Anemia Seconday UGIB

De La Salle Health Sciences Institute
College of Nursing and School of Midwifery

Dasmarias, Cavite
NURSING
CASE
STUDY
Submitted by:
Submitted to:
ALDRIN D. SAMSON
BSN 3-1
Prof. Regiebie Vicencio RN, MAN
FINAL DIAGNOSIS
Anemia secondary Upper Gastro Intestinal Bleeding
HEALTH HISTORY
A DEMOGRAPHIC (BIOGRAPHICAL DATA)
1
2
3
4
5
6
7
Clients Initial: A.C.P

Gender: Female
Age, Birthdate, and Birthplace: 76 years old /October 13,1937 /Samar
Marital (Civil) Status: Widowed
Race and Nationality: Filipino
Religion: Roman Catholic
Address, Telephone Number, E-mail Address: Block 65. Lot 9.
Barangay Sto. Cristo, City of Dasmarias /0927******
8 Educational Background: Elementary Undergraduate
9 Occupation (usual and present): None
10 . Usual Source of Medical Care: Hospitals
11. Date of Admission: August 30, 2014
B SOURCE AND RELIABILITY OF INFORMATION
Client herself who seems reliable but speaks in a soft, weak, hardly audible
voice
Clients niece who seems reliable
Clients medical record/chart
C CHIEF COMPLAINTS
Dumi ako ng dumi pero hindi naman sumasakit yung tiyan ko
Yung dumi ko ay may dugo
D HISTORY OF PRESENT ILLNESS

Client A.C.P was apparently well until 2 days prior to admission when
she noticed a change in her bowel consistency. She voided black tarry stool,
which she described as soft and foul smelling. No other symptoms were felt
like abdominal pain, nausea and vomiting and fever. No medications were
taken and no consultation was done.
On the day of consultation as the patient was taking a bath she passed
out and lost balance hitting her shoulder on the wall with only tolerable pain.
She was immediately rushed to De La Salle University Medical Center and
was given laxative as an initial medication and she reported a total of 4 bowel
movements with a presence of black tarry stool. She was immediately
admitted for further evaluation.
E PAST MEDICAL HISTORY OR PAST HEALTH

Client A.C.P was diagnosed as Hypertensive for more than 10 years and
was diagnosed with Diabetes for about 5 years of duration. She cant recall
here vaccination record because of old age. She also verbalized that she
didnt have any surgical operations before.
She verbalized that she is taking Felodipine 5mg/tab once a day,
Cliclazide 60mg/tab twice a day, Telmisartan 40mg/tab once a day, and
Atorvastatin 20mg/tab once a day. There was no Illnesses noted and she
verbalized that she had no allergies to food and medications. She is taking
Naproxen whenever she felt joint pains on the knees and feet.
F FAMILY HISTORY
Genogram:
70
72
70
HTN
89
68
Anemia
2oUGIB
65
DM
60
A&W
Synthesis:
Based on the family history, she verbalized that both of her parents died of Old age
and didnt exhibit any signs and symptoms any diseases However, her brother and
sister have Hypertension and Diabetes Mellitus which make their grandchildren prone to
the said diseases. She verbalized that their family have been prioritizing their health
status because they dont want to have any complications that may affect their way of
living.
Legend:
Male
Female
Patient
G SOCIO-ECONOMIC HISTORY
Deceased
Client A.C.P lives Barangay Sto. Cristo, City of Dasmarias with her niece
and son in law. The main provider of their family is her daughter who is
working as a nurse in Dubai. The clients son-in-law refused to disclose
the amount of their monthly income but reported that it is enough to
support all of their needs and there is little budget allotted for emergency
health needs. Although this was the case, they also shared that they are
attempting to meet their health financial demands that is why they were
setting aside a reasonable amount of money for the health needs of the
client.
H PSYCHOSOCIAL ASSESSMENT
Patients Age: 76
Developmental Stage Older Adult (65 years and older)
Developmental Task: Ego Integrity vs. Despair
Older adults play a role in childrearing today because many
of them give childcare to young children while parents work. The
developmental task of older adults is integrity versus despair. An older
adult with integrity feels good about the life choices he or she has made;
one with a feeling of despair wishes life would begin over again so that
things could turn out differently. A sense of integrity is helpful in a
grandparent who does childcare, as it helps children develop a sense of
trust and learn activity.
On the case of the patient, she had developed a sense of
contentment since throughout her 76 years of existence she had always
been a happy person and living as productive as she could. She also
stated that shes always looking back at her life and analyzing all her
accomplishments and failures to have a motivation to be a better person.
Thus, the client is in the stage of integrity.
H. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION

1. ROS & PE September 02 and 03 2014
SYSTEM
R.O.S.
a.
P.E.
Received patient in supine
General/Overall
Hindi na ako nanghihina
position, conscious, coherent,
Health Status
di tulad ng dati..
oriented to time and place;

hooked to cardiac monitor
Patient is well groomed, wearing
gown.
Patient can talk freely and
express her feelings.
(-) loss of appetite
V/S: Her vital signs were: Temp.:
36.8 degrees Celsius, PR: 85
beats per minute, RR: 21 cycles
per minute and BP: 120/80
mmHg
b. Integument
SKIN:
SKIN
Makati yung binti ko sa
Wrinkles distributed in the whole
kaliwa
body
With normal skin color
(-) jaundice
Minsan sumasakit kapag

hinahawakan ang binti
(-) masses
ko.
HAIR:
Maputi na nga ang buhok
ko eh kaya nagpapakulay
ako.
Naglalagay ako ng
langis pagtapos maligo
NAILS
(+) well trimmed
(-) clubbing of nails
HAIR
(+) Presence of white hairs
(-) presence of dandruffs
para makintab ang buhok

ko.
c. Head
Sumasakit ang ulo ko

napapagod ako
Symmetrically arranged
Normally hard and smooth
(-) lesions
Full ROM
Gumagamit ako ng
Eyeballs symmetrically aligned in
salamin para makakita
sockets, not protruding or sinking

(+) eye movement is smooth and
minsan kapag
d. Eyes
ako ng malinaw
symmetric in all six directions

(-) teary eye on both eyes
Pupils equal:
Di masakit ang mata ko.
Di rin nangangati.
May pinapatak ako sa
mata ko araw-araw. Di ko
na matandaan yung
pangalan nun eh.
OD pupil is greater/ dilated than

OS (4mm in diameter)
Patient is using glasses
(+) cloudy appearance of eyes
(-) redness
e. Ears
Di Makati ang tenga

Hindi rin naman masakit
Equal and bilateral

(-) lesions
(-) discharge
(-) tinnitus
Nakakarinig pa naman
ako ng maayos pag
malapit sakin. Pag
malayo di ko na rining.
Cotton buds ang gamit
ko panglinis ng tenga.
f. Nose and
Di ako mabilis sipunin
Sinuses
(+) nasal structure is smooth

and asymmetric
(+) nasal mucosa is dark,
pink and moist
(+) straight nasal septum
(-) discharge
Client was able to blow
through nostrils while other is
occluded but only on the
right side using a strip of
paper
g. Mouth and
Throat
Gumagamit ako ng
pustiso dahil sira ang
ibang ngipin ko.
minsan sumasakit yung
ngipin ko.
(+) dry lips

(+) dryness of buccal mucosa
(-) canker sores
(+) dark pink tongue
(+) gag reflex
(-) bleeding
Di na nga ako nagpapacheck-up sa dentista eh.

h. Neck
Neck is symmetric with head

Di masakit ang leeg ko
pag gumagalaw
i. Breast and
Axillary
Meron ngang nakalagay

dito sa dibdib ko .
j. Respiratory
inuubo ako ngayon eh
centered
(-) swelling
(-) tenderness of cervical
lymph nodes
No enlarged lymph nodes
FULL ROM (Active)
Breast is Flabby, less firm and
saggy
Areola is dark brown
(-) nasal flaring
(-) pursed lip breathing
(-) cough
(-) hemoptysis
(-) use of accessory muscles
normal breath sounds upon
auscultation, bronchial,
bronchovesicular, and vesicular
No adventitious breath sounds
(+) sternum positioned midline
and straight, prominent due to old
Mabilis na ako
age
Pulse rate of bpm
(-) distension of the jugular vein
pulse amplitude scale of 3+
upon auscultation of carotid
mapagod, matanda na
artery, no blowing or swishing
kasi
noted.
pulse equality of carotid pulse
k. Cardiovascular
radial pulse, ulnar, brachial,

popliteal and dorsalis pedis pulse.
Edema on the left foot, grade 1+
slight pitting, no visible distortion,
disappears rapidly
(-) varicosities
l. Gastrointestinal
Di ako nahihirapan
kumain.
Malakas parin ako
kumain. Pinagbabawalan
na nga ako ng mga anak
ko at mga doktor. Konti
lang daw kainin ko.
White skin (normal pigmentation)

(-) striae
(-) scars
(-) lesions
(-) rashes
umbilical is midline
Round abdominal contour
Abdomen is symmetric
Upon auscultation of the
abdomen, 18 bowel sounds was
noted.
(-) enlargement
m. Urinary
Madalas din ako maihi
(+) Yellowish urine
sa gabi.
Madalas ako umihi. Mga
tatlo-apat sa isang araw.
Di ko na mapigilan ang
ihi ko.
n. Genitalia
Wala naman akong

problema, dami dami ko
ngang anak eh
magkakaproblema ba
ako?
Patient refused to be assessed.
o. Musculoskeletal
Nagagalaw ko pa ang
FULL ROM (active)
mga kamay at paa ko,
Upon inspection of the TMJ, the jaw
ang lakas ko pa noh?
moves laterally 1-2cm
Nakakalakad pa nga ako
(-) snapping, clicking sound of TMJ

Patient cannot be assessed on some
eh.
parts due to weakness.
Di sumasakit ang likod

ko.
p. Neurologic
Medyo nakakalimot na
rin ako.
CN I: smell intact
CN II: slight loss of visual fields
CN III, IV, & VI: unequal PERRLA on
both eyes.
CN V: patient can close his eyes.
CN VII: patient can smile and move
q. Hematologic
Ayun nga may dugo na

naman na isasalin sa
his lips.
CN VIII: hearing still intact
CN IX & X: (+) gag reflex
CN XI: turns head against resistance
CN XII: symmetric tongue movement
(-) bleeding
(-)easy bruising
akin
r. Endocrine
Hindi naman ako
ginawin eh
(-) Thyroid not enlarged

Intolerance to cold
1 LABORATORY AND DIAGNOSTICS
Procedure and
Date
Hematology
August 30, 2014
Indication
Detects anemia,
infection, or cell
abnormalities;
standard procedure
just in case there is
any need for blood
transfusion.
Hemoglobin
Hemoglobin is the
oxygen-carrying
substance in our
blood. This test
Normal
Values/
Finding
s
Actual
Findings
Nursing
Responsibilities
(pre, intra, post)
Before
procedure:
Male:
140-175
g/L
Female:
123 -153
g/L
the
>Check
for
physicians orders.
74
(Low)
>
Confirm
the
identity of the client
for
sample
extraction.
> Inform the patient
facilitates the
identification of the
oxygen carrying
capability of the blood.
Hematocrit
Hematocrit is the
proportion of blood
volume that is
composed by red
blood cells. This test
indicates relative
proportion of RBC and
Plasma in blood.
Abnormal levels may
indicate anemia/
leukemia.
and his family of the

procedure and its
purpose to allay
anxiety.
Male:
0.420.52
Female:
0.360.46
0.22%
(Low)
> In case that no

laboratory personnel
is available, the
attending nurse will
be extracting the
blood
sample.
Inform the patient
time when blood
extraction will be
performed.
WBC
5 -10 x
109 / L
White Blood cells are
blood cells that lacks
hemoglobin and
functions as the bodys
defense against
foreign bodies. This
test would determine
the amount of
circulating WBC. This
can be a guide in
determining the
severity of disease
process. WBC count in
blood usually elevates
with infection.

and his family that
will come to the
ward
for
the
extraction of blood
sample.
14.0 L
(High)
> Practice aseptic

technique
by
washing hands and
wearing gloves if to
be performed by the
attending nurse.
During
procedure:
the
> Provide support

for the client.
> If the attending
0.22
0.40
Lymphocytes
Segmenters
This type of WBC

produces antibodies
and responsible for
destroying
microorganisms that
enters the body. This
test
determines presence
of viral and bacterial
infections, toxic
metabolic processes,
even diagnose
leukemia stages
This test determines

the amount of
segmented neutrophils
in the blood which
phagocytizes
microorganism and
other substances.
0.36
0.66
0.20
(Low)
0.74
(High)
This test is done to

determine the amount
of eosinophils in the
blood which is
responsible for
combating multicellular
parasites and certain
infections in
vertebrates. Along with
mast cells, they also
control mechanisms
associated with allergy
and asthma.
the
the
as
as
After
procedure:
the
> Document
procedure on
patients chart.
the
the
> Document the

patients response
and tolerance to the
procedure.
0.01
0.04
0.01
(Normal)
Eosinophils
nurse will extract

sample, perform
procedure
efficiently
possible.
>
Assess
the
venipuncture site for
bleeding
or
hematoma
formation.
>
Inform
physician of
results.
the
the
> Inform the client

and his family that
the physician will
explain the results of
the procedure and
its implications on
his condition.
> Practice aseptic
technique
by
washing hands and
disposing gloves in
Basophils
Platelet count
-To determine the

capability of the blood
to clot thus preventing
bleeding
This test is done to

determine the number
of platelets circulating
in the blood that
reflects the capability
of the blood to clot
thus preventing
bleeding.
0.00
0.02
0.01
(Normal)
150450x109/
L
288
proper waste bin if

to be performed by
the attending nurse.
(Normal)
Before
the
procedure:
>
Hematology
PT / PTT
August 30, 2014
Check
for
physicians orders.
>
Confirm
the

Prothrombin
Time
Time
for
sample
extraction.
12
14.5
seconds

13.0 seconds

procedure
purpose
% Activity
INR
70
100%
106 %
0.08
1.3
0.97
and
to
its
allay
anxiety.
and his family that
will
come
to
the
ward
Partial
Thromboplastin
Time
Ratio
0.76
(</= to
1.2)
23.6 seconds
(24-36
seconds)
for
the
extraction of blood
sample.
> In case that no
is
available,
the

be
extracting
blood
the
sample.
Inform
the
patient

time
when
extraction
blood
will
be
performed.
> Practice aseptic
technique
by
washing hands and

be performed by the
attending nurse.
During
the
procedure:
> Provide support
for the client.
> If the attending
nurse will extract the
sample, perform the
procedure
as
efficiently
as
possible.
After
the
procedure:
>
Document
procedure
on
the
the
patients chart.
>
Document
patients
the
response

procedure.
>
Assess
the

bleeding
or
hematoma
formation.
>
Inform
physician
of
the
the
results.
> Inform the client
and his family that
the
physician
will

the procedure and
its implications on
his condition.
> Practice aseptic
technique
by
washing hands and

disposing gloves in
proper waste bin if

to be performed by
Blood Chemistry
test
August 30, 2014
Serum
Creatinine
Sodium
Potassium
Before
procedure:
Creatinine is a non
protein end product of
creatine
metabolism.Testing for
creatinine assesses
renal glomerular
filtration rate and
screens for renal
damage.
53.00
97umol/
L
136.00
Sodium is the major
145.00
cation in the
mmol/L
extracellular (found in
the vessels and tissue
spaces) fluid. Testing
for levels of sodium
evaluates water loss or
water retention,
hepatic failure and
others.
Potassium is an
important cellular
cation that is prevalent
in the intracellular
fluids. Potassium is
needed for the
3.5 5.1
mmol/L
146.0
(High)
the
>
Check
for
physicians orders.
>
Confirm
the
for
sample
extraction.
procedure and its
purpose to allay
anxiety.
135
(Low)

and his family that
will come to the
ward
for
the
extraction of blood
sample.
and his family of
4.1
(Normal)
the time when blood

extraction will be
performed. In case
that no laboratory
personnel
are
available,
the
transmission and
conduction of nerve
impulses and for the
contraction of skeletal,
cardiac, and smooth
muscles. Testing for
potassium assesses
renal failure, cirrhosis,
protracted vomiting
and others.
Blood Urea
Nitrogen
To evaluate kidney
function; an increased
level may indicate an
underlying disease
such as kidney failure.
be extracting
blood sample.
the
> Assess client if he

has eaten a meal
with
very
high
sodium content in
the past 24 hours.
> Assess client for
vital signs especially
the cardiac and
mental status.
3.0 9.2
mmol/L .
22.3
(High)
> Practice aseptic

technique
by
washing hands and
be performed by the
attending nurse.
During
procedure:
the
> Provide support

for the client.
> If the attending
sample, perform the
procedure
as
efficiently
as
possible.
After
procedure:
the
> Document
procedure on
patients chart.
the
the
> Document the

patients response
procedure.
>
Assess
the
bleeding
or
hematoma
formation.
>
Inform
physician of
results.
the
the
> Inform the client

and his family that
the physician will
the procedure and
its implications on
his condition.
> Practice aseptic
technique
by
washing hands and
disposing gloves in
proper waste bin if
to be performed by
Chemistry
August 30, 2014
Uric Acid
Before
the
procedure:
-Determines the
amount of uric acid in
the blood; it is an
indicator of gouty
arthritis
0.15
0.45
mmol/L
0.49
(High)
>
Check
for
physicians orders.
> Confirm the identity
of the client for sample
ALT(SGPT)
0 55
U/L
21
(Normal)
extraction.
and her family of the
procedure
purpose
and
to
its
allay
anxiety.
and her family that
laboratory
personnel
will come to the ward

for the extraction of
blood sample.
and her family of the
time
when
extraction
blood
will
be
performed.
> Assess client if she
has eaten a meal with
very high sodium or
sugar content in the
past 24 hours.
> Assess client for
vital signs especially
the
cardiac
and
mental status.
>
Practice
aseptic
technique by washing
hands
and
gloves
if
wearing
to
be
performed
by
the
attending nurse.
During
the
procedure:
> Provide support for
the client.
>
If
the
attending

sample, perform the
procedure
as
efficiently as possible.
> Be honest about
discomfort that may
be felt.
> Cotton or a bandage
may be applied to the
puncture site if there is
continued bleeding.
After the procedure:
>
Document
procedure
on
the
the
patients chart.
>
Document
the
patients response and

tolerance
to
the
procedure.
>
Assess
the
bleeding or hematoma
formation.
> Inform the physician
of the results.
> Inform the client and
her family that the
physician will explain
the
results
procedure
implications
of
the
and
its
on
her
condition.
>
Practice
aseptic
hands and disposing
gloves in proper waste
bin if to be performed
by
the
attending
nurse.
> Inform patient that

her physician will
discuss the tests
results.
Serology
August 30, 2014
HBA1C
refers
to
glycated
haemoglobin.
It
develops
when
haemoglobin, a protein 4.27
within red blood cells 6.02%
that carries oxygen
throughout your body,
joins with glucose in
the blood, becoming
'glycated'.
By measuring glycated
6.4
(High)
haemoglobin (HbA1c),
clinicians are able to
get an overall picture
of what our average
blood sugar levels
have been over a
period
of
weeks/months.
2. OTHER ASSESSMENT TOOLS

Date Taken
Comprehensive Actual
Actual Result
Content/Legend
None taken
None taken
None taken
FUNCTIONAL ASSESSMENT
1. Health Perception-Health Management Pattern

She believes that health is very important. Prior to admission, she said
that she felt okay and did not notice any signs that may pertain to her current
condition. She verbalized during the interview she has been noticing that she is
experiencing body weakness since she had been admitted. The client said that
while she was at the hospital, the most important thing for her to do is to
recuperate and eventually go out of the hospital. She asked for the assistance of
nurses and doctors to help her go back to her usual activities so that she could
go home.
2. Self-esteem, Self-Concept/Self-Perception
She describes herself as an outgoing person since she wants to have

adventure and is not living a sedentary lifestyle. She usually feels good about
herself and contented about her own features.
3. Activity-exercise Pattern
She verbalized that she really has a lot of energy before admission to do
tasks in order to keep fit and healthy. She stated that she is unable to exercise
due to her old age.
Function
Functional Level
Feeding
Bathing
Toileting
Bed Mobility
Dressing
Grooming
General Mobility
Cooking
Home Maintenance
Shopping
Legend:
Functional Legend Code:
Level 0
Full Self Care
Level 1
Requires use of devices
Level 2
Requires use of assistance from

another person
Level 3
Requires use of assistance from

another person or device
Level 4
It depends and does not participate
4. Sleep-Rest Pattern
The patient normally sleeps 4 to 6 hours a day. She usually practices

siesta in the afternoon for at least 30 minutes a day. She usually feels good and
feels relaxed when she wakes up. She does not take any medications to aid in
her sleeping.
5. Nutritional/Elimination
The patient usually eats 3 times a day. She typically wants Vegetables
and meats. She prefers drinking water rather than juices and soft drinks. She
verbalized that since she always had a good appetite, she is receiving enough
nutrients for sufficient energy. The patient does not have any allergies or
intolerance pertaining to food. The patient also added that she never had any
dental problems. She usually voids about 5 times a day and moves her bowel
once a day.
6. Sexuality-Reproductive Patterns
The client preferred not to be vocal regarding this matter.
7. Interpersonal relationships/Resources
The patient normally views her role as a sole mother to her children and
an understanding grandmother. She also stated that she easily gets along with
other people.
8. Coping and Stress Management/Tolerance Pattern
Financial crisis is her heaviest stress in life. For her, without sufficient
money, one could not survive in this world and one cannot provide for his or her
basic needs. She believes that due to this particular stress, her health has been
compromised. To deal with her stress she takes a nap to somehow relieve her
anxiety when it comes to money. She also verbalized that she often come to the
house of her daughters whenever she feels bored. She does not use any
medications to relieve her stress.
9. Personal Habits
The patient stated that she is a non-alcoholic, a non-smoker person and

she does not take illicit drugs. For her, she does not even consider trying to take
alcohol, cigarettes or illicit drugs because it is against her values.
10. Environmental Hazards
The patient and her family have been living in Barangay Sto. Cristo. They are
presently residing in a subdivision in the said municipality. According to the
patient, the subdivision they are living in has a large population and it is quite
impossible to have knowledge of all the neighbors. She also added that she and
her family encountered minor problems in the community such as too much noise
within their neighborhood. The patient stated that they have no problem in
accessing the market to buy their needs since its a walking distance to their
house.
II
PROBLEM LIST
A Actual or Active
Problem No.
Problem
Date Identified
Date
Resolved/Remark
s
Anxiety
September 02,
2014
September 03,
2014 The client
verbalized that she
felt okay and more
relaxed at the end
of the shift.
Activity Intolerance
September 02,
2014
Not yet resolved.

The client said that
she still felt weak at
the end of the shift.
B Risk or Potential
Problem No.
Problem
Date identified
Risk for Impaired Skin Integrity
September 02, 2014
III
NURSING CARE PLAN

CUES
S> Gusto ko
na umuwi eh.
Kaya lang wala
pa si doc, di
tuloy
namin
alam
kung
kelan
ako
makakauwi.
O>
(+) restlessness
(+)
facial
grimace
> (+) irritability
> vital signs at
8AM:
Temp.:
36.8
degrees
Celsius,
PR: 85 beats
per minute,
RR: 21 cycles
per minute and
BP:
120/80
mmHg
NURSING
DIAGNOSIS
Anxiety
related to
unknown
outcomes of
health
management
LONG TERM
GOALS
SHORT
TERM
GOALS
INTERVENTION
The client will

identify and
accept
positive and
negative
expressions,
feelings, and
reactions
throughout the
clients
hospitalization
.
The client
will verbalize
her feelings
and
concerns
and appear
relaxed
within the
shift.
Independent
Established
rapport
with the client and her
family
RATIONALE
To facilitate a
trusting
relationship
between
the
client and the
health
care
provider
and
perform
necessary
assessment and
procedures with
ease
Assessed the clients

level of anxiety.
To determine the
kind
of
interventions
required
Explained
procedures / care as
delivered
To
provide
information,
enhance clients
knowledge
and
reduce anxiety of
the client
Encouraged
verbalization
of
feelings and concerns
To
determine
interventions
required to be
done
EVALUATION
Goal met. The

client verbalized
that she felt okay
and
appeared
relaxed at the end
of the shift.
Provided a quiet and

relaxing environment
conducive for resting
To
decrease
factors which may
increase
the
stress felt by the
client
To
avert
the
clients focus on
her anxiety
Encouraged
diversional
activities
such as sleeping
To help the client

reduce expenses
on hospitalization
and
medical
treatments
necessary
Collaborative
Assisted in addressing
financial
considerations
as
appropriate.
S> Nanghihina
ang
katawan
ko.
O> (+) sunken
Activity
Intolerance
related to
imbalance
between
oxygen
supply and
demand
The client will

be able to
perform
optimal
activity,
exercise, rest
and sleep
throughout
The
client
will be able
to manifest
no signs of
fatigue such
as shortness
of
breath,
dizziness
Independent
Assessed the clients
ability
to
perform
activities of daily living
(ADLs)
To determine the
appropriate
choices
of
interventions
/
needed
assistance
Goal not met. The

client verbalized
that although she
was
able
to
ambulate to the
comfort room with
assistance without
shortness
of
appearance
the eyes
of
> (+) pallor of

conjunctiva and
both extremities
> capillary refill
> 3 seconds
>
(+)
generalized
body malaise
> Vital signs at
8AM:
Temp.:
degrees
Celsius,
36.8
PR: 85 beats
per minute,
RR: 21 cycles
per minute and
BP:
120/80
mmHg
her treatment
regimen
and
increased
heart
rate
when
ambulating
with
assistance
from bed to
comfort
room within
the shift.
Encouraged the client

to
verbalize
her
feelings and concerns
To
determine
interventions
required to be
done
Provided a quiet and

relaxing environment
conducive for resting
To enhance rest
and lower bodys
oxygen
requirements,
and
reduces
strain
on
the
heart and lungs
To
promote
clients self
reliance
Assisted the client in

performing
activities
when necessary;
Encouraged the client
to change position
slowly
To avoid postural
hypotension
or
cerebral hypoxia
which may cause
dizziness, fainting
and
increased
risk of injury
Provided
health
teachings about the
importance of proper
positioning during rest
periods
To enhance lung
expansion
to
maximize
oxygenation for
cellular uptake
Collaborative
Administered
medications
as
prescribed
To
improve
clients condition
as
part
of
treatment
regimen
breath, she still

felt her body was
weak at the end of
the shift.
S> Dry ang

balat
ko
at
nangangati
ako.
O> (+) sunken
appearance of
the eyes;
> (+) irritability;
> (+) facial
grimace;
Risk for
Impaired
Skin Integrity
related to
accumulation
of toxins in
the skin
The client will

be able to
maintain
safety through
prevention of
injury or other
trauma
throughout
her treatment
regimen
The
client
will
demonstrate
behaviours
to
prevent
skin
breakdown
or
injury
within
the
shift.
Independent
Assessed the skin for

changes
in
color,
turgor and vascularity; To determine the
presence
of
dehydration that
affects circulation
tissue
Monitored fluid intake and
integrity
at
the
and output strictly as
cellular
level
well as the hydration
of skin and mucous
To reduce dermal
membranes
irritation and risk
of breakdown
> poor skin

turgor and skin
mobility;
> (+) dryness
and pruritus on
both upper and
lower
extremities;
> (+) scaling of
skin on the legs
and
feet
bilaterally;
>
(+)
generalized
body malaise
To
determine
areas of poor
circulation
To
alleviate
discomfort
and
reduce risk of
dermal injury
Ensured that linens
are dry and wrinkle
free
Recommended
the
client
to
keep
fingernails short and
rub itchy areas instead
of scratching.
To
alleviate
clients discomfort
Goal not met. The

client verbalized
that her skin still
felt very itchy and
that she continued
to scratch her skin
throughout
the
shift.
> with a diet of

meat
free,
decrease
protein and limit
oral fluid intake
to 1 Liter per
day. > vital
signs at 8AM:
Temp.:
36.8
degrees
Celsius, PR: 85
beats
per
minute, RR: 21
cycles
per
minute and BP:
120/80 mmHg
Collaborative
Encouraged client to
ask her physician if
she
can
apply
particular ointments /
creams on the itchy
areas of the skin
IV ANATOMY AND PHYSIOLOGY
Main Organ / System Involved Blood and blood products; GastroIntestinal
BLOOD
Blood is a type of connective
tissue that consists of cells and cell
fragments surrounded by a liquid matrix.
The cells and cell fragments are the
formed elements, and the liquid is the
plasma. The formed elements account
for slightly less than half and plasma
accounts for slightly more than half the
total blood volume. The total blood
volume in the average adult is about 4-5
liters in females and 5-6 in males. Blood
makes up about 8% of total body weight.
Figu Figure 1: Blood
Functions
Blood is pumped by the heart through blood vessels, which extend throughout
the body. Blood helps to maintain homeostasis in several ways:
1. Transport of gases, nutrients and waste products. Oxygen enters blood in the
lungs and is carried to the cells. Carbon dioxide, produced by the cells, is
carried in the blood to the lungs, from which it is expelled. Ingested nutrients,
ions, and water are transported by the blood from the digestive tract to cells,
and the waste products of the cells are transported to the kidneys for
elimination.
2. Transport of processed molecules. Many substances are produced in one

part of the body and transported in the blood to another part, where they are
modified. For example, the precursor to vitamin D is produced in the skin and
transported by the blood to the liver and then to the kidneys for processing in
3.
4.
5.
6.
7.
active vitamin D. The active vitamin D is transported in the small intestines,

where it promotes the uptake of calcium. Another example is lactic acid
produced by the skeletal muscles during anaerobic respiration. The lactic acid
is carried to the liver, where it is converted to glucose.
Transport of regulatory molecules. Many of the hormones and enzymes that
regulate body processes are carried from one part of the body to another
within the blood.
Regulation of pH and osmosis. Buffers, which help keep the bloods pH within
its normal limits of 7.35-7.45, are found in the blood. The osmotic composition
of blood is also critical for maintaining normal fluid and ion balance.
Maintenance of body temperature. Blood is involved in body temperature
regulation because warm blood is transported from the interior to the surface
of the body, where heat is released from the blood.
Protection against foreign substances. Cells and chemicals of the blood
constitute an important part of the immune system, protecting against foreign
substances such as microorganisms an toxins
Clot formation. Blood clotting provides protection against excessive blood loss
when blood vessels are damaged. When tissues are damaged, the blood clot
that forms is also the first step in tissue repair and restoration of normal
function.
Composition
A. Plasma
Plasma is pale yellow fluid that consists of about 91% water, 7% proteins and
2% other substances, such as ions, nutrients, gases, and waste products. Plasma
proteins include albumin, globulins, and fibrinogen. Albumin makes up 58% of the
plasma proteins. Although the osmotic pressure of blood results primarily from
sodium chloride, albumin makes an important contribution. The water balance
between blood and tissues is determined by the movement of water into and out of
the blood by osmosis. Globulins account for 38% of the plasma proteins. Some
globulins, such as antibodies and complement, are part of the immune system.
Other globulins and albumin functions as transport molecules because they bind to
molecules such as hormones and carry them in the blood throughout the body.
Some globulins are clotting factors, which is necessary for the formation of blood
clots. Fibrinogen is a clotting factor which constitutes 4% of plasma proteins.
Activation of clotting factors results in the conversion of fibrinogen into fibrin, a

threadlike protein that forms blood clots. Serum is plasma without the clotting
factors
Plasma volume remains relatively constant. Normally water intake through the
digestive tract closely matches water loss through the kidneys, lungs, digestive
tract, and skin. Oxygen enters blood in the lungs, and carbon dioxide enters blood
form tissues.
Figure 2:
Blood Components
B. Formed Elements
About 95% of the volume of the formed elements consists of red blood cells
or erythrocytes. The remaining 5% of the formed elements consists of white blood
cells or leukocytes, and cell fragments called platelets or thrombocytes. Red blood
cells are 700 times more numerous than white blood cells and 17 times more
numerous than platelets.
Production of Formed Elements
Figure
3:Hematopoiesis
The
process of
blood cell production is called hematopoiesis. In the fetus, hematopoiesis occurs in
several tissues such as the liver, thymus gland, spleen, lymph nodes, and red bone
marrow. After birth, hematopoiesis is confined primarily to red bone marrow, but
some white blood cells are produced in lymphatic tissues. All the formed elements
of blood are derived from a single population of cells called stem cells or
hemocytoblast. These stem cells differentiate to give rise to different cell lines,
each of which ends with the formation of a particular type of formed element. The
development of each cell line is regulated by specific growth factors. That is, the
types of formed element derived from the stem cells and how many formed
elements are produced are determined by the growth factors.
Red Blood Cells

Normal red blood cells are disk-shaped cells with edges that are thicker than
the center of the cell. The biconcave shape increases the surface area of the red
blood cell compared with a flat disk of the same size. The greater surface area
makes it easier for gases to move into and out of the red blood cell. In addition,
the red blood cell can bend or fold around its thin center, decreasing its size and
enabling it to pass more easily through small blood vessels.
Figure 4: Red blood cells
During their development, red blood cells

lose their nuclei and most of their organelles.
Consequently, they are unable to divide. RBCs
live for about 120 days in males and 110 days in
females. The main component of a red blood cell is the pigmented protein
hemoglobin, which accounts for about a third of the cells volume and is
responsible for its red color.
The primary functions of red blood cells are to transport oxygen from the
lungs to the various tissues of the body and to assist in the transport of carbon
dioxide from the tissues to the lungs. Oxygen transport is accomplished by
hemoglobin, which consists of 4 protein chains and 4 heme groups. Each protein
called a globin, is bound to one heme, a red pigmented molecule. Each heme
contains one iron atom, which is necessary for the normal function of hemoglobin.
Each iron in a heme molecule can reversibly associate with an oxygen molecule.
Hemoglobin picks up oxygen in the lungs and releases oxygen in other tissues.
Hemoglobin that is bound to oxygen is bright red in color, whereas hemoglobin
without bound oxygen us a darker red color. Hemoglobin is responsible for 98.5%
of the oxygen transported in blood. The remaining 1.5% is transported dissolved in
plasma. Because iron is necessary for oxygen transport, it is not surprising that two
thirds of the bodys iron is found in hemoglobin. Small amounts of iron are required
in the diet to replace the small amounts lost in the urine and feces. Women need
more dietary iron than men do because women losses iron as a result of
menstruation.
White Blood Cells
White blood cells or leukocytes are spherical cells that lack hemoglobin.
WBCs form thin white layer of cells between plasma and RBCs when the
components of blood are separated from each other. They are larger than RBCs
and each has a nucleus. Although WBCs are components of the blood, the blood
serves primarily as a means of transport these cells to other tissues of the body.
WBCs can leave the blood and move by ameboid movement though the tissues. In
this process, the cell projects a cytoplasmic extension that attaches to an object.
Then the rest of the cells cytoplasm flows into the extension. Two functions of
WBCs are to protect the body against invading microorganisms and to remove
dead cells and debris from the tissues by phagocytosis.
Figure 5: White blood cell
Each WBC type is named according to its appearance in stained

preparations. Those containing large cytoplasmic granules are granulocytes, and
those with very small granules that cannot be easily seen with the light microscope
are agranulocytes.
There are 3 kinds of granulocytes: neutrophils, basophils, and eosinophils.

Neutrophils, the most common type of WBC have small cytoplasmic granules that
stain with both acidic and basic dyes. Their nuclei are commonly lobed, with the
number of lobes varying from two to four. Neutrophils usually remain in the blood
for a short time, move into other tissues, and phagocytize microorganisms and
other foreign substances. Dead neutrophils, cell debris, and fluids can accumulate
as pus at sites of infection.
Basophils, the least common of all WBC contain large cytoplasmic granules
that stain blue or purple with basic dyes. Basophils release histamine and other
chemicals that promote inflammation. They also release heparin, which prevents
the formation of clots.
Eosinophils contain cytoplasmic granules that stain bright red with eosin, an
acidic stain. They often have two-lobed nucleus. Eosinophils release chemicals
that reduce inflammation. In addition, chemicals from eosinophils are involved with
the destruction of certain worm parasites.
There are 2 kinds of agranulocytes: lymphocytes and monocytes.

Lymphocytes are the smallest of the WBCs. The lymphocytic cytoplasm consists of
only a thin, sometimes imperceptible ring around the nucleus. There are several
types of lymphocytes, and they play a role in the bodys immune response. Their
diverse activities involve the production of antibodies and other chemicals that
destroy microorganisms, contribute to allergic reactions, reject grafts, control
tumors, and regulate the immune system.
Monocytes are the largest of the WBCs. After they leave the blood and enter
the tissues, monocytes enlarge and become macrophages, which phagocytize
bacteria, dead cells, cell fragments and other debris within the tissues. In addition,
macrophages can break down phagocytized foreign substances and present the
processed substances to lymphocytes, which results in activation of the
lymphocytes.
Platelets
Platelets or thrombocytes are minute
fragments of cells, each consisting of a small
amount of cytoplasm surrounded by a cell
membrane. They are produced in the red
bone marrow from megakaryocyte, which are
large cells. Small fragments of these cells
break off and enter as platelets, which play
an important role in preventing blood loss.
This prevention is accomplished in 2 ways:
the formation of platelet plugs, which seal
holes in small vessels, and the formation of
clots, which help seal off larger wounds in the vessels.
Figure 6: Platelet (Middle)
Preventing Blood Loss
When a blood vessel is damaged, blood can leak into other tissues and interfere
with normal tissue function, or blood can be lost from the body. A small amount of
blood loss from the body can be tolerated, and new blood is produced to replace it. If
a large amount of blood is lost, death can occur. Fortunately, when a blood vessel is
damaged, vascular spasm, platelet plug formation, and blood clotting minimize the
loss of blood.
A. Vascular Spasm
Vascular spasm is an immediate but temporary constriction of a blood vessel

resulting from contraction of smooth muscle within the wall of the vessel. This
constriction can close small vessels completely and stop the flow of blood through
them. Damage to blood vessels can activate nervous system reflexes that cause
vascular spasm. Chemicals also produce vascular spasms. For example, platelets
release thromboxanes which are derived from certain prostaglandins, and
endothelial cells lining blood vessels release the peptide endothelin.
B. Platelet Plugs
A platelet plug is an accumulation of platelets that can seal up a small break
in a blood vessel. Platelet plug formation is very important in maintaining the
integrity if the circulatory system because small tears occur in smaller vessels and
capillaries many times each day, and platelet plug formation quickly closes them.
People who lack the normal number of platelets tend to develop numerous small
hemorrhages in their skin and internal organs.
The formation of platelet plug can be described as a series of steps, but in

actuality many of these steps occur at the same time. Platelet adhesion results in
platelets sticking to collagen exposed by blood vessel damage. Most platelet
adhesion is mediated through von Willebrand factor, which is a protein produced
and secreted by blood vessel endothelial cells. Von Willebrand factor forms a
bridge between collagen and platelets by binding to platelet surface receptors and
collagen. After platelets adhere to collagen, they become activated, change shape,
and release chemicals. In the platelet release reaction, platelets release chemicals,
such ADP and thromboxane. ADP and thromboxane bind to their respective
receptors on the surfaces of platelets, resulting in the activation of the platelets.
These activated platelets also release ADP and thromboxane, which activates
more platelets. Thus, a cascade of chemical release activates many platelets. As
platelets become activated they express surface receptors called fibrinogen
receptors, which can bind to fibrinogen, a plasma protein. In platelet aggregation,
fibrinogen forms bridges between the fibrinogen receptors of numerous platelets,
resulting in the formation of a platelet plug.
C. Blood Clotting
Blood vessel constriction and platelet plugs alone are not sufficient to close
large tears or cuts in blood vessels. When a blood vessel is severely damaged,
blood clotting or coagulation results in the formation of a clot. A clot is a network of
thread-like protein fibers, called fibrin that traps blood cells, platelets, and fluids.
The formation of a blood clot depends on a number of proteins found within

plasma called clotting factor. Normally the clotting factors are inactive and do not
cause clotting. Following injury, however, the clotting factors are activated to
produce a clot. This is a complex process involving many chemical reactions, but it
can be summarized in 3 main stages.
1. The chemical reactions can be started in two ways: (a) the contact of
inactive clotting factors with exposed connective tissue can result in their
activation; (b) chemicals, such as thromboplastin released from injured
tissues can cause activation of clotting factors. After the initial clotting
factors are activated, they in turn activate other clotting factors. A series of
reactions results in which each clotting factors activates the next in the
series until the clotting factor prothrombinase is formed.
2. Prothrombinase acts on an inactive clotting factor called prothrombin to
convert it to its active form called thrombin.
3. Thrombin converts the inactive clotting factor fibrinogen into its active
form, fibrin which is a thread-like protein. A clot is a network of fibrin that
traps blood cells, platelets, and fluid.
At each step of the clotting process, each clotting factor activates many
additional clotting factors. Consequently, a large quantity of clotting factors is
activated, resulting in the formation of the clot.
Most clot factors are manufactured in the liver, and many of them require
vitamin K for their synthesis. In addition, many of the chemical reactions of clot
formation require calcium ions and the chemicals released from platelets. Low
levels of vitamin K, low levels of calcium ions, low number of platelets, of reduced
synthesis of clotting factors because of liver dysfunction can seriously impair the
blood-clotting process.
D. Control of Clot Formation
Without control, clotting would spread from the point of its initiation throughout
the entire circulatory system. The blood contains several anticoagulants, which
prevent clotting factors from clots. Antithrombin and heparin inactivate thrombin.
Without thrombin, fibrinogen is not converted to fibrin, and no clot forms. Normally
there are enough anticoagulants in the blood to prevent clot formation. At the injury
site, however, the activation of clotting factors is very rapid. Enough clotting
factors are activated so that the anticoagulants can no longer prevent a clot from
forming. Away from the injury site there are enough anticoagulants to prevent clot
formation from spreading.
E. Clot Retraction and Fibrinolysis

After a clot has formed, it begins to condense into a more compact structure
by a process known as clot retraction. Platelets contain the contractile proteins,
actin and myosin, which operate in a similar fashion to the actin and myosin in
muscle. Platelets form small extensions that attach to fibrin through surface
receptors. Contraction of the extension pulls on the fibrin and is responsible for clot
retraction. Serum, which is plasma without the clotting factors, is squeezed out of
the clot during clot retraction.
Retraction of the clot pulls the edges of the damaged blood vessel together,
helping to stop flow of blood, reducing the probability of infection, and enhancing
healing. The damaged vessel in repaired by the movement of fibroblasts into the
damaged area and the formation of new connective tissue. In addition, epithelial
cells around the wound divide and fill in the torn area.
Clots are dissolved by a process called fibrinolysis. An active plasma protein
calles plasminogen is converted to its active form, plasmin. Thrombin, other
clotting factors activated during clot formation, and tissue plasminogen activator
released from surrounding tissues can stimulate the conversion of plasminogen to
plasmin. Over a period of few days, plasmin slowly breaks down the fibrin.
ABO Blood Group

The ABO blood group system is used to recognize human blood. ABO
antigens appear on the surface of the red blood cells. Type A blood has type A
antigens, type B blood has type B antigens, type AB blood has both types of
antigens, and type O blood has neither A nor B antigens. In addition, plasma from
type A blood contains anti-B antibodies, which act against type B antigen; whereas
plasma from type B blood contains anti-A antibodies, which act against type A
antigens. Type AB blood plasma has neither type of antibody, and type O blood
plasma has both anti-A and anti-B antibodies.
Antibodies do not normally develop against an antigen unless the body is
exposed to that antigen. One possible explanation for the production of an anti-A
and/or anti-B antibodies is that type A or B antigens on bacteria or food in the
digestive tract stimulate the formation of antibodies against antigens that are
different from ones own antigens. In support of this explanation is the observation
that anti-A and anti-B antibodies are not found in the blood until about 2 months
after birth. For example, an infant with type A blood would not produce antibodies
against the A antigen on bacteria or food because mechanisms exist in the body to
prevent the production of antibodies that would react with the bodys own antigens.
Figure 7: ABO Blood Groups
A donor is a person who gives blood, and a recipient is a person who receives
blood. Usually a recipient can receive blood from a donor if they both have the
same blood type. For example, a person with type A blood can receive blood from
a person with type A blood. There would be no ABO transfusion reaction because
the recipient has no anti-A antibodies against the type A antigen. On the other
hand, if type A blood were donated to a person with type B blood, a transfusion
reaction would occur because the person with type B blood has anti-A antibodies
against the type A antigen, and agglutination would result.
Historically, people with type O blood have been called universal donors
because they usually can give blood to other ABO blood types without causing an
ABO transfusion reaction. Their red blood cells have no ABO surface antigens and
therefore do not react with anti-A or anti-B antibodies. For example, if type O blood
is given to a person with the anti-B antibodies in the recipients blood. In a similar
fashion, if type O blood is given to a person with type B blood, there would be no
reaction with the recipients anti-A antibodies.
It should be noted, however, that the term universal donor is misleading.
There are two ways in which transfusion of type O blood can produce a transfusion
reaction. First, mismatching blood groups other than the ABO blood groups can
cause a transfusion reaction. To reduce the likelihood of the transfusion reaction,
all the blood groups must be correctly matched. Second, antibodies in the blood of
the donor can react with antigens on the red blood cells in the blood of the
recipient. For example, type O blood has anti-A and anti-B antibodies. If type O
blood type is transfused into a person with type a blood, the anti-A antibodies react
against the A antigens. Usually such reactions are not serious because the
antibodies in the donors blood are diluted in the large volume of the recipients
blood, and few reactions take place. Type O blood is given to a person with
another blood type only in life-or-death conditions because it sometimes can cause
a transfusion reaction.
The Gastro Intestinal System
The
then
gastro-intestinal system is essentially a long tube running right

through the body, with specialised sections that are
capable of digesting material put in at the top end
and extracting any useful components from it,
expelling the waste products at the bottom end.
The whole system is under hormonal control,
with the presence of food in the mouth triggering
off a cascade of hormonal actions; when there is
food in the stomach, different hormones activate
acid secretion, increased gut motility, enzyme release
etc. etc.
Nutrients from the GI tract are not processed on-site; they are taken to the liver to be
broken down further, stored, or distributed.
Once food has been chewed and mixed with saliva in the mouth, it is swallowed
and passes down the oesophagus. The oesophagus has a stratified squamous
epithelial lining (SE) which protects the oesophagus from trauma; the
submucosa (SM)secretes mucus from mucous glands (MG) which aid the passage of
food down the oesophagus. The lumen of the oesophagus is surrounded by layers of
muscle (M)- voluntary in the top third, progressing to involuntary in the bottom third- and
food is propelled into the stomach by waves of peristalisis.
The stomach is a 'j'-shaped organ, with two openings- the oesophageal and the
duodenal- and four regions- the cardiac, fundus, body and pylorus. Each region
performs different functions; the fundus collects digestive gases, the body secretes
pepsinogen and hydrochloric acid, and the pylorus is responsible for mucus, gastrin and
pepsinogen secretion.
The stomach has five major functions;
Temporary food storage
Control the rate at which food enters the duodenum
Acid secretion and antibacterial action
Fluidisation of stomach contents
Preliminary digestion with pepsin, lipases etc.
The Small Intestine
The small intestine is the site where most of the chemical and mechanical
digestion is carried out, and where virtually all of the absorption of useful materials is
carried out. The whole of the small intestine is lined with an absorptive mucosal type,
with certain modifications for each section. The intestine also has a smooth muscle wall
with two layers of muscle; rhythmical contractions force products of digestion through
the intestine (peristalisis). There are three main sections to the small intestine;
The duodenum forms a 'C' shape around the head of the pancreas. Its main
function is to neutralise the acidic gastric contents (called 'chyme') and to initiate
further digestion; Brunner's glands in the submucosa secrete an alkaline mucus
which neutralises the chyme and protects the surface of the duodenum.
The jejunum
The ileum. The jejunum and the ileum are the greatly coiled parts of the small
intestine, and together are about 4-6 metres long; the junction between the two
sections is not well-defined. The mucosa of these sections is highly folded (the
folds are called plicae), increasing the surface area available for absorption
dramatically.
The Large Intestine
By the time digestive products reach the large intestine, almost all of the
nutritionally useful products have been removed. The large intestine removes water
from the remainder, passing semi-solid faeces into the rectum to be expelled from
the body through the anus. The mucosa (M) is arranged into tightly-packed straight
tubular glands (G) which consist of cells specialised for water absorption and mucussecreting goblet cells to aid the passage of faeces. The large intestine also contains
areas of lymphoid tissue (L); these can be found in the ileum too (called Peyer's
patches), and they provide local immunological protection of potential weak-spots in
the body's defences. As the gut is teeming with bacteria, reinforcement of the
standard surface defences seems only sensible.
V
PATHOPHYSIOLOGY
Modifiable factors
Diabetic Nephropathy
Hypertension
Glomerulonephritis
Non Modifiable factors

Genetic
Race African
Age
Decreased renal perfusion
Blood test
Tissue atrophy due to lack of blood supply

Complications
Renal Biopsy
Decrease kidney function
Urinalysis
Process of scarring
CVD
Anemia
Pericarditis
Treatment
Renal replacement therapy

Hemodialysis
Kidney Transplant
Blood transfusions
Death of cells responsible for

manufacturing erythropoietin
Inflammatory cytokines
Inflammatory cytokines
suppress the proliferation of
erythroid precursors in the
bone marrow;
inflammatory cytokines inhibit

the release of erythropoietin
(EPO) from the kidney; and
Affects other important elements

of iron metabolism,
Increased amounts
of hepcidin
Promote the
production of white
Fewerblood
stemcells
cells to
differentiate into red blood
cells
- Decreased
ferroportin expression,
Decreased erythropoiesis
- CBC
- Stool Hgb test
and red blood cell

production
- Peripheral blood
smear
- Iron level
- Ferritin
- Folate
- Vitamin B12
- Bilirubin
Fatigue
Weakness
ANEMIA
SOB
Lightheadedness
Palpitations
Pallor
Chest pain
LEGEND:
Rounded rectangle
Precipitating and Predisposing factors
Rectangle
Sequence of events
Circle
Laboratory and Diagnostic results
Triangle
Clinical manifestation
Red ink
Actual signs and symptoms, laboratory and diagnostic exams experienced

by the client
SYNTHESIS
i MEDICAL-SURGICAL MANAGEMENT
1 Procedures
Procedure and Date
Blood Transfusion
September 02, 2014
(4 units of Packed Red Blood
Cells)
Indications
Nursing
responsibilities
Pre:
> Assess for laboratory
To provide blood or blood values.
components when the > Verify the medical
body
is
unable
to prescription
of
the
synthesize
sufficient
amount of blood or blood
components
due
to
certain illness such as
kidney disorders
physician.
> Assess for clients
baseline vital signs,
urine output, skin color,
and
history
of
transfusion reaction.
> Obtain venous access
using a G19 needle if
possible.
>
Secure
informed
consent.
> Obtain blood products
from blood bank and
transfuse immediately.
> Verify clients name
and number, check
blood compatibility, and
note expiration time.
>
Practice
aseptic
hands
if
to
be
performed
by
the
attending nurse.
>
Provide
supplementary
information to the client
regarding
the
side
effects
of
blood
transfusion such as
allergic reactions.
> Inform the client that
the procedure usually
takes 1 to 4 hours.
Intra:
> Administer the blood
product
using
the
appropriate
filtered
tubing.
> If blood product
needs to be diluted, use
normal saline solution
only.
> Remain with client for
first 15 30 minutes of
infusion.
> Monitor for any
untoward signs and
symptoms.
> Regulate the infusion
rate.
Post:
> Discontinue after
infusion and dispose
bag and tubing.
>Monitor vital signs
every 15 minutes for
the first hour after the
procedure.
>Inform the client that
she may have some
bruising or soreness for
a few days at the site
where the IV was
inserted.
> Advise the client to
have adequate fluid
intake.
>
Maintain
proper
positioning.
>
Document
the
procedure.
Esophagogastroduodenoscop
y
(EGD)
September 02, 2014
Pre:
>Verify
order
a test to examine the
lining
of
the
esophagus, stomach,
and first part of the small
intestine.
the
Doctors
>Put the patient on

NPO 6 12 hours as
per Doctors order
>Follow
instructions
about stopping aspirin
and
other
bloodthinning
medicines
before the test.
>Explain to the patient
the procedures
Intra:
>Assess patients
consciousness
>Assist the physician
>WOF any patient
discomfort
Post:
>Put the patient on
NPO until Gag reflex
returns
>Document all
procedures done
2 Pharmacotherapeutics / Medicines
Generic Name (Brand Name)
Indication (client-specific)
Nursing Responsibilities
Classification
Dosage
/Implication
Stock Dose
Frequency
Used to treat high blood
(pre,intra,post)
Pre:
Felodipine (Cabren)
pressure. It may be used
Calcium Channel Blockers
alone or in combination with
5mg/Tab
other drugs. Felodipine also
>Check the doctors order.

>Monitor vital signs.
>Observe the 10 rights of
is used to treat patients
drug administration.
with angina although it is not

FDA approved for this use.
Intra:
Dosage:5mg/Tab
>Provide drug with meals to
Route & Frequency: PO
prevent GI ulcerations
OD
Post:
>Explained to patient that
he/she may experience the
following side effects
Peripheral edema (swollen
ankles and feet), headache,
flushing, dizziness, and
increased heart rate, low
blood pressure
It stimulates the pancreas,
.
Pre:
Gliclazide (Diamicron)
which helps in more insulin
>Assess any history of liver
Anti Diabetic
secretion.
and kidney problems
60mg/tab
>Assess for any allergy

Dosage:60mg/tab
during pregnancy
Intra:
BID
>Monitor Patient Blood

Sugar
Post:
>Explain to patient that she
may experienced GI
disturbances, decreased in
blood cell count, jaundice,
nausea and vomiting,
diarrhea and stomach
Telmisartan (Pritor)
Angiotensin-II receptor
antagonist
80mg/tab
For Hypertension
inflammation
Pre:
Routes & Frequency: PO

OD
Dosage: 40mg/tab
Intra:
>Administer as ordered.
>Monitor the clients
response and tolerance
during administration of the
drug.
Post:
>Advice the client to report
difficulty breathing or
nausea.
Atorvastatin (Lipitor)
Adjunct to treatment of
elevated total cholesterol,
Antihyperlipidimic
reduction in the risk of fatal
Pre:
20mg/tab
and non-fatal stroke and
heart failure
Intra:
Dosage: 20mg/tab OD
Route &Frequency: PO OD

drug.
Post:
>Instruct patient not to take
this drug with grapefruit juice.
>Instruct patient to eat small
frequent meals if nauseous.
>Inform client to use
protective clothing due to
sensitivity to light.
Pre:
Febuxostat (Uloric)
Antigout
Chronic management of
40mg
hyperuricemia in patients
with gout.
Dosage: 40mg/tab
OD

>Ensure that client has not
yet eaten.
>Inform client to swallow the
tablet whole.
Intra:
drug.
Post:
>Monitor client for any side
effects and adverse
reactions such as nausea
and vomiting and diarrhea.

>Document
Omeprazole (Prilosec)
Part of an adjunctive therapy

to anticoagulants
Antacid, Antiulcerant
20 mg/tab
Dosage: 40mg/tab
ODAM
Pre:
>Ensure that client has not
yet eaten.
>Inform client to swallow the
tablet whole.
Intra:
>Administer antacids
concomitantly, as ordered.
drug.
Post:
>Raise side rails and
accompany patient due to
possible dizziness.
>Instruct patient to avoid
driving or performing
Lactulose (Generalac)
hazardous tasks.
- Prevention and treatment of Pre:
portal-systemic
Laxatives
encephalopathy.

>Check for laboratory exam
30cc
Dosage:30cc
results.
>Explain to patient the drug
Route and Frequency: PO

ODHS
to be administered.

Intra:
>Administer as ordered.
drug.
Post:
>Monitor client for any side
effects and adverse
reactions such as nausea
and vomiting and diarrhea.
>Monitor intake and output.
>Document the
administration of drug on the
patients chart.
>Document the patients
response and tolerance to
Mucosta (Rebapimide)
Treatment of Gastric
Antacids, Anti Ulcerants
mucosal lesions(erosion,
40mg
bleeding, redness, & edema)

in acute gastritis &
exarbation of chronic
gastritis
Dosage: 40mg TID
Route and Frequency: PO
TID
the drug administered.

Pre:
>Check for laboratory exam
results.
>Explain to patient the drug
to be administered.
drug administration
Intra:

drug.
Post:
>Monitor for signs of any
adverse reaction
ii PROGRESS NOTES
Day #
Existing Cues/Problems
Interventions Actually Done (Nursing and Collaborative)
Client Responses
Day 1
September 2,2014
On the first day of contact, patient was received awake,

conscious and coherent lying on bed in a Semi - Fowlers
position. Was on an NPO diet. Upon interview, she verbalized
that her body feels weak and that she wanted to go home;
however, her physician has not visited her on that day yet. Thus,
she is not sure of her health status and if she can go home soon.
She also mentioned that her skin is dry and it feels very itchy.
Her vital signs were: Temp.: 36.8 degrees Celsius, PR: 85 beats
per minute, RR: 21 cycles per minute and BP: 120/80 mmHg.
The doctor ordered 5units of Humulin R insulin and CBG was
taken after 30 minutes of administration, the result was

200mg/dL.
The priority nursing problems identified during the shift were:

Anxiety related to unknown outcomes of health management;
Activity Intolerance related to imbalance between oxygen supply
and demand; and Risk for Impaired Skin Integrity related to
accumulation of toxins in the skin.
To relieve her anxiety, the following interventions were

performed: rapport was established with the client and her
family; encouraged the client to verbalize her feelings and
concerns; assessed the clients level of anxiety; explained
procedures / care as delivered; provided a quiet and relaxing
environment conducive for resting; and encouraged diversional
activities such as sleeping. Collaborative intervention done was
by assisting in addressing financial considerations as
appropriate.
Since the client felt weak in general, the following interventions

were performed: encouraged the client to verbalize her feelings
and concerns; assessed the clients ability to perform activities of
daily living (ADLs); provided a quiet and relaxing environment
conducive for resting; assisted the client in performing activities
when necessary; encouraged the client to change position
slowly; and provided health teachings about the importance of
complying with patients medications and proper positioning
during rest periods. Collaborative intervention done was
administering medications as prescribed.
To address the clients risk for impaired skin integrity, the

following interventions were performed: assessed the skin for
changes in color, turgor and vascularity; monitored fluid intake
and output strictly as well as the hydration of skin and mucous
membranes; ensured that linens are dry and wrinkle free; and
recommended the client to keep fingernails short and rub itchy

areas instead of scratching. Collaborative intervention done was
recommending the client to consult her physician if there are
ointments / creams which she can apply to the itchy areas of her
skin.
At the end of the shift, the client verbalized that she felt okay and
was more relaxed. Although interventions were done to improve
activity tolerance and avoid impairment of skin integrity, the client
still felt that she was weak; her skin was very itchy and
continued to scratch her skin.
Day 2
September 3, 2014
On the second day of contact, patient was received awake,

conscious and coherent lying on bed in a Semi - Fowlers
position. With IVF of D5NSS
Her vital signs were: Temp.: 36.5 degrees Celsius, PR: 86 beats
per minute, RR: 20 cycles per minute and BP: 130/80 mmHg
Administered Febuxostat 40mg and Gliclazide 60mg at 8:00 and
Mucosta at 11:30am
Performed CBG at 11:30am with a result of 128mg/dL
Removed #4 Packed RBC at 11:30am
VI.
DISCHARGE HEALTH TEACHING PLANS

Content
Strategy
1. Compliance
Medication
- Instruct the client and her - Health Teaching

family to take all medications as
prescribed.
-Advise the family members to
avoid using non-prescription
drug unless use is approved by
the physician.
-Encouraging
the
family
members
to
administer
medications
exactly
as
prescribed by the physician
-Encouraging
the
family
members to follow the diet and
fluid intake recommended to the
patient.
-Instruct the patients relatives

about how to assist the patient
do simple ROM exercises like
flexion of upper and lower
extremities
Diet
-Instruct the relatives about the - Health Teaching

importance of exercise in the
body and its benefits to ones
health.
Exercise
.
- Health Teaching
Activity/Lifestyle
2. Follow up/ Check- -Instruct client to seek for - Health Teaching

up
consult if there are any concerns
or abnormal conditions, effects
of medication that aggravate or
alleviate the patients condition
outside the hospital premises.
-Stress to the patient the
importance of scheduling and
keeping check-up appointments
and make sure she has the
doctors office or telephone
number
iii SUMMARY OF CLIENTS STATUS OR CONDITION AS OF LAST DAY OF

CONTACT
Date: September 03, 2014

Received client awake, conscious and coherent lying on bed in Semi Fowlers position.
The latest vital signs elicited at 12 noon were: Temp: 36C; PR: 60 bpm; RR: 15 cpm and BP:
130 / 80 mmHg.
The problem regarding anxiety was resolved on September 03, 2014 through the clients
verbalization the she felt okay and more relaxed at the end of the shift. On the other hand, the
two other problems were not resolved. The client verbalized that she still felt weak and she also
continued to scratch her skin throughout the shift.
In general, the client and her family were cooperative especially during procedures. Although
she verbalized that she felt okay and more relaxed, the client said that she continued to feel
weak and that her skin was very itchy. Thus, the client continued to experience the problems
identified earlier on the last day of contact.
Other References:
http://www.le.ac.uk/pa/teach/va/anatomy/case6/frmst6.html
http://www.nlm.nih.gov/medlineplus/ency/article/003888.htm
http://www.medscape.com/
http://www.surgeryencyclopedia.com/Ce-Fi/Esophagogastroduodenoscopy.html
http://www.conemaugh.org/template_article.aspx?id=8670
http://www.webmd.com/a-to-z-guides/prothrombin-time
ALDRIN D. SAMSON, SN16

Anemia Seconday UGIB

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De La Salle Health Sciences Institute

College of Nursing and School of Midwifery

Clients Initial: A.C.P

D HISTORY OF PRESENT ILLNESS

E PAST MEDICAL HISTORY OR PAST HEALTH

H. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION

Hindi na ako nanghihina

position, conscious, coherent,

oriented to time and place;

Makati yung binti ko sa

Wrinkles distributed in the whole

Minsan sumasakit kapag

para makintab ang buhok

Sumasakit ang ulo ko

Eyeballs symmetrically aligned in

salamin para makakita

sockets, not protruding or sinking

symmetric in all six directions

OD pupil is greater/ dilated than

Di Makati ang tenga

Equal and bilateral

Di ako mabilis sipunin

(+) nasal structure is smooth

(+) dry lips

Di na nga ako nagpapacheck-up sa dentista eh.

Neck is symmetric with head

Meron ngang nakalagay

artery, no blowing or swishing

radial pulse, ulnar, brachial,

White skin (normal pigmentation)

(+) Yellowish urine

Wala naman akong

Patient refused to be assessed.

FULL ROM (active)

mga kamay at paa ko,

Upon inspection of the TMJ, the jaw

ang lakas ko pa noh?

moves laterally 1-2cm

Nakakalakad pa nga ako

(-) snapping, clicking sound of TMJ

parts due to weakness.

Di sumasakit ang likod

Ayun nga may dugo na

(-) Thyroid not enlarged

1 LABORATORY AND DIAGNOSTICS

and his family of the

> In case that no

> Inform the patient

> Practice aseptic

> Provide support

This type of WBC

This test determines

This test is done to

> Document the

nurse will extract

> Inform the client

-To determine the

This test is done to

proper waste bin if

identity of the client

> Inform the patient

and his family of the

attending nurse will

and his family of the