Published on January 2, 2009
Velez College – College of Nursing F. Ramos St., Cebu City Presented by: Dave Jay S. Manriquez, RN. A Case Study Presentation on G.M., Diagnosed with Hypokalemia, Hypoxic Ischemic Encephalopathy, Nosocomial Pneumonia and Urinary Tract Infection INTRODUCTION: G.M., 37 y.o., M, was admitted for the first time at CVGH Hospital on November 24, 2006, 7:00 pm via taxi, accompanied by his co-workers under the services of he Department of Family Medicine, co-managed with the Department of Internal Medicine for complaints of lower extremity weakness noted hours PTA. HYPOKALEMIA Definition Hypokalemia is a condition of below normal levels of potassium in the blood serum. Potassium is a necessary electrolyte which facilitates nerve impulse conduction and the contraction of skeletal and smooth muscles, including the heart. It also facilitates cell membrane function and proper enzyme activity. Nearly 98% of the body's potassium is intracellular. Levels must be kept in a proper (homeostatic) balance for the maintenance of health. The kidney determines potassium homeostasis, and excess potassium is excreted in the urine. The normal concentration of potassium in the serum is in the range of 3.5-5.0 mEq/L, thus, hypokalemia means serum or plasma levels of potassium ions that fall below 3.5 mEq/L. Moderate hypokalemia is a serum level of 2.5-3 mEq/L, and severe hypokalemia is defined as a level less than 2.5 mEq/L The patient’s potassium level is 1.5 meq/L, and is classified as severe. Symptoms Mild hypokalemia usually results in no symptoms, while moderate hypokalemia results in: confusion, disorientation, weakness, and discomfort of muscles. It also causes cramps during exercise, and a discomfort in the legs experienced while sitting still. Severe hypokalemia results in: extreme weakness of the body, and occasionally in paralysis, which occurs as quot;flaccid paralysisquot; or limpness. The symptoms manifested by the patient was the weakness of his lower extremities hours prior to admission. Paralysis of the muscles of the lungs results in death. Our patient persistently complained of dyspnea, though pulse oximetry revealed 98-100%. Patient experienced respiratory arrest, on his first day at the ICU, and was intubated with continuous ambubagging at 10 LPM. Another dangerous result is abnormal heart beat (arrhythmia) that can lead to death from cardiac arrest (cessation of heart beat), because of the need for potassium to control muscle action. Mild QRS complexes were documented in ECG. Along the course of intubation, patient went into cardiopulmonary arrest and was resuscitated accordingly.
Causes The most common cause is by the use of diuretics, drugs that increase the excretion of water and salts in the urine. These are used to treat medical conditions, including hypertension (high blood pressure), congestive heart failure, liver disease, and kidney disease. However, its side effects produce hypokalemia, the most common cause of hypokalemia in elderly patients. Another common cause is excessive diarrhea and / or vomiting. These can be produced by infections of the gastrointestinal tract. Diarrhea is a major world health problem, responsible for about a quarter of the 10 million deaths that occur each year. in the parts of Asia and Africa. This also results in various abnormalities or complications, such as dehydration (loss in body water), hyponatremia (low sodium level in the blood), and hypokalemia. Diarrhea was the identified cause of the patient’s hypokalemia, who experienced diarrhea, with 10 episodes per day, amounting to 1 cup per episode. No meds were taken nor hydration to correct his condition. His diarrhea was said to be acquired from eating seafood in Cebu. Vomiting provokes an increase in potassium loss in the urine. Vomiting expels acid from the mouth, and this loss of acid results in alkalization of the blood. (pH of the blood increases slightly.) An increased blood pH has a direct effect on the kidneys. Alkaline blood provokes the kidneys to release excessive amounts of potassium in the urine. So, severe and continual vomiting can cause excessive losses of potassium from the body and hypokalemia. Prolonged fasting and starvation also declines the blood serum potassium levels to below 3.0 mEq/L. But eating an unbalanced diet does not cause hypokalemia because most foods, such as fruits (especially bananas, oranges, and melons), vegetables, meat, milk, and cheese, are good sources of potassium. Only foods such as butter, margarine, vegetable oil, soda water, jelly beans, and hard candies are extremely poor in potassium. Diagnosis Hypokalemia can be measured by acquiring a sample of blood, to measure the concentration of potassium ions. Another way is by measuring the potassium content of the urine. In the patient’s case, the serum potassium was measured with the value 1.5 meq/L(3.5-5meq/L). The electrocardiogram is also useful in the diagnosis of hypokalemia, since hypokalemia results in abnormalities in heart behavior. ECG changes may be helpful if present, their absence should not be taken as reassurance of normal cardiac conduction. The ECG of the patient showed mild QRS complexes. Medical Management Asymptomatic or mild hypokalemia may be treated with enteral potassium supplements in the form of pills. This is the safest and most effective treatment for hypokalemia. Symptomatic or severe hypokalemia should be corrected with a solution of intravenous potassium. For people taking diuretics, potassium supplements are not necessary as long as they eat a balanced diet containing foods rich in potassium. But if hypokalemia has already occurred, use of the high potassium diet alone may not reverse hypokalemia. The treatment of the patient’s hypokalemia consisted of kalium durule (C: mineral and electrolyte replacement or supplement; A: replaces potassium and maintains potassium level , 2 durules TID per NGT. Surgical Management Management is nonsurgical. Medical therapy is aimed at potassium supplementation by the enteral (ie, oral or through feeding tubes) or parenteral route. Potassium supplements restore body potassium storage. Electrolytes are used to correct disturbances in fluid and electrolyte homoeostasis or acid-base balance and to reestablish osmotic equilibrium of specific ion..
HYPOXIC-ISCHEMIC ENCEPHALOPATHY Definition This is a serious condition causing significant mortality and long-term morbidity. HIE is characterized by clinical and laboratory evidence of acute or subacute brain injury due to asphyxia (ie, hypoxia, acidosis). This damages the cells in the central nervous system (the brain and spinal cord) from inadequate oxygen. Most often, the underlying cause remains unknown. Hypoxic-ischemic encephalopathy allegedly may cause in death or result in what is later recognized as developmental delay, mental retardation, or cerebral palsy. The time of brain injury often remains uncertain, and an abnormal brain (eg, growth failure, impaired development) might be an underlying risk factor. Symptoms May show symptoms of developmental delay, mental retardation, cerebral palsy and growth failure. Causes Brain hypoxia and ischemia due to systemic hypoxemia, reduced cerebral blood flow or both are the primary physiological processes that trigger HIE. A possible cause in the patient’s case is the occurrence of respiratory arrest, secondary to weakness of respiratory muscles while he was in the ICU, leading to the lack of delivery of oxygen to the brain. He complained of dyspnea, and metabolic acidosis was revealed. Diagnosis Diagnosis of HIE is made based on the history and physical and neurological examinations. Many of the tests are performed to assess the severity of brain injury and to monitor the functional status of systemic organs. The results of the tests should be interpreted in conjunction with the clinical history and the findings from physical examination. Cranial ultrasound can also reveal internal hemorrhage; however, visualizations may be difficult in routine ultrasound examination. A CT scan of the head can be useful to confirm cerebral edema (obliteration of cerebral ventricles, blurring of sulci). Echocardiography (ECHO) also helps to define myocardial contractility and the existence of structural heart defects, if any. Medical Management Seizures are generally self-limited, but may significantly compromise other body functions such as maintenance of ventilation, oxygenation, and blood pressure. Seizures should be treated early and be well controlled, since even asymptomatic seizures (ie, seen only on EEG) may continue to injure the brain. Fluid and glucose homeostasis should also be achieved. Avoid hypoglycemia or hyperglycemia, as both are known to cause brain injury. Treatment is supportive and directed at the organ system manifestations. For the brain injury, no established effective treatment is used. Citicoline (Somazine) can be used as a neuroprotectant(C: CNS stimulant; A: it produces CNS stimulation by increasing level of neurotransmitters in the CNS. Produce CNS stimulation and respiratory stimulation dilated pupils, increase motor activity and mental alertness, and a diminished sense of fatigue.); . Surgical Management In cases of posterior cranial fossa hematoma, surgical drainage may be lifesaving if no additional pathologies are present
NOSOCOMIAL PNEUMONIA Definition Hospital-acquired pneumonia, also called nosocomial pneumonia, is an infection that patients get while they’re in the hospital. This means the infection is not present at the time a patient is admitted to the hospital. Pathogens thrive in hospitals that could not survive in other environments. These pathogens include resistent aerobic gram-negative rods, such as Pseudomonas, Enterobacter and Serratia; resistent gram positive cocci, such as ORSA. Because of risk factors, underlying morbidity and resistent bacteria, hospital-acquired pneumonia tends to be more deadly than its community counterpart. Hospital acquired pneumonia occurs mostly in patients who are severely debilitated or who are immune suppressed. Nosocomial pneumonia can generally be described as “early nosocomial” (appearing within five days of hospitalization) or “late nosocomial” (more than five days after hospitalization). The nosocomial pneumonia of our patient was identified on the 3 rd day at the ICU which is also the 3rd day of his admission. The organisms leading to community-acquired pneumonia, predominantly Gram-positive cocci, are seen in patients present with pneumonia very shortly after admission to hospital (if no antibiotic therapy has so far been given) and Gram-negative bacilli predominate in patients developing pneumonia after five days of hospitalization. The preliminary result of the tracheal aspirate revealed gram (-) woffi, acinetobacter hypersensitive to Ciprofloxacin and Piperacillin. Symptoms These may include fever, shortness of breath, and a cough that produces yellow, green, or gray sputum from the respiratory tract. Because nosocomial pneumonia is such a serious infection, patients may need to receive more than one type of antibiotic to treat it. Getting pneumonia while in the hospital may prolong the hospital stay, and intravenous (I.V.) antibiotic treatment usually lasts for up to 2 weeks. If patients begin to feel better, they may be switched from I.V. treatment to oral (tablet) treatment. Patient had a productive cough with whitish sputum. Rales were heard on both lung fields. Causes Increased duration of hospital stay (risk increases with >14 days of stay). • Trauma (particularly head trauma). • Chronic underlying diseases (e.g. diabetes and chronic lung disease). • Immunosuppression. • General anaesthetic. • Endotracheal intubations. The patient was intubated for 12 days in the ICU, starting on his first day in the ICU • Hospital admission during the previous month. • Antibiotic history. • Diagnosis • X-ray or CT scan.
Purulent sputum. • Fever. • Leucocytosis or leucopenia. • Laboratory Tests • Blood cultures • Sputum Gram stain and culture The patient’s culture of sputum aspirate revealed gram (-) woffi, acinetobacter hypersensitive to Ciprofloxacin (C: Fluroquinolones; A: it inhibits bacterial cell wall synthesis) and Piperacillin (C: Penicillin A: An extended-spectrum penicillin that inhibits cell-wall synthesis during microorganism multiplication.) Treatment Antibiotics used for hospital-acquired pneumonia include aminoglycosides, fluoroquinolones, carbapenems, and vancomycin.. Multiple antibiotics are administered in combination in order to cover all the possible organisms effectively and rapidly, before the infectious agent can be known. The antibiotics administered to the patient are the ff:. Ciprofloxacin 500mg 1 and ½ tab BID (C: Fluroquinolones; A: it inhibits bacterial cell wall synthesis); Clindamycin 300g 1 cup every 6 hrs (C: miscellaneous anti-infective; A: inhibits bacterial protein synthesis by binding to the 50S subunit of the ribosome) and Piperacillin + Tazobactam 4.5 gm IVTT (C: Penicillin A: An extended-spectrum penicillin that inhibits cell-wall synthesis during microorganism multiplication. Tazobactam increases piperacillin’s effectiveness by inactivating beta-lactamases, which destroy penicillins). Management Antibiotic treatment must be started promptly. URINARY TRACT INFECTION Definition The second most common type of infection in the body. Women are especially prone to UTIs. One woman in five develops a UTI during her lifetime. UTIs in men are not as common as in women but can be very serious when they do occur. The urinary system consists of the kidneys, ureters, bladder, and urethra. The key elements in the system are the kidneys, a pair of purplish-brown organs located below the ribs toward the middle of the back. The kidneys: • remove excess liquid and wastes from the blood in the form of urine • keep a stable balance of salts and other substances in the blood, and • produce a hormone that aids the formation of red blood cells.
The narrow tubes called ureters, carry urine from the kidneys to the bladder, a sack-like organ in the lower abdomen. Urine is stored in the bladder and emptied through the urethra Urine is normally sterile -- thus, it does not normally contain bacteria. This is a good thing, since the mineral and sugar content of urine makes it a great medium for bacteria to grow in. Several things keep bacteria out of the urine. These include: · The urethral sphincter: when the urethra is squeezed shut, bacteria cannot climb up the urethra from the quot;meatusquot; (the outside opening) into the bladder. · The length of the urethra: it's a long way up to the bladder for a bacterium. (A woman's urethra is shorter than a man's, which is one reason why women are much more likely than men to get UTI's.) · Frequent washing: any bacteria that make it into the urethra are flushed out the next time you urinate, and since most people empty their bladders almost completely when they urinate any bacteria that get to the bladder will be flushed out too. There are also valves where the ureters enter the bladder to prevent urine from quot;refluxingquot; from the bladder to the kidneys, so even if the bladder and its urine is infected the bacteria shouldn't travel up to the kidneys. Symptoms Not everyone with a UTI has symptoms, but most people get at least some symptoms. These may include a frequent urge to urinate and a painful, burning feeling in the area of the bladder or urethra during urination. Often women feel an uncomfortable pressure above the pubic bone, and some men experience a fullness in the rectum. It is common for a person with a urinary infection to complain that, despite the urge to urinate, only a small amount of urine is passed. The urine itself may look milky or cloudy, even reddish if blood is present. A UTI does not normally cause fever if it is in the bladder or urethra. A fever may mean that the infection has reached the kidneys. Other symptoms of a kidney infection include pain in the back or side below the ribs, nausea, or vomiting. Cystitis may show up as burning on urination, often in the quot;middlequot; of urination. However, it may have no symptoms other than fever, lower abdominal (just above the pubic bone) pain, or even just a funny smell or colour or appearance (cloudy, dark, even blood-tinged) to your urine. And since kidneys are located at back, just below the bottom ribs, pyelonephritis may appear as pain at the back or flank(s), or in the abdomen. Fever usually (but not always) comes along with the pain. If the kidneys are severely affected, one may also start seeing some of the complications due to kidney malfunction. Complications The biggest problem with a UTI is if it progresses to pyelonephritis. This can result in scarring and damage to the kidney tissue. If there is enough damage to the filter system, waste products can't be removed properly. This constitutes kidney failure, and if it is bad enough and long-lasting enough, the only solutions are dialysis (filtering blood through an quot;artificial kidneyquot;) or a kidney transplant A different complication occurs if the pressure-regulation tissues in the kidney are scarred. If this is bad enough, your blood pressure may be kept too low (and one may faint frequently at the very least) or too high (leading to strokes, heart disease). Causes
Since urine is normally sterile. It is usually free of bacteria, viruses, and fungi but does contain fluids, salts, and waste products. An infection occurs when tiny organisms, usually bacteria from the digestive tract, cling to the opening of the urethra and begin to multiply. The urethra is the tube that carries urine from the bladder to outside the body. Most infections arise from one type of bacteria, Escherichia coli (E. coli), which normally lives in the colon. In many cases, bacteria first travel to the urethra. When bacteria multiply, an infection can occur. • An infection limited to the urethra is called Urethritis. This can be due to other things besides the organisms usually involved in UTI's; in particular, many sexually-transmitted diseases (STD's) appear initially as urethritis. Another is stool-related bacteria (the most common bacteria on the skin near the meatus) will also often cause urethritis. • If bacteria move to the bladder and multiply, a bladder infection, called Cystitis, results. This is the most common form of UTI; it can be aggravated if the bladder does not empty completely when urinating. • An infection of the ureter is called, Ureteritis. This can occur if the bacteria entered the urinary tract from above, or if the ureter-to-bladder valves don't work properly and allow urine to quot;refluxquot; from the bladder into the ureters. • If the infection is not treated promptly, bacteria may then travel further up the ureters to multiply and infect the kidneys. A kidney infection is called Pyelonephritis. Microorganisms called Chlamydia and Mycoplasma may also cause UTIs in both men and women, but these infections tend to remain limited to the urethra and reproductive system. Unlike E. coli, Chlamydia and Mycoplasma may be sexually transmitted, and infections require treatment of both partners. The urinary system is structured in a way that helps ward off infection. The ureters and bladder normally prevent urine from backing up toward the kidneys, and the flow of urine from the bladder helps wash bacteria out of the body. In men, the prostate gland produces secretions that slow bacterial growth. In both sexes, immune defenses also prevent infection. But despite these safeguards, infections still occur. Risk Factors Any abnormality of the urinary tract that obstructs the flow of urine (a kidney stone, for example) sets the stage for an infection. An enlarged prostate gland also can slow the flow of urine, thus raising the risk of infection. A common source of infection is catheters, or tubes, placed in the urethra and bladder. The patient has been catheterized since December 5, 2006 until December 12, 2006 (7 days), was inserted on December 14, 2006. Urinary Tract infection was diagnosed on December 26, 2006. So on December 27, 2006 FBC was removed. A person who cannot void or who is unconscious or critically ill often needs a catheter that stays in place for a long time. Some people, especially the
elderly or those with nervous system disorders who lose bladder control, may need a catheter for life. Bacteria on the catheter can infect the bladder, thus, hospital staff take special care to keep the catheter clean and remove it as soon as possible. People with diabetes have a higher risk of a UTI because of changes in the immune system. Any other disorder that suppresses the immune system raises the risk of a urinary infection. Diagnosis A sample of urine is tested for pus and bacteria. A quot;clean catchquot; urine sample is collected by washing the genital area and collecting a quot;midstreamquot; sample of urine in a sterile container. In the urinalysis test, the urine is examined for white and red blood cells and bacteria. Bacteria are then grown in a culture and tested against different antibiotics to see which drug best destroys the bacteria. This last step is called a sensitivity test. Some microbes, like Chlamydia and Mycoplasma, can be detected only with special bacterial cultures. A doctor suspects one of these infections when a person has symptoms of a UTI and pus in the urine, but a standard culture fails to grow any bacteria. The results of the patients urinalysis, revealed cloudy appearance, RBC of 5-10/hpf, epithelial cells of 2-5/hpf, moderate(++) blood, 30(++)protein and heat & acetic acid: (+) An ultrasound exam is also used, which gives pictures from the echo patterns of soundwaves bounced back from internal organs. Another useful test is cystoscopy. A cystoscope is an instrument made of a hollow tube with several lenses and a light source, which allows the doctor to see inside the bladder from the urethra. Treatment UTIs are treated with antibacterial drugs. The choice of drug and length of treatment depend on the patient's history and the urine tests that identify the offending bacteria. The sensitivity test is especially useful in helping the doctor select the most effective drug. A class of drugs called quinolones includes four drugs approved in recent years for treating UTI. These drugs include ofloxacin (Floxin), norfloxacin (Noroxin), ciprofloxacin (Cipro), and trovafloxin (Trovan). A followup urinalysis helps to confirm that the urinary tract is infection-free. It is important to take the full course of treatment because symptoms may disappear before the infection is fully cleared. Various drugs are available to relieve the pain of a UTI. A heating pad may also help. Most doctors suggest that drinking plenty of water helps cleanse the urinary tract of bacteria. During treatment, it is best to avoid coffee, alcohol, and spicy foods. And one of the best things a smoker can do for his or her bladder is to quit smoking. Smoking is the major known cause of bladder cancer.
Management • Drink plenty of water every day. • Urinate when you feel the need; don't resist the urge to urinate. • Wipe from front to back to prevent bacteria around the anus from entering the vagina or urethra. • Take showers instead of tub baths. • Cleanse the genital area before sexual intercourse. In women, avoid using feminine hygiene sprays and scented douches, which may irritate the urethra. Anatomy & Physiology Brain Major regions of the brain and their functions
The major regions of the brain are the cerebral hemispheres, diencephalon, brain stem and cerebellum. Cerebral hemispheres The cerebral hemispheres, located on the most superior part of the brain, are separated by the longitudinal fissure. They make up approximately 83% of total brain mass, and are collectively referred to as the cerebrum. The cerebral cortex constitutes a 2-4 mm thick grey matter surface layer and, because of its many convolutions, accounts for about 40% of total brain mass. It is responsible for conscious behaviour and contains three different functional areas: the motor areas, sensory areas and association areas. Located internally are the white matter, responsible for communication between cerebral areas and between the cerebral cortex and lower regions of the CNS, as well as the basal nuclei (or basal ganglia), involved in controlling muscular movement. Midbrain Function: Controls Responses to Sight, Eye Movement, Pupil Dilation, Body Movemen,t Hearing. Location: The mesencephalon/midbrain is the most rostral portion of the brainstem. It is located between the forebrain and brainstem. Forebrain Function: Chewing ,Directs Sense Impulses Throughout the Body ,Equilibrium ,Eye Movement, Vision ,Facial Sensation Hearing, Phonation ,Intelligence Memory, Personality Respiration Salivation, Swallowing Smell, Taste Location: The prosencephalon/forbreain is the most anterior portion of the brain. Diencephalon The diencephalon is located centrally within the forebrain. It consists of the thalamus, hypothalamus and epithalamus, which together enclose the third ventricle. The thalamus acts as a grouping and relay station for sensory inputs ascending to the sensory cortex and association areas. It also mediates motor activities, cortical arousal and memories. The hypothalamus, by controlling the autonomic (involuntary) nervous system, is responsible for maintaining the body’s homeostatic balance. Moreover it forms a part of the limbic system, the ‘emotional’ brain. The epithalamus consists of the pineal gland and the CSF producing choroid plexus. Brain stem The brain stem is similarly structured as the spinal cord: it consists of grey matter surrounded by white matter fibre tracts. Its major regions are the midbrain, pons and medulla oblongata. The midbrain, which surrounds the cerebral aqueduct, provides fibre pathways between higher and lower brain centres, contains visual and auditory reflex and subcortical motor centres. The pons is mainly a conduction region, but its nuclei also contribute to the regulation of respiration and cranial nerves. The medulla oblongata takes an important role as an autonomic reflex centre involved in maintaining body homeostasis. In particular, nuclei in the medulla
regulate respiratory rhythm, heart rate, blood pressure and several cranial nerves. Moreover, it provides conduction pathways between the inferior spinal cord and higher brain centres. Cerebral Cortex Lobes Frontal Lobe Function: Motor Functions Higher Order Functions Planning Reasoning Judgement Impulse Control Memory Location: The frontal lobes are the anterior portion of the cerebral cortex. Occipital Lobe Function: Controls Vision Color Recognition Location: The occipital lobes are the most caudal portion of the cerebral cortex. Parietal Lobe Function: Cognition Information Processing Pain and Touch Sensation Spatial Orientation Speech Visual Perception Location: The parietal lobes are anterior to the occipital lobes and posterior to the central sulcus (fissure) and frontal lobes. Temporal Lobe Function: Emotional Responses Hearing Memory Speech Location: The temporal lobes are anterior to the occipital lobes and lateral to the Fissure of Sylvius. Insula Function: Associated With Visceral Functions Integrates Autonomic Information Location: The insula is located within the cerebral cortex, beneath the frontal, parietal and temporal opercula. Cerebellum The cerebellum, which is located dorsal to the pons and medulla, accounts for about 11% of total brain mass. Like the cerebrum, it has a thin outer cortex of grey matter, internal white matter, and small, deeply situated, paired masses (nuclei) of grey matter. The cerebellum processes impulses received from the cerebral motor cortex, various brain stem nuclei and sensory receptors in order to appropriately control skeletal muscle contraction, thus giving smooth, coordinated movements. The cerebral circulatory system Blood is transported through the body via a continuous system of blood vessels. Arteries carry oxygenated blood away from the heart into capillaries supplying tissue cells. Veins collect the blood from the capillary bed and carry it back to the heart. The main purpose of blood flow through body tissues is to deliver oxygen and nutrients to and waste from the cells, exchange gas in the lungs, absorb nutrients from the digestive tract, and help forming urine in the kidneys. All the circulation besides the heart and the pulmonary circulation is called the systemic circulation.
The internal carotid arteries, branches of the common carotid arteries, run through the neck and enter the skull through the temporal bone. Once inside the cranium, each divides into the anterior and middle cerebral arteries, which supply most of the cerebrum. The paired vertebral arteries pass upward from the subclavian arteries at the base of the neck. Within the skull, the vertebral arteries join to form the single basilar artery, which serves the brain stem and cerebellum as it travels upward. At the base of the cerebrum, the basilar artery divides to form the posterior cerebral arteries, which supply the posterior part of the cerebrum. The anterior and posterior blood supplies of the brain are united by small communicating arterial branches. The result is a complete circle of connecting blood vessels called the circle of Willis, which surrounds the base of the brain. The circle of Willis protects the brain, because it provides more than one route for blood to reach brain tissue in case of a clot or impaired blood flow anywhere in the system. Respiratory System
The respiratory system is composed of the nose, the pharynx, the larynx, the trachea, the bronchi & their smaller branches and the lungs. The major function of this system is to supply the body with oxygen and dispose carbon dioxide from the body. During breathing, air enters the body through the nose which is the only externally visible part of the respiratory system. The air passes through the external nares then to the nasal cavity where it is first filtered and warmed. After which passes through pharynx or most commonly known as the “throat” which is the common passageway for both food and air. After passing through the pharynx, the air is now being routed to its proper channel by the larynx also known as the “voice box” which is lies just below the pharynx. The epiglottis protects the superior opening of the larynx which closes as the person swallows so that food will not enter into the trachea, also called the “windpipe”. The trachea extends from the larynx to the primary bronchi. As the air comes down the trachea and enters the right and left primary bronchi, it is again filtered by the ciliated mucosa lining which propels dust particles and other debris away from the lungs. From the subdivision of the trachea results the left and right primary bronchi which are the ones plunged into the hilus of the lungs on its sides. By the time air reaches the bronchi, it is already warm, cleansed and well humidified but because the right primary bronchi is wider, shorter and straighter than the left, inhaled foreign objects are consequently lodged in it. After the primary bronchi enter the lungs, they subdivide into smaller and smaller branches called bronchioles, until it terminates/ends in clusters of alveoli (air sacs) inside the lungs where gas exchange takes place.
The paired lungs are fairly large organs. They occupy the entire thoracic cavity except for the most central area, the mediastinum, which houses the heart, the great blood vessels, bronchi, esophagus, and other organs. The narrow superior portion of each lung, the apex, is located just deep to the clavicle. The broad lung area resting on the diaphragm is the base. Each lung is divided into lobes by fissures; the left lung has two lobes, and the right lung has three. The surface of each lung is covered with a visceral serosa called the pulmonary, or visceral, pleura and the walls of the thoracic cavity are lined by the parietal pleura. The pleural membranes produce pleural fluid, a slippery serous secretion which allows the lungs to glide easily over the thorax wall during breathing movements and causes the two pleural layers to cling together. The pleurae can slide easily from side to side across one another, but they strongly resist being pulled apart. Consequently, the lungs are held tightly to the thorax wall, and the pleural space is more of a potential space than an actual one. As described shortly, this condition of tightly adhering pleural membranes is absolutely essential for normal breathing. After the primary bronchi enter the lungs, they subdivide into smaller and smaller branches (secondary and tertiary bronchi, and so on), finally ending in the smallest of the conducting passageways, the bronchioles. Because of this branching and rebranching of the respiratory passageways within the lungs, the network formed is often referred to as the bronchial or respiratory tree. All but the smallest branches have reinforcing cartilage in their walls. The terminal bronchioles lead into respiratory zone structures, even smaller conditions that eventually terminate in alveoli, or air sacs. The respiratory zone, which includes the respiratory bronchioles, alveolar ducts, alveolar sacs, and alveoli, is the only site of gas exchange. All other respiratory passages are conducting zone structures that serve as conduits to and from the respiratory zone. There are millions of the clustered alveoli, which resemble bunches of grapes, and they make up the bulk of the lungs. The balance of the lung tissue, its stroma, is elastic connective tissue. Thus, in spite of their relatively large size, the lungs weigh only about 2 ½ pounds, and they are soft and spongy. The Respiratory Membrane The walls of the alveoli are composed largely of a single, thin layer of squamous epithelial cells. The thinness of their walls is hard to imagine, but a sheet of tissue paper is much thicker. Alveolar pores connect neighboring air sacs and provide alternate routes for air to reach alveoli whose feeder bronchioles have been clogged by mucus or otherwise blocked. The external surfaces of the alveoli are covered with a “cobweb” of pulmonary capillaries. Together, the alveolar and capillary walls and their fused basement membranes construct the respiratory membrane (air-blood barrier), which has gas (air) flowing past on one side and blood flowing past on the other. The gas exchanges occur by simple diffusion through the respiratory membrane – oxygen passing from the alveolar air into the capillary blood and carbon dioxide leaving the blood to enter the gas-filled alveolus. It has been estimated that the total gas exchange surface provided by the alveolar walls of a healthy man is 50 to 70 square meters, or approximately 50 times greater than the surface area of the skin. The final line of defense for the respiratory system is in the alveoli. Macropahges, sometimes called “dust cells,” wander in and out of the alveoli picking up bacteria, carbon particles, and other debris. Also scattered amid the epithelial cells that form most of the alveolar walls are chunky cuboidal cells, which look very different. The cuboidal cells produce a lipid (fat) molecule called surfactant, which coats the gas-exposed alveolar surfaces and is very important in lung function.
Urinary System The urinary system consists of the kidneys, ureters, urinary bladder, and urethra. The kidneys form the urine and account for the other functions attributed to the urinary system. The ureters carry the urine away from kidneys to the urinary bladder, which is a temporary reservoir for the urine. The urethra is a tubular structure that carries the urine from the urinary bladder to the outside. Kidneys The kidneys are the primary organs of the urinary system. The kidneys are the organs that filter the blood, remove the wastes, and excrete the wastes in the urine. They are the organs that perform the functions of the urinary system. The other components are accessory structures to eliminate the urine from the body. The paired kidneys are located between the twelfth thoracic and third lumbar vertebrae, one on each side of the vertebral column. The right kidney usually is slightly lower than the left because the liver displaces it downward. The kidneys protected by the lower ribs, lie in shallow depressions against the posterior abdominal wall and behind the parietal peritoneum. This means they are retroperitoneal. Each kidney is held in place by connective tissue, called renal fascia, and is surrounded by a
thick layer of adipose tissue, called perirenal fat, which helps to protect it. A tough, fibrous, connective tissue renal capsule closely envelopes each kidney and provides support for the soft tissue that is inside. In the adult, each kidney is approximately 3 cm thick, 6 cm wide, and 12 cm long. It is roughly bean-shaped with an indentation, called the hilum, on the medial side. The hilum leads to a large cavity, called the renal sinus, within the kidney. The ureter and renal vein leave the kidney, and the renal artery enters the kidney at the hilum. The outer, reddish region, next to the capsule, is the renal cortex. This surrounds a darker reddish-brown region called the renal medulla. The renal medulla consists of a series of renal pyramids, which appear striated because they contain straight tubular structures and blood vessels. The wide bases of the pyramids are adjacent to the cortex and the pointed ends, called renal papillae, are directed toward the center of the kidney. Portions of the renal cortex extend into the spaces between adjacent pyramids to form renal columns. The cortex and medulla make up the parenchyma, or functional tissue, of the kidney. The central region of the kidney contains the renal pelvis, which is located in the renal sinus and is continuous with the ureter. The renal pelvis is a large cavity that collects the urine as it is produced. The periphery of the renal pelvis is interrupted by cuplike projections called calyces. A minor calyx surrounds the renal papillae of each pyramid and collects urine from that pyramid. Several minor calyces converge to form a major calyx. From the major calyces the urine flows into the renal pelvis and from there into the ureter. Each kidney contains over a million functional units, called nephrons, in the parenchyma (cortex and medulla). A nephron has two parts: a renal corpuscle and a renal tubule.The renal corpuscle consists of a cluster of capillaries, called the glomerulus, surrounded by a double-layered epithelial cup, called the glomerular capsule. An afferent arteriole leads into the renal corpuscle and an efferent arteriole leaves the renal corpuscle. Urine passes from the nephrons into collecting ducts then into the minor calyces. The juxtaglomerular apparatus, which monitors blood pressure and secretes renin, is formed from modified cells in the afferent arteriole and the ascending limb of the nephron loop. Ureters Each ureter is a small tube, about 25 cm long, that carries urine from the renal pelvis to the urinary bladder. It descends from the renal pelvis, along the posterior abdominal wall, behind the parietal peritoneum, and enters the urinary bladder on the posterior inferior surface. The wall of the ureter consists of three layers. The outer layer, the fibrous coat, is a supporting layer of fibrous connective tissue. The middle layer, the muscular coat, consists of inner circular and outer longitudinal smooth muscle. The main function of this layer is peristalsis to propel the urine. The inner layer, the mucosa, is transitional epithelium that is continuous with the lining of the renal
pelvis and the urinary bladder. This layer secretes mucus which coats and protects the surface of the cells. Urinary Bladder The urinary bladder is a temporary storage reservoir for urine. It is located in the pelvic cavity, posterior to the symphysis pubis, and below the parietal peritoneum. The size and shape of the urinary bladder varies with the amount of urine it contains and with pressure it receives from surrounding organs. The inner lining of the urinary bladder is a mucous membrane of transitional epithelium that is continuous with that in the ureters. When the bladder is empty, the mucosa has numerous folds called rugae. The rugae and transitional epithelium allow the bladder to expand as it fills. The second layer in the walls is the submucosa that supports the mucous membrane. It is composed of connective tissue with elastic fibers. The next layer is the muscularis, which is composed of smooth muscle. The smooth muscle fibers are interwoven in all directions and collectively these are called the detrusor muscle. Contraction of this muscle expels urine from the bladder. On the superior surface, the outer layer of the bladder wall is parietal peritoneum. In all other regions, the outer layer is fibrous connective tissue. There is a triangular area, called the trigone, formed by three openings in the floor of the urinary bladder. Two of the openings are from the ureters and form the base of the trigone. Small flaps of mucosa cover these openings and act as valves that allow urine to enter the bladder but prevent it from backing up from the bladder into the ureters. The third opening, at the apex of the trigone, is the opening into the urethra. A band of the detrusor muscle encircles this opening to form the internal urethral sphincter. Urethra The final passageway for the flow of urine is the urethra, a thin-walled tube that conveys urine from the floor of the urinary bladder to the outside. The opening to the outside is the external urethral orifice. The mucosal lining of the urethra is transitional epithelium. The wall also contains smooth muscle fibers and is supported by connective tissue. The internal urethral sphincter surrounds the beginning of the urethra, where it leaves the urinary bladder. This sphincter is smooth (involuntary) muscle. Another sphincter, the external urethral sphincter, is skeletal (voluntary) muscle and encircles the urethra where it goes through the pelvic floor. These two sphincters control the flow of urine through the urethra. In females, the urethra is short, only 3 to 4 cm (about 1.5 inches) long. The external urethral orifice opens to the outside just anterior to the opening for the vagina.
In males, the urethra is much longer, about 20 cm (7 to 8 inches) in length, and transports both urine and semen. The first part, next to the urinary bladder, passes through the prostate gland and is called the prostatic urethra. The second part, a short region that penetrates the pelvic floor and enters the penis, is called the membranous urethra. The third part, the spongy urethra, is the longest region. This portion of the urethra extends the entire length of the penis, and the external urethral orifice opens to the outside at the tip of the penis. CLIENT IN CONTEXT PRESENT STATE INTERVENTIONS EVALUATION PHYSICAL EXAMINATION: Informant: father and eldest son, Date: December 13, 2006, 1:45 mostly father pm, Wednesday 65% Reliability G.M., 37 y.o., male, married, General appearance: Roman Catholic, Filipino, Seen lying on bed, awake, currently residing in Tisa conscious, responsive to pain,
afebrile, with O2 inhalation @ 2L/ Labangon, Cebu city, was minute via nasal cannula, with admitted for the first time in NGT @ left nostril, with FBC CVGH on November 24, 2006 at draining well to CDU, with the 7:00pm via taxi accompanied by following v/s: BP: 130/90 mmHg, co-worker for complaint of PR: 62 bpm, RR: 15 cpm, T: weakness on the lower extremities 36.5°C/ axilla, height: 5’6” IBW = noted 5 hours PTA, under the service of Dr. Pama of the SKIN: Department of Family Medicine warm, dry, good skin tugor, with and co-managed by Dr. Español of scalings found on both lower the Department of Internal extremities, no rashes, dark Medicine with the case # 84334. complexion, a grade 2 bed sore History of present illness: located approx. 1/2 inch in 5 days , patient had history diameter, circular in form at the of profuse diarrhea approximately inner leg of the left ankle and 10-15 episodes per day amounting approx. 2 inches in diameter, to 1cup per episode. No meds irregular in form 1 inch above the taken nor hydration correction outer right ankle done. Condition tolerated. NAIL: Few hours PTA, patient had pinkish nail bed, smooth and short, weakness of the lower extremities dirty fingernails, CRT <2 seconds, no clubbing of nails associated with numbness which HAIR & HEAD: progressively reached the level evenly distributed short, black below the umbilicus. Patient was hair, no lesions, no lice unable to stand alone, prompting infestations, no dandruff, hair is to seek consult at CVGH-(Cebu smooth, normocephalic Velez General Hospital) and subsequently admitted. Labs taken EYES: outer canthus of eye is inline with were potassium which showed the pinna, eyebrows and eyelashes hypokalemia at 1.5mmOl/L and mild QRS complexes documented evenly distributed, no discharges, on ECG. Pt. was the transferred to pinkish palpebral conjunctivae, iris
and pupil are round in shape, ICU for further monitoring. ABG sclera is white, eyes are was likewise taken because he symmetrical in shape, (+) complained of dyspnea which PERRLA,(-) cardinal gaze, (-) revealed acidosis with adequate peripheral gaze, cannot see oxygenation. EARS: On first day at ICU, pt. pinna is in line with the outer complained of persistent dyspnea. canthus of the eye, symmetrical, Pulse oximetry revealed 98-100%. no tenderness, no abnormal or foul Approval of the family was done discharges, can hear spoken words pertaining of possible intubation if at 1 ft. distance respiratory arrest would occur 30 NOSE: mins later. O2 saturated declined With NGT @ left nostril, nasal to less than 90% and was septum at midline, no discharges, subsequently intubated with patent airway, sinuses not tender, continuous ambubagging at (+) frontal and maxillary 10L/min. Along the course of transillumination intubation, pt went into MOUTH: cardiopulmonary arrest and was pinkish and moist lips, pink resuscitated accordingly. mucosa, no lesions, tongue at the floor of the mouth, 30 teeth, On the second day, CBC was NECK: taken which showed WBC of 10.4 supple, located at midline, no k/uL(4.10-10.9 k/uL) and serum tenderness, no lymphadenopathy, potassium of 2.1 mmOl/L(3.5- trachea located at midline, no 5mmOl/L). Pt was comatosed with masses or lesions noted blank stare. Citicoline 1 gm IVTT CHEST and LUNGS: (C: CNS stimulant; A: it produces Presence of tattoo located @ the CNS stimulation by increasing right scapular region, no palpable level of neurotransmitters in the lesions, no bruises, no masses CNS. Produce CNS stimulation palpated, equal chest expansion, and respiratory stimulation dilated rales on both lung fields pupils, increase motor activity and CARDIOVASCULAR: mental alertness, and a diminished
no murmurs heard, distinct S1 & sense of fatigue.); Esomeprazole S2, regular rhythm, PR:62 bpm 40mg IVTT OD (C: Anti-ulcer, ABDOMEN: proton pump inhibitor; A: binds an protuberant, umbilicus at midline, enzyme on gastric parietal cells in 5 clicks/min. no masses palpated, the presence of acidic gastric pH, no abdominal distention preventing the final transport of GENITALIA: hydrogen ion into the gastric grossly male, no discharges, no lumen); kalium durule, 2 durules lesions noted QID (C: mineral and electrolyte EXTREMITIES: replacement or supplement; A: upper extremities and lower replaces potassium and maintains extremities are symmetrical in size potassium level); sodium and in decorticate state, palpable bicarbonate gr10 1 tab TID (C: peripheral pulses, a grade 2 bed alkalinizer; A: restores buffering sore located approx. 1/2 inch in capacity of the body and diameter, circular in form at the neutralizes excess acid) were inner leg of the left ankle and likewise given. approx. 2 inches in diameter, On the third day at ICU, irregular in form 1 inch above the preliminary result of the tracheal outer right ankle aspirate revealed acinetobacter woffi sensitive to ciprofloxacin Neurologic assessment: and Piperacillin + Tazobactam. MENTAL STATUS: conscious, Thus was started on Ciprofloxacin incoherent, with GCS of 6 500mg 1 and ½ tab BID (C: SENSORY STATUS: cannot be Fluroquinolones; A: it inhibits assessed bacterial cell wall synthesis); MOTOR STATUS: cannot be Clindamycin 300g 1 cup every 6 assessed hrs (C: miscellaneous anti- infective; A: inhibits bacterial CRANIAL NERVES: protein synthesis by binding to the I: n/a 50S subunit of the ribosome) and II: n/a Piperacillin + Tazobactam 4.5 gm III, IV, VI: (+) PERRLA, (-) IVTT (C: Penicillin A: An
cardinal gaze, (-) peripheral gaze extended-spectrum penicillin that V: (+) blink reflex, can open & inhibits cell-wall synthesis during close mouth, microorganism multiplication. VII: n/a Tazobactam increases VIII: can hear spoken words at 1 piperacillin’s effectiveness by ft. distance inactivating beta-lactamases, IX, X: n/a which destroy penicillins). XI: n/a Potassium was taken with a result XII: (+) gag reflex of 3.7 mmol/L. On the 12th day of ICU, pt DEEP TENDON REFLEXES: was extubated but weaning with T- Biceps: (+), triceps (+) piece at 4 LPM was done a day before which he tolerated. Then MUSCLE STRENGTH: nebulization with Salbutamol 1/5 1/5 and Hydrocortisone was done. 1/5 1/5 Finally he was transferred to Ward Date: December 18, 2006, 10:15 though still comatose with blank am Monday stare. He had a working diagnosis of 1 Hypoxic – Ischemic General appearance: Encephalopathy 2 severe Seen lying on bed, awake, hypokalemia - corrected 3 conscious, incoherent, afebrile, Nosocomial pneumonia with NGT @ left nostril, with O2 inhalation @ 2L/minute via nasal Past history illness: cannula, with FBC draining well Patient is known to CDU, with the following v/s: hypertensive with unrecalled bp, BP: 120/80 mmHg, PR: 69 bpm, non-diabetic, non-asthmatic with RR: 22 cpm, T: 36.7°C/ axilla, no known food and drug allergies. He is a non-smoker and an SIGNIFICANT FINDINGS: occasional alcoholic beverage drinker. Heredofamilial disease • includes hypertension on maternal (-) cardinal and side and cancer on the paternal (-)peripheral gaze
• still can’t see side. • with O2 inhalation @ Previous hospitalization: 2L/min 1st hospitalization was in the • with NGT @ left nostril 1990s due to appendectomy. • presence of tattoo at right However patient’s father forgot scapular region the details pertaining to it such as • rales in both lung fields the name of the hospital, doctor, • dirty fingernails and take home meds. • with FBC draining well to 2nd hospitalization was in CDU 1993 at unrecalled hospital with • Both upper and lower the diagnosis of urolithiasis. extremities are still in Surgery was done. Number of decorticate state days in the hospital and take home • a grade 2 bed sore located meds were unrecalled. Patient’s approx. 1/2 inch in condition improved upon diameter, circular in form discharged. at the inner leg of the left 1. Health perception - Health ankle and approx. 2 inches management Pattern in diameter, irregular in When he was still residing form 1 inch above the at Manila, he had a regular check outer right ankle up at Genreal hospital, Pasig City • with scalings found both under Dr. Casino. Now that he is on lower extremities residing in Cebu for three years, Date: December 19, 2006, 10: 15 S.O. doesn’t know if the patient am Tuesday still practices regular check-ups. Patient takes OTC drugs. If he has General appearance: fever, he takes Biogesic (C: Seen lying on bed, awake, antipyretic and anti-inflammatory conscious, incoherent, afebrile, A: Inhibits the synthesis of with O2 inhalation @ 2L/minute prostaglandin that serve as via nasal cannula, with NGT @ mediators of pain and fever left nostril, with FBC draining primarily in the CNS) and if he has well to CDU, with the following v/
s: BP: 130/90 mmHg, PR: 79 bpm, colds, he takes Neozep and RR: 20 cpm, T: 365°C/ axilla, afforded relief. He does not take herbal medicines and does not SIGNIFICANT FINDINGS: believe in folk healers. S.O. doesn’t know if patient performs • (-) cardinal and TSE. Patient is fully immunized, (-)peripheral gaze and goes to the dentist when need • still can’t see arises. • with O2 inhalation @ 2. Nutritional-metabolic Pattern 2L/min Patient eats 3 to 4 times a • with NGT @ left nostril day with snacks in the morning, • presence of tattoo at right afternoon and evening. He usually scapular region eats breakfast at 7 to 8 am • rales in both lung fields comprising of egg, rice and milo. • with FBC draining well to If rice is unavailable, he replaces CDU them with bread. He takes his • Both upper and lower lunch at 12 to 1 pm and usually extremities are still in eats fried meat, at least 3cups of decorticate state rice and cold water. Dinner is • taken at around 7 – 8 pm a grade 2 bed sore located comprising of meat, at least 3 cups approx. 1/2 inch in of rice and cold water. Patient's diameter, circular in form favorite food is adobong baboy at the inner leg of the left and prefers to drink cold water. He ankle and approx. 2 inches does not have intolerance to any in diameter, irregular in type of food and can chew and form 1 inch above the swallow without difficulty. He outer right ankle does not take any vitamins and • with scalings found both supplements. The last time he took on lower extremities multivitamins is when he was 7 years old brand name unrecalled. Date: December 20, 2006 1:45 pm, Patient drinks at least 8 glasses of Wednesday water/day.
General appearance: During hospitalization, Px is Seen lying on bed, awake currently on NGT since he was conscious, inoherent, afebrile, with released at ICU at Dec 5, 2006. O2 inhalation @ 2L/minute via His diet prescription is 1800cal in nasal cannula, with NGT @ left 1000cc volume into 6 equal nostril, with FBC draining well to feedings with 300cc as CDU, with the following v/s: BP: volume/feeding. On December 18, 120/90 mmHg, PR: 66 bpm, RR: 2006 his diet prescription was 24 cpm, T: 36.6 °C/axilla increased to 2500 cal in 2500 cc volume with the same SIGNIFICANT FINDINGS: specification and 100 cc water every 4 hours per NGT. • (-) cardinal and 3. Elimination pattern Pattern (-)peripheral gaze S.O. doesn’t know patient’s • still can’t see elimination pattern before • with O2 inhalation @ admission but claimed that the px 2L/min does not use any laxatives. When • with NGT @ left nostril patient experiences constipation, • presence of tattoo at right he just drinks lots of water and scapular region when experiences diarrhea, patient • rales in both lung fields takes in Lomotil or Diatabs • with FBC draining well to During hospitalization, CDU Patient is currently w/ Foley bag • Both upper and lower catheter draining well to clsed extremities are still in drainage unit (Fbc-cdu) since decorticate state released on December 5, 2006 and • a grade 2 bed sore located urinates more than 1,000ml of approx. 1/2 inch in urine per day with a dark yellow diameter, circular in form colored urine. On December 12, at the inner leg of the left 2006 FBC was removed but ankle and approx. 2 inches patient experienced bladder in diameter, irregular in distention, which was then form 1 inch above the
outer right ankle relieved by hot and cold compress • with scalings found both but due to persistent bladder on lower extremities distention FBC, was inserted on December 14, 2006. Urinary Tract Date: January 3, 2007 9:30 am infection was diagnosed on Wednesday December 26, 2006. So on December 27, 2006 FBC was General appearance: removed and was not reinserted Seen lying on bed, asleep, afebrile, again because patient was able to with NGT @ left nostril, with the void thereafter and also due to the following v/s: BP: 120/80 mmHg, UTI. He defecates everyday with a PR: 89 bpm, RR: 20 cpm, T: yellow watery stool. Patient 36.5°C/ axilla, experiences urinary and bowel incontinence and constantly wears SIGNIFICANT FINDINGS: diaper up to present. • (-) cardinal and 4. Activity-exercise pattern (-)peripheral gaze Patient is a supervisor at • still can’t see global insurance for 3 yrs. S.O. • with NGT @ left nostril does not know his daily activities, • presence of tattoo at right and time of patient's work and scapular region patient does not engage in any • rales in both lung fields form of exercise and sports. • Both upper and lower Patient used to play basketball extremities are still in with friends at least once a week decorticate state but stopped after he got married. • with scalings found both Patient’s form of recreation
Prevention of Nosocomial Infections & Illnesses . Nosocomial infections are often caused by breaches of infection control practices and procedures, unclean ...
Anoxic or hypoxic encephalopathy may occur at any time in life. ... Infections are a cause of encephalopathy. ... Ischemic encephalopathy.
Urinary tract infections can ... Renal papillary necrosis refers to ischemic ... A European perspective on nosocomial urinary tract infections ...
What does Perinatal Infection ... GBS can cause vaginitis and urinary tract infections. ... Infants treated with antibiotics for eye infection or pneumonia ...
Hypoxic-ischemic encephalopathy is ... infancy from aspiration pneumonia or systemic infections. ... Hypoxic-ischemic brain ...
Klebsiella Infections Treatment ... Treatment of Klebsiella pneumonia has ... Hospital-acquired urinary tract infections associated with ...
Lower urinary tract infections are common in the ... of lower urinary tract infection in ... tract is the most common source of nosocomial ...
... loss from the gastrointestinal tract or kidneys. The changes of hypokalemia may include vacuolation of ... urinary tract infection ...