St.

Paul University Dumaguete College of Nursing SY 2011-2012

In Partial Fulfillment of the Requirements in RELATED LEARNING EXPERIENCE

A CASE STUDY OF HYPOXIC ISCHEMIC ENCEPHALOPATHY, COMMUNITY AQUIRED PNEUMONIA & DIABETES MELLITUS TYPE 2

Submitted to: Mr. Benedict Ian J. Futalan, RN Clinical Instructor

Submitted by: Roxanne M. Delvo BSN IIB

Hypoxic ischemic encephalopathy Hypoxic-ischemic encephalopathy is characterized by clinical and laboratory evidence of acute or sub acute brain injury due to asphyxia (ie, hypoxia, acidosis). Most often, the exact timing and underlying cause remain unknown.

Signs and Symptoms

Mild case: Difficulty concentrating or paying attention Poor judgment Poor coordination Euphoria Extreme lethargy Severe oxygen deprivation: Seizure Disorder Coma No brain stem reflexes (eg, breathing, responding to light) Only blood pressure and heart function reflexes are functioning Etiology (Energy Crisis) Recurrent seizures- Lactic acid can get through cell membranes and can damage not only neurons but glial and mesenchymal cells as well. Additionally, lactic acid and hydrogen ions cause cerebral edema by attracting water. Obviously, lactic acidosis is more severe in patients with HIE who are hyperglycemic and is not a significant factor in hypoglycemic encephalopathy or seizures. Lung disease- Hypoxia develops acutely in CO poisoning, which displaces oxygen from hemoglobin. Global ischemia is worse than hypoxia, hypoglycemia, and seizures because, in addition to causing energy failure, it results in accumulation of lactic acid and other toxic metabolites that are normally removed by the circulation.

Complications (Neurological impairments) Persistent vegetative states Seizures Myoclonus Movement disorders Cognitive dysfunction Treatments: adequate ventilation and perfusion careful fluid management Avoidance of hypoglycemia and
hyperglycemia treatment of seizures

Nursing Responsibilities Monitor neurologic status every 30 minutes Take seizure precautions (support head, siderales, suctioning machines) Monitor motor activity

Treatments: (Medical) CT scana scan that uses x-rays and computer software to make pictures of your brain MRI scana test that uses magnetic waves to make pictures of structures inside the brain Electrocardiogram (EKG, ECG)a test that records the hearts activity by measuring electrical currents through the heart muscle Echocardiograma test that uses high-frequency sound waves (ultrasound) to examine the size, shape, and motion of the heart Blood tests, including arterial blood gases and blood glucose levels Electroencephalogram (EEG)a test that records the brains activity by measuring electrical currents through the brain Ultrasounda test that uses sound waves to evaluate blood flow in the vessels going to the brain or within the brain Evoked potential testneurophysiologic test that evaluates functioning of the brain by recording brain waves

Community Acquired Pneumonia is usually acquired via inhalation or aspiration of pulmonary pathogenic organisms into a lung segment or lobe.

Signs and symptoms A single episode of shaking chills followed by fever Chest pain on the side of the infected lung. Severe abdominal pain sometimes occurs in people with pneumonia in the lower lobes of the lung Cough, which may be dry at first, but eventually produces phlegm (sputum) Nausea, vomiting, and muscle aches Rapid breathing and heartbeat

Shortness of breath

(Emergency) Etiology (Gram positive bacteria) Streptococcus (S.) pneumoniae (also called pneumococcus), the most common cause of pneumonia. This Gram-positive bacterium causes 20 - 60% of all community-acquired bacterial pneumonia (CAP) in adults. Studies also suggest it causes 13 - 38% of CAP in children. Staphylococcus (S.) aureus, the other major Grampositive bacterium responsible for pneumonia, causes about 2% of CAP and 10 - 15% of hospitalacquired pneumonias. It is the organism most often associated with viral influenza, and can develop about 5 days after the start of flu symptoms. Pneumonia from S. aureus most often occurs in people with weakened immune systems, very young children, hospitalized patients, and drug abusers who use needles. It is uncommon in healthy adults. Streptococcus pyogenes or Group A streptococcus. Blood in sputum Bluish-toned (cyanotic) skin High fever Labored and heavy breathing Mental confusion or reduced mental function in the elderly Rapid heart rate Weight loss

(Gram negative bacteria) Haemophilus (H.) influenzae is the second most common organism causing communityacquired pneumonia, accounting for 3 - 10% of all cases. It generally occurs in patients with chronic lung disease, older people, and alcoholics. Klebsiella (K.) pneumoniae may be responsible for pneumonia in alcoholics and other people who are physically debilitated. It is also associated with recent use of very strong antibiotics. Pseudomonas (P.) aeruginosa is a major cause of hospital-acquired pneumonia (nosocomial pneumonia). It is a common cause of pneumonia in patients with chronic or severe lung disease. Moraxella (M.) catarrhalis is found in everyone's nose and mouth. Experts have identified this bacterium as an uncommon cause of certain pneumonias, particularly in people with lung problems such as asthma or emphysema. Neisseria (N.) meningitidis is one of the most common causes of meningitis (central nervous system infection). The organism has also been reported in pneumonia, particularly in epidemics of military recruits.

Other Gram-negative bacteria that cause pneumonia include E. coli, proteus (found in damaged lung tissue), enterobacter, and acetinobacter.

Complications

Adult respiratory distress syndrome Empyema Lung abscess Meningitis Pericarditis Peritonitis Pulmonary fibrosis Respiratory failure Sepsis

Diagnostic Testing for Community-Acquired Pneumonia Chest radiography Complete blood count Complete metabolic profile Blood gases or pulse oximetry Severely ill or immunocompromised patients, patients with anatomic lung disease Sputum Gram stain and culture Blood cultures: two sets before antibiotics Legionella serology, urinary antigen, direct fluorescent antibody testing Pneumococcal urinary antigen testing HIV serology Mycoplasma serology Chlamydia serology Fungal serology SARS-associated coronavirus serology or PCR Stains or cultures for fungi, mycobacteria, Pneumocystis jiroveci Analysis or cultures of pleural or cerebrospinal fluid Nasopharyngeal swab for viral direct fluorescent antibody or other rapid technique Tuberculin skin testing Bronchoscopy (bronchoalveolar lavage, protected catheter, transbronchial biopsy) Thoracoscopic or open-lung biopsy Radiographically guided transthoracic aspirate Legionella, Chlamydia, Mycoplasma serology Fungal serology Evaluation for congestive heart failure, pulmonary embolus, neoplasm, connective tissue disease.

Inpatients with appropriate history or physical findings

Deteriorating patient without definitive diagnosis of cause

Treatments: (Medical) Fluids and antibiotics in your veins Oxygen therapy Breathing treatments (possibly) Suctioning

(Surgery) Thoracotomy Endotracheal tubings

Nursing Responsibilities Administer due medications Back tapping ang chest tapping to loosen secretions Nebulization Proper positioning and turning to sides Oxygen administration

Health Teachings Tell patient not to miss a single dose of the medication Do not take cough or cold medicines until the doctors says okay. Because coughing may help in getting rid of the mucus in the lungs. Do not smoke Do not drink alcohol Perform chest tapping before coughing Increase fluid intake daily

Diabetes Mellitus Type 2 Type 2 diabetes mellitus comprises an array of dysfunctions resulting from the combination of resistance to insulin action and inadequate insulin secretion. It is disorders are characterized by hyperglycemia and associated with microvascular (ie, retinal, renal, possibly neuropathic), macrovascular (ie, coronary, peripheral vascular), and neuropathic (ie, autonomic, peripheral) complications. Signs and Symptoms

Frequent urination Excessive thirst Extreme hunger

Unusual weight loss Increased fatigue Irritability Blurry vision

Etiology complicated interplay of genes environment insulin abnormalities increased glucose production in the liver increased fat breakdown defective hormonal secretions in the intestine. Obesity

Complications Heart and blood vessel disease Nerve damage (neuropathy) Kidney damage (neuropathy) Eye damage (neuropathy) Foot damage Skin and mouth conditions Osteoporosis Alzheimers disease Hearing problems

Treatments (Medical) Prescribed medications (insulin, metformin, etc.) Foot guards

(Surgical) Amputation

Nursing Responsibilities Explain patient about diet modification Encourage increase of activities (exercise) let patient understand the importance of drug administration tell patient to wear proper footwear discourage smoking cessation and alcoholic beverages monitor CBS