Velez College Nursing Case Study

Velez College – College of Nursing
F. Ramos St., Cebu City

Presented by: Dave Jay S. Manriquez, RN.
A Case Study Presentation on G.M., Diagnosed with Hypokalemia, Hypoxic Ischemic Encephalopathy, Nosocomial Pneumonia and Urinary Tract Infection

INTRODUCTION:

G.M., 37 y.o., M, was admitted for the first time at CVGH Hospital on November 24, 2006, 7:00 pm via taxi, accompanied by his co-workers under the services of
he Department of Family Medicine, co-managed with the Department of Internal Medicine for complaints of lower extremity weakness noted hours PTA.

HYPOKALEMIA

Definition
Hypokalemia is a condition of below normal levels of potassium in the blood serum. Potassium is a necessary electrolyte which facilitates nerve impulse
conduction and the contraction of skeletal and smooth muscles, including the heart. It also facilitates cell membrane function and proper enzyme activity. Nearly 98% of
the body's potassium is intracellular. Levels must be kept in a proper (homeostatic) balance for the maintenance of health. The kidney determines potassium homeostasis,
and excess potassium is excreted in the urine.

The normal concentration of potassium in the serum is in the range of 3.5-5.0 mEq/L, thus, hypokalemia means serum or plasma levels of potassium ions that fall
below 3.5 mEq/L. Moderate hypokalemia is a serum level of 2.5-3 mEq/L, and severe hypokalemia is defined as a level less than 2.5 mEq/L The patient’s potassium
level is 1.5 meq/L, and is classified as severe.

Symptoms
Mild hypokalemia usually results in no symptoms, while moderate hypokalemia results in: confusion, disorientation, weakness, and discomfort of muscles. It also
causes cramps during exercise, and a discomfort in the legs experienced while sitting still. Severe hypokalemia results in: extreme weakness of the body, and occasionally
in paralysis, which occurs as quot;flaccid paralysisquot; or limpness. The symptoms manifested by the patient was the weakness of his lower extremities hours prior to
admission. Paralysis of the muscles of the lungs results in death. Our patient persistently complained of dyspnea, though pulse oximetry revealed 98-100%. Patient
experienced respiratory arrest, on his first day at the ICU, and was intubated with continuous ambubagging at 10 LPM. Another dangerous result is abnormal heart beat
(arrhythmia) that can lead to death from cardiac arrest (cessation of heart beat), because of the need for potassium to control muscle action. Mild QRS complexes were
documented in ECG. Along the course of intubation, patient went into cardiopulmonary arrest and was resuscitated accordingly.

Causes
The most common cause is by the use of diuretics, drugs that increase the excretion of water and salts in the urine. These are used to treat medical conditions,
including hypertension (high blood pressure), congestive heart failure, liver disease, and kidney disease. However, its side effects produce hypokalemia, the most
common cause of hypokalemia in elderly patients.

Another common cause is excessive diarrhea and / or vomiting. These can be produced by infections of the gastrointestinal tract. Diarrhea is a major world health
problem, responsible for about a quarter of the 10 million deaths that occur each year. in the parts of Asia and Africa. This also results in various abnormalities or
complications, such as dehydration (loss in body water), hyponatremia (low sodium level in the blood), and hypokalemia. Diarrhea was the identified cause of the
patient’s hypokalemia, who experienced diarrhea, with 10 episodes per day, amounting to 1 cup per episode. No meds were taken nor hydration to correct his condition.
His diarrhea was said to be acquired from eating seafood in Cebu.

Vomiting provokes an increase in potassium loss in the urine. Vomiting expels acid from the mouth, and this loss of acid results in alkalization of the blood. (pH
of the blood increases slightly.) An increased blood pH has a direct effect on the kidneys. Alkaline blood provokes the kidneys to release excessive amounts of potassium
in the urine. So, severe and continual vomiting can cause excessive losses of potassium from the body and hypokalemia.

Prolonged fasting and starvation also declines the blood serum potassium levels to below 3.0 mEq/L. But eating an unbalanced diet does not cause hypokalemia
because most foods, such as fruits (especially bananas, oranges, and melons), vegetables, meat, milk, and cheese, are good sources of potassium. Only foods such as
butter, margarine, vegetable oil, soda water, jelly beans, and hard candies are extremely poor in potassium.

Diagnosis
Hypokalemia can be measured by acquiring a sample of blood, to measure the concentration of potassium ions. Another way is by measuring the potassium
content of the urine. In the patient’s case, the serum potassium was measured with the value 1.5 meq/L(3.5-5meq/L). The electrocardiogram is also useful in the
diagnosis of hypokalemia, since hypokalemia results in abnormalities in heart behavior. ECG changes may be helpful if present, their absence should not be taken as
reassurance of normal cardiac conduction. The ECG of the patient showed mild QRS complexes.

Medical Management
Asymptomatic or mild hypokalemia may be treated with enteral potassium supplements in the form of pills. This is the safest and most effective treatment for
hypokalemia. Symptomatic or severe hypokalemia should be corrected with a solution of intravenous potassium. For people taking diuretics, potassium supplements are
not necessary as long as they eat a balanced diet containing foods rich in potassium. But if hypokalemia has already occurred, use of the high potassium diet alone may
not reverse hypokalemia. The treatment of the patient’s hypokalemia consisted of kalium durule (C: mineral and electrolyte replacement or supplement; A: replaces
potassium and maintains potassium level , 2 durules TID per NGT.

Surgical Management
Management is nonsurgical. Medical therapy is aimed at potassium supplementation by the enteral (ie, oral or through feeding tubes) or parenteral route.
Potassium supplements restore body potassium storage. Electrolytes are used to correct disturbances in fluid and electrolyte homoeostasis or acid-base balance and to
reestablish osmotic equilibrium of specific ion..

HYPOXIC-ISCHEMIC ENCEPHALOPATHY

Definition
This is a serious condition causing significant mortality and long-term morbidity. HIE is characterized by clinical and laboratory evidence of acute or subacute
brain injury due to asphyxia (ie, hypoxia, acidosis). This damages the cells in the central nervous system (the brain and spinal cord) from inadequate oxygen. Most often,
the underlying cause remains unknown. Hypoxic-ischemic encephalopathy allegedly may cause in death or result in what is later recognized as developmental delay,
mental retardation, or cerebral palsy. The time of brain injury often remains uncertain, and an abnormal brain (eg, growth failure, impaired development) might be an
underlying risk factor.

Symptoms
May show symptoms of developmental delay, mental retardation, cerebral palsy and growth failure.

Causes
Brain hypoxia and ischemia due to systemic hypoxemia, reduced cerebral blood flow or both are the primary physiological processes that trigger HIE. A possible
cause in the patient’s case is the occurrence of respiratory arrest, secondary to weakness of respiratory muscles while he was in the ICU, leading to the lack of delivery of
oxygen to the brain. He complained of dyspnea, and metabolic acidosis was revealed.

Diagnosis
Diagnosis of HIE is made based on the history and physical and neurological examinations. Many of the tests are performed to assess the severity of brain injury
and to monitor the functional status of systemic organs. The results of the tests should be interpreted in conjunction with the clinical history and the findings from physical
examination. Cranial ultrasound can also reveal internal hemorrhage; however, visualizations may be difficult in routine ultrasound examination. A CT scan of the head
can be useful to confirm cerebral edema (obliteration of cerebral ventricles, blurring of sulci). Echocardiography (ECHO) also helps to define myocardial contractility and
the existence of structural heart defects, if any.

Medical Management
Seizures are generally self-limited, but may significantly compromise other body functions such as maintenance of ventilation, oxygenation, and blood pressure.
Seizures should be treated early and be well controlled, since even asymptomatic seizures (ie, seen only on EEG) may continue to injure the brain. Fluid and glucose
homeostasis should also be achieved. Avoid hypoglycemia or hyperglycemia, as both are known to cause brain injury. Treatment is supportive and directed at the organ
system manifestations. For the brain injury, no established effective treatment is used. Citicoline (Somazine) can be used as a neuroprotectant(C: CNS stimulant; A: it
produces CNS stimulation by increasing level of neurotransmitters in the CNS. Produce CNS stimulation and respiratory stimulation dilated pupils, increase motor
activity and mental alertness, and a diminished sense of fatigue.); .

Surgical Management
In cases of posterior cranial fossa hematoma, surgical drainage may be lifesaving if no additional pathologies are present

NOSOCOMIAL PNEUMONIA

Definition
Hospital-acquired pneumonia, also called nosocomial pneumonia, is an infection that patients get while they’re in the hospital. This means the infection is
not present at the time a patient is admitted to the hospital. Pathogens thrive in hospitals that could not survive in other environments. These pathogens include
resistent aerobic gram-negative rods, such as Pseudomonas, Enterobacter and Serratia; resistent gram positive cocci, such as ORSA. Because of risk factors,
underlying morbidity and resistent bacteria, hospital-acquired pneumonia tends to be more deadly than its community counterpart. Hospital acquired pneumonia
occurs mostly in patients who are severely debilitated or who are immune suppressed.

Nosocomial pneumonia can generally be described as “early nosocomial” (appearing within five days of hospitalization) or “late nosocomial” (more than
five days after hospitalization). The nosocomial pneumonia of our patient was identified on the 3 rd day at the ICU which is also the 3rd day of his admission. The
organisms leading to community-acquired pneumonia, predominantly Gram-positive cocci, are seen in patients present with pneumonia very shortly after admission
to hospital (if no antibiotic therapy has so far been given) and Gram-negative bacilli predominate in patients developing pneumonia after five days of
hospitalization. The preliminary result of the tracheal aspirate revealed gram (-) woffi, acinetobacter hypersensitive to Ciprofloxacin and Piperacillin.

Symptoms
These may include fever, shortness of breath, and a cough that produces yellow, green, or gray sputum from the respiratory tract. Because nosocomial
pneumonia is such a serious infection, patients may need to receive more than one type of antibiotic to treat it. Getting pneumonia while in the hospital may prolong
the hospital stay, and intravenous (I.V.) antibiotic treatment usually lasts for up to 2 weeks. If patients begin to feel better, they may be switched from I.V. treatment
to oral (tablet) treatment. Patient had a productive cough with whitish sputum. Rales were heard on both lung fields.

Causes
Increased duration of hospital stay (risk increases with >14 days of stay).
•
Trauma (particularly head trauma).
•
Chronic underlying diseases (e.g. diabetes and chronic lung disease).
•
Immunosuppression.
•
General anaesthetic.
•
Endotracheal intubations. The patient was intubated for 12 days in the ICU, starting on his first day in the ICU
•
Hospital admission during the previous month.
•
Antibiotic history.
•

Diagnosis
• X-ray or CT scan.

Purulent sputum.
•
Fever.
•
Leucocytosis or leucopenia.
•

Laboratory Tests
• Blood cultures
• Sputum Gram stain and culture
The patient’s culture of sputum aspirate revealed gram (-) woffi, acinetobacter hypersensitive to Ciprofloxacin (C: Fluroquinolones; A: it inhibits bacterial cell
wall synthesis) and Piperacillin (C: Penicillin A: An extended-spectrum penicillin that inhibits cell-wall synthesis during microorganism multiplication.)

Treatment
Antibiotics used for hospital-acquired pneumonia include aminoglycosides, fluoroquinolones, carbapenems, and vancomycin.. Multiple antibiotics are
administered in combination in order to cover all the possible organisms effectively and rapidly, before the infectious agent can be known. The antibiotics
administered to the patient are the ff:. Ciprofloxacin 500mg 1 and ½ tab BID (C: Fluroquinolones; A: it inhibits bacterial cell wall synthesis); Clindamycin 300g 1
cup every 6 hrs (C: miscellaneous anti-infective; A: inhibits bacterial protein synthesis by binding to the 50S subunit of the ribosome) and Piperacillin +
Tazobactam 4.5 gm IVTT (C: Penicillin A: An extended-spectrum penicillin that inhibits cell-wall synthesis during microorganism multiplication. Tazobactam
increases piperacillin’s effectiveness by inactivating beta-lactamases, which destroy penicillins).

Management
Antibiotic treatment must be started promptly.

URINARY TRACT INFECTION

Definition
The second most common type of infection in the body. Women are especially prone to UTIs. One woman in five develops a UTI during her lifetime. UTIs
in men are not as common as in women but can be very serious when they do occur.

The urinary system consists of the kidneys, ureters, bladder, and urethra. The key elements in the system are the kidneys, a pair of purplish-brown organs located
below the ribs toward the middle of the back. The kidneys:
• remove excess liquid and wastes from the blood in the form of urine
• keep a stable balance of salts and other substances in the blood, and
• produce a hormone that aids the formation of red blood cells.

The narrow tubes called ureters, carry urine from the kidneys to the bladder, a sack-like organ in the lower abdomen. Urine is stored in the bladder and emptied
through the urethra

Urine is normally sterile -- thus, it does not normally contain bacteria. This is a good thing, since the mineral and sugar content of urine makes it a great medium for
bacteria to grow in. Several things keep bacteria out of the urine. These include:
· The urethral sphincter: when the urethra is squeezed shut, bacteria cannot climb up the urethra from the quot;meatusquot; (the outside opening) into the bladder.
· The length of the urethra: it's a long way up to the bladder for a bacterium. (A woman's urethra is shorter than a man's, which is one reason why women are
much more likely than men to get UTI's.)
· Frequent washing: any bacteria that make it into the urethra are flushed out the next time you urinate, and since most people empty their bladders almost
completely when they urinate any bacteria that get to the bladder will be flushed out too. There are also valves where the ureters enter the bladder to prevent
urine from quot;refluxingquot; from the bladder to the kidneys, so even if the bladder and its urine is infected the bacteria shouldn't travel up to the kidneys.

Symptoms
Not everyone with a UTI has symptoms, but most people get at least some symptoms. These may include a frequent urge to urinate and a painful, burning
feeling in the area of the bladder or urethra during urination. Often women feel an uncomfortable pressure above the pubic bone, and some men experience a
fullness in the rectum. It is common for a person with a urinary infection to complain that, despite the urge to urinate, only a small amount of urine is passed. The
urine itself may look milky or cloudy, even reddish if blood is present. A UTI does not normally cause fever if it is in the bladder or urethra. A fever may mean that
the infection has reached the kidneys. Other symptoms of a kidney infection include pain in the back or side below the ribs, nausea, or vomiting.

Cystitis may show up as burning on urination, often in the quot;middlequot; of urination. However, it may have no symptoms other than fever, lower
abdominal (just above the pubic bone) pain, or even just a funny smell or colour or appearance (cloudy, dark, even blood-tinged) to your urine. And since kidneys
are located at back, just below the bottom ribs, pyelonephritis may appear as pain at the back or flank(s), or in the abdomen. Fever usually (but not always) comes
along with the pain. If the kidneys are severely affected, one may also start seeing some of the complications due to kidney malfunction.

Complications
The biggest problem with a UTI is if it progresses to pyelonephritis. This can result in scarring and damage to the kidney tissue. If there is enough damage to
the filter system, waste products can't be removed properly. This constitutes kidney failure, and if it is bad enough and long-lasting enough, the only solutions are
dialysis (filtering blood through an quot;artificial kidneyquot;) or a kidney transplant

A different complication occurs if the pressure-regulation tissues in the kidney are scarred. If this is bad enough, your blood pressure may be kept too low
(and one may faint frequently at the very least) or too high (leading to strokes, heart disease).

Causes

Since urine is normally sterile. It is usually free of bacteria, viruses, and fungi but does contain fluids, salts, and waste products. An infection occurs when
tiny organisms, usually bacteria from the digestive tract, cling to the opening of the urethra and begin to multiply. The urethra is the tube that carries urine from the
bladder to outside the body. Most infections arise from one type of bacteria, Escherichia coli (E. coli), which normally lives in the colon. In many cases, bacteria
first travel to the urethra. When bacteria multiply, an infection can occur.

• An infection limited to the urethra is called Urethritis.
This can be due to other things besides the organisms usually involved in UTI's; in particular, many sexually-transmitted diseases (STD's) appear initially as
urethritis. Another is stool-related bacteria (the most common bacteria on the skin near the meatus) will also often cause urethritis.

• If bacteria move to the bladder and multiply, a bladder infection, called Cystitis, results.
This is the most common form of UTI; it can be aggravated if the bladder does not empty completely when urinating.

• An infection of the ureter is called, Ureteritis. This can occur if the bacteria entered the urinary tract from above, or if the ureter-to-bladder valves don't work
properly and allow urine to quot;refluxquot; from the bladder into the ureters.

• If the infection is not treated promptly, bacteria may then travel further up the ureters to multiply and infect the kidneys. A kidney infection is called
Pyelonephritis.

Microorganisms called Chlamydia and Mycoplasma may also cause UTIs in both men and women, but these infections tend to remain limited to the urethra
and reproductive system. Unlike E. coli, Chlamydia and Mycoplasma may be sexually transmitted, and infections require treatment of both partners.

The urinary system is structured in a way that helps ward off infection. The ureters and bladder normally prevent urine from backing up toward the kidneys,
and the flow of urine from the bladder helps wash bacteria out of the body. In men, the prostate gland produces secretions that slow bacterial growth. In both sexes,
immune defenses also prevent infection. But despite these safeguards, infections still occur.

Risk Factors
Any abnormality of the urinary tract that obstructs the flow of urine (a kidney stone, for example) sets the stage for an infection. An enlarged prostate gland
also can slow the flow of urine, thus raising the risk of infection.

A common source of infection is catheters, or tubes, placed in the urethra and bladder. The patient has been catheterized since December 5, 2006 until
December 12, 2006 (7 days), was inserted on December 14, 2006. Urinary Tract infection was diagnosed on December 26, 2006. So on December 27, 2006 FBC
was removed. A person who cannot void or who is unconscious or critically ill often needs a catheter that stays in place for a long time. Some people, especially the

elderly or those with nervous system disorders who lose bladder control, may need a catheter for life. Bacteria on the catheter can infect the bladder, thus, hospital
staff take special care to keep the catheter clean and remove it as soon as possible.

People with diabetes have a higher risk of a UTI because of changes in the immune system. Any other disorder that suppresses the immune system raises the
risk of a urinary infection.

Diagnosis
A sample of urine is tested for pus and bacteria. A quot;clean catchquot; urine sample is collected by washing the genital area and collecting a quot;midstreamquot; sample of
urine in a sterile container.

In the urinalysis test, the urine is examined for white and red blood cells and bacteria. Bacteria are then grown in a culture and tested against different
antibiotics to see which drug best destroys the bacteria. This last step is called a sensitivity test. Some microbes, like Chlamydia and Mycoplasma, can be detected
only with special bacterial cultures. A doctor suspects one of these infections when a person has symptoms of a UTI and pus in the urine, but a standard culture fails
to grow any bacteria.

The results of the patients urinalysis, revealed cloudy appearance, RBC of 5-10/hpf, epithelial cells of 2-5/hpf, moderate(++) blood, 30(++)protein and heat
& acetic acid: (+)

An ultrasound exam is also used, which gives pictures from the echo patterns of soundwaves bounced back from internal organs. Another useful test is
cystoscopy. A cystoscope is an instrument made of a hollow tube with several lenses and a light source, which allows the doctor to see inside the bladder from the
urethra.

Treatment
UTIs are treated with antibacterial drugs. The choice of drug and length of treatment depend on the patient's history and the urine tests that identify the
offending bacteria. The sensitivity test is especially useful in helping the doctor select the most effective drug. A class of drugs called quinolones includes four
drugs approved in recent years for treating UTI. These drugs include ofloxacin (Floxin), norfloxacin (Noroxin), ciprofloxacin (Cipro), and trovafloxin (Trovan). A
followup urinalysis helps to confirm that the urinary tract is infection-free. It is important to take the full course of treatment because symptoms may disappear
before the infection is fully cleared.

Various drugs are available to relieve the pain of a UTI. A heating pad may also help. Most doctors suggest that drinking plenty of water helps cleanse the
urinary tract of bacteria. During treatment, it is best to avoid coffee, alcohol, and spicy foods. And one of the best things a smoker can do for his or her bladder is to
quit smoking. Smoking is the major known cause of bladder cancer.

Management
• Drink plenty of water every day.
• Urinate when you feel the need; don't resist the urge to urinate.
• Wipe from front to back to prevent bacteria around the anus from entering the vagina or urethra.
• Take showers instead of tub baths.
• Cleanse the genital area before sexual intercourse.
In women, avoid using feminine hygiene sprays and scented douches, which may irritate the urethra.

Anatomy & Physiology
Brain

Major regions of the brain and their functions

The major regions of the brain are the cerebral hemispheres, diencephalon, brain stem and cerebellum.

Cerebral hemispheres
The cerebral hemispheres, located on the most superior part of the brain, are separated by the longitudinal fissure. They make up approximately 83% of total brain
mass, and are collectively referred to as the cerebrum. The cerebral cortex constitutes a 2-4 mm thick grey matter surface layer and, because of its many
convolutions, accounts for about 40% of total brain mass. It is responsible for conscious behaviour and contains three different functional areas: the motor areas,
sensory areas and association areas. Located internally are the white matter, responsible for communication between cerebral areas and between the cerebral cortex
and lower regions of the CNS, as well as the basal nuclei (or basal ganglia), involved in controlling muscular movement.

Midbrain
Function: Controls Responses to Sight, Eye Movement, Pupil Dilation, Body Movemen,t Hearing.
Location: The mesencephalon/midbrain is the most rostral portion of the brainstem. It is located between the forebrain and brainstem.

Forebrain
Function: Chewing ,Directs Sense Impulses Throughout the Body ,Equilibrium ,Eye Movement, Vision ,Facial Sensation Hearing, Phonation ,Intelligence Memory,
Personality Respiration
Salivation, Swallowing Smell, Taste
Location: The prosencephalon/forbreain is the most anterior portion of the brain.

Diencephalon
The diencephalon is located centrally within the forebrain. It consists of the thalamus, hypothalamus and epithalamus, which together enclose the third ventricle.
The thalamus
acts as a grouping and relay station for sensory inputs ascending to the sensory cortex and association areas. It also mediates motor activities, cortical arousal and
memories. The
hypothalamus, by controlling the autonomic (involuntary) nervous system, is responsible for maintaining the body’s homeostatic balance. Moreover it forms a part
of the limbic
system, the ‘emotional’ brain. The epithalamus consists of the pineal gland and the CSF producing choroid plexus.

Brain stem
The brain stem is similarly structured as the spinal cord: it consists of grey matter surrounded by white matter fibre tracts. Its major regions are the midbrain, pons
and medulla oblongata. The midbrain, which surrounds the cerebral aqueduct, provides fibre pathways between higher and lower brain centres, contains visual and
auditory reflex and subcortical motor centres. The pons is mainly a conduction region, but its nuclei also contribute to the regulation of respiration and cranial
nerves. The medulla oblongata takes an important role as an autonomic reflex centre involved in maintaining body homeostasis. In particular, nuclei in the medulla

regulate respiratory rhythm, heart rate, blood pressure and several cranial nerves. Moreover, it provides conduction pathways between the inferior spinal cord and
higher brain centres.

Cerebral Cortex Lobes
Frontal Lobe
Function: Motor Functions Higher Order Functions Planning Reasoning Judgement Impulse Control Memory
Location: The frontal lobes are the anterior portion of the cerebral cortex.
Occipital Lobe
Function: Controls Vision Color Recognition
Location: The occipital lobes are the most caudal portion of the cerebral cortex.
Parietal Lobe
Function: Cognition Information Processing Pain and Touch Sensation Spatial Orientation Speech Visual Perception
Location: The parietal lobes are anterior to the occipital lobes and posterior to the central sulcus (fissure) and frontal lobes.
Temporal Lobe
Function: Emotional Responses Hearing Memory Speech
Location: The temporal lobes are anterior to the occipital lobes and lateral to the Fissure of Sylvius.
Insula
Function: Associated With Visceral Functions Integrates Autonomic Information
Location: The insula is located within the cerebral cortex, beneath the frontal, parietal and temporal opercula.

Cerebellum
The cerebellum, which is located dorsal to the pons and medulla, accounts for about 11% of total brain mass. Like the cerebrum, it has a thin outer cortex of grey
matter, internal white matter, and small, deeply situated, paired masses (nuclei) of grey matter. The cerebellum processes impulses received from the cerebral motor
cortex, various brain stem nuclei and sensory receptors in order to appropriately control skeletal muscle contraction, thus giving smooth, coordinated movements.

The cerebral circulatory system
Blood is transported through the body via a continuous system of blood vessels. Arteries carry oxygenated blood away from the heart into capillaries supplying
tissue cells. Veins collect the blood from the capillary bed and carry it back to the heart. The main purpose of blood flow through body tissues is to deliver oxygen
and nutrients to and waste from the cells, exchange gas in the lungs, absorb nutrients from the digestive tract, and help forming urine in the kidneys. All the
circulation besides the heart and the pulmonary circulation is called the systemic circulation.

The internal carotid arteries, branches of the common carotid arteries, run through the neck and enter the skull through the temporal bone. Once inside the
cranium, each divides into the anterior and middle cerebral arteries, which supply most of the cerebrum.
The paired vertebral arteries pass upward from the subclavian arteries at the base of the neck. Within the skull, the vertebral arteries join to form the single
basilar artery, which serves the brain stem and cerebellum as it travels upward. At the base of the cerebrum, the basilar artery divides to form the posterior cerebral
arteries, which supply the posterior part of the cerebrum.
The anterior and posterior blood supplies of the brain are united by small communicating arterial branches. The result is a complete circle of connecting
blood vessels called the circle of Willis, which surrounds the base of the brain. The circle of Willis protects the brain, because it provides more than one route for
blood to reach brain tissue in case of a clot or impaired blood flow anywhere in the system.

Respiratory System

The respiratory system is composed of the nose, the pharynx, the larynx, the trachea, the bronchi & their smaller branches and the lungs. The major function
of this system is to supply the body with oxygen and dispose carbon dioxide from the body.
During breathing, air enters the body through the nose which is the only externally visible part of the respiratory system. The air passes through the external
nares then to the nasal cavity where it is first filtered and warmed. After which passes through pharynx or most commonly known as the “throat” which is the
common passageway for both food and air. After passing through the pharynx, the air is now being routed to its proper channel by the larynx also known as the
“voice box” which is lies just below the pharynx. The epiglottis protects the superior opening of the larynx which closes as the person swallows so that food will not
enter into the trachea, also called the “windpipe”. The trachea extends from the larynx to the primary bronchi. As the air comes down the trachea and enters the
right and left primary bronchi, it is again filtered by the ciliated mucosa lining which propels dust particles and other debris away from the lungs. From the
subdivision of the trachea results the left and right primary bronchi which are the ones plunged into the hilus of the lungs on its sides. By the time air reaches the
bronchi, it is already warm, cleansed and well humidified but because the right primary bronchi is wider, shorter and straighter than the left, inhaled foreign objects
are consequently lodged in it. After the primary bronchi enter the lungs, they subdivide into smaller and smaller branches called bronchioles, until it
terminates/ends in clusters of alveoli (air sacs) inside the lungs where gas exchange takes place.

The paired lungs are fairly large organs. They occupy the entire thoracic cavity except for the most central area, the mediastinum, which houses the heart,
the great blood vessels, bronchi, esophagus, and other organs. The narrow superior portion of each lung, the apex, is located just deep to the clavicle. The broad
lung area resting on the diaphragm is the base. Each lung is divided into lobes by fissures; the left lung has two lobes, and the right lung has three.
The surface of each lung is covered with a visceral serosa called the pulmonary, or visceral, pleura and the walls of the thoracic cavity are lined by the
parietal pleura. The pleural membranes produce pleural fluid, a slippery serous secretion which allows the lungs to glide easily over the thorax wall during
breathing movements and causes the two pleural layers to cling together. The pleurae can slide easily from side to side across one another, but they strongly resist
being pulled apart. Consequently, the lungs are held tightly to the thorax wall, and the pleural space is more of a potential space than an actual one. As described
shortly, this condition of tightly adhering pleural membranes is absolutely essential for normal breathing.
After the primary bronchi enter the lungs, they subdivide into smaller and smaller branches (secondary and tertiary bronchi, and so on), finally ending in the
smallest of the conducting passageways, the bronchioles. Because of this branching and rebranching of the respiratory passageways within the lungs, the network
formed is often referred to as the bronchial or respiratory tree. All but the smallest branches have reinforcing cartilage in their walls.
The terminal bronchioles lead into respiratory zone structures, even smaller conditions that eventually terminate in alveoli, or air sacs. The respiratory zone,
which includes the respiratory bronchioles, alveolar ducts, alveolar sacs, and alveoli, is the only site of gas exchange. All other respiratory passages are conducting
zone structures that serve as conduits to and from the respiratory zone. There are millions of the clustered alveoli, which resemble bunches of grapes, and they
make up the bulk of the lungs. The balance of the lung tissue, its stroma, is elastic connective tissue. Thus, in spite of their relatively large size, the lungs weigh only
about 2 ½ pounds, and they are soft and spongy.

The Respiratory Membrane

The walls of the alveoli are composed largely of a single, thin layer of squamous epithelial cells. The thinness of their walls is hard to imagine, but a sheet of
tissue paper is much thicker. Alveolar pores connect neighboring air sacs and provide alternate routes for air to reach alveoli whose feeder bronchioles have been
clogged by mucus or otherwise blocked. The external surfaces of the alveoli are covered with a “cobweb” of pulmonary capillaries. Together, the alveolar and
capillary walls and their fused basement membranes construct the respiratory membrane (air-blood barrier), which has gas (air) flowing past on one side and
blood flowing past on the other. The gas exchanges occur by simple diffusion through the respiratory membrane – oxygen passing from the alveolar air into the
capillary blood and carbon dioxide leaving the blood to enter the gas-filled alveolus. It has been estimated that the total gas exchange surface provided by the
alveolar walls of a healthy man is 50 to 70 square meters, or approximately 50 times greater than the surface area of the skin. The final line of defense for the
respiratory system is in the alveoli. Macropahges, sometimes called “dust cells,” wander in and out of the alveoli picking up bacteria, carbon particles, and other
debris. Also scattered amid the epithelial cells that form most of the alveolar walls are chunky cuboidal cells, which look very different. The cuboidal cells produce
a lipid (fat) molecule called surfactant, which coats the gas-exposed alveolar surfaces and is very important in lung function.

Urinary System

The urinary system consists of the kidneys, ureters, urinary bladder, and urethra. The kidneys form the urine and account for the other functions attributed to the
urinary system. The ureters carry the urine away from kidneys to the urinary bladder, which is a temporary reservoir for the urine. The urethra is a tubular structure
that carries the urine from the urinary bladder to the outside.

Kidneys

The kidneys are the primary organs of the urinary system. The kidneys are the organs that filter the blood, remove the wastes, and excrete the wastes in the urine.
They are the organs that perform the functions of the urinary system. The other components are accessory structures to eliminate the urine from the body.

The paired kidneys are located between the twelfth thoracic and third lumbar vertebrae, one on each side of the vertebral column. The right kidney usually is slightly
lower than the left because the liver displaces it downward. The kidneys protected by the lower ribs, lie in shallow depressions against the posterior abdominal wall
and behind the parietal peritoneum. This means they are retroperitoneal. Each kidney is held in place by connective tissue, called renal fascia, and is surrounded by a

thick layer of adipose tissue, called perirenal fat, which helps to protect it. A tough, fibrous, connective tissue renal capsule closely envelopes each kidney and
provides support for the soft tissue that is inside.

In the adult, each kidney is approximately 3 cm thick, 6 cm wide, and 12 cm long. It is roughly bean-shaped with an indentation, called the hilum, on the medial
side. The hilum leads to a large cavity, called the renal sinus, within the kidney. The ureter and renal vein leave the kidney, and the renal artery enters the kidney at
the hilum.

The outer, reddish region, next to the capsule, is the renal cortex. This surrounds a darker reddish-brown region called the renal medulla. The renal medulla consists
of a series of renal pyramids, which appear striated because they contain straight tubular structures and blood vessels. The wide bases of the pyramids are adjacent
to the cortex and the pointed ends, called renal papillae, are directed toward the center of the kidney. Portions of the renal cortex extend into the spaces between
adjacent pyramids to form renal columns. The cortex and medulla make up the parenchyma, or functional tissue, of the kidney.

The central region of the kidney contains the renal pelvis, which is located in the renal sinus and is continuous with the ureter. The renal pelvis is a large cavity that
collects the urine as it is produced. The periphery of the renal pelvis is interrupted by cuplike projections called calyces. A minor calyx surrounds the renal papillae
of each pyramid and collects urine from that pyramid. Several minor calyces converge to form a major calyx. From the major calyces the urine flows into the renal
pelvis and from there into the ureter.

Each kidney contains over a million functional units, called nephrons, in the parenchyma (cortex and medulla). A nephron has two parts: a renal corpuscle and a
renal tubule.The renal corpuscle consists of a cluster of capillaries, called the glomerulus, surrounded by a double-layered epithelial cup, called the glomerular
capsule. An afferent arteriole leads into the renal corpuscle and an efferent arteriole leaves the renal corpuscle. Urine passes from the nephrons into collecting ducts
then into the minor calyces.

The juxtaglomerular apparatus, which monitors blood pressure and secretes renin, is formed from modified cells in the afferent arteriole and the ascending limb of
the nephron loop.

Ureters

Each ureter is a small tube, about 25 cm long, that carries urine from the renal pelvis to the urinary bladder. It descends from the renal pelvis, along the posterior
abdominal wall, behind the parietal peritoneum, and enters the urinary bladder on the posterior inferior surface.

The wall of the ureter consists of three layers. The outer layer, the fibrous coat, is a supporting layer of fibrous connective tissue. The middle layer, the muscular
coat, consists of inner circular and outer longitudinal smooth muscle. The main function of this layer is peristalsis to propel the urine. The inner layer, the mucosa, is
transitional epithelium that is continuous with the lining of the renal

pelvis and the urinary bladder. This layer secretes mucus which coats and protects the surface of the cells.

Urinary Bladder

The urinary bladder is a temporary storage reservoir for urine. It is located in the pelvic cavity, posterior to the symphysis pubis, and below the parietal peritoneum.
The size and shape of the urinary bladder varies with the amount of urine it contains and with pressure it receives from surrounding organs.

The inner lining of the urinary bladder is a mucous membrane of transitional epithelium that is continuous with that in the ureters. When the bladder is empty, the
mucosa has numerous folds called rugae. The rugae and transitional epithelium allow the bladder to expand as it fills.

The second layer in the walls is the submucosa that supports the mucous membrane. It is composed of connective tissue with elastic fibers.

The next layer is the muscularis, which is composed of smooth muscle. The smooth muscle fibers are interwoven in all directions and collectively these are called
the detrusor muscle. Contraction of this muscle expels urine from the bladder. On the superior surface, the outer layer of the bladder wall is parietal peritoneum. In
all other regions, the outer layer is fibrous connective tissue.

There is a triangular area, called the trigone, formed by three openings in the floor of the urinary bladder. Two of the openings are from the ureters and form the
base of the trigone. Small flaps of mucosa cover these openings and act as valves that allow urine to enter the bladder but prevent it from backing up from the
bladder into the ureters. The third opening, at the apex of the trigone, is the opening into the urethra. A band of the detrusor muscle encircles this opening to form
the internal urethral sphincter.

Urethra

The final passageway for the flow of urine is the urethra, a thin-walled tube that conveys urine from the floor of the urinary bladder to the outside. The opening to
the outside is the external urethral orifice. The mucosal lining of the urethra is transitional epithelium. The wall also contains smooth muscle fibers and is supported
by connective tissue.

The internal urethral sphincter surrounds the beginning of the urethra, where it leaves the urinary bladder. This sphincter is smooth (involuntary) muscle. Another
sphincter, the external urethral sphincter, is skeletal (voluntary) muscle and encircles the urethra where it goes through the pelvic floor. These two sphincters control
the flow of urine through the urethra.

In females, the urethra is short, only 3 to 4 cm (about 1.5 inches) long. The external urethral orifice opens to the outside just anterior to the opening for the vagina.

In males, the urethra is much longer, about 20 cm (7 to 8 inches) in length, and transports both urine and semen. The first part, next to the urinary bladder, passes
through the prostate gland and is called the prostatic urethra. The second part, a short region that penetrates the pelvic floor and enters the penis, is called the
membranous urethra. The third part, the spongy urethra, is the longest region. This portion of the urethra extends the entire length of the penis, and the external
urethral orifice opens to the outside at the tip of the penis.

CLIENT IN CONTEXT PRESENT STATE INTERVENTIONS EVALUATION
PHYSICAL EXAMINATION:
Informant: father and eldest son,
Date: December 13, 2006, 1:45
mostly father
pm, Wednesday
65% Reliability
G.M., 37 y.o., male, married, General appearance:
Roman Catholic, Filipino, Seen lying on bed, awake,
currently residing in Tisa conscious, responsive to pain,

afebrile, with O2 inhalation @ 2L/
Labangon, Cebu city, was
minute via nasal cannula, with
admitted for the first time in
NGT @ left nostril, with FBC
CVGH on November 24, 2006 at
draining well to CDU, with the
7:00pm via taxi accompanied by
following v/s: BP: 130/90 mmHg,
co-worker for complaint of
PR: 62 bpm, RR: 15 cpm, T:
weakness on the lower extremities
36.5°C/ axilla, height: 5’6” IBW =
noted 5 hours PTA, under the
service of Dr. Pama of the
SKIN:
Department of Family Medicine
warm, dry, good skin tugor, with
and co-managed by Dr. Español of
scalings found on both lower
the Department of Internal
extremities, no rashes, dark
Medicine with the case # 84334.
complexion, a grade 2 bed sore
History of present illness: located approx. 1/2 inch in
5 days , patient had history diameter, circular in form at the
of profuse diarrhea approximately inner leg of the left ankle and
10-15 episodes per day amounting approx. 2 inches in diameter,
to 1cup per episode. No meds irregular in form 1 inch above the
taken nor hydration correction outer right ankle
done. Condition tolerated. NAIL:
Few hours PTA, patient had pinkish nail bed, smooth and short,
weakness of the lower extremities dirty fingernails, CRT <2 seconds,
no clubbing of nails
associated with numbness which
HAIR & HEAD:
progressively reached the level
evenly distributed short, black
below the umbilicus. Patient was
hair, no lesions, no lice
unable to stand alone, prompting
infestations, no dandruff, hair is
to seek consult at CVGH-(Cebu
smooth, normocephalic
Velez General Hospital) and
subsequently admitted. Labs taken EYES:
outer canthus of eye is inline with
were potassium which showed
the pinna, eyebrows and eyelashes
hypokalemia at 1.5mmOl/L and
mild QRS complexes documented evenly distributed, no discharges,
on ECG. Pt. was the transferred to pinkish palpebral conjunctivae, iris

and pupil are round in shape,
ICU for further monitoring. ABG
sclera is white, eyes are
was likewise taken because he
symmetrical in shape, (+)
complained of dyspnea which
PERRLA,(-) cardinal gaze, (-)
revealed acidosis with adequate
peripheral gaze, cannot see
oxygenation.
EARS:
On first day at ICU, pt. pinna is in line with the outer
complained of persistent dyspnea. canthus of the eye, symmetrical,
Pulse oximetry revealed 98-100%. no tenderness, no abnormal or foul
Approval of the family was done discharges, can hear spoken words
pertaining of possible intubation if at 1 ft. distance
respiratory arrest would occur 30 NOSE:
mins later. O2 saturated declined With NGT @ left nostril, nasal
to less than 90% and was septum at midline, no discharges,
subsequently intubated with patent airway, sinuses not tender,
continuous ambubagging at (+) frontal and maxillary
10L/min. Along the course of transillumination
intubation, pt went into MOUTH:
cardiopulmonary arrest and was pinkish and moist lips, pink
resuscitated accordingly. mucosa, no lesions, tongue at the
floor of the mouth, 30 teeth,
On the second day, CBC was
NECK:
taken which showed WBC of 10.4
supple, located at midline, no
k/uL(4.10-10.9 k/uL) and serum
tenderness, no lymphadenopathy,
potassium of 2.1 mmOl/L(3.5-
trachea located at midline, no
5mmOl/L). Pt was comatosed with
masses or lesions noted
blank stare. Citicoline 1 gm IVTT
CHEST and LUNGS:
(C: CNS stimulant; A: it produces
Presence of tattoo located @ the
CNS stimulation by increasing
right scapular region, no palpable
level of neurotransmitters in the
lesions, no bruises, no masses
CNS. Produce CNS stimulation
palpated, equal chest expansion,
and respiratory stimulation dilated
rales on both lung fields
pupils, increase motor activity and
CARDIOVASCULAR:
mental alertness, and a diminished

no murmurs heard, distinct S1 &
sense of fatigue.); Esomeprazole
S2, regular rhythm, PR:62 bpm
40mg IVTT OD (C: Anti-ulcer,
ABDOMEN:
proton pump inhibitor; A: binds an
protuberant, umbilicus at midline,
enzyme on gastric parietal cells in
5 clicks/min. no masses palpated,
the presence of acidic gastric pH,
no abdominal distention
preventing the final transport of
GENITALIA:
hydrogen ion into the gastric
grossly male, no discharges, no
lumen); kalium durule, 2 durules
lesions noted
QID (C: mineral and electrolyte
EXTREMITIES:
replacement or supplement; A:
upper extremities and lower
replaces potassium and maintains
extremities are symmetrical in size
potassium level); sodium
and in decorticate state, palpable
bicarbonate gr10 1 tab TID (C:
peripheral pulses, a grade 2 bed
alkalinizer; A: restores buffering
sore located approx. 1/2 inch in
capacity of the body and
diameter, circular in form at the
neutralizes excess acid) were
inner leg of the left ankle and
likewise given.
approx. 2 inches in diameter,
On the third day at ICU, irregular in form 1 inch above the
preliminary result of the tracheal outer right ankle
aspirate revealed acinetobacter
woffi sensitive to ciprofloxacin Neurologic assessment:
and Piperacillin + Tazobactam. MENTAL STATUS: conscious,
Thus was started on Ciprofloxacin incoherent, with GCS of 6
500mg 1 and ½ tab BID (C: SENSORY STATUS: cannot be
Fluroquinolones; A: it inhibits assessed
bacterial cell wall synthesis); MOTOR STATUS: cannot be
Clindamycin 300g 1 cup every 6 assessed
hrs (C: miscellaneous anti-
infective; A: inhibits bacterial CRANIAL NERVES:
protein synthesis by binding to the I: n/a
50S subunit of the ribosome) and II: n/a
Piperacillin + Tazobactam 4.5 gm III, IV, VI: (+) PERRLA, (-)
IVTT (C: Penicillin A: An

cardinal gaze, (-) peripheral gaze
extended-spectrum penicillin that
V: (+) blink reflex, can open &
inhibits cell-wall synthesis during
close mouth,
microorganism multiplication.
VII: n/a
Tazobactam increases
VIII: can hear spoken words at 1
piperacillin’s effectiveness by
ft. distance
inactivating beta-lactamases,
IX, X: n/a
which destroy penicillins).
XI: n/a
Potassium was taken with a result
XII: (+) gag reflex
of 3.7 mmol/L.
On the 12th day of ICU, pt DEEP TENDON REFLEXES:
was extubated but weaning with T- Biceps: (+), triceps (+)
piece at 4 LPM was done a day
before which he tolerated. Then MUSCLE STRENGTH:
nebulization with Salbutamol 1/5 1/5
and Hydrocortisone was done. 1/5 1/5
Finally he was transferred to Ward Date: December 18, 2006, 10:15
though still comatose with blank am Monday
stare. He had a working diagnosis
of 1 Hypoxic – Ischemic General appearance:
Encephalopathy 2 severe Seen lying on bed, awake,
hypokalemia - corrected 3 conscious, incoherent, afebrile,
Nosocomial pneumonia with NGT @ left nostril, with O2
inhalation @ 2L/minute via nasal
Past history illness:
cannula, with FBC draining well
Patient is known
to CDU, with the following v/s:
hypertensive with unrecalled bp,
BP: 120/80 mmHg, PR: 69 bpm,
non-diabetic, non-asthmatic with
RR: 22 cpm, T: 36.7°C/ axilla,
no known food and drug allergies.
He is a non-smoker and an
SIGNIFICANT FINDINGS:
occasional alcoholic beverage
drinker. Heredofamilial disease
•
includes hypertension on maternal (-) cardinal and
side and cancer on the paternal (-)peripheral gaze

• still can’t see
side.
• with O2 inhalation @
Previous hospitalization:
2L/min
1st hospitalization was in the
• with NGT @ left nostril
1990s due to appendectomy.
• presence of tattoo at right
However patient’s father forgot
scapular region
the details pertaining to it such as
• rales in both lung fields
the name of the hospital, doctor,
• dirty fingernails
and take home meds.
• with FBC draining well to
2nd hospitalization was in
CDU
1993 at unrecalled hospital with
• Both upper and lower
the diagnosis of urolithiasis.
extremities are still in
Surgery was done. Number of
decorticate state
days in the hospital and take home
• a grade 2 bed sore located
meds were unrecalled. Patient’s
approx. 1/2 inch in
condition improved upon
diameter, circular in form
discharged.
at the inner leg of the left
1. Health perception - Health ankle and approx. 2 inches
management Pattern in diameter, irregular in
When he was still residing form 1 inch above the
at Manila, he had a regular check outer right ankle
up at Genreal hospital, Pasig City • with scalings found both
under Dr. Casino. Now that he is on lower extremities
residing in Cebu for three years, Date: December 19, 2006, 10: 15
S.O. doesn’t know if the patient am Tuesday
still practices regular check-ups.
Patient takes OTC drugs. If he has General appearance:
fever, he takes Biogesic (C: Seen lying on bed, awake,
antipyretic and anti-inflammatory conscious, incoherent, afebrile,
A: Inhibits the synthesis of with O2 inhalation @ 2L/minute
prostaglandin that serve as via nasal cannula, with NGT @
mediators of pain and fever left nostril, with FBC draining
primarily in the CNS) and if he has well to CDU, with the following v/

s: BP: 130/90 mmHg, PR: 79 bpm,
colds, he takes Neozep and
RR: 20 cpm, T: 365°C/ axilla,
afforded relief. He does not take
herbal medicines and does not
believe in folk healers. S.O.
doesn’t know if patient performs
• (-) cardinal and
TSE. Patient is fully immunized,
(-)peripheral gaze
and goes to the dentist when need
arises.
2. Nutritional-metabolic Pattern
2L/min
Patient eats 3 to 4 times a
day with snacks in the morning,
afternoon and evening. He usually
scapular region
eats breakfast at 7 to 8 am
comprising of egg, rice and milo.
If rice is unavailable, he replaces
CDU
them with bread. He takes his
lunch at 12 to 1 pm and usually
eats fried meat, at least 3cups of
decorticate state
rice and cold water. Dinner is
•
taken at around 7 – 8 pm a grade 2 bed sore located
comprising of meat, at least 3 cups approx. 1/2 inch in
of rice and cold water. Patient's diameter, circular in form
favorite food is adobong baboy at the inner leg of the left
and prefers to drink cold water. He ankle and approx. 2 inches
does not have intolerance to any in diameter, irregular in
type of food and can chew and form 1 inch above the
swallow without difficulty. He outer right ankle
does not take any vitamins and • with scalings found both
supplements. The last time he took on lower extremities
multivitamins is when he was 7
years old brand name unrecalled. Date: December 20, 2006 1:45 pm,
Patient drinks at least 8 glasses of Wednesday
water/day.

General appearance:
During hospitalization, Px is
Seen lying on bed, awake
currently on NGT since he was
conscious, inoherent, afebrile, with
released at ICU at Dec 5, 2006.
O2 inhalation @ 2L/minute via
His diet prescription is 1800cal in
nasal cannula, with NGT @ left
1000cc volume into 6 equal
nostril, with FBC draining well to
feedings with 300cc as
CDU, with the following v/s: BP:
volume/feeding. On December 18,
120/90 mmHg, PR: 66 bpm, RR:
2006 his diet prescription was
24 cpm, T: 36.6 °C/axilla
increased to 2500 cal in 2500 cc
volume with the same
specification and 100 cc water
every 4 hours per NGT.
3. Elimination pattern Pattern (-)peripheral gaze
S.O. doesn’t know patient’s
elimination pattern before
admission but claimed that the px
2L/min
does not use any laxatives. When
patient experiences constipation,
he just drinks lots of water and
scapular region
when experiences diarrhea, patient
takes in Lomotil or Diatabs
During hospitalization,
CDU
Patient is currently w/ Foley bag
catheter draining well to clsed
drainage unit (Fbc-cdu) since
decorticate state
released on December 5, 2006 and
• a grade 2 bed sore located
urinates more than 1,000ml of
approx. 1/2 inch in
urine per day with a dark yellow
colored urine. On December 12,
at the inner leg of the left
2006 FBC was removed but
ankle and approx. 2 inches
patient experienced bladder
in diameter, irregular in
distention, which was then
form 1 inch above the

outer right ankle
relieved by hot and cold compress
• with scalings found both
but due to persistent bladder
on lower extremities
distention FBC, was inserted on
December 14, 2006. Urinary Tract
Date: January 3, 2007 9:30 am
infection was diagnosed on
Wednesday
December 26, 2006. So on
December 27, 2006 FBC was
General appearance:
removed and was not reinserted
Seen lying on bed, asleep, afebrile,
again because patient was able to
with NGT @ left nostril, with the
void thereafter and also due to the
following v/s: BP: 120/80 mmHg,
UTI. He defecates everyday with a
yellow watery stool. Patient
36.5°C/ axilla,
experiences urinary and bowel
incontinence and constantly wears
diaper up to present.
4. Activity-exercise pattern
(-)peripheral gaze
Patient is a supervisor at
global insurance for 3 yrs. S.O.
does not know his daily activities,
and time of patient's work and
scapular region
patient does not engage in any
form of exercise and sports.
Patient used to play basketball
with friends at least once a week
decorticate state
but stopped after he got married.
Patient’s form of recreation
include reading, sleeping, and
• A whitish, grade 2
watching tv.
bedsore, half inch in
During hospitalization,
patient is always on hospital bed
was noted on the left inner
and cannot change positions such
ankle and a reddish, grade
as turning to sides, sitting down
2 bedsore, one inch in

diameter, irregular in form
and standing up on his own. He
was noted 1 inch above the
has a schedule positioning every 2
right outer ankle
hours. He depends on his S.O. in
doing his ADL’s.
5. Sleep-rest pattern Date: January 8, 2007 10:30 am
When patient is on a Monday
vacation in Manila, S.O. said that
the patient usually sleeps at around General appearance:
9pm shortly after eating snacks Seen lying on bed, asleep, with
and wakes up at around 9am. And NGT left nostril, with the
he does not take any sleeping following v/s: BP 110/80 mmHg,
medications. Patient takes nap for PR: 79 bpm, RR: 18 cpm, T:
about 1-3 hours in the afternoon. 36.4°C/axilla
Patient prefers to sleep in a cold
room and uses 2 pillows. S.O. does SIGNIFICANT FINDINGS:
not know if the patient experiences
nightmares. • (-) cardinal and
During hospitalization, (-)peripheral gaze
•
patient sleeps most of the time. still can’t see
6. Cognitive-perceptual pattern
Patient does not wear
scapular region
eyeglasses and does not have any
hearing problems. Patient is a
•
college graduate with a course of distended bladder
banking finance. S.O. couldn’t • Both upper and lower
recall the name of the school. extremities are still in
decorticate state
7. Role-relationship pattern
The patient, as described
by his father is a loving person,
father and a boyfriend. He is also
the comedian in the family. He is

the eldest among 3 siblings and
has 4 offsprings; 3 of which are
males. He is the provider together
right outer ankle
with his wife but because of his
work, he isn’t living together with
his family but communicates 2-3x/
week through cellular phone. He is
in good terms with his parents,
Date: January 9, 2007 2:30 pm
siblings, girlfriend and friends.
Tuesday
GENOGRAM:
General appearance:
Seen lying on bed, asleep, with
NGT @ left nostril, with FBC
draining well to CDU, with the
following v/s: BP 120/80 mmHg,
36.7°C/axilla

SIGIFICANT FINDINGS:

(-)peripheral gaze
scapular region
CDU

9. Sexuality-reproductive
decorticate state
pattern
Patient had his
circumcision at 10 years old at the
health center at Novaliches,
Quezon city. He has no history of
STD. S.O. does not know if the
patient performs TSE and does not
know the patient's sexual
activities.
right outer ankle
10. Coping-stress pattern
When asked, S.O
verbalized that the patient's major
stressors are financial problems
but is able to afford family's needs
Date: January 19, 2007 9:45 am
such as tuition fees, food, etc.
Wednesday
Support comes mainly from family
and close relatives and seeks for
General appearance:
friend's advices. He usually
Seen lying on bed, awake,
relieves stress by resting.
conscious, incoherent, afebrile,
11. Value-belief pattern with NGT @ left nostril, with FBC
Patient is a roman draining well to CDU, with the
catholic. S.O. does not know if the following v/s: BP: 120/80 mmHg,
patient prays everyday and goes to PR: 73 bpm, RR: 18 cpm, T:
mass every Sunday. Patient is not 36.8°C/axilla
involved in any religious
organizations. Patient does not SIGNIFICANT FINDINGS:
have cultural practices that causes
guilt. • (-) cardinal and
(-)peripheral gaze
Environmental history:
Patient is currrently

residing at Happy-happy
scapular region
compound, Tisa Labangon, Cebu
city. According to S.O., this place
serves as the patient’s office and
CDU
home in Cebu however the S.O.
has not yet been to the patient’s
place so he can’t further describe
decorticate state
the place.
In Pasig, Manila, they
have been living there for 37
years, the house and lot is owned.
They have been living in a two-
storey house with 4 bedrooms
occupied by 14 people and a
separate room for kitchen and
dining room. It has 6 windows. It
is beside the main road, 1 meter
away from the church, 2 meters
right outer ankle
away from the brgy. Hall, 3 meters
away from the market, and 10
MUSCLE STRENGTH:
meters away from the health
center. Transportation is
1/5 1/5
accessible. They have 1 pet, dog
1/5 1/5 December 13, 18-20,
named Rocky. Water source is
2006
supplied by Nawasa and electricity
is supplied by Meralco.
2/5 2/5
2/5 2/5 January 3, 8-10, 2007

Summary of Significant Summary of Significant Findings:
Findings: PHYSICAL EXAMINATION:
1. Heredofamilial disease
(-)peripheral gaze
includes hypertension and

•
cancer on the paternal side. still can’t see
2. Px is currently on NGT. • with NGT @ left nostril
3. Px has been w/ fbc-cdu • presence of tattoo at right
from Dec. 5-12, 2006 and scapular region
Dec. 14-26, 2006 and • rales in both lung fields
urinates more than 1,000ml • with FBC draining well to
of urine per day with a CDU
dark yellow colored urine.
But was removed last Dec.
27, 2006 due to the
decorticate state
presence of UTI
4. He defecates everyday with
a yellow watery stool.
5. Px is currently always on
hospital bed and cannot
change positions such as
turning to sides, sitting
down and standing up on
his own.
right outer ankle

LABORATORY:

11/24/06
Urinalysis

Color: straw
RBC: 0-2/hpf
heat & acetic acid: (-)
pH: 6.5
WBC: 0-1/hpf

Specific Gravity: 1.006
epithelial cells: 0-2/hpf
Protein: trace
ketone: (-)
Glucose: ++
blood: +
Reducing Substances: ++
amorphous materials: (-)

Purpose:
Means of knowing the various
properties of urine, a routine
procedure for every patient to
determine any pathological
disorders.

Implication:
Presence of protein, glucose,
Reducing substance, blood in urine
and low specific gravity usually
indicates Infection

11/24/06
ECG

Rate: Atrial = 107/min.
Ventricular = 107/ min.
Rhythm: sinus
Axis: (+) 40
PR interval: 0.16 sec.
QRS interval: 0.08 sec.
QT interval: 0.40 sec.
P Wave: low to flat

QRS: bizarre complexes seen in
V1, V4 r S R pattern seen in V1,
V2
Transitional zone : V4
T wave: upright
ST segment: isoelectric

Interpretation:
Sinus tachycardia with premature
ventricular contractions,
intraventricular conduction defect.
Non specific ST-T wave changes.

11/27/06
Gram Staining: Gram (+) cocci in
pairs: few/OIF
Pus cells: moderate

11/28/06
Smear Culture: Gram (-) rods
Culture: Acinetobacter iwoffi
Remarks: Sensitivity test result of
culture: A.iwoffi

Purpose:
Allows for morphologic
examination of cells contained in
the specimen and differentiate any
bacteria present, may be used to
differentiate true sputum from
saliva and upper respiratory tract
infections

Implication:
Indicates infection of the
respiratory tract secondary to
pneumonia as manifested by
whitish sputum and rales.

12/6/06
Complete Blood Count
Normal Values
WBC ↑17 K/uL
4.10-10.9 K/uL
NEU ↑12.5 73.2%N
2.5-7.5 47-80%N
LYM ↑1.60 ↓9.36%L
1-4 13-40%L
MONO 1.08 6.34% M
1-1.20 2-11%M
EOS. ↑1.78 ↑10.4%E
0-.5 0-5%E

BASO ↑.107 .625% B
0-.1 0-2%B
RBC ↑5.91M/uL
4-5.2M/uL
HGB ↓11.7.0 g/dL
12-16 g/dL
HCT 36.1 %
36-46%
MCV ↓61.1.0 fL
80-100 fL
MCH ↓25.6 pg
26-34 pg
MCHC 32.3 g/dL

31-36 g/dL
RDW 17 %
11.6-18%
PLT 417 K/uL
140-440 K/uL
MPV 7.69 fL
0-100 fL

Purpose:
To determine whether specific
blood levels are higher or lower
than normal and can be useful I the
diagnosis of such diseases such as
anemia, leukemia, and infection

Implication:
An increase in WBC and
neutrophils indicate an infection
secondary to nosocomial
pneumonia and as manifested by
rales and whitish sputum
A decrease in HBG, MCV and
MCHC may indicate red
hepatization secondary nosocomial
pneumonia
An increase in RBC may indicate
dehydration

12/6/06
Creatinine = 1.3 mg/dL
Normal Value (0.5-13 mg/dL)

Purpose:

To determine for renal function

Implication:
Within normal range

12 – 6 – 06
Calcium = 4.32 mg %↓
Normal Value (4.6 – 5.16 mg %)

Purpose:
To aid diagnosis of
neuromuscular, skeletal and
endocrine disorder, arrhythmias,
blood clotting deficiencies, acid-
base imbalance.

Implication:
Decrease in calcium levels
indicates hypocalcemia as
manifested by generalized muscle
spasms, as seen in the patient
having decorticate

Potassium = 4.7 mmol/L
Normal Value (4.0 – 5.6 mmol/L)

Sodium = 131 mmol/ L↓
Normal Value (136 – 142 mmol/L)

Purpose:
To evaluate fluid electrolyte and
acid-base balance and related
neuromuscular, renal and adrenal

functions

Implication:
Abnormally low serum sodium
levels result from diarrhea
Potassium value is within normal

12/11/06 5:58pm

WBC 11.7 k/ul ↓
NEU 7.25 61.7% N
LYM 2.10 17.9% L
MONO .356 3.03%M
EOS 1.92 16.4%E↑
BASO .114 .970%B
RBC 5.39m/uL
HGB 10.5 g/dL↓
HCT 33.5%↓
MCV 62.2 fL↓
MCH 19.4 pg↓
MCHC 31.3 g/dL
RDW 17.3%
PLT 398 k/uL
MPV 7.47 fL

Implication:
An elevated WBC and Eosinophils
usually signal infection as
manifested by blood in urine,
cloudy appearance
A decreased Hgb, HCT, MCV,
MCH indicates red hepatization
secondary to nosocomial

pneumonia

12/26/06
Urinalysis

Color: yellow
Appearance: cloudy
RBC: 5-10/hpf
heat & acetic acid: (+)
pH: 6.5
WBC: 30-40/hpf
Bacteria: moderate
Specific Gravity: 1.020
Protein: 30(++ )
ketone: (-)
Glucose(-)
blood: moderate(++)
Reducing Substances:(-)
amorphous materials: urates: rare

Purpose:
Means of knowing the various
properties of urine, a routine
procedure for every patient to
determine any pathological
disorders.

Implication:
Cloudy urine, proteinuria,
Increased WBC, presence of
epitheilai cells and bacteria
indicates infection secondary

Urinary Tract Infection

Summary of Lab test
11/24 11/25
HGB 12 10.4
HCT 38 31.8
WBC CT 16 18
PH CT 305 268

Summary of Significant findings
LABS:
12/6/06
Complete Blood Count
WBC ↑17 K/uL
4.10-10.9 K/uL
NEU ↑12.5 73.2%N
2.5-7.5 47-80%N
LYM ↑1.60 ↓9.36%L
1-4 13-40%L
EOS. ↑1.78 ↑10.4%E
0-.5 0-5%E
BASO ↑.107 .625% B
0-.1 0-2%B
RBC ↑5.91M/uL
4-5.2M/uL
HGB ↓11.7.0 g/dL
12-16 g/dL
HCT ↑36.1 %
36-46%
MCV ↓61.1.0 fL
80-100 fL
MCH ↓25.6 pg
26-34 pg

11/24/06
Urinalysis
RBC: 0-2/hpf
pH: 6.5
WBC: 0-1/hpf
Protein: trace
Glucose:++
blood: +
Reducing Substances:++
amorphous materials: (-)

12/26/06
Urinalysis
RBC: 5-10/hpf
heat & acetic acid: (+)
WBC: 30-40/hpf
Bacteria: moderate
Protein: 30(++ )
blood: moderate(++)
amorphous materials: urates: rare

11/24/06

ECG

QRS : bizarre complexes seen
in V1, V4 r S R pattern seen in V1,
V2

12 – 6 – 06

Results
Normal Values
Calcium = 4.32 mg %↓
4.6 – 5.16 mg %
Sodium = 131 mmol/ L↓
136 – 142 mmol/L

12/11/06 5:58pm

WBC 11.7 k/ul ↓
EOS 1.92 16.4%E↑
HGB 10.5 g/dL↓
HCT 33.5%↓
MCV 62.2 fL↓
MCH 19.4 pg↓

11/27/06
Gram Staining: Gram (+) cocci in
pairs: few/OIF
Pus cells: moderate

11/28/06
Smear Culture: Gram (-) rods
Culture: Acinetobacter iwoffi
Remarks: Sensitivity test result of
culture: A.iwoffi

KEY ISSUES
December 13, 2006 Desired Outcome:
Independent Interventions: Within 8 hours of nursing
1. Ineffective airway clearance 1. Auscultated chest, noted presence of intervention, the patient:
• will be able to maintain
related to excessive secretions and adventitious breath sounds and presence of
prolonged immobility 2˚ to secretions patent airway and will be

nosocomial pneumonia as R: Provides information regarding inflow through clear from secretions
•
manifested by presence of the airway and the presence or absence of fluid able to breathe
productive cough with whitish mucus obstruction independently without
sputum, with rales heard on both 2. Monitored respiratory rate and noted presence Oxygen therapy,
lung fields upon auscultation, use of dyspnea, Tachypnea, or reports of air hunger • will manifest clear lung
of accessory muscles (subcostal), and use of accessory muscles. sounds
restlessness, O2 at 2L/min, noisy R: Tachypnea might further develop to • no longer use of accessory
breathing and a culture of gram (-) respiratory distress. muscles in breathing,
rods of Acinetobacter iwoffi 3. Observed sputum noting color, odor and • will have a respiratory rate
volume within the range of 14-
Scientific Basis: R: Normal sputum is clear or gray and minimal; 20cpm
Immobilized clients and those on abnormal sputum is green, yellow or bloody, • will no longer manifest
bed rest are generally weakened. If malodorous and often copious restlessness and noisy
weakness progresses, the cough 4. Maintained a moderate high back rest position, breathing
reflex gradually becomes positioned head midline with flexion
inefficient. The stasis of secretions R: Lessen pressure on lungs allowing more room Actual Outcome:
in the lungs may be life for expansion 12/13/06
threatening for an immobilized 5. Elevated head of bed with the use of pillows. After 8 hours of nursing
client since pneumonia can easily R: Stimulates respiratory functioning or lung intervention, the client manifested
develop. (Fundamentals of expansion the ff:
Nursing, Potter and Perry 6th Ed 6. Provided oral care every four hours
• whitish sputum was present
pg. 1451) R: Oral care freshens the mouth after respiratory
• Strong rales were heard at both
secretions have been expectorated
lung fields
• used accessory muscles for
Collaborative Interventions:
breathing
1. Suctioned PRN
• O2 was on at 2LPM
R: Suctioning clears the airway from secretions,
• RR was at 16 cpm
thus promoting better airway passage.
2. Administered O2 inhalation via nasal cannula
12/18/06
at 2L/min.
After 8 hours of nursing
R: Maintain adequate O2 supply, and prevent
intervention, the client manifested
hypoxia.
the ff:
3. Administered Salbuterol(Salbutamol) 1/2 neb +

• Sputum was present
2cc NSS q 8hrs
R: Bronchodilators; relaxes bronchial, uterine and • Strong rales were still heard at
vascular smooth muscles by stimulating the beta2 both lung fields
receptors • Still used accessory muscles
5. Performed Chest Physiotherapy after for breathing
nebulization for 15 minutes • O2 was on at 2LPM
R: To encourage loosening and expectoration of • RR was 20 cpm
mucus from the respiratory tract through the
postural gravity drainage and percussion and 12/19-20/06, 01/03/07
vibrating techniques After 8 hours of nursing
the ff:
• Minimal rales were heard at
both lung fields
• Still used accessory muscles
for breathing

• RR was within normal range

12/28/06
the ff:
• O2 was out of bedside

01/08-10/07
the ff:
• Strong rales were heard at both
lung fields

for breathing
• O2 was out of bedside

2. Ineffective breathing pattern Independent Interventions: Desired Outcome:
related to neuromuscular 1. Monitored respiratory rate, depth and effort. Within 8 hours of nursing
dysfunction and retained R: Dyspnea may be present because of hypoxia interventions,
secretions 2˚ nosocomial 2. Auscultated breath sounds, noting crackles on the patient:
• will show improved
pneumonia as manifested by use both lung fields.
of accessory muscles (subcostal), R: Indicates developing complications, increasing respiratory pattern
shortness of breath, noisy risk of infection. • will lessen use of
breathing pattern and O2 at 2LPM 3. Maintained MHBR position by placing 2 accessory muscles
pillows under head when lying down. • have RR within normal
SB: The onset of all pneumonias is R: Facilitates breathing by reducing pressure on range 14-20cpm
generally marked by any or all of the diaphragm and minimizes risk of aspiration of • Will no longer manifest
the following manifestations: secretions shortness of breath and
fever, chills, sweats, pleuritic chest 4. Encouraged adequate rest and limit activities noisy breathing pattern
pain, cough, sputum production, within client tolerance.
hemoptysis, increased in R: Helps limit oxygen needs/consumption. Actual Outcome:
respiration, dyspnea, headache, 12/13/06, 12/18-20/06
and fatigue. (Medical-Surgical Collaborative Interventions: After 8 hours of nursing
Nursing 6th Edition page 1713 by 1. Suctioned PRN intervention, the client manifested
Joyce M. Black) R: Suctioning clears the airway from secretions, the ff:
thus promoting better airway passage. • Still used accessory muscles
2. Administered O2 inhalation via nasal cannula for breathing
at 2L/min.
• O2 was on at 2LPM
R: Maintain adequate O2 supply, and prevent
hypoxia.
• Noisy breathing and shortness
3. Administered Salbuterol(Salbutamol) 1/2 neb +
of breath
2cc NSS q 8hrs
R: Bronchodilators; relaxes bronchial, uterine and

vascular smooth muscles by stimulating the beta2 01/03/07, 01/08-10/07
receptors After 8 hours of nursing
4. Performed Chest Physiotherapy after intervention, the client manifested
nebulization for 15 minutes the ff:
R: To encourage loosening and expectoration of
mucus from the respiratory tract through the for breathing
postural gravity drainage and percussion and • O2 was out of bedside
vibrating techniques • RR was within normal range
• Noisy breathing and shortness
of breath was no longer
present

3. Risk for Aspiration Independent Interventions: Desired Outcome:
Cues: 1. Noted client’s level of consciousness Within 8 hours of nursing
• Presence of NGT R: To assess causative/contributing factors intervention, the patient:
• will be able to experience
2. Assessed RR
• Impaired swallowing
R: To assist in correcting factors that can lead to no aspiration as evidenced
• Reduced level of
aspiration by noiseless respiration,
consciousness with the GCS
3. Check gag reflex clear breath sounds
of 6 (E-4, M-1, V-1)
R: To assist in correcting factors that can lead to • maintain patent airway
aspiration The SO:
Scientific Basis:
4. Assessed the Glasgow coma scale of the • will follow correct
A serious complication associated
patient.
with enteral feeding is aspiration instructions regarding NGT
R: To assist in correcting factors that can lead to
of formula into the feeding
aspiration
tracheobronchial tree. Aspiration
5. Auscultated for gurgling sounds in the stomach
of enteral formula into the lungs Actual Outcome:
prior to NGT feeding
irritates the bronchial mucosa, 12/13, 12/18-20, 01/03, 01/08-10
R: To ensure patency of NGT
resulting in decreased blood After 8 hours of nursing
6. Suction client before NGT feeding
supply to affected pulmonary intervention, the client manifested
R: To prevent aspiration of ingested food
tissues. (Fundamentals of Nursing, the ff:
7. Positioned client in a high Fowler’s position • Was positioned at high
Potter and Perry 6th Ed pg. 1304)
before feeding Fowler’s prior to every NGT
R: To prevent aspiration if ingested food feeding and patency of the

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