Professional Documents
Culture Documents
Introduction
Mr. Mickey (not his real name) is a 52 years old married male, Filipino
who was born on February 16, 1954 in Angeles City. He is the eldest among
the eight siblings of Disney family (not their real family name) and has 5
unmarried sisters. He, together with Mrs. Minnie (not her wife’s real name)
and their eight children, currently resides near main road in Robinson’s mall,
Angeles City, Pampanga. He is religiously affiliated as a Roman Catholic. He is
presently working as a Barangay Tanod. He was admitted at Ospital Ning
Angeles (ONA) on April 27, 2008 because of hypertension and Diabetes
Mellitus type 2.
- Normal
- With diabetes
- With hypertension
Two years ago, Mr. Mickey went to the clinic and consulted the Doctor.
He complained of pain and loss of hearing in his left ear. The Doctor
prescribed him antibiotic (eardrops) and advised him to wear hearing aid.
One year after, two ears became affected. In January 2008 when he went to
health center, his blood pressure was increased, it was 140/90. Last April 23,
morning, when he sought medical help in the OPD of ONA. During that time,
he has no appetite in eating and his furuncle was still small. The Doctor
prescribed him to take Amoxicillin, Appebon with Iron and Cetrizine
Dihydrochloride. On the night of April 27, 2008, he was admitted to the
hospital for the first time with admitting diagnosis of intractable vomiting,
Electrolyte imbalance, Anemia, furuncle, Diabetes Mellitus type 2,
Hypertension 2.
The following doctor’s orders were given: (lifted from the Mr. Mickey’s
chart):
Initial V/S were, T-36.0 PR-84 RR-21 BP-170/100
Pls admit to medical ward
Secure consent from admin and management
NPO temporarily except meds
IVF PNSS 1L x 30 gtts/min
Dxtic: CBC-done RBC-done
U/A-done
Na, K-done
Creatinine-Requested
BUN
FBS
Lipid profile
CXR-PA
12 lead ECG
Tx: Ceftriaxone 1g/IV q 12
Metformin 500mg 1 tab BID
Plasil tab TID PRN for Vomiting
FeSO4 tab BID
Monitor VS q4
Refer accordingly
Amlodipine (Lopicard) 5g I tab OD
E. Physical Examination
Vital Signs:
T- 37°C RR- 17 cpm
PR- 74 bpm BP- 150/90 mmHg
1. General Appearance
a. Body built is ectomorphic
b. Presence of halitosis for the breath odor
c. Attitude is cooperative
d. Affect or mood is appropriate for the situation
2. Skin
a. There is good skin turgor
b. Skin is dry, pale on the palms and soles of the feet, with scars on lower
extremities
c. Absence of facial and periorbital edema
d. (+) 3-cm-diameter furuncle on left upper arm, draining purulent
secretion
3. Head
a. Skull is round in shape and has normal contour, with no palpated
depressions
b. Hair is thick, with fine strands; scalp is excessively oily with no masses
palpated
c. Facial features are symmetrical with no noted abnormalities
4. Eyes
a. Pupils are equally round and reactive to light and accommodation
b. Palpebral conjunctiva are pale
c. Eyebrows are symmetrically aligned, hair is thick, evenly distributed;
skin is intact
d. Eyelashes are equally distributed and curled slightly outward
e. No discharges present
f. Absence of periorbital edema
g. Cornea is transparent, smooth and shiny
h. Details of the iris are visible, color brown
i. Sclera appears white
5. Ears
a. Ears are symmetrical and aligned with the outer canthus of the eye,
with no lesions noted.
b. Color is same as facial skin
c. Ears have no foul smelling discharges, with impacted cerumen on the
middle ear
d. Pinna recoils after being folded
6. Nose
a. Nose has no discharge, no lesions, not occluded & with patent airway
b. Color is same as facial skin
8. Neck
a. Color is slightly darker than facial skin
b. Absence of enlarged thyroid area
c. Absence of jugular vein distention
d. Movement is coordinated and smooth
9. Chest
a. Breasts are not enlarged, with no lesions
b. No masses assessed upon palpation
10. Cardiovascular
a. Absence of chest pain and murmurs
b. Normal heart rhythm, PR = 74 bpm
11. Respiratory
a. Chest is symmetric; anteroposterior to transverse diameter ratio is 1:2
b. Chest expansions are symmetrical
c. Absence of rales on both lung fields
12. Gastrointestinal
a. Presence of bowel sounds 5/min, presence of flatus
b. Absence of bowel movement
c. Absence of organomegaly
13. Extremities
a. Upper- symmetrical, absence of edema; capillary refill >2 seconds; (+)
3-cm-diameter furuncle on left upper arm, draining purulent secretion
b. Lower- symmetrical, absence of edema
14. Urogenital
a. Urine output: approximately 30cc per hour, amber yellow in color,
cloudy
b. Genitals- no foul smelling discharges
Neurological Assessment
Cranial Nerve Normal Findings Actual Findings
1. Olfactory Client must be able to Client was able to
Type: Sensory identify the scent of identify the scent of
Fxn: Sense of smell perfume when allowed to perfume when allowed
smell it. to smell it.
2. Optic Client must see the pen or Client was able to see
Type: Sensory penlight clearly from a the pen or penlight
Fxn: Sense of vision and certain distance; must be from a certain distance,
visual fields able to read newspaper but was not able to
print. read newspaper print.
Client needs to wear
eyeglasses for better
vision.
3. Oculomotor Eyes must follow the The client was able to
Type: Motor direction of the movement follow the movement of
Fxn: Pupil constriction and of the penlight; the penlight through
raising of eyelid In lightly dimmed her eyes.
environment, the pupils of
the eyes will dilate but
upon the introduction of
light, pupils will constrict.
4. Trochlear The eye must follow the The client was able to
Type: Motor movement of a pen in follow the pen with her
Fxn: Downward inward different directions with eyes without moving
eye movement coordination. her head.
5. Trigeminal The client must elicit The client elicited
Type: Sensory and Motor blinking reflex upon blinking reflex upon
Fxn: Jaw movements, touching the cornea with touching the cornea.
chewing and mastication the use of cotton.
(Corneal Sensitivity Test)
6. Abducens Client must follow the The client was able to
Type: Motor index finger of the follow the index finger
Fxn: Lateral movements examiner and its of the examiner and its
of the eyes movements. movements.
7. Facial Client must be able to The client was able to
Type: Motor and Sensory raise eyebrows, show raise eyebrows, show
Fxn: Movement of teeth, frown, smile, pout teeth frown, smile, pout
muscles of the face and and puff out cheeks. Also, and puff out cheeks.
sense of taste on the the client must also be Also, the client was not
anterior two-thirds of the able to distinguish sweet, able to distinguish
tongue sour, and salty foods. sweet, sour, and salty
foods. Test not
performed due to
anorexia and vomiting.
8. Acoustic Client must be able to The client was not able
(Vestibulocochlear) hear a snap of the finger. to hear the snap of the
Type: Sensory finger.
Fxn: Sense of hearing
9. Glossopharyngeal The patient must be able The client was not able
Type: Motor and Sensory to swallow foods that were to taste the food. Test
Fxn: Pharyngeal chewed and taste bitter not performed due to
movements and foods. Also, the gag reflex anorexia and vomiting.
swallowing should be stimulated.
Sense of taste on the
posterior one-third of the
tongue
10. Vagus The patient must be able The client was able to
Type: Motor to speak clearly. speak clearly.
Fxn: Swallowing and
speaking
11. Accessory The patient must able to The client was able to
Type: Motor elevate her shoulders elevate her shoulders
Fxn: Movement of against resistance. against resistance.
shoulder muscles (Sternocleidomastoid and
Trapezius muscles function
test)
12. Hypoglossal The patient must able to The patient was able to
Type: Motor move her tongue side to move her tongue side
Fxn: Movement of tongue side and protrude her to side and protrude
and strength of the tongue. her tongue.
tongue
Diagnostic and Laboratory Procedures
CLINICAL
CHEMISTRY
FBS/RBS Date Ordered: A test that is 137 (70-105mg/dl) A fasting blood
04-27-08 routinely done in all sugar level of
clients with possible 126 mg/dL or
Date Results In: cardiovascular higher is
04-27-08 disorders to determine consistent with
blood glucose levels. either type 1 or
type 2 diabetes.
Patient’s FBS is
exceeds the
normal limits
indicating the
patient has
diabetes.
113.4 135 – 150 mEq/L
• SODIUM The sodium
- To monitor the electrolyte level
electrolytes and check is below normal
for imbalances any range. It
imbalance in the fluid indicates that the
and electrolytes. patient has
Sodium plays a major hyponatremia.
role in homeostasis in
a variety of ways
including the renal
retention and excretion
of water.
3.8 3.5 – 5.2 mEq/L
• POTASSIUM The potassium
- While, Potassium electrolyte level
is checked in order to is within normal
assess a known and range.
suspected disorder
associated with renal
disease, glucose
metabolism, trauma or
burns.
Normally
Pus negative.
cells/HPF: Leukocytes are
3-6 the white blood
cells (or pus
cells). This looks
for white blood
cells by reacting
with an enzyme
in the white cells.
White blood cells
in the urine
suggests a
urinary tract
infection.
Normally there is
RBC/HPF: no blood in the
5-8 urine. Blood can
indicate an
infection, kidney
stones, trauma,
or bleeding from
a bladder or
kidney tumor.
The technician
may indicate
whether it is
hemolyzed
(dissolved blood)
or non-
hemolyzed
(intact red blood
cells). Rarely,
muscle injury can
cause myoglobin
to appear in the
urine which also
causes the
3.2-5.0 g/dl reagent pad to
falsely indicate
blood.
Albumin:
Positive (3+) Albumin is
slightly below
normal. Lower
levels indicate
Sugar: infection, kidney
(Negative) disease, and
inadequate iron
HEMATOLOGY: intake.
93
HDL C Date Results In: -It has the lowest 33.2 M=30-75 The HDL is within
04-29-08 concentration of normal limit
cholesterol and which indicates a
transport endogenous healthy
cholesterol to body metabolic
cells. system.
SGOT/AST
- used o determine any The SGOT level is
condition involving within normal
necrosis of limit.
hepatocytes,
myocardial cells, or
skeletal muscle cells.
NURSING RESPONSIBILITIES
.
BLOOD TESTING
Before the Procedure:
a. Explain the procedure to the client in order to gain cooperation.
b. Inform the client that she may feel pain during needle insertion.
c. Prepare the materials necessary for the test.
d. Practice aseptic technique by cleaning the area of blood extraction with alcohol in an outward circular
motion.
URINALYSIS
Before the Procedure:
a. Explain the procedure to the client in order to gain her
b. Inform the client that there is no need for NPO.
c. Educate the patient on the proper way of collecting urine (clean catch midstream specimen).
d. Prepare the container for the urine.
The components of the urinary system are: two kidneys, two ureters, urinary
bladder and urethra. The kidneys process blood and form urine by filtering
blood plasma (glomerular filtration) and returning most of the water and
solutes to the bloodstream (tubular reabsorption). The remaining water and
solutes constitute the urine (secretion) which passes through ureters, are
stored in the urinary bladder, then excreted from the body through the
urethra.
The main functions of the kidneys are to regulate blood volume and
composition, help regulate blood pressure, synthesize glucose, release
erythropoietin, participate in vitamin D synthesis and excrete wastes in the
urine.
The nephron is functional unit of the kidney. The parts of the nephron are:
renal corpuscle- where blood plasma is filtered and renal tubule- into which
filtered fluid passes. The renal corpusclelies within the renal cortex and
consists of two components: glomerulus and the glomerular (Bowman's)
capsule- a double-walled epithelial cup that surrounds the glomerulus. The
parts of a renal tubule are: proximal convoluted tubule- lies within the renal
cortex, loop of Henle (nephron loop)- extends into the renal medulla, distal
convoluted tubule- lies within the renal cortex, distal convoluted tubules of
several nephrons empty into a single collecting duct.
Malfunctioning of one of the small portions that make up the nephron will
cause impairment in the functioning of the kidneys. Glomerular filtration rate
may decrease, and as a result, large molecules are drained out and secreted
in the urine. Examples of which are RBC and protein molecules. Likewise,
accumulation of sodium causes formation of crystals, which, when dislodged,
may either block passageways of urine, or be excreted and seen as crystals
in the urine.
The major glands of the endocrine system are the pituitary, thyroid,
parathyroids, adrenals, pineal body, thymus, and the reproductive organs
(ovaries and testes). The pancreas is also a part of this system; it has a role
in hormone production as well as in digestion. A gland is a group of cells that
produces and secretes chemicals. A gland selects and removes materials
from the blood, processes them, and secretes the finished chemical product
for use somewhere in the body. The endocrine gland cells release a hormone
into the blood stream for distribution throughout the entire body. These
hormones act as chemical messengers and can alter the activity of many
organs at once.
The pancreatic duct (also called the duct of Wirsung) runs the length of
the pancreas and empties into the second part of the duodenum at the
ampulla of Vater. The common bile duct usually joins the pancreatic duct at or
near this point. Many people also have a small accessory duct, the duct of
Santorini, which extends from the main duct more upstream (towards the tail)
to the duodenum, joining it more proximal than the ampulla of Vater.
Name of % of islet
Endocrine product Representative function
cells cells
beta cells Insulin and Amylin 50-80% lower blood sugar
alpha cells Glucagon 15-20% raise blood sugar
delta cells Somatostatin 3-10% inhibit endocrine pancreas
PP cells Pancreatic polypeptide 1% inhibit exocrine pancreas
There are two main types of exocrine pancreatic cells, responsible for
two main classes of secretions:
Venous ↑Fluid
Constriction Volume
Structural Functional
hypertrophy Constriction
Decreased organ perfusion
HYPERGLYCEMIA
Polydipsia
↓ tubular reabsorption
↓ Iron absorption
at the intestines
↓ Iron available to
the tissues (red
blood cells)
Decrease
circulating red
blood cell along
with its hemoglobin Enlarged
Spleen
Decrease in
hemoglobin
Development
of wound
↑Biochemical
mediation through ↑
blood flow
Enlargement of wound,
turning red, firm and swollen
Development of a single,
small, firm, swollen,
red/pink, tender nodule
(furuncle) draining
purulent secretions
PATHOPHYSIOLOGY (patient-centered)
Non-modifiable Factors Modifiable Factors
- Age – 54 y/o - Excess dietary sodium
- Gender – male - Lack of exercise
- Race – brown race - Stress
- Family history of - Diabetes
hypertension
Venous ↑Fluid
Functional Constriction Constriction Volume
↑Peripheral Resistance
↑Contractility ↑Preload
Modifiable Factors
↓Perfusion to the pancreas - Diabetes mellitus;
Non-modifiable Factors
- Age – 54 years old - active electrolyte loss from
vomiting; current low Na intake
Impairment in the
functioning of the pancreas
↓Renal perfusion/ ineffective blood supply to the
Impaired insulin secretion kidneys
Hyperglycemia
Non-modifiable Factors Modifiable Factors
- Age - Older than 40 - History of previous impaired Renal
years fasting glucose tissue
- Family history of DM - Hypertension (>140/90 mm Hg); hypoxia
dyslipidemia (HDL level <40
mg/dl)
- Stress: hormones at times of
Impairment BUN: 93
in mg/dl –
↑Blood Blood Sugar Level Glucose uptake ↓Energy renal April
Osmolarity exceeds renal by the cells Level functioning 29,
threshold : 137 2008
mg/dl: April 27,
2008, 117.5mg/dl:
Fluid shifting April 28, 2008 Cellular Body malaise,
from starvation Fatigue: April 27-30,
intracellular to 2008
extracellular
Excretion of excess Hunger due to the ↓ tubular
glucose in the urine stimulation of Satiety reabsorption
Center of Hypothalamus
Intracellular
dehydration /
Excretion of
volume
albumin
depletion Glucose attracts water Polyphagia
↑ Sodium Albuminuria
↑Urine Output: excretion : +3 : U/A-
polyuria April
Thirst Sluggish blood Anorexia: ↓ serum Na
sensation April 23-30, levels: 113.4 27, 2008
due to the Modifiable Factor: 2008 mEq/l: April
stimulatio ↓ Iron intake & low 27, 2008
n of Thirst Depletion of iron stores
socio-economic status
Center of at the bone marrow to
↓ Iron available to
hypotha- compensate
↓ Iron for
absorption
the tissues (red
lamus decreased
atblood availability
the intestines
cells)
↓organ Delayed
perfusio biochemical ↓ sodium
n mediation intake
Greater proportion of
Dry ↓ Iron absorption water in the blood
skin: Modifiable at the intestines compared to sodium:
April Factor:
Hemodilution: Hct –
Polydipsi 28- -Insect bite
0.29: April 27, 2008
a 30,
200
↓ Iron available to
8
the tissues (red
Development
blood cells) Fluid shifting from ↓cerebral
of wound
Intravascular to perfusion/
↓
↓ interstitial intracellular esp. in ineffective
interstitial the brain which is blood supply
Depletion of iron stores fluid
fluid sensitive to serum to the brain
↑Biochemic at the bone marrow to volume Na changes
al mediation volume
compensate for
through ↑ decreased availability
blood flow
Dry skin:
April 28-30,
Alteration in brain
2008
functioning
Enlargement of wound, Impaired
turning red, firm and swollen hemoglobin and red
blood cell synthesis
↓impulse Lethargy:
transmission to April 29,
Development of a single,
Decrease the muscles 2008
red, swollen firm furuncle
(approx. 3cm diameter, circulating red
located at the left upper blood cell along
arm) draining purulent with its hemoglobin
secretions: Weakness: April
April 27-30, 2008 27-30, 2008
Decrease in
hemoglobin: 95
Increased need
g/l: April 27, 2008
for the heart to
Decreased pump more of
Shortness
Pallor: Fatigue -
oxyen blood
breath,to meet
April 28- April 27-30,
supply to the oxygen
tachypneademand
b. Synthesis of the Disease
b.1 Hypertension
b.1.1 Definition
Obesity Pills)
Steroids
Diabetes
Nonsteroidal anti-inflammatory
Kidney disease
drugs
Hormonal disorders
Decongestants
Porphyria
Diet pills
Antidepressants
Type 2 diabetes often goes undetected for long periods of time, since
symptoms are usually not pronounced. Insulin is produced, but it is not
enough, or it does not work properly to transport glucose through the
receptor cells. Type 2 diabetics can often be controlled with a carefully
planned diet, an exercise program, oral medication, or insulin, used as
necessary.Uncontrolled Type 2 diabetes results in hyperglycemia. Since
symptoms have an insidious onset, the patient may not recognize that there
is any difficulty. Left uncontrolled for a long period of time, Type 2 diabetics
develop more serious symptoms such as severe hyperglycemia, dehydration,
confusion, and shock. This is called “hyperglycemic hyperosmolar non-ketotic
coma.” These symptoms are most common in the elderly population and
people suffering from illness or infection.
Non-modifiable Factors:
Age - Older than 40 years
Family history of type 2 diabetes
Hispanic, Native American, African American, Asian American, or Pacific
Islander descent, Asian
Modifiable Factors:
History of previous impaired glucose tolerance (IGT) or impaired fasting
glucose (IFG) – FBS:137 mg/dl: April 27, 2008; 117.5mg/dl: April 28, 2008
Obesity - Weight >20% of desirable body weight (true for approximately
90% of patients with type 2 diabetes)
Hypertension (>140/90 mm Hg)(↑BP: 170/100 mmHg: April 27, 2008;
150/90mmHg: April 28, 2008, 140/100 mmHg: April 29, 2008), or
dyslipidemia (high-density lipoprotein [HDL] cholesterol level <40 mg/dL
or triglyceride level >150 mg/dL)
History of GDM or of delivering a baby with a birth weight of > 9 lbs
Polycystic ovarian syndrome (which results in insulin resistance)
Viruses: certain viruses may destroy beta cells
Faulty Immune System: multiple factors may cause the immune system to
destroy beta cells, such as infection
Physical Trauma: injury or trauma may destroy the ability of the pancreas
to produce insulin
Drugs: drugs used for other conditions could cause the development of
diabetes
Stress: hormones at times of stress may block the effectiveness of insulin
Pregnancy: hormones produced during pregnancy can block the
effectiveness of insulin
Non-modifiable Factors:
Age. Low blood sodium is more common in older adults. This is due to
age-related changes and increased prevalence of chronic disease that
may impair the body's normal sodium balance.
Sex. Hyponatremia is more common in women than in men.
Non-modifiable Factors:
Serum sodium level that is below normal (<135 mEq/l): 113.4 meQ/l:April
27
Neurologic manifestations such as headache, lethargy (April 29, 2008),
confusion, apprehension – due to fluid shifting from intravascular to
intracellular space in an attempt to raise the proportion of Na with water
Decreased BP, orthostatic hypotension – due to decreased vascular
volume secondary to water and sodium loss
Tachycardia – compensatory response which is a direct result of triggering
sympathetic catecholamine
Sympathetic responses of the heart – due to stimulation of
chemoreceptors on the aortic and carotid bodies
Crackles in the lungs – due to fluid shifting to the pulmonary alveoli
secondary to increased pressure of circulating fluids in the pulmonary
capillaries
Greater blood volume (water component>serum Na) – Hct of 0.29: April
27
Tachypnea (April 27, 2008), dyspnea, othopnea, shortness of breath – fluid
accumulation in the alveoli alters oxygen-carbon dioxide exchange
transport
Nausea, vomiting, abdominal cramping, hyperactive bowel sounds – due
to fluid shifting from intravascular to intracellular space causing an urge to
expel excess water
Dry skin (April 28-30, 2008), tongue and mucous membranes – due to
decrease in interstitial fluid caused by sodium deficit in the blood
The term anemiais used for a group of conditions in which the number
of red blood cells in the blood is lower than normal, or the red blood cells do
not have enough hemoglobin. Hemoglobin—an iron-rich protein that gives the
red color to blood—carries the oxygen from the lungs to the rest of the body.
In people with anemia, the blood does not carry enough oxygen to the rest of
the body. Red blood cells also remove carbon dioxide, a waste product, from
cells and carry it to the lungs to be exhaled.
There are many types of anemia. The three major causes of anemia
are blood loss, decreased production of red blood cells, or increased
destruction of red blood cells. White blood cells and platelets are the two
other kinds of blood cells. White blood cells help fight infection. Platelets help
blood to clot. In some kinds of anemia, there are low amounts of all three
types of blood cells. The most common symptom of all types of anemia is
feeling tired because the body is not receiving enough oxygen.
In iron-deficiency anemia, the body does not have enough iron to form
hemoglobin, which means there is not enough hemoglobin to carry oxygen to
the whole body. The body gets its iron from food. The main foods that contain
iron are meat and shellfish as well as iron-fortified foods. A steady supply of
iron is needed to form hemoglobin and healthy red blood cells.
The four main causes of IDA include: Blood loss, either from disease or
injury, Not getting enough iron in the diet, Not being able to absorb the iron
in the diet. Iron-deficiency anemia also can develop when the body needs
higher levels of iron, such as during pregnancy
Non-modifiable Factors:
Sex - Women - Women who lose a lot of blood during their monthly
periods are at higher risk of developing iron-deficiency anemia. About 1 in
5 women of childbearing age has iron-deficiency anemia. - Pregnant
women need twice as much iron in their diet than women who are not
pregnant. If a pregnant woman doesn't get enough iron for herself and the
growing baby, she can develop iron-deficiency anemia. About half of all
pregnant women have this type of anemia.
Age - Young Children - Infants and toddlers 6-24 months of age need a lot
of iron to grow and develop. Premature and low-birth-weight babies are at
even greater risk for iron-deficiency anemia because they don't have as
much iron stored in their bodies.
Modifiable Factors:
Fatigue (April 27-30, 2008) is caused by having too few red blood cells to
carry oxygen to the body. This lack of oxygen in the body can cause
people to feel weak or dizzy, have a headache, or even pass out when
changing position (for example, standing up).
Shortness of breath, tachypnea (April 27, 2008) and chest pain - Since the
heart must work harder to move the reduced amount of oxygen, signs and
symptoms may include shortness of breath and chest pain. This can lead
to a fast or irregular heartbeat or a heart murmur.
Pallor (April 28-30, 2008) - In anemia, the red blood cells don't have
enough hemoglobin. Common signs of lack of hemoglobin include pale
skin, tongue, gums, and nail beds.
Cold hands and feet as well as brittle nails – due to decrease oxygenation
and circulating blood that provides heat to the body
Swelling or soreness of the tongue and cracks in the sides of the mouth –
due to decrease oxygen supply to the integument causing easy bruising
An enlarged spleen – due to increased number of dead RBC
Frequent infections – due to compromised immune system and decreased
perfusion to any affected part causing delay in biochemical mediation
Some of the signs and symptoms of iron-deficiency anemia are related to
its causes, such as blood loss. Blood loss is most often seen with very
heavy or long lasting menstrual bleeding or vaginal bleeding in women
after menopause. Other signs of internal bleeding are bright red blood in
the stool or black, tarry-looking stools.
Decreased hemoglobin on lab exams – 95g/l: April 27, 2008
b.5 Furuncle
b.5.1 Definition
Nursing Responsibilities:
Prior to:
1. Prepare the equipment
2. Verify doctor’s order
3. Use strict aseptic technique
4. Explain the procedure to the S0 and give formation about the purpose of IVF to be inserted
5. Identify the client
6. Assess vital signs for baseline data
7. Assess skin turgor, allergy to tape
8. Check the status or veins to determine appropriate venipuncture site
During:
9. Use the smallest gauge needle possible.
10.Check for patency of the tubing
11.Spike the solution container
12.Cleanse the fluid to be given, make sure it is the same with the prescribed fluid.
13.Partially fill the drip chamber gently with solution.
14.Select a suitable vein for venipuncture
15.Dilate the vein
16.Put on clean gloves and clean the venipuncture site.
After:
17.Label the IVF (name, date started, number)
18.Ensure appropriate infusion flow.
19.Adjust the rate of fluids appropriate to the needs f the patient as ordered. If there is any question with the flow
rate ordered, check with the physician who gave the order.
20.Monitor IV flow and patient’s response
21.Monitor patient for evidence of IV infiltrations
22.Check for presence of air in the tubing, if air is present, remove immediately
23.Check for the patency of the line always.
24.Regulate and monitor the IV rate of fluid.
25.Document relevant data.
b. Drugs
Name of Drugs: Date Route Indication(s) or Client’s Nursing Responsibilities
ordered, Dosage Purpose(s) Response
performed and to the
, Frequency Treatment
Generic Name: D.O. 1g/IV q 12 Treatment of: No adverse 1.Assess for infection (vital signs;
ceftriaxone 04-27-08 Skin and skin reaction appearance of wound, sputum,
structure with urine, and stool; WBC) at
Brand Name: D.P. infections, bone Ceftriaxone beginning of and throughout
Rocephin 04-27-08 and joint was noted. therapy.
04-28-08 infections,
04-29-08 urinary and 2.IV: Monitor injection site
04-30-08 gynecologic frequently for phlebitis (pain,
infections redness, swelling)
including
gonorrhea, resp. 3.Advise patient to report signs of
tract infections, superinfection (furry overgrowth
intra-abdominal on the tongue, loose or foul
inmfections, smelling stools) and allergy.
septicemia,
meningitis.
Generic Name: D.O. 500mg 1 Management of The 1. Observe for signs and
Metformin 04-27-08 tab BID type 2 diabetes patient’s symptoms of hypoglycemic
mellitus; may be blood reactions (abdominal pain,
Brand Name: D.P. used with diet, glucose sweating, hunger,
Fortamet 04-28-08 insulin, or decreased weakness,dizziness,
04-29-08 sulfonylurea oral from 137 to h/a,tremor,tachycardia,anxi
04-30-08 hypoglycemics. 88 on April ety) when combined with
28, 2008 oral sulfonylureas.
AEB lab 2. PO: Administer metformin
results with meals to minimize GI
(FBS/RBS). effects.
3. Explain to explain that
metformin helps control
hyperglycemia but does
not cure diabetes.
Treatment is usually long
term.
Generic Name: D.O. 1 tab TID Disturbances of No adverse 1. Assess pt. for nausea,
Metoclopramide 04-27-08 for GI motility. reaction vomiting, abdominal
Vomiting Nausea & with Plasil distention, and bowel
Brand Name: D.P. vomiting of was noted. sounds before and after
Plasil 04-28-08 central & administration.
04-29-08 peripheral origin 2. PO: Administer doses
04-30-08 associated w/ 30min. before meals and at
surgery, bedtime.
metabolic 3. Advise pt. to avoid
diseases, concurrent use of alcohol
infectious & and other CNS depressants
drug-induced while taking this
diseases. medication.
Facilitate small
bowel intubation
& radiological
procedures of
GIT
Generic Name: D.O. 1 tab BID Simple Fe The patient 1. Assess nutritional status
FeSO4 04-27-08 deficiency & Fe- responded and dietary history to
deficiency well with determine possible cause
Brand Name: D.P. anemia. Patient the of anemia and need for
Feosol 04-28-08 intolerant to medication patient teaching.
04-29-08 conventional Fe and no 2. Discontinue oral iron
04-30-08 & those prone to adverse preparations prior to
GI upsets reaction parenteral administration.
was noted. 3. Advise patient that stools
may become dark green or
black and that this change
is harmless.
Generic Name: D.O. 5g 1 tab Hypertension, The 1. Monitor BP and pulse
Amlodipine 04-27-08 OD angina, patient’s before therapy, during dose
myocardial blood titration, and periodically
Brand Name: D.P. ischemia. pressure during therapy.
Norvasc 04-28-08 Reduce the risk decreased 2. PO: May be administered
04-29-08 of coronary from without regard to meals.
04-30-08 revascularizatio 170/100 to 3. Advise pt. to take
n. 150/100 on medication as directed,
April 28, even if feeling well.
2008.
Generic Name: D.O. 300 Treatment of No adverse 1. Assess for infection (vital
Clindamycin 04-28-08 mg/tab q serious reaction signs; appearance of
12 anaerobic with wound, sputum, urine, and
Brand Name: D.P. infections esp Clindamyci stool; WBC) at beginning of
Clindal 04-28-08 those caused by n was and during therapy.
04-29-08 Bacteroides noted. 2. PO: administer with a full
04-30-08 fragilis. glass of water. May be
Alternative to given with meals. Do not
penicillin in refrigerate.
some severe 3. Instruct pt. to notify HCP
Staph & Strep immediately if diarrhea,
infections, abdominal cramping, fever,
including Staph or bloody stools occur and
osteomyelitis. not to treat with
antidiarrheals without
consulting HCP.
Generic Name: D.O. 1 cap OD Underwt due to The 1. May be taken with or
Pizotifen 04-29-08 lack of appetite patient’s without food (May be taken
associated w/ appetite w/ meals to reduce GI
Brand Name: D.P. vit B deficiency was discomfort.).
Mosegor Vita 04-30-08 secondary to enhanced 2. Timed-release tablets and
cap impaired dietary as capsules should be
intake or verbalized swallowed whole, without
absorption; by himself. crushing, breaking or
nervous chewing.
disorders in 3. Emphasize the importance
puberty of follow-up examinations
(anorexia to evaluate progress.
nervosa) old
age when
prevention of
deficiency of B-
group vit is
indicated.
Nursing Responsibilities:
Prior:
1. Check the written medication order for completeness. It should include the drug name, dosage, frequency,
and duration of the therapy.
2. Check if IV in.
3. Check to see if there are any special circumstances surrounding administration of the dose to the patient.
4. Be certain that you know the expected action, safe dosage range, special instructions for administration and
adverse effects associated with drug orders.
5. Prepare the necessary equipment.
6. Wash your hands.
7. Check the label on the medications three times before administering any drug.
8. Prepare the dosage as ordered.
9. Explain the procedure to the patient. The action of the drug and its side effects.
During:
10.Identify the patient.
11.Identify if the patient expresses any doubt about the medication; always recheck the order, drug label and
dosage on the medication card.
12.For oral meds do special regulation and precaution to avoid or prevent aspiration.
After:
13.Following administration, be certain that the patient is comfortable, then immediately record the procedure.
14.Maintain patient’s safety
15.Monitor patient for side effects
16.Instruct the patient to report signs of superinfection and allergy.
17.Inspect IV insertion sites for sign of phlebitis.
18. Document and assess the patient's reaction to the given drug
c. Diet
Date General Indications Specific Client’s
Type of Diet ordered, Description or Purposes foods taken response
date and
performed reaction to
the diet
D.O. The low fat Indicated for Low salt and The client
complied
04-27-08 and salt diet bed patients low fat
with the
is designed whose foods. prescribed
diet.
D.P. to limit the condition
Low Fat, Low 04-27-08 total requires
Salt Diet 04-28-08 amount of modified
04-29-08 fat, salt and diet in order
04-30-08 cholesterol to prevent
in the diet further
to reduce aggravation
serum lipid of condition.
levels and
avoid
excessive
sodium
retention
Nursing Responsibilities:
Prior to:
1. Check the doctor’s order for the type of diet prescribed
2. Explain the importance of the diet given.
3. Explain the importance of compliance to the diet given.
4. Inform dietary department on the patient’s diet
During:
5. Give appropriate foods to the patient.
6. Enumerate the foods that the patient may or may not take.
7. Emphasize strict compliance to diet
8. Reiterate diet frequently
After:
9. Document the patient’s tolerance to the diet given.
April 28, 2008
7am – 7pm shift
S>Ø
O>received supine on bed; asleep; with an ongoing IVF #1 0.9 NaCl 1L @ 550
ml level, regulated @ 30gtts/min, infusing well on right hand; appears weak;
with 3cm-diameter open wound on left upper arm, with erythematous,
inflamed surroundings, draining purulent secretions; with dry, scaly skin on
left upper arm; with difficulty hearing; (+) pallor; with cold, clammy skin;
capillary refill in 3 seconds; with VS taken and recorded as follows: T=37°C,
PR=74bpm, RR=17cpm, BP=150/90mmHg.
I>Established rapport
>Assessed patient’s condition
>VS taken and recorded
>Assessed character of wound and wound drainage
>Reviewed laboratory data for any deviations from the normal range
>Assessed for capillary refill through blanch test
>Assisted in position changes
>Maintained aseptic technique during wound care
>Advised to inform health care provider should vomiting occur
>Instructed to dangle feet first before standing and walking
>Emphasized the importance of hand washing technique before and after
would cleaning
>Instructed SO on the proper and aseptic method of doing wound cleaning
>Encouraged rest periods
>Encouraged to avoid sweet, fatty and salty foods
>Seen on rounds by Dr. Delmas @ 7am with orders made and carried out
- FBS, lipid profile SGPT, SGOT, BUN, Creatinine – requested
- daily wound cleaning – done
- IVF to FF D5LRS 1 liter x 30gtts
- start Clindamycin 300mg/tab q 12 hrs – prescribed
- refer
>Monitored and regulated IVF as ordered
>Due meds given as prescribed
>Needs attended
>Refer accordingly
>Endorsed
S>Ø
S>Ø
O>received sitting on bed; awake, conscious and coherent; with an ongoing
IVF #5 D5LRS 1L @ 900 ml level, regulated @ 30gtts/min, infusing well on
right hand; appears weak; (+) pallor; with purulent secretion draining from
inflamed 3-cm-diameter furuncle @ left upper arm; with dry, scaly skin; with
vomiting 2x, vomitus is thick in consistency, yellowish color, approximately
100cc within the shift; with difficulty hearing; with pale conjunctiva; capillary
refill within 2 seconds; with VS taken and recorded as follows: T=36.2°C,
PR=73bpm, RR=20cpm, BP=110/70mmHg.
A>Risk for deficient fluid volume related to loss of fluid through normal route
(vomiting).
I>Established rapport
>Assessed patient’s condition
>Monitored and recorded vital signs
>Determined ability to chew, swallow, taste
>Assessed skin turgor and capillary refill
>assessed body built, activity, rest level
>Reviewed laboratory results
>Auscultated bowel sounds
>Practiced aseptic technique in wound cleaning
>Promoted relaxing environment to enhance intake
>Encouraged small frequent feedings
>Reinforced low salt, low fat diet
>Instructed SO on the proper way of doing wound care
>Emphasized the importance of hand washing before and after wound care
>Seen on rounds by Dr. Bondoc @ 9:00 am with orders made and carried out
- continue meds
- D5NM 1L x 8hrs
- change dressing OD – done
- refer
>Due meds given as prescribed
>Regulated IVF as ordered
>Needs attended
>Refer according ly
>Endorsed
E>Goal met; patient did not manifest evidences of fluid volume deficit such
as poor skin turgor, dry mucous membranes, increased PR and temperature,
and decreased BP.
>
*
Decreased
cardiac output
related to
decreased
afterload as
evidenced by
blood pressure
elevation,
cold, clammy
skin,
prolonged
capillary refill
>2 seconds,
and pallor.
*
> Impaired
Skin Integrity.
*
> Risk for
deficient fluid
volume
related to loss
of fluid
through
normal route
(vomiting).
27 28 29
30
FBS/RBS
(70-100mg/dl) 137 88 117.5
Na
(135-150 mg/dl) 113.4
K
(3.5-5.2 mg/dl) 3.8
Urinalysis *
Hgb
(140-180 gm/L) 95
WBC
(5-10 x 10 ^9/L) 14.5
Hct.
(0.40-0.54 L/L) .29
Lymph.= 0.10
.10
BUN= 93
(7-18 mg/dl) 93
Cholesterol= 192.5
(150-250 mg/dl) 160.7 192.5
Creatinine= 18
(0.4-1.4) 18.0
HDL C=33.2
(30-75) 33.2
LDL C= 145.22
(66-178) 145.22
SGPT/ALT= 17
(up to lu/ml) 17.0
SGOT/AST= 19.9
(up to 40 lu/ml) 19.9
Medical Management
IVF’S 27 28 29 30
D5LRS * * *
D5NM *
Diet am pm am pm am pm am pm
Conclusion:
The Groups’ Goal in this study is to at least help the patient deal with
the situation in order to prevent further complications and gain cooperation
with the nurses and to somewhat help in stabilizing and improve the patient’s
health and well-being because the patient is still responsible in achieving his
health goal. Many Interventions were done according to the level of
knowledge and understanding of the student nurses about the diseases he is
afflicting right now in order to meet the said Goal. Through constant
monitoring of his Vital Signs, laboratory results and checking the patient’s
Daily Progress chart, the Group was able to identify if their Goals were
achieved. During the first day of handling the patient, his vital signs were
monitored and blood pressure appeared to be elevated and at the same time
he feels weak. Vital signs were normal during the second day except for the
blood pressure same with the third day. On the last day that the group
handled the patient, Vital Signs were normal and the patient was still
appeared weak, pale and lethargic. Medications were given on time at the
desired dose. Other records such as laboratory results show that there are
still complications particularly the Random Blood Sugar, however, some
laboratory findings show within normal range. The Goal was not totally met
because there are still abnormalities presented during the first until the last
day that the group handled him though he is cooperative when it comes to
medical regimen.
VIII. BIBLIOGRAPHY
Doenges, Marilynn E. Nursing Care Plans: Guidelines for Planning Patient Care
Seely, R., Stephens, T., Tate, P. (2005). Essentials of Human Anatomy &
Physiology. New York: McGrw-Hill.
Retrieved at
http://www.emedicinehealth.com/anatomy_of_the_endocrine_system/ar
ticle_em.htm accessed on April 29, 2008 9:37 pm
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http://www.nurseslearning.com/courses/nrp/NRP1605/course/diabetes.
pdf accessed on April 30, 2008 at 7:05 pm
Retrieved at
http://webpages.charter.net/saabrio/ENDO_Diabetes_mellitus.htm,
accessed on April 30, 2008 at 7:05 pm
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http://www.nhlbi.nih.gov/health/dci/Diseases/anemia/anemia_whatis.ht
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accessed on May 2, 2008, 3:46pm
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on April 30, 2008 at 7:05 pm)
Retrieved at
http://health.discovery.com/diseasesandcond/encyclopedia/2935.html.
Retrieved
athttp://webpages.charter.net/saabrio/ENDO_Diabetes_mellitus.htm,
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http://www.nurseslearning.com/courses/nrp/NRP1605/course/diabetes.pdf,
ANGELES UNIVERSITY FOUNDATION
Angeles City
College of Nursing
CASE STUDY:
HYPERTENSION II
DIABETES MELLITUS TYPE II
ELECTROLYTE IMBALANCE
(HYPONATREMIA)
IRON DEFICIENCY ANEMIA
FURUNCLE