Académique Documents
Professionnel Documents
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Submitted to:
Ms. Paula Gene Maniago, ST.N
Mr. Nikko Jay Sulpot, ST.N
Practicing Clinical Instructor
And
Mrs. Marilou Dela Cruz-Sawan, RN, MN
Clinical Instructor
Submitted by:
Flauta, Reina Alyannah
Jimena, Phil Anthony
Lego, Roselle Carmi
Loquias, Mariel Anne
Mamaluba, Desiree May
Saballo, Kevin Van Erick
Table of Contents
Rationale
Goal and Objectives
Data Base
Biographical Data
Clinical Data
Family Health History
Past Health History
History of Present Illness
Definition of Diagnosis
Developmental Tasks
Physical & Neuro Assessment
Anatomy & Physiology
Pathophysiology
Medical Management
Diagnostic Exams
Management
Drug Studies
Nursing Care
Nursing Care Plans
Discharge Plan
Prognosis
References
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92
Rationale
Oxygen is one of the main needs for the bodys life-supporting functions. No one
can live without sufficient quantities of food, water, and oxygen. Of the three, oxygen is
by far the most urgently needed. If necessary, a well-nourished person can go without
food for many days or weeks, living on what are stored in the body. The need for water
is more immediate but still will not become critical for several days. The supply of
oxygen in the body is limited to a few minutes. When that supply is exhausted, death is
inevitable. Oxygenation is a dynamic interaction involved in the transportation of oxygen
to all body parts and the removal of carbon dioxide. In this rotation we had our duty in
Sta. Rosa ward at San Pedro Hospital and we conducted a study on our patients case
which has UTI, CKD secondary to diabetes and hypertensive, Pleural effusion and
ascites secondary to hypoalbumin secondary to CKD/liver pathology and DM type II
uncontrolled. Through this, we can determine the interrelationship of kidney to other
complications such as diabetes and diabetes.
Chronic kidney disease (CKD), also known as chronic renal disease, is a
progressive loss of renal function over a period of months or years. The symptoms of
worsening kidney function are unspecific, and might include feeling generally unwell and
experiencing a reduced appetite. Often, chronic kidney disease is diagnosed as a result
of screening of people known to be at risk of kidney problems, such as those with high
blood pressure or diabetes and those with a blood relative with chronic kidney disease.
Chronic kidney disease may also be identified when it leads to one of its recognized
complications, such as cardiovascular disease, anemia or pericarditis.
Recent professional guidelines classify the severity of chronic kidney disease in
five stages, with stage 1 being the mildest and usually causing few symptoms and stage
5 being a severe illness with poor life expectancy if untreated. Stage 5 CKD is also
called established chronic kidney disease and is synonymous with the now outdated
terms end-stage renal disease (ESRD), chronic kidney failure (CKF) or chronic renal
failure (CRF).
Kidney diseases rank as the number 10 killer in the Philippines causing death to
about 7,000 Filipinos every year, DOH reported. The DOH stepped up the advocacy on
kidney disease prevention in observance of the 25th year of Kidney month with theme
"25 Taong Pangunguna sa Serbisyo para sa Kalusugan ng Bato ng Sambayanang
Pilipino".
The population of Filipinos aged 20 years and above in 2005 was 46,627,172. A
prevalence of 2.6% means that 1,212,306 adult Filipinos have CKD. Philippines have a
total of 254 dialysis centers where most of the dialysis machines are located in the
National Capital Region with 41 % while Region 6 has only 5%. Iloilo and Negros
Occidental provinces have the most number of dialysis machines while the provinces of
Antique and Guimaras have none.
Chronic kidney disease is a worldwide public health problem. In the United
States, there is a rising incidence and prevalence of kidney failure, with poor outcomes
and high cost. There is an even higher prevalence of earlier stages of chronic kidney
disease.
Recent reports from the United States estimate that nearly half a million patients
in the United States were treated for end-stage renal disease (ESRD) in 2004 and by
2010 this figure is expected to increase by approximately 40%. The number of people
with renal replacement therapy has increased from 426,000 in 1990 to 1.5 million in
2000 and is expected to rise to 2.5 million by 2010. An Estimated 26 Million Adults in the
United States have Chronic Kidney Disease (CKD). In 2006, CKD was responsible for
the death of nearly 45,000 people, ranking as the ninth leading cause of death in the
United States.
A population survey in 1999-2000 found that 1 in 7 (13.4%) Australians adults
over 25 years of age have some degree of CKD.
In year 19992004 an estimated 11.5 percent of adults ages 20 or older (23
million adults) have physiological evidence of chronic kidney disease determined from
data collected through the National Health and Nutrition Examination Survey. The
frequency of CKD continues to increase worldwide as does the prevalence of end-stage
renal disease (ESRD). Consequently, the identification and reduction of CKD has
become a vital public health priority.
The reported prevalence of CKD stages 1-4 in the most recent NHANES
(national health and nutrition examination survey) between 1999 and 2006 was 26
million (13%) out of approximately 200 million United States residents aged 20 and
older. Of these, 65.3% had CKD stage 3 or 4. The most recent report of the United
States Renal Data System estimates that nearly one-half million patients in the United
States were treated for ESRD in the year 2004, and by 2010 this figure is expected to
increase by approximately 40%. The elderly are a growing segment of the population
and at increased risk for renal disease. Additionally, males and African-Americans with
pre-existing hypertension or diabetes and CKD are also at much higher risk for ESRD.
These observations have also been confirmed throughout the developed world: Europe,
Asia, Australia as well as in developing regions such as China, India and Africa.
Recent reports from the United States estimate that nearly half a million patients
in the United States were treated for end-stage renal disease (ESRD) in 2004 and by
2010 this figure is expected to increase by approximately 40%.
The economic burden for developing countries is particularly severe, partly
because CKD generally occurs at a younger age. For example, in Guatemala, 40% of
patients receiving RRT are under 40. In China, the economy will lose US$558 billion
over the next decade due to effects on death and disability attributable to chronic
cardiovascular and renal disease.
More than 80% of individuals receiving renal replacement therapy (RRT) live in
the developed world because in developing countries it is largely unaffordable. In
countries such as India and Pakistan, less than 10% of all patients who need it
receive any kind of renal replacement therapy. In many African countries there is little
or no access to RRT, meaning many people simply die.
Through this we have come up with ideas that this kind of disease are increasing
now a days. In line with nursing implications and research, we as a student nurse
should know the disease process and the possible complication that may occur if not
treated; the therapies that could help lessen the disease and the medication appropriate
for our client. By this we are conducting this case study so that we can upgrade our
knowledge and skills on how we could render our care appropriately. It will serve as a
research material in which the case is thoroughly studied. It will give the future
researcher a background on the disease and a literature on this disease and basis for
future studies.
In Nursing Education the group will learn firsthand about the client case. The
group will be the one who will learn themselves. Education and learning is not limited to
the confines of a classroom but it is also achieved through effort and exposure to actual
cases like in the clinical area
To conclude, this case study will serve as a learning tool for nursing student and
will give experiences that will broaden the groups skill in handling this condition, use of
Personal Data
Name: Pt. S
Gender: M
Age: 76 yrs old
Birthday: August 27, 1933
Birthplace: Panabo City
Nationality: Filipino
Address: 7091 Liceralde Subdivision, Panabo City
Religion: Jehovas Witnesses
Education Level: High School Graduate
Occupation: Farmer and Photographer
No. of Dependents and Siblings: Seven siblings
Marital Status: Married
Clinical Data
Benjamin
Aniano
Teodoro
Raquel
Becaya
David Sr.
Susana
Rebeca
Estrelieta
David Jr.
Levi
Legend:
Narrative:
Male
Female
?
Unknown
Hypertension
Asthma
Diabetes
Client
Deceased
Denis
Danny
Susaneth
Norodine
Juceth
10
We dont have gathered data about the grandparents of our client because he cannot remember it anymore. Both
parents of our client had already passed away due to old age and they had seven children named Benjamin as the eldest
had experienced hypertension, Raquel as the second child experience asthma, Theodoro was the third, next to him were
two siblings whom are unknown and next to them was our client David who had a diabetes and hypertension and lastly
was Becaya as the youngest. Only two of them are living, David and Becaya.
Our client marry Susana which they had nine offsprings. Their eldest was Rebeca, second is Estrelieta who had a
hypertension, third was David Jr. who also had hypertension and diabetes, fourth was Levi, next is Denis, then Danny,
then Susaneth, and then Norodine, and lastly the youngest was Juceth.
11
Past History
According to our patient, in year 1996 he experienced gangrenous at the
right leg which causes amputation of his right big toe. He was diagnosed to have
diabetes mellitus, twenty years ago and diagnosed as hypertensive, ten years
ago.
Present History
Eight days prior to admission, the patient had onset of body malaise and
numbness of lower extremities which resulted to difficulty in walking, chills were
noted and also colds and dyspnea. Consultation was done and also laboratory
tests which had a result of decrease in K, which mange by giving Kalium Dumule
and Insulin injection.
Six days prior to admission there is a presence of symptoms of CKD
which he was admitted in Panabo Polymedic Hospital. There were episodes of
fever, chills, and constipation.
Definition of Diagnosis
1. Chronic Kidney Disease (CKD) Secondary to Diabetes & Hypertensive
Nephropathy
12
DIAGNOSIS
Chronic
Kidney
Disease
(CKD)
RATIONALE
BIBLIOGRAPHY
3.
Chronic
renal
failure
represents
progressive and irreversible destruction
of kidney structures. It results in loss of
renal cells with progressive deterioration
of
glomerular
filtration,
tubular
reabsorptive capacity, and endocrine
functions of the kidney.
4.
http://en.wikipedia.org/wiiki/
Diabetes
1.
13
Professional Guide to
Diseases. 323
2. DM is a chronic disease of absolute or
Norristown
relative insulin deficiency or resistance
Road, Suite 200, Ambler.
characterized
by
disturbances
in
Lippincott Williams &
Wilkins. 8th Ed. p.865.
carbohydrate, protein, and fat metabolism.
14
Singapore. Elsevier.
p.
2.
15
RATIONALE
BIBLIOGRAPHY
1. Pleural effusion is a collection of fluid in the pleural Smeltzer, Suzanne C., EdD,
RN, FAAN, et.al (2010).
space, is rarely a disease process; it is usually
Medical- Surgical
secondary to other diseases. Normally, the pleural
Nursing. 530 Walnut
Street, Philadelphia.
space must contain only a small amount of fluid
Wolters
Kluwer health
which acts as a lubricant that allows the pleural
& Lippincott Williams &
surfaces to move without friction.
Wilkins. 12th Ed. p.574.
2. It is an abnormal collection of fluid or exudate in
the pleural cavity. The fluid maybe a transudate,
exudate, purulent drainage, chyle, or blood. I
Ascites
1. Accumulation of fluid in the peritoneal cavity that Black, Joyce M., PhD, RN,
CPSN, CWCN, FAPWCA&
results from the interaction of several
Jane Hokanson Hoaks,
pthophysologic changes. Portal hypertension,
DNSc, RN, BC (2009).
Medical- Surgical Nursing:
lowered plasma colloidal osmotic pressure, &
Clinical Management for
sodium retention all contribute to this condition.
Positive Outcomes. 3
Killiney Road # 08-01
Winsland House 1
Singapore. Elsevier.
Hypoalbumin 1. Hypoalbuminemia
(low
blood
albumin
level)
16
emia
Liver
1. A large, highly vascular organ located behind the Smeltzer, Suzanne C., EdD,
RN, FAAN, et.al (2010).
ribs in the upper right portion of the abdominal
Medical- Surgical
cavity. It is considered as a chemical factory that
Nursing. 530 Walnut
Street, Philadelphia.
manufactures, stores, alters, and excretes large
Wolters
Kluwer health
number of substances involved in metabolism. It
& Lippincott Williams &
receives nutrient-rich blood directly from the
Wilkins. 12th Ed. p.1117.
gastrointestinal tract (GI) and then either stores or
transforms these nutrients into chemicals that are Microsoft Student 2008 [DVD].
Redmond, WA: Microsoft
used elsewhere in the body for metabolic needs.
Corporation, 2007.
2. Largest internal organ of the human body. Its
essential functions include helping the body to
digest fats, storing reserves of nutrients, filtering
poisons and wastes from the blood, synthesizing a
variety of proteins, and regulating the levels of
many chemicals found in the bloodstream.
Pathology
Derrickson (2007).
Principles of Anatomy and
Physiology. 111 River
Street, Hoboken, USA.
John Wiley & Sons, Inc.
11th ed. p. 1030.
RATIONALE
1. Type 2 DM range from mostly insulin
resistance with relative insulin deficiency to
predominantly secretory defect with insulin
resistance. It is a nonketotic form of DM and
there is no autoimmune destruction of the
pancreatic islet b cells.
BIBLIOGRAPHY
Bullock, Barbara L., RN,
MSN
& Reet L. Henze, DSN,
RN (2000).
Pathophysiology.
Philadelphia. Lippincott
Williams & Wilkins.
P.696
17
Winsland House 1
3. Type 2 DM has 2 main problems and these
Singapore. Elsevier.
are insulin resistance and impaired insulin
p.1063.
secretion. Insulin resistance refers to
decreased tissue sensitivity to insulin. Smeltzer, Suzanne C., EdD,
RN, FAAN, et.al
Normally, insulin binds to special receptors
on cell surfaces and initiates a series of (2010).
Medical- Surgical
reactions involved in glucose metabolism.
Nursing. 530 Walnut
But, in type 2 DM, these intracellular
Street, Philadelphia.
reactions are diminished, making insulin less
Wolters Kluwer health
& Lippincott Williams &
effective at stimulating glucose uptake by
Wilkins. 12th Ed. p.1199.
the tissues and at regulating glucose release
by the liver.
MEANING
BIBLIOGRAPHY
Urinary Tract 1. Used to describe either an infection of a part Tortora, Gerald J. & Bryan
Derrickson (2007).
Infection
of the urinary system of the presence of
Principles of Anatomy
(UTI)
large numbers of microbes in urine. and
Physiology. 111 River
Symptoms include painful or burning
Street, Hoboken, USA.
urination, urgent and frequent urination, low
John Wiley & Sons, Inc.
back pain, and bed wetting.
11th ed. p. 1030.
2. UTIs
are
caused
by
pathogenic Smeltzer, Suzanne C., EdD,
RN, FAAN, et.al
microorganisms in the urinary tract. They are
(2010).
generally classified as infections involving
Medical- Surgical
the upper and lower urinary tract and further
Nursing. 530 Walnut
Street, Philadelphia.
classified as uncomplicated or complicated,
Wolters Kluwer health
depending
on
other
patient-related
& Lippincott Williams &
conditions.
Wilkins. 12th Ed.
p.1359.
Description
Passed or
Failed
Justification
1. Adjusting to
decreasing physical
strength and health
Passed
2. Adjusting to
retirement and
reduced income
A central
developmental task
that characterized the
transition into old age
is adjustment to
retirement. The period
after retirement has to
be filled with new
projects, but is
characterized by few
valid cultural
guidelines. The
achievement of this
task may be
obstructed by the
management of
another task, living in
a reduced income
after retirement.
Passed
Passed
19
decades, widowhood
may force older
people to adjust to
loneliness, moving to
a smaller place,and
learning about
business matters.
had 9 children.
4. Establishing an
The development of a
explicit affiliation with large part of the
one's aged group
population into old
age is historically
recent phenomenon
to modern cities.
Thus, advancements
understanding of the
aging process may
lead to identifying
further developmental
tasks associated with
gains and purposeful
lives for adults.
Passed
Passed
6. Establishing
satisfactory physical
living arrangements
Passed
20
Erikson felt that much of life is preparing for the middle adulthood stage and
the last stage recovering from it. Perhaps that is because as older adults we can often
look back on our lives with happiness and are contented, feeling fulfilled with a deep
sense that life has meaning and we've made contribution to life, a feeling Erikson called
integrity. On the other hand, some adults may reach this stage and despair at their
experiences and perceived failure.
Our patient achieved happiness and contentment in his life based on his
actions and speeches. He is faithful and devoted to his religion. When asked what his
principle in life he said is, Mamatay man kun buhi, mapabilin kay Jehovah. He is ready
to accept death completely and he has shared his experiences to his beloved
grandchildren. Even though he accepted death fully but his faith and love for his
worshipped God never changed.
Physical Assessment
21
Name: Mrs. J
Bed: 304-6
Age: 56
Status: Married
Civil
Vital Signs
Axillary T= 37.3 C, PR= 77 bpm, RR= 22, CR= 79 bpm, BP= 110/70 mmHg.
General survey
Height= 5 ft and 3 inches, weight=46 kilos, head circumference=21cm,
abdominal circumference= 28 inches. Mesomorph. No signs of distress noted upon
assessment, able to smile, cooperate well, responsive to questions, conscious and alert,
conversant. Well oriented. Show calmness during the examination. She has no IVF
infused, and was asleep at initial assessment.
Skin
Skin is brown in color, rough, dry and warm. She has good skin turgor. Brownish
discolorations that resemble freckles are observed on arms and face.
Head
Skull is round in shape, symmetrical (normocephalic). No masses noted. Facial
movement is symmetrical. Hair is dry in texture; its color is black with mimimal streaks of
gray. Scalp is clear from dandruff and lice. No scars and wounds noted.
Eyes
Has symmetrical eyebrows movement, shape and hair distribution. Eyebrows
have same color with hair. Eyelashes are evenly distributed and curled outward. Eyelids
have no discharges and bilaterally blink. Upper lid covers the small portion of the iris and
cornea. Lacrimal duct openings (puncta) are evident at nasal ends of upper and lower lid
with no tenderness noted. Palpebral conjunctiva are pinkish in color while the pupils
constricted to light (2mm), round in shape, isocoric, shows uniform convergence. She is
able to rotate eyes and has coordinated eye movements.
Ears
Auricle has same color with the skin, has symmetrical shape and located a little
bit higher than the eye. Pinnas are symmetrical, mobile, and able to recoil, with no
lesions noted. She has wet cerumen noted on both ears when pulled down and back for
better visualization. She is able to hear on both ears. Her ears lobules have holes for
jewelry.
Nose
22
Nose has uniform color and symmetrical in shape. Nasal hairs are very evident
when light is flashed through the nasal passageways; its color is black. No nasal flaring
observed upon respiration. Both nares are patent, air moves freely as client breathes
through the nares. Nasal septum is straight and in midline. Nasal mucosa is pinkish in
color, has no discharges and no lesions. No tenderness of sinuses noted.
Mouth
Lips are a little brownish in color, dry and has cracks. Tongue is in midline,
pinkish in color with thin whitish coating on top. Able to move tongue freely (up & down,
side to side). Soft palate is light pink in color while hard palate is lighter in color. Gums
are pinkish in color. Her first and second right molars of the lower teeth, and her first left
molar of the upper teeth are missing. Her teeth are a little yellow in color with few
plaques usually found on her remaining molars.
Pharynx
Uvula is found well placed in midline of soft palate. Mucosa is pinkish in color.
Tonsils are not inflamed.
Neck
Trachea is in midline. No tenderness of thyroid noted. No enlargement of the
neck noted. She is able to flex and extend neck and move it laterally (L and R).
Chest and Lungs
Breathing pattern is regular (eupnea). Anteroposterior diameter to transverse
diameter is in 1:2. Respiratory excursion is symmetrical (thumb separates to 2-3cm).
Vocal tactile fremitus is bilaterally equal. She refused to have her breasts examined.
Heart and Central Vessels
Heart sounds are regular. Pulsation of heart is heard in 4 anatomical areas but
more audible in apical area upon auscultation.
Back and Extremities
Peripheral pulses are symmetrical and regular. Nails are long and untrimmed,
pinkish in color, and have a capillary refill time of 2 sec. after blanching; and no clubbing
of fingernails were noted. Calluses were observed at the tip of her fingers and toes. Her
hands are a little rough. Muscle strength is equal on both sides of the upper and lower
extremities. Spine is a little deviated to the left as seen when client was asked to bend
over. She is able to stand and walk on both feet independently, and her movements are
well coordinated. Toes point straight ahead. And she is able to sit up straight.
Abdomen
23
Her abdomens color is same with the rest of the part of the body. Her umbilicus
is coated with blackish dirt. She has globular abdomen and dullness was noted upon
percussion.
Neurologic Assessment
Cranial Nerves: (CN1) able to identify aromas by smelling with eyes closed;
(CN2) able to see objects; (CN3) pupil constricted to light sensation; (CN4&6) able to
move eyeball downward and laterally; (CN5) able to blink eyes; (CN7) able to smile,
raise eyebrows, puff cheeks and close eyes; (CN8) able to respond to questions being
heard; (CN10) has rough and vibrating sound; (CN11) able to shrug shoulders, elevate
and flex arms and legs against resistance; (CN12) able to protrude tongue and move it
side to side.
24
25
regulating the concentrations of various electrolytes in the body fluids and maintaining
normal pH of the blood.
In addition to maintaining fluid homeostasis in the body, the urinary system
controls red blood cell production by secreting the hormone erythropoietin. The urinary
system also plays a role in maintaining normal blood pressure by secreting the enzyme
renin.
Components
of
the
Urinary
System:
The
urinary
system
26
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.
27
28
vessels. Most of the plasma leaks out into the Bowman's capsules. This is about 160
litres of liquid every 24 hours.
Most of this liquid, which we call "ultra-filtrate" is re-absorbed in the medulla and
put back into the blood. Blood supplied to the kidney contains a toxic product called urea
which must be removed from the blood. It may have too much salt and too much water.
The kidney removes these excess materials.
Glomerulus and Bowman's Capsule - This is where ultra-filtration takes place. Blood
from the renal artery is forced into the glomerulus under high pressure. Most of the liquid
is forced out of the glomerulus into the Bowman's capsule which surrounds it.
Proximal Convoluted Tubules - Proximal means "near to" and convoluted means "coiled
up" so this is the coiled up tube near to the Bowman's capsule. This is the place where
all that useful glucose is re-absorbed from the ultra-filtrate and put back into the blood. If
the glucose was not absorbed it would end up in your urine. This happens in people who
are suffering from diabetes.
Loop of Henl - This part of the nephron is where water is reabsorbed. Kidney cells in
this region spend all their time pumping sodium ions. This makes the medulla very salty;
you could say that this is a region of very low water concentration. If you remember the
definition of osmosis, you will realize that water will pass from a region of high water
concentration (the ultra-filtrate and urine) into a region of low water concentration (the
medulla) through cell membranes which are semi-permeable.
Distal Convoluted Tubules - Distal means "distant" so it is at the other end of the
nephron from the Bowman's capsule. This is where most of the salts in the ultra-filtrate
are re-absorbed.
Collecting Duct - Collecting ducts run through the medulla and are surrounded by loops
of Henl. The liquid in the collecting ducts (ultra-filtrate) is turned into urine as water and
salts are removed from it. Although our kidneys make about 160 litres of urine every 24
hours, we only produce about litre of urine. It is called a collecting duct because it
collects the liquid produced by lots of nephrons.
29
URETERS
30
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.
31
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.
32
LIVER
The liver is the largest internal organ in the body, and weighs about 3 pounds in
an adult. The liver is located in the right upper quadrant of the abdomen, just below the
diaphragm. A thick capsule of connective tissue called Glisson's capsule covers the
entire surface of the liver. The liver is divided into a large right lobe and a smaller left
lobe. The falciform ligament divides the two lobes of the liver.
Each lobe is further divided into lobules that are approximately 2 mm high and 1
mm in circumference.
These hepatic lobules are the functioning units of the liver. Each of the
approximately 1 million lobules consists of a hexagonal row of hepatic cells called
hepatocytes. The hepatocytes secrete bile into the bile channels and also perform a
33
variety of metabolic functions. Between each row of hepatocytes are small cavities
called sinusoids. Each sinusoid is lined with Kupffer cells, phagocytic cells that remove
amino acids, nutrients, sugar, old red blood cells, bacteria and debris from the blood that
flows through the sinusoids. The main functions of the sinusoids are to destroy old or
defective red blood cells, to remove bacteria and foreign particles from the blood, and to
detoxify toxins and other harmful substances. Approximately 1500 ml of blood enters the
liver each minute, making it one of the most vascular organs in the body. Seventy-five
percent of the blood flowing to the liver comes through the portal vein; the remaining
25% is oxygenated blood that is carried by the hepatic artery.
Central Role of Liver in Metabolism
The liver is vitally important in helping to maintain blood glucose levels within
normal range. After a carbohydrate-rich meal, thousands of glucose molecules are
removed from the blood and combined to form the large polysaccharide molecules
called glycogen, which are then stored in the liver. This process is glycogenesis, literally,
glycogen formation. Later, as body cells continue to remove glucose from the blood to
meet their needs, blood glucose levels begin to drop. At this time, liver cells break down
the stored glycogen, by a process called glycogenolysis, which means glycogen
splitting. The liver cells then release glucose bit by bit t the blood to maintain
homeostasis of blood glucose levels. If necessary, the liver can also make glucose from
noncarbohydrate
substances
such
as
fats
and
proteins.
This
process
is
34
nonessential amino acids and detoxify ammonia (produced when amino acids are
oxidized for energy) by converting into urea.
The liver is responsible for important functions, including:
Enzyme activation
Synthesis of plasma proteins, such as albumin and globulin, and clotting factors
for fat digestion. Bile is a combination of water, bile acids, bile pigments, cholesterol,
bilirubin, phospholipids, potassium, sodium, and chloride. Primary bile acids are
produced from cholesterol. When bile acids are converted or "conjugated" in the liver,
they become bile salts.
Bilirubin is the main bile pigment that is formed from the breakdown of heme in
red blood cells. The broken-down heme travels to the liver, where is it secreted into the
bile by the liver. Bilirubin production and excretion follow a specific pathway. When the
reticuloendothelial system breaks down old red blood cells, bilirubin is one of the waste
products. This "free bilirubin" is a lipid soluble form that must be made water-soluble to
be excreted. The conjugation process in the liver converts the bilirubin from a fat-soluble
to a water-soluble form. The liver also plays a major role in excreting cholesterol,
hormones, and drugs from the body.
The liver plays an important role in metabolizing nutrients such as carbohydrates,
proteins, and fats. The liver helps metabolize carbohydrates in three ways:
35
PANCREAS
The hormones administered by the pancreas are responsible for controlling and
manipulating blood glucose levels. The pancreas houses islets responsible for
production and secretion of the hormones, glucagon and insulin. Because of this, the
pancreas falls under both the endocrine glandular system as well as the exocrine
glandular system. The islets which produce these hormones are semi scattered
throughout the pancreas and are known as the islets of Langerhans. These particular
endocrine functioning structures are typically able to be located in the body and along
the tail of the pancreas. Alpha cells and Beta cells are the cells that are known to secrete
36
the hormones within the islets. Glucagon is administered from the Alpha cells and insulin
comes from the Beta cells. Gulcagon has an affect on insulin by providing the
appropriate stimulus for the liver to convert glycogen into glucose. The Alpha cells are
able to respond appropriately to the feedback provided and thus are able to self monitor.
High blood sugar, which is also known as hypoglycemia, can be the result of continuous
output of glucagon.
Insulins function on the human physiology is opposite of its counterpart,
glucagon. Insulin is designed to lower the blood sugar in the body. Insulin is the initiating
factor that allows blood glucose to the necessary movement through the cell
membranes. Muscular cells and adipose cells rely on this movement of glucose for their
ability to function. The glucose level within the cell drops as the glucose moves
throughout the cell membrane. Insulin is also an initiating factor in the conversion of
glucose to glycogen by the cells of the muscles and liver. This action actually assists
amino acids into the cells and provides the foundation for the creation of fats and
proteins. When Beta cells are incapable of producing the appropriate amount of insulin,
diseases
such
as
diabetes
occur.
The pancreas is rather soft, created from lobes, Measures about 6 inches long
and 1 inch thick, and performs the functions of a mixed gland. Serving both endocrine
functions and exocrine functions, the pancreas is serving dual systems. The islets of
Langerhans, or pancreatic islets, are the cell clusters responsible for the pancreas
endocrine functions. Insulin and glucagon are required hormones of the bloodstream to
maintain optimal homeostasis. Performing the exocrine functions requires the proper
ability to secrete pancreatic juices which aid in digestion. The pancreatic juice is created
within the pancreas and immediately released into the pancreatic duct which empties
into
the duodenum.
The pancreas is positioned snugly up against the greater curvature of
the stomach, which runs along the posterior wall of the abdominal cavity. It head is
located close to the duodenum, which is expanded over the central body. The tail tapers
off
near
the
location
of
the
spleen.
The exocrine secretion units are tucked inside the pancreatic lobules. These
37
secretion units are technically referred to as the pancreatic acini. The endocrine
secretion units are found right next to the exocrine secretion units, these are referred to
as pancreatic islet cells however. The pancreatic juice is secreted from the acini, and
each individual acinus has only one mere layer of epithelial acinar cells which
encompass
lumen.
Branches from the celiac plexus are responsible for the innervation of the
pancreas. The innervation of the pancreas is segregated by function; the glandular
functional
innervation
portion
is
receives
held
the parasympathetic
for
the
blood
innervation
while
sympathetic
vessels of
the
pancreas.
The splenic artery branches off into the pancreatic branch in order to deliver the
appropriate blood supply. The splenic artery is a branch from the celiac artery. The
pancreatoduodenal artery is a branch derived from the superior mesenteric artery, which
also serves the pancreas; blood flow demands. Venous return is naturally through the
splenic and superior mesenteric veins. These veins drain into the hepatic portal vein.
Presence
(+)
Mechanism/Justification
Initial decrease in beta cell
mass related to genetic
factors responsible for beta
cell
differentiation
or
presence of diabetogenic
gene.
Pancreas, similar to several
38
Age >40
Precipitating Factors
Factors
Over weight/Obesity
(+)
Presence
Mechanism/Justification
Obese
people
have
increased resistance to the
action of insulin and impaired
suppression of glucose by
liver,
resulting
both
hyperglycemia
and
hyperinsulinemia. 85% of all
people with diabetes are
obese.
Initial decrease in beta cell
mass related to presence of
Maternal Diabetes Mellitus
during pregnancy or in
uterine factors such as
intrauterine growth restriction.
Mumps, coxsackeivirus
Nitrosamines that are found
in smoked and cured meats,
are related to streptozoin that
is used to induce DM in
experimental animals, rat
poison named Vacor that
induces DM when ingested
by Human
Low potassium level impairs
release of insulin
Environment
stage)
(intrapartal
(-)
Virus Infection
(-)
Presence of Toxin
(-)
Decrease
potassium level
serum
(-)
b. Symptomatology
Symptoms
Polyuria
urination)
Presence
(excessive
(+)
Polydipsia
thirst)
(excessive
(+)
Polyphagia
hunger)
(excessive
(+)
Blurred Vision
(+)
Mechanism/Justification
Glucose exceeds the amount
that can be reabsorbed by
renal tubules this results
glycosuria.
Excess glucose in the blood
pulls water out of the cell
causing
intracellular
dehydration, including those
in thirst center.
Results from depleation of
cellular
reserves
of
carbohydrates,
fats
and
proteins.
Lens and retina are exposed
39
to hyperosmolar fluids
(+)
Lowered plasma volume
(+)
Temporary dysfunction of
peripheral sensory nerves
(-)
Hypergycemia
and
glycosuria favors growth of
yeast organisms.
Decrease insulin
(-)
Initial loss due to depleation
production/sensitivity
of water, glycogen, and
triglyceride store; chronic
loss secondary to decrease
muscle mass as amino acid
are diverted to form glucose
and ketone bodies.
Elevated Serum
The body is able to adopt ta
Glucose
a slow rise of blood glucose
level to a greater extent than
it can to a rapid rise.
Predisposing
Factors
Paresthesias
Genetics
Age >40
Pruritus, vaginitis, chronic
skin infections
Weight loss
Precipitating
Environment(intrapartal)
Toxin/Virus
Obesity
Decrease Serum Potasium
Increased Osmolarity
Often Asymptomatic
due to Glucose
Polydipsia
Polyuria
Chronic elevation of
Serum Glucose
Polyphagia
Weight loss
Diabetic
neuropathy
Small vessel
disease
Accelerated
atherosclerosis
Diabetic
retinopathy
Impaired immune
function
Hypertension
Symmetrical loss
of sensation
Diabetic
nephropathy
Numbness and
paresthesia
c. of
Schematic Tracing
Wasting
End-stage
intrinsic muscles
renal failure
Infection
Coronary artery
disease
Loss of vision
Increase
LDL levels
Delayed wound
healing
Autonomic
neuropathy
Impotence
Diabetic foot
ulceration
Dry, cracked
skin
40
Charcot changes in joints
Gastroparesis
Neurogenic
bladder
d. Narrative
Type two Diabetes Mellitus is a heterogeneous condition that describes the presence
of excess serum glucose level in association with relative insulin deficiency. Type 2
Diabetes is associated with high, normal, low insulin levels. However there is a presence
of insulin resistance thus the insulin cannot function effectively and hyperglycemia will
occur. Most people with this type of diabetes are older and obese, but type 2 Diabetes is
becoming a more common occurrence in obese adolescent. The metabolic
abnormalities that contribute in hyperglycemia in people with type 2 diabetes are
41
impaired beta cell function and insulin production, peripheral insulin resistance, and
increase hepatic glucose production.
Insulin is a anabolic hormone. Without insulin three major metabolic problem occur:
decrease glucose uptake and utilization, increase fat and lipid mobilization and
increased protein and amino acid utilization.
Beta cells chronically exposed to high blood levels of glucose become progressively
less efficient when responding to further glucose elevation. Insulin resistance initially
produces an increase beta cell secretion of insulin as body attempt to maintain
normoglycemic state. In time, however the insulin response declines because of
increasing beta cell dysfunction. This results to postprandial hyperglycemia. Eventually
fasting blood glucose level also rise until frank type 2 Diabetes occurs.
Cells that require insulin as carrier of glucose can take only 25% of glucose they
require for fuel, but nerve tissues, erythrocytes, and cells of intestine, liver, kidney
tubules do not require insulin for glucose transport. However, adipose tissue, along with
skeletal and cardiac muscle requires insulin for glucose transport.
During severe stress such as hospitalization, the body of a type 2 diabetes patient
will turn fat reserves into glucose for energy production when glucose is not available.
Fat and lipid metabolism cause breakdown products called ketones to form. Ketones
accumulate in the blood and excreted through kidneys and lungs. Ketones interfere with
the bodys acid base balance by producing Hydrogen ions. The pH can decrease, and
metabolic acidosis can result. In addition when ketone is excreted in urine, sodium is
also eliminated, causing sodium depletion and further acidosis. The excretion of ketone
also increases osmotic pressure, leading to increase fluid loss.
In this type of Diabetes Mellitus the onset of clinical manifestation may develop
gradually that clients may notice a few or no clinical manifestations for a number of year.
Some of the manifestations are frequency in urination, increase thirst or fluid intake, and
as the disease progresses, weight loss despite hunger and increased food intake.
Clients with diabetes mellitus are living longer, with an increased risk for
development of chronic complications. Chronic complication are the major cause of
morbidity and mortality in client with diabetes mellitus. Diabetes mellitus-related
complications are classified into two types: macrovascular, including coronary artery
diseases, cerebrovascular disease, hypertension, peripheral vascular disease and
infection; and microvascular, including retinopathy, nephropathy, and neuropathy.
42
The very-low density lipoprotein and low density lipoprotein level are increased and
high density lipoproteins are decreased, and the most characteristic of lipid abnormality
in diabetes mellitus is an increase triglyceride level. Therefore the influence of diabetes
in these disease are not additive, it is multiplicative. Macrovascular disease tends to
occur year before the onset of clinical diabetes mellitus.
Clients with DM are two to four times more likely to have coronary artery disease
than those who do not have DM. In many clients with DM, often presents atypical or
silent CAD, that often presents as indgestion, or unexplained heart failure, dyspnea or
excretions, or epigastric pain. CAD is common in clients younger than 40 years old, of
diabetes mellitus is of long duration. DM patients with history of myocardial infarction
have higher chance of having second infarct than the patient who does not have DM.
The incidence of cerebrovascular disease is two to three times greater in diabetic client,
and is more severe. Atherothromboembolic infarction manifested by transient ischemic
attracts and cerebrovascular accidents are the most commont incidence of CVD that are
the complication of DM.
Hypertension has increased of 40% occurrence in diabetic population. Hypertension
is a major risk factor for stroke and nephropathy.
Diabetis mellitus augments the process of atherosclerosclerosis by variety of
mechanism thus causing peripheral vascular disease. Hyperglycemia and insulin
resistance contribute to endothelial dysfunction by decreasing available nitric oxide
bioavailability and altering the function of various cell mediators.
Clients with diabetes are susceptible to different type of infection. Three factors may
contribute to the development of infection are impaired polymorphonuclear-leukocyte
function, diabetic nephropathies and vascular insufficiencies. Damaged area heals
slowly because the damaged vascular system cannot carry sufficient amount of oxygen,
white blood cells, nutrients and antibodies to the injured site. Infection increases the
need for insulin and enhances the possibility of ketoacidosis. Urinary tract infection is the
most
common
infection
especially
in
women.
Factors
that
impairs
the
43
44
Medical Management
Legend: Red HIGH
Green - LOW
1.1 ACTUAL
Date
06/26/10
Test
Chest
X-
Result
-The lungs show no
Interpretation and
Significance
Left Pleural Effusion
45
Ray
most commonly
performed diagnostic xray examination. A chest
x-ray makes images of the
heart, lungs, airways,
blood vessels and the
bones of the spine and
chest.
An x-ray (radiograph) is a
noninvasive medical test
that helps physicians
diagnose and treat
medical conditions.
Imaging with x-rays
involves exposing a part
of the body to a small
dose of ionizing
radiation to produce
pictures of the inside of
the body. X-rays are the
oldest and most frequently
used form of medical
imaging.
06/26/10
Complete
Blood
Count
Normal Values:
Hemoglobin
Erythrocyte
MCH
MCV
MCHC
Leukocytes
Neutrophils
Lymphocytes
Monocytes
Eosinophils
140-180
4.5-5.0
27-33
80-96
32-36
5-10
0.55-0.65
0.25-0.40
0.02-0.06
0.01-0.05
Hemoglobin
Erythrocyte
MCH
MCV
MCHC
121
3.88
31.1
95.0
Leukocytes
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Hematocrit
Platelet
12.1
0.70
0.17
0.08
0.05
0.00
0.37
278
Decreased hemoglobin
and erythrocyte
-indicates anemia. If
RBC is decreased, the
hemoglobin decreases
also. This means that
exchange of gases
between the alveoli, and
the capillary beds are
affected, and there will
be less oxygenated
blood circulating the
body, and hypoxia
results.
This is caused by
impaired production of
erythropoietin by the
kidney. Eythropoietin
stimulates the bone
marrow to produce blood
products especially RBC.
Increased Leukocytes
46
Basophils
Hematocrit
Platelelt
-Increase in number
indicates infection or
damage caused by
bacteria, viruses, etc.
The patient is diagnosed
to have UTI, specifically
cystitis.
0.000-0..005
0.40-0.48
150-300
Increased Neutrophils
-Also indicates infection.
Neutrophils are avid
phagocytes at sites of
acute infection.
Decreased
Lymphocytes
-Patient is prone to
immunosupression since
his lymphocytes are
small in number.
Lymphocytes play an
important role in immune
response (B and T
lymphocytes).
Increased Monocytes
-Indicates chronic
infection. Monocytes are
active phagocytes that
become macrophages in
the tissues. They are
called the long-term
clean-up team.
Decreased Hematocrit
-Hemodilution or there is
decreased concentration
of RBC in the blood.
Plasma volume is
increased because of
fluid shifting.
For 06/28/10:
Same results +
06/28/10
Hemoglobin
Erythrocyte
MCH
MCV
MCHC
Leukocytes
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Hematocrit
Platelet
107
3.46
31.0
94.7
32.8
15.5
0.70
0.16
0.08
0.05
0.01
0.37
322
High Platelet
-Risk for
coagulation/clotting, and
may lead to
arteriosclerosis due to
thrombus formation.
For 07/02/10:
47
07/02/10
Hemoglobin
Erythrocyte
MCH
MCV
MCHC
Leukocytes
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Hematocrit
Platelet
06/26/10
Urine
Culture and
Sensitivity
A urine specimen is
collected tested for growth
of microorganisms.
Antibiotics are also tested
if the discovered microbe
is sensitive to the drug.
06/26/10
Serum
Electrolytes
07/01/10
07/02/10
Normal:
Creatinine
Albumin
Sodium
Potassium
Calcium
Magnesium
Alanine
Aminotransfe
rase
53-115
34-50
136-145
3.5-5.1
2.12-2.52
0.79-0.99
30-65
94
3.10
30.4
91.8
33.1
12.6
0.78
0.13
0.05
0.04
0.00
0.28
466
Multiple Growth of
Microorganisms
Creatinine
Albumin
Sodium
Potassium
Calcium
Magnesium
Alanine
Aminotransfe
rase
272.8
17
126
4.7
1.81
0.87
37
Creatinine
Albumin
Sodium
Potassium
Calcium
359.6
25
131
4.0
2.06
Creatinine
Sodium
Potassium
389.0
131
4.2
Fatigue, lack of
concentration, poor
appetite, or trouble
sleeping
Swelling or
puffiness, particularly
around the eyes or in
the face, wrists,
abdomen, thighs or
ankles
Urine that is
foamy, bloody, or
coffee-colored
A decrease in the
amount of urine
Problems
urinating, such as a
burning feeling or
abnormal discharge
during urination, or a
change in the
frequency of urination,
especially at night
Mid-back pain
(flank), below the ribs,
near where the
kidneys are located
48
High blood
pressure
-Low sodium affects the
neuromuscular function
and water-electrolyte
balance in the body.
- On the cellular level,
calcium is used to
regulate the
permeability and
electrical properties of
biological membranes
(such as cell walls),
which in turn control
muscle and nerve
functions, glandular
secretions, and blood
vessel dilation and
contraction. Ca
deficiency can make the
muscles or tissues
spastic, therefore
contractility is impaired.
-Renal kidney
dysfunction can cause
hypoalbuminemia, since
more albumin is
excreted in the urine.
Ascites, muscle
weakness, and fatigue
can be brought about by
low albumin in the
blood.
06/27/10
Urinalysis
Straw,
amber
Transparen
t
4.5 - 8
Color
Appearance
Reaction
Specific
gravity
Chemical
Characteristics
Pus Cells
RBC
Yellow
Cloudy
6.0
1.00
Alb- trace
Sugar-+++
20-30
1-2
-Urine is not
concentrated since color
is not dark. Cloudy urine
indicates presence of
WBC, bacteria, pus,
contaminants, or
prostatic fluid.
Glycosuria indicates high
blood glucose levels and
maybe indicative of
uncontrolled DM.
Hematuria can be
caused by irritation or
injury to endothelial wall
of the ureters
Proteinuria indicates
kidney damage.
There is an increased
pus cells which means
infection is present.
49
Specific
gravity
Chemical
Characterist
ics
Pus Cells
RBC
06/26/10
ABG Test
1.0101.025
Alb- absent
Sugarabsent
1-5 hpf
none
pH
PCO2
PO2
HCO3
TCO2
BE
O2 Sat
7.37
67 acidosis
83
15 acidosis
16
-8.3
96%
pH
PCO2
PO2
HCO3
TCO2
BE
O2 Sat
7.385
27.9 alkalosis
79.8
16.3 acidosis
17.2
-6.8
95.6%
Normal Values:
pH
PCO2
PO2
HCO3
TCO2
BE
O2 Sat
7.35-7.45
35-45
80-100
22-26
25-30
+/-1
95-100%
06/27/10
06/28/10
Lipoprotein
Profile with
Glucose
and Uric
Acid
Cholesterol
LDL
TGL
HDL
Glucose
Uric Acid
4.0
3.0
1.35
0.40
6.7
0.31
-A high
PaCO2 (respiratory
acidosis) indicates
underventilation.
Carbon dioxide is
produced constantly as
the body burns energy,
and this CO2 will
accumulate rapidly if the
lungs do not adequately
dispel it
through alveolar ventilati
on. Alveolar
hypoventilation thus
leads to an
increased PaCO2 (called
hypercapnia). The
increase in PaCO2in turn
decreases the
HCO3/PaCO2 ratio and
decreases pH.
-A low HCO2 indicates
metabolic acidosis
which is a condition that
occurs when the body
produces too much acid
or when the kidneys are
not removing enough
acid from the body.
Fully Compensated
Metabolic Acidosis
50
a heart
attack or stroke caused by
blockage of blood vessels or
hardening of the arteries
(atherosclerois).
Normal Values:
Cholesterol
LDL
TGL
HDL
Glucose
Uric Acid
06/28/10
Ferritin
Test
0.0-5.2
0.0-3.4
0.00-1.70
0.90-1.55
3.9-6.1
0.16-0.43
Left Kidney
Right Kidney
11.3
Length
11.1
4.0
Width
4.7
4.6
Thick
4.9
1.8
C. Thick
1.6
Normal Values:
Men: 68-236 ng/mL
Women: 9.3-58 ng/mL
06/28/10
KUB/Prost
ate USD
It is an ultrasound-based
diagnostic medical
imaging technique used to
visualize muscles,
tendons, and many
internal organs, to capture
their size, structure and
any pathological lesions
with real time tomographic
images.
Normal Size in cm:
Left Kidney
Right Kidney
10.8 +- Length
9.7 +0.8
0.7
4.2 +
Width
4.3 +-0.5
0.5
4.8 +Thick
3.9 +0.5
0.5
1.5
C. Thick
1.5
51
Impression:
-Diffuse Bilateral Renal
Parenchymal Disease
-Cystitis
-Grade 1 Prostatic
Enlargement
-Ultrasonographically
normal ureters
-Significant urinary
bladder retention
07/2/10
Arterial
Duplex
Scan
Peripheral Arterial
Disease >50% stenosis
bilateral posterior tibilais
arteries & bilateral
dorsalis pedis arteries.
Peripheral arterial
disease <50% stenosis
bilateral common
femoral arteries, bilateral
superficial femoral
arteries, bilateral
popliteal arteries.
Incomprehensive
arteries bilaterally
07/02/10
Creatinine
Clearance
Test
07/04/10
Creatinine in the 24 hr
urine
sample
falls
between the
normal
range.
Due to impaired kidney
function, creatinine in the
blood elevates.
Normal Values:
24 hr urine: 0.6-1.6 q/24 h
Blood: 0.8-1.4 mg/dL
1.2 POSSIBLE
Test
Rationale
Result (Normal
Values)
Interpretation
and Significance
Nursing
Responsibilities
52
Uric Acid
Test
Male:
mg/dL
2.1-8.5
Female: 2.0-7.0
mg/dL
Evaluate or
continuously monitor
degree of joint
inflammation or pain.
Level of activity
or exercise depends on
progression and
resolution of
inflammatory process.
Maintain bed rest
or chair rest when
indicated. Schedule
activities providing
frequent rest periods and
uninterrupted night time
sleep.
Systemic rest during
acute attacks and
important throughout all
phases of disease to
reduce fatigue and
improve strength.
Encourage adequate
fluid intake.
To assist with
excretion of uric acid
and
decrease likelihood of
stone formation.
Assist with active or
passive range of motion.
Maintains or improves
joint function, muscle
strength, and general
stamina.
Encourage patient to
maintain upright and
erect posture when
sitting, standing, or
walking.
Maximizes joint
function, maintains
mobility.
Encourage the patient
to avoid alcohol.
Alcohol precipitates
acute attacks.
Review foods that
are rich in purines
like sardines, anchovies,
shell fish and organ
meats.
These foods are rich
in purine. Uric acid is by
53
product of purine
metabolism in the liver.
Provide safety needs.
Prevents injuries and
falls.
Administer antiinflammatory drugs and
also colchicines as
prescribed.
These medications
relieve pain and
swelling during acute
attacks.
Management
Therapuetics
Date
Order
Rationale
06/27/10
06/27/10
O6/27/10
06/27/10
06/27/10
54
06/27/10
06/27/10
06/27/10
Hgt q 6
06/28/10
06/30/10
06/30/10
07/04/10
07/05/10
07/07/10
For discharge
To combat dehydration.
Promotes thoracic
facilities breathing.
expansion
and
Drug Study
Domperidone
55
Concomitant administration of anti-cholinergic drugs may inhibit the antidyspeptic effects of MOTILIUM.
As MOTILIUM interferes with serum prolactin levels, it may interfere with other
hypoprolactinaemic agents and with some diagnostic tests.
Reduced
gastric
acidity
impairs
the
absorption
of
domperidone.
56
Reversible raised serum prolactin levels have been observed which may lead to
galactorrhoea and gynaecomastia.
Where the blood brain barrier is not fully developed (mainly in young babies) or is
impaired, the possible occurrence of neurological side-effects cannot be totally
excluded
Nursing Responsibilities:
1. Assess for extra-pyramidal effects such as jerking and tongue protrusion.
2. Check for hypotension.
Imdur
Durule (60 mg tab OD @ HS)
Classification: Anti-anginal
Desired Dosage: 60 mg once daily in the morning, may be
increased
to
120
mg
daily
in
the
morning.
57
Hypotension with symptoms eg, dizziness and nausea with syncope in isolated
cases, has occasionally been reported. These symptoms generally disappear
during continued treatment.
Nursing Responsibilities:
1. Check for hypotension.
2. Put patient on bed rest because of fainting. Provide supervision when ambulating.
3. Perform nonpharmacologic measures for nausea and vomiting such as letting client to
drink weak tea, Gatorade, carbonated beverages, pedialyte and eat gelatin, crackers
and dry toast.
Calcium Carbonate
(1 tab tid)
Classification: Electrolyte replacement or
supplements. Antacid
Desired Dosage: 500 mg (200 mg Ca), 600 mg (240 mg Ca), 650 mg (260 mg Ca), 667
mg (266.8 mg Ca), 1 g (400 mg Ca), 1.25 mg (500 mg Ca), 1.5 mg (600 mg Ca)
58
Mode of Action: Essential for nervous, muscular, and skeletal systems. Maintain cell
membrane and capillary permeability. Act as an activator in the transmission of nerve
impulses and contraction of cardiac, skeletal and smooth muscles. It is essential for
bone formation and blood coagulation. It is also used a replacement of calcium in
deficiency states. It controls of hyperphosphatemia in end-stage renal disease without
promoting aluminum absorption.
Interactions: Hypercalcemia increases the risk of digoxin toxicity. Chronic use with
antacids in renal insufficiency may lead to milk-alkali syndrome. Ingestion by mouth may
decrease the absorption of orally administered tetracyclines, fluoroquinolones,
phenytoin, and iron salts. Excessive amounts may decrease the effects of calcium
channel blockers, atenolol. Concurrent use with diuretics may result in hypercalcemia.
Side Effects:
Nursing Responsibilities:
1. Monitor VS especially BP and PR.
2. Obtain ECG result.
3. Asses for heartburn, indigestion, abdominal pain.
4. Monitor serum calcium before treatment.
5. Assess for nausea and vomiting, anorexia, thirst, severe constipation.
Metoprolol
Beloc, Betaloc Durules, Lopresor, Metoprol (100
mg 1 tab q 12 hrs)
Classification: Anti-anginal and Anti-hypertensive:
Beta-blockers
59
Desired Dosage: (PO) 25-100 mg/day as a single dose initially divided or 2 divided
doses; maybe increased q 7 days as needed up to 450 mg/day.
Mode of Action: Blocks stimulation of beta1 (myocardial)-adrenergic receptors. It does
not usually affect beta2 (pulmonary, vascular, uterine)-adrenergic receptor sites. It also
decreases blood pressure and heart rate. It decreases frequency of attacks of angina
pectoris, and decreases rate of cardiovascular mortality and hospitalization in patients
with heart failure.
Interaction:
Paradoxical
response
concentrations
to
epinephrine
may
with
occur.
CYP2D6
Increased
plasma
inhibitors
May increase negative inotropic and negative dromotropic effect of antiarrhythmic drugs e.g. quinidine and amiodarone.
Concurrent use with indomethacin may reduce the antihypertensive efficacy of blocker.
60
Nursing Responsibilities:
1. Monitor blood pressure, and pulse frequently.
2. Monitor intake and output ratios and daily weight.
3. Assess routinely for signs and symptoms of CHF (dyspnea, rales, crackles, weight
gain, peripheral edema, jugular venous distention)
4. Take apical pulse before administering. If <50bpm or if arrhythmia occurs, withhold
medication and notify health care professional.
5. Administer metoprolol with meals or directly after eating.
6. Caution patient minimize activities that require alertness because metoprolol can
cause dizziness.
7. Caution patient that this medication can increase sensitivity to cold.
8. Instruct to avoid caffeinated drinks like teas and colas.
9. Monitor blood glucose levels especially if weakness, malaise, irritability, or fatigue
occurs.
10. Reinforce the need to continue additional therapies for hypertension such as sodium
restriction, stress reduction, regular exercise)
11. Emphasize compliance to the medication.
Prednisone
Sterapred (5000 u 2x/week SC)
61
Side Effects:
Insomnia,
nervousness,
increased
appetite,
indigestion,
62
Albumin 25%
Albuminar, Albutein, Buminate, Normal Human Serum Albumin,
Plasbumin (50cc + Furosemide 20 mg x 4 to OD)
Classification: Volume expanders, blood products, colloids
Desired Dosage: (IV) 12.5-50 g/day in 3-4 divided doses. (Availability Injection: 250
mg/mL)
Mode of Action: It provides colloidal oncotic pressure, which serves to mobilize fluid from
extravascular tissues back into intravascular space. It increases intravascular fluid
volume.
Interactions: Do not mix with protein hydrolysates, amino acid solution and alcohol.
Side Effects:
CNS: Headache
Nursing Responsibilities:
1. Monitor vital signs, and intake and output.
2. Assess for signs of vascular overload such as elevated CVD, rales/crackles, dyspnea,
hypertension, jugular venous distention) during and after administration.
3. Monitor serum sodium levels because it may cause increase concentrations.
4. Solution should be clear amber, and do not administer solutions that are discolored or
contain particulate matter.
Sodium Bicarbonate
Baking Soda, Bell-Ans, Citrocarbonate, Neut, Soda Mint (650 mg 1
tab tid)
Classification: Anti-ulcer agent and alkalinizing agent
Desired Dosage: Alkalinization of urine: (PO) 48 mEq or 4 g initially. Then 1-2 g q4 hr or
1 tsp of powder q4 hr as needed. Metabolic acidosis: >4.8 g/day as needed.
Mode of Action: Acts as an alkalinizing agent by releasing bicarbonate ions. It is used to
alkalinize urine and promote excretion of certain drugs in overdosage situations.
Interactions: Increase toxicity of amphetamins, ephedrine, pseudoephedrine, flecainide,
quinidine and quinine. It decreases effects of lithium, chlorpropamide and salicylates due
to increased clearance. It may affect the absorption of certain drugs due to raised intragastric pH.
64
Side Effects: Metabolic alkalosis; mood changes, tiredness, shortness of breath, muscle
weakness, irregular heartbeat; muscle hypertonicity, twitching, tetany; hypernatraemia,
hyperosmolality, hypocalcaemia, hypokalaemia; stomach cramps, flatulence.
Nursing Responsibilities:
1. Assess for signs of acidosis (disorientation, headache, weakness, dyspnea,
hyperventilation), alkalosis (confusion, irritability, paresthesia, tetany, altered breathing
pattern), hypernatremia (edema, weight gain, hypertension, tachycardia, fever, flushed
skin, mental irritability), or hypokalemia (weakness, fatigue, arrhythmias, polyuria,
polydypsia)
2. Assess fluid balance (intake and output, daily weight, edema, lung sounds)
3. Take med with full glass of water.
4. Monitor serum electrolyte concentrations, serum osmolarity, acid-base balance, and
renal function prior to and periodically through out the therapy.
Clonazepam
Rivotril (1/4 tab daily)
Classification: Anticonvulsant
Desired Dosage: 0.5 mg 3x daily
Mode of Action: It produces sedative effects in the CNS, probably by stimulating
inhibitory GABA receptors. It prevents seizures and decreases manifestations of panic
disorder.
Interactions:
CNS
depression
with
alcohol,
antidepressants,
antihistamines,
other
65
Cimetidine,
hormonal
contraceptives,
disulfiram,
fluoxetine,
isoniazid,
Epoetin B
Recormon (5000 u SC)
Classification: Hematopoeitic Agent
Desired Dosage:
50-100 u/kg 3x weekly initially, then adjust dose base on Hct.
66
67
Side Effects:
Nursing Responsibilities:
1. Monitor blood pressure before and after therapy. Additional antihypertensive drug
maybe required during initiation of therapy.
2. Monitor Hct and other hematopoietic parameters (CBC with differential and platelet
count)
3. Monitor renal function studies and electrolytes closely. Increase in BUN, creatinine,
uric acid, phosphorus, and potassium may occur.
4. Do not shake vial because inactivation of medication may occur.
5. Discard vial immediately after withdrawing dose from single-use 1-ml vial. Refrigerate
multi-dose 2-ml vial; stable for 21 days after initial entry.
6. Stress importance of compliance with dietary restrictions, medications, and dialysis.
Foods high in iron and low in potassium include liver, pork, veal, beef, mustard and
turnip greens, etc
Gabapentin
Neurontin (300 mg 1 tab @ night)
Classification: Analgesic adjuncts, anticonvulsants, mood
stabilizers
Desired Dosage: CCr 30-60 mL/min300 mg 2x daily; 1530 mL/min300 mg 1x daily.
68
Mode of Action: Mechanism of action is not known. It may affect transport of amino acids
across and stabilize neuronal membranes. It can decrease incidence of seizures.
Gabapentin is structurally related to the neurotransmitter GABA but is neither a GABA
agonist nor antagonist. Gabapentin-binding sites have been identified throughout the
brain tissues e.g. neocortex and hippocampus. However, the exact mechanism of action
is still unknown.
Interactions:
Increase risk of CNS depression with other CNS depressants like alcohol,
antihistamines, opioids, and sedatives.
Side Effects:
Somnolence, dizziness, ataxia, weakness, paraesthesia, fatigue, headache; nystagmus,
diplopia; nausea, vomiting, wt gain, dyspepsia; rhinitis; tremor; leucopenia; altered LFTs;
Stevens-Johnson syndrome
Nursing Responsibilities:
1. Caution patient to avoid activities that require alertness to prevent injury d/t dizziness.
2. Provide supervision when patient is ambulating.
3. Monitor for side effects and instruct patient to refer if adverse effects are felt.
Sennosides
Senokot
Classification: Laxative
Desired Dosage: 12-50 mg 1-2x daily
69
Mode of Action: Active components of senna (sennosides) alter water and electrolyte
transport in the large intestine, resulting in accumulation of water and increased
peristalsis.
Interactions: May decrease absorption of other orally administered drugs because of
decreased transit time.
Side Effects:
Nursing Responsibilities:
1. Asses patient for abdominal distention, presence of bowel sounds, and usual pattern
of bowel function.
2. Assess for color, consistency, and amount of stool produced.
3. Take with full glass of water. Ideally, administer at bedtime for evacuation 6-12 hours
later. Administer on an empty stomach for a rapid result.
4. Advise patient that laxatives should be used only for short-term therapy. Long-term
therapy may cause electrolyte imbalance and dependence,
5. Encourage patient to use other forms of bowel regulation such as increasing bulk in
the diet, increasing fluid intake, and increasing mobility.
6. Inform that medication may cause change in his urines color to pink, red, violet,
yellow or brown.
Berodual (neb)
Ipratropnium Br, Fenoterol HBr
Classification: Anticholinergic
70
B2 adrenergics,
xanthine
derivatives and corticosteroids may increase in effect and may occur on concurrent
administration of B2 blocker.
Availability & Prize: UDV solution for inhalation 4ml (58.85)
Inhalation solution 20 ml (932.00)
Metered aerosol 10ml (1,253.00)
Norgesic Forte
Per norgesic tab- Ophenadrine citrate 35 mg + Paracetamol
450mg.
71
72
73
viscous.
7.
8.
9.
Explain to the patient that this medication controls hyperglycemia but does
Loperamide
Diar-aid caplets, Imodium, Imodium A-D, Kaopectate II caplets,
Maalox antidiarrheal caplets, Neo-Diaral, Pepto Diarrhea
control
Classification: Antidiarrheals
Indications: Adjunctive therapy of acute diarrhea. Chronic
diarrhea associated with inflammatory bowel disease decrease the volume of ileostomy
drainage.
Action: Inhibits peristalsis and prolongs transit time by a direct effect on nerves in the
intestinal muscle wall. Reduces fecal volume, increases fecal viscosity and bulk while
diminishing loss of fluid and electrolytes.
Therapeutic effects: Relief of diarrhea.
Contraindications: Hypersensitivity; patients in whom constipation must be avoided;
abdominal pain of unknown cause, especially if associated with fever; alcohol
intolerance(liquid only).
Precautions: Hepatic dysfunction
Side effects: CNS drowsiness , dizziness
GI constipation, abdominal pain/distention/discomfort, dry mouth, nausea
and vomiting.
Misc allergic reactions
Drug-Drug interactions: Increase CNS depression with other CNS depressants including
alcohol, antihistamines, opioid analgesics, and sedatives. Increase anticholinergic
74
properties
with
the
other
drugs
having
anticholinergic
properties
including
Edema
d/t
heart
failure,
hepatic
75
GU excessive urination
Derm photosensitivity, rash
F and E dehydration
Nursing Responsibilities:
1. Assess fluid status. Notify physician or other health care professional if thirst,
dry mouth, hypotension, or oliguria occurs.
2. Monitor blood pressure and pulse before and during administration.
3. Monitor blood glucose closely; may cause increased blood glucose level.
4. Caution patient to change positions slowly to minimize orthostatic
hypotension.
5. Advise patient to contact health care professional immediately if muscle
weakness, cramps, nausea, dizziness and numbness occurs.
6. Caution older patients or their caregivers about increased risk for falls.
Lactulose
Duphalac
Classification: Laxatives
Indications: Treatment of chronic constipation in adults and
geriatric patients. Adjunct in the management or portal- systemic
(hepatic) encephalopathy.
Action: Increases water and softens the stool. Lowers the pH of
the colon, which inhibits the diffusion of ammonia from the colon
into the blood, thereby reducing blood ammonia levels.
Contraindication: Patients on low-galactose diets.
Precautions: Diabetes mellitus; excessive use may lead to dependence.
Side effects: GI belching, cramps, distention, diarrhea
Endo hyperglycemia
Drug-Drug interactions: should not be used with other laxatives in the treatment of
hepatic encephalopathy (leads to inability to determine optimal dose of lactulose). Antiinfectives may diminish effectiveness in treatment of hepatic encephalopathy.
Dosage: 30 cc PO
Nursing Interventions:
1. Assess patient for abdominal distention, presence of bowel sounds, and
normal pattern of bowel function.
76
77
Date
Cues
Need
07/0
5/10
Subjective:
Paminaw nako kay
puno kaayo diri,
stated by Mr. S.
N
U
T
R
I
T
I
O
N
A
L
@
9:15
am
Objective:
-with IVF of
PNSS1L @ 60
cc/hr
-abdominal girth:
90 cm
-ascitis
-bipedal edema
-weak and sleepy
-CXR shows pleural
effusion
-(+) crackles
-decreased Hb (94)
and Hct (0.28)
-increase glucose
in the blood.
-Furosemide
M
E
T
A
B
O
L
I
C
P
A
T
T
E
R
N
Nursing
Diagnosis
Excess fluid
volume related to
compromised
regulatory
mechanism.
Fluid volume
excess or
hypervolemia
occurs from an
increase in total
body sodium
content and an
increase in total
body water. This
fluid excess
usually results
from compromised
regulatory
mechanisms for
sodium and water
as seen in CHF,
kidney failure, and
liver failure.
Bibliography:
Gulanick, Meg, PhD, RN,
et.al (2003).Nursing
Care Plan: Nursing
Diagnosis &
Goal of Care
Intervention Plan
a. Balanced intake
and output;
b. Vitals signs
within normal
limits and;
c. Drain at least 1
liter of urine at
foley catheter.
Evaluation
78
Interpretation.
Westline Dive St.
Louise. Mosby Inc.
5th ed, p. 65
79
restrictions as appropriate.
Facilitates reduction of
extracellular volume.
11. Instruct patient to take
diuretics as prescribed.
Diuretic therapy may
include several different types
of agents for optimal therapy,
depending on the acuteness
or chronicity of the problem.
12. Note medications that may
cause fluid retention, such as
non-steroidal antiinflammatory agents,
vasodilators, and steroids.
13. Instruct to avoid crossing of
legs
Reduce constriction of
vessels thus preventing
pooling.
14. Assist patient in repositioning
every 2 hours
Prevent accumulation of
fluid in dependent areas.
80
Date
07/0
6/10
@
9:15
AM
Cues
Subjective:
Kapoy kaayo ang
paminaw, Mr. S
said.
Daghan kaayo na
siyag ma-ihi, as
verbalized by the
watcher.
Objective:
-with IVF of PNSS
1L infusing well @
R metacarpal vein
running @ 60cc/hr
@ 400 cc level.
-with good skin
turgor
-with capillary refill
time of 2 seconds
- VS taken result
of:
T=
PR=
CR=
RR= 17
BP= 130/80
-drowsy & weak
-urine output of
approx. 4000 mL
-abnormal serum
Need
Nursing
Diagnosis
Goal of Care
Intervention Plan
Evaluation
N
U
T
R
I
T
I
O
N
A
L
GOAL PARTIALLY
MET
07/06/20
2:15 PM
M
E
T
A
B
O
L
I
C
P
A
T
T
E
R
N
Excessive
urination coupled
by impaired
glomerular
filtration rate can
affect reabsorption
of sodium in the
distal renal tubule,
excretion of
creatinine in the
urine and wastage
of calcium which
will result to
muscular spasms
if not corrected.
consume whole
meal served;
g. maintain good
skin turgor and
good capillary
refill time and;
h. exhibit alertness
or intact level of
consciousness.
After 5 hours of
nursing interventions,
the patient showed
no signs of
dehydration as
evidence by:
a. able to consume
950 mL of fluids;
b. had good appetite
and consumed entire
meal;
c. maintained good
skin turgor and
capillary refill time of
less than 2 seconds
and;
d. alert and
81
electrolyte result
of:
Sodium=126 (low)
Creatinine=272.8
(high)
Calcium=1.81
(low)
-with medications
of:
Furosemide
NaHCO3
CaCO3
Lactulose
responsive to any
stimuli
82
Date
07/0
5/10
@
8
AM
Cues
Subjective:
Kapoy ang
paminaw!
answered by the
client when asked
about how hes
doing.
Objective:
-always sleeping or
drowsy
-(+) sleep
disturbances such
as administration of
drugs during days
and repeated
medical procedures
done early in the
morning
-irritable
-answers questions
crossly and
Need
A
C
T
I
V
I
T
Y
E
X
E
R
C
I
S
E
P
A
T
T
E
R
Nursing
Diagnosis
Goal of Care
Intervention Plan
Fatigue r/t
increase
decrease insulin
production
An imbalance in
blood sugar is the
main cause of
diabetes-related
fatigue. Cells use
glucose - sugar for fuel. The
hormone insulin
controls the
distribution and
use of glucose in
the body. In
diabetics, due to
poor production of
insulin, the
glucose is not
properly utilized by
the cells; instead,
it's floating around
a. lessened or
diminished irritability;
2. Determine presence/degree
of sleep disturbances.
Fatigue can be a
consequence of, and/or
exacerbated by, sleep
deprivation.
Evaluation
GOAL MET
@
07/07/10
b. ability to answer
questions or
communicate with high
spirits;
c. ability to sit
independently on chair
and;
d. having greater time
being awake.
12 nn
After 21 hours of
care, Mr. S was
able to improve
sense of energy as
evidenced by:
a. welcomes visitors
and gives jokes;
b. open to
questions and
answers patiently,
and initiates
communication to
student nurse;
83
impatiently
-gives inadequate
answers
-needs supervision
from watcher
-weak
-in bed rest
-blood glucose
level of: 278 mg/dL
-takes Humulin
70/30
SC
in the
bloodstream,
where it can't be
used as
energy. As a
result, diabetic
people will feel
drained.
84
85
Date
Cues
Need
Nursing
Diagnosis
Goal of Care
07/0
6/10
Subjective:
Dili nako makatindog ug ako ra,
stated by the client.
A
C
T
I
V
I
T
Y
Activity intolerance
r/t muscular
weakness as
evidenced by high
serum creatinine
level
@
7:00
Objective:
AM
-creatinine levels
of:
272.8
(06/26/10)
359 (07/01/10)
389 (07/02/10)
-needs assistance
-PT 2 sessions
-complained of pain
in pelvic area
A
N
D
E
X
E
R
C
Creatinine can
cause dehydration
and fatigue.
medicinenet.com
a) able to perform a
specific task with
improved
strength;
b) able to seek help
in performing
activities of daily
living;
Intervention Plan
Evaluation
GOAL MET
@
07/07/10
12:00 nn
a. had great
strength on lower
86
I
S
E
P
A
T
T
E
R
N
c) verbalize
acceptance of
decreased
activity level
and;
d) experience less
discomfort when
transferring, or
performing other
activities.
nonessential procedures
Patients with limited
activity tolerance need to
prioritize tasks.
4. Assist with ADLs as
indicated; however, avoid
doing for patient what he
or she can do for self
Assisting the patient with
ADLs allows for
conservation of energy.
Caregivers need to
balance providing
assistance with facilitating
progressive endurance
that will ultimately enhance
the patients activity
tolerance and self-esteem.
extremities;
observed during
draping for removal
of catheter
b. asked help from
student nurse or
watcher in changing
positions;
c. Ana jud ng
mutiguwang ka, he
joked.
d. Nagasakit
gihapon diri dapita
(arthritis) pag
mulihok, pero
gamay gamay na
lang.
87
environment
Appropriate aids will
enable the patient to
achieve optimal
independence for selfcare.
Date/
Time
Cues
Need
Nursing
Diagnosis
Objective of
Care
Nursing Interventions
Evaluation
88
Subjective:
07/05/ - Doc, kani dinhi
10
ba(holding the
right leg, pelvic
area) sakit man
@
kaayo, kaning
bukog-bukog,
10
maglisod ko ug
AM
lakaw, wala man
gud koy kusog,
naunsa naman
ni? Dili man ko
ing ani pag-abot
diri, as
verbalized by the
patient.
- rated the
intensity of pain
as 7 in the pain
scale of:
1 - no pain
2
less
3
pain
4
slightly
moderate
5
pain
6
7
moderate
pain
8
9
severe
C
O
G
N
I
T
I
V
E
P
E
R
C
P
T
U
A
L
P
A
T
T
E
R
N
1. Assess pain
characteristics.
Assessment of the pain
experience, is the first step
in planning pain
management strategies.
2. Accept clients
description of pain.
Pain is subjective
experience and cannot be
felt by others.
3. Respond immediately
to complaint of pain
Prompt responses to
complaints may result in
decrease anxiety in the
patient. Demonstrated
concern for the patients
welfare and comfort fosters
the development of a
trusting relationship.
4. Instruct the patient to
report pain.
Relief measures may be
instituted
.
5. Position the patient
comfortably on bed.
Comfortable position will
aid in relaxing the muscle
and it will help to lessen the
pain.
GOAL MET
@
07/05/10
12pm
After 2-hour
span of care, the
patients
condition is
improved as
evidenced by:
- pain scale of 1
- grimaced face
not noted
- no withdrawal
when there is
physical contact
with the joint
- di naman sakit
akong mga joints
karon(holding
the right leg), as
verbalized by the
patient.
89
Discharge Planning
Categories
Plan
Medication
Instruct
patient
to
Rationale
take
prescribed
-Compliance to appropriate
physician.
drug,
its
dosage,
time
of
to him.
-Drug interactions may occur
it.
optimal health.
-The patient has the right to know
patient.
Instruct the significant others to report
Exercise
complicated reactions.
-Exercises promote proper blood
and
regular
exercise
like
walking
90
the muscles.
after
eating
before
performing
any
physical activities.
breathing exercise.
Treatment
therapeutic effect.
case of accidents.
91
medications effectiveness.
-Glucose monitoring is a big factor
mellitus.
for
medical
help
if
level
is
abnormally high.
Instruct patient to practice foot care to
gangrenous
tissues
to
the
lower
extremities.
- Check and carefully wash your feet
every day.
-Do not wear shoes that are too small or
socks that do not fit right inside your
shoes.
-Soak your feet in warm soapy water for
10 minutes before cutting your nails.
Trim your toenails straight across to
prevent ingrown toenails. You may also
file down your toenails. Do not cut your
nails into the corners or close to the skin.
You should not dig under or around the
nail.
hygiene.
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underwear.
Out-Patient
Referral
UTI/Cystitis.
-A Physical Therapist is a source of
information to understand agerelated changes and offer
assistance for regaining lost
abilities or develop new ones.
Physical therapy can be applied to
the clients condition: arthritis,
urinary and fecal incontinence,
amputation, and cardiac and
pulmonary disorders. It can :
a). increase, restore or maintain
range of motion, physical strength,
flexibility, coordination, balance and
endurance
b.) aids adaptations to make the
home accessible and safe
teach positioning, transfers, and
walking skills
c.) promote maximum function and
independence within an individual's
capability
d.) increase overall fitness through
exercise programs
e.) prevent further decline in
functional abilities through
education, energy conservation
techniques, joint protection, and
use of assistive devices to promote
independence
f.) improve sensation, joint
proprioception
g.) reduce pain
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vegetables.
94
pulmonary circulation.
-Since the patient is suffering from
hyponatremia, do not deprive client
of sodium but just limit his intake,
because too much sodium can
result to fluid shifting and edema.
Hyponatremia stimulate
juxtaglomerular cells to activate
RAAS, the precursor of
hypertension. Also hypontremia
affects action-potential of the heart,
affecting repolarization and
depolarization. Low levels of
sodium can also result to
neurologic problems.
Maintain good oral hydration.
Prognosis
Diabetes needs to be considered a very serious condition. It is a chronic
condition for which we have no cure. About 2/3 of people with diabetes die of heart
disease. It is the leading cause of adult blindness, the leading cause of kidney failure,
and the leading cause of lower extremity amputation. It is also the second most common
chronic condition seen by American doctors.
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Although diabetes is a serious and chronic condition, early diagnosis and proper
patient self-management can reduce and possibly eliminate the majority of the chronic
complications. Meticulous control of blood glucose (HbA1c below 7% which would
correlate to an average blood glucose below 150 mg/dL), good blood pressure control
(below 130/80), low LDL (low density lipoprotein) cholesterol levels (below 100 mg/dL),
one daily aspirin (either adult or children's), and daily foot inspection can make a major
impact on improving one's risk for all diabetes-related problems.
Pain
High blood glucose levels do not cause pain. However, having high glucose
levels for many years can lead to nerve damage in the feet (called neuropathy), which
can be painful. It is estimated that 25% of newly diagnosed patients with type 2 diabetes
have pain or numbness in their feet from neuropathy.
Client can take analgesics for pain.
Debilitation
Diabetes can be debilitating, and there are many reasons for this.
It is not uncommon for people with diabetes to experience advanced neuropathy
to the point that he or she cannot walk. For Mrs. Js case, she sometimes stoops while
walking, but still does not need supervision.
The good news is that debilitation can be prevented if treatment is started early
and aggressively. This treatment includes meticulous control of blood glucose (average
glucose below 150 mg/dL), blood pressure (below 130/80), LDL cholesterol (bad
cholesterol below 100 mg/dL), daily aspirin, and smoking cessation. Research also has
shown that one particular type of blood pressure medication, called ACE (angiotensin
converting enzyme) inhibitors, has an additional protective effect on complications
besides lowering blood pressure. ACE inhibitors appear to stabilize or even reverse
diabetic kidney disease if it is caught early enough. These drugs also have been found
useful for people who have had heart attacks or have heart failure. One study even
showed these drugs reduced the risk of heart attack or stroke by 25%. Finally, there is a
growing body of research suggesting ACE inhibitors may protect against diabetic eye
disease.
Comfort
Diabetes usually does not cause discomfort. In fact, one of the biggest public
health problems in America is that there are over 5 million Americans who have
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asymptomatic diabetes and do not know it. The most common reason for any discomfort
is the neuropathy noted above. Another common reason people have discomfort is from
the finger sticks to measure blood glucose. Fortunately, this technology is quickly
improving so that discomfort is minimal.
Curability
Diabetes is currently not curable. Type 1 diabetes is defined as no requirement
for insulin with normal blood sugars. Scientists are working on this so that the cells that
make insulin ("islets") may be able to be transplanted to result in a cure. To date these
experiments are not quite ready and are still in the research phases. For type 2 diabetes,
there is no "cure" but often it can be treated early in its course with a strict diet, exercise,
and weight loss. However, it is rare for the diabetes to "disappear" even with these
measures. The main focus of research now is to prevent both types of diabetes.
Independence
In the vast majority of cases patients with diabetes should have no problems with
independence. But for elderly, fatigue and neuropathies can occur, so strict supervision
is needed. Family members should also make sure that their home environment is free
from injury causing objects.
Mrs. J still belongs in the middle adulthood, thus she can experience
independence more than elders without causing harm to self.
Mobility
Again, in the vast majority of cases, diabetes should have no impact on
someone's ability to move about. The exceptions to this are those people who suffer
from advanced neuropathy or vascular disease. A complication involving the foot, such
as a foot ulcer or amputation can impact one's ability to move around. Visual problems
also will impact one's ability to move about. These are true to young diabetic patients.
Mrs. J has complained of blurry vision, thus her ability to move about is readily
and always affected. But she said that she uses eye glasses which aids her sight.
But complications brought about by aging should not be neglected. Senile people
are mostly at risk for injury.
Daily activities
For most people however, small amounts of time should be reserved for selfmanagement. This would include time for home blood glucose monitoring (although our
current meters take as little as 5 seconds) and extra time to ensure the proper
medication is received.
97
Exercise is encouraged for people with diabetes, although for those over the age
of 40 years old it is recommended a stress test is performed to rule out early heart
disease (claudication).
Rest is always a necessity.
Energy
Extremes in blood glucose levels can cause fatigue. Although it is difficult to give
exact levels since it differs with the person, many people note fatigue when the blood
glucose exceeds 400 mg/dL. Although hypoglycemia often presents with a tremor, fast
heart rate, a sweating, it may be noted only as fatigue. This often occurs when the blood
glucose drops below 60 mg/dL.
Mrs. J can have some time for rest. Though she has to baby sit for her grand son
Benedict, and perform all the house chores, she can have a bit of time in the afternoon
while her grandson is at school to rest and sleep.
Diet
In general, it is recommended that one eats a low-fat diet with less than 10% of
the calories coming from saturated fat. For people with high levels of LDL-cholesterol
(the "bad" cholesterol) the January 2002 guidelines from the ADA suggest only 7% of
total calories from saturated fat.
The most confusion about diet for people with diabetes has to do with
carbohydrates, which are the types of foods most quickly broken down to glucose (such
as breads, potatoes, pasta, fruit, and simple sugar). Research has clearly shown that
table sugar (sucrose) does not increase blood sugar any more than breads, pasta or
other carbohydrates AS LONG AS THE SAME NUMBER OF CALORIES ARE
CONSUMED. For example, putting table sugar into coffee (about 15 grams of
carbohydrate) would not change blood glucose any more than 1 piece of bread (about
15 grams of carbohydrate). Therefore, simple sugars ("sweets") do not need to be
restricted by people with diabetes, but rather need to be substituted for other
carbohydrate sources. For people using insulin, it is much easier since additional insulin
can be administered to "cover" additional carbohydrate.
Relationships
The
interactions
between
relationships
and
diabetes
are
greatly
underappreciated.
Communication becomes particularly important for people in their early adult
years, as issues pertaining to marriage and family planning are discussed. It is critical
98
that concerns be discussed in the open with the assistance from a health care provider
with understanding about the disease.
For older adults, the impact of both the daily living of diabetes and its
complications becomes even more important. Again, one needs to talk to a healthcare
provider knowledgeable about diabetes to explore its complications and how it affects
everything from work performance to driving or sexual function.
Everyone living with an individual who has diabetes needs to have some
knowledge about how to treat emergencies (hypoglycemia). Finally, psychological
support can be extremely effective for many individuals due to the extreme challenges
this condition presents for many individuals.
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