PYELONEPHRITIS

GROUP 1

I.

INTRODUCTION
The diagnosis of a urinary tract infection (UTI) is typically confirmed on the basis of a certain number of microorganisms in the urinary system, although manifestation may begin with many fewer organisms. The infectious process usually affects the bladder, but the uretrhra, ureters, and kidney may be involved.

Urinary tract infection (UTI) is one of the most common infection treated by primary care providers, untreated, it has the potential for serious consequence, such as pyelonephritis and bacteremia. On rare occasions, complication of UTI can lead death. Cystisis is the most common types of UTI.

DEFINITION:
CYSTITIS Inflammation of the urinary bladder s/sx: Pressure in lower pelvis Painful urination (dysuria) Frequent urination(polyuria) Abnormal urine color(cloudy) Foul odor of urine

-URETHRITIS inflammation of the urethra. s/sx: Dysuria Painful urination -URETERITIS Inflammation of the ureter. s/sx: Renal colic Fever Blood in the urine

PYELONEPHRITIS Inflammation of renal pelvis. s/sx: Acutely ill with chills and Flank pain fever CVA tenderness High fever and chills Nausea

Leukocytosis Bacteriuria Dysuria

Foul smelling urine

CAUSES:

Pyelonephritis is caused by Escherichia coli this is a type of bacteria that normally in the large intestine. However, any physical obstruction to the flow of urine, such as structural abnormality, bladder tumor, strictures, kidney stone or an enlarged prostrate or backflow (reflux) of urine from the bladder into the ureters may cause pyelonephritis

PREVALENCE RATE:
EPIDEMIOLOGY: -Pyelonephritis is very common, with 12-13 cases annually per 10,000 populations in women and 3-4 cases per 10,000 in men. Young women are most likely to be affected, traditionally affecting sexual activity in that age group. Infants and the elderly are also at increase risk, reflecting anatomical changes and hormonal status.

6 years of age; Boys: 1.8% Girls: 6.6% 5-7% Female febrile infant (8 weeks of age) 1% School-age children 1-3% Girl between 1-5 years of age 0.003% School age boys

DIAGNOSIS:

The presence of nitrite and leukocyte (white blood cell) on a urine dipstick test in patients with typical symptoms are sufficient for the diagnosis of pyelonephritis, and are an indication for empirical treatment. Formal diagnosis is with culture of the urine blood cultures may be needed if the source of the infection is initially doubtful.

II.NURSING HISTORY

PATIENTS PROFILE Name: Ms. Yuri Age:21 Sex: Female Address: P2 Dubinan west Santiago city Nationality: Filipino Civil status: Single Religion: Roman Catholic Occupation: Office secretary Date admitted: 3/4/2011 Time admitted: 8:10am Admitting diagnosis: UTI, Pyelonephritis Chief complaint: Right lower quadrant and radiating flank pain since Saturday February 26, 2011.

B. HISTORY OF PRESENT ILLNESS

The day PTA, the patient complained of back pain and couldnt stand alone because she felt dizzy and radiating flank pain in night lower quadrant of the abdomen and general also complaining for body malaise and painful urination.

PAST MEDICAL HISTORY The patient has been hospitalized when she was in 4th yr. high school due to bronchitis FAMILY HISTORY The patient verbalized that her father had also suffered urinary tract infection.

E. GORDONS FUNCTIONAL PATTERN

HEALTH PERCEPTION BEFORE CONFINEMENT: -The patient stated that she consider herself healthy because she cannot feel something unusual. DURING CONFINEMENT: -She stated that shes already unhealthy because she can feel pain NUTRITION BEFORE CONFINEMENT: -The patient seldom drink water and sometimes not at all. Shes also fun in eating sweets and salty foods. DURING CONFINEMENT: -On her first day of confinement the ROD ordered DAT.

ELIMINATION PATTERN PRIOR CONFINEMENT -The patient usually voids for 1-2 times a day. The color of her urine was dark yellow. However, 1 day PTA she complained of pain upon urination in the pain scale 7 that causes her to void in small quantities. DURING CONFINEMENT -She voids 2-4 times a day in normal quantities and slight pain upon urination ACTIVITY BEFORE CONFINEMENT: -The patient can go to work and stayed at the office from 7-5 pm can do activity daily living. DURING CONFINEMENT: -The patient appears weak to go the bathroom.

SLEEP/REST PATTERN: BEFORE CONFINEMENT: -Her usual sleeping pattern was 6-8 hours daily. DURING CONFINEMENT: -She is able to sleep 8-10 hours and an hour of snaps in the afternoon COGNITIVE PERCEPTUAL PATTERN -The patient can read and write and her senses functions well. The decision for the benefit of the patient always comes from her. However, at times she asks for assistance her family.

SELF PERCEPTION BEFORE CONFINEMENT: -She said that prior to hospitalization; she believed she was perfectly fine. Not until she experienced those symptoms 1 day PTA. DURING CONFINEMENT: -The patient recognizes how important drinking water and proper elimination pattern and she are thinking she might prevent it if she had recognized it. ROLE RELATIONSHIP: -The patient stated that she has a good relationship with her family. However she is the bread winner. Sometimes shes some of the decision maker at their home.

SEXUAL PATTERN: -The client is single COPING STRESS TOLERANCE -She asks for assistance from her mother in terms of making decision to avoid stress. She managed her problem through praying. VALUES AND BELIEF PATTERNS BEFORE CONFINEMENT: -She said she attends Sunday masses regularly but her recent confinement hinders her practice. DURING CONFINEMENT: -During hospitalization, she prays to GOD to bless her and her family with good health.

III.PHYSICAL EXAMINATION
March 4, 2011 General appearance: The patient looks weak and irritable, complaining pain at the right lower quadrant and radiating flank pain, (+) guarding and facial grimace and pale looking with excessive sweating. Vital Sign: BP: 100/70 mmHg Temperature: 38.3 RR: 25 cpm PR: 89 bpm

Parts

Technique

Abnormal

Analysis

Hair Head Face

Eyes Ears Mouth Neck Lungs

Abdomen

Extremities Upper:

Nail Skin

Lower:

Nail

Inspection Inspection Inspection Palpation Inspection Inspection Palpation Inspection Inspection Palpation Inspection Palpation Percussion Auscultation Inspection Palpation Percussion Auscultation Inspection Inspection Palpation Inspection Palpation Inspection Palpation
Inspection Palpation

Weak looking and facial grimace pale, and with eye bags

As body response to pain Due to inadequate sleep

Dry mouth, pale, cracked and dry lips.

As body response to fever and fluid loss of the body

Shivers Pale Dry Pale

Due to fever Response of the body to Inflammation Due to fever Response of the body to inflammation Due to fever

Skin

Pale

MARCH 5, 2011 General appearance: the patient looks pale and weak. Vital sign: BP: 100/80mmHg Temperature: 37.5 RR: 19 cpm PR: 87 bpm

Parts

Technique

Abnormal

Analysis

Hair Head
Face Eyes

Inspection Inspection Palpation Inspection Palpation Inspection Inspection Palpation Inspection Inspection Palpation Inspection Palpation Percussion Auscultation Inspection Palpation Percussion Auscultation Inspection Inspection Palpation Inspection Palpation Inspection Palpation Inspection Palpation

Weak looking Pale and with eye bags

Due to uncomfortable feeling Due to inflammation and inadequate sleep

Ears
Mouth Neck Lungs

Cracked and dry lips

Due to fever and fluid loss of the body

Abdomen

Extremities Upper:

Pale

Nail
Skin

Response of the body to inflammation

Dry Pale Response of the body to inflammation

Lower:

Nail

Skin

Dry

IV.LABORATORY RESULTS
A. MARCH 4, 2011
URANALYSIS NORMAL VALUES RESULTS ANALYSIS

COLOR

Amber

Dark yellow

Urine becomes over concentrated with waste that makes urine dark yellow

TRANSPARENCY

Clear

Turbid

The presence of bacteria, increase WBC and RBC that cause her urine turns to turbid

SPECIFIC GRAVITY PH PROTEIN

1.010 - 1.025 4.5 8.0 6 8 g/d

1.015 Alkaline (+) 2 Due to infection, medications, and physical stress

SUGAR

65 99 mg/dl

(-)

URANALYSIS

NORMAL VALUES

RESULTS

ANALYSIS

WBC

5000 10000/mm3

TNTC

Due to her body response to invasion, they provide components of coagulation, transportation and complement

production during acute

infection. RBC 4.2 5.4 mil/mm3 12 15

AMORPHUS URATES

Moderate

EPITHELIAL CELLS

Moderate

BACTERIA

Many

Due to infection

HEMATOLOGIC REPORT
A. MARCH 4, 2011
Complete Blood Count
Hemoglobin 110 160 g/d

Normal Values
139

Results

Hemotocrit

34-47

41.5

White Cell Count

5-10x10 9

23.6

Segmenters

50-65%

93

Lymphocytes

25-35%

4.2

Eosinophils

1-3% 2.8

Monocytes

3-7%

Platelet count

150-450 X 10 9

24

V.REVIEW SYSTEM
-ANATOMY OF URINARY SYSTEM The urinary system consist of two kidneys, two ureters, the urinary bladder, and the urethra. A large volume of blood flows through the kidneys, which removes substances from the blood to form urine. The urine contains excess water and ion metabolic wastes such as urine and toxic substances consumed with food. The urine produce by the kidneys flows through the ureters to the urinary bladder, where it is stored until it is eliminated through the urethra.

FUNCTIONS OF THE URINARY SYSTEM

KIDNEYS: The major functions of the urinary system are performed by the kidneys, and the kidneys play the following essential roles in controlling the composition and volume of body fluids. 1. Excretion. The kidneys are the major excretory organs of the body. They remove waste products, many of with are toxic from the blood.

The kidneys control blood volume by regulating the volume of urine produced. 3. The kidneys help regulate the concentration of major ions in the body fluid. 4. The kidneys help regulate the pH of the fluids. 5. The kidneys regulate the concentration of red blood cell in the blood. 6. The kidneys participate with the skin, and liver,in vitamin D synthyesis.

URINARY BLADDER is a hollow muscular container that lies in the pelvic cavity just posterior to the pubic symphisis. It functions to store urine, and its size depends on the quality of urine present. URETHRA is a tube that exist the urinary bladder infection and anteriorly the triangle-shape portion of the urinary bladder located between the opening of the ureters and the opening of the urethra is called the trigone. The urethra carries urine from the urinary bladder to the outside of the body.

KIDNEY are been shape organs, each about the size of a tightly clenched fist. They lie in the posterior abdominal wall, behind the peritoneum, with one kidney on either side of the vertebral column.

OUTER KIDNEY
Hilium (opening)-where the renal artery and nerves enter and where the renal vein and ureter exit the kidney. Renal artery-branch off the abdominal aorta and abdominal aorta and enter the kidneys. They give rise to several branches. Renal vein-are veins that drain the kidney. They correct the kidney to the inferior vena cava.

Renal pelvis-is the funnel-like dilated proximal part of the ureter in the kidney. In humans, the renal pelvis is the point of convergence of two or three major calyces. URETER-are muscular tubes that proper urine from the kidneys to the urinary bladder.

INNER KIDNEY
Cortex-is the outer part of the substance or the kidney, composed mainly of glomeruli and convulated tubules. Renal pyramid -the conical masses composing the medullary substance of the kidney. Major calyces -in the kidney, surrounds the apex of the malphighian pyramids. Urine formed in the kidney passes through a papilla at the apex into a minor calyx then into the major calyx before passing through the renal pelvis into the ureter. A fusion of minor calyx.

Renal artery-brach off the abdominal aorta and enter the kidneys. Minor calyces -the cup-shape dilation of the intrarenal ureter, into which a single papilla of a multiple-lobe kidney protrudes. Nephron -is the basic structure and functional unit of the kidney. Its chief function is to regulate the concentration of water and soluble substance like sodium salts by filtering the blood, reabsorbed what is needed and excreting the rest of urine.

NORMAL KIDNEYS AND PARTS

PYELONEPHRITIS

URINE FLOW Urine is produced by the processes of filtration, reabsorption and secretion. FILTRATION The renal filtrate passes from the glomerulus into Bowmans capsule and contains no blood cells and few blood proteins then filtration pressure is responsible for filtrate formation. REABSORPTION About 99% of the filtrate volume is reabsorbed, 1% becomes urine. Proteins, amino acids, glucose, fructose, sodium, potassium, calcium are among the substances reabsorbed. About 65%of the filtrate volume is reabsorbed in the proximal tubule and collecting ducts. SECRETIONS Hydrogen ions same by-products of metabolism, and some drugs are actively secreted into the nephron.

B. PATHOPHYSIOLOGY

PYELONEPHRITIS

Precipitating factor: Immunocompro mise patient Lifestyle Misconception with regard to proper hygiene care

Etiology: Attachment of Eschericha coli bacteria in the urethra

Predisposing factor: Age Gender Health problem

B. PATHOPHYSIOLOGY
Proliferation of bacteria in the urethra

Urethritis

Urethrovesical reflux

B. PATHOPHYSIOLOGY
Introduction of bacteria in the bladder

Inflammation of the bladder

Cystitis

Ureterovesicial reflux

B. PATHOPHYSIOLOGY

Introduction of bacteria to the Ureter

Inflammation of the Ureter

Ureteritis

B. PATHOPHYSIOLOGY

Infection ascends to the kidneys

Pyelonephritis

Dysuria Activation of the immune response General Body Malaise Nausea and vomiting Colic

B. PATHOPHYSIOLOGY
Release of pyrogens from bacteria

Flank pain

Release of prostaglandins E2

Elevation of the body thermostat by the hypothalamus

B. PATHOPHYSIOLOGY

Vasoconstriction

Shivers

Fever

VII. NURSING CARE PLAN

March 4, 2011
ASSESSMENT SUBJECTIVE: Giniginaw ako as verbalized by the patient. OBJECTIVE: -Warm to touch flush face teary eyes shivering -TEMP: 38.3c -chills DIAGNOSIS Alteration in thermoregulator: hyperthermia r/t bodys response against invading pyrogens 2 to UTI. PLANNING After 30 minutes of continuous nursing intervention the patient will be able to stabilized body temperature in normal range.from 38.337.5 c INTERVENTION Monitor v/s Wrap in warm blankets extra clothing and check clothing. Provide warm liquids if the client can swallow Close the window and doors and turns the light on. Turn off electric fan and aircon if necessary Provide extra pillow beside the patient Administer paracetamol as prescribed by the ROD RATIONALE -For base line data -To provide warm and comfort. -To elevate the body temperature EVALUATION After 30 minutes of continuous nursing intervention the patient was able to stabilized body temperature from 38.3 to 37.2 c -GOAL MET-

March 4, 2011
ASSESSMENT SUBJECTIVE: Masakit tang tagiliran ko hanggang likod ko. As verbalized by the patient. OBJECTIVE: Facial grimace guarding irritable body weakness pale -Pain scale:8/10 DIAGNOSIS PLANNING INTERVENTION Monitor v/s and record Perform a comprehensive assessment of pain severity(0-10 scale) Encourage verbalization of feelings about pain Provide quit environment comfort measures like back rub Encourage adequate rest period Keep comfortable. RATIONALE -For baseline data -For baseline data -Help determine possibility of underlying condition -To prevent fatigue -To provide non pharmacologic pain management -To prevent fatigue -For quick recovery EVALUATION After 30 minutes or 1 hour of giving appropriate intervention, the patient was able to elevate pain. -GOAL METAcute pain r/t an After 30 minutes or inflammatory 1 hour of giving process in the appropriate kidney. intervention, the patient will be able to alleviate pain.

March 4, 2011
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Nagsusuka akoas verbalized by the patient. OBJECTIVE: -Pale -weak looking -dry skin and lips -restlessness (+)vomit for 3 times

Risk for deficient fluid volume r/t nausea and vomiting secondary to dehydration.

After 30 minutes to 1 hour the patient will be able to maintain fluid balance.

Monitor v/s Monitor I and O balance, being aware of altered intake output Encourage the client to increase fluid intake at least 6-8 glasses a day. Review appropriate use of medication Give hard candies

-For baseline data -To ensure accurate picture of fluid status -To maintain fluid and electrolytes balance - To have potential for causing of exacerbating Dehydration. -To lessen the stimulation of saliva that enduses vomiting

After 30 minutes to 1 hour the patient was able to maintain fluid balance. -GOAL MET-

March 4, 2011
ASESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Impaired urinary OBJECTIVE: elimination r/t -Small frequent inflammation of urination with pain bladder mucosa -PAIN SCALE:7/10 -WBC: TNTC -DYSURIA -Urine analysis: -COLOR: Dark yellow TRANSPARENCY:Tur bid -S.G.:1.015 -PH: Alkaline -PROTINE: +2 SUGAR: RBC:12-15

Within 8 hours of nursing intervention the patient verbalize understanding of condition and techniques to prevent urinary tract infection (UTI)

Monitor v/s Encourage fluid intake at least 8-10 glasses a day Discuss possible dietary restriction base on individual symptoms. Discuss proper genitalia cleansing and using of feminine wash Monitor and assess urine output

-For baseline data -To help maintain renal function, prevent infection and urinary stones -To help elevate the present condition -To let the patient understand the said topics -For base line data, for any particular changes

Within 8 hours of nursing intervention the patient verbalized understanding of condition and techniques to prevent urinary tract infection (UTI). -GOAL MET-

March 5, 2011
ASESSMENT SUBJECTIVE: Nanghihina ako as verbalized by the patient OBJECTIVE: -Decrease range of motion -weak looking -pale -irritable -slowed movement DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION After 2-3 hours of nursing intervention the patient was able to increase strength and function of compensatory body parts. -GOAL MET-

Impaired physical After 2-3 hours of mobility r/t nursing intervention decrease muscle the patient will able strength secondary to increase strength to fatigue and function of compensatory body parts.

Establish rapport Assess nutritional status and clients report of energy with monitor v/s Provide comfort measures such as therapeutic touch Encourage the patient to eat nutritious food which is rich in vitamin c such as orange fruits, malunggay. Identify energy conserving techniques for ADLs Schedule activities with adequate rest periods during the day. Provide safety measures

-To gain trust and cooperation -For baseline data -To provide comfort -To promote well being and maximize energy production -To limits fatigue, Maximize participation. -To relive fatigue -To prevent falling

VIII. DRUG STUDY

DRUG (CLASSIFICATON)

INDICATION

ACTION

ADVERSE EFFECT

CONTRAINDICATION

NSG. CONSIDERATION

CEFUROXIME Brand name : Ceftin (Anti-infectives) 750mg IV

For Urinary infection

tract Second-generation cephalosporin that inhibits cell-wall synthesis promoting osmotic instability; usually bactericidal.

CV: Phlebitis GI: nausea, vomiting, diarrhea Other: hypersensitivity reaction

Contraindicated in patients hypersensitive to drug and other Cephalosporins. Use cautiously in the patients hypersensitivity to penicillin because of possibility of crosssensitivity with other beta-lactam antibiotics.

Before giving ask patient if she has allergies to penicillins or cephalosporin. Obtain sensitivity test before giving the first dose. If large doses are given, therapy is prolonged or patient is at risk, monitor patient for sign and symptoms of infection. Look-alikesound alike: Dont confuse drug with other Cephalosporins that alike

DRUG (CLASSIFICATON) GENTAMICIN (Anti-infectives) 80mg IV

INDICATION

ACTION

ADVERSE EFFECT

CONTRAINDICATIO N Contraindicated in patients hypersensitivity to drug or other aminoglycosides. Use cautiously in neonates, infants, elder patients with impaired renal function or neuromuscular disorders.

NSG. CONSIDERATION

Serious infections caused by sensitive strains of pseudomonas aeruginosa, Escherichia coli, Proteus, Klebsiella or Staphylococcus

Inhibits protein synthesis by binding directly to the 30s ribosomal subunits; bactericidal.

CNS: fever, headache,, lethargy,confusion, dizziness CV:Hypotension Respiratory: Apnea GI: vomiting, nausea Skin: rash

Obtain sensitivity tests before giving first dose. Evaluate patients hearing before and during therapy. Notify and during therapy. Notify prescriber if patients complain tinnitus, vertigo, hearing loss. Weight patient and review renal function studies before therapy begins. Obtain blood peak gentamicin level 30 minutes after IV infusion finishes. Monitor renal function Watch for s/sx of superinfection Therapy usually continues for 7-10days. If no response occurs in 3-5days, stop therapy and obtain new specimen for culture and sensitivity.

DRUG (CLASSIFICATON)

INDICATION

ACTION Stimulates motility of upper GI tract, in cases lower esophageal sphincter tone, and blocks dopamine receptors at the chemoreceptor trigger zone.

ADVERSE EFFECT CONTRAINDICATI ON CNS: fatigue, anxiety CV: Hypotension GI: nausea, bowel disorders, diarrhea GU: urinary frequency, incontinence Skin: rash Contraindicated in patients hypersensitivity to drug. Contraindicated in patients for whom stimulation of GI motility might be dangerous (those with hemorrhage, obstruction or perforation)

NSG. CONSIDERATION Monitor bowel sounds. Safety and effectiveness of drug havent been established for therapy lasting longer than 12 weeks. Alert: use 25mg diphenhydramin e IV counteract extrapyramidal adverse effects from high doses.

METOCLOPRAMID To prevent or E reduce nausea (antiemetics) and vomiting 1amp IV

DRUG (CLASSIFICATON) KETOROLAC Brand name: Toradol (non steroidal antiinflammatory drugs) 1amp IV

INDICATION

ACTION

ADVERSE EFFECT

CONTRAINDICATIO N Contraindicated in patients hypersensitivity to drug and in those with advanced renal impairment and those at risk for renal impairment depletion or at risk of bleeding. Contraindicated as prophylactic analgesic before major surgery or intraoperatively when hemostatic is critical; and in patients currently receiving aspirin, an NSAID or pronecid.

NSG. CONSIDERATION

Short-term management of moderately severe, acute pain for single dose treatment.

May inhibit prostaglandin synthesis, to produce antiinflammatory, analgesic and antipyretics.

CNS: dizziness, headache GI: vomitin, flatulence Skin: rash Other: pain at injection site.

Alert. The maximum combined duration of parenteral and oral therapy is 5 days. Dont give drugs epidurally or intrathecally because of alcohol content. NSAIDs may mask the s/sx of infection because of their antipyretic and inflammatory actions. Serious GI toxicity, including peptic ulcers and bleeding, can occur in patient taking NSAIDs, despite lack of symptoms. Look-alike-sound alike: dont confuse Toradol with Tegretol or Foradil

DRUG (CLASSIFICATON) Calcium Carbonate Brand name: Contylan (antacid and antiflatulent)

INDICATION Used for acute hypocalcemiaa, electrolyte depletion, cardiac arrest, hyperkalemia and hypermagnesia. Used in chronic hypocalcemia, calcium deficiency, and as an antacid. Used treatment of hyperphosphat emia

ACTION Calcium is essential for function, integrity of nervous, muscular and skeletal systems. It plays an important role in normal cardiac and renal function, respiration blood coagulation, cell membrane and capillary permeability. It assists in regulating the release and storage of neurotransmitters and hormones. Calcium neutralizes or reduces gastric acid production.

ADVERSE EFFECT

CONTRAINDICATION

NSG. CONSIDERATION Assess bp, ECG reading, renal function. Give syrup diluted in juice or water. Chew chewable tablet well before swallowing. Monitor for sign of hypercalcemia.

CNS: headache No contraindicated CV: Hypotension had notify. GI: nausea, vomiting GU: difficult or painful urination Skin: flushing, warmth, rash, redness, sweating Other: burning sensation at injection site

DRUG

INDICATION

ACTION

ADVERSE EFFECT

PARACETAMOL Mild pain and Inhibits to synthesis Classification: fever of prostaglandins -Therapeutics: that serve as Antipyretics, non medicines of pairs opioid analgesics and fever primarily in the CNS has no significant antiinflammatory properties or G.I toxicity

GI: hepatic failure, hepatoxicity GV: Renal failure(high doses/chronic use) HEMAT: neutropehia. Fancy topenia, Leukopenia DERM: rash, urticaria

CONTRAINDICATIO NSG. CONSIDERATION N Previous Assess overall hypersensitivity health status and products alcohol usage containing alcohol, before aspartame, administering sacharin, sugar or paracetamol tartrazine should patients who are be avoided in malnourished or patients who have chronically abuse hypersensitivity or alcohol are at intolerance to higher risks of these compound. developing hepatotoxicity With chronic use of usual doses of drugs. Assess amount frequently and type of drugs taken in patients self medicating, especially with over the counter drugs prolonged use of paracetamol increase the risk of adverse renal effects. Assess fever: Note

END OF CASE PRESENTATIONTHANK YOU!

GROUP 1 (GROUP BULILIT & BAGTIT!)