A CASE STUDY ON CNS INFECTION

Submitted to; Ms. Verlyn Perez RN,MSN

Submitted by; Marie Joy R. Luczon Student Nurse

I.INTRODUCTION A febrile seizure is a convulsion in a child triggered by a fever. Such convulsions occur without any underlying brain or spinal cord infection or other neurological cause. A febrile seizure is a convulsion that occurs in some children with a high temperature (fever). The vast majority of febrile seizures are not serious. A seizure triggered by a fever is usually harmless and typically doesn't indicate a longterm or ongoing problem. The first febrile seizure is one of lifes most frightening moments for parents. Most parents are afraid that their child will die or have brain damage. Thankfully, simple febrile seizures are harmless. There is no evidence that simple febrile seizures cause death, brain damage, mental retardation, a decrease in IQ, or learning difficulties. However, a very small percentage of children go on to develop other seizure disorders such as epilepsy later in life. Although described by the ancient Greeks, it was not until this century that febrile seizures were recognized as a distinct syndrome separate from epilepsy. In 1980, a consensus conference held by the National Institutes of Health described a febrile seizure as, "An event in infancy or childhood usually occurring between three months and five years of age, associated with fever, but without evidence of intracranial infection or defined cause."It does not exclude children with prior neurological impairment and neither provides specific temperature criteria nor defines a "seizure." Another definition from the International League Against Epilepsy (ILAE) is "a seizure occurring in childhood after 1 month of age associated with a febrile illness not caused by an infection of the central nervous system (CNS), without previous neonatal seizures or a previous unprovoked seizure, and not meeting the criteria for other acute symptomatic seizures".

Signs and Symptoms A fever, usually higher than 38.9 C Loss of consciousness Jerking of the arms & legs Eyes rolled back in the head Difficulty breathing Vomiting & urinating Crying or moaning Incidence rate Febrile convulsions are common paediatric patients. According to studies, about 3-5% of otherwise healthy children between the ages of 9 months and 5 years will have a seizure

caused by a fever. Toddlers are most commonly affected. Most occur well within the first 24 hours of an illness, not necessarily when the fever is highest. Epidemiology Between 2% and 4% of European children have a febrile convulsion; the peak incidence is age 18 months.Most are the simple febrile seizure type. Complex febrile seizures occur in about 20% and febrile status epilepticus in about 5%.

Prognosis Generally the prognosis is good: By definition, febrile seizures do not recur beyond the age of 5 years approximately. There is no evidence for an increased risk of death, even for children with status epilepticus Intellect is not affected. Febrile seizures recur in about 30%. Risk factors for recurrence are: family history of febrile seizures, onset aged <18 months, lower temperature or shorter duration of fever at onset. Risk of epilepsy: The chance of developing epilepsy increases with certain features, which include: complex febrile seizure, other neurological abnormality, family history of epilepsy, and fever <1 hour before the seizure. Without these features, 2.4 % of children with febrile seizures develop epilepsy (compared with 1.4% for the general population).

Risk factors Several risk factors have been identified that increase your child's likelihood of experiencing a febrile seizure. These include: Age. Young age is the strongest risk factor, and most febrile seizures are seen in children who are between 6 months and 5 years of age. It's unusual for children under 6 months old to have a febrile seizure, and it's rare for these seizures to occur after 3 years of age. About 1 in 25 children experience a febrile seizure. Family history. Some children inherit a family's tendency to have seizures with a fever. Additionally, researchers have linked several genes to a susceptibility to febrile seizures.

Complications

Although febrile seizures may cause great fear and concern for parents, most febrile seizures produce no lasting effects. Simple febrile seizures don't cause brain damage, mental retardation or learning disabilities, and they don't mean your child has a more serious underlying disorder. Febrile seizures also aren't an indication of epilepsy, a tendency to have recurrent seizures caused by abnormal electrical signals in the brain. The odds that your child will develop epilepsy after a febrile seizure are small. Only a small percentage of children who have a febrile seizure go on to develop epilepsy, but not because of the febrile seizures. Recurrent febrile seizures The most common complication of febrile seizures is the possibility of more febrile seizures. About a third of children who have a febrile seizure will have another one with a subsequent fever. The risk of recurrence is higher if: Your child had a low fever at the time of the first febrile seizure. The period between the start of the fever and the seizure was short. An immediate family member has a history of febrile seizures.

Tests and diagnosis After experiencing a febrile seizure, your child will likely have: A physical exam Blood tests Urine tests These tests can help determine possible causes of the fever and seizure. If your doctor suspects a central nervous system infection, a lumbar puncture (spinal tap) may be necessary. In this procedure, a doctor inserts a needle into your child's lower back to remove a small amount of spinal fluid.

This test can reveal evidence of infection in the fluid that surrounds the brain and spinal cord.Further tests such as an electroencephalogram (EEG) a test that measures brain activity may be necessary if your child had a complex febrile seizure.

II.NURSING HISTORY

Patient Profile

Name; Age; Sex; Address; Nationality; Religion; Bithplace; Admission date Time;

Patient M 2 y/o Female Purok 4 Bulanao Tabuk,Kalinga Filipino Jehovahs Witness S/A ; August 15,2011

10;00 PM

Attending Physician: Dr. Ramirez/Dr.Pacicolan

PAST HEALTH HISTORY

No previous hospitalization. The patient was confined @ Cagayan Valley Medical Center because of persistent high grade fever for 20 hours, upward rolling of eyeballs and stiltering of extremities lasting to about 5 min x 1 episode.

PRESENT ILLNESS HISTORY

The patient was admitted August 15, 2011 @ 10;00 pm with chief complaint of dizziness, fever and headache increase in sleeping time.3 days prior to admission, the patient was noted to have cough and colds. She was given with paracetamol syrup before she was hospitalized. The patients parent consulted @ emergency room of CVMV hospital and was managed and subsequently admitted.

FAMILY HEALTH HISTORY

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

PEARSONS FUNCTIONAL PATTERN Condition before Hospitalization She has good stress coping pattern wherein she dont react to simple things that is done to her, even if it is not meant accidentally Condition During Hospitalization Her coping stress pattern is not quite good after she was hospitalized. She usually cries whenever she wants to or even when you accidentally touch her body. Patients mother said that the patient usually voids 2-3 times a day. When she was hospitalized, she defecates once. Mother stated that the patient was irritable when her diaper was full of void or even when she made pu-pu. Patient seems irritated all the time. She doesnt want to play with anybody even to her father and mother.

PSYCHOLOGICAL

ELIMINATION

Patients mother stated the patient usually voids 5-6 times a day. The patient usually wears her diaper all night. She usually defecates twice in a row.

ACTIVITY

Patients mother stated that she used to be a jolly child that loves to play with her cousin and her tita and tita.She loved to go to the neighbourhood just to hang around.

ROLE RELATIONSHIP PATTERN

She has a good relationship with her family as stated by her mother. She makes her family happy by simply giving them simple sing and dance sample Patient M usually sleeps about 9 in the evening until 7 in the morning. She always took nap during noontime for about 2-3 hours.

Her relatives especially her parents are very concerned with her present conditions.

SLEEP

Patients mother stated that her daughter sleep anytime she want to. She was easily distracted by environmental factors such as noise an even the temperature inside the room (hotness) . During her hospitalization, she has an order of o2 inhalation of 1-2 cpm because there is sign of DOB. She is NPO during the hospitalization.

OXYGEN

NUTRITION

Before she was admitted, she inhaled deep and slow due to her fever.She has difficulty of breathing according to her. Before she was admitted, her mother stated that she is fond of eating any food that is served to her. She is a christian.She and her family they usually go to church together. She was thought to become a good citizen by her parents.

SPIRITUAL

Her mother stated that as soon as they went out to the hospital, they plan to visit the church.

Laboratory Result
Hematology Normal Values Erythrocyte Volume Male 0.40Fraction 0.54 Female 0.380.47 Mean Corpuscular 80-100 fL Result 0.36 Interpretation Due to tachypnea

78.4

Decrease in the

Volume (MCV) Mean Corpuscular Hemoglobin(MCH) 26-32 pg 25.6

volume of the average RBC Decrease in the number of grams of hemoglobin/unit volume

WBC Differential Count Neutrophils Lymphocytes Monocytes

0.35-0.65 0.20-0.40 0.02-0.08

81.8 12.7 5.4

Eosinophil

0.0-0.5

0.0

Presence of infections Presence of chronic infections Presence of certain infections such as glandular fever normal

I.

PHYSICAL ASSESSMENT

A 1. GENERAL APPEARANCE/ HEALTH STATUS Appearance and mental status Body build Posture and gait, standing, sitting and walking Technique used Inspection Inspection Normal findings Proportionate Erect posture coordinated movement Actual Findings Analysis

Proportionate Proportionate

Normal Normal

MEASUREMENTS:

Level of consciousness; spontaneous Grooming: satisfactory

2VITAL SIGNS: NORMAL FINDING BODY TEMPERATURE PULSE RATE RESPIRATION BLOOD PRESSURE 37.0 OUTCOME 38.4C 132 BPM 36CPM 90/70MMHG ANALYSIS Presence of on infection tachycardia tachypnea NORMAL

120-160BPM 20-30CPM 100/60MMHG

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

Head to Toe assessment

AREA ASSESSED

TECHNIQUE USED

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Head Skull

Inspection

Normocephalic Size of the proportional to size of the body

Normal

Hair

Inspection

c& smooth texture Black & smooth straight

Normal

Scalp

No wounds, no abrasion

Normal No wounds, mo abrasion

Face

Inspection Symmetrical Normal Due to fever

Eyes

Inspection

Symmetrical Flushed face

Due to fever

Sclera White Pupils Black

Teary eyes Redness of the eye

Due to fever

Red, watery

Black in color and equal in size

AREA ASSESSED

TECHNIQU E USED Inspection

NORMAL FINDINGS Normal voice Tones audible Parallel, Symmetrical, Proportional to the size of the head and bean shape

ACTUAL FINDINGS Normal voice Tones audible Parallel, Symmetrical, Proportional to the size of the head and bean shape

ANALYSI S Normal

Ears/ hearing

Normal

Pinna

Ear Canal Ear canal has no abundant cerumen/ ear wax Hair in the ear canal are visible

Ear canal has no abundant cerumen/ ear wax Hair in the ear canal are visible

Normal Nose and sinuses Inspection Nose is in midline and symmetrical (-) secretion of mucous Nose is in midline and symmetrical (-) secretion of mucous

Mouth Teeth

Inspection (-) swelling of gums and bleeding Gums is pinkish in color

Dry lips (+) swelling of gums and bleeding Gums is reddish

Tongue

In central position, freely movable, pinkish and with prominent veins on the sublingual area.

In central position, freely movable, reddish (STRAWBERY)

Because of the diffuse erythema and prominent papillae.

Moist Mucosal lining Symmetrical and lip margin is well defined Lips is pinkish Lips (-) swelling Tonsils (-) swelling Uvula

Moist Symmetrical and lip margin is well defined Lips is dry and Reddish (strawberry) (-) swelling

(-) swelling

2. Neck

Inspection

(-) rashes and visible masses No scars

(-) rashes

Normal

Inspection 3.Chest

No scars

Normal

Palpation

(-) tenderness and masses

(-) tenderness and masses

Breath sound

Auscultatio n

(+) broncho vesicular breath sound at 2nd ICS

(+) broncho vesicular breath sound at 2nd lungs

Normal

Breast Inspection

Breast is even with the chest wall

Breast is even with the chest wall

Normal

Nipple Inspection

Nipple are round, and equal in size

Nipple are round, and equal in size

Normal

Areola

Areola are round symmetrical, color brown

Areola are round symmetrical, color brown

Normal

Heart Auscultatio n

(-) arrhythmia, bounding pulse heart murmurs and any abnormal pulsation being auscultated

(-) arrhythmia, bounding pulse heart murmurs and any abnormal pulsation being auscultated

Normal

2.

Posterior thorax

Inspection

No scars

No scars

Normal

Palpation

Spine vertically align; spinal column is straight right and left shoulder and

Spine vertically align; spinal column is straight right and left shoulder and

hips are at the same height

hips are at the same height

Auscultaion

Fermitus is heard most clearly at the apex of the lungs No effort when breathing with good breathing pattern

Fermitus is heard most clearly at the apex of the lungs No effort when breathing with good breathing pattern

Lungs

Percussion (+) resonance NBS (normal lung sound) (+) resonance NBS (normal lung sound)

Normal

3.

Abdomen

Inspection

Abdominal skin is unblemished, no scars, with flat and rounded abdomen/symmetric al contour.

Abdominal skin is unblemished, no scars, with flat and rounded abdomen/symmetric al contour

Normal

Auscultatio n

Audible bowel sound

Active bowel sound (10-30 bowel sound in every 5min) tympany

Due to peristaltic activity

Percussion

(+) presence of tympany No evidence of enlargement of the liver

Normal

Palpation

No evidence of enlargement of the liver

Normal

4.

Upper Extremities

Skin Arms

Inspection

(-) scars at the lower forearm

(-) scars at the lower forearm With fine hair evenly distributed and few visible veins Normal

smooth

With fine hair evenly distributed and few visible veins Symmetrical Palpation Symmetrical

Finger

Inspection With complete five finger in each hand smooth, convex with pinkish nail bed Smooth, convex with pinkish nail bed

Desquamation of finger Peeling and erythema of the fingertips. Transverse grooves of fingers and toenails (Beaus lines).

Nail

5.

Lower extremities

Inspection

(-) negative scars

Legs

(-) negative scars

Fine hair is evenly distributed

Fine hair is evenly distributed

Muscles symmetrical, length symmetrical

Muscles symmetrical, length

Inspection

symmetrical Dorsal surface is smooth & warm

Feet Dorsal surface is smooth & warm With convex nails, pinkish nail bed and good capillary refill of 2-3 seconds

Normal

Toe Nails

With convex nails, pinkish nail bed and good capillary refill of 2-3 seconds

(-) long and dirty toe nail Normal

(+) short and with clear and white translucent tips toe nails.

ANATOMY AND PHYSIOLOGY

Anatomy of the Brain: Brain Divisions The forebrain is responsible for a variety of functions including receiving and processing sensory information, thinking, perceiving, producing and understanding language, and controlling motor function. There are two major divisions of forebrain: the diencephalon and the telencephalon. The diencephalon contains structures such as the thalamus and hypothalamus which are responsible for such functions as motor control, relaying sensory information, and controlling autonomic functions. The telencephalon contains the largest part of the brain, the cerebrum. Most of the actual information processing in the brain takes place in the cerebral cortex. The midbrain and the hindbrain together make up the brainstem. The midbrain is the portion of the brainstem that connects the hindbrain and the forebrain. This region of the brain is involved in auditory and visual responses as well as motor function. The hindbrain extends from the spinal cord and is composed of the metencephalon and myelencephalon. The metencephalon contains structures such as the pons and cerebellum. These regions assists in maintaining balance and equilibrium, movement coordination, and the conduction of sensory information. The myelencephalon is composed of the medulla oblongata which is responsible for controlling such autonomic functions as breathing, heart rate, and digestion. The brain contains various structures that have a multitude of functions. Below is a list of major structures of the brain and some of their functions. Basal Ganglia Involved in cognition and voluntary movement Diseases related to damages of this area are Parkinson's and Huntington's

Brainstem Relays information between the peripheral nerves and spinal cord to the upper parts of the brain Consists of the midbrain, medulla oblongata, and the pons

Broca's Area Speech production Understanding language

Central Sulcus (Fissure of Rolando) Deep grove that separates the parietal and frontal lobes

Cerebellum Controls movement coordination Maintains balance and equilibrium

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

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

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

Corpus Callosum Thick band of fibers that connects the left and right brain hemispheres

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

Fissure of Sylvius (Lateral Sulcus) Deep grove that separates the parietal and temporal lobes

Limbic System Structures Amygdala - involved in emotional responses, hormonal secretions, and memory

Cingulate Gyrus - a fold in the brain involved with sensory input concerning emotions and the regulation of aggressive behavior Fornix - an arching, fibrous band of nerve fibers that connect the hippocampus to the hypothalamus Hippocampus - sends memories out to the appropriate part of the cerebral hemisphere for long-term storage and retrievs them when necessary Hypothalamus - directs a multitude of important functions such as body temperature, hunger, and homeostasis Olfactory Cortex - receives sensory information from the olfactory bulb and is involved in the identification of odors Thalamus - mass of grey matter cells that relay sensory signals to and from the spinal cord and the cerebrum

Medulla Oblongata Lower part of the brainstem that helps to control autonomic functions

Meninges Membranes that cover and protect the brain and spinal cord

Olfactory Bulb Bulb-shaped end of the olfactory lobe Involved in the sense of smell

Pineal Gland Endocrine gland involved in biological rhythms Secretes the hormone melatonin

Pituitary Gland Pons Relays sensory information between the cerebrum and cerebellum Endocrine gland involved in homeostasis Regulates other endocrine glands

Reticular Formation

Nerve fibers located inside the brainstem Regulates awareness and sleep

Substantia Nigra Helps to control voluntary movement and regualtes mood

Tectum The dorsal region of the mesencephalon (mid brain)

Tegmentum The ventral region of the mesencephalon (mid brain).

Ventricular System - connecting system of internal brain cavities filled with cerebrospinal fluid Aqueduct of Sylvius - canal that is located between the third ventricle and the fourth ventricle Choroid Plexus - produces cerebrospinal fluid Fourth Ventricle - canal that runs between the pons, medulla oblongata, and the cerebellum Lateral Ventricle - largest of the ventricles and located in both brain hemispheres Third Ventricle - provides a pathway for cerebrospinal fluid to flow

Wernicke's Area Region of the brain where spoken language is understood

PATHOGENESIS AND PATHOPHYSIOLOGY The pathophysiology of febrile seizures is unknown. The role of cytokine network activation is presently being studied along with an increased susceptibility to febrile seizures associated with specific interleukin alleles. Circulating toxins, immune reaction products, and viral or bacterial invasion of the central nervous system have been implicated, together with relative lack of myelination in the immature brain and increased oxygen consumption during the febrile episode. Immaturity of thermoregulatory mechanisms and a limited capacity to increase cellular energy metabolism at elevated temperatures have been suggested as contributory factors .

A recently documented pathogen associated with febrile seizures is human Herpes virus type 6. This is the etiologic agent for infant rosella, a common infection of infants and toddlers usually associated with fever greater than or equal to 103F. It is postulated that the direct viral invasion of the brain or fever causes the initial febrile seizure, and that the virus might be reactivated by fever during subsequent illnesses, causing recurrent febrile seizures.

COURSE IN THE WARD

DATE 8/15/11 TIME 10pm DOCTORS ORDER Pls. admit to Pedia Ward under the service of Dr. Ramirez/Dr.Pasicolan Secure consent for admission TPR q shift and record RATIONALE For continuous care, monitoring and treatment For legal purposes Serves as baseline data

Wt. 10.3 kg BP-80/50 Temp-39.5 CR-124 RR-34

NPO

Diagnostics CBC ; APL Urinalysis;SG SE Hgb now Cranial CT scan EEG

Patient is under observation To provide baseline data on patients hematology CBC:To determine the extent of the disease process.To determine the blood type and its composition Urinalysis;To determine characteristics and components of urine which are not usually present that also signal infection in the urinary system To replace fluid loss and for further nourishment

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

Chloramphenicol 260 mg IV q 6 hours (-)ANST

Paracetamol 105 mg IV q 4 hours RTC Diazepam 2 mg IV q 4 hours RTC

O2 inhalation 1-2 cpm/nasal cannula

Monitor IV q and record Monitor I and O q shift and record Watch out for seizure Dr. Pasicolan Seizure precaution @ bedside Refer

8/16/11 afebrile

NPO Cont. D5 0.3 NaCl @38-39 ugtts/min

(-) seizure

Follow-up CBC with APL and SE

(-) DOB

Still for cranial CT Scan and EEG

It has an effect against susceptible bacteria, serve as antibiotic To decrease temperature and for mild pain It suppresses the spread of seizure activity(prevent seizure) Inhalation of Oxygen aimed at restoring toward normal to pathophysiologic alterations of gas exchange in the cardiopulmonary system. To serve as baseline data To serve as baseline data To prevent any further injury To prevent further injury For further evaluation and management Still the patient is under observation To continue in replacement of fluid loss and for further management CBC:To determine the extent of the disease process.To determine the blood type and its composition To visualize if there is affected part on the cranial

Continue medications and management Continue vital signs monitoring

8/16/11 10am

Seizure precaution @ bedside DAT

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

Continue medications and management Continue vital signs monitoring

Refer HAMA

area For continuous treatment For baseline data and to monitor alteration To prevent further injury To provide adequate nutrition in order to regain strength To continue in replacement of fluid loss and for further nourishment For continuous treatment For baseline data and to monitor alteration To continue medications at home with physicians consent

PARACETAMOL
CLASSIFICATION DOSAGE INDICATION CONTRAINDICATION ADVERSE REACTION

Antipyretics

105 mg IV q 4 hours RTC

Inhibits synthesis of prostaglan dins that may serve as meditators of pain and

Products containing ame,saccharinalco hol,aspartame,sac charin sugar tartrazine should be avoided in patients who have hypersensitivity or

GI;hepatic failure,hepat otoxicity (overdose) GU:renal failure Derm;rash

fever,prima rily in the CNShas no significant antiinfllammat ory property of GI toxicity.

intolerance to these compounds.

CHORAMPHENICOL
CLASSIFICATION DOSAGE INDICATION CONTRAINDICATION ADVERSE REACTION

Antibiotic

260 mg IV q 6 hours (-) ANST

May rarely cause systemic hematologic toxicity if used chronically and in excessive causes.It has bacterostatic effect,effe ct against susceptible bacteria;pre vent cell replication

Contraindicated in patients hypersensitive to drug or its components and in those with perforated eardrum.

EENT;ear irritation or itching Skin;urticaria

DIAZEPAM

CLASSIFICATION

DOSAGE

INDICATION

CONTRAINDICATION

ADVERSE REACTION

Anxiolytics

2 mg IV q 6 hours

A benzodi azepine that probably potentia tes the effects of GABA,d epresses the CNS,an d suppress es the spread of seizure activity.

Contraindicated in patient hypersensitivity to drug or soy protein; in patients experiencing shock, coma or acute alcohol intoxication.

CNS;drowsine ss,dysarthia,slu rred speech CV;hypotensio n,bradycardia, Cv collapse EENT;diplopia, blurred vision Respiratory;res piratorydepres sion,apnea

Assessment

Objective: :

Nursing Diagnosis Hyperthermia

Planning Short term: Long Term:

Nursing Interventions > >

Rationale > > .

After 2 days of > > > nursing interventions, > the patient will be able to be free of complications and maintain core temperature within normal range.

Assessment

Nursing

Planning

Nursing Interventions

Rationale

Subjective: Objective: the patient manifested: > body weakness > weight of 7.9kg > loss of appetite > poor muscle tone the patient may manifest: > abnormal laboratory studies > pallor

Diagnosis Imbalance Nutrition: Less than the body requirement related to economical factors.

>Review patients records. >To obtain bas data. After 4 hours of >Assess underlying nursing interventions, condition. >To determine the patients will specific identify measures to >discuss eating habits and interventions. promote nutrition and encourage diet for age. follow the treatment >To achieve he regimen needs of the pa > Note total daily intake includes patterns and time with the proper diet for his dise Long Term: of eating. Short term: After 2 days of nursing >Consult physician for interventions, the will further assessment and demonstrate recommendation regarding behaviours or lifestyle food preferences and changes to regain nutritional support. appropriate weight.

>To reveal cha that should be m in the clients d intake.

>For greater understanding a further assessm specific food.

Nursing Planning Nursing Interventions Rationale Diagnosis Ineffective Short term: > Establish rapport. > To gain patient and S.O. Subjective: tissue trust and promote After 4 hours of nursing > Monitor VS. perfusion cooperation. intervention, the patient realated to will demonstrate > Determine factors related > To monitor patients statu Objective: decreased behaviour lifestyle to individual situation. Hgb changes to improve > To gain information concentration The patient circulation. regarding the condition. in blood as manifested: > Evaluate for signs of evidenced by infection especially when Long term: low Hgb immune system is >To observe for possible >Body temperature count in CBC Assessment

changes. >Skin discoloration The patient may manifest: > Anemia

result

After 2 days of nursing compromised. intervention, the patients S.O. will > Discuss individual risk verbalize understanding factors. of the condition. > Elevate head of bed at night. > Discuss the importance of a healthy diet..

risk factors. > This information would necessary for the clients S.O.

> To increase gravitationa blood flow.

>To promote a healthy die to help increase RBC synthesis and Hgb count fo faster recovery.

AssessmentNursing DiagnosisPlanningNursing InterventionsRationaleExpected OutcomeS = O = the patient manifested: >body weakness >fatigue >poor muscle tone =The patient may manifest: >elevated body temperature >Hgb = 112 >WBC = 22.9 >RBC = 3.97

>HCT = 0.34 >Platelet count = 234 Risk for (spread) of infection Short Term: After 3 hours of nursing interventions, the patient will verbalize understanding of ways on how to prevent spread of infection. Long Term: After 1week of nursing interventions, the patient will be free from infections and further complications >Establish good working relationship with the client and S.O. >Monitor and record vital signs > Determine pts individual strength >Provide peaceful environment >Provide adequate rest and sleep. >Emphasize importance of hand washing >Provide safety measures >Monitor I & O >Check IV and Regulate IVF >Advice pt to increase oral fluid intake when allowed >To gain their trust and cooperation >For comparative baseline data >To know when to assist client

>To promote optimum level of functioning >To prevent fatigue and conserve energy >.to prevent occurrence of further infections >To prevent falls and injuries >To note for imbalances >To ensure proper hydration > To replace fluid electrolyte loss Short Term: After 3 hours of nursing interventions, the patient shall have verbalized understanding of ways on how to prevent spread of infection. Long Term: After 1week of nursing interventions, the patient shall have been free from infections and further complications.

AssessmentNursing DiagnosisPlanningNursing InterventionsRationaleExpected OutcomeSubjective: Objective: the patient may manifest the following: >Fever

>Convulsion >Low >Low Hgb Level = 112 Risk for injury related to possible convulsion.Short term: After 4 hours of nursing interventions, the SO will modify environment as indicated to enhance safety. Long term: After 2 days of nursing interventions, the SO will verbalize understanding of individual factors that contribute to possibility of injury. >establish rapport >monitor and record Vital Signs > ascertain knwlge of safety needs/ injury prevention > note clients gender, age, developmnt stage, decision makng ability, level of cognition/competence >provide health care within a culture of safety > identify interventions/safety devices > discuss importance of self monitoring of conditions/ emotions > To gain patients trust >To obtain baseline data > to prevent injuries in home, community, and work setting >affects clients ability to protect self/others and influence choice of interventions/ teachings >to prevent errors resulting in client injury, promote client safety and model safety behaviors for client/SO >to promote safe physical environment and individual safety

>it can contribute to occurence of injury Short term: The SO shall have modified environment as indicated to enhance safety. Long term: The SO shall have verbalized understanding of individual factors that contribute to possibility of injury.

DISCHARGE CARE PLAN

Instructed and explained to the patient the importance of taking medication as well as the duration in taking medicine Advised SO to continue giving vitamin supplements to patient to boost her immune system Advised to avoid strenuous activities and have moderate exercises lie adduction and abduction of upper and lower extremities Instructed patient to follow strict compliance with the medicines ordered and have regular wound dressing Advised SO the importance of adherence to treatment regimen Encouraged patient to have proper hand washing regularly, brush teeth 3 times a day and take a bath daily Advised SO to come back @CVMC for further follow-up check-up after discharged SO is advised to consult doctor if

MEDICATION

EXERCISE

TREATMENT

HYGIENE

OPD

DIET

SPIRITUAL

any problems or complications encountered Advised SO to give nutritious foods which is high in protein and essential vitamins Encouraged SO to increased fluid intake of the patient Encouraged the SO to have strong faith for fast recovery of the patient Advised SO not to be discouraged and lose hope even if there are many problems theyve encountered