marriage was filled with joy and excitement as they were able to
plan and prepare for their first child. Both of them worked hard to save money for JP. Their
parents advised them to secure PhilHealth insurance; however, they just neglected this and took
things for granted.
Bob and Marley came from small families since both of them were the only child of their
parents respectively. They originally decided to have 2-3 children. They considered proper
spacing of years between them. They also learned from seminars they attended about family
planning and the different options they could take. However, when JP got ill, these plans were set
aside since they wanted to focus on him first and with all the hardwork and expenses, they
cannot afford to have another child yet.
JP was breastfed until 1 week old. He was then hospitalized since he had “cord infection”
according to her mother. “Nahospital mana siya atong 4 days pa human pagkaanak kay
naimpeksyon iyang pusod. Mga usa pud kasemana to.”, as verbalized by Marley. After which,
breastfeeding was stopped and he was bottle-fed from then on. He took 3 multivitamins:
PedZinc, Clusivol and Tiki-Tiki. The mother failed to remember how long JP was taking each of
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these vitamins. What she knew was, she stopped giving Tiki-Tiki to JP when his second
hospitalization began.
There were no known familial illnesses such as Diabetes Mellitus, Asthma, and
Hypertension in the family. Bob claimed his father has hypertension however, this is not
diagnosed. His father is not also taking maintenance medications for the said illness. As far as
Marley can recall, this is the first case of Bacterial Meningitis in the family and close relatives.
Past Health History
JP was delivered through normal spontaneous vaginal delivery in a maternity clinic at
San Francisco, Agusandel Sur. In his age, he has received a dose of BCG, 3 doses of OPV, 3
doses of DPT and 2 doses of Hepatitis B vaccine. Measles vaccine is not yet given to him since
he is not yet of age. He has not received Haemophilus Influenza Type B (Hib) vaccine too.
His first hospitalization was when he was still 4 days old. According to her mother, he
had high-grade fever with convulsions and his skin turned yellowish. It was found out there in
the hospital that he had infection of the umbilical cord. This prompted his admission and stayed
in the hospital for a week. Marley decided to stop breastfeeding since JP cries every time she
attempts to breastfeed. From then on, she feeds her baby with formula milk and never came back
to breastfeeding. She failed to remember the exact medications given to JP however she was
“sure” that some of those were antibiotics.
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History of Present Illness
Three days prior to his admission at DO Plaza Memorial Hospital on September 3, 2010,
Marley noticed his son to be irritable and crying most of the day. He also had intermittent fever
reaching up to 40°C relieved by paracetamol. Marley also noticed generalized body stiffness.
“Manuskig usahay iyang lawas unya magsulirap iyang mata.”, as she described. She also
observed generalized pallor. Persistence of the said symptoms led them to consultation.
During the course of his admission, several tests were run including urinalysis, fecalysis,
and some blood tests. After the results were secured, they were discharged on the 8 th of
September and were asked to return of September 22 since, as explained by the physician, they
found a bacteria in the patient’s blood. JP was given dicycloverine, metronidazole, and ranitidine
as home medications.
Two days after admission, on September 10, 2010, JP began to cry loudly again as if he
was in pain. He also had fever that day and so they rushed him again to the same hospital. The
hospital again made some routine tests however they were not able to get the results since the
physician decided to refer them at Southern Philippines Medical Center (SPMC).
They arrived at SPMC on September 12, 2010 and JP was admitted at the Pediatric Ward.
Effects and Expectations of Illness to Family
Everyone in the family, including the grandparents, was greatly alarmed by JP’s illness. It
is their first time to experience this health crisis and they are clueless on what further actions to
take. His parents regretted that they didn’t get a PhilHealth insurance. Only now that they
realized how helpful it is in paying the bills. The grandparents were very supportive and
promised to help in the expenses. Bob and Marley also promised to do everything they can for
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their son. Spiritually, the mother is very submissive to God’s plans. “Gina ampo na lang jud
nako na mahimong okay tanan. Gipasa-Diyos na lang man nako. Kabalo ko dili ko niya
pasagdan.”.They have also been asking for God’s guidance and help. As of now, they just leave
it all to the hands of the health team taking care of JP. They hope that they will do their best too
in treating his illness.
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DEVELOPMENTAL DATA
These are just a few of the fascinating aspects of the field of “human development”: the
science that studies how we learn and develop psychologically, from birth to the end of life. This
very young science not only enables us to understand how each individual develops, it also gives
us profound insights into who we are as adults. Each theory has its own perspective on the
development of man.
Erik Erikson’s Theory of Psychosocial Development
Erikson's stages of psychosocial development as articulated by Erik
Erikson explain eight stages through which a healthily developing human should pass
from infancy to late adulthood. In each stage the person confronts, and hopefully masters,
new challenges. Each stage builds on the successful completion of earlier stages. The
challenges of stages not successfully completed may be expected to reappear as problems in
the future.
Developmental Description Achieved or Justification
stage Not Achieved

Trust vs. The first stage of Erik Achieved Our client was just four months
Mistrust Erikson's theory centers old; he is dependent to his
Infants ( 0- 1 on the infant's basic needs parents especially to his mother
year old) being met by the parents. when it comes to his needs.
The infant depends on the The client is rich in love from
parents, especially the his parents. They always
mother, for food, provide the client’s needs
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sustenance, and comfort. especially the love and
If the parents expose the affection. Now that the client is
child to warmth, sick, they really do their best to
regularity, and dependable provide the medications the
affection, the infant's view client needed despite the
of the world will be one financial constraints they had.
of trust. If the parents fail Through giving the child’s
to provide a secure needs like food and most
environment and to meet especially love, the child had
the child's basic need a form sense of security when he
sense of mistrust will was with his parents. He stayed
result. calm and comfy when he was
with them.
Freud’s Psychosexual Theory of development
Stage Description Achieved or Not Justification
Achieved
Oral stage (birth- The oral stage begins Achieved The client has
1year) at birth, when the oral achieved this stage,
cavity is the primary since we have
Erogenous zone: focus of libidal observed that the
mouth energy. The child, of mother bottle fed the
course, preoccupies child as necessary or
himself with nursing, when the child
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with the pleasure of demands it from his
sucking and accepting mother. The
things into the mouth. erogenous zone is the
The oral character mouth which means
who is frustrated at the child feels
this stage, whose pleasure as she was
mother refused to being nursed by her
nurse him on demand mother. The client was
or who truncated being bottle fed until
nursing sessions early, he’s satisfied and fell
is characterized by asleep as he’s sucking
pessimism, envy, the milk from the
suspicion and bottle.
sarcasm. The
overindulged oral
character, whose
nursing urges were
always and often
excessively satisfied,
is optimistic, gullible,
and is full of
admiration for others
around him. The stage
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culminates in the
primary conflict of
weaning, which both
deprives the child of
the sensory pleasures
of nursing and of the
psychological
pleasure of being
cared for, mothered,
and held.
Jean Piaget’s Theories of Cognitive Development
Stage Description Achieved or Justification
Not Achieved
Sensorimotor The first stage of Piaget’s Achieved The child has achieved this
Stage theory lasts from birth to stage since he has been trying
Secondary approximately age two to be more focused in the
Circular and is centered on the world. He tries to observe his
Reactions (4-8 infant trying to make surrounding and the people
months) sense of the world. During around his. Also, he now
the sensorimotor stage, an utilizes his grasping ability in
infant’s knowledge of the which, as observed, he’s been
world is limited to their trying to reach out some
sensory perceptions and things and put it on his mouth
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motor activities. like when he’s being bottle
Behaviors are limited to fed he tries to grasp the bottle
simple motor responses and put on his mouth.
caused by sensory stimuli.
Children utilize skills and
abilities they were born
with, such as looking,
sucking, grasping, and
listening, to learn more
about the environment.
DEFINITION OF COMPLETE DIAGNOSIS
BACTERIAL MENINGITIS
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Infection of the layers of tissue covering the brain and spinal cord (meninges). Meningitis
is similar in older children, adolescents, and adults but different in newborns and infants.
Meningitis in newborns is typically caused by bacteria acquired from the birth canal. The most
common such bacteria are group B streptococci, Escherichia coli, and Listeria monocytogenes.
Mark H. Beers, MD, et al. Merck Manual.2nd Edition.
Merck and Co, Inc. Copyright 2003.Page 1411.
An inflammation of the brain and spinal cord that may be caused by either bacterial or
viral infection. Any microorganism that enters the body can result in meningitis. Bacterial
meningitis is a serious infection that is spread by direct contact with discharge from the
respiratory tract of an infected person.
Linda S. Williams, et.al. Understanding Medical Surgical Nursing.
3rd Edition. F.A. Davis Company. Copyright 2007.Page 1054.
It is an inflammation of the meninges. It can be caused by either a viral or bacterial
infection. Symptoms usually include stiffness in the neck, headache, and fever. In severe cases,
meningitis can also cause paralysis, coma or death.
Seeley, Stephens and Tate.Essentials of Anatomy and Physiology.
6th Edition.Mc-Graw Hill.Copyright 2007.Page 232.
Meningitis is an infection of the fluid in the spinal cord and the fluid that surrounds the
brain. Meningitis is usually caused by an infection with a virus or a bacterium. Knowing whether
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meningitis is caused by a virus or a bacterium is important because of differences in the
seriousness of the illness and the treatment needed. Bacterial meningitis is much more serious. It
can cause severe disease that can result in brain damage and even death.
Kluwer.Medical Terminology Handbook.2nd Edition.
Lippincott Williams and Wilkins.Copyright 2002.Page 114.
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PHYSICAL ASSESSMENT
Date and Time of Assessment: September 13, 2010 @ 6:00 A.M.
General Survey
The patient is lying supine on bed, awake, with IVF of D5.3Nacl @ 300 cc level infusing
well at left metacarpal vein. He is not in respiratory distress. He has a newly changed diaper. He
is calm and is not crying during the assessment process.
Vital Signs
The patient has temperature of 37.1 degrees Celsius, afebrile. He has a respiratory rate of
41 cycles per minute which is normal for his age. He has a pulse rate of 136 beats per minute,
with no skip beats noted, taken via his apical pulse.
Anthropometric Measurement
The patient’s height is 62 cm. The patient’s weight is 5.5 kilograms. Head circumference
is 41 centimeters while chest circumference is 38 centimeters. The patient’s abdominal
circumference is 44 centimeters.
Skin
The patient’s skin color is light brown and uniform in all areas. No birthmark is noted
upon inspection. No odor is noted. It has a good skin turgor. The skin is soft, warm and slightly
moist and free from lesions and edema. Diaper dermatitis is not noted.
Hair
Hairs are unevenly distributed over the scalp. It is black in color. It is thin and dry. No
infestation or dandruff is noted.
Nail
The patient’s nails are clean. It has a concave shape. It is thin and has pale nail beds with
no infection noted. It is soft to touch with a capillary refill time of 3 seconds.
Head
The patient’s head is normocephalic and rounded. It is proportional to body size. It has
symmetrical facial features with symmetrical facial movements. Head circumference is 41
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centimeters. It has a uniform consistency with no nodules or masses noted. It is non tender.
Bulging anterior fontanel is noted while posterior fontanel is already closed.
Eyes
Eyes are symmetrical. Hairs are evenly distributed with intact skin. Eyebrows are
symmetrically aligned. Visual following is noted with equal eye movement. No discharges and
discoloration of the eyelids. When the eyelids are closed, no sclera is visible. Anicteric sclera is
noted. Pale palbebral conjunctiva is noted. No edema or tenderness is noted over the lacrimal
glands.
Ears
Ears are symmetrical with color that is same as the facial skin. Auricles are aligned with
the outer canthus of the eyes. No lesions noted. It is firm and non tender. When a sound was
made on his ears, the patient blinks but did not turn his head on the side where the sound was
produced.
Nose
The nose is symmetrical with uniform skin color that is the same as facial skin. No
discharges and nasal flaring noted. Nose is non-tender. Nasal septum is intact and in the midline.
Nares are patent. Maxillary and ethmoid sinuses are non-tender upon palpation.
Mouth and Oropharynx

Tooth is not present. Lips are soft, moist and have a smooth texture. There is a uniform
pink color of gums, tongue and tonsils. Tongue is located at the midline with moist texture.
Tongue is able to move. Deviations and abnormalities are not noted upon inspection of soft and
hard palate. Uvula is positioned in the midline. Rooting and sucking reflexes are noted.
Neck
Neck is located at the midline. It is short and with intact skin. The skin color is the same
as facial skin. Nuchal rigidity is noted as manifested by difficulty of the head to turn to sides.
Thorax and Lungs
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The thorax is rounded with chest circumference of 38 centimeters. The skin is intact with
no tenderness noted. Skin color is consistent with facial skin. Respiratory rate is 41 cycle per
minute with regular pattern of breathing. Patient has regular depths of respiration. Upon
auscultation, crackles are noted on both lung fields. No stridor is noted upon inspiration.
Heart and Peripheral Pulses

The patient has a cardiac rate of 136 beats per minute. No abnormal heart sound is noted
upon auscultation. Peripheral pulses have regular and full pulsations. It is symmetric on both
sides. The skin is warm upon palpation with no discolored extremities. Capillary refill time is 3
seconds.
Abdomen
The patient has an enlarged, globular and distended abdomen with an abdominal
circumference of 44 centimeters. It has a uniform color. No lesions or tenderness noted. It is non-
tender. Abdominal movements are symmetric that are caused by respiration. Umbilicus is located
at the center with no signs of infection and protrusions.
Genito-Urinary
The patient is uncircumcised with tight foreskin. External meatus is located at the tip of
the glans penis. Testes are descended. No swelling or tenderness in the inguinal area. Pateint is
able to void freely.
Musculo-Skeletal
Upper Extremities
Upon inspection, no lesions and scars is noted on arms and shoulders. No tenderness,
inflammations, or masses is evident on elbows. 5 fingers are present on each hand, with no
deformed fingers. No contractures, bone enlargements, nodules or redness is noted. Tenderness
and nodules are not noted on the left wrist, hands and fingers upon palpation. It is free from
inflammation and with normal angle curvature. No hand tremors noted. He is able to exhibit
hand grip when an object touches his hand.
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Lower Extremities
No lesions and scar is noted. No tenderness, inflammation or mass is seen. 5 toes are
present on each foot with no deformed toes. He is able to move his legs without difficulty. No
fractures and dislocation is noted. No tremor noted.

No edema noted on both extremities.
Neurolomuscular Reflexes
Upon assessment, the patient startles and abducts and adducts arms in response to stimuli
indicating that Moro Reflex is still present. Plantar Reflex is present. Palmar Grasp Reflex is also
present as the patient exhibits hand grip when an object touches his hand.
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ANATOMY AND PHYSIOLOGY
The nervous system is an intricate, highly organized network of billions of neurons and
neuroglia. The structures that make up the nervous system include the brain, cranial nerves,
spinal nerves, ganglia, enteric plexuses and sensory receptors. The two main subdivisions of the
nervous system are the central nervous system and the peripheral nervous system.
The central nervous system consists of the brain and spinal cord. The brain is the center
for registering sensations, correlating them with one another and with stored information, making
decisions and taking actions. It also is the center for the intellect, emotions, behavior, and
memory. The major parts of the brain include: the brain stem, cerebellum, diencephalon, and
cerebrum. The spinal cord is connected to a section of the brain called the brainstem and runs
through the spinal canal. Cranial nerves exit the brainstem. Nerve roots exit the spinal cord to
both sides of the body. The spinal cord carries signals (messages) back and forth between the
brain and the peripheral nerves.
The brain stem is continuous with the spinal cord and consists of the medulla oblongata,
pons, and midbrain. The medulla oblongata forms the inferior part of the brain stem. The
medulla contains the cardiac, respiratory, vomiting and vasomotor centers and deals with
breathing, heart rate and blood pressure. The pons is a bridge that connects parts of the brain with
one another. The midbrain extends from the pons to the diencephalon. The midbrain is a short
section of the brain stem between the diencephalon and the pons.
Posterior to the brain stem is the cerebellum. Traditionally, the cerebellum has been
known to control equilibrium and coordination and contributes to the generation of muscle tone.
It has more recently become evident, however, that the cerebellum plays more diverse roles such
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as participating in some types of memory and exerting a complex influence on musical and
mathematical skills.
Superior to the brain stem is the diencephalon, which consists of the thalamus,
hypothalamus, and epithalamus. The thalamus acts a relay center for all sensory impulses, except
smell, to the cerebral cortex. The hypothalamus is involved in the acceleration or deceleration of
the heart. Impulses from the posterior hypothalamus produce a rise in arterial blood pressure and
an increase of the heart rate. Impulses from the anterior portion have the opposite effect. The
hypothalamus is also involved in body-temperature regulation. If the arterial blood flowing
through the anterior portion of the hypothalamus is above normal level, the hypothalamus
initiates impulses that cause heat loss through sweating and vasodilation of cutaneous vessels of
the skin. A below-normal blood temperature causes the hypothalamus to relay impulses that
result in heat production and retention through the initiation of shivering, the contraction of
cutaneous blood vessels. The hypothalamus is also involved in the regulation of hunger and
control of gastrointestinal activity. Low levels of blood glucose, fatty acids and amino acids are
partially responsible for the sensation of hunger elicited from the hypothalamus. When sufficient
amounts of food have been ingested, the hypothalamus inhibits the feeding center. It also
regulates sleeping and wakefulness. A specialized sexual center in the hypothalamus responds to
sexual stimulation of the tactile receptors within the genital organs. Also, the hypothalamus is
associated with specific emotional responses, such as anger, fear, pain and pleasure. The
hypothalamus produces neurosecretory chemicals that stimulate the anterior pituitary gland to
release various hormones. The epithalamus is the posterior portion of the diencephalon.
Supported on the diencephalon and brain stem is the cerebrum, which is the largest part
of the brain. The cerebrum is the largest part of the brain and controls voluntary actions, speech,
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senses, thought, and memory. The surface of the cerebral cortex has grooves or infoldings (called
sulci), the largest of which are termed fissures. Some fissures separate lobes.
The frontal lobes are located in the front of the brain and are responsible for voluntary
movement and, via their connections with other lobes, participate in the execution of sequential
tasks; speech output; organizational skills; and certain aspects of behavior, mood, and memory.
The parietal lobes are located behind the frontal lobes and in front of the occipital lobes.
They process sensory information such as temperature, pain, taste, and touch. In addition, the
processing includes information about numbers, attentiveness to the position of one’s body parts,
the space around one’s body, and one's relationship to this space.
The temporal lobes are located on each side of the brain. They process memory and
auditory (hearing) information and speech and language functions.
The occipital lobes are located at the back of the brain. They receive and process visual
information.
Nervous tissue consists of groupings of nerve cells or neurons that transmit information
called nerve impulses in the form of electrochemical changes. A nerve is a bundle of nerve cells
or fibers. Nervous tissue is also composed of cells that perform support and protection. These
cells are called neuroglia or glial cell. Over 60% of all brain cells are neuroglia cells. There are
different kinds of neuroglial cells, and, unlike neurons, they do not conduct impulses. Astrocytes
are star-shaped cells that wrap around nerve cells to form a supporting network in the brain and
spinal cord. They attach neurons to their blood vessels, thus helping regulate nutrients and ions
that are needed by the nerve cells. Oligodendroglia look like small astrocytes. They also provide
support by forming semi rigid connective-like tissue rows between neurons in the brain and the
spinal cord of the CNS. Microglial cells are small cells that protect the CNS and whose role is to
28 | P a g e
engulf microorganisms like bacteria and cellular debris. They are responsible for the
phagocytosis of unwanted substances in the CNS. Ependymal cells line the fluid-filled ventricles
of the brain. Some produce cerebrospinal fluid and others with cilia move the fluid through the
CNS. Schwann cells form myelin sheaths around nerve fibers in the PNS.
The meninges comprise three membranes that, together with the cerebrospinal fluid,
enclose and protect the brain and spinal cord (the central nervous system). The pia mater is a
very delicate impermeable membrane that firmly adheres to the surface of the brain and the
spinal cord, following all the minor contours. The arachnoid mater (so named because of its
spider-web-like appearance) is a loosely fitting sac on top of the pia mater. The subarachnoid
space separates the arachnoid and pia mater membranes, and is filled with cerebrospinal fluid.
The outermost membrane, the dura mater, is a thick durable membrane, which is attached to both
the arachnoid membrane and the skull.
29 | P a g e
Each of the four ventricles of the brain contains a choroid plexus, a capillary network that
forms cerebrospinal fluid from blood plasma. As the tissue fluid of the CNS, cerebrospinal fluid
permits the exchange of nutrients and wastes between the blood and CNS neurons. It also acts as
a cushion or shock absorber for the CNS. The pressure and constituents of the cerebrospinal fluid
may be determined by means of a lumbar puncture and may be helpful in the diagnosis of
diseases such as meningitis.
In bacterial meningitis, bacteria reach the meninges by one of two main routes: through
the bloodstream or through direct contact between the meninges and either the nasal cavity or the
skin. In most cases, meningitis follows invasion of the bloodstream by organisms that live upon
mucous surfaces such as the nasal cavity. This is often in turn preceded by viral infections, which
break down the normal barrier provided by the mucous surfaces. Once bacteria have entered the
bloodstream, they enter the subarachnoid space in places where the blood-brain barrier is
vulnerable—such as the choroid plexus. Direct contamination of the cerebrospinal fluid may
arise from indwelling devices, skull fractures, or infections of the nasopharynx or the nasal
30 | P a g e
sinuses that have formed a tract with the subarachnoid space; occasionally, congenital defects of
the dura mater can be identified.
The blood-brain barrier (BBB) is a separation of circulating blood and cerebrospinal fluid
(CSF) in the central nervous system (CNS). It occurs along all capillaries and consists of tight
junctions around the capillaries that do not exist in normal circulation. Endothelial cells restrict
the diffusion of microscopic objects (e.g. bacteria) and large or hydrophilic molecules into the
CSF, while allowing the diffusion of small hydrophobic molecules (O2, hormones, CO2). Cells
of the barrier actively transport metabolic products such as glucose across the barrier with
specific proteins.
The blood-brain barrier acts very effectively to protect the brain from many common
bacterial infections. Thus, infections of the brain are very rare. However, since antibodies and
antibiotics are too large to cross the blood-brain barrier, infections of the brain that do occur are
often very serious and difficult to treat. However, the blood-brain barrier becomes more
permeable during inflammation, meaning that some antibiotics can get across. Viruses easily
bypass the blood-brain barrier by attaching themselves to circulating immune cells.
31 | P a g e
The inflammation that occurs in the subarachnoid space during meningitis is not a direct
result of bacterial infection but can rather largely be attributed to the response of the immune
system to the entrance of bacteria into the central nervous system. When components of the
bacterial cell membrane are identified by the immune cells of the brain (astrocytes and
microglia), they respond by releasing large amounts of cytokines, hormone-like mediators that
recruit other immune cells and stimulate other tissues to participate in an immune response.
Large numbers of white blood cells enter the CSF, causing inflammation of the meninges, and
leading to "interstitial" edema.
32 | P a g e
ETIOLOGY AND SYMPTOMATOLOGY
Etiology
Predisposing Factor Rationale Present/ Absent Justification

Age The anatomical structure of the Present The patient is 4
Auditory tube is different in children months old.
below 2-3 years of age. Children of
this age have a more horizontal
auditory tube leading to the pharynx
which increases the likelihood of ear
infection that may lead to meningeal
infection.
(Medical-surgical nursing: an
integrated approach by Lois White,
Gena Duncan)
Underdeveloped Infancy is a factor which makes a Present The patient is an
immune system person more susceptible to meningitis infant, 4 months
and other diseases since infants don’t old, so his
have a fully developed immune immune system
sysytem. Removal of your spleen, an is still
important part of the immune system, underdeveloped.
also may increase the risk.
(Handbook of medical-surgical
nursing by Lippincott Williams &
33 | P a g e
Wilkins)
Precipitating Factor Rationale Present/ Absent Justification

Trauma to the skull Recent trauma to the skull gives Absent The patient has no
or skull fractures bacteria in the nasal cavity the history of trauma
potential to enter the meningeal of the skull.
space. Fractures allow continuity
between the external environment
and the nervous system which can
lead to infection such as meningitis.
(Medical-Surgical Nursing Made
Incredibly Easy! by Springhouse)

Prolonged contact Meningitis is a communicable Absent According to the
to a patient with disease. Prolonged contact may parents, the patient
meningitis increase the likelihood of cross- did not have any
contamination. contact, prolonged
(Medical-surgical nursing: an or not, to a patient
integrated approach by Lois White, with meningitis.
Gena Duncan)
Recent respiratory Meningitis follows invasion of the Present The patient had a
and/or ear infection, bloodstream by organisms that live recent respiratory
or sinusitis. upon mucous surfaces such as the infection as
nasal cavity and the respiratory tract. manifested by
Infection in a space adjacent to the cough.
meninges such as the ears may also
34 | P a g e
lead to meningitis.
(Understanding Medical-Surgical
Nursing by Linda S. Williams,
Paula D. Hopper)
Myelomeningocele These diseases are neural tube Absent The patient does
and meningocele defects that are congenital not have
anomalies. There is a failure of the myelomeningocele
posterior spinous processes on the and meningocele.
vertebrate to fuse, which may permit
meninges and spinal cord to
herniate, resulting in neurologic
impairment. Meningitis may occur
in infants with these diseases if
direct communication occurs
between the skin and the meninges.
(Pathophysiology for the Health
Professions 3rdEdtion by Barbara E.
Gould. 2006)
35 | P a g e
Symptomatology
Symptom Rationale Present/ Absent Justification

Nuchal rigidity This is the inability to flex the Present It was noted that the
neck forward passively due to patient has stiffness of
increased neck muscle tone and the neck. It was also
stiffness related to the disease written in the
process. physician’s side notes.
(Evaluating signs and symptoms
by Lippincott, Williams &
Wilkins. 2009
Brudzinski's sign A positive Brudzinski’s sign Absent The patient did not
signals meningeal irritation. manifest this
Passive flexion of the neck symptom.
stretches the nerve roots, causing
pain and involuntary flexion of
the knees and hips.
Wilkins. 2009)
Kernig's sign Kernig’s sign is hamstring Absent This symptom is not
stiffness and muscle pain when present in the patient.
the examiner attempts to extend
the knee while the hip and knee
36 | P a g e
are flexed 90 degrees. Hamstring
muscle resistance results from
stretching the blood or exudate-
irritated meninges surrounding
the spinal nerve roots.
Wilkins. 2009)
Seizure Seizures may result from Present It was written in the
increased pressure and from areas physician’s side notes
of inflammation in the brain that the patient is
tissue. positive for seizure
(Understanding Medical-Surgical which prompted for
Nursing by Linda S. Williams, his admission to the
Paula D. Hopper) PICU.

Decreased level A decrease in the patient’s level Present Prior to
of consciousness of consciousness usually results hospitalization, the
from a neurologic disorder or patient was noted to
infection. Consciousness is be lethargic.
affected by the reticular activating
system (RAS), an intricate
network of neurons with axons
extending from the brain stem,
thalamus, and hypothalamus to
37 | P a g e
the cerebral cortex. A disturbance
in any part of this system prevents
the intercommunication that
makes consciousness possible.
Wilkins. 2009)
Fever Macrophages, white blood cells, Present The patient had this
and injured cells release chemical symptom prior to and
substances called pyrogens that during his
act directly on the hypothalamus, hospitalization.
causing its thermostat to be set to
a higher temperature. Also,
immunological reactions are sped
up by temperature.
(Medical-surgical nursing: an
integrated approach by Lois
White, Gena Duncan)

Vomiting Vomiting results from an Present According to the
increased intracranial pressure as patient’s parents, the
a response to the inflammatory patient had episodes
process associated with of vomiting before his
meningitis. hospitalization. Also,
(Pathophysiology for the Health it was written in the
38 | P a g e
Professions 3rdEdtion by Barbara physician’s side notes
E. Gould. 2006) that the patient is
positive for vomiting.

Bulging Fontanel This is due to the inflammatory Present It was observed has a
process associated with the bulging anterior
disease and the increased fontanel.
permeability of the blood-brain
barrier. This is only present in
infants up to 6 months of age.
(Clinical Manual of Pediatric
nursing 6th Edition by Marilyn j.
Hockenberry. 2004)
Poor feeding As a response of the immune Absent The patient did not
system to infection, interferon is manifest this
triggered which initiates a stress symptom.
response. The stress response can
elicit changes in the nervous and
endocrine systems and, changes
in behavior seen during an
infection acting through the
mediation of neuropeptides. An
effect of this is anorexia.
Anorexia may be beneficial in the
early phase of infection because
39 | P a g e
of the reduction of nutrients
available which is essential for
microbial growth.
(Pathophysiology: The Biologic
Basis for Disease in Adults and
Children 2nd Edition by Kathryn
L. McCance& Sue E.
Huether.1994 )
Irritability In meningitis, the infection of the Present According to the
meninges may also lead to the patient’s mother, the
inflammation of the blood patient was irritable
vessels, encountered in acute prior to the
infection, which means it is hospitalization.
harder for blood to enter the
brain, and brain cells are deprived
of oxygen which may lead to
irritability.
(Clinical Manual of Pediatric
nursing 6th Edition by Marilyn j.
Hockenberry. 2004)
Opisthotonos Opisthotonus occurs due to Absent The patient did not
facilitation of the anterior manifest this
reticulospinal tract caused by the symptom.
inactivation of inhibitory
40 | P a g e
corticoreticular fibers which
normally act upon the pons
reticular formation
Wilkins. 2009)
41 | P a g e
PATHOPHYSIOLOGY
Predisposing Factors Precipitating Factors

 Age
 Underdeveloped immune system  Infection
Bacteria enters into the blood stream
Crosses the blood-brain

barrier
Bacteria proliferates in the

CSF
Irritates and induces inflammatory reaction to the

CSF and meninges
Immune response of astrocytes, microglia and

Fever
cytokins is released
42 | P a g e
Irritation of the Irritability
nerve endings
Muscle
Inflammation of the Meninges rigidity Nuchal rigidity
Increase in the
number of WBC
Increased Leaked fluid

Vasodilation blood and proteins Purulent
flow move into exudates
inflamed tissue formation
Bulging
Increased Increased ICP fontanel
permeability Edema
Irritates
nerve cells
Seizure
of the brain
IF TREATED: Infected CSF and purulent exudates travel

 Fluid and Electrolyte throughout the CNS and proliferates in the brain,
Management sheath of cranial and spinal nerves and to
 Antibiotic Therapy perivascular areas
Encephalitis
GOOD PROGNOSIS
IF NOT TREATED
43 | P a g e
NARRATIVE PATHOPHYSIOLOGY
Meningitis is an inflammation of the pia mater, the arachnoid space and the cerebrospinal
fluid-filled subarachnoid space. Meningitis is classified as septic or aseptic. In this case, the
patient experience septic meningitis as the condition is cause by bacteria. There are different
bacteria that cause bacterial meningitis and that includes Streptoccocus pneumoniae and Nesseria
meningitides. Other factors that placed an individual at risk for bacterial meningitis are otitis
media, skull fracture and respiratory tract infection as these serves as the gateway for the
infecting bacteria to enter the blood stream. Usually, children from 1-23 months are highly
susceptible to this condition as their immune system is not yet fully developed, enabling them to
fight off infection.
As the bacteria enter into the body, it passes through the blood stream. It the crosses the
blood-brain barrier, a protective barrier that enables many substances to enter the CNS. Due to
the accompanying infection of the bacteria, the blood-brain barrier becomes permeable, thus
allowing the infected blood to pass through. The bacteria then penetrates the cerebrospinal fluid
and reaches the subarachnoid space. Once pathogens enter the subarachnoid space, an intense
host inflammatory response is triggered by lipoteichoic acid and other bacterial cell wall
products produced as a result of bacterial lysis. This response is mediated by the stimulation of
macrophage-equivalent brain cells that produce cytokines and other inflammatory mediators.
Temperature spikes up thus casuing fever.
As the microglia and astrocytes are release, the inflammation of the meninges occurs. The
whole process of inflammation takes place. There will be irritation of the nerve cells thus causing
irritability. Muscle rigidity also takes place. This results into signs such as nuchal rigidity,
positive Kerneg’s and Brudzinski’s sign. Blood examination shows an increase in white blood
44 | P a g e
cells as a result of infection. Vasodilation and increased permeability also take place where
leaked fluids and other protein accumulate in the inflamed tissue to produce pus. This will also
lead to edema causing increased intracranial pressure. As the CNS is continuously affected, brain
cells are also triggered to produce seizure.
Lumbar puncture is the best way to diagnose the condition and to detect what
microorganism has infected. Medical management includes prevention of fever and febrile
symptoms, fluid and electrolyte management, antibiotic therapy and corticosteroids. Dehydration
and shock are treated with fluid volume expanders. Seizures are controlled with phenytoin. Once
diagnosed and properly managed, bacterial meningitis is not fatal and leads to a good prognosis.
However, if no treatment is done, there is a continuous circulation of the infected
cerebrospinal fluid accompanied by the purulent exudates formed. It will then reach the brain as
well as the cranial sheaths. Another infection will occur. As soon as infection takes place, it can
lead to brain damage, decreased cerebral blood flow and encephalitis among others. Death will
soon take place if no treatment is done.
45 | P a g e
DOCTOR’S ORDER
DATE ORDER JUSTIFICATION REMARKS

9/12/10 Admit to IMCU under For close monitoring of the patient and
Admitted
P1 service, Level 3 proper management of his condition.
Please secure consent Informed consent is the permission
for care obtained from a patient/guardian to
allow health care providers to do their
tasks. This also evaluates whether the Consent
patient has understood the reason for secured
his admission and his or her condition.
To secure the consent of the client is
important for legal purposes.
Labs:
CBC with PC CBC is a standard routine laboratory
test which determines the quantity of
each quantity of blood cell in a given
specimen of blood. This is done to Done
know any underlying condition that
produces changes in the blood
components.
UA Urinalysis is a routine and standard Done
laboratory test performed to screen for
urinary tract disorders, kidney
disorders, urinary neoplasm and other
medical conditions that produce
changes in the urine.
46 | P a g e
CXR PAL A chest x ray is a procedure used to
evaluate organs and structures within
the chest for symptoms of disease.
Chest x rays include views of the lungs, Done
heart, small portions of the
gastrointestinal tract, thyroid gland, and
the bones of the chest area.
Cranial Ultrasound Cranial ultrasound is a procedure where
reflected sound waves are used to
produce the images of the brain and
inner fluid chambers. Cranial
ultrasound test is useful for diagnosing
the problems in babies (up to 18 months
Done
old). The test should be done before the
bones of the brain grow together
because ultrasound waves cannot pass
through the bones. This is done to find
out infection and abnormal growths in
or around the brain.
For Lumbar Puncture if Lumbar puncture (colloquially known Not Done
with consent as a spinal tap) is
a diagnostic procedure that is
performed in order to collect a sample
of cerebrospinal fluid (CSF)
for biochemical, microbiological,
and cytological analysis. Its most
common purpose is to collect CSF in a
case of suspected meningitis, since
there is no other reliable tool with
which meningitis can be excluded.
47 | P a g e
Blood GSCS Gram staining and culture and
sensitivity tests are used to determine Done
what type of bacteria the specimen has. without
In this case, the patient’s blood is used result
as the specimen.
Venoclysis: IVF to start D5 0.3NaCl is a hypertonic solution
with D5 0.3 NaCl 500cc which has free water, salt and calories
to run at 34cc/hour that is commonly used for rehydration.
Done
Intravenous lines also provide easy
access for drug administration
intravenously (IVTT).
Meds:
Ceftriaxone 183mg Ceftriaxone is an antibacterial indicated
IVTT q8 hours ANST for meningitis caused by Streptococcus Given
(-) pneumonia and Haemophilus influenza. ANST
This also used as prophylaxis.
Paracetamol 100ml, give It is an antipyretic and analgesic drug
1.1 mL q4 hours, prn for used to decrease fever and for control Given
fever >38°C of pain.
Neuro VS q2 hours Neuro vital signs is an assessment tool
used to evaluate neurological status. It Taken and
is mostly expressed using Glasgow Recorded
Coma Scale and Reaction Level Score.
Vital Signs q4 hours Vital signs are important for baseline
assessment and to monitor patient’s Taken and
condition which evaluates the whole Recorded
treatment course.
I & O q shift The measurement and recording of all
fluid intake and output during a period
Monitored
provides important data about the
and
patient’s fluid balance and ability of
Recorded
kidneys to excrete normral volume of
urine.
48 | P a g e
Monitor for further These changes could be indicative of a
decrease in LOC, worsening condition and increased
Monitored
seizure activity, damaged in the patient’s central
shortness of breath nervous system.
Refer accordingly This creates a collaborative treatment
among the client and the health care
providers; thus it also makes a good Referred
coordination on the treatment of the
client.
Revise Ceftriaxone to Revision of the frequency of drug
550mg IVTT OD administration may be upon the
Revised
physician’s discretion. This could mean
a more potent effect for the drug.
Revise Paracetamol Decreasing drug dosage is ordered
drops to 0.8ml q4 for since the fever of the patient is already
fever controlled. It could also mean that this Revised
dosage is more suitable for the patient
that the last one ordered.
Diet for age Age-appropriate diet means that the Significant
patient may feed on within the other
limitations and tolerance of his age. informed
9/13/10 Labs:
Follow up CXR PAL An order made to remind the patient or
Blood GSCS significant others to obtain result of the Done
specified laboratory tests.
Continue IVF at SR IVF continues to rehydrate the patient.
This also serves as an access for IVTT Continued
medications.
Meds:
Continue Ceftriaxone These medications are continued until
Given
550mg IVTT q8 their desired effects are met. PRN
Paracetamol 0.8ml q4
medications are only given as the need
prn for fever
arises.
49 | P a g e
VS q6 Vital signs are important for baseline
assessment and to monitor patient’s
Given
condition which evaluates the whole
treatment course.
I & O q shift The measurement and recording of all
Monitored
and
Recorded
urine.
Refer accordingly This creates a collaborative treatment
among the client and the health care
providers; thus it also makes a good Referred
coordination on the treatment of the
client.
With UTI Start cefuroxime Since the patient’s latest urinalysis
125mg/5ml 4ml TID showed that he has UTI, cefuroxime, an
Given
antibacterial primarily indicated for the
said condition, is ordered.
9/14/10 For cranial ultrasound This is done to find out infection and
tomorrow abnormal growths in or around the Done
brain.
09/15/10 For cranial ultrasound Patient is scheduled for the said test
today at 1:30pm today. This is done to find out infection
Done
and abnormal growths in or around the
brain.
Still for Lumbar Patient has not yet undergone the said
Puncture conclusive diagnostic test for bacterial Not Done
meningitis on this date.
Continue IVF at SR IVF continues to rehydrate the patient.
This also serves as an access for IVTT
medications.
50 | P a g e
09/16/10 For serum Na, K, Ca, This test is being ordered in order to
Mg create a baseline data and to know the
specific values of electrolytes in the
blood. It also suggests if there is
progress in the treatment if the unusual
Done
levels of the serum will be back to the
desired normal values. Patients with
kidney diseases have electrolyte
imbalances due to decreased
functioning of the kidneys.
s/f LP Patient has not yet undergone the said
conclusive diagnostic test for bacterial Not Done
meningitis as of this date.
Continue meds Existing ordered medications are
continued until their desired effects are Continued
met.
Transfer to Blue/ This transfer of service is done for the
Nephro service (UTI) management of the patient’s urinary Done
tract infection.
09/17/10 For UA (midstream Midstream catch of urine is preferred
(+) seizure catch) since the specimen is most likely not
Done
upon contaminated yet by other external
admission factors.
I and O q shift The measurement and recording of all
(-) BFC
Monitored
and
Recorded
urine.
VS q 4 Vital signs are important for baseline Taken and
assessment and to monitor patient’s Recorded
condition which evaluates the whole
treatment course.
51 | P a g e
Refused LP The family has opted not to have the
(signed by father) Lumbar Puncture procedure due to
financial constraints. The father was Done
asked to sign three times for formality
and legality purposes.
09/18/10 Follow up serum An order made to remind the patient or
-Normal UA electrolytes and repeat significant others to obtain result of the Done
(-) fever UA specified laboratory tests.
Continue IVF @ SR IVF continues to rehydrate the patient.
GCS 15
-awaiting
medications.
blood culture
Refer to derma for Physician observed papular lesions on
result
evaluation of skin the patient’s right arm and for further
-if normal,
lesions evaluation, she referred it to a
parents opt
dermatologist.
to go home Referred
-with papular
lesion and
rash on right
arm
9/19/10 For transfer to PICU Patient is for transfer to Pediatric ICU
(+) vomiting once with available bed since physician noted worsening of his Done
(+) condition that are already alarming.
O2 inhalation at 10 L/m This is to relieve hypoxia, headache,
tachypnea
via face mask nausea, as well as to restore the ability
(+) labored
of the cells of the body to carry on Done
breathing
normal metabolic function. This helps
provide oxygenation of the vital organs.
Nebulization with Salbutamol is a bronchodilator that is
salbutamol q1 indicated for acute attacks of
Done
bronchospasm. Patient noted to be in
respiratory distress.
52 | P a g e
7:30pm Follow up blood GSCS An order made to remind the patient or
Febrile and serum electrolytes significant others to obtain result of the Done
Awake specified laboratory tests.
Shift paracetamol PO to Shifting of paracetamol from PO to
Irritable
paracetamol IVTT 55mg IVTT is most probably ordered either
Tachypneic
q4 prn for fever for faster effect or giving PO is not Shifted
(+)
already feasible due to some factors
intercostal
such as irritability.
retractions
For CBC PC CBC with PC determines the quantity
(+) nuchal
of each quantity of blood cell in a given
rigidity
specimen of blood, often including the
UTI resolved
amount of hemoglobin, hematocrit, and Done
the proportion of various white blood
cells. This test monitors patient’s
condition through blood sample.
For ABG ABG testing is mainly used
in pulmonology, to determine gas
exchange levels in the blood related Done
to lung function, but has a variety of
applications in other areas.
Give Epinephrine 0.1ml Epinephrine facilitates air passage by
SQ now dilating bronchioles in patients on Given
respiratory distress.
Compensate Give 14 meqs of Patient has a significantly low
d respiratory NaHCO3 slow IVTT 1:1 bicarbonate levels thus sodium
Given
alkalosis dilution now bicarbonate is given to correct the
abnormality.
7/20/10 Transfuse 1 unit PRBC CBC results showed low levels of Transfused
55cc of patient’s blood hematocrit, hemoglobin and RBC
type after proper cross count. Transfusion was ordered to
matching to run in 4 correct these abnormalities.
hours
53 | P a g e
May give cetirizine Citirizine, an antihistamine is ordered
drops 0.3ml either due to allergies brought about by
Given
the blood transfusion or for the popular
lesions and rashes seen on the patient.
Continue IVF @ SR IVF continues to rehydrate the patient.
medications.
Start Amikacin 82mg It is a bactericidal indicated for the
OD IVTT treatment of infections due to
susceptible strains of microorganisms, Given
bacterial septicemia and serious and
complicated UTIs.
7/21/10 Repeat CBC This is done to evaluate if the blood
4am transfusion has been enough to correct
Done
Awake the abnormal levels seen in the previous
Afebrile CBCs.
For urine KOH The potassium hydroxide test is a
(+) rales
procedure in which potassium
Post 1 unit
hydroxide (KOH) is used to Done
PRBC
detect fungi by dissolving human cells
in a given specimen.
Continue IVF at same IVF continues to rehydrate the patient.
rate This also serves as an access for IVTT Done
medications.
54 | P a g e
DIAGNOSTIC EXAMS
September 12, 2010
Chest X-RAY
The chest x-ray is the most commonly performed diagnostic x-ray examination. A chest x-ray makes images of the heart,
lungs, airways, blood vessels and the bones of the spine and chest. An x-ray (radiograph) is a noninvasive medical test that helps
physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing
radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging.
Findings:
Minimal hazy sensities are seen in both inner lung zones. The rest of the lungs are clear and well expanded. The heart is within
normal size limit. There are no other additional significant remarkable findings.
Impression: Bronchopneumonia
55 | P a g e
September 19, 2010
Blood Chemistry Test
A procedure in which a sample of blood is examined to measure the amounts of certain substances made in the body. An
abnormal amount of a substance can be a sign of disease in the organ or tissue that produces it.
Test Result Normal Clinical Significance Rationale Interpretation

Range
Glucose L – 4.0 4.10-6.60 Decreased Level: This test is done in order to check the Below Normal
RBS Low blood glucose levels indicate patient’s sugar level. Range
hypoglycemia is termed as the state
produced by a lower than normal level The Client is
of blood glucose. suffering from
Hypoglycemia.

Range
Sodium 141.40 131.00- No Clinical Significance This test is a part of the routine lab Within normal
56 | P a g e
145.00 evaluation of most patients. It is one range
of the blood electrolytes, which are
often ordered as a group. It is also
included in the basic metabolic
panel, widely used when someone
has non-specific health complaints,
and in monitoring treatment
involving IV fluids or when there is
a possibility of developing
dehydration.
http://www.labtestsonline.org/
understanding/analytes/
uric_acid/test.html
Potassium 4.17 3.6-6.8 No Clinical Significance Potassium testing is frequently Within Normal
ordered, along with other Range
electrolytes, as part of a routine
physical. It is used to detect
concentrations that are too high or
too low .
COMPLETE BLOOD COUNT
Complete blood count (CBC) gives important information about the kinds and numbers of cells in the blood, especially red
blood cells, white blood cells, and platelets. A CBC helps your health professional check any symptoms, such as weakness, fatigue, or
bruising, you may have. A CBC also helps him or her diagnose conditions, such as anemia, infection, and many other disorders.
57 | P a g e
DATE: September 11, 2010
Test Result Normal Values Clinical Significance Rationale Interpretation
Hemoglobin 97 M:140-180 Decreased level: A hemoglobin test is A low hemoglobin is

F:120-140 May indicate anemia from performed to determine the referred to as
blood loss, dietary amount of hemoglobin in a anemia.
deficiency, malnutrition, person's red blood cells
sickle-cell anemia; hemolysis (RBCs). This is important
from splenomegaly; kidney because the amount of oxygen
diseases; systemic lupus available to tissues depends
erythematosus; upon how much oxygen is in
malignancies;hemoglobinopa the RBCs, and local perfusion
thies; or sarcoidosis. of the tissues. Without
sufficient hemoglobin, the
tissues lack oxygen and the
heart and lungs must work
harder to compensate.
Leukocytes 9.1 4-11 No significance A WBC count is normally Within Normal Values.
ordered as part of the
complete blood count (CBC).
In some circumstances, a
WBC count may be ordered
to monitor recovery from
58 | P a g e
illness.
59 | P a g e
Values
Neutrophils 0.75 0.50-0.70 Increased level: Evaluated in relation to total Above normal range.
May indicate bacterial WBC count. If neutrophil The increase in
infection such as otitis media, count is significantly greater neutrophil count may be
endocarditis, or bacterial than overall WBC count, a result of Bacterial
meningitis. immune function may be poor Meningitis.
or an overwhelming infection
is
present.http://www.labtestsonli
ne.org/
Lymphocytes 0.50 0.25-0.40 Increased level: A WBC count is normally Above Normal Values.
Elevated WBC count can ordered as part of the complete The patient has an
result from bacterial blood count (CBC). In some increase of leukocyte
infections, inflammation, circumstances, a WBC count count due to the
leukemia, trauma, intense may be ordered to monitor inflammation brought
exercise, or stress. recovery from illness. about by Bacterial
Meningitis.
Eosinophils 0.05 0.02-0.04 Increased level: These measures the number of Above normal range.
May indicate allergic response white blood cells called May be a result of a
such as asthma; parasitic eosinophils. Bacterial infection.
infection such as amebiasis; Eosinophilsbecome active
60 | P a g e
skin disorder such as shingles; when you have certain allergic
neoplastic disorder such as diseases, infections, and other
chromic myelocytic anemia medical conditions.
and necrosis of solid tumor;
pernicious anemia; scarlet
fever; excessive exercise; http://www.nlm.nih.gov/
autoimmune disease; or a medlineplus/ency/article/
splenectomy 003649.htm
Hematocrit 0.27 M: 0.40-0.52 Decreased level: The hematocrit is normally Below Normal Range
F:0.36-0.48 May indicate anemia, blood ordered as a part of the May indicate anemia.
loss, dietary deficiency, complete blood count (CBC).
malnutrition, bone marrow It is also repeated at regular
failure, haemolytic reaction, intervals for many conditions,
rheumatoid arthritis, cirrhosis, including:
hyperthyroidism, Hodgkin’s the diagnosis of anemia and
disease, fluid volume polycythemia,
overload, or multiple myeloma the monitoring of treatment for
anemia,
recovery from dehydration, and
monitoring of ongoing
bleeding to check its severity.
http://labtestsonline.org/
61 | P a g e
understanding/analytes/
hematocrit/test.html
Thrombocyte 257 150-400 No Clinical Significance A platelet count is often Within Normal Range
ordered as a part of a complete
blood count, which may be
done at an annual physical
examination. It is almost
always ordered when a patient
has unexplained bruises or
takes what appears to be an
unusually long time to stop
bleeding from a small cut or
wound.
http://www.nlm.nih.gov/
medlineplus/ency/article/
003649.htm
September 18, 2010

Range
62 | P a g e
Hemoglobin 90.0 115-175 Decreased level: A hemoglobin test is performed to Below
May indicate anemia from blood loss, determine the amount of normal range.
dietary deficiency, malnutrition, hemoglobin in a person's red blood May indicate
sickle-cell anemia; hemolysis from cells (RBCs). This is important anemia.
splenomegaly; kidney diseases; because the amount of oxygen
systemic lupus erythematosus; available to tissues depends upon
malignancies;hemoglobinopathies; or how much oxygen is in the RBCs,
sarcoidosis. and local perfusion of the tissues.
Without sufficient hemoglobin, the
tissues lack oxygen and the heart
and lungs must work harder to
compensate.
Hematocrit 0.27 0.36-0.52 Decreased Level: This test is given in order to Below
Low levels of hematocrit are most measure the concentration of red Normal
frequently found in anemias and blood cells in the blood. Range
leukemias. Kee, Joyce Lefever. Laboratory and And is
diagnostic tests with nursing associated
implications. 2nd ed. with anemia.
Appleton&Lange.1987.
RBC 3.48 4.20-6.10 Decreased level: An RBC count is ordered as a part Below
A decreased number of RBCs results of the complete blood count (CBC), Normal
from either acute or chronic blood often as part of a routine physical, Range.
63 | P a g e
loss. Acute blood loss is a rapid pre-surgical procedure, or for other
depletion of blood volume. Chronic clinical reasons. The test is also May be a
blood loss stems from various repeated in patients who have result of
conditions that often results in some hematologic disorders, bleeding anemia.
form of an anemia. problems, chronic anemias,
polycythemia, and/or patients
undergoing chemotherapy or
radiation therapy.
WBC 11.15 5.0-10.0 Increased level: A WBC count is normally ordered Above
Elevated WBC count can result from as part of the complete blood count Normal
bacterial infections, inflammation, (CBC). In some circumstances, a Range.
leukemia, trauma, intense exercise, or WBC count may be ordered to A result of
stress. monitor recovery from illness. the
inflammation
http://www.labtestsonline.org/ brought
about by
Bacterial
Infection.
Neutrophils 15 55-75 Decrease in Neutrophils indicates viral Neutrophil count aids in helping in Below
diseases such as chicken pox, monitoring the immune response of Normal
measles, rubella, and Leukemia and the patient. Range
anemia.
May indicate
64 | P a g e
anemia.
Lymphocytes 78 20-35 Lymphocytes can increase in cases of It is used to diagnose the severity of Above
viral infection, leukemia, cancer of the infestations with worm and other Normal
bone marrow, or radiation therapy. large parasites and response to Range.
treatments. May be a
http://www.labtestsonline.org/ result of the
inflammation
Brought
about by
Bacterial
Meningitis.
Monocyte 9 2-10 No Clinical Significance Monocyte levels are checked to Within
know the increase in response to Normal
infection of all kinds as well as to Range
inflammatory disorders.
Eosinophil 0 1-8 Decreased Levels: These measures the number of Below
Decreased levels of eosinophils can white blood cells called eosinophils. Normal
occur as a result of infection. Eosinophils become active when Range.
you have certain allergic diseases,
infections, and other medical A result of a
conditions. bacterial
65 | P a g e
infection.
003649.htm
Platelet Count 417 150-400 Increased Level: Platelet count is ordered To assist in Above
Increased platelet counts occur in the diagnosis of bleeding disorders Normal
polycythemia, and fractures and after and to monitor patients who are Range
splenectomy. being treated for any disease
involving bone marrow failure. This
test determines the number of
platelets in the patient’s blood.
MCH 26.0 26.0-32.20 No Clinical Significance This test is done to determine the Within
(Mean weight of hemoglobin in RBCs, Normal
Corpuscular regardless of their size. Range
Hemoglobin) Kee, Joyce Lefever. Laboratory and
diagnostic tests with nursing
implications. 2nd ed. Appleton&
Lange.1987.
MCHC 34.0 32.20-36.50 No Clinical Significance This is ordered to measure the Within
(Mean hemoglobin concentration per unit Normal
Corpuscular volume of RBCs. Range
Hemoglobin Kee, Joyce Lefever. Laboratory and
concentration) diagnostic tests with nursing
66 | P a g e
Lange.1987.
MCV 78.3 79.00-94.80 Decreased levels may indicate This test is done in order to Below
(Mean Microcytic anemias( iron-deficiency determine the Mean volume of normal range.
Corpuscular anemia). Malignancy, Rheumatoid RBCs. May be
volume) Arthritis, Sickle cell Anemia. indicative of
Anemia.
September 19, 2010

Range
67 | P a g e
compensate.
implications. 2nd ed. Appleton& with anemia.
Lange.1987.
radiation therapy.
68 | P a g e
inflammation
about by
Bacterial
Infection.
Neutrophils 57 55-75 No Clinical Significance Neutrophil count aids in helping in Within
monitoring the immune response of Normal
the patient. Range
Lymphocytes 31 20-35 No Clinical Significance It is used to diagnose the severity of Within

infestations with worm and other Normal
large parasites and response to Range
treatments.
69 | P a g e
infection.
003649.htm
MCH 28.0 26.0-32.20 No Clinical Significance This test is done to determine the Within
(Mean weight of hemoglobin in RBCs, Normal
Corpuscular regardless of their size. Range
Lange.1987.
MCHC 32.3 32.20-36.50 No Clinical Significance This is ordered to measure the Within
(Mean hemoglobin concentration per unit Normal
70 | P a g e
Corpuscular volume of RBCs. Range
Lange.1987.
MCV 79 79.00-94.80 No Clinical Significance This test is done in order to Within
(Mean determine the Mean volume of Normal
Corpuscular RBCs. Range.
volume)
September 21, 2010
Range
71 | P a g e
compensate.
implications. 2nd ed. with anemia.
radiation therapy.
72 | P a g e
inflammation
about by
Bacterial
Infection.
Lymphocytes 59 20-35 Increased level: It is used to diagnose the severity of Above
Lymphocyte increase means there is infestations with worm and other Normal
viral infection, leukemia, cancer of the large parasites and response to Range
bone marrow, or radiation therapy. treatments.
73 | P a g e
infection.
003649.htm
MCH 25.6 26.0-32.20 Decreased level: This test is done to determine the Below
(Mean May indicate microcytic anemia or weight of hemoglobin in RBCs, Normal
Corpuscular hypochromic anemia. regardless of their size. Range
Lange.1987.
MCHC 31.6 32.20-36.50 Decreased level: This is ordered to measure the Below
(Mean May indicate iron deficiency anemia hemoglobin concentration per unit Normal
Corpuscular or thalassemia. volume of RBCs. Range
74 | P a g e
implications. 2nd ed.
MCV 80.8 79.00-94.80 No Clinical Significance This test is done in order to Within
(Mean determine the Mean volume of Normal
Corpuscular RBCs. Range.
volume)
ARTERIAL BLOOD GAS

Determination of ABGs is usually ordered to assess disturbances of acid-base balance caused by a respiratory disorder, cardiac
failure, drug overdose, renal failure, uncontrolled diabetes mellitus, and other metabolic disorders.
September 19, 2010
Range
PH 7.39 7.35-7.45 No Clinical Significance This test is ordered to determine the Within
acidity and alkalinity of body fluids. Normal
Kee, Joyce Lefever. Laboratory and Range
Lange.1987.
PCO2 13.0 35-45 Decreased Level: pCO2 measures the adequacy of Below
Low levels of PCO2 may indicate alveolar ventilation in view of current Normal
anxiety, hysteria, hypoxia. metabolic demands. Range
PO2 150.0 80-100 Increased Level: This test reflects the amount of Above
75 | P a g e
Elevated pO2 levels are associated oxygen gas dissolved in the Normal
with Increased oxygen levels in the blood. It primarily measures Range
inhaled air, Polycythemia. the effectiveness of the lungs
in pulling oxygen into the
blood stream from the
atmosphere.
http://www.brooksidepress.org/
HCO3 6.5 22.0-27.0 Decreased Level: The HCO3− ion indicates Below
A low HCO3− indicates metabolic whether a metabolic problem Normal
acidosis, a high HCO3− indicates is present (such as Range
metabolic alkalosis. HCO3− levels ketoacidosis).
can also become abnormal when
the kidneys are working to
compensate for a respiratory issue
so as to normalize the blood pH.
BE (ECT) -19.6 (-2)-(+2) Negative Values of Base Excess To indicate whether the patient Negative
may Indicate: Lactic Acidosis, has metabolic acidosis or Result
Ketoacidosis, Ingestion of acids, metabolic alkalosis.
Cardiopulmonary collapse,
Shock.
76 | P a g e
O2 SAT 98.8 80-100 No Clinical Significance This measures the percent of Within
hemoglobin which is fully Normal
combined with oxygen. Values
ctC02 6.9 23.0-30.0 Decreased Level: The bicarbonate (or total CO2) Below
May be due to Addison’s disease, test is almost never ordered by Normal
Chronic diarrhea, Diabetic itself. It is usually ordered Range
ketoacidosis, Metabolic acidosis, along with sodium, potassium,
Kidney disease, Ethylene glycol or and chloride as part of an
methanol poisoning, Salicylate electrolyte panel. The
(aspirin) overdose. electrolyte panel is used to
detect, evaluate, and monitor
electrolyte imbalances. It may
be ordered as part of a routine
exam or to help evaluate a
chronic or acute illness. It may
be ordered at intervals to help
monitor conditions, such as
kidney disease and
hypertension, and to monitor
the effectiveness of treatment
for known imbalances.
77 | P a g e
Urinalysis
The examination of the chemical and physical components of urine is useful in measuring many kidney functions such as acid-
base balance, electrolyte regulation, and elimination of the products of metabolism.
Date: September 11, 2010
CHEMICAL ANALYSIS
Values
Glucose Negative Negative An excessively high To help detect if sugar is Within normal result
glucose concentration in present in the urine and
the blood, such as may be determine if patient has
seen with people who glucosuria.
have uncontrolled diabetes
mellitus.
A reduction in the “renal
threshold.” When blood
glucose levels reach a
certain concentration, the
kidneys begin to excrete
glucose into the urine to
decrease blood
concentrations.
Albumin Negative Negative This measures the amount To help detect traces of Within normal results
of albumin in the urine. protein present in the urine
78 | P a g e
Normally, there will not and determine if patient has
be detectable quantities. albuminuria.
When urine protein is
elevated, there is a
condition called
proteinuria; this can be an
early sign of kidney
disease.
Specific 1.025 1.010 and There are no "abnormal" Knowing the urine Within Normal Range
gravity 1.030 specific gravity values. concentration helps health
This test simply indicates care providers decide if the
how concentrated the urine specimen they are
urine is. Specific gravity evaluating is the best one to
measurements are actually detect a particular substance.
a comparison of the For example, if they are
amount of solutes looking for very small
(substances dissolved) in amounts of protein, a
urine as compared to pure concentrated morning urine
water. specimen would be the best
sample.
Microscopic Examination
79 | P a g e
Values
RBC 0.3/hpf 0 – 3 /hpf Normally, a few RBCs are This measures Inflammation, This means that the patient
present in urine sediment. injury, or disease in the Is not experiencing any
Inflammation, injury, or kidneys or elsewhere in the injury
disease in the kidneys or urinary tract. In the kidneys or in the
elsewhere in the urinary urinary tract.
tract, for example, in the
bladder or urethra, can
cause RBCs to leak out of
the blood vessels into the
urine. RBCs can also be a
contaminant due to an
improper sample
collection and blood from
hemorrhoids or
menstruation.
EPITHELIAL Positive Negative Normally in men and In urinary tract conditions There is a presence of
CELLS women, a few epithelial such as infections, inflammation.
cells from the bladder inflammation, and
(transitional epithelial malignancies, more epithelial
cells) or from the external cells are present. Determining
urethra (squamous the kinds of cells present
epithelial cells) can be helps the health care provider
80 | P a g e
found in the urine pinpoint where the condition
sediment. Cells from the is located.
kidney (kidney cells) are
less common
September 18, 2010

Values
Glucose Negative Negative An excessively high To help detect if sugar is Within normal result
glucose concentration in present in the urine and
the blood, such as may be determine if patient has
seen with people who glucosuria.
have uncontrolled diabetes
mellitus.
A reduction in the “renal
threshold.” When blood
glucose levels reach a
certain concentration, the
kidneys begin to excrete
glucose into the urine to
decrease blood
concentrations.
Albumin Negative Negative This measures the amount To help detect traces of Within normal results
81 | P a g e
of albumin in the urine. protein present in the urine
Normally, there will not and determine if patient has
be detectable quantities. albuminuria.
When urine protein is
elevated, there is a
condition called
proteinuria; this can be an
early sign of kidney
disease.
Specific 1.025 1.010 and There are no "abnormal" Knowing the urine Within Normal Range
gravity 1.030 specific gravity values. concentration helps health
This test simply indicates care providers decide if the
how concentrated the urine specimen they are
urine is. Specific gravity evaluating is the best one to
measurements are actually detect a particular substance.
a comparison of the For example, if they are
amount of solutes looking for very small
(substances dissolved) in amounts of protein, a
urine as compared to pure concentrated morning urine
water. specimen would be the best
sample.
Microscopic Examination
82 | P a g e
Values
RBC 0.3/hpf 0 – 3 /hpf Normally, a few RBCs are This measures Inflammation, This means that the patient
present in urine sediment. injury, or disease in the Is not experiencing any
Inflammation, injury, or kidneys or elsewhere in the injury
disease in the kidneys or urinary tract. In the kidneys or in the
elsewhere in the urinary urinary tract.
tract, for example, in the
bladder or urethra, can
cause RBCs to leak out of
the blood vessels into the
urine. RBCs can also be a
contaminant due to an
improper sample
collection and blood from
hemorrhoids or
menstruation.
EPITHELIAL Negative Negative Normally in men and In urinary tract conditions There is no presence of
CELLS women, a few epithelial such as infections, inflammation.
cells from the bladder inflammation, and
(transitional epithelial malignancies, more epithelial
cells) or from the external cells are present. Determining
urethra (squamous the kinds of cells present
83 | P a g e
epithelial cells) can be helps the health care provider
found in the urine pinpoint where the condition
sediment. Cells from the is located.
kidney (kidney cells) are
less common
Tubex Test
TUBEX (IDL Biotech) is a 5 min semiquantitative colorimetric test for typhoid fever, a widely endemic disease. TUBEX
detects anti-Salmonella O9 antibodies from a patient's serum by the ability of these antibodies to inhibit the binding between
an indicator antibody-bound particle and a magnetic antigen-bound particle.
Result Score Interpretation Guide
≤2 NEGATIVE- Does not indicate current
Typhoid Fever infection
3 BORDERLINE- Inconclusive score, repeat
analysis. If still inconclusive repeat sampling
at a later date.
4-5 POSITIVE – Indicate of current Typhoid Fever
infection.
≥6 POSITIVE – Strong indication of current
Typhoid Fever infection.
INDETERMINATE No Clear score obtained due to:
3.) Poor adherence to assay protocol analysis.
4.) Poor specimen quality. Repeat sampling
and analysis.
Cranial Ultrasound
84 | P a g e
Cranial ultrasound uses reflected sound waves to produce pictures of the brain and the inner fluid chambers (ventricles)
through which cerebrospinal fluid (CSF) flows. This test is most commonly done on babies to evaluate complications of birth. In
adults, cranial ultrasound may be done to visualize brain masses during brain surgery.
Date requested : 9/13/10
REAL TIME SCANS OVER THE ANTERIOR FONTANEL SHOW A HOMOGENOUS BRAIN PARENCHYMA WITH NO
ABNORMAL FOCAL MASS LESIONS. THE GYRI AND SULCI PATTERNS ARE REMARKABLE. THE LATERAL 3 RD AND
4TH VENTRICLES ARE NOT DILATED. NO EXTRA-AXIAL FLUID COLLECTION NOTED.
85 | P a g e
DRUG STUDY
Generic Name: Paracetamol

Brand Name: Perfalgan
Classification: Non-narcotic analgesic, Antipyretic
Dosage: 9/12 180 mg/ml 1.1 ml q4 prn; 0.8 ml q4 prn
55 mg IVTT for prn fever

Mode of Action: Decreases fever by hypothalamic effect leading to sweating and
vasodilation. Also inhibits the effect of pyrogens on the hypothalamic
heat-regulating centers. May cause analgesia by inhibiting CNS
prostaglandin synthesis; however, due to minimal effects on peripheral
prostaglandin synthesis, it has no anti-inflammatory or uricosuric
effects. Antipyretic and analgesic effects are comparable to those of
aspirin
Indication: Control of pain due to headache, earache, dysmenorrheal, arthralgia,
myalgia, musculoskeletal pain, arthritis, immunizations, teething,
tonsillectomy; to reduce fever in bacterial or viral infections; as a
substitute for aspirin in upper GI disease, aspirin allergy, bleeding
disorders, clients on anticoagulant therapy, and gouty arthritis.

Contraindication Contraindicated in patients hypersensitive to drug; renal insufficiency,
anemia; clients with cardiac or pulmonary disease

Drug Activated charcoal, cholestyramine and colestipol: Decreased
Interactions: absorption
Barbiturates, carbamezepine, diflunisal, hydantoins, isoniazid,
rifabutim, rifampin, sulfinpyrazone: Increased risk of hepatotoxicity
Hormonal contraceptives: Decreased efficacy
Oral anticoagulants: Increased anticoagulant effect
Phenothiazines: Severe hypothermia
86 | P a g e
Zidovudine: Increased risk of granulocytopenia
Hematologic: hemolytic anemia, neutropenia, leukopenia,
Side/ Adverse pancytopenia
Effects: Hepatic: jaundice
Metabolic: hypoglycemia
Skin: rash urticaria

Nursing 1. Assess vital signs.
Responsibilities: 2. Document presence of fever.
3. Instruct the client’s mother to give the drug only for complaints
indicated.
4. Tell the client’s mother not to exceed the recommended dose;
do not take longer for 10 days.
5. Encourage the client to avoid using other over-the-counter
drug preparations; if the client needs an OTC preparation,
instruct the client to consult the health care provider.
6. Discuss with the client the possible side effects of the drug.
7. Reassess the vital signs to evaluate the efficacy of the drug.
8. If any of the side effects occur, report it immediately to the
physician.
Generic Name: Ceftriaxone sodium

Brand Name: Rocephin
Classification: Antibiotic
Dosage: 9/12- 183 mg IVTT q8 ANST
9/12 550 MG OD
Mode of Action: Bactericidal: Inhibits bacterial cell wall synthesis, causing cell death.
Indication:  Lower Respiratory tract infections caused by Streptococcus
pneumoniae, Staphylococcus aureus, Haemophilus influenza,
87 | P a g e
Escherichia coli, and Proteus mirabilis.
 UTI caused by E.coli, Klebsiella, Proteus vulgaris, P. mirabilis.
 Meningitis caused Streptococcus pneumoniae, Haemophilus
influenza.
 Dermatologic infections caused by Klebsiella, S. aureus, P.
mirabilis.
 Bone and joint infection caused by by Streptococcus pneumoniae,
Staphylococcus aureus, Escherichia coli, Klebsiella pneumonia,
Proteus mirabilis and Enterobacter.
Contraindication Contraindicated with allergy to cephalosphorins or penicillins.

Drug  Increased nephrotoxicity with aminoglycosides.
 Increased bleeding effects with oral anticoagulants.
interactions:  Disulfiram-like reaction may occur if taken within 72 hr after
ceftriaxone administration.
Side/ Adverse CNS: headache, dizziness, lethargy
Effects: GI: nausea, vomiting, diarrhea, abdominal pain, flatulence,
hepatotoxicity
GU: nephrotoxicity
Hematologic: decreased WBC, platelets and Hct
Hypersensitivity: ranging from rash to fever to anaphylaxis

Nursing 1. Ask the mother if the client has any history of allergy with the
Responsibilities: drug.
2. Tell the client to receive the full course of therapy as prescribed.
3. Have vitamin K available in case of hypoprothrombinemia occurs.
4. Do not mix it with other antimicrobial drugs.
5. Discontinue if hypersensitivity reaction occurs.
6. Discuss the possible side effects to the client like stomach upset or
diarrhea.
7. Do not double dose the drug.
8. Report any unusualities to the physician immediately.
88 | P a g e
Generic Name: Albuterol sulfate
Brand Name: Salbutamol
Classification: Bronchodilator
Dosage: 9/19 -1 nebule q1
9/19- 1 nebule q4
Mode of Action: Acts relatively selectively at beta2- adrenergic receptors to cause
bronchodilation and vasodilation

Indication: Inhalation: Treatment of acute attacks of bronchospasm
Contraindication
Hypersensitivity to albuterol; tachycardia, tachyarrythmisa caused by
digitalis intoxication; hypertension, coronary insufficiency, CAD,
COPD patients with degenerative heart disease.

Drug interactions:  Decreased bronchodilating effects with beta-adrenergic blockers
 Decreased effectiveness of insulin, oral hypoglycaemic drugs
 Decreased serum levels and therapeutic effects of digoxin
 Increased risk of toxicity when used with theopylline and
aminophylline
 Increased symphatomimetic effects with other symphatomimetic
drugs
Side/ Adverse Effects:  CNS: restlessness, anxiety, fear, tremor, drowsiness, weakness,
vertigo, headache
 CV: cardiac arrhythmias, tachycardia, palpitations, angina pain
 GI: nausea, vomiting, heartburn
 Respiratory: coughing, bronchospasm
Nursing 1. Ask the client’s mother if the client has any history of allergy with
Responsibilities: the drug.

2. Instruct the mother not to exceed recommended dosage of the drug
because it may loss its effectiveness or may cause adverse effects.

3. Explain the possible side effects of the drug like dizziness,
89 | P a g e
drowsiness, fatigue, rapid heart rate, nausea and vomiting.
4. Encourage mother to feed her child to avoid vomiting.
5. Assist the client in performing his daily activities because it may
cause drowsiness and dizziness.

6. Instruct the mother to perform oral care for the child to avoid
changes in taste.
7. Perform gentle back tapping after the administration of the drug
through inhalation.
Generic Name Cefuroxime
Brand Name Aeruginox

Classification Second Generation
Suggested Dose 125/5 ml tid
Mechanism of Second-generation cephalosporin that inhibits cell-wall synthesis, promoting
Action osmotic instability; usually bactericidal.

Indication  Serious lower respiratory tract infection UTI, skin or skin-structure
infections, bone or joint infection, septicemia, meningitis, and gonorrhea

 Perioperative prevention
 Bacterial exacerbations of chronic bronchitis or secondary bacterial
infection of acute bronchitis

 Acute bacterial maxillary sinusitis
 Pharyngitis and tonsillitis
 Otitis media
 Uncomplicated UTI
 Early Lyme disease
 Impetigo
Contraindication  Contraindicated in patients hypersensitive to drug or other cephalosporins.
 Use cautiously in patients hypersensitive to penicillin because of possibility
of cross-sensitivity with other beta-lactam antibiotics.

 Use cautiously in breast-feeding women and in patients with history of
colitis or renal insufficiency.

Drug Interaction  Drug-drug.
o Aminoglycosides: May cause synergistic activity against some
90 | P a g e
organisms; may increase nephrotoxicity. Monitor patient’s renal
function closely.
o Loop diuretics: May increase risk of adverse renal reactions.
Monitor renal function test results closely.

o Probenicid: May inhibit excretion and increasecefuroxime level.
Probenicid may be used for this effect.

 Drug-food.
o Any food: may increase absorption. Give drug with food.
Side/Adverse Effects  CV: phlebitis, thrombophlebitis
 GI: diarrhea, pseudomembrabous colitis, nausea, anorexia, vomiting.
 Hematologic: hemolytic anemia, thrombocytopenia, transient
neutropenia, eosinophilia
 Skin: maculopopular and erythematous rashes, urticaria, pain, induration,
sterile abscesses, temperature elevation, tissue slaughting at I.M. injection
site.
 Other: anaphylaxis, hypersensitivity reactions, serum sickness.
Nursing 1. Before giving the drug, ask the mother if her child is allergic to penicillins
Responsibilities or cephalosporins.
2. Absorption of oral drug is enhanced by food.
3. Monitor patient for signs and symptoms of superinfection.
4. Tell patient’s mother to give the drug as prescribed even after he feels
better.
5. Do not double dose the drug.
6. Explain the possible side effects of the drug like nausea and vomiting.
7. Report any unusualities immediately if it occur.
Generic Name Sodium Bicarbonate

Brand Name Neut
Classification Alkanizer
Suggested Dose
14 mEqs
Mechanism ofDissociates to provide bicarbonate ion which neutralizes hydrogen ion
Action concentration and raises blood and urinary pH

Indication Metabolic acidosis, Systemic or urinary alkalanization, Antacid, Cardiac
91 | P a g e
Arrest
Contraindication Alkalosis, hypernatremia, severe pulmonary edema, hypocalcemia, unknown
abdominal pain
Drug Interaction  Decreased effect/levels of lithium, chlorpropamide, methotrexate,
tetracyclines, and salicylates due to urinary alkalinization
 Increased toxicity/levels of amphetamines, anorexiants, mecamylamine,
ephedrine, pseudoephedrine, flecainide, quinidine, quinine due to urinary
alkalinization
Side/Adverse Effects CNS: tetany
CV: edema
Metabolic: hypokalemia, metabolic alkalosis, hypernatremia,
hyperosmolarity with overdose
Skin: pain and irritation a injection site

Nursing 1. To avoid risk of alkalosis, obtain blood pH, partial pressure of arterial
Responsibilities oxygen, partial pressure of arterial carbon dioxide, and electrolyte levels.
Tell prescriber laboratory results.
2. Monitor the cardiac rhythm carefully during I.V. administration.
3. Tell patient’s mother not to let the child take drug with milk because doing
so may cause high levels of calcium in the blood, abnormally high
alkalinity in tissues and fluids, or kidney stones.
4. Inform about milk-alkali syndrome (characterized by hypercalcemia
caused by repeated ingestion of calcium and absorbable alkali) if use is
long-term.
5. Observe for extravasations when giving I.V.
6. Explain the possible side effects of the drug, like pain and irritation in the
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injection site.
7. Report to the physician immediately if unusualities occur.
Generic Name Cetirizine Hydrochloride

Brand Name Histrine
Classification Antihistamine
Suggested Dose
0.3 drops prn
Mechanism ofPotent histamine (H1) receptor antagonist; inhibits histamine release and
Action eosinophil chemotaxis during inflammation, leading to reduced swelling and
decreased inflammatory response.

Indication Management of allergic rhinitis, treatment of idiopathic or chroni urticaria
Contraindication Contraindicated with allergy to any antihistamines, hydroxyzine
Side/Adverse Effects CNS: somnolence, sedation
CV: edema
GI: nausea, diarrhea, abdominal pain, constipation
Respiratory: bronchospasm
Other : fever, rash

Nursing 1. Ask the mother if the client has any history of allergy with the drug.
Responsibilities 2. Instruct to take the drug as prescribed.
3. Tell the mother not to double dose the drug.
4. Give without regards to meal.
5. Encourage adequate intake of fluids.
6. Explain the possible side effects of the drug such as sedation, fever and
rash.
7. Provide skin care if urticaria had occur.
8. Report any unsualities if it occur.
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Generic Name: Amikacin sulfate
Brand Name: Amikacil
Classification: Aminoglycoside
Dosage: 82 IVTT OD
Mode of Action: Bactericidal; inhibits protein synthesis in susceptible strains of gram-
negative bacteria and the functional integrity of bacterial cell membrane
appears to be disrupted, causing cell death.

Indication: Treatment of the following infections due to susceptible strains of
microorganisms: Bacterial septicemia including neonatal sepsis; serious
infections of the respiratory tract; infections of the bones and joints;
intra-abdominal infections including peritonitis; burns and
postoperative infections; serious and complicated urinary tract
infections due to susceptible organisms.

Contraindication Hypersensitivity to aminoglycosides.
Drug interactions:  Increased ototoxic and nephrotoxic effects with potent diuretics
and similarly toxic drugs.
 Risk for inactivation if mixed with parenteral penicillins.

Side/ Adverse CNS: ototoxicity, visual disturbances, lethargy, muscle twitching, tremor,
Effects: apnea
CV: palpitation
GI: nausea, vomiting, diarrhea, stomatitis
GU: nephrotoxicity
Hematologic: electrolyte disturbances, haemolytic anemia, anemia,
thrombocytopenia, leukopenia,
Hepatic: hepatic toxicity
Hypersensitivity: rash, urticaria, itching
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Other: pain at the injection site
Nursing 1. Ask the mother if the client has any history of allergy with the
Responsibilities: drug.
2. Ensure that the patient is well hydrated before and during the
therapy; encourage increase oral fluid intake.
3. Instruct the mother to give frequent oral care to the child.
4. Explain the possible side effects of the drug like nausea, vomiting
and dizziness.
5. Report any unusalities immediately to the physician.
Generic Name: Epinephrine hydrochloride

Brand Name: Uni-amp
Classification: Sympathomimetic, alpha adrenergic agonist,
beta adrenergic agonist, cardiac stimulant,
vasopressor, bronchodilator, anti-astmatic

Dosage: 0.1 ml SQ now
Mode of Action: Epinephrine, an active principle of the adrenal medulla, is a direct-
acting sympathomimetic. It stimulates α- and β-adrenergic receptors
resulting in relaxation of smooth muscle of the bronchial tree, cardiac
stimulation and dilation of skeletal muscle vasculature. It is frequently
added to local anaesthetics to retard diffusion and limit absorption, to
prolong the duration of effect and to lessen the danger of toxicity.
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Indication: INJECTION: relief from respiratory distress of bronchial asthma, chronic
bronchitis, emphysema and other COPDs

Contraindication Preexisting hypertension; occlusive vascular disease; angle-closure
glaucoma (eye drops); hypersensitivity; cardiac arrhythmias or
tachycardia. When used in addition to local anaesthetics: Procedures
involving digits, ears, nose, penis or scrotum.

Drug interactions:  Increased sympathomimetic effects with other TCAs
 Excessive hypertension with beta-blockers, propanolol,
furazolidone
 Decreased cardio-stimulating and bronchodilating effects with
beta adrenergic blockers
 Decreased vasopressor effects with chlorpromazine
 Decreased antihypertensive effects with methyldopa,
guanethidine
Side/ Adverse CNS: fear, drowsiness, lightheadedness, weakness
Effects: CV: arrhythmias
GI: nausea, vomiting
GU: dysuria, urinary retention, decrease urine formation
Other: pallor, respiratory difficulty, sweating
Local: necrosis at sites of repeat injection

Nursing 1. Do not exceed the recommended dosage; loss of effectivess or
Responsibilities: adverse effects may result.
2. Ensure that the drug solution should be clear and colorless, do not
use pink or brown solution.
3. Protect the drug solution from extreme light, extreme heat and
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freezing.
4. Rotate subcutaneous injection sites to prevent necrosis. Monitor it
frequently.
5. Monitor client’s cardiac rate.
6. Have an alpha-adrenergic blocker readily available if pulmonary
edema occurs or a beta- adrenergic blocker in case of cardiac
arrhythmias.
7. Explain the possible side effects of the drug like drowsiness,
nausea, vomiting and fast heart rate.
8. Observe for unusualities and if it occurs, notify the physician
immediately.
NURSING THEORIES
Florence Nightingales’s Environmental Theory
Florence Nightingale, the lady with the lamp defined nursing as, “the act of utilizing the
environment of the patient to assist him in his recovery.” This theory focuses on changing and
manipulating the environment in order to put the patient in the best possible conditions for nature
to act.
She identified 5 environmental factors: fresh air, pure water, efficient drainage,
cleanliness/sanitation and light/direct sunlight. Any deficiencies in these 5 factors produce illness
or lack of health, but with a nurturing environment, the body could repair itself.
In the case of our client, he has an infection, so he really needed a clean and sound
environment conducive for his healing. He was admitted at SPMC Pediatric ward-IMCU, as
observed the ward’s cleanliness was well maintained by the utility men but there are a lot of
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patients who occupied the ward so, sometimes the cleanliness of the place is compromised. Also,
sometimes there are rats that can be seen around the ward that made it not so conducive for the
healing process. The client was able to drink fresh water and was able to breathe fresh air since
her bed is located near the window. The hospital has an efficient drainage system, as well. The
client was not able to get direct sunlight since he was not allowed to go out the hospital premises.
Lydia Hall’s Care, Core, Cure Theory
Hall defined nursing, “participation in care, core cure aspects of patient care where care is
the sole function of the nurses, whereas the core and cure are shared with other members of the
health team.” The major purpose of care is to achieve an interpersonal relationship with the
individual to facilitate the development of core.
KEY CONCEPTS OF 3 INTERLOCKING CIRCLES:
CORE
THE PERSON
THERAPEUTIC
USE OF SELF
CARE CURE
THE BODY THE DISEASE
SEEING
THE INTIMATE THROUGH THE
BODILY CARE MEDICAL
CARE
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We student nurses did our best to render the quality nursing care we could offer to our
client. We offered ourselves to his and are always there to lend a hand whenever he and his
mother needed help. Our client is our concern and we must aid him in his recovery. In the
case of our client, we had given his mother health teachings especially regarding the
breastfeeding and its benefits, since his mother stopped breastfeeding the child. Also, since
the client is dependent to his parents, they must be there all the time to help the child in doing
his activities of daily living. Together with the other members of the health team, as student
nurses, we had cooperated with them in giving the quality care our client needed. We help out
in carrying out the doctor’s orders giving to follow intravenous fluid for the client. A
collaborative work between the physicians and nurses is very significant in the disease
process, and is very important for faster recovery of the patient but without the patient’s
cooperation and as well as the significant others, we health care providers will not be able to
render the best care we could possibly give to the client so relationship between the client
and health team is also essential.
Since the major purpose of the care is to achieve an interpersonal relationship with the
individual that will facilitate the development of the core, our client; in our case, we had
developed a good working relationship with our colleagues in the hospital, especially with
the staff nurses and together we had implemented our different plans of care for the
alleviation of the client’s situation. In order to achieve our goals in caring for our client it‘s
really important to develop a sense of unity and of course communication between
colleagues is also very significant all throughout the nursing process.
Virginia Henderson’s Definition 14 Basic Needs
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Henderson defined nursing as: “assisting the individual, sick or well, in the performance
of those activities contributing to health or its recovery (or to peaceful death) that an individual
would perform unaided if he had the necessary strength, will or knowledge”. She formulated a
nursing theory which focuses on person’s basic needs and he enumerated 14 basic needs that a
person must possess.
The following are the14 basic needs:
1. Breathing normally
2. Eating and drinking adequately
3. Eliminating body wastes
4. Moving and maintaining desirable position
5. Sleeping and resting
6. Selecting suitable clothes
7. Maintaining body temperature within normal range
8. Keeping the body clean and well-groomed
9. Avoiding dangers in the environment
10. Communicating with others
11. Worshipping according to one’s faith
12. Working in such a way that one feels a sense of accomplishment
13. Playing/participating in various forms of recreation
14. Learning, discovering or satisfying the curiosity that leads to normal development
and health and using available health facilities.
The first 9 components are physiological. The tenth and fourteenth are psychological
aspects of communicating and learning. The eleventh component is spiritual and moral. The
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twelfth and thirteenth components are sociologically oriented to occupation and recreation.
Henderson believed nursing as primarily complementing the patient by supplying what he needs
in knowledge, will or strength to perform his daily activities and to carry out the treatment
prescribed for him by the physician.
In the case of our client he is only four months old and we would understand why he
couldn’t meet all of these needs discussed by Henderson. The client was able eliminate her body
wastes. The client also had an adequate rest and sleep. Her mother chose suitable clothes for him
and kept him well- groomed all the time. Furthermore, he was also able to participate in play
suitable for her age. The client was also fed as necessary and the client can also communicate
with her parents through her gesture and actions.
But since the client was too young to understand everything, he was not able to meet the
14 basic needs, he was not able to worship according to her own belief, he doesn’t work, and he
has not yet learned on his own the available medical facilities that he could utilize for his
recovery and lastly, he couldn’t avoid the dangers that the environment may bring by himself.
The client was also tachypnic most of the time and he was not able to maintain his desirable
position or move freely since he had nuchal rigidity.. Lastly, he was not able to maintain his
normal body temperature when we have handled him.
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NURSING CARE PLAN
Date Cues Needs Nursing Diagnosis Plan of Care Nursing Interventions Evaluation
09/22/10 OBJECTIVE: A Impaired Gas After 2 hours of nursing 1. Assess respiratory rate, GOAL MET
3-11  Respirator C Exchange related to care, the patient will: depth and ease. 09/22/10
5:30pm y rate of T bronchospasms  Demonstrate R: Manifestations of 7:30pm
59 cycles I ® A state in which improved respiratory distress are After 2 hours of
per V an individual is ventilation; and, dependent on the degree of nursing care, the
 Exhibit absence
minute. I unable to clear lung involvement in the patient was able
 Tachypnea of symptoms of
T secretions or underlying general health to:
noted. respiratory
 Rales Y obstructions from status.  Demonstrate
distress.
heard & the respiratory tract 2. Monitor heart rate. improved
E to maintain airway R: Tachycardia is usually ventilation;

upon
and
auscultatio X patency. present as a result of fever or
 Exhibit
 Restlessne
E dehydration but may present as absence of
ss and
R Gulanick, et. al. a response to hypoxemia. symptoms of
irritability
C Nursing Care Plans. 3. Monitor body respirator
noted.
I temperature as distress
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 Labored S indicated.  RR=33cpm
 Labored
breathing E R: Elevated temperature is a
breathing not
noted result of increased metabolic
noted
 Intercostal
P and oxygen demand and alters  Patient asleep
retraction
A cellular oxygenation.
noted
 Nasal T 4. Observe color of skin
flaring T and nail beds.
noted. E R: Cyanosis is a general sign
R that patient is already
N experiencing an increase in
oxygen demand.
5. Administer
bronchodilators as
indicated.
R: Bronchodilators facilitate
air passage by dilating the
airways allowing more oxygen
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to be inhaled.
6. Administer oxygen
inhalation as ordered.
R: O2 reinforcement can
compensate for the increased
oxygen demand of the patient.
7. Elevate head and
encourage position
changes.
R: These measures promote
maximal inspiration to
promote ventilation.
8. Promote comfort and
decrease stimuli.
R: Restlessness and irritability
of the the patient could
increase oxygen demand thus
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comfort measures should be
observed.
Date Cues Need Nursing Plan of Care Nursing Interventions Evaluation
Diagnosis
September OBJECTIVE: A Ineffective At the end of the 2 1. Determine factors related to GOAL MET
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14, 2010  Hemoglobin C tissue perfusion hours nursing individual situation. September 15,
® To assess causative factor
@ 11pm (115-175 T related to low intervention, the 2010 @ 1am
of the condition
g/Dl)= 90 I hemoglobin patient’s mother 2. Note customary baseline
 RBC (4.20-
11-7 V concentration in will be able to: data. At the end of 2
6.10)= 3.48 ® To provide comparison
 Hematocrit I blood  Verbalize hours of nursing
with current findings
(0.36-0.52)= T awareness and 3. Review laboratory studies. care, the patient’s
® To serve as a scientific
0.27 Y R: A decrease in understanding mother was able
 Weak basis for the problem.
- oxygen results of the 4. Encourage for a quiet and to:
peripheral
E in the failure to existence of restful atmosphere.  Verbalize
pulses ® To conserve energy and
 Pallor X nourish the the condition awareness and
 CRT=3sec lowers tissue oxygen
E tissues at the and measures understanding
demands
R capillary level. that can 5. Inform significant others to of the
C Nurses’ Pocket improve reduce stimulation and existence of
I guide by circulation stress to the patient. the condition

® This limits oxygen
S Doenges et.al. and measures
demand and promotes
E that can
conservation of energy.
6. Place pillow under patient’s improve
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P lower legs when the patient circulation,
A is sleeping. “Ahh ok, ana

7. ® This helps in the
T man diay no?
promotion of good
T sige, himuon
circulation and increases
E nako tong
sense of comfort.
R 8. Discuss with the significant imong gi-
N other the importance of ingon.”, as
adherence to diet regimen. verbalized by

® Proper diet will promote
patient’s
necessary nutrients that
mother.
would be helpful in
maintaining proper
circulation.
9. Promote position changes
and discourage staying at
the same position for a long
period of time.
® Helps in maximization
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of tissue perfusion.
10. Discuss ways to improve
circulation such as intake of
iron rich vitamin syrups and
nutritious milk.
® It is effective in
increasing hemoglobin
levels, which relieves the
clinical manifestations of
the disease.
11. Administer medications
with precautions.
® Drug response, half-life
and toxicity levels may be
affected by altered tissue
perfusion.
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September Hyperthermia r/t Within my 4 hours 1. Establish rapport to the
13, 2010 @ Subjective: N increase metabolic, span of care, the client.

® to gain trust and
5:00 am U presence of Bacteria patient will maintain
cooperation
“ Murag init lagi T in the body core temperature 2. Monitor vital signs and
akong anak Sr.” R secondary to within normal range recorded.

® It serves as a baseline
11/7 verbalized by the I Bacterial Menigitis
data of the patient’s health
mother. T
condition
I ® Bacterial 3. Administer antipyretic as
Objective: O Meningitis is the prescribed.

® For therapeutic relief and
N inflammation of the
it is given to reduce fever
Vital signs taken as A protective 4. Promote surface cooling by
Follows: L membranes covering means of cool environment,
T 38 the brain and spinal by letting the Mother use a
PR 132 M cord, known fan. (heat loss by
RR 46 E collectively as the evaporation and conduction)

® to assist with measures to
T meninges caused by
reduce body temperature
 flushed skin A bacteria. 5. Monitor heart rate and
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 warm to B Hyperthermia is a rhythm
® Dysrhythmias are
touch O systemic response to
 lips are dry common due to electrolyte
L invading viruses
imbalance , dehydration
I that enter the body,
and direct effects of
C thus the body tries to
hyperthermia on blood and
compensate to
cardiac tissue
P release pyrogens that 6. Monitor intake and output
® I and O monitoring
A act on the
provides important data
T hypothalamus
about the client’s fluid and
T causing it to higher
electrolyte balance.
E temperature. Fever 7. Provide tepid sponge bath;
R ,by increasing avoid use of alcohol

® It may help reduce fever
N metabolic rate, helps
and increase heat loss
speed various healing
through conduction. Use of
processes and also
alcohol may cause chills,
appears to inhibit
and alcohol is very drying
growth of
110 | P a g e
microorganisms and to the skin.
8. Encourage to increase fluid
virusesd.
intake.
® This is to correct fluid
loss from perspiration and
Resource: fever and increases patient’s
level of comfort
9. Administer prescribed
Brunner &
replacement of fluids and
Suddarth’s
electrolytes.
Medical-Surgical ® To support circulating
Nursing 10th Edition: volume and tissue perfusion.
2008
Smeltzer and Bare
111 | P a g e
Date / Cues Need Nursing Diagnosis Objective of Care Nursing Intervention Evaluation
Time
N Altered nutrition: less At a span of 4 1. Document patient’s GOAL PARTIALLY
Septemb OBJECTIVE: U
 Low BMI T than body requirements hours of nursing actual weight. MET
er 14, (14.3 kg/m2) R
 Aversion or lack I related to inability to intervention: Documenting
2010 T a. The client will Patient’s family
of interest in I procure inadequate actual weight can
117 O tolerate oral understand the
eating N amounts of food. determine the
 Constant crying A feedings, and importance of
 Inadequate food L R: b. The client and weight lost.
A state in which an 2. Weigh patient adequate nutrition to
intake; bottle fed. & family
 Perceived individual’s intake of weekly. Evaluates their son, especially
M members will
inability to ingest E nutrients is insufficient to the patient’s on the importance of
T communicate
food A meet metabolic needs. progress. breast milk. Still,
 Low hemoglobin: B understanding 3. Monitor or explore
O Ref: client is still bottle
96.0 g/L (135- L Nursing Care Plans, of special attitudes toward
I fed.
rd
175) C Gulanick et. al., 3 dietary needs eating/food. Many
 Low RBC count:
P edition. psychological,
A
3.73 (4.20-6.10)
T psychosocial, and
T
E cultural factors
R
112 | P a g e
N determine the type,
amount, and
appropriateness of
food consumed.
4. Document appetite.
Monitor intake and
output. Determine
how many calories
and nutrients the
client intakes.
5. Provide a diet
prescribed for
patient’s specific
condition. Improves
patient’s nutritional
status and
increases weight.
6. Maintain parenteral
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fluids, as ordered.
Provide patient
with needed fluids
and electrolytes.
7. Review and
reinforce to family
the importance of
maintaining
adequate caloric
intake. Helps in
patient’s condition
like burns, wounds
or severe infection.
8. Assist client with
meals or feedings
as needed, ensure a
pleasant
environment, a
114 | P a g e
facilitative position
and good oral
hygiene. Ensure
client safety and
reduces risk of
aspiration.
9. Monitor electrolyte
levels and report
abnormal values.
Poor nutritional
status may cause
electrolyte
imbalance.
10. Teach the principles
of good nutrition
for patient’s
specific condition.
Encourages client’s
115 | P a g e
family to
participate in his
care.
Date/Time Cues Need Nursing Diagnosis Objective of Nursing Interventions Evaluation

With ® With Rationale
/ shift Care
September Objective cues: H Risk for injury Within 4 hours 1. Ascertain knowledge of
Goal met
22, E 8:00 pm
2010  Sometimes A related to span of care the safety needs and injury Within 4 hours
L
@ infant was left T developmental age client will be prevention. span of care, the
4:00 pm H ® To prevent injury in the
3
11 shift unattended in secondary to able to: client was able
P hospital setting.
an elevated E bacterial  Be free from 2. Monitor the environment to be free from
R
surface. C meningitis. injury for potentially unsafe injury and the
 Infant less E ® Infants learn by  Enhance his
P conditions and modify as significant
T exploring with safety through
than 1 year
I needed. others was able
environment
old (4 months O their bodies. ® Monitoring helps in
N modification to modify
old) - Young children do identifying the hazards that
 Restless H as indicated environment
 Irritable E not learn simply the environment may
A that had help
L by being told
116 | P a g e
T something. They cause. enhance client’s
H 3. Instruct the mother to place
discover meaning. safety.
M pillow on baby’s both side.
A It is important that ® To prevent falls.
N 4. Position the client
A they have as many
G comfortably at the center of
E chances to explore
M the bed.
E and learn as ® To reduce the risk of
N
T possible. They falling from the elevated
P must do this area.

A 5. Straighten up the curled
T exploring in an
T I.V. tubing.
E environment that ® To prevent choking
R
N is safe. Also, hazards since the client is
infants try to put an infant.

6. Administer the medication
everything in their
using the 5 rights system
mouths. Watch for
(right patient, medication,
small objects that
route, dose and time).
can fit in infant’s ® To prevent errors upon
mouth. giving the medication.
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7. Educate significant others
Reference:
http://www.nncc.or regarding the medications
g/child.dev/infant. that the client is receiving.

® To alleviate their
dev.html ; National
knowledge about the
Network for Child
medication that the client
Care
is receiving.
8. Encourage the significant
others not to leave the child
unattended.
® Leaving the child
unattended will increase
the risk for injuries like
falls.
9. Practice client safety.
® Demonstrating client
safety will motivate the
significant others to
emulate such act.
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DISCHARGE PLAN
Medication
1. Encourage Parents of the client to take the full course of the prescribed medications.
Abide with all ordered medications

® Medications are being prescribed in order to promote healing and recovery from the current
condition of the patient, as well as to prevent any further complications.

2. Stress that over the counter drugs or self medication should not be practiced especially if
it is somehow unfamiliar, it is better to consult the physician first.

® Unprescribed medications may interact with the ones prescribed by the physician which may
decrease or increase the effect. Some drugs are not compatible with the prescribed drug. Notify
physician if an over the counter drug is to be taken.

3. Warn about the possible side effects and adverse effects of the medications given.
® Side effects are those expected of the drugs aside from its main effect or affection; Adverse
effects are those that are life threatening. Explanation will make the patient aware of the possible
unusual developments brought about by the drugs being prescribed.

4. Tell the client and significant others to report immediately any adverse reactions towards
the drugs.
® Relieves apprehensions about the drugs and prevents worsening of the clients physical and
mental condition.
5. Instruct client that it is important to check the expiration date of the drugs.
® Ensures that the drug still aiding in the recovery of the client. Drugs that are expired are no
longer helpful and it may result to many untoward effects and complications.
Exercise
1. Encourage significant others to perform play activities or therapy to the child.
R: To develop the fine motor adaptive behavior, gross motor behavior and personal-social
behavior of the child and to promote circulation in the body.

Treatment
1. Give the client and significant other information about the disease and the possible
treatment applicable after hospitalization
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® Giving the client and significant others an overview of the disease process and treatment
available for her particular condition so that client as well as significant others may be able to
know the DO’S and the Don’ts for caring the patient.
3. Explain to the significant others why and how the current treatment procedures should be
done and the purpose of treatment to be continued at home.

® Reduces the level of anxiety of the Parents and significant others and promotes cooperation
and makes the client and significant others aware that the treatment may be continued at home to
achieve optimal recovery.

HealthTeaching
1. Provide knowledge about current illness of the child to his significant others
® Bacterial meningitis is a life-threatening illness that results from bacterial infection of the
meninges. The more the significant others can understand it, the more they can participate in the
treatment of their child and in order for them to prevent the possibility for it to reoccur.
2. Encourage significant others to promote proper hygiene to the child.
® This will aid to prevent in acquiring certain diseases and to prevent the recurrence of Bacterial
Meningitis.
4. Encourage significant others to help the child get plenty of rest.
® Adequate rest is important to maintain progress toward full recovery and to avoid relapse.
3. Encourage significant others to maintain a comfortable and clean environment.
® A comfortable and clean environment is conducive for recovery and promotes relaxation.
Out patient
1. Instruct patient to have regular check-ups
® Allows the physician to continually monitor and evaluate the client’s overall condition.
2. Keep all of follow-up appointments.
R: Vision and auditory testing should be done in order to provide early interventions to prevent
developmental delays.
3. Advice Parents to seek for medical advice and inform the physician for any abnormalities
noted.
R: To prevent further complications in the long run.
Diet
1. Encourage mother to always breastfeed the baby if possible
® Breast milk provides the natural nutrients that the child needs for growth and development.
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PROGNOSIS
GOOD FAIR POOR JUSTIFICATION

Onset of the √ There is an acute manifestation of illness. Signs
illness and symptoms of the illness were seen 3 days prior
to admission in a local hospital in Prosperidad,
Agusan del Sur.. These symptoms include
productive cough, intermittent fever, nausea and
vomiting, abdominal distention and irritability lead
to admission. The patient was then referred to
Southern Philippine Medical Center where
additional manifestations of illness such as nuchal
rigidity and seizure were observed. These
additional manifestations relate that the infection
has already affected the CNS.

Duration of illness √ The illness of the patient started only this month.
Acute symptoms appearden the. Abrupt and sudden
manifestations such as fever, irritability and nausea
and vomiting appeared during the 1st week of
September. Upon referral to SPMC last September
11, 2010, more symptoms related to the illness
appeared including nuchal rigidity and the onset of
seizure. The seizure experience by the patient lead
to his admission to the Pediatric Intensive Care
Unit. Upon follow-up, the patient is back at the
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Pediatric Ward.
Precipitating √ Only one precipitating factor is present in the
factors patient. However, this precipitating factor is one of
the major causes of the development of his illness.
The respiratory infection he had, as evidenced by
productive cough and crackles upon auscultation
served as the gateway for the bacteria to enter into
the bloodstream.
Willingness to √ After being admitted and diagnosed with bacterial
take medications meningitis, medication orders and treatment plan
and treatment was ordered. The patient’s family was able to
follow the treatment regimen knowing that this is
the best thing for him. This was shown by
following the transfer orders from their local
hospital to SPMC for further treatment and co-
management. However, the family refused to have
a lumbar puncture, the best confirmatory test for
bacterial meningitis.
Age √ The patient is still 4 months old. With his body still
on the process of development, he is predisposed to
this kind of illness. His immune system is still
weak and has a lesser capability to fight off
infection.
123 | P a g e
Environmental √ Now that the patient has been transferred to
factors Pediatric ICU, the environment is conducive for
achieving optimum health. It is not crowded. It is
clean and well-ventilated. On the other hand, The
client’s environment is conducive for achieving
optimum health. As claimed by the parents, their
community is clean and favors for rest and
recovery. It is peaceful and calm. Their place is
surrounded with trees and is not exposed to the
pollution of the crowded city.

Family Support √ The support given by the family is remarkable.
Since the start of the illness, the parents have been
very prompt in providing the needs of their only
child. They travelled from Agusan del Sur to
Davao in order to find treatment to their son’s
condition.
Computation:
 Poor: (1*1)/7 = 1/7

 Fair: (1*2)/7 =2/7
 Good: (5*3)/7 =15/7
Total: 2.57
Total
General Prognosis:
1-1.6 = POOR
1.7-2.3 = FAIR
2.4-3.0 = GOOD
124 | P a g e
Rationale for a Good Prognosis
At 4 months old, the patient is at risk for several infections and diseases since his immune
system is not yet fully developed. Along with this, his body is not yet fully capable of adapting to
the different physiological disturbances in his body. However, this downside of the patient’s
situation did not hinder the group from perceiving a good prognosis to his condition. First,
during the early signs of the illness, prompt attention was already made by the patient’s family.
They immediately seek for medical attention to find out what’s wrong in their child. They even
went to Davao for a more concrete and aggressive medical management. In addition, the
antibiotic therapy as well as the intensive care rendered greatly helped in managing the patient’s
illness. Moreover, the support given by the family is admirable and greatly helps in the whole
process.
With his improving condition out of the intensive care unit, his chances of recuperating
from this illness and improving his health is increase..
125 | P a g e
RECOMMENDATION
To the patient. Compliance with the treatment regimen should be recommended, to achieve a
good recovery. More importantly, having a healthy lifestyle is recommended for the patient to
provide him a proper growth and development. Following treatments and medications is also
recommended for an easy restoration of health.
The client should be provided with a nourishing environment filled with love and care.
The client needs to feel that he is in a safe place surrounded by the people who care for him. The
client is encouraged to be given the right nutrition, rest, and activities to aid him during his
growth and development.
To the patient’s family. The support of each family member is vital for the recovery of the
patient. By simply being present during the hospital stays of the patient is enough to feel that he
is being cared for.
Also, the client’s family should keep update with follow-up check-ups and laboratory
tests even after discharge. The family should also be responsible in terms of complying to the
medications and other therapeutic regimens in order to facilitate an improving health status of the
patient.
To the Ateneo de Davao University- College of Nursing. For years the faculty of the College of
Nursing has been offering excellent quality education, they are recommended to continue
improving and aim for becoming one of the best nursing schools. We appreciate them for
assigning us in a remarkable institution for having to expand our experiences in wards. May the
Academe continue to serve excellence and yield top professionals in future generations.
126 | P a g e
To the Southern Philippines Medical Center. The group would like to recommend the hospital to
continue giving better service to their clients. Another recommendation goes to the staff, that
they continue being patient and understanding to the clients regardless of their diagnosis and
social class.
Kinds of treatment and care should be emphasized and considered to different wards and
areas. Specifically the Pediatrics ward with patients ranging from neonates to school aged
children; they should be treated differently and given care according to their developmental
stage.
To the student nurses. May we continue to strive hard in attaining success and the best in our
exposures. May we continue to provide better care for our patients and enhance our nurse-patient
interaction. May we student nurses continue to provide a more concise and comprehensive case
presentation and provide optimum care to our patients from the knowledge and learning derived
from our lectures in school.
Learning to accept and be motivated to improve in our endeavors is an important
characteristic a student nurse should possess. We, as student nurses, should still be open to more
changes in order to become the best nurses that we can be someday. A lot of practice is expected
to student nurses to increase our experience in the work assigned to us. Lastly, may we continue
to uphold our legacy and strive for excellence as we continue to integrate both our character and
competence.
127 | P a g e
REFERENCES
BOOKS
Ann Ehrlich, Carol L. Schroeder. Medical Terminology for Health Professions. Copyright ©
2004.
Barbara Janson-Cohen. Medical Terminology: An Illustrated Guide 5 th edition. Copyright ©
2007.
Charlene J. Reeves, Gayle M. Roux, Robin Lockhart. Medical-surgical nursing. Copyright ©
1995.
Jane Hokanson Hawks. Medical-surgical Nursing: Clinical Management for Positive Outcomes.
Copyright © 2008.
Kozier and Erb’s Fundmentals of Nursing 8th Edition
Nursing Pocket Guide to Diagnoses, Prioritized Interventions and Rationale
Doenges et. al.
Wilma J. Phipps, Judith K. Sands, Jane F. Marek. Medical-Surgical Nursing: Concepts &
Clinical Practice, 6th Edition. USA. Copyright © 2000.
Understanding Medical Surgical Nursing 3rd edition; International Edition; Williams,S.L.;
Hopper, P. D.;F.A. Davis Company, 2007
Brunner and Suddarth’s Textbook of Medical Surgical Nursing, 11 th edition; Smeltze, S.C.; Bare,
B.G.; Hinkle, J.L.; Cheever, K.H.; Lippincot, Williams and Wilkins; 2008
128 | P a g e

A Case Study On: Bacterial Meningitis

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What is the patient's diagnosis?

What is the patient's diagnosis?

What diagnostic exams were done?

What diagnostic exams were done?

A Case Study

Presented to the Faculty of

III. Objectives (General & Specific)

IV. Patient’s Data

V. Family Background and Health History

VI. Developmental Data

VII. Definition of Complete Diagnosis

VIII. Physical Assessment

IX. Anatomy and Physiology

X. Etiology and Symptomatology

XII. Doctor’s Order

XIII. Diagnostic Exams

XIV. Drug Study

XV. Nursing Theories

XVI. Nursing Care Plan

XVII. Discharge Plan (M. E. T. H. O. D.)

and effort extended to us.

restlessness and sometimes to endure their unexplainable combative behaviors; it was an

experience to care for them.

People sometimes refer to it as spinal meningitis. Meningitis is usually caused by a viral or

bacterial infection. Knowing whether meningitis is caused by a virus or bacterium is important

manifestations. These are difficult to distinguish from a coexisting septicemia.

(www.nmaus.org/meningitis). Nationwide, an estimate of 926 incidences out of 86,241,697 of

the whole population were cited leading to 20% of deaths

(www.nationmaster.com/graph/mor_bac_men_not_els_cla). Locally, only an estimate of 10-15%

The objective of the group is to present a holistic and comprehensive case

In order to meet the general objective, the group aims to:

Erikson, Freud, and Piaget.

 Define the complete diagnosis of the patient, Bacterial Meningitis,

 Rationalize the doctor’s order obtained from the patient’s chart,

 Interpret the laboratory test results of the patient,

 State the past and present health history of the client,

 Trace the family genogram,

 Present the cephalocaudal assessment obtained from the patient,

 Present the etiology and symptomatology of the patient’s disease,

 Trace the pathophysiology of the patient’s disease,

indications, contraindications, side effects, adverse reactions, nursing responsibilities, and

importance to the client’s condition;

 Justify the client’s prognosis according to the different criteria,

 Establish rapport to the patient’s significant others,

the medical world, etc.

Patients Name: “JP”

Birth date: May 10, 2010

Date of admission: September 11, 2010

Time of admission: 11:40 pm

Chief Complaint Stomachache and fever

Hospital & Hospital Number: Southern Philippines Medical Center [2220291]

Ward [Room & Bed Numbers]: Pediatric Ward – IMCU

Admitting Diagnosis: Bacterial Meningitis

Vital signs on admission:

Temperature: 37.6 Degrees Celsius

Pulse Rate: 120 Beats per Minute

Respiratory Rate: 40 Cycles per Minute

Source of Information: Patient’s mother and the patient’s chart

her parents as a wedding gift to them.