18123427 Tb Meningitis Case Studygrup49 0910(2)

Angeles University Foundation College of Nursing AY 2009 – 2010 First Semester

A Case Study TB MENINGITIS (A Requirement for NCM 101 Pedia, Second Rotation)

PRESENTED BY: Antonio, Alneil T. Diyco, Kevin Gutierrez, Richell Manalac, Alexis

PRESENTED TO: Mrs. Nona Gonzales, RN INSTRUCTOR

I. INTRODUCTION

If we were to look back through history, it would seem as if meningitis has no definite origin. Some say that Hippocrates may have realized the existence of the disease. Tuberculosis meningitis, which was called “dropsy in the brain”, is often attributed to Edinburgh physician Sir Robert Whytt in a posthumous report that appeared in 1768, although the link with tuberculosis and its pathogen was not made until the next century. But no matter how unclear the origins of meningitis are, we could definitely say that it is a serious problem. Although studies have shown that viral meningitis is more common (10.9 per 100,000), bacterial meningitis still has a relatively high incidence rate of about 3 per 100,000 annually in Western countries. And in Brazil, the rate of bacterial meningitis is higher, at 45.8 per 100,000 annually. In subSaharan Africa, large epidemics of meningococcal meningitis occur in the dry season, leading to it being labeled the “meningitis belt”. In this area, there are 500 cases encountered per 100,000 annually because it is poorly served by medical care. The most recent epidemic, affecting Nigeria, Niger, Mali and Burkina Faso, started in January 2009 and is ongoing. (Wikipedia, 2009) As said by former Sec. Manuel Dayrit, there was an emerging trend of meningitis, an ailment less fatal than meningococcemia, but is caused by the same bacteria, Neisseria meningitidis. Whereas in the United States, Pneumococcus is responsible for 3,000 cases of meningitis, 50,000 cases of bacteremia, and 500,000 cases of pneumonia every year. Additionally, Pneumococcus is the most common cause of bacterial meningitis and bacterial pneumonia in children younger that 2 years old and has been the featured topic of pediatric journals since then. (Philippine Daily Inquirer, January 18, 2005) Bacterial meningitis is a true emergency because it requires immediate hospital-based treatment and can be life threatening if not treated promptly. Of course, there are always risk factors involved which could increase the chances of a person to acquire the disease. In addition, the absence of any

risk factor, or having a protective factor does not necessarily guard a person from the disease. Risk factors would include contact with meningococcal cases, and travel to Africa or parts of Asia where meningococcus is more common. Institutions like schools and dormitories have been associated with meningococcal outbreaks. Low humidity, dust storms, and cigarette smoke also increases the risk of getting infected with the bacteria. And lastly, breaks in the skin also would permit the entry of bacteria, as well as through droplet and kissing.

As for neonatal meningitis, persistence of cases results from

increasing numbers of infants surviving puncture delivery and limited access to medical resources in developing countries. (Adele Pillitteri, 2003) Almost any bacteria entering the body can cause meningitis. The most common

are

meningococci

(Neisseria

meningitidis),

pneumococci

(Streptococcus pneumoniae), and Haemophilus influenzae. These organisms are often present in the nasopharynx, and they are fairly common and are more often associated with other everyday illnesses. (Joyce M. Black, Jane Hokanson Hawks, 2008)

The long-term outlook for children who develop meningitis varies greatly and depends on the child’s age, the microorganisms causing the infection, other complications, and the treatment the child receives. The complications of bacterial meningitis can be severe and include neurological problems such as hearing loss, visual impairment, seizures and learning disabilities. Although some children develop long lasting neurological problems from bacterial meningitis, most who receive prompt diagnosis and treatment recover fully. (Joyce M. Black, et al, 2005) A. CURRENT TRENDS Many times meningeal infections can be prevented, especially when the infecting pathogen is H. influenzae, S. pmeumoniae, or N. meningitidis. The current immunization guidelines endorsed by the Advising Committee on

Immunization Practices and American Academy of Pediatrics are that all children be immunized against H. Influenzae. The role of the government is very crucial in times of outbreaks and life threatening diseases. The government engages in research activities, continuous proper management and initial treatment such as immunization, which is the concern of everyone. While the treatment and prevention of bacterial meningitis have greatly improved over the past decade. Significant therapeutic challenges still exist. Controversies include the choice of empiric antimicrobial agents and the administration of corticosteroids; the introduction of pneumococcal vaccines and the new antibiotics have changed the epidemiology of meningitis. Together, the availability of antibiotics has contributed to the emergence of resistant organisms. One of the activities of the government is to respond to this dilemma,

according

to Carlos,

et al, through a study

entitled

“Antimicrobial Resistance Surveillance Program in the Philippines” which was held last 2000, and was about the resistance of H. influenzae to cotrimoxazole, ampicillin and chloramphenicol whereas it is concluded the three drugs are still recommended to use for H. influenzae. In addition to this, scientists believe they may have found a way to protect people against every strain of meningitis. The most current study that was published, “Vaccine could beat meningitis”, talks about the new approach towards management of meningitis. It shows that a vaccine against A and C strain of the disease exists, however there is no job against the lethal B strain. Scientists use genetic engineering technology to create a strain of meningitis B that is incapable of causing for disease, after injecting the strains of the disease the finding suggested that it may be possible to create a single vaccine to protect against each strain. The unique thing about this research is that it provides hope for a complete vaccine protecting people against all types of meningococcal bacteria, the most common cause of meningitis worldwide. (Carlos, 2004) Successful eradication of CSF infection will rely on the continued development of new antibiotics and vaccines as well as judicious use of those

antibiotics currently available. Routine immunization of young adolescent will help prevent the rare but serious infection of the disease. In addition, the absence of specific clinical findings makes diagnosis of meningitis more difficult. As stated by Lincoln, whether its making sure that families have access to quality health care and child care, in making sure that the children receive the best educational opportunities we can give them, we must remain committed to these needs because our children are our future. Embracing the vital role of the government in creating barriers against the disease, the initiative and braveness of the stat to fight for the children against the disease is like struggling for a better economy. (Sarah Yuan, 2004) B. REASONS FOR CHOOSING THIS CASE The group’s main reasons for choosing this particular case would have to be the patient’s mother and father. They both were nice people who have let us student nurses handle their child without being hard to please or hard to talk to. In other words, we were able to achieve a much more mutual relationship with them, and this helped us a lot in understanding their child’s overall condition. In doing so, we were able to raise our level of awareness in terms of the forms of treatment and management that were needed. Considering that the chosen case was meningitis, future encounters with the disease as well as its complications would be much easier for us because we have already established a background about it. In addition, knowing the various risk factors involved in the occurrence of the disease would allow us to give health teachings easily, especially when it comes to prevention.

II. Nursing Process II. A. ASSESSMENT 1.

Personal Data

I.A Demographic Data Gian Dave Canlas, a 1y/o child, male. He is the son of Albert and Vivian Canlas. He is presently residing at Block 4, Lot 31, Phase 1 Sapang Bayabas Resettlement Dau Mabalacat. He was born on June 14, 2008 at JBLMGH and a natural born Filipino and a Catholic. He was admitted at JBLMGH on July 17, 2009 at 3:10pm with a diagnosis of t/c CNS infection Probably TB Meningitis. INFORMANT: Vivian Canlas RELATION: Mother 2.

Pertinent Family History Gian Dave belongs to a nuclear type of family, which is consist of five members. Mr. Albert Canlas, his father works as construction worker, Mrs. Vivian Canlas on the otherhand serves as a fulltime housewife. eldest is Gladilyn Canlas supposetedly

The

13 years old but unfortunately she

died in the womb of her mother before she was born because of weak fetal heart rate. The second eldest is Ma. Paulina, 11 years old she was born on October 25, 1997. Next to her is Albert Ian Canlas a 5 year old boy that was born on June 18, 2004. According to her mother Gian Dave and Ma. Paulina didn’t had complications when they were born but Albert Ian was born premature at 7 months old of gestation and he was confined at JBLMGH NICU for almost a month because of respiratory problem. The family lives in a small house which is made up of woods with poor environmental condition. According to Mrs. Canlas, they only have one room

which is crowded and it has poor ventilation and poor lightning as evidenced by a 2 small window which is blocked with black curtain and not exceeding size of 10% of the total floor area. Their source of their family income, comes only from the father who works as a construction worker and earns P200.00 per day Mrs. Canlas stays at home and take care of their children.. Some of their health habits are the use of some medicinal plants and consultation to the Hilot and Herbolarios. Despite of their practice of superstitious belief, they don’t hold them as their basis in living their lives because they strongly believe in God and He is the only one who serves as their mode of strength. Thus, they always see to it that their whole family goes to church every Sunday morning. This is to show their devotedness to God. Typically, they usually eat together as a sign of their close family ties bound with familial love and trust. They teach their children to respect their elders. 3.

Personal History When Mrs Canlas was pregnant her common habit is to taking a

bath every day, she always consulted the health center, and if there is seminars related to pregnancy and family planning in the barangay, she's always present. She eats lots of food, especially fruits and vegetables. She is regularly taking vitamins. She undergo ultasounds or xrays to assure that her baby will be deliver in normal. She believes in what others termed as “lihi”. Her food intake is twice as what she usually eats before. According to her, she loves eating mango, apples, sayote and potatoes which are cheaper but nutritious one. She told us that her husband restricted her from doing extreme activities. So to wash off her boredom, she spends her time watching teleserye programs. Every morning, she sees to it that she had accomplished walking along their street and sometimes she's doing light household chores such us washing the plates. Mrs. Canlas had also mentioned about her beliefs during her pregnancy such as when you drink milk, the baby will be delivered with fair skin. She

also believes that if a pregnant woman is beautiful during the period of her pregnancy, her child will be a girl. And if she is not that pretty her child will be a guy. According to Mrs. Canlas her obstetrical history is G4P4T3P1A0L3M0. Mr and Mrs. Canlas have 4 children; Gian Dave weighs 6.5lbs at birth, with AOG of 36 weeks . He is the fourth child and has one sister and one brother and the eldest sibling who died at birth. During all of Mr. Canlas pregnancy with Gian Dave he always visit their health center for prenatal check up. When Mrs. Canlas was pregnant with Gian she always eats bread, rice, fruits and vegetables. Despite of these all of her children were delivered through a normal spontaneous delivery but her 1st child died in her womb because of weak heart rate and her third child that was delivered premature at 7 months. Being a mother she practiced breastfeeding but she abstain from it since Gian got sick. GROWTH AND DEVELOPMENT Erik Erickson (Psychosocial Theory) Gian Dave is in the Trust vs. Mistrust stage of Erik Erickson’s Growth and Development Stage. The infant depends on the parents, especially the mother, for food, sustenance, and comfort. The child's relative understanding of world and society come from the parents and their interaction with the child. In this situation, the parents should expose their child to warmth, regularity, and dependable affection, so that the baby will have trust to them. The group instructed mother to give comfort, warmth of love, emotions and feelings to provide a secure environment and to meet the child's basic needs, and a sense of trust will result. Failed to provide this will be mistrust. Jean Piaget (Cognitive Development)

Gian Dave is in the Sensorimotor period of new means through sensory combination of Piaget’s Cognitive Development. In this stage, infants construct an understanding of the world by coordinating sensory experiences (such as seeing and hearing) with physical, motoric actions. Sigmund Freud (Psychosexual) Gian Dave is in the stage of Oral receptive personality wherein it is preoccupied with eating/drinking and reduces tension through oral activity such as eating, drinking, biting nails. They are generally passive, needy and sensitive to rejection. They will easily 'swallow' other people's ideas.. During this stage, the focus of gratification is on the mouth and pleasure is the result. It is also an exploration of the surroundings (as infants tend to put new objects in their mouths). In this stage the id is dominant, since neither the ego nor the super ego is yet fully formed. Thus the baby does not have a sense of self and all actions are based on the pleasure principle. MOTOR AND SOCIAL DEVELOPMENT IN INFANCY AGE One month

Two months

MOTOR DEVELOPMENT • Keeps hands

SOCIAL DEVELOPMENT • Can differentiate

fisted

between faces and

•

Able to follow

objects.

•

object to midline Holds head up

•

when prone Three months

• •

Has social smile Holds head and

Makes cooing sounds

• •

Differentiate a cry Laughs out loud

•

Very talkative,

chest up when Four months

•

prone Grasp, stepping, tonic neck

cooing babbling

reflexes are

and gurgling when

fading

Five months

• •

Turns front and

spoken to •

Recognize familiar

•

objects Says some simple

back

vowel sound (goo-

No longer has

goo and gah-gah)

head lag when pulled upright

Six months

•

Bears partial

•

weight Can raise their

•

chest and the upper part of their

sounds •

abdomen off the table. •

Starts to imitate May say vowel sounds

•

Plays pick a boo

•

Show beginning

Can sit with support

Seven months

•

Turns both ways

•

More reflex fading

•

Uses palmar

•

reflex Can transfer toy from one hand to

fear of strangers

another •

First tooth erupts (central incisor

Eight months

•

below) Can sit without

•

Has peaked fear of

Nine months

•

support Creeps and crawls

•

strangers Says first word (da-

•

Sits so steady that they can lean forward and

da) •

Aware of changes in voice tone

regain their •

Ten months

balance Brings the thumb

•

and first fingers together in a

Eleven months

word (bye-bye) •

Recognize their

pincer-grasp

names and listen

•

Pull themselves in

actively

•

standing position Learns to cruise

•

(walks with support)

Twelve months

Master another

•

Can hold objects

•

Cannot perform activities

Imitates speech sounds

•

Reacts with frustration when

•

restricted Depended to parents and SO

according to age due to sickness fever and seizures. • BCG

DPT

Complete

Complete

Growth and development slow OPV HEPA B down. Complete Complete

IMMUNIZATION STATUS

4. HISTORY OF PRESENT ILLNESS June 15, 2009 MDH •

Unknown Diagnosis

MEASLES Incomplete

•

Incomplete Immunization

5. HISTORY OF PAST ILLNESS 3 wks PTA •

patient was diagnose with papillary complex By a PMD was given Rifampicin, Isoniazid, Pyrazinamide, Zinc Sulfite, Vitamin B Complex

10 days PTa •

(+) LBM/Vomitting

•

intermittent fever(-)

3 days PTA •

Persistence of above Seizure prompted consult Mabalacat district Hospital

! day PTA While at MDH, pt had seizure hence was transferred to JBLMRH for further evaluation. PAST MEDICAL HISTORY June 15, 2009 MDH- Unknown Dx Incomplete Immunization(no measles vaccine) Family medical history (-)seizure (-)asthma Personal environment and Social History

(+) exposure to PTB patient(grandfather)

6. PHYSICAL EXAMINATION (IPPA –Cephalocaudal Approach) July 17, 2009 Weight: 6.7 kgs Vital Signs: Temperature: 36.7O C Pulse Rate: 140 bpm Respiratory Rate:24 bpm •

GS:

weak looking, conscious, coherent

•

Skin:

(-) jaundice, (-) pallor, (-) cyanosis, no active dermatoses,

poor skin turgor •

HEENT:

(+) dry lips, NAD, sunken eyeballs, dry lips, PPC, AS

•

C/L:

SCE, (-) retractions, (-) crackles, no wheezes noted,

subcostal and intercostals refract •

AP:

no murmur

•

Heart:

Normal Rate Regular Rhythm, (-) murmurs

•

Abdomen:

flat, no mass palpated, no tenderness

•

GUT:

Unremarkable

•

IE:

Unremarkable

•

Extremities: no atrophy noted

•

Neuro:

drowsy

○

(+) neck rigidity

○

(+) brudzinki’s sign

○

(+) kernig’s sign

○

(-) babinski reflex

July 18, 2009 General Appearance: Patient is awake, lethargic. Vital Signs:

Temperature: 36.40O C Pulse Rate: 133 bpm

SKIN:

There is cyanosis, poor skin turgor, warm to touch and dry.

HAIR &

The hair is black in color; no infestations.

SCALP NAILS HEAD FACE EYES

EARS NOSE MOUTH & THROAT CHEST AND LUNGS

Nails are normal in size and shape, they are short and clean, with a normal capillary refill of 3 sec. No tenderness of the scalp noted, presence of bulging fontanelle Symmetrical in shape, no tenderness upon palpation Upward rolling of eyeballs, with pale palpebral conjunctiva, sclera is white in color Skin color is pale, auricle aligned with outer canthus of eye, mobile, firm, and not tender Nose is symmetrical, not tender and no lesions, without discharges, absence of bleeding and swelling Tongue is normal pale and dry, with dry mucous membrane,

Presence of subcostal retraction, symmetrical lungs

HEART ABDOMEN

No murmurs, normal rate and regular rhythm. Borborygmi sounds heard upon auscultation. no mass and lesion,

Respiratory Rate: 35 bpm

July 23, 2009 Vital Signs:

Temperature: 36.9O C Pulse Rate: 135 bpm

SKIN:

There is cyanosis, poor skin turgor, warm to touch and dry.

HAIR &

The hair is black in color; no infestations.

SCALP NAILS HEAD FACE

Nails are pale,no clubbing capillary refill of 4sec Presence of bulging fontanelles No tendernesss upon palpation

EYES

Symmetrical, with pale palpebral conjunctiva, sclera is white in color, upward rolling of eyeballs

EARS

No abnormal discharges or swelling

NOSE

Nose is symmetrical, not tender and no lesions

MOUTH & THROAT CHEST AND LUNGS HEART ABDOMEN

Tongue is pale, dry lips

Subcostal and intercostals refract

No murmurs, normal rate and regular rhythm. Borborygmi sounds heard upon auscultation. with masses Respiratory Rate: 38 bpm

7. DIAGNOSTIC AND LABORATORY PROCEDURES Diagnostic Procedures

Date

Indications/

Ordered

Purpose

Result

Normal

Analysis and

Values

Interpretation

Date Result Complete Blood Count Hemoglobin

D.O.:

It measures the

7.17.09

total amount of

D.R.: 7.17.09

104

hemoglobin in the

M: 125-

Malnutrition is

175g/L

recognized to the

F: 115-

blood, to determine

155g/L

the O2 carrying

patient that may indicate the cause of

capacity of the

decrease In the

blood.

level of haemoglobin

Hematocrit

D.O.:

It measures the

7.17.09

percentage of RBCS

D.R.:7.17.0 9

0.31

in the total blood

M:0.40-

There was a

0.52

decrease in the

F:0.38-

volume

0.48

result due to hemodilution and the recognized malnutrition.

Leukocytes (WBC)

D.O.: 7.17.09 D.R.:7.17.0 9

It determines the number of circulating WBCS of the whole blood.

6.0

5-

The result is 9

10x10 /L

within the normal values

Neutrophils

D.O.:

Phagocytes present 0.37

7.17.09

in the circulation or

lower than

along the capillary

normal which

walls.

indicatates risk

D.R.:7.17.0 9 Plate count

To evaluate

7.17.09

9

Neutrophils is

for infection.

D.O.:

D.R.:7.17.0

(0.5-0.7)

404

(150-

The result is

platelet production,

450x10g

within normal

to monitor and

/l)

values.

(M: 60-

A decreased

diagnose severe thrombocytosis or thrombocytopenia

Blood

D.O.:

Specimen of

Chemistry

7.17.09

venous blood are

Creatinine

D.R.:7.22.0 9

taken for a CBC which includes hemoglobin and hematocrit measurements,

Creatinine 52.3

120umol/ value for this test L) (F: 58100umol/ L)

is rarely a concern. It can occur with decreased muscle mass.

erythrocyte RBC

Conditions such

Count, Leukocyte

as muscular

WBC count RBC

dystrophy, which

indices and

is an inherited

differential white

defect in

cell count.

muscles, can

CBC is one of the most frequently ordered blood test, it shows the increase, and decrease of the blood cell count

cause a low value for this test.

that may be associated with different disorders, and also determines the presence of bacterial infection or viral infections. To asses for electrolyte imbalance. Lympocytes

D.O.: 7.17.09 D.R.:7.17.0 9

0.63

0.20-.0.3

Lymphocytes is

5

higher than normal range which may help in fighting against infection

Urinalysis

D.O.7.17.0

To determine

9

urinary

D.R.:7.18. 09

complications and possible

Color: yellow Transparenc y: clear

abnormal

Albumin:

components

negative

(e.g. CHON, glucose blood, pus) or infection.

Pale yellow

The result is within

to Amber

normal values.

Yellow

Clear

Reaction: Acidic Specific Gravity : 1.010 Pus cell 01/HPF RBC 0-1.HPF

Stool Exam

D.O.:

Use to assess

Color: Light

Color: dark

The result is within

7.17.09

gross

brown

brown

normal values,

Result: No

Consistency

ova or

: formed

D.R.:7.21. 09

appearance of ova or parasites in the stool.

parasite seen Consistency: Semi-formed

Chest X- Ray

D.O.:7.17.09 D.R.:7.17.09

•

Provides

Both lung

Normal lung

The result is

information

fields are

fields.

normal with

about location

clear. •

and extent of

Heart and

pneumonia and

great

cardiac

vessels are

abnormalities.

normal in

Normal heart size and configuration

size and configuratio n. •

Other chest structures are not remarkable

IMPRESSION: Normal Chest

NURSING RESPONSIBILITIES:

HEMATOLOGY (CBC) Prior: 1. Explain the procedure to the S.O 2. Tell the S.O that no fasting is required 3. Assure S.O. that collecting blood sample take less than 3 minutes 4. Inform S.O that pt. will be experiencing pain on the site where the needle was pricked. During: 1. Collect 5-7 ml of venous blood in a lavender top tube

no signs of pneumonia or heart problems.

After: 1.

Apply pressure or a pressure dressing to the venipuncture site

2. Check the venipuncture site for bleeding 3. Fill- up the laboratory form properly or label the specimen and send to the laboratory technician 4. Record all procedure done URINALYSIS (U/A) Prior: 1.

Explain the procedure to the S.O.

2.

Obtain the materials needed for the procedure

3.

Advise S.O. to wash the genital area of the pt. prior to collection of specimen to prevent contamination

During: 1.

Collect a fresh urine specimen using wee bag ( urine container)

After:

1.

Label the specimen and transfer it to the laboratory immediately and promptly.

STOOL ANALYSIS Prior: 1. Explain procedure to S.O. 2. Determine the reason for collecting stool specimen and the correct method of obtaining and handling 3. Obtain the necessary materials During:

1.

Wear gloves

2.

Use tongue blade to obtain specimen from the diaper using scraping method

3.

Take the sample from the center of a formed stool to ensure a uniform sample.

After: 1.

Ensure that the specimen label and laboratory requisition have the correct information on them and are securely attached to the specimen container.

2.

Transfer the specimen to the laboratory immediately and promptly.

3.

Document all relevant information.

CHEST X-RAY Prior: 1. Verify doctor’s order 2. Explain to the S.O. the importance of the procedure 3. Ask the S.O. to remove any radiopaque objects (jewelry, metal buttons) During: 1. Client assumes various positions so that x-ray films can be obtained from the most useful angles. After: 1. Assist S.O. and patient to go back to his bed Record all procedures done NURSING RESPONSIBILITIES FOR BLOOD SPECIMEN COLLECTION: •

Place the tourniquet above the venepuncture site

•

Palpate and locate the vein. it is difficult to disinfect the venepuncture site meticulously with 10% isopropyl alcohol by swabbing the skin concentrically from the center of the venepuncture site outwards. Let

the disinfectant evaporate. Do not repalpate the vein again. Perform venepuncture. •

If withdrawing with conventional disposable syringes, withdraw 510 ml of whole blood from adults, 25 ml from children and .52ml for infants.

•

IF withdrawing using vacuum systems, withdraw the desired amount of blood directly into each. Transport tube and culture bottles.

•

Remove the tourniquet. Apply pressure to site until bleeding has stop, and apply sticking plaster (if desired)

•

Using aseptic technique transfer the specimen to the relevant cap transport tubes and culture bottles. Secure caps tightly Be sure to follow manufacturer’s instructions on the correct amount and method for inoculation of blood culture bottles.

•

Label the tube including patient identification number using indelible marker pen.

•

Do not recap used sharps. Discard directly into the sharps disposable container.

•

Complete the case investigation and the laboratory request form using the same identification

•

8. ANATOMY AND PHYSIOLOGY

Central Nervous System The central nervous system (CNS) is the largest part of the nervous system, and includes the brain and spinal cord. The spinal cavity holds and protects the spinal cord, while the head contains and protects the brain. The CNS is covered by the meninges, a three layered protective coat. The brain is also protected by the skull, and the spinal cord is also protected by the vertebrae. The central nervous system (CNS) is the part of the nervous system that functions to coordinate the activity of all parts of the bodies of

multicellular organisms. In vertebrates, the central nervous system is enclosed in the meninges. The meninges (singular meninx) is the system of membranes which envelops the central nervous system. The meninges consist of three layers: the dura mater, the arachnoid mater, and the pia mater. The primary function of the meninges and of the cerebrospinal fluid is to protect the central nervous system. It contains the majority of the nervous system and consists of the brain (in vertebrates which have them), and the spinal cord.

The meninges (singular meninx) is the system of membranes which envelops the central nervous system. The meninges consist of three layers: the dura mater, the arachnoid mater, and the pia mater. The primary function of the meninges and of the cerebrospinal fluid is to protect the central nervous system. The space between these membranes is bathed with a spinal fluid much like lymph, which serves as a protective cushion for the delicate nerve tissue, and allows some expansion space for the brain when its blood supply is increased.

3 layers of meninges: •

Dura mater - (also rarely called meninx fibrosa, or pachymeninx) is a thick, durable membrane, closest to the skull. It consists of two layers, the periosteal layer, closest to the calvaria and the inner meningeal layer. It contains larger blood vessels which split into the capilliaries in the pia mater. It is composed of dense fibrous tissue, and its inner surface is covered by flattened cells like those present on the surfaces of the pia mater and arachnoid. The dura mater is a sac which envelops the arachnoid and has been modified to serve several functions. The dura mater surrounds and supports the large venous channels (dural sinuses) carrying blood from the brain toward the heart.

The falx cerebri separates the hemispheres of the cerebrum. The falx cerebelli separates the lobes of the cerebellum. The tentorium cerebelli separates the cerebrum from the cerebellum. The epidural space is a potential space between the dura mater and the skull. If there is hemorrhaging in the brain, blood may collect here. Adults are more likely than children to bleed here as a result of closed head injury.

The subdural space is another potential space. It is between the dura mater and the middle layer of the meninges, the arachnoid mater. When bleeding occurs in the cranium, blood may collect here and push down on the lower layers of the meninges. If bleeding continues, brain damage will result from this pressure. Children are especially likely to have bleeding in the subdural space in cases of head injury.

•

Arachnoid mater - The middle element of the meninges is the arachnoid membrane, so named because of its spider web-like appearance. It provides a cushioning effect for the central nervous system. The arachnoid mater exists as a thin, transparent membrane. It is composed of fibrous tissue and, like the pia mater, is covered by flat cells also thought to be impermeable to fluid. The arachnoid does not follow the convolutions of the surface of the brain and so looks like a loosely fitting sac. In the region of the brain, particularly, a large number of fine filaments called arachnoid trabeculae pass from the arachnoid through the subarachnoid space to blend with the tissue of the pia mater.

The

arachnoid

and

pia

mater

are

sometimes

together

called

the

leptomeninges. The subarachanoid space lies between the arachnoid and pia mater. It is filled with cerebrospinal fluid. All blood vessels entering the brain, as well as cranial nerves pass through this space. The term arachnoid refers to the spider web like appearance of the blood vessels within the space.

• Pia mater - The pia or pia mater is a very delicate membrane. It is the meningeal envelope which firmly adheres to the surface of the brain and spinal cord. As such it follows all the minor contours of the brain (gyri and sulci). It is a very thin membrane composed of fibrous tissue covered on its outer surface by a sheet of flat cells thought to be impermeable to fluid. The pia mater is pierced by blood vessels which travel to the brain and spinal cord, and its capillaries are responsible for nourishing the brain.

Cerebrospinal fluid - is a clear liquid produced within spaces in the brain called ventricles. Like saliva it is a filtrate of blood. It is also found inside the subarachnoid space of the meninges which surrounds both the brain and the spinal chord. In addition, a space inside the spinal chord called the central canal also contains cerebrospinal fluid. It acts as a cushion for the neuraxis, also bringing nutrients to the brain and spinal cord and removing waste from the system. Choroid Plexus All of the ventricles contain choroid plexuses which produce cerebrospinal fluid by allowing certain components of blood to enter the ventricles. The choroid plexuses are formed by the fusion of the pia mater, the most internal layer of the meninges and the ependyma, the lining of the ventricles. The Ventricles These four spaces are filled with cerebrospinal fluid and protect the brain by cushioning it and supporting its weight. The two lateral ventricles extend across a large area of the brain. The anterior horns of these structures are located in the frontal lobes. They extend posteriorly into the parietal lobes and their inferior horns are found in the temporal lobes. The third ventricle lies between the two thalamic bodies. The massa intermedia passes through it and the hypothalamus forms its floor and part of its lateral walls. The fourth ventricle is located between the cerebellum and the pons. The four ventricles are connected to one another. The two foramina of Munro, which are also know as the interventricular foramina, link the lateral ventricles to the third ventricle. The Aqueduct of Sylvius which is also called the cerebral aqueduct connects the third and fourth ventricles.

The fourth ventricle is connected to the subarachnoid space via two lateral foramina of Luschka and by one medial foramen of Magendie.

ANATOMY OF THE CNS BRAIN The center of the nervous system. The brain is located in the head, protected by the skull and close to the primary sensory apparatus of vision, hearing, balance, taste, and smell.

• The frontal lobe is concerned with higher intellectual functions, such as abstract thought and reason, speech (Broca's area in the left hemisphere only), olfaction, and emotion. Voluntary movement is controlled in the precentral gyrus (the primary motor area). •

The parietal lobe is dedicated to sensory awareness, particularly in the postcentral gyrus (the primary sensory area). It is also concernes with abstract reasoning, language interpretation and formation of a mental egocentric map of the surrounding area.

•

The occipital lobe is responsible for interpretation and processing of visual stimuli from the optic nerves, and association of these stimuli with other nervous imputs and memories.

•

The temporal lobe is concerned with emotional development and formation, and also contains the auditory area responsible for processing

and discrimination of sound. It is also the area thought to be responsible for the formation and processing of memories. The brain can be subdivided into several distinct regions: 1. Brainstem – consists of medulla oblongata, pons and midbrain. • Medulla oblongata - is the lower portion of the brainstem. It deals with autonomic functions, such as breathing and blood pressure. The cardiac center is the part of the medulla oblongata responsible for controlling the heart rate. • Pons - relays sensory information between the cerebellum and cerebrum; aids in relaying other messages in the brain; controls arousal, and regulates respiration (see respiratory centres). In some theories, the pons has a role in dreaming.

• Midbrain (mesencephalon) - The mesencephalon is considered part of the brain stem. Its substantia nigra is closely associated with motor system pathways of the basal ganglia. The human mesencephalon is archipallian in origin, meaning its general architecture is shared with the most ancient of vertebrates. Dopamine produced in the substantia nigra plays a role in motivation and habituation of species from humans to the most elementary animals such as insects.

1. Cerebellum - is a region of the brain that plays an important role in the integration of sensory perception, coordination and motor control. In order to coordinate motor control, there are many neural pathways linking the cerebellum with the cerebral motor cortex (which sends information to the muscles causing them to move) and the spinocerebellar tract (which provides proprioceptive feedback on the position of the body in space). The cerebellum integrates these pathways, like a train conductor, using the constant feedback on body position to fine-tune motor movements.

2. Diencephalon - (or interbrain) is the region of the brain that includes the thalamus, hypothalamus, epithalamus, prethalamus or subthalamus and pretectum. The diencephalon is located at the midline of the brain, above the mesencephalon of the brain stem. The diencephalon contains the zona

limitans intrathalamica as morphological boundary and signalling center between the prethalamus and the thalamus.

•

Thalamus - plays an important role in regulating states of sleep and wakefulness. Thalamic nuclei have strong reciprocal connections with the cerebral cortex, forming thalamo-cortico-thalamic circuits that are believed to be involved with consciousness. The thalamus plays a major role in regulating arousal, the level of awareness, and activity. Damage to the thalamus can lead to permanent coma.

•

Epithalamus – is a dorsal posterior segment of the diencephalon (a segment in the middle of the brain also containing the hypothalamus and the thalamus) which includes the habenula, the stria medullaris and the pineal body. Its function is the connection between the limbic system to other parts of the brain.

•

Hypothalamus - is a small part of the brain located just below the thalamus on both sides of the third ventricle. Lesions of the hypothalamus interfere with several vegetative functions and some so called motivated behaviors like sexuality, combativeness, and hunger. The hypothalamus also plays a role in emotion. Specifically, the lateral parts seem to be involved with pleasure and rage, while the medial part is linked to aversion, displeasure, and a tendency to uncontrollable

and

loud

laughing.

However,

in

general

the

hypothalamus has more to do with the expression of emotions 1. Cerebrum - or top portion of the brain, is divided by a deep crevice, called the longitudinal sulcus. The longitudinal sulcus separates the cerebrum in to the right and left hemispheres. In the hemispheres you will find the cerebral cortex, basal ganglia and the limbic system. The two hemispheres are connected by a bundle of nerve fibers called the corpus callosum. The right hemisphere is responsible for the left side of the body while the opposite is true of the left hemisphere.

PHYSIOLOGY OF THE CNS Medulla

The medulla is the control center for respiratory, cardiovascular and digestive functions. Pons The pons houses the control centers for respiration and inhibitory functions. Here it will interact with the cerebellum. Cerebrum The cerebrum, or top portion of the brain, is divided by a deep crevice, called the longitudinal sulcus. The longitudinal sulcus separates the cerebrum in to the right and left hemispheres. In the hemispheres you will find the cerebral cortex, basal ganglia and the limbic system. The two hemispheres are connected by a bundle of nerve fibers called the corpus callosum. The right hemisphere is responsible for the left side of the body while the opposite is true of the left hemisphere. Each of the two hemispheres are divided into four separated lobes: the frontal in control of specialized motor control, learning, planning and speech; parietal in control of somatic sensory functions; occipital in control of vision; and temporal lobes which consists of hearing centers and some speech. Located deep to the temporal lobe of the cerebrum is the insula. Cerebellum The cerebellum is the part of the brain that is located posterior to the medulla oblongata and pons. It coordinates skeletal muscles to produce smooth, graceful motions. The cerebellum receives information from our eyes, ears, muscles,

and

joints

about

what

position

our

body

is

currently

in

(proprioception). It also receives output from the cerebral cortex about where these

parts

should

be.

After

processing

this

information, the cerebellum sends motor impulses from the brainstem to the skeletal muscles. The main function of the cerebellum is coordination. The cerebellum is also responsible for balance and posture. It also assists us when we are learning a new motor skill, such as playing a sport or musical instrument.

The Limbic System

The Limbic System is a complex set of structures found just beneath the cerebrum and on both sides of the thalamus. It combines higher mental functions, and primitive emotion, into one system. It is often referred to as the emotional nervous system. It is not only responsible for our emotional lives, but also our higher mental functions, such as learning and formation of memories. The Limbic system explains why some things seem so pleasurable to us, such as eating and why some medical conditions are caused by mental stress, such as high blood pressure. There are two significant structures within the limbic system and several smaller structures that are important as well. They are:

1. The Hippocampus 2. The Amygdala 3. The Thalamus 4. The Hypothalamus 5. The Fornix and Parahippocampus 6. The Cingulate Gyrus

Structures of the Limbic System

Hippocampus The Hippocampus is found deep in the temporal lobe, shaped like a seahorse. It consists of two horns that curve back from the amygdala. It is situated in the brain so as to make the prefrontal area aware of our past experiences stored in that area. The prefrontal area of the brain consults this structure to use memories to modify our behavior. The hippocampus is responsible for memory.

Amygdala The

Amygdala

is

a

little

almond

shaped

structure,

deep

inside

the

anteroinferior region of the temporal lobe, connects with the hippocampus, the septi nuclei, the prefrontal area and the medial dorsal nucleus of the thalamus. These connections make it possible for the amygdala to play its important role on the mediation and control of such activities and feelings as love, friendship, affection, and expression of mood. The amygdala is the center for identification of danger and is fundamental for self preservation. The amygdala is the nucleus responsible for fear.

Thalamus Lesions or stimulation of the medial, dorsal, and anterior nuclei of the thalamus are associated with changes in emotional reactivity. However, the importance of these nuclei on the regulation of emotional behavior is not due to the thalamus itself, but to the connections of these nuclei with other limbic system structures. The medial dorsal nucleus makes connections with cortical zones of the prefrontal area and with the hypothalamus. The anterior nuclei connect with the mamillary bodies and through them, via fornix, with the hippocampus and the cingulated gyrus, thus taking part in what is known as the Papez's circuit.

Hypothalamus The Hypothalamus is a small part of the brain located just below the thalamus on both sides of the third ventricle. Lesions of the hypothalamus interfere with several vegetative functions and some so called motivated behaviors like sexuality, combativeness, and hunger. The hypothalamus also plays a role in emotion. Specifically, the lateral parts seem to be involved with pleasure and rage, while the medial part is linked to aversion, displeasure, and a tendency to uncontrollable and loud laughing. However, in general the hypothalamus has more to do with the expression of emotions. When the physical symptoms of

emotion appear, the threat they pose returns, via the hypothalamus, to the limbic centers and then the prefrontal nuclei, increasing anxiety.

The Fornix and Parahippocampal These small structures are important connecting pathways for the limbic system.

The Cingulate Gyrus The Cingulate Gyrus is located in the medial side of the brain between the cingulated sulcus and the corpus callosum. There is still much to be learned about this gyrus, but it is already known that its frontal part coordinates smells and sights, with pleasant memories of previous emotions. The region participates in the emotional reaction to pain and in the regulation of aggressive behavior.

Memory and Learning Memory is defined as: The mental faculty of retaining and recalling past experiences, the act or instance of remembering recollection. Learning takes place when we retain and utilize past memories.

Overall, the mechanisms of memory are not completely understood. Brain areas such as the hippocampus, the amygdala, the striatum, or the mammillary bodies are thought to be involved in specific types of memory. For example, the hippocampus is believed to be involved in spatial learning and declarative learning (learning information such as what you're reading now), while the amygdala is thought to be involved in emotional memory. Damage to certain areas in patients and animal models and subsequent memory deficits is a primary source of information. However, rather than implicating a specific area, it could be that damage to adjacent areas, or to a pathway traveling

through the area is actually responsible for the observed deficit. Further, it is not sufficient to describe memory, and its counterpart, learning, as solely dependent on specific brain regions. Learning and memory are attributed to changes in neuronal synapses, thought to be mediated by long-term potentiation and long-term depression.

There are three basic types of memory: 1. Sensory Memory 2. Short Term Memory 3. Long Term Memory

Sensory Memory The sensory memories act as a buffer for stimuli through senses. A sensory memory retains an exact copy of what is seen or heard: iconic memory for visual, echoic memory for aural and haptic memory for touch. Information is passed from sensory memory into short term memory. Some believe it lasts only 300 milliseconds, it has unlimited capacity. Selective attention determines what information moves from sensory memory to short term memory.

Short Term Memory Short Term Memory acts as a scratch pad for temporary recall of the information under process. For instance, in order to understand this sentence you need to hold in your mind the beginning of the sentence as you read the rest. Short term memory decays rapidly and also has a limited capacity. Chunking of information can lead to an increase in the short term memory capacity, this is the reason why a hyphenated phone number is easier to remember than a single long number. The successful formation of a chunk is known as closure. Interference often causes disturbance in short term memory retention. This accounts for the desire to complete a task held in short term memory as soon as possible.

Within short term memory there are three basic operations: 1. Iconic memory - the ability to hold visual images 2. Acoustic memory - the ability to hold sounds. Can be held longer than iconic. 3. Working memory - an active process to keep it until it is put to use. Note that the goal is not really to move the information from short term memory to long term memory, but merely to put it to immediate use.

The process of transferring information from short term to long term memory involves the encoding or consolidation of information. This is not a function of time, that is, the longer the memory stays in the short term the more likely it is to be placed in the long term memory. On organizing complex information in short term before it can be encoded into the long term memory, in this process the meaningfulness or emotional content of an item may play a greater role in its retention in the long term memory. The limbic system sets up local reverberating circuits such as the Papaz's Circuit.

Long Term Memory Long Term Memory is used for storage of information over a long time. Information from short to long term memory is transferred after a short period. Unlike short term memory, long term memory has little decay. Long term potential is an enhanced response at the synapse within the hippocampus. It is essential to memory storage. The limbic system isn't directly involved in long term memory necessarily but it selects them from short term memory, consolidates these memories by playing them like a continuous tape, and involves the hippocampus and amygdala.

There are two types of long term memory: 1. Episodic Memory

2. Semantic Memory

Episodic memory represents our memory of events and experiences in a serial form. It is from this memory that we can reconstruct the actual events that took place at a given point in our lives. Semantic memory, on the other hand, is a structured record of facts, concepts, and skills that we have acquired. The information in the semantic memory is derived from our own episode memory, such as that we can learn new facts or concepts from experiences.

There are three main activities that are related to long term memory: 1. Storage 2. Deletion 3. Retrieval

Information for short term memory is stored in long term memory by rehearsal. The repeated exposure to a stimulus or the rehearsal of a piece of information transfers it into long term memory. Experiments also suggest that learning is most effective if it is distributed over time. Deletion is mainly caused by decay and interference. Emotional factors also affect long term memory. However, it is debatable whether we actually ever forget anything or whether it just sometimes becomes increasingly difficult to retrieve it. Information may not be recalled sometimes but may be recognized, or may be recalled only with prompting. This leads us to the third operation of memory, information retrieval.

There are two types of information retrieval: 1. Recall 2. Recognition

In recall, the information is reproduced from memory. In recognition the presentation of the information provides the knowledge that the information has been seen before. Recognition is of lesser complexity, as the information is provided as a cue. However, the recall may be assisted by the provision of retrieval cues which enable the subject to quickly access the information in memory. ANATOMY OF THE PNS

The peripheral nervous system includes 12 cranial nerves 31 pairs of spinal nerves. It can be subdivided into the somatic and autonomic systems. It is a way of communication from the central nervous system to the rest of the body by nerve impulses that regulate the functions of the human body.

The twelve cranial nerves are I Olfactory Nerve for smell

II Optic Nerve for vision III Oculomotor for looking around IV Trochlear for moving eye V Trigeminal for feeling touch on face VI Abducens to move eye muscles VII Facial to smile, wink, and help us taste VIII Vestibulocochlear to help with balance, equilibrium, and hearing IX Glossopharengeal for swallowing and gagging X Vagus for swallowing, talking, and parasympathetic actions of digestion XI Spinal accessory for shrugging shoulders XII Hypoglossal for tongue more divided into different regions as muscles

The 10 out of the 12 cranial nerves originate from the brainstem, and mainly control the functions of the anatomic structures of the head with some exceptions. CN X receives visceral sensory information from the thorax and abdomen, and CN XI is responsible for innervating the sternocleidomastoid and trapezius muscles, neither of which is exclusively in the head.

Spinal nerves take their origins from the spinal cord. They control the functions of the rest of the body. In humans, there are 31 pairs of spinal nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal. The naming convention for spinal nerves is to name it after the vertebra immediately above it. Thus the fourth thoracic nerve originates just below the fourth thoracic vertebra. This convention breaks down in the cervical spine. The first spinal nerve originates above the first cervical vertebra and is called C1. This continues down to the last cervical spinal nerve, C8. There are only 7 cervical vertebrae and 8 cervical spinal nerves.

Peripheral nervous system The PNS is a regional term for the collective nervous structures that do not lie in the CNS. The bodies of the nerve cells lie in the CNS, either in the brain or the spinal cord, and the longer of the cellular processes of these cells, known as axons, extend through the limbs and the flesh of the torso. The large majority of the axons which are commonly called nerves, are considered to be PNS. The peripheral nervous system (PNS) resides or extends outside the central nervous system (CNS), which consists of the brain and spinal cord. The main function of the PNS is to connect the CNS to the limbs and organs. Unlike the central nervous system, the PNS is not protected by bone or by the blood-brain barrier, leaving it exposed to toxins and mechanical injuries. The peripheral nervous system is divided into the somatic nervous system and the autonomic nervous system.

Physiological division A less anatomical but much more functional way of dividing the human nervous system is classification according to the role that the different neural pathways play, regardless of whether or not they cross through the CNS/PNS:

•

The somatic nervous system is responsible for coordinating voluntary body movements (i.e. activities that are under conscious control).

•

The

autonomic

nervous

system

is

responsible

for

coordinating

involuntary functions, such as breathing and digestion.

In turn, these divisions of the nervous system can be further divided according to the direction in which they conduct nerve impulses:

•

Afferent system by sensory neurons, which carries impulses from a somatic receptor to the CNS

•

Efferent system by motor neurons, which carries impulses from the CNS to an effector

•

Relay system by interneurons (also called "relay neurons"), which transmit impulses between the sensory and motor neurons (both in the CNS and PNS).

•

The junction between two neurons is called a synapse. There is a very narrow gap (about 20nm in width) between the neurons called the synaptic cleft. This is where an action potential (the "message" being carried by the neurons, also known as the nerve impulse) is transmitted from one neuron to the next. This is achieved by relaying the message across the synaptic cleft using neurotransmitters, which diffuse across the gap. The neurotransmitters then bind to receptor sites on the neighboring (postsynaptic) neuron, which in turn produces its own electrical/nerve impulse. This impulse is sent to the next synapse, and the cycle repeats itself.

•

Nerve impulses are a change in ion balance between the inside and outside of a neuron. Because the nervous system uses a combination of electrical and chemical signals, it is incredibly fast. Although the chemical aspect of signaling is much slower than the electrical aspect, a nerve impulse is still fast enough for the reaction time to be negligible in day to day situations. Speed is a necessary characteristic in order for an organism to quickly identify the presence of danger, and thus avoid injury/death. For example, a hand touching a hot stove. If the nervous system was only comprised of chemical signals, the nervous system would not be able to signal the arm to move fast enough to escape dangerous

burns.

Thus,

the

speed

of

the

nervous

evolutionarily valuable, and is in fact a necessity for life.

The Somatic System

system

is

The somatic nervous system is that part of the peripheral nervous system associated with the voluntary control of body movements through the action of skeletal muscles, and also reception of external stimuli. The somatic nervous system consists of afferent fibers that receive information from external sources, and efferent fibers that are responsible for muscle contraction. The somatic system includes the pathways from the skin and skeletal muscles to the Central Nervous System. It is also described as involved with activities that involve consciousness.

The basic route of the efferent somatic nervous system includes a two neuron sequence. The first is the upper motor neuron, whose cell body is located in the precentral gyrus (Brodman Area 4) of the brain. It receives stimuli from this area to control skeletal (voluntary) muscle. The upper motor neuron carries this stimulus down the corticospinal tract and synapses in the ventral horn of the spinal cord with the alpha motor neuron, a lower motor neuron. The upper motor neuron releases acetylcholine from its axon terminal knobs and these are received by nicotinic receptors on the alpha motor neuron. The alpha motor neurons cell body sends the stimulus down its axon via the ventral root of the spinal cord and proceeds to its neuromuscular junction of its skeletal muscle. There, it releases acetylcholine from its axon terminal knobs to the muscles nicotinic receptors, resulting in stimulus to contract the muscle. The somatic system includes all the neurons connected with the muscles, sense organs and skin. It deals with sensory information and controls the movement of the body. The Autonomic System The Autonomic system deals with the visceral organs, like the heart, stomach, gland, and the intestines. It regulates systems that are unconsciously carried out to keep our body alive and well, such as breathing, digestion (peristalsis), and regulation of the heartbeat. The Autonomic system consists of the sympathetic and the parasympathetic divisions. Both divisions work without conscious effort, and they have similar nerve pathways, but the sympathetic and parasympathetic systems generally have opposite effects on target tissues

(they are antagonistic). By controlling the relative input from each division, the autonomic system regulates many aspects of homeostasis. One of the main nerves for the parasympathetic autonomic system is Cranial Nerve X, the Vagus nerve. Ten out of the twelve cranial nerves originate from the brainstem, and mainly control the functions of the anatomic structures of the head with some exceptions. The nuclei of cranial nerves I and II lie in the forebrain and thalamus, respectively, and are thus not considered to be true cranial nerves. CN X (10) receives visceral sensory information from the thorax and abdomen, and CN XI (11) is responsible for innervating the sternocleidomastoid and trapezius muscles, neither of which is exclusively in the head. Spinal nerves take their origins from the spinal cord. They control the functions of the rest of the body. In humans, there are 31 pairs of spinal nerves: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal. In the cervical region, the spinal nerve roots come out above the corresponding vertebrae (i.e. nerve root between the skull and 1st cervical vertebrae is called spinal nerve C1). From the thoracic region to the coccygeal region, the spinal nerve roots come out below the corresponding vertebrae. It is important to note that this method creates a problem when naming the spinal nerve root between C7 and T1 (so it is called spinal nerve root C8). In the lumbar and sacral region, the spinal nerve roots travel within the dural sac and they travel below the level of L2 as the cauda equina.

Cervical spinal nerves (C1-C4) The first 4 cervical spinal nerves, C1 through C4, split and recombine to produce a variety of nerves that subserve the neck and back of head. Spinal nerve C1 is called the suboccipital nerve which provides motor innervation to muscles at the base of the skull. C2 and C3 form many of the nerves of the neck, providing both sensory and motor control. These include the greater occipital nerve which provides sensation to the back of the head, the lesser occipital nerve which provides sensation to the area behind the ears, the greater auricular nerve and the lesser auricular nerve. See occipital

neuralgia. The phrenic nerve arises from nerve roots C3, C4 and C5. It innervates the diaphragm, enabling breathing. If the spinal cord is transected above C3, then spontaneous breathing is not possible. Brachial plexus (C5-T1) The last four cervical spinal nerves, C5 through C8, and the first thoracic spinal nerve, T1,combine to form the brachial plexus, or plexus brachialis, a tangled array of nerves, splitting, combining and recombining, to form the nerves that subserve the arm and upper back. Although the brachial plexus may appear tangled, it is highly organized and predictable, with little variation between people. Neurotransmitters The main neurotransmitters of the peripheral nervous system are acetylcholine and noradrenaline. However, there are several other neurotransmitters as well, jointly

labeled

Non-noradrenergic,

non-cholinergic

(NANC)

transmitters.

Examples of such transmitters include non-peptides: ATP, GABA, dopamine, NO, and peptides: neuropeptide Y, VIP, GnRH, Substance P and CGRP.

The Sympathetic System

The Sympathetic Division The sympathetic nervous system activates what is often termed the fight or flight response, as it is most active under sudden stressful circumstances (such as being attacked). This response is also known as sympathetico-adrenal response of the body, as the pre-ganglionic sympathetic fibers that end in the adrenal medulla (but also all other sympathetic fibers) secrete acetylcholine, which activates the secretion of adrenaline (epinephrine) and to a lesser extent noradrenaline (norepinephrine) from it. Therefore, this response that acts primarily on the cardiovascular system is mediated directly via impulses transmitted through the sympathetic nervous system and indirectly via catecholamines secreted from the adrenal medulla.

Neurons Neurons are electrically excitable cells in the nervous system that process and transmit information. Neurons are the core components of the brain, the vertebrate spinal cord, the invertebrate ventral nerve cord, and the peripheral nerves. A number of different types of neurons exist: sensory neurons respond to touch, sound, light and numerous other stimuli effecting sensory organs and send signals to the spinal cord and brain, motor neurons receive signals from the brain and spinal cord and cause muscle contractions and affect glands, Interneurons connect neurons to other neurons within the brain and spinal cord. There are three types of directions of the neurons: •

Sensory system by sensory neurons, between the sensory and motor neurons. However, there are relay neurons in the CNS as well.

•

By function, the peripheral nervous system is divided into the somatic nervous system, autonomic nervous system and the enteric nervous system. The somatic nervous system is responsible for coordinating the body movements, and also for receiving external stimuli. It is the system that regulates activities that are under conscious control. The autonomic nervous

system

is

then

split

into

the

sympathetic

division,

parasympathetic division, and enteric division. The sympathetic nervous system responds to impending danger or stress, and is responsible for the increase of one's heartbeat and blood pressure, among other physiological changes, along with the sense of excitement one feels due to the increase of adrenaline in the system. The parasympathetic nervous system, on the other hand, is evident when a person is resting and feels relaxed, and is responsible for such things as the constriction of the pupil, the slowing of the heart, the dilation of the blood vessels, and the stimulation of the digestive and genitourinary systems. The role of the enteric nervous system is to manage every aspect of digestion, from the esophagus to the stomach, small intestine and colon.

Glial cells

Glial cells are non-neuronal cells that provide support and nutrition, maintain homeostasis, form myelin, and participate in signal transmission in the nervous system. In the human brain, glia are estimated to outnumber neurons by about 10 to 1.

Glial cells provide support and protection for neurons. They are thus known as the "glue" of the nervous system. The four main functions of glial cells are to surround neurons and hold them in place, to supply nutrients and oxygen to neurons, to insulate one neuron from another, and to destroy pathogens and remove dead neurons.

Organization Sympathetic nerves originate inside the vertebral column, toward the middle of the spinal cord in the intermediolateral cell column (or lateral horn), beginning at the first thoracic segment of the spinal cord and extending into the second or third lumbar segments. Because its cells begin in the thoracic and lumbar regions of the spinal cord, the SNS is said to have a thoracolumbar outflow. Axons of these nerves leave the spinal cord in the ventral branches (rami) of the spinal nerves, and then separate out as 'white rami' (so called from the shiny white sheaths of myelin around each axon) which connect to two chain ganglia extending alongside the vertebral column on the left and right. These elongated ganglia are also known as paravertebral ganglia or sympathetic trunks. In these hubs, connections (synapses) are made which then distribute the nerves to major organs, glands, and other parts of the body.

In order to reach the target organs and glands, the axons must travel long distances in the body, and, to accomplish this, many axons link up with the axon of a second cell. The ends of the axons do not make direct contact, but rather link across a space, the synapse.

In the SNS and other components of the peripheral nervous system, these synapses are made at sites called ganglia. The cell that sends its fiber is called a preganglionic cell, while the cell whose fiber leaves the ganglion is called a postganglionic cell. As mentioned previously, the preganglionic cells of the SNS are located between the first thoracic segment and the second or third lumbar segments of the spinal cord. Postganglionic cells have their cell bodies in the ganglia and send their axons to target organs or glands.

The ganglia include not just the sympathetic trunks but also the superior cervical ganglion (which sends sympathetic nerve fibers to the head), and the celiac and mesenteric ganglia (which send sympathetic fibers to the gut).

Relationship to sympathetic While an oversimplification, it is said that the parasympathetic system acts in a reciprocal manner to the effects of the sympathetic nervous system; in fact, in some tissues innervated by both systems, the effects are synergistic.

The Parasympathetic Division

The parasympathetic nervous system is part of the autonomic nervous system. Sometimes called the rest and digest system or feed and breed. The parasympathetic system conserves energy as it slows the heart rate, increases intestinal

and

gland

activity,

and

relaxes

sphincter

muscles

in

the

gastrointestinal tract.

Receptors The parasympathetic nervous system uses only acetylcholine (ACh) as its neurotransmitter. The ACh acts on two types of receptors, the muscarinic and nicotinic cholinergic receptors. Most transmissions occur in two stages: When

stimulated, the preganglionic nerve releases ACh at the ganglion, which acts on nicotinic receptors of the postganglionic nerve. The postganglionic nerve then releases ACh to stimulate the muscarinic receptors of the target organ.

The three main types of muscarinic receptors that are well characterised are: •

The M1 muscarinic receptors are located in the neural system.

•

The M2 muscarinic receptors are located in the heart, and act to bring the heart back to normal after the actions of the sympathetic nervous system: slowing down the heart rate, reducing contractile forces of the atrial

cardiac

muscle,

and

reducing

conduction

velocity

of

the

atrioventricular node (AV node). Note, they have no effect on the contractile forces of the ventricular muscle. •

The M3 muscarinic receptors are located at many places in the body, such as the smooth muscles of the blood vessels, as well as the lungs, which means that they cause vasoconstriction and bronchoconstriction. They are also in the smooth muscles of the gastrointestinal tract (GIT), which help in increasing intestinal motility and dilating sphincters. The M3 receptors are also located in many glands that help to stimulate secretion in salivary glands and other glands of the body.

Nervous Tissue The nervous system coordinates the activity of the muscles, monitors the organs, constructs and also stops input from the senses, and initiates actions. Prominent participants in a nervous system include neurons and nerves, which play roles in such coordination.Our nervous tissue only consists of two types of cells. These cells are neurons and neuroglia cells. The neurons are responsible for transmitting nerve impulses. Neuroglia cells are responsible for supporting and nourishing the neuron cells. Types of neurons

There are three types of neurons in the body. We have sensory neurons, interneurons, and motor neurons. Neurons are a major class of cells in the nervous system. Neurons are sometimes called nerve cells, though this term is technically imprecise, as many neurons do not form nerves. In vertebrates, neurons are found in the brain, the spinal cord and in the nerves and ganglia of the peripheral nervous system. Their main role is to process and transmit information. Neurons have excitable membranes, which allow them to generate and propagate electrical impulses. Sensory neuron takes nerve impulses or messages right from the sensory receptor and delivers it to the central nervous system. A sensory receptor is a structure that can find any kind of change in it's surroundings or environment.

Structure of a neuron Neurons have three different parts to them. They all have an axon, a cell body and dendrites. The axon is the part of the neuron that conducts nerve impulses. Axons can get to be quite long. When an axon is present in nerves, it

is called a nerve fiber. A cell body has a nucleous and it also has other organelles. The dendrites are the short pieces that come off of the cell body that receive the signals from sensory receptors and other neurons.

Myelin Sheath Schwann cells contain a lipid substance called myelin in their plasma membranes. When schwann cells wrap around axons, a myelin sheath forms. There are gaps that have no myelin sheath around them; these gaps are called nodes of Ranvier. Myelin sheathes make excellent insulators. Axons that are longer have a myelin sheath, while shorter axons do not. The disease multiple sclerosis is an autoimmune disease where the body attacks the myelin sheath of the central nervous system.

Information transmission Messages travel through the SNS in a bidirectional flow. Efferent messages can trigger changes in different parts of the body simultaneously. For example, the sympathetic nervous system can accelerate heart rate; widen bronchial passages; decrease motility (movement) of the large intestine; constrict blood vessels; increase peristalsis in the esophagus; cause pupil dilation, piloerection (goose bumps) and perspiration (sweating); and raise blood pressure. Afferent messages carry sensations such as heat, cold, or pain.

The first synapse (in the sympathetic chain) is mediated by nicotinic receptors physiologically activated by acetylcholine, and the target synapse is mediated by adrenergic receptors physiologically activated by either noradrenaline or adrenaline. An exception is with sweat glands which receive sympathetic innervation but have muscarinic acetylcholine receptors which are normally characteristic of PNS. Another exception is with certain deep muscle blood vessels, which have acetylcholine receptors and which dilate (rather than constrict) with an increase in sympathetic tone. The sympathetic system cell bodies are located on the spinal cord excluding the cranial and sacral regions.

The preganglonic neurons exit from the vertebral column and synapse with the postganglonic nerouns in the sympathetic trunk.

The parasympathetic nervous system is one of three divisions of the autonomic nervous

system.

Sometimes

called

the

rest

and

digest

system,

the

parasympathetic system conserves energy as it slows the heart rate, increases intestinal

and

gland

activity,

and

relaxes

sphincter

muscles

in

the

gastrointestinal tract.

Precipitataing factors Predisposing Factors: Age (1 year old)

Male high incidence

Malnutrition Weight=6.7kg below normal

Low economic Status (P400/day)

Immature immune system Low immune response

Decrease quantity and quality of food

Crowded environment (5members, 25sq m)

High risk for contagious or communicable disease

Invasion of microorganisms to nasopharyngeal area (nisserea meningitides)

Colonization of microorganisms Stiffening of the neck Meningeal Vomiting 7.17.09-7.23.09 irritation 7.14.09

fever

Neutrophils bind to cerebral Bulging Inflammatory fontanelle responce endothelial cell of blood brain Disrupts level of Congestion of Cerebralof Release Increase Obstruction Formation of Release Release ofof toxic of Increase permeability 07.17-07.23.09 barrier blood brainendotoxins barrier Infection Invasion Microorganism Hematogenous to leads the to subarachnoid systemic enter spread systemic affection space surrounding tissues edema Increase ICP lymphocytes .63 Inflammation of meninges adhesion CSF flow products of bloodcytokines brain barrier

Set the Increase body hypothalamus Increase basal Release of temperature center metabolic rate interleukins

Release of Increase histamine and vascular serotonin permeability

SYNTHESIS OF THE DISEASE DEFINITION OF THE DISEASE Tuberculous meningoencephalitis,

(TB) as

meningitis it

affects

is not

correctly only

characterized

meninges

but

also

as

a

brain

parenchyma and vasculature. The primary pathologic event is formation of thick TB exudate within subarachnoid space, most prominently at the base of the brain. Accompanying this exudate is inflammation affecting adjacent blood vessels. Ischemic cerebral infarction, resulting from vascular occlusion, is a common sequela most often found in the distribution of the middle cerebral

artery (reflecting presence of TB exudate within sylvian fissure) and striate arteries as they penetrate the base of the brain. Another characteristic feature of TB meningitis is hydrocephalus secondary to CSF dynamic disturbance. TB meningitis is divided into three clinical stages: Stage

I (early)

Neurologic syndrome Nonspecific (e.g., generalized malaise) Lethargy

II

Meningismus

(intermediate)

Moderate focal neurologic deficits (e.g., cranial nerve palsies) Seizures

III (advanced)

Severe neurologic deficits (e.g., paresis) Stupor or coma

Tuberculous meningitis is also known as TB meningitis or tubercular meningitis. Tuberculous meningitis is Mycobacterium tuberculosis infection of the meninges—the system of membranes which envelops the central nervous system. It is the most common form of CNS tuberculosis. Fever and headache are the cardinal features. Confusion is a late feature and coma bears a poor prognosis. Meningism is absent in a fifth of patients with TB meningitis. Patients may also have focal neurological deficits. Causes are Tension headaches are due to contraction (tightness) of the muscles in your shoulders, neck, scalp, and jaw. They are often related to stress, depression, or anxiety. Overworking, not getting enough sleep, missing meals, and using alcohol or street drugs can make you more susceptible to headaches. Foods that can trigger a headache include chocolate, cheese, and monosodium glutamate (MSG), a flavor enhancer. People who drink caffeine can have headaches when they don't get their usual daily amount.

Mycobacterium tuberculosis of the meninges is the cardinal feature and the inflammation is concentrated towards the base of the brain. Infection begins in the lungs and may spread to the meninges by a variety of routes. Predisposing factors: •

Not completing the childhood vaccine schedule increases your risk of meningitis

•

Age. People that are too young or too old are prone to develop meningitis due to immature or weakened state of immune system. Most cases of meningitis occur in children below 5 years old(about 70%).

•

Compromised Immune system. People with underdeveloped immune systems are susceptible to any infection. Since the immune system is immature, it cannot readily defend itself from invasion thus baby’s are required to drink breast milk because the mother at that point transfers her immunoglobulins to the baby thus strengthening the immune system while babies who rely on bottle milk have lower immunity.

•

Sex. Male (95% of cases) are more prone to meningitis than to female.

•

Newborns and infants are at a higher risk of contracting certain types of bacterial meningitis, not only because they are more commonly exposed to some of the bacteria, but also because they may not yet have received

all

the

preventive

immunizations.

Infant

meningitis

is

frequently attributed to Group B streptococcus infections or exposure to E.coli or listeria in milk or food products Precipitating Factors a. Low Economic Status (contractual salary of Php 200/day) – usually those who can’t afford a healthy diet are in relation to malnutrition are susceptible to develop meningitis b. Crowded area (5 members living in one house of 25 sq. meters) – close proximity in congested areas is a contributing factor of meningitis due to easy transmission of disease c. Malnutrition – people are susceptible to infection due to lack of energy production and immune-builders

Signs and Symptoms 1. Fever and leukocytosis (an increase in the number of WBC’s) – are the initial signs and symptoms of a systemic reactions caused by inflammation. WBC increases as the body respond to the invasion within the host. 2. Nuchal rigidity – due to the invasion of microbes in the meninges. 3. Elevated CSF protein – infection or inflammatory process that interrupts the blood-brain barrier increases protein because there is greater diffusion. 4. Increase intracranial pressure (vomiting) – may occur with an increase in CSF volume, blood entering the CSF, cerebral edema, space-occupying lesion such as trauma, hydrocephalus, infection, Guillain-Barrie Syndrome (vomiting is triggered by the activation of CTZ in the medulla this a forceful reflux of gastric content out through the oral cavity) 5. Increase head circumference, bulging fontanels – due to increase intracranial pressure secondary to the inflammation of the meninges.

1. NURSING MANAGEMENT (ACTUAL SOAPIERS) July 17, 2009 SOAPIE S: “Apat neng aldo e tatakla” verbalized by the SO. O: Received patient cuddled by his mother with an ongoing IVF of D5 0.3 NaCl 500 cc regulated @ 41-42 ugtts/min @ 400 cc level infusing well on his right hand; skin is warm to touch; with poor skin turgor; with upward rolling of the eye balls; with hypoactive bowel sounds; VS taken and recorded as follow: T: 36.9°C; PR: 123 bpm; RR: 33cpm. A: Constipation related to irregular defecation habits as evidenced by hypoactive bowel sounds. P: The significant others will be able to verbalize understanding of etiology and appropriate intervention/solutions for individual situations. I: > Established rapport. ‘> Assessed patient general conditions.

‘> Reviewed medical history often associated with constipation. ‘> Reviewed clients medications. ‘> Palpated abdomen for presence of distention, masses. ‘> Checked rectum for presence of fecal impaction. ‘> Discussed usual elimination habits and problems ‘> Auscultated abdomen for presence, location, and characteristics of bowel sounds. ‘Change position q 2° E: Goal met as evidenced by the significant others will be able to verbalized understanding of etiology and appropriate intervention/solutions for individual situations. July 18, 2009 SOAPIE S: “Medyo kumukulobot ang balat nya” verbalized by the mother. O: Received patient awake, cuddled by his mother, with an IVF of D5IMB 500 cc regulated at 16-17 ugtts/min at 400cc level infusing well on his left foot with poor skin turgor, dry skin, no lesions, and with mild involuntary shaking. VS taken and recorded as follows: T: 37.2; PR: 127 bpm: RR: 38 cpm. A: Impaired skin integrity related to poor skin turgor secondary to dehydration. P: After 4° of nursing interventions the SO will participate in prevention measures and treatment program. I: > Established rapport. ‘> Assessed patients general condition. ‘> Monitored skin color, texture and turgor ‘> Noted presence of compromised vision, hearing or speech. ‘> Repositioned patient every 2 hours.

‘> Reviewed importance of skin and measures to maintain proper skin functioning. ‘> Assisted the SO in understanding and following medical regimen and developing program of preventive care and daily maintenance. ‘> Stressed the importance of proper hygiene. ‘> Due meds given. E: Goal met as evidenced by the SO able to participate in prevention measures and treatment program. July 23, 2009 SOAPIE S: “Magumpisa nabengi melagnat ne” as verbalized by the mother. O: Received patient on bed, awake with chills, with on-going IVF of D5IMB 500 cc regulated at 10-17 ugtts/min, 400cc level infusing well on his left foot; skin is warm to touch, with flushed skin, with poor skin turgor; with muscle rigidity. VS taken and recorded as follows: T: 38.6°C; RR: 124 bpm; RR: 39 cpm. A: Hyperthermia P: After 4° of nursing interventions the patient will maintain care temperature within normal range. I:> Established rapport. ‘> Assessed general condition. ‘> Identified underlying cause. ‘> Noted chronological and development age of the client. ‘> Monitored core temperature. ‘> Assessed neurological response. ‘> Monitored heart rate and rhythm. ‘> Monitored respirations.

‘> Auscultated breath sounds. ‘> Monitored/recorded all source of fluid loss such as urine. ‘> TSB done. ‘> Noted presence and absence of weaning. ‘> Promoted surface cooling by means of undressing. ‘> Administered medications as ordered. ‘> Promoted client safety. ‘> Maintained bed rest. ‘> Due medications given. E: Goal met as evidenced by the patient will able to maintained core temperature within normal range.

DOCTOR’S ORDER July 17, 2009 Problem: Seizure Wt= 6.7kg July 18, 2009 Afebrile (-) seizure (+) bulging fontanelle ➢ -Please admit pedia ward under yellow service ➢ -TPR q shift ➢ -NPO except meds

Dx: •

Complete Blood Count with Platelet count

•

Serum Na, K, Ca

•

Urinalysis

•

FCA

•

CXR AP/L)

IVF: D5 0.3 NaCl 500cc @ 41-42mggts/min t/c CNS infection probably meningitis with AGE with some Dehydration ➢ -Penicillin G 500,000U q 6 hours.

July 19, 2009 July 20, 2009 Afebrile Bulging fontanelle July 20, 2009 OPTHA NOTES Dx seen Opthaklmic exam done findings EDNS glossy eyeball, equal, white conjunctiva, clear cornea, clear lens, 3mm papillary round. Fundoscopy A. unremarkable fundoscopic examination at the time of exam ➢ Follow up for electrolyte test ➢ Follow up for chest x-ray ➢ Still for cranial ultrasound ➢ Refer to ophthalmologist ➢ Still for CT Scan ➢ IVF: D5IMB 500cc @ 16-17mgtts.min ➢ Insert NGT

July 21, 2009 July 22, 2009

July 23, 2009 SURGERY NOTES Pt seen and examined and is being referred for neuroevaluation Patient is awake Afebrile No seizure episode Pink palpebral conjuctiva Clear bowel sounds No immediate surgical interventions needed at the time of exam TB Meningitis with communicating hydrocephalus ➢ Insert NGT ➢ For Cranial Ct Scan ➢ For Ct Scan ➢ Reinsert NGT ➢ Vs q 1 hour ➢ Carry out giving of streptomycin as previously ordered ➢ Mainitain IVF ➢ Follow up for Ct Scan ➢ Refer for Neuroscan For issuance of clinical abstract

Days

1 07.17.0 9

2 07.18.0 9

3 07.23.0 9

Nursing Problems Hyperthermia

•

Constipation

•

Impaired skin integrity r/t

poor

skin

secondary

•

turgor to

dehydration Impaired skin integrity r/t

poor

skin

secondary

•

•

•

turgor to

dehydration Delayed

growth

development

r/t

&

•

impaired

nutrition Sleep pattern disturbances related to increase body temperature

•

Vital signs Temperature

36.9˚C

37.2˚C

38.6˚C

Pulse Rate

123bp

127bp

124bp

m

m

m

33cpm

38cpm

39cpm

Respiratory Rate Dx. Test Hemoglobin

104

–

normal Hematocrit

0.31

–

lower than normal

NOTE: Nsg. Prob: •

= presence

Meds: •

= taken/done

VII. CONCLUSIONS The central nervous system is of vital importance to sustain one’s life, since it coordinates the activities of all parts of the body. It is covered and protected by the meninges. So if these meninges would fail to function, a person’s health would be at serious risk. Meningitis is such a condition, and it is a fairly common illness that affects lots of children. The severity of the illness

will depend on the type of infection causing the disease, as well as the overall health of the person who has it. Outbreaks of meningitis can be a major health problem in the community, especially when they occur in schools. A vaccine is available and is recommended for those living in tight quarters, such as dormitories. Considering that prevention is better than the cure, this could significantly reduce morbidity and mortality. And since it is common in the Philippines, the group decided to focus on the interventions that could be rendered for the clients as well as to give health teachings on how to prevent the occurrence of the said disease. The group wanted to contribute in some ways in order to minimize the increasing number of children who are infected through interventions and health teachings. RECOMMENDATIONS Surgery is very much recommended, but considering the parents’ financial capabilities, it might not be performed unless it would be included in their hospital bill. With that in mind, health teachings should be directed towards maintaining the patient’s protocol for treatment, specifically the use of antibiotics, since they have been known to reduce the death rate to less than 5% for all types of bacterial meningitis. It should also be stressed to the patient’s parents that if untreated, their child’s condition could be fatal within days. With regards to nutrition, adequate fluid and electrolyte balance must be maintained while adhering to the indicated diet. There should be a focus on IVF fluids while the patient is on NPO status until he is able to feed through NGT or OGT. Neurologic status should also be frequently assessed as indicated to detect early manifestations of increasing ICP and seizures. Anticonvulsants may be prescribed for seizure prevention.

BIBLIOGRAPHY •

Seeley, Stephens & Tate. Essentials of Anatomy and Physiology. (Fifth Edition). Mc. Graw Hill Co. Inc., 2005.

•

Robert S. Feldman, Understanding Psychology. (Seventh Edition). Mc.GrawHill Co. Inc., 2005

•

Amy M. Karch. Nursing Drug Guide. 2009 Lippincotts William and Wilkins

•

George R. Spratto. Adrienne L. Woods. Nurse’s Drug Handbook. (2008 edition)

•

Kozier. Fundamentals of Nursing: Concepts, Process and Practice. (Eighth edition). Pearson education Inc., 2008.

•

Adelle Pillitteri. Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. (Fifth edition). Lippincotts William and Wilkins 2008

•

Doenges, Marilynn E. Nursing Care Plans: Guidelines for Individualizing Patient Care. (6th edition). F.A. Davis Co., 2002.

•

Bacterial Meningitis two hours by Ria Rose Celis/2006

•

Dengue Hemorrhagic fever grade 3 by Emmanuel yambao02007

•

Acyte myecolytic leukemia by jenalyn Cao02005

Internet source: http://www.pdfcoke.com http://pediatrics.about.com/cs/commoninfections/a/meningitis.htm http://www.mims.com

SOCIOGRAM July 17, 18 & 23, 2009

LEGEND

ALNEIL ANTONIO

PATIENT RICHELL GUTIERREZ

MALE ALEXIS STUDENT NURSE MANALAC

CLINICAL INSTRUCTOR

FEMALE STUDENT NURSE

OTHER STUDENT NURSES KEVINDIRECT DIYCO CONTACT INDIRECT CONTACT

GIAN DAVE CANLAS (patient)

OTHER STUDENT NURSES