Gbs Sinco Mark

SURIGAO EDUCATION CENTER Km. 2, National Highway Surigao City

College of Allied Medical Sciences

GUILLAIN BARRE SYNDROME A CASE PRESENTATION

Presented by:

Presented to:

Alberto, Kyra Czarelle O. Arlan, Arwela Jane Bansag, Girlie Bordas, Regie R. Caerlang, Kimberly Y. Dagamihan, Edwin Jr. Espinile, Kathleen Gonzales, Gazilyn P. Gruyal, Gienette Claire B. Jurcales, Yvonne V. Manlimos, Dan Warren N. Paelmar, Cheenee Rose R. Segura, Jheril E. Suazo, Marichu L.

Mary Claire C. Urag, RN Teresita P. Adobas, RN Frederick Jones Perez, RN Bonifacio Salmayor, RN Christine Sykimte, RN Aida Manto, RN Edcel Paler, RN, USRN Rhea Mesias, RN Rocelyn Dawsan, RN Tracy Paula Catelo, RN Vivian Ceryn Cabuga, RN Jeanith Muñoz, RN

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TABLE OF CONTENTS • • • • •

•

Dedication Acknowledgement Introduction Review of Related Literature Patient’s History  Biographic data (Patient’s Profile)  Admission Data  History of Present Illness  Past Health History  Child illness  Immunizations (records)  History of hospitalizations  Family health history √ Lifestyle √ Personal habits √ Diet √ Sleep and Rest Patterns √ Elimination Pattern √ Activities of Daily Living (ADL)  Social Data  Environmental Data  Psychologic data  Patterns of Health Care Physical Assessment and Review of Systems  General Survey  Vital Signs  Integumentary System  Hair  Nails  Head  Eyes and Vision  Ears and Hearing  Nose and Sinuses  Oropharynx (mouth and throat)  Neck  Breast and Axillae  Abdomen  Extremities  Musculoskeletal System  Respiratory System  Cardiovascular System  Genitourinary System 2

•

• • • • •

 Neurologic System  Mental Status √ Language √ Orientation √ Memory √ Level of Consciousness  Cranial Nerves I – XII Laboratory Data  Hematology  Urine Analysis  Electrolytes Anatomy and Physiology Pathology and Physiology of the disease  Detailed discussion of the schematic diagram  Schematic diagram (landscape format) Drug Study Nursing Care Plan (NCP) Discharge Plan (detailed)  Medication  Exercise  Treatment Regimen  Out patient follow up check up  Diet  Spiritual

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DEDICATION

We heartily dedicate this Case Presentation to the following:

To our families and loved ones, especially our parents. You are our constant source of strength and inspiration.

To our dutiful Clinical Instructors. May your passion for teaching never fades.

And to the Heavenly Father. We offer this product of our hard work to you dear Lord.

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ACKNOWLEDGEMENT

Bringing about a Case Presentation is no easy task. Certainly, this Case Presentation would not have been possible without the aid of some people. We extend our sincerest gratitude to the following:

To our families and loved ones, for their unconditional love and support. Mere words cannot convey our unending gratitude.

To our Clinical Instructors, for the knowledge, skills and attitude that they have imparted on us.

To all the people who may have knowingly or unknowingly contributed to the fulfillment of this Case Presentation.

And most importantly, we thank the most Gracious Heavenly Father who makes all things possible.

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INTRODUCTION Guillain-Barre Syndrome is a neuromuscular autoimmune disorder wherein the body’s own immune system attacks the peripheral nerves that convey sensory information (e.g., pain, temperature) from the body to the brain and motor (i.e., movement) signals from the brain to the body. It is a rare condition occurring once in every 100,000 people per year but it is one of the leading causes of non-trauma induced paralysis in the world. Exactly what triggers Guillain-Barre syndrome is unknown and it may occur at any age but is most common among young adults and the elderly. The condition is often preceded by either a viral or bacterial infection of the lungs or gastrointestinal tract. Signs of the original infection have already disappeared before the symptoms of Guillain-Barre begin. People with GBS usually have muscle weakness or paralysis that starts in the legs and feet. It progresses up toward the arms and head. Sometimes the weakness starts in the arms and moves downward. Occasionally, it starts in the arms and legs at the same time. The spread from feet to head can occur within 24 to 72 hours but can take longer. Mild cases of Guillain-Barre syndrome may present only with ataxia (difficulty in walking and balancing), whereas severe cases may present with difficulty in respiration due to paralysis of the respiratory muscles and cranial nerves. Treatment for Guillain-Barre Syndrome consists of supportive care, ventilatory management (in about one third of patients), and specific therapy with intravenous immunoglobulin or plasmapheresis. However, each case of Guillain-Barre' Syndrome is different. It is important to realize that the complications and therefore treatments of Guillain-Barre' syndrome are not predictable. For the most part, treatments are highly individualized. Our patient is Mr. C, a seventeen year old first year high school student of Loreto National High School. He was admitted last September 25, 2009 at the Caraga Regional Hospital after being referred by the Loreto District Hospital. His chief complaint upon admission was sudden onset of weakness on both legs. Guillain-Barre Syndrome is a serious disorder requiring prompt medical attention which can even be a medical emergency. However, most Filipinos have not even heard of such a condition. Yes, it is a rare condition, but more and more Filipinos are struck by it. Hence, our group decided to present this case with the earnest intention to acquire sufficient and accurate information about the disorder for us to be able to play our part on the prevention of the said disorder through information dissemination. As 6

future nurses, we understand the indispensable role of health promotion in the prevention of diseases.

REVIEW OF RELATED LITERATURE Guillain-Barré syndrome (GBS) causes progressive muscle weakness and paralysis (the complete inability to use a particular muscle or muscle group), which develops over days or up to four weeks, and lasts several weeks or even months. Description The classic scenario in GBS involves a patient who has just recovered from a typical, seemingly uncomplicated viral infection. Symptoms of muscle weakness appear one to four weeks later. The most common preceding infections are cytomegalovirus, herpes, Epstein-Barr virus, and viral hepatitis. A gastrointestinal infection with the bacteria Campylobacter jejuni is also common and may cause a severe type of GBS from which it is particularly difficult to recover. About 5% of GBS patients have a surgical procedure as a preceding event. Patients with lymphoma, systemic lupus erythematosus, or AIDS have a higher than normal risk of GBS. Other GBS patients have recently received an immunization, while still others have no known preceding event. In 1976–77, there was a vastly increased number of GBS cases among people who had been recently vaccinated against the Swine flu. The reason for this phenomenon has never been identified, and no other flu vaccine has caused such an increase in GBS cases. GBS can be divided into types on the basis of the type of destruction caused. If the myelin sheath (described below, see figure 1) insulating an axon is damaged or destroyed, the nerve signals through the axon are disrupted or slowed down, causing symptoms such as abnormal sensations and weakness. This inflammation is the demyelinising type, and the process is called primary demyelination. In the axonal type, the nerve axon itself is destroyed in a process called secondary demyelination. This is said to occur in patients who experience a very violent inflammation phase. If the axon dies, the nerve signal is blocked, and cannot be transmitted further. This causes weakness and paralysis in the body area controlled by the nerve. The axonal type occurs most frequently after preceding diarrhoea. It may be responsible for a less favourable prognosis (outcome), as axons regenerate after a long delay compared to the myelin sheath, which heals faster. There are however some kinds of axonal types that have a more favourable prognosis.

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The mixed type destroys both axons and myelin. Long-term paralysis in some GBS patients is thought to be caused by permanent damage to both axons and myelin sheaths. Peripheral nerves and spinal roots are the major sites of demyelination, but cranial nerves may also be involved. Destruction of nerve insulation The immune system's attack on the peripheral nerve cells starts a chain reaction: The immune system is responsible for the production of special proteins, the antibodies or immunoglobulins (Ig), as part of the body's normal defence mechanism. These antibodies are produced in reaction to the presence of antigens, or introduced particles in the body, such as various bacteria and vira. Antibodies match specific antigens, and when the two come in contact, they bind together and a number of destructive reactions occur. In GBS patients, antibodies are somehow produced against myelin. They circulate in the blood seeking myelin, which is found in nerve cells. Nerve cells have long, thin extensions called axons, that transmit signals between nerve cells. Some axons are surrounded by a myelin sheath, a little like electrical cables are surrounded by plastic. The myelin sheath insulates and protects the nerve cells. It also increases both the speed and the distance over which nerve signals can be transmitted. For example, signals from the brain to muscles are transmitted at a speed of over 50 km/h!

Fig.1: Longitudinal section of an axon and its myelin sheath. The axon is part of nerve cell 1, stretching toward nerve cell 2. The myelin sheath resembles tape, wrapped around the axon in several layers.

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Myelin does not cover the axon in an uninterrupted tube, like an electrical cable. Instead, it resembles long beads on a string, with space between the beads (see figure above). The spaces are known as Ranvier Nodes. Axons are uncovered between these nodes of Ranvier and are therefore vulnerable to attack here.

The nerve signals transmitted are also delayed a little at the nodes, and the more nodes there are, the slower the signal becomes. This fact is important when understanding recovery - increased numbers of Ranvier nodes may be produced during nerve recovery, slowing signal transmission. The myelin-attacking antibodies produced in the GBS patient circulate in the blood and eventually find myelin. They attack and destroy it with the help of white blood cells, producing inflammation in the nerves. The inflamed cells in turn secrete chemicals that affect the Schwann cells. These cells produce the fatty materials required to produce myelin. Affecting Schwann cells reduces myelin production, and some of them may even die, further reducing myelin production, while at the same time the existing myelin is destroyed by the antibodies. As the attack progresses, the peripheral nerve network is gradually destroyed. Motor, sensory or autonomic nerves are attacked, signals are slowed down, blocked or disrupted and the patient's body is affected accordingly. If the signal transmission speed of a motor nerve is reduced, the patient experiences weakness in the body area controlled by the nerve. If the signal speed is reduced further, or blocked, the patient can become paralysed. Similarly, attacks on sensory or autonomic nerves result in disturbances of the organs hooked up to the nerves. Simultaneously, the patient's brain receives fewer signals from the body, and these may be disrupted. This results in parts of the body feeling numb, as well as strange sensations of pain, tingling, and pins and needles. Signals to and from the arms and legs must travel furthest from the brain and spinal cord, and are therefore most susceptible to a barrage of disturbances while en route. This is why hands and feet are usually the first body areas that display GBS symptoms. Attack on the peripheral nerves All the nerves in the human body, with the exception of the brain and spinal cord, belong to the peripheral group of nerves. i.e. the peripheral nervous system comprises most of the cranial nerves and the spinal nerves (sensory, motor, autonomic, and mixed).

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The peripheral nerves transmit signals from the brain and spinal cord to, and from, the muscles, organs and skin. Depending on their function, the nerves can be classified as motor, sensory and autonomous (involuntary) peripheral nerves. When the immune system malfunctions temporarily and GBS sets in, an attack is launched on the peripheral nerves, damaging them. This causes sensory disturbances, progressive weakening and/or acute paralysis. Metaphorically speaking, the nervous system short-circuits. Exactly how the nerves are damaged is described below. Only the peripheral nervous system is affected, which is why GBS is also known as "peripheral neuropathy". Causes and symptoms The cause of the weakness and paralysis of GBS is the loss of myelin, which is the material that coats nerve cells (the loss of myelin is called demyelination). Myelin is an insulating substance which is wrapped around nerves in the body, serving to speed conduction of nerve impulses. Without myelin, nerve conduction slows or stops. GBS has a short, severe course. It causes inflammation and destruction of the myelin sheath, and it disturbs multiple nerves. Therefore, it is considered an acute inflammatory demyelinating polyneuropathy. The reason for the destruction of myelin in GBS is unknown, although it is thought that the underlying problem is autoimmune in nature. An autoimmune disorder is one in which the body's immune system, trained to fight against such foreign invaders as viruses and bacteria, somehow becomes improperly programmed. The immune system becomes confused, and is not able to distinguish between foreign invaders and the body itself. Elements of the immune system are unleashed against areas of the body, resulting in damage and destruction. For some reason, in the case of GBS, the myelin sheath appears to become a target for the body's own immune system. The first symptoms of GBS consist of muscle weakness (legs first, then arms, then face), accompanied by prickly, tingling sensations (paresthesias). Symptoms affect both sides of the body simultaneously, a characteristic that helps distinguish GBS from other causes of weakness and paresthesias. Normal reflexes are first diminished, then lost. The weakness eventually affects all the voluntary muscles, resulting in paralysis. When those muscles necessary for breathing become paralyzed, the patient must be placed on a mechanical ventilator which takes over the function of breathing. This occurs about 30% of the time. Very severely ill GBS patients may have complications stemming from other nervous system abnormalities which can result in problems with fluid balance in the body, severely fluctuating blood pressure, and heart rhythm irregularities. Diagnosis Diagnosis of GBS is made by looking for a particular cluster of symptoms (progressively worse muscle weakness and then paralysis), and by examining the fluid that bathes the brain and spinal canal through cerebrospinal fluid (CSF) analysis. This fluid is obtained by inserting a needle into the lower back (lumbar region). When examined in a 10

laboratory, the CSF of a GBS patient will reveal a greater-than-normal quantity of protein, with normal numbers of white blood cells and a normal amount of sugar. Electrodiagnostic studies may show slowing or block of conduction in nerve endings in parts of the body other than the brain. Minor abnormalities will be present in 90% of patients.

Diagnostic tests Lumbar Puncture A needle is inserted in between the bones of the lower back into the fluid around the spinal cord. A small amount of spinal fluid is taken and the protein level is tested. In GBS, the protein level is usually increased. Electromyogram (EMG or Electromyography) A thin-needle electrode is inserted into the muscle to be tested and electrodes are placed on the skin over peripheral nerves. This test helps to determine if the peripheral nerves are not communicating between the brains and muscles in the body. Nerve Conduction Study (NCS) Two electrodes are taped to the skin in the affected area of the patient's body. A small shock is then passed through to measure the electrical impulses from one electrode to the other. This test records how long it takes for the electrical impulse to travel from one electrode to another. If the impulse is slow, it suggests nerve damage Treatment There is no direct treatment for GBS. Instead, treatments are used that support the patient with the disabilities caused by the disease. The progress of paralysis must be carefully monitored, in order to provide mechanical assistance for breathing if it becomes necessary. Careful attention must also be paid to the amount of fluid the patient is taking in by drinking and eliminating by urinating. Blood pressure, heart rate, and heart rhythm also must be monitored. A procedure called plasmapheresis, performed early in the course of GBS, has been shown to shorten the course and severity of GBS. Plasmapheresis consists of withdrawing the patient's blood, passing it through an instrument that separates the different types of blood cells, and returning all the cellular components (red and white blood cells and platelets) along with either donor plasma or a manufactured 11

replacement solution. This is thought to rid the blood of the substances that are attacking the patient's myelin. It has also been shown that the use of high doses of immunoglobulin given intravenously (by drip through a needle in a vein) may be just as helpful as plasmapheresis. Immunoglobulin is a substance naturally manufactured by the body's immune system in response to various threats. It is interesting to note that corticosteroid medications (such as prednisone), often the mainstay of anti-autoimmune disease treatment, are not only unhelpful, but may in fact be harmful to patients with GBS. Prognosis About 85% of GBS patients make reasonably good recoveries. However, 30% of adult patients, and a greater percentage of children, never fully regain their previous level of muscle strength. Some of these patients suffer from residual weakness, others from permanent paralysis. About 10% of GBS patients begin to improve, then suffer a relapse. These patients suffer chronic GBS symptoms. About 5% of all GBS patients die, most from cardiac rhythm disturbances. Patients with certain characteristics tend to have a worse outcome. These include people of older age, those who required breathing support with a mechanical ventilator, and those who had their worst symptoms within the first seven days. Prevention Because so little is known about what causes GBS to develop, there are no known methods of prevention.

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ASSESSMENT Nursing Health History Hospital Ward service Name of Patient Age Sex Birth date Nationality Address Religion Height Weight Admitting date and time Attending Physician Chief complaint Admission diagnosis Principal diagnosis

: : : : : : : : : : : : : : : :

Vital Signs upon Admission: T = 36.3°C P = 89 bpm R = 19 cpm BP = 110/70 mmHg

IBW = 118

Caraga Regional Hospital Pedia Ward - Misc Mr. C 17 years old Male October 21, 1993 Filipino Esperanza, Loreto, Province of Dinagat Island IFI 5’2” feet 47 kgs (103.61 lbs) September 25, 2009 (10:25 am) Dr. Asodisen Sudden onset of weakness on both legs Guillain barre syndrome Guillain barre syndrome Date of Assessment: September 29, 2009 Vital Signs during Assessment: T = 36.7°C P = 88 bpm R = 20 cpm BP= 110/70 mmHg

118 13

BMI

-10

+10

129

- 128 lbs

patient is only 103.61 lbs, therefore patient is underweight

= weight (in kgs) / height (in m)2 = 47 kg / (1.585 m)2 = 47 / 2.51 = 18.72

patient’s BMI is normal NURSING HEALTH HISTORY

Date of Assessment: September 29- October 1, 2009 (date of duty) Source of information: Patient and his mother HISTORY OF PRESENT ILLNESS One (1) month prior to hospitalization, Mr. C stated that he experienced abdominal cramps and diarrhea for 2 days. A week after, he suffered on and off lower back pain which he described as “morag gitusok” (sharp pain) than lasted for about a week. When the pain abated, it was replaced by a sudden tingling “pins and needle” sensation on both feet which he noticed to worsen during rest periods. Thinking that it was only an effect of a frequent 4-km walk to and from school, Mr. C just massaged the area with herbal oils. Two days passed the tingling sensation disappeared but was replaced with numbness, weakness and eventually loss of sensation not only on his feet but also on both of his lower legs. It ascended to his pelvic area in two days time. Mr. C can neither stand nor walk due to such condition. As people who believe in folk practitioners’ healing powers, Mr. C’s family sought advice from the local “manghihilot” who massaged the affected area with his own-made mixture of herbs. The latter believed that Mr. C’s condition is caused by “buyag sa engkanto”. They also asked help from a “mantayhopay” who gave the same impression. Mr. C and his mother followed the instructions of the said persons such as soaking his feet with“nilagang sambong” every morning and at night before sleeping for about nine (9) days. Hospitalization was not possible during the said span of time because of financial constraints. One day prior to hospitalization, our patient was seen by his mother crying on his bedroom. His mother stated “morag nag-wild ang akong anak…nagsinggit singgit ug hilak kay gusto na magpahospital kay nahadlok na siya nga dili makalakaw pagbalik…” 14

That incident prompted the family to bring their son to Loreto District Hospital that day but was referred directly to Caraga Regional Hospital for further assessment and management. Mr. C was admitted to Caraga Regional Hospital last September 25, 2009 at exactly 10:25 am for complaints of weakness on both legs and pelvic area. Upon confinement, the doctor prescribed the following: • • •

IVF D5IMB100 @ 25 gtts/min Vitamin B complex 1 cap OD Hydrocortisone 100mg IVTT q80

Laboratory tests were also ordered by the attending physician such as: • • • •

Hematology Electrolytes Urinalysis Lumbar puncture

PAST HEALTH HISTORY History of Hospitalization Mr. C claimed that he has not been admitted to any hospital before for whatever illness or disease. Childhood Illnesses Mr. C experienced having measles when he was three years old and chicken pox when he was on his 4th grade. He did not have any history of poliomyelitis and rubella. Immunizations Her mother said that his son (Mr. C) don’t have childhood immunization such as DPT, OPV, Hepatitis A, Hepatitis B, Influenza and MMR except for BCG. Allergy He claimed to have no allergy on certain foods, drugs, animals and other environmental agents. 15

Family Health History According to the patient, they don’t have any history of this kind of health condition. Mr. C’s maternal grandfather has arthritis and his grandmother has cataract on the right eye. On his paternal side, both his deceased grandparents died of kidney problem with generalized edema. His 56 year old father complains of episodes of joint pains while his mother who is 43 years old claimed to have no health problems except for occasional cough, colds and fever which can be relieved by over the counter drugs such as biogesic, neozep, carbocisteine and paracetamol. Among the four siblings, he is the only one diagnosed with Guillain Barre Syndrome. SURGICAL HISTORY: As claimed by his mother, the patient has not yet undergone any invasive surgical procedure.

PERSONAL AND SOCIAL HISTORY

LIFESTYLE: Personal Habits Mr. C used to enjoy strolling together with his other gay friends every night. His early morning task was to feed their native chicken in their backyard. He also stated that he loves to cook, clean their house and read novels. He claimed that he doesn’t drink hard liquors, smoke or use recreational drugs Diet Before hospitalization, our patient’s regular diet was 2 cups of rice, fish and vegetables. His mother told us that the patient was fond of eating “kinilaw” whenever they can buy fish. He preferred eating raw fish “kinilaw” with vinegar than cooked. He eats 3 large meals a day and drinks 5-6 glasses of water. Her mother also stated that his son is fond of eating raw egg with salt every morning. During hospitalization, the patient claimed that his appetite is as good as before. 16

Sleep and Rest Pattern Our patient usually sleeps at around 9:00pm and wakes up at 5:00 in the morning to prepare for school. During hospitalization, he spends most of the time sleeping during the day because of weakness and boredom. However at night time, he reported that he has trouble sleeping because of the noise of other patient’s watchers and bright light. Elimination Pattern Before hospitalization our patient defecates everyday and urinates three to four times a day. During the appearance of the symptoms, he only defecated once a week. During hospitalization, he never defecated until he was inserted rectally with a suppository (bisacodyl pedia). He has hard and well formed yellow-colored feces. During defecation, he is usually carried and assisted by his father to the comfort room. His mother reported that Mr. C experienced urinary incontinence. Subsequently, we have observed his pants to be wet with urine during assessment. Activities of Daily Living Before hospitalization, the patient did not experience any difficulties in the basic activities of eating, grooming, dressing, elimination and locomotion. During hospitalization, he always needs help from his mother and father in eating, dressing, grooming, elimination and locomotion. SOCIAL DATA The patient and his family are followers of IFI (Iglesia Filipina Independiente). Our patient is known to be a gay. He is friendly and very close to his brother and sisters. Usually, they would wake up early morning and would wait for their hens to lay eggs. They would eat those eggs raw with salt. Mr. C believed of “engkanto”. The “quack doctors” they consulted had the belief on how the patient got the disease. All said that the disease was given by the “engkanto” or “gibuyagan”. The patient and his family also believed that a person with fever or other illnesses should not take a bath because it will aggravate the disease. Our patient is a first year high school student of Loreto National High School. During this hospitalization, he has not gone to school due to his illness. 17

ENVIRONMENTAL DATA The patient’s house is situated just beside the street in Esperanza Loreto Dinagat Island. Their house is made of wood and nipa with fruit trees shading the house. Their house has only one (1) bedroom and their CR is situated outside their house. It is well ventilated, clean and spacious. Their source of drinking water is from a common government faucet shared by the whole sitio. They have ornamental and herbal plants in front of their house. They also have poultry in their backyard. The patient and his family usually used herbal plants as alternative medicine such as guava for diarrhea, helbas for abdominal pain, lemon grass and carabo for cough. However, they are also fond of buying over the counter drugs such as Biogesic, Neozep, Kremil-s, and Paracetamol as the need arises. PSYCHOLOGIC DATA The patient’s major stressor was his disease and sometimes if he is scolded by his mother. In addition, it makes him feel rejected when teased by his peers as “bayot” that exacerbated when his feminine gait became more pronounced as one of the early signs and symptoms of Guillain Barre Syndrome began to manifest (gait changes). PATTERNS OF HEALTH CARE Their family is not Philhealth members. Whenever a member got ill, they usually sought help from “tambayon”,”mantayhopay” and “manghihilot”. They only seek medical attention whenever the condition cannot be treated by the said folk healers. DEVELOPMENTAL TASK According to Erick Erickson, a 17 year old person’s developmental task is identity versus role confusion. During this stage, a person attempts to find his/her own identity, struggle with social interactions, and grapple with moral issues. The task is to discover his/her true identity as individual separate from family of origin and as member of a wider society. In our case, our patient is unsuccessful in navigating this stage because he was being interrupted by his disease. His world focused mainly on his disease and family members. He is constantly confused as to why it suddenly happened to him. Being dependent to his parents, aloof to her peers and without own identity will be the most probable outcome. He will most probably experience role confusion and upheaval. In Freud’s psychosexual development, our patient will likely be fixated in the genital phase. As a 17 year-old boy, he is concerned about body image, “crushes” – romantic idealization and develops a strong interest in the same sex since he claimed to be homosexual. However, he finds it difficult to express such interest because of his 18

health condition especially that the disease had caused him to compulsory stay in the house. During this stage also, there is an increase comparison of oneself to the peer group that further resulted in negative self-appraisals that cause lower self-esteem and poor self-worth. Unpleasant comments from peers as to why he got the disease also contributed to the possible genital phase fixation.

PHYSICAL ASSESSMENT Vital Signs during Assessment : September 29, 2009 T = 36.7°C P = 88 bpm R = 20 cpm BP= 110/70 mmHg

September 30, 2009 T = 36.8°C P = 90 bpm R = 19 cpm BP= 110/70 mmHg

October 1, 2009 T = 36.8°C P = 90 bpm R = 20 cpm BP= 110/70 mmHg

GENERAL SURVEY: • • • • • • •

Patient lies quietly on bed in a left lateral position with head elevated with 1 pillow, awake, conscious and coherent Ongoing IVF solution of D5IMB300 running at 25gtts/min, hooked at right dorsal metacarpal vein, infused well Patient appeared weak and pale Poor hygiene and grooming noted Patient wears loose clothing Patient cannot move his lower extremities Patient is cooperative

SKIN • • • • • •

Generalized pallor skin noted Scars from chicken pox noted on the abdomen part Skin is dry Diaphoresis noted Crusted lesions noted at the left dorsalis pedis, right knee and at the right big toe Good skin turgor

HAIR • Hair color is brown 19

• • •

Thin and dry hair Not properly combed No lice infestation noted

NAILS • • •

Nails are convex with an angle at about 160 degrees Untrimmed dirty nails With intact epidermis surrounding the nail

• •

Prompt return of pink or usual color (blanch capillary refill of 2 seconds) Nail texture is smooth

SKULL AND FACE • • • • • •

Normocephallic and symmetrical with frontal, parietal, and occipital prominences Symmetric facial features Symmetric facial movements Dandruff noted Smooth skull contour Absence of nodules or masses upon palpation

EYES AND VISION • • • • • • • • • • • •

Hair in eyebrows are evenly distributed Eyebrows are symmetrically aligned and move equally Eyelashes equally distributed and slightly curled outward Pupil equally round and reactive to light and accommodation Normal bilateral involuntary blinking Non-icteric sclerae Shiny, and pink palpebral conjunctiva noted upon inspection No edema noted around the eyes Patient blinks when cornea is touched indicating trigeminal nerve is intact Pupils constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is moved toward nose Both eyes coordinated, move in unison with parallel alignment Able to read printed materials

EARS AND HEARING •

Auricles same color as facial skin, symmetrical and are aligned with outer canthus of eye 20

• • • • •

Dry cerumen Able to hear spoken words clearly Able to hear watch ticking in both ears Pinna is mobile, firm and not tender Pinna recoils after it is folded

NOSE • Nose has the same color as facial skin • No discharge or flaring • Air moves freely as the client breathes through the nares • Not tender; No lesion noted MOUTH AND THROAT • • • • • • • •

Lips are dry and pale Lips are symmetrical Plaques on teeth noted Tongue moves freely and no tenderness noted Tongue in central position Halitosis noted Gag reflex is intact and present Pink and smooth tonsils of normal size

NECK • • • • •

Neck muscles equal in size; head centered Head movement is coordinated and with no discomfort Head can hyperextend, flexes and rotates normally Neck muscles has equal strength No palpable lymph nodes

THORAX & LUNGS • • • • • •

Chest is symmetric Spine vertically aligned Spinal column is straight, shoulders and hips are at the same height Chest wall intact With full and symmetric chest expansion No tenderness and masses noted

ABDOMEN • Skin in the abdomen is uniformly pale in color 21

• •

Flat abdominal contour observed hypoactive bowel sounds heard during auscultation

UPPER EXTREMITIES Inspection • Able to flex and extend arms • Normal Biceps reflex (++) • Normal Triceps reflex (++) Palpation • Immediate return of color upon Capillary refill test LOWER EXTREMITIES Inspection • Unable to flex and extend legs • Positive westphal’s sign noted • Positive babinski reflex Palpation • Non-pitting bipedal edema noted • Pedal pulse is present upon palpation • Immediate return of color upon Capillary refill test

NEUROLOGIC TEST • • • • • •

Oriented to date, time and place Displays normal non-verbal and verbal communication Able to recall word being said a while ago to him. Bicep and tricep reflexes are hypoactive Positive westphal’s sign noted Level of Consciousness; Glasgow Coma Scale.

Faculty Measured Eye opening Motor Response

Response Spontaneous To verbal command To pain No Response To verbal command To localized pain Flexes and withdraw Flexes abnormally

Score 4 3 2 1 6 5 4 3

22

Verbal response

•

Extends abnormally No response Oriented, converses Disoriented, converses Uses inappropriate words Make incomprehensible sounds No response

2 1 5 4 3 2 1

Total score of 14 out of 15 possible highest score.

Cranial Nerves Assessment Cranial nerves I II

III

Types

Function

Olfactory

Sensory

Smell

Optic

Sensory

Vision and visual acuity

Oculomotor

IV

Trochlear

V

Trigeminal; Ophthalmic Branch Maxillary Branch

Motor

Extraocular eye movement. Movement of sphincter of pupil.

Motor

EOM; specifically moves eyeball downward and laterally.

Sensory Motor

Sensation of cornea, skin of face & nasal mucosa.

Sensory Sensation of skin of pace and anterior oral

Result Able to identify different aromas being introduced to him (cologne/soap/orange) Able to read title of our assessment book Pupil is constricted upon focused to light; the six ocular movements are present and intact in the patient. Patient is able to move his eyeball downward and laterally without difficulty. Patient sensation of skin in face is present, he can differentiate what is blunt, dull and sharp; patient blinks when the sclera is touch. Able to feel the sensation being introduced to him. 23

Mandibular Branch

VI

Abducens

VII

Facial

VIII

X

XI

XII

Motor

EOM, moves eyeball laterally.

Motor & Facial Sensory expression: taste

Auditory; Sensory Vestibular Branch Cochlear Branch

IX

Motor & Sensory

cavity. Muscles of mastication, sensation of skin of face.

Sensory

Equilibrium Hearing

Swallowing ability tongue Motor & Glossopharyngeal movement; taste Sensory (posterior tongue) Sensation of pharynx & Motor & larynx; Vagus Sensory swallowing, vocal cord movement. Head movement; Accessory Motor shrugging of shoulders. Protrusion of tongue; moves Hypoglossal Motor tongue up & down side to side.

Patient is able to clench his teeth. Able to move his eyeball laterally as where the direction of gaze. The patient can wrinkle his forehead, raise and lower his eyebrows, smile to show his teeth; patient can identify taste of salt, sugar and vinegar The patient cannot stand due to leg muscle weakness The patient can hear whispered words and ticking of a wrist watch Able to swallow properly & move his tongue side to side.

Patient voice is clear and speaks properly Able to move head and can shrug his shoulders The patient can protrude tongue and can move it side to side

24

REVIEW OF SYSTEMS INTEGUMENTARY SYSTEM • With complaints of infected wounds • With complaints of itching • With complaints of diaphoresis • With complaints of non-pitting edema • With complaints of dry skin and dandruff RESPIRATORY SYSTEM • No history of difficulty of breathing. • No history of asthma • No history of hemoptysis CARDIOVASCULAR SYSTEM • No history of chest pain • No history of hypertension GENITOURINARY SYSTEM • With complaints of less urine excretion (oliguria) GASTROINTESTINAL SYSTEM • No history of nausea and vomiting • With history of abdominal pain • With complaints of constipation MUSCULOSKELETAL SYSTEM • With complaints of lower extremities weakness • With complaints of paresthesia • No history of fracture • With history of prickling “pins and needles” sensation at lower extremities • With history of back pain • With complaints of leg muscle spasm 25

ENDOCRINE SYSTEM • No history of hyperthyroidism • No history of hyperglycemia • No history of cold intolerance NEUROLOGIC SYSTEM • With history of headache • No history of seizure • Positive babinski reflex • Positive Westphal’s sign • No history of memory loss LABORATORY TESTS ELECTROLYTE September 26,2009 ELECTROLYTES SODIUM POTASSIUM

RESULTS 143mmol/L 5.4 mmol/L

NORMAL VALUES 135-155mmol/L 3.5-5.5mmol/L

SIGNIFICANCE NORMAL NORMAL

HEMATOLOGY September 26,2009 Criteria Hematocrit Platelet WBC Neutrophils Lymphocytes

Result 35%

Normal Values M:40-52% F:36-48%

ADEQUATE 8.4 x 10 9/L 69 35

150 – 400 4.0 – 11 25-75% 15-35%

Significance Reduced number of RBC in the blood (anemia) Normal Normal Normal Normal

PONCIANO LIMCANGCO, MD, FPSP Pathologist Note: Other test ordered by the attending physician such as lumbar puncture were not done because the patient refused to have the test for reasons of financial constraint. 26

ANATOMY AND PHYSIOLOGY

THE NERVOUS SYSTEM Typical Structure of a Nerve Cell

27

A nerve cell (neuron) consists of a large cell body and nerve fibers—one elongated extension (axon) for sending impulses and usually many branches (dendrites) for receiving impulses. Each large axon is surrounded by oligodendrocytes in the brain and spinal cord and by Schwann cells in the peripheral nervous system. The membranes of these cells consist of a fat (lipoprotein) called myelin. The membranes are wrapped tightly around the axon, forming a multilayered sheath. This myelin sheath resembles insulation, such as that around an electrical wire. Nerve impulses travel much faster in nerves with a myelin sheath than in those without one. If the myelin sheath of a nerve is damaged, nerve transmission slows or stops

The nervous system is divided into the: 28

• •

peripheral nervous system (PNS) central nervous system (CNS)

The PNS consists of

29

• •

sensory neurons running from stimulus receptors that inform the CNS of the stimuli motor neurons running from the CNS to the muscles and glands - called effectors - that take action.

The CNS consists of the • •

spinal cord and the brain

THE PERIPHERAL NERVOUS SYSTEM IN FOCUS In the peripheral nervous system, neurons can be functionally divided in three ways: 1. Sensory (afferent) - carry information INTO the central nervous system from sense organs or motor (efferent) - carry information away from the central nervous system (for muscle control). 2. Cranial - connects the brain with the periphery or spinal - connects the spinal cord with the periphery. 3. Somatic - connects the skin or muscle with the central nervous system or visceral - connects the internal organs with the central nervous system The peripheral nervous system is subdivided into the • •

sensory-somatic nervous system and the autonomic nervous system

The Sensory-Somatic Nervous System The sensory-somatic system consists of: • •

12 pairs of cranial nerves and 31 pairs of spinal nerves. The Cranial Nerves

Nerves I Olfactory II Optic III Oculomotor IV Trochlear V Trigeminal

Type

Function

sensory olfaction (smell) sensory

vision (Contain 38% of all the axons connecting to the brain.)

motor* eyelid and eyeball muscles motor* mixed

eyeball muscles Sensory: facial and mouth sensation Motor: chewing 30

VI Abducens VII Facial

motor* eyeball movement mixed

VIII Auditory IX Glossopharyngeal X Vagus XI Accessory XII Hypoglossal

Sensory: taste Motor: facial muscles and salivary glands

sensory hearing and balance mixed mixed motor

Sensory: taste Motor: swallowing main nerve of the parasympathetic nervous system (PNS) swallowing; moving head and shoulder

motor* tongue muscles

*Note: These do contain a few sensory neurons that bring back signals from the muscle spindles in the muscles they control.

The Spinal Nerves All of the spinal nerves are "mixed"; that is, they contain both sensory and motor neurons. All our conscious awareness of the external environment and all our motor activity to cope with it operate through the sensory-somatic division of the PNS. The Autonomic Nervous System The autonomic nervous system consists of sensory neurons and motor neurons that run between the central nervous system (especially the hypothalamus and medulla oblongata) and various internal organs such as the: • • • •

heart lungs viscera glands (both exocrine and endocrine)

It is responsible for monitoring conditions in the internal environment and bringing about appropriate changes in them. The contraction of both smooth muscle and cardiac muscle is controlled by motor neurons of the autonomic system. The actions of the autonomic nervous system are largely involuntary (in contrast to those of the sensory-somatic system). It also differs from the sensory-somatic system is using two groups of motor neurons to stimulate the effectors instead of one.

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• •

The first, the preganglionic neurons, arise in the CNS and run to a ganglion in the body. Here they synapse with postganglionic neurons, which run to the effector organ (cardiac muscle, smooth muscle, or a gland).

The autonomic nervous system has two subdivisions, the • •

sympathetic nervous system and the parasympathetic nervous system.

The Sympathetic Nervous System The preganglionic motor neurons of the sympathetic system arise in the spinal cord. They pass into sympathetic ganglia which are organized into two chains that run parallel to and on either side of the spinal cord. The preganglionic neuron may do one of three things in the sympathetic ganglion: •

• •

synapse with postganglionic neurons which then reenter the spinal nerve and ultimately pass out to the sweat glands and the walls of blood vessels near the surface of the body. pass up or down the sympathetic chain and finally synapse with postganglionic neurons in a higher or lower ganglion leave the ganglion by way of a cord leading to special ganglia (e.g. the solar plexus) in the viscera. Here it may synapse with postganglionic sympathetic neurons running to the smooth muscular walls of the viscera. However, some of these preganglionic neurons pass right on through this second ganglion and into the adrenal medulla. Here they synapse with the highlymodified postganglionic cells that make up the secretory portion of the adrenal medulla.

The neurotransmitter of the preganglionic sympathetic neurons is acetylcholine (ACh). It stimulates action potentials in the postganglionic neurons. The neurotransmitter released by noradrenaline (also called norepinephrine).

the

postganglionic neurons is

The action of noradrenaline on a particular gland or muscle is excitatory is some cases, inhibitory in others. (At excitatory terminals, ATP may be released along with noradrenaline.) The release of noradrenaline • •

stimulates heartbeat raises blood pressure 32

• • • • • • •

dilates the pupils dilates the trachea and bronchi stimulates the conversion of liver glycogen into glucose shunts blood away from the skin and viscera to the skeletal muscles, brain, and heart inhibits peristalsis in the gastrointestinal (GI) tract inhibits contraction of the bladder and rectum and, at least in rats and mice, increases the number of AMPA receptors in the hippocampus and thus increases long-term potentiation (LTP).

In short, stimulation of the sympathetic branch of the autonomic nervous system prepares the body for emergencies: for "fight or flight" (and, perhaps, enhances the memory of the event that triggered the response). Activation of the sympathetic system is quite general because • •

a single preganglionic neuron usually synapses with many postganglionic neurons; the release of adrenaline from the adrenal medulla into the blood ensures that all the cells of the body will be exposed to sympathetic stimulation even if no postganglionic neurons reach them directly.

The Parasympathetic Nervous System The main nerves of the parasympathetic system are the tenth cranial nerves, the vagus nerves. They originate in the medulla oblongata. Other preganglionic parasympathetic neurons also extend from the brain as well as from the lower tip of the spinal cord. Each preganglionic parasympathetic neuron synapses with just a few postganglionic neurons, which are located near - or in - the effector organ, a muscle or gland. Acetylcholine (ACh) is the neurotransmitter at all the pre- and many of the postganglionic neurons of the parasympathetic system. However, some of the postganglionic neurons release nitric oxide (NO) as their neurotransmitter. Parasympathetic stimulation causes • • • • •

slowing down of the heartbeat lowering of blood pressure constriction of the pupils increased blood flow to the skin and viscera peristalsis of the GI tract

In short, the parasympathetic system returns the body functions to normal after they have been altered by sympathetic stimulation. In times of danger, the sympathetic system prepares the body for violent activity. The parasympathetic system reverses these changes when the danger is over. 33

The vagus nerves also help keep inflammation under control. Inflammation stimulates nearby sensory neurons of the vagus. When these nerve impulses reach the medulla oblongata, they are relayed back along motor fibers to the inflamed area. The acetylcholine from the motor neurons suppresses the release of inflammatory cytokines, e.g., tumor necrosis factor (TNF), from macrophages in the inflamed tissue. Although the autonomic nervous system is considered to be involuntary, this is not entirely true. A certain amount of conscious control can be exerted over it as has long been demonstrated by practitioners of Yoga and Zen Buddhism. During their periods of meditation, these people are clearly able to alter a number of autonomic functions including heart rate and the rate of oxygen consumption. These changes are not simply a reflection of decreased physical activity because they exceed the amount of change occurring during sleep or hypnosis.

IMMUNE SYSTEM The immune system is composed of many interdependent cell types that collectively protect the body from bacterial, parasitic, fungal, viral infections and from the growth of tumor cells. Many of these cell types have specialized functions. The cells of the immune system can engulf bacteria, kill parasites or tumor cells, or kill viral-infected cells. Often, these cells depend on the T helper subset for activation signals in the form of secretions formally known as cytokines, lymphokines, or more specifically interleukins. The Organs of the Immune System Bone Marrow -- All the cells of the immune system are initially derived from the bone marrow. They form through a process called hematopoiesis. During hematopoiesis, bone marrow-derived stem cells differentiate into either mature cells of the immune system or into precursors of cells that migrate out of the bone marrow to continue their maturation elsewhere. The bone marrow produces B cells, natural killer cells, granulocytes and immature thymocytes, in addition to red blood cells and platelets. Thymus -- The function of the thymus is to produce mature T cells. Immature thymocytes, also known as prothymocytes, leave the bone marrow and migrate into the thymus. Through a remarkable maturation process sometimes referred to as thymic education, T cells that are beneficial to the immune system are spared, while those T cells that might evoke a detrimental autoimmune response are eliminated. The mature T cells are then released into the bloodstream. Spleen -- The spleen is an immunologic filter of the blood. It is made up of B cells, T cells, macrophages, dendritic cells, natural killer cells and red blood cells. In addition to capturing foreign materials (antigens) from the blood that passes through the spleen, migratory macrophages and dendritic cells bring antigens to the spleen via the 34

bloodstream. An immune response is initiated when the macrophage or dendritic cells present the antigen to the appropriate B or T cells. This organ can be thought of as an immunological conference center. In the spleen, B cells become activated and produce large amounts of antibody. Also, old red blood cells are destroyed in the spleen. Lymph Nodes -- The lymph nodes function as an immunologic filter for the bodily fluid known as lymph. Lymph nodes are found throughout the body. Composed mostly of T cells, B cells, dendritic cells and macrophages, the nodes drain fluid from most of our tissues. Antigens are filtered out of the lymph in the lymph node before returning the lymph to the circulation. In a similar fashion as the spleen, the macrophages and dendritic cells that capture antigens present these foreign materials to T and B cells, consequently initiating an immune response.

The Cells of the Immune System T-Cells -- T lymphocytes are usually divided into two major subsets that are functionally and phenotypically (identifiably) different. The T helper subset, also called the CD4+ T cell, is a pertinent coordinator of immune regulation. The main function of the T helper cell is to augment or potentiate immune responses by the secretion of specialized factors that activate other white blood cells to fight off infection. Another important type of T cell is called the T killer/suppressor subset or CD8+ T cell. These cells are important in directly killing certain tumor cells, viral-infected cells and sometimes parasites. The CD8+ T cells are also important in down-regulation of immune responses. Both types of T cells can be found throughout the body. They often depend on the secondary lymphoid organs (the lymph nodes and spleen) as sites where activation occurs, but they are also found in other tissues of the body, most conspicuously the liver, lung, blood, and intestinal and reproductive tracts. 35

Natural Killer Cells -- Natural killer cells, often referred to as NK cells, are similar to the killer T cell subset (CD8+ T cells). They function as effector cells that directly kill certain tumors such as melanomas, lymphomas and viral-infected cells, most notably herpes and cytomegalovirus-infected cells. NK cells, unlike the CD8+ (killer) T cells, kill their targets without a prior "conference" in the lymphoid organs. However, NK cells that have been activated by secretions from CD4+ T cells will kill their tumor or viral-infected targets more effectively. B Cells -- The major function of B lymphocytes is the production of antibodies in response to foreign proteins of bacteria, viruses, and tumor cells. Antibodies are specialized proteins that specifically recognize and bind to one particular protein that specifically recognize and bind to one particular protein. Antibody production and binding to a foreign substance or antigen, often is critical as a means of signaling other cells to engulf, kill or remove that substance from the body. Granulocytes or Polymorphonuclear (PMN) Leukocytes -- Another group of white blood cells is collectively referred to as granulocytes or polymorphonuclear leukocytes (PMNs). Granulocytes are composed of three cell types identified as neutrophils, eosinophils and basophils, based on their staining characteristics with certain dyes. These cells are predominantly important in the removal of bacteria and parasites from the body. They engulf these foreign bodies and degrade them using their powerful enzymes. Macrophages -- Macrophages are important in the regulation of immune responses. They are often referred to as scavengers or antigen-presenting cells (APC) because they pick up and ingest foreign materials and present these antigens to other cells of the immune system such as T cells and B cells. This is one of the important first steps in the initiation of an immune response. Stimulated macrophages exhibit increased levels of phagocytosis and are also secretory. Dendritic Cells -- Another cell type, addressed only recently, is the dendritic cell. Dendritic cells, which also originate in the bone marrow, function as antigen presenting cells (APC). In fact, the dendritic cells are more efficient apcs than macrophages. These cells are usually found in the structural compartment of the lymphoid organs such as the thymus, lymph nodes and spleen. However, they are also found in the bloodstream and other tissues of the body. It is believed that they capture antigen or bring it to the lymphoid organs where an immune response is initiated. Unfortunately, one reason we know so little about dendritic cells is that they are extremely hard to isolate, which is often a prerequisite for the study of the functional qualities of specific cell types. Of particular issue here is the recent finding that dendritic cells bind high amount of HIV, and may be a reservoir of virus that is transmitted to CD4+ T cells during an activation event.

36

An animal’s immune system protects its body from intruders: bacteria, viruses, parasites, cancer cells, etc. An immune system is present in several animal groups, especially within the vertebrates. Animals have both non-specific and specific defense mechanisms to fight invaders. We will be focusing on the human immune system. Non-specific defense mechanisms work against a wide variety of invaders. These defense mechanisms include the barrier formed by our skin; chemicals in perspiration, skin oil, saliva, tears, etc.; the hairs in our nostrils; the ciliary escalator (the cilia and mucus that clean out dust and debris from our lungs and trachea) in our respiratory tracts; the inflammatory response which is the dilation of blood vessels and accumulation of WBCs at the site of an injury (the signs of which are that the area is red, hot, and swollen); and fever, a raised body temperature to inhibit the growth of pathogens. Note that a fever is caused by your body to inhibit the growth of bacteria, etc., not by the “germs” themselves, per se. Specific defense mechanisms are effective against specific pathogens. This involves various WBCs called lymphocytes or leukocytes. There are several kinds of WBCs involved in the immune system, all of which originate in the bone marrow. Leukemia is a cancer of the bone marrow, thus it typically is treated by killing all of the person’s bone marrow. Unfortunately, this leaves the person with no immune system, so (s)he must be extremely careful during that time to avoid all possible pathogens. There are two main types of specific defense mechanisms involved in the immune system. The humoral immune system consists of Bcells which originate in the Bone marrow and stay there to develop.

The cell-mediated immune system consists of T-cells which originate in the bone marrow, but go to the Thymus to finish their development.

B-cells can produce antibodies, but need exposure to foreign antigens to do so. These antigens are cell surface oligosaccharides and proteins which the cell uses as “ID tags”.

T-cells are highly-specialized cells in the blood and lymph to fight bacteria, viruses, fungi, protozoans, cancer, etc. within host cells and react against foreign matter such as organ transplants.

Antibodies are proteins in blood plasma and lymph to fight bacteria and viruses in body fluids. All daughter cells of a B-cell will be able to produce the same antibodies as the mother cell. Antibodies bind to certain parts of an antigen to mark it for destruction (by the T-cells).

There are three kinds of T-cells. Cytotoxic T-cells directly kill invaders. Helper T-cells aid B and other Tcells to do their jobs, and HIV lives in and kills them. Suppressor T-cells suppress the activities of B- and other T-cells so they don’t overreact. Allergy injections are supposed to increase the number of supressor Tcells to make the person less sensitive to allergens.

37

Immunity is the ability to “remember” foreign substance previously encountered and react again, promptly. There are two kinds of immunity: active immunity, when the body is stimulated to produce its own antibodies, and passive immunity, where the antibodies come from outside the person’s body. Active immunity is usually permanent, and can be induced due to actual illness or vaccination. Passive immunity is not permanent because the antibodies are introduced from outside the body, thus the Bcells never “learn” how to make them. Some examples of passive immunity include antibodies passed across the placenta and in milk from a mother to her baby, some travelers’ shots, and the Rhogam shots we we discussed earlier this quarter. Because antibodies are only protein, they don’t last very long and must be replaced if the immunity is to continue.

38

DRUG STUDY

Generic Name, Brand Name, and Classification

Prescribed and recommended Dosage, Frequency, and Route of Administration

Mechanism of Action

Indication

•

Hydrocortisone Cortef Corticosteroids

100 mg IVTT Q8H

Decreases inflammation, mainly by stabilizing leukocytes lysosomal membranes; suppresses immune response;stimulat es bone marrow; and influences protein, fat, and carbohydrate metabolism.

•

• •

Severe inflammation, adrenal insufficiency. Shock Adjunct treatment for ulcerative colitis and proctitis

Adverse Reactions

Contraindication

• •

Contraindicate d in pt. hypersensitive to drug or its ingredients, in those w/ systemic fungal infection, in those receiving immunosuppre ssive doses together w/ live virus vaccines, and in premature infant(succinat e). Use w/ cautions in pt. w/ recent MI. Use cautiously in pt. w/ GI ulcer, renal dse., HPT and hypothyroidism .

•

•

• •

CNS: euphorea,in somia,pares thesia, seizures.psu edotumor cerebri. CV: heart failure, edema,HPN arrhythmias, thromboembolisms. EENT: cataract, glaucoma. GI: peptic ulcer, GI irriration, increase appetite,& pancreatitis.

Nursing Implications

•

•

•

• •

Determine whether the pt. is Is sensitive to other corticosteroid Give oral dose with food when possible.pt. may need another drug to prevent GI irritation. Most adverse reaction to corticosteroids are dose-durationdependent. Monitor pt. weight BP, and electrolyte level Monitor pt. cushingoid effects including moon face, buffalo hump, central obesity, thinning hair, hypertension and increased susceptibility to infection.

39

DRUG STUDY

Generic Name, Brand Name, and Classification

Prescribed and recommended Dosage, Frequency, and Route of Administration 1 tab OD

Vitamin C (Ascorbic acid)

Mechanism of Action

Stimulates collagen formation and tissue repair; involved in oxygenationreduction reactions.

Indication

Contraindication

RDA Frank and subclinical scurvy • Extensive burns, delayed fracture or wound healing, postoperativ e wound healing, severe febrile or chronic dse. State. To prevent vit. C deficiency in pt. w/ poor nutritional habits or increased requirements.

Contraindicated in patients w/ an allergy to tartrazine or sulfates. Large doses are contraindicated during pregnancy.

• •

Adverse Reaction

• •

•

•

CNS; • faintness, dizziness. GI: diarrhea, • heartburn, nausea, vomiting. • GU: acid urine, oxaluria, renal • calculi. OTHER: discomfort at injection site.

Nursing Implication

Stress proper nutritional habits to prevent recurrence of deficiency. Advise smokers to increase intake of vitamin C. When giving for urine acidification, check urine pH to ensure efficacy. For pt. receiving vit. C I.M., explain that M.I, route may promote better utilization.

40

DRUG STUDY

41

Generic Name, Brand Name, and Classification

Prescribed and recommended Dosage, Frequency, and Route of Administration Rectal Suppository insert 1 RS

Bisacodyl Pedia Laxative

Mechanism of Action Stimulant • laxative that increases peristalsis, probably by direct effect on smooth muscle of the intestine, by irritating the muscle or stimulating the colonic intramural plexus. Drug also promotes fluid accumulation in colon and small intestine.

Indication

Chronic constipation; preparation for childbirth, surgery, or rectal or bowel examination.

Adverse Reactions

Contraindication

•

Contraindicat ed in patients hypersensitiv e to drug or its components and in those with rectal bleeding, gastroenteriti s, intestinal obstruction, abdominal pain, nausea, vomiting, or other symptoms of appendicitis or acute surgical abdomen.

•

•

•

CNS: dizziness, faintness, muscle weakness with excessive use. GI: abdominal cramps, burning sensation in rectum with suppositor ies, nausea, vomiting, diarrhea with high doses, laxative dependen ce with long-term or excessive use, proteinlosing enteropat hy with excessive use. Metabolic: alkalosis, fluid, and electrolyte imbalance ,

Nursing Implications

•

•

•

•

•

Give drug at times that don’t interfere with scheduled activities or sleep. Soft, formed stools are usually produced 15 to 60 minutes after rectal use. Before giving for constipation, determine whether pt. has adequate fluid intake, exercise, intake and diet. Tablets and suppositories are used together to clean the colon before and after surgery and before and after surgery and before barium enema. Insert suppositoryas high as possible into the rectum , and try to position suppository against the rectal wall. Avoid embedding within fecal material because doing so may delay onset of action. Bisco-Lax may contain tartrazine.

42

DRUG STUDY

Generic Name, Brand Name, and Classification vitamin Bcomplex

Prescribed and recommended Dosage, Frequency, and Route of Administration 1 amp IVTT q8h

Mechanism of Action

Indication

Vitamins B1, B2, B3, and biotin participate in different aspects of energy production, vitamin B6 is essential for amino acid metabolism, and vitamin B12 and

combat everyday stress, boost energy B1, B2, B3, and biotin participate in different aspects of energy production, vitamin B6 is essential for amino acid

Contraindication

Adverse Reactions

Nursing Implications

Vitamin B-complex includes several different components, each of which has the potential to interact with drugs. It is recommended that before taking this vitamins, doctor or pharmacist should discuss the use of vitamin B-complex and current medication(s)

43

folic acid facilitate steps required for cell division.

metabolism, and vitamin B12 and folic acid facilitate steps required for cell division improve overall micronutrient intake and prevent deficiencies

44

GENOGRAM 74 years old With cataract

74 years old With arthritis

80 years old Kidney problem

43 years old

17 years old Patient with Guillain barre syndrome

13 years old

77 years old Kidney problem

56 years old Joint pains

10 years old

7 years old

= Patient =

deceased

Male

female mother

father

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Nursing Care Plan # 1 (September 29, 2009) Subjective cue: “Sige naku siya bantayan mam kay basin mahulog sa katre ug masamad…dili raba makabati iyang mga tiil” as verbalized by the mother. Objective cues: • Loss of sensation • Muscles weakness noted • Ascending paralysis Diagnosis: High risk for injury related to loss of sensation Planning: After 4 hours of duty patient will be free from any risk of injuries Intervention: Independent 1. Ascertained knowledge of safety need/ injury prevention 2. Provided information regarding disease conditions that may result in increased risk for injury 3. Raised side rails 4. Kept the sharp objects away from the patient 5. Educated the SO about the possibility of injury and how to prevent

Rationale To prevent injury To prevent injury To prevent from falling To prevent injury or harmful damage To protect and prevent injury

Evaluation: Goal met. After 4 hours of rendering of nursing intervention the patient is free from injury as evidenced by absence of any signs of injury.

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Nursing Care Plan # 2 (September 29, 2009) Objective cues: • paresthesia • Acute onset of symmetrical progressive muscle weakness (beginning in the legs that ascends to the trunk) • Vital signs: o Temp = 36.70C o RR = 20 cpm o P = 88 bpm o BP = 110/70 mmHg Diagnosis: High risk for Ineffective Breathing Pattern related to neuromuscular dysfunction secondary to ascending paralysis Planning: Within 2 hours of rendering nursing interventions, patient will maintain a normal/effective breathing pattern Intervention: Rationale 1. Auscultated chest, noting to assess adequacy of air flow and detects presence/character of breath sounds, presence of adventitious sounds presence of secretions 2. Noted rate and depth of respirations, To assess types of breathing pattern so to type of breathing pattern: tachypnea, watch sign of respiratory fatigue cheyne-stokes, other irregular patterns 3. Maintained calm environment To promote comfort and relaxation 4. Position patient with head of bed To provide maximum chest excursion elevated 5. Monitored for signs of impending Prepare to intubate if patient’s heart rate is respiratory failure above 120 or below 70 bpm and respiratory rate above 30bpm 6. Prepared emergency equipment in To provide emergency intubation if needed readily accessible location and include appropriate ET tubes 7. Encouraged adequate rest periods To limit fatigue between activities 8. Assisted client to learn breathing Pursed lip breathing helps get rid of the old exercises such as pursed lip breathing stale air in your lungs that is trapped in the airways and to help patient breath more fresh air through nose Evaluation: Goal met. After 2 hours of rendering nursing intervention, patient maintains a normal/effective breathing pattern as evidenced by normal respiration rate (RR=19cpm).

47

NURSING CARE PLAN # 3 (September 29, 2009) Subjective cue: “Dili ko kalihok-lihok” as verbalized by the patient. Objective cues: • • •

• •

Ascending paralysis noted (from feet to the pelvic part) Limited ROM Slowed body movements noted Weakness Nonpitting bipedal edema

Analysis: High risk for impaired skin integrity related to immobility as evidenced by ascending paralysis Planning: After 8 hours of rendering appropriate nursing interventions patient will be free from any risk of impaired skin integrity. INTERVENTIONS 1. Changed patient position every 2 hours.

RATIONALE -to promote circulation and prevent bed sore and constipation 2. Removed wet/wrinkled linens promptly. -moisture potentiates skin breakdown 3. Developed repositioning schedule for -to enhance understanding and client, involving client in reasons for and cooperation. decisions about times and positions in conjunction w/ other activities. 4. Provided w/ well ventilated environment. -To promote comfort 5. Elevated both legs with a pillow To promote blood venous return 6. Encouraged patient to touch his lower -To remind the patient that his lower extremities every now and then extremities are present and still needs care 7. Increased fluid and high fiber in diet. -to prevent constipation. Evaluation: Goal met. Patient is free from impaired skin integrity as evidenced by absence of any signs of complication of immobility.

48

Nursing Care Plan # 4 (September 29, 2009) Subjective cues: “Di ko kalakaw kay dili nako maalsa akong duha ka tiil ” as verbalized by the patient Objective cues: • Ascending paralysis • Muscle weakness noted • Paresthesia noted • Loss of sensation • Functional level classification # 3 (requires help from another person & equipment device) Diagnosis: Impaired physical mobility related to neuromuscular dysfunction Planning: After 3 days of duty patient will verbalize understanding of his condition and will demonstrate willingness to participate in activities with in physical limitations Intervention

Rationale

Independent: 1. Determined degree of immobility To assess functional level of the patient as based on functional level basis in giving appropriate interventions classification scale 2. Assisted client in ADLs

To promote independence, prevent fatigue and to promote blood circulation

3. Provided support to affective body To maintain body parts function, reduce parts using pillows and rolls risk of pressure ulcers and to avoid contractures 4. Encouraged participation in self- To enhance self-concept and sense of care and diversional activity independence 5. Encouraged adequate intake of Promote well being and maximize energy fluids and nutritious foods production 6. Scheduled activities with adequate To reduce fatigue rest periods during the day Evaluation: Goal met. After 3 days of duty patient verbalize understanding of his condition and demonstrate participation in activities within physical limitations.

49

Nursing care plan # 5 (September 30, 2009) Subjective cues: “Wala pa ko kalibang sulod sa upat ka adlaw” as verbalized by the patient. Objective cues: • Hypoactive bowel sounds heard upon auscultation • Paralysis noted Analysis: Constipation related to abdominal muscle weakness and immobility. Planning: After 8 hours of duty, patient will be able to verbalize understanding of the importance of mobility and diet to normal bowel movement INTERVENTIONS Independent: 1. Advised patient to drink adequate fluid and include foods that are high in fiber like papaya, oatmeal and pineapple 2. Encouraged activity/exercises within personal limitation. 3.Provided with privacy and routinely scheduled time defecation 4.Educated patient about the importance of mobility and diet to normal bowel movement Dependent: 1.Administered Bisacodyl (pedia) suppository as prescribed

RATIONALE -to promote moist and soft stool -to stimulate abdominal muscle contraction. -to promote defecation -to provide information

To increase peristalsis promoting easy defecation

Evaluation: Goal met. After 8 hours of duty, patient verbalized understanding of the importance of normal bowel movement as evidenced by saying “nakalibang ra gjud ko…importante gajud diay ang exercise ug diet hilabina ang tambal nga gisuksok sa akong lubot” as verbalized by the patient.

50

NURSING CARE PLAN # 6 (October 1, 2009) Subjective: “di ko kabantay na makaihi na diay ko ” as verbalized by the patient. Objective: • • • •

Uncontrolled urination ascending paralysis (feet up to pelvic area) Wet pants observed Ammonia odor on the patient’s linens

Analysis: Urinary Incontinence related to neuromuscular dysfunction Planning: After 4 hours of duty, patient will be able to verbalize understanding of condition and identify appropriate interventions to prevent incontinence INTERVENTIONS 1. encouraged use of diaper 2. scheduled voiding for every 3 hours 3. suggested limiting intake of coffee, tea and alcohol

RATIONALE -to prevent wet pants -to minimize bladder pressure Such beverages have diuretic effects

4. maintained positive regard

-to reduce embarrassment associated w/ incontinence. -to save time and energy

5. provided bedside commode, urinal or bedpad as indicated.

Evaluation: Goal met. After 8 hours of duty, patient verbalized understanding of his condition and identified appropriate interventions to prevent incontinence such as scheduling voiding every 3 hours.

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Nursing Care Plan # 7 (September 30, 2009) Subjective: “di ko karajaw katulog” as verbalized by the patient Objectives: • • • •

Eyebags noted Frequent yawning noted Restlessness noted Lethargy noted

Analysis: Sleep Pattern Disturbance related to environmental factors such as external noise and lack of sleep privacy. Planning: After 8 hours of duty, patient will be able to report improvement in sleep pattern INTERVENTIONS Independent 1. provided with quiet and calm environment during bedtime 2. Advised to limit fluid intake in evening 3. Encouraged participation in regular exercise program during day 4. Identified the factors that affect the sleeping pattern 5..Recommended to limit intake of chocolates and caffeinated beverages Dependent 1. Administered sedative / other sleep medication when indicated

RATIONALE To promote rest and sleep -to reduce need for nighttime micturation -to aid stress control/release of energy -to reduce sleep disturbance Such beverages are stimulants that inhibits sleep -to enhance clients ability to fall asleep

Evaluation: Goal met. After 8 hours of duty, patient verbalized improvement in sleeping pattern as evidenced by increase number of sleeping hours.

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Nursing Care Plan # 8 (September 29, 2009) Subjective cues: “Kamaguyangan raba ni siya unya mga gagmay pa iya mga manghud wala nay nagbantay nila didto sa amoa…wala na rabay magpautang nila didto pangkonsumo” as verbalized by the mother Objective cues: • •

Frequent verbalization of worries regarding family functioning Verbalization of financial problems

Diagnosis: Interrupted family processes related to shift in health status of a family member Planning: After 3 days of duty, family members maintain functional system of mutual support for one another Intervention

Rationale

Independent:

1. Dealt with family members in warm, To establish rapport caring and respectful manner 2. Acknowledged difficulties and realities of the situation

Reinforces that some degree of conflict is to be expected and can be used to promote learning and acceptance

3. Encouraged expressions of emotions

Encouraging client to share feelings can provide a safe outlet for fears and frustrations and can increase selfawareness

4. Emphasized importance of open dialogue between family members

To facilitate ongoing problem solving

5. Encouraged family members to reorganized their schedules to meet their own physical and psychological needs

Family members who ignore their own health requirements are prone to becoming ill which may reduce their effectiveness as support persons. A family member who falls ill may cause the

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client to have feelings of guilt 6. Involved family members in physical care of client and show your appreciation of the family involvement 7. Addressed the client financial concerns and responsibilities a. Promote an environment for client to verbalize concerns b. Initiate a referral to social for assistance

Allowing involvement of family members with care will maintain a supportive family structure and strengthen the family units The sudden look of income can be overwhelming causing excessive mental anguish and slowing progress with goal setting

Evaluation: Goal met. After 3 days of duty, family members verbalize understanding of the importance mutual support for one another as evidenced by saying “bisan nagkalisod kami sa kwarta nakasabot kami nga kami ra gajud ang magtinabangay” as verbalized by the mother.

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Nursing Care Plan # 9 (September 29, 2009) Subjective cue: “Waya pa ako kaligo pila na kaadlaw” as verbalized by the patient. Objective cues: • Dirty nails noted • Bad body odor noted • Dandruff noted • Halitosis noted • Patient is not properly groomed • Dry skin noted Diagnosis: Self-care deficit related to impaired physical mobility Planning: After 2 hours of rendering nursing intervention patient will be able to perform self-care activities within physical limitations. Intervention: 1. Determined individual strengths and skills /of the client 2. Provide for communication among those who are involved in caring 3. Provide health teaching to patient about the importance of good hygiene 4. Develop plan of care appropriate to individual situation, scheduling activities to conform to clients normal schedule 5. Plan time for listening to the client and SO 6. Demonstrated to the client and SO the basic ways in self care such as handwashing, combing the hair, trimming nails, toothbrushing and bathing 7. Encouraged patient and SO to use products to enhance self image such as deodorant

Rationale To know the strengths and weaknesses of the client as basis in giving appropriate interventions To gain trust and cooperation from the client and SO To promote good hygiene to the patient To encourage performance of ADL within physical limitation To discover barriers to participation in regimen To provide awareness that self care activities are still possible even with physical limitations To promote self care

Evaluation: Goal met. After 4 hours of rendering nursing intervention patient was able to perform self-care activities such as combing, toothbrushing and trimming of nails

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NURSING CARE PLAN # 10 (September 29, 2009) Subjective cue: “Maulaw nako sa ako kahimtang” as verbalized by the patient Objective cue: • • • • •

Paralysis noted (feet to pelvic area) Loss of body function noted Restlessness noted Hiding body parts with blanket (lower extremities) Less eye contact

Analysis: Disturbed body image related to physical illness as evidenced by inability to walk Planning: After 8 hours of rendering nursing intervention patient will acknowledge self as an individual who has responsibility for self Intervention

Rationale

Encouraged family member to treat client normally and not as invalid

To avoid feeling of isolation or rejection

Encouraged expression of feeling regarding his condition

To provide appropriate emotional support

Encouraged client to look and touch affected body parts

To begin to incorporate changes into body image

Discussed meaning of loss change to client

A change of function such as immobility may be more different for some to deal with than a change in appearance

Visited client frequently and acknowledged the individual as someone who is worthwhile

Provides opportunities for listening of patient’s concerns and questions.

Evaluation: Goal met. After 8 hours of rendering nursing intervention, the patient verbalized feeling of acceptance and responsibility of his affected body parts as evidenced by frequent checking and touching of his lower extremities.

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NURSING CARE PLAN #11 Subjective cue: “Nabiro ko nga di na ko makalakaw” as verbalized by the patient Objective cue: • Poor eye contact • Tearfulness during conversation • Verbalization of concerns (refer to subjective cue) Analysis: Anxiety related to threat on role function secondary to physical illness Planning: After 8 hours of duty patient will be able to identify healthy ways to deal with and relieve anxiety Intervention

Rationale

1. Provided opportunities for question and answer session

Enhance sense of trust and nurse client relationship

2. Compared verbal and non-verbal responses

To note misperception of situations

3. Encouraged verbalization of feelings To provide appropriate emotional supportive care 4. Discussed the disease of Guillain-Barre Syndrome

To provide information that could help patient understand conditions

5. Enumerated ways the patient may use to relieve anxiety such as accepting the reality of his condition, optimistic way of seeing things and having faith in God’s love

To provide information and to boost patient’s hope

Evaluation: Goal partially met. After 8 hours of intervening, the patient was able to enumerate ways to relieve anxiety but verbally said, “ Bisan nakasabot na ko..Dili gajud naku malikayan na magisip ng ako kahimtang karon.”

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Nursing Care Plan # 12 (September 30, 2009) Subjective cues: “Pasmo ra man daw ni sa kusog kay manhimasa man ko human baktas, morag mao man to laong ni doctor” as verbalized by the mother. Objective cues: • Apathy noted • Misinterpretation of information Diagnosis: Knowledge deficit related to cognitive limitation Planning: After 4 hours of rendering nursing intervention patient will be able to verbalize understanding of condition disease process and treatment Intervention: 1. Determined information the client already knows and move to what the client does not know, progressing from simple to complex 2. Explained the cause of the symptoms and disease

Rationale To facilitate learning and determine the client and SO’s cognitive limitation

To provide knowledge

3. Explained the goal of treatment

To provide appropriate information

4. Provide an environment that is conducive to learning 5. Identify support persons or SO requiring information

To facilitate learning To let the SO aware of the condition of the client

Evaluation: Goal met. After 4 hours of rendering of nursing intervention the patient was able to participate in learning process and was able to verbalize understanding of condition of treatment.

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Nursing Care Plan # 13 (September 29, 2009) Subjective cues: “Taglaay ko diri, walay koy lingaw ” as verbalized by the client Objective cues: • Restlessness noted • Lethargy noted • Frequent yawning noted • Verbal expression of boredom Diagnosis: Deficient diversional activity related to physical limitations and lack of sources Planning: After 8 hours of duty patient will engage in satisfying activities within personal limitations Intervention: Independent

Rationale

1. Acknowledged reality of situation and feelings of the client

To establish therapeutic relationship

2. Provided with diversional activities such as reading materials

To relieve boredom

3. Provided change of scenery

To direct attention

4. Encouraged expression of feelings

To determine concerns that needs intervention

5. Provided requirements for mobility such as wheelchair 6. Developed plan of care appropriate to individual situation, scheduling activities to conform to clients normal schedule

For mobility To encourage performance of ADL within physical limitation

Evaluation: Goal met. After 8 hours of duty the patient verbalizes feelings of satisfaction in activities engaged with in personal limitations.

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DISCHARGE PLAN Upon discharge from the hospital, the patient and his significant others will be given home care instructions containing the following: MEDICATIONS

•

Instructed patient to follow medication regimen prescribed by the physician: Vit. B complex

Environmental Consideration s

Treatment

Health Teachings

Time After breakfast

Dose 1 capsule by mouth 1 tablet by mouth

Vit. C (Ascorbic After breakfast Acid)  Encouraged patient to stay in a calm and quiet environment.  Advised SO to keep away sharp objects to prevent accident since the patient has sensory problem  Encouraged patient to refrain from strenuous activities as much as possible.  Instructed the SO to keep their environment clean  Discussed the importance of the medications prescribed by the physician.  Instructed patient to understand and follow discharge plan instruction religiously and accurately.  Encouraged patient to have enough rest and sleep  Instructed SO to place patient in a comfortable patientpreferred position.  Encouraged patient to have a healthy lifestyle like having regular exercise, healthy diet and positive outlook in life  Encouraged personal hygiene such as regular bathing, toothbrushing and grooming  Encouraged patient to increase fluid and fiber in diet.  Discussed the disease process of Guillain-Barre Syndrome.  Encouraged the SO to do passive range of motion exercises to the patient.  Explained function of medical equipment and mobility aids, such as walkers and wheel chairs.  Teach patient and SO about proper handwashing o Steps of proper handwashing 1. Turn on the faucet 2. Wet hands with water 3. Squeeze a small amount of sanitiser gel/soap on palms. 4. Rub palms together 5. Rub the back of both hands 6. Interlace fingers and rub hands together 60

7. Interlock fingers and rub the back of fingers of both hands. 8. Rub thumb in a radiating manner followed by the area between index finger and thumb for both hands 9. Rub fingers on palm for both hands. 10. Rub both wrists in a rotating manner. 11. Rinse and dry thoroughly. Out-Patient check-up Diet

Spiritual

Instructed patient of follow scheduled check-up Instructed patient to seek immediate medical attention when condition worsens  Encouraged patient to have a balanced diet.  Encouraged patient to eat nutritious foods such as vegetables and fruits.  Encouraged patient to be more faithful and have trust in God.  Encouraged SO to pray for patients early recovery  Encouraged patient to visit church and attend holy mass regularly  

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Guillain-Barre Syndrome Glossary of Terms Autoimmune: Pertaining to autoimmunity, a misdirected immune response that occurs when the immune system goes awry and attacks the body itself. See the entire definition of Autoimmune Autoimmune disease: An illness that occurs when the body tissues are attacked by its own immune system . The immune system is a complex organization within the body that is designed normally to "seek and destroy" invaders of the body, including infectious agents. Patients with autoimmune diseases frequently have unusual antibodies circulating in their blood that target their own body tissues. See the entire definition of Autoimmune disease Axon: A long fiber of a nerve cell (a neuron) that acts somewhat like a fiber-optic cable carrying outgoing (efferent) messages. See the entire definition of Axon Bacteria: Single-celled microorganisms which can exist either as independent (freeliving) organisms or as parasites (dependent upon another organism for life). See the entire definition of Bacteria Bacterial: Of or pertaining to bacteria. For example, a bacterial lung infection. Blood pressure: The blood pressure is the pressure of the blood within the arteries. It is produced primarily by the contraction of the heart muscle. It's measurement is recorded by two numbers. The first (systolic pressure) is measured after the heart contracts and is highest. The second (diastolic pressure) is measured before the heart contracts and lowest. A blood pressure cuff is used to measure the pressure. Elevation of blood pressure is called "hypertension". Brain: That part of the central nervous system that is located within the cranium ( skull ). The brain functions as the primary receiver, organizer and distributor of information for the body. It has two (right and left) halves called "hemispheres." See the entire definition of Brain Breathing: The process of respiration, during which air is inhaled into the lungs through the mouth or nose due to muscle contraction, and then exhaled due to muscle relaxation. Campylobacter jejuni: a species of curved, rod-shaped, non-spore forming, Gramnegative microaerophilic, bacteria commonly found in animal feces.[1] It is one of the most common causes of human gastroenteritis in the world. Food poisoning caused by Campylobacter species can be severely debilitating but is rarely life-threatening. It has been linked with subsequent development of Guillain-Barré syndrome (GBS), which usually develops two to three weeks after the initial illness. 62

Cerebrospinal fluid: CSF. A watery fluid, continuously produced and absorbed, which flows in the ventricles (cavities) within the brain and around the surface of the brain and spinal cord. See the entire definition of Cerebrospinal fluid Clinical trials: Trials to evaluate the effectiveness and safety of medications or medical devices by monitoring their effects on large groups of people. See the entire definition of Clinical trials Cure: 1. To heal, to make well, to restore to good health. Cures are easy to claim and, all too often, difficult to confirm. 2. A time without recurrence of a disease so that the risk of recurrence is small, as in the 5-year cure rate for malignant melanoma . 3. Particularly in the past, a course of treatment. For example, take a cure at a spa. See the entire definition of Cure Diagnosis: 1 The nature of a disease ; the identification of an illness. 2 A conclusion or decision reached by diagnosis. The diagnosis is rabies . 3 The identification of any problem. The diagnosis was a plugged IV. See the entire definition of Diagnosis Gastrointestinal: Adjective referring collectively to the stomach and small and large intestines. Hammer: The malleus. Heart: The muscle that pumps blood received from veins into arteries throughout the body. It is positioned in the chest behind the sternum (breastbone; in front of the trachea, esophagus, and aorta; and above the diaphragm muscle that separates the chest and abdominal cavities. The normal heart is about the size of a closed fist, and weighs about 10.5 ounces. It is cone-shaped, with the point of the cone pointing down to the left. Two-thirds of the heart lies in the left side of the chest with the balance in the right chest. See the entire definition of Heart Heart rate: The number of heart beats per unit time, usually per minute. The heart rate is based on the number of contractions of the ventricles (the lower chambers of the heart). The heart rate may be too fast ( tachycardia ) or too slow ( bradycardia ). The pulse is bulge of an artery from the wave of blood coursing through the blood vessel as a result of the heart beat. The pulse is often taken at the wrist to estimate the heart rate. See the entire definition of Heart rate Immune: Protected against infection. The Latin immunis means free, exempt. Immune system: A complex system that is responsible for distinguishing us from everything foreign to us, and for protecting us against infections and foreign substances.

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The immune system works to seek and kill invaders. See the entire definition of Immune system Infection: The growth of a parasitic organism within the body. (A parasitic organism is one that lives on or in another organism and draws its nourishment therefrom.) A person with an infection has another organism (a "germ") growing within him, drawing its nourishment from the person. Intensive care: See critical care. Knee: The knee is a joint which has three parts. The thigh bone (the femur) meets the large shin bone (the tibia) to form the main knee joint. This joint has an inner (medial) and an outer (lateral) compartment. The kneecap (the patella) joins the femur to form a third joint, called the patellofemoral joint. The patella protects the front of the knee joint. Limb: The arm or leg. Low blood pressure : Any blood pressure that is below the normal expected for an individual in a given environment. Low blood pressure is also referred to as hypotension. See the entire definition of Low blood pressure Muscle: Muscle is the tissue of the body which primarily functions as a source of power. There are three types of muscle in the body. Muscle which is responsible for moving extremities and external areas of the body is called "skeletal muscle." Heart muscle is called "cardiac muscle." Muscle that is in the walls of arteries and bowel is called "smooth muscle." Myelin: The fatty substance that covers and protects nerves. Myelin is a layered tissue that sheathes the axons (nerve fibers). This sheath around the axon acts like a conduit in an electrical system, ensuring that messages sent by axons are not lost en route. It allows efficient conduction of action potentials down the axon. Myelin consists of 70% lipids (cholesterol and phospholipid) and 30% proteins. It is produced by oligodendrocytes in the central nervous system. Nerve: A bundle of fibers that uses chemical and electrical signals to transmit sensory and motor information from one body part to another. See: Nervous system. Neurological: Having to do with the nerves or the nervous system. Onset: In medicine, the first appearance of the signs or symptoms of an illness as, for example, the onset of rheumatoid arthritis . There is always an onset to a disease but never to the return to good health. The default setting is good health. Pain: An unpleasant sensation that can range from mild, localized discomfort to agony. Pain has both physical and emotional components. The physical part of pain results from nerve stimulation. Pain may be contained to a discrete area, as in an injury, or it can be more diffuse, as in disorders like fibromyalgia . Pain is mediated by specific 64

nerve fibers that carry the pain impulses to the brain where their conscious appreciation may be modified by many factors. Paralysis: Loss of voluntary movement (motor function). Paralysis that affects only one muscle or limb is partial paralysis, also known as palsy; paralysis of all muscles is total paralysis, as may occur in cases of botulism. Paresthesia: An abnormal sensation of the skin, such as numbness, tingling, pricking, burning, or creeping on the skin that has no objective cause. Paresthesia is the usual American spelling and paraesthesia the preferred English spelling. Peripheral: Situated away from the center, as opposed to centrally located. Peripheral nervous system (PNS): That portion of the nervous system that is outside the brain and spinal cord. Physical therapy: A branch of rehabilitative health that uses specially designed exercises and equipment to help patients regain or improve their physical abilities. Physical therapists work with many types of patients, from infants born with musculoskeletal birth defects, to adults suffering from sciatica or the after- effects of injury, to elderly post-stroke patients. Plasma: The liquid part of the blood and lymphatic fluid, which makes up about half of its volume. Plasma is devoid of cells and, unlike serum, has not clotted. Blood plasma contains antibodies and other proteins. It is taken from donors and made into medications for a variety of blood-related conditions. Some blood plasma is also used in non-medical products. Plasmapheresis: A procedure designed to deplete the body of blood plasma (the liquid part of the blood) without depleting the body of its blood cells. Whole blood is removed from the body, the plasma is separated from the cells, the cells are suspended in saline, a plasma substitute or donor plasma), and the reconstituted solution may be returned to the patient. The procedure is used to remove excess antibodies from the blood in lupus, multiple sclerosis, multiple myeloma, etc. Plasmapheresis carries with it the same risks as any intravenous procedure. The risk of infection increases with the use of donor plasma, which may carry viral particles despite screening procedures. The procedure is done in a clinic or hospital. Pneumonia: Inflammation of one or both lungs with consolidation. Pneumonia is frequently but not always due to infection. The infection may be bacterial, viral, fungal or parasitic. Symptoms may include fever, chills, cough with sputum production, chest pain, and shortness of breath. Protein: A large molecule composed of one or more chains of amino acids in a specific order determined by the base sequence of nucleotides in the DNA coding for the protein.

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Proteins: Large molecules composed of one or more chains of amino acids in a specific order determined by the base sequence of nucleotides in the DNA coding for the protein. Relapse: The return of signs and symptoms of a disease after a patient has enjoyed a remission . For example, after treatment a patient with cancer of the colon went into remission with no sign or symptom of the tumor, remained in remission for 4 years, but then suffered a relapse and had to be treated once again for colon cancer. Residual: Something left behind. With residual disease, the disease has not been eradicated. See the entire definition of Residual Respiratory: Having to do with respiration, the exchange of oxygen and carbon dioxide. From the Latin re- (again) + spirare (to breathe) = to breathe again. Sensory: Relating to sensation , to the perception of a stimulus and the voyage made by incoming ( afferent ) nerve impulses from the sense organs to the nerve centers. Spinal cord: The major column of nerve tissue that is connected to the brain and lies within the vertebral canal and from which the spinal nerves emerge. Thirty-one pairs of spinal nerves originate in the spinal cord: 8 cervical , 12 thoracic , 5 lumbar, 5 sacral, and 1 coccygeal. The spinal cord and the brain constitute the central nervous system ( CNS ). The spinal cord consists of nerve fibers that transmit impulses to and from the brain. Like the brain, the spinal cord is covered by three connective-tissue envelopes called the meninges . The space between the outer and middle envelopes is filled with cerebrospinal fluid ( CSF ), a clear colorless fluid that cushions the spinal cord against jarring shock. Also known simply as the cord. See the entire definition of Spinal cord Spinal tap: Also known as a lumbar puncture or "LP", a spinal tap is a procedure whereby spinal fluid is removed from the spinal canal for the purpose of diagnostic testing. It is particularly helpful in the diagnosis of inflammatory diseases of the central nervous system, especially infections, such as meningitis. It can also provide clues to the diagnosis of stroke , spinal cord tumor and cancer in the central nervous system. Stage: As regards cancer , the extent of a cancer, especially whether the disease has spread from the original site to other parts of the body. See also: Staging . Steroid: A general class of chemical substances that are structurally related to one another and share the same chemical skeleton (a tetracyclic cyclopenta[a]phenanthrene skeleton). Stroke : The sudden death of some brain cells due to a lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. A stroke is also called a cerebrovascular accident or, for short, a CVA.

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Surgery: The word "surgery" has multiple meanings. It is the branch of medicine concerned with diseases and conditions which require or are amenable to operative procedures. Surgery is the work done by a surgeon. By analogy, the work of an editor wielding his pen as a scalpel is s form of surgery. A surgery in England (and some other countries) is a physician's or dentist's office. Syndrome: A set of signs and symptoms that tend to occur together and which reflect the presence of a particular disease or an increased chance of developing a particular disease. Trigger: Something that either sets off a disease in people who are genetically predisposed to developing the disease, or that causes a certain symptom to occur in a person who has a disease. For example, sunlight can trigger rashes in people with lupus. Ventilator: A ventilator is a machine which mechanically assists patients in the exchange of oxygen and carbon dioxide (sometimes referred to as artificial respiration). Viral: Of or pertaining to a virus. For example, "My daughter has a viral rash ." Viral infection: Infection caused by the presence of a virus in the body. Depending on the virus and the person's state of health, various viruses can infect almost any type of body tissue, from the brain to the skin. Viral infections cannot be treated with antibiotics; in fact, in some cases the use of antibiotics makes the infection worse. The vast majority of human viral infections can be effectively fought by the body's own immune system , with a little help in the form of proper diet, hydration, and rest. As for the rest, treatment depends on the type and location of the virus, and may include anti-viral or other drugs. Virus: A microorganism smaller than a bacteria, which cannot grow or reproduce apart from a living cell. A virus invades living cells and uses their chemical machinery to keep itself alive and to replicate itself. It may reproduce with fidelity or with errors (mutations)this ability to mutate is responsible for the ability of some viruses to change slightly in each infected person, making treatment more difficult. Viruses: Small living particles that can infect cells and change how the cells function. Infection with a virus can cause a person to develop symptoms. The disease and symptoms that are caused depend on the type of virus and the type of cells that are infected.

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REFERENCES: Brunner and Suddarth’s Medical and Surgical Nursing eleventh edition Pathophysiology 3rd edition by Thomas J. Nowak Assessment by Lippincott Williams and Wilkins http://en.wikipedia.org/wiki/Campylobacter_jejuni http://www.about-guillain-barre.com/ http://www.cehs.siu.edu/fix/medmicro/cmir.htm http://www.about-campylobacter.com/campylobacter_symptoms_risks http://www.medicinenet.com/guillain-barre_syndrome/article.htm http://www.direct-ms.org/pdf/MolecularMimicryOther/GillianBarrMolMimicry.pdf http://www.microbiologybytes.com/blog/2008/01/30/how-campylobacter-jejuni-surviveswithin-cells/ http://www.microbiologybytes.com/blog/2008/01/30/how-campylobacter-jejuni-surviveswithin-cells/ http://en.wikipedia.org/wiki/Myelin_sheath http://www.drkaslow.com/html/blood_cell_counts.html

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