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INTRODUCTION Overview of the Case Chronic Kidney Disease is the failure of the kidneys to perform the function of cleansing the blood of waste products. The primary method of cleansing the body of waste involves the liver forming urea and the kidneys filtering this product out of the blood to be excreted in the urine. Blood urea nitrogen and creatinine are nitrogenous wastes, end products of protein metabolism. The amount of urea in the blood can be measured with a blood test called blood urea nitrogen (BUN). Creatinine levels also can be measured in the blood. BUN and creatinine levels are utilized to measure kidney function. A high level in the blood is called uremia, literally meaning urine in the blood. Urea is eventually converted to ammonia, leading to toxicity and related symptoms in all systems of the body.
End Stage Renal Disease is already the 7th leading cause of death among Filipinos? It is said that a Filipino is having the disease hourly or 120 Filipinos per million populations per year. This shows that about 10, 000 Filipinos need to replace their kidney function. Unfortunately though only 73% or about 7, 267 patients received treatment. An estimate of about a quarter of the whole population probably just died without receiving any treatment.
The kidneys play key roles in body function, not only by filtering the blood and getting rid of waste products, but also by balancing levels of electrolyte levels in the body, controlling blood pressure, and stimulating the production of red blood cells.
Treatment for chronic kidney failure, also called chronic kidney disease, focuses on slowing the progression of the kidney damage, usually by controlling the underlying cause. Chronic kidney failure can progress to end-stage kidney disease, which is fatal without artificial filtering (dialysis) or a kidney transplant.
Objective of the Study As a third year (N104) nursing student of Liceo de Cagayan University, within two days of nursing intervention on a client with Chronic Kidney Disease of Northern Mindanao Medical Centre, I will be able to conduct a thorough and comprehensive study of the assigned patient according to the data that was gathered by conducting a series of interviews. The condition of the aforementioned will augment and free of possible complications from the disorder.
The completion of this case study enables the proponent to do the following: 1. To organize my patients data for the establishment of good background information 2. To show the family history as well as the history of past and present illness for the knowledge of what could be the predisposing factors that might contribute to the patients illness 3. To trace the psychological development of the patient through the analysis of different developmental theories with comparison of the patients data 4. To review Patients Chart and carry out Medical Orders; thus, relate these interventions to the alleviation of the Patients health condition 5. To present the different results of the patients diagnostic exams together with the comparison of normal values for the understanding of what changes during the disease 6. To discuss the Anatomy, Physiology and Pathophysiology of the Patients health condition 7. To present the data from the nursing assessment performed on the patient using the cephalocaudal approach for the good overview of her over-all health 8. To identify Patients Clinical Manifestations as basis for a specific, measurable, attainable, realistic and time-bounded Actual and Ideal Nursing Care Plans. 9. To impart appropriate health teachings specifically for the patient to promote wellness and appropriate discharge plan 10. To have an over-all conclusion and recommendation about the care study
Scope and limitation The case presentation merely covers data that have been gathered through interview per assessment tool and chart referral on the day of the assessment phase in loading assigned patients and in the succeeding days of the rotation, in the care formulated and intervened to its progress as the weeks rotation ended. Thus, it is limited to the days in the rotation the student nurse interacted with the client in the hope to gather the necessary data to support the presentation which is not enough to acquire a bulk of specific details.
Clients Name: Age: Address: Civil Status: Spouse: Sex: Job: Nationality: Religion: Birthday: Height: Weight: Allergy:
Patient EBG 80 years old Kalinaw Dampias, Binuangan, Misamis Oriental Married Mrs. CRG Male Farmer Filipino Roman Catholic May 7, 1931 167.74 cm (55) 82 Kilogram No Known Food and Drug Allergies
Melissa Suzanne Y. Abamongan, M.D. July 30, 2011 7:30 in the morning Prior to admission, patient EBG from Binuangan Misamis Oriental complains of shortness of breath. Patient then sought consult and was admitted for the first time in Northern Mindanao Medical Centre
Admitting Diagnosis:
Family Health History During the interview, there were no traced of underlying condition of her family. Most common illness experienced by the members of the family is only mild cough and fever, and a medication bought on a near Botika ng Bayan was their primary source to medicate their illness. On both maternal and paternal sides of Patient EBG, his parents are both diabetic and hypertension. So genetically, it comes on their blood line that they are diabetic and hypertensive.
Personal Health History Patient EBG is married with Mrs. CRG with 2 children, a professional teacher from an elementary school and a government employee at Binuangan.. He smokes occasionally and can consume 3-4 sticks of cigarettes, while he is a hard drinker of liquor and can consume 1 case of beer every 24 hours. According to patient EBG, he drinks a lot together with his friends and there were no days that they skip from drinking. With no known food and drug allergies. Patient EBG had tried all the skilled works, from driving a very huge truck, go farming and working in an auto-repair shop. Because of his stressful work and due to the influence of friends, he then became a hard liquor drinker. Hes a diabetic for almost 15 year and did not seek medical admission and no maintenance of medication.
Past Medical History Patient EBG has not yet experienced any admission at the hospital since birth. During my interview he said that its his first time to be admitted in a hospital.
History of present health illness 5 months prior to admission, patient EBG noticed to have a decrease in urine output and it is below 500mL/day. No consult was done and no medications given.
Aging Pallor The condition has tolerated until 3 days prior to admission, patient EBG complains in loss of appetite.
Fever, still with decrease urine output Until the night prior to admission, patient complains of difficulty in breathing and unable to sleep man Until morning prior to admission, the patient then brought to the hospital and then admitted to have a better condition
Chief complains Prior to admission, patient EBG an 80 years old from Binuangan Mis. Or., admitted for the first time in Northern Mindanao Medical Centre, complains of shortness of breathing.
Description
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. 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 or Failed
Passed
Justification
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.
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 of Older adults may 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 decades, widowhood
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 had 9 children.
may force older people to adjust to loneliness, moving to a smaller place,and learning about business matters. 4. Establishing an explicit affiliation with one's aged group The development of a large part of the 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. Our patient tells stories about his childhood life to his grandchildren. He shares experiences to them which served as a guide and lesson. 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.
Older people might accumulate knowledge about life, and thus may contribute to the development of younger people and the society. 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.
Passed
Passed
Psychosocial theory (Erick Erikson) Middle Adulthood: 65 and above Ego Development Outcome: Integrity vs. Despair Basic Strengths: Production and Care
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.
This phase occurs during old age and is focused on reflecting back on life. Those who are unsuccessful during this phase will feel that their life has been wasted and will experience many regrets. The individual will be left with feelings of bitterness and despair. Those who feel proud of their accomplishments will feel a sense of integrity. Successfully completing this phase means looking back with few regrets and a general feeling of satisfaction. These individuals will attain wisdom, even when confronting death. Justification: My 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. .
IV. MEDICAL MANAGEMENT Medical orders July 30, 2011 (7:30AM) Please admit patient at P1F3-MRI Rationale For confinement and in need for medical attention For legal purposes and to ensure that the client understands the nature of treatment and procedures done are in accordance to patients will Able to take foods as wished with aspiration precaution to prevent from choking
IVF PNSS iL + 2amp D50 Glucose at NSS is a solution of common salt in 10gtts/minute 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. With addition of D50 glucose, this is to prevent hypoglycemia and maintain glucose level. Diagnostics
To test for loss of blood, abnormalities in the production or destruction of cells, acute and chronic infections, allergies, and problems in blood clotting and bleeding Done to determine persons blood type for blood transfusion or transplant purposes, because not all blood types are compatible with each other A screening to detect renal and metabolic diseases
Blood typing
U/A
Na+, K+, BUN and Creatinine Ca, Mg, Phosphorus and Albumin
To screen imbalances
for
an
electrolyte
Use to help find problems with the organs and structure inside the chest To record electrical changes in the heart and also used to evaluate symptoms such as chest pain, shortness of breath and palpitations Done in a regular basis for diabetic patients to determine the glucose level in the blood
CBG every 2H
Therapeutics
A test used to measure the amount of the enzyme glutamate pyruvate transaminase (GPT) in blood. Most commonly ordered to check for problems of the liver
Given as an intravenous bolus to patients who have hypoglycemia and increases blood serum glucose level
Used to eliminate water and salt from the body. works by blocking the absorption of sodium, chloride, and water from the filtered fluid in the kidney tubules, causing a profound increase in the output of urine
Antacid. 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. Alkalinizing agent. Acts as an alkalinizing agent by releasing bicarbonate ions. It is used to alkalinize urine and promote excretion of certain drugs in overdosage situations. Essential Amino Acid. Normalizes metabolic process, promotes recycling product exchange and reduces ion concentration of potassium, magnesium and phosphate.
Alkalinizing agent. Acts as an alkalinizing agent by releasing bicarbonate ions. It is used to alkalinize urine and promote excretion of certain drugs in overdosage situations.
Acts as an alkalinizing agent by
NaHCO3 side drip with D50 water 500cc + NaHCO3 100meq at 20cc/hour (to consume in 24 hours)
releasing bicarbonate ions. It is used to alkalinize urine and promote excretion of certain drugs in overdosage situations in addition to D50 water it prevents hypoglycemia To monitor and identify abnormalities from the patients normal state, and to establish basis for the effect of the treatment and medications
Evaluate clients fluid and electrolyte balance., also influence the choice of the fluid therapy; document clients ability to tolerate oral fluids and recognize significant fluid losses Promote proper ventilation The most commonly transfused blood component which can restore the bloods oxygen-carrying capacity, specially for patients with bleeding problem and anemia
MHBR To secure 2 u PRBC of patients blood type to transfuse blood once available in 6H with 8H apart
Rationale
Rationale
Electrolytes. Treatment for hypokalemia, prophylaxis during treatment with diuretics
To establish a diagnosis of hepatitis B infection and to assess immune status in naturally infected and experimentally vaccinated individuals Used for immunization in the prevention of tetanus To prevent the bacteria from producing toxins and to remove anaerobic conditions
Give para 300mg IVTT NOW For maximum therapeutic effects, and Give Diphenhydramine i amp IVTT prevention of complications NOW It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration
Laboratory results
REFERENCE RANGE
WBC
High WBC count often means that an infection is present in the body, while a low number can mean that a specific disease or drug has impaired the bone marrows ability to produce new cells.
19.4
20.0
10^3/uL (5.0-10.0)
RBC
Decreased RBC is usually in anemia any cause with the possible exception thalassemia minor, where a mild borderline anemia is seen with a high borderline-high RBC. Increased RBC seen in erythrocytotoxic state.
of of or or is
2.78
2.76
10^6/uL (4.2-5.4)
Hgb
Decreased in various anemias, pregnancy, severe or prolonged hemorrhage with excessive fluid intake. Increased in polycythemia, chronic obstructive pulmonary disease failure of oxygenation because of CHF and normally in people living at high altitudes.
7.6
7.5
g/dL(12.0-16.0)
Hct
Decreased in sever anemias, anemia in pregnancy, acute massive loss. Increased in erythrocytosis of any cause and in dehydration or hemoconcentration associated with shock.
22.1
21.8
% (37.0-47.0)
79.5
79.0
fL (82.0-98.0)
27.3
27.2
pg (27.0-31.0)
34.4
34.4
g/dL (31.5-35.0)
14.3
13.8
% (12.0-17.0)
9.8
7-10-11 11:44 AM
9.9
7-12-11 12:18PM
fL (8.0-12.0)
6.4
6.7
(17.4-48.2)
Neutrophils
Increased with acute infections, trauma, or surgery, leukemia, malignant disease and necrosis. Decreased with viral infections, bone marrow suspension and primary bone marrow disease.
89.3
85.3
(43.4-76.2)
Monocytes
Increased with viral infections, parasitic disease, collagen and hemolytic disorders. Decreased with use of corticosteroids, RA and HIV infection
3.8
6.6
(4.5-10.5)
Eosinophils
Increased in allergies, parasitic disease, collagen disease, and subacute infections. Decreased with stress and use of meds.
0.4
1.4
(1.0-3.0)
Basophils
Increase in acute leukemia and following surgery or trauma. Decreased with allergic reactions, stress, parasitic disease and use of corticosteroids
0.1
0.0
(0.0-2.0)
Platelet
Both increases and decreases can point to abnormal conditions of excess bleeding or clotting.
303,000
280,000
(150,000400,000)
BLOOD CHEMISTRY RESULT (7-10-11) TEST Blood sugar (Fbs, Rbs, 2HPP)
Increased in DM, nephritis, hypothyroidism and infections. Decreased in hyperinsulinism, hyperthyroidism and hepatic damage.
RESULT
REFERENCE RANGE
309.0
mgs% (60-110)
37.76
mgs% (4.6-23.4)
etc). Decreased: starvation, liver failure, pregnancy, infancy, nephrotic syndrome, overhydration.
Creatinine
Increased: renal failure including prerenal, drug-induced (aminoglycosides, vancomycin, others), acromegaly. Decreased: loss of muscle mass, pregnancy.
3.70
mgs% (0.6-1.2)
Potassium
Increased in renal failure, acidosis, cell lysis and hemolysis. Decreased in hyperparathyroidism, vit. D deficiency, GI losses and diuretic administration.
3.32
mmol/L (3.5-5.3)
Sodium
Increased in hemoconcentration, nephritis and pyloric obstruction. Decreased in alkali deficit, Addisons disease and myxedema.
127.30
mmol/L (135-145)
V. HUMAN ANATOMY and PHYSIOLOGY with PATHOPHYSIOLOGY Anatomy and Physiology of Liver The liver is the largest organ of the human body, weighs approximately 1500 g, and is located in the upper right corner of the abdomen. The organ is closely associated with the small intestine, processing the nutrient-enriched venous blood that leaves the digestive tract. The liver performs over 500 metabolic functions, resulting in synthesis of products that are released into the blood stream (e.g. glucose derived from glycogenesis, plasma proteins, clotting factors and urea), or that are excreted to the intestinal tract (bile). Also, several products are stored in liver parenchyma (e.g. glycogen, fat and fat soluble vitamins).
Almost all blood that enters the liver via the portal tract originates from the gastrointestinal tract as well as from the spleen, pancreas and gallbladder. A second blood supply to the liver comes from the hepatic artery, branching directly from the celiac trunk and descending aorta. The portal vein supplies venous blood under low pressure conditions to the liver, while the hepatic artery supplies high-pressured arterial blood. Since the capillary bed of the gastrointestinal tract already extracts most O2, portal venous blood has a low O2 content. Blood from the hepatic artery on the other hand, originates directly from the aorta and is, therefore, saturated with O2. Blood from both vessels joins in the capillary bed of the liver and leaves via central veins to the inferior caval vein.
Basic liver architecture The major blood vessels, portal vein and hepatic artery, lymphatics, nerves and hepatic bile duct communicate with the liver at a common site, the hilus. From the hilus, they branch and re-branch within the liver to form a system that travels together in a conduit structure, the portal canal. From this portal canal, after numerous branching, the portal vein finally drains into the sinusoids, which is the capillary system of the liver. Here, in the sinusoids, blood from the portal vein joins with blood flow from end-arterial branches of the hepatic artery. Once passed through the sinusoids, blood enters the collecting branch of the central vein, and finally leaves the liver via the hepatic vein. The hexagonal structure with, in most cases, three portal canals in its corners draining into
one central vein, is defined as a lobule. The lobule largely consists of hepatocytes (liver cells) which are arranged as interconnected plates, usually one or two hepatocytes thick. The space between the plates forms the sinusoid. A more functional unit of the liver forms the acinus. In the acinus, the portal canal forms the center and the central veins the corners. The functional acinus can be divided into three zones: 1) the periportal zone, which is the circular zone directly around the portal canal, 2) the central zone, the circular area around the central vein, and 3) a mid-zonal area, which is the zone between the periportal and pericentral zone.
Sinusoids Sinusoids are the canals formed by the plates of hepatocytes. They are approximately 8-10 m in diameter and comparable with the diameter of normal capillaries. They are orientated in a radial direction in the lobule. Sinusoids are lined with endothelial cells and Kupffer cells, which have a phagocytic function. Plasma and proteins migrate through these lining cells via so-called fenestrations (100-150 nm) into the Space of Disse, where direct contact with the hepatocytes occurs and uptake of nutrients and oxygen by the hepatocytes takes place. On the opposite side of the hepatocyte plates are the bile canaliculi situated (1 m diameter). Bile produced by the hepatocytes empties in these bile canaliculi and is transported back towards the portal canal into bile ductiles and bile ducts, and finally to the main bile duct and gallbladder to become available for digestive processes in the intestine. The direction of bile flow is opposite to the direction of the blood flow through the sinusoids.
The liver lobule with portal canals (hepatic artery, portal vein and bile duct), sinusoids and collecting central veins.
Pressure distribution Blood pressure in afferent vessels and pressure distribution inside the liver is essentially similar for most species. Pressure in the hepatic artery, originating from the descending aorta and the celiac trunk, is considered to be the same as aortic pressure. This includes a high pulsatile pressure between 120 and 80 mmHg with a frequency equal to the heart rate. Vessel compliance causes a gradual decrease in pulsation as the hepatic artery branches and re-branches inside the liver. Once at the sinusoidal level, pulsation amplitude decreases to virtually zero and pressure drops to approximately 2-5 mmHg. On the other hand, pressure in the portal vein, originating from capillaries of the digestive tract, has no pulsation and a pressure of 10-12 mmHg.
In the sinusoids, both portal venous and hepatic arterial pressure is 3-5 mmHg. Consequently, the pressure drop inside the liver is much less in the portal venous system than in the arterial system. The pressure drop from the collecting central veins to the vena cava is then approximately 1-3 mmHg, fluctuating slightly with respiration.
Flow distribution Total human liver blood flow represents approximately 25% of the cardiac output; up to 1500 ml/min. Hepatic flow is subdivided in 25-30% for the hepatic artery (500 ml/min) and the major part for the portal vein (1000 ml/min). Assuming a human liver weighs 1500 g, total liver flow is 100 ml/min per 100 g liver. Comparing this normalized flow rate to other species, it can be concluded that total liver blood flow is 100 130 ml/min per 100 g liver, independent of the species. The ratio of arterial: portal blood flow, however, is species-dependent. The hepatic artery originates directly from the descending aorta, and is therefore saturated with oxygen. It accounts for 65% of total oxygen supply to the liver. The hepatic artery also plays an important role in liver blood
vessel wall and connective tissue perfusion. It also secures bile duct integrity. The blood from the portal vein is full of nutrients derived from the intestine and allows the hepatocytes to perform their tasks. Blood from the hepatic artery and the portal vein joins in the sinusoids. However, recent studies by others as well as our own observations have revealed that there are both common and separate channels for arterial and portal blood. The hepatic artery perfuses the liver vascular bed in a 'spotty' pattern, while the portal vein perfuses the liver uniformly. The liver is able to regulate mainly arterial flow by means of so-called sphincters, situated at the in- and outlets of the sinusoids. One of the most important triggers for sphincter function is the need for constant oxygen supply. If the rate of oxygen delivery to the liver varies, the sphincters will react and the ratio of arterial: portal blood flow alters.
[ ] no problem RESPIRATORY: [ ] asymmetric [ ] tachypnea [ ] apnea [ ] rales [x] cough [ ] barrel chest [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [x] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic Assess resp. rate, rhythm, pulse blood breath sounds, Comfort [ ] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain Assess heart sound, rate, rhythm, pulse, blood pressure, circulation, fluid retention, comfort [x]no problem
GASTROINTESTINAL TRACT: [ ] obese [ ] distention [ ] mass [ ] dysphagia [ ] rigidity [ ] pain Assess abdomen, bowel habits, swallowing bowel sounds, Comfort [x] no problem GENITO-URINARY AND GYNE: [ ] pain [ ] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia
Warm to touch Sweating T = 38.7c P = 74bpm R = 28 cpm BP = 160/90 mmHg Edema on upper extremities;
Assess urine frequency, control, color,odor, Comfort, gyne bleeding, discharge [x] no problem NEURO: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [x] lethargic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] grip Assess motor, function, sensation, LOC, Strength, grip, gait, coordination, Speech [x] No problem MUSCULOSKELETAL AND SKIN: [ ] appliance [ ] stiffness [x] itching [ ] petechiae [x] hot [ ] drainage [ ] prosthesis [x] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] deformity [ ] wound [ ] rash [ ] skin color [ ] flushed [ ] atrophy [x] pain [ ] ecchymosis [ ] diaphoretic [ ] moist Assess mobility, motion, gait, alignment, joint function, skin color, texture, turgor, integrity [ ] no problem
SUBJECTIVE
Communication: [ ] hearing loss Comments: Hearing is good. Client [ ] visual changes is responsive and hears [x] denied clearly when talked to.
OBJECTIVE
[ ] glasses [ ] languages [ ] contact lens [ ] hearing aide R L Pupil size: 2-3mm [ ] speech difficulties Reaction: Pupil Equally Round and Reactive to Light and Accommodation
Oxygenation: [x] dyspnea Comments : Mejo galisud lage ko [ ] smoking history ug ginhawa. Naa pud [x] cough koy ubo karon gamay
R: R lung is not symmetrical to left lung L: L lung is not symmetrical to right lung.
Heart Rhythm [x] regular [] irregular Ankle Edema: Edema noted; pitting grade: 4 Pulse R: L: Car. Rad. + 74 bpm + 74 bpm DP. FEM* + not obtain + not obtain
Comments: All pulse sites are palpable. *If applicable Nutrition: Diet : Diet as tolerated Aspiration precaution. [ ]N [ ]V Comments: Wala kayo ko gana Character: mukaon. Gagmay ra kaayo [x] recent change in akong kinan-an.. weight, appetite As verbalized by the client. [ ] swallowing difficulty [ ] denied Elimination: Usual bowel pattern [ ] urinary frequency 1 times a day once a day [ ] constipation [ ] urgency remedy [ ] dysuria [ ] hematuria none Date of Last BM [ ] incontinence 07/12/11 [ ] polyuria [ ] Diarrhea [ ] foley in place character : [ ] denied MGT. of Health & Illness: [ ]alcohol ___________ [ ]smoking :_____________ [ ] denied (amount, frequency) [ ] SBE: N/A Last Pap Smear: Not obtained LMP: N/A [ ] dentures Full Upper Lower [ ] [ ] [x] none Partial [ ] [ ] W/ Patient [ ] [ ]
Bowel sounds: normoactive bowel sounds Abdominal distention Present [ ] yes [x] no Urine:(consistency, odor) Slightly hazy and dark yellow with aromatic odor.
Briefly describe the patients ability to follow treatments (diet, meds, etc.) for chronic health problems (if present). Patient was irritable but able to follow compliance to medication and follows the right diet to be eaten.
OBJECTIVE
[ ] cold [ ] pale Comments: Sige lage ko ug panga-. [ ] dry [ ] flushed [ ] warm tol, ambot lang pud ug [ ] moist [ ] cyanotic ngano ni. *rashes, ulcers, decubitus (describe size, location, As verbalized by the client drainage) Edema was noted on the lower extremities; pitting grade 4 and a blister formation on the right calf. .
Activity/Safety: [ ] convulsion Comments: Nang hupong akong tiil. [ ] LOC and orientation The patient is oriented to [ ] dizziness dili ko kalakaw tungod place, time and date. [ ] limited motion of joints tungod aning buhag sa Gait: [ ] walker [ ] cane [ ] other sa akong ti-ilan, sakit itunob. [ ] steady [ ] unsteady Limitation in ability to [x] ambulate As verbalized by the client [ ] sensory and motor losses in face or extremities: [x]bathe self No sensory and motor losses in face or extremities. [ ]other [ ] denied [ ] ROM limitations: The patient has normal range of motion. Comfort/Sleep/Awake: [x] pain Comment: Sakit ang hubag sa akong [x] facial grimaces [x] guarding (Location paa. frequency) As verbalized by the client [ ]No other signs of pain: [ ] nocturia [ ] side rail release from signed (60 + years) [ ] sleep difficulties N/A [x] denied Coping: Observed non-verbal behavior: The patient is very Occupation: Housewife active and alert during the interview Member of household: Husband, children and grandchildren Person(Phone number): kept confidential Most supportive person: Aileen Gabato (Daugther)
VII. NURSING MANAGEMENT Ideal Nursing Management Nursing Diagnosis: Activity intolerance related to fatigue and body malaise
INTERVENTIONS Assess level of activity intolerance and degree of fatigue and malaise when performing routine activity of
RATIONALE Provides baseline for further assessment and criteria for assessment of effectiveness of
daily living
interventions.
Encourage rest when fatigued or when abdominal pain or discomfort occurs. Assist with selection and pacing of desired activities and exercise
interest
in
Provide diet high in carbohydrates with protein intake consistent with liver function
Nursing Diagnosis: Imbalance nutrition; less than body requirements related to abdominal discomfort and anorexia
INTERVENTIONS
RATIONALE
Assess dietary intake and nutritional status through diet history and diary, daily weight measurements and laboratory data.
identifying low
Reduces discomfort from abdominal distention and decreases sense of fullness produced by pressure of abdominal contents and ascites on the stomach
Provide oral hygiene before meals and pleasant environment for meals at mealtime
Nursing Diagnosis: Fluid volume excess related to decrease renal function and inability to excrete fluids and electrolytes
Record intake and output regularly depending on response to interventions and on patient acuity
SOAPIE
S Sakit kau akong hubag sa paa. as verbalized by the client
A P
redness, pain scale 7/10 pallor guarding Temp 38.7c irritable warm to touch restless Acute pain related to inflammation of the dermal and subcutaneous layer of the skin Long term: Within eight hours of clinical rotation client will be alleviated from discomforts brought about by pain Short term: At the end of fifteen minutes client will verbalize reduction and or controlled pain 1. Asses level of pain through pain scale To obtain baseline data and measure amount of pain. 2. Assist client to a comfortable position and provide a non irritating environment Helps reduce pain and provides conducive environment 3. Assist into non pharmacological pain management Diverts attention to pain causing relief 4. Monitor vital signs-usually altered during pain assist into relaxation exercises To reduce aggravation of pain. 5. assist into relaxation exercises To reduce aggravation of pain.
Long term: At the end of eight hours client experienced relief of discomforts thus long term goal is met Short term: At the end of fifteen minutes client verbalized reduction of pain per cooperation and participation during the implementation phase
SOAPIE
S O Mejo galisod lage ko ug ginhawa as verbalized by the client Respiratory Rate 28
A P
shallow breathing lip pallor gasps for air nasal flaring weak lethargic
Ineffective breathing pattern related to abdominal distention and compression of lungs. Long term: Within fifteen minutes client will obtain an o2 sat of 99-100% Short term: At the end of five minutes client will manifest normal breathing cycle 12-20 cpm 1. Assess v/s especially RR To obtain baseline data and determine the nursing action to implement 2. Raise the head of bed or place in high fowlers position To increase lung expansion 3. Monitor Abg levels To determine level of o2 saturation 4. Encourage breathing techniques, purse lip breathing To facilitate breathing and allows sufficient flow of oxygen to lungs 5. Encourage adequate rest To limit fatigue
Long term: At the end of fifteen minutes client obtained an o2 sat of 99%, therefore goal is met. Short term: At the end of five minutes, client obtained and showed normal breathing pattern, with an RR of 17cpm, therefore goal is met
SOAPIE
S O Naghupong ang ako mga tiil. as verbalized by the client pitting edema on lower extremities; grade four
A P
increase in size of the gastrocnemeus region increase in weight skin warm to touch tightness of skin
Fluid volume excess related to localized retention of fluids at the extremities Long term: Within two days of clinical rotation client will display reduced edema on site Short term: At the end of eight hours clinical rotation client will demonstrate understanding of the necessary interventions. 1. Restrict sodium and fluid intake if prescribed Minimizes formation of edema and reduce fluid retention 2. Record intake and output regularly depending on response to interventions and on patient acuity Indicates effectiveness of treatment and adequacy of fluid intake 3. Measure and record abdominal girth and weight daily Monitors changes in ascites formation and fluid accumulation 4. Explain rationale for sodium and fluid restriction. Promotes patients understanding of restriction and cooperation with it 5. Provided with adequate activity, positive changes as able and assist with repositioning every 2H To prevent accumulation in dependent areas
Long term: At the end of two days clinical rotation client displayed decrease in size of edema. Short term: At the end of eight hours intervention client demonstrated understanding and significance to adherence to instructions.
Drug Study
Name of Drug Generic/ Date Brand Ordered Classification Dose/ Frequency/ Route Mechanism of Action Specific Indication Contraindication Side Effects Nursing Precaution
Essentiale forte
7-10-11
Hepatic protectors
Icap TID PO
In very rare Normalizes Indicated for Do not use cases it can the metabolism the treatment Essentiale of lipids and of fatty in hypersensitivi- cause: abdominal proteins, degeneration ty or allergy to improves of the any ingredients pain, nausea, diarrhea and the detoxificati liver, hepatitis of the on function of (including toxic preparation. The allergic reaction (skin the liver, hepatitis, liver application of rash). restores the damage Essentiale in cellular caused by newborn children structure of the medicines or is not safe. liver and alcohol During retards the abuse), cirrhos pregnancy producing of is of the liver, women are conjunctive disturbances recommended to tissue. in liver function consult their associated health care with different provider prior to illnesses. taking Essentiale
Do not use Essentiale forte in hypersensitivity or allergy to any ingredients of the preparation. The application of Essentiale to new born is not safe. During pregnancy, woman are advised to consult their health care provider prior to taking Essentiale
Drug Study
Name of Drug Generic/ Date Brand Ordered Classification Dose/ Frequency/ Route Mechanism of Action Specific Indication Contraindication Side Effects Nursing Precaution
Spironolacto 7-10-11 Potassium25mg itab Spironolactone Removes Anuria, acute ne sparing diuretic BID PO inhibits the excess fluid renal action of (Aldactone) from the body insufficiency; aldosterone in congestive progressing thereby causing heart failure, impairment of the kidneys to cirrhosis of the kidney function, excrete salt and liver, hyperkalemia; fluid in the urine and kidney pregnancy and while retaining disease and to lactation. potassium. treat elevated Therefore, blood pressure spironolactone and for treating is classified as diuretica potassiumsparing diuretic, induced low potassium a drug that promotes the (hypokalemia) output of urine (diuretic) while allowing the kidneys to hold onto potassium.
Side effects of spironolactone include headache, diarrhea, cramps, drowsiness, rash, nausea, vomiting, impotence, irregular menstrual periods, and irregular hair growth.
Check blood pressure before initiation of therapy and at regular intervals throughout therapy Assess for signs of fluid and electrolyte imbalance, and signs of digoxin toxicity. Monitor daily I&O and check for edema. Report lack of diuretic response or development of edema; both may indicate tolerance to drugs
VIII. Referrals and Follow-up Medication Referral and Follow-up Instruct the patient and the family to follow the home medications as prescribed by the physician Explain each purpose of the medication Instruct the client not to take over-the-counter drugs without doctors knowledge Explain the side effects or adverse reaction on each medication. Report immediately as soon as there is an occurrence or such Inculcate to the mind of the patient to comply all the medications prescribed at the ordered dosage, route and at the ordered time Let the patient complete the whole course of drug therapy Rationale Treatment regimen is important to have fast recovery Knowledge about the medication will make the client become aware of what he is taking and for the family to participate in patients treatment Non-prescribed drug may have antagonistic or synergistic effect in any drug therapy Explaining the side effects will make the patient and the family identify what harmful effects to expect Taking the drugs at the ordered dose, route and time limits the chance of toxicity and ensure its effectiveness This can help the patient alleviate the problem and be able to experience the full therapeutic effect of the medication Walking is a good exercise and could promote circulation, hence, proper healing This will promote good physical health Activities that required great muscle strength should be avoided to prevent injury and muscle strain To gain back the lost strength and able to return to its normal state thus allow ample time for healing This will help alleviate any pain or discomfort that patient will encounter
Exercise
Encourage early ambulation Promote exercise to the patient especially ROM Instruct client to avoid strenuous activities for at least a week or month until fully recovered Advise patient to have adequate rest and sleep Practice deep breathing exercise
Treatment
Explain the need of treatment after discharge and must take it seriously to prevent such complication to the patient Explain to the family the condition of the patient and give them factual information about the illness
To make the client and family aware that the treatment does not only end up in hospital but needs to be continued at home to make he client responsible towards medication To have better understanding of the patients condition and to be able to know what intervention should they give and could not alter the effect of the therapy Hygiene provides comfort and cleanliness to the patient. It also increases the patients sense of wellbeing, which is very much needed in the therapy process Keeping all practiced measures is necessary in consistent maintenance of proper hygiene
Hygiene
Encourage having proper hygiene like taking a bath, meticulous hand washing, and brushing of teeth every after meal Encourage patient to continue hygienic measures practiced at present such as changing of clothes everyday and changing of underwear as often as necessary, keeping the nails neatly trimmed, maintaining own supplies/items for personal necessities Provide a calm and accepting
Calm, clean and non threatening may lessen the occurrence of possible infection and would be a good place for healing Through constant visit as out patient, the physician would still monitor the progress of the therapeutic intervention availed by the patient This is to evaluate the therapeutic response of the patient to the treatment This will help detect early signs and symptoms of the recurrence of disease
Out Patient
Inform the patient that follow-up check-up is important to have a continuous monitoring and care even after attainment of the course medical therapy Advice the patient and the family to carry out follow-up diagnostic examinations Instruct the family to report any unusual signs and symptoms experienced by the patient
Diet
Encourage the client to eat variety of nutritious foods like fruits and vegetables once instructed by the physician Instruct client to take vitamins as ordered Advise client not to skip meals and have a regular eating pattern/schedule Tell the patient not to take foods
To boost the bodys immune system Regular interval of meals is the basic principle of a good dietary plan To prevent the occurrence of complication
IX. Evaluation and Implication Category Poor (1) 1. Duration of illness x Fair (2) Good (3) It has been six months since he has been having lower extremity edema Having edema could have been avoided by having good hygiene Race and location predispose Patient R to getting cirrhosis Economic status and lifestyle precipitates Patient R in getting cirrhosis, these could have been prevented by simple hygiene and prevention methods Patient R is very willing to take her medications. She knows the good effects of drug and intravenous therapy Patient R was admitted at P1F3 female reverse isolation ward There were only 2 members of the family were present in the ward. Her sister and her daughter were the only supportive persons that time Justification
3 + 6 + 3 = 12 Calculations 3x1 =3 3x2 =6 3x1 =3 12/7 = 1.7 Ranges: 1.0 - 1.5 = Poor 1.5 2.5 = Fair 2.5 3.0 = Good
Patient R condition has been with her for 6 months before she choose to seek treatment. She took for granted the worsening of her condition. She could have been prevented the complications brought about by her condition if she had consulted a health care professional immediately. Also simple observance of good hygiene could have been to prevent him from contracting the infection of Liver Cirrhosis. On the other hand, patient and other members of the family seek medical care; family support and good compliance of medication were observed. Through this, the prognosis has come up to the fair category.
The entire two days exposure at pediatric ward assigned to a client with Pediatric Community Acquired Pneumonia has thought me a lot of things. That is, understanding the entire pathogenesis of the disorder its affectation and what approach are to be implemented. Thus, consequently an improvement of clients condition is achieved with the help and assistance of the team of caregivers implementing effective plan of care including active participation of the client and significant other. Therapeutic relationship and communication between the caregivers and the client with the significant others contributed to the achievement of the set goal. Personally my nursing skills and interpersonal relationship with the people Ive worked with has improved accordingly in the experience of the exposure.