BIOGRAPHICAL DATA

CASE DATA AND INFORMATION

Name: TBN
Address: LDDC
Sex: Female
Birthdate: September 22, 1939
Place of Birth: MNO
Race: Asian
Nationality: Filipino
Culture: Filipino
Marital Status: Widow
Contact Person: G. N; granddaughter
Religion: Roman Catholic
Education: High School Level
Occupation: Self-employed: Vendor
Health Insurance: None
Referral: Dr. B
Source and Reliabiliy:
Patient 25%
Significant Other 40%
Chart 35%
REASON FOR SEEKING HEALTHCARE
Ga-sige sakit ako kuto-kuto mga duha na ka-semana. Wala-wala ang
sakit. Kapoy kaayo akong lawas, luya, sigeg labad sa ulo. Ga-suka pod
ko ika-upat sa wa pako ma-admit
CURRENT HEALTH STATUS
Patient states that the onset of the epigastric pain started two
(2) weeks prior to admission. She had been experiencing intermittent
epigastric pain with a pain scale of 7 or 8 out of 10. She said this
pain is accompanied with body malaise, generalized body weakness,
headache, loss of appetite and vomiting. Patient states she is active
before the incident, but she states that she sometimes misses her
meals and seldom drinks fluids. Prior to admission, her usual fluid
intake per day is 600-750 mL. Her granddaughter decided to seek for
medical treatment at Negros Oriental Provincial Hospital because they
were alarmed of the intermittent pain. Since the day of admission,
January 26, 2014, until the present, patient is receiving treatment
and medications in the hospital.

PAST HEALTH HISTORY

Childhood Illnesses
Patient has a positive history of cough and colds, fever, sore
eyes, mumps and chicken pox. There were no severe illnesses during her
childhood.
Hospitalizations:
1

This is the first time the patient has been confined in the
hospital, as verbalized by the significant other.
Serious/Chronic Illnesses
Patient has Hypertension since 2002. Patient has an admitting
impression of Ischemic Heart Disease; Gastritis with Moderate
Dehydration; R/I Acute Coronary Syndrome; R/O Urinary Tract Infection;
End-stage Renal Disease (ESRD) which was diagnosed last January 26,
2014.
Immunizations
Patient cannot recall the immunizations she received before.
Allergies
No known allergies to food, latex, chemical, adhesives,
medication or environment.
Medications
Patient has maintenance medication of Metoprolol 100 mg once
daily for her hypertension.
Travel
Patient has no recent travel.
FUNCTIONAL HEALTH PATTERNS
Health Practices and Beliefs
Patient states that she believes in the healing power of God and
that through her prayers, her illness will be treated. She claims she
only ignores headaches, stomachaches, cough and colds prior to
admission and does not take any medication for it.
Typical day
Prior to admission, patient usually wakes up at 4:00 AM to cook
food and puto which she will sell in the school canteens nearby. She
usually takes her breakfast at around 6:00 AM and sends the puto to
the respective schools, after which, she only stays home and does
household chores. She takes her lunch at 1:00 PM and takes her dinner
at 8:00 PM. Patient usually goes to bed at 9:00 PM.
Nutritional Patterns
24-hour recall prior to admission: Breakfast 2 pieces bread, 1
glass of milk and glass water. Lunch cup rice, fish, soup and 1
glass water. Dinner cup rice, fish, soup and 1 glass water.
Patient takes Metoprolol 100 mg in the morning.
Metabolism
Prior to admission, patients bowel movement was regular.
Cognitive-Perceptual
Prior to admission, patient had apparently no mental or cognitive
problems.

Recreation, Pets, Hobbies

Usually watches television, listens to the radio, or cooks during
her spare time. Patient has no pets at home.
Sleep/Rest Pattern
Patient wakes up at 4:00 AM and goes to sleep at 9:00 PM. She
does not take afternoon/daytime naps.
Socioeconomic Status
Aside from her own income from selling puto, she also receives
financial help from her children.
Environmental Health Patterns
Patient considers her neighborhood as safe. Stores and schools
are nearby.

Family Roles and Relationships

Patient has a good relationship with her family and relatives.
She describes herself to be a responsible grandmother to her
granddaughter who is staying with her.
Cultural Influences
No specific cultural influences that would affect healthcare
practices.
Religious/Spiritual Influences
Patient is a devoted Roman Catholic. She usually attends Sunday
masses and prays to God for thanksgiving and supplication.
Sexuality Pattern
Patient is not sexually active.
Social Support
She is supported by her immediate family members as well as her
close relatives. She does not belong to any organized groups or
cooperatives.
Stress and Coping Patterns
She usually cooks or sleeps to cope with the daily stresses.

FAMILY GENOGRAM
+
83
CR

+
87
HTN

+
75
HA

+
80
HTN

+
80
CR

+
87
HTN

+
80
HTN

+
72
HTN

+
80
HTN, DM

70
HTN

74
ESRD, HTN
CVD
GI

68
HTN, DM

Legend:
+ - deceased
DM Diabetes Mellitus

Male

HTN- Hypertension
HA Heart Attack

Female

ESRD End-Stage Renal Disease

CVD Cardio-Vascular Disease
GI Gastrointestinal Disease

Patient

CR Cannot Recall

Interpretation:
Patients maternal grandmother died at the age of 83 while her
maternal grandfather died at the age of 87 and was known to have
Hypertension. Her paternal grandfather died at the age of 87 due to
Hypertension while her paternal grandmother died at the age of 80.
Patients father died at the age of 80 and was known to have
Hypertension and Diabetes Mellitus while her mother died at the age of
80 also due to Hypertension. Her maternal aunt died at the age of75
because of heart attack. All 4 siblings of the patient, including the
patient herself have hypertension, two of which died because of the
disease. One brother has Diabetes Mellitus. Currently, the patient has
End-stage Renal Disease (ESRD); Cardiovascular Disease: Ischemic Heart
Disease, Acute Coronary Syndrome; Gastritis and Hypertension, of which
she inherited from her parents and grandparents.

REVIEW OF SYSTEMS
General Health Status
Awake, conscious and coherent. Patient is oriented to person,
place and time. She is currently suffering from end-stage renal
disease (ESRD), Hypertension, Ischemic Heart Disease, Acute Coronary
Syndrome and Gastritis.

Vital Signs:

Temperature: 34.2C
Pulse Rate: 62 bpm
Respiratory Rate: 28 cpm
BP: 160/100 mmHg

Skin

Patient has fair complexion with darker exposed areas than

unexposed ones.
Bruises were noted around his left and right upper extremities

especially in her forearms.

Skin is cold to touch and is very dry.
Patient has poor skin turgor.
Edema of the right foot noted.

Hair

Hair is evenly distributed

Black in color, gray hair noted.
Scalp is intact.
Presence of lice and nits noted.
Less body hair noted.

Nails

Patients nails are convex in shape

Nails are white and are smooth to touch
Nail clubbing noted
Capillary Refill of 4 to 5 seconds

Head, Neck and Face

Head is appropriate in size in relation to patients body.

Head is midline and symmetrical.
7

No lesions or masses were noted.

Facial movements are appropriate and symmetrical.
Neck is midline and is symmetrical.
Skin is cold to touch.
No lesions or masses noted on the patients neck.

Eyes

Eyelashes and eyebrows are evenly distributed.

Eyelids are in contact with the eye balls. No lesions noted.
Eye movements are coordinated and symmetrical.
Lacrimal and nasolacrimal glands are non-tender.
Conjunctiva is clear and pale to light pink in color. Few blood

vessels are visible.

Sclera is white in color. Mucosal membrane is pale in color.
Irises and pupils are equal in size and shape and is reactive to
light and accommodation.

Ears

Patient has hearing problems.

Auricles are pliable and non-tender.
Cerumen noted on both ears.
No pain, inflammation, lesions and unusual discharges noted

Nose and Sinuses

Nose is midline and is symmetrical.

Nares are patent.
Patient has a good sense a good sense of smell.
No congestion or unusual drainages noted
No nasal flaring noted.
Sinuses are nontender.

Mouth

Lips are midline, symmetrical, with dry skin

Presence of unusual odor.
Tongue is dry, cracks noted on the side. Teeth are incomplete.

White to yellowish in color.

Palate and mucous membranes are intact and light pink to pale in

color.
Tonsils are symmetrical.

Respiratory system

Respiratory rate is ranging from 24-28 cycles per minute, regular

in rhythm.
Use of accessory muscles noted.
Antero-posterior lateral ratio= 1:2
Trachea is midline.
Chest is non-tender.
Wheezes heard on all lung fields.

Cardiovascular

Carotid pulsations are visible.

Pulses are regular and symmetrical.
Capillary refill of 4 to 5 seconds
BP 160/100 mmHg
Pulse rate 63 beats per minute

Breasts

Breasts are symmetrical

No masses or lesions reported.

Abdomen

Skin is intact.
Abdomen is slightly rounded and is symmetrical.
Abdomen is non-tender.
Hypoactive bowel sounds noted on all quadrants.
No hemorrhoids, inflammation, rashes and ulcers were reported in
the rectal area.

Genitourinary System
Reproductive

No swelling, lesions or masses were reported.

No abnormal discharges were reported.

Urinary

Patient is on diaper for almost a month now.

Patient states she has no difficulty urinating.
Urine is yellow and clear.

Patient urinates about 3 to 4 times a day voiding approximately

200 mL each time she urinates.

Motor-Musculoskeletal System

Patient can normally move her upper extremities.

Muscle strength grading: 4 on both upper extremities.
Upper extremities are symmetrical and are mobile.
Patient can normally move her left lower extremity. Slight
weakness and pain noted on right lower extremity.

Sensory-Neurologic System

Patient is unkempt.
Patient is awake, conscious and coherent.
Patients affect and mood is appropriate to situation.
Patient is oriented to person, place, and time.
Patient is responsive and obeys simple commands.
Reports of fatigue and generalized body weakness.
Glasgow Coma Scale:
o Eyes Open: To command
4
o Best Verbal Response: Oriented
5
o Best Motor Response: Obeys commands
6
Total:
15: No brain injury

10

LABORATORY EXAMINATIONS
Complete Blood Count
A complete blood count (CBC) test is done to measure the
following: number of red blood cells (RBC count), the number of
white blood cells (WBC count), the total number of Hemoglobin in
the blood, and the fraction of the blood composed of red blood
cells (Hematocrit).The CBC test also provides information about
the following measurements: average red blood cell size (MCV),
hemoglobin amount per red blood cell (MCH), and the amount of
hemoglobin relative to the size of the cell (hemoglobin
concentration) per red blood cell (MCHC). Platelet count is also
usually included in the CBC.
To perform the test, blood is drawn from a vein, usually
from the inside of the elbow or the back of the hand. The site is
cleaned with antiseptic. A tourniquet is wrapped around the upper
arm to apply pressure to the area and to make the vein swell with
blood. Next, a needle is inserted into the vein to extract blood.
The blood is collected into an airtight vial or tube attached to
the needle. The tourniquet is removed from the arm after
collection. The needle is then removed, and the puncture site is
covered with gauze to stop any bleeding.
CBC was done to the patient as baseline laboratory procedure
to rule in or rule out infection.
Date taken: January 26, 2014
Table 1. (1.1)
CBC Results: Jan 26, 2014

WBC
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
ALY
UC
RBC
Hemoglobin
Hematocrit
MCV
MCH
MCHC
RDW
PLT
MPV
PCT
PDW
Interpretation:

Findings

Range

Normal Limits

9.8
68.9
25.3
4.3
1.1
0.4
1.4
0.6

10/mm
3.07
2.74
0.61
0.10
0.04
0.16
0.04

2.00-7.50
1.50-4.00
0.00-0.80
0.00-0.40
0.00-0.10
0.00-0.25
0.00-0.30

2.88
8.9
26.7
93
30.9
33.2
14.0
241
8.6
0.206
13.8

102/mm

3.80-5.80
11.5-16.0
37.0-47.0
76-96
27.0-32.0
32.0-35
11-16
150-450
8-12
0.100-0.500
8.0-18.0

11

The result of the CBC test reveals increased levels of WBC

components: neutrophils, lymphocytes, monocytes, eosinophils,
basophils, ALY, and UC. This might be due to an ongoing bacterial
infection such as Urinary Tract Infection.
RBC and Hemoglobin results are low, this may suggest anemia
to the patient which is having ESRD.
Table 2. (1.2)
CBC Results: Jan 28, 2014

WBC
RBC
Hemoglobin
Hematocrit
MCV
MCH
MCHC
RDW
PLT
MPV
PCT
PDW

Findings

Limits

8.8
2.88
8.7
28.1
98
30.1
30.8
18.0
247
9.9
0.244
15.8

4.0-11.0
3.80-5.80
11.5-16.0
37.0-47.0
76-96
27.0-32.0
32.0-35
11-16
150-450
8-12
0.100-0.500
8.0-18.0

Interpretatio
n
Normal
Low
Low
Low
High
Normal
Low
High
Normal
Normal
Normal
Normal

Interpretation: Compared with Jan 26, 2014

The result shows that the WBC is in the normal limits. Thus,
infection is ruled out. The RBC, hematocrit, hemoglobin, and MCHC
are low, this suggests anemia.
Table 3. (1.3)
CBC Results: Feb 02, 2014

WBC
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
ALY
UC

Findings

Range

8.7
8.2
2.9
0.9
0.3
1.1
0.8
0.6

10/mm
3.07
2.74
0.61
0.10
0.04
0.16
0.04

H
H
H
H
H
H

2.00-7.50
1.50-4.00
0.00-0.80
0.00-0.40
0.00-0.10
0.00-0.25
0.00-0.30

RBC
2.88
102/mm
3.80-5.80
Hemoglobin
8.9
11.5-16.0
Hematocrit
26.7
37.0-47.0
MCV
93
76-96
MCH
30.9
27.0-32.0
MCHC
33.2
32.0-35
RDW
14.0
11-16
PLT
241
150-450
MPV
8.6
8-12
PCT
0.206
0.100-0.500
PDW
13.8
8.0-18.0
Interpretation:
The result shows high levels of WBC and WBC Differential
Counts which suggests that the patient has infection.
12

Table 4 (1.4)
CBC Results: Feb 08, 2014

WBC
RBC
Hemoglobin
Hematocrit
MCV
MCH
MCHC
RDW
PLT
MPV
PCT
PDW

Findings

Limits

6.3
2.72
8.7
27.7
102
32.0
31.5
17.8
155
10.0
0.155
18.8

4.0-11.0
3.80-5.80
11.5-16.0
37.0-47.0
76-96
27.0-32.0
32.0-35
11-16
150-450
8-12
0.100-0.500
8.0-18.0

Interpretatio
n
Normal
Low
Low
Low
High
Normal
Low
High
Normal
Normal
Normal
High

Interpretation:
The result shows that the WBC is in the normal limits. Thus,
infection is ruled out. The RBC, and RBC Blood Components:
hematocrit, hemoglobin, PDW and MCHC are low, this suggests
anemia.
Blood Chemistry
Analysis of blood chemistry can provide important
information about the function of the kidneys and other organs.
This common panel of blood tests measures levels of important
electrolytes and other chemicals, including the following:
glucose, sodium, potassium, chloride, carbon dioxide, BUN, and
creatinine.
The purpose of blood chemistry analysis is to provide
general information about how your body is functioning; to screen
for a wide range of problems, including kidney, liver, heart,
adrenal, gastrointestinal, endocrine, and neuromuscular
disorders; and to measure chemical substances in the blood.
Blood chemistry analysis was done to the patient in order to
rule in or rule out impression upon admission which is ESRD.

13

Table 5 (1.5)
Blood Chemistry Results: Jan 26, 2014
Result

Normal Range

Interpretation

Na

134.5

135-148 mmol/L

Low

5.74

3.5-5.3 mmol/L

Normal

RBS

125

45-130 mg/dL

Normal

Table 6 (1.6)
Blood Chemistry Results: Jan 26, 2014
Result

Normal Range

Interpretation

Creatinin

5.35

0.57-0.9 mg/dL

High

e
Uric Acid

10.0

2.5-6.8 U/L

High

SGPT

67

0-36 U/L

High

Amylase

76

0-450 U/L

Normal

Table 7 (1.7)
Blood Chemistry Results: Jan 28, 2014
Result

Normal Range

Interpretation

Creatinin

5.8

0.57-0.9 mg/dL

High

e
K

5.14

3.5-5.3 mmol/L

Normal

Table 8 (1.8)
Blood Chemistry Results: Feb 2, 2014

Creatinin

Result

Normal Range

Interpretation

6.06

0.57-0.9 mg/dL

High

e
Table 9 (1.9)
Blood Chemistry Results: Feb 3, 2014

Creatinin

Result

Normal Range

Interpretation

7.8

0.57-0.9 mg/dL

High

Table 10 (1.10)
Blood Chemistry Results: Feb 3, 2014

14

Result

Normal Range

Interpretation

Na

134.8

135-148 mmol/L

Low

6.10

3.5-5.3 mmol/L

High

15

Table 11 (1.11)
Blood Chemistry Results: Feb 8, 2014
Result

Normal Range

Interpretation

Na

139.2

135-148 mmol/L

Normal

4.23

3.5-5.3 mmol/L

Normal

Interpretation:
Blood Chemistry component RBS is normal, this means that the
patient does not have Diabetes Mellitus or any endocrine
problems. Sodium and Potassium levels had been ranging from low
to normal. Uric Acid, SGPT and Creatinine levels are high, this
might be an indication of decreased efficiency of the kidneys and
due to long-term raised blood pressure or dehydration.
Urinalysis
Urinalysis is a test that evaluates a sample of your urine.
Urinalysis is used to detect and assess a wide range of
disorders, including urinary tract infection, kidney disease and
diabetes. It is the physical, chemical, and microscopic
examination of urine. It involves a number of tests to detect and
measure various compounds that pass through the urine. Urinalysis
also involves examining the appearance, concentration and content
of urine. Abnormal urinalysis results may point to a disease or
illness. For example, a urinary tract infection can make urine
look cloudy instead of clear. Increased levels of protein in
urine can be a sign of kidney disease.
This test was ordered to make sure that the kidneys and
certain organs are functioning properly or to rule in our rule
out infection, specifically urinary tract infection.
Date taken: January 26, 2014

16

Table 12 (1.12)
Urinalysis Results
Physical
Color
Transparency
Specific Gravity

Results
Light Yellow
Hazy
1.015

Chemistry
Glucose
pH
Protein

(-)
5.0
(++)

Microscopic
Pus
RBC
Epithelial Cells
Mucous Threads
Casts
Bacteria

10-12
0-3
Moderate
Few
Fine grain 0-2/LFP
Moderate

Results of the Urinalysis reveal presence of pus, epithelial

cells, bacteria, casts RBC and mucous threads in the urine; this
might be due to an underlying infection in the urinary system.
The results also reveal hazy urine which indicates the inability
of the kidneys to produce normal urine, or may be due to urinary
tract infection, or the presence of kidney stones. The results
also reveal presence of protein; this suggests that there is a
problem in the kidneys.
Diagnostic/Imaging Studies
Ultrasound
Date taken: February 10, 2014
Ultrasound of the whole abdomen
Results:
-

Liver, pancreas and spleen are within normal size and

appearance without demonstrable masses.

The gallbladder with normal wall thickness and

echofree.
(-) for hepatobiliary tree dilatation and ascites.
The abdominal aorta and para-aortic areas are

unremarkable.
Right kidney measures 6.9 c 3.1 cm with poorly
differentiated cortico-medullary junction. No stones

or caliectasia.
The left kidney measures 10.1 x 4.7 cm. No stones or

caliectasia.
Urinary bladder with non-thickened walls and echofree.
The uterus measures 4.6 x 3.5 x 3.8 m with normal

echotexture pattern.
No adrenal masses noted.
No free-fluid in posterior cut-de-sac.
17

Remarks:
1. Renal parenchymal disease, T2, Right Kidney
2. Contracted bladder
3. Incidental findings of bilateral pleural effusion Right
505 cc, Left 318 cc
4. The rest of the intra-abdominal organs are
sonographically negative
The result of the ultrasound reveals Renal parenchymal
disease specifically at the right kidney; contracted
bladder; and an incidental findings of bilateral pleural
effusion.

18

CASE STUDY
1. Ischemic Heart Disease
Definition
Ischaemic (or ischemic) heart disease is a disease
characterized by reduced blood supply to the heart.
Ischemic Heart Disease, also known as Coronary Heart Disease
is a narrowing of the coronary arteries, the vessels that supply
blood to the heart muscle, generally due to the buildup of
plaques in the arterial walls, a process known as
atherosclerosis. Plaques are composed of cholesterol-rich fatty
deposits, collagen, other proteins, and excess smooth muscle
cells.
Etiology
Blood supply to the heart is limited because of the narrowed
coronary arteries in Ischemic Heart Disease or Coronary Heart
Disease.
Common causes are:
Smoking, which promotes the development of plaque in the

arteries.
High blood cholesterol. LDL (low-density lipoprotein) enters
the lining of the arterial walls where, after being chemically

altered, its cholesterol can be incorporated into plaque.

High blood pressure predisposes one to CAD.
People with diabetes mellitus are at greater risk for

atherosclerosis.
Obesity may promote atherosclerosis.
Lack of exercise (a sedentary lifestyle) may encourage

atherosclerosis.
Women over age 35 who take oral contraceptives and smoke

cigarettes have a higher risk of atherosclerosis.

A family history of premature heart attacks is associated with

greater CAD risk.

A spasm of the muscular layer of the arterial walls may cause
an artery to contract and produce angina. Spasms may be
induced by smoking, extreme emotional stress or exposure to
cold air.

19

Clinical Manifestations
In the early stages, there are generally no symptoms, but
the disease can start when a patient is very young (pre-teen).
Over time, fat builds up and can injure the vessel walls where
plaques will begin to adhere and collect. In attempt to heal the
troubled area, blood may form a clot around the plaque causing
the artery to narrow even further preventing the flow of blood
and oxygen which can cause chest pain (angina pectoris) during
periods of physical activity or emotional stress (times that
require increased amounts of oxygen). Angina usually subsides
quickly with rest, but over time, symptoms arise with less
exertion and CAD may eventually lead to a heart attack. However,
in one-third of all CAD cases, angina never develops and a heart
attack can occur suddenly with no prior warning.

The following are the most common symptoms of IHD/CAD:

Chest pain (angina), or milder pressure, tightness, squeezing,
burning, aching or heaviness in the chest, lasting from 30
seconds to five minutes. The pain or discomfort is usually
located in the center of the chest and may radiate down the
arm (usually the left), up into the neck or along the jaw
line. The pain is generally brought on by exertion or stress

and stops with rest.

Shortness of breath, dizziness or a choking sensation,

accompanying chest pain.

Rapid or irregular heartbeats.
A sudden increase in the severity of angina, or angina at
rest, is a sign of unstable angina that requires immediate
medical attention because a heart attack may shortly occur.

Management
Medical Management

Antiplatelet Therapy
Low dose antiplatelet therapy reduces the risk of adverse
events such as MI. It should be prescribes in all patients with
CAD.

Cardiac Rehabilitation
A cardiac rehabilitation program provides an excellent

opportunity to begin an exercise program, learn about your heart

disease, and learn strategies to change your lifestyle to prevent
further progression of your disease.
Surgical Management
Angioplasty

20

Angioplasty, formally called percutaneous transluminal

coronary angioplasty (PTCA), is a procedure to open up narrowed
arteries. Using local anesthesia, the doctor will insert a
catheter (a long, narrow tube) with a deflated balloon at its tip
into the narrowed part of the artery. Then the balloon is
inflated, compressing the plaque and enlarging the inner diameter
of the blood vessel so blood can flow more easily.

Atherectomy
Atherectomy is a procedure to remove plaque from arteries.

The doctor uses a laser catheter or a rotating shaver. The

catheter is inserted into the body and advanced through an artery
to the area of narrowing.

Stent Implant
It is a wire mesh tube used to prop open an artery that has

recently been cleared using angioplasty. The stent is collapsed

to a small diameter and put over a balloon catheter, then moved
into the area of the blockage. When the balloon is inflated, the
stent expands, locks in place and forms a scaffold to hold the
artery open. The stent stays in the artery permanently, improving
blood flow to the heart muscle.

Coronary Bypass Surgery

Coronary bypass surgery may be performed in more serious
cases to improve blood flow to the heart. A mammary artery or a
vein taken from the leg is grafted onto the damaged coronary
artery to circumvent a narrowed or blocked portion.

Nursing Management

Monitor and review the characteristics and location of pain

(angina pectoris).
Monitor vital signs (blood pressure, pulse, respirations,

level of consciousness)
Instruct patient to report for any signs of increasing pain

or any unusualities.
Create an atmosphere of calm and comfortable environment.
Teach and encourage the patient to do relaxation techniques.
Instruct the patient not to "push" at the time of

defecation.
Explain to the patient about the stages of activity that may
be performed by the patient.

21

Serve food that is easy to digest and reduce the consumption

of caffeine.
Measure intake and output (fluid balance).
Serve a meal with a low-salt diet.
Ensure medication compliance.
Give analgesics as ordered.

2. Hypertension
Definition
High blood pressure; transitory or sustained elevation of
systemic arterial blood pressure to a level likely to induce
cardiovascular damage or other adverse consequences.
Hypertension may be classified as essential or secondary.
Essential hypertension is the term for high blood pressure with
unknown cause. It accounts for about 95% of cases. Secondary
hypertension is the term for high blood pressure with a known
direct cause, such as kidney disease, tumors, or birth control
pills.
Etiology
The exact causes of high blood pressure are not known, but
several factors and conditions may play a role in its
development, including:
Smoking
Obesity
Diabetes
Sedentary lifestyle
High level of salt intake
Insufficient calcium, potassium, and magnesium consumption
Vit D deficiency
Aging
Stress
Alcohol consumption
Use of birth control pills
Genetics
Chronic Kidney Disease
Adrenal and thyroid problems
Clinical Manifestations
There is no guarantee that a person with hypertension will
present any symptoms of the condition. For this reason, it is
advisable to undergo periodic blood pressure screenings even when

no symptoms are present.

Other symptoms accompanying high blood pressure:
Severe headache
Fatigue
Confusion
Dizziness
Nausea
Blurred vision
Chest pain
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Breathing problems
Irregular heartbeat
Presence of blood in the urine
Management
The main goal of treatment for hypertension is to lower
blood pressure to less than 140/90 mmHg or even lower in some
groups, such as people with Diabetes and Chronic Kidney Disease.
Treating hypertension is important for reducing the risk of
stroke, heart attack, and heart failure.

Pharmacologic Management
Diuretics
They help the kidneys eliminate sodium and water from the
body. This process decreases blood volume, so your heart has
less to pump with each beat, which in turn lowers blood
pressure.

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Anti-adrenergics
Anti-adrenergics lower blood pressure by limiting the action
of the hormones epinephrine and norepinephrine, thereby
relaxing the blood vessels and reducing the speed and force of

the hearts contractions.

Calcium-Channel Blockers
Calcium-channel blockers slow the movement of calcium into
the smooth-muscle cells of the heart and blood vessels. This
weakens heart muscle contractions and dilates blood vessels,

lowering blood pressure.

ACE Inhibitors
These agents prevent your kidneys from retaining sodium and
water by deactivating angiotensin-converting enzyme, which
converts inactive angiotensin I to the active angiotensin II.
Angiotensin II raises blood pressure by triggering sodium and

water retention and constricting the arteries.

Angiotensin-receptor blockers (ARB)
These agents blocks angiotensin II from constricting the

blood vessels and stimulating salt and water retention.

Direct Renin Inhibitors
Renin inhibitors work by inhibiting the activity of renin,
the enzyme largely responsible for angiotensin II levels.

3. Acute Coronary Syndrome

Definition
Acute coronary syndrome (ACS) refers to any group of
symptoms attributed to obstruction of the coronary arteries. The
most common symptom prompting diagnosis of ACS is chest pain,
often radiating to the left arm or angle of the jaw, pressurelike in character, and associated with nausea and sweating. Acute
coronary syndrome usually occurs as a result of one of three
problems: ST elevation myocardial infarction (30%), non ST
elevation myocardial infarction (25%), or unstable angina (38%).
Etiology
Acute coronary syndrome is most often a complication of
plaque buildup in the arteries in your heart (coronary
atherosclerosis) These plaques, made up of fatty deposits, cause
the arteries to narrow and make it more difficult for blood to
flow through them.
The risk factors for acute coronary syndrome are similar to
those for other types of heart disease. Acute coronary syndrome
risk factors include:

Older age (older than 45 for men and older than 55 for
women)
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High blood pressure

High blood cholesterol
Cigarette smoking
Lack of physical activity
Type 2 diabetes
Family history of chest pain, heart disease or stroke. For
women, a history of high blood pressure, preeclampsia or
diabetes during pregnancy

Clinical Manifestations
Acute coronary syndrome symptoms are the same as those of a
heart attack. And if acute coronary syndrome isn't treated
quickly, a heart attack will occur.
The symptoms are:
Chest pain (angina) that feels like burning, pressure or

tightness
Pain elsewhere in the body, such as the left upper arm or

jaw (referred pain)

Nausea
Vomiting
Shortness of breath (dyspnea)
Sudden, heavy sweating (diaphoresis)
Abdominal pain
Pain similar to heartburn
Clammy skin
Lightheadedness, dizziness or fainting
Unusual or unexplained fatigue
Feeling restless or apprehensive

Management
Pharmacologic Management
Aspirin. Aspirin decreases blood clotting, helping to keep

blood flowing through narrowed heart arteries.

Thrombolytics. These drugs, also called clotbusters, help
dissolve a blood clot that is blocking the blood flow to the
heart.

Nitroglycerin. This medication for treating chest pain and

angina temporarily widens narrowed blood vessels, improving
blood flow to and from the heart.

Beta blockers. These drugs help relax your heart muscle,

slow your heart rate and decrease your blood pressure, which

decreases the demand on the heart.

Angiotensin-converting enzyme (ACE) inhibitors and
angiotensin receptor blockers (ARBs). These drugs allow

blood to flow from the heart more easily.

Calcium channel blockers. These medications relax the heart
and allow more blood to flow to and from the heart.

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Cholesterol-lowering drugs. Commonly used drugs known as

statins can lower your cholesterol levels, making plaque
deposits less likely, and they can stabilize plaque, making
it less likely to rupture.

Clot-preventing drugs. Medications such as clopidogrel

(Plavix) and prasugrel (Effient) can help prevent blood
clots from forming by making the blood platelets less likely
to stick together.

Surgical Management
Angioplasty and stenting. In this procedure, the doctor
inserts a long, thin tube (catheter) into the blocked or
narrowed part of your artery.

Coronary bypass surgery. This procedure creates an

alternative route for blood to go around a blocked
coronary artery.

Nursing Management

Evaluate chest pain

Administer medications to relieve pain
Monitor vital signs

Ensure medication compliance

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4. Gastritis with Moderate Dehydration

Definition
Gastritis is an inflammation, irritation, or erosion of the
lining of the stomach. It can occur suddenly (acute) or gradually
(chronic).
Etiology
Gastritis can be caused by irritation due to excessive
alcohol use, chronic vomiting, stress, or the use of certain
medications such as aspirin or other anti-inflammatory drugs. It
may also be caused by any of the following:

Helicobacter pylori (H. pylori): A bacteria that lives in

the mucous lining of the stomach. Without treatment the
infection can lead to ulcers, and in some people, stomach

cancer.
Pernicious anemia: A form of anemia that occurs when the
stomach lacks a naturally occurring substance needed to

properly absorb and digest vitamin B12.

Bile reflux: A backflow of bile into the stomach from the

bile tract (that connects to the liver and gallbladder).

Infections caused by bacteria and viruses.

Clinical Manifestations
Nausea or recurrent upset stomach
Abdominal bloating
Abdominal pain
Vomiting
Indigestion
Burning or gnawing feeling in the stomach between meals or

at night
Hiccups
Loss of appetite
Vomiting blood or coffee ground-like material
Black, tarry stools

Management
Medical Management
Pharmacologic Management

Taking antacids and other drugs to reduce stomach acid.

For gastritis caused by H. pylori infection, your doctor

will prescribe a regimen of several antibiotics plus an acid

blocking drug (used for heartburn).

If the gastritis is caused by pernicious anemia, B12 vitamin
shots will be given.

Nursing Management
Ensure medication compliance
Instruct patient to avoid hot and spicy foods
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Instruct patient to eliminate irritating foods from the

diet - such as lactose from dairy or gluten from wheat.

5. ESRD (End-stage Renal Disease)

Definition
End-stage renal disease is when the kidneys permanently fail
to work.
Renal failure refers to temporary or permanent damage to the
kidneys that result in loss of normal kidney function. There are
two different types of renal failure--acute and chronic. Acute
renal failure has an abrupt onset and is potentially reversible.
Chronic renal failure progresses slowly over at least three
months and can lead to permanent renal failure. The causes,
symptoms, treatments, and outcomes of acute and chronic are
different.
Etiology
Diabetes and hypertension (high blood pressure) are the two
most common causes of ESRD. Diabetics cannot break down glucose
(sugar) correctly, and levels remain high in the blood. High
levels of glucose in the blood damage the glomeruli in the
nephrons. If you have hypertension, the increased pressure that
is forced upon the small vessels in the kidneys leads to damage
that makes the vessels unable to perform their blood-filtering
duties.
Risk

factors include:
Genetics
Smoking
Hyperlipidemia
Recreational drug use
Glomerulonephritis

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Clinical Manifestations
Symptoms of ESRD include:
Poor appetite
Vomiting
Bone pain
Headache
Insomnia
Itching
Dry skin
Malaise
Fatigue with light activity
Muscle cramps
High urine output or no urine output
Recurrent urinary tract infections
Urinary incontinence
Pale skin
Bad breath
Hearing deficit
Detectable abdominal mass
Tissue swelling
Irritability
Poor muscle tone
Change in mental alertness
Metallic taste in mouth
Management
Medical Management
Specific diet restrictions or modifications
Dialysis
Dialysis is a procedure that is performed routinely on
persons who suffer from acute or chronic renal failure,
or who have ESRD. The process involves removing waste
substances and fluid from the blood that are normally
eliminated by the kidneys. Dialysis may also be used for
individuals who have been exposed to or ingested toxic
substances to prevent renal failure from occurring. There
are two types of dialysis that may be performed,
including the following:

Hemodialysis
During hemodialysis, blood is removed from a vein. It
is run through filters to remove waste products. The
blood is then returned to the body. It is usually done at
a dialysis center. Treatments are done three times a week
in three to four-hour sessions.
Peritoneal Dialysis
During peritoneal dialysis, sterile fluid is infused
into the abdomen. Waste products gradually accumulate in
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the fluid, which is drained several hours later.

Peritoneal dialysis is done at home. It takes longer than
hemodialysis and must be done four to five times a day.
It can be automated to occur during sleep.

Kidney transplantation
This involves removing the kidneys and replacing
them with a donated organ. One healthy kidney is all that
is needed.

Pharmacologic Management
ACE Inhibitors to reduce protein in the urine and help

Nursing

manage high blood pressure.

Statins to lower cholesterol levels.
Management
Reinforce the need for sodium restrictions in diet
Strict I & O
Assess for edema, SOB, increased respiratory rate, pulse,

& BP, crackles in lungs

Teach patient the importance of taking meds at home

Teach patient to plan activities to avoid fatigue with

frequent rest periods

Provide mouth care and hard candy or gum to improve taste

Safety measures as appropriate

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