UNIVERSITY OF SANTO TOMAS

COLLEGE OF NURSING
COMPETENCY APPRAISAL 2
MS CASE # 4
(Neuro, Endocrine, Urinary)
FOCUS OF STUDY:
A. ENDOCRINE DISORDERS: THYROID & DM
B. URINARY: RENAL FAILURE
C. NEUROLOGICAL: BRAIN INJURY, INCREASED ICP, SEIZURE DISORDER,
CRANIOTOMY
CASE SCENARIO:
PART I
S.B. is a 72-year-old married woman with a past medical history of seizure
disorder controlled with Tegretol (last seizure was 5 years ago), underwent Total
Thyroidectomy for Toxic Nodular Goiter three years ago and presently receiving
Synthyroid. She has a history of HTN for the past 10 years and is receiving Enalapril
for it. She has been diagnosed with DM Type 2 since age 40 years old and being
managed with Oral antidiabetic agents. She is obese and the family admits to her
being non-compliant to her diabetic control regimen. She sought consult at the
doctors clinic last September 2012 for her non-healing 2-cm wound with seropurulent drainage at her right foot. She reports that her latest blood tests two
months ago reveal an elevated glycosylated hemoglobin, BUN & creatinine levels.
The daughter states that the patient has been advised to undergo further tests for
her kidneys to determine the extent of her Diabetic Nephropathy. After the consult
visit, the doctor advised admission for treatment of the foot ulcer and further
evaluation of her diabetic condition.
1. What relevant assessment data will you need related each of your
patients medical condition?
Give the rationale for each assessment
data.
2. Identify predisposing factors to each of her medical problems that you
need to check out with S.B.
3. Illustrate using a flow chart the pathophysiology of each of the medical
problems of S.B. and their possible complications . Oral report by RLE 1a
4. Using another flow chart, indicate the pathophysiologic relationship of the
medical problems of S.B. How do these conditions relate to each other, if
they do? Oral report by RLE 1b
5. Prior to the thyroid surgery of your patient,
5.1. What manifestations would you have seen for a toxic nodular goiter ?
5.2. What medications were ordered to SB to help manage her condition?
Give their rationale?
6. Following total thyroidectomy,
6.1 What complications can possibly occur and why? Give their nursing
and collaborative preventive interventions.
6.2. Why is the patient being given Synthyroid? What specifIc health
teachings need to be given regarding this drug.
7. What criteria is used for the establishment of a definite diagnosis of DM?

8. What health teachings can be given to the family members of S.B. to keep
them from developing DM?
9. What 2 acute complications of DM2 should be watched out for in S.B.? Give
their manifestations, preventive and therapeutic interventions. Oral report
by RLE 2a
10. Can the patient develop a DKA? If it does, give the pathophysiologic
basis.Oral report 2a
11. How do you recognize the difference between a Somogyi effect & the
Dawn phenomenon?
12. Discuss briefly the management strategies for DM and their rationale.
13. Make a nutritional health teaching plan for S.B.
14. What are the different types of oral antihyperglycemic agents that can be
given? Make a table to include: Type of drug; examples; therapeutic action;
onset, peak & duration of action; side effects. Using review of journals,
what other interventions are available for DM? Oral report 2b
S.Bs non-healing wound is debrided and treated further with oral antibiotics.
15. The patient asks, When will this wound heal? Why is it taking so long?
What other bad
thing can I have because of this? What would be your
response to these queries?
16. What relevant teaching can you provide at this time?
17. Should the patients foot condition further deteriorate, when would
amputation be indicated? What major concerns related to care would you
have?
The doctor evaluates for other possible effects of her poorly managed DM.
18. What tests would you expect to be ordered? What would their findings be
to indicate the
presence of complications?
The lab test results return confirming previous results with elevated BUN &
creatinine.
S.B. appears worried & states, My mother had DM and had dialysis for several
years before she died because of chonic Renal failure. I dont want to have the same
thing happen to me.
19. How will you address this concern?
20. When does the nephrologist generally decide to perform dialysis on a
patient? What is the purpose of this procedure?
21. Differentiate hemodialysis from peritoneal dialysis?
22. What is CRRT?
23. Do you believe the patient would be a good candidate for renal
transplant? Defend your answer.
Oral report of RLE 3 for # 19-23
S.B. is eventually sent home after a weeks stay in the hospital with take home
regimen for her medical problems.
Last December 31, 2014, while helping out in the kitchen to prepare for the New
Years Eve dinner, the gas tank exploded in the kitchen and her clothes caught fire.
She sustained 30% body surfacepartial thickness burns on her face, arms and
anterior trunk.

24. S.B. undergoes fluid resuscitation using the standard Parkland formula.
She was burned at 6:00PM and was admitted to the hospital at 7:00 PM. She weighs
120 lbs. Calculate her fluid requirements and specify how much will be given at
specific times in the next 48 hours.
25. Considering the location of the burns, what other immediate concerns do
you have related to her care? What assessment findings would collaborate this
concern?
26. Discuss briefly the pathophysiologic changes in the different stages of
burns that you expect to happen in S.B. Use a flowchart diagram to illustrate your
discussion
27. What possible complications should you watch out for post-burn, at what
time and using what assessment parameters?
Oral report for RLE 4a # 26 & 27.
28. Discuss briefly the impact of the Stress response and RAAS on S.B. What
pathophysiologic changes will you expect to see.
29. At 0600 on Jan 1, 2015, S.B. is assessed with the following: BP 90/70, HR
98, RR-30, SaO2 80, total urine output for the last 2hrs- 30 ml., restless. She
has an IV of PNSS running at 30 gtt/min. What concerns you here? What other
assessments will you do? What will be your priority action? What will you expect the
doctor to order for further assessment and treatment?
30. S.B. is in severe pain. What is the drug of choice for pain relief following
burn injury, and how should it be given?
31. S.Bs burns are treated by the open method with topical application of
silver sulfadiazine. What is the major drawback to this method of treatment? What
nursing considerations will apply?
32. A special burn diet is ordered for S.B. What diet-related teaching will you
provide?
33. What factors prevailing in the patient could will greatly influence his
condition, the severity of his burn and his recovery?
34. Design a five-day nursing care plan for S.B. using a critical pathway.
Oral report for RLE 4b # 33 & 34
35. What challenges will S.B. encounter on her road to full recovery after
discharge? What supportive nursing intervention can you give?

Ist/ustcn/2015