Pedia Grand CAsE

8/3/2019 Pedia Grand CAsE

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Grand case

presentation

BSN III / Group 1


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Patients profile


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Name : Patient AA

Address: Brgy. Saugan Oras Eastern SamarBirthdate: March 10, 2010Age: 1 year oldReligion: Roman CatholicFather: Mr. J.A.

Mother: G.A.Admission: February 18, 2012 @ 7:30 pmDiagnosis: Increase ICP from CNS infection probably ASMfrom Pneumonia


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Prenatalhistory


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The mother did not undergo

any prenatal check ups while shewas still pregnant. Nor was hermother aware that she was

pregnant. Her mother found outthat she was pregnant when shegot home from Manila and shewas on her ninth month.


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Birth history


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Patient was delivered full term

via NSVD at home assisted by atrained Hilot. At birth the patienthad a good cry. There were nocyanosis, dyspnea and convulsionthat were noted.


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Neonatal history


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Patient passed firsturine and meconiumwithin the first 24

hours of life. Umbilicalstump was cleanedwith cotton alcohol andsloughed off at the 7thday of life without

redness and


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Feedinghistory


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The patient was

exclusively breastfed afterbirth up to 2 months perdemand.

At 2 months up to 6 monthsold, Nido was introduced tothe patient.

At 6 months to 10 months hestarted to eat porridge and

cerelac.


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PSYCHOSOCIA

L HISTORY

P


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vPatient is a 1 year old child from Brgy.


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vHe usually sleeps at 7pm in the evening and

vThe grandmothers source of income is from

v


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Past healthhistory


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Patient was fully immunized according to

his grandmother, he has no known allergies tofoods and any medication. He has notexperienced any childhood illness such as chickenpox, measles and mumps.

October 2011 he is months, the patientexperienced inflammation in his lymph nodes buthis grandmother did not mind it. No medicationwas given and no was consultation done.

At December 18, 2012, he was hospitalized

with the chief complaint of LBM and was admittedfor 4 days. He was given a medication to treatLBM but was unrecalled.


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Present healthhistory


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January 2012, a month PTA the patientexperienced cough and fever and was given Lakdan

and Kalabo juice by his grandmother for treatment.No was consultation done. January 7, 2012, with the persistence of coughand fever and now associated with vomiting andseizures, such symptoms prompted the grandmother

to seek consultation at Oras District Hospital, henceadmission. The patient was requested to undergo X-ray examination. After a week, the patient lostconsciousness and was referred to Eastern SamarProvincial Hospital.


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January 28, 2012 at ESPH, during the

physical examination, results showed positivesigns of nuchal rigidity, bradzinski andkernig's signs and due to the hospitalsscarcity of facilities, patient was referred toEVRMC for further management, hence

admission.


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February 13, 2012, patient was

admitted to EVRMC and wasdiagnosed of increased ICP from CNSinfection probably ASM fromPneumonia.


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Patternsof

functioning

Patterns of Functioning Clinical Inspection Other Sources


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Patterns of Functioning Clinical Inspection Other Sources

Respiratory-experienced productive

cough for a week and wasgiven Lakdan and Calaboas remedies.

Circulatory-no history of palpation-no history of heartdisease

-RR 23 cpm-productive coughI Symmetrical LungExpansion

-nasal flaring noted-chest indrawing

P No palpable massesP Dullness noted uponpercussionA crackles heard at Rlung & wheezes

occasionally noted

HR: 150bpmI no edema noted, nodiscoloration, arms are

bilaterally symmetric andminimal variation in size

-CXR resultImpression: R

posterobasalpneumonia

-Hematology Result:

Leucocytes: 9.2Segmenters: 0.65Lymphocytes: 0.35Thrombocytes: 188Hematocrit: 0.35

PATTERNS OF FUNCTIONING\ CLINICAL OTHER SOURCES


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CLINICALINSPECTION

OTHER SOURCES

Food and Fluid Intake-exclusively breastfed frombirth to 2 months

-from 2 months to six months:drink NIDO-from 6months to 10months hestarted to eat porridge andcerelac.-12 months he started to eat rice

ith fish and vegetables

Elimination-at 8months he experiencedLBM for 3 days, consistency:

atery-change 4-5 diaper per day

Regulatory Mechanism-experienced intermittent feverno medication taken

-with NGTI flat, no abdominaldistentionA normoactive bowelsoundP tympanic in all

regionsP soft, no tenderness

-change diaper 2-3diapers per day

-temperature: 38.9C-

-with IVF of D50.3 NaCl@ 500cc @ 45ugtts/min

Acetaminophen 140mg IVTTnow, then every 4h for tempgreater than 38.5C

PATTERNS OF FUNCTIONING CLINICAL OTHER SOURCES


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PATTERNS OF FUNCTIONING CLINICALINSPECTION

OTHER SOURCESHygiene-bathed daily-change clothes 2 times a day

Exercise and Locomotion-play sometimes with his grandmother

Rest and SleepUsually sleep from 7pm to 6am usuallyin prone position.-nap at noon for 2hours

Communication and special senses-can say mama

-untidy-nails are dirty

-skin is dry-no lesions

-change in motorresponses-lying on bed, bodyweakness-with nuchal rigidity-positive brudzinskissign

-positive kernigs sign

-sleep is interrupted bypain-irritable

-look tired-restless

PATTERNS OF FUNCTIONING CLINICAL OTHER SOURCES


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CLINICALINSPECTION

OTHER SOURCESSensory

-with history of seizure-loss of consciousness

Pain and Discomfort

Recreation and Diversion

Religious Life

Coping Mechanism-always saying mama and crying

hen she feel pain

Social Occupation

-lethargic-restlessness

-experienced nuchalrigidity-facial grimace (scaleof 4)

-his grandmother isalways at her side

DRUG NAME DRUG CLASSES THERAPEUTIC


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DRUG NAME DRUG CLASSES THERAPEUTICACTIONSPhenobarbital

45mg/ppt i ppt OD mixin 5cc of milk

BarbiturateSedativeHypnotic

Anti-epileptic

General CNS depressant;barbiturates inhibit impulseconduction in the ascending RAS,depress the cerebral cortex, altercerebellar function, depress motoroutput and can produce excitation,sedation, hypnosis, anesthesia anddeep coma; at subhypnotic doses,has antiseizure activity, making itsuitable for long term use as anantiepileptic.

NDICATION CONTRAINDICATION SIDE EFFECTS NURSINGCONSIDERATIONS

SedativeEmergency

ontrol of certaincute seizuremeningitis)

Contraindicatedwith

hypersensitivity tobarbiturates.

CNS: Confusion,hallucinations,

anxiety,nightmares.GI: Nausea,vomiting,constipation,

diarrhea,

Observe 10 RsDo not reduce the

doasge/discontinue this drug; abruptdiscontinuationcould result in aserious increase

ICP.



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DRUG NAME DRUG CLASSES THERAPEUTICACTIONS

Ceftriaxone900mg IV as low as IVdripOD ANST (-)

AntibioticCephalosporin (3rdGeneration)

Bactericidal; Inhibitssynthesis of bacterialcell wall; causing celldeath.


Lowerespiratory

nfections causedy streptococcusneumoniae.

Meningitis causedy streptococcus

neumoniae.

Contraindicatedwith

hypersensitivity tocephalosporins/penicillins.

CNS: Headache,dizziness,

lethargy.GI: Nausea,vomiting,abdominal pain- Bone marrow

depression;decreased WBC

Observe 10 RsAdminister drug

slowly via IVTT.Assess pain uponadministration aswell as adverseeffects.



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Ampicillin450mg

Antibiotic Bactericidal; Inhibitssynthesis of bacterialcell wall; causing celldeath.


Meningitis causedy Neisseria

eningitidis.

Contraindicatedwith

hypersensitivity tocephalosporins/penicillins.

CNS: Headache,dizziness,

lethargy.GI: Nausea,vomiting,abdominal pain- Bone marrow

depression;decreased WBC

Observe 10 RsCheck IV site

carefully/



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Femotidine H2 Receptor Antagonist Competitively blocksthe action of histamineat the histamine (H2)receptors of the parietalcells of the stomach;inhibits basal gastricacid secretion.


Short termreatment and

aintenance ofuodenal ulcer.

Contraindicatedwith

hypersensitivity todrug.

Headache,malaise, diarrhea,

constipation,abdominal pain.

Observe 10 Rs



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Dexamethasone CorticosteroidGlucocorticoidHormone

Enters target cells andbinds to specificreceptors, initiatingmany complex reactionsthat are responsible forits anti-inflammatoryand immunosuppresive

effects.NDICATION CONTRAINDICATION SIDE EFFECTS NURSING

CONSIDERATIONS

Cerebral edemaue to brain

njury.

Contraindicatedwith infection

especially to TB.

Headache,convulsion,

asthma.

Observe 10 Rs



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Acetaminophen AntipyreticAnalgesic (nonopiod)

Antipyretic: reducesfever by acting directlyon the hypothalamicheat-regulating center tocause vasodilation andsweating, which helpsdissipate heat.

Analgesic: site andmechanism of actionunclear.

INDICATION CONTRAINDICATION SIDE EFFECTS NURSINGCONSIDERATIONS

Analgesic-antipyretic inAEG with aspirinallergy,

hemostaticdisturbances,bleeding diathesis,upper GI disease,common cold, flu

& other viral

Contraindicatedwith allergy toacetaminophen,impaired hepatic

function, chronicalcoholism,

pregnancy andlactation.

Headache, chestpain, dyspnea,hepatic toxicity,

jaundice, acute

renal failure, rash,fever.

Observe 10 RsAsk for history ofallergic reactionsto drug.

Give drug withfood in GI upsetoccurs.

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