Foundation University COLLEGE OF NURSING Dumaguete City

CASE STUDY ON CNS INFECTION WITH SEIZURE ARI WITH SEVERE DISEASE

In partial fulfilment of the requirements In Nursing Care Management (NCM) 101

Submitted to:
Mrs. Ivy Monteclaro - Cornelia, R.N.

Clinical Instructor Submitted by:

Catacutan, Rudyard Go, Teyfel Joline A. Palubon, Bjon Troy O.

BSN III B5 Date Submitted:

October 04, 2008

TABLE OF CONTENTS
I. II. III. IV. V. VI. Introduction Central Objectives Specific Objectives Demographic Profile/ Biographical Information Erik Eriksons Theory on Psychosocial Development Nursing History a. Chief Complaints b. Admitting Impression/ Diagnosis c. HPI d. Past Health History e. Family History with Genogram f. Psychosocial History g. Environmental History h. Spiritual History VII. Physical Assessment Findings VIII. Anatomy and Physiology of Systems/ involved in the disease condition IX. Review of Related Literature X. Pathophysiology XI. Medical Interventions a. treatment b. laboratory exams and Correlation c. Drug Study XII. Nursing Theory applicable to care of patient XIII. Gordons Functional Health Pattern XIV. List of Nursing Care Plan XV. Annotated Readings XVI. Conclusion XVII. Bibliography

INTRODUCTION
The central nervous system, or CNS, comprises the brain, the spinal cord, and associated membranes. Under some circumstances, bacteria may enter areas of the CNS. If this occurs, abscesses or empyemas may be established. The CNS is well defended against infection. The spine and brain are sheathed in tough, protective membranes. The outermost membrane, the dura mater, and the next layer, the arachnoid, entirely encase the brain and spinal cord. However, these defenses are not absolute. In rare cases, bacteria gain access to areas within the CNS. Bacterial infection of the CNS can result in abscesses and empyemas (accumulations of pus). Abscesses have fixed boundaries, but empyemas lack definable shape and size. CNS infections are classified according to the location where they occur. For example, a spinal epidural abscess is located above the dura mater, and a cranial subdural empyema occurs between the dura mater and the arachnoid. As pus and other material from an infection accumulate, pressure is exerted on the brain or spinal cord. This pressure can damage the nervous system tissue, possibly permanently. Without treatment, a CNS infection is fatal. A seizure complication of infection can consist of a single seizure or can go on to become a chronic epilepsy. Seizures can arise as an acute, subacute, or long- term consequence of an infectious state. The type of epileptic complication and when it arises from an infection depend on the nature of the infectious illness, its duration, and the type and extent of damage to the CNS. Quantitative data on seizure risk from infection would be extremely useful but there are few detailed studies. One reason is that retrospective analysis of seizure risk factors is complicated by the interdependence of the many multisystemic and iatrogenic events typically impacting patients during the course of their illness. A retrospective study of survivors of encephalitis or meningitis between 1935 and 1981 was conducted to assess the risk of unprovoked seizures after CNS infection. The 20-year risk of developing unprovoked seizures was 6.8%, and the ratio of observed to expected cases of unprovoked seizures was 6.9%. The increased incidence of unprovoked seizures was highest during the first 5 years after CNS infection but remained elevated over the next 15 years of follow-up.

OBJECTIVES OF THE STUDY

I. Central Objective:

At the end of two hours case presentation, the learners shall acquire deeper knowledge, develop beginning skills and manifested desirable attitudes / values towards the management of client with CNS Infection with Seizure and ARI with Severe Disease.

II.

Specific Objectives:

Given the time and resources, the learners shall: Obtain information regarding the demographic profile and the history of the client completely. Review the anatomy and physiology of the organs involved and affected in CNS Infection with Seizure. Name the medical intervention or treatment given for the disease involved accurately. Formulate an effective Nursing Care Plan relative and applicable to the client based on the conditions the client is subjective to. Evaluate the data in Gordons Functional Health Pattern intensively. Develop priorities for the initial management of client with CNS Infection with Seizure. Demonstrate reassessment after each therapeutic intervention. Able to trace the pathophysiology of CNS Infection with Seizure. Objectively evaluate the case study presentation through a socialized discussion. Demonstrate an understanding of the pharmacologic action, dose, indication, and toxicity of the following drugs: Paracetamol, Diazepam, Ceftriaxone, Dexamethasone, and Cimetidine. Assist clients condition prior to beginning any treatment.

DEMOGRAPHIC PROFILE

Date of assessment:

September 11, 2008 Room and Bed Number: ICU AND Bed # 07 Attending Physician: Dr. Bollos

Name: Juniel Medina Lijarso Age: 3 months old Sex: Male Religion: Roman Catholic Birth date: May 31, 2008 Address: Bio os, Amlan, Oriental Negros Parents Father: Jose Lijarso Mother: Mary Ann M. Lijarso

Occupation: Farmer Occupation: House wife

Date and Time of Admission: Admitted on September 09, 2008 at 7:43 pm at pediatric ward Chief Complaints:

Non productive cough, high grade fever, on and off with convulsive episodes was noted four days PTA.

History of Present Illness: Patients condition started four days PTA. Patient had four days on and off fever, three days cough, 2 days PTA had sought and consult and was given paracetamol, klancid, and ambroxol. Several hours PTA had rolling of eyeballs and stiffness of extremities for a few minutes, then this was followed by another at 5:00pm at the time of admission. Admitting Impression:

R/O, CNS Infection ARI with several diseases

General Impression:

Received sleeping on bed with D5 0.3% NaCl at right metacarpal vein, no inflammation, redness and swelling noted at IV site, with continuous O2 administration at 1 2 L/min. NPO with breastfed with strict aspiration precaution.

NURSING HISTORY
A. Chief Complaints:

 Non productive cough, high grade fever, on and off with convulsive episodes was noted four days PTA. B. Admitting Impression/Diagnosis: R/O, CNS Infection ARI with severe disease

C. History of Present Illness:

Patients condition started four days PTA. Patient had four days on and off fever, three days cough, 2 days PTA had sought

and consult and was given paracetamol, klaricid, and ambroxol. Several hours PTA had rolling of eyeballs and stiffness of extremities for a few minutes, and then this was followed by another at 5:00pm at the time of admission. D. Past Health History:
Mother delivered the baby by NSVD. General health in the past has been good despite minor illnesses such as coughs and colds. Breast

fed since birth up to present. And has no allergies. Had not yet given any immunizations. It is his first time to be admitted in the hospital and also he is the first child of his parents. E. Psychosocial History:
He is taking cared by his parents. At the age of 3 months, he doesnt want other people to carry him, except his mother.

F. Environmental History:

 He lives with his mother and father @ Bio-os, Amlan, Negros Oriental, where they live in a small house made of bamboo. Their place is peaceful and they can breathe fresh air.

G. Spiritual History:
The family is pure Roman Catholic and they go to church every Sunday. They also go to church on Wednesday and pray the Rosary with the neighbourhood every Friday.

H. Family History with Genogram:

Berto Lijarso (Grandfather)

*Father Side *
Emetria Lijarso (Grandmother) Housewife Lodrigo Medina (Grandfather) Farmer

* Mother Side*
Norma Buenaflor Medina (Grandmother) Housewife

Gorio Lijarso Eldest Son

Rosie Lijarso Eldest Sister

Mario Lijarso Third Child

Jose Lijarso 30 y.o Father Farmer

Christophe r

Miko Medina 35 y.o Eldest Son

Mary Ann M. Lijarso 29 y.o Mother Housewife

Junito Medin a 22 y.o Third Child

Jovanni Medina 20 y.o Younges t Son

Lijarso Younges t Son

Juniel M. Lijarso

Conclusion:

3 months

The father side family of our client had two genetic diseases these are cancer and anemia. His grandfather died due to cancer and his grandmother is anemic. They are five in the family and only Ms. Rosie Lijarso got the hereditary disease which is anemia, for the boys they dont know if they got any of it. The mother side family of our client had hypertension. Both of his grandfather and grandmother have hypertension. They are four in the family and she is the only girl in the family. His elder brother has hypertension while the rest they dont know if they got that disease.

LEGEND: - decease - died because of cancer - Anemic - Hypertension - Client - With CNS infection

Cues / Evidences Subjective Cue: Gi hilantan akong anak upat na ka adlaw mu balik daun mawala iyang hilanat ug taas pud as verbalized by the mother.

Nursing Diagnosis Hyperthermia related to excessive fluid loss as evidenced by increase in body temperature higher than normal range.

Objectives Within our care the client will show maintain core temperature within normal range as evidenced by: + Demonstrate behaviours to monitor

Interventions Independent:
+ Monitor client temperature note shaking, chills/profuse diaphoresis. + Monitor environmental temperature, limit or add bed linens.

Rationale
+ To be able to administer medication in case of fever. + Room temperature or number of blankets should be altered to maintain near normal body temperature.

Evaluation The objective of care as partially met as evidenced by: + Vital signs stabilized. + Freed from seizure acitivity.

Objective Cues: Vital Signs: T = 38.2 C P = 142 bpm, weak and irregular R = 38 cpm, unlabored Seizure and convulsion present Skin warm to touch \ Adventitious breath sound present : rales O2 therapy 1 2 L/ Min. (nasal cannula)

and promote normothermia. + Be free of seizure activity. + Monitor heart rate and rhythm. + Auscultate breath sounds noting adventitious sounds such as rales. + Monitor input and output. + Administer medications as ordered. + Provide Supplemental oxygen. + Review signs and symptoms of hyperthermia. + Maintain Bed rest.

+ Provide tepid sponge bath, avoid using alcohol. + Maintain bed rest.

+ May help reduce fever. + To reduce metabolic demands or oxygen consumption.

+ Absence of adventitious sounds : rales + Monitored input and output. + Administered medications as ordered. +Reviewed signs and symptoms of hyperthermia. + Maintained bed rest.

Collaborative:
+ Administer Paracetamol 125 mg supp. stick Q 4 PRN for T = 38 and up C + Decreases fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilation. Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not have anti inflammatory action because of its minimal effect on peripheral prostaglandin synthesis.

+ Administer Diazepam 1.2 mg IVTT Q 4 PRN for seizure

+ Facilitates/potentiates the inhibitory activity of GABA at the limbic system and reticular formation to reduce anxiety, promote calmness and sleep. This inhibition also suppresses the spread of seizure activity produce by epileptogenic foci in the cortex, thalamus and limbic system. Enhancement of

GABA mediated presympathetic inhibition at the spinal level and brain stem reticular formation results to skeletal muscle relaxation. + Administer Ceftriaxone 300 mg IVTT Q 12 + Inhibits bacterial cell wall synthesis, rendering cell wall osmotically unstable, leading to cell death. + Synthetic glucocorticoid with marked anti inflammatory effect because of its ability to inhibit prostaglandin synthesis, inhibit migration of macrophages, leukocytes and fibroblasts at sites of inflammation, phagocytosis and lysosomal enzyme release. It can also cause the reversal of increased capillary permeability. + Competitively inhibits histamine at H2 - receptor site of gastric parietal cells , resulting to decreased gastric acid secretion by about 50 80 %. + Used to reduce fever. + Provide cooling blanket + IVF: D5 0.3% NaCl at 20 mgtts/min. To run for 24H + To support circulating volume and tissue perfusion.

+ Administer Dexamethasone 0.5 mg IVTT Q 6

+ Administer Cimetidine 30 mg IVTT Q 6

Medical Interventions
A.Treatments: Treatments
September 09, 2008 (7:45 pm) Please admit to Pedia ICU TPR + In order to monitor his vital signs.

Rationale

NPO CBC, U/A, Stool Exam start venoclysis 8:05 pm D50.3 NaCl 500 mL to run at 30 mgtts/min. Ceftriaxone 600 mg IVTT now then 300 mg every 12 hours IVTT Dexamethasone 0.5 mg IVTT every 6 hours Cimetidine 30 mg IVTT every 6 hours Diazepam 1.2 mg IVTT every 4 hours prn, for seizure O2 inhalation 1 2 L/min. Suction Secretions prn Padded tongue Depressor for access For close watch

+ Indicates more thorough assessment and replace fluid loss and electrolytes imbalance. + Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal. + Decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses immune response; stimulates bone marrow; and influences protein, fat, and carbohydrate metabolism. + Competitively inhibits action of histamine on the H2 receptor sites of parietal cells, decreasing gastric acid secretion. + A benzodiazepine that probably potentiates the effects of GABA, depresses the CNS, and suppresses the spread of seizure activity.

(10:00 pm) - Blood typing stat - Request FWB of patients type 250 mL and transfuse 75 cc as packed RBC September 10, 2008 (12:20am) - Paracetamol 125 mg supp stick for rectum then every 4 hours PRN for T=38 and above (8:00 am) - May breastfeed with strict aspiration precaution - D5 0.3% NaCl 500 mL at SR (6:20 pm) - IVF to ff D5 0.3% NaCl at SR

+ indicates more thorough assessment

+ Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. May relieve fever through central action in the hypothalamic heat-regulating center. + To support circulating volume and tissue perfusion. + To support circulating volume and tissue perfusion.

 September 11, 2008 - Follow up blood and transfuse when available - D5 0.3 % NaCl 500 mL for 24 hours September 12, 2008 - D5 IMB 500 mL at SR - Repeat CBC in ARI September 13, 2008 D5 IMB 500 mL at SR Consume Cimetidine Transfer to respi.

+ To support circulating volume and tissue perfusion. + To support circulating volume and tissue perfusion.

+ To support circulating volume and tissue perfusion.

September 14, 2008 - D/C Dexamethasone - D5 IMB 500 mL at SR September 15, 2008 - D5 IMB at SR September 16, 2008 Consume IVTT meds and IVF MGH Immunize drops 0.3 mL OD

+ To support circulating volume and tissue perfusion. + To support circulating volume and tissue perfusion.

B.Laboratory Exams and correlation: Laboratory Exams

+ Urinalysis: Color Transparency Specific Gravity Glucose Protein pH Yellow Hazy 1.015 Negative Trace 6.0 Straw to dark yellow Clear 1.005 1.035 Negative Negative 4.5 - 8 Within normal range Within normal range Within normal range Glucosuria Protinuria Within normal range

Result

Normal Values

Correlation

U1 + Microscopic Examination:

Pus cells RBC Epith. Cells Amorph. Urates Bacteria

0 -2/hpf None None Moderate Few

0-2/hpf 0 5/hpf Few negative Negative

Within normal range Within normal range Within normal range Within normal range Within normal range

+ Fecalysis: - Color - Consistency F1 + Microscopic Examination: Ascaris Ring worm Hook worm Trienuns Troph Cyst Yellow Soft No ova None Parasites Seen None Seen Within normal range Within normal range

+ Cross Matching: No. of Units Blood Type Serial No. Blood Component Extraction Expiration 1 O+ 755441 PRBC 8.22 9.26

+ Complete Blood Count: Hemoglobin Hematocrit 11.5 33.5 13 18 g/dL 40 - 50 L% Malignancy of organs; chronic renal failure

Platelet Count WBC

280,00 26,900

150-400T/cumm 4 11 k/uL

Within normal range Acute infection; tissue necrosis; parasitic disease Within normal range Within normal range Within normal range Within normal range Within normal range

+ Differential Count: - Neutrophil - Lymphocyte - Monocyte - Eosinophil - Basophil

51 37 7 4 1

40 75 20 45 0 20 06 0-1

C.

Drug Study:

1. Diazepam 1.2 mg IVTT every 4 hours PRN for Seizure

Generic Name: Brand Name: Classification:

Diazepam Diazepam Intensol Anticonvulasants A benzodiazepine that probably potentiates the effects of GABA, depresses the CNS, and suppresses the spread of seizure activity.

Mechanism of Action:

Adverse Reactions:

CNS: drowsiness, dysarthria, slurred speech, tremor, headache, transient amnesia, fatigue, ataxia, insomnia, paradoxical, anxiety, hallucinations, minor changes in EEG patterns. CV: CV collapse, bradycardia, hypotension EENT: diplopia, blured vision, nystagmus GI: nausea, constipation, diarrhea with rectal form. GU: incontinence, urine retention. Hematologic: neutropenia Respiratory: respiratory depression, apne SKIN: rash

Nursing Consideration:

2. Ceftriaxone 600 mg IVTT now then 300 mg every 12 hours IVTT

Generic name: Brand Name: Classification:

Use Diastat rectal gel to treat no more than five episodes per month and no more than one episode every 5 days because tolerance may develop. When using oral solution, dilute dose just before giving. Monitor periodic hepatic, renal, and hematopoietic function studies in patients receiving repeated or prolonged therapy.

Ceftriaxone Sodium Rocephin Anti infectives Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.

Mechanism of Action:

Adverse Reaction:

CNS: fever, headache, dizziness CV: phlebitis

GI: diarrhea GU: genital pruritis, candidiasis HEMATOLOGIC: leukopenia SKIN: pain, induration, tenderness at injection site, rash, pruritis

Nursing Considerations:

Before giving drugs, ask patient if he is allergic to penicillins Obtain specimen for culture and sensitivity tests before giving first dose.

3. Dexamethasone 0.5 mg IVTT every 6 hours

Generic Name: Brand Name: Classification:

Dexamethasone Cortastat Corticosteroids

Mechanism of Action:

Decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses immune response; stimulates bone marrow; and influences protein, fat, and carbohydrate metabolism.

Adverse Effects:

CNS: Insomnia, psychotic behaviour, vertigo, headache, seizures, depression CV: heart failure, hypertension, edema, thrombophlebitis

EENT: cataracts, glaucoma GI: peptic ulceration, GI irritation, increase appetite, nausea, vomiting GU: menstrual irregularities, increased urine glucose and calcium levels

Nursing Diagnosis: Determine whether patient is sensitive to other corticosteroids. Most adverse reactions to corticosteroids are dose or duration dependent. Give oral dose with food when possible. Always adjust to lowest effective dose.

4. Cimetidine 30 mg IVTT every 6 hours

Generic Name: Barnd Name: Classification:

Cimetidine Tagamet Anti ulcer

Mechanism of Action: Competitively inhibits action of histamine on the H2 receptor sites of parietal cells, decreasing gastric acid secretion

Adverse Reactions:

CNS: confusion. Dizziness, hallucinations, headache GI: mild and transient diarrhea GU: impotence

MUSCULOSKELETAL: arthralgia, muscle pain

Nursing Considerations: Assess patient for abdominal pain. Schedule dose at the end of hemodialysis treatment IM injection may be given undiluted.

5. Paracetamol 125 mg stick every 4 hours PRN for T= 38 and above

Generic Name: Brand Name: Classification:

Parctamol Tempra antipyretics

Mechanism of action:

Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. May relieve fever through central action in the hypothalamic heat-regulating center.

Adverse Reaction:

Hematologic: haemolytic anemia, leukopenia, neutropenia, pancytopenia

Hepatic: jaundice Metabolic: hypoglycemia Skin: rash, trauma

Nursing Considerations: Many OTC and prescription products contain acetaminophen; be aware of this when calculating total daily dose. Use liquid form for children who have difficulty swallowing. In children, dont exceed five doses in 24 hours.

Erik Eriksons Theory on

Psychosocial Development

Functional Health Pattern And

Nursing Care Plan

Review of Related Literature

ANATOMY AND PHYSIOLOGY OF THE

INVOLVED SYSTEMS

PHYSICAL ASSESSMENT FINDINGS

Nursing Theory applicable to care of patient

ANNOTATED READINGS

CONCLUSIONS

BIBLIOGRAPHY

 WWW.WIKIPEDIA.ORG

Smeltzer, Suzanne C. Et. Al. Medical surgical Nursing . Volume 2. 11th edition.

http://cks.library.nhs.uk/search?&page=1&9=CNS.Infection%20&site=2

Margolis, S. Et. Al. (2003). John Hopkins Symptoms Remedies.

Black, Joyce M. Et. Al. (2005). Medical-surgical nursing (clinical management for positive outcome). Volume 1.7th edition.

Mosbys pocket dictionary of medicine, nursing and health profession. 5t edition.(2006)

Freshwater, Dawn. Et. Al. (2005). Blackswells Nursing dictionary.

 Malan Press. PPDs Nursing Drug Guide.2007 edition.

Lippincott, Williams & Wilkins. Et. al. (2008). Nursing drug handbook. 28th edition. www.mimsonline.com

Physical Assessment I. Comprehensive Health History:

A. Patients History: Name: Juniel Medina Lijarso Room and Bed Number: ICU AND Bed # 07

Age: 3 months old Sex: Male Religion: Roman Catholic Attending Physician: Dr. Bollos

Birth date: May 31, 2008 Address: Bio os, Amlan, Oriental Negros Parents Father: Jose Lijarso Mother: Mary Ann M. Lijarso Occupation: Farmer Occupation: House wife

Date and Time of Admission: Admitted on September 09, 2008 at 7:43 pm at pediatric ward B. Chief Complaints: Non productive cough, high grade fever, on and off with convulsive episodes was noted four days PTA.

C. History of Present Illness: Admitted on September 09, 2008 at 7:43 pm at pediatric ward with the chief complaints of Non productive cough, high grade fever, on and off with convulsive episodes was noted four days PTA. Medications: + Paracetamol 125 mg supp. stick Q 4 PRN for T = 38 C and up + Diazepam 1.2 mg IVTT q 4 PRN for seizure + Ceftriaxone 300 mg IVTT Q 12 + Dexamethasone 0.5 IVTT Q 6 + Cimetidine 30 mg IVTT Q 6

D. Past Health History:

Mother delivered the baby by NSVD. General health in the past has been good despite minor illnesses such as coughs and colds. Breast fed since birth up to present. And has no allergies. Had not yet given any immunizations. It is his first time to be admitted in the hospital and also he is the first child of his parents.

E. Family History: Father Side: + The father side family of our client had two genetic diseases these are cancer and anemia. His grandfather died due to cancer and his grandmother is anemic. They are five in the family and only Ms. Rosie Lijarso got the hereditary disease which is anemia, for the boys they dont know if they got any of it. Mother Side: + The mother side family of our client had hypertension. Both of his grandfather and grandmother have hypertension. They are four in the family and she is the only girl in the family. His elder brother has hypertension while the rest they dont know if they got that disease.

II. General Survey:

Received sleeping on bed with D5 0.3% NaCl at right metacarpal vein, no inflammation, redness and swelling noted at IV site,

with continuous O2 administration at 1 2 L/min. NPO with breastfed with strict aspiration precaution. With the final vital signs T = 38..2 C, P = 142 bpm, weak and irregular, and R = 38 cpm, unlabored.