Republic of the Philippines UNIVERSITY OF NORTHERN PHILIPPINES Tamag, Vigan City

COLLEGE OF NURSING
A Case Study on

Atrial Septal defect Hospital acquired pneumonia Acute urinary retention

In Partial Fulfillment of the Requirement of the subject: Nursing Elective 2 Metro Vigan Cooperative Hospital Intensive Care Unit

Presented To:

Presented By:

Republic of the Philippines UNIVERSITY OF NORTHERN PHILIPPINES Tamag, Vigan City

COLLEGE OF NURSING
Grading Sheet
Categories Percentage Actual Grade

Introduction and Objectives Personal Date Nursing History of Past and Present Illness PEARSON Assessment Diagnostics (Idela and Actual) Anatomy and Physiology Algorithm and Explanation of Pathophysiology Medical and Surgical Management Nursing Care Plan Promotive and Preventive Management Drug Study Discharge Planning Updates Bibliography Organization and Punctuality Total C. I. Remarks

5 2.5 2.5 15 5 5 15 5 20 5 5 5 5 2.5 2.5 100

Clinical Instructor

INTRODUCTION
This is a case of Sergio Abbago, 75 years old, male, widower, Filipino, Roman Catholic, born on April 5, 1936 in San Quintin, Abra currently residing in the same locality. He was admitted in Metro Vigan Cooperative Hospital on February 8, 2012 due to difficulty of breathing and bipedal edema. After thorough investigation, atrial septal defect, hospital acquired pneumonia and acute urinary retention was found out. One of the more commonly recognized congenital cardiac anomalies presenting in adulthood, Atrial Septal defect (ASD) is characterized by a defect in the interatrial septum allowing pulmonary venous return from the left atrium to pass directly to the right atrium. Depending on the size of the defect, size of the shunt, and associated anomalies, this can result in a spectrum of disease from no significant cardiac sequelae to right-sided volume overload, pulmonary arterial hypertension, and even atrial arrhythmias. Hospital-acquired pneumonia on the other hand is an infection of the lungs that occurs 24 hours after hospital stay. It tends to be more serious than other lung infections, because patients in the hospital are often sicker and unable to fight off germs and the types of germs present in a hospital are often more dangerous than those encountered in the community. It occurs more often in patients who are using a respirator machine (also called a ventilator) to help them breathe. Lastly, Acute Urinary Retention is usually symptomatic of another condition that requires treatment. At about the age of 60, men are more often affected as a result of benign prostatic hyperplasia (BPH), by obstruction in the bladder or in the tube that carries urine from the bladder outside the body (urethra), by a disruption of sensory information in the nervous system (e.g., spinal cord or nerve damage), or by distention (swelling) of the bladder (e.g., by delaying urination for a long period of time).

OBJECTIVES OF THE STUDY

General Objective: With the acquired information given by the patient and his family, we aim to present the case of patient X comprehensively and formulate a case analysis that would provide essential knowledge and skills in delivering quality health care to patients diagnosed with atrial septal defect, hospital acquired pneumonia and acute urinary retention. Specific Objectives for the Student- Nurses: 1. To present accurate patients profile 2. To obtain a comprehensive past, present and family history of patients illness. 3. To assess the health status of the patient using the cephalocaudal method and organize cues for Nursing Care Plan. 4. To know the different diagnostic examinations (ideal and actual) related to the patients case and understand the purpose and limitation of each examination. 5. To study the results/outcome of the diagnostic procedures that the patient has undergone and explain how these are related to the case of the patient. 6. To discuss the anatomy and physiology of the organ involved in the case. 7. To illustrate through a schematic diagram the pathophysiology of the patients case and explain the mechanism that is involved. 8. To present the medical and surgical management done to the patient. 9. To formulate a practical and realistic plan of care for the patient through:

a. systematic organization of the subjective and the objective cues related to the case. b. identifying and prioritizing nursing diagnoses using the PES format (ProblemEtiology-Signs/Symptoms) and according to NANDA. c. analysis of the pathophysiology of the identified diagnosis based on the presentation of the patient d. formulating appropriate nursing objectives following the SMART criteria. e. planning for independent, dependent and collaborative interventions and explaining the rationale for every intervention done. f. evaluating the degree of achievement for all the objectives set at the beginning of the intervention. 10. To make a list of the different drugs taken and is presently taking by the patient with their corresponding dosages, mechanisms of action, side/adverse effects and nursing responsibilities. 11. To formulate a Discharge Plan covering the following areas: METHOD (Medications, Exercises, Treatments, Health Teachings, Out-Patient Department and Diet). 12. To present updates related to clients case and condition. Specific Objectives for the Patient/ Family: This case study also aims to attain the following specific objectives on the part of the patient and his family: To develop an understanding about the condition of the patient. To determine the underlying risk factors that predisposed and precipitated the patient to develop the disease To be fully- informed about the significance of patients laboratory results in conjunction with his current condition. To understand, in the simplest way possible the anatomy and physiology of the organ involved in the patients disease. To gain information about the drugs administered. To develop a coordinated plan of care in partnership with the healthcare team. To recognize the importance of medical- surgical interventions being rendered to him and to gain knowledge on promotive and preventive measures that can be applied.

PATIENTS PROFILE

Personal Information: Name: Address: Birthday: Age: Sex: Civil Status: Nationality: Religion: Sergio C. Abbago San Quintin, Abra April 5, 1936 75 years old Male Widower Filipino Roman Catholic

Medical Information: Hospital: Chief complaint: Date of Admission: Time of admission: Admitting Physician: Attending physician: Metro Vigan Cooperative Hospital Difficulty of breathing and bipedal edema February 8, 2012 2:10 pm Dr. Charles Hubert Rabara Dr. Deanne Quilala Dr. Charles Hubert Rabara Dr. Robert Lim Dr. Datu Bronchial Asthma in Acute Exacerbation Chronic Heart Failure ICU (bed 5) Atrial Septal Defect, Hospital-Acquired Pneumonia and Acute Urinary Retention

Admitting Diagnosis:

Room: Final Diagnosis:

NURSING HISTORY OF PAST AND PRESENT ILLNESS

PAST HISTORY Per interview regarding the past health history of the client, pertinent data were obtained. According to his eldest son, the patient is a farmer who spends most of his time in the farm. He stayed under the sun from 8am to 5pm most of the days. Furthermore, he is not allergic to any intrinsic (certain foods and medications) or extrinsic factors (dust, environment) but admitted to have history of hypertension (mother side). He added that even his mother died due to cardiovascular problem (name was forgotten). With regards to childhood illnesses, the patient typically experienced fever, cough and colds and diarrhea. Primary interventions usually rendered include water therapy and rest. About 4-5 years ago, he noticed that his father frequently complained of DOB and easy fatigability accompanied by non-productive cough which usually lasts for weeks. The duration of DOB usually lasted about 3-5 minutes occurring right after physical exertion. Being financially handicapped, the client never had any medical consultations instead, they relied on alternative remedies such as herbal plant usage (lagundi) to manage cough in conjunction likewise with their cultural preferences of treating illnesses. Considering his personal/ health habits and practices, the client usually ate green- leafy vegetables like string beans, saluyot and horseradish (2-3 servings per meal in a day). He was not fond of eating foods rich in fats particularly meat. Moreover, he drank alcohol occasionally (2-3 bottles of any kind) but was not engaged in smoking. His water intake was estimated to be 2-3 glasses a day (about 150-200ml/ glass). Infrequently, he defecated once a day, brownish in color, formed and small in size while he voided twice a day, depending on the amount of fluid he take. His sleep pattern that usually lasts 8 hours (from 9 pm- 5 am) was enough for him. Exercise was done in the form of normal household chores (farming).

PRESENT HISTORY According to patients relative, 1 week prior to admission, patient experienced shortness of breath with easy fatigability and bipedal edema. Nine days prior to admission, he had chest xray showing gross cardiomegaly with pulmonary congestion. Patient was admitted at Abra Christian Hospital 2 days prior to admission due to persistence of the condition. The attending physician referred the patient to an internal medicine specialist so was later transferred to Metro Vigan Cooperative Hospital for further evaluation and management. Upon admission, Dr. Rabara, his attending physician assessed him thoroughly. He was put on a low salt and low fat diet. Diagnostic work up done were, Complete Blood Count, Sodium (Na), Potassium (K), Fasting Blood Sugar, Blood Urea Nitrogen, Creatinine, BUA, Lipid Profile, 12 lead ECG, Chest X-ray and Troponin T quantitative. The present IVF, D5W 1/2L was regulated to KVO and was hooked to oxygen inhalation 2-4LPM via nasal cannula. Medications started were Furosemide 20 mg IV every 8 hours, Salbutamol + Ipratropium Bromide nebulisation every 4 hours, Hydrocortisone 100mg IV every 4 hours. Patient was also referred to a Cardiologist for co-management and was scheduled for 2D echo.

PEARSON ASSESSMENT
February 13, 2012 75 years old, male, widower, Filipino, Roman Catholic and was born on April 5, 1936 currently residing at San Quintin Abra. Admitted last February 8, 2012 at 2:10pm due to Difficulty of breathing and bipedal edema According to Erick Eriksons Psychosocial Development, Patient is under Generativity vs. Stagnation. He strived to create or nurture things that will outlast them; often by having children or contributing to positive changes that benefits other people. February 14, 2012 75 years old, male, widower, Filipino, Roman Catholic and was born on April 5, 1936 currently residing at San Quintin Abra. Admitted last February 8, 2012 at 2:10pm due to Difficulty of breathing and bipedal edema He strived to create or nurture things that will outlast them; often by having children or contributing to positive changes that benefits other people.

P
Psychosocial

E
Elimination

Patient is with IFC connected to urine bag draining into yellow colored urine 970 cc in amount during the shift No bowel movement noted during the shift. With thick copious endotracheal tube aspirate No diaphoresis noted No vomiting noted

Patient is with IFC connected to urine bag draining into yellow colored urine 775 cc in amount during the shift No bowel movement noted during the shift. With thick copious endotracheal tube aspirate No diaphoresis noted No vomiting noted

A/R
Activity and rest

Patients activity is limited since he is weak and cant tolerate normal activities of his age. Usually sleeps during the shift lasting for 1- 2 hours each. Slept on the bed with side rails up in a semi fowlers position with a medium sized pillow under his head.

Patients activity is limited since he is weak and cant tolerate normal activities of his age. Usually sleeps during the shift lasting for 1- 2 hours each. Slept on the bed with side rails up in a semi fowlers position with a medium sized pillow under his head.

Safe Environment

Patients primary caregiver is his youngest daughter. He has a good skin turgor, wrinkled dry skin and fair in complexion. With slightly long and uncut nails at both upper and lower extremities. Skin is not warm to touch. Afebrile at 37.1*C Patient is placed on bed in appropriate and comfortable position (semi fowlers); side rails up; bed linens are wrinkle-free and clean. Room is well lit and ventilated. IVF is regulated accordingly and is infusing well Constant provision of safety was observed during the shift. No known allergies to drugs

Patients primary caregiver is his youngest daughter. IVF is regulated accordingly and is infusing well He has a good skin turgor, wrinkled dry skin and fair in complexion. With slightly long and uncut nails at both upper and lower extremities. Skin is not warm to touch. Afebrile at 36.2*C Patient is placed on bed in appropriate and comfortable position (semi fowlers); side rails up; bed linens are wrinkle-free and clean. Room is well lit and ventilated. IVF is regulated accordingly and is infusing well Constant provision of safety was observed during the shift. No known allergies to drugs

O
Oxygenation

Room is well ventilated With endotracheal tube connected to mechanical ventilator with the following set up: FiO2- 40% TV 450 BUR 12 PFR 60 AC mode With audible crackles noted on both lungs upon expiration With mild productive cough noted With thick copious ETA pale palpebral conjunctiva and nail beds RR:25CPM CR:110 bpm BP: 140/80mmHg No cyanosis noted

Room is well ventilated With mild productive cough noted With endotracheal tube connected to mechanical ventilator with the following set up: FiO2- 40% TV 450 BUR 8 PFR 60 SIMV mode With thick copious ETA RR:20 cpm CR:98 bpm BP: 140/90mmHg pale palpebral conjunctiva and nail beds No cyanosis noted

N
Nutrition

Not cachectic in appearance Low salt low fat diet With NGT for feeding and medications; OF 1400kcal/day every 4 hours; able to tolerate 125 cc of OF PLUS 50 CC water every 4 hours. With an IVF of D5W IL at 250 CC level for 24 hours Intake during the shift: 413.2 cc No known allergy to foods

Not cachectic in appearance Low salt low fat diet With NGT for feeding and medications; OF 1400kcal/day every 4 hours; able to tolerate 125 cc of OF PLUS 50 CC water every 4 hours. With an IVF of D5W IL at 250 CC level for 24 hours Intake during the shift: 1140cc No known allergy to foods

DIAGNOSTIC EXAMS
I. ACTUAL
COMPLETE BLOOD COUNT February 8, 2012 Hemoglobin Hematocrit RBC WBC 135-180 g/L 40-54% 4.6- 6.2 4.5-11x 10 9/L 121 L 39 L 4.31 N 11.3 H February 14, 2012 132 N 42 N 4.62 N 23.3 H February 16, 2012 145 N 47 N 5.10 N 15.4 H February 18, 2012 144 N 47 N 5.15 N 20.0 H

Implications: Increased RBC count indicates hemoconcentration(dehydration), and polycythemia vera while decreased RBC count indicates hemorrhage, anemias, hemodilution(overhydration) Increased hematocrit indicates hemoconcentration(dehydration), and polycythemia vera while decreased hematocrit indicates anemias, acute blood loss and hemodilution Increased in hemoglobin indicates hemoconcentration(dehydration), and polycythemia vera while decreased in haemoglobin results in anemias and hemodilution Nursing Responsibility Explain the purpose of the test and its procedure to the Significant Others Assist the med. Tech while obtaining specimen. Apply pressure to vein for 5 minutes after specimen is obtained Provide rest after procedure Refer the result to the physician

SERUM ELECTROLYTES Februa ry 8, 2012 N a 135148 mmol/ L 3.55.3 mmol/ L 98107 mmol/ L 137.2 N Februa ry 10, 2012 137.4 N Februa ry 13, 2012 134.0 L Februa ry 14, 2012 Februa ry 15, 2012 132 L Februa ry 16, 2012 129 L Februa ry 18, 2012 126.3 L Februa ry 19, 2012 124.2 L

----------

3.6 N

3.34 L

2.18 L

2.96 L

2.51 L

3.09 L

2.88 L

4.05 N

Cl

----------

-----------

-----------

-----------

133 H

155 H

70.5 L

75.5 L

Implications Na- muscle weakness K- hypotension,cardiac dysrhythmias, muscle weakness

Nursing Responsibility Explain the purpose of the test and its procedure to the Significant Others Assist the med. Tech while obtaining specimen. Apply pressure to vein for 5 minutes after specimen is obtained Provide rest after procedure Refer the result to the physician

BLOOD CHEMISTRY Normal values 525mg/dl 80-115 umol/L February 8, 2012 9.1 133 H February 14, 2012 -------------135 H February 15, 2012 -----------133 H February 16, 2012 -----------155 H February 18, 2012 -----------141 H

BUN CREATININE

Implication BUN -hypotension, increased respirations, overhydration Creatinine - CRF Nursing Responsibility Explain the purpose of the test and its procedure to the Significant Others Assist the med. Tech while obtaining specimen. Apply pressure to vein for 5 minutes after specimen is obtained Provide rest after procedure Refer the result to the physician TPAG Normal Values Total Protein Albumin Globulin A/G 64-83 g/L > 60 years : 24-38 23-35 g/L 0.9: 1 February 8, 2012 71 N 34 N 38 H 1.1- 1.8 : 1 H

Implication: Globulin-DHN Nursing Responsibility Explain the purpose of the test and its procedure to the Significant Others Assist the med. Tech while obtaining specimen. Apply pressure to vein for 5 minutes after specimen is obtained Provide rest after procedure Refer the result to the physician

LIPID PROFILE Normal Values 3.89- 5.83 mmol/L 210 420 umol/L <5.20 mmol/L 0.70- 1.70 mmol/L >1.56 mmol/L < 2.6 mmol/L February 9, 2012 7.4 H 851 H 3.6 N 0.81 H 1.3 N 1.95 N

FBS Uric acid Total Cholesterol Triglycerides HDL Cholesterol LDL Cholesterol Implication

FBS: infection Triglycerides: hyperlipoproteinuria, HTN Nursing Responsibility Explain procedure to patient. NPO 8 hours before exam. Notify the laboratory department to start the procedure. Apply pressure to the puncture site. ARTERIAL BLOOD GAS Normal Values 7.35- 7.45 35- 48 mmHg 83- 108 mmHg 21-28 mmol/L 95-99 February 14, 2012 7.605 H 71.5 H 77 L 71.2 H 97 N February 16, 2012 7.548 N 75.1 H 330 H 65.9 H 100 N

pH pCO2 pO2 HCO3 SO2

Nursing Responsibility Explain the purpose of the test and its procedure to the Significant Others Assist the med. Tech while obtaining specimen. Apply pressure to vein for 5 minutes after specimen is obtained Provide rest after procedure

URINALYSIS 02-10-12 Clear Yellow 1.101 5 (-) (-) (-) (-) 02-12-12 Slightly turbid Yellow 1.010 5 (-) +2 (-) (-)

Transparency Color Specific gravity pH Albumin Blood(hgb) Nitrates Sugar

Nursing Responsibility Explain procedure to patient. Collect a freshly voided urine, approximately 50ml, in a clean, dry, container and send it to the laboratory within 30mins.

Impression: Increased USG indicates fluid retention Presence of hgb in the urine indicates hemoglobinuria Chest X-Ray (01-30-12) Impression: Gross cardiomegaly with pulmonary congestion Developing pneumonia is not excluded Suspicious pulmonary nodule, Right suggests follow-up Atheromatous aorta

(02-08-12) Impression: Pneumonia with minimal pleural effusion, Right Minimal PTB, Right upper lobe not initially excluded Solitary pulmonary nodule, Right(Kochs granuloma vs. New growth) Mild cardiomegaly Atheromatous aorta

(02-13-12) Impression: Mild regression of the pneumonia infiltrate Resolution of the minimal pleural effusion, Right The solitary nodule is in the Right upper lobe is again seen (probably Kochs granuloma) Other previous chest findings are the same

Nursing Responsibility Explain procedure to patient. Foods and fluids are not restricted Assist in positioning patient Remove clothing and jewelry Tell patient to take a deep breath and hold it as the x-ray is taken.

Kidney-Ureter-Bladder Ultrasound Impression: Distended urinary bladder with significant urinary retention Mild bilateral pelvocaliectasia(probably due to pressure effect from the distended urinary bladder Unremarkable prostate gland Nursing Responsibility Explain procedure to patient. NPO 6 hours prior to abdominal studies. Assist patient in voiding and positioning. Confirm if patient has other tests that may interfere with the study like upper GI series

Echocardiogram Report Impression: Normal left ventricular dimension with adequate wall and contractility Normal left atrium dimension Dilated left atrium and right ventricle dimensions without evidences of thrombus Structurally mitral valve, aortic valve, tricuspid valve, and pulmonic valve Mitral annular calcification and aortic annular calcification structurally at main pulmonary artery dimension

Nursing Responsibility Explain procedure to patient. Foods and fluids are not restricted Assist in positioning patient Remove clothing and jewelry Tell patient to take a deep breath and hold it as the procedure is taken.

Electrocardiogram Report CR BBB Multiple PVCs RVH RAD

Nursing Responsibility Explain procedure to patient. Foods and fluids are not restricted Assist in positioning patient Remove clothing and jewelry Tell patient to take a deep breath and hold it as the procedure is taken.

II. IDEAL DIAGNOSTIC TEST ATRIAL SEPTAL DEFECT Diagnosis in children Most individuals with a significant ASD are diagnosed in utero or in early childhood with the use of ultrasonography or auscultation of the heart sounds during physical examination. Diagnosis in adults Some individuals with an ASD will have undergone surgical correction of their ASD during childhood. The development of signs and symptoms due to an ASD are related to the size of the intracardiac shunt. Individuals with a larger shunt tend to present with symptoms at a younger age. Adults with an uncorrected ASD will present with symptoms of dyspnea on exertion (shortness of breath with minimal exercise), congestive heart failure, or cerebrovascular accident (stroke). They may be noted on routine testing to have an abnormal chest x-ray or an abnormal ECG and may have atrial fibrillation. Physical exam auscultation of the heart

The physical findings in an adult with an ASD include those related directly to the intracardiac shunt, and those that are secondary to the right heart failure that may be present in these individuals. Upon auscultation of the heart sounds, there may be an ejection systolic murmur that is attributed to the pulmonic valve. This is due to the increased flow of blood through the pulmonic valve rather than any structural abnormality of the valve leaflets. In unaffected individuals, there are respiratory variations in the splitting of the second heart sound (S2). During respiratory inspiration, the negative intrathoracic pressure causes increased blood return into the right side of the heart. The increased blood volume in the right ventricle causes the pulmonic valve to stay open longer during ventricular systole. This causes a normal delay in the P2 component of S2. During expiration, the positive intrathoracic pressure causes decreased blood return to the right side of the heart. The reduced volume in the right ventricle allows the pulmonic valve to close earlier at the end of ventricular systole, causing P2 to occur earlier. In individuals with an ASD, there is a fixed splitting of S2. The reason that there is a fixed splitting of the second heart sound is that the extra blood return during inspiration gets equalized between the left and right atrium due to the communication that exists between the atria in individuals with ASD. The right ventricle can be thought of as continuously overloaded because of the left to right shunt, producing a widely split S2. Because the atria are linked via the atrial septal defect, inspiration produces no net pressure change between them, and has no effect on the splitting of S2. Thus, S2 is split to the same degree during inspiration as expiration, and is said to be fixed. Echocardiography In transthoracic echocardiography, an atrial septal defect may be seen on color flow imaging as a jet of blood from the left atrium to the right atrium. If agitated saline is injected into a peripheral vein during echocardiography, small air bubbles can be seen on echocardiographic imaging. It may be possible to see bubbles travel across an ASD either at rest or during a cough. (Bubbles will only flow from right atrium to left atrium if the RA pressure is greater than LA). Because better visualization of the atria is achieved with transesophageal echocardiography, this test may be performed in individuals with a suspected ASD which is not visualized on transthoracic imaging. Newer techniques to visualize these defects involve intracardiac imaging with special catheters that are typically placed in the venous system and advanced to the level of the heart. This type of imaging is becoming more common and involves only mild sedation for the patient typically. If the individual has adequate echocardiographic windows, it is possible to use the echocardiogram to measure the cardiac output of the left ventricle and the right ventricle independently. In this way, it is possible to estimate the shunt fraction using echocardiograpy. Transcranial Doppler (TCD) Bubble study A less invasive method for detecting a PFO or other ASDs than transesophagal ultrasound is Transcranial Doppler with bubble contrast. This method reveals the cerebral impact of the ASD or PFO. Electrocardiogram The ECG findings in atrial septal defect vary with the type of defect the individual has. Individuals with atrial septal defects may have a prolonged PR interval (a first degree heart block). The prolongation of the PR interval is probably due to the enlargement of the atria that is

common in ASDs and the increased distance due to the defect itself. Both of these can cause an increased distance of internodal conduction from the SA node to the AV node. In addition to the PR prolongation, individuals with a primum ASD have a left axis deviation of the QRS complex while those with a secundum ASD have a right axis deviation of the QRS complex. Individuals with a sinus venosus ASD exhibit a left axis deviation of the P wave (not the QRS complex). A common finding in the ECG is the presence of incomplete RBBB (Right Bundle Branch Block). In fact this finding is so characteristic that if it is absent, the diagnosis of ASD should be revised. URINARY RETENTION Urine flow tests may aid in establishing the type of micturition (urination) abnormality. Common findings, determined by ultrasound of the bladder, include a slow rate of flow, intermittent flow, and a large amount of urine retained in the bladder after urination. A normal test result should be 20-25 mL/sec peak flow rate. A post-void residual urine greater than 50 ml is a significant amount of urine and increases the potential for recurring urinary tract infections. In adults older than 60 years, 50-100 ml of residual urine may remain after each voiding because of the decreased contractility of the detrusor muscle. In chronic retention, ultrasound of the bladder may show massive increase in bladder capacity (normal capacity being 400-600 ml). Determination of the serum prostate-specific antigen (PSA) may aid in diagnosing or ruling out prostate cancer, though this is also raised in BPH and prostatitis. A TRUS biopsy of the prostate (trans-rectal ultra-sound guided) can distinguish between these prostate conditions. Serum urea and creatinine determinations may be necessary to rule out backflow kidney damage. Cystoscopy may be needed to explore the urinary passage and rule out blockages. In acute cases of urinary retention where associated symptoms in the lumbar spine are present such as pain, numbness (saddle anesthesia), parasthesias, decreased anal sphincter tone, or altered deep tendon reflexes, an MRI of the lumbar spine should be considered to further assess cauda equina syndrome. HOSPITAL-ACQUIRED PNEUMONIA In hospitalised patients who develop respiratory symptoms and fever one should consider the diagnosis. The likelihood increases when upon investigation symptoms are found of respiratory insufficiency, purulent secretions, newly developed infiltrate on the chest X-Ray, and increasing leucocyte count. If pneumonia is suspected material from sputum or tracheal aspirates are sent to the microbiology department for cultures. In case of pleural effusion thoracentesis is performed for examination of pleural fluid. In suspected ventilator-associated pneumonia it has been suggested that bronchoscopy(BAL) is necessary because of the known risks surrounding clinical diagnoses. Bronchoscopy is a technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. An instrument (bronchoscope) is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy. This allows the practitioner to examine the patient's airways for abnormalities such as foreign bodies, bleeding, tumors, or inflammation. Specimens may be taken from inside the lungs. The construction of bronchoscopes ranges from rigid metal tubes with attached lighting devices to flexible optical fiber instruments with realtime video equipment. Chest X-ray (CXR), is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are among the most common films taken, being diagnostic of many conditions. Leukocytosis is a raised white blood cell count (the leukocyte count) above the normal range in the blood. It is frequently a sign of an inflammatory response, most commonly the result of

infection, and is observed in certain parasitic infections. It may also occur after strenuous exercise, convulsions such as epilepsy, emotional stress, pregnancy and labour, anesthesia, and epinephrine administration. Thoracentesis, also known as thoracocentesis or pleural tap, is an invasive procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia.

ANATOMY AND PHYSIOLOGY OF ORGANS INVOLVED

HEART
Coronary Arteries Because the heart is composed primarily of cardiac muscle tissue that continuously contracts and relaxes, it must have a constant supply of oxygen and nutrients. The coronary arteries are the network of blood vessels that carry oxygen- and nutrient-rich blood to the cardiac muscle tissue. The blood leaving the left ventricle exits through the aorta, the bodys main artery. Two coronary arteries, referred to as the "left" and "right" coronary arteries, emerge from the beginning of the aorta, near the top of the heart. The initial segment of the left coronary artery is called the left main coronary. This blood vessel is approximately the width of a soda straw and is less than an inch long. It branches into two slightly smaller arteries: the left anterior descending coronary artery and the left circumflex coronary artery. The left anterior descending coronary artery is embedded in the surface of the front side of the heart. The left circumflex coronary artery circles around the left side of the heart and is embedded in the surface of the back of the heart. Just like branches on a tree, the coronary arteries branch into progressively smaller vessels. The larger vessels travel along the surface of the heart; however, the smaller branches penetrate the heart muscle. The smallest branches, called capillaries, are so narrow that the red blood cells must travel in single file. In the capillaries, the red blood cells provide oxygen and nutrients to the cardiac muscle tissue and bond with carbon dioxide and other metabolic waste products, taking them away from the heart for disposal through the lungs, kidneys and liver. When cholesterol plaque accumulates to the point of blocking the flow of blood through a coronary artery, the cardiac muscle tissue fed by the coronary artery beyond the point of the blockage is deprived of oxygen and nutrients. This area of cardiac muscle tissue ceases to function properly. The condition when a coronary artery becomes blocked causing damage to the cardiac muscle tissue it serves is called a myocardial infarction or heart attack. Superior Vena Cava The superior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the head and upper body feed into the superior vena cava, which empties into the right atrium of the heart. Inferior Vena Cava The inferior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the legs and lower torso feed into the inferior vena cava, which empties into the right atrium of the heart. Aorta The aorta is the largest single blood vessel in the body. It is approximately the diameter of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of the body. Pulmonary Artery

The pulmonary artery is the vessel transporting de-oxygenated blood from the right ventricle to the lungs. A common misconception is that all arteries carry oxygen-rich blood. It is more appropriate to classify arteries as vessels carrying blood away from the heart. Pulmonary Vein The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the left atrium. A common misconception is that all veins carry de-oxygenated blood. It is more appropriate to classify veins as vessels carrying blood to the heart. Right Atrium The right atrium receives de-oxygenated blood from the body through the superior vena cava (head and upper body) and inferior vena cava (legs and lower torso). The sinoatrial node sends an impulse that causes the cardiac muscle tissue of the atrium to contract in a coordinated, wave-like manner. The tricuspid valve, which separates the right atrium from the right ventricle, opens to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle. Right Ventricle The right ventricle receives de-oxygenated blood as the right atrium contracts. The pulmonary valve leading into the pulmonary artery is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the right ventricle contracts, the tricuspid valve closes and the pulmonary valve opens. The closure of the tricuspid valve prevents blood from backing into the right atrium and the opening of the pulmonary valve allows the blood to flow into the pulmonary artery toward the lungs. Left Atrium The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As the contraction triggered by the sinoatrial node progresses through the atria, the blood passes through the mitral valve into the left ventricle. Left Ventricle The left ventricle receives oxygenated blood as the left atrium contracts. The blood passes through the mitral valve into the left ventricle. The aortic valve leading into the aorta is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the left ventricle contracts, the mitral valve closes and the aortic valve opens. The closure of the mitral valve prevents blood from backing into the left atrium and the opening of the aortic valve allows the blood to flow into the aorta and flow throughout the body. Papillary Muscles The papillary muscles attach to the lower portion of the interior wall of the ventricles. They connect to the chordae tendineae, which attach to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. The contraction of the papillary muscles closes these valves. When the papillary muscles relax, the valves open. Chordae Tendineae The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. As the papillary muscles contract and relax, the chordae tendineae transmit the resulting increase and decrease in tension to the respective valves, causing them to open and close. The chordae tendineae are string-like in appearance and are sometimes referred to as "heart strings."

Tricuspid Valve The tricuspid valve separates the right atrium from the right ventricle. It opens to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle. It closes as the right ventricle contracts, preventing blood from returning to the right atrium; thereby, forcing it to exit through the pulmonary valve into the pulmonary artery. Mitral Value The mitral valve separates the left atrium from the left ventricle. It opens to allow the oxygenated blood collected in the left atrium to flow into the left ventricle. It closes as the left ventricle contracts, preventing blood from returning to the left atrium; thereby, forcing it to exit through the aortic valve into the aorta. Pulmonary Valve The pulmonary valve separates the right ventricle from the pulmonary artery. As the ventricles contract, it opens to allow the de-oxygenated blood collected in the right ventricle to flow to the lungs. It closes as the ventricles relax, preventing blood from returning to the heart. Aortic Valve The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it opens to allow the oxygenated blood collected in the left ventricle to flow throughout the body. It closes as the ventricles relax, pr eventing blood from returning to the heart.

LUNGS
The lower respiratory tract begins with the trachea, which is just below the larynx. The trachea, or windpipe, is a hollow, flexible, but sturdy air tube that contains C-shaped cartilage in its walls. The inner portion of the trachea is called the lumen. The first branching point of the respiratory tree occurs at the lower end of the trachea, which divides into two larger airways of the lower respiratory tract called the right bronchus and left bronchus. The wall of each bronchus contains substantial amounts of cartilage that help keep the airway open. Each bronchus enters a lung at a site called the hilum. The bronchi branch sequentially into secondary bronchi and tertiary bronchi. The tertiary bronchi branch into the bronchioles. The bronchioles branch several times until they arrive at the terminal bronchioles, each of which subsequently branches into two or more respiratory bronchioles. The respiratory bronchiole leads into alveolar ducts and alveoli. The alveoli are bubble-like, elastic, thin-walled structures that are responsible for the lungs most vital function: the exchange of oxygen and carbon dioxide. Each structure of the lower respiratory tract, beginning with the trachea, divides into smaller branches. This branching pattern occurs multiple times, creating multiple branches. In this way, the lower respiratory tract resembles an upside-down tree that begins with one trachea trunk and ends with more than 250 million alveoli leaves. Because of this resemblance, the lower respiratory tract is often referred to as the respiratory tree. In

descending order, these generations of branches include: trachea, right bronchus and left bronchus, secondary bronchi, tertiary bronchi, bronchioles, terminal bronchioles, respiratory bronchioles, alveoli

MALE BLADDER AND URETHRA

The urinary bladder stores urine prior to its elimination from the body (functions of the urinary system). At micturation/urination, the bladder expels urine into the urethra, leading to the exterior of the body. The bladder is a musculomembranous sac located on the floor of the pelvic cavity, anterior to the uterus and upper vagina (in females). Outer surfaces of the Bladder: The upper and side surfaces of the bladder are covered by peritoneum (also called "serosa"). This serous membrane of the abdominal cavity consists of mesthelium and elastic fibrous connective tissue. "Visceral peritoneum" covers the bladder and other abdominal organs, while "parietal peritoneum" lines the abdomen walls. Ureters: The ureters deliver urine to the bladder from the kidneys (one ureter from each kidney - see components of human urinary system). The ureters pass through the posterior surface of the bladder at the Ureter Orifices (shown above). Urine drains through the ureters directly into the bladder as there are no sphincter muscles or valves at the ureter orifices. The bladder itself consists of 4 layers:- (1) Serous - this outer layer being a partial layer derived from the peritoneum, (2) Muscular - the detrusor muscle of the urinary bladder wall, which consists of 3 layers incl. both longitudinal and circularly arranged muscle fibres, (3) Sub-mucous - a thin layer of areolar tissue loosely connecting the muscular layer with the mucous layer, and (4) Mucous - the innermost layer of the wall of the urinary bladder loosely attached to the (strong and substantial) muscular layer. The mucosa falls into many folds known as rugae when the bladder is empty or near empty. The features observable on the inside of the bladder are the ureter orifices, the trigone, and the internal orifice of the urethra. The trigone is a smooth triangular region between the openings of the two ureters and the urethra and never presents any rugae even when the bladder is empty - because this area is more tightly bound to its outer layer of bladder tissue. The internal urethral sphincter is a sphincter (circular) muscle located at the neck of the bladder and formed from a thickening of the detrusor muscle. It closes the urethra when the bladder has emptied.

Pathophysiology
Algorithm Risk Factor (Familial History of Cardiovascular Disease and HPN)

Foramen ovale after birth failed to seal entirely Atrial Septal Defect

Defect in the inter-atrial septum Dilated left atrium and right ventricle (Echocardio gram)

Blood draws back from left atrium to the right atrium (leftright-shunt)

Increase volume and pressure in the right chambers of the heart

Mixing of venous and arterial blood

Pulmonary congestion and mild Cardiomega ly (CXR)

Pulmonary hypertension

Decrease oxygenated blood in the circulation

Ventricular hypertrophy

DOB

Mechanical Ventilation

Decrease oxygen concentration in blood; low hgb (121g/dl); low HCT (39%)

Mucosal inflammation and Hypersecretion Prolonged stay in the hospital

Secretions are retained Pale palpebral conjunctiva and nail beds; RR:25CPM; CR:110 bpm

Hospital- Acquired Pnemonia

Increased WBC: 11.3x109/L

Legend:

Clouds: risk factor Circle: manifestations Rectangle: physiologic process

Explanation: The patient has Familial History of Cardiovascular Disease and HPN. Because of this, he was predisposed to develop abnormality during fetal development. His foramen ovale, an opening between the two atria which allows blood to bypass the nonfunctional fetal lungs when the fetus obtains its oxygen from the placenta may have been failed to seal entirely soon after birth. These cases often occur to 25% of all adults. Since no consultation was made, this condition arose or worsens allowing the inter-atrial septum of the patient to become defective which caused backflow of blood from left atrium to the right atrium or vice versa. This results in the mixing of arterial and venous blood, which may or may not be clinically significant. This mixture of blood may or may not result in what is known as a "shunt". The amount of shunting present, if any, dictates hemodynamic significance- a condition called Atrial Septal Defect. In fact, the usual cause of congenital heart disorders is failure of the heart structure to progress beyond an early stage of embryonic development. Since pressure is higher in the left side of the heart, blood tends to return to the right side which has lesser pressure though the created communication between the two atria. The right side of the heart contains venous blood with low oxygen content, and the left side of the heart contains arterial blood with high oxygen content. A normal heart has an inter-atrial septum that prevents oxygen-rich blood and oxygen-deficient blood from mixing together. This then causes an increase volume and pressure in the right chambers of the heart as well as mixing of venous and arterial blood. The latter caused the client to have pulmonary hypertension. The right ventricle will have to push out more blood than the left ventricle due to the left-to-right shunt. This constant overload of the right side of the heart caused an overload of the entire pulmonary vasculature. Eventually pulmonary hypertension developed. The pulmonary hypertension in turn caused the right ventricle to face increased afterload in addition to the increased preload that the shunted blood from the left atrium to the right atrium caused. The right ventricle was forced to generate higher pressures to try to overcome the pulmonary hypertension. This led to right ventricular hypertrophy. These processes gave rise to the results of the patients echocardiogram (dilated left atrium and right ventricle) and Chest X-Ra (Pulmonary congestion with mild Cardiomegaly) which led the patient to suffer from difficulty of breathing. As left-to-right shunting occurred, venous blood (oxygen-deficient) was mixed with

arterial blood (oxygen-rich) decreasing oxygenated blood to be transported in the circulation. This gave rise to low hgb (121g/dl), low HCT (39%), pale palpebral conjunctiva and nail beds. RR of 25CPM and CR of 110 bpm were compensatory mechanisms to increase the delivery of oxygen to the tissues of his body. The latter findings in conjunction with DOB subjected the client for artificial airway insertion (Mechanical Ventilator). Frequently, translaryngeal intubation is performed to clear secretions retained in the central airways. However, the presence of such an apparatus can also cause mucosal inflammation and significant mucus hypersecretion predisposing to infection and encouraging hypoxia. Since secretions were retained, aggravated by his prolonged stay in the institution, the patient then developed Hospital- Acquired Pnemonia as evidenced by an increased in his WBC (11.3x109/L).

MEDICAL AND SURGICAL MANAGEMENT

Ideal Management for Atrial Septal Defect Many patients have no symptoms, and require no medications. However, some patients may need to take medications to help the heart work better, since the right side is under strain from the extra blood passing through the ASD. Medications that may be prescribed include the following:

digoxin - a medication that helps strengthen the heart muscle, enabling it to pump more efficiently. diuretics - the body's water balance can be affected when the heart is not working as well as it could. These medications help the kidneys remove excess fluid from the body. Drugs may also be used to reduce the risk of complications after surgery. Medications may include those to: Keep the heartbeat regular. Examples include beta blockers (Lopressor, Inderal) and digoxin (Lanoxin). Reduce the risk of blood clots. Anticoagulants, often called blood thinners, can help reduce the chances of developing a blood clot and having a stroke. Anticoagulants include warfarin (Coumadin) and antiplatelet agents, such as aspirin.

Infection control

Patients with certain heart defects are at risk for developing an infection of the inner surfaces of the heart known as bacterial endocarditis. It is important that you inform all medical personnel that the patient has an ASD so they may determine if the antibiotics are necessary before a procedure.

Cardiac catheterization. A thin tube (catheter) is inserted into a blood vessel in the groin and guided to the heart. Through the catheter, a mesh patch or plug is put into place to close the hole. The heart tissue grows around the mesh, permanently sealing the hole.

Open-heart surgery. This type of surgery is done under general anesthesia and requires the use of a heart-lung machine. Through an incision in the chest, surgeons use patches or stitches to close the hole.

Ideal Medical Management for Acute Urinary Retention Complete bladder decompression: usually with a Foley urinary catheter. This can be undertaken in a community or hospital setting. The patient should then be referred to the urologists for longer term management. Silver alloy indwelling catheters for catheterizing hospitalized adults short-term (<14 days) reduces the risk of catheter acquired urinary tract infection, but the cost-effectiveness of their use remains unproven.

Ideal Medical Management for Hospital Acquired Pneumonia Treatment aims to cure the infection with antibiotics. An antibiotic is chosen based on the specific germ found by sputum culture. However, the bacteria cannot always be identified with tests. Antibiotic therapy is given to fight the most common bacteria that infect hospitalized patients, taking into account the most common bacteria in each hospital -- Staphylococcus aureus and gram-negative bacteria.

Actual Management of the Patient Upon admission, the patient was put on low salt and low fat diet. Diagnostic work up include CBC, Na-K determination, Fasting Blood Sugar (FBS), Blood Urea Nitrogen (BUN), Creatinine, Blood Uric Acid (BUA), Lipid profile, 12 lead ECG, Chest x-ray, and Troponin T Quantitative and 2D Echo. D5W 500 cc was regulated to KVO and was hooked to oxygen inhalation 2-4 lpm via nasal cannula. Medications started were Furosemide 20 mg IV Q8*, Salbutamol + Ipratropium Bromide nebulization q4*, and Hydrocortisone 100 mg IV Q4*. He was referred to a cardiologist for co-management. In the ward, additional laboratories requested were TPAG determination, sputum AFB and sputum gram stain, and also culture and sensitivity. Cefixime 750 mg IV Q8* was started. The next day, laboratory results were noted. BUA was 851 umol/L. The patient was started on Colchicine 1 tablet TID as needed, Allopurinol 100 mg 1 tablet OD and Oxygen inhalation was decreased to 1 lpm. On the same day, the patient was subjected for urinalysis, repeat Na and K, for PSA determination and Kidney Ureter Bladder-Prostate ultrasound. Azithromycin 500 mg OD was added in medication. Potassium was below normal which is 3.34 mmol/L, hence started on KCl 1 tablet once a day. Terazosin 1 g once a day was also started. February 10, 2012, patient experienced urinary retention; alternate hot and cold compress on hypogastric area was done. Dosage of Furosemide was increased to 40mg IV q12*, Ramelteon 8mg 1 tablet at bedtime was started. The patient was not relieved of bladder distention so IFC was inserted. On the fourth day, IFC was removed. Water intake was limited to 800ml/ day. He was referred to a nephrologist due to urinary retention the next day. Repeat urinalysis and prostate ultrasound was ordered. IFC was reinserted due to bladder distention. Creatinine determination was ordered. He was started on Bethanecol 23mg 1 tablet 2 times a day. Nebulization was decreased to q6*. Hydrocortisone was also decreased to every 8* for 3 doses then to consume. KCl drip was started, 40 mEqs KCl + 80 cc PNSS to run for 6* for 2 cycles. On the sixth hospital day, Cefuroxime was discontinued and was started on PiperacillinTazobactam 2.25 mg IV q8*. The patient was referred to a pulmonologist. Furosemide was shifted to oral form, 40 mg tablet once a day. He was started on Buclizine 1 tablet once a day and Carvidolol 25 mg tablet once a day. Potassium determination was repeated. IFC was removed but patient was for straight catheterization if still with no urine output. Later, the patient was noted to have chills, disorientation and incoherence and difficulty of breathing. Oxygen saturation was at 70%. He was referred to an anaesthesiologist for endotracheal intubation and was hooked to mechanical ventilator. He was then transferred to ICU for close monitoring. Patient had fever hence given Paracetamol 300mg IV q4* for fever. In the ICU, the patient removed his endotracheal tube. No respiratory distress was noted. Oxygen saturation at >90%. He was hooked back to Oxygen inhalation 2-4 Lpm per nasal cannula. Patients BP was at 80/50 mmHg. Hgt determination was at 116mg/dl. Dopamine drip was started. He was still hypotensive hence Dobutamine drip was also hooked.

On the seventh hospital day, the patient was put on soft diet with strict aspiration precaution. Budesonide nebulisation every 12* was started. Furosemide, Carvedolol and Terazosin were held. Na and K were repeated. Potassium was still low @ 2.51 mmol/L so another KCl drip was ordered for 3 cycles. The next day, the patient was noted to be restless and unable to sleep. He was given Hydroxyzine 25mg 1 tablet. The patient had one episode of seizure then had cardiopulmonary arrest. The patient was reintubated and was hooked to mechanical ventilator. Phenytoin was started 200 mg as loading dose then 100mg IV every 8 hours as maintenance dose. No BP was appreciated, hence Levophed drip was started. Diazepam 5mg IV was ordered for frank seizure. Citicholine 500mg IV once a day was started. The patient was subjected for plain cranial CT scan once stable. Chest x-ray, CBC, Na, K, Creatinine and Arterial Blood Gas were repeated. Potassium (K) was still low at 3.09 mmol/L so another cycle of KCl drip was given. NGT was inserted and osteorized feeding was started. Later, the patient had diffuse wheezes; he was given Hydrocortisone 100mg IV every 8 hours for 3 doses. He was also noted to have myoclonic jerks. Leviteracetam 500 mg 2 times a day and Divalproex 500mg 2 times a day were started. On the 9th hospital day, weaning off from mechanical ventilator was started. Inotropics were titrated to maintain systolic BP of 100 mmHg. On 10th day, the patient was noted to have a labored breathing. Oxygen inhalation was provided. Nebulization with Salbutamol+ Ipratropium was done for 3 doses, CBC, Creatinine, Na, K, and Cl were repeated. Sodium and Potassium are low so KCl drip was continued.

PROMOTIVE AND PREVENTIVE MANAGEMENT

Atrial Septal Defect
Exercise. Having an atrial septal defect usually doesn't restrict from activities or exercise as

long as it is not to strenuous. Cardiologist can help you learn what is safe.
Diet. A heart-healthy diet based on fruits, vegetables and whole grains and low in

saturated fat, cholesterol and sodium can help the patient keep his heart healthy. Eating one or two servings of fish a week also is beneficial.
Preventing infection. Some heart defects, and the repair of defects, create changes to the

surface of the heart in which bacteria can become stuck and grow into an infection (infective endocarditis).
Promote relaxation techniques like DBE and positioning every 2 hours as tolerated.

Hospital Acquired Pneumonia

Promote relaxation techniques like DBE and positioning every 2 hours as tolerated. Educate the staffs to perform handwashing Perform Chest physiotherapy unless contraindicated Render Nebulization as ordered.

Acute Urinary Retention

1. Identify patients at risk; consider age and fluid status 2. Avoid making the patient anxious as this may contribute to his inability to void 3. Assist the patient to ambulate as soon as possible unless contraindicated 4. Turn the water on so that the patient can hear it as it obliterates the sound of urination. 5. Lightly stroke the inner aspect of the thigh or apply ice to the inner thigh to stimulate trigger points thus initiating the micturition reflex.

DISCHARGE PLAN

M E T H

Home medications are not yet given since patient is still in but medications currently taking by the patient is shown in the drug study. Encourage rest in between periods of activities. Passive exercises Gentle Massage. Instruct client and relatives in the prescribed medication regimen. Encourage routine and reminders to facilitate adherence. Teach the patient and relatives on the right time to take his medications as well as other measures that will be advised by his physician The family members must provide the patient with adequate emotional support, care, and may pray for the patient Instruct the relatives of importance of aseptic technique in food preparation Instruct the relatives to serve variety of fruits and vegetables. These foods may help in the healing process and may keep his body healthy. Instruct client to comply with the prescribed medications of as well as treatments and modifications. Stress the significance of maintaining a good personal hygiene to promote sense of well- being. Providing a calm environment should also be instructed to the clients significant others for him to take enough rest periods. Instruct clients mother to attend follow up check up of her son gave by the Physician Likewise, instruct his family to seek immediate medical care if the patient experienced difficulty of breathing. Encourage to eat fruits, vegetables and whole grains and low in saturated fat, cholesterol and sodium Encourage family members to pray constantly and surrender all their worries to God especially their present condition to lessen anxiety and to promote presence of mind.

O D S

UPDATES
High prevalence of multidrug-resistant nonfermenters in hospital-acquired pneumonia in Asia Am J Respir Crit Care Med. 2011 Dec 15;184(12):1409-17. Epub 2011 Sep 15. Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) remain important causes of morbidity and mortality. Increasing antimicrobial resistance has aroused the concern of the failure of antibiotic treatment. To determine the distribution of the bacterial isolates of HAP and VAP, their antimicrobial resistance patterns, and impact of discordant antibiotic therapy on clinical outcome in Asian countries A prospective surveillance study was conducted in 73 hospitals in 10 Asian countries from 2008-2009. A total of 2,554 cases with HAP or VAP in adults were enrolled and 2,445 bacterial isolates were collected from 1,897 cases. Clinical characteristics and antimicrobial resistance profiles were analyzed. Major bacterial isolates from HAP and VAP cases in Asian countries were Acinetobacter spp., Pseudomonas aeruginosa, Staphylococcus aureus, and Klebsiella pneumoniae. Imipenem resistance rates of Acinetobacter and P. aeruginosa were 67.3% and 27.2%, respectively. Multidrug-resistant rates were 82% and 42.8%, and extensively drug-resistant rates were 51.1% and 4.9%. Multidrug-resistant rate of K. pneumoniae was 44.7%. Oxacillin resistance rate of S. aureus was 82.1%. All-cause mortality rate was 38.9%. Discordant initial empirical antimicrobial therapy increased the likelihood of pneumonia-related mortality (odds ratio, 1.542; 95% confidence interval, 1.127-2.110). Acinetobacter spp., P. aeruginosa, S. aureus, and K. pneumoniae are the most frequent isolates from adults with HAP or VAP in Asian countries. These isolates are highly resistant to major antimicrobial agents, which could limit the therapeutic options in the clinical practice. Discordant initial empirical antimicrobial therapy significantly increases the likelihood of pneumonia-related mortality.

SOURCE: http://www.ncbi.nlm.nih.gov/pubmed/21920919

Elevated blood glucose level as a risk factor of hospital-acquired pneumonia among patients treated in the intensiv care unit (ICU)] Kubisz A, Kulig J, Szczepanik AM, Solecki R. Hospital acquired-pneumonia is the most frequently occurring hospital-acquired infection in intensive care units (ICU). The study group consisted of 233 patients treated over 12 months in the ICU of the 1st Department of General Surgery and Gastroenterological Surgery Clinics, University Hospital in Krakow. Patients were divided in two groups: experimental--consisting of 92 patients with hospital-acquired pneumonia, and control--consisting of 141 patients without the disease. The following risk factors of hospital-acquired pneumonia risk were analysed for both groups: length of stay in the ICU, duration of mechanical ventilation, kind of treatment applied, presence of a gastrointestinal tube, blood glucose levels. Significantly more patients with hospital-acquired pneumonia than controls had blood glucose level above 6 mmol/l (OR = 2.23). Monitoring and maintainment of glucose level within the normal ranges is an important element of successful treatment. In fact, glucose level is the only risk factor that can be easily modified compared with other analyzed factors. SOURCE: http://www.ncbi.nlm.nih.gov/pubmed/21812227

Characterization of intensive care unit acquired hyponatremia and hypernatremia following cardiac surgery Department of Critical Care Medicine, University of Calgary, Foothills Medical Centre, Canada. tom.stelfox@albertahealthservices.ca

Although intensive care unit (ICU) acquired sodium disturbances are common in critically ill patients, few studies have examined sodium disturbances in patients following cardiac surgery. The objective of this study was to describe the epidemiology of ICU-acquired hyponatremia and hypernatremia in patients following cardiac surgery.

We identified 6,727 adults (> or =18 yr) who were admitted consecutively to a regional cardiovascular intensive care unit (CVICU) from January 1, 2000 to December 31, 2006 and were documented as having normal serum sodium levels (133 to 145 mmol.L(-1)) during the first day of ICU admission. ICU-acquired hyponatremia and hypernatremia were defined as a change in serum sodium concentration to <133 mmol.L(-1) or >145 mmol.L(-1), respectively, following ICU day one. A first episode of ICU-acquired hyponatremia and hypernatremia developed in 785 (12%) and 242 (4%) patients, respectively, (95% confidence interval [CI] 11-12% and 95% CI 3-4%, respectively), with a respective incidence density of 4.2 and 1.3 patients per 100 days of ICU admission (95% CI 4.0-4.5 and 95% CI 1.2-1.5). The incidence of ICU-acquired sodium disturbances varied according to the patients' demographic and clinical variables for both hyponatremia (age, diabetes, Acute Physiology and Chronic Health Evaluation [APACHE II] score, mechanical ventilation, length of ICU stay, serum glucose level, and serum potassium level) and hypernatremia (APACHE II score, mechanical ventilation, length of hospital stay prior to ICU admission, length of ICU stay, serum glucose level, and serum potassium level). Compared with patients with normal serum sodium levels, hospital mortality was increased in patients with ICU-acquired hyponatremia (1.6% vs 10%, respectively; P < 0.001) and ICUacquired hypernatremia (1.6% vs 14%, respectively; P < 0.001). ICU-acquired hyponatremia and hypernatremia are common complications in critically ill patients following cardiac surgery. They are associated with patient demographic and clinical characteristics and an increased risk of hospital mortality.

SOURCE: http://www.ncbi.nlm.nih.gov/pubmed/20405264