I.

Introduction Children are the living messages we send to a time we will not see. ~John W. Whitehead, the Stealing of America, 1983 Many would say that the Children are future. If we would think about it

logically, children will become adults someday. Children will become future professionals and they will replace adult someday, so children really are the future of the world. Pediatric Nursing is defined as the branch of nursing concerned with the care of infants and children. Truly, nursing pediatrics is important. Having nursing pediatrics as a branch of nursing gives opportunity to caregivers to focus on children because of the care of children is different than the care of adults. One of the common childhood diseases is bacteremia. Bacteremia is defined as the presence of bacteria in the blood stream. Bacteremia may occur as a result of children playing anywhere, eating and putting things in their mouth enetering through the differennc portals of entry like breaks in the skin and through the mouth. Symptoms include fever which is the main symptom, can include rapid heart rate, rapid breathing, diarrhea, nausea, vomiting, and abdominal pain. Bacteremia can be treated mainly through antibiotics. According to the Philippine Mortality Fact Sheet 2006 of the World Health Organization, in 1000 live births of neonates 17% of it died due to severe infection that includes deaths from pneumonia, meningitis, sepsis/septicemia, and other infections during the neonatal period. (www.merck.com) Also, according to world health statistics done in the year 2004 Neonatal Infection rank as no 11 as a leading cause of death it was further compared to the mortality statistics of the year 2030. In the year 2030 it was projected that in the year 2030 Neonatal Infection will be lower down to rank 21 as a leading cause of death. Updated mortality projections are based on historically observed

relationships between trends in economic and social development and causespecific mortality. A. Current Trends Significant Reduction In Antibiotic Resistant Pneumococcal Disease Since The Introduction Of PREVNAR According to Medicalnewstoday.com, retrieved on 09 Apr 2006 - 22:00 PDT. Antibiotic resistance is a worldwide public health issue. Physicians around the world face an increasing clinical challenge as many life-threatening bacterial infections, once responsive to therapy, are building resistance to the most commonly prescribed antibiotic treatments. However, preventing the occurrence of disease through vaccination may help alleviate the challenges of antibiotic resistance. A study published in today's New England Journal of Medicine (NEJM) "Effect of Introduction of the Pneumococcal Conjugate Vaccine on DrugResistant Streptococcus pneumoniae" has found that, since the introduction of PREVNAR, Pneumococcal 7-valent Conjugate Vaccine (Diphtheria CRM197 Protein), in the United States, the rate of antibiotic-resistant invasive pneumococcal disease (IPD) has substantially decreased in infants and young children. In addition, the rate of antibiotic-resistant IPD decreased in adults over 65 years of age, an unvaccinated group, suggesting an indirect effect in the nonvaccinated population. The study analyzed population-based data from the Active Bacterial Core Surveillance, part of the Emerging Infections Program of the Centers for Disease Control and Prevention (CDC), and found that since the introduction of PREVNAR, IPD caused by penicillin-resistant strains targeted by the vaccine has been reduced by:

* 87 percent among the full study population (persons of any age); * 98 percent among children younger than two years of age; * 79 percent among adults aged 65 years or older. The study documented significant overall reductions in antibiotic-resistant IPD, irrespective of pneumococcal serotype, although the rate of penicillin nonsusceptible disease due to non-vaccine serotypes increased from 0.2 per 100,000 in 1999 to 0.5 per 100,000 in 2004. Wyeth Pharmaceuticals is developing a 13-valent pneumococcal conjugate vaccine which targets additional pneumococcal serotypes. This new vaccine is currently undergoing clinical development. The New England Journal of Medicine findings continue to document the impact of routine immunization with PREVNAR on public health. In addition, the development of the 13-valent pneumococcal conjugate vaccine further demonstrates Wyeth's continued dedication to helping protect infants and toddlers against invasive pneumococcal infection and its potentially devastating consequences. IPD describes a group of illnesses, some of which may be life threatening, caused by the bacterium Streptococcus pneumoniae. S. pneumoniae has been associated with the highest level of morbidity and mortality due to bacterial meningitis in children. IPD includes serious diseases such as bacteremia/sepsis, meningitis, and bacteremic pneumonia. PREVNAR is the first and only vaccine indicated for active immunization of infants and toddlers against invasive disease caused by S. pneumoniae due to capsular serotypes included in the vaccine (4, 6B, 9V, 14, 18C, 19F, and 23F). These seven serotypes accounted for approximately 80 percent of IPD in children under age six in the United States prior to the licensure of PREVNAR.

PREVNAR is recommended by the CDC and the American Academy of Pediatrics for infants two months of age and older, and children younger than two years of age. The routine schedule is 2, 4, 6, and 12 to 15 months of age Since the introduction of PREVNAR in the United States, IPD incidence has decreased dramatically. Three years after the introduction of routine PREVNAR use in the United States, surveillance sites of the CDC noted a 94 percent reduction in IPD in children younger than five years of age caused by pneumococcal serotypes targeted by the vaccine, as well as a reduction in the incidence of vaccine serotype IPD in adult populations. However, reduction in IPD rates due to non-vaccine serotypes should not be expected, and PREVNAR is not indicated for use in adults. Important Safety Information In clinical trials (n=18,168), the most frequently reported adverse events included injection site reactions, fever (>38C/100.4F), irritability, drowsiness, restless sleep, decreased appetite, vomiting, diarrhea and rash. Risks are associated with all vaccines, including PREVNAR.

Hypersensitivity to any vaccine component, including diphtheria toxoid, is a contraindication to its use. PREVNAR does not provide 100% protection against vaccine serotypes or protect against nonvaccine serotypes. Reasons for choosing such case presentation Due to the peculiarity of the disease condition and the need to increase awareness regarding the condition, the group was prompted to pick Bacteremia as the topic of this case study in attempt to gain vital information regarding the syndrome and how the different managements work in correcting the condition. More so, Bacteremia is highly preventable with proper diet and proper management of other conditions that can result the occurrence of the syndrome.

With this, the group believes that proper information dissemination will help in reducing the occurrence of Bacteremia especially to those who are considered to be members of high-risk groups. It interests the researchers because Usually, bacteremia, particularly if it occurs during ordinary activities, does not cause infections because bacteria typically are present only in small numbers and are rapidly removed from the bloodstream by the immune system. However, if bacteria are present long enough and in large enough numbers, particularly in people who have a weakened immune system, bacteremia can lead to other infections and sometimes trigger a serious bodywide response called sepsis. Although we can readily get information from books, articles, and the internet; it is still not enough to compare to having a hands on experience to taking care of a patient with all the knowledge that we have acquired, wed be able to know the appropriate treatment for this disease. Wed also be able to give the most appropriate nursing interventions and management we can give to our clients. So that we can help them progress to a better and healthier self.

II. NURSING ASSESSMENT A. Personal History Teri is a 10 year old female clientele, Filipino, and a member of the Roman Catholic Community. She is the youngest among the five children of Mr. and Mrs. Bacteria and was born on March 3, 1999 via normal spontaneous delivery at a secondary hospital in Pampanga. Together with her family, they are currently residing in Anunas, Angeles City. With a chief complain of fever and cough for two weeks, she was admitted in a secondary hospital in Angeles City on April 24, 2009 at 03:00 PM. Her admitting diagnosis was Bacteremia to consider Primary complex. After 6 days of confinement, with all the necessary treatment, diagnostic procedures and medications given, she was discharged on April 30, 2009 at around 10:00 in the morning.

B. Pertinent Family History FATHERS SIDE Grand Nanay Grand Tatay HPN MOTHERS SIDE Grand Mama Grand Papa HPN

CHA 65

GIBS 61
ARTH -RITIS

CRIS 57

CES 54

HAZE L 50

SAM DM 59

NHAS

HPN 53

MRS. BACT ERIA HPN 51

CATH 63

MELA

MOND

HPN

59

56

MR. BACT ERIA 53

EVA

23

FRAN 22

CARLA 19

MARIA 18

TERI 10

Their family, which is composed of only the parents and the children in their own house, is a nuclear type of family. Mr. and Ms. Bacteria have been living together for 26 years. They were blessed with 5 children. The eldest was born on January 17, 1986 and is a teacher in a public school in Angeles City. Their second child was born on February 14, 1987 stopped schooling in order to help his family. The third borns birthday was August 26, 1989 was is currently enrolled in a university in Angeles City with a course of Nursing. All four of their children was born via normal spontaneous delivery in a health center somewhere in the city while Teri was born on March 3, 1999 via normal delivery in a secondary hospital in Angeles City. Mrs. Bacteria states that she experienced excitement and happiness in her pregnancies. On her first and last pregnancy on Eva and Teri respectively, she had experienced difficulty because she encountered infection and hypertension. The family lives in a one-storey concrete house having a bathroom, a living room and a kitchen. Eva told the researchers that their house is painted but there is no ceiling yet. The house has three rooms. The three girls have the first room, the second room is for Fran, and the second child of Mr. And Mrs. Bacteria and lastly, the masters bedroom is for the couple. Eva also stated that in each room there is a corresponding window. Mrs. Bacteria states that basic utilities and furniture can be seen inside the house. Their main source of water supply is through the water district of their town. She also mentioned about their source of drinking water which is from water refilling station. They mainly use fluorescent bulbs as their source of lighting. Moreover, their source of electricity is from the citys electric corporation. When asked, she told the researchers that the house is not crowded. With regards to their socio economic and cultural factors, Mrs. Bacteria is a plain housewife. She only stays at home with her family. Her husband, Mr. Bacteria, and her son, Fran, who are tricycle drivers, and her daughter, Eva, a teacher were the ones working to meet their basic necessities. The family has 7

members. Both Mr. Bacteria and Fran earn an average of P200.00/day and her daughter earns P12, 000.00/month. The familys average total monthly income is twenty four thousand pesos (P24, 000.00) which is based from National Economic Development Authority (NEDA), the family is classified as not poor since each member has P3428.57 a month for their needs. The family believes in herbalaryo which they consult for minor fractures and the usage of herbal medicines such as guava leaves for diarrhea, to heal wounds and to prevent infections and oregano for cough. Their family also goes to church every Sunday and during special occasions such as a members birthday, Christmas day etc and every Friday; Mrs. Bacteria goes to a church after buying her needs which is somewhere in Angeles where it is surrounded by a market. In addition to the superstitious beliefs she accept as true is she do not sweep the floor during night time or after 6:00 PM because it brings no luck, she also prepares a lot of fruits and kalamay during Christmas and New Year as a sign of good luck for the upcoming year. C. Personal History Mrs. Bacteria has a GPTPAL of G5P5 5005. During Mrs. Bacterias pregnancy with baby Teri, she regularly goes for a monthly check-up. Teri was in full term when born in a secondary hospital in Angeles city weighing 7 kg. Mrs. Bacteria states that she experienced excitement and happiness in her pregnancies. On her first and last pregnancy on Eva and Teri respectively, she had experienced difficulty because she encountered infection and hypertension. She has a believe that she should not wear necklaces or towels around her neck because her babys umbilical cord might be put around her babys neck, she should not also go to funerals because her baby might die and use a cap or anything that would cover her head when going out at night because she considers usog as true. In all of her pregnancies, on her first pregnancy, she had difficulty in her labor to Eva and it took at least 40 minutes at a tertiary

hospital in City of San Fernando. According to her doctor, she is prohibited to eat salty foods to prevent further infection and eats fish and vegetables only. She then avoids meat. According to her, she had taken Ferrous sulfate but she is not sure if it is during her pregnancy or post partum. As an exercise, she walks especially during her ninth month. Teri was in full term when born in a secondary hospital in Angeles city weighing 7 kg. She does bottle feeding because Teri is lactose intolerant. At Teris sixth month, she eats potatoes, egg white, baby foods like Gerber and squash. At her ninth month, she already is eats meat. Growth and Development Erik Erickson (Psychosocial Theory) Psychosocial development as articulated by Erik Erikson explains eight stages through which a healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future. Teri has already stepped into the 4 stages of development according to Erik Ericksons Psychosocial theory Trust vs. Mistrust, Autonomy vs. Shame and Doubt, Initiative vs. Guilt, and Industry vs. Inferiority. She is currently on the Industry vs. Inferiority.

Trust vs. Mistrust

Developing trust is the first task of the ego, and it is never complete. The child will let its mother out of sight without anxiety and rage because she has become an inner certainty as well as an outer predictability. But when a mother is not present, the father becomes the inner certainty along with other relatives usually surrounding the child daily. The balance of trust with mistrust depends largely on the quality of the maternal relationship.

Autonomy vs. Shame & Doubt

If denied independence, the child will turn against his/her urges to manipulate and discriminate. Shame develops with the child's self-consciousness. Doubt has to do with having a front and back -- a "behind" subject to its own rules. Left over doubt may become paranoia. The sense of autonomy fostered in the child and modified as life progresses serves the preservation in economic and political life of a sense of justice. Initiative vs. Guilt

Initiative adds to autonomy the quality of undertaking, planning, and attacking a task for the sake of being active and on the move. The child is learning to master the world around him or her, learning basic skills and principles of physics; things fall to the ground, not up; round things roll, how to zip and tie, count and speak with ease. At this stage the child wants to begin and complete his or her own actions for a purpose. Guilt is a new emotion and is confusing to the child; he or she may feel guilty over things which are not logically guilt producing and he or she will feel guilt when his or her initiative does not produce the desired results. As described in Bee and Boyd (2004), the child during this stage faces the complexities of planning and developing a sense of judgment. During this stage, the child learns to take initiative and prepare him or herself towards roles of leadership and goal achievement. Activities sought out by a child in this stage may include risk-taking behaviors, such as crossing a street on his or her own or riding a bike without a helmet; both examples involving self-limits. Within instances requiring initiative as, the child may also develop negative behaviors. These behaviors are a result of the child developing a sense of frustration for not being able to achieve his or her goal as planned and may engage in behaviors that seem aggressive, ruthless, and overly assertive to parents; aggressive behaviors, such as throwing objects, hitting, or yelling, are examples of observable behaviors during this stage. Industry vs. Inferiority

10

To bring a productive situation to completion is an aim which gradually supersedes the whims and wishes of play. The fundamentals of technology are developed. To lose the hope of such "industrious" association may pull the child back to the more isolated, less conscious familial rivalry of the oedipal time. "Children at this age are becoming more aware of themselves as individuals." They work hard at "being responsible, being good, and doing it right." They are now more reasonable to share and cooperate. Allen and Marotz (2003) also list some perceptual cognitive developmental traits specific for this age group: Children understand the concepts of space and time, in more logical, practical ways, beginning to grasp, gain better understanding of cause and effect and understand calendar time. At this stage, children are eager to learn and accomplish more complex skills: reading, writing, telling time. They also get to form moral values, recognize cultural and individual differences and are able to manage most of their personal need and grooming with minimal assistance (Allen and Marotz, 2003). At this stage, children might express their independence by being disobedient, using back talk and being rebellious. SPECIFIC DATE 9 months DEVELOPMENTA L TASK Trust vs. Mistrust

AGE Infant Birth 18 months

BEHAVIOR According to her mother, the patient became close to her because the patient has learned that her mother was her primary care giver The patient developed trust to her mother because she always cares for her. The patient also never wants to be separated from her mother as evidenced by her crying when somebody

11

else touches her. The patient became independent and was able to make simple decisions for herself, specifically with the food she eats and the toys she plays with. Also, the patient can show dislike Toddler 18 months 3 yrs 2 years old Autonomy vs. Shame & Doubt when he says Ayaw or Hindi also the mother noticed that whenever the patient do not want something or being controlled when doing something, she shows Temper Tantrums because she recognized that she can decide for her own. The patient showed simple problem solving skill like on how to get candies from the Preschoole r 3-5 yrs 4 years old Initiative vs. Guilt top of the cabinet by using a chair and the patient developed her personality of being shy and quiet whenever there are visitors in their home.

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At this period, the patient verbalized that she wants to get good grades at school as stated by the mother. Also the mother School Age 5-12 yrs 10 years old Industry vs. Inferiority stated that the patient always compares her skill with her playmates, in example her skills in playing a specific game compared to her playmates skill in playing that same specific game. Jean Piaget (Cognitive Development) Piaget's four levels of development are (1) infancy, (2) preschool, (3) childhood, and (4) adolescence. Each stage is characterized by a general cognitive structure that affects all of the child's thinking. Each stage represents the child's understanding of reality during that period, and each but the last is an inadequate approximation of reality. Development from one stage to the next is thus caused by the accumulation of errors in the child's understanding of the environment; this accumulation eventually causes such a degree of cognitive disequilibrium that thought structures require reorganizing. Teri is already in the concrete operational thought stage. Sensorimotor Infants are born with a set of congenital reflexes that allow them to float in the heavily dense world, according to Piaget, in addition to a drive to explore their world. Their initial schemes are formed through differentiation of the congenital reflexes. The sensorimotor period is the first of the four periods. According to Piaget, this stage marks the

13

development of essential spatial abilities and understanding of the world in six sub-stages: Reflex Scheme, Primary circular reactions, Secondary circular reactions, Co-ordination of secondary course round modest circular reactions, Tertiary circular reactions, and Beginnings of symbolic representation. Pre-operational The Preoperational stage is the second of four stages of cognitive development. By observing sequences of play, Piaget was able to demonstrate that towards the end of the second year a qualitatively new kind of psychological functioning occurs. According to Piaget, the Pre-Operational stage of development follows the Sensorimotor stage and occurs between 27 years of age. In this stage, children develop their language skills. They begin representing things with words and images. However, they still use intuitive rather than logical reasoning. At the beginning of this stage, they tend to be egocentric, that is, they are not aware that other people do not think, know and perceive the same as them. Children have highly imaginative minds at this time and actually assign emotions to inanimate objects. The theory of mind is also critical to this stage. The Preoperational Stage can be further broken down into the Preconceptual Stage and the Intuitive Stage. The Preconceptual stage (24 years) is marked by egocentric thinking and animistic thought. A child who displays animistic thought tends to assign living attributes to inanimate objects, for example that a glass would feel pain if it were broken. Concrete Operational

14

The Concrete operational stage is the third of four stages of cognitive development in Piaget's theory. This stage, which follows the Preoperational stage, occurs between the ages of 7 and 12 years and is characterized by the appropriate use of logic. Important processes during this stage include: Seriation or the ability to sort objects in an order according to size, shape, or any other characteristic. For example, if given different-shaded objects they may make a color gradient. Transitivity or the ability to recognize logical relationships among elements in a serial order (for example, If A is taller than B, and B is taller than C, then A must be taller than C). Classification or the ability to name and identify sets of objects according to appearance, size or other characteristic, including the idea that one set of objects can include another. Decentering or where the child takes into account multiple aspects of a problem to solve it. For example, the child will no longer perceive an exceptionally wide but short cup to contain less than a normally-wide, taller cup. Reversibility or the child understands that numbers or objects can be changed, then returned to their original state. For this reason, a child will be able to rapidly determine that if 4+4 equals t, 84 will equal 4, the original quantity. Conservation or understanding that quantity, length or number of items is unrelated to the arrangement or appearance of the object or items. Elimination of Egocentrism or the ability to view things from another's perspective (even if they think incorrectly). For instance, show a child a comic in which Jane puts a doll under a box, leaves the room, and then Melissa moves the doll to a drawer, and Jane comes back. A child in the concrete operations stage will say that Jane will still think it's under the box even though the child knows it is in the drawer.

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AGE

SPECIFIC DATE

DEVELOPMENTAL TASK

BEHAVIOR

The patient was able to form a hand-eye Birth - 2 yrs (1-4 months) Sensorimotor Stage 3 months - Primary circular reactions phase coordination, whenever her mother holds something, his eyes follow the object or the hand. The patient was able to formulate new habits, Sensorimotor Stage Birth - 2 yrs (4-8 months) 7 months - Secondary circular reactions phase like placing her toy under her pillow whenever she sleeps and she also wraps a blanket in here fist Birth - 2 yrs (12-18 months) 15 months Sensorimotor Stage - Tertiary circular reactions before she sleeps. The patient was given a toy by her godfather capable of producing sounds or short tones of nursery rhymes. The patient wants a particular sound, the sound of happy birthday to you. But the sound can only produced if the cellphones button is pressed two times after
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the song jingle bells. The patient was able to play the song happy birthday by repeatedly experimenting with the coordination of the number of presses with the toy and hearing the sound. The patients mother began to notice that the patient was talking to herself. The patient became imaginative Pre-operational 2 - 7 years (2-4 years) 2 years Stage pre- conventional stage and talks to herself as if she has an imaginary playmate. And one time, as her mother stated, The patient accidentally dropped her toy on the floor, she immediately picked it up and patted it and said Sorry The patients mother noticed that the patient has begun to ask many questions about many (4-7 years) 7 years Pre-operational Stage Intuitive Stage topics. The usual questions of the patient are about why the things are like that and
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she even compares two situations from one another. 7-12 years 10 years Concrete Operational Stage Sigmund Freud (Psychosexual) The concept of psychosexual development, as envisioned by Sigmund Freud, is a central element in his sexual drive theory, which posits that, from birth, humans have instinctual sexual appetites (libido) which unfold in a series of stages. Each stage is characterized by the erogenous zone that is the source of the libidinal drive during that stage. These stages are, in order: oral, anal, phallic, latency, and genital. Oral Phase During this stage, the focus of gratification is on the mouth and pleasure is the result of nursing, but also of exploration of the surroundings. Anal Phase In the anal stage of the psychosexual development the focus of drive energy (erogenous zone) moves from the upper digestive tract to the lower end and the anus. According to the theory, the major experience during this stage is toilet training. Phallic Stage In the phallic stage, the child learns sexual identity through awareness of the genital areas. They play with their bodies largely out of curiosity. Electra/Oedipus complex also starts in this stage. Latent Stage During this stage, the focus is directed toward physical and intellectual activities, while sexual tendencies seem to be repressed.
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AGE

SPECIFIC DATE

DEVELOPMENTAL TASK

BEHAVIOR

The patient enjoyed Infant Birth 1 yr 3 months Oral Stage thumb sucking, biting nipples and even swallowing objects. The patient calls her Toddler 1 yr 3 yrs 2 years old Anal Stage mother whenever she feels an urge to urinate or defecate. Preschooler 3-5 yrs The child became close with her father. The patient started to School Age 5-12 yrs 9 years old Latent Stage focus more on studies and play with her playmates. Teri has completed her immunization, as verbalized by Mrs. Bacteria. D. History of Past Illness According to Mrs. Bacteria, Teri often experience common colds and fever which usually lasted for a couple of days. As a form of management, she would use over the counter drugs such as Paracetamol to treat the condition. She also had mumps when she was one, and Mrs. Bacteria said that she usually applies

4 years old

Phallic Stage

19

hot compress in the lump under Teris ear. She also had sore eyes and as an intervention, Eye mo has been used. E. History of Present Illness Two weeks prior to admission, Teri experienced on and off fever which was reduced when she was given a Paracetamol then comes back after 4-6 hours, she also experience cough and colds with clear nasal discharge and yellowish sputum which was managed by taking Solmux. As verbalized by Mrs. Bacteria, her husband smokes, their neighbors burn their garbages and outside their house is full of dust. She also experience weakness all over her body a day prior to her admission. She was admitted in a secondary hospital in Angeles city with an admitting diagnosis of Bacteremia to consider primary complex disease. F. Physical Examination (Lifted from the chart April 24 2009) Chief Complaint: Fever and cough for two weeks T: 37.*C/axilla PR: 89bpm RR: 22bpm Skin: warm to touch Lungs: (-) retraction Cardiovascular: (-) murmur (1st day nurse-patient interaction- April 28 2009) VITAL SIGNS: Temp: 37C/axilla PR: 84 bpm RR: 30 bpm Appearance and Mental Status

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Teri has a proportionate body built. Her posture is erect. Her overall hygiene/grooming is clean and neat; Teri does not have body and breathe odor. She is cooperative throughout the assessment period. Her speech is understandable, in a moderate pace and exhibit thought association. The Integument Teris skin has no odor and is warm to touch. When pinched, skin goes back to previous state immediately. Her hair is evenly distributed; thin and silky and has no dandruff. Teris nails are pinkish in color, convex curve, smooth and intact epidermis. When nails are pressed, they return to its usual color in less than 4 seconds. Her nails are pinkinsh, convex curve, smooth and intact epidermis. The Head Teri has rounded normocephalic shape and symmetrical head with absence of masses, depressions and nodules. Her face is smooth, it is uniform in consistency with absence of masses and nodules; Teri has symmetrical facial movements. Her facial features are symmetric, palpebral fissures are equal in size, symmetric nasolabial folds, hair is evenly distributed and skin is intact. She was able to smile, frown, close eyes, and show her teeth. Eyes and Vision Teris eyebrows are symmetrically aligned and have equal movement. Her eyelashes are equally distributed; they are curled slightly outward. Teris eyelids close symmetrically, do not have discharges and discoloration. Bulbar conjunctiva is transparent. Palpebral conjunctiva is shiny and pink in color. There is no tearing upon palpation of lacrimal ducts. Teris cornea is transparent, shiny and smooth. Pupils are black in color, round and reactive to light and accommodation. The Nose and Sinuses

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Teris nose is straight, and straight, uniform color, with clear nasal discharges, with nasal flaring , and it is not tender upon palpation and does not have lesions. Mucosa is pink, clear, watery discharge, no lesions and midline septum. The Ears and Hearing Teris ears are same as the color of facial skin; they are symmetric and aligned with the outer canthus of the eye. Her ears are mobile and firm and not tender, pinna recoils after it is folded. There are no discharges and obstructions upon inspection. Teri can hear normal voice tones, able to hear ticking in both ears. Mouth and Oropharynx Teris maxillary and frontal sinuses are not tender. Lips are dry and appear pale in color. Dental caries noted. Gums are pink and the tongue is at the center and pink in color, moist lateral margins, without lesions and tenderness with raised papillae, moves freely. The floor of the mouth is smooth with no palpable nodules. Soft and hard palate are smooth with prominent veins. Uvula is positioned in midline of soft palate. Gag reflex present. Neck and Jugular Veins Teris neck muscles are equal in sizes and the head is in center, it has smooth, coordinated movements with no discomfort. Teri can move her chin to her chest. She can shrug his shoulders against the resistance of the student nurses hands. Cervical nodes are not palpable and her trachea is in the midline of her neck. The thyroid gland is not visible upon inspection and the gland ascends during swallowing but is not visible. Upper Extremities Teris skin is fair in color; with lesions and scars noted . Temperature on muscles is generally equal.

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Thorax and Lungs Teri does not experience difficulty of breathing. She has no bruises or lesions upon inspection. Chest wall is intact. Shallow breathing was noted. Crackles were heard on the right lobe upon auscultation. Heart Teri has no abnormal heart sounds upon auscultation. Abdomen Teris abdomen was unblemished and uniform in color and with symmetric movements upon respiration. She has audible bowel sounds. masses in her abdomen. Lower Extremities Teris skin is fair in color; lesions and scars were observed in both feet. Temperature on muscles is generally equal. She has no contractures and deformities in both extremities Teri has no

(2nd day nurse-patient interaction- April 29 2009) VITAL SIGNS: Temp: 37C/axilla PR: 100 bpm RR: 25 bpm Appearance and Mental Status Teri has a proportionate body built. Her posture is erect. Her overall hygiene/grooming is clean and neat; Teri does not have body and breathe odor. She is cooperative throughout the assessment period

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The Integument Teris skin has no odor. When pinched, skin goes back to previous state immediately. Her hair is evenly distributed; thin and silky and has no dandruff. Teris nails are pinkish in color, convex curve, smooth and intact epidermis. When nails are pressed, they return to its usual color in less than 3 seconds. The Head Teri has round normocephalic shape of the head with absence of masses and nodules. Her face is smooth, it is uniform in consistency with absence of masses and nodules; Teri has symmetrical facial movements. She was able to smile, frown, close eyes, and show her teeth. Eyes and Vision Teris eyebrows are symmetrically aligned and have equal movement. Her eyelashes are equally distributed; they are curled slightly outward. Teris eyelids close symmetrically, do not have discharges and discoloration. Bulbar conjunctiva is transparent. Palpebral conjunctiva is shiny and pink in color. There is no tearing upon palpation of lacrimal ducts. Teris cornea is transparent, shiny and smooth. Pupils are black in color, round and reactive to light and accommodation. The Nose and Sinuses Teris nose is straight, with clear nasal discharges, with nasal flaring , and it is not tender upon palpation and does not have lesions. The Ears and Hearing Teris ears are same as the color of facial skin; they are symmetric and aligned with the outer canthus of the eye. Her ears are mobile and firm and not tender, pinna recoils after it is folded. There are no discharges and obstructions upon inspection. Teri can hear normal voice tones.

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Mouth and Oropharynx Teris maxillary and frontal sinuses are not tender. Lips are dry and appear pale in color. Dental caries noted. Gums are pink and the tongue is at the center and pink in color without lesions and tenderness. Neck and Jugular Veins Teris neck muscles are equal in sizes and the head is in center, it has smooth, coordinated movements with no discomfort. Teri can move her chin to her chest. She can shrug his shoulders against the resistance of the student nurses hands. Cervical nodes are not palpable and her trachea is in the midline of her neck. The thyroid gland is not visible upon inspection and the gland ascends during swallowing but is not visible. Upper Extremities Teris skin is fair in color; with lesions and scars noted . Temperature on muscles is generally equal. Thorax and Lungs Teri does not experience difficulty of breathing. He has no bruises or lesions upon inspection. Chest wall is intact. Shallow breathing was noted. Crackles were heard on the right lobe upon auscultation. Heart Teri has no abnormal heart sounds upon auscultation. Abdomen Teris abdomen was unblemished and uniform in color and with symmetric movements upon respiration. She has audible bowel sounds. masses in his abdomen. Lower Extremities Teri has no

25

Teris skin is fair in color; lesions and scars were observed in both feet. Temperature on muscles is generally equal. She has no contractures and deformities in both extremities

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G. Diagnostic and Lab procedures

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DIAGNOSTIC/ LABORATORY PROCEDURES Complete Blood Count (CBC) Hemoglobin

DATE ORDERED DATE RESULT(S) DO:04/24/09 DR:04/27/09

INDICATION OR PURPOSES

RESUL TS

NORMAL VALUES

ANALYSIS

INTERPRET

OF RESU

Hgb: it measures the total amount of hemoglobin in blood to measure its oxygen carrying capacity.

123

M= 140-180 F= 120-160

NORMAL w

means the p

has adeq

oxygen in b

Hematocrit

Hct: it measures the percentage of RBC in the total blood volume and is important to the oxygen carrying capacity of the blood.

0.37

M= 0.400.54 F= 0.370.47

NORMAL w

means the p

has adeq

oxygen in b

White Blood Cell (WBC)

WBC: helpful in the evaluation of the patient with infection.

21.5

5-10 x 10

ELEVAT

Presenc

infectio .12 0.20-0.35

Lymphocytes

To detect for the presence of viral infection.

Lymphocyt

activated w

antigens att

promoting

productio

antibodies there is

result indica

decreased c . Segmenters To 28detect for the presence of bacterial infection. 85 50-70

of infectio

further take

ELEVAT

Presenc

bacterial inf

NURSING RESPONSIBILITIES: Complete Blood Count (CBC) BEFORE: 1. 2. 3. 4. 5. Check the doctors order. Identify the client. Explain the procedure, its purpose and how is done. Inform the patient that no fasting is required. Inform the patient that the test may require blood specimen and might bring a little pain to the punctured site. DURING: 1. 2. 3. Maintain sterile technique. Tell the patient when to insert the needle for her to be prepared. Do not use hand or arm receiving IV fluid this causes hemodilution. Do not leave the tourniquet for more than one minute because doing so causes hemoconcentration. 4. 5. Encourage the patient to remain calm during the test. Assist the patient when necessary.

AFTER: 1. 2. 3. 4. Apply pressure to the punctured site to prevent bleeding. Label the specimen and transport it to the laboratory. Document pertinent data. Discuss with SO signs of inflammation of punctured site such as swelling and advice to report immediately. 5. Wash hands.

29

DATE ORDERED DATE RESULTS IN Chest APL x- DO:04/24/09 ray DR:04/25/09

DIAGNOSTIC/ LABORATORY PROCEDURES

INDICATION(S) OR PURPOSE(S)

RESULTS

To detect vertebral Radiologic degeneration, infection findings: and Patchy densities mid-lower defined

ANALYSIS AND INTERPRETAT ION Both lung fields are Impression: clear. Heart vessels normal and are size Bilateral great pneumonia within with and consolidation right chest lobe. middle

NORMAL VALUES

congenital disorders. are evident in the To detect vertebral right fractures, dislocations, subluxation, deformities. determine vertebral effects Poorly and infiltrates the retrocardiac of regions. Para-tracheal and hilar Heart enlarged Diaphragm bony thorax unremarkable. and are nodularities is not are noted. lung zones.

configuration.

are Other remarkable. IMPRESSION: Normal chest.

To apparent in the left structures Concomittant PPTB cannot be ruled out

metabolic disorders.

30

NURSING RESPONSIBILITIES Chest x-ray (APL) BEFORE: 1. make sure that patient has signed an appropriate consent form 2. note and report all allergies 3. stress to the patient the importance of remaining still and holding his 4. breath for film exposure during the procedure 5. explain that the test usually takes 15 to 30 minutes

DURING: 1. assist the patient into a supine position on the X-ray table 2. x-rays are obtained as required

AFTER: 1. Assist the patient in dressing up after the procedure 2. Document the pertinent data.

31

DIAGNOSTIC/ LABORATORY PROCEDURES Sputum Fast Bacilli

DATE ORDERED DATE INDICATION(S) OR PURPOSE(S) Most common staining technique identify bacteria. Acid-fast bacilli (AFB) are rod-shaped bacteria that can be seen and counted microscope under on the a used acid to fast RESULTS

NORMAL VALUES ANALYSIS AND INTERPRETATION Negative Indicates absence of acid fast bacteria.

RESULT(S) IN Acid DO:04/25-27/09 DR:04/25-27/09

Negative

specially stained sample on a glass slide, called an AFB smear. The most common acid-fast bacilli are members of the Mycobacterium. genus

32

NURSING RESPONSIBILITIES: Sputum Acid Fast Bacilli

Before: 1. Emphasized patient to drink a lot of fluids the night before the test. It makes the test more accurate if it's done first thing in the morning. 2. Make sure that the client knows that there is no discomfort, unless a bronchoscopy needs to be performed. 3. emphasize to patient and SO that To increase the accuracy of this test, it is sometimes done three times, often three days in a row.

During: 1. Maintain medical asepsis. 2. Assist patient to spit the sputum and make sure that it is done early in the morning without eating or drinking.

After: 1. Cover the specimen when it is obtained. 2. Allow the patient to brush her teeth in order to prevent microorganisms to increase. 3. Do hand washing. 4. Document pertinent data.

33

Anatomy and Physiology The Circulatory System

The circulatory system is responsible for the transport of water and dissolved materials throughout the body, including oxygen, carbon dioxide, nutrients, and waste. The circulatory system transports oxygen from the lungs and nutrients from the digestive tract to every cell in the body, allowing for the continuation of cell metabolism. The circulatory system also transports the waste products of cell metabolism to the lungs and kidneys where they can be expelled from the body. Without this important function toxic substances would quickly build up in the body.

Anatomy of the Circulatory System

The

human

circulatory

system

is

organized into two major circulations. Each has its own pump with both pumps being incorporated into a single organthe heart. The two sides of the human heart are separated by partitions, the interatrial septum and the interventricular septum. Both septa are complete so that the two sides are anatomically pumps blood and functionally the separate pulmonary pumping units. The right side of the heart through circulation (the lungs) while the left side of the heart pumps blood through the systemic circulation (the body).
34

The human heart is a specialized, four-chambered muscle that maintains the blood flow in the circulatory system. It lies immediately behind the sternum, or breastbone, and between the lungs. The apex, or bottom of the heart, is tilted to the left side. At rest, the heart pumps about 59 cc (2 oz) of blood per beat and 5 l (5 qt) per minute. During exercise it pumps 120-220 cc (4-7.3 oz) of blood per beat and 20-30 l (21-32 qt) per minute. The adult human heart is about the size of a fist and weighs about 250-350 gm (9 oz). The human heart begins beating early in fetal life and continues regular beating throughout the life span of the individual. If the heart stops beating for more than 3 or 4 minutes permanent brain damage may occur. Blood flow to the heart muscle itself also depends on the continued beating of the heart and if this flow is stopped for more than a few minutes, as in a heart attack, the heart muscle may be damaged to such a great extent that it may be irreversibly stopped. The heart is made up of two muscle masses. One of these forms the two atria (the upper chambers) of the heart, and the other forms the two ventricles (the lower chambers). Both atria contract or relax at the same time, as do both ventricles. An electrical impulse called an action potential is generated at regular intervals in a specialized region of the right atrium called the sinoauricular (or sinoatrial, or SA) node. Since the two atria form a single muscular unit, the action potential will spread over the atria. A fraction of a second later, having been triggered by the action potential, the atrial muscle contracts. The ventricles form a single muscle mass separate from the atria. When the atrial action potential reaches the juncture of the atria and the ventricles, the atrioventricular or AV node (another specialized region for conduction) conducts the impulse. After a slight delay, the impulse is passed by way of yet another

35

bundle of muscle fibers (the Bundle of His and the Purkinje system.) Contraction of the ventricle quickly follows the onset of its action potential. From this pattern it can be seen that both atria will contract simultaneously and that both ventricles will contract simultaneously, with a brief delay between the contraction of the two parts of the heart. The electrical stimulus that leads to contraction of the heart muscle thus originates in the heart itself, in the sinoatrial node (SA node), which is also known as the heart's pacemaker. This node, which lies just in front of the opening of the superior vena cava, measures no more than a few millimeters. It consists of heart cells that emit regular impulses. Because of this spontaneous discharge of the sinoatrial node, the heart muscle is automated. A completely isolated heart can contract on its own as long as its metabolic processes remain intact. The rate at which the cells of the SA node discharge is externally influenced through the autonomic nervous system, which sends nerve branches to the heart. Through their stimulatory and inhibitory influences they determine the resultant heart rate. In adults at rest this is between 60 and 74 beats a minute. In infants and young children it may be between 100 and 120 beats a minute. Tension, exertion, or fever may cause the rate of the heart to vary between 55 and 200 beats a minute. The Heart Sounds The closure of the heart valves and the contraction of the heart muscle produce sounds that can be heard through the thoracic wall by the unaided ear, although they can be heard better when amplified by a stethoscope. The sounds of the heart may be represented as lubb-dubb-pause-lubb-dubb-pause. The lubb sound indicates the closing of the valves between the atria and ventricles and the contracting ventricles; the dubb sound indicates the closing of the semilunar valves. In addition, there may also be cardiac murmurs, especially when the

36

valves are abnormal. Some heart murmurs, however, may also occur in healthy persons, mainly during rapid or pronounced cardiac action. The study of heart sounds and murmurs furnishes valuable information to physicians regarding the condition of the heart muscle and valves. Coronary Circulation The coronary arteries supply blood to the heart muscle. These vessels originate from the aorta immediately after the aortic valve and branch out through the heart muscle. The coronary veins transport the deoxygenated blood from the heart muscle to the right atrium. The heart's energy supply is almost completely dependent on these coronary vessels. When the coronary vessels become blocked, as in arteriosclerosis or hardening of the arteries, blood flow to the cardiac muscle is compromised. This is when the common "bypass surgery" is performed where the coronary arteries are "bypassed" by replacing them with, for example, a vein from the leg. A "double bypass" is when two coronary arteries are bypassed. A "triple bypass" is when three are bypassed, etc. The Heartbeat The heart muscle pumps the blood through the body by means of rhythmical contractions (systole) and relaxations or dilations (diastole). The heart's left and right halves work almost synchronously. When the ventricles contract (systole), the valves between the atria and the ventricles close as the result of increasing pressure, and the valves to the pulmonary artery and the aorta open. When the ventricles become flaccid during diastole, and the pressure decreases, the reverse process takes place. The Pulmonary Circulation

37

From the right atrium the blood passes to the right ventricle through the tricuspid valve, which consists of three flaps (or cusps) of tissue. The tricuspid valve remains open during diastole, or ventricular filling. When the ventricle contracts, the valve closes, sealing the opening and preventing backflow into the right atrium. Five cords attached to small muscles, called papillary muscles, on the ventricles' inner surface prevent the valves' flaps from being forced backward. From the right ventricle blood is pumped through the pulmonary or semilunar valve, which has three half-moon-shaped flaps, into the pulmonary artery. This valve prevents backflow from the artery into the right ventricle. From the pulmonary artery blood is pumped to the lungs where it releases carbon dioxide and picks up oxygen. The Systemic Circulation From the lungs, the blood is returned to the heart through pulmonary veins, two from each lung. From the pulmonary veins the blood enters the left atrium and then passes through the mitral valve to the left ventricle. As the ventricles contract, the mitral valve prevents backflow of blood into the left atrium, and blood is driven through the aortic valve into the aorta, the major artery that supplies blood to the entire body . The aortic valve, like the pulmonary valve, has a semilunar shape. The aorta has many branches, which carry the blood to various parts of the body. Each of these branches in turn has branches, and these branches divide, and so on until there are literally millions of small blood vessels. The smallest of these on the arterial side of the circulation are called arterioles. They contain a great deal of smooth muscle, and because of their ability to constrict or dilate, they play a major role in regulating blood flow through the tissues.

The major artery that supplies blood to the body is the aorta.
38

The blood passing through the arterioles passes through a bed of minute vessels called capillaries, which are a single cell thick. These capillaries are so small that the red blood cells must line up single file to pass through. The exchange of nutrients and waste products takes place between the capillary blood and the tissue fluids. The arterialized blood that enters the capillaries thus becomes venous blood as it passes through them. The capillaries empty the venous blood into collecting tubes called venules, and these in turn empty into small veins, which empty into larger veins, and so on until finally all the blood returns to the heart through two large veins, the superior and inferior vena cavae. These terminate in the right atrium, and the systemic circulation is complete. A one-way flow of blood in this system is maintained by valves located, not only in the heart, but in the veins as well. Some veins also have semilunar valves and the pressure of contracting muscles against the veins works with the action of these valves to increase the venous return to the heart. This is the reason that exercise is so important for the circulation.

The tiniest of the blood vessels, and the place where the exchange of nutrients and waste products takes place between the blood and the tissue fluids, is the capillaries.

The Lymphatic System

An often overlooked part of the circulatory system is the lymphatic system. As blood passes through the capillaries, some of the fluid diffuses into the surrounding tissues. One function of the lymphatic system is to collect and
39

recycle this fluid (called lymph). Lymph passes from capillaries to lymph vessels and flows through lymph nodes that are located along the course of these vessels. Cells of the lymph nodes phagocytize, or ingest, impurities such as bacteria, old red blood cells, and toxic and cellular waste. Finally, lymph flows into the thoracic duct, a large vessel that runs parallel to the spinal column, or into the right lymphatic duct, both of which transport the lymph back into veins of the shoulder areas where is mixes with blood and is returned to the heart. All lymph vessels contain one-way valves, like the veins, to prevent backflow. The tissues of the lymphatic system include the spleen. The spleen serves as a reservoir for blood, releasing additional blood into the circulatory system as needed. It is also involved with destruction of old cells and other substances by phagocytosis. The lymphatic system is also responsible for collecting nutrients that the digestive system has extracted from our foods, and is a very important part of the immune system. We will cover the lymphatic system in detail in the lesson on the immune system.

The Blood The blood transports life-supporting food and oxygen to every cell of the body and removes their waste products. It also helps to maintain body temperature, transports hormones, and fights infections. The brain cells in particular are very dependent on a constant supply of oxygen. If the circulation to the brain is stopped, death shortly follows. Blood has two main constituents. The cells, or corpuscles, comprise about 45 percent, and the liquid portion, or plasma, in which the cells are suspended comprises 55 percent. The blood cells comprise three main types: red blood cells, or erythrocytes; white blood cells, or leukocytes, which in turn are of many different types; and platelets, or thrombocytes. Each type of cell has its own individual functions in the body. The plasma is a complex colorless solution, about 90 percent water, that carries different ions and molecules including

40

proteins, enzymes, hormones, nutrients, waste materials such as urea, and fibrinogen, the protein that aids in clotting. Red Blood Cells The red blood cells are tiny, round, biconcave disks, averaging about 7.5 microns (0.003 in) in diameter. A normal-sized man has about 5 l (5.3 qt) of blood in his body, containing more than 25 trillion red cells. Because the normal life span of red cells in the circulation is only about 120 days, more than 200 billion cells are normally destroyed each day by the spleen and must be replaced. Red blood cells, as well as most white cells and platelets, are made by the bone marrow. The main function of the red blood cells is to transport oxygen from the lungs to the tissues and to transport carbon dioxide, one of the chief waste products, it to the lungs for release from the body. The substance in the red blood cells that is largely responsible for their ability to carry oxygen and carbon dioxide is hemoglobin, the material that gives the cells their red color. It is a protein complex comprising many linked amino acids, and occupies almost the entire volume of a red blood cell. Essential to its structure and function is the mineral iron. White Blood Cells The leukocytes, or white blood cells, are of three types; granulocytes, lymphocytes, and monocytes. All are involved in defending the body against foreign organisms. There are three types of granulocytes: neutrophils, eosinophils, and basophils, with neutrophils the most abundant. Neutrophils seek out bacteria and phagocytize, or engulf, them.

41

The lymphocytes' chief function is to migrate into the connective tissue and build antibodies against bacteria and viruses. Leukocytes are almost colorless, considerably larger than red cells, have a nucleus, and are much less numerous; only one or two exist for every 1,000 red cells. The number increases in the presence of infection. Monocytes, representing only 4 to 8 percent of white cells, attack organisms not destroyed by granulocytes and leukocytes. The granulocytes, accounting for about 70 percent of all white blood cells, are formed in the bone marrow. The lymphocytes on the other hand are produced primarily by the lymphoid tissues of the bodythe spleen and lymph nodes. They are usually smaller than the granulocytes. Monocytes are believed to originate from lymphocytes. Just as the oxygen-carrying function of red cells is necessary for our survival, so are normal numbers of leukocytes, which protect us against infection. Platelets Platelets, or thrombocytes, are much smaller than the red blood cells. They are round or biconcave disks and are normally about 30 to 40 times more numerous than the white blood cells. The platelets' primary function is to stop bleeding. When tissue is damaged, the platelets aggregate in clumps to obstruct blood flow. Plasma The plasma is more than 90 percent water and contains a large number of substances, many essential to life. Its major solute is a mixture of proteins. The most abundant plasma protein is albumin. The globulins are even larger protein molecules than albumin and are of many chemical structures and functions. The antibodies, produced by lymphocytes, are globulins and are carried throughout the body, where many of them fight bacteria and viruses.

42

An important function of plasma is to transport nutrients to the tissues. Glucose, for example, absorbed from the intestines, constitutes a major source of body energy. Some of the plasma proteins and fats, or lipids, are also used by the tissues for cell growth and energy. Minerals essential to body function, although present only in trace amounts, are other important elements of the plasma. The calcium ion, for example, is essential to the building of bone, as is phosphorus. Calcium is also essential to the clotting of blood. Copper is another necessary component of the plasma.

43

44

IV. THE PATIENT AND HER ILLNESS A. SCHEMATIC DIAGRAM 1. BOOK BASED

Modifiable and Non-Modifiable Factors and Sources Bacteria enter the body through different portals of entry Bacteria travel to the body through the blood stream Bacteria produce local infection Bacteria spread to other parts of the body through the blood. Bacteria are detected in the Blood The body elicits a vigorous immune system response Serious bacterial infections can occur Pneumonia, Cellulitis, Meningitis, Sepsis Fev er Cytokines are produced Cytokines reset the thermoregulatory center in the hypothalamus N and V Irritates the GI tract Diarrhe a

45

Modifiable Factors
Environmen t Dirty Environmen t Diet Unhealthy and Improperly prepared foods Community Acquired Infections

CLIENT BASED
Non - Modifiable Factors

Bacteria enters the body from different portals of entry Bacteria travel to the body through the blood stream Bacteria produce Local Infection movement of plasma and leukocytes from the blood into the injured tissues. Cascade of biochemical events propagates and matures the inflammatory response Involves the local vascular system, the immune system, and various cells within the injured tissue

WBC Count (April 27, 2009) Bacteria irritates the GI tract/lining Nausea, Diarrhea, Vomiting

The tubercle bacilli multiply initially within the alveoli and alveolar ducts. Bacilli are carried to the regional lymph node by macrophages

Bacteria may spread to other parts of the body through the blood. Bacteria are detected in the Blood

Bacteria invades the lungs

Penetration of lower respiratory tract

The body elicits a vigorous immune system response

Inflammatory response takes place

46

Local reaction in the parenchyma of the lung

Pyrogens released by MO Stimulates the thermoregulat ory center of the brain Reset the temp Increase temperature Fever Prior to Admission

Release of chemical mediators Increase mucus production of goblet cells Cilliary motility Stimulati on of cough center (medulla oblongat Cough PTA and (April 2829)

The parenchymal lesion continues to enlarge resulting in focal pneumonitis and thickening of the overlying pleura. Signs and symptoms of tuberculosis

Fluid filled alveoli Mucus production Crackles/Ral es upon auscultation (April 28-29)

47

B.

Synthesis of the Disease

1. Definition of the disease (Bacteremia) Bacteremia is the presence of viable bacteria in the blood stream. Bacteremia is different from sepsis (so-called blood poisoning or toxemia), which is a condition where bacteremia is associated with an inflammatory response from the body (causing systemic inflammatory response syndrome, characterised by rapid breathing, low blood pressure, fever, etc.). For example, a dental procedure (or even brushing your teeth) introduces a detectable amount of bacteria into the bloodstream, but these are unable to replicate in the blood of most people. Some patients with prosthetic heart valves however need antibiotic prophylaxis for dental surgery because bacteremia might lead to endocarditis (infection of the interior lining of the heart). Salmonella - which is assumed to only cause gastroenteritis in much of the middle-class or developed world - can cause a specific and virulent form of bacteremia in the developing world, especially in Africa. This form of bacteremia is particularly deadly to infants and people whose immune systems have been damaged by HIV, according to studies done by the Universities of Malawi and Liverpool at the Wellcome Trust Clinical Research Programme in Blantyre. Researchers announced in March 2008 in the Journal of Clinical Investigation that a study of 352 Malawian children had revealed antibodies against salmonella when the bacteria leaves the safety of the cells and moves into the bloodstream, and these antibodies may form the basis of an eventual vaccine. Septicemia is an ill-defined non-scientific term introducing more confusion between sepsis and bacteremia: it suggests there is something in the bloodstream causing sepsis. Bacteremia may also occur in children with focal infections or in children who have sepsis (ie, clinical evidence other than fever of a systemic response to infection). Children with sepsis generally appear ill, have an increased heart rate or respiratory rate and may have a change in temperature (typically fever, although hypothermia is often seen in very young infants and newborns). Severe sepsis results in hypotension, hypoperfusion, or
48

organ dysfunction. Septic shock occurs in children who do not respond to adequate volume resuscitation or require vasopressors or inotropes. 2. Modifiable and Non-modifiable Factors (Book-based) Modifiable factors: Hospital-acquired infections Indwelling catheters are a frequent cause of bacteremia and subsequent nosocomial infections, because they provide a means by which bacteria normally found on the skin can enter the bloodstream. Community-acquired infections Causes of occult bacteremia vary depending on the age of the infant or child. Very young infants most commonly acquire infections from the mother during childbirth. As a patient's age increases, a gradual shift occurs toward community-acquired infections. Trauma, like dental work Dental work is a cause of mild bacteremia. When someone gets dental work, bacteria in the mouth can get into the bloodstream through tiny breaks in the gums. This bacteremia doesn't usually last long because the number of bacteria involved is small enough that the immune system can kill them quickly. Someone who has an artificial valve in their heart has to take antibiotics before and during dental work because the bacteria can "stick" to a foreign object and cause significant damage. Worsening bacterial infection

49

A more serious type of bacteremia is caused by an infection somewhere in the body that gets bad enough that the bacteria are able to invade the blood vessels and get into the blood stream. Certain skin infections are more likely than others to cause bacteremia. For example, a cellulitis or carbuncle would be more likely to cause bacteremia than hot tub folliculitis or erythrasma. Surgery Bacteremia may also be seen in oropharyngeal, gastrointestinal or genitourinary surgery or exploration. International According to the World Health Organization, at least 6 million children die each year of pneumococcal infections (eg, pneumonia, meningitis, bacteremia); most of these fatalities occur in developing countries. Non-modifiable Factors: Age Studies of occult bacteremia focus on children younger than 3 years. Some studies show that age does not affect the risk of developing occult bacteremia, whereas other analyses have found that variations in age-based risk depend on the infecting organism. Season A seasonal variation in febrile children presenting for evaluation is recognized. The peak is from late fall to early spring in children of all ages and is likely because of respiratory and GI viral infections. Another peak
50

occurs during the summer in infants younger than 3 months and is likely due to enteroviral infections and thermoregulation during hot weather. However, most studies do not specifically address seasonal variation associated with bacteremia. Modifiable and Non-modifiable Factors (Client-centered) Modifiable factors: Environment Depending on the environment, every person is prone to having diseases. If the environment is dirty, diseases like bacteremia commonly occur. Diet Whatever food enters the body, it also affects the outcome of the health of the patient. If the food is properly cooked and nutritious it would be beneficial but if not, it can cause diseases such as bacteremia.

Community-acquired infections Causes of occult bacteremia vary depending on the age of the infant or child. Very young infants most commonly acquire infections from the mother during childbirth. As a patient's age increases, a gradual shift occurs toward community-acquired infections.

Location

51

According to the World Health Organization, at least 6 million children die each year of pneumococcal infections (eg, pneumonia, meningitis, bacteremia); most of these fatalities occur in developing countries. Non-modifiable Factors: 3. Signs and Symptoms (Book-based) Fever A systemic response to infection. Fever is common in pediatric patients. Children average 4-6 fevers by age 2 years. Fever also prompts many visits to the pediatric clinic and emergency department. Approximately 8-25% of doctor's visits by children younger than 3 years are for fever; 65% of children younger than 3 years visit a physician for acute febrile illness. Chills When an infection occurs, infection-fighting cells in the body make certain chemicals. In some cases, these chemicals may travel through the bloodstream and cause the brain to raise the normal temperature inside the body. This is how a fever occurs. When the brain raises the temperature set point in the body, a person gets a feeling of cold. This feeling may stop if the new set point is reached. Shivering may even occur, as the body tries to use muscle movement to raise the temperature. Rapid heart rate Infections can cause tachycardia, primarily due to increase in metabolic demands.

52

Rapid breathing - this can be caused by damage to the cells causing hypoxia, resulting to increased RR to compensate for the loss.

Hematogenous spread

Bacteremia is the principal means by which local infections are spread to distant organs. Minor infections Bacteria that are not removed by the immune system may accumulate in various places throughout the body, causing infections there, as in the following: Tissues that cover the brain (meningitis), The sac around the heart (pericarditis), The cells lining the heart valves and the heart (endocarditis),Bones (osteomyelitis),Joints (infectious arthritis. GI symptoms - abdominal pain, nausea, vomiting, and diarrhea

Signs and Symptoms (Patient-centered) Fever A systemic response to infection. Fever is common in pediatric patients. Children average 4-6 fevers by age 2 years. Fever also prompts many visits to the pediatric clinic and emergency department. Approximately 8-25% of doctor's visits by children younger than 3 years are for fever; 65% of children younger than 3 years visit a physician for acute febrile illness.
53

Hematogenous spread Bacteremia is the principal means by which local infections are spread to distant organs.

Minor infections Bacteria that are not removed by the immune system may accumulate in various places throughout the body, causing infections there, as in the following: Tissues that cover the brain (meningitis), The sac around the heart (pericarditis), The cells lining the heart valves and the heart (endocarditis),Bones (osteomyelitis),Joints (infectious arthritis.

GI symptoms - abdominal pain, nausea, vomiting, and diarrhea

4. Health Promotion and Prevention Early, aggressive treatment boosts your chances of surviving sepsis. People with severe sepsis require close monitoring and treatment in a hospital intensive care unit. If you have severe sepsis or septic shock, lifesaving measures may be needed to stabilize breathing and heart function. A priority in treating sepsis is to identify the source and type of the infection and treat it. Your medical team will test blood, urine, sputum or other body fluids to identify the infectious agent most often, bacterial. Surgery to remove sources of infection, such as medical devices, intravenous lines and surgical drainage tubes, may be needed. Doctors will also drain any collections of pus (abscesses). A number of different types of medications are used in treating sepsis. They include:
54

Antibiotics. Treatment with antibiotics begins immediately even before the infectious agent is identified. Initially you'll receive "broad-spectrum" antibiotics, which are effective against a variety of bacteria. The antibiotics are administered intravenously (IV). After learning the results of blood tests, your doctor may switch to a different antibiotic that's more appropriate against the particular bacteria causing the infection.

Vasopressors. If your blood pressure remains too low even after receiving intravenous fluids, you may be given a vasopressor medication, which constricts blood vessels and helps to increase blood pressure.

Activated protein C. People with severe sepsis whose organs are failing or who are at high risk of dying may receive a newer drug called activated protein C (Xigris). This drug interferes with some of the body's responses to severe infection, helping to curb the overactive inflammatory reaction, but it can cause serious bleeding.

Others. Other medications you may receive include low doses of corticosteroids, insulin to help maintain stable blood sugar levels, and painkillers or sedatives. People with severe sepsis usually receive supportive care including

intravenous fluids and oxygen. Depending on your condition, you may need mechanical ventilation (respirator) in case of breathing problems or dialysis for kidney failure. Many cases of sepsis aren't preventable. But you can take steps to avoid infections and to protect yourself from illnesses that weaken your immune system. Wash your hands thoroughly after preparing or eating food, coughing or sneezing, and using the toilet. Get recommended pneumonia and flu shots. Seek prompt medical care for any serious infection. If you're hospitalized because of illness or for surgery, wash your hands after handling any soiled

55

material. Alert the medical staff if catheters, drainage tubes or bandages become loose or if you see redness, swelling or pus on these sites. Tell the staff if wounds become wet or exposed to outside debris.

56

V. THE PATIENT AND HIS CARE A. Medical Management 1. IVF MEDICAL MANAGEMENT/ TREATMENT PLRS 1L x KVO DATE ORDERED DATE PERFORMED DATE CHANGED DO: 04/24/09 DP: 04/24-28/09 GENERAL DESCRIPTION Isotonic, balanced For INDICATION (S) OR PURPOSES maintenance and CLIENTS RESPONSE TO THE TREATMENT of The patient was able to

electrolyte solution with hydration major electrolytes in the supply. same concentration as in blood. Contains sodium, potassium, as lactate.

caloric meet her caloric needs.

calcium, For administration of IV

chloride, and bicarbonate medications.

D5LRS 1L x KVO

DO: 04/29/09 DP: 04/29-30/09

Hypertonic solution, 5% For Dextrose Ringers sterile, solution. in Solution is a supply.

maintenance and

of The patient was able to

Lactated hydration

caloric meet her caloric needs.

nonpyrogenic

57

NURSING RESPONSIBILITIES:

IVF BEFORE IVF INSERTION: a. Ask the patients name for clarification and explain the procedure to be done to gain patients trust. b. Prepare the equipment needed: prescribed IV Solution, administration set including insertion spike, sterile tubing, drip chamber, roller clamp, rubber injection parts and protective covers for needle adapter. c. Gather supplies: Povidone Iodine or betadine swabs, alcohol swabs, plastic or paper tape, tourniquet and clean disposable gloves. d. Wash hands.

DURING: a. Clean the infusion site with cotton and alcohol. b. Select an IV site; puncture the distal end of the vein first. c. Don gloves, and remove the sterile cover from the IV needle. d. After needle insertion, open the clamp and check the drip chamber for flow of fluids and the IV site for swelling. e. Set the drip rate as ordered; mark the expected hourly flow rate with tape or a prepared commercial label.

AFTER: a. Remove gloves, dispose supplies properly and wash hands. b. Assess the IV site, drip rate, volume infused at least every hour. c. Monitor signs of fluid overload or dehydration. d. Monitor fluid and electrolyte balance.

58

2. Drugs NAME OF DRUGS GENERIC NAME BRAND NAME GN: Cefuroxime Sodium DATE ORDERED DATE PERFORMED DATE CHANGED DO: 04/24/09 DP: 04/24/09 BN: Zinacef DC: not changed 1.5 g IV THEN 750 mg IV q 8 ROUTE, DOSAGE & FREQ OF ADMIN This that drug was is as classified (2nd treatment as The of 9/17/08 INDICATION (S) OR PURPOSES CLIENTS RESPONSE TO THE MEDS WITH ACTUAL S/E patient which

CEPHALOSPORIN given

generation) manifested fever on indicates infection.

respiratory tract infections.

NURSING RESPONSIBILITIES BEFORE: a. Check the name of the patient and the doctors order before administration. b. Check for the expiration date of the drug. c. Check the label, contents and appearance. d. Obtain specimen for culture and sensitivity tests before giving 1st dose. e. Check for hypersensitivity reaction before giving the drug.

DURING: a. Maintain sterile technique.

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b. Check IVF patency before administering the medication.

AFTER: a. Tell patient to take all of the drugs as prescribed, even after he feels better. b. Instruct patient to notify prescriber about rash or evidence of superinfection. c. Tell patient to notify prescriber about loose stools or diarrhea.

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NAME OF DRUGS GENERIC NAME BRAND NAME

DATE ORDERED DATE PERFORMED DATE CHANGED

ROUTE, DOSAGE & FREQ OF ADMIN Decreases fever by a hypothalamic effect leading to sweating and vasodilation and inhibits the effect of INDICATION (S) OR PURPOSES

CLIENT

RESPONSE T ACTUAL

MEDS W

DO: 04/24/09 Paracetamol DP: 04/24/09 DC: Not changed 300mg IV if T 37.8C

pyrogens on the hypothalamic heat regulating centers. May cause analgesia by inhibiting CNS prostaglandin synthesis, however, due to minimal effects on peripheral prostaglandin synthesis, it has no anti inflammatory or uricosuric effect.

Patient was r experienced

from fever

sweatin

NURSING RESPONSIBILITIES BEFORE: a. Check the name of the patient and the doctors order before administration. b. Check for the expiration date of the drug. c. Check the label, contents and appearance. d. Obtain specimen for culture and sensitivity tests before giving 1st dose. e. Check for hypersensitivity reaction before giving the drug. f. Read labels on all OTC products consumed. g. Make sure that patient has taken food or milk to decrease GI upset.

DURING: a. Maintain sterile technique. b. Check IVF patency before administering the medication.

AFTER: a. Tell patient to take all of the drugs as prescribed, even after he feels better.

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b. Make sure that patient will increase OFI as tolerated. c. Instruct patient to notify prescriber about rash or evidence of superinfection. d. Tell patient to notify prescriber about paleness, weakness and heart beat skips; signs and symptoms of hemolytic anemia. e. Report any unexplainred pain or fever that persists for longer than 3-5 days.

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3. Diet

DATE ORDERED TYPE OF DIET DATE PERFORMED DATE CHANGED Diet as Tolerated (DAT) DO: 04/24/09 DP: 04/24-30/09 DC: not changed Nearly normal diet To GENERAL DESCRIPTION INDICATION (S) OR PURPOSES

SPECIFIC FOODS TAKEN

CLIENTS RESPONSE TO DIET

prevent Cup water.

noodles, The AEB

client

responded and on the and and

based on the basic aspiration contents sky four (4) food groups to the lungs. given to patients who are healthy, no restrictions but with precautions in eating.

flakes, well to the treatment patient patients SO verbalized understanding

Arrozcaldo, fudgee water

type

of

diet well

bar, complied

patient did not manifest any sign of dyspnea.

63

NURSING RESPONSIBILITIES:

BEFORE: a. Explain to the patient and SO the purpose of the diet and how the diet can affect the patient b. Check for the doctors order c. Know the indication of the type of diet.

DURING: a. Wash your hands. b. Help the client wash his hands and face in preparation for eating. c. Remove or move any unpleasant visual stimuli such as commodes, bedpans and urinals. d. Have the client sit on the side of the bed or in a chair. e. Check to be sure that the food presented is in fact this clients food and corresponds to what the client ordered. f. Start the meal with a sip of cool beverage to lubricate the inside of the mouth.

AFTER: a. Tell patient to report if she has any reaction against diet or if patient cannot tolerate the diet b. Encourage the client to keep his head up or continue to sit up for at least 15 minutes following the meal. c. Allow client to wash his hands and face if needed. d. Evaluate whether the client had an appetite for the meal. e. Document how well the client tolerated the meal. f. Note any eating difficulties client exhibited.

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4. Activity and Exercise

DATE ORDERED TYPE OF EXERCISE DATE STARTED DATE CHANGED Non-Strenuous Exercise Date Ordered: 04/24/09 Date Started: 04/24/09 Date Changed: not changed Walking, Bedrest. GENERAL DESCRIPTION

INDICATION(S) OR PURPOSE(S) CLIENTS RESPONSE TO THE EXERCISE.

Advised the patient to avoid activities that are strenuous and to have adequate rest periods in order to recuperate and to prevent over exertion of the body, so that the patient keeps up his/her energy. to perform deep breathing exercises to facilitate better oxygenation.

The client responded well.

65

NURSING RESPONSIBILITIES

a. Provide patient with a safe environment to do exercise b. Instruct pts. S.O. to observe client for clients limitations when doing exercise. c. Check the doctors order sheet every shift for the appropriate exercise for the patient d. Strictly follow the ordered exercise to prevent over exhaustion and further complications. e. Explain to the patient the significance of enforcing the exercise and its relevance to the patients condition. Assist the patient accordingly. f. If client shows any unwanted result while doing the prescribed exercise refers accordingly.

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B, NURSING MANAGEMENT PROBLEM # 1: INEFFECTIVE AIRWAY CLEARANCE RELATED TO RETAINED SECRETIONS IN THE BRONCHI AEB NON PRODUCTIVE COUGH ASSESSMENT S = the pt may verbalize dyspnea NURSING DIAGNOSIS Ineffective airway clearance related to retained secretions in the bronchi SCIENTIFIC EXPLANATION Pneumonia is a serious infection and/or inflammation of your lungs. Microorganisms and aenvironmental pollutants irritate the airways resulting to hypersecretion of mucus and inflammation. The constant irritation causes the mucus secreting glands and goblet cells to in number. Ciliary function is reduced and more mucus is produced. The bronchial walls become thickened; the bronchial lumen PLAN SHORT TERM: blish rapport NURSING INTERVENTIONS Esta RATIONALE To obtain pt and SOs trust and cooperation To obtain baseline data To obtain baseline data Tac hypnea is usually present to some degree and may be pronounced on admission or during stress or concurrent acute infectious process c infection, allergic reaction and the stage of chronicity in a client c established cues. So me degree of bronchospasm is present c
EXPECTED OUTCOME

SHORT TERM: The pt shall have demonstra ted behaviors to improve airway clearance e.g., cough effectively and expectorat ed secretions .

O = the pt manifested: Nonproductive cough Yellowish sputum Rales heard on right lung field (04/2829/09) in RR 04/28/09=30 04/29/09=25 Uses

After 4 of NI, the pt Ass will ess pts general demonst condition rate Mon behavior itor & record VS s to improve Ass airway ess/monitor RR. clearanc Note e e.g., inspiratory/expiratory cough ration. effectivel y and expector ate secretio

LONG

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accessory muscles when breathing Crackles (04/28-29/09) Nasal flaring Weakness fatigue

= the pt. May manifest: Chest pain Chronic air hunger Persistent cough c sputum Cyanosis Difficulty speaking sentences (>4 words) Restlessness Pale palpebral conjunctiva and nail beds Tripod position & high fowlers

narrows and mucus may plug the airway. Alveoli adjacent to the bronchioles may become damaged and fibrosed, resulting in altered function of the alveolar macrophages.

ns.

LONG TERM: After 2-7 days of NI, the pt will cultate maintain sounds patent airway c breath sounds clear.

Aus breath

Assi st client to assume position of comfort e.g., elevate HOB, have client lean on an overbed table or sit on edge of bed

obstructions in airway and may or may not be manifested in adventitious breath sounds. Elev ation of HOB facilitates respiratory function by use of gravity; however, client in severe distress will seek the position that most eases breathing. Supporting arms or legs c table, pillow and so on help reduce muscle fatigue. Hyd ration helps decrease the viscosity of secretions, facilitating expectoration. Pro vides client c some means to cope or control dyspnea and reduce air trapping. Cou

TERM: The pt shall have maintaine d patent airway c breath sounds clear.

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position when breathing

according to the pts situation.

gh can be persistent but ineffective. It is most effective in an upright or in a head down position p chest percussion. To promote recovery of illness. To provide proper nutrition as well as prevent further complications.

Incr ease OFI as tolerated (3000 ml/day).

Enc ourage or assist c abdominal or pursed lip breathing exercises Obs erve characteristics of cough. Assist c measures to improve effectiveness of

69

cough effort. Ad minister medications as indicated. Enc ourage a soft diet and DAT PROBLEM # 2: INEFFECTIVE BREATHING PATTERN RELATED TO HYPERVENTILATION AEB RR OF 30 CPM ASSESSMENT S = the pt may verbalize dyspnea NURSING DIAGNOSIS Ineffective breathing pattern related to hyperventilat ion AEB RR of 30 cpm SCIENTIFIC EXPLANATION Pneumonia is a serious infection and/or inflammation of your lungs. Microorganisms and aenvironmental pollutants irritate the airways resulting to hypersecretion of mucus and inflammation. The constant irritation causes the mucus secreting glands and goblet cells to in number. Ciliary function is reduced PLAN SHORT TERM: ablish rapport NURSING INTERVENTIONS Est RATIONALE To obtain pts trust and cooperation To obtain baseline data
EXPECTED OUTCOME

SHORT TERM: The pt shall have demonstra ted appropriat e coping behaviors.

O = the pt manifested: Nonproductive cough Yellowish sputum Rales heard on right lung field (04/2829/09) in RR

After 4 Ass of NI, ess pts general the pt condition will be Mon To able to itor and record VS obtain baseline data demonst Ass rate ess/monitor RR. appropri Tac Note ate hypnea is usually inspiratory/expiratory coping present to some ration. degree and may be behavior pronounced on s. admission or during stress or concurrent acute infectious

LONG TERM:

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04/28/09=30 04/29/09=25 Uses accessory muscles when breathing Crackles (04/28-29/09) Nasal flaring Weakness fatigue

= the pt. May manifest: Chest pain Chronic air hunger Persistent cough c sputum Cyanosis Difficulty speaking sentences (>4 words) Restlessness Pale palpebral

and more mucus is produced. The bronchial walls become thickened; the bronchial lumen narrows and mucus may plug the airway. Alveoli adjacent to the bronchioles may become damaged and fibrosed, resulting in altered function of the alveolar macrophages.

LONG TERM: After 2 days of Ni, the pt will establish a normal respirato ry pattern AEB RR of 17 cpm.

cultate sounds

process c infection, allergic reaction and the stage of chronicity in a client c established cues. So me degree of bronchospasm is present c obstructions in airway and may or may not be manifested in adventitious breath sounds. Elev Aus ation of HOB breath facilitates respiratory function by use of gravity; however, client in severe distress will seek the position that most eases breathing. Supporting arms or legs c table, pillow and so on help reduce muscle fatigue. Hyd ration helps decrease the Assi viscosity of

The pt shall have establishe d a normal respiratory pattern AEB RR of 17 cpm.

71

conjunctiva and nail beds Tripod position & high fowlers position when breathing

st client to assume secretions, position of comfort facilitating e.g., elevate HOB, expectoration. have client lean on Pro an overbed table or vides client c some sit on edge of bed means to cope or according to the pts control dyspnea and situation. reduce air trapping. Cou gh can be persistent but ineffective. It is most effective in an upright or in a head down position p chest percussion. To promote recovery of illness. To provide proper nutrition as well as prevent further complications.

Incr ease OFI as tolerated (3000 ml/day).

Enc ourage or assist c abdominal or pursed lip breathing exercises

72

Obs erve characteristics of cough. Assist c measures to improve effectiveness of cough effort.

Ad minister medications as indicated. Enc ourage a soft diet and DAT

PROBLEM #3: HYPERTHERMIA

73

ASSESSMENT S = nilalagnat parin siya as verbalized by SO

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION Bacterial infection could trigger the inflammatory process which fights the infection. Several inflammatory chemicals are released. One of which is prostaglandin that increases the set pont of the body temperature causing hyperthermia. PLAN SHORT TERM: After 4 hours of nursing intervent ions the patient will manifest decreas e in temp. from 38.2 to 37.4 oC

NURSING INTERVENTIONS Establish rapport Assess and record VS Assess patients general condition provide am care and loosen clothing Carry out TSB and encourage pts SO to perform TSB if body temp. continues to rise provide adequate rest encour age deep breathing keep patient back dry Administered Paracetamol as ordered

RATIONALE To gain trust and cooperation To have baseline data To identify plans of nursing care to provide comfort to the client to help decrease the patients fever

EXPECTED OUTCOME

Hyperther mia

SHORT TERM: After 4 hours of nursing interventio ns the patient shall manifest decreased in temp. from 38.2 to 37.4 oC

O= The patient manifested: skin is warm to touch with cracked lips and dry mouth with good skin turgor with pink palpebral conjunctiva with clear nasal secretions incre ased temperature of 38.2 last 04/25/09 slight increase in RR: 28 cpm (04/25/09) swea ting thirst

LONG TERM: After 2 days of nursing intervent ions the patient will maintain core temp. within normal range AEB 74 absence of fever

to decrease oxygen consumption to maintain airway to prevent the occurrence of cough and colds To lower down fever

LONG TERM: After 2 days of nursing interventio ns the patient shall maintain core temp. within normal range AEB absence of fever

=The patient may manifest: s dration Dehy Chill

PROBLEM #4: DISTURBED SLEEP PATTERN RELATED TO FATIGUE AND UNFAMILIAR ENVIRONMENT NURSING
DIAGNOSIS

ASSESSMENT S=Hindi ako nakatulog kagabi as verbalized by the patient

SCIENTIFIC EXPLANATION Because of the unfamiliar environment, the noise, heat and light irritates the patient causing him to have difficulty of sleeping.

PLAN SHORT TERM: After 4 hours of NI, the patient will demonst rate improve ment on

NURSING INTERVENTIONS Establish rapport

EXPECTED

RATIONALE to obtain patient and So trust and cooperation to obtain baseline data to obtain baseline data for baseline data

OUTCOME

Sleep pattern disturbance related to fatigue and O= the patient unfamiliar manifested: environmen t Round circles around the eyes Nonproductive cough Yellowish

LONG TERM:

Assess pts general condition monitor and record vital signs note environmental factors affecting sleep determine patients

to

be

able

The pt Shall demonstra te improvem ent on her sleep pattern by to doing the

75

sputum Rales heard on right lung field (04/28-29/09) in RR 04/28/09=30 04/29/09=25 Uses accessory muscles when breathing Crackles (04/28-29/09) Nasal flaring Weakness fatigue =the patient may manifest: irritability listlessness lethargy restlessness

her sleep pattern by doing the health teaching s given

usual sleep pattern and expectations Observe physical signs of fatigue avoid eating large evening or late night meals support continuation of usual bedtime rituals Restrict intake of caffeine-containing foods or fluids

monitor and check health for sleeping teachings patterns given to provide comfort because they impair ability to sleep at night promotes relaxation and readiness for sleep Caffeine may delay patients falling asleep and interfere with rapid eye movement sleep, resulting in patient not feeling well rested. to provide comfort and aid for sleeping

LONG TERM: After 3 days of NI, the patient will demonst rate good sleep pattern.

LONG TERM: The pt Shall demonstra te good sleep pattern.

provide quiet environment and comfort measures like back rub, cleaning and straightening bed linens in

76

preparation sleep

for

77

PROBLEM # 5: RISK FOR DEFICIENT FLUID VOLUME

PROBLEM # 6: RISK FOR FURTHER SPREAD INFECTION AEB WBC COUNT OF 21.5 SECONDARY TO BACTEREMIA SCIENTIFIC NURSING EXPECTED NURSING ASSESSMENTNURSING PLAN RATIONALE EXPECTED ASSESSMENT SCIENTIFIC PLAN NURSING RATIONALE DIAGNOSIS OUTCOME EXPLANATION INTERVENTIONS DIAGNOSIS OUTCOME S=O Risk for When fever Short Term: INTERVENTIONS Short Establis To EXPLANATION O= The patient Deficient occurs there is After 4hrs of h Rapport establish Nurse- Term: manifested: Fluid increased NI the SO will The SO S= Risk for Bacteremia is the SHORT Es Patient relationship To SHORT Volume metabolic rate verbalize shall have Non-productive further presence of viable TERM: ToTERM: tablish rapport Assessobtain pts trust in inresponse understandin verbalized O =cough the pt infection bacteria the blood toAfter 4 of and cooperation pt general condition obtain baseline The data pt and workloadNI, gthe about the Bacteremia pt SO shall have manifested: Yellowish AEB WBC stream.the As To Monitor To understan the need ding of the count of is different from and SO will to sess identified sputum Nonpts general obtainobtain baseline and record VS baseline data hypothalamus breastfeed Health 21.5 sepsis (so-called identify interventions productive Rales heard on condition data Encoura To w/c leads to teachings secondary blood poisoning or intervention to prevent or cough right lung field M ge rest prevent To insensible insensible fluid Long Term: of the toxemia), which is a s to prevent reduce the (04/28-29/09) Yellowish to onitor and record obtainfluid loss baseline loss w/c mayor After 2-3 need to Bacteremia condition where reduce risk or spread sputum in RR VS data Encoura To eventually days of NI breastfeed bacteremia is the risk or of secondary Rales 04/28/09=30 In Alt ge increase fluid prevent dehydration develop intospread the of patient associated with an infection. heard on 04/29/09=25 the client hough pt may find intake dehydration will maintain struct Long inflammatory secondary lungaccessory right Uses concerning the expectoration to fluid volume response from the infection. LONG Term: field (04/28- when disposition of offensive and muscles increase nutritional at functional body (causing LONG TERM:The 29/09) secretions (raising attempt to limit or breathing Encoura intake level and will patient systemic TERM: The pt shall in RR (04/28and it, it is Crackles geexpectorating to eat foods rich avoid in have inflammatory After 2-7 good have shall have vs. vitamin swallowing) essential that 29/09) C and protein to achieved skin maintain response syndrome, days ofturgor. NI, 04/28/09=30 and reporting sputum be Nasal flaring regulate ensure adequate characterised by the pt will timely fluid changes disposed of in a IVF in color, nutritional Weakness volume at rapid breathing, low achieve resolution of 04/29/09=25 amount and odor safe requirement. manner. functional blood pressure, timely current fatigue of in Uses secretions. InstructChanges Toinfection level and fever, etc.). resolution of s The patient may characteristics of accessory have good current complications the So to keep pt. prevent worsening mainifest: sputum reflect muscles skin turgor infection s Back dry of condition . dehydrati resolution of PNU when complicatio Administ Promot on er meds e wellness pallor lethargy

78

breathing Crackles (04/2829/09) Nasal flaring Weaknes s fatigue

ns.

= The pt may manifest: Persistent productive cough Fever Severe DOB d/t inflammatio n Restlessn ess Excessive mucus production Adventitio us sounds

or development of secondary infection. D Eff emonstrate and ective means of encourage good reducing spread or hand washing acquisition of technique. infection. C Pr hange position omotes frequently and expectoration, provide good clearing of pulmonary toilet. infection A Th dminister ese are used to antimicrobials as combat most of the indicated by microbial PNU. results of sputum or blood cultures. M Sig onitor ns of improvement effectiveness of in condition should antimicrobial occur c in 24-48 therapy. hrs. Pr E ovides client c ncourage or assist some means to c abdominal or cope or control pursed lip dyspnea and breathing reduce air exercises trapping. To A promote recovery

79

dminister medications indicated.

of illness. as To provide proper nutrition as well as prevent further complications.

E ncourage a soft diet and DAT

PROBLEM # 7: RISK FOR CONSTIPATION RELATED TO INSUFFICIENT PHYSICAL MOBILITY SECONDARY WEAKNESS AND FATIGUE ASSESSMENT S = The pt may verbalize absence of defecation for 2 days NURSING DIAGNOSIS Risk for constipation related to insufficient physical mobility secondary weakness and fatigue SCIENTIFIC EXPLANATION Constipation is an abnormal in frequency or irregularity at defecation, abnormal hardening of stools that makes their passage difficult and sometimes PLAN SHORT TERM: After 4 of NI, the pt and So will verbaliz e underst NURSING INTERVENTIONS Esta RATIONALE
EXPECTED OUTCOME

O = the pt manifested:

To blish rapport obtain pts trust and cooperation To Ass obtain baseline data ess pts general To condition obtain baseline data Mon Dat itor and record VS a required as Asc baseline for future ertain usual evaluation of

SHORT TERM: The pt and So shall have verbalized understandi ng of factors and appropriate

80

Fatigue Weakness Change in bowel pattern Hypoactive bowel sounds Irritability = The pt may manifest: Abdominal pain Nausea Vomiting Straining Dry, hard formed stool Distended abdomen Anorexia Restlessness Abdominal cramping headache

painful, a decrease in stool volume or retention of the stool in the rectum for a prolonged period. Any variation from normal habits may be considered a problem.

anding elimination habits. therapeutic needs. Defi of nes the problem. factors Constipation is one and of the earliest signs appropri Ass of neurotoxicity. ate ess bowel sounds interven and monitor or record bowel tions or movements solution including frequency, Inad s consistency. equate fluid intake related Mon may potentate to itor I&O and weight. constipation and individu Encourage increase stimulates al OFI, fiber in diet and peristalsis. situatio exercise as tolerated. n. Furt her interventions or alternative bowel LONG care may be Che TERM: needed. ck for impaction if After 1client has not yet had bowel 2 days movement in 3 days of NI, or if abdominal the pt distention, will cramping, headache maintai are present. n usual Elec Mon trolyte imbalances bowel itor lab results as

intervention s or solutions related to individual situation.

LONG TERM: The pt shall have maintained usual bowel consistency .

81

consiste ncy.

may be the result of or contribute to altered GI function. Prev ents DHN and may soften stool. Prov Adm ides client c some inister IV fluids. means to cope or control dyspnea and reduce air trapping. Enc To ourage or assist c promote recovery of abdominal or pursed illness. lip breathing exercises Adm inister medications as indicated. Enc ourage a soft diet and DAT To provide proper nutrition as well as prevent further complications.

indicated.

PROBLEM # 8: READINESS FOR ENHANCED THERAPEUTIC REGIMEN MANAGEMENT RELATED TO UNEXPECTED ACCELERATION OF ILLNESS SYMPTOMS

82

ASSESSMENT S=

NURSING DIAGNOSIS Readiness for enhanced therapeutic regimen managemen t related to unexpected acceleration of illness symptoms

SCIENTIFIC EXPLANATION This is a pattern of regulating and integrating into daily living program for treatment of illness and its recovery that is sufficient for meeting health related goals and can be strengthened.

PLAN SHORT TERM: After 4 of NI, the pt and SO will verbaliz e and demons trate underst anding for continui ty of care.

NURSING INTERVENTIONS Estab lish rapport

RATIONALE

EXPECTED OUTCOME

O = the pt manifested: Good skin turgor Nourished skin Diminished adventitious sounds (crackles) Diminished sputum production Diminished feelings of weakness and fatigue Pinkish palpebral conjunctiva and nail beds

LONG TERM: After 5 days of Ni, the pt will

To obtain pts trust and cooperation To Asses obtain baseline s pts general data condition To Monit obtain baseline or and record VS data provid pro e information and motes early help client or SO recognition of identify and evaluate changes, allowing resources they can proactive response access on their own assist to client to develop strategies for encourage monitoring continuation of therapeutic regimen desired behaviors provid e positive for reinforcement for optimizing efforts outcomes prom ote client and SO participation for identif follow-up care y home and community base

SHORT TERM: The pt and SO shall have verbalized and demonstrate d understandin g for continuity of care.

LONG TERM: The pt shall have remained free from preventable complication

83

= The pt may manifest: Normal VS Increase in muscle strength Absence of nasal flaring Absence of food aversion

remain free from prevent able complic ations or progres sion of illness.

health care setting to ensure understanding of the health teachings Pr ovides client c some means to cope or control dyspnea and Admi reduce air nister medications as trapping. indicated. To Enco promote recovery urage a soft diet and of illness. DAT To provide proper nutrition as well as prevent further complications. Enco urage or assist c abdominal or pursed lip breathing exercises

s or progression of illness.

84

ACTUAL SOAPIERs April 28, 2009 S O > > Malangi ku kuku at magpalwal kung plema pag manguku ku Received on bed, supine position, conscious, coherent, and conversant with an ongoing IVF of #6 D5LRS x 1 gtts/min @ 950cc level, infusing well on right hand with no signs of infiltration, with shallow and fast breathing pattern; with CRT of <2 seconds; with long finger nails; with good skin turgor; with thin physical appearance; with productive cough with yellowish green sputum; with presence of rales on right middle and lower lung field upon auscultation; with initial VS of T= 37.5, P = 102, R = 40 A > Ineffective airway clearance related tp retained secretions in the bronchi secondary to disease condition P > After 3 hours of Nursing Interventions, the patient will demonstrate reduction of congestion AEB reduction of breath sounds and noiseless respirations. I > Established rapport

> Assessed pts general condition > > > > > > Monitored, assessed and recorded VS Ausculatated breath sounds Regulated the IVF Provided Comfort measures Observed for signs and symptoms of infection Instructed about proper positioning

85

> > > > > > E >

Encouraged deep breathing and coughing exercises Performed Back rubs Elevated HOB Demonstrated proper breathing exercises Instructed to increase Oral Fluid Intake as tolerated Observed for signs and symptoms of respiratory depression
Goal met AEB the patients demonstration of reduction of congestion

AEB reduction of breath sounds and noiseless respiration. April 29, 2009 S O > > Received patient lying on bed; awake; c an ongoing IVF of #7 D5LRS 1L x 15 gtts/min @ 710 cc level infusing well on the right metacarpal vein; c normal capillary refill of < 3 sec; c pinkish palpebral conjuctiva; c normal skin turgor of < 3 sec; c absence of inflammation; c absence of pallor/cyanosis; c presence of clear nasal discharges; c non prodctive cough; c clear sputum; c crackles heard on the right lung field upon auscultation; c ansence of weakness and fatigue; c VS taken and recorded as follors: AT-37C; PR=100 bpm; RR= 25 cpm. A > Ineffective airway clearance related tp retained secretions in the bronchi P > After 4-5 hours of NI, the pt will demonstrate an improvement in airway patency I > Established rapport

> Assessed pts general condition

86

> Monitored and recorded VS > Noted RR, use of accessory muscles and if there is presence of pallor/cyanosis > Auscultated breath sounds > Elevated HOB > Kept back dry > DAT reinstructed > Encouraged frequent position changes > Reviewed Oxygen conserving techniques to pt and SO > Encouraged rest periods > Emphasized importance of increasing OFI c in cardiac tolerance > Emphasized importance of treatment regimen > Due meds given > IVO @ 7:00 PM > Needs attended > Endorsed E > Goal met AEB the pt will demonstrate an improvement in airway patency AEB less crackles heard upon auscultation and an RR of 14 cpm.

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VI. CLIENTS DAILY PROGRESS CHART DAYS 24 25 26 27 28 29 30

NURSING PROBLEMS 1. Ineffective Airway Clearance 2. Impaired Breathing Pattern 3. Hyperthermia 4. Sleep Disturbance 5. Risk For Deficient Fluid Volume 6. Risk For Further Spread Of Infection 7. Risk For Constipation 8. Readiness For Enhance Therapeutic Regimen * * * * * * * * * * * * * * * * * * * * * * * * * * *

* *

VITAL SIGNS TEMPERATURE PULSE RATE RESPIRATORY RATE 36c 80 bpm 25 bpm 38.2c 94 bpm 28 bpm 36.5c 86 bpm 25 bpm 36.7c 83 bpm 38 bpm 37c 84bpm 30 bpm 36.4c 90 bpm 14 bpm 36.1c 53 bpm 23 bpm

DIAGNOSTIC / LABORATORY PROCEDURES 1. CBC (Complete *

88

Blood Count) 2. Chest X-ray 3. AFB A. IVF 1. PLRS 2. D5LRS B. Drugs 1. Paracetamol 2. Cefuroxime C. Diet 1. DAT D. Exercise 1. Non Strenuous Activities
DISCHARGE PLANNING S O > >

* * * * MEDICAL MANAGEMENT * * * * * * * * * * *

* * *

* * *

* * *

* * *

* * *

* * *

Received pt lying in a high fowlers position; awake; conscious and coherent; c an ongoing IVF of # 8 D5LRS 1L x 15 gtts/min @ 610 cc level infusing well on the right metacarpal vein; c absence of cyanosis; c minimal productive cough; c crackles upon auscultation heard on the right lobe; c absence of weakness and fatigue; c absence of weakness and fatigue; c absence of food aversion; c good skin turgor of less than 3 seconds; c normal capillary refill time of less than 3 seconds; c VS taken and recorded as follows: AT=36.1C; PR=53 bpm; RR=23 cpm;

A P

> >

for home maintenance and management After 4 of NO, the pt and SO will verbalize understanding of health teachings given regarding home maintenance and management.

M E

> >

Cefuroxime 500 mg BID x 5 days Encouraged deep breathing and coughing exercises

89

Promoted adequate rest T H > > Instructed to comply c the therapy regimen Encourage to keep area from allergens Advised SO to position the client to high fowlers position if patient has presence of DOB Encouraged adequate OFI as tolerated Encouraged proper hygiene and proper handwashing O > Instructed pt and SO to come back to OPD after 1 week for follow up check up D E > > Encouraged to eat foods rich in Vitamin C and protein.

Goal met AEB pt and SO verbalized understanding of health teachings given regarding home maintenance and management.

VII. CONCLUSION AND RECOMMENDATION

In conclusion, Pediatric Nursing is an important branch of nursing. As mentioned in the quote at the start of the introduction, children are the living messages we send to a time we will not see. Because children are the future of the world, it is important that there will be a specialized branch of nursing dedicated to them.

Bacteremia is a disease that can be easily prevented. There is a saying that states that Prevention is better than cure watching out for little children and practicing good hygienic habits will greatly decrease the chance of acquiring

90

disease. Handwashing is also important because it is the single most effective way of preventing the spread of transfer of diseases.

Many lessons can be made from clinical duties. One lesson is on how to better care for patients with diseases like bacteremia. Also seeing the condition in the Philippines, where it seems that a lot of people do not know about good hygienic practices, health education is very important and that is very helpful in preventing the spread of diseases. Also, informing the patients or if not available, his/her significant others about the proper adherence to treatment plans, for example the use of antibiotics will help in the full recovery of the patient.

At the course of the study, the researchers had found out that an in-depth knowledge about the disease process will benefit not only the patient and his/her family but also the nurse and the medical staff as well. The following is a list of recommendations made by the researcher:

For the Nurses: An in-depth knowledge should be acquired regarding the disease condition so that proper treatment and prevention can be implemented. Nurses must stress the need for good prenatal care and emphasize on parents, the value of regular check-ups at wellbaby clinics. Proper infection control especially strict hand washing should be implemented in the hospital because it is the most effective method in controlling the spread of infection from staff to patient. For the hospital:

91

sterility or cleanliness of hospital equipment should be maintained Seminars about infection control should be conducted so that hospital staff will be knowledgeable in the prevention of infection from spreading.

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BIBLIOGRAPHY Books: Allbough, B., and Gettrust, K. (1994). Plans of Care for Specialty Practice: Medical Nursing. Albany, NY: Delmar Publisher Inc. Doenges, M., et., al. (2006). Nurses Pocket Guide: Diagnoses, Prioritized, Interventions, and Rationale (10th edition). Philadelphia: F.A. Davis Company Rabe KF, Hurd S, Anzueto A, et al (2007). "Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: GOLD Executive Summary". Am. J. Respir. Crit. Care Med. 176 (6): 53255. Smeltzer, S., et., al.(2008). Brunner and Suddarths Textbook of MedicalSurgical nursing (11th edition). Philadelphia: Lippincott Williams and Wilkins Spratto, G., and Woods, A. (2008). 2008 Edition PDR Nurses Drug Handbook. Clifton Park, NY: Thomson Delmar Learning Websites:

http://www.lungusa.org/site/apps/nlnet/content3.aspx? c=dvLUK9O0E&b=2060321&content_id={71CC3CFD-4B3E-49C8-AA88D76EAE1FB9F5}&notoc=1 http://www.nlm.nih.gov/medlineplus/ency/article/003724.htm http://www.health.am/diseases/more/acid_fast_bacilli_stain/ http://www.ncbi.nlm.nih.gov/pubmed/17047905 http://www.ncbi.nlm.nih.gov/pubmed/6349346 http://www.merck.com/mmpe/sec14/ch167/ch167g.html http://emedicine.medscape.com/article/961169-overview

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http://en.wikipedia.org/wiki/Bacteremia

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