Schistosomiasis Leads to Liver Cirrhosis

ABSTRACT
We, group 1 of Level III section 1, have chosen this case to gain more knowledge
about the mechanism of Schistosomiasis that leads to Liver Cirrhosis and manifests
complications (Ascites, CVI & Edema). Our patient R.P is a 68 -year old female who
was first diagnosed of Schistosomiasis, Liver Cirrhosis and Chronic Venous
Insufficiency in the year 2010. Her disease leads to fluid accumulation to his lungs and
in the abdominal cavity and edema on her extremities. Our group chose the case
because it is also our first time to handle a case that is unusual. We also want to
improve our knowledge and skills in dealing with individuals with this kind of disease,
especially in preventing the occurrence of its complications.
Schistosomiasis (also known as bilharzia, bilharziosis or snail fever) is a
collective name of parasitic diseases caused by several species of trematodes
belonging to the genus Schistosoma. Snails serve as the intermediary agent between
mammalian hosts. Individuals within developing countries who cannot afford proper
water and sanitation facilities are often exposed to contaminated water containing the
infected snails.
This disease is most commonly found in Asia, Africa, and South America,
especially in areas where the water contains numerous freshwater snails, which may
carry the parasite.
The disease affects many people in developing countries, particularly children
who may acquire the disease by swimming or playing in infected water. When children
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come into contact with a contaminated water source, the parasitic larvae easily enter
through their skin and further mature within organ tissues. As of 2009, 74 developing
countries statistically identified epidemics of Schistosomiasis within their respective
populations
Cirrhosis is an abnormal liver condition in which there is irreversible scarring of
the liver. The main causes are sustained excessive alcohol consumption, viral hepatitis
B and C, and fatty liver disease; however, there are many possible causes. People with
cirrhosis may develop jaundice, itching and extreme tiredness. For cirrhosis to develop
long-term, continuous damage to the liver needs to occur. When healthy liver tissue is
destroyed and replaced by scar tissue the condition becomes serious, as it can start
blocking the flow of blood through the liver. Cirrhosis is a progressive disease,
developing slowly over many years, until eventually it can stop liver function (liver
failure). The liver carries out several essential functions, including the detoxification of
harmful substances in the body. It also purifies the blood and manufactures vital
nutrients.
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I.
DEMOGRAPHIC DATA:
Name: R.P
Date of Interview: August 01, 2013
Age: 68 years old
Primary informant: Patient R.P
Birthday: September 09, 1944
Secondary Informant: Relatives
Birthplace: Tabon-Tabon Northern Leyte
Other Sources: Patients Chart and Lab
Address: GMA, Cavite
Date Admitted: July 21, 2013
Gender: Female
Time Admitted; 07:15 am
Civil Status: Married

Religion: Roman Catholic
Highest Educational Attainment: Elementary Graduate
Occupation: Sari-sari Store Owner
Monthly Income: 25, 000
Monthly Expenses: 10, 000
Medical support: PhilHealth
II.
CHIEF COMPLAINT:
One month prior to admission she noted unexpected weight gain from 59 kg to
63.2 kg and enlargement of the abdomen. Four days prior to admission, the patient had
experienced difficulty of breathing and dyspnea on exertion.
III.
HISTORY OF PRESENT ILLNESS:

In the year 2010, the patient was diagnosed with Schistosomiasis and
Liver Cirrhosis in Philippine General Hospital. She was also diagnosed with Chronic
Venous Insufficiency on the said year.
Her relatives claimed that she got her disease when she had her vacation in
Leyte last 2009. When she got back in Cavite on the same year, she noticed that her
legs were edematous due to the lacerated wound she got upon farming in Leyte. After a
year, her daughter insisted on getting her mother a medical attention at the said
hospital. At the day of admission, as her wounds slowly healed, she was given the
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medication-propranolol to be taken three times a day and Praziquantel and was advised
to clean her wound properly. Her abdomen was also enlarged and an evident edema on
her lower extremities was noted. After seeking medical attention, she did not attend her
follow up consultation because she claimed that she will be fine due to the given
medication.
This 2013, four days prior to her admission, she developed productive cough with
whitish phlegm accompanied with difficulty of breathing. Two days prior to admission,
her abdomen was enlarged and evident edema on her lower extremities was noted.
IV.
PAST MEDICAL HISTORY:

According to the patient, she cannot recall if she was fully immunized during her
childhood days. She perceives herself to be healthy and she claimed, Hindi naman ako
sakitin noong bata pa ako,. She also claimed that she did experience common
illnesses like fever, cough and colds. Pag may sakit si nanay kahit nung bata pa kami,
di siya mahilig uminom kaagad ng gamot mas gusto niya yung mga herbal medicine
katulad ng lagundi at oregano, as verbalized by her daughter. She didnt rely on over
the counter drugs because for her it will just make you more dependent in synthetic
remedies. She claimed that she has no known allergies in foods and in medications.
She claimed that in their family, there are no history of hereditary diseases such as
diabetes and hypertension. Also, she claimed that, Nung dinala ako sa PGH, dun
naming nalaman na tumaas na BP ko hanggang ngayon kasi di naman tumataas yun
dati hanggang 110/80 lang. RP also claimed that, Yunhg kapatid lang ng nanay ko
namatay dahil sa colon cancer at yung kapatid ko na bunso may asthma.
The patient didnt encounter any accidents or fall thus she didnt have any
fracture in the past. Di naman yan naaksidente kahit dati pa, yun lang talaga nung
nagbakasyon siya sa probinsya namin tapos pag- uwi may sugat siya at biglang
namaga na yung paa tapos ayaw niya na magpacheck-up kaya March 2010 na namin
siya nadala., as verbalized by her sibling. She was hospitalized in Philippine General
Hospital on the year 2010 for four days after she came back from their province and
was then diagnosed of Chronic Venous Insufficiency and Schistosomiasis and Liver
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Cirrhosis. Nasugatan po kasi yung paa niya sa kahoy nung nasa palyan daw sila tapos
ayan pag-uwi namaga na paa niya at marami dun sa amin ang may ganiyang sakit, as
verbalized by the daughter. They seeked medical attention because they thought that
the wound was healing slowly. Nililinis po namin ng dextrose na may zonrox yung paa
niya, yun po kasi sabi ng doktor, as verbalized by her daughter. She was then
maintained on the given medication (propranolol) and she refused her follow-up check
up because she claimed that she will become fine, knowing that she just appropriately
took her medication. Ayaw niya na magpa-check up kasi daw umiinom naman daw siya
ng gamot tapos naging okay naman siya. Ngayon lang
V.
OBSTETRIC- GYNECOLOGICAL HISTORY:

Patient R.P claimed that she had her menarche during her elementary day
(Grade 6), she just dont remember the exact date. She also claimed that she had a
regular menstrual cycle and did experience dysmenorrhea but she didnt take any
analgesic. She had her last menstrual period during her late 40s.
Name of the Child
Year of
AOG
Place of Birth
Manner of
Birth
Delivery
P. P
1973
Full Term
House
NSD
M. P
1975
Full Term
House
NSD
Interpretation:
Patient R.Ps OB score is G2P2T2A0L2. She delivered her children in their
house here in Cavite and through NSD. She claimed that she didnt experience any
complication during her pregnancies.
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VI.
HEREDO- FAMILIAL HISTORY:
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Interpretation:
The genogram is a pictorial display of patients R.Ps family relationship and
medical history. It shows the three-generation family of the patient. The diagram
includes the current ages and current health status of each family member from the
three generation from the patient.
The paternal and maternal side of the patient in both of her grandparents were
dead but she was not sure for the exact cause of her death.
For the second generation, most of the family members were dead. His father
and mother both died due to a vehicular accident. Her uncle on the mothers side died
because of colon cancer.
For the third generation, her older brother died due to myocardial infarction and
her brother L.P developed asthma.
VII.
DEVELOPMENTAL HISTORY:
Erik Eriksons Psychosocial Development

According to Erik Erikson, our personality traits come in opposites. We think of
ourselves as optimistic or pessimistic, independent or dependent, emotional or
unemotional, adventurous or cautious, leader or follower, aggressive or passive. Many
of these are inborn temperament traits, but other characteristics, such as feeling either
competent or inferior, appear to be learned, based on the challenges and support we
receive while growing up.
The man who did a great deal to explore this concept is Erik Erikson. Although
he was influenced by Freud, he believed that the ego exists from birth and that behavior
is not totally defensive. Based in part on his study of Sioux Indians on a reservation,
Erikson became aware of the massive influence of culture on behavior and placed more
emphasis on the external world, such as depression and wars. He felt the course of
development is determined by the interaction of the body (genetic biological
programming), mind (psychological), and cultural (ethos) influences. His developmental
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stages were based on his philosophy that: (1) the world gets bigger as we go along and
(2) failure is cumulative.
He organized life into eight stages that extend from birth to death (many
developmental theories only cover childhood). Then, since adulthood covers a span of
many years, Erikson divided the stages of adulthood into the experiences of young
adults, middle aged adults and older adults. While the actual ages may vary
considerably from one stage to another, the ages seem to be appropriate for the
majority of people.
Stage 1. Infancy: Birth to 18 Months
Ego Development Outcome: Trust vs. Mistrust
Basic strength: Drive and Hope
At this stage babies learn to trust that their parents will meet their basic needs. If
a child's basic needs aren't properly met at this age, he or she might grow up with a
general mistrust of the world. The patient grew up with her parents and siblings in their
province. Upon questioning the patient regarding on this developmental stage, she
stated that, Ang pagkakatanda ko, nanay ko ang madalas na nagaalaga sakin dahil si
tatay ang palaging nasa bukid. Breastfed din naman ako at hindi naman daw ako
mahirap padedehen. Kapag umiyak na daw ako hindi daw agad ako mapatahan,
kailangan matagal akong kinakarga para tumahan. Nung di na ako nadede, pinapakain
na ako ng magulang ko ng nilagang patatas, kalabasa na dinurog. Sabi ng nanay ko
dati, hindi daw ako ganun katakot sa mga tao hindi din naman ako nangingilala,
nasama agad ako kapag nagpapakarga. Minsan daw umiiyak ako kapag nakakakita
ako ng mga malalaking tao, lalo na yung mga tito at yung lolo ko, sa tatay ko lang ako
hindi takot. Umiiyak lang daw ako kapag naalis yung mga magulang ko lalo na nanay
ko.
An infant is helpless, totally dependent on others for his needs. During this stage,
the infant learns whether the world in which he lives can be trusted. If an infant's
physical and emotional needs are met in a consistent and caring way, she learns that
his mother or caregiver can be counted on and he develops an attitude of trust in
people. If her needs are not met, an infant may become fearful and learns not to trust
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the people around her. The implications of Erikson's first stage for parents, it is to
ensure that an infant experiences a trusting relationship with her parent (or caregiver).
For a trusting relationship to exist there must be a consistent relationship.
The most significant relationship is with the maternal parent, or whoever is our
most significant and constant caregiver. Based on our interview with the client, we can
say that she gained trust as she had a constant caregiver, which was her mother, who
made sure all his needs were met and gave her constant love.
Stage 2. Early Childhood: 18 Months to 3 Years

Ego Development Outcome: Autonomy vs. Shame
Basic Strengths: Self-control, Courage, and Will
As toddlers, children begin to develop independence and start to learn that they
can do some things on their own (such as going to the toilet). If a child is not
encouraged properly at this age, he or she might develop shame and doubt about their
abilities.
The patient states that Noong dalawang taong gulang pa lang daw ako at sa
pagkakatanda ko mabilis daw akong natutong magsalita, madaldal ako at mahilig akong
tumakbo kapag lumalabas kami ng bahay, sobrang likot at kulit ko daw noon, hindi daw
agad ako basta-basta nasasaway lalo na pagpupunta si tatay sa bukid mamimilit akong
sumama. Minsan mabait naman daw ako, pero dapat daw ibigay lang ang gusto ko para
hindi ako mangulit. Bata palang din daw ako mahilig na ako magsulat ng kung anu-ano,
basta kapag nakakita ako ng lapis bigla na lang ako guguhit. Tinuturuan din ako ni nanay
kung saan ako tatae at iihi, nagsasabi ako sa kanila na tatae ako, at kusa naman akong
pupunta sa banyo. Meron din naman minsan na pag di ko mapigilan yung pag- ihi
napapaihi din naman ako sa panty ko.
The toddler realizes that she is a separate person with her own desires and
abilities. She wants to do things for herself without help or hindrance from other people.
The toddler's favorite word "No" is a declaration of independence and a bid for
increased autonomy. It is a reflection of being made in the image of God ... with the
ability to make choices.
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This push for autonomy is enhanced by muscular maturation as toddlers try to

use their developing muscles to walk, climb, hop and jump and to explore their
environment. Potentially, toddlers can get into dangerous situations. Therefore, parents
have to balance the opposing virtues of encouragement and restraint. If a toddler's
efforts to do things on her own were frustrated by over-protective parents then she may
not have many opportunities to develop autonomy. On the other hand, if a toddler was
harshly criticized for "accidents" (e.g., wetting, soiling, spilling or breaking things) then
she may develop doubt about his own abilities to tackle new challenges.
Children need to develop a sense of personal control over physical skills and a
sense of independence. Success leads to feelings of autonomy, failure results in
feelings of shame and doubt. The most significant relationships are with parents. Based
on our interview with the client, we can say that she established autonomy. She was
also taught how to the things the correct way and was allowed to do these things by
herself.
Stage 3. Play Age: 3 to 5 Years
Ego Development Outcome: Initiative vs. Guilt
Basic Strength: Purpose
As preschoolers, children continue to develop more independence and start to do
things of their own initiative. If a child is not able to take initiative and succeed at
appropriate tasks, he or she might develop guilt over their needs and desires.
During this period, the patient experiences a desire to copy the adults around her
and take initiative in creating play situations. The patient also begins to use that
wonderful word for exploring the world "WHY?" As she verbalized, Noong mga 5 na
taon daw ako, palagi daw akong nasunod sa nanay ko tapos ang hilig ko daw
magkwento pag dumadating si tatay kinukwentuhan ko siya. Kapag wala naman daw
akong ginagawa naglalaro lang daw ako sa bakuran namin. Naalala ko din noon na
mahilig ako mangialam ng mga bagay na di akin lalo na gamit ng mga kapatid ko.
Naalala ko din na mahilig ako sumama sa mga magulang ko sa bukid kapag napipilit ko
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sila na isama ako. Sabi ng nanay ko, pipilitin ko din na magsaka ako na parang kayang
kaya ko daw, ginagaya ko pa ang ginagawa ng tatay ko kaya tuwang tuwa mga
katrabaho niya.
Increased muscular, mental and language abilities set the stage for more
activities and questions. There is a great curiosity and openness to learning. The
favorite word of a pre-school is "why." Parents who take time to answer their
preschoolers questions reinforce their intellectual initiative. But parents who see their
children's questions as a nuisance may stifle their initiative and cause them to be too
dependent on others and to be ashamed of themselves. Imaginative play is the basic
activity of this stage. The preschooler explores and reenacts the different roles and
activities of people, both real (home life) and fictional (often based on television).
Preschoolers learn through play. Play is their "work." Children who are given much
freedom and opportunity to initiate imaginative and motor play have their sense of
initiative reinforced. Parents who inhibit their children's imaginative play or deride them
as silly may cause them to develop a sense of guilt over self-initiated activities. Based
on our interview, it can be said that the patient established autonomy due to her
experiences in terms. Her experiences brought on such a powerful effect on her
personality they influenced her actions.
Children need to begin asserting control and power over the environment.
Success in this stage leads to a sense of purpose. Children who try to exert too much
power experience disapproval, resulting in a sense of guilt.
Stage 4. School Age: 6 to 12 Years

Ego Development Outcome: Industry vs. Inferiority
Basic Strengths: Method and Competence
Throughout their school years, children continue to develop self-confidence
through learning new things. If they are not encouraged and praised properly at this
age, they may develop an inferiority complex.
During this stage, often called the Latency, we are capable of learning, creating
and accomplishing numerous new skills and knowledge, thus developing a sense of
industry. This is also a very social stage of development and if we experience
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unresolved feelings of inadequacy and inferiority among our peers, we can have serious
problems in terms of competence and self-esteem.
The patient at this stage learned to read, to write and make things on her own.
She verbalized that, Six year old ako nagsimulang mag-grade1. Sabi sa akin ng nanay
ko palagi ako sumasagot sa klase, kaya tuwang-tuwa daw ang teacher ko sa akin. Kahit
hirap kami noon nairaraos pa din naman kami nila nanay. Nairaos din nila ang pagaaral ko hanggang magtapos ako ng elementarya. Kahit di ako ganun ka talino kahit
papaano nakapagtapos ako.
At the school-going stage, the child's world extends beyond the home to the
school. The emphasis is on academic performance. There is a movement from play to
work. Earlier the child could play at activities with little or no attention given to the quality
of results. Now, she needs to perform and produce good results.
The child soon learns that she can win recognition from parents, teachers and
peers by being proficient in her school work. The attitudes and opinions of others
become important. The school plays a major role in the resolution of the developmental
crisis of initiative versus inferiority.
If children are praised for doing their best and encouraged to finish tasks then
work enjoyment and industry may result. Children's efforts to master school work help
them to grow and form a positive self-concept ... a sense of who they are. Children who
cannot master their school work may consider themselves a failure and feelings of
inferiority may arise.
A child may also feel a sense of shame if his parents unthinkingly share her
"failures" with others. Shame stems from a sense of self-exposure, a feeling that one's
deficiencies are exposed to others.
There is a danger in "I am what I can achieve" ... children may come to believe
that they must earn love and acceptance. This thinking runs counter to the gospel of
grace (Eph. 2:8-9). Parents need to give their children "unconditional love" that no
matter what they do, they are still your children. Based on the interview, it is determined
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that the patient established industry because she received praise from his teacher. Also,
her parents showed their support in giving her better future even they are not wealthy
enough just to sustain their child.
Stage 5. Adolescence: 12 to 18 Years
Ego Development Outcome: Identity vs. Role Confusion
Basic Strengths: Devotion and Fidelity
When they reach the teenage years, children start to care about how they look to
others. They start forming their own identity by experimenting with who they are. If a
teenager is unable to properly develop an identity at this age, his or her role confusion
will probably continue on into adulthood.
The patient verbalized that, Nung nagsimula na ako maging teenager, simple
lang ako hindi ako gaanong nag-aayos. Madali akong magkaroon ng kaibigan kasi
madali naman akong makisama at pakisamahan. Hindi rin ako nagkaroon ng
karelasyon dahil bawal pa at ayaw din ng mga magulang ko. Sabi kasi nila madali lang
daw magasawa at dapat nasa tamang edad na.
Teens need to develop a sense of self and personal identity. Success leads to an
ability to stay true to yourself, while failure leads to role confusion and a weak sense of
self.
Our task is to discover who we are as individuals separate from our family of
origin and as members of a wider society. Unfortunately for those around us, in this
process many of us go into a period of withdrawing from responsibilities, which Erikson
called a "moratorium." And if we are unsuccessful in navigating this stage, we will
experience role confusion and upheaval. A significant task for us is to establish a
philosophy of life and in this process we tend to think in terms of ideals, which are
conflict free, rather than reality, which is not. The problem is that we don't have much
experience and find it easy to substitute ideals for experience. However, we can also
develop strong devotion to friends and causes.
The most significant relationships are with peer groups. Based on the interview, it
is determined that the patient established identity because as a young man, he had a lot
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of confidence and made friends easily. She was not influenced by other people and
made her own decisions as seen with his former relationship.
Stage 6. Young Adulthood: 18 to 35

Ego Development Outcome: Intimacy and Solidarity vs. Isolation
Basic Strengths: Affiliation and Love
During early adulthood most people fall in love, get married and start building
their own family. If a person is unable to develop intimacy with others at this age
(whether through marriage or close friendships), they will probably develop feelings of
isolation.
The patient stated that in this stage, Lumipat ako dito sa Cavite nung 20 years
old na ako. Kasi may kamag- anak kami dito at magtatrabaho na din ako kasi mahirap
ang buhay namin sa probinsya. Dito ko din nakilala yung asawa ko. Nagkakilala kami sa
pinagtatrabahuhan ko. Suki namin siya sa restaurant at dun na nag- umpisa yung
pagmamahalan namin hanggang sa nagkaroon kami ng dalawa anak. Masaya kami
hanggang sa nagkaroon kami ng sariling tindahan.
Young adults need to form intimate, loving relationships with other people.
Success leads to strong relationships, while failure results in loneliness and isolation.
In the initial stage of being an adult we seek one or more companions and love.
As we try to find mutually satisfying relationships, primarily through marriage and
friends, we generally also begin to start a family, though this age has been pushed back
for many couples who today don't start their families until their late thirties. If negotiating
this stage is successful, we can experience intimacy on a deep level. If we're not
successful, isolation and distance from others may occur. And when we don't find it
easy to create satisfying relationships, our world can begin to shrink as, in defense, we
can feel superior to others.
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The significant relationships are with marital partners and friends. Based on the
interview, the patient is said to have gained intimacy because he has established a
marital relationship and has a family.
Stage 7. Middle Adulthood: 35 to 55 or 65
Ego Development Outcome: Generativity vs. Self absorption or Stagnation
Basic Strengths: Production and Care
This is the longest period of a human's life. It is the stage in which people are
usually working and contributing to society in some way and perhaps raising their
children. If a person does not find proper ways to be productive during this period, they
will probably develop feelings of stagnation.
During this period, the patient is already having his own family. As we
interviewed her, she stated that, Noong nasa mga nasa 40s na ako, wala akong ibang
ginawa kundi ang magtrabaho at maghanap ng pera para sa pamilya. Hindi ko na nga
masyadong iniintindi ang sarili ko dahil ang lagi kong iniisip ay ang para sa pamilya ko.
Nakapagpundar din kami ng sari-sari store at yan nagsilbing negosyo namin.
Adults need to create or nurture things that will outlast them, often by having
children or creating a positive change that benefits other people. Success leads to
feelings of usefulness and accomplishment, while failure results in shallow involvement
in the world. Now work is most crucial. Erikson observed that middle-age is when we
tend to be occupied with creative and meaningful work and with issues surrounding our
family. Also, middle adulthood is when we can expect to "be in charge," the role we've
longer envied.
The significant task is to perpetuate culture and transmit values of the culture
through the family (taming the kids) and working to establish a stable environment.
Strength comes through care of others and production of something that contributes to
the betterment of society, which Erikson calls generativity, so when we're in this stage
we often fear inactivity and meaninglessness. As our children leave home, or our
relationships or goals change, we may be faced with major life changes the mid-life
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crisis and struggle with finding new meanings and purposes. If we don't get through
this stage successfully, we can become self-absorbed and stagnate. Significant
relationships are within the workplace, the community and the family.
Stage 8. Late Adulthood: 55 or 65 to Death
Ego Development Outcome: Integrity vs. Despair
Basic Strengths: Wisdom
As senior citizens, people tend to look back on their lives and think about what
they have or have not accomplished. If a person has led a productive life, they will
develop a feeling of integrity. If not, they might fall into despair.
Erikson felt that much of life is preparing for the middle adulthood stage and the
last stage is recovering from it. Perhaps that is because as older adults we can often
look back on our lives with happiness and are content, feeling fulfilled with a deep sense
that life has meaning and we've made a contribution to life, a feeling Erikson calls
integrity. Our strength comes from a wisdom that the world is very large and we now
have a detached concern for the whole of life, accepting death as the completion of life.
As we interviewed her, she stated that Ngayon sa kalagayan ko, aaminin ko na
hirap na ako at handa na akong mamatay. Pinagsasadiyos ko nalang ang mga
mangyayari kahit alam kong mahirap lalo na sa pamilya ko. Wala akong pinagsisihan sa
buhay ko, lahat naman naging maayos, masaya at walang naging problema, Kahit hindi
kami gaanong mayaman at naging ganito ang kondisyon ko nagpapasalamat pa din ako
sa diyos.
On the other hand, some adults may reach this stage and despair at their
experiences and perceived failures. They may fear death as they struggle to find a
purpose to their lives, wondering "Was the trip worth it?" Alternatively, they may feel
they have all the answers (not unlike going back to adolescence) and end with a strong
dogmatism that only their view has been correct. Older adults need to look back on life
and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while
failure results in regret, bitterness, and despair. The significant relationship is with all of
mankind.
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VIII.
GORDONS FUNCTIONAL HEALTH PATTERN:
1) HEALTH PERCEPTION- HEALTH MANAGEMENT PATTERN

At present, the patient perceives that her general health was compromised as
she was diagnosed with Schistosomiasis, Liver Cirrhosis, Ascites and CVI. Her relatives
claimed that it started when she had her vacation in Leyte and her legs got a wound
while farming. Also, she claimed that she was not an alcoholic drinker nor did she
practice any sort of vices while growing up. According to her before she was admitted,
she does not rely on over the counter drugs and seldom seek medical attention
whenever she got sick. The patient would rather take herbal medicines as her form of
remedy whenever she feels unwell. She believes that one should not be dependent on
certain medication in treating a disease. Also, whenever she felt something wrong or
she does not feel good, she would simply rest or go to sleep. She claimed that she
walks every morning and perform some household chores that serve as her daily
exercise.
When she first seek medical attention at Philippine General Hospital in the year
2010 due to the slow healing process of her legs as well being edematous, she was
prescribed by her doctor with propranolol to be taken three times a day and another was
Praziquentel. She was then advised to avoid fatty foods and always clean her legs with
NaCl Solution with Zonrox, thus she goes after the advice of her doctor. From then on
she did not attend her check ups believing that she will be just fine as long as she
properly took her medications.
But when RP was hospitalized due to her worsening condition, it was the only
time she finally followed the doctors order and advice, realizing that it will help her to
improve her condition. Her relatives also took good care of her especially when the
client can no longer perform a few of her ADLs (activities of daily living). RP claimed
that before her hospitalization, she was persistent to her own perspective of health and
in keeping herself well. Now, she realized the importance of following doctors orders
and check ups, because as time goes by, aging and health status changes.
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2) NUTRITIONAL- METABOLIC PATTERN

Patient R.P was instructed to limit fluid intake of less than 1 liter per day as
doctors order. Before hospitalization she consumes 5-8 glasses of water a day. Also,
her relatives claimed that, Nung pagkahospital ni nanay sa PGH sinabihan siya na
bawal siya ng malalangsa at matatabang pagkain. According to her daughter, patient
R.Ps meal before hospitalization usually includes vegetables, fruits, rice and cereals.
She also drinks coffee every morning. During hospitalization, she usually eats porridge,
biscuit, cereals, soup and vegetables. Her relatives claimed that before hospitalization,
she ate a lot and has a good appetite.
Her relatives claimed that RPs legs were really swollen and that her enlarged
abdomen made it look like she gained weight. Her weight increased from 59kg to
63.2kg prior to admission.
Upon observation, we noticed that the patients skin was dry and with poor skin
turgor. She also ha hematoma throughout both arms due to administration of
medications and switching of IV positions. Although RP did not have any problem
chewing, she wore dentures since she was 56 years old and had difficulty in swallowing
foods that are quite rigid.
5- Day Diet Recall (Hospital Setting)
Meals
Breakfast
Sept. 29,
Sept. 30,
Sept. 31,
Aug. 01,
Aug. 02,
2013
2013
2013
2013
2013
1 cup Lugaw
1 small bowl
1 slice bread
1 cup
1 slice
200 ml water
vegetable
grapes
oatmeal
bread
soup
240 ml water
200 ml water
1 cup
240 ml water
oatmeal
200 ml
water
Lunch
1 cup of rice
1 cup of rice
1 cup of rice
1 cup of rice
1 cup of
with sabaw
Vegetables
Vegetables
Vegetables
rice
ng tinola
240 ml water
240 ml water
240 ml water 200 ml water
Vegetables
200 ml
water
Page 18
Snack
Dinner
Total
Fluid
Biscuits
1 slice of
1 cup
Biscuit
Grapes
Grapes
bread
oatmeal
I cup lugaw
I cup lugaw
1 cup of rice
1 cup of rice
I cup lugaw
200 ml water
grapes
Vegetables
Vegetables
200 ml
240 ml water
200 ml water
200 ml water
water
720 ml
680 ml
600 ml
640 ml
600
Intake
3) ELIMINATION PATTERN
Patient R.P claimed that before hospitalization, she usually defecates once every
two days with dark brown in color. On the other hand, she urinates 5 times a day with
yellow in color. She claimed, Normal naman yung dami ng ihi ko. She has no trouble
in holding her urine. Also, she claimed that, Di naman ako mabiilis pawisan at kung
mapawisan man ako di naman sobra-soobra.
During hospitalization, she had 2-3 bowel movements per week with a dark
brown color stool, with hard formed in consistency. She was on a catheter for accurate
monitoring of her urine output. She claimed that she is experiencing discomfort due to
the inserted catheter and has difficulty in defecating. Upon observation, she doesnt
perspire excessively.
4) ACTIVITY- EXERCISE PATTERN
According to patient R.P her usual activities before hospitalization was that upon
waking up she sometimes walk in the morning or rather swept the floor. She claimed
that this serves as her exercise and after that she watches her sari-sari store together
with her husband. Sometimes, she took a nap in the afternoon or watch television. Her
daughter claimed that she was not able to perform certain things that exert too much
effort rather than before especially because of her age and as well due to her condition.
During hospitalization, her relatives claimed that most of the time she was on her
bed. Also, she needs assistance whenever going to the bathroom or even standing up
in preventing accidents especially fall. Her relatives claimed that she usually sleeps and
sometimes became irritated when there are nurses doing their rounds. Upon
Page 19
observation, she looks very weak and was not able to perform certain things on her
own. She was placed on semi-fowlers position because she claimed that she
experience difficulty on breathing when lying on flat.
7-Day Activity Table (Hospital Setting)
TIME
Days Of The Week

Sept. 27
Sept. 28
Sept. 29
Sept. 30
Sept. 31
Aug. 01
Sleeping
Sleeping
Sleeping
Aug. 02
1 am
2 am
3 am
Sleeping
Sleeping
Sleeping
Sleeping
4 am
5 am
6 am
7 am
Having
Having
Having
Having
Having
breakfast
breakfast
breakfast
breakfast
breakfast
Morning
Having
Care
breakfast
Morning Care
Morning Care
Chatting with
Chatting with
her relatives
her relatives
8 am
Having
Chatting
breakfast
with her
10
Chatting
relatives
am
with her
11
relatives
9 am
1 pm
Having lunch
Having lunch
Chatting with
Having
Chatting with
lunch
her relatives
her relatives
relatives
Lying in bed
Having
lunch
Resting
Having Snack
Resting
Having
Chatting with
Having lunch
Resting
Chatting with
Having snack
snack
Lying on Bed
her relatives
Having snack
snack
Having
Resting
Having lunch
Resting
relatives
5 pm
her relatives
Resting
Chatting
with her
Chatting with
bed
with her
Care
Chatting with
lunch
3 pm
4 pm
Lying in bed
Lying in
Chatting
breakfast
Morning
Having
2 pm
Lying in bed
her relatives
am
12 nn
Having
her relatives
Resting
Having
Chatting with
snack
her relatives
Page 20
6 pm
Resting
Lying in
Chatting with
7 pm
Having dinner
Lying in bed
bed
Resting
her relatives
Having dinner
Having
dinner
8 pm
Having
Having
dinner
dinner
Having dinner
Resting
Having dinner
Resting
Resting
9 pm
10
Sleeping
Sleeping
Resting
Sleeping
pm
Lying in bed
Sleeping
11
Sleeping
Sleeping
Sleeping
pm
12
mn
Katz Index of Independence in Activities of Daily Living

Activities
Independence
Dependence
Points (1 or 0)
No supervision, direction or
With supervision, direction or personal
personal assistance needed
assistance or total care
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
TOTAL POINTS:
0 point
6 points
Interpretation:
As seen on the table above, patient R.P was not capable of doing the activities of
daily living without supervision, direction and personal assistance from family member
or from health care provider.
Page 21
5) SLEEP- REST PATTERN

Patient R.P claimed that before hospitalization she sleeps around 8 pm and
wakes up around 6 oclock in the morning. Her daughter claimed that sometimes she
snores and sometimes experienced dreams at night that comprised of sleep talking.
During hospitalization, she claimed that she doesnt have any enough sleep
especially when the nurses were doing their rounds. Also, she was not satisfied in her
stay in the hospital because there are also several patients in the ward. She claimed
that sometimes she feels dizzy upon awakening and doesnt feel rested.
5-Day Sleep Diary (Hospital Setting)
Constructs
Sept. 27
Sept.
Sept. 29
Sept. 30
28
Hours
of 9 hours
Sept.
Aug.
Aug.
31
01
02
9 hours 9 hours
7 hours
9 hours
7hours
7 hours
9 pm
9 pm
10 pm
11 pm
10 pm
11 pm
11 pm
6 am
6 am
6 am
4 am
6 am
6 am
6 am
Praying
Praying Praying
Praying
Praying
Praying
Praying
Irritable
Not
Feels
Irritable
Not well Not
Not
upon
well
dizzy
rested
well
well
Waking Up
rested
rested
rested
Body
Being
Being
malaise
sleepy
sleepy
Sleep
Sleeping
Time
Waking
Time
Bedtime
Rituals
Feeling
Problem
Body
Encountered malaise
Body
malaise
Headache Body
malaise
6) COGNITIVE- PERCEPTUAL
The patient had hematoma throughout her both arm and claimed that she feels
pain in both hands due to IV insertion and when giving medications. Her relatives
massage her hands and we applied warm compress to help ease the pain. She also
Page 22
said that her abdomen is also in pain. When we asked the pain scale, she answered 6
out of 10.
Upon the interview, the patient does not wear any eyeglasses and hearing aids.
She stated that she is experiencing blurred vision in both eyes due to her age, the grade
of her eyes were 4.00 and her last opthalmoscopic examination was January, 2013.
She claimed that she cannot read small texts mainly in dim lights. She needs assistance
whenever going to the bathroom or even standing up in preventing accidents especially
from fall. She is also having difficulty in hearing. She said that she easily forgets mainly
due to her age. Medyo makakalimutin na din ako, siguro dahil narin sa katandaan, as
verbalized by the patient. When we asked her whats the date today she answered
hindi ko alam, anu nga ba neng?
7) SELF PERCEPTION-SELF CONCEPT PATTERN
The patient describes herself as a good and responsible mother, wife and a
grandmother. When she was admitted, she easily gets irritated because of the noise
and the ambiance in the hospital as well as when the nurse doing their rounds because
she cannot rest well. She claimed that she knew that her health was then compromised
and was not able to perform things like before. She claimed that, Ako na nga ngayon
yung inaalagaan ng mga anak ko na dapat gawain ko yun pero nagpapasalamat pa din
ako sa kanila at sa asawa ko.
8) ROLE RELATIONSHIP PATTERN
The patient lives with her husband while her children have their own family. As of
her condition, she claimed that her family supports her for her fast recovery. The patient
stated that she has a good relationship with the family. In regards with her children, they
have their own family as well they still have a good relationship. Matibay ang
pagsasamahan nilang mag-asawa. Syempre minsan nagkakatampuhan o nag-aaway,
pero naayos din naman agad, as verbalized by the patients relatives.
She said that her family is the most important thing for her. Her family is her
motivation and strength to fight for her condition.
9) SEXUALITY-REPRODUCTIVE PATTERN
Patient R.P claimed that she had her menarche during her elementary days, she
just dont remember the exact date. She also claimed that she had a regular menstrual
Page 23
cycle and did experience dysmenorrhea but she didnt take any analgesic. She had her
last menstrual period during her 40s. Patient R.Ps OB score is G2P2T2A0L2.
Her relatives claimed that, Masaya naman sila ni nanay at palagi na nga silang
magkasama kasi sila din ang nagbabantay sa tindahan. Siguro hanggang 2 nalang
talaga kami, mahirap na dagdagan.
10) COPING-STRESS TOLERANCE
Before she was admitted, when client R.P. feels tired, she will rest and sleep.
She claimed that when she got problems especially in terms of money, she talk with her
husband and children. Sometimes she used to have her past time activities which are
watching television and listening in a radio while into their sari-sari store. This serves as
her coping mechanisms to overcome the feeling of being stressed. Also, she talks and
sometimes plays with her granddaughter.
When she was admitted, there have been many changes occurred that made her
difficult to adjust. She cannot perform her usual activities due to her condition and she
easily gets irritated.
11) VALUE-BELIEF PATTERN
Patient R.P. is a roman catholic. Before she was admitted, she usually goes to
mass every Sunday with her husband. The patient has a strong faith in God. She said
that God helps her to get through to her problems in life. She always prays and asked
God to guide her and her family especially for her illness that she was experiencing.
She stated that she doesnt want to stay in the hospital anymore and wanted to go
home.
When she was asked about what is the most important thing in her life, she
answered her family. Her family is the reason why she wanted to live longer. The patient
does believe in superstitions and still practiced it until now specifically, Bawal maligo
pag may menstruation and Bawal magwalis pag gabi. In terms of medical
approaches, she was really into the herbal medicines and claimed that she doesnt rely
too much on the over the counter drugs.
Page 24
IX.
COMPREHENSIVE PHYSICAL EXAMINATION

(Date Performed: August 01-02, 2013)
A. Vital Signs: (10:00pm to 6:00am shift)

August 01, 2013
TIME
BLOOD
TEMPERATURE
PRESSURE
RESPIRATORY
PULSE
RATE
RATE
10:00pm(Initial)
140/80 mmHg
36.1 0C
21 cpm
59 bpm
12:00mn
140/80 mmHg
36.3 0C
20 cpm
62 bpm
4:00am
130/80 mmHg
35.4 0C
21 cpm
60 bpm
August 02, 2013

TIME
BLOOD
TEMPERATURE
PRESSURE
0
RESPIRATORY
PULSE
RATE
RATE
10:00pm(Initial)
130/80 mmHg
36.0 C
20 cpm
64 bpm
12:00mn
130/80 mmHg
36.1 0C
22 cpm
62 bpm
4:00am
130/80 mmHg
35.9 0C
20 cpm
63 bpm
ABDOMINAL GIRTH MEASUREMENT:

DATE:
MEASUREMENT:
July 21, 2013
105 cm
July 23, 2013
113 cm
July 26, 2013
110 cm
July 30, 2013
107 cm
August 02, 2013

(taken & noted by the group)
100 cm
Page 25
B. Anthropometric Data:
Body Mass Index:
weight (kg)
Conversion:
height (m )
1ft=12 inches
1 inch=2.54 cm
1 m=100 cm
Patient RP who is a female, age of 68 years with a height of 52 and weight

of 63.2 kg
63.2 kg
Ht: 5 ft= 60 inches
2.48
+ 02 inches
= 62 inches x 2.54
=25.48
= 157.48 cm
= 157.48 cm / 100
= 1.5748
= 1.57482
= 2.479995 or 2.48
INPUT AND OUTPUT MONITORING: (10pm-6am shift)

August 01, 2013
INTAKE
OUTPUT
Oral: 100 cc
Urine: 300 cc
IV: 90 cc
Vomitus: 0
Stool: 0
TOTAL: 190 mL
TOTAL: 300 mL
August 02, 2013
INTAKE
OUTPUT
Oral: 120 cc
Urine: 500 cc
IV: 90 cc
Vomitus: 0
Stool: 0
TOTAL: 210 mL
TOTAL: 500 mL
Page 26
NAME
HEIGHT(cm)
WEIGHT(kg)
BMI
WHO
ASIA-
Classification
PACIFIC
Classification
Client RP (68 y/o)
157.48 cm
63.2 kg
25.48
Obese Grade
Obese I
C. General Appearance
GENERAL
ACTUAL
APPEARANCE
FINDINGS
Body built
NORMAL FINDINGS
CLINICAL
SIGNIFICANCE
> Endomorph body
>Proportionate
According to Webber &
type
>Varies with lifestyle
Kelley Health
> Evident
Assessment in Nursing
protuberant
3rd edition that the
abdomen
shorter built, round
> Generally soft and
physique is a
shorter build with
characteristic of
thin arms and legs.
endomorphs. Normal
findings noted.
Posture and Gait
>looks weak and
>Relaxed
not relaxed

Kelley Health
3rd edition that not
relaxed finding is
abnormal due to the
uncomfortable condition
experience and the
disease per se.
Over-all Hygiene
> neat
>Clean, neat and
and Grooming
> with unsoiled
well groomed.
Kelley Health
Page 27
clothes
3rd edition that clean and
neat must see
appropriately. Normal
findings noted.
Body and Breath
> No unusual body
>No body and breath
Odor
and breath odor.
odor.
Kelley Health
3rd edition that no
unusual odors should be
assess. Normal findings
noted.
Obvious Sign of
> irritable
>No signs of distress
Distress/Illness
> with body malaise
>Healthy
Kelley Health
Appearance
3rd edition that the actual
findings in patient is a
signs of distress or
illness predispose to the
experience condition and
health status due to
present condition.
Certain findings noted
are not normal.
Attitude
>expresses herself
>Cooperative
to what she feels
Kelley Health
>slightly
accommodating.

finding in patient is
normal because she can
express herself well and
Page 28
with cooperative
behavior.
Affect/Mood;
>patient was slightly >Appropriate to
Appropriateness of
irritable.
Kelley Health
situation
Response
findings in patient is
abnormal due to signs of
distress or illness
predispose to the
experience condition and
health status due to
present condition.
Certain findings noted
are not normal.
Quantity and Quality
> The voice can be
>Clear and
of Speech
heard.
explicable
Kelley Health
>Moderate pace
3rd edition that clear and
explicable executes
chronological thought
processes.
Relevance and
>Answers make
Organization of
sense and concisely of conversation are
Kelley Health
Thoughts
> Conscious and
coherent
>The arrangements
comprehensible.

arrangements of
conversation must be
comprehensible and can
be understood clearly.
Normal findings noted.
Page 29
D. Cephalocaudal Assessment:
Focused Assessment (Geriatrics)

Body Part Examined
Actual Finding
Normal Finding
Inspect and palpate
>no lesion palpated
*Lentigenes: Hyper
According to Weber
skin lesions. Wear
>solar lentigenes are
pigmentation in sun
and Kelly- Health
gloves when palpating
noted in the skin
exposed areas
Assessment in
lesions. Note whether
>hematoma on both
appears as brown,
Nursing; 3rd edition
lesions are flat or
of the forearm
pigmented, round or
that the decrease in
raised, palpable or
>edema on both lower rectangular patches
the total number of
nonpalpable. Also
extremities (2+ pitting
often called liver
melanocytes, hyper
note color, size, and
for 7 seconds) 4mm
spots.
pigmentation occurs in
exudates, if any.
measurement
skin exposed to
>with lacerated wound
sunlight, which
in both crural area
manifest as brown
>Jaundice with
pigmented areas
associated hepatic
called lentigines that
dysfunction
are commonly
>with varicose vein at
referred to as liver or
posterior region of the
age spots
thigh
Hematoma formation
Clinical Significance
SKIN AND HAIR
is an abnormal finding
due to the intravenous
insertion site and
medication.
Edema an abnormal
accumulation of fluid
in the interstitium,
Page 30
which are locations

beneath the skin or in
one or more cavities
of the body.
A wound is a break in
the outer layer of the
skin, called the
epidermis. Laceration
wounds in both crural
area are caused by
cuts or scrapes.
Jaundice is a
condition that causes
the skin, eyes, and
mucus membranes to
become yellow. It is a
disorder that results
from high levels of
bilirubin in the blood.
The condition itself is
not a fatal condition;
however, it can be a
sign of extensive liver
damage, which can be
life-threatening.
As you get older, your
veins can lose
elasticity causing
them to stretch. The
valves in your veins
may become weak,
Page 31
allowing blood that

should be moving
toward your heart to
flow backward. Blood
pools in your veins,
and your veins
enlarge and become
varicose. The veins
appear blue because
they contain
deoxygenated blood,
which is in the
process of being
recirculated through
the lungs.
Note color, texture,
>skin is dry
*Somewhat
According to Weber
integrity, and
>with wrinkles and
transparent, pale, skin
and Kelly- Health
moisture of skin and
tent to pinched
with an overall
Assessment in
sensitivity to heat or
decrease in body hair
cold.
on lower extremities is
that the finding in
normal. Dry skin is
noted was normal
common.
because dryness of
*Skin may wrinkle and
skin is cause of
tent when pinched.
decreased of
sebaceous gland
function due to aging.
Wrinkles are
prominent because
subcutaneous fat
decrease with age.
Inspect and palpate
>60% black and 40%
*Thinning and graying
According to Weber
Page 32
hair and scalp.
gray color with short
of scalp, axillary, and
and Kelly- Health
hair
pubic hair are normal.
Assessment in
>loss of hair pigment
*Some women may
have mild hair growth
that the finding noted
on upper lip.
was normal because

loss of hair pigment is
the cause of graying.
NAIL
Inspect plate shape,
> Rounded Long and
* Round or square nail According to Weber
texture, bed color
thick nail shape of the
shape according to
and Kelly- Health
and surrounding
fingernails
the cuticle.
Assessment in
tissue.
> Soft tissue and
* Nails are hard and
intact in skin with pink
basically immobile.
that Toenails usually
tones
* Pink tones should be thicken; but fingernails
> slightly yellowish
seen. Some
may become thin and
and dull in bed color
longitudinal ridging is
split. They may also
both in fingernails and
normal.
appear yellowish and
toenails
* Soft tissue and
dull. A thickened,
without any lesions.
yellow toenail
indicates
onychomycosis, a
fungal infection.
Perform blanch test
> Capillary refill at 3
* Pink tones returns
According to Weber
seconds.
immediately to
and Kelly- Health
blanched nail beds
Assessment in
when pressure is
released.
that the finding noted

was abnormal
because there is slow
(greater than 2 sec.)
capillary refill with
Page 33
those who have

respiratory or
cardiovascular
diseases that can
cause hypoxia.
HEAD AND NECK
Inspect head and
>cervical curvature
*Atrophy of face and
According to Weber
neck for symmetry
> Normocephalic,
neck muscle
and Kelly- Health
and movement.
symmetric and oval in
*Reduced range of
Assessment in
Observe facial
shape
motion of head and
expression.
>Descent of the chin
neck
that the cervical
>facial expression of
*Shortening of neck
curvature may
the patient was
due to vertebral
increase because of
irritable.
degeneration and
kyphosis of the spine.
development of
Moreover, fat may
buffalo humpat top
accumulate around
of cervical vertebrae.
the cervical vertebrae.

Descent of the chin is
a normal age-related
finding in elderly.
Slight Irritable is a
signs of distress or
illness predispose to
the experience
condition and health
status.
MOUTH AND THROAT
Inspect the lips for
>Symmetric in contour *lips are smooth and
According to Weber
symmetry of
>no lesion
moist without lesions
and Kelly- Health
contour, color,
>with dark lining in
or swelling. Pink lips
Assessment in
texture, moisture,
upper and lower lips
are normal in light-

Page 34
lesion
>lips are dry
skinned clients as are
that the
bluish or freckled lips
Dryness of lips is due
some dark-skinned.
to dehydration.
Dark lining of lips is
due to excessive
consumption of
caffeine and
dehydration can all
contribute to the
darkening of the lips.
Inspect the gums
>decreased saliva
*Decreased salivary
According to Weber
and buccal mucosa
production
gland secretions are
and Kelly- Health
for color and
>gums and mucosa
commonly seen in the
Assessment in
consistency.
are pink and without
elderly client.
swelling, bleeding, or
*Gums and mucosa
that the findings noted
lesions.
should be pink and
was normal,
without swelling,
decreased in saliva
bleeding, or lesions.
production with aging.

However, the major
cause of xerostomia
(dry mouth) in the
elderly is from using
medications that have
anticholinergic effects.
Because saliva has
anti-bacterial, antifungal, and toothcleansing properties,
decreased production
may promote dental
caries.
Page 35
If the client is wearing
> with dentures
*Resorption of gum
According to Weber
dentures, inspect
>no teeth at all (upper
ridge commonly
and Kelly- Health
them for fit. Then ask
and lower)
results in poorly fitting
Assessment in
dentures.
the client to remove

them for the rest of
that it was considered
the oral examination.
normal to lose your

teeth as you grew old.
But if you have
missing teeth, you
lose the ability to
chew on food and stay
healthy.
Dentures should be
removed before the
mouth is examined.
Dentures increase risk
of oral candidiasis and
resorption of the
alveolar ridges.
Inflammation of the
palatal mucosa and
ulcers of the alveolar
ridges may result from
poorly fitting dentures.
Examine the tongue.
> The tongue is color
*The tongue should
According to Weber
Observe symmetry
light pink, moist, and
be pink and moist.
and Kelly- Health
and size.
symmetric.
Assessment in
that the tongue must
be in the midline and
with no discharges
Page 36
found.
Observe the client
>slow motion in eating *A mild decrease in
According to Weber
swallowing food or
or in swallowing the
swallowing ability is
and Kelly- Health
fluids.
food
normal.
Assessment in
that in older adults,
esophageal motility is
slower and more
disorganized, giving
rise to dysphagia, a
swallowing
dysfunction involving
the transfer of a bolus
of food from the
mouth to the stomach.
NOSE AND SINUSES
Inspect the nose for
>color is same with
*Nose and nasal
According to Weber
color and
the face
passages are not
and Kelly- Health
consistency
> symmetric in
inflamed, and skin and Assessment in
appearance
mucus membranes
>not inflamed but
are intact.
that nose may seem
intact
more prominent on
face because of loss
of subcutaneous fat.
Evaluate the sense of
>slow detection of the
*Client has slightly
According to Weber
smell. Have the client
odor
diminished sense of
and Kelly- Health
close the eyes and
smell and ability to
Assessment in
smell a common
detect odors.
substance, such as
that olfactory function
mint, lemon or soap.
gradually decreased
with aging and may
Page 37
lead to a decreased
ability to detect odors.
Diminish smell may
also lead to a decline
in appetite.
Test nasal patency by
>able to breath in both *Client can breathe
According to Weber
asking the client to
sided nose while
and Kelly- Health
breathe while blocking
blocking one nostril at
Assessment in
one nostril at a time.
a time
with reasonable ease
that normally the

patient will be able to
exhale through the
unoccluded nares.
Nasal obstruction is
present if the patient
is unable to exhale
through the nares.
Normal with the age of
the patient
Palpate the frontal
>no tenderness in
*Area is free of lesions According to Weber
and maxillary sinuses
palpating and crepitus
and pain
and Kelly- Health
for consistency and to
Assessment in
elicit possible pain

that negative pain in
sinuses during
percussion indicates
absence of
discomforts.
EYES AND VISION
Inspect eyes,
>periorbital darkening
*The skin around the
According to Weber
eyelids, eyelashes,
edema
eyes becomes thin,
and Kelly- Health

Page 38
and conjunctiva.
>with wrinkles
and wrinkles appear
Assessment in
Also observe eye and
>eyelids easily close
normally with age.
conjunctiva for
>eyelashes turn
*Eyelids close easily,
that eyelids skin is the
dryness, redness,
outward
and eyelashes turn
thinnest skin of the
tearing, or increased
outward.
body, it tends to
sensitivity to light and
*Client may have
stretch over time. In
wind
some dryness
the upper eye lid, this
resulting from
stretch skin may limit
diminished tear
the peripheral field of
production that occurs
vision and may
with aging.
produce a feeling of
heaviness and tired
appearance. In the
lower eyelid, bags
form.
Periorbital darkening
edema due to sleep
deprivation Interrupted sleep
cycles are common
causes of eye
puffiness. And
normal aging - As a
person grows older,
the skin around the
eyes becomes thinner
and may swell or
droop. Further a
gradual and generally
permanent increase in
the size of the
Page 39
suborbicularis oculi fat

pad along with the
thinning and
weakening of the
overlying musculature
contributes to the
apparent distention of
the lower eye lids.
Inspect the cornea
> slightly grayish ring
*An arcus senilis, a
According to Weber
and lens. Also ask
around the iris
cloudy or grayish ring
and Kelly- Health
the client when he or
>vision acuity of the
around the iris, and
Assessment in
she last had an eye
patient has same
decreased pigment in
and vision
grade in left and right
iris are age-related
that the finding in
examination.
eyes (4.00)
changes.
client ; Age-related
>Last
macular degeneration
opthalomoscopic
(AMD) is an eye
examination: Jan.
disease affecting the
2013
macula, the center of

the light sensitive
retina at the back of
the eye, causing loss
of central vision.
Although small, the
macula is the part of
the retina that allows
us to see fine detail
and colors. While
macular degeneration
causes changes in
central vision,
Page 40
peripheral or side
vision remains
unaffected.
Grayish ring around
the iris of eyes or
called arcus senilis is
results from
cholesterol deposits in
or hyalinosis of the
corneal stroma, and
may be associated
with ocular defects or
with familial
hyperlipidemia. It is
common in the
apparently healthy
middle aged and
elderly.
Inspect the pupils.
>pupils are slowly
*Overall decrease in
According to Weber
With a penlight or
constricts
size of pupil and
and Kelly- Health
similar device, test
ability to dilate in dark
Assessment in
papillary reaction to
and constrict in light
light
may occur with
that the muscles that
advanced age; this
work to regulate the
result in poorer night
size of the pupils
vision and decreased
weaken with age. The
tolerance to glare.
pupils become
smaller, react more
sluggishly to light, and
dilate more slowly in
the dark. Therefore,
Page 41
people older than 60

may find that objects
are not as bright, that
they are dazzled
initially when going
outdoors (or when
facing oncoming cars
during night driving),
and that they have
difficulty going from a
brightly light
environment to a
darker one. These
changes may be
particularly
bothersome when
combined with the
effects of a cataract.
Test vision. Ask the
>not able to read due
*Impaired near vision
According to Weber
client to read from a
to no available
is indicative of
and Kelly- Health
newspaper or
reading glass
presbyopia
Assessment in
magazine. Use only
(farsightedness), a
room lighting for the
common finding in
that Presbyopia is the
initial reading. Use
older adults. Also
loss of the ability to
task lighting for a
common are light
clearly see close
second reading.
decreases in
objects or small print.
peripheral vision and
It is a normal process
difficulty in
that happens slowly
differentiating blues
over a lifetime, but
from greens.
you may not notice

any change until
Page 42
around age 40.

Presbyopia is often
corrected with reading
glasses and contacts.
EARS AND HEARING
Inspect the external
>same color with the
*Hairs may become
According to Weber
ear. Observe shape,
skin
coarser and thicker in
and Kelly- Health
color, and hair growth.
>no odor and ear is
the external ear,
Assessment in
Also look for lesions
clean
especially in men.
or drainage.
> minimal amount of
*Earlobes may be
that structural
cerumen
pendulous.
changes in the outer
>slightly moist
ear begin in middle
>lesions-free
adulthood. The
.>hair in ear was
earlobes elongate,
slightly coarser
and the pinna

increases in length
and width. The hairs
become coarser.
Cerumen production
decreases leading to
dryness and the
increased tendency
toward impaction.
Perform the voice-
>patient repeats or
*The inability to hear
According to Weber
whisper test, a
hear the word whisper
high-frequency
and Kelly- Health
functional examination to her in 3 out of 5
sounds or to
Assessment in
to detect obvious
words.
discriminate a variety
(conversational)
> slightly cannot hear
of simultaneous sound that hearing loss
hearing loss.
well
results from
associated with aging
Instruct the client to
degeneration of the
is called presbycusis.
put a hand over one
hair cells of the inner
It involves the
Page 43
ear and to repeat the
ear and is called
diminished ability to
sentence you say.
presbycusis.
hear high-frequency
Stand approximately 2
sounds and is due to
feet away from the
degeneration in the
client and whisper a
hair cells of the inner
sentence.
ear.
THORAX AND LUNGS
Inspect shape of
>Respiratory Rate:
*Increased in normal
According to Weber
thorax. Note
(August 01, 2013)
respiratory rate of 16
and Kelly- Health
respiratory rate,
10pm: 21 cpm
to 25 .
Assessment in
rhythm, and quality
12mn: 20 cpm
*Increased reliance on Nursing; 3rd edition
of breathing.
04am: 21 cpm
diaphragmatic
that the Normal
breathing and
breathing is quiet and
(August 02, 2013)
increased work of
unlabored. If it is
10pm: 20 cpm
breathing related to
labored, it is important
12mn: 22 cpm
the anatomic changes
to note respiratory
04am: 20 cpm
in the costal cartilage,
effort.
respiratory muscles,
Orthopnea is due to
and lung tissue.
increased distribution
>DOB when lying on

flat surface
of blood to the
pulmonary circulation
while recumbent, but
usually can be
attribute to a more
fundamental cause.
Percuss lung tones
>resonant sound
*In general, the
According to Weber
as you would in a
>symmetric
normal sound to
and Kelly- Health
percussion is the
Assessment in
same in an older adult
as it is in a younger
that air-filled lungs
adult-resonant.
create a resonant
younger adult.
Page 44
*However, in the
sound.
presence of structural
changes such as
kyposis or slight barrel
chest, resonance may
increase.
Auscultate lung
> crackles noted in

rd
th
*Vesicular sounds
According to Weber
sounds as you
the left 3 and 4
should be heard over
and Kelly- Health
would in a younger
intercostals space
all areas of air
Assessment in
adult.
>with clear mucous in
exchange. However,
respiratory tract
because lung
that the finding in
expansion maybe e
client is abnormal
diminished, it may be
because
necessary to
Rhonchi and rales
emphasize taking
(crackles) may
deep breaths with the
indicate a number of
mouth open during the respiratory diseases
exam. This may be
such as pneumonia,
very difficult for those
bronchitis or
with dementia.
bronchiolitis.
HEART AND BLOOD VESSELS
Blood Pressure
>Blood Pressure:
*An elderly persons
According to Weber
Take blood pressure
(August 01, 2013)
baroreceptor
and Kelly- Health
to detect actual or
10pm: 140/80 mmHg
response to positional
Assessment in
potential orthostatic
12mn: 140/80 mmHg
changes is slightly
hypotension and,
04am: 130/80 mmHg
less efficient.
that Prehypertension
*Blood pressure
is a systolic pressure
therefore, the risk

for falling. Measure
(August 02, 2013)
increases as elasticity
range of 120 to 139
pressure with the
10pm: 130/80 mmHg
decreases in arteries
and a diastolic
client lying, sitting and
12mn: 130/80 mmHg
with proportionately
pressure range of 80
standing positions.
04am: 130/80 mmHg
greater increase in
to 89. Diagnosis with

Page 45
Also measure pulse
systolic pressure
prehypertension
rate. Have the client
resulting in a widening
provides an
lie down for 5 min;
of pulse pressure.
opportunity to work
take the blood
hard-through physical
pressure; at 1 min,
activity, diet, and
take blood pressure
possibly medication-to
and pulse after client
reduce blood pressure
is sitting and again at
to a healthy level.
1 min after client
Within four years of
stands.
diagnosis with
-If dizziness occurs,
prehypertension, one
instruct client to sit a
in three adults ages
few minutes before
35 to 64 will develop
attempting to stand up
definite high blood
from a supine ore
pressure. One in two
reclining position.
adults over age 65 will
-Any client with
develop definite high
blood pressure
blood pressure.
exceeding 160/90
mmHg should be
referred to the health
care provider for
follow up.
Exercise Tolerance
>evident activity
*The maximal heart
According to Weber
Measure activity
intolerance
rate with exercise is
and Kelly- Health
tolerance. Evaluate,
less than in a younger
Assessment in
either by reviewing
person. The heart rate
results of stress
will also take longer to
that most activity
testing or by
return to its pre-
intolerance is related
observing the clients
exercise rate.
to generalized
ability to move from
*Normally the rise in
weakness and
Page 46
sitting to standing
pulse rate should be
debilitation secondary
position or to flex and
no greater than 10 to
to acute or chronic
extend fingers rapidly.
20 beats/min. the
illness and disease
pulse rate should
especially apparent in
return to the baseline
elderly patients. The
rate within 2 minutes.
aging process itself

causes reduction in
muscle strength and
function, which can
impair the ability to
maintain activity.
Activity intolerance
may also be related to
factors such as
obesity,
malnourishment, side
effects of medications
(e.g., Beta-blockers),
or emotional states
such as depression or
lack of confidence to
exert one's self.
Pulses
>Pulse Rate:
*Proximal pulses may
According to Weber
Determined
(August 01, 2013)
be easier to palpate
and Kelly- Health
adequacy of blood
10pm: 59 bpm
due to loss of
Assessment in
flow by palpating the 12mn: 62 bpm
supporting
arterial pulses in all
surrounding tissue.
that while your pulse
However, distal lower
rate may vary a bit as
04am: 60 bpm
locations (carotid,
brachial, radial,
(August 02, 2013)
extremity pulses
you age, this range
femoral, and
10pm: 64 bpm
maybe more difficult o
changes only 1 to 2
popliteal, posterior
12mn: 62 bpm
feel or even
beats a minute over

Page 47
tibial, and dorsalis
04am: 63 bpm
nonpalpable. The
the years, and returns
pedis) for strength
dorsalis pedis pulse is
to the 66 to 69 beat
and quality.
absent in
baseline for women
approximately 20% of
65 years or older in
older persons.
above-average
condition.
Inspect and palpate
>patient cannot stand
*Prominent, bulging
According to Weber
veins while client is
well due to her
veins are common.
and Kelly- Health
standing.
edematous leg.
*Varicosities are
Assessment in
considered a problem
only if ulcerations,
that the Cords are
signs of
nontender, palpable
thrombophlebitis, or
veins having a rubber
cords are present.
tubing consistency.
Heart
> Normal respiratory
*The precordium is
According to Weber
Inspect and palpate
>no tenderness
still and without thrills,
and Kelly- Health
the precordium
> no apical impulses
heavens, or visible,
Assessment in
palpable pulsations
(noted exception may
that no pulsation
be the apex of the
should be palpated.
heart if close to the

surface)
Auscultate heart
>S1 is loud heard at
*Extra heart sounds
According to Weber
sounds.
apex while S2 is
(low intensity,
and Kelly- Health
loader heard at base.
systolic murmur and
Assessment in
>normal heart sound
an S4) result from
>no heart murmurs
normal age-related
that there should be
heard
calcification of heart
no heart murmur or
valves and vessels
any abnormalities
and fibrotic changes in heard sounds in the

the heart muscle.
heart.
Page 48
BREAST
Inspect and palpate
>The patient refused
*The breast of elderly
According to Weber
breast and axillae.
to inspect her breast.
women are often n
and Kelly- Health
When viewing axillae
described as
Assessment in
and contour of
pendulous due to the
breasts, assist a client
atrophy of breast
that Breast can be a
with arthritis to raise
tissue and supporting
variety of sizes and
the arms over the
tissue and the forward
somewhat round and
head. Do this gently
thrust of the client
pendulous. One
and without force and
brought about by
breast may normally
only if it is not painful
kyphosis.
be larger than the
for the client.
other.
The pigmentation on
the areola varies to
the race and health
state condition.
Nipples are usually
everted, but they may
inverted or flat.
If the breast is
*Decrease in fat
According to Weber
pendulous, assist the
composition and
and Kelly- Health
client to lean slightly
increase in fibrotic
Assessment in
so the breast hang
tissue may make the
away from the chest
terminal ducts feel
that the aged breasts,
wall, enabling you to
more fibrotic and
particularly in women,
best observe
palpable as linear,
are often described as
symmetry and form.
spoke-like strands.
pendulous. This is
*Nipples may retract
because fat and
due to loss in
elastic tissue
musculature. Unlike
decrease and the
nipple retraction due
existing tissue
Page 49
to a mass, nipples
become more fibrotic.
retracted because of
Overall, breast tissue
aging can be everted
mass declines with
with gentle pressure.
aging.
Inspect skin under
*Skin is intact without
According to Weber
breast.
lesions or rashes.
and Kelly- Health

Assessment in
that no discharge
should be present or
noted.
ABDOMEN
Nutritional Status
*Antral cells and
According to Weber
Elderly clients typically >Weight: 63.2 kg
intestinal villi atrophy,
and Kelly- Health
report gastrointestinal
>BMI=25.48
and gastric production
Assessment in
problems related not
Obese Grade I
of hydrochloric acid
only to elimination but
(WHO Classification)
decreases with age.
that the Elderly
also to diet and
Obese I (Asia-Pacific
become vulnerable to
nutrition. Therefore,
Classification)
malnutrition owing to
measure and record
>slow movement in
inappropriate dietary
the clients height and
swallowing or chewing
intake, poor economic
weight, noting weight
>DIET: Low Salt, Low
status and social
changes and
Fat Diet with Fluid
deprivation.
problems with
Restriction of less
Body Mass Index
swallowing or
than 1000 mL
(BMI) is estimated
chewing.
>Height: 157.48 cm
according to the
formula BMI = weight
(kg)/height (m)2. BMI
results of less than
18.5 are classified as
underweight, 18.5
Page 50
24.9 as normal,
25.029.9 as
overweight, and over
30.0 as obese (Health
Canada 2003).
Hydration Status
>Weight: 63.2 kg
Because muscle mass >URINE: Specific
*Normal findings
According to Weber
include stable weight
and Kelly- Health
decreases and fatty
Gravity=1.015 (normal and stable mental
Assessment in
tissues increase, the
range 1.005-1.025)
elderly client is at
status.
that Fluid intake of
increased risk for
>Input and Output:
fewer than 1500 mL
dehydration. Evaluate
(10pm-6am shift)
daily (excluding
hydration status as
July 31, 2013
cafferine-containing
you would nutritional
INTAKE
beverages) is a
status. Begin with
Oral: 210 cc
possible indicator of
accurate serial
IV: 300 cc
dehydration. Fluid
measurements of
TOTAL=510 mL
requirements for older
weight, careful review
OUTPUT
persons without
of laboratory test
Urine: 700 cc
cardiac or renal
findings (serial serum
Vomitus: 0
disease are
sodium level, and
Stool: 0
approximately 30
urine-specific gravity),
TOTAL= 700 mL
mL/kg of body weight
and a 2-3 day dairy of
per day.
fluid intake and
August 01, 2013
output.
INTAKE
Oral: 100 cc
IV: 90 cc
TOTAL= 190 mL
OUTPUT
Urine: 300 cc
Vomitus: 0
Page 51
Stool: 0
TOTAL= 300 mL
August 02, 2013

INTAKE
Oral: 120 cc
IV: 90 cc
TOTAL= 210 mL
OUTPUT
Urine: 500 cc
Vomitus: 0
Stool: 0
TOTAL= 500 mL
Motility
>25 sounds per
*5-30 sounds/min is
According to Weber
Assess GI motility
minute
heard.
and Kelly- Health
and auscultate
Assessment in
bowel sounds.

that the finding in
client in
GI Motility is in the
normal range.
Inspect and percuss
> Inspection: cirrhotic
*Liver, pancreases,
According to Weber
abdomen in same
ascites in the
and kidneys normally
and Kelly- Health
manner as for
abdomen-measured
decrease in size, but
Assessment in
younger adults.
of 100 centimeter
the decrease is not
(Aug. 02)
generally appreciable
that Cirrhotic ascites
>Protuberant
upon physical
forms as the result of
Abdomen
examination
a particular sequence
Previous waistline: 32
of events.
Page 52
inches(1 month prior
Development of portal
to admission)
hypertension is the
>Percussion: dullness
first abnormality to
sound heard
occur. As portal
hypertension
develops, vasodilators
are locally released.
These vasodilators
affect the splanchnic
arteries and thereby
decrease the effective
arterial blood flow and
arterial pressures. The
precise agent(s)
responsible for
vasodilation is a
subject of wide
debate; however,
most the recent
literature has focused
on the likely role of
nitric oxide.
Abnormal dullness is
heard over a
distended ascites on
percussion.
Movements of a fluid
wave against the
resting hands suggest
large amounts of fluid
are present (ascites).
Page 53
Palpate the bladder.
>bladder is not
*Empty bladder is not
According to Weber
(Ask client to empty
palpable
palpable or
and Kelly- Health
percussable.
Assessment in
bladder before
examination.) If the
bladder is palpable,
that distended bladder
percuss from
is palpated as a
symphysis pubis to
smooth, round, and
umbilicus. If the client
somewhat firm mass
is incontinent, post
extending as far as
void residual content
the as the umbilicus. It
may also need to be
may further validated
measured.
by dull percussion
tones.
GENITALIA
Female
*Pubic hair is usually
According to Weber
Inspect external
to inspect her external
sparse, and labia are
and Kelly- Health
genitalia. Assist the
genital.
flattened. Clitoris is
Assessment in
decreased in size.
client into the

lithotomy position.
that because
Inspect the urethral
reproduction and
meatus and vaginal
breast tissue depend
opening.
on estrogen for
growth, many atrophic
changes begin in
women at
menopause. The size
of the ovaries, uterus,
and cervix decreases.
The pubic hair
becomes more brittle.
Loss of elasticity and
Page 54
reduced vaginal
lubrication from
diminishing levels of
estrogen can cause
dyspareunia (painful
intercourse).
Ask the client to
*No leakage of urine
According to Weber
cough, while in the
occurs.
and Kelly- Health
lithotomy position.
genital.
Assessment in
no leakage of urine
occurs.
Test for prolapsed.
*No prolapsed is
According to Weber
Ask the client to bear
evident.
and Kelly- Health
down while you
genital.
Assessment in
observe the vaginal
opening.
that
a stretching of the
vaginal tissue, the
thinning of tissue,
aging with estrogen
deficiency at
menopause, and
breaks in the fascia of
the vagina has a very
little is known about
the physical and
biological
manifestations of
prolapse. A potential
Page 55
cure at the molecular

level appears unlikely.
Perform a pelvic
*Vaginal secretion
examination. Put on
should be white, clear, and Kelly- Health
disposable gloves and
genital.
and odorless.
Assessment in
use a small speculum
*The vaginal
if the vaginal opening
epithelium is thinner,
that for pelvic
has narrowed with
drier, and may be pale examination, patients
age. Use lubrication
and shiny. Atrophic
who lack hip mobility
on speculum and
changes are
may lie on their left
hand because natural
intensified by
side. Postmenopausal
lubrication is
infrequent intercourse. reduction of estrogen
decreased.
*Because the ovaries,
leads to atrophy of the
uterus, and cervix
vaginal and urethral
shrink with age, the
mucosa; the vaginal
ovaries may not be
mucosa appears dry
palpable.
and lacks rugal folds.
According to Weber
The ovaries should

not be palpable 10
year after menopause;
palpable ovaries
suggest cancer.
Patients should be
examined for
evidence of prolapse
of the urethra, vagina,
cervix, and uterus.
They are asked to
cough to check for
urine leakage and
intermittent prolapse.
Page 56
Test pelvic muscle
*The vaginal wall
According to Weber
tone. Ask the woman
should constrict
and Kelly- Health
to squeeze muscle
genital.
around the examiners
Assessment in
while the examiners
finger, and the
finger is in the vagina.
perineum should feel
that vaginal wall
Assess perineal
smooth.
should be constrict
strength by turning
around the perineum.
fingers posterior to the

perineum while the
woman squeezes
muscles in the vaginal
area.
ANUS AND RECTUM
Inspect the anus and >The patient refused

rectum.
*The anus is darker
According to Weber
to inspect her anus
than the surrounding
and Kelly- Health
and rectum.
skin.
Assessment in
that the finding in
client is normal
because if there is
Bluish, grapelike
lumps at the anus are
indication of
haemorrhoids .
Put on gloves to
palpate the anus and to inspect her anus

rectum.
and rectum.
*No masses or
According to Weber
swelling should be
and Kelly- Health
palpated.
Assessment in
no abnormalities
found while
Page 57
performing the
procedure.
EXTREMITIES
Lower extremities
>with grade 2 pitting
*equal in size
According to Webber
I: size, contour, and
edema in both legs of
*same contour with
& Kelley Health
movements
the patient
prominence of joints.
Assessment in
> slight pitting/4 mm,
*no involuntary
Nursing 3rd edition,
disappears rapidly.
movements.
Edema an abnormal
>with wound in both
*No edema.
accumulation of fluid
crural area
*Color is even
in the interstitium,
>with varicose vein at
which are locations
posterior region of the
beneath the skin or in
thigh
one or more cavities

of the body.
A wound is a break in
the outer layer of the
skin, called the
epidermis. Laceration
wounds in both crural
area are caused by
cuts or scrapes.
As you get older, your
veins can lose
elasticity causing
them to stretch. The
valves in your veins
may become weak,
allowing blood that
should be moving
toward your heart to
flow backward. Blood
Page 58
pools in your veins,

and your veins
enlarge and become
varicose. The veins
appear blue because
they contain
deoxygenated blood,
which is in the
process of being
recirculated through
the lungs.
MUSCULOSKELETAL
INSPECTION
>has slightly difficulty
*No difficulty in
According to Webber
when moving
moving
& Kelley Health
> Muscle strength-
Assessment in
appear weak during
Nursing 3rd edition
routine testing
that the findings were

determined if there
are no signs of
disproportion.
Difficulty when moving
may suggests the
disease condition and
the pain felt by the
patient examined.
Sarcopenia (a
decrease in muscle
mass) is a common
age-related finding. It
is insignificant unless
accompanied by a
Page 59
decline or change in
function.
NEUROLOGIC
INSPECTION
>the client is not tense *cooperative actively
According to Webber
during the
& Kelley Health
examination but
Assessment in
irritable due to her
Nursing 3rd edition
condition
that patient is no
neurological problem.
SENSORY FUNCTION
INSPECTION
>can distinguish 6
*can distinguish 6
According to Webber
given colors
given colors
& Kelley Health
(red,green,yellow,
Assessment in
white, black,blue)
Nursing 3rd edition
>numbness in both
that Aging has limited
lower extremities
effects on sensation.
>diminished sense of
Many elderly patients
smell
report numbness,
>altered sense of
especially in the feet.
taste
It may result from a
>decrease sense of
decrease in size of
hearing
fibers in the peripheral
>decrease sense of
nerves, particularly
sight
the large fibers.

In many elderly
people, sense of smell
is diminished because
they have fewer
olfactory neurons,
Page 60
have had numerous

upper respiratory
infections, or have
chronic rhinitis.
However, asymmetric
loss (loss of smell in
one nostril) is
abnormal. Taste may
be altered because
the sense of smell is
diminished or because
patients take drugs
that decrease
salivation.
Visual and hearing
deficits may result
from abnormalities in
the eyes and ears
rather than in nerve
pathways.
Page 61
Review of System
SYSTEM:
Neurologic System
SUBJECTIVE DATA
Medyo makakalimutin na din ako, siguro
dahil narin sa katandaan, as verbalized by
the patient.
Pulmonary System
Kaya dinala namin siya dito gawa ng

nahihirapan nga daw siyang huminga, as
verbalized by the patients sibling.
Cardiovascular System
Mataas nga yung BP ko pero di naman

sumasakit yung batok ko, as verbalized
by the patient.
Hematologic System
Yung pasa ko sa kamay ay dahil sa

injection ng mga gamot, as verbalized by
the patient.
Immunologic System
Di naman sakitin si nanay ngayon lang

talaga, as verbalized by her daughter.
Gastrointestinal System
Dito sa ospital nakaka dalawa o tatlong

beses siyang dumumi sa isang lingo
tapos., as stated by the patients sibling.
Okay lang naman yung mga kinakain ko
bawal lang talaga ako sa mamantika at
maalat, as verbalized by the patient.
Renal System
Bago siya maospital nakaka limang beses

siyang umihi sa isang araw, medyo dilaw
yung kulay ng ihi niya pero dito
nakamonitor at nakacatheter siya as
verbalized by the sibling.
Musculoskeletal System
May umaalalay sakin kapag tumatayo

ako o kaya kapag magbabanyo ako, kasi
nga nanghihina ako, as stated by the
patient.
Page 62
Reproductive System
Natapos yung menstruation ko mga 40s

na ako, tapos wala naman akong nagging
komplikasyon nung nagbuntis at
manganak, as verbalized by the patient.
Integumentary System
Medyo madilaw si nanay, as verbalized

by the patients daughter.
Page 63
HEMATOLOGY REPORT
Date: July 22, 2013
Time: 07:16 am
TEST
NORMAL
ACTUAL
FINDINGS
FINDING
ANALYSIS
S
White Blood
5-10 x
Cells
10^3u/L
Red Blood
4.0-5.5x
Cells
10^6u/L
Hemoglobin
120-160
4.36
WBCs, which are produced in the bone

marrow, are an important part of your
immune system and your bodys natural
weapon to fight off bacteria, viruses and other
germs. When you have a low white blood cell
count you may be immunosuppressed, which
means that you are more vulnerable to
potentially serious infections that do not go
away or are hard to treat.
3.70
Abnormalities in lipid metabolism that occur in

liver disease can lead to changes in red blood
cell size and shape. Macrocytosis may be an
initial finding, followed by the development of
target cells and acanthocytes (spur cells)
These changes are associated with abnormal
cholesterol loading of the red blood cell
membrane. Cholesterol loading of the lipid
bilayer acts to restrict the mobility of integral
membrane proteins. The erythrocytes are
therefore unable to undergo normal
deformation as they transit the
vasculature.When cholesterol loading is
sufficiently severe, passage of such red blood
cells through the microcirculation of the
spleen leads to cytoskeletal damage and the
irreversible deformation of the red blood cell
noted morphologically as spur cells
Low hemoglobin levels are usually due to
106.0 G/L
G/L
nutritional deficiency especially iron

deficiency.
Hematocrit
37.0-47.0%
31.1
The value of the hematocrit is dependent

upon the number of RBC's. If the Hct is
abnormal, then the RBC count is possibly
abnormal. Low hematocrit may indicate:

Anemia (various types)
Blood loss (hemorrhage)
Bone marrow failure (for example, due to
radiation, toxin, fibrosis, tumor)
Hemolysis (RBC destruction) related to
transfusion reaction
Leukemia
Malnutrition or specific nutritional
deficiency
Multiple myeloma
Rheumatoid arthritis
MCV
M: 81-
84.1
99femtoliter
s
MCH
27-31
28.6
pitogram
MCHC
33.0-
34.1
37.0g/dL
Neutrophil
50-70%
82.0
Lymphocyte
25-40%
7.8
3.0-11.0%
9.4
Monocyte
The MCV (mean corpuscular volume) is an

index of the size of the RBCs. Increase or
decrease in both MCV levels are used to
determine vitamin B6 or mineral (copper or
iron) deficiencies and/or excess B12 and folic
acid.
MCH is the average amount of hemoglobin
inside an RBC
The MCHC is dependent upon the size of the

RBC as well as the amount of hemoglobin in
each cell. Certain diseases and anemias will
alter the RBC count and/or the amount of
hemoglobin in the cell. The MCHC is not as
dependent upon the RBC count as the other
tests in this section.
Neutrophils are essential in protecting the
body against disease and infections by
removing and destroying some types of
bacteria, wastes, foreign substances, and
other cells. Damage or inflammation of
tissues can also lead to a high neutrophil
count.
Low levels of lymphocytes can lead to
conditions such as cancer or an infection in a
person. On the other hand, low levels of
lymphocytes (T cell or B cells) can indicate a
less threatening condition (than cancer) of
infection.
Normal relative (%) content of monocytes.
Monocytes are a type of white blood cell and
Page 65
Eosinophils
1.0-4.0%
are part of the innate immune

system of vertebrates including
all mammals (humans included), birds, reptile
s, and fish. Monocytes play multiple roles in
immune function. Such roles include: (1)
replenish resident macrophages and dendritic
cells under normal states, and (2) in response
to inflammation signals, monocytes can move
quickly (approx. 812 hours) to sites of
infection in the tissues and divide/differentiate
into macrophages and dendritic cells to elicit
an immune response
A lower-than-normal eosinophil count may be
due to:
0.0
Basophils
0.0-1.0%
0.0
RDW-CV
11.5-14.5%
20.4
Alcohol intoxication
Over production of certain steroids in
the body (such as cortisol)
Normal relative (%) content of basophils .

Basophils are a type of white blood cell that
are involved in inflammatory reactions in your
body, especially those related to allergies and
asthma. When stimulated, basophils release
histamine and other enzymes that can lead
to inflammation, bronchoconstriction,
and asthma symptoms.
RDW- CV is the relative distribution width of
red blood cells by volume, coefficient of
variation. MCV goes hand in hand with red
blood cell distribution width (RDW) in terms of
anemia and other hematology disorders, and
the values of both are influenced by each
other. Elevated RDW and normal MCV is
associated with the following conditions:
Platelet
150-450 x
Count
16^3 u/L
152
Early iron, vitamin B12, or folate deficiency

Dimorphic anemia (for example, iron and
folate deficiency)
Sickle cell disease
Chronic liver disease
Myelodysplastic syndrome
A platelet count is a test to measure how
many platelets you have in your blood.
Platelets help the blood clot. They are smaller
Page 66
than red or white blood cells.
HEMATOLOGY REPORT
Date: July 27, 2013
Time: 07:40 am
TEST
NORMAL
ACTUAL
FINDINGS
FINDING
ANALYSIS
S
White Blood
5-10 x
Cells
10^3u/L
Red Blood
M: 4.0-5.5x
Cells
10^6u/L
2.88

weapon to fight off bacteria, viruses and other
germs. When you have a low white blood cell
count you may be immunosuppressed, which
means that you are more vulnerable to
potentially serious infections that do not go
away or are hard to treat.
3.77
Abnormalities in lipid metabolism that occur in

liver disease can lead to changes in red blood
cell size and shape. Macrocytosis may be an
initial finding, followed by the development of
target cells and acanthocytes (spur cells)
These changes are associated with abnormal
cholesterol loading of the red blood cell
membrane. Cholesterol loading of the lipid
bilayer acts to restrict the mobility of integral
membrane proteins. The erythrocytes are
therefore unable to undergo normal
deformation as they transit the
vasculature.When cholesterol loading is
sufficiently severe, passage of such red blood
cells through the microcirculation of the
spleen leads to cytoskeletal damage and the
irreversible deformation of the red blood cell
noted morphologically as spur cells
Page 67
Hemoglobin
M: 120-160
111.0 G/L
G/L

deficiency.
Hematocrit
37.0-47.0%
32.3

Leukemia
deficiency
Multiple myeloma
MCV
M: 81-
85.7

iron) deficiencies and/or excess B12 and folic
acid.
99femtoliter
s
MCH
27-31
29.4
pitogram
MCHC
33.0-
inside an RBC
34.4
37.0g/dL
Neutrophil
50-70%
88.3
The MCHC is dependent upon the size of the

RBC as well as the amount of hemoglobin in
each cell. Certain diseases and anemias will
alter the RBC count and/or the amount of
hemoglobin in the cell. The MCHC is not as
dependent upon the RBC count as the other
tests in this section.
Page 68
Lymphocyte
25-40%
4.3
Monocyte
3.0-11.0%
07.4
Eosinophils
1.0-4.0%
0.0
count.
conditions such as cancer or an infection in a
person. On the other hand, low levels of
infection
all mammals (humans included), birds, reptile
s, and fish. Monocytes play multiple roles in
immune function. Such roles include: (1)
replenish resident macrophages and dendritic
cells under normal states, and (2) in response
to inflammation signals, monocytes can move
quickly (approx. 812 hours) to sites of
infection in the tissues and divide/differentiate
into macrophages and dendritic cells to elicit
an immune response
A lower-than-normal eosinophil count may be
due to:
Basophils
0.0-1.0%
0.0
RDW-CV
11.5-14.5%
21.3

are involved in inflammatory reactions in your
body, especially those related to allergies and
asthma. When stimulated, basophils release
histamine and other enzymes that can lead
other. RDW- CV is the relative distribution
Page 69
width of red blood cells by volume, coefficient

of variation. MCV goes hand in hand with red
other. Elevated RDW and normal MCV is
associated with the following conditions:
Platelet
150-450 x
Count
16^3 u/L
44

folate deficiency)
Sickle cell disease
A lower-than-normal number of platelets
(thrombocytopenia) may be due to:
Cancer chemotherapy
Certain medications
Disseminated intravascular
coagulation (DIC)
Hemolytic anemia
Hypersplenism
Idiopathic thrombocytopenic
purpura (ITP)
Leukemia
Massive blood transfusion
Prosthetic heart valve
Thombotic thrombocytopenic purpura
(TTP)
Celiac disease
Vitamin K deficiency
Page 70
HEMATOLOGY REPORT
Date: July 28, 2013
Time: 04:48 am
TEST
NORMAL
ACTUAL
FINDINGS
FINDINGS
White Blood
5-10 x
2.04
Cells
10^3u/L
Red Blood
M: 4.0-5.5x
Cells
10^6u/L
Hemoglobin
120-160 G/L
103.0 G/L
Hematocrit
37.0-47.0%
29.7%
3.53
ANALYSIS

weapon to fight off bacteria, viruses and
other germs. When you have a low white
blood cell count you may be
immunosuppressed, which means that you
are more vulnerable to potentially serious
infections that do not go away or are hard to
treat.
Abnormalities in lipid metabolism that occur
in liver disease can lead to changes in red
blood cell size and shape. Macrocytosis may
be an initial finding, followed by the
development of target cells and
acanthocytes (spur cells) These changes
are associated with abnormal cholesterol
loading of the red blood cell membrane.
Cholesterol loading of the lipid bilayer acts
to restrict the mobility of integral membrane
proteins. The erythrocytes are therefore
unable to undergo normal deformation as
they transit the vasculature.When
cholesterol loading is sufficiently severe,
passage of such red blood cells through the
microcirculation of the spleen leads to
cytoskeletal damage and the irreversible
deformation of the red blood cell noted
morphologically as spur cells
deficiency.
Page 71

Leukemia
deficiency
Multiple myeloma
MCV
: 81-
84.1
99femtoliter
s
MCH
27-31
29.2
pitogram
MCHC
33.0-
34.7
37.0g/dL
Neutrophil
50-70%
86.3
Lymphocyte
25-40%
5.4

iron) deficiencies and/or excess B12 and
folic acid.
inside an RBC
The MCHC is dependent upon the size of

the RBC as well as the amount of
hemoglobin in each cell. Certain diseases
and anemias will alter the RBC count and/or
the amount of hemoglobin in the cell. The
MCHC is not as dependent upon the RBC
count as the other tests in this section.
count.
conditions such as cancer or an infection in
a person. On the other hand, low levels of
infection
Page 72
Monocyte
3.0-11.0%
7.8
Eosinophils
1.0-4.0%
0.0

all mammals (humans included), birds, reptil
es, and fish. Monocytes play multiple roles
in immune function. Such roles include:
(1) replenish
resident macrophages and dendritic
cells under normal states,
(2) in response to inflammation signals,
monocytes can move quickly (approx. 812
hours) to sites of infection in the tissues and
divide/differentiate into macrophages and
dendritic cells to elicit an immune response
A lower-than-normal eosinophil count may
be due to:
Basophils
0.0-1.0%
0.5
RDW-CV
11.5-14.5%
21.7

are involved in inflammatory reactions in
your body, especially those related to
allergies and asthma. When stimulated,
basophils release histamine and other
enzymes that can lead
blood cell distribution width (RDW) in terms
of anemia and other hematology disorders,
and the values of both are influenced by
each other. RDW- CV is the relative
distribution width of red blood cells by
volume, coefficient of variation. MCV goes
hand in hand with red blood cell distribution
width (RDW) in terms of anemia and other
hematology disorders, and the values of
both are influenced by each other. Elevated
RDW and normal MCV is associated with
Page 73
the following conditions:
Platelet
150-450 x
Count
16^3 u/L
55

folate deficiency)
Sickle cell disease
A lower-than-normal number of platelets
(thrombocytopenia) may be due to:
Cancer chemotherapy
Certain medications
Disseminated intravascular
coagulation (DIC)
Hemolytic anemia
Hypersplenism
Idiopathic thrombocytopenic
purpura (ITP)
Leukemia
Massive blood transfusion
Prosthetic heart valve
Thombotic thrombocytopenic purpura
(TTP)
Celiac disease
Vitamin K deficiency
Page 74
PROTIME/ PARTIAL THROMBOPLASTIN TIME

Date: July 21, 2013
Time: 6:00 am
TEST
PROTIME:
Control:
Activity:
INR:
APPT:
Control:
NORMAL
FINDINGS
11-15.5 secs.
------22-35 secs.
---
ACTUAL
FINDINGS
26.2 secs.
13.3 secs.
32.4%
2.60
61.4 secs.
31.3 secs.
According to http//webmd.com, Prothrombin Time 100% or 1216 seconds

Prothrombin time may be prolonged in liver disease. It will not return to normal with
vitamin K in severe liver cell damage. A partial thromboplastin time (PTT) test measures
how long it takes for a clot to form in a blood sample. A clot is a thick lump of blood that
the body produces to seal leaks, wounds, cuts, and scratches and prevent excessive
bleeding. The blood's ability to clot involves platelets (also called thrombocytes) and
proteins called clotting factors. Platelets are oval-shaped cells made in the bone
marrow. Most clotting factors are made in the liver. When a blood vessel breaks,
platelets are first to the area to help seal off the leak and temporarily stop or slow the
bleeding. But for the clot to become strong and stable, the action of clotting factors is
required.
Page 75
CLINICAL CHEMISTRY
Date: July 27, 2013
TEST
Creatinine
NORMAL
FINDINGS
44-80 umol/L
ACTUAL
FINDINGS
120.97umol/L
Potassium
3.6-5.5 mmol/L
3.91mmol/L
ANALYSIS
High creatinine
levels often indicate
serious kidney
damage, which may
be due to low blood
flow, shock, cancer
or a life-threatening
infection. Conditions
that often produce
high creatinine
levels consist of
urinary tract
blockages, cardiac
problems, thyroid
problems or
dehydration.
Potassium is
another of the
important
electrolytes in the
body. Our body is
quite sensitive to
abnormal levels of
potassium. The
finding in the test of
Potassium is
normal.
Page 76
CLINICAL CHEMISTRY
Date: July 30, 2013
Time: 10:20 am
TEST
Total Protein
NORMAL
FINDINGS
84-93 o/L
ACTUAL
FINDINGS
62.02
Albumin
35-52 o/L
17.60
ANALYSIS
A total serum
protein test
measures the total
amount of protein in
the blood. It also
measures the
amounts of two
major groups of
proteins in the
blood: albumin and
globulin
Albumin is the major
form of protein in
the
blood. Abnormal
albumin levels are
associated with
protein issues.
Low blood albumin
levels
(hypoalbuminemia)
can be caused by:
Liver
disease; cirrhosi
s of the liver is
most common
Excess
excretion by
the kidneys (as
in nephrotic
syndrome)
Excess loss in
bowel (proteinlosing
enteropathy,
e.g., Mntrier's
Page 77
disease)
Burns (plasma
loss in the
absence of skin
barrier)
increased
vascular
permeability or
decreased
lymphatic
clearance)
Acute disease
states (referred
to as a
negative acutephase protein)
Mutation
causing
analbuminemia
Globulin
23-35 o/L
44.50
A/G ratio
1.1-2.5
0.39
High serum globulin

causes can be
anything starting
from really serious
cases such as
cancer to nothing
more than a little
dehydration, it
causes the blood to
thicken, causing the
concentration of its
elements.
A low A/G ratio can
be due to
overproduction of
gamma-globulin due
to an autoimmune
disease. A low A/G
ratio can also be
due to a low
albumin level
caused by liver
Page 78
cirrhosis or kidney
nephritis.
CLINICAL CHEMISTRY
Date: August 1, 2013
Time: 11:00 am
TEST
Potassium
NORMAL
FINDINGS
3.6-5.5 mmol/L
ACTUAL
FINDINGS
2.27 mmol/L
ANALYSIS
Low potassium levels
(hypokalaemia) can cause
weakness as cellular processes
are affected. Low potassium
causes are:
Dehydration, diarrhoea, excessive
sweating (hyperhidrosis) and
laxative abuse are common
causes of low potassium levels.
It may also be caused by a lack of
potassium in the diet; however,
this is uncommon.
Other causes
include medicines that affect the
amount of potassium in the body,
such as water pills.
Page 79
CLINICAL CHEMISTRY
Date: August 1, 2013
Time: 8:40 pm
TEST
Creatinine
NORMAL
FINDINGS
44-80 umol/L
ACTUAL
FINDINGS
112.88 umol/L
Potassium
3.6-5.5 mmol/L
1.88 mmol/L
ANALYSIS
Creatinine level temporarily
increase if dehydrated, have a
low blood volume, eat a large
amount of meat or take certain
medications. The dietary
supplement creatine can have the
same effect.
Low potassium levels
(hypokalaemia) can cause
weakness as cellular processes
are affected. Causes of it are:
Dehydration, diarrhoea, excessive
sweating (hyperhidrosis) and
laxative abuse are common
causes of low potassium levels.
It may also be caused by a lack of
potassium in the diet; however,
this is uncommon.
Other causes
include medicines that affect the
amount of potassium in the body,
such as water pills.
Page 80
BODY FLUID EXAMINATION

July 30, 2013
Quali/Quanti Analysis (CSF/Body)
Microscopic:
TEST
Fluid
NORMAL
FINDINGS
Normally clear
ACTUAL
FINDINGS
Pleural Fluid
Color
Clear and
Colourless
Yellow
Character
Clear
Cloudy
Specific Gravity
1.0061.009
pH
7.35-7.45
1.010
8.0
ANALYSIS
CSF should be clear as the
water.
The yellow appearance is
caused by red blood
cells entering the CSF during
the bleeding. The cells are
eventually destroyed by the
body, releasing their oxygencarrying molecule heme,
which is degraded
by enzymes into the yellowgreen pigmentbilirubin.
If the CSF looks cloudy, it
could mean there is an
infection or a build up of white
blood cells or protein.
specific gravity (SG) were
determined at two or more
temperatures between 23 and
37 C for 15 samples of normal
human cerebrospinal fluid
(CSF) and CSF mixed with
tetracaine, and for tetracaine
solutions commonly used for
spinal anesthesia
High CSF pH may
causes dizziness and syncope
Microscopic:
TEST
WBC count
NORMAL
FINDINGS
0-5mm3
ACTUAL
FINDINGS
144/cumm
ANALYSIS
Increased white blood cells in the

CSF may be a sign of
Page 81
meningitis, acute infection,

beginning of a chronic illness,
tumor, abscess, stroke, or
demyelinating disease (such as
multiple sclerosis) and intracranial
hemorrhage
Lymphocytes Approximately
70%
RBC count
Not present
96%
3,600/cumm
Lymphocytes normally make up 25

percent or more of the total WBC count.
There are two forms: B cells, which make
antibodies, and T cells, which recognize
and remove foreign substances.
Red blood cells in the CSF sample

may be a sign of bleeding into the
spinal fluid or the result of a
traumatic lumbar puncture.
Normally, there are no red blood
cells in the CSF unless the needle
passes through a blood vessel on
route to the CSF.
Chemistry:
TEST
Sugar
NORMAL
FINDINGS
16.7 mmol/L
ACTUAL
FINDINGS
9.33 mmol/L
ANALYSIS
Chemical
meningitis,
inflammatory
conditions,
subarachnoid
hemorrhage,
and
hypoglycemia
also cause
hypoglycorrha
chia (low
glucose level
in CSF)
Protein
0.18 to 0.58 g/L
31 g/L
Elevated CSF
protein is seen
Page 82
in infections,
intracranial
hemorrhages,
multiple
sclerosis,
Guillain Barr
syndrome,
malignancies,
some
endocrine
abnormalities,
certain
medication
use, and a
variety of
inflammatory
conditions
FECALYSIS EXAMINATION
Date: July 22, 2013
Time: 11:00 am
TEST
NORMAL
ACTUAL
FINDINGS
FINDINGS
Color
Brown
Consistency
Form, Soft,
Semisolid, Moist
Brown
Soft
ANALYSIS
Color such as clay

or white may
indicate bile
pigment or
diagnostic study
using barium
Hard and dry
consistency may
cause of
dehydration:
decreased intestinal
motility resulting
from lack of fiber in
diet, lack of
Page 83
exercise, emotional
upset and laxative
abuse
Occult Blood
Not present
Negative
blood in stool can

refer to multiple
conditions:
Microscopic
Negative
No ova or parasite
seen
Melena, with
more blackish
appearance,
originating in
upper parts of
the
gastrointestinal
tract
Hematochezia,
with more red
color, originating
in latter parts of
the
gastrointestinal
tract
Parasites may
indicated infection
URINALYSIS
Date: July 26, 2013
Time: 07:10 pm
TEST
NORMAL
ACTUAL
FINDINGS
FINDINGS
Macroscopic
Color
Dark Yellow
Yellow
ANALYSIS
Some drugs can

change the color of
the urine. Normal
Page 84
Transparency
Reaction
Specific Gravity
Clear
Slightly Turbid
Slightly Acidic(4.5 8.0. Average is 6.0)
Acidic
1.005 to 1.025
1.015
urine color is a light

yellow to a dark
amber color.
Inflammation may
also cloud the urine
as well as other
pathological
conditions.
The turbidity of the
urine is gauged
subjectively and
reported as clear,
slightly cloudy,
cloudy, opaque or
flocculent. Normally
fresh urine is clear
to very slightly
cloudy. Excess
turbidity results from
the presence of
suspended particles
in the urine
A highly acidic urine
pH occurs in:
Respiratory
diseases in which
carbon dioxide
retention occurs and
acidosis develops
Specific Gravity will

increase with the
amount of dissolved
particles
(concentrated) in it.
Specific gravity will
decrease when the
water content is
high and the
dissolved particles
are low (less
concentrated). Low
specific gravity
(<1.005) is
characteristic of
Page 85
Albumin
none
+1
Sugar
none
Negative
diabetes insipidus,
nephrogenic
diabetes insipidus,
acute tubular
necrosis, or
pyelonephritis.
Fixed specific
gravity, in which
values remain 1.010
regardless of fluid
intake, occurs in
chronic
glomerulonephritis
with severe renal
damage. High
specific
gravity(>1.035)
occurs in nephrotic
syndrome,
dehydration, acute
glomerulonephritis,
heart failure, liver
failure, or shock.
Albumin is a type of
protein found in
large amounts in the
blood. Because it is
a small molecule in
size, it is one of the
first proteins able to
pass through the
kidneys into the
urine when there
are kidney
problems. This
presence of small
amounts of albumin
in the urine is the
condition called
microalbuminuria.
Sugar in urine is an
abnormal finding.
Normally, the kidney
filters blood in such
a way that it holds
on to blood sugar,
Page 86
keeping it in the
blood. No glucose
should be present in
the urine under
normal
circumstances.
Sugar can be found
in urine in
conditions where
the blood glucose
levels are high,
hyperglycemia, as
occurs with diabetes
mellitus.
Microscopic
Pus cells
0-5/hpf
2-3/hpf
Finding a few pus

cells or white blood
cells (WBCs) in
urine is quite
normal. But too
many of them may
signal a problem
somewhere in
your urinary tract,
the commonest of
which is a urinary
tract infection (UTI).
Lab will usually
report the result as
number of cells
counted per high
power field of the
microscope (hpf) or
number of
WBCs/mL of urine.
Usually, 5 to 10 pus
cells/hpf or 105
WBCs/mL of urine
is considered
normal. A high
number of pus cells
in urine is called
pyuria. When a
large number of
WBCs are present
in urine, they may
Page 87
RBC
Ephitelial cells
<5/hpf
0-1 /hpf
---
Many
also be detected on
a urine dipstick test
for leukocyte
esterase.
Gross bleeding into
the urine is usually
obvious. On lab
exam of the urine,
numerous, many,
and gross are terms
used to describe the
amount of blood in
gross bleeding.
However, all
bleeding is not that
obvious. In order to
detect slower
bleeding and
inflammation in the
urinary tract, the
microscopic exam is
needed. In some
normal conditions, a
very few RBC's may
get into the urine.
When a level of
more than 3 RBC's
are found, a disease
condition is often
present. One of the
most common
causes of RBC's in
the urine, is
infection or
inflammation of the
urinary tract itself
(i.e., cystitis).
Trauma and several
other conditions
may also cause
bleeding into the
urine
Epithelial cells often
are present in the
urinary sediment.
Squamous epithelial
Page 88
Amorphous Urates
--
Few
cells are large and

irregularly shaped,
with a small nucleus
and fine granular
cytoplasm; their
presence suggests
contamination. The
presence of
transitional epithelial
cells is normal.
These cells are
smaller and rounder
than squamous
cells, and they have
larger nuclei. The
presence of renal
tubule cells
indicates significant
renal pathology
(Figure 2).
Erythrocytes are
best visualized
under high-power
magnification.
Dysmorphic
erythrocytes, which
have odd shapes
because of their
passage through an
abnormal
glomerulus, suggest
glomerular disease.
Uric acid crystallizes
in the orthorombic
system. Uric acid
crystals can appear
under several
shapes. The classic
crystals are thin
rhombus shaped
plates with more or
less eroded tops.
The other forms are
the hexagonal plate,
the needle and the
rosette. Uric acid
Page 89
Mucus Threads
none
Few
crystals usually
have a
characteristic yellow
color. The intensity
of the color depends
on the thickness of
the crystal, thus
very thin plates
seem colorless,
while the massive
crystals have a
color that tends to
be brown. Under
polarized light, uric
acid shows a
polarization color,
and with thicker
crystals, a series of
concentric black
lines. The color
variation seen under
polarized light is
quite typical of uric
acid. With rare
exceptions, uric acid
crystals are of little
clinical value and
represent a
punctual situation.
Mucus forming cells
are found scattered
all over the urinary
tract from the
ascending section
of the Loop of Henle
in the kidney
tubules (the filtering
system of the
kidney) to the
bladder.
Consequently,
mucus can originate
from the kidney or
from the lower
urinary tract. Mucus
originating from the
Page 90
kidney is made of
Tamm-Horsfall
protein. This
explains the
frequent association
of mucus threads
and casts. In elderly
patients, mucus is a
frequent finding and
seems to originate
from the lower
urinary tract.
URINALYSIS
Date: July, 25, 2013
Time: 09:30 am
TEST
NORMAL
ACTUAL
FINDINGS
FINDINGS
Macroscopic
Color
Dark Yellow
Yellow
Transparency
Clear
Slightly Turbid
ANALYSIS
Some drugs can

change the color of
the urine. Normal
urine color is a light
yellow to a dark
amber color.
Inflammation may
also cloud the urine
as well as other
pathological
conditions.
The turbidity of the
urine is gauged
subjectively and
reported as clear,
slightly cloudy,
cloudy, opaque or
flocculent. Normally
fresh urine is clear
to very slightly
cloudy. Excess
turbidity results from
Page 91
Reaction
Specific Gravity
Slightly Acidic(4.5 8.0. Average is 6.0)
Acidic
1.005 to 1.025
1.015
the presence of
suspended particles
in the urine
A highly acidic urine
pH occurs in:
Respiratory
diseases in which
carbon dioxide
retention occurs and
acidosis develops
Specific Gravity will

increase with the
amount of dissolved
particles
(concentrated) in it.
Specific gravity will
decrease when the
water content is
high and the
dissolved particles
are low (less
concentrated). Low
specific gravity
(<1.005) is
characteristic of
diabetes insipidus,
nephrogenic
diabetes insipidus,
acute tubular
necrosis, or
pyelonephritis.
Fixed specific
gravity, in which
values remain 1.010
regardless of fluid
intake, occurs in
chronic
glomerulonephritis
with severe renal
damage. High
specific
gravity(>1.035)
occurs in nephrotic
syndrome,
Page 92
Albumin
None
Negative
Sugar
None
Negative
0-5/hpf
0-1/hpf
Microscopic
Pus cells
dehydration, acute
glomerulonephritis,
heart failure, liver
failure, or shock.
Albumin is a type of
protein found in
large amounts in the
blood. Because it is
a small molecule in
size, it is one of the
first proteins able to
pass through the
kidneys into the
urine when there
are kidney
problems. This
presence of small
amounts of albumin
in the urine is the
condition called
microalbuminuria.
Sugar in urine is an
abnormal finding.
Normally, the kidney
filters blood in such
a way that it holds
on to blood sugar,
keeping it in the
blood. No glucose
should be present in
the urine under
normal
circumstances.
Sugar can be found
in urine in
conditions where
the blood glucose
levels are high,
hyperglycemia, as
occurs with diabetes
mellitus.
Finding a few pus
cells or white blood
cells (WBCs) in
urine is quite
Page 93
RBC
<5/hpf
0-2 /hpf
normal. But too

many of them may
signal a problem
somewhere in
your urinary tract,
the commonest of
which is a urinary
tract infection (UTI).
lab will usually
report the result as
number of cells
counted per high
power field of the
microscope (hpf) or
number of
WBCs/mL of urine.
Usually, 5 to 10 pus
cells/hpf or 105
WBCs/mL of urine
is considered
normal. A high
number of pus cells
in urine is called
pyuria. When a
large number of
WBCs are present
in urine, they may
also be detected on
a urine dipstick test
for leukocyte
esterase.
Gross bleeding into
the urine is usually
obvious. On lab
exam of the urine,
numerous, many,
and gross are terms
used to describe the
amount of blood in
gross bleeding.
However, all
bleeding is not that
obvious. In order to
detect slower
bleeding and
inflammation in the
Page 94
Ephitelial cells
Occasional
urinary tract, the

microscopic exam is
needed. In some
normal conditions, a
very few RBC's may
get into the urine.
When a level of
more than 3 RBC's
are found, a disease
condition is often
present. One of the
most common
causes of RBC's in
the urine, is
infection or
inflammation of the
urinary tract itself
(i.e., cystitis).
Trauma and several
other conditions
may also cause
bleeding into the
urine. Of course, the
nurse will carefully
observe the patient
with gross bleeding.
Epithelial cells often
are present in the
urinary sediment.
Squamous epithelial
cells are large and
irregularly shaped,
with a small nucleus
and fine granular
cytoplasm; their
presence suggests
contamination. The
presence of
transitional epithelial
cells is normal.
These cells are
smaller and rounder
than squamous
cells, and they have
larger nuclei. The
presence of renal
Page 95
tubule cells
indicates significant
renal pathology
RADIOLOGY REPORT
Date: July 28, 2013
ROENTGENOLOGICAL FINDINGS:
Examination done: Chest AP (Port)
Chest; The latest study since 7-20-2013 shows development of pleural effusion at
the left
The rest is unchanged.
According to Brunner and Suddarths Textbook of Medical-Surgical Nursing
twelfth edition, Pleural effusion is a collection of fluid in the pleural space is rarely a
primary disease process; it is usually secondary to other diseases. Normally, the pleural
space contains a small amount of fluid (5 to 15 mL) which acts a lubricant that allows
the pleural surfaces to move without friction. Pleural effusion may be a complication of
heart failure, TB, pneumonia, Cirrhosis with Ascites, pulmonary infections, nephrotic
syndrome, connective tissue disease, pulmonary embolus, and neoplastic tumors.
Ultrasound Report
Date: July 30, 2013
Sonographic Findings:
Massive Pleural effusion is noted in the left hemithorax measuring 684.3 cc
No pleural effusion noted at the right hemithorax
Analysis: According to http//:webmed.com, Cirrhosis with ascites (hepatic

hydrothorax) are common in Right-sided effusions in 70%; left-sided in 15%; and
Page 96
bilateral in 15%.
Ascitic fluid migration to the pleural space through diaphragmatic defects causes
Pleural effusion. Effusion present in about 5% of patients with clinically apparent
ascites.
Page 97
Case Management
Page 98
A. Pharmacologic Intervention
Drug Features
Mechanism of
Indication
Contraindication
Adverse Effects
Nursing Responsibility
Actions
Generic
Inhibits the
Edema
Name:
reabsorption of
in CHF,
FUROSEMIDE
sodium and
nephritic
Brand Name:
chloride from
Lasix
Hypersensitivity CNS: blurred

vision, dizziness,
daily weight, intake and output
sensitivity with
headache,
ratios, amount and location of
syndrome,
thiazides and
vertigo.
edema, lung sounds, skin
the loop of
ascites,
sulfonamides may EENT: hearing
turgor, and mucous
Classification:
Henle and
caused by
occur
loss, tinnitus.
membranes. Notify physician or
Loop Diuretic
distal renal
hepatic
CV: hypotension.
other health care professional if
Dosage:
tubule.
disease,
GI: anorexia,
thirst, dry mouth, lethargy,
Some liquid
constipation,
weakness, hypotension, or
products may
diarrhea, dry
oliguria occurs.
Hepatic coma
or anuria
20 mg
Increases
Route:
renal excretion
IV
of water,
contain alcohol,
mouth,
Frequency:
sodium,
avoid in patients
dyspepsia,
pulse before and during
OD
chloride,
with alcohol
nausea,
administration. Monitor
Form:
magnesium,
intolerance.
pancreatitis,
frequency of prescription refills
Liquid
potassium, and
vomiting.
to determine compliance in
Color:
calcium.
GU: excessive
patients treated for
urination.
hypertension.
White
Effectiveness
hepatic
Cross-
Assess fluid status. Monitor
cirrhosis.
Monitor blood pressure and
persists in
Derma:
Assess patients receiving
impaired renal
photosensitivity,
digoxin for anorexia, nausea,
function.
pruritis, rash.
vomiting, muscle cramps,
Page 99
Endo:
paresthesia, and confusion.
hyperglycemia,
Patients taking digoxin are at
hyperuricemia. F
increased risk of digoxin toxicity
and E:
because of the potassium-
dehydration,
depleting effect of the diuretic.
hypocalcemia,
Potassium supplements or
hypochloremia,
potassium-sparing diuretics
hypokalemia,
may be used concurrently to
hypomagnesemia
prevent hypokalemia.
, hyponatremia,
Assess patient for tinnitus
hypovolemia,
and hearing loss. Audiometry is
metabolic
recommended for patients
alkalosis.
receiving prolonged high-dose
Hema: anemia,
IV therapy. Hearing loss is most
Agranulocytosis,
common after rapid or high-
hemolytic anemia, dose IV administration in

leukopenia,
patients with decreased renal
thrombocytopenia
function or those taking other
MS: muscle
ototoxic drugs.
cramps.
Neuro:
paresthesia.
Assess for allergy to

sulfonamides.
Lab Test Considerations:
Page 100
Misc: fever,
Monitor electrolytes, renal and
increased BUN,
hepatic function, serum
nephrocalcinosis
glucose, and uric acid levels

before and periodically
throughout therapy. Commonly
serum potassium. May cause
serum sodium, calcium, and
magnesium concentrations.
May also cause BUN, serum
glucose, creatinine, and uric
acid levels.
Page 101
Drug Features
Mechanism
Indication
Contraindication
Adverse Effects
of Actions
Generic
Decrease
Severe
Psychosis,
CNS: depression,
Name:
inflammation
inflammati
hypersensitivity,
euphoria, headache,
of adrenal insufficiency
HYDROCORTI
by
on, septic
idiopathic
increased intracranial
(hypotension, weight loss,
SONE
suppressing
shock,
thrombocytopenia
pressure (children
weakness, nausea,
Brand Name:
migration of
adrenal
, acute
only), personality
vomiting, anorexia,
Hydrocortone
polymorphonu
insufficienc
glomerulonephriti
changes, psychoses,
lethargy, confusion,
Classification:
clear
y,ulcerative s, fungal infection. restlessness.
restlessness) before and
colitis,
periodically during therapy.
Short
acting leukocytes
AIDS, TB.
EENT: cataracts,
Assess patient for signs
glucocorticoids
and fibroblast
collegen
increased intraocular
Monitor intake and
Dosage:
and reversing
disorder,
pressure.
output ratios and daily
100mg
increased
pruritus.
CV: hypertension.
weights. Observe patient
Route:
capillary
GI: PEPTIC
for peripheral edema,
IV
permeability
ULCERATION,
steady weight gain,
Frequency:
and lysosomal
anorexia, nausea,
rales/crackles, or dyspnea.
q5
stabilization
vomiting.
Notify health care
Form:
(systemic),
Derma: acne,
professional if these occur.
Liquid
antipruritic,
decreased wound
Color:
anti-
healing, ecchymoses,
patient for changes in level
White
inflammatory.
fragility, hirsutism,
of consciousness and
petechiae.
headache during therapy.
Cerebral Edema: Assess
Page 102
Endo: adrenal
suppression,
Monitor serum electrolytes
hyperglycemia. F and
and glucose. May cause
E: fluid retention (long-
hyperglycemia, especially
term high doses),
in persons with diabetes.
hypokalemia,
May cause hypokalemia.
hypokalemic alkalosis.
Patients on prolonged
Hema:
therapy should routinely
THROMBOEMBOLIS
have CBC, serum
M, thrombophlebitis.
electrolytes, and serum and
Metabolism: weight
urine glucose evaluated.
gain.
May WBCs. May cause
MS: muscle wasting,
hyperglycemia, especially
osteoporosis, aseptic
in persons with diabetes.
necrosis of joints,
May serum potassium
muscle pain.
and calcium and serum
Misc: cushingoid
sodium concentrations.
appearance (moon
face, buffalo hump),
increased susceptibility
to infection.
Page 103
Drug Features
Mechanism
Indication
Contraindication
Adverse
of Actions
Effects
Generic Name:
Needed for
Prevention
Renal disease,
CNS:
Assess for signs and
POTASSIUM
adequate
and
severe hemolytic
confusion,
symptoms of hypokalemia
CHLORIDE
transmission
treatment
disease,
restlessness,
(weakness, fatigue, U wave on
Brand Name:
of nerve
for
Addisons
weakness.
ECG, arrhythmias, polyuria,
KALIUM
impulses and
hypokalemia disease,
CV:
polydipsia) and hyperkalemia
DURULES
cardiac
hyperkalemia,
ARRHYTHMIA
(see Toxicity and Overdose).
Classification:
contraction,
acute
S, ECG
Potassium
renal function,
dehydration,
changes.
and ECG periodically during IV
sparing diuretic
intracellular
extensive tissue
GI: abdominal
therapy.
Dosage:
ion
breakdown
pain, diarrhea,
100mg
maintenance.
Monitor pulse, blood pressure,
flatulence,
Monitor serum potassium before
Route:
nausea,
and periodically during therapy.
Oral
vomiting
Monitor renal function, serum
Frequency:
GU: oliguria
bicarbonate, and pH. Determine
TID
INTEG: rash
serum magnesium level if patient
Form:
has refractory hypokalemia;
Tablet
hypomagnesemia should be
Color:
corrected to facilitate
Orange
effectiveness of potassium
replacement. Monitor serum
Page 104
chloride because hypochloremia

may occur if replacing potassium
without concurrent chloride.
Toxicity and Overdose:
Symptoms of toxicity are those of
hyperkalemia (slow, irregular
heartbeat; fatigue; muscle
weakness; paresthesia;
confusion; dyspnea; peaked T
waves; depressed ST segments;
prolonged QT segments;
widened QRS complexes; loss of
P waves; and cardiac
arrhythmias).
Treatment includes
discontinuation of potassium,
administration of sodium
bicarbonate to correct acidosis,
dextrose and insulin to facilitate
passage of potassium into cells,
calcium salts to reverse ECG
effects (in patients who are not
Page 105
receiving digoxin), sodium

polystyrene used as an exchange
resin, and/or dialysis for patient
with impaired renal function.
Page 106
Drug Features
Mechanism of
Indication
Contraindication
Actions
Generic
Blocks
Name:
Adverse
Effects
Chronic
Hypersensitivity
CNS: fatigue,
Monitor blood pressure and
stimulations of B- stable
to this drug, heart
weakness,
pulse frequently during dose
PROPRANOL
adrenergic
angina
failure,
anxiety,
adjustment period and
OL
receptor within
pectoris,
cardiogenic
dizziness,
periodically during therapy.
Brand Name:
vascular smooth
hypertension
shock,
drowsiness,
NovoPranol
muscle;
, MI,
bronchospatic
insomnia,
propranolol may precipitate life-
Classification:
producechronotr
dysrhtmias,
disease, sinus
memory loss,
threatening arrhythmias,
Antihypertensiv
opic, inotropic
cyanotic
bradycardia, CHF
mental
hypertension, or myocardial
activity
spells
depression,
ischemia. Drug should be
Dosage:
(decrease SA
related to
mental status
tapered over a 2 week period
40mg
node discharge,
hypertrophic
changes,
before discontinuation. Assess
Route:
increase
subaortic
nervousness,
patient carefully during tapering
Oral
recovery time),
stenosis.
nightmares.
and after medication is
Frequency:
slows conduction
EENT: blurred
discontinued. Consider that
BID
of AV node,
vision, dry
patients taking propranolol for
Form:
decrease heart
eyes, nasal
non-cardiac indications may
Tablet
rate, which
stuffiness.
have undiagnosed cardiac
Color:
decreases
Resp:
disease. Abrupt discontinuation
Blue
oxygen
bronchospasm or withdrawal over too-short a
consumption in
, wheezing.
Abrupt withdrawal of
period of time (less than 9

Page 107
myocardium.
CV:
ARRHYTHMI
AS,
days) should be avoided.

Patients receiving
propranolol IV must have
BRADYCARDI continuous ECG monitoring and

A, CHF,
may have pulmonary capillary
PULMONARY
wedge pressure (PCWP) or
EDEMA,
central venous pressure (CVP)
orthostatic
monitoring during and for
hypotension,
several hours after
peripheral
administration. .
vasoconstricti
Assess for orthostatic
on.
hypotension when assisting
GI:
patient up from supine position.
constipation,
Monitor intake and output
diarrhea,
ratios and daily weight. Assess
nausea.
patient routinely for evidence of
GU: erectile
fluid overload (peripheral
dysfunction,
edema, dyspnea,
decreased
rales/crackles, fatigue, weight
libido.
gain, jugular venous distention).
Derm: itching,
rashes.
Angina: Assess frequency

and characteristics of anginal
Page 108
Endo:
attacks periodically during
hyperglycemia
therapy.
hypoglycemia
PTSD: Assess frequency of
(increased in
symptoms (flashbacks,
children).
nightmares, efforts to avoid
MS: arthralgia, thoughts or activities that may

back pain,
trigger memories of the trauma,
muscle
and hypervigilance) periodically
cramps.
throughout therapy.
Neuro:
paresthesia.
May cause BUN, serum
Misc: drug-
lipoprotein, potassium,
induced lupus
triglyceride, and uric acid levels.
syndrome.
May cause ANA titers.

May cause or in blood
glucose levels. In labile diabetic
patients, hypoglycemia may be
accompanied by precipitous
of blood pressure. .
Toxicity and Overdose:
Monitor patients receiving beta
blockers for signs of overdose
Page 109
(bradycardia, severe dizziness

or fainting, severe drowsiness,
dyspnea, bluish fingernails or
palms, seizures). Notify
physician or other health care
professional immediately if
these signs occur.
Hypotension may be treated
with modified Trendelenburg
position and IV fluids unless
contraindicated. Vasopressors
(epinephrine, norepinephrine,
dopamine, dobutamine) may
also be used. Hypotension
does not respond to beta
agonists.
Glucagon has been used to
treat bradycardia and
hypotension.
Page 110
Drug Features
Mechanism of
Indication
Contraindication
Actions
Adverse
Effects
Generic
Competes with
Edema of
Pregnancy D,
CNS:
Monitor intake and output ratios
Name:
aldosterone at
CHF,
hypersensitivity,
dizzinessspi and daily weight during therapy.
SPIRONOLAC
receptor sites
hypetension,
anuria, severe
ronolactone
TONE
in the distal
diuretic-
renal disease,
only:
adjunct to antihypertensive therapy,
Brand Name:
tube in the
induced
hyperkalemia
clumsiness,
monitor blood pressure before
ALDACTONE
renal system,
hypokalemia
headache.
administering.
Classification:
resulting in
, edema of
CV:
Potassium-
excretion of
nephritic
arrhythmias
symptoms of hypokalemia
sparing diuretic
sodium
syndrome,
GI:
(weakness, fatigue, U wave on
Dosage:
chloride, water
liver cirrhosis
amiloride:
ECG, arrhythmias, polyuria,
50mg
bicarbonate
with ascites
constipation
polydipsia). Assess patient
Route:
and calcium;
, nausea,
frequently for development of
Oral
potassium,
vomiting.
hyperkalemia (fatigue, muscle
Frequency:
phosphate and
GU:
weakness, paresthesia, confusion,
BID
hydrogen are
spironolacto dyspnea, ECG changes, cardiac
Form:
retained.
ne-: erectile
arrhythmias). Patients who have
Tablet
dysfunctiont
diabetes mellitus or kidney disease
Color:
riamterene-: and geriatric patients are at
Yellow
nephrolithia
increased risk of developing these
sis.
symptoms.
If medication is given as an
Monitor response of signs and
Page 111
Derma:
Periodic ECGs are recommended
triamterene:
in patients receiving prolonged
photosensiti
therapy.
vity.
Endo:
Lab Test Considerations: Serum

potassium levels should be
hyperkalemi evaluated before and routinely

a,
during therapy. Withhold drug and
hyponatrem
notify physician or other health care
ia.
professional if patient becomes
Hema:
hyperkalemic.
spironolacto
Monitor BUN, serum creatinine,
ne:
and electrolytes before and
agranulocyt
periodically during therapy. May
osistriamter
cause serum magnesium, BUN,
ene-:
creatinine, potassium, and urinary
hemolytic
calcium excretion levels. May also
anemia,
cause sodium levels.
thrombocyt
Discontinue potassium-sparing
openia.
diuretics 3 days before a glucose
MS: muscle
tolerance test because of risk of
cramps.
severe hyperkalemia.
Misc:
Spironolactone may cause false

Page 112
allergic
of plasma cortisol concentrations.
reactions.
Spironolactone should be
withdrawn 4-7 days before test.
Monitor platelet count and total
and differential leukocyte count
periodically during therapy in
patients taking triamterene.
Page 113
Drug Features
Generic name:
Indication
Omeprazole
Symptomatic
Mechanisms of
Action
Inhibits proton
Contraindication
Adverse Effects
Contraindicate
CNS:
Nursing
Responsibilities
Tell patient to
gastroesopha
pump activity
d in patients
headache,
swallow tablets
geal reflux
by binding to
with
dizziness,
whole and not to
Brand name:
disease
hydrogen-
hypersensitivity
asthenia
open, crush or
Omepron
(GERD)
potassium
to drug or its
GI: abdominal
chew them.
without
adenosine
components.
pain,
Classification:
esophageal
triphosphatase
Use cautiously
constipation,
take drug at least
Anti-
lesions
, located at
in patients with
diarrhea, dry
1 hour before
Short-term
secretory
Bartter
mouth,
meals.
therapy of
surface of
syndrome,
flatulence,
active benign
gastric parietal
hypokalemia,
nausea,
avoid hazardous
gastric ulcer
cells, to
and respiratory
vomiting
activities if he
Erosive
suppress
alkalosis and in
Musculoskele
gets dizzy.
esophagitis
gastric acid
patients on a
Pathologic
secretion
low-sodium
ulcer/Proton-
Pump Inhibitor
Dosage: 20 mg
Route: Oral
Form: Tablet
y conditions,
respiratory
including
tract infection
White
Ellison
Caution patient to
Respiratory:
hypersecretor
Zollinger-
Instruct patient to
tal: back pain
Frequency: OD
Color:
diet.
cough, upper
Skin: rash
Page 114
syndrome
Duodenal
Ulcer (shortterm
treatment)
Helicobacter
pylori infection
and duodenal
ulcer disease,
to eradicate H.
pylori with
clarithromycin
and amoxicillin
(triple therapy)
Frequent
heartburn (2
or more days
a week)
Page 115
Drug Features
Generic Name:
Mechanism of
Action
Needed for
Indications
Contraindications
Adverse Effects
Nursing
Responsibilities
Monitor for
Vitamin K
Hypersensitivity,
CNS: headache,
Vitamin K1
adequate blood
malabsorption,
severe hepatic
brain damage
bleeding,
clotting.
hypoprothrombinemia, disease, last few
(large doses)
pulse, and
Brand Name:
prevention of
week of
GI: nausea,
blood
Phytonadione
hypoprothrombinemia
pregnancy.
decrease liver
pressure.
caused by oral anti-
function tests
Assess
Classification:
coagulants,
Hema: hemolytic
nutritional
fat-soluble
prevention of
anemia,
status: liver
vitamin
hemorrhagic disease
hemoglobinuria,
(beef),
of the newborn.
hyperbilirubinemia
spinach,
Dosage: 10
Integ: rash,
tomatoes,
mg/ml
urticuria
coffee,
asparagus
Route: IV
Assess for
bleeding or
Frequency: BID
bruising:
hematuria,
Form: Ampule
back tarry
Color:
stool,
Pale yellow
hematemesis
Page 116
Drug Features
Generic Name:
Mechanism
of Action
Normal blood
Albumin
protein;
treatment of shock
with allergy to
heart failure,
studies: Hct,
(Normal Serum
maintains
due to burns,
albumin; severe
pulmonary edema
Hgb; if serum
5-25%)
plasma
trauma, surgery and
anemia cardiac
after rapid
protein
Brand Name:
osmotic
infections
failure, normal
infusion
declines,
Albuminar 5%
pressure and
or increased
Hypersensitivity:
dyspnea,
Classification:
is important in
intravascular
fever, chills,
hypoxemia
volume current
changes in blood
can result;
Blood derivative, maintaining
Indications
Emergency
Contraindications
Adverse Effects
Contraindicated
CV: hypotension,
Acute liver failure

(20% or 25%)
Hyperbilirubinemia
Nursing
Responsibilities
Monitor blood
volume
normal blood
and erythroblastosis
use of
pressure,
check for
expander
volume.
fetalis: adjunct in
cardiopulmonar
flushing, nausea,
decrease
Dosage:
exchange
y bypass
vomiting, changes
blood
1000-2000 ml(5-
transfusion.
Use cautiously
in respiration,
pressure,
10 ml/min)
with hepatic or
rashes
erratic pulse,
Route:
renal failure.
IV
respiration.
Monitor CVP:
Frequency:
pulmonary
OD
wedge
Form:
pressure will
Liquid
increase if
Color:
overload
Light Amber
occurs; I & O
Page 117
ratio: urinary
output may
decrease;
shortness of
breath,
anxiety and
respiratory
crackles.
Assess for
allergy: fever,
rash, itching,
chills, flushing
nausea,
vomiting.
Page 118
Drug Features
Generic Name:
Mechanism of
action
Acetylcysteine
Treatment of
Known
GI: nausea,
Acetylcysteine
solution is a
respiratory
hypersensitivity to
vomiting, diarrhea,
effectiveness
mucolytic. It works
affections
acetylcysteine. As
heartburn,
of therapy and
BrandName:
by thinning out
characterized by
Acetylcystein
dyspepsia, rectal
advent of
Flumucil
mucus secretions,
thick and viscous
(Fluimucil)
bleeding,
adverse/
making them
hypersecretions:
granules and
epigastric pain.
allergic effects.
Classification:
easier to move
acute bronchitis,
tablets contain
CNS: dizziness,
Instruct patient
Mucolytic
through the lungs.
chronic bronchitis
aspartame, it is
drowsiness,
in appropriate
and its
contraindicated in
lightheadedness,
use and
exacerbations;
patients suffering
asthenia
adverse effects
pulmonary
from
RESPI:
to report.
emphysema,
phenylketonuria.
bronchospasm,
Dosage: 60 mg
Route: oral
Frequency: BID
Form: tablet
Indication
Contraindication
Side Effects
mucoviscidosis
Others: urticarial
and
rash, pruritus,
bronchiectasis.
flushing, a warm
Nursing
Responsibilities
Monitor
feeling of the skin,

occasional
Color: white
bronchospasm or
hypotension,
angioedema,
dyspnea,
Page 119
Drug Features
Generic Name:
Mechanism of
action
Hepatic protector.
Silymarin
It reduces the
treatment of
any component of
bloating, nausea,
patient that
turnover of
chronic
product.
diarrhea, stomach
the drug may
Brand Name:
membrane
inflammatory
upset
be taken with
Legalon
phospholipids and
diseases of
stabilises the cell
the liver and
CNS:Weakness, H
Classification:
membranes of
hepatic
eadache, Joint
Liver supplement,
hepatocytes. It
cirrhosis.
pain,
antioxidant
has potent
Dosage: 140 mg
antioxidant action
and prevents lipid

Route: oral
peroxidation
Frequency: bid
Indication
Contraindication
Side Effects
Supportive
Hypersensitivity to
GI: dyspepsia,
Nursing
Responsibilities
Tell the
regard for
meals.
Regenerate
liver cells
damaged by
alcohol or
drugs
Decongest the
liver (A liver
decongestant
Form: capsule
stimulates bile
flow through
Color: brown
the liver and

gallbladder,
thus reducing
Page 120
stagnation and
preventing
gallstone
formation and
bile-induced
liver damage.)
Complement
the treatment
of viral
hepatitis
Page 121
Overview
Thoracentesis
Also known as thoracocentesis or pleural tap is an invasive procedure to

remove fluid or air from the pleural space for diagnostic or therapeutic purposes.
A cannula, or hollow needle, is carefully introduced into the thorax, generally
after administration of local anesthesia
Should be done in almost all patients who have pleural fluid that is 10 mm in
thickness on CT, ultrasonography, or lateral decubitus x-ray and that is new or of
uncertain etiology. In general, the only patients who do not require thoracentesis
are those who have heart failure with symmetric pleural effusions and no chest
pain or fever; in these patients, diuresis can be tried, and thoracentesis avoided
unless effusions persist for 3 days.
Thoracentesis and subsequent pleural fluid analysis often are not necessary for
pleural effusions that are chronic, have a known cause, and cause no symptoms.
Ultrasonography is helpful for identifying the site for thoracentesis when the
amount of pleural fluid is small, the fluid is loculated, or blind thoracentesis is
unsuccessful.
The most common causes of pleural effusions are cancer, congestive heart
failure,pneumonia, and recent surgery.
Page 122
Pleural fluid analysis is done to diagnose the cause of pleural effusion. Analysis
begins with visual inspection, which can
Distinguish bloody and chylous (or chyliform) from other effusions
Identify purulent effusions strongly suggestive of empyema
Identify viscous fluid, which is characteristic of some mesothelioma.
Indwelling Foley Catheter
A urinary catheter is a tube placed in the body to drain and collect urine from the
bladder.
An indwelling catheter collects urine by attaching to a drainage bag. A newer
type of catheter has a valve that can be opened to allow urine to flow out.
An indwelling catheter may be inserted into the bladder in two ways:
1. Most often, the catheter is inserted through the urethra. This is the tube that
carries urine from the bladder to the outside of the body.
2. Sometimes, the health care provider will insert a catheter into your bladder
through a small hole in your belly. This is done at a hospital or health care
provider's office.
An indwelling catheter has a small balloon inflated on the end of it. This prevents
the catheter from sliding out of your body. When the catheter needs to be
removed, the balloon is deflated.
Everyday care of catheter and drainage bag is important to reduce the risk of
infection. Such precautions include:
Cleansing the urethral area (area where catheter exits body) and the catheter itself.
b. Disconnecting drainage bag from catheter only with clean hands
c. Disconnecting drainage bag as seldom as possible.
a.
Page 123
Keeping drainage bag connector as clean as possible and cleansing the drainage
bag periodically.
e. Use of a thin catheter where possible to reduce risk of harming the urethra during
insertion.
f. Drinking sufficient liquid to produce at least two liters of urine daily
g. Sexual activity is very high risk for urinary infections, especially for catheterized
women.
d.
Nasal Cannula
The nasal cannula (NC) is a device used to deliver supplemental oxygen or

airflow to a patient or person in need of respiratory help.
This device consists of a lightweight tube which on one end splits into two prongs
which are placed in the nostrils and from which a mixture of air and oxygen flows.
The other end of the tube is connected to an oxygen supply such as a portable
oxygen generator, or a wall connection in a hospital via a flowmeter.
The cannula is generally attached to the patient by way of the tube hooking
around the patient's ears or by elastic head band.
The earliest, and most widely used form of adult nasal cannula carries 15 litres
of oxygen per minute.
Cannulae with smaller prongs intended for infant or neonatal use can carry less
than one litre per minute. Flow rates of up to 60 litres of air/oxygen per minute
can be delivered through wider bore humidified nasal cannula.
Oxygen therapy is the administration of oxygen at concentrations greater than
that in room air to treat or prevent hypoxemia (not enough oxygen in the blood).
Oxygen delivery systems are classified as stationary, portable, or ambulatory.
Oxygen can be administered bynasal cannula, mask, and tent. Hyperbaric
Page 124
oxygen therapy involves placing the patient in an airtight chamber with oxygen
under pressure.
Chest X-ray
is a painless, noninvasive test that creates pictures of the structures inside your
chest, such as your heart, lungs, and blood vessels.
They use ionizing radiation to create pictures of the inside of your body.
A chest x ray takes pictures of the inside of your chest. The different tissues in
your chest absorb different amounts of radiation.
A chest X-ray, which is almost always done to check for changes in the lungs
that may mean pneumonia and to look for other causes of your symptoms. But
an X-ray does not always show whether you have pneumonia, especially if it is
done when you first get sick. In some cases, the X-ray results may:
Suggest the type of organism (bacterial, viral, or fungal) causing

pneumonia.
Show complications of pneumonia.
Show conditions that may occur with pneumonia, such as fluid in the chest
cavity or a collapsed lung.
Reveal another condition, such as heart failure, lung cancer, or acute
bronchitis.
Page 125
B. Dietary Prescription/ Restriction

According to the doctors order, Patient R.P was maintained on Low Salt Low
Fat Diet and with fluid restriction of below 1L a day due to her abnormal accumulation of
fluid in the abdomen since admission.
C. Procedures
Oxygenation
Patient R.P was given an oxygen delivery system as a relief for breathing. The
patient was given oxygen inhalator via nasal cannula as needed prior to admission. The
nasal cannula delivers 10% to 40% at 4-5L per minute.
Intravenous Fluids
Patient R.P was given 1L of PNSS KVO to run for 8 hours upon admission, July
21, 2013 and was hooked at 6:45pm. Last IV fluid of PNSS no. 12 without incorporation
was given at July 31, 2013. When the above IVF was consumed, it was replaced with
No. 13 PNSS 90cc incorporated with medication of 20 meqs KCL to run for 2 hours and
was hooked August 01, 2013 at 10:00 pm in treating low blood levels of potassium
(hypokalemia) as doctors order. Intravenous fluid is necessary to supply fluid especially
to the elders with fluid restriction because the patient cannot attain enough nutrients for
her body.
Intravenous Catheterization
Patient R.P was catheterized with PNSS on her right metacarpal vein (July 21,
2013 started at 6:45pm). The IV line was infusing well and no air and back flow seen. It
was monitored and regulated on appropriate drops/min.
Blood Transfusion
The patient was undergone Blood Transfusion of 2 units of Packed Red Blood
Cells infused for 6 hours last July 22, 2013 due to low RBC count , low plasma volume
Page 126
and prolong APTT. Her blood type was B and Rh positive. The patient doesnt show any
allergic reaction.
Indwelling Foley Catheter
Patient R.P was inserted of Indwelling Foley Catheter July 23, 2013. The patient
had slightly orange in color urine and no blood was seen. The urine output was
recorded every end of the shift. The measurement of urine output was 300cc at August
1, 2013 and 500cc at August 2, 2013 in our 10pm-6am shift. The patient used to change
diapers 2-3 times a day and does perineal hygiene. Indications for IFC are sudden and
complete inability to void, need for immediate and rapid bladder decompression and
monitoring of intake and output.
Thoracentesis
Patient R.P undergone thoracentesis which an invasive procedure that remove
fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or
hollow needle, is carefully introduced into the thorax, generally after administration
of local anesthesia. This procedure is indicated when unexplained fluid accumulates in
the chest cavity outside the lung. Patient R.P was diagnosed of Pleural effusion and the
cause of it was cirrhosis with ascites because ascitic fluid migrates to the pleural space
through diaphragmatic. It was performed July 30, 2013 and the findings were yellowish
in color and cloudy in character, with specific gravity of 1.010; pH was 6.0; protein of 31
g/L and the volume was approximately 20mL.
Page 127
Overview
Anatomy and Physiology
Page 128
ANATOMY AND PHYSIOLOGY OF LIVER

The liver, the largest internal organ, is located in the upper right quadrant of the
abdominal cavity, just inferior to the diaphragm. It is partially surrounded by the ribs and
extends from the level of the fifth intercostals space to the lower margin of the ribs.
The liver is a roughly triangular organ that extends across the entire abdominal cavity
just inferior to the diaphragm. Most of the livers mass is located on the right side of the
body where it descends inferiorly toward the right kidney. The liver is made of very soft,
pinkish-brown tissues encapsulated by a connective tissue capsule. This capsule is
further covered and reinforced by the peritoneum of the abdominal cavity, which
protects the liver and holds it in place within the abdomen.
The peritoneum connects the liver in 4 locations: the coronary ligament, the left and
right triangular ligaments, and the falciform ligament. These connections are not true
ligaments in the anatomical sense; rather, they are condensed regions of peritoneal
membrane that support the liver.
The wide coronary ligament connects the central superior portion of the liver to the
diaphragm.
Located on the lateral borders of the left and right lobes, respectively, the left and
righttriangular ligaments connect the superior ends of the liver to the diaphragm.
Page 129
The falciform ligament runs inferiorly from the diaphragm across the anterior edge of
the liver to its inferior border. At the inferior end of the liver, the falciform ligament
forms the round ligament (ligamentum teres) of the liver and connects the liver to
the umbilicus. The round ligament is a remnant of the umbilical vein that carries
blood into the body during fetal development.
The liver consists of 4 distinct lobes the left, right, caudate, and quadrate lobes.
The left and right lobes are the largest lobes and are separated by the falciform
ligament. The right lobe is about 5 to 6 times larger than the tapered left lobe.
The small caudate lobe extends from the posterior side of the right lobe and wraps
around the inferior vena cava.
The small quadrate lobe is inferior to the caudate lobe and extends from the posterior
side of the right lobe and wraps around the gallbladder.
Bile Ducts
The tubes that carry bile through the liver and gallbladder are known as bile ducts and
form a branched structure known as the biliary tree. Bile produced by liver cells drains
into microscopic canals known as bile canaliculi. The countless bile canaliculi join
together into many larger bile ducts found throughout the liver.
These bile ducts next join to form the larger left and right hepatic ducts, which carry bile
from the left and right lobes of the liver. Those two hepatic ducts join to form the
common hepatic duct that drains all bile away from the liver. The common hepatic duct
finally joins with the cystic duct from the gallbladder to form the common bile duct,
carrying bile to the duodenum of the small intestine. Most of the bile produced by the
liver is pushed back up the cystic duct by peristalsis to arrive in the gallbladder for
storage, until it is needed for digestion.
Blood Vessels
The blood supply of the liver is unique among all organs of the body due to the hepatic
portal vein system. Blood traveling to the spleen, stomach, pancreas, gallbladder, and
intestines passes through capillaries in these organs and is collected into the hepatic
Page 130
portal vein. The hepatic portal vein then delivers this blood to the tissues of the liver
where the contents of the blood are divided up into smaller vessels and processed
before being passed on to the rest of the body. Blood leaving the tissues of the liver
collects into the hepatic veins that lead to the vena cava and return to the heart. The
liver also has its own system of arteries and arterioles that provide oxygenated blood to
its tissues just like any other organ.
Lobules
The internal structure of the liver is made of around 100,000 small hexagonal functional
units known as lobules. Each lobule consists of a central vein surrounded by 6 hepatic
portal veins and 6 hepatic arteries. These blood vessels are connected by many
capillary-like tubes called sinusoids, which extend from the portal veins and arteries to
meet the central vein like spokes on a wheel.
Each sinusoid passes through liver tissue containing 2 main cell types: Kupffer cells and
hepatocytes.
Kupffer cells are a type of macrophage that capture and break down old, worn out red
blood cells passing through the sinusoids.
Hepatocytes are cuboidal epithelial cells that line the sinusoids and make up the majority of
cells in the liver. Hepatocytes perform most of the livers functions metabolism, storage,
digestion, and bile production. Tiny bile collection vessels known as bile canaliculi run parallel
to the sinusoids on the other side of the hepatocytes and drain into the bile ducts of the liver.
Functions of the Liver
1. Glucose Metabolism
The liver plays a major role in the metabolism of glucose and the regulation of blood
glucose concentration. After a meal, glucose is taken up from the portal venous blood
by the liver and converted into glycogen, which is stored in the hepatocytes.
Subsequently, the glycogen is converted back to glucose (glycogenolysis) and released
as needed into the bloodstream to maintain normal levels of blood glucose.
Page 131
However, this process provides a limited amount of glucose. Additional glucose can be
synthesized by the liver through a process called gluconeogenesis. For this process, the
liver uses amino acids from protein breakdown or lactate produced by exercising
muscles. This process occurs in response to hypoglycemia (Shils, Shike, Ross, et al.,
2006).
2. Ammonia Conversion
It is a use of amino acids from protein for gluconeogenesis results in the formation of
ammonia as a by-product. The liver converts this metabolically generated ammonia into
urea. Ammonia produced by bacteria in the intestines is also removed from portal blood
for urea synthesis. In this way, the liver converts ammonia, a potential toxin, into urea, a
compound that is excreted in the urine (Porth & Matfin, 2009).
3. Protein Metabolism
The liver also plays an important role in protein metabolism. It synthesizes almost all of
the plasma proteins (except gamma-globulin), including albumin, alpha-globulins and
beta-globulins, blood clotting factors, specific transport proteins, and most of the plasma
lipoproteins. Vitamin K is required by the liver for synthesis of prothrombin and some of
the other clotting factors. Amino acids are used by the liver for protein synthesis (Porth
& Matfin, 2009).
4. Fat Metabolism
The liver is also active in fat metabolism. Fatty acids can be broken down for the
production of energy and ketone bodies (acetoacetic acid, beta-hydroxybutyric acid, and
acetone). Ketone bodies are small compounds that can enter the bloodstream and
provide a source of energy for muscles and other tissues. Breakdown of fatty acids into
ketone bodies occurs primarily when the availability of glucose for metabolism is limited,
as in starvation or in uncontrolled diabetes. Fatty acids and their metabolic products are
also used for the synthesis of cholesterol, lecithin, lipoproteins, and other complex lipids
(Porth & Matfin, 2009). In some conditions, lipids may accumulate in the hepatocytes,
resulting in the abnormal condition called fatty liver.
Page 132
5. Vitamin and Iron Storage

Vitamins A, B, and D and several of the B-complex vitamins are stored in large amounts
in the liver. Certain substances, such as iron and copper, are also stored in the liver.
Because the liver is rich in these substances, liver extract have been used for therapy
for more than a century for a wide range of nutritional disorders; however, the U.S. Food
and Drug Administration (FDA) has urged caution regarding the use of any animal
organ extract because of possible risk of exposure to pathogenic organisms.
6. Bile Formation
Bile is continuously formed by the hepatocytes and collected in the canaliculi and bile
ducts. It is composed mainly of water and electrolytes such as sodium, potassium,
calcium, chloride, and bicarbonate, and it also contains significant amounts of lecithin,
fatty acids, cholesterol, bilirubin, and bile salts. Bile is collected and stored in the
gallbladder and is emptied into the intestine when needed for digestion. The functions of
bile are excretory, as in the excretion of bilirubin; bile also serves as an aid to digestion
through the emulsification of fats by bile salts. Bile salts are synthesized by the
hepatocytes from cholesterol. After conjugation or binding with amino acids (taurine and
glycine), bile salts are excreted into the bile. The bile salts, together with cholesterol and
lecithin, are required for emulsification of fats in the intestine, which is necessary for
efficient digestion and absorption. Bile salts are then reabsorbed, primarily in the distal
ileum, into portal blood for return to the liver and are again excreted into the bile. This
pathway from hepatocytes to bile to intestine and back to the hepatocytes is called the
enterohepatic circulation. Because of the enterohepatic circulation, only a small fraction
of the bile salts that enter the intestine are excreted in the feces. This decreases the
need for active synthesis of bile salts by the liver cells (Porth & Matfin, 2009).
7. Bilirubin Excretion
Bilirubin is a pigment derived from the breakdown of haemoglobin by cells of the
reticuloendothelial system, including the Kupffer cells of the liver. Hepatocytes remove
bilirubin from the blood and chemically modify it through conjugation to glucuronic acid,
which makes the bilirubin more soluble in aqueous solutions. The conjugated bilirubin is
Page 133
secreted by the hepatocytes into the adjacent bile canaliculi and is eventually carried in
the bile into the duodenum.
In the small intestine, bilirubin is converted into urobilinogen, which is partially excreted
in the feces and partially absorbed through the intestinal mucosa into the portal blood.
Much of this reabsorbed urobilinogen is removed by the hepatocytes and secreted into
the bile once again (enterohepatic circulation). Some of the urobilinogen enters the
systemic circulation and is excreted by the kidneys in the urine. Elimination of bilirubin in
the bile represents the major route of its excretion.
The bilirubin concentration in the blood may be increased in the presence of liver
disease, if the flow of bile is impeded (eg, by gallstones in the bile ducts), or if there is
excessive destruction of red blood cells. With bile duct obstruction, bilirubin does not
enter the intestine; as a consequence, urobilinogen is absent from the urine and
decreased in the stool (Porth & Matfin, 2009).
8. Drug Metabolism
The liver metabolizes many medications, such as barbiturates, opioids, sedatives,
anesthetics, and amphetamines. Metabolism generally results in drug inactivation,
although activation may also occur. One of the important pathways for medication
metabolism involves conjugation (binding) of the medication with a variety of
compounds, such as glucuronic acid or acetic acid, to form more soluble substances.
These substances may be excreted in the feces or urine, similar to bilirubin excretion.
Bioavailability is the fraction of the administered medication that actually reaches the
systemic circulation. The bioavailability of an oral medication (absorbed from the GI
tract) can be decreased if the medication is metabolized to a great extent by the liver
before it reaches the systemic circulation; this is known as first-pass effect. Some
medications have such a large first-pass effect that their use is essentially limited to the
parenteral route, or oral doses must be substantially larger than parenteral doses to
achieve the same effect.
Page 134
ANATOMY AND PHYSIOLOGY OFSPLEEN

organ shaped like a shoe that lies relative to the 9th and 11th ribs and is located
in the left hypochondrium and partly in the epigastrium
between the fundus of the stomach and the diaphragm
very vascular and reddish purple in color
its size and weight vary
A healthy spleen is not palpable.
Development
The spleen develops in the cephalic part of dorsal mesogastrium (from its left layer;
during the sixth week of intrauterine life) into a number of nodules that fuse and form a
lobulated spleen. Notching of the superior border of the adult spleen is evidence of its
multiple origin .
Gross Anatomy
The spleen's 2 ends are the anterior and posterior end.
The anterior end of the spleen is expanded and is more like a border; it is
directed forward and downward to reach the midaxillary line.
The posterior end is rounded and is directed upward and backward; it rests on
the upper pole of the left kidney.
Page 135
The spleen's 3 borders are the superior, inferior, and intermediate.

The superior border of the spleen is notched by the anterior end.
The inferior border is rounded.
The intermediate border directs toward the right.
The 2 surfaces of the spleen are the diaphragmatic and visceral. The
diaphragmatic surface is smooth and convex, and the visceral surface is irregular and
concave and has impressions. The gastric impression is for the fundus of the stomach,
which is the largest and most concave impression on the spleen. The renal impression
is for the left kidney and lies between the inferior and intermediate borders. The colic
impression is for the splenic flexure of the colon; its lower part is related to the
phrenicocolic ligament. The pancreatic impression for the tail of the pancreas lies
between the hilum and colic impression .
Spleen anatomy. This image shows different surfaces and impressions caused by
different organs in relation to the spleen's hilum.
Hilum
Page 136
The hilum can be found on the inferomedial part of the gastric impression. The hilum
transmits the splenic vessels and nerves and provides attachment to the gastrosplenic
and splenorenal (lienorenal) ligaments.
Peritoneal relations
The spleen is surrounded by peritoneum and is suspended by multiple ligaments, as
follows:
The gastrosplenic ligament extends from the hilum of the spleen to the greater
curvature of the stomach; it contains short gastric vessels and associated lymphatics
and sympathetic nerves.
The splenorenal ligament extends from the hilum of the spleen to the anterior surface
of the left kidney; it contains the tail of the pancreas and splenic vessels.
The phrenicocolic ligament is a horizontal fold of peritoneum that extends from the
splenic flexure of the colon to the diaphragm along the midaxillary line; it forms the
upper end of the left paracolic gutter.
Visceral relations
The visceral surface of the spleen contacts the following organs:
Anterior surface of the left kidney
Splenic flexure of the colon
The fundus of the stomach
Tail of the pancreas

The diaphragmatic surface is related to the diaphragm; the diaphragm separates the
spleen from the pleura and the lung.
Vascular supply
The splenic artery supplies blood to the spleen. This artery is the largest branch of the
celiac trunk and reaches the spleen's hilum by passing through the splenorenal
Page 137
ligament. It divides into multiple branches at the hilum. It divides into straight vessels
called penicillin, ellipsoids, and arterial capillaries in the spleen.
The splenic circulation is adapted for the separation and storage of the red blood cells.
The spleen has superior and inferior vascular segments based on the blood supply. The
2 segments are separated by an avascular plane.
Its terminal branches aside, the splenic artery also gives off branches to the pancreas,
5-7 short gastric branches, and the left gastro-omental (gastroepiploic) artery.
Spleen anatomy. Hilum of the spleen along with anatomy of the splenic artery (a) and
the splenic vein (v).
Nerve supply
Sympathetic fibers are derived from the celiac plexus.
Surface marking
Page 138
The spleen is marked on the left side of the back with the long axis of the 10th
rib.
The upper border is marked along the upper border of the ninth rib; the lower
border, along the 11th rib.
The medial end lies 5 cm from the midline.
The lateral extension ends at the midaxillary line.
Venous drainage
The splenic vein provides the principal venous drainage of the spleen. It runs behind the
pancreas (after forming at the hilum) before joining the superior mesenteric vein behind
the neck of the pancreas to form the portal vein. The short gastric, left gastro-omental,
pancreatic, and inferior mesenteric veins are its tributaries.
Lymphatic drainage
Proper splenic tissue has no lymphatics; however, some arise from the capsule and
trabeculae and drain to the pancreaticosplenic lymph nodes.
Microscopic Anatomy
The spleen is made up of the following 4 components:
Supporting tissue
White pulp
Red pulp
Vascular system
Supporting tissue is fibroelastic and forms the capsule, coarse trabeculae, and a fine
reticulum.
The white pulp consists of lymphatic nodules, which are arranged around an eccentric
arteriole called the Malpighian corpuscle.
Page 139
The red pulp is formed by a collection of cells in the interstices of the reticulum, in
between the sinusoids. The cell population includes all types of lymphocytes, blood
cells, and fixed and free macrophages. The lymphocytes are freely transformed into
plasma cells, which can produce large amounts of antibodies and immunoglobulins .
Spleen anatomy. This section shows the spleen's red pulp and the white pulp and its
relation to the liver and diaphragm.
The vascular system traverses the spleen and permeates it.

Natural and Pathophysiologic Variants
Accessory spleens or splenunculi are natural anatomic variants formed from nodules
that fail to fuse during development. These are found in various locations such as the
gastrosplenic ligament, splenorenal ligament, gastrophrenic ligament, and gastrocolic
ligament. They have also been reported to have been found in the broad ligament of the
uterus and in the spermatic cord.
Pathophysiologic anatomic variants include splenomegaly, asplenia, and

autosplenectomy. Splenomegaly is the enlargement of the spleen. It occurs due to
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various conditions, such as infections (eg, malaria, kala azar), malignancies (eg,
lymphomas, leukemias), and other conditions (eg, portal hypertension). The spleen then
projects toward the right iliac fossa in the direction of axis of the 10th rib.
Asplenia is a rare condition in which a congenital absence of the spleen occurs.
Autosplenectomy is a condition in which splenic infarction occurs due to sickle cell

anemia.
Functions of the Spleen

Immune responses
After antigenic stimulation, increased formation of plasma cells for humoral responses
and increased lymphopoiesis for cellular responses occurs.
Phagocytosis
One of the spleen's most important functions is phagocytosis. The spleen is a
component of the reticuloendothelial system. The splenic phagocytes include reticular
cells, free macrophages of the red pulp, and modified reticular cells of the ellipsoids.
Phagocytes in the spleen remove debris, old and effete red blood cells (RBCs), other
blood cells, and microorganisms, thereby filtering the blood. Phagocytosis of circulating
antigens initiates the humoral and cellular immune responses.
Hematopoiesis
The spleen is an important hematopoietic organ during fetal life; lymphopoiesis
continues throughout life. The manufactured lymphocytes take part in immune
responses of the body. In the adult spleen, hematopoiesis can restart in certain
diseases such as chronic myeloid leukemia and myelosclerosis.
Storage of red blood cells
The RBCs are stored in the spleen. Approximately 8% of the circulating RBCs are
present within the spleen; however, this function is seen better in animals than humans.
Page 141
ANATOMY AND PHYSIOLOGY OF KIDNEY
The most basic structures of the kidneys are nephrons. Inside each kidney there are
about one million of these microscopic structures. They are responsible for filtering the
blood... removing waste products.
The renal artery delivers blood to the kidneys each day. Over 180 liters (50 gallons) of
blood pass through the kidneys every day. When this blood enters the kidneys it is
filtered and returned to the heart via the renal vein.
The kidneys are full of blood vessels. Blood vessels are integral to efficient kidney
function. Every function of the kidney involves blood; it therefore, requires a lot of blood
vessels to facilitate these functions. Together, the two kidneys contain about 160 km of
blood vessels.
Page 142
Hepatic Portal Circulation

The liver is unusual in that it receives the majority of its metabolic requirements from a
venous source. The normal liver gets about 70% of its O2 requirement via the portal
vein. The portal vein also delivers the dietary carbohydrates used to fuel liver
activityThe portal system begins in the capillaries and venules of the digestive system. It
collects venous blood from the lower esophagus, stomach, duodenum, jejunum, ileum,
colon, spleen and delivers it to the liver via portal vein. Consequently, portal blood
contains the substances absorbed by the digestive tract.
Normal portal flow and pressure vary depending upon: cardiac output, intra-abdominal
pressure, disease process, positioning, feeding schedule, time of day, etc. Circadian
variations begin to increase portal pressure around 19:00 hours, reaching peak
pressures around 09:00. Portal pressure decreases from 09:00 to about 19:00 hours.
Interestingly, peak reports of bleeding varies correspond with 09:00 and 23:00 hours.
Normal hepatic circulation is a high flow - low resistance system. Branches of the portal
vein deliver 1000-1500 ml/min of blood into the sinusoids of the hepatic lobules. Normal
portal venous pressure is 5-10 mm Hg. The blood passes through the sinusoids and
drains into the inferior vena cava. Inferior vena cava pressure ranges from -5 to +5
mmHg.* Portal pressure >10mm Hg may indicate portal hypertension.
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The cardiovascular system is composed of two circulatory paths: pulmonary circulation,

the circuit through the lungs where blood is oxygenated; and systemic circulation, the
circuit through the rest of the body to provide oxygenated blood.
Pulmonary Circulation
Pulmonary circulation is the movement of blood from the heart to the lungs for
oxygenation, then back to the heart again. Oxygen-depleted blood from the body leaves
the systemic circulation when it enters the right atrium through the superior and inferior
venae cava. The blood is then pumped through the tricuspid valve into the right
ventricle. From the right ventricle, blood is pumped through the pulmonary valve and
into the pulmonary artery. The pulmonary artery splits into the right and left pulmonary
arteries and travel to each lung. At the lungs, the blood travels through capillary beds on
the alveoli where respiration occurs, removing carbon dioxide and adding oxygen to the
blood. The alveoli are air sacs in the lungs that provide the surface for gas exchange
during respiration. The oxygenated blood then leaves the lungs through pulmonary
veins, which returns it to the left atrium, completing the pulmonary circuit. Once entering
Page 144
the left heart, the blood flows through the bicuspid valve into the left ventricle. From the
left ventricle, the blood is pumped through the aortic valve into the aorta to travel
through systemic circulation, delivering oxygenated blood to the body before returning
again to the pulmonary circulation.
Systemic Circulation
Systemic circulation is the movement of blood from the heart through the body to
provide oxygen and nutrients, and bringing deoxygenated blood back to the heart.
Oxygen-rich blood from the lungs leaves the pulmonary circulation when it enters the
left atrium through the pulmonary veins. The blood is then pumped through the mitral
valve into the left ventricle. From the left ventricle, blood is pumped through the aortic
valve and into the aorta, the body's largest artery. The aorta arches and branches into
major arteries to the upper body before passing through the diaphragm, where it
branches further into arteries which supply the lower parts of the body. The arteries
branch into smaller arteries, arterioles, and finally capillaries. Waste and carbon dioxide
diffuse out of the cell into the blood, while oxygen in the blood diffuses out of the blood
and into the cell. The deoxygenated blood continues through the capillaries which
merge into venules, then veins, and finally the venae cava, which drain into the right
atrium of the heart. From the right atrium, the blood will travel through the pulmonary
circulation to be oxygenated before returning gain to the system circulation. Coronary
circulation, blood supply to the heart muscle itself, is also part of the systemic circulation
Page 145
Page 146
SCHISTOSOMIASIS
Schistosomiasis (also known as bilharzia, bilharziosis or snail fever) is a collective name
of parasitic diseases caused by several species of trematodes belonging to the genus
Schistosoma. Snails serve as the intermediary agent between mammalian hosts.
Individuals within developing countries who cannot afford proper water and sanitation
facilities are often exposed to contaminated water containing the infected snails.
Although it has a low mortality rate, schistosomiasis often is a chronic illness that can
damage internal organs and, in children, impair growth and cognitive development. The
urinary form of schistosomiasis is associated with increased risks for bladder cancer in
adults. Schistosomiasis is the second most socioeconomically devastating parasitic
disease after malaria.
This disease is most commonly found in Asia, Africa, and South America, especially in
areas where the water contains numerous freshwater snails, which may carry the
parasite.
The disease affects many people in developing countries, particularly children who may
acquire the disease by swimming or playing in infected water. When children come into
contact with a contaminated water source, the parasitic larvae easily enter through their
skin and further mature within organ tissues. As of 2009, 74 developing countries
statistically identified epidemics of Schistosomiasis within their respective populations.
Species of Schistosoma that can infect humans:
Schistosoma mansoni and Schistosoma intercalatum cause intestinal schistosomiasis
Schistosoma haematobium causes urinary schistosomiasis
Schistosoma
japonicum
and
Schistosoma
mekongi
cause
Asian
intestinal
schistosomiasis. Avian schistosomiasis species cause swimmer's itch and clam digger
itch
Page 147
LIFE CYCLE
The life cycles of all five human schistosomes are broadly similar: parasite eggs are
released into the environment from infected individuals, hatching on contact with fresh
water to release the free-swimming miracidium. Miracidia infect freshwater snails by
penetrating the snail's foot. After infection, close to the site of penetration, the
miracidium transforms into a primary (mother) sporocyst. Germ cells within the primary
sporocyst will then begin dividing to produce secondary (daughter) sporocysts, which
migrate to the snail's hepatopancreas. Once at the hepatopancreas, germ cells within
the secondary sporocyst begin to divide again, this time producing thousands of new
parasites, known as cercariae, which are the larvae capable of infecting mammals.
Cercariae emerge daily from the snail host in a circadian rhythm, dependent on ambient
temperature and light. Young cercariae are highly mobile, alternating between vigorous
upward movements and sinking to maintain their position in the water. Cercarial activity
is particularly stimulated by water turbulence, by shadows and by chemicals found on
human skin.
The most common way of getting schistosomiasis in developing countries is by wading
or swimming in lakes, ponds and other bodies of water that are infested with the snails
usually of the genera Biomphalaria, Bulinus, or Oncomelania that are the natural
reservoirs of the Schistosoma pathogen.
Penetration of the human skin occurs after the cercaria have attached to and explored
the skin. The parasite secretes enzymes that break down the skin's protein to enable
penetration of the cercarial head through the skin. As the cercaria penetrates the skin it
transforms into a migrating schistosomulum stage.
The newly transformed schistosomulum may remain in the skin for two days before
locating a post-capillary venule; from here the schistosomulum travels to the lungs
where it undergoes further developmental changes necessary for subsequent migration
to the liver. Eight to ten days after penetration of the skin, the parasite migrates to the
liver sinusoids. S. japonicum migrates more quickly than S. mansoni, and usually
reaches the liver within eight days of penetration. Juvenile S. mansoni and S. japonicum
Page 148
worms develop an oral sucker after arriving at the liver, and it is during this period that
the parasite begins to feed on red blood cells. The nearly-mature worms pair, with the
longer female worm residing in the gynaecophoric channel of the shorter male. Adult
worms are about 10 mm long. Worm pairs of S. mansoni and S. japonicum relocate to
the mesenteric or rectal veins. S. haematobium schistosomula ultimately migrate from
the liver to the perivesical venous plexus of the bladder, ureters, and kidneys through
the hemorrhoidal plexus.
Parasites reach maturity in six to eight weeks, at which time they begin to produce
eggs. Adult S. mansoni pairs residing in the mesenteric vessels may produce up to
300 eggs per day during their reproductive lives. S. japonicum may produce up to 3,000
eggs per day. Many of the eggs pass through the walls of the blood vessels, and
through the intestinal wall, to be passed out of the body in feces. S. haematobium eggs
pass through the ureteral or bladder wall and into the urine. Only mature eggs are
capable of crossing into the digestive tract, possibly through the release of proteolytic
enzymes, but also as a function of host immune response, which fosters local tissue
ulceration. Up to half the eggs released by the worm pairs become trapped in the
mesenteric veins, or will be washed back into the liver, where they will become lodged.
Worm pairs can live in the body for an average of four and a half years, but may persist
up to twenty years. Trapped eggs mature normally, secreting antigens that elicit a
vigorous immune response. The eggs themselves do not damage the body. Rather it is
the cellular infiltration resultant from the immune response that causes the pathology
classically associated with schistosomiasis.
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Embryonated eggs (ova) of adult schistosomes are expelled together with the feces of an infected
person in fresh water, those eggs then hatch due to the lower osmolarity of the fresh water. Though
the nature of hatching is poorly understood, current information suggests that miracidium inside the
egg increases in its ciliary activity then, due to the osmosis, a vent opens in the side of the egg and
the miracidium is released. In the process, some eggs do not hatch and others hatch
prematurely. As the miracidia are released in the water, they immediately swim ceaselessly
thereby increasing the chances of encountering an important host. There are different hosts
depending upon the type of schistosoma. Particularly for SchistosomaJaponicum, the snail
Oncomelaniaquadrasi is the typical host. Upon contact of a miracidium into the snail host, it
penetrates into the snail. Immediately after penetration, it sheds its epithelium and then develops
into a mother sporocyst which continues to produce daughter sporocysts, asexually, that will
migrate into other parts of the snailsbody. Production continues from 6-7 weeks. The daughter
sporocysts will transform into theinfective stage called cercaria. These cercarias are then released
by the snail into thewater where they sink toward the bottom and can remain in this state for 1-3
days. They can potentially enter the skin of a man and other warm blooded animals like dogs,
cows, carabaos, that wade in the water.
Page 150
Pathophysiology
Page 151
Predisposing Factor:
Precipitating Factor:
Geographical Location (Leyte)

Age (68 years old)
Educational Status
Actual contact with infected

water
Cercaria penetrated and attached to the skin
Schistosomules enters peripheral circulation of the blood
Flows to the systemic circulation
Distributed to the liver via hepatic artery
Distributed t the spleen via spleen via splenic artery
Lodges in the sinusoids (small vessels in the liver)
Some schistosomules trapped in the spleen
Schistosomules will grow and mature
Phagocytic cells activation (Macrophage)
Some schistosomes travel to

intestinal vein and
undergone sexual
reproduction
Inflammation and
destruction of the
hepatocytes
Inflammation of the spleen
Splenomegaly
Page 152
Egg released by
schistosomes to the
intestine (later on
expelled with the feces)
Liver tissue necrosis
Inability to synthesize
albumin
Decrease albumin
formation
Decrease osmotic
pressure
Contributes to the fluid
shifting
Accumulation of fluid in
the third space
Hepatic abscess
formation and increase
collagen in falciform
ligaments
Fibrotic regeneration of
hepatocytes
Signs and Symptoms:
Risk for bleeding

Clotting factor affected (coagulation
factor) APPT: 61.4 secs
Distended abdomen
Palpable mass (Left upper quadrant)
Pain
Irreverversible scarring
formation
Liver cirrhosis
Signs and Symptoms:

Early
Anorexia
Nausea & vomiting
Diarrhea
Abdominal pain
Compression of portal
veins
Intrahepatic obstruction
occurs
Late
Result to backing up blood

to the liver and spleen
Splanchnic artery dilated

to compensate increasing
pressure
Ascites
Circulatory of blood to the
kidney will decrease
Portal Hypertension
Pleural Effusion
Limited thoracic
expansion
Lethargy
Jaundice
Anemia
Portal hypertension
Edema
Increased venous
pressure
Page 153
Causes diaphragmatic
defects
Negative intrathoracic
pressure draws ascitic
fluid into the pleural
space
Pleural Effusion
Stimulates of ADH by posterior pituitary

gland to change osmolality to blood
Decrease urine
output
Increased sodium and water

retention by the kidney
Edema
Venous valve
damage
Blood backflows
Chronic Venous
Insufficiency
Signs and Symptoms:

-
Edema
Ankle Swells
Calve feels tight
Associated with
Varicose veins
Page 154

Schistosomiasis Leads to Liver Cirrhosis

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Schistosomiasis Leads to Liver Cirrhosis

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ABSTRACT

Date of Interview: August 01, 2013

Age: 68 years old

Primary informant: Patient R.P

Birthday: September 09, 1944

Secondary Informant: Relatives

Birthplace: Tabon-Tabon Northern Leyte

Other Sources: Patients Chart and Lab

Address: GMA, Cavite

Date Admitted: July 21, 2013

Time Admitted; 07:15 am

Civil Status: Married

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY:

OBSTETRIC- GYNECOLOGICAL HISTORY:

HEREDO- FAMILIAL HISTORY:

Erik Eriksons Psychosocial Development

Stage 2. Early Childhood: 18 Months to 3 Years

This push for autonomy is enhanced by muscular maturation as toddlers try to

Stage 4. School Age: 6 to 12 Years

Stage 6. Young Adulthood: 18 to 35

GORDONS FUNCTIONAL HEALTH PATTERN:

1) HEALTH PERCEPTION- HEALTH MANAGEMENT PATTERN

2) NUTRITIONAL- METABOLIC PATTERN

240 ml water 200 ml water

Days Of The Week

Katz Index of Independence in Activities of Daily Living

With supervision, direction or personal

personal assistance needed

assistance or total care

5) SLEEP- REST PATTERN

Not well Not

COMPREHENSIVE PHYSICAL EXAMINATION

A. Vital Signs: (10:00pm to 6:00am shift)

August 02, 2013

ABDOMINAL GIRTH MEASUREMENT:

July 21, 2013

July 23, 2013

July 26, 2013

July 30, 2013

August 02, 2013

Patient RP who is a female, age of 68 years with a height of 52 and weight

Ht: 5 ft= 60 inches

INPUT AND OUTPUT MONITORING: (10pm-6am shift)

Client RP (68 y/o)

> Endomorph body

According to Webber &

>Varies with lifestyle

3rd edition that the

shorter built, round

> Generally soft and

shorter build with

thin arms and legs.

Posture and Gait

>looks weak and

According to Webber &

>Clean, neat and

According to Webber &

> with unsoiled

Body and Breath

> No unusual body

>No body and breath