Introduction

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When wealth is lost, nothing is lost. When health is lost, something is lost. When character is lost, all is lost. Billy Graham

Acute biologic crisis is any condition that may result to patient mortality if left untreated in a brief period of time; it also refers to patient condition that warrants immediate attention for the reversal of disease process and prevention of further morbidity and mortality. (Smeltzer, S.2010) Septic encephalopathy is caused by systemic inflammation in the absence of direct brain infection and clinically characterized by slowing of mental processes, impaired attention, disorientation, delirium or coma. Importantly, septic encephalopathy is an early sign of sepsis and associated with an increased rate of morbidity and mortality. The pathogenesis of septic encephalopathy is unlikely to be directly induced by a pathogenic toxin, as similar encephalopathy can develop as a result of a number of systemic inflammatory response syndromes that lack an infectious etiology. (Medicaldictionary.com) Despite advances in modern medicine, the number of sepsis cases continues to increase dramatically. Sepsis and its complications are the leading causes of mortality in intensive care units accounting for 1050% of deaths, contributing to 750,000 cases per year in the United States. More than 70% of these patients have underlying comorbidities and more than 60% of these cases occur in those aged 65 years and older. (doh.gov.ph) Globally, the statistics are even more staggering: an estimated 18 million cases of sepsis occur each year. In the Philippines, although only 2% of patients were hospitalized for it, it accounted for 17% of all hospital deaths. Since most of the patients being hospitalized for sepsis were over 65. In Davao, there were 121 reported cases of sepsis out of the total population of 1,353,394 in the year 2012. (davaohealth.brinkster.net) The group clients SG, is 37 years old. He is diagnosed with septic encephalopathy. Our group decided to have patient SG as the topic for the case study since his condition can be considered rare. Also, it fits with our concept of Acute Biologic Crisis for patients with the said condition truly needs close and intensive monitoring or care. As student nurses, we contribute to the implications of the nursing profession namely; nursing education, nursing practice and nursing research.

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This case study would be an extreme assistance to the total development in the nursing education of the group for a reason that it would be added to the broad array of knowledge needed for the skills which the group could use in their potential profession and related line of work. Furthermore, as student nurses, the group aspires to provide suitable care and interventions to our client and upcoming clients. Through this case study, the group demonstrates and implements appropriate interventions that were learned and practiced in school. It will aid in enhancing our abilities to a more multifaceted setting in the hospital and lead our clients to a better quality of life. In the search for new discoveries for treatment and management of the disease, this case study aims to be a helpful tool in promoting further investigation and additional studies in aiming to determine the best cure to the disease.

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OBJECTIVES

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GENERAL OBJECTIVE:
That within our three weeks span of hospital exposure at Intensive Care Unit (ICU), the BSN 4E Group 3 Subgroup 2 will be able to comprehensively formulate a case study with at most honesty and confidentiality regarding the client utilizing the learning from Acute Biologic Crisis (ABC) and apply appropriate nursing interventions to uphold holistic patient care.

SPECIFIC OBJECTIVES:
The group aims to: a. Provide a brief overview, presenting the basic understanding about the case, its incidence and prevalence, globally and locally; b. impart the importance of this case study to nursing education, practice and research; c. formulate specific, measurable, attainable, realistic and time-bound objectives; d. gather the pertinent data that would aid in making this study; e. trace down family health history of the client including the past and present status through genogram and narrative form; f. discuss clients developmental task from the theories of Erik Erikson and Robert Havighurst; g. relate with the applicable theories of nursing; h. give detailed definitions of the complete diagnoses from at least three references; i. assess clients physical state from head to toe using a comprehensive and precise inspection, palpation, percussion and auscultation; j. discuss the anatomy and physiology of all the affected body systems particularly the skeletal, integument and central nervous system; k. trace the pathophysiology of the final diagnoses of our client; l. enumerate the precipitation and predisposing factors that could have possibly lead to the disease; m. identify the symptoms that are present in the client; n. provide the definition, essential features, ideal results and interpretations from the actual and possible diagnostic exams; o. compile drug studies from all the medications given to the client;

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p. present an effective, well coordinated, and goal-directed nursing care plans appropriate for the client; q. formulate the discharge plan using the METHOD approach; r. evaluate the prognosis of the disease condition; and

s. Cite the references used in constructing the study.

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Data Base

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A. Biographical Data

Name: Gender: Age: Birthday: Place of Birth: Civil Status: Occupation: Nationality: Address: Religion: Number of Siblings: Fathers Name: Educational attainment: Occupation: Mothers Name: Educational attainment: Occupation:

Patient SG Male 37 years old May 11, 1975 Makilala North Cotabato Married Farmer Filipino Purok Batasan Makilala Roman Catholic 4 FG Elementary Graduate Farmer CG High school Graduate Housewife

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B. Clinical Data Chief Complaint: Date of Admission: Room #: Attending Physician: Tentative Diagnosis: changes in sensorium January 12, 2013 @ 6:00 am ICU 16 Dr. Judy Anne Gatmin Yuzon, MD Septic Encephalopathy secondary to

urosepsis r/o typhoid psychosis

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Health History
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Past Health Histoy

Patient SG was born via normal spontaneous vaginal delivery on cephalic presentation and without any complication. He was delivered at a hospital at their home. He was breastfed exclusive for about 1 year and 11 months then shifted to formula milk up to 5 years of age. He has never experienced allergies, chicken pox, and mumps during his childhood years as reported. Patient SG is a non-smoker and drinks only during occasions. Also, there were no accidents or serious injuries that had been experienced. Aside from common colds and cough, only occasional drinking was found related to his present condition. He has no childhood hospitalizations.
1 Measles 3 OPV 3 Hepa B

IMMUNIZATIONS 1 BCG 3 DPT

Present Health History

Two weeks prior to his admission, patient experienced intermittent moderate high grade fever associated with body malaise. He then self medicated with Paracetamol 500mg tab. The condition persisted for a week thus he decided to seek for medical help at a local hospital in Bansalan where he was managed as a case of typhoid fever. However, five days later, there was onset of bipedal edema and jaundice. Hence, he was referred to Southern Philippines Medical Center. There He was informed of having liver problem and pleural effusion, but there was a decrease in his edema and jaundice. A day prior to his admission, patient experienced changes in sensorium, thus the family decided to transfer to San Pedro Hospital for further test.

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Patient SG is a non-smoker and occasionally drinks. He also observed a healthy diet and is not a fan of fatty and fried food

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Genogram Narrative
Basing on the trace genogram of patient SG, it revealed that on his maternal side, both of his grandparents were hypertensive and have died. They have three siblings, Roberto 68 years old, Senyo 70 years old, both are alive and well. While our patients mother, CG 65 years old is deceased and our patient cannot recall the reason behind. On the paternal side, our patients grandmother had diabetes and died at the age of 65, while his grandfather had hypertension and died at the age of 61. They have four children. Namely Erlinda 58 years old, Dolor, 49 years old, both are alive and well. While Elenor who is 52 years old have hypertension and our patients father, EG had died at the age of 63, still our patient cannot recall the reason of his fathers death. Mrs. CG and Mr. EG have four children. These are Linda, who had hypertension and died at the age of 43. On the other hand, Ramon, who is 40 years old and Armando who is 35 years old are alive and well. Moreover, our patient, a 37 years old, have not inherited any of the mentioned diseases, but currently suffers from septic encephalopathy.

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Maternal Side
W 67

Paternal Side
X 53
Y 65 Z 61

CG 65

Roberto 68

Senyo 70

EG 63

Erlinda 58

Elenor 52

Dolor 49

Linda 43

Ramon 40

Patient SG 37

Armando 35

Legend: Hypertension Diabetes Diseased Alive & Well Female Male Patient

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Developmental Task

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Psychosocial Development ( Generativity vs Stagnation) Erik Erikson adapted and expanded Freuds theory of development to include the entire life span, believing that people continue to develop throughout life. According to Erikson's theory, personality development goes through a series of eight, hierarchically ordered stages. Associated with each stage is a psychosocial crisis that the individual either successfully resolves or fails to resolve. Erikson believes that the more success an individual has at each developmental stage, the healthier the personality of the individual. Failure to complete any developmental stage influences the persons ability to progress to the next level. He described eight stages of development. Eriksons eight stages reflect both positive and negative aspects of the critical life periods. The resolution of the conflicts at each stage enables the person to function effectively in society. Patient X belongs to middle adulthood. Middle adulthood starts between the ages of approximately 40 and 65. During this time, adults strive to create or nurture things that will outlast them; often by having children or contributing to positive changes that benefits other people. Contributing to society and doing things to benefit future generations are important needs at the generativity versus stagnation stage of development. Generativity refers to "making your mark" on the world, through caring for others, creating things and accomplishing things that make the world a better place. Stagnation refers to the failure to find a way to contribute. These individuals may feel disconnected or uninvolved with their community and with society as a whole. Those who are successful during this phase will feel that they are contributing to the world by being active in their home and community. Those who fail to attain this skill will feel unproductive and uninvolved in the world.

Psychosocial Conflict: Generativity Versus Stagnation

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Major Question: "How can I contribute to the world? Basic Virtue: Care Important Event(s): Parenthood and Work Patient SG was able to achieve this task fully because he had a family of his own. He was also able to have a stable job for years and, he was also able to fulfill his role in the society and that is to race his own child for he has two children. Psychosocial Development (Adolescence) Robert Havighurst believed that learning is basic to life and that people continue to learn throughout life. He described growth and development as occurring during six stages, each associated with six to ten tasks to be learned. Havighursts developmental tasks provide a framework that the nurse can use to evaluate a persons general accomplishments. However, some nurses find that the broad categories limit its usefulness as a tool in assessing specific accomplishments, particularly those of infancy and childhood. In a multi-cultural society, the definition of success as well, making these task less relevant for some. Patient SG is now 37 years old which categorized him in middle adulthood. The tasks in this stage which he is expected to accomplish are as follows: Task Achieved or not achieved 1. accepting and adjusting to physiological changes, such as menopause/andropau se Not Achieved 2. reaching and maintaining Patient verbalized how tiring his work is and wishes, if given a chance to look for alternative jobs.
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Justification

Achieved

Patient

verbalized

that

physiological changes is expected as a person ages.

satisfaction in one's occupation 3. adjusting to and possibly caring for aging parents Not Achieved Patient X was not able to take care of his parents before they died and was not able to support them.
Not Achieved 4. helping teenage children to become responsible adults 5. achieving adult social Achieved Our patient achieved this task. He was able to pay taxes in the government and at the same time worked for his familys needs. Achieved 6. relating to one's spouse as a person Patient SG verbalized that they have a good relationship with his wife and seldom experience quarrels. Also, he added when they have Patients children are not yet at teenage years.

and civic responsibility

misunderstandings, they are able to resolve it before the end of the day. Achieved 7. developing leisure-time activities Patient identified spending quality time with his family specifically with his children as his leisure time.

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PHYSICAL ASSESSMENT

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Date and time of Assessment: January 15, 2013 @ 9:00 AM GENERAL SURVEY Patient SG, 37 years old, stands 5 feet and 2 inches and weighs 43 kilograms. She has a BMI of 19.7 kg/m2, underweight. He has an ectomorph type of body built. Upon assessment he was wearing a hospital gown. He was lying on bed and awake. He has dry, frizzy, coarse and medium-length hair. He has an IVF of PNSS 1L at 80cc/hour with side drip of Albumin 20% 50cc to run for 12 hours infusing well at his left metacarpal vein at 350 cc level. He has a nasogastric tube french 14t at his right nostril. Body odor was not noted. He was able to maintain eye contact during the interview and was able to answer our questions appropriately. He also did not appear irritable and confused. VITAL SIGNS Normal Values Temperature Respiratory Rate Cardiac Rate Pulse Rate Blood Pressure 36.5-37.5 C 16-20 cpm 70-80 bpm 70-80 bpm 90/60-130/90 mmHg Actual Findings 36.7 C 19 cpm 73 bpm 71 bpm 120/80 mmHg

Skin Upon inspection, his skin color is brown and is generally uniform. He has good skin turgor which felt rough with capillary refill of 2 seconds. Skin temperature was generally warm; it is uniform in temperature and within normal range. Cyanosis was not noted. Petechial rash not noted. There was no evidence of bruising and lesions. Jaundice at sole was noted. Grade one edema at righ hand, forearm and foot was noted.
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Hair Upon inspection, he has dry, frizzy, coarse and medium-length hair. His hair color is black with brown hair color at the end. There is no presence of infections or infestations noted. Hirsutism was not noted. Nails Upon inspection, fingernail plates shape was on convex curvature and the angle of nail plate is about 160 degrees. The nails were not properly trimmed. The texture of fingernails and toenails was smooth. The tissue surrounding the nails was intact. Blanch test was performed to test for his capillary refill. He had a capillary refill of 2 seconds. Head Upon inspection, the skull was normocephalic and round in shape. No mass or lesions were noted. Eyes Upon inspection, his eyebrows were evenly distributed, no flakes noted, skin was intact. Eyelashes were equally distributed and slightly curled outward. Pus discharge were not noted. Bulbar conjunctiva was transparent, capillaries were visible, and with slightly yellowish sclera. Palpebral conjunctiva was shiny but slightly pale. Upon inspection and palpation of the lacrimal sac and nasolabial duct, there was no edema, tearing or tender. His cornea is clear and shiny making the iris visible. The pupil was black in color, and 2mm in diameter if stimulated with light. There was no cloudiness noted. His pupil constricts when looking at a near object and dilate when looking at a far object. Visual acuity was also tested by letting our patient rewrite the sentence that was written on a bond paper, and he was able to rewrite it at a distance of 20 cm. our patient was not using any eyeglasses. Ears Upon inspection of the auricles for color, symmetry of size and position, both has the same color as the facial skin and is aligned with the outer canthus of the eye. Upon palpation of the auricles for texture, elasticity and areas of tenderness, the auricles are
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mobile, senile, and not tender; pinna recoils after it is folded. Lesions, masses, tenderness and swelling were not noted. No inflammation noted as well. For the external ear canal and tympanic membrane, upon inspection the ear contains hair follicles, and impacted cerumen with yellowish brown color. Gross hearing acuity test was also determined by the watch tick test, a watch was placed near his ear while occluding the other. He was not able to hear ticking in both ears though he is able to hear the tone of our voices around him. Nose Upon inspection, the nose was of the same color as of the rest of the face, was along the center of client's face, with the nasal septum and nasolabial fold along the midline. There were no deviations across the bridge of the nose and the septum. Nasal flaring was not observed, and no discharges were noted. The nasal mucosa was pinkish. Facial sinuses were not protruding. Upon palpation, there were no displacements of the bone and cartilage of the nose, as well as any tenderness and masses. Both nares were patent. Frontal, ethmoid, sphenoid and maxillary sinuses were non-tender. A nasogastric tube was inserted through his right nostril. Client was immediately able to smell the aroma of coffee, alcohol and perfume. Mouth Upon inspection of the outer lips for contour and color, the outer lips are dry and pale pink in color. Lesions and swelling were not noted. Upon inspection and palpation of the inner lips and buccal mucosa, it is uniformly pink in color and moist. He only had 24 teeth, 12 in the upper and 12 in the lower teeth. No dental carries was noted. He has pink gums, moist and firm texture to gums. Swelling of the gums was also not noted. The tongue was in midline position, pink in color, moist and has thin whitish coating, lateral margins, and no lesions noted. The tongue can move freely.

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Neck Upon inspection, his neck was symmetrical and no edema or lesions were noted. Upon palpation, neck has no lumps, bulges or masses. There was no unusual swelling that is noted. Lymph nodes are non palpable. Jugular veins are not distended. He was able to move his head against the resistance on both left and right. Also, he was able to move his chin towards the chest and can hyperextend head towards the back. He is able to move his head from left to right and does not complains of pain. Chest Upon inspection, the anteroposterior to transverse diameter is in ratio of 1:2. His chest is symmetric. Upon palpation of the posterior thorax, skin temperature is uniform and skin is intact. It moves easily without impairment upon respiration. When respiratory excursion was palpated, there was a full and symmetric chest expansion because when we asked the client to take a deep breath, the examiner's thumbs moved apart in an equal distance at the same time in about 3 to 5cm. Vocal tactile fremitus was present. Crackles were noted upon auscultation. HEART AND CENTRAL VESSELS Upon inspection and palpation of the precordium, there were no pulsations, no lifts or heaves, pulsations are visible and palpable in the apical area and fifth left intercostals space. His heart rate is 73 beats per minute and point of maximum impulse is best heard at 5th intercostals space midclavicular line. Murmurs were not noted during auscultation. PERIPHERAL PERFUSION Upon inspection of skin of the hands and feet, skin color is brown. Skin temperature is not excessively warm or cold. Buergers Test was done and with negative result. Capillary Refill Test of 2 seconds. BREAST

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Upon inspection, the areola is round and bilaterally the same, brown in color. The nipples are round, everted, equal in size, and are dark brown in color. Upon palpation of the axillary, subclavicular, and supraclavicular lymph nodes, there were no nodules, masses or tenderness. Upon palpation of the breast for masses, there was no tenderness, no discharges, no masses, and no nodules noted. ABDOMEN Upon inspection of the abdomen, the skin is uniform in color. The abdomen is flat. There are symmetric movements caused by respiration. Upon auscultation, there are audible bowel sounds. The clients bowel sound is approximately 8 sounds per minute. Upon percussion, there was tympanitic sound over the stomach; dullness, over the liver and spleen. Upon light palpation of the abdomen, there is no tenderness. Upon palpation of the liver: the liver is palpable. Upon palpation of the bladder, the bladder is not palpable. GENITALS The patient refused to have his genitals assessed. Moreover, he do have a French 14 foley catheter draining to yellowish urine. RECTUM AND ANUS The patient refuses to have his rectum and anus assessed. EXTREMITIES UPPER EXTREMITY Shoulders are symmetrical. There are no swellings, and deformities noted. There were no scars noted on left and right arms. He is able to move with range of motion without discomfort. He is able to extend and flex his forearms. His fingers are complete and are not deformed. Grade one edema was noted on his right hand and forearm.

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LOWER EXTREMITY Both legs are equal in length. There are no deformities noted and he can move with range of motion without any discomfort. Edema was noted on his right foot. NEUROLOGIC ASSESSMENT The patient is able able to communicate and was able to give correct an clear answers to our questions. He is well-oriented of the present situation and can fully remember all the past events that have happened. He was oriented of the present time, place and date. Pupil size: Left- with mass Pupil reaction: Left- with mass Handgrip: Left- strong Leg movement: Left- strong Right- Strong Right- strong Right- brisk Right-2mm

He had an RLS of 1: ALERT and a GCS of 15. NVS: 1/15 Eye openingVerbal response4, Patient opens his eyes spontaneously. 5, No verbal response.

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Motor responseCRANIAL NERVES Cranial Nerve Olfactory

6, Obeying motor response.

Type Sensory

Function Smell

Assessment He can identify the smell of alcohol and cologne.

Optic

Sensory

Vision

He can read without the aid of any eyeglasses. He was able to read and rewrite the writings on the bond paper.

Oculomotor

Motor

EOM, constriction,

pupil Both pupils are briskly reactive to light with an isocoric size of 2

provides movement mm. Unison movement of both for four of six eyes. Eyes were able to follow the penlight while assessing the six ocular movements. Trochlear Motor EOM of downward He was able to move his eyes and lateral direction downward and to the sides with ease. Trigeminal Sensory Sensation of cornea, His blinking reflex on both eyes skin of face and were present and is able to feel the wisp of cotton on both cheeks. He was also able to determine light touch and pain with the eraser of the pencil. He was able to do clenching of teeth.

muscles of the eye

nasal mucosa

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Abducens

Motor

EOM upward

of

lateral, The patient is able to move his and eyes upward, downward and to

downward direction the sides. Facial Both Facial expression The patient was able to raise his eyebrows and close his eyes, smile, frown and puff his cheeks with symmetry.

Vestibulocochlear

Sensory

Sense of balance He can hear our voices and and hearing commands on both ears. He is able to hear whispered word such as hello and able to rewrite the words on a bond paper correctly. Balance was not assessed since patient was not allowed to get out of bed.

Glossopharyngeal Both

Swallowing ability, He gag reflex, taste

can

swallow

without

complaint of pain. We cannot assess if he can taste the food given to because food is given through the NGT. He was able to move his tongue up, side and down.

Vagus

Both

Sensation of larynx He was able to speak freely and pharynx, vocal and there was positive gag cord movement reflex.

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Accessory

Motor

Head

movement He was able move his head, he hyperextend his head

and shrugging of can shoulders

towards the back. He has equal shoulders. He was able to move his head against the resistance that was applied. He was able to shrug his shoulders against the minimal resistance that was applied.

Hypoglossal

Motor

Protrusion movement tongue

and He was able to stick his tongue of out and move it upward,

downward, and laterally.

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Definition of Diagnosis
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Septic Encephalopathy
Sepsis is often characterized by an acute brain dysfunction ranging from confusion to coma, which is associated with increased mortality. This encephalopathy is characterized by inattention, disorganized thinking, and fluctuating mental status changes, and therefore, matches with current criteria for delirium. Delirium refers to an acute brain dysfunction frequently observed in critically ill patients that is nearly always a component of the multiple organ dysfunction syndrome. (http://www.springerreference.com/docs/html/chapterdbid/338324.html)

Encephalopathy refers to an abnormal condition of the structure or function of brain tissues (specifically degenerative conditions) that can result in inflammation and hemorrhaging. Encephalopathy may be caused by chronic conditions such as liver disease, viral or bacterial infections, high blood pressure, metabolic or nutritional diseases, or hereditary diseases. Some destructive conditions resulting in encephalopathy include long-term exposure to chemotherapeutic drugs or toxic chemicals and radiation therapy. It can also be caused by repeated head trauma during boxing (boxer's encephalopathy) or develop during the final stage of a terminal illness. Encephalopathy may also resolve without treatment and without any lasting effects. (http://www.mdguidelines.com/encephalopathy/definition)

Encephalopathy means disorder or disease of the brain. In modern usage, encephalopathy does not refer to a single disease, but rather to a syndrome of global brain dysfunction; this syndrome can be caused by many different organic and inorganic origins.

(http://www.answers.com/topic/encephalopathy#ixzz2JDxFurZr)

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Anatomy and Physiology

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Immune System
I INTRODUCTION

Immune System, group of cells, molecules, and organs that act together to defend the body against foreign invaders that may cause disease, such as bacteria, viruses, and fungi. The health of the body is dependent on the immune systems ability to recognize and then repel or destroy these invaders.

II

IMMUNITY: INNATE AND ADAPTIVE

Most animals have systems that resist disease. The disease resistance provided by these systems is called immunity. There are two types of immunity: innate and adaptive. Innate, or nonspecific, immunity is the bodys first, generalized line of defense against all invaders. Innate immunity is furnished by barriers such as skin, tears, mucus, and saliva, as well as by the rapid inflammation of tissues that takes place shortly after injury or infection. These innate immune mechanisms hinder the entrance and spread of disease but can rarely prevent disease completely.

If an invader gets past this first line of defense, the cells, molecules, and organs of the immune system develop specifically tailored defenses against the invader. The immune system can call upon these defenses whenever this particular invader attacks again in the future. These specifically adapted defenses are known as adaptive, or specific, immunity. Adaptive immunity has four distinguishing properties: First, it responds only after the invader is present. Second, it is specific, tailoring each response to act only on a specific type of invader. Third, it displays memory, responding better after the first exposure to an invader, even if the second exposure is years later. Fourth, it does not usually attack normal body components, only those substances it recognizes as nonself.

Adaptive immune responses are actually reactions of the immune system to structures on the surface of the invading organism called antigens. There are two types of adaptive immune responses: humoral and cell mediated. During humoral immune responses, proteins called antibodies, which can stick to and destroy antigens, appear in the blood and other body fluids. Humoral immune responses resist invaders that act outside of cells, such as bacteria and toxins (poisonous substances produced by living organisms). Humoral immune responses can also prevent viruses from entering cells. 32 | P a g e

During cell-mediated immune responses, cells that can destroy other cells become active. Their destructive activity is limited to cells that are either infected with, or producing, a specific antigen. Cell-mediated immune responses resist invaders that reproduce within the body cells, such as viruses. Cell-mediated responses may also destroy cells making mutated (changed) forms of normal molecules, as in some cancers. III COMPONENTS OF THE IMMUNE SYSTEM

The ability of the immune system to mount a response to disease is dependent on many complex interactions between the components of the immune system and the antigens on the invading pathogens, or disease-causing agents. A Macrophages

White blood cells are the mainstay of the immune system. Some white blood cells, known as macrophages, play a function in innate immunity by surrounding, ingesting, and destroying invading bacteria and other foreign organisms in a process called phagocytosis (literally, cell eating), which is part of the inflammatory reaction. Macrophages also play an important role in adaptive immunity in that they attach to invading antigens and deliver them to be destroyed by other components of the adaptive immune system. B Lymphocytes

Lymphocytes are specialized white blood cells whose function is to identify and destroy invading antigens. All lymphocytes begin as stem cells in the bone marrow, the soft tissue that fills most bone cavities, but they mature in two different places. Some lymphocytes mature in the bone marrow and are called B lymphocytes. B lymphocytes, or B cells, make antibodies, which circulate through the blood and other body fluids, binding to antigens and helping to destroy them in humoral immune responses.

Other lymphocytes, called T lymphocytes, or T cells, mature in the thymus, a small glandular organ located behind the breastbone. Some T lymphocytes, called cytotoxic (cell-poisoning) or killer T lymphocytes, generate cell-mediated immune responses, directly destroying cells that have specific antigens on their surface that are recognized by the killer T cells. Helper T lymphocytes, a second kind of T lymphocyte, regulate the immune system by controlling the strength and quality of all immune responses. 33 | P a g e

Most contact between antigens and lymphocytes occurs in the lymphoid organsthe lymph nodes, spleen, and tonsils, as well as specialized areas of the intestine and lungs. Mature lymphocytes constantly travel through the blood to the lymphoid organs and then back to the blood again. This recirculation ensures that the body is continuously monitored for invading substances. C Antigen Receptors

One of the characteristics of adaptive immunity is that it is specific: Each response is tailored to a specific type of invading antigen. Each lymphocyte, as it matures, makes an antigen receptorthat is, a specific structure on its surface that can bind with a matching structure on the antigen like a lock and key. Although lymphocytes can make billions of different kinds of antigen receptors, each individual lymphocyte makes only one kind. When an antigen enters the body, it activates only the lymphocytes whose receptors match up with it.

Antigen-Presenting Cells

When an antigen enters a body cell, certain transport molecules within the cell attach themselves to the antigen and transport it to the surface of the cell, where they present the antigen to T lymphocytes. These transport molecules are made by a group of genes called the major histocompatibility complex (MHC) and are therefore known as MHC molecules. Some MHC molecules, called class I MHC molecules, present antigens to killer T cells; other MHC molecules, called class II MHC molecules, present antigens to helper T cells.

IV

HUMORAL IMMUNE RESPONSE

The humoral immune response involves a complex series of events after antigens enter the body. First, macrophages take up some of the antigen and attach it to class II MHC molecules, which then present the antigen to T helper cells. The T helper cells bind the presented antigen, which stimulates the T helper cells to divide and secrete stimulatory molecules called interleukins. The interleukins in turn activate any B lymphocytes that have also bound the antigen. The activated B cells then divide and secrete antibodies. Finally, the secreted antibodies bind the antigen and help destroy it.

Antibodies

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Antibodies are Y-shaped proteins called immunoglobulins (Ig) and are made only by B cells. The antibody binds to the antigen at the ends of the arms of the Y. The area at the base of the Y determines how the antibody will destroy the antigen. This area is used to categorize antibodies into five main classes: IgM, IgG, IgA, IgD, and IgE. During the humoral immune response, IgM is the first class of antibody made. After several days, other classes appear. Exactly which other Ig classes a B cell makes depends on the kind of interleukins it receives from the T helper cells. Antibodies can sometimes stop an antigens disease-causing activities simply by neutralizationthat is, by binding the antigen and preventing it from interfering with the cells normal activities. For example, the toxin made by tetanus bacteria binds to nerve cells and interferes with their control of muscles. Antibodies against tetanus toxin stick to the toxin and cover the part of it that binds to nerve cells, thereby preventing serious disease. All classes of antibodies can neutralize antigens.

Antibodies also help destroy antigens by preparing them for ingestion by macrophages in a process called opsonization. In opsonization, antibodies coat the surface of antigens. Since macrophages have receptors that stick to the base of the antibodys Y structure, antigens coated with antibodies are more likely to stick to the macrophages and be ingested. Opsonization is especially important in helping the body resist bacterial diseases.

Finally, IgM and IgG antibodies can trigger the complement system, a group of proteins that cause cells to disintegrate by cutting holes in the cell membrane. Complement is important in resisting bacteria that are hard to destroy in other ways. For example, some of the bacteria that cause pneumonia have a slimy coating, making it hard for macrophages to ingest and eliminate them. However, if IgM and IgG antibodies bind to the pneumonia bacteria and activate the complement system, it is able to cut holes in the bacteria to destroy them.

Although the IgM and IgG classes of antibodies work best in the circulatory system, IgA can exit the bloodstream and appear in other body fluids. IgA is thus important in preventing infection at mucosal surfaces, such as the intestine and the lung. Since these are the sites where most infectious agents enter, IgA is particularly important in resistance to many diseases. IgA is also found in mothers milk and may help nursing newborns resist disease.

CELL-MEDIATED IMMUNE RESPONSE 35 | P a g e

As with the humoral immune response, the cell-mediated immune response involves a complex series of events after antigens enter the body. Helper T cells are required, so some of the antigen must be taken up by macrophages and presented to helper T cells. The helper T cells bind the presented antigen and thereby become activated to divide and secrete interleukins. The interleukins in turn activate any killer T cells that have already bound antigen attached to class I MHC molecules on infected cells. The activated killer T cells can then kill any cells displaying antigen attached to class I MHC molecules, effectively eliminating any cells infected with the antigen.

VI

IMMUNIZATION

When the body is first exposed to an antigen, several days pass before the adaptive immune response becomes active. Immune activity then rises, levels off, and falls. During following exposures to the same antigen, the immune system responds much more quickly and reaches higher levels. Because the first, or primary, immune response is slow, it cannot prevent disease, although it may help in recovery. In contrast, subsequent, or secondary, immune responses usually can prevent disease because the pathogen is detected, attacked, and destroyed before symptoms appear. This complete resistance to disease is called immunity and may be achieved through either active or passive immunization.

Active Immunization

Active immunization occurs when a persons own immune system is activated and generates a primary immune response. Active immunization can be triggered in two ways, either by natural immunization or by vaccination. In natural immunization, the body contracts a disease and recovers. Because a primary immune response occurs during the illness, the immune system will mount a disease-preventing secondary response every time it is subsequently exposed to the disease. Natural immunization is developed during childhood diseases, such as chicken pox. After having had the disease once, a person is no longer susceptible to it.

Vaccination is intentional immunization against a particular disease by the use of vaccines, substances that are structurally similar to the actual disease-producing agents but that do not produce disease themselves. Most vaccines take one of two forms. The first type of vaccine, such as the vaccines for tetanus and whooping cough, contains chemically killed bacteria or

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other pathogenic organisms. The other type, such as the oral polio vaccine, contains weakened forms of living organisms that have been genetically selected so they do not produce disease.

Passive Immunization

Another way to provide immunity is by means of passive immunization. Passive immunization does not engage the persons own immune system. Instead, the individual receives antibodies that were created in another person or animal. Such antibodies can be lifesaving when a disease progresses too rapidly for natural immunization to occur. For example, if a person who has not been immunized against tetanus bacteria is exposed to tetanus, the toxin produced by these bacteria would reach a deadly level before a primary immune response could begin. Administering antibodies against tetanus toxin quickly neutralizes the toxin and prevents death. Passive immunization has two drawbacks: First, the person does not mount an active immune response, so the immunizing effect is temporary and the person is not immune after recovery. Second, if passive immunization is used repeatedly, it occasionally produces side effects.

VII

IMMUNE SYSTEM DISORDERS

Disorders of the immune system can range from the less serious, such as mild allergy, to the life threatening, such as more serious allergy, transplant rejection, immune deficiencies, and autoimmune diseases.

Allergy

Allergy, sometimes called hypersensitivity, is caused by immune responses to some antigens. Antigens that provoke an allergic response are known as allergens. The two major categories of allergic reaction, rapid and delayed, correspond to the two major types of immune responses. Rapid allergic reactions, such as those to bee venom, pollen or pets, are caused by humoral immune mechanisms. These immediate hypersensitivity reactions result from the production of IgE antibodies when a person is first exposed to an allergen. The IgE antibodies become attached to mast cellswhite blood cells containing histamine, the chemical that causes the 37 | P a g e

familiar allergic symptoms of runny nose, watery eyes, and sneezing. Mast cells are particularly abundant in the lungs and intestine. If the antigen-binding sites of mast cells become filled with an allergen, the mast cells release histamine.

Allergic reactions that are slow in onset (known as delayed-type hypersensitivity, or DTH), such as those to poison ivy or poison oak, are cell mediated. Extreme examples of DTH occur when macrophages cannot easily destroy invading substances. As a result, T cells are activated, leading to inflammation of the body tissue. This inflammation continues for as long as the T cells are activated. The bacterium that causes tuberculosis also falls into this category because this bacterium is covered with a waxy coat that macrophages cannot destroy. The resulting DTH leads to the lung and liver damage associated with tuberculosis.

Transplant Rejection

The immune system recognizes and attacks anything different from the substances normally present within an individual, even substances that are only slightly different, such as transplanted tissues and organs (see Transplantation, Medical).

When an organ is transplanted, the MHC of the donor organ is recognized as foreign and attacked by the recipients immune system. To minimize the chances of transplant rejection, physicians seek transplant donors who share as many MHC genes as possible with the transplant recipient. Even then, most transplant recipients are given drugs to suppress their immune response and prevent rejection of the transplant.

If the transplanted tissue contains T lymphocytes from the donor, as in bone marrow transplants, these donor T lymphocytes may recognize the recipients tissues as foreign and attack them. Physicians can reduce or prevent this potentially fatal graft-versus-host (GVH) reaction by removing all mature T lymphocytes from the organ or tissue before performing the transplant.

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Deficiencies in immune function may be either inherited or acquired. Inherited immune deficiencies usually reflect the failure of a gene important to the generation or function of immune system components. Some inherited diseases damage a persons innate immunity by making macrophages incapable of ingesting or breaking down invading organisms. Individuals affected by these diseases are especially susceptible to opportunistic infectionsthat is, infections by normally harmless organisms that can flourish in a person whose immune system has been weakened. DiGeorge syndrome is an inherited immune disorder in which a person has no thymus and, therefore, cannot produce mature T lymphocytes. People with this disorder can mount only limited humoral immune responses, and their cell-mediated immune responses are severely limited.

The most extreme example of a hereditary immune deficiency is severe combined immunodeficiency (SCID). Individuals with this disease completely lack both T and B lymphocytes and thus have no adaptive immune responses. People with SCID must live in a completely sterile environment, or else they will quickly die from infections.

Acquired immune deficiencies can be caused by infections and also other agents. For example, radiation therapy (see Radiology) and some kinds of drugs used in treating disease reduce lymphocyte production, resulting in damaged immune function. People undergoing such therapies must be carefully monitored for lowered immune function and susceptibility to infections. Environmental and lifestyle factors, such as poor nutrition or stress, can also affect the immune systems general status.

An infectious agent resulting in fatal immune deficiency is the human immunodeficiency virus (HIV). This virus causes acquired immunodeficiency syndrome (AIDS) by infecting and eventually destroying helper T cells. Because helper T cells regulate all immune responses, their loss results in an inability to make adaptive immune responses. This complete lack of immune function makes individuals with AIDS highly susceptible to all infectious agents.

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Autoimmunity is the immune response of the body turned against its own cells and tissues. Autoimmune diseases may involve either cell-mediated responses, humoral responses, or both. For example, in Type 1 diabetes, the body makes an immune response against its insulinproducing cells and destroys them, with the result that the body cannot use sugars. In myasthenia gravis, the immune system makes antibodies against the normal molecules that control neuromuscular activity, causing weakness and paralysis. In rheumatic fever, the immune system makes antibodies that bind to the hearts valves, leading to permanent heart damage. In systemic lupus erythematosus, commonly known as lupus, the body makes antibodies against many different body tissues, resulting in widespread symptoms. The mechanisms of autoimmune diseases are poorly understood, and thus the basis for autoimmunity is unclear. Much research focuses on trying to understand these mechanisms and should eventually result in cures

Lymphatic System

INTRODUCTION

Lymphatic System, common name for the circulatory vessels or ducts in which the fluid bathing the tissue cells of vertebrates is collected and carried to join the bloodstream proper. The lymphatic system is of primary importance in transporting digested fat from the intestine to the bloodstream; in removing and destroying toxic substances; and in resisting the spread of disease throughout the body.

The portions of the lymphatic system that collect the tissue fluids are known as lymphatic capillaries and are similar in structure to ordinary capillaries. The lymphatic capillaries that pick up digested fat in the villi of the intestine are known as lacteals. The lymphatic capillaries are more permeable than ordinary capillaries and allow passage of larger particles than would ordinarily pass through capillary walls; large-molecule proteins, produced as a result of tissue breakdown, pass into the lymphatics for transport away from the tissues. II LYMPHATIC CAPILLARIES

These vessels are found in all body tissues except the central nervous system, which has a circulatory system known as the cerebrospinal system. The lymphatic capillaries run together to form larger ducts that intertwine about the arteries and veins. The lymph in these larger ducts, which are similar to thin, dilated veins, is moved along by the muscular movements of the body 40 | P a g e

as a whole; it is prevented from moving back through the ducts by valves located along them at intervals. The ducts from the lower limbs and abdomen come together at the dorsal left side of the body to form a channel, known as the cisterna chyli, that gives rise to the chief lymphatic vessel of the body, the thoracic duct. This vessel receives lymph from the left side of the thorax, the left arm, and the left side of the head and neck; it empties into the junction of the left jugular and left subclavian veins. Another, smaller vessel, known as the right lymphatic duct, receives lymph from the right side of the thorax, the right arm, and the right side of the head and neck and empties its contents into the right subclavian vein.

III

LYMPH NODES

Along the course of the lymphatic vessels are situated the lymph nodes, more commonly called the lymph glands. These nodes are bean-shaped organs containing large numbers of leukocytes, embedded in a network of connective tissue. All the lymph being returned along the lymphatics to the bloodstream must pass through several of these nodes, which filter out infectious and toxic material and destroy it. The nodes serve as a center for the production of phagocytes, which engulf bacteria and poisonous substances. During the course of any infection, the nodes become enlarged because of the large number of phagocytes being produced; these nodes are often painful and inflamed. The swollen glands most often observed are located on the neck, in the armpit, and in the groin. Certain malignant tumors tend to travel along the lymphatics; surgical removal of all nodes that are suspected of being involved in the spread of such malignancies is an accepted therapeutic procedure. IV OTHER ORGANS

In addition to the lymph nodes that occur in the lymphatic vessels, several organs, composed of similar tissue, are included in the lymphatic system. The largest and most important of these organs is the spleen. Embryologically, the lymphatic vessels arise as outbuddings from several veins, especially from the internal jugular and iliac veins. The buds spread throughout the body and separate from the venous system at many points. Among the abnormal conditions affecting the lymphatic system are inflammation of the lymphatics or of the lymph nodes, seen in infections; tuberculosis of the lymph nodes; malignancies in the lymphatic system (Cancer; Hodgkin's Disease); and elephantiasis.

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Circulatory System
I INTRODUCTION

Circulatory System, or cardiovascular system, in humans, the combined function of the heart, blood, and blood vessels to transport oxygen and nutrients to organs and tissues throughout the body and carry away waste products. Among its vital functions, the circulatory system increases the flow of blood to meet increased energy demands during exercise and regulates body temperature. In addition, when foreign substances or organisms invade the body, the circulatory system swiftly conveys disease-fighting elements of the immune system, such as white blood cells and antibodies, to regions under attack. Also, in the case of injury or bleeding, the circulatory system sends clotting cells and proteins to the affected site, which quickly stop bleeding and promote healing.

II

COMPONENTS OF THE CIRCULATORY SYSTEM

The heart, blood, and blood vessels are the three structural elements that make up the circulatory system. The heart is the engine of the circulatory system. It is divided into four chambers: the right atrium, the right ventricle, the left atrium, and the left ventricle. The walls of these chambers are made of a special muscle called myocardium, which contracts continuously and rhythmically to pump blood. The pumping action of the heart occurs in two stages for each heart beat: diastole, when the heart is at rest; and systole, when the heart contracts to pump deoxygenated blood toward the lungs and oxygenated blood to the body. During each heartbeat, typically about 60 to 90 ml (about 2 to 3 oz) of blood are pumped out of the heart. If the heart stops pumping, death usually occurs within four to five minutes.

Blood consists of three types of cells: oxygen-bearing red blood cells, disease-fighting white blood cells, and blood-clotting platelets, all of which are carried through blood vessels in a liquid called plasma. Plasma is yellowish and consists of water, salts, proteins, vitamins, minerals, hormones, dissolved gases, and fats.

Three types of blood vessels form a complex network of tubes throughout the body. Arteries carry blood away from the heart, and veins carry it toward the heart. Capillaries are the tiny links between the arteries and the veins where oxygen and nutrients diffuse to body tissues. The inner layer of blood vessels is lined with endothelial cells that create a smooth passage for the 42 | P a g e

transit of blood. This inner layer is surrounded by connective tissue and smooth muscle that enable the blood vessel to expand or contract. Blood vessels expand during exercise to meet the increased demand for blood and to cool the body. Blood vessels contract after an injury to reduce bleeding and also to conserve body heat.

Arteries have thicker walls than veins to withstand the pressure of blood being pumped from the heart. Blood in the veins is at a lower pressure, so veins have one-way valves to prevent blood from flowing backwards away from the heart. Capillaries, the smallest of blood vessels, are only visible by microscopeten capillaries lying side by side are barely as thick as a human hair. If all the arteries, veins, and capillaries in the human body were placed end to end, the total length would equal more than 100,000 km (more than 60,000 mi)they could stretch around the earth nearly two and a half times.

The arteries, veins, and capillaries are divided into two systems of circulation: systemic and pulmonary. The systemic circulation carries oxygenated blood from the heart to all the tissues in the body except the lungs and returns deoxygenated blood carrying waste products, such as carbon dioxide, back to the heart. The pulmonary circulation carries this spent blood from the heart to the lungs. In the lungs, the blood releases its carbon dioxide and absorbs oxygen. The oxygenated blood then returns to the heart before transferring to the systemic circulation. III OPERATION AND FUNCTION

Only in the past 400 years have scientists recognized that blood moves in a cycle through the heart and body. Before the 17th century, scientists believed that the liver creates new blood, and then the blood passes through the heart to gain warmth and finally is soaked up and consumed in the tissues. In 1628 English physician William Harvey first proposed that blood circulates continuously. Using modern methods of observation and experimentation, Harvey noted that veins have one-way valves that lead blood back to the heart from all parts of the body. He noted that the heart works as a pump, and he estimated correctly that the daily output of fresh blood is more than seven tons. He pointed out the absurdity of the old doctrine, which would require the liver to produce this much fresh blood daily. Harveys theory was soon proven correct and became the cornerstone of modern medical science.

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The heart ejects oxygen-rich blood under high pressure out of the hearts main pumping chamber, the left ventricle, through the largest artery, the aorta. Smaller arteries branch off from the aorta, leading to various parts of the body. These smaller arteries in turn branch out into even smaller arteries, called arterioles. Branches of arterioles become progressively smaller in diameter, eventually forming the capillaries. Once blood reaches the capillary level, blood pressure is greatly reduced.

Capillaries have extremely thin walls that permit dissolved oxygen and nutrients from the blood to diffuse across to a fluid, known as interstitial fluid, that fills the gaps between the cells of tissues or organs. The dissolved oxygen and nutrients then enter the cells from the interstitial fluid by diffusion across the cell membranes. Meanwhile, carbon dioxide and other wastes leave the cell, diffuse through the interstitial fluid, cross the capillary walls, and enter the blood. In this way, the blood delivers nutrients and removes wastes without leaving the capillary tube. After delivering oxygen to tissues and absorbing wastes, the deoxygenated blood in the capillaries then starts the return trip to the heart. The capillaries merge to form tiny veins, called venules. These veins in turn join together to form progressively larger veins. Ultimately, the veins converge into two large veins: the inferior vena cava, bringing blood from the lower half of the body; and the superior vena cava, bringing blood from the upper half. Both of these two large veins join at the right atrium of the heart.

Because the pressure is dissipated in the arterioles and capillaries, blood in veins flows back to the heart at very low pressure, often running uphill when a person is standing. Flow against gravity is made possible by the one-way valves, located several centimeters apart, in the veins. When surrounding muscles contract, for example in the calf or arm, the muscles squeeze blood back toward the heart. If the one-way valves work properly, blood travels only toward the heart and cannot lapse backward. Veins with defective valves, which allow the blood to flow backward, become enlarged or dilated to form varicose veins.

Pulmonary Circulation

In pulmonary circulation, deoxygenated blood returning from the organs and tissues of the body travels from the right atrium of the heart to the right ventricle. From there it is pushed through the pulmonary artery to the lung. In the lung, the pulmonary artery divides, forming the pulmonary capillary region of the lung. At this site, microscopic vessels pass adjacent to the 44 | P a g e

alveoli, or air sacs of the lung, and gases are exchanged across a thin membrane: oxygen crosses the membrane into the blood while carbon dioxide leaves the blood through this same membrane. Newly oxygenated blood then flows into the pulmonary veins, where it is collected by the left atrium of the heart, a chamber that serves as collecting pool for the left ventricle. The contraction of the left ventricle sends blood into the aorta, completing the circulatory loop. On average, a single blood cell takes roughly 30 seconds to complete a full circuit through both the pulmonary and systemic circulation. C Additional Functions

In addition to oxygen, the circulatory system also transports nutrients derived from digested food to the body. These nutrients enter the bloodstream by passing through the walls of the intestine. The nutrients are absorbed through a network of capillaries and veins that drain the intestines, called the hepatic portal circulation. The hepatic portal circulation carries the nutrients to the liver for further metabolic processing. The liver stores a variety of substances, such as sugars, fats, and vitamins, and releases these to the blood as needed. The liver also cleans the blood by removing waste products and toxins. After hepatic portal blood has crossed the liver cells, veins converge to form the large hepatic vein that joins the vena cava near the right atrium. The circulatory system plays an important role in regulating body temperature. During exercise, working muscles generate heat. The blood supplying the muscles with oxygen and nutrients absorbs much of this heat and carries it away to other parts of the body. If the body gets too warm, blood vessels near the skin enlarge to disperse excess heat outward through the skin. In cold environments, these blood vessels constrict to retain heat.

The circulatory system works in tandem with the endocrine system, a collection of hormoneproducing glands. These glands release chemical messengers, called hormones, directly into the bloodstream to be transported to specific organs and tissues. Once they reach their target destination, hormones regulate the bodys rate of metabolism, growth, sexual development, and other functions.

The circulatory system also works with the immune system and the coagulation system. The immune system is a complex system of many types of cells that work together to combat diseases and infections. Disease-fighting white blood cells and antibodies circulate in the blood and are transported to sites of infection by the circulatory system. The coagulation system is composed of special blood cells, called platelets, and special proteins, called clotting factors, 45 | P a g e

that circulate in the blood. Whenever blood vessels are cut or torn, the coagulation system works rapidly to stop the bleeding by forming clots.

Other organs support the circulatory system. The brain and other parts of the nervous system constantly monitor blood circulation, sending signals to the heart or blood vessels to maintain constant blood pressure. New blood cells are manufactured in the bone marrow. Old blood cells are broken down in the spleen, where valuable constituents, such as iron, are recycled. Metabolic waste products are removed from the blood by the kidneys, which also screen the blood for excess salt and maintain blood pressure and the bodys balance of minerals and fluids. D Blood Pressure

The pressure generated by the pumping action of the heart propels the blood to the arteries. In order to maintain an adequate flow of blood to all parts of the body, a certain level of blood pressure is needed. Blood pressure, for instance, enables a person to rise quickly from a horizontal position without blood pooling in the legs, which would cause fainting from deprivation of blood to the brain. Normal blood pressure is regulated by a number of factors, such as the contraction of the heart, the elasticity of arterial walls, blood volume, and resistance of blood vessels to the passage of blood.

Blood pressure is measured using an inflatable device with a gauge called a that is wrapped around the upper arm. Blood pressure is measured during systole, the active pumping phase of the heart, and diastole, the resting phase between heartbeats. Systolic and diastolic pressures are measured in units of millimeters of mercury (abbreviated mm Hg) and displayed as a ratio. Blood pressure varies between individuals and even during the normal course of a day in response to emotion, exertion, sleep, and other physical and mental changes. Normal blood pressure is less than 120/80 mm Hg, in which 120 describes systolic pressure and 80 describes diastolic pressure. Higher blood pressures that are sustained over a long period of time may indicate hypertension, a damaging circulatory condition. Lower blood pressures could signal shock from heart failure, dehydration, internal bleeding, or blood loss.

IV

CIRCULATORY SYSTEM DISORDERS

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Disorders of the circulatory system include any injury or disease that damages the heart, the blood, or the blood vessels. The three most important circulatory diseases are hypertension, arteriosclerosis, and atherosclerosis. Hypertension, or elevated blood pressure, develops when the bodys blood vessels narrow, causing the heart to pump harder than normal to push blood through the narrowed openings. Hypertension that remains untreated may cause heart enlargement and thickening of the heart muscle. Eventually the heart needs more oxygen to function, which can lead to heart failure, brain stroke, or kidney impairment. Some cases of hypertension can be treated by lifestyle changes such as a low-salt diet, maintenance of ideal weight, aerobic exercise, and a diet rich in fruits, vegetables, plant fiber, and the mineral potassium. If blood pressure remains high despite these lifestyle adjustments, medications may be effective in lowering the pressure by relaxing blood vessels and reducing the output of blood.

In arteriosclerosis, commonly known as hardening of the arteries, the walls of the arteries thicken, harden, and lose their elasticity. The heart must work harder than normal to deliver blood, and in advanced cases, it becomes impossible for the heart to supply sufficient blood to all parts of the body. Nobody knows what causes arteriosclerosis, but heredity, obesity, smoking, and a high-fat diet all appear to play roles. Atherosclerosis, a form of arteriosclerosis, is the reduction in blood flow through the arteries caused by greasy deposits called plaque that form on the insides of arteries and partially restrict the flow of blood. Plaque deposits are associated with high concentrations of cholesterol in the blood. Recent studies have also shown an association between inflammation and plaque deposits. Blood flow is often further reduced by the formation of blood clots (see Thrombosis), which are most likely to form where the artery walls have been roughened by plaque. These blood clots can also break free and travel through the circulatory system until they become lodged somewhere else and reduce blood flow there (see Embolism). Reduction in blood flow can cause organ damage. When brain arteries become blocked and brain function is impaired, the result is a stroke. A heart attack occurs when a coronary artery becomes blocked and heart muscle is destroyed.

Risk factors that contribute to atherosclerosis include physical inactivity, smoking, a diet high in fat, high blood pressure, and diabetes. Some cases of atherosclerosis can be corrected with healthy lifestyle changes, aspirin to reduce blood clotting or inflammation, or drugs to lower the 47 | P a g e

blood cholesterol concentration. For more serious cases, surgery to dilate narrowed blood vessels with a balloon, known as angioplasty, or to remove plaque with a high-speed cutting drill, known as atherectomy, may be effective. Surgical bypass, in which spare arteries are used to construct a new path for blood flow, is also an option.

Nervous System
I INTRODUCTION

Nervous System, those elements within the animal organism that are concerned with the reception of stimuli, the transmission of nerve impulses, or the activation of muscle mechanisms.

II

ANATOMY AND FUNCTION

The reception of stimuli is the function of special sensory cells. The conducting elements of the nervous system are cells called neurons; these may be capable of only slow and generalized activity, or they may be highly efficient and rapidly conducting units. The specific response of the neuronthe nerve impulseand the capacity of the cell to be stimulated make this cell a receiving and transmitting unit capable of transferring information from one part of the body to another.

Nerve Cell

Each nerve cell consists of a central portion containing the nucleus, known as the cell body, and one or more structures referred to as axons and dendrites. The dendrites are rather short extensions of the cell body and are involved in the reception of stimuli. The axon, by contrast, is usually a single elongated extension; it is especially important in the transmission of nerve impulses from the region of the cell body to other cells.

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Simple Systems

Although all many-celled animals have some kind of nervous system, the complexity of its organization varies considerably among different animal types. In simple animals such as jellyfish, the nerve cells form a network capable of mediating only a relatively stereotyped response. In more complex animals, such as shellfish, insects, and spiders, the nervous system is more complicated. The cell bodies of neurons are organized in clusters called ganglia. These clusters are interconnected by the neuronal processes to form a ganglionated chain. Such chains are found in all vertebrates, in which they represent a special part of the nervous system, related especially to the regulation of the activities of the heart, the glands, and the involuntary muscles.

Vertebrate Systems

Vertebrate animals have a bony spine and skull in which the central part of the nervous system is housed; the peripheral part extends throughout the remainder of the body. That part of the nervous system located in the skull is referred to as the brain; that found in the spine is called the spinal cord. The brain and the spinal cord are continuous through an opening in the base of the skull; both are also in contact with other parts of the body through the nerves. The distinction made between the central nervous system and the peripheral nervous system is based on the different locations of the two intimately related parts of a single system. Some of the processes of the cell bodies conduct sense impressions and others conduct muscle responses, called reflexes, such as those caused by pain.

In the skin are cells of several types called receptors; each is especially sensitive to particular stimuli. Free nerve endings are sensitive to pain and are directly activated. The neurons so activated send impulses into the central nervous system and have junctions with other cells that have axons extending back into the periphery. Impulses are carried from processes of these cells to motor endings within the muscles. These neuromuscular endings excite the muscles, resulting in muscular contraction and appropriate movement. The pathway taken by the nerve impulse in mediating this simple response is in the form of a two-neuron arc that begins and ends in the periphery. Many of the actions of the nervous system can be explained on the basis

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of such reflex arcs, which are chains of interconnected nerve cells, stimulated at one end and capable of bringing about movement or glandular secretion at the other.

The Nerve Network

The cranial nerves connect to the brain by passing through openings in the skull, or cranium. Nerves associated with the spinal cord pass through openings in the vertebral column and are called spinal nerves. Both cranial and spinal nerves consist of large numbers of processes that convey impulses to the central nervous system and also carry messages outward; the former processes are called afferent, the latter are called efferent. Afferent impulses are referred to as sensory; efferent impulses are referred to as either somatic or visceral motor, according to what part of the body they reach. Most nerves are mixed nerves made up of both sensory and motor elements.

The cranial and spinal nerves are paired; the number in humans are 12 and 31, respectively. Cranial nerves are distributed to the head and neck regions of the body, with one conspicuous exception: the tenth cranial nerve, called the vagus. In addition to supplying structures in the neck, the vagus is distributed to structures located in the chest and abdomen. Vision, auditory and vestibular sensation, and taste are mediated by the second, eighth, and seventh cranial nerves, respectively. Cranial nerves also mediate motor functions of the head, the eyes, the face, the tongue, and the larynx, as well as the muscles that function in chewing and swallowing. Spinal nerves, after they exit from the vertebrae, are distributed in a bandlike fashion to regions of the trunk and to the limbs. They interconnect extensively, thereby forming the brachial plexus, which runs to the upper extremities; and the lumbar plexus, which passes to the lower limbs. E Autonomic Nervous System

Among the motor fibers may be found groups that carry impulses to viscera. These fibers are designated by the special name of autonomic nervous system. That system consists of two divisions, more or less antagonistic in function, that emerge from the central nervous system at different points of origin. One division, the sympathetic, arises from the middle portion of the spinal cord, joins the sympathetic ganglionated chain, courses through the spinal nerves, and is widely distributed throughout the body. The other division, the parasympathetic, arises both 50 | P a g e

above and below the sympathetic, that is, from the brain and from the lower part of the spinal cord. These two divisions control the functions of the respiratory, circulatory, digestive, and urogenital systems.

III

DISORDERS OF THE NERVOUS SYSTEM

Consideration of disorders of the nervous system is the province of neurology; psychiatry deals with behavioral disturbances of a functional nature. The division between these two medical specialties cannot be sharply defined, because neurological disorders often manifest both organic and mental symptoms. For a discussion of functional mental illness, Mental Illness. Diseases of the nervous system include genetic malformations, poisonings, metabolic defects, vascular disorders, inflammations, degeneration, and tumors, and they involve either nerve cells or their supporting elements. Vascular disorders, such as cerebral hemorrhage or other forms of stroke, are among the most common causes of paralysis and other neurologic complications. Some diseases exhibit peculiar geographic and age distribution. In temperate zones, multiple sclerosis is a common degenerative disease of the nervous system, but it is rare in the Tropics. The nervous system is subject to infection by a great variety of bacteria, parasites, and viruses. For example, meningitis, or infection of the meninges investing the brain and spinal cord, can be caused by many different agents. On the other hand, one specific virus causes rabies. Some viruses causing neurological ills affect only certain parts of the nervous system. For example, the virus causing poliomyelitis commonly affects the spinal cord; viruses causing encephalitis attack the brain. Inflammations of the nervous system are named according to the part affected. Myelitis is an inflammation of the spinal cord; neuritis is an inflammation of a nerve. It may be caused not only by infection but also by poisoning, alcoholism, or injury. Tumors originating in the nervous system usually are composed of meningeal tissue or neuroglia (supporting tissue) cells, depending on the specific part of the nervous system affected, but other types of tumor may metastasize to or invade the nervous system. In certain disorders of the nervous system, such as neuralgia, migraine, and epilepsy, no evidence may exist of organic damage. Another disorder, cerebral palsy, is associated with birth defects.

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PATHOPHYSIOOGY

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Predisposinf Factor Geographical area tropical islands in thePacific (Philippines) and Asia Young adult(19-45) 40yrs old

Washing of hands inadequately Sharing of food from the same plate Drinking unpurified water Eating foods from the outside source (carinderia)

Ingestion of foods and fluids contaminated with Salmonella typhi bacteria

Infectious particles meets the uninfected cells

Phagocytosis

S/Sx: Abdominal Pain Nausea and Vomiting Diarrhea itin

Transcription of DNA Diagnostic: Hematology: Stool Exam and Culture UrineTest Treatment: Antibiotic Treatment Fluid Rescusitation Analgesics, Antipyretics

Reorganization into reticulate body

Bacteria Survives Phagocytosis

Continued Multiplication

Further Reorganization

Lysis of Cell

Breaking out of the blood stream

Systemic Infection

Fever Warmth Head Ache Body Weakness

Typhoid
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Infection extends towards the urinary tract

Further Bacterecemia S/Sx: Abdominal Pain Guarding Behavior Tachypnea Pain upon urinating

Infection travels across the urinary circulation

Infection travels on the bodys circulation

Invasion of the urinary system

Brain involvement and Invasion

UROSEPSIS
Diagnostics: Blood Tests Urine exam Urine Culture BloodTest Treatment: Antibiotic Treatment Analgesics

Obstruction of Urine flow S/Sx: Abdominal Discomfort Decreased Urine Output Pain upon Urination

Blood Brain Barrier is disturbed

Destruction of normal microflora

Urine starts solidifying

Over stimulation of Nuerotransmitters

Damaging of urinary linings

Crystallization of Urine

Chemical Imbalance S/Sx: Hallucinations Delusions

Bladder and Kidney dysfunction

Increased Dopamine level

S/Sx: Increased Serum Creatinin Bun

Retained waste products

Water and electrolyte imbalance S/Sx: Dyspnea Decreased Tissue Perfusion

Increased motor neuron workload S/Sx: Poor Concentration Decreased Motivation Disorganized Speech Flight of Ideas

Reabsorption of waste materials in the body

Pulmonary Congestion

Nerve cell shut down

Toxic Waste Circulate on the system

Impaired oxygen-carbon dioxide cycle

Psychosis

Septic Shock

Lung Collapse

Diagnostics: MRI, Drug Exams, Blood Tests Treatment: Antipsychotic Drugs Psychiatric check up

If not Treated

Death

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Pathophysio Narrative:

When there is ingestion of foods and fluids contaminated with Salmonella typhi bacteria, this will precipitate the Infectious particles to meet the uninfected cells, as a defense mechanism, the cell will try to engulf the bacteria by Phagocytosis thenTranscripting DNA of the bacteria and reorganizing into reticulate body, but when the bacteria survives Phagocytosis, it will continue to multiply and the cell will further be reorganized by then there will be Lysis of Cell allowing the infection to break out of the blood stream causing Systemic Infection that cause Typhoid Fever. In a two way process, when the body experiencesFurther Bacterecemia, the Infection travels on the bodys circulation up until brain involvement and invasion causing the Blood Brain Barrier to be disturbed. As a autonomic response, there will be over stimulation of neurotransmitters, altering the chemical components resulting to chemical Imbalancesin the brain that would channel to increased Dopamine level That triggers the motor neurons to work more. As it works harder than usual, the nerve experiences exhaustion and deterioration, by then causing the nerve cell to shut down, causing this psychological abnormality called Psychosis On the other hand when the infection extends towards the urinary tract, it will travel across the urinary circulation, invading the urinary system causing, Urosepsis, destroying the normal microflora of the urinary tract and damaging its linings, also, because of the invasion of the urinary system, there will be , Obstruction of Urine flow then the urine starts to solidify, making it crystallized. In both ways, this will resolve to bladder and kidney dysfunction. Again in two ways around, the retained waste products because the kidneys cannot filter well, will be reabsorbed into the body and the toxic wastes will circulate on the system causing Septic Shock. Since there would be water and electrolyte imbalance, there will be edema formation specifically in the lungs, impeding the gas exchange that can precipitate to lung collapse. Both the complications under the bladder and kidney dysfunction, if not treated, will sadly lead to DEATH.

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DIAGNOSTIC EXAM
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CHEST X-RAY 1/12/13 It is a non-invasive diagnostic procedure which uses radiation that is absorbed by dense objects and will pass through lesser dense objects. Dense objects such as bone appear white on the xray file and lesser dense objects, such as air, appears black or a lighter shade of gray such as fluid or fat. RATIONALE: To view inside the body without opening the skin and assess for pulmonary disease or disorder. RESULT: Both lungs are hazy. A band of opacification is seen in the lower lung field insinuating into the minor tissues and obliterating the right hemidiaphragm and costophrenic sulci. Pulmonary vascular markings are prominent. Heart is magnified with prominent left border. The left costophrenic sulcus is obscured. Left hemidiagphragm is is intact. The rest of the included structures are unremarkable. IMPRESSION: Suggestive left ventricular cardiomegaly with pulmonary congestion. Intercurrent bilateral pneumonia is considered. Kochs etiology cannot be ruled out. Bilateral pleural effusion, more in the right.

HEMATOLOGY

Date

Diagnostic

Rationale

Results

Interpretation &

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exam

& Normal Range Hemoglobin is a protein in red blood cells that carries oxygen. 104g/L N: 140180g/L (male)

Significance

responsibilities

Hemoglobin 1/12/1 3

LOW: decreased hemoglobin leads to anemia, can result in: Irondeficiency Sickle anemia Excessive bleeding *Ceftriaxone can decrease hemoglobin, hematocrit, neutrophil and platelet counts.

> Inform the patient this test can assist in evaluating the amount of hemoglobin in the blood to assist in diagnosis and monitor therapy. >Explain why the procedure is needed. >Avoid getting the sample on the part where the IV is located. >Clean the area where you choose before getting the blood sample. >Use gloves in extracting for safety. >Obtain a history of the patient's complaints, including a list of known allergens, especially allergies or sensitivities to latex. >Obtain a 58 | P a g e

Erythrocyte s

Erythrocytes contain haemoglobin, and transport oxygen and CO2 in the blood back and forth from tissues and the lungs. The MCH is a measure of the amount of hemoglobin in a red blood cell. MCV is a blood test that measures the average red blood cell volume. Is used to tell the difference between types (causes) of anemia. MCHC is the average concentration of hemoglobin in a given volume of

3.88 10^12/L N: 4.55.0 (male)

LOW: parts of the patients body do not get enough oxygen to do their work.

MCH (mean corpuscular hemoglobin )

26.8pg N: 27.033.0pg

LOW: decreased MCH leads to microcytic anemia

MCV (mean corpuscular volume)

82fl N:8596fl

LOW: decreased MCV leads to iron deficiency and thalassanemia

MCHC (mean cell hemoglobin concentrati on)

32.8g/dl N: 3236 g/dl

NORMAL

blood. Leukocytes A colorless blood corpuscle capable of amoeboid movement, whose chief function is to protect the body against microorganisms causing disease. A type of white blood cell, specifically a form of granulocyte, filled with neutrally-staining granules, tiny sacs of enzymes that help the cell to kill and digest microorganisms it has engulfed by phagocytosis. Fundamental to the immune system, regulating and participating in acquired immunity . A large, circulating, phagocytic white blood cell, having a single welldefined nucleus and very fine granulation in the cytoplasm. Basophils are part of your immune system that normally protects your body from 118 10^9/L N: 50100 10^9/L HIGH: indicates infection

Neutrophils

0.40% N: 0.550.65%

LOW: Indicates vulnerability to infectious diseases.

history of the patient's cardiovascular, gastrointestinal , hematopoietic, hepatobiliary, immune, and respiratory systems; symptoms; and results of previously performed laboratory tests and diagnostic and surgical procedures. >Note any recent procedures that can interfere with test results.

Lymphocyte

0.49% N: 0.250.40%

HIGH: increased in normal lymphocytes might signify some kind of infection.

Monocyte

0.10 N: 0.020.06%

HIGH: Indicates infection

>Obtain a list of the patient's current medications, including herbs, nutritional supplements, and nutraceuticals >Review the procedure with the patient. Inform the patient that specimen collection takes approximately 5 to 10 min. Address concerns 59 | P a g e

Basophils

0.00% N: 0.0000.005%

NORMAL

infection, but can also be partly responsible for your asthma symptoms. Basophils are a type of white blood cell that is involved in inflammatory reactions in your body, especially those related to allergies and asthma. Hematocrit the percentage of blood volume that is occupied by red blood cells. 0.32% N: 0.400.48% (male) LOW: may indicate: Anemia

about pain and explain that there may be some discomfort during the venipuncture. >Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.

blood cells Malnutrition deficiencies of iron, folate, vitamin B12, and vitamin B6

*Ceftriaxone can decrease hemoglobin, hematocrit, neutrophil and platelet counts. Thrombocyt e The goal of thrombocyte transfusion is to give the recipient a sufficient number of normally functioning thrombocytes for the purpose of stopping or preventing hemorrhages. 123 10^9/L N:150.0 -300.0 10^9/L LOW: occurs as a result of a separate disorder, such as leukemia or an immune system malfunction, or as a medication side effect.

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SERUM CREATININE 1/12/13 Serum creatinine (a blood measurement) is an important indicator of renal health because it is an easily-measured by-product of muscle metabolism. Creatinine itself is an important biomolecule because it is a major by-product of energy usage in muscle via biological system involving creatinine, phosphocreatinine and adenosine triphospate (the bodys energy supply ).

Test Serum creatinine

Rationale Result To evaluate 130.1 umol/L kidney function

Normal Result N:80-115

Interpretation The result is high and may indicate that there is a problem in the kidney function.

SERUM ELECTROLYTES
POTASSIUM

A blood test that measures the main electrolyte in the body- sodium, potassium, chloride and bicarbonate bicarbonate that can also be used to evaluate symptoms of heart disease and monitor the effectiveness of treatments for high blood pressure, heart failure and liver and kidney disease. RESULT 5.6 NORMAL VALUE 3.5- 5.1 mmol/L INTERPRETATION HIGH: The kidneys normally remove excess potassium from the body. High potassium levels are more likely to occur when the kidneys are not working properly and are less able to get rid of potassium

1/13/13

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RESULT 4.6

NORMAL VALUE 3.5-5.1mmol/L

INTERPRETATION NORMAL

SMEAR FOR MALARIAL PARASITE (SMP)

Microscopic examination of thick and thin peripheral blood smears stained with Romanovsky dye. Thick smears are more difficult to interpret but greatly increase sensitivity. Thick smears require considerable experience with malaria. Recent techniques: DNA hybridization probes for detection of malarial parasites

DATE 1st: 1/13/13 6:57 2nd: 1/13/13 17:08 3rd: 1/13/13 22:44

RESULT Result: NMPS (no malarial parasite seen) Result: NMPS Result: NMPS

ARTERIAL BLOOD GAS (ABG)

This test is used to determine the pH of the blood, the partial pressure of carbon dioxide and oxygen, and the bicarbonate level. Many blood gas analyzers will also report concentrations of lactate, hemoglobin, several electrolytes, oxyhemoglobin, carboxyhemoglobin and methemoglobin. ABG testing is mainly used in pulmonology and critical care medicine to determine gas exchange which reflect gas exchange across the alveolar-capillary membrane. DATE 1/12/13 COMPONE NT pH PCO2 PO2 HCO3 TCO3 B.E COMPONE NT pH PCO2 RESULT 7.34 36 130 19 20 -5 RESULT 7.40 29.1 NORMAL VALUES 7.35-7.45 35-45 80-100 21-23 23-30 (-)2-(+)2 NORMAL VALUES 7.35-7.45 35-45 62 | P a g e

DATE 1/13/13

PO2 HCO3 TCO3 B.E

87.1 17.6 18.5 -5.5

80-100 21-23 23-30 (-)2-(+)2 CLINICAL MICROSCOPY

DATE

PARAMETE R

RESULTS & NORMAL VALUES 8 HIGH (0-11/UL)

RATIONALE

SIGNIFICANCE

NURSING INTERVENTI ON

1/13/13

WBC

RBC

107 HIGH (0-11/UL)

The presence of white blood cells in the urine usually signifies a urinary tract infection, such as cystitis, or renal disease, such as pyelonephritis or glomerulonephritis. The RBC urine test measures the number of red blood cells in a urine sample

INCREASE: Increase in count can be due to renalimpairement. 1.) Check for recent use of medication that ma affect the test result. INCREASE: abnormal levels of either red cells or hemoglobin, which may be caused by excessive red cell destruction, glomerular disease, kidney or urinary tract infection, malignancy, or urinary tract injury. 2.) Instruct he client to cleanse the preurethral area with soap and water and dry. 3.) Advise to sit with legs

Epithelial Cell

6 NORMAL (0-17/UL)

Epithelial cells (cells in the lining of the bladder or urethra) may suggest inflammation within the bladder, but they also may originate form the

separate at the toilet . 4.) Open the sterile container, placing the lid on a firm surface with

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skin and could be contamination. Cast 0 NORMAL (0-1/UL) The presence of casts and their composition can give us more information about kidney function. Urine casts are small cylindershaped formations of cells and debris from inside the tubules of the kidneys. It is used to test or examine the presence of bacteria. Small amounts of bacteria in a urine sample may be from contamination during sample collection. Large amounts of bacteria usually indicate a bladder infection, especially if an uncontaminated sample was obtained via cystocentesis. PHYSICAL EXAMINATION Changes in color Patients urine can result from result in color is

in easy reach.

During: 5.) Instruct the client to use the midstream catch.

Bacteria

3 NORMAL ()

Patients bacteria is within normal range which happens to be common in urine specimens because of the abundant normal microbial flora and the the external urethral meatus in both sexes and because of their ability to rapidly multiply in urine standing at room temperature. Therefore, microbial organisms found in all but the most scrupulously collected urines should be interpreted and correlated with the condition of the patient.

Color

yellow

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diet, drugs and maybe from metabolic, inflammatory or infectious disease. It is included in the urinalysis to detect whether the concentration of the urine, whether it is diluted, concentrated or clear. This may detect abnormalities in the body especially in the kidney and would be a contribution to diagnose a disease.

normal. Normal urine is straw yellow to amber in color. Abnormal colors include bright yellow, brown, black (gray), red, and green. These pigments may result from medications, dietary sources, or diseases. For example, red urine may be caused by blood or hemoglobin, beets, medications, and some porphyrias. Black-gray urine may result from melanin (melanoma) or homogentisic acid (alkaptonuria, a result of a metabolic disorder). Bright yellow urine may be caused by bilirubin (a bile pigment). Green urine may be caused by biliverdin or certain medications. Orange urine may be caused by some medications or excessive urobilinogen (chemical relatives of urobilinogen). Brown urine may be caused by excessive amounts of prophobilin or urobilin (a 65 | P a g e

Clarity

Hazy

Reaction

5.0 NORMAL (4.5-8)

Specific gravity

1.020 NORMAL (1.0031.030)

Clarity of the urine is included in the test to detect some abnormalities, which can be also a contribution in the diagnosis. This is to determine appearance of the urine. Changes in clarity may indicate certain problems such as infection. It is included to detect how the body reacts to a specific disease. A positive or negative reactions will be the result. Specific gravity (which is directly proportional to urine osmolality which measures solute concentration) measures urine density, or the ability of the kidney to concentrate or dilute the urine over that of plasma.

chemical produced in the intestines). Urine is normally clear. Bacteria, blood, sperm, crystals, or mucus can make urine look hazy.

Patients reaction is elevated which means reactive. This indicates that the body is reacting on a particular disease. Patients result is within normal range. Specific gravity between 1.002 and 1.035 on a random sample should be considered normal if kidney function is normal. Since the sp gr of the glomerular filtrate in Bowman's space ranges from 1.007 to 1.010, any measurement below this range indicates hydration

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and any measurement above it indicates relative dehydration. CHEMICAL ANALYSIS Glucose is the Patient reveals type of sugar negative in found in blood. Normally there is glucose content in very little or no urine. High in glucose in urine. When the blood such, indicates sugar level is very uncontrolled high, as in uncontrolled diabetes because diabetes, the the sugar or the sugar spills over into the urine. glucose spills over Glucose can also into the urine. be found in urine when the kidneys are damaged or diseased. Used to Presence of protein in urine detect protein in may indicate that the urine, to help the function of the kidney is impaired. evaluate and monitor kidney function, and to help detect and diagnose early kidney damage and disease.

Glucose

(-) negative

protein

(+) negative

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GRAM STAINING 1/13/13 This test is to detect presence of organism in the urine that may indicate presence or sign of infection. SPECIMEN: URINE RESULT: NO ORGANISM SEEN

SERUM AMMONIA 1/14/13 Result: 42 HIGH NORMAL: 11-34umol/L Ammonia levels rise when there are large amounts of protein being catabolized and the liver is unable for some reason to convert it into urea so it can be excreted through the kidneys. anything that interferes with the breakdown of ammonia in the system will increase serum levels. that includes such conditions as hepatic encephalopathy, hepatic coma, hepatocellular disease and many other liver-related conditions.

TYPHIDOT 1/14/13 It is a medical test consisting of a dot ELISA kit that detects IgM and IgG antibodies against the outer membrane protein (OMP) of the Salmonella typhi. The typhidot test becomes positive within 23 days of infection and separately identifies IgM and IgG antibodies. The test is based on the presence of specific IgM and IgG antibodies to a specific 50Kd OMP antigen, which is impregnated on nitrocellulose strips. IgM shows recent infection whereas IgG signifies remote infection. RESULT: IgM and IgG NEGATIVE INTERPRETATION: Probably not typhoid feve.

ALBUMIN:

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Albumin testing is used in a variety of settings to help diagnose disease, to monitor changes in health status with treatment or with disease progression, and as a screen that may indicate the need for other kinds of testing.

An albumin test may be ordered as part of a liver panel to evaluate liver function, along with a creatinine and BUN (Blood Urea Nitrogen) to evaluate kidney function, or along with a prealbumin to evaluate a person's nutritional status. RESULT: 19g/L LOW: Low albumin levels can reflect diseases in which the kidneys cannot prevent albumin from leaking from the blood into the urine and being lost. In this case, the amount of albumin or protein in the urine also may be measured

SGPT(ALT) Serum Glutamic Pyruvic Transaminase, an enzyme that is normally present in liver and heart cells. SGPT is released into blood when the liver or heart are damaged. RESULT: 467u/L HIGH: This may indicate liver damage.

BLOOD CULTURE Blood culture is a microbiological culture of blood. It is employed to detect infections that are spreading through the bloodstream (such as bacteremia, septicemia amongst others). This is possible because the bloodstream is usually a sterile environment. RESULT No growth in 24 hours. 1 day of incubation

ULTRASOUND OF THE WHOLE ABDOMEN Abdominal ultrasound is an imaging procedure used to examine the internal organs of the abdomen, including the liver, gallbladder, spleen, pancreas, and kidneys. The blood vessels that lead to some of these organs can also be looked at with ultrasound. LENGTH WIDTH THICKNESS L: 11.2 cm L 4.9 cm L 4.1 NORMAL: 10.8- R: 10.6 cm 0.8 NORMAL: 4.2-0.5 R 4.5 NORMAL R 4.2 NORMAL: 9.70.7 NORMAL:4.30.5 NORMAL:390.5 69 | P a g e

Impression: Moderate ascites. Cystitis may be due to ascites or hypoalabumenimia incidental finding of bilateral minimal pleural effusion ultrasononically normal liver, gallbladder, bilateral tree pancreas, spleen, abdominal aorta, para-aortic areas, kidneys, ureters and prostate gland.

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Possible Diagnostic Exam

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Lumbar Tap:

It is a diagnostic and at times therapeutic procedure that is performed in order to collect a sample of cerebrospinal fluid (CSF) for biochemical, microbiological, and cytological analysis, or very rarely as a treatment. The most common purpose for a lumbar puncture is to collect cerebrospinal fluid in a case of suspected meningitis, since there is no other reliable tool with which meningitis, a life-threatening but highly treatable condition, can be excluded.

CT Scan:

To view the kidney and urinary tract. This tells whether the kidneys are too large or too small, whether it has a problem in its structure.

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Drug Studies
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Generic Name Brand Name/s Classification Mode Of Action

Ceftriaxone Rocephin Antibiotics Works by inhibiting the mucopeptide synthesis in the bacterial cell wall. The beta-lactam moiety of Ceftriaxone binds to carboxypeptidases, endopeptidases, and transpeptidases in the bacterial cytoplasmic membrane. These enzymes are involved in cell-wall synthesis and cell division. By binding to these enzymes, Ceftriaxone results in the formation of of defective cell walls and cell death.

Ordered Dose Date Ordered Suggested Dose

3 grams IVTT OD 1/12/13 Adult Dose 12g IM or IV once daily or in 2 equally divided doses; max

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4g/day. Gonorrhea: 250mg IM once. Surgery: 1g IV 2 hours pre-op. Children's Dose 5075mg/kg per day in equally divided doses every 12 hours; max 2g/day. Skin and skin structures: may give as a single dose or in 2 equally divided doses every 12 hours; max 2g/day. Meningitis: 100mg/kg (max 4g) for 1 dose, then 100mg/kg per day (max 4g/day) once daily or in 2 equally divided doses every 12 hours for 714 days. Otitis media: 50mg/kg (max 1g) IM once. Indications Infections of the lower respiratory tract, bacterial septicemia, meningitis. Contraindications Hypersensitivity to cephalosporins.Hypersensitivity to Lidocaine, Hyperbilirubinemic neonates (esp. prematures) Side / Adverse Effects Phlebitis Rash Diarrhea Thrombocytosis Leucopenia Glossitis(inflammation of the tongue) Respiratory superinfections Drug Interactions Aminoglycosides: may increase nephrotoxicity Probenecid: May inhibit excretion and increase blood levels of the drug. Nursing Interventions Assess patients previous sensitivity reaction to penicillin or other cephalosphorins. Obtain C&S before beginning drug therapy to identify if correct treatment has been initiated.

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Be aware that drug can increase ALT, AST, alkaline phosphatase, bilirubin levels and decrease hemoglobin, hematocrit, neutrophil and platelet counts.

Instruct patient to report if he/she experiences loose stools or diarrhea Instruct patient to report signs of superinfection such as: itching fever, malaise,

redness, diarrhea

Generic Name Brand Name/s Classification Mode Of Action Ordered Dose Date Ordered Suggested Dose

Ciprofloxacin Ciprobay Antibacterial Inhibition of topoisomerase (DNA gyrase) enzymes, which inhibits relaxation of supercoiled DNA and promotes breakage of double stranded DNA. 500 mg/ tab BID 1/12/13 CIPRO film-coated tablets are available in 250 mg, 500 mg and 750 mg (ciprofloxacin equivalent) strengths.

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Indications

Infections of the lower respiratory tract, bacterial septicemia, meningitis.

Contraindications

Ciprofloxacin is contraindicated in persons with a history of hypersensitivity to ciprofloxacin, any member of the quinolone class of antimicrobial agents, or any of the product components.

Contraindicated for the treatment of certain sexually transmitted diseases by some experts due to bacterial resistance.

Side / Adverse Effects

Nausea, Vomiting, Stomach pain, Heartburn, Diarrhea, Feeling an urgent need to urinate, Headache, Hives, Difficulty breathing or swallowing, Hoarseness or throat tightness, Rapid, irregular, or pounding, heartbeat, Fainting, Fever, Joint or muscle pain, Unusual bruising or bleeding, Extreme tiredness, Lack of energy or appetite, Seizures, Dizziness, Confusion, Nervousness, Restlessness, Anxiety, Difficulty falling asleep or staying asleep, Dark colored urine

Drug Interactions Nursing Interventions

None significant

Instruct patient not to take ciprofloxacin with dairy products such as milk or yogurt, or with calcium fortified juice. He may eat

or drink dairy products or calcium-fortified juice with a regular meal, but do not use them alone when taking ciprofloxacin. They could make the medication less effective. Tell patient that Ciprofloxacin can cause side effects that may impair his thinking or reactions. Tell patient to be careful if he plans to drive or do anything that requires him
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to be awake and alert. Instruct patient to take ciprofloxacin with a full glass of water (8 ounces). Instruct patient to avoid taking the drug with antacid because it can decrease the effectiveness of ciprobay. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Instruct client to report any adverse reaction to the physician or nurse

Generic Name Brand Name/s Classification Mode Of Action

Omeprazole Omepron proton pump inhibitor An antisecretory compound that is a gastric acid pump inhibitor. Suppresses gastric acid secretion by inhibiting the H+, K+ATPase enzyme system [the acid (proton H+) pump] in the parietal cells

Ordered Dose Date Ordered Suggested Dose Indications

40mg/ tab OD 1/12/13 10-40mgs Prophylaxis. To prevent stress ulcer.

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Contraindications

Long-term use for gastroesophageal reflux disease, duodenal ulcers; lactation.

Side / Adverse Effects

CNS: Headache, dizziness, fatigue. GI: Diarrhea, abdominal pain, nausea, mild transient increases in liver function tests. Urogenital: Hematuria, proteinuria. Skin: Rash.

Drug Interactions Nursing Interventions

Diazepam: dcreases hepatic clearance

Give before food, preferably breakfast; capsules must be swallowed whole (do not open, chew, or crush). Monitor urinalysis for hematuria and proteinuria. Periodic liver function tests with prolonged use. Instruct patient to report any changes in urinary elimination such as pain or discomfort associated with urination, or blood in urine. For lactating mothers, instruct her not to breast feed while taking this drug.

Generic Name Brand Name/s

Calcium polystyrene sulfonate powder Kalimate

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Classification Mode Of Action Ordered Dose Date Ordered Suggested Dose

Serum potassium lowering agent Removes potassium from the gut in exchange for sodium

3 mg 3 sachet TID x3 doses 1/12/13 Oral: 50 g in 30 mL of sorbitol solution Rectal: 50 g in a retention enema

Indications Contraindications Side / Adverse Effects Drug Interactions Nursing Interventions

Hyperkalemia Hypokalemia, intestinal obstruction Constipation, hypokalemia, anorexia, GI disturbance

Digoxin- enhanced effect of the drug

Assess the need for medication Check initial potassium level of the patient for basis After administering the medication, instruct patient to increase oral fluid intake to prevent constipation Instruct patient to pay attention to their feces and report if constipation is followed by significant symptoms such as abdominal pain, abdominal distention, or vomiting, etc.

Continuously monitor potassium level of the patient.

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Generic Name Brand Name/s Classification Mode Of Action Ordered Dose Date Ordered Suggested Dose

Meropenem Merrem antiinfective; carbapenem antibiotic Inhibits bacterial cell wall synthesis. It readily penetrates cell wall of most gram (+) and (-) bacteria to reach penicillin-bindingprotein targets 2g now then 2g q8 hours 1/12/13 Adults: 1g IV q8 hours Pedia: 3 months and older weighing less than 5kg(110lb)= 20mg/kg q8 hours

Indications Contraindications

bacterial septicemia, meningitis. Hypersensitivity to the drug components and patients who have anaphylactic reactions to beta-lactams.

Side / Adverse Effects Drug Interactions

Seizure, headache, diarrhea, nausea, vomiting, constipation, presence of RBC in the urine Probenecid: decrease renal excretion of meropenem

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Nursing Interventions

Assess need for medication Assess patients sensitivity to the drug. Give the medication at the right time, dose, patient and frequency. Be knowledgeable that drug can cause presence of RBC in the urine, increase ALT, AST,bilirubin and BUN levels. Instruct patient to report any side effects immediately.

Generic Name Brand Name/s Classification Mode Of Action Ordered Dose Date Ordered Suggested Dose Indications Contraindications Side / Adverse Effects

Paracetamol Biogesic Anti-pyretic, analgesics It is thought to produce analgesia by blocking generation of pain impulses, probably by inhibiting prostaglandin synthesis in the CNS or the synthesis or action of other substances that sensitize pain receptor to mechanical or chemical stimulation. 500mg now, q4 1/12/13 300-600mg Symptomatic relief of pain and fever. Patients hypersensitive to drug. No known side effects Adverse Effect: Hematologic: pancytopenia. Hepatic: Jaundice Metabolic: Hypoglycemia Skin: rash, urticaria.
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hemolytic

anemia,

neutropenia,

leucopenia,

Drug Interactions

Warfarin: May increase hypoprothrombinemic effects with long term use. Zidovudine: May increase risk forbone marrow suppression.

Nursing Interventions

Assess the need for medication Check the patients temperature before giving the medication Give the right dose and drug. Instruct patient that drug is only for short term use and to consult the physician if giving to children for longer than 5 days or adults for longer than 10 days.

Warn patient that high doses or unsupervised long term use can cause liver damage. Continuously monitor patients temperature.

Generic Name Brand Name/s Classification Mode Of Action

Sodium bicarbonate Sodium bicarbonate Alkalanizer Restores buffering capacity of the body and neutralizes excess acid.

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Ordered Dose Date Ordered Suggested Dose Indications Contraindications Side / Adverse Effects Drug Interactions Nursing Interventions

50 meqs bolus NOW 1/13/13 1 meq/kg Acidosis Patients with respiratory or metabolic alkalosis, hypocalcemia Flatulence, pain or irritation at the IV site

Tetracycline: increased urine alkalinization

Assess the need for medication Instruct patient not to drink milk when taking the medication because it can cause hypercalcemia, alkalosis and renal calculi

Before administering the medication, obtain ABG and check the results. Inform physician immediately if the patient experiences unwanted effects of the drug.

Generic Name Brand Name/s Classification Mode Of Action

Acetylcysteine Fluimucil Mucolytic agent Exerts mucolytic action through its free sulfhydryl group which opensup the disulfide bonds in the mucoproteins thus lowering mucous viscosity.

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Ordered Dose Date Ordered Suggested Dose Indications

1.2g IV q12 hours 1/14/13 1-2g Treatment of respiratory affections characterized by thick and viscous hypersecretions: acute bronchitis, chronic bronchitis and its exacerbations; pulmonaryemphysema, mucoviscidosis and bronchiectasis.

Contraindications Side / Adverse Effects Drug Interactions Nursing Interventions

Patients with hypersensitivity to the drug. Drowsiness, tachycardia,bronchospasm, chest tightness

No known interaction

Assess the need for medication Position the patient to moderate high back rest Check patients vital signs esp. RR Monitor cough type and frequency Instruct patient to cover mouth when coughing. Instruct patient to do deep breathing exercise.

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Generic Name Brand Name/s Classification Mode Of Action Ordered Dose Date Ordered Suggested Dose

Albumin Buminate 25% Blood derivative Human albumin increases intravascular oncotic pressure and causes movement of fluids from interstitial into intravascular space. 50cc IV q12 hours 1/14/13 Adult: IV Acute hypovolaemic shock Initial: 25 g, adjust

according to response. Usual rate: Up to 5 mL/min using 5% soln. Hypoproteinaemia Up to 2 g/kg/day. Usual rate: Up to 5 mL/min using 5% soln. Indications Contraindications Hypoalbuminemia Cardiac failure, severe anaemia, history of hypersensitivity, parenteral nutrition. Side / Adverse Effects Allergic reactions, nausea, vomiting, increased salivation, fever and chills; vascular overload, haemodilution and pulmonary oedema. Potentially Fatal: Anaphylactic shock. Drug Interactions Albumin solution should not be mixed by protein hydrolysates or alcoholic solutions. Risk of atypical reactions to ACE inhibitors in patients undergoing therapeutic plasma exchange with albumin human replacement. Nursing Interventions Assess the need for medication Check albumin level of the patient Regulate the medication correctly.

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Check the IV site for patency. Instruct patient to report unwanted effects of the drug.

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RELATED NURSNG THEORY

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Related Nursing Theory This section contains the theories to which this case study had been based on and how it is related to our case. We contended that an individual tends to be more susceptible to infection if he / she has a decreased in resistance to infection. Moreover, the disease process of our patient leads to a more risky complications that need further patientcentered care. Based on the book of Tomey, A. (2002), Florence Nightingale defined nursing as the act of utilizing the environment of the patient to ass ist him in his recovery. The environment greatly affects the health of a person as well as the duration of the disease process. Changes and alterations in the environment could even be the cause of certain illnesses. She linked health with five environmental factors which are pure fresh air, pure water, efficient drainage, cleanliness and light. Deficiencies in these five factors produced lack of health or illness. Part of the environment is bedside lines, garments, medication table and almost everything that comes in contact with our patients. According to the theory of Mandell, the most important defense against transmission of viruses and other infectious agents is detailed and continuing education of staff and strict adherence to infection control policies. In addition, Henderson identified fourteen (14) basic needs of the patient in which the third is eliminating body waste and the eighth is keeping the body clean and groomed to protect the patient. Therefore, it is the nurses goal to assist the client in achieving independence to meet these needs. Part of the process of meeting the third and eighth need of the patient is to make sure the facilities used for elimination would be safe for the client. It is one of the nurses responsibilities to be aware that materials such as instruments used in the patient may be a means of acquiring infections and must be changed from time to time.

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Jean Watsons theory of the Philosophy and Science of Caring, was based on the 10 carative factors. The 8th carative factor speaks about the provision for supportive, protective and corrective environment. It says that nurses must recognize the influence that the external environment have on the health and illness of individuals and other external variable include a clean and aesthetic environment. In relation to our study, ileostomy bag are part of the external environment that is why it is important that we maintain its cleanliness because it may have an effect on the overall well-being of a person. Another theory that has a relation to our study is the theory of comfort by Katherine Kolcaba. According to this theory, in order to provide comfort to a patient certain measures must be observed and these measures are defined as nursing interventions designed to address comfort needs of recipient, including the environmental interventions. So in relation to our case study, part of the environmental interventions is keeping the external environment of the patient clean and free from disease causing microorganism, this includes our frequent handwashing before handling our patients and also keeping their hygiene as monitored as possible.

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DISCHARGE PLANNING

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Medication Instruct the family to administer the drugs to the patient that are prescribed.

Rationale

Other drugs may interfere with the prescribed drugs in terms of its effectiveness in the management of the disease.

Instruct the family to check first the label and expiry date of the drugs that are to be given.

To ensure accuracy of the drug and its date of expiration.

Educate the patient and the family about the side effects of the drug.

Educating the patient and the family is important for them to be aware of the side effects that the drugs may cause.

Instruct the patient and family to consult In order for the physician to discontinue the physician and immediately other if adverse the drugsand evaluate adverse reaction to are prevent further complications reactions problems

experienced.

Advise the family to let patient complete the course of treatment.

To prevent the risk of drug resistance if the medication regimen is not strictly and continuously followed.

Ensure that the patient has been fed Some drugs such as non steroidal antibefore administering medications, inflammatory drugs usually causes especially non steroidal anti- inflammatory gastrointestinal irritation. drugs. EXERCISE RATIONALE

Instruct the family to assist patient in doing

Passive range of motion will help the

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passive range of motion.

patient in somehow stretching the muscles and improving its strength.

Instruct the family to move the patient from side to another side by securing the facial mass.

Since the patient is bedridden, therefore he is prone to developing bed sores which may cause another complication.

TREATMENT

RATIONALE

Have a regular and follow up check-ups with the physician.

The physician will check for the health status of the patient and to evaluate whether the treatment given was effective.

Advise the family to let the patient to have adequate rest and sleep.

To promote relaxation and conserve energy.

HYGIENE

RATIONALE

Maintain personal hygiene such as rendering shampoo and bathing in bed everyday.

Bathing reduces the chance of acquiring further infection since the patient is immunocompromised.

Maintain a clean environment.

Clean environment is conducive for a healthy leaving. Acquiring diseases from the environment will be lessen.

Encourage the family to wash the hands of Prevents the client from ingesting the client. microorganism that could alter the clients condition.

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Encourage the family about the clients The client will achieve the sense of wellclient personal grooming such as combing being and also comfort though the patient the hair and mouth care. cannot do the daily activities of living.

Instruct the family about the importance of The improper disposal of waste could be a sanitary practices such as in disposing precipitating factor in acquiring further wastes on elimination of the patient. infection.

Out patient

Rationale

Comply with regular and follow-up checkups as ordered by the physician.

To evaluate the ongoing process of treatment and to give more interventions.

Ask for a prescription from the doctor for continues medications as ordered.

To facilitate in managing the disease of the patient and for fast recovery.

DIET Administer NGT feeding as ordered.

RATIONALE NGT feeding is used for prolonged nutrition, as in elderly and debilitated patient. Osteorized feeding contains vitamins, minerals and nutrients that will support the nutritional needs of the patient.

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Prognosis

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Septic encephalopathy is a common term indicating the development of signs of progressing cerebral dysfunction and is associated with the presence of microorganisms and their toxins in the blood. SE syndrome has a favorable prognosis if macroscopic lesion and dissemination if microorganisms in CNS are not present, and simultaneously it represent changes in metabolic-electrolytic state with early presentation of consciousness disorders that represent clinically significant indicator for sepsis syndrome outcome. There are widespread disturbances in hepatic and peripheral metabolism in sepsis. Although the main objective in the treatment of septic patients, of course, is to remove or drain the septic focus, recent studies have shown that administration of BCAA-enriched solutions may be beneficial in the improvement of metabolic derangements and septic encephalopathy. Approximately 2035% of people with severe sepsis and 3070% of people with septic shock die. Lactate is a useful method of determining prognosis with those who have a level greater than 4 mmol/L having a mortality of 40% and those with a level of less than 2 mmol/L have a mortality of less than 15%. There are a number of prognostic stratification systems such as APACHE II and Mortality in Emergency Department Sepsis. APACHE II factors in the person's age, underlying condition, and various physiologic variables can yield estimates of the risk of dying of severe sepsis. Of the individual covariates, the severity of underlying disease most strongly influences the risk of death. Moreover, our patient did not inherit any of the familys history of hypertension, diabetes and any other hereditary disease. Also, he practiced a healthy lifestyle since his diet used to be comprised of vegetables and fruits and occasionally drinks and is a non-smoker. On the other hand, expensive treatment and medical demands may not be met, because of their lack of financial sources. We then conclude that patient SG has a fair prognosis.

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REFERENCE

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BOOK SOURCES:

Black, J. & Hawks, J. (2009). Medical-Surgical Nursing. 8th edition. Saunders, an imprint of Elsevier Inc.

Doenges, Marilynn E., (2006). Nurses Pocket Guide diagnoses, prioritized intervention and rationales. 10th ed. Ingatavicius, D. and Workman, L. (2010) Medical-Surgical Nursing. 6th edition. Saunders, an imprint of Elsevier Inc.

Kozier, Barbara. (2004). Fundamentals of Nursing concepts processes and practice. 7th ed. Osborn, K. et al. (2010). Medical-Surgical Nursing. Pearson Education, Inc. Porth, C.M. (2007). Essentials of Pathophysiology: Concepts of Altered Health States. Lippincott Williams & Wilkins. Smeltzer, S.C., Bare, B.G. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins. Smeltzur, S. et al. (2010). Brunner and Suddarths Textbook of Medical -Surgical Nursing. 12th edition. Lippincott Williams and Wilkins Timby, Barbara K. et al. (2007). Introductory Medical-Surgical Nursing. 9th edition. Lippincott Williams and Wilkins. Karch, A.M (2008). Lippincotts Nursing Drug Guide. 530 Walnut Street, Philapelphia: Lippincott Williams & Wilkins Deglin, J., & Vallerand, A. (2009). Davis Drug Guide for Nurses (11th edition), Philadelphia: F.A. Davis Company

INTERNET SOURCE: http://medical-dictionary.thefreedictionary.com/precipitating+factor http://www.springerreference.com/docs/html/chapterdbid/338324.html http://www.mdguidelines.com/encephalopathy/definition

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http://www.answers.com/topic/encephalopathy#ixzz2JDxFurZr

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