Case Study On Chronic Kidney Disease

CRITERIA
Intro & Objective

Pts Data & Hx History
Definition of Diagnosis
Developmental Data
Physical Assessment
Anatomy & Physiology
Pathophysiology
Diagnostic exams
Drug Studies
Nsg Care Plans
Discharge Planning
Prognosis
Bibliography
Promptness
TOTAL
5%
5%
5%
5%
10%
5%
10%
5%
5%
20%
5%
5%
5%
10%
100%
A Nursing Case Study
In Partial Fulfillment of the Requirements

in NCM 103- RLE Oxygenation
Submitted to:
Ms. Paula Gene Maniago, ST.N
Mr. Nikko Jay Sulpot, ST.N
Practicing Clinical Instructor
And
Mrs. Marilou Dela Cruz-Sawan, RN, MN
Clinical Instructor
Submitted by:
Flauta, Reina Alyannah
Jimena, Phil Anthony
Lego, Roselle Carmi
Loquias, Mariel Anne
Mamaluba, Desiree May
Saballo, Kevin Van Erick
July 12, 2010
Table of Contents
Rationale
Goal and Objectives
Data Base
Biographical Data
Clinical Data
Family Health History
Past Health History
History of Present Illness
Developmental Tasks
Physical & Neuro Assessment
Anatomy & Physiology
Pathophysiology
Medical Management
Diagnostic Exams
Management
Drug Studies
Nursing Care
Nursing Care Plans
Discharge Plan
Prognosis
References
1
5
7
8
9
11
11
12
18
21
24
38
45
53
55
74
86
92
Rationale
Oxygen is one of the main needs for the bodys life-supporting functions. No one
can live without sufficient quantities of food, water, and oxygen. Of the three, oxygen is
by far the most urgently needed. If necessary, a well-nourished person can go without
food for many days or weeks, living on what are stored in the body. The need for water
is more immediate but still will not become critical for several days. The supply of
oxygen in the body is limited to a few minutes. When that supply is exhausted, death is
inevitable. Oxygenation is a dynamic interaction involved in the transportation of oxygen
to all body parts and the removal of carbon dioxide. In this rotation we had our duty in
Sta. Rosa ward at San Pedro Hospital and we conducted a study on our patients case
which has UTI, CKD secondary to diabetes and hypertensive, Pleural effusion and
ascites secondary to hypoalbumin secondary to CKD/liver pathology and DM type II
uncontrolled. Through this, we can determine the interrelationship of kidney to other
complications such as diabetes and diabetes.
Chronic kidney disease (CKD), also known as chronic renal disease, is a
progressive loss of renal function over a period of months or years. The symptoms of
worsening kidney function are unspecific, and might include feeling generally unwell and
experiencing a reduced appetite. Often, chronic kidney disease is diagnosed as a result
of screening of people known to be at risk of kidney problems, such as those with high
blood pressure or diabetes and those with a blood relative with chronic kidney disease.
Chronic kidney disease may also be identified when it leads to one of its recognized
complications, such as cardiovascular disease, anemia or pericarditis.
Recent professional guidelines classify the severity of chronic kidney disease in
five stages, with stage 1 being the mildest and usually causing few symptoms and stage
5 being a severe illness with poor life expectancy if untreated. Stage 5 CKD is also
called established chronic kidney disease and is synonymous with the now outdated
terms end-stage renal disease (ESRD), chronic kidney failure (CKF) or chronic renal
failure (CRF).
Kidney diseases rank as the number 10 killer in the Philippines causing death to
about 7,000 Filipinos every year, DOH reported. The DOH stepped up the advocacy on
kidney disease prevention in observance of the 25th year of Kidney month with theme
"25 Taong Pangunguna sa Serbisyo para sa Kalusugan ng Bato ng Sambayanang
Pilipino".
The population of Filipinos aged 20 years and above in 2005 was 46,627,172. A
prevalence of 2.6% means that 1,212,306 adult Filipinos have CKD. Philippines have a
total of 254 dialysis centers where most of the dialysis machines are located in the
National Capital Region with 41 % while Region 6 has only 5%. Iloilo and Negros
Occidental provinces have the most number of dialysis machines while the provinces of
Antique and Guimaras have none.
Chronic kidney disease is a worldwide public health problem. In the United
States, there is a rising incidence and prevalence of kidney failure, with poor outcomes
and high cost. There is an even higher prevalence of earlier stages of chronic kidney
disease.
Recent reports from the United States estimate that nearly half a million patients
in the United States were treated for end-stage renal disease (ESRD) in 2004 and by
2010 this figure is expected to increase by approximately 40%. The number of people
with renal replacement therapy has increased from 426,000 in 1990 to 1.5 million in
2000 and is expected to rise to 2.5 million by 2010. An Estimated 26 Million Adults in the
United States have Chronic Kidney Disease (CKD). In 2006, CKD was responsible for
the death of nearly 45,000 people, ranking as the ninth leading cause of death in the
United States.
A population survey in 1999-2000 found that 1 in 7 (13.4%) Australians adults
over 25 years of age have some degree of CKD.
In year 19992004 an estimated 11.5 percent of adults ages 20 or older (23
million adults) have physiological evidence of chronic kidney disease determined from
data collected through the National Health and Nutrition Examination Survey. The
frequency of CKD continues to increase worldwide as does the prevalence of end-stage
renal disease (ESRD). Consequently, the identification and reduction of CKD has
become a vital public health priority.
The reported prevalence of CKD stages 1-4 in the most recent NHANES
(national health and nutrition examination survey) between 1999 and 2006 was 26
million (13%) out of approximately 200 million United States residents aged 20 and
older. Of these, 65.3% had CKD stage 3 or 4. The most recent report of the United
States Renal Data System estimates that nearly one-half million patients in the United
States were treated for ESRD in the year 2004, and by 2010 this figure is expected to
increase by approximately 40%. The elderly are a growing segment of the population
and at increased risk for renal disease. Additionally, males and African-Americans with
pre-existing hypertension or diabetes and CKD are also at much higher risk for ESRD.
These observations have also been confirmed throughout the developed world: Europe,
Asia, Australia as well as in developing regions such as China, India and Africa.
Recent reports from the United States estimate that nearly half a million patients
in the United States were treated for end-stage renal disease (ESRD) in 2004 and by
2010 this figure is expected to increase by approximately 40%.
The economic burden for developing countries is particularly severe, partly
because CKD generally occurs at a younger age. For example, in Guatemala, 40% of
patients receiving RRT are under 40. In China, the economy will lose US$558 billion
over the next decade due to effects on death and disability attributable to chronic
cardiovascular and renal disease.
More than 80% of individuals receiving renal replacement therapy (RRT) live in
the developed world because in developing countries it is largely unaffordable. In
countries such as India and Pakistan, less than 10% of all patients who need it
receive any kind of renal replacement therapy. In many African countries there is little
or no access to RRT, meaning many people simply die.
Through this we have come up with ideas that this kind of disease are increasing
now a days. In line with nursing implications and research, we as a student nurse
should know the disease process and the possible complication that may occur if not
treated; the therapies that could help lessen the disease and the medication appropriate
for our client. By this we are conducting this case study so that we can upgrade our
knowledge and skills on how we could render our care appropriately. It will serve as a
research material in which the case is thoroughly studied. It will give the future
researcher a background on the disease and a literature on this disease and basis for
future studies.
In Nursing Education the group will learn firsthand about the client case. The
group will be the one who will learn themselves. Education and learning is not limited to
the confines of a classroom but it is also achieved through effort and exposure to actual
cases like in the clinical area
To conclude, this case study will serve as a learning tool for nursing student and
will give experiences that will broaden the groups skill in handling this condition, use of
interpersonal skills, acquire knowledge, and stimulate critical thinking.
Goal and Objective

We, the BSN 3K, Group 3 Subgroup 1, formulated the following goals that will
serve as our guide towards the completion of this nursing case study. Our group aims to
achieve the objectives below and come up with a well-organized and comprehensive
and detailed output.
General Objectives:
That within 32 intermittent hours of rotation oxygenation, we, the group 3
subgroup 1 of BSN 3K would be able to do a systematic way of research about Chronic
Kidney Disease with regards to our patients condition and we will be able to present this
case study to our Clinical Instructor and Practicing Clinical Instructor for further
discussion to be utilized by future researchers and aid in understanding the disease
mentioned.
Specific Objectives:
At the end of our rotation at Sta. Rosa ward, the group will be able to specifically:
a. Select a subject for our case study;
b. establish a nurse-client relationship to the client, as well as to the family by
rendering a therapeutic nurse-patient relationship;
c. gather adequate information to be used in the development of the study

d. make a specific, measurable, attainable, realistic and time bounded
objectives that will serve as a guide to have a good nursing management;
e. present the clients personal data;
f. illustrate the patients family tree and trace significant diseases which may
be of relevance to the study;
g. trace the health history of the client and the family by collecting information
both of the past and present illnesses;
h. identify the clients developmental data basing on Erik Erikson and Robert
Havighursts theories;
i. have a cephalocaudal assessment of the client providing relevance to
changes both physically and physiologically because of the disease;
j. tackle the systems involved in the development of the disease in the human
anatomy and physiology;
k. provide a schematic and narrative explanation of the pathophysiology in a
comprehensive manner;
l. present the predisposing factors, precipitating factors and symptomatology
of the disease process and each of its rationales;
m. explain and interpret the diagnostic studies including the indication, result
and their implications;
n. discuss the medications given to our client which includes the classification,
suggested and ordered dose, action, indication, contraindication, side
effects, drug interactions and nursing responsibilities;
o. formulate nursing care plans that is applicable to our patients condition;
p. give health teachings to the client and to his family in relation to their needs
in response to the disease process and therapy;
q. evaluate the outcome of the disease and therapy whether there is good, fair
or poor prognosis; and
r. present and defend comprehensively our case study to the group.
Personal Data
Name: Pt. S
Gender: M
Age: 76 yrs old
Birthday: August 27, 1933
Birthplace: Panabo City
Nationality: Filipino
Address: 7091 Liceralde Subdivision, Panabo City
Religion: Jehovas Witnesses
Education Level: High School Graduate
Occupation: Farmer and Photographer
No. of Dependents and Siblings: Seven siblings
Marital Status: Married
Clinical Data
Chief Complaint: Body Malaise

Date of Admission: June 27, 2010
Admitting Diagnosis:
UTI
CKD secondary to diabetes and hypertensive
Pleural effusion and ascites secondary to hypoalbumin secondary to CKD/liverpathology
DM type II uncontrolled
Ward: Sta. Rosa
Attending Physician: Dr. Maria Clara Teresa, M.D.
Date of Discharge:
Final Diagnosis:
Family Health History (Genogram)

Apolonia
Benjamin
Aniano
Teodoro
Raquel
Becaya
David Sr.
Susana
Rebeca
Estrelieta
David Jr.
Levi
Legend:
Narrative:
Male
Female
?
Unknown
Hypertension
Asthma
Diabetes
Client
Deceased
Denis
Danny
Susaneth
Norodine
Juceth
10
We dont have gathered data about the grandparents of our client because he cannot remember it anymore. Both
parents of our client had already passed away due to old age and they had seven children named Benjamin as the eldest
had experienced hypertension, Raquel as the second child experience asthma, Theodoro was the third, next to him were
two siblings whom are unknown and next to them was our client David who had a diabetes and hypertension and lastly
was Becaya as the youngest. Only two of them are living, David and Becaya.
Our client marry Susana which they had nine offsprings. Their eldest was Rebeca, second is Estrelieta who had a
hypertension, third was David Jr. who also had hypertension and diabetes, fourth was Levi, next is Denis, then Danny,
then Susaneth, and then Norodine, and lastly the youngest was Juceth.
11
Past History
According to our patient, in year 1996 he experienced gangrenous at the
right leg which causes amputation of his right big toe. He was diagnosed to have
diabetes mellitus, twenty years ago and diagnosed as hypertensive, ten years
ago.
Present History
Eight days prior to admission, the patient had onset of body malaise and
numbness of lower extremities which resulted to difficulty in walking, chills were
noted and also colds and dyspnea. Consultation was done and also laboratory
tests which had a result of decrease in K, which mange by giving Kalium Dumule
and Insulin injection.
Six days prior to admission there is a presence of symptoms of CKD
which he was admitted in Panabo Polymedic Hospital. There were episodes of
fever, chills, and constipation.
1. Chronic Kidney Disease (CKD) Secondary to Diabetes & Hypertensive
Nephropathy
12
DIAGNOSIS
Chronic
Kidney
Disease
(CKD)
RATIONALE
BIBLIOGRAPHY
1. CKD is a progressive, irreversible loss of Swearingen, Pamela L., RN

(2008).All-in-One Care
kidney function that develops over days to
Planning Resource.
years. Aggressive
management
of
Westline Industrial
Drive St. Louise,
hypertension and diabetes mellitus and
Missouri. Mosby, Inc.
avoidance of nephrotoxic agents may
2nd Ed. p.217.
slow progression of CKD; however loss of
glomerular filtration is irreversible and can
lead to end-stage renal disease (ESDR).
2. CKD is a term that describes kidney
damage or a decrease in glomerular
filtration rate for 3 or more months.
Untreated CKD can result in end-stage
renal disease (ESRD) and necessitate
renal replacement therapy.
Smeltzer, Suzanne C., EdD,

RN, FAAN, et.al (2010).
Medical- Surgical
Nursing. 530 Walnut
Street, Philadelphia.
Wolters Kluwer Health
& Lippincott Williams &
Wilkins. 12th Ed. p.1313.
Porth, Carol Mattson. (2005).
Pathophysiology:
Concepts of Altered
Health Science.
Philippines. Wolters
Kluwer Health &
Lippincott
Williams & Wilkins. 7th
Ed.
Pg. 837
3.
Chronic
renal
failure
represents
progressive and irreversible destruction
of kidney structures. It results in loss of
renal cells with progressive deterioration
of
glomerular
filtration,
tubular
reabsorptive capacity, and endocrine
functions of the kidney.
4.
Chronic kidney disease (CKD), also Chronic_kidney_disease

known as chronic renal disease, is a
progressive loss of renal function over a
period of months or years. Chronic
kidney disease is identified by a blood
test for creatinine. Higher levels of
creatinine indicate a falling glomerular
filtration rate and as a result a decreased
capability of the kidneys to excrete waste
products.
http://en.wikipedia.org/wiiki/
Diabetes
1.
DM is a group of metabolic disease Smeltzer, Suzanne C., EdD,

characterized by increased level of
Medical- Surgical
glucose in the blood (hyperglycemia)
Nursing. 530 Walnut
resulting from defects in insulin secretion,
Wolters Kluwer health
insulin action, or both. The major source
of glucose is absorption of ingested food
Wilkins. 12th Ed. p. 1196.
in the gastrointestinal tract and formation
of glucose by the liver from food
McCann, Judith A. Schilling,
substances.
RN, MSN (2005).
13
Professional Guide to
Diseases. 323
2. DM is a chronic disease of absolute or
Norristown
relative insulin deficiency or resistance
Road, Suite 200, Ambler.
characterized
by
disturbances
in
Lippincott Williams &
carbohydrate, protein, and fat metabolism.
3. DM is a chronic, progressive disease

characterized by the bodys inability to
metabolized carbohydrates, fats, and
proteins, leading to hyperglycemia (high
blood glucose level).
4. DM is a disorder of carbohydrate, fat,

and protein metabolism brought about
by impaired beta cell synthesis or
release of insulin, or the inability of
tissues to use glucose.
Type 1: results from loss of beta cell
function
and
absolute
insulin
deficiency.
Type 2: results from impaired ability
of the tissues to use insulin (insulin
resistance) accompanied by a relative
lack of insulin or impaired release of
insulin in relation to blood glucose
levels.
Hypertensive 1. It is a persistently high blood pressure. In
adults, this means a systolic pressure that

is equal to or greater than 140 mmHg & a
diastolic pressure that is equal to or
greater than 90 mmHg.
Black, Joyce M., PhD, RN,

CPSN, CWCN, FAPWCA
&
Jane Hokanson Hoaks,
DNSc, RN, BC (2009).
Medical- Surgical Nursing:
Clinical Management for
Positive Outcomes. 3
Killiney Road # 08-01
Winsland House 1
Singapore. Elsevier.
p.1062.
Pathophysiology:
Concepts of Altered
Health Science.
Kluwer Health &
Lippincott
Ed.
pg. 995
deWit, Susan C., MSN, RNCs

(1998). Essentials of
Medical- Surgial Nursing.
Independence Square
West Philadelphia,
Pennsylvania. W.B.
Saunders Company. 4th Ed. p.
Black, Joyce M., PhD, RN,
CPSN, CWCN, FAPWCA
2. Persistent elevation of the systolic blood

pressure (SBP) at a level of 140 mmHg or &
higher & diastolip blood pressure (DBP) at
a level of 90 mmHg or above.

Winsland House 1
14
p.
3. A persistently high blood pressure. It is

known as silent killer bcause it can
cause considerable damage to the blood
vessels, heart, brain, and kidneys before it
causes
pain
or
other
noticeable
symptoms. This damages the kidney
arterioles, causing them to thicken, which
narrow the lumen; because the blood
supply to the kidney is thereby reduced,
the kidney secrete more renin, which
elevates the blood pressure even more.
4.
Nephropathy 1. Diabetic Nephropathy is the result of an
alteration in glomerular function. There is

thickening of the basement membranes of
the glomerular capillaries, leading to the
development of glomerular sclerosis.
These changes in the glomeruli are
accompanied by a small urinary loss of
albumin.
2.
Tortora, Gerald J. & Bryan

Derrickson (2007).
Principles of Anatomy and
Physiology. 111 River
Street, Hoboken, USA.
John Wiley & Sons, Inc.
11th ed. p. 798.
Bullock, Barbara L., RN, MSN

&
Reet L. Henze, DSN, RN
(2000). Pathophysiology.
Philadelphia. Lippincott
Williams & Wilkins. p. 703.
Joyce M., PhD, RN,

Diabetic Nephropathy is the most Black,
CPSN, CWCN, FAPWCA
common cause of stage 5 chronic kidney &
disease, formerly known as end-stage
renal disease. Nephropathy involves
damage to and obliteration of the
capillaries that supply the glomeruli of the
kidney.
Winsland House 1
p.1103.
Derrickson (2007).
11th ed. p. 1030.
3. Any disease of the kidney. Nephrotic

syndrome is a condition characterized by
proteinuria (protein in urine) and
hyperlipidemia (high blood levels of
cholesterol,
phospholipids,
and
triglycerides). Proteinuria is due to an
increased permeability of the filtration
membrane, which permits proteins, Porth, Carol Mattson. (2005).
Pathophysiology:
especially albumin, to escape from blood
Concepts of Altered
into urine.
Health Science.
Kluwer Health &

4. Diabetic nephropathies is used to describe
Lippincott
the combination of lesions that often
15

occur concurrently in diabetic kidney. The
Ed.
most kidney lesions in diabetic people
pg. 1010
are those that affect the glomeruli. It is
the leading cause of end-stage renal
failure (ESRD).
2. Pleural Effusion & Ascites Secondary to Hypoalbuminemia Secondary to CKD/

Liver Pathology
DIAGNOSIS
Pleural
Effusion
RATIONALE
BIBLIOGRAPHY
1. Pleural effusion is a collection of fluid in the pleural Smeltzer, Suzanne C., EdD,
space, is rarely a disease process; it is usually
Medical- Surgical
secondary to other diseases. Normally, the pleural
Nursing. 530 Walnut
space must contain only a small amount of fluid
Wolters
Kluwer health
which acts as a lubricant that allows the pleural
surfaces to move without friction.
2. It is an abnormal collection of fluid or exudate in
the pleural cavity. The fluid maybe a transudate,
exudate, purulent drainage, chyle, or blood. I
Ascites

Pathophysiology:
Concepts of Altered
Health Science.
Kluwer Health &
Lippincot Williams &
Wilkins. 7th Ed.
pg. 690
1. Accumulation of fluid in the peritoneal cavity that Black, Joyce M., PhD, RN,
CPSN, CWCN, FAPWCA&
results from the interaction of several
pthophysologic changes. Portal hypertension,
lowered plasma colloidal osmotic pressure, &
sodium retention all contribute to this condition.
Winsland House 1
Smeltzer, Suzanne C., EdD,

Medical- Surgical
Nursing. 530 Walnut
2. Accumulation of serous fluid in the peritoneal

cavity.
Hypoalbumin 1. Hypoalbuminemia
(low
blood
albumin
level)
16
emia
Liver
happens once liver production of albumin fails to

meet increased urinary losses.
1. A large, highly vascular organ located behind the Smeltzer, Suzanne C., EdD,
ribs in the upper right portion of the abdominal
Medical- Surgical
cavity. It is considered as a chemical factory that
Nursing. 530 Walnut
manufactures, stores, alters, and excretes large
Wolters
Kluwer health
number of substances involved in metabolism. It
receives nutrient-rich blood directly from the
gastrointestinal tract (GI) and then either stores or
transforms these nutrients into chemicals that are Microsoft Student 2008 [DVD].
Redmond, WA: Microsoft
used elsewhere in the body for metabolic needs.
Corporation, 2007.
2. Largest internal organ of the human body. Its
essential functions include helping the body to
digest fats, storing reserves of nutrients, filtering
poisons and wastes from the blood, synthesizing a
variety of proteins, and regulating the levels of
many chemicals found in the bloodstream.
Pathology
Derrickson (2007).
11th ed. p. 1030.
1. Study of disease: the scientific study of the

nature, origin, progress and cause of disease.
Microsoft Encarta 2008.

1993-2007 Microsoft Corporation.
All rights reserved.
Microsoft Student 2008 [DVD].

Redmond, WA: Microsoft
Corporation, 2007.
Microsoft Encarta 2008.
1993-2007 Microsoft Corporation.
All rights reserved.
3. Diabetes mellitus (DM) Type 2 Uncontrolled

DIAGNOSIS
DM Type 2
RATIONALE
1. Type 2 DM range from mostly insulin
resistance with relative insulin deficiency to
predominantly secretory defect with insulin
resistance. It is a nonketotic form of DM and
there is no autoimmune destruction of the
pancreatic islet b cells.
BIBLIOGRAPHY
Bullock, Barbara L., RN,
MSN
& Reet L. Henze, DSN,
RN (2000).
Pathophysiology.
Philadelphia. Lippincott
Williams & Wilkins.
P.696
2. Type 2 DM is previously called adult-onset

diabetes mellitus, is a disorder involving
both genetic and environmental factors. This Black, Joyce M., PhD, RN,
CPSN, CWCN, FAPWCA
type of DM has limited beta-cell response to
& Jane Hokanson
hyperglycemia. As the beta-cells are Hoaks,
exposed to high levels of glucose, they
Medical- Surgical
become progressively less efficient.
Nursing:
17
Winsland House 1
3. Type 2 DM has 2 main problems and these
are insulin resistance and impaired insulin
p.1063.
secretion. Insulin resistance refers to
decreased tissue sensitivity to insulin. Smeltzer, Suzanne C., EdD,
RN, FAAN, et.al
Normally, insulin binds to special receptors
on cell surfaces and initiates a series of (2010).
Medical- Surgical
reactions involved in glucose metabolism.
Nursing. 530 Walnut
But, in type 2 DM, these intracellular
reactions are diminished, making insulin less
effective at stimulating glucose uptake by
the tissues and at regulating glucose release
by the liver.
4. Urinary Tract Infection

DIAGNOSIS
MEANING
BIBLIOGRAPHY
Urinary Tract 1. Used to describe either an infection of a part Tortora, Gerald J. & Bryan
Derrickson (2007).
Infection
of the urinary system of the presence of
Principles of Anatomy
(UTI)
large numbers of microbes in urine. and
Symptoms include painful or burning
urination, urgent and frequent urination, low
back pain, and bed wetting.
11th ed. p. 1030.
2. UTIs
are
caused
by
pathogenic Smeltzer, Suzanne C., EdD,
RN, FAAN, et.al
microorganisms in the urinary tract. They are
(2010).
generally classified as infections involving
Medical- Surgical
the upper and lower urinary tract and further
Nursing. 530 Walnut
classified as uncomplicated or complicated,
depending
on
other
patient-related
conditions.
Wilkins. 12th Ed.
p.1359.
Developmental Tasks of Later Maturity

18
Robert Havighursts Developmental Tasks

Developmental
Tasks
Description
Passed or
Failed
Justification
1. Adjusting to
decreasing physical
strength and health
Older adults also have

to adjust to
decreasing physical
strength and health.
The prevalence of
chronic and acute
diseases increase in
old age. Thus, older
adults may be
confronted with life
situations that are
characterized by not
being in perfect
health,serious illness
and dependency on
people.
Passed
Our patient is aware about

his health and is very
cooperative on the student
nurses who provide care to
him. He is cooperative in a
way that he follows the
student nurses in
procedures like removing
the catheter. Also, when
giving meds, he does not
refuse in taking the due
meds given to him.
2. Adjusting to
retirement and
reduced income
A central
developmental task
that characterized the
transition into old age
is adjustment to
retirement. The period
after retirement has to
be filled with new
projects, but is
characterized by few
valid cultural
guidelines. The
achievement of this
task may be
obstructed by the
management of
another task, living in
a reduced income
after retirement.
Passed
Our patient is not receiving

pension but gets his income
from his farm (banana
plantation) and his photo
studio. He is a
photographer by experience
according to his
grandchildren. His annual
income at his photo studio
is 200,000 pesos.
3. Adjusting to death Older adults may

of a spouse
become caregivers to
their spouses. Some
older adults have to
adjust to the death of
their spouses. After
they have lived with a
spouse for many
Passed
When asked, the patient

stated that his wife is
already dead. He accepts
that he is now a widow. His
deceased wife's name is
Susanna. She died on
November 7, 2005 due to
cancer (not specified). They
19
decades, widowhood
may force older
people to adjust to
loneliness, moving to
a smaller place,and
learning about
business matters.
had 9 children.
4. Establishing an
The development of a
explicit affiliation with large part of the
one's aged group
population into old
age is historically
recent phenomenon
to modern cities.
Thus, advancements
understanding of the
aging process may
lead to identifying
further developmental
tasks associated with
gains and purposeful
lives for adults.
Passed
Our patient is a member of

PHIC and a congregation of
Jehovah's witnesses in
Panabo City. According to
him, they have 7
congregations in Panabo
and it is composed of 100
members per congregation.
In their congregation, their
focus is on teaching the
good news of Jehovah. He
also mentioned that he has
friends of the same age
group namely Helson
Daclan who delivers meds
and Oscar Emier.
5. Meeting social and Older people might

civil obligations
accumulate
knowledge about life,
and thus may
contribute to the
development of
younger people and
the society.
Passed
Our patient tells stories

about his childhood life to
his grandchildren. He
shares experiences to them
which served as a guide
and lesson.
6. Establishing
satisfactory physical
living arrangements
Passed
Our patient lives in a

subdivision in a Panabo
City together with his
daughter. According to him,
his daughter is the only one
who is not married among
his children. All eight had
their own families
nonetheless he sometimes
would visit them.
Oder adults are

generally challenged
to create positive
sense of their lives as
a whole. The feeling
that life has order and
meaning results in
happiness.
Eric Eriksons Developmental Task

Integrity vs. Despair
20
Erikson felt that much of life is preparing for the middle adulthood stage and
the last stage recovering from it. Perhaps that is because as older adults we can often
look back on our lives with happiness and are contented, feeling fulfilled with a deep
sense that life has meaning and we've made contribution to life, a feeling Erikson called
integrity. On the other hand, some adults may reach this stage and despair at their
experiences and perceived failure.
Our patient achieved happiness and contentment in his life based on his
actions and speeches. He is faithful and devoted to his religion. When asked what his
principle in life he said is, Mamatay man kun buhi, mapabilin kay Jehovah. He is ready
to accept death completely and he has shared his experiences to his beloved
grandchildren. Even though he accepted death fully but his faith and love for his
worshipped God never changed.
Physical Assessment
21
Name: Mrs. J
Bed: 304-6
Age: 56
Status: Married
Ward: San Lorenzo Ward

Sex: Female
Civil
Vital Signs
Axillary T= 37.3 C, PR= 77 bpm, RR= 22, CR= 79 bpm, BP= 110/70 mmHg.
General survey
Height= 5 ft and 3 inches, weight=46 kilos, head circumference=21cm,
abdominal circumference= 28 inches. Mesomorph. No signs of distress noted upon
assessment, able to smile, cooperate well, responsive to questions, conscious and alert,
conversant. Well oriented. Show calmness during the examination. She has no IVF
infused, and was asleep at initial assessment.
Skin
Skin is brown in color, rough, dry and warm. She has good skin turgor. Brownish
discolorations that resemble freckles are observed on arms and face.
Head
Skull is round in shape, symmetrical (normocephalic). No masses noted. Facial
movement is symmetrical. Hair is dry in texture; its color is black with mimimal streaks of
gray. Scalp is clear from dandruff and lice. No scars and wounds noted.
Eyes
Has symmetrical eyebrows movement, shape and hair distribution. Eyebrows
have same color with hair. Eyelashes are evenly distributed and curled outward. Eyelids
have no discharges and bilaterally blink. Upper lid covers the small portion of the iris and
cornea. Lacrimal duct openings (puncta) are evident at nasal ends of upper and lower lid
with no tenderness noted. Palpebral conjunctiva are pinkish in color while the pupils
constricted to light (2mm), round in shape, isocoric, shows uniform convergence. She is
able to rotate eyes and has coordinated eye movements.
Ears
Auricle has same color with the skin, has symmetrical shape and located a little
bit higher than the eye. Pinnas are symmetrical, mobile, and able to recoil, with no
lesions noted. She has wet cerumen noted on both ears when pulled down and back for
better visualization. She is able to hear on both ears. Her ears lobules have holes for
jewelry.
Nose
22
Nose has uniform color and symmetrical in shape. Nasal hairs are very evident
when light is flashed through the nasal passageways; its color is black. No nasal flaring
observed upon respiration. Both nares are patent, air moves freely as client breathes
through the nares. Nasal septum is straight and in midline. Nasal mucosa is pinkish in
color, has no discharges and no lesions. No tenderness of sinuses noted.
Mouth
Lips are a little brownish in color, dry and has cracks. Tongue is in midline,
pinkish in color with thin whitish coating on top. Able to move tongue freely (up & down,
side to side). Soft palate is light pink in color while hard palate is lighter in color. Gums
are pinkish in color. Her first and second right molars of the lower teeth, and her first left
molar of the upper teeth are missing. Her teeth are a little yellow in color with few
plaques usually found on her remaining molars.
Pharynx
Uvula is found well placed in midline of soft palate. Mucosa is pinkish in color.
Tonsils are not inflamed.
Neck
Trachea is in midline. No tenderness of thyroid noted. No enlargement of the
neck noted. She is able to flex and extend neck and move it laterally (L and R).
Chest and Lungs
Breathing pattern is regular (eupnea). Anteroposterior diameter to transverse
diameter is in 1:2. Respiratory excursion is symmetrical (thumb separates to 2-3cm).
Vocal tactile fremitus is bilaterally equal. She refused to have her breasts examined.
Heart and Central Vessels
Heart sounds are regular. Pulsation of heart is heard in 4 anatomical areas but
more audible in apical area upon auscultation.
Back and Extremities
Peripheral pulses are symmetrical and regular. Nails are long and untrimmed,
pinkish in color, and have a capillary refill time of 2 sec. after blanching; and no clubbing
of fingernails were noted. Calluses were observed at the tip of her fingers and toes. Her
hands are a little rough. Muscle strength is equal on both sides of the upper and lower
extremities. Spine is a little deviated to the left as seen when client was asked to bend
over. She is able to stand and walk on both feet independently, and her movements are
well coordinated. Toes point straight ahead. And she is able to sit up straight.
Abdomen
23
Her abdomens color is same with the rest of the part of the body. Her umbilicus
is coated with blackish dirt. She has globular abdomen and dullness was noted upon
percussion.
Neurologic Assessment
Cranial Nerves: (CN1) able to identify aromas by smelling with eyes closed;
(CN2) able to see objects; (CN3) pupil constricted to light sensation; (CN4&6) able to
move eyeball downward and laterally; (CN5) able to blink eyes; (CN7) able to smile,
raise eyebrows, puff cheeks and close eyes; (CN8) able to respond to questions being
heard; (CN10) has rough and vibrating sound; (CN11) able to shrug shoulders, elevate
and flex arms and legs against resistance; (CN12) able to protrude tongue and move it
side to side.
Anatomy and Physiology
24
Function of the Urinary System:

The principal function of the urinary system is to maintain the volume and
composition of body fluids within normal limits. One aspect of this function is to rid the
body of waste products that accumulate as a result of cellular metabolism and because
of this, it is sometimes referred to as the excretory system.
Although the urinary system has a major role in excretion, other organs
contribute to the excretory function. The lungs in the respiratory system excrete some
waste products, such as carbon dioxide and water. The skin is another excretory organ
that rids the body of wastes through the sweat glands. The liver and intestines excrete
bile pigments that result from the destruction of hemoglobin. The major task of excretion
still belongs to the urinary system. If it fails the other organs cannot take over and
compensate adequately.
The urinary system maintains an appropriate fluid volume by regulating the
amount of water that is excreted in the urine. Other aspects of its function include
25
regulating the concentrations of various electrolytes in the body fluids and maintaining
normal pH of the blood.
In addition to maintaining fluid homeostasis in the body, the urinary system
controls red blood cell production by secreting the hormone erythropoietin. The urinary
system also plays a role in maintaining normal blood pressure by secreting the enzyme
renin.
Components
of
the
Urinary
System:
The
urinary
system
consists of the kidneys, ureters,

urinary bladder, and urethra.
The kidneys form the urine and
account for the other functions
attributed to the urinary system.
The ureters carry the urine away
from kidneys to the urinary
bladder, which is a temporary
reservoir for the urine. The
urethra is a tubular structure that carries the urine from the urinary bladder to the
outside.
KIDNEYS
The kidneys are the primary organs of the urinary system. The kidneys are the organs
that filter the blood, remove the wastes, and excrete the wastes in the urine. They are
the organs that perform the functions of the urinary system. The other components are
accessory structures to eliminate the urine from the body.
The paired kidneys are located between the twelfth thoracic and third lumbar
vertebrae, one on each side of the vertebral column. The right kidney usually is slightly
lower than the left because the liver displaces it downward. The kidneys protected by the
lower ribs, lie in shallow depressions against the posterior abdominal wall and behind
26
the parietal peritoneum. This means they are retroperitoneal. Each kidney is held in
place by connective tissue, called renal fascia, and is surrounded by a thick layer of
adipose tissue, called perirenal fat, which helps to protect it. A tough, fibrous, connective
tissue renal capsule closely envelopes each kidney and provides support for the soft
tissue that is inside.
In the adult, each kidney is approximately 3 cm thick, 6 cm wide and 12 cm long.
It is roughly bean-shaped with an indentation, called the hilum, on the medial side. The
hilum leads to a large cavity, called the renal sinus, within the kidney. The ureter and
renal vein leave the kidney, and the renal artery enters the kidney at the hilum.
The outer, reddish region, next to the capsule, is the renal cortex. This surrounds
a darker reddish-brown region called the renal medulla. The renal medulla consists of a
series of renal pyramids, which appear striated because they contain straight tubular
structures and blood vessels. The wide bases of the pyramids are adjacent to the cortex
and the pointed ends, called renal papillae, are directed toward the center of the kidney.
Portions of the renal cortex extend into the spaces between adjacent pyramids to form
renal columns. The cortex and medulla make up the parenchyma, or functional tissue, of
the kidney.
The central region of the kidney contains the renal pelvis, which is located in the
renal sinus and is continuous with the ureter. The renal pelvis is a large cavity that
collects the urine as it is produced. The periphery of the renal pelvis is interrupted by
cuplike projections called calyces. A minor calyx surrounds the renal papillae of each
pyramid and collects urine from that pyramid. Several minor calyces converge to form a
major calyx. From the major calyces the urine flows into the renal pelvis and from there
into the ureter.
Each kidney contains over a million functional units, called nephrons, in the
parenchyma (cortex and medulla). A nephron has two parts: a renal corpuscle and a
renal tubule. The renal corpuscle consists of a cluster of capillaries, called the
glomerulus, surrounded by a double-layered epithelial cup, called the glomerular
capsule. An afferent arteriole leads into the renal corpuscle and an efferent arteriole
leaves the renal corpuscle. Urine passes from the nephrons into collecting ducts then
into the minor calyces.
27
The juxtaglomerular apparatus, which monitors blood pressure and secretes

renin, is formed from modified cells in the afferent arteriole and the ascending limb of the
nephron loop.
Parts of the Kidney:
Renal Vein -This has a large diameter and a thin wall. It carries blood away from the
kidney and back to the right hand side of the heart. Blood in the kidney has had all its
urea removed. Urea is produced by your liver to get rid of excess amino-acids.
Blood in the renal vein also has exactly the right amount of water and salts. This
is because the kidney gets rid of excess water and salts. The kidney is controlled by the
brain. A hormone in our blood called Anti-Diuretic Hormone (ADH for short) is used to
control exactly how much water is excreted.
Renal Artery - This blood vessel supplies blood to the kidney from the left hand side of
the heart. This blood must contain glucose and oxygen because the kidney has to work
hard producing urine. Blood in the renal artery must have sufficient pressure or the
kidney will not be able to filter the blood.
Medulla - The medulla is the inside part of the kidney. This is where the amount of salt
and water in your urine is controlled. It consists of billions of loops of Henl. These work
very hard pumping sodium ions. ADH makes the loops work harder to pump more
sodium ions. The result of this is that very concentrated urine is produced.
Cortex - The cortex is the outer part of the kidney. This is where blood is filtered. We call
this process "ultra-filtration" or "high pressure filtration" because it only works if the blood
entering the kidney in the renal artery is at high pressure.
Billions of glomeruli are found in the cortex. A glomerulus is a tiny ball of
capillaries. Each glomerulus is surrounded by a "Bowman's Capsule". Glomeruli leak.
Things like red blood cells, white blood cells, platelets and fibrinogen stay in the blood
28
vessels. Most of the plasma leaks out into the Bowman's capsules. This is about 160
litres of liquid every 24 hours.
Most of this liquid, which we call "ultra-filtrate" is re-absorbed in the medulla and
put back into the blood. Blood supplied to the kidney contains a toxic product called urea
which must be removed from the blood. It may have too much salt and too much water.
The kidney removes these excess materials.
Glomerulus and Bowman's Capsule - This is where ultra-filtration takes place. Blood
from the renal artery is forced into the glomerulus under high pressure. Most of the liquid
is forced out of the glomerulus into the Bowman's capsule which surrounds it.
Proximal Convoluted Tubules - Proximal means "near to" and convoluted means "coiled
up" so this is the coiled up tube near to the Bowman's capsule. This is the place where
all that useful glucose is re-absorbed from the ultra-filtrate and put back into the blood. If
the glucose was not absorbed it would end up in your urine. This happens in people who
are suffering from diabetes.
Loop of Henl - This part of the nephron is where water is reabsorbed. Kidney cells in
this region spend all their time pumping sodium ions. This makes the medulla very salty;
you could say that this is a region of very low water concentration. If you remember the
definition of osmosis, you will realize that water will pass from a region of high water
concentration (the ultra-filtrate and urine) into a region of low water concentration (the
medulla) through cell membranes which are semi-permeable.
Distal Convoluted Tubules - Distal means "distant" so it is at the other end of the
nephron from the Bowman's capsule. This is where most of the salts in the ultra-filtrate
are re-absorbed.
Collecting Duct - Collecting ducts run through the medulla and are surrounded by loops
of Henl. The liquid in the collecting ducts (ultra-filtrate) is turned into urine as water and
salts are removed from it. Although our kidneys make about 160 litres of urine every 24
hours, we only produce about litre of urine. It is called a collecting duct because it
collects the liquid produced by lots of nephrons.
29
URETERS
Each ureter is a small tube, about 25 cm long

that carries urine from the renal pelvis to the urinary
bladder. It descends from the renal pelvis, along the posterior abdominal wall, behind the
parietal peritoneum, and enters the urinary bladder on the posterior inferior surface.
The wall of the ureter consists of three layers. The outer layer, the fibrous coat, is
a supporting layer of fibrous connective tissue. The middle layer, the muscular coat,
30
consists of inner circular and outer longitudinal smooth muscle. The main function of this
layer is peristalsis to propel the urine. The inner layer, the mucosa, is transitional
epithelium that is continuous with the lining of the renal pelvis and the urinary bladder.
This layer secretes mucus which coats and protects the surface of the cells.
URINARY BLADDER
The urinary bladder is a
temporary storage reservoir for
urine. It is located in the pelvic
cavity, posterior to the symphysis
pubis, and below the parietal
peritoneum. The size and shape
of the urinary bladder varies with
the amount of urine it contains
and with pressure it receives from
surrounding organs.
The inner lining of the urinary bladder is a mucous membrane of transitional
epithelium that is continuous with that in the ureters. When the bladder is empty, the
mucosa has numerous folds called rugae. The rugae and transitional epithelium allow
the bladder to expand as it fills.
The second layer in the walls is the submucosa that supports the mucous
membrane. It is composed of connective tissue with elastic fibers.
The next layer is the muscularis, which is composed of smooth muscle. The
smooth muscle fibers are interwoven in all directions and collectively these are called the
detrusor muscle. Contraction of this muscle expels urine from the bladder. On the
superior surface, the outer layer of the bladder wall is parietal peritoneum. In all other
regions, the outer layer is fibrous connective tissue.
31
There is a triangular area, called the trigone, formed by three openings in the
floor of the urinary bladder. Two of the openings are from the ureters and form the base
of the trigone. Small flaps of mucosa cover these openings and act as valves that allow
urine to enter the bladder but prevent it from backing up from the bladder into the
ureters. The third opening, at the apex of the trigone, is the opening into the urethra. A
band of the detrusor muscle encircles this opening to form the internal urethral sphincter.
URETHRA
The final passageway for the flow of urine is the urethra, a thin-walled tube that
conveys urine from the floor of the urinary bladder to
the outside. The opening to the outside is the
external urethral orifice. The mucosal lining of the
urethra is transitional epithelium. The wall also
contains smooth muscle fibers and is supported by
connective tissue.
The internal urethral sphincter surrounds the
beginning of the urethra, where it leaves the urinary
bladder. This sphincter is smooth (involuntary)
muscle. Another sphincter, the external urethral sphincter, is skeletal (voluntary) muscle
and encircles the urethra where it goes through the pelvic floor. These two sphincters
control the flow of urine through the urethra.
In females, the urethra is short, only 3 to 4 cm (about 1.5 inches) long. The
external urethral orifice opens to the outside just anterior to the opening for the vagina.
In males, the urethra is much longer, about 20 cm (7 to 8 inches) in length, and
transports both urine and semen. The first part, next to the urinary bladder, passes
through the prostate gland and is called the prostatic urethra. The second part, a short
region that penetrates the pelvic floor and enters the penis, is called the membranous
urethra. The third part, the spongy urethra, is the longest region. This portion of the
urethra extends the entire length of the penis, and the external urethral orifice opens to
the outside at the tip of the penis.
32
LIVER
The liver is the largest internal organ in the body, and weighs about 3 pounds in
an adult. The liver is located in the right upper quadrant of the abdomen, just below the
diaphragm. A thick capsule of connective tissue called Glisson's capsule covers the
entire surface of the liver. The liver is divided into a large right lobe and a smaller left
lobe. The falciform ligament divides the two lobes of the liver.
Each lobe is further divided into lobules that are approximately 2 mm high and 1
mm in circumference.
These hepatic lobules are the functioning units of the liver. Each of the
approximately 1 million lobules consists of a hexagonal row of hepatic cells called
hepatocytes. The hepatocytes secrete bile into the bile channels and also perform a
33
variety of metabolic functions. Between each row of hepatocytes are small cavities
called sinusoids. Each sinusoid is lined with Kupffer cells, phagocytic cells that remove
amino acids, nutrients, sugar, old red blood cells, bacteria and debris from the blood that
flows through the sinusoids. The main functions of the sinusoids are to destroy old or
defective red blood cells, to remove bacteria and foreign particles from the blood, and to
detoxify toxins and other harmful substances. Approximately 1500 ml of blood enters the
liver each minute, making it one of the most vascular organs in the body. Seventy-five
percent of the blood flowing to the liver comes through the portal vein; the remaining
25% is oxygenated blood that is carried by the hepatic artery.
Central Role of Liver in Metabolism
The liver is vitally important in helping to maintain blood glucose levels within
normal range. After a carbohydrate-rich meal, thousands of glucose molecules are
removed from the blood and combined to form the large polysaccharide molecules
called glycogen, which are then stored in the liver. This process is glycogenesis, literally,
glycogen formation. Later, as body cells continue to remove glucose from the blood to
meet their needs, blood glucose levels begin to drop. At this time, liver cells break down
the stored glycogen, by a process called glycogenolysis, which means glycogen
splitting. The liver cells then release glucose bit by bit t the blood to maintain
homeostasis of blood glucose levels. If necessary, the liver can also make glucose from
noncarbohydrate
substances
such
as
fats
and
proteins.
This
process
is
gluconeogenesis, which means formation of new sugar.

Some of the fats and fatty acids picked up by the liver cells are oxidized for
energy to make ATP for use by the liver cells themselves. The rest are broken down to
simpler substances such as acetic acid and acetoacetic acid (two acetic acids linked
together) and released into the blood, or stored as fat reserves in the liver. The liver also
makes cholesterol and secretes cholesterols breakdown products in bile.
All blood proteins made by the liver are built from the amino acids its cells pick up
from the blood. The completed proteins are then released back into the blood to travel
throughout the circulation. Albumin, the most abundant protein in blood, holds fluid in the
bloodstream. When insufficient albumin is present in blood, fluid leaves the bloodstream
and accumulates in the tissue spaces, causing edema. The liver cells also synthesize
34
nonessential amino acids and detoxify ammonia (produced when amino acids are
oxidized for energy) by converting into urea.
The liver is responsible for important functions, including:
Bile production and excretion
Excretion of bilirubin, cholesterol, hormones, and drugs
Metabolism of fats, proteins, and carbohydrates
Enzyme activation
Storage of glycogen, vitamins, and minerals
Synthesis of plasma proteins, such as albumin and globulin, and clotting factors
Blood detoxification and purification

The liver synthesizes and transports bile pigments and bile salts that are needed
for fat digestion. Bile is a combination of water, bile acids, bile pigments, cholesterol,
bilirubin, phospholipids, potassium, sodium, and chloride. Primary bile acids are
produced from cholesterol. When bile acids are converted or "conjugated" in the liver,
they become bile salts.
Bilirubin is the main bile pigment that is formed from the breakdown of heme in
red blood cells. The broken-down heme travels to the liver, where is it secreted into the
bile by the liver. Bilirubin production and excretion follow a specific pathway. When the
reticuloendothelial system breaks down old red blood cells, bilirubin is one of the waste
products. This "free bilirubin" is a lipid soluble form that must be made water-soluble to
be excreted. The conjugation process in the liver converts the bilirubin from a fat-soluble
to a water-soluble form. The liver also plays a major role in excreting cholesterol,
hormones, and drugs from the body.
The liver plays an important role in metabolizing nutrients such as carbohydrates,
proteins, and fats. The liver helps metabolize carbohydrates in three ways:
Through the process of glycogenesis, glucose, fructose, and
galactose are converted to glycogen and stored in the liver.
35
Through the process of glycogenolysis, the liver breaks down
stored glycogen to maintain blood glucose levels when there is a decrease in

carbohydrate intake.
Through the process of gluconeogenesis, the liver synthesizes
glucose from proteins or fats to maintain blood glucose levels.

The liver synthesizes about 50 grams of protein each day, primarily in the form of
albumin. Liver cells also chemically convert amino acids to produce ketoacids and
ammonia, from which urea is formed and excreted in the urine. Digested fat is converted
in the intestine to triglycerides, cholesterol, phospholipids, and lipoproteins. These
substances are converted in the liver into glycerol and fatty acids, through a process
known as ketogenesis.
Prothrombin and fibrinogen, substances needed to help blood coagulate, are
both produced by the liver. The liver also produces the anticoagulant heparin and
releases vasopressor substances after hemorrhage.
Liver cells protect the body from toxic injury by detoxifying potentially harmful
substances. By making toxic substances more water soluble, they can be excreted from
the body in the urine. The liver also has an important role in vitamin storage. High
concentrations of riboflavin or Vitamin B1 are found in the liver. 95% of the body's
vitamin A stores are concentrated in the liver. The liver also contains small amounts of
Vitamin C, most of the body's Vitamin D stores, and Vitamins E and K.
PANCREAS
The hormones administered by the pancreas are responsible for controlling and
manipulating blood glucose levels. The pancreas houses islets responsible for
production and secretion of the hormones, glucagon and insulin. Because of this, the
pancreas falls under both the endocrine glandular system as well as the exocrine
glandular system. The islets which produce these hormones are semi scattered
throughout the pancreas and are known as the islets of Langerhans. These particular
endocrine functioning structures are typically able to be located in the body and along
the tail of the pancreas. Alpha cells and Beta cells are the cells that are known to secrete
36
the hormones within the islets. Glucagon is administered from the Alpha cells and insulin
comes from the Beta cells. Gulcagon has an affect on insulin by providing the
appropriate stimulus for the liver to convert glycogen into glucose. The Alpha cells are
able to respond appropriately to the feedback provided and thus are able to self monitor.
High blood sugar, which is also known as hypoglycemia, can be the result of continuous
output of glucagon.
Insulins function on the human physiology is opposite of its counterpart,
glucagon. Insulin is designed to lower the blood sugar in the body. Insulin is the initiating
factor that allows blood glucose to the necessary movement through the cell
membranes. Muscular cells and adipose cells rely on this movement of glucose for their
ability to function. The glucose level within the cell drops as the glucose moves
throughout the cell membrane. Insulin is also an initiating factor in the conversion of
glucose to glycogen by the cells of the muscles and liver. This action actually assists
amino acids into the cells and provides the foundation for the creation of fats and
proteins. When Beta cells are incapable of producing the appropriate amount of insulin,
diseases
such
as
diabetes
occur.
The pancreas is rather soft, created from lobes, Measures about 6 inches long
and 1 inch thick, and performs the functions of a mixed gland. Serving both endocrine
functions and exocrine functions, the pancreas is serving dual systems. The islets of
Langerhans, or pancreatic islets, are the cell clusters responsible for the pancreas
endocrine functions. Insulin and glucagon are required hormones of the bloodstream to
maintain optimal homeostasis. Performing the exocrine functions requires the proper
ability to secrete pancreatic juices which aid in digestion. The pancreatic juice is created
within the pancreas and immediately released into the pancreatic duct which empties
into
the duodenum.
The pancreas is positioned snugly up against the greater curvature of
the stomach, which runs along the posterior wall of the abdominal cavity. It head is
located close to the duodenum, which is expanded over the central body. The tail tapers
off
near
the
location
of
the
spleen.
The exocrine secretion units are tucked inside the pancreatic lobules. These
37
secretion units are technically referred to as the pancreatic acini. The endocrine
secretion units are found right next to the exocrine secretion units, these are referred to
as pancreatic islet cells however. The pancreatic juice is secreted from the acini, and
each individual acinus has only one mere layer of epithelial acinar cells which
encompass
lumen.
Branches from the celiac plexus are responsible for the innervation of the
pancreas. The innervation of the pancreas is segregated by function; the glandular
functional
innervation
portion
is
receives
held
the parasympathetic
for
the
blood
innervation
while
sympathetic
vessels of
the
pancreas.
The splenic artery branches off into the pancreatic branch in order to deliver the
appropriate blood supply. The splenic artery is a branch from the celiac artery. The
pancreatoduodenal artery is a branch derived from the superior mesenteric artery, which
also serves the pancreas; blood flow demands. Venous return is naturally through the
splenic and superior mesenteric veins. These veins drain into the hepatic portal vein.
Pathophysiology Diabetes Mellitus

a. Etiology:
Predisposing Factors
Factors
Genetic
Presence
(+)
Mechanism/Justification
Initial decrease in beta cell
mass related to genetic
factors responsible for beta
cell
differentiation
or
presence of diabetogenic
gene.
Pancreas, similar to several
38
Age >40
Precipitating Factors
Factors
Over weight/Obesity
(+)
other components of the

body, does not function well
due to old age.
Presence
Obese
people
have
increased resistance to the
action of insulin and impaired
suppression of glucose by
liver,
resulting
both
hyperglycemia
and
hyperinsulinemia. 85% of all
people with diabetes are
obese.
Initial decrease in beta cell
mass related to presence of
Maternal Diabetes Mellitus
during pregnancy or in
uterine factors such as
intrauterine growth restriction.
Mumps, coxsackeivirus
Nitrosamines that are found
in smoked and cured meats,
are related to streptozoin that
is used to induce DM in
experimental animals, rat
poison named Vacor that
induces DM when ingested
by Human
Low potassium level impairs
release of insulin
BMI 21.0 (Normal)

(-)
Environment
stage)
(intrapartal
(-)
Virus Infection
(-)
Presence of Toxin
(-)
Decrease
potassium level
serum
(-)
b. Symptomatology
Symptoms
Polyuria
urination)
Presence
(excessive
(+)
Polydipsia
thirst)
(excessive
(+)
Polyphagia
hunger)
(excessive
(+)
Blurred Vision
(+)
Glucose exceeds the amount
that can be reabsorbed by
renal tubules this results
glycosuria.
Excess glucose in the blood
pulls water out of the cell
causing
intracellular
dehydration, including those
in thirst center.
Results from depleation of
cellular
reserves
of
carbohydrates,
fats
and
proteins.
Lens and retina are exposed
39
to hyperosmolar fluids
(+)
Lowered plasma volume
(+)
Temporary dysfunction of
peripheral sensory nerves
(-)
Hypergycemia
and
glycosuria favors growth of
yeast organisms.
Decrease insulin
(-)
Initial loss due to depleation
production/sensitivity
of water, glycogen, and
triglyceride store; chronic
loss secondary to decrease
muscle mass as amino acid
are diverted to form glucose
and ketone bodies.
Elevated Serum
The body is able to adopt ta
Glucose
a slow rise of blood glucose
level to a greater extent than
it can to a rapid rise.
Weakness and fatigue
Predisposing
Factors
Paresthesias
Genetics
Age >40
Pruritus, vaginitis, chronic
skin infections
Weight loss
Precipitating
Environment(intrapartal)
Toxin/Virus
Obesity
Decrease Serum Potasium
Increased Osmolarity
Often Asymptomatic
due to Glucose
Polydipsia
Polyuria
Chronic elevation of
Serum Glucose
Polyphagia
Weight loss
Diabetic
neuropathy
Small vessel
disease
Accelerated
atherosclerosis
Diabetic
retinopathy
Impaired immune
function
Hypertension
Symmetrical loss
of sensation
Diabetic
nephropathy
Numbness and
paresthesia
c. of
Schematic Tracing
Wasting
End-stage
intrinsic muscles
renal failure
Infection
Coronary artery
disease
Loss of vision
Increase
LDL levels
Delayed wound
healing
Autonomic
neuropathy
Impotence
Diabetic foot
ulceration
Dry, cracked
skin
40
Charcot changes in joints
Gastroparesis
Neurogenic
bladder
d. Narrative
Type two Diabetes Mellitus is a heterogeneous condition that describes the presence
of excess serum glucose level in association with relative insulin deficiency. Type 2
Diabetes is associated with high, normal, low insulin levels. However there is a presence
of insulin resistance thus the insulin cannot function effectively and hyperglycemia will
occur. Most people with this type of diabetes are older and obese, but type 2 Diabetes is
becoming a more common occurrence in obese adolescent. The metabolic
abnormalities that contribute in hyperglycemia in people with type 2 diabetes are
41
impaired beta cell function and insulin production, peripheral insulin resistance, and
increase hepatic glucose production.
Insulin is a anabolic hormone. Without insulin three major metabolic problem occur:
decrease glucose uptake and utilization, increase fat and lipid mobilization and
increased protein and amino acid utilization.
Beta cells chronically exposed to high blood levels of glucose become progressively
less efficient when responding to further glucose elevation. Insulin resistance initially
produces an increase beta cell secretion of insulin as body attempt to maintain
normoglycemic state. In time, however the insulin response declines because of
increasing beta cell dysfunction. This results to postprandial hyperglycemia. Eventually
fasting blood glucose level also rise until frank type 2 Diabetes occurs.
Cells that require insulin as carrier of glucose can take only 25% of glucose they
require for fuel, but nerve tissues, erythrocytes, and cells of intestine, liver, kidney
tubules do not require insulin for glucose transport. However, adipose tissue, along with
skeletal and cardiac muscle requires insulin for glucose transport.
During severe stress such as hospitalization, the body of a type 2 diabetes patient
will turn fat reserves into glucose for energy production when glucose is not available.
Fat and lipid metabolism cause breakdown products called ketones to form. Ketones
accumulate in the blood and excreted through kidneys and lungs. Ketones interfere with
the bodys acid base balance by producing Hydrogen ions. The pH can decrease, and
metabolic acidosis can result. In addition when ketone is excreted in urine, sodium is
also eliminated, causing sodium depletion and further acidosis. The excretion of ketone
also increases osmotic pressure, leading to increase fluid loss.
In this type of Diabetes Mellitus the onset of clinical manifestation may develop
gradually that clients may notice a few or no clinical manifestations for a number of year.
Some of the manifestations are frequency in urination, increase thirst or fluid intake, and
as the disease progresses, weight loss despite hunger and increased food intake.
Clients with diabetes mellitus are living longer, with an increased risk for
development of chronic complications. Chronic complication are the major cause of
morbidity and mortality in client with diabetes mellitus. Diabetes mellitus-related
complications are classified into two types: macrovascular, including coronary artery
diseases, cerebrovascular disease, hypertension, peripheral vascular disease and
infection; and microvascular, including retinopathy, nephropathy, and neuropathy.
42
The very-low density lipoprotein and low density lipoprotein level are increased and
high density lipoproteins are decreased, and the most characteristic of lipid abnormality
in diabetes mellitus is an increase triglyceride level. Therefore the influence of diabetes
in these disease are not additive, it is multiplicative. Macrovascular disease tends to
occur year before the onset of clinical diabetes mellitus.
Clients with DM are two to four times more likely to have coronary artery disease
than those who do not have DM. In many clients with DM, often presents atypical or
silent CAD, that often presents as indgestion, or unexplained heart failure, dyspnea or
excretions, or epigastric pain. CAD is common in clients younger than 40 years old, of
diabetes mellitus is of long duration. DM patients with history of myocardial infarction
have higher chance of having second infarct than the patient who does not have DM.
The incidence of cerebrovascular disease is two to three times greater in diabetic client,
and is more severe. Atherothromboembolic infarction manifested by transient ischemic
attracts and cerebrovascular accidents are the most commont incidence of CVD that are
the complication of DM.
Hypertension has increased of 40% occurrence in diabetic population. Hypertension
is a major risk factor for stroke and nephropathy.
Diabetis mellitus augments the process of atherosclerosclerosis by variety of
mechanism thus causing peripheral vascular disease. Hyperglycemia and insulin
resistance contribute to endothelial dysfunction by decreasing available nitric oxide
bioavailability and altering the function of various cell mediators.
Clients with diabetes are susceptible to different type of infection. Three factors may
contribute to the development of infection are impaired polymorphonuclear-leukocyte
function, diabetic nephropathies and vascular insufficiencies. Damaged area heals
slowly because the damaged vascular system cannot carry sufficient amount of oxygen,
white blood cells, nutrients and antibodies to the injured site. Infection increases the
need for insulin and enhances the possibility of ketoacidosis. Urinary tract infection is the
most
common
infection
especially
in
women.
Factors
that
impairs
the
polymorphonuclear-leukocyte is the presence of glycosuria and the development of

neurogenic bladder, which results in incomplete emptying and or urinary stasis.
About 80% of clients with DM have some form of retinopathy, the exact cause of
retinopathy is not understood but it is probably a multifactorial and associated with
protein glycosylation, ischemia, and hemodynamics mechanism that increases the
permeability and decreases the elasticity of capillaries.
43
About 20% of diagnosed DM type 2 patients have nephropathy 5 to 10 years after

diagnosis. A consequence of microangiopathy, nephropathy involves damage to and
eventual obliteration of the capillaries that supply the glomeruli of the kidney. This
damage leads to complex pathologic changes and manifestations such as intercapillary
glomerolonecrosis, nephrosis, gross albuminuria and hypertension. Unsuccessful
treatment of nephropathy will lead to stage 5 chronic kidney disease. Like retinopathy,
diabetic nephropathy is irreversible.
Neuropathy, the most common chronic complication of diabetes mellitus. Nearly 60%
of diabetic patients experience it. Because nerve fibers do not have their own blood
supply, they depend on diffusion of nutriens, and oxygen across membrane. When axon
and dendrites do not receive nourishment their transmission of impulses becomes slow.
Both temporary and permanent neurologic problem may develop. The neuropathy might
be mild that causing minor inconveniences or severe that quality of life is affected.
Clients might present mononeuropathy or polyneuropathy and may have motor or
sensory impairment, depending on which nerve that are involved. Mononeuropathy
usually involves single or group nerves. It produces sharp, stabbing pain and is usually
caused by an infarction of blood supply. Polyneuropathy also known as diffuse
neuropathy, which involves both sensory and autonomic nerves. Sensory neuropathy is
most common type. It is commonly assed as bilateral, symmetrical and is affecting the
lower extremity. Client may describe tingling, numbness, burning, and mild to severe
sensory loss, a major factor in injuries to the legs.
Autonomic neuropathy affects the nerves that regulate vital functions, including the heart
muscle and smooth muscles. Autonomic neuropathy involves damage to the nerves that
run through a part of the peripheral nervous system. The peripheral nervous system
includes the nerves used for communication to and from the brain and spinal cord
(central nervous system) and all other parts of the body, including the internal organs,
muscles, skin, and blood vessels. Damage to the autonomic nerves affects the function
of areas connected to the problem nerve. Some of the autonomic neuropathy are:
autonomic neuropathy of the pupil which interferes with pupils ability to adapt to dark
because pupils dilation is inadequate; autonomic neuropathy of the cardiovascular
system is evidence by abnormal response to exercise, fixed heart maybe noted;
autonomic neuropathy of gastrointestinal, client may have dysphagia, abdominal pain,
nausea, vomiting, diarrhea malabsorption, post prandial hypoglycemia, constipation, or
fecal incontinence and gastroparesis. Bladder hypotonisity of neurogenic bladder is
44
common manifestation of autonomic neuropathy of genitourinary organs. In male client it

can contribute to erectile dysfunction and retrograde ejaculation. Women may
experience painful coitus.
All of these complication can be prevented by good control of blood sugar level,
exercise and diet modification.
Medical Management
Legend: Red HIGH
Green - LOW
1.1 ACTUAL
Date
06/26/10
Definition and Normal

Range
Test
Chest
X-
The chest x-ray is the
Result
-The lungs show no
Interpretation and
Significance
Left Pleural Effusion
45
Ray
most commonly
performed diagnostic xray examination. A chest
x-ray makes images of the
heart, lungs, airways,
blood vessels and the
bones of the spine and
chest.
An x-ray (radiograph) is a
noninvasive medical test
that helps physicians
diagnose and treat
medical conditions.
Imaging with x-rays
involves exposing a part
of the body to a small
dose of ionizing
radiation to produce
pictures of the inside of
the body. X-rays are the
oldest and most frequently
used form of medical
imaging.
definite recent evidence

of active pulmonary
infiltrates.
-Heart is magnified.
-Aortic knob is calcified.
-Left costrophenic sulcu
is blusted. Diaphragm
and right costrophenic
sulcus are intact.
-Old healed fracture is
appreciated in the 5th
right posterior rib.
-The rest of the included
structure are
unremarkable.
- may compress the

lungs and cause
collapse of the alveoli;
impairing gas exchange
and result to respiratory
distress
Atherosclerotic Aorta
- the thrombus that
formed in the intimal
layer of the aorta may
dislodge and become an
emboli and travels to the
pulmonary circulation,
causing pulmonary
embolism and later on
would result to CHF, or
travel to the systemic
circulation obstructing
blood flow to the
peripheries causing
hypotension or worse
tissue necrosis.
Old healed fracture left
5th posterior rib
-may become brittle as
client aged. It might
break again and cause
injury to the underlying
organs.
06/26/10
Complete
Blood
Count
The complete blood count

(CBC) is one of the most
commonly ordered blood
tests. The complete blood
count is the calculation of
the cellular (formed
elements) of blood.
Normal Values:
Hemoglobin
Erythrocyte
MCH
MCV
MCHC
Leukocytes
Neutrophils
Lymphocytes
Monocytes
Eosinophils
140-180
4.5-5.0
27-33
80-96
32-36
5-10
0.55-0.65
0.25-0.40
0.02-0.06
0.01-0.05
Hemoglobin
Erythrocyte
MCH
MCV
MCHC
121
3.88
31.1
95.0
Leukocytes
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Hematocrit
Platelet
12.1
0.70
0.17
0.08
0.05
0.00
0.37
278
Decreased hemoglobin
and erythrocyte
-indicates anemia. If
RBC is decreased, the
hemoglobin decreases
also. This means that
exchange of gases
between the alveoli, and
the capillary beds are
affected, and there will
be less oxygenated
blood circulating the
body, and hypoxia
results.
This is caused by
impaired production of
erythropoietin by the
kidney. Eythropoietin
stimulates the bone
marrow to produce blood
products especially RBC.
Increased Leukocytes
46
Basophils
Hematocrit
Platelelt
-Increase in number
indicates infection or
damage caused by
bacteria, viruses, etc.
The patient is diagnosed
to have UTI, specifically
cystitis.
0.000-0..005
0.40-0.48
150-300
Increased Neutrophils
-Also indicates infection.
Neutrophils are avid
phagocytes at sites of
acute infection.
Decreased
Lymphocytes
-Patient is prone to
immunosupression since
his lymphocytes are
small in number.
Lymphocytes play an
important role in immune
response (B and T
lymphocytes).
Increased Monocytes
-Indicates chronic
infection. Monocytes are
active phagocytes that
become macrophages in
the tissues. They are
called the long-term
clean-up team.
Decreased Hematocrit
-Hemodilution or there is
decreased concentration
of RBC in the blood.
Plasma volume is
increased because of
fluid shifting.
For 06/28/10:
Same results +
06/28/10
Hemoglobin
Erythrocyte
MCH
MCV
MCHC
Leukocytes
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Hematocrit
Platelet
107
3.46
31.0
94.7
32.8
15.5
0.70
0.16
0.08
0.05
0.01
0.37
322
High Platelet
-Risk for
coagulation/clotting, and
may lead to
arteriosclerosis due to
thrombus formation.
For 07/02/10:
47
07/02/10
Hemoglobin
Erythrocyte
MCH
MCV
MCHC
Leukocytes
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Hematocrit
Platelet
06/26/10
Urine
Culture and
Sensitivity
A urine specimen is
collected tested for growth
of microorganisms.
Antibiotics are also tested
if the discovered microbe
is sensitive to the drug.
06/26/10
Serum
Electrolytes
Tests that measure the

concentration of
electrolytes are needed
for both the diagnosis and
management of renal,
endocrine, acid-base,
water balance, and many
other conditions. Their
importance lies in part
with the serious
consequences that follow
from the relatively small
changes that diseases or
abnormal conditions may
cause.
07/01/10
07/02/10
Normal:
Creatinine
Albumin
Sodium
Potassium
Calcium
Magnesium
Alanine
Aminotransfe
rase
53-115
34-50
136-145
3.5-5.1
2.12-2.52
0.79-0.99
30-65
94
3.10
30.4
91.8
33.1
12.6
0.78
0.13
0.05
0.04
0.00
0.28
466
Multiple Growth of
Microorganisms
Creatinine
Albumin
Sodium
Potassium
Calcium
Magnesium
Alanine
Aminotransfe
rase
272.8
17
126
4.7
1.81
0.87
37
Creatinine
Albumin
Sodium
Potassium
Calcium
359.6
25
131
4.0
2.06
Creatinine
Sodium
Potassium
389.0
131
4.2
Same results with the

first two tests except:
-Number of monocytes
normalized.
-Result proves infection

of the urinary tract
(cystitis).
-Increased creatinine levels

in the blood suggest
diseases or conditions that
affect kidney function.
Creatinine reflects glomeruli
filtration rate.
Some signs and
symptoms of kidney
dysfunction include:
Fatigue, lack of
concentration, poor
appetite, or trouble
sleeping
Swelling or
puffiness, particularly
around the eyes or in
the face, wrists,
abdomen, thighs or
ankles
Urine that is
foamy, bloody, or
coffee-colored
A decrease in the
amount of urine
Problems
urinating, such as a
burning feeling or
abnormal discharge
during urination, or a
change in the
frequency of urination,
especially at night
Mid-back pain
(flank), below the ribs,
near where the
kidneys are located
48
High blood
pressure
-Low sodium affects the
neuromuscular function
and water-electrolyte
balance in the body.
- On the cellular level,
calcium is used to
regulate the
permeability and
electrical properties of
biological membranes
(such as cell walls),
which in turn control
muscle and nerve
functions, glandular
secretions, and blood
vessel dilation and
contraction. Ca
deficiency can make the
muscles or tissues
spastic, therefore
contractility is impaired.
-Renal kidney
dysfunction can cause
hypoalbuminemia, since
more albumin is
excreted in the urine.
Ascites, muscle
weakness, and fatigue
can be brought about by
low albumin in the
blood.
06/27/10
Urinalysis
Tests for specific gravity

(urine concentration or the
amount of solutes present
in the urine), and
presence of abnormal
constituents such as pus
cells, glucose, protein,
and RBC.
Urinalysis is the physical,
chemical, and microscopic
examination of urine. It
involves a number of tests
to detect and measure
various compounds that
pass through the urine.
Normal:
Color
Appearance
Reaction
Straw,
amber
Transparen
t
4.5 - 8
Color
Appearance
Reaction
Specific
gravity
Chemical
Characteristics
Pus Cells
RBC
Yellow
Cloudy
6.0
1.00
Alb- trace
Sugar-+++
20-30
1-2
-Urine is not
concentrated since color
is not dark. Cloudy urine
indicates presence of
WBC, bacteria, pus,
contaminants, or
prostatic fluid.
Glycosuria indicates high
blood glucose levels and
maybe indicative of
uncontrolled DM.
Hematuria can be
caused by irritation or
injury to endothelial wall
of the ureters
Proteinuria indicates
kidney damage.
There is an increased
pus cells which means
infection is present.
49
Specific
gravity
Chemical
Characterist
ics
Pus Cells
RBC
06/26/10
ABG Test
1.0101.025
Alb- absent
Sugarabsent
1-5 hpf
none
The test is used to

determine the pH of the
blood, the partial
pressure of carbon
dioxide and oxygen, and
the bicarbonate level.
pH
PCO2
PO2
HCO3
TCO2
BE
O2 Sat
7.37
67 acidosis
83
15 acidosis
16
-8.3
96%
pH
PCO2
PO2
HCO3
TCO2
BE
O2 Sat
7.385
27.9 alkalosis
79.8
16.3 acidosis
17.2
-6.8
95.6%
Normal Values:
pH
PCO2
PO2
HCO3
TCO2
BE
O2 Sat
7.35-7.45
35-45
80-100
22-26
25-30
+/-1
95-100%
06/27/10
06/28/10
Lipoprotein
Profile with
Glucose
and Uric
Acid
The lipid profile is a group of

tests that are often ordered
together to determine risk
of coronary heart disease.
They are tests that have
been shown to be good
indicators of whether
someone is likely to have
Cholesterol
LDL
TGL
HDL
Glucose
Uric Acid
4.0
3.0
1.35
0.40
6.7
0.31
-A high
PaCO2 (respiratory
acidosis) indicates
underventilation.
Carbon dioxide is
produced constantly as
the body burns energy,
and this CO2 will
accumulate rapidly if the
lungs do not adequately
dispel it
through alveolar ventilati
on. Alveolar
hypoventilation thus
leads to an
increased PaCO2 (called
hypercapnia). The
increase in PaCO2in turn
decreases the
HCO3/PaCO2 ratio and
decreases pH.
-A low HCO2 indicates
metabolic acidosis
which is a condition that
occurs when the body
produces too much acid
or when the kidneys are
not removing enough
acid from the body.
Fully Compensated
Metabolic Acidosis
-There is very little high

density lipoprotein or
good cholesterol which
implies that there is
lesser chance for the
remaining HDL to
remove more cholesterol
from atheromas within
50
the arteris and transport

it back to the liver for
excretion or re-utilization.
a heart
attack or stroke caused by
blockage of blood vessels or
hardening of the arteries
(atherosclerois).
Normal Values:
Cholesterol
LDL
TGL
HDL
Glucose
Uric Acid
06/28/10
Ferritin
Test
0.0-5.2
0.0-3.4
0.00-1.70
0.90-1.55
3.9-6.1
0.16-0.43
The ferritin test is ordered to

assess a person's iron stores
in the body. The test is
sometimes ordered along
with an iron test and
a TIBC to detect the
presence and evaluate the
severity of an iron deficiency
or overload.
Ferritin is a protein that
releases iron in a controlled
fashion.
Ferritin = 1021.71 ng/mL
If there is damage in the

liver (where ferritin is
stored), ferritin levels can
become elevated
because livers function
is affected. Also, low iron
or hemoglobin coupled
with increase ferritin
production is a sign of a
chronic illness.
Left Kidney
Right Kidney
11.3
Length
11.1
4.0
Width
4.7
4.6
Thick
4.9
1.8
C. Thick
1.6
-No significant disparity

in size, shape and
location of the kidneys
and both show intact
central echocomplexes
of both renal
corticomedullary
differentiation.
-There is an increase in
the echogenecity of both
renal cortices relative to
the liver and spleen.
-No focal lesions.
-Ureters are not dilated.
-Urinary bladder distends
adequately.
-Has smooth thickened
walls with trabeculations.
-Prostate gland
measures: 40mm x 47
mm x 26 mm, 26 grams.
-Pre void urine volume is
about 437 cc.
-Post void scan shows
76% (333 cc) residual
urine.
Normal Values:
Men: 68-236 ng/mL
Women: 9.3-58 ng/mL
06/28/10
KUB/Prost
ate USD
It is an ultrasound-based
diagnostic medical
imaging technique used to
visualize muscles,
tendons, and many
internal organs, to capture
their size, structure and
any pathological lesions
with real time tomographic
images.
Normal Size in cm:
Left Kidney
Right Kidney
10.8 +- Length
9.7 +0.8
0.7
4.2 +
Width
4.3 +-0.5
0.5
4.8 +Thick
3.9 +0.5
0.5
1.5
C. Thick
1.5
51
Impression:
-Diffuse Bilateral Renal
Parenchymal Disease
-Cystitis
-Grade 1 Prostatic
Enlargement
-Ultrasonographically
normal ureters
-Significant urinary
bladder retention
07/2/10
Arterial
Duplex
Scan
Arterial duplex scan is a

painless exam that uses
high-frequency sound
waves (ultrasound) to
capture internal images of
the major arteries in the
arms, legs and neck.
-Intimal irregularities with

occasional type III and V
plaques in the bilateral
popliteal arteries with
normal triphasic
waveform pattern with full
color except the bilateral
posterior tibialis arteries
and bilateral dorsalis
pedis arteries with
monophasic waveform
patterns.
-No focal increase in flow
velocities noted.
Peripheral Arterial
Disease >50% stenosis
bilateral posterior tibilais
arteries & bilateral
dorsalis pedis arteries.
Peripheral arterial
disease <50% stenosis
bilateral common
femoral arteries, bilateral
superficial femoral
arteries, bilateral
popliteal arteries.
Incomprehensive
arteries bilaterally
07/02/10
Creatinine
Clearance
Test
07/04/10
A creatinine clearance test

measures how well
creatinine is removed from
your blood by your
kidneys. A creatinine
clearance test gives better
information than a blood
creatinine test on how well
your kidneys are working.
A creatinine clearance test
is done on both a blood
sample and on a sample
of urine collected over 24
hours (24-hour urine
sample).
Crea: 1.53 q/24 hr
Crea: 14.1 mg/dL
Creatinine in the 24 hr
urine
sample
falls
between the
normal
range.
Due to impaired kidney
function, creatinine in the
blood elevates.
Normal Values:
24 hr urine: 0.6-1.6 q/24 h
Blood: 0.8-1.4 mg/dL
1.2 POSSIBLE
Test
Rationale
Result (Normal
Values)
Interpretation
and Significance
Nursing
Responsibilities
52
Uric Acid
Test
The patient has

been complaining of
pain in the pelvic
area. Since he has
CKD, his kidneys
might have broken
down purine
(protein) rather very
fast causing
accumulation to the
joints. It has to be
checked to know if
the patient is
suffering from gout,
Some patients with
high levels of uric acid
have a disease
called gout, which is
an inherited disorder
that affects purine
breakdown. Patients
with gout suffer from
joint pain, most often
in their toes but in
other joints as well.
Male:
mg/dL
2.1-8.5
Female: 2.0-7.0
mg/dL
High uric acid level

indicates impaired
GFR and
destruction of RBC
to purine.
Evaluate or
continuously monitor
degree of joint
inflammation or pain.
Level of activity
or exercise depends on
progression and
resolution of
inflammatory process.
Maintain bed rest
or chair rest when
indicated. Schedule
activities providing
frequent rest periods and
uninterrupted night time
sleep.
Systemic rest during
acute attacks and
important throughout all
phases of disease to
reduce fatigue and
improve strength.
Encourage adequate
fluid intake.
To assist with
excretion of uric acid
and
decrease likelihood of
stone formation.
Assist with active or
passive range of motion.
Maintains or improves
joint function, muscle
strength, and general
stamina.
Encourage patient to
maintain upright and
erect posture when
sitting, standing, or
walking.
Maximizes joint
function, maintains
mobility.
Encourage the patient
to avoid alcohol.
Alcohol precipitates
acute attacks.
Review foods that
are rich in purines
like sardines, anchovies,
shell fish and organ
meats.
These foods are rich
in purine. Uric acid is by
53
product of purine
metabolism in the liver.
Provide safety needs.
Prevents injuries and
falls.
Administer antiinflammatory drugs and
also colchicines as
prescribed.
These medications
relieve pain and
swelling during acute
attacks.
Management
Therapuetics
Date
Order
Rationale
06/27/10
Venoclysis of PNSS1L to run at KVO

rate.
NSS is a solution of common salt in

distilled water, of strength of 0.9%. It is
called normal saline because the
percentage of salt resembles that of the
crystalloids in the blood plasma. It is an
isotonic solution. It is less irritating for
the body cells. It is used to patients
with salt and water deprivation. KVO
rate is ordered for prophylactic access.
06/27/10
I & O q shift and VS q 4
This measures how much fluids are

taken and how much has been
excreted. This also indicates any
problem in the kidneys. Vital signs are
done every 4 hours to monitor the
clients well being such as temperature
which is indicative of hyperthermia.
O6/27/10
Calibrated diabetic diet
Diet for diabetic patients must be

accurately weighed or gauged. Too
many carbohydrates mean too much
glucose; too much protein and fats may
overwork the liver and kidneys.
06/27/10
Increase oral fluid intake
To minimize formation of crystals in the

urine.
06/27/10
Lipid profile, CBC, serum uric acid, KOH

and urine culture
These laboratory tests measures the

body chemistry such lipoproteins, blood
54
products, nitrogenous wastes, and

presence of infection in the urinary
system.
06/27/10
Doppler scan the left extremity
To determine adequate blood flow in

the extremities and to rule out any
obstruction.
06/27/10
Weighing once a day
To monitor any weight gain due to

edema or increased extra-cellular fluid.
06/27/10
Nebulization q 6 with Berodual
Berodual is a bronchodilating and

anticholinergic agent which gives of
parasympatholytic effects. It relieves
bronchospasms.
06/27/10
Hgt q 6
To monitor any fluctuations in the blood

glucose
levels
and
evaluate
effectiveness of insulin taking.
06/28/10
IVF rate to 60 cc/hr
06/30/10
Moderate high back rest
06/30/10
Abdominal girth measurement
07/04/10
Physical therapy session 3x
07/05/10
Insertion of foley catheter
To relieve urinary retention
07/07/10
Removal of foley catheter
For discharge
To combat dehydration.
Promotes thoracic
facilities breathing.
expansion
and
Measures extent of ascites

Promotes well being of an elderly
client; facilitates fast recovery
Drug Study
Domperidone
55
Motilium (1 tab, 100 mg)

Classification: Anti-emetic and anti-vertigo
Desired Dosage and Directions for use: Acute conditions (mainly nausea, vomiting,
hiccup)
Adults: Two tablets (20 mg) 3 to 4 times per day, 15 to 30 minutes before meals and, if
necessary, before retiring.
Chronic conditions (mainly dyspepsia) Adults: One tablet (10 mg) taken 3 times per day,
15 to 30 minutes before meals and, if necessary, before retiring. The dosage may be
doubled.
Mode of Action: Domperidone is a dopamine-receptor blocking agent. Its action on the
dopamine-receptors in the chemo-emetic trigger zone produces an anti-emetic effect.
Interactions:
Concomitant administration of anti-cholinergic drugs may inhibit the antidyspeptic effects of MOTILIUM.
Anti-muscarinic agents and opioid analgesics may antagonize the effect of

MOTILIUM
MOTILIUM suppresses the peripheral effects (digestive disorders, nausea and

vomiting) of dopaminergic agonists.
Since MOTILIUM has gastro-kinetic effects, it could influence the absorption of

concomitant orally administered medicines, particularly those with sustained
release or enteric coated formulations.
As MOTILIUM interferes with serum prolactin levels, it may interfere with other
hypoprolactinaemic agents and with some diagnostic tests.
Antacids and anti-secretory agents lower the oral bioavailability of domperidone.

They should be taken after meals and not before meals, i.e. they should not be
taken simultaneously with MOTILIUM.
Reduced
gastric
acidity
impairs
the
absorption
of
domperidone.
Oral bioavailability is decreased by prior administration of cimetidine or sodium

bicarbonate
Side Effects:
Allergic reactions, such as rash or urticaria, have been reported.
Abdominal cramps have been reported.
Dystonic reactions (extrapyramidal phenomena) may occur.
56
Reversible raised serum prolactin levels have been observed which may lead to
galactorrhoea and gynaecomastia.
Hypertensive crises in patients with phaeochromocytoma may occur with

administration of domperidone.
Where the blood brain barrier is not fully developed (mainly in young babies) or is
impaired, the possible occurrence of neurological side-effects cannot be totally
excluded
Nursing Responsibilities:
1. Assess for extra-pyramidal effects such as jerking and tongue protrusion.
2. Check for hypotension.
Imdur
Durule (60 mg tab OD @ HS)
Classification: Anti-anginal
Desired Dosage: 60 mg once daily in the morning, may be
increased
to
120
mg
daily
in
the
morning.
If headache occurs, the dose may initially be reduced to

30 mg daily for the 1st 2-4 days.
Mode of Action: The principal pharmacological action of isosorbide-5-mononitrate, an
active metabolite of isosorbide dinitrate, is relaxation of the vascular smooth muscle,
producing vasodilatation of both arteries and veins, with the latter effect predominating.
The effect of the treatment is dependent of the dose. Low plasma concentrations lead to
venous dilatation, resulting in peripheral pooling of blood, decreased venous return and
reduction in left ventricular end-diastolic pressure (preload). High plasma concentrations
also dilate the arteries reducing systemic vascular resistance and arterial pressure
leading to a reduction in cardiac afterload.
Isosorbide-5-mononitrate may also have a direct dilating effect on the coronary arteries.
By reducing the end-diastolic pressure and volume, the preparation lowers the
intramural pressure, thereby leading to an improvement in the sub-endocardial blood
flow. The net effect when administering isosorbide-5-mononitrate is therefore a reduced
workload of the heart and an improved oxygen supply/demand balance in the
myocardium.
57
Interactions: Concomitant administration of Imdur and phosphodiesterase type 5

inhibitors can potentiate the vasodilatory effect of Imdur with the potential results of
serious side effects as syncope or myocardial infarction.
Side Effects:
Most of the adverse reactions are pharmacodynamically mediated and dose

dependent. Headache may occur when treatment is initiated, but usually
disappears during continued treatment.
Hypotension with symptoms eg, dizziness and nausea with syncope in isolated
cases, has occasionally been reported. These symptoms generally disappear
during continued treatment.
Cardiovascular System: Common: Hypotension, tachycardia
Central Nervous System: Common: Headache, dizziness. Rare: Fainting.
Gastrointestinal: Common: Nausea. Uncommon: Vomiting, diarrhea.
Musculoskeletal: Very Rare: Myalgia.
Skin: Rare: Rash, pruritus.
1. Check for hypotension.
2. Put patient on bed rest because of fainting. Provide supervision when ambulating.
3. Perform nonpharmacologic measures for nausea and vomiting such as letting client to
drink weak tea, Gatorade, carbonated beverages, pedialyte and eat gelatin, crackers
and dry toast.
Calcium Carbonate
(1 tab tid)
Classification: Electrolyte replacement or
supplements. Antacid
Desired Dosage: 500 mg (200 mg Ca), 600 mg (240 mg Ca), 650 mg (260 mg Ca), 667
mg (266.8 mg Ca), 1 g (400 mg Ca), 1.25 mg (500 mg Ca), 1.5 mg (600 mg Ca)
58
Mode of Action: Essential for nervous, muscular, and skeletal systems. Maintain cell
membrane and capillary permeability. Act as an activator in the transmission of nerve
impulses and contraction of cardiac, skeletal and smooth muscles. It is essential for
bone formation and blood coagulation. It is also used a replacement of calcium in
deficiency states. It controls of hyperphosphatemia in end-stage renal disease without
promoting aluminum absorption.
Interactions: Hypercalcemia increases the risk of digoxin toxicity. Chronic use with
antacids in renal insufficiency may lead to milk-alkali syndrome. Ingestion by mouth may
decrease the absorption of orally administered tetracyclines, fluoroquinolones,
phenytoin, and iron salts. Excessive amounts may decrease the effects of calcium
channel blockers, atenolol. Concurrent use with diuretics may result in hypercalcemia.
Side Effects:
CNS: syncope, tingling
CV: cardiac arrest, arrythmias, bradycardia
GI: constipation, nausea, vomting
GU: calculi, hypercalciuruia
Local: phlebitis (IV only)
1. Monitor VS especially BP and PR.
2. Obtain ECG result.
3. Asses for heartburn, indigestion, abdominal pain.
4. Monitor serum calcium before treatment.
5. Assess for nausea and vomiting, anorexia, thirst, severe constipation.
Metoprolol
Beloc, Betaloc Durules, Lopresor, Metoprol (100
mg 1 tab q 12 hrs)
Classification: Anti-anginal and Anti-hypertensive:
Beta-blockers
59
Desired Dosage: (PO) 25-100 mg/day as a single dose initially divided or 2 divided
doses; maybe increased q 7 days as needed up to 450 mg/day.
Mode of Action: Blocks stimulation of beta1 (myocardial)-adrenergic receptors. It does
not usually affect beta2 (pulmonary, vascular, uterine)-adrenergic receptor sites. It also
decreases blood pressure and heart rate. It decreases frequency of attacks of angina
pectoris, and decreases rate of cardiovascular mortality and hospitalization in patients
with heart failure.
Interaction:
Additive effect with catecholamine-depleting drugs e.g. reserpine and MAOIs.
May antagonise 1-adrenergic stimulating effects of sympathomimetics.
Additive negative effects on SA or AV nodal conduction with cardiac glycosides,

nondihydropyridine calcium-channel blockers.
Increased oral bioavailability with aluminium/magnesium-containing antacids.
Paradoxical
response
concentrations
to
epinephrine
may
with
occur.
CYP2D6
Increased
plasma
inhibitors
(e.g. bupropion, cimetidine,diphenhydramine, fluoxetine,

hydroxycholoquine, paroxetine, propafenone, quinidine,ritonavir, terbinafine,
thioridazine).
Increased risk of hypotension and heart failure with myocardial depressant

general anaesthetics (e.g. diethyl ether).
Risk of pulmonary hypertension with vasodilators e.g. hydralazine in uraemic

patients.
Reduced plasma levels with rifampicin.
May increase negative inotropic and negative dromotropic effect of antiarrhythmic drugs e.g. quinidine and amiodarone.
Propafenone may increase serum levels of metoprolol.
Concurrent use with indomethacin may reduce the antihypertensive efficacy of blocker.
May reduce clearance of lidocaine.
May increase effects of hypoglycemics.
Efficacy may be reduced by isoprenaline.
60
Concurrent use with digoxin may lead to additive bradycardia.
1. Monitor blood pressure, and pulse frequently.
2. Monitor intake and output ratios and daily weight.
3. Assess routinely for signs and symptoms of CHF (dyspnea, rales, crackles, weight
gain, peripheral edema, jugular venous distention)
4. Take apical pulse before administering. If <50bpm or if arrhythmia occurs, withhold
medication and notify health care professional.
5. Administer metoprolol with meals or directly after eating.
6. Caution patient minimize activities that require alertness because metoprolol can
cause dizziness.
7. Caution patient that this medication can increase sensitivity to cold.
8. Instruct to avoid caffeinated drinks like teas and colas.
9. Monitor blood glucose levels especially if weakness, malaise, irritability, or fatigue
occurs.
10. Reinforce the need to continue additional therapies for hypertension such as sodium
restriction, stress reduction, regular exercise)
11. Emphasize compliance to the medication.
Prednisone
Sterapred (5000 u 2x/week SC)
61
Classification: Systemic corticosteroids, anti-asthmatics

Desired Dosage: (PO) 5-60 mg/day as single dose or in divided doses.
Mode of Action: It suppresses inflammation and the normal immune response.
Prednisone is biologically inert and converted to the predominantly prednisolone in the
liver. It decreases inflammation by suppression of migration of polymorphonuclear
leukocytes and reversal of increased capillary permeability; suppresses the immune
system by reducing activity and vol of the lymphatic system; suppresses adrenal function
at high doses.
Interaction:
Increase risk of hypokalemia with thiazide and loop diuretics, or amphotericin B.
May increase requirement for insulin or oral hypoglycemic agents.
Pheytoin, Phenobarbital, and rifampin increase metabolism; may decrease

effectiveness.
At chronic cases, may decrease antibody response to and increase risk of

adverse reactions from live-virus vaccines.
Antacids decrease absorption of it.
Increase risk of GI ulceration with NSAIDs.
Side Effects:
Insomnia,
nervousness,
increased
appetite,
indigestion,
dizziness/lightheadedness, headache, hirsutism, hypopigmentation, diabetes

mellitus, glucose intolerance, hyperglycaemia, arthralgia, cataracts, glaucoma,
epistaxis, diaphoresis, Cushing's syndrome, edema, fractures, hallucinations,
hypertension, muscle-wasting, osteoporosis, pancreatitis, pituitary-adrenal axis
suppression, seizures
Nursing Responsibilities.
1. Assess for adverse effects
2. Implement safety measures to prevent falls and fractures.
62
3. Monitor clients with diabetes for hyperglycemia.

4. Assess for fluid and electrolyte imbalance.
5. Assess stools for melena.
6. Administer with food to minimize gastric irritation.
7. Instruct to avoid people with active infection because resistance is low.
8. Instruct to avoid activities that could cause bone fracture.
9. Not to take NSAIDs unless directed.
10. Increase intake of protein, calcium, and potassium.
Albumin 25%
Albuminar, Albutein, Buminate, Normal Human Serum Albumin,
Plasbumin (50cc + Furosemide 20 mg x 4 to OD)
Classification: Volume expanders, blood products, colloids
Desired Dosage: (IV) 12.5-50 g/day in 3-4 divided doses. (Availability Injection: 250
mg/mL)
Mode of Action: It provides colloidal oncotic pressure, which serves to mobilize fluid from
extravascular tissues back into intravascular space. It increases intravascular fluid
volume.
Interactions: Do not mix with protein hydrolysates, amino acid solution and alcohol.
Side Effects:
CNS: Headache
CV: Pulmonary edema, fluid overload, hypertension, hypotension, tachycardia
GI: Vomiting, increased salivation, nausea

63
Derm: Rash, urticaria
MS: Back pain
Chills, fever, flushing
1. Monitor vital signs, and intake and output.
2. Assess for signs of vascular overload such as elevated CVD, rales/crackles, dyspnea,
hypertension, jugular venous distention) during and after administration.
3. Monitor serum sodium levels because it may cause increase concentrations.
4. Solution should be clear amber, and do not administer solutions that are discolored or
contain particulate matter.
Sodium Bicarbonate
Baking Soda, Bell-Ans, Citrocarbonate, Neut, Soda Mint (650 mg 1
tab tid)
Classification: Anti-ulcer agent and alkalinizing agent
Desired Dosage: Alkalinization of urine: (PO) 48 mEq or 4 g initially. Then 1-2 g q4 hr or
1 tsp of powder q4 hr as needed. Metabolic acidosis: >4.8 g/day as needed.
Mode of Action: Acts as an alkalinizing agent by releasing bicarbonate ions. It is used to
alkalinize urine and promote excretion of certain drugs in overdosage situations.
Interactions: Increase toxicity of amphetamins, ephedrine, pseudoephedrine, flecainide,
quinidine and quinine. It decreases effects of lithium, chlorpropamide and salicylates due
to increased clearance. It may affect the absorption of certain drugs due to raised intragastric pH.
64
Side Effects: Metabolic alkalosis; mood changes, tiredness, shortness of breath, muscle
weakness, irregular heartbeat; muscle hypertonicity, twitching, tetany; hypernatraemia,
hyperosmolality, hypocalcaemia, hypokalaemia; stomach cramps, flatulence.
1. Assess for signs of acidosis (disorientation, headache, weakness, dyspnea,
hyperventilation), alkalosis (confusion, irritability, paresthesia, tetany, altered breathing
pattern), hypernatremia (edema, weight gain, hypertension, tachycardia, fever, flushed
skin, mental irritability), or hypokalemia (weakness, fatigue, arrhythmias, polyuria,
polydypsia)
2. Assess fluid balance (intake and output, daily weight, edema, lung sounds)
3. Take med with full glass of water.
4. Monitor serum electrolyte concentrations, serum osmolarity, acid-base balance, and
renal function prior to and periodically through out the therapy.
Clonazepam
Rivotril (1/4 tab daily)
Classification: Anticonvulsant
Desired Dosage: 0.5 mg 3x daily
Mode of Action: It produces sedative effects in the CNS, probably by stimulating
inhibitory GABA receptors. It prevents seizures and decreases manifestations of panic
disorder.
Interactions:
CNS
depression
with
alcohol,
antidepressants,
antihistamines,
other
benzodiazepines, and opioid analgesics.
65
Cimetidine,
hormonal
contraceptives,
disulfiram,
fluoxetine,
isoniazid,
ketoconazole, metoprolol, propoxyphene, propanolol, or valproic acid may

decrease metabolism of clonazepam.
Sedative effects with theophylline.
Side Effects: Fatigue, somnolence, muscular hypotonia, coordination disturbances,

aggressiveness, irritability or agitation.
1. Assess for drowsiness, unsteadiness, and clumsiness. These symptoms are dose
related and most sever during initial therapy.
2. Administer with food to minimize gastric irritation.
3. Have CBC and liver function test results evaluated periodically because it may cause
increase in serum bilirubin, AST and ALT.
Epoetin B
Recormon (5000 u SC)
Classification: Hematopoeitic Agent
Desired Dosage:
50-100 u/kg 3x weekly initially, then adjust dose base on Hct.
Anemia w/ CRF: Correction phase SC inj Initially, 3 x 20 iu/kg/wk, may be

increased every 4 wk by 3 x 20 iu/kg/wk if the increase of packed cell vol (PCV) is
inadequate (< 0.5% per wk). Wkly dose can be divided into daily doses or administered
as a single dose. Max: 720 iu/kg/wk. IV inj Initially, 3 x 40 iu/kg/wk. Dose may be
increased after 4 wk to 3 x 80 iu/kg/wk. If further increments are needed, increase at 20
iu/kg 3 times wkly at mthly intervals. Max: 720 iu/kg/wk.
66
Maintenance phase In SC inj, to maintain a PCV of 30-35%, initially reduce to

of the previously administered amount. Subsequently, adjust dose at 1-2 wk intervals
individually for the patient. Patient stable on a once-wkly dosing regimen may be
switched to once every 2 wk administration.
Prevention of anaemia of prematurity SC inj 3 x 250 iu/kg/wk for 6 wk.

Increasing the amount of autologous blood SC or IV inj Twice wkly over 4 wk.
Max IV Dose: 1,600 iu/kg/wk. Max SC Dose: 1,200 iu/kg/wk.
Symptomatic anaemia in cancer SC inj 1 inj/wk or 3-7 divided doses/wk.

Recommended Dose: Initially, 30,000 iu/wk (approx 450 iu/kg body wt/wk based on ave
wt). Treatment is indicated if haemoglobin value is 11 g/dL (6.83 mmol/L), should not
exceed 13 g/dL (8.07 mmol/L). After 4 wk therapy, if haemoglobin value increased by at
least 1 g/dL (0.62 mmol/L), continue therapy; if not, double the wkly dose. After 8 wk, if
value has not increased by at least 1 g/dL, discontinue therapy. After the end of
chemotherapy, continue therapy up to 4 wk. Max: 60,000 iu/wk. When therapeutic
objective has been achieved, reduce dose by 25-50% to maintain haemoglobin at that
level, may reduce further to ensure haemoglobin level does not exceed 13 g/dL. If >2
g/dL (1.3 mmol/L) haemoglobin rise in 4 wk, reduce dose by 25-50%.
Mode of Action:
Epoetin beta is identical in its amino acid and carbohydrate composition to erythropoietin
that has been isolated from the urine of anemic patients. Erythropoietin is a glycoprotein
that stimulates the formation of erythrocytes from precursors of the stem cell
compartment. It acts as a mitosis-stimulating factor and differentiation hormone.
After administration of epoetin beta, the number of erythrocytes, the Hb values and
reticulocyte counts increase as well as the 59Fe-incorporation rate. An increased 3Hthymidine incorporation in the erythroid-nucleated spleen cells has been found in
vitro (mouse spleen cell culture) after incubation with epoetin beta.
Interaction: The clinical results obtained so far do not indicate any interaction of
Recormon with other substances. Incompatibilities: To avoid incompatibility or loss of
activity, do not mix with other drugs or infusion solutions.
67
Side Effects:
CNS: Seizures, headache
CV: Hypertension, thrombotic events such as MI or stroke
Derm: Transient rashes
1. Monitor blood pressure before and after therapy. Additional antihypertensive drug
maybe required during initiation of therapy.
2. Monitor Hct and other hematopoietic parameters (CBC with differential and platelet
count)
3. Monitor renal function studies and electrolytes closely. Increase in BUN, creatinine,
uric acid, phosphorus, and potassium may occur.
4. Do not shake vial because inactivation of medication may occur.
5. Discard vial immediately after withdrawing dose from single-use 1-ml vial. Refrigerate
multi-dose 2-ml vial; stable for 21 days after initial entry.
6. Stress importance of compliance with dietary restrictions, medications, and dialysis.
Foods high in iron and low in potassium include liver, pork, veal, beef, mustard and
turnip greens, etc
Gabapentin
Neurontin (300 mg 1 tab @ night)
Classification: Analgesic adjuncts, anticonvulsants, mood
stabilizers
Desired Dosage: CCr 30-60 mL/min300 mg 2x daily; 1530 mL/min300 mg 1x daily.
68
Mode of Action: Mechanism of action is not known. It may affect transport of amino acids
across and stabilize neuronal membranes. It can decrease incidence of seizures.
Gabapentin is structurally related to the neurotransmitter GABA but is neither a GABA
agonist nor antagonist. Gabapentin-binding sites have been identified throughout the
brain tissues e.g. neocortex and hippocampus. However, the exact mechanism of action
is still unknown.
Interactions:
Antacids may decrease absorption of gabapentin.
Increase risk of CNS depression with other CNS depressants like alcohol,
antihistamines, opioids, and sedatives.
Morphine may increase level of gabapentin and increase risk of toxicity.
Side Effects:
Somnolence, dizziness, ataxia, weakness, paraesthesia, fatigue, headache; nystagmus,
diplopia; nausea, vomiting, wt gain, dyspepsia; rhinitis; tremor; leucopenia; altered LFTs;
Stevens-Johnson syndrome
1. Caution patient to avoid activities that require alertness to prevent injury d/t dizziness.
2. Provide supervision when patient is ambulating.
3. Monitor for side effects and instruct patient to refer if adverse effects are felt.
Sennosides
Senokot
Classification: Laxative
Desired Dosage: 12-50 mg 1-2x daily
69
Mode of Action: Active components of senna (sennosides) alter water and electrolyte
transport in the large intestine, resulting in accumulation of water and increased
peristalsis.
Interactions: May decrease absorption of other orally administered drugs because of
decreased transit time.
Side Effects:
GI: cramping, diarrhea, nausea
GU: pink-red or brown-black discoloration of urine
F & E: electrolyte abnormalities
Misc: laxative dependence
1. Asses patient for abdominal distention, presence of bowel sounds, and usual pattern
of bowel function.
2. Assess for color, consistency, and amount of stool produced.
3. Take with full glass of water. Ideally, administer at bedtime for evacuation 6-12 hours
later. Administer on an empty stomach for a rapid result.
4. Advise patient that laxatives should be used only for short-term therapy. Long-term
therapy may cause electrolyte imbalance and dependence,
5. Encourage patient to use other forms of bowel regulation such as increasing bulk in
the diet, increasing fluid intake, and increasing mobility.
6. Inform that medication may cause change in his urines color to pink, red, violet,
yellow or brown.
Berodual (neb)
Ipratropnium Br, Fenoterol HBr
Classification: Anticholinergic
70
Indication: Acute prevention and treatment of symptoms of chronic obstructive airway

disorders with reversible bronchospasm (e.g.bronchial asthma schronic bronchitis with
or without emphysema)
Contraindication: Hypertrophic obstructive cardiomayopathy, tachyarrhythmia.
Precaution: Diabetic patient with unstable metabolism, recent myocardial infarction,
severe organic heart or vascular disorder; transient dose dependent doer in serum K+;
hyperthyroidism; narrow-angle glaucoma; urinary outflow obstruction d/t prostatic
hypertrophy.
Side effects: Tremor, restlessness, palpitation, tachycardia, dizziness, head ache,
potentially serious hypokalemia, dryness of mouth, throat irritation, allrergic reactions,
cough.
Interactions:
B2 adrenergics,
systematically absorbed anticholinergics,
xanthine
derivatives and corticosteroids may increase in effect and may occur on concurrent
administration of B2 blocker.
Availability & Prize: UDV solution for inhalation 4ml (58.85)
Inhalation solution 20 ml (932.00)
Metered aerosol 10ml (1,253.00)
Norgesic Forte
Per norgesic tab- Ophenadrine citrate 35 mg + Paracetamol
450mg.
Per norgesic forte tab- Ophenadrine
citrate 50 mg + Paracetamol 659mg.

Indication: For the relief of painful skeletal muscle spasm
associated with chronic low back pain, spasms and strains,
prolapsed intervertebral disc, muscle injury, non-articular
rheumatism (fibrisitis, myositis, & myalgia) whiplash injuries, tension head ache,
dysmenorrhea, and other acute or chronic painful muscular condition.
Dosage: Norgesic tab 1-2 tab TID.
Contraindications: Glaucoma; prostatic hypertrophy or bladder neck obstruction.
71
Precaution: Cardiac arrhythmias, tachycardia, cardiac decompensation, coronary

insuffiency, pregnancy.
Side effects: Nausea, dry mouth, blurred vision, rarely rash, drowsiness, dizziness, and
restlessness.
Prize: Norgesic Forte tab (21.00); Norgesic tab (14.00)
Cilostazol
Pletal
Classification: Antiplatelet
Action: Inhibits the enzyme cyclic adenosine monophosphate
(cAMP) phosphodiesterase III, which results in increased
cAMP in platelets and blood vessels, producing inhibition of
platelet aggregation and vasodilation.
Indication: Reduction of symptoms of intermittent claudication allowing increased
walking distance.
Contraindications: Hypersensitivity, heart failure, active bleeding, hemostatic disorders.
Use cautiously with renal dysfunction.
Availability: 50,100 mg tablets
Dosage: 100 mg po BID @ least 30 minute before or 2 hours post breakfast and dinner.
Adverse effects: CNS dizziness, head ache
CV heart failure, tachycardia, palpitations
GI diarrhea, nausea, flatulence, dyspepsia
Respiratory cough, pharyngitis, rhinitis
Others peripheral edema, infection, back pain
1. Assess patient for intermittent claudication
2. Administer on an n empty stomach, 1 hour before of 2 hours post meal.
3. Do not administer with grapefruit juice. May increase cilostazol levels.
4. Caution patient to avoid driving or other activities requiring alertness.
5. Advise patient to avoid smoking; nicotine constricts blood vessels.
6. Prevent injury which may cause bleeding.
- use soft bristled toothbrush.
- avoid sharp objects.
72
- instruct patient not to strain too much while defecating to avoid

perforating the rectal muscle.
Humulin 70/30
Insulin (mixtures)
Classification: Antidiabetics, hormones
Action: Lowers blood glucose by: stimulating glucose
uptake in skeletal muscle and fat, inhibiting hepatic
glucose production.
Contraindications: Hypoglycemia; allergy or hypersensitivy.
Precautions: In patient with real/hepatic impairment (may decrease insulin requirements)
Adverse effects: Endo Hypoglycemia
Local Erythema, lipodystrophy, pruritus, swelling
Misc Allergic reactions including anaphylaxis
Drug-Drug interactions: B-blockers, clonidine and reserpine may mask some of the
signs andsymptoms of hypoglycemia. Corticosteroids, thyroid supplements, estrogens,
isoniazid,niacin, phenothiazines and rifampin increase insulin requirements. Alcohol,
ACE inhibitors, MAO inhibitors, oral hypoglycemic agents and salicylates decrease
insulin requirements
Availability: (100 units/ml total) in 10 ml vials and 3 ml disposable delivery devices.
Nursing Interventions:
1. Assess for symptoms of hypoglycemia such as: anxiety, restlessness, tingling
in hands, feet, lips or tongue, chills, cold sweat, confusion, pale skin, difficulty
in concentration, drowsiness, excessive hunger, head ache, irritability,
nightmares or trouble sleeping, nausea, tachycardia, tremor, weakness,
unsteady gait.
2. Assess for symptoms of hyperglycemia: confusion, drowsiness, flushed and
dry skin, rapid deep breathing, polyuria, loss of appetite, nausea & vomiting,
unusual thirst.
3. Monitor body weight periodically. Changes in weight may necessitate
changes in insulin dose.
4. Monitor blood glucose every 6 hours during therapy.
5. Note for toxicity and overdose: HYPOGLYCEMIA
- let patient ingest oral glucose
73
- if severe hypoglycemia: administer IV glucose, glucagon or epinephrine.

6.
Store insulin in refrigerator. Do not use if cloudy, discolored or unusually
viscous.
7.
Rotate site of infection.
8.
Instruct patient on proper techniques for administration.
9.
Explain to the patient that this medication controls hyperglycemia but does
not cure diabetes.

10.
Emphasize the importance of compliance with nutritional guidelines and
regular exercise as directed.
Loperamide
Diar-aid caplets, Imodium, Imodium A-D, Kaopectate II caplets,
Maalox antidiarrheal caplets, Neo-Diaral, Pepto Diarrhea
control
Classification: Antidiarrheals
Indications: Adjunctive therapy of acute diarrhea. Chronic
diarrhea associated with inflammatory bowel disease decrease the volume of ileostomy
drainage.
Action: Inhibits peristalsis and prolongs transit time by a direct effect on nerves in the
intestinal muscle wall. Reduces fecal volume, increases fecal viscosity and bulk while
diminishing loss of fluid and electrolytes.
Therapeutic effects: Relief of diarrhea.
Contraindications: Hypersensitivity; patients in whom constipation must be avoided;
abdominal pain of unknown cause, especially if associated with fever; alcohol
intolerance(liquid only).
Precautions: Hepatic dysfunction
Side effects: CNS drowsiness , dizziness
GI constipation, abdominal pain/distention/discomfort, dry mouth, nausea
and vomiting.
Misc allergic reactions
Drug-Drug interactions: Increase CNS depression with other CNS depressants including
alcohol, antihistamines, opioid analgesics, and sedatives. Increase anticholinergic
74
properties
with
the
other
drugs
having
anticholinergic
properties
including
antidepressants and antihistamines.

Nursing Management:
1. Assess frequency and consistency of stools and bowel sounds prior to and
during therapy.
2. Assess skin turgor for dehydration.
3. Administer with clear fluids to help prevent dehydration which may
accompany diarrhea.
4. Instruct patient to take medication as directed. In acute diarrhea, medication
may be ordered after each unformed stool.
5. Advise patient that frequent mouth rinses and good oral hygiene may relieve
dry mouth.
6. Instruct patient to notify health care professional if diarrhea persist or if fever,
abdominal pain, or distention occurs.
Furosemide
Novosimide; PMS-Furosimide
Classification: Loop diuretics
Indications:
Edema
d/t
heart
failure,
hepatic
impairment or renal disease. Hypertension.

Action: Inhibits the reabsorption of sodium and
chloride from the loop of Henle and distal renal tubule.
Increases renal excretion of water, sodium, chloride,
magnesium, potassium, and calcium. Effectiveness persists in impaired renal function.
Decreased blood pressure.
Dosage: 1 tablet, 200 mg
Contraindication: Hypersensitivity; Cross-sensitivity with thiazides and sulfonamides may
occur; Hepatic coma or anuria; Some liquid products may contain alcohol, avoid in
patients with alcohol intolerance.
Precautions: Severe liver disease; electrolyte depression
Side effects: CNS blurred vision, dizziness, head ache, vertigo
EENT hearing loss, tinnitus
CV hypotension
GI anorexia, constipation, diarrhea, dry mouth, nausea, vomiting
75
GU excessive urination
Derm photosensitivity, rash
F and E dehydration
1. Assess fluid status. Notify physician or other health care professional if thirst,
dry mouth, hypotension, or oliguria occurs.
2. Monitor blood pressure and pulse before and during administration.
3. Monitor blood glucose closely; may cause increased blood glucose level.
4. Caution patient to change positions slowly to minimize orthostatic
hypotension.
5. Advise patient to contact health care professional immediately if muscle
weakness, cramps, nausea, dizziness and numbness occurs.
6. Caution older patients or their caregivers about increased risk for falls.
Lactulose
Duphalac
Classification: Laxatives
Indications: Treatment of chronic constipation in adults and
geriatric patients. Adjunct in the management or portal- systemic
(hepatic) encephalopathy.
Action: Increases water and softens the stool. Lowers the pH of
the colon, which inhibits the diffusion of ammonia from the colon
into the blood, thereby reducing blood ammonia levels.
Contraindication: Patients on low-galactose diets.
Precautions: Diabetes mellitus; excessive use may lead to dependence.
Side effects: GI belching, cramps, distention, diarrhea
Endo hyperglycemia
Drug-Drug interactions: should not be used with other laxatives in the treatment of
hepatic encephalopathy (leads to inability to determine optimal dose of lactulose). Antiinfectives may diminish effectiveness in treatment of hepatic encephalopathy.
Dosage: 30 cc PO
Nursing Interventions:
1. Assess patient for abdominal distention, presence of bowel sounds, and
normal pattern of bowel function.
76
2. Assess color, consistency, and amount of stool produced.

3. May cause increased blood glucose levels in diabetic patients.
4. Encourage patient to increased oral fluid intake.
5. Caution patients that this medication may cause belching, flatulence, or
abdominal cramping. Health care professional should be notified if this
becomes bothersome or if diarrhea occurs.
77
Date
Cues
Need
07/0
5/10
Subjective:
Paminaw nako kay
puno kaayo diri,
stated by Mr. S.
N
U
T
R
I
T
I
O
N
A
L
@
9:15
am
Objective:
-with IVF of
PNSS1L @ 60
cc/hr
-abdominal girth:
90 cm
-ascitis
-bipedal edema
-weak and sleepy
-CXR shows pleural
effusion
-(+) crackles
-decreased Hb (94)
and Hct (0.28)
-increase glucose
in the blood.
-Furosemide
M
E
T
A
B
O
L
I
C
P
A
T
T
E
R
N
Nursing
Diagnosis
Excess fluid
volume related to
compromised
regulatory
mechanism.
Fluid volume
excess or
hypervolemia
occurs from an
increase in total
body sodium
content and an
increase in total
body water. This
fluid excess
usually results
from compromised
regulatory
mechanisms for
sodium and water
as seen in CHF,
kidney failure, and
liver failure.
Bibliography:
Gulanick, Meg, PhD, RN,
et.al (2003).Nursing
Care Plan: Nursing
Diagnosis &
Goal of Care
Intervention Plan
At the end of 5 hours of

nursing interventions,
the patient will be able
to stabilize fluid volume
as evidenced by:
1. Assess for presence of

edema by palpating over tibia,
ankles, feet, and sacrum.
Pitting edema is manifested
by a depression that remains
after ones finer is pressed
over an edematous area and
then removed.
a. Balanced intake
and output;
b. Vitals signs
within normal
limits and;
c. Drain at least 1
liter of urine at
foley catheter.
Evaluation
2. Monitor daily weight of the

patient.
Any change in weight is
indicative of increase
extracellular fluid volume.
3. Monitor VS of the patient.
Tachycardia and increased
blood pressure are seen in
early stages. Elderly patients
have reduced response to
catecholamines, thus their
response to fluid overload
may be blunted, with less rise
in heart rate.
4. Auscultate for a 3rd sound.
S3 sound is an early sign of
pulmonary congestion.
78
Interpretation.
Westline Dive St.
Louise. Mosby Inc.
5th ed, p. 65
5. Monitor for distended neck

veins and ascites.
Distended neck veins mean
increase pressure in the
jugular veins brought about
by increased circulating fluid.
6.
Monitor abdominal girth daily.
7. Monitor input an output

Although overall fluid intake
may be adequate, shifting of
fluid out of the intravascular
to extravascular spaces may
result in dehydration.
8. Evaluate urine output in
response to diuretic therapy.
Focus on monitoring the
response to the diuretics,
rather than the actual amount
voided. Fluid volume excess
in the abdomen may interfere
with the absorption of oral
diuretic medications.
9. Check urinary catheter for
presence of urine.
Treatment focuses on
diuresis of excess fluid
10. Instruct patient regarding fluid
79
restrictions as appropriate.
Facilitates reduction of
extracellular volume.
11. Instruct patient to take
diuretics as prescribed.
Diuretic therapy may
include several different types
of agents for optimal therapy,
depending on the acuteness
or chronicity of the problem.
12. Note medications that may
cause fluid retention, such as
non-steroidal antiinflammatory agents,
vasodilators, and steroids.
13. Instruct to avoid crossing of
legs
Reduce constriction of
vessels thus preventing
pooling.
14. Assist patient in repositioning
every 2 hours
Prevent accumulation of
fluid in dependent areas.
80
Date
07/0
6/10
@
9:15
AM
Cues
Subjective:
Kapoy kaayo ang
paminaw, Mr. S
said.
Daghan kaayo na
siyag ma-ihi, as
verbalized by the
watcher.
Objective:
-with IVF of PNSS
1L infusing well @
R metacarpal vein
running @ 60cc/hr
@ 400 cc level.
-with good skin
turgor
-with capillary refill
time of 2 seconds
- VS taken result
of:
T=
PR=
CR=
RR= 17
BP= 130/80
-drowsy & weak
-urine output of
approx. 4000 mL
-abnormal serum
Need
Nursing
Diagnosis
Goal of Care
Intervention Plan
Evaluation
N
U
T
R
I
T
I
O
N
A
L
Fluid & electrolyte

imbalance related
to excessive
urination
At the end of 5 hours of

the patient will be able
to show negative signs
of dehydration as
evidenced by:
1. Assess capillary refill time of

the patient regularly including
the mucus membrane and
skin turgor.
GOAL PARTIALLY
MET
These are indicators of

dehydration, adequacy of
circulating volume.
07/06/20
2:15 PM
M
E
T
A
B
O
L
I
C
P
A
T
T
E
R
N
Excessive
urination coupled
by impaired
glomerular
filtration rate can
affect reabsorption
of sodium in the
distal renal tubule,
excretion of
creatinine in the
urine and wastage
of calcium which
will result to
muscular spasms
if not corrected.
d. Vital signs within

normal range;
2. Monitor intake and output

e. increase fluid
intake to at least
850 ml;
f.
consume whole
meal served;
g. maintain good
skin turgor and
good capillary
refill time and;
h. exhibit alertness
or intact level of
consciousness.
Provide ongoing estimation

of volume replacement
needs, kidney function, &
effectiveness of therapy.
3. Instruct patient to increase
oral fluid intake to at least 2.5
L/day or above depending on
the amount determined by the
health care provider.
Maintains hydration and
circulatory volume.
4. Promote comfortable
environment: cover patient
with light sheets.
After 5 hours of
the patient showed
no signs of
dehydration as
evidence by:
a. able to consume
950 mL of fluids;
b. had good appetite
and consumed entire
meal;
c. maintained good
skin turgor and
capillary refill time of
less than 2 seconds
and;
d. alert and
81
electrolyte result
of:
Sodium=126 (low)
Creatinine=272.8
(high)
Calcium=1.81
(low)
-with medications
of:
Furosemide
NaHCO3
CaCO3
Lactulose
Avoid overheating which

could promote further fluid
loss.
responsive to any
stimuli
5. Continue to administer fluids

Type and amount of fluids
depends on the degree of
deficit and individual patient
response
6. Instruct patient to take highwater content foods like
watermelon and soup if not
contraindicated.
Replace fluid loss in the
body due to excessive
urination
7. Administer medications as
ordered.
8. Monitor serum electrolytes
and urine osmolarity
Elevated hemoglobin and
elevated blood urea nitrogen
suggest fluid deficit. Urinespecific gravity is likewise
increased.
9. Instruct to eat the whole meal
serve.
82
Date
07/0
5/10
@
8
AM
Cues
Subjective:
Kapoy ang
paminaw!
answered by the
client when asked
about how hes
doing.
Objective:
-always sleeping or
drowsy
-(+) sleep
disturbances such
as administration of
drugs during days
and repeated
medical procedures
done early in the
morning
-irritable
-answers questions
crossly and
Need
A
C
T
I
V
I
T
Y
E
X
E
R
C
I
S
E
P
A
T
T
E
R
Nursing
Diagnosis
Goal of Care
Intervention Plan
Fatigue r/t
increase
decrease insulin
production
After 21 hours of care,

Mr. S will be able to
improve sense of
energy as evidenced by:
1. Assess vital signs.

To evaluate fluid status and
cardiopulmonary response to
activity.
An imbalance in
blood sugar is the
main cause of
diabetes-related
fatigue. Cells use
glucose - sugar for fuel. The
hormone insulin
controls the
distribution and
use of glucose in
the body. In
diabetics, due to
poor production of
insulin, the
glucose is not
properly utilized by
the cells; instead,
it's floating around
a. lessened or
diminished irritability;
2. Determine presence/degree
of sleep disturbances.
Fatigue can be a
consequence of, and/or
exacerbated by, sleep
deprivation.
Evaluation
GOAL MET
@
07/07/10
b. ability to answer
questions or
communicate with high
spirits;
c. ability to sit
independently on chair
and;
d. having greater time
being awake.
3. Obtain clients description of

fatigue (i.e. lacking energy or
strength, tiredness, weakness
over length of time)
To assist in evaluating impact
on clients life.
4. Ask client to rate fatigue (110 scale).
To assess level of fatigue
based on clients perception.
12 nn
After 21 hours of
care, Mr. S was
able to improve
sense of energy as
evidenced by:
a. welcomes visitors
and gives jokes;
b. open to
questions and
answers patiently,
and initiates
communication to
student nurse;
83
impatiently
-gives inadequate
answers
-needs supervision
from watcher
-weak
-in bed rest
-blood glucose
level of: 278 mg/dL
-takes Humulin
70/30
SC
in the
bloodstream,
where it can't be
used as
energy. As a
result, diabetic
people will feel
drained.
5. Encourage use of assistive

devices (e.g. wheeled walker or
crutches).
Conserves energy for other
tasks.
6. Assist with self-care need like
ambulation, as indicated.
c. able to sit on the

chair without
maximum
supervision and;
d. is awake most of
the time during the
day.
7. Avoid or limit exposure to

temperature and humidity
extremes.
Temperature extremes can
negatively impact energy level.
8. Provide diversional activities
like open and jovial
communication.
Participating in pleasurable
activities can refocus energy
and diminish feelings of
unhappiness, sluggishness,
and worthlessness that can
accompany fatigue.
9. Encourage to drink fluids.
It is important to keep up fluid
intake as even mild dehydration
can cause fatigue. Dehydration
can also lead to an increase in
blood sugar. Calming herbal
teas are more beneficial than
caffeine based drinks.
84
10. Avoid drinks containing

caffeine.
Small amounts may affect
our brain in such a way that we
are not aware that we are
fatigued and drinking too many
cups of tea, coffee or soft
drinks, leads to restlessness
and interferes with sleep.
11. Instruct to breathe more
evenly, deeply and slowly.
Deep breathing exercises
can help turn off the body's
stress switch and reduce blood
sugar levels.
12. Provide a sound and
comfortable environment
conducive for resting. Limit
noise and bring the curtains
down to prevent light from
getting inside. Provide
adequate clothing.
It is easier to false asleep if
the environment is dim and
cool. Enough clothing can
provide the body enough
warmth.
13. Stress the importance of
sleep.
A basic way to feel less
stressed during the day is to get
85
enough sleep at night. Research

shows that not having enough
sleep may contribute to insulin
resistance. One reason is that
poor sleepers often experience
sleep apnea; this is a condition
that interferes with normal
breathing and has been linked to
diabetes.
Date
Cues
Need
Nursing
Diagnosis
Goal of Care
07/0
6/10
Subjective:
Dili nako makatindog ug ako ra,
stated by the client.
A
C
T
I
V
I
T
Y
Activity intolerance
r/t muscular
weakness as
evidenced by high
serum creatinine
level
At the end of 2 days of

care, Mr. S. will be able
to demonstrate a
decrease in
physiological signs of
intolerance as
evidenced by:
@
7:00
Objective:
AM
-creatinine levels
of:
272.8
(06/26/10)
359 (07/01/10)
389 (07/02/10)
-needs assistance
-PT 2 sessions
-complained of pain
in pelvic area
A
N
D
E
X
E
R
C
Creatinine can
cause dehydration
and fatigue.
medicinenet.com
a) able to perform a
specific task with
improved
strength;
b) able to seek help
in performing
activities of daily
living;
Intervention Plan
1. Establish guidelines and

goals of activity with the
patient and the caregiver
Motivation is enhanced
if the patient participates in
goal setting.
Evaluation
GOAL MET
@
07/07/10
12:00 nn
2. Encourage adequate rest

periods, especially before
meals, other ADLs,
exercise sessions, and
ambulation
Rest between activities
provides time for energy
conservation and recovery.
At the end of 2 days

of care, Mr. S was
able to demonstrate
a decrease
physiological signs
of intolerance as
evidenced by:
3. Refrain from performing
a. had great
strength on lower
86
I
S
E
P
A
T
T
E
R
N
c) verbalize
acceptance of
decreased
activity level
and;
d) experience less
discomfort when
transferring, or
performing other
activities.
nonessential procedures
Patients with limited
activity tolerance need to
prioritize tasks.
4. Assist with ADLs as
indicated; however, avoid
doing for patient what he
or she can do for self
Assisting the patient with
ADLs allows for
conservation of energy.
Caregivers need to
balance providing
assistance with facilitating
progressive endurance
that will ultimately enhance
the patients activity
tolerance and self-esteem.
extremities;
observed during
draping for removal
of catheter
b. asked help from
student nurse or
watcher in changing
positions;
c. Ana jud ng
mutiguwang ka, he
joked.
d. Nagasakit
gihapon diri dapita
(arthritis) pag
mulihok, pero
gamay gamay na
lang.
5. Assist patient to plan

activities for times when he
has the most energy
Not all self-care and
hygiene activities need to
be completed in the
morning. Likewise, not all
housecleaning needs to be
completed in 1 day.
6. Improvise in adapting
87
environment
Appropriate aids will
enable the patient to
achieve optimal
independence for selfcare.
Date/
Time
Cues
Need
Nursing
Diagnosis
Objective of
Care
Nursing Interventions
Evaluation
88
Subjective:
07/05/ - Doc, kani dinhi
10
ba(holding the
right leg, pelvic
area) sakit man
@
kaayo, kaning
bukog-bukog,
10
maglisod ko ug
AM
lakaw, wala man
gud koy kusog,
naunsa naman
ni? Dili man ko
ing ani pag-abot
diri, as
verbalized by the
patient.
- rated the
intensity of pain
as 7 in the pain
scale of:
1 - no pain
2
less
3
pain
4
slightly
moderate
5
pain
6
7
moderate
pain
8
9
severe
C
O
G
N
I
T
I
V
E
P
E
R
C
P
T
U
A
L
P
A
T
T
E
R
N
Acute pain related

to inflammation of
the joints
Inflammation is a
defensive reaction
intended to
neutralize, control,
or eliminate the
offending agent and
to prepare the site
for repair.
Regardless of the
cause, a general
sequence of events
occurs in the local
inflammatory
response. This
sequence involves
changes in the
microcirculation,
including
vasodilation,
increased vascular
permeability, and
leukocytic cellular
infiltration. As these
changes take place,
five cardinal signs
of inflammation are
produced: redness,
heat swelling, pain,
and loss of function.
That within the

2-hour span of
care, my
patients
comfort
condition will
improve as
evidenced by:
- decreased
pain intensity
as 1 in pain
scale
- no grimaced
face noted
- no withdrawal
when there is
physical
contact with the
joint
- verbalization
of feeling of
comfort
1. Assess pain
characteristics.
Assessment of the pain
experience, is the first step
in planning pain
management strategies.
2. Accept clients
description of pain.
Pain is subjective
experience and cannot be
felt by others.
3. Respond immediately
to complaint of pain
Prompt responses to
complaints may result in
decrease anxiety in the
patient. Demonstrated
concern for the patients
welfare and comfort fosters
the development of a
trusting relationship.
4. Instruct the patient to
report pain.
Relief measures may be
instituted
.
5. Position the patient
comfortably on bed.
Comfortable position will
aid in relaxing the muscle
and it will help to lessen the
pain.
GOAL MET
@
07/05/10
12pm
After 2-hour
span of care, the
patients
condition is
improved as
evidenced by:
- pain scale of 1
- grimaced face
not noted
- no withdrawal
when there is
physical contact
with the joint
- di naman sakit
akong mga joints
karon(holding
the right leg), as
verbalized by the
patient.
89
Discharge Planning
Categories
Plan
Medication
Instruct
patient
to
Rationale
take
prescribed
-Compliance to appropriate
medications regularly and comply with
medication and treatment
the treatment regimen prescribed by the
prevents further complications
physician.
and resistance to antibiotics and

promote continuous recovery of
Teach patient regarding the names of

the
drug,
its
dosage,
time
of
administration, its contraindication and

side effects.
awareness about why is it given
to take drugs not prescribed by the
to him.
-Drug interactions may occur
physician, especially OTC drugs.

Instruct the patient to check for the
which may be fatal to patients

current situation.
-Checking for the expiration date
of the drug before administering it
Do not administer any other drug with

same action without the physicians
prescription.
Educate the patient and the significant
others about the expected responses of
drug to the body, side effects, adverse
well as its adverse effects. He
Inform patient and significant others not
it.
his drugs therapeutic effects as

also has the right to gain
expiration date of the drug before taking
optimal health.
-The patient has the right to know
ensures it potency and safety. It

also prevents any unwanted
reactions like hypersensitivity.
-Non-prescription drug may have
antagonistic or synergistic effects
if taken with other drugs.
effects that may possibly seen into the
-To be geared up of enough
patient.
Instruct the significant others to report
information that may lead to

immediate medical responses.
any remarkable adverse reactions or

any appearance of side effects noted.
-For immediate remedial action

response and to prevent any
Exercise
Explain to patient the significance of
complicated reactions.
-Exercises promote proper blood
and
circulation and prevent arterial and
stretching. If unable to mobilize alone,
venous stasis thus lessens platelet
regular
exercise
like
walking
90
instruct the watcher to give assistance
coagulation to aged people. Older
all the time. Encourage to use crutches
people have weakened blood
or any device for support. Stretching
vessel walls which can cause any
upper extremities also promote healthy
alteration in blood flow.
living. Also instruct patient to perform
Also exercise prevents atrophy of
passive range of motion.
the muscles.
Teach patient to wait for 1 to 2 hours
-Older people has slower digestion
after
rate, thus they need to conserve
eating
before
performing
any
physical activities.
more oxygen which will be

necessary for digestion of food.
Activities must be limited to
decrease oxygen demand by
organs and tissues other than the
digestive system.
If patients pleural effusion worsens,
-Deep breathing exercises promote
instruct the patient to practice deep
thoracic expansion which allows air
breathing exercise.
to enter the respiratory tract and

provide oxygen to the alveoli to
avoid atelectasis or lung collapse
due to increase fluid pressure in
Treatment
Instruct patient to comply with his
the pleural space.

-Maintenance meds should not be
medication treatment like the continuous
forgotten to achieve highest
use of beta blocker Metoprolol for
therapeutic effect.
control of hypertension and Insulin for

diabetes mellitus.
Instruct client to seek medical help if any
-These unusualties may be
unusualties are felt such as tingling
indicative of worsening condition.
sensation or paresthesia, fatigue and

body malaise, dizziness, headaches,
irritability, tremors, diaphoresis, etc.
As part of long-time treatment, advise
-Medical alert bracelet provides
patient to wear medical alert bracelet all
basic information about the client in
the time and wherever he goes. It
case of accidents.
contains the patients name, disease
91
condition, address and contact person.
Advise to have a family member take
-Monitor of blood pressure is
your blood pressure to check if youre
significant for evaluating the
maintaining a stable blood pressure.
medications effectiveness.
-Glucose monitoring is a big factor
Since the client has his own glucose
in the management of diabetes
monitor, tell client to continue monitoring
mellitus.
blood glucose level, and immediately

seek
Hygiene
for
medical
help
if
level
is
abnormally high.
Instruct patient to practice foot care to
-Proper foot care prevents injury to
prevent ulceration and formation of
feet and toes.
gangrenous
tissues
to
the
lower
extremities.
- Check and carefully wash your feet
every day.
-Do not wear shoes that are too small or
socks that do not fit right inside your
shoes.
-Soak your feet in warm soapy water for
10 minutes before cutting your nails.
Trim your toenails straight across to
prevent ingrown toenails. You may also
file down your toenails. Do not cut your
nails into the corners or close to the skin.
You should not dig under or around the
nail.
Emphasize the importance of bathing

everyday. Wash genitals with mild soap.
-Proper bathing eliminates

proliferation of germs and bacteria
in the body. Mild soap does not
irritate the skin and the genitals.
Instruct client to maintain good oral
-Tooth brushing prevents build up
hygiene.
of plaques and cavities.
92
Instruct to wear clean clothes and
-Dirty or improperly washed
underwear.
underwear may become a

sanctuary for microbial growth.
Microbes may enter the genitals
and might worsen the clients
Out-Patient
Referral
Encourage patient to undergo physical

therapy sessions.
UTI/Cystitis.
-A Physical Therapist is a source of
information to understand agerelated changes and offer
assistance for regaining lost
abilities or develop new ones.
Physical therapy can be applied to
the clients condition: arthritis,
urinary and fecal incontinence,
amputation, and cardiac and
pulmonary disorders. It can :
a). increase, restore or maintain
range of motion, physical strength,
flexibility, coordination, balance and
endurance
b.) aids adaptations to make the
home accessible and safe
teach positioning, transfers, and
walking skills
c.) promote maximum function and
independence within an individual's
capability
d.) increase overall fitness through
exercise programs
e.) prevent further decline in
functional abilities through
education, energy conservation
techniques, joint protection, and
use of assistive devices to promote
independence
f.) improve sensation, joint
proprioception
g.) reduce pain
93
Advise to have check-ups after discharge.
-Serves as an evaluation process

to note if condition has progressed
to better or worse.
Advise to have regular laboratory exams
-To assess for renal function.
for creatinine, albumin, sodium,

potassium and calcium.
Encourage to undergo ABG Test every
Diet
month or once every 2 months.

Instruct client to avoid simple sugars.
-Simple sugars easily break down
Take energy from complex carbohydrates
and enter the blood stream.
like unpolished rice, bread and
Complex carbohydrates can
vegetables.
sustain the bodys energy

requirement for a longer time
because they are not broken down
easily.
Encourage patient to eat fibrous foods
-A diet rich in fiber relieves
like fruits and vegetables. But do not eat
constipation. It adds bulk to the
too much as it can irritate the GI tract and
excreta and facilities expulsion.
causes bleeding. Other examples of

sources of fiber are: whole grains, cereals
and legumes.
Limit intake of purine rich foods such as
-Accumulation of uric acid in the
sardines, liver, beef kidneys, brains and
joints causes arthritis. Uric acid is
meat extracts. Encourage to eat in
the by product of purine break
moderate amount: asparagus, cauliflower,
down in the liver. Because of renal
spinach, mushrooms, green peas, dried
malfunction, uric acid is retained in
peas and beans.
the blood stream and is shunted to

connective tissues.
Instruct patients family to prepare foods

low in fat and cholesterol. Also have
moderate amount of sodium in the diet.
-Cholesterol build up can cause

atherosclerosis. Since elder people
have weakened blood vessel walls,
cholesterol or atherosclerotic
plaques (atheromas) can lodge in
the blood vessels and obstruct
blood flow. If the atheroma is
dislodged, it might become an
emboli and travel through the
94
pulmonary circulation.
-Since the patient is suffering from
hyponatremia, do not deprive client
of sodium but just limit his intake,
because too much sodium can
result to fluid shifting and edema.
Hyponatremia stimulate
juxtaglomerular cells to activate
RAAS, the precursor of
hypertension. Also hypontremia
affects action-potential of the heart,
affecting repolarization and
depolarization. Low levels of
sodium can also result to
neurologic problems.
Maintain good oral hydration.
-Water replenishes the cells and

decreases the chance of
crystalluria.
Prognosis
Diabetes needs to be considered a very serious condition. It is a chronic
condition for which we have no cure. About 2/3 of people with diabetes die of heart
disease. It is the leading cause of adult blindness, the leading cause of kidney failure,
and the leading cause of lower extremity amputation. It is also the second most common
chronic condition seen by American doctors.
95
Although diabetes is a serious and chronic condition, early diagnosis and proper
patient self-management can reduce and possibly eliminate the majority of the chronic
complications. Meticulous control of blood glucose (HbA1c below 7% which would
correlate to an average blood glucose below 150 mg/dL), good blood pressure control
(below 130/80), low LDL (low density lipoprotein) cholesterol levels (below 100 mg/dL),
one daily aspirin (either adult or children's), and daily foot inspection can make a major
impact on improving one's risk for all diabetes-related problems.
Pain
High blood glucose levels do not cause pain. However, having high glucose
levels for many years can lead to nerve damage in the feet (called neuropathy), which
can be painful. It is estimated that 25% of newly diagnosed patients with type 2 diabetes
have pain or numbness in their feet from neuropathy.
Client can take analgesics for pain.
Debilitation
Diabetes can be debilitating, and there are many reasons for this.
It is not uncommon for people with diabetes to experience advanced neuropathy
to the point that he or she cannot walk. For Mrs. Js case, she sometimes stoops while
walking, but still does not need supervision.
The good news is that debilitation can be prevented if treatment is started early
and aggressively. This treatment includes meticulous control of blood glucose (average
glucose below 150 mg/dL), blood pressure (below 130/80), LDL cholesterol (bad
cholesterol below 100 mg/dL), daily aspirin, and smoking cessation. Research also has
shown that one particular type of blood pressure medication, called ACE (angiotensin
converting enzyme) inhibitors, has an additional protective effect on complications
besides lowering blood pressure. ACE inhibitors appear to stabilize or even reverse
diabetic kidney disease if it is caught early enough. These drugs also have been found
useful for people who have had heart attacks or have heart failure. One study even
showed these drugs reduced the risk of heart attack or stroke by 25%. Finally, there is a
growing body of research suggesting ACE inhibitors may protect against diabetic eye
disease.
Comfort
Diabetes usually does not cause discomfort. In fact, one of the biggest public
health problems in America is that there are over 5 million Americans who have
96
asymptomatic diabetes and do not know it. The most common reason for any discomfort
is the neuropathy noted above. Another common reason people have discomfort is from
the finger sticks to measure blood glucose. Fortunately, this technology is quickly
improving so that discomfort is minimal.
Curability
Diabetes is currently not curable. Type 1 diabetes is defined as no requirement
for insulin with normal blood sugars. Scientists are working on this so that the cells that
make insulin ("islets") may be able to be transplanted to result in a cure. To date these
experiments are not quite ready and are still in the research phases. For type 2 diabetes,
there is no "cure" but often it can be treated early in its course with a strict diet, exercise,
and weight loss. However, it is rare for the diabetes to "disappear" even with these
measures. The main focus of research now is to prevent both types of diabetes.
Independence
In the vast majority of cases patients with diabetes should have no problems with
independence. But for elderly, fatigue and neuropathies can occur, so strict supervision
is needed. Family members should also make sure that their home environment is free
from injury causing objects.
Mrs. J still belongs in the middle adulthood, thus she can experience
independence more than elders without causing harm to self.
Mobility
Again, in the vast majority of cases, diabetes should have no impact on
someone's ability to move about. The exceptions to this are those people who suffer
from advanced neuropathy or vascular disease. A complication involving the foot, such
as a foot ulcer or amputation can impact one's ability to move around. Visual problems
also will impact one's ability to move about. These are true to young diabetic patients.
Mrs. J has complained of blurry vision, thus her ability to move about is readily
and always affected. But she said that she uses eye glasses which aids her sight.
But complications brought about by aging should not be neglected. Senile people
are mostly at risk for injury.
Daily activities
For most people however, small amounts of time should be reserved for selfmanagement. This would include time for home blood glucose monitoring (although our
current meters take as little as 5 seconds) and extra time to ensure the proper
medication is received.
97
Exercise is encouraged for people with diabetes, although for those over the age
of 40 years old it is recommended a stress test is performed to rule out early heart
disease (claudication).
Rest is always a necessity.
Energy
Extremes in blood glucose levels can cause fatigue. Although it is difficult to give
exact levels since it differs with the person, many people note fatigue when the blood
glucose exceeds 400 mg/dL. Although hypoglycemia often presents with a tremor, fast
heart rate, a sweating, it may be noted only as fatigue. This often occurs when the blood
glucose drops below 60 mg/dL.
Mrs. J can have some time for rest. Though she has to baby sit for her grand son
Benedict, and perform all the house chores, she can have a bit of time in the afternoon
while her grandson is at school to rest and sleep.
Diet
In general, it is recommended that one eats a low-fat diet with less than 10% of
the calories coming from saturated fat. For people with high levels of LDL-cholesterol
(the "bad" cholesterol) the January 2002 guidelines from the ADA suggest only 7% of
total calories from saturated fat.
The most confusion about diet for people with diabetes has to do with
carbohydrates, which are the types of foods most quickly broken down to glucose (such
as breads, potatoes, pasta, fruit, and simple sugar). Research has clearly shown that
table sugar (sucrose) does not increase blood sugar any more than breads, pasta or
other carbohydrates AS LONG AS THE SAME NUMBER OF CALORIES ARE
CONSUMED. For example, putting table sugar into coffee (about 15 grams of
carbohydrate) would not change blood glucose any more than 1 piece of bread (about
15 grams of carbohydrate). Therefore, simple sugars ("sweets") do not need to be
restricted by people with diabetes, but rather need to be substituted for other
carbohydrate sources. For people using insulin, it is much easier since additional insulin
can be administered to "cover" additional carbohydrate.
Relationships
The
interactions
between
relationships
and
diabetes
are
greatly
underappreciated.
Communication becomes particularly important for people in their early adult
years, as issues pertaining to marriage and family planning are discussed. It is critical
98
that concerns be discussed in the open with the assistance from a health care provider
with understanding about the disease.
For older adults, the impact of both the daily living of diabetes and its
complications becomes even more important. Again, one needs to talk to a healthcare
provider knowledgeable about diabetes to explore its complications and how it affects
everything from work performance to driving or sexual function.
Everyone living with an individual who has diabetes needs to have some
knowledge about how to treat emergencies (hypoglycemia). Finally, psychological
support can be extremely effective for many individuals due to the extreme challenges
this condition presents for many individuals.
References
Black, Joyce M., PhD, RN, CPSN, CWCN, FAPWCA & Jane Hokanson Hoaks,
DNSc,
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Outcomes. Singapore. Elsevier.
Bullock, Barbara L., RN, MSN & Reet L. Henze, DSN, RN. (2000).
Pathophysiology.
Philadelphia. Lippincott William & Wilkins.
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Deglin, J.H. & Vallerand, A.H. (2009) Daviss Drug Guide for Nurses (20 th
Edition). Philadelphia. F.A. Davis Company.
Delaune, S., & Ladner, P. (2006) Fundamentals of Nursing: Standards and
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(4th
Edition). West Philadelphia, Pennsylvania. W.B. Saunders Company.
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Saunders-Elsevier
Karch, A. (2008) Lippincotts Nursing Drug Guide. (6 th Edition) USA. Lippincott
Williams & Wilkins.
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101

Case Study On Chronic Kidney Disease

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Case Study On Chronic Kidney Disease

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CRITERIA

Intro & Objective

A Nursing Case Study

In Partial Fulfillment of the Requirements

July 12, 2010

interpersonal skills, acquire knowledge, and stimulate critical thinking.

Goal and Objective

c. gather adequate information to be used in the development of the study

Chief Complaint: Body Malaise

Family Health History (Genogram)

1. CKD is a progressive, irreversible loss of Swearingen, Pamela L., RN

Smeltzer, Suzanne C., EdD,

Chronic kidney disease (CKD), also Chronic_kidney_disease

DM is a group of metabolic disease Smeltzer, Suzanne C., EdD,

3. DM is a chronic, progressive disease

4. DM is a disorder of carbohydrate, fat,

adults, this means a systolic pressure that

Black, Joyce M., PhD, RN,

deWit, Susan C., MSN, RNCs

2. Persistent elevation of the systolic blood

Jane Hokanson Hoaks,

3. A persistently high blood pressure. It is

Nephropathy 1. Diabetic Nephropathy is the result of an

alteration in glomerular function. There is

Tortora, Gerald J. & Bryan

Bullock, Barbara L., RN, MSN

Joyce M., PhD, RN,

3. Any disease of the kidney. Nephrotic

Kluwer Health &

Williams & Wilkins. 7th

2. Pleural Effusion & Ascites Secondary to Hypoalbuminemia Secondary to CKD/

Porth, Carol Mattson. (2005).

Smeltzer, Suzanne C., EdD,

2. Accumulation of serous fluid in the peritoneal

Tortora, Gerald J. & Bryan

happens once liver production of albumin fails to

1. Study of disease: the scientific study of the

Microsoft Encarta 2008.

Microsoft Student 2008 [DVD].

3. Diabetes mellitus (DM) Type 2 Uncontrolled

2. Type 2 DM is previously called adult-onset

4. Urinary Tract Infection

Developmental Tasks of Later Maturity

Robert Havighursts Developmental Tasks

Older adults also have

Our patient is aware about

Our patient is not receiving

3. Adjusting to death Older adults may

When asked, the patient

Our patient is a member of

5. Meeting social and Older people might

Our patient tells stories

Our patient lives in a

Oder adults are

Eric Eriksons Developmental Task

Ward: San Lorenzo Ward

Anatomy and Physiology

Function of the Urinary System:

consists of the kidneys, ureters,

The juxtaglomerular apparatus, which monitors blood pressure and secretes

Each ureter is a small tube, about 25 cm long

gluconeogenesis, which means formation of new sugar.

Bile production and excretion