I.

INTRODUCTION Subdural empyema (ie, abscess) is an intracranial focal collection of purulent material located between the dura mater and the arachnoid mater. About 95% of subdural empyemas are located within the cranium; most involve the frontal lobe, and 5% involve the spinal neuraxis. This chapter focuses on the intracranial type, which causes clinical problems through extrinsic compression of the brain by an inflammatory mass and inflammation of the brain and meninges. Subdural empyema is a life-threatening infection that was first reported in the literature about 100 years ago. It accounts for about 15-22% of focal intracranial infections. The mortality rate approached 100% before the introduction of penicillin in 1944 and has declined since that time. Because the symptoms might be very mild initially, rapid recognition and treatment are important; the early institution of appropriate treatment gives the patient a good chance of recovery with little or no neurological deficit. Bacterial or occasionally fungal infection of the skull bones or air sinuses can spread to the subdural space, producing a subdural empyema. The underlying arachnoid and subarachnoid spaces are usually unaffected, but a large subdural empyema may produce a mass effect. Further, a thrombophlebitis may develop in the bridging veins that cross the subdural space, resulting in venous occlusion and infarction of the brain. Brain herniation, also known as cistern obliteration, is a deadly side effect of very highintracranial pressure that occurs when the brain shifts across structures within the skull. The brain can shift by such structures as the falx cerebri, the tentorium cerebelli, and even through the hole called the foramen magnum in the base of the skull (through which the spinal cordconnects with the brain). Herniation can be caused by a number of factors that cause a mass effect and increase intracranial pressure (ICP): these include traumatic brain injury, stroke, orbrain tumor.[1] Because herniation puts extreme pressure on parts of the brain and thereby cuts off the blood supply to various parts of the brain, it is often fatal. Therefore, extreme measures are taken in hospital settings to prevent the condition by reducing intracranial pressure. Herniation can also occur in the absence of high ICP when mass lesions such as hematomas occur at the borders of brain compartments.[2] Subfalcine herniation is a conditon associated with a one-sided cerebral mass lesion (of any type). The medial surface of the affected hemisphere is pressed against the firm falx cerebri and then herniates beneath it. The cingulate gyrus is most commonly involved. Often clinically silent. Secondary effects include hemorrhage and necrosis of the affected area (essentially a contusion) which if the patient survives would resolve to a cystic area with gliosis. Compression of the anterior cerebral artery with subsequent

infarction.
This study is presenting the case of Jamaika Borromeo, referred from Albay, to National Childrens Hospital With the chief complaints of high grade fever, seizures, and enlargement of the head. Admitted in the said institution last February 23, 2011 at 4:40 pm. Admitted by Dr. Salazar for proper management of the existing medical condition, Subdural Empyema with midline shifting and subfalcine herniation secondary to Tuberculosis Meningitis.

II. OBJECTIVES: This case presentation aims to identify and determine the general health problems and needs of the patient with a diagnosis of Subdural Empyema with Middle Shifting & Subfalcine Herniation to the Left Frontal Lobe Secondary to TB Meningitis. This presentation also intends to help the patient promote health and medical understanding of such condition through the application of nursing skills. Specific Objectives: Patient and Significant Other Centered  To establish a good working relationship with the nurse  To give patient and significant other a welcoming atmosphere for her to express their needs.  To give the watcher health teachings about her condition.  To raise the level of awareness of the SO regarding her condition  To promote patients wellness by teaching the SO ways to manage airway obstruction  To motivate family to care for the patient religiously  To aid patients needs not only physically but as a whole  To assist patient with activities of daily living  To promote self esteem of the patient.  promote positive outlook of the patient towards healing Student-Centered  To establish rapport with the patient and SO  To increase knowledge regarding the case of the patient  To understand the principles underlying Subdural Empyema/ Brain Abscess  To broaden understanding to the disease process and  To familiarized with the tests done in diagnosing a Subdural Empyema  To give the appropriate interventions appropriate for the diagnosed case  To know the different surgical and medical management and nursing management as well  To identify verbal and non-verbal cues by the patient.  To set a SMART nursing care plan  To identify appropriate nursing interventions.  To apply the concepts learned at school  To work with the health care team and maintain good working relationships with them  To give the developmental needs of the patient  To maintain consistency of care to the patient  To develop self-awareness and professionalism  To gain experiences and apply them in the future

III. PATIENTS PROFILE Name: Jamaica De Monteverde Borromeo Age: 2 1/12 old Gender: female Address: B4-L4 Nazarene Ville, Brgy. San Roque, Antipolo City Birthday: January 26, 2009 Mother: Vannessa Vallega De Montverde- Borromeo Father: Joseph Sartil Borromeo Nationality: Filipino Religion: Roman Catholic Date of admission: February 27, 2011 Chief Complaints: high grade fever & enlargement of the head Admitting diagnosis: Central Venous System Infection Probably TB Meningitis Principal diagnosis: r/o Sepsis Occupying Lesion Tuberculoma with Hydrocephalus Final diagnosis: Subdural Empyema with Middle Shifting and Subfalcine Herniation to the Left Secondary to TB Meningitis Admitting physician: Dr. Salazar Attending Physician: Dr. Balles

IV. HISTORY OF PAST AND PRESENT ILLNESSES History of Past Illness: Jamaika De Monteverde Borromeo is a 2 year old, female, child from B4-L4 Nazarene Ville, Barangay San Roque, Antipolo City, Rizal. Born as a Filipino at Albay in January 26, 2009 and was baptized as Roman Catholic. Her mother was then 16 when she has given birth to her. She was the first child of two in the family. Her mother was attended by a traditional midwife when she gave birth through normal spontaneous delivery and she is full termed. According to her mother, she had urinary infection during her seventh month of pregnancy but taken no medications at all. According to her mother Jamaica Had completed all her vaccinations, the vaccines that were given at the rural health units. She was breastfed from birth until nine (9) months olds then shifted to bottle-feeding, Nestogen is her milk. As per mothers information, they have several familial illnesses. Hypertension is on father and mother side, imperforate anus on maternal side, tuberculosis wherein Mrs. Borromeos brother has tuberculosis, no familial illness of sexually transmitted infections. She has no known allergies to food or drugs. The patient is living in a bungalow concrete house in Antipolo City with her mother, father, younger sister, and her mothers siblings who happened to be smokers and one of them have a past history of tuberculosis disease. History of Present Illness: One month prior to admission, the patient was noted to have moderate to high fever mostly 39-41 oC but not associated with cough, colds, vomiting, or diarrhea. They sought consult a local clinic where Paracetamol 5ml every 4 hours is prescribed which relieved the fever temporarily. Three weeks prior to admission, the patient is still with high grade fever, and had experienced episodes of seizure lasting for few minutes and even lasts to an hour according to her mother. She was brought to a nearby hospital but was not admitted. They consulted another hospital where admission is advised. Blood exams were taken and diagnosed to have typhoid fever. However, the illness get worse and worse as the days go by, and the doctors cannot anymore manage her illness, doctors advised them to seek help or consult to an albularyo which they also did. The signs and symptoms of the patient abated after they visit the albularyo. Two weeks prior to admission, the patient was noted to have cough that was productive and also there was a preferential gaze to the left, and weakness on the upper 4

and lower extremities especially on the left side are also noted and enlargement of the head was also observed. There was no fever, no convulsions, no colds, vomiting, or diarrhea. No medications were taken and no consultation was done. Few hours prior to admission, the patient was having fever and febrile convulsions or seizures, hence sought consult to the nearest hospital and was referred to National Childrens Hospital for admission, hence admitted by Dr. Salazar last February 27, 2011 at 4:40 pm with chief complaints of high grade fever, convulsions, enlargement of head. Having an admitting diagnosis of Central Nervous System Infection probably Tuberculosis Meningitis.

V. PEARSON ASSESSMENT

DATE:
y y y

PEARSON ASSESSMENT APRIL 26, 2011

Jamaika Borromeo is a 2 year old child from a typical Filipino family she is living with her father, mother and baby sister together with her three uncle they are currently residing at B4-L4 Nazarene Ville, Brgy. San Roque, Antipolo City in a bungalow type house made of heavy materials with five bedrooms that is privately owned by her grandparents. According to Ms. Vanessa, their place was a noisy but safe community. According to the Erik Eriksons Psycho developmental theory Jamaika is under Autonomy vs. Shame and Doubt. Children ages 2-3 or in early childhood are super curious and wanted to do things independently exploring this shows autonomy or self control/ governance in literal meaning things where sometimes causes them to feel ashamed when they fail to do something and doubt because of anxiety of failing again refuses to be carried and cuddled and cries when the primary care giver is away The patient enjoys to be carried and cuddled by the care giver Active and playful y y y y y y

APRIL 27, 2011

P
Psychosocial

Infant refuses to be carried and cuddled and cries when the primary care giver is away Same observations are noted The patient was very playful and looks at the other patients Patient is more energetic and playful compared to the past days Cries when she sees a stethoscope due to fear of mutilation Gets irritated when hearing loud noisy sounds

y y y

y y

E
Elimination

y y y y y y y y

A
Activity

During my first contact with the patient, stranger anxiety was very evident It is evident that the child is still dependent to the watcher with his primary needs such as food and comfort During my stay in the ward the watcher changed the diaper (lampin) once It was fully soaked and the color was amber and is aromatic There was no pain in urination Marked diaphoresis was observed from the patient Oral mucosa is not dry Plays with her bottle when awake Talks and plays with her mother at times Turns side-side when asleep Mostly cuddled by her mother

y y y y

During my stay in the ward the watcher changed the diaper once Same findings were observed Minimal diaphoresis was observed from the patient Oral mucosa is not dry

y y y y

Plays with her bottle when awake Talks and plays with her mother at times Turns side-side when asleep Mostly cuddled by her mother

R
Rest

y y y y y
y

The patient slept after milk feeding y Frequent naps lasts for 1H with waking periods of y 10minutes y The patient is on supine position when sleeping The patient gets irritated when she hears noise Sleeps with one pillow
During my stay in the ward, constant provision of safety was observed from the watcher She feeds the infant head is slightly elevated when hungry Patient is placed in a side lying position when sleeping Watcher raises side rails when the watcher she goes away Watcher asks the other watcher to look at the patient when y y y y

The patient was sound asleep for 3H The patient is on prone position when sleeping No interruption of sleep alterations

y y y y

During my stay in the ward, constant provision of safety was provided by the watcher She feeds the infant on fowlers position when hungry Same safety measures were observed According to watcher medications were given as follows: y Rifampicin 2.6 cc OD per orem

Safety

running an errand According to watcher medications were given as follows: y Rifampicin 2.6 cc OD per orem y Isoniazid 3.5 ml OD per orem y Pyrazinamide 3.5 ml OD per orem y Ceftriaxone 515mg IV q12 y Phenobarbital 20mg/pptab q12 Precaution was observed by the institution evidenced by the presence of installed water sprinkler and smoke detectors and presence of fire exit and fire exit plan illustrations. With initial Vital signs of : y BT: 36.8 oC y PR:152 bpm (crying) y RR: 30 cpm afebrile

y Isoniazid 3.5 ml OD per orem y Pyrazinamide 3.5 ml OD per orem y Ceftriaxone 515mg IV q12 y Metronidazaole 5 ml q8 y Phenobarbital 20mg/pptab q12 y Vit. B complex 1 tab OD y With initial Vital signs of : y BT: 36.6 oC y PR:142 bpm y RR: 31 cpm y With heplock inserted at the left cephalic vein y Heplock is secured with plaster properly with no bleeding nor inflammation observed

O
Oxygenation

y y y y y y y y y y y y

N
Nutrition

The room is well ventilated Light clothing was used by the patient No respiratory distress was observed CR is @ 30cpm No cyanosis of the nail beds and lips was observed No respiratory distress was noted HR is @ 152 bpm Marked tachycardia was assessed may be because the patient is crying The patient is on DAT diet With good suck and appetite Bottle feeding with nestogen Consumed five 250ml bottled milk during the shift

y y y y y y y y y y y y

The room is well ventilated Light clothing was used by the patient No respiratory distress was observed The patient is no longer with O2 inhalation CR is @ 31cpm No cyanosis of the nail beds and lips was observed No respiratory distress was noted HR is @ 125bpm The patient is on DAT diet With good suck and appetite Bottle feeding with nestogen Consumed five 250ml bottled milk during the shift

VI. DIAGNOSTIC PROCEDURES IDEAL a. Laboratory Examinations

y

Complete Blood Count

y

CBC count may show a toxic leukocytosis from the bodys immune response to combat the infection

Erythrocyte sedimentation rate (ESR)

y

Erythrocyte sedimentation rate (ESR) may be elevated because of the presence of the inflammation of the meninges and brain tissues that are affected of the infection.

Blood Culture and Sensitivity

y

Blood should be cultured for aerobic and anaerobic organisms, this enables the physician to choose the appropriate antibiotic to prescribed to combat infection and prevent sepsis

b. Imaging Studies
y

Cranial Magnetic Resonance Imaging (MRI)

y

Cranial MRI is now the imaging study of choice, being superior to cranial CT scan in outlining the extent of subdural empyema and demonstrating the convexity and interhemispheric collections. MRI also shows greater morphological detail than CT scan. The sensitivity of MRI is improved by using gadolinium contrast medium.

y y

Cranial CT- scan- can was the standard technique for quick diagnosis before the advent of MRI. The use of high-resolution, contrast-enhanced CT scan increases diagnostic yield, although it sometimes gives equivocal or normal results.
y

On CT scan, subdural empyema shows as a hypodense area over the hemisphere or along the falx; the margins are better delineated with the infusion of contrast material. Cerebral involvement also is visible. Cranial osteomyelitis may be seen. CT scan is the modality of choice if the patient is comatose or critically ill and MRI is not possible or is contraindicated.

y y

Cranial Ultrasonography
y

Cranial ultrasound has been helpful in differentiating subdural empyema from anechoic reactive subdural effusion in infants with meningitis accompanied by complex features (eg, increased echogenicity in the convexity collections, presence of hyperechoic fibrinous strands or thick hyperechoic inner membrane, and increases in echogenicity of the piaarachnoid).

c. other test (preoperatively)

y

Studies to define causes

y

- Chest radiograph for pulmonary source, CT scan of paranasal sinuses and mastoid cells, sputum culture, nasal drip culture

Preoperative tests should include electrolytes, BUN, liver function tests, and CBC count if surgical intervention is being considered. ACTUAL According to my patients mother my patient had undergone several tests these include: y y y y y y CBC Urinalysis CT scan X-ray Creatinine Clotting time tests

These following tests were charted on the chart as done but none of all their results were attached on the patients chart.

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VII. ANATOMY AND PHYSIOLOGY Anatomy and Physiology of the Human Brain Anatomy of the Brain The brain serves many important functions. It gives meaning to things that happen in the world surrounding us. Through the five senses of sight, smell, hearing, touch and taste, the brain receives messages, often many at the same time. The brain controls thoughts, memory and speech, arm and leg movements, and the function of many organs within the body. It also determines how people respond to stressful situations (i.e. writing of an exam, loss of a job, birth of a child, illness, etc.) by regulating heart and breathing rates. The brain is an organized structure, divided into many components that serve specific and important functions. The weight of the brain changes from birth through adulthood. At birth, the average brain weighs about one pound, and grows to about two pounds during childhood. The average weight of an adult female brain is about 2.7 pounds, while the brain of an adult male weighs about three pounds. The Nervous System The nervous system is commonly divided into the central nervous system and the peripheral nervous system. The central nervous system is made up of the brain, its cranial nerves and the spinal cord. The peripheral nervous system is composed of the spinal nerves that branch from the spinal cord and the autonomous nervous system (divided into the sympathetic and parasympathetic nervous system). The Cell Structure of the Brain The brain is made up of two types of cells: neurons and glial cells, also known as neuroglia or glia. The neuron is responsible for sending and receiving nerve impulses or signals. Glial cells are non-neuronal cells that provide support and nutrition, maintain homeostasis, form myelin, and facilitate signal transmission in the nervous system. In the human brain, glial cells outnumber neurons by about 50 to one. Glial cells are the most common cells found in primary brain tumors. When a person is diagnosed with a brain tumor, a biopsy may be done, in which tissue is removed from the tumor for identification purposes by a pathologist. Pathologists identify the type of cells that are present in this brain tissue, and brain tumors are named based on this association. The type of brain tumor and cells involved impact patient prognosis and treatment.

11

The Meninges The brain is housed inside the bony covering called the cranium. The cranium protects the brain from injury. Together, the cranium and bones that protect the face are called the skull. Between the skull and brain is the meninges, which consist of three layers of tissue that cover and protect the brain and spinal cord. From the outermost layer inward they are: the dura mater, arachnoid and pia mater. `In the brain, the dura mater is made up of two layers of whitish, nonelastic film or membrane. The outer layer is called the periosteum. An inner layer, the dura, lines the inside of the entire skull and creates little folds or compartments in which parts of the brain are protected and secured. The two special folds of the dura in the brain are called the falx and the tentorium. The falx separates the right and left half of the brain and the tentorium separates the upper and lower parts of the brain. The second layer of the meninges is the arachnoid. This membrane is thin and delicate and covers the entire brain. There is a space between the dura and the arachnoid membranes that is called the subdural space. The arachnoid is made up of delicate, elastic tissue and blood vessels of varying sizes. The layer of meninges closest to the surface of the brain is called the pia mater. The pia mater has many blood vessels that reach deep into the surface of the brain. The pia, which covers the entire surface of the brain, follows the folds of the brain. The major arteries supplying the brain provide the pia with its blood vessels. The space that separates the arachnoid and the pia is called the subarachnoid space. It is within this area that cerebrospinal fluid flows.

12

Cerebrospinal Fluid Cerebrospinal fluid (CSF) is found within the brain and surrounds the brain and the spinal cord. It is a clear, watery substance that helps to cushion the brain and spinal cord from injury. This fluid circulates through channels around the spinal cord and brain, constantly being absorbed and replenished. It is within hollow channels in the brain, called ventricles, that the fluid is produced. A specialized structure within each ventricle, called the choroid plexus, is responsible for the majority of CSF production. The brain normally maintains a balance between the amount of CSF that is absorbed and the amount that is produced. However, disruptions in this system may occur. The Ventricular System The ventricular system is divided into four cavities called ventricles, which are connected by a series of holes called foramen, and tubes. Two ventricles enclosed in the cerebral hemispheres are called the lateral ventricles (first and second). They each communicate with the third ventricle through a separate opening called the Foramen of Munro. The third ventricle is in the center of the brain, and its walls are made up of the thalamus and hypothalamus. The third ventricle connects with the fourth ventricle through a long tube called the Aqueduct of Sylvius. CSF flowing through the fourth ventricle flows around the brain and spinal cord by passing through another series of openings. Brain Components and Functions Brainstem The brainstem is the lower extension of the brain, located in front of the cerebellum and connected to the spinal cord. It consists of three structures: the midbrain, pons and medulla oblongata. It serves as a relay station, passing messages back and forth between various parts of the body and the cerebral cortex. Many simple or primitive functions that are essential for survival are located here. The midbrain is an important center for ocular motion while the pons is involved with coordinating eye and facial movements, facial sensation, hearing and balance. 13

The medulla oblongata controls breathing, blood pressure, heart rhythms and swallowing. Messages from the cortex to the spinal cord and nerves that branch from the spinal cord are sent through the pons and the brainstem. Destruction of these regions of the brain will cause "brain death." Without these key functions, humans cannot survive. The reticular activating system is found in the midbrain, pons, medulla and part of the thalamus. It controls levels of wakefulness, enables people to pay attention to their environments, and is involved in sleep patterns.

Originating in the brainstem are 10 of the 12 cranial nerves that control hearing, eye movement, facial sensations, taste, swallowing and movements of the face, neck, shoulder and tongue muscles. The cranial nerves for smell and vision originate in the cerebrum. Four pairs of cranial nerves originate from the pons: nerves 5 through 8. Cerebellum The cerebellum is located at the back of the brain beneath the occipital lobes. It is separated from the cerebrum by the tentorium (fold of dura). The cerebellum fine tunes motor activity or movement, e.g. the fine movements of fingers as they perform surgery or paint a picture. It helps one maintain posture, sense of balance or equilibrium, by controlling the tone of muscles and the position of limbs. The cerebellum is important in one's ability to perform rapid and repetitive actions such as playing a video game. In the cerebellum, right-sided abnormalities produce symptoms on the same side of the body. Cerebrum The cerebrum, which forms the major portion of the brain, is divided into two major parts: the right and left cerebral hemispheres. The cerebrum is a term often used to describe the entire brain. A fissure or groove that separates the two hemispheres is called the great longitudinal fissure. The two sides of the brain are joined at the bottom 14

by the corpus callosum. The corpus callosum connects the two halves of the brain and delivers messages from one half of the brain to the other. The surface of the cerebrum contains billions of neurons and glia that together form the cerebral cortex. The cerebral cortex appears grayish brown in color and is called the "gray matter." The surface of the brain appears wrinkled. The cerebral cortex has sulci (small grooves), fissures (larger grooves) and bulges between the grooves called gyri. Scientists have specific names for the bulges and grooves on the surface of the brain. Decades of scientific research have revealed the specific functions of the various regions of the brain. Beneath the cerebral cortex or surface of the brain, connecting fibers between neurons form a white-colored area called the "white matter."

The cerebral hemispheres have several distinct fissures. By locating these landmarks on the surface of the brain, it can effectively be divided into pairs of "lobes." Lobes are simply broad regions of the brain. The cerebrum or brain can be divided into pairs of frontal, temporal, parietal and occipital lobes. Each hemisphere has a frontal, temporal, parietal and occipital lobe. Each lobe may be divided, once again, into areas that serve very specific functions. The lobes of the brain do not function alone they function through very complex relationships with one another. Messages within the brain are delivered in many ways. The signals are transported along routes called pathways. Any destruction of brain tissue by a tumor can disrupt the communication between different parts of the brain. The result will be a loss of function such as speech, the ability to read, or the ability to follow simple spoken commands. Messages can travel from one bulge on the brain to another (gyri to gyri), from one lobe to another, from one side of the brain to the other, from one lobe of the brain to structures that are found deep in the brain, e.g. thalamus, or from the deep structures of the brain to another region in the central nervous system.

15

Research has determined that touching one side of the brain sends electrical signals to the other side of the body. Touching the motor region on the right side of the brain, would cause the opposite side or the left side of the body to move. Stimulating the left primary motor cortex would cause the right side of the body to move. The messages for movement and sensation cross to the other side of the brain and cause the opposite limb to move or feel a sensation. The right side of the brain controls the left side of the body and vice versa. So if a brain tumor occurs on the right side of the brain that controls the movement of the arm, the left arm may be weak or paralyzed. Cranial Nerves There are 12 pairs of nerves that originate from the brain itself. These nerves are responsible for very specific activities and are named and numbered as follows: 1. Olfactory: Smell 2. Optic: Visual fields and ability to see 3. Oculomotor: Eye movements; eyelid opening 4. Trochlear: Eye movements 5. Trigeminal: Facial sensation 6. Abducens: Eye movements 7. Facial: Eyelid closing; facial expression; taste sensation 8. Auditory/vestibular: Hearing; sense of balance 9. Glossopharyngeal: sensation; swallowing 10. Vagus: sensation 11. Accessory: Control of neck and shoulder muscles 12. Hypoglossal: Tongue movement Hypothalamus The hypothalamus is a small structure that contains nerve connections that send messages to the pituitary gland. The hypothalamus handles information that comes from the autonomic nervous system. It plays a role in controlling functions such as eating, sexual behavior and sleeping; and regulates body temperature, emotions, secretion of hormones and movement. The pituitary gland develops from an extension of the hypothalamus downwards and from a second component extending upward from the roof of the mouth. Swallowing; taste Taste

16

The Lobes Frontal Lobes The frontal lobes are the largest of the four lobes responsible for many different functions. These include motor skills such as voluntary movement, speech, intellectual and behavioral functions. The areas that produce movement in parts of the body are found in the primary motor cortex or precentral gyrus. The prefrontal cortex plays an important part in memory, intelligence, concentration, temper and personality. The premotor cortex is a region found beside the primary motor cortex. It guides eye and head movements and a persons sense of orientation. Broca's area, important in language production, is found in the frontal lobe, usually on the left side. Occipital Lobes These lobes are located at the back of the brain and enable humans to receive and process visual information. They influence how humans process colors and shapes. The occipital lobe on the right interprets visual signals from the left visual space, while the left occipital lobe performs the same function for the right visual space. Parietal Lobes These lobes interpret simultaneously, signals received from other areas of the brain such as vision, hearing, motor, sensory and memory. A persons memory and the new sensory information received, give meaning to objects. Temporal Lobes These lobes are located on each side of the brain at about ear level, and can be divided into two parts. One part is on the bottom (ventral) of each hemisphere, and the other part is on the side (lateral) of each hemisphere. An area on the right side is involved in visual memory and helps humans recognize objects and peoples' faces. An area on the left side is involved in verbal memory and helps humans remember and understand language. The rear of the temporal lobe enables humans to interpret other peoples emotions and reactions. Limbic System This system is involved in emotions. Included in this system are the hypothalamus, part of the thalamus, amygdala (active in producing aggressive behavior) and hippocampus (plays a role in the ability to remember new information). Pineal Gland This gland is an outgrowth from the posterior or back portion of the third ventricle. In some mammals, it controls the response to darkness and light. In humans, it has some role in sexual maturation, although the exact function of the pineal gland in humans is unclear.

17

Pituitary Gland The pituitary is a small gland attached to the base of the brain (behind the nose) in an area called the pituitary fossa or sella turcica. The pituitary is often called the "master gland" because it controls the secretion of hormones. The pituitary is responsible for controlling and coordinating the following:
  

Growth and development The function of various body organs (i.e. kidneys, breasts and uterus) The function of other glands (i.e. thyroid, gonads, and adrenal glands) This is a cavity in the back part of the skull which contains the cerebellum,

Posterior Fossa brainstem, and cranial nerves 5-12. Thalamus The thalamus serves as a relay station for almost all information that comes and goes to the cortex. It plays a role in pain sensation, attention and alertness. It consists of four parts: the hypothalamus, the epythalamus, the ventral thalamus, and the dorsal thalamus. The basal ganglia are clusters of nerve cells surrounding the thalamus. Language and Speech Functions In general, the left hemisphere or side of the brain is responsible for language and speech. Because of this, it has been called the "dominant" hemisphere. The right hemisphere plays a large part in interpreting visual information and spatial processing. In about one third of individuals who are left-handed, speech function may be located on the right side of the brain. Left-handed individuals may need specialized testing to determine if their speech center is on the left or right side prior to any surgery in that area. Many neuroscientists believe that the left hemisphere and perhaps other portions of the brain are important in language. Aphasia is simply a disturbance of language. Certain parts of the brain are responsible for specific functions in language production. There are many types of aphasias, each depending upon the brain area that is affected, and the role that area plays in language production. There is an area in the frontal lobe of the left hemisphere called Brocas area. It is next to the region that controls the movement of facial muscles, tongue, jaw and throat. If this area is destroyed, a person will have difficulty producing the sounds of speech, because of the inability to move the tongue or facial muscles to form words. A person with Broca's aphasia can still read and understand spoken language, but has difficulty speaking and writing. There is a region in the left temporal lobe called Wernicke's area. Damage to this area causes Wernicke's aphasia. An individual can make speech sounds, but they are meaningless (receptive aphasia) because they do not make any sense.

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VIII. PATHOPHYSIOLOGY Algorithm

Etiology/risk factors: AGE: 2 yrs. old(vulnerable age group), history of Tuberculosis exposure

Mycobacterium tubercle travels into the bloodstream

Bacteria reaches and filtrated in the Blood Brain Barrier

Bacterial growth and build up damaging the BBB

Leukocyte proliferation

Bacteria enters the brain

Fever and headache (immune response)

Deposition of Antigen-antibody complex to the right brain

Inflammation & Exudate formation occurs

Accumulation of exudates from the right frontal lobe on the subdural and subarachnoid spaces

Blockage of: Choroid plexus (slight) cervical canal of spinal cord

Continuous CSF production and circulation

decrease circulation & absorption of CSF in the brain and spinal cord canal

Malabsorption increase CSF + exudate fluid volume Increase intracranial pressure Compression of blood vessels and veins Increase pressure from the inside of the skull shifting and herniation Expansion of the fontanels and suture lines of the skull Seizures and convulsions hypoxia

Signs & symptoms: Hydrocephalus, motor deficits, neurologic deficits

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Explanation:
Considering that the patient is two years old, this age belongs to what we call the extreme ages or vulnerable ages wherein the immune system of the child is may be developed but not strong enough to fight such infections. Due to the age, the child immune system becomes extreme low when she was exposed to the tuberculosis infection of her uncle living with them these are the considered etiologic factors. From the tuberculosis infection exposure, the pathogen enters the airway and travels going to the lungs. From the lungs, the tubercle bacilli invades the blood vessels that carries unoxygenated blood from the heart going to the lung via pulmonary artery for oxygenation. The bacillus travels to the heart to be distributed into the systemic circulation via aorta. Bacilli reaches the brain but strained by the blood brain barrier which the first line of defense of the brain from the invading pathogens. Since the bacillus is strained in the brain barrier it can easily multiply because in this barrier nutrients like glucose passes. These glucose is therefore eaten and used by the bacilli to multiply instead of going into the brain to be used by the brain cells. After the bacillus had multiplied, they will now attack and damage the blood brain barrier because they have enough force to penetrate the barriers. As the bodys response to the destruction, the body will immediately send leukocytes to the infection site, the first set of leukocytes will combat the bacilli but due to their large number, they will release chemical mediators like cytokines to attract more leukocytes or leukocyte proliferation occurs. The body will increase the temperature to kill the bacteria in high temperature as bodys auto immune response. Headache is also present due to the inflammation in the brain tissue and decreased glucose supply to the cells.As the leukocytes and bacilli fights there are waste products that are called antigen-antibody complex that accumulates in subdural and subarachnoid spaces including the canal going to and from choroids plexus where CSF is produced. If the is blocked slightly, it will continuously producing CSF but the CSF volume is not decreasing because the walls of the subarachnoid and subdural spaces are blocked or coated by exudates so CSF absorption is absent or very slow. So if the volume of fluid is continuously increasing the intracranial pressure will increase, exerting force on the fontianels and suture lines of the skull causing hydrocephalus. On the other hand, there is also a possibility that nt only the choroid plexus will be blocked but also the cervical canal of the spinal cord wherein CSF flows into it going to the spinal cord and spinal nerve endings for absorption and serve as shock absorber in case of trauma and lubricant. If the cervical canal will be blocked there will be more decrease absorption or worst no absorption will take place. This will cause increase CSF and exudate volume, increasing intracranial pressure exerting force on the fontanels and suture lines of the skull causing hydrocephalus. Or from the increase CSF plus exudate volume there will be compression of blood vessels and vein, decreasing oxygen supply/ hypoxia that may cause seizures. And due to the compression there will be shifting of the cells and herniation.

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IX. MANAGEMENT Ideal a. Medical y Antobiotics

y

Antibiotic therapy alone may be adequate for small subdural empyema (ie, < 1.5 cm diameter). Because of the aggressive nature of this disease, however, this option is not widely utilized. This is an option for patients with major contraindications to surgery or significant mortality risks.

Antipyretic
y

For the treatment of fever

Anti-tuberculosis medications
y

These drugs are prescribe not only to patients with tuberculosis confined in the lungs but also to patients with extrapulmonary tuberculosis like Potts Disease, Tuberculosis meningitis.

Anti-seizure medications
y

Anti-seizure are prescribed to those patient with febrile convulsive episode during acute or severe exacerbations.

b. surgical craniotomy
y

Allows wide exposure, adequate exploration, and better evacuation of the purulent collection than other procedures.

Stereotatic burr hole placement with drainage and irrigation

y

is another option but is less desirable because of decreased exposure and possible incomplete evacuation of the purulent material.

Drainage and debridement

y y

Removal of the primary source of infection may be necessary. Samples should be collected for Gram staining, culture, and sensitivity tests.

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Actual a. Medical 1. antibiotics y y Ceftriaxone 515 mg IV q12o Oxacillin 500 mg IV q6o

2. Antituberculosis medications y y y Rifampicin 2.6 ml OD per orem Isoniazid 3.5 ml OD per orem Pyrazinamide 3.5 ml OD per orem

3. Anti-seizure medication y y Phenobarbital 20 mg/pptab q12o Diazepam 3.1 mg PRN for seizure

4. multivitamins y Vitamin B complex 1 tab OD

5. Blood coagulator y b. surgical 1. Stereotatic burr hole craniotomy placement with drainage and irrigation y y The patient is status post evacuation last March 5, 2011. According to her mother there was hole created and drainage bag (urine bag) was attached, draining a yellowish (pus) and combination of blood clots. The amount of the discharge drained was about two bagsfirst was full and the other was nearly full. Vitamin K 5mg for five days- prescribed after surgery

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X. NURSING CARE PLAN Cues/Data S:

Nursing Diagnosis

Nursing Analysis
Presence of infection Exudate formation

Nursing Objectives

Nursing Interventions

Rationale

Evaluation
April 26, 2011 2:00pm After the shift and rendering of nursing interventions the goals set were partially met as evidenced by: y Increase in grasp on the left hand y Increase strength in the affected side

P: Mabuti ngayon Impaired Physical Mobility naigagalaw na niya ang mga paa at kamay related to niya pero medyo E: nanghihina pa lalo na Neuromuscular and sa left side niya. AVB musculoskeletal patients mother impairment Nakakaupo naman as evidenced by siya pag pinaupo pero di niya mabalance ang S: katawan niya. Added y Weakness on the by the mother left side of the O: body y active and playful y Weak grasp on y cries at times the left y weak in y Mothers appearance verbalization of: y with good suck medyo nanghihina and appetite y weakness on the pa yung mga kamay left side of the at paa niya lalo na sa left side niya body y with weak grasp on the left y vital signs of: y BT-36.8 oC y PR- 152 bpm y RR- 25 cpm

April 26, 2011 10am-2 pm

After rendering four hours of nursing interventions the client will: Increase CSF plus y Increase strength Exudate fluid Volume and function of the affected body Irritation part y increase strength Inflammation of affected and compensatory IICP body parts y demonstrate skills Compression that shows increase strength Compression of in grasp on the control center left side of the body Neurologic and motor deficits Altered CSF flow and absorption Source:

Medical-Surgical Nursing: Clinical Management for Positive Outcomes, Eight Edition

Independent: y Review the y Indentifies the probable functional ability functional impairments and reasons for and influences choice of impairment. interventions. y Assess degree of y Client may be immobility, using a completely scale to rate independent (0), may dependence (0-4) require minimal assistance (1), moderate (2), extensive assistance (3), or be completely dependent on caregivers (4). y Provide/ assist with y Maintains mobility and ROM exercises function of joints/ functional alignment of extremities and reduces Provide bed rest: venous stasis y Position the client y Regular turning more every two hours to normally distributes prevent pressure body weight and ulcer promotes circulation in all areas. If paralysis or limited cognition is present , the client must be repositioned frequently y Provide meticulous y Promotes circulation skin care, and skin elasticity and massaging with reduces risk of skin emollients. Remove excoriation.

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wet linen/ clothing, keep bedding free of wrinkles. y Monitor urinary output. Note the color and odor of the urine. Assist with bladder training if appropriate.

Encourage to y increase OFI specially acidic drinks, juices like cranberry juice if not contraindicated

Inspect for localized y tenderness, redness in skin, warmth, muscle tension, and/or ropy veins in calves of the legs. Observe for sudden dyspnea,tachypnea, fever, respiratory distress or chest pain. COLLABORATIVE: y Refer to physical/ y occupational therapists as indicated

Monitoring input and output of the patients help in assessing the extent of neurologic damage. Some patients with neurologic deficits have no control on bowel and urination thus increased risk in urinary retention and constipation. Increasing OFI will help cleanse the bladder and wash out possible pathogen that may cause UTI. Increasing the acidity will kill bacteria in the bladder lining. Client is at risk for development of deep vein thrombosis and pulmonary embolus, requiring prompt medical evaluation/ intervention to prevent serious complications.

Useful in determining individual needs, therapeutic activities, and assistive devices

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S:Mabuti ngayon
naigagalaw na niya ang mga paa at kamay niya pero medyo nanghihina pa lalo na sa left side niya. AVB patients mother Nakakaupo naman siya pag pinaupo pero di niya mabalance ang katawan niya. Added by the mother O: y active and playful y cries at times y weak in appearance y with good suck and appetite y weakness on the left side of the body y with weak grasp on the left y vital signs of: y BT-36.8 oC y PR- 152 bpm y RR- 25 cpm

P: Impaired Physical Mobility

Presence of infection April 27, 2011 10am-2 pm Exudate formation After rendering four related to hours of nursing Altered CSF flow E: interventions the and absorption Perceptual & client will: cognitive impairment, Increase CSF plus y Have increase decrease strength and Exudate fluid strength and endurance Volume function of the affected body part as evidenced by Irritation y Have increase ROM S: Inflammation y Limited ROM IICP y Decrease muscle strength/control Compression y Weak grasp on the left Compression of y Mothers control center verbalization of: medyo nanghihina pa yung mga kamay at paa niya lalo na sa left side niya Neurologic and motor deficits

Independent: y Assess functional y Identifies strengths/ ability/ extent of deficiencies and may impairment initially provide information and on a regular basis. regarding the Classify according to recovery. Assists in 0-4 scale. choice of interventions because different techniques are used for flaccid and spastic types of paralysis y Reduces risk of tissue y Change positions at ischemia/ injury. least every 2 hours Affected side has poorer and possible more circulation and reduced often if placed on the sensation and is more affected side.
predisposed breakdown/ ulcer. to skin decubitus

April 27, 2011 2 pm After the shift and rendering of nursing interventions the goals set were met as evidenced by: y Increase strength in the affected side Have increase ROM

Source: Medical-Surgical Nursing: Clinical Management for Positive Outcomes, Eight Edition

y Helps maintain hip extension functional, however, may increase anxiety specially about the ability to breathe. y Flexion contractures y Evaluate the use of / occur because flexor need for positional muscles are stronger aids and /or splints than extensors. during spactic paralysis. y Edematous tissue is y Observe affected side more easily to be for color, edema, or traumatized and heals other signs of more slowly. compromised circulation. y Pressure points are the y Inspect skin regularly, bony prominences are particularly the bony most at risk for prominences. Gently decreased perfusion massage any reddened /ischemia. Circulatory areas and provide aids stimulation padding y Position in prone position once or twice a day if the client can tolerate.

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such as sheepskin pads as necessary and if available

help prevent breakdown decubitus development.

skin and ulcer

Exercise therapy: y Minimizes muscle y Begin active/passive atrophy, promotes ROM exercise to all circulation, and help extremities. prevent contractures. Reduces the risk of hypercalcemia and osteoporosis. y Aids in retaining y Assist to develop neuronal pathways, sitting balance by enhancing assisting her to sit at proprioception and the edge of the bed, motor response. supporting body weight by holding the client while she moves. Assisting in walking with the stronger legs supporting the weaker part of the body. y Individualized COLLABORATIVE: program can be y Consult with the developed to meet physical therapist particular needs/ regarding the deal with deficits in passive/ active ROM balance, exercise. coordination, strength. y May assist with y Assist with electrical muscle stimulation (TENS) strengthening and if ordered. increase voluntary muscle control, as well as pain control.

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XI. PROMOTIVE AND PREVENTIVE MANAGENT PROMOTIVE Promote Nutrition  Increase caloric intake per day by adding one extra ounce of milk per feeding as tolerated  Introduction solid foods in the diet for additional nutrition  Small frequent feeding for additional caloric intake  Dilute milk powder thoroughly  Place child in fowlers position when bottle feeding  Burp the infant every after feeding  Provide resting hours when feeding the infant to avoid aspiration  Do not introduce food that she cannot swallow  Assess the weight of the infant weekly to monitor progress of growth Promote Proper Hygiene  Bathe the infant daily to prevent skin diseases  Change the clothing daily and apply powder on the skin for comfort  Change diapers when soaked to avoid diaper rash  Wipe the rectum of the infant thoroughly when infant defecates  Do not let infant to play on a dirty environment (soil, sand, near the waterways, river) Promote Activity and Play  Give the infant age appropriate toys for age  Do give small toys that could fit in the childs mouth  Tell the mother to play with the infant often  Teach infant to count, recite the alphabet, name objects, and action songs  When playing with infant, see to it that the play area is free from any sharp objects and small things that she can put inside her mouth  See to it that when they leave the infant playing on the crib, the side rails are raised Promote Proper Elimination  Change the diapers frequently when soaked and when child evacuates stool  Do not introduce foods that causes constipation  Give foods that are easy to digest and  Give sufficient amounts of fluid daily  When constipation occurs, maintain fluid and electrolyte balance, if, untreated go to nearest health center Religious Adherence to treatment  Instruct the parent to give the medications on time  Tell the watcher about the effects of the medication and its possible side effects Promotion of rest  Provide good ventilation  Position the child in supine position when sleeping  Do not wake infant early in the morning, allow her to wake up spontaneously  Stay with infant when sleeping  Fan the infant when environment is hot

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Provision of emotional support (maternal-child bonding)  Tell the mother to stay with the infant before sleeping  Cuddle and caress the child  Play with child before putting to sleep  Read her a story, through books with illustrations, or sing her a lullaby before sleeping PREVENTIVE Fall precaution  Raise side rails up when leaving the infant  Do not let infant play on high chairs or tables  Do not carry infant when exhausted for there is a chance that one cannot support infants weight Aspiration precaution  Feed the infant slowly  Dilute the powdered milk thoroughly  Use warm water when preparing the formula feeding  Have the infant rest in between feedings, to avoid exhaustion  Do not give foods that are too big to swallow and too hard to chew  Give foods which are tender and soft  Position the infant in fowlers when initiating feeding Nosocomial Infection Prevention  Bathe the infant daily  Change the diapers when soaked or when child evacuates  Change bed linens routinely  Change the position of the infant frequently to mobilize secretions  Promote elimination to avoid urine retention that may lead to UTI  Do not expose child to patient with infectious diseases to avoid cross infection

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XII. DRUG STUDY

NAME OF DRUG CEFTRIAXONE DOSAGE, ROUTE AND FREQUENCY  515 mg  IV  every 12 hours INDICATIONS Third generation Cephalosporin given to treat uncomplicated gonococcal vulvovaginitis, serious infections of lower respiratory and urinary tract, skin & skin structure infection, bacteremia, septicemia, MENINGITIS, preoperative prophylaxis, Otitis media, lymes disease, STIs MECHANISM OF ACTION Ceftriaxone 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. CONTRAINDICATIONS Contraindicated to patients hypersensitive to drug and other cephalosporins and use cautiously to patients with history of sensitivity to penicillin. SIDE/ADVERSE EFFECTS CNS: dizziness, fever, headache GI: diarrhea, dysgeusia, colitis, vomiting GU: genital pruritus, candidiasis HEMA: eosiniphilia, luekopenia, thrombocytosis SKIN: pain, induration, tenderness at injection site, phlebitis, rash Other: hypersensitivity NURSING RESPONSIBLITY

y y y

Check physicians order. Identify the patient. Tell the primary care giver what you will do to gain cooperation Inform the primary care giver about the drugs action, its indication and some expected side effects. Always follow the 10 rights of giving any form of medication Shake well before administering medication Position the patient in supine when administering medication Taper the dosage when stopping to prevent unwanted reactions

29

OXACILLIN

 500 mg  IV  Every 6 hours

Used in the treatment of resistant staphylococci infections

By binding to specific penicillin-binding proteins (PBPs) located inside the bacterial cell wall, Oxacillin inhibits the third and last stage of bacterial cell wall synthesis. Cell lysis is then mediated by bacterial cell wall autolytic enzymes such as autolysins; it is possible that Oxacillin interferes with an autolysin inhibitor.

Hypersensitivity to penicillins. Caution: renal impairment; asthmatic patients; porphyria. Elderly; neonates. Prolonged use may result in fungal or bacterial superinfection, including C. difficileassociated diarrhoea (CDAD) and pseudomembranous colitis.

Fever; rash; diarrhoea, nausea, vomiting; agranulocytosis, eosinophilia, leukopenia, neutropenia, thrombocytopenia; AST increased, hepatotoxicity; acute interstitial nephritis, haematuria; serum sickness-like reactions. Potentially Fatal: Anaphylaxis

y y y

Check physicians order. Identify the patient. Tell the primary care giver what you will do to gain cooperation Inform the primary care giver about the drugs action, its indication and some expected side effects. Always follow the 10 rights of giving any form of medication Shake well before administering medication Position the patient in supine when administering medication Taper the dosage when stopping to prevent unwanted reactions

30

Pyrazinamide

3.5 ml OD PO

Active tuberculosis

Unknown

Malaise, fever, anorexia, nausea, vomiting, dsyuria, interstitial nephritis, thrombocytopenia, hepatotoxicity, hyperuricemia, rash, urticaria, pruritus

Hypersensitive to drug

y Always give pyrazinamide with other anti-TB to prevent the development of resistant organisms y Obtain baseline uric acid level and liver function test result before treatment y Monitor hematopoietic study and liver function test result, as well as uric acid level; assess patient for jaundice and liver tenderness or enlargement before and frequently during therapy y Tell parent to report adverse reactions promptly y stress importance of compliance with drug therapy

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Rifampicin

2.66 ml OD PO

Pulmonary tuberculosis

Inhibits DNA-dependent RNA polymerase, which impairs RNA synthesis; bactericidal

Isoniazid (INH)

3.5 ml OD PO

Actively growing tubercle bacilli.

Unknown. Appears to inhibit cell wall biosynthesis by interfering lipid and DNA synthesis. Bactericidal.

Headache, fatigue, drowsiness, behavioral changes, dizziness, generalized numbness, visual disturbances, nausea, vomiting, abdominal pain,diarrhea,hematuri a, thrombocytopenia, hepatotoxicity, osteomalacia, shortness of breath, pruritus, flulike syndrome Seizures, optic neuritis, hepatitis, hemolytic anemia, jaundice.

Contraindicated in patients hypersensitive to the drug.

Use cautiously in patients with liver disease. Give 1 hour before or 2 hours after meals for optimal absorption.

Contraindicated to patients with acute hepatic disease or isoniazid liver damage.

Always give isoniazid with other antitubercul otics to prevent development of resistant organisms. Explain the action of the drug to the watcher. Instruct client or the watcher to take drug exactly as prescribed.

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PHENOBARBITAL 20mg/pptab q12

Antiepileptic to control partial & generalized tonic-clonic seizures, given parenterally as part of the management of acute seizures & for control ofstatus epilepticus in adults.

Pharmacology: Phenoba rbital sodium is a longacting barbiturate with a general depressant effect on all levels of the CNS. The ascending reticular activating system is particularly sensitive to its action. Phenobarbital sodium increases the threshold for electrical stimulation of the cerebral cortex, thereby limiting the spread of seizure activity. It has hypnotic, sedative and anticonvulsant properties.

Central Nervous System Effects: Dizziness, headache, hangover, confusion especially in the elderly, paradoxical excitation, exacerbation of preexisting pain. Gastrointestinal: Nausea, vomiting, epigastric pain. Cardiovascular: Hypotension. Allergic: Facial edema, skin rash, bullae and vesicles, purpura, erythema multiforme and rarely, exfoliative dermatitis. Severe allergic reactions may result in degenerative changes in the liver. Hematologic: Megaloblastic anemia, agranulocytosis, thrombocytopenia.

Hypersensitivity to any barbiturate; porphyria. Use in pregnancy: Retrospect ive studies demonstrate an increased incidence of congenital malformations among offspring of epileptic women taking barbiturates as anticonvulsant medications. Also, withdrawal symptoms have been observed in neonates following use of barbiturates during pregnancy. (See Warnings). Therefore, phenobarbital sodium should not be used in women of childbearing potential, and particularly during early pregnancy, unless in the judgement of the physician the benefits outweigh the potential risks.

y y

Check physicians order. Identify the patient. Tell the primary care giver what you will do to gain cooperation Inform the primary care giver about the drugs action, its indication and some expected side effects. Always follow the 10 rights of giving any form of medication Shake well before administering medication
Position the patient in supine when administering medication Taper the dosage when stopping to prevent unwanted

reactions

33

XIII. DISCHARGE PLAN DISCHARGE PLAN

M E T H

y y y y y

Rifampicin 2.6 cc OD per orem Isoniazid 3.5 ml OD per orem Pyrazinamide 3.5 ml OD per orem Ceftriaxone 515mg IV q12 Phenobarbital 20mg/pptab q12

all prescribed take home medications must be taken according to its ordered dosage, time, frequency to attain their therapeutic effects  Assist with active or passive exercise  Play with the patient to allows use of muscles  Massage can be performed if exercises is contraindicated to prevent muscle atrophy  Deep breathing exercise for better oxygenation of the body and expansion and exercise of lungs  Treatment of tuberculosis by taking anti TB drugs  Treatment for seizures- Phenobarbital  Exercises to promote circulation and helps bring back the lost function or strength of the affected limb or extremity.  Bacteria controlled by antibiotic therapy  Immediately rush the child when home remedies is not effective to the nearest hospital for proper management PROMOTE PROPER HYGIENE/PREVENTIONOF INFECTION  Tell the watcher to bathe the infant daily in the morning with warm water, clean the ears, nose, eyes, and brush the teeth. Perform hand hygiene every time the primary care giver handles the patient. Provide a clean and dust free environment for the infant to play. Clean toys which the infant plays with because there are tendencies that she will put it in her mouth. ADHERE TO TREATMENT REGIMEN  Medications should be administered at proper time and proper dosage. Follow the right directions given by the pediatrician when giving the drug. Tell the patient about the mechanism of the drug its effect and possible side effects to monitor. PROMOTE SAFETY  Since infant under the age of 1y/o are very playful and loves to discover thing. It is important to keep an eye on them, assist them when reaching over colourful toys and put them in cribs with high rails to avoid accidents such as falls. Educate the patient about preventive measure to avoid aspiration, chocking, and the like. Give the infant toys which she cannot shallow to prevent chocking. Put volatile and poisonous substances high on top of cabinets to avoid poisoning, since children under this age lives to grab things and putting them in their mouths. PROPER SKIN CARE  Apply baby lotion every after bathing to prevent the skin from drying, Dry skin is prone to contracting wounds from scratching which will contribute to the development of skin infection because open wounds serve as an entry points for microorganisms. MEETING NUTRITIONAL AND FLUID NEEDS  It is important to provide the infant with foods that are high in calories, such as carbohydrates, for example; baby food (Cerelac) and milk. Give foods which are tender and easy to chew and swallow.  Stress the importance of breastfeeding, in cases no breastmilk is produced by the mother; give formula milk feeding which are high in caloric level and high in nutrition by checking the label and the nutritional facts. Introduce new kinds of foods as once a month to better meet nutritional needs. See to it 34

O D

that the food is affordable and highly economic without altering the right amount of nutrients. Always prepare diluted milk in cases that the child will be hungry, keep in mind that the child is under trust vs. Mistrust which says that the needs of the infant should be constantly met because if unmet, it would affect the childs development in the later years. PROVISION OF EMOTIONAL SUPPORT  Tell that the mother or the primary care giver should always meet the needs of the child constantly. The mother should cuddle her child daily to promote maternal-child bonding.  Usually patients that were discharged come back after one week for the follow-up check up  Check-up may take before the set follow-up check up if the disease reoccur  High grade fever, chill, and convulsions even in a short span of time should alarm the parents to rush their child in the nearest hospital for proper management HIGH CALORIC FOODS  Since the child needs high demand for calories, the caregiver should give food high in caloric content. Children this age is very active. Such food includes baby foods, tender vegetables, and the like. HIGH NUTRITION MILK  As mentioned above, children this age needs high demands of calories. INTRODUCTION OF NUTRITIOS FOODS  Introduction of food high in CHON should be introduced because children must develop good muscle tone.

35

XIV. UPDATES AND REACTION IV Treatment May Lower Risk of Dying from Bacterial Meningitis ScienceDaily (Sep. 30, 2010) New research shows that an intravenous (IV) treatment may cut a person's risk of dying from bacterial meningitis. The research is published in the September 29, 2010, online issue of Neurology, the medical journal of the American Academy of Neurology. The treatment is called dexamethasone.

"Using this treatment in people infected with meningitis has been under debate because in a few large studies it was shown to be ineffective," said study author Diederik van de Beek, MD, PhD, with the Academic Medical Center, University of Amsterdam in the Netherlands and a member of the American Academy of Neurology. "Our results provide valuable evidence suggesting that dexamethasone is effective in adult cases of bacterial meningitis and should continue to be used." Bacterial meningitis is a condition that causes membranes in the brain and spinal cord to become inflamed. The disease can be deadly, or result in hearing loss, brain damage and learning disabilities. Pneumococcal meningitis is the most common and severe form of bacterial meningitis. It is estimated that about 25 to 30 percent of people die from the disease. For the study, researchers evaluated 357 Dutch people age 16 or older with pneumococcal meningitis between 2006 and 2009. Of those, 84 percent were given dexamethasone through an IV with or before the first dose of antibiotics. The results were compared to an earlier study of 352 people treated for bacterial meningitis in 1998-2002, before Netherlands guidelines recommended using dexamethasone. In that study, only three percent of the people were given dexamethasone. In both studies, participants were assessed on a rating scale of one to five. A score of one was given for death, two for coma, three for severe disability, four for moderate disability and five for mild or no disability. In the later study, 39 percent had an "unfavorable outcome," or a score of four or lower on the scale, compared to 50 percent in the earlier study group. The study found that the rate of death for those who were given dexamethasone was 10 percent lower than in those in early study group. The rates of hearing loss were also nearly 10 percent lower for those in the later study group. Reaction: This research shows that dexamethasone is effective to be one of the treament of meningitis. Its action is to decrease the inflammations in the brain which helps in preventing or relieving some of the signs and symptoms caused by compression due to the inflammation of the brain cells and linings or meninges. This will also help decrease exudate formation from the complexes formed from the combat of WBC and pathogens by decreasing the inflammation caused by the proliferation and irritation caused by the bacterium in the linings of the brain.

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Treatment With Naturally Occurring Protein Prevents and Reverses Brain Damage Caused by Meningitis ScienceDaily (May 25, 2010) This bacterium,Escherichia coli K1, is the most common cause of meningitis in premature infants and the second most common cause of the disease in newborns. "The ineffectiveness of antibiotics in treating newborns with meningitis and the emergence of antibiotic-resistant strains of bacteria require new strategies," explains Nemani V. Prasadarao, PhD, associate professor of infectious disease at Childrens Hospital Los Angeles. Meningitis is the irritation of membranes covering the brain and spinal cord. This irritation can result from viral or bacterial infection. Bacterial meningitis can be very serious, possibly resulting in hearing loss, brain damage, or death, even when treated. Although the mortality rate can be decreased through use of antibiotics significant neurological consequences, like mental retardation, still occur in 30 to 40 percent of survivors. "A recent surge in antibiotic-resistant strains of E. coli K1 is likely to significantly increase the rates of illness and death," said Prasadarao. "Also, the diagnosis of meningitis is difficult until the bacteria reach the cerebrospinal fluid. By that time, brain damage has begun. With large numbers of circulating bacteria, treatment with antibiotics can result in biochemical reactions that may cause septic shock and ultimately, organ failure. So identifying alternatives to antibiotic therapy is crucial." One of a class of proteins known as cytokines, IL-10 is involved in immune function. "We found that during an episode of bacteremia, when a large number of bacteria are circulating in normally sterile blood, IL-10 acts to clear antibiotic-sensitive as well as antibiotic-resistant E. coli from the circulation of infected mice," said Rahul Mittal, Ph.D., lead author on the paper and a post-doctoral fellow in Prasadarao's lab. They also determined that E. coli infection produced damage to the mouse brain comparable to that seen in humans. Three-dimensional imaging studies of infected animal and human infant brains showed similar gross morphological changes. "When we gave IL-10 to mice 48 hours after infection, those changes to the brain were reversed," said Mittal. Tumor necrosis factor (TNF) is a cytokine active in producing inflammation. When the researchers replicated these experiments using antibiotic or anti-TNF, brain damage resulting from E. coli infection was not prevented. The team also discovered a mechanism of action for IL-10 protection. In culture, using mouse and human white blood cells called neutrophils, they found that exposing these cells to IL-10 produced an increase in the number of a certain type of receptor on the surface of the neutrophils. An increase in the CR 3 receptor led to enhanced killing of bacteria. Another white blood cell, called a macrophage, works to clear bacteria from the blood by engulfing or "eating" the pathogen. Similar to what was seen in neutrophils, macrophages treated with IL-10 showed an increase in CR 3 receptors that enhanced their ability to destroy invading bacteria. To confirm that the CR 3 receptor is critical to the protective effect of IL-10 against E. coli, CR 3 expression was suppressed in a group of mice. Before exposing the animals to bacteria, white blood cells were examined and the CR 3 receptor was determined to be absent. These animals were exposed to E. coli and then treated with IL-10. The mice were found subsequently to have bacteria in the CSF and morphological changes indicating brain damage. The protective effect of IL-10 during bacteremia was absent in animals without CR 3 receptors. The researchers further concluded that the crucial increase in CR 3 receptors was a result of IL10 suppressing an important inflammatory agent, prostaglandin E-2. REACTION: . These studies provide a basis for exploring the use of IL-10 in newborns. If these are work, the bodys immune antibodies will be stronger to fight for the infection. I can see that they can use this protein to come up with a new vaccine. May be this protein can also be used in decreasing the neurologic damage in patients suffered from brain injury and CVA. Since diagnosing meningitis is difficult until bacteria reach the central nervous system, finding an agent that can clear the bacteria while also preventing or restoring the damaged brain is very exciting. 37

New Vaccine Hope in Fight Against Pneumonia and Meningitis ScienceDaily (Nov. 12, 2010) A new breakthrough in the fight against pneumonia, meningitis and septicaemia has been announced November 11 by scientists in Dublin and Leicester. The discovery will lead to a dramatic shift in our understanding of how the body's immune system responds to infection caused by Streptococcus pneumoniae and pave the way for more effective vaccines. The collaborative research, jointly led by Dr Ed Lavelle from Trinity College Dublin and Dr Aras Kadioglu from the University of Leicester, with Dr Edel McNeela of TCD as its lead author, has been published in the international peer-reviewed journalPLoS Pathogens. The research was carried out by the teams from Dublin and Leicester with other collaborators from Trinity College Dublin, the U.S and Switzerland over four years and supported by Science Foundation Ireland, Enterprise Ireland, the Medical Research Council (MRC) and the Meningitis Research Foundation. The two teams say they have shown for the first time that the bacterial toxin pneumolysin triggers an immune response by activating a recently discovered group of proteins, called the NLRP3 inflammasome. Once activated, the inflammasome provides protection against infection caused by this pathogen. The Leicester and Dublin research groups demonstrated that this mechanism operates independently of other previously described immune response proteins -- contrary to a dogma in the field. Importantly, this paper is the first to demonstrate that the NLRP3 inflammasome is essential in the immune response against infection by the pathogen and that the bacterial toxin pneumolysin is the key driver of this process. The researchers state that this new knowledge of how the toxin interacts with the immune system will mean that new vaccines can be developed and targeted more effectively. Describing the results as exciting, the researchers say it will potentially have a significant impact in the development of vaccines against pneumococcal disease. REACTION: This is a very exciting finding and supports the development of inflammasome activating vaccines to prevent pneumococcal diseases including pneumonia and septicaemia. If a protein based vaccine could be produced that can protect against all strains of the pneumococcus, this would be of tremendous value and our discovery that NLRP3 is needed for protection will point us in the right direction in terms of how to develop such vaccines. This is a major breakthrough in our understanding of the immune response to Streptococcus pneumoniae; a human pathogen of global significance, responsible for over one million infant deaths annually and the major cause of illness and death in the elderly from infections of the respiratory tract. In order to develop improved pneumococcal vaccines for both the very young and the elderly, it is essential to understand how this bacterium interacts with the host immune system. The discoveries described in our paper represent a huge stride towards this objective. That is why these are exciting new findings, discovered in the course of a unique collaboration between scientists

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XV. BIBLIOGRAPHY Books Black, J.M.. & Hawks, J. H. (2009) Medical-surgical nursing: Clinical mangement for positive outcomes, 8th ed. Philippines: Elsever (Singapore)PTE Ltd. Smeltzer, S. C.; Bare, B.; Wilkinson, J. M. Bruner and Suddarths textbook of medicalsurgical nursing, 10th Edition, Prentice Hall: Nursing Diagnosis Handbook, 8th ed. Doenges, M. E.; Moorehouse, M. F.; Murr, A. C. (2006) Nursing care plans: Guidelines for individualizing client care across the lifespan. Pennsylvania, F. A. Davis Co. Marieb, E. N. (2006) Essentials of human anatomy and physiology. 8th ed. Singapore: Pearson Education South Asia Pte. London, M. L.; Ladewig, P. A.; Ball, J. W.; Bindler, R. A. (2007) Fundamentals of maternal and child nursing care. 2nd ed. Singapore, Pearson Education, Inc. Estes, M. E. Z. (2006) Health Assessment and physical examination, 3rd ed.Singapore, Delmar Learning Kluwer, W. (2009) Nursing 2009 student drug handbook, Philadelphia, Lipincott, Williams and Wilkins Kluwer, W. (2008) Springhouse nurses drug guide 2008, Philadelphia, Lipincott, Williams and Wilkins Scully, J.H. Psychiatry, 3rd ed. Hong Kong, InfoMed Internet http://emedicine.medscape.com/article/1168415-overview http://en.wikipedia.org/wiki/Brain_herniation http://medical-dictionary.thefreedictionary.com/Subfalcine+herniation http://mims.com/Philippines http://www.google.com/search?rlz=1C1SKPL_enPH397PH397&sourceid=chrome&ie=UTF8&q =diagnostic+exams+for+TB+meningitis http://www.radswiki.net/main/index.php?title=Subfalcine_herniation http://www.sciencedaily.com/releases/2010/05/100524121246.htm http://www.sciencedaily.com/releases/2010/09/100929163415.htm http://www.sciencedaily.com/releases/2010/11/101111172619.htm

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