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West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

Vision: WVSU as one of the TOP TEN universities in Southeast Asia by 2015.
Mission: To produce globally competitive individuals who are life-long learners.
Core Values: S - Service H – Harmony E – Excellence

PEDIATRIC NURSING PROCESS

I. VITAL INFORMATION
Name of Child: K.L.C. Name of Informant: R.C.
Sex: Female Relationship with the child:
Mother
Date of Birth: 08/04/95
Age: 13 years old
Address: Brgy. Malugsod, Dueñas, Iloilo
Date and Time Admitted: 08/09/08 @ 4:00 pm
Chief Complaints: “Gin-convulsion siya nga naglawig mga pulo ka minutos.”
Ward: PSW-B
Religious Affiliation: Roman Catholic
Name of Mother: R.C.
Educational Attainment: 3rd year high school Age: 48 years old
Occupation: none
Name of Father: N.C.
Educational Attainment: 3rd year high school Age: 49 years old
Occupation: Farmer,
carpenting
Approximate Monthly Income of the Family:
a.) Mother – N/A
b.) Father – Php 9000-9500
c.) Others – Php 2000 ( Patient’s uncle)
TOTAL Php 11000-11500

Physician: Dr. G.
Impression/Diagnosis: Status Epilepticus
Pre-op Diagnosis: N/A
Post-op Diagnosis: N/A

I. CLINICAL ASSESSMENT

A. Nursing History

Usual Health status

“Halin sang gamay siya, sang 3 years old pa lang, gina-convulsion na siya
nga da-an. Ga turong gid na iya mata pero mga segundo man lang ang kalawigon.
Sang nagadako siya, daw gasige-sige na, halos kada adlaw na gani ang atake niya.
Kun mabug-atan, makulba-an kag kun grabe iya hulag, amu gid na siya atakihun.
Gamay ni siya dayon pakan-on kay medyo pisli-an. Kun masobrahan gani ka gutom,
gina atake man siya. Ginapapahuway man lang siya namun tapos ginahilot-hilot ang
likod sang iya li-og.” As verbalized by patient’s mother.

Chronologic story

When K.L.C. was 2 years old, a small vase fell in her head (exact location
unrecalled). K.L.C. then lost consciousness. She regained her consciousness a few
minutes later. No medical check-up made after the incident. 9 years prior to
admission, 1998, K.L.C. experienced episodes of seizure attack characterized by
crying, upper rolling of eyeballs and involuntary muscle jerking which lasted for
about 30-40 seconds. Parents did not seek any medical help. Episodes of seizure
attack of same symptoms continued with approximately 5-6 days interval. Still,
parents did not seek medical help. Instead, they just massage the lower portion of
the neck and let the patient rest.
In year 2000, patient had a seizure attack characterized by change in lost of
consciousness, stiffening of the body and upper rolling of eyeballs which lasted for
almost 3 minutes. “Daw nag grabe iya atake tapos medyo mas dugay siya
komparar sa mga na una ya nga convulsion. Amo ‘to gindali-dali dala sa Western.”
As verbalized by the mother. An EEG was done and the mother claimed that the
result showed an impinged vessel. Unrecalled anticonvulsant meds were given and
monthly check-up was advised. K.L.C. complied with the prescribed meds and
medical check-up for 4 months only. There was a noticeable decreased in frequency
of seizure attacks with 3-4 weeks interval. The mother stated “ Daw kamahal na gid
ya galing sang bulong, amo ‘to gin-untatan na lang namun.” Thus, the seizure
attacks recurred with 5-6-day interval.
If the patient would feel hungry or tired, a seizure attack would occur which
would last for seconds. The patient would complain of dizziness thereafter. Rest and
massage in the neck were again the management of folks after the attack.
1 month prior to admission, July 2008, there was an increase in frequency of
seizure attacks (4x weekly).
2 days prior to admission, K.L.C. experienced episodes of seizure attack
which lasted for 5 hours within 5-minute interval with no febrile episodes or
difficulty of breathing.
A day prior to admission, seizure attacks continued which lasted for 10
minutes with seconds interval and K.L.C. was admitted in Iloilo Provincial Hospital.
K.L.C. was then referred to WVSU-MC for further treatment. Thus, last August 9,
2008, K.L.C. was admitted in WVSU-MC, PSW-B.

Past Medical History

Parasitism____________ Tuberculosis____________
Anemia____________
AGE____________ Measles 8 years old Seizure since 3
years old
AGN____________ BPN____________ Emotional
Disorder____________
Allergy none Accidents (specify) ______ Others:

No. of Previous Hospitalizations: 1


Date of Last Confinement: August 8, 2008
Where: Iloilo Provincial Hospital
Reasons for Confinement: seizure attacks

Family History

Birth order of Patient: 5th


Total no. of siblings: 8
No. of living siblings: 8
Serious diseases/illnesses of siblings: none
Cause of death/serious illnesses of siblings: N/A

Heredo-familial diseases: (state relationship with patient)


Tuberculosis_________________ Hypertension__________________
DM________________________ Cancer________________________
Asthma_____________________ Genetic Disorders (specify)________
Others (specify)
Maternal and Prenatal History

Maternal age when child was born: 35 years old

Age of Gestation and Birth Weight Unrecalled


Preterm
Full-term /
Postterm

TYPE OF DELIVERY Home Hospital


Attendant/Mid
wife

Spontaneous /
Caesarian Section/Forceps (specify
reasons)

Complications related to pregnancy:


None as claimed by mother

Parental views of pregnancy:


“Para sa amon, gapasalamat gid kami kay nadugangan ang kalipay nga ginhatag
sang Diyos sa amun.” as verbalized by the mother.

Patient’s problem: (1st month):


None as claimed by the mother.

Child’s ability to get along with people as viewed by parents:


“Medyo supladahun ni siya. Naspoiled da-an ni lola ya pero ma-ayo man siya
makisama sa iban ya nga utod kag mga miga ya.” as verbalized by the mother.

Early behavior patterns as viewed by parents:


“ Gamay-gamay lang ni nga akig sa iya, ga sunggod siya dayon. Amo na daw indi
gid siya ma-akigan gawa. Sang gamay siya da-an kun ano gusto ya, ginahatag
dayon ni lola ya.” As verbalized by the mother.

Parent’s attitude towards rearing:


K.L.C. was brought up by her grandmother. Usually the grandmother was in charged
in disciplining her. As verbalized by the mother, “Na-spoiled gid ni siya ni lola ya.”

II. PATTERNS OF FUNCTIONING

Nutritional History and eating Patterns

Meal Type and Amount of foods usually taken

Breakfast ½ cup steamed rice, 1 bowl of noodles

Morning snacks 1 pack of Cheese Curls, 1 bottle of


softdrinks
Lunch 1 cup steamed rice, 1 pc. fried fish

Dinner 1 cup steamed rice, 1 bowl of noodles, 1


pc. chorizo

Food likes:
Cheeze Curls, fried chicken, “lumpia”
Allergies: None
Problems related to nutrition: none
Elimination Patterns

Frequency Problems/Difficultie Usual Remedy


s
Bowel Movement Twice a day none N/A

Urination 4x a day none N/A

Toilet Training

Age in Found in As seen in the patient Significance


Month Textbook and/or verbalized by
s significant person
Starte
d
Bowel: 3 Toilet training must As recalled by the This was normal
years start during toddler mother, “ Indi na na because K.L.C.
old years or when the siya magpa-upod sa was in the right
child has already the banyo kun daw age to be toilet-
capacity to heed mamus-on siya. Siya trained.
instructions. lang na dayon ga-uba
Bladder: sang iya nga panty.”
3
years
old

Sleeping Patterns

Usual Usual Time Approximat Sleeping Special Problems


Patterns e total no. Arrangemen Rituals with
of sleep/24 t Sleeping
hours
Bed time 8:30-9:00 9 hours K.L.C. none none
pm sleeps at
Waking the side of
time 6:00-6:30 her younger
am sister

Immunization Status

Type 1st Age 2nd Age 3rd Age


dose dose dose
BCG / unrecalled
DPT / unrecalled / unrecalled / unrecalled
OPV / unrecalled / unrecalled / unrecalled
Hepa B
Measles/MMR
Play

a.) Appropriateness of available toys:


K.L.C. is fond of playing chinese garter, jackstones and cell phone games with
her playmates. These toys are appropriate for her age since her choice of
games is competitive in nature.

b.)Availability and safety of play areas:


K.L.C. usually plays within her school campus. Her mother stated, “ Daw
tawhan man ang ila eskwelahan kag malapad man ang lugar nga pwede ya
hampangan.”
c.)Favorite toys and activities:
-chinese garter
-jackstones
-texting
-watching TV

d.)Child initiative and amount of creative play:


“Kun wala bi klase, siya gid ni gapanghagad sa mga utod ya kag sa mga taga
pihak balay nga maghampang” as verbalized by the mother.

Preferred play: Solitary: ____ Parallel: _____ Cooperative: ____


Competitive:_/__

Peer interaction:
“Palahampang ni siya sa mga kilala ya lang galing nga ka-edad ya.Indi man
siya pala-away pero amo lang na eh, kun indi ya makwa gusto ya,
masinuplada na siya.” As verbalized by the mother.

Current Development Assessment

AREAS AGE OBSERVATIONS ACTUAL SIGNIFICANCE


FOUND IN OBSERVATION
TEXTBOOKS
Gross Motor In adolescence “Wala man siya
stage the problema sa iya,
development of normal man siya
locomotion skills is
maglakat, wala man
achieved. One is
able to walk and has siya gakadasma.
good coordination Luwas lang kung
and equilibrium. In akigan ko siya,
this stage, one can madalagan na siya
walk up and down kag
the stairs, can jump magkandadasma.”
using both feet, can
As verbalized by the
stand on one foot,
walk on tiptoe, and mother.
climb upstairs with
alternate footing.
Fine Motor Demonstrated in
12 y.o. increasingly skillful
manual dexterity.

Improved flexibility
and coordination;
plays musical
instrument.

Sensory Vision is 20/20.


12 y.o.

Psychosocial The development of “babae gid siya ya,


13 y.o. identity is macrush sa gain nga
(Role identiy characterized by classmate man niya.
vs role rapid and marked Ang mga upod niya
confusion) physical changes. pirme maghampang
Previous trust in mag babae man nga
their bodies is ara sa piyak balay
shaken, and children namon.” As
become overly verbalized by the
preoccupied with mother.
the way they
appeared in the
eyes of others as
compared with their
own self-concept.
Adolescents
struggle to fit the
roles they have
played and those
they hope to play
with the current
roles and fashions
adopted by their
peers, to integrate
their concepts and
values with those of
society.
Psychosexu Genital Stage: The
al 13 y.o. last significant stage
Genital begins at puberty
Stage with maturation of
the reproductive
system and
production of sex
hormones. The
sexual organs
become the major
source of sexual
tensions and
pleasures, but
energies are also
invested in forming
friends.

Spiritual Individuating-
13 y.o. reflexive:
Adolescents become
more skeptical and
begin to compare
the religious
standards of their
parents with those
of others. They
attempt to
determine which to
adopt and
incorporate to their
own set of values.
They also begin to
compare religious
standards with
scientific viewpoint.
It is a time of
searching than
reaching.
Adolescents are
uncertain about
many religious ideas
but will not achieve
profound insights
until late
adolescence or early
adulthood.
Cognitive Formal operations:
13 y.o. formal operational
thought is
characterized by
adaptability and
flexibility.
Adolescents can
think in abstract
terms, use abstract
symbols, and draw
logical conclusions
from a set of
observations. They
can consider
abstract, theoretic,
and philosophic
matters. Although
they may confuse
the ideal with the
practical, most
contraindications in
the world can be
dealt with and
resolved.

Moral Younger children


13 y.o. merely accept the
decisions or part of
view of adults,
adolescents, to gain
autonomy from
adults, most
substitute their own
set of morals and
values. Their
decision involving
moral dilemmas
must be based on
an internalized set
of moral principles
that provides them
with the resources
to evaluate the
demands of the
situations and to
plan actions that are
consistent with their
ideals.
Language Increase level of
and Speech 12 y.o. comprehension.
Vocalizations are
intelligible. Uses
multi word
sentences. Speech
is understandable.
Has mastery of
grammatical rules.

V. PRESENT MEDICAL HISTORY

A. Measurements:

Weight: _40_kg Height: _150 cm.

B. Clinical Inspection

Date and Time Taken: August 27, 2008

Vital Signs:
Temperature: _37.2˚C per axilla__________ Pulse Rate: _76 beats per
minute______
Respiratory Rate: _21 breaths per minute__ Blood Pressure: _110/70
mmHg_______
VI. PHYSICAL ASSESSMENT

General Appearance:
Appears restless, irritable, and disheveled. Easily cries when
approached. Has strong tenseness and rigid movement. Does not follow through
with directives. Does not observe eye contact.
Presence of four point restraints on right and left hands and right and
left feet, attached to bed frame.

A. Integumentary System
Skin is brown in color. It is soft and warm to touch. When pinched at
the abdomen, it returned in one second, which indicated good turgor. Reddish,
dry, scattered lesions on right forearm, approximately 2 cm. in diameter. Wound
with pus draining on right ankle of 2 cm. in diameter and 1 mm. in depth.
Moderate dandruff noted on hair, as well as lice and nit infestations.
Nails are not well-trimmed and cleaned. Nail beds are pink and firm. No
clubbing or beau lines.

Neurologic System / EENT


Conjunctivae are pale. Anicteric sclerae without increased vascularity.
Irises uniformly black in color. Nares patent. Nasal septum is at midline.

CRANIAL NORMAL PATIENT’S


HOW ILICITED
NERVE RESPONSE RESPONSE
Cologne will be held
under one nostril with
Identifies scent
I the other occluded while
correctly with each Not assessed.
OLFACTORY the client is closing her
nostril.
eyes. Repeat with the
other nostril.
Newspaper or nameplate
II Reads clearly,
will be held 14 inches Not assessed.
OPTIC without difficulty.
away from the eyes.
Ask client to look
Pupils equally round Pupils constrict
straight ahead and
III and reactive to light upon
approach each eye from
OCULOMOTOR and illumination of
the client’s side with a
accommodation. penlight.
penlight.
Ask client to look
straight ahead, covering Uncovered eye
IV one eye with a cover does not move as
Not assessed.
TROCHLEAR card and observe opposite eye is
uncovered eye for covered.
movement.
With closed eyes, touch
forehead, cheeks and
Identifies light
V chin with the tip of
touch, dull, and PRESENT
TRIGEMINAL cotton applicator and
sharp sensations.
broken stem of cotton
applicator.
Both eyes move in
Ask client to follow
a smooth,
VI examiner’s finger as it
coordinated PRESENT
ABDUCENS moved in six cardinal
manner in all
fields.
directions.
VII Ask client to smile, Follows instructions No facial
FACIAL frown, purse lips, blow accurately. anomalies.
out cheeks, and raise
eyebrows.
Able to discern
sweet taste. Not assessed.
Let patient taste sugar.
VIII Whisper a word 1 foot Able to repeat the
PRESENT
ACOUSTIC behind the client. whispered word.
Brisk response as if
IX Touch back of tongue
to expel tongue Gag reflex
GLOSSOPHARYN with tongue depressor to
depressor from present.
GEAL test for gag reflex.
mouth.
X Ask client to open mouth Uvula elevates
PRESENT
VAGUS and say “ah”. upon phonation.
Symmetrical, strong
Ask client to shrug contraction of
shoulders against trapezius muscles.
XI examiner’s hands. Strong contraction Able to turn
SPINAL of head to sides
ACCESSORY Ask client to turn head sternocleidomastoid against hand.
against examiner’s muscle on opposite
hand. side that head is
turned.
Symmetrical tongue
Ask client to protrude
with smooth
XII tongue and move it to
outward movement PRESENT
HYPOGLOSSAL each side against tongue
and bilateral
depressor.
strength.

B. Respiratory System
Respiratory patterns are even and unlabored. No use of accessory
muscles upon respiration. Deep inhalation and shallow expiration. Usual
respiratory rate is 20 breaths per minute. Clear breath sounds ascultated on all
lung fields.

C. Cardiovascular / Circulatory System


Apical of 76 beats per minute. Palpable right and left radial and
posterior tibi al pulses. It is not thready nor bounding. Regular in rhythm. Clear,
brief heart sounds throughout. No murmurs.

D. Genito – urinary System


Pubic hair sparsely distributed. Voids freely to a clear, yellowish urine
with an amount of 400 cc per diaper. Consumes 3 diapers per day.

E. Gastrointestinal System
Canker sore of approximately 2 cm. on lower lip. Buccal mucosa is pink
and dry. Pinkish gums. Papillae present on tongue and midline fissure present.
Abdomen is flat. Umbilicus is midline.

F. Reproductive System
Breasts are bilaterally symmetrical. Areolae are light brown. No
discharges on both nipples.

G. Endocrine System
No swelling and tenderness of thyroid gland. No excessive sweating.
Equal body hair distribution.

H. Musculoskeletal System
Full ROM of the arms and legs. Hand grip is strong. Brief voluntary
muscular jerking of both extremities. Generalized tensed movements.

I. Lymphatic System
Thyroid and cervical lymph nodes are not assessed. No presence of
swelling. Neck is symmetrical and can rotate freely.

J. Hematopoietic System
Capillary refill of 1 second. No bruising.

VII. LABORATORY AND DIAGNOSTIC PROCEDURES

1. CLINICAL CHEMISTRY

Name of Examination: Serum Electrolytes

• Definition:
Sodium is the most abundant cation (90% of the electrolyte fluid) and the
chief base of the blood. Its primary functions in the body are to maintain osmotic
pressure and acid-base balance chemically and to transmit nerve impulses.

Potassium is the principal electrolyte (cation) of the intercellular fluid and the
primary buffer within the cell itself. 90% of potassium is the blood by damaged
cells.

Creatinine is a nitrogenous waste product each day, which is related to the


muscle mass, seldom changes rapidly. Creatinine is eliminated from the body by
the kidneys.

Calcium is an important cation found, predominantly in bones and teeth,


combined with phosphate and carbonate. This combination, deposited in bony
tissue, provides the mineralization and resulting strength of the skeleton. The
remaining 10% of the body calcium is found in the blood serum and is essential for
normal functioning of neuromuscular tissue, cardiac activity and the coagulation of
blood.

• Purpose
o It is used to indicate acid-base balance and hydration status.

• Preparation
o Inform the client about the reason why the specimen was ordered, how
is to be collected, the equipments needed and the stinging sensation
that may be felt.
o Foods and fluid are usually not restricted before the collection of the
specimen.

• Specimen
o Venous blood collected in a collecting tube or syringe.

Results Significance of Abnormal


Normal Values
8/9 8/14 Results

146.4 139.9
Serum Sodium 135-148 mmol/L Within normal range
mmol/L mmol/L

Sodium 3.76 3.57


3.5-5.3 mmol/L Within normal range
Potassium mmol/L mmol/L

2.62
Serum Calcium 2.18-2.68 mmol/L Within normal range
mmol/L -

Serum 72.48
20-40 µmol/L Increased. UTI
Creatinine µmol/L -

2. HEMATOLOGY

Name of Examination: Complete Blood Count (CBC)


• Definition:
Complete blood count a screening test, is one of the most frequently ordered
laboratory procedures. It is a group of tests that includes the hemoglobin,
hematocrit, and red blood cell (RBC) count, white blood cell (WBC) count,
differential white blood cell count, red cell indices and stained cell examination
(peripheral blood smear). A platelet count may also be included in CBC.

Hematocrit is a measurement of the percentage of red cells in the total


volume of blood. It is expressed in the percentage of red cells in the total blood
volume.

Red blood cells are produced by erthyroid elements in the bone marrow.
Under the stimulation of erythropoietin, RBC production is increased. Within each
RBC are molecules of hemoglobin that permits the transport and exchange of
oxygen to the tissues and carbon dioxide in tissues.

Hemoglobin is the main component of red blood cells. Its main function is to
carry oxygen from the lungs to the body tissues and to transport carbon dioxide,
the product of cellular metabolism, back to the lungs. Another function of
hemoglobin is to act as a buffer to help maintain acid-base balance.

White blood cells (WBC) are produced in red bone marrow and lymphatic
tissue. After they are formed they enter the blood, which transport them to the
parts of the body where they are needed to defend against invading organisms
through phagocytosis and produce or antibodies to help maintain immunity.

Neutrophils which constitute 55%-65% of white of the total number of white


blood cells. The protective function of neutrophils includes phagocytosis. Foreign
particles are degraded, and pyrogens are released that produce fever by acting on
the hypothalamus to set the body’s thermostat at higher level.

Eosinophil constitutes 1% to 3% of the total number of white blood cells.


Their protective function is not fully understood. They play a role in allergic
reactions, possibly inactivating histamine.

Platelets, also called thrombocytes, are large, non-nucleated cells derived


from the megakaryocytes produced in the bone marrow. Two-thirds are found in
the blood and one-third in the spleen. One-tenth of the platelets found in the blood
maintain endothelial integrity and the rest are available for homeostasis. The
adhesive or sticky quality of platelets allows them to clump together or aggregate
and adhere to injured surface. Along with fibrin, they form the network for a clot to
form.
• Purpose
o It determines the number, variety, percentage, concentrations, and
quality of blood cells. It provides information about the hematologic
and other body systems, prognosis, response to treatments, and
recovery.

• Preparation
o Inform the client about the reason why the specimen was ordered, how
is to be collected, the equipments needed and the stinging sensation
that may be felt.
o Foods and fluid are usually not restricted before the collection of the
specimen.
o Instruct the patient to remain still and to hold the arm extended either
resting flat on bed on supported firmly during specimen extraction.

• Specimen
o 5-10 mL sample of venous blood collected in a tube or syringe.

Results Significance
Normal Values
8/9 8/13 8/22 Abnormal Results

Hemoglobin Decreased on 8/9.


mass 106 133 110 120-173 g/L Hemoglobin is the main
concentration component of RBC. Slight
decrease of Hgb and
Erythrocyte erythrocytes (RBC)
0.32 0.41 - 0.35-4.9 L/L indicate nutritional
volume fraction
deficiency. Stress.

erythrocyte
number 3.81 4.82 3.96 3.7-5.3 x 1012/L Within normal range
concentration

leukocyte
6.2-17.0 x
number 12.4 9.0 10.8 Within normal range
109/L
concentration

Neutrophil 0.86 0.92 0.10 0.50-0.70 Increased due to


infection such as Urinary
Tract Infection. Acute
Segmenter 0.83 - - 0.50-0.70 bacterial infection and
trauma stimulate
neutrophil production.

Lymphocytes 0.13 0.08 - 0.20-0.40 Decreased.

Eosinophil 0.07 - - .01-.04 Increased.

200,000-
Platelets 232 220 281 473,000/cu Within normal range
mm

Protime sec sec - 100%


INR 1.36 0.95 -

APTT 28.7 - -

3. URINALYSIS

• Definition:
A urinalysis involves multiple routine test of urine specimen. It includes
remarks about the color, appearance, and odor of the urine. The pH is also
determined. The urine is tested for the presence of proteins, glucose, ketones,
blood and leukocytes esterase.

Urine is a clear, amber-colored fluid that is approximately 95% of water and


5% of dissolved solids. The kidneys normally produce approximately 1.5L of urine
each day. Normal urine contains metabolic wastes and few or no plasma proteins,
blood cells, or glucose molecules.

The pH of the urine indicated the acid-base balance of the patient.

Specific gravity is a measure of concentration of particles including waste and


electrolytes in the urine. Specific gravity refers to the weight of urine compared with
that of distilled water. It is used to evaluate the concentrating and excretory power
of the kidney. It is also the measurement of hydration status of the patient.

Urine specimens that have been left standing may contain lysed red blood
cells, disintegrated casts, and rapidly multiplying bacteria.

Casts are molds of the distal nephron lumen. A gel like substance called tam-
horsfall mucoprotein, which is formed in the tubular epithelium, is the major protein
constituent of urinary casts. These develops when protein concentration of the urine
is high, urine osmolality is high. And urine pH is low.

• Purpose
o It is used to evaluate the patient’s urine for renal or urinary tract
disease. It is also to help detect
metabolic or systemic disease on related to renal disorders and to
detect substance use.

• Preparation
o Instruct the patient about the type of specimen needed and the best
time to collect it.
(early morning urine)
o Inform client to collect the midstream urine about 30cc.
o The container should be labeled with the patient’s name, date, and the
type of the specimen.

• Specimen
o 30cc of midstream urine collected in a specimen container.

Results Normal Significance of


Component
8/13 8/26 Values Abnormal Results

Physical Properties
Pale Straw Straw Clear - Straw Within normal range
Color

Slightly Clear-Slightly
Transparency Hazy Within normal range
Hazy Hazy

Acidic Acidic
Reaction (pH) 4.6-8.0 Within normal range
(6.0) (6.5)

Specific Gravity 1.025 1.025 1.005-1.030 Within normal range

Chemical Tests
negative
Sugar negative Trace - None Within normal range

Albumin negative negative Trace - None Within normal range

Increased. Pus cells


Microscopic Findings in the urine
Pus Cells 2-5 0-3 0-1/hpf indicates Urinary
Tract Infection.

Increased. Any
distruption in the
blood-urine barrier,
whether at the
RBC 2-7 0-2 0-1/hpf
glomerular, tubular
or bladder level, will
cause RBC’s to enter
the urine.

Results Normal Significance


8/13 8/26 Values Abnormal Results

Cast None - Trace - None Within normal range

Crystals
Urates-
Amorphous - Trace - None Within normal range
Few

Squamous Epithelial
Few Occasional Trace - None Within normal range
Cells

Round Epithelial Cells Few Few Trace - None Within normal range
Yeast Cells - Occasional Trace - None Within normal range
4. Blood Culture and Sensitivity

Date Taken: 8/17/08

• Definition
A blood culture and sensitivity test is used to identify the microorganisms
causing the infection. The culture is then subjected into antibiotics to identify which
one is the most effective treatment and which one is not.

• Preparation
o Blood culture should ideally be obtained before any antibiotic therapy.
o Cleanse skin first before obtaining specimen
o NPO status not required.

• Specimen : Blood Culture Isolate: Moderate-Heavy Growth of


Klebsiella Species

Generic/Brand Potency Intermediate


Sensitive Resistant
Name ug/disc Sensitive

Amikacin 30 *

Ampicillin 10 *

Amoxicillin 25 *

Augmentin 30 *

Cefaclor 30 *

Cefamandole 30 *

Ceftazidime 30 *

Cefotaxime 30 *

Ceftriaxone 30 *

Cefuroxime 30 *

Cephalexin 30 *

Chloramphenico *
30
l

Ciprofloxacin 5 *

Cotrimoxazole 25 *

Erythromycin 15 *

Gentamycin 30 *

Imepenem 10 *

Nalidixic Acid 30 *

Netilmicin 30 *

Nitrofurantoin 300 *

Norfloxacin 10 *
Piperacillin *
10/75
Tazobactam

Meropenem

Tetracycline 30 *

Interpretation

Of the drugs the bacteria Klebsiella was subjected to, only chloramphenicol,
cotrimoxazole, ceftazedime, and piperacillin tazobactam were considered effective
in treating it. Out of these drugs, Chloramphenicol was chosen over the others
because it was the cheapest of the group.

5. Name of Examination: ARTERIAL BLOOD GAS ANALYSIS

Date Taken: August 9, 2008

Measurement of ABGs provide valuable information in assessing and managing a


patient’s respiratory (ventilation) and metabolic (renal) acid/base and electrolyte
homeostasis. It is also used to monitor patients on ventilators, critically ill non-
ventilator patients, establish pre-operative baseline parameters and enlighten
electrolyte therapy.

Definition:

pH – hydrogen ion concentration, is a measure of alkalinity (>7.4) and acidity


(<7.35) of the respiratory
and metabolic aspects.

PCO2 – is a measure of the partial pressure of CO2 in the blood. It is a measurement


of ventilation
capability. The faster and more deeply one breathes, the more CO2 is blown
off and PCO2
levels drop. Therefore, PCO2 is referred to as the respiratory component in
the acid-base
determination because they are primarily controlled by the lungs.

HCO3 – bicarbonate ion or CO2 content. It is a measure of the metabolic


(renal/kidney) component of
acid-base equilibrium. This ion can be directly measured by the
bicarbonate value or indirectly
by the CO2 content.

PO2 – this is an indirect measure of the oxygen content of arterial blood. PO2 is a
measure of the tension
(pressure) of oxygen dissolved in plasma.

O2 saturation – is an indication of the percentage of hemoglobin saturated with O2.


When 92% to 100%
of the hemoglobin carries O2, the tissues are adequately provided
with O2 assuming
normal O2 dissociation.
Base Excess/Deficit – it represent the amount of buffering anions in the blood.
Base excess is a way to
take all these anions into account when determining acid-base
treatment based
on the metabolic component. Base deficit indicates a metabolic
acidosis and
otherwise.

Preparation:

• Explain procedure to patient


• Perform Allen’s test to assess collateral circulation.
• Cleanse arterial site

Specimen: Arterial blood obtained from any area of the body where strong pulses
are palpable. Usually
from the radial, brachial, or femoral artery.

Compon
Result Normal Values Significance
ent
pH 7.409 7.35-7.45 Normal
PCO2 32.4mmHg 35-45 mmHg Decreased due to
20.3meq/L 21-28meq/L Decreased due to lactic acidosis,
a form of metabolic acidosis
HCO3 experienced by status epilepticus
patients

PO2 173mmHg 80-100mmHg Increased due to


O2 Sat 99.6% 95-100% Normal

6. Name of Examination: CRANIAL TOMOGRAPHY OF BRAIN

Definition:

CT scan of the brain consists of a computerized analysis of multiple tomographic x-


ray films taken of the brain tissue and its successive layers, providing a three-
dimensional view of the cranial contents. CT scan is used in differential diagnosis of
intracranial neoplasms, cerebral infarctions, ventricular displacement or
enlargement, cortical atrophy, cerebral aneurysms, etc.

Preparation:

• Explain the procedure to the patient. Cooperation is necessary since the


patient is required to lie still during the examination.

• Lessen patient anxiety by showing him/her the machine first and encouraging
to verbalize concerns.

• NPO status for 4 hours before the study if oral contrast medium is used.

• Remove hairpins, wigs, or any other hair clips and paraphernalia in the head.

Date Taken: August 12, 2008


Result:

• Plain and contrast-enhanced axial tomographic sections of the head revealed


no evident focal parenchymal mass or abnormally-enhancing lesions.

• The ventricles are unenlarged.

• The cerebral sulci and cisterns are unaffected.

• No abnormal extra-axial fluid collagen demonstration

The posterior fisa, brainstem and sellar region are unremarkable.

• The petromastoids, included orbits, paranasal sinuses and bony calvarium


appear unremarkable.

• Impression : Normal Cranial Study.

7. Name of Examination: CHEST X-RAY

Definition: The chest x-ray film is important in a complete evaluation of the


pulmonary and cardiac systems. Much information can be provided by the chest x-
ray film such as identification of:

• Tumors

• Inflammation

• Fluid and air accumulation

• Fractures of the bones in the thorax

• Diaphragmatic hernia

• Heart size

• Location of centrally placed intravenous access devices.

Preparation:

• Explain procedure to the patient

• No fasting is required

• Instruct patient to remove clothing to waist and to put on an x-ray gown.

• Inform patient to remove all metal objects or accessories so as they won’t


block the visualization

• Instruct patient that he or she will have to take a deep breath and hold it
while the x-ray films are being taken.

• Instruct men to cover their testicles and women to cover their ovaries using
lead shield to prevent radiation-induced abnormalities.

Date Taken: August 9, 2008

Result:
• No evident peritubular densities

• No demonstratable hilar adenopathies

• Retrosternal and retrocardiac spaces are intact

• Trachea is at midline

• Cardiac silhouette is not enlarged

• Costophrenic sulci are intact

• Hemidiaphragms are smooth

• The rest of the findings are unremarkable

Impression: Essential (-) Cardiopulmonary Findings.

VIII. LIST OF PRIORITY NURSING PROBLEMS

1. Ineffective airway clearance r/t NGT


2. Acute pain r/t stomatitis (canker sore)
3. High risk for aspiration
4. Impaired physical mobility r/t neuromuscular impairment secondary to
status epilepticus
5. High risk for falls
6. Risk for deficient fluid volume
7. High risk for infection
8. Hyperthermia r/t underlying illness secondary infection
9. Impaired oral mucous membrane r/t mechanical trauma secondary to status
epilepticus
10.Impaired swallowing r/t behavioral changes secondary to status epilepticus
11.Imbalanced nutrition: less than body requirements r/t inability to ingest
food secondary to absence of voluntary swallow reflex
12.Impaired tissue integrity r/t mechanical factors as to restraints secondary to
status epilepticus
13.Impaired skin integrity r/t mechanical factors as to shearing forces/ increase
friction against skin secondary to status epilepticus
14.Disturbed sleep pattern r/t behavioral changes secondary to status
epilepticus
15.Disturbed thought process r/t mental disorders secondary to status
epilepticus
16.Self-care deficit: bathing/hygiene/dressing/grooming/feeding/toileting r/t
status epilepticus

IX. ON-GOING APPRAISAL (SOAPIE)

8/28/08 @830AM

S–

 “Kung kaisa hindi ma-igo sang mga Doctor ang ugat, te hala
saylo e. Kag daan grabe siya pa hulagon, budlayan gid guro mga
doctor sa iya,” as verbalized by the mother.

 “Hala saylo eh, kung kaisa ginahukas niya ukon mag-dinugo na,”
referred
 IV tubing accidentally being pulled out by patient herself.
 “Hulagan siya abi, sadto nga may banig kami di, siguro nag-sag-
id hala ka nusnus eh te nagkapilas sya.”

 “May bactram cream man kami di ginapahid sa mga pilas niya.”

 “Kung wala pa siya guro nahigot, napangkutkot niya pilas nya.”

O–

 redness on IV site of about 3 mm in diameter

 Guarding behavior

 Grimacing upon direct flushing via 10cc syringe through Piggy


back port

 2mm diameter wound, 1 mm in depth without pus draining on


right ankle

 Scattered dry abrasions 3 inches in length on forearm

A - Impaired skin integrity r/t mechanical factors as to shearing forces/


increase friction against skin secondary to status epilepticus

P/I –

1. Application of bactram cream (antibacterial) to wound to prevent infection


and promote wound healing.
2. Providing bed linens which are cotton in nature and no rough edges
present on it.
3. Increase fluid intake via NGT tube to promote wound healing.
4. Check temperature for assessing progress of infection if swelling and
redness on site and wound is still evident.
5. Administer anti-bacterial and/or anti-viral medications as prescribed.
6. Provide a clean environment by cleaning and arranging the bedside, and
the bed itself which includes the bed linens, sheets, pillow cases etc.
7. Restraint patient accordingly as prescribed to prevent falls and to prevent
further alimentation of current state
8. Perform ROM exercises on the inflamed site to promote venous return and
prevent hypercoagulation of blood that could lead to thrombophlebitis.
9. Assist patient to reposition in a supported manner with pillows as
necessary (side lying for 1 hour, supine for 1 hour, vice versa).
10.Application of cold compress to inflamed IV site to promote
vasoconstriction, relieving pain, redness and swelling.
11.IV pull –out keeping set sterile and reinsertion of the same IVF.
8/28/08 @ 10AM

E–

• Application of bactram cream, keeping it dry and clean


• IV site inflammation still present on left hand
• IV infusion patent and infusing well on right metacarpal vein
• Application of cold compress on right ankle wound
• Pinkish wound
• Pus draining in lesser amount on right ankle wound
TEXTBOOK DISCUSSION AND SCHEMATIC DIAGRAM OF PATHOPHYSIOLOGY

A. Definition

A seizure is a sudden, abnormal electrical discharge from the brain that results
in changes sensation, behavior, movements, perception or consciousness.

Seizure disorders have numerous and varied causes. Most are idiopathic.
Genetic factors may in some way alter the seizure threshold to influence neuronal
discharge. It can also be acquired as a result of brain injury during prenatal,
perinatal or postnatal periods.This injury may be caused by trauma, hypoxia,
infections. Biochemical events and nutritional deficiencies produce seizure activity

Epilepsy is a chronic of recurrent seizures. An epileptic syndrome is


composed of paroxysmal neurologic dysfunction causing recurrent
episodes of one or more of the following manifestations: loss of
consciousness, convulsive movements or other motor activity, sensory
phenomena, and behavioral abnormalities.

Status epilepticus is a tonic clonic or absence seizures that follow one another
without restoration of consciousness. Common precipitating factors include abrupt
cessation of anticonvulsant medications and alcohol withdrawal. This disorder is life
threatening and produces greatly accelerated neuronal metabolic rate, hypoxia,
acidosis, hyperthermia, and alterations in cerebral blood flow. Damage occurs to the
cerebral cortex, hippocampus, and cerebellum, along with other metabolic
derangements.

Tonic-Clonic Seizures are the most common major motor seizure. The tonic
phase is followed by the clonic phase, which involves rhythmic bilateral contraction
and relaxation of the extremities.

Absence seizures are generalized, nonconvulsive epileptic events and are


expressed mainly as disturbances in consciousness. Typical absence seizures have
been characterized as a blank stare, motionless, and unresponsiveness, though
motion occurs in many cases of absence seizures.

B. Signs and Symptoms

Signs and Symptoms found in the Signs and Symptoms manifested by


textbook the patient

Prolonged seizure (lasting longer than (+) Aug. 8,2008


5 min.)

Rolling of eyes upward (+) Aug. 8,2008

Immediate loss of consciousness (+) Aug. 8,2008

Rigidness of the body (+)Aug. 8,2008

Peculiar piercing cry (+)Aug. 8,2008

Respiratory Distress (-)

Cyanosis (-)

Loss of swallowing reflex (-)


Rhythmic muscular contraction and (+)Aug. 8,2008
relaxation

Jerking movements (+)Aug. 8,2008

Bladder incontinence (+) Aug. 9, 2008

Bowel incontinence (-)

Hypoxia (-)

Lactic acidosis (+)Aug. 8,2008

C. Schematic Diagram

Predisposing factors Precipitating Factors

Genetic factors Head


injury

Head trauma

Cerebrovascular disease

Infection

Physiologic Stimuli

Alteration of the integrity of the neuronal cell membrane

Hyperexcitable cells initiate spontaneous electric discharge

Intensity of discharges reaches a threshold

Neuronal firing spreads to adjacent normal neurons


muscle contraction,

loss of consciousness,

jerking movements,

rolling of eyes upward,

rigidness of body

Neuronal excitation spreads to the brainstem

Uncontrolled bursts of electrical activity from the cortex

Seizure

Hypoxia Repeated occurrence of abnormal electrical discharges


lactic acidosis

Status Epilepticus
D. Management

a. Nursing Management

The management of epilepsy does not usually involve hospitalization.


However, a client may initially be hospitalized for assessment, diagnosis,
and education immediately after a first seizure. Hospitalization may also
be required if seizures become uncontrolled or if status epilepticus
develops. Nurses have a role in assessing for altered health maintenance
of injury related to knowledge deficit or other barriers, anticipating risk of
injury, and providing support for clients and their families who experience
life changes related to seizure disorder.

Assessment of clients not actively experiencing seizures includes the


following:

• History, including prenatal, birth, and developmental history; family


history; age at seizure onset; history of all illnesses and trauma;
previous brain surgery or stroke; complete description of seizures,
including precipitating factors; and presence of an aura

• Medication use and postictal symptoms

• Psychosocial assessment, including mental status examination

• Complete physical examination, focusing on neurologic signs

The child must be protected from injury during the seizure. It is


impossible to halt a seizure once it has begun, and no attempt should
be made to do so. The nurse must remain calm, stay with the child,
and prevent the child from sustaining any harm during the seizure. If
possible, the child should be isolated from the view of others by closing
door or pulling screens. A seizure can be very upsetting to the child,
other visitors or families. If other persons are present, they should be
assured that everything is being done for the child. After the seizure,
they can be given a simple explanation about the event as needed.
b. Medical Management

The goals of management of clients with seizures and epilepsy are to


prevent injury during seizures, to eliminate factors that precipitate
seizures, to diagnose and to treat the cause of the seizures, and to control
seizures to allow a desired lifestyle.

During a seizure, the major goals are to maintain the airway, to prevent
injury, to observe seizure activity and to administer appropriate
anticonvulsant medications. Today, “seizure precautions” as identified in a
hospital setting refers to the availability of an oral airway, and suction
equipment.

For decades, the main antiepileptic drugs (AEDs) were phenytoin,


phenobarbital, carbamazepine and valproate sodium. Currently available
antiepileptic drugs appear to act primarily by blocking the initiation or
spread of seizures. There are no drugs known to prevent the formation of
a seizure focus after a CNS injury in humans.

Medical intervention focuses on prescribing AEDs to arrest or prevent


seizures. Developing a program of correctly prescribed anticonvulsants
requires weeks of medication adjustment by trial and error. The desired
outcome pharmacologic management is monotherapy. Large doses of a
single anticonvulsant are often more helpful than smaller doses of several
drugs.

Ideally, initial treatment begins with a single drug (primarily


anticonvulsant) until either seizure control is attained or unacceptable
side effects appear. If side effects become intolerable before seizures are
controlled, another drug is added. Combining medications does carry the
potential risk of drug-drug interactions, which decrease effectiveness.

c. Surgical Management

The safest and most effective surgical treatment is cortical resection of


the anterior temporal lobe for complex partial seizures.

Criteria for resection includes:

• Failure of the medical approach


• Localization and identification of a focus of abnormal discharge that
is easily accessible surgically and is located in the “dispensable”
areas of the cerebral cortex. Dispensable areas are those for which
there is a duplicative area in the cortex.

Cortical resection or Corpus Callosotomy is designed to make the


seizures more tolerable. It involves the excision of one section of
cortex to reduce the spread of epileptic discharges.

Temporal Lobectomy is performed to remove the area in which the


seizures begin without causing neurologic or cognitive deficits.

Hemispherectomy is the removal of most of the cortex of one


hemisphere done in children with intractable seizures to control those
that are injurious, not to stop all seizures.

Vagal nerve stimulator implantation offers fully understood, the VNS is


believed to provide a stimulus that desynchronizes the abnormal
uncontrolled electrical discharge of the brain activity during a seizure.

REFERENCES:

Maternal and child health nursing, 4th ed. Pillitteri

Nursing: Understanding Diseases 2008, Lippincott Williams and Wilkins

Focus on Pathophysiology 2008, Lippincott Williams and Wilkins

Medical-Surgical Nursing 7th ed, Black and Hawks

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