Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Submitted To:
Ms. Obdulia M. Almarez, RN, MAEd, MAN
Clinical Instructor
SEPTEMBER 2016
I. PATIENT PROFILE
Patient Name: V.D
Gender: Female
Patient VD has no known allergies to food. In 2008, they found out that she has allergy to
Amlodipine Besylate because she experienced itchiness and dry skin. Her attending physician
changed her anti-hypertensive medication from Amlodipine Besylate to Lacarnidipine. As
Patient VD claimed, she could not remember if she received any vaccination before. She claimed
that she had Mumps, Chicken Pox, Measles, and Rubella before when she was still young.
V. DEVELOPMENTAL THEORY
A. SIGMUND FREUD PSYCHOSEXUAL THEORY
Freud Psychosexual Development theory emphasized that on the fifth stage in the
Genital Stage that spans Puberty throughout Adult life and thus represents most of a persons
life; Its purpose is the psychological detachment and independence from the parents Patient VD
started to live without her parents after getting married at the age of 24. She was blessed with 5
children but after 20years of getting married, she and her husband decided to separate. With
regards to her current relationship, she is with her youngest son taking care of her.
B. ERIK ERIKSONs PSYCHOSOCIAL THEORY
A persons social view of self is more important than instinctual drives in determining
behaviors that allows for a more optimistic view of the possible human growth according to this
theory. He describes 8 stages.
Patient VD whose age is 54years old falls under Generativity vs. Stagnation. The adult
stage of generativity has broad application to family relationships, work and society. Patient VD
is separated with her husband 10years ago. Patient VD also verbalized Hindi ako masyado
lumalabas ng bahay at nakikihalubilo sa iba kahit sa kapit bahay She is living with her
youngest son who was the one taking care of her. With the situation mentioned above Patient VD
develops Stagnation.
Patient VD verbalized Yung mga anak ko areglado sa pag-control ng pagkain ko, minsan
nahihirapan na ako
C. ELIMINATION PATTERN
Patient VD verbalized that she has having difficulty in voiding, there was a time wherein
her urine has scant amount of blood. But she claimed that they just ignore it and does not consult
a physician regarding the incidence. As she claimed her urine output has the same amount as
same as her fluid intake. Usually, 800 cc to 1000 cc per day clear in color and without foul odor.
Patient VD verbalized that she defecates twice a day during early morning and in the
afternoon. As she claimed her feces was not odorous, semi-solid in consistency and brown in
color. Shes not having difficulty defecating.
D. ACTIVITY-EXERCISE PATTERN
As Patient VD claimed she seldom exercise even before when she was still not diagnosed
with her illnesses. She claimed that before, she has a lot of things to do in their house that is why
exercising is not a priority and she believes that by doing household chores it is a form of
exercise. She claimed that when she was diagnosed with DM her doctor advised her to do
minimum amount of exercise such as brisk walking or having a jog everyday but she doesnt
follow the order.
Patient VDs son verbalized that as of today her mother is having difficulty in
ambulating, therefore most of the time, her mother is just sitting in their house, watching TV and
seldom stands up. She just stand up when VD will eat and has to go to the restroom.
Majority of patient VDs activities of daily living require assistance from bathing,
dressing, toileting, transferring, and feeding. Patient VD is completely dependent.
E. SLEEP-REST PATTERN
Patient VD claimed that she have trouble sleeping continuously at night because she feels
pain and that she also have difficulty in breathing, that makes her sleep pattern be interrupted and
be limited to few hours of sleep for the entire day.
F. COGNITIVE-PERCEPTUAL PATTERN
Patient VD have no problem with her sense of smell but her eyesight is slightly impaired
due to her past history of glaucoma in the year 2013. Patient VD was also observed to have
difficulty hearing different sounds.
G. SELF-PERCEPTION AND SELF-CONCEPT PATTERN
Upon assessment, patient VD verbalized that she feels weak and that she thinks she wont
be able to feel better soon. Patient also verbalized that, Simula nung nag dialysis ako, lalo
akong humina.
H. ROLE-RELATIONSHIP PATTERN
Patient VD admitted that she is already separated to her husband for already 10 years
now. She was left with their 5 children, 4 sons 1 daughter. But she is only living with their
youngest who is still studying. She also said that she rarely communicate and participate to
different community activity.
I. SEXUALITY- REPRODUCTIVE PATTERN
Patient verbalizes that her menarche happened when she was just 11 years old. She
admitted that her menstrual duration lasts for only 3 days. During her younger years whe was
sexually active that leads her to gravida 5. Year 2005, she was diagnosed with left and right
myoma, with idiopathic cause, and she claimed that shes been operated for TAHBSO.
J. COPING-STRESS TOLERANCE PATTERN
Patient VDs coping is absent because she, herself, believes that she is severely sick and
that her disease will not be cured nor be alleviated anymore. She doesnt follow her diet
restrictions for she believes that Okay lang naman kumain ng bawal kasi may gamot naman
ako
K. VALUE-BELIEF PATTERN
Patient VD states that she is a Roman Catholic but she does not attend mass regularly.
Though she practices praying, still, she doesnt believe that the Almighty can help her current
condition.
VII. PHYSICAL EXAMINATION
A. GENERAL INFORMATION
Patient VD started to gain weight two months ago. She feels really weak and ill. Even
when at rest she feels tired. She complains of flank pain, bipedal edema and difficulty of
breathing.
B. MENTAL ACUITY
During assessment Patient VD was oriented, conscious and coherent. She was able to
respond to the student nurses appropriately.
C. SKIN
Upon assessing Patient VD, she has dry and itchy skin. She has no lesions, bruise or
bleeding. The only complaint gathered from her is that her skin was always itchy. Upon
assessment student nurses noticed that she has dry, flaky skin. Her skin itchiness was caused by
increased phosphorus level in her blood. We observed that she has non pitting bipedal edema.
D. HEAD
Patient VD has symmetric, round head. Her face is symmetrical with oval in appearance.
Patient VD has soft, silky hair and no signs of alopecia.
E. EENT (EYES, EARS, NOSE&THROAT)
Patient VD has pale palpebral conjunctiva, her cornea has some opacities. Her pupils was
equal, round, reactive to light and accommodation. She admitted that she has glaucoma. Patient
VDs ears are equal in size and has similar appearance. No presence of cerumen. Patient VD has
difficulty in hearing. Upon assessing VDs nose it was clean and free from any obstruction. She
has no episodes of epistaxis. Patient VD has no episodes of bleeding gums, toothaches or sore
throat. Patient VD uses dentures.
F. CHEST AND BREAST
Upon assessing patient VDs chest she has crackles predominantly during inspiration. She
has a Respiratory Rate 34cpm. She is experiencing difficulty of breathing. Patient VD has a slow
bounding pulse. Her pulse rate was 60bpm. The patient refused to assess her breast.
G. GASTRO-INTESTINAL TRACT
Patient VD has a dull abdominal sound. Ascites is present. She has an abdominal girth of
44inches. She has no reported incidence of constipation, change in BM, or Heart burn.
H. GENITO-URINARY TRACT
Patient VD has flank pain, dysuria and urine retention. She was not able to urinate the
same amount of fluid she takes.
I. EXTREMITIES
Patient VD has a non pitting bipedal edema, upon assessment she has joint pain and
muscle stiffness. She has no injuries or lesion.
J. NEUROLOGICAL STATUS
Patient VD experiences numbness and tingling sensation specifically on her lower
extremities. She has an episode of fainting last March 2016. She can still remember past events
clearly.
IX. PATHOPHYSIOLOGY
PREDISPOSING FACTORS
PRECIPITATING FACTORS
-Age
-Family History
-Sedentary Lifestyle
-Genetics
Decreased tissue
perfusion of the
kidney
Sluggish flow
of blood
Increase serum
osmolarity
Impaired
delivery of
blood
components
Increase blood
viscosity
Impair
removal of
waste
Decreased
blood flow to
the organs and
extremities
Impaired
removal of
waste from
the blood
Inadequate
inflammatory
response
Failure to
initiate
erythropoie
tin
RBC
production
decreased
Hyperglycemia
Decrease
osmotic
pressure in
blood
Increase
Glucose
concentratio
n in urine
Decrease
Glucose
intake of
cells
Water from
cell towards
the blood
Decreased
reabsorption
of glucose in
renal tubule
Decrease
ATP
production
Dehydration
Decrease
osmotic
pressure
Decrease
Energy for
normal cells
function
Microorganism
would enter
the body at any
route
Infection
occurs
Decrease
perfusion in
nerves
Nerve hypoxia
WBC (11,820)
Eosinophils 2 %
Segmental
demyelinizatio
n
Nerve Damage
Excessive glucose is
converted into
SORBITOL which
accumulate in nerves
Sorbitol
impairs motor
nerve
conduction
Glucose
level
exceeds
renal
threshold
Impaired
Renal
function
Increase
permeability
of the renal
cell wall
Filtration of
macrocells
and particles
Glycosuria
RBC 2.82
Stimulation
of
osmorecepto
rs
Decrease
water
reabsorption
Cells
starvation
occurs
THIRST
Increased
Urine output
Stimulation
of the
hunger
mechanism
Polydipsia
Polyuria
Hunger
occurs
Polyphagia
Parasthesia, Numbness
TYPE 2
DIABETES MELLITUS
Increase
BUN and
Creatinine
Abnormal
Calcium and
pH
Edema
Hypoparathyroi
dism
Signs and
Symptoms
Pulmonary
Congestion
Decreased
calcium level
(2.82)
Cold intolerance
Tremors
Syncope
X. LABORATORY
Component
WBC
Hemoglobin
Result
11, 820 (H)
8.44 (L)
Normal values
5000 10,000 cumm
M: 13.5 -18 gms
Interpretation
Infection
Few
RBC,
F: 12- 16 gms
Hypothyroidism,
Chronic
Hematocrit
Segmenters
Lymphocytes
Monocyte
24.51 (L)
52
30
16 (L)
Kidney
M: 40- 48gms
Disease
Destruction of red
F: 37-45 gms
blood
40- 60 %
20- 40%
2- 10%
Overhydration
Within normal values
Within normal values
Autoimmune
disorder,
cells,
blood
disorder.
Might be a sign of
infection, or a heart
Eosinophils
Basophil
Platelet count
2
0
Adequate
count
0-5%
0-2 %
platelet
complication
Within normal values
Within normal values
2.82 (L)
Chronic
disease,
kidney
Hypothyroidism,
MCV
MCH
MCHC
86.95
29.93
34.42
82 -98%
28- 32%
32- 38%
anemia.
Within normal values
Within normal values
Within normal values
Test
Ionized calcium
Result
1.04 (L)
Normal Values
1.13- 1.32 mmol/L
Interpretation
Hypocalcemia, Water
intoxication
Hyponatremia, Water
3.5- 5 mmol/ L
intoxication
Within normal values
Sodium
Potassium
129.3 (L)
4.61
NURSING PROBLEM
Ineffective breathing pattern
Fluid volume excess
Impaired Skin Integrity
High risk for decreased cardiac output
Risk for Infection
DATE IDENTIFIED
September 1, 2016
September 1, 2016
September 1, 2016
September 1, 2016
September 1, 2016
M: Medication:
Lecarnidipine, as one of her home medication must be taken once a day with a dosage of 20mg/ tab. This is taken to treat her
hypertension. As well as, Carvedilol, an anti-hypertensive agent, must be taken once a day with 6.25 mg/ tab. Another type of
hypertensive medication is Clonidine which should be taken thrice a day, 75 mcg/ tab. She is also prescribed with Tradjenta, to treat
her Type II Diabetes. A 500 mg/ tab of Calcium carbonate is also prescribed three times a day. Because of her hypoparathyroidism, she
is prescribed to take Levothyroxine 25mcg + 12.5 mg once a day. Patient VD must also take her diuretic medication which is
Furosemide, 40mg/ tab twice daily, to treat her edema.
E: Exercise:
Since the patients physical mobility is limited, she cant perform strenuous exercises, instead her attending physician advised her to
use a stress ball to exercise her fistula for it to be used as an access during her hemodialysis.
T: Treatment:
The patient is recommended to have her dialysis three times a week.
H: Health Teaching:
The patient was advised to comply with her home medication. She was also advised to follow the prescribed diet and exercise given to
her by her attending physician.
O: Outpatient follow up:
Her attending physician advised her to have monthly consultation and laboratory work-ups.
D: Diet
The patient is restricted to 1L of fluid a day, she is also instructed to avoid foods that contains large amount of sodium, potassium and
glucose. The patient was also advised to limit her cholesterol intake thus foods that are rich in fat.
S: Spiritual
The patient was encouraged to pray, never lose hope and remain strong to lessen the pain that she experiences despite of her condition.